Oral dexmedetomidine versus midazolam as anesthetic premedication in children undergoing congenital heart surgery

Background: Premedication is required for reducing anxiety and child�s struggling against mask acceptance on anesthesia in pediatric surgery for congenital heart disease. Midazolam has been widely used for this purpose, but because of its side effects, finding an effective replacement with less complication is necessary. Objectives: In the present study, we compared the efficacy of oral midazolam versus dexmedetomidine in terms of anxiolysis and mask acceptance behavior. Patients and Methods: Sixty children aged between 2 and 12 years, and scheduled for on-pump surgery due to a congenital heart disease were randomly assigned into two groups. Oral midazolam (0.5 mg/kg up to 15 mg per patient) and dexmedetomidine (2 μg/kg) were administered 45 minutes pre-anesthesia. Children�s anxiety, mask acceptance behavior, hemodynamic measures, and cardiopulmonary outcomes were recorded and compared. Results: The mean age of patients was 3.96 ± 2.04 years. Twenty-eight (46.7) patients were females. Two drugs have similar effects on cardiopulmonary outcomes and hemodynamic measures (P > 0.05). They equally relieved the children�s anxiety (mean sedation score 1.93 ± 0.63 and 2.0 ± 0.63 for midazolam and dexmedetomidine groups, respectively; P > 0.05), while dexmedetomidine showed a better effect on improving the mask acceptance behavior (mean mask acceptance score 2.58 ± 0.6 and 1.6 ± 0.67 for midazolam and dexmedetomidine, respectively; P < 0.05). Conclusions: It appears reasonable to apply oral premedication with dexmedetomidine 45 minutes before transferring the patient to the operating room when he or she is more prone to resist inhalation anesthesia induction. © 2015, Iranian Society of Regional Anesthesia and Pain Medicine (ISRAPM)

Hemodynamic responses to two different anesthesia regimens in compromised left ventricular function patients undergoing coronary artery bypass graft surgery: Etomidate-midazolam versus propofol-ketamine

Background: Various methods have been suggested to prevent hemodynamic instability caused by propofol and adverse effects caused by etomidate induction. The current study evaluated hemodynamic effects of propofol-ketamine mixture in comparison to etomidate-midazolam mixture during anesthesia induction. Objectives: The aim of this study was to evaluate the hemodynamic effects of etomidate-midazolam by comparing it with propofol-ketamine for the induction of anesthesia in patients with left ventricular dysfunction undergoing coronary artery bypass graft surgery. Patients and Methods: One-hundred patients aged between 40 and 65 with coronary artery disease and low ejection fraction scheduled for elective coronary artery bypass surgery participated in this study. The patients were randomly allotted to one of the two groups to receive either propofol-ketamine or etomidate-midazolam combination. Two groups were compared for pain on injection and myoclonus, Heart Rate (HR), Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP), Mean Arterial Pressure (MAP), Cardiac Index (CI) and Systemic Vascular Resistance (SVR), before and one minute after induction of anesthesia, and one, three and five minutes after intubation. Results: Incidence of pain on injection (2 - 4) and myoclonus (10) was less in both groups. The hemodynamic response was similar in the two groups for all variables over the time interval, except for CI at one and three minutes after intubation (P = 0.024 and P = 0.048, respectively), and SVR in five minutes after intubation (P = 0.009), with differences being statistically significant. Conclusions: Both anesthetic regimens were acceptable for induction in patients with coronary artery disease and left ventricular dysfunction undergoing coronary artery bypass graft surgery. © 2015, Iranian Society of Regional Anesthesia and Pain Medicine (ISRAPM)

Heparinized and saline solutions in the maintenance of arterial and central venous catheters after cardiac surgery

Background: Heparinized saline solution is used to prevent occlusion in the arterial catheters and central venous pressure monitoring catheters. Even at low dose, heparin administration can be associated with serious complications. Normal saline solution can maintain patency of arterial catheters and central venous pressure monitoring catheters. Objectives: The current study aimed to compare the efficacy of normal saline with that of heparinized one to maintain patency of arterial and central venous catheters after cardiac surgery. Patients and Methods: In the current randomized controlled trial, 100 patients, with an age range of 18 - 65 years of valve and coronary artery surgery were studied in Rajaie heart center, Tehran, Iran. Patients were randomized to receive either heparinized saline (n = 50) or normal saline flush solutions (n = 50). In the study, arterial catheters and central venous pressure monitoring catheters were daily checked for any signs of occlusion in three postoperative days as primary end-point of the study. Results: According to the information obtained from the study, four (8) arterial catheters in the saline group (P value: 0.135) and three (6) arterial catheters in the heparin group (P value = 0.097) were obstructed. Statistical analysis showed that the incidence of obstruction and changes in all other parameters between the two groups during the three-day follow-up was not significant (all P values > 0.05). Conclusions: It seems that there is no difference in the use of heparinized and normal saline solutions to prevent catheter occlusion of arterial and central venous pressure. © 2015, Iranian Society of Regional Anesthesia and Pain Medicine (ISRAPM)

The effect of combined conventional and modified ultrafiltration on mechanical ventilation and hemodynamic changes in congenital heart surgery

Background: Cardiopulmonary bypass is associated with increased fluid accumulation around the heart which influences pulmonary and cardiac diastolic function. The aim of this study was to compare the effects of modified ultrafiltration (MUF) versus conventional ultrafiltration (CUF) on duration of mechanical ventilation and hemodynamic status in children undergoing congenital heart surgery. Materials and Methods: A randomized clinical trial was conducted on 46 pediatric patients undergoing cardiopulmonary bypass throughout their congenital heart surgery. Arteriovenous MUF plus CUF was performed in 23 patients (intervention group) and sole CUF was performed for other 23 patients (control group). In MUF group, arterial cannula was linked to the filter inlet through the arterial line, and for 10 min, 10 ml/kg/min of blood was filtered and returned via cardioplegia line to the right atrium. Different parameters including hemodynamic variables, length of mechanical ventilation, Intensive Care Unit (ICU) stay, and inotrope requirement were compared between the two groups. Results: At immediate post�MUF phase, there was a statistically significant increase in the mean arterial pressure, systolic blood pressure, and diastolic blood pressure (P < 0.05) only in the study group. Furthermore, there was a significant difference in time of mechanical ventilation (P = 0.004) and ICU stay (P = 0.007) between the two groups. Inotropes including milrinone (P = 0.04), epinephrine (P = 0.001), and dobutamine (P = 0.002) were used significantly less frequently for patients in the intervention than the control group. Conclusion: Administration of MUF following surgery improves hemodynamic status of patients and also significantly decreases the duration of mechanical ventilation and inotrope requirement within 48 h after surgery. � 2016 Journal of Research in Medical Sciences

Transient bilateral visual loss due to posterior ischemic optic neuropathy after cardiac surgery: A very rare case

Visual loss is a relatively rare but devastating and unpredictable complication of open heart surgery with cardiopulmonary bypass. The most common cause of postoperative visual loss following cardiac surgery is ischemic optic neuropathy (ION), which is generally categorized as anterior ischemic optic neuropathy (AION) and posterior ischemic optic neuropathy (PION). PION is clinically differentiated from AION with a normal-appearing optic nerve head. PION is relatively more common in cases of spinal surgery and radical neck dissection, while AION appears to be more common than PION after cardiac surgery. We report a very rare case of transient bilateral visual loss due to PION in a 44-year-old man undergoing mitral valve replacement and coronary artery bypass graft surgery. © 2019, Iranian Heart Association. All rights reserved

Evaluation of dysrhythmias following transfusion after coronary artery bypasses grafting

Background: Coronary artery bypass graft surgery (CABG) is a common surgical operation usually performed under cardiopulmonary bypass. Although the relationship between the transfusion of blood products during and after surgery with the incidence of arrhythmia has been studied, contradictory results have been achieved. In the current study, we investigated the correlation between blood products transfusion during and after surgery with the incidence of postoperative arrhythmia. Method: Patients candidated for CABG were entered into the present cross-sectional study. The incidence of arrhythmia (supraventricular and ventricular, transient or permanent), history of medications and renal diseases, and transfusion of blood products during or after the operation were recorded and analyzed. Results: Twenty-two (8.2) patients experienced atrial fibrillation and 50 (18.7) experienced premature ventricular contractions. The use of packed red blood cells in the operating room was inversely correlated with the odds of the incidence of at least one of the arrhythmias (OR = 0.5, 95 CI: 0.28 to 0.87; P = 0.015). The number of grafts, high blood pressure, duration of mechanical ventilation in the ICU, and the potassium level upon admission to the ICU were directly correlated with the incidence of arrhythmia. Moreover, the transfusion of platelets in the ICU and the use of cryoprecipitate in the operating room were inversely correlated with the incidence of atrial fibrillation (not all arrhythmias). Conclusions: According to the findings of the present study, conditionings to maintain the normal hematocrit level and platelet count is associated with decreased odds of arrhythmia incidence during and after CABG. © 2018, Iranian Heart Association. All rights reserved

Effects of advanced hemodynamic monitoring on the postoperative intubation time in patients with moderate-to-severe left ventricular dysfunction undergoing cardiac surgery

Background: Advanced monitoring can lead to the early recovery of patients in complicated and high-risk surgical operations. The aim of this study was to evaluate the effects of advanced monitoring on the hemodynamics of patients undergoing cardiac surgery. Methods: In this study, patients undergoing cardiac surgery were divided into 2 groups of control and advanced monitoring. In each group, 25 patients were examined. The patients had moderate-to-severe left ventricular dysfunction (ejection fraction < 35). The patients in the case group were placed on the FloTrac cardiac output monitor, which is used as a therapeutic guide in the operating room and the intensive care unit (ICU). Results: Upon ICU admission, the average stroke volume variation and the mean cardiac index in the advanced monitoring group in the first 6 hours were 10 and 2.7, respectively, and in the second 6 hours were 11 and 2.8, correspondingly. The mean serum level administered was 1000 cc in the first 6 hours and 500 cc in the second 6 hours. In the control group, the mean serum level administered was 2000 cc in the first 6 hours and 500 cc in the second 6 hours, which had a significant relationship between the 2 groups in the first 6 hours (P = 0.01). Additionally, 84 of the patients with advanced monitoring were extubated in the first 6 hours (P = 0.0). Conclusions: This study showed that cardiac surgery in patients with moderate-to-severe left ventricular dysfunction using advanced monitoring and goal-directed hemodynamic therapy based on the cardiac index, the stroke volume variation, and the stroke volume index reduced the duration of intubation after surgery. © 2020, Iranian Heart Association. All rights reserved