Effects of ferric carboxymaltose on hemoglobin level after cardiac surgery: A randomized controlled trial

BACKGROUND

Perioperative anemia is common in cardiac surgery. Few studies investigated the effect of postoperative intravenous (IV) iron supplementation and were mostly inconclusive.

METHODS

Design: A randomized single-center, double-blind, placebo-controlled, parallel-group trial.

PARTICIPANTS

195 non-anemic patients were recruited from December 2018 to December 2020: 97 patients received 1 g of ferric carboxymaltose (FCM) and 98 patients received 100 mL of physiological serum on postoperative day 1.

MEASUREMENTS

hemoglobin levels, reticulocyte count, serum iron, serum ferritin, and transferrin saturation were measured at induction of anesthesia, postoperative days 1, 5, and 30. Transfusion rate, duration of mechanical ventilation, critical care unit length of stay, and side effects associated with IV iron administration were measured. The primary outcome was hemoglobin level on day 30. Secondary outcomes included iron balance, transfused red cell packs, and critical care unit length of stay.

RESULTS

At day 30, the hemoglobine level was higher in the FCM group than in the placebo group (mean 12.9 ± 1.2 vs. 12.1 ± 1.3 g/dL (95%CI 0.41-1.23, p-value <0.001)). Patients in the FCM group received fewer blood units (median 1[0-2] unit vs. 2 [0-3] units, p-value = 0.037) and had significant improvement in iron balance compared to the control group. No side effects associated with FCM administration were reported.

CONCLUSION

In this randomized controlled trial, administration of FCM on postoperative day 1 in non-anemic patients undergoing cardiac surgery increased hemoglobin levels by 0.8 g/dL on postoperative day 30, leading to reduced transfusion rate, and improved iron levels on postoperative day 5 and 30.

CLINICAL TRIAL REGISTRY NUMBER

NCT03759964.

Preoperative Oral Magnesium loading to prevent postoperative Atrial Fibrillation following Coronary Surgery (POMAF-CS): A prospective randomized controlled trial

OBJECTIVES

Postoperative atrial fibrillation is common following coronary artery bypass grafting surgery. Hypomagnesemia is frequent after coronary artery bypass grafting surgery. No previous trials have assessed the effect of preoperative magnesium loading on postoperative atrial fibrillation incidence.

METHODS

Design: This was a single-center, double-blind, placebo-controlled, parallel-group trial, with balanced randomization [1:1]. Participants: were recruited from November 2018 until May 2019. Patients received either 3.2 g of magnesium daily (4 tablets of 0.4 g each twice daily) for 72 hours preoperatively and 1.6 g of magnesium (4 tablets) on the day of surgery, or placebo tablets.

RESULTS

The primary outcome was the incidence of postoperative atrial fibrillation. Secondary outcomes included time to extubation, transfusion rate, critical care unit and hospital length of stay. Of the 210 randomized participants, 200 (100 in each group) completed the study. 10 (10%) and 22(22%) subjects developed postoperative atrial fibrillation in the magnesium and placebo groups, respectively (RR = 0.45, 95% CI: 0.23 - 0.91). Hospital and critical care unit length of stay were comparable between the 2 groups. No side effect related to magnesium administration were documented.

CONCLUSION

In this randomized controlled trial, preoperative loading with oral administration of magnesium for 3 days in patients admitted for coronary artery bypass grafting surgery decreases the incidence of postoperative atrial fibrillation compared to placebo (NCT03703349).

CLINICAL TRIAL REGISTRY NUMBER

NCT03703349.

[Cervical plexus block as an alternative anesthetic approach for type I thyroplasty: a case report]

BACKGROUND

The role of type I thyroplasty (TIP) is well established as the treatment for glottal insufficiency due to vocal fold paralysis, but the ideal anesthetic management for this procedure is still largely debated. We present the case of a novel anesthetic approach for TIP using combined intermediate and superficial Cervical Plexus Block (CPB) and intermittent mild sedation analgesia.

CASE REPORT

A 51-year-old presenting with left vocal fold paralysis and obstructive sleep apnea was scheduled for TIP. An ultrasound-guided intermediate CPB was performed using the posterior approach, and 15 mL of ropivacaine 0.5% were injected in the posterior cervical space between the sternocleidomastoid muscle and the prevertebral fascia. Then, for the superficial CPB, a total of 10 mL 0.5% ropivacaine was injected subcutaneously, adjacently to the posterior border of the sternocleidomastoid muscle, without penetrating the investing fascia. An intermittent sedation analgesia with a target-controlled infusion of remifentanyl (target 0.5 ng.mL^-1) was used to facilitate prosthesis insertion and the fiberoptic laryngoscopy. This technique offered a safe anesthetic airway and good operating conditions for the surgeon, as well as feasible voice monitoring and optimal patient comfort.

CONCLUSION

The use of regional technique is a promising method for the anesthetic management in TIP, especially in patients with compromised airway.

Cervical plexus block as an alternative anesthetic approach for type I thyroplasty: a case report

Background

The role of type I thyroplasty (TIP) is well established as the treatment for glottal insufficiency due to vocal fold paralysis, but the ideal anesthetic management for this procedure is still largely debated. We present the case of a novel anesthetic approach for TIP using combined intermediate and superficial Cervical Plexus Block (CPB) and intermittent mild sedation analgesia.

Case report

A 51-year-old presenting with left vocal fold paralysis and obstructive sleep apnea was scheduled for TIP. An ultrasound-guided intermediate CPB was performed using the posterior approach, and 15 mL of ropivacaine 0.5% were injected in the posterior cervical space between the sternocleidomastoid muscle and the prevertebral fascia. Then, for the superficial CPB, a total of 10 mL 0.5% ropivacaine was injected subcutaneously, adjacently to the posterior border of the sternocleidomastoid muscle, without penetrating the investing fascia An intermittent sedation analgesia with a target-controlled infusion of remifentanyl (target 0.5 ng.mL^-1) was used to facilitate prosthesis insertion and the fiberoptic laryngoscopy. This technique offered a safe anesthetic airway and good operating conditions for the surgeon, as well as feasible voice monitoring and optimal patient comfort.

Conclusion

The use of a regional technique is a promising method for the anesthetic management in TIP, especially in patients with compromised airway.

Preoperative fasting: Assessment of the practices of Lebanese Anesthesiologists

Background:

Although new guidelines developed by the American Society of Anesthesiologists (ASA) recommend a liberalized preoperative nutrition, authorized clinical practice guidelines or recommendations have not yet been proposed by the Lebanese Society of Anesthesia (LSA).

Objective:

The purpose of this study was to examine Lebanese anesthesiologists’ preoperative fasting routines and determine their knowledge and acceptance of the ASA recommendations, their attitude toward liberalized fasting, and the factors favoring their nonadherence to the new recommendations.

Materials and Methods:

This study was conducted in university hospitals, affiliated hospitals, and nonuniversity hospitals located in different regions of Lebanon. The survey was approved by the local ethics committee. A written questionnaire was emailed to all anesthesiologist members of the LSA which was completed anonymously.

Results:

Out of the 294 anesthesiologists registered in the LSA and who read the email, 118 (40.1%) completed the questionnaire. Of respondents, 90% are aware of the latest ASA practice guidelines for preoperative fasting, and 78.7% claim to apply them in their practices; however, 75% of respondents still require adult patients to stop eating after midnight, and only 45% allow them to drink clear fluids up to 2 h preoperatively. One of the main reasons for not complying with the ASA guidelines was “to allow flexibility for changes in the operating schedule.”

Conclusion:

A long preoperative fasting period is still the common practice for Lebanese anesthesiologists. National guideline for preoperative fasting as liberal as that recommended by the ASA should be considered.

The effect of low-dose intravenous ketamine on continuous intercostal analgesia following thoracotomy

Ketamine, a noncompetitive N-methyl-d-aspartate antagonist, provides analgesia and prevents chronic pain following thoracotomy. The study was aimed to assess the effect of intravenous low-dose ketamine on continuous intercostal nerve block analgesia following thoracotomy. The study was a prospective, randomized, double-blinded, and placebo-controlled clinical study, performed in a single university hospital. Sixty patients, undergoing elective lobectomy through an open posterolateral thoracotomy, were included. For postoperative pain, all patients received a continuous intercostal nerve block with bupivacaine plus intravenous paracetamol and ketoprofen. In addition, patients were randomized to have intravenous ketamine (0.1 mg/kg as a preincisional bolus followed by a continuous infusion of 0.05 mg/kg/h) in group 1 or intravenous placebo in group 2. Patients reporting a visual analog scale pain score at rest ≥40 mm received intravenous morphine sulfate as rescue analgesia. The following parameters were assessed every 6 hours for 3 postoperative days: Visual analog scale pain scores at rest and during coughing, requirement of rescue analgesia with morphine, Ramsay sedation scores and psychomimetic adverse effects. Both the groups were statistically comparable regarding visual analog scale pain scores at rest (P=0.75) and during coughing (P=0.70), number of morphine deliveries (P=0.17), cumulative dose of rescue morphine (P=0.2), sedation scores (P=0.4), and psychomimetic adverse effects (P=0.09). Intravenous low-dose ketamine, when combined with continuous intercostal nerve block, did not decrease acute pain scores and supplemental morphine consumption following thoracotomy.

Pulse pressure variation predicts fluid responsiveness in elderly patients after coronary artery bypass graft surgery

OBJECTIVE

To assess the ability of pulse pressure variation to predict fluid responsiveness in mechanically ventilated elderly patients after coronary artery bypass graft surgery.

DESIGN

A prospective, interventional study.

SETTING

An academic, tertiary referral hospital.

PARTICIPANTS

Sixty patients >70 years old and mechanically ventilated after coronary artery bypass graft surgery.

INTERVENTIONS

Intravascular volume expansion using 6% hydroxyethyl starch solution, 7 mL/kg over 20 minutes.

MEASUREMENTS AND MAIN RESULTS

Heart rate, arterial blood pressure, pulse pressure variation, central venous pressure, pulmonary artery occlusion pressure, and stroke volume index were measured immediately before and after volume expansion. Fluid responsiveness was defined as an increase in stroke volume index ≥ 15% after volume expansion. Forty-one patients were fluid responders and 19 patients were nonresponders. In contrast to central venous pressure or pulmonary artery occlusion pressure, pulse pressure variation was higher in the responders than in the nonresponders (22 ± 6% v 9.3 ± 3%, p = 0.001) and correlated with the percent changes in the stroke volume index after volume expansion (r = 0.47, p = 0.001). The area under the receiver operating characteristic curve for pulse pressure variation was 0.85 (95% confidence interval 0.75-0.94). The threshold value of 11.5% allowed the discrimination between responders and nonresponders with a sensitivity of 80% and a specificity of 74%.

CONCLUSIONS

Pulse pressure variation is a reliable predictor of fluid responsiveness in mechanically ventilated elderly patients after coronary artery bypass graft surgery.

Myocardial extraction of intracellular magnesium and atrial fibrillation after coronary surgery

BACKGROUND

The effects of magnesium loading on the incidence of atrial fibrillation following coronary artery bypass graft surgery (CAGB) are equivocal. None of the previous studies assessed the influence of myocardial extraction of magnesium in these settings. The current trial aims to elucidate whether the incidence of atrial fibrillation following CABG is affected by the preoperative rate of myocardial extraction of magnesium.

METHODS

The ethical committee approved the study protocol. 113 patients (94 male, mean age 63 ± 11 years) planned for elective CABG surgery under normothermic cardiopulmonary bypass were prospectively included. Preoperative independent variables included preoperative treatment, electrocardiographic abnormalities, left ventricular ejection fraction estimation, left atrial size, creatinine clearance and assays of plasma and intracellular magnesium, calcium, albumin, potassium and ionized calcium, drawn preoperatively from the coronary sinus and the aortic root. The covariates - including the rate of myocardial extraction of magnesium - were entered in a logistic regression model to predict the odds of atrial fibrillation.

RESULTS

The incidence of post operative atrial fibrillation was 16%. A rate of myocardial extraction of intracellular magnesium ≥ 7% increases fivefold the multivariate risk of postoperative atrial fibrillation (p < .01). Advanced age was also significantly associated to postoperative atrial fibrillation.

CONCLUSIONS

This study suggests that a preoperative rate of myocardial extraction of intracellular magnesium ≥ 7% could be a new and a potent predictive factor for postoperative atrial fibrillation.

[Does nasal decontamination reduce the incidence of infections after cardiac surgery?]

INTRODUCTION

Mupirocin applied to the anterior nares four times daily usually eliminates Staphylococcus aureus, including methicillin resistant, within 48 hours. Prophylactic intranasal mupirocin is safe, inexpensive and effective in reducing the overall sternal wound infection after open-heart surgery. This study was designed to determine whether decreasing nasal bacterial colonization by applying mupirocin intra nasally decreases mediastinal, sternal, pulmonary and cutaneous infections after open-heart surgery.

MATERIAL & METHODS

After institutional approval and informed consent, 392 patients were included in a randomized, prospective study. Nasal cultures were taken for all patients before surgery. Patients were divided in two groups: Group I (n = 190) receiving mupirocin in the anterior nares 4 times daily for 48 hours before surgery; Group II (n = 202) was the control group. Patients were followed for a month after surgery. All mediastinal, sternal, pulmonary and cutaneous infections were documented and treated with appropriate antibiotics. A Student test for quantitative data and a chi2 test for qualitative data were used for statistical analysis. p < or = 0.05 was considered significant.

RESULTS

The two groups had the same demographic characteristics and risk factors. Nasal carriage of Staphylococcus was 36.2% in the two groups. Neither mediastinitis nor sternitis were noticed in any of the two groups. There was no statistical difference between the groups according to the frequency of the cutaneous infections (Group I: 19/190 - Group II: 13/202) and pneumonia (Group I: 7/190 - Group II: 13/202). In patients who had nasal carriage of Staphylococcus, nasal decontamination has not shown a statistical difference of cutaneous infections of the lower limbs nor pneumonia. Although nasal decontamination reduced the incidence of sternal wound infection (Gr I 0/190 - Gr II 4/202 ; p = 0.017). Staphylococcus aureus, in the control group, induced more cutaneous infections (30.8% vs 11.7% ; p = 0.048).

CONCLUSION

The usage of mupirocin for nasal decontamination before open-heart surgery reduces the incidence of the sternal wound infection, and does not seem to affect the frequency of cutaneous infections of the lower limbs nor pneumonia after this surgery.

[A national survey of postoperative pain management in Lebanon]

INTRODUCTION

Postoperative pain relief in Lebanon is a public health problem because its coverage is insufficient.

STUDY DESIGN

A survey was performed with a questionnaire distributed to anaesthesiologists during the Lebanese national meeting of anaesthesia in May 2006.

RESULTS

A total of 106 out of the 230 distributed questionnaires were collected. The coverage of the postoperative pain is different in the university hospitals and others. A preoperative information and postoperative evaluation of pain are only performed by 26% of anesthesiologists. A multimodal analgesia is begun in the operative room or in postanaesthesist care unit for 92% of the patients. Only 71% of the anaesthesiologists have pumps for patient-controlled analgesia. Written protocols for postoperative analgesia are available in only 58% of the centres. Among anaesthesiologists, only 36% have an initial and/or continuous formation to treat the postoperative pain. The major obstacle for improvement of postoperative pain is the cost of such treatments, which must be supported by the patients.

CONCLUSION

Even if there is a good awareness of the importance to relieve the postoperative pain, important efforts must be done in this domain in Lebanon.

Correlation between central venous oxygen saturation and oxygen delivery changes following fluid therapy

BACKGROUND

The rationale for using central venous oxygen saturation (ScvO(2)) in various clinical scenarios is that it reflects the balance between oxygen delivery (DO(2)) and demands. In this study, we evaluated the correlation between ScvO(2) and DO(2) changes (Delta Do(2), DeltaScvO(2)) in patients receiving fluid therapy following coronary surgery. We also correlated the changes of mean arterial pressure (Delta MAP) and central venous pressure (Delta CVP), with Delta DO(2).

METHODS

Sixty consecutive sedated and mechanically ventilated adult patients, with cardiac index <or=2.3 L/min/m(2) and a pulmonary artery occlusion pressure <or=12 mmHg following coronary surgery, were included. Concomitant hemodynamic parameters, arterial and venous blood gases were measured before (T0) and after (T1) administration of a 500 ml bolus of an isotonic crystalloid solution over 30 min. The correlations between Delta DO(2) and DeltaScvO(2), Delta MAP or Delta CVP were evaluated by linear regression analysis and Pearson test.

RESULTS

Cardiac index (1.9+/-0.2 vs 2.3+/-0.5 ml/min/m(2)), MAP (83+/-11 vs 94+/-13 mm Hg) and CVP (5.7+/-3 vs 7.1+/-3 mmHg) were significantly higher at T1 compared with T0. The correlation of Delta DO(2) with DeltaScvO(2) was positive, significant (r=0.41; P=0.004) and superior to its correlation with Delta MAP (r=0.30; P=0.01) or Delta CVP (r=0.03; P=0.78).

CONCLUSION

A significant correlation between ScvO(2) and DO(2) changes was found in patients receiving fluid therapy following coronary surgery. ScvO(2) could be used as an indicator to track DO(2) and to guide volume loading.

Prevention of hypotension after spinal anesthesia for cesarean section: 6% hydroxyethyl starch 130/0.4 (Voluven) versus lactated Ringer's solution

GOALS

The aim of this study is to compare the efficacy of HES 130/0.4, a new hydroxyethyl starch, to lactated Ringer's solution (LR) in the prevention of hypotension after spinal anesthesia for cesarean section (CS).

MATERIAL AND METHODS

One hundred and twenty nonlaboring ASA I and II women having non urgent CS were enrolled in this prospective and randomized study. Subjects were randomly assigned to receive prior to anesthesia either 1 liter of LR (Gr I: n = 59) or 500 ml of HES 130/0.4 (Gr II : n = 61). Blood pressure was measured until discharge from the post anesthesia care unit. Hypotension was treated with i.v. boluses of 3 mg of ephedrine. The nausea scale was recorded. Arterial and venous umbilical blood gazes were obtained. Data were compared using Mann-Whitney U-test and Student's t-test (p < 0.05 was significant).

RESULTS

Thirty-nine patients in Gr II while 48 pts in Gr I experienced hypotension (p = .033). The total dose of ephedrine was statistically smaller in Gr II compared with Gr I (p = .001). Nausea after induction of spinal anesthesia occurred with similar frequency in both groups. Neonatal outcome was excellent and similar in both groups.

CONCLUSION

HES 130/0.4 is more effective than LR to prevent hypotension following spinal anesthesia for CS; its routine use in this purpose should be considered.

Is prompt exploratory laparotomy the best attitude for mesenteric ischemia after cardiac surgery?

Mesenteric ischemia following cardiac surgery is a life-threatening complication. Early identification of patients may help optimizing management and improving outcome. Between January 2000 and July 2007, surgical exploration was realized when mesenteric ischemia was suspected after coronary-artery bypass grafts (CABG). Patients were divided in two groups according to diagnosis confirmation upon laparotomy. Peri-operative predictors of complication and death were analyzed. Of 1634 consecutive patients, 13 (0.8%) developed acute abdomen with suspicion of mesenteric ischemia. Seven (0.4%) underwent resection for ischemic lesions (group 1), of whom two were during a second look laparotomy. The other six patients had normal bowel (group 2). Both groups were comparable according to preoperative status, clinical signs, biological and radiological findings. Delays to laparotomy were 13.7+/-19.0 and 51.4+/-29.0 h in group 1 and 2, respectively (P=0.02). Mortality rates were 46.1% (6/13) overall, 42.8% for group 1 and 50% for group 2. All deaths occurred within the first nine postoperative days. Mesenteric ischemia following CABG is a fatal complication in almost half the cases. Diagnostic tools and timely laparotomy still need to be optimized. Low threshold-based strategy for prompt surgical intervention is efficient for both diagnosis and treatment.

Anesthetic management of a patient with Freeman-Sheldon syndrome: case report

The Freeman-Sheldon syndrome (FSS) is a rare congenital myopathy and dysplasia. The musculoskeletal and soft-tissue manifestations of FSS often require orthopedic and plastic reconstructive surgery. We report a case of a 7-year-old girl with FSS operated for lower limb malformation during spinal anesthesia.

Combined coronary surgery and aortic valve replacement after previous right pneumonectomy

Cardiac surgery in patients with previous pneumonectomy is infrequently reported. We report a case of combined coronary artery bypass grafting and aortic valve replacement in a patient with left ventricular ejection fraction less then 35% and a previous right pneumonectomy. All steps in operative management of this rare condition are discussed.

Effect of vital capacity manoeuvres on arterial oxygenation in morbidly obese patients undergoing open bariatric surgery

BACKGROUND

Arterial oxygenation may be compromised in morbidly obese patients undergoing bariatric surgery. The aim of this study was to evaluate the effect of a vital capacity manoeuvre (VCM), followed by ventilation with positive end-expiratory pressure (PEEP), on arterial oxygenation in morbidly obese patients undergoing open bariatric surgery.

METHODS

Fifty-two morbidly obese patients (body mass index >40 kg m-2) undergoing open bariatric surgery were enrolled in this prospective and randomized study. Anaesthesia and surgical techniques were standardized. Patients were ventilated with a tidal volume of 10 mL kg-1 of ideal body weight, a mixture of oxygen and nitrous oxide (FiO2 = 40%) and respiratory rate was adjusted to maintain end-tidal carbon dioxide at a level of 30-35 mmHg. After abdominal opening, patients in Group 1 had a PEEP of 8 cm H2O applied and patients in Group 2 had a VCM followed by PEEP of 8 cm H2O. This manoeuvre was defined as lung inflation by a positive inspiratory pressure of 40 cm H2O maintained for 15 s. PEEP was maintained until extubation in the two groups. Haemodynamics, ventilatory and arterial oxygenation parameters were measured at the following times: T0 = before application of VCM and/or PEEP, T1 = 5 min after VCM and/or PEEP and T2 = before abdominal closure.

RESULTS

Patients in the two groups were comparable regarding patient characteristics, surgical, haemodynamic and ventilatory parameters. In Group 1, arterial oxygen partial pressure (PaO2) and arterial haemoglobin oxygen saturation (SaO2) were significantly increased and alveolar-arterial oxygen pressure gradient (A-aDO2) decreased at T2 when compared with T0 and T1. In Group 2, PaO2 and SaO2 were significantly increased and A-aDO2 decreased at T1 and T2 when compared with T0. Arterial oxygenation parameters at T1 and T2 were significantly improved in Group 2 when compared with Group 1.

CONCLUSION

The addition of VCM to PEEP improves intraoperative arterial oxygenation in morbidly obese patients undergoing open bariatric surgery.

Cervical plexus block for carotid endarterectomy followed by general anesthesia for abdominal aortic surgery--a case report

The aim of this clinical report is to describe the use of sequential regional and general anesthesia for concomitant carotid and abdominal aortic surgery. We performed, in a 70-year-old man, a cervical plexus block for carotid endarterectomy (CEA) followed immediately by general anesthesia for resection of an abdominal aortic aneurysm. This anesthetic approach provided adequate surgical conditions. Intraoperative neurological status and cardiovascular parameters were stable and postoperative course was uneventful. Sequential regional and general anesthesia may be an alternative to general anesthesia for concomitant carotid and abdominal aortic surgery. This approach offers an adequate neurological monitoring during the CEA phase of the combined surgery and the opportunity to postpone the aortic surgery should the CEA be associated with a non-reversible neurological deficit.

Staged anesthesia for combined carotid and coronary artery revascularization: a different approach

OBJECTIVE

Combined coronary artery bypass graft (CABG) surgery and carotid endarterectomy (CEA) are performed in an attempt to reduce the risk of postoperative stroke after CABG surgery in patients with significant or symptomatic carotid artery stenosis. The choice between regional and general anesthesia for CEA is still under debate. Regional anesthesia offers an excellent monitoring technique of the neurologic status of the awake patient during carotid clamping. In an attempt to improve monitoring of the neurologic status and avoid the use of temporary shunting in patients undergoing the combined procedure, a different approach is described combining regional anesthesia for CEA followed immediately by general anesthesia for CABG surgery.

DESIGN

Prospective nonrandomized case series.

SETTING

University hospital.

PARTICIPANTS

Twenty patients scheduled for combined CEA and CABG surgery underwent a "staged" anesthetic approach from January to December 2004.

INTERVENTIONS

Pulmonary, femoral artery, and urinary catheters were inserted under local anesthesia. A deep cervical plexus block was then performed and supplemented by a superficial cervical plexus block. The patient was draped for standard combined CEA and CABG surgery. CEA was then performed using standard techniques. Without altering the surgical field, general anesthesia was given and endotracheal intubation performed following the successful CEA. Coronary revascularization was then completed.

MEASUREMENTS AND MAIN RESULTS

CEA and CABG surgery were completed successfully in all patients. There was no need for conversion from local to general anesthesia. Endotracheal intubation was easily performed in all patients. There was no hospital mortality in this series. No neurologic events were observed during the CEA. A reversible ischemic stroke, ipsilateral to the CEA, occurred postoperatively on awakening from CABG surgery in 1 patient.

CONCLUSIONS

This staged anesthetic approach for combined CABG and CEA surgery is an alternative in this complex subset of patients.

L’analgésie péridurale thoracique et rachidienne ont des effets comparables sur la douleur et la fonction respiratoire après chirurgie thoracique

PURPOSE

To compare in a prospective randomized trial the effects of thoracic epidural infusions of fentanyl (F) and bupivacaine (B) to intrathecal morphine (M) and sufentanil (S) on analgesia and respiratory function following thoracotomy.

PATIENTS AND METHODS

55 patients undergoing an elective postero-lateral thoracotomy were randomly assigned to one of two groups: Group I (n = 27): received intrathecal S (5 microg) and M (0.5 mg) one hour before surgery. Group II (n = 28) received, after induction of anesthesia, an initial dose of 10 to 20 mL of a solution of B 0.25% and F 2 microg.mL(-1) via an epidural thoracic catheter previously inserted between T5 and T8. The same solution was infused during surgery. After surgery, patients received a continuous infusion of B 0.1% and F 2 microg.mL(-1) with a bolus every 15 min if needed. Heart rate (HR), mean arterial pressure (MAP), SpO(2), PaCO(2), respiratory rate (RR), forced expiratory volume in one second, peak expiratory flow rate and forced vital capacity were recorded at different times from the day before surgery till T48 = 48 hr after surgery. Subjective pain was assessed using a 10 cm visual analogue scale (VAS) scoring at rest and during cough.

RESULTS

No significant difference was noted between both groups concerning VAS, HR, MAP, SpO(2), PaCO(2) and RR. Variations of the respiratory function tests were identical in both groups.

CONCLUSION

This study shows that intrathecal M and S offer analgesia comparable to thoracic epidural infusion of B and F.

Postoperative oral amiodarone as prophylaxis against atrial fibrillation after coronary artery surgery

OBJECTIVE

To assess the prophylactic effect of postoperative oral amiodarone on the incidence and severity of atrial fibrillation (AF) after coronary artery surgery.

DESIGN

Prospective, randomized, blinded, controlled study.

SETTING

University hospital.

PARTICIPANTS

Patients who had coronary artery surgery (n = 200).

INTERVENTIONS

Patients in group 1 (n = 100) received oral amiodarone, 15 mg/kg, 4 hours after arrival in the intensive care unit, followed by 7 mg/kg/d until hospital discharge. Patients in group 2 (n = 100) received placebo.

MEASUREMENTS AND MAIN RESULTS

Incidence, duration, and recurrence of new episodes of AF and maximal ventricular rate response were recorded from day 0 until hospital discharge. Side effects related to amiodarone and complications induced by new-onset AF were noted. The incidence of new-onset AF (12% v 25%) and maximal ventricular rate response (120 +/- 21 beats/min v 135 +/- 24 beats/min) were significantly lower in the amiodarone group. There were no side effects related to the administration of amiodarone. The incidence of complications induced by AF was comparable between the 2 groups.

CONCLUSION

Postoperative prophylactic oral amiodarone after coronary artery surgery is safe and effective in reducing the incidence of new-onset AF and maximal ventricular rate response.

Prophylactic ondansetron is effective in the treatment of nausea and vomiting but not on pruritus after cesarean delivery with intrathecal sufentanil-morphine

STUDY OBJECTIVES

To assess the safety and efficacy of ondansetron for prevention of pruritus, nausea and vomiting after cesarean delivery with intrathecal sufentanil-morphine.

DESIGN

Randomized, double-blind, placebo-controlled study.

SETTING

Referral center, institutional practice.

PATIENTS

100 nonbreastfeeding women undergoing elective cesarean delivery with sufentanil-morphine-bupivacaine anesthesia.

INTERVENTIONS

After the umbilical cord was clamped, patients in Group 1 received ondansetron 8 mg intravenously (IV) and patients in Group 2 received placebo.

MEASUREMENTS

Frequency and severity of postoperative (24-hour) pruritus, nausea and vomiting, surgical pain, and side effects related to ondansetron were recorded.

MAIN RESULTS

In the ondansetron group, 38 patients had pruritus (16 mild and 22 severe) and 9 patients had nausea and vomiting (5 mild and 4 severe). In the placebo group, 41 patients had pruritus (21 mild and 20 severe) and 29 patients had nausea and vomiting (9 mild and 15 severe). The frequency and severity of the nausea and vomiting episodes were significantly reduced in the ondansetron group. Pain scores were comparable between groups. No side effects related to ondansetron were reported.

CONCLUSIONS

Prophylactic IV ondansetron 8 mg is safe and effective in reducing the frequency and the severity of nausea and vomiting, but not pruritus, following cesarean delivery with intrathecal sufentanil-morphine.

[Comparison of nicardipine and isradipine in hypertension following coronary artery bypass graft]

OBJECTIVE

Compare the efficacy of isradipine to that of nicardipine for the control of arterial hypertension following coronary artery bypass graft (CABG).

STUDY DESIGN

Clinical prospective, randomised study.

MATERIAL AND METHODS

40 patients ASA II or III, mean age 66 +/- 8 years, scheduled for elective CABG were included. If the mean arterial pressure (MAP) was > or = 100 mmHg within the first six post operative hours, the patients were included and randomly attributed to either one of the 2 groups: Gr I (n = 20) received nicardipine, Gr II (n = 20) received isradipine in bolus then in continuous perfusion. HR, MAP, MPAP, CVP, PCWP, CI, SVRI, PVRI and SVI were recorded at: T0 before administration of drugs, T1 = 2 min after the first bolus. T2 when MAP reached 85 +/- 5 mmHg. T3, T4, T5, T6, T7 and T8 at 5, 10, 30, 60, 90 and 120 min after the continuous perfusion. T9 before stopping the perfusion.

RESULTS

No significant changes in HR, CVP, PCWP, MPAP or PVRI at any time in both groups. Significant increase in CI at T2 in both groups. Reduction of MAP at T2 was more important (-27%) in Gr I compared to that in Gr II (-22%). This was mainly due to a significant decrease in SVRI.

CONCLUSION

Isradipine is effective in the treatment of arterial hypertension following CABG. However there is not any significant beneficial effect of isradipine over nicardipine.

Accuracy of radial arterial pressure measurement during surgery under controlled hypotension

BACKGROUND

Radial arterial pressure underestimates the pressure in the aorta in several clinical situations. A central-to-radial pressure gradient was attributed to intense vasodilation. The aim of this study was to evaluate the accuracy of radial pressure monitoring during controlled hypotension achieved with profound arterial vasodilation.

METHODS

Ten patients with ASA physical status I and II undergoing maxillofacial surgery under general anesthesia were enrolled in this prospective study. Radial and femoral arteries were cannulated and connected to a pressure monitoring system. Controlled hypotension was achieved with an infusion of nicardipine titrated to maintain MAP between 50 and 60 mmHg. Simultaneous radial and femoral systolic, mean and diastolic arterial pressures were recorded before, during and after controlled hypotension. Results were expressed as mean +/- SD. Concomitant radial and femoral pressures were compared by a paired Student's test, P < 0.05 being significant.

RESULTS

In all, 150 sets of arterial pressures measurement were obtained. There were no statistically significant differences between radial and femoral arterial pressures measured before, during or after controlled hypotension.

CONCLUSION

Radial arterial pressure is an accurate measure of central arterial pressure during controlled hypotension achieved with arterial vasodilation.

[Intraoperative malignant hyperthermia: apropos of a case]

Malignant hyperthermia (MHS) is a rare potentially fatal complication of general anesthesia. Anesthetic agents most frequently incriminated are succinylcholine and halogenated agents. Respiratory acidosis is the most specific and sensitive sign. Hyperthermia per se may occur secondarily or may stay totally absent. Tachycardia and/or arrhythmias often develop due to hyperkalemia and metabolic acidosis. Muscle rigidity whenever present is pathognomonic The "gold standard" test for the diagnosis of MHS is the halothane-caffeine contracture test. Dantrolene is the treatment of choice and prognosis depends on the early administration of this agent.

[Comparative measurement of pressure in the abdominal inferior vena cava and in the superior vena cava in adults]

Abdominal inferior vena cava pressure was compared to intrathoracic central venous pressure in 30 adults admitted in an intensive care unit following coronary artery bypass grafting. Mean pressures were obtained during controlled ventilation with a positive end expiratory pressure (PEEP) of zero and 10 cmH2O respectively, and during spontaneous breathing as well. Ninety measurements were obtained. Limits of agreement between intra-abdominal and intrathoracic cava pressures were below 2.5 mmHg in all cases. In this study, inferior vena cava pressure has predicted central venous pressure in adults during both controlled and spontaneous ventilation.

Hemodynamic effects of pressure support ventilation following cardiac surgery

Hemodynamic effects of pressure support ventilation (PSV) were assessed in 33 patients, after cardiac surgery. The patients, selected for their stable left ventricular and respiratory functions, underwent uncomplicated coronary artery bypass grafting. They all underwent the same anesthetic protocol, and an invasive hemodynamic monitoring. Eight to ten hours postoperatively, while all patients were fully awake, normothermic and hemodynamically stable, controlled ventilation (CV) was replaced by 3 levels of PSV (20, 10, 5 cm H2O). These levels were applied consecutively for 20 minutes each, before extubation. Hemodynamic and gas exchange data were recorded on CV, on each level of PSV, and on spontaneous breathing. The results were analyzed using ANOVA and Bonfferoni methods. No statistical significance could be noted between the five modes of ventilation as to hemodynamic parameters, arterial and mixed venous blood gases, and oxygen consumption (VO2). The only 2 parameters that reached statistical significance were central venous pressure and respiratory rate. Our study demonstrates that patients with stable cardiovascular and respiratory function can adapt to different levels of PSV without hemodynamic modifications or an increase in their VO2.

[Fibrinolytic inhibitors and prevention of bleeding in cardiac valve surgery. Comparison of tranexamic acid and high dose aprotinin]

In order to assess the effects of tranexamic acid in comparison to the high dose regimen of aprotinin recommended by Royston and considered to be the reference in postoperative bleeding in cardiac surgery, 35 consecutive patients were randomised to two groups according to the product prescribed. The global postoperative bleeding was comparable in the two groups (p = 0.49). One surgical reoperation for haemostasis was required in the reference group. There was one case of renal failure in the same group due to cardiac failure. No thrombotic complications were observed. Platelet function, as judged by the bleeding time and platelet aggregation to ristocetin, was the same in the two groups. The D-dimers remained low in both groups, reflecting the absence of intravascular coagulation and fibrinolysis. Tranexamic acid was as effective and as safe as high dose aprotinin. These two substances, in addition to their fibrinolytic inhibitory activity, conserved platelet protection by blocking the action of plasmin. These results seem to justify the preventive use of tranexamic acid from the moment of skin incision, especially in reoperation.