Inadvertent Puncture of Dilated Right Ventricle During Transversus Thoracic Muscle Plane Block: Lessons Learnt.

ABSTRACT: The transversus thoracic muscle plane (TTP) block is gaining widespread recognition in cardiac surgery, particularly in facilitating fast-tracking. Here, we report a case of inadvertent puncture of the right ventricle (RV) during the administration of ultra sound-guided (USG) TTP block in a 3-year-old child posted for atrial septal defect (ASD) closure and mitral valve repair. We also discuss the care that should be taken to avoid such complications and such cases require extra caution during TTP block.

Intraoperative Transesophageal Echocardiographic Assessment of Aortic Valve Repair in a Child - What to Look for?

ABSTRACT: Aortic valve (AV) repair is the desired surgical treatment option for young patients with aortic regurgitation (AR). It is considered as a class I indication for the surgical treatment of severeAR. The success of an AV repair depends on the detailed intraoperative transesophageal echocardiographic (TEE) examination which should fulfil the information required by the surgeon. The objective of this echo round is to describe the role of intraoperative TEE in systematic evaluation of the AV, before and after repair.

Tricuspid Annular Plane Systolic Excursion (TAPSE) for the Assessment of Right Ventricular Function in Adult and Pediatric Cardiac Surgery: Modified Two-dimensional and M-mode TAPSE by Transesophageal Echocardiography Compared to M-mode TAPSE by Transthoracic Echocardiography.

OBJECTIVES: To compare transesophageal echocardiography-guided 2-dimensional and M-mode tricuspid annular plane systolic excursion (TAPSE) to transthoracic echocardiography (TTE)-guided M-mode TAPSE in terms of accuracy, interobserver, and intra-observer variability. DESIGN: A prospective, observational study. SETTING: Adult and pediatric operating rooms. PARTICIPANTS: Adult and pediatric patients (42 each) undergoing cardiac surgeries. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Modified midesophageal (Mod-ME), deep transgastric, and transgastric TAPSEs were analyzed for reliability and were compared to TTE TAPSE in both adult and pediatric groups. Modified ME TAPSE showed good method agreement with TTE TAPSE (bias = -0.97, p = 0.08 (adult); bias = 0.17, p = 0.71 [pediatric]), and showed a moderate correlation with right ventricular (RV) fractional area change (FAC) (r = 0.41, p = 0.006, [adult]; r = 0.57, p < 0.001, [pediatric]), with acceptable interobserver variability (percentage error =10.56 [adult]; 4.42 [pediatric]) and intraobserver variability (percentage error = 13.1 [adults]; 12.24 [pediatric]). Transgastric TAPSE poorly agreed with TTE TAPSE and had higher interobserver and intraobserver variability. Deep transgastric TAPSE had good method agreement with TTE TAPSE and had acceptable interobserver and intra-observer variability. CONCLUSIONS: Modified ME TAPSE is a reliable and reproducible measure of RV function before pericardiotomy in both adult and pediatric cardiac surgery. Right ventricular FAC values reflected the RV systolic function better than TAPSE after pericardiotomy. Deep transgastric TAPSE is reliable and reproducible but is less accurate than Mod-ME TAPSE.

A Lung ultrasound-based comparison of postoperative respiratory outcome after pediatric congenital heart surgery in COVID-19 recovered and COVID-19 unaffected children-a pilot study.

Background: COVID-19 is known to affect the alveolar-capillary membrane and interstitial tissue. Cardiopulmonary bypass (CPB) is proven to cause "pump-lung" syndrome. Little is known about the subgroup of COVID-19-recovered children undergoing cardiac surgeries under CPB. Aim: To compare the lung ultrasound score (LUSS) and morbidity of COVID-19-recovered children to those without COVID-19 after congenital cardiac surgery. Setting and Design: Prospective observational pilot study at a tertiary care institution. Materials and Methods: The study was carried out on 15 COVID-recovered children and 15 matched controls (Group B) posted for congenital cardiac surgery. COVID-recovered children were further divided into those who received in-hospital care for COVID (Group C) and those who did not (Group A). LUSS measured immediately after cardiac surgery was compared between the groups. PaO2/FiO2 ratio, incidence of pulmonary infection, re-intubation rate, duration of ventilation, in-hospital mortality, and 30-day mortality were also compared between the groups. Results: LUSS was comparable between Groups A and B (mean difference = 1.467, P = 0.721). Compared to the control group, Group C showed higher LUSS (mean difference = 11.67, P < 0.001), lower PaO2/FiO2 ratio (207.8 ± 95.49 Vs 357.6 ± 63.82, P = 0.003), and one in-hospital mortality. A significant negative correlation was seen between LUSS and PaO2/FiO2 ratio (rs = -0.75, P < 0.001). Conclusion: LUSS was not higher in COVID-recovered children. Children with a history of severe COVID-19 recorded higher LUSS, in-hospital mortality, duration of ICU stay, and duration of ventilation.

Three-Dimensional transesophageal echocardiographic detection of left ventricular outflow tract obstruction by residual native mitral leaflet following mitral valve replacement in a hypertrophic obstructive cardiomyopathy patient.

Hypertrophic obstructive cardiomyopathy (HOCM), although a worldwide prevalent cardiac disease, it imposes a greater task in the patient management. The association of coronary artery disease with HOCM poses an immense perioperative challenge and it demands an expert transesophageal echocardiography (TEE) examination for guiding the surgery and detailed assessment after surgical correction. We report a case of HOCM with coronary artery disease where the post-cardiopulmonary bypass three-dimensional TEE played a crucial role in exact identification of the mechanism of fixed left ventricular outflow tract obstruction, when the two-dimensional TEE failed to provide adequate information.

Sepsis in the Pediatric Cardiac Intensive Care Unit: An Updated Review.

Sepsis remains among the most common causes of mortality in children with congenital heart disease (CHD). Extensive literature is available regarding managing sepsis in pediatric patients without CHD. Because the cardiovascular pathophysiology of children with CHD differs entirely from their typical peers, the available diagnosis and management recommendations for sepsis cannot be implemented directly in children with CHD. This review discusses the risk factors, etiopathogenesis, available diagnostic tools, resuscitation protocols, and anesthetic management of pediatric patients suffering from various congenital cardiac lesions. Further research should focus on establishing a standard guideline for managing children with CHD with sepsis and septic shock admitted to the intensive care unit.

Computed Tomography Scan Evidence of Bronchospasm and Its Resolution During Computed Tomography Coronary Angiogram in a Child With Kawasaki Disease: A Case Report.

Bronchospasm in children is common; however, due to its sudden nature, radiographic correlation is uncommon. We planned a computed tomography (CT) coronary angiogram for a 5-year-old child for evaluation of Kawasaki disease. The child started to desaturate during the CT scanning after intravenous contrast injection under conscious sedation. CT scan documented spasm of trachea and bronchi, as well as crowding of ribs and elevated diaphragm during the event. Repeat CT scan documented well-aerated lung fields. The development of acute bronchospasm under anesthesia results in definite changes in the CT scan of the thoracic cavity as evidenced by this incident.

A study on the effect of intraoperative continuous positive airway pressure (CPAP) on the postoperative pulmonary function in overweight patients undergoing lower limb, lower abdominal or vaginal surgeries under spinal anesthesia.

INTRODUCTION: Spinal anaesthesia, supine position and higher BMI are risk factors for pulmonary atelectasis. NIV, PEEP and CPAP are employed in ICU's to treat atelectasis postoperatively. However, we wanted to investigate whether CPAP was protective against atelectasis when used intraoperatively, in high risk patients. MATERIAL AND METHODS: This study was a randomized controlled trial. Overweight patients, who were to undergo surgeries under spinal anesthesia were included in the study. After informed consent, 126 patients underwent preoperative pulmonary function tests (PFT: FEV1, FVC, PEFR). Following the onset of spinal anaesthesia patients were randomised into group E (n = 63, received CPAP) and control group, group C ( n =63, received nil intervention). Postoperative PFT was done at 20 minutes, 1 hour, 2 hours and 3 hours after surgery. Patients were followed up till discharge for pulmonary complications. RESULTS: We observed significant reduction in pulmonary function (FEV1, FVC and PEFR) postoperatively compared to base-line. CPAP group had better pulmonary function when compared to control group, the difference being significant 20 minu-tes after the surgery(p < 0.05). No postoperative pulmonary complication was reported among the 126 patients studied. CONCLUSION: Intraoperative use of CPAP in overweight patients undergoing surgeries under spinal anaesthesia could be beneficial in improving pulmonary function in the immediate post-operative period.