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  Citation statistics : Table of Contents
   2013| July-December  | Volume 7 | Issue 2  
    Online since December 31, 2013

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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.
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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.
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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.
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Perioperative mortality: an emergent global public health problem
Landoni Giovanni, Ruggeri Laura, Borghi Giovanni, Zangrillo Alberto
July-December 2013, 7(2):41-42
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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.
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Preoperative serum levels of interleukin-6 and interleukin-8 as predictors of the development of postoperative atrial fibrillation among patients undergoing coronary artery bypass grafting surgery
Ahmed A Mohamed, Dalia M Nor El-Dien
July-December 2013, 7(2):50-55
Objectives The aim of the study was to evaluate the ability of preoperative estimation of serum interleukins (IL-6 and IL-8) for predicting the possibility of development of postoperative atrial fibrillation (POAF) among patients who have undergone coronary artery bypass grafting (CABG) surgery. Patients and methods The study included 90 patients who underwent CABG, with a mean age of 63.8 ± 4.7 years. All patients underwent on-pump surgery with a mean aortic cross-clamping time of 65.9 ± 14.6 min and a mean cardiopulmonary bypass (CPB) time of 99.1 ± 19.7 min. Preoperative blood samples were collected for enzyme-linked immunosorbent assay estimation of serum IL-6 and IL-8 levels. Results After CABG surgery, 24 patients developed POAF (26.7%); five were female and 19 were male with a mean age of 64.1 ± 5.2 years. Four patients had a history of previous atrial fibrillation (AF), whereas 20 patients had no history of preoperative AF. Mean aortic clamping and CPB times were significantly longer in POAF patients compared with AF-free patients. Mean preoperative serum IL-6 and IL-8 levels were significantly higher in patients compared with controls, with significantly higher levels in POAF patients compared with AF-free patients. There was a positive significant correlation between the occurrence of POAF and history of preoperative AF, preoperative serum levels of IL-6 and IL-8, and aortic clamping and CPB times. Regression analysis defined elevated serum levels of IL-6 and IL-8, prolonged aortic clamping and CPB times, and history of preoperative AF as predictors of the occurrence of POAF among patients undergoing CABG in decreasing order of significance. Conclusion Inflammatory factors play a prominent role in the pathogenesis of POAF; high preoperative serum levels of IL-6 and IL-8 could aid in identification of patients liable to develop POAF, especially when associated with prolonged clamping time or preoperative history of AF.
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Awake versus combined general and epidural technique for off-pump coronary artery bypass grafting surgery: A retrospective comparative study
Ashraf Fawzy, Walid S Taha, Abdelhay Ebade, Sherry N Risk
July-December 2013, 7(2):56-62
Objectives Our aim was to evaluate the effectiveness of thoracic epidural anesthesia and analgesia in off-pump coronary artery bypass grafting surgery. We examined its validity in patients under combined general/epidural anesthesia and in awake patients receiving epidural anesthesia as a sole anesthetic technique. Patients and methods We evaluated 318 patients who underwent off-pump coronary artery bypass graft surgery between January 2008 and September 2009. Group A (n = 242 patients, 76.2%) received combined general/epidural anesthesia and group B (n = 76 patients, 23.8%) received only a thoracic epidural catheter as the sole anesthetic technique without general anesthesia or endotracheal intubation (awake). We compared the intraoperative hemodynamic and respiratory variables, postoperative pain (by Visual Analogue Scale), myocardial infarction, atrial fibrillation, intensive care, and hospital stay. We followed our patients for 1 year, clinically and angiographically, and compared the rate of graft occlusion. Results There was no statistical difference in the intraoperative hemodynamic and respiratory variables (mean arterial pressure, heart rate, and partial pressure of arterial carbon dioxide) between the two groups, except for the partial pressure of arterial oxygen, which was higher in group A because of mechanical ventilation. There was no intraoperative mortality or postoperative myocardial infarctions in both groups. There was no statistical difference in the operative time between the two groups, but the patients in group A received a higher number of grafts than those in group B. There was no statistical difference in the postoperative pain scores; the mean pain score was 1.425 ± 0.42 in group A and 1.29 ± 0.3 in group B. The rate of atrial fibrillation was higher in group B (17%) than group A (7.02%) (P = 0.025). The mean intensive care stay and the mean hospital stay were higher (2.77 ± 0.9 and 7.314 ± 2.8 days) in group A than group B (1.269 ± 0.4 and 3.743 ± 1.2 days) (P = 0.0038 and 0.0021, respectively). Follow-up through the first postoperative year with coronary angiography indicated vein graft occlusion in three patients of group A (1.23%) and one patient in group B (1.31%), but this was not statistically significant. Conclusion We successfully performed off-bypass coronary revascularization surgery, including multivessel disease, under combined general/epidural anesthesia and in awake patients with thoracic epidural anesthesia as the sole anesthetic technique. Patients who are considered at high risk for general anesthesia and/or prolonged endotracheal intubation were good candidates for the awake technique as a valid alternative.
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New-onset atrial fibrillation after coronary artery bypass grafting: A prospective study between off-pump and on-pump surgery
Mohamed S Mahmoud, Mohamed M Nabil Elsahfie, Waleed A.M. Al Taher, Hani Elgalab, Emad Sarawy
July-December 2013, 7(2):63-68
Background Atrial fibrillation (AF) is one of the most common complications after cardiac surgery. It occurs mostly between the second and the third postoperative day. The aim of this study was to compare the distribution of the incidence of AF between patients operated upon with the standard on-pump coronary artery bypass grafting (CABG) and off-pump CABG techniques. Materials and methods This was a prospective analysis of 173 patients with coronary artery disease operated upon at the Dar Al Fouad Hospital and the National Heart Institute. Eighty-five patients undergoing off-pump CABG were matched for age and number of distal anastomoses with another 88 patients undergoing on-pump CABG. The possible risk factors for postoperative new-onset AF were recorded. Results AF occurred in 42 (24.3%) of the 173 patients for whom data could be analyzed. AF occurred in 19 patients (22.4%) in the off-pump group versus 23 (26.14%) in the on-pump group, but this difference was not statistically significant. On univariate analysis, age and serum creatinine levels were found to be the significant risk factors for the occurrence of AF. In a multivariate analysis that included operative technique, age was found to be the only significant risk factor. Also, the length of hospital stay was significantly longer in the on-pump group (P < 0.05). Conclusion The occurrence of AF after CABG does not depend on the type of operation of CABG.
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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.
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