Arrest Outcome Consortium Registry Analysis [AOCRA 2022]: Outcome Statistics of Cardiac Arrest in Tertiary Care Hospitals in India, Analysis of Five Year Data of Indian Online Cardiac Arrest Registry, www.aocregistry.com.

Aim and background: To publish data with outcome statistics from our online cardiac arrest (CA) outcome consortium (AOC) online registry. Materials and methods: Data on cardiac arrest (CA) from tertiary care hospitals were collected on the AOC registry online portal from January 2017 to May 2022. Survival endpoints from cardiac arrest events like ROSC, and survival at hospital discharge with neurological status at discharge were analyzed and presented. Studies of demographics, the association of outcome with age, gender, bystander CPR, low and no flow times, and admission lactate were also done along with suitable statistical analysis. Results: Out of 2,235 CA, 2,121 received CPR (1,998 IHCA, 123 Out of hospital Cardiac Arrest (OHCA)) as 114 were DNR. The males-female ratio was 70:30. Average age at arrest was 58.7 years. 26% OHCA received bystander CPR but survival advantage was not significant. (with 16%, without 14% p = 0.78). Asystole (67.7%), Pulseless Electrical Activity (PEA) (25.6%), and VF/pVT (6.7%) as first rhythm significantly influence survival (4.9, 8.6 and 39.4%: p < 0.001) ROSC was achieved in 355 (16.7%), with 173 (8.2%) alive and 141 (6.6%) having good (CPC ≤ 2) neurological state at discharge. At discharge, survival as well as CPC ≤ 2 outcomes were significantly better in females. On multivariate regression analysis, first rhythm and low flow time influence survival at discharge. Admission lactate (available only in 102 OHCA) was lower in survivors than non-survivors 10.3 vs 11.5 mmol/L but the difference was not statistically significant (p = 0.397]. Conclusion: Data from our AOC registry shows poor overall survival from CA. The Female gender had a higher survival rate. Ventricular Fibrillation/Pulseless Ventricular Tachycardia (VF/pVT) as first rhythm and low flow time influence the survival to discharge (CTRI/2022/11/047140). How to cite this article: Clerk AM, Patel K, Shah BA, Prajapati D, Shah RJ, Rachhadia J, et al. Arrest Outcome Consortium Registry Analysis [AOCRA 2022]: Outcome Statistics of Cardiac Arrest in Tertiary Care Hospitals in India, Analysis of Five Year Data of Indian Online Cardiac Arrest Registry, www.aocregistry.com. Indian J Crit Care Med 2023;27(5):322-329.

Effect of Goal-directed Hemodynamic Therapy in Postcardiac Surgery Patients.

BACKGROUND AND AIMS: Early goal-directed therapy (EGDT) provides preset goals to be achieved by intravenous fluid therapy and inotropic therapy with earliest detection of change in the hemodynamic profile. Improved outcome in cardiac surgery patients has been shown by perioperative volume optimization, while postoperative intensive care unit (ICU) stay can be decreased by improving oxygen delivery. Our aim of this study was to study the outcome of EGDT in patients undergoing elective cardiac surgery. MATERIALS AND METHODS: This is a prospective single institute study involving a total of 478 patients. Patients were divided into group I, who received standard hospital care, and group II, who received EGDT. Postoperatively, patients were observed in ICU for 72 hours. Hemodynamics, laboratory data, fluid bolus, inotrope score, complication, ventilatory time, and mortality data were collected. RESULTS: Postoperative ventilatory period (11.12 ± 10.11 vs 9.45 ± 8.87, p = 0.0719) and frequency of change in inotropes (1.900 ± 0.9 vs 1.19 ± 0.61, p = 0.0717) were lower in group II. Frequency of crystalloid boluses (1.33 ± 0.65 vs 1.75 ± 1.09, p = 0.0126), and quantity of packed cell volume (PCV) used (1.63 ± 1.03 vs 2.04 ± 1.42, p = 0.0364) were highly significant in group II. Use of colloids was higher in group II and was statistically significant (1.98 ± 1.99 vs 3.05 ± 2.17, p = 0.0012). The acute kidney injury (AKI) rate was (58 (23.10%) vs 30 (13.21%), p = 0.007) lower and statistically significant (p = 0.007) in group II. CONCLUSION: Early goal-directed therapy reduces the postoperative ventilatory period, frequency of changes in inotropes, and incidence of AKI, and decreases ventilation hours, number of times inotropes changed, and AKI. HOW TO CITE THIS ARTICLE: Patel H, Parikh N, Shah R, Patel R, Thosani R, Shah P, et al. Effect of Goal-directed Hemodynamic Therapy in Postcardiac Surgery Patients. Indian J Crit Care Med 2020;24(5):321-326.

Anomalous origin of a pulmonary artery in a teenager with tetralogy of Fallot with associated double aortic arch and coronary arteriovenous fistula.

We report the case of a 14-year-old female who had tetralogy of Fallot along with anomalous origin of the left pulmonary artery from the ascending aorta with co-dominant double aortic arch forming a complete vascular ring compressing the oesophagus along with a left main coronary artery to right ventricular outflow tract fistula. She underwent surgical correction without conduit placement.

Does It Matter: Total Hip Arthroplasty or Lumbar Spinal Fusion First? Preoperative Sagittal Spinopelvic Measurements Guide Patient-Specific Surgical Strategies in Patients Requiring Both.

BACKGROUND: In patients requiring both total hip arthroplasty (THA) and lumbar spinal fusion (LSF), consideration of preoperative sagittal spinopelvic measurements can aid in the prediction of postfusion compensatory changes in pelvic tilt (PT) and inform adjustments to traditional THA cup anteversion. This study aims to identify relationships between spinopelvic measurements and post-THA hip instability and to determine if procedure order reveals a difference in hip dislocation rate. METHODS: Patients at a single practice site who received both THA and LSF between 2005 and 2015 (292: 158 = LSF prior to THA, 134 = THA prior to LSF) were retrospectively reviewed for incidents of THA instability. Those with complete radiograph series (89) had their sagittal (standing) spinopelvic profiles measured preoperatively, immediately postoperatively, and 3 months, 6 months, 1 year, 1.5 years, and 2 years postoperatively. Measured parameters included lumbar lordosis (LL), pelvic incidence (PI), PT, and sacral slope (SS). RESULTS: No significant differences in dislocation rates between operative order groups were elicited (7/73 LSF first, 4/62 THA first; Z = 0.664, P = .509). Compared to nondislocators, dislocators had lower LL (-10.9) and SS (-7.8), and higher PT (+4.3) and PI-LL (+7.3). Additional risk factors for dislocation included sacral fusion (relative risk [RR] = 3.0) and revision fusion (RR = 2.7) . Predictive power of the model generated through multiple regression to characterize individual profiles of post-LSF PT compensation based on perioperative measurements was most significant at 1 year (R2 = 0.565, F = 0.000456, P = .028) and 2 years (R2 = 0.741, F = 0.031, P = .001) postoperatively. CONCLUSION: In performing THA after LSF, it is theoretically ideal to proceed with THA at a postfusion interval of at least 1 year, beyond which further compensatory PT change is minimal. However, the order of surgical procedure revealed no statistical difference in hip instability rates. In cases characterized by large PI-LL mismatch (larger or less predictable compensation profiles) or large SS or LL loss (considerably atypical muscle recruitment), consideration of full functional anteversion range between sitting and standing positions to account for abnormalities not appreciated with standing radiographic assessment alone may be warranted.

Effect of Red Blood Cell Storage Duration on Outcome After Paediatric Cardiac Surgery: A Prospective Observational Study.

BACKGROUND: Retrospective reviews have found the use of stored packed red blood cells (PRBCs) in priming to be associated with increased risk of postoperative complications. The purpose of study was to prospectively investigate the influence of duration of storage of PRBCs used in priming the cardiopulmonary bypass (CPB) circuit on the metabolic profile of the patients, and postoperative outcome after paediatric cardiac surgery. METHODS: Between January 2015 and December 2015, 198 consecutive children operated for cardiac surgery using CPB and received blood for priming the circuit were included. Patients were divided into two groups based on the duration of storage of the blood, newer PRBCs group who received blood stored for ≤14days and the older PRBCs group who received blood stored for >14 days. RESULTS: Mean duration of blood storage used for priming in newer PRBCs blood group (n=103) was 8.4±3.7days while it was 21.9±4.5days in older PRBCs group (n=95). Metabolic parameters of the PRBCs improved to physiological limits in both the groups after initiation of CPB. Postoperative hepatic, pulmonary, haematological complications, sepsis and multi-organ failure were more in the old PRBCs group. However, the difference was not significant. Similarly, there was no significant difference in incidence of prolonged mechanical ventilation, intensive care unit stay and hospital stay and mortality between the two groups. CONCLUSIONS: Metabolic parameters of the stored blood become normal after initiation of CPB irrespective of duration of storage. In paediatric patients without significant co-morbidity, undergoing cardiac surgery, transfusion of washed stored blood up to 28days in CPB priming is safe especially if lesser amount of transfusion is required.

Alarmingly High Rate of Implant Fractures in One Modular Femoral Stem Design: A Comparison of Two Implants.

BACKGROUND: Reports of implant fracture at the modular junction have been seen in modular neck designs, stem-sleeve modular femoral stems, and diaphyseal engaging bi-body modular stems. To date, however, there has never been a direct comparison between 2 different implant designs from the same modular family. The purpose of this study is to compare the rate of implant failure of 2 such stem-sleeve modular femoral stem designs, the S-ROM and Emperion, to further identify factors which increase the risk of this mode of failure. METHODS: A retrospective, single surgeon, review of our institutional database was performed to compare the 2 groups of patients. RESULTS: A total of 1168 total hip arthroplasty procedures were included in our analysis, 547 (47%) with Emperion and 621 (53%) with S-ROM. Eight (1.5%) fractures in 7 patients occurred in the Emperion group compared to 1 (0.2%) fracture in the S-ROM group (P = .015). CONCLUSION: The precise cause of the stem fractures in our study remains unknown and is likely multifactorial. Given the unexpectedly high rate of catastrophic implant failures in the form of stem fracture at the stem-sleeve junction, we recommend more judicious use of modularity in primary total hip arthroplasty.

Total Knee Arthroplasty in Obesity: In-Hospital Outcomes and National Trends.

BACKGROUND: Both the prevalence of obesity and the utilization rate of total knee arthroplasty are increasing. The rate and proportion of total knee arthroplasty (TKA) performed in the setting of obesity/morbid obesity is increasing significantly over time. METHODS: Using International Classification of Diseases-Ninth Revision codes, we searched the National Hospitals Discharge Survey national database for patients admitted for primary TKA between 2001 and 2010. We then used International Classification of Diseases-Ninth Revision codes for obesity (body mass index = 30-40 kg/m2) and morbid obesity (body mass index, ≥ 40 kg/m2) to select the obese cohorts. RESULTS: We found 29,694 nonobese, 2645 obese, and 1150 morbidly obese patients. There was an increase in each group over time. The rate of obesity/morbid obesity was strongly correlated with time. Obese and morbidly obese patients were more likely to be younger, female, diabetic, and have Medicaid than nonobese patients. Obese and morbidly obese patients had shorter hospital stays and higher home discharge rates than nonobese patients. Obese and morbidly obese patients had lower transfusion rates, shorter hospital stays, and no increase in inpatient wound infection or venous thromboembolic complications than nonobese patients. The Midwest region saw a greater burden of obese TKA patients. CONCLUSION: With the right measures and precautions, satisfactory inhospital outcomes are possible in the obese patient after primary TKA. A limitation of this study is short inhospital stay of the index procedure as complications may present later after discharge.

National trends and in hospital outcomes for total hip arthroplasty in avascular necrosis in the United States.

PURPOSE: While a majority of total hip arthroplasty (THA) is performed for osteoarthritis (OA), a significant portion is performed in the setting of avascular necrosis (AVN). The purpose of this study is to evaluate recent trends, patient demographics, and in hospital outcomes for primary THA in the setting of AVN in the United States. METHODS: The National Hospital Discharge Survey database was searched for patients admitted to US hospitals after a primary THA for the years 2001-2010. Patients were then separated into two groups by ICD-9 diagnosis codes for OA and AVN. RESULTS: The rates of THA for AVN (r = 0.65) and THA for OA (r = 0.82) both demonstrated a positive correlation with time. The mean patient age of the AVN group was significantly lower (56.9 vs 65.9 years, p < 0.01). Men accounted for 51.9 % of the AVN group and 43.0 % of the OA group (p < 0.01). The AVN group had a significantly higher percentage of African Americans (11.2 % vs 5.4 %, p < 0.01) when compared to the OA group. The AVN group had a higher rate of myocardial infarction (0.3 % vs 0.07 %, p = 0.0163) and a higher average number of medical co-morbidities (5.16 vs 4.77, p < 0.01). CONCLUSIONS: Patients undergoing THA for AVN were more likely to be younger, male, African American, have more medical co-morbidities, and more likely to have a myocardial infarction than those with OA. While the number of primary THAs performed for AVN in the United States has increased over the past ten years, the rate of primary THA for OA increased at a much more rapid rate.

Evaluation of the 3-dimensional, weight-bearing orientation of the normal adult knee.

The purpose of this study was to use 3-dimensional, weight-bearing images corrected for rotation to establish normative data of limb alignment and joint line orientation in asymptomatic, adult knees. One hundred adults (200 lower extremities) were recruited to receive weight-bearing, simultaneous biplanar imaging of both lower extremities. Multiple radiographic parameters were measured from 3D images, corrected for limb rotation. 70.0% of knees were in neutral, 19.5% in varus, and 10.5% in valgus overall alignment. Only 31 % of knees possessed both a neutral mechanical axis and the absence of joint line obliquity. There was substantial agreement between the 2D and 3D images for overall mechanical alignment (κ = 0.77), but only a moderate agreement for joint line obliquity (κ = 0.58). A substantial portion of asymptomatic adults possess either a varus or valgus mechanical alignment and joint line obliquity.

Ventral aorta repair for retroesophageal circumflex aortic arch in an adult.

We present the surgical management of an adult patient with circumflex aortic arch (CAA). We performed a ventral aorta repair with transposition of the left subclavian artery (LSCA) and resection of the arch. The usefulness of sternotomy and cardiopulmonary bypass in the management of these patients is described.

Demonstration of saw blade accuracy and excursion: a cadaveric comparison study of blade types used in total knee arthroplasty.

In total knee arthroplasty, outcomes partly depend on accurate osteotomies and integrity of stabilizing structures. We compared accuracy and excursion between a conventional and an oscillating tip saw blade. Two sets of osteotomies were made on cadaveric knees. Bi-planar accuracy was compared using computer navigation, and excursion was compared using methylene blue. Wilcoxon-Mann-Whitney testing demonstrated no significant difference in blade accuracy (p=0.35). Blades were within 0.5 degrees of neutral coronally and 2.0 degrees sagittally. The oscillating tip blade demonstrated less dye markings on the surrounding tissues. Accurate osteotomies and soft tissue protection are critical to successful arthroplasties. Although comparative accuracy was equal, the oscillating tip blade exhibited less excursion displaying potential for less iatrogenic soft tissue injuries leading to catastrophic failure.

Computer-assisted total knee arthroplasty for significant tibial deformities.

Computer-assisted total knee arthroplasty has been demonstrated to provide reproducible limb mechanical alignment within 3° from the neutral mechanical axis. However, restoring proper implant and extremity alignment remains a significant challenge with proximal tibial deficiencies. In this prospective study, we describe the use of computer navigation to quantify the amount of bone loss on the medial or lateral tibial plateau and the use of these data to assess the need for augmentation with metallic tibial wedges. In this study, we demonstrate that computer-assisted total knee arthroplasty in patients with significant tibial deformities can accurately measure severe tibial deformities, predict tibial augment thickness, and provide excellent mechanical alignment and restore the joint line without excessive bony resection, repeated osteotomies, and repeated augment trialing.

Formulation development of carvedilol compression coated tablet.

PURPOSE: The aim of present research was to produce carvedilol compression coated tablet to provide biphasic drug release. METHOD: A compressed coated tablet made of a sustained release core tablet and an immediate release coat tablet. Both the core and the coat contained carvedilol. The sustained release effect was achieved with polymers (HPMC K4M and PEO WSR 205) to modulate the release of the drug. The powder blends for core and coat tablets were evaluated for angle of repose, bulk density, compressibility index, and drug content. Compressed coated tablets were evaluated for thickness, diameter, weight variation test, drug content, hardness, friability, disintegration and in vitro release studies. RESULT: The powder blends showed satisfactory flow properties, compressibility, drug content and all the tablet formulations showed acceptable pharmaco-technical properties. Carvedilol contained in the fast releasing component was released within 3 min, whereas the drug in the core tablet was released at different times up to 24 h, depending on the composition of the matrix tablet. The mechanism of drug release was fickian diffusion or anomalous behavior. DISCUSSION: Batch F7, containing 10 mg PEO WSR 205 and 5 mg HPMC K4M, showed maximum similarity with theoretical profile and zero order drug release kinetic.

Failure to wean off after a routine total anomalous pulmonary venous connection operation: An uncommon association.

A 6-month-old infant was operated on for supracardiac total anomalous pulmonary venous connection (TAPVC) with usual anatomy. The vertical vein was ligated. Weaning from bypass was attempted twice but was unsuccessful. Coronary sinus atresia was suspected and identified on the opening of the right atrium. A smooth postoperative course occurred after unroofing the coronary sinus. Coronary sinus atresia should be remembered as an uncommon association with TAPVC.

Total hip arthroplasty in a patient with myelomeningocele.

The pathophysiology of hip subluxation and advanced arthritic changes in patients with myelomeningocele is usually due to a muscle imbalance between intact hip flexor and adductor muscles and weak gluteal and abductor muscles. Operative options include resection arthroplasty, hip arthrodesis, and total hip arthroplasty (THA). Each option has been reported to be fraught with complications. Previous reports of THA in these patients have largely been unsuccessful with catastrophic failures characterized by instability and early loosening. We report a case of a 46-year-old woman with L4 level myelomeningocele with a neurogenic dysplastic advanced arthritic left hip with subluxation. She underwent a successful THA with unique combination of implants that allowed for maximal options in this challenging clinical situation.

Clinical profile and surgical outcome of pars plana vitrectomy in non-diabetic vitreous hemorrhage.

Background: Spontaneous vitreous hemorrhage is one of the common causes of ocular emergency. There are very few prospective studies on the clinical profile and surgical outcomes for patients with dense vitreous hemorrhage caused by non-diabetic and non-traumatic till date to our knowledge. Objectives: This study was conducted to better understand the etiologies, clinical profile, surgical outcome, and visual prognosis following pars plana vitrectomy for dense vitreous hemorrhage in adults with non-traumatic and non-diabetic retinopathy. Design: This was a prospective interventional study. Methods: This study was conducted in Mechi Eye Hospital (Birtamod, Nepal) from October 2018 to September 2019. All consecutive cases, 46 eyes of 46 patients, with vitreous hemorrhage that underwent vitrectomy were included in our study. There were 14 (30.4%) female and 32 (69.6%) male patients, and the average age at presentation was 43.74 ± 16.19 (17-84) years. The success rate of surgery in terms of visual outcome was evaluated. Results: The most common cause of vitreous hemorrhage was retinal vasculitis with fibrovascular changes and vascular sheathing 19 (41%). The indication of vitrectomy on patient demand was 20 (43.5%). Success rate of surgery in terms of visual outcome (functional outcome) was defined as final visual acuity of >6/60 which was 86.9%. Conclusion: The most common cause of spontaneous vitreous hemorrhage in our study was retinal vasculitis with fibrovascular changes and vascular sheathing. Vitrectomy has a good surgical outcome for spontaneous vitreous hemorrhage in terms of visual outcome (functional outcome) unless guarded by other factors like chorioretinal atrophy followed by optic atrophy and epiretinal membrane.

Clinical Phenotype of FASTKD2 Mutation.

Mitochondrial disorders (MIDs) are frequently multisystemic in nature and cause significant morbidity and mortality. Accurate assessment of mitochondrial disease prevalence has been difficult in the past. Primary MIDs are due to mutations in mitochondrial DNA (mtDNA) or nuclear DNA (nDNA)-located genes. Here we report cases of two siblings who presented to the pediatric emergency department with status epilepticus. Initially, the elder sibling was treated for metabolic encephalopathy and viral encephalitis, during his admission to the hospital. On treatment with multiple antiepileptic drugs, the status epilepticus subsided. A provisional diagnosis of mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes was made. Magnetic resonance imaging showed diffusion restriction in the left temporal lobe, insular cortex, and left lentiform nucleus, which completely resolved on follow-up after 1 month. His sudden demise in May 2019 due to status epilepticus, and a similar case presentation in his younger sibling, prompted us to do a genetic analysis test. The exome sequence revealed FASTKD2 mutation, a rare variant. This case report helps in increasing the awareness among the clinicians about the clinical presentation of FASTKD2 mutation case.

Subretinal Cysticercosis in a Challenging Case: A Case Report.

Ocular cysticercosis occurs rarely and may involve various parts of the eye including subretinal space. We report a case of a 42 years-old female with diminution of vision in the right eye for one month and no vision in the left eye for 10 years. Best corrected visual acuity in the right eye was 5/60. Fundus examination showed whitish round elevated cystic mass temporal to the macula. It was confirmed as a subretinal cyst by Brightness scan and Magnetic Resonance Imaging. The subretinal cyst was removed in toto by pars plana vitrectomy followed by histopathological examination of the cyst which confirmed the diagnosis of cysticercosis. This case report highlights the importance of early diagnosis of subretinal cysticercosis which could threaten the vision in a one-eyed patient. Pars plana vitrectomy could be an effective method for subretinal cyst removal in toto even in a challenging case.

Anesthetic management of right brachiocephalic artery aneurysm causing tracheal compression.

The airway compression poses a challenge for the anesthesiologist in airway management during aneurysm repair surgery.

Survivorship of the Modular Femoral Revision Stem.

The geriatric population represents a rapidly growing segment of society with prolonged life expectancies and more active lifestyles. Many of these patients have already undergone primary total hip arthroplasty (THA) and are presenting with aseptic loosening, polyethylene wear, osteolysis, or periprosthetic fractures. Therefore, the demand for hip revision procedures is expected to grow. Currently, there are many modular implant options available for use in complicated revision THA. Early results of modular femoral revision systems are promising for the treatment of the deficient femur in complex revision THA. The objective of this study was to evaluate component survivorship of a modular femoral revision system in revision THA. A retrospective review was conducted using electronic health records of patients who underwent revision THA performed by 1 of 3 surgeon investigators from 2010 through 2014. The authors included all patients who underwent a revision THA using a specific modular femoral revision system. The authors evaluated component survivorship and time to re-revision THA. Fifty-one revision THAs were included. Seven patients required a second revision THA (13.7%; 95% confidence interval, 4%-23%). Mean time to re-revision THA was 4.88±3.9 months. Kaplan-Meier survivorship using re-revision for any reason was 86.3% at 60 months. This study showed excellent component survivorship of the specific modular femoral revision system in revision THA. [Orthopedics. 2019; 42(5):294-298.].