Hypercoiling of the umbilical cord in uncomplicated singleton pregnancies.

BACKGROUND: The umbilical coiling index (UCI) is a measure of the number of coils in the umbilical cord in relation to its length. Hypercoiled cords with a UCI of >0.3 coils/cm have been associated with adverse fetal and neonatal outcomes. AIMS: The primary aim is to determine the accuracy of UCI measured on second trimester ultrasound in predicting UCI at birth. The secondary outcome is to investigate the association between hypercoiling of the umbilical cord on prenatal ultrasound and adverse maternal, fetal and neonatal outcomes. METHODS: This was a prospective cohort study of uncomplicated singleton pregnancies. Seventy two patients were included in the study. UCI was measured in the second trimester ultrasound, and compared to UCI measured postnatally. Outcomes of patients with hypercoiled cords on ultrasound were compared to outcomes of patients with normocoiled cords. RESULTS: Our results failed to show a strong correlation between the UCI determined with ultrasound, and the UCI determined with examination of the umbilical cord after delivery. We also did not demonstrate that measurement of the UCI on second trimester ultrasound is able to predict adverse maternal, fetal or neonatal outcomes. CONCLUSION: This study suggests that measurement of the umbilical coiling index should not be part of routine second trimester sonography in patients with uncomplicated singleton pregnancies, with no other medical or surgical comorbidities.

Heart rate variability measures poorly predict atrial fibrillation after off-pump coronary artery bypass grafting.

STUDY OBJECTIVE: To investigate associations of heart rate variability (HRV) measurements with postoperative atrial fibrillation (AF) in patients undergoing off-pump coronary surgery. DESIGN: Prospective, observational, exploratory study. SETTING: Large university-affiliated community medical center. PATIENTS: 50 patients undergoing off-pump coronary artery bypass grafting (CABG). INTERVENTIONS: Preoperative recording of electrocardiograms (ECGs) with subsequent off-line HRV analysis. Monitored ECG telemetry for 5 days after operation. MEASUREMENTS: Frequency and time domain analyses, and additional non-linear HRV determinations. Multivariate regression analysis of predictors of postoperative AF. MAIN RESULTS: AF occurred in 23 (46%) patients. Only the low to high-frequency ratio was associated with AF (2.35 ± 1.8 v. 4.57 ± 5.0 for patients without AF, P < 0.05). CONCLUSIONS: The off-pump approach does not protect against AF, and nonlinear HRV analyses provide little value in predicting AF after off-pump CABG.

Prophylactic glycopyrrolate prevents bradycardia after spinal anesthesia for Cesarean section: a randomized, double-blinded, placebo-controlled prospective trial with heart rate variability correlation.

STUDY OBJECTIVE: To determine if prophylactic glycopyrrolate prevents bradycardia after spinal anesthesia. DESIGN: Prospective, randomized, double-blinded, placebo-controlled study. SETTING: Large university-affiliated community hospital. PATIENTS: 81 consecutive term parturients (not in active labor) who were scheduled for elective Cesarean section. INTERVENTIONS: Parturients received 1.0 to 1.5 L of intravenous Ringer's lactate and either glycopyrrolate 0.4 mg or an equal volume of saline, with caregivers blinded to the immediate sequelae of study drug. Each patient received intrathecal bupivacaine (12 to 14 mg) with morphine sulfate (0.1 to 0.2 mg). MEASUREMENTS: Continuous heart rate (HR) and blood pressure monitoring occurred for 20 minutes, with the minimum HR recorded for each 5-minute epoch. Heart rates < 60 beats per minute defined bradycardia. Heart rate variability (HRV) analysis occurred offline. MAIN RESULTS: None of 34 patients administered glycopyrrolate and 6 of 35 (17%) patients receiving saline experienced bradycardia (P = 0.02476). Time domain, frequency domain, and nonlinear and embedded spectrum entropy analyses all reflected the decrease in HRV accompanying administration of glycopyrrolate. CONCLUSION: Bradycardia after spinal anesthesia occurs commonly. Prophylactic glycopyrrolate may prevent the bradycardia, but not necessarily the hypotension.

The impact of immediate extubation in the operating room after cardiac surgery on intensive care and hospital lengths of stay.

OBJECTIVE: To determine if lengths of stay in intensive care and the hospital are associated with extubation in the operating room at the conclusion of cardiac surgery. DESIGN: A nonrandomized, observational study with propensity score-guided case-control matching of prospectively collected data. SETTING: Three interrelated, university-affiliated, community hospitals. PARTICIPANTS: Three thousand three hundred seventeen patients undergoing elective or urgent coronary artery, valve repair or replacement, or combined surgery between 2000 and 2006. INTERVENTIONS: Tracheal extubation occurred, based on history and intraoperative events, either immediately in the operating room or in the intensive care unit. MEASUREMENTS AND MAIN RESULTS: Of 3,317 patients in the institutions' Society of Thoracic Surgeons database, 3,089 were extubated within 24 hours, 69% of them in the operating room. Only 0.6% of patients extubated in the operating room required reintubation, compared with 5.9% extubated in the intensive care unit (p < 0.0001). By logistic regression, 12 of 25 preoperative and intraoperative factors generated a propensity score for each of the 2,595 patients with complete data, representing the likelihood of immediate extubation (c-statistic = 0.727). A "greedy 5 to 1" propensity score-matching technique created 713 matched pairs of patients by extubation pathway. Those undergoing immediate extubation had reductions in intensive care duration by 23 hours on average (median from 46 to 27 hours, p < 0.0001) and in hospital length of stay by 0.8 days on average (median = 6 for each, p < 0.0001). Cox regression, using matched pairs as strata, identified the following independent predictors of length of stay in the intensive care unit and hospital: immediate extubation in the operating room, need for reintubation, postoperative renal failure, and postoperative atrial fibrillation. CONCLUSIONS: Selection of patients for immediate extubation in the operating room by experienced clinicians was associated with shorter ICU and hospital stays. Immediate extubation rarely resulted in tracheal re-intubation.

Placenta percreta with invasion of the bladder wall: management with a multi-disciplinary approach.

Placenta percreta with pelvic organ invasion carries a high mortality for mother and fetus. Appropriate multidisciplinary consultation, strategy, and preoperative planning for Cesarean hysterectomy permitted caregivers to provide a maternal-infant bonding experience, surgical hemostasis, preservation of bladder function, and a healthy, vigorous neonate.

Nonlinear heart rate variability analysis may predict atrial fibrillation after coronary artery bypass grafting.

BACKGROUND: Heart rate variability might predict arrhythmias after coronary artery bypass grafting. METHODS: Off-line processing of 10-min electrocardiogram recordings of consecutive patients provided R-R intervals for time domain, frequency domain, Poincaré, and point correlation analyses and subsequent association with postoperative atrial fibrillation by stepwise multivariate logistic regression. RESULTS: Of 88 patients who met entry criteria, 13 developed atrial fibrillation. Peak point correlation dimension (odds ratio 3.985/unit, P = 0.0096) and age (odds ratio 1.144/yr, P = 0.0019) were independently associated with atrial fibrillation (c-statistic = 0.839). CONCLUSIONS: Further study should confirm the ability of peak point correlation dimension to predict atrial fibrillation after coronary artery surgery with cardiopulmonary bypass.

Using heart rate variability to stratify risk of obstetric patients undergoing spinal anesthesia.

In this study, we evaluated whether point correlation dimension (PD2), a measure of heart rate variability, can predict hypotension accompanying spinal anesthesia for cesarean delivery. After the administration of spinal anesthesia with bupivacaine, hypotension was defined as systolic blood pressure

Does off-pump coronary artery bypass reduce the incidence of clinically evident renal dysfunction after multivessel myocardial revascularization?

In this prospective, observational trial, we determined whether off-pump coronary artery bypass (OPCAB) was associated with less postoperative renal dysfunction (RD) compared with coronary bypass surgery with cardiopulmonary bypass (CABG). All patients undergoing primary, isolated coronary surgery at our institution in the year 2000 participated. Data collected on each patient included demographics, preoperative risk factors for RD, perioperative events, and serum creatinine concentrations from date of admission until discharge or death. The criteria for RD was both a >or=50% increase from preoperative creatinine and an absolute postoperative creatinine >or=2.0 mg/dL (177 microM). Student's t-test or the Fisher's exact test was used to compare groups. Stepwise multiple logistic regression identified determinants of RD; P < 0.05 significant. The CABG group (n = 119) differed from the OPCAB group (n = 220) with respect to age (64 +/- 13 versus 67 +/- 10 yr, P = 0.0074) and number of distal grafts (median 4 versus 3, P = 0.0003). Type of operation did not associate with the presence of postoperative RD: 18 (8.2%) of 220 OPCAB patients versus 12 (10%) of 119 CABG patients (P = 0.55). Our data suggest that choice of operative technique (OPCAB versus CABG) is not associated with reduced renal morbidity.