A rare case of herniation of liver through incision of cabg: A case report and review of literature.

Herniation of liver through an incision of previous surgery is a very rare phenomena. Here we present a case of herniation of part of left lobe of liver through a defect in the anterior abdominal wall due to previous coronary artery bypass surgery (CABG) surgery. Up till now only two cases have been reported for liver herniation through scar of previous of CABG surgery and this would be the third case as per our knowledge.

BYPASS SURGERY BY GRAFTING ARTERY MAMMARIA INTERNA ONTO CORONARY ARTERY DURING OPEN HEART SURGERY / Шинэ санаа Шинэ нээлт

According to the 2013 WHO survey, the world’s leading cause of death is a coronary heart disease which is accounted for 12.9%. Bypass surgery by grafting Artery mammaria interna to the left anterior descending coronary artery is more clinically significant and has long become an international standard. Aim: To study the outcomes in patients who undergone a bypass surgery ofgrafting the Artery mammaria interna to the left anterior descending coronary artery in an open heart surgery. In 2014 in the case-control study conducted at the Shastin 3rd National Central Hospital, 8 patients who undergone a bypass surgery of grafing Artery mammaria internasinistra to the left anterior descending coronary artery were selected for a case group and 8 patients with bypass grafting of a superficial vein of the leg to the coronary artery were selected as a control group. Related diseases, heart function, type of grafting performed, and post-operative complications were studied. The successful bypass surgeries of grafting the Artery mammaria interna sinistra to the left anterior descending coronary artery without complications in the case group in 2014 has demonstrated that the Mongolian cardiosurgical team was able to successfully and fully introduce this innovative approach that has become an international standard of coronary artery surgery. The introduction of this method enables to eliminate angina pectoris symptoms in patients, restore and improve heart contractions, reduce the chances of a repeat heart attack, and thus, to improve the patient’s ability to live and work normally.

Proper Target Concentration of Fentanyl during Endotracheal Intubation with a CACI (Computer Assisted Continuous Infusion) in Patients Undergoing Coronary Artery Bypass Graft Surgery / 대한마취과학회지

BACKGROUND: The computer-assisted continuous infusion (CACI) system was developed to more rapidly attain and to maintain stable effect-site fentanyl concentrations as compared with the intermittent injection method. The CACI system allows the anesthesiologist to control effect-site fentanyl concentrations during various surgical stimuli during cardiac anesthesia. This system can rapidly control the depth of anesthesia and compensate for the disadvantages of IV anesthesia. Early patient recovery also enables early tracheal extubation, which is an important component of the "fast track" cardiac surgery pathway. In this study, the use of a target-controlled infusion of low-dose propofol was combined with the target-controlled infusion of fentanyl for patients undergoing coronary artery bypass graft surgery. The purpose of this study was to evaluate the proper effect-site concentration of fentanyl for the tracheal intubation of patients undergoing coronary artery bypass graft surgery. METHODS: Fifty patients scheduled for elective coronary artery bypass graft surgery were included, and randomly allocated to group L (effect-site fentanyl concentration = 5 ng/ml, n = 25) or group H (effect-site fentanyl concentration = 7.5 ng/ml, n = 25). Anesthesia was induced and maintained by the computer-controlled infusions of propofol and fentanyl. Hemodynamics and other variables were recorded preinduction, and before and 1 minute after intubation. RESULTS: The two groups were compared with regard to demographic and perioperative data. The two groups were similar demographically, and no significant differences was found in any hemodynamic parameter at any time between the two groups. CONCLUSIONS: Both fentanyl regimens provided stable hemodynamics and adequate anesthesia in patients during endotracheal intubation. It is reasonable to say that the lower dose of fentanyl (5 ng/ml) may be the better choice, because it provides the same level of anesthesia during endotracheal intubation during coronary artery bypass graft surgery.

Effects of Clonidine on the Requirements of Dopamine Used as a Concomitant Drug of Amrinone in Coronary Artery Bypass Surgery (CABG) / 대한마취과학회지

BACKGROUND: Clonidine premedication has many beneficial effects in patients undergoing CABG surgery. Amrinone, having the ability to increase cardiac performance without increasing myocardial O2 consumption, is a valuable drug in postoperative management after cardiopulmonary bypass (CPB). The use of amrinone with a catecholamine is also important clinically because the cathecholamines support perfusion pressure and the combined use exerts synergistic or additive effects. We performed this study to examine whether clonidine premedication could change the amount of dopamine used concomitantly with amrinone for management after CPB. METHODS: Nineteen patients for elective CABG were allocated to two groups according to their premedication; a placebo (Group 1, n = 13) or clonidine 4 microgram/kg p.o. (Group 2, n = 6). All patients arrived in the operating room with infusion of isosorbide dinitrate (ID). Anesthesia was performed with standard techniques. Before initiation of CPB, significant lowering of BP or HR was treated with phenylephrine or atropine respectively. Amrinone was given bolus (0.75 mg/kg) and infusion (10 microgram/ kg/min) was begun instead of ID at the release of aortic cross-clamp. Dopamine infusion (3 microgram/kg/min) was started at 35degree C (rectal) and its rate was adjusted for maintaining acceptable hemodynamics. We compared the amount of infused dopamine within 90 mins after CPB between the two groups. We also compared systolic BP, HR and CVP before induction, 10 mins after induction and 60 mins after CPB. RESULTS: Systolic BP and HR before induction and HR 10 mins after induction were significantly lower in Group 2 (P < 0.05), but they were all within normal range. The proportion of patients who needed phenylephrine or atropine before CPB was not significantly different in the two groups. The amount of infused dopamine was significantly larger in Group 2 (P < 0.05). Hemodynamics were acceptable after CPB although HR 60 min after CPB was significantly lower within the normal range in Group 2 (P < 0.05). Weaning time from CPB was not significantly different in the two groups. No significant adverse effect was observed throughout this study. CONCLUSIONS: Clonidine, used as premedication, increases the need of catecholamine which is concomitantly administered with amrinone for weaning from CPB. But this method provides clinically effective result without jeopardizing hemodynamics in CABG.

A Comparison of Cardiac Output Measurements between Non-Invasive Partial Rebreathing Method and Invasive Intermittent Thermodilution Method during Coronary Artery Bypass Graft / 대한마취과학회지

BACKGROUND: A reliable non-invasive cardiac output measurement could enhance patient safety and reduce risk. Partial rebreathing cardiac output (RBCO) measurement is a non-invasive method based on a differential form of the CO2 Fick equation. The relative change in CO2 and ETCO2 in response to addition of dead space to the breathing circuit is used to measure cardiac output. The aim of this study was to compare this method in coronary artery bypass graft (CABG) patients during pre-cardiopulmonary bypass (CPB) and post-CPB with the currently accepted technique of intermittent thermodilution cardiac output (TDCO) measurement. METHODS: Eleven patients (n = 11, age = 50 +/- 13 years) undergoing CABG operations with CPB were studied. We measured the cardiac output non-invasively by using a RBCO monitor (NICO(R) , Novametrix Medical Systems Inc., USA) and used SpO2 and FiO2 to correct for intrapulmonary shunts. Invasively, using a pulmonary artery catheter (Hands-Off Thermodilution Catheter(R) , Arrow Co., USA) and 10 ml of iced 5% dextrose, an average of three consecutive TDCO was measured during end-expiration and compared with corresponding RBCO during pre-CPB and post-CPB for a total of 6 times respectively. Data was analyzed by paired T-test with significance set at P value < 0.05. RESULTS: Pre-CPB paired T-test analysis revealed no significant difference between partial rebreathing and bolus thermodilution cardiac output measurements. On the other hand, post-CPB differences between the two methods were significant (P < 0.05) and tended to decrease with time. Similarly, Pa-ETCO2 was increased abnormally after CPB, then decreased with time to a normal value. CONCLUSION: Post-CPB, partial rebreathing cardiac output did not correlate well with the thermodilution cardiac output. As a cause for the differences of the two cardiac output measurements, we couldconsider a thermal noise during thermodilution and an inadequate correction for the shunts in partial rebreathing measurements, but further investigation is needed.