Aparna Williams

Antibiotic prescription patterns at admission into a tertiary level intensive care unit in Northern India

Context: An audit of antibiotic prescribing patterns is an important indicator of the quality and standard of clinical practice. Aims: To study the (1) antibiotic prescription and consumption patterns at admission into the intensive care unit (ICU); (2) average costs of antibiotics prescribed; and (3) correlation of antibiotic usage and the costs incurred with age, severity of illness, and diagnosis. Settings and Design: A 13-bedded tertiary level ICU. A prospective, observational audit. Materials and Methods: Two hundred consecutive prescriptions on patients admitted to the ICU from August to October, 2008, were audited. The total number of drugs and antibiotics, the class, dose, route, and cost of antibiotics were noted and the Defined Daily Dose/100 bed-days (DDD/100 bed-days) of the 10 most frequently prescribed antibiotics were calculated. Statistical analysis used: Univariate analysis was performed using Epi Info software (version 8.0). Results: A total of 1246 drugs and 418 antibiotics were prescribed in the 200 patients studied, that is, an average of 6.23 (± SD 2.73) drugs/prescription and 2.09 (± SD 1.27) antibiotics/prescription. Antibiotics were prescribed on 190 patients (95%) at admission. There was a significant correlation between the number of patients prescribed three or more antibiotics and mortality rates (53% nonsurvivors vs. 33.5% survivors (P = 0.015). The average cost of the antibiotics was Rupees 1995.08 (± SD 2099.99) per patient and antibiotics expenditure accounted for 73.2% of the total drug costs. Conclusions: Antibiotics are commonly prescribed to most ICU patients at admission and contribute significantly to the total drug costs. Antibiotic restriction policies and a multidisciplinary effort to reduce usage are urgently required.

An audit of morbidity and mortality associated with foreign body aspiration in children from a tertiary level hospital in Northern India

Background: There is paucity of data regarding the morbidity and mortality of rigid bronchoscopy in children for foreign body (FB) retrieval from India. The aim was to audit data regarding anaesthetic management of rigid bronchoscopy in children and associated morbidity and mortality. Materials and Methods: Hospital records of all patients below 18 years of age undergoing rigid bronchoscopy for suspected FB aspiration (FBA) between January 1, 2002 and December 31, 2011 were audited to assess their demographic profile, anaesthetic management, complications, and postoperative outcomes. The children were divided into early and late diagnosis groups depending on whether they presented to the hospital within 24 hours of FBA, or later. Results: One hundred and forty children, predominantly male (75%), with an average age of 1-year and 8 months, presented to our hospital for rigid bronchoscopy during the study period. Majority of children presented in the late diagnosis group (59.29% vs. 40.71%). The penetration syndrome was observed in 22% of patients. Majority of patients aspirated an organic FB (organic: Inorganic FB = 3:1), with peanuts being the most common (49.28%). A significantly higher number of children presented with cough (P = 0.0001) and history of choking (P = 0.0022) in the early diagnosis group and crepitations (P = 0.0011) in the late diagnosis group. Major complications included cardiac arrest (2.1%), pneumothorax (0.7%), and laryngeal oedema (9.3%). The average duration of hospitalization in our series was 3.08 ± 0.7 days. Conclusions: Foreign body aspiration causes considerable morbidity, especially when diagnosis is delayed.

Crystalloid preload versus crystalloid coload for parturients undergoing cesarean section under spinal anesthesia

Context: There is a paucity of studies comparing crystalloid preload and coload in parturients undergoing cesarean section under spinal anesthesia from India. Aims: To compare crystalloid preload and coload for the prevention of maternal hypotension in parturients undergoing cesarean section under spinal anesthesia. Secondary outcomes studied included requirement of ephedrine for treatment of hypotension, maternal nausea and vomiting, neonatal APGAR scores and acid base status. Settings and Design: Tertiary level, teaching hospital. Prospective, randomized study. Materials and Methods: Hundred parturients, aged 20 to 40 years, American Society of Anesthesiologist (ASA) physical status 1 or 2, with singleton, uncomplicated pregnancies scheduled for cesarean section under spinal anesthesia were randomized into two groups. Subjects in group P received 15 ml/kg of lactated Ringers (RL) solution as preload over 20 min before the placement of spinal block, while those in group C received 15 ml/kg of RL over 20 min, starting as soon as CSF was tapped. Statistical Analysis Used: Students t-test, Chi-square test, Fishers test. Results: The number of parturients developing hypotension in group P and C was 30 and 23 respectively and was comparable statistically. More number of patients developed nausea (19 versus 10, P = 0.0473) and vomiting (14 versus 6, P = 0.0455) in group P as compared to group C and these values were statistically significant. The mean number of doses of ephedrine required (2.6 in group P and 1.8 in group C) and the total dose of ephedrine used (14.2 mg and 12.6 mg in groups P and C respectively) in the groups were comparable statistically. Conclusions: Both preloading and coloading with 15 ml/ kg of RL solution are ineffective in the prevention of spinal-induced maternal hypotension. We recommend frequent monitoring of maternal blood pressure (at 1-min intervals) and prompt treatment of maternal hypotension with vasopressors for better neonatal outcomes.

Tetany: A diagnostic dilemma.

Tetany is a disorder of increased neuronal excitability usually associated with hypocalcemia. We report a patient with typical tetanic cramps and carpopedal spasm in the postoperative period, despite normal serum concentrations of calcium, which responded to intravenous infusion of calcium.

Fatal airway obstruction following arterial trauma during internal jugular venous cannulation

Central venous cannulations are commonly performed in the intensive care unit. However, these may be associated with severe mechanical or bleeding complications. Here, we describe a patient who died following severe and rapid airway obstruction secondary to an arterial trauma during internal jugular vein cannulation. This case report highlights the importance of prompt recognition of arterial trauma so that it can be repaired surgically instead of sheath removal. The prompt diagnosis of an impending airway obstruction and obtaining early airway access cannot be overemphasized. Finally, we discuss the risk factors associated with this complication and what we could have possibly done to prevent this outcome.

Stridor in children: Is airway always the cause?

Stridor in children is usually, but not always caused by airway pathology. The anesthesiologists should have a sound knowledge of the neurological associations of stridor and its management. In such cases, prompt treatment of the neurological pathology usually resolves the stridor and may prevent unnecessary airway evaluation and intervention in the child.

Tongue bite injury after use of transcranial electric stimulation motor-evoked potential monitoring

Journal of Anaesthesiology Clinical Pharmacology | July-September 2014 | Vol 30 | Issue 3 439 on the patient’s condition and a communication between the anesthesiologist, surgeon and interventional radiologist is essential. C. Voscopoulos et al.[2] and Basem Abdalmalak et al.[3] have successfully used dexmedetomidine based technique in tracheobronchial stenting in the cases of central airway obstruction. Bergese SD et al.[4] evaluated the safety and efficacy of dexmedetomidine for sedation during awake fiberoptic intubation and they found that dexmedetomidine is effective as the primary sedative in the patients undergoing the awake fiberoptic intubation with difficult airway.

Anesthetic considerations in a preterm: Extremely low birth weight neonate posted for exploratory laparotomy

Preterm neonates present unique challenges to the anesthesiologist due to their immature physiology and anatomy. Many preterm neonates are critically ill and can develop necrotizing enterocolitis, respiratory distress syndrome, intra ventricular hemorrhage, and heart failure or retinopathy of prematurity. Anesthesiologists play a vital role in the management of preterm neonates requiring surgical interventions, by integrating their knowledge of the developmental physiology and pharmacology. The successful conduct of anesthesia in premature neonates requires an understanding of the basic principles of neonatal care.

Comparison of intrathecal bupivacaine-fentanyl and bupivacaine-butorphanol mixtures for lower limb orthopedic procedures

Context: Intrathecal use of butorphanol is less explored in human subjects. Aims: To compare the safety and efficacy of anesthesia and analgesia of intrathecal bupivacaine-butorphanol mixture with intrathecal bupivacaine-fentanyl mixture. Settings and Design: Tertiary level, teaching hospital. Prospective, randomized, double-blind study Materials and Methods: Eighty patients aged above 18 years, of ASA physical status 1 or 2, undergoing lower limb orthopedic surgeries were randomly allocated to two groups of 40 patients each. Patients in group A and group B received intrathecal 2.5 ml of hyperbaric bupivacaine (0.5%), with 25 μg of fentanyl and 25 μg of butorphanol, respectively. Statistical Analysis Used: Fishers exact test and Chi square tests Results: The times required for onset of sensory and motor blockade were comparable among the two groups. Significantly slower block regression to S2 level was observed in the group receiving intrathecal butorphanol as compared to intrathecal fentanyl (P=0.0230). A higher number of patients in group A requested for rescue analgesia during the postoperative period than in group B (9 versus 2; P=0.0238). The average times to first request for rescue analgesia were 308.6±14.9 minutes and 365.9±12.3 minutes in group A and B, respectively (P=0.0254). Conclusions: Both 25 μg fentanyl and 25 μg butorphanol given intrathecally along with 12.5 mg of hyperbaric bupivacaine provide effective anesthesia for lower limb surgeries. Intrathecal bupivacaine-butorphanol mixture provides longer duration of sensory blockade and superior analgesia than intrathecal fentanyl-bupivacaine mixture.

Submental intubation for airway management of patients with complex caniomaxillofacial injuries: Our experience

Context: There is paucity of data regarding the role of submental intubation (SI) in the airway management of patients with craniomaxillofacial trauma from India. Aims: To study the characteristics of patients presenting with craniomaxillofacial injuries requiring submental intubation, the duration of SI procedure and complications of this technique. Settings and Design: Tertiary level, teaching institute, retrospective, observational study. Materials and Methods: Forty patients requiring submental intubation between June, 2007 and December, 2009. The primary outcome measure was the time required for submental intubation defined as starting from the completion of the orotracheal intubation to the fixation of the submental tube. The secondary outcome measures included characteristics of patients with craniomaxillofacial injuries, intraoperative and postoperative complications of the SI technique. Statistical Analysis Used: Data are presented as mean± standard deviation and frequency and percentages, where relevant. Results: Most of the patients were young (average age = 35.15 ± 12.02 years), males (75%) and sustained craniomaxillofacial injuries due to road traffic accidents (85%). The 40 patients included in this audit had 56 injuries recorded at the time of admission including, orthopedic injuries in 65% and head injuries in 55% of patients. The mean time required for completion of SI was 8.90 min. The complications observed included, intraoperative tube migration, development of extra oral fistula, and sialocele, in one patient each. Conclusions: Submental intubation is a simple, safe, quick, and relatively harmless alternative to tracheostomy for securing the airway in selected patients with craniofacial trauma. Familiarity with the submental intubation technique will help the anesthesiologist to avoid tracheostomy in selected patients with craniofacial trauma who do not require long-term mechanical ventilation.