Vipul Krishen Sharma

Does intravenous sildenafil clinically ameliorate pulmonary hypertension during perioperative management of congenital heart diseases in children? - A prospective randomized study

Background: Pulmonary hypertension (PHT), if present, can be a significant cause of increased morbidity and mortality in children undergoing surgery for congenital heart diseases (CHD). Various techniques and drugs have been used perioperatively to alleviate the effects of PHT. Intravenous (IV) sildenafil is one of them and not many studies validate its clinical use. Aims and Objectives: To compare perioperative PaO2 – FiO2 ratio peak filling rate (PFR), systolic pulmonary artery pressure (PAP) – systolic aortic pressure (AoP) ratio, extubation time, and Intensive Care Unit (ICU) stay between two groups of children when one of them is administered IV sildenafil perioperatively during surgery for CHDs. Materials and Methods: Patients with ventricular septal defects and proven PHT, <14 years of age, all American Society of Anesthesiologists physical status III, undergoing cardiac surgery, were enrolled into two groups – Group S (IV sildenafil) and Group C (control) – over a period of 14 months, starting from October 2013. Independent t-test and Mann–Whitney U-test were used to compare the various parameters between two groups. Results: PFR was higher throughout, perioperatively, in Group S. PAP/AoP was 0.3 and 0.4 in Group S and Group C, respectively. In Group S, mean group extubation time was 7 ± 7.34 h, whereas in Group C it was 22.1 ± 10.6. Postoperative ICU stay in Group S and Group C were 42.3 ± 8.8 h and 64.4 ± 15.9 h, respectively. Conclusion: IV sildenafil, when used perioperatively, in children with CHD having PHT undergoing corrective surgery, improves not only PaO2 – FiO2 ratio and PAP – AoP ratio but also reduces extubation time and postoperative ICU stay.

Antiphospholipid syndrome, cardiac surgery and cardiopulmonary bypass

of APLS are cerebrovascular accident, transient ischemic attack, seizures, chorea, migraine, pseudotumor cerebri, visual disturbances and dementia. Cutaneous features include livedo reticularis, ulcers, infarcts and superficial thrombophlebitis. These patients may develop renal arterial or venous thrombosis, acute or chronic renal failure, hemolytic anemia or thrombocytopenia.[15-17] Catastrophic APLS is a distinct entity that results in simultaneous multiple small vessel thromboses. Factors precipitating this ‘thrombotic storm’ include surgical trauma, infection, any change in anticoagulation therapy, or oral contraceptives. It is associated with nearly 50% mortality.[18-20]

Cardiac Calcified Amorphous Tumor in a Newborn

Calcified amorphous tumors (CATs) of the heart are rare, nonneoplastic, intracavitary lesions, previously thought of as pseudotumors, hamartomas, or calcified thrombi, only reported in few adults in the available literature. This report describes a case of a pedunculated oscillating CAT arising from the left atrial appendage that prolapses through the mitral valve and causes severe mitral regurgitation in a newborn. This is the only case of cardiac CAT described in a neonate.

ALCAPA Associated with Congenital Lobar Emphysema: A Very Rare Association

We describe a rare association of anomalous left coronary artery from pulmonary artery (ALCAPA) with Congenital lobar emphysema (CLE) in a five month old male infant. The patient presented to our hospital with lower respiratory tract infection. Incidental detection of cardiomegaly and hyperinflation on chest X-ray was further evaluated with echocardiography and CT scan. Child was given a final diagnosis of ALCAPA with CLE right upper and middle lobe. He underwent corrective surgery for both the condition.

Ivabradine for junctional ectopic tachycardia in post congenital heart surgery

We report two cases of malignant junctional ectopic tachycardia (JET), in infants following congenital heart surgery. After the failure of conventional therapy the arrhythmia was controlled by oral Ivabradine, a drug which is routinely used to lower heart rate in angina and heart failure in adult practice.

Unusual Case of Left Bronchial Compression by Aneurysmal Pulmonary Arteries in a Child With Atrial Septal Defect.

We report an uncommon case of large ostium secundum atrial septal defect (ASD) with severe pulmonary arterial hypertension, with associated aneurysmal dilatation of the pulmonary arteries (PAs) leading to compression of the left main bronchus and collapse of the entire left lung in a 15-month-old female child. The patient was managed by surgical closure of the ASD, translocation of the right PA anterior to the aorta with PA aneurysmorrhaphy. Left bronchial compression was relieved with complete lung expansion on the third postoperative day.

Acute renal failure in the ICU setting: A prospective observational study

BACKGROUNDnAcute renal failure (ARF) is a common entity in the intensive care unit (ICU) setting. There is scanty data regarding acute kidney injury (AKI) in ICUs from our country and no data from the service setting.nnnMETHODSnAll patients admitted to the ICU of a tertiary care teaching hospital for six months were included in the study. They were divided into two groups: surg gr (admitted in surgical ICU) and med gr (admitted in medical ICU). During the stay in ICU, patients were observed for the development of AKI depending on the creatinine values and hourly urine output. Staging was done based upon the Risk Injury Failure Loss and End stage kidney (RIFLE) criteria. Relevant data associated with development of AKI was collected for correlation.nnnRESULTSn17.15% patients developed AKI after admission to the ICU 40% patients admitted with sepsis developed AKI. An increased susceptibility to develop AKI was found on day 4 of admission in both the groups. Of the patients who developed AKI, the surg gr of patients had a higher sequential organ failure assessment (SOFA) score both on day of admission (7.85 vs 5.65) and on the day of development of AKI (9.47 vs 6.18) as compared to the medical group.nnnCONCLUSIONnThe incidence of ARF in our study was 17.2% with the patients of polytrauma/MODS being of major concern. The initial 3-4 days are the most critical and susceptible patients must be intensive monitored during this time for prevention of ARF. Medical ICU patients develop ARF at a low SOFA score in comparison to surgical ICU patients and thus need greater attention.

Lung protective ventilation in the intraoperative period.

To the Editor: We read with interest the article titled “A Description of Intraoperative Ventilator Management in Patients with Acute Lung Injury and the Use of Lung Protective Ventilation Strategies.” It was also discussed in detail during our journal club as part of the departmental training program. The concept and the idea behind the article are very interesting and thought-provoking and we congratulate the authors on the same. We have a few observations, however. First, current information systems being used in hospitals are programmed to a large extent not to accept values of parameters that are invalid. It was noted that a large number of patients were excluded (320 265 31) because of invalid tidal volume, height, and weight. A total 616 of 2,652 patients, approximately 23.23% of cases, were excluded. This reflects poorly on the reliability of the database and of the entries considered as valid and included in the study. Second, in the materials and methods section all patients undergoing surgery who had at least one preoperative arterial blood gas assessment were included in the study. There exists a possibility that there were some patients with hypoxia who had not undergone preoperative arterial blood gas assessment and so were not included in the study. This situation also would have an effect on the final analysis. Third and most important, the mode of ventilation used intraoperatively has not been mentioned. Because only peak inspiratory pressures were monitored in the “post lung protective ventilation strategy era” it is evident that pressurecontrolled mode of ventilation may have been used. As a result, the findings of the ARDSnet study cannot be applied because that was carried out exclusively using volume control ventilation. This has also been discussed by Slutsky et al. However, if volume-controlled ventilation was used, the plateau pressures (Pplat) would have been lower than the peak inspiratory pressures. Whether the trend of peak inspiratory pressures would have accurately reflected the trend of Pplat as is the authors’ contention is a moot point. Moreover, if that was the case, Pplat would not have been universally used as a surrogate of pressures at the level of the alveolus and peak inspiratory pressures, which is actually an indicator of airway resistance would have sufficed. Thus, it may not be appropriate for the authors to conclude that lung protective ventilation strategy was not used intraoperatively in patients with acute lung injury in their hospital. Lung protective ventilation strategy by definition is use of low tidal volumes in volume-controlled mode of ventilation targeting a tidal volume of 6 ml/kg predicted body weight and plateau pressures of 25 cm of water. Fourth, the authors have concluded that the tidal volume settings appear to mirror the ventilator settings provided to the patients in the intensive care unit, which is borne out by the fact that table 5 shows that the tidal volume being delivered in the preoperative setting in the intensive care unit to the patients with acute lung injury is 8.25 ml/kg predicted body weight, compared with 8.58 ml/kg predicted body weight in the intraoperative period. Is it, therefore, to be inferred that even in the intensive care unit these patients were not being ventilated with a lung protective ventilation strategy using tidal volumes of 6 ml/kg predicted body weight? Finally, there are a number of typographical errors where PaO2 has been repeatedly substituted by PaCO2 in the abstract. In table 1 and figure 1, P/F has been mentioned as PaOC/FiO2. In tables 3, 4, and 5, Fio2 has not been mentioned as a fraction but probably as the percentage of inspired oxygen.