This blog is penned by Dr Kiran VS, Consultant Pediatric Cardiologist on behalf of Pediatric Cardiology team of Narayana Hrudayalaya Institute of Cardiac Sciences, Bangalore. Ours is the biggest and most voluminous Pediatric Cardiology and Pediatric Cardiac surgical unit of India. The objective of the blog is to develop mutual interaction.
Friday, July 11, 2014
Dr Kiran welcomes all the readers to the blog of Pediatric
cardiology department, Narayana Hrudayalaya Hospital,
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
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
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?
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.
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.
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
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