Interrogation of Superior Vena Cava by Deep Transgastric Transesophageal Echocardiography Imaging: Clinical Applications

The advantages of intraoperative deep transgastric interrogation by transesophageal echocardiography (TEE) of the superior vena cava (SVC) in comparison to the standard bicaval view was studied in pediatric cardiac surgical cases. The view was found to be helpful in obtaining additional data in pediatric cardiac surgical patients.

Assessment of Stress Response Attenuation with Caudal Morphine Using a Surrogate Marker During Pediatric Cardiac Surgery

Background:Measurement of biomarkers representing sympathetic tone and the surgical stress response are helpful for objective comparison of anesthetic protocols. Aims: The primary aim was to compare changes in chromogranin A levels following pump pediatric cardiac surgery between children who received bolus caudal morphine and those who received a conventional intravenous narcotic?based anesthesia regime. The secondary objectives were to compare hemodynamic responses to skin incision and the magnitude of the rise in blood sugar values between the groups. Settings and Design: A prospective observational study at a tertiary cardiac center. Measurements and Methods: Sixty pediatric cardiac surgical patients were randomized to Group I [n = 30] to receive intravenous narcotic?based anesthesia and Group II [n = 30] to receive single?shot caudal morphine. Baseline and postoperative chromogranin A levels, the hemodynamic response to skin incision, changes in blood sugar levels, and the total intravenous narcotic dose administered were recorded for each participant. Statistical Analysis: Pearson’s Chi?squared test was used for comparison of categorized variables, and Mann–Whitney test was used for the analysis of continuous data. Results: Changes in chromogranin A levels and blood sugar levels were comparable in both groups. Group II received a lower narcotic dosage (P ? 0.001), and the response to skin incision as reflected by systolic pressure rise was less (P = 0.006). Conclusions: Surgical stress response attenuation was similar to caudal morphine as compared with intravenous narcotic?based anesthesia techniques as reflected by a similar increase in chromogranin A levels

Effect of low-dose dexamethasone on extra vascular lung water in patients following on-pump elective primary coronary artery bypass graft surgery

Background: The primary objective was to compare the effect of a low-dose dexamethasone as against a saline placebo on extravascular lung water index (EVLWI) in patients undergoing elective primary coronary artery bypass surgery. The secondary endpoints were to assess the effect of dexamethasone on other volumetric parameters (pulmonary vascular permeability index, global end diastolic volume index, and intrathoracic blood volume index), Vasoactive Inotrope Scores, hemodynamic parameters and serum osmolality in both groups. Settings and Design: Prospective observational study performed at a single tertiary cardiac care center. Materials and Methods: Twenty patients were randomized to receive either dexamethasone (steroid group, n = 10) or placebo (nonsteroid group, n = 10) twice before the institution of cardiopulmonary bypass (CPB). EVLWI and other volumetric parameters were obtained with the help of VolumeView™ Combo Kit connected to EV 1000 clinical platform at predetermined intervals. Hemodynamic parameters, vasoactive-inotropic Scores, hematocrit values were recorded at the predetermined time intervals. Baseline and 1st postoperative day serum osmolality values were also obtained. Results: The two groups were evenly matched in terms of demographic and CPB data. Intra- and inter-group comparison of the baseline EVLWI including other volumetric and hemodynamic parameters with those recorded at subsequent intervals revealed no statistical difference and was similar. Generalized estimating equation model was obtained to compare the changes between the groups over the entire study period which showed that on an average the changes between the steroid and nonsteroid group in terms of all volumetric parameters were not statistically significant. Conclusions: There were no beneficial effects of low-dose dexamethasone on EVLWI or other volumetric parameters in patients subjected to on-pump primary coronary bypass surgery. Hemodynamic parameters were also not affected. Probably, the advanced hemodynamic monitoring aided in optimal fluid management in the nonsteroidal group impacting EVLW accumulation.

A rare cause of wheezing in a child with pulmonary atresia

The determination of the exact cause for symptomatic airway obstruction in pediatric patients not responding to medication can be a clinical dilemma. Very rarely external vascular compressions can produce airway obstruction symptoms unresponsive to usual bronchodilator medications. The successful management of a child with pulmonary atresia and an innominate artery compression syndrome with respiratory compromise due to tracheal compression is described.

Preoperative predictors of poor laryngoscope views in pediatric population undergoing cardiac catheterization

Background: The primary objective of this study was to identify pre-anesthetic airway assessment parameters that would predict Cormack and Lehane grade III and IV laryngoscopy views in pediatric patients undergoing cardiac catheterization procedures. The secondary end points were to identify factors that would contribute to difficult laryngoscope views in this subset of patients. Settings and Design: Prospective observational study performed at a single tertiary cardiac care center. Materials and Methods: 199 children below 5 years of age undergoing elective cardiac catheterization were included. Pre-anesthetic airway assessment was done by modified Mallampati grading, lower lip to chin distance [LCD], tragus to mouth angle [TMA], thyromental distance [TMD], neck circumference [NC], and the ratio of height to thyromental distance [RHTMD]. Demographic data including American Society of Anesthesiologists physical status [ASA PS] were recorded for each child. Receiver Operating Characteristic curves were plotted and Areas Under the Curve were measured to identify the best cut off values for each of the airway evaluation method that would predict poor laryngoscopy views as well as assess their accuracy in doing so. Results: LCD, TMD and low body mass index were found to have good sensitivity, specificity and accuracy in predicting Grade III and IV laryngoscope views. ASA PS grade III and above patients had a significantly higher incidence of poor laryngoscope visualization. Conclusions: LCD, TMA, TMD, NC, RHTMD and BMI could all be used combinedly as screening tools during pre-anesthetic airway evaluation for predicting difficult laryngoscope views in children. Among these, LCD, TMD along with low body mass index might have better accuracy.

Accidental arterial puncture during right internal jugular vein cannulation in cardiac surgical patients.

Background: The primary aim of this study was to compare the incidence of accidental arterial puncture during right internal jugular vein (RIJV) cannulation with and without ultrasound guidance (USG). The secondary end points were to assess if USG improves the chances of successful first pass cannulation and if BMI has an impact on incidence of arterial puncture and the number of attempts that are to be made for successful cannulation. Settings and Design: Prospective observational study performed at a single tertiary cardiac care center. Material and methods: 255 consecutive adult and pediatric cardiac surgical patients were included. In Group I (n = 124) USG was used for the right internal jugular vein cannulation and in Group II (n = 81) it was not used. There were 135 adult patients and 70 pediatric patients. Statistical analysis: Demographic and categorical data were analyzed using Student ‘t’ test and chi- square test was used for qualitative variables. Results: The overall incidence of accidental arterial puncture in the entire study population was significantly higher when ultrasound guidance was not used (P < 0.001). In subgroup analysis, incidence of arterial puncture was significant in both adult (P = 0.03) and pediatric patients (P < 0.001) without USG. First attempt cannulation was more often possible in pediatric patients under USG (P = 0.03). In adult patients USG did not improve first attempt cannulation except in underweight patients. Conclusions: USG helped in the avoidance of inadvertent arterial puncture during RIJV cannulation and simultaneously improved the chances of first attempt cannulation in pediatric and in underweight adult cardiac surgical patients.

"Air embolism during fontan operation".

In patients with a right to left intracardiac shunt, air embolism results in an obligatory systemic embolization. Nonembolization of entrained air is described in a child with a single ventricle physiology who had earlier undergone bidirectional Glenn shunt construction and Damus–Kaye–Stansel anastomosis. The air entrainment was detected by intra-operative transesophageal echocardiography. The combined effect of a “diving bell” phenomenon and mild aortic valve regurgitation are suggested as the reasons for the confi nement of air into the ventricle preventing catastrophic systemic embolization.

Cardiac pacing in left bundle branch/ bifascicular block patients.

The primary concern in patients with bifascicular block is the increased risk of progression to complete heart block. Further, an additional first-degree A-V block in patients with bifascicular block or LBBB might increase the risk of block progression. Anesthesia, monitoring and surgical techniques can induce conduction defects and bradyarrhythmias in patients with pre-existing bundle branch block. In the setting of an acute MI, several different types of conduction disturbance may become manifest and complete heart block occurs usually in patients with acute myocardial infarction more commonly if there is pre-existing or new bundle branch block. The question that arises is whether it is necessary to insert a temporary pacing catheter in patients with bifascicular block undergoing anesthesia. It is important that an anesthesiologist should be aware of the indications for temporary cardiac pacing as well as the current recommendations for permanent pacing in patients with chronic bifascicular and trifascicular block. This article also highlights the recent guidelines for temporary transvenous pacing in the setting of acute MI and the different pacing modalities that are available for an anesthesiologist.

Off-pump bidirectional Glenn shunt by active decompression of the superior vena cava.

We report 2 cases of infants in whom off-pump bidirectional Glenn shunts were performed. A technique of decompressing the superior vena cava by active manual aspiration has been described. The challenges of maintaning the hemodynamic status, and cerebral protection maneuvers in association with mild hypothermia and a high transcranial pressure have been highlighted.