Background: In Bangladesh, although OPCAB surgery are done, the number of centers are limited and as a result, studies on this subject are also few. Consequently, there are no exclusive data regarding the best anaesthetic technique in the context of superior haemodynamic stability. This study has been undertaken with a view to find out whether a combined HTEA with GA (TIVA) is safe and more efficient in providing overall cardiovascular stability. The common challenges for the cardiac anaesthesiologist during off pump coronary artery surgery (OPCAB) to maintain optimal cardiovascular parameters such as heart rate, blood pressure, CVP and arrhythmias during the different stressful surgical events and multiple cardiac manipulations, providing adequate myocardial protection, are sometimes difficult. This study has been undertaken with a view to find out whether a combined HTEA with TIVA is safe and more efficient in providing overall cardiovascular stability. Method: Sixty patients aged between 40-70 years, without having any coagulopathy disorder , any emergency surgery or left main disease scheduled for CABG on beating heart were enrolled in prospective, randomized observational comparative study. Patients were divided in two groups. In group A patients received TIVA alone and in group B patients received high thoracic epidural anaesthesia with TIVA. The parameters including heart rate , SPO2 , CVP , arterial blood pressure , rate pressure product , arrhythmia in ECG, were recorded before induction, during induction , intubation and during different events of the surgery ( skin incision, sternotomy, pericardiotomy, coronary artery anastomosis with graft , sternum closure and wound closure) was recorded. Result: Significant per-operative mean heart rate changes were observed all the events except at wound closure and during anastomosis with D1/D2 and the mean difference of mean of mean arterial pressure at intubations, skin incision, sternotomy, pericardiotomy, during anastomosis of distal end of the graft with RCA, PDA, LCX and D1/D2 were observed statistically significant (p<0.05) . No incidence of different arrhythmia occurred in group B, premature ventricular complex (PVC) was statistically significant (p<0.05) between two groups. Conclusion: HTEA with TIVA appeared to be most comprehensive, allowing for revascularization of any coronary artery, providing good cardiovascular stability during OPCAB.Key Words: CABG; OPCAB; HTEA; TIVA DOI: 10.3329/cardio.v2i2.6633Cardiovasc. j. 2010; 2(2) : 163-167
Introduction :Selective anaesthesia of T1 to T5 thoracic dermatomes with epidural local anaesthetic inhibits symphathetic innervation of the heart and regional vasculature, decreases left ventricular contractility and heart rate while prolonging phase IV of the cardiac action potential. 1 It decreases myocardial oxygen consumption, reduces arrhythmogenicity and increases diameter of the stenotic coronary arteries.
A 54 years old pleasant gentleman weighing about 60 Kg was admitted in NICVD with the complaint of transient ischaemic attack (T I A). He was a diagnosed case of left internal carotid artery (ICA) atherosclerotic lesion. He was hypertensive, non diabetic and non asthmatic of A.S.A grade II and scheduled for carotid endarterectomy under CEA. He was duly informed about the anaesthetic procedure during preanaesthtic check up. Patient was premedicated with tablet midazolam (7.5mg) 1 hour before arrival at OT.An 18 G epidural catheter was introduced aseptically and uneventfully at C 7 -T 1 intervertebtal space with patient in sitting position through midline approach using loss of resistance technique. Anaesthesia was induced with a mixture of 0.5% Lidocaine (5ml). 0.25% Bupivacaine (5ml) and Fentanyl citrate (50μg). After 20 minutes the onset of anaesthesia was completed and pin-prick pain sensation was abolished, Monitoring of Spo 2 , ECG, Respiration, Heart rate, Urine out put, Intraarterial blood pressure and ABG analysis etc were done. The patient received Oxygen @ 4L/ min via a nasal cannula.Surgery was conducted smoothly and uneventfully under CEA with good analgesia. Patient was awake during surgery. Total duration of surgery was 2 hours and one additional top up dose (1/3 rd of initial bolus) was given after 1 and 1/ 2 hour with intermittent propofol infusion @ 25-50μg/kg/min. Post operative recovery was smooth. Patient was started on a liquid diet and allowed to mobilize 4 hours after surgery. Post operative analgesia was maintained with 0.125% Bupivacaine (4 ml) with Fentanyl citrate 2μg/ml through epidural catheter 6 hourly or earlier if the patient complains of pain. No other rescue analgesia was required. Discussion:Carotid endarterectomy can be performed under general or regional anaesthesia. Regional anaesthesia may be either cervical plexus block or cervical epidural anaesthsia. Regional anaesthesia is more cost-effective, given that less intensive care and shorter hospital stays are required. 2 GA is the conventional method, CEA is practiced less often because of the fear of potential complication. Cervical plexus block is an alternative for CEA but this may be incomplete, surgery cannot be prolonged, and post operative analgesia is not possible. Monitoring of cerebral function is difficult under GA. By contrast, continuous monitoring of awareness and neurological deficit and hence adequacy of cerebral perfusion is possible under regional anaesthesia. 3 This however can become a disadvantage if the patient develops cerebral ischaemia which may lead to disorientation, Cervical Epidural Anesthesia for Carotid Endarterectomy
Background: In recent years, high thoracic anaesthesia (HTEA) combined with general anaesthesia has been extensively studied in patients undergoing coronary artery bypass graft surgery with or without cardiopulmonary bypass. Off-pump coronary artery bypass grafting was implemented to reduce trauma of surgical coronary revascularization by avoiding extracorporeal circulation. TEA in combination with GA further reduces intraoperative stress resulting in more rapid extubation and significantly better pain relief in patients undergoing off-pump coronary artery bypass grafting (OPCAB). In addition, common postoperative complications are also decreased. Methodology: 40 male patients aged between 40-65 years with CAD undergoing OPCAB surgery at NICVD from April 2006 to October 2008 were randomly divided in two groups. Group A received epidural analgesic drugs through an indwelling catheter introduced before induction of anesthesia while group B patients received standard general anesthesia (GA) alone. Group A patients received continuous epidural analgesia delivered through the indwelling catheter with a mixture of Lignocaine (2%) 20 ml + Bupivacaine (0.5%) 20 ml + Fentanyl 50 gm 1 ml + normal saline q.v. 50 ml at the rate of 1-2 ml/hour by a syringe pump for up to 72 hours. Group B patients received conventional intermittent narcotics (Morphine)/NSAIDS (Ketorolac/Diclofen) for up to 72 hours. Results: Haemodynamic parameters of all patients in both the groups were within acceptable range throughout operations. Incidence of cardiac dysrhythmias was less in patients of group A. Group A patients showed faster recovery and better analgesia compared to Group B patients. There was also decreased incidence of nausea, vomiting, arrhythmia, O2 desaturation, confusional states, renal failure and requirement of iontropic support in ICU in Group A patients. TEA for postoperative analgesia was safe and well accepted by the patients. There was no complication related to epidural anesthesia in any patient. Conclusion: TEA in general anesthesia provides faster recovery and effective analgesia. Nonetheless, the actual and potential risks of TEA during cardiac surgery should not be underestimated. Keywords: Thoracic epidural anaesthesia; OPCAB; Postoperative analgesia DOI: 10.3329/cardio.v2i2.6632Cardiovasc. j. 2010; 2(2) : 156-162
This cross sectional study was done among 20 patients with aortic stenosis and 20 healthy controls to evaluate the association of cardiac specific troponin 1 (ant) and sonic valvular heart diseases. The study was conducted in °militant, department in National laminae of Cardiovascular Diseases (N1CVD.)A structured queslionilaire and checklist was used to collect data through face to face interview. Color dapple, echocarchiognsphy was done and 5 ml of venous sample was dmwo from each subjects and laboratory estimation of an, was done. The arid in control group and sonic stenosis patients showed significant difference in mean (<0.001). ant level in aortic stenosis patients increases in the absence of heart failure indicating that it can expose the cardiotnyocnes to injury prior to development of oven left ventricular dysftinction. So. serial monitoring of aid may help clinicians to give definitive treatment (reface development af complications.
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