Dr. Sandeep Agarwala

Dr. Sandeep Agarwala

Sr. Consultant Cardio-thoracic Surgery

ECMO-Game Changer/ Life-saver

It was a routine morning and we were getting ready for the routine surgical list. I just stepped to the neurosurgical ICU to see a patient who was admitted early morning with multiple trauma and had been referred to me for chest injury. He was being ventilated and needed a fair bit of support to maintain his respiratory parameters. His neurological status seemed to be borderline and he had fracture involving ribs, collar bone (clavicle) and pelvis and femur. His lung injury seemed bad as well. Usually these injuries recover on their own but they do need prolonged support with ventilator. After speaking to his relative about the seriousness of the injuries and the fact there was little for me to add on anything at this stage to the treatment of the intensivist I made my way back to my OT. I did warn them that next 24-48 hours were crucial and that once he crosses that recovery will be slow and prolonged.
Later on in the day he seemed to deteriorate and the intensivist found him difficult to ventilate. He was unable to maintain his gas exchange despite full ventilator settings. His carbon dioxide levels were rising up dangerously. There’ was only one option available to support his failing lungs and that too was fraught with dangers. But as he was a young lad who had been married only last year we decided to offer this option to the family. ECMO is a machine which works as the artificial lungs and heart for a patient like this. It needs blood to be kept very thin and that increases the risk of bleeding in cases of trauma which can cause major internal bleeding and death.
As there was no option but to accept the risks family decided to go ahead. We were successful in putting the patient on ECMO. His gas exchange immediately improved and he stabilized. Rest of the injuries needed operative treatment but as he was on blood thinners these had to be postponed. Only if there was a chance that he would survive, it would make sense in undergoing these surgeries. After 3-4 days his neurological status improved and he became fully awake which kept our hope alive. By 10th day his lungs had cleared up completely and we were able to remove the ECMO. In next 24 hours his hemoglobin levels dropped significantly and we were not sure where would he be loosing the blood. Luckily for us as his blood thinners were off we hoped his bleeding would not worsen.. Then his urine output stopped and an ultrasound confirmed that he had bleed behind his pelvic bone from the fracture site and this blood created compression on the bladder. He went to surgery for evacuation of blood clots ( hematoma)and this solved his problem. Urine output recovered and all other fracture fixations` were done. After staying in hospital for one month and efforts of team of doctors he was finally sent home and has now recovered completely.
Sometimes modern technology with back up of experts and infrastructure with a blind faith of the family in the treating team leads to saving precious lives.

To be or not to be (TB or not TB)

Tuberculosis is endemic in our country and any one who has fever of unknown origin invariably lands up on anti tubercular drugs. Sometimes patients respond to this empiric treatment and sometimes there is something more sinister lurking around.. We had a middle age gentleman who was in as similar situation. He had fever for six months, had lost weight and was persistently feeling unwell. All antibiotics had been tried and even a course of anti tubercular drugs was given. But fever kept on coming and his inflammatory parameters were raised. When he presented here an echocardiography showed small clumps of possible growth of organisms on his valve. To us this seemed to be the most likely reason for his symptoms. We suggested him to get operated and get his valve changed. As he was fed up of having antibiotics for such a long time he agreed to undergo surgery with lot of reluctance and apprehension.
During surgery, the valve appeared not particularly bad except for the few suspicious areas, which were removed and sent for laboratory examination. He recovered uneventfully his fever subsided and his inflammatory parameters came back normal. Six months later he is a happy relieved man. The cultures from the valve came negative.
Sometimes it is a culture negative endocarditis, which can cause these symptoms, and sometimes it is asterile vegetation which can still continue to cause systemic constitutional symptoms. It is impossible to be sure all the time but yes with lot of experience the chances of getting these things wrong become very low.

Nature’s Miracle

Early morning calls from the ER are usually for patients who have been in an accident and for most of the times our emergency department team is excellent in managing chest trauma. So most of the times I am informed about the patient but they have invariably done whatever is needed to sort out the patient. So when the phone rang at 3.00 am I was half asleep expecting the usual conversation with the ER, but 30 seconds later in the talk I was wide awake…I was being asked to see a young lady in her late 40’s with a condition involving tear in the main artery in the body. This is a condition which is lethal and almost 50 percent people who develop it die on the spot and are unable to seek any help.. Those who survive also die at almost 1% per hour. So practically everyone is dead in 48 hours.
Anyhow this was not the story with our lady…As I stepped out of the bed and got ready to go to the hospital there were thoughts already racing through my mind trying to foresee various possibilities and what could be done to save her. By the time I reached the ER they had already done the CT scan and Echo and I had all the information needed to guide the further treatment.
A review of the CT scan showed that the aorta had a tear from inside beginning at the very beginning of the main vessel of the body which carries all the blood namely the aorta and going across the arch of aorta and had involved the blood vessels in the neck which supply blood to the brain also. The distal part of the aorta appeared normal. Surprisingly she did not have a stroke yet although she did complain of mild dizziness when she had initial symptoms.. But obviously looking at the scan it was clear that she was sitting on the edge of her deathbed and needed to be in OT urgently.
Relatives were counseled and explained the grievous nature of the condition and the option available. It was already morning by that time and I suggested we take her once thing were ready in OT. Unfortunately only one team was available in morning and they very occupied with a elective surgery so we had to wait till they became free from the surgery and..that meant delaying surgery for another 5 hours…this was a tense time for everyone involved as anything could have happened during this time. Also as these surgeries take 10 -12 hours I wanted to finish in reasonable time
Anyhow by god’s grace we were in OT eventually without any disasters…During the surgery, the findings were same as what we saw on the CT scan and we ended up replacing the entire ascending aorta, arch and its three branches with artificial grafts…to my utter dismay, I landed up ligating the right side neck vessel supplying the brain (carotid artery) as it was badly damaged and there was no conceivable way to salvage it.
After a grueling 12 hour surgery she was finally out of the theatre.. I had to clearly inform the relatives that we had to ligate the right carotid artery and we should be prepared for the worst, as there was a 99% chance that she would develop massive stroke on left side.
Waiting again for next 12 hours for her to start waking was very agonizing ..,not knowing whether we had done any good for her or had added to her problems was exasperating. Overnight I could not sleep very well as it kept on playing on my mind if I could have offered or done anything better for her. Every time the answer was same there was simply no other conceivable way out.
Finally after 15 hours or so she started waking up with movements of all four limbs and she was clearly obeying all verbal commands. It was clear that we had not done any major damage. She subsequently got better and just before discharge we did a CT scan of the brain to see how much damage we had inflicted…Luckily for us and for her and her family there was miniscule changes on the scan and our neurologist was clear that this wouldn’t affect her in any way in leading a normal life.
It is a year since her surgery and she is doing well…Sometimes God is great ..Nature has given us so many inbuilt protective mechanisms that if one fails the system falls on to the back up setting and life continues undisturbed.. Truly human body is remarkably complex and certain things are beyond our understanding.. The only thing to do is to marvel at its way of working and be grateful for it every moment.

Curious Case of Anaemia

I was relaxing on a Saturday evening making plans for spending time with my family on Sunday when I received a call from our cardiology colleague regarding a sick young lady who had been received in ER. Briefly she had been having trouble since last six months and had been consulting various doctors in Rajasthan for long standing anemia. Her Hemoglobin persistently stayed around 7-8 gm% and she had undergone extensive investigations for ruling out blood malignancies and had even been seen by oncophysician.
On her arrival in ER simple clinical examination revealed a murmur in the precordial area and a Cardiologist was asked to evaluate her.
The subsequent echo images which my colleague sent me on whats app was something which I had never seen.
There was a ventricular septal defect ( a hole in the heart )
which is not unusual to see sometimes in young adults. To my horror there were huge ball of infection ( vegetation’s ) surrounding the VSD. Briefly I told the cardiologist that she would need surgery and that I would assess her the next morning and do the needful.
Next 24 hours had however something else in store for us. She deteriorated overnight and went into shock due to infection and had low blood pressure She landed up on ventilator and by next day needed lot of medicines to support her blood pressure. In view of the critical status her other organs like kidney and liver were also showing signs of decompensation.
Clearly surgery was the only alternative and it would have been very high risk with the possibility of death on table itself.
With understandable reluctance the relatives did give consent for surgery. She was taken up for open heart surgery and I too was shocked to the findings which I saw intra operatively.
The vegetation’s were so extensive that they occupied the entire right side of the heart. They had also invaded onto the left sided heart valves(both mitral and aortic.)
With great difficulty and meticulous dissection, I could clear the vegetation’s and close the VSD.
While removing the vegetation’s on the aortic valve I landed up with a hole in the leaflet of the valve and now was left with two choices ; either to replace it with a metal valve or to try and repair it. Replacing would not only be technically challenging but also in a young girl would mean lifelong anticoagulation with its own set of problems. So I decided to give it a try with repairing it. I took a patch from the patients own pericardium and repaired the hole and after testing it seemed that we had got it right.
Postoperative echo showed a perfect repair.
She made a excellent recovery and was discharged subsequently. At follow up of three months her hemoglobin had climbed up to 13 and her cheeks were blushing pink and she was full of energy. All her organs were working normally now.
It has been almost a year now and she continues to do well.
Sometimes in the era of technology and fast paced life we all forget to do the basic things like clinical examination which leads to patient being labeled as a diagnosis and everyone else subsequently works around the same.. a simple thing here would have saved her so much trouble but we are happy that eventually all is well that ends well especially for our young lady who has a whole life in front of her.

Breath of Life

Around 3 years back I had started to my morning with my usual schedule and had arrived at the hospital at 8 o'clock and after my rounds was preparing to get ready for a scheduled case. Around 12 o'clock I got a call from our Emergency Room asking me to urgently review a case. When I went to the emergency room I saw a young man who must be in his 20s who appeared to be very critical. He was already being ventilated and had tube in his chest to drain blood and air accumulated in his chest.
As he was being shifted to the CT scanner for further assessment of his injuries I decided to talk to the emergency medicine consultant to find out his story so far. As he had been shifted from a peripheral hospital and was on the verge of having a cardiac arrest the consultant told me that even they had very little idea about his mode of injury but they were told by the ambulance crew that the patient had in industrial trauma and had apparently come in between the blades of a heavy machine. By the time the CT Scan was done he had stabilized a little bit after the initial resuscitative treatment given by the emergency department.
A further analysis of all his radiological results and clinical examination showed that he had sustained major poly trauma he had injuries involving his facial bones with multiple fractures all over in his body and also trauma to his eyes and brain .The injury which was needing the most urgent attention were the fracture ribs and underlying lung injury. As there was a lot of air leaking from his chest tube there was a high index of suspicion to rule out major airway injury.
A detailed analysis of the CT scan showed that his right main bronchus had sustained a tear which appeared to be partial. As it was increasingly becoming difficult to ventilate the patient due to the air leak we decided to take the patient to operating room and do a bronchoscopy urgently. The patient was shifted to the operating room and a bronchoscopy was done which revealed the presence of significant injury in right main bronchus which explained the reason for massive air leak and inability to ventilate the patient. In view of this it was decided to pass the endotracheal tube from the trachea into the left main bronchus so that we could ventilate the left lung ( one lung ventilation) and try and maintain his respiratory parameters. This would have given us sometime to stabilize the patient and also so give us some time to plan out for the surgical strategy. More importantly also give us time assess his neurological status. With single lung ventilation the air leak immediately stopped subsequently we shifted him to the ICU.
After a couple of hours his respiratory parameters and blood gases started to get better so our first step seem to be in the right direction. We decided to give him another 24 hours to assess neurological status and for the day and night we left him ventilated so that we could asses him again the next day. Next day when I came in the morning for rounds I was pleasantly surprised to see him fully awake and obeying all verbal commands being fully conscious. His blood gases had further improved overnight and now he seemed to be in a condition where we could consider him to be reasonably ok to be taken for a major surgery.
We took him to the operation theatre not sure what we are going to find inside but one thing was sure we were expecting it to be a very messy and big injury and there was every possibility that we may not be able to ventilate him while doing this repair in view of this we also had kept on Extra Corporeal Membrane Oxygenator (ECMO) machine ready. Incase if he was unable to maintain his ventilation during the surgery then we could perhaps put him on ECMO (which would supply his vital organs with oxygenated blood ),would give us more time and safety to carry on with repair on the bronchial tree. When I opened the chest I was shocked to see the right lung completely detached from the trachea and it was completely collapsed and lying in one corner of the chest cavity. There was complete transection of the right main bronchus just at the level of tracheal division (carina). Only lucky part was the lung tissue itself was not severely injured and the blood supply to the lung was intact.
After cleaning up the ends I re implanted the lungs back into the tracheo- bronchial junction and reinforce the anastomosis using the intercostal muscle flap .During the surgery, the repair looked good but one thing which is always precarious in these cases is the ability for the airway to heal as blood supply in this area is very less.
Fingers crossed this is the maximum which we could have done for a patient at this stage whether the lungs heal and whether the area anastomosis holds the test of time would be seen in next two weeks.
The next 10 days went very slowly as he remained very stable on the ventilator. His facial injuries clavicular injury and other injuries including eye injury were addressed to by my other colleagues. Almost three weeks after his injury, he was taken off ventilator and was immediately mobilized. Subsequently his tracheostomy was removed and he was ready for discharge almost after a month of his injury.
At the time of discharge we got to listen to his complete story and the grit and determination which kept him alive. He was checking out some machinery part when the machine was not working and one office colleagues came from outside and did not realize that he was inside the machine and by mistake switched it on and patient was caught inside the heavy machine with heavy compression on his chest wall. This anteroposterior sudden force caused rupture of the airway and also lead to multiple bony injuries. It took almost two hours for him to be removed from the machine and then subsequently be transferred from the factory to the local hospital and from there to our hospital it was almost 6 hours since the time he had an injury initially.
All throughout till the time he came to our hospital he was fully conscious and fully aware that he is going to die but he kept on telling himself that he will not give up and all throughout his stay in ICU and hospital he never complained about anything and to take each day as it came. It is almost 3 years now and every few months he calls up or visits us to tell us how grateful he is for his life. He has now fully recovered and is back to his productive life and is looking for greener pastures to move and settle with his brother in Australia.
Sometimes in life grit determination courage teamwork and God's grace can pull you through the gravest disasters. The message is - never lose hope in life, as they say it's Never Over until it's all over.