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.

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.

Prediction of postoperative atrial fibrillation after coronary artery bypass grafting surgery: Is CHA 2 DS 2 -VASc score useful.

Aims and Objectives: Postoperative atrial fibrillation (POAF) is the most common arrhythmia after coronary artery bypass grafting (CABG) surgery. The identification of patients at risk for POAF would be helpful to guide prophylactic therapy. Presently, there is no simple preoperative scoring system available to predict patients at higher risk of POAF. In a retrospective observational study, we evaluated the usefulness of CHA 2 DS 2 -VASc score to predict POAF after CABG. Materials and Methods: After obtaining approval from Institutional Review Board, 729 patients undergoing CABG on cardiopulmonary bypass (CPB) were enrolled. Patients were followed in the postoperative period for POAF. A multiple regression analysis was run to predict POAF from various variables. The area under the receiver operating characteristic (ROC) curve was calculated to test discriminatory power of CHA 2 DS 2 -VASc score to predict POAF. Results: POAF occurred in 95 (13%) patients. The patients with POAF had higher CHA 2 DS 2 -VASc scores than those without POAF (4.09 ± 0.90 vs. 2.31 ± 1.21; P < 0.001). The POAF rates after cardiac surgery increased with increasing CHA 2 DS 2 -VASc scores. The odds ratio for predicting POAF was highest with higher CHA 2 DS 2 -VASc scores (3.68). When ROC curve was calculated for the CHA 2 DS 2 -VASc scores, area of 0.87 was obtained, which was statistically significant (P < 0.0001). Conclusions: The CHA 2 DS 2 -VASc score was found useful in predicting POAF after CABG. This scoring system is simple and convenient to use in the preoperative period to alert the clinician about higher probability of POAF after CABG surgery.

The application of European system for cardiac operative risk evaluation II (EuroSCORE II) and Society of Thoracic Surgeons (STS) risk-score for risk stratification in Indian patients undergoing cardiac surgery.

Aims and Objectives: To validate European system for cardiac operative risk evaluation II (EuroSCORE II) and Society of Thoracic Surgeons (STS) risk-score for predicting mortality and STS risk-score for predicting morbidity in Indian patients after cardiac surgery. Materials and Methods: EuroSCORE II and STS risk-scores were obtained pre-operatively for 498 consecutive patients. The patients were followed for mortality and various morbidities. The calibration of the scoring systems was assessed using Hosmer-Lemeshow test. The discriminative capacity was estimated by area under receiver operating characteristic (ROC) curves. Results: The mortality was 1.6%. For EuroSCORE II and STS risk-score C-statics of 5.43 and 6.11 were obtained indicating satisfactory model fit for both the scores. Area under ROC was 0.69 and 0.65 for EuroSCORE II and STS risk-score with P values of 0.068 and 0.15, respectively, indicating poor discriminatory power. Good fit and discrimination was obtained for renal failure, long-stay in hospital, prolonged ventilator support and deep sternal wound infection but the scores failed in predicting risk of reoperation and stroke. Mortality risk was correctly estimated in low (< 2%) and moderate (2-5%) risk patients, but over-estimated in high-risk (> 5%) patients by both scoring systems. Conclusions: EuroSCORE II and STS risk-scores have satisfactory calibration power in Indian patients but their discriminatory power is poor. Mortality risk was over-estimated by both the scoring systems in high-risk patients. The present study highlights the need for forming a national database and formulating risk stratification tools to provide better quality care to cardiac surgical patients in India.

Management of patients with hematological malignancies undergoing coronary artery bypass grafting.

The number of patients with a previously diagnosed malignancy who need cardiac surgery is increasing. Patients with hematological malignancies represent only 0.38% of all patients undergoing cardiac surgery. The literature in this subset of patients is limited to only a few retrospective case series, with limited number of patients undergoing emergency cardiac surgery. We describe three cases with hematological malignancies namely chronic myelogenous leukemia, acute promyelocytic leukemia and chronic lymphocytic leukemia presenting for coronary artery bypass grafting (CABG). Two patients were taken up for emergency CABG in view of ongoing ischemia, one of them was on preoperative intra-aortic balloon pump support. No mortality was observed. Two patients needed transfusion of blood products which was guided by thromboelastography. One patient developed superficial sternal wound infection requiring antibiotic therapy.