Serotonin syndrome in a postoperative patient

Depression is common in patients with ischemic heart disease. According to mental health surveys, approximately one-fifth of the patients with angiographic evidence of coronary artery disease have major depression.[1] It is well-recognized that stigma associated with mental disorders leads to individuals avoiding treatment or concealing treatment for them. We report a case of serotonin syndrome that occurred during postoperative period in a patient who underwent coronary artery bypass grafting. The patient was receiving 60 mg/day fluoxetine for the last 4 years, which she and her attendants concealed during the preoperative evaluation. To our knowledge this is the first case of serotonin syndrome, reported in biomedical literature, in a postoperative patient. We suggest that history taking should also focus on antidepressant drug intake by patients. If serotonin syndrome occurs in such patients aggressive and timely management can help avert mortality

Mucormycosis: An Uncommon Cutaneous Infection at Permanent Pacemaker-Implanted Site in a Very Low-Birthweight Baby

Permanent pacemaker implantation in low birthweight (LBW) babies with congenital complete heart block is extremely challenging due to a paucity of appropriate pulse generator placement pocket sites. The development of infection following an implantation procedure can pose a life-threatening risk to the patients. With more patients in the younger group receiving these devices than ever before and the rate of infection increasing rapidly, a closer look at the burden of infection and its impact on outcome of these patients is warranted. We report mucormycosis infection at the abdominal pacemaker pocket site of an infant requiring pacemaker explantation and re-insertion into the intrapleural space

Parasternal Block with Two Different Concentration of Ropivacaine for Post-Operative Analgesia in Patient Undergoing Coronary Artery Bypass Grafting: A Randomized Double Blind Controlled Trial

Background: Postoperative sternal pain is one of the most important factors affecting patients’ quality of life during the early post-operative days. Optimal pain management after cardiac surgery improve comfort and wellbeing of the patients. Conventionally used techniques of postoperative analgesia mostly provided by intravenous route, have their own side effects, causing a delay in tracheal extubation. Parasternal intercostals block is one such technique which has several potential advantages and devoid of the above side effects.Objective: To study the effect and effi cacy of parasternal intercostals block analgesia with two different doses of ropivacaine for post-operative analgesia in patients undergoing coronary artery bypass grafting (CABG).Design: Randomized, prospective, double blind study Setting: Tertiary health care teaching hospitalParticipants: One hundred and twenty adult cardiac surgical patients scheduled for elective coronary artery bypass grafting.Intervention: 0.75% ( group R1) and 0.5% (group R2) ropivacaine injection with 5 doses of 4 ml each on each side of Parasternal intercostals space with a total dose of ropivacaine 200 mg and 300 mg respectively or same volume of saline (group S) prior to surgical incision.Measurements and results: The average time of extubation was signifi cantly lower in R1 and R2 group compared to S group, being 5.15±1.13,5.24±0.88 and 7.29±1.41 hours respectively (p &lt;0.0010).The length of ICU stay was 1.67±0.57 days in group R1,2.0±0.61 days in group R2 and 2.11±0.64 days in group S ( p=0.007) . A similar fi nding was also present when the duration of hospital stay was concerned. The cumulative 24 hr fentanyl dose was signifi cantly higher in group S compared to that of R1 and R2. (186.73±28.3, 217±36.8 and 344±68.2 μ gm respectively, p, 0.01).VAS score was highest in S group of patients with a mean of 5.08±0.82 for all the time periods, whereas that for group R1 and R2 was 3.64±0.84 and 3.77±0.71 respectively except that at post extubation. Statistical signifi cance was observed for VAS score during inter group comparison (R1 vs S, p&lt;0.001, R2 vs. S,p&lt;0.001). The mean heart rate and mean arterial pressure remained in higher side in group S patients when compared to the other two groups (p &lt; 0.01 in each case). One patient in group R1, three in group R2 and seven in group S had arrhythmia during their ICU stay. Two patients from each R2 and S group had evidence of pneumonia and none of the patients in any group had evidence of sternal wound infection during the&nbsp; course of stay and one month follow up period.Conclusion: Parasternal intercostals block for postoperative pain relief for adult cardiac surgical patients is a simple technique, which is easy to perform and appears to be a useful adjunct to post-operative pain relief during the postoperative period. 0.75 % ropivacaine is more effi cacious than that of 0.5% when used in the same route without any additional side effects. Unlike neuroaxial blocks, it can be used in patients who are anti-coagulated perioperatively and have deranged coagulation parameters.</p

Comparison the Effect of Etomidate vs. Thiopentone on Left Ventricular Strain and Strain Rate at the Time of Anesthesia Induction in Patients Undergoing Elective Coronary Artery Bypass Surgery: A Randomized Double Blind Controlled Trial

Myocardial strain imaging with speckle tracking echocardiography (STE) is getting popularity because it does not depends on insonation angle and has shown good correlation with intraoperative and postoperative ventricular function in patients with coronary artery disease. The impact of thiopentone and etomidate induction on myocardial function was studied and compared on sixty patients undergoing elective coronary artery bypass grafting. Three loops for each views (apical 4 chamber, apical 2 chamber, and apical long axis ) were acquired at base line (T0) and 1 minute (T1) after induction for offline analysis. In Group T, significant increase in HR from the base line values (67.8 ± 13.8 vs 79.2 ± 15.6, p = 0.001) occurred post induction, where as in Group E it remain near to the base line (71.7 ± 8.3 vs 70.1± 8.9, p = 0.345). A reduction in mean arterial pressure (MAP) was noted in both the groups after the injection of the allocated drug. There was no significant difference in the index of contractility (ICON) (T0 vs T1: 48.7 ± 10.6 vs 47.0 ± 11.7, p = 0.120) in Group E where as in Group T there was a reduction in the ICON value (T0 vs T1: 45.0 ± 10.7 vs 41.0 ± 8.4, p = 0.005). A similar picture was also noted in systemic vascular resistance index. A significant decrease in cardiac index (CI) was seen in Group E (T0 vs T1: 2.7 ± 0.4 vs 2.5 ± 0.4, p = 0.027), however it remain near to the base line in Group T. There occurred no changes in stroke index (SI) in Group E (T0 vs T1: 38.7 ± 6 vs 37.0± 5.3, p = 0.134), where as a significant decrease was noted after injection of thiopental (T0 vs T1: 38.0 ± 6.2 vs 36.1± 4.9, p = 0.049). A significant decline in cardiac performance index (CPI) was also recorded in Group E (T0 vs T1: 0.57 ± 0.15 vs 0.52 ± 0.12, p = 0.032), and not in Group T. There was decrease in left ventricular ejection fraction (LVEF) after the injection of both the drugs (Group E, T0 vs T1: 57 ± 3.7 vs 54± 3.7, p= 0.001; and Group T, T0 vs T1: 57 ± 3.7 vs 54± 3.7, p = 0.001). In Group E, global longitudinal peak systolic strain (GLPSS) showed no change after the injection of the drug (T0 vs T1: −13.2 ± 2.2 vs −13.1± 2.3, p = 0.631). However, a significant decrease in GLPSS (T0 vs T1: −13.5 ± 1.5 vs – 10 ± 1.8, p = 0.001) after injection of thiopental. Longitudinal peak systolic strain rate (LPSSR) was significantly decreased in all echocardiographic views after the injection of respective drugs. However, the decrease in LPSSR was significantly less in Group E in comparison to Group T. To conclude, STE provides accurate and reliable real time quantitative regional and global LV assessment. Use of thiopentone for anesthesia induction is associated with more profound impairment of LV function in comparison to etomidate as assessed by a decreased longitudinal peak systolic strain rate and global longitudinal peak systolic strain. Further studies are warranted to understand the exact clinical impact, which may influence the choice of intravenous induction agent based upon preoperative patient characteristics

Comparison of Left Ventricular Global Longitudinal Strain with Ejection Fraction as a Predictor for Peri-operative IABP Insertion in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting: A Pilot Study

Background: Prophylactic use of intra-aortic balloon pump (IABP) mainly depends on left ventricular (LV) systolic function. Global longitudinal strain (GLS) is a robust prognostic parameter for LV strain. It has proved to be more sensitive than LV ejection fraction (EF) as a measure of LV systolic function and is a strong predictor of outcome. Aim: To determine whether GLS can be used as a reliable marker and its cut-off value for IABP insertion in patients undergoing elective off-pump coronary artery bypass grafting (OPCABG). Settings and Design: A prospective observational clinical study which included 100 adult patients scheduled for elective OPCABG. Materials and Methods: Two-dimensional (2D) speckle tracking echocardiography (STE)-estimated GLS was computed and compared with LV EF measured by three dimensional (3D) echocardiography for the insertion of IABP. The intensive care unit (ICU) parameters were correlated with echocardiographic parameters to predict early post-operative outcome. Results: IABP insertion correlates better with GLS (post-revascularization > pre-revascularization) than with 3D LV EF. Receiver operating characteristic (ROC) curve analysis revealed the highest area under the curve (AUC, 0.972) with a cut-off value of > -9.8% for GLS compared to 3D LV EF (AUC, 0.938) with a cut-off value of ≤ 44%. ICU parameters show better correlation with E/e'> GLS > WMSI than 3D LV EF. Conclusion: GLS is a better predictor of IABP insertion compared to 3D LV EF in patients undergoing OPCABG

Is endothelin gene polymorphism associated with postoperative atrial fibrillation in patients undergoing coronary artery bypass grafting?

Background: The mechanism of development of atrial fibrillation (AF) in patients undergoing coronary artery bypass grafting (CABG) has not been clearly defined, and the involvement of multiple factors such as advanced age, withdrawal of β-blockers, inadequate atrial protection, and electrolyte imbalance, particularly hypomagnesemia has been documented by several authors. Despite all the available pharmacologic prophylaxis, incidence of AF still remains high in this group of patients. This unexplained cause could be genetic inheritance of endothelin-1 (ET-1) gene which is thought to have a pro-arrhythmogenic effect. Aim: This study aims to investigate the relationship between plasma ET-1 concentrations, ET-1 gene polymorphisms in loci -1370 T/G, -134 (3A/4A) Ins/del, Lys198Asn (G/T), and occurrence of AF in patients undergoing CABG. Methodology: Ninety-eight nonrelated, nondiabetic patients over a period of 4 years undergoing routine CABG were selected for the present study. All patients were genotyped for three single nucleotide polymorphisms (SNPs) in loci -1370 T/G, -134 (3A/4A) Ins/del, and Lys198Asn (G/T) in the ET-1 gene by gene sequencing. The plasma ET-1 concentrations were measured using an ET immunoassay. Results: Plasma ET-1 concentrations were higher in AF+ group (P = 0.001) as compared to AF− group. The allele frequencies between AF+ and AF− group were significantly different only with respect to the Lys198Asn (G/T) SNP of the ET-1 gene. Conclusion: The study described the possible correlation of polymorphism of ET gene in CABG population from India. The ET-1 gene might play a disease-modifying role in atrial fibrillation

Goal-directed therapy improves the outcome of high-risk cardiac patients undergoing off-pump coronary artery bypass

Background: There has been a constant emphasis on developing management strategies to improve the outcome of high-risk cardiac patients undergoing surgical revascularization. The performance of coronary artery bypass surgery on an off-pump coronary artery bypass (OPCAB) avoids the risks associated with extra-corporeal circulation. The preliminary results of goal-directed therapy (GDT) for hemodynamic management of high-risk cardiac surgical patients are encouraging. The present study was conducted to study the outcome benefits with the combined use of GDT with OPCAB as compared to the conventional hemodynamic management. Material and Method: Patients with the European System for Cardiac Operative Risk Evaluation ≥3 scheduled for OPCAB were randomly divided into two groups; the control and GDT groups. The GDT group included the monitoring and optimization of advanced parameters, including cardiac index (CI), systemic vascular resistance index, oxygen delivery index, stroke volume variation; continuous central venous oxygen saturation (ScVO 2 ), global end-diastolic volume, and extravascular lung water (EVLW), using FloTrac™ , PreSep™ , and EV-1000 ® monitoring panels, in addition to the conventional hemodynamic management in the control group. The hemodynamic parameters were continuously monitored for 48 h in Intensive Care Unit (ICU) and corrected according to GDT protocol. A total of 163 patients consented for the study. Result: Seventy-five patients were assigned to the GDT group and 88 patients were in the control group. In view of 9 exclusions from the GDT group and 12 exclusions from control group, 66 patients in the GDT group and 76 patients in control group completed the study. Conclusion: The length of stay in hospital (LOS-H) (7.42 ± 1.48 vs. 5.61 ± 1.11 days, P < 0.001) and ICU stay (4.2 ± 0.82 vs. 2.53 ± 0.56 days, P < 0.001) were significantly lower in the GDT group as compared to control group. The duration of inotropes (3.24 ± 0.73 vs. 2.89 ± 0.68 h, P = 0.005) was also significantly lower in the GDT group. The two groups did not differ in duration of ventilated hours, mortality, and other complications. The parameters such as ScVO 2 , CI, and EVLW had a strong negative and positive correlation with the LOS-H with r values of − 0.331, −0.319, and 0.798, respectively. The study elucidates the role of a goal-directed hemodynamic optimization for improved outcome in high-risk cardiac patients undergoing OPCAB

Tracheostomy in Postoperative Pediatric Cardiac Surgical Patients—The Earlier, the Better

Objectives This study was aimed to assess the benefits of early tracheostomy (ET) compared with late tracheostomy (LT) on postoperative outcomes in pediatric cardiac surgical patients. Design Present one is a prospective, observational study. Setting The study was conducted at a cardiac surgical intensive care unit (ICU) of a tertiary care hospital. Participants All pediatric patients below 10 years of age, who underwent tracheostomy after cardiac surgery from January2019 to december2019, were subdivided into two groups according to the timing of tracheostomy: “early” if done before 7 days or “late” if done after 7 days postcardiac surgery. Interventions ET versus LT was measured in the study. Results Out of all 1,084 pediatric patients who underwent cardiac surgery over the study period, 41 (3.7%) received tracheostomy. Sixteen (39%) patients underwent ET and 25 (61%) underwent LT. ET had advantages by having reduced risk associations with the following variables: preoperative hospital stay (p = 0.0016), sepsis (p = 0.03), high risk surgery (p = 0.04), postoperative sepsis (p = 0.001), C-reactive protein (p = 0.04), ventilator-associated pneumonia (VAP; p = 0.006), antibiotic escalation (p = 0.006), and antifungal therapy (p = 0.01) requirement. Furthermore, ET was associated with lesser duration of mechanical ventilation (p = 0.0027), length of ICU stay (LOICUS; p = 0.01), length of hospital stay (LOHS; p = 0.001), lesser days of feed interruption (p = 0.0017), and tracheostomy tube change (p = 0.02). ET group of children, who had higher total ventilation-free days (p = 0.02), were decannulated earlier (p = 0.03) and discharged earlier (p = 0.0089). Conclusion ET had significant benefits in reduction of postoperative morbidities with overall shorter mechanical ventilation, LOICUS, and LOHS, better nutrition supplementation, lesser infection, etc. These benefits may promote faster patient convalescence and rehabilitation with reduced hospital costs