Bhupesh Kumar

Comparative Effect of Levosimendan and Milrinone in Cardiac Surgery Patients With Pulmonary Hypertension and Left Ventricular Dysfunction

OBJECTIVE To compare the effects of levosimendan with milrinone in cardiac surgical patients with pulmonary hypertension and left ventricular dysfunction. DESIGN A prospective, randomized study. SETTING Tertiary care teaching hospital. PARTICIPANTS The study included patients with valvular heart disease and pulmonary artery hypertension undergoing valve surgery. INTERVENTIONS Forty patients were allocated randomly to receive either milrinone, 50 µg/kg bolus followed by infusion at a rate of 0.5 µg/kg/min (group 1), or levosimendan, 10 µg/kg bolus followed by infusion at a rate of 0.1 µg/kg/min (group 2) for 24 hours after surgery. MEASUREMENTS AND MAIN RESULTS Hemodynamic parameters were measured using a pulmonary artery catheter, and biventricular functions were assessed using echocardiography. Mean pulmonary artery pressures and the pulmonary vascular resistance index were comparable between the 2 groups at several time points in the intensive care unit. Biventricular function was comparable between both groups. Postcardiopulmonary bypass right ventricular systolic and diastolic functions decreased in both groups compared with baseline, whereas 6 hours postbypass left ventricular ejection fraction improved in patients with stenotic valvular lesions. Levosimendan use was associated with higher heart rate, increased cardiac index, decreased systemic vascular resistance index, and increased requirement of norepinephrine infusion compared with milrinone. CONCLUSIONS The results of this study demonstrated that levosimendan was not clinically better than milrinone. Levosimendan therapy resulted in a greater increase in heart rate, decrease in systemic vascular resistance, and a greater need for norepinephrine than in patients who received milrinone.

Effect of continuous paravertebral dexmedetomidine administration on intraoperative anesthetic drug requirement and post thoracotomy pain syndrome after thoracotomy: A randomized controlled trial

OBJECTIVES To assess the effect of paravertebral administration of dexmedetomidine as an adjuvant to local anesthetic on the intraoperative anesthetic drug requirement and incidence of post-thoracotomy pain syndrome. DESIGN Prospective, randomized, controlled, double-blind trial. SETTING Single university hospital. PARTICIPANTS The study comprised 30 patients who underwent elective thoracotomy and were assigned randomly to either the Ropin or Dexem group (n = 15 each). INTERVENTIONS All patients received the study medications through paravertebral catheter. Patients in the Ropin group received a bolus of 15 mL of 0.75% ropivacaine over 3-to-5 minutes followed by an infusion of 0.2% ropivacaine at 0.1 mL/kg/hour. Patients in the Dexem group received 15 mL of 0.75% ropivacaine plus dexmedetomidine, 1 µg/kg bolus over 3-to-5 minutes followed by an infusion of 0.2% ropivacaine plus 0.2 µg/kg/hour of dexmedetomidine at 0.1 mL/kg/hour. MEASUREMENTS AND MAIN RESULTS The primary outcome of the study was intraoperative anesthetic drug requirement. The secondary outcome was the incidence of post-thoracotomy pain syndrome 2 months after surgery. The amount of propofol required for induction of anesthesia was significantly less in the Dexem group (Dexem 49.33±20.51 v 74.33±18.40 in the Ropin group, p = 0.002). End-tidal isoflurane needed to maintain target entropy was significantly less in the Dexem group at all time points. Intraoperative fentanyl requirement was lower in the Dexem group (Dexem 115.33±33.77 v 178.67±32.48 in the Ropin group, p = 0.002). Postoperative pain scores and morphine consumption were significantly less in the Dexem group (p<0.001). The incidence of post-thoracotomy pain syndrome was comparable between the 2 groups (69.23% v 50%, p = 0.496). CONCLUSIONS Paravertebral dexmedetomidine administration resulted in decreased intraoperative anesthetic drug requirement, less pain, and lower requirements of supplemental opioid in the postoperative period. However, it had no effect on the incidence of post-thoracotomy pain syndrome.

Management of Pseudohypoparathyroidism Type 1a during Pregnancy and Labor: A Case Report

Pseudohypoparathyroidism is rare during pregnancy and poses multiple challenges related to its diagnosis and management during pregnancy. We hereby report a case of a young woman who was diagnosed to have type 1a pseudohypoparathyroidism. She was managed by multidisciplinary team and had good maternal and perinatal outcome. Management-related issues are discussed here in detail.

Evaluation of the Effect of Aneurysmal Clipping on Electrocardiography and Echocardiographic Changes in Patients With Subarachnoid Hemorrhage: A Prospective Observational Study.

Background: Electrocardiographic (ECG) and echocardiographic changes that are subsequent to aneurysmal subarachnoid hemorrhage (a-SAH) are commonly observed with a prevalence varying from 27% to 100% and 13% to 18%, respectively. There are sparse data in the literature about the pattern of ECG and echocardiographic changes in patients with SAH after clipping of the aneurysm. Hence, we observed the effect of aneurysmal clipping on ECG and echocardiographic changes during the first week after surgery, and the impact of these changes on outcome at the end of 1 year. Materials and Methods: This prospective, observational study was conducted in 100 consecutive patients with a-SAH undergoing clipping of ruptured aneurysm. ECG and echocardiographic changes were recorded preoperatively and every day after surgery until 7 days. Outcome was evaluated using the Glasgow outcome scale at the end of 1 year. Results: Of 100 patients, 75 had ECG changes and 17 had echocardiographic changes preoperatively. The ECG changes observed were QTc prolongation, conduction defects, ST-wave and T-wave abnormalities, tachyarrhythmias, and bradyarrhythmias. The echocardiography changes included global hypokinesia and regional wall motion abnormalities. Both echocardiographic and ECG changes showed significant recovery on the first postoperative day. Patients presenting with both echocardiographic and ECG changes were found to require higher ionotropic support to maintain the desired blood pressure, and were associated with poor outcome (Glasgow outcome scale, 1 to 2) at 1 year after surgery. There was no association of ECG and echocardiographic changes with mortality (both in-hospital or at 1 year). Conclusions: The ECG changes, such as QTc prolongation, bradycardia, conduction abnormality, and echocardiographic changes, recover on postoperative day-1, in most of the cases after clipping. Patients with combined ECG and echocardiographic changes tend to have poor neurological outcome at the end of 1 year.

Utility of Sonoclot in Prediction of Postoperative Bleeding in Pediatric Patients Undergoing Cardiac Surgery for Congenital Cyanotic Heart Disease: A Prospective Observational Study

OBJECTIVES To assess the utility of Sonoclot in prediction of postoperative bleeding in pediatric patients undergoing cardiac surgery with cardiopulmonary bypass for congenital cyanotic heart disease. DESIGN Prospective, observational study. SETTING Single university hospital. PARTICIPANTS Eighty-seven pediatric patients undergoing cardiac surgery for congenital cyanotic heart disease. INTERVENTIONS Laboratory coagulation parameters (prothrombin time, international normalization ratio, activated partial thromboplastin time, fibrinogen, D-dimer) as well as point-of-care Sonoclot glass bead activation time, clot rate, and platelet function (gbPF) were done before induction of anesthesia and following heparin reversal after termination of cardiopulmonary bypass (CPB) in all patients. MEASUREMENTS AND MAIN RESULTS Postoperative blood loss was monitored by the amount of chest tube drainage. The primary outcome was to define Sonoclot parameters for prediction of postoperative bleeding. Secondary outcomes studied were amount of postoperative blood loss, transfusion requirement of various blood products, incidence of surgical re-exploration, duration of postoperative mechanical ventilation, intensive care unit and hospital stay. Among studied subjects, 37.9% (33 of 87 patients) were designated as bleeders while 62.1% (54 of 87 patients) were non-bleeders. Lower age, D-dimer, and gbPF test after termination of CPB following heparin neutralization were predictive for postoperative bleeders. Among these, post-protamine gbPF had the highest area under the curve (0.725), 95% confidence interval (0.619-0.831) for prediction of postoperative bleeders. Duration of mechanical ventilation (26.41±36.44 v 8.25±6.36 h, respectively, p = 0.001), intensive care unit stay (7.36 ± 4.05 v 4.96 ± 2.49, p = 0.001), and hospital stay (11.69±4.82 v 8.63±3.48 p = 0.001) were higher in bleeders; however, incidence of re-exploration was comparable between both groups. CONCLUSION Postoperative bleeders may be predicted independently by post-CPB gbPF, postoperative D-dimer, and lower age of patients. Among these, post-CPB gbPF has maximum predictive value.

Left atrial myxoma, ruptured chordae tendinae causing mitral regurgitation and coronary artery disease.

Mitral regurgitation is uncommon with left atrial myxoma. The echocardiographic assessment of presence of mitral regurgitation and its severity are impaired by the presence of left atrial myxoma. We describe an uncommon association of left atrial myxoma with coronary artery disease and mitral regurgitation. MR was reported as mild on pre-operative transthoracic echocardiography but found to be severe due to ruptured chordae tendinae during intra-operative transesophageal echocardiography, which lead to change in the surgical plan to mitral valve replacement in addition to excision of myxoma.

CASE 4—2013 Large Ascending Aortic and Arch Aneurysm: An Unusual Cause of Preoperative Airway Compromise

Graduate Institute of Medical Education India; and †Department of Cardiothoraci Pant Hospital, New Delhi, India. Address reprint requests to Dr Bhupesh Department of Anaesthesia and Intensive of Medical Education and Research, C bhupeshkr@yahoo.com

A comparison of 3% saline and mannitol for brain relaxation during elective supratentorial brain tumor surgery.

1. Topatan B, Basaran A. Imaging during pregnancy: computed tomography pulmonary angiography versus ventilation perfusion scintigraphy. Anesth Analg 2011:112:484 2. Hurwitz LM, Reiman RE, Yoshizumi TT, Goodman PC, Toncheva G, Nguyen G, Lowry C. Radiation dose from contemporary cardiothoracic multidetector CT protocols with an anthropomorphic female phantom: implications for cancer induction. Radiology 2007;245:742–50 3. Cahill AG, Stout MJ, Macones GA, Bhalla S. Diagnosing pulmonary embolism in pregnancy using computedtomographic angiography or ventilation-perfusion. Obstet Gynecol 2009;114:124 –9 4. Ridge CA, McDermott S, Freyne BJ, Brennan DJ, Collins CD, Skehan SJ. Pulmonary embolism in pregnancy: comparison of pulmonary CT angiography and lung scintigraphy. AJR Am J Roentgenol 2009;193:1223–7 5. Scarsbrook AF, Evans AL, Owen AR, Gleeson FV. Diagnosis of suspected venous thromboembolic disease in pregnancy. Clin Radiol 2006;61:1–12 6. Hayashino Y, Goto M, Noguchi Y, Fukui T. Ventilationperfusion scanning and helical CT in suspected pulmonary embolism: meta-analysis of diagnostic performance. Radiology 2005;234:740–8 7. Winer-Muram HT, Boone JM, Brown HL, Jennings SG, Mabie WC, Lombardo GT. Pulmonary embolism in pregnant patients: fetal radiation dose with helical CT. Radiology 2002;224:487–92 8. Gottschalk A, Stein PD, Goodman LR, Sostman HD. Overview of prospective investigation of pulmonary embolism diagnosis II. Semin Nucl Med 2002;32:173–82 DOI: 10.1213/ANE.0b013e3181fe7aea

Anesthetic management for surgical repair of Ebstein's anomaly along with coexistent Wolff-Parkinson-White syndrome in a patient with severe mitral stenosis

Ebsteins anomaly (EA) is the most common cause of congenital tricuspid regurgitation. The associated anomalies commonly seen are atrial septal defect or patent foramen ovale and accessory conduction pathways. Its association with coexisting mitral stenosis (MS) has uncommonly been described. The hemodynamic consequences and anesthetic implications, of a combination of EA and rheumatic MS, have not so far been discussed in the literature. We report successful anesthetic management of a repair of EA and mitral valve replacement in a patient with coexisting Wolff-Parkinson-White (WPW) syndrome.

Tricuspid valve straddling: An uncommon cause of left ventricular outflow tract obstruction in transposition of great artery with ventricular septal defect

Transposition of great arteries (TGA) can be associated with left ventricle outflow tract (LVOT) obstruction. In the presence of ventricular septal defect (VSD), septal leaflet of tricuspid valve may prolapse through perimembranous VSD or rarely tricuspid valve tissue may override to produce LVOT obstruction. Occasionally, this may be mistaken for vegetation due to associated pulmonary valve endocarditis. We report a case of d-TGA with presumptive pulmonary valve endocarditis and LVOT obstruction that was found to be due to tricuspid valve straddling on transesophageal echocardiography, resulting in change in the surgical plan and thus avoiding catastrophe.