Rapid detection of acute kidney injury by urinary neutrophil gelatinase-associated lipocalin after cardiopulmonary bypass surgery

To determine the accuracy of neutrophil gelatinase-associated lipocalin [NGAL] in early detection of acute kidney injury [AKI] after cardiopulmonary bypass [CPB] surgery by comparing with serum creatinine. Descriptive study. Department of Chemical Pathology and Endocrinology, AFIP in collaboration with AFIC/ NIHD, Rawalpindi, from April to December 2011. Eighty eight patients undergoing CPB surgery in AFIC/NIHD were included by consecutive sampling. Blood samples of subjects for serum creatinine analysis were drawn pre-operatively, 4 h, 24 h and 48 h after CPB surgery. Spot urine samples for NGAL were collected at 4 h after CPB surgery. Urine samples were analyzed on Abbott ARCHITECT i2000SR analyzer whereas serum creatinine samples were measured on Beckman UniCel DxC 600 Synchron Clinical System. Out of 88 patients, 11 [13%] cases developed AKI 4 h postoperatively. Urinary NGAL increased markedly at 4 h postoperatively as compared to serum creatinine which showed rise at 24 - 48 h after cardiac surgery. Analysis of urine NGAL at a cutoff value of 87 ng/ml showed area under the curve of 0.91 [95% confidence interval [Cl] 0.83 - 0.96] with sensitivity of 90.9% [95% Cl 58.7 - 98.5] and specificity of 98.7% [95% Cl 92.9-99.8]. There was a positive correlation of 4 h urine NGAL and serum delta creatinine at 48 h, which was statistically significant [r[s] = 0.33, p = 0.001]. The study demonstrated that levels of urine NGAL in patients suffering from AKI increased significantly at 4 has compared to serum creatinine levels. Urine NGAL is an early predictive biomarker of AKI after CPB

Comparison of urine with plasma neutrophil gelatinase-associated lipocalin in detecting acute kidney injury after cardiopulmonary bypass surgery

To compare the accuracy of urine with plasma neutrophil gelatinase-associated lipocalin [NGAL] in early detection of acute kidney injury [AKI] following cardiopulmonary bypass [CPB] surgery. A prospective cohort study. Department of Chemical Pathology and Endocrinology, AFIP from December 2011 to July 2012. Ninety three adult patients planned for CPB surgery in AFIC/NIHD were consecutively included. Blood for serum creatinine were collected preoperatively, 4, 24 and 48 hours [h] after CPB surgery. Blood and urine samples for NGAL analysis were collected only at 4 h. Serum creatinine, plasma and urine NGAL samples were analyzed on UniCel[R] DxC 600 [Beckman], TRIAGE meter pro [Biosite] and ARCHITECT i2000SR analyzer [Abbott] respectively. Out of 93 patients undergoing CPB surgery, 12 [13%] developed AKI. AKI patients had significantly higher median interquartile range [IQR] urine NGAL of 180 ng/ml [105-277 ng/ml] as compared to control of 6 ng/ml [2-15 ng/ml] and median plasma NGAL of 170 ng/ml [126-274 ng/ml] as compared to control of 75 ng/ml [61-131 ng/ml]. The patients had increased urine vs plasma NGAL area under curve [AUC] [0.91 vs 0.70 [p = <0.001]], better sensitivity [91% vs 82%] and specificity [98% vs 65%]. Plasma and urine NGAL values increased significantly in AKI patients as compared to serum creatinine values. Urine in comparison to plasma NGAL revealed more sensitivity and specificity in detecting AKI following CPB surgery

Comparison of two methods of arterial cannulation in paediatric cardiac surgical patients

To compare the ease of arterial cannulation in terms of number of attempts and time taken to cannulate radial artery, using two different techniques of arterial cannulation in paediatric cardiac surgical patients. Randomized control trial Armed Forces Institute of Cardiology and National Institute of Heart Diseases, Rawalpindi Pakistan. One hundred consecutive paediatric patients up to the age of 12 years were cannulated in the radial artery using two methods of arterial cannulation randomly. One group was cannulated using plain cannula while the other was cannulated with saline technique i.e., filling the hub of the cannula with normal saline before arterial puncture. Time taken to cannulate the radial artery and number of attempts was noted in each case. There was a significant reduced mean time to cannulate radial artery in patients with 'saline-technique' compared to 'plain-technique' [135.55 +/- 65.14 seconds vs 108.75u +/- 52.84 seconds [p<0.05]. Similarly, the number of attempts to cannulate was lower in the saline technique group. Saline-technique to cannulate radial artery is better in paediatric patients as it helps in early detection of blood flashback and thus, successful cannulation

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

Walking epidural with low dose bupivacaine plus tramadol on normal labour in Primipara

To determine the obstetric outcome in terms of duration of labour and mode of delivery between the walking epidural analgesia with 0.1% Bupivacaine + 0.5% tramadol and routine labour practice. Non-randomized controlled trial. Department of Anaesthesia, Military Hospital, Rawalpindi, from August 2004 to July 2007. Consecutive 50 primiparous patients, ASA-I, coming to antenatal clinic for routine delivery were included in control group-A, and consecutive 50 primiparous ASA-I, coming to antenatal clinic and requesting for painless delivery were included in group-B. In group-A, only injection Nalbuphine 10 mg intramuscular was given when pain was unbearable, on patient's request as a routine practice. In group-B epidural analgesia was given with 15 ml of 0.1% Bupivacaine + 0.5 mg/ml Tramadol. First stage, second stage and total duration of labour were noted. Mode of delivery was also recorded in both groups. Patient satisfaction was assessed by interviewing the parturient ast evening round after delivery. In group-A, fist stage duration of labour was 3.72 +/- 1.16 hours and in group-B, it was 4.03 +/- 1.00 hours, [p < 0.001]. Second stage of labour in group-A was 0.55 +/- 0.35 hours and in group-B it was 0.67 +/- 0.33 hours; [p = 0.072]. Total duration of labour, group-A was 7.57 +/- 1.13 hours and in group-B it was 4.77 +/- 1.21 hours, [p < 0.001]. In group-A 46/50 [92%] patients were delivered spontaneously, while 4/50 [8%] required instrumental assistance, In group B 36/50 [72%] patients were delivered spontaneously and instrumental deliveries were 13/50 [26%] [p = 0.015]. One patient developed fetal distress and went through cesarean section in group B. Patient satisfaction was excellent in 88% of group-B parturients. Epidural analgesia with combination of low concentration of Bupivacaine, injection Tramadol and ambulation markedly reduce the duration of labour

Effects of modified ultrafiltration on blood products requirement in children undergoing open heart surgery

To find out the effects of modified ultrafiltration on blood products requirement for transfusion in congenital heart disease children after open heart surgery.This was a quasi-experimental study between two clinical groups. Patients were assigned to both groups by using convenient sampling; to do Modified Ultrafiltration or not was surgeon's preference who was unaware whether the patient is participating in any study or not. The study was carried out at Armed Forces Institute of Cardiology/National Institute of Heart Diseases [AFIC/NIHD] Rawalpindi between August, 2005 and September, 2006. Total 200 patients were included in this study and were divided equally into two groups; study group [MUF] and control group [non MUF] keeping hundred patients in each group. Significantly increased level of hemoglobin after MUF [9.7 +/- 1.4 gm/dl before MUF versus 13.6 +/- 1.6 gm/dl after MUF, p<0.001] and significantly decreased volume of blood products required for transfusion in study group [24.1 +/- 24.5 ml/kg versus control: 43.81 +/- 42.4 ml/kg, p<0.001]. Significantly increased hemoglobin level was observed during first three days of ICU stay [12.6 +/- 1.8 g/dl versus control: 11.6 +/- 2.1 g/dl, p=0.001on first postoperative day, 11.3 +/- 1.8 g/dl versus control: 10.8 +/- 1.9 g/dl, p=0.039 on second postoperative day and 11.3 +/- 1.5 g/dl versus control: 10.5 +/- 1.8 g/dl, p=0.022 on third postoperative day]. From this study we concluded that use of MUF is well tolerated in all the patients and due to removal of extra water from patients circulation after separation from CPB resulted in hemodynamic benefits, significantly less use of blood products and better postoperative hemoglobin and hematocrit management

Off pump coronary artery surgery and intraoperative safety-experience at AFIC/NIHD, Rawalpindi

Coronary Artery Bypass Grafting [CABG] with cardiopulmonary bypass [CPB] on one hand allows controlled haemodynamics with superior graft quality while on the other hand carries inherent risks of CPB which has renewed interest in Off-pump coronary artery bypass [OPCAB]. Haemodynamic instability and intraoperative dysrythmias are major procedural complications of OPCAB, threatening conversion to emergency on-pump surgery. The purpose of this study was to compare intraoperative dysrythmias and inotropic use for haemodynamic stabilization during OPCAB surgery against conventional CABG. Consecutive CABG cases operated between 1[st] June 2003 and 31[st] May 2006 were included while conversions were excluded. Primary end points were analyzed using chi square and t test and values described in percentages, means and probability [p value]. Six hundred and eighty-four cases were divided in group-A [on-pump, n=574] and B [OPCAB, n=97]. Conversion rate was 11.8%. Intraoperative dysrythmias [A, 3.5%, B, 15%, p<0.0001] and use of inotropic support was higher in group-B [A, 15.3%, B, 30.3%, p<0.0001]. Actual mortality in group-B was higher than the predictive value [A, 3.8%, B, 3.6%, Predictive value 3-5% and 0-3% respectively]. OPCAB leads to higher frequency of dysrythmias and inotropic use intraoperatively, highlighting lower procedural safety over conventional CABG

Amiodarone prophylaxis for atrial fibrillation after coronary artery bypass grafting

This study was planned to evaluate the preventive role of Amiodarone against atrial fibrillation after coronary artery bypass grafting. A comparative and interventional study. The study was done at Armed Institute of Cardiology / National Institute of Heart Diseases AFIC/NIHD Rawalpindi. In this study, 100 patients admitted three days before coronary artery bypass grafting were divided into Control and Amiodarone groups of 50 patients each. Patients in Control group did not receive any prophylaxis against atrial fibrillation before and after the coronary artery bypass grafting. While the patients in Amiodarone group received 200 mg oral Amiodarone thrice daily for three days, then 200 mg once daily on operative day and continued so until discharge. Postoperative atrial fibrillation occurred in 8 of 50 patients in the Control group [16%] and 2 of 50 patients in the Amiodarone group [4%] [p=0.045]. Maximum ventricular rate during atrial fibrillation episode in Control group was 122 +/- 5.83 beats per minute and 108 +/- 2.89 beats per minute in amiodarone group. Preoperative amiodarone was found to be significantly useful prophylactic agent to prevent atrial fibrillation after coronary artery bypass grafting and this drug can be used safely

Modified ultrafiltration in adult cardiac surgery is it really beneficial? A pospective randomized clinical trial

Cardiopulmonary bypass initiates systemic inflammatory response syndrome [SIRS] causing deleterious effects on various body systems with increased morbidity. Modified ultrafiltration [MUF] is a technique that removes excess water and inflammatory mediators from the circulation in the post-bypass period resulting in reduced bleeding, less blood transfusion requirements and overall reduced morbidity. 96 patients were randomly selected and divided into two groups. In Group I called MUF group [n=50], modified ultrafiltration was carried out for 15 min in the post bypass period. Group II called NON-MUF group [n=46], MUF was not carried out. Clinical assessment was based on ASA class. Mean cardiopulmonary bypass and aortic cross clamp times were 95.42 and56.94 min and 77.98 and 43.64 min in the MUF and NON-MUF groups respectively. Variables were expressed as mean and percentage. In the MUF group, there was increase in Hb by more than 2g/dl in 32 patients [64%] whereas in the NON-MU F group, this increase was only in 12 patients [20%] Mean postoperative chest drainage was far less [422 ml] in MUF group as compared to NON-MUF group [842.50 ml]. Transfusion [449.12ml Vs 996.58 ml] and postoperative ventilatory requirements [40% Vs 47.8%] were also less in MUF group than NON-MUF group. Inotropic support was nearly comparable in both the groups but overall morbidity [Low cardiac output state, sepsis, reopening] was less in the MUF group [18%] as compared to NON-MUF group [30%]. Mean ICU stay was also less in MUF group [mean 51.52 hrs] than in NON-MUF group [mean 55.43 hrs]. One patient in each group died. Modified Ultrafiltration is associated with improved hemoglobin, less postoperative bleeding, reopening and transfusion requirements with overall reduced morbidity and ICU stay. However, the need for inotropes were not significantly different in the two groups

Comparison of haemodynamic effects of unilateral versus bilateral spinal anaesthesia

A comparative study was carried out to determine whether the unilateral spinal block produces comparatively less hemodynamic disturbances as compared to bilateral spinal block or not. Fifty male patients of age 25- 40 years of comparable weight and height, and ASA status I and II were selected and divided into two groups, Group A and Group B. Each group was assigned 25 patients by convenience sampling. Blood loss was comparable in both groups. All patients were assessed pre-operatively a night before operation. Two variables i.e. pulse and blood pressure was measured a night before operation, just before spinal injection and every thirty minutes for a total period of 180 minutes after the spinal injection. Average duration of surgical procedures was 57 +/- 13 minutes. Each patient was premedicated with tablet "Diazepam 10 mg" a night before operation and injection Diazepam 05 mg IV just before spinal injection and pre- loaded with 5% Dextrose Saline 500 ml. All patients were injected "abocaine spinal" 0.75% [heavy] 1.5 ml at L4-5 or L3-4 interspace intradurally with the help of 23G spinal needles under aseptic measures. Group-A patients were kept supine in flexed position for 10 minutes and Group B patients were kept in lateral decubitus position with surgical side down, for 10 minutes. Block was achieved up to T10-11 level. Contra lateral side was checked for block. Two groups were clinically comparable as regard to patient characteristics and methods of study e.g. dose and type of drug used and level of anaesthesia achieved. There was no significant hypotension or bradycardia in any group; rather there was an increase in blood pressure and heart rate in few patients signifying sympathetic over activation in younger patients. In younger age group haemodynamic changes were negligible in either group of study most probably due to active sympathetic system at the unblocked area. Unilateral block could be a more useful concept in older age group and autonomically compromised patients

Outcome of ventricular septal defect closure

To identify the factors affecting the outcome, measured in terms of morbidity and mortality, after primary ventricular septal defect [VSD] closure. Design: Descriptive study. Place and Duration of Study: Armed Forces Institute of Cardiology / National Institute of Heart Diseases, Rawalpindi, from January 2002 to October 2003. Subjects and Children upto the age of 5 years who had primary VSD closure were studied. Patients were divided into two groups. Group-I included survivors and group-II included non-survivors. There was no difference in the conduct of operation among the two groups. A total of 53 patients were operated of whom 47 survived. Pulmonary hypertensive crisis [p < 0.001], pulmonary infections [p < 0.001] and pleural effusions [p < 0.003] were higher in non-survivor group. Patients in non survivor group were younger [0.75 + 0.34 years vs 2.24 + 1.16 years, p = 0.01] having less body weight [4.91 + 1.56 kg vs 7.94 + 3.35, p = 0.03] and high pulmonary artery to systemic pressure ratio at the time of coming off bypass [0.63 + 0.13 vs 0.43 + 0.09, p < 0.001]. Non survivors had higher association [66.6% vs 19.1%] of additional left to right shunts [p < 0.001]. Body weight less than 5 kg along with young age, high pulmonary artery to systemic pressure ratio at the time of coming off bypass and presence of additional left to right shunt are risk factors for adverse outcome

Continuous renal replacement therapy for acute renal failure patients in ICU setting: various techniques and their dynamics

Incidence of acute renal failure [ARF] in post cardiac surgical patients remains high [5 - 18%] and mortality associated with it is still said to be nearer to 80%. But, even this fact does not make renal failure an acceptable cause of death unless a conscious decision has been made not to treat it in the face of another non-recoverable disease. So the message remains that every patient suffering from ARF in an ICU setting MUST be treated aggressively unless DNAR [Do Not Attempt Resuscitation] status has been decided by a team of consultants. Vast majority of the patients suffering from ARF in a post cardiac surgical ICU have low cardiac output syndrome [LCOS]. These patients remain on aggressive cardiorespiratory and monitoring support and hence can not be moved to haemodialysis units. At the same time they are unable to tolerate the osmotic and haemodynamic stress of haemodialysis. Thus continuous renal replacement therapies [CRRT] remain the only option available to them. Different types of CRRT are available. The list includes Peritoneal dialysis [PD], slow continuous ultrafiltration [SCUF], Continuous arteriovenous haemofiltration [CAVH], Continuous veno-venous haemofiltration [CVVH], continuous arteriovenous haemodiafiltration [CAVHDF], and continuous veno-venous haemodiafiltration [CVVHDF]. Every modality has its own advantages and limitations and should be selected according to requirement of the patient