Shvetank Agarwal

Management of a Jehovah’s Witness Patient with Sepsis and Profuse Bleeding After Emergency Coronary Artery Bypass Graft Surgery: Rethinking the Critical Threshold of Oxygen Delivery

The duration and extent of acute hemodilution that the human body can withstand remains unclear. Many consider 184 mL/m/min to be the oxygen delivery (DO2) threshold below which oxygen consumption (VO2) begins to decrease. We describe a critically ill Jehovahs Witness patient who tolerated a much lower level of DO2, coupled with severe acute anemia that persisted for >10 days without any sequelae. This case challenges the currently accepted critical DO2 threshold and highlights the need for a comprehensive approach to increase DO2 and decrease VO2 for best patient outcomes. Minimizing VO2, which is usually underemphasized in current clinical practice, probably played an important role in the survival of this patient.

Perioperative Takotsubo Cardiomyopathy: A Systematic Review of Published Cases:

Takotsubo cardiomyopathy (TCM) is a condition that is characterized as a transient ventricular dysfunction in the absence of obstructive coronary artery disease (CAD) and is usually triggered by an acute medical illness or intense physical or emotional stress. Multiple cases of perioperative TCM (pTCM) have been reported from around the world, but a qualitative analysis of these cases has not yet been done. For this systematic review, we searched PubMed for case reports and case series of pTCM published from 1966 to April 2015 with the objective being to evaluate whether differences in demographics, clinical features and outcomes exist between pTCM and nonperioperative (npTCM), as well as to attempt to identify any predictors of the severe form of pTCM, which requires mechanical circulatory support (MCS) devices or leads to death. A total of 93 articles describing 102 cases were retrieved and reviewed. The findings were compared with the analysis of the International Takotsubo Registry by Templin et al and a systematic review of mainly non-perioperative TCM (npTCM) by Gianni et al. Although we were unable to identify definitive risk factors for pTCM, our review suggests that pTCM appears to occur in younger patients and with a lower likelihood of ST segment elevations and T-wave abnormalities than in npTCM. No demographic or clinical factors were identified that were predictive of more severe outcomes. As TCM in general can be a life-threatening event, it would therefore be prudent to consider pTCM within a differential diagnosis in any patient who decompensates in the perioperative period.

Incidental finding of tracheal bronchus complicating the anesthetic management of a left video-assisted thoracoscopic procedure

Congenital abnormalities of the large airways are uncommon, but may occasionally pose significant difficulties for anesthesiologists. The tracheal bronchus is an anatomical variant in which an accessory bronchus originates directly from the trachea rather than distal to the carina, as a takeoff from the right mainstem bronchus. Anesthesiologists should be aware of this uncommon anomaly, its different variants, and its management in order to successfully establish one lung ventilation (OLV) for surgical isolation. In this article, we report the challenges encountered in establishing OLV in a patient with a previously undiagnosed aberrant right upper lobe bronchus arising directly from the trachea.

Severe Bilateral Ocular Hypotony after Emergent Coronary Artery Bypass Graft Surgery Complicated with Cardiogenic Shock

<zdoi;10.1097/ALN.0000000000000860> Anesthesiology, V 124 • No 3 722 March 2016 I n t r ao c u l a r hypotony (IH), defined as a decrease in intraocular pressure (IoP) below 5 mmHg, is sometimes seen after ocular surgeries, but it is rarely clinically significant unless IoP decreases to the 0 to 4 mmHg range.1 Severe IH after cardiac surgery is exceedingly rare.2 The figure shows a marked bilateral distortion of the corneas with an almost “sucked-in effect” in an elderly patient who underwent an emergent coronary artery bypass grafting with hypothermic cardiopulmonary bypass complicated by cardiogenic and vasoplegic shock with severe lactic acidosis. acute decrease in IoP after hypothermic cardiopulmonary bypass may occur due to alterations in aqueous humor fluid dynamics, either by decreasing production of aqueous humor fluid due to a decrease in ophthalmic and ciliary artery blood flow or by increasing drainage because of either an increase in plasma oncotic pressure or a decrease in central venous pressure.2,3 other factors that may play a role are decreases in the choroidal blood and vitreous volume as well as in extraocular muscle tone.2,3 all of these mechanisms can easily be influenced by anesthetic drugs and exacerbated by prolonged hypothermia, systemic hypertonicity, persistent hypotension, aggressive diuresis, and severe acid–base disturbances, which may warrant frequent corneal examination during and after surgery in high-risk patients. Intraocular hypotony may cause acute loss of vision because of corneal edema and formation of Descemet’s folds, cataracts, anterior rotation of the lens–iris diaphragm, maculopathy characterized by horizontal choroidal folds, engorged tortuous vessels, and optic nerve edema, finally leading to phthisis bulbi or atrophic bulbi with complete intraocular disorganization in chronic cases.1 ocular movements are rarely affected. Management of IH depends on the cause and may involve steroids or surgery for postinflammatory and postsurgical IH, respectively1,4; however, acute IH after cardiac surgery may be reversed simply by correction of systemic hyperosmolality and acid–base disturbances. It is unknown whether patients with chronic IH are more susceptible to these changes in IoP during cardiac surgery and whether this condition can be significant enough to cause long-term complications. our patient required no treatment other than hemodynamic stability and correction of the acid–base disturbance and was discharged without any visual or motor alterations. Further studies are required to clarify the physiological mechanisms of IoP changes and the relation between IoP changes and cardiac surgery.

Alcohol Septal Ablation in a Patient With Hypertrophic Obstructive Cardiomyopathy

TRANSCORONARY ABLATION of septal hypertrophy (TASH), first introduced in 1994, has become an important option for treating symptomatic hypertrophic obstructive cardiomyopathy (HOCM), a rare disorder. The first septal branch of the left anterior descending artery (LAD) is located and 96% alcohol is instilled to induce an artificial myocardial infarction and necrosis at the base of the hypertrophied septum. This resolves the left ventricular outflow tract (LVOT) gradient due to its widening, restricted septal excursion, decreased mitral regurgitation, and subsequent global negative ventricular remodeling. Despite its growing acceptance, some risks are inherent to the procedure. Here, the authors describe the management of a case of TASH complicated by complete atrioventricular (AV) block.

Iatrogenic atrio-esophageal fistula following a video-assisted thoracoscopic maze procedure: Is esophageal instrumentation justified even when the diagnosis is equivocal?

A 74-year-old female underwent an uneventful bilateral thoracoscopic maze procedure for persistent atrial fibrillation with continuous transesophageal echocardiographic (TEE) guidance. She presented six weeks later with persistent fever and focal neurological signs. Computed tomography of the thorax revealed air in the posterior LA, raising suspicion for an abscess versus an atrioesophageal fistula (AEF). Before undergoing an exploratory median sternotomy, an esophagogastroduodenoscopy (EGD) was performed by the surgeon to check for any esophageal pathology. This however, resulted in sudden hemodynamic compromise that required intensive treatment with vasopressors and inotropes. In this case-report, we review the various intraoperative risk factors associated with the development of AEF during cardiac ablation procedures as well as the potential hazards of esophageal instrumentation with TEE, naso- or oro- gastric devices, and/or an EGD when an AEF is suspected.

Dural ectasia as an incidental finding on MRI in a patient with Marfan syndrome

A 48-year-old female with a history of Marfan syndrome and type A aortic dissection repaired with valve-sparing aortic root replacement and stable residual type B aortic dissection presented for surveillance MR angiography. At that time, dural ectasia was appreciated as an incidental finding with MRI showing high T2-weighted multilobar cerebrospinal fluid (CSF) spaces within the lower sacrum (figures 1 and …

Safety and efficacy of a modified HeRO dialysis device in achieving early graft cannulation: A single-institution experience

Hemodialysis Reliable Outflow (HeRO) grafts (Merit Medical Systems, Inc, South Jordan, Utah) provide a means for access in catheter-dependent hemodialysis patients but typically require several weeks for tissue incorporation. Modifying the HeRO graft with an ACUSEAL graft (W. L. Gore & Associates, Newark, Del) can allow immediate cannulation, thus reducing catheter dependence time and its associated complications. A retrospective review of patients at our institution from 2013 to 2016 who underwent placement of a modified HeRO dialysis system with ACUSEAL graft was performed. Complications and outcomes were analyzed, with patency rates and hours to successful cannulation being major end points. Modified HeRO grafts were successfully placed in 10 catheter-dependent patients. Postoperative complications included two thromboses and one hematoma. At 6 months of follow-up, mean time to graft cannulation was 33.7 hours, with 100% success; the primary and secondary patency rates were 70% and 90%, respectively. Our modification allows an accelerated use of the HeRO system, reducing catheter dependence time with acceptable postoperative complications and patency rates.

Multidetector computed tomography-derived emphysema index for preoperative quantification of emphysema severity.

Emphysema is a chronic obstructive airway disease (COPD) characterized by loss of elastic recoil of the lungs, which results in alveolar hyperinflation and collapse of the airways during exhalation. This disease presents multiple challenges during anesthesia, and assessing its severity preoperatively may help with intraoperative management. Pulmonary function tests provide only functional information, and conventional chest radiography provides only a gross estimation of disease severity. Multidetector computed tomography (MDCT) combined with dedicated post-processing software however, is a novel tool that utilizes high-resolution imaging, thereby allowing quantitative assessment of emphysema. This rapidly evolving technology provides detailed anatomical information about lung parenchyma, the airways, and the distribution of emphysematous lung tissue. It requires no intravenous contrast material and can be used to differentiate between airway-predominant and emphysema-predominant COPD. Quantitatively, it allows assessment of the density of each voxel (three-dimensional [3D] volume unit representing a pixel on the 2D image) of lung parenchyma using vendor-specific software that calculates total lung volume (TLV) and emphysematous volume (EV) of both lungs. The typical value for the attenuation coefficient, Housefield units, is set at -950 to differentiate between emphysema (seen as red dots) and normal lung tissue (Figure). The EV/TLV or the emphysema ratio (ER) (%) can then be calculated for individual lobes of the lungs. The Figure shows an overall ER of 17.1%, which signifies that at least 17% of the patient’s lungs are not

Anticoagulation dilemma in a high-risk patient with On-X valves.

Thromboembolism continues to be a major concern in patients with mechanical heart valves, especially in those with unsatisfactory anticoagulation levels. The new On-X valve (On-X Life Technologies, Austin, TX, USA) has been reported as having unique structural characteristics that offer lower thrombogenicity to the valve. We report a case where the patient received no or minimal systemic anticoagulation after placement of On-X mitral and aortic valves due to development of severe mucosal arterio-venous malformations yet did not show any evidence of thromboembolism. This case report reinforces the findings of recent studies that lower anticoagulation levels may be acceptable in patients with On-X valves and suggests this valve may be particularly useful in those in whom therapeutic levels of anticoagulation cannot be achieved due to increased risk of bleeding.