Comparison of fast-track anesthesia and conventional cardiac anesthesia for valve replacement cardiac surgery

Background: Fast-track anesthesia has gained widespread use in cardiac centers around the world mainly for coronary artery bypass surgeries. However, only few studies have focused on fast-track anesthesia after valve surgeries. This study examines the feasibility and hemodynamic stability of fast-track anesthesia after valve surgeries

Methodology: The study was designed as a retrospective observational study. A total of 367 patients who underwent valve replacement surgery between January 2006 and November 2015 were included in this study. Conventional cardiac anesthesia [CCA] technique was followed initially from January 2006 to May 2010 while fast-track anesthesia protocol [FTA] was implemented from August 2010 onwards till November 2015. The objectives were to compare the duration of ventilation, the incidence of reintubation and postoperative pneumonia, incidence of low cardiac output syndrome, mortality and postoperative length of stay in the ICU, intermediate care unit and the hospital

Results: The CCA group comprised of 140 patients and the FTA group had 227 patients. There was a significantly shorter median time to extubation [4.30 hrs vs. 18.14 hrs], and reduced intensive care unit stay [40.85 hrs vs. 64.25 hrs] in FTA group. Patients in FTA group required inotropic support only for 12 hours in the immediate postoperative period, whereas CCA group required inotropic drugs for almost 30 hours. One patient in FTA group had pneumonia compared to 5 in CCA group. Two patients in FTA group required re-intubation for re-exploration. The fast-track group had significantly decreased median length of hospital stay [6.28 vs 8.41 days]

Conclusion: This study shows that fast-track anesthesia protocol can be applied safely to patients undergoing cardiac surgery other than coronary artery bypass grafting. Fast-tracking not only reduces ventilation time but also reduces hospital stay, with acceptable morbidity and mortality

C-MAC videolaryngoscope improves the laryngoscopic view in Mallampati class 2 and 3 patients

Objective: We aimed to compare C-MAC videolaryngoscope [VLC] with Macintosh laryngoscope with regard to the laryngoscopic view, the need for external laryngeal manipulation, requirement of airway adjuncts like stylet, time required to complete the tracheal intubation and the hemodynamic changes in Mallampati class 2 and 3 patients

Methodology: Sixty patients who were admitted for elective surgery requiring general anesthesia with endotracheal intubation were randomly allocated to proceed with endotracheal intubation using the conventional Macintosh laryngoscope [Group A] or the C-MAC VLC [Group B]. Following a standardised general anesthetic protocol, time for intubation, laryngoscopic view, need for external manipulation, and hemodynamic parameters during and after intubation were registered during study period

Results: It was observed that C-MAC VLC improves the laryngoscopic view in predicted difficult airway setting, and thus reduces the need for external laryngeal manipulation and the use of stylet. However, the hemodynamic stress response was significant with C-MAC VLC than Macintosh laryngoscopy. There was significant reduction in time taken for intubation with conventional Macintosh laryngoscope when compared with C-MAC® VLC. The median total intubation time for the Macintosh and C-MAC® VLC were 23.8 and 35.33 sec respectively [p = 0.000]

Conclusion: C-MAC® videolaryngoscope improves laryngoscopic view in difficult airway settings compared to the conventional Macintosh laryngoscope, but at the cost of prolonged time taken for intubation and increased hemodynamic stress response. Large scale studies may be required to determine the ultimate success of intubation with this new tool

Perioperative management of polytrauma in a post MVR patient with severe left ventricular systolic dysfunction

The anesthetic management of a patient with severe left ventricular dysfunction undergoing non cardiac surgery is a challenging task, as left ventricular systolic dysfunction [LVSD] is commonly complicated by progressive congestive heart failure and malignant arrhythmias. When the cause for LVSD is post valve replacement, additional complications like intraoperative thrombosis, bleeding and infective endocarditis need to be addressed peri-operatively. In such situations, the anesthesiologist must have the knowledge of hemodynamic changes, diagnostic and treatment modalities, as well as various drugs used during anesthesia. We report a case of post mitral valve replaced patient with severe LVSD posted for surgery of fracture of femur and facial fractures managed successfully during anesthesia

Randomized double blinded controlled study of ropivacaine versus bupivacaine in combined spinal epidural anesthesia

Ropivacaine and bupivacaine were compared in various combinations for orthopedic and obstetrics patients. We have compared the clinical efficacy of two combined spinal epidural drug regimens using equal volume of 0.75% isobaric ropivacaine to 0.5% hyperbaric bupivacaine intrathecally, and 0.125% of the plain drug along with epidural opioid for elective lower abdominal surgeries. 50 patients of ASA I or II of either sex, between 18 to 60 years of age scheduled for elective surgery under combined spinal and epidural anesthesia [CSEA] were randomly allocated into two groups. Bupivacaine group [B] received 3 ml of 0.5% bupivacaine intrathecally and 0.125% bupivacaine with fentanyl 2 microg/ml epidurally while Ropivacaine group [R], received 3 ml of 0.75% ropivacaine intrathecally and 0.125% ropivacaine with fentanyl 2 microg/ml epidurally. The two groups were compared for the onset of analgesia, onset of motor blockade, duration of analgesia, time for motor recovery and the haemodynamic variables. There were no significant haemodynamic changes in both the groups. The onset of motor block was similar in both groups [4 min] but the onset of sensory block was faster with group B patients [4 min] as compared to group R [6 min]. The duration of analgesia and the time till the need for start of epidural infusion was longer in group B [221.60 +/- 10.677 min] when compared to group R [198.40 +/- 23.216 min]. However, the time for regression of motor blockade was faster in group R [172.20 +/- 10.712 min] as compared to group B [205.20 +/- 13.423 min], facilitating early ambulation of the patients. This study illustrates that both the regimens were comparable in terms of level of block, analgesia and haemodynamic stability. Intrathecal ropivacaine and epidural ropivacaine with fentanyl was shown to result in adequate level of block, complete analgesia and haemodynamic stability. The onset of analgesia however was faster in patients who received intrathecal bupivacaine

Anesthetic management of a case of alkaptonuria

Alkaptonuria is a rare inherited autosomal recessive disorder of metabolism due to deficiency of homogentisic acid oxidase. This results in deposition of homogentisic acid in almost all the collagenous structures of the body leading to progressive multisystem involvement [alkaptonuric ochronosis] and poses a big challenge in anesthetizing such patients. We present one such case posted for total hip replacement and its successful management under general anesthesia

Perioperative management of a patient with gilberts syndrome and rheumatic heart disease

Anaesthetic management of patients with hepatic dysfunction can be quite challenging, as many anaesthetic agents are metabolized by liver. Heart disease on anti coagulation can pose additional challenge. Here we report a case of Gilbert's syndrome with rheumatic heart disease on anti coagulation posted for elective hernia repair