Objectives: Microcirculation is bound to be altered during cardiac surgery due to multiple factors, mainly the intense systemic inflammatory response syndrome which peaks in the first 24-h postoperatively. Decreased microvascular flow associated with increased postoperative morbidity has been reported. The literature suggests a potential independence of macrocirculation and microcirculation during fluid loading. The present study was conducted to assess thenar muscle tissue oxygen saturation (StO2) changes during vascular occlusion test (VOT) in response to hypovolemia and to assess the dynamic responses of the StO2 variables post-volume expansion (VE). Material and Methods: Thirty-five adult post-cardiac surgical patients, with stroke volume (SV) variation >12% were included in the study. Fifty-two fluid challenges were studied. Functional evaluation of microcirculation using VOT and near infrared spectroscopy (NIRS) variables along with monitoring of macrocirculatory indices was performed before and after VE. Statistical analysis was done using Student t -test. Results: Post-VE, 34 were responders with increase in SV ≥15% and 18 were non-responders (SV <15%). Rate of resaturation was significantly faster in responders compared to non-responders after VE ( P = 0.0293 vs. P = 0.1480). However, macrocirculatory indices including cardiac output, SV, and delivery of oxygen showed significant improvement in both responders and non-responders. Conclusion: Preload dependence is associated with significant change in the StO2 recovery slope measured at the thenar eminence in volume responders. Functional evaluation of microcirculation using VOT and StO2 can be a useful complimentary tool along with the macrocirculatory indices for optimal fluid rescuscitaion in adult post-cardiac surgical patients.

The existence of sunlight, air, and different resources on Earth must be used wisely for human welfare while also safeguarding the environment and its living creatures. The use of the sunlight and air as a significant source of renewable energy (RE) is already an object of research and development in recent years. The high integration costs of various RE energy sources are a significant hurdle to their development. The RE contributes different energy domains: wind energy, solar energy, geothermal energy, hydro energy, ocean energy, bioenergy, hydrogen energy, and hybrid energy. Nowadays, artificial intelligence (AI) plays an inevitable role in RE, and it could assist in achieving the future goals of the RE. AI approaches in the research and development of the abovementioned RE sources will be comprehensively analyzed. This chapter analyzes and discusses challenges estimating the value creation of AI methods in RE.

Aim: The present study was conducted to validate cardiac output (CO) and cardiac index (CI) obtained from electrical cardiometry (EC) ICON ® with transthoracic echocardiography (TTE) in postoperative pediatric cardiac surgical patients. Materials and Methods: A prospective observational study was conducted in 25 pediatric patients with age < 10 years who underwent elective cardiac surgery. Data Analysis: BlandAltman plot was constructed for interchangeability and Polar plot was constructed to know trending ability. Results: A total of 250 datasets were analyzed. Spearman's correlation coefficient for CO between ICON ® and TTE showed good positive correlation (r = 0.850, 95% confidence interval 0.81 to 0.881, P <.0001). Moderate positive correlation was observed between ICON ® and TTE for CI (r = 0.60, 95% confidence interval 0.515 to 0.674, P <.0001). Linear regression equations for CO and CI between ICON ® and TTE were: y = 0.5230 + 0.8078 X (R2 = 0.6597, P <.001) and y = 1.8350 + 0.5869 X (R2 = 0.3985, P <.001) [y- ICON ®; X - TTE], respectively. BlandAltman plot for CO between ICON ® and TTE showed a bias of 0.3012 with limits of agreement (LOA) being -0.69 to 1.3 and for CI bias was 0.6939 with LOA˗2.1 to 3.5. Polar plot analysis showed an angular bias of 8.1750, with radial LOA being −13.74° to 30.08° for CO and angular bias of 6.6931, with radial LOA being −15.69° to 29.07° for CI. Conclusion: ICON ® monitor-derived parameters are not interchangeable with the values derived from TTE. However, the ICON ® monitor demonstrated a good trending ability for both CO and CI.

This chapter intends to explore the necessity of sustainable infrastructure and the key factors affecting sustainability. Sustainable infrastructure constructs the environment to be crucial for society's survival, health, and comfort. The environment comprises engineering works, buildings, transports, power production facilities, wastewater and water treatment plants, storm water management systems, and even natural systems such as rivers and harbors. The infrastructure systems provide the structures required for the operation of society and facilitate access to goods and services. The demand for infrastructure is rising in tandem with population growth and urbanization structure. The increasing population consumes a large volume of materials and energy to upgrade themselves and their infrastructure. The rising urbanism is adopting the updated information and communication technology (ICT) to transform cities into smart cities. More infrastructure results in some vulnerable effects that create unsustainable burdens. However, more solutions must be implemented at the local level. This study addresses the fundamental science of sustainability, various obstacles inherent in the ICT transformation, recommendations for diplomats, innovators, researchers, scientists, project developers, sponsors, traders, allied stakeholders, and faculties to reach the sustainable infrastructure based on the review of similar works.

Environmental change is probably the greatest danger that every human being is at present confronting. With these difficulties which lie before the public authority and different energy arrangement suppliers, it has become essential for them to give a supportable method of sustainable energy. Sustainable energy has been elective energy with petroleum products, as well. The significant benefit is that sustainable energy is a lot more secure, cleaner, and eco-friendly than existing resources. Artificial Intelligence (AI) and machine learning (ML) have become significant innovation technologies as the business is continually searching for approaches to be taken into account that quickly expand the interest for transparency, modesty, and reliability. These cutting-edge innovations can possibly investigate the past, upgrade the present, and foresee what's to come. The machine learning approach and its applications are a subset of AI, where calculations figure out how to recognize designs from information with negligible human intervention. Many organizations use it to discover approaches to improve or foresee forthcoming changes that would influence their business. This example-based forecast can help sustainable power, as well. Since renewable energy depends on nature, their productivity and creation can fluctuate generally. Better prescient instruments can help energy organizations and clients take advantage of these establishments. This implies that AI and ML can possibly tackle the vast majority of the difficulties that currently exist. With innovation making quick headways, the environmentally friendly power area has gained huge headway somewhat recently. Notwithstanding, there are a couple of difficulties that actually win which can be tended to with the assistance of AI and ML. There is no question that the interest in solar energy is and will increment sooner rather than later which makes it more significant for the interest in arising advancements like AI, ML, and IoT to further develop efficiency and conquer the setbacks. Indeed, solar energy has significantly profited from the force of AI, AI-prescient models, and information science over the previous years. They have figured out how to bring down their expenses, improve expectations, and increment their portfolio's pace of return.

Background:Low cardiac output is a common complication following cardiac surgery and it is associated with higher mortality in the pediatric population. A gold standard method for cardiac output (CO) monitoring in the pediatric population is lacking. The present study was conducted to validate cardiac output and cardiac index measured by transthoracic echocardiography and Pressure recording analytical method, a continuous pulse contour method, MostCareUp in postoperative pediatric cardiac surgical patients. Materials and Methods:This was a prospective observational clinical study conducted at a tertiary care hospital. A total of 23 pediatric patients weighed between 2 and 20 kg who had undergone elective cardiac surgery were included in the study. Results:Spearman's correlation coefficient of CO between transthoracic echocardiography (TTE) and Pressure Recording Analytical Method (PRAM) showed of positive correlation (r = 0.69, 95% Confidence interval 0.59-0.77, P < 0.0001) Linear regression equations for CO between TTE and PRAM were y = 0.55 + 0.88x (R2 = 0.46, P < 0.0001). (y = PRAM, x = TTE), respectively. Bland- Altman plot for CO between TTE and PRAM showed a bias of -0.397 with limits of the agreement being -2.01 to 1.22. Polar plot analysis showed an angular bias of 6.55° with radial limits of the agreement being -21.46 to 34.58 for CO and angular bias of 6.22° with radial limits of the agreement being -22.4 to 34.84 for CI. Conclusion:PRAM has shown good trending ability for cardiac output. However, values measured by PRAM are not interchangeable with the values measured by transthoracic echocardiography.

The proposed method is based on multimodal brain tumour segmentation method (MBTSM) using improved fuzzy c-means (IFCM) and active contour model (ACM). This proposed MBTSM presents a brain tissue and tumour segmentation method that segments magnetic resonance imaging (MRI) of human head scans into grey matter (GM), white matter (WM), cerebrospinal fluid (CSF), oedema, core tumour and compete tumour. The proposed method consists of three stages. Stage 1 is an IFCM method, modifying the conventional FCM for brain tissue segmentation process and this method gives comparable results than existing segmentation techniques. Stage 2 is an abnormal detection process that helps to check the results of IFCM method by fuzzy symmetric measure (FSM). Stage 3 is segment the tumour region from multimodal MRI head scans by modified Chan-Vese (MCV) model. The accuracy analysis of proposed MBTSM used the parameters dice coefficient (DC), positive predictive value (PPV), sensitivity, kappa coefficient (KC) and processing time. The mean DC values are 83% for GM, 86% for WM, 13% for CSF and 75% for complete tumour.

OBJECTIVE:Thoracic Epidural Analgesia (TEA) was compared with ultrasound-guided bilateral erector spinae plane (ESP) block in aorto-femoral arterial bypass surgery for analgesic efficacy, hemodynamic effects, and pulmonary rehabilitation. DESIGN:Prospective randomized. SETTING:Tertiary care centre. PARTICIPANTS:Adult patients, who were scheduled for elective aorto-femoral arterial bypass surgery. INTERVENTIONS:It was a prospective pilot study enrolling 20 adult patients who were randomized to group A (ESP block = 10) and group B (TEA = 10). Monitoring of heart rate (HR) and mean arterial pressure (MAP) and pain assessment at rest and deep breathing using visual analog scale (VAS) were done till 48-h post-extubation. Rescue analgesic requirement, Incentive spirometry, oxygenation, duration of ventilation and stay in Intensive Care Unit (ICU) were reported as outcome measures. Statistical analysis was performed using unpaired Student T-test or Mann-Whitney U test. A value of P < 0.05 was considered significant. RESULTS:HR was lower in group B than group A at 1 and 2 h post- surgery and at 0.5, 16, 20, and 32 h post-extubation (P < 0.05). MAP were lower in group B than A at 60, 90, 120, 150, 180, 210, 240, 270 minutes and at 0 hour post-surgery and at 4 hours, every 4 hours till 32 hours post-extubation (P < 0.05). Intraoperative midazolam and fentanyl consumption, ventilatory hours, VAS at rest, incentive spirometry, oxygenation, and ICU stay were comparable between the two groups. VAS during deep breathing was more in group A than B at 0.5, 4 hours and every 4 hours till 44 hours post-extubation. The time to receive the first rescue analgesia was shorter in group A than B (P < 0.05). CONCLUSION:Both ESP block and TEA provided comparable analgesia at rest. Further studies with larger sample size are required to evaluate whether ESP block could be an alternative to TEA in aorto-femoral arterial bypass surgery.

Deep learning is reaching new heights as a result of its cutting-edge performance in a variety of fields, including computer vision, natural language processing, time series analysis, and healthcare. Deep learning is implemented using batch and stochastic gradient descent methods, as well as a few optimizers; however, this led to subpar model performance. However, there is now a lot of effort being done to improve deep learning’s performance using gradient optimization methods. The suggested work analyses convolutional neural networks (CNN) and deep neural networks (DNN) using several cutting-edge optimizers to enhance the performance of architectures. This work uses specific optimizers (SGD, RMSprop, Adam, Adadelta, etc.) to enhance the performance of designs using different types of datasets for result matching. A thorough report on the optimizers’ performance across a variety of architectures and datasets finishes the study effort. This research will be helpful to researchers in developing their framework and appropriate architecture optimizers. The proposed work involves eight new optimizers using four CNN and DNN architectures. The experimental results exploit breakthrough results for improving the efficiency of CNN and DNN architectures using various datasets.

Aim: To determine the factors associated with an inadequate response to adenosine infusion during cardiac stress magnetic resonance imaging (MRI). Study Design: It is a retrospective cohort study. Introduction: Stress cardiac MRI is a highly accurate and non-invasive method to diagnose coronary artery disease (CAD). Stress MRI is performed by inducing stress with adenosine infusion. There is an increase in systemic and myocardial blood flow (MBF) with vasodilator agents. Capillaries are maximally dilated in a diseased artery and cannot sustain increased myocardial oxygen demand. It results in delayed delivery of contrast, which leads to an area of perfusion defect in the myocardium. These perfusion defects can be accurately seen by cardiovascular magnetic resonance (CMR) and help in the prognosis of patients. Methods: A retrospective study on patients subjected to cardiac stress MRI was conducted in a Tertiary Care Cardiac Center from January 2019 to January 2022. In total, 99 patients underwent adenosine stress perfusion cardiac MRI. All patients received an adenosine infusion of 140 mcg/kg/min for 2 min. Subsequently, the dosage was increased by 20 mcg/kg/min every 2 min to a maximum of 210 mcg/kg/min until an adequate stress response was achieved. Adequate stress was defined as two or more of the following criteria: 1) Increase in heart rate >/= 10 beats per minute. 2) Decrease in systolic blood pressure SBP by >/= 10 mm Hg Symptoms like chest discomfort, breathlessness, and headache. Patients who satisfied two or more of the above criteria were labeled as responders and the patients who did not satisfy the above criteria with the maximum dose of 210 mcg/kg/min of adenosine infusion were labeled as non-responders. Multivariable logistic regression analysis with forward and backward stepwise selection was used to identify predictors in non-responders. Basic demographic variables with P value </= 0.2 were examined for inclusion in the model. A P value </= 0.05 was considered significant. Results: Nine patients (9.1%) showed inadequate stress response to adenosine infusion even with a maximum dose of 210 mcg/kg/min. Multivariate logistic regression analysis showed that left ventricular end-diastolic volume (LVEDV) was a predictor of inadequate response to adenosine infusion. Conclusion: Inadequate stress response to adenosine occurred in 9.1% of subjects with an infusion of 140–210 ug/kg/min. LVEDV is an independent and strong predictor in non-responders.

Background: Cardiac output (CO) assessment is a corner stone in advanced haemodynamic management, especially in critical ill patients. The present study was conducted to validate cardiac index and cardiac output by NICaS™ with the thermodilution technique using pulmonary artery catheter in post-operative cardiac surgical patients. Materials and Methods: This was a prospective observational clinical study conducted at a tertiary care hospital. 23 adult patients in the age range of 18-65 years who had undergone for elective coronary artery bypass grafting were included in the study. Results: Spearman's correlation coefficient of cardiac index between continuous Thermodilution (cTD) and Non-Invasive Cardiac System (NICaS™) showed a good correlation (r = 0.765, 95% confidence interval 0.70 to 0.82, P < 0.0001). There was a good correlation between cTD and NICaS™ for cardiac output (r = 0.759, 95% confidence interval 0.69 to 0.81, P < 0.0001), Bland-Altman plot for cardiac index between cTD and NICaS™ showed a mean bias of −0.66 ± 0.6919 with limits of agreement being −2.02 to 0.6936. Bland-Altman plot for cardiac output between cTD and NICaS™ showed a mean bias of −1.0386 ± 1.17 with limits of agreement being −3.34 to + 1.26. Percentage error for cardiac index and cardiac output were 64.78% and 64% respectively. Polar plot analysis showed an angular bias of 6.32° with radial limits of agreement being −8.114° to 20.75° for cardiac index and angular bias of 5.6682° with radial limits of agreement being −9.1422° to 20.4784° for cardiac output. Conclusion: NICaS™ demonstrated a good trending ability for both CI and CO. However, NICaS™ derived parameters are not interchangeable with the values derived from continuous thermodilution technique.

Background: Right ventricular (RV) has a vital role in maintaining optimal tissue perfusion. Assessment of portal venous flow characteristics can be alternative and emerging technique to assess RV function. Aims: To investigate if portal venous pulsatility fraction (PF) could serve as effective and complementary tool in identifying RV dysfunction. Materials and Methods: Thirty adult patients aged 18-65 years undergoing cardiac surgery under general anesthesia were enrolled in study. Intraoperative transesophageal echocardiographic examination was performed. Tricuspid annular plane systolic excursion (TAPSE), RV fractional area change (FAC), RV ejection fraction (EF), and portal vein flow pulsatility were assessed. Portal vein PF was used to quantify degree of pulsatility. Results: Portal vein was demonstrated in 27 patients (90%). 27 values of portal vein PF, RV EF, FAC, and TAPSE were analyzed. Portal vein PF demonstrated significant linear correlation with TAPSE (r = −0.55, P = 0.003), RV FAC (r = −0.44, P = 0.02), and RV EF (r = −0.53, P = 0.004). ROC curve was constructed to calculate sensitivity and specificity of portal vein PF for assessing RV function. Portal vein PF value of ≥45% indicated RV dysfunction with sensitivity of 92.3%, specificity of 71.4%, positive predictive value of 75%, and negative predictive value of 90.9%. Area under ROC curve was 0.819 (95% confidence interval = 0.624 – 0.939, P = 0.0006). Conclusion: Portal vein PF is simple and feasible method for assessment of RV function. It complements the existing echocardiographic measures to diagnose RV dysfunction.

The frequency of problems related to tracheal extubation probably exceeds those related to tracheal intubation. Our study was undertaken to determine the post extubation sequelae and haemodynamic responses during tracheal extubation. The study group consisted of randomly selected 250 adult patients in the age group of 18-65 years, belonging to ASA Grade I, II, III, posted for elective surgery under general anaesthesia. We observed the following; Haemodynamic changes [Heart rate (HR), Mean arterial pressure (MAP) changes] and immediate problems associated with post operative tracheal extubation such as bucking, breath holding, cough, airway obstruction, stridor, sorethroat, vomiting, aspiration, pulmonary oedema, residual paralysis occurring during the first 30 minutes of extubation. The changes in HR and MAP were significant soon after extubation (p<0.00) with HR reaching baseline value at 10 min (p=0.074) whereas MAP continued to be significant(p=0.032) even at 30 min. Incidence of immediate problems associated with postoperative tracheal extubation was 38.4% and these were: Bucking – 26.8%, Breath holding – 4.8%, Persistent cough – 4%, Airway obstruction – 2.4%, Stridor – 0.4%, Sorethroat – 4%, Vomiting – 2.4%. There was no incidence of pulmonary aspiration, pulmonary oedema, residual paralysis. It is concluded that tracheal extubation causes haemodynamic instability and can be associated with detrimental responses.

Background: The deceleration time of the pulmonary venous diastolic flow has been well-correlated with invasive pulmonary capillary wedge pressure in several studies regardless of left ventricular systolic function. This study was conducted to correlate deceleration time of pulmonary venous diastolic wave, DT(D), and left atrial pressure (LAP), obtained noninvasively from mitral early diastolic inflow velocity-to-early diastolic mitral annulus velocity ratio (E/e′), and to assess the ease of each method in patients with coronary artery disease undergoing off-pump coronary artery bypass grafting (OPCAB) by transesophageal echocardiography. Methods: Forty-five adult patients with coronary artery disease, with left ventricular ejection fraction of ≥50% posted for elective OPCAB were enrolled in the study. Results: Forty values of LAP and DT(D) were analyzed. A significant linear correlation (r = −0.64) was found between DT(D) and LAP. Area under the curve of DT(D) of ≤183 ms for predicting elevated LAP (>15) was 0.903 (95% confidence interval: 0.767 to 0.974, P < 0.0001). Conclusion: Deceleration time of pulmonary venous flow diastolic waveform, DT(D), feasible promising echocardiographic measure in determining elevated LAP and DT(D)≤183 ms predicts elevated LAP.

Aims and Objectives: The objective of the study was to determine the preconditioning myocardial protective effects of intralipid (IL) in off-pump coronary artery bypass (OPCAB) surgery by measuring highly sensitive troponin T (hsTnT) and cardiac-specific creatine kinase (CK-MB) as markers of myocardial injury. Materials and Methods: Thirty patients, scheduled to undergo elective OPCAB surgery, were randomly assigned to the IL group (n = 15) or control (C) group (n = 15); the IL group received an infusion of 20% IL 2 ml/kg, 30 min prior to revascularization and the control group received an equivalent volume of normal saline. Serum levels of hsTnT and CK-MB were measured before surgery and at 6 h, 24 h, 48 h, and 72 h postoperatively. Also, intraoperative hemodynamic parameters, inotrope use, ventilatory hours, ICU stay, postoperative left ventricular ejection fraction, postoperative lipid profile, renal and hepatic function tests were measured. Results: The hsTnT values at the 24 h, 48 h, and 72 h in IL group were significantly lower as compared with the control group. The decline in plasma levels of CK-MB mirrored the hsTnT levels post revascularization at 24 h and 48 h in the IL group compared with the control group; however, at 72 h, level was comparable in both the groups. None of the treated patients had abnormal lipid metabolism, deranged renal, and hepatic function. Conclusion: The study revealed Intralipid as a safe pharmacological preconditioning agent for OPCAB surgeries which can reduce the postischemic myocardial injury indicated by the reduction in postischemic cardiac enzymes hsTnT and CK-MB.

Background:Medullary hypoxia is the initial critical event for kidney injury during cardiopulmonary bypass, and therefore urinary PO2 with its potential of detecting medullary oxygenation for its management. Therefore, we tested the role of urinary PO2 in predicting kidney injury in those undergoing conventional versus combined (conventional and modified) ultrafiltration during cardiac surgery in adults.Methodology:We prospectively evaluated 32 adults between 18 and 65 years of age undergoing elective on-pump cardiac surgery with ejection fraction >35% by conventional (group C) versus combined ultrafiltration (group CM). Urine samples were analyzed for PO2 after induction, 30 min, 3 h, and 6 h post filtration along with blood urea and serum creatinine after induction, at 6 h, 24 h, and 48 h post filtration. Demographic variables, cardiopulmonary bypass duration, flow rates, inotropic score, ventilation duration, diuretic use, and intensive care unit (ICU) stay were assessed between two groups.Results:Both the groups (16 in each group) had comparable urinary PO2 after induction (P = 0.387) with significant decrease in group C at 30 min, 3 h, and 6 h post filtration (P < 0.05). There was a statistically significant increase in serum creatinine (mg/dL) at 48 h in group C compared with group CM (1.57 vs. 1.25, respectively; P ≤ 0.05). There was an increased diuretic usage and length of ICU stay in group C.Conclusion:Combined ultrafiltration technique had renoprotective effect in cardiac surgery analyzed by urinary PO2 levels.

A prospective randomised double blind clinical study comparing ropivacaine and fentanyl with bupivacaine and fentanyl for labour epidural analgesia - IJCA- Print ISSN No: - 2394-4781 Online ISSN No:- 2394-4994 Article DOI No:- 10.18231/2394-4994.2019.0016, Indian Journal of Clinical Anaesthesia-Indian J Clin Anaesth

Objective:Allogeneic blood product transfusions are associated with an increased morbidity and mortality risk in cardiac surgery. At present, a few transfusion risk scores have been proposed for cardiac surgery patients. The present study is aimed to develop a new score and to compare with preexisting scores - Transfusion Risk and Clinical Knowledge (TRACK) and Transfusion Risk Understanding Scoring Tool (TRUST) score. Methodology:A total of 1014 adult patients undergoing cardiac surgery were enrolled in the retrospective study. Independent predictors of allogeneic blood transfusions were selected from TRACK and TRUST scores. A predictive score was developed from six variables using logistic regression analysis, and new score was compared to the other existing scores - TRACK and TRUST. Results:The new score had following predictors: age >58 years, weight <63 kg for males and <49 kg for females, gender (female), complex surgery, hemoglobin <13.5 g/dl, and creatinine >1.36 mg/dl. Validation of new score demonstrated an acceptable predictive power (area under the curve [AUC] 0.749) and a good calibration at the Hosmer-Lemeshow test. New score was comparable with TRACK score with P = 0.578 (AUC of TRACK 0.756 and AUC of new score 0.749). There was a significant difference between new score and TRUST score, P = 0.01 (AUC of TRUST 0.72 and AUC of new score 0.749). Conclusion:New score is a simple risk model based on six predictors having a similar accuracy and calibration in predicting the transfusion rate in cardiac surgery as compared to TRACK score.