Export selected to
Reference Manager
Medlars Format
RefWorks Format
BibTex Format
  Most popular articles (Since )

  Archives   Most popular articles   Most cited articles
Hide all abstracts  Show selected abstracts  Export selected to
  Viewed PDF Cited
Subclinical hypothyroidism affects the intraoperative and postoperative hemodynamics in coronary artery bypass graft surgery: should we supplement with thyroxine preoperatively
Ashraf F Mahmoud, Mohammed Rehan, Walid S Taha, Safinaz H Osman, Osama M Assad, Osama M Al Fayoumy
July-December 2013, 7(2):43-49
Background Our aim was to reveal the effect of the subclinical hypothyroid state on cardiac surgery, to derive a conclusion to include thyroid profile tests as a routine in cardiac surgery patients, and to know the role of thyroxine supplementation preoperatively in subclinical hypothyroid patients on the perioperative course. Patients and methods Between March 2007 and April 2010, we operated upon 87 patients of coronary artery revascularization, who had subclinical hypothyroidism as confirmed by laboratory investigations [high thyroid-stimulating hormone (TSH) and normal levels of T3 and T4]. We divided them into two groups: group A included patients who received preoperative thyroxine (47 patients) and group B included patients who were not supplemented with thyroxine preoperatively (40 patients). Preoperative, intraoperative, 24-h postoperative, and before discharge assessment of the cardiac function [ejection fraction percent (EF%)] as well as assessment of the thyroid profile (TSH, T3, and T4) were performed in all patients in both groups. Results We found an increased incidence of operative and postoperative complications in group B than in group A. The intraoperative and immediate postoperative EF% showed significant myocardial depression in group B (P < 0.003) and group A (P < 0.001) when compared with preoperative value. After 24 h of operation, the effect of thyroxine started to appear with a marked improvement in the cardiac functions in both groups. In group B, the EF% improved from 37.5 ± 3.07% at 12 h after operation to 45.6 ± 2.0% at 24 h after operation and to 53.76 ± 7.7% just before hospital discharge. With respect to the thyroid profile, there was a marked decrease in the level of T3 in group B intraoperatively (0.9 ± 0.3 pg/ml; P < 0.002). The level was corrected 24 h postoperatively, after the intake of the Eltroxine, to 2.3 ± 0.8 pg/ml and then to 2.5 ± 1.1 pg/ml before hospital discharge. The level of TSH was markedly increased in group B intraoperatively (14.3 ± 4.7 μIU/l; P = 0.007 between both groups). The TSH level started to decrease in both groups after intake of Eltroxine in hospital. There was an increased incidence of supraventricular arrhythmias, mainly atrial fibrillation (four cases in group A and eight cases in group B). Conclusion Thyroid function tests should be a routine preoperative investigation in any patient admitted for cardiac surgery. The preoperative supplementation of thyroxine is vital and decreases the operative and postoperative morbidity and mortality in patients with subclinical hypothyroidism.
  7,790 2,085 -
Anesthetic management of ruptured ectopic pregnancy in immune thrombocytopenic purpura patient: a case report
Babita Ambush, Bhupendra Singh, Sakshi Maheshwari, Rakesh Karnawat
May-August 2015, 9(2):29-31
Bleeding in patients with low platelet counts is an important anesthetic challenge. We report a case of a 22-year-old woman who presented with a ruptured extrauterine pregnancy. The patient was a known case of immune thrombocytopenic purpura and she was on treatment with steroids. Her Hb was 6 g/dl and platelet count was 5000/ml. The postoperative period was uneventful and the patient was discharged 8 days after surgery. Here, we discuss the management and outcome of this rare presentation performed successfully under general anesthesia without the use of intravenous immunoglobulin that is an important agent for preoperative management of a planned surgical procedure for immune thrombocytopenic purpura patient to increase platelet count. The duration of surgery was 1 h. Hemostasis was achieved in this period as well.
  6,842 647 -
Anesthesia for high-risk patients undergoing percutaneous mitral valve repair with the MitraClip system in the catheterization laboratory
Rabie Soliman, Reda Abuel Atta
September-December 2015, 9(3):33-38
Background MitraClip system implantation is a new technique for high-risk patients with severe mitral regurgitation and patients risky for surgical repair or replacement of mitral valve through cardiopulmonary bypass. Aim The aim of this study was to evaluate the anesthetic experience in high-risk patients undergoing MitraClip implantation. Setting Madinah Cardiac Center, Saudi Arabia. Patients and methods The study included 34 patients scheduled for MitraClip implantations in the catheterization laboratory. An arterial line and a central venous line were inserted before induction. Epinephrine was started before induction and milrinone infusion was started after induction. The anesthetic technique for induction and maintenance was the same for all patients. Monitors included the heart rate, the arterial blood pressure, the central venous pressure, arterial blood gases, the temperature, and the urine output. Results All patients were hemodynamically stable intraoperatively and postoperatively. The intervention was successful in 33 cases and aborted in one case because of severe posteromedial leaflet tethering. Epinephrine and milrinone were weaned, and all patients were extubated, except for one mortality case that happened within the first 8 h postoperatively. Conclusion Percutaneous mitral valve repair with MitraClip implantation is a successful alternative in high-risk patients with symptomatic severe mitral regurgitation. Proper preoperative evaluation of the patients by an anesthetist and a cardiologist is very important. Starting epinephrine before anesthetic induction and milrinone infusion after induction resulted in a decreased pulmonary artery pressure, an increased ejection fraction, and maintained the arterial blood pressure during the procedure.
  3,094 4,088 -
Licorice versus ketamine gargle for postoperative sore throat due to insertion of a double-lumen endobronchial tube
Ahmed Nabil Ibrahim, Sherif Anis
September-December 2016, 10(3):45-49
Background Postoperative sore throat (POST) is common after tracheal intubation, especially with double-lumen endobronchial tube (DLT). Licorice has many uses such as dental hygiene and in sore throat. Ketamine gargle is a newly proposed adjunct for reducing the incidence of POST in anesthesia. The aim of this study was to determine the efficacy of licorice and ketamine gargles in patients undergoing the insertion of DLT in preventing POST within 24 h. Methods This prospective, randomized, double-blind study included 90 patients undergoing thoracic surgery requiring DLT for one-lung ventilation. Patients were randomized to three groups (n=30) and were asked to gargle for 1 min to 15 min before operations. Group A received ketamine gargle (0.5 mg/kg ketamine in 30 ml of dextrose water 20%), group B received licorice gargle (500 mg licorice powder in 30 ml of dextrose water 20%), and group C (the control group) received 30 ml of dextrose water 20% gargle. Assessment of patients for the incidence and the severity of POST and any side effect was carried out in the recovery room. Sore throat (yes/no) and severity of its pain measured using visual analogue scale were recorded at baseline in the recovery room and then at 2, 4, and 24 h after operation with a specified questionnaire. Results The incidence of sore throat was significantly higher in group C at all time points in comparison with the other two groups. There was a marked decrease in the incidence of sore throat in groups A and B, with no significant difference between them. The severity of POST pain was significantly higher in group C when compared with the other two groups, with no significant difference between them and with no complications. Conclusion Ketamine and licorice gargles decrease the incidence and severity of sore throat occurring postoperatively due to DLT intubation, with no significant differences between them.
  3,049 3,728 2
Truncus arteriosus ( perioperative management)
Marie Bosman
June 2012, 6(1):1-6

Truncus arteriosus is a congenital cardiovascular anomaly characterized by a single arterial vessel (truncus) with one valve arising from the heart. The truncus overrides a large perimembranous ventricular septal defect and receives mixed blood from both ventricles and supplies blood to the pulmonary, systemic, and coronary circulation, the ratio of the bloodflow vary according to the different vascular resistances. The anomaly is divided into four types according to Collett and Edwards classification on the basis of the origin of the pulmonary arteries from the truncal artery. In truncus, the goal is to balance the circulation to obtain QP:QS = 1 to maintain reasonable oxygen saturation as well as adequate organ perfusion. Careful titration of anesthetic agents and careful monitoring of their hemodynamic effects and appropriate measures to adjust pulmonary (PVR) and systemic vascular (SVR) resistances and cardiac performance are probably more important than the selection of a particular anesthetic agent. Postoperatively, low cardiac output can be expected because of high PVR and right ventricular failure. High PVR, both sustained and paroxysmal, should be anticipated. Pulmonary hypertensive crisis presents as low cardiac output and right ventricular failure. Avoidance of these potentially fatal events is essential to decrease the mortality and morbidity associated with repair. Events that trigger a hypertensive crisis, such as hypoxia, hypercapnia, acidosis, pain, airway stimulation, and left ventricular failure, must be avoided.

  5,499 895 -
A prospective randomized comparative study between two different milrinone regimens in adult patients with pulmonary hypertension undergoing cardiac surgery
Rabie Soliman, Reda Abuel Atta
September-December 2014, 8(3):91-96
Context Milrinone is an inodilator commonly used to improve myocardial function and to decrease pulmonary hypertension. Aim The aim of this study was to compare two different regimens of milrinone administration in adult cardiac surgery patients with pulmonary hypertension. Setting and design A prospective, randomized, comparative study was conducted in Madinah Cardiac Center, Almadinah Almonourah, Saudi Arabia. Material and methods The study included 100 adult patients undergoing cardiac surgery with mean pulmonary artery pressure greater than 25 mmHg, as estimated preoperatively by Doppler echocardiography. The patients were classified randomly into two groups (n = 50): group A and group B. In group A, milrinone was started by infusion at a rate of 0.5 μg/kg/min without a loading dose at the beginning of CPB and continued postoperatively at a rate of 0.5-0.75 μg/kg/min in the cardiac surgical ICU. In group B, milrinone was given as a loading dose of 50 μg/kg over 10 min before weaning from CPB followed by infusion at a rate of 0.5-0.75 μg/kg/min postoperatively in the cardiac surgical ICU. Statistical analysis used Data were statistically described in terms of mean ΁ SD or frequencies and percentages, when appropriate, using the paired t-test. Measurements and main results Early milrinone using significantly decreased pulmonary artery pressure and pulmonary and systemic vascular resistances; it increased the right ventricular fractional area change, cardiac index, and urine output; and it decreased the serum lactate, pharmacological and mechanical supports, and ICU and hospital length of stay (P < 0.05). Conclusion The early administration of milrinone in adult cardiac surgery was associated with better hemodynamic effect, and it decreased the need for pharmacological supports. In addition, it was associated with shorter ICU and hospital length of stay without any side effects related to milrinone.
  2,140 4,093 -
Ultrasound guidance versus transillumination for peripheral intravenous cannulation in pediatric patients with difficult venous access
Karim K Girgis
January-June 2014, 8(1):39-44
Objective Venous access can be technically difficult in pediatric patients because of the small size and impalpability of their veins. The aim of this prospective randomized study was to compare the use of ultrasound (US) guidance and transillumination as aids to facilitate peripheral intravenous cannulation in pediatric patients with difficult venous access. Patients and methods We included 80 children, less than 6 years of age, undergoing elective surgery, and having difficult venous access as predicted by a Difficult Intravenous Access score of at least 4. The patients were randomized to either US guidance (the US group, n = 40) or transillumination using the Veinlite EMS (the Veinlite group, n = 40). Cannulation was performed after inhalation induction of anesthesia. The primary outcome measure was the first-attempt success rate of cannulation. The secondary outcome measures were the overall success rate of cannulation, number of attempts, and time required to achieve successful cannulation. Results The first-attempt success rate was significantly higher in the US group (82.5%) compared with the Veinlite group (57.5%, P < 0.05). Both groups showed a high overall success rate (92.5% in the US group and 80% in the Veinlite group, P = 0.19). The time to achieve successful cannulation was significantly shorter in the US group (67.1 ± 19.3 s) than in the Veinlite group (94.1 ± 49.9 s, P < 0.01). The number of attempts required was not significantly different between the two groups. Conclusion Both US guidance and transillumination facilitate peripheral intravenous cannulation in pediatric patients with difficult venous access, resulting in a high overall success rate of cannulation. US guidance is superior as it results in a higher first-attempt success rate with less time required to achieve successful cannulation compared with transillumination.
  5,004 441 1
The novel use of spinal anesthesia at the mid-thoracic level: a feasibility study
Ahmed Abdelaal Ahmed Mahmoud, Hazem Abdelwahab Hussein, Karim Girgis, Ahmed Mostafa Kamal, Hesham Ahmed Nafady
January-June 2014, 8(1):21-26
Background Breast surgery is commonly performed in geriatric patients. In this age group, patients commonly suffer from comorbidities, making regional anesthesia the preferred option during surgery. Recently, segmental thoracic spinal anesthesia for laparoscopic cholecystectomy was tried successfully. Anatomical studies showed that the posterior dural-spinal cord distance is wider at the mid-thoracic region. This encouraged us to test the feasibility of performing spinal anesthesia at the mid-thoracic level for surgeries in the thoracic region, namely breast surgery. Materials and methods We performed a prospective feasibility trial including 25 patients, American Society of Anesthesiologists-I (ASA-I), undergoing minor breast surgery (lumpectomy or simple mastectomy) under segmental thoracic spinal anesthesia at T5 level with 1 ml plain bupivacaine (5 mg/ml) and 0.3 ml fentanyl (50 μg/ml). We assessed the number of attempts required, paresthesia during needle insertion, sensory block level, need for supplemental analgesics or general anesthesia, and block-related complications. Hemodynamics as well as patient satisfaction were also recorded. Results The block was successful in all patients. A single insertion attempt was needed in 22 (88%) patients. No paresthesia was recorded during needle insertion. The upper sensory level was at T1 (T1-T2) and the lower sensory level at T11 (T11-T12). No additional analgesics or general anesthesia were needed during procedure. Four patients required ephedrine to correct hypotension. Two of these patients developed nausea during hypotension. No other complications were recorded. Total satisfaction was reported by 23 (92%) patients. Conclusion Segmental thoracic spinal anesthesia at T5 level in healthy patients undergoing breast surgery can be used successfully with minimal hemodynamic instability. The safety of this technique needs to be confirmed by further studies involving larger number of patients, with comorbid conditions, before it can be advised for routine use.
  4,822 513 1
Intraoperative applications of tissue Doppler imaging
Mohamed Elsayed Abd Elhay
December 2012, 6(2):21-26

Intraoperative Doppler tissue imaging with pulsed wave Doppler is a rapid method to determine the direction, timing, and velocity of regional longitudinal myocardial motion and quantify systolic and diastolic function. Although DTI provides regional measurements, sampling from different sites will help compensate for any differences, facilitating the evaluation of global EF and diastolic function and the calculation of filling pressures. Repeated DTI observations in the same patient enable the detection of regional ischemia, and the appearance or detection of postsystolic shortening is a sensitive index of ischemic but viable myocardium. DTI has also been used to detect subclinical ventricular dysfunction in asymptomatic patients with valvular disease and differentiate physiologic from pathologic hypertrophy and distinguish constrictive pericarditis from cardiomyopathy.

  1,704 3,549 -
Perioperative mortality: an emergent global public health problem
Landoni Giovanni, Ruggeri Laura, Borghi Giovanni, Zangrillo Alberto
July-December 2013, 7(2):41-42
  1,764 3,422 -
What the cardiac surgeons have to know about cold agglutination management
Mahnoosh Foroughi, Masoud Majidi, Manouchehr Hekmat, Mahmood Beheshti
September-December 2014, 8(3):101-103
Cold agglutinin has specific importance in cardiac surgery field due to routine use of the systemic, topical hypothermia in cardiopulmonary bypass and cold cardioplegic solutions (4-12΀C). We describe a case of coronary artery bypass in which cold agglutinin was detected intraoperatively; hence, cardiopulmonary bypass and myocardial protection strategies were changed. A simple and not expensive test is introduced to screen these patients before operation, as screening is not routine before cardiac surgery in many heart centers. In addition, we provide a literature review for surgical consideration and highlight some important concerns that need to be addressed.
  4,349 586 -
Outcome after mitral valve replacement in patients with rheumatic mitral valve regurgitation and severe pulmonary hypertension
Shady E Elwany, Ahmed H Mohamed, Amany K Abu El-Hussein
July-December 2013, 7(2):74-78
Objective The aim of this study was to assess the early outcome after elective mitral valve replacement (MVR) in patients with rheumatic mitral valve regurgitation and severe pulmonary arterial hypertension. Patients and methods The study included patients with baseline systolic pulmonary artery pressure (sPAP) of at least 40 mmHg who underwent elective MVR for rheumatic mitral valve regurgitation. The systemic and pulmonary hemodynamic changes and arterial blood gas parameters were reported at baseline, after intubation, after bypass, 30 min after extubation, and 24 and 48 h postoperatively. Preoperative and postoperative transthoracic echocardiography was performed. Results Thirty patients (11 men and 19 women), median age 31 years (range: 16-52), were included in the study. The operative mortality rate was 10%. The receiver operating characteristic curves identified sPAP as a good predictor of operative mortality. Postoperatively, there was a significant reduction in left atrial diameter and right ventricular systolic pressure in survivors. The median sPAP and pulmonary capillary wedge pressure decreased significantly after bypass and persisted throughout the study period. Central venous pressure decreased after cardiopulmonary bypass time and remained so for 48 h postoperatively. After intubation, on intermittent positive-pressure ventilation and FiO 2 of 1.0, there was a significant improvement in PaO 2 and SaO 2 . pH and HCO3 - concentration increased significantly postoperatively. Conclusion Proper perioperative care and anesthetic techniques resulted in improved left atrial diameter, right ventricular systolic pressure, sPAP, pulmonary capillary wedge pressure, and oxygenation with reduced operative mortality in patients who underwent MVR for mitral valve regurgitation with severe pulmonary hypertension.
  4,289 405 1
The dual mode of ventilation 'pressure-controlled ventilation-volume guaranteed' does not provide anymore benefit in obese anesthetized patients
Mohamed A El-Ramely, Ahmed Abdelaal Ahmed Mahmoud, Mohamed M Abdelhaq
September-December 2015, 9(3):39-45
Background Ventilatory strategies aim at the prevention of atelectasis and the improvement of oxygenation, but yet none is optimal. On comparing pressure-controlled ventilation (PCV) with volume-controlled ventilation (VCV) with the same tidal volume and inspiratory time, PCV tends to produce higher mean airway pressures, and thereby improves oxygenation. However, volume-targeted ventilators (VTV) allow to set the tidal volume directly. In order to deliver that volume. We compared PCV and pressure-controlled ventilation volume guaranteed (PCV-VG) with regard to the airway pressures produced when aiming to achieve the same tidal volume. Patients and methods Thirty obese ASA I-III patients scheduled for abdominal surgery were ventilated with PCV for 45 min; then, the PCV-VG mode was applied to all patients with the same parameters, targeting the same tidal volume of conventional PCV during the first phase. The plateau pressure and the mean airway pressure were recorded and compared between both modes. Vital signs, EtCO 2 , SpO 2 , arterial blood gases, and the oxygenation index were compared. Results No difference was observed between both modes of ventilation in terms of the plateau airway pressure (34.2 ΁ 1.8 vs. 34.1 ΁ 2.9 cmH 2 O, P = 0.484) and the mean airway pressure (13.4 ΁ 1.6 vs. 13.2 ΁ 1.8 cmH 2 O, P = 0.326). No significant difference was observed between PCV and PCV-VG with regard to the hemodynamics, EtCO 2 , and SpO 2 . No significant change was observed in the arterial blood gas analysis including pH (7.39 ΁ 0.3 versus 7.4 ΁ 0.2 with P value 0.204), PaCO 2 (30.8e 0.204) change in 0.2 with P value 0.06), PaO 2 (155.8 0.06)) change in0.2 with blood P value 0.316) and oxygenation index (4.34 oxygenation index.2 with bP value 0.176). Conclusion No significant difference was observed between both modes of ventilation (PCV vs. PCV-VG) in obese patients.
  2,791 1,556 -
Ketamine/propofol (ketofol) versus propofol/fentanyl for induction of general anesthesia in parturients with rheumatic valvular lesions undergoing elective cesarean section
Nashwa Samy ELZayyat, Amira Refae Hassan, Ahmed Ibrahim ELSakka, Ahmed Hussein Saad
July-December 2013, 7(2):79-84
In this study, we assumed that the addition of ketamine to propofol (ketofol) would maintain cardiac stability in parturients with valvular heart without any deleterious effect on the fetus, that is no respiratory depression for the baby and hence a better Apgar score. This open-label randomized study was carried out in the High-risk Obstetric Unit, Cairo University Hospitals, in collaboration with the Anesthesia Department. The study included full-term parturients, 36-38 weeks' gestational age, 25-40 years old with severe rheumatic valvular heart lesions (mitral stenosis, mitral regurge, aortic stenosis, aortic regurge) of functional class II or III according to the New York Heart Association Classification. At the time of induction, patients were allocated randomly to one of the two study groups: group K (n = 25) received intravenous ketamine 1 mg/kg combined with propofol 1 mg/kg. Group P (n = 25) received propofol 2 mg/kg and fentanyl 2 mg/kg. Mean arterial blood pressure (MAP), heart rate (HR), and central venous pressure were recorded at the following times:T1, T2, T3, T4, T5, and T6. Decrease in MAP was only significant in group P (P < 0.001 at T2 and T3). The magnitude decreases in MAP. The absolute value of MAP was significantly lower in group P after induction, intubation, and skin incision. The median decrease in MAP was significantly higher in group P after induction and intubation. HR increased significantly after induction of anesthesia and after endotracheal intubation in the two groups. It reverted to near baseline values thereafter. The magnitude decreases in HR. The absolute value of HR was significantly lower in group P after intubation and skin incision. Apgar scoring was significantly better (higher) in the ketofol group at 1 and 5 min. We can conclude that a combination of ketamine and propofol seems to be an appropriate choice for anesthesia of critically ill rheumatic cardiac parturients undergoing cesarean section. It proved to be effective and hemodynamically safe for such a critical situation.
  3,794 373 -
Is this the time to introduce ketamine in acute respiratory distress syndrome? A pilot study
Radwa A Elhefny, Mohamed Elsonbaty, Sherif Nassib, Mohamed Mansour
May-August 2015, 9(2):23-28
Introduction Acute respiratory distress syndrome is regarded to be an acute, diffuse inflammation of the lung that leads to an increase in the permeability of the pulmonary vascular tissue. The relations between ARDS classes and the permeability of the pulmonary microvasculature as well as the water content of the pulmonary extravasculature remains to be clarified. The anti-inflammatory and the antioxidant properties of ketamine were observed in acute lung injury; ketamine promotes the attenuation of the expression of mediators of inflammation. The aim of the work The aim of this study was to test whether ketamine treatment by the inhaled route or the infusion route could be an efficient method of treatment for ARDS. Participants and methods Mechanically ventilated critically ill adult trauma patients admitted to the ICU with developing ARDS were eligible to participate in this study. Group A was treated by ketamine inhalation, group B was treated with ketamine infusion, and group C was treated by pulse steroid therapy. The serum interleukin-6 level was analyzed. Results Concerning group A (ketamine inhalation) and group B (ketamine infusion), there were significant correlations in both the groups starting from day 2 till day 5 of treatment with regard to the tidal volume and positive end-expiratory pressure and from day 3 of treatment with regard to the blood pressure and FiO 2 .
  3,805 358 2
Prophylactic use of a preoperative intra-aortic balloon pump in patients with severe left ventricular dysfunction undergoing coronary artery bypass grafting
Imran Khan, Hadia M Mian, Madiha Iqbal, Hira Ijaz, Zafar Tufail
September-December 2014, 8(3):97-100
Objective The aim of this work was to study the effectiveness of preoperative intra-aortic balloon pump (IABP) in patients with severe left ventricular dysfunction undergoing coronary artery bypass grafting (CABG). Materials and methods We studied 80 consecutive patients of both sexes undergoing elective on-pump CABG having an ejection fraction less than 30%. Thirty patients received preoperative IABP support prophylactically, whereas 50 patients did not. The decision to put an IABP was made by the individual surgeon operating the patient. Preoperative, intraoperative, and postoperative variables were recorded and 30 days' follow-up was obtained. Results were subjected to statistical analysis. Results Fifty one patients (63.7%) were male while 29 (36.25%) were female with a mean age of 55.62 ΁ 9.65 years. Patients who received preoperative IABP had high in-hospital mortality (P = 0.002) and decreased rate of postoperative acute kidney injury (P = 0.048), ICU stay (P = 0.031) and less requirement for postoperative inotropic support (P = 0.047) compared to those who did not receive IABP preoperatively. Conclusion The prophylactic use of IABP in patients with a low ejection fraction undergoing CABG does not decrease the mortality, but it has a favorable effect on postoperative major complications.
  2,302 1,858 2
Methylene blue for the management of pediatric patients with vasoplegic syndrome
Ghada A Hassan, Yasser A Salem, Heba A Labib, Ashraf A. H. Elmidany
July-December 2014, 8(2):66-74
Background Vasoplegic syndrome is a form of vasodilatory shock that can occur after cardiopulmonary bypass. Although norepinephrine is sufficient in most cases to restore adequate systemic vascular resistance and support systemic pressures, vasoplegia refractory to norepinephrine has been reported and is associated with high morbidity and mortality, especially in pediatric patients. The guanylate cyclase inhibitor methylene blue infusion could be a promising therapy for such cases. We reported in this study the response of pediatric cardiac patients with norepinephrine-refractory vasoplegic syndrome to methylene blue infusion. Patient and methods A total of 20 pediatric patients mean age 21.60 ± 9.88 months and mean weight 11.70 ± 3.63 kg, with norepinephrine-refractory vasoplegia after cardiopulmonary bypass were treated with an intravenous infusion of methylene blue (1.5 mg/kg) over 20 min. The effects on hemodynamic parameters, cardiac index, systemic vascular resistance index, and norepinephrine dosage were assessed 1 h after infusion. Results The mean arterial pressure increased significantly, with a mean difference of 16.70 ± 4.88 mmHg; also, a significant increase in systemic vascular resistance (P < 0.001), normalization of cardiac output, and a significant decrease in norepinephrine dosage (from 0.57 ± 0.05 to 0.11 ± 0.13 μg/kg/min) were observed in all patients within 1 h. No adverse effects related to methylene blue infusion were observed. Conclusion A single-dose methylene blue infusion appears to be a promising treatment for norepinepherine-refractory vasoplegia after cardiopulmonary bypass during pediatric cardiac surgery.
  3,395 347 1
Protamine adverse reactions in NPH insulin treated diabetics undergoing coronary artery bypass grafting
Hoda Shokri, Ihab Ali, Hoda M El Sayed
July-December 2016, 10(2):25-30
Background The routine use of protamine in cardiac surgery to neutralize heparin is usually associated with systemic reactions that result in substantial morbidity and mortality. Aim This study aimed to investigate the relationship between neutral protamine Hagedorn (NPH) insulin use and severe adverse reactions to intravenous protamine given after cardiopulmonary bypass. Methods After obtaining hospital ethics committee approval and after obtaining informed consent, 100 patients between 45 and 70 years of age of American Society of Anesthesiologist physical status II–III undergoing elective primary isolated coronary artery bypass grafting were included in this prospective study, which was conducted between May 2013 and June 2014. Patients were divided into two groups: the NPH group (50 patients), which included patients who were on NPH insulin preparation for more than 5 years before the study, and the non-NPH group (50 patients), which included patients on oral hypoglycemics. The incidence of protamine reactions was recorded for 30 min after protamine infusion. The incidence of severe hypotension, increased airway pressure, and cardiac arrest were compared using the χ2-test. A P value less than 0.05 was considered significant. Results All patients (50 in each group) completed the study. There was no significant difference in patients’ demographic data, preoperative comorbidities, and surgical factors between the two study groups. The number of patients who had hypotension was significantly higher in the NPH insulin group compared with the non-NPH group. For both groups, there was no significant difference with respect to bronchospasm, cardiac arrest, and increased pulmonary artery pressure. Conclusion This prospective study showed increased risk for hypotension among patients receiving NPH insulin for more than 5 years compared with those who were not exposed to NPH insulin.
  3,392 299 2
Terlipressin infusion versus norepinephrine infusion for management of postcoronary artery bypass grafting refractory hypotension: a comparative study
Ahmed M El-Shaarawy, Tarek A Marei, Hisham M Elbatanony
September-December 2017, 11(3):31-37
Objective The aim was to evaluate outcome of diabetic patients who developed refractory hypotension after coronary artery bypass grafting (CABG) surgery on using terlipressin (TP) versus norepinephrine (NE) infusions. Patients and methods A total of 44 patients were divided into two groups: group NE received NE infusion (0.1 µg/kg/min) and group TP received TP infusion (2 µg/kg/h). On cardiopulmonary bypass weaning (0 h), hemodynamic parameters, levels of blood glucose (BG) and blood lactate, serum creatine kinase-MB, and cardiac troponin T were determined. If systolic less than 90 mmHg and/or mean arterial pressure (MAP) less than 60 mmHg persisted after 5 min of adequate volume resuscitation, vasopressor infusions were started and hemodynamic parameters were recorded. If initial doses failed to achieve adequate hemodynamic stability at 10 min, the dose was increased. Postoperative levels of studied parameters were estimated. Results NE significantly whereas TP nonsignificantly increased heart rate. Both infusions induced persistently higher MAP at 10 min, 30 min, and 4 h compared with 0 h, with nonsignificantly higher MAP with TP versus NE. Both infusions increased BG levels compared with 0 h estimates, with significant difference with NE. At 24 h, serum creatine kinase-MB levels were significantly lower with TP than NE, whereas serum cardiac troponin T levels showed nonsignificant difference. Lactate clearance rate was significantly higher with TP. Conclusion Vasopressor infusion improved hemodynamics. TP did well than NE with significant increase of blood pressure measures but minimized cardiac ischemic risk and the increase of BG and blood lactate levels.
  2,329 1,341 -
A prospective randomized comparative pilot trial on extended daily dialysis versus continuous venovenous hemodiafiltration in acute kidney injury after cardiac surgery
Sahar S.I. Badawy, Amira R Hassan, Enas M Samir
July-December 2013, 7(2):69-73
Background and objectives Acute kidney injury (AKI) requiring dialysis after cardiac surgery is accompanied by high mortality. Continuous venovenous hemodiafiltration (CVVHDF) and extended daily dialysis (EDD) are commonly used for critically ill patients with AKI. The aim of this prospective randomized comparative pilot trial was to compare the efficacy of CVVHDF and EDD in patients with AKI after cardiac surgery. Patients and methods A total of 80 patients who developed AKI and who needed renal replacement therapy (RRT) after cardiac surgery were included in this prospective randomized comparative trial. Patients were randomized to receive either CVVHDF or EDD. The outcomes assessed were renal recovery, mortality rate at day 30, and cost of RRT in the ICU. Results Both groups were comparable with respect to demographic data and APACHE II score. The frequencies of renal recovery and mortalities were comparable in both groups. The cost of RRT was significantly lower in the EDD group compared with the CVVHDF group (P < 0.001). Conclusion Both CVVHDF and EDD are effective in patients with AKI after cardiac surgery, with EDD having the advantage of lower cost.
  3,024 312 7
Anaesthetic management of posterior mediastinal mass: a case report
Anjum Saiyed, Reema Meena, Babita Ambesh, Indu Verma
September-December 2014, 8(3):104-107
Posterior mediastinal mass surgery is a challenge to the anaesthetist in terms of airway obstruction, compression of great vessels due to mass effect of tumour and severe cardiovascular and/or respiratory collapse. This may occur following decrease in chest wall tone associated with neuromuscular blockade. In this case study, we report an 8-year-old male child presented with a large posterior mediastinal mass, displacing and partially encasing the aorta at our institution, SMS Medical College & Hospitals, Jaipur, Rajasthan. Mass was removed by left thoracotomy; endotracheal tube was advanced into the right bronchus to ventilate the right lung to improve access in the surgical field because tumour was situated on the left side. While dissecting the mass, there was considerable blood loss. This was replaced with hydroxyethyl starch and whole blood. Patient was extubated next day with uneventful recovery.
  3,034 292 -
Duct occluder in the management of persistent postoperative pleural effusion after bidirectional Glenn's shunt
Soumendu Pal, Sandeep Khandelwal, Manvinder S Sachdev, Prabhat Dutta
January-June 2014, 8(1):51-54
The bidirectional Glenn's shunt (BDG) is the first step in the systematic, staged approach to a Fontan operation for patients with univentricular hearts. For the BDG to function well, the flow of blood through the pulmonary circulation must be free from significant impediments so that systemic venous pressure does not reach physiologically unacceptable levels. High systemic venous pressures are associated with high morbidity because of persistent bilateral pleural effusions and pericardial effusions, low oxygenation, increased plasma transfusion requirements, albumin infusions to maintain plasma protein levels, and prolonged ICU stay. We present a case of BDG complicated by prolonged pleural effusions in the immediate postoperative period, which was managed successfully using a percutaneous catheter-based approach, and thereby avoiding the complications of a major redo cardiac surgery.
  3,011 189 -
Ischemia, reperfusion, and myocardial protection ( readdressed)
Mostafa Eladawy
December 2012, 6(2):27-34

Measures to minimize myocardial damage have been an important target of research; therefore, a better understanding of the role of anesthetics in the prevention of myocardial injury may provide anesthesiologists with strategies to improve outcome. Myocardial ischemia initiates a range of cellular events, which are initially mild and become progressively damaging with increasing duration of ischemia. Perioperative myocardial ischemia is a serious adverse event that can increase morbidity and mortality after cardiac and noncardiac surgery. Several treatment approaches that prevent or lessen myocardial ischemia during and after surgery have been proposed. The use of particular anesthetics for the induction and maintenance of general anesthesia is one approach to protect against the adverse effects of ischemia. Experimental data indicate that some anesthetics, such as volatile general anesthetics, exert protective effects against ischemia–reperfusion injury that are independent of their hemodynamic effects. To approach this subject, several points should be well understood, such as myocardial metabolism, the pathophysiology of myocardial ischemia, myocardial stunning and hibernation, the effects of ischemia on myocardial metabolism, reperfusion injury, preconditioning, myocardial protection, temperature control, cardioplegia, ischemic and anesthetic preconditioning, and pharmacotherapy.

  1,857 1,325 -
The effect of different phenylephrine infusion rates on uteroplacental blood flow during cesarean delivery under spinal anesthesia
Sherry N Rizk, Karim Girgis, Ahmed Mahmoud Sayed, Rana M.N. Abdella
July-December 2013, 7(2):85-91
Introduction Hypotension associated with spinal anesthesia is more common and profound in the pregnant population, resulting in adverse effects to both the mother and the fetus. It is now widely accepted that the vasopressor of choice during cesarean delivery is phenylephrine. However, an overdose of phenylephrine may cause reflex bradycardia and decreased maternal and fetal cardiac output. In contrast, lower phenylephrine doses may not be adequate to avoid or control hypotension. The optimal phenylephrine dose and its direct effect on uteroplacental blood flow are yet to be determined. Aim of the work This study aimed to examine the direct effect of different phenylephrine infusion rates on uterine blood flow during cesarean delivery spinal anesthesia. Assessment of uteroplacental blood flow was performed using Doppler ultrasound of the uterine artery from which uterine blood flow indices were obtained, namely, peak systolic velocity (PSV) and pulsatility index (PI). Materials and methods This is a prospective, randomized double-blind study. We included 90 age-matched American Society of Anesthesiologists (ASA) I or II parturients with term singleton pregnancies admitted for elective cesarean delivery under spinal anesthesia. We excluded candidates with hypertension, cardiovascular or cerebrovascular disease, type 1 diabetes mellitus, allergy or hypersenstivity to phenylephrine, known fetal abnormalities, intrauterine growth retardation, and any contraindication to spinal anesthesia. The patients were distributed randomly into three equal groups (n = 30 each). Groups 25, 50, and 75 received 25, 50, and 75 μg/min phenylephrine infusion, respectively, after spinal anesthesia was administered. The maternal uterine artery was identified by colored Doppler ultrasound and pulsed-wave Doppler was used to measure PSV and calculate PI before spinal anesthesia and at 5 and 15 min after the block was performed. Maternal hemodynamics and measures of fetal well-being (Apgar score and umbilical venous pH) were also recorded. Results PI at 15 min after spinal anesthesia was significantly higher in group 75 in comparison with the baseline value (P < 0.05) and also in comparison with groups 50 and 25 (P < 0.05). Furthermore, the percentage of decrease in PSV, compared with the baseline, was also significantly higher in group 75 compared with the other two groups at both 5 and 15 min (P < 0.05). Group 75 also showed a significantly higher incidence of hypertension and bradycardia in comparison with both the other groups. However, the number of hypotensive episodes as well as nausea and vomiting was significantly higher in group 25 compared with the other two groups (P < 0.05). There was no significant difference in fetal outcome among the different groups. Conclusion and recommendations At a dose of 75 μg/min, phenylephrine induced a significant reduction in uteroplacental blood flow as evidenced by decreased PSV compared with baseline values and an increase in PI compared with the other two groups. This decrease in uteroplacental blood flow was not associated, however, with poor fetal outcome. Further studies are needed to address the correlation between uteroplacental blood flow and fetal outcome with different phenylephrine doses in patients with uteroplacental insufficiency.
  2,839 259 1
The role of dexmedetomidine in fast-track extubation for closed congenital heart surgery in children: a randomized double-blinded placebo-controlled trial
Passaint H Fahim, Mai A Madkour
September-December 2016, 10(3):50-56
Background The definition of early extubation is not well-established; some authors extended its time to 24 h postoperatively. In our study, we tried to extubate the patients by the end of the surgery. We investigated the role of dexmedetomidine use during induction of anesthesia in the improvement of outcomes with fast-track extubation in children undergoing cardiac surgery. We assumed that the use of dexmedetomidine will help in extubating the patients at the end of operation with decreased use of inhalational anesthetic and fentanyl, thus improving oxygenation and decreasing the need for analgesia postoperatively. Patients and methods A study was conducted in a population of 84 pediatric patients scheduled for closed congenital heart surgery. Patients were randomly allocated to two groups: group D (42 patients), which received a single dose of dexmedetomidine 0.4 mg/kg over 10 min in the induction of anesthesia, and group C (42 patients), which received normal saline. Both groups were compared in relation to percentage of extubated patients by the end of the surgery as primary outcome. Hemodynamics (mean arterial blood pressure and heart rate), sevoflurane consumption, fentanyl consumption, incidence of postoperative infection, and length of ICU stay were recorded. Arterial blood gases were analyzed before extubation and in the ICU 1 and 3 h after transfer to the ICU. Results Compared with the control group, group D showed lower intraoperative sevoflurane and fentanyl consumption (14.2±2.9 vs. 37.8±24.1, P<0.01; 48±12.5 vs. 85.2±43.2, P<0.01). The blood pressure at T1 and T2 showed a statistically significant decrease compared with baseline (P=0.05 and 0.01, respectively) and heart rate showed a significant decrease (P=0.05) at T1 and (P<0.01) at T2. Group D showed a higher incidence of successful extubation (64 vs. 26.7%, P=0.04) and higher pO2 after extubation (82±28.45 vs. 68±0.23, P=0.04). The length of ICU stay was lower in group D (1.8±0.8) compared with 5.5±3.2 in the control group (P<0.01), and the incidence of postoperative infections was lower in group D compared with group C (29.4 vs. 65.2%, P=0.04). Conclusion Adding dexmedetomidine as an adjuvant to induction of anesthesia in children undergoing congenital heart surgery improved the success of extubation, the oxygenation, and decreased the length of hospital stay.
  1,672 1,370 -