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To determine the most effective dose regimen of aprotinin for infants undergoing arterial switch operation for transposition of the great arteries in reducing blood loss and postoperative packed red blood cell (PRBC) requirements. A total of 24 infants scheduled for arterial switch operation for transposition of the great arteries were included in the study. The infants were randomly assigned to one of the three groups. Group I (n = 8) patients received aprotinin in a dose of 20,000 kallikrein inhibiting units (KIU)/kg after induction of anesthesia, 20,000 KIU/kg was added to the pump prime, and 20,000 KIU/kg/hour infusion for three hours after weaning from bypass; group II (n = 8) patients received aprotinin 30,000 KIU/kg after induction of anesthesia, 30,000 KIU/kg was added to the pump prime and 30,000 KIU/Kg/hour infusion for three hours after weaning from bypass; group III patients (n = 8) received aprotinin 40,000 KIU/kg after induction of anesthesia, 40,000 KIU/kg was added to the pump prime and 40,000 KIU/kg/hour infusion for three hours after weaning from bypass. Postoperatively, the cumulative hourly blood loss and PRBC requirements were noted up to 24 hours from the time of admission in the intensive care unit (ICU). Use of blood and blood products were noted. Coagulation parameters such as hematocrit, activated clotting time (ACT), fibrinogen, prothrombin time (PT), international normalized ratio (INR), platelet count, and fibrin degradation products (FDP) were investigated before cardiopulmonary bypass (CPB), after protamine administration, and at four hours postoperatively in the ICU. The number of infants reexplored for increased mediastinal drainage was recorded. Renal functions were monitored by measuring urine output (hourly) and serum urea (mg%) and serum creatinine (mg%) at 24 hours. The sternal closure time was comparable in all the three groups. Cumulative blood loss (ml/kg/24 hours) was greatest in group I (17.30 ± 7.7), least in group III (8.14 ± 3.17), whereas in group II, it was 16.45 ± 6.33 (P = 0.019 group I versus group III; (P = 0.036 group II versus group III). Postoperative PRBC requirements were significantly less in high dose group III (P = 0.008, group I versus III; p = 0.116, group II versus group III) . Tests for coagulation performed at four hours postoperatively, viz. ACT, PT, INR, FDP, and platelets were comparable in the three groups. Urine output on CPB was comparable in all the groups. Serum urea and creatinine showed no significant difference between the three groups twenty four hours postoperatively. Aprotinin dosage regimen of 40,000 KIU/kg at induction, in CPB prime and postoperatively for three hours was most effective in reducing postoperative blood loss and PRBC transfusion requirements. Aprotinin does not have any adverse effect on renal function.

Surgery and anaesthesia are known to cause stress response. Attenuation of stress response can decrease morbidity, postoperative hospital length of stay and, thus, cost. Intrathecal and epidural techniques produce reliable analgesia in patients undergoing surgery along with stress response attenuation. The present study was undertaken to evaluate the efficacy of caudal sufentanil and bupivacaine combination on perioperative stress response in paediatric patients undergoing open heart surgery. Thirty patients (ASA grade II-III) undergoing elective corrective cardiac surgery for acyanotic congenital heart disease, were randomly allocated to two groups. In group GA ( n = 15), patients received balanced general anaesthesia. In group GC ( n = 15), in addition to general anaesthesia, caudal block with bupivacaine and sufentanil combination was given after endotracheal intubation. Monitoring included electrocardiography, invasive arterial pressure, end-tidal carbon dioxide, pulse oximetry, arterial blood gases including serum electrolytes, blood glucose, serum cortisol, urine output, central venous pressure and temperature. Haemodynamic responses in both groups were statistically similar. Serum cortisol levels were significantly lower in GC group than GA group ( P < 0.05) after sternotomy (9.8±7.5 vs. 34.74±27.35), on cardiopulmonary bypass (CPB) (12.17 ± 6.2 vs. 35.36 ± 24.15), after sternal closure (14.03 ± 5.1 vs. 37.62 ± 20.69), 4 hours (26.64 ± 14.61 vs. 37.62 ± 9.13) and 24 hours (14.30 ± 8.11 vs. 28.12 ± 16.31) after intubation. Blood glucose levels were significantly higher in GA group as compared to GC group at sternal closure (277.46 ± 77.25 vs.197.73 ± 42.17) and 4 hours (255.26 ± 73.73 vs. 185.26 ± 57.41) after intubation ( P < 0.05). To conclude, supplementation of caudal epidural bupivacaine and sufentanil could effectively attenuate the stress response in paediatric patients undergoing cardiac surgery under CPB in acyanotic congenital heart anomaly.

Byline: Usha. Kiran, Arindam. Dutta, Alok. Mehra, Sambhu. Das, Khalid. Zuber An 8-week old 3-kilogram male baby was brought to this tertiary care hospital with respiratory distress, marked tracheal tug, [...]

Maintenance of sinus rhythm (SR) is superior to rate control in atrial fibrillation (AF). In order to achieve SR, we administered single-dose intravenous amiodarone intraoperatively and evaluated its effect on conversion of rheumatic AF to SR in patients undergoing valvular heart surgery. Patients were randomly assigned to amiodarone ( n = 42) or control ( n = 40) group in a double blind manner. The amiodarone group received amiodarone (3 mg/kg) intravenously prior to the institution of cardiopulmonary bypass and the control group received the same volume of normal saline. In the amiodarone group, the initial rhythm after the release of aortic cross clamp was noted to be AF in 14.3% ( n = 6) and remained so in 9.5% ( n = 4) of patients till the end of surgery. In the control group, the rhythm soon after the release of aortic cross clamp was AF in 37.5% ( n = 15) ( p = 0.035) and remained so in 32.5% ( n = 13) of patients till the end of surgery ( p = 0.01). At the end of first post-operative day 21.4% ( n = 9) of patients in amiodarone group and 55% ( n = 22) of patients in control group were in AF ( p = 0.002). The requirement of cardioversion/defibrillation was 1.5 (±0.54) in amiodarone group and 2.26 (±0.73) in the control group ( p = 0.014), and the energy needed was 22.5 (±8.86) joules in the amiodarone group and 40.53 (±16.5) in the control group ( p = 0.008). A single intraoperative dose of intravenous amiodarone increased the conversion rate of AF to normal sinus rhythm, reduced the need and energy required for cardioversion/defibrillation and reduced the recurrence of AF within one day.

Thirty children undergoing cardiac surgery under cardiopulmonary bypass (CPB) were prospectively studied to assess beneficial effects of modified ultrafiltration (MUF) over and above conventional ultrafiltration (CUF). Transoesophaegeal echocardiography determined ejection fraction (EF), fractional area change (FAC) and posterior wall thickness in end-diastole and end-systole were measured and compared in two groups undergoing CUF (group I) and CUF plus MUF (group II). Haemodynamic data, haematocrit, temperature drift, postoperative chest tube drainage in first 48 hours, ventilation and intensive care unit (ICU) stay were also recorded. Within group data were analysed by general linear trend and intergroup comparisons were made with t-test. EF and FAC decreased at 0 min after CPB in both groups, but both recovered at 10 and 30 min after CPB in group II. Increase in EF and FAC in group II was about 12-15 % and 3-5 % from 0 min respectively. There was also significant improvement in posterior wall thickness and haematocrit (P<0.05) in group II. Patients in group II maintained better systolic blood pressure and heamoglobin after CPB. Chest tube drainage in first 48 hours was significantly less in group 1I (100 -18 verses 85 +/-20 ml, P<0.05), but ventilation and ICU stay were not different between the two groups. Combined ultrafiltration has beneficial effect an haemodynamics with improvement in EF and FAC. It improves haematocrit and decreases chest pulse drainage.