Haemorrhagic peritonitis as a late complication of echocardiography guided pericardiocentesis.

Clinically significant pericardial effusion is an uncommon complication after cardiac surgery. Pericardiocentesis can be performed either through a mini-sternotomy or under echocardiography guidance. Echocardiography guidance is a relatively safe procedure and it avoids the need for another general anaesthetic. However, in this post cardiac surgical patient echocardiography guided pericardiocentesis was complicated several days later by haemorrhagic peritonitis.

Exploration of xenon as a potential cardiostable sedative: a comparison with propofol after cardiac surgery.

Xenon anaesthesia is thought to have minimal haemodynamic side-effects. It is, however, expensive and requires special delivery systems for economic use. In this randomised cross-over study, we: (i) investigated the haemodynamic profile and recovery characteristics of xenon compared with propofol sedation in postoperative cardiac surgery patients, and (ii) evaluated a fully closed breathing system to minimise xenon consumption. We demonstrated a significantly faster recovery from xenon (3 min 11 s) than propofol sedation (25 min 23 s). Relative to propofol, xenon sedation produced no change in heart rate or mean arterial pressure and there were significantly higher mean values for central venous pressure (10.6 vs. 8.9 mmHg), pulmonary artery occlusion pressure (11.2 vs. 9.5 mmHg), mean pulmonary artery pressure (20.1 vs. 18.3 mmHg) and systemic vascular resistance index (2170 vs. 1896 dyn.s.cm-5.m-2). The haemodynamic profile seen with propofol reflected its known vasodilator effects. This was supported by the almost identical left ventricular stroke work indexes seen with both methods of sedation.

The role of nicorandil in the treatment of myocardial ischaemia.

Nicorandil is an anti-anginal agent that has been used in the United Kingdom for over 6 years and is becoming increasingly popular. It induces coronary and peripheral vasodilatation via a dualistic mode of action, mediated by the opening of potassium-ATP channels (K(ATP)) and its nitrate effect by stimulation of adenyl cyclase, with an increase in cGMP levels. Comparison to nitrates and other anti-anginal agents have shown it to be of equal efficacy in relieving ischaemic symptoms. Recent evidence suggests a role for nicorandil as a myocardial preconditioning agent but this may be limited by systemic vasodilatation. There is ongoing research into its role in improving the long-term outcome of patients with ischaemic heart disease (IHD). It has been shown to be of proven efficacy in the treatment of IHD and further research will clarify other uses of this agent.

Nicorandil-induced peripheral vasodilatation during cardiopulmonary bypass.

Nicorandil is an antianginal agent with actions at epicardial coronary arteries and arterioles, systemic arterioles, and veins. We report our experience with 7 patients taking oral Nicorandil who had severe vasodilation and hypotension requiring significant vasoconstrictor support after cardiopulmonary bypass. Although the mechanism for this phenomenon remains unknown Nicorandil might be interacting with other factors present during cardiopulmonary bypass, as it has relatively mild hemodynamic effects outside this situation.

Emergency thoracotomy for thoracic trauma in the accident and emergency department: indications and outcome.

To assess the efficacy of emergency thoracotomy performed for thoracic trauma in the accident and emergency department, a retrospective analysis of patients who underwent this procedure and were brought to hospital by the Helicopter Emergency Medical Service was carried out. Between 1991 and 1994, 16 patients had emergency thoracotomy performed in the accident department. Twelve patients had sustained blunt trauma and four patients had sustained penetrating injuries. Three patients first assessed at the scene and 11 patients on arrival at the emergency department had Glasgow Coma Scores < 3. Eight thoracotomies were performed by the cardiothoracic team and eight by the trauma team. There was one survivor in this group; he had been stabbed at multiple sites and emergency thoracotomy was required to control bleeding from an intercostal vessel. Our results demonstrate experience of one of the first phase Level One trauma centres in the United Kingdom. From our small series, we believe that selection criteria for emergency thoracotomy in trauma patients need to be revised. From this series and a review of the literature, patients with penetrating injuries, vital signs at the scene and those with a high index of suspicion for tamponade seem to benefit most from thoracotomy in the emergency setting.

Coronary artery bypass surgery and minor aortic stenosis--to replace or not to replace?

Seven patients with a mean age of 65 years (range 50-76 years) who had minor aortic valve gradients (less than 25 mmHg) at preoperative cardiac catheterization underwent coronary artery bypass surgery without aortic valve surgery, but required a second operation for aortic valve replacement between five and nine years later because of symptomatic aortic valve stenosis with a valve gradient which had increased to between 60 and 100 mmHg. Serial hemodynamic observations in patients with aortic stenosis have demonstrated that the rate at which stenosis progresses is widely variable. However, replacement of aortic valves at the time of initial coronary artery surgery may subject the patients to an increased risk of operative mortality and prosthetic valve-related complications. On the other hand, the patient may miss the opportunity to obtain maximum benefit from valve replacement before deterioration of left ventricular function, particularly in the presence of coronary artery disease, and there are also the risks of resternotomy. We are currently inclined to replace the aortic valve in coronary patients with asymptomatic aortic stenosis, but our experience is not sufficient to draw final conclusions and the relevant literature does not provide a clear guidance. The aim of this publication is to expose this dilemma.

Surgical glove punctures during cardiac operations.

A new method of detecting occult glove punctures was devised to determine its frequency during cardiac operations. Glove puncture is of relevance to the transmission of infectious diseases and the potential contamination of implanted cardiac prostheses. A study was therefore carried out in 48 adult patients undergoing open heart operations in which gloves worn by surgeons and nurses were collected and evaluated at the end of each procedure. In 22 of these cases, gloves were changed at three different stages of the cardiac operation for the principal operators: stage I, skin incision to commencement of cardiopulmonary bypass; stage II, cardiopulmonary bypass to sternotomy closure; and stage III, sternotomy closure to skin closure. One hundred sixty-two gloves (31.5%) had one or more punctures out of a total of 514 gloves tested. Only 20 glove punctures were recognized either at the time or at the end of the operation. There were 185 occult glove punctures. The majority (60%) of punctures were on the nondominant hand, with 30% of perforations located in the nondominant index finger. Using the chi 2 test with two degrees of freedom, there is no significant difference between the glove perforation rates for the principal operators in stages I, II, and III. The most important finding from this study was that 61% of gloves worn by scrub nurses had one or more punctures compared with 23.6% of surgeons.

Severe rheumatic mitral stenosis with pericardial effusion causing left ventricular tamponade.

A woman of 38 was admitted for urgent surgery of severe mitral stenosis causing pulmonary oedema. Echocardiography showed a pericardial effusion with apparent distortion and collapse of the left ventricle. Urgent drainage of the effusion before mitral valve surgery led to an improvement in cardiac output with no detectable change in right heart pressures.