Anesthetic management for open heart surgery and extracorporeal circulation

Cardiopulmonary bypass [CPB] required for cardiac surgery presents unique challenges to the cardiac anesthesiologist who is responsible not only for maintaining hemodynamics but at the same time anesthesia and analgesia for these patients. Unique pathophysiologic changes during CPB result in pharmacokinetic alterations that impact the serum and tissue concentrations of IV and volatile anesthetics. CPB has evolved into routine, safe and reliable system that requires intensive specialized training to operate. It is the function of the perfusionist to maintain and operate this equipment during CPB; however anesthesiologist and surgeon caring for the patient undergoing CPB bear the responsibility of understanding this equipment and its function in order to manage the patient undergoing surgical procedure safely. Anesthetic management of patient coming for cardiac surgery and different component of cardiopulmonary bypass will be discuss in this review article

Rare presentation of posterior reversible encephalopathy syndrome [PRES] and neurogenic stunned myocardium in a patient after emergency cesarean section

Posterior Reversible Encephalopathy Syndrome [PRES] is clinically characterized by seizures, lethargy, nausea and visual impairment. These findings are thought to be due to vasogenic edema, predominantly in the posterior cerebral hemispheres and are reversible with appropriate management. Neurogenic-stunned myocardium is a syndrome of reversible left ventricular dysfunction, associated with excessive sympathetic discharge states like pheochromocytoma, high-grade subarachnoid hemorrhage [SAH], status epilepticus and significant emotional stress. Here, we report a case of PRES and Neurogenic-stunned myocardium occurring simultaneously in a 25 year old primigravida at 34 weeks of gestation with twin pregnancy who presented to the emergency department with eclampsia and fetal distress. A careful review of literature did not return any report where these two conditions co-existed in an obstetric patient

Complications and interventions associated with epidural analgesia for postoperative pain relief in a tertiary care hospital

Epidural analgesia is one of the commonly used methods of postoperative pain control despite its associated complications. Early recognition and intervention is required to minimize the effect of these complications. Present audit was conducted to find out the incidence of complications and type of interventions required to change the outcome. The record of all the patients who had epidural catheter placed for postoperative pain management reviewed from the departmental acute pain management register. Parameters included level of insertion, drugs used, number of days infusion continued and complications like nausea, vomiting, motor block, sedation, dural tap, catheter pull out, hypotension and itching. In addition, the intervention done to manage these complications was also recorded. Total 1706 entries of epidurals were recorded in study period 2001 to 2007. The overall incidence of the complication was 26.6%. The common complications were motor block [13.4%], dural tap [1.2%], ineffective pain control [2.4%], accidental catheter pull outs [3.8%] and problems associated with the delivery system of drug [1.7%]. The 12% of patients required intervention for the particular complications. The regime was discontinued in 28%, drug concentration changed in 21.5% while the other modes of pain management were used in 19% of patients. 0.9% of patients required epidural blood patch while 2% of patients required catheterization for urinary retention. This audit shows the importance of regular assessment and early intervention to manage epidural related complications in improving outcome

Grown up Congenital Heart Disease patient presenting for non cardiac surgery: anaesthetic implications

Congenital heart disease patients surviving to adulthood have increased over the years due to various reasons. These patients are admitted in the hospital for non cardiac surgeries and other procedures more often than normal adult population. Management of grown up congenital heart disease patient presents a challenge during perioperative period for cardiologists, surgeons, intensivists and particularly for the anaesthetist. Management issues include psychological and physiological impact on the patient, complexity of defects, presence of previous palliative procedure, impact of anaesthetic agents on shunting and myocardium, endocarditis prophylaxis and associated extra cardiac anamolies

Hemodynamic effects of anesthetic induction in patients treated with beta and calcium channel blockers

The response to anesthetic induction and airway manipulation in the presence of cardiovascular disease and anti-hypertensive therapy has not been adequately investigated. The blood pressure, pulse pressure and heart rate changes at induction and following tracheal intubation were compared in patients who were on either preoperative beta-adrenergic blocker therapy [BB group, n = 20] or a combination of beta-adrenergic blocker and calcium channel blocker therapy [BB + CCB group, n = 20]. A standardized anesthesia induction protocol was followed, in the two gourps. No statistical difference was observed in the hemodynamic parameters between the two groups. The total number of hypotensive patients [SAP 90

role of prophylactic intra-aortic balloon pump counterpulsation [IABP] in emergency non-cardiac surgery

Patients with recent myocardial infarction [MI], congestive heart failure, severe angina, or uncorrected multivessel coronary artery disease are at increased risk of cardiac complications after urgent major non-cardiac surgery. Although invasive haemodynamic monitoring and preoperative optimization of cardiac status may lead to some reduction in the rate of perioperative cardiac events, the mortality from such events still remains high. The use of an intra-aortic balloon pump [IABP] may play a role in such patients by improving the function of the injured heart. We report our experience with the use of perioperative IABP in a patient with unstable angina and recent MI who underwent urgent cholecystectomy. There were no perioperative cardiac events while the IABP was in place. The anaesthetic concerns, intraoperative and postoperative monitoring and care and usefulness of IABP will be discussed

Comparison between tramadol and pethidine in patien controlled intravenous analgesia

To compare the efficacy and side effects related to Tramadol with Pethidine in patient controlled intravenous analgesia [PCIA] after total abdominal hysterectomies. A total of 60 patients were randomized to receive either Tramadol or Pethidine by PCIA [30 in each group] after total abdominal hysterectomy. Pain assessments were recorded one hour after starting the PCIA and then at 6, 12, and 24 hours by using visual analogue scale [VAS]. Nausea vomiting score and sedation score were also recorded. Good attempts, total attempts and total drug consumption was noted from PCIA pump at the end of the study period. The analgesia achieved in Tramadol group was comparable to Pethidine. The incidence of nausea and vomiting was similar in both groups. Tramadol causes significantly less sedation than Pethidine [p < 0.05]. Mean drug consumption, total attempts and good attempts were also significantly less in Tramadol group than Pethidine group [p < 0.05]. Tramadol produces equivalent analgesia and less sedation and can be used as an alternative to Pethidine in Patient Controlled Intravenous Analgesia for postoperative pain relief after Total Abdominal Hysterectomy [TAH]

Unplanned prolonged postanaesthesia care unit length of stay and factors affecting it

To identify the factors that prolong the length of stay in the post anaesthesia care unit [PACU]. This audit was conducted in the PACU of a university hospital. A special form was designed and filled for those patients who stayed unplanned in the PACU for more than two hours. All patients who were admitted to the PACU after surgery were included. Patients undergoing cardiothoracic surgery, those directly shifted to ICU and cases done under local anaesthesia were excluded. Data was collected for 20 months by a designated recovery nurse for all included patients including those admitted outside the scheduled surgery hours. The total number of patients who were admitted to the PACU during the audit period were 13644, out of these 1114 [8.1%] stayed in the PACU for more than 2 hours. The percentage of overstay patients on monthly basis ranged from 6.4% to 10%. The commonest reason was the need for postoperative monitoring 578 [51.8%], unavailability of beds in the special care areas 264 [23.7%], pain management 68 [6.1%] and 61 [5.4%] for postoperative ventilation. Our results show that majority of patients stayed in the PACU for more than two hours either because they needed postoperative monitoring or because of unavailability of bed in the special care areas