sanjula virmani - Academia.edu (original) (raw)

Papers by sanjula virmani

PubMed, Oct 1, 1999

Maintenance of adequate oxygen balance to all tissues is one of the primary objectives when deali... more Maintenance of adequate oxygen balance to all tissues is one of the primary objectives when dealing with patients undergoing cardiac surgery. Cardiac output is one of the major components of oxygen delivery so that its maintenance is an important consideration. Due to pre-operative cardiac lesion and myocardial dysfunction secondary to the events related to cardiac surgery and cardiopulmonary by-pass, circulatory support by pharmacological or mechanical means is frequently required after surgery. Therefore, inotropes and vasodilators are used to improve the myocardial performance after cardiac surgery. Epinephrine, dopamine and dobutamine are commonly used inotropes. Dopexamine and phosphodiesterase inhibitors such as amrinone, milrinone and enoximone are some of the newer agents that have been introduced in clinical practice. Amongst the vasodilators, sodium nitroprusside and nitroglycerin are commonly used. Alpha adrenergic blockers such as phentolamine and phenoxybenzamine and calcium channel blockers such as diltiazem are some other vasodilators that can be used. Many units still regard epinephrine as an inotrope of choice and use its predominant beta agonist effect in the dose range of 0.02 to 0.04 mg/kg/minute. Some prefer dobutamine and others a combination of inotrope and vasodilator or an inodilator. Phosphodiesterase inhibitors can be useful in certain situations such as pre-existing ventricular dysfunction or when stunning of the myocardium is suspected with down regulation of beta receptors. Dopamine is useful in the renal vasodilating dose to improve renal perfusion and improve output. There is no ideal inotrope at present and each one has its own drawbacks. The clinician must learn to use the inotropes (especially the newer ones) based on his own clinical experience.

Annals of Cardiac Anaesthesia, 2002

MAMC journal of medical sciences, 2016

Journal of Cardiothoracic and Vascular Anesthesia, Apr 1, 2003

Annals of Cardiac Anaesthesia, 2023

Background: Ivabradine is a specific heart rate (HR)-lowering agent which blocks the cardiac pace... more Background: Ivabradine is a specific heart rate (HR)-lowering agent which blocks the cardiac pacemaker If channels. It reduces the HR without causing a negative inotropic or lusitropic effect, thus preserving ventricular contractility. The authors hypothesized that its usefulness in lowering HR can be utilized in patients undergoing off-pump coronary artery bypass (OPCAB) surgery. Objective: To study the effects of preoperative ivabradine on hemodynamics (during surgery) in patients undergoing elective OPCAB surgery. Methods: Fifty patients, New York Heart Association (NYHA) class I and II, were randomized into group I (control, n = 25) and group II (ivabradine group, n = 25). In group I, patients received the usual anti-anginal medications in the preoperative period, as per the institutional protocol. In group II, patients received ivabradine 5 mg twice daily for 3 days before surgery, in addition to the usual anti-anginal medications. Anesthesia was induced with fentanyl, thiopentone sodium, and pancuronium bromide as a muscle relaxant and maintained with fentanyl, midazolam, pancuronium bromide, and isoflurane. The hemodynamic parameters [HR and mean arterial pressure (MAP)] and pulmonary artery (PA) catheter-derived data were recorded at the baseline (before induction), 3 min after the induction of anesthesia at 1 min and 3 min after intubation and at 5 min and 30 min after protamine administration. Intraoperatively, hemodynamic data (HR and MAP) were recorded every 10 min, except during distal anastomosis of the coronary arteries when it was recorded every 5 min. Post-operatively, at 24 hours, the levels of troponin T and brain natriuretic peptide (BNP) were measured. This trial’s CTRI registration number is CTRI/005858. Results: The HR in group II was lower when compared to group I (range 59.6–72.4 beats/min and 65.8–80.2 beats/min, respectively) throughout the study period. MAP was comparable [range (78.5–87.8 mm Hg) vs. (78.9-88.5 mm Hg) in group II vs. group I, respectively] throughout the study period. Intraoperatively, 5 patients received metoprolol in group I to control the HR, whereas none of the patients in group II required metoprolol. The incidence of preoperative bradycardia (HR <60 beats/min) was higher in group II (20%) vs. group I (8%). There was no difference in both the groups in terms of troponin T and BNP level after 24 hours, time to extubation, requirement of inotropes, incidence of arrhythmias, in-hospital morbidity, and 30-day mortality. Conclusion: Ivabradine can be safely used along with other anti-anginal agents during the preoperative period in patients undergoing OPCAB surgery. It helps to maintain a lower HR during surgery and reduces the need for beta-blockers in the intraoperative period, a desirable and beneficial effect in situations where the use of beta-blockers may be potentially harmful. Further studies are needed to evaluate the beneficial effects of perioperative Ivabradine in patients with moderate-to-severe left ventricular dysfunction.

Journal of Anaesthesia and Critical Care Reports, 2021

The total anomalous pulmonary venous communication [TAPVC] is a rare cyanotic congenital cardiac ... more The total anomalous pulmonary venous communication [TAPVC] is a rare cyanotic congenital cardiac defect accounting for 1.5-3% of the congenital heart disease, in which pulmonary venous [PV] blood drains directly into the right side of the heart or into the systemic veins. Neonates with obstructive TAPVC may present with cyanosis, metabolic acidosis, respiratory failure, and shock. A subset of patients with unobstructed TAPVC may remain symptoms free and attain adulthood, or present with pulmonary congestion, pulmonary arterial hypertension [PAH]. The anesthetic management of either obstructed TAPVC or unobstructed with PAH can be quite challenging. The described patient is a 23-year male who presented with self – limiting single episode of chest pain, palpitations and dyspnea, diagnosed as supracardiac unobstructed TAPVC with ostium secundum atrial septal defect [OS – ASD] and PAH, who underwent successful intracardiac repair under cardiopulmonary bypass [CPB]. The protocol for the ...

Annals of cardiac anaesthesia

World Journal of Cardiovascular Surgery, 2014

We present a case of an isolated large ventricular septal defect (VSD) following blunt chest trau... more We present a case of an isolated large ventricular septal defect (VSD) following blunt chest trauma in a motor vehicle accident in the patient with preexisting mechanical mitral valve. Transthoracic echocardiography revealed a large muscular VSD with significant left to right shunt along with septal edema. Surgical repair was performed in view of Qp:Qs of 2.5 with significant hemodynamic instability despite intra-aortic balloon pump. The ventricular septal defect was found in apical muscular portion of the interventricular septum, which was closed through left ventriculotomy. We here discuss the possible mechanisms of damage and importance of timely surgery. To conclude, minor looking external injury might contain devastating damage inside, especially with patients on anti-coagulant therapy.

Authorea (Authorea), Jun 21, 2022

Pseudoaneurysm of ascending aorta following cardiac surgery is a very rare and life threatening e... more Pseudoaneurysm of ascending aorta following cardiac surgery is a very rare and life threatening entity due to risk of exsanguination from its rupture. This is a case report of a 39 year old male patient who presented with impending rupture of ascending aorta pseudoaneurysm following mitral valve replacement. He underwent urgent reoperation under femoro-femoral cardiopulmonary bypass and deep hypothermic circulatory arrest. The pseudoaneurysm was excised and repaired with pericardial patch. He was discharged after an uneventful postoperative course.

Journal of Cardiac Surgery, 2021

Annals of Cardiac Anaesthesia, 2020

In patients with critical tracheal stenosis, particularly involving the lower part of trachea, a ... more In patients with critical tracheal stenosis, particularly involving the lower part of trachea, a highly experienced team of anesthesiologists to tackle the difficulties of securing and maintaining the ventilation, cardiac surgeon who can swiftly establish cardiopulmonary bypass, an experienced surgeon for tracheal reconstruction are a prerequisite for managing these highly complex cases. The present paper describes three patients suffering from severe tracheal narrowing wherein spontaneous bag-mask ventilation was used for establishing cardiopulmonary bypass via mid-sternotomy as a rare life-saving procedure for urgent tracheal reconstructive surgery. A highly experienced team of anesthesiologists to tackle the difficulties of securing and maintaining the ventilation, cardiac surgeon who can swiftly establish CPB, and an experienced surgeon for tracheal reconstruction are a prerequisite for managing these highly complex cases. The present paper describes three patients suffering from severe tracheal narrowing wherein spontaneous bag-mask ventilation was used for establishing CPB via mid-sternotomy as a rare life-saving procedure for urgent tracheal reconstructive surgery.

Sixty six patients undergoing elective valve surgery were randomized to receive rocuronium bromid... more Sixty six patients undergoing elective valve surgery were randomized to receive rocuronium bromide 0.6 mg/Kg (Group R, n=22), pancuronium bromide 0.1 mg/Kg (Group P, n= 22) and vecuronium bromide 0.1 mg/Kg (Group V, n=22), Measurements of heart rate and arterial pressure (systolic, diastolic and mean) were noted at the following stages: 1) baseline when haemodynamics were stable for 2 minutes after induction of anaesthesia (2) one, (3) three, (4) five minutes after administration of muscle relaxants, (5) One, (6) three, and (7) five minutes after intubation. In group R, the heart rate decreased 5 min after injection of muscle relaxant from 93.9 +/- 21.3 to 82.4 +/- 20.7 beats/min (p<0.001). However, it increased to 128.3 +/- 25.8 beats/min (p<0.001) following intubation and returned to baseline at 5 min after intubation. In group P, heart rate increased from 98.8 +/- 32.6 to 109.6 +/- 32.7 beats/min (p<0.001), 1 min after injection of pancuronium and this increase persisted...

Journal of Obstetric Anaesthesia and Critical Care

Pregnancy with prosthetic valve is a challenging situation since this is a hypercoagulable state ... more Pregnancy with prosthetic valve is a challenging situation since this is a hypercoagulable state and maintenance of anticoagulation for prosthetic valves becomes difficult due to the teratogenic effects and altered pharmacokinetics of anticoagulant drugs. This may result in prosthetic valve thrombosis which is an emergency and requires multidisciplinary approach for management. We present a case of a patient who presented with thrombosed mitral prosthesis at 34 wks of gestation; after a multispeciality consultation, she eventually underwent caesarean section followed by mitral valve replacement.

Anesthesia and Clinical Research

Background: The aim of the present study was to study the hemodynamic profile of dexmedetomidine ... more Background: The aim of the present study was to study the hemodynamic profile of dexmedetomidine during induction and distal anastomosis of coronary arteries in patients undergoing OPCAB in comparison to the institutional practice of using midazolam. Methods: In Group I, (n=25) patients were anaesthetised using fentanyl, pancuronium bromide, Isoflurane and midazolam. Group II (n=25) patients received a loading dose of dexmedetomidine infusion (1µg/Kg) over 10 minutes followed by an infusion of dexmedetomidine at the rate of 0.6 µg/Kg/hour, along with fentanyl, Pancuronium bromide and isoflurane. Heart rate (HR) mean arterial pressure (MAP), pulmonary artery (PA) catheter derived data and BIS were recorded at baseline, at 1 and 3 minutes after induction, at 1, 3 and 5 minutes after intubation, and at 5 and 30 minutes after protamine administration. MAP and HR were recorded every 10 min during the operation, except during distal anastomosis of the coronary arteries when it was recorde...

The safety of transesophageal echocardiography (TEE) probes has been documented in pediatric pati... more The safety of transesophageal echocardiography (TEE) probes has been documented in pediatric patients (neonates, infants, and small children even < 2.5 Kg). The overall safety profile of TEE probe is quite favourable with a reported incidence of complications is about 1-3%. However, insertion of the TEE probe can induce vagal and sympathetic reflexes such as hypertension or hypotension, non-sustained ventricular and supraventricular tachyarrhythmias or bradyarrhythmias [3rd degree heart block], and even angina and myocardial infarction. We hereby document a repeated and fatal intraoperative VF precipitated by TEE probe in a 2-year-old, 10 kg paediatric patient diagnosed with ostium secundum atrial septal defect (OS-ASD), supravalvular pulmonary stenosis (PS) and severe right ventricular (RV) dysfunction.

Annals of Cardiac Anaesthesia

MAMC Journal of Medical Sciences, 2016

J Cardiothorac Vasc Anesth, 2006

Perfusion, Jan 10, 2016

Postoperative hepatic dysfunction may occur in an otherwise uncomplicated open heart surgery. One... more Postoperative hepatic dysfunction may occur in an otherwise uncomplicated open heart surgery. One of the reasons is malpositioning of the inferior vena cava (IVC) cannula in the hepatic vein (HV) or beyond. A straight cannula is considered more likely to be malpositioned compared to the angled cannula and a malpositioned cannula can lead to hepatic dysfunction. In this prospective study, forty adult patients undergoing atrial septal defect repair were randomized into two groups as: straight cannula group (n=20) and angled cannula group (n=20). The cannula position was assessed by transesophageal echocardiography (TEE) (hepatic vein view). Alanine aminotransferase levels (ALT) and bilirubin levels were measured immediately, at 6 hours and on day 1, day 2 and day 7 after surgery as a marker of hepatic injury. TEE localization of the IVC cannula was achieved in all patients except one. Visualization was good in 85% of patients. A cannula in the HV or beyond the HV in the IVC was consid...

Annals of Cardiac Anaesthesia, 2016

Context: We hypothesized that reduced oropharyngolaryngeal stimulation with video laryngoscopes w... more Context: We hypothesized that reduced oropharyngolaryngeal stimulation with video laryngoscopes would attenuate hemodynamic response to laryngoscopy and intubation. Aim: Comparison of hemodynamic response to laryngoscopy and intubation with video laryngoscopes and Macintosh (MC) laryngoscope. Setting and Design: Superspecialty tertiary care public hospital; prospective, randomized control study. Methods: Sixty adult patients undergoing elective coronary artery bypass grafting (CABG) were randomly allocated to three groups of 20 each: MC, McGrath (MG), and Truview (TV). Hemodynamic parameters were serially recorded before and after intubation. Laryngoscopic grade, laryngoscopy, and tracheal intubation time, ST segment changes, and intra-/post-operative complications were also recorded and compared between groups. Statistical Analysis: SPSS version 17 was used, and appropriate tests applied. P < 0.05 was considered significant. Results: Heart rate and diastolic arterial pressure increased at 0 and 1 min of intubation in all the three groups (P < 0.05) while mean arterial pressure increased at 0 min in the MG and TV groups and at 1 min in all three groups (P < 0.05). A significant increase in systolic arterial pressure was only observed in TV group at 1 min (P < 0.05). These hemodynamic parameters returned to baseline by 3 min of intubation in all the groups. The intergroup comparisons of all hemodynamic parameters were not significant at any time of observation. Highest intubation difficulty score was observed with MC (2.16 ± 1.86) as compared with MG (0.55 ± 0.88) and TV (0.42 ± 0.83) groups (P = 0.003 and P = 0.001, respectively). However, duration of laryngoscopy and intubation was significantly less in MC (36.68 ± 16.15 s) as compared with MG (75.25 ± 30.94 s) and TV (60.47 ± 27.45 s) groups (P = 0.000 and 0.003, respectively). Conclusions: Video laryngoscopes did not demonstrate any advantage in terms of hemodynamic response in patients with normal airway undergoing CABG.