Aggressive Management of a Bilateral Chylothorax Complicating an Orthotopic Heart-Kidney Transplantation

ABSTRACT Chylothorax after an orthotopic heart transplant is a rare but potentially detrimental occurrence. This is the first reported case of bilateral chylothorax complicating a heart-kidney transplant patient. No universally accepted protocol exists for the management of chylothorax in general population, let alone the immunocompromised transplant patient. This case presents unique challenges to the management of postoperative chylothorax given heart-kidney transplant's effect on the patient's volume status and immunocompromised state. We make the argument for aggressive treatment of chylothorax in an immunocompromised heart-kidney transplant patient to limit complications in a patient population predisposed to infection.

Primary extraneural ependymoma of the broad ligament: A rare entity

Extraneural broad ligament ependymoma is a rare entity. Herein, we present a case of unusually large broad ligament ependymoma in a 32-year-old female with pain and lump in the lower abdomen. Contrast-enhanced computed tomography abdomen revealed multiple heterogeneously enhancing pelvic masses with lobulated surface in bilateral adnexa along with multiple peritoneal nodules. Her relevant serum tumor markers were unremarkable. Core biopsy revealed tumor composed of elongated cells arranged predominantly in true and pseudoperivascular rosettes. The histopathological differentials included ependymoma, primitive neuroectodermal tumor, and teratoma with neural differentiation. Results of immunohistochemistry favored the diagnosis of ependymoma. Surgical exploration and optimal cytoreduction were done, and a final diagnosis of primary broad ligament ependymoma with peritoneal metastasis was made. The patient received six cycles of adjuvant chemotherapy and is doing well after 8-month follow-up. The present case highlights the diagnostic workup and management of a rare and an unusually large broad ligament ependymoma with peritoneal metastasis

Normative Data of Optimally Placed Endotracheal Tube by Point-of-care Ultrasound in Neonates

Objective: To derive normative data of the distance betweenoptimally placed endotracheal tube tip and arch of aorta byultrasound in neonates across different weight and gestation.Design: Cross-sectional study.Setting: Tertiary care neonatal intensive care unit from April 2015to May 2016.Participants: All neonates requiring endotracheal intubation wereeligible for the study.Methods: During intubation, insertional length was determinedusing weight-based formula. The distance between endotrachealtube tip and arch of aorta was measured by ultrasound.Endotracheal tube position was confirmed by chest radiograph.Results: Out of 133 enrolled infants, 101 (75.9%) had optimallyplaced endotracheal tubes. The mean (SD) distance betweenendotracheal tube tip and arch of aorta by ultrasound was 0.78(0.21) cm in infants <1500 g and 1.04 (0.32) cm in infants ≥1500 g.The regression equation to estimate insertional length fromweight, crown heel length (CHL), occipito-frontal circumference(OFC), nasal tragus length (NTL) and sternal length (SL) wereWt(kg)+4.95, 0.15×CHL(cm)+0.57, 0.22×OFC(cm)+0.49, 0.82×NTL(cm)+1.24 and 0.75×SL(cm)+2.26, respectively.Conclusion: Our study reports normative data of the distancebetween optimally placed endotracheal tube tip and arch of aortaby ultrasound in neonates. The distance between endotrachealtube tip and arch of aorta increases with increase in weight andgestation. Insertional length correlates strongly with all theanthropometric parameters

Milky Mesentery: Acute Abdomen with Chylous Ascites

Background: Clinical presentations of intestinal lymphangiectasia include pitting edema,chylous ascites, pleural effusion, diarrhea, malabsorption and intestinal obstruction. CaseCharacteristics: An 8-year-old male child presented to the emergency department withclinical features of peritonitis, raising suspicion of appendicular or small bowel perforation.Intervention/Outcome: Diagnosis of chylous ascites with primary intestinallymphangiectasia made on laparotomy. Message: Acute peritonitis may be a presentationof primary intestinal lymphangiectasia and chylous ascites.

Impact of Quality Improvement Program on Expressed Breastmilk Usage in Very Low Birth Weight Infants

Objective: To improve the usage of expressed breast milk invery low birth weight infants admitted in the neonatal intensivecare unit of a tertiary centre in India.Methods: Between April 2015 and August 2016, various Plan-do-act-study cycles were conducted to test change ideas likeantenatal counselling including help of brochure and video, post-natal telephonic reminders within 4-6 hours of birth,standardization of Kangaroo mother care, and non-nutritivesucking protocol. Data was analyzed using statistical processcontrol charts.Results: 156 very low birth weight infants were deliveredduring the study period, of which 31 were excluded due tovarious reasons. Within 6 months of implementation, theproportion of very low birth weight infants who receivedexpressed breast milk within 48 hours improved to 100% from38.7% and this was sustained at 100% for next 8 months. Themean time of availability and volume of expressed breast milkwithin 48 hours, improved gradually from 73.3 h to 20.9 h and 4.7mL to 15.8 mL, respectively. The mean proportion of expressedbreast milk once infant reached a feed volume of 100 mL/kg/dayalso improved from 61.3% to 82.3%.Conclusion: Quality improvement interventions showedpromising results of increased expressed breast milk usage invery low birth weight infants.

Prevalence of cardiovascular diseases in patients hospitalized for acute exacerbation of COPD: prospective observational study

Background: Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) has considerable cardiovascular risk. Various cardiovascular diseases are common during exacerbations. Both diseases share several similarities such as older age of the patient, smoking as a common risk factor and symptoms of exertional dyspnea. Knowledge regarding the magnitude of underlying cardiovascular diseases during AECOPD is limited. Authors performed this study to assess the presence of different associated cardiovascular diseases (CVDs) in patients hospitalized for AECOPD and its effect on the outcome.Methods: It was a prospective observational study involving 436 patients of AECOPD divided to Group 1 (AECOPD with CVD- 137 (31.4%) patients) and Group 2 (AECOPD without CVD 299 (68.6%) patients). All the patients were subjected to full history taking, clinical examination, chest X-ray, spirometry, ECG and echocardiography.Results: COPD patients in exacerbation with CVD, were significantly more likely to have longer duration of hospital stay (p < 0.0001), high CRP level (p<0.001), more frequent mechanical ventilations (p < 0.001), two or more exacerbations per year (p <0.0001) and the mortality was (p<0.0001). Also, they have GOLD grade III/IV severe (43.5%) and very severe (19.5%) air flow limitation. The high percentage of them had (64.8%) pulmonary hypertension, (37.3%) systemic arterial hypertension, (31.5%) arrhythmia, (27.8%) ischemic heart diseases and (21.3%) heart failure.Conclusions: The prevalence of cardiovascular diseases (CVD) in patients hospitalized for COPD was high. Age, sex and CVD trends, as well as life style changes, should be considered when prevention and control strategies are formulated.

Risk factors for delayed extubation after ventricular septal defect closure: a prospective observational study

Objective: The objective of our study was to determine the feasibility of early extubation and to identify the risk factors for delayed extubation in pediatric patients operated for ventricular septal defect closure. Methods: A prospective, observational study was carried out at our Institute. This study involved consecutive 135 patients undergoing ventricular septal defect closure. Patients were extubated if feasible within six hours after surgery. Based on duration of extubation, patients were divided two groups: Group 1= extubation time ≤ 6 hours, Group 2= extubation time >6 hours. Results: A total of 99 patients were in Group 1 and 36 patients in Group 2. Duration of ventilation was 4.4±0.9 hours in Group 1 and 25.9±24.9 hours in Group 2 (P<0.001). Univariate analysis showed that young age, low weight, low partial pressure of oxygen, trisomy 21, multiple ventricular septal defect, high vasoactive inotropic score, transient heart block and low cardiac output syndrome were associated with delayed extubation. However, regression analysis revealed that only trisomy 21 (OR: 0.248; 95%CI: 0.176-0.701; P=0.001), low cardiac output syndrome (OR: 0.291; 95%CI: 0.267-0.979; P=0.001), multiple ventricular septal defect (OR: 0.243; 95%CI: 0.147-0.606; P=0.002) and vasoactive inotropic score (OR: 0.174 95%CI: 0.002-0.062; P=0.039) are strongest predictors for delayed extubation. Conclusion: Trisomy 21, low cardiac output syndrome, multiple ventricular septal defect and high vasoactive inotropic score are significant risk factors for delay in extubation. Age, weight, pulmonary artery hypertension, size of ventricular septal defect, aortic cross-clamp and cardiopulmonary bypass time did not affect early extubation.

Anterior minithoracotomy: a safe approach for surgical asd closure & asd device retrieval

Abstract Objective: Midline sternotomy is the preferred approach for device migration following transcatheter device closure of ostium secundum atrial septal defect. Results of patients operated for device migration were retrospectively reviewed after transcatheter closure of atrial septal defect. Methods: Among the 643 patients who underwent atrial septal defect with closure device, 15 (2.3%) patients were referred for device retrieval and surgical closure of atrial septal defect. Twelve patients underwent device retrieval and surgical closure of atrial septal defect through right antero-lateral minithoracotomy with femoral cannulation. Three patients were operated through midline sternotomy. Results: Twelve patients operated through minithoracotomy did not require conversion to sternotomy. Due to device migration to site of difficult access through thoracotomy, cardiac tamponade and hemodynamic instability, respectively, three patients were operated through midline sternotomy. Mean aortic cross-clamp time and cardiopulmonary bypass time were 28.1±17.7 and 58.3±20.4 minutes, respectively. No patient had surgical complication or mortality. Mean intensive care unit and hospital stay were 1.6±0.5 days and 7.1±2.2 days, respectively. Postoperative echocardiography confirmed absence of any residual defect and ventricular dysfunction. In a mean follow-up period of six months, no mortality was observed. All patients were in New York Heart Association class I without wound or vascular complication. Conclusion: Minithoracotomy with femoral cannulation for cardiopulmonary bypass is a safe-approach for selected group of patients with device migration following transcatheter device closure of atrial septal defect without increasing the risk of cardiac, vascular or neurological complications and with good cosmetic and surgical results.

Transverse sternal split: a safe mini-invasive approach for perventricular device closure of ventricular septal defect

Abstract Objective: Perventricular device closure of ventricular septal defect through midline sternotomy avoids the cardiopulmonary bypass, however, lacks the cosmetic advantage. Perventricular device closure of ventricular septal defect with transverse split sternotomy was performed to add the cosmetic advantage of mini-invasive technique. Methods: Thirty-six pediatric patients with mean age 7.14±3.24 months and weight 5.00±0.88 kg were operated for perventricular device closure of ventricular septal defect through transverse split sternotomy in 4th intercostal space under transesophageal echocardiography guidance. In case of failure or complication, surgical closure of ventricular septal defect was performed through the same incision with cervical cannulation of common carotid artery and internal jugular vein for commencement of cardiopulmonary bypass. All the patients were postoperatively followed, and then discharged from hospital due to their surgical outcome, morbidity and mortality. Results: Procedure was successful in 35 patients. Two patients developed transient heart block. Surgical closure of ventricular septal defect was required in one patient. Mean duration of ventilation was 11.83±3.63 hours. Mean intensive care unit and hospital stay were 1.88±0.74 days and 6.58±1.38 days, respectively. There was no in-hospital mortality. A patient died one day after hospital discharge due to arrhythmia. No patients developed wound related, vascular or neurological complication. In a mean follow-up period of 23.3±18.45 months, all 35 patients were doing well without residual defect with regression of pulmonary artery hypertension as seen on transthoracic echocardiography. Conclusion: Transverse split sternotomy incision is a safe and effective alternative to a median sternotomy for perventricular device closure of ventricular septal defect with combined advantage of better cosmetic outcomes and avoidance of cardiopulmonary bypass.

Single-dose lignocaine-based blood cardioplegia in single valve replacement patients

Abstract OBJECTIVE: Myocardial protection is the most important in cardiac surgery. We compared our modified single-dose long-acting lignocaine-based blood cardioplegia with short-acting St Thomas 1 blood cardioplegia in patients undergoing single valve replacement. METHODS: A total of 110 patients who underwent single (aortic or mitral) valve replacement surgery were enrolled. Patients were divided in two groups based on the cardioplegia solution used. In group 1 (56 patients), long-acting lignocaine based-blood cardioplegia solution was administered as a single dose while in group 2 (54 patients), standard St Thomas IB (short-acting blood-based cardioplegia solution) was administered and repeated every 20 minutes. All the patients were compared for preoperative baseline parameters, intraoperative and all the postoperative parameters. RESULTS: We did not find any statistically significant difference in preoperative baseline parameters. Cardiopulmonary bypass time were 73.8±16.5 and 76.4±16.9 minutes (P=0.43) and cross clamp time were 58.9±10.3 and 66.3±11.2 minutes (P=0.23) in group 1 and group 2, respectively. Mean of maximum inotrope score was 6.3±2.52 and 6.1±2.13 (P=0.65) in group 1 and group 2, respectively. We also did not find any statistically significant difference in creatine-phosphokinase-MB (CPK-MB), Troponin-I levels, lactate level and cardiac functions postoperatively. CONCLUSION: This study proves the safety and efficacy of long-acting lignocaine-based single-dose blood cardioplegia compared to the standard short-acting multi-dose blood cardioplegia in patients requiring the single valve replacement. Further studies need to be undertaken to establish this non-inferiority in situations of complex cardiac procedures especially in compromised patients.

Cervical cannulation for surgical repair of congenital cardiac defects in infants and small children

Abstract INTRODUCTION: The biggest challenge faced in minimally invasive pediatric cardiac surgery is cannulation for cardiopulmonary bypass. Our technique and experience of cervical cannulation in infants and small children for repair of congenital cardiac defects is reported in this study. METHODS: From January 2013 to June 2015, 37 children (22 males) with mean age of 17.97±8.63 months and weight of 8.06±1.59 kg were operated on for congenital cardiac defects through right lateral thoracotomy. The most common diagnosis was ventricular septal defect (18 patients). In all patients, right common carotid artery, right internal jugular vein and inferior vena cava were cannulated for institution of cardiopulmonary bypass and aorta was cross clamped through right 2nd intercostal space. RESULTS: There were no deaths or any major complications related to cervical cannulation. Common carotid artery cannulation provided adequate arterial inflow while internal jugular vein with inferior vena cava provided adequate venous return in all patients. No patient required conversion to sternotomy or developed vascular, neurological or wound related complications. Three patients had residual lesions (small leak across ventricular septal defect patch-2, Grade II left atrio-ventricular valve regurgitation-1) and one patient had mild left ventricular dysfunction. At discharge, both common carotid artery and internal jugular vein were patent on color Doppler ultrasonography in all patients. In a mean follow-up period of 11.4±2.85 months, all patients were doing well. No patient had any wound related, neurological or vascular complication. No patient had residual leak across ventricular septal defect patch. CONCLUSION: Cervical cannulation of common carotid artery and internal jugular vein is a safe, reliable, efficient and quick method for institution of cardiopulmonary bypass in minimally invasive pediatric cardiac surgery.

Variability of Thinness and its Relation to Cardio-metabolic Risk Factors using Four Body Mass Index References in School-children from Delhi, India.

Objectives: To compare: (i) prevalences of thinness in schoolchildren by four body mass index references in common use viz., Centre for Disease Control (CDC); Cole; Indian Academy of Pediatrics (IAP); World Health Organization (WHO); and (ii) relationship of thinness with absence of cardio-metabolic risk factors in these BMI references. Design: Cross-sectional. Setting: Schools in Delhi. Participants: Anthropometry and blood pressure were measured in 16,245 school children aged 5 to 18 years. Fasting lipids and blood sugar were estimated in 2796 subjects. Outcome measures: Age and sex-specific prevalences of thinness and predictive ability of reference cut-off for detecting any cardio-metabolic risk factor were compared. Results: Prevalence of thinness varied with the reference employed; more so for boys. Overall prevalence of thinness was least with IAP reference and highest with CDC cut-offs (6.6% to 16.9% in boys, 6.5% to 10.3% in girls). Children identified as thin by any reference had comparable, significantly lower risks (OR 0.59 to 0.73) of associated cardio-metabolic aberrations. In subjects with any cardio-metabolic or blood pressure aberration, the prevalence of thinness was highest with CDC and least with IAP definition. Conclusion: Prevalence of thinness varies considerably with the reference employed. Thin children, identified by any reference, have a lower risk of associated cardio-metabolic aberrations; however, thinness is a poor diagnostic test for this purpose. In populations undergoing nutrition transition, there is a need to link cardio-metabolic risk factors with recommended anthropometric criteria to define undernutrition.

Adult intussusception: Is associated bowel gangrene common.

Introduction: Adult intussusception is a rare clinical entity in contrast to pediatric intussusception. Varied and non-specific clinical features, delayed presentation, and lack of awareness among attending surgeons to consider it as differential diagnosis complicates the clinical course of the disease. Methods: A retrospective study was conducted in a tertiary care teaching hospital in north India. Nine adult patients who presented with intussusception over a period of six years were analyzed. Their clinical profile, management and underlying pathology were studied. Results: Five out of nine patients had acute presentation while remaining four presented with subacute/chronic symptoms. Median duration of presentation was 8 days (range 2-180 days). Clinical diagnosis of intussusception was considered in only one patient. Ultrasonography clinched the diagnosis in all four patients who presented with subacute/chronic symptoms. Ileo-ileal intussusception was present in five patients, with one having associated jejunojejunal intussusception. Other four patients had ileo-colic intussusception. Seven of the 9 patients (77%) were found to have associated bowel gangrene. Resection of the bowel segment having intussusception was done in all patients. Five patients had associated benign intestinal pathology while idiopathic intussusception was present in four patients. Conclusion: The patients presented in the series are distinct from cases reported earlier in literature in term of late presentation, manifesting as acute intestinal obstruction, high frequency of associated intestinal gangrene, and absence of associated intestinal malignancy. Patients presenting with features of intestinal obstruction and abdominal lump should be subjected to urgent imaging studies to examine the possibility of intussusception. The high frequency of bowel gangrene encountered in patients of adult intussusception mandates prompt surgical intervention soon after diagnosis.

Growth of Very Low Birth-Weight Indian Infants During Hospital Stay.

Objectives: To evaluate the growth pattern of Very Low Birth Weight (VLBW) infants (birthweight <1500g) during hospital stay and to compare the growth of Small for gestational age (SGA) and Appropriate for gestational age (AGA) infants. Study design: Prospective observational study. Setting. Level III Neonatal Intensive Care Unit (NICU) in Northern India. Participants: A cohort of 97 VLBW infants, admitted to NICU at Sir Ganga Ram Hospital, from 1 January, 2007 to 31 July, 2008. Intervention/Measurement: Weight, length and head circumference (HC) were serially measured from birth till discharge and respective Z scores were calculated as per data from Fenton’s references. Growth was also assessed by superimposing these trends on Ehrenkranz’s postnatal growth charts. Results: The mean Z scores for weight, length and HC at birth were –1.17, –1.09 and –0.54, respectively. These decreased to –2.16, –2.24 and –1.35, respectively by discharge. Both SGA and AGA infants exhibited a decrease of approximately 1 Z score in all parameters. On postnatal charts, growth of infants remained at or above respective reference lines, except in those below 1000g at birth. Average daily weight gain after regaining birth weight was 15.18 ± 1.7 g/kg/d, whereas the increase in HC and length were 0.48 ± 0.2 cm/week and 0.60 ± 0.4 cm/week, respectively. These increments when compared to the intrauterine growth rates, indicated discrepant growth trends. Conclusions: VLBW infants suffered significant growth lag during NICU stay and exhibited disproportionately slow growth of HC and length.

Acanthameba meningitis with successful outcome.

We report a rare cause of sub acute meningitis in a 15-yr-old immunocompetent female child with successful outcome. The etiological agent was Acanthameba. The child was sucessfully treat with combination of Ketoconazole. Rifampicin, cotrimoxa zole and for a period of 9 month.