The Effect of Preoperative Creatinine Clearances on Postoperative Oxygenation in Coronary Artery Bypass Grafting: A Cohort Study

 End-stage kidney disease has a high prevalence in patients undergone Coronary Artery Bypass Grafting (CABG) and could cause a wide spectrum of morbidities, due to deep water and electrolyte or acid-base impairments. The aim of this study was to assess the effect of low Creatinine Clearances (ClCr) on arterial oxygenation defect, as common post-CABG morbidity. The study was conducted as a prospective cohort, the pure on pump CABG patients were grouped based on their preoperative ClCr to groups A (ClCr≥60) and B (ClCr<60). Postoperatively, the PaO2/FiO2 values in 1 hour after ICU admission and 4 hours after extubation, intubation time duration, duration of ICU stay and high concentration oxygen demand were compared. Among 229 patients who remain in the study, 121 were in group A, and 108 in B group. Except for age, weight, height, BMI, and pump time, other demographic and independent variables were similar between two groups. The higher values of PaO2/FiO2 and PaO2, 1 hour after ICU admission and 4 hours after extubation in group B, were not statistically significant, while SpO2 value, 1 hour after ICU admission was higher in group B (98.19±1.37) in compare with group A (97.78±1.57) (P=0.040). Intubation time duration (10.85 in A vs. 12.79 in B; P=0.306), duration of ICU stay (39.04 in A vs. 43.09 in B; P=0.114) and high concentration oxygen demand (2.5% in A vs. 3.8% in B; P=0.089) were similar between groups of study. Lower Preoperative ClCr values do not deteriorate post-CABG arterial oxygenation

Sanyar Video Laryngoscope Improved Time and First Pass Success of Tracheal Intubation in Intensive Care Unit in Compared to Direct Laryngoscopy

Background: Airway management and tracheal intubation in the ICU is a difficult procedure that may be concomitant with major complications. The purpose of this study was to evaluate the effect of the SANYAR ® video laryngoscope(S-VL) on laryngeal view and first Pass Success of tracheal Intubation compared with direct laryngoscopy. Methods: This comparative, prospective clinical study was conducted on 120 adult patients in a single-center, in a surgical ICU under the supervision of an anesthesiologist in a university hospital. Difficult airway predictors, glottic view, first Pass Success of tracheal Intubation and time of intubation were evaluated with Macintosh laryngoscopy (ML) or the SANYAR® Video Laryngoscope(S-VL). Results: Tracheal intubation was performed in 58 critically ill patients using ML and 62 patients using S-VL. According to Cormack and Lehane (C&L) grading glottic visualization was more difficult using ML (41%, C&L grade 3 and 4) compared with S-VL (13%, C&L grade 3 and 4) p<0.001. Intubation of trachea was more successful in the first attempt, in patients with at least one difficult airway predictor with a S-VL compared to ML (87% vs. 38%; P = 0.001), time of intubation was also shorter by using S-VL. Conclusion: Among critically ill patients in the intensive care unit, who require intubation, the SANYAR video laryngoscopy improved glottis view compared to the Macintosh direct laryngoscopy and first-pass orotracheal intubation rate especially in patients with potentially difficult airways

The Effect of Ephedrine on Fetal Outcome in Treatment of Maternal Hypotension Caused by Spinal Anesthesia During Cesarean Section

Objective: To compare maternal complications and labor outcome in obese and non-obese women. Materials and methods: It is a retrospective comparative study conducted at the Department of obstetrics and gynecology, Unit 1, Civil Hospital, Karachi from December 2008 to December 2009. A sample size of 220 gravid women is selected by Non Probability Convenience sampling technique. In these 110 obese women as cases was compared with 110 non-obese women as controls, booked at <20 weeks of gestation. Data were collected regarding maternal complication, mode of delivery and neonatal outcome by trained medical officers. Data were entered and analyzed by SPSS version 11.0 through descriptive analysis, chi-square test  and independent sample t test. The p-value of <0.05 was considered significant. Results: Pregnancy induced hypertension was present in 9 (8.2%) women in control group and 21 (19.1%) in cases (p=0.01). Gestational diabetes was seen in one (0.9%) in control compared to 8 (7.3%) in obese women (p=0.01). Obese women were found to be at increased risk of caesarean section [17 (15.5%)  Vs. 39 (35.4%), p=0.002]. Apgar score at 1 and 10 minute were lower in cases compared to controls (p=0.0001). Conclusion: Obese women are at increased risk of pregnancy induced obesity and associated with an increased risk of hypertension, gestational diabetes mellitus, thromboembolic disease and urinary tract infection

Clinical outcome of tracheal extubatedcardiac surgery patients who did not meet protocol driven laboratory criteria for extubation

Background: We retrospectively compared the clinical outcome of post-cardiac surgery tracheal extubation between patients extubated with a lower than normal pH and patients extubated according to our routine institutional protocol. Our main goal was to clarify that strict adherence to the current criteria is dispensable. Methods: In this retrospective cohort study, we recruited 256 patients who met our study criteria and divided them into the exposed group (n= 95) and the control group (n= 161). The inclusion criteria consisted of coronary artery bypass grafting alone and age> 18 years. The exclusion criteria comprised the use of corticosteroids in the preceding 2 weeks, Serum creatinine (SCr)> 2 mg/dL, uncontrolled diabetes, liver dysfunction, Glasgow coma scale <13, and acetazolamide and sodium bicarbonate use. The arterial blood gas (ABG) characteristics before and 6 hours after extubation, extubation failure rate, length of stay in the in ICU, length of stay in the hospital and mortality were compared between the two groups. Results: In the control group, the males outnumbered the females and the ejection fraction was higher relative to that in the exposure group (P= 0.01 and P= 0.02, respectively). There were more patients with chronic obstructive pulmonary disease in the exposure group (P< 0.005) and also the euroSCORE was higher (P< 0.002). There were no significant differences between the groups regarding the ABG values at the time of ICU admission. Significantly higher levels of FiO2 and PaCO2 (P< 0.001 for both) as well as lower HCO3 and pH (P< 0.001 for both) were observed in the exposure group immediately before extubation. Following extubation, there was a significant increase in pH and a significant reduction in FiO2 need in the exposure group (P< 0.001 for both). The extubation failure rate, length of stay in the in ICU, length of stay in the hospital, and mortality rate were not different between the 2 groups. Conclusion: The patients with a lower than normal pH, tracheal extubated at the discretion of the ICU anesthesiologist did not have a clinical outcome worse than that of the patients extubated in accordance with our routine institutional protocol

Can a New Antiseptic Agent Reduce the Bacterial Colonization Rate of Central Venous Lines in Post- Cardiac Surgery Patients?

Background: Central venous (CV) catheters play an essential role in the management of critically ill patients in the Intensive Care Unit (ICU). CV lines are, however, allied to catheter-associated blood stream infections. Bacterial colonization of CV lines is deemed the main cause of catheter-associated infection. The purpose of our study was to compare bacterial colony counts in the catheter site before CV line insertion in two groups of post-cardiac surgery patients: a group receiving Sanosil (an antiseptic agent composed of H2 O2 and silver) and a control group. Methods: This interventional prospective double-blinded clinical trial recruited the patients in three post-cardiac surgeryICUs of a heart center. The participants were divided into interventional (113 patients) and control (136 patients) groups. Sanosil was added to the routine preparation procedure (Chlorhexidine bath one day before and scrub with Povidone-Iodine just before the CV line insertion). After the removal of the CV lines, the catheters tips were sent for culture and evaluation of colony counts. Results: Catheter colonization occurred in 55 (22.1%) patients: 26 (23%) patients in the Sanosil group and 29 (21.3%) in the control group; there was no significant statistical difference between the two groups (p value = 0.75, RR = 1.05, 95%CI:0.76-1.45). The most common organism having colonized in the cultures of the catheter tips was staphylococcus epidermis:20 cases in the control group and 16 cases in the intervention group. Conclusion: Catheter colonization frequently occurs in post-cardiac surgery patients. However, our results did not indicate the effectiveness of adding Sanosil to the routine preparation procedure with respect to reducing catheter bacterial colonization

Effect of dexamethasone on the frequency of postdural puncture headache after spinal anesthesia for cesarean section : a double-blind randomized clinical trial

In this study, we evaluated the effect of dexamethasone used as a prophylaxis for nausea and vomiting on the incidence of postdural puncture headache (PDPH) in pregnant women receiving spinal anesthesia for cesarean section. In a prospective, randomized, double-blind, placebo-controlled study, 372 women under spinal anesthesia received 8 mg of dexamethasone or placebo intravenously just after the umbilical cord was clamped. The rate of PDPH and correlated risk factors were evaluated. The prevalence of nausea and vomiting in the dexamethasone and placebo groups was 54.4 and 51.7 %, respectively. There was no statistically meaningful difference between the results (P value = 0.673). The overall incidence rate of PDPH was 10.8 %, with 28 cases from the dexamethasone group compared with 11 subjects from the placebo group (P value = 0.006). This effect was most prominent on the first day (P value = 0.046) and disappeared on the second day after spinal anesthesia (P value = 0.678). Prophylactic treatment with 8 mg of dexamethasone not only increases the severity and incidence of PDPH, but is also ineffective in decreasing the prevalence of intra-operative nausea and vomiting during cesarean section. The treatment is a significant risk factor for the development of PDPH

The Effect of Continuous Low Dose Methylprednisolone Infusion on Inflammatory Parameters in Patients Undergoing Coronary Artery Bypass Graft Surgery: a Randomized-Controlled Clinical Trial

This trial was performed to determine if a continuous low-dose infusion of methylprednisolone is as effective as its bolus of high-dose in reducing inflammatory response. The study was single-center, double-blinded randomized clinical trial and performed in a surgical intensive care unit of an academic hospital. In this study, 72 consecutive patients undergoing elective coronary artery bypass grafting (CABG) were assigned to receive either a methylprednisolone loading dose (1mg/kg) followed by continuous infusion (2mg/Kg/24 hours for 1 day) (low-dose regime) or a single dose of methylprednisolone (15 mg/kg) before cardiopulmonary bypass (high dose regime). Serum concentrations of IL-6 and C- reactive protein (CRP) were measured preoperatively and 6, 24 and 48 hours after surgery, and serum creatinine was measured before the operation and 24, 48 and 72 hours postoperatively. The measurements were then compared between the groups to evaluate the efficacy of each regimen. The basic characteristics and measurements were not different between the study groups. There was no significant difference in IL-6 and CRP elevation (P=0.52 and P=0.46, respectively). Early outcomes such as the length of stay in the intensive care unit, intubation time, changes in serum creatinine and blood glucose levels, inotropic support, insulin requirements, and rate of infection were also similar in both groups. A continuous low dose infusion of methylprednisolone was as effective as a single high dose methylprednisolone in reducing the inflammatory response after CABG with extracorporeal circulation with no significant difference in the postoperative measurements and outcomes