Anupam Shrivastava

Impact of advanced cardiac life support training program on the outcome of cardiopulmonary resuscitation in a tertiary care hospital

Background: Guidelines on performing cardiopulmonary resuscitation (CPR) have been published from time to time, and formal training programs are conducted based on these guidelines. Very few data are available in world literature highlighting the impact of these trainings on CPR outcome. Aim: The aim of our study was to evaluate the impact of the American Heart Association (AHA)-certified basic life support (BLS) and advanced cardiac life support (ACLS) provider course on the outcomes of CPR in our hospital. Materials and Methods: An AHA-certified BLS and ACLS provider training programme was conducted in our hospital in the first week of October 2009, in which all doctors in the code blue team and intensive care units were given training. The retrospective study was performed over an 18-month period. All in-hospital adult cardiac arrest victims in the pre-BLS/ACLS training period (January 2009 to September 2009) and the post-BLS/ACLS training period (October 2009 to June 2010) were included in the study. We compared the outcomes of CPR between these two study periods. Results: There were a total of 627 in-hospital cardiac arrests, 284 during the pre-BLS/ACLS training period and 343 during the post-BLS/ACLS training period. In the pre-BLS/ACLS training period, 52 patients (18.3%) had return of spontaneous circulation, compared with 97 patients (28.3%) in the post-BLS/ACLS training period (P < 0.005). Survival to hospital discharge was also significantly higher in the post-BLS/ACLS training period (67 patients, 69.1%) than in the pre-BLS/ACLS training period (12 patients, 23.1%) (P < 0.0001). Conclusion: Formal certified BLS and ACLS training of healthcare professionals leads to definitive improvement in the outcome of CPR.

Knowledge of infection control practices among intensive care nurses in a tertiary care hospital.

BACKGROUND The threat of hospital-acquired infections persists despite advances in the health care system. A lack of knowledge regarding infection control practices among health care workers decreases compliance with these practices. We conducted a study to assess the knowledge of infection control practices among nursing professionals at our hospital. METHODS In total, 100 nurses in the intensive care units at our hospital were given a questionnaire with 40 multiple choice questions, including 10 questions each regarding hand hygiene, standard and transmission-based precautions, care bundles and general infection control practices. The responses were scored as percentages. RESULTS The overall knowledge and awareness regarding different infection control practices were excellent (>90% positive responses) in 5% of the nursing professionals, good (80-90% positive responses) in 37%, average (70-80% positive responses) in 40% and below average (<70% positive responses) in 18%. CONCLUSION The infection control knowledge among the nurses was fairly good; however, there is still a wide scope of improvement with regular educational programs and in-house training.

Successful Management of Potentially Fatal Vasodilator-Resistant Spasm of a Nongrafted Coronary Artery

SPASM OF THE native coronary artery is a rare but life-threatening complication after coronary artery bypass graft (CABG) surgery. Therefore, the emphasis is placed on early postoperative coronary angiography (CAG) in patients whose condition is inexplicably unstable after the surgery. There are reports in which the coronary artery spasm was relieved with intracoronary infusions of various vasodilators, but in others the spasm could not be relieved and mortalities have occurred. The authors present a case of a postoperative spasm of a nongrafted coronary artery resistant to intracoronary vasodilator administration that needed reoperation with grafting of the affected vessel. Subsequent CAG after 6 days showed relief of the spasm. CASE REPORT A 64-year-old man presented with complaints of uneasiness, chest pain, and a history of syncopal attack 1 day before admission with a history suggestive of variant angina for the last 6 months, for which he was on medical management. He had hypertension and type-2 diabetes mellitus. The patient was an occasional drinker and a nonsmoker. An electrocardiogram showed significant ST-segment depression in the inferior leads. Auscultation revealed bilateral carotid bruit. Echocardiography showed an ejection fraction of 55%. Color Doppler of the carotid arteries revealed bilateral carotid artery disease. Angiography showed 30% stenosis in the left anterior descending artery (LAD), 70% stenosis in the left circumflex artery, and 60% stenosis in the dominant right coronary artery (RCA). In addition, there were 80% and 50% stenoses of the right internal carotid artery and left external carotid artery, respectively. Because the patient was having unstable angina, he was referred for CABG surgery with right carotid artery endarterectomy. The patient underwent off-pump coronary artery bypass graft surgery with right carotid artery endarterectomy. After carotid endarterectomy, saphenous veins were grafted to the obtuse marginal branch of the left circumflex artery and the RCA on the beating heart, with proximal anastomoses to the ascending aorta. The intraoperative course remained uneventful, and the patient was shifted to the cardiac recovery room with minimal inotropic support (epinephrine, 0.01 g/kg/min). Gradual weaning from the ventilator was started, and the patient was put on a pressure support mode of ventilation after 3 hours. At that time, his heart rate was 122 beats/min, arterial blood pressure was 144/92 mmHg, temperature was 37.1°C, and the epinephrine infusion was administered at 0.01 g/kg/min. Just before extubation, the patient had an episode of ventricular fibrillation that was immediately converted with a 200 J DC shock. It was followed by significant STsegment elevation in the anterior chest leads and hypotension with a systolic blood pressure of 50 mmHg. Epinephrine infusion was stepped up, dobutamine infusion was started, and an intra-aortic balloon pump was inserted. Transesophageal echocardiography (TEE) surprisingly showed hypokinesis of the anterior wall, the area being supplied by the LAD that was not grafted. The patient was taken for urgent coronary angiography that, in accordance with the TEE findings, showed severe spasm of the proximal LAD (Fig 1) with patent vein grafts to the obtuse marginal branch and the RCA. Intracoronary vasodilators in the form of nitroglycerin, nicorandil, and diltiazem were administered in an attempt to relieve the spasm, but the spasm remained refractory. The cardiologist also tried to pass a guidewire across the lesion but was not successful. Because of persistent unstable hemodynamics, the patient was taken back to the operating room for grafting to the LAD. The left internal mammary artery (LIMA) was harvested and grafted to the LAD on the beating heart. After grafting of the LAD, the hemodynamics showed marked improvement, with a significant reduction in inotropic requirement. Electrocardiographic and echocardiographic changes also reverted back to normal. The patient was extubated after 12 hours. The IABP was removed the next day. The rest of the intraoperative course remained uneventful. Repeat angiography performed after 6 days showed relief of the LAD spasm (Fig 2). The patient was discharged from the hospital on the 7th postoperative day.

Do Intensive Care Unit treatment modalities predict mortality in geriatric patients: An observational study from an Indian Intensive Care Unit

Background: Ageing being a global phenomenon, increasing number of elderly patients are admitted to Intensive Care Units (ICU). Hence, there is a need for continued research on outcomes of ICU treatment in the elderly. Objectives: Examine age-related difference in outcomes of geriatric ICU patients. Analyze ICU treatment modalities predicting mortality in patients >65 years of age. Materials and Methods: A retrospective observational study was conducted in 2317 patients admitted in a multi-specialty ICU of a tertiary care hospital over 2-year study period from January 1, 2011 to December 31, 2012. A clinical database was collected which included age, sex, specialty under which admitted, APACHE-II and SOFA scores, patient outcome, average length of ICU stay, and the treatment modalities used in ICU including mechanical ventilation, inotropes, hemodialysis, and tracheostomy. Patients were divided into two groups: <65 years (Control group) and >65 years (Geriatric age group). Results: The observed overall ICU mortality rate in the study population was 19.6%; no statistical difference was observed between the control and geriatric age group in overall mortality (P > 0.05). Mechanical ventilation (P = 0.003, odds ratio [OR] =0.573, 95% confidence interval [CI] =0.390–0.843) and use of inotropes (P = 0.018, OR = 0.661, 95% CI = 0.456–0.958) were found to be predictors of mortality in elderly population. On multivariate analysis, inotropic support was found to be an independent ICU treatment modality predicting mortality in the geriatric age group (β coefficient = 1.221, P = 0.000). Conclusion: Intensive Care Unit mortality rates increased in the geriatric population requiring mechanical ventilation and inotropes during ICU stay. Only inotropic support could be identified as independent risk factor for mortality.

Pulmonary embolectomy with use of pediatric bronchoscope for the detection of residual emboli: an innovative surgical technique

Pulmonary embolectomy in the treatment of massive pulmonary embolus has been in doubt since the introduction of thrombolytic therapy. Recent indications for surgical intervention are- contraindication to thrombolysis, failed medical treatment and severe Right Ventricular (RV) dysfunction. A 54-year male came to us with complaints of palpitation, tachypnea and repeated syncope . Transthoracic echocardiography and Computed Tomography pulmonary angiogram demonstrated- Biatrial mass with right atrial mass extending into right ventricle and main pulmonary artery. Pulmonary embolectomy was performed. Residual emboli of bilateral pulmonary arteries were detected with a fiberoptic pediatric bronchoscope and removed. Bronchoscopic evaluation appears to be safe and useful for direct visual detection of emboli.

Potentially fatal tricuspid valve aspergilloma detected after laparoscopic abdominal surgery

Abstract Fungal endocarditis accounts for 1.3–6% of all cases of infective endocarditis. The most common causative organism is Candida, followed by Aspergillus and other mould fungi. Aspergillus endocarditis is usually associated with high morbidity and mortality. Establishing a definitive and timely diagnosis remains difficult and there are many reports of undetected aspergillomas leading to fatalities in the perioperative period. We present a case report of preoperatively undiagnosed large mobile tricuspid valve aspergilloma obstructing the right ventricular inlet, diagnosed incidentally on the second postoperative day after laparoscopic pancreatic abscess drainage. The patient was successfully managed with emergency open-heart surgery and systemic antifungal agents in the postoperative period.

An Observational Comparative Study of Cardiac Index Estimated ByFloTrac and Intermittent Thermo Dilution in Off-Pump Coronary ArteryBypass Grafting

Objective: The purpose of this study was to determine the correlation between cardiac index (CI) measurements made using intermittent thermodilution (ITD) technique by pulmonary artery catheter (PAC) and arterial pulse-contour analysis by FloTrac. Design: Prospective observational study. Setting: Cardiac surgery unit in a 350 bedded tertiary care hospital in India. Participants: 31 adult patients undergoing elective off-pump coronary artery bypass grafting (OPCABG) Interventions: CI measurements performed by the two different methods at six time points during the surgery (before skin incision, during grafting of left anterior descending artery, obtuse marginal artery and right coronary/ posterior descending artery, after protamine administration and after shifting the patient to recovery room). Measurements and results: The techniques a weak correlation at all six time points during the OPCABG. The mean bias of 0.85 L/min/m2 and precision of 0.55 was found in the study population. The percentage error calculated using Critchley s criteria was found to be 46%. Conclusion: CI measurements obtained using FloTrac showed a limited correlation with those acquired by ITD technique at different stages of OPCABG. Further studies are required in other patient populations and clinical situations.

End-tidal CO2 Should not be a Parameter for Ventilatory Adjustment during Low Cardiac Output States Like Off-pump Coronary Artery Bypass Grafting

Background: Capnography is widely used as a non-invasive monitoring technique for intra-operative and postoperative mechanically ventilated patients. Aim: To study whether the EtCO2 values should be used to adjust mechanical ventilation during low cardiac output states such as off pump cardiac bypass surgery (OPCABG). Setting and design: Prospective study in 50 patients undergoing OPCABG. Material and Methods: The values of cardiac index (CI), EtCO2, PaCO2 and P(a-Et)CO2 gradient were compared at two time points during OPCABG: immediately before skin incision and during grafting of obtuse marginal artery, as usually OM grafting is considered to be associated with low cardiac output. Statistics: Data was analysed using student’s t-test. Results: There was a significant decrease in the value of CI from point A to point B (2.33 vs. 1.75 L/min/m2, p<0.001), significant decrease in EtCO2 from 25.28 to 21.88mmHg (p<0.001) and statistically significant increase in P(a-Et)CO2 gradient 4.39 at point A to 9.18 mmHg at point B (p<0.003). Conclusion: The decrease in EtCO2 had a positive correlation with the decrease in cardiac index. So during the low flow periods as found in OPCABG, EtCO2 cannot reliably estimate the adequacy of ventilation.

Convulsions in a critically ill patient on hemodialysis: Possible role of low dose colistin

The increasing prevalence of multi-drug resistant Gram-negative pathogens in intensive care units has led to the revival of colistin. Colistin had gone into disrepute in early 1970s because of numerous reports of adverse renal and neurological effects. The renewed interest in colistin has also revived the discussion about its toxicity. The neurotoxicity reported in literature is usually with higher doses of colistin. We present a case report of seizures in a critically ill-patient, possibly with low dose colistin. A 47-year-old hypertensive female with chronic kidney disease-5 with sepsis on colistimethate sodium 1 million units (80 mg), intravenous once daily, developed paresthesias and seizures on 12th day of therapy, which were subsequently controlled after withdrawl of the drug. To conclude, colistin should be considered as a cause of convulsions in critically ill-patients with renal failure, even when given in low dose and patient receiving intermittent hemodialysis, when other obvious causes have been ruled out. When possible, cessation of therapy may be considered.

An observation of impact of neurological consultations in intensive care patients: Case series of 23 patients

Objective: The objective of the present study was to assess the impact of neurological consultation and intervention upon patient outcome in intensive care unit (ICU). Settings: A retrospective observational study was conducted in the 24-bedded multispecialty ICU of a 350 bedded tertiary care hospital over 8 months period, from January 2011 to August 2011. Critically, ill-patients with varied neurological symptomatology affecting the course of illness and ICU discharge were included. Neurological consult sought for, investigations ordered by the neurologist, interventions carried out, treatment started and the impact of such treatment on the outcome of patients were noted. The length of ICU stay was also noted. Results: Over a period of 8 months, there were 864 ICU admissions. On neurological consult, 23 patients had a positive finding affecting the outcome: 5 patients were diagnosed to have parkinsons disease, 4 patients had neuromuscular disease, 9 patients had high creatinine phosphokinase levels, 2 patients had restless legs syndrome and 3 patients were diagnosed to have seizure disorder. Conclusions: On being examined and investigated by neurologist, a variety of co-existing neurological disorders could be diagnosed and if managed early, patients had a faster recovery, rapid weaning and early discharge from the ICU.