A review of venous thromboembolism risk assessment models for different patient populations: What we know and don't!

Venous thromboembolism (VTE) is a common cause of morbidity and mortality in hospitalized patients. Globally, it is also the third leading vascular disease, after myocardial infarction and stroke. The incidence of VTE is reportedly higher in Western countries than in Asian countries. However, recent reports suggest an increasing incidence of VTE in Asian countries, including India. Since VTE is largely a preventable disease, early identification of risk factors can lead to disease prevention or the adoption of appropriate prophylactic measures. To this end, several VTE risk assessment models (RAMs) have been developed and validated for different populations who are at risk of developing VTE, such as hospitalized patients with medical illness/surgical indication, patients with cancer, and pregnant women. Evidence indicates that the systematic use of RAMs improves prophylaxis rates and lowers the burden of VTE. Given the increasing burden of VTE in the Indian population and poor prophylaxis rates, the implementation of systematic RAMs in routine clinical practice might ameliorate the disease burden in the country. We have assessed the evidence-based utilities of available RAMs and have delineated the most common and suitable RAMs for different populations including coronavirus disease 2019 affected patients. This review depicts the current status of implementation and validation of RAMs in the Indian scenario. It also highlights the need for additional validation studies, improved awareness, and implementation of RAMs in clinical practice for lowering the burden of VTE.

Physiological effects of a single chest physiotherapy session in mechanically ventilated and extubated preterm neonates.

OBJECTIVE: To assess the changes on various physiological cardio-respiratory parameters with a single chest physiotherapy session in mechanically ventilated and extubated preterm neonates with respiratory distress syndrome. STUDY DESIGN: This is a prospective observational study in a neonatal intensive care unit setting. Sixty preterm neonates with respiratory distress syndrome, thirty mechanically ventilated and thirty extubated preterm neonates requiring chest physiotherapy were enrolled in the study. Parameters like heart rate (HR), respiratory rate (RR), Silverman Anderson score (SA score in extubated), oxygen saturation (SpO2) and auscultation findings were noted just before, immediately after chest physiotherapy but before suctioning, immediately after suctioning and after 5 minutes of the session. RESULTS: The mean age of neonates was 9.55±5.86 days and mean birth weight was 1550±511.5 g. As there was no significant difference in the change in parameters on intergroup comparison, further analysis was done considering two groups together (n = 60) except for SA score. As SA score was measured only in extubated neonates. HR did not change significantly during chest physiotherapy compared to the baseline but significantly decreased after 15 minutes (p = 0.01). RR and SA score significantly increased after suctioning (p = 0.014) but reduced after 15 minutes (p = <0.0001). SpO2 significantly reduced post-suctioning compared to the baseline and increased after positioning and 15 minutes of chest physiotherapy (p = <0.0001). Clinically, there was a reduction in HR, RR and SA score with an improvement in SpO2. This signifies that chest physiotherapy may help facilitate the overall well-being of a fragile preterm neonate. Lung auscultation finding suggests that after suctioning, there was a significant reduction in crepitation (p = 0.0000) but significant increase in crepitation after 15 minutes (p = <0.01), suggesting the importance of around-the-clock chest physiotherapy. CONCLUSION: Chest physiotherapy is safe in preterm neonates. Suctioning causes significant cardio-respiratory parameter changes, but within normal physiological range. Thus, chest physiotherapy should be performed with continuous monitoring only when indicated and not as a routine procedure. More research is needed to study the long term effects of chest physical therapy.

Life threatening tension pneumothorax during cardiac surgery. A case report.

Tension pneumothorax is a life threatening condition that occurs when the intrapleural pressure exceeds atmospheric pressure. It requires prompt diagnosis and immediate treatment. Tension pneumothorax developing postoperatively after cardiac surgery is not uncommon but occurrence in the operating room during cardiac surgery is rare. We report a case of tension pneumothorax intraoperatively during off pump coronary artery bypass grafting.

Effectiveness of a multidimensional approach for prevention of ventilator-associated pneumonia in 21 adult intensive-care units from 10 cities in India: findings of the International Nosocomial Infection Control Consortium (INICC).

We report on the effect of the International Nosocomial Infection Control Consortium's (INICC) multidimensional approach for the reduction of ventilator-associated pneumonia (VAP) in adult patients hospitalized in 21 intensive-care units (ICUs), from 14 hospitals in 10 Indian cities. A quasi-experimental study was conducted, which was divided into baseline and intervention periods. During baseline, prospective surveillance of VAP was performed applying the Centers for Disease Control and Prevention/National Healthcare Safety Network definitions and INICC methods. During intervention, our approach in each ICU included a bundle of interventions, education, outcome and process surveillance, and feedback of VAP rates and performance. Crude stratified rates were calculated, and by using random-effects Poisson regression to allow for clustering by ICU, the incidence rate ratio for each time period compared with the 3-month baseline was determined. The VAP rate was 17.43/1000 mechanical ventilator days during baseline, and 10.81 for intervention, showing a 38% VAP rate reduction (relative risk 0.62, 95% confidence interval 0.5-0.78, P = 0.0001).

Anaesthesia for robotic gynaecological surgery.

Robotic surgery is gaining widespread popularity due to advantages such as reduced blood loss, reduced postoperative pain, shorter hospital stay and better visualisation of fine structures. Robots are being used in urological, cardiac, thoracic, orthopaedic, gynaecological and general surgery. Robotic surgery received US Food and Drug Administration approval for use in gynaecological surgery in 2005. The various gynaecological robotic operations being performed are myomectomy, total and supracervical hysterectomy, ovarian cystectomy, sacral colpopexy, tubal reanastomosis, lymph node dissection, surgery of retroperitoneal ectopic pregnancy, Moskowitz procedure and endometriosis surgery. The anaesthetic considerations include difficult access to the patient intraoperatively, steep Trendelenburg position, long surgical duration and the impact of pneumoperitoneum. We highlight the complications encountered in these surgeries and methods to prevent these complications. Robotic gynaecological surgery can be safely performed after considering the physiological effects of the steep Trendelenburg position and of pneumoperitoneum. The benefits of the surgical procedure should be weighed against the risks in patients with underlying cardiorespiratory problems.

Combined high thoracic and lumbar epidural block for a patient with severe peripheral vascular disease undergoing axillo bifemoral bypass surgery.

A 63 years old patient with severely impaired pulmonary function presented with bilateral lower limb vascular blockade and was operated for emergency aortobifemoral bypass. The patient was considered to be at very high risk for general anesthesia but doing the case under regional anesthesia was also challenging because of the multiple dermatomal levels needed to be anesthetized and because of the potential of adverse effects with such extensive block. There are only a few reported cases of using combination of central neuraxial blocks. The procedure was successfully performed using combined high thoracic and lumbar epidural blockade with two different local anesthetics to minimizing toxicity and observing no adverse effects related to anesthesia technique.

Epidural analgesia in high risk cardiac surgical patients.

Cardiac surgery is associated with high morbidity and mortality in patients with renal, hepatic or pulmonary dysfunction, advanced age and morbid obesity. Thoracic epidural analgesia is associated with decreased morbidity in these patients. Thoracic epidural analgesia in cardiac surgery is associated with haemodynamic stability, decreased catecholamine response, good pulmonary function, early extubation and discharge from intensive care unit. It is an important component of fast tracking in cardiac surgery as well. Its use has significantly increased over the years and has been used as an adjuvant to general anaesthesia as well as the sole anaesthetic technique in selected groups of patients. Proper selection of patients for thoracic epidural analgesia is mandatory. Timing of epidural catheter insertion and removal should be judiciously selected. The risk of epidural hematoma secondary to anticoagulation or residual effects of antiplatelet drug that can be reduced by taking standard precautions. In conclusion thoracic epidural analgesia in high risk cardiac surgery might decrease pulmonary, cardiovascular or renal complications, provide excellent analgesia and allow early extubation.

Use of recombinant activated factor VII for bleeding following resection of mediastinal angiosarcoma.

Sarcomatous lesions of the mediastinum usually present as aggressive and multicentre masses often attached to adjoining structures including heart and lungs. A forty one year male diagnosed with sarcomatous lesion in mediastinum presented for biopsy through midsternotomy later confirmed as angiosarcoma on histopathology. Patient bled excessively after surgery and required reopening of the chest. However, bleeding could not be controlled with reopening, blood products and packing of the mediastinal cavity. Bleeding could only be controlled by using recombinant activated factor VII as rescue therapy without any adverse effects.

Level of gold in normal and pathological semen.

The study included the estimation of gold in seminal plasma and spermatozoa of 36 semen samples of normal and different pathological conditions. The method employed for analysis was atomic absorption spectrophotometry. The metal was seen in seminal plasma and spermatozoa of all normal samples.

Device-associated nosocomial infection rates in intensive care units of seven Indian cities. Findings of the International Nosocomial Infection Control Consortium (INICC).

We sought to determine the rate of healthcare-associated infection (HCAI), microbiological profile, bacterial resistance, length of stay (LOS) and excess mortality in 12 ICUs of the seven hospital members of the International Infection Control Consortium (INICC) of seven Indian cities. Prospective surveillance was introduced from July 2004 to March 2007; 10 835 patients hospitalized for 52 518 days acquired 476 HCAIs, an overall rate of 4.4%, and 9.06 HCAIs per 1000 ICU-days. The central venous catheter-related bloodstream infection (CVC-BSI) rate was 7.92 per 1000 catheter-days;the ventilator-associated pneumonia (VAP) rate was 10.46 per 1000 ventilator-days; and the catheter-associated urinary tract infection (CAUTI) rate was 1.41 per 1000 catheter-days. Overall 87.5% of all Staphylococcus aureus HCAIs were caused by meticillin-resistant strains, 71.4% of Enterobacteriaceae were resistant to ceftriaxone and 26.1% to piperacillin-tazobactam; 28.6% of the Pseudomonas aeruginosa strains were resistant to ciprofloxacin, 64.9% to ceftazidime and 42.0% to imipenem. LOS of patients was 4.4 days for those without HCAI, 9.4 days for those with CVC-BSI, 15.3 days for those with VAP and 12.4 days for those with CAUTI. Excess mortality was 19.0% [relative risk (RR) 3.87; P < or = 0.001] for VAP, 4.0% (RR 1.60; P=0.0174) for CVC-BSI, and 11.6% (RR 2.74; P=0.0102) for CAUTI. Data may not accurately reflect the clinical setting of the country and variations regarding surveillance may have affected HCAI rates. HCAI rates, LOS, mortality and bacterial resistance were high. Infection control programmes including surveillance and antibiotic policies are a priority in India.

The effect of cannula material on the incidence of peripheral venous thrombophlebitis.

The incidence of thrombophlebitis following the use of two types of cannulae, a new generation polyurethane cannula Biovalve PUR and a polyurethane hybrid co-polymer Vialon cannula, was compared in a randomised trial. Seventy patients scheduled for elective cardiac surgery were randomly assigned to have either a Biovalve cannula or a Vialon cannula inserted before induction of anaesthesia. Postoperatively, the cannulae were removed either as soon as signs of thrombophlebitis were observed or at the end of seven days, whichever was earlier. There was a significantly lower incidence of thrombophlebitis in the Biovalve PUR group (17%) compared to the Vialon group (60%) at the end of seven days (p < 0.001). None of the cannulae tip cultures resulted in the growth of micro-organisms. There was also a lower incidence of the need for re-siting with the Biovalve than with the Vialon cannulae.

Robotically enhanced coronary artery bypass surgery.

Robotically enhanced telemanipulation surgery is a rapidly developing technique which enables totally endoscopic cardiac surgery with utmost precision and perfection on both beating heart and arrested heart. Between December 2002 and September 2006, 268 patients underwent robotically enhanced coronary artery bypass surgery using the da Vinci telemanipulation system. Fourteen patients underwent total endoscopic coronary artery bypass surgery. Of these 12 were performed on a beating heart and 2 on an arrested heart. Two-hundred and fifty-four patients had endoscopic takedown of the internal mammary artery followed by minimally invasive direct coronary artery bypass in 193 patients and left anterolateral thoracotomy in 61 patients. The internal mammary artery mobilization time was 36 min (28-76 min) and the left internal mammary artery to left anterior descending artery anastomosis time ranged from 20 to 36 min for the totally endoscopic coronary artery bypass patients. The right internal mammary artery of one patient was anastomosed to diagonal artery totally endoscopically. The mean internal mammary artery flow by Doppler measurement in patients undergoing minimally invasive direct coronary artery bypass was 58 ml min(-1). Seven patients required conversion to median sternotomy and coronary bypass surgery on the beating heart. The mean intensive care unit stay was 1.2 days and the mean hospital stay 4.5 days. There was one in-hospital mortality. All 14 patients who underwent total endoscopic bypass surgery had coronary angiography 3 months later which showed 100% patency in 13 patients. One patient had 50% anastomotic narrowing for which coronary angioplasty was performed in the same sitting. By using telematic technology, a complete endoscopic anastomosis is possible in both single vessels and suitable double vessel disease patients. The use of robotics is now extended to achieve complete myocardial revascularization by harvesting both the internal mammary arteries and making a small thoracotomy for direct anastomosis also.

Comparison of cardiac output in OPCAB: bolus thermodilution technique versus pulse contour analysis.

The study was designed to evaluate the clinical agreement between intermittent bolus thermodilution technique and pulse contour analysis technique. Sixty patients with normal left ventricular function undergoing elective off-pump coronary bypass surgery were included in this prospective study. In addition to routine monitoring, a 7.5F pulmonary artery thermodilution catheter via right internal jugular vein and a 4F arterial thermodilution catheter into femoral artery were also placed. Cardiac output measurements were compared before induction, after induction, after sternotomy, during the various anastomoses, post-protamine and post-sternal closure. Statistical analysis was performed using analysis of agreement to assure bias distribution of differences between the two methods by using Bland and Altman analysis. The cardiac output values obtained at preinduction, post-induction, and post-sternal closure time points showed good agreement, whereas the values obtained during the various anastomoses showed significant differences (p <0.05). Therefore it was concluded that pulse contour analysis cannot be relied upon completely whenever there is a change in the position of heart or alteration in systemic vascular resistance. But the trends in cardiac output were in complete agreement during the entire procedure.

Robotically enhanced coronary artery bypass surgery.

BACKGROUND: Robotically enhanced telemanipulation surgery is a fast developing technique which allows totally endoscopic cardiac surgery with utmost precision and perfection on both beating heart as well as arrested heart. METHODS AND RESULTS: Between December 2002 and February 2004, 125 patients underwent robotically enhanced coronary artery bypass surgery using the da Vinci telemanipulation system (Intuitive Surgical Inc., California). Eleven patients underwent totally endoscopic coronary artery bypass surgery. Of them 9 were done on beating heart while 2 were done on arrested heart. One hundred and fourteen patients had endoscopic takedown of internal mammary artery followed by minimally invasive direct coronary artery bypass in 63 patients and left anterolateral thoracotomy in 51 patients. The internal mammary artery mobilization time was 42 min (35-74 min) while the left internal mammary artery to left anterior descending artery anastomosis time ranged from 20 to 36 min for the totally endoscopic coronary artery bypass patients. In 1 patient, the right internal mammary artery was anastomosed to diagonal artery totally endoscopically. The mean internal mammary artery flow by Doppler measurement done in patients undergoing minimally invasive direct coronary artery bypass was 64 ml/min. Seven patients required conversion to median sternotomy and coronary bypass surgery on beating heart. The mean intensive care unit stay was 1.2 days and the mean hospital stay 4.5 days. There was 1 in-hospital mortality. All 11 patients who underwent totally endoscopic bypass surgery had coronary angiography done at 3 months interval which showed 100% patency in 10 patients while one patient had 50% anastomotic narrowing for which coronary angioplasty was done in the same sitting. CONCLUSIONS: Using telematic technology, a complete endoscopic anastomosis is possible in both single vessel and suitable double vessel disease patients. The use of robotics is now extended to achieve complete myocardial revascularization by harvesting both the internal mammary arteries and making a small thoracotomy for direct anastomosis as well.

Role of antiidiotypic antibodies on the clinical course of idiopathic thrombocytopenic purpura.

The severity and clinical course of idiopathic thrombocytopenic purpura (ITP) vary from patient to patient. The factors responsible for this variation are not well understood. In this study we attempted to evaluate the role of antiidiotypic antibodies in the immunoregulation of the disease. We investigated 114 cases of chronic ITP in adults. We determined antiidiotypic antibodies against antiplatelet antibodies using (a) idiotype-binding enzyme-linked immunosorbent assay (ELISA), (b) paratope-blocking ELISA, and (c) Western blotting. Results indicated that 80.6%, 11.2%, and 8.3% of the patients, respectively, presented with antiidiotypes against antibodies to GPIIb/IIIa, GPIb/IX, and both GPIIb/IIIa and GPIb/IX. More than 70% of the patients who showed high levels of blocking of antiidiotypic antibodies went into complete remission, compared with less than 5% of patients who showed low levels of such antibodies (P <.01). Disease severity was also found to be inversely related (P < 0.01) to the degree of blocking of antiidiotypic antibodies. The results of this study suggest that antiidiotypic antibodies against antiplatelet antibodies are a potential prognostic marker in chronic ITP.

Mechanical ventilation in the prone position: a strategy for acute respiratory failure after cardiac surgery.

Ventilation in the prone position, initially introduced in respiratory therapy to improve the drainage of secretions, has been used in intensive care to improve oxygenation. We report a case of an obese male patient who underwent elective coronary artery bypass grafting and had low PaO2 in the postoperative period. The PaO2 improved whenever the patient was ventilated in the prone position. On each occasion, oxygenation improved without any change in the hemodynamic parameters. The PaO2 increased from 57.8 to 249.7 mmHg on the first occasion, from 48.7 to 194.6 mmHg on the second and 62.5 to 199.7 mmHg on the third at an FIO2 of 1.0. The shunt fraction (Qva/Qt) decreased from 43.6% to 7.2% on the first occasion and from 46.7% to 12.5% on the second. Ventilation in the prone position can be an effective method for improving oxygenation in patients suffering from postoperative acute respiratory failure who are not responding to other ventilatory strategies.