Sufentanil reduces emergence delirium in children undergoing transthoracic device closure of vsd after sevoflurane-based cardiac anesthesia

Abstract Objective: The aim of this study was to evaluate whether sufentanil can reduce emergence delirium in children undergoing transthoracic device closure of ventricular septal defect (VSD) after sevoflurane-based cardiac anesthesia. Methods: From February 2019 to May 2019, 68 children who underwent transthoracic device closure of VSD at our center were retrospectively analyzed. All patients were divided into two groups: 36 patients in group S, who were given sufentanil and sevoflurane-based cardiac anesthesia, and 32 patients in group F, who were given fentanyl and sevoflurane-based cardiac anesthesia. The following clinical data were recorded: age, sex, body weight, operation time, and bispectral index (BIS). After the children were sent to the intensive care unit (ICU), pediatric anesthesia emergence delirium (PAED) and face, legs, activity, cry, consolability (FLACC) scale scores were also assessed. The incidence of adverse reactions, such as nausea, vomiting, drowsiness and dizziness, was recorded. Results: There was no significant difference in age, sex, body weight, operation time or BIS value between the two groups. Extubation time (min), PEAD score and FLACC scale score in group S were significantly better than those in group F (P<0.05). No serious anesthesia or drug-related side effects occurred. Conclusions: Sufentanil can be safely used in sevoflurane-based fast-track cardiac anesthesia for transthoracic device closure of VSD in children. Compared to fentanyl, sufentanil is more effective in reducing postoperative emergence delirium, with lower analgesia scores and greater comfort.

A sufentanil-based rapid cardiac anesthesia regimen in children undergoing percutaneous minimally-invasive intraoperative device closure of ventricular septal defect

Abstract Objective: To assess the effectiveness and safety of fast-track cardiac anesthesia using the short-acting opioid sufentanil in children undergoing intraoperative device closure of ventricular septal defect (VSD). Methods: This retrospective clinical study included 65 children who underwent intraoperative device closure of VSD between January 2017 and June 2017. Patients were diagnosed with isolated perimembranous VSD by transthoracic echocardiography. Then, they were divided into two groups, group F (n=30), whose patients were given sufentanil-based fast-track cardiac anesthesia, and group C (n=35), whose patients were given conventional cardiac anesthesia. Perioperative clinical data were analyzed. Results: No significant differences were found between the preoperative clinical parameters and intraoperative hemodynamic indices between the two groups. In group C, compared with group F, the postoperative duration of mechanical ventilation, the length of stay in the intensive care unit, the length of hospital stay, and the hospital costs were significantly increased. Conclusion: In this retrospective study at a single center, sufentanil-based fast-track cardiac anesthesia was shown to be a safe and effective technique for minimally-invasive intraoperative device closure of VSD in children, which was performed with reduced in-hospital costs.

Incidence of nausea and vomiting after fast-track anaesthesia for heart surgery

Abstract Objective: The aim of this study was to evaluate the incidence of postoperative nausea and vomiting (PONV) after fast-track cardiac anesthesia (FTCA) in the first 24-48 hours in the cardiac intensive care unit (CICU) after open-heart surgery, risk factors for PONV and its influence on CICU length of stay. Methods: A prospective observational study from January 1, 2013 to the end of December 2015 was performed in the CICU of a university hospital in the north of Jordan and Queen Alia Heart Institute, Amman, Jordan. Three hundred consecutive patients undergoing fast-track cardiac anesthesia in elective cardiac surgery were enrolled in the study. Nausea and vomiting were assessed after tracheal extubation, which was performed within 6-10 hours after surgery and during the first 24-48 hours in the CICU. Metoclopramide 10 mg intravenously was used as the initial antiemetic drug, but ondansetron 4 mg intravenously was also used as second line of management. Results: Nausea was reported in 46 (15.3%) patients, and vomiting in 31 (10.3%). Among females, 38 (33.9%) patients developed nausea and 20 (17.9%) developed vomiting. Among males, 8 (4.3%) patients developed nausea and 11 (5.9%) developed vomiting. Conclusion: PONV are relatively low after FTCA and the prophylactic administration of antiemetic drug before anesthesia or after extubation is not necessary.

Eventos críticos en anestesia / Critical events in Anesthesia

Introducción. El manejo de eventos críticos en el quirófano no siempre coincide con el manejo general de la reanimación, y se puede considerar una acción terapéutica de la anestesiología. Metodología. A partir del estudio australiano de monitoreo de 4.000 incidentes en anestesia se ha podido implementar un algoritmo de reglas nemotécnicas simplificadas. La Asociación Americana del Corazón (AHA) utiliza el cuadrante cardiovascular para ubicar la causa principal de inestabilidad hemodinámica de acuerdo con 4 componentes: bomba cardiaca, frecuencia cardiaca, resistencia y volumen. Resultados. En esta revisión se conjugan ambos sistemas, para intervenir de manera exitosa en el manejo de los eventos críticos en anestesia.

Introduction. Managing critical events in the OR is not always consistent with the usual resuscitation management and can be considered an anesthesia therapeutic approach. Mathodologhy. On the basis of an Australian study that monitored 4,000 anesthesia incidents, an algorithm of simplified acronyms has been implemented. The American Heart Association (AHA) uses the cardiovascular quadrant to localize the main cause of hemodynamic instability, in accordance with 4 components: Cardiac pump, heart rate, resistance and volume. Results. This review combines both systems to successfully manage any critical events during anesthesia.

Anestesia para tratamento de aspergilose cardíaca em paciente com trombocitopenia: o uso criterioso da aprotinina / Anesthesia for treatment of cardiac aspergillosis in a patient with thrombocytopenia and the judicious use of aprotinin

JUSTIFICATIVA E OBJETIVOS: A aprotinina tem sido muito utilizada em intervenções cirúrgicas cardíacas como recurso terapêutico para redução dos efeitos da circulação extracorpórea (CEC) sobre a coagulação e fibrinólise. A recuperação da hemostasia adequada ao final do procedimento é um dos objetivos do anestesiologista. Porém, o uso da aprotinina tem indicação específica. O objetivo deste trabalho foi apresentar o caso de um paciente com plaquetopenia intensa submetido à intervenção cirúrgica cardíaca no qual a interconsulta com a Hematologia e o planejamento adequado permitiram o sucesso do procedimento. RELATO DO CASO: Paciente do sexo masculino, 18 anos, 64 kg, estado físico ASA IV, portador de aplasia de medula, em investigação para ser submetido a transplante de medula. Apresentava febre persistente, de um mês de evolução, sem melhora com antibioticoterapia. Na investigação com métodos de imagem, diagnosticou-se massa intra-atrial esquerda. Ao exame laboratorial apresentava hemoglobina de 9 g.dL-1 e trombocitopenia - 6.000 plaquetas.mm-3. Foi submetido à esternotomia com CEC para retirada de trombo intracavitário. Com objetivo de controlar o sangramento intra-operatório foram administrados: plaquetaférese, hidrocortisona e aprotinina. Durante a intervenção cirúrgica não houve aumento do sangramento nem instabilidade hemodinâmica e o paciente foi encaminhado à Unidade de Terapia Intensiva (UTI) sem intercorrências. O exame anatomopatológico revelou trombo repleto de Aspergillus (massa fúngica). No sétimo dia de pós-operatório o paciente evoluiu com insuficiência respiratória e parada cardiorrespiratória sem resposta às manobras de reanimação. CONCLUSÕES: Apesar do grande risco de sangramento no paciente descrito, conseguiu-se realizar intervenção cirúrgica cardíaca com CEC sem intercorrências graças ao uso de aprotinina e plaquetoaférese.

BACKGROUND AND OBJECTIVES: Aprotinin has been widely used in cardiac surgeries as a therapeutic resource for reducing the effects of cardiopulmonary bypass (CPB) on coagulation and fibrinolysis. Recovery of adequate hemostasia at the end of the procedure is one of the objectives of the anesthesiologist. However, aprotinin has specific indications. The objective of this report was to present the case of a patient with severe thrombocytopenia undergoing cardiac surgery in which consultation with Hematology and adequate planning were responsible for the success of the procedure. CASE REPORT: An 18-year old male patient, weighing 64 kg, physical status ASA IV, with a diagnosis of bone marrow aplasia, was being investigated to undergo bone marrow transplantation. He had persistent fever for a month, which did not improve with antibiotics. During the investigation with imaging exams, a left atrial mass was discovered. Laboratory exams revealed hemoglobin 9 g.dL-1 and thrombocytopenia with 6,000 platelets.mm³. He underwent a sternotomy with CPB to remove the intracavitary thrombus. In order to control intraoperative bleeding, the following was administered: plateletpheresis, hydrocortisone, and aprotinin. Increased bleeding and hemodynamic instability did not develop during the surgery, and the patient was transferred to the Intensive Care Unit (ICU) without intercurrences. The anatomo-pathologic exam revealed the thrombus to be filled with Aspergillus (fungal mass). On the seventh postoperative day the patient developed respiratory failure and cardiorespiratory arrest that did not respond to resuscitation maneuvers. CONCLUSIONS: Despite the increased risk of bleeding in this patient, cardiac surgery with CPB was performed without intercurrences due to the use of aprotinin and plateletpheresis.

JUSTIFICATIVA Y OBJETIVOS: La aprotinina ha sido muy utilizada en intervenciones quirúrgicas cardiacas como recurso terapéutico para la reducción de los efectos de la circulación extracorpórea (CEC) sobre la coagulación y la fibrinólisis. La recuperación de la hemostasia adecuada al final del procedimiento es uno de los objetivos del anestesiólogo. Sin embargo, el uso de la aprotinina tiene una indicación específica. El objetivo de este trabajo fue presentar el caso de un paciente con plaquetopenia intensa sometido a la intervención quirúrgica cardiaca en el cual la interconsulta con hematología y la planificación adecuada permitieron el éxito del procedimiento. RELATO DEL CASO: Paciente del sexo masculino, 18 años, 64 kg, estado físico ASA IV, portador de aplasia de medula, en investigación para ser sometido al transplante de médula. Presentaba fiebre persistente, de un mes de evolución, sin mejoría con antibioticoterapia. En la investigación con métodos de imagen, se diagnosticó masa intra atrial izquierda. En el examen de laboratorio presentaba hemoglobina de 9 g.dL-1 y trombocitopenia - 6.000 plaquetas mm-3. Se sometió a la esternotomía con CEC para retirada de trombo intracavitario. Con el objetivo de controlar el sangramiento intraoperatorio fueron administrados: plaqueto-aferesis, hidrocortisona y aprotinina. Durante la intervención quirúrgica no hubo aumento del sangramiento ni inestabilidad hemodinámica y el paciente fue llevado a la Unidad de Terapia Intensiva (UTI) sin intercurrencias. El examen anátomo patológico reveló trombo repleto de Aspergilus (masa fúngica). Al sétimo día del postoperatorio el paciente evolucionó con insuficiencia respiratoria y parada cardiorrespiratoria sin respuesta a las maniobras de reanimación. CONCLUSIONES: A pesar del gran riesgo de sangramiento en el paciente descrito, se logró realizar la intervención quirúrgica cardiaca con CEC sin intercurrencias gracias al uso de aprotinina y plaquetoaféresis.

Intraoperative Management of Patients Undergoing Off-pump Coronary Artery Bypass Graft Using the Tissue Stabilizer / 대한마취과학회지

BACKGROUND: Coronary artery bypass graft with cardiopulmonary bypass is the standard surgical coronary revascularization procedure; however, there are many adverse effects such as air embolism, and high rate of neurologic and coagulation complications. In this article, we describe hemodynamic alterations during coronary bypass grafting (CABG) without cardiopulmonary bypass but using a medical tissue stabilizer. METHODS: Thirty patients were included in our study who underwent an off-pump CABG (OPCAB) between 1/1999 and 12/1999. RESULTS: We created 73 anastomoses. Movement of the heart to reach the target site of anastomosis caused hemodynamic alterations. These could be corrected by anesthetic interventions such as fluid load and low dose inotropics. Complications included postoperative panperitonitis (one patient), and delirium tremens (one patient). On the other hand, major complications, such as intraoperative myocardial infarction and stroke did not occur. The median postoperative length of hospital stay was 14 days. Overall operative mortality was 3.3% (one patient). CONCLUSIONS: On the basis of the present data, off-pump coronary artery bypass grafting appeared to be a safe and effective technique in selected patients with appropriate coronary lesions. Off-pump CABG surgery requires anesthetic interventions because hemodynamic alterations are caused by the presentation of the heart to the surgeon.

Anesthesia for Noncardiac Surgery in Heart Transplanted Patients: 2 cases report / 대한마취과학회지

With the introduction of cyclosporine, heart transplantation has become a widely accepted treatment for patients with end-stage heart failure. Number of operation increased steadily during recent 6 years with many postoperative follow up cases. A number of survivors are now presenting for non-cardiac surgery. Cardiac transplanted patients present anesthesiologists with challenging problems related to the infection in immunosuppressed patients, rejection phenomena, denervated heart pathophysiology with altered hemodynamic function of their own and under circumstances of stress and drug therapies. We experienced 2 cases of general anesthesia for noncardiac surgery in heart transplanted patients without important hemodynamic changes. Preoperative evaluation including heart status, rejection, immunosuppressive drug therapy and its complications is mandatory. These patients present few problems during anesthesia if adequate hydration, aseptic technique, selection of proper vasoactive drugs are provided.

Propofol-Fentanyl Total Intravenous Anesthesia for Coronary Artery Bypass Graft / 대한마취과학회지

BACKGROUND: Total intravenous anesthesia (TIVA) is by definition a technique involving the induction and maintenance of the anesthetic state with intravenous drugs alone. In particular, propofol and opioid and muscle relaxants allow enhanced control of the state of anesthesia for the entire duration of the surgical procedure. We evaluated the clinical usefulness of TIVA with fixed fentanyl concentration 3 ng/ml using isoconcentration nomogram and titrated propofol for coronary artery bypass graft. METHODS: Anesthesia was induced using 1% propofol mixed with lidocaine 0.5 mg/kg and ephedrine 10 mg (150 ml/hr) until loss of consciousness in 19 patients undergoing coronary artery bypass graft. Infusion rate of propofol was adjusted in response to blood pressure and pulse rate. To achieve constant fentanyl concentration, infusion rate of fentanyl was changed timely according to isoconcentration nomogram. Infusion of propofol and fentanyl was discontinued 15 and 30 min before predictable end of surgery, respectively. Intraoperative hemodynamics, recovery profile and postoperative analgesic requirements were checked. RESULTS: Overall intraoperative hemodynamics including cardiac index and PCWP showed no significant changes compared with preinduction control value except during CPB period. Average flow rate of propofol and fentanyl was 3.4 0.2 mg/kg/hr and 2.8 0.4 g/kg/hr, respectively. Spontaneous eye opening time was 96.4 min after discontinuation of fentanyl. More than 80% (16/19) of patients did not require any analgesic during first postoperative 24hrs for pain relief. CONCLUSIONS: TIVA with propofol and fentanyl (3 ng/ml) could be a suitable and safe anesthetic technique for coronary artery bypass graft.

Correlation between the Change of Mean Arterial Pressure and the Change of Percutaneous Oxygen Saturation in Patients with Tetralogy of Fallot / 대한마취과학회지

BACKGROUND: Hypoxia often occurs during anesthesia of patients with tetralogy of Fallot (TOF). The factors that determine pulmonary circulation and oxygenation in patient with TOF are the degree of obstruction of right ventricular outflow tract (RVOT), right ventricular filling pressure, systemic vascular resistance, loss of negative pleural cavity pressure by thoracotomy, change of pulmonary vascular resistance due to positive pressure ventilation and degree of arteriopulmonary collateral connection. Hence pulse oximetry is a noninvasive technique for measuring arterial O2 saturation continuously, this study examined the correlation between the change of percutaneous arterial oxygen saturation (delta SpO2) and the change of mean arterial pressure (delta MAP) using pulse oximetry in these patients. METHODS: Twenty pediatric patients undergoing modified Blalock-Taussig shunt or total corrective operation were prospectively investigated. Immediately after induction, baseline values of MAP and SpO2 were determined and if there were some changes in SpO2 from baseline during operation, MAP on that value of SpO2 were collected. If SpO2 reduced, patients were treated with infusion of fresh frozen plasma or pentastach (2-10 ml/kg), injection of phenylephrine (10 microgram/kg) or esmolol (0.5 mg/kg). RESULTS: Intravascular volume loading only was executed in 4 patients, intravascular volume loading and phenylephrine administration was executed in 11 patients, and intravascular volume loading, phenylephrine and beta-blocker administration was executed in 5 patients. There were no significant correlation between delta MAP and delta SpO2 from linear correlation and regression analysis (r=0.23, p<0.05). CONCLUSIONS: Because delta SpO2 were not closely related with delta MAP and above mentioned factors could act closely among each others, meticulous anesthetic management is necessary during palliative or total corrective operation in patients with TOF.

The Effect of Hypothermic Cardiopulmonary Bypass on Gastric Mucosal pH / 대한마취과학회지

BACKGROUND: It has been postulated that the derangement of gut perfusion is a factor of the development of multi-organ dysfunction and increasing postoperative morbidity. Gastric mucosal pH (pHim) correlates with splanchnic perfusion and the persistent gastric mucosal acidosis has been supposed to be a predictor of complications after cardiac surgery. The purpose of this study is to measure the change of pHim induced by hypothermic cardiopulmonary bypass (CPB). METHODS: Twelve patients undergoing cardiac surgery were anesthetized with fentanyl and isoflurane. Gastric mucosal PCO2 (PrCO2) and pHim were measured by Tonocap. Temperature was maintained about 28oC during CPB and arterial blood gas tension was managed by alpha-stat mode. Measurement was made at: (1) baseline, after induction of anesthesia, (2) 30 minutes after starting CPB, (3) 60 minutes after starting CPB, (4) at the end of CPB, (5) at the end of operation and (6) at 24 hours after CPB. Statistical analysis was performed using one-way ANOVA and Student t test. RESULTS: The PrCO2 and the CO2 gap (PrCO2 - PaCO2) increased at the end of CPB and maintained the increased state for 24 hours after CPB. The pHim decreased during CPB and maintained the decreased state for 24 hours after CPB. The difference between pHim and pHa increased significantly after CPB. CONCLUSION: We conclude that the hypothermic CPB induces gastric mucosal acidosis and it did not recover for 24 hours after CPB.

Changes of Lung Compliance in Pediatric Patients after Surgical Correction of Left to Right Shunt / 대한마취과학회지

BACKGROUND: Low values of lung compliance have been reported in patients with increased pulmonary blood flow due to intracardiac left to right(L-R) shunt. The compliance had returned to within normal limits 4 to 6 weeks after surgical correction of the shunt. We investigated whether lung compliance was improved immediately after surgical correction of the shunt. METHODS: Fifty four pediatric patients who were undergoing repair of intracardiac L-R shunt were evaluated. Lung compliance, arterial oxygen tension(PaO2) and arterial to end-tidal carbon dioxide tension difference(Pa-ETCO2) were measured after induction of anesthesia and at the completion of surgery. Left atrial pressure(LAP) was monitored. Lung compliance and end-tidal carbon dioxide tension were measured by monitoring system built in Cato anesthetic ventilator system. RESULTS: Lung compliance was significantly lower after surgery(6.57+/-6.46 ml/mbar) than after induction of anesthesia(7.71+/-7.18 ml/mbar). After surgery, PaO2 was significantly decreased and Pa-ETCO2 significantly increased than after induction of anesthesia. The decrease in lung compliance after surgery significantly correlated with a decrease in PaO2(r=0.43) and an increase in Pa-ETCO2 (r=0.47) but not correlated with LAP. CONCLUSIONS: Although surgical correction of intracardiac L-R shunt reduces pulmonary blood flow, the lung compliance decreases in immediate postoperative period. Therefore a deterioration of postoperative lung compliance may need judicious management for pulmonary and hemodynamic instability.

Development of Pressure Gradient between Radial and Femoral Artery due to Aortic Cannula Malposition in Pediatric Cardiac Surgery / 대한마취과학회지

BACKGROUND: Appropriate placement of aortic and venous cannulas is important to ensure effective systemic perfusion. The malposition of the aortic cannula may promote preferential flow down the aorta or induce flow to aortic arch vessels causing pressure gradient between mean radial arterial pressure (RAP) and femoral arterial pressure (FAP). In this study we compared mean radial to femoral artery pressure gradient before and immediately after aortic cannulation and during cardiopulmonary bypass (CPB). METHODS: Ninety two pediatric patients undergoing open heart surgery were examined. After induction of anesthesia RAP and FAP were measured. The pressure gradient was measured before and after aortic cannulation, 15, 30 and 60 minutes after aortic cross clamping (ACC). When the pressure gradient of more than 10 mmHg developed, the surgeon was recommended to manipulate position of the aortic cannula. If the pressure gradient returned to pre-CPB level after manipulation, the pressure gradient was considered to develop due to aortic cannula. The age, presence of cyanosis, adjustment of shape of aortic cannula tip before cannulation and side of radial artery cannulation as factors developing pressure gradient were examined. RESULTS: Fifteen patients (16.3%) developed pressure gradient due to position of aortic cannula. Two patients (2.2%) developed immediately after aortic cannulation and fourteen patients (15.2%) during CPB. There was no statistically significant factor developing pressure gradient except non-cyanotic disease. CONCLUSIONS: The pediatric patient could develop pressure gradient due to malposition of aortic cannula frequently during CPB. Therefore, the simultaneous monitoring of RAP and FAP may be beneficial for managing CPB in pediatric cardiac surgery.

A Comparison of Hemodynamic Indices Derived by Invasive Monitoring and Transesophageal Echocardiography in Patients with Aortic Stenosis / 대한마취과학회지

BACKGROUND: Intraoperative fluid management should be aimed at maintaining appropriate left-sided filling pressures. The pulmonary capillary wedge pressure (PCWP) will overestimate the left ventricular end-diastolic volume (LVEDV) when ventricular compliance is markedly reduced in patients with aortic stenosis. Intraoperative transesophageal echocardiography (TEE) is useful for monitoring global left ventricular function and change of preload. This study was undertaken to evaluate preload derived by conventional invasive monitoring technique compare with preload obtained simultaneously from TEE in patients with aortic stenosis. METHODS: Fifteen patients with aortic stenosis who underwent aortic valve replacement were examined. The preload was examined by the short axis view of left ventricle with TEE at the level of the papillary muscles. For each patient, simultaneous measurements of PCWP, thermodilution cardiac output and left ventricular end-diastolic area (LVEDA) measured by TEE were made after the induction of anesthesia and after surgery. RESULTS: The correlation between echo-derived LVEDA and thermodilution cardiac index (CI) (r=0.53, p<0.05) or stroke index (SI) (r=0.56, p<0.05) was good after surgery, but the correlation was not found after induction of anesthesia. No correlation was observed between PCWP and CI or SI. CONCLUSIONS: The PCWP did not provide a reliable estimate of preload and did not allow good prediction of cardiac index. These findings demonstrate that, in patients with aortic stenosis who underwent aortic valve replacement, TEE provides a better index of left ventricular preload than conventional invasive hemodynamic monitoring particularly after surgery.

Quantification of Tranexamic Acid Reversal of Fibrinolysis Using Thromboelastography and Low Dose Tranexamic Acid Effect in Open Heart Surgery / 대한마취과학회지

BACKGROUND: Prophylactic administration of tranexamic acid (TA) reduces bleeding and transfusion requirement after open heart operations. This study was performed to determine the relationship between inhibition of fibrinolysis and TA blood concentration. METHOD: In phase I, recombinant tissue plasminogen activator[r-tPA (0, 50, 100, 150 ng/ml)] was added to the blood of volunteer and induced fibrinolysis. In phase II, 4 thromboelastography (TEG) models of severe fibrinolysis in which TA was added to achieve blood levels (0, 0.72, 1.44, 2.88 mg/ml) were compared to determine the lowest effective dose. In phase III, the lowest dose (0.72 mg/ml) was mixed with the blood and evaluated on TEG in open heart operation. In phase IV, a placebo group and study group receiving TA in an loading dose of 5 mg/kg before bypass following infusion of 2 mg/kg/hour. Used analysis is Mann Whitney U test and Wilcoxon rank signed test. RESULT: In phase I, fibrinolytic inhibition at A30/MA (r=0.752) and A60/MA (r=0.735) were linearly correlated with the blood r-tPA concentration. In phase II, severe fibrinolysis (r-tPA 100 ng/ml) was reversed completely at all doses of TA. In phase III, the fibrinolysis index at 10 min. after starting bypass, aorta declamping, and 1 hour after operation were improved when the patient's blood was treated with TA (0.72 mg/ml). In phase IV, blood treated with TA showed less fibrinolysis and better TEG results than the placebo group. CONCLUSION: A small dose of TA (5 mg/kg), which was determined by an in vitro model of fibrinolysis on TEG, was effective in preventing changes in fibrinolytic index during cardiopulmonary bypass in open heart surgery.

Changes of Blood Glucose and Insulin under Different Fentanyl Dosage in Neonates and Infants Undergoing Open Heart Surgery / 대한마취과학회지

Background: Hyperglycemia during cardiopulmonary bypass may increase the incidence and severity of neurologic deficits that may result from cerebral ischemia. Moderate hyperglycemia has been noted to occur in pediatric patients undergoing cardiac surgery despite measures such as eliminating dextrose from the CPB clear pump priming solution and from the intra-operative iv fluids. To ameliorate the hormonal and hemodynamic stress responses during cardiac surgery in neonates, infants and children, high dose fentanyl anesthesia is widely used. The authors wished to determine prospectively whether fentanyl dosage is associated with reduced blood glucose or not in pediatric patients undergoing cardiac surgery. METHODS: Twenty four pediatric patients undergoing cardiac surgery were allocated randomly into 3 groups who received 25 g/kg fentanyl, 50 g/kg fentanyl or 75 g/kg fentanyl before CPB. The changes of plasma glucose and insulin levels were observed after sternotomy, on bypass, 30 min after bypass, off bypass, and the end of the operation. RESULTS: Blood glucose levels were not increased after sternotomy, but significantly increased at bypass to the end of the operation in all fentanyl dosage groups. Plasma insulin level increased, but statistically not significant. Different fentanyl dosage (25~75 g/kg) is not associated with differences in blood glucose level. CONCLUSION: At a dosage of 25~75 g/kg fentanyl anesthesia during pediatric open heart surgery were associated with no differences and below 250 mg/dl of blood glucose level and no significant changes in insulin level.

Cardiovascular Effects of Pancuronium, Vecuronium and Pipecuronium during High-Dose Fentanyl Anesthesia in Neonates, Infants and Children / 대한마취과학회지

BACKGROUND: High dose fentanyl for cardiac surgery in neonates, infants and children can cause severe bradycardia and chest wall rigidity that result in decreased cardiac output and oxygen desaturation due to fixed stroke volume in pediatric patients. To ameliorate the effects of fentanyl, it is common to administer neuromuscular blocking drugs with wanted cardiovascular side effects. This study was designed to compare the cardiovascular variables and oxygen saturation among different muscular relaxants in high dose fentanyl anesthesia. METHODS: Thirty pediatric cardiac patients were allocated randomly into three muscle relaxant groups treated with 0.2 mg/kg pancuronium (n=10), 0.2 mg/kg vecuronium (n=10) or 0.2 mg/kg pipecuronium (n=10) after receiving an initial bolus dose of 25 g/kg of fentanyl. Changes of heart rate (HR), mean arterial blood pressure (MAP), rate-pressure-product (RPP) and oxygen saturation (SpO2) were observed. The same cardiovascular variables were also observed 1 and 2 minutes after the second bolus dose of 25 g/kg fentanyl and compared to the results among muscle relaxants. RESULTS: HR, MAP and RPP decreased significantly (p<0.05) 1 and 2 minutes after injection of the 1st fentanyl, which returned to levels above the control value after administration of pancuronium, vecuronium or pipecuronium. Among muscle relaxants, pancuronium caused the most rapid and significantly high level compared to the control value in HR and MAP. Next was pipecuronium and then vecuronium. In clinical setting, SpO2 was decreased after the 1st fentanyl injection and increased after the injection of muscle relaxants, but not significant statistically. CONCLUSION: In view of hemodynamic changes, pancuronium is most efficient and rapid in returning the hemodynamic variables that was decreased after high dose fentanyl anesthesia in neonates, infants and children whose cardiac output was dependent on HR due to relatively fixed stroke volume.