Role of Using a Thromboelastometry-Based Protocol for Transfusion Management in Combined Coronary Artery Bypass Grafting and Valve Surgery: A Randomized Clinical Trail.

The aim of this study was to evaluate the impact of using a thromboelastometry-based protocol on transfusion requirements in patients undergoing combined coronary artery bypass grafting (CABG) and valve surgery. 80 adult patients scheduled for elective combined CABG and valve surgery were included in this clinical trial study. Patients were randomly allocated to the thromboelastometry (ROTEM) (n = 40) or control groups (n = 40). In the ROTEM group, transfusion was directed according to a thromboelastometry-based protocol. In the control group, transfusion was conducted according to the routine practices including conventional coagulation testing and clinical judgments. Finally, transfusion requirements were compared between groups. Use of thromboelastometry- based protocol resulted in 67% reduction in blood products units' consumption as well as 23% in the percentage of patients transfused. This reduction was especially evident in relation to fresh frozen plasma (FFP) and platelet consumption. No significant differences were found both in the percentage of patients receiving RBC and number of transfused RBC units. Using thromboelastometry tests incorporated a protocol results in reduction of transfusion requirements in patients undergoing elective combined CABG and valve surgery.

Fluid Balance Has Effects on the Length of Hospital Stay After Coronary Artery Bypass Grafting Surgery.

INTRODUCTION: A vast range of factors cause adverse outcomes after coronary surgery. The goal of this study was to figure out if there was a relation between large volumes of fluid balance in patients who underwent coronary surgery and common complications after CABG. METHODS: 130 candidates for on-pump CABG were enrolled in our study at Rajaie Cardiovascular Medical and Research Center in 2016. After calculating balance volume for each patient, they were divided into 3 groups; Group (1): fluid balance < 2000 mL, Group (2): fluid balance 2000-3000 mL, Group (3): fluid balance > 3000 mL. Some of the post-surgery complications were studied in these 3 groups. Since in similar studies, fluid overload has been investigated based on the patient's weight gain after surgery or only on the basis of the patient's fluid intake, we designed a study based on an accurate fluid balance measurement, which included the subtraction of the patient's outputs and losses from their intakes. RESULTS: Logistic Regression showed that fluid balance > 3000ml was the predictor of long mechanical ventilation [ (Odds Ratio (95% CI) = 4.6 (1.9 - 11.5), P < .05], more than 3 days of ICU stay [(Odds Ratio (95% CI) = 3.2 (1.09 - 9.6), P < .05], and longer hospital stay [Odds Ratio (95% CI) = 5.2 (1.9 - 14.08), P < .05]. There was no significant relation between AKI and fluid balance. CONCLUSION: Administration of large fluid volumes in CABG patients would lead to fluid accumulation and independently associated with prolonged mechanical ventilation, longer ICU stays and extended hospital stays.

Echocardiographic findings before and after surgical repair of Tetralogy of Fallot.

OBJECTIVE: To compare echocardiographic findings before and after surgical repair of Tetralogy of Fallot. METHODS: The interventional study was conducted in Ali-ebne-Abitaleb Hospital, Zahedan, Iran, from September 2008 to March 2010, and comprised patients undergoing surgical repair of Tetralogy of Fallot. Physical examination, chest radiography and electrocardiography were done before echocardiography. Data were analysed by using SPSS 20. RESULTS: Of the 30 patients, 10(33.3%) were girls and 20(66.6%) boys, with an overall pre-surgery mean age of 47.40±21.34 months and 74.46±20.63 months post-surgery (p=0.001). The mean duration of post-operative period was 37.86±18.27 months. The results for right heart showed that Z scores for peak E velocity, peak A velocity, pre-ejection period, isovolumic relaxation time, myocardial performance index and isovolumic contraction time were significantly different (p<0.05). In the left heart, aortic, left atrium, left ventricular end-systolic dimension, left ventricular end-diastolic dimension, deceleration time, Peak E velocity/Peak A velocity, Peak E velocity, Peak A velocity, pre-ejection period/ejection time, pre-ejection period, shortening fraction and ejection fraction had significant difference (p<0.05). CONCLUSIONS: Right ventricular performance indices can serve as valuable parameters in assessing cardiac performance.

Preoperative anxiety in candidates for heart surgery.

OBJECTIVE: The goal of this study was to evaluate preoperative anxiety and its predisposing factors in a group of adult patients who were candidate for any kind of heart surgery. METHODS: We evaluated preoperative anxiety in 300 patients undergoing heart surgery whose ages ranged between 18-65 years. Relationship of probable demographic factors like gender, educational level, marital status, number of children, family support, opium addiction, occupational status, and left ventricular ejection fraction (LVEF) with anxiety level of the patients were evaluated. To determine anxiety, the State-Trait Anxiety Inventory (STAI) was completed by the subjects. RESULTS: Descriptive anxiety levels showed that mean of state and trait anxiety of our studied patients were in moderate scaling. Correlation between state and trait anxiety was more prominent in females (r = 0.80) than in males (r = 0.70) (p < 0.001). Distribution of males and females was significantly different (p = 0.048). All the patients had significantly different underlying diseases (p = 0.018), opioid addiction (yes/no) was significantly different in all of the patients (p < 0.001), while family support (yes/no) was not significantly different in all of the patients (p = 0.453). There were significant differences between mean of preoperative anxiety at different LVEF values of any EF level (p < 0.001, F = 6.47); those who had LVEF of more than 50% had significantly lower mean anxiety scores. CONCLUSION: Preoperative psychiatric consultation should be focused more on women and patients with higher EF. Moreover, physical activity strength may be effective on reducing preoperative anxiety.

Patient-controlled analgesia after coronary bypass: Remifentanil or sufentanil?

BACKGROUND: adequate pain control after cardiac surgery is mandatory to reduce its remarkable morbidity. In this study, we aimed to compare the efficacy of patient-controlled analgesia with remifentanil or sufentanil for pain management after coronary artery bypass grafting. METHODS: 249 patients who underwent coronary artery bypass were randomly assigned to receive patient-controlled analgesia with remifentanil or sufentanil during the first 24 h postoperatively. Pain intensity during patient-controlled analgesia was assessed using 4 different pain rating scales. RESULTS: patients given remifentanil had lower Visual Analog Scale scores at 24 h compared to those given sufentanil (p = 0.002). The Numeric Rating Scale at 24 h was also significantly lower in patients using remifentanil (p = 0.004). The Faces Pain Scale scores at 4, 18, and 24 h were significantly lower in patients using remifentanil compared to those using sufentanil (p = 0.045, 0.036, and 0.011, respectively). No significant differences between groups were seen in the pain intensity assessed by the Behavior Rating Scale at any time point during the first 24 h postoperatively. CONCLUSION: our study showed that both remifentanil and sufentanil patient-controlled analgesia can provide acceptable analgesia after coronary artery bypass. The difference between their efficacies was inconspicuous until 24 h postoperatively. Remifentanil seems to result in better pain relief at 24 h postoperatively.

Intravenous patient-controlled remifentanil versus paracetamol in post-operative pain management in patients undergoing coronary artery bypass graft surgery.

BACKGROUND: Pain management after cardiac surgery has been based on parenteral long-acting opioids such as morphine. The other alternatives are paracetamol and remifentanil. OBJECTIVES: In this prospective, double-blind, randomized study, we compared the efficacy of intravenous patient-controlled analgesia (IV-PCA) paracetamol and remifentanil for post cardiac surgery pain relief. MATERIALS AND METHODS: One-hundred patients scheduled for elective coronary artery bypass grafting from May to October 2011, were randomized into two groups after the surgery. For the first group (group R, n = 50, with mean age of 58.16 ± 11.80), the IV-PCA protocol was remifentanil infusion 100 µg/h; bolus of 25 µg and lockout time of 15 minutes. In the second group (group P, n = 50, with mean age of 53.8 ± 15.08), patients received paracetamol 15 mg/kg as a bolus at the end of surgery and then IV-PCA protocol was 100 µg/h, bolus of 25 µg; and lockout time of 15 minutes. Pain was assessed with visual analog scale score (VAS) in the first 24 hours after surgery for seven times. RESULTS: The trend of pain scores did not have any significantly difference between group R and group P except for hour 8 and hour 18 after surgery that VAS was significantly lower in group P than group R (P = 0.031, P = 0.023, respectively). Respiratory rate (RR) was also statistically lower in group R comparing to group P in all seven evaluating times. The groups were similar in terms of hemodynamic, ABG results (except for PaO2, which was significantly lower in group R than group P at 6 evaluating times), intubation time, renal function tests, and incidences of atelectasis, myocardial infarction or adverse effects. CONCLUSIONS: Both PCA techniques provided effective pain scores (< 3) after cardiac surgery; but generally, PCA-paracetamol infusion has a better analgesic effect.

Comparison of right and left side heart functions in patients with thalassemia major, patients with thalassemia intermedia, and control group.

BACKGROUND: Heart disease is the main cause of mortality and morbidity in patients with beta thalassemia, rendering its early diagnosis vital. We studied and compared echocardiographic findings in patients with beta thalassemia major, patients with beta thalassemia intermedia, and a control group. METHODS: Eighty asymptomatic patients with thalassemia major and 22 asymptomatic cases with thalassemia intermedia (8-25 years old) were selected from those referred to Ali Asghar Hospital (Zahedan-Iran) between June 2008 and June 2009. Additionally, 80 healthy individuals within the same age and sex groups were used as controls. All the individuals underwent echocardiography, the data of which were analyzed with the Student t-test. RESULTS: The mean value of the pre-ejection period/ejection time ratio of the left ventricle during systole, the diameter of the posterior wall of the left ventricle during diastole, the left and right isovolumic relaxation times, and the right myocardial performance index in the patients with beta thalassemia major and intermedia increased significantly compared to those of the controls, but the other parameters were similar between the two patient groups. The mean values of the left and right pre-ejection periods, left ventricular end systolic dimension, and left isovolumic contraction time in the patients with thalassemia intermedia increased significantly compared to those of the controls. In the left side, myocardial performance index, left ventricular mass index, isovolumic contraction time, and deceleration time exhibited significant changes between the patients with thalassemia major and those with thalassemia intermedia, whereas all the echocardiographic parameters of the right side were similar between these two groups. CONCLUSION: The results showed that the systolic and diastolic functions of the right and left sides of the heart would be impaired in patients with thalassemia major and thalassemia intermedia. Consequently, serial echocardiography is suggested in asymptomatic patients with beta thalassemia for an early diagnosis of heart dysfunction and proper treatment.

Diagnostic value of electrocardiography compared with echocardiography in measuring left ventricular mass index in major thalassemia patients over 10 years of age.

BACKGROUND: Patients suffering from major beta thalassemia need frequent blood transfusions and, if not treated well, would be at risk of heart dysfunction. This study was performed to determine the diagnostic value of electrocardiography versus echocardiography in measuring the left ventricular mass index in these patients. METHODS: Between July 2010 and June 2011, 82 asymptomatic patients over 10 years of age with major thalassemia (42 men with a mean age of 17.65 ± 3.39 years and 40 women with a mean age of 16.9 ± 3.38 years) were enrolled in this study. For all the patients, standard electrocardiography (to measure R in aVL and S in V3 and calculate left ventricular mass index by electrocardiography) and echocardiography (to measure interventricular septum diameter in diastole, left ventricular posterior wall diameter in diastole, and left ventricular diameter in diastole in order to calculate left ventricular mass index by echocardiography) were performed, at least one week after transfusion. The calculated left ventricular mass indices were thereafter compared between the two methods (electrocardiography and echocardiography). RESULTS: Sensitivity, specificity, positive predictive value, and negative predictive value in the two techniques in determining the left ventricular mass index were 67%, 25%, 89%, and 7% in the females, 65%, 33%, 92%, and 6% in the males, and 67%, 14%, 89%, and 3% in the total population, respectively. Furthermore, this study demonstrated that the average left ventricular mass index by echocardiography and electrocardiography was 104.86 ± 21.65 gr/m2 and 91.69 ± 12.03 gr/m2, respectively. Echocardiography was much more accurate than electrocardiography in determining the left ventricular mass index (p value = 0.0001). CONCLUSION: The findings of this study demonstrated that echocardiography was more accurate and more reliable than electrocardiography in determining the left ventricular mass index in major thalassemia patients.

Diagnosis and treatment of disseminated intravascular coagulation: a case report.

Disseminated intravascular coagulation is a pathologic syndrome with different medical disorders. Diagnosis and treatment of this syndrome is one of the difficult managements in medical science. Thromboelastogram is the only guide for early diagnosis and precise management of this syndrome. We describe a patient who developed disseminated intravascular coagulation due to endocarditis and spleen abscess. She was diagnosed by thromboelastography and treated successfully.