Skeletonization of left internal mammary artery in coronary artery bypass grafting

Objective: To compare mean per-operative flow capacity between skeletonized and pedicled left internal mammary artery [LIMA] in patients undergoing coronary artery bypass grafting [CABG] surgery

Study Design: Randomized control trial

Place and Duration of Study: Department of Cardiac Surgery, Armed Forces Institute of Cardiology and National Institute of Heart Diseases [AFIC-NIHD], Rawalpindi, Pakistan from February to August, 2013

Methodology: Patients undergoing CABG for coronary artery disease, under 80 years, excluded by the exclusion criteria; and fulfilling the inclusion criteria were randomly assigned to two groups of 70 each. One group underwent skeletonized and the other underwent pedicled technique of LIMA harvesting. Free flow was checked just before anastamosis of each LIMA to the LAD, manually in blood flow in ml per minute during cardiopulmonary bypass by allowing it to bleed into a 100 ml container over 20 seconds. A specialized proforma was used to record the age, gender, weight, disease, type of IMA used, and free flow of the IMA. Data was analyzed using SPSS 18

Results: The mean age of the patients was 57.16 years in 40 patients, ranging from 36 to 75 years. Disease pattern analysis showed 5%, 10.7% and 84.3% single, double and triple vessel coronary artery disease, respectively. There was significantly higher free flow in the skeletonized group than the pedicled group [p=0.04]

Conclusion: Skeletonized IMA had superior flow to pedicled IMA in addition to its traditional proven advantages, which justifies its further use as a conduit for myocardial revascularization

Developing sub-specialties in anesthesia - why we need cardiac anesthetists?

The specialty of anesthesia has progressed at a rapid pace since its first successful demonstration in 1846. Recognition and training in sub-specialties of anesthesia is not new and has been trending for last four decades in the developed countries. Cardiac anesthesia was conceived as a sub-specialty with a series of successful Blalock Taussig shunts and publication of first paper in 'Cardiac Anesthesia' in 1946. About 86% of the global burden of the cardiovascular disease is in the developing countries; coronary artery disease and rheumatic heart disease especially on a rise in Pakistan. With an increasing number of specialized cardiac centers across the country and specialists in cardiac surgery, there is a need of specialized cardiac anesthetists to meet the increasing demands

Comparison of topical use of protamine and tranexamic acid in surgical patients requiring cardio-pulmonary bypass

To determine the effectiveness of local protamine in reducing post-operative blood loss compared to loca1 tranexamic acid. Randomized controlled trial. Armed Forces Institute of Cardiology/National Institute of Heart Diseases Rawalpindi from January 2011 to September 2011. One hundred and twenty cardiac surgrcal patients were randomly divided into two equal groups, one receiving local protamine while the other group receiving local tranexamic acid before chest closure. The efficiency was measured as post-operative blood loss and requirement of blood and blood products in the post-surgical ICU. RAverage blood loss in protamine group was significantly less [252.97 ml] compared to tranexamic acie group [680.67 ml]. hTumber of patients requiring no post-operative blood transfusion was sigruficantly higher in protamine group [76.7%] compared to tranexamic acid group [53.3%]. Local protamine is more effective in reducing post-operative blood loss than local tranexamic acid

Topical application of tranexamic acid reduces postoperative bleeding in open-heart surgery: myth or fact?

To determine the efficacy of topical application of Tranexamic acid in controlling postoperative bleeding in open-heart surgery. Double blind randomized control trial. Departments of Cardiac Surgery and Intensive Care of Armed Forces Institute of Cardiology and National Institute of Heart Diseases [AFIC-NIHD], Rawalpindi, Pakistan, from May to October 2011. A total of 100 consecutive adult patients fulfilling the inclusion criteria undergoing elective on-pump cardiac surgeries were randomly divided in groups [A] and [B]. A study solution that contained 2.5 g of Tranexamic acid in 250 ml normal saline in group-A and equal amount of normal saline [placebo] in group-B was poured in the pericardial cavity over the mediastinal tissues before sternal closure. Postoperative bleeding was measured in both groups for 24 hours in the cardiac surgical ICU. Efficacy of Topical Tranexamic Acid / Placebo was measured in terms of mean postoperative bleeding in ml. Kindly again include these lines which seem to have been omitted in the final proof. There was significant difference in the mean postoperative bleeding within 24 hours among the two groups 340.1 +/- 112.4 ml in Tranexamic acid group vs. 665 +/- 187.28 ml in placebo group [p < 0.001]. Patients who did not have topical Tranexamic acid before chest closure had a significantly higher postoperative bleeding. Topical Tranexamic acid application is an effective and economical way for controlling non-surgical bleeding in patients undergoing cardiac surgery with cardiopulmonary bypass

Aortic aneurysm: a rare cause of Ortner's syndrome

A young man presented with hoarseness of voice and was found to have left vocal cord paralysis and a large opacity on chest X-ray in the left upper zone. CT angiography showed a giant aneurysm of the aortic arch involving the left subclavian artery. Using a dual perfusion system, with the femoral bypass circuit taking care of the spinal protection and the aortic bypass circuit providing the cerebral protection, the aneurysm was excised and a 16 mm Dacron [registered] graft was anastomosed to the aortic arch and the left subclavian artery was anastomosed to the interposition graft. He had a smooth postoperative course and his hoarseness subsided in next 6 months.

School children training for basic life support

To determine the background knowledge of high school children on basic life support by calculating the points scored in a MCQ-based test; to evaluate results of teaching basic life support skills to them; and assessing their power of retention by re-testing them on skills and MCQ test after the workshop. Quasi-experimental study. Armed Forces Institute of Cardiology and National Institute of Heart Diseases, Rawalpindi, Pakistan, from 1st September to 31st December 2008. Thirty children aged 11 - 15 years from 9 different schools of Rawalpindi were subjected to knowledge and skill based test at three different times. First was taken just after brief introduction to the subject of CPR and its related definitions, second after providing them hands-on CPR training, and last, after 3 months of CPR training, knowledge as well as CPR skills were tested. The children showed highly significant improvement in knowledge after CPR training and retention of knowledge and skills of CPR after 3 months period. There was no correlation of age, gender and weight to depth of compression and fatigue. There was a correlation between height and depth of compression. Children can learn and perform basic life support skills with reasonable accuracy and can retain these skills for longer periods. CPR training should be provided to all school children after 6[th] grade

Awareness during coronary artery bypass grafting surgery

To determine the frequency of awareness in patients undergoing coronary artery bypass grafting [CABG] with cardiopulmonary bypass [CPB]. Cross-sectional Survey. Armed Forces Institute of Cardiology, Rawalpindi - Pakistan. A total of 100 patients [both males and females] of age > 18 years, undergoing elective CABG, were interviewed 24-72 hours after anesthesia using a modified Brice questionnaire. Patient's anesthesia record was consulted and the drugs and doses used at induction and maintenance of Anesthesia at different stages of the surgery were noted down. Overall frequency of awareness was found to be 5%. It was found to be less in patients who received propofol infusion during CPB compared to the patients who did not. Regular use of sedation with propofol infusion during CPB can reduce the frequency of awareness. Bispectral index [BIS] monitoring can prove to be a helpful monitor of the depth of anesthesia during CPB

Maternal satisfaction after spinal anaesthesia for caesarean deliveries

To determine the level of satisfaction in terms of intra-operative pain and postoperative nausea, vomiting and backache among patients receiving spinal anaesthesia for caesarean section. Cross-sectional survey. Department of Anaesthesia and Intensive Care at the Combined Military Hospital, Bahawalpur, from August 2005 to June 2007. A total of 246 pregnant patients undergoing caesarean section under spinal anaesthesia were surveyed. Postoperatively, a questionnaire was given to the patients to score their satisfaction on a four-point visual analogue scale regarding pain during surgery, Postoperative Nausea and Vomiting [PONV], and postoperative backache. The average of response to the questions in each of these three areas was taken as the Fundamental Area Score [FAS] and the average of all these individual area scores was taken as the Patient Satisfaction Score [PSS]. There was high satisfaction score for PONV [98.17%]; but the satisfaction regarding intra-operative pain/ discomfort and postoperative backache was low as shown by a decrease in satisfaction score in these areas [74.09% and 76.83%]. Patient`s overall level of satisfaction with spinal anaesthesia was 81.40%. Patients [53.66%] would opt for spinal anaesthesia in future, if required, 90 [36.59%] would not and 8 patients [9.8%] were not sure. Most of the patients were satisfied with their experience with spinal anaesthesia although there was a higher frequency of postoperative backache

Intensive care management after inadvertent intravascular injection of liquid paraffin

Medication errors in the hospitals are not uncommon even in the developed countries. A 30 years old lady was admitted with 32 weeks pregnancy with gastroenteritis followed by intrauterine death. In the high dependency unit of obstetric department, accidentally 50 milliliters of liquid paraffin was administered intravenously. With 12 days of vigorous treatment comprising mechanical ventilation with positive end-expiratory pressure, an emergency hysterotomy to avoid the complications of intrauterine death; 3 cycles of plasmapherisis; and ultimately broncho-alveolar lavage, her condition improved and she was discharged from hospital

Field anesthesia - experience in United Nation missions

To communicate the experiences of anaesthesiologists while working in United Nations [UN] peace keeping missions in different parts of the world. Questionnaire based observational study. A questionnaire was sent to anaesthesiologists who had served in UN missions. The response was evaluated by simple percentage. Problems identified in a UN missions are: setup of operating room, high prevalences of HIV, Hepatitis B virus and Hepatitis C virus among the population of host country, different sources of medical stores, short supply of medical gases and problems related to malaria and its prophylaxis. The problems can be overcome by prior planning, use of non conventional practices of anesthesia and vigilance in monitoring in operating rooms and post operative recovery units. Optimal utilization of the equipment can be achieved with the help of non governmental organizations

Efficacy of esophageal detector device in verification of endotracheal tube placement

To assess accuracy of esophageal detector device [EED] for detection of endotracheal tube placement and to compare its performance with that of capnography. A prospective study in which 400 patients were divided into two groups. In group-I the patients were intubated as per routine, then the EDD and capnograph were again used to check both the tubes. The result showed 100% sensitivity, 100% specificity and 100% predictive value for EDD. The EDD was found to be very effective device in differentiating esophageal from tracheal intubation

Seroprevalence of hepatitis B and C in young adults seeking recruitment in Armed Forces

Hepatitis B virus [HBV] and hepatitis C virus [HCV] are the commonest causes of chronic liver disease all over the world including Pakistan. According to the Pakistan Armed Forces policy, all the military recruits are now screened for the Hepatitis B surface antigen [HBsAg] and antibodies to Hepatitis C virus [Anti-HCV] before induction. Previous studies have shown a wide variation in the results regarding the prevalence of HBV and HCV infections. We analysed sera of 15550 young adults seeking recruitment in Armed forces for the presence of HBsAg and Anti-HCV. Sera of healthy adult individuals who presented for medical evaluation as prerecruitment criteria in the Punjab Regiment Centre, Mardan, were tested for presence of hepatitis B surface antigen [HBsAg] and anti-hepatitis C virus [Anti-HCV] by rapid method. Positive cases were confirmed by ELISA technique from Armed Forces Institute of Pathology [AFIP] Rawalpindi. A total of 15550 individuals were examined. Out of these, 504 [3.24%] individuals had positive HBsAg whereas 574 [3.69%] were positive for anti-HCV. Hepatitis B surface antigen and anti-HCV both were found in 49 [0.31%] individuals. This study which evaluated predominantly healthy young male population, showed a high seroprevalence of anti-HCV than Hepatitis B surface antigen. Although there is downward trend in prevalence of hepatitis B, there is considerable threat of HBV and HCV to our younger population and there is a genuine need for strict adherence to preventive measures

Predicting difficult intubation - a comparison between Mallampati classification and Wilson risk-sum

To compare the Mallampati classification and Wilson risk-sum and adopt a predictive rule in our setup that has better results. An analytical study. The main Operation Theatre of Combined Military Hospital, Rawalpindi from 1st September to 31st December 2000. Three hundred and thirty-eight patients were evaluated pre-operatively for difficult intubation using both the tests. The sensitivities, specificities and positive predictive values [PPV] were determined in grading the laryngeal view in each case during direct laryngoscopy. Both tests identified only 3 out of 7 difficult intubations, giving a similar sensitivity of 0.42. Twice as many patients were predicted to be difficult by Maflampati classification than by Wilson risk-sum [specificity 84% and 93%]. The Wilson risk-sum had better positive predictive value [11%] as compared to 5% of Mallampati classification. The Wilson risk-sum had preferred for assessment of the airway because of its better specificity and positive predictive value while noting that both tests have poor sensitivities when used alone