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:

306.    CUTTING OFF THE HIGH-WAY

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.

307. PROXIMAL COMPLIANCE

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.

308. TO CROSS OR NOT TO CROSS

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.

309.ANYTHING LEFT OTHER THAN LEFT?

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.

310.BREATHLESS AFTER SURGERY

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 kiran.vs.dr@nhhospitals.org I shall post them on your behalf.

Regards

Kiran

42 comments:

  1. Interesting blog. This is one of my favorite blog also I want you to update more post like this. Thanks for sharing this article.
    Pediatricians in Chennai

    ReplyDelete
  2. Kiran
    kudos to your blog
    it's nice to discuss such topics in a very relaxed and informal way
    I admire your entrepreneur friend
    where the individual is still regarded very important
    sadly cannot be said of many large institutions

    ReplyDelete
  3. Nice blog you can find more best cardiologist in delhi NCR at helpingdoc.

    ReplyDelete
  4. Very Helpful blog if you need to know best cardiologist in gurgaon logon to Helpingdoc.

    ReplyDelete
  5. Indeed an excellent post. Good thing is that knowing a particular risk earlier and having a proper treatment suitable for our body will make a huge difference in cardiovascular health. This action will definitely reduce the risk of having a heart attacks. http://www.cardiacsurgeryindia.com

    ReplyDelete
  6. This is very informative post.Every man should have a good sense about pediatric cardiology fellowship. I am waiting for this kinds of post. Thanks Again!!

    ReplyDelete
  7. cardiology fellowship is a good service. Through this, we can learn about a variety of topics heart. We will learn more about it, the more profit for us. We need to know in detail about the issues.

    ReplyDelete
  8. Dear Sir
    I'm interested in pursuing pediatric cardiology
    could u Plz Tell me what is the general pay package as a consultant pediatric cardiologist?

    ReplyDelete
  9. I am very happy to see your blog, very good article for audience,

    Each year, cardiac complications and diseased occur within 30 days after major noncardiac surgery in more than 10 million people worldwide.

    Today, however, the tether is fraying. How can we use technology to bring
    Cardiologist database in USA closer to patients rather than making them more remote?

    Small tips to avoid heart attack

    • Take responsibility for your health. ...
    • Know your risks. ...
    • Don't smoke or expose yourself to second-hand smoke. ...
    • Maintain a healthy blood pressure. ...
    • Monitor your cholesterol (blood lipids). ...
    • Limit your calories. ...
    • Make exercise a daily habit. ...
    • Pick your pills wisely.

    ReplyDelete
  10. If you're looking for a Cardiologist nearby you then do visit web health network

    ReplyDelete
  11. Very Informative blog!
    Glad to visit this blog!
    We can search for Best Oncologist in Bangalore on cancer doctor in Bangalore

    ReplyDelete
  12. Thanks for sharing good information, Find Genuine patient reviews about Best Pulmonologist in Bangalore & view all details of Top Chest specialist Doctors in Bangalore.

    ReplyDelete
  13. I am very happy to see your blog, good article and interesting,

    *reach your marketing lists or Sales Leads*

    Email Appending list is continuously updated with most accurate, quality and verified

    contacts.

    Ehealthcarelists can provide Cardiothoracic Surgeons Mailing list & Email list
    complete marketing information

    ReplyDelete
  14. Hi,
    I am very happy to see your blog Thanks for sharing.We provide Best Custom made suits in Bangalore.
    Custom made suits in Bangalore | Custom made suits in Bangalore, Designer

    ReplyDelete
  15. Hello,

    Thank you for the Blog.Parana Impact help you reach the right target customers
    to advertise your products and services.
    Director of Cardiology Users Email List

    ReplyDelete
  16. Wonderful information. You just pointed out some important things in your post which are very much appreciable. I Thankful for that.
    Best Specialist Doctors in Bahrain

    ReplyDelete
  17. Do you need a quick long or short term loan with a relatively low interest rate as low as 3%? We offer Xmas loan, business loan, personal loan, home loan, auto loan,student loan, debt consolidation loan e.t.c. no matter your score, If yes contact us via Email: finance2014911@gmail.com Fill The Loan Application Form Below Name............ Amount Needed........ Duration.......... Country............ Monthly income....... Age............. Phone Number........ Sex ................. Email................Business Plan/Use Of Your Loan:....... Apply now on this email :finance2014911@gmail.com Warm Regards Dr Purva Sharegistry

    ReplyDelete
  18. Do you need a quick long or short term loan with a relatively low interest rate as low as 3%? We offer Xmas loan, business loan, personal loan, home loan, auto loan,student loan, debt consolidation loan e.t.c. no matter your score, If yes contact us via Email: finance2014911@gmail.com Fill The Loan Application Form Below Name............ Amount Needed........ Duration.......... Country............ Monthly income....... Age............. Phone Number........ Sex ................. Email................Business Plan/Use Of Your Loan:....... Apply now on this email :finance2014911@gmail.com Warm Regards Dr Purva Sharegistry

    ReplyDelete
  19. Thanks for this great post! - This provides good insight. You might also be interested to know more about generating more leads and getting the right intelligence to engage prospects.
    Techno Data Group implements new lead gen ideas and strategies for generating more leads and targeting the right leads and accounts.
    Cardiologist Email List

    ReplyDelete
  20. The possible objects and values would possibly help students regarding various concerns which they must needed to occupy within.

    ReplyDelete


  21. Today's childhood is quite inactive, they spends our whole day without doing any physical work its not happened all of sudden actually video games, computer games slowly takes place of park play acts. now days children are not physically active just because of inactive acts schedules and i think its causes pediatric cardio problems many children now days facing this problem and just to diagnoses the exact problem we need to know the ayurvedic doctors in bangalore those gives us best prevention and prescription



    ReplyDelete
  22. Nice blog..thanks for this info..for more details visit goo.gl/54Ge6a

    ReplyDelete
  23. Thanks for sharing your post, its really informative blog, I appreciate your blog, find best general physician in bangalore.

    ReplyDelete
  24. Great information - thanks a lot for the detailed article! You might also be interested to know more about our company. Techno Data Group helps you achieve your business goals through customized database, connect with interested qualified prospects who are seeking information to move forward in the buying process.Cardiologist Email List

    ReplyDelete
  25. "Awesome read and it's nice to get some perspective from someone with experience"!!
    Best cardiologist in Indore

    ReplyDelete
  26. The information which you have provided is very good. It is very useful for me. General Surgeon in Bangalore

    ReplyDelete
  27. Welcome to Novena Heart Centre, the largest Heart Failure Centre in Singapore .

    Heart Surgery Centre

    ReplyDelete
  28. Thanks for this great post! -This provides good insight.You might also be interested to know more about generating more leads and getting the right intelligence to engage prospects.pegasimediagroup implements new lead gen ideas and strategies for generating more leads and targeting the right leads and accounts.Cardiologist email list

    ReplyDelete
  29. The possible objects and other prospects have been well initiated here and hopefully for the future would proved to be much better.

    ReplyDelete
  30. It has really brought around more of the possible objects and analysis which are indeed considered to be of utmost importance. Check electronic gadgets for best electronic gadgets

    ReplyDelete
  31. Hello Everybody,
    My name is Ahmad Asnul Brunei, I contacted Mr Osman Loan Firm for a business loan amount of $250,000, Then i was told about the step of approving my requested loan amount, after taking the risk again because i was so much desperate of setting up a business to my greatest surprise, the loan amount was credited to my bank account within 24 banking hours without any stress of getting my loan. I was surprise because i was first fall a victim of scam! If you are interested of securing any loan amount & you are located in any country, I'll advise you can contact Mr Osman Loan Firm via email osmanloanserves@gmail.com

    LOAN APPLICATION INFORMATION FORM
    First name......
    Middle name.....
    2) Gender:.........
    3) Loan Amount Needed:.........
    4) Loan Duration:.........
    5) Country:.........
    6) Home Address:.........
    7) Mobile Number:.........
    8) Email address..........
    9) Monthly Income:.....................
    10) Occupation:...........................
    11)Which site did you here about us.....................
    Thanks and Best Regards.
    Derek Email osmanloanserves@gmail.com

    ReplyDelete
  32. Very informative post. There is no hard and fast rule that a person will have heart problems whether he/she is a vegan
    or a non-vegan. Anyone can get heart problem. Whatever you eat, you need to do regular exercises to keep fit.
    Please find our link. If you may be interested, please refer to
    Cordiologist Mailing list & Email list

    ReplyDelete
  33. Thanks for sharing the post. It is useful for everyone. Please share http://ow.ly/IX1H30dEqxA

    ReplyDelete
  34. Very nice posting. Your article us quite informative. Thanks for the same. Our service also helps you to market your products with various marketing strategies, right from emails to social media. Whether you seek to increase ROI or drive higher efficiencies at lower costs, Pegasi Media Group is your committed partner will provide b2bleads.
    Pediatric Cardiologists

    ReplyDelete
  35. Excellent and Beautiful post Thanks for sharing this most excellent information. Worth the time I am glad that you shared this useful info with us. One thing in my mind came while reading that it is not wasting of time. This is very helpful. I strongly believe, the future is mainly depends on E Learning. I just read your article, it’s amazing. This article gave more and more idea to me I would strongly recommend checking out Our service also helps you to market your products with various marketing strategies, right from emails to social media.

    Visit Our Website : b2bcontactlists.com

    ReplyDelete
  36. Nice blog. Thanks for sharing the information. If you want online doctor health tips check here http://cure.plus/doctor-in-bangalore.php

    ReplyDelete