General anesthesia for primary pulmonary hypertension patient during labour: a case report

The management of PPH is a challenge for the anesthesiologist because the risk of right sided heart failure and mortality are markedly increased. Here we describe a case of a 25-year- old pregnant woman presenting with severe PPH with high systolic pulmonary artery pressure [SPAP] that equals the systemic arterial blood pressure. Her Echocardiogram showed severe right ventricular [RV] dilatation and hypertrophy [RVH], she had an elective Caesarean section under general anesthesia at 32 weeks gestation. Pulmonary artery pressure [PAP] measured by a pulmonary artery catheter before induction of anesthesia was 102 mm Hg! Intraoperatively; nitroglycerin and nitric oxide [NO] were used to reduce SPAP. After the delivery of a healthy infant; she was transferred to the critical care unite where extubation done after 9 hours later. SPAP was controlled with NO 20 p.p.m while patient still intubated. After extibation, nitroglycerin, nebulized iloprost, and silandifil used to control PAP. Five days later she transferred from intensive care, and discharged from hospital on day 14. She maintained on silandifil 50 mg three times daily and warfarin. She was given the appropriate outpatient clinic appointments to be referred to the heart lung transplant service

Recombinant activated factor VII in cardiac surgery: Is it effective in reducing postoperative bleeding?

The FDA approved recombinant factor Vila [rFVIIa][Novo Nordisk, Bagsvaerd, Denmark] in 1999 for treatment of spontaneous or surgical bleeding episodes in patients with hemophilia A or B. rFVIIa was rapidly used in the treatment or prophylaxis of bleeding in other conditions including cardiac surgery. The question addressed was whether use of rFVIIa could help Hemostasis, and decrease blood or blood product requirements in cardiac surgery patients and its safety as regards thrombosis risk. This is a retrospective comparative study conducted in King Fahad Cardiac Center [KFCC], King Saud University [KSU] Riyadh, KSA. Discharge data of 250 patients who had cardiac surgery through August 2010 to July 2011 were reviewed, 14 patients without hemophilia received Recombinant Activated Factor VII were included in the study as rFVIIa group. Another 15 patient were randomly assigned to the control group. Data analyzed are: patient's age, sex, procedure done, CPB time, blood loss, blood or blood products transfusion, intensive care unit [ICU] stay, dose of rFVIIa, and any reported thrombotic adverse effect. A single dose of 1.2 rFVIIa was given to rFVIIa group patients, Demographic data were comparable in both groups without significance. Cardiopulmonary bypass time was 114.91 +/- 654 minutes in rFVIIa group and 119.44 +/- 139 in control group [p=0.6229]. Post operative drain was 598.33 +/- 153.68 and 945.75 +/- 946.8 in rFVIIa and control group respectively [p=0.395]. Blood and product transfusion showed no statistical difference between the groups as well as ICU stay and hospital stay. One patient in the control group was re-explored due to a surgical cause. No reported thrombo embolic complications among study patients. Small dose rFVIIa cannot be considered effective for bleeding after cardiac surgery. Further larger randomized trials will better provide evidence of the effective value of rFVIIa in this setting. Further investigation is warranted in order to design guidelines on the use of rVIIa in cardiac surgery and to determine its safety and efficacy profile

Comparison of neurological outcomes in patients undergoing conventional coronary artery bypass grafting, on-pump beating heart coronary bypass, and off-pump coronary bypass

To study the differences in the prevalence of neurological complications following coronary artery bypass [CAB] carried out by conventional, on-pump beating and off-pump techniques. A retrospective analysis of all isolated coronary bypass operations [n=127] performed in King Fahad Cardiac Center, Riyadh over a period of one year starting from January 2005. Out of 127 patients, 73 underwent conventional CAB graft [CABG], 33 patents on-pump beating heart coronary bypass, and 21 had off pump coronary bypass grafting [OPCAB]. All patients had preoperative carotid scans and those who developed neurological complications underwent CT-brain and expert neuro-psychiatric assessment. Preoperative characteristics of patients in all 3 groups were similar. The bypass times in the conventional CABG group were significantly longer than the on-pump beating group. The maximum number of grafts was in the on-pump beating group, followed by the conventional CABG, and the least in the OPCAB group. Seven out of 73 cases in the conventional bypass group developed neurological events of various severities. Only one out of 33 patients developed acute confusional state in the on-pump beating group and no neurological events were noticed in 21 patients operated by the OPCAB technique. Low ejection fraction, preoperative congestive cardiac failure, non-elective surgery and preoperative catastrophic state were found to be significant risk factors independent of the bypass technique. This study shows no significant difference in the prevalence of neurological complications among different types of bypass surgery in our institution. There was a trend towards less neurological outcomes in the OPCAB and on-pump beating groups