Bilateral diaphragmatic palsy after congenital heart surgery: management options.

Diaphragmatic paralysis following phrenic nerve injury is a major complication following congenital cardiac surgery. In contrast to unilateral paralysis, patients with bilateral diaphragmatic paralysis present a higher risk group, require different management methods, and have poorer prognosis. We retrospectively analysed seven patients who had bilateral diaphragmatic paralysis following congenital heart surgery during the period from July, 2006 to July, 2014. Considerations were given to the time to diagnosis of diaphragm paralysis, total ventilator days, interval after plication, and lengths of ICU and hospital stays. The incidence of bilateral diaphragmatic paralysis was 0.68% with a median age of 2 months (0.6-12 months). There was one neonate and six infants with a median weight of 4 kg (3-7 kg); five patients underwent unilateral plication of the paradoxical diaphragm following recovery of the other side, whereas the remaining two patients who did not demonstrate a paradoxical movement were successfully weaned from the ventilator following recovery of function in one of the diaphragms. The median ventilation time for the whole group was 48 days (20-90 days). The median length of ICU stay was 46 days (24-110 days), and the median length of hospital stay was 50 days (30-116 days). None of the patients required tracheostomy for respiratory support and there were no mortalities, although all the patients except one developed ventilator-associated pneumonia. The outcome of different management options for bilateral diaphragmatic paralysis following surgery for CHD is discussed.

Efficacy of nil per oral, total parenteral nutrition, milrinone and non-suction chest tube drainage-based management for chylothorax following pediatric cardiac surgery.

OBJECTIVE: A single centre experience with chylothorax in post cardiac surgical patients. METHODS: Retrospective review. RESULTS: Chylothorax developed in 55 out of 873 operated patients (6.3%). Median age of the chylothorax cohort was 95 days (range 1-995). Neonates constituted 36% and 49% were infants. Group-1(35 patients-treated during the years 2011-2015) included those who were managed with low fat diet initially with other standard measures including steroid, octreotide, pleurodesis, lymphangiogram or thoracic duct ligation whenever required.Group-2 (20 patients, treated between year 2016-2018) were managed with nil per oral, total parenteral nutrition, extended use of milrinone and no use of chest tube suction with other above standard measures when required.Group-1 and group-2 were comparable in terms of their age and weight (p > 0.05).We observed lower volume of chest drainage, shorter intubation time, length of intensive care stay and hospital stay in group-2 compared to group-1 though they were statistically not significant (p > 0.05). Occurrence of massive chylothorax (>20 ml/kg/day) in group-1 was significantly higher [18 patients (51%) in group-1 vs 4 patients in group-2 (20%) (Chi-square 5.25, p = 0.02)]. In hospital mortality in group-1 was higher compared to group-2 (5/35 = 14.5% vs 1/20 = 5%), however, it was statistically not significant [risk ratio 2.86; 95% CI 0.36, 22.77; p = 0.59)]. Acute kidney injury was observed in about 25% of patients who had chylothorax. A higher mortality was observed in patients with chylothorax who had acute kidney injury [5/14 (35%)] compared to those who did not have acute kidney injury [1/41 (2.4%)] (Chi-square 11.89, p = 0.001)]. SUMMARY: In a heterogenous cohort of post-cardiac surgical patients who developed chylothorax, our suggested new regime (nil per oral, parenteral nutrition, extended use of milrinone and no suction applied to the chest drains) contributed to reduce the frequency of massive chylothorax occurrence significantly.

Intraoperative Management of a Child Undergoing Cardiac Surgery With Congenital Methemoglobinemia Detected in the Operating Room: A Case Report.

Congenital methemoglobinemia is a rare disease that is easily overlooked in its mild form. It can lead to tissue hypoxia as methemoglobin does not possess oxygen-carrying capacity. Its management approach depends on the severity of the symptoms, methemoglobin level, and associated medical conditions. The perioperative management of congenital methemoglobinemia is well described in the literature; however, its management in children with congenital heart disease and undergoing cardiac surgery using cardiopulmonary bypass has not been reported. We present a case and its management where congenital methemoglobinemia was detected in the operating room in a child scheduled for cardiac surgery.

Ascaris through a chest tube: a rare presentation.

A rare case of an Ascaris worm emerging through an intercostal chest tube is reported here because of its unusual presentation. A five-year-old male child had a liver abscess, which had ruptured into the right pleural cavity. An intercostal chest tube was inserted for right pleural effusion. On the 5th postoperative day, a 7 cm long worm was noticed emerging through the chest tube. Ascaris lumbricoides infestation can lead to serious complications because of the mobility of the worms. Though complications such as intestinal obstruction, volvulus, gangrene, pancreatitis, biliary obstruction, cholangiohepatitis, and liver abscess have been reported to occur, intrapleural ascariasis is an extremely rare situation. This report describes a clinical situation of intrapleural ascariasis and emphasizes the importance of remaining aware of this rare complication of ascariasis.

3D-modelling of transient left bronchial obstruction following bidirectional superior cavopulmonary shunt.

Extrinsic compression of airways is one the most important causes of respiratory insufficiency in the perioperative period in children with congenital heart disease. This is especially true of pathologies that involve surgery of the aortic arch or conduit replacement of the right ventricular outflow tract. However bronchial obstruction is uncommon in the setting of bidirectional cavopulmonary shunt alone. We report the case of an infant with a functionally univentricular heart who had a bidirectional superior cavopulmonary shunt and disconnection of the main pulmonary artery from the ventricular mass with oversewing of pulmonary valve. Post-operatively the patient desaturated due to compression of left main bronchus by the left pulmonary artery anteriorly and the descending aorta posteriorly. This was clearly defined by CT based on 3D-modelling of the airways and great vessels. The child was managed conservatively by ventilator support, selective bronchial suctioning and systemic steroids with a successful outcome.

Use of high-frequency ventilation to wean off cardiopulmonary bypass in a patient with pulmonary hemorrhage after failure of conventional ventilation.

The management of an infant who underwent corrective surgery for a supracardiac total anomalous pulmonary venous drainage, which was complicated by the development of pulmonary hemorrhage while separating from cardiopulmonary bypass, is presented. Initiation of high-frequency oscillatory ventilation was effective in weaning the patient off cardiopulmonary bypass.

Anesthetic management of an infant with Joubert syndrome for cardiac surgery.

The anesthetic implications of Joubert syndrome in an infant who required cardiac surgery using cardiopulmonary bypass (CPB) is presented. Children with Joubert syndrome present with central apnea due to malformations in the midbrain and cerebellum. These patients have a marked sensitivity to opioids. The use of dexmedetomidine along with remifentanil was effective in this case.

Role of preoperative chemotherapy in squamous cell carcinoma of esophagus in kashmir, a cancer belt - a pilot study.

BACKGROUND: Esophageal carcinoma is the fifth leading gastrointestinal malignancy and is one of the leading causes of cancer related death. Despite improvements in surgical technique over the last few decades, the outcome has been dismal, with overall 5 year survival not exceeding 15%-25%. AIMS AND OBJECTIVES: To evaluate the effect of preoperative chemotherapy on resectability, complication rate and overall survival in patients with squamous cell carcinoma esophagus. MATERIALS AND METHODS: 50 patients with histologically confirmed squamous cell carcinoma (SCC), with localised or loco-regional disease (stage 4 excluded) were divided into 2 groups. Group A patients were subjected to 2-3 cycles of pre-operative chemotherapy (5FU-CDDP), whereas Group B patients were directly operated on. OBSERVATIONS: 3 (12%) patients in group A showed complete pathological response to chemotherapy and 18 (72%) showed a partial response, with four patients (16%) showing resistance to chemotherapy. There was no statistically significant difference in terms of response to chemotherapy with respect to degree of differentiation of tumor. There was no significant difference in the overall resectability rates between the two groups (p > 0.05), but R0 resection was achieved in 20 (80%) of group A and only 10 (40%) of group B, the difference being statistically significant (p < 0.05). The rate of overall complications was also much higher in the control group. Initially there was no significant difference in the survival between the two groups, but later (20 months) the study group showed a slight non-significant advantage. CONCLUSION: Preoperative chemotherapy significantly increases the rate of R0 resection without significantly increasing postoperative morbidity and mortality in patients with squamous cell carcinoma of esophagus. However, to assess the impact on survival the study period needs to be extended.

Prevalence of Exfoliative Glaucoma among Kashmiri Population: A Hospital Based Study.

BACKGROUND: The Prevalence of exfiolative glaucoma has shown extensive variation all over world ranging from 0 to 50%. OBJECTIVE: To know the prevalence of exfoliative glaucoma in Kashmir. METHODS: A hospital based cross-sectional study was conducted from January 2006 to January 2007 on 300 patients with documented raised intra ocular pressure (IOP), glaucomatous changes in the fundus and open angle of anterior chamber. RESULTS: The study included 236 males and 64 females. Out of 300 patients, 115 had exfiolative glaucoma and among those left eye was involved in 47 patients, right eye in 31 and 37 had bilateral involvement. The patients above 60 years of age were found to have this condition more frequently as compared to those below 60 years of age. Occupation of patients had a strong association with this condition, as the disorder was seen more commonly in patients engaged in outdoor activites. The patients with exfiolative glaucoma were found to be having less Visual acuity; a higher IOP at presentation and a more severe and early optic nerve head involvement as compared to those with open angle glaucoma. CONCLUSIONS: The study reveals that prevalence of exfoliative glaucoma as seen in our OPD based cross sectional study was found to be 38.3%. This prevalence was high as compared to prevalence studies conducted in southern parts of the country and low as compared to the studies conducted in the Scandinavian countries. The difference in the prevalence of the condition was probably inpart related to the differences in the climatic conditions, ethnic origin and in part related to genetic factors of the studied population.

Idiopathic massive spontaneous hemothorax: adhesion disruption.

BACKGROUND: Hemothorax has been reported to occur along with spontaneous pneumothorax due to adhesion disruption. Rupture of pleural adhesions spontaneously or after unnoticeable trivial trauma causing massive hemothorax alone is rare. METHODS: We present a series of seven cases of idiopathic massive spontaneous hemothorax due to adhesion disruption, of which all required emergency thoracotomy with ligation or cauterization of bleeding adhesions. RESULTS: Six patients had bleeding pleural lung adhesions of which five involved the upper lobes. Another had bleeding from pleuropericardial adhesions. All patients are doing well on follow-up. CONCLUSIONS: Disruption of pleural adhesions may cause massive hemothorax, requiring early surgical intervention. After thoracotomy the outcome in these patients is excellent.

Missile diaphragmatic injuries: kashmir experience.

BACKGROUND: Importance of repairing a diaphragmatic tear due to a missile injury cannot be overemphasized. Even a small diaphragmatic rent should be repaired because of morbidity and mortality caused by subsequent herniation and strangulation. METHODS: Fifty-three cases with diaphragmatic injuries caused by penetrating missiles were studied from January 1997 to January 2007. All the patients were primarily explored either for thoracic or abdominal penetrating trauma; the diaphragmatic injury was an associated incidental intraoperative finding. Thoracotomy was performed in 18 patients, Laprotomy in 33 patients and in two patients combined thorocoabdominal approach was utilised for managing associated visceral injuries. RESULTS: Overall mortality was 37.7%. Mortality was dependent on associated injuries of thoracic and abdominal viscera. Most patients died due to associated injuries and septicaemia. None of the patients had any sequelae of diaphragmatic repair. CONCLUSION: Immediate repair of diaphragmatic injury is of paramount importance to prevent subsequent complications of herniation and strangulation.

Surgeon and human immunodeficiency virus infection.

HIV infection has attained extraordinary attention among surgeons and other health care workers as a potential source of occupational infection. Disease is usually blood-borne and transmissible, and due to the nature of surgical work, surgical community has become involved and is developing sterile surgical barriers, and improved surgical techniques and procedures.

Atrial myxoma: trends in management.

Myxomas are the most common type of cardiac tumours in all age groups accounting for one-third to one-half of cases at postmortum and for about three quarter of tumours treated surgically. Most atrial myxomas, whether left or right, arise from the atrial septum. About 10% have other sites of origin, particularly posterior wall, anterior wall and the appendages (in order of frequency). Myxomas are frequently located in left atrium and produce symptoms when they fragment and cause systemic emboli or when they interfere with cardiac valvular function and cause pulmonary congestion. Careful surgical management of these lesions should be curative with minimal early and late morbidity and mortality. Recurrence of atrial myxomas can occur most likely in about 3% of patients. However, extensive resection of the myxoma attached to atrial septum or atrial wall can reduce the likelihood of recurrence to a greater extent. Long term clinical and echocardiographic follow-up is mandatory.