Intraoperative Awareness in Patients Undergoing Cardiac Surgery in an Academic Center in the North of Iran

Background

Coronary artery bypass grafting (CABG) has distinctive characteristics that may increase the risk of awareness during general anesthesia (AGA).

Objectives

This study was conducted to assess the incidence of AGA in cardiac surgery in an academic hospital in Guilan, Iran.

Methods

This descriptive cross-sectional study was performed in Dr. Heshmat Hospital in Rasht, Iran. Eligible patients candidates for CABG were enrolled in the survey in 2022. After surgery, when the patient was cooperative enough, a questionnaire including demographic data and specialized questions related to different stages of anesthesia was completed via face-to-face interviews. The data were analyzed using IBM SPSS Statistics 21 with chi-square, Fisher's exact, and t-test.

Results

The data from 322 patients were analyzed, of whom 14 (4.3%) experienced AGA. Among them, the "feeling of fear and anxiety" reported by 9 (39.1%) cases was the most common awareness state. "Dreaming during surgery and anesthesia" and "feeling unable to move during anesthesia,", each reported by 6 (26.1%) cases, were the other common types of awareness state. None of the demographic data had a significant association with the occurrence of AGA.

Conclusions

The incidence of AGA during CABG was almost acceptable according to the credible evidence.

Glycemic Control in Coronary Artery Bypass Graft Surgery: A Different Perspective

Background

Hyperglycemia during coronary artery bypass graft surgery (CABG) strongly predicts intra- and post-operative adverse consequences.

Objectives

This study aimed to evaluate the quality of glycemic management during CABG in an academic center regarding peripheral blood and coronary sinus values.

Methods

This prospective descriptive study encompassed 55 eligible patients undergoing on-pump CABG surgery in 2020. Peripheral blood glucose (BG) was measured four times, before anesthesia induction (T0), before cardiopulmonary bypass pump (CPB) (T1), during CPB (T2), at the end of CPB (T3), and at the end of surgery (T4). The surgeon also took a sample of the coronary sinus BG.

Results

The BG variations from T0 to T4 were statistically significant (P < 0.0001). The higher values detected in the ASA class III compared to ASA classes II were statistically significant at T1 (P = 0.01) and T2 (P = 0.025): patients with the higher BMI showed the higher levels of BG. In this regard, the differences were significant at T0 (P = 0.0001), T2 (P = 0.004), and T3 (P = 0.015). Regarding coronary sinus, the mean BG was 222.18 ± 75.74 mg/dL. It was also observed that the ASA class III (P = 0.001), longer duration of CPB (P = 0.021), higher IV fluid volume administrated during surgery (P = 0.023), higher BMI (P = 0.0001), and less urine volume at the end of surgery (P = 0.049) were significantly associated with the higher BG of the coronary sinus.

Conclusions

The existing glycemic management protocols on the CABG patients were acceptable in our hospital. However, the BG level of the coronary sinus was higher than the peripheral one.

The Effects of Intravenous Vitamin C on Stress Response Severity in Abdominal Hysterectomy Following Prolonged Fasting Time

Background

Inevitable prolonged fasting time before surgery leads to inflammatory reactions, surgery-related stress response, and consequently unfavorable outcomes; thus, developing strategies to mitigate these consequences is crucial.

Objectives

In this study, we evaluated the effect of ascorbic acid on stress response reduction in abdominal hysterectomy following prolonged fasting time.

Methods

Eligible women candidates for abdominal hysterectomy following prolonged fasting time were enrolled in the study and divided into 2 groups of vitamin C [group C; 1 g intravenously (IV) before surgery] and placebo (group P). Before induction of anesthesia, C-reactive protein (CRP), mean arterial pressure (MAP), heart rate (HR), and blood sugar (BS) were measured and compared between the 2 groups at 4-point times, 24 and 48 hours immediately after extubation.

Results

Finally, the data of 80 patients were included for the final analysis. A statistically significant difference was observed between the 2 groups in terms of CRP and BS values in T1 CRP serum levels; at the end of the study, CRP values were 0.5 ± 0.55 and 0.92 ± 0.69 in groups C and P, respectively (P = 0.012), and BS levels were 124.12 ± 18.11 and 152.0 ± 17.36 in groups C and P, respectively (P = 0.0001). However, this significant difference was not observed at T2 regarding CRP (P = 0.145) and BS (P = 0.135), as well as at T3 regarding CRP (P = 0.282) and BS (P = 0.213). However, according to both CRP and BS values, the trend of changes from T0 to T3 was significant in the 2 groups (P < 0.0001). Hemodynamic parameters were not significantly different between the 2 groups. No adverse event was reported in the 2 groups.

Conclusions

We found that ascorbic acid could induce short-term positive effects in abdominal hysterectomy following prolonged fasting time. Obviously, the optimal dosage, timing, and specific cases that benefit the most from this intervention should be investigated.

Comparing the Effects of Low Dose of Ketamine, Tramadol, and Ondansetron in Prevention of Post Spinal Anesthesia Shivering in Cesarean Section

Background

Shivering frequently occurs in cesarean section (CS) under spinal anesthesia (SA), resulting in several complications. To date, pethidine has been considered as the gold standard for post-SA shivering control, but it is contraindicated in breastfeeding women.

Methods

This randomized, double-blind study was conducted at Alzahra hospital in Guilan, Iran, From January 2019 to November 2020. A total of 508 eligible term parturient women were enrolled and randomly divided into four groups of low dose ketamine (K), tramadol (T), ondansetron (O), and placebo (P). The incidence and severity of shivering and patients' complications were recorded and compared among the groups.

Results

The patients were homogenous in terms of demographic variables. Shivering was witnessed in 68 (53.5%), 26 (20.5%), 75 (59.1%), and 82 (64.6%) patients in K, T, O, and P groups, respectively (P = 0.0001). Regarding shivering severity, there was a significant difference among the four groups (P = 0.0001). In addition, a significant difference was seen regarding Apgar scores at the first minute, but not at the fifth minute (P = 0.168).

Conclusions

Considering the high incidence of shivering in placebo group, prophylactic intervention in CS under SA seems to be necessary. Among the studied drugs, tramadol was the most effective one, followed by a low dose of ketamine and ondansetron.

Knowledge, Attitude, and Performance of Pregnant Women Regarding General Anesthesia Neurotoxicity in Children under Three: A Report from an Academic Hospital

Background: Recently, concerns about general anesthesia (GA)-related neurotoxicity has been growing in societies. Parents’ information obviously plays an important role to make right decision for elective surgeries on children aged under three years old. Objectives: The aim of this survey was to evaluate the knowledge, attitude, and performance of pregnant women about the GA-related neurotoxicity in children aged under three years old. Methods: This descriptive study was conducted at Alzahra Teaching Hospital in Guilan, Iran, during 2020. The eligible pregnant women admitted to this center were interviewed, and a questionnaire containing 10 items was filled out by the responsible resident of anesthesiology. Results: In this research, a total of 361 pregnant women were enrolled and underwent a face-to-face interview. The mean age of the participants was 31.4 ± 7 years, 64.5% were living in urban areas, 82.5% were housewives, and 65.7% were multipara. Moreover, 83.7% of participants believed that receiving information in this regard was crucial, and 81.7% preferred physicians as the source of information. Only 8% of mothers had received information regarding the issue. A significant correlation was observed between the habitat, employment, the level of education, knowledge, and attitude status, and the source of receiving information. Conclusions: According to our results, the knowledge, attitude, and performance of pregnant women were not optimal and needed to be improved through practical strategies.

Post-dural Puncture Headache in Cesarean Section; Frequency and Risk Factors: A Report From the North of Iran

Background: Spinal Anesthesia (SA) as a safe, reliable, and cost-effective method is widely used for Cesarean Section (CS). However, it is sometimes complicated by Post-Dural Puncture Headache (PDPH). Objectives: We investigated the frequency of PDPH in CS under SA and related risk factors in an academic referral hospital in the north of Iran. Materials & Methods: This descriptive cross-sectional prospective study was conducted at Alzahra hospital as an academic referral center affiliated with the Guilan University of Medical Sciences on 147 eligible cases During from May 2019 to October 2019. Then questionnaires containing questions about patients’ demographic data and some PDPH-related factors were filled out via face-to-face interviews. The collected data were analyzed by SPSS v. 21 using Chi-squared and and Fisher’s exact test. Results: The incidence of PDPH was 6.1%. Early ambulation, the number of attempts, and having a history of headache were significantly associated with a higher incidence of PDPH (P=0.001), while body mass index (P=0.106), age (P=0.093), and residents’ experience (P=0.384) had no significant association. None of our cases experienced a severe or persistent headache. Conclusion: The main predisposing factors for PDPH were found to be the history of HA, early ambulation, and the number of dura punctures. Women at risk for PDPH should be objectively screened before CS under SA.

Comparing the Effectiveness of Patient Control Analgesia Pump and Bolus Morphine in Controlling Pain After Cardiopulmonary Bypass Graft Surgery

Background

Postoperative pain is a complex process commonly caused by surgical trauma. It is one of the major concerns of patients undergoing heart surgery. Despite new techniques and modern analgesic treatments, postoperative pain is still one of the most important controversial issues.

Methods

68 patients scheduled for elective CABG with CPB were included in a prospective, double-blind clinical trial. They were randomly divided into two groups. One group received PCA pump including morphine (group P) with underlying infusion of 0.02 mg/kg/Qh, bolus dose of 1 mg, lockout time of 15 minutes, and a maximum of 4 bolus of 0.02 mg/kg for one hour and the other group received morphine bolus (group B). Three patients were excluded from the study, and 33 and 32 patients participated in the groups P and B, respectively. Variables including age, gender, pump time, aortic clamp time, duration of surgery, complications (nausea and vomiting, GI Bleeding, and hypoxia), level of pain based on VAS, opioid consumption, hemodynamic, and sedation status were measured in both groups.

Results

There was no significant difference between the groups regarding age, gender, pump time, clamp time, duration of surgery, complication, sedation score, and hemodynamic status in most of the assessment periods. By assessing the pain severity in the groups at different periods, results showed a significant difference between the groups except at enrollment, and a lower severity of pain was noted in the group P compared to the group B. The consumed opioid was significantly higher in the group P than in the group B. However, higher doses of diclofenac and paracetamol were administered in the group B compared to the group P.

Conclusions

Results showed that higher morphine would be used in patients with PCA pump after extubation following heart surgery, and this increased dose of opioid was associated with better pain control and lack of complication. Therefore, PCA pump with underlying infusion could be effectively used in patients undergoing CABG that are directly assessed in intensive care unite.

Effect of Selenium on Stress Response in Coronary Artery Bypass Graft Surgery: A Clinical Trial

Background

In spite of significant improvements in surgical and anesthetic techniques, acute stress response to surgery remains a main cause of mortality and morbidity in coronary artery bypass graft (CABG) surgery patients. Therefore, doing research to find safe and effective modalities with more cardio protective properties seems necessary.

Objectives

In this study, we sought to determine whether intravenous injection of 600 μg Selenium (Se) prior to surgery would limit stress response measured by blood sugar.

Methods

This double blind clinical trial was conducted at a referral center of cardiac surgery affiliated to Guilan University of Medical Sciences (GUMS) from June 2015 to October 2015. 73 eligible patients candidate for elective isolated CABG surgery were enrolled in the trial. They were randomly allocated to either Se group (n = 36) receiving 600 μg Se prior to surgery or control group (n = 37). Our evaluation was based on blood sugar (BS) which was measured at four point times, including before induction of anesthesia (T0), at the end of CPB (T1), 24 hours (T2) and 48 hours (T3) after surgery.

Results

The data obtained from 73 patients in group S (n = 36) and group C (n = 37) were analyzed. There was no significant difference between the two groups regarding the baseline characteristics. In both groups, a sharp rise in BS levels was observed following CPB (P = 0.0001). Although the trend of BS changes was remarkable in both groups (P = 0.0001), there was no statistically significant difference between the groups at all point times including T0 (P = 0.45), T1 (P = 0.48), T2 (P = 0.92), and T3 (P = 0.42). Within the study time, our patients were monitored for any adverse effect but nothing was observed.

Conclusions

This investigation showed that intravenous single dose of 600 μg Se was safe in CABG patients, but had no positive effect on stress response to surgery.

Effects of Low-dose Selenium on the Inflammatory Response in Coronary Artery Bypass Graft Surgery: A Clinical Trial

Background

Coronary artery bypass graft (CABG) surgery with cardiopulmonary bypass (CPB) triggers an inflammatory reaction, leading to the development of myocardial damage and dysfunction. It is suggested that selenium (Se), an essential trace element, has a protective role against oxidative stress. Decreased intraoperative Se levels might be an independent predictive factor for postoperative multiorgan failure. In spite of its proposed advantages, however, the optimal timing and dosage are not well known.

Objectives

To determine whether 600 µg of intravenous Se administration before induction of anesthesia for CABG surgery could attenuate inflammatory reactions in an Iranian population.

Methods

This randomized triple-blind clinical trial took place in the department of cardiac surgery of an academic hospital affiliated with Guilan University of Medical Sciences (GUMS) from May 2015 to September 2015. Eighty-eight eligible patients scheduled for elective on-pump CABG surgery were divided into two groups using randomized fixed quadripartite blocks. They received either an intravenous bolus of 600 µg Se before induction of anesthesia, or normal saline as a placebo. We had four measurement time-points: just before induction of anesthesia (T0), immediately after the end of CPB (T1), 24 hours after surgery (T2), and 48 hours after surgery (T3). Interleukin 6 (IL-6), tumor necrosis factor-alpha (TNF-α), and C-reactive protein (CRP) serum levels were measured using the enzyme-linked immunosorbent assay (ELISA).

Results

Data from a total of 81 patients were analyzed: group S (n = 41) and group C (n = 40). There was no significant difference between the two groups with regard to baseline characteristics. In both groups, CPB caused markedly increased IL-6, TNF-α, and CRP plasma concentrations compared with baseline (P = 0.0001). However, the pattern of changes was not significantly different between group S (P = 0.068) and group C (P = 0.26). The IL-6 and TNF-α change trends were significant in each group (P=0.0001). However, comparing the two groups showed no significant difference. With regard to IL-6, there was no significant difference between the two groups at the time-points of T1 (P = 0.34), T2 (P = 0.17), and T3 (P = 0.056), and the same was found for TNF-α at T1 (P = 0.34), T2 (P = 0.17), and T3 (P = 0.056). With regard to CRP, the trend of the changes was significant in each group (P = 0.0001). However, comparing two groups showed a borderline significant difference between them at T1 (P = 0.039), but not at T2 (P = 0.075) or T3 (P = 0.11).

Conclusions

This study revealed that the administration of 600 μg of intravenous Se immediately before induction of anesthesia was safe, but when compared to a placebo, no predominant clinical effects or modifications in the systemic inflammatory response induced by on-pump CABG were observed.

Significance of preoperative total lymphocyte count as a prognostic criterion in adult cardiac surgery

BACKGROUND

Evaluation of operational risk is a consequential goal in perioperative management of patients in cardiac surgery. Preoperative total lymphocyte count (PTLC) is a prognostic criterion of adverse major cardiovascular outcomes.

OBJECTIVES

The purpose of this study was to investigate the prognostic value of PTLC as an independent predictor of postoperative morbidity and mortality in cardiac surgery.

PATIENTS AND METHODS

Of 1604 patients scheduled for cardiac surgery between September, 2012 and March, 2013, a total of 1171 consecutive patients underwent elective primary valvular heart surgery and coronary artery bypass grafting. The patients were divided to three groups according to their PTLCs. The baseline characteristics and postoperative mortality and morbidity of the patients as well as the intensive care unit (ICU) stay according to the PTLCs were recorded and analyzed. The only inclusion criterion was a preoperative complete blood count. Exclusion criteria included: ages under 18 or over 80 years old, emergency surgery, adult patients with congenital heart disease and previous open heart surgery, and patients with any bacterial or viral infection during two weeks before the surgery. Protocol of anesthetic medications was used in all the patients similarly and according to standard. All the patients were admitted to the ICU after the surgery.

RESULTS

A PTLC < 1500 cells/µL was associated with significantly high mortality and morbidity (P = 0.0001). In-hospital mortality and major composite morbidity were 9.65% and 28.4%, respectively. Low PTLC was associated with more frequent need for inotropic and intra-aortic balloon pump (IABP) support (P < 0.001), dialysis-dependent acute renal failure (P = 0.0001), postoperative superficial wound infections (P = 0.0001) and prolong ICU stay (P = 0.0001).

CONCLUSIONS

Our study results showed that low PTLC was an independent, valuable prognostic criterion, with high sensitivity and specificity for evaluation of postoperative morbidity and mortality in cardiac surgery.