Success and failure of fast track extubation in cardiac surgery patients of tertiary care hospital: one year audit

OBJECTIVE: To identify the causes of delayed extubation in patients planned for fast tract extubation during cardiac surgery. METHODS: A prospective observational study was conducted at cardiothoracic unit of Aga Khan University Hospital for the period of one year. All elective coronary artery bypass graft (CABG) surgery patients, between the ages of 35-75 years with LVEF \u3e or = 40 percent were included. Patients with Intra aortic balloon pump, chronic renal failure, respiratory compromise and requiring high ionotropic support were excluded from this audit. A performa was designed and later filled by the primary investigator. Patient demographics and various reasons for delayed extubation were noted in this proforma. RESULTS: Total 614 patients underwent CABG surgery and 388 (63.19%) patients were planned for fast track extubation. A total of 196 (49.5%) patients could be extubated within six hours of arrival in the cardiac ICU. Common reasons for delayed extubation included deep sedation in 80 (46.5%), confusion 44 (25%), excessive bleeding in 20 (11.3%) and high inotropic support in 10 (5.68%). CONCLUSION: Major contributing factors for delayed extubation were identified by this audit. These factors need to be targeted accordingly by modifications in intra operative management

Incidence and pattern of thrombocytopenia in cardiac surgery patients

Objective: To observe the incidence and pattern of thrombocytopenia in cardiac surgery patients.Methods: This prospective, cohort study was conducted at the Aga Khan University Hospital, Karachi, from November 2014 to April 2015, and comprised adult cardiac patients. Patients with platelet count less than 150,000 x 109/L, history of malignancy, immune thrombocytopenic purpura and on chemo or radiotherapy were excluded. All information including demographics, platelet count, heparin doses, total cardiopulmonary bypass time, cross-clamp time, blood products transfused, any thromboembolic complication and the presence of infection were recorded on a pre-designed proforma. SPSS 19 was used for data analysis..Results: Of the 177 patients, 130(73.4%) were males and 47(26.6%) were females. The overall mean age was 59.21±10.99 years. Thrombocytopenia was observed in 167(94.4%) patients. Of them, platelet count dropped below 50% in 71(42.5%) patients, 30-50% in 68(40.7%) patients and 20-30% in 28(16.8%) from the baseline value. Regarding pattern of thrombocytopenia, maximum drop in platelet count was noticed on 2nd and 3rd day of surgery. Furthermore, 9(5.3%) patients developed severe thrombocytopenia (\u3c50,000 x 109/l).Conclusions: The incidence of thrombocytopeni

Manual trans-tracheal high frequency positive pressure ventilation for left main bronchus and carinal mass surgical resection in a child

Inflammatory myofibroblastic tumor (IMT), also called pseudo-tumor, is a very rare condition and accounts for less than 1% of primary lung tumor. It is most common benign tumor of lung in children. This case is reported with the objective of highlighting the role of manual trans-tracheal high frequency positive pressure ventilation (HFPPV) in facilitating surgical resection with maintenance of adequate oxygenation and a little compromised ventilation. A 9-year boy, weighing 21 kg, was diagnosed as a case of IMT of left main bronchus on biopsy and was successfully treated by surgical excision through left thoracotomy. HFPPV through improvised technique was used for ventilation and oxygenation during surgery. Total Intravenous anaesthesia with propofol infusion and increments of fentanyl was used during HFPPV. After the completion of the surgery, conventional positive pressure ventilation (PPV) was continued through the endotracheal tube (ETT) to check any bronchial stump leak. After the surgery, patient was weaned and extubated in the operating room. Hospital course remained uneventful and the patient was discharged after 6 days. HFPPV with manually improvised technique is applicable in carinal surgery for optimization of oxygenation, ventilation, and uninterrupted surgical resection

Magnesium, a drug of diverse use

Magnesium has evolved as a drug with diverse clinical applications. Mg++ is an important caution and its homeostasis is very important for normal body functioning. The physiological role of Mg is due to its calcium channel blocking properties at smooth muscle, skeletal muscle and conduction system levels. The analgesic properties are due to NMDA receptor blocking action. Mg++ is beneficial in acute Myocardial Infarction, protection during open heart surgery and treatment and prevention of heart rhythm disturbances. Mg has an established role in the management of preeclampsia and eclampsia. Magnesium prevents or controls convulsions by blocking neuromuscular transmission and decreasing the release of acetylcholine at the motor nerve terminals. The use of MgSO4 in treating tetanus and acute asthma is established. In conclusion, Mg is a cost effective, widely used drug with multidisciplinary applications. Its majority of physiological effects are attributed to calcium channel blocking properties

Immediate changes in hemodynamics and gas exchange after initiation of noninvasive ventilation in cardiac surgical patients

Introduction: Cardiac surgery is associated with pulmonary dysfunction and complications such as prolonged intubation and reintubation. Bilevel positive airway pressure (BiPAP) machine has been used in the clinical settings to improve oxygenation, reduce work of breathing, and avoid reintubation. The effect of BiPAP on cardiovascular parameters is not well established, and very few studies have targeted hemodynamic changes. The aim of the study was to assess the immediate effect of BiPAP on respiratory and hemodynamic parameters in post-cardiac surgery patients.Materials and methods: This quasi-experimental study was done on 33 adult cardiac surgery patients. Ethical review committee approval was sought and consent was taken. All patients who were in respiratory distress with respiratory rate of \u3e30/min and/or PaO2:FiO2 ratio of variables, PaO2:FiO2 ratio.Results: A total of 33 patients were included in the study. The average age of the patients was 60.97 ± 10.8, of which 23 (69.7%) were males and 10 (30.7%) females. BiPAP application leads to statistically significant improvement in ventilator parameters including SaO2 29 (87.7%), PaO2 29 (87.8%), PaCO2 21 (63.6%), and PaO2:FiO2 ratio in 27 (81.8%).Conclusion: Ventilatory parameters were significantly improved after BiPAP application in this study, but hemodynamic parameters showed no statistically significant change. BiPAP application was also able to decrease the need for reintubation in post-cardiac surgery patients

Sleeping pattern before thoracic surgery: A comparison of baseline and night before surgery

Background: Sleep deprivation is considered a stress factor in the perioperative period. There are several studies on sleep disturbance after surgery but very limited literature available on preoperative sleep patterns, predictors of sleep disturbance and its effect on surgical outcome.Methodology: Patients scheduled for thoracic surgery were asked to fill out a written Pittsburgh Sleep Quality Index (PSQI) questionnaire. The primary investigator explained this form to all the patients. This was filled out before premedication for subjective assessment of sleeping pattern at two different time point. Only those patients included who spent the previous night at home. Participants were asked to respond to the questions regarding their baseline sleeping pattern and compare it with last night.Results: Total eighty-three patients with a mean age of 47.83 ± 17.88 were included in the study. Overall mean PSQI scores were significantly higher (p-value \u3c 0.01) during the night before surgery (6.94 ± 2.115) when compared with baseline (3.88 ± 1.877). Sleep latency was also significantly affected when last night-1 (the night before admission) was compared with usual sleep latency. Twenty patients were unable to sleep more than 5 hrs at night before admission which was significant when compared with their last month status (20 vs 3). Logistic regression model demonstrated the age and Timing of surgery as a strong predictors of poor sleep (defined as PSQI ≥ 5).Conclusion: Quality of sleep was profoundly affected at night before thoracic surgery, mainly due to a significant change in sleep latency and sleep duration. Although age and Timing of surgery were strong predictors of poor sleep we were unable to find any association between quality of sleep and type of surgery

Hosseini’s The Kite Runner: Some Critical Surveys, Impacts and Suggestions

Khaled Hossieni’s The Kite Runner (2003) is a multi-dimensional novel, which gives a variety of material for research from diverse angles. The critics and reviewers have explored the thematic, structural, political, denominational and strategic understanding of Afghanistan in their reviews. Their focus on ethnic through political to religious conflicts is revealed through socio-cultural dynamics of the characters. This study aims at focusing on the existing literature on the novel in such a way as to highlight its symbolic/ psychological suggestiveness. The in-depth analysis of the study shows that both the social and psychological sides of the humans are juxtaposed. If one side is balanced, the other will be developed and vice versa. Hence, the fundamental finding of the paper shows that prejudice, lack of cooperation, evils and stereotypes are caused by the psychological imbalance which can be corrected if one works on self-examination, self-criticism and self-improvement. Keywords: The Kite Runner; Political; Multi-dimensional; Psychological Imbalance; Self-examination

Pulmonary artery catheter knotting in a coronary artery bypass surgery patient

A fifty seven years old female patient came to operating room for coronary artery bypass grafting (CABG) surgery. After induction, invasive monitoring lines were placed. Pulmonary artery catheter (PAC) floated after three attempts and it was wedged at 60cm. Intra operative course was smooth and patient transferred to cardiac intensive care unit (CICU). First chest X-ray revealed PAC knotting in the right ventricle. Vascular surgeon was involved and he removed it through right internal jugular vein under fluoroscopic guidance. Pulmonary arterial catheterization is an invasive procedure. Knotting usually occurs due to excessive advancement of the pulmonary artery catheter beyond the normally expected distance. The removal of a catheter should never be forced when resistance is encountered. PA catheter knotting is a rare complication but it should be suspected whenever there is excessive length of catheter required to reach pulmonary artery