Effect of slow versus rapid rewarming on jugular bulb oxygen saturation in adult patients undergoing open heart surgery

A debate has appeared in the recent literature about the optimum rewarming strategy [slow vs. rapid] for the best brain function. This study was designed to compare the effect of slow versus rapid rewarming on jugular bulb oxygen saturation [SjO2] in adult patients undergoing open heart surgery. A total of 80 patients undergoing valve and adult congenital heart surgery were randomly allocated equally to rapid rewarming group 0.5 [0.136] [degree]C/min and slow rewarming group 0.219 [0.055][degree]C/min in jugular bulb sampling was taken before, during and after surgery. Surgery was done at cardiopulmonary bypass [CPB] temperature of 28-30[degree]C and rewarming was performed at the end of the surgical procedure. CPB time, rewarming period were significantly longer in the slow rewarming group. Significant difference was observed in the number of the desaturated patients [SjO[2]

effects of hypothermic versus normothermic cardiopulmonary bypass on hepatic blood flow

To explore Trans-esophageal Echo [TEE] as a monitoring device for hepatic blood flow during cardiac1 surgery and to correlate between the hepatic venous blood flow measurements and the liver function tests during normothermic and hypothermic cardiopulmonary bypass. Forty patients scheduled for cardiac surgery were randomly divided into 2 groups: group 1 [Gl] undergoing normothermic cardiopulmonary bypass [CPB] and group 2 [G2] undergoing hypothermic CPB. Serum AST, ALT, billirubin and hyalurinic acid levels were measured before, during and 6 hours after the bypass. During these same phases, TEE was used to measure both cardiac index [Cl] and middle hepatic vein blood flow. During CPB there were no significant differences in demographic data, AST, ALT or billirubin levels between the 2 groups. There was, however, a significant increase [P<0.001], in both groups, in serum hyalurinic acid levels during CBP in relation to the baseline and in Cl 6 hours after bypass in relation to pre and intra bypass phases. The middle hepatic venous blood flow was significantly higher amongst Gl patients six hours following the procedure in relation to the pre and intra bypass phases, whereas G2 patients showed a significant decrease in middle hepatic venous flow during the bypass followed by a significant increase 6 hours after the procedure in relation to the baseline. Hepatic venous blood flow is reduced significantly more during hypothermic bypass than during normothermic bypass. This may cause disturbances in sinusoidal endothelial cell [SEC] function. However, this change may be well tolerated by the healthy liver. Multiplan TEE may be used to monitor hepatic blood flow during CPB

role of recombinant factor VII in controlling the intraoperative blood loss in patients with severe coagulopathy and portal hypertension during living donor liver transplant surgery

Liver transplantation is the standard form of treatment for patients with end stage liver disease, with the use of blood product as a standard method for transfusion. Recombinant factor Vila [rVlla] may help those patients to acquire less amount of transfusion. This will have an impact not only the morbidity and mortality of the recipient and the donor, but also on the economical aspect of this tremendously expensive procedure. We conducted this study to verify the possible beneficial effects of using rVlla at a lower dose than the standard dosage, which could have an impact on the future use of rVlla. Twenty-four patients scheduled for orthotropic livertransplantation, divided into 2 groups; a control group and an rVlla group. Both groups received the same anesthetics enlisted in our protocol for liver transplantation. The rVlla group received a loading dose of 30 microg/kg of rVlla following the induction of anesthesia, followed by a maintenance dose of 5 microg / kg until the end of the dissection phase. Demographic data, coagulation profile [prothrombin time [PT], prothrombin concentration [PC], partial thromboplastin time [PTT], International normalized ratio [INR]], blood loss, transfusion requirements, the duration of the dissection phase, the duration of surgery, hemoglobin concentration [Hb], and platelet count were done immediately after induction and 1, 2, 3 and 6 hours post induction [dissection phase]. Finally, a Doppler assessment of the graft vessels was performed subsequent to anastomosis. The rVlla group had a lower PT in the first two hours of the dissection phase in relation to the baseline and significantly lower than the control group [P = 0.0002]. The INR showed a significant improvement in the rVlla group during the dissection phase compared to the control group, and during the first two hours compared with the baseline in the rVlla group [P = 0.0002]. When compared to the control group, the rVlla group had a significant increase in the platelet count, in all samples taken during the dissection phase. There was a significant decrease in the intraoperative requirements of packed red blood cells [P = 0.014], platelets [P = 0.0005] and fresh frozen plasma [P = 0.01] in the rVlla group compared to the control group. We conclude that administering low dose of rVlla would be helpful during liver transplantation surgery. Improvement in the coagulation profile, transfusion requirements, and consequently postoperative morbidity and mortality could be achieved

Factors affecting mortality in patients treated with intra-aortic balloon counter pulsation due to cardiogenic shock post CABG

During many years of intra-aortic balloon counter pulsation [IABP] application in the treatment of myocardial infarction [MI] more and more indications for this treatment have been proposed. Despite increasing experience with IABP, the clinical effects of IABP use are still unclear, especially when applied in cardiogenic shock. Incidence of cardiogenic shock has remained high, complicating 7 to 10 per cent of acute MI [I]. The aim of this study was to determine results of IABP use and factors which affect mortality in cardiogenic shock [CS] post CABG. 30 patients [mean age 58.3 +/- 12.6 years, 22 males] undergoing IABP were included in the study. Data were collected and mortality rates were assessed. In-hospital death occurred in 12 patients. Over half of these patients [n = 7; 58.3%] died during first 7 days from insertion of IABP. The reason for IABP introduction was CS post CABG in all patients. The mortality in patients complicated by CS was 40%. The features which significantly influenced mortality in these patients were age-patients who died were older [64 +/- 7.8 Vs. 58.6 +/- 8.2; p = 0.03] and ST segment changes-there was lower mortality rate in a subgroup with ST elevation AMI [8 Vs. 4 patients, p = 0.003]. We also observed slightly higher incidence of anterior wall AMI in survivors than in non-survivors [p = 0.06]. Our study presents CS post CABG treated with IABP. In this study, survivors and non-survivors differed mainly in age, ST segment changes and infarction site. Non ST segment elevation AMI was associated with worse prognosis

Comparative study between propofol and sevoflurane anaesthesia for cerebral protection in cardiac surgery

Despite advances in anaesthesia and surgical techniques, cerebral injury remains a major source of morbidity after cardiac surgery. In this study, we evaluated the effect of two anaesthetic techniques, sevoflurane/fentanyl versus propofol/fentanyl on neurological outcome and S100S Protein levels and its correlation to secretion of cytokine IL-6 in patients undergoing coronary artery bypass grafting surgery [CABG]. Thirty patients undergoing CABG, randomly allocated into two groups, were enrolled in this prospective study. Sevoflurane was used in group S and propofol in group P. Neurological examination was performed preoperatively and on the third and sixth postoperative days. Blood samples for analysis of S100B Protein and IL-6 were collected before anaesthesia [TO], after heparinization and before CPB [Tl], after aortic declamping [T2], end of CPB [T3] and 24 hours after the operation [T4] in all patients. S-100B, Protein levels increased with the beginning of surgery in both groups but did not reach a pathological level except after aortic declamping [T2]. Maximum levels were reached at the end of operation [T3] and decreased to baseline levels at 24 hr postoperatively [T4]. The increase was statistically significant in both groups [at T2 and T3] but no significant difference was observed between the two groups. IL-6 level was significantly higher in Group S than in Group P before the start of cardiopulmonary bypass [Tl]. After aortic declamping [T2], concentration of IL-6 started to increase significantly and peaked at the end of operation [T3] but there were no differences between groups after cardiopulmonary bypass or postoperatively. There was a positive correlation between IL-6 and S-100B in both groups. Despite the increase in S-100B protein levels, no difference in deterioration of neurological examination after the operation was seen between groups. We conclude that propofol appears to offer no advantage over Sevoflurane for brain protection during CPB in this preliminary study. Also we concluded that the choice of anaesthetic technique may affect the pro-inflammatory cytokine response to surgery. However, neither technique could modify the cytokine response to the effect of the ischemia- reperfusion phenomenon or CPB itself

Predictive value of ischaemia modified albumin [IMA] in patients with acute coronary syndromes [ACS]

Establishing a diagnosis of acute coronary syndrome in the clinical setting remains a challenging task. The advent of testing for cardiac biomarkers such as myoglobin, creatine kinase [CK-MB], and the troponins has facilitated this process. Unfortunately, although these blood markers are extremely sensitive for the identification of patients with myocardial necrosis, their ability to identify patients with acute coronary ischaemia remains limited. During myocardial ischaemia, several changes occur in the amino terminus of ischaemia, several changes occur in the aminot terminus of albumin. Therefore, if reliable, an assay measuring IMA might represent a promising marker for early identification of patients with myocardial ischaemia. To assess the role of IMA and its predictive value for early diagnosis of patients with acute coronary syndromes. Seventy three patients with suspected ACS attending the emergency department at Assiut university hospital were included in addition to -sex and age matched -20 healthy control subjects. All patients were presented within 6h of the typical chest pain episode with negative troponin and normal serum albumin levels. Any patient with liver diseases, renal failure, anaemia, malignancy, acute infections, peripheral vascular diseases, cerebral ischaemia and physical exercise within the last 48 hours was excluded. Full history, clinical examination and standard 12 lead ECG, laboratory investigations including CPK, IMA, CRP, lipogram, kidney and liver functions were done. Twenty two patients were diagnosed as non ischaemic chest pain [NICP] and 51 cases as ACS. CPK and troponin levels were normal in all groups at presentations but 6 hours later CPK levels were significantly higher in ACS patients if compared with NICP or control groups [p<0.000]. on the other hand, IMA levels were statistically significantly high in ACS group only [p<0.000] with a good negative predictive value to diagnose NICP [86.3%]. Moreover, IMA levels were statistically significantly higher in patients finally diagnosed as unstable angina [UA] than those who diagnosed as non ST elevation myocardial infarction [NSTEMI] [p<0.04] meanwhile, it is insignificantly higher than that in STEMI patients. The sensitivity of IMA to predict ACS cases [94.1%] was higher than that of ECG [78.4%] and CPK at presentation [14.7%] and after 6 hours [54.7%]. On the other hand, the specificity of IMA, ECG, CPK at presentation and 6 hours later [86.4%, 90.9%, 86.4% and 97% respectively]. IMA can be used at the emergency setting to exclude the diagnosis of ADS. Moreover, the use of IMA as a diagnostic biomarker in addition to standard markers of myocardial injury is very useful for the evaluation of patients with suspected ACS

role of intraoperative epiaortic echo in decision making in coronary artery bypass surgery

Objective: A cerebrovascular accident [CVA] is a devastating complication of coronary artery bypass grafting [CABG] and a major cause for morbidity and mortality. Aortic manipulation, cannulation, and clamping during CABG may lead to release of atheromatous material from the ascending aorta, which may cause a CVA. This study assessed the hypothesis that the use of intraoperative epiaortic ultrasonography [EAUS] would supplement imaging information with that derived from manual aortic palpation and influence the surgical decision-making approach accordingly

Methods: After undergoing a mid-sternotomy for CABG, 100 patients underwent EAUS with an 7-MHz transducer ordinarily used for conventional transthoracic echocardiography. The surgical strategy was decided on at three stages: preoperatively, after manual aortic palpation, and following EAUS

Results: Pathologic lesions of the atheromatotic ascending aorta were evident in 40 patients [40%], with the lesions detected in 22 patients [22%] by both palpation and EAUS, and in 18 patients [18%] by EAUS alone. The planned surgical strategy was changed in 29 patients [29%]: 25 patients [25%] were converted from on-pump CABG to OPCAB, and the EAUS influenced the choice of the aortic cannulation, cross-clamping and proximal anastomosis site in 4 patients [4%]. Among the changes in surgical decision making, changes in 11 patients [11%] were based on lesion detection by both manual palpation and EAUS; in 18 patients [18%], changes resulted from pathologic evidence provided by EAUS alone

Conclusions: This study showed EAUS to be more sensitive in detecting atherosclerotic lesions than manual intraoperative palpation of the ascending aorta especially for atheromas involving posterior aortic wall. The use of EAUS has emerged as an important tool in intraoperative decision making, and we recommend its use routinely in CABG procedures