Predictive model for blood product use in coronary artery bypass grafting

Objective: To build a clinical predictive model to determine the need for transfusing blood and its products in coronary artery bypass grafting [CABG] procedures in South East Asian population

Study Design: Analytical study

Place and Duration of Study: Section of Cardiothoracic Surgery, Aga Khan University Hospital, Karachi, from January 2006 to October 2014

Methodology: Information on pre-, intra- and postoperative variables were collected for all adult patients who underwent on-pump CABG. The patients grouped into those who received blood and its components, and those who did not. A univariate as well as multivariate logistic model was built to determine the predictors of transfusion

Results: A total of 3,550 patients underwent CABG and males were dominant in both groups [75 vs. 93%]. The transfusion rate was 56.4% [n=2001]. Age [adjusted OR 1.03, p < 0.001], obesity [1.50, p=0.001], tobacco use [1.29, p=0.001], and male gender [4.51, p < 0.001] found to be a stronger predictor. Among preoperative comorbidities, diabetes [1.20, p=0.016], myocardial infarction [1.22, p=0.009], preoperative creatinine [1.12, p=0.033], and left main vessel disease of > 50% [1.49, p < 0.001] were independently associated with the outcome. Compared to elective cases, transfusion rates were high in urgent and emergent cases [OR: 1.93 and 3.36 respectively, p < 0.001 for both]

Conclusion: Age, male gender, obesity, tobacco use, diabetes, myocardial infarction, high creatinine, urgent and emergent cases were independent predictors of transfusion in CABG procedure. This model can be utilized for preoperative risk stratification of patients and their management to improve the outcomes

Outcome of cardiac arrest post open heart procedures in a tertiary care hospital

Introduction: Cardiac arrest following an open-heart surgery can be a devastating event, leading to severe mortality and morbidity. Various factors may precipitate cardiac arrest by decreasing perfusion to the heart. Open chest cardiac resuscitation is superior to closed chest cardiac resuscitation in restoring blood flow to the heart. The time between the onset of cardiac arrest to the provision of necessary method of resuscitation is of crucial significance, in deciding the outcome. If perfusion is not restored to the heart, within 5 minutes of closed chest cardiac resuscitation, a resternotomy is indicated. In this article we document number of cardiac arrests after open heart procedures in a tertiary care hospital

Methodology: We retrospectively analyzed 2.5 year data of cardiac patients admitted to our Cardiac Intensive Care Unit from January 2014 to June 2016, after open heart procedures, and recorded the number of cardiac arrests post open heart procedures, and the outcome of the resuscitation

Results: In 2.5 years out of 2505 admissions to the Cardiac Intensive Care Unit [CICU], 44 [1.76%] experienced cardiac arrest out of which only 4 [9.09%] patients survived to be discharged home

Conclusion: The results of our study show that the survival rate of cardiac arrests post open heart procedures in our Cardiac Intensive Care Unit is 9.09% as compared to most of published studies from advanced centers showing a survival rate of 25 to 50%. To find out the cause-effect factors was not the objective of this study, but needs to be researched in all Cardiac Intensive Care Units of the country

Cardiac surgery benchmarking: a quality improvement initiative

Background: Benchmarking programs help in reviewing and validating clinical practice and improves quality of care

Methodology: Fifteen accredited hospitals participated in International cardiac surgery benchmarking [ICSB] project from eight different countries including ours, Aga Khan University Hospital, a "clinical data coordinator" was trained to facilitate data collection, verification and eventual submission. The data was collected prospectively for preoperative characteristics, intraoperative variables and postoperative outcomes. Onsite data validation was also performed by a JCI representative for the accuracy of data. Data analyzed and reported on six quarters starting from October, 2009 to March, 2011

Results: A total of 4761 isolated CABG including 474 from our hospital entered into ICSB. The postoperative complication rate for ICSB and our hospital were calculated showing a higher rate of reopening [2.5 vs. 1.7%], higher postop renal dysfunction [5% vs. 1%] and a higher RBC transfusion [61 vs. 36%] but the incidence of stroke, myocardial infarction and deep sternal wound infection were low at our hospital. Risk factors that predict surgical death for CABG in this model are very similar to those used in New York state hospitals. The overall risk adjusted 30-day mortality was 3.4% at our hospital compared to 1.9% for ICSB

Conclusion: By benchmarking program our practice and data collection methodology has been reviewed and validated. Feedback will serve as regulatory function leading towards self-assessments to improve quality of care

Perfusion science: an international and Pakistani perspective

Surgery on the heart was considered out of bounds till the invention of the bypass machine in 1953. Since then the significant advancements have been made in the heart lung machine, as it evolved over time. In the initial era, it was operated by operating room technicians or physicians, but with its increased use in the 1960s, a need was soon felt for more trained professionals to operate the machine. Hence, a new breed of professional cardiovascular perfusionists came into existence with formal certification and accreditation. In United States, Ohio University started formal training of perfusionists in 1969. This was followed by the creation of various organizations to facilitate the accreditation process, such as The American Society of Extra-Corporeal Technology [AmSECT] and American Board of Cardiovascular Perfusion [ABCP]. In Europe, The European Board of Cardiovascular Perfusion [EBCP] was founded in 1991 by Cardiovascular Perfusionists, which continued to certify perfusionists. In Pakistan the Pakistan Society of Clinical Perfusionists [PSCP] was formed in 2009, to facilitate former education and certification in perfusion sciences. Increased demand for quality assurance and to maintain standards of practice in the field of perfusion sciences, has led to the creation of International Consortium for Evidence Based Perfusion [ICEBP]. With constant improvements in the heart lung machine to make bypass safer, the perfusionist must be familiar with updated protocols and knowledge to ensure the safety of the patient during cardiac procedures

Impact of chronic kidney disease on short term clinical outcomes of patients undergoing coronary revascularization

When compared with medical treatment, coronary revascularization is an effective tool to restore cardiac functions in patients suffering from chronic kidney disease but at times it is associated with poor clinical outcome. This study was done to determine the short term clinical outcome in chronic kidney disease patients undergoing coronary revascularization i.e coronary artery bypass graft or percutaneous coronary intervention. Cross sectional study, conducted at coronary revascularization center of Aga Khan University Hospital, Karachi between January 2012 and August 2013. All chronic kidney disease patients were enrolled and grouped into mild, moderate and severe kidney disease cases according to creatinine clearance estimated by the Cockroft-Gault equation. The primary outcome was in-hospital major adverse cardiac cerebral events, including myocardial infarction, stroke, and death. A total of 159 patients were included in the study [122 males and 37 females] whose mean age was 65 +/- 9.6 years. Based on the creatinine clearance, 59 cases had severe, 79 moderate and 21 mild chronic kidney disease. Before revascularization, 20 patients with severe, 3 patients with moderate and 2 patients with mild kidney disease were on long term hemodialysis. In the moderate to severe group, 79 patients underwent percutaneous coronary intervention whereas, in the mild group, 15 patients underwent coronary artery bypass graft. Though the rate of failed PCI [uncrossable total occlusions of coronary artery] was similar among the 3 groups but complete revascularization was more evident 18 [85.7% and 60 [75.9%] in mild to moderate cases respectively. During hospitalization, 9 [15.3%] patients died in severe cases out of whom 2 [3.4%] died due to cardiogenic cause and 7 [11.9%] died due to non-cardiogenic causes. Mortality in moderate group was similar 9 [11.4%] and among them, 2 patients died due to cardiogenic cause and rest due to non-cardiogenic cause but none died in mild group. Though all 3 groups of chronic kidney disease patients had similar clinical and angiographic findings but poor clinical outcome was noted in patients having moderate to severe chronic kidney disease irrespective of whether they underwent PCI or CABG

Mode of coronary revascularization and short term clinical outcomes in patients with chronic kidney disease

Percutaneous coronary intervention [PCI] and coronary artery bypass graft [CABG] surgery are two alternative methods for coronary revascularization, but it remains controversial as which one is associated with lower risks of worse clinical outcomes for chronic kidney disease [CKD] patients. We determined the mode of coronary revascularization [PCI vs. CABG] which is associated with lower risk of mortality and morbidity in CKD patients. In this cross sectional study, 159 patients with CKD were enrolled from single center of coronary revascularization at Aga Khan University Hospital Karachi between January 2012 and August 2013. All patients with CKD underwent PCI or CABG. The primary outcome was in-hospital composite of death, myocardial infarction [MI], or stroke. We evaluated which mode of coronary revascularization was associated with reduced risks of clinical outcomes. Out of 159 patients with CKD, 85 [53.5%] received PCI and 74 [46.5%] received CABG. The primary finding of this study is that more patients with moderate to severe CKD underwent PCI and more patients with mild to moderate CKD underwent CABG. In both these categories, no difference was observed in clinical outcomes. There are few factors like age, ST- elevation myocardial infarction [STEMI], non-ST elevation myocardial infarction [NSTEMI] and number of coronary artery disease predicted PCI as treatment strategy in patients with moderate to severe CKD. Patients with moderate to severe CKD have similar rates of short term clinical outcomes whether they underwent PCI or CABG. Therefore, PCI can be acceptable and less invasive treatment option alternative to CABG, particularly in patients with moderate to severe CKD

A case of cellulitis of the hands caused by a predatory bird attack

Many species have been drastically affected by rapid urbanization. Harris's hawks from their natural habitat of open spaces and a supply of rodents, lizards and other small prey have been forced to change their natural environment adapting to living in open spaces in sub- and peri-urban areas. Specific areas include playgrounds, parks and school courtyards. The migration of this predatory species into these areas poses a risk to individuals, and especially the children are often attacked by claws, talons and beaks intentionally or as collateral damage while attacking rodent prey. In addition, the diverse micro-organisms harbored in the beaks and talons can result in wound infections, presenting a challenge to clinical management. Here we would like to present a case of an 80-year-old man with cellulitis of both hands after sustaining minor injuries from the talons of a Harris's hawk and review the management options. We would also like to draw attention to the matter that, even though previously a rarity, more cases of injuries caused by birds of prey may be seen in hospital settings.

Carotid cavernous fistula in a patient with coronary artery disease

Carotid cavernous fistulas are abnormal communications between the carotid and cavernous vasculature, with potential for serious neurological and ocular sequelae. There is considerable literature on the neuro-radiological management of carotico-cavernous fistula depending upon their flow status. The coronary artery bypass grafting [CABG] for coronary artery disease [CAD] is a well established method of revascularization. However, the association of carotid cavernous fistula in presence of CAD is an infrequent occurrence. We present a case of coronary artery disease scheduled for bypass surgery, developed spontaneous bilateral carotid cavernous fistulas, highlighting a unique aspect of association between coronary and carotid disease

Life threatening mediastinal haematoma: a complication of central venous catheterization

Central venous catheterization [CVC] has established risks and benefits in its application as a vascular access source, particularly in situations involving temporary cannulation. We present a rare case of life-threatening mediastinal haematoma resulting from CVC usage. Even though aggressive intervention yielded survival, the patient was left with permanent vocal compromise owing to traumatic palsy of the right recurrent laryngeal nerve. One should be careful in selection of venous access and be aware of alternatives routes

Non - traumatic emergencies - Experience from a tertiary care centre In Karachi

To review the incidence, clinical presentation and outcome of Non traumatic Aortic emergencies in a tertiary care hospital and its evaluation in the Emergency department [ED]. We conducted a retrospective review of cases presented to the ED at Aga Khan University Hospital during 15 year period [1988 - 2002] who had final diagnosis of Aortic Dissection or Ruptured Aortic Aneurysm. Patients without confirmatory investigations were excluded. We aimed at looking for the incidence, clinical presentation, evaluation in the ED and final outcome. Of the 12 cases, 7 had aortic dissection while the remaining 5 had ruptured aortic aneurysm. For Aortic dissection, mean age of presentation was 53 years with male predominance. Most of these patients had chest pain. Most common comorbid condition was hypertension. Pulse deficit was found in 2 cases, murmur in 4 cases, and focal neurologic deficit in 2 cases. Electrocardiogram revealed ischemic changes in 3 cases. Widened mediastinum on chest x-ray was present in all cases. The only initial misdiagnosis was cardiac ischemia. One patient survived to discharge. For patients presenting with ruptured aortic aneurysm, mean age of presentation was 52 yrs with a male predominance. The associated comorbid condition was hypertension. Almost all patients presented classically with abdominal pain, hypotension and palpable mass. No patient survived to discharge. Aortic emergencies although rare, are associated with significant mortality. High index of suspicion and prompt recognition by the emergency physician is of key importance

case of transient diabetes insipidus following cardiopulmonary bypass

Cardiopulmonary bypass surgery has been linked with a number of postoperative complications. One of the frequently reported physiological alterations is the relative diuresis seen in the immediate post-op period. Rarely reported though is the development of full-blown diabetes insipidus in such patients. The etiology is unknown and has only been hypothesized in the past. We present the clinical course of a 54 year old male who developed transient diabetes insipidus post bypass surgery with subsequent recovery following exogenous vasopressin administration. The physiological alteration leading to the development of diabetes insipidus in a small fraction of bypass patients remains unknown. We propose that the variation in natriuretic peptide levels in the post-bypass period could account for the transient event

Pulmonary embolism in Pemphigus Vulgaris, the need for judicious immunotherapy

Pemphigus vulgaris is a serious chronic mucocutaneous ailment. In recent decades advances in diagnostic and therapeutic measures have led to a significant decline in morbidity and mortality. However, with the advent of active and prolonged immunotherapy involving corticosteroids, there has been a rise in steroid-associated complications. This has led to significant concern globally over the sensible use of treatment regimen in pemphigus patients. We present a patient who underwent a massive pulmonary embolism following over usage of corticosteroid therapy for pemphigus vulgaris. Whilst the patient survived owing to timely assessment and aggressive surgical intervention, the need for cautious and judicious immunotherapy in pemphigus is emphasized