Rajiv Juneja

Nonanalgesic benefits of combined thoracic epidural analgesia with general anesthesia in high risk elderly off pump coronary artery bypass patients.

Objective: Epidural anesthesia is a central neuraxial block technique with many applications. It is a versatile anesthetic technique, with applications in surgery, obstetrics and pain control. Its versatility means it can be used as an anesthetic, as an analgesic adjuvant to general anesthesia, and for postoperative analgesia. Off pump coronary artery bypass (OPCAB) surgery triggers a systemic stress response as seen in coronary artery bypass grafting (CABG). Thoracic epidural anesthesia (TEA), combined with general anesthesia (GA) attenuates the stress response to CABG. There is Reduction in levels of Plasma epinephrine, Cortisol and catecholamine surge, tumor necrosis factor-Alpha(TNF ά), interleukin-6 and leucocyte count. Design: A prospective randomised non blind study. Setting: A clinical study in a multi specialty hospital. Participants: Eighty six patients. Material and Methods/intervention: The study was approved by hospital research ethics committee and written informed consent was obtained from all patients. Patients were randomised to receive either GA plus epidural (study group) or GA only (control group). Inclusion Criteria (for participants) were -Age ≥ 70 years, Patient posted for OPCAB surgery, and patient with comorbidities (diabetes mellitus, chronic obstructive pulmonary disease, cerebrovascular disease, peripheral vascular disease, renal dysfunction). Serum concentration of Interlukin: – 6, TNF ά, cortisol, Troponin – I, CK-MB, and HsCRP (highly sensitive C reactive protein), was compared for both the group and venous blood samples were collected and compared just after induction, at day 2, and day 5 postoperatively. Time to mobilization, extubation, total intensive care unit stay and hospital stay were noted and compared. Independent t test was used for statistical analysis. Primary Outcomes: Postoperative complications, total intensive care unit stay and hospital stay. Secondary Outcome: Stress response. Result: Study group showed decreased Interlukin – 6 at day 2, TNF ά at day 2 and 5, troponin I at day 5, and decreased total hospital stay (p < 0.05). Conclusion: Thoracic epidural anesthesia decreases stress and inflammatory response to surgery and decreases hospital stay. However a large multicentre study may be needed to confirm it.

Off-pump cardiac surgery (OPCAB) in a patient with recent leech therapy

I read a recent publication on coronary artery bypass grafting and dengue fever with a great interest,[1] in which Trehan et al. had concluded that the presence of dengue should be kept in mind in any postoperative patient with unexplained thrombocytopenia.[1] However, I have some concerns regarding this work. Although there is no doubt that the case discussed was of dengue hemorrhagic fever, it should have been kept in mind that there are many similar infections that can cause thrombocytopenia with fever. The other diseases that can cause fever and thrombocytopenia in the postoperative period includes Chikungunya fever (common), Congo-Crimean hemorrhagic fever (rare), Omsk hemorrhagic fever (rare), and Kyasanur forest disease (rare).[2] Besides, in this case report, focus should have been more on the source of infection. The case was a postoperative case, and hence the source of infection should have been within the hospital. Thus, it might have been a nosocomial infection case. If this is true, then it is a very big problem. The mosquito control within the hospital is very important for the area of endemic mosquito-borne diseases.

Cardiomyopathies and anaesthesia

Cardiomyopathy is considered as a heart muscle disease of multiple aetiologies, unlike other cardiac diseases related to a definitive pathophysiology. With more and more research and with the advent of genetic analysis pin pointing the disease causing mutations, causative factors have been defined and classifications and definitions have changed over time. Patients with these conditions present to anaesthesiologists in elective and emergency situations, placement of automated internal cardioverter defibrillator (AICD) devices or biventricular pacing but may also be diagnosed at anaesthetic pre-assessment. We describe cardiomyopathies such as dilated cardiomyopathy, hypertrophic cardiomyopathy, post-partum cardiomyopathy and Takotsubo cardiomyopathy in brief and their anaesthetic management.

Motor stereotypy after cardiac surgery.

From the *Medanta Institute of Critical Care and Anesthesiology, Medanta, The Medicity, Haryana, India; and yDiplomate of the American Board of Cardiothoracic Surgery. Address reprint requests to Yatin Mehta, Medanta Institute of Critical Care and Anesthesiology, Medanta The Medicity, Sector 38, Gurgaon, Haryana-122001, India. E-mail: yatinmehta@hotmail.com & 2014 Elsevier Inc. All rights reserved. 1053-0770/2605-0031

Changes in transfusion therapy guided by thromboelastograph in cardiac surgery.

36.00/0 http://dx.doi.org/10.1053/j.jvca.2013.01.030