Hemodynamic Complications Research Articles

Implementing a pediatric robotic surgery program: future perspectives.

The minimally invasive approach using robotic technology is fully incorporated in the treatment of adult pathologies. The first international pediatric studies with a robotic approach date from 2002, and in Spain, from 2009. We present the implementation of a Pediatric Robotic Surgery program in our setting. A proposal for the application of robotic technology in pediatrics was developed, and after the acquisition of a Da Vinci Xi system at our center, a program was initiated under the guidance of a pediatric surgeon experienced in this approach. 732 patients with a median age of 12 years (7 months-17 years) have been operated on since January 2019. 56% of the procedures were abdominal. 3 thoracic approaches and 11 urologic procedures were carried out. 1 conversion to open surgery was performed during a fundoplication. The median combined duration of abdominal and thoracic approaches was 155 minutes (70-380 minutes). There were no anesthetic or hemodynamic complications. The postoperative period in the cases in which the procedure was completed was uneventful, and patients were discharged after a median of 2 days (1-16 days). The main advantage of robotic procedures is the symmetrical movement in line with the surgeon's hands, which makes the learning curve shorter. In our experience, the robotic approach has allowed for greater precision in the surgical technique, favoring the patient's recovery.

Management of congenital heart disease in the peripartum period: An illustrative case series

More women with complex congenital heart disease (CHD) reach adulthood resulting in a cohort of patients who are at high risk for adverse events during pregnancy. The haemodynamic changes usual to pregnancy may be poorly tolerated in patients with poor systemic ventricular function, cyanosis, left-sided obstructive lesions and pulmonary hypertension. Complex CHD patients are best managed by a multi-disciplinary team at a high-risk centre. Pre-conception counselling aims at risk stratifying by means of a clinical evaluation, electrocardiogram and echocardiography. Echocardiography plays a vital role in delineating the initial lesions and residual lesions with its haemodynamic complications. The modified WHO (mWHO) classification provides a helpful tool to stratify anatomical and physiological lesions by maternal and foetal event rates and is recommended by the European Society of Cardiology (ESC). Patients with cyanosis, severe aortopathy and severe pulmonary hypertension fall into Class IV and termination of pregnancy is advised. Patients may however choose to continue their pregnancy. We present 3 such cases of complex CHD (Fontan circulation, severe aortopathy and severe pulmonary hypertension) and illustrate some pertinent management principles in the peripartum period.

Rectal Dieulafoy's lesion: a comprehensive review of patient characteristics, presentation patterns, diagnosis, management, and clinical outcomes.

Dieulafoy's lesion is an abnormally large, tortuous, submucosal vessel that erodes the overlying mucosa, without primary ulceration or erosion. Although these lesions predominantly involve the stomach and upper small intestine, they are being detected with increasing frequency in the rectum. We conducted a systematic literature search of MEDLINE, Cochrane, Embase, and Scopus databases for adult rectal Dieulafoy's lesion. After careful review of the search results, a total of 101 cases were identified. The data on patient characteristics, clinical features, colonoscopy findings, diagnosis, treatment, and clinical outcomes were collected and analyzed. The mean age of presentation was 66±17 years (range, 18-94 years), with 54% of cases reported in males. Clinical presentation was dominated by acute lower gastrointestinal bleeding in the form of bright-red blood per rectum 47% and hematochezia 36%, whereas 16% of patients were admitted with symptoms related to other medical conditions. Major underlying disorders were hypertension 29%, diabetes mellitus 21%, and chronic kidney disease 16%. The average number of colonoscopies required for the diagnosis of rectal Dieulafoy's lesion was 1.5±0.7. In regard to treatment, endoscopic therapy was applied in 80%, direct surgical suturing in 12%, angiographic embolization in 4%, and endoscopic therapy followed by surgical ligation was performed in 4% of patients. The endoscopic treatment was a feasible choice for rectal disease, with a primary hemostasis rate of 88%. Although the overall mortality rate was 6%, the causes of death were unrelated to this entity. This review illustrates that patients with rectal Dieulafoy's lesion can have a favorable clinical outcome. Prompt diagnosis and appropriate management are of paramount importance to prevent serious hemodynamic complications. The best therapeutic modality remains to be determined but the data presented here support the use of mechanical endoscopic methods as safe and effective.

Comparison of spinal anaesthesia with isobaric chloroprocaine and general anaesthesia for short duration ambulatory urological procedures.

Background and Aims:Chloroprocaine is a short-acting local anaesthetic agent for spinal anaesthesia (SA) that has been used in day care surgeries due to its faster recovery characteristics and faster discharge rates compared to other local anaesthetics. This study aimed at finding out its efficacy for the same as compared to general anaesthesia (GA).Material and Methods:This observational study was conducted on 60 patients belonging to the American Society of Anaesthesiologists (ASA) physical status I and II who underwent short elective urological procedures (<60 min) under GA (group GA) as per standard of care in our hospital (n = 30) and SA (group SA) with 50 mg 1% isobaric 2-Chloroprocaine (n = 30). Time taken to meet the discharge criteria, modified Aldrete score and modified post anaesthesia discharge score in each group were noted. The cost of the anaesthetic procedure, anaesthetic procedural time, hemodynamics, supplemental analgesia, complications related to the procedure were noted and compared.Results:Patient characteristics and duration of surgery were comparable. Time taken by group SA was significantly higher than group GA to meet the discharge criteria. Cost of GA [2624.76 (166.16) units] was significantly more than SA [1561.63 (81.32) units, P < 0.05]. There was no requirement of supplemental analgesia in group SA and no hemodynamic instability or complications in either group.Conclusion:GA is significantly better as compared to SA with 50 mg 1% isobaric 2-Chloroprocaine as an anesthetic technique in day care urology surgeries in terms of faster recovery and faster discharge rate but is costlier.

Conservative treatment of acute limb ischemia in a child - case report

Acute limb ischemia is a rare event in the pediatric population, with an estimated incidence of 26 per 100,000 admissions, the majority of which are associated with trauma or iatrogeny. The ideal treatment for these cases is not well-established in the literature, although there is a tendency to choose noninvasive treatment. We report the case of an infant who suffered ischemia to all four limbs secondary to hemodynamic complications after complex heart surgery and in whom significant tissue preservation was achieved with conservative treatment.

Tratamento conservador de isquemia aguda de extremidades em lactente - relato de caso

Abstract Acute limb ischemia is a rare event in the pediatric population, with an estimated incidence of 26 per 100,000 admissions, the majority of which are associated with trauma or iatrogeny. The ideal treatment for these cases is not well-established in the literature, although there is a tendency to choose noninvasive treatment. We report the case of an infant who suffered ischemia to all four limbs secondary to hemodynamic complications after complex heart surgery and in whom significant tissue preservation was achieved with conservative treatment.

Outcome of Monochorionic Monoamniotic Twin Reversed Arterial Perfusion Sequence Diagnosed in the First Trimester

Introduction: The aim of this study is to evaluate the outcome of pregnancies complicated by monochorionic monoamniotic twin reversed arterial perfusion sequence (MOMA TRAP) diagnosed in the first trimester. Methods: All patients diagnosed with MOMA TRAP sequence <14.0 weeks of gestation in a 10-year study period were retrospectively analyzed for intrauterine course and outcome. All patients were offered either expectant management or intrauterine intervention. Adverse outcome was defined as either intrauterine death (IUD), neonatal death or preterm birth <34.0 weeks of gestation. Results: In the study period, 17 cases with MOMA TRAP sequence were diagnosed. Of these, 2 couples opted for termination of pregnancy. The remaining 15 were divided into 2 groups depending on the management: group A (n = 8) with expectant management and group B (n = 7) with intrauterine intervention. All fetuses in group A died before 20 weeks. Survival in group B was significantly better with 4/7 (57.1%) life births at a median of 39.6 weeks of gestation (p = 0.0256). The reasons for IUD in the 3 cases in group B were hemodynamic, strangulation, and bleeding complications during intervention. Conclusions: Intrauterine intervention in MOMA TRAP pregnancies significantly improves neonatal survival, although it is still associated with a substantial risk for IUD by hemodynamic complications or entanglement.

509 A biochemical approach to atrial fibrillation in older patients

Abstract Aims Atrial fibrillation (AF) is the most common arrhythmia among the elderly. It is characterized by a disordered electrical activity of the atria and is associated with increased morbidity and mortality. The pathogenesis of AF is not completely understood as it depends on a multifactorial combination of electrical and structural remodelling and inflammation. Metabolomics is the study of the small molecules present in a given biological sample and it has been widely used to determine the metabolic signatures of certain diseases. Untargeted metabolomics consists of a comprehensive screening of all measurable metabolites to identify patterns related to a certain disease, while targeted metabolomics aims at analysing a defined group of metabolites belonging to a specific metabolic pathway or class of compounds. Mass spectrometry (MS), coupled with gas chromatography (GC) and liquid chromatography (LC) offers the possibility of performing quantitative analyses with high selectivity and sensitivity. Aims of this project were to understand the biomolecular mechanisms underlying the onset of AF. Methods We compared plasma samples of older patients with AF with those of healthy subjects. We started from untargeted metabolomics to explore the whole metabolome; then we focused on the lipidomic profile, and, finally, we measured the plasma concentration of acylcarnitines and some amino acids, known to be diagnostic markers of certain metabolic diseases. Fifty patients (age: 76 ± 6 years) and 26 healthy subjects (age: 65 ±19 years) were recruited for the study. A blood sample was drawn by each patient. Samples for metabolomics and lipidomics were processed, respectively, with a GC-MS platform and with high-resolution LC-MS. Results Differences in diseased and healthy metabolomic and lipidomic profiles were not detected, while the concentration of some acylcarnitines and amino acids resulted to be significantly different in the two groups. In particular, two long-chain acylcarnitines (LCACs), C14 and C18:1, were more abundant in the plasma of AF patients, while glycine, which has scavenger properties, had a lower concentration. High levels of circulating LCACs have been associated with cardiovascular diseases and they are known to alter the heart electrophysiology, thus representing a possible marker of the development of arrhythmias. We can hypothesize that the different concentrations we found possibly reflect a higher oxidative and metabolic stress induced by the arrhythmia. Conclusions The alterations of the LCACs we found in AF patients could represent the basis to guide specific therapeutic interventions aimed at reducing the incidence of the hemodynamic and embolic complications of the arrhythmia. In particular, recent guidelines for the management of AF patients introduced the acronym ABC, which means ‘Avoid stroke’—A, ‘Better symptoms management’—B, and ‘Cardiovascular risk and comorbidity management’—C. In this sense, the present research represents an attempt to join and enrich the traditional clinical approach with data derived from laboratory activity, to improve the outcome of the oldest segment of cardiac patients, often presenting rhythm alterations.

Role of endotracheal tube size on nasal and laryngeal morbidity during awake fiberoptic nasotracheal intubation: A Randomized controlled trial.

Background and Aims:Awake fibreoptic nasotracheal intubation is associated with adverse airway and hemodynamic complications. The aim of this study was to evaluate the role of endotracheal tube size on nasal and laryngeal morbidity during awake fibreoptic-guided nasotracheal intubation.Material and Methods:Eighty patients recruited to undergo awake fibreoptic intubation were randomly allocated to Group C (standard size endotracheal tube) and Group S (small size endotracheal tube followed by exchange to standard size using Airway Exchange Catheter under general anesthesia). Nasal morbidity was assessed by incidence of epistaxis, olfactory acuity, and mucociliary clearance. Patient discomfort during intubation was assessed using grimace score and hemodynamic parameters were recorded. Postoperatively, the incidence of nasal and laryngeal injury was recorded using nasendoscopy and telelaryngoscopy, respectively.Results:Demographic profile between the two groups was comparable. Epistaxis was noted in 47.5% of patients in group C as compared to 12.5% in group S. Postoperative olfactory acuity was decreased [2 (1-4) vs 4 (2-5)] and saccharin clearance time was prolonged (314 s vs 134 s) in Group C as compared to Group S. (P-value <0.001) Higher grimace score [2 (1-3) vs 1 (0-2)] and increased hemodynamic response was demonstrated in Group C. (P-value <0.001) Incidence of nasal injury [2 (1-4) vs 1 (0-2)] and laryngeal injury [1 (0-2) vs 0 (0-2)] was more in Group C as compared to Group S.Conclusion:Awake fibreoptic nasotracheal intubation with small size endotracheal tube followed by exchange to standard size under general anesthesia reduces nasal, laryngeal, and hemodynamic complications.

Rapid Ventricular Pacing as a Safe Procedure for Clipping of Complex Ruptured and Unruptured Intracranial Aneurysms.

Surgical treatment of intracranial aneurysm requires advanced technologies to achieve optimal results. Recently, rapid ventricular pacing (RVP) has been described to be an elegant technique that facilitates clip reconstruction of complex unruptured intracranial aneurysm (uIA). However, there is also a growing need for intraoperative tools to ensure safe clip reconstruction of complex ruptured intracranial aneurysm (rIA). We conducted a retrospective analysis of 17 patients who underwent RVP during surgical reconstruction of complex aneurysms. Nine patients had uIA while eight patients underwent surgery for rIA suffering from consecutive subarachnoid hemorrhage (SAH). Hemodynamic data, critical events, laboratory results, and anesthesia-related complications were evaluated. No complications were reported concerning anesthesia induction and induction times were similar between patients exhibiting uIA or rIA (p = 0.08). RVP induced a significant decline of median arterial pressure (MAP) in both groups (p < 0.0001). However, median MAP before and after RVP was not different in both groups (uIA group: p = 0.27; rIA group: p = 0.18). Furthermore, high-sensitive Troponin T (hsTnT) levels were not increased after RVP in any group. One patient in the rIA group exhibited ventricular fibrillation and required cardiopulmonary resuscitation, but has presented with cardiac arrest due to SAH. Otherwise, no arrhythmias or complications occurred. In summary, our data suggest RVP to be feasible in surgery for ruptured intracranial aneurysms.

Effectiveness and safety of intravenous dexmedetomidine sedation for ophthalmic surgery under regional anesthesia.

To assess the effectiveness and safety of intravenous (IV) dexmedetomidine for sedation in ophthalmic surgery. Prospective, observational, uncontrolled, single-center study. Patients were sedated with a continuous dexmedetomidine IV infusion started 15 min before regional anesthesia administration and maintained up to the end of surgery. Effectiveness of dexmedetomidine was assessed by the Modified Observer's Assessment of Alertness and Sedation (MOAA/S) targeted at 5. Safety was assessed by the incidence of patients' movements/snoring and by the incidence of respiratory and haemodynamic complications. An eleven-point numerical rating scale (NRS) was used to assess the level of satisfaction of both the surgeon and the patient. 123 patients (73 males, mean age: 63 ± 13) were included; 81 (81/123; 65.8%) patients reached the requested MOAA/S score of 5. Any intraoperative movement - mostly voluntary - occurred in 34 (34/123; 27.6%) cases with no need for a switch to general anaesthesia; no ocular complications related to the intraoperative movements occurred. Intraoperative snoring occurred in 30 (30/123; 24.4%) patients and it did not affect the surgical manoeuvres. Respiratory drive depression requiring manual or mechanical ventilation never occurred. Bradycardia occurred in 14 (14/123; 11.3%), cases but only 4 (4/123; 3.2%) patients required atropine administration, which was always effective. Intraoperative analgesia was consistently obtained and both the surgeons and the patients reported a high NRS satisfaction score. Dexmedetomidine provided adequate sedation in patients undergoing ocular surgery under local anaesthesia and showed a good effectiveness and safety profile. Upper airway obstruction, apnoea and snoring can occur.

Evaluation and Management of Sternoclavicular Dislocation in the Emergency Department.

Sternoclavicular dislocation (SCD) is a rare injury but can result in hemodynamic and neurovascular complications. Emergency clinicians play an integral role in the evaluation and management of these injuries. This article provides a narrative review of the diagnosis and management of SCD for the emergency clinician. SCD is an infrequent injury and may be misdiagnosed in the emergency department (ED). SCDs may be anterior or posterior. Although anterior SCD is more common, posterior SCD is more dangerous with a risk of pneumothorax or injury to the subclavian artery or vein, esophagus, trachea, or brachial plexus. Most patients present with shoulder and clavicular pain and decreased active range of motion. Clinicians should assess the sternoclavicular joint in patients with shoulder symptoms and consider SCD in traumatic shoulder injuries. Plain radiographs might not identify SCD, and computed tomography is recommended for both the diagnosis of SCD and evaluation of complications. Anterior SCD can be managed in the ED with analgesia, sedation, and closed reduction. If patients with posterior SCDs display airway, hemodynamic, or vascular compromise, emergent reduction is recommended with cardiothoracic consultation. Any complicated anterior SCD, including those with fracture, and all posterior SCDs require emergent orthopedic consultation, with considerations for cardiothoracic or vascular surgery notification. SCD is an uncommon orthopedic injury but may result in patient morbidity or mortality. Knowledge of SCDs can optimize emergency clinician evaluation and management of this condition.

Impact of Opioid-free Anesthesia After Video-assisted Thoracic Surgery: A Propensity Score Study

BackgroundAdequate postoperative morphine consumption and pain management after thoracic surgery are major issues in the prevention of respiratory complications. Opioid-free anesthesia (OFA) may decrease morphine consumption and postoperative pain. The objective of this study was to evaluate the impact of OFA on the consumption of morphine and pain after video-assisted thoracic surgery or robotic-assisted thoracic surgery. MethodsThe main objective of this retrospective study with propensity score analysis (PSA) was to compare the cumulative postoperative morphine consumption at 48 hours between an OFA group receiving dexmedetomidine, lidocaine, and ketamine; and an opioid anesthesia (OA) group receiving remifentanil plus morphine. Postoperative pain at 24 and 48 hours and respiratory and hemodynamics complications were also assessed. ResultsEighty-one patients were included, 48 in the OFA group and 33 in the OA group. The cumulative postoperative morphine consumption at 48 hours was lower in the OFA group than in the OA group (28.5 mg [0 to 62.25 mg] vs 55 mg [34 to 79.5 mg], P = .002, with PSA; OFA −27.67 mg [−46 mg to −11.5 mg], P = .002). The postoperative pain score was significantly lower in the OFA group compared with the OA group at 24 hours (2 [0 to 4] vs 3 [2 to 5], P = .064, with PSA; OFA −1.40 [−2.47 to −0.33], P = .0088) and 48 hours (0 [0 to 3] vs 2.5 [0 to 5], P = .034, with PSA; OFA −1.87 [−3.45 to −0.28], P = .021). There were no differences between groups concerning respiratory or hemodynamic complications. ConclusionsOur results suggest that OFA after video-assisted thoracic surgery or robotic-assisted thoracic surgery is safe and is associated with less postoperative morphine cumulative consumption and pain at 48 hours.

Activated platelets in central venous catheters: a flow cytometry and numerical simulation approach

The central venous catheter that is inserted in patients undergoing hemodialysis can cause hemodynamic instability and trigger complications such as thrombus formation. The objective of this study was to investigate hemostatic and numerical influences on thrombus formation in patients undergoing hemodialysis with a central venous catheter. Participants were assigned to three groups: I: clinical and laboratorial healthy individuals matched by sex and age (controls); II: participants after one month of insertion of the catheter and III: participants after 4 months of insertion of the catheter. Platelet activation was investigated by GPIIb/IIIa and p-selectin expressions using flow cytometry. A three-dimensional model of the catheter was constructed in the numerical simulation for the calculation of partial differential equation of a platelet activation model. A significant difference was detected by the expression of p-selectin comparing the group I (33.42 ± 4.74), group II (40.79 ± 5.54) and group III(51.00 ± 7.21) (p &lt; 0.0001). The median values for GPIIb/IIIa were 10426 (10029-10721), 13921 (13412-15652) and 19946 (18714-21815) after catheter insertion (p &lt; 0.0001), for groups I, II and III, respectively. Excluding the first arterial orifice, venous orifices tend to have greater platelet activation when compared to the other arterial orifices. The results of this study showed the influence of arterial and venous lateral orifices in stimulating the development of thrombi associated with the activation of platelet markers the longer the catheter was used

Complications of epi- and endocardial pacing in children

Abstract Aim To analyze complications of cardiac pacing in children depending on the implantation method. Actuality Recently epicardial lead implantation becomes more and more popular either due to more serious complications of transvenous pacing or due to possibility of choice of hemodynamically optimal pacing zone. Methods and materials 242 patients with pacemakers are under our supervision. Epicardial pacemakers were implanted to 145 patients, endocardial – to 97 patients. In “old era” in most children the primary epicardial implantations were performed at RV free wall. In 27 children, having primary implantation at our Institute lately, the epicardial lead was placed at LV apex, or endocardial – at RV apex. Results The comparative analysis of complications of epi- and endocardial implantation showed the following results: 22% of complications at epicardial stimulation, and at transvenous stimulation – 45%. The most often complications at epicardial stimulation (53%) were connected with hemodynamic disorders – dyssinchronous cardiomyopathy. Hemodynamic complications, connected with dyssinchrony of endocardial RV pacing, were disclosed in 16%. The most often complication of endocardial stimulation was TV insufficiency (32%). Venous vessel thrombosis was diagnosed in 9%. Epicardial and transvenous lead failure was discovered in similar percentage ratio (28%). Infectious complications of transvenous pacing, especially, bacterial endocarditis, took place in 6,8%. Thus, progressive bacterial endocarditis and TV insufficiency (3d deg.) appeared in one patient in 10 years after the primary implantation. Afterwards, elimination of endocardial system by open surgery, TV plasty followed by epicardial pacing implantation are required. Infection of pacing site was disclosed in both types of implantation (1%). Perforation of atrial endocardial lead was found in two cases (4%). A case of mechanical complication (cardiac strangulation) was diagnosed in a child (3%) in four years after the primary implantation of epicardial pacing system. Pericarditis was recorded immediately after the epicardil pacemaker implantation in 9% of cases. Our center performs epicardial lead implantation with the help of midline sternotomy that provides clear approach to right atrium. However, the difficulties of lead fixation at LV apex appear here. It concerns, especially, the patients after CHD correction as the repeated sternotomy in them presents high risk of RV insufficiency. Nevertheless, the given approach is still the best possible with epicardial pacing if there is a “preclude”, sufficient experience of CHD correction. Conclusion The possibility of choice of optimal epicardial pacing site exceeds risks of leads and midline sternotomy. Any primary pacemaker implantation in children of any age with ventricular lead should be epicardial. Funding Acknowledgement Type of funding sources: None.

Effect of genetic polymorphisms and haplotypes on the efficacy and safety of postoperative analgesia with ketoprofen in patients with coronary artery disease after cardiac surgery

Abstract Background Most cardiac surgeries are associated with post-sternotomy pain syndrome. Pain causes elevation of blood pressure, heart rate and may be associated with hemodynamic instability, respiratory infections, and other postoperative complications. Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most commonly used analgesics in cardiac surgery. The majority of NSAIDs are metabolized by cytochrome P-450. The mechanism of action of NSAIDs is associated with blocking of prostaglandin-endoperoxide synthase (PTGS). Individual variabilities and gene polymorphisms may affect ketoprofen exposure, efficacy and safety. Purpose Evaluation of the influence of CYP2C9 - CYP2D6 and PTGS-2 rs20417 – PTGS-1 rs12353214 haplotypes on the efficacy and safety of postoperative analgesia with ketoprofen in patients with coronary artery disease after cardiac surgery. Methods The study included 90 patients. Pain intensity assessment was measured by the Numeric Rating Scale (NRS). Dyspeptic symptoms were evaluated using the Gastrointestinal Symptom Rating Scale (GSRS). Acute kidney injury was determined by Kidney Disease Improving Global Outcomes criteria. Genotyping of polymorphisms CYP2C9*3 (1075A&amp;gt;C) rs1057910, CYP2D6*4 (1846G&amp;gt;A) rs3892097, PTGS-2 (G&amp;gt;C) rs20417, PTGS-1 (C&amp;gt;T) rs12353214 was performed. Results The study revealed the following haplotypes: (1) CYP2C9*3 rs1057910 (AA) – CYP2D6*4 rs3892097 (GG), (2) CYP2C9*3 rs1057910 (AC) – CYP2D6*4 rs3892097 (GA), (3) PTGS-2 rs20417 (GG) – PTGS-1 rs12353214 (CT), (4) PTGS-2 rs20417 (CC) – PTGS-1 rs12353214 (CC). Pain intensity by the NRS score was significantly higher in patients with AA-GG haplotype compared to AC-GA haplotype for CYP2C9*3 - CYP2D6*4: 7,13±2,14 and 5±1,52 (p=0,009); 7,06±1,99 and 4,86±1,57 (p=0,007); 4,96±1,83 and 3,29±1,79 (p=0,04); 4,57±1,66 and 2,86±1,57 (p=0,02), on days 1, 2, 3 and 5 in the postoperative period, respectively. There were no significant differences in pain intensity by the NRS in patients with PTGS-2 rs20417 – PTGS-1 rs12353214 haplotypes. Also there were no significant differences in GSRS score and acute kidney injury frequency in patients with AA-GG and AC-GA haplotypes for CYP2C9*3 – CYP2D6*4 and GG-CT and CC-CC haplotypes for PTGS-2 rs20417 – PTGS-1 rs12353214. Conclusion CYP2C9*3 - CYP2D6*4 haplotypes affect efficacy of postoperative analgesia with ketoprofen in patients with coronary artery disease after cardiac surgery. Further studies are needed to develop genotype-guided postoperative pain management. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This study was financially supported by RF President's grant for scientific schools, project No. NSh 2698.2020.7 Pain intensity by NRSDyspepsia symptoms by GSRS

Outcomes of Radial Versus Femoral Approach in Patients with St Segment Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention

Abstract Aim of the work To compare transradial and transfemoral approaches in 1ry and rescue PCI for STEMI. Methods This prospective observational study was done at Alexandria University Hospital and International Cardiac Center from January 2020 to August 2020 by recruiting every patient had met our inclusion criteria (the third universal definition of MI) admitted to the coronary care unit after doing primary or rescue PCI 200 patients were involved. Exclusion criteria were (Thrombophilia and thrombocytopenia, known hematological abnormalities, and patients with known sever peripheral vascular disease. Randomization made by a computer-generated program into two equal parallel groups that were randomly assigned to either Radial access approach or femoral access approach for primary or rescue PCI. Chest pain to time of first medical contact (FMC), and the procedural time were computed. Coronary angiography and PCI procedure were described including materials used and the intra-procedure complications. MACE (Major Adverse Cardiac Events) or other hemodynamic complications were documented. All the patients were contacted for follow up to 6 months after the procedure by interviewing with the patients via telephone or the responsible physician to determine the outcomes procedure. Results The distribution of demographic variables and risk factors were similar among 200 patients in the radial and femoral groups. There had been significant differences between the groups concerning the primary end point MACE after 6 months in favor of radial group patients with p value (0.004), there was significant deference between the two studied groups concerning the total bleeding complication with higher risk in femoral group 11% compared to radial group 3% with P value (0.02). Despite the nearly equal mean time from pain to FMC (9.01 hours in radial group and 9.2 hours in femoral group), the total procedural time was significantly longer in radial group compared to femoral group with (p value 0.037). However the rate of non-culprit vessel revascularsation was significantly higher in radial group 17% compared to 6% in femoral group with p value of (0.015). In-hospital stay was significantly shorter in the radial group patients P value (0.02). Conclusion Transradial approach is safe, and effective with a high procedural success rate as the transfemoral approach but with lower risk for bleeding vascular complications and other access site complications as hematoma especially for patients where aggressive antiplatelet and anticoagulation therapy is needed, or patients who are expected to suffer from access site complications as those who need rescue PCI. Transradial approach has major additional advantages of decreasing the incidence of MACE compared to transfemoral approach. Transradial approach has another advantages of decreasing the in hospital stay.

COMPARISON OF HEMODYNAMIC STATUS AND COMPLICATIONS BETWEEN TWO DIFFERENT DOSES OF INTRAMYOMETRIAL VASOPRESSIN DURING LAPAROSCOPIC MYOMECTOMY: A RETROSPECTIVE STUDY, THE LESSER THE BETTER

Objective: Our aim is comparison of hemodynamic status and complications between two different doses of intramyometrial vasopressin during laparoscopic myomectomy. Methods: We did a retrospective analysis of hemodynamic status and its anesthetic concerns in patients who received two different doses of intramyometrial vasopressin. Eighty patients undergoing laparoscopic myomectomy under general anesthesia were divided into two groups of 40 patients in each group. In Group A (n=40), 10 units of intramyometrial vasopressin in 200 ml of normal saline were given and, in Group B, 20 units of intramyometrial vasopressin in 200 ml of NS were given intraoperatively by surgeon. Results: 20 units intramyometrial vasopressin used dogmatically by surgeons drops blood loss but it is connected with cardiovascular impediments. Hence, 10 units of intramyometrial vasopressin as compared to 20 units which are used by some surgeons are associated with similar blood loss and lesser side effects such as bradycardia, pulmonary edema, hypotension, blood loss, and increased airway pressure. Conclusion: Hence, anesthesiologists and gynecologists must take the precautions to escape and minimize the frequency of impediments with intramyometrial vasopressin by selecting the appropriate dosage of vasopressin.

Outcomes of Excision of Parasagittal Meningiomas

Background: Meningiomas that have any relation to the superior sagittal sinus are called parasagittal meningiomas. They have an insidious onset and grow gradually and can reach a large size without any manifestations. The surgical management of these tumors is still controversial whether to excise the tumor completely with risks of cerebral infarction and massive brain edema or to excise it gradually with lifting some tumor remains with the risk of tumor recurrence. Objective: To report our experience with the surgically managed parasagittal meningiomas with analysis of factors that influence the patients’ outcome and reporting the complications including tumor recurrence. Patient and method: A retrospective study was applied on 27 patients (17 females and 10 males) with parasagittal meningiomas in Sohag District between September 2015 and September 2018 with a mean age of 53.5 ± 2 years. Preoperative and postoperative data were collected and analyzed. Results: Out of 27 patients, in 14 of them the sinus was patent, in 9 the sinus was partially occluded, and 4 patients had complete sinus occlusion. The sinus was ligated and excised with the tumor in 11 patients, of those eleven patients, four had venous infarction and three had postoperative massive brain edema. The second group included 16 patients at which, residuals of tumors were left behind with the sinus. Remote follow-up of this group show recurrence in 3 patients. Conclusion: The outcome of radical resection is favorable whenever possible as the main limiting factor for achieving gross total resection is sinus involvement. However complete excision is crucial to prevent recurrence and many factors share in the success of the surgery. However, the sinus invaded meningiomas should be cautiously managed to prevent postoperative hemodynamic complications.

THE INFLUENCE OF CLINICAL AND LABORATORY FACTORS ON THE DEVELOPMENT OF HEMODYNAMIC COMPLICATIONS DURING ANESTHESIA IN CARDIAC SURGERY

Background. Currently, cardioanesthesiology is one of the most actively developing areas of modern medicine. Thanks to new methods of treatment, the contingent of patients for whom it became possible to undergo cardiac surgery has significantly expanded. The main problems that lead to hemodynamic complications are endothelial dysfunction and cellular hypoxia. Purpose. To present data on the influence of clinical and laboratory factors of endothelial dysfunction and cellular hypoxia on the development of hemodynamic complications during anesthesia in cardiac surgery. Material and methods. The review and analysis of literature data from 49 sources is presented. Results. The laboratory markers of endothelial dysfunction leading to the development of major hemodynamic complications in cardiovascular diseases are MPC-1, CRP, NO, TNF-α, IL-6, homocysteine. Conclusion. The data obtained indicate a significant effect of cell markers (MPC-1, CRP, NO, TNF-A, IL-6, homocysteine) as well as clinical and laboratory factors of endothelial dysfunction not only on the development of major diseases of the cardiovascular system, but also on their complications. An early study of these markers can improve anesthesia during cardiac surgery as well as reduce complications in the postoperative period.