Sandeep Chauhan

Comparison of three dose regimens of aprotinin in infants undergoing the arterial switch operation

To determine the most effective dose regimen of aprotinin for infants undergoing arterial switch operation for transposition of the great arteries in reducing blood loss and postoperative packed red blood cell (PRBC) requirements. A total of 24 infants scheduled for arterial switch operation for transposition of the great arteries were included in the study. The infants were randomly assigned to one of the three groups. Group I (n = 8) patients received aprotinin in a dose of 20,000 kallikrein inhibiting units (KIU)/kg after induction of anesthesia, 20,000 KIU/kg was added to the pump prime, and 20,000 KIU/kg/hour infusion for three hours after weaning from bypass; group II (n = 8) patients received aprotinin 30,000 KIU/kg after induction of anesthesia, 30,000 KIU/kg was added to the pump prime and 30,000 KIU/Kg/hour infusion for three hours after weaning from bypass; group III patients (n = 8) received aprotinin 40,000 KIU/kg after induction of anesthesia, 40,000 KIU/kg was added to the pump prime and 40,000 KIU/kg/hour infusion for three hours after weaning from bypass. Postoperatively, the cumulative hourly blood loss and PRBC requirements were noted up to 24 hours from the time of admission in the intensive care unit (ICU). Use of blood and blood products were noted. Coagulation parameters such as hematocrit, activated clotting time (ACT), fibrinogen, prothrombin time (PT), international normalized ratio (INR), platelet count, and fibrin degradation products (FDP) were investigated before cardiopulmonary bypass (CPB), after protamine administration, and at four hours postoperatively in the ICU. The number of infants reexplored for increased mediastinal drainage was recorded. Renal functions were monitored by measuring urine output (hourly) and serum urea (mg%) and serum creatinine (mg%) at 24 hours. The sternal closure time was comparable in all the three groups. Cumulative blood loss (ml/kg/24 hours) was greatest in group I (17.30 +/- 7.7), least in group III (8.14 +/- 3.17), whereas in group II, it was 16.45 +/- 6.33 (P = 0.019 group I versus group III; (P = 0.036 group II versus group III). Postoperative PRBC requirements were significantly less in high dose group III (P = 0.008, group I versus III; p = 0.116, group II versus group III) . Tests for coagulation performed at four hours postoperatively, viz. ACT, PT, INR, FDP, and platelets were comparable in the three groups. Urine output on CPB was comparable in all the groups. Serum urea and creatinine showed no significant difference between the three groups twenty four hours postoperatively. Aprotinin dosage regimen of 40,000 KIU/kg at induction, in CPB prime and postoperatively for three hours was most effective in reducing postoperative blood loss and PRBC transfusion requirements. Aprotinin does not have any adverse effect on renal function.

Anesthetic management of patent ductus arteriosus--not always an easy option.

Annals of Cardiac Anaesthesia  Vol. 13:3  Sep-Dec-2010 and organizationally complex environment of the operation theatre. Retained foreign bodies were most likely to occur during an emergency operation, after an unexpected change in the operative procedure and in obese patients. Routine exploration of the abdomen or any cavity that has been opened before closure, use of only sponges with radioopaque markers, two counts after fascial closure and by the new personnel on permanent relief of either the scrub person or the circulating nurse and routine intraoperative X-rays are also a useful adjunct to the swab counts.

Comparison of tranexamic acid with aprotinin in pediatric cardiac surgery.

The ma in p rob lem re l a t ing to the use o f antifibrinolytics in children is the fact that there are very few studies if any which have studied the pharmacokinetics of these drugs in children. Most of the doses used (and there are as many doses as there are publications), are extrapolated from adult studies and have no basis on pharmacokinetics specially in neonates and children, where the volume of drug distribution and drug elimination may vary significantly in neonates, infants and older children compared with adults.

Comparison of the efficacy of Ultrasound-guided Serratus anterior plane block, Pectoral Nerves II block and Intercostal Nerve block for the management of postoperative thoracotomy pain after pediatric cardiac surgery

OBJECTIVE The aim of this study was to compare the relative efficacy of ultrasound-guided serratus anterior plane block (SAPB), pectoral nerves (Pecs) II block, and intercostal nerve block (ICNB) for the management of post-thoracotomy pain in pediatric cardiac surgery. DESIGN A prospective, randomized, single-blind, comparative study. SETTING Single-institution tertiary referral cardiac center. PARTICIPANTS The study comprised 108 children with congenital heart disease requiring surgery through a thoracotomy. INTERVENTIONS Children were allocated randomly to 1 of the 3 groups: SAPB, Pecs II, or ICNB. All participants received 3 mg/kg of 0.2% ropivacaine for ultrasound-guided block after induction of anesthesia. Postoperatively, intravenous paracetamol was used for multimodal and fentanyl was used for rescue analgesia. MEASUREMENTS AND MAIN RESULTS A modified objective pain score (MOPS) was evaluated at 1, 2, 4, 6, 8, 10, and 12 hours post-extubation. The early mean MOPS at 1, 2, and 4 hours was similar in the 3 groups. The late mean MOPS was significantly lower in the SAPB group compared with that of the ICNB group (p < 0.001). The Pecs II group also had a lower MOPS compared with the ICNB group at 6, 8, and 10 hours (p < 0.001), but the MOPS was comparable at hour 12 (p = 0.301). The requirement for rescue fentanyl was significantly higher in ICNB group in contrast to the SAPB and Pecs II groups. CONCLUSION SAPB and Pecs II fascial plane blocks are equally efficacious in post-thoracotomy pain management compared with ICNB, but they have the additional benefit of being longer lasting and are as easily performed as the traditional ICNB.

Atrioventricular septal defects

Operations for atrioventricular septal defects carry substantial risks, and these are one of the most challenging groups of children for cardiac surgeons and anesthetists, taking their care. Children with AVSDs, especially the complete AVSD have a significant morbidity and mortality resulting from postoperative left atrioventricular valve regurgitation, residual intracardiac shunts, postoperative pulmonary hypertension, and various life‐threatening cardiac arrhythmias.

Hyperthermia and malfunction of transesophageal echocardiographic probe

Sir, Saluja et al. encountered transesophageal echocardiography (TEE) probe malfunction in a patient who developed fever.[1] The TEE probe stopped functioning when the TEE monitor showed a temperature of 42.5°C. TEE transducers have piezoelectric materials in which energy dissipation or energy losses are one of the most critical issues. If a piezoelectric element is heated to its Curie point, the domains become disordered and the element becomes completely depolarized. A piezoelectric element can therefore function for a long period without marked depolarization only at a temperature well below the Curie point.[2,3] A safe operating temperature would normally be halfway between 0°C and the Curie point. That is the reason for which heat sterilization of the probes should never be used because high temperature depolarizes piezoelectric crystals inside the probe and transducer loses its piezoelectric properties forever. Being in a high-volume cardiothoracic unit, we use TEE routinely as a real-time monitoring system in all the patients in operating room as well as in intensive care unit. The TEE transducer system has two levels of upper thermal limit: The first high limit is set at 41.0°C and the second high limit is set at 42.5°C. If the temperature of the transducer tip reaches 41.1°C, the temperature display turns reverse highlight and a warning appears (auto cool eminent) on a frozen images. This warning only appears once per examination. If the temperature reaches 42.5°C, the system freezes unconditionally. The user will not be allowed to scan until the temperature has decreased below 42.0°C. To restart scanning, the user must press the freeze key. The system has a lower thermal limit of 17.5°C. If the temperature of the transducer tip reaches 17.5°C, the temperature display turns reverse highlight and the system freeze unconditionally. The user will not be allowed to scan until the temperature has increased above 18°C. To restart scanning, the user must press the freeze key. The general guidelines for reducing the temperature in two-dimensional (2D) Doppler modes are as follows: Increasing image depth reduces the transducer surface temperature When imaging in color mode, there are no imaging changes that can reduce the transducer surface temperature When imaging in pulsed wave Doppler, decreasing pulse-repetition frequency and/or positioning the Doppler sample gate to a shallower depth generally reduces the surface temperature When imaging in continuous Doppler mode (CWD), increasing the depth of the CWD sample line (2D image depth before turning on Doppler trace mode) generally reduces the transducer surface temperature In any imaging mode, freezing the image will temporarily reduce the transducer surface temperature. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Sinus venosus atrial septal defect in a patient with Pentalogy of Fallot

and fluids were flowing well. After the dissection, the surgeon checked the patency of the vein, and it was found to be damaged. Proper positioning of the CVC is important to ensure optimal catheter function and to decrease complications. Many of the cases of left superior intercostal vein cannulation in the literature document the findings, with no report of patient symptoms, catheter function or management. Sekerci and colleagues[7] reported inadvertent malpositioning of a drum catheter in the left internal mammary vein following an attempt at central venous cannulation via the right antecubital fossa.