The study did not reveal any difference in myocardial protection after OPCAB with either sevoflurane or desflurane or TIVA using propofol as assessed by measuring serial cTnT values.
Postoperative hemorrhagic complications is still one of the major problems in cardiac surgeries. It may be caused by surgical issues, coagulopathy caused by the side effects of the intravenous fluids administered to produce plasma volume expansion such as hydroxyl ethyl starch (HES). In order to thwart this hemorrhagic issue, few agents are available. Fibrinolytic inhibitors like tranexamic acid (TA) may be effective modes to promote blood conservation; but the possible complications of thrombosis of coronary artery graft, precludes their generous use in coronary artery bypass graft surgery. The issue is a balance between agents that promote coagulation and those which oppose it. Therefore, in this study we have assessed the effects of concomitant use of HES and TA. Thromboelastogram (TEG) was used to assess the effect of the combination of HES and TA. With ethical committee approval and patient's consent, 100 consecutive patients were recruited for the study. Surgical and anesthetic techniques were standardized. Patients fulfilling our inclusion criteria were randomly allocated into 4 groups of 25 each. The patients in group A received 20 ml/kg of HES (130/0.4), 10 mg/kg of T.A over 30 minutes followed by infusion of 1 mg/kg/hr over the next 12 hrs. The patients in group B received Ringer's lactate + TA at same dose. The patients in the Group C received 20 ml/kg of HES. Group D patients received RL. Fluid therapy was goal directed. Total blood loss was assessed. Reaction time (r), α angle, maximum amplitude (MA) values of TEG were assessed at baseline, 12, 36 hrs. The possible perioperative myocardial infraction (MI) was assessed by electrocardiogram (ECG) and troponin T values at the baseline, postoperative day 1. Duration on ventilator, length of stay (LOS) in the intensive care unit (ICU) were also assessed. The demographical profile was similar among the groups. Use of HES increased blood loss significantly (P < 0.05). Concomitant use of TA reduced blood loss when used along with HES. r value was prolonged at 12 hours in all the groups and α angle was reduced at 12 hours in all the groups, where as MA value was reduced at 12 th hour in the HES group compared to the baseline and increased in TA + HES group. These findings were statistically significant. No significant change in Troponin T values/ECG, duration of ventilation and LOS ICU was observed. No adverse events was noticed in any of the four groups. HES (130/0.4) used at a dose of 20 ml/kg seems to produce coagulopathy causing increased blood loss perioperatively. Hemodilution produced by fluid therapy seems to produce Coagulopathy as observed by TEG parameters. Concomitant use of TA with HES appears to reverse these changes without causing any adverse effects in patients undergoing OPCAB surgery.
Interesting Images venous obstruction. After induction of general anesthesia, transesophageal echocardiography (TEE) probe was inserted. TEE confirmed the diagnosis made earlier. Further, a restrictive fleshy membrane in the left atrium (cor triatriatum) contributing to pulmonary vein stenosis was observed. Surgery commenced via mid-sternotomy. Total body heparinisation was achieved with 6000 IU of heparin; the resultant activated clotting time was 450 s. The pulmonary artery (PA) pressure measured via a fine needle inserted in the main pulmonary artery revealed supra-systemic PA pressure. The systemic pressure was 73/56 and mean 63 mmHg, while the PA pressure was 98/60 mmHg. Cardiopulmonary bypass (CPB) was instituted without events after cannulation of ascending aorta and cannulation of superior and inferior vena cavae. It is our institution policy to confirm the empty status of the heart with adequate venous return and absence of aortic regurgitation after establishing CPB using TEE. During such routine examination in this patient, hitherto unreported ductal flow was detected and patent ductus arteriosus (PDA) was diagnosed [Video 1]. PDA was visualized in the upper esophageal view. As the tee probe is withdrawn gradually from the mid-esophageal position, just beyond A 15-year-old African girl, weighing 27 kilos, with a height of 148 cm was admitted to the hospital for repair of pulmonary venous obstruction and cor triatriatum. She was comfortable at rest, but had severe limitation of activities beyond those of daily living. Pulse oximetry on room air was 92%, which improved to 95% with oxygen.Blood investigations were unremarkable except for hemoglobin 19 g/dL and her Sickling test was negative. Preoperative transthoracic echocardiogram revealed stenosis of right upper and left lower pulmonary veins with a peak gradient of 15 mmHg at their respective junctions with the left atrium (LA). Normal flow was noted in the other pulmonary veins. A membrane was visualized in the left atrium without significant obstruction to flow. Severe pulmonary hypertension (94/65 mmHg) was detected. The pulmonary artery pressure was noted to be 95% of the systemic pressure. Flow velocities in the pulmonary artery and descending aorta were normal, there was no pericardial effusion. A computerized tomographic angiogram confirmed the anatomical findings noted by the transthoracic echocardiogram. The patient was scheduled for repair of pulmonary
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