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   Table of Contents - Current issue
May-August 2022
Volume 16 | Issue 2
Page Nos. 23-46

Online since Friday, September 2, 2022

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Perioperative anesthetic management of transposition of great arteries: a review p. 23
Vishnu Datt, Suman Kashav, Rachna Wadhwa, Shardha Malik, Saket Agarwal, Harpreet Singh Minhas, Prashant Rai
Transposition of great arteries (TGA) comprises 5–7% of all CHDs. It is characterized by atrioventricular concordance and ventriculoarterial discordance, resulting in the systemic and pulmonary circulations as parallel instead of the normal in-series circulation. Survival of the baby depends on mixing of blood between these two circulations either with an atrial septal defect, ventricular septal defect, or at the great arterial level via patent ductus arteriosus. Therefore, the clinical manifestation is highly variable and influenced by the presence or absence of these associated anomalies. Patients with TGA without mixing of blood present with cyanosis and acidosis and are hemodynamically compromised soon after birth and require resuscitation to re-establish connection between parallel circuits by reopening the ductus with intravenous prostaglandin (0.05–0.1 μg/kg/min) or establishing interatrial flow with balloon atrial septostomy. In addition, patients may require inotropic support, ventilator support, or extracorporeal membrane oxygenation in extreme cases with refractory cardiorespiratory decompensation for survival or as a bridge to definitive therapy. TGA is uniformly fatal in the infant period, with 30% mortality in the first week of life, and 50% within the first month, and 90% in the first year of life if untreated. Fortunately, modern medical and surgical management techniques have resulted in 90% of patients living into adulthood, typically with a vigorous quality of life. Currently, the definitive corrective surgery is the arterial switch operation (ASO), as a single-stage procedure with excellent short-term and long-term outcomes. The overall perioperative survival following ASO is more than 90%. Long-term and arrhythmia-free survival is ∼97% at 25 years. All standard general anesthetics can be used safely for perioperative management, and mortality owing to anesthetic management has not been witnessed. This systematic review describes the definition and etiology of TGA, clinical presentation, pathophysiology, brief current surgical approaches, anesthetic and cardiopulmonary bypass management, and postoperative course of a patient with TGA undergoing ASO.
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Hemodynamic and analgesic aspects in conscoius sedation for chronic subdural hematoma evacuation: a rendomized controlled comparison between magnesium sulphate versus fentanyl p. 36
Rania S Fahmy, Amal A Elsawy, Maha Mostafa, Ahmed Hasanin, Tarek Radwan, Nasr M Abdallah
Objectives Subdural hematoma evacuation has been performed under general anesthesia, local anesthesia, and conscious sedation, though the adequacy of any of those techniques on its own is questionable. We aimed to compare the hemodynamic and analgesic effects of magnesium sulfate versus fentanyl as adjuncts to propofol-induced conscious sedation in patients subjected to chronic subdural hematoma (CSDH) evacuation with local infiltration. Patients and methods In this randomized controlled trial, we included adult patients with CSDH undergoing evacuation through burr-hole surgery. All patients received continuous infusion of propofol. Patients in the magnesium group (n=16) received magnesium sulfate (loading dose of 50 mg/kg and then continuous infusion at 15 mg/kg/h). Patients in the fentanyl group (n=16) received fentanyl (loading dose: 1 μg/kg and then continuous infusion at 0.5 μg/kg/h). The primary outcome was intraoperative systolic blood pressure. The secondary outcomes included incidence of hypotension and bradycardia, the total dose of propofol, time to awake, and the incidence of postoperative nausea and vomiting. Results A total of 32 patients were analyzed. The average intraoperative systolic blood pressure was better maintained in the magnesium group. Furthermore, the incidence of hypotension, nausea, and vomiting was lower in the magnesium group. The time to awake was shorter in the magnesium group. The incidence of bradycardia, total propofol requirements, time to first rescue analgesia, and surgeon satisfaction were comparable between groups. Conclusion Magnesium sulfate was associated with a better hemodynamic profile and less incidence of nausea and vomiting in comparison with fentanyl when combined with propofol for conscious sedation during CSDH evacuation. It produced an anesthetic-sparing effect comparable to fentanyl.
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Anesthetic management of a multiple and mixed cardiac valvular disease for noncardiac surgery: a case report p. 43
Reena R Kadni, Ranjan Nayak, Mita E Sarkar, Laji Abraham Samuel
A thorough knowledge of pathophysiology of multiple and mixed valvular heart disease is a requirement for a stable perioperative care. We present anesthetic management of a 62-year male patient with bivalvular mixed lesions with gastric adenocarcinoma for gastrectomy. Fixed-output cardiac state, anemia, maintenance of hemodynamic goals for longer duration, and postoperative analgesia were the anesthetic concerns. Hemodynamic aberrations can be inevitable in such scenario. Proper understanding of the lesions, optimization, preparation, and planning for anticipation of adverse hemodynamic events plays a crucial role for expecting a better clinical outcome.
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