Post-cardiac Surgery Delirium: When the Details Matter!

How to cite this article: Suresh V, Magoon R. Post-cardiac Surgery Delirium: When the Details Matter! Indian J Crit Care Med 2024;28(2):185-187.

Mirror, Mirror on the Wall; He Had a "Bypass" After All!

How to cite this article: Magoon R, Jose J, Kumar M. Mirror, Mirror on the Wall; He Had a "Bypass" After All! Indian J Crit Care Med 2024;28(7):706-707.

Hemodynamics: Strangers to Lung-kidney Crosstalk in ARDS?

How to cite this article: Magoon R, Sharma AG, Yadav N, Choupoo NS. Hemodynamics: Strangers to Lung-kidney Crosstalk in ARDS? Indian J Crit Care Med 2024;28(2):177-178.

Leucoglycemic index predicts post-operative vasopressor-inotropic requirement after adult cardiac surgery (LEUCOGLYPTICS): A retrospective single-center study.

Background and Aims: Cardiac surgery often necessitates considerable post-operative vasoactive-inotropic support. Given an encouraging literature on the prognostic potential of leucoglycemic index (LGI) [serum glucose (mg/dl) × total leucocytes count (cells/mm3)/1000], we aimed to evaluate whether intensive care unit (ICU)-admission LGI can predict post-operative vasopressor-inotropic requirements following cardiac surgery on cardio-pulmonary bypass (CPB). Material and Methods: The data of patients undergoing cardiac surgery at our tertiary care center between January 2015 and December 2020 was retrospectively reviewed. The vasopressor-inotropic requirement was estimated using the VIS (vasoactive-inotropic score) values over the first post-operative 72 hrs. Subsequently, VISi (indexed VIS) was computed as maxVIS[0-24hrs] + maxVIS[24-48hrs] +2 × maxVIS[48-72hrs]/10), and the study participants were divided into h-VISi (VISi ≥3) and l-VISi (VISi <3). Results: Out of 2138 patients, 479 (22.40%) patients categorized as h-VISi. On univariate analysis: LGI, age, European System for Cardiac Operative Risk Evaluation score (EuroSCORE II), left-ventricle ejection fraction, prior congestive heart failure (CHF), chronic renal failure, angiotensin-converting enzyme inhibitors, combined surgeries, CPB and aortic cross-clamp (ACC) duration, blood transfusion, and immediate post-operative glucose were significant h-VISi predictors. Subsequent to multi-variate analysis, the predictive performance of LGI (OR: 1.09; 95% CI: 1.03-1.14; P = 0.002) prior CHF (OR: 2.35; 95% CI: 1.44-3.82; P = 0.001), CPB time (OR: 1.08; 95% CI: 1.02-1.14; P = 0.019), ACC time (OR: 1.03; 95% CI: 1.02-1.04; P = 0.008), and EuroSCORE II (OR: 1.14; 95% CI: 1.06-1.21; P < 0.001) remained significant. With 1484.75 emerging as the h-VISi predictive cut-off, patients with LGI ≥ 1484.75 also had a higher incidence of vasoplegia, low-cardiac output syndrome, new-onset atrial fibrillation, acute kidney injury, and mortality. LGI additionally exhibited a significant positive correlation with duration of mechanical ventilation and ICU stay (R = 0.495 and 0.564, P value < 0.001). Conclusion: An elevated LGI of greater than 1484.75 independently predicted a VISindex ≥3 following adult cardiac surgery on CPB.

SOFA-based Prognostication in PICU: A Cardiovascular Critique!

How to cite this article: Magoon R. SOFA-based Prognostication in PICU: A Cardiovascular Critique! Indian J Crit Care Med 2023;27(11):861-862.

Deliberating a Re(n)al-world Research Setting.

How to cite this article: Choudhary N, Magoon R, Jose J. Deliberating a Re(n)al-world Research Setting. Indian J Crit Care Med 2023;27(4):297.

Harmonizing the Septic Shock Terminology: Need of the Hour.

How to cite this article: Magoon R, Puri S, Bandyopadhyay A. Harmonizing the Septic Shock Terminology: Need of the Hour. Indian J Crit Care Med 2023;27(4):294-295.

Optic Nerve Sheath Diameter in Hyponatremia: A Closer Look.

How to cite this article: Jose J, Suresh V, Magoon R. Optic Nerve Sheath Diameter in Hyponatremia: A Closer Look. Indian J Crit Care Med 2023;27(6):452.

Inflammation and Hemorrhagic Stroke Outcomes: Other Players in the Nexus.

How to cite this article: Magoon R. Inflammation and Hemorrhagic Stroke Outcomes: Other Players in the Nexus. Indian J Crit Care Med 2022;26(5):651.

A Clarion Call for a More Comprehensive Approach to Acute Respiratory Distress Syndrome Severity Categorization.

How to cite this article: Magoon R, Suresh V. A Clarion Call for a More Comprehensive Approach to Acute Respiratory Distress Syndrome Severity Categorization. Indian J Crit Care Med 2022;26(12):1308-1309.

Fibrinolysis and D-dimer in COVID-19: A Twisted Plot!

Coronavirus disease-2019 (COVID-19) and the associated pathophysiological perturbations continue to bewilder the fraternity at large. In this context, the thromboembolic predisposition in COVID-19 has particularly emerged as a matter of an ardent debate. The index commentary aims to present an account of the recent developments in the understanding of the immunothrombosis in the enigmatical setting of COVID-19. How to cite this article: Magoon R, Choudhary N, Jose J. Fibrinolysis and D-dimer in COVID-19: A Twisted Plot! Indian J Crit Care Med 2022;26(2):164-166.

Haemodynamic predisposition to acute kidney injury: Shadow and light!

Acute kidney injury (AKI) could well be regarded as a sentinel complication given it is relatively common and associated with a substantial risk of subsequent morbidity and mortality. On the aegis of 'prevention is better than cure', there has been a wide interest in evaluating haemodynamic predisposition to AKI so as to provide a favourable renoprotective haemodynamic milieu to the subset of patients presenting a significant risk of developing AKI. In this context, the last decade has witnessed a series of evaluation of the hypotension value and duration cut-offs associated with risk of AKI across diverse non-operative and operative settings. Nevertheless, a holistic comprehension of the haemodynamic predisposition to AKI has been a laggard with only few reports highlighting the potential of elevated central venous pressure, intra-abdominal hypertension and high mean airway pressures in considerably attenuating the effective renal perfusion, particularly in scenarios where kidneys are highly sensitive to any untoward elevation in the afterload. Despite the inherent autoregulatory mechanisms, the effective renal perfusion pressure (RPP) can be modulated by a number of haemodynamic factors in addition to mean arterial pressure (MAP) as the escalation of renal interstitial pressure, in particular hampers kidney perfusion which in itself is a dynamic interplay of a number of innate pressures. The present article aims to review the subject of haemodynamic predisposition to AKI centralising the focus on effective RPP (over and above the conventional 'tunnel-vision' for MAP) and discuss the relevant literature accumulating in this area of ever-growing clinical interest.

A randomized comparative evaluation of C-MAC video-laryngoscope with Miller laryngoscope for neonatal endotracheal intubation.

Background and Aims: An efficient neonatal airway management is peculiarly challenging even in the most experienced hands. Considering the recent interest in assessing the performance of various video-laryngoscopes (VL) in pediatric cohort, the prospective randomized study was contemplated to stage a comparative evaluation of C-MAC with Miller laryngoscope for neonatal endotracheal intubation. Material and Methods: 150 neonates were randomized to undergo intubation with either the C-MAC VL (n = 75) or the Miller laryngoscope (n = 75) performed by an experienced anesthesiologist in a tertiary care perioperative setting. The percentage of glottic opening (POGO), time to best glottic view (TTBGV), time to intubation (TTI), number of attempts, optimal external laryngeal manipulation (OELM) employed, and the complications were assessed and compared between the two groups. Results: C-MAC group demonstrated a significantly higher POGO, compared to the Miller group (88 ± 26.7%;76.8 ± 32.1%, respectively, P = 0.022). TTBGV was significantly lower in the C-MAC (7.7 ± 0.1s) group as opposed to the Miller group (11.3 ± 1.1s). The C-MAC group displayed higher TTI values compared to the Miller group (25.4 ± 1.6s; 19.7 ± 1.2s, respectively, P < 0.01). The first-attempt intubation success rate and the number of attempts were comparable in both the groups. OELM was required in 24% of the patients in the Miller group as opposed to 10.7% in the C-MAC group (P = 0.031). Higher patient percentage in the C-MAC group required the need of stylet for assisting a successful intubation, although the difference between the two groups was not statistically significant. Conclusion: Despite an improved view of the glottis, the TTI was higher for C-MAC compared to direct laryngoscopy with a comparable first-attempt success rate in the two techniques.

Systemic Immune-Inflammation Index Predicts Poor Outcome After Elective Off-Pump CABG: A Retrospective, Single-Center Study.

OBJECTIVES: To investigate the role of preoperative hematologic indices (neutrophil-lymphocyte ratio [NLR], platelet-lymphocyte ratio [PLR], systemic immune-inflammation index [SII; neutrophil × platelet/lymphocyte) in predicting short-term outcomes after off-pump coronary artery bypass grafting (OPCABG). DESIGN: A single-center, retrospective, risk-prediction study. SETTING: A tertiary cardiac center. PARTICIPANTS: 1,007 patients undergoing elective OPCABG. INTERVENTIONS: No specific intervention. MEASUREMENTS AND MAIN RESULTS: Two hundred five patients out of 1,007 (20.4%) manifested poor postoperative outcome (defined by ≥1 of: major adverse cardiac and cardiovascular events, duration of mechanical ventilation (DO-MV) >24 hours, new-onset renal failure, sepsis, and death). On univariate analysis, age, diabetes mellitus (DM), European System for Cardiac Operative Risk Evaluation II (EuroSCORE II), left-main disease, recent myocardial infarction, poor left ventricular ejection fraction, hemoglobin, NLR, PLR, and SII significantly predicted poor outcome. However, DM, EuroSCORE II, and SII emerged as independent predictors on multivariate analysis (odds ratio 0.136; 0.035-0.521, 3.377; 95% confidence interval 2.373-4.806, 1.01, 1.003-1.016). The SII cutoff of 878.06 × 103/mm3 predicted poor outcome with 97.6% sensitivity, 91%, specificity, and area under the curve 0.984. There was a significant positive correlation between the SII values and DO-MV and length of intensive care unit stay (R = 0.676; 0.527, p < 0.001). The incidence of complications, such as atrial fibrillation, intra-aortic balloon pump requirement, vasoactive-ionotropic score >20 for >6 hours, and other infections, was also significantly higher in patients with SII ≥878.06 × 103/mm3. CONCLUSIONS: SII constitutes a parsimonious and reproducible parameter demonstrating the potential of delineating the patients vulnerable to poor outcomes after OPCABG given the combined contribution of pro-inflammatory and pro-thrombotic corpuscular lines in computing the novel index.

Stress Hyperglycemia Ratio may Portend Poor Outcomes in COVID-19.

Magoon R, Jose J. Stress Hyperglycemia Ratio may Portend Poor Outcomes in COVID-19. Indian J Crit Care Med 2021;25(11):1329.

Efficacy of Bilateral Erector Spinae Plane Block in Management of Acute Postoperative Surgical Pain After Pediatric Cardiac Surgeries Through a Midline Sternotomy.

OBJECTIVE: Regional analgesia continues to evolve with the introduction of ultrasound-guided fascial plane blocks. Erector spinae plane block (ESPB) is a novel technique gaining recent acceptability as a perioperative modality of analgesia in various thoracic and abdominal surgeries. However, literature on the use of ESPB in pediatric cardiac surgery is limited. DESIGN: A prospective, randomized, single-blind, comparative study. SETTING: Single-institution tertiary referral cardiac center. PARTICIPANTS: Eighty children with acyanotic congenital heart disease undergoing cardiac surgery through midline sternotomy. INTERVENTIONS: The subjects were allocated randomly into 2 groups: ESPB (group B, n = 40) received ultrasound-guided bilateral ESPB at the level of T3 transverse process and control (group C, n = 40) receiving no block. MEASUREMENTS AND MAIN RESULTS: The postoperative pain was assessed using Modified Objective Pain Scores (MOPS) which were evaluated at 0, 1, 2, 4, 6, 8, 10, and 12 hours after extubation. Group B demonstrated significantly reduced MOPS as compared with group C until the 10th postoperative hour (p < 0.0001), with comparable MOPS at the 12th hour. The consumption of postoperative rescue fentanyl was also significantly less in group B in comparison to group C (p < 0.0001) with a longer duration to first rescue dose requirement in group B. In addition, the group B showed lower postoperative sedation scores and intensive care unit stay in contrast to group C. CONCLUSION: Ultrasound-guided bilateral ESPB presents a simple, innovative, reliable, and effective postoperative analgesic modality for pediatric cardiac surgeries contemplated through a midline sternotomy.

Transesophageal Echocardiographic Estimation of Coronary Sinus Blood Flow for Predicting Favorable Postoperative Transit Time Coronary Graft Flow Measurements: A Pilot Study.

BACKGROUND: Augmentation of coronary artery flow by surgical grafting increases coronary sinus blood flow (CSBF), which can be quantified on transesophageal echocardiography (TEE). However, transit time flowmetry (TTF) technology remains the most used intraoperative technique for coronary artery graft assessment. The purpose of the present pilot study was to evaluate the predictive value of TEE-based CSBF estimation for identifying favorable TTF graft measurements. DESIGN: Prospective observational study. SETTING: Single university hospital. PATIENTS: Forty patients undergoing triple vessel coronary artery bypass grafting. MEASUREMENTS AND MAIN RESULTS: CSBF was assessed on TEE examination before and after revascularization, estimating the percentage increase in CSBF (∆CSBF). Postoperative TTF graft measurements were averaged to compute mean diastolic filling (DF) and pulsatility index (PI). Subjects were grouped based on favorable (PI ≤ 3, DF ≥ 50%) and unfavorable (PI > 3, DF < 50%) parameters. The group with PI ≤ 3 (n = 32) had significantly higher ∆CSBF compared with the group with PI > 3 (n = 8) (38.22% ± 12.05%, 13.75% ± 3.37%, p < 0.001). ∆CSBF was higher in the DF ≥ 50% group (n = 35) (36.40 ± 12.99) in contrast to DF < 50% group (n = 5) (11.80 ± 2.59%). A strong negative and significantly positive correlation was observed between ∆CSBF with PI, DF (r = -0.903, 0.571, respectively, p < 0.001). A ∆CSBF ≥15.5% was found to predict a mean PI ≤ 3 and DF ≥ 50% with sensitivity and specificity of 100% and 62.5% for PI and 100% and 100% for DF. A ∆CSBF ≥19% demonstrated a sensitivity and specificity of 100% and 100%, 100% and 91.4% for prediction of PI ≤ 3 and DF ≥ 50%, respectively. CONCLUSION: TEE-based demonstration of an augmented CSBF can ensure favorable TTF graft parameters, guiding the adequacy of surgical revascularization.

Pulmonary Vascular Permeability Indices: Fine Prints of Lung Protection?

How to cite this article: Choudhary N, Magoon R, Walian A, Kohli JK. Pulmonary Vascular Permeability Indices: Fine Prints of Lung Protection? Indian J Crit Care Med 2020;24(6):473-474.