Early and mid-term results of minimally invasive coronary artery bypass grafting.

INTRODUCTION: Minimally invasive coronary artery bypass grafting (MICABG) is a less invasive method of performing surgical revascularization. This technique coupled with use of off pump technique of surgical revascularization makes it truly less invasive. This method is highly effective even in high-risk patients. Results of this procedure are comparable to standard off pump technique and are better than percutaneous coronary intervention utilizing drug-eluting stent. We present an early and mid-term result of the use of this technique. METHOD: We enrolled 33 patients for analysis operated between 2008 and 2012. Operation was performed utilizing off-pump technique of coronary artery bypass grafting through a minimal invasive incision. Left internal mammary artery graft was done for single vessel disease and radial artery was utilized for other grafts if required. Median follow up of 2.5 years (6 months-4 years) is available. RESULTS: Median age was 58.5 years (41-77) and all were male. Single vessel disease was present in 7, double vessel in 14 and triple vessel disease in 12 patients. All the patients had normal left ventricular size and function. There was no operative and 30-day mortality. Conversion to median sternotomy to complete the operation was done in 6.6% (2 out of 33 patients). One patient had acute myocardial infarction and there were no deaths during follow up. CONCLUSION: MICABG is a safe and effective method of revascularization in low risk candidates for coronary artery bypass grafting.

A mixture of organophosphate and pyrethroid intoxication requiring intensive care unit admission: a diagnostic dilemma and therapeutic approach.

The illegal mixing of organophosphates and pyrethroids in marketed agriculture insecticides is becoming prevalent in developing countries. Over a 12-mo period, 8 patients were admitted to the emergency department of a university hospital in Dharan, Nepal after ingestion of such a mixture with suicidal intent. All patients presented with a combination of miosis, bradycardia, tachypnea, and unconsciousness. The occurrence of both pupillary dilation after a small-dose infusion of atropine (0.08 to 0.2 mg/kg in 1-3 h) and seizures raised the possibility of pyrethroid poisoning. In each case, an examination of the insecticide container confirmed that it contained a mixture of organophosphate and pyrethroid. After seizure control, gastric lavage, respiratory support, hemodynamic stabilization and diuresis, seven of the patients recovered without neurological deficit. One patient suffered aspiration pneumonia and died. The early clinical picture after this mixed poisoning is based on the toxicity of organophosphates rather than pyrethroids. Because the patients responded to a small dose of atropine with mydriasis and tachycardia, it suggested a mixed poisoning. Early suspicion of mixed poisoning may have a significant prognostic impact.

Direction of the J-tip of the guidewire, in seldinger technique, is a significant factor in misplacement of subclavian vein catheter: a randomized, controlled study.

Misplacement of central venous catheters, predisposing to poor functioning including inability to aspirate blood, is common with the subclavian approach. In this prospective study we sought to determine whether the direction of the guidewire J-tip influenced the catheter tip placement during right subclavian catheterization. In this randomized, double-blind clinical study, we observed the placement of catheters via the right subclavian vein while keeping the J-tip directed either caudad in Group 1 (n=147) or cephalad in Group 2 (n=148) patients. The majority of catheters (97% and 57%) in Groups 1 and 2 respectively entered the superior vena cava/right atrium (P <0.05). The incidence of catheter misplacement into the ipsilateral internal jugular vein was 2% and 40% in Groups 1 and 2, respectively (P = <0.01). Subsequent experimental study confirmed that the direction of the J-tip was retained inside a model of vascular tubes and its tip led the guidewire into the tubing on the same side even at the acute angulation formed between tubings representing the subclavian, internal jugular, and superior vena cava junction complex. The authors conclude that the simple measure of keeping the guidewire J-tip directed caudad increased correct placement of central venous catheters towards the right atrium during right subclavian catheterization.

Ondansetron in prophylaxis of postoperative nausea and vomiting in patients undergoing breast surgery: a placebo-controlled double blind study.

The present study was to evaluate the efficacy of ondansetron, 5-HT3 receptor antagonist, versus placebo in the prevention of postoperative nausea and vomiting (PONV) in a homogenous group of female patients undergoing breast reduction surgery under general anaesthesia. Approximately one hour before skin closure, 70 patients were randomly divided into two groups of 35 each. In a double blind manner each group of patients received either intravenous ondansetron (4mg) or a matching placebo. The overall incidences of PONV during first 24-hour were 60% and 20% in placebo and ondansetron group respectively (p<0.05). However, there was no significant difference after 24-hour postoperatively. In placebo group 42.9% of patients received rescue anti-emetic (metoclopramide) for the treatment of severe PONV (ie, 2 or more episodes of PONV), whereas, only 8.6% patients were administered such intervention in the ondansetron group (p<0.05). It is, therefore, concluded that prophylactic administration of intravenous ondansetron (4mg) one hour before skin closure is safe and effective in preventing PONV in female patients undergoing breast surgery and routine use of ondansetron in the patient population is recommended.

Percutaneous tracheostomy with single dilatation technique: a prospective, randomized comparison of Ciaglia blue rhino versus Griggs' guidewire dilating forceps.

UNLABELLED: Percutaneous tracheostomy with single-step dilation technique using Griggs' guidewire dilating forceps (GWDF) is a well-recognized procedure. Recently, Ciaglia has introduced a one-step dilation technique using a curved, gradually tapered dilator, the Ciaglia Blue Rhino (CBR). In a prospective, randomized study, we performed percutaneous tracheostomy in 60 consecutive patients, using either the CBR or the GWDF technique. Postoperatively, all patients had bronchoscopy by a blinded consultant, and stoma characteristics and injuries to the trachea were studied. Mean tracheostomy time (skin incision to insertion of tracheostomy tube) in the two procedures (CBR 7.5 min versus GWDF 6.5 min) was not different (P > 0.05). The GWDF technique was associated with under-dilation and over-dilation of the tracheal stoma, each in almost one-third of patients. In the CBR group, the procedure was associated with a significant increase in peak airway pressure (P < 0.05) in all patients. There were nine cases of tracheal cartilage rupture, three cases of longitudinal tracheal abrasion, and one pneumothorax. Three patients had tracheal in-drawing at the scar site with huskiness of voice at 8 wk after decannulation; however, none had any breathing difficulty. We conclude that the techniques are equally effective in the formation of percutaneous tracheostomy. However, tracheal stoma over-dilation with GWDF and increase in peak airway pressure and rupture of tracheal rings with CBR remain major concerns. IMPLICATIONS: The tracheas of 60 patients were cannulated through an artificial opening by using a single-step dilation technique with Ciaglia Blue Rhino or Griggs' dilation forceps. The techniques were equally effective for cannulation of the trachea. However, Ciaglia Blue Rhino was associated with rupture of tracheal rings in one-third of patients and increased airway pressure in all, whereas the Griggs' technique was associated with under- or over-formation of the tracheal opening, each in one-third of patients.

Comparison of sensitivity of neuromuscular monitoring tests: twitch versus tetanic test.

PURPOSE: The study was planned to compare the sensitivity of a twitch neuromuscular monitoring test, the train-of-four (TOF), with a tetanic test, double-burst stimulation (DBS), during a subclinical dose of vecuronium. METHODS: Twenty consenting. ASA I patients (16 to 65 years of age) of both sexes were studied. The ulnar nerve was stimulated at the wrist through surface electrodes by Myotest-DBS, and the adductor pollicis response was recorded on Myograph-2000. After stabilization of the twitch tension at titrated supramaximal stimuli (1 Hz), patients were randomly allocated into groups. In group 1 (n=10), the TOF test was monitored; in group 2 (n=10), the DBS test was monitoral. All patients received a priming dose of vecuronium (0.015 mg·kg-1); parameters such asT 1 and TOF ratio (TOFr) (T 4/T 1) were noted in group 1, andD 1 and DBS ratio (DBSr) (D 2/D 1) were noted during the vecuronium effect. RESULTS: The DBS test showed a wider range of change (from control 1.00 to 0.62±0.19 forD 1 and to 0.37±0.14 for DBSr) at a faster rate (0.07±0.04 min-1 forD 1 and 0.08±0.02 min-1 for DBSr) during the block progression phase than the TOF test parameters (T 1 and TOFr). The tetanic fade or DBSr showed peak onset later than peak twitch suppression. The rate of recovery of the DBS test was also slower than that of the TOF test after the peak effect. CONCLUSIONS: DBS is a more sensitive test than TOF to quantify the subclinical dose effect of vecuronium, and among the studied parameters (T 1, TOFr,D 1 and DBSr), DBSr, measuring tetanic fade, was the most sensitive single parameter.

Target controlled priming for rapid onset of intubation dose: A new approach.

PURPOSE: To determine the pattern of onset of the intubating dose when given at a monitored target priming block in either phase of the priming drug effect. METHODS: Sixty consenting ASA I and II patients were premedicated by intramuscular buprenorphine (5 µg·kg-1) 1h before surgery. Neuromuscular junction monitoring was done by stimulating the ulnar nerve at the wrist using Myotest and recording the adductor pollicis response on Myograph-2000. After stabilization of the twitch tension at the titrated supramaximal stimulus (1 Hz), double-burst stimuli (DBS) were given to monitor the priming effect of vecuronium bromide (Vb) (0.015 mg·kg-1). The DBS ratio (DBSr=D 2/D 1) was calculated for the DBS response, repeated at 20s. Depending on the target priming block level (DBSr 0.8, 0.6, or 0.5) and the phase of the priming block to give an intubating dose of Vb (0.8 mg·kg-1) injection, all patients were randomly assigned to six study groups: group 1 (DBSr 0.8), group 3 (DBSr 0.6), and group 5 (DBSr 0.5) during the priming block progression phase (before peakD 1 suppression), and group 2 (DBSr 0.8), group 4 (DBSr 0.6), and group 6 (DBSr 0.5) during the priming block regression phase (after peakD 1 suppression). Anesthesia was induced by thiopental (5-7 mg·kg-1) just before the intubating dose. The effect of the intubating dose on twitch stimuli (1 Hz) was monitored. RESULTS: We observed that in spite of significantly variable priming intervals for identical DBSr in two different phases, the onset time of the intubating dose to 0 response was identical in similar DBSr group patients; i.e., at 0.8 DBSr, 65.0±5.2s (group 1)vs 66.0±8.0s (group 2); at DBSr 0.6, 55.2±3.7s (group 3)vs 55.2±4.9s (group 4); and at DBSr 0.5, 43.5±4.8s (group 5)vs 43.5±4.2s (group 6). At 0 twitch response, the intubating conditions were comparable in patients of the six groups. CONCLUSION: In conclusion, target controlled priming (DBSr) for administration of the intubating dose appears to be a useful double-vision sign to predict the onset of the effect of the intubating dose precisely.