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   Table of Contents - Current issue
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October-December 2018
Volume 21 | Issue 4
Page Nos. 349-469

Online since Wednesday, October 17, 2018

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EDITORIAL  

Statistical literacy for healthcare professionals: Why is it important? p. 349
Rakesh Aggarwal
DOI:10.4103/aca.ACA_177_18  PMID:30333326
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REVIEW ARTICLES Top

Facilitating noncardiac surgery for the patient with left ventricular assist device: A guide for the anesthesiologist Highly accessed article p. 351
Kai-Yin Hwang, Nian-Chih Hwang
DOI:10.4103/aca.ACA_239_17  PMID:30333327
The introduction of left ventricular assist device (LVAD) has improved survival rates for patients with end-stage heart failure. Two categories of VADs exist: one generates pulsatile flow and the other produces nonpulsatile continuous flow. Survival is better for patients with continuous-flow LVADs. With improved survival, more of such patients now present for noncardiac surgery (NCS). This review, written for the general anesthesiologists, addresses the perioperative considerations when the patient undergoes NCS. For best outcomes, a multidisciplinary approach is essential in perioperative management of the patient.
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The efficacy of different modes of analgesia in postoperative pain management and early mobilization in postoperative cardiac surgical patients: A systematic review Highly accessed article p. 363
Brenda Nachiyunde, Louisa Lam
DOI:10.4103/aca.ACA_186_17  PMID:30333328
Cardiac surgery induces severe postoperative pain and impairment of pulmonary function, increases the length of stay (LOS) in hospital, and increases mortality and morbidity; therefore, evaluation of the evidence is needed to assess the comparative benefits of different techniques of pain management, to guide clinical practice, and to identify areas of further research. A systematic search of the Cochrane Central Register of Controlled Trials, DARE database, Joanna Briggs Institute, Google scholar, PUBMED, MEDLINE, EMBASE, Academic OneFile, SCOPUS, and Academic search premier was conducted retrieving 1875 articles. This was for pain management postcardiac surgery in intensive care. Four hundred and seventy-one article titles and 266 abstracts screened, 52 full text articles retrieved for critical appraisal, and ten studies were included including 511 patients. Postoperative pain (patient reported), complications, and LOS in intensive care and the hospital were evaluated. Anesthetic infiltrations and intercostal or parasternal blocks are recommended the immediate postoperative period (4–6 h), and patient-controlled analgesia (PCA) and local subcutaneous anesthetic infusions are recommended immediate postoperative and 24–72 h postcardiac surgery. However, the use of mixed techniques, that is, PCA with opioids and local anesthetic subcutaneous infusions might be the way to go in pain management postcardiac surgery to avoid oversedation and severe nausea and vomiting from the narcotics. Adequate studies in the use of ketamine for pain management postcardiac surgery need to be done and it should be used cautiously.
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ORIGINAL ARTICLES Top

Tissue oximetry during cardiac surgery and in the cardiac intensive care unit: A prospective observational trial Highly accessed article p. 371
Benjamin J Heller, Pranav Deshpande, Joshua A Heller, Patrick McCormick, Hung-Mo Lin, Ruiqi Huang, Gregory Fischer, Menachem M Weiner
DOI:10.4103/aca.ACA_105_17  PMID:30333329
Background: Cerebral oximetry using near-infrared spectroscopy (NIRS) has well-documented benefits during cardiac surgery. The authors tested the hypothesis that NIRS technology can be used at other sites as a tissue oximeter during cardiac surgery and in the Intensive Care Unit (ICU). Aims: To establish feasibility of monitoring tissue oximetry during and after cardiac surgery, to examine the correlations between tissue oximetry values and cerebral oximetry values, and to examine correlations between oximetry values and mean arterial pressure (MAP) in order to test whether cerebral oximetry can be used as an index organ. Settings and Designs: A large, single-center tertiary care university hospital prospective observational trial of 31 patients undergoing cardiac surgery with cardiopulmonary bypass was conducted. Materials and Methods: Oximetry stickers were applied to both sides of the forehead, the nonarterial line forearm, and the skin above one paraspinal muscle. Data were collected from before anesthesia induction until extubation or for at least 24 h in patients who remained intubated. Statistical Analysis: Categorical variables were evaluated with Chi-square or Fisher's exact tests, while Wilcoxon rank-sum tests or student's t-tests were used for continuous variables. Results: The correlation between cerebral oximetry values and back oximetry values ranged from r = 0.37 to 0.40. The correlation between cerebral oximetry values and forearm oximetry values ranged from r = 0.11 to 0.13. None of the sites correlated with MAP. Conclusions: Tissue oximetry at the paraspinal muscle correlates with cerebral oximetry values while at the arm does not. Further research is needed to evaluate the role of tissue oximetry on outcomes such as acute renal failure, prolonged need for mechanical ventilation, stroke, vascular ischemic complications, prolonged ICU and hospital length of stay, and mortality in cardiac surgery.
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Preoperative predictors of poor laryngoscope views in pediatric population undergoing cardiac catheterization p. 376
Madan Mohan Maddali, Haifa Mohammed Ali Al-Zaabi, Is'haq Said Salim Al-Aamri, Nishant Ram Arora, Sathiya Murthi Panchatcharam
DOI:10.4103/aca.ACA_47_18  PMID:30333330
Background: The primary objective of this study was to identify pre-anesthetic airway assessment parameters that would predict Cormack and Lehane grade III and IV laryngoscopy views in pediatric patients undergoing cardiac catheterization procedures. The secondary end points were to identify factors that would contribute to difficult laryngoscope views in this subset of patients. Settings and Design: Prospective observational study performed at a single tertiary cardiac care center. Materials and Methods: 199 children below 5 years of age undergoing elective cardiac catheterization were included. Pre-anesthetic airway assessment was done by modified Mallampati grading, lower lip to chin distance [LCD], tragus to mouth angle [TMA], thyromental distance [TMD], neck circumference [NC], and the ratio of height to thyromental distance [RHTMD]. Demographic data including American Society of Anesthesiologists physical status [ASA PS] were recorded for each child. Receiver Operating Characteristic curves were plotted and Areas Under the Curve were measured to identify the best cut off values for each of the airway evaluation method that would predict poor laryngoscopy views as well as assess their accuracy in doing so. Results: LCD, TMD and low body mass index were found to have good sensitivity, specificity and accuracy in predicting Grade III and IV laryngoscope views. ASA PS grade III and above patients had a significantly higher incidence of poor laryngoscope visualization. Conclusions: LCD, TMA, TMD, NC, RHTMD and BMI could all be used combinedly as screening tools during pre-anesthetic airway evaluation for predicting difficult laryngoscope views in children. Among these, LCD, TMD along with low body mass index might have better accuracy.
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Usefulness of ultrasound-guided measurement of minimal transverse diameter of subglottic airway in determining the endotracheal tube size in children with congenital heart disease: A prospective observational study p. 382
Rahul Pillai, Suresh Kumaran, L Jeyaseelan, Sajan P George, Raj Sahajanandan
DOI:10.4103/aca.ACA_220_17  PMID:30333331
Introduction: The search for an accurate and predictable method to estimate the endotracheal tube (ETT) size in pediatric population had led to derivation of many formulae. Of this, age-based formulae are the most commonly used. Studies have shown that minimal transverse diameter of subglottic airway (MTDSA) measurements using a high-frequency probe improves the success rate of predicting the airway diameter to about 90%. We did a prospective observational study using MTDSA as the criteria to select the size of ETT in children with congenital heart disease. Methods: In this prospective observational study, 51 children aged from 1 day to 5 years, scheduled for cardiac surgery, were enrolled for this study. The ETT size was guided solely based on the MTDSA. Leak test was used to determine the best-fit ETT size. Results: Data from 49 patients were analyzed. Agreement between the ETT determined by MTDSA and that predicted by Cole's age-based formulas with the best-fit ETT size was analyzed using a Bland–Altman plot. Conclusion: Age-based formula showed poor correlation (27.5%) compared to MTDSA (87.8%) in predicting the best-fit ETT. We observed that pediatric patients with congenital heart disease need a larger sized ETT as compared to what was predicted by age-based formula. Using ultrasound MTDSA measurements to guide selection of ETT size is a safe and accurate method in pediatric cardiac population.
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Dreams content and emotional load in cardiac rehabilitation patients and their relation to anxiety and depression p. 388
Saeid Komasi, Ali Soroush, Habibolah Khazaie, Ali Zakiei, Mozhgan Saeidi
DOI:10.4103/aca.ACA_210_17  PMID:30333332
Background: The assessment of a dream and its mechanisms and functions may help us to percept cognitions, emotions, and complex behaviors of patients. Hence, the present study aimed to assess (i) the rate of perceived dream and its emotional load and content and (ii) the relationship between functions of dream with anxiety and depression. Methods: In this cross-sectional study, 167 cardiac patients who had undergone rehabilitation in the western part of Iran were assessed during May–October 2016. Research instrument included Beck depression inventory, Beck anxiety inventory, Schredl's dream emotions manual, and content analysis of dreams manual. The findings were analyzed through Pearson's correlative coefficient and multiple regression analysis. Results: The mean age of participants (66.5% men) was 59.1 ± 9 years. The results indicated that the emotional content of patients' dreams included happiness (49.1%), distress (43.1%), sad (13.8%), fear (13.2%), and anger (3%). Although women report more sad dreams than men (P = 0.026), there was no difference between them in terms of other components of dreams, anxiety, and depression. Regression models showed that anxiety and depression were significantly able to predict perceived dream rates (P = 0.030) and emotionally negative dreams (P = 0.019). Conclusion: The increased rates of depression, especially anxiety, are related to increasing perceived dreams with negative and harmful emotional load. Regarding severity and negative content of dreams are reflexes of stressful emotional daily experiences, the management of experienced psychological symptoms such as depression and anxiety is concerned as an undeniable necessity.
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Is elevated blood glucose a marker of occult tissue hypoperfusion in off-pump coronary artery bypass grafting? p. 393
Soumi Das, Kakali Ghosh, Avijit Hazra, Chaitali Sen, Anupam Goswami
DOI:10.4103/aca.ACA_202_17  PMID:30333333
Context: Hyperglycemia has been found to occur during myocardial infarction and cardiac surgery even in nondiabetic patients. These being essentially stressful processes associated with hypoperfusion, we decided to find a possible relationship between the occurrence of global tissue hypoperfusion (GTH) and elevated blood glucose level in adult nondiabetic patients undergoing elective off-pump coronary artery bypass grafting (CABG). Aims: This study aims to observe for the occurrence of global tissue hypoperfusion and its effect on blood glucose level and whether raised blood glucose level can be used as a marker for GTH. Design: Prospective, observational study. Settings: Cardiothoracic operation theater and intensive care unit of a tertiary care teaching hospital. Materials and Methods: The occurrence of global tissue hypoperfusion were detected with the help of combined markers of mixed venous oxygen saturation and arterial lactate level at various perioperative study points together with arterial blood glucose level. Blood glucose level compared between the patients with and without GTH. Statistical Analysis Used: Numerical variables were compared between groups by Student's t-test and categorical variables by Fisher's exact test. Two-tailed P ≤ 0.05 was considered for statistically significant. Results: The incidence of GTH was 67%. Blood glucose level was raised in patients with GTH at some study time points but with poor sensitivity and specificity values. Conclusions: Global tissue hypoperfusion is a common occurrence in even nondiabetic patients undergoing elective off-pump CABG. A relationship exists between rise in blood glucose level and global tissue hypoperfusion in such patients, although it cannot be viewed as marker of the same.
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Predictors and outcome of early extubation in infants postcardiac surgery: A single-center observational study p. 402
Shahzad Alam, Akunuri Shalini, Rajesh G Hegde, Rufaida Mazahir, Akanksha Jain
DOI:10.4103/aca.ACA_209_17  PMID:30333334
Objective: The objective of the current study was to evaluate the timing of first extubation and compare the outcome of patient extubated early with others; we also evaluated the predictors of early extubation in our cohort. Materials and Methods: This prospective cohort study included children <1 year of age undergoing surgery for congenital heart disease. Timing of first extubation was noted, and patients were dichotomized in the group taking 6 h after completion of surgery as cutoff for early extubation. The outcome of the patients extubated early was compared with those who required prolonged ventilation. Variables were compared between the groups, and predictors of early extubation were evaluated using multivariate logistic regression analysis. Results: One hundred and ninety-four (33.8%) patients were extubated early including 2 extubation in operating room and 406 (70.7%) were extubated within 24 h. Four (0.7%) patients died without extubation. No significant difference in mortality and reintubation was observed between groups. Patient extubated early had a significant lower incidence of sepsis (P = 0.003) and duration of Intensive Care Unit (ICU) stay (P = 0.000). Age <6 months, risk adjustment for congenital heart surgery category ≥3, cardiopulmonary bypass time ≥80 min, aortic cross-clamp time ≥ 60 min, and vasoactive-inotropic score >10 were independently associated with prolonged ventilation. Conclusion: Early extubation in infants postcardiac surgery lowers pediatric ICU stay and sepsis without increasing the risk of mortality or reintubation. Age more than 6 months, less complex of procedure, shorter surgery time, and lower inotropic requirement are independent predictors of early extubation.
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COMMENTARY Top

Predictors and outcome of early extubation in infants postcardiac surgery: A single-center observational study p. 407
Bhupesh Kumar, Ganesh Kumar Munirathinam
DOI:10.4103/aca.ACA_172_18  PMID:30333335
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ORIGINAL ARTICLES Top

Evaluation of local intra-pleural application of tranexamic acid on postoperative blood loss in lung decortication surgery, a prospective, randomized, double-blind, placebo-controlled study p. 409
Mohab M Sabry, Ayman A Sallam, Ahmed Said Elgebaly, Amr A Abdelwahab
DOI:10.4103/aca.ACA_231_17  PMID:30333336
Background: During decortication surgery, fibrous peel over the lung was removed to allow expansion of the lung and therefore, wide raw area was created with surface oozing. The phenomenon of fibrinolysis usually activated after such procedure, resulting in increasing the postoperative bleeding. Tranexamic acid is one of antifibrinolytic therapies that could be used topically and to targets directly the source of bleeding and reducing the local activation of the fibrinolytic process and consequently reducing the postoperative bleeding. Patients and Methods: A total of 70 patients underwent lung decortication surgery in Cardiothoracic Surgery Department at Tanta University Hospital from January 2015 to May 2017. Patients were randomly allocated into two groups, Group I (35 patients) receiving 3 g of tranexamic acid in 100 ml of saline solution and Group II (35 patients) receiving 100 ml of saline solution as placebo. At the end of the operation and before closing the chest, in both groups, drug or placebo solution was distributed locally all over the pleural cavity. Comparison between the groups was done regarding the amount of postoperative bleeding, postoperative hemoglobin in the first 24 and 48 h postoperatively, blood transfusion, Intensive Care Unit (ICU) stay, and hospital stay. Results: Both groups were comparable regarding demographic and surgical data. Group I patients had the significantly lesser amount of postoperative blood loss than Group II during the first postoperative 48 h, and hence, the need of postoperative blood transfusion was significantly lower in Group I with better postoperative hemoglobin level than Group II. However, there was no difference in overall ICU and hospital stay. Conclusion: The local intrapleural use of tranexamic acid after decortication surgery of the lung is safe and significantly reduces the amount of postoperative blood loss and in consequence reduces the amount of postoperative blood transfusion.
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A prospective, randomized, comparison study on effect of perioperative use of chloride liberal intravenous fluids versus chloride restricted intravenous fluids on postoperative acute kidney injury in patients undergoing off-pump coronary artery bypass grafting surgeries p. 413
K Bhaskaran, Ganapathy Arumugam, PV Vinay Kumar
DOI:10.4103/aca.ACA_230_17  PMID:30333337
Context and Aims: Off-pump coronary artery bypass graft (OPCABG) is a form of CABG surgery. It is performed without the use of cardiopulmonary bypass machine as a surgical treatment for coronary heart disease. Acute kidney injury (AKI) is one of the common postoperative complications of OPCABG. Previous studies suggest important differences related to intravenous fluid (IVF) chloride content and renal function. We hypothesize that perioperative use of chloride restricted IVFs may decrease incidence and severity of postoperative AKI in patients undergoing OPCABG. Methods: Six hundred patients were randomly divided into two groups of 300 each. In Group A (n = 300), chloride liberal IVFs, namely, hydroxyethyl starch (130/0.4) in 0.9% normal saline (Voluven), 0.9% normal saline, and Ringer's lactate were used for perioperative fluid management. In Group B (n = 300), chloride-restricted IVFs, namely, hydroxyethyl starch (130/0.4) in balanced colloid solution (Volulyte) and balanced salt crystalloid solution (PlasmaLyte A), were used for perioperative fluid management. Serum creatinine values were taken preoperatively, postoperatively at 24 h and at 48 h. Postoperative AKI was determined by AKI network (AKIN) criteria. Results: In Group A, 9.2% patients and in Group B 4.6% patients developed Stage-I AKI determined by AKIN criteria which was statistically significant (P < 0.05). Conclusion: Perioperative use of chloride restricted IVF was found to decrease incidence of postoperative AKI. The use of chloride liberal IVF was associated with hyperchloremic metabolic acidosis.
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Scales of measurement and presentation of statistical data p. 419
Prabhaker Mishra, CM Pandey, Uttam Singh, Anshul Gupta
DOI:10.4103/aca.ACA_131_18  PMID:30333338
Measurement scale is an important part of data collection, analysis, and presentation. In the data collection and data analysis, statistical tools differ from one data type to another. There are four types of variables, namely nominal, ordinal, discrete, and continuous, and their nature and application are different. Graphs are a common method to visually present and illustrate relationships in the data. There are several statistical diagrams available to present data sets. However, their use depends on our objectives and data types. We should use the appropriate diagram for the data set, which is very useful for easily and quickly communicating summaries and findings to the audience. In the present study, statistical data type and its presentation, which are used in the field of biomedical research, have been discussed.
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CASE REPORTS Top

Congenital combined atresia of the left main coronary with supravalvar aortic stenosis p. 423
Feridoun Sabzi, Aghighe Heidari, Reza Faraji
DOI:10.4103/aca.ACA_217_17  PMID:30333339
Congenital atresia of the left main coronary artery (LMCA) is an exceedingly rare phenomenon, and in the most of them, coronary artery bypass graft is required. We here describe a rare case of this anomaly that concomitantly was associated with supravalvar aortic stenosis and coronary–pulmonary fistula without the presence of conventional collateral circulation in a 16-year-old boy. The patient was admitted to our center with chest pain and dyspnea. Echocardiographic examinations showed supravalvar aortic stenosis with normal function of the aortic valve. Coronary angiography revealed atresia of LMCA with poorly developed left anterior descending coronary artery and well-developed circumflex coronary artery and diagonal artery that perfused by dominant and lengthy right coronary artery. The patient underwent coronary artery bypass grafting with repair of supravalvar aortic stenosis. The postoperative course was uneventful. The 6-month follow-up revealed normal diameter of the ascending aorta with symptomatic relief of preoperative chest complaint.
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Traumatic aortic dissection pseudoaneurysm with multiple entry: Role of transesophageal echocardiography p. 427
Kalla Krishna Prasad Gaurav, Bhupesh Kumar, Shyam K S Thingnam
DOI:10.4103/aca.ACA_218_17  PMID:30333340
Traumatic aortic dissection following sudden deceleration injury requires urgent treatment as it may result in formation of aneurysm that may expand or rupture leading to catastrophe. Confirmation of diagnosis of aortic dissection often requires contrast-enhanced computed tomography (CECT) or magnetic resonance imaging, which is time-consuming. Often, there is a significant time lag between the CECT chest and surgical intervention. Progression of aortic dissections may be missed on CECT chest, which would be done in the initial hours after injury. Transesophageal echocardiography (TEE) is equally efficient for the diagnosis of aortic dissection. It may also provide additional information that can be very useful for the management. We report the case of a descending thoracic aortic dissection where TEE plays a crucial role during the surgical management of the patient.
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Perioperative management of critical right ventricular inflow obstruction from right atrial rhabdomyoma p. 430
Rahul Norawat, Deepa Sarkar, Marc O Maybauer
DOI:10.4103/aca.ACA_233_17  PMID:30333341
Rhabdomyoma is the most common cardiac tumor in infancy and commonly located in the ventricles causing outflow obstruction or arrhythmias. We report a rare pediatric (7 month old) case of a right atrial rhabdomyoma presenting with severe cyanosis and low cardiac output from significant tricuspid inflow obstruction with right to left shunt across a stretched patent foramen ovale. We present an emergency cardiac surgery for right atrial tumor resection, and the management of separating the patient with failing right ventricle from cardiopulmonary bypass using a Glenn shunt, since extracorporeal membrane oxygenation (ECMO) or nitric oxide was not available.
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The value of institutional protocols and focused cardiac ultrasound during a case of ultramassive transfusion p. 433
Muhammad Salman Tahir Janjua, Shvetank Agarwal, Manuel R Castresana
DOI:10.4103/aca.ACA_49_18  PMID:30333342
A 53-year-old female was admitted to the emergency department with an exsanguinating bleed from the rectum which was of unclear origin. In what could be considered an ultramassive transfusion, 60 units packed red blood cells, 23 units fresh frozen plasma, 20 units platelets, 6 units cryoprecipitate, 30 L of crystalloids, 2 L of colloids, and 4 g of tranexamic acid were transfused over the course of 7 h. An arterio-enteric fistula was diagnosed and treated by an interventional radiologist. The patient recovered rapidly thereafter without any major neurologic, pulmonary, cardiac, or hematologic complications.
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Right atrial myxoma: Unusual location; uncommon association p. 437
Om Prakash Sanjeev, Soumya Sankar Nath, Deepak Malviya, Subhas Singh Rajput
DOI:10.4103/aca.ACA_130_17  PMID:30333343
We are presenting a case of the right atrial myxoma found in a case of rheumatic heart disease. During transthoracic echocardiography for the evaluation of a suspected rheumatic valvular heart disease, a diagnosis of severe mitral stenosis with severe mitral regurgitation with the right atrial thrombus was made. On transesophageal echocardiography, a pedunculated mass in the right atrium was confirmed. In the course of surgery, it was found that there is a tumor originating from the right atrial appendage (RAA) which was confused with clot on echocardiography. Rheumatic heart disease and myxomas have different etiopathogenesis, and this coexistence has not been reported. Further, right atrial myxoma arising out of RAA is also being reported for the first time.
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INTERESTING IMAGES Top

Unrecognized hyperlucent lesion on lateral film of chest X-Ray p. 440
Ankita Singh, Navneet Kumar Srivastva, Prabhat Tewari, Gauranga Majumdar
DOI:10.4103/aca.ACA_84_18  PMID:30333344
We report an interesting case of bulla right lung, incidently found during CABG surgery.
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Aortic regurgitation after chemoport catheter insertion: Diagnostic dilemma p. 442
Vijay Mohan Hanjoora, Gaurav Gupta, Monish S Raut
DOI:10.4103/aca.ACA_79_18  PMID:30333345
Catheter insertion in central vein can potentially cause accidental arterial injury. However it is very unusual to see such catheter in aorta causing aortic regurgitation. Pressure monitoring and Ultrasound guidance can reliably prevent accidental arterial puncture.
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Abdominal compartment syndrome after surgical repair of Type A aortic dissection p. 444
Fotini Ampatzidou, Athanasios Madesis, George Kechagioglou, George Drossos
DOI:10.4103/aca.ACA_247_17  PMID:30333346
Abdominal compartment syndrome is associated with severe dysfunction of intra-abdominal and intrathoracic organs. Medical therapy, with the goal of reducing intra-abdominal pressure, leads to improvement in organ perfusion.
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Watch out for left atrial roof thrombus p. 446
Amruta Shringarpure, Pushkar M Desai, Sanjeeta Umbarkar, Manjula Sarkar
DOI:10.4103/aca.ACA_43_18  PMID:30333347
Rheumatic mitral stenosis is often associated with thrombus formation in the left atrium (LA), especially in patients with atrial fibrillation. Although thrombus can occur anywhere within the LA, the most common site is the left atrial appendage. Therefore, it is important to carefully screen the entire LA during perioperative transesophageal echocardiography to exclude thrombus.
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ORIGINAL ARTICLE - JANAK MEHTA AWARD Top

Predictors of acute kidney injury in patients undergoing adult cardiac surgery p. 448
Sreja Gangadharan, KR Sundaram, Senthilvelan Vasudevan, B Ananthakrishnan, Rakhi Balachandran, Abraham Cherian, Praveen Kerala Varma, Luis Bakero Gracia, K Murukan, Ashish Madaiker, Rajesh Jose, Rakesh Seetharaman, Kirun Gopal, Sujatha Menon, M Thushara, Reshmi Liza Jose, G Deepak, Sudheer Babu Vanga, Aveek Jayant
DOI:10.4103/aca.ACA_21_18  PMID:30333348
Background: Acute kidney injury (AKI) after cardiac surgery (CS) is not uncommon and has serious effects on mortality and morbidity. A majority of patients suffer mild forms of AKI. There is a paucity of Indian data regarding this important complication after CS. Aims and Objectives: The primary objective was to study the incidence of AKI associated with CS in an Indian study population. Secondary objectives were to describe the risk factors associated with AKI-CS in our population and to generate outcome data in patients who suffer this complication. Methods: Serial patients (n = 400) presenting for adult CS (emergency/elective) at a tertiary referral care hospital in South India from August 2016 to November 2017 were included as the study individuals. The incidence of AKI-CS AKI network (AKIN criteria), risk factors associated with this condition and the outcomes following AKI-CS are described. Results: Out of 400, 37 (9.25%) patients developed AKI after CS. AKI associated with CS was associated with a mortality of 13.5% (no AKI group mortality 2.8%, P = 0.001 [P < 0.05]). When AKI was severe enough to need renal replacement therapy, the mortality increased to 75%. Patients with AKI had a mean hospital stay 16.92 ± 12.75 days which was comparatively longer than patients without AKI (14 ± 7.98 days). Recent acute coronary syndrome, postoperative atrial fibrillation, and systemic hypertension significantly predicted the onset of AKI-CS in our population. Conclusions: The overall incidence of AKI-CS was 9.25%. The incidence of AKI-CS requiring dialysis (Stage 3 AKIN) AKI-CS was lower (2%). However, mortality risks were disproportionately high in patients with AKIN Stage 3 AKI-CS (75%). There is a need for quality improvement in the care of patients with AKI-CS in its most severe forms since mortality risks posed by the development of Stage 3 AKIN AKI is higher than reported in other index populations from high resource settings.
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Early prediction of acute kidney injury using serum phosphorus as a biomarker in pediatric cardiac surgical patients p. 455
Vijitha Burra, PS Nagaraja, Naveen G Singh, V Prabhakar, N Manjunatha
DOI:10.4103/aca.ACA_14_18  PMID:30333349
Background: Acute kidney injury (AKI) is a strong predictor of morbidity and mortality after cardiac surgery. Lack of valid early biomarkers for predicting AKI has hampered the ability to take therapeutic measures for preventive cause. Hyperphosphatemia that occurs in AKI due to renal excretion defect was not studied in this context and could be simple marker of AKI. Therefore, we tested role of serum phosphorus in prediction of AKI as a biomarker after cardiac surgery in children. Methodology: We prospectively evaluated 51 children aged between 3 weeks and 12 years undergoing elective cardiac surgery. Serum creatinine and phosphorus were measured preoperatively and postoperatively at 24 and 48 h. As per the Kidney Disease Improving Global Outcomes criteria, patients were grouped into AKI and non-AKI on the basis of the development of AKI within 48 h postsurgery. The postoperative diagnostic performance of phosphorus thresholds was analyzed by the area under receiver operating characteristic curves (AUC-ROC). Results: From 51 children included, 10 developed AKI. In AKI group, serum phosphorus increased significantly from 4.47 ± 0.43 baseline to 6.29 ± 0.32 at 24 h postsurgery (P = 0.01) while serum creatinine increased from baseline 0.33 (0.24–0.46) to 0.49 (0.26–0.91) at 24 h which is statistically insignificant (P = 0.16). ROC analysis showed that serum phosphorus at 24 h, the AUC was 0.84 with sensitivity 0.75 and specificity 0.93 for a cutoff value of 6.4 mg/dl. Whereas serum phosphorus at 48 h, the AUC was 0.86 with sensitivity 66.67% and specificity 97.62% for a cutoff value of 5.4 mg/dl. Conclusion: Serum phosphorus can be an alternative biomarker as early as 24 h for early prediction of AKI in pediatric cardiac surgery.
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Is routine preoperative chest X-ray: An underutilized tool in asymptomatic patients! p. 460
Swati Jindal, Satinder Gombar, Kompal Jain
DOI:10.4103/aca.ACA_102_18  PMID:30333350
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On-table extubation following off-pump bidirectional cavopulmonary anastomosis: Two sides of the coin Highly accessed article p. 461
Rohan Magoon, Ira Dhawan, Neeti Makhija
DOI:10.4103/aca.ACA_31_18  PMID:30333351
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Missing swan ganz catheter p. 462
Monish S Raut, Arun Maheshwari
DOI:10.4103/aca.ACA_241_17  PMID:30333352
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Rationale for change in the criteria for defining severe ischemic mitral regurgitation in 2017 American College of Cardiology/American heart association guidelines p. 464
Reshmi Liza Jose, Praveen Kerala Varma
DOI:10.4103/aca.ACA_51_18  PMID:30333353
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Anesthesia considerations in neonate with tetralogy of fallot posted for laparotomy p. 465
Sushama Raghunath Tandale, Kalpana V Kelkar, Amey A Ghude, Priyanka V Kambale
DOI:10.4103/aca.ACA_75_18  PMID:30333354
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Balloon mitral valvuloplasty in kyphoscoliotic patient: It's not a cakewalk! p. 466
Azho Kezo, Pushkar Mahendra Desai, Monal Shah, Sanjeeta R Umbarkar, Manjula Sarkar
DOI:10.4103/aca.ACA_23_18  PMID:30333355
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Surgical technique and chylothorax following coronary artery bypass grafting p. 468
Achilleas Lazopoulos, Dimitrios Paliouras, Nikolaos Barbetakis
DOI:10.4103/aca.ACA_162_18  PMID:30333356
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In response – Surgical technique and chylothorax following coronary artery bypass grafting p. 468
Hemant Digambar Waikar
DOI:10.4103/aca.ACA_174_18  PMID:30333357
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