Dmitri Chamchad

Using heart rate variability to stratify risk of obstetric patients undergoing spinal anesthesia.

In this study, we evaluated whether point correlation dimension (PD2), a measure of heart rate variability, can predict hypotension accompanying spinal anesthesia for cesarean delivery. After the administration of spinal anesthesia with bupivacaine, hypotension was defined as systolic blood pressure ≤75% of baseline within 20 min of intrathecal injection. Using the median prespinal PD2 (3.90) to form 2 groups, LO and HI, all 11 hypotensive patients were in the LO group, and all 11 patients without hypotension were in the HI group. Baseline heart rate in the LO group was 95 bpm (10.2 sd), versus 81 bpm (9.6 sd) in the HI group. PD2 shows promise as a predictor of hypotension in pregnant women receiving spinal anesthesia.

Does Off-Pump Coronary Artery Bypass Reduce the Incidence of Clinically Evident Renal Dysfunction After Multivessel Myocardial Revascularization?

In this prospective, observational trial, we determined whether off-pump coronary artery bypass (OPCAB) was associated with less postoperative renal dysfunction (RD) compared with coronary bypass surgery with cardiopulmonary bypass (CABG). All patients undergoing primary, isolated coronary surgery at our institution in the year 2000 participated. Data collected on each patient included demographics, preoperative risk factors for RD, perioperative events, and serum creatinine concentrations from date of admission until discharge or death. The criteria for RD was both a ≥50% increase from preoperative creatinine and an absolute postoperative creatinine ≥2.0 mg/dL (177 &mgr;M). Student’s t-test or the Fisher’s exact test was used to compare groups. Stepwise multiple logistic regression identified determinants of RD; P < 0.05 significant. The CABG group (n = 119) differed from the OPCAB group (n = 220) with respect to age (64 ± 13 versus 67 ± 10 yr, P = 0.0074) and number of distal grafts (median 4 versus 3, P = 0.0003). Type of operation did not associate with the presence of postoperative RD: 18 (8.2%) of 220 OPCAB patients versus 12 (10%) of 119 CABG patients (P = 0.55). Our data suggest that choice of operative technique (OPCAB versus CABG) is not associated with reduced renal morbidity.

Nonlinear heart rate variability analysis may predict atrial fibrillation after coronary artery bypass grafting

BACKGROUND: Heart rate variability might predict arrhythmias after coronary artery bypass grafting. METHODS: Off-line processing of 10-min electrocardiogram recordings of consecutive patients provided R–R intervals for time domain, frequency domain, Poincaré, and point correlation analyses and subsequent association with postoperative atrial fibrillation by stepwise multivariate logistic regression. RESULTS: Of 88 patients who met entry criteria, 13 developed atrial fibrillation. Peak point correlation dimension (odds ratio 3.985/unit, P = 0.0096) and age (odds ratio 1.144/yr, P = 0.0019) were independently associated with atrial fibrillation (c-statistic = 0.839). CONCLUSIONS: Further study should confirm the ability of peak point correlation dimension to predict atrial fibrillation after coronary artery surgery with cardiopulmonary bypass.

Placenta percreta with invasion of the bladder wall: management with a multi-disciplinary approach.

Placenta percreta with pelvic organ invasion carries a high mortality for mother and fetus. Appropriate multidisciplinary consultation, strategy, and preoperative planning for Cesarean hysterectomy permitted caregivers to provide a maternal-infant bonding experience, surgical hemostasis, preservation of bladder function, and a healthy, vigorous neonate.

Heart rate variability measures poorly predict atrial fibrillation after off-pump coronary artery bypass grafting.

STUDY OBJECTIVE To investigate associations of heart rate variability (HRV) measurements with postoperative atrial fibrillation (AF) in patients undergoing off-pump coronary surgery. DESIGN Prospective, observational, exploratory study. SETTING Large university-affiliated community medical center. PATIENTS 50 patients undergoing off-pump coronary artery bypass grafting (CABG). INTERVENTIONS Preoperative recording of electrocardiograms (ECGs) with subsequent off-line HRV analysis. Monitored ECG telemetry for 5 days after operation. MEASUREMENTS Frequency and time domain analyses, and additional non-linear HRV determinations. Multivariate regression analysis of predictors of postoperative AF. MAIN RESULTS AF occurred in 23 (46%) patients. Only the low to high-frequency ratio was associated with AF (2.35 ± 1.8 v. 4.57 ± 5.0 for patients without AF, P < 0.05). CONCLUSIONS The off-pump approach does not protect against AF, and nonlinear HRV analyses provide little value in predicting AF after off-pump CABG.

Prophylactic glycopyrrolate prevents bradycardia after spinal anesthesia for Cesarean section: a randomized, double-blinded, placebo-controlled prospective trial with heart rate variability correlation

STUDY OBJECTIVE To determine if prophylactic glycopyrrolate prevents bradycardia after spinal anesthesia. DESIGN Prospective, randomized, double-blinded, placebo-controlled study. SETTING Large university-affiliated community hospital. PATIENTS 81 consecutive term parturients (not in active labor) who were scheduled for elective Cesarean section. INTERVENTIONS Parturients received 1.0 to 1.5 L of intravenous Ringers lactate and either glycopyrrolate 0.4 mg or an equal volume of saline, with caregivers blinded to the immediate sequelae of study drug. Each patient received intrathecal bupivacaine (12 to 14 mg) with morphine sulfate (0.1 to 0.2 mg). MEASUREMENTS Continuous heart rate (HR) and blood pressure monitoring occurred for 20 minutes, with the minimum HR recorded for each 5-minute epoch. Heart rates < 60 beats per minute defined bradycardia. Heart rate variability (HRV) analysis occurred offline. MAIN RESULTS None of 34 patients administered glycopyrrolate and 6 of 35 (17%) patients receiving saline experienced bradycardia (P = 0.02476). Time domain, frequency domain, and nonlinear and embedded spectrum entropy analyses all reflected the decrease in HRV accompanying administration of glycopyrrolate. CONCLUSION Bradycardia after spinal anesthesia occurs commonly. Prophylactic glycopyrrolate may prevent the bradycardia, but not necessarily the hypotension.

Spinal, but not epidural anesthesia, for pubic symphysis separation.

Anesthesia, for Pubic Symphysis Separation We cared for a 30-yr-old healthy primigravida patient whose pubic symphysis separated during active labor. We were able to relieve her pain with spinal anesthesia after failing to provide analgesia with epidural anesthesia. The patient had received an epidural catheter at L2-3, followed by continuous infusion of ropivacaine 0.2% and fentanyl 2 g/mL at 12 mL/h. Although she could not feel contractions, she was able to move her legs. Approximately 1.5 h after placing the epidural catheter, the patient described “the worst pain in my life” in her low pelvic area. Multiple boluses of 10 mL 2% lidocaine and insertion of a new epidural catheter at L4-5 failed to relieve the pain. The obstetricians ruled out full bladder, placental detachment, and uterine rupture. When the patient assumed the lateral position, the pain intensified from pressure over the iliac crests, suggesting a diagnosis of symphysis pubis separation (Fig. 1). We inserted a 19-gauge spinal catheter (FlexTip Plus; Arrow International, Reading, PA) at L3-4 and delivered 1 mL 0.5% bupivacaine and 12.5 g fentanyl. Within several seconds, the patient reported her pain had disappeared. We maintained pain relief with a continuous infusion of 0.2% ropivacaine and 2 g/mL fentanyl at 3–4 mL/h. Forceps delivery occurred 100 min later. We administered morphine 0.2 mg intrathecally for postpartum analgesia before removing the spinal catheter. Postdural puncture headache did not occur. Pubic symphysis separation can arise from trauma, very rapid labor, cephalopelvic disproportion, epidural anesthesia, the “McRobert maneuver,” or previous symphyseal rupture (1–4). The sole reference describing epidural anesthesia during or after pubic symphysis separation (5) reports inadequate pain relief from epidural anesthesia. In our case, spinal anesthesia succeeded where well-functioning epidural anesthetics failed, perhaps because intrathecal anesthetic allows better access to the somatic fibers originating in the sacral plexus (S1-4). Further study in models of osteal pain may elucidate the disparate results of spinal and epidural anesthesia. For patients who report a sudden onset of severe pain during labor, we recommend considering a diagnosis of pubic symphysis separation, confirmed with a radiograph. If this occurs, epidural anesthesia may prove ineffective, and prompt placement of a spinal anesthetic may provide rapid pain relief.

Hypercoiling of the umbilical cord in uncomplicated singleton pregnancies

Abstract Background: The umbilical coiling index (UCI) is a measure of the number of coils in the umbilical cord in relation to its length. Hypercoiled cords with a UCI of >0.3 coils/cm have been associated with adverse fetal and neonatal outcomes. Aims: The primary aim is to determine the accuracy of UCI measured on second trimester ultrasound in predicting UCI at birth. The secondary outcome is to investigate the association between hypercoiling of the umbilical cord on prenatal ultrasound and adverse maternal, fetal and neonatal outcomes. Methods: This was a prospective cohort study of uncomplicated singleton pregnancies. Seventy two patients were included in the study. UCI was measured in the second trimester ultrasound, and compared to UCI measured postnatally. Outcomes of patients with hypercoiled cords on ultrasound were compared to outcomes of patients with normocoiled cords. Results: Our results failed to show a strong correlation between the UCI determined with ultrasound, and the UCI determined with examination of the umbilical cord after delivery. We also did not demonstrate that measurement of the UCI on second trimester ultrasound is able to predict adverse maternal, fetal or neonatal outcomes. Conclusion: This study suggests that measurement of the umbilical coiling index should not be part of routine second trimester sonography in patients with uncomplicated singleton pregnancies, with no other medical or surgical comorbidities.