Challenges in Preparing and Managing the Critical Care Services for a Large Urban Area During COVID-19 Outbreak: Perspective From Delhi.

The coronavirus disease-2019 (COVID-19) pandemic has put healthcare services all over the world into a challenging situation. The contagious nature of the disease and the respiratory failure necessitating ventilatory care of these patients have put extra burden on intensive care unit (ICU) services. India has been no exception; by March 2020, the number of COVID-19 patients started increasing in India. This article describes the measures taken and challenges faced in creating ample ICU bed capacity to cater to the anticipated load of patients in the state of Delhi, India, as a result of the COVID-19 pandemic. The main challenges faced, among others, were estimating the number of ICU beds to be created; deciding on dedicated hospitals to treat COVID-19 patients; procuring ventilators, personal protective equipment, and other related material; mobilizing human resources and providing their training; and providing isolated in-house accommodations to the staff on duty. The authors acknowledge and agree that the methodology proposed in this article is but one way of approaching this difficult scenario and that there could be other, perhaps better, methods of dealing with such a problem.

History of Cardiac Anesthesia in India.

Before the 19th century, the heart was considered as a "no-go" area, although minor and superficial procedures were performed in the early 1800s. It was only in the later part of the century that surgical repair of the wounds of the cardiac chambers was attempted. Cardiac surgery came to India in the mid-20th century and the operations performed were minor and extracardiac. Initially, the surgeries were performed at a select few centers located at Mumbai, Vellore, Delhi, Chennai, and Kolkata. The anesthesiologists of an earlier era in India worked with limited facilities, and with their interest and devotion contributed immensely to the growth of the specialty of cardiac anesthesia. The progress was somewhat modest until the 1980s, when it started increasing rapidly and India caught up with the Western world by the turn of century. The progress was seen not only in the clinical field, but also in technology, teaching, and academic fields. This article presents an account of the progress in the field of cardiac anesthesia in India, and highlights the contribution of some of the dedicated anesthesiologists because of whom the specialty has reached the present stature.

Disseminated intravascular and intracardiac thrombosis after cardiopulmonary bypass.

Massive intracardiac and intravascular thrombosis is a rare complication following cardiopulmonary bypass (CPB). Most of the cases of the disseminated thrombosis have been reported in patients undergoing complex cardiac surgeries and those receiving antifibrinolytic agents during CPB. We report the occurrence of disseminated intravascular and intracardiac thrombosis after CPB in a patient undergoing mitral valve replacement in which no antifibrinolytic agent was used. The possible pathophysiology and management of the patient is discussed.

Evaluation of different types of inferior vena cava cannulae placement by transesophageal echocardiography and its impact on hepatic dysfunction.

BACKGROUND: Postoperative hepatic dysfunction may occur in an otherwise uncomplicated open heart surgery. One of the reasons is malpositioning of the inferior vena cava (IVC) cannula in the hepatic vein (HV) or beyond. A straight cannula is considered more likely to be malpositioned compared to the angled cannula and a malpositioned cannula can lead to hepatic dysfunction. METHODS: In this prospective study, forty adult patients undergoing atrial septal defect repair were randomized into two groups as: straight cannula group (n=20) and angled cannula group (n=20). The cannula position was assessed by transesophageal echocardiography (TEE) (hepatic vein view). Alanine aminotransferase levels (ALT) and bilirubin levels were measured immediately, at 6 hours and on day 1, day 2 and day 7 after surgery as a marker of hepatic injury. RESULTS: TEE localization of the IVC cannula was achieved in all patients except one. Visualization was good in 85% of patients. A cannula in the HV or beyond the HV in the IVC was considered malpositioned. The number of cases of cannula malposition was 10 (50%) and 4 (20%) in the straight and angled cannula groups, respectively. The pattern of change in serum bilirubin and liver enzymes levels in the postoperative period was similar in both the groups (p>0.05). The mean distance between the right atrium (RA) - inferior vena cava (IVC) junction to the hepatic vein was 1.94±0.56 cm and the mean diameters of the IVC and HV were 1.95±0.5 and 1.31±0.33 cm, respectively. CONCLUSION: TEE can be used to monitor IVC cannula position. A higher frequency of cannula malposition was observed with the straight cannula compared to the angled cannula, but was not found to be associated with hepatic dysfunction.