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2010| November-December | Volume 54 | Issue 6
Online since
November 22, 2010
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CASE REPORTS
Femoro-femoral cardiopulmonary bypass for the resection of an anterior mediastinal mass
Chaitali SenDasgupta, Gautam Sengupta, Kakali Ghosh, Asit Munshi, Anupam Goswami
November-December 2010, 54(6):565-568
DOI
:10.4103/0019-5049.72649
PMID
:21224977
The perioperative management of patients with mediastinal mass is challenging. Complete airway obstruction and cardiovascular collapse may occur during the induction of general anaesthesia, tracheal intubation, and positive pressure ventilation. The intubation of trachea may be difficult or even impossible due to the compressed, tortuous trachea. Positive pressure ventilation may increase pre-existing superior vena cava (SVC) obstruction, reducing venous return from the SVC causing cardiovascular collapse and acute cerebral oedema. We are describing here the successful management of a patient with a large anterior mediastinal mass by anaesthetizing the patient through a femoro-femoral cardiopulmonary bypass (fem-fem CPB).
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CLINICAL INVESTIGATIONS
A study of ventilator-associated pneumonia: Incidence, outcome, risk factors and measures to be taken for prevention
Hina Gadani, Arun Vyas, Akhya Kumar Kar
November-December 2010, 54(6):535-540
DOI
:10.4103/0019-5049.72643
PMID
:21224971
Ventilator-associated pneumonia (VAP) is a major cause of hospital morbidity and mortality despite recent advances in diagnosis and accuracy of management. However, as taught in medical science, prevention is better than cure is probably more appropriate as concerned to VAP because of the fact that it is a well preventable disease and a proper approach decreases the hospital stay, cost, morbidity and mortality. The aim of the study is to critically review the incidence and outcome, identify various risk factors and conclude specific measures that should be undertaken to prevent VAP. We studied 100 patients randomly, kept on ventilatory support for more than 48 h. After excluding those who developed pneumonia within 48 h, VAP was diagnosed when a score of ≥6 was obtained in the clinical pulmonary infection scoring system having six variables and a maximum score of 12. After evaluating, the data were subjected to univariate analysis using the chi-square test. The level of significance was set at
P
<0.05. It was found that 37 patients developed VAP. The risk factor significantly associated with VAP in our study was found to be duration of ventilator support, reintubation, supine position, advanced age and altered consciousness. Declining ratio of partial pressure to inspired fraction of oxygen (PaO
2
/FiO
2
ratio) was found to be the earliest indicator of VAP. The most common organism isolated in our institution was Pseudomonas. The incidence of early-onset VAP (within 96 h) was found to be 27% while the late-onset type (>96 h) was 73%. Late-onset VAP had poor prognosis in terms of mortality (66%) as compared to the early-onset type (20%). The mortality of patients of the non-VAP group was found to be 41% while that of VAP patients was 54%. Targeted strategies aimed at preventing VAP should be implemented to improve patient outcome and reduce length of intensive care unit stay and costs. Above all, everyone of the critical care unit should understand the factors that place the patients at risk of VAP and utmost importance must be given to prevent VAP.
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ProSeal laryngeal mask airway: An alternative to endotracheal intubation in paediatric patients for short duration surgical procedures
Jaya Lalwani, Kamta Prasad Dubey, Bal Swaroop Sahu, Pratibha Jain Shah
November-December 2010, 54(6):541-545
DOI
:10.4103/0019-5049.72644
PMID
:21224972
The laryngeal mask airway (LMA) is a supraglottic airway management device. The LMA is preferred for airway management in paediatric patients for short duration surgical procedures. The recently introduced ProSeal (PLMA), a modification of Classic LMA, has a gastric drainage tube placed lateral to main airway tube which allows the regurgitated gastric contents to bypass the glottis and prevents the pulmonary aspiration. This study was done to compare the efficacy of ProSeal LMA with an endotracheal tube in paediatric patients with respect to number of attempts for placement of devices, haemodynamic responses and perioperative respiratory complications. Sixty children, ASA I and II, weighing 10-20 kg between 2 and 8 years of age group of either sex undergoing elective ophthalmological and lower abdominal surgeries of 30-60 min duration, randomly divided into two groups of 30 patients each were studied. The number of attempts for endotracheal intubation was less than the placement of PLMA. Haemodynamic responses were significantly higher (
P
<0.05) after endotracheal intubation as compared to the placement of PLMA. There were no significant differences in mean SpO
2
(%) and EtCO
2
levels recorded at different time intervals between the two groups. The incidence of post-operative respiratory complications cough and bronchospasm was higher after extubation than after removal of PLMA. The incidence of soft tissue trauma was noted to be higher for PLMA after its removal. There were no incidences of aspiration and hoarseness/sore throat in either group. It is concluded that ProSeal LMA can be safely considered as a suitable and effective alternative to endotracheal intubation in paediatric patients for short duration surgical procedures.
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Efficacy of stellate ganglion block with an adjuvant ketamine for peripheral vascular disease of the upper limbs
Kalpana R Kulkarni, Anita I Kadam, Ismile J Namazi
November-December 2010, 54(6):546-551
DOI
:10.4103/0019-5049.72645
PMID
:21224973
Stellate ganglion block (STGB) is commonly indicated in painful conditions like reflex sympathetic dystrophy, malignancies of head and neck, Reynaud's disease and vascular insufficiency of the upper limbs. The sympathetic blockade helps to relieve pain and ischaemia. Diagnostic STGB is usually performed with local anaesthetics followed by therapeutic blockade with steroids, neurolytic agents or radiofrequency ablation of ganglion. There is increasing popularity and evidence for the use of adjuvants like opioid, clonidine and N Methyl d Aspartate (NMDA) receptor antagonist - ketamine - for the regional and neuroaxial blocks. The action of ketamine with sympatholytic block is through blockade of peripherally located NMDA receptors that are the target in the management of neuropathic pain, with the added benefit of counteracting the "wind-up" phenomena of chronic pain. We studied ketamine as an adjuvant to the local anaesthetic for STGB in 20 cases of peripheral vascular disease of upper limbs during the last 5 years at our institution. STGB was given for 2 days with 2 ml of 2% lignocaine + 8 ml of 0.25% bupivacaine, followed by block with the addition of 0.5 mg/kg of ketamine for three consecutive days. There was significant pain relief of longer duration with significant rise in hand temperature. We also observed complete healing of the gangrenous fingers in 17/19 patients.
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Immediate extubation versus standard postoperative ventilation: Our experience in on pump open heart surgery
Srikanta Gangopadhyay, Amita Acharjee, Sushil Kumar Nayak, Satrajit Dawn, Gautam Piplai, Krishna Gupta
November-December 2010, 54(6):525-530
DOI
:10.4103/0019-5049.72641
PMID
:21224969
Elective postoperative ventilation in patients undergoing "on pump" open heart surgery has been a standard practice. Ultra fast-track extubation in the operating room is now an accepted technique for "off pump" coronary artery bypass grafting. We tried to incorporate these experiences in on pump open heart surgery and compare the haemodynamic and respiratory parameters in the immediate postoperative period, in patients on standard postoperative ventilation for 8-12 hours. After ethical committee's approval and informed consent were obtained, 72 patients, between 28 and 45 years of age, undergoing on pump open heart surgery, were selected for our study. We followed same standard anaesthetic, cardiopulmonary bypass (CPB) and cardioplegic protocol. Thirty-six patients (Group E) were randomly allocated for immediate extubation following operation, after fulfillment of standard extubation criteria. Those who failed to meet these criteria were not extubated and were excluded from the study. The remaining 36 patients (Group V) were electively ventilated and extubated after 8-12 hours. Standard monitoring for on pump open heart surgery, including bispectral index was done. The demographic data, surgical procedures, preoperative parameters, aortic cross clamp and cardiopulmonary bypass times were comparable in both the groups. Extubation was possible in more than 88% of cases (n=32 out of 36 cases) in Group E and none required reintubation for respiratory insufficiency. Respiratory, haemodynamic parameters and postoperative complications were comparable in both the groups in the postoperative period. Therefore, we can safely conclude that immediate extubation in the operating room after on pump open heart surgery is an alternative acceptable method to avoid postoperative ventilation and its related complications in selected patients.
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REVIEW ARTICLES
Morbidly obese parturient: Challenges for the anaesthesiologist, including managing the difficult airway in obstetrics. What is new?
Durga Prasada Rao, Venkateswara A Rao
November-December 2010, 54(6):508-521
DOI
:10.4103/0019-5049.72639
PMID
:21224967
The purpose of this article is to review the fundamental aspects of obesity, pregnancy and a combination of both. The scientific aim is to understand the physiological changes, pathological clinical presentations and application of technical skills and pharmacological knowledge on this unique clinical condition. The goal of this presentation is to define the difficult airway, highlight the main reasons for difficult or failed intubation and propose a practical approach to management Throughout the review, an important component is the necessity for team work between the anaesthesiologist and the obstetrician. Certain protocols are recommended to meet the anaesthetic challenges and finally concluding with "what is new?" in obstetric anaesthesia.
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Antifibrinolytics in liver surgery
Jalpa Makwana, Saloni Paranjape, Jyotsna Goswami
November-December 2010, 54(6):489-495
DOI
:10.4103/0019-5049.72636
PMID
:21224964
Hyperfibrinolysis, a known complication of liver surgery and orthotopic liver transplantation (OLT), plays a significant role in blood loss. This fact justifies the use of antifibrinolytic drugs during these procedures. Two groups of drug namely lysine analogues [epsilon aminocaproic acid (EACA) and tranexamic acid (TA)] and serine-protease-inhibitors (aprotinin) are frequently used for this purpose. But uniform data or guidelines on the type of antifibrinolytic drugs to be used, their indications and correct dose, is still insufficient. Antifibrinolytics behave like a double-edged sword. On one hand, there are benefits of less transfusion requirements but on the other hand there is potential complication like thromboembolism, which has been reported in several studies. We performed a systematic search in PubMed and Cochrane Library, and we included studies wherein antifibrinolytic drugs (EACA, TA, or aprotinin) were compared with each other or with controls/placebo. We analysed factors like intraoperative red blood cell and fresh frozen plasma requirements, the perioperative incidence of hepatic artery thrombosis, venous thromboembolic events and mortality. Among the three drugs, EACA is least studied. Use of extensively studied drug like aprotinin has been restricted because of its side effects. Haemostatic effect of aprotinin and tranexamic acid has been comparable. However, proper patient selection and individualized treatment for each of them is required. Purpose of this review is to study various clinical trials on antifibrinolytic drugs and address the related issues like benefits claimed and associated potential complications.
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CASE REPORTS
General anaesthesia for insertion of an automated implantable cardioverter defibrillator in a child with Brugada and autism
Shwetal Goraksha, Sneha Bidaye, Supriya Gajendragadkar, Jitendra Bapat, Manju Butani
November-December 2010, 54(6):562-564
DOI
:10.4103/0019-5049.72648
PMID
:21224976
A 14-year-old autistic boy presented with acute gastroenteritis and hypotension. The electrocardiogram showed a ventricular fibrillation rhythm - he went into cardiorespiratory arrest and was immediately resuscitated. On investigation, the electrocardiogram showed a partial right bundle branch block with a "coved" pattern of ST elevation in leads v
1
-v
3
. A provisional diagnosis of Brugada syndrome was made, for which an automated implantable cardioverter defibrillator (AICD) implantation was advised. Although the automated implantable cardioverter defibrillator implantation is usually performed under sedation, because this was an autistic child, he needed general anaesthesia. We performed the procedure uneventfully under general anaesthesia and he was discharged after a short hospital stay.
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391
REVIEW ARTICLES
Setting up and functioning of a preanaesthetic clinic
Anju Gupta, Nishkarsh Gupta
November-December 2010, 54(6):504-507
DOI
:10.4103/0019-5049.72638
PMID
:21224966
The goal of preoperative risk assessment is to identify and modify the procedure and patient factors that significantly increase the risk for complications. Preanaesthesia clinics (PACs) have been developed to improve the preoperative experience of the patients by coordinating surgical, anaesthesia, nursing and laboratory care. These clinics can also help in developing practice guidelines, and decreasing the number of consultations, laboratory tests and surgical cancellations. Though these clinics are present in most of our hospitals, a major effort is needed to upgrade these setups so as to maximise the benefits. This review gives a brief account of organisation and functioning of PACs.
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CLINICAL INVESTIGATIONS
Pulse oximeter accuracy and precision at five different sensor locations in infants and children with cyanotic heart disease
Jyotirmoy Das, Amit Aggarwal, Naresh Kumar Aggarwal
November-December 2010, 54(6):531-534
DOI
:10.4103/0019-5049.72642
PMID
:21224970
Since the invention of pulse oximetry by Takuo Aoyagi in the early 1970s, its use has expanded beyond the perioperative care into neonatal, paediatric and adult intensive care units (ICUs). Pulse oximetry is one of the most important advances in respiratory monitoring as its readings (SpO
2
) are used clinically as an indirect estimation of arterial oxygen saturation (SaO
2
). Sensors were placed frequently on the sole, palm, ear lobe or toes in addition to finger. On performing an extensive Medline search using the terms "accuracy of pulse oximetry" and "precision of pulse oximetry", limited data were found in congenital heart disease patients in the immediate post-corrective stage. Also, there are no reports and comparative data of the reliability and precision of pulse oximetry when readings from five different sensor locations (viz. finger, palm, toe, sole and ear) are analysed simultaneously. To fill these lacunae of knowledge, we undertook the present study in 50 infants and children with cyanotic heart disease in the immediate post-corrective stage.
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EDITORIAL
Changing concepts in anaesthesia for day care surgery
SS Harsoor
November-December 2010, 54(6):485-488
DOI
:10.4103/0019-5049.72635
PMID
:21224963
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LETTERS TO EDITOR
Guide wire loss during central venous cannulation
Ashoo Wadehra, Pragati Ganjoo, Monica S Tandon
November-December 2010, 54(6):587-588
DOI
:10.4103/0019-5049.72665
PMID
:21224993
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4
2,052
336
Priapism during transurethral surgery under spinal anaesthesia: Implications and review of management options
Jyotirmoy Das, Achyut Deuri, Preety Mittal Roy, Vijaya Pant
November-December 2010, 54(6):576-577
DOI
:10.4103/0019-5049.72654
PMID
:21224981
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2,127
331
Correlation of invasive and non-invasive blood pressure: A must for management
Sameer Sethi
November-December 2010, 54(6):581-582
DOI
:10.4103/0019-5049.72658
PMID
:21224986
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2
2,497
373
REVIEW ARTICLES
Role of human recombinant activated protein C and low dose corticosteroid therapy in sepsis
Aparna Shukla, Shilpi Awasthi
November-December 2010, 54(6):496-503
DOI
:10.4103/0019-5049.72637
PMID
:21224965
Despite advances in modern medicine, sepsis remains a complex syndrome that has been associated with significant morbidity and mortality
.
Multiple organ failure associated with sepsis leads to high mortality and morbidity. About 28 - 50% deaths have been reported in patients with sepsis. The number of sepsis patients is increasing, with considerable burden on healthcare facilities. Various factors leading to a rise in the incidence of sepsis are (1) Improvement of diagnostic procedures (2) Increase in the number of immunocompromised patients taking treatment for various autoimmune disease, carcinomas, organ transplantation (3) Advances in intensive procedures (4) Nosocomial infections (5) Extensive use of antibiotics. With the better understanding of sepsis various modalities to modify pathophysiological response of septic patients have developed. Activated protein C and low-dose corticosteroid therapy have been tried in patients, with variable results.
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2
3,176
698
BRIEF COMMUNICATION
Extravasation of catheter tip following central venous catheterisation: A near fatal complication
Mridu Paban Nath, Sachin Gupta, Anulekha Chakrabarty
November-December 2010, 54(6):572-573
DOI
:10.4103/0019-5049.72651
PMID
:21224979
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1
2,497
368
CLINICAL INVESTIGATIONS
A comparative study of efficacy of propofol auto-co-induction versus midazolam propofol co-induction using the priming principle
Roopam Kataria, Ajay Singhal, Sukirti Prakash, Ishwar Singh
November-December 2010, 54(6):558-561
DOI
:10.4103/0019-5049.72647
PMID
:21224975
Application of priming principle is well documented in relation to the use of muscle relaxants. The aim of the present study was to evaluate the efficacy of priming technique in relation to induction agents. Clinical efficacy in terms of dose reduction and alteration in peri-intubation haemodynamics was compared in propofol auto-co-induction and midazolam propofol co-induction groups along with a control group. The study was carried out in 90 patients scheduled for upper abdominal surgery, who were randomly divided into three equal groups. Group I received 0.5 mg/kg propofol IV (20% of the pre-calculated induction dose), group II received 0.05 mg/kg IV midazolam and group III received 3 ml of normal saline. This was followed by IV induction with propofol 2 minutes later in all the three groups at a predetermined rate till the bispectral index value of 45 was attained. The results showed a significant decrease in induction dose requirement in both the groups but haemodynamic stability during induction and intubation was more in propofol auto-co-induction group.
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3,357
803
LETTERS TO EDITOR
Severe pain and hypertension following intravesical instillation of formalin necessitating epidural analgesia
Anjolie Chhabra, Krithika Krishnan
November-December 2010, 54(6):582-583
DOI
:10.4103/0019-5049.72660
PMID
:21224987
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2,759
261
Retrograde intubation: An alternative in difficult airway management in the absence of a fiberoptic laryngoscope
Kishan Rao Bagam, SGK Murthy, C Vikramaditya, V Jagadeesh
November-December 2010, 54(6):585-585
DOI
:10.4103/0019-5049.72662
PMID
:21224990
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SPECIAL ARTICLE
Attitude of resident doctors towards intensive care units' alarm settings
Rakesh Garg, Anju R Bhalotra, Nitesh Goel, Amit Pruthi, Poonam Bhadoria, Raktima Anand
November-December 2010, 54(6):522-524
DOI
:10.4103/0019-5049.72640
PMID
:21224968
Intensive care unit (ICU) monitors have alarm options to intimate the staff of critical incidents but these alarms needs to be adjusted in every patient. With this objective in mind, this study was done among resident doctors, with the aim of assessing the existing attitude among resident doctors towards ICU alarm settings. This study was conducted among residents working at ICU of a multispeciality centre, with the help of a printed questionnaire. The study involved 80 residents. All residents were in full agreement on routine use of ECG, pulse oximeter, capnograph and NIBP monitoring. 86% residents realised the necessity of monitoring oxygen concentration, apnoea monitoring and expired minute ventilation monitoring. 87% PGs and 70% SRs routinely checked alarm limits for various parameters. 50% PGs and 46.6% SRs set these alarm limits. The initial response to an alarm among all the residents was to disable the alarm temporarily and try to look for a cause. 92% of PGs and 98% of SRs were aware of alarms priority and colour coding. 55% residents believed that the alarm occurred due to patient disturbance, 15% believed that alarm was due to technical problem with monitor/sensor and 30% thought it was truly related to patient's clinical status. 82% residents set the alarms by themselves, 10% believed that alarms should be adjusted by nurse, 4% believed the technical staff should take responsibility of setting alarm limits and 4% believed that alarm levels should be pre-adjusted by the manufacturer. We conclude that although alarms are an important, indispensable, and lifesaving feature, they can be a nuisance and can compromise quality and safety of care by frequent false positive alarms. We should be familiar of the alarm modes, check and reset the alarm settings at regular interval or after a change in clinical status of the patient.
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CASE REPORTS
Nonawakening following general anaesthesia after ventriculo-peritoneal shunt surgery: An acute presentation of intracerebral haemorrhage
Achyut Deuri, Devalina Goswami, Mukesh Samplay, Jyotirmoy Das
November-December 2010, 54(6):569-571
DOI
:10.4103/0019-5049.72650
PMID
:21224978
Emergence from general anaesthesia has been a process characterized by large individual variability. Delayed emergence from anaesthesia remains a major cause of concern both for anaesthesiologist and surgeon. The principal factor for delayed awakening from anaesthesia is assumed to be the medications and anaesthetic agents used in the perioperative period. However, sometimes certain non-anaesthetic events may lead to delayed awakening or even non-awakening from general anaesthesia. We report the non-anaesthetic cause (acute intracerebral haemorrhage) for non-awakening following ventriculo-peritoneal shunt surgery.
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2,520
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CLINICAL INVESTIGATIONS
A randomized controlled double-blinded prospective study of the efficacy of clonidine added to bupivacaine as compared with bupivacaine alone used in supraclavicular brachial plexus block for upper limb surgeries
Shivinder Singh, Amitabh Aggarwal
November-December 2010, 54(6):552-557
DOI
:10.4103/0019-5049.72646
PMID
:21224974
We compared the effects of clonidine added to bupivacaine with bupivacaine alone on supraclavicular brachial plexus block and observed the side-effects of both the groups. In this prospective, randomized,double-blinded, controlled trial, two groups of 25 patients each were investigated using (i) 40 ml of bupivacaine 0.25% plus 0.150 mg of clonidine and (ii) 40 ml of bupivacaine 0.25% plus 1 ml of NaCl 0.9, respectively. The onset of motor and sensory block and duration of sensory block were recorded along with monitoring of heart rate, non-invasive blood pressure, oxygen saturation and sedation. It was observed that addition of clonidine to bupivacaine resulted in faster onset of sensory block, longer duration of analgesia (as assessed by visual analogue score), prolongation of the motor block (as assessed by modified Lovett Rating Scale), prolongation of the duration of recovery of sensation and no association with any haemodynamic changes (heart rate and blood pressure), sedation or any other adverse effects. These findings suggest that clonidine added to bupivacaine is an attractive option for improving the quality and duration of supraclavicular brachial plexus block in upper limb surgeries.
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HISTORY
N P Singh: History of the first intensive care unit in Delhi - Reminiscences
SP Devanandan
November-December 2010, 54(6):574-575
DOI
:10.4103/0019-5049.72652
PMID
:21224980
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1,616
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LETTERS TO EDITOR
An unusual cause of altered airway pressure during surgery under general anaesthesia
Surya K Dube, Sachidanand J Bharati, Hemanshu Prabhakar
November-December 2010, 54(6):576-576
DOI
:10.4103/0019-5049.72653
PMID
:21224982
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1,632
294
Could postoperative pulmonary oedema be attributed to the use of neostigmine?
Mukul C Kapoor
November-December 2010, 54(6):582-582
DOI
:10.4103/0019-5049.72659
PMID
:21224988
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1,710
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Importance of transoesophageal echocardiography in preventing complications due to intraoperative dislodgement of left atrial thrombus
Rahul Guru
November-December 2010, 54(6):577-579
DOI
:10.4103/0019-5049.72655
PMID
:21224983
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Tumescent anaesthesia for post burn contracture release
Rajeev Sharma
November-December 2010, 54(6):579-580
DOI
:10.4103/0019-5049.72656
PMID
:21224984
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2,298
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If air conditioning is not functioning...
Medha Mohta
November-December 2010, 54(6):580-580
DOI
:10.4103/0019-5049.72657
PMID
:21224985
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1,896
301
A novel way of managing shearing of epidural catheter during tunnelling
Kamal Kishore, Sandeep Sahu, Manish Kumar Singh, Anil Agarwal, PK Singh
November-December 2010, 54(6):586-586
DOI
:10.4103/0019-5049.72663
PMID
:21224991
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2,211
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A simple, no-cost method of preventing contamination of anaesthesia work area
Ravi L Bhat, Harihar V Hegde, P Raghavendra Rao
November-December 2010, 54(6):586-587
DOI
:10.4103/0019-5049.72664
PMID
:21224992
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1,509
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Haemothorax after removal of subclavian venous catheter: An unusual complication
Srinivasan Swaminathan, Rajnish K Jain
November-December 2010, 54(6):583-584
DOI
:10.4103/0019-5049.72661
PMID
:21224989
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3,211
264
Hoarseness of voice: An alarming sign to recheck the position of naso-gastric tube
Pratibha Jain Shah, KP Dubey
November-December 2010, 54(6):588-590
DOI
:10.4103/0019-5049.72666
PMID
:21224994
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MEDICOLEGAL ISSUES
Vicarious liability
SC Parakh
November-December 2010, 54(6):591-591
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