The Use of Ketamine as an Induction Agent for Anesthesia in Pulmonary Thromboendarterectomy Surgery: A Case Series

Pulmonary thromboendarterectomy (PTE) surgery is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension (CTEPH). The induction of anesthesia in patients with severe pulmonary hypertension (PHT) can be challenging, with a risk of cardiovascular collapse. The administration of ketamine in patients with PHT is controversial, with some recommendations contraindicating its use. However, ketamine has been used safely in children with severe PHT. We present a retrospective case series of adult patients with severe PHT presenting for PTE surgery, using intravenous ketamine as a co?induction anesthetic agent.

An analytical study of Comparison between Ketamine - Dexmedetomidine versus Ketamine - Propofol for Sedation in Children Undergoing Minor Cardiac Procedures in a Cardiac Catheterization Laboratory

Background: The management of children with heart diseases has been a major challenge for cardiac anesthesiologist. The anesthetic technique to be used should be easy, safer and provide cardiac stability throughout the operation. So interventional cardiologist prefer deep sedation with the patient breathing spontaneously and painlessly in the room. Propofol, Ketamine along with other combinations drugs have been used worldwide by cardiac anesthesiologist to achieve these goals. We carried out this study to evaluate the combination drugs for pediatric cardiac procedures which are Ketamine – Dexmedetomidine (KD) and Ketamine – Propofol (KP). Methodology:This study was conducted in the Department of Cardiology. A total number of 80 cases were selected, 40 from each comparative groups of Ketamine – Dexmedetomidine (KD) and Ketamine – Propofol (KP). Patient data was categorized into age, sex, procedure done and recovery time, analgesic boluses required and hemodynamic parameters during the surgery. Results: Mean age in KD group was 5.24 ± 1.25 years and in KP group was 4.95 ± 1.86 years. There were total 24 males (60%) and 16 females (40%) in KD group and total 22 males (55%) and 18 females (45%) in KP group. Most common procedures done in both the groups was ASD for device closure done in 12 patients (30%) in KD group and 13 patients (32.5%) in KP group. There was signi?cant difference between the mean recovery time and number of ketamine boluses consumption in both the groups. (p<0.05) Heart rate was signi?cantly lower in KD group at 5, 10, 15 and 20 min post induction when compared to KP group. No statistically signi?cance was found in difference between the Mean Respiratory rate and MAP. Conclusion:Our study concludes that the use of KD combination is relatively safe, practical alternative, we did not ?nd any hemodynamic or respiratory effects during the cardiac procedures but there was some delayed recovery.

A survey of practices during cardiopulmonary bypass in India: An Indian association of cardiovascular and thoracic anesthesiologist endeavor

Context: Cardiac anesthesiologists play a key role during the conduct of cardiopulmonary bypass (CPB). There are variations in the practice of CPB among extracorporeal technologists in India. Aims: The aim of this survey is to gather information on variations during the conduct of CPB in India. Settings and Design: This was an online conducted survey by Indian College of Cardiac Anaesthesia, which is the research and academic wing of the Indian Association of Cardiovascular Thoracic Anaesthesiologists. Subjects and Methods: Senior consultants heading cardiac anesthesia departments in both teaching and nonteaching centers (performing at least 15 cases a month) were contacted using an online questionnaire fielded using SurveyMonkey™ software. There were 33 questions focusing on institute information, perfusion practices, blood conservation on CPB; monitoring and anesthesia practices. Results: The response rate was 74.2% (187/252). Fifty-one (26%) centers were teaching centers; 18% centers performed more than 1000 cases annually. Crystalloid solution was the most common priming solution used. Twenty-three percent centers used corticosteroids routinely; methylprednisone was the most commonly used agent. The cardioplegia solution used by most responders was the one available commercially containing high potassium St. Thomas solution (55%), followed by Del Nido cardioplegia (33%). Majority of the responders used nasopharyngeal site to monitor intraoperative patient temperature. Antifibrinolytics were commonly used only in patients who were at high risk for bleeding by 51% of responders, while yet, another 39% used them routinely, and 11% never did. About 59% of the centers insist on only fresh blood (<7 days old) when blood transfusion was indicated. The facility to use vaporizer on CPB was available in 62% of the centers. All the teaching centers or high volume centers in India had access to transesophageal echocardiography probe and echo machine, with 51% using them routinely and 38% using them at least sometimes. Conclusions: There is a wide heterogeneity in CPB management protocols among various Indian cardiac surgery centers. The survey suggests that adherence to evidence-based and internationally accepted practices appears to be more prevalent in centers that have ongoing teaching programs and/or have high volumes, strengthening the need to devise guidelines by appropriate body to help bring in uniformity in CPB management to ensure patient safety and high quality of clinical care for best outcomes.

Comparison of immediate extubation versus ultrafast tracking strategy in the management of off-pump coronary artery bypass surgery

Introduction: Ultrafast tracking of anesthesia (UFTA) is practiced routinely, whereas immediate on-table extubation after off-pump coronary artery bypass (OPCAB) grafting surgery has many concerns. The purpose of our study was to evaluate the safety and feasibility of immediate extubation (IE) versus UFTA. Methods: Sixty patients were enrolled who underwent OPCAB surgery. The two groups IE and UFTA had thirty patients each. Inclusion criteria were patients for OPCAB surgery including left main stenosis. Exclusion criteria were patients with Ejection Fraction(EF) <30%, with unstable hemodynamics, on intra-aortic balloon pump (IABP), with renal dysfunction, with associated valvular heart diseases, on inotropes, on temporary pacemaker, with intraoperative conversion to on-pump coronary artery bypass grafting (CABG), who are chronic smokers, and with chronic obstructive pulmonary disease. Statistical analysis was done with Minitab 15 software. Descriptive statistics were summarized as mean, standard deviation, and percentage. Student's t-test was used to determine the significance of normally distributed parametric values. Z-test was used for proportion. Statistical significance was accepted at P < 0.05. Results: OT extubation was found to be safe as no patient had reintubation or respiratory insufficiency. None of the patients in either group had postoperative myocardial infarction, stroke, low cardiac output, mediastinitis, and renal failure. Hypothermia, blood transfusion, atrial fibrillation, and re-exploration did not occur. Intensive Care Unit length of stay was similar in the two groups. Discharge day is statistically significant (P = 0.001), with 5.66 days in the IE group and 6.36 days in the UFTA group. Time spent in the operating room at the end of surgery is statistically significant, with 14.03 min in UFTA group and 33.9 min in IE group. Conclusion: IE appears to be safe and effective in OPCAB patients without any major complications. It can be achieved after fulfilling traditional extubation criteria but is confined to highly selective group of patients.

Retrospective study of complete atrioventricular canal defects: Anesthetic and perioperative challenges

Objective: The objective of this study was to highlight anesthetic and perioperative management and the outcomes of infants with complete atrioventricular (AV) canal defects. Design: This retrospective descriptive study included children who underwent staged and primary biventricular repair for complete AV canal defects from 1999 to 2013. Setting: A single-center study at a university affiliated heart center. Participants: One hundred and fifty-seven patients with a mean age at surgery of 125 ± 56.9 days were included in the study. About 63.6% of them were diagnosed as Down syndrome. Mean body weight at surgery was 5.6 ± 6.3 kg. Methods: Primary and staged biventricular repair of complete AV canal defects. Measurements and main results: A predefined protocol including timing of surgery, management of induction and maintenance of anesthesia, cardiopulmonary bypass, and perioperative intensive care treatment was used throughout the study. Demographic data as well as intraoperative and perioperative Intensive Care Unit (ICU) data, such as length of stay in ICU, total duration of ventilation including reintubations, and total length of stay in hospital and in hospital mortality, were collected from the clinical information system. Pulmonary hypertension was noted in 60% of patients from which 30% needed nitric oxide therapy. Nearly 2.5% of patients needed permanent pacemaker implantation. Thorax was closed secondarily in 7% of patients. In 3.8% of patients, reoperations due to residual defects were undertaken. Duration of hospital stay was 14.5 ± 4.7 days. The in-hospital mortality was 0%. Conclusion: Protocolized perioperative management leads to excellent outcome in AV canal defect repair surgery.

Perioperative management of patients with left ventricular assist devices undergoing noncardiac surgery.

Aim: The aim of this study was to describe our institutional experience, primarily with general anesthesiologists consulting with cardiac anesthesiologists, caring for left ventricular assist device (LVAD) patients undergoing noncardiac surgery. Materials and Methods: This is a retrospective review of the population of patients with LVADs at a single institution undergoing noncardiac procedures between 2009 and 2014. Demographic, perioperative, and procedural data collected included the type of procedure performed, anesthetic technique, vasopressor requirements, invasive monitors used, anesthesia provider type, blood product management, need for postoperative intubation, postoperative disposition and length of stay, and perioperative complications including mortality. Statistical Analysis: Descriptive statistics for categorical variables are presented as frequency distributions and percentages. Continuous variables are expressed as mean ± standard deviation and range when applicable. Results: During the study, 31 patients with LVADs underwent a total of 74 procedures. Each patient underwent an average of 2.4 procedures. Of the total number of procedures, 48 (65%) were upper or lower endoscopies. Considering all procedures, 81% were performed under monitored anesthesia care (MAC). Perioperative care was provided by faculty outside of the division of cardiac anesthesia in 62% of procedures. Invasive blood pressure monitoring was used in 27 (36%) procedures, and a central line, peripherally inserted central catheter or midline was in place preoperatively and used intraoperatively for 38 (51%) procedures. Vasopressors were not required in the majority (65; 88%) of procedures. There was one inhospital mortality secondary to multiorgan failure; 97% of patients survived to discharge after their procedure. Conclusion: At our institution, LVAD patients undergoing noncardiac procedures most frequently require endoscopy. These procedures can frequently be done safely under MAC, with or without consultation by a cardiac anesthesiologist.

Different transseptal puncture for different procedures: Optimization of left atrial catheterization guided by transesophageal echocardiography.

Background: Left atrial catheterization through transseptal puncture is frequently performed in cardiac catheterization procedures. Appropriate transseptal puncture is critical to achieve procedural success. Aims: The aim of the study is to evaluate the feasibility of selective transseptal punctures, using a modified radiofrequency (RF) transseptal needle and transesophageal echocardiography (TEE), in different types of procedures that require specific sites of left atrial catheterization. Setting and Design: This was an observational trial in a cardiac catheterization laboratory of a teaching hospital. Materials and Methods: Patients undergoing different percutaneous procedures requiring atrial transseptal puncture such as atrial fibrillation (AF) ablation, left atrial appendage (LAA) occlusion, and mitral valve repair were included in the study. All procedures were guided by TEE and an RF transseptal needle targeting a specific region of the septum to perform the puncture. Statistical Analysis: The statistical analysis was descriptive only. Results: RF‑assisted transseptal punctures were performed in six consecutive patients who underwent AF ablation (two patients), LAA closure (two patients), and mitral valve repair (two patients). In all patients, transseptal punctures were performed successfully at the desired site. No adverse events or complications were observed. Conclusions: Selective transseptal puncture, using TEE and an RF needle, is a feasible technique that can be used in multiple approaches requiring a precise site of access for left atrial catheterization.

Effect of etomidate and propofol induction on hemodynamic and endocrine response in patients undergoing coronary artery bypass grafting/mitral valve and aortic valve replacement surgery on cardiopulmonary bypass.

Introduction: The concerns for induction of anaesthesia in patients undergoing cardiac surgery include hemodynamic stability, attenuation of stress response and maintenance of balance between myocardial oxygen demand and supply. Various Intravenous anaesthetic agents like Thiopentone, Etomidate, Propofol, Midazolam, and Ketamine have been used for anesthetizing patients for cardiac surgeries. However, many authors have expressed concerns regarding induction with thiopentone, midazolam and ketamine. Hence, Propofol and Etomidate are preferred for induction in these patients. However, these two drugs have different characteristics. Etomidate is preferred for patients with poor left ventricular (LV) function as it provides stable cardiovascular profile. But there are concerns about reduction in adrenal suppression and serum cortisol levels. Propofol, on the other hand may cause a reduction in systemic vascular resistance and subsequent hypotension. Thus, this study was conducted to compare induction with these two agents in cardiac surgeries. Methods: Baseline categorical and continuous variables were compared using Fisher’s exact test and student’s t test respectively. Hemodynamic variables were compared using student’s t test for independent samples. The primary outcome (serum cortisol and blood sugar) of the study was compared using Wilcoxon Rank Sum test. The P value less than 0.05 was considered significant. Results: Etomidate provides more stable hemodynamic parameters as compared to Propofol. Propofol causes vasodilation and may result in drop of systematic BP. Etomidate can therefore be safely used for induction in patients with good LV function for CABG/MVR/AVR on CPB without serious cortisol suppression lasting more than twenty-four hours.

Comparison of cardioprotection between sevoflurane-remifentanil and midazolam-sufentanil total intravenous anesthesia during off-pump coronary artery bypass surgery

BACKGROUND: Volatile agents have been reported to protect myocardium against ischemia. But, there were a few clinical reports about the myocardial protection of inhalation agents. So we investigated the cardiac protection of sevoflurane in comparison with total intravenous anesthesia (TIVA). The study is a retrospective unrandomized study via the medical record review. METHODS: The records of 102 patients who received off-pump CABG were reviewed. One patient group received TIVA by midazolam and sufentanil continuous infusion (TIVA group, n = 68), and the other patient group received an inhalational anesthesia by sevoflurane (sevoflurane group, n = 34). Except maintenance of anesthesia, two groups of patients received an identical surgical, anesthetical, and postoperative care. At arrival in the intensive care unit, and after 1, 2, 3 and 5 days, serum cardiac enzyme levels were measured. RESULTS: All the median values of cardiac enzyme concentrations were lower in the sevoflurane group than TIVA group. Moreover, there were the significant differences between groups at the immediate postoperative CK-MB (median 4.7 ng/ml versus 5.9 ng/ml (P = 0.049)), 1-5 days postoperative LD (1 day 271.5 U/L versus 292 U/L (P = 0.045), 2 day 227.5 U/L versus 270 U/L (P = 0.009), 3 day 215 U/L versus 250 U/L (P = 0.030), 5 day 218 U/L versus 231 U/L (P = 0.005)), and 1, 3 postoperative troponin I level (0.485 ng/ml versus 1.12 ng/ml [P = 0.029], 0.090 ng/ml versus 0.235 ng/ml [P = 0.047] respectively). CONCLUSIONS: Sevoflurane lowered cardiac enzyme levels in comparison with TIVA after off-pump CABG anesthesia. These data suggest a cardioprotective effect of sevoflurane during CABG.

Validation of a decision-making strategy for systolic anterior motion following mitral valve repair.

Low cardiac output syndrome and hypotension are dreadful consequences of systolic anterior motion (SAM) after a mitral valve (MV) repair. The management of SAM in the operating room remains controversial. We validate a recently suggested two-step management method and classification of this complication. This was a teaching hospital-based observational study. We validated a novel two-step conservative management method, consisting in intravascular volume expansion and discontinuation of inotropic drugs (step 1), and increasing the afterload by ascending aorta manual compression while administering esmolol e.v. (step 2). We also validate a novel classification of SAM: easy-to-revert (responding to step 1), difficult-to-revert (responding to step 2), or persistent. Fifty patients had an easy-to-revert while 26 had a difficult-to-revert SAM; 4 patients had a persistent condition (promptly diagnosed through our decisional algorithm) and underwent an immediate second pump run to repeat the mitral repair surgery. We confirmed that SAM after a repair of a degenerative MV is common and validated a simple two-step conservative management method that allows to clearly identify those few patients who require immediate surgical revision.

Preoperative ephedrine counters hypotension with propofol anesthesia during valve surgery: A dose dependent study.

The prophylactic use of small doses of ephedrine may counter the hypotension response to propofol anesthesia with minimal hemodynamic changes. One hundred-fifty patients scheduled for valve surgery were randomly assigned into five groups (n = 30 for each) to receive saline, 0.07, 0.1, or 0.15 mg/kg of ephedrine, or phenylephrine 1.5 μg/kg before induction of propofol-fentanyl anesthesia. After induction, patient receiving ephedrine had higher mean arterial pressure, systemic vascular resistance (SVRI), cardiac (CI), stroke volume (SVI), and left ventricular stroke work (LVSWI) indices. Patients received 0.15 mg/kg of ephedrine showed additional increased heart rate and frequent ischemic episodes (P < 0.001). However, those who received phenylephrine showed greater rise in SVRI, reduced CI, SVI, and LVSWI and more frequent ischemic episodes. We conclude that the prophylactic use of small doses of ephedrine (0.07−0.1 mg/kg) is safe and effective in the counteracting propofol-induced hypotension during anesthesia for valve surgery.

Dexmedetomidine as an adjunct to anesthetic induction to attenuate hemodynamic response to endotracheal intubation in patients undergoing fast-track CABG.

During induction of general anesthesia hypertension and tachycardia caused by tracheal intubation may lead to cardiac ischemia and arrhythmias. In this prospective, randomized study, dexmedetomidine has been used to attenuate the hemodynamic response to endotracheal intubation with low dose fentanyl and etomidate in patients undergoing myocardial revascularization receiving beta blocker treatment. Thirty patients undergoing myocardial revascularization received in a double blind manner, either a saline placebo or a dexmedetomidine infusion (1 µg/kg) before the anesthesia induction. Heart rate (HR) and blood pressure (BP) were monitored at baseline, after placebo or dexmedetomidine infusion, after induction of general anesthesia, one, three and five minutes after endotracheal intubation. In the dexmedetomidine (DEX) group systolic (SAP), diastolic (DAP) and mean arterial pressures (MAP) were lower at all times in comparison to baseline values; in the placebo (PLA) group SAP, DAP and MAP decreased after the induction of general anesthesia and five minutes after the intubation compared to baseline values. This decrease was not significantly different between the groups. After the induction of general anesthesia, the drop in HR was higher in DEX group compared to PLA group. One minute after endotracheal intubation, HR significantly increased in PLA group while, it decreased in the DEX group. The incidence of tachycardia, hypotension and bradycardia was not different between the groups. The incidence of hypertension requiring treatment was significantly greater in the PLA group. It is concluded that dexmedetomidine can safely be used to attenuate the hemodynamic response to endotracheal intubation in patients undergoing myocardial revascularization receiving beta blockers.

Comparison between Regional Cerebral Oxygen Saturation and Jugular Bulb Venous Oxygen Saturation in Patients Undergoing OPCAB Surgery / 대한마취과학회지

BACKGROUND: Hypoperfusion during manipulation of the heart in off-pump coronary artery bypass (OPCAB) surgery may lead to postoperative neurological complications. Therefore, it will be necessary to monitor cerebral function during OPCAB surgery. In this study, we compared regional cerebral oxygenation (rSO2) by near-infrared spectroscopy (NIRS) with jugular bulb venous oxygen saturation (SjvO2) and assessed whether rSO2 measured by NIRS could be an alternative method of SjvO2 during OPCAB surgery. METHODS: A total of 20 patients who underwent OPCAB surgery were studied. A fiberoptic catheter was placed in the right jugular bulb to measure SjvO2 while a cerebral oximeter based on NIRS, INVOS 5100B was used to monitor rSO2. Radial arterial and jugular bulb blood samples were drawn simultaneously from baseline every hour during operation. The values of rSO2 were compared with SjvO2 values. RESULTS: For all data points (n = 78) for all patients combined, rSO2 values were significantly correlated with SjvO2 values (r = 0.513, P < 0.0001). There were significant correlations between arterial carbon dioxide and values of SjvO2 (r = 0.393, P = 0.0002) and rSO2 (r = 0.432, P < 0.0001). CONCLUSIONS: We concluded that NIRS correlates with SjvO2 in this patient population. These findings suggest that near-infrared spectroscopy may be useful in assessing cerebral oxygenation during OPCAB surgery.

Continuous Cardiac Output by using Arterial Pressure Waveform Analysis and Central Venous Oxygen Saturation during Cardiac Surgery: A case report / 대한마취과학회지

The determination of arterial pressure wave-derived cardiac output (APCO) and central venous O2 saturation (ScvO2) has been introduced as a less invasive procedure for monitoring cardiac function and oxygen delivery. We have used an APCO sensor (FloTracTM) and a monitor for ScvO2 (Vigileo(TM)) in two cases of cardiac valve surgery, where placement of pulmonary artery catheter (PAC) was not applicable due to unfavorable cardiac structure (case 1) and was contraindicated due to an unstable cardiac conduction disorder and arrhythmia (case 2). In case 1, monitoring of APCO was started from the beginning of anesthesia induction and a ScvO2 monitoring central venous catheter was inserted just after anesthesia induction. APCO, ScvO2 and other hemodyanamic information such as arterial BP, CVP, and data obtained from transesophageal echocardiography (TEE) during the pre- cardiopulmonary bypass (CPB) period were measured. APCO and ScvO2 during the post-CPB period showed a reliable correspondence with continuous cardiac output (CCO) and mixed venous O2 saturation (SvO2) as measured by PAC at the end of CPB. In case 2, APCO and ScvO2 were monitored instead of CCO and SvO2. The values of APCO showed a good correlation to intraoperative COs indirectly calculated by the velocity-time integral of the aortic outflow determined in the TEE examination. We experienced that monitoring APCO and ScvO2 is useful for anesthesia management in cardiac valve surgery and can be an alternative to CCO and SvO2 if the placement of PAC and the thermodilution method are not applicable.

Aortic/Radial Arterial Pressure Difference during Weaning from Cardiopulmonary Bypass in Open Heart Surgery Patients Anesthetized with Propofol-Alfentanil / 대한마취과학회지

BACKGROUND: Cardiovascular drugs are frequently used to assist myocardial function after discontinuation of cardiopulmonary bypass (CPB) in the open heart surgery (OHS) because of unstable hemodynamics. At this time we should always consider that the radial arterial pressure (RAP) may be lower than the aortic pressure (AP). In this study we evaluated the difference between AP and RAP in propofol-alfentanil anesthesia. METHODS: 28 patients undergoing elective OHS were randomly allocated into a midazolam-fentanyl (MA) group (n = 14) or a propofol-alfentanil (PA) group (n = 14). Anesthesia in the MF group consisted of midazolam and fentanyl with intermittent bolus injection, and anesthesia in the PA group consisted of propofol and alfentanil with continuous in fusion. RAP and AP in the two groups were recorded for 5 minutes after CPB discontinuation. RESULTS: No significant difference was founded between the two groups in age, weight, height, CPB time, aortic cross clamping (ACC) time, or temperature. There was a relatively high correlation between the difference of systolic AP-RAP and CPB time (r = 0.01), and ACC time (0.001). The systolic and mean blood pressure difference between the aorta and the radial artery in the MF group was significantly greater than in the PA group. CONCLUSIONS: This findings suggest that propofol-alfentanil anesthesia in OHS may be more helpful for hemodynamic management after CPB discontinuation than midazolam-fentanyl anesthesia.

Anesthetic Management for Off-Pump Coronary Artery Bypass Graft Surgery / 대한마취과학회지

Off-pump coronary artery bypass graft surgery (OPCAB) may be of benefit overall for the patient and surgical techniques for OPCAB have been developed markedly. The development of surgical techniques without severe hemodynamic instability allows surgeons to access to all coronary arteries. Hemodynamic instability due to the displacement and restraining of the heart and transient ischemia during anastomoses are major problems associated with OPCAB. The maintenance of stable hamodynamic and minimization of cardiac dysfunction during anastomosis should be stressed in the anesthesia for OPCAB. The baseline anesthetic methods and monitoring for OPCAB are the same as for conventional coronary artery bypass graft surgery (CABG). The temperature management is a significant problem and appropriate provision is needed for defibrillation and pacing during anastomosis because rhythm problems are not uncommon. Prevention and treatment of hypotension, low cardiac output, and dysrhythmia is a major focus of anesthetic management. Volume loading and Trendelenberg position is helpful maintaining cardiac output and perfusion pressure. If hemodynamic deterioration occurs, quickly progress to potent vasopressors/ inotropic agents. Treatment of myocardial ischemia must be guided by the patient's overall hemodynamic status. Therapies to consider include titrated beta-adrenergic blockers, increasing blood pressure to improve collateral flow, treating the spasm of native coronaries or arterial conduits, reversing Trendelenberg to reduce left ventricular filling and wall stress and shunting. Close observation for surgical field and open communication with surgeon is essential to predict the patients most likely to need above modalities and bearing similarities with anesthesia for CABG in mind will help the anesthesiologist to be more comfortable with anesthesia for OPCAB.

Comparison between Fast Track Cardiac Anesthesia and Regular Anesthesia for Pediatric Patients with Congenital Heart Disease / 中国微创外科杂志

Objective To retrospectively compare the postoperative recovery and medical cost of pediatric patients underwent fast track cardiac anesthesia(FTCA,extubated in operating room)or regular anesthesia(extubated out of operating room).Methods From January 2005 to January 2006,108 children with congenital heart disease were operated under FTCA,108 patients who received regular anesthesia were set as a control group.The general characteristics,anesthetic method,postoperative treatments,recovery,and medical cost of the two groups were compared.Results The mean body weight of FTCA group was significantly higher than that in the control [(13.8?4.2)kg vs(10.9?3.8)kg,t=5.321,P=0.000].The patients received sevoflurane for anesthesia induction in the FTCA group were more than those in the control(58 vs 16,?2=36.260,P=0.000).The mean dosage of fentanyl used during operation in FTCA group was significantly lower than that in the control [(10.9?7.3)?g/kg vs(18.0?5.7)?g/kg,t=-7.697,P=0.000].In addition,fewer patients in FTCA group used more than one kind of sedative after the operation(7 vs 19,?2=6.296,P=0.012).95 patients in FTCA group returned to their ward without extubation-related complications.No significant difference in length of hospital stay was found between the two groups,however,the medical cost of FTCA group was significantly lower than that in the control(P

The Circulatory Effect of Pheniramice Malate at Initial Period of Extracorporeal Circulation in Pediatric Open Heart Surgery / 대한마취과학회지

Plasma protein derivatives such as plasms protein fraction and 5% albumin are popular pump primes in extracorporeal circulation. But, the use of plasma protein fraction is in s dilemma due to its hypotensive effect. The aim of this study is to evaluate the effects of plasma protein fraction on arterial pressure and central venous pressure as one of the components of priming solution. And also in order to assess the role of histamine indirectly as a possible vssodepressive substance causing hypotension, we used one of the antihistamines as a indirect indicator. Fourty pediatric eardiac patients undergoing cardiopulmonary bypass were randomly assigned to two groups as with or without pheniramine malate and plasma protein fraction 250ml was mixed in priming solution in all cases. Mean arterial snd central venous pressure were checked just before cardiopulmonary bypass(baseline) and every one minute after pump on for 5 minutes. Pheniramine malate, 0.75mg/ kg, was added in prime solution 10 minutes before pump on to twenty patients and not the other twenty patients. In both groups, mean arterial pressure at the beginning of pump showed significant decrease (P<0.05) from baseline. But there were no differences between two groups. Central venous pressure showed no significant chsnge between groups and intra group. These data suggest that other plasma expander other than plasma protein fraction should be considered for prime in pediatric cardiac surgery and other vasodepressive materials than histamine may play major role in inducing hypotension.

Cardiovascular Responses of General Anesthesia with Nalbuphine - Diazepam - O2 - 1/2 MAC Halothane and Awareness during Operation for Adult Open Heart Surgery / 대한마취과학회지

Recently, nalbuphine has been used for reversal of opioid indueed respiratory depression. Because of its structural chsracter, nalbuphine has been known as a better nareotic antagonist with keeping analgesic potency and without considerable cardiovascular responses. Some investigators reported nalbuphine can decrease minimum alveolar concentration(MAC) of major inhalation anesthetic agents and can be a intravenous anesthetic adjuvant but can accompany several adverse reactions such as hypertension and tachycardia etc. To evaluate the eligibility and efficacy of nalbuphine as a intravenous narcotic adjuvant for cardiac anesthesia, we selected 24 adult cardiac patients and divided them into 3 groups. Valvular surgerys were performed for group I patients, aorto-coronary-bypass surgerys(CABG) for group II and correction of congenital heart disease for group III, respectively, All patients were inducted general anesthesia with 0.3 mg/kg nalbuphine+0.1 mg/kg diazepam+2 mg/kg thio- pental sodium and maintained with intermittent injection of 0.3-0.5 mg/kg nalbuphine and O.l mg/kg diazepam just before the time of most stressful surgical stimuli with 1/2 MAC halothane inhalation under vecuronization for muscle relaxation. We measured heart rate(HR), systolic blood pressure(BP), central venous pressure(CVP) at pre-induction as a control data, and just after endotracheal intubation, skin incision, sternotomy, and skin closure respectively to compare basic cardiovascular responses of patients at surgical stimuli with control data. We also checked recovery time of consciousness and presence of awareness during operation. The results were as follows: 1) Significant HR changes occurred in group I at just after intubation time from 104+/-18.6 to 134+/-25.9 and in group II from 83+/-10.5 to 115+/-32.3 respectively. 2) There were few significant changes of systolic blood pressure during anesthesia of all groups except just after intubation in group II from 135+/-32.8 torr to 168+/-37.9 torr.3) A significant CVP decrease occurred only in group I at the time of skin closure from 13+/-3. 5 cmHO to 10+/-3.8 cmH2O because of operative correction of tricuspid regurgitation of group I patients rather than anesthesia effects. 4) Recovery of consciousness needed average 1 hr 30 mins in group I and 2 hr 45 mins in group II. None of patients complained awareness during operations. Above results demonstrate that Nalbuphine-Diazepam-O2-1/2 MAC Halothane can be a anesthetic method for open heart surgery without any significant cardiovascular responses at surgical and anesthetic stimuli except intubation stimulus, but for more evaluation study of Nalbuphine-Diazepam-O2 Anesthesia will be needed.