Publications by authors named "Usha Kiran"

144 Publications

Identifying Traits Associated With Terminal Drought Tolerance in Sesame ( L.) Genotypes.

Front Plant Sci 2021 10;12:739896. Epub 2021 Dec 10.

Department of Plant Physiology, Indira Gandhi Agricultural University, Raipur, India.

Sesame is predominantly cultivated in rainfed and low fertile lands and is frequently exposed to terminal drought. species inhabiting dryland ecosystems adaptively diverge from those inhabiting rainfed habitats, and drought-specific traits have a genetic basis. In sesame, traits associated with drought conditions have not been explored to date, yet studies of these traits are needed given that drought is predicted to become more frequent and severe in many parts of the world because of climate change. Here, 76 accessions from the available Indian core set were used to quantify variation in several traits under irrigated (WW) and terminal drought stress (WS) conditions as well as their association with seed yield over two consecutive years. The range of trait variation among the studied genotypes under WW and WS was significant. Furthermore, the traits associated with seed yield under WW and WS differed. The performance of the accessions indicated that the expression of most traits was reduced under WS. The correlation analysis revealed that the number of branches, leaf area (LA), leaves dry weight (LDW), number of capsules plant, and harvest index (HI) were positively correlated with seed yield under WW and WS, and total dry matter (TDM), plant stem weight, and canopy temperature (CT) were negatively correlated with seed yield under WW and WS, indicating that smaller and cooler canopy genotypes had higher yields. The genotypes IC-131936, IC-204045, IC-204861, IC-205363, IC-205311, and IC-73576 with the highest seed yields were characterized by low canopy temperature, high relative water content, and high harvest index under WS. Phenotypic and molecular diversity analysis was conducted on genotypes along with checks. Phenotypic diversity was assessed using multivariate analysis, whereas molecular diversity was estimated using simple sequence repeat (SSR) loci to facilitate the use of sesame in breeding and genetic mapping. SSRs showed low allelic variation, as indicated by a low average number of alleles (2.31) per locus, gene diversity (0.25), and polymorphism information content (0.22). Cluster analysis (CA) [neighbor-joining (NJ) tree] revealed three major genotypic groups and structure analysis showed 4 populations. The diverse genotypes identified with promising morpho-physiological traits can be used in breeding programs to develop new varieties.
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http://dx.doi.org/10.3389/fpls.2021.739896DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8709571PMC
December 2021

Perioperative Anxiety and Stress in Children Undergoing Congenital Cardiac Surgery and Their Parents: Effect of Brief Intervention-A Randomized Control Trial.

J Cardiothorac Vasc Anesth 2019 May 22;33(5):1244-1250. Epub 2018 Aug 22.

Department of Clinical Psychology, All India Institute of Medical Sciences, New Delhi, India.

Objective: To know the effects of psychological preparation on perioperative stress, anxiety, and mood in children undergoing cardiac surgery and their parents.

Design: Prospective randomized control nonblinded trial.

Setting: Single-center tertiary teaching hospital.

Participants: A total of 60 children aged 5 to 15 years undergoing cardiac surgery were included in the study. One of the parents, preferably the father, was selected from the respective children.

Interventions: Subjects were randomized into 2 groups: noninterventional (group 1) and interventional (group 2). Intervention was in the form of toys and video games in children, and counseling and information in parents. Preoperative and postoperative anxiety in parents was measured using the State-Trait Anxiety Inventory (STAI), stress using the Index of Clinical Stress (ICS) scale by Abell, and the Ottawa mood scale. In children, the STAI-C (child version of STAI), Ottawa mood and Ottawa stress scales, and Wong-Baker faces pain scale were applied and serum cortisol was measured.

Measurements And Main Results: Group 2 children had significantly less (p < 0.001) stress, anxiety, and pain and improved mood. Group 2 parents had a significant reduction in state anxiety (42 ± 4.4 v 54.5 ± 7.8; p < 0.001) and ICS score (68.1±9.6 v 84.2 ± 9.2; p < 0.001) and an improvement in mood (7.5 ± 0.7 v 5.9 ± 1; p < 0.001) compared with group 1. Postoperatively, cortisol levels in group 2 were lower than group 1 (571.3 nmol/L [123.3 -1247.14] v 718.9 nmol/L [53-1642.0]).

Conclusion: Providing video games and toys preoperatively reduced postoperative stress and anxiety and improved mood in children undergoing congenital cardiac surgery. Parents were relieved of anxiety and stress with proper counseling and information.
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http://dx.doi.org/10.1053/j.jvca.2018.08.187DOI Listing
May 2019

Transcutaneous nerve stimulation for pain relief during chest tube removal following cardiac surgery.

J Anaesthesiol Clin Pharmacol 2018 Apr-Jun;34(2):216-220

Department of Cardiac Anaesthesia, Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India.

Background And Aims: In patients undergoing open heart surgery, chest tubes are removed postoperatively when patients are well awake and stable. Pain during chest tube removal can be moderate to severe and can be the worst experience of hospitalization. Various modalities of pain relief during chest tube removal have been tried with variable results. We sought to examine the effect of transcutaneous electrical nerve stimulation (TENS) as an intervention for pain relief during chest tube removal after cardiac surgery.

Material And Methods: In a tertiary care center, fifty patients undergoing open heart surgery were randomized into two groups. Group TENS ( = 25) received TENS from 30 min before and continued up to 30 min after chest tube removal. Control Group ( = 25) did not receive TENS. In both the groups, additional analgesic medication was provided on demand, besides the standard analgesic regime which was injection ketorolac 30 mg intramuscularly every 8 h. Patients were studied for pain during chest drain removal and pain related nausea, vomiting, and sense of well-being.

Results: Mean visual analog pain score assessed for chest tube removal was significantly less 4.1 ± 1.2 ( < 0.05) in TENS Group as compared to 6.1 ± 0.8 in Control Group. Significantly greater number of patients ( = 14) ( < 0.05) in Control Group demanded additional analgesia as compared to TENS Group ( = 5). Feeling of well-being, improvement in appetite, and sleep was better in TENS Group as compared to Control Group.

Conclusion: We conclude that TENS might not replace the conventional analgesics but has definite adjuvant role in decreasing pain scores and improves sense of well-being during chest tube removal after cardiac surgery.
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http://dx.doi.org/10.4103/joacp.JOACP_336_15DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6066881PMC
August 2018

Homozygous Familial Hypercholesterolemia: Anesthetic Challenges and Review of Literature.

World J Pediatr Congenit Heart Surg 2020 Jul 27;11(4):NP83-NP87. Epub 2017 Sep 27.

Department of Pathology, All India Institute of Medical Sciences, New Delhi, India.

Homozygous familial hypercholesterolemia (HoFH; Fredrickson IIa) is a rare autosomal dominant hereditary disease associated with increased low-density lipoprotein cholesterol. We hereby report anesthetic challenges in a rare case of HoFH having severe progressive aortic stenosis, mitral regurgitation, diffuse aortic and carotid vessel involvement, and severe left ventricular dysfunction. The patient underwent a Konno aortoventriculoplasty with mechanical prosthesis along with mitral valve repair.
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http://dx.doi.org/10.1177/2150135117702127DOI Listing
July 2020

Prosthetic Mitral Valve Strut Masquerading as Left Ventricular Outflow Tract Obstruction: 3D Transesophageal Echocardiography Comes to the Rescue.

J Cardiothorac Vasc Anesth 2018 02 19;32(1):e6-e8. Epub 2017 Apr 19.

Department of Cardiac Anesthesiology, Cardio and Neuro sciences Centre, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.1053/j.jvca.2017.04.032DOI Listing
February 2018

An integrated nutrition and health program package on IYCN improves breastfeeding but not complementary feeding and nutritional status in rural northern India: A quasi-experimental randomized longitudinal study.

PLoS One 2017 20;12(9):e0185030. Epub 2017 Sep 20.

Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.

Background: Undernutrition below two years of age remains a major public health problem in India. We conducted an evaluation of an integrated nutrition and health program that aimed to improve nutritional status of young children by improving breast and complementary feeding practices over that offered by the Government of India's standard nutrition and health care program.

Methods: In Uttar Pradesh state, through multi-stage cluster random sampling, 81 villages in an intervention district and 84 villages in a comparison district were selected. A cohort of 957 third trimester pregnant women identified during house-to-house surveys was enrolled and, following childbirth, mother-child dyads were followed every three months from birth to 18 months of age. The primary outcomes were improvements in weight-for-age and length-for-age z scores, with improved breastfeeding and complementary feeding practices as intermediate outcomes.

Findings: Optimal breastfeeding practices were higher among women in intervention than comparison areas, including initiating breastfeeding within one hour of delivery (17.4% vs. 2.7%, p<0.001), feeding colostrum (34.7% vs. 8.4%, p<0.001), avoiding pre-lacteals (19.6% vs. 2.1%, p<0.001) and exclusively breastfeeding up to 6 months (24.1% vs. 15.3%, p = 0.001). However, differences were few and mixed between study arms with respect to complementary feeding practices. The mean weight-for-age z-score was higher at 9 months (-2.1 vs. -2.4, p = 0.0026) and the prevalence of underweight status was lower at 12 months (58.5% vs. 69.3%, p = 0.047) among intervention children. The prevalence of stunting was similar between study arms at all ages. Coefficients to show the differences between the intervention and comparison districts (0.13 cm/mo) suggested significant faster linear growth among intervention district infants at earlier ages (0-5 months).

Interpretation: Mothers participating in the intervention district were more likely to follow optimal breast, although not complementary feeding practices. The program modestly improved linear growth in earlier age and weight gain in late infancy. Comprehensive nutrition and health interventions are complex; the implementation strategies need careful examination to improve feeding practices and thus impact growth.

Trial Registration: The trial was registered with ClinicalTrials.gov, NCT00198835.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0185030PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5607187PMC
October 2017

Non-governmental organization facilitation of a community-based nutrition and health program: Effect on program exposure and associated infant feeding practices in rural India.

PLoS One 2017 14;12(9):e0183316. Epub 2017 Sep 14.

Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.

Background: Integrated nutrition and health programs seek to reduce undernutrition by educating child caregivers about infant feeding and care. Data on the quality of program implementation and consequent effects on infant feeding practices are limited. This study evaluated the effectiveness of enhancing a nutrition and health program on breastfeeding and complementary-feeding practices in rural India.

Methods: Utilizing a quasi-experimental design, one of the implementing districts of a Cooperative for Assistance and Relief Everywhere (CARE) nutrition and health program was randomly selected for enhanced services and compared with a district receiving the Government of India's standard nutrition and health package alone. A cohort of 942 mother-child dyads was longitudinally followed from birth to 18 months. In both districts, the evaluation focused on responses to services delivered by community-based nutrition and health care providers [anganwadi workers (AWWs) and auxiliary nurse midwives (ANMs)].

Findings: The CARE enhanced program district showed an improvement in program coverage indicators (e.g., contacts, advice) through outreach visits by both AWWs (28.8-59.8% vs. 0.7-12.4%; all p<0.05) and ANMs (8.6-46.2% vs. 6.1-44.2%; <0.05 for ages ≥6 months). A significantly higher percentage of child caregivers reported being contacted by the AWWs in the CARE program district (20.5-45.6% vs. 0.3-21.6%; p<0.05 for all ages except at 6months). No differences in ANM household contacts were reported. Overall, coverage remained low in both areas. Less than a quarter of women received any infant feeding advice in the intervention district. Earlier and exclusive breastfeeding improved with increasing number or quality of visits by either level of health care provider (OR: 2.04-3.08, p = <0.001), after adjusting for potentially confounding factors. Socio-demographic indicators were the major determinants of exclusive breastfeeding up to 6 month and age-appropriate complementary-feeding practices thereafter in the program-enhanced but not comparison district.

Interpretation: An enhanced nutrition and health intervention package improved program exposure and associated breastfeeding but not complementary-feeding practices, compared to standard government package.

Trial Registration: ClinicalTrials.gov NCT00198835.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0183316PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5598933PMC
October 2017

Management of iatrogenic pulmonary artery injury during pulmonary artery banding.

Ann Card Anaesth 2017 Jul-Sep;20(3):379-380

Department of Cardiac Anaesthesia, Cardiothoracic Centre, All Institute of Medical Sciences, New Delhi, India.

Pulmonary Artery banding (PAB) is limited to selected patients who cannot undergo primary repair due to complex anatomy, associated co-morbidities, as a part of staged univentricular palliation, and for preparing the left ventricle prior to an arterial switch operation. We report a catastrophic iatrogenic complication in which the pulmonary artery was injured during the PAB. We discuss its multi-pronged management.
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http://dx.doi.org/10.4103/aca.ACA_47_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5535589PMC
May 2018

The blalock and taussig shunt revisited.

Ann Card Anaesth 2017 Jul-Sep;20(3):323-330

Department of Cardiac Anaesthesia, CTC, AIIMS, New Delhi, India.

The systemic to pulmonary artery shunts are done as palliative procedures for cyanotic congenital heart diseases ranging from simple tetralogy of Fallots (TOFs)/pulmonary atresia (PA) to complex univentricular hearts. They allow growth of pulmonary arteries and maintain regulated blood flow to the lungs till a proper age and body weight suitable for definitive corrective repair is reached. We have reviewed the BT shunt with its anaesthtic considerations and management of associated complications.
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http://dx.doi.org/10.4103/aca.ACA_80_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5535574PMC
May 2018

Diagnostic dilemma: Low oxygen saturation during cardiac surgery.

Ann Card Anaesth 2017 Apr-Jun;20(2):262-264

Department of Cardiothoracic and Vascular Surgery, CNC, AIIMS, New Delhi, India.

We report a case of rheumatic heart disease with severe mitral stenosis having cyanosis and low oxygen saturation on pulse oximetry. The findings of clinical examination and low values on pulse oximetry were inconsistent with the findings of normal partial pressure of oxygen and oxygen saturation on arterial blood gas analysis, leading to diagnostic dilemma. In such clinical scenario, the anesthesiologist should be aware and vigilant about the differential diagnosis of low oxygen saturation on pulse oximetry.
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http://dx.doi.org/10.4103/aca.ACA_34_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5408540PMC
November 2017

Does sleep quality affects the immediate clinical outcome in patients undergoing coronary artery bypass grafting: A clinico-biochemical correlation.

Ann Card Anaesth 2017 Apr-Jun;20(2):193-199

Department of Cardiac Anaesthesia, All India Institute of Medical Sciences, New Delhi, India.

Objective: Poor sleep quality is emerging as high prevalence among the patients suffering from cardiometabolic disturbances. The vascular polypeptide endothelin 1 (ET-1) is involved in many of the health disorders. However, its potential involvement in patients having poor sleep quality along with cardiovascular problem is limited. The present study was formulated to conduct a prospective analysis of the relationship between ET-1 and in hospital outcome in sleep disorder patients undergoing routine coronary artery bypass grafting (CABG).

Methods: A total of 156 patients were enrolled and divided into two groups based on the Pittsburg Sleep Quality Index (PSQI) of ≤5 (Group I, n = 101) or >5 (Group II, n = 55). Blood sample was collected before anesthesia induction (ET-1a) and at 48 h (ET-1b) to analyze the plasma ET-1 and blood sugar level. The patients were monitored for any intraoperative adverse events and postoperative complications during their hospital stay.

Results: Both groups were comparable in relation to age, sex, incidence of smoking and alcohol consumption. The distribution of comorbid conditions was also similar in both groups. The ET-1 level was higher in Group II than Group I before anesthesia induction as well as 48 h postoperatively (4.5 ± 1.75 vs. 10.61 ± 9.3, P = 0.001; 2.08 ± 1.3 vs. 8.3 ± 9.86, P = 0.0001, respectively). The Group II patients had a longer duration of mechanical ventilation (14.6 ± 12.05 vs. 10.1 ± 8.19, P = 0.001), Intensive Care Unit stay (2.08 ± 0.95 vs. 2.7 ± 1.45, P = 0016) and hospital stay (5.98 ± 1.73 vs. 7.8 ± 3.66, P = 0.0001, respectively). The high number of patients from Group II required inotrope and intra-aortic balloon pump support while compared with Group I (P ≤ 0.05 in each). The overall postoperative complication rate was significantly higher among patients with PSQI of >5 (Group II) except the rate of infection and neurological complications which was similar among both group of patients. The postoperative in hospital mortality was nil in Group I and 3.6% in Group II (P = 0.05). There was a strong relationship between PSQI and ET-1 at both the time points.

Conclusion: Poor sleep quality associated with a higher incidence of adverse perioperative events in patients undergoing elective CABG. There exists a potential link between poor sleep quality and ET-1 in these groups of patients.
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http://dx.doi.org/10.4103/aca.ACA_30_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5408525PMC
November 2017

The role of Rajyoga meditation for modulation of anxiety and serum cortisol in patients undergoing coronary artery bypass surgery: A prospective randomized control study.

Ann Card Anaesth 2017 Apr-Jun;20(2):158-162

Department of Cardiac Anaesthesia and Surgery, Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India.

Introduction: Rajyoga meditation is a form of mind body intervention that is promoted by the Brahma Kumaris World Spiritual University. This form of meditation can be easily performed without rituals or mantras and can be practiced anywhere at any time. The practice of Rajyoga meditation can have beneficial effects on modulating anxiety and cortisol level in patients undergoing major cardiac surgery.

Materials And Methods: A prospective randomized control study was carried out in a single tertiary care center. One hundred and fifty patients undergoing elective coronary artery bypass surgery were enrolled in the study. The patients were randomized in two groups namely, Group 1 (Rajyoga group) and Group 2 (Control Group). Anxiety was measured on a visual analog scale 1-10 before the start of Rajyoga training or patient counseling (T1), on the morning of the day of surgery (T2), on the 2nd postoperative day (T3), and on the 5th postoperative day (T4). The serum cortisol level was measured in the morning of the day of surgery (T1), on the 2nd postoperative day (T2) and on the 5th postoperative day (T3), respectively.

Results: In the study, it was seen that the anxiety level of the patients before the surgery (T1) and on the day of surgery (T2) were comparable between the two groups. However on the 2nd postoperative day (T3), the patients who underwent Rajyoga training had lower anxiety level in comparison to the control group (3.12 ± 1.45 vs. 6.12 ± 0.14, P < 0.05) and on the 5th postoperative day (T4) it was seen that Rajyoga practice had resulted in significant decline in anxiety level (0.69 ± 1.1 vs. 5.6 ± 1.38, P < 0.05). The serum cortisol level was also favorably modulated by the practice of Rajyoga meditation.

Conclusion: Mindbody intervention is found to effective in reducing the anxiety of the patients and modulating the cortisol level in patients undergoing wellknown stressful surgery like coronary artery bypass surgery.
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http://dx.doi.org/10.4103/aca.ACA_32_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5408519PMC
November 2017

Anger: An enemy of heart, raj yoga meditation is heart friendly.

Ann Card Anaesth 2017 Apr-Jun;20(2):127-128

Department of Cardiac Anaesthesia, CTC, AIIMS, New Delhi, India.

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http://dx.doi.org/10.4103/aca.ACA_29_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5408513PMC
August 2018

Assessment of Changes in Hemodynamics and Intrathoracic Fluid Using Electrical Cardiometry During Autologous Blood Harvest.

J Cardiothorac Vasc Anesth 2017 Feb 26;31(1):84-89. Epub 2016 Jul 26.

Department of Cardio-Thoracic and Vascular Surgery, Cardio and Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India.

Objective: To evaluate the effect of autologous blood harvest (ABH)-induced volume shifts using electrical cardiometry (EC) in patients with pulmonary artery hypertension secondary to left heart disease.

Design: Prospective, randomized, controlled trial.

Setting: A tertiary care hospital.

Participants: The study comprised 50 patients scheduled to undergo heart valve replacement.

Interventions: Patients were divided randomly into 2 experimental groups that were distinguished by whether ABH was performed. Blood volume extracted in the test group was replaced simultaneously with 1:1 colloid (Tetraspan; B Braun Melsungen, Melsungen, Germany). Hemodynamic, respiratory, and EC-derived parameters were recorded at predefined set points (T1 [post-induction/pre-ABH] and T2 [20 minutes post-ABH]).

Measurements And Main Results: Withdrawal of 15% of blood volume in the ABH group caused significant reductions in thoracic fluid content (TFC) (-10.1% [-15.0% to -6.1%]); right atrial pressure (-23% [-26.6% to -17.6%]); mean arterial pressure (-12.6% [-22.2% to -3.8%]); airway pressures: (peak -6.2% [-11.7% to -2.8%] and mean -15.4% [-25.0% to -8.3%]); and oxygenation index (-10.34% [-16.4% to -4.8%]). Linear regression analysis showed good correlation between the percentage change in TFC after ABH and the percentage of change in right atrial pressure, stroke volume variation, autologous blood extracted, peak and mean airway pressures, and oxygen index.

Conclusions: In addition to its proven role in blood conservation, therapeutic benefits derived from ABH include decongestion of volume-loaded patients, decrease in TFC, and improved gas exchange. EC tracks beat-to-beat fluid and hemodynamic fluctuations during ABH and helps in the execution of an early patient-specific, goal-directed therapy, allowing for its safe implementation in patients with pulmonary hypertension secondary to left heart disease.
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http://dx.doi.org/10.1053/j.jvca.2016.07.032DOI Listing
February 2017

Global end-diastolic volume an emerging preload marker vis-a-vis other markers - Have we reached our goal?

Ann Card Anaesth 2016 Oct-Dec;19(4):699-704

Department of Cardiac Anaesthesia, CTC, AIIMS, New Delhi, India.

A reliable estimation of cardiac preload is helpful in the management of severe circulatory dysfunction. The estimation of cardiac preload has evolved from nuclear angiography, pulmonary artery catheterization to echocardiography, and transpulmonary thermodilution (TPTD). Global end-diastolic volume (GEDV) is the combined end-diastolic volumes of all the four cardiac chambers. GEDV has been demonstrated to be a reliable preload marker in comparison with traditionally used pulmonary artery catheter-derived pressure preload parameters. Recently, a new TPTD system called EV1000™ has been developed and introduced into the expanding field of advanced hemodynamic monitoring. GEDV has emerged as a better preload marker than its previous conventional counterparts. The advantage of it being measured by minimum invasive methods such as PiCCO™ and newly developed EV1000™ system makes it a promising bedside advanced hemodynamic parameter.
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http://dx.doi.org/10.4103/0971-9784.191554DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5070331PMC
March 2017

Echocardiographic Predictors of Immediate Postoperative Outcomes in Patients With Severe Left Ventricular Systolic Dysfunction Undergoing On-Pump Coronary Artery Bypass Grafting.

J Cardiothorac Vasc Anesth 2017 Feb 29;31(1):184-190. Epub 2016 Apr 29.

All India Institute of Medical Sciences, New Delhi, India.

Objectives: The postoperative course following on-pump coronary artery bypass grafting (CABG) in patients with severe left ventricular (LV) systolic dysfunction is often unpredictable. Therefore, the aim of this study was to identify predictors of poor postoperative outcome in this subset of patients.

Design: Prospective observational study SETTING: Single university hospital PARTICIPANTS: Forty patients with severe LV systolic dysfunction undergoing isolated on-pump CABG INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: Comprehensive transesophageal echocardiographic examination was performed to obtain the indices of systolic and diastolic LV function after induction of anesthesia. A poor postoperative outcome was defined as patient death or vasoactive inotropic score≥20 for at least 6 hours and/or requiring intra-aortic balloon counterpulsation and/or mechanical ventilation for≥24 hours. Poor postoperative outcome was observed in 40% (16/40) of patients. Patients with poor postoperative outcomes had a significantly higher systolic dyssynchrony index, septal-lateral delay with a significantly lower global longitudinal strain and isovolumic acceleration, end-diastolic volume, end-systolic volume, and lateral and medial mitral annulus systolic velocity. In a binary logistic regression model, global longitudinal strain (odds ratio, 1.5, confidence interval [CI] 95%, 1.19-1.88, p = 0.001), septal-lateral delay (odds ratio, 1.02, 95% CI, 1.01-1.03; p = 0.001) and systolic dyssychrony index (odds ratio, 1.3, 95% CI, 1.13-1.48; p = 0.000) were found to be predictors of poor postoperative outcome.

Conclusion: Global longitudinal strain, systolic dyssynchrony index, and septal-lateral delay were reliable and accurate predictors of adverse outcomes in patients with severe LV systolic dysfunction undergoing on-pump CABG.
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http://dx.doi.org/10.1053/j.jvca.2016.04.025DOI Listing
February 2017

Simulation in cardiac catheterization laboratory: Need of the hour to improve the clinical skills.

Ann Card Anaesth 2016 Jul-Sep;19(3):521-6

Department of Cardiac Anaesthesia, CTC, AIIMS, New Delhi, India.

Simulation is an effective teaching tool to decrease the learning curve for novices without compromising patient safety. Simulation helps interventionalist in mentally translating a two dimentional, black and white image into a usable three dimentional model. It also bridges the gap in training diverse team members on new procedures and products. All simulators have collision detection, i.e., virtual contact forces generated from collision which updates haptic output with new calculations.
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http://dx.doi.org/10.4103/0971-9784.185548DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4971983PMC
March 2017

Serum albumin perturbations in cyanotics after cardiac surgery: Patterns and predictions.

Ann Card Anaesth 2016 Apr-Jun;19(2):300-5

Department of Cardiac Anaesthesiology, Cardiothoracic and Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India.

Introduction: Hypoalbuminemia is a well-recognized predictor of general surgical risk and frequently occurs in patients with cyanotic congenital heart disease (CCHD). Moreover, cardiopulmonary bypass (CPB)-induced an inflammatory response, and the overall surgical stress can effect albumin concentration greatly. The objective of his study was to track CPB-induced changes in albumin concentration in patients with CCHD and to determine the effect of hypoalbuminemia on postoperative outcomes.

Materials And Methods: Prospective observational study conducted in 150 patients, Group 1 ≤18 years (n = 75) and Group 2 >18 years (n = 75) of age. Albumin levels were measured preoperatively (T1), after termination of CPB (T2) and 48 h post-CPB (T3). Primary parameters (mortality, duration of postoperative ventilation, duration of inotropes and duration of Intensive Care Unit [ICU] stay) and secondary parameters (urine output, oliguria, arrhythmias, and hemodynamic parameters) were recorded.

Results: The albumin levels in Group 1 at T1, T2, and T3 were 3.8 ± 0.48, 3.2 ± 0.45 and 2.6 ± 0.71 mg/dL; and in Group 2 were 3.7 ± 0.50, 3.2 ± 0.49 and 2.7 ± 0.62 mg/dL respectively. All patients showed a significant decrease in albumin concentration 48 h after surgery (P < 0.01). Analysis between the groups, however, showed no statistical difference. Eleven patients expired during the study period, and nonsurvivors showed significantly lower serum albumin concentration 48 h after surgery 2.3 ± 0.62 mg/dL versus 3.7 ± 0.56 mg/dL in the survivors (P < 0.05). Receiver operating characteristic curve showed that a baseline albumin cut-off value of 3.3 g/dL predicts mortality with a positive predictive value 47.6% and a negative predictive value of 99.2% (P < 0.05). A strong correlation was seen between albumin levels at 48 h with duration of CPB (r2 = 0.6321), ICU stay (r2 = 0.7447) and incidence of oliguria (r2 = 0.8803).

Conclusions: The study demonstrated similar fall in albumin concentration in cyanotic patients (both adult and pediatric) in response to CPB. Low preoperative serum albumin concentrations (<3.3 g/dL) can be used to identify and prognosticate subset of cyanotics predisposed to additional surgical risk.
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http://dx.doi.org/10.4103/0971-9784.179633DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4900356PMC
January 2017

The role of blood lactate clearance as a predictor of mortality in children undergoing surgery for tetralogy of Fallot.

Ann Card Anaesth 2016 Apr-Jun;19(2):217-24

Department of Cardiac Anesthesia, C. N. Centre, All India Institute of Medical Sciences, New Delhi, India.

Background: The identification of biomarkers for predicting morbidity and mortality, particularly in pediatric population undergoing cardiac surgery will contribute toward improving the patient outcome. There is an increasing body of literature establishing the clinical utility of hyperlactatemia and lactate clearance as prognostic indicator in adult cardiac surgical patients. However, the relationship between lactate clearance and mortality risk in the pediatric population remains to be established.

Objective: To assess the role of lactate clearance in determining the outcome in children undergoing corrective surgery for tetralogy of Fallot (TOF).

Methods And Study Design: A prospective, observational study.

Setting: A tertiary care center.

Study Population: Two hundred children undergoing elective surgery for TOF.

Study Method: Blood lactate levels were obtained as baseline before operation (T0), postoperatively at admission to the cardiac intensive care unit after surgery (T1), and then at every 6 h for the first 24 h of Intensive Care Unit (ICU) stay (T6, T12, T18, and T24, respectively). The lactate clearance in the study is defined by the equation ([lactate initial - lactate delayed]/lactate initial) ×100%. Lactate clearance was determined at T1-T6, T1-T12, T1-T18, and T1-T24 time interval, respectively. The primary outcome measured was mortality. Secondary outcomes measured were the duration of mechanical ventilation, duration of inotropic requirement, and duration of ICU stay.

Results: Eleven out of the two hundred patients enrolled in the study died. Nonsurvivors had higher postoperative lactate concentration (P < 0.05) and low-blood lactate clearance rate during 24 h (P < 0.05) in comparison to the survivors. Lactate clearance was significantly higher in survivors than in nonsurvivors for the T1-T6 period (19.55 ± 14.28 vs. 5.24 ± 27.79%, P = 0.009) and remained significantly higher for each studied interval in first 24 h. Multivariate logistic regression analysis of statistically significant univariate variables showed early lactate clearance to have a significant relationship with mortality. Patients with a lactate clearance >10%, relative to patients with a lactate clearance <10%, in the early postoperative period, had improved outcome and lower mortality.

Conclusion: Lactate clearance in the early postoperative period (6 h) is associated with decreased mortality rate. Patients with higher lactate clearance (>10%) after 6 h have improved outcome compared with those with lower lactate clearance.
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http://dx.doi.org/10.4103/0971-9784.179589DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4900343PMC
January 2017

Life-threatening ruptured femoral artery pseudoaneurysm: A delayed complication of endovascular aortic repair of abdominal aortic aneurysm.

Ann Card Anaesth 2016 Jan-Mar;19(1):154-5

Department of Cardiac Anaesthesia, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.4103/0971-9784.173037DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4900381PMC
October 2016

Role of phenoxybenzamine in perioperative clinical practice.

Ann Card Anaesth 2015 Oct-Dec;18(4):577-8

Department of Cardiac Anaesthesia, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.4103/0971-9784.166473DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4881667PMC
July 2016

Comparison of the effects of inhalational anesthesia with desflurane and total intravenous anesthesia on cardiac biomarkers after aortic valve replacement.

Ann Card Anaesth 2015 Oct-Dec;18(4):502-9

Department of Cardiac Anesthesiology, All India Institute of Medical Sciences, New Delhi, India.

Objective (s): The aim of this study was to compare the effects of using inhalational anesthesia with desflurane with that of a total intravenous (iv) anesthetic technique using midazolam-fentanyl-propofol on the release of cardiac biomarkers after aortic valve replacement (AVR) for aortic stenosis (AS). The specific objectives included (a) determination of the levels of ischemia-modified albumin (IMA) and cardiac troponin I (cTnI) as markers of myocardial injury, (b) effect on mortality, morbidity, duration of mechanical ventilation, length of Intensive Care Unit (ICU) and hospital stay, incidence of arrhythmias, pacing, cardioversion, urine output, and serum creatinine. Methodology and Design: Prospective randomized clinical study.

Setting: Operation room of a cardiac surgery center of a tertiary teaching hospital.

Participants: Seventy-six patients in New York Heart Association classification II to III presenting electively for AVR for severe symptomatic AS.

Interventions: Patients included in the study were randomized into two groups and subjected to either a desflurane-fentanyl based technique or total IV anesthesia (TIVA). Blood samples were drawn at preordained intervals to determine the levels of IMA, cTnI, and serum creatinine.

Measurements And Main Results: The IMA and cTnI levels were not found to be significantly different between both the study groups. Patients in the desflurane group were found to had significantly lower ICU and hospital stays and duration of postoperative mechanical ventilation as compared to those in the TIVA group. There was no difference found in mean heart rate, urine output, serum creatinine, incidence of arrhythmias, need for cardioversion, and 30-day mortality between both groups. The patients in the TIVA group had higher mean arterial pressures on weaning off cardiopulmonary bypass as well as postoperatively in the ICU and recorded lower inotrope usage.

Conclusion: The result of our study remains ambiguous regarding the overall protective effect of desflurane in patients undergoing AVR although some benefit in terms of shorter duration of postoperative mechanical ventilation, ICU and hospital stays, as well as cTnI, were seen. However, no difference in overall outcome could be clearly established between patients who received desflurane and those that were managed solely with IV anesthetic technique using propofol.
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http://dx.doi.org/10.4103/0971-9784.166455DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4881682PMC
July 2016

Echocardiographic Assessment of the Alterations in Pulmonary Blood Flow Associated with Ketamine and Etomidate Administration in Children with Tetralogy of Fallot.

Echocardiography 2016 Feb 19;33(2):307-13. Epub 2015 Jul 19.

All India Institute of Medical Sciences, New Delhi, India.

Background: Despite widespread uses of ketamine, the clinical studies determining its effect on pulmonary blood flow in children with tetralogy of Fallot (TOF) are lacking. Furthermore, the quantification of pulmonary blood flow is not possible in these patients, because pulmonary artery catheter is contraindicated. Therefore, the purpose of this study was to evaluate the changes in pulmonary blood flow by intra-operative transesophageal echocardiography after ketamine or etomidate administration in children with TOF.

Methods: Eleven children each in the two clinical variants of TOF (group A-moderate to severe cyanosis; group B-mild to minimal cyanosis) undergoing intracardiac repair were prospectively studied after endotracheal intubation. A single bolus dose of ketamine (2 mg/kg) and etomidate (0.3 mg/kg) was administered in a random order after 15 minute interval. Hemodynamic, arterial blood gas, and echocardiographic measurements were obtained at 7 consecutive times (T) points (baseline, 1, 2, 4, 6, 8, and 15 minutes after drug administration).

Results: Ketamine produced a significant reduction in VTI-T (velocity time integrals total of left upper pulmonary vein), RVOT-PG (right ventricular outflow tract peak gradient), and MG (mean gradient) in group A while those in group B had a significant increase in VTI-T, RVOT-PG, and RVOT-MG at time (T1, T2, T4, and T6; P = 0.00). This divergent behavior, however, was not observed with etomidate.

Conclusion: Etomidate does not change pulmonary blood flow. However, ketamine produces divergent effects; it increases pulmonary blood flow in children with minimal cyanosis and decreases pulmonary blood flow in children with moderate to severe cyanosis.
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http://dx.doi.org/10.1111/echo.13014DOI Listing
February 2016

Inverted left atrial appendage: a complication of de-airing during cardiac surgery.

Can J Anaesth 2015 Oct 3;62(10):1119-20. Epub 2015 Jul 3.

Department of Cardiac Anaesthesiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India,

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http://dx.doi.org/10.1007/s12630-015-0412-1DOI Listing
October 2015

Effect of Levosimendan on Diastolic Function in Patients Undergoing Coronary Artery Bypass Grafting: A Comparative Study.

J Cardiovasc Pharmacol 2015 Aug;66(2):141-7

Departments of *Cardiac Anesthesiology; and †Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India.

Purpose: To compare the efficacy of levosimendan with nitroglycerin in patients with isolated diastolic dysfunction undergoing coronary artery bypass grafting.

Procedure: Thirty patients with isolated diastolic dysfunction undergoing on-pump coronary artery bypass grafting were randomized into 2 groups receiving levosimendan or nitroglycerin infusion. The infusion was started before sternotomy and continued in the postoperative period. Perioperatively, diastolic function was serially evaluated at 3 different time points using echocardiography. N-terminal fragment of pro-B-natriuretic peptide (NT-proBNP) levels were measured in both the groups.

Results: There was a significant improvement in diastolic function as measured by isovolumic relaxation time (P = 0.0001, P = 0.001) and deceleration time (P = 0.0001, P = 0.0001) in the levosimendan group from the baseline in patients with impaired relaxation. Similarly, tissue Doppler imaging also revealed an improvement from the baseline in patients with a pseudonormal pattern (P = 0.018, P = 0.001). Furthermore, there was a significant improvement in the above parameters when compared with the nitroglycerin group. The NT-proBNP levels also demonstrated a similar pattern between the 2 groups (P = 0.03, P = 0.02) when levosimendan was compared with nitroglycerin in patients with a pseudonormal pattern on echocardiography.

Conclusions: Levosimendan is superior to nitroglycerin in improving diastolic function irrespective of coronary revascularization.
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http://dx.doi.org/10.1097/FJC.0000000000000256DOI Listing
August 2015

Flambeau in the left atrium.

Ann Card Anaesth 2015 Apr-Jun;18(2):274-5

Department of Cardiac Anaesthesia, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.4103/0971-9784.154503DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4881637PMC
January 2016

Comparison of two-dose priming plus 9-month booster with a standard three-dose priming schedule for a ten-valent pneumococcal conjugate vaccine in Nepalese infants: a randomised, controlled, open-label, non-inferiority trial.

Lancet Infect Dis 2015 Apr 18;15(4):405-14. Epub 2015 Feb 18.

Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the NIHR Oxford Biomedical Research Centre, Oxford, UK.

Background: Use of pneumococcal conjugate vaccines (PCVs) in resource-poor countries has focused on early infant immunisation with little emphasis on protection in late infancy and beyond. Boosting of the immune response later in infancy might provide improved persistence of immunogenicity into early childhood, however data are scarce. The aim of this study was to investigate if a two-dose prime with booster at age 9 months compared with a three-dose prime-only PCV schedule provided non-inferior immunogenicity in early infancy and superior persistence of antibody responses in early childhood.

Methods: We did an open-label, randomised, parallel group, controlled trial in healthy infants aged 40-60 days from Kathmandu, Nepal. Participants were randomly allocated (4:4:5 ratio) to receive PCV10 in addition to routine immunisations either as a two-dose prime and boost (2+1), three-dose prime (3+0), or two doses after completion of the initial study phase (0+2). We used a computer generated randomisation list with randomly varying block sizes. We followed up participants at age 2-4 years together with a group of unvaccinated controls. Sera were analysed for opsonophagocytic activity, protein D, and PCV10 serotype-specific IgG. Laboratory staff was masked to intervention group assignment. The primary outcome measure was to determine the proportion of participants in the 2+1 group at age 10 months with specific IgG for serotypes 1, 5, and 14 of at least 0·2 μg/mL in the per-protocol population. The secondary outcomes were non-inferiority (within 10% levels) at age 18 weeks for the proportion of participants in the 2+1 group compared with the 3+0 group with serotypes 1, 5, and 14 specific IgG of at least 0·2 μg/mL; the proportion of participants with PCV10 serotype-specific IgG of at least 0·2 μg/mL and opsonophagocytic activity reciprocal titre of at least 8 at ages 18 weeks and 10 months; and nasopharyngeal pneumococcal serotype-specific carriage rates at age 9 months in each study group. In the follow-up study, the primary outcome measure was the proportion of participants with IgG of at least 0·2 μg/mL for PCV10 serotypes at age 2-4 years in children previously immunised with a 3+0 schedule compared with a 2+1 schedule. The trial is registered with Current Controlled Trials, registration number ISRCTN56766232.

Findings: Between May 10, 2010, and Jan 7, 2011, 390 children were randomly assigned to each group: 119 to the 2+1 group, 120 to the 3+0 group, and 151 to the 0+2 group. At age 10 months, the proportions of 2+1 participants with IgG of at least 0·2 μg/mL were 99·0% (95% CI 94·2-100·0) for serotype 1, 100% (96·2-100·0) for serotype 5, and 97·9% (92·5-99·7) for serotype 14. At age 18 weeks, non-inferiority (within 10% levels) of the 2+1 group was shown compared with the 3+0 group, and there was no difference between the 2+1 and 3+0 groups for the proportion with IgG of at least 0·2 μg/mL for any of the PCV10 serotypes. At age 10 months, proportions with IgG of at least 0·2 μg/mL for serotypes 1, 5, 6B, and 23F, were higher in the 2+1 group than in the 3+0 group. At age 18 weeks, there were no differences in opsonophagocytic activity between the 2+1 and 3+0 groups for reciprocal titres of at least 8, but at age 10 months, proportions with an opsonophagocytic reciprocal titre of at least 8 for serotypes 1, 4, 5, 6B, 18C, 19F and 23F were higher in the 2+1 group than in the 3+0 group. At age 2-4 years, there were higher proportions in the 2+1 group versus the 3+0 group with IgG of at least 0·2 μg/mL for serotypes 1, 5, 6B, and 18C.

Interpretation: Use of a 2+1 PCV schedule with booster at age 9 months in a resource-poor setting improved antibody persistence through early childhood without compromising antibody responses in early infancy. This schedule is now recommended by WHO for progressive introduction across Nepal, with PCV10 introduction having commenced on Jan 18, 2015. Concurrent pre-implementation and post-implementation surveillance is being done by a GAVI Alliance funded study.

Funding: This study was supported by funding from the National Institute for Public Health and the Environment, The Netherlands; Oxford Vaccine Group, University of Oxford, UK; and GlaxoSmithKline Biologicals, Belgium.
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http://dx.doi.org/10.1016/S1473-3099(15)70007-1DOI Listing
April 2015

Sutureless left pulmonary vein augmentation for primary endoluminal pulmonary vein ostial stenosis: role of pulmonary venous Doppler.

Ann Card Anaesth 2015 Jan-Mar;18(1):113-4

Department of Cardiac Anesthesiology, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.4103/0971-9784.148337DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4900316PMC
September 2015
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