Ahmed Elhaddad

Background: Erector Spinae Plane Block (ESPB) is a simple and safe analgesic technique to relieve thoracotomy pain, but we need to increase the duration of analgesia with a single shot. so, we compared the analgesic efficacy of Dexmedetomidine (DEX) versus ketamine as an adjuvant to bupivacaine ESPB in children scheduled for thoracotomy cardiothoracic surgeries.Methods: 90 children aged 3 to 36 months, scheduled for thoracotomy cardiothoracic surgeries, were divided into group Bupivacaine (B) (n=30) and received ESPB using 0.5 ml/kg bupivacaine 0.25% in 15 ml saline. Group Bupivacaine-ketamine (BK) (n=30) received the same as group B plus ketamine 2 mg/kg. Group Bupivacaine-Dexamedetomedine (BD) received the same as group B plus dex 1 μg/kg. The time to first rescue analgesia, perioperative hemodynamics, postoperative pain intensity, total consumption of opioids, and frequency of complications were measured.Results: The addition of dexmedetomidine and ketamine to bupivacaine resulted in a significant prolongation of postoperative analgesia duration (16.4 ± 3.79 hr,95%CI: 14.951:17.783, P<0.001) and(10.1 ± 2.36 hr,95%CI: 9.184:10.949, P<0.001), respectively compared with 0.5% bupivacaine alone (5.2 ± 1.26 hr. 95%CI: 4.714:5.625). postoperative analgesia duration was more prolonged in the BD group than in the Bk group( P<0.001). with lower perioperative opioid consumption, better hemodynamic profile, and better predictive indexes (extubation time and hospital stay) in the BD and BK groups than in the B group. Conclusion: Dexmedetomidine as an adjuvant to bupivacaine provides a longer duration of analgesia as compared to ketamine without any significant side effects.

Background: Fast-tracking in cardiac surgery refers to the early extubation,Lung ultrasound can detect pulmonary congestion by assessing extravascular lung water. This study aims to show if immediate postoperative lung ultrasound together with the measurement of arterial blood gas at the end of pediatric cardiac surgeries can predict extubation within the next 6 hours.Method:: A prospective observational study, where forty-five pediatric patients underwent repair of congenital heart diseases with cardiopulmonary bypass. Patients were examined with arterial blood gases and lung ultrasound after induction of anesthesia and at the end of the surgery, and given a score according to the number of B lines in each region, the receiver operating characteristics (ROC) curve was used to assess the predictive value of lung ultrasound score (LUS) and PaO2/FiO2(PF) ratio to predict early extubation at the optimal cutoff points. Results: Thirty two children (71%) were extubated early, and thirteen children (29%) experienced delayed extubation. The LUS showed good discriminative power for the prediction of early extubation (area under the ROC curve (AUC) 0.95 with sensitivity (93%) and specificity (89%) at cutoff point < 13. The PF ratio was less sensitive (87%) but more specific (100%) for the prediction of early extubation at a cutoff point > 230. The study showed a strong negative correlation between LUS and PF ratio (r = 0.76, p-value <0.001). We found an adequate interobserver agreement for LUS (weighted kappa 0.94)Conclusions: Lung ultrasound is a simple, non-invasive, reproducible, and reliable tool for predicting early extubation .

BACKGROUND: Junctional ectopic tachycardia (JET) is a serious tachyarrhythmia following pediatric cardiac surgery. It isn't easy to treat and better to be prevented. This study aimed to examine the prophylactic effects of dexmedetomidine, MgSO, or their combination in reducing JET following pediatric open cardiac surgery.

METHODS: Hundred and twenty children under 5 years, weighing more than 5 kg, who were scheduled for corrective acyanotic cardiac surgeries were randomized into three groups. Group MD (Dexmedetomidine-MgSO group): received dexmedetomidine 0.5 μg/kg IV over 20 min after induction, then infusion 0.5 μg/kg/h for 72 h, and 50 mg/kg bolus of MgSO with aortic cross-clamp release, then continued administration for 72 h postoperatively at a dose of 30 mg/kg/day. Group D (the dexmedetomidine group) received the same dexmedetomidine as the MD group in addition to normal saline instead of MgSO. Group C (control group): received normal saline instead of dexmedetomidine and MgSO. The primary outcome was the detection of JET incidence; the secondary outcomes were hemodynamic parameters, ionized Mg, vasoactive-inotropic score, extubation time, PCCU and hospital stay, and perioperative complications.

RESULTS: The incidence of JET was significantly reduced in Group MD and Group D (p = .007) compared to Group C. Ionized Mg was significantly higher in Group MD than in Groups D and C during rewarming and in the ICU (p < .001). Better hemodynamic profile in Group MD compared to Group D and Group C throughout surgery and in the ICU, the predictive indexes were significantly better in Group MD than in Groups D and C (p < .001). Including the extubation time, PCCU, and hospital stay.

CONCLUSION: Dexmedetomidine alone or combined with MgSO had a therapeutic role in the prevention of JET in children after congenital heart surgery.

BACKGROUND: Postoperative pain management after pacemaker insertion routinely requires opioid agents, nonsteroidal anti-inflammatory drugs, or paracetamol. However, interest in opioid-sparing multimodal pain management to minimize postoperative narcotic use has increased recently. This study aimed to assess the pectoral nerve (PECS) block versus standard treatment on postoperative pain control and opioid consumption in pediatric patients after transvenous subpectoral pacemaker insertion.

METHODS: In this randomized controlled study, 40 pediatric patients underwent transvenous subpectoral pacemaker insertion with either congenital or postoperative complete heart block. Patients were randomly assigned to two groups: Group C (control) received conventional analgesic care without any block and Group P (pectoral) received a PECS block. Demographics, procedural variables, postoperative pain, and postoperative opioid consumption were compared between the two groups.

RESULTS: In children undergoing transvenous subpectoral pacemaker insertion, the PECS block was associated with a longer procedure time; however, the cumulative dose of fentanyl and atracurium was reduced and the hemodynamic profile was superior in Group P compared with Group C intraoperatively. Postoperatively, the PECS block was associated with lower postprocedural pain scores, which was reflected by the longer interval before the first call for rescue analgesia and lower postoperative morphine consumption, without an increase in the rate of complications.

CONCLUSION: Ultrasound-guided PECS blocks are associated with a good intraoperative hemodynamic profile, reduced postoperative pain scores, and lower total opioid consumption in children undergoing transvenous subpectoral pacemaker placement.

BackgroundOff-pump bidirectional Glenn (BDG) operation can be associated with elevation of superior vena cava (SVC) pressure that may lead to neurological damage.

Aim

Off-pump BDG operation was done using either a veno-atrial shunt or external shunt to decompress SVC during clamping.

Patients and methods

A prospective, randomized comparative study in a single tertiary care cardiac center where 30 patients with functional single ventricle underwent off-pump BDG. Group I with a veno-atrial shunt (internal) and group E with an external shunt.

Measurements and main results

There was no early hospital mortality. The mean SVC pressure during clamping was 40.4±3.4 mmHg before and 28.5±3.8 mmHg after shunt opening in group I and 37.6±4.5 mmHg before and 26.4±2.1 mmHg after shunt opening in group E. The mean clamp time was 19.8±3.5 min in group I and 16.9±4.4 min in group E. The transcranial pressure gradient was 58.1±6.89 mmHg in group I, while 54.86±9.1 mmHg in group E. There were no major neurological complications apart from treatable convulsions in one (3%) case in group I and delayed recovery in one (3%) case in group E.

Conclusions

Off-pump BDG can be safely performed with either external or internal shunt avoiding cardiopulmonary bypass complications.

OBJECTIVES: To compare the effects of 3 ventilation strategies during cardiopulmonary bypass (CPB) on arterial oxygenation and postoperative pulmonary complications (PPCs).

DESIGN: A prospective, randomized, controlled study.

SETTING: A single-center tertiary teaching hospital.

PARTICIPANTS: One hundred twenty pediatric patients undergoing elective repair of congenital acyanotic heart diseases with CPB.

INTERVENTIONS: Patients were assigned randomly into 3 groups according to ventilation strategy during CPB as follows: (1) no mechanical ventilation (NOV), (2) continuous positive airway pressure (CPAP) of 5 cmHO, (3) low tidal volume (LTV), pressure controlled ventilation (PCV), respiratory rate (RR) 20-to-30/min, and peak inspiratory pressure adjusted to keep tidal volume (Vt) 2 mL/kg.

MEASUREMENTS AND MAIN RESULTS: The PaO/fraction of inspired oxygen (FO) ratio and PaO were higher in the 5 minutes postbypass period in the LTV group but were nonsignificant. The PaO/FO ratio and PaO were significant after chest closure and 1 hour after arrival to the intensive care unit with a higher PaO/FO ratio and PaO in the LTV group. Regarding the oxygenation index, the LTV group was superior to the NOV group at the 3 time points, with lower values in the LTV group. There were no significant differences in the predictive indices among the 3 groups, including the extubation time, and postoperative intensive care unit stays days. The incidence of PPCs did not significantly differ among the 3 groups.

CONCLUSIONS: Maintaining ventilation during CPB was associated with better oxygenation and did not reduce the incidence of PPCs in pediatric patients undergoing cardiac surgery.

IntroductionChildren undergoing cardiac catheterization are usually in need for perioperative analgesia.

Aim and objective

We studied the effects of local infiltration of bupivacaine at the groin in generally anesthetized children as against caudal bupivacaine combined with dexmedetomidine–ketamine sedation on intraoperative and postoperative hemodynamics and duration of postoperative analgesia in pediatric patients undergoing cardiac catheterization.

Materials and methods

A total of 40 patients (1–7 years) were randomly assigned into one of the two groups: one group (group GI) received general anesthesia (GA) together with local infiltration using 5 ml bupivacaine 0.25% at the beginning and at the end of the procedure and the other group (group SC) received sedation by ketamine at 3 mg/kg followed by infusion at a rate of 1 mg/kg/h to maintain sedation with caudal administration of a mixture of bupivacaine 0.25% at 3 mg/kg with dexmedetomidine 0.5 mcg/kg both diluted in normal saline to a volume of 1.2 ml/kg. Hemodynamic variables (blood pressure (BP) and heart rate (HR)) were evaluated at T1 (baseline, after induction), T2 (10 min after local infiltration/caudal administration), T3 (at time of puncture for vascular access), T4 (10 min after emergence), T5 (1 h after the procedure), and T6 (4 h after the procedure).

Pain was evaluated 10 min after emergence (P1), after 1 h in the ICU (P2), after 4 h in the ICU (P3), and after 8 h (P4) by the FLACC (Face, Leg, Activity, Crying, Consolability) score. Side effects were observed for 12 h.

Results

The severity of pain was much less in the SC group than in the GI group. FLACC pain score was evaluated at P1 (10 min after emergence), P2 (1 h after procedure), P3 (4 h after procedure), and P4 (8 h after procedure) and it was found that pain is much less in the SC group than in the GI group during the first 4 h after the procedure with significant difference between the two groups (P < 0.05).

There was a more stable hemodynamic profile for the SC group than for the GI group. The mean arterial pressure (MAP) and HR decreased from the baseline in both groups and they decreased more significantly in the SC group than in the GI group. In addition, the decrease in MAP and HR continued for a longer duration in the SC group than in the GI group.

We observed a slightly prolonged analgesia with less need for supplemental analgesics in the SC group than in the GI group.

Conclusion

Combining caudal anesthesia using bupivacaine and dexmedetomidine with ketamine sedation provided prolonged and potent analgesia with much stable perioperative hemodynamic parameters than giving general anesthesia combined with local infiltration in the setting of pediatric cardiac catheterization.

Ebstein’s anomaly is considered one of the most common causes of congenital tricuspid regurgitation. It is usually associated with other anomalies such as atrial septal defects and accessory conduction pathways. The hemodynamic consequences and anesthetic implications for repair of Ebstein’s anomaly are challenging. Severe complicated cases of Ebstein’s anomaly usually manifest with significant tachyarrhythmia and hemodynamic derangement, leading to heart failure. This is a report of successful anesthetic management of a repair of Ebstein’s anomaly in a patient with coexisting Wolff–Parkinson–White syndrome.