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Viscoelastic assays help in identifying disorders of clotting factors, platelet function, and detection of excessive fibrinolysis. Rotational thromboelastometry (ROTEM) assesses quantitative and qualitative aspects of whole blood coagulation which allows for the determination of the mechanism of hemostatic disturbance. This helps clinicians in targeting the correct blood component therapy transfusion. Now, using verify we aim to study platelet reactivity, VA ECMO which will reflect the platelet aggregation response to an aggregating agent like Aspirin and thus know the etiology of bleeding on VA ECMO, to know the right component therapy to be transfused with a Point of Care test. For extracorporeal membrane oxygenation, although the conventional laboratory tests are used to monitor anticoagulation on whole blood, viscoelastic tests reflect coagulation status like no other standard laboratory tests. They show the status of color propagation, formation, and stabilization. It was reported that platelet function was impaired over time in all parameters with different activators. [ABSTRACT FROM AUTHOR]

Remimazolam is a novel intravenous ultrashort acting benzodiazepine that has a potential for safe and effective sedative. This recent addition in anesthesia armamentarium has a great role in procedural sedation and general anesthesia which is well-approved. The main beauty of this drug is, if needed its effects can be reversed by flumazenil which allows prompt termination of sedation. Remimizolam has fast predictive effect and recovery time, high procedural success rate, and minor respiratory and hemodynamic fluctuation when used for procedural sedation and general anesthesia. Although has a great potential for sedation in patients admitted to intensive care unit (ICU), some randomized trials are necessary to prove its long-term efficacy and safety in patients admitted to ICU. [ABSTRACT FROM AUTHOR]

Objective: To identify the correlation between systolic time ratio(STR) measured with electrical cardiometry (EC) device ICON (Osypka Medical, Berlin, Germany) and echocardiography in patients undergoing cardiac surgery and to find a noninvasive technique for estimating left ventricular systolic function during the perioperative period. Materials and Methods: Systolic time ratio data were obtained simultaneously from the electrical cardiometry device ICON (Osypka Medical, Berlin, Germany) and transthoracic echocardiography at the following predefined timepoints--before anaesthesia induction (T0 baseline), after induction (T1), at the end of the surgery(T2), and after extubation (T3) in patients undergoing elective cardiac surgery. The agreement between the systolic time ratio measured by electrical cardiometry and transthoracic echocardiography was studied using Bland-Altman plots. Paired t-tests were used to compare systolic time ratio measurements at different time points. Results: Mean STR by EC and Echocardiography at T0 was 0.456 (0.429-0.483) and 0.348 (0.330-.366) at T1 was 0.464 (0.442 -0.486) and 0.372 (0.344-0.401) at T2 was 0.421 (0.402 -0.439) and 0.305 (0.290-0.320) and at T3 was 0.438 (0.419-0.457) and 0.353 (0.336-0.370), P value <0.001. Bland-Altman analysis showed that EC measured STR compared with echocardiography at T0 with a mean bias of 0.108 and (with limits of agreement -0.19,0.14) at T1 it was 0.092 (with limits of agreement -0.21,0.40) at T2 it was 0.11 (with limits of agreement -0.04,0.28) and at T3 it was 0.085 (with limits of agreement -0.101,0.271). Conclusion: In conclusion, no association between systolic time ratio as measured by electrical cardiometry and echocardiography was found in our study. Our results do not conclusively prohibit using electrical cardiometry in the perioperative period to evaluate LV systolic function. Further work must be done to establish the role of STR as a surrogate marker of LV systolic function. [ABSTRACT FROM AUTHOR]

Objectives: Patients with Tetralogy of Fallot (TOF) undergoing corrective surgery experience a vast majority of pulmonary, cardiac, and renal dysfunction due to the effect of cardiopulmonary bypass (CPB). Tumor necrosis factor-α (TNF-α) is a pro-inflammatory cytokine that has been shown to play a major role in systemic inflammatory response syndrome secondary to CPB. The rise of level of inflammatory mediator may serve as a clue for post-operative organ dysfunction and may determine the post-operative course of the patient. They may enable us to detect morbidity earlier, thereby taking steps to decrease the same. We have done this study with the aim to evaluate changes in serum concentration of TNF-α in patients with TOF undergoing intracardiac repair (ICR) on CPB and correlate changes in its level with correlate them with clinical outcome and mortality. Material and Methods: TOF patients divided into two groups (< and >15 years) after approval from the ethics committee and written informed consent were enrolled in this prospective and observational study with ICR on CPB. Routine anesthesia and CPB as per AIIMS protocol were performed on all the patients. Routine arterial blood gas, heart rate, mean arterial pressure, temperature, and urine output monitoring were done in all cases. Arterial blood samples were collected at three time intervals - T1, T2, and T3 and processed for biomarker level detection by Enzyme-linked immunosorbent assay method. Appropriate statistical analysis was done for the correlation between biomarkers and clinical variables. Results: There were no significant differences between the two groups in terms of gender distribution, CPB time, and aortic cross-clamp time. Duration of mechanical ventilation, inotropes use, intensive care unit stay, and hospital stay were all significantly prolonged (P < 0.001) in Group 1 (age <15 years) when compared to Group II (age more than 15 years). Conclusion: Level of TNF-α correlated significantly with duration of mechanical ventilation, ionotrope use, intensive care unit stay, and hospital stay in children <15 years. However, a larger study population is required to further prove this hypothesis. [ABSTRACT FROM AUTHOR]

Direct thrombin inhibitors directly bind to active sites on thrombin and exert their anticoagulant effect. Bivalirudin is used an alternative in cases of heparin-induced thrombocytopenia, heparin resistance, anaphylactic reaction to UFH, or anti-thrombin III deficiency. Here, we report a case of a 31-year-old female patient, diagnosed with recurrent chronic thromboembolic pulmonary hypertension posted for redo pulmonary thromboendarterectomy. Monitoring anticoagulation during bivalirudin therapy is sometimes confounding and challenging. Prolongation of CT on INTEM and HEPTEM has shown moderate to strong correlation with traditional laboratory tests like aPTT and HPTT (aPTT with Hepzyme). ROTEM can be a way forward for monitoring bivalirudin therapy. [ABSTRACT FROM AUTHOR]

The deleterious effects of anesthetic agents in patients suffering from coronary artery disease are well known. The risk increases when a patient has compromised ventricular function. There is a paucity of literature regarding the choice of the suitable agent to avoid deleterious effects in such patients. The use of etomidate and propofol has been considered superior to other intravenous anesthetic agents in these groups of patients. The aim of the present study is to compare the hemodynamic effects of anesthesia induction with etomidate, thiopentone, propofol, and midazolam in patients with coronary artery disease and left ventricular dysfunction. This randomized clinical trail was conducted at the All Indian Institute of Medical Sciences, New Delhi, India. Sixty patients with coronary artery disease and left ventricular dysfunction (ejection fraction < 45%) scheduled for elective coronary artery bypass surgery participated in this study. After stabilization baseline hemodynamic data stroke volume variation and systemic vascular resistance index were recorded for all patients (Flo Trac TM sensor with Vigileo cardiac output monitor used for hemodynamic monitoring). The patients were randomly alloted to one of the four groups and the intravenous induction agent was administered for over 60 - 90 seconds (Group E - Etomidate 0.2 mg/Kg; Group M - Midazolam 0.15 mg/Kg; Group T - Thiopentone 5 mg/Kg; Group P - Propofol 1.5 mg/Kg). Hemodynamic data were recorded at one minute intervals starting from induction till seven minutes after intubation, - the end point of the present study. There was a significant decrease in the heart rate in comparison to the baseline(-7 to -15%, P = 0.001), mean arterial pressure (-27 to -32%, P = 0.001), cardiac index (-36 to -38%, P = 0.001), and stroke volume index (-27 to -34%, P = 0.001) after induction in all four groups. The hemodynamic response was similar in all the four groups. There was no significant change in central venous pressure and stroke volume variation (SVV) during induction and intubation, while the effects on the systemic vascular resistance index (SVRI) were variable. The midazolam group was the most effective in preventing intubation stress (tachycardia,hypertension). The change from baseline values in heart rate (+ 4%, P = 0.12) and mean arterial pressure (-1%, P = 0.77) after intubation were not statistically significant in the midazolam group. The etomidate group was the least effective of all the four groups in minimizing stress response, with statistically significant increase from baseline in both heart rate (P = 0.001) and mean arterial pressure (P = 0.001) at 1 minute after intubation. All the four anesthetic agents were acceptable for induction in patients with coronary artery disease and left ventricular dysfunction despite a 30 - 40% decrease in the cardiac index. Clinician experience along with knowledge of the potential interactions (e.g., premedication, concurrent opioid use) is needed to determine hemodynamic stability during anesthetic induction in these patients with ventricular dysfunction.

Objectives: The presence of pulmonary artery hypertension (PAH) affects the prognosis of patients; therefore, it is important to treat it. The aim of this study is to compare the acute hemodynamic effects of inhaled nitroglycerine (iNTG), intravenous nitroglycerine (IV NTG) alone and their combination with intravenous dobutamine (IV DOB) during the early postoperative period, in patients with PAH undergoing mitral valve or double valve replacement surgery. Materials and Methods: In the study, 40 patients with secondary PAH were administered iNTG 2.5 μg/kg/min, IV NTG 2.5 μg/kg/min, a combination of iNTG 2.5 μg/kg/min + IV DOB 10 μg/kg/min, and IV NTG 2.5 μg/kg/min + IV DOB 10 μg/kg/min for 10 minutes each following valve replacement surgery, in random order. The hemodynamic parameters were recorded before (T0) and immediately after the intervention. (T1). Results: iNTG effectively decreased mean pulmonary arterial pressure (mPAP), pulmonary vascular resistance index (PVRI), and the PVR / SVR ratio, without affecting arterial pressures, systemic vascular resistance or mixed venous oxygen saturation (SvO 2 ). IV NTG produced both systemic and pulmonary vasodilation along with a significant fall in SvO 2 . The combination of iNTG and IV DOB caused a significant decrease in mPAP and PVRI, with no significant change in SVRI, PVR / SVR ratio, and SvO 2 . A combination of IV NTG + IV DOB caused both pulmonary and systemic vasodilatation with a significant decrease in SvO 2 . None of the drugs caused any significant change in the cardiac index. Conclusion: All drugs were of similar efficacy in reducing the pulmonary vascular resistance index. Only iNTG produced selective pulmonary vasodilatation, while IV NTG and its combination with IV dobutamine had a significant concomitant systemic vasodilatory effect.

Chronic constrictive pericarditis (CCP) due to tuberculosis has high morbidity and mortality in the periopeartive period following pericardiectomy because of left ventricular (LV) dysfunction. Brain-type natriuretic peptide (BNP) is considered a marker for both LV systolic and diastolic dysfunction. We undertook this prospective study in 24 patients, to measure the BNP levels and to compare it with transmitral Doppler flow velocities, that is, the E/A ratio (E = initial peak velocity during early diastolic filling and A = late peak flow velocity during atrial systole), as a marker of diastolic function and systolic parameters, pre- and post-pericardiectomy, at the time of discharge. The latter parameters have been taken as a flow velocity across the mitral valve on a transthoracic echo. There was a significant decrease in the mean values of log BNP (6.19 ± 0.33 to 4.65 ± 0.14) (P = 0.001) and E/A ratio (1.81 ± 0.21 to 1.01 ± 0.14) (P = 0.001) post pericardiectomy, with a positive correlation, r = 0.896 and 0.837, respectively, between the two values at both the time periods. There was significant improvement in the systolic parameters of the LV function, that is, stroke volume index, cardiac index, systemic vascular resistance index, and delivered oxygen index. However, no correlation was observed between these values and the BNP levels. We believe that BNP can be used as a marker for LV diastolic dysfunction in place of the E/A ratio in patients with CCP, undergoing pericardiectomy. However, more studies have to be performed for validation of the same.

Early goal-directed therapy is a term used to describe the guidance of intravenous fluid and vasopressor/inotropic therapy by using cardiac output or similar parameters in the immediate post-cardiopulmonary bypass in cardiac surgery patients. Early recognition and therapy during this period may result in better outcome. In keeping with this aim in the cardiac surgery patients, we conducted the present study. The study included 30 patients of both sexes, with EuroSCORE ≥3 undergoing coronary artery bypass surgery under cardiopulmonary bypass. The patients were randomly divided into two groups, namely, control and early goal-directed therapy (EGDT) groups. All the subjects received standardized care; arterial pressure was monitored through radial artery, central venous pressure through a triple lumen in the right internal jugular vein, electrocardiogram, oxygen saturation, temperature, urine output per hour and frequent arterial blood gas analysis. In addition, cardiac index monitoring using FloTrac and continuous central venous oxygen saturation using PreSep was used in patients in the EGTD group. Our aim was to maintain the cardiac index at 2.5-4.2 l/min/m 2 , stroke volume index 30-65 ml/beat/m 2 , systemic vascular resistance index 1500-2500 dynes/s/cm 5 /m 2 , oxygen delivery index 450-600 ml/min/m 2 , continuous central venous oximetry more than 70%, stroke volume variation less than 10%; in addition to the control group parameters such as central venous pressure 6-8 mmHg, mean arterial pressure 90-105 mmHg, normal arterial blood gas analysis values, pulse oximetry, hematocrit value above 30% and urine output more than 1 ml/kg/h. The aims were achieved by altering the administration of intravenous fluids and doses of inotropic or vasodilator agents. Three patients were excluded from the study and the data of 27 patients analyzed. The extra volume used (330 ± 160 v/s 80 ± 80 ml, P = 0.043) number of adjustments of inotropic agents (3.4 ± 1.5 v/s 0.4 ± 0.7, P = 0.026) in the EGDT group were significant. The average duration of ventilation (13.8 ± 3.2 v/s 20.7 ± 7.1 h), days of use of inotropic agents (1.6 ± 0.9 v/s 3.8 ± 1.6 d), ICU stay (2.6 ± 0.9 v/s 4.9 ± 1.8 d) and hospital stay (5.6 ± 1.2 v/s 8.9 ± 2.1 d) were less in the EGDT group, compared to those in the control group. This study is inconclusive with regard to the beneficial aspects of the early goal-directed therapy in cardiac surgery patients, although a few benefits were observed.

Byline: Minati. Choudhury Parturient with corrected or uncorrected cardiac problem may undergo neuraxial anaesthesia for several reasons and in different trimesters. The altered physiological state in a parturient is further [...]

Byline: Minati. Choudhury The annual heart transplant rate is gradually increasing worldwide. A proportion of this patient population present for an elective or emergency surgery which may or may not [...]