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OBJECTIVE: To assess the association of vaginal commensal and low grade pathogenic bacteria including Ureaplasma parvum, Ureaplasma urealyticum, Mycoplasma hominis, Mycoplasma genitalium, Group B Streptococcus (GBS), and Gardnerella vaginalis, in women who delivered preterm at less than 37 weeks gestation in the presence or absence of inflammation of the chorioamnionitic membranes.METHODS: A case control study involving women who delivered before 37 weeks gestation with and without inflammation of chorioamnionitic membranes. A total of 57 placental samples were histologically examined for polymorphonuclear leukocyte infiltration of placental tissue for evidence of chorioamnionitis, and by type-specific nucleic acid amplification for evidence of infection with one or more of the target bacteria. Demographic data was collected for each mother.RESULTS: Amongst the 57 placental samples, 42.1% had chorioamnionitis and 24.6% delivered in the second trimester of pregnancy; U. parvum, U. urealyticum, G. vaginalis and GBS were all detected in the study with respective prevalence of 19.3%, 3.5%, 17.5% and 15.8%; M.genitalium and M. hominis were not detected. U. parvum was significantly associated with chorioamnionitis (p value = 0.02; OR 5.0; (95% CI 1.2-21.5) and was more common in women who delivered in the second (35.7%) compared to the third trimester of pregnancy (13.9%). None of the other bacteria were associated with chorioamnionitis or earlier delivery and all G.vaginalis positive women delivered in the third trimester of pregnancy (p value 0.04).CONCLUSIONS: The detection of U. parvum in placental tissue was significantly associated with acute chorioamnionitis in women presenting in extreme preterm labour.

MARFAN SYNDROME is an autosomal disorder of connective tissue with variable manifestations primarily involving the cardiovascular, musculoskeletal, and ocular systems.1 It is serious because of its cardiovascular complications.2 The most striking cardiovascular lesions are progressive dilation of the aortic root with a resultant ascending aortic aneurysm and aortic valve incompetence. Replacement of the aneurysmal aorta with a prosthetic graft prolongs the life expectancy in patients with Marfan syndrome. Cardiopulmonary bypass (CPB) is necessary, and profound hypothermia and total circulatory arrest are often required for this procedure. Heparin has been used as the anticoagulant of choice since 1953, and activated coagulation time (ACT) is the most common intraoperative test to monitor heparin anticoagulation during extracorporeal circulation.3-7 Infrequently, a large amount of heparin may be necessary to prolong the ACT to 400 seconds. This condition is known as heparin resistance, the definite cause of which has not been well understood.8-11 Heparin resistance was observed in 3 patients with Marfan syndrome who underwent surgery for the associated aortic aneurysm. Of the 3 patients, 1 patient had antithrombin III (AT III) deficiency, whereas in the other 2 the level of this protein was found to be normal. The authors posed the question: Is there any association between heparin resistance and Marfan syndrome?

ECTOPIA CORDIS, a rare congenital anomaly, presents as a neonatal emergency demanding early surgical intervention. Anesthetic and intensive care management of a patient with ectopia cordis can be challenging. The anatomic defects comprising this disorder include an extrathoracic heart with associated sternal, chest wall, pericardial, and abdominal wall defects in addition to intracardiac anomalies, such as septal defects, tetralogy of Fallot, and ventricular diverticula, and craniofacial, renal, and anorectal anomalies. Despite improvements in surgical, anesthetic, and intensive care management, survivors are consistently rare.1,2 Although the surgical management of ectopia cordis has been well described in the available literature,3-5 anesthetic management and perioperative critical care need more elaboration. The case of a neonate with ectopia cordis who presented to this referral center is reported with the aim of increasing awareness about this unusual congenital anomaly and conceivably improving future outcomes.

Background . Aprotinin and epsilon aminocaproic acid are antifibrinolytic agents used to reduce postoperative blood loss after cardiopulmonary bypass. We compared low dose aprotinin with epsilon aminocaproic acid and a combination of the two agents to reduce postoperative blood loss in infants with congenital cyanotic heart disease undergoing corrective surgical procedures. Methods . This prospective study was conducted randomly on 300 children. Group I (n = 80) acted as the control and did not receive either of the study drugs. Group II (n = 100) received low dose aprotinin, group III (n = 60) received epsilon aminocaproic acid, and group IV (n = 60) received a combination of the two antifibrinolytic agents. Results . The control group had the longest time for sternal closure, maximum blood loss at 24 hours, and greatest requirements for packed red blood cells and platelets. Fibrinogen levels were significantly lower, and levels of fibrin breakdown products were significantly higher compared with the groups given either or both of the antifibrinolytics. Conclusions . Epsilon aminocaproic acid is as efficacious as low dose aprotinin in reducing postoperative blood loss and packed red blood cell and platelet requirements in children with congenital cyanotic heart disease. The combination of the two was slightly more effective.

Postoperative blood loss, blood and blood-product requirements, and complications were compared for 3 commonly used doses of epsilon-aminocaproic acid in 150 patients undergoing first-time coronary artery bypass surgery. The patients were randomly assigned to one of 4 groups. Group 1 (n = 30) served as a control, group 2 (n = 30) received a single dose of 150 mg·kg−1 of epsilon-aminocaproic acid after anesthetic induction, group 3 (n = 30) received a loading dose of 150 mg·kg−1 followed by infusion of 1 g·h−1 for 6 hours, and group 4 (n = 60) received doses of 150 mg·kg−1 at induction, on bypass, and after protamine. No patients, including those who had endarterectomies, experienced any complications attributable to epsilon-aminocaproic acid administration. All patients who received epsilon-aminocaproic acid had significantly less bleeding compared to controls. Groups 3 and 4 had the least blood loss and packed-cell requirements.

Objective: To determine if quicker cardiac standstill obtained by adding adenosine to potassium crystalloid cardioplegia translated into better myocardial preservation and cardiac function in the early postoperative period compared with the same cardioplegia without adenosine. Design: A prospective study. Setting: Cardiac center of a teaching institute. Participants: Sixty consecutive patients with left main vessel or triple-vessel disease undergoing coronary artery bypass surgery under moderate hypothermia. Interventions: The study comprised two groups of patients. Group N (n = 15) was the control group, given St Thomas cardioplegic solution after aortic cross-clamping, without adenosine; whereas group A (n = 45) received 250 μg/kg of adenosine into the aortic root after aortic cross-clamping, followed by the same St Thomas cardioplegia as in group N. The two groups were otherwise similar in all aspects of perfusion management. Measurements and Main Results: Time taken to achieve cardiac standstill after aortic cross-clamping was significantly greater, 18.7 ± 3.1 seconds, in the control group compared with the adenosine group, 3.4 ± 0.9 seconds (p < 0.001). The quicker arrest of the adenosine group led to better postoperative function, in the form of higher cardiac index (p < 0.01), lower filling pressures (pulmonary artery wedge pressure) (p < 0.05), and lower mean pulmonary artery pressure (p < 0.05) at 6 hours. In the adenosine group, only 3 of 45 (6.6%) patients had elevated creatine phosphokinase (CPK) (MB) values greater than 50 U/L over preoperative CPK values compared with 3 of 15 (20%) in the control group (p < 0.01). Conclusions: Injection of 250 μg/kg of adenosine into the aortic root before administration of cold crystalloid St Thomas cardioplegia solution after cross-clamping, in patients with severe coronary artery disease, produces significantly faster cardiac standstill, better myocardial preservation, and better cardiac function in the early postoperative period.

In a prospective randomized study from October to December 1996 at the All India Institute of Medical Sciences, we compared normothermic cardiopulmonary bypass with conventional hypothermic bypass. Sixty patients undergoing open-heart surgery for valvular heart disorders were assigned to undergo either normothermic bypass (35°C to 37°C, n = 30) or moderate hypothermic bypass (28°C, n = 30). Bypass time, pump flow, urine output, need for vasopressors, arterial blood gases on bypass, duration of cardioplegia, need for defibrillation, postoperative blood loss, rewarming time to a peripheral (toe) temperature above 35°C, awakening time, and neurologic outcome were studied. Mean bypass time in the normothermic patients (67.33 ± 23.5 minutes) was 23% less (p < 0.05) than in the hypothermic group (89.6 ± 49.26 minutes). Higher flows were required initially in the normothermic group due to low systemic vascular resistance. Early return of sinus node electrical activity in patients (70%) in the normothermic group required more frequent use of topical ice slush and cardioplegia administration. Postoperative blood loss was similar in both groups but fluid and blood requirements in the normothermic group (514 ± 220 mL·m−2) was significantly less (p < 0.05) than in the hypothermic group (722.3 ± 383 mLm−2). Normothermic patients rewarmed earlier (4.25 ± 1.79 hours) to peripheral (toe) temperatures above 35 °C and awoke earlier compared with the hypothermic group, which took a mean time of 6.1 ± 2.3 hours to rewarm. We concluded that normothermic bypass is more physiologic and significantly reduces bypass time while avoiding the deleterious effects of hypothermia.

During cardiac catheterization, a 2(1/2)-year-old boy developed sudden cardiac arrest. The presence of a long QT interval in the electrocardiogram (ECG) along with ventricular arrhythmia and syncope at that moment enabled us to diagnose long QT syndrome (LQTS). Immediate defibrillation and beta-blocker (metoprolol) therapy saved the life of the child. Cardiac catheterization was completed and the child was planned for Fontan operation. Beta-blocker coverage, prevention of sympathetic stimulation and avoidance of agents which prolong the QT interval made anesthesia uneventful. There were episodes of ventricular fibrillation (VF) in the postoperative period. The child was managed with electrical defibrillation, metoprolol and magnesium.

Myasthenia gravis is a challenging situation for anaesthesiologists due to its neuromuscular involvement. The main concerns are respiratory muscle weakness and side effects due to a heavy dose of anticholinesterases. This limits the use of sedatives, hypnotics and muscle relaxants. Inhalational anaesthetics are best suited. We describe our experience with sevoflurane as a sole anaesthetic in a child having juvenile-type myasthenia gravis with thymoma, who underwent thymectomy by midsternal incision. Very smooth and short duration of induction (35 s) and easy intubation within 60 s without use of muscle relaxant were the remarkable features. Sevoflurane in oxygen and nitrous oxide (MAC=0.5-0.7) was used for maintenance of anaesthesia. Recovery was smooth and fast with no residual respiratory insufficiency. Hence we found sevoflurane to be a highly suitable agent for thymectomy in mysthenia gravis.

A N E U R Y S M OF the ductus arteriosus (DAA) is a relatively rare but potentially fatal condition. The aneurysm may occur either spontaneously or result as a complicat ion after surgical closure of a patent ductus arteriosus (PDA). 1,2 Forty cases of D A A after surgical closure of P D A have been reported to date. 2,3 The diagnosis o f D A A in the pre-1969 period was established at autopsy or during exploratory thoracotomy for suspected lung or mediast inal tumor. 4 D A A is now more frequently diagnosed preoperat ively because of improved diagnostic methods, such as echocardiography 5 and computed tomography. The authors present the successful anesthetic management of a very large false aneurysm of the ductus arteriosus (DA) that presented as a case o f collapse and consolidat ion o f the left lung.

A large number of patients scheduled to undergo elective coronary artery bypass grafting continue to take aspirin along with other antianginal medication up to the day of surgery. Patients taking aspirin preoperatively are known to bleed more in the postoperative period than those not taking aspirin. This study was undertaken to determine whether the method of heparin administration (protocol-based bolus dose versus an individualized dose) affected postoperative blood loss or requirements of blood and blood products in patients taking aspirin preoperatively. In this prospective study, 300 consecutive patients taking aspirin prior to coronary artery bypass graft surgery were randomly assigned to receive heparin either as a protocol-based bolus of 400 IU·kg−1 (group A) or according to a dose-response curve to obtain an activated coagulation time of 500 seconds on cardiopulmonarybypass (group B). Group B required significantly less heparin (mean 275 IU·kg−1)and less protamine than group A. Postoperative blood loss, requirement of blood and blood products, and time spent on hemostasis in group B was significantly less at 24 hours than group A. We concluded that individualized dosing of heparin using a dose-response curve is preferable to a protocol-based bolus heparin dose in patients taking preoperative aspirin.

Haemodilution resulting from crystalloid priming of the cardiopulmonary bypass (CPB) circuit is one of the important reasons for blood transfusion in cardiac surgery, especially in patients with low body surface area (BSA). A prospective study was performed to investigate the technique of intraoperative blood donation (IAD) and retrograde autologous priming (RAP) to limit haemodilution and transfusion requirements. Forty patients with low BSA (1.7 m2) undergoing primary valvular cardiac surgery were assigned to either RAP group or a control group (C). The RAP group (n=20) was subjected to IAD by collecting a calculated volume of blood (272+/-44.3 mL) after induction of anaesthesia. Prior to initiation of CPB the prime volume was reduced by discarding some of it and the CPB reservoir was filled retrogradely through the aortic cannula draining 482+/-78.4 mL of blood. In group C (n=20) only IAD was carried out collecting 295.0+/-62.6 mL of blood. Anaesthetic technique was similar in both groups. Strict transfusion thresholds were observed. There were no significant difference between the groups with respect to baseline characteristics, BSA, type of procedure, perfusion technique and haematologic profile. The haematocrit on CPB was significantly higher in the RAP group as compared with group C (24.2+/-1.3% and 22.1+/-2.5% respectively, p=0.009). Transfusion of allogenic blood during and after surgery was significantly lower in the RAP group (143.6+/-117 mL) versus 405.2+/-358.1 mL in group C (p=0.02). Postoperative chest tube drainage was 218+/-67.4 mL in the RAP group and 300+/-191 mL in group C which was not significantly different (p=0.18). The technique of intraoperative autologous donation and retrograde priming is simple, safe and cost effective procedure for blood conservation in patients with small BSA undergoing primary valvular surgery.

Background . The immediate and intermediate-term neurodevelopmental outcome in infants undergoing open heart procedures using deep hypothermic cardiopulmonary bypass was assessed prospectively. Methods . One hundred consecutive infants (age 2 to 174 days) were operated on using either deep hypothermic bypass only (group A, n=28), or with associated circulatory arrest (group B, n=72). Early neurological outcome was recorded. Survivors underwent mental development evaluation after 31 to 55 months. Fifty other children of similar demographic profile but without heart disease were also tested as controls. Results . In group A, there were two neurological deaths. In group B, 5 patients had clinical seizures, 1 had monoparesis and 1 had hyperkinetic syndrome with decreased attention span. Mean mental performance quotient was 90.0 ± 8.2 in group A, and 89.1 ± 6.8 in group B, (group A vs. B, p = 0.60). Mean mental performance quotient in the control group was 101.4 ± 8.4, which was significantly higher than the patient population ( p ≪ 0.001). No correlation was found between duration of circulatory arrest and postoperative mental performance quotient. Conclusions . There was significant retardation of mental development in infants operated with deep hypothermic cardiopulmonary bypass. However, use of total circulatory arrest and its duration did not affect clinical outcome up to preschool age.

Objective: To compare radial and femoral artery perfusion pressure during initiation and various stages of cardiopulmonary bypass (CPB). Design: Prospective study. Setting: The cardiac center of a tertiary referral teaching institute. Participants: Sixty consecutive patients of all ages undergoing a variety of cardiac operations. Interventions: Radial and femoral arterial pressures were measured in all patients on the same transducer, from the beginning to end of CPB. Measurements and Main Results: Mean perfusion pressures on CPB measured at the femoral artery at 1, 5, 10, and 15 minutes of CPB were 38.4 ± 3.6, 46.2 ± 3.1, 49.7 ± 3.9, and 52.8 ± 4.1 mmHg and were significantly greater than the corresponding radial artery pressures (29.9 ± 4.1, 35.3 ± 6.1, 40.9 ± 4.8, and 41.8 ± 5.3 mmHg) (p < 0.001). At 30 minutes and 60 minutes of CPB, femoral artery pressures are higher (60.3 ± 8.8 mmHg and 66.4 ± 8.2 mmHg) compared with radial artery pressures (54.7 ± 6.9 mmHg and 59.6 ± 6.1 mmHg), but the difference is less significant (p < 0.05). On conclusion of CPB, mean femoral artery pressures (70.9 ± 6.7 mmHg) are greater than mean radial artery pressures (67.6 ± 8.1 mmHg) (NS). Conclusions: Although radial artery pressures are more commonly monitored during cardiac surgery, femoral artery perfusion pressures are more reliable during the initial part of CPB, and routine monitoring of femoral artery pressures may prevent vasoconstrictor use on initiation of CPB. Copyright © 2000 by W.B. Saunders Company

Intracranial pressure was measured in 12 hydrocephalic children during ketamine anesthesia. Of the four who received no premedication, intracranial pressure increased in three and decreased in one patient. Seven out of eight children who received premedication with trimeperazine tartrate (3 mg/kg) orally showed a decrease in pressure. One patient who had a high initial pressure showed a steep rise necessitating termination of the study. Second dose of ketamine (1 mg/kg iv) produced a fall in all patients, being more prominent in those who had an elevation after the first dose. It is possible that the premedicants alter the response of cerebral vasculature to ketamine leading to a fall in intracranial pressure. Another possibility is that the standard intravenous dose of ketamine (2 mg/kg) is not uniformly effective in all patients of hydrocephalus.

A case report describing anesthetic management of a child suffering from cancrum oris is described. The patient presented with respiratory obstruction with necrotic lesions of the skin surrounding the mouth and of oral mucosa. Generalised septicemia was present. It was not possible to pass an endotracheal tube and anesthesia was therefore achieved with intravenous infusion of ketamine without the use of an airway or endotracheal tube.