Simultaneous surgical management of malignancy and coronary heart disease.

Coronary heart disease and cancer are the most common causes of mortality across the globe. It has been a dilemma for the surgical team to decide which surgical procedure should be done first when a patient needs surgery for both. This is a single-center retrospective observational study. Six patients who underwent simultaneous coronary artery bypass graft (CABG) and oncological surgeries between January 2018 and July 2021 were included in the study. One patient underwent lung bilobectomy via the same sternotomy incision; one underwent surgery for breast cancer, stomach cancer, and colon cancer; and one patient each of buccal mucosa carcinoma and tongue carcinoma. The median age was 65 years (59-70). Median blood loss was 550 ml (400-800). The median intensive care unit (ICU) stay was 60 h (46-130) and hospital stay was 7.5 days (6-14). The median follow-up of the present study was 31.5 months (6-38). One patient with lung carcinoma developed recurrence after 6 months and the patient is in remission after a follow-up of 32 months. Simultaneous CABG and oncological resection can be performed effectively and safely by an experienced team of cardiothoracic surgeons, surgical oncologists, and anesthetists after good patient selection.

Epidemiology and preventability of hospital-onset bacteremia and fungemia in 2 hospitals in India.

OBJECTIVE: Studies evaluating the incidence, source, and preventability of hospital-onset bacteremia and fungemia (HOB), defined as any positive blood culture obtained after 3 calendar days of hospital admission, are lacking in low- and middle-income countries (LMICs). DESIGN, SETTING, AND PARTICIPANTS: All consecutive blood cultures performed for 6 months during 2020-2021 in 2 hospitals in India were reviewed to assess HOB and National Healthcare Safety Network (NHSN) reportable central-line-associated bloodstream infection (CLABSI) events. Medical records of a convenience sample of 300 consecutive HOB events were retrospectively reviewed to determine source and preventability. Univariate and multivariable logistic regression analyses were performed to identify factors associated with HOB preventability. RESULTS: Among 6,733 blood cultures obtained from 3,558 hospitalized patients, there were 409 and 59 unique HOB and NHSN-reportable CLABSI events, respectively. CLABSIs accounted for 59 (14%) of 409 HOB events. There was a moderate but non-significant correlation (r = 0.51; P = .070) between HOB and CLABSI rates. Among 300 reviewed HOB cases, CLABSIs were identified as source in only 38 (13%). Although 157 (52%) of all 300 HOB cases were potentially preventable, CLABSIs accounted for only 22 (14%) of these 157 preventable HOB events. In multivariable analysis, neutropenia, and sepsis as an indication for blood culture were associated with decreased odds of HOB preventability, whereas hospital stay ≥7 days and presence of a urinary catheter were associated with increased likelihood of preventability. CONCLUSIONS: HOB may have utility as a healthcare-associated infection metric in LMIC settings because it captures preventable bloodstream infections beyond NHSN-reportable CLABSIs.

Hemoadsorption in Complex Cardiac Surgery-A Single Center Experience.

(1) Background: Cardiac surgery may evoke a generalized inflammatory response, typically magnified in complex, combined, redo, and emergency procedures with long aortic cross-clamp times. Various treatment options have been introduced to help regain control over post-cardiac surgery hyper-inflammation, including hemoadsorptive immunomodulation with CytoSorb®. (2) Methods: We conducted a single-center retrospective observational study of patients undergoing complex cardiac surgery. Patients intra-operatively treated with CytoSorb® were compared to a control group. The primary outcome was the change in the vasoactive-inotropic score (VIS) from pre-operatively to post-operatively. (3) Results: A total of 52 patients were included in the analysis, where 23 were treated with CytoSorb® (CS) and 29 without (controls). The mean VIS increase from pre-operative to post-operative values was significantly lower in the CS group compared to the control group (3.5 vs. 5.5, respectively, p = 0.05). In-hospital mortality in the control group was 20.7% (6 patients) and 9.1% (2 patients) in the CS group (p = 0.26). Lactate level changes were comparable, and the median intensive care unit and hospital lengths of stay were similar between groups. (4) Conclusions: Despite notable imbalances between the groups, the signals revealed point toward better hemodynamic stability with CytoSorb® hemoadsorption in complex cardiac surgery and a trend of lower mortality.

Normative Transesophageal Echocardiographic Values of Cardiac Structures in the Indian Population-Indian Normative TEE Measurements (INTEEM) Study.

OBJECTIVES: Information on normative reference values for cardiac structures is critical for the accurate application of echocardiography for guiding clinical decision-making. Many studies using transthoracic echocardiography (TTE) have shown that Indians have smaller diameters of various cardiac structures. There are no normative studies for transesophageal echocardiography (TEE). The authors observed dimensions of various cardiac structures in healthy Indian patients under general anesthesia using TEE and compared them with existing guidelines from non-Indian data. DESIGN: The Indian Normative TEE Measurements study was a multicenter, prospective observational study conducted in India. SETTING: Operating rooms for noncardiac surgeries in tertiary care-level hospitals. PARTICIPANTS: Adult patients undergoing noncardiac surgery who were free from any cardiac, respiratory, and renal diseases and had no contraindications for TEE. INTERVENTIONS: After inducing general anesthesia and achieving stable hemodynamic conditions, a comprehensive TEE examination was performed and various measurements were made. MEASUREMENTS AND MAIN RESULTS: For each of the 83 patients undergoing noncardiac surgery, 39 various measurements for left ventricle, right ventricle, both atria, and all valves were made. This included diameters and functional parameters. They were analyzed in a vendor-neutral software off-line. The absolute values of many of the measurements were higher in men, but when indexed to body surface area (BSA) they were similar in both sexes. The values were lower than most of the Western data but matched previous Indian studies using TTE. CONCLUSIONS: The authors present normative values of various echocardiographic parameters using TEE. Because of its variations, it is recommended to use India-specific data to make decisions in Indian patients. It may be prudent to use BSA-indexed values during decision-making.

Perioperative temperature management: a survey of 6 Asia-Pacific countries.

BACKGROUND: Anesthesia leads to impairments in central and peripheral thermoregulatory responses. Inadvertent perioperative hypothermia is hence a common perioperative complication, and is associated with coagulopathy, increased surgical site infection, delayed drug metabolism, prolonged recovery, and shivering. However, surveys across the world have shown poor compliance to perioperative temperature management guidelines. Therefore, we evaluated the prevalent practices and attitudes to perioperative temperature management in the Asia-Pacific region, and determined the individual and institutional factors that lead to noncompliance. METHODS: A 40-question anonymous online questionnaire was distributed to anesthesiologists and anesthesia trainees in six countries in the Asia-Pacific (Singapore, Malaysia, Philippines, Thailand, India and South Korea). Participants were polled about their current practices in patient warming and temperature measurement across the preoperative, intraoperative and postoperative periods. Questions were also asked regarding various individual and environmental barriers to compliance. RESULTS: In total, 1154 valid survey responses were obtained and analyzed. 279 (24.2%) of respondents prewarm, 508 (44.0%) perform intraoperative active warming, and 486 (42.1%) perform postoperative active warming in the majority of patients. Additionally, 531 (46.0%) measure temperature preoperatively, 767 (67.5%) measure temperature intraoperatively during general anesthesia, and 953 (82.6%) measure temperature postoperatively in the majority of patients. The availability of active warming devices in the operating room (p < 0.001, OR 10.040), absence of financial restriction (p < 0.001, OR 2.817), presence of hospital training courses (p = 0.011, OR 1.428), and presence of a hospital SOP (p < 0.001, OR 1.926) were significantly associated with compliance to intraoperative active warming. CONCLUSIONS: Compliance to international perioperative temperature management guidelines in Asia-Pacific remains poor, especially in small hospitals. Barriers to compliance were limited temperature management equipment, lack of locally-relevant standard operating procedures and training. This may inform international guideline committees on the needs of developing countries, or spur local anesthesiology societies to publish their own national guidelines.

A career in cardiac anaesthesia in India: The heart of the matter.

Cardiac anaesthesia is a demanding, but fulfilling speciality which challenges the skills, knowledge, professional and personal competence of cardiac anaesthesiologists on a daily basis. This article outlines the brief history of the subspecialty of cardiac anaesthesia in India, its growth and progress over the decades, reasons for choosing it as a career option, variations in practice standards and how the speciality has been affected by the coronavirus 2019 pan?demic.

Routine preoperative doppler ultrasound examination of arterial system in patients undergoing cardiac surgery is beneficial: A retrospective study.

Background: Presence of peripheral vascular disease enhances surgical risk in cardiac surgical patients. Prior knowledge of peripheral arterial disease may help the physician make changes in the monitoring and cardiopulmonary bypass cannulation plans. It is claimed that the incidence of peripheral vascular disease in cardiac surgical patients ranges from 11 to 30%. Aims: This study was conducted to understand the characteristics of peripheral vascular disease and their implication on cardiac surgery. Settings and Design: This was a prospective study undertaken in a tertiary referral hospital. Materials and Methods: All adult patients who underwent cardiac surgery during the period of six months were included. A Doppler examination of the neck, upper limb, abdomen and lower limb was carried out by our inhouse radiologist. The incidence of peripheral vascular disease, the implication on invasive pressure monitoring site and cannulation for cardiopulmonary bypass or intraaortic balloon pump or extracorporeal membrane oxygenation were made note of. Results: During the said period, six hundred twenty eight patients underwent cardiac surgery, of whom five hundred and sixty-one patients who underwent CABG surgery. All these were subjected to Doppler examination. We observed peripheral arterial disease in 105 patients (20%). In general men suffered from PAD more often than women. Monitoring site of invasive arterial pressure, the choice of beating heart surgery, insertion of intraaortic balloon pump, femoral arterial route for cardiopulmonary bypass were some of the decision that were altered. Conclusions: Performing Doppler examination in cardiac surgical patients may yield important data that might prevent complications and support patient safety.

Six-year multicenter study on short-term peripheral venous catheters-related bloodstream infection rates in 204 intensive care units of 57 hospitals in 19 cities of India: International Nosocomial Infection Control Consortium (INICC) findings.

BACKGROUND: Short-term peripheral venous catheters-related bloodstream infections (PVCR-BSIs) rates have not been systematically studied in developing countries, and data on their incidence by number of device-days are not available. METHODS: Prospective, surveillance study on PVCR-BSI conducted from September 1, 2013 to May 31, 2019 in 204 intensive care units (ICUs), members of the International Nosocomial Infection Control Consortium (INICC), from 57 hospitals in 19 cities of India. We applied US INICC definition criteria and reported methods using the INICC Surveillance Online System. RESULTS: We followed 7,513 ICU patients for 296,893 bed-days and 295,795 short term peripheral venous catheter (PVC)-days. We identified 863 PVCR-BSIs, amounting to a rate of 2.91/1,000 PVC-days. Mortality in patients with PVC but without PVCR-BSI was 4.14%, and 11.59% in patients with PVCR-BSI. The length of stay in patients with PVC but without PVCR-BSI was 4.13 days, and 5.9 days in patients with PVCR-BSI. The micro-organism profile showed 68% of gram negative bacteria: Escherichia coli (23%), Klebsiella spp (15%), Pseudomonas aeruginosa (5%), and others. The predominant gram-positive bacteria were Staphylococcus aureus (10%). CONCLUSIONS: PVCR-BSI rates found in our ICUs were much higher than rates published from industrialized countries. Infection prevention programs must be implemented to reduce the incidence of PVCR-BSIs.

Evaluation of Percutaneous Electrical Nerve Stimulation of the Auricle for Relief of Postoperative Pain Following Cesarean Section.

Objective: Percutaneous electrical nerve stimulation is a nonpharmacologic modality of analgesia. This study was conducted to evaluate such a technology (ANSiStim™, DyAnsys Inc., San Mateo, CA) prospectively, in conjunction with standard analgesia per patient demand, for managing postoperative pain following lower-segment cesarean section. Materials and Methods: One hundred parturients were randomized into 2 equal groups (controls and study cases). The latter cohort consisted of parturients for whom nerve stimulation was exerted on the pinna. Pain scores were compared across subjects at corresponding time points with 17 intervals in 48 hours, and, in totality, using estimated area under the curves of numerical scores. Conditional inference analysis was also performed. Results: Ninety-six parturients were finally included. The device was well-tolerated by a majority of parturients. Pain scores were significantly lower in the study group, both at corresponding time intervals and in totality. (H - 15)*(0.74 - H)*(H2 - 17H + 110)/440, where H was the corresponding hour, fit the pain scores in the control group. Controls could be detected at the 11 hour with greater pain scores (≥ 4), whereas smaller scores (≤ 2) at the 42nd hour mostly revealed that electrical stimulation was performed (p < 0.001). Requirements for supplementary analgesics were lower for subjects who were given the electroanalgesia. Conclusions: Neurostimulation via the ANSiStim™ is a safe and reasonably effective ambulatory analgesic adjuvant following abdominal delivery. There are no serious adverse effects.

Conversion during off-pump coronary artery bypass graft surgery: A case-control study.

Objectives: Off pump coronary artery bypass (OPCAB) surgery is carried out as an alternative to conventional coronary artery bypass grafting using cardiopulmonary bypass (CPB). At times 'conversion' to CPB may be required to bail out a situation resulting from acute decompensation of the heart. It is reported that such conversion carries significant mortality risk. Since we conduct coronary revascularization by OPCAB technique as the preferred technique, we conducted this study with an aim to identify the markers of adverse outcome during conversion in Indian patients. Design: Case control retrospective study. Setting: Tertiary referral center. Participants: We conducted three thousand two hundred OPAB surgeries in the period between 2013 to16. Ninety patients (3.1%) required conversion to complete the revascularization (Con version group). Twice the number of patients who underwent OPCAB surgery without conver sion were chosen as controls (Control group). Intervention: OPCAB surgery Results: Mortality in the conversion group was 5.56% in contrast to 0.06% in the controls (P = 0.01). The conversion group had higher left ventricular end diastolic pressure, incidence of endarterectomy, and intra-aortic balloon counter pulsation requirement. Female gender was also predictive of conversion. The total chest drain, duration of ventilation, ICU stay and hospital stay were also higher in the conversion group. Conversion was associated with 9.47 times the odds for mortality. Conclusion: Conversion during OPCAB is associated with significantly increased mortality. Female gender, increased left ventricular end diastolic pressure and preoperative requirement of Intra-aortic balloon are markers of increased risk of mortality when converted.

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.

Knowledge of Nurses About Preoperative Fasting in a Corporate Hospital.

BACKGROUND: Preoperative fasting is a requirement to be made by anesthesiologists, but they generally depend on nurses to ensure it is carried out by patients. Lack of updated knowledge among nurses may cause complications. METHOD: The objective of this study was to understand the knowledge of nurses about preoperative fasting. The multi-unit study was conducted in the units of our hospitals using an Internet-based survey. The responders were anonymous to the authors. RESULTS: The survey was sent to approximately 5,000 nurses, with more than 600 responding to the survey. Most of the respondents were aware of the preoperative fasting guidelines. The understanding regarding preoperative fasting appeared to be insufficient among nurses. The nurses appreciated the concern of the anesthesiologists about fasting. The nurses opined that additional training regarding preoperative fasting might benefit them. CONCLUSION: This survey conveyed to the authors that the nurses of our hospitals were knowledgeable but required further training to update them. J Contin Educ Nurs. 2018;49(3):127-131.

Anaesthetic consideration in patients with cardiac implantable electronic devices scheduled for surgery.

With advances in cardiology and cardiothoracic surgery, several newer implantable cardiac devices have become common in the surgical population. Multichamber pacemakers, implanted cardiac defibrillators and ventricular assist devices are frequent in current day practice. Many of the newer implantable cardiac electronic devices are targeted at managing heart failure. While managing such patients for non-cardiac surgeries, specific issues related to equipment characteristics and troubleshooting should be a priority for the anaesthesiologists. There is a possibility of malfunction of the devices resulting in catastrophic outcomes. Therefore, it is imperative to understand the pathophysiology, device characteristics and troubleshooting before embarking on anaesthetising patients with implantable cardiac electronic devices.

Modifying risks to improve outcome in cardiac surgery: An anesthesiologist's perspective.

Challenging times are here for cardiac surgical and anesthesia team. The interventional cardiologist seem to have closed the flow of 'good cases' coming up for any of the surgery,; successful percutaneous interventions seem to be offering reasonable results in these patients, who therefore do not knock on the doors of the surgeons any more . It is a common experience among the cardiac anesthesiologists and surgeons that the type of the cases that come by now are high risk. That may be presence of comorbidities, ongoing medical therapies, unstable angina, uncontrolled heart failure and rhythm disturbances; and in patients with ischemic heart disease, the target coronaries are far from ideal. Several activities such as institution of preoperative supportive circulatory, ventilatory, and systemic disease control maneuvers seem to have helped improving the outcome of these 'high risk ' patients. This review attempts to look at various interventions and the resulting improvement in outcomes. Several changes have happened in the realm of cardiac surgery and several more are en route. At times, for want of evidence, maximal optimization may not take place and the patient may encounter unfavorable outcomes.. This review is an attempt to bring the focus of the members of the cardiac surgical team on the value of preoperative optimization of risks to improve the outcome. The cardiac surgical patients may broadly be divided into adults undergoing coronary artery bypass graft surgery, valve surgery and pediatric patients undergoing repair/ palliation of congenital heart ailments. Optimization of risks appear to be different in each genre of patients. This review also brings less often discussed issues such as anemia, nutritional issues and endocrine problems. The review is an attempt to data on ameliorating modifiable risk factors and altering non modifiable ones.