Annals of Cardiac Anaesthesia

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Atrial entrapment of flow directed pulmonary artery catheter-a technique for non-surgical removal.
(1998-01-11) Vakamudi, M; Ramakrishnan, T V; Rao, S; Acharya, D; Kamat, V; Srinivasa, S K; Saldana, R; Balakrishnan, K R
A 43 year old patient who underwent mitral valve replacement had pulmonary artery catheter inserted before induction of anaesthesia. The catheter could no be removed postoperatively by routine manoeuvres in the intensive care unit. Fluoroscopy in the cardiac catheterization revealed a straight course of the catheter indicating the probability of its inclusion in the left atrial suture line. The pulmonary artery catheter was successfully removed percutaneously in the cardiac catheterization laborartory. The procedure is described.
Bacteriological Profile of Patients Undergoing Open Heart Surgery and Evaluation of a Bacterial Filter using Protected Broncho-Alveolar Lavage.
(1998-01-11) Tempe, D K; Mehta, N; Mishra, B; Tondon, M S; Tomar, A S; Budharaja, P; Nigam, M
Twenty seven patients undergoing elective open heart surgery were included in this prospective study. They were randomly divided into two groups. Group C (n = 12) constituted the control group in whom no breathing filter was used in the anaesthesia circuit in the operating room or in the ICU. Humidification of breathing gases was achieved with the help of conventional heated humidifier. In group F (n = 15), heat and moisture exahanging bacterial / viral filter was incorporated in the breathing circuit at the patient end between the catheter mount and Y connection of the breathing circuit. In both the groups, samples of throat swab, protected broncho-alveolar lavage with double catheter and Ryles tube aspirate were collected preoperatively (in the operation theatre) and postoperatively (in the Intensive Care Unit on day 1). All the samples were sent to the laboratory immediately after the collection for Gram staining and culture and sensitivity. Pathogenic organisms were isolated from a total of 9 patients (33%) preoperatively. Exogenous spread of the organisms to the lungs was considered to have occurred if new pathogenic organisms were isolated from the postoperative bronchoalveolar lavage and the simultaneous samples of the throat swab and Ryles tube did not contain the same organism. By this definition, the exogenous spread of the organisms occurred in one patient in group C and in no patient in group F (P = 0.46, Fishers test). The commonest organisms isolated were Staphylococcus aureus, Klebsiella sp. and Pseudomonas sp. We conclude that colonization of the pathogenic organisms is common (33%) in orophrynx and gastrointestinal tract in hospitalized patients. There was no difference in the exogenous spread of the organisms between the two groups. The unity of the filter, therefore, appears to be limited to prevent contamination of anaesthesia machines or ventilators as has been shown by earlier studies.
Intraoperative echocardiography as a routine adjunct in assessing repair of congenital heart defects: experience with 300 cases.
(1998-01-11) Kaushal, S K; Dagar, K S; Singh, A; Kumar, K; Radhakrishnan, S; Girotra, S; Shrivastava, S; Iyer, K S
Utility of intraoperative echocardiography (IOE) in perioperative management of congenital heart disease has been reported in literature. However, its consistent use as a monitoring tool has not yet been reported from our country. The aim of this study was to evaluate the role of routine use of IOE for intraoperative assessment of surgical repairs in terms of residual shunt, residual gradient, valvular insufficiency and ventricular function. Three hundred consecutive patients above 3 Kg body weight were included in this study. In 152 patients epicardial and in 148 patients transoesophageal echocardiography (TEE) was performed intraoperatively. Age ranged from 4 months to 52 years (median 5.8 yrs) and body weight from 3 Kg to 62 Kg (Median 12 Kg). IOE Doppler and Doppler colour flow imaging studies were performed before cardiopulmonary bypass (CPB) whenever feasible and after CPB in all patients. Pre-bypass examination yielded additional information in 17 (5.6%) patients. In 9 (3%) such patients it had an impact on surgery. In post CPB IOE studies, surgery was found to be 'perfect' in 210 (70%) patients and 'acceptable' residual defects in 70 (23.3%) patients. In 20 (6.6%) cases post CPB IOE found surgical repair 'unacceptable'. Ten of these patients required immediate surgical revision with excellent outcome, thus saving them from late reoperation or postoperative complications. No short term complications were encountered relating to the procedure. We conclude that intraoperative echocardiography is an inexpensive, accurate, valuable and safe addition to the perioperative care of patients and should be mandatory during all corrective surgical procedures for congenital heart disease. It is especially applicable in our country where the costs of reoperation for residual defects are prohibitive.
Transmyocardial Laser Revascularisation: The last hope for refractory angina sufferers? A new challenge for the cardiac anaesthetist.
(1998-01-11) Vuylsteke, A; Mur, D; Gray, S; Mackay, J; Latimer, R D
Anaesthetic management of acquired non malignant tracheo-oesophageal fistula.
(1998-01-11) Soundaravalli, B; Thomas, J; Sundar, R; Chandrasekar, P; Krishnan, E; Muralidharan, S
Acquired non malignant tracheo-oesophageal fistula is an uncommon complication of endotracheal intubation and tracheostomy. Patients are usually diagnosed while on mechanical ventilation. The rationale of management is to prevent pulmonary contamination, maintain nutrition and achieve spontaneous ventilation prior to surgical repair. Cautious management of the airway is required during tracheal reconstruction. We present a case of non malignant tracheo-oesophageal fistula in which repair was achieved by primary closure of the tracheal and oesophageal defects.
Clinical evaluation of the leukogard-6 arterial line filter.
(1998-01-11) Juneja, R; Mehta, Y; Dhar, A; Swaminathan, M; Trehan, N
To assess the leucocyte depleting characteristics of the Pall leukogard-6 arterial line leucocyte depleting filter, it was incorporated in the extracorporeal circuit of 30 patients with normal left ventricular function scheduled for elective coronary artery bypass grafting. The Intersept Medtronic 40 micro arterial line filter which is normally used at our centre was used in 29 similar patients. Blood samples were drawn for estimation of total and differential leucocyte and platelet counts, blood gas analysis, superoxide dismutase levels and renal function tests at various time points. Ventilation time, length of ICU stay and incidence of infection were recorded. No significant difference was observed between the two groups regarding total leucocyte count, percentage of neutrophils and lymphocytes, platelet count, arterial oxygen and carbon dioxide tensions, pulmonary vascular resistance, ventilation time and postoperative infection. A significant difference was observed between the prebypass levels of superoxide dismutase 89.63 +/- 49.69 SOD units/ml, and 24 hours post bypass levels 66.62 +/- 36.23 SOD units/ml, (p<0.01), in the control group. In the leukogard filter group, the difference between pre bypass levels of superoxide dismutase 82.47 +/- 50.58 SOD units/ml and 24 hours post bypass 73.44 +/- 41.10 SOD units/ml, (p>0.05), was not significant. This indicated less free radical activity in the leukogard filter group, but this beneficial effect of the leukogard-6 filter did not correlate with any clinical parameter. In this study, the leukoard-6 filter did not exhibit leucocyte depleting characteristics following cardiopulmonary bypass and is unlikely to be of significant advantage when incorporated in the extracorporeal circuit for coronary artery bypass grafting, in patients with normal ejection fraction.
Anaesthetic management of a patient undergoing whole lung lavage for pulmonary alveolar proteinosis.
(1998-01-11) Gandhe, U; Gandhe, R; Nandkumar, S; Butani, M
Pulmonary alveolar proteinosis is a rare disorder characterized by accumulation of amorphous, acellular and lipoproteinaceous material in the lungs. We discuss the anaesthetic management of a patient suffering from this condition who was treated whole lung lavage.
Editorial.
(1998-01-11) Mehta, Y
ICU management of blunt chest trauma: our experience.
(1998-01-11) Rao, P M; Puri, G D; Bharadwaj, N; Chari, P; Acup, D
Blunt chest tramma is a major cause of mortality and morbidity following road side accident. An understanding of the factors affecting the mortality and morbidity will help in formulating better management strategies. The records of 40 consecutive patients presenting with blunt chest trauma (BCT) requiring ICU care from 1994-1996 were reviewed. Flail chest was the most common chest injury seen in 35 patients (87.5%). Isolated flail chest was seen in 22 patients, isolated pulmonary contusion in 2 patients and a combined injury in 13 patients. Ventilatory assistance was required in 34 patients (85%) for an average duration of 16 days (range 2-43 days). All patients with anterior flail required assisted ventilation in contrast to 75% and 88% of patients with unilateral and bilateral flail respectively. Presence of pulmonary contusion with or without flail was also associated with a high incidence of ventilatory support requirement. Chest infection (pneumonia) was the most common complication seen (65%). Adverse outcome occurred in 12 patients (30%). The main contributing factors for increased morbidity and mortality were: associated pulmonary contusion, associated extrathoracic injuries and preexisting medical illness. Statistical significance was observed only with pulmonary contusion.
Anaesthesiologist in the net.
(1998-01-11) Swaminathan, M
Neurologic injury after cardiac surgery.
(1998-01-11) Murkin, J M
Emergency mitral valve replacement for traumatic mitral insufficiency following balloon mitral valvotomy: an early haemodynamic study.
(1998-07-12) Tempe, D K; Mehta, N; Mohan, J C; Tandon, M S; Nigam, M
Acute severe mitral insufficiency may occur during percutaneous transvenous balloon mitarl valvotomy. Urgent surgical intervention in the form of mitral valve repair or replacement may be necessary in these patients. The haemodynamic measurements at various stages in these patients were obtained and compared with those of patients undergoing elective mitral valve replacement for chronic mitral regurgitation. Between September 1995 and December 1947, urgent mitral valve replacement was performed in 14 patients out of a total of 1688 patients who underwent balloon mitral valvotomy. Haemodynamic measurements could be obtained in 7 of these patients and they constituted group I. Eight other patients undergoing elective mitral valve replacement during the same period for chronic mitral regurgitation constituted group II. Standard haemodynamic measurements were obtained at the following stages: (1) Baseline- 20-30 min after endotracheal intubation; (2) stage 1- 20-30 min after termination of the cardiopulmonary bypass: (3) stage 2- four hours after the patient was transferred to ICU and (4) stage 3-30 min after extubation. All the patients were suffering from severe pulmonary hypertension. However, the indices of pulmonary artery hypertension such as mean pulmonary artery pressure, pulmonary capillary wedge pressure, pulmonary vascular resistance as well as right ventricular systolic and end-diastolic pressures did not decrease after surgery in group I. In contrast, in group II, there was significant decrease in mean pulmonary artery pressure (p<0.05), pulmonary capillary wedge pressure (p<0.05), right ventricular systolic (p<0.001) and end-diastolic pressures (p<0.05) at stage 1. These changes persisted throughout the study period. Pulmonary vascular resistance showed a decreasing trend, but attained statistical significance at stage 1 only. Two patients died; one of intractable cardiac failure and another from septicaemia and multiple organ failure in group I, but there were no deaths in group II. Reactive pulmonary hypertension secondary to acute mitral regurgitation may not recover immediately following mitral valve replacement and may be responsible for poor outcome in these patients.
The inflammatory response to extracorporeal circulation.
(1998-07-12) Tonneson, E; Toft, P; Brix-Christensen, V
Oxygenation of crystalloid cardioplegia.
(1998-07-12) Puri, G D; Krishna, P; Chari, P; Singh, G J
A simple economical apparatus for oxygenation of cold crystalloid cardioplegic solutions is presented. It is sterile, practically feasible for use in open heart surgery, provides a PO2 of 98.7 kPa and sustains it for a period of more than 20 minutes.
Suppression of the inflammatory response to cardiopulmonary bypass.
(1998-07-12) Pardeshi, S R; Mandke, A N; Mandke, N V
The inflammatory response to major surgery, especially cardiac surgery using cardiopulmonary bypass (CPB) is now a well established entity. A whole body inflammatory response can lead to severe organ dysfunction, postoperative bleeding disorders, respiratory distress syndrome and sometimes death. There is, however, controversy over various methods and their efficacy towards suppression of this response. We studied forty consecutive patients undergoing coronary artery bypass grafting (CABG) using CPB. Ten patients in group A served as control while ten patients in group B received piroxicam, a non steroidal anti-inflammatory drug (NSAID). Ten patients in group C received aprotinin, a kallikrein inhibitor and ten patients in group D underwent haemofiltration during CPB. Inflammatory response by way of increase in total white blood cell (WBC) count (p<0.007), decrease in lymphocyte count (p<0.005), increase in C-reactive protein (CRP, p <0.005) was observed in all four groups at 24 hour after CPB. A decrease in complement C3 and C4 (p<0.01) was observed in groups A and C at 24 hours after CPB. The response observed was not severe enough to cause any organ damage in any group. None of the methods studied could effectively suppress the inflammatory response to CPB but the response was altered in some way by each method.
An unusual case of steep rise of blood glucose during cardiopulmonary bypass.
(1998-07-12) Bhojraj, S
Disturbances of blood glucose insulin relationships have been repeatedly observed during and after cardiac surgery. We report a case where a blood sugar level of 2000 mg/dl was encountered after commencement of cardiopulmonary bypass and discuss its management.
Role of Preoperative Upper Gastrointestinal Endoscopy in Preventing postoperative Upper Gastrointestinal Bleed in Patients Undergoing CABG.
(1998-07-12) Setya, A K; Mehta, Y; Kshatriya, M; Trehan, N
One hundred and three patients (Group A), mean age 55.81 +/- 8.54 years, 94 males and 9 females, scheduled for coronary artery bypass graft (CABG) surgery were subjected to preoperative upper gastro-intestinal (UGI) endoscopy. 51.5% of these were found to have significant mucosal lesions in the UGI tract. Twenty one (20.4%) had severe lesions which could have bled, warranting postponement of their surgery. All of these 21 were treated with Omeprezole 20 mg / day for a mean of 35.87 +/- 4.64 days and subjected to check endoscopy after the treatment. 16 of these 21 patients were taken up for CABG after the lesions had healed. Five deferred surgery. None of the 103 patients had a postoperative UGI bleed. A retrospective analysis of 1274 patients (group B) was carried out for number of patients (42) having postoperative UGI bleed. The results of group A and group B were then compared. Patients in group A had significant lower incidence of postoperative UGI bleed than those in group B. Postoperative hospital stay in patients of UGI bleed in group B was 24.71 +/- 20.88 (range 8 days - 129 days). In group A it was 14.34 +/- 12.44 days (range 7 days - 88 days). The difference is statistically highly significant. It appears that patients who have postoperative UGI bleed probably bleed from pre existing lesions. We conclude that preoperative UGI endoscopy is a valuable tool in preventing postoperative UGI bleed.
Anaesthesiologist in the net.
(1998-07-12) Swaminathan, M
The Internet is expanding very rapidly with more people joining hands and minds everyday. The encouraging news is that a lot of these people are medical professionals. This makes for a scientific community with better interaction and understanding of problems relating to health care. As anaesthesiologists, we are at an advantage that our discipline allows maximal interaction with related subjects like paediatrics, critical care, pulmonology, cardiology and emergency medicine. This article will deal with some interesting websites relating mainly to fields associated with cardiovascular anaesthesia.
Other uses of tube changer.
(1998-07-12) Jacob, R; Subash, P N; Immanuel, A; George, S P
Traditionally major surgical procedures are contemplated in tracheobronchial pathology as the first line of management. Efficient and skillful use of airway equipment can help in the management and prevention of significant perioperative morbidity. Three cases of airway pathology (tracheal stenosis, bronchial stenosis and tracheal tumour) which were managed with the help of airway equipment such as fibreoptic bronchoscope, Cook's and Patil tube changers are presented. The techniques are simple and safe and may help the surgeons to 'buy' time to plan definitive treatment.
Cardiovascular morbidity association with surgery: perspectives and new findings.
(1998-07-12) Mangano, D T

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