Relationship between difference of preoperative and cardiopulmonary bypass mean arterial pressure, and acute kidney injury in cardiac surgical patients undergoing valve surgery.

BACKGROUND: Modifiable and non-modifiable factors contribute to development and progression of acute kidney injury (AKI) during cardiac surgery. We hypothesized that, the difference between preoperative mean arterial pressure (MAP) and the average mean arterial pressure maintained on cardiopulmonary bypass (CPB) would be strongly predictive of AKI. We also measured plasma Neutrophil gelatinase-associated lipocalin (NGAL), to establish its association with cardiac surgery associated-AKI (CSA-AKI). METHODS: One hundred and twelve high-risk patients undergoing valve, and valve plus coronary artery bypass grafting (CABG) surgery under cardiopulmonary bypass (CPB) were included in this study. Delta mean arterial pressure (MAP) was calculated as the difference between the average of pre-operative and on-bypass MAP, and blood was sampled for NGAL levels, at baseline, and 6-h after CPB. Detailed data collection was done, tabulating most of the factors which might influence development of post-operative cardiac surgery associated-AKI (CSA-AKI). To define CSA-AKI within the first 24-h post-operatively, the Kidney Disease Improving Global Outcomes (KDIGO) classification was used. RESULTS: Out of 112 patients, 44 (39.3%) developed CSA-AKI postoperatively. With an ROC analysis cut-off of delta MAP of more than 25.67 mmHg, 46.4% patients developed post-operative AKI, and the average CPB flows which were 1.8 ± 0.2 were not contributory to the development of early CSA-AKI. In our study, ELISA test for human NGAL was performed on serum samples, and the estimated cut-off value of 1661 ng/mL was found to be significantly associated with early CSA-AKI. CONCLUSIONS: Delta MAP and CPB flows are not related to early post-surgical CSA-AKI in cases with prior high-risk elements. However, baseline serum NGAL, as well as its percent change during the early post-surgical period independently predicted the development of CSA-AKI. This implies that, there may be patients with a higher pre-operative preponderance to develop this complication, which could actually be delineated by the use of serum NGAL estimations at baseline.

Relationship between transesophageal echocardiography-derived pulmonary artery systolic pressure measurements and early morbidity in patients undergoing coronary artery bypass grafting.

Context: We studied the relationship between intraoperative transesophageal echocardiography-derived (TEE-derived) pulmonary artery systolic pressure (PASP) measurements with early morbidity in on-pump coronary artery bypass grafting (CABG) surgery. Aims: The objective of the study was to assess whether TEE-derived elevated PASP is independently predictive of significant morbidity. Settings and Design: Prospective observational study in a university hospital. Materials and. Methods: Around 54 patients who underwent CABG under cardiopulmonary bypass (CPB) were divided into two groups; with PASP ≥35 mmHg and PASP <35 mmHg, assessed by intraoperative TEE. Outcomes studied were poor coronary revascularization, postoperative arrhythmias, myocardial infarction, respiratory failure, intra-aortic balloon pump use, pacemaker dependence, significant inotrope use, prolonged intensive care unit stay, and the total length of stay in the hospital. Mortality analysis was not a part of this study since expected sample sizes were low. Results: Patients with PASP ≥35 mmHg had a higher risk of respiratory failure, increased inotrope use and prolonged hospital stay, although multivariate analysis failed to demonstrate an independent association of PASP with these outcomes. Diabetes mellitus (DM), peripheral vascular disease, low cardiac output and elevated mitral annular E/e' ratio were significantly associated with higher pulmonary arterial pressures. Multivariate analysis showed that PASP was independently associated with higher mitral annular E/e' ratio. Conclusions: Our study, therefore, suggests that higher PASP may predict higher left ventricular filling pressures, and although elevated PASP ≥35 mmHg may be associated with DM; peripheral vascular disease, lower intraoperative cardiac output, postoperative respiratory failure, higher inotrope use, and delayed hospital discharge, it is not an independent predictor of any of these variables.

Influence of anaesthetic technique on maternal and foetal outcome in category 1 caesarean sections - A prospective single-centre observational study.

BACKGROUND AND AIMS: In category 1 caesarean section (CS), there is limited evidence regarding superior anaesthetic technique. Hence, this study was designed to study the influence of anaesthetic technique on the maternal and foetal outcome. METHODS: Patient characteristics, indication for CS, decision-to-delivery interval (DDI), uterine incision-to-delivery time (UIDT), cord blood pH, Apgar scores and neonatal and maternal outcome were noted. Composite endpoint (Apgar score <7, umbilical cord blood pH <7.2, neonatal intensive care unit admission or death) was created for adverse neonatal outcome. Logistic regression was done to assess the influence of confounding factors on the occurrence of adverse neonatal outcome. RESULTS: Of 123 patients who underwent category 1 cesarean section, 114 patients were included for analysis. The DDI and UIDT were comparable. One and 5-min Apgar scores were significantly lower in the group general anaesthesia (GA) than in the group spinal anaesthesia (SA). The umbilical cord blood pH was comparable (7.21 ± 0.15 vs 7.25 ± 0.11 in groups GA and SA, respectively). Neonatal intensive care admission and maternal outcome were comparable in both the groups. Subgroup analysis of patients with foetal heart rate of less than 100 showed that group GA had significantly lower 1-min Apgar scores and umbilical cord blood pH and significantly more neonatal admission and mortality. Binominal logistic regression showed that group GA (odds ratio 2.9, 95% confidence intervals 1.27-6.41) and gestational age were independently associated with adverse neonatal outcome. CONCLUSION: GA for category 1 CS was associated with increased incidence of adverse neonatal outcome.

Comparing epidural and wound infiltration analgesia for total abdominal hysterectomy: A randomised controlled study.

BACKGROUND AND AIMS: Continuous wound infiltration (CWI) is emerging as an alternative to continuous epidural infusion (CEI). This study compared postoperative pain scores of CEI with CWI in patients undergoing total abdominal hysterectomy (TAH). METHODS: This prospective randomised controlled trial included 102 patients planned for TAH who were randomised into either Group E (CEI) or Group L (CWI). The catheter (epidural/wound infiltration) was inserted in Group E before induction) and Group L at the end of surgery. General anaesthesia was administered according to standard protocol. At the end of surgery, both groups received 10 mL bolus of 0.2% ropivacaine followed by infusion at 6 mL/h through the respective catheters. They also received intravenous patient-controlled analgesia with morphine. The primary outcome was the visual analogue score at rest (VASR) and at deep breathing (VASDB) post-operatively. Secondary outcomes were post-operative morphine consumption, side effects and patient satisfaction. RESULTS: The mean VASR between two groups were comparable up to 8 h. Group E showed significantly reduced VASR compared to Group L at 12 h (2.32 ± 0.59 vs 2.62 ± 0.67, P = 0.019) and 24 h (2.30 ± 0.58 vs 2.62 ± 0.57, P = 0.006). Group E showed significantly reduced VASDB compared to Group L at 5 min and from 4 to 24 h. Total morphine consumption, side effects and patient satisfaction were comparable. CONCLUSION: We conclude that CEI is a superior analgesic technique compared to CWI in total abdominal hysterectomy in terms of reduced pain scores.

Role of transoesophageal echocardiography in renal cell carcinoma: a brief review.

Transoesophageal echocardiography (TOE) is regularly used in cardiac and also increasingly in non-cardiac surgeries. It has a leading role in the perioperative management of renal cell carcinoma with tumour extension into inferior vena cava. We report two cases in which TOE was of immense help for patient management. This report highlights the two cases where intraoperative TOE was of immense help to establish diagnosis, to modify surgical plan, to guide the surgeon during clamp placement, to monitor cardiac function, to rule out tumour embolism and to confirm the complete removal of tumour thrombus.

Cardiac tachyarrhythmias and anaesthesia: General principles and focus on atrial fibrillation.

Cardiac tachyarrhythmias are encountered commonly during the perioperative period and need to be promptly identified and appropriately managed by the anaesthesiologist. This review intends to highlight important aspects of these tachyarrhythmias and explore a temporal relationship between common medications employed in the perioperative period and their causation. Mechanisms of initiation of tachyarrhythmias, drugs that can trigger those, as well as their diagnosis and management, are also parts of the current review. Cardiac tachyarrhythmias may not always require treatment, and sometimes, aggressive management can trigger more serious types of arrhythmias. A thorough understanding of these tachyarrhythmias and their pathogenesis enables adopting a more objective approach, eschewing risks of inappropriate or unnecessary management strategies. We performed a MEDLINE search using combinations of MeSH terms such as 'cardiac', 'arrhythmias', 'anaesthesia', 'perioperative', 'tachyarrhythmias' and 'anaesthetic implications'. We reviewed the relevant publications with regard to cardiac tachyarrhythmias occurring in the perioperative period.

Prolonged postoperative desaturation in a child with Down syndrome and atrial septal defect.

We report prolonged desaturation in a child with Down syndrome (DS) and atrial septal defect due to undiagnosed interstitial lung disease. An 18-month-old child with DS was scheduled for bilateral lens aspiration for cataract. The child had atrial septal defect and hypothyroidism. He also had delayed milestones and hypotonia with episodes of recurrent respiratory tract infection necessitating repeated hospitalization. Preoperative evaluation was unremarkable. General anaesthesia and controlled ventilation using proseal laryngeal mask airway was instituted. He had uneventful intraoperative period. In the postoperative period, the child had desaturation 1 hour after surgery on discontinuation of oxygen supplementation by face mask, which improved with oxygen therapy. Supplemental oxygen via face mask was continued and weaned off over several days. On further evaluation, the child was diagnosed as having interstitial lung disease. He improved and discharged from the hospital 15 days after the surgery with room air saturation of 90%.

Dexamethasone before total laparoscopic hysterectomy: a randomized controlled dose-response study.

PURPOSE: A prospective, randomized, double blind, placebo-controlled study was undertaken to evaluate the efficacy of a single preoperative dose of dexamethasone, in different dosages, in providing postoperative analgesia in patients undergoing total laparoscopic hysterectomy (TLH). METHOD: The study included 55 patients randomly divided into three groups. Patients in Groups P, D4, and D8 received saline, 4, and 8 mg dexamethasone, respectively, intravenously, 2 h before induction. RESULTS: The time to first analgesic requirement was significantly delayed in patients in the D8 group compared with the D4 group (P = 0.01) and placebo (P = 0.01). Total postoperative fentanyl consumption was significantly less in patients in the D8 group compared with the D4 group (P = 0.01) and placebo (P = 0.01). Use of 8 mg dexamethasone resulted in a 99.3 mcg decrease in total 24-h fentanyl consumption. Postoperative nausea and vomiting (PONV) was significantly less in the D8 group with a complete response rate (no emetic episodes and no rescue medication for 24 h) of 36.8% compared with the placebo group in which all the patients had PONV. No adverse effects were observed in any group. CONCLUSION: Dexamethasone at a dose of 8 mg given intravenously 2 h before induction, delays patient request for analgesia and reduces total fentanyl consumption and PONV in patients undergoing TLH.