Mridul Agarwal

Assessment of Risk Factors for a Sustainable "On-Table Extubation" Program in Pediatric Congenital Cardiac Surgery: 5-Year Experience.

OBJECTIVE To delineate risk factors for failure of extubation in the operating room among pediatric cardiac surgery patients. DESIGN Prospective, observational study. SETTING Single center, tertiary care, teaching hospital. PARTICIPANTS The study comprised 448 congenital cardiac surgery patients who were enrolled for intended extubation in the pediatric cardiac operating room over 5 years. INTERVENTIONS The airways of enrolled patients were extubated in the operating room if predetermined suitability criteria were met. If the criteria were not met, patients were transferred to the intensive care unit with an endotracheal tube in situ. Patients whose airways were extubated successfully were followed up to determine specifically whether reintubation or use of noninvasive ventilation was necessary post-procedure. MEASUREMENTS AND MAIN RESULTS The airways of 92% (412) patients were extubated in the operating room. Incidence of reintubation in the intensive care unit was 2.4%. There were 4 mortalities in the whole group. A 100% success rate for operating room extubation was achieved for patients in Risk Adjusted Congenital Heart Surgery category 1, and patients undergoing adult congenital cardiac disease surgery and redo sternotomy. The airways of 85% of patients with preoperative pulmonary hypertension were extubated in the operating room. Statistical analysis was applied to identify risk factors present in the group that made extubation in the operating room unachievable. CONCLUSIONS Extubation in the operating room was successful in a majority of patients undergoing cardiac surgery. Multivariate analysis identified weight<5 kg, age<1 year, cardiopulmonary bypass time>120 minutes, and presence of significant noncardiac structural anomalies as significant factors affecting extubation in the operating room, with an adjusted odds ratio (95% confidence interval) of 10 (2.7-37), 7.2 (2-22), 5.5 (1.7-17.7), and 3.3 (1.2-9.3), respectively. Pulmonary hypertension, redo sternotomy, higher Risk Adjusted Congenital Heart Surgery category, and aortic clamp time>60 minutes did not achieve significance in the multivariate analysis as risk factors for extubation in the operating room.

An Unusual Cause of Persisting Hyperlactatemia in a Neonate Undergoing Open Heart Surgery

Being a reflection of the degree of global tissue anoxia, serum lactate levels therefore can be used as a marker of organ damage and eventual outcome. A statistically significant association was observed between serum lactate levels and subsequent mortality and morbidity in critically ill adults, children, and neonates. In cardiac critical care, hyperlactatemia is usually multifactorial in origin, resulting from a combination of etiologies. Many centers are using serial lactate levels in conjugation with other parameters of cellular oxygen delivery, consumption, or extraction to monitor prognosis after pediatric cardiac surgery. A single initial lactate level has a lesser predictive value for morbidity and mortality after pediatric cardiac surgery than its failure to fall within 48 hours of surgery. In case of persistently high lactate levels with no other evidence of cellular hypoperfusion, other possibilities must be considered. There has been an established association of lactic acidosis with thiamine deficiency, but this has not yet been reported in newborns undergoing congenital cardiac surgery. We present one such rare case.

Right atrial diverticulosis and early-onset arrhythmia: Rare cause of incessant neonatal arrhythmia

BackgroundAtrial flutter not responding to medications could be secondary to structural malformations of heart.Case characteristicsA 5-year-old child with resistant arrhythmia, with onset in neonatal period.OutcomeMultiple right atrial diverticuli were detected on CT angiography and cardiac catheterization. Patient reverted to sinus rhythm following surgical excision of diverticuli.MessageIn cases of intractable supraventricular tachycardia, structural anomalies of atrium should be suspected.

Device closure of patent ductus arteriosus in interrupted inferior vena cava

Introduction A 3-year-old child, weighing 8 kg, presented with patent ductus arteriosus (PDA) and interrupted inferior vena cava (IVC). The patient underwent successful PDA device closure via transjugular route after failing attempt at femoral venous route. Case summary PDA device closure was attempted via femoral venous route but could not be accomplished due to difficult curves to negotiate. Following this, PDA could be closed by device from jugular venous route with ease. Discussion Interrupted IVC poses challenges for PDA device closure and various alternative routes are described like internal jugular, transhepatic, or femoral venous – azygous route. Our case describes difficulties associated with femoral venous route and advantages of jugular venous route in such cases. Conclusion Internal jugular access is a safe and feasible method of PDA device closure in cases of interrupted IVC even in smaller children.