Tricuspid Annular Plane Systolic Excursion (TAPSE) for the Assessment of Right Ventricular Function in Adult and Pediatric Cardiac Surgery: Modified Two-dimensional and M-mode TAPSE by Transesophageal Echocardiography Compared to M-mode TAPSE by Transthoracic Echocardiography

OBJECTIVES

To compare transesophageal echocardiography-guided 2-dimensional and M-mode tricuspid annular plane systolic excursion (TAPSE) to transthoracic echocardiography (TTE)-guided M-mode TAPSE in terms of accuracy, interobserver, and intra-observer variability.

DESIGN

A prospective, observational study.

SETTING

Adult and pediatric operating rooms.

PARTICIPANTS

Adult and pediatric patients (42 each) undergoing cardiac surgeries.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Modified midesophageal (Mod-ME), deep transgastric, and transgastric TAPSEs were analyzed for reliability and were compared to TTE TAPSE in both adult and pediatric groups. Modified ME TAPSE showed good method agreement with TTE TAPSE (bias = -0.97, p = 0.08 (adult); bias = 0.17, p = 0.71 [pediatric]), and showed a moderate correlation with right ventricular (RV) fractional area change (FAC) (r = 0.41, p = 0.006, [adult]; r = 0.57, p < 0.001, [pediatric]), with acceptable interobserver variability (percentage error =10.56 [adult]; 4.42 [pediatric]) and intraobserver variability (percentage error = 13.1 [adults]; 12.24 [pediatric]). Transgastric TAPSE poorly agreed with TTE TAPSE and had higher interobserver and intraobserver variability. Deep transgastric TAPSE had good method agreement with TTE TAPSE and had acceptable interobserver and intra-observer variability.

CONCLUSIONS

Modified ME TAPSE is a reliable and reproducible measure of RV function before pericardiotomy in both adult and pediatric cardiac surgery. Right ventricular FAC values reflected the RV systolic function better than TAPSE after pericardiotomy. Deep transgastric TAPSE is reliable and reproducible but is less accurate than Mod-ME TAPSE.

A Lung ultrasound-based comparison of postoperative respiratory outcome after pediatric congenital heart surgery in COVID-19 recovered and COVID-19 unaffected children-a pilot study

Background

COVID-19 is known to affect the alveolar-capillary membrane and interstitial tissue. Cardiopulmonary bypass (CPB) is proven to cause "pump-lung" syndrome. Little is known about the subgroup of COVID-19-recovered children undergoing cardiac surgeries under CPB.

Aim

To compare the lung ultrasound score (LUSS) and morbidity of COVID-19-recovered children to those without COVID-19 after congenital cardiac surgery.

Setting and Design

Prospective observational pilot study at a tertiary care institution.

Materials and Methods

The study was carried out on 15 COVID-recovered children and 15 matched controls (Group B) posted for congenital cardiac surgery. COVID-recovered children were further divided into those who received in-hospital care for COVID (Group C) and those who did not (Group A). LUSS measured immediately after cardiac surgery was compared between the groups. PaO2/FiO2 ratio, incidence of pulmonary infection, re-intubation rate, duration of ventilation, in-hospital mortality, and 30-day mortality were also compared between the groups.

Results

LUSS was comparable between Groups A and B (mean difference = 1.467, P = 0.721). Compared to the control group, Group C showed higher LUSS (mean difference = 11.67, P < 0.001), lower PaO2/FiO2 ratio (207.8 ± 95.49 Vs 357.6 ± 63.82, P = 0.003), and one in-hospital mortality. A significant negative correlation was seen between LUSS and PaO2/FiO2 ratio (rs = -0.75, P < 0.001).

Conclusion

LUSS was not higher in COVID-recovered children. Children with a history of severe COVID-19 recorded higher LUSS, in-hospital mortality, duration of ICU stay, and duration of ventilation.

Intra-Caval Balloon Pump

This clinical image vignette describes the inadvertent placement of a balloon pump in the vena cava during a "code blue" scenario, and the lessons to be learned from that experience. The hemodynamic benefits of intra-aortic balloon pump during experimental cardiac arrest include shorter circulation time and increases in end-tidal CO2 and coronary perfusion pressure. However, the hemodynamic effects of venous diastolic augmentation during experimental cardiogenic shock vary, being detrimental in cases of low preload, and possibly beneficial in a high preload state. When performed emergently at the bedside, inadvertent intra-caval placement of a balloon pump can occur due to elevated venous pressures, in the presence of severe tricuspid regurgitation, or through an arteriovenous fistula. A similar radiographic appearance can also be seen in the presence of a right-sided aortic arch. Clues to improper position include an abnormal pressure waveform and the absence of hemodynamic changes or blood pressure augmentation.

Use of a Video Laryngoscope to Reduce Complications of Transesophageal Echocardiography Probe Insertion: A Multicenter Randomized Study

OBJECTIVE

The objective of this multicenter study was to test the hypothesis of whether the use of a video laryngoscope (VL) reduces complications related to transesophageal echocardiography (TEE) probe insertion.

DESIGN

A multicenter randomized control study.

SETTING

At 5 tertiary care level hospitals.

PARTICIPANTS

Three hundred sixty-three adult patients undergoing elective cardiac surgery.

INTERVENTIONS

The patients were randomized into 2 groups-the conventional group (C group; n = 177) and the VL group (n = 186) for TEE probe insertion.

MEASUREMENTS AND MAIN RESULTS

The primary endpoint of the study was the incidence of oropharyngeal injury, which was defined as blood at the tip of the TEE probe at the end of surgery and/or evidence of injury on VL examination at the end of surgery. The secondary endpoints of the study were the number of attempts required for successful TEE probe insertion and the relation between the esophageal inlet and the larynx. There was a higher incidence of injuries in the C group (n = 26; 14.7%) compared to the VL group (n = 14; 7.5%; p = 0.029). The number of attempts for probe insertion was significantly lower in the VL group (p = 0.0023). The most common relation between the esophageal inlet and the larynx was posterolateral (n = 88; 47%), followed by posterior (n = 77; 41%) and lateral (n = 21;12%).

CONCLUSION

The use of VL was associated with a lesser incidence of injury compared to the conventional technique, and its use for this purpose is recommended. The use of VL for probe insertion resulted in fewer attempts compared with the conventional technique. Significant variations do exist in the relation between the esophageal inlet and the larynx, and direct visualization with VL may contribute to better safety.

Anomalous Connection of Superior Vena Cava to Left Atrium-A Rare Congenital Cardiac Anomaly and Its Implications

Exclusive drainage of superior vena cava (SVC) into the left atrium (LA) is one of the rare causes of right-to-left connection. Usually, this anomaly occurs in association with other cardiac defects, and is diagnosed in early childhood. But if it remains an isolated anomaly, this connection may be underdiagnosed and could lead to systemic manifestations. We describe a case of anomalous connection of SVC to LA with drainage of right upper pulmonary vein into SVC and its implications for the perioperative physician. The patient presented with dyspnea on exertion, cyanosis, and a past history of cerebral abscess.

A Comparison of Two Multi-Layer Sacral Foam Dressings for the Prevention of Hospital-Acquired Pressure Injuries

Hospital-acquired pressure injuries (HAPIs) represent a significant detriment to patient health by increasing mortality risk, negatively impacting quality of life, and increasing risk of complications such as infection. Prophylactic use of sacral foam dressings is known to decrease the occurrence of HAPIs in various patient populations. This retrospective study compared the effect of two multi-layer sacral foam dressings on HAPI incidence in patients admitted to a short-term, acute care hospital during the years 2015 (dressing one: Mepilex® Border Protect sacral dressing [Mölnlycke Healthcare AB, Göteborg, Sweden]) and 2017 (dressing two: Optifoam® Gentle LQ silicone faced foam < border sacral dressing [Medline Industries, LP, Northfield, Illinois]). Patient medical charts were examined for full sample (n=297) and subsample (n=284) analysis, respectively. The HAPI incidence for dressing two was found to be significantly less than dressing one (full sample: 5.12% compared to 10.79% [p=0.0001], and subsample: 4.07% compared to 9.31% [p=0.0001]). The incidence rate ratio (IRR) for dressing two was 0.39 for the full sample and 0.35 for the subsample, indicating that compared to dressing one, the HAPI count was approximately 40% lower for dressing two for the full sample and approximately 35% lower for dressing two for the subsample. These results demonstrate that dressing two performed better than dressing one in HAPI prevention. The results of this study may inform clinicians in their choice of prophylactic dressings.

Perioperative cardiovascular outcome in patients with coronary artery disease undergoing major vascular surgery: A retrospective cohort study

Background:

Major adverse cardiac events (MACE) are a major contributor to morbidity and mortality in patients undergoing major vascular surgeries. We aim to assess the incidence, risk factors, and outcome of MACE in patients with coronary artery disease (CAD) undergoing aortic surgeries.

Methods:

In this retrospective observational study, we included patients with CAD who underwent elective major vascular surgery, namely, thoracoabdominal aortic aneurysm repairs and vascular bypass surgeries for aorto-occlusive disease, in our institute from January 2010 to December 2019. The association of preoperative risk factors including revised cardiac risk index factors, functional status of patients, severity of CAD, and its treatment status and technique of anesthesia with occurrence of MACE was analyzed.

Results:

Medical records of 141 patients were studied. The incidence of perioperative MACE was 11.3% (16/141) and overall in-hospital mortality was 6.4% (9/141), all of them related to MACE; implicating a 56.2% mortality in patients who develop MACE. The odds of a patient who had undergone preoperative coronary revascularization to develop a MACE was higher than a nonrevascularized patient (odds ratio: 3.9; 95% confidence interval [CI], 1.34–11.34). There was found to be no benefit in the addition of epidural analgesia to general anesthesia in reducing perioperative MACE.

Conclusions:

Major vascular surgeries in patients with CAD are a highly morbid procedure and a perioperative MACE places them at a significantly high risk of mortality. Early detection of CAD and preoperative medical optimization can play a major role in reducing the risk of MACE.

The changing face of postgraduate anaesthesia teaching curriculum: Need of the hour!

The speciality of anaesthesiology is evolving rapidly. The recent pandemic witnessed anaesthesiologists as the front-liners catering not only as critical care physicians but also as trainers and even administrators. Today, anaesthesiologists are required to have not just sound clinical knowledge but also proficiency in skills and techniques and aptitude for leadership. The recently introduced competency-based postgraduate training programme for anaesthesiology in India with its specific learning objectives envisages the creation of competent specialists with a broad range of skills who are competent not only to handle effectively medical problems but also acquire the basic teaching skills, communication skills and leadership qualities. The curriculum marks a paradigm shift from university-based, passive, teacher-centric to student-centric, active teaching-learning methods including problem-based and self-directed learning. The mindset, lack of adequately trained faculty, infrastructure, learning resources and time constraints form the major impediment in the successful implementation of the new curriculum.

Quantification of Right Atrial-Indexed End-Systolic Volumes and Emptying Fraction in Children Undergoing Cardiac Surgery With Two-Dimensional Transesophageal Echocardiography: A Prospective Observational Study

OBJECTIVES

The primary objective of this study was to establish "normal" right atrial (RA)-indexed end-systolic volumes (ESVs) and emptying fraction (EF) in children undergoing ventricular septal defect (VSD) repair using two-dimensional (2D) transesophageal echocardiography (TEE). Secondary objectives were to obtain RA-indexed ESV and EF in children with RA/right ventricular (RV) volume overload (atrial septal defect [ASD]) and RV pressure overload (tetralogy of Fallot [TOF]) and to determine whether baseline differences existed in these indices among the three lesions.

DESIGN

A prospective observational study.

SETTING

Tertiary referral center and a university level teaching hospital.

PARTICIPANTS

The study comprised 90 children (30 in each cohort) >3 kg and <14 years old admitted for elective repair of either VSD, TOF, or ASD.

MEASUREMENTS AND MAIN RESULTS

RA ESV and EF were measured in the midesophageal four-chamber view using the area-length and the modified Simpson's methods with 2D TEE in the prebypass period. Mean RA- indexed ESV (area-length method) in the VSD cohort was 24.2 ± 6.7 mL/m², whereas it was significantly greater in the TOF (31.9 ± 9.8 mL/m²; p = 0.0008) and ASD (52 ± 12.9 mL/m²; p < 0.0001) cohorts. RA EF in the TOF cohort was 48.4% ± 7.6%, which was significantly more than in the VSD (41.5% ± 11.8%; p = 0.0093) and ASD (39.1% ± 12.3%; p = 0.0008) cohorts.

CONCLUSIONS

This was the first study using 2D TEE to measure RA indices in children with and without right-sided heart dilation undergoing cardiac surgery. In this study, RA, ESV, and EF were considerably different in children with congenital heart disease causing RV pressure or volume overload. Additional studies can examine how these values can be used for risk stratification in this cohort of patients or how they correlate with measures of ventricular performances.

Role of Transesophageal and Epicardial Echocardiography to Assess Surgical Repair in Double-Outlet Left Ventricle

A double-outlet left ventricle (DOLV) is a congenital cardiac anomaly that rarely is encountered. This case report demonstrates the echocardiographic features of DOLV in the form of the pulmonary artery arising completely from the left ventricle with D-looped ventricles, especially when evaluated by intraoperative transesophageal echocardiography (TEE), along with the correlation of characteristic features with cardiac computerized tomography. The features pertinent to the differentiation of DOLV from double-outlet right ventricle and congenitally corrected transposition of the great arteries by echocardiography have been described. To the authors' knowledge, this was the first report of intraoperative TEE in the case of DOLV. In addition, the use of intraoperative echocardiography to rule out coronary compression as a cause for post-repair ventricular tachycardia, by use of TEE to rule out ventricular dysfunction and regional wall motion abnormalities, as well as epicardial echocardiography to demonstrate normal coronary blood flow, has been reported.

Fluid responsiveness to passive leg raising in patients with and without coronary artery disease: A prospective observational study

Introduction:

Hemodynamic stability and fluid responsiveness (FR) assume importance in perioperative management of patients undergoing major surgery. Passive leg raising (PLR) is validated in assessing FR in intensive care unit patients. Very few studies have examined FR to PLR in intraoperative scenario. We prospectively studied FR to PLR using transesophageal echocardiography (TEE), in patients with no coronary artery disease (CAD) undergoing major neurosurgery and those with CAD undergoing coronary artery bypass grafting (CABG).

Methods:

We enrolled 29 adult consenting patients undergoing major neurosurgery with TEE monitoring and 25 patients undergoing CABG. After induction of anesthesia, baseline hemodynamic parameters were obtained which was followed by PLR using automated adjustment of the operating table. Clinical and TEE-derived hemodynamic parameters were recorded at 1 and 10 min after PLR following which patients were returned to supine position.

Results:

A total of 162 TEE and clinical examinations were done across baseline, 1 and 10 min after PLR; and paired comparison was done at data intervals of baseline versus 1 min PLR, baseline versus 10 min PLR, and 1 min versus 10 min PLR. There was no significant change in hemodynamic variables at any of the paired comparison intervals in patients undergoing neurosurgery. CABG cases had significant hemodynamic improvement 1 min after PLR, partially sustained at 10 min.

Conclusion:

Patients undergoing CABG had significant hemodynamic response to PLR, whereas non-CAD patients undergoing neurosurgery did not. A blood pressure–left ventricular end-diastolic volume combination represented strong correlation in response prediction (Pearson's coefficient 0.641; P < 0.01).

Acute cardio-embolic stroke in a preschooler-a surgical dilemma

Myxomas are the most common primary intra-cardiac tumors in adults. Myxoma occurring in a preschooler is very rare, and cardiac surgery in acute stroke is a challenging decision. We present a rare case of acute cardio-embolic stroke in a 3-year-old child due to left atrial myxoma which was successfully treated.

Internal Jugular Vein Cannulation Using a 3-Dimensional Ultrasound Probe in Patients Undergoing Cardiac Surgery: Comparison Between Biplane View and Short-Axis View

OBJECTIVE

To compare the clinical performance in terms of procedure time, success rate, and cannulation attempts between ultrasound biplane view (BPX) and short-axis (SAX) view for internal jugular vein cannulation (IJV) in patients undergoing cardiac surgery.

DESIGN

Prospective, observational pilot study.

SETTING

University level tertiary referral hospital.

PATIENTS

The study comprised 100 patients between ages 18 and 75 years undergoing elective cardiac surgery.

INTERVENTIONS

One hundred patients were divided into 2 groups of 50 (BPX group and SAX group) by assigning the study participants alternatively to each group. IJV cannulation was performed using a 3-dimensional ultrasound probe in all patients with either BPX view (BPX group, n = 50) or the SAX view (SAX group, n = 50) by an experienced anesthesiologist.

MEASUREMENTS AND MAIN RESULTS

Time required for imaging, time for IJV puncture, time for guidewire confirmation, number of needle punctures and needle redirections, and incidence of posterior wall puncture were noted in both groups. In addition, the quality of needle visualization and the incidence of complications were recorded. The time taken for imaging was significantly greater in the BPX group than in the SAX group (9.52 ± 2.69 s v 7.94 ± 2.55 s; p = 0.0034), whereas the time taken for IJV puncture (10.39 ± 2.33 s v 23.7 ± 2.46 s; p < 0.0001), time taken for confirmation of guidewire (32.94 ± 4.50 s v 57.64 ± 7.14 s; p < 0.0001), and the incidence of posterior wall puncture (4% v 26%; p = 0.0022) were significantly less in the BPX group than in the SAX group. The total number of attempts taken to puncture the IJV was fewer in the BPX group than in the SAX group (55 v 78). Successful puncture of the IJV occurred on the first attempt in 90% of patients in the BPX group, whereas it was only 50% in the SAX group (p < 0.0001). The quality of needle visualization was good in 90% of patients in the BPX group, whereas it was only 6% in the SAX group. The number of needle redirections for IJV puncture was less in the BPX group than in the SAX group (48 v 116). The incidence of complications was not significant between the 2 groups.

CONCLUSION

The results suggested that the BPX view may be a safer, feasible and more reliable method than the SAX view for IJV cannulation in cardiac surgical patients.

Impact of COVID-19 pandemic on STEMI care: An expanded analysis from the United States

OBJECTIVE

To evaluate the impact of COVID-19 pandemic migitation measures on of ST-elevation myocardial infarction (STEMI) care.

BACKGROUND

We previously reported a 38% decline in cardiac catheterization activations during the early phase of the COVID-19 pandemic mitigation measures. This study extends our early observations using a larger sample of STEMI programs representative of different US regions with the inclusion of more contemporary data.

METHODS

Data from 18 hospitals or healthcare systems in the US from January 2019 to April 2020 were collecting including number activations for STEMI, the number of activations leading to angiography and primary percutaneous coronary intervention (PPCI), and average door to balloon (D2B) times. Two periods, January 2019-February 2020 and March-April 2020, were defined to represent periods before (BC) and after (AC) initiation of pandemic mitigation measures, respectively. A generalized estimating equations approach was used to estimate the change in response variables at AC from BC.

RESULTS

Compared to BC, the AC period was characterized by a marked reduction in the number of activations for STEMI (29%, 95% CI:18-38, p < .001), number of activations leading to angiography (34%, 95% CI: 12-50, p = .005) and number of activations leading to PPCI (20%, 95% CI: 11-27, p < .001). A decline in STEMI activations drove the reductions in angiography and PPCI volumes. Relative to BC, the D2B times in the AC period increased on average by 20%, 95%CI (-0.2 to 44, p = .05).

CONCLUSIONS

The COVID-19 Pandemic has adversely affected many aspects of STEMI care, including timely access to the cardiac catheterization laboratory for PPCI.

Finding the Calm in the Chaos: An Institutional Protocol for Anesthetic Management of a Patient for Neurosurgery during Coronavirus Disease 2019 Pandemic

“Coronavirus disease 2019” (COVID-19) transmitted by a novel coronavirus via contact or droplet spread is a highly infectious disease, the containment of which requires vigilance and stringent infection control policies. In the backdrop of hospitals becoming hot zones and an increasing number of health care workers contracting the disease, it is crucial to formulate an approach while administering anesthesia during the testing times of COVID-19 pandemic. In this background, this comprehensive article deals with the perioperative management during this pandemic and includes risk stratification based on an innovative simple scoring system, rationale use of personal protective equipments, and infection prevention protocols. The document of updated literature, though not intended to replace any guidelines, is aimed at providing protocol to health care workers to protect themselves while providing the best care in this pandemic.

A survey of practices during cardiopulmonary bypass in India: An Indian association of cardiovascular and thoracic anesthesiologist endeavor

Context:

Cardiac anesthesiologists play a key role during the conduct of cardiopulmonary bypass (CPB). There are variations in the practice of CPB among extracorporeal technologists in India.

Aims:

The aim of this survey is to gather information on variations during the conduct of CPB in India.

Settings and Design:

This was an online conducted survey by Indian College of Cardiac Anaesthesia, which is the research and academic wing of the Indian Association of Cardiovascular Thoracic Anaesthesiologists.

Subjects and Methods:

Senior consultants heading cardiac anesthesia departments in both teaching and nonteaching centers (performing at least 15 cases a month) were contacted using an online questionnaire fielded using SurveyMonkey™ software. There were 33 questions focusing on institute information, perfusion practices, blood conservation on CPB; monitoring and anesthesia practices.

Results:

The response rate was 74.2% (187/252). Fifty-one (26%) centers were teaching centers; 18% centers performed more than 1000 cases annually. Crystalloid solution was the most common priming solution used. Twenty-three percent centers used corticosteroids routinely; methylprednisone was the most commonly used agent. The cardioplegia solution used by most responders was the one available commercially containing high potassium St. Thomas solution (55%), followed by Del Nido cardioplegia (33%). Majority of the responders used nasopharyngeal site to monitor intraoperative patient temperature. Antifibrinolytics were commonly used only in patients who were at high risk for bleeding by 51% of responders, while yet, another 39% used them routinely, and 11% never did. About 59% of the centers insist on only fresh blood (<7 days old) when blood transfusion was indicated. The facility to use vaporizer on CPB was available in 62% of the centers. All the teaching centers or high volume centers in India had access to transesophageal echocardiography probe and echo machine, with 51% using them routinely and 38% using them at least sometimes.

Conclusions:

There is a wide heterogeneity in CPB management protocols among various Indian cardiac surgery centers. The survey suggests that adherence to evidence-based and internationally accepted practices appears to be more prevalent in centers that have ongoing teaching programs and/or have high volumes, strengthening the need to devise guidelines by appropriate body to help bring in uniformity in CPB management to ensure patient safety and high quality of clinical care for best outcomes.

Role of Hospital Volumes in Identifying Low-Performing and High-Performing Aortic and Mitral Valve Surgical Centers in the United States

Importance

Identifying high-performing surgical valve centers with the best surgical outcomes is challenging. Hospital surgical volume is a frequently used surrogate for outcomes. However, its ability to distinguish low-performing and high-performing hospitals remains unknown.

Objective

To examine the association of hospital procedure volume with hospital performance for aortic and mitral valve (MV) surgical procedures.

Design, Setting, and Participants

Within an all-payer nationally representative data set of inpatient hospitalizations, this study identified 682 unique hospitals performing surgical aortic valve replacement (SAVR) and MV replacement and repair with or without coronary artery bypass grafting (CABG) between 2007 and 2011. Procedural outcomes were further assessed for a 10-year period (2005-2014) to assess representativeness of study period.

Main Outcomes and Measures

In-hospital risk-standardized mortality rate (RSMR) calculated using hierarchical models and an empirical bayesian approach with volume-based shrinkage that allowed for reliability adjustment.

Results

At 682 US hospitals, 70 295 SAVR, 19 913 MV replacement, and 17 037 MV repair procedures were performed between 2007 and 2011, with a median annual volume of 43 (interquartile range [IQR], 23-76) SAVR, 13 (IQR, 6-22) MV replacement, and 9 (IQR, 4-19) MV repair procedures. Of 225 SAVR hospitals in the highest-volume tertile, 34.7% and 36.0% were in the highest-RSMR tertile for SAVR + CABG and isolated SAVR procedures, respectively, while 21.5% and 17.5% of the 228 SAVR hospitals in the lowest-volume tertile were in the lowest respective RSMR tertile. Similarly, 36.8% and 43.5% of hospitals in the highest tertile of volume for MV replacement and repair, respectively, were in the corresponding highest-RSMR tertile, and 17.4% and 11.2% of the low-volume hospitals were in the lowest-RSMR tertile for MV replacement and repair, respectively. There was limited correlation between outcomes for SAVR and MV procedures at an institution. If solely volume-based tertiles were used to categorize hospitals for quality, 44.7% of all valve hospitals would be misclassified (as either low performing or high performing) when assessing performance based on tertiles of RSMR.

Conclusions and Relevance

Hospital procedure volume alone frequently misclassifies hospital performance with regard to risk-standardized outcomes after aortic and MV surgical procedures. Valve surgery quality improvement endeavors should focus on a more comprehensive assessment that includes risk-adjusted outcomes rather than hospital volume alone.

Variations of transesophageal echocardiography practices in India: A survey by Indian College of Cardiac Anaesthesia

CONTEXT

Use of perioperative transesophageal echocardiography (TEE) has expanded in India. Despite attempts to standardize the practice of TEE in cardiac surgical procedures, variation in practice and application exists. This is the first online survey by Indian College of Cardiac Anaesthesia, research and academic wing of the Indian Association of Cardiovascular Thoracic Anaesthesiologists (IACTA).

AIMS

We hypothesized that variations in practice of intraoperative TEE exist among centers and this survey aimed at analyzing them.

SETTINGS AND DESIGN

This is an online survey conducted among members of the IACTA.

SUBJECTS AND METHODS

All members of IACTA were contacted using online questionnaire fielded using SurveyMonkey™ software. There were 21 questions over four pages evaluating infrastructure, documentation of TEE, experience and accreditation of anesthesiologist performing TEE, and finally impact of TEE on clinical practice. Questions were also asked about national TEE workshop conducted by the IACTA, and suggestions were invited by members on overseas training.

RESULTS

Response rate was 29.7% (382/1222). 53.9% were from high-volume centers (>500 cases annually). TEE machine/probe was available to 75.9% of the respondents and those in high-volume centers had easier (86.9%) access. There was poor documentation of preoperative consent (23.3%) as well as TEE findings (66%). Only 18.2% of responders were board qualified. Almost 90% of the responders felt surgeons respected their TEE diagnosis. Around half of the responders felt that new intraoperative findings by TEE were considered in decision-making in most of the cases and 70% of the responders reported that surgical plan was altered based on TEE finding more than 10 times in the last year. Despite this, only 5% of the responders in this survey were monetarily awarded for performing impactful skill of TEE. Majority (57%) felt that there is no need for overseas training for Indian cardiac anesthesiologists.

CONCLUSIONS

In this survey of members of the IACTA, use of TEE has increased substantially, but still a lot of variations in practice patterns exist in India. There is urgent need for improving TEE certification and upgrade documentation standards, motivate use of TTE across all centers, promote awareness and usefulness of TEE use among surgical fraternity, monitor impact of TEE, and support separate remuneration policy in India.

Guidelines of the Indian Association of Cardiovascular and Thoracic Anaesthesiologists and Indian College of Cardiac Anaesthesia for perioperative transesophageal echocardiography fellowship examination

During current medical care, perioperative transesophageal echocardiography (TEE) has become a vital component of patient management, especially in cardiac operating rooms and in critical care medicine. Information derived from echocardiography has an important bearing on the patient's outcome. The Indian Association of Cardiovascular and Thoracic Anaesthesiologists (IACTA) has promoted the use of TEE during routine clinical care of patients undergoing cardiac surgery. An important mission of IACTA is to oversee training and certify anesthesiologists in the perioperative and intensive care use of TEE. The provision of “Fellowship” is by way of conducting IACTA – TEE fellowship (F-TEE) examination. This has been done annually for the past 7 years using well-established curriculums by accredited national and international societies. Now, with the transformation and reconstitution of IACTA education and research cell into the newly formed Indian College of Cardiac Anaesthesia, F-TEE is bound to meet international standards. To ensure that the examinations are conducted in a transparent and foolproof manner, the guideline committee (formulated in 2010) of IACTA has taken the onus of formulating the guidelines for the same. These guidelines have been formally reviewed and updated since 2010 and are detailed here to serve as a guide to both the examinee and examiner ensuring standardization, efficiency, and competency of the IACTA F-TEE certification process.

Accuracy of a Chest X-Ray-Based Method for Predicting the Depth of Insertion of Endotracheal Tubes in Pediatric Patients Undergoing Cardiac Surgery

OBJECTIVES

The incidence of endotracheal tube (ETT) malposition in children with various described methods is 15% to 30%. Chest x-ray (CXR) is the gold standard for confirming appropriate ETT position. The aim of this study was to measure the accuracy of a preoperative CXR-based method in determining depth of insertion of ETTs and to compare it with methods based on the intubation depth mark or formulae (age, height, and ETT internal diameter) in children undergoing cardiac surgery.

DESIGN

Prospective observational study.

SETTING

University-affiliated tertiary care hospital.

PARTICIPANTS

Sixty-six consecutive children scheduled for elective pediatric cardiac surgery.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The distance from carina to mid-trachea was measured for each child preoperatively on the CXR displayed as a computed radiography image in a picture archival and communications system computer. Following intubation, ETTs deliberately were pushed endobronchially and then pulled back to the carina; they were further withdrawn by the previously measured carina to mid-tracheal distance and secured. CXRs postoperatively were repeated to confirm ETT position. The ETT position was measured with other methods using the picture archival and communications system ruler on the postoperative CXR and compared with the CXR method. The proportion of appropriate ETT position with the CXR method was 98.5% (p≤0.001 v other methods). In children younger than 3 years, the appropriate proportion was 97.4%.

CONCLUSION

The appropriate positioning of ETTs in the trachea by the CXR method is superior to other methods.

A review of the practice of sedation with inhalational anaesthetics in the intensive care unit with the AnaConDa(®) device

The intensive care unit (ICU) environment is often perceived to be hostile and frightening by patients due to unfamiliar surroundings coupled with presence of numerous personnel, monitors and other equipments as well as a loss of perception of time. Mechanical ventilation and multiple painful procedures that often need to be carried out in these critically ill patients add to their overall anxiety. Sedation is therefore required not only to allay the stress and anxiety, but also to allow for mechanical ventilation and other invasive therapeutic and diagnostic procedures to be performed. The conventional intravenous sedative agents used in ICUs suffer from problems of over sedation, tachyphylaxis, drug accumulation, organ specific elimination and often lead to patient agitation on withdrawal. All this tend to prolong the ventilatory as well as ICU and hospital discharge time, which increase the risk for infection and add to the overall increase in morbidity, mortality and hospital costs. In 2005, the anaesthetic conserving device (AnaConDa(®)) was marketed for ICU sedation with volatile anaesthetic agents. A number of trials have shown the effectiveness of using volatile anaesthetic agents for ICU sedation with the AnaConDa device. Compared with intravenous sedatives, use of volatile anaesthetic agents have resulted in shorter wake up and extubation time, lesser duration of mechanical ventilation and faster discharge from hospitals. This review shall focus on the benefits, technical pre-requisites and status of sedation with volatile anaesthetic agents in ICUs with the AnaConDa(®) device.

Sudden decrease in end-tidal carbon-dioxide in a neonate undergoing surgery for type B interrupted aortic arch

Interruption of the aortic arch is a rare anomaly affecting 1% of children with congenital heart disease. The systemic circulation is ductal dependent and is determined principally by the ratio of the resistances in the systemic and the pulmonary vascular bed. Any increase in the pulmonary vascular resistance may increase the dead space ventilation due to acute pulmonary hypoperfusion. We report a case where sudden decreases in the end-tidal carbon-dioxide due to pulmonary hypoperfusion mimicked accidental endotracheal tube extubation in an infant undergoing repair of interrupted aortic arch.

Coronary Artery Disease in Patients Aged 35 or less - A Different Beast?

Aim:

To assess the extent and severity of coronary artery disease (CAD) in 200 consecutive patients aged 35 years or less undergoing diagnostic coronary angiography.

Patients and Methods:

Findings in these 200 patients (≤ 35 years of age) were analyzed to find the extent and severity of CAD. The mean age was 31.69 (±3.76) years. Majority were males (94%) and from the Arab ethnicity (70.5%).

Result:

Smoking (71%) and history of premature CAD (27%) were the most frequent risk factors (RF). History of previous ST elevation myocardial infarction (MI) was present in 68%. Anterior wall MI was the most frequent location (63.3%). The majority (54.3%) had moderate or large size MI. Ejection fraction (EF) less than 50% was noted in 30.3%. Left main or triple vessel CAD was seen in 15%. One- and two-vessel CAD was seen in 32.5% and 19% patients, respectively. Coronary angiogram was completely normal in 23.5%. The majority (54.5%) were treated conservatively and the rest (45.5%) needed percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). The mean number of stents used was 1.3 ± 0.67 and the mean length of stents used was 20.3 ± 12.6 mm.

Conclusion:

The extent and severity of CAD was very significant in this subgroup of very young (≤35 years) Asian patients. Smoking was the main risk factor and half of the patients needed either PCI or CABG.