Use of Handheld Ultrasound Device with Artificial Intelligence for Evaluation of Cardiorespiratory System in COVID-19.

BACKGROUND: Coronavirus disease-2019 (COVID-19) causes various cardiopulmonary manifestations. Bedside ultrasound helps in the rapid diagnosis of these manifestations. Vscan Extend™ (GE, Wauwatosa, WI, USA) is a handheld ultrasound device with a dual probe and an artificial intelligence application to detect ejection fraction. It can help in reducing the time for diagnosis, duration, and the number of healthcare workers exposed to COVID-19. This is a prospective observational study comparing the cardiorespiratory parameters and time duration for assessment between Vscan Extend™ and the conventional ultrasound machine. MATERIALS AND METHODS: Paired observations were made in 96 COVID-19 patients admitted to the intensive care unit by two intensivists. Intensivist A used the Vscan Extend™ device to assess the cardiac function, lung fields, diaphragm, deep veins, and abdomen. Intensivist B used clinical examination, X-ray chest, ECG, and conventional echocardiogram for assessment. The agreement between the findings and the time duration required in both the methods was compared. RESULTS: The use of handheld ultrasound has significantly decreased the duration of bedside examination of patients than the conventional method. The median duration of examination using handheld ultrasound was 9 (8.0-11.0) minutes, compared to 20 (17-22) minutes with the conventional method (P < 0.001). The Cohen's kappa coefficient was 1.0 for left ventricular systolic function, most of the lung fields, and diaphragmatic movement. CONCLUSION: Vscan Extend™ helps in the rapid identification and diagnosis of cardiopulmonary manifestations in COVID-19 patients. The agreement between the handheld device and the conventional method proves its efficacy and safety. CTRI NUMBER: CTRI/2020/07/026701. HOW TO CITE THIS ARTICLE: Maheshwarappa HM, Mishra S, Kulkarni AV, Gunaseelan V, Kanchi M. Use of Handheld Ultrasound Device with Artificial Intelligence for Evaluation of Cardiorespiratory System in COVID-19. J Crit Care Med 2021;25(5):524-527.

Effect of sodium bicarbonate infusion in off-pump coronary artery bypass grafting in patients with renal dysfunction.

BACKGROUND AND AIMS: Acute kidney injury (AKI) following cardiac surgery is a major complication resulting in increased morbidity, mortality and economic burden. This study was designed to determine the benefit of sodium bicarbonate (NaHCO3) supplementation in patients with stable chronic kidney disease (CKD) undergoing off-pump coronary artery bypass grafting (OP-CABG). MATERIAL AND METHODS: We prospectively studied 60 non-dialysis CKD patients with glomerular filtration rate (GFR) ≤60 ml/min/1.73 m2 requiring elective OP-CABG. They were randomly allocatted to one of the two groups. One group received NaHCO3 infusion at 0.5 mmol/kg first hour followed by 0.2 mmol/kg/h till the end of surgery and the other group received 0.9% NaCl. A third group of 30 patients without renal dysfunction undergoing OP-CABG was included. The serum creatinine was estimated prior to surgery, immediately after surgery and on postoperative days 1, 2, 3 and 4. RESULTS: Ten patients (33.3%) in NaCl and 6 (20%) patients each in NaHCO3 and normal groups developed Stage-1 AKI. None of our study patient required renal replacement therapy and no mortality was observed in any of the groups during the perioperative and hospitalization period. CONCLUSION: Perioperative infusion of NaHCO3 in OP-CABG reduced the incidence of Stage-1 AKI by about 40% when compared to NaCl. The incidence of Stage-I AKI in NaHCO3 group was similar to that in patients with normal renal function undergoing OP-CABG. A larger group of patients may be required to suggest a significance of renal protective benefit of NaHCO3 in patients undergoing OP-CABG.

Intraoperative cardiac arrest due to allergic acute coronary syndrome (Kounis syndrome) triggered by cephalosporin.

An acute coronary syndrome due to mast-cell activation in the presence of an allergen is known as Kounis Syndrome (KS). This relatively new entity of KS is being increasingly recognized among allergists, cardiologists, and emergency physicians; however, it is not well-known among anesthesiologists. We report here, a case of type 2 KS due to antibiotic administration causing sudden perioperative cardiac arrest.

Postgraduate training in anaesthesiology - A modular curriculum.

The primary objective of postgraduate medical education is to produce specialists who provide highest quality of health care to suffering patients and return them to the community in the most functional capability. The secondary objective is to advance the cause of science through research and training. A postgraduate, after undergoing the required training in anaesthesiology, should be able to recognise the health needs of the community and apply cognitive and psychomotor skills to provide optimal anaesthetic care. Additionally, the anaesthesiologist should function as a perioperative physician being adept in perioperative care, pain medicine and critical care medicine. The 3-year postgraduate curriculum comprises experience in basic, subspeciality and advanced anaesthesia training. This structured training programme with a curriculum of increasing difficulty and learning incorporates ascending grades of difficulty, posing a challenge to the trainee's intellect and technical skills. Experience in basic anaesthesia training is aimed to lay stress on basic and fundamental aspects of anaesthetic management. Subspeciality anaesthesia training is needed to lay stress on the theory, special considerations and practice of subdisciplines of anaesthesiology. This document proposes a modular-structured, continuous, objectively evaluated, systematic training process that is monitored frequently and periodically, such that the trainee, at the end of training, is capable of appropriate anaesthetic management of disease conditions in a wide variety of situations.

Single value of NephroCheck™ performed at 4 hours after surgery does not predict acute kidney injury in off-pump coronary artery bypass surgery.

Background: Quantification of urinary tissue inhibitor of metalloproteinase-2 (TIMP-2) and insulin-like growth factor binding protein (IFGBP-7), which is commercially known as NephroCheck™(NC) test have been suggested as promising tools for the early detection of acute kidney injury (AKI) after cardiac surgery involving cardio-pulmonary bypass (CPB). Objectives: The aim of the present study was to test the hypothesis that single value of postoperative NC test performed at 4 hours after surgery can predict AKI in off-pump coronary artery bypass grafting (OPCABG) surgery. Setting and Design: This prospective single-center study was conducted at the tertiary cardiac center in India from December 2017 to November 2018. Methods: Ninety adult patients of both sex undergoing elective OPCABG were included. Anesthesia was standardized to all patients. Urine samples were collected preoperatively and at 4 hours after surgery for NC test. Urine output, serum creatinine, estimated glomerular filtration rate (eGFR) were also measured. AKI staging was based on kidney disease improving global outcomes (KDIGO) guidelines. Statistical Analysis: To assess the predictability of NC test for the primary endpoint, area under the receiver operating characteristic curve (ROC), was calculated. Results: Thirteen patients developed AKI in the study cohort (14.4%) out of which 7 patients (7.8%) developed stage 2/3 AKI and the remaining stage 1 AKI. Baseline renal parameters were similar between AKI and non-AKI group. The area under curve (AUC) of NC test at 4 hours after surgery was 0.60 [95% confidence interval (CI): 0.42-0.77]. Postoperative NC test performed at 4 hours after surgery did not predict AKI in this study population (P = 0.24). There were no significant differences in duration of mechanical ventilation, length of intensive care stay and hospital stay between the two groups (P > 0.05). Conclusion: NephroCheck™ test performed at 4 hours after surgery did not identify patients at risk for developing AKI following OPCABG surgery.

Adjunct tele-yoga on clinical status at 14 days in hospitalized patients with mild and moderate COVID-19: A randomized control trial.

Background: The initial insights from the studies on COVID-19 had been disappointing, indicating the necessity of an aggravated search for alternative strategies. In this regard, the adjunct potential of yoga has been proposed for enhancing the effectiveness of the standard of care with respect to COVID-19 management. We tested whether a telemodel of yoga intervention could aid in better clinical management for hospitalized patients with mild-to-moderate COVID-19 when complemented with the standard of care. Methods: This was a randomized controlled trial conducted at the Narayana Hrudyalaya, Bengaluru, India, on hospitalized patients with mild-to-moderate COVID-19 infection enrolled between 31 May and 22 July 2021. The patients (n = 225) were randomized in a 1:1 ratio [adjunct tele-yoga (n = 113) or standard of care]. The adjunct yoga group received intervention in tele-mode within 4-h post-randomization until 14 days along with the standard of care. The primary outcome was the clinical status on day 14 post-randomization, assessed with a seven-category ordinal scale. The secondary outcome set included scores on the COVID Outcomes Scale on day 7, follow-up for clinical status and all-cause mortality on day 28, post-randomization, duration of days at the hospital, 5th-day changes post-randomization for viral load expressed as cyclic threshold (Ct), and inflammatory markers and perceived stress scores on day 14. Results: As compared with the standard of care alone, the proportional odds of having a higher score on the 7-point ordinal scale on day 14 were ~1.8 for the adjunct tele-yoga group (OR = 1.83, 95% CI, 1.11-3.03). On day 5, there were significant reductions in CRP (P = 0.001) and LDH levels (P = 0.029) in the adjunct yoga group compared to the standard of care alone. CRP reduction was also observed as a potential mediator for the yoga-induced improvement of clinical outcomes. The Kaplan-Meier estimate of all-cause mortality on day 28 was the adjusted hazard ratio (HR) of 0.26 (95% CI, 0.05-1.30). Conclusion: The observed 1.8-fold improvement in the clinical status on day 14 of patients of COVID-19 with adjunct use of tele-yoga contests its use as a complementary treatment in hospital settings.

Extracorporeal Membrane Oxygenation (ECMO) for Pulmonary and/or Cardiopulmonary Support-a Brief Review and Our Experience.

Extracorporeal membrane oxygenation (ECMO) is a modality utilized for partially or completely supporting the cardiac and/or pulmonary function. There are multiple vascular access techniques depending upon the necessity and the mode of ECMO used. ECMO has evolved over the years as an integral part of the cardiac care discipline. Historically, this lifesaving modality began as an extension of cardiopulmonary bypass and was associated with adverse outcomes. Currently, ECMO has evolved as an accepted and viable solution to patients with severe cardiac/respiratory/cardiorespiratory failure that is refractory to conservative management. The outcomes of patients on ECMO are dependent on multiple factors originating from demographic and pathophysiological status of patients as well as the control of homeostasis during ECMO within the acceptable range. Various studies have been published by many practitioners over past decades since the dawn of ECMO era. A brief review of such experience is summated, and a conclusion is derived about the clinical course of the patients on ECMO, while adding the author's experience about the same in a tertiary care large-volume center.

Automated versus manual B-lines counting, left ventricular outflow tract velocity time integral and inferior vena cava collapsibility index in COVID-19 patients.

Background and Aims: The incorporation of artificial intelligence (AI) in point-of-care ultrasound (POCUS) has become a very useful tool to quickly assess cardiorespiratory function in coronavirus disease (COVID)-19 patients. The objective of this study was to test the agreement between manual and automated B-lines counting, left ventricular outflow tract velocity time integral (LVOT-VTI) and inferior vena cava collapsibility index (IVC-CI) in suspected or confirmed COVID-19 patients using AI integrated POCUS. In addition, we investigated the inter-observer, intra-observer variability and reliability of assessment of echocardiographic parameters using AI by a novice. Methods: Two experienced sonographers in POCUS and one novice learner independently and consecutively performed ultrasound assessment of B-lines counting, LVOT-VTI and IVC-CI in 83 suspected and confirmed COVID-19 cases which included both manual and AI methods. Results: Agreement between automated and manual assessment of LVOT-VTI, and IVC-CI were excellent [intraclass correlation coefficient (ICC) 0.98, P < 0.001]. Intra-observer reliability and inter-observer reliability of these parameters were excellent [ICC 0.96-0.99, P < 0.001]. Moreover, agreement between novice and experts using AI for LVOT-VTI and IVC-CI assessment was also excellent [ICC 0.95-0.97, P < 0.001]. However, correlation and intra-observer reliability between automated and manual B-lines counting was moderate [(ICC) 0.52-0.53, P < 0.001] and [ICC 0.56-0.69, P < 0.001], respectively. Inter-observer reliability was good [ICC 0.79-0.87, P < 0.001]. Agreement of B-lines counting between novice and experts using AI was weak [ICC 0.18, P < 0.001]. Conclusion: AI-guided assessment of LVOT-VTI, IVC-CI and B-lines counting is reliable and consistent with manual assessment in COVID-19 patients. Novices can reliably estimate LVOT-VTI and IVC-CI using AI software in COVID-19 patients.

Management of intrapulmonary hemorrhage in patients undergoing pulmonary thrombo-endarterectomy.

Massive pulmonary hemorrhage during pulmonary thromboendarterectomy (PTE) can be managed by a conservative approach with mechanical ventilatory support, positive end-expiratory pressure, lung isolation, reversal of heparin, and correct of coagulopathy. We present three challenging cases that developed intrapulmonary hemorrhage during/after PTE and managed successfully. The first patient had bleeding from the bronchial artery and right internal mammary collaterals, which was managed by coil-embolization. The second patient had a breach in the blood airway barrier in the right upper lobar segment of the lung, and the repair was done using a surgical absorbable hemostat. The third patient developed reperfusion injury, he was instituted on veno-venous extracorporeal membranous oxygenation, a week later, the patient recovered completely. An algorithm was adopted and modified to our requirements; all the 3 challenging intrapulmonary hemorrhage cases were successfully managed. This algorithm can be used for satisfactory outcomes in patients who suffer intrapulmonary hemorrhage during PTE.

Effectiveness of Tranexamic Acid in Reducing Postoperative Blood Loss in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting.

Background Off-pump coronary artery bypass grafting (OP-CABG) is an accepted surgical option in treating ischemic heart disease and has proven safer than traditional on-pump CABG in terms of reducing perioperative bleeding, coagulopathy, avoiding cardiopulmonary bypass machine and its related morbidity. However, there is evidence that shows the risk of bleeding in OP-CABG due to surgical trauma, heart manipulations, and heparin-protamine exposure. We aim to evaluate the effectiveness of tranexamic acid (TxA) in reducing blood loss and related perioperative complications in patients undergoing OP-CABG. Method An individual matched cohort study was conducted at a cardiac centre over a period of one year. We enrolled a total of 60 patients undergoing OPCABG in our study. The basic strategy was to enroll every possible intervention patient until the desired sample size (30 in each group) was achieved and then to select and enroll controls, using a prospective individual matching strategy. Preoperative cardiac risk evaluation was done using the European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) in both groups. The intervention group (I) received TxA 10 mg/kg over 10 minutes at the time of induction while the control group (C) did not receive any TxA. Postoperative blood loss was measured by observing chest drain output 24 hourly till the chest drain tube was removed. Perioperative complications were also recorded. Results Demographics and baseline characteristics were comparable among groups (p > 0.05). The mean volume of postoperative blood loss in the I group at 24 hours and 48 hours were 352.67 ml and 86.83 ml, respectively. On the other hand, in the C group, the mean volume of postoperative blood loss was 602.00 ml and 166.3 ml. The data showed a statistically significant difference in the postoperative chest drainage output between the groups (unpaired t-test, p < 0.05) and exhibiting a significant reduction in postoperative blood loss in the I group. However, there was no significant difference in blood transfusion requirements in both of the groups (Mann Whitney U test, p > 0.05). The mean duration of postoperative complications, inotropic support, intermittent positive pressure ventilation, intensive care, and hospital stay were also comparable depicting no significant effect of TxA on reducing the perioperative morbidity. Conclusion This study showed the significance of TxA in reducing bleeding in the postoperative period in patients undergoing OP-CABG.

Hyperbaric oxygen therapy: Can it be a novel supportive therapy in COVID-19?

The coronavirus disease 2019 (COVID-19) is a pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV2). Although 85% of infected patients remain asymptomatic, 5% show severe symptoms such as hypoxaemic respiratory failure and multiple end organ dysfunction (MODS) requiring intensive care unit (ICU) admission with a mortality rate of about 2.8%. Since a definitive treatment is yet to be identified, preventive and supportive strategies remain the mainstay of management. Supportive measures such as oxygen therapy with nasal cannula, face mask, noninvasive ventilation, mechanical ventilation and even extreme measures such as extracorporeal membrane oxygenation (ECMO) fail to improve oxygenation in some patients. Hence, hyperbaric oxygen therapy (HBOT) has been proposed as a supportive strategy to improve oxygenation in COVID-19 patients. HBOT is known to increase tissue oxygenation by increasing the amount of dissolved oxygen in plasma. HBOT also mitigates tissue inflammation thus reducing the ill effects of cytokine storm in COVID-19 patients. Though there is limited literature available on HBOT in COVID-19 patients, considering the present need for additional supportive therapy to improve oxygenation, HBOT has been proposed as a novel supportive treatment in COVID-19 patients.

Effect of dexmedetomidine on pulmonary artery pressure in children with congenital heart disease and pulmonary hypertension.

Background: This study was undertaken to determine the effects of dexmedetomidine on pulmonary artery pressure (PAP) in children with congenital heart disease (CHD) and pulmonary hypertension (PH) undergoing cardiac catheterization with and without a planned intervention during monitored anesthetic care using midazolam and ketamine. Materials and Methods: Children (<18 years) with known CHD and PH who were scheduled for cardiac catheterization and interventional procedures were included in the study. The procedures were performed under monitored anesthesia. After obtaining baseline PAPs, an intravenous (IV) infusion of dexmedetomidine (1 µg/kg) was given for over 10 min. During infusion, heart rate (HR), blood pressure (BP), respiratory rate (RR), and peripheral arterial oxygen saturation (SPO2) were recorded every 2 min until completion of dexmedetomidine infusion, 15 min later, and when the procedure was completed. In addition, pulmonary artery systolic and diastolic pressures, and mean pulmonary artery pressure (MPAP) were recorded and the pulmonary artery systolic pressure (PASP)/systolic blood pressure (BP) ratio was calculated. Results: All children tolerated the procedure without adverse events. The HR decreased significantly over time during dexmedetomidine infusion. The changes in systemic systolic BP and PAPs were not significantly different from the baseline value at all points of measurement as was the ratio between the systolic pulmonary artery and systolic systemic BPs. Conclusions: Administration of dexmedetomidine in a dose of 1 µg/kg over 10 min did not significantly alter the PAP in children with CHD and PH. There was a decrease in the HR that was not clinically significant. The children tolerated dexmedetomidine without adverse events.

Validation of a Genome-Wide Polygenic Score for Coronary Artery Disease in South Asians.

BACKGROUND: Genome-wide polygenic scores (GPS) integrate information from many common DNA variants into a single number. Because rates of coronary artery disease (CAD) are substantially higher among South Asians, a GPS to identify high-risk individuals may be particularly useful in this population. OBJECTIVES: This analysis used summary statistics from a prior genome-wide association study to derive a new GPSCAD for South Asians. METHODS: This GPSCAD was validated in 7,244 South Asian UK Biobank participants and tested in 491 individuals from a case-control study in Bangladesh. Next, a static ancestry and GPSCAD reference distribution was built using whole-genome sequencing from 1,522 Indian individuals, and a framework was tested for projecting individuals onto this static ancestry and GPSCAD reference distribution using 1,800 CAD cases and 1,163 control subjects newly recruited in India. RESULTS: The GPSCAD, containing 6,630,150 common DNA variants, had an odds ratio (OR) per SD of 1.58 in South Asian UK Biobank participants and 1.60 in the Bangladeshi study (p < 0.001 for each). Next, individuals of the Indian case-control study were projected onto static reference distributions, observing an OR/SD of 1.66 (p < 0.001). Compared with the middle quintile, risk for CAD was most pronounced for those in the top 5% of the GPSCAD distribution-ORs of 4.16, 2.46, and 3.22 in the South Asian UK Biobank, Bangladeshi, and Indian studies, respectively (p < 0.05 for each). CONCLUSIONS: The new GPSCAD has been developed and tested using 3 distinct South Asian studies, and provides a generalizable framework for ancestry-specific GPS assessment.

Thyromental height test for prediction of difficult laryngoscopy in patients undergoing coronary artery bypass graft surgical procedure.

BACKGROUND: Patients undergoing coronary artery bypass graft (CABG) procedures have higher incidence of difficult laryngoscopy and intubation than general surgery population. Accurate prediction of difficult laryngoscopy in CABG patients is desirable to reduce the hemodynamic response and myocardial oxygen requirements. Recently, thyromental height test (TMHT) has been proposed as one of the highly sensitive and specific bedside tests to predict difficult airway. We, in our prospective observational study, evaluated the accuracy of the TMHT in predicting difficult laryngoscopy. METHODOLOGY: A total of 345 patients undergoing CABG of either sex, in the age group of 35-80 years, American Society of Anesthesiologists 111, undergoing CABG, were studied. Airway assessment was performed with modified Mallampati test with the addition of thyromental distance, sternomental distance, and TMHT. Intraoperatively, direct laryngoscopy was done in accordance with Cormack and Lehane grade of laryngoscopy. The preoperative data and laryngoscopic findings were used together to evaluate the accuracy of TMHT. The sensitivity, specificity, positive and negative predictive values of other three tests were calculated according to standard formula. RESULTS: A total of 345 patients were in the group with mean age of study population at 56.7 (standard deviation 9.1) years (35-80 years). This study showed that almost all tests had good specificity, but sensitivity was poor. However, sensitivity of TMHT was 75% with accuracy of 95%. Receiver operating characteristic curve analysis of TMHT-derived cutoff was 52.17 which increased sensitivity to 81.25% and specificity to 92.3%. CONCLUSION: TMHT had a higher sensitivity compared to other tests along with good positive and negative predictive value and a very high specificity.