Anaesthesia

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Browsing Anaesthesia by Author "Don Jose Palamattam"

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    Bedside Chest Ultrasound in post operative pediatric Cardiac Surgery patients: Comparison with bedside chest radiography.
    (2019-12-31) Don Jose Palamattam
    Traditionally, chest imaging in post operative cardiac surgical patients, is performed using bedside chest radiography (CXR). It is considered as standard of care to evaluate intra-thoracic structures including heart, lung, mediastinum and their abnormalities. CXR also evaluates position of chest tubes, mediastinal tubes, central venous lines, pulmonary artery catheters, endotracheal tubes and enteral feeding tube [1]. Respiratory complication is one of the major causes of morbidity and death in cardiac post operative patients in adult and pediatric population. Whenever there is a suspicion of intra thoracic pathology, including improper position of tubes and catheters, the need for repeated bedside CXR and thus subsequent unavoidable radiation exposure is inevitable. Other factors leading to the need for repetition of bedside CXR are suboptimal X-ray films, improper positioning of patient and poor correlation with CT scan [2]. Each bed side CXR exposes a patient to 0.02 milli-sieverts of radiation [3]. Though it looks invariably small, repeated CXRs exposes patient to increasing amounts of radiation. Paediatric age group especially neonates , have greater areas of exposure, due to small body surface area and are thus sensitive to hazardous effects of ionizing radiation. The threat of developing immune dysfunction, cataract, cognitive decline and malignancy in later part of life is a possibility [4]. Therefore, effort should be made to minimize radiation exposure whenever possible [5]. Chest ultrasound (CUS) is a fast, repeatable and radiation free methodology. 2 It is simple to use and requires a limited period of training [6]. It allows for bedside detection of primary pulmonary pathologies [7] such as pleural effusion, pneumothorax, lung atelectasis, or secondary pulmonary pathologies due to cardiac causes (interstitial pulmonary oedema, basal atelectasis) and conditions such as diaphragmatic palsy, subcutaneous emphysema, pericardial effusion, cardiac tamponade and endobronchial intubation [8]. Examination can be done alone or in combination with echocardiography and intravascular volume assessment, thus reducing cost and time. Diaphragmatic dysfunction, due to phrenic nerve injury, is a complication in postoperative cardiac surgery patients, with an incidence between 0.3% - 20% [9]. Most phrenic nerve injuries are due to transient neuroapraxia of the nerve, secondary to traction, local application of cold solutions, or accidental injury [10]. Rarely, it is caused by direct transection of the phrenic nerve. Diaphragmatic dysfunction impedes normal lung expansion during inspiration [9] and weaning from mechanical ventilation becomes difficult. It is associated with prolonged ventilatory support, intensive care stay, increased risk of nosocomial infections, and an overall morbidity and death [11]. Chest fluoroscopy is the gold standard for diagnosis of diaphragmatic dysfunction. But it is associated with shifting of critically ill children to radiology suite and exposure to higher ionizing radiation. Other modalities include phrenic nerve conduction studies and CUS. CUS being a rapid and easily available technique at the bedside, allows for early diagnosis of abnormal diaphragmatic motion [12]. 3 The use of CUS in the post operative adult cardiac patients is gaining popularity [6]. However, there is little data available concerning the use of CUS in the post operative cardiac pediatric and neonatal populations [13]. To address the above issue, we intend to study the degree of agreement between CUS and CXR; to compare the diagnostic performance of bedside chest ultrasound (CUS) with bedside chest radiography (CXR), for the detection of abnormalities of thorax including abnormal diaphragmatic motion, in postoperative pediatric cardiac surgical patients. We also intend to compare the therapeutic interventions done on basis of CUS and CXR derived information in the postoperative setting.