Effect of transesophageal echocardiography probe on tracheal perfusion pressure and ventilatory parameters in pediatric patients undergoing cardiac surgery using cardiopulmonary bypass: A prospective observational study.

Background: Overinflation of cuffed endotracheal tubes and transesophageal echocardiography (TEE) probe causes increased intracuff pressure (CP) compromising tracheal perfusion pressure (TPP). Primary objective of the study was to assess CP, TPP on TEE probe insertion and examination during pediatric cardiac surgeries. Secondary objectives were to evaluate the effect of the probe on peak airway pressures (Ppeak), mean airway pressures (Pmean) and to monitor CP, TPP on cardiopulmonary bypass (CPB). Materials and Methods: This prospective observational study included fifty patients, aged 1-5 years undergoing cardiac surgeries using CPB. Following induction, TEE probe was introduced. CP, TPP, Ppeak, Pmean were measured before insertion of TEE probe (T1), during probe insertion (T2) and examination at mid-esophageal (T3), transgastric level (T4), and on removing probe (T6). CP, TPP were monitored on CPB (T5). Statistical analysis was done using paired t-test. Results: CP, Ppeak and Pmean increased significantly, while TPP decreased significantly from T1 to T2, T3, T4 (P < 0.001). CP, TPP decreased significantly at T5 in comparison to T6 (P < 0.001). In 48% of the patients CP increased above 30 cm H2O at T2. Conclusion: TEE probe causes an increase in CP and decreases TPP. Constant monitoring and maintaining CP, TPP in optimum range is recommended.

Thoracic paravertebral versus interpleural catheter for post-thoracotomy pain control in minimally invasive cardiac surgery.

OBJECTIVE: The aim of this study was to compare efficacy and safety of paravertebral block (PVB) and interpleural analgesia (IPA) after minimally invasive cardiac surgery through thoracotomy in terms of quality of analgesia, post-operative mechanical ventilation time, intensive care unit (ICU) and hospital length of stay (LOS) and complications. DESIGN: A randomized, prospective study. PARTICIPANTS: A total of 50 adult patients (18-50 years old) undergoing minimally invasive cardiac surgery via thoracotomy. INTERVENTION: Patients were randomized for group A: paravertebral epidural catheter (n = 25), group B: interpleural catheter (n = 25). All patients were given Inj. Bupivacaine 0.125%, 8 ml and Inj. Tramadol 100 mg as an adjuvant, total volume 10 ml. RESULTS: After obtaining institutional review board approval, data collected and analysed - visual analogue score (VAS) at rest and on coughing, haemodynamic and respiratory parameters, time to extubation, supplementary analgesia requirement, LOS and complications. VAS was recorded at 0, 2, 3, 4, 8, 12 and 24 h post-extubation, while blood gases at-after shifting, 4, 8, 12 and 24 h. There were no significant differences in haemodynamic or respiratory parameters, VAS at rest and on coughing, ventilation duration, ICU and hospital LOS between two groups. The requirement of rescue analgesia was in one patient of mini coronary artery bypass in group B, while one patient in group A required reintubation due to respiratory acidosis and got successfully extubated on next day morning. CONCLUSION: PVB and IPA both are safe and effective techniques for minimally invasive cardiac surgery with thoracotomy. It allows optimal pain control and safe ICU fast-track post-operative course.

Comparison of hemodynamic consequences of hand ventilation versus machine ventilation for transportation of post-operative pediatric cardiac patients.

Learning Objective: Hemodynamic monitoring during in-hospital transport of intubated patients is vital; however, no prospective randomized trials have evaluated the hemodynamic consequences of hand versus machine ventilation during transport among pediatric patients' post-cardiac surgery. The authors hypothesized that manual ventilation after pediatric cardiac surgery would alter hemodynamic and arterial blood gas (ABG) parameters during transport compared to mechanical ventilation. Design: A prospective randomized trial. Setting: Tertiary cardiac care hospital. Participants: Pediatric cardiac surgery patients. Materials and Methods: One hundred intubated pediatric patients were randomized to hand or machine ventilation immediately post-cardiac surgery during transport from the operating room to the pediatric post-operative intensive care unit (PICU). Hemodynamic variables, including end-tidal CO2 (ETCO2), oxygen saturation, heart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP), peak airway pressure (Ppeak), and mean airway pressure (Pmean), were measured at origin, during transport, and at the destination. ABG was measured before and upon arrival in the PICU, and adverse events were recorded. The Chi-square test and independent t-test were used for comparison of categorical and continuous parameters, respectively. Results and Discussion: The mean transport time was comparable between hand-ventilated (5.77 ± 1.46 min) and machine-ventilated (5.96 ± 1.19 min) groups (P = 0.47). ETCO2 consistently dropped during transport and after shifting in the hand-ventilated group, with significantly higher ETCO2 excursion than in machine-ventilated patients (P < 0.05). SBP and DBP significantly decreased during transport (at 5 and 6 min intervals) and after shifting in hand-ventilated patients than in the other group (P < 0.05). Additionally, after shifting, a significant increase in Ppeak (P < 0.001), Pmean (P < 0.001), and pH (P < 0.001), and a decrease in pCO2 (P = 0.0072) was observed in hand-ventilated patients than machine-ventilated patients. No adverse event was noted during either mode of ventilation. Conclusion: Hand ventilation leads to more significant variation in ABG and hemodynamic parameters than machine ventilation in pediatric patients during transport post-cardiac surgery. Therefore, using a mechanical ventilator is the preferred method for transporting post-operative pediatric cardiac patients.

Left main coronary artery aneurysm with fistula to superior vena cava: A challenging case.

Coronary artery fistulas (CAFs) are rare congenital coronary artery abnormalities, with direct communication between a coronary artery and a cardiac chamber, great vessel or other structure. We report here, a rare case of a 25-year-old male with CAF from the aneurysmal left main coronary artery to the superior vena cava detected on echocardiography and computerized tomography (CT) coronary angiography.

Correlation of venous to arterial carbon dioxide partial pressure difference with other cardiac output indices in patients undergoing intracardiac repair for tetralogy of fallot.

Background: Clearance of tissue carbon dioxide by circulation is measured by venous to arterial carbon dioxide partial pressure difference (AVCO2) and is correlated with cardiac output (CO) in critically ill adult patients. This study aimed to correlate AVCO2 with other CO indices like arteriovenous oxygen saturation difference (AVO2), central venous oxygen saturation (ScVO2), and serum lactate in pediatric patients undergoing intracardiac repair (ICR) for tetralogy of Fallot (TOF). Methods: We conducted a prospective observational study in 50 patients, of age 5 months to 5 years, undergoing ICR for TOF and analyzed AVO2, AVCO2, ScVO2, and lactate from arterial and venous blood gas pairs obtained at different time intervals from admission to pediatric intensive care unit (PICU) (T0), at 6 h (T1), 12 h (T2), 24 h (T3), and 48 h (T4) postoperatively. Bivariate correlations were analyzed using Pearson for parametric variables. Results: Admission AVCO2 was not correlated with AVO2 (R2 = 0.166, P = 0.246), ScVO2 (R2 = -2.2, P = 0.124), and lactate (R2 = -0.07, P = 0.624). At T1, AVCO2 was correlated with AVO2 (R2 = 0.283, P = 0.0464) but not with ScVO2 (R2 = - 0.25, P = 0.079) and lactate (R2 = -0.07, P = 0.623). At T2, T3 and T4, AVCO2 was correlated with AVO2 (R2 = 0.338,0.440 & 0.318, P = 0.0162, 0.0013, and 0.024), ScVO2 (R2 = - 0.344, - 0.488, and -0.366; P = 0.0143, <0.0001, and 0.017), and lactate (R2 = 0.305, 0.467 and 0.607; P = 0.0314, 0.00062 and <0.0001). AVCO2 was negatively correlated with ScVO2. No correlation observed between admission AVCO2 and mechanical ventilation duration. Two nonsurvivors had higher value of admission AVCO2 compared to survivors. Conclusion: AVCO2 is correlated with other CO surrogates like AVO2, ScVO2, and lactate in pediatric patients undergoing ICR for TOF.

Assessment of the effect of two regimens of milrinone infusion in paediatric patients with pulmonary artery hypertension undergoing corrective cardiac procedure: A prospective observational study.

Background: The aim of the study was to compare the effect of two different regimens of milrinone in pediatric patients with pulmonary artery hypertension (PAH) undergoing corrective procedure. Materials and Methods: This randomized prospective study included 100 pediatric patients undergoing corrective cardiac surgeries. Group E: Milrinone was started as infusion 0.5 µg/kg/min without a loading dose after induction of anesthesia and continued as infusion 0.5-0.75 µg/kg/min in the pediatric cardiac surgical intensive care unit (PSICU). Group L: Milrinone was started as a loading dose 50 µg/kg over 10 min before weaning from cardiopulmonary bypass (CPB) followed by infusion 0.5-0.75 µg/kg/min in the PSICU. We compared heart rate, mean arterial blood pressure, central venous pressure, cardiac index (CI), mean pulmonary arterial pressure (MPAP), serum lactate level, urine output, vasoactive inotropic score, mechanical ventilation duration, and intensive care unit (ICU)- and hospital length of stay between the groups. Results: There was an increase in mean arterial blood pressure, CI, and urine output in Group E compared to Group L (P < 0.05). MPAP, serum lactate level, and requirement of inotropes and vasopressors were lower in Group E compared to Group L (P < 0.05). Mechanical ventilation duration, ICU, and hospital length of stay were shorter in Group E than Group L (P < 0.05). Conclusions: Early use of milrinone in patients with PAH undergoing corrective cardiac surgeries improved CI and mean arterial pressure, decreased MPAP, improved urine output, decreased serum lactate level, and decreased requirement of inotropes and vasopressors after weaning from CPB compared to the milrinone bolus group.

A novel lung recruitment technique in pediatric patients with congenital heart diseases: A case series.

Background: Lung recruitment techniques are employed to help in improvement of pulmonary mechanics, facilitate early weaning, and shorten the duration of mechanical ventilation. We are reporting a novel lung recruitment technique employed in four children with left lung atelectasis, who underwent corrective surgery for congenital heart disease. Materials and Methods: From January 2020 to March 2021, four pediatric cardiac patients having left lung atelectasis, undergoing corrective surgery were subjected to lung recruitment technique and had elective endobronchial intubation and suctioning with chest physiotherapy in the form of vibration and percussion. This was done along with intermittent ventilation with 100% oxygen. Results: Successful recruitment of lung segments and clearance of atelectasis were confirmed by auscultation and chest X-ray in all four patients. All the cases were successfully weaned off the ventilator within 24-48 h. One patient had an opposite lung collapse after extubation, which was managed conservatively with chest physiotherapy. Another patient had bradycardia and desaturation during the procedure, which was improved after withdrawing the tube and instituting two lung ventilation with 100% oxygen. Conclusions: This novel lung recruitment technique helps in recruitment of collapsed lung segments and thus helps in early weaning and shortens the duration of mechanical ventilation.

Nephrocalcinosis in a patient with extrapulmonary tuberculosis - A rare entity.

Nephrocalcinosis is a rare condition in clinical practice where there is an increased renal deposition of calcium. Varied causes of this condition have been given in literature, and tuberculosis (TB) has been an important one. Hypercalcemia is a known complication of granulomatous diseases. We report a rare case explicitly showing relationship of extrapulmonary (genitourinary) TB with nephrocalcinosis.