Early thrombolysis is associated with decreased operative mortality in postinfarction ventricular septal rupture.

BACKGROUND: Post myocardial infarction ventricular septal rupture (PMI-VSR) is a dreaded mechanical complication of acute coronary syndromes. Given that surgical mortality approaches 50%, it is pragmatic that the risk factors for mortality and outcomes after surgical correction of PMI- VSR are carefully scrutinized. METHODS: We performed a single-center, retrospective cohort study of 35 patients presenting for surgical closure of post myocardial infarction ventricular septal rupture over six years. We reviewed patient characteristics, clinical, echocardiographic, angiographic and perioperative risk factors which may affect mortality after surgical repair of PMIVSR and 30 day and one year mortality rates of these patients. Univariate and multivariate logistic and cox proportional hazard regression analysis was used to identify predictors of operative and overall mortality. Long term survival was presented with Kaplan-Meier Survival Curve. RESULTS: Sixteen patients (46%) were in cardiogenic shock. Concomitant coronary artery bypass grafting (CABG) was done in 22 patients (63%) but did not influence survival. Preoperative thrombolysis was done in 12 patients (34%) out of which 10 (53%) survived Operative mortality was 46% and one-year mortality was 49%. Multivariate analysis identified preoperative thrombolysis: Hazards ratio, 0.12; 95% CI, 0.02-0.61; p value of 0.01, as significant independent predictor of survival in PMIVSR cohort. CONCLUSIONS: Preoperative thrombolysis is associated with decreased odds of operative and overall mortality after surgical repair in PMIVSR patients.

Anesthesia in pregnancy with heart disease.

Management of pregnant women with heart disease remains challenging due to the advancement of innovations in cardiac surgery and correction of complex cardiac anomalies, and more recently, with the successful performance of heart transplants, cardiac diseases are not only likely to coexist with pregnancy, but will also increase in frequency over the years to come. In developing countries with a higher prevalence of rheumatic fever, cardiac disease may complicate as many as 5.9% of pregnancies with a high incidence of maternal death. Since many of these deaths occur during or immediately following parturition, heart disease is of special importance to the anesthesiologist. This importance arises from the fact that drugs used for preventing or relieving pain during labor and delivery exert a major influence - for better or for worse - on the prognosis of the mother and newborn. Properly administered anesthesia and analgesia can contribute to the reduction of maternal and neonatal mortality and morbidity.

Delirium after cardiac surgery: A pilot study from a single tertiary referral center.

BACKGROUND: Advances in cardiac surgery has shifted paradigm of management to perioperative psychological illnesses. Delirium is a state of altered consciousness with easy distraction of thoughts. The pathophysiology of this complication is not clear, but identification of risk factors is important for positive postoperative outcomes. The goal of the present study was to prospectively identify the incidence, motoric subtypes, and risk factors associated with development of delirium in cardiac surgical patients admitted to postoperative cardiac intensive care, using a validated delirium monitoring instrument. MATERIALS AND METHODS: This is a prospective, observational study. This study included 120 patients of age 18-80 years, admitted to undergo cardiac surgery after applying inclusion and exclusion criteria. Specific preoperative, intraoperative, and postoperative data for possible risk factors were obtained. Once in a day, assessment of delirium was done. Continuous variables were measured as mean ± standard deviation, whereas categorical variables were described as proportions. Differences between groups were analyzed using Student's t-test, Mann-Whitney U-test, or Chi-square test. Variables with a P < 0.1 were then used to develop a predictive model using stepwise logistic regression with bootstrapping. RESULTS: Delirium was seen in 17.5% patients. The majority of cases were of hypoactive delirium type (85.72%). Multiple risk factors were found to be associated with delirium, and when logistic regression with bootstrapping applied to these risk factors, five independent variables were detected. History of hypertension (relative risk [RR] =6.7857, P = 0.0003), carotid artery disease (RR = 4.5000, P < 0.0001) in the form of stroke or hemorrhage, noninvasive ventilation (NIV) use (RR = 5.0446, P < 0.0001), Intensive Care Unit (ICU) stay more than 10 days (RR = 3.1630, P = 0.0021), and poor postoperative pain control (RR = 2.4958, P = 0.0063) was associated with postcardiac surgical delirium. CONCLUSIONS: Patients who developed delirium had systemic disease in the form of hypertension and cerebrovascular disease. Delirium was seen in patients who had higher postoperative pain scores, longer ICU stay, and NIV use. This study can be used to develop a predictive tool for diagnosing postcardiac surgical delirium.

Comparative Effect of Levosimendan and Milrinone in Cardiac Surgery Patients With Pulmonary Hypertension and Left Ventricular Dysfunction.

OBJECTIVE: To compare the effects of levosimendan with milrinone in cardiac surgical patients with pulmonary hypertension and left ventricular dysfunction. DESIGN: A prospective, randomized study. SETTING: Tertiary care teaching hospital. PARTICIPANTS: The study included patients with valvular heart disease and pulmonary artery hypertension undergoing valve surgery. INTERVENTIONS: Forty patients were allocated randomly to receive either milrinone, 50 µg/kg bolus followed by infusion at a rate of 0.5 µg/kg/min (group 1), or levosimendan, 10 µg/kg bolus followed by infusion at a rate of 0.1 µg/kg/min (group 2) for 24 hours after surgery. MEASUREMENTS AND MAIN RESULTS: Hemodynamic parameters were measured using a pulmonary artery catheter, and biventricular functions were assessed using echocardiography. Mean pulmonary artery pressures and the pulmonary vascular resistance index were comparable between the 2 groups at several time points in the intensive care unit. Biventricular function was comparable between both groups. Postcardiopulmonary bypass right ventricular systolic and diastolic functions decreased in both groups compared with baseline, whereas 6 hours postbypass left ventricular ejection fraction improved in patients with stenotic valvular lesions. Levosimendan use was associated with higher heart rate, increased cardiac index, decreased systemic vascular resistance index, and increased requirement of norepinephrine infusion compared with milrinone. CONCLUSIONS: The results of this study demonstrated that levosimendan was not clinically better than milrinone. Levosimendan therapy resulted in a greater increase in heart rate, decrease in systemic vascular resistance, and a greater need for norepinephrine than in patients who received milrinone.

Preinduction hemodynamic fluctuations in renal transplant recipients--comparison of two combined anesthesia regimens.

An ideal anesthetic technique for a renal allograft recipient must ensure hemodynamic stability, enhance graft reperfusion, and provide good postoperative pain relief. Hence, a combined general and epidural anesthesia is preferred. In our clinical practice, it has been observed that in chronically ill end-stage renal disease (ESRD) patients, a bolus injection of epidural local anesthetics invariably necessitated the use of vasopressor agents. Such hemodynamic fluctuations may not be favorable for the graft. A prospective, randomized, double-blind study was conducted on 50 ESRD adults, 18-55 years, scheduled for elective live related kidney transplantation. The patients randomly received either epidural fentanyl (50 µg) and normal saline (10 mL) or epidural fentanyl (50 µg) and bupivacaine (0.5%; 10 mL) followed by standardized general anesthesia. Perioperative hemodynamics and vasopressor requirements were compared with both regimens. Early graft function was assessed by the onset of diuresis after declamping, serial creatinine values, glomerular filtration rate, and 24-hour urine output estimation. In the preoperative period, statistically significant reduction in the mean arterial pressure and the cardiac index occurred in 60% of the patients receiving epidural bupivacaine boluses. These hypotensive episodes required a therapeutic intervention prior to general anesthesia, that is, intravenous mephenteramine (3-6 mg; 9.60±2.32 mg) and crystalloid infusion (189.28±21.29 mL). Intraoperative hemodynamic parameters, surgical blood loss, and transplanted kidney function were comparable between the groups. We concluded that the use of regional anesthetics needed to administered cautiously in renal transplant recipients to maintain hemodynamic parameters.

First and second trimester induced abortions in women with cardiac disorders: a 12-year analysis from a developing country.

This was a retrospective analysis of induced abortions (1st and 2nd trimester) in women with cardiac disease over a 12-year period (September 1994-December 2006). Of the 3,096 women who underwent an induced abortion during this period, 65 (2.1%) had an associated cardiac disease (NYHA class I or II = 58, class III or IV = 7). Their mean age was 29.6 years and 48/65 (73.9%) had opted for concurrent sterilisation. Nearly all 1st trimester abortions (52/53) were performed by suction evacuation. Among the 12 women undergoing 2nd trimester abortions, seven received vaginal misoprostol with or without oral mifepristone, four received varying combinations of intracervical dinoprostone, extra-amniotic saline (EAS) and oxytocin and elective hysterotomy was performed in one. Complications observed among the 1st trimester terminations were incomplete abortion in 1/53 (1.8%) and prolonged bleeding in 3/53 (5.6%). Method failure was the only complication seen in 2/12 (16.6%) 2nd trimester abortions. There was no major morbidity or mortality. Mifepristone and misoprostol used for 2nd trimester induced abortions were found to be safe in the few women so treated.

Analgesic efficacy of intramuscular opioids versus epidural analgesia in labor.

OBJECTIVES: To compare analgesic efficacy of intramuscular opioids: meperidine and tramadol with epidural analgesia. METHODS: One hundred and twenty-eight term nulliparous women with singleton pregnancy and vertex presentation were randomized to receive either epidural (n=43), meperidine (n=39) or tramadol (n=44). A visual analog scale (VAS) was used to assess the severity of pain. The parameters analyzed were analgesic efficacy, effect on labor, other maternal side effects, perinatal outcome and maternal satisfaction. RESULTS: Median VAS scores following first dose were 0 (0-5), 5 (3-8) and 5 (3-8) in epidural, meperidine and tramadol groups, respectively. Ninety percent of women rated analgesia as good to excellent in the epidural group as compared with 72% of women in the meperidine group and 65% in tramadol group. However, epidural caused a significant prolongation of first (P<0.05) and second (P<0.01) stage of labor with an increased number of operative deliveries (27% in the epidural, 7.6% in the meperidine, and 11.4% in the tramadol groups, P<0.05). In the epidural group 40% women had urinary retention and 16% had motor weakness, whereas sedation was the only side effect seen in the meperidine (41%) and tramadol groups (9%). Respiratory depression was noted among three neonates in the meperidine group, two in the tramadol group and none in the epidural group. CONCLUSIONS: The analgesic efficacy and maternal satisfaction is better with epidural analgesia than with opioids. Analgesia provided by meperidine and tramadol is comparable and approximately 50% of women rated the analgesia as good. Meperidine is better in the second stage than tramadol. Hence in developing nations where availability of facilities is the main limiting factor, intramuscular opioids can be considered suitable alternatives.

Dose response study of caudal neostigmine for postoperative analgesia in paediatric patients undergoing genitourinary surgery.

BACKGROUND: Neostigmine given through the neuraxial route has been found to have analgesic properties. In this clinical trial, we evaluated for the first time the efficacy of a varying dose of caudal neostigmine for postoperative analgesia in children undergoing genitourinary surgery. METHOD: In this double blind prospective study, we studied 120 children ASA physical status I in age group of 2-8 years scheduled for surgical repair of hypospadias under general anaesthesia. Children were randomly allocated to one of the six groups (n = 20 each) and received either no caudal block (group C) or neostigmine (groups I-V) in doses of 10, 20, 30, 40 and 50 microgram.kg-1 respectively at the end of the surgery. Postoperatively pain was assessed using an objective pain score for 24 h. Blood pressure, heart rate, SpO2, total amount of analgesic consumed and adverse effects, if any, were also recorded. RESULT: The duration of postoperative analgesia did not differ significantly between group C and I (P > 0.05). There was significant prolongation in the duration of analgesia in rest of the groups (group II-3.52 +/- 1.37 h; group III-6.50 +/- 1.93 h; group IV-10.45 +/- 3.41 h; group V-13.70 +/- 5.52 h) (P < 0.05). A dose dependent increase in the incidence of nausea and vomiting was also observed with highest incidence in group IV and V (group C-15%; group I-20%; group II and III-30%; group IV-45% and group V-60%) (P < 0.05). No significant alteration in vital signs and other adverse effects were noticed. CONCLUSION: Caudal neostigmine in the dose range of 20-50 microgram.kg-1 provides dose dependent analgesia. However, dose exceeding 30 microgram.kg-1 is associated with a higher incidence of nausea and vomiting.

Anesthetic management of patients with Takayasu's arteritis: a case series and review.

UNLABELLED: Takayasu's arteritis is a rare, chronic progressive panendarteritis involving the aorta and its main branches. Anesthesia for patients with Takayasu's arteritis is complicated by their severe uncontrolled hypertension, end-organ dysfunction resulting from hypertension, stenosis of major blood vessels affecting regional circulation, and difficulties encountered in monitoring arterial blood pressure. Takayasu's arteritis is an uncommon disease and previous descriptions of the anesthetic management of patients with this disease have been limited to isolated case reports in the anesthetic literature, mostly in women undergoing cesarean delivery. We present our experience in this series of eight patients for various emergency and elective surgical procedures and review their perioperative problems and management. IMPLICATIONS: This case series describes the anesthetic problems and management of patients with pulseless disease.

Reinforcement of laryngeal mask airway cuff position with endotracheal tube cuff for airway control in a patient with altered upper airway anatomy.

IMPLICATIONS: This case report suggests that the laryngeal mask airway (LMA) cuff position may not be optimal in some difficult airway situations in which the anatomical position of the larynx is altered. Reinforcement of the LMA cuff position by an additional cuff on the dorsal side of the LMA cuff may prove helpful. In this case, in which a difficult airway was anticipated, a nasopharyngeal tube cuff placed behind the standard LMA cuff helped relieve upper airway obstruction.

Comparison of caudal tramadol vs bupivacaine for post-operative analgesia in children undergoing hypospadias surgery.

In a prospective double-blind study, 40 children scheduled for hypospadias repair were allocated randomly to receive either caudal tramadol (1 mg/kg) or 0.25% plain bupivacaine (0.5 ml/kg). Postoperative pain score, side-effects and oxygen saturation (SaO2) were recorded during 24-hour observation period. The results point toward a significantly lower pain scores with caudal bupivacaine in the immediate postoperative period, whereas caudal tramadol caused a significantly lower pain score in the late postoperative period. Total consumption of rescue analgesics was significantly higher in bupivacaine group as compared to tramadol group during the study period (p < 0.001). The incidence of side-effects such as vomiting was more frequent with caudal tramadol, but there was no detectable difference in SaO2. We conclude that caudal tramadol can safely be used for postoperative analgesia with a longer duration as compared to caudal bupivacaine.