Pulmonary hypertensive crisis and its efficient management. A Case report and literature review.

Perioperative anaesthetic management of patients with pulmonary hypertensive crisis is complex and challenging because of limited window period and treatment options. This case report describes the successful management of a patient with severe valvular heart disease superimposed by severe pulmonary hypertension, who developed pulmonary hypertensive crisis soon after induction of general anaesthesia for cardiac surgery. Pulmonary hypertensive crisis is not a usual phenomenon in these patients, but if it occurs it can be fatal. Anticipatory care of the patient to prevent crisis is the mainstay of treatment, otherwise it adds additional morbidity to such patients. Fortunately our patient survived the crisis without causing any additional morbidity during his hospital stay.

INCIDENCE, OUTCOME AND RISK FACTORS FOR SEPSIS--A TWO YEAR RETROSPECTIVE STUDY AT SURGICAL INTENSIVE CARE UNIT OF A TEACHING HOSPITAL IN PAKISTAN.

BACKGROUND: Sepsis is amongst the leading causes of admission to the intensive care units and is associated with a high mortality. However, data from developing countries is scares. Aim of conducting this study was to determine the incidence, outcome and risk factors for sepsis on admission to surgical intensive care unit (SICU) of a teaching hospital in Pakistan. METHODS: Two year retrospective observational study included all consecutive adult admissions to the surgical intensive care unit (SICU) of a University Hospital, from January 2012 to December 2013. RESULTS: Two hundred and twenty-nine patients met the inclusion criteria. Average age of the patients was 46.35 ± 18.23 years (16-85), mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 15.92 ± 8.13 and males were 67.6%. Median length of ICU stay was 4 [IQR 5]. 43% patients fulfilled the criteria of sepsis at the time of admission to the SICU and incidence of severe sepsis/septic shock was 35%. Abdominal sepsis was the most frequent source of infection (57.5%). The overall intensive care unit mortality was 32.31% but the mortality of sepsis-group was 51.15% as compared to 17.7% of the non- sepsis group. Stepwise logistic regression model showed that increasing age, female gender, non-operative admission, admission under general surgery and co-morbidities like ischaemic heart disease and chronic kidney disease were significant predictors of sepsis. CONCLUSION: The incidence of sepsis and severe sepsis/septic shock, on admission to SICU is high and mortality of the sepsis group is nearly three times the mortality of the non-sepsis group.

Fast Track Extubation In Adult Patients On Pump Open Heart Surgery At A Tertiary Care Hospital.

BACKGROUND: Fast-track cardiac surgery programs have been established as the standard of cardiac surgical care. Studies have shown that early extubation in elective cardiac surgery patients, including coronary and non-coronary open-heart surgery patients does not increase perioperative morbidity and mortality. The objective of this observational study was to determine the success and failure profile of fast track extubation (FTE) practice in adult open-heart surgical patients. METHODS: The study was conducted at cardiac operating room and Cardiac Intensive Care Unit (CICU) of a tertiary care hospital for a period of nine months, i.e., from Oct 2014 to June-2015. All on pump elective adult cardiac surgery patients including isolated CABG, isolated Valve replacements, combined procedures and aortic root replacements were enrolled in the study. Standardized anesthetic technique was adopted. Surgical and bypass techniques were tailored according to the procedure. Success of Fast track extubation was defined as extubation within 6 hours of arrival in CICU. RESULTS: A total of 290 patients were recruited. The average age of the patients was 56.3±10.5 years. There were 77.6% male and 22.4% female patients. Overall success rate was 51.9% and failure rate was 48.1%. The peri-operative renal insufficiency, cross clamp time and CICU stay (hours) were significantly lower in success group. Re-intubation rate was 0.74%. CONCLUSION: The perioperative parameters were significantly better in success group and the safety was also demonstrated in the patients who were fast tracked successfully. To implement the practice in its full capacity and benefit, a fast track protocol needs to be devised to standardize the current practices and to disseminate the strategy among junior anaesthesiologists, perfusionists and nursing staff.

To compare the accuracy of prayer's sign and Mallampatti test in predicting difficult intubation in diabetic patients.

OBJECTIVE: To determine the accuracy of Prayer's sign and Mallampatti test in predicting difficult endotracheal intubation in diabetic patients. METHODS: The cross-sectional study was performed at Aga Khan University Hospital, Karachi, over a period from January 2009 to April 2010, and comprised 357 patients who required endotracheal intubation for elective surgical procedures. Prayer's sign and Mallampatti tests were performed for the assessment of airway by trained observers. Ease or difficulty of laryngoscopy after the patient was fully anaesthetised with standard technique were observed and laryngoscopic view of first attempt was rated according to Cormack-Lehan grade of intubation. SPSS 15 was used for statistical analysis. RESULTS: Of the 357 patients, 125 (35%) were classified as difficult to intubate. Prayer's sign showed significantly lower accuracy, positive and negative predictive values than Mallampatti test. The sensitivity of Prayer's sign was lower 29.6 (95% Confidence Interval, 21.9-38.5) than Mallampatti test 79.3 (95% confidence interval, 70.8-85.7) while specificity of both the tests was not found to be significantly different. CONCLUSION: Prayer's sign is not acceptable as a single best bedside test for prediction of difficult intubation.

APACHE-II score correlation with mortality and length of stay in an intensive care unit.

OBJECTIVE: To correlate the APACHE-II score system with mortality and length of stay in ICU. STUDY DESIGN: Cohort study. PLACE AND DURATION OF STUDY: The Intensive Care Unit (ICU) of the Aga Khan University Hospital, Karachi, from May 2005 to May 2006. METHODOLOGY: All adult patients who were admitted in the ICU were included. APACHE-II score was calculated at the second and seventh days of admission in the ICU. Patients who were discharged alive from the ICU or died after first APACHE-II Score (at 2nd day) were noted as the primary outcome measurement. Second APACHE-II score (at 7th day) was used to predict the length of stay in the ICU. Pearson's correlation coefficient (r) was determined with significance at p < 0.05. RESULTS: In the lowest score category 3-10, 27 out of 30 patients (90%) were discharged and only 3 (10%) died. Out of those 39 patients whose APACHE-II score was found in high category 31-40, 33 (84.6%) deaths were observed. This revealed that there might be more chances of death in case of high APACHE-II score (p=0.001). Insignificant but an inverse correlation (r = -0.084, p < 0.183) was observed between APACHE-II score and length of ICU stay. CONCLUSION: The APACHE-II scoring system was found useful for classifying patients according to their disease severity. There was an inverse relationship between the high score and the length of stay as well higher chances of mortality.

Grown up congenital heart disease patient presenting for non cardiac surgery: anaesthetic implications.

Congenital heart disease patients surviving to adulthood have increased over the years due to various reasons. These patients are admitted in the hospital for non cardiac surgeries and other procedures more often than normal adult population. Management of grown up congenital heart disease patient presents a challenge during perioperative period for cardiologists, surgeons, intensivists and particularly for the anaesthetist. Management issues include psychological and physiological impact on the patient, complexity of defects, presence of previous palliative procedure, impact of anaesthetic agents on shunting and myocardium, endocarditis prophylaxis and associated extra cardiac anamolies.

Effect of single dose magnesium on arrhythmias in patients undergoing coronary artery bypass surgery.

OBJECTIVE: To evaluate the safety and role of prophylactic administration of magnesium in preventing arrhythmias. METHOD: This double blind randomized placebo controlled clinical trial was conducted at Aga Khan University Hospital on coronary artery bypass surgery patients. All patients were connected to holter monitor before induction of anaesthesia and this monitoring continued for 24 hours. Study drug containing either 2-grams of magnesium or normal saline was given after intubation. Levels of serum magnesium was checked preoperatively and then in ICU at 0, 6, 12, and 24 hours. Independent t-test and chi square test were used for analysis. Statistical significance was defined as p-value < 0.05. RESULTS: A total of 104 patients consented to participate in the study, 53 patients were randomly allocated in magnesium (Mg) group and 51 in placebo group. Two (3.77%) patients in magnesium group and five patients (9.8%) in placebo group developed atrial fibrillation. Incidence of ventricular and supraventricular tachycardia was also slightly higher in placebo. Mg level after arrival in CICU (Cardiac Intensive Care Unit) showed mean of 2.1 in magnesium group and 1.6 in placebo group (p = 0.6). CONCLUSION: Low magnesium levels were noticed in the placebo group after cardiopulmonary bypass and although prophylactic administration of magnesium sulphate was relatively safe but significant benefit on prevention of arrhythmias could not be attained.

Misplaced Central Venous Catheter in Carotid Artery during Emergency Surgery for the Total Correction of Tetralogy of Fallot of an Adolescent Boy.

Ultrasound-guided central venous cannulation is now considered as the standard of care, and this has largely replaced blind central venous cannulation using anatomical landmarks. We are reporting a case of inadvertent placement of central venous catheter in the right common carotid artery with the use of ultrasound guidance during emergency surgery for the total correction of Tetralogy of Fallot (ToF). This patient luckily had a favourable outcome despite this inadvertent catheter placement which was not recognised even after completion of surgery .The patient also received drug infusions of inotropes and vasopressors through this malplaced central line into the aorta. The possible mechanism, consequences, prevention and management of this inadvertent cannulation are discussed in this report.

Haemodynamic response to tracheal intubation via intubating laryngeal mask airway versus direct laryngoscopic tracheal intubation.

OBJECTIVE: To compare the haemodynamic response to tracheal intubation using either direct larygoscopy or Intubating Laryngeal Mask Airway. METHODS: This was a prospective randomized controlled trial. One hundred adult ASA-I and ASA-II patients coming to the Anaesthesia Department of Aga Khan University Hospital were randomly divided into two groups. In group-I endotracheal intubation was done with the help of Macintosh laryngoscope while in group-II patients were intubated with the help of the Intubating Laryngeal Mask Airway. Systolic, diastolic, mean arterial blood pressure and heart rate were recorded at baseline, at laryngoscopy and at 1 minute interval for 10 minutes following intubation. RESULTS: There was no statistically significant difference between the groups with respect to age, weight, height and gender. The rise in systolic blood pressure in group-I was 26 and 13% when compared with the baseline for first two minutes, while in group II the increase was 8-12%. When both groups were compared statistically significant difference (P < 0.05) was observed. The rise in diastolic blood pressure was 23% and 7% in group-I and II respectively when compared with the baseline. Statistically significant difference (P < 0.05) was observed at first two minutes following intubation between the two groups. The rise in mean arterial blood pressure after intubation was statistically significant. The increase in heart rate was observed after intubation in both the groups and when both the groups were compared the rise was not statistically significant. CONCLUSION: We concluded that intubation through intubating laryngeal mask airway is accompanied by minimal cardiovascular responses than those associated with direct laryngoscopic tracheal intubation, so it can be used for patients in whom a marked pressor response would be deleterious.

Attenuation of hypotension using phenylephrine during induction of anaesthesia with propofol.

OBJECTIVE: To observe if phenylephrine mixed with propofol can attenuate hypotensive effects of propofol during induction of anaesthesia. METHODS: A total number of 135 adult ASA-I and ASA-II patients were divided into three groups. (Group A, B and C). All patients were induced with propofol 2.5 mg per kg. In Group A (control group) patients received propofol mixed with 2cc of 0.9% normal saline. Group B (study group) patients received propofol mixed with 2cc of a solution containing phenylephrine 25 microg/cc (total 50 microg); Group C (study group) patients received propofol mixed with 2cc of a solution containing phenylephrine 50 microg/cc (total 100 microg). Haemodynamic variables like systolic, diastolic, mean arterial blood pressure and heart rate were noted. Hypotension was defined as 20% decrease in baseline systolic blood pressure recorded before induction of anaesthesia. RESULTS: Phenylephrine in a dose of 100 micrograms attenuated the drop in systolic blood pressure. However phenylephrine in a dose 50 micrograms did not effectively prevent anticipated drop in SBP. CONCLUSION: Phenylephrine in doses of 100 micrograms effectively attenuates anticipated hypotension upon induction of general anaesthesia with propofol.

Emergency airway management of a patient with mediastinal mass.

Appropriate airway management is an essential part of anaesthesiologist's role. Extrinsic airway compression by rapidly growing mediastinal masses represents a therapeutic challenge to anaesthesiologists. We report a case of successful airway management in a patient with obstructed airway. The patient was a middle aged female who presented with severe respiratory distress secondary to a huge mediastinal mass. CT scan showed widened superior mediastinum with circumferential narrowing of trachea and left main bronchus. Her condition continued to deteriorate during her hospital admission, so emergency intubation and tracheostomy was planned. She was intubated with the help of a bougie using size 6 microlaryngoscopic tube after inhalational induction and mediastinal tracheostomy was done. Intraoperatively, there were few episodes of hypotension and desaturation, otherwise rest of intraoperative course remained uneventful.

Pulmonary artery catheter knotting in a coronary artery bypass surgery patient.

A fifty seven years old female patient came to operating room for coronary artery bypass grafting (CABG) surgery. After induction, invasive monitoring lines were placed. Pulmonary artery catheter (PAC) floated after three attempts and it was wedged at 60cm. Intra operative course was smooth and patient transferred to cardiac intensive care unit (CICU). First chest X-ray revealed PAC knotting in the right ventricle. Vascular surgeon was involved and he removed it through right internal jugular vein under fluoroscopic guidance. Pulmonary arterial catheterization is an invasive procedure. Knotting usually occurs due to excessive advancement of the pulmonary artery catheter beyond the normally expected distance. The removal of a catheter should never be forced when resistance is encountered. PA catheter knotting is a rare complication but it should be suspected whenever there is excessive length of catheter required to reach pulmonary artery.

Anesthetic management of lower tracheal reconstruction.

We report a case of 26 years old man who presented with dyspnoea and stridor in the emergency room. He was diagnosed as a case of posttracheostomy lower tracheal stenosis and scheduled for lower tracheal reconstruction. Patient was intubated in the operating room while breathing spontaneously. Due to proximity of stenosis to carina, a portex microlaryngeal tube was used to ventilate left lung during the period of tracheal resection.