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Annals of Cardiac Anaesthesia Volume 11 - Issue 1 - January-June 2008
Contents Editorial Cardiac output - Have we found the ‘gold standard’? Murali Chakravarthy ........................................................................................................................................................................ 1
Guest Editorial Grown-up congenital heart (GUCH) disease: An evolving global challenge James A DiNardo ............................................................................................................................................................................. 3
Review Article Current status of bosentan for treatment of pulmonary hypertension Shahzad G Raja, Gilles D Dreyfus ................................................................................................................................................... 6
Original Articles Blood transfusion is associated with increased resource utilisation, morbidity and mortality in cardiac surgery Bharathi H Scott, Frank C Seifert, Roger Grimson .......................................................................................................................... 15
Resistance in gram-negative bacilli in a cardiac intensive care unit in India: Risk factors and outcome Mandakini Pawar, Yatin Mehta, Apoorva Purohit, Naresh Trehan, Rosenthal Victor Daniel ........................................................... 20
Early goal-directed therapy in moderate to high-risk cardiac surgery patients Poonam Malhotra Kapoor, Madhava Kakani, Ujjwal Chowdhury, Minati Choudhury, Lakshmy R, Usha Kiran .............................. 27
Case Reports Use of intraaortic balloon counter pulsation in a patient with tortuous aorta Murali Chakravarthy, Vivek Jawali ................................................................................................................................................. 35
Tako-Tsubo syndrome in an anaesthetised patient undergoing arthroscopic knee surgery Feyzi Artukoglu, Andrew Owen, Thomas M. Hemmerling............................................................................................................. 38
Anomalous connection of superior vena cava to the left atrium masquerading as epilepsy: A case report with review of literatures Sandeep Singh, Muhammed Abid Geelani, Pranav Modi, Yogesh Niwaria, Sudhir Shahi, Amit Banerjee ....................................... 42
Simultaneous off-pump coronary artery bypass graft surgery and wide glossectomy Shilpa Bhojraj, Sanjesh Jain, Zainul Hamdulay, Pawan Kumar, Mohammed Ali, Sultan Pradhan .................................................... 46
Interesting image Incidental TOE finding - Carpentier mitral annuloplasty ring dehiscence during heart transplantation Harish Ramakrishna....................................................................................................................................................................... 49
Congenital left atrial appendage aneurysms Thiruvenkadam Selvaraj, Poonam Malhotra Kapoor, Murali Krishna T, Usha Kiran, Ujjwal Chowdhury, Sandeep Seth.................. 51
Letters to Editor An unusual cause of hypoxaemia in a patient with pneumonia Tiziana Bove, Giuseppe Crescenzi, Mariagrazia Calabró, Camilla Biselli, Martina Crivellari, Giulia Maj, Giovanni Landoni, Alberto Zangrillor .......................................................................................................................................................................... 53
Arterial inflow cannula obstruction during paediatric cardiac surgery Sambhunath Das, Madhava Kakani,Usha Kiran, Akshaya Kumar Bisoi, Ritu Airan ......................................................................... 54
Tutorial Cardiac output monitoring Lailu Mathews, Kalyan RK Singh.................................................................................................................................................... 56
Erratum ..................................................................................................................................................................... 52 Conference calendar 2008-2009 ............................................................................................................................... 69 Instructions to Authors ............................................................................................................................................. 70 78
Annals of Cardiac Anaesthesia ! Vol. 11:1 ! Jan-June-2008
[Downloaded free from http://www.annals.in on Wednesday, September 28, 2016, IP: 190.39.8.182] Letters to the editor Department of Cardiothoracic Anaesthesia and Intensive Care, Universitá Vita-Salute San Raffaele, Milano, Italia e Istituto Scientifico San Raffaele, Milano, Italia Address for correspondence: Dr. Landoni Giovanni, Department of Cardiothoracic Anaesthesia and Intensive Care, Istituto Scientifico San Raffaele, Milano, Italia. E-mail:
[email protected]
REFERENCES 1.
2. Figure 1: Bicaval view showing the atrial septal aneurysm projected into the right atrium (RA) during diastole. LA: left atrium; RA: right atrium
Jaffe RA, Pinto FJ, Schnittger I, Brock-Utne JG. Intraoperative ventilator-induced right-to-left intracardiac shunt. Anesthesiology 1991;75:153-5. Fellahi JL, Mourgeon E, Goarin JP, Law-Koune JD, Riou B, Coriat P, et al. Inhaled nitric oxide-induced closure of a patent foramen ovale in a patient with acute respiratory distress syndrome and life-threatening hypoxaemia. Anesthesiology 1995;83:635-8.
Sir,
Figure 2: Contrast study during Valsalva’s maneuver shows the early passage of bubbles in the left atrium. LA: left atrium; RA: right atrium
PFO should be systematically investigated in mechanically ventilated patients with unexplained severe arterial hypoxaemia. If present, a low concentration of inhaled nitric oxide may reverse the atrial pressure gradient, inducing a functional closure of the foramen ovale and a dramatic improvement in arterial oxygen concentration. ACKNOWLEDGMENTS We are indebted to Castelnuovo Lara, RN; Costantini Marco, RN; e Tolja Marina, RN, for the care provided to this patient and for revising the manuscript.
Tiziana Bove, Giuseppe Crescenzi, Mariagrazia Calabró, Camilla Biselli, Martina Crivellari, Giulia Maj, Giovanni Landoni, Alberto Zangrillo 54
The developments in cardiac surgery are dependent on the continuous refinements in the use of cardiopulmonary bypass (CPB). The major complications encountered during the placement of aortic cannula and aortic cross-clamp (ACC) are the dissection of the aortic wall, cannula malposition and disruption of atheromatous plaques.[1] As a result, cerebral injuries and acute renal failure may occur in the postoperative period.[1,2] Here, we describe a case of arterial inflow cannula (AIC) obstruction due to the placement of the ACC during Senning operation. A 19-month-old male child (7.5 kg) was diagnosed to have d-transposition of the great arteries, atrial septal defect and intact ventricular septum. The child was scheduled to undergo Senning operation. Anaesthesia was induced and maintained with ketamine, sufentanil, midazolam and pancuronium. Electrocardiogram, pulse oximeter, end-tidal carbon dioxide, bispectral index (BIS), femoral artery invasive pressure and central venous pressure were monitored. After heparinization, the ascending aorta was cannulated with a 10-F cannula (Biomedicus, Medtronic Inc., Minneapolis, USA). Annals of Cardiac Anaesthesia ! Vol. 11:1 ! Jan-June-2008
[Downloaded free from http://www.annals.in on Wednesday, September 28, 2016, IP: 190.39.8.182] Letters to the editor
Bicaval venous cannulation was established with 18-F and 16-F angled cannulae. Arterial inflow line pressure (AILP) and femoral artery mean pressure (FAMP) were monitored according to the institutional protocol. At the onset of CPB, the AILP value was 120 mmHg and FAMP, 30 mmHg. Cardioplegia cannula was inserted into the aortic root. ACC was placed between the AIC and cardioplegia cannula, and cardioplegia was commenced. Immediately, the FAMP value decreased to 10 mmHg. The pump flow was increased up to 200 ml/kg and a high dose of norepinephrine (5-20 µg) was introduced into the pump, presuming that the systemic vascular resistance in the patient had decreased grossly. The FAMP value decreased to 0 mmHg in a period of 3-4 min. The BIS value decreased to 20 from 40. The anaesthesiologist noticed the AILP value more than 500 mmHg on the pressure gauge of the heart-lung machine (Sarns 7000 roller pump, Sarns Inc., Ann Arbor, Michigan, USA). The surgeon and perfusionist were informed. A quick check of the CPB circuitry did not reveal a kink on the arterial limb of the circuit. Since we were unable to find any cause for this systemic hypoperfusion, we suspected an inadvertent partial obstruction of AIC by ACC. ACC was released and an immediate reversal of the complication was noted, with a decrease in AILP up to 150 mmHg and increase in FAMP and BIS values to 36 mmHg and 46, respectively. The patient was cooled to 24ºC. Empirically, methyl prednisolone, 225 mg; 20% mannitol, 35 ml; magnesium, 0.5 gm and ketamine, 5 mg were administered in the venous reservoir of the oxygenator, presuming that it would provide neuroprotection. Acid-base abnormalities and hyperglycemia were corrected. The ACC was reapplied without any events. Senning operation was performed according to the plan and the patient was transferred to the intensive care unit. In the postoperative period, the child was conscious and recognizing the parents. The patient was electively ventilated for two days. After extubation, he was examined by a neurologist and his neuropsychological behavior and motor function was found to be normal. The patient was discharged on the 8th postoperative day. During CPB, the obstruction to the AIC produces cerebral ischemia and other organ dysfunctions due to absence of systemic perfusion.[1,2] We suspected
Annals of Cardiac Anaesthesia ! Vol. 11:1 ! Jan-June-2008
the possible obstruction to AIC because of an abrupt decrease in the FAMP and increase in AILP. The ACC was assumed to have partially occluded the AIC. Had the ACC obstructed the AIC completely, the pressure changes would have been observed earlier, and the effects of a lack of systemic perfusion may have been severe. A ‘blowout’ of the CPB circuit tubing on the arterial side can occur, if this complication is not rectified and CPB continues. The other possible causes of such an abrupt increase in the AILP and decrease in the peripheral arterial pressure are kinks in either the AIC or the CPB circuit tubing on the arterial side and occlusion of the AIC tip by the aortic wall. An audible high-pressure alarm (provided by the manufacturer of the heart-lung machine) probably remained unnoticed. The use of bilateral near-infrared spectroscopy and BIS have been used in the detection of AIC malposition.[3,4] Early detection of the AIC obstruction by vigilant monitoring of AILP and FAMP during CPB may prevent an adverse outcome due to the absence of systemic perfusion.
Sambhunath Das, Madhava Kakani, Usha Kiran, Akshaya Kumar Bisoi1, Ritu Airan2 Department of Cardiac Anaesthesia, 1Department of Cardio Thoracic and Vascular Surgery, 2Department of Perfusion, Cardiothoracic Center, All India Institute of Medical Sciences, New Delhi - 110 029, India
Address for correspondence: Dr. Sambhunath Das, Department of Cardiac Anaesthesia, 7th Floor, CN Center, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029, India. E-mail:
[email protected]
REFERENCES 1.
2.
3.
4.
Ruchat P, Hurni M, Stumpe F, Fischer AP, Segesser LK. Acute ascending aortic dissection complicating open heart surgery. Eur J Cardiothorac Surg 1998;14:449-52. Murakami J, Yamaura K, Akata T, Takahashi S. Acute renal failure in an infant attributable to arterial cannula malposition during cardiopulmonary bypass via ministernotomy. Masui 2002;51:264-9. Gottlieb EA, Fraser CD Jr, Andropoulos DB, Diaz LK. Bilateral monitoring of cerebral oxygen saturation results in recognition of aotic cannula malposition during pediatric congenital heart surgery. Paediatr Anaesth 2006;16:787-9. Ellenberger C, Diaper J, Licker M, Panos A. Bispectral index and detection of acute brain injury during cardiac surgery. Eur J Anaesth 2007;24:807-9.
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