Virendra K Arya

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.

Basics of fluid and blood transfusion therapy in paediatric surgical patients.

Perioperative fluid, electrolyte and blood transfusion therapy for infants and children can be confusing due the numerous opinions, formulas and clinical applications, which can result in a picture that is not practical and is often misleading. Perioperatively, crystalloids, colloids and blood components are required to meet the ongoing losses and for maintaining cardiovascular stability to sustain adequate tissue perfusion. Recently controversies have been raised regarding historically used formulas and practices of glucose containing hypotonic maintenance crystalloid solutions for perioperative fluid therapy in children. Paediatric intraoperative transfusion therapy, particularly the approach to massive blood transfusion (blood loss ≥ one blood volume) can be quite complex because of the unique relationship between the patients blood volume and the volume of the individual blood product transfused. A meticulous fluid, electrolyte and blood transfusion management is required in paediatric patients perioperatively because of an extremely limited margin for error. This article reviews the basic concepts in perioperative fluid and blood transfusion therapy for paediatric patients, along with recent recommendations. For this review, Pubmed, Ovid MEDLINE, HINARI and Google scholar were searched without date restrictions. Search terms included the following in various combinations: Perioperative, fluid therapy, paediatrics, blood transfusion, electrolyte disturbances and guidelines. Only articles with English translation were used.

Ultrasound-guided supraclavicular brachial plexus anaesthesia improves arteriovenous fistula flow characteristics in end-stage renal disease patients

Background: Surgical construction of an arteriovenous fistula is preferred for end-stage renal failure patients requiring long-term haemodialysis. Methods: Patients were randomised into two groups: brachial plexus group (n = 30) or local infiltration group (n = 30). In all patients, a radiocephalic arteriovenous fistula was created by an experienced surgeon using a standard surgical technique. In both groups 20 ml of 0.375% ropivacaine was used. Doppler assessment of vessels was performed at fixed time intervals.
 Results: 
Primary patency rate was 100% in the brachial plexus block group whereas there was 10% fistula failure rate in the local infiltration group (p-value = 0.237). Diameter of the vessels, peak systolic velocity, mean diastolic velocity, and blood flow at 30 minutes, 48 hours, 2 weeks, and 6 weeks after the fistula creation was significantly greater than the preoperative diameter in all patients (p-value < 0.05). Intergroup comparison revealed that vascular parameters were significantly better in the brachial plexus analgesia group versus local infiltration group at all observation points up to and including six weeks post fistula creation (p-value < 0.05). Conclusion: Brachial plexus anaesthesia significantly dilates the vessel diameter and increases blood flow whereas local infiltration has a negligible effect on vessel diameter and blood flow.

Preinduction hemodynamic fluctuations in renal transplant recipients-Comparison of two combined anesthesia regimens

An ideal anesthetic technique for a renal allograft recipient must ensure hemodynamic stability, enhance graft reperfusion, and provide good postoperative pain relief. Hence, a combined general and epidural anesthesia is preferred. In our clinical practice, it has been observed that in chronically ill end-stage renal disease (ESRD) patients, a bolus injection of epidural local anesthetics invariably necessitated the use of vasopressor agents. Such hemodynamic fluctuations may not be favorable for the graft. A prospective, randomized, double-blind study was conducted on 50 ESRD adults, 18-55 years, scheduled for elective live related kidney transplantation. The patients randomly received either epidural fentanyl (50 μg) and normal saline (10 mL) or epidural fentanyl (50 μg) and bupivacaine (0.5%; 10 mL) followed by standardized general anesthesia. Perioperative hemodynamics and vasopressor requirements were compared with both regimens. Early graft function was assessed by the onset of diuresis after declamping, serial creatinine values, glomerular filtration rate, and 24-hour urine output estimation. In the preoperative period, statistically significant reduction in the mean arterial pressure and the cardiac index occurred in 60% of the patients receiving epidural bupivacaine boluses. These hypotensive episodes required a therapeutic intervention prior to general anesthesia, that is, intravenous mephenteramine (3-6 mg; 9.60±2.32 mg) and crystalloid infusion (189.28±21.29 mL). Intraoperative hemodynamic parameters, surgical blood loss, and transplanted kidney function were comparable between the groups. We concluded that the use of regional anesthetics needed to administered cautiously in renal transplant recipients to maintain hemodynamic parameters.

Role of radiofrequency ablation in unresectable hepatocellular carcinoma: An Indian experience

Aims: To evaluate the role of radiofrequency ablation (RFA) as an ablative technique in patients with unresectable hepatocellular carcinoma (HCC). Settings and Design: A tertiary care center, prospective study. Materials and Methods: The subjects comprised 31 patients (30 males, one female; age range 32-75 years) with HCC (41 lesions) who were treated with image-guided RFA. The follow-up period ranged from 3 months to 6 years, and included a multiphasic computed tomography (CT) at 1, 3 and 6 months post-RFA, and every 6 months thereafter. Patient outcome was evaluated and the tumor recurrence, survival and complications were assessed. Statistical Analysis Used: Discrete categorical data were presented as n (%) and continuous data as mean ± SD. Pearson correlation coefficient was used to determine the relationship between the different variables. Kaplan–Meier survival curve and Log-rank test were used to test the significance of difference between the survival time of the different groups. Results: The ablation success rate was 80.5% (33/41 HCC lesions). 12.2% (5/41) of the lesions were managed with repeat RFA due to tumor residue. 4.9% (2/41) of the lesions were managed with repeated RFA and transarterial chemoembolization. Eight patients had tumor recurrence (five patients (16.1%) had local recurrence and three patients (9.6%) had distant recurrence). Eleven patients died within 3.5-20 months post-RFA. The survival rate at 1 year in patients who completed at least 1 year of follow-up was 63.3%. There was one major complication (1/31, 3.2%) in a patient with a subcapsular lesion and ascites. This patient developed hemoperitoneum in the immediate postprocedure period and was managed with endovascular treatment. She, however, had hepatic decompensation and died 48 h post-RFA. Conclusion: RFA is an effective and safe treatment for small unresectable HCC.

Intraoperative myocardial ischemia during renal transplantation caused by anomalous origin of the right coronary artery.

Anomalous origin of the right coronary artery (AORCA) is a rare congenital anomaly with an incidence of 0.92% during routine cardiac catheterization. Its presence raises an important concern to the anaesthesiologist because it can lead on to myocardial ischaemia manifesting as either angina pectoris or myocardial infarction, or sudden death in young patients with minimal exertion, even in the absence of atherosclerosis. Patients with AORCA may be intolerant to stress and the high cardiac output condition owing to volume loading. Such a therapeutic manoeuvre may be desirable during renal transplantation to enable better perfusion of the renal graft immediately after grafting the kidney, in order to improve its function. Hence, haemodynamic goals in renal transplant recipient with AORCA can be contradictory during surgery, thereby rendering anaesthetic management challenging. We report a case of acute myocardial ischemia precipitated by fluid loading conditions in a patient with AORCA during renal transplant that was successfully treated with emergent intra-aortic balloon pump therapy intraoperatively. Judicious intraoperative fluid replacement is recommended, and volume overload must be avoided in AORCA patients undergoing surgery.

Effect of discontinuing morning dose of antihypertensive for renal transplant surgery on haemodynamic and early graft functioning: A prospective, double-blind, randomised study

Background and Aims: Antihypertensive drugs are continued until the day of renal transplant surgery. These are associated with increased incidence of hypotension and bradycardia. Hence, this study was designed to evaluate perioperative haemodynamic and early graft functioning in renal recipients with discontinuation of antihypertensive drugs on the morning of surgery. Methods: This prospective, randomised, double-blind study recruited 120 patients. Group 1 patients received placebo tablet while Group 2 patients received usual antihypertensive drugs on the day of surgery. Perioperative haemodynamics and time for reinstitution of antihypertensives were the primary outcome measures. The secondary outcome measures were need for inotropic support and graft function. Perioperative haemodynamics were analysed using ANOVA and Student′s t-tests with Bonferroni correction. Fischer′s exact test was used for analysis. Results: Systolic blood pressure (SBP) declined, which was more in Group 2. Forty-one patients developed significant hypotension; a correlation was found between the maximum observed hypotension and number of antihypertensive medications (P = 0.003). Four cases had slow graft function (one in Group 1 and three in Group 2). Twenty-eight patients in Group 2 required mephentermine boluses to maintain their SBP compared to 13 patients in Group 1 (P < 0.001). Two patients in Group 2 required dopamine to maintain SBP above 90 mmHg after the establishment of reperfusion as compared to none in Group 1. Conclusion: Single dose of long-acting antihypertensive drugs can be omitted on the morning of surgery without any haemodynamic fluctuations and graft function in controlled hypertensive end-stage renal disease renal transplant patients receiving a combined epidural and general anaesthesia.

Silicone tracheobronchial stent: A rare cause for bronchoesophageal fistula and distortion of airway anatomy

Silicone tracheobronchial stents are being increasingly used in a large number of patients for the treatment of tracheal stenosis. One very rare complication due to tracheobronchial stenting is bronchoesophageal fistula (BEF), which has been associated with the use of metallic stents. We report intraoperative management of a patient undergoing repair of a BEF, following previous insertion of a silicone Y-stent that is soft in texture and has not been implicated for this complication till date. In addition, misalignment of this silicone tracheobronchial Y-stent resulted in a tracheal mucosal bulge proximal to the stent that vanished after its removal.

Indigenous Devices in Difficult Airway Management

Management of difficult airway has been always a challenge for the practising anaesthesiologist. Currently many gadgets are available to deal with difficult airway situations. However; these may not be available in remote locations and in all types of hospitals especially in developing nations. This chapter describes some simple valuable modifications of routinely available instruments in medical practice for dealing with difficult airway situations. All these gadgets are reported in the literature and familiarity with these can be helpful in certain difficult airway management situations with limited resources.

Complex Left Atrial Wall Dissection After Combined Aortic and Mitral Valve Replacement

• Volume 119 • Number 2 www.anesthesia-analgesia.org 251 A 70-year-old man underwent coronary artery bypass grafting and double valve replacement (CarpentierEdwards Magna: 33-mm prosthesis for rheumatic severe mitral regurgitation and 23 mm for moderate aortic stenosis). After cardiopulmonary bypass (CPB), his pulmonary artery wedge pressure (PAWP) was elevated to 31 mm Hg and central venous pressure to 18 mm Hg compared to pre-CPB values of 24 and 12 mm Hg, respectively. Transesophageal echocardiography (TEE) in the midesophageal 4-chamber and long-axis view revealed a left atrial (LA) linear structure of homogeneous intensity and random motion, dividing the LA into a small anterior (adjacent to the aortic valve, along the anterior mitral annulus) and a large posterior (along the posterior mitral annulus) compartments (Video Clips 1 and 2, see Supplemental Digital Content 1, http://links.lww.com/AA/A912, Supplemental Digital Content 2, http://links.lww.com/ AA/A913; Fig. 1, A and B). In addition, a freely oscillating mass was noticed inside the left ventricle (LV) (Video Clip 1, see Supplemental Digital Content 1, http://links. lww.com/AA/A912; Fig. 1A). Color flow Doppler examination of the LA showed antegrade diastolic blood flow from the anterior LA compartment through the mitral prosthesis with proximal flow acceleration (Video Clip 2, see Supplemental Digital Content 2, http://links.lww.com/AA/A913; Fig. 1, C and D). Continuous-wave Doppler revealed a mean diastolic transmitral pressure gradient of 16 mm Hg (Fig. 2B). In a modified midesophageal 4-chamber view, a continuous left-to-right shunt from the anterior LA compartment across the interatrial septum (IAS) was also seen, with a peak gradient of 23 mm Hg (Video Clip 3, see Supplemental Digital Content 3, http://links.lww.com/ AA/A914; Fig. 2C). The posterior LA compartment communicated with the LV through a mitral paraprosthetic defect adjacent to posterior mitral annulus (Video Clip 2, see Supplemental Digital Content 2, http://links.lww.com/AA/A913; Fig. 2A), with blood flow during systole and diastole. The free-floating LV structure was identified as part of the anterolateral papillary muscle (Video Clip 3, see Supplemental Digital Content 3, http://links.lww.com/ AA/A914) in a transgastric midpapillary short-axis view. Pulsed-wave Doppler examination of the pulmonary veins,