Effects of Early Mobilization Protocol on Cognitive Outcome after Cardiac Surgery

Background: This study aimed at determining the effects of implementation of “early mobilization protocol” on incidence of cognitive dysfunction after cardiac surgery. Methods: In a randomized controlled trial, 80 adult patients, who had undergone elective cardiac surgery were randomly assigned to intervention (early mobilization protocol; n = 40) and control (routine physical therapy; n = 40) groups. Early mobilization was initiated from the first post-op morning and continued until discharge from the ICU. Cognitive dysfunction was assessed by the mini mental state examination (MMSE) questionnaire. The MMSE questionnaire was completed at three occasions for every patient: one day before surgery, second post-op day, and at the time of discharge from the intensive care unit (ICU). Results: Preoperative cognitive status had no difference between the two groups (P = 0.310). Post-op cognitive dysfunction was significantly more commonly reported in the control group. The MMSE scores were higher in early mobilized patients compared to the control group on the first post-op day (median: 28; inter quartile range: 26 to 30 versus median: 25; IQR: 22 to 27; p = 0.001) and at the time of discharge from the ICU (median: 29; IQR: 28 to 30 versus median: 26; IQR: 25 to 28; p = 0.001). In multivariate analysis, duration of tracheal intubation and “early mobilization protocol” had significant effects on patients’ length of ICU stay. Conclusions: Implementation of early mobilization protocol has positive effects on cognitive outcome and ICU stay after cardiac surgery

Management of difficult airway with laryngeal mask in a child with mucopolysaccharidosis and mitral regurgitation: A case report

Introduction: Mucopolysaccharidoses (MPSs) are a group of heredity storage diseases, transmitted in an autosomal recessive manner, associated with the accumulation of glycosaminoglycans (GAGs) in various tissues and organs. The concerned patients have multiple concomitant hereditary anomalies. Considering the craniofacial abnormality in these patients, airway management may be difficult for anesthesiologists. In these patients, preanesthetic assessment is necessary and performed with the accurate assessment of airways, consisting of the physical exam and radiography, MRI or CT of head and neck. An anesthesiologist should set up a ≴difficult intubation set≵ with a flexible fiber-optic bronchoscope and also, it may be necessary to discuss with an ear-nose and throat (ENT) specialist if required, for unpredicted emergency situations. Case Presentation: In this case-report we presented a 2-year-old boy with known MPSs with psychomotor retardation, bilateral corneal opacities, impaired hearing and vision, inguinal hernia, severe mitral regurgitation, micrognathia, coarse facial feature, stiff and short neck and restricted mouth opening. He scheduled for left inguinal hernia repair surgery. Discussion: The patient's difficult airway was managed successfully and the anesthesia of his surgical procedure had an uneventful course

Arrhythmia in Acute Right Ventricular Infarction

Acute inferior myocardial infarction (MI) frequently involves the right ventricle (RV).1-3 We assessed the prognostic impact of RV myocardial involvement in patients with inferior MI. One hundred seventy patients were admitted to the cardiac care unit of Madani Heart Hospital (Tabriz-Iran) with the diagnosis of inferior MI with (group1) or without (group2) the simultaneous involvement of RV during the study period (from 2005 to 2006). Patients presenting within 12h of symptom onset were eligible for inclusion. Patients with simultaneous anterior wall MI or renal impairment (creatinine > 2 mg/dl), as well as those undergoing primary percutaneous translational coronary angioplasty, were excluded. Eighty eight percent of the patients with RVMI and 75% of those with isolated inferior MI had some type of arrhythmia. Atrioventricular (AV) block occurred in 42% of the infarctions with RV involvement and only in 29% of the control group. Intra-ventricular conduction disturbance (IVCD) was also more frequent in RVMI (29.4% vs. 13.1%, p=0.021), especially right bundle branch block (RBBB) (20% vs. 7.4%, P=0.003). There was, however, no meaningful difference in the incidence of left bundle branch block (LBBB) between the two groups (3.5% vs. 2.35%, P=0.95). Ventricular fibrillation (VF) was observed in 5.2% and 1.2% and ventricular tachycardia in 26% and 12.2% of the patients in groups 1 and 2, respectively. In 27% of patients with RVMI, it was necessary to implant a pacemaker as compared to 10% of those in the control group. Mortality was higher in the patients with inferior infarction extended to the RV (15.3% vs. 3.5%, P= 0.0001). Thus, the differences between the findings in the two groups in terms of the occurrence of post-MI arrhythmias and conduction disorders were quite significant, but there was no meaningful difference with respect to the incidence of LBBB between the two groups. Additionally, patients with inferior MI who also had RV myocardial involvement were at increased risk of death and arrhythmias. This suggests that the RV may be more arrhythmogenic than the LV; a hypothesis that warrants further investigation

A Review of Current Analgesic Techniques in Cardiac Surgery. Is Epidural Worth it?

In this review we addressed the various analgesic techniques in cardiac surgery, especially regional methods such as thoracic epidural anesthesia (TEA). There are many techniques available for management of postoperative pain after cardiac operation including intravenous administration of analgesic drugs, infiltration of local anesthetics, nerve blocks, and neuroaxial techniques. Although there are many evidences declaring the benefits of neuroaxial blockade in improving postoperative well-being and quality of care in these patients, some studies have revealed limited effect of TEA on overall morbidity and mortality after cardiac surgery. On the other hand, some investigators have raised the concern about epidural hematoma in altered coagulation and risks of infection and local anesthetics toxicity during and after cardiac procedures. In present review, we tried to discuss the most recent arguments in the field of this controversial issue. The final conclusion about either using regional anesthesia in cardiac surgery or not has been assigned to the readers

Comparison of serum Homocysteine concentrations between smoker and nonsmoker patients with acute coronary syndrome in Tabriz ShahidMadani Hospital during 2008-2009

Background: According to previous studies elevated blood total homosyteine has been suggested to be an independent risk factor for cardiovascular disease. The aim of this study was evaluation of homosyteine serum in smoker and nonsmoker patients with acute coronary syndrome (ACS). Methods: Eighty five patients were enrolled in this study .Forty eight patients (21smoker and 27non-smoker) diagnosed with acute myocardial infarction (AMI), 37 patients (14smoker and 23non-smoker) with unstable angina (UA) that admitted in Shahid Madani Heart center in Tabriz in 2008-2009. The mean age of patients with AMI and UA were 61.83±13.78 and 59.90±11.95 years, respectively. Homocysteine serum Levels were measured by Hitachi Auto analyzer. Results: The mean age of patients with AMI was 61.83±13.78 years and in patients with UA was 59.90±11.95 years (p=0.53). Mean serum levels of homocysteine were not significant difference between AMI and UA patients (17.61±11.25 μmol/L vs. 22.25±12.44, p=0.78). There was also a significant correlation between high levels of homocysteine with AMI and UA diseases in comparison with normal reference values. There were not statistically significant differences in serum homocysteine levels between smoker and nonsmoker patients in both AMI and UA groups. Conclusion: The Mean levels of Homocysteine in AMI and UA groups were not significantly different. Our study showed age of smoker patients in AMI and UA groups were significantly lower than nonsmoker patient

Evaluation of Anthropometric Indices of Patients with Left Ventricle Dysfunction Fallowing First Acute Anterior Myocardial Infarction

Introduction: In the current study, we evaluated the effect of anthropometric indices on ejection fraction following first acute anterior myocardial infarction. Methods: In an analytic-cross sectional study, 50 patients with acute anterior myocardial infarction and abnormal anthropometric indices (Body Mass Index (BMI) ≥ 30, Waist Hip Ratio (WHR) ≥ 1 and ≥ 0.85 in males and females respectively and Waist Circumference (WC) ≥ 102 cm and ≥ 88 cm in males and females respectively) were recruited as case group and 50 patients with acute anterior myocardial infarction and normal anthropometric indices as control group. Subsequently, the relation between anthropometric indices and left ventricle dysfunction was evaluated and compared between two groups. Results: 77 peopleof the studied patients were male and 23 female with the mean age of 59± 1.2 years and an age range of 32-90 years. To evaluate the left ventricle function, the mean ejection fraction of the patients was measured as 34.3± 7.2 % and 44.8± 6.3% in patients withabnormal anthropometric indices and patients with normal anthropometric indices respectively (P= 0.0001). Calculation of the correlation coefficient between ejection fraction and BMI, WHR and WC in males and females revealed a moderate reverse (r=-0.521 tor=-0.691) and statistically significant (P= 0.0001) relations which was of more strength in females. Conclusion: Anthropometric indices including BMI and waist circumference influence cardiac function following myocardial infarction

Hemodynamic changes following endotracheal intubation with glidescope® video-laryngoscope in patients with untreated hypertension

Background: Tracheal intubation can be associated with considerable hemodynamic changes, particularly in patients with uncontrolled hypertension. The GlideScope® video-laryngoscope (GVL) is a novel video laryngoscope that does not need direct exposure of the vocal cords, and it can also produce lower hemodynamic changes due to lower degrees of trauma and stimuli to the oropharynx than a Macintosh direct laryngoscope (MDL). Objectives: The aim of this clinical trial was to compare hemodynamic alterations following tracheal intubation with a GVL and MDL in patients with uncontrolled hypertension. Patients and Methods: Sixty patients who had uncontrolled hypertension and scheduled for elective surgery requiring tracheal intubation, were randomly assigned to receive intubated with either a GVL (n = 30) or a MDL (n = 30). Intubation time, heart rate, rate pressure product (RPP), and mean arterial blood pressure (MAP), were compared between the two groups at; baseline, following induction of anesthesia, after intubation, and at one minute intervals for 5 minutes. Results: A total of 59 patients finished the study. Intubation time was longer in the GVL group (9.80 ± 1.27 s) than in the MDL group (8.20 ± 1.17 s) (P < 0.05). MAP, pulse rate, and RPP were lower in the GVL than the MDL group after endotracheal intubation (P < 0.05). MAP, heart rate, and RPP returned to pre-intubation values at 3 and 4 minutes after intubation in the GVL and MDL groups, respectively (P < 0.05). Conclusions: Hemodynamic fluctuations in patients with uncontrolled hypertension after endotracheal intubation were lower with the GVL than the MDL technique

Factors influencing prolonged icu stay after open heart surgery

Background: There are different risk factors that affect the intensive care unit (ICU) stay after cardiac surgery. Objectives: The aim of this study was to evaluate possible risk factors influencing prolonged ICU stay in a large referral hospital. Patients and Methods: We conducted a case-control study to determinate causes of prolonged ICU stay in 280 adult patients undergoing cardiac surgery in a tertiary care center for cardiovascular patients, Tehran, Iran. These patients were divided into two groups according to ICU stay ≤ 96 and > 96 hours. We evaluated perioperative risk factors of ICU stay > 96 hours. Results: Among the 280 patients studied, 184 (65.7%) had stayed ≤ 96 hours and 96 (34.3%) had stayed > 96 hours in ICU. Frequency of prolonged ICU stay was 34.2% in patients undergoing coronary artery bypass graft (CABG), 30.8% in patients with valve surgery, and 44.8% in patients with CABG plus valve surgery. Patients with > 96 hours of ICU stay received more blood transfusion and intravenous inotropes. They also had longer anesthesia, cardiopulmonary bypass, and postoperative intubation time. There were higher incidence of postoperative tamponade, re-exploration, re-intubation, hemodialysis, and hypotension in this group (P < 0.05 for all comparisons). Conclusions: In this study, about one-third of patients had prolonged ICU stay. Factors influencing prolonged ICU stay were medical and some non-medical factors. In the present study, up to 30% of the patients had a prolonged ICU stay of > 96 hours. Additional data from well-designed investigations are needed for further assessment of the factors influencing prolonged ICU stay after cardiac surgery

Echocardiographic Findings in Thalassemia Major: A Case Report and Literature Review

We introduce a 28-year-old woman with Thalassemia major whose clinical assessment, including two-dimensional Doppler echocardiography demonstrated severe left ventricular hypertrophy with severe biventricular enlargement and systolic dysfunction as well as severe diastolic dysfunction. We hereby address these issues from an echocardiographic point of view