randomized comparison of ultrasound guided versus direct palpation method of radial artery cannulation techniques in adult patients undergoing open heart surgery

Background and Objective: The use of two dimensional ultrasound technique allows radial artery cannulation to take place under real time visualization and may increase the success rate of first time pass of the needle and reduce the complications of the invasive procedure compared to traditional palpation and trial method

We aimed to compare the success rate of radial arterial catheter insertion at first attempt and average time for successful first attempt by traditional palpation method with ultrasound guided technique in adult patients undergoing open heart surgery

Methodology: A randomized study was conducted at our hospital during a 12 months period from 1st January 2014 to 31st December 2014. After taking permission from hospital ethical committee, one hundred adult patients were enrolled in whom radial artery cannulation was required prior to open heart surgical procedures including CABG, valvular heart disease, atrial septal and ventricular septal defect repairs and total correction. Patients were divided in two equal groups. In Group I radial artery cannulation was performed by ultrasound guidance and in Group II it was done by palpation method; in both groups Seldinger technique was used

Demographic and medical data were recorded in both groups. Heart rate, and invasive blood pressure monitoring was done in the arm in which the catheter was going to be inserted. Alien test with the help of pulse oximeter was also performed in all patients for detecting adequacy of ulnar artery flow. Time to first successful cannulation and the number of attempts were noted

Computer software SPSS 19.0 was used for data statistical analysis, the Chi-square/Fisher's exact test used for the comparison of qualitative/categorical variable in between groups. Student's t-test used for comparison of quantitative / continuous variables in between groups

Results: Average time to first successful attempt was 72.4 +/- 23.0 sec vs. 94.6 +/- 13.7 sec in Group I and II respectively [p=0.001]. Average number of attempts at same radial artery was significantly less in ultrasound group [1.4 +/- 1.0] as compared to palpation group [2.0 +/- 0.7] [p=0.001]. Ultrasound group [Group 1] had successful insertion at the first attempt in 36 [72%] patients, as compared to 32 [64%] patients in [Group II], but the difference was statistically not significant [p = 0.391]

Conclusion: Average time for successful first attempt was significantly less for radial artery cannulation performed by two dimensional ultrasound guidance as compared to palpation method; however, it did not significantly increase the success rate of first time cannulation of radial artery

Frequency and predictors of cognitive decline in patients undergoing coronary artery bypass graft surgery

To determine the frequency of cognitive impairment and its predictors in patients, who underwent first time coronary artery bypass graft surgery [CABGS]. An observational study. The National Institute of Cardiovascular Diseases [NICVD], Karachi, from December 2008 to December 2009. Study included patients > 18 years, who underwent first-time elective CABGS. Emergency CABGS, with additional cardiac procedures, myocardial infarction [MI] within one month and known psychiatric illness were excluded. Patients were evaluated for their socio-demographic profile, medical history, intra-operative, anesthetic and surgical techniques and postoperative complications/therapy in ICU. Cognitive functioning, before the surgery, at discharge, 6 weeks and 6 months post-CABG was evaluated by McNair's and MMSE scales. HDRS was added to see if depression was a confounding factor for cognitive decline. One hundred and thirty four patients were followed-up at discharge, 74 at 6 weeks and 73 at 6 months. There were 113 [84.3%] males and 21 [15.7%] females, with mean age of 53.7 +/- 8.36 years. Prevalence of cognitive disturbance at baseline was 44.8%, which increased to 54.5% at discharge, and improvement was seen at 6 months, it was 39.7%. Older age, female gender, higher bleeding episodes, and high post-surgery creatinine level were more frequently associated with cognitive decline. Postoperative cognitive deficit was common and remained persistent at short-term. Older age, females and high postoperative creatinine were identified as its important predictors. There was high frequency of acute depression before surgery with significant reduction over time

Anticoagulation therapy during pregnancy and puerperium

Thrombotic complications are three to five times higher than non-pregnant women and even in pregnant women anticoagulant therapy is indicated for the prevention and treatment of a number of cardiac and non-cardiac conditions. This therapy may have some serious concerns for the safety of the new life in the womb of the mother or to the mother if she has to undergo some type of operative delivery. Whether, anti-coagulation is achieved with oral or injectable drugs, we must be fully aware of the pharmacology, and the means to control the undesirable side effects

Brain Abscess with cyanotic heart disease

Twenty-eight patients of congenital cyanotic heart disease associated with brain abscess, who underwent neurosurgical intervention over a period of 5 years from June 1995 to June 2000 were reviewed. The mean age was 6.32 +/- 3.2 years [range 3-14 years] with a male preponderance. Patients having the tetralogy of Fallot were 78.57 percent. Abscesses located supratentorially were 49.28 percent with 42.8 percent predominance in the frontal lobe. Eighteen out of 28 patients were polycythemic with a mean haemoglobin of 16.07 +/- 2.7gm percent while their arterial oxygen saturation varied between 64 percent-92 percent. Twenty one patients underwent CT guided burrhole aspiration, under anaesthetist monitored local anaesthesia, with a repeat aspiration in 12 while aspiration was followed by craniotomy and excision of abscess in seven. Seven underwent primary excision. Mortality in patients undergoing craniotomy for excision of abscess was 35.7 percent as compared to burrhole aspiration group of 14.2 percent with an over all mortality of 25 percent. Morbidity in patients who survived surgery and were discharged was 57.42 percent. We found burrhole aspiration under anaesthetist monitored local anaesthesia relatively simple, effective and well tolerated in this particular group of patients. The overall prognosis of brain abscess associated with congenital cyanotic heart disease is poor; therefore early recognition of symptoms of brain abscess becomes mandatory

Importance of preoperative assessment: a view of anaesthetic outpatient at JPMC Karachi

To evaluate the patients preoperatively and follow them for any significant morbidity or mortality in peri or post operative period in relation to American Society of Anesthesiologist [ASA] physical status grading system. Design: A prospective study on 400 patients visiting our Preanaesthetic Outpatient Clinic in one month. Setting: Anaestnetic Outpatient clinic at Jinnah Postgraduate Medical Centre and their follow up in theatre and surgical wards. Subjects: Four hunderd patients Four hundred patients scheduled for elective surgery were evaluated in one month. 70% were new while 30% were reassessed. 78.75% were fit for anaesthesia while 21.25% were called back for reassessment. 79,25% were scheduled for major to moderate surgery while 20.25% for minor surgery. 21% patients were in ASA physical status grade I, 54% in ASA grade II, 22.50% were in ASA grade III while 2.5% in ASA grade Iv showing significant distribution of proportion with P< 0.001. Maximum patients i.e. 46.25% had cardiovascular problems while 32.25% had respiratory diseases, 4,50% were diabetic while 14.25% had haenologlobin below 10 gm%. There was no peri operative mortality in this series. Patients in ASA grade I and II had no postoperative mortality as well while morbidity was 2.38% and 3.24% respectively. In ASA grade III and IV mortality was 3.30% and 30% with morbidity of 11.11% and 40%respectively. Total mortality in this series was 1.5% and morbidity was 5.75%. By evaluating the patients preoperatively unsuspected abnormalities were detected and patients with associated problems were optimized clinically. A definite correlation was found between ASA physical status of the patients and their overall outcome

Cerbral aneurysmal surgery: anaesthetic management and outcome

Twenty-one patients were admitted to out Neurosurgical Unit with subarachnoid haemorrhage due to ruptured cerebral aneurysm in the year 1995. Five patients in Hess and Hunt Grade V died within 48 hours, four patients in Grade III and IV were judged to be unfit for surgery while twelve patients underwent surgical intervention at about 17.50 +/- 0.20 days after the first subarachnoid bleed. All underwent a strandard cerebral protective general anaesthesia. They were kept normotensive. Normocapnic and normothermic intra-operatively; brain relaxation was achieved with lumbar drainage and mannitol. Ten patients underwent temporary clipping prior to clipping of aneurysm. Thiopentone sodium 2 mg/kg was given for cerebral protection. Blood pressure and central venous pressure were increased by giving haemaccel. Mean clipping time was 8.7 +/- 2.58 minutes, range [5-14 min]; no deterioration was noted in the neurological status of these patients postoperatively. There were no per- or post-operative mortality in this series. One operative morbidity [rupture of an aneurysm in the anterior communicating artery during operation] and one postoperative morbidity [hydrocephalus on the seventh postoperative day] were encountered. The mean GCS [Glasgow Coma Scale] at the time of discharge of all these patients was 14.42 +/- 0.28. It is concluded that patients with cerebral aneurysms can safely be operated upon under normotensive, normocapnic and normothermic anaethesia with provision of drugs for cerebral protection between temporary arterial occlusion and clipping of aneurysm