Peripheral arterial blood pressure versus central arterial blood pressure monitoring in critically ill patient safter Cardio-pulmonary Bypass

Objective: To determine the accuracy of peripheral [radial] arterial access as compared to central [femoral] arterial access for measurement of invasive blood pressure [IBP] in critically ill patients after cardiopulmonary bypass

Methods: Sixty patients [60] who required high inotropic/vasopressor support on weaning from cardio-pulmonary bypass and weaned off in 2nd attempt were included in this study. The duration of this study was from June 2015 to August 2016. Radial and femoral arterial access was achieved in all patients for simultaneous measurement of blood pressure. Arterial pressures were noted after 5, 15 and 30 minutes of weaning from cardiopulmonary bypass for both radial and femoral artery simultaneously

Results: Mean age of study patients was 56.48+/-11.17 years. 85% patients were male. There was significant difference in systolic blood pressure, diastolic blood pressure and mean arterial pressures between the radial artery and femoral artery cannulation. Mean arterial pressures were significantly high in femoral artery as compared to the radial artery. The mean arterial pressures after five minutes of weaning using central access were 76.28+/-10.21 mmHg versus 64.15+/-6.76 mmHg in peripheral arterial access [p-value <0.001]. Similarly we also found significant difference in mean arterial pressures after 15 minutes of weaning from cardiopulmonary bypass 78.70+/-10.12 mmHg in central access versus 72.03+/-6.76 mmHg using peripheral arterial access [p-value <0.001]. The difference in arterial pressures were less marked as compared to the previous differences after 30 minutes of weaning from cardiopulmonary bypass as compared to the earlier readings [p-value 0.001]

Conclusion: Peripheral arterial pressures are unreliable in critically ill patients after cardiopulmonary bypass receiving high dose of inotropic drugs. Central arterial access should be used in these patients to get accurate estimates of patients' blood pressure in early periods after cardiopulmonary bypass

Myocardial protection with glucose-insulin-potassiuminfusion during adult cardiac surgery

Background and Objective: Recent meta-analysis reports have called for more randomized trials to evaluate the effectiveness of GIK solution in patients of cardiac surgery. So this study was conducted to evaluate the effectiveness of Glucose-insulin-potassium [GIK] solutions in non-diabetic patients undergoing coronary artery bypass grafting

Methods: A total number of one hundred and sixty [160] patients were randomized into two equal groups; GIK Group and non-GIK group. In GIK group, 5% dextrose containing 70 IU/L regular insulin and 70 meq/L of potassium was administered. The infusion was started at a rate of 30 ml/hour after induction of anesthesia and before the start of cardiopulmonary bypass. The infusion was started again after removal of aortic cross clamp and was continued for six hours after the operation

Results: In early post-operative period, peak CKMB levels were high in non-GIK group 48.50+/-19.79 IU/L versus 33.40+/-14.69 IU/L in GIK group [p-value <0.001]. There was no statistically significant difference in requirements of inotropic support between the groups. The mean duration of inotropic support in GIK group was only 5.50+/-6.88 hours in GIK group and 8.64+/-7.74 hours in non-GIK group [p-value 0.008]. Mean ventilation time in GIK group was 5.06+/-2.39 hours versus 6.55+/-3.58 hours in non-GIK group [p-value 0.002]. Similarly, ICU stay period was also shorter in GIK group [p-value 0.01]. We did not found any detrimental effect of GIK infusion on non-cardiac complications e.g. renal, pulmonary and neurologic complications

Conclusion: Glucose-insulin-potassium [GIK] infusion has a beneficial role in myocardial protection and is associated with better post-operative outcomes without increasing the risk of non-cardiac complications

Incidence and risk factors of pulmonary complications after cardiopulmonary bypass

Objective: To determine the frequency of post-operative pulmonary complications [PPCs] after cardio-pulmonary bypass and association of pre-operative and intraoperative risk factors with incidence of PPCs

Methods: This study was an observational analysis of five hundred and seventeen [517] patients who underwent cardiac surgery using cardiopulmonary bypass. Incidence of PPCs and risk factors of PPCs were noted. Logistic regression was applied to determine the association of pre-operative and intraoperative risk factors with incidence of PPCs

Results: Post-operative pulmonary complications occurred in 32 [6.2%] patients. Most common postoperative pulmonary complication was atelectasis that occurred in 20 [3.86%] patients, respiratory failure in 8 [1.54%] patients, pneumonia in 3 [0.58%] patients and acute respiratory distress syndrome in 1 [0.19%] patients. The main risk factor of PPCs were advance age > 60 years [odds ratio 4.16 [1.99-8.67], p-value <0.001], prolonged CPB time > 120 minutes [odds ratio 3.62 [1.46-8.97] p-value 0.003], pre-op pulmonary hypertension [odds ratio 2.60 [1.18-5.73] p-value 0.016] and intraoperative phrenic nerve injury [odds ratio 7.06 [1.73-28.74], p-value 0.002]. Operative mortality was 9.4% in patients with PPCs and 1.0% in patients without PPCs [p-value 0.01]

Conclusion: The incidence of post-operative pulmonary complications was 6.2% in this study. Advanced age [age > 60 years], prolonged CPB time [CPB time > 120 minutes], pre-op pulmonary hypertension and intraoperative phrenic nerve injury are independent risk factors of PPCs after surgery

Effect of applying lignocaine gel, diclofenac gel or their combination on endotracheal tube on the hemodynamic response and incidence of postoperative complications in patients undergoing CABG surgery

Objectives: Hoarseness of voice, cough and sore throat are well known complications of endotracheal intubation. Many pharmacological strategies are used to reduce the incidence of these complications post surgery. We conducted this study to see the effectiveness of local application of diclofenac sodium gel, lidocaine gel or the effect of these two drugs when applied in combination on tracheal tube during intubation, regarding hemodynamic response and the incidence of postoperative sore throat, hoarseness of voice and cough

Methodology: In this prospective, randomized single blind trial, 150 patients undergoing coronary artery bypass graft [CABG] surgery at Chaudhry Pervaiz Elahi Institute of Cardiology from January 2016 to March 2016, were selected. The patients were divided into three groups; Group X [control Group] in which endotracheal tube [ETT] was lubricated with 2% lignocaine gel. Group D: ETT was lubricated with diclofenac sodium gel [2%]. And Group XD: where a mixture of lignocaine and diclofenac sodium gels was used to lubricate ETT before insertion. Data were analyzed in SPSS V16. One way ANOVA and chi-square test was used for analysis of quantitative and qualitative variables respectively taking p-value < 0.05 to be significant

Results: There was no difference in the age and gender of patients between groups. Post intubation HR increased more in Group D [108.94 +/- 7.40 beats/min.], and least in Group XD 96.62 +/- 3.84 beats/min and 100.72 +/- 6.98 beats/min in group X [p < 0.0001]. HR returned back to baseline value in group X and Group XD within five minutes after intubation but remained higher in diclofenac group [p < 0.0001]. The rise in blood pressure after intubation was highest in Group D [162.46 +/- 5.05 mmHg], then 157.34 +/- 5.43 mmHg in Group X, and least in Group XD [154.12 +/- 6.07 mmHg] [p < 0.0001]. Similarly blood pressure after five minutes of intubation was still high in Group D and was least in Group XD [p < 0.0001]. The time of return of HR and systolic blood pressure to baseline value was 9.00 +/- 1.33 min in Group D, 4.59 +/- 1.03 min in Group X and 3.43 +/- 0.81 min in group XD [p < 0.0001]. Incidence of sore throat, hoarseness of voice and cough was highest in Group X and less in Group D and was least in Group XD [p-values 0.039, 0.025 and 0.002 respectively]

Conclusion: Local application of a combination of lignocaine and diclofenac sodium gels over the endotracheal tube before intubation is associated with better hemodynamic control and significantly lower incidence of postoperative sore throat, hoarseness of voice and cough

Continuous low tidal volume ventilation during cardiopulmonary bypass reduces the risk of pulmonary dysfunction

Objective: Pulmonary dysfunction is considered to be the most important complication after open heart surgery. Different maneuvers like intermittent or continuous positive pressure ventilation, low tidal volume ventilation and different vital capacity maneuvers have been used for reducing the incidence of pulmonary dysfunction after cardiac surgery. In this study we evaluated the effects of low tidal volume ventilation versus no-ventilation during cardiopulmonary bypass [CPB] in patients undergoing conventional CABG surgery

Methodology: This randomized clinical trial was conducted in a tertiary care cardiac hospital. One hundred patients who were planned to undergo conventional CABG surgery were divided into two groups by using draw randomization procedure. In Group A patients [ventilation group] ventilation was continued at low tidal volume of 3 ml/kg, respiration rate of 12 breaths/min and PEEP of 5 cmH[2]O. In Group B patients [non-ventilation group] ventilation was arrested during CPB. For data analysis Statistical Package for Social Sciences [SPSS] V17 was used. Parametric variables were compared using unpaired t-test and non-parametric variables were compared using o[2]-test

Results: The mean patient's age in this study was 57.70 +/- 8.57 years in ventilated group and 54.5 +/- 8.33 years in non-ventilated group. PaO[2]/FiO[2] ratio and alveolar-arterial oxygen tension gradient immediately after intubation was same in groups. But PaO[2]/FiO[2] was significantly high in ventilated group after one hours of CPB and even after four hours of CPB [p < 0.001 and 0.002 respectively]. Alveolar arterial oxygen tension [A-a O[2]] gradient after 1 hour and four hours of CPB was significantly low in Ventilated group [p < 0.001 and 0.001 respectively]. Total Mechanical ventilation time was also significantly shorter in ventilated group 5.19 +/- 1.96 hours versus 6.42 +/- 2.60 hours in non-ventilated group [p 0.009]. On 4th post-operative day, incidence of atelectasis was significantly low 20% in ventilated group versus 38% in non-ventilated group [p = 0.04]

Conclusion: Continuous low tidal volume ventilation is associated with better oxygenation after surgery and reduced risk of post-op pulmonary complications during cardiopulmonary bypass in patients undergoing conventional coronary artery bypass graft surgery

comparison of post-operative analgesic and hemodynamic effects of extradural neostigmine plus fentanyl with fentanyl alone in patients of hysterectomy

To study the comparative analgesic and haemodynamic effects of fentanyl with a combination of neostigmine plus fentanyl administered epidurally for post-operative pain in patients undergoing hysterectomy. This is an interventional, randomized, controlled study leading to therapeutic trial of a combination of drugs. The study was conducted at High Dependency Unit [HDU], Nishtar Hospital Multan, Pakistan. The study was completed in six months period from June to December 2004. One hundred female patients belonging to age range 40 60 years, of ASA 1 and 2, undergoing elective abdominal hysterectomy, were included in this study. They were randomly divided into two groups by the consultant anaesthetist. Patients having any clinical or biochemical evidence of any systemic diseases were excluded from the study. The procedure was explained to the patients and informed consent was obtained. All the patients were examined an evening before the operation. A lumber epidural catheter was passed before induction of general anesthesia. From immediate postoperative period till 20 hours, patients were given fentanyl alone in group A and fentanyl plus neostigmine in group B by epidural infusion. While assessing the intensity of pain relief in both the groups, the effects on hemodynamics were also recorded. Significant reduction in the intensity of pain was noted in the neostigmine plus fentanyl group. Moreover lower values of mean arterial pressure were recorded in this group, while significantly slower heart rates were found in the 4 th to 7 th hours of postoperative period. Epidurally administered neostigmine along with fentanyl gives better pain [qualitative] relief than fentanyl alone. Lower values of mean arterial pressure and slower heart rates at 4,5,6 and 7 hrs of infusion were seen