Does pre-procedure ultrasound increase the success and safety of right internal jugular venous catheterization? An intervention study.

BACKGROUND: Real-time ultrasound (US) in central venous catheterization is superior to pre-procedure US. However, ensuring real-time US into routine practice is impeded by its perceived expense and difficulty. This expertise requires hand-eye coordination and learning curve. Moreover, availability of multiple US machines and probes for multiple operation theatres may not be possible even at the tertiary level care set-up. Currently, pre-procedure US and landmark methods are most widely used. We investigated both the techniques with application of skin markings in the pre-procedure group to ascertain efficacy and safety with a view to incorporate pre-procedure US in our practice. METHODS: In this randomized study, we investigated 66 patients. Thirty-three patients in the pre-procedure ultrasound group and 33 patients in the landmark group were included for right internal jugular vein (RIJV) cannulation. We recorded the first needle pass success rate, cannulation time and complications. RESULTS: Pre-procedure US was associated with more successful attempts, shorter cannulation times and less complications. Under pre-procedure US, 75.76% of first attempts were successful with a cannulation time of 50 (25-180) seconds. Under landmark technique, 27.27% of first attempts were successful with a cannulation time of 85 (20-200) seconds. First puncture success rates were higher in pre-procedure US than landmark technique, 66.67% vs 27.27%, respectively. CONCLUSION: Pre-procedure US for RIJV catheterization is safer, quicker and superior to landmark technique.

Spinal cord imaging by transesophageal echocardiography: a new modality of monitoring.

A 45-year-old patient with known history of Aortic arch aneurysm presented in the emergency ward with features of rupture of the aneurysm into the left lung with compressive signs in the pulmonary parenchyma. Diagnosis was confirmed by magnetic resonance imaging. The patient underwent repair of thoracic aortic aneurysm with left upper lobectomy under general anesthesia and cardio-pulmonary bypass support. Transesophageal echocardiography (TEE) was used for an intraoperative monitoring. While imaging the thoracic aorta with TEE was underway, we accidentally visualized an image that was confirmed to be the spinal cord. So, in this article we discuss how the spinal cord monitoring can be made possible with TEE.

A large angiosarcoma of the right atrium: anaesthetic management.

We present the case of a young man diagnosed with a right atrial mass and a large pericardial effusion. The patient had presented in the emergency department with chest pain, shortness of breath, pedal oedema and loss of appetite. A transthoracic echocardiogram showed a bright echodensity in the right atrium with a large pericardial effusion. He was treated for presumed tubercular pericardial effusion. Pericardiocentesis showed a straw-coloured non-tubercular pericardial effusion. Surgical removal of the right atrial tumour was planned with cardiopulmonary bypass support. The tumour could only be partially resected due to large adhesions with the myocardium. The patient suffered a cardiorespiratory arrest in the intensive care unit 3 hours after surgery due to persistent bleeding in the pericardial cavity with refractory hypovolemic shock and could not be revived. The pathological examination performed later revealed a primary cardiac angiosarcoma. The case highlights the initial clinical presentation, current diagnostic modalities, and anaesthetic management options for cardiac angiosarcoma.

Ketamine-etomidate for children undergoing cardiac catheterization.

The purpose of this study was to determine the effects of combined low-dose ketamine and etomidate on hemodynamics during cardiac catheterization in children with congenital cardiac shunts. Sixty children undergoing routine diagnostic cardiac catheterization were included: 30 had a right-to-left shunt, and 30 had a left-to-right shunt. Both groups were given a single dose of etomidate 0.3 mg·kg(-1) with ketamine 1 mg·kg(-1). There were no hemodynamic changes in the group with a right-to-left shunt. In cases of left-to-right shunt, there were significant differences in heart rate, right atrial pressure, mean arterial pressure, mean pulmonary artery pressure, pulmonary artery wedge pressure, and systemic vascular resistance index. Decreases in pulmonary blood flow and pulmonary-systemic shunt ratio were also observed. Further studies are required with dose titration of this anesthetic combination in pediatric patients with congenital heart disease involving a left-to-right shunt.

Hemodynamic responses to etomidate in pediatric patients with congenital cardiac shunt lesions.

OBJECTIVE: The authors investigated the effects of intravenous etomidate on hemodynamics in children with congenital cardiac shunts. DESIGN: Prospective observational study. SETTING: Catheterization laboratory in tertiary referral cardiac center. PARTICIPANTS: Thirty children with congenital cardiac shunt lesions. INTERVENTIONS: Fifteen children having congenital right to left shunts (group A) and 15 children with left to right shunts (group B) were studied. Systemic mean arterial pressure (SMAP), mean pulmonary artery pressures (MPAP), right atrial pressures (RAP), and pulmonary artery wedge pressure (PAWP) were recorded. Systemic vascular resistance index (SVRI), pulmonary vascular resistance index (PVRI), and pulmonary-to-systemic blood flow ratio (Qp/Qs) were calculated on room air at baseline and following a single dose of 0.3 mg/kg of etomidate. MEASUREMENTS AND MAIN RESULTS: Heart rate (HR), SMAP, RAP, systemic blood flow (Qs), Qp/Qs, and SVRI did not show any significant change; whereas systemic arterial saturation increased from 77.3% to 79.3%, which was statistically but not clinically significant in the authors' opinion following etomidate in group A. No significant differences in HR, SMAP, MPAP, PAWP, PVRI, SVRI, Qs, pulmonary blood flow (Qp), and Qp/Qs ratio were seen; whereas RAP, systemic, and pulmonary artery saturation decreased in group B after etomidate. Although statistically significant, the decreases were not clinically significant. CONCLUSION: Etomidate at 0.3 mg/kg produces very minimal changes in hemodynamic parameters and shunt fraction in children with congenital shunt lesions.

Effect of rectal diclofenac in reducing postoperative pain and rescue analgesia requirement after cardiac surgery.

BACKGROUND: Adequate analgesic medication is mandatory after coronary artery bypass grafting (CABG) surgery. The aim of this study was to assess the analgesic efficacy, side effects, and need for rescue analgesia after CABG surgery comparing diclofenac and placebo rectal suppository. METHODS: Thirty-seven consenting adults undergoing elective CABG surgery were randomly assigned in a double-blind fashion to receive either rectal diclofenac 100 mg (Group 1, n = 19) or placebo suppository (Group 2, n = 18) postoperatively, just after extubation. Both groups were given intravenous tramadol as a rescue analgesic. Pain scores in the two groups were assessed on a 10-cm visual analog scale at 0, 0.5, 1, 1.5, 2, 6, 12, 18, and 24 hours after suppository administration. Rescue analgesic consumption, sedation, nausea, and vomiting in both the groups were also recorded. RESULTS: Twenty-four-hour tramadol consumption in Group 1 was 92.5 +/- 33.5 mg compared to 157.5 +/- 63.4 mg in Group 2 (P = 0.002). Patients in the placebo group had significantly greater pain scores 1.5 to 12 hours after extubation. Group 1 patients were significantly more awake compared to Group 2 (P < 0.05). The incidence of postoperative nausea was less in Group 1 than in Group 2 (P = 0.001). Though not statistically significant, three patients in Group 2 each had a single episode of vomiting, whereas no patient had vomiting in Group 1. CONCLUSION: Rectal diclofenac suppository with tramadol provides adequate pain relief after cardiac surgery, and also reduces tramadol consumption and side effects commonly associated with tramadol.