Ganne S. Umamaheswara Rao

Acute kidney injury in survivors of surgery for severe traumatic brain injury: Incidence, risk factors, and outcome from a tertiary neuroscience center in India

Abstract Background. Non-neurological complications like acute kidney injury (AKI) can affect outcome of traumatic brain injury (TBI). This study aims to analyze the incidence, predictive factors, and impact of AKI in operated patients with severe TBI. Methods. We retrospectively reviewed the data of 395 patients who underwent surgery for severe TBI and survived to be discharged from the hospital over a 1-year period. Of these, 95 patients were finally included in the analysis. Their demographic data, laboratory parameters, and clinical courses were reviewed. Diagnosis and staging of AKI was made using Acute Kidney Injury Network (AKIN) criteria. Results. The incidence of AKI was 11.6% (11 patients). Out of the11 patients who had AKI, 7 were in stage I (63.6%), 3 were in stage II (27.3%), and 1 in stage III (9.1%). Nine Patients (81.8%) developed AKI within 5 days of admission. Aminoglycoside therapy had an association with occurrence of AKI. There was no mortality and none of the patients required renal replacement therapy (RRT). Renal function of all these patients returned to baseline before hospital discharge. Hospital stay and intensive care unit (ICU) stay were longer and Glasgow coma scale (GCS) was lower in patients with AKI when compared with patients without AKI group at discharge. Conclusion. Reversible AKI without need for RRT occurred in nearly12% of patients with severe TBI requiring surgical intervention. Aminoglycoside therapy was the only predictive factor for the occurrence of AKI. Patients with AKI have a longer period of mechanical ventilation, longer ICU and hospital stay, and poorer GCS at discharge.

Fall in inspired oxygen and anaesthetic agent concentrations during change of soda lime absorber

Following an episode of reduction in inspired oxygen concentration (FiO2) and inhalational agent concentration (Fi agent) during the changing of a soda lime absorber, We conducted an in vitro experiment to understand the impact of disconnection of the absorber on inspired gas dilution at different fresh gas flows. We found that both in Dräger Fabius GS and Primus anaesthesia work stations, disconnection of the absorber caused progressive reduction in FiO2 and Fi agent as the FGF was decreased. The operating principle of fresh gas decoupling (FGD) valve is a potential source of this complication, which must be kept in mind while changing the soda lime during the course of surgery where an anaesthetic work stations utilizing FGD valves are used.

Anesthetic management of patients with Joubert syndrome: a retrospective analysis of a single-institutional case series.

To analyze the anesthetic techniques used for sedation during magnetic resonance imaging (MRI) study of patients with Joubert syndrome (JS) and assess the safety and efficacy of these anesthetic regimens in these children.

Cerebral vasospasm: current understanding

Purpose of review With recent research trying to explore the pathophysiologic mechanisms behind vasospasm, newer pharmacological and nonpharmacological treatments are being targeted at various pathways involved. This review is aimed at understanding the mechanisms and current and future therapies available to treat vasospasm. Recent findings Computed tomography perfusion is a useful alternative tool to digital subtraction angiography to diagnose vasospasm. Various biomarkers have been tried to predict the onset of vasospasm but none seems to be helpful. Transcranial Doppler still remains a useful tool at the bedside to screen and follow up patients with vasospasm. Hypertension rather than hypervolemia and hemodilution in ‘Triple-H’ therapy has been found to be helpful in reversing the vasospasm. Hyperdynamic therapy in addition to hypertension has shown promising effects. Endovascular approaches with balloon angioplasty and intra-arterial nimodipine, nicardipine, and milrinone have shown consistent benefits. Endothelin receptor antagonists though relieved vasospasm, did not show any benefit on functional outcome. Summary Endovascular therapy has shown consistent benefit in relieving vasospasm. An aggressive combination therapy through various routes seems to be the most useful approach to reduce the complications of vasospasm.

Seasonal variation in the clinical recovery of patients with Guillain Barré syndrome requiring mechanical ventilation

BACKGROUND Guillain Barré Syndrome (GBS) has a variable clinical course. The influence of season on the rate of recovery has not been evaluated previously, despite documentation of seasonal variation in the occurrence of GBS. This study evaluated the influence of season on the rate of recovery from GBS. MATERIALS AND METHODS Records of 184 patients with GBS over a 10-year period were reviewed. Patients were divided into four groups depending on the date of admission: Q1 (March-May), Q2 (June-August), Q3 (September-November), and Q4 (December-February). Demographic characteristics and recovery characteristics (duration of mechanical ventilation, ICU and hospital stay, and time for recovery from the time of initiation of definitive therapy) were compared across the four quarters. RESULTS There was no significant difference in age, antecedent illnesses, treatment received, electrophysiological findings, and muscle power at admission across the four groups. Significant differences among various seasons were found with respect to duration of mechanical ventilation (23 ± 20, 36 ± 34, 27 ± 22, and 38 ± 28 days for Q1-Q4, respectively; P = 0.05), ICU stay (27 ± 22, 40 ± 37, 31 ± 23, and 43 ± 30 days for Q1-Q4, respectively; P = 0.05), hospital stay (42 ± 28, 55 ± 44, 47 ± 34, and 72 ± 54 days for Q1-Q4, respectively; P = 0.02), and time for recovery from treatment (15 ± 14, 29 ± 34, 18 ± 14, and 29 ± 20 days for Q1-Q4, respectively; P = 0.02). CONCLUSIONS This study demonstrates a seasonal variation in the recovery of patients with GBS requiring mechanical ventilation. Patients admitted in Q1 have the fastest recovery and those in Q4 have the slowest recovery.

Biomarkers and prognostication in traumatic brain injury

A number of patients who suffer from mild head injury later on develop significant disabilities. Biomarkers help identify and quantify the extent of injury and help predict the possible functional outcome of the patients. There are promising candidate biomarkers for axonal injury (Tau) and astrocytic damage (glial fibrillary acidic protein and S100β) in traumatic brain injury. However, the biological significance of these markers cannot be confidently declared due to lack of studies with adequate sample size.

Translational research in neuroanaesthesia

Translational research in anaesthesia provided great solutions to medicine, well beyond its scope, in the past. Exciting opportunities exist for neuroanaesthesiologists to conduct translational research not just in anaesthesia alone but in the wider realm of neurosciences. This research is expected to provide solutions to clinical neuroscience questions and to help understand some of the complex neurocognitive functions. Despite several technical developments, progress in translational sciences has been rather slow in the recent years. Re-orientation of the research programmes to a translational format with the involvement of all the stakeholders is likely to conserve the cost and provide rapid solutions to the healthcare.

Systemic care in the acute management of patients with stroke

Early and effective systemic management plays an important role in the outcome of patients with stroke. Vigilant respiratory and hemodynamic monitoring and optimisation along with nutritional and metabolic correction goes a long way in improving results of definitive treatment in patients with stroke. This review discusses the systemic changes occurring after stroke and provides current evidence in the management of these factors, which significantly influence the outcome.

Influence of acute haemodynamic changes on the oxygen saturation during electro-convulsive therapy

Background: Electro-convulsive therapy (ECT) is a safe and effective treatment for various psychiatric disorders. Among the various complications associated with ECT, acute haemodynamic responses and decrease in the oxygen saturation are the most common. The current study is designed to evaluate the relationship between the haemodynamic response and oxygen de-saturation occurring during ECT. Materials and Methods: Patients undergoing modified ECT for their psychiatric illness over a one-year period were prospectively included in this observational study. The following parameters were collected from each patient: Age, body mass index (BMI), doses of thiopentone and suxamethonium, stimulus current, ECT session number, pre-and post-ECT heart rate, systolic, diastolic and mean arterial pressure, seizure duration and pre- and post-ECT oxygen saturation. Results: The incidence of oxygen de-saturation was 27% (139/507 sessions). The change in the heart rate and systolic blood pressure caused by ECT and the BMI of the patient were independently predictive of the change in the oxygen saturation. Conclusions: The current study identified ECT-induced acute haemodynamic changes as independent predictors of severity of oxygen de-saturation.

Adequate hypnosis at very low isoflurane concentration during craniotomy monitored by electroencephalography

We report a patient with Parkinson’s disease undergoing craniotomy for a brain tumor, who had clinically adequate hypnosis at a very low concentration of isoflurane. While the raw EEG showed low-voltage slow electrical activity, the EEG analyzer of the monitor displayed high burst suppression ratios. The role of intracranial pathology and drug therapy as possible causes of the low anesthetic requirement for adequate hypnosis are discussed. This report also draws attention to the possibility of erroneous analysis of burst suppression by EEG modules.