Role of pre-operative counseling with NSQIP surgical risk calculator in the surgical patients.

Introduction: Patient satisfaction is important tool to monitor health care performance and quality of health plans, emphasizing effective counseling and consent processes. The objective of the study is to assess patient satisfaction and anxiety with the use of NSQIP surgical risk calculator in comparison to standardized questionnaires. Methodology: This is an interventional prospective randomized study. Difference in patient satisfaction is assessed by a 7-point Likert scale and anxiety assessment by 5-point Likert scale of Amsterdam Preoperative Anxiety and Information Scale (APAIS) questionnaire written in Nepalese. Satisfaction scores were compared using analysis of variance (ANOVA), or the Kruskal-Wallis test. P- value <0.05 was considered statistically significant. Results: Satisfaction score regarding comfort during counseling and consent process was similar with and without use of NSQIP surgical risk calculator (83.3 % and 76.9 %, respectively). Satisfaction score regarding plan of anesthesia was 63.33 % with the use of NSQIP and 53.8 % without NSQIP tool. 30.76 % of patients with high school education developed negative feelings following counseling when NSQIP tool was not used (p value 0.002). NSQIP usage increased anxiety about anesthesia and surgery and led to higher continual thinking about the procedure.Duration of counseling was 12 min with NSQIP tool use in comparison to 9.67 min following conventional counseling (p value 0.047). Conclusion: NSQIP surgical risk calculator is a reliable tool that can be used alongside conventional methods during preoperative period for decision-making and counseling with similar satisfaction scores but a higher incidence of anxiety and continual thinking about procedures.

Removing knotted or stuck epidural catheters: a systematic review of case reports.

BACKGROUND: The knotting or in vivo entrapment of epidural catheters is an uncommon but challenging issue for anesthesiologists. This study aimed to identify the possible causes behind entrapped epidural catheters and the effective methods for their removal. METHODS: A systematic review of relevant case reports and series was conducted using the patient/population, intervention, comparison and outcome framework and keywords such as "epidural," "catheter," "knotting," "stuck," "entrapped," and "entrapment." The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was followed, and the review protocol was registered with International Prospective Register for Systematic Reviews (CRD42021291266). RESULTS: The analysis included 59 cases with a mean depth of catheter insertion from the skin of 11.825 cm and an average duration of 8.17 h for the detection of non-functioning catheters. In 27 cases (45.8%), a radiological knot was found, with an average length of 2.59 cm from the tip. The chi-squared test revealed a significant difference between the initial and final positions of catheter insertion (P = 0.049). CONCLUSIONS: Deep insertion was the primary cause of epidural catheter entrapment. To remove the entrapped catheters, the lateral decubitus position should be attempted first, followed by the position used during insertion. Based on these findings, recommendations for the prevention and removal of entrapped catheters have been formulated.

Coronary Artery Bypass Grafting Following COVID-19 Infection: Difficulties and Challenges.

The COVID-19 pandemic has raised challenges and dilemmas to perform cardiac surgery in the patients following COVID-19 infection due to lasting adverse impacts of the disease on the lungs. A 74-years-old patient, recently infected by COVID-19, with previous myocardial infarction and multiple percutaneous coronary interventions, in-stent thrombosis to the left anterior descending artery, and low resting saturation, presented with chest pain and underwent urgent coronary artery bypass grafting. His postoperative period remained challenging due to high oxygen requirements. He had otherwise an uneventful recovery and was discharged on domiciliary oxygen, which was weaned off over three months and he continues to do well at six months of follow-up. Keywords: Cardiac surgery; COVID-19; coronary artery bypass surgery; pandemic.

Perioperative Point-of-Care Ultrasound and Transesophageal Echocardiography in Resource- Limited Settings-A Focus on Nepal and Bangladesh.

The use of point-of-care ultrasound (POCUS) and transesophageal echocardiography (TEE) in the perioperative and critical care setting is increasing worldwide. This increase has been driven by increasing educational opportunities and technologic advances. Nepal and Bangladesh are resource-limited countries where concerted efforts have been made to increase training in POCUS or TEE in the perioperative and critical care settings. This paper's focus is to present the current state of use and international efforts to improve education and skills in perioperative POCUS and TEE in Nepal and Bangladesh. The authors also examine the challenges to improving and expanding ultrasound use in the perioperative environment in resource- limited environments in general, using the Nepalese and Bangladeshi experiences as case studies. The authors have held multiple short courses in POCUS or TEE in Nepal and Bangladesh over the past several years. The authors found a high level of interest in learning POCUS and TEE skills among participants. They encountered challenges with maintaining continuing education and quality assurance for participants after the courses. They also identified barriers to incorporating ultrasound into daily practice in local hospitals. An increasing prevalence of cardiovascular disease will increase the need for diagnostic strategies for patients worldwide, including the use of POCUS and TEE, to manage patients in the perioperative and critical care settings. The courses held in Nepal and Bangladesh may serve as models to expand educational opportunities in POCUS and perioperative TEE in resource-limited settings.

Comparison of Lung Ultrasound to X-ray for Diagnosis of Pulmonary Complications after Cardiac Surgery in Children.

BACKGROUND: The purpose of this study was to compare diagnostic performance of lung ultrasound in comparison to chest X-ray to detect pulmonary complication after cardiac surgery in children. METHODS: A prospective observational study was conducted in tertiary center of Nepal. 141 consecutive paediatric patients aged less than 14 years scheduled for cardiac surgery were enrolled during the 6 months period. Ultrasound was done on the first post-operative day of cardiac surgery and compared to chest X-ray done on the same day to detect pleural effusion, consolidation, atelectasis and pneumothorax. RESULTS: Sensitivity, specificity, positive and negative predictive values and diagnostic accuracy were calculated using standard formulas. lung ultrasonography had overall sensitivity of 60 %, specificity of 72.4%, positive predictive value of 31.9% and negative predictive value of 89.3% and diagnostic accuracy of 70.2% for diagnosing consolidation. Similarly, lung ultrasonography had overall sensitivity of 90%, specificity of 82.6%, positive predictive value of 46.1% and negative predictive value of 98% and diagnostic accuracy of 83.6 % for diagnosing pleural effusion. For atelectasis, ultrasonography had sensitivity of 50%, specificity of 76.9%, positive predictive value of 30.7% and negative predictive value of 88.2% and diagnostic accuracy of 72.3%. No pneumothoraxes were detected during our study period. CONCLUSIONS: Lung ultrasound is an alternative non-invasive technique which is able to diagnose pulmonary complications after cardiac surgery with acceptable diagnostic accuracy with no proven complications but with decreasing exposure to ionizing radiation and possibly cost.

Double Aortic Arch with Coarctation of Aorta in an Adolescent: Unraveling the Vascular Ring.

We report the case of a 12-year-old girl with balanced double aortic arch with coarctation of the aorta presenting with symptoms of respiratory and swallowing difficulty. On investigation, the patient had a double aortic arch with coarctation and clinically nonsignificant disease in the infrarenal aorta. Division of the nondominant aortic arch was done through a left thoracotomy, along with resection of the coarctation segment and placement of an interposition Dacron tube graft.

An artificial neural network model for prediction of hypoxemia during sedation for gastrointestinal endoscopy.

OBJECTIVE: This study was designed to assess clinical predictors of hypoxemia and develop an artificial neural network (ANN) model for prediction of hypoxemia during sedation for gastrointestinal endoscopy examination. METHODS: A total of 220 patients were enrolled in this prospective observational study. Data on demographics, chronic concomitant disease information, neck circumference, thyromental distance and anaesthetic dose were collected and statistically analysed. RESULTS: Univariate analysis indicated that body mass index (BMI), habitual snoring and neck circumference were associated with hypoxemia. An ANN model was developed with three variables (BMI, habitual snoring and neck circumference). The area under the receiver operating characteristic curve for the ANN model was 0.80. CONCLUSIONS: The ANN model developed here, comprising BMI, habitual snoring and neck circumference, was useful for prediction of hypoxemia during sedation for gastrointestinal endoscopy.

Primary surgical repair of coarctation of the aorta in adolescents and adults: intermediate results and consequences of hypertension.

OBJECTIVES: Coarctation of the aorta is known to present with hypertension in older patients; we reviewed our experience and assessed the outcome of hypertension following surgical correction. METHODS: From April 2004 to date, 43 patients above the age of 12 underwent coarctation of the aorta repair. The mean age was 20.4 + 9.7 years (maximum 56 years); 21 (48.8%) were older than 18 years and 28 (65.1%) were men. Thirty (69.8%) patients had hypertension. Fourteen (32.6%) had a bicuspid aortic valve; 11 (25.6%) had patent ductus arteriosus; 6 (14%) had myxomatous mitral valve; 4 (9.3%) had ascending aortic aneurysms; and 2 (4.7%) had descending aneurysms. RESULTS: Surgical correction included resection and interposition of a tube graft in 31 (72.1%), an end-to-end anastomosis in 6 (14%) and patch aortoplasty in 3 (7%). Three (7%) patients required an extra-anatomical bypass: 1 had a long segment coarctation of the aorta, and 2 had a Bentall procedure with an ascending-to-descending aortic bypass. Staged procedures were done for concomitant disease in 4 (9.3%). There was 1 death: a 56-year-old woman died of refractory ventricular fibrillation during surgery. Thirty (69.8%) patients were discharged with antihypertensive medication. At a follow-up of 2.8 ± 2.2 years (maximum 9.2 years), the number of hypertensive patients decreased (17/36; 47.2%) (P = 0.042). Univariable predictors for persistence of hypertension revealed the use of an interpositional tube graft for repair (odds ratio 13.855, confidence interval 0.000-0.001; P = 0.001) as an indicator, whereas there were no independent predictors for persistence of hypertension. CONCLUSIONS: Surgical intervention is warranted irrespective of age and helps correct and control hypertension better; however, significant numbers of patients still require antihypertensive medication and regular monitoring. Intervention using an interposition tube graft may affect the prevalence of hypertension.

Submitral Aneurysm: An Unusual Aneurysm of the Left Ventricle.

We report a case of a 42-year-old man with a submitral aneurysm who presented to the emergency room in circulatory collapse, with left ventricular obstruction and severe mitral valve stenosis and regurgitation secondary to the aneurysm. Resection of the aneurysm and mitral valve replacement were performed through a median sternotomy without any complication and with good results.

Extracorporeal membrane oxygenation in aluminum phosphide poisoning in Nepal: a case report.

BACKGROUND: Aluminum phosphide is a very common suicide agent in developing countries like Nepal. Due to the unavailability of a specific antidote, mortality is very high because the phosphine molecule that is formed leads to inhibition of the cytochrome oxidase enzyme system in mitochondria. Extracorporeal membrane oxygenation provides life-saving support to the cardiovascular and respiratory systems until the deadly poison is eliminated from the body. CASE PRESENTATION: We encountered one case of 67-year-old Asian woman, a known case of major depressive disorder, who presented to our center with suicidal ingestion of aluminum phosphide with cardiovascular and respiratory dysfunction. On presentation in our emergency room, she had an ejection fraction of 20% and had to be immediately intubated for respiratory failure. Based on the evidence of almost 100% mortality with aluminum phosphide poisoning, extracorporeal membrane oxygenation was initiated in our intensive care unit. Her general condition and hemodynamics gradually improved over the course of 2 days and she was weaned from extracorporeal membrane oxygenation and ventilator by post-extracorporeal membrane oxygenation days 3 and 4, respectively. After psychiatric evaluation and establishment of normal vital parameters, she was moved out of intensive care unit on post-extracorporeal membrane oxygenation day 6 and discharged to home on post-extracorporeal membrane oxygenation day 10. CONCLUSIONS: Although this seems to be a small step in terms of global perspective, it is a giant stride for a developing country. The management of reversible but severe cardiac and respiratory failure certainly opens up newer scopes where we can ensure a quality health care service being made accessible even to the most underprivileged people.

eFAST for the diagnosis of a perioperative complication during percutaneous nephrolithotomy.

A 29-year-old patient with normal preanesthetic evaluation was planned for percutaneous nephrolithotomy (PCNL) for right nephrolithiasis with right pyelolithiasis. Surgery was performed under general anesthesia with endotracheal intubation with muscle relaxation. At the conclusion of surgery, when the patient was turned over to supine position, tense abdomen was noted. Immediately extended focused assessment with sonography in trauma (eFAST) was done in which both right and left quadrants of abdomen including pericardial and suprapubic region, right and left thoracic, and both lung basis were examined. Fluid collection was seen in Morison's pouch which was drained by the urologist under real-time ultrasonography guidance by anesthesiologist. Distension of abdomen subsequently subsided and patient had normal vitals. Trachea was extubated and patient shifted to post-operative ward. eFAST and FAST scans are routine procedures in the rapid assessment of trauma victims in emergency settings. The fluid extravasation during a routine PCNL procedure may lead to abdominal compartment syndrome. This case demonstrated that use of eFAST rapidly detected abdominal collection and ruled out life-threatening conditions such as hemothorax and pneumothorax and prevented abdominal compartment syndrome. Our case is only an example that potentially lethal conditions like these may be encountered in the perioperative setting and the knowledge of eFAST scan may be of great help.

Differences in Return of Spontaneous Circulation in Early vs Late Endotracheal Intubation among Patients in Hospital Cardiac Arrest.

BACKGROUND: Common airway management strategies during cardiopulmonary resuscitation are bag- mask-valve ventilation followed by endotracheal intubation. Timing of endotracheal intubation is controversial. This study was designed to compare the effect of early vs late endotracheal intubation in terms of return of spontaneous circulation. METHODS: This is an observational retrospective study done at tertiary center for the period of two years. The study population was inpatient, adult and pediatric with witnessed cardiac arrest in whom airway management was initially done with bag-valve-mask ventilation followed by endotracheal intubation. Timing of intubations were grouped into early and late with cut off time of five minutes and the groups were compared in terms of return of spontaneous circulation. RESULTS: There were total of 193 patients included in the study. Early intubation was done in 114 patients (59.06%) and late intubation was done in 79 patients (40.94%). Mean time for early intubation was 3.11 minutes. Mean time for late intubation was 7.89 minutes. Seventy three patients (37.8%) attained sustained ROSC. Thirty five patients (30.7%) achieved ROSC in early intubation group while 38 patients (48.1%) attained sustained ROSC in late intubation group(p = 0.016). CONCLUSIONS: Early intubation during cardiopulmonary resuscitation was associated with lower rate of return of spontaneous circulation.

Complex Cervical Aortic Arch With Hypoplasia: A Simple Solution to a Complex Problem.

We report a rare case of a 6-year-old boy with a complex right-sided cervical aortic arch, with retroesophageal hypoplastic transverse arch, left subclavian artery arising from the Kommerell diverticulum of the descending aorta, and a vascular ring formed by the ductus ligament. An extraanatomic ascending-to-descending aorta bypass was done through a median sternotomy along with division of the ductus ligament, without any complications and good results.