influence of intact pleura on postoperative respiratory dysfunction after coronary artery bypass grafting [CABG] using bilateral internal mammary arteries [BIMA]

Bilateral internal mammary artery harvesting for coronary artery bypass graft had shown to be superior compared to venous grafts in regard to cardiac events, however the major drawbacks from such technique is early postoperative complications; namely bleeding, wound infection [deep or superficial] and impairment of respiratory function. We tested the hypothesis of modifying the surgical technique when harvesting bilateral mammary arteries with maintaining pleural integrity [Npo group A n=25] and conventional technique with pleura opened [po group B n=25] and its effect on early postoperative complications. Patients in group A [Npo] had demonstrated more favorable early postoperative outcome compared to group B [po] evidenced by better PaO2/FiO2, dynamic spirometry function [FEV1 72.5% versus 59.9% of expected and FVC 64.5% versus 52.3% of expected], less morbidities [4 incidences versus 10 incidences], less postoperative bleeding [461 ml versus 570.8 ml] and better cough score. Meticulous harvesting of bilateral internal mammary artery with preservation of pleura could dramatically decrease early postoperative complications associated with such technique

Perioperative sedative and haemodynamic effects of dexmedetomedine versus midazolam in elective coronary artery bypass grafting

Background: alpha 2-adrenoceptor agonists are being increasingly used in anaesthesia and critical care. Dexmedetomidine [DMM] is the most recent agent used for both analgesia and sedation. This study, was carried out to evaluate the sedative and haemodynamic effects of using DMM versus Midazolam during elective Coronary Artery Bypass Graft [CABG] surgery both intraoperatively and over the first 6 postoperative hours

Patients and Methods: Our prospective comparative study was done in the Department of cardiothoracic surgery and anaesthesia of Kasr El Aini University Teaching Hospitals between 2004 and 2006 after approval of the local ethical committee. We included 40 adult patients who underwent CABG surgery. Patients were allocated into two equally-numbered groups: Group A [no 20] included patients who were given dexmedetomidine [DMM] infusion starting by 1 micro g/kg over 10 minutes then maintained on 0.2 - 0.7 micro g/kg/hour; while group B patients [no 20] were given Midazolam [Mz] infusion first by 0.05 mg/kg over 1 minute then 0.02 - 0.05 mg/kg/hour. Haemodynamics [mean arterial blood pressure, heart rate and central venous pressure] and analgesic requirements were recorded intraoperatively, and over the 1[st] 6 hours postoperatively. Duration of ventilation and ICU stay are also recorded

Results: No difference was present between both groups as regards the total operative time and other surgical and preoperative data. DMM caused more attenuation of the mean arterial blood pressure [ABP] during induction of anaesthesia, intraoperative and postoperatively. DMM produced more control of the heart rate and decreased episodes of tachycardia during induction, intraoperative and postoperatively and the difference was significant as regard mean [ABP] and HR. The total intraoperative dose of Fentanyl was 610 +/- 18 micro g with DMM; vs. 850 +/- 23 micro g with MZ [p < 0.02]. Mean extubation time was 280 +/- 28 minutes with DMM; vs.430 +/- 45minutes with MZ [p < 0.02]. Mean ICU stay time was 17 +/- 2.2 hours for DMM; vs. 25 +/- 4.5 hours with MZ [p < 0.01]. The mean dose of morphine needed in the first 6 postoperative hours was 6 +/- 0.5 mg for DMM; versus 11 +/- 1.5 mg for MZ [p < 0.001]

Conclusion: Compared to Midazolam, use of DMM in the intraoperative and the early postoperative periods after elective coronary artery bypass graft surgery, was associated with more haemodynamic stability, and better perioperative anxiolysis as depicted by the less need for sedation-analgesia and early extubation and discharge from the ICU

Perioperative assessment of coagulation in pediatric neurosurgical patients using thromboelastography

Primary brain tumors may be associated with coagulation disorders which can pose intraoperative and postoperative management difficulties. Thromboelastography [TEG] is a useful technique for evaluating coagulability. In this study we evaluated the perioperative coagulation profile using both standard laboratory work and TEG in pediatric patients undergoing craniotomy for primary brain tumors. 40 Pediatric patients were enrolled in the study. All patients received standard anesthesia. Blood was analyzed for both standard laboratory work and TEG at three points for each patient: Preoperatively, intraoperatively, and postoperatively. Post operatively patients were divided into two groups according to occurrence or not of postoperative haematomas. GNH [non haematoma group] and GH [haematoma group]. The standard blood work and TEG values for both groups were compared. Perioperative standard blood work was within normal limits for all patients with no significant difference between both groups. In GNH TEG values were indicative of a hyper-coagulable state which started intraoperative and continued into the 1[st] postoperative day. In GH TEG values were indicative of a hypocoagulable state which was evident in the preoperative TEG values and continued into the intraoperative as well as post operative period. In conclusion TEG may be useful in the perioperative assessment and monitoring of coagulation in pediatric neurosurgical patients and helps in identifying patients at increased risk of bleeding or thromboembolic events