Friday, July 11, 2014

Dr Kiran welcomes all the readers to the blog of Pediatric cardiology department, Narayana Hrudayalaya Hospital, Bangalore.

Recently I met my primary school-mate. Discarded as “mediocre” by my teachers then, he is a successful entrepreneur today! He runs a software firm with 80 people working under him! His company develops custom-made computer softwares and high-end smartphone apps for medium to large scale companies.

“Managing 80 employees must be quite difficult. How do you deal with problem of recruitment and attrition?” I asked him.

His answer was eye-opener. He has simple logic. “I believe in them!” he said. “I select my employees through known circles, mostly through the existing ones. That leads to better accountability and indirect control. But, I assign job responsibilities for everyone as per my assessment. I don’t care about their legacy, the institute they have graduated from or certificates of credentials they carry. CVs are the easiest to fake nowadays and getting references cross-checked is cumbersome. I just want to make sure that they understand what they are doing and how good they are at that work. We pay one of the best packages in this sector. So, I am all about what I want from them.”
“Not that alone”, he continued. “I don’t allow back-biting or speaking negative of anyone. We address workplace problems through a confidential information system where the identity of whistle-blower is completely safe. We have works meant for individuals and groups. If a person does not qualify for either, I fire him! I hate parasites who do not know the work and who live only on the ability of others. To sustain that status, such people usually cause rift between one-another. Their entire existence is dependent on such ill-wills. When one of their hosts realize this, such parasites simply shift their host! Such people are blemish to civilized world. We don’t lose anything by getting rid of them! In fact, on a long run, their absence caters growth of the company.”

“Even better would be sending them to your rivals!” I said jokingly and we laughed.

I was smitten by his insight. He is of my age and how much of worldly sense he has gained by self-industrious path! I was wondering how big time corporates can make use of this principle. After all, ergonomics is the key for eventual profit.

I came across an article in the June 2014 issue of “Journal of Cardiothoracic and Vascular Anesthesia” titled “Extubation in the Operating Room After Cardiac Surgery in Children: A Prospective  Observational Study With Multidisciplinary Coordinated Approach.” Matter of pride is, it is from Narayana Hrudayalaya! Our senior pediatric cardiac anesthesiologists, Dr Rajneesh Garg and Dr Keshava Murthy have authored this.

This was a prospective observational study with controls taken from past, on historic basis. They have studied 1000 patients in the “study group” (age: 1 day to 18 years) with another 1000 historic controls, comprising “before study group”. The study group had undergone cardiac surgery with combination of general anesthesia and neuraxial analgesia with a mixture of caudal morphine and dexmedetomidine. These patients were planned for extubation in the operating room after completion of the surgical procedure. They were compared with historic controls for impact of extubation in operating room on ICU stay and resource utilization.

The authors have been successful in extubating 87.1% of study group patients, including 40% neonates. Of these, 45 required reintubation within 24 hours. The authors observe that overall ICU stay was reduced by 50% in the study group as compared to control group with positive impact on resource utilization.

The authors give a detailed yet lucid account of the patient groups and sub-groups undergoing surgery. They have also documented the factors that lead to deferring extubation in OR. High risk category demanding reintubation has been discussed. They have done detailed statistical analyses of their observations and findings.

The main limitation of this study is utilization of historic controls. This point is acknowledged by the authors. Also, such studies need to be properly blinded to enhance their value and neutralize the bias. The authors have also observed this limitation. But when the number is so large, the chances of bias are not very high, especially when standard protocols are applied as a rule. The cost-benefit analysis is an extrapolated conclusion in this study, with no actual measurements. The authors have acknowledged this fact.

Can this be followed in other centres with lesser numbers and lesser resources? The authors recommend that if early extubation within 2 to 4 hours in the ICU can be practiced, then the re-intubations for re-exploration for surgical bleeding and diaphragmatic palsy can be avoided. They also recommend that perioperative course can be planned in such a way that many patients can be extubated safely at the completion of the surgery either in the OR or early in the ICU, depending on the applicability in that particular center, instead of planning elective ventilation. This helps in keeping a custom-made approach than a blanket version.

The study does not inform the age and weight related mortality in the study group. Weight or Body Surface Area, being an important factor in pediatric ages, could have found a place in their otherwise detailed analysis. Extubation failures related to age and weight/BSA can carry more practical message. Also, if the authors had risk-stratified the patients based on diagnosis and pre-operative conditions, it would have has better impact for those who would like to emulate. Such large numbers are not easy to study. The authors should be applauded for their commendable work. Equal credit should go to the intensive care team for managing the aftermath!

With that, let us get back to few learning scenarios:


In children with single ventricle physiology with pulmonary atresia, PDA forms the highway for pulmonary circulation along with some collaterals. In cath study, entering PA through PDA is risky. We take reverse pulmonary venous wedge pressures as correlates of mean PA pressure. How much reliability can be attributed to this correlation? We at NH had done a small observational study a couple of years back and found a difference of 2 to 3 mmHg between the two. The question remains, is the cath study required for pre-surgical hemodynamic data in such cases? Wouldn’t interrupting PDA enough to bring down PA pressures to normal? How many centres still follow doing cath studies in such children before single ventricle palliation? Does any centre “not practice” cath study in such scenarios? What is their experience? Please let us know your learnings on this.


We speak of compliance of ventricles a lot. But, we largely take the compliance of atrial cavities for granted. Can there be issues in this regard? Let us take Mitral stenosis or Mitral regurgitation as example. The progress of high PA pressures and RV dysfunction varies in different patients. Can LA compliance be used to explain this variation? Logically, if LA compliance is good, the progress of PAH should be slow. On the other hand, the progress would be faster if LA compliance is poor. Is there any study looking at this issue? What is the personal experience in other centres? Please share.


One of the feeders for perpetual tussle between pediatric cardiologist and surgeon is on the coronary crossing RVOT in children with Tetralogy of Fallot. Acts of both commission and omission are held accountable here. Even after advent of CT, this tussle hasn’t doused off. Despite all this, is there any systematic study on the actual disparity between the data on echo report and on-table occurrence? It would be interesting to know this data in high volume centres. Has any centre studied this? It would be interesting to know.


We have earlier discussed various possibilities of great artery relationship in TGA. We have seen d-malposition, L-malposition, antero-posterior or side-by-side in children with TGA. However, in children with congenitally corrected TGA, we hardly see any relationship other than L-malposition. Has anyone come across any other malposition of great arteries in CCTGA? What is the explanation for this rule? Please let us know.


What is the incidence of diaphragm palsy after cardiac surgery, which mandates intervention? Diaphragm palsy offers significant morbidity in the post-op period. It also increases the ICU stay, overall expenditure and cumulative mortality. But the actual incidence reported seems quite different from what is usually seen. Is there any reliable data on this? What is the break-up incidence for different lesions? Is there any correlation with CPB time? What is the usual outcome? How many such incidents require placation or other interventions? Please let us know your observations.

That brings us to the end of this post. Please pen in your comments in the comments section. If you find any problem in posting comments, please mail it to my email id I shall post them on your behalf.