Ankur Khandelwal

Intense Intraoperative Thirst: A Neglected Concern during Awake Craniotomy Surgeries.

Cyrill Meuwly, MMed* Tumul Chowdhury, MD, DM, FRCPCw Ricardo Gelpi, MD, PhDz Paul Erne, MD* Bernhard Schaller, MD, PhD, DSCy *Department of Research, University Hospital Basel, Basel, Switzerland wDepartment of Anaesthesiology and Perioperative Medicine, University of Manitoba, Winnipeg, Canada zDepartment of Pathology, University of Buenos Aires, Buenos Aires, Argentina yDepartment of Research, University of Southampton, Southampton, UK

Non- neurological complications after traumatic brain injury: A prospective observational study

Introduction and Aims: Recognizing and treating nonneurological complications occurring in traumatic brain injury (TBI) patients during intensive care unit (ICU) stay are challenging. The aim is to estimate various nonneurological complications in TBI patients. The secondary aim is to see the effect of these complications on ICU stay, disability, and mortality. Materials and Methods: This was a prospective observational study at the neuro-ICU of a Level-I trauma center. A total of 154 TBI patients were enrolled. The period of the study was from admission to discharge from ICU or demise. Inclusion criteria were patients aged >16 years and patients with severe TBI (Glasgow coma score [GCS] ≤8). Nonneurological complications were frequent in TBI patients. Results: We observed respiratory complications to be the most common (61%). Other complications, in the decreasing order, included dyselectrolytemia (46.1%), cardiovascular (34.4%), coagulopathy (33.1%), sepsis (26%), abdominal complications (17.5%), and acute kidney injury (AKI, 3.9%). The presence of systemic complications except AKI was found to be significantly associated with increased ICU stay. Most of the patients of AKI died early in ICU. Respiratory dysfunction was found to be independently associated with 3.05 times higher risk of worsening clinical condition (disability) (P < 0.018). The presence of cardiovascular complications during ICU stay (4.2 times, P < 0.005), AKI (24.7 times, P < 0.02), coagulopathy (3.13 times, P < 0.047), and GCS <6 (4.2 times, P < 0.006) of TBI was independently associated with significantly increased risk of ICU mortality. Conclusion: TBI patients tend to have poor outcome due to concomitant nonneurological complications. These have significant bearing on ICU stay, disability, and mortality.

Sustained intraoperative bradycardia revealing Sengers syndrome

We read with interest the article by Zarrouki et al. revealing the characteristic manifestations of Sengers syndrome in a 6-month-old infant.[1] The authors encountered bradycardia unresponsive to atropine in the infant immediately following induction of anaesthesia. It was associated with decrease in end-tidal carbon dioxide (EtCO2) as low as 8 mmHg. Following resuscitation and completion of surgery, transthoracic echocardiography showed hypertrophied and apical hypokinesia of the left ventricle responsible for the event.

Delayed emergence from anaesthesia and bilateral mydriasis following bilateral pallidotomy

Pallidotomy is a surgical procedure done widely for Parkinsons disease and various dystonias refractory to medical treatment. The technique involves radiofrequency (RF) thermal coagulation of globus pallidus internus, either unilaterally or bilaterally. The technique has been shown to produce good success. However, the involvement of nearby vital structures can result in new post-operative complications. We encountered a case of delayed emergence from anaesthesia associated with bilateral mydriasis and visual field defects in a patient after bilateral RF thermal lesioning.

Suction catheter as a crucial rescuer in lost tracheostomy tract situation during percutaneous tracheostomy

Sir, Percutaneous dilatational tracheostomy (PCT) even though has appropriately replaced the surgical tracheostomy by far in critical care settings, yet the fact that it accompanies a myriad of both trivial and nontrivial complications cannot be denied. One such complication already mentioned in literature includes inadvertent migration of guidewire into the Murphy’s eye of endotracheal tube (ETT) during PCT.[1]

Bowel Preparation in Awake Craniotomy: An Overlooked Entity.

To JNA Readers: The success of surgeries such as awake craniotomy depends much on the education status and the cooperation of the patient. All efforts should be made to relieve the anxiety of the patients during the perioperative period. Inadequate bowel preparation inciting the urge to defecate once the patient is inside the operating room can be a distressing factor both for the patient and the medical staff. Moreover, the urge to defecate during the intraoperative period can make the patient restless and all efforts of tedious preoperative counselling for awake craniotomy can end up in vain. We had faced similar situation with 2 of our patients posted for awake craniotomy where one of them wished to defecate after we had already placed peripheral intravenous cannulae and arterial access under local anesthesia including administration of low dose intravenous midazolam as premedicant. He had to be escorted to the lavatory by 2 additional staffs to avoid any undue complication in view of mild sedation. The other patient, however, wished to defecate when we were yet to administer premedicants. Both the patients later admitted of incomplete evacuation during preoperative course. After encountering such situations, we have developed a protocol of prescribing laxative the night before surgery to all the patients and enema on the morning of the surgery in those complaining of incomplete evacuation. This in turn abridged patient anxiety and improved patient cooperation during awake neurosurgery. In addition, the delay in starting the surgery as clearly evident in the above 2 patients was also curtailed. Another advantage of administering enema was the unnecessary need of straining during evacuation either during morning hours of the preoperative period or in the early postoperative period. This will avoid potentially increasing the intracranial pressure in the background of a patient’s intracranial pathology.

Subcutaneous hematoma following subcutaneous emphysema: An occult association

Indian Journal of Critical Care Medicine ¦ Volume 21 ¦ Issue 9 ¦ September 2017 618 Some evidence suggests that lung‐protective mechanical ventilation (MV) with low‐tidal volume ventilation (LTVV) in addition to positive end‐expiratory pressure (PEEP) could prevent PGD‐induced hypoxemia in the recipients of LT. Nevertheless, these suggestions require further validation in prospective clinical studies.[3] In addition, these strategies of MV could not provide sufficient gas exchange in the episode of refractory hypoxemia. Therefore, because of a lack of clear evidence on how to optimally ventilate and manage patients, the current practices of MV strategy following LT are not based on rigorous evidence[1] and need further investigation.

A rare case of variation in the anatomical relationship between the common carotid artery and the internal jugular vein due to enlarged thyroid

How to cite this article: Umesh G, Kaur J, Annigeri R, Thilakchand KR. Sneaky leaks: Old devil, new location. Indian J Anaesth 2017;61:600-1.

An iron rod restricting access to airway: an unusual presentation

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Pneumothorax during percutaneous tracheostomy ― a brief review of literature on attributable causes and preventable strategies

The significant advantages of percutaneous tracheostomy over surgical (open) tracheostomy has enabled its widespread acceptability and practice in intensive care units. Over the years, various modifications in the technique of percutaneous tracheostomy has increased its safety profile and reduced the overall complication rate. However, even though it is a bedside procedure, inappropriate patient selection and poor adherence to protocols can lead to devastating complications. One such complication, namely pneumothorax, is often overlooked. In this article, we have highlighted all the possible etiologies of pneumothorax during percutaneous tracheostomy. A brief insight into some of the preventable strategies is also discussed.