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BackgroundAppropriate placement of left-sided double-lumen endotracheal tubes (LDLTs) is paramount for optimal visualization of the operative field during thoracic surgeries that require single lung ventilation. Appropriate placement of LDLTs is therefore confirmed with fiberoptic bronchoscopy (FOB) rather than clinical assessment alone. Recent studies have demonstrated lung ultrasound (US) is superior to clinical assessment alone for confirming placement of LDLT, but no large trials have compared US to the gold standard of FOB. This noninferiority trial was devised to compare lung US with FOB for LDLT positioning and achievement of lung collapse for operative exposure.MethodsThis randomized, controlled, double-blind, noninferiority trial was conducted at the Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand from October 2017 to July 2019. The study enrolled 200 ASA classification 1-3 patients that were scheduled for elective thoracic surgery requiring placement of LDLT. Study patients were randomized into either the FOB group or the lung US group after initial blind placement of LDLT. Five patients were excluded due to protocol deviation. In the FOB group (n = 98), fiberoptic bronchoscopy was used to confirm lung collapse due to proper positioning of the LDLT, and to adjust the tube if necessary. In the US group (n = 97), lung ultrasonography of four pre-specified zones (upper and lower posterior and mid-axillary) was used to assess lung collapse and guide adjustment of the tube if necessary. The primary outcome was presence of adequate lung collapse as determined by visual grading by the attending surgeon on scale from 1 to 4. Secondary outcomes included the time needed to adjust and confirm lung collapse, the time from finishing LDLT positioning to the grading of lung collapse, and intraoperative parameters such has hypotension or hypertension, hypoxia, and hypercarbia. The patient, attending anesthesiologist, and attending thoracic surgeon were all blinded to the intervention arm.ResultsThe primary outcome of lung collapse by visual grading was similar between the intervention and the control groups, with 89 patients (91.8%) in the US group compared to 83 patients (84.1%) in the FOB group (p = 0.18) experiencing adequate collapse. This met criteria for noninferiority per protocol analysis. The median time needed to confirm and adjust LDLT position in the US group was 3 min (IQR 2-5), which was significantly shorter than the median time needed to perform the task in the FOB group (6 min, IQR 4-10) (p = 0.002).ConclusionsIn selected patients undergoing thoracic surgery requiring LDLT, lung ultrasonography was noninferior to fiberoptic bronchoscopy in achieving adequate lung collapse and reaches the desired outcome in less time.Trial registrationThis study was registered at clinicaltrials.gov, NCT03314519 , Principal investigator: Kasana Raksamani, Date of registration: 19/10/2017.

Background: Cardiopulmonary bypass (CPB) activates inflammatory and fibrinolytic pathways, potentially disrupting hemostasis. Transfusion of non-red cell blood product is a conventional method of restoring hemostasis and treating coagulopathy and thrombocytopenia, the two common adverse outcomes of CPB. Objective: To determine the incidence and outcomes of postoperative thrombocytopenia and coagulopathy in adult Thai cardiac surgery patients with CPB receiving non-red cell blood product transfusions. Materials and Methods: The present study included patients aged 18 years and older that underwent cardiac surgery with CPB at Siriraj Hospital between January 2017 and June 2018. Enrolled patients were divided into four groups, no non-red cell blood products in Group 1, platelets (PLT) only in Group 2, fresh frozen plasma (FFP) and/or cryoprecipitate (cryo) in Group 3, and PLT, FFP and/or cryo in Group 4. Patients, clinical status and histories, intraoperative outcomes, and perioperative outcomes were collected and assessed for all groups. Postoperative thrombocytopenia was defined by PLT counts less than 100,000 cells/mm³. Coagulopathy was defined by prothrombin time (PT) or activated partial thromboplastin time (aPTT) greater than 1.5 of its institutional reference values. Non-red cell blood product transfusions for cardiac patients were determined by their attending physician. Results: Of the 360 patients included, 61.7% were male, with a mean (±SD) age of 65.3±11.7 years, and BMI of 24.1±4.0 kg/m². Most patients were classified as ASA-PS class 3 (71.9%), had elective surgeries (96.4%), history of antiplatelet use (65.8%), and coronary artery bypass graft (CABG) surgical procedure (56.9%). Postoperative thrombocytopenia was significantly more prevalent in Group 1 at 11.6%, followed by Group 3 at 9.5%, Group 4 at 3.7%, and Group 2 at 0% (p=0.010). Post-operative coagulopathy was more prevalent in Group 3 at 4.8%, followed by Group 2 at 4.1%, Group 1 at 3.9%, and Group 4 at 0.7%. Group 4 had a significantly greater incidence of anticoagulant use at 17.8% (p=0.007) and significantly longer CPB durations compared to the other groups at 146.6±74.7 minutes (p<0.01). Conclusion: The researchers' study confirmed that preoperative antithrombotic use prior to cardiac surgical procedures and longer CPB duration influences physicians' decision to transfuse. The present study recommended prohibiting prophylactic administration of FFP and PLT as well as implementing restrictive non-red cell blood product transfusion strategies. [ABSTRACT FROM AUTHOR]

Purpose The use of an endobronchial blocker in conjunction with a supraglottic device in elective thoracic cases has never been studied. The aim of this study was to report the success rate and time to placement of the endobronchial blocker in anaesthetized patients with a laryngeal mask airway (LMA)-ProSeal[TM] in place. Methods This was a single-center, prospective, descriptive pilot study that enrolled 30 patients aged 18-75 years, with ASA I-III, who underwent elective thoracotomy or video-assisted thoracoscopy. We collected data on time to placement of the endobronchial blocker into the selected bronchus, time consumed for final blocker positioning and inflation, lung deflation score at chest opening, and postoperative airway complications. Results One patient was excluded because of high peak airway pressure during LMA ventilation. The time required for blocker placement in the right main bronchus was shorter [mean 160 (78-480) s] compared with that for the left main bronchus [225 (117-420) s]. The blocker was successfully placed on the first attempt in 25 patients. Lung deflation score graded by the surgeon was 8/10 (median). Minor postoperative airway complications, such as sore throat (28.6 %) and hoarseness of voice (17.9 %), were reported. Conclusions The use of LMA-ProSeal[TM] in conjunction with the COOPDECH Endobronchial Blocker Tube may be considered an alternative one-lung ventilation technique in selected cases. However, success rates and time required for placement of the blocker seem dependent on the operator's skill. Although postoperative sore throat and hoarseness of voice were reported, these improved in 24 h. Electronic supplementary material The online version of this article (doi:10.1007/s00540-015-2004-1) contains supplementary material, which is available to authorized users., Author(s): Prasert Sawasdiwipachai[sup.1] , Settapong Boonsri[sup.1] , Sirilak Suksompong[sup.1] , Paron Prowpan[sup.1] Author Affiliations: (1) Mahidol University, Bangkoknoi, Bangkok, Thailand Introduction Anesthesia for thoracic surgery frequently employs one-lung ventilation (OLV) [...]

Background: Postoperative hypothermia (PH) may result in perioperative complications such as adverse cardiovascular events, coagulopathy with consecutive blood loss, and wound infection. Patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) are at risk for hypothermia throughout the postoperative period. Objective: To determine the incidence and risk factors of PH in patients after open cardiac surgery. Materials and Methods: The present study was a retrospective cohort study of patients that underwent open cardiac or thoracic aortic surgery using CPB between January and December 2013. Patient characteristics, clinical data, and perioperative outcomes were abstracted and analyzed. PH was defined as body temperatures of less than 36℃ upon arrival at the cardiac surgical intensive care unit (CSICU). Postoperative outcomes including bleeding from the chest tube, postoperative inotropic support, ventilator days, CSICU length of stay, and mortality were reviewed. Results: Seven hundred sixty patients were included in the present study with 60.4% male, a mean age of 61.7 years, and 92.4% elective surgery with 96.3% first time surgery. The incidence of PH was 43.4%. Multiple logistic regression analysis demonstrated that factors associated with PH were increasing age (odds ratio 1.013 per year, 95% CI 1.002 to 1.023, p=0.020), female patients (odds ratio 1.40, 95% CI 1.03 to 1.89, p=0.032), deep hypothermia during CPB (odds ratio 2.33, 95% CI 1.26 to 4.30, p=0.007), and administration of more than 3L of intravenous fluid including crystalloids, colloids, and blood products, after separation of CPB until discharge from the operating room (OR) (odds ratio 1.52, 95% CI 1.09 to 2.12, p=0.014). Conclusion: Approximately 43.4% of the cardiac surgical patients develop hypothermia following open cardiac or thoracic aortic surgeries. Factors associated with PH were increasing age, female patients, deep hypothermia during CPB, and administration of more than 3L of intravenous fluid after separation of CPB until discharge from the OR. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the report "A comparison of fibrinogen measurement methods with fibrin clot elasticity assessed by thromboelastometry, before and after administration of fibrinogen concentrate in cardiac surgery patients," by C Solomon and colleagues.

Background: Pain after major craniotomy has been believed to be less severe than the other operations., Objective: To determine the incidence and risk factors of moderate to severe pain after major craniotomy., Material and Method: This is a prospective observational study in a neurosurgical intensive care unit and wards of a university, tertiary hospital. After institutional IRB approval, patients undergoing major craniotomy during May 2011-August 2012 were interviewed preoperatively and 24 and 48 hours postoperatively. Demographic data, preoperative anxiety scores, operative data and postoperative pain characteristics were recorded., Results: Two hundred and eighty patients completed the study. The incidence of moderate to severe pain was 75%. Mean pain score during 24 and 48 hours were 5.5 ± 2.7 and 3.5 ± 2.6, respectively. Univariate analysis identified age under 45 years and perioperative steroid therapy as predictors of moderate to severe postoperative pain. Using multivariate analysis, only age under 45 years was a significant risk factor. Patients' satisfaction scores were good in both mild and moderate to severe pain groups (9.49 ± 1.08 and 8.37 ± 1.76). During postoperative period, almost all of the patients received intravenous opioid and oral acetaminophen for pain treatment. No respiratory depression occurred, but postoperative nausea and vomiting occurred in 51.7% and pruritus in 23.6%., Conclusion: Incidence of pain after craniotomy was high especially in younger age group, which is not in accordance with all similar reports. However we believe pain management after major craniotomy in our hospital requires improvement.

Objective: To study the patients' characteristics, outcomes, contributory factors, factors minimizing the incidence and suggested corrective strategies for perioperative pulmonary aspiration in Thailand., Material and Method: This is a prospective descriptive research design. The relevant data was extracted from the incident reports on aspiration from 51 hospitals across Thailand during the study period between January 1 and June 30, 2007 from the Thai Anesthesia Incident Monitoring Study (Thai AIMS) database. Descriptive statistics was used. Each incident report was reviewed by three senior anesthesiologists. Any disagreement was discussed to achieve a consensus., Results: From 1,996 incident reports, there were 28 reports (1.4%) that met the definition of pulmonary aspiration. Most of the incidents occurred in patients with ASA 1-2 (85.7%), during the official hour (64.3%) and the anesthesiologists were in charge (67.9%). Eleven incidents (39.3%) occurred during induction, seven (25%) during maintenance and seven (25%) during emergence phases. Anesthetic factors played an important role in 26 incidents (92.9%). All the incidents except one (96.4%) were considered human errors and 25 (89.2%) were preventable. Of the incidents caused by human errors, nine (32.1%) were caused by skill-based errors. Thirteen patients (46.4%) had major physiologic changes and 10 (35.7%) of them needed unplanned ICU admission. Ten patients (35.7%) needed prolonged ventilator support and two (7.14%) of them died., Conclusion: The contributing factors that might lead to the incidents were improper decision (75%), lack of experience (53.5%) and lack of knowledge (21.4%). Factors minimizing incident, were vigilance (85.7%), having experienced assistant (50%) and experience in that situation (25%). Suggested preventive strategies were guidelines practice in anesthetic management (67.8%), improvement of supervision (57.1%), additional training (42.8%) and quality assurance activity (28.6%).

Objective: As part of the Thai Anesthesia Incident Monitoring Study (Thai AIMS), the present study was aimed to analyze the problems of oxygen desaturation in the post-anesthetic care unit in Thailand including clinical course, outcomes, contributing factors, and preventive strategies., Material and Method: The authors prospectively collected incident reports of oxygen desaturation in the post-anesthetic care unit between January and June 2007 from 51 studied hospitals across Thailand Clinical characteristics, outcomes, and contributing factors were recorded. All data were analyzed to identify contributing factors and preventive strategies., Results: Eighty-six of post-anesthetic oxygen desaturation incidents were reported Forty-six cases (53.5%) were diagnosed by pulse oximetry. Forty-eight cases (55.8%) were immediately detected within a minute upon arrival at the PACU. Thirty-one cases (36%) were caused by inadequate awakening. Eighty-two cases (95.3%) were anesthesia-related and preventable. The major clinical outcomes were re-intubation (51 cases; 59.3%), prolonged artificial ventilation (23 cases; 26.7%), unplanned ICU admission (16 cases; 18.6%), and prolonged hospital stay (3 cases; 3.5%). Sixty-three patients (73.3%) recovered completely within 24 hours but one died. Judgment error and lack of adequate patient evaluation were the two most common contributing factors that were minimized by high awareness and prior experience. Main strategies suggested to prevent the incidents included the development of specific guideline and quality assurance. These incidents did not effectively decrease when labor was increased., Conclusion: Post-anesthetic oxygen desaturation was frequently found during the transport period. It can cause morbidity and mortality. Anesthesia providers should be aware of these potential incidents and strictly follow guidelines.

Objectives: Analyze the clinical course, management, outcome, and contributing factors of perioperative allergic reactions in the Thai Anesthesia Incident Monitoring Study (Thai AIMS)., Material and Method: A prospective descriptive multicenter study was conducted in 51 hospitals across Thailand Voluntary, anonymous reports of any adverse or undesirable events during the first 24 hours of anesthesia were sent to the Thai AIMS data management unit. Possible perioperative allergic reactions were extracted and examined independently by three peer reviewers., Results: Forty-three reports of possible perioperative allergic reactions from the 2,537 incidents reported to the Thai AIMS (1.6%) were reviewed. There was a female predominance (1.9:1). The most common features were cutaneous manifestations (93%), arterial hypotension (20.1%), and bronchospasm (11.6%) respectively. The severity grades were 69.8% in grade I, 4.7% in grade II, and 25.6% in grade III. The three most suspected causative agents were neuromuscular blocking agents (39.5%, 30.2%-succinylcholine), antibiotics (27.9%), and opioids (18.6%) respectively. All but one responded well to treatment with complete recovery. One patient suffered acute myocardial infarction and had to stay at the hospital for longer than one week. None had further allergic reaction., Conclusion: Perioperative allergic reactions accounted for 1.6% of anesthetic adverse events. The most common features were cutaneous manifestations. A quarter of these were life-threatening but responded well to treatment. The most common suspected causative agent was succinylcholine.

Background and Rationale: The present study is a part of the Multicentered Study of Model of Anesthesia related Adverse Events in Thailand by Incident Report (The Thai Anesthesia Incident Monitoring Study or Thai AIMS). The objective of the present study was to determine the frequency distribution, outcomes, contributory factors, and factors minimizing incident., Material and Method: The present study is a prospective descriptive research design. The authors extracted relevant data from the incident reports on oxygen desaturation from the Thai AIMS database and analyzed during the study period between January and June 2007., Results: From the relevant 445 incidents, most of the incidents (89%) occurred in patients receiving general anesthesia. The incidence in patients receiving regional anesthesia was 4.0%. The events mostly occurred in patients aged between 16-65 years (52.8%). Most of the events (76%) took place in the operating theater during the induction period (30.1%). More than 81% of the patients experienced severe oxygen desaturation (SpO2 < 85%). There were 55 patients (12.4%) who had unplanned ICU admission and 2 patients (0.4%) who had unplanned hospital admission. Factors that may relate to the incident involve combined factors (50.8%). Anesthetic factors were found to involve 38.4% of incidents. The common contributing factors that might lead to the incidents were inexperienced (57.5%), inappropriate decision (56.2%), and haste (23.8%). For factors minimizing incident, the important factors were vigilance (86.3%), experienced in that tropic (71.2%), and experienced assistance (54.8%). Quality assurance activity was the most common suggestive corrective strategy (79.1%). The others were improvement of supervision (47.2%) and guideline practice (46.5%)., Conclusion: To lower the incidence of oxygen desaturation, the anesthesia personnel has to improve the anesthesia services by quality assurance activity, improvement of supervision, clinical practice guidelines, and additional training.

Children undergoing cardiac operations using cardiopulmonary bypass (CPB) are at risk of significant postoperative bleeding and the need for transfusion. The antifibrinolytic drug, tranexamic acid, decreases blood loss in adult patients undergoing cardiac surgery. However, its efficacy has not been extensively studied in patients with cyanotic congenital heart defects (CHD). Using a prospective, randomized, double-blind study design, we examined 67 children undergoing repair of cyanotic CHD. After induction of anesthesia and prior to skin incision, patients received 15 mg/kg of tranexamic acid intravenously. At the end of CPB, a second bolus of tranexamic acid (15 mg/kg) or saline placebo was administered. Postoperative blood loss and transfusion requirements from the period after protamine administration until 24 hours after admission to the intensive care unit were recorded. In addition, the hematocrit, platelet count and other indices of coagulation were recorded every 6 hours. There was no significant difference in postoperative blood loss between the treated and the placebo group (12.51 +/- 13.20 ml/kg per 24 hours, in the tranexamic acid group, vs 10.68 + 6.38 ml/kg per 24 hours, in the placebo group). Also there was no significant difference in the amounts of blood and blood products administered between the two groups. No adverse effects of tranexamic acid were found in this study. In conclusion, there was no significant difference in postoperative blood loss or blood and blood product requirement between those children with cyanotic CHD undergoing open heart surgery who received a single dose of tranexamic acid compared with those who received two doses.

Objective: To evaluate the anesthetic management in patients undergoing aortic surgery cerebral perfusion; with particular emphasis on under hypothemic circulatory arrest and retrograde intraoperative brain protection, blood salvage and postoperative outcomes., Material and Method: Retrospective case series. Data on medical conditions, anesthesia, surgery and postoperative care from patients who underwent operation between June 1993 and December 1999 were analyzed., Results: There were 53 patients involved in this study. They all received general balanced anesthesia; 70.6 per cent had single-lumen endotracheal intubation, while the remaining required double-lumen endotracheal intubation. The duration of the anesthetic procedure, aortic cross-clamping and circulatory arrest, were 365.58 +/- 89.21, 126.35 +/- 34.64 and 48.35 +/- 19.47 min respectively. The lowest nasopharyngeal and rectal temperature were 17.42 +/- 1.40 degrees C and 21.26 +/- 2.80 degrees C respectively. Thiopental 804.68 +/- 353.93 mg and dexamethasone 14.41 +/- 7.88 mg were administered for brain protection, in addition to retrograde cerebral perfusion; 82.35 per cent received 785.71 +/- 273.86 mg of tranexamic acid and only 23.52 per cent received aprotinin in order to reduce blood loss. However, massive blood replacement therapy was always necessary. In the postoperative period, the patients were ventilated for 39.18 +/- 59.53 h, the length of hospital stay was 14.58 +/- 5.83 d, and the mortality was 13.2 per cent., Conclusion: This preliminary data indicate that hypothermic circulatory arrest in aortic surgery is associated with a high mortality rate, despite attempts to provide adequate cerebral protection as well as intraoperative blood salvage.

Anesthetic management of cardiac patients with complete transposition of the great arteries (TGA) undergoing arterial switch operation (ASO) is challenging. The anesthetic course and perioperative problems were studied. A prospective data collection study of 87 patients was performed between January 1991 and February 2002. The patients were divided into 3 groups: Group 1; 27 neonates with TGA with an intact ventricular septum (IVS), Group 2; 21 with TGA, with IVS who underwent two-stage ASO, and Group 3; 39 with TGA, with a large VSD. The anesthesia consisted of low-dose fentanyl, thiopental, atracurium and isoflurane. Monitoring included ECG, radial or femoral arterial pressure, CVP, LAP, core temperature, SpO2, P(E)CO2, urine output, ABG's, Hct, ACT, serum glucose and potassium. Fortunately the courses of anesthesia were uneventful. Usual vasoactive medication administered following CPB included nitroglycerin, dobutamine and dopamine. Groups I, 2 and 3 contained 18.5 per cent, 14.3 per cent and 33.3 per cent of patients who required adrenaline respectively. And only 7.7 per cent of patients in Group 3 had milrinone as an inotrope. Early tracheal extubation, 2 hours after admission to ICU was performed in 3 patients. Perioperative complications included bleeding, low cardiac output, diaphragmatic paresis, digitalis intoxication, metabolic alkalosis, convulsion, pulmonary hypertensive crisis and death. Two patients who developed a pulmonary hypertensive crisis were successfully managed with inhaled nitric oxide. The overall hospital mortality rate was 19.54 per cent. In conclusion, the anesthetic management for ASO in 87 simple dTGA patients was uneventful at Siriraj Hospital. The major perioperative morbidity and hospital mortality were not directly anesthetic contribution.

Objective: To evaluate neuropsychological dysfunction in patients following elective coronary artery bypass graft surgery at Siriraj Hospital., Patients and Method: One hundred and ten patients who were scheduled for elective coronary artery bypass graft surgery were included in this study. We used the Thai Mental State Examination (TMSE) in order to detectthe presence of cognitive impairment aftercoronary artery bypass graft surgery. The examinations were conducted on two consecutive occasions; first preoperatively, the day before surgery, secondly on the third - fifth postoperative day. The patients' clinical characteristics were assessed perioperatively., Results: The overall occurrence of neuropsychological deficit was 18.18 per cent. Predictors of neuropsychological dysfunction were older age and preexisting disease such as hypertension, hypercholesterolemia and renal insufficiency. Other risk factors such as gender, history of congestive heart failure, myocardial infarction, diabetes mellitus, dysrhythmia, cardiopulmonary bypass time, hemoglobin during cardiopulmonary bypass <7 g/dl, hemoglobin on admission to surgical cardiac care unit <10 g/dl, and atrial fibrillation arising after surgery were not significant., Conclusion: Neuropsychological impairments after coronary artery bypass graft surgery are relatively common. This study did not find an increased incidence with respect to gender as other studies have done. However, long-term follow-up of these patients would be very valuable.

In the present study, the authors compared sufentanil to fentanyl in pediatric patients undergoing congenital cardiac repair. The purpose of the study was to evaluate the hemodynamic variables, time of awakening and successful extubation of the two groups. A prospective, randomized study of 60 children scheduled for elective surgery of congenital cardiac defects was made. Patients were randomly divided into two groups: Group I; sufentanil and Group II; fentanyl (mean body weight, 16.02 +/- 6.67 kg; range 4 to 35 kg; mean age, 5.22 +/- 3.55 years; range 4 months to 1 year). All were premedicated with oral chloralhydrate 50 mg/kg, one hour preoperatively. Anesthesia was induced with sufentanil 1 microg/kg (Group I) or fentanyl 2 microg/kg (Group II) and thiopenthal 2 mg/kg, followed by atracurium 0.6 mg/kg. All patients were intubated with atracurium 0.6 mg/kg. Anesthesia was maintained using isoflurane in oxygen, nitrous oxide (in non-cyanotic patients). In Group I, sufentanil 0.5 microg/kg was administered intravenously prior to skin incision, median sternotomy, cardiopulmonary bypass (CPB) and after coming off CPB. In Group II, fentanyl 1 mg/kg was administered at the same time periods. Hemodynamic parameters, heart rate (HR), systolic (SBP), diastolic (DBP) and mean arterial blood pressure (MAP), central venous pressure (CVP) were recorded. The administration of pain therapy was determined postoperatively. There was no statistical difference in the demographic data between the patients in the two groups. Following induction of anesthesia, the systolic, diastolic and mean arterial pressures and heart rate decreased. Following tracheal intubation, all hemodynamic parameters in the sufentanil group remained below the baseline values, while the fentanyl group showed an increase above baseline values. An increase above control values of all hemodynamic variables was detected in both groups following skin incision and sternotomy, except that the mean systolic blood pressure and heart rate in the sufentanil group was less than the baseline values. No differences in hemodynamic variables were detected between the two groups following median sternotomy and skin closure. There were significant differences in mean arterial pressure at the time of intubation and skin incision between the two groups. No significant changes in CVP occurred. There were no significant differences in the average time of awakening from anesthesia. The average time before postoperative tracheal extubation was 171.38 +/- 112.74 and 113.72 +/- 67.83 minutes in the sufentanil group and fentanyl group respectively, which was statistically significant. There was no difference in the requirements for morphine (pain relief) and sedation with chlolorahydrate between the groups. Bradycardia was found in 7 and 3 patients receiving sufentanil and fentanyl respectively which was not statistically significantly different. The bradycardia recovered in a few minutes, following intravenous injection of atropine. Slow injection of the anesthetic drugs can protect patients against serious bradycardia. In conclusion, the safety and efficacy of sufentanil in patients undergoing repair of complex congenital heart defects was the same as fentanyl. There were no significant differences in times of awakening in the two groups. The patients in sufentanyl group had a longer time to extubate than the fentanyl group. The need of postoperative sedation and analgesia was the same in both groups.