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   2016| July-December  | Volume 10 | Issue 2  
    Online since October 14, 2016

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Protamine adverse reactions in NPH insulin treated diabetics undergoing coronary artery bypass grafting
Hoda Shokri, Ihab Ali, Hoda M El Sayed
July-December 2016, 10(2):25-30
Background The routine use of protamine in cardiac surgery to neutralize heparin is usually associated with systemic reactions that result in substantial morbidity and mortality. Aim This study aimed to investigate the relationship between neutral protamine Hagedorn (NPH) insulin use and severe adverse reactions to intravenous protamine given after cardiopulmonary bypass. Methods After obtaining hospital ethics committee approval and after obtaining informed consent, 100 patients between 45 and 70 years of age of American Society of Anesthesiologist physical status II–III undergoing elective primary isolated coronary artery bypass grafting were included in this prospective study, which was conducted between May 2013 and June 2014. Patients were divided into two groups: the NPH group (50 patients), which included patients who were on NPH insulin preparation for more than 5 years before the study, and the non-NPH group (50 patients), which included patients on oral hypoglycemics. The incidence of protamine reactions was recorded for 30 min after protamine infusion. The incidence of severe hypotension, increased airway pressure, and cardiac arrest were compared using the χ2-test. A P value less than 0.05 was considered significant. Results All patients (50 in each group) completed the study. There was no significant difference in patients’ demographic data, preoperative comorbidities, and surgical factors between the two study groups. The number of patients who had hypotension was significantly higher in the NPH insulin group compared with the non-NPH group. For both groups, there was no significant difference with respect to bronchospasm, cardiac arrest, and increased pulmonary artery pressure. Conclusion This prospective study showed increased risk for hypotension among patients receiving NPH insulin for more than 5 years compared with those who were not exposed to NPH insulin.
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Cardiac surgery in renal transplanted patient : A case report
PS Nagaraja, Naveen G Singh, N Sathish, CG Prabhu Shankar, V Manjunath
July-December 2016, 10(2):42-44
Cardiac surgery causes high mortality among post-renal-transplant patients. These patients are on steroids, which can accelerate atherosclerosis, and on immunosuppressive drugs, which expose the patient to infection. Here we report a case of a post-renal-transplant patient who underwent off-pump coronary artery bypass graft surgery with favorable outcome. In the present case, perioperative renal dysfunction was prevented by maintaining strict asepsis and adequate renal perfusion, by titrating the fluid based on pulmonary artery pressures, by maintaining urine output greater than 1 ml/kg/h, by avoiding cardiopulmonary bypass, and by titrating drugs according to the bispectral index, which resulted in early extubation and better outcome of the patient.
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Remote ischemic preconditioning for myocardial protection during single valvular heart surgery: a randomized-controlled trial
Ahmed M Abd El-Hamid, Ahmed T Abd El-Moneim
July-December 2016, 10(2):31-35
Objectives This study aimed to investigate the potential of remote ischemic preconditioning (RIPC) in myocardial protection after elective single valve replacement. Patients and methods Forty patients were randomized to single valve replacement (mitral or aortic) with RIPC or conventional single valve replacement (control). The RIPC protocol was induced by four (5 min) cycles of upper limb ischemia and (5 min) reperfusion using a blood-pressure cuff. Troponin I level at 30 min preoperatively, 3, 6, 12, and 24 h postoperatively, operative time, the duration of cardioplegia, aortic cross-clamping time, cardiopulmonary bypass time, the length of ICU stay, ventilation time, dose of inotropic support requirements, and hemodynamic parameters (central venous pressure, urine output, and mean arterial pressure) were recorded. Results The RIPC group showed a highly significant decrease in serum troponin level at 6, 12, and 24 h postoperatively. There were no significant differences between groups in operative time, duration of cardioplegia, cross-clamping duration, cardiopulmonary bypass time, and hemodynamic parameters. The length of ICU stay and ventilation time showed a nonsignificant decrease in the RIPC group. Total inotropic support in the first 24 h postoperatively showed a highly significant reduction in the RIPC group. Conclusion RIPC reduced the total amount of troponin I significantly postoperatively; also, it decreased the inotropic support needed postoperatively and nonsignificantly improved the ventilation time and ICU stay time.
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Intraoperative haemodynamic stability and stress response to surgery in patients undergoing thoracotomy: comparison between ultrasound-assisted thoracic paravertebral and epidural block
Ahmed Mostafa Abd El-Hamid, Ayman Fawzy Azab
July-December 2016, 10(2):36-41
Objectives and aim Thoracotomy is a procedure usually associated with severe postoperative pain. This study aimed to evaluate intraoperative haemodynamics and stress response to thoracotomy in patients receiving thoracic epidural or thoracic paravertebral block. Patients and methods Sixty patients undergoing elective thoracotomy were randomly allocated into two equal groups: the thoracic paravertebral analgesia (TPVA) group, which received ultrasound-assisted thoracic paravertebral catheter, and the thoracic epidural analgesia (TEA) group, which received ultrasound-assisted thoracic epidural catheter. The primary outcome was the measuring of stress response to surgery using plasma cortisol level. The secondary outcomes included intraoperative haemodynamic parameters, visual analogue pain score and postoperative complications. Results Heart rate showed significantly lower values in the TEA group compared with the TPVA group. The mean arterial blood pressure showed significantly lower values in the TEA group compared with the TPVA group. In both groups, there was a significant increase in plasma cortisol level after surgical stress compared with basal values. Moreover, there were significantly lower values in the TPVA group compared with the TEA group at 2 h after surgical incision, 2 h postoperatively and 24 h postoperatively. Visual analogue pain score was noncomparable in both groups at all measurement timepoints. As regards complications, group TPVA had less complications compared with group TEA. Conclusion Thoracic paravertebral block is an effective analgesic technique showing greater haemodynamic stability and less stress response to surgery compared with epidural analgesia in patients undergoing thoracotomy.
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