Extracorporeal Cardiopulmonary Resuscitation for an Out-of-Hospital Cardiac Arrest

Extra corporeal membrane oxygenation (ECMO) for refractory out?of?hospital cardiac arrest (OHCA) has been shown to improve outcome in many Western countries. There are no reports of ECMO being used to support OHCA in India till date. We report a case of a young man who developed cardiac arrest (CA) while driving and was given bystander cardiac massage. He was brought to tertiary care center where an ECMO was utilized for refractory CA. The patient subsequently underwent emergency coronary artery stenting and was weaned off ECMO and ventilation. We discuss the case and highlight the role of bystander cardiopulmonary resuscitation.

Multiple submucosal lipomas of small intestine: a case report

Small bowel obstruction can be due to benign or malignant pathologies. Gastro intestinal lipomas are one of the benign subepithelial tumours causing obstruction. These are usually detected incidentally if asymptomatic. Adult intussusception due to intestinal lipoma is a very rare cause. We are presenting a case of male hypertensive patient with features of multiple subacute obstruction due to multiple submucosal lipomas in ileum. Exploratory laparotomy with intra-operative enteroscopy was performed and resection-anastomosis of affected segment was done.

Indian Guidelines for Indications and Timing of Intervention for Common Congenital Heart Diseases: Revised and Updated Consensus Statement of the Working Group on Management of Congenital Heart Diseases. Abridged Secondary Publication

ustification: A number of guidelines are available for management of congenital heart diseases from infancy to adult life. However,these guidelines are for patients living in high income countries. Separate guidelines, applicable to Indian children, are required whenrecommending an intervention for congenital heart diseases, as often these patients present late in the course of the disease and mayhave co-existing morbidities and malnutrition. Process: Guidelines emerged following expert deliberations at the National ConsensusMeeting on Management of Congenital Heart Diseases in India, held on 10th and 11th of August 2018 at the All India Institute of MedicalSciences, New Delhi. The meeting was supported by Children’s HeartLink, a non-governmental organization based in Minnesota, USA.Objectives: To frame evidence based guidelines for (i) indications and optimal timing of intervention in common congenital heartdiseases; (ii) follow-up protocols for patients who have undergone cardiac surgery/catheter interventions for congenital heart diseases.Recommendations: Evidence based recommendations are provided for indications and timing of intervention in common congenitalheart diseases, including left-to-right shunts (atrial septal defect, ventricular septal defect, atrioventricular septal defect, patent ductusarteriosus and others), obstructive lesions (pulmonary stenosis, aortic stenosis and coarctation of aorta) and cyanotic congenital heartdiseases (tetralogy of Fallot, transposition of great arteries, univentricular hearts, total anomalous pulmonary venous connection, Ebsteinanomaly and others). In addition, protocols for follow-up of post surgical patients are also described, disease wise.

Design And In Vivo Evaluation Of Manidipine By Self-Nanoemulsifying Drug Delivery Systems

The current research is aimed at developing liquid self-nanoemulsifying drug delivery system (liquid-SNEDDS) of Manidipine for enhanced solubility and oral bioavailability. The Manidipine SNEDDS are formulated with excipients comprising of Capmul MCM (oil phase), Transcutol P (surfactant) Lutrol L 300 as co-surfactant. The prepared fifteen formulations of Manidipine SNEDDS analysed for emulsification time, percentage transmittance, particle size, in vitro drug release, and stability studies. In vivo pharmacokinetic studies of the optimized formulation were carried out in Wistar rats in comparison with control (pure drug). The morphology of Manidipine SNEDDS indicates spherical shape with uniform particle distribution. The percentage drug release from optimized formulation F14 is 98.24 ± 5.14%. The particle size F14 formulation was 22.4 nm and Z-Average 23.3 nm. The PDI and zeta potential of Manidipine SNEDDS optimized formulation (F14) were 0.313 and-5.1mV respectively. From in vivo bioavailability data the optimized formulation exhibited a significantly greater Cmax and Tmax of the SNEDDS was found to be 3.42 ± 0.46ng/ml & 2.00 ± 0.05 h respectively. AUC0-∞ infinity for formulation was significantly higher (11.25 ± 3.45 ng.h/ml) than pure drug (7.45 ± 2.24ng. h/ml). Hence a potential SNEDDS formulation of Manidipine developed with enhanced solubility and bioavailability.

Clinical, biochemical and haematological changes in leptospirosis

Background: Leptospirosis is a globally important zoonotic disease caused by pathogenic leptospira. Leptospira species are spirochetes belonging to the order spirochetes and the family leptospiraceae. Present study is done to find out the incidence of thrombocytopenia in leptospirosis and to correlate it with other parameters like renal dysfunction, hepatic dysfunction and bleeding manifestation.Methods: Study includes 51 clinically suspected and diagnosed cases of leptospirosis, in Government hospital, South Gujarat, during a period from January 2017 to December 2017. Clinical signs and symptoms and complications, biochemical profile like bilirubin and creatinine, haematological profile like Hb, WBC count and platelet count were recorded. Thrombocytopenia was defined as a platelet count below 1,50,000/cmm.Results: The present study includes 51 cases of Leptospirosis. Age ranged from 16 years to 61 years (male-39 and Females-12) There were 38 (74.5%) cases with thrombocytopenia and 13 (25.4%) cases with normal platelet count. Out of 38 thrombocytopenic cases, 32 (84.2%) cases had renal dysfunction, 26 (68.4%) cases had hepatic dysfunction and 16 (42.1%) cases had pulmonary haemorrhage. Among 13 cases with normal platelet count, 8 (61.5%) cases had hepatic dysfunction and 7 (53.8%) cases had renal dysfunction and 3 (23%) cases had pulmonary haemorrhage.Conclusions: Thrombocytopenia is a frequent complication (present in more than half of the patient) in leptospirosis and associated with more frequent and more severe complications. Therefore, early recognition of thrombocytopenia is recommended to prevent complications and mortality in leptospirosis.

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.

Does Excision of Heterotopic Ossification of the Elbow Result in Satisfactory Patient-Rated Outcomes?

Introduction: Treatment of heterotopic ossification (HO) of the elbow is challenging and fraught with complications. Patients who sustain direct trauma to the elbow joint, the central nervous system, and thermal burns are at increased risk for development of HO. There is a paucity of studies and reports on patient’s self-evaluation after the excision of the heterotopic ossification. Materials and Methods: This retrospective study assessed outcomes after excision of heterotopic ossification around the elbow in a cohort of ten patients operated from 2012 to 2015. The outcome assessment was done by the Mayo Elbow Performance index (MEPI) and the American Shoulder and Elbow Surgeons-Elbow score (ASES-E scores). Results: The mean follow-up was 18.11 months after the operation. The Mayo Elbow Performance Score was excellent in two elbows, good in six and fair in two. The mean gain in flexion-extension arc after excision of HO was 80 degrees. All of the patients had residual flexion deformity postoperatively. Eight of the nine patients were able to do activities requiring flexion at final follow-up. Conclusion: Excision of HO around the elbow is associated with satisfactory patient-rated outcomes in spite of failure to regain full range of motion.

Effect of dexmeditomidine on postoperative junctional ectopic tachycardia after complete surgical repair of tetralogy of Fallot: A prospective randomized controlled study.

Introduction: Incidence of junctional ectopic tachycardia (JET) after repair of tetralogy of Fallot (TOF) is 5.6–14%. Dexmeditomidine is a α-2 adrenoceptor agonist modulates the release of catecholamine, resulting in bradycardia and hypotension. These effects are being explored as a therapeutic option for the prevention of perioperative tachyarrhythmia. We undertook this study to examine possible preventive effects of dexmedetomidine on postoperative JET and its impact on the duration of ventilation time and length of Intensive Care Unit stay. Methods: After obtaining approval from the hospitals ethics committee and written informed consent from parents, this quasi-randomized trial was initiated. Of 94 patients, 47 patients received dexmedetomidine (dexmedetomidine group) and 47 patients did not receive the drug (control group). Results: Dexmedetomidine group had more number of complex variants like TOF with an absent pulmonary valve or pulmonary atresia (P = 0.041). Hematocrit on cardiopulmonary bypass (CPB), heart rate while coming off from CPB and inotrope score was significantly low in the dexmedetomidine group compared to control group. The incidence of JET was significantly low in dexmedetomidine group (P = 0.040) compared to control group. Conclusions: Dexmedetomidine may have a potential benefit of preventing perioperative JET.

Impact of the International Quality Improvement Collaborative on outcomes after congenital heart surgery: A single center experience in a developing economy.

Background: The International Quality Improvement Collaborative (IQIC) for Congenital Heart Surgery in Developing Countries was initiated to decrease mortality and major complications after congenital heart surgery in the developing world. Objective: We sought to assess the impact of IQIC on postoperative outcomes after congenital heart surgery at our institution. Methods: The key components of the IQIC program included creation of a robust worldwide database on key outcome measures and nurse education on quality driven best practices using telemedicine platforms. We evaluated 1702 consecutive patients ≤18 years undergoing congenital heart surgery in our institute from January 2010-December 2012 using the IQIC database. Preoperative variables included age, gender, weight at surgery and surgical complexity as per the RACHS-1 model. The outcome variables included, in- hospital mortality, duration of ventilation, intensive care unit (ICU) stay, bacterial sepsis and surgical site infection. Results: The 1702 patients included 771(45.3%) females. The median age was 8 months (0.03-216) and the median weight was 6.1Kg (1-100). The overall in-‑hospital mortality was 3.1%, Over the three years there was a significant decline in bacterial sepsis (from 15.1%, to 9.6%, P < 0.001), surgical site infection (11.1% to 2.4%, P < 0.001) and duration of ICU stay from 114(8-999) hours to 72 (18-999) hours (P < 0.001) The decline in mortality from (4.3% to 2.2%) did not reach statistical significance. Conclusions: The inclusion of our institution in the IQIC program was associated with improvement in key outcome measures following congenital heart surgery over a three year period.

Fulminating septicemia due to persistent pan-resistant community-acquired metallo-β-lactamase (IMP-1)-positive Acinetobacter baumannii

Acinetobacter baumannii is considered as an emerging nosocominal pathogen and is renowned for its multi-drug resistance. We report a case of community-acquired pan-resistant A. baumannii strain isolated from blood, pus , urine and tracheal aspirate was confirmed by 16S r-RNA sequence homology and found positive for metallo-ß-lactamase IMP-1, and was found to be a strong biofilm producer The isolate was only susceptible (moderately) to colistin.

Atrial fibrillation after cardiac surgery.

Once considered as nothing more than a nuisance after cardiac surgery, the importance of postoperative atrial fibrillation (POAF) has been realized in the last decade, primarily because of the morbidity associated with the condition. Numerous causative factors have been described without any single factor being singled out as the cause of this complication. POAF has been associated with stroke, renal failure and congestive heart failure, although it is difficult to state whether POAF is directly responsible for these complications. Guidelines have been formulated for prevention of POAF. However, very few cardiothoracic centers follow any form of protocol to prevent POAF. Routine use of prophylaxis would subject all patients to the side effects of anti-arrhythmic drugs, while only a minority of the patients do actually develop this problem postoperatively. Withdrawal of beta blockers in the postoperative period has been implicated as one of the major causes of POAF. Amiodarone, calcium channel blockers and a variety of other pharmacological agents have been used for the prevention of POAF. Atrial pacing is a non-pharmacological measure which has gained popularity in the prevention of POAF. There is considerable controversy regarding whether rate control is superior to rhythm control in the treatment of established atrial fibrillation (AF). Amiodarone plays a central role in both rate control and rhythm control in postoperative AF. Newer drugs like dronedarone and ranazoline are likely to come into the market in the coming years.

Malnutrition in children with congenital heart disease (CHD) determinants and short term impact of corrective intervention.

OBJECTIVE: To identify determinants of malnutrition in children with congenital heart disease (CHD) and examine the short-term effects of corrective intervention. METHODS: Patients with CHD admitted for corrective intervention were evaluated for nutritional status before and 3 months after surgery. Detailed anthropometry was performed and z-scores calculated. Malnutrition was defined as weight, height and weight/height z-score <or= -2. Determinants of malnutrition were entered into a multivariate logistic regression analysis model. RESULTS: 476 consecutive patients undergoing corrective intervention were included. There were 16 deaths (3.4%; 13 in-hospital, 3 follow-up). The 3-month follow-up data of 358 (77.8%) of remaining 460 patients were analyzed. Predictors of malnutrition at presentation are as summarized: weight z-score <or= -2 (59%): congestive heart failure (CHF), age at correction, lower birth weight and fat intake, previous hospitalizations, >or= 2 children; height z-score <or= -2 (26.3%): small for gestation, lower maternal height and fat intake, genetic syndromes; and weight/height z-score <or= -2 (55.9%): CHF, age at correction, lower birthweight and maternal weight, previous hospitalizations, religion (Hindu) and level of education of father.Comparison of z-scores on 3-month follow-up showed a significant improvement from baseline, irrespective of the cardiac diagnosis. CONCLUSIONS: Malnutrition is common in children with CHD. Corrective intervention results in significant improvement in nutritional status on short-term follow-up.

Clinical and demographic features of infection caused by Acinetobacter species.

BACKGROUND: Recently, Acinetobacter emerged as an important pathogen and the prevalence of isolation has increased since the last two decades worldwide. AIMS: To determine Acinetobacter incidence, their clinical demography, antibiotyping and speciation. SETTINGS AND DESIGN: A study of the clinical samples submitted to microbiology laboratory of a teaching hospital over a period of 3 years (December 1994 through November 1997). MATERIALS AND METHODS: Identification, speciation and antibiotyping were performed for the isolates of Acinetobacter recovered from infective samples. Clinical demographic characteristics were studied retrospectively. RESULTS: Total 510 of 5391 (9.6%) of isolates were Acinetobacter, responsible for 71.2% (363 of 510) monomicrobial and 28.8% (147 of 510) polymicrobial infections. The organism was responsible for 156 (30.6%) cases of urinary tract infection and 140 (27.5%) cases of wound infection and was most prevalent in the intensive care unit (30.8%, 140 of 455). The crude mortality rate due to multi-drug resistant Acinetobacter septicemia was 7.9% (36 of 455). The isolates could be classified into 7 species, with A. baumannii being most predominant. No peculiar pattern during antibiotyping was observed, but most of them were multi-drug resistant. CONCLUSION: Multi-drug resistant Acinetobacter nosocomial infection has emerged as an increasing problem in intensive care units of the hospital, responsible for 7.9% deaths. The analysis of risk factors and susceptibility pattern will be useful in understanding epidemiology of this organism in a hospital setup.