Preoperative Heart Rate Research Articles

Predictors of the need for pacemaker implantation after the Cox maze IV procedure for atrial fibrillation.

The Cox maze IV (CMIV) procedure is being used increasingly frequently for surgical ablation of atrial fibrillation (AF). This study aimed to identify the risk factors of the need for postoperative pacemaker implantation (PMI) after CMIV. Preoperative, intraoperative, and postoperative data were retrospectively collected from 67 consecutive patients who underwent CMIV at our institution; 7 (10.4%) required PMI (as a treatment of brady AF or sick sinus syndrome). Patients who needed PMI tended to have lower preoperative heart rates than those who did not on a 12-lead electrocardiogram (ECG; 68.7 ± 11.6 vs. 79.1 ± 18.5bpm, p = 0.07) and a 24-h ECG (94,772 ± 9800 vs. 109,854 ± 19,078beats/day, p = 0.03). A multivariate analysis identified a low amplitude of the fibrillatory wave on preoperative ECG as a risk factor of PMI necessity after CMIV [odds ratio = 14.7; 95% confidence interval (CI) 1.9-324.7; p = 0.007] and internal use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACEIs/ARBs) as a negative risk factor (odds ratio = 0.16; 95% CI 0.02-0.99; p = 0.049). A low amplitude of the fibrillatory wave was identified as a risk factor of PMI necessity, whereas the internal use of ACEIs/ARBs diminished the need for PMI. These factors should be considered before CMIV is performed.

Obstetric spinal hypotension: Preoperative risk factors and the development of a preliminary risk score - the PRAM score.

Obstetric spinal hypotension is a common and important problem during caesarean delivery. Identifying patients at risk for hypotension may guide clinical decision-making and allow timeous referral. Using preoperative risk factors, to develop a simple scoring system to predict systolic hypotension. This prospective, single-centre, observational study of patients undergoing elective or urgent caesarean delivery assessed body mass index, baseline heart rate, baseline mean arterial pressure (MAP), maternal age, urgency of surgery (elective v. non-elective) and preoperative haemoglobin concentration as predictors of spinal hypotension (systolic blood pressure <90 mmHg). We used empirical cut-point estimations in a logistic regression model to develop a scoring system for prediction of hypotension. From 504 eligible patients, preoperative heart rate (odds ratio (OR) 1.02, 95% confidence interval (CI) 1.00 - 1.03; p=0.012), preoperative MAP (OR 0.97, 95% CI 0.95 - 0.98; p<0.001) and maternal age (OR 1.05, 95% CI 1.02 - 1.08; p=0.002) were found to be predictors of hypotension. We derived a preliminary scoring system (pulse rate >90 bpm, age >25 years, MAP <90 mmHg - the PRAM score) for the prediction of systolic hypotension following obstetric spinal anaesthesia. Patients with three factors had a 53% chance of developing hypotension, compared with the overall incidence of 30%. The PRAM score showed good discrimination, with a c-statistic of 0.626 (95% CI 0.576 - 0.676) and good calibration. Preoperative heart rate, preoperative MAP and maternal age were predictive of hypotension in elective and emergency caesarean delivery. The PRAM score shows promise as a simple, practical means to identify these patients preoperatively, but requires prospective validation.

Late outcome of surgical radiofrequency ablation for persistent valvular atrial fibrillation in China: a single-center study

BackgroundAtrial fibrillation (AF) adversely affects surgical outcomes of cardiac valve surgery. Surgical ablation is an effective way to treat valvular AF. The aim of this study was to evaluate the late outcome of surgical radiofrequency ablation and explore the risk factors of AF recurrence in Chinese patients undergoing cardiac valve surgery.MethodsThree hundred ninety six consecutive patients with persistent valvular AF were enrolled in this study. They underwent concomitant modified Maze IV and were completed follow-ups. Cox survival regression model was used to screen independent risk factors for predicting late recurrence of AF.ResultsDuring the follow-up period of 28 (6 ~ 61) months, AF recurred in 151 patients (38.1%). In multivariate survival regression, factors predictive of AF late recurrence were AF duration, pre-operative serum B-type natriuretic peptide (BNP), pre-operative heart rate and left atrial diameter (LAD), post-operative atrial tachyarrhythmias and AF at discharge. According to receiver operating characteristic curve analysis, the best cutoff values for AF duration, BNP, heart rate and LAD were 66.5 months, 251 pg/ml, 82 beats/min and 67.9 mm, respectively.ConclusionsLonger AF duration, larger LAD, higher BNP level and lower heart rate indicated a poor late outcome of surgical radiofrequency ablation in persistent AF patients undergoing cardiac valve surgery. Therefore, indication to radiofrequency ablation should be carefully considered in these patients.

Elevated preoperative heart rate is associated with cardiopulmonary and autonomic impairment in high-risk surgical patients

BackgroundElevated preoperative heart rate (HR) is associated with perioperative myocardial injury and death. In apparently healthy individuals, high resting HR is associated with development of cardiac failure. Given that patients with overt cardiac failure have poor perioperative outcomes, we hypothesized that subclinical cardiac failure, identified by cardiopulmonary exercise testing, was associated with elevated preoperative HR > 87 beats min−1 (HR > 87). MethodsThis was a secondary analysis of an observational cohort study of surgical patients aged ≥45 yr. The exposure of interest was HR > 87, recorded at rest before preoperative cardiopulmonary exercise testing. The predefined outcome measures were the following established predictors of mortality in patients with overt cardiac failure in the general population: ventilatory equivalent for carbon dioxide ( V˙E/V˙co2) ratio ≥34, heart rate recovery ≤6 and peak oxygen uptake ( V˙o2) ≤14 ml kg−1 min−1. We used logistic regression analysis to test for association between HR > 87 and markers of cardiac failure. We also examined the relationship between HR > 87 and preoperative left ventricular stroke volume in a separate cohort of patients. ResultsHR > 87 was present in 399/1250 (32%) patients, of whom 438/1250 (35%) had V˙E/V˙co2 ratio ≥34, 200/1250 (16%) had heart rate recovery ≤6, and 396/1250 (32%) had peak V˙o2 ≤14 ml kg−1 min−1. HR > 87 was independently associated with peak V˙o2 ≤14 ml kg−1 min−1 {odds ratio (OR) 1.69 [1.12–3.55]; P=0.01} and heart rate recovery ≤6 (OR 2.02 [1.30–3.14]; P<0.01). However, HR > 87 was not associated with V˙E/V˙co2 ratio ≥34 (OR 1.31 [0.92–1.87]; P=0.14). In a separate cohort, HR > 87 (33/181; 18.5%) was associated with impaired preoperative stroke volume (OR 3.21 [1.26–8.20]; P=0.01). ConclusionsElevated preoperative heart rate is associated with impaired cardiopulmonary performance consistent with clinically unsuspected, subclinical cardiac failure. Clinical trial registrationISRCTN88456378.

Factors influencing postoperative atrial fibrillation in patients undergoing on-pump coronary artery bypass grafting, single center experience

BackgroundThe reported incidence of AF after CABG surgery varies from 20 to 40%, with the arrhythmia usually occurring between second and fourth postoperative days. Postoperative AF after CABG was associated with greater in-hospital mortality and worse survival at long-term follow-up. Therefore, intensive attention has focused on the prevention of AF in high-risk patients. Many perioperative factors have been suggested to increase the incidence of postoperative AF after conventional CABG. In this study we are trying to examine some of these risk factors as predictors for Post-operative AF in our patients. In this study, our aim was to identify the perioperative predictors of AF in our patients who underwent Coronary Artery Bypass Grafting.MethodsOur Patients were divided into two groups; Group A included patients who did not develop PO AF (168 patients) and Group B patients who developed PO AF (84 patients). Perioperative Data, including gender, age, demographic variables and postoperative morbidity and mortality were extracted from the medical records.ResultsThis retrospective cohort study was conducted on 252 consecutive adult patients underwent CABG, in King Faisal Specialist Hospital and Research Center in Jeddah, Saudi Arabia. The mean age for patients with PO AF was 65 years (P = .0001). Eight-three patients (49.4%) were diabetics in group A and 56 patients (66.7%) in group B (P = .0001). Patients who developed POAF had a lower ejection fraction (44.8 ± 5.7%) (P = .0001), diastolic dysfunction (P = .0001), Larger Left atrial volume (P = .0001). Bleeding requiring re-opening for exploration and Postoperative shock were identified as significant predictors for POAF. Multivariate logistic regression (odds ratio, ±95% CI, P value) was performed to identify the effect of age, preoperative heart rate, ejection fraction, postoperative bleeding, Shock, ventilator time, Sensitivity was 89.5%, specificity was 94.6%, positive predictive value was 89.5%, and negative predictive value was 94.6%.ConclusionIn our study, advanced age, enlarged LA volume, low ejection fraction, combined surgeries and prolonged ventilation time were found to be predictors of atrial fibrillations after coronary artery bypass grafting.

Pre- and post-orthotopic heart transplantation electrocardiogram characteristics of 998 patients

Objective: To analyze pre- and post-operation electrocardiograms (ECGs) features of patients underwent orthotopic heart transplantation (OHT), and provide evidences for identifying and analyzing post OHT ECGs. Methods: Nine hundreds and ninty-eight pre- and post- OHT standard 12-leads ECGs from 110 consecutive patients, who underwent OHT in our hospital from May 2008 to May 2014, were analyzed. Results: The mean heart rate(HR)was (86.9±16.4) beats per minute before OHT, and (100.0±0.4) beats per minute after OHT. P wave's amplitude, duration, amplitude multiplied by duration of donor heart in lead Ⅱ were (0.124±0.069)mV, (111.1±17.2)ms, (14.34±9.51)mV·ms before OHT; (0.054±0.037)mV, (86.9±27.0)ms, (5.02±4.03)mV·ms at 1 month after OHT; (0.073±0.049)mV, (93.9±17.5) ms, (7.00±4.81)mV·ms at 6 years after OHT. ECGs rotation occurred in 83.64%(92/110) patients after OHT, and prevalence of clockwise rotation was 76.36%(84/110). Sinus tachycardia was evidenced in 99.09%(109/110) patients after OHT, and incomplete right bundle branch block was present in 60.91%(67/110) patients after OHT. Pseudo complete atrioventricular block mostly occurred at 2 days after OHT. Prevalence of double sinus rhythm was 27.95%(263/941) post OHT, 40% of them occurred between the 1st and the 2nd month post OHT; the atrial rate of recipient hearts was (104.0±10.2) beats per minucte between the 3rd and the 6th month post OHT, and was (95.3±4.2) beats per minucte between the 4th year and the 5th year. P wave's amplitude, duration, amplitude multiplied by duration of recipient heart in lead Ⅱ were (0.066±0.055) mV, (52.8±34.7) ms, (4.67±4.95) mV·ms at 1 month after OHT, (0.043±0.040)mV, (44.4±40.5) ms , (3.11±3.61) mV·ms between the 1st year and 2nd year after OHT. The absolute value of P-wave(originating from the donor heart) terminal force in chest leads increased in 48.99%(461/941) patients post OHT, the P-wave terminal force of V(1) , V(2) and V(3) were -0.044(-0.066, -0.028), -0.060(-0.087, -0.038), -0.035(-0.056, 0) mm·s. Notched P wave in chest leads was presented in 10.31%(97/941) patients post OHT. PR segment depression in chest leads occurred in 60.24%(100/166) patients between the 3rd month and the 6th month, the incidence of PR segment depression in V(1) , V(2) and V(3) was 21.04%(198/941), 37.41%(352/941) and 28.69%(270/941), respectively. Conclusions: OHT is related to significantly changed ECGs. The mean HR increased significantly after OHT, then decreased gradually after half a year to one year, but it was still higher than preoperative mean HR after five or six years; the P waves of donor heart were usually inconspicuous or small in first month after OHT, and they became bigger after 2 months, and their duration and amplitude then became relatively steady afterwards. ECGs rotation, especially the clockwise rotation, was common post OHT. A variety of arrhythmias originating from the donor heart including sinus tachycardia and incomplete right bundle branch block could be found. Pseudo complete atrioventricular block could also be found in the early phase after OHT. With the extension of time, the incidence of double sinus rhythm reduced gradually. The atrial rate and P wave of recipient heart presented with a tendency to become lower. The absolute value of P-waves(originating from the donor heart) terminal force in chest leads (mainly V(1), V(2) and V(3)) increased, notched P waves in chest leads (mainly V(1), V(2)) and PR segments depression in chest leads (mainly V(2), V(3) and V(4)) also belong to typical post OHT ECGs features.

Low pre-operative heart rate variability and complexity are associated with hypotension after anesthesia induction in major abdominal surgery.

Significant hypotension after induction of general anesthesia is common and has the potential for serious complications. This study aimed to determine if pre-operative heart rate variability (HRV) was associated with post-induction hypotension in patients undergoing major abdominal surgery. Patients undergoing semi-elective major abdominal surgery were consecutively recruited during pre-admission clinic assessment. Exclusion criteria included cardiac conduction disease, arrhythmias or severe liver or renal disease. Ten minutes of electrocardiogram at 1024Hz were recorded a median of 3 days pre-operatively. Pre-operative HRV parameters were compared in patients who experienced significant hypotension (fall in systolic and mean arterial pressure (MAP) >30% baseline and MAP ≤60mmHg) versus those who remained haemodynamically stable after induction of general anesthesia with propofol and fentanyl. Patients who experienced hypotension after general anesthesia induction had significantly lower pre-operative HRV (SDNN 16 vs. 37ms, p < 0.001), reduced spectral power (total power 262 vs. 1236 ms2, p = 0.002) and reduced correlation dimension, a measure of signal complexity (0.11 vs. 2.13, p < 0.001). Hypotension occurred relatively frequently in our cohort and was associated with a higher ASA grade (36 vs. 6% ASA 3, p = 0.036), hence post-induction hypotension and lower HRV may be associated with severity of illness or poor physiological reserve. Pre-operative HRV was a useful screening tool in identifying patients undergoing major abdominal surgery who were at risk of haemodynamic instability after anesthesia induction.

Left bundle branch block after sutureless, transcatheter, and stented biological aortic valve replacement for aortic stenosis.

Conventional aortic valve replacement (AVR), sutureless AVR (su-AVR) and transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS) are associated with conduction abnormalities. The aim of the present study was to assess the incidence of left bundle branch block (LBBB) after su-AVR and TAVI, in comparison to conventional AVR. A total of 501 patients (mean age 74±8 years, 53% male) without preoperative cardiac conduction disturbances who underwent AVR or TAVI were included in the study. Su-AVR patients and TAVI patients had a higher incidence of new-onset LBBB at hospital discharge (23% and 16%, respectively) compared to patients treated with conventional AVR (4%; p<0.001). On multivariate logistic regression analyses, the type of AVR was independently associated with complete LBBB, after correcting for age, preoperative QRS duration and heart rate (su-AVR and TAVI relative to the reference category conventional AVR: odds ratio [OR] 8.5, 95% confidence interval [CI]: 3.7-19.5; p<0.001, and OR 5.8, 95% CI: 2.4-14.1; p<0.001, respectively). Su-AVR and TAVI were associated with higher risk of developing postoperative LBBB compared to conventional AVR, after adjusting for age, preoperative heart rate and QRS duration.

Left Atrial Ganglionated Plexi Detection is Related to Heart Rate and Early Recurrence of Atrial Fibrillation after Surgical Ablation.

IntroductionLeft atrial ganglionated plexi ablation is an adjuvant technique used to increase the success rate of surgical ablation of atrial fibrillation. Ganglionated plexi ablation requires previous detection. We aimed to assess determinants of successful ganglionated plexi detection and to correlate range of ganglionated plexi ablation with risk of early atrial fibrillation recurrence.MethodsThe study involved 34 consecutive patients referred for surgical coronary revascularization with concomitant atrial fibrillation ablation. Ganglionated plexi detection was done by inducing vagal reflexes in the area of the pulmonary veins and left atrial fat pads.ResultsDetection of GP was successful in 85% of the patients. There was no difference in preoperative characteristics nor in atrial fibrillation type between patients in whom ganglionated plexi detection was successful and others. The number of detected ganglionated plexi correlated significantly only with preoperative resting heart rate. Significant negative correlation was found in patients with preoperative heart rate>75 beat/min in terms of total number of detected ganglionated plexi (P=0.04). Average number of detected ganglionated plexi was significantly higher in patients with in-hospital atrial fibrillation recurrence requiring electrical cardioversion (3.8±3) in comparison to rest of the study population (2±1.3; P=0.02). In patients in whom 4 or more ganglionated plexi were detected, significantly increased risk of in-hospital atrial fibrillation recurrence was observed (OR 15; 95% CI 1.5-164; P=0.003).ConclusionLeft atrial ganglionated plexi detection was unsuccessful in a considerable percentage of patients. Preoperative heart rate significantly influenced positive ganglionated plexi detection and number of ablated ganglia. Higher number of detected ganglionated plexi was related with early recurrence of atrial fibrillation.

Preoperative heart rate and myocardial injury after non-cardiac surgery: results of a predefined secondary analysis of the VISION study

BackgroundIncreased baseline heart rate is associated with cardiovascular risk and all-cause mortality in the general population. We hypothesized that elevated preoperative heart rate increases the risk of myocardial injury after non-cardiac surgery (MINS). MethodsWe performed a secondary analysis of a prospective international cohort study of patients aged ≥45 yr undergoing non-cardiac surgery. Preoperative heart rate was defined as the last measurement before induction of anaesthesia. The sample was divided into deciles by heart rate. Multivariable logistic regression models were used to determine relationships between preoperative heart rate and MINS (determined by serum troponin concentration), myocardial infarction (MI), and death within 30 days of surgery. Separate models were used to test the relationship between these outcomes and predefined binary heart rate thresholds. ResultsPatients with missing outcomes or heart rate data were excluded from respective analyses. Of 15 087 patients, 1197 (7.9%) sustained MINS, 454 of 16 007 patients (2.8%) sustained MI, and 315 of 16 037 patients (2.0%) died. The highest heart rate decile (>96 beats min−1) was independently associated with MINS {odds ratio (OR) 1.48 [1.23–1.77]; P <0.01}, MI (OR 1.71 [1.34–2.18]; P <0.01), and mortality (OR 3.16 [2.45–4.07]; P <0.01). The lowest decile (<60 beats min−1) was independently associated with reduced mortality (OR 0.50 [0.29–0.88]; P=0.02), but not MINS or MI. The predefined binary thresholds were also associated with MINS, but more weakly than the highest heart rate decile. ConclusionsPreoperative heart rate >96 beats min−1 is associated with MINS, MI, and mortality after non-cardiac surgery. This association persists after accounting for potential confounding factors. Clinical trial registrationNCT00512109.

Incidence and risk factors of delirium in patients post permanent pacemaker implantation

To evaluate the incidence and risk factors of postoperative delirium in patients post permanent pacemaker implantation. Patients underwent permanent pacemaker implantation in our department from September 2013 to February 2015 were included in this study. Delirium was measured by the confusion assessment method on the first three postoperative days. All the patients were divided into the postoperative delirium group and the non-delirium control group according to whether new onset delirium was diagnosed. Risk factors significantly associated with postoperative delirium detected by univariate analysis were entered into multivariable analysis to define the independent predictors of postoperative delirium. A total of 225 patients were enrolled in this study. The incidence of postoperative delirium was 5.3%. Patients developing postoperative delirium were older ((83±5) years vs. (74±11) years, P=0.002), had a significantly higher incidence of blood pressure fluctuations (58.3% (7/12) vs. 4.7% (10/213), P<0.001), hyponatremia (25.0% (3/12) vs. 5.2% (11/213), P=0.030) and had higher systolic blood pressure ((157±35) mmHg vs. (136±22)mmHg, 1 mmHg=0.133 kPa, P=0.007). However, patients developing postoperative delirium had lower preoperative average heart rate ( (47±18)bpm vs. (58±15)bpm, P=0.007). Multiple regression analysis showed that advanced age (OR= 2.984, 95% CI: 1.226-7.624, P=0.016) and blood pressure fluctuations (OR=27.393, 95% CI: 6.735-111.417, P<0.001) are the independent risk factors for pacemaker patients with postoperative delirium. Advanced age and blood pressure fluctuations are independent risk factors of postoperative delirium in patients post permanent pacemaker implantation.

Successful Anaesthetic Management of Elderly Patients with Leprosy.

Leprosy is a chronic granulomatous infection that is caused by Mycobacterium leprae (1), wherein autonomic function is affected to varying degrees, and the important manifestations of such a dysfunction include orthostatic hypotension, baroreflex dysfunction and postprandial hypotension (2). Patients with leprosy have impaired respiratory function, breath holding time and response to cough (3). Hence, anaesthesiologists should be aware of complications, including difficult intubation and perioperative anaesthetic problems, in the management of patients with leprosy. Herein we present a case of a patient with leprosy having a transtrochanteric femur fracture who was successfully operated under spinal anaesthesia. A 70-year-old male patient with lepromatous leprosy, Parkinson’s disease and coronary artery disease was scheduled for a surgical repair of a transtrochanteric fracture of the femur. The patient was a known case of lepromatous leprosy for at least 2 years and received 100 mg dapsone per day po. The patient was symptomatic for cardiovascular disease. Preoperative electrocardiogram (ECG) revealed sinus rhythm, complete left bundle branch block and inferior wall ischaemia. Echocardiography revealed an ejection fraction of 50% with left ventricular diastolic dysfunction. After explaining the procedure and the risks involved to the patient, written informed consent was obtained. In the operating room, ECG, non-invasive blood pressure (NIBP) and pulse oximetry were attached and baseline parameters were noted. An 18-G intravenous cannula was secured. Preoperative heart rate was 90/min, blood pressure was 170/100 mm Hg, respiratory rate was 22/min and SpO2 (on room air) was 90%. An 18-G epidural catheter was inserted via the L3-L4 space with the patient in the left lateral position using midline approach and fixed at 11 cm. At the same level, 15 mg of 0.5% heavy bupivacaine was administered in the subarachnoid space using a 25-G Quincke’s spinal needle. Supplemented oxygen was administered via a venturi facemask (FiO2 0.5). A sensory loss up to T7 level was achieved with adequate motor paralysis after 9 min, and surgery was then initiated. ECG, NIBP and SpO2 were monitored. No complication was developed during operation. Leprosy is an uncommon disease in developed countries. A literature review suggests that there is limited information regarding the surgical management of patients with leprosy. During the course of leprosy, cell-mediated immunity reduces because of a decline in T-cell responses (4). In addition, patients with leprosy may have cardiac and respiratory dysautonomia and autonomic involvement. Therefore, proper pre-anaesthetic assessment and optimization with intraoperative period, adequate monitoring and preparation are essential while managing patients with leprosy. In our patient with leprosy, the other risk factor was advanced age. However, no adverse events were observed in the intra- and postoperative period. In conclusion, anaesthesiologists can use both spinal and epidural anaesthesia in elderly patients with leprosy.

Anaesthetic concerns of a pregnant patient with Pott's spine for spine surgery in prone position.

Sir, Surgical decompression is the treatment of choice in pregnancy complicated by spinal tuberculosis with neurologic deficit.[1] We report the anaesthetic management of a pregnant patient with Pott's spine in prone position and discuss the various anaesthetic concerns including haemodynamic instability. A 23-year-old multipara, 17 weeks of gestation, weighing 52 kg, with Pott's spine involving T7–T10 segments with progressive neurological deficit was scheduled for decompression and posterior screw fixation. Obstetrician's opinion was sought. Preoperative foetal heart rate (FHR) was documented. Anti-aspiration prophylaxis was administered. Her baseline HR was 112/min and blood pressure (BP) was 132/82 mmHg. Invasive arterial BP monitoring could not be done due to the logistic problems. General anaesthesia was induced with propofol and morphine. Endotracheal intubation was facilitated using vecuronium with size 7.0 orotracheal cuffed tube. Injection glycopyrrolate 0.2 mg was administered as anti-sialagogue. Anaesthesia was maintained with isoflurane in 50% nitrous oxide and oxygen mixture. Soon following positioning, patient developed hypotension i.e., more than 20% fall from the baseline systolic BP (SBP). Fluid replacement and pressure-free abdomen were rechecked but the SBP continued to remain between 90 and 100 mmHg. Initially, hydrocortisone 100 mg was administered intravenously. The oozing from the surgical site resolved following injection tranexamic acid 500 mg. Surgery lasted for 5 h but BP persisted in the same aforementioned range. Blood loss was 1000 ml approximately. Haemodynamics and FHR remained stable post-operatively. The anaesthetic concerns related to spine surgery in pregnant patient include both obstetric and surgery-related i.e., prolonged surgery in prone position, major blood loss, relative hypotension and risk of postoperative visual loss.[2] The risk of radiation is of paramount concern due to the inability to use abdominal shield and the proximity of radiation to the foetus. The additional problem with prone position here includes the inability to perform emergent caesarean section. Technical problems may limit the usefulness of continuous FHR monitoring between 16 and 20 weeks and it is recommended to document FHR before and after surgery which was done in our patient. The American College of Obstetricians and Gynaecologists recommends continuous FHR monitoring in non-obstetric surgery from 18 to 20 weeks of gestation, based on the patient and the surgery to be performed.[3] There has been controversy related to the use of controlled hypotension and intraoperative tests/monitoring to detect spinal cord injury during pregnancy. Invasive arterial BP monitoring must be performed, more so, if controlled hypotension is instituted. Various risk factors for haemodynamic instability in these patients include pregnancy-induced aortocaval compression, massive fluid shift, blood loss and prolonged surgery. In addition, autonomic dysfunction has been reported as the cause for high incidence of intraoperative hypotension in adult patients with thoracic spine tuberculosis.[4] In our patient, vasopressor was not considered to treat hypotension:First, because, as the SBP remained in the acceptable range of 90–100 mmHg, and second, its use could have further led to increased blood loss. Since the hypotension occurred soon after positioning, it could be attributed by factors such as pregnancy-induced aortocaval compression, pre-operative hydration status and autonomic neuropathy related to thoracic spine tuberculosis. The initial two factors were ruled out by ensuring adequate fluid replacement and free and hanging abdomen in prone position. It is also reported that prone position in pregnant patient is associated with lesser risk of aortocaval compression than sitting or lateral position.[5] To conclude, intraoperative haemodynamic stability is of paramount anaesthetic concern in pregnant patients with thoracic spine tuberculosis and autonomic dysfunction must be considered as a potential cause for intraoperative hypotension. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

A Randomized Controlled Study of 0.5% Bupivacaine, 0.5% Ropivacaine and 0.75% Ropivacaine for Supraclavicular Brachial Plexus Block.

For any surgery in the upper extremity that does not involve the shoulder, a supraclavicular block is preferred, as it is a safe procedure associated with rapid onset and reliable anaesthesia. Although ropivacaine has been extensively studied for epidural anaesthesia, very few reports exist on its use in supraclavicular brachial plexus block. This study was conducted to investigate and compare the effectiveness of supraclavicular brachial plexus anaesthesia with two different concentrations of ropivacaine (0.5% and 0.75%) and to compare them with the standard 0.5% bupivacaine. Ninety patients of age 18 to 60 years belonging to American Society of Anaesthesiologists (ASA) status 1 or 2, admitted to Pondicherry Institute of Medical Sciences were chosen for the study and were divided into three groups. Group A received 30 ml of 0.5% bupivacaine, group B received 30 ml of 0.5% ropivacaine and group C received 30 ml of 0.75% ropivacaine into the supraclavicular region, by a nerve-stimulator technique. Onset time of each of the drug was recorded both for the sensory and motor block. Duration of sensory and motor block was recorded along with peri-operative haemodynamic monitoring. The onset of complete sensory and motor block observed with both ropivacaine groups and bupivacaine was similar (16.85±6.67 min in group A, 17.79±5.03 min in group B and 18.48±6.14 in group C, p>0.05); onset of motor block (21.45±4.45 min in group A, 22.23±4.05 min in group B and 22.33±5.17 in group C, p < 0.05). The duration of sensory block with 0.5% bupivacaine was 11.58 hours, with 0.5% ropivacaine was 9.02 hours with 0.75% ropivacaine was 8.87 hours (p<0.001). The duration of motor block with 0.5% bupivacaine was 12.94 hours, with 0.5% ropivacaine was 8.29 hours with 0.75% ropivacaine was 7.89 hours (p<0.001). Multiple comparison test with Bonferroni correction showed there was statistically significant difference in mean duration of sensory block between Group A (0.5% bupivacaine) and Group B (0.5% ropivacaine) and also between Group A (0.5% bupivacaine) and Group C (0.75% ropivacaine). However, there were no statistically significant difference in mean duration of sensory block between Group B (0.5% ropivacaine) and Group C (0.75% ropivacaine). The preoperative, intra operative and postoperative heart rate, systolic & diastolic blood pressure and oxygen saturation were comparable among the three study groups (p>0.05). No side effects were recorded in the study. The onset of sensory and motor block was similar in all the three groups. However, when compared to bupivacaine group, recovery of motor functions was faster in both the ropivacaine groups. Patients in all the 3 groups did not experience any adverse effects.

전신마취하 개복술 환자의 수술중 체온에 영향을 미치는 요인

Purpose: The study was conducted to identify factors affecting the intraoperative core body temperature (CBT) of surgical patients under general anesthesia. Methods: This study was performed through a prospective descriptive research design. The sample consisted of 138 patients who had undergone elective laparotomy surgery. Age, weight, height, the basal preoperative CBT, blood pressure, and heart rate were collected. CBT was again measured at induction of anesthesia, 1 hour, 2 hours, and 3 hours following induction of general anesthesia. Results: Factors affecting intraoperative hypothermia < 36˚C at 1 hour following induction, were CBT at induction and total body fat (TBF) (R 2 = .569, p < .001); at 2 hours after induction, CBT at induction and TBF (R 2 = .507, p < .001); at 3 hours after induction, CBT at induction (β = 0.34), TBF, age and the ambient temperature in the operating room (R 2 = .449, p < .001). Conclusion: CBT at induction and TBF appear to be factors affecting intraoperative CBT within 2 hours after induction of anesthesia; CBT at induction, TBF, advanced age and the ambient temperature after 3 hours following induction. We recommend keeping surgical patients warm before induction of anesthesia and providing intraoperative warming for surgical patients of advanced age with low TBF and when the duration of general anesthesia will last more than 3 hours.

A Comparative Study Of Intravenous Clonidine And Intravenous Dexmedetomidine Premedication On Cardiovascular Response To Ketamine Anesthesia In Patients Undergoing Dilatation &amp; Curettage.

Background- Ketamine induced hemodynamic pressor response should be attenuated by appropriate premedication. The present study was designed to evaluate and compare the efficacy of dexmedetomidine and clonidine premedication to counter the effects of ketamine.Method-A total of 68 normotensive adult female patients of ASA grade I and II, aged 20-50 years, weighing between 40-65 kgs and undergoing dilatation and curettage under ketamine anaesthesia were randomized for this double blind, interventional, hospital based study.These patients were divided into two treatment groups of 34 patients each. Group A (n=34) received Clonidine 1mcg/kg as continuous i.v. infusion over 30 minutes before induction. Group B (n=34) received Dexmedetomidine 1mcg/kg as continuous i.v. infusion over 10 minutes before induction Observations regarding the demographic profile, preoperative and intraoperative heart rate, mean arterial pressure were recorded. Analysis of data was done using unpaired student “t” test and chisquare tests.A “p” value 0.05 ). Mean heart rate in Group A was 81.91± 6.84 and in Group B 80.94±7.09 (P value = 0.56 no statistical significance); after induction with ketamine,HR in Group A was 102.35± 12.55 and in Group B 78.02± 9.91 (P value = 0.000 high statistical significance). Mean arterial pressure in Group A was 90.85± 5.86 and in Group B 93.43± 8.14 (P value = 0.13 no statistical significance); after induction with ketamine, MAP in Group A was 103.76±7.74 and in Group B 99.05± 11 (P value = 0.04 statistical significance). Conclusion: Dexmedetomidine attenuates ketamine induced hemodynamic pressor response more effectively than clonidine. It maintains stable hemodynamic parameters during dilatation & curettage under ketamine anaesthesia.

Postoperative Nausea and Vomiting: Palonosetron with Dexamethasone vs. Ondansetron with Dexamethasone in Laparoscopic Hysterectomies

Postoperative nausea and vomiting (PONV) is the most common complication seen following laparoscopic surgery. Our study sought to evaluate the efficacy of the newer drug palonosetron with that of ondansetron, in combination with dexamethasone, for PONV in patients undergoing laparoscopic hysterectomies. . A total of 90 patients, aged between 30-50 years old, posted for elective laparoscopic hysterectomies under general anesthesia belonging to the American Society of Anesthesiologist (ASA) physical status I and II were included in the study. Patients were randomly divided into one of two groups (n=45). Before induction, patients in the first group (group I) received 0.075mg palonosetron with 8mg dexamethasone and patients in the second group (group II) received 4mg ondansetron with 8mg dexamethasone. Postoperatively, any incidences of early or delayed vomiting, requirement of rescue antiemetic, and side effects were recorded. Patient's hemodynamics were also monitored. Statistical analysis was done using Student's t-test, chi-square test, and Fisher's exact test. . Preoperative, intraoperative, and postoperative heart rate, mean arterial pressure, peripheral capillary oxygen saturation were statistically not significant (p>0.050) in either group. In group II, eight patients had nausea in the first two hours and three patients had nausea in the two to six-hour postoperative period. In group I, three patients experienced nausea in the first six hours period. Eight patients in group II had vomited in the first two-hour period compared to one patient in group I (p=0.013). The requirement of rescue antiemetic was greater in group II than group I (20% vs. 4%). No side effects of antiemetic use were observed in either group. . The combination of palonosetron with dexamethasone is more effective in treating early, delayed, and long term PONV compared to ondansetron with dexamethasone in patients undergoing elective laparoscopic hysterectomies under general anesthesia.

The GoMo study: a randomized clinical trial assessing neonatal pain with Gomco vs Mogen clamp circumcision

Our objective was to compare the pain/stress levels of newborns among the 2 most common circumcision techniques after resident-wide education. The study period of this randomized control trial was October 2012 through March 2014. Following informed consent, full-term males from uncomplicated singleton pregnancies were randomized to Gomco (n=137) or Mogen (n=137) devices. Resident-wide education for an obstetrics and gynecology residency program at a single institution was performed to ensure standardized training. All infants received a subcutaneous ring block before the procedure and oral sucrose intraoperatively. The primary outcome was neonatal pain assessed physiologically by salivary cortisol levels (enzyme-linked immunosorbent assay) and clinically by a validated neonatal pain score (crying, requires increased oxygen administration, increased vital signs, expression, sleeplessness [CRIES]). Secondary outcomes were immediate complications, duration of procedure, and short-term outcomes as reported by mothers and pediatricians. A sample size of 274 (accounting for 20% loss of follow-up) was determined sufficient to detect a mean difference of 1.22 μg/dL in cortisol levels (Gomco, SD±3.34; Mogen, SD±0.81) with 80% power, P=.05 level of significance. A total of 251 infants completed the protocol. There were no significant differences in maternal or neonatal demographics including preoperative heart rate and mean arterial pressure. In the Mogen circumcision, the percentage change of cortisol was significantly lower than Gomco (279.1±498.15 vs 167.75±272.22; P=.049). There were no differences in postoperative CRIES scores. Postoperative heart rate was higher in infants undergoing Gomco circumcision than Mogen circumcision (138.7±16.5 vs 133.4±17.5; P=.015) as was mean arterial blood pressure (63.3±9.2 vs 60.4±8.6; P=.012). Mogen circumcisions were shorter (7.00±2.97 vs 3.65±1.84 minutes; P<.001). There were no significant differences in bleeding complications. A total of 168 maternal surveys were completed, with 98.7% maternal satisfaction in Gomco vs 98.9% in Mogen. There were no reports of bleeding after discharge or circumcision revisions in either group to date. Mogen clamp is associated with less neonatal pain physiologically by significantly lower percentage change in salivary cortisol, lower heart rate, and mean arterial blood pressure. There was no difference in CRIES scores. Mogen clamp circumcision duration is significantly shorter than Gomco clamp. Both methods demonstrate satisfactory maternal and pediatrician short-term follow-up.

Ultrasound-guided transversus abdominis plane block versus dexmedetomidine infusion in open ovarian cystectomy: Analgesic efficacy and effect on stress response

Background Ultrasound (US)-guided transversus abdominis plane (TAP) block has been proven to be an effective method of providing postoperative analgesia in laparotomy. Dexmedetomidine has sedative, analgesic, sympatholytic, and amnestic properties. In the present study, we evaluated the analgesic efficacy and the attenuation of stress surgical response of US-guided TAP block in comparison with dexmedetomidine infusion in patients undergoing open ovarian cystectomy in a randomized, double-blinded clinical study. Patients and methods A total of 60 patients were randomly assigned into two groups (30 in each) to be administered, before skin incision, either a combination of general anesthesia with a US-guided TAP block (TAP group), or an intraoperative intravenous infusion of dexmedetomidine (DEX group). In the DEX group, loading dose of 1 μg/kg of dexmedetomidine was infused over 10 min, followed by infusion of 0.2-0.6 μg/kg/h. Measurements included hemodynamics, stress hormones, pain score, time of first analgesia, and amount of pethidine during the first 24 h postoperative. Results In the DEX group, there was a significant decrease in heart rate (HR) at 45, 60, and 90 min after surgical incision in comparison with preoperative HR. In the TAP group, there was a significant decrease in HR at 60 and 90 min after surgical incision in comparison with preoperative HR. In the DEX group, there was a significant decrease in mean arterial pressure at 30, 45, 60, and 90 min after surgical incision in comparison with preoperative mean arterial pressure. The DEX group had shown a statistically significant increase with regard to change in the blood level of stress hormones 12 and 24 h postoperative in comparison with the preoperative values. There was a highly significant increase in postoperative pethidine supplementation in the DEX group than in the TAP group. There was a significant difference with regard to time of the first postoperative request of analgesia in the DEX group than in the TAP group. Conclusion In open ovarian cystectomy, US-guided TAP block was comparable to dexmedetomidine infusion with regard to intraoperative hemodynamic stability and opioid requirement without change in stress response hormones. However, TAP block provided superior analgesia when compared with dexmedetomidine infusion up to 24 h postoperatively.

Oral premedication with pregabalin and clonidine for hemodynamic stability during laryngoscopy: a comparative study

Background: Airway instrumentation of direct laryngoscopy and tracheal intubation are noxious stimuli that should be attenuated by appropriate premedication, smooth induction, and rapid intubation. The present study evaluated the clinical efficacy of oral premedication with pregabalin or clonidine for attenuation of hemodynamic pressure response of airway instrumentation. The objective was to find out the efficacy of pregabalin and clonidine as an oral premedication and to observe hemodynamic stability during laryngoscopy. Methods: A total of 100 healthy patients aged 30-70 years with American Society of Anesthesiology Physical Status I and II of both gender, who met the inclusion criteria of general anesthesia, were randomly received pregabalin (150 mg) Group I or clonidine (100 µg) Group II, 60-70 mins before surgery as an oral premedication. Both groups were compared to pre-operative sedation, anxiety, heart rate (HR), and mean arterial pressure (MAP) at baseline, after premedication, induction, laryngoscopy, and extubation. Intraoperative analgesic drug requirement and any post-operative complication were recorded. Results : Incidence of hypotension and bradycardia were observed in 4% case in the clonidine group. Pre-operative sedation level was higher in the pregabalin group as compared to clonidine group. p>0.05 which shows there is no difference in both the drugs in terms of control of HR and MAP perioperatively. Both drugs are equally good to maintain hemodynamic stability during laryngoscopy. None of the patients has suffered from any post-operative side effects. Conclusion: Hemodynamic pressure response of airway instrumentation was attenuated with pregabalin and clonidine oral premedication without prolongation of recovery time and side effects.