Georgene Singh

Incidence and outcome of acute lung injury and acute respiratory distress syndrome in the surgical intensive care unit

Introduction: To determine the incidence and mortality of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) in a cohort of patients with risk factors admitted to the Surgical Intensive Care Unit (SICU). Materials and Methods: A prospective observational inception cohort study with no intervention was conducted over 12 months. All patients with at least one known risk factor for ALI/ARDS admitted to the SICU were included in the study. The APACHE II severity of disease classification system scoring was performed within 1 h of admission. The ventilatory parameters and chest radiographs were recorded every 24 h. The P/F ratio, PEEP and Lung Injury Score were calculated each day until the day of discharge from the Intensive Care Unit or for the first 7 days of admission, whichever was shorter. Results: The incidence of ARDS among those who were mechanically ventilated was 11.4%. Sepsis was the most common (34.6%) etiology. Among those with risk factors, the incidence of ARDS was 30% and that of ALI was 32.7%. The mortality in those with ARDS was 41.8%. Those who develop ARDS had higher APACHE II scores, lower pH and higher PaCO2 at admission compared with those who developed ALI or no lung injury. Conclusion: The incidence and mortality of ARDS was similar to other studies. Identifying those with risk factors for ARDS or mortality will enable appropriate interventional measures.

Endotracheal cuff pressure changes with change in position in neurosurgical patients

Background: Placement of a cuffed endotracheal tube for the administration of general anesthesia is routine. The cuff of the endotracheal tube is inflated with air to achieve an adequate seal to prevent micro-aspiration. Over inflation of the cuff can decrease the mucosal perfusion, leading to pressure necrosis and nerve palsies. Inadequate seal can lead to micro aspiration. So the cuff pressure has to be monitored and kept within the prescribed limits of 20-30 cms of water. Aim of the Study: To observe the effect of different positions on the endotracheal cuff pressure in patients undergoing neurosurgical procedures. Materials and Methods: This is an observational study conducted on 70 patients undergoing neurosurgical procedures in various positions. After intubation, the cuff pressure was checked with a cuff pressure manometer, Endotest (Teleflex Medical, Rush) and adjusted to be within the allowable pressure limits as is the routine practice. The cuff pressure was checked again at three time points after achieving the final position with the head on pins, at the end of the procedure and before extubation. Various factors such as the age, position, duration of surgery were studied. There were no major complications like aspiration, stridor or hoarseness of voice post extubation in any of the patients. Results: A significant decline in the cuff pressures were noted from the initial supine position to extubation (P < .001) in the supine group. Also a significant decline in the cuff pressures were found in the prone group from their initial intubated supine position to all the other three corresponding time points namely after final positioning (P < .001), at the end of the procedure (P < .001) and before extubation (P < .001). Conclusion: Cuff pressure has to be checked after achieving the final positioning of the patient and adjusted to the prescribed limits to prevent micro aspiration.

Low-concentration, continuous brachial plexus block in the management of Purple Glove Syndrome: a case report

IntroductionPurple Glove Syndrome is a devastating complication of intravenous phenytoin administration. Adequate analgesia and preservation of limb movement for physiotherapy are the two essential components of management.Case presentationA 26-year-old Tamil woman from India developed Purple Glove Syndrome after intravenous administration of phenytoin. She was managed conservatively by limb elevation, physiotherapy and oral antibiotics. A 20G intravenous cannula was inserted into the sheath of her brachial plexus and a continuous infusion of bupivacaine at a low concentration (0.1%) with fentanyl (2 μg/ml) at a rate of 1 to 2 ml/hr was given. She had adequate analgesia with preserved motor function which helped in physiotherapy and functional recovery of the hand in a month.ConclusionA continuous blockade of the brachial plexus with a low concentration of bupivacaine and fentanyl helps to alleviate the vasospasm and the pain while preserving the motor function for the patient to perform active movements of the finger and hand.

A randomized controlled trial to determine the role of intraoperative lumbar cerebrospinal fluid drainage in patients undergoing endoscopic transsphenoidal surgery for pituitary adenomas

Background: Intraoperative cerebrospinal fluid (CSF) leaks are a frequent cause of morbidity in patients undergoing transsphenoidal surgery. This prospective study was performed to examine the impact of intraoperative lumbar subarachnoid drainage (LSAD) on the incidence of this complication and on the extent of resection in patients undergoing endoscopic transsphenoidal surgery for pituitary adenomas. Materials and Methods: This prospective study was conducted in a single large academic medical center. All patients with pituitary adenomas who had not undergone prior transsphenoidal surgery were eligible for inclusion in the study. Patients were randomly assigned to undergo transsphenoidal surgery with intraoperative lumbar drain insertion (LSAD group) or no lumbar drain insertion (no LSAD group). An otolaryngologist independently determined the occurrence of an intraoperative CSF leak. Extent of tumor resection was determined by volumetric analysis of postoperative magnetic resonance images in patients with nonfunctional tumors or functional adenomas with a large suprasellar component. Results: Sixty patients were eligible for inclusion, of which 30 were assigned to the LSAD group and 30 to the no LSAD group. There were no statistically significant differences in patient demographics, tumor pathology, or radiology between the two groups. The LSAD catheter was successfully inserted in all patients in the LSAD group. Intraoperative CSF drainage significantly reduced the incidence of CSF leak from 46.7% in the no LSAD group to 3.3% in the LSAD group (P < 0.001). However, there were no statistically significant differences in the incidence of postoperative CSF rhinorrhea between the two groups. There were no major catheter-related complications. There was no statistically significant difference in the extent of resection between the two groups. Conclusions: Controlled intraoperative CSF drainage significantly reduces the incidence of intraoperative CSF leakage in patients undergoing endoscopic transsphenoidal surgery for pituitary adenomas.

Takotsubo cardiomyopathy in a patient with pituitary adenoma and secondary adrenal insufficiency

We describe a case of Takotsubo cardiomyopathy in a case of pituitary macroadenoma in acute adrenal crisis. A 48-year-old man presented with acute onset altered sensorium, vomiting, and gasping. On admission, he was unresponsive and hemodynamically unstable. He was intubated and ventilated and resuscitated with fluids and inotropes. The biochemical evaluation revealed hyponatremia, hyperkalemia, and hypocortisolism. Hyponatremia was corrected with 3% hypertonic saline. Contrast enhanced computed tomography (CT) scan of the brain revealed a sellar-suprasellar mass with hypothalamic extension with no evidence of pituitary apoplexy. A diagnosis of invasive pituitary adenoma with the Addisonian crisis was made and steroid replacement was initiated. Despite volume resuscitation, he had persistent refractory hypotension, recurrent ventricular tachycardia, and metabolic acidosis. Electrocardiogram (ECG) showed ST elevation and T-wave inversion in lateral leads; cardiac-enzymes were increased suggestive of acute coronary syndrome. Transthoracic echocardiography showed severe regional wall motion abnormalities (RWMAs) involving left anterior descending territory and low ejection fraction (EF). Coronary angiogram revealed normal coronaries, apical ballooning, and severe left ventricular dysfunction, consistent with a diagnosis of Takotsubos cardiomyopathy. Patient was managed with angiotensin-converting enzyme inhibitors and B-blockers. He improved over few days and recovered completely. At discharge, ECG changes and RWMA resolved and EF normalized to 56%. In patients with Addisonian Crisis with persistent hypotension refractory to optimal resuscitation, possibility of Takotsubos cardiomyopathy should be considered. Early recognition of association of Takotsubos cardiomyopathy in neurological conditions, prompt resuscitation, and supportive care are essential to ensure favorable outcomes in this potentially lethal condition.

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.

Comparison of the effect of lignocaine instilled through the endotracheal tube and intravenous lignocaine on the extubation response in patients undergoing craniotomy with skull pins: A randomized double blind clinical trial.

Background: A desirable combination of smooth extubation and an awake patient after neurosurgical procedures is difficult to achieve in patients with skull pins. Lignocaine instilled into endotracheal tube has been reported to suppress cough by a local mucosal anesthetizing effect. We aimed to evaluate if this effect will last till extubation, if given before pin removal. Materials and Methods: A total of 114 patients undergoing elective craniotomy were divided into three groups and were given 1 mg/kg of intravenous (IV), 2% lignocaine (Group 1), placebo (Group 2) and 1 mg/kg of 2% lignocaine sprayed down the endotracheal tube (Group 3) before skull pin removal. The effectiveness of each to blunt extubation response was compared. Plasma levels of lignocaine were measured 10 min after administration of the study drug and at extubation. Sedation scores were noted, immediately after extubation and 10 min later. Results: Two percent of lignocaine instilled through endotracheal route was not superior to the IV route or placebo in attenuating cough or hemodynamic response at extubation when given 20-30 min before extubation. The plasma levels of lignocaine (0.8 μg/ml) were not high enough even at the end of 10 min to have a suppressive effect on cough if given IV or intratracheally (IT). Lignocaine did not delay awakening in these groups. Conclusion: IT lignocaine in the dose of 1 mg/kg does not prevent cough at extubation if given 20-30 min before extubation. If the action is by a local mucosal anesthetizing effect, it does not last for 20-30 min to cover the period from pin removal to extubation.

Endotracheal tube fixation in neurosurgical procedures operated in prone position.

isoflurane group. Hemodynamic profile in propofol group was thus better than the isoflurane group. Regarding comparison of emergence, we compared the time for eye opening and time taken to reach an Aldrete score of 9. Aldrete score contains parameters like consciousness and motor activity. So, eye opening, consciousness, and motor activity are reasonably enough parameters to compare emergence. We used a single isoflurane vaporizer for all cases in control group. Isoflurane consumed per case was calculated by dividing total isoflurane used in the vaporizer with total number of cases anesthetized. Indeed, it was a rough estimate, but we could not find any better and more practical method to calculate the isoflurane dose. The surgery was performed by same neurosurgical team, time required was nearly identical (as shown in the relevant observations in the manuscript) in most cases. In propofol group, we calculated the cost of the propofol used. We did not consider the amount of propofol that remained in the syringe after operation, because that was used in next patient, after changing the connecting tubing to avoid wastage of the drug. We routinely use midazolam 30 mcg/kg intravenous 3 minutes before starting administration of propofol in all cases. We titrated the infusion dose of propofol according to bispectral index scores, which were kept in a range of 40 to 60.

Differentiation Between the Potential Subdural Space and Subarachnoid Space Was Difficult With Fluoroscopy Due to Obesity.

nonfunctioning right ventriculoatrial shunt, which warranted a revision. We planned a general anesthetic with controlled ventilation for this child. After anesthetizing the child, a pediatric Transesophageal Echo probe (HDIIXE Philips Healthcare) was inserted to guide the placement of the ventriculoatrial shunt. The surgical plan was to assess the position of the previous ventriculoatrial shunt, and to reinsert another ventriculoatrial shunt. The initial imaging in the esophageal bicaval view showed 2 echo-dense structures, as depicted in Figure 1A. The more anteriorly placed is the previously placed ventriculoatrial shunt, which was not seen to be draining and the structure below is possibly the crista terminalis. After the insertion of the new atrial catheter, its appearance into the chamber was not visualized initially and there was a suspicion of catheter migration into the subclavian vein, which was confirmed by fluoroscopy. The surgeons repositioned the catheter and its correct placement was confirmed by Transesophageal Echo imaging, as depicted in Figure 1B. The surgeon flushed the open end of the atrial catheter with saline and the visualization of the bubbles from the atrial catheter holes helped to differentiate the new from the old ventriculoatrial shunt and its correct depth of insertion. Ventriculoatrial shunt is performed in patients with hydrocephalus where a ventriculoperitoneal shunt is contraindicated like peritoneal adhesions, shunt ascitis, pregnancy, and previous laparotomy.1 However, it is associated with complications such as, thrombus formation, infective endocarditis, shunt malfunction, pulmonary hypertension, and glomerulonephritis. The role of transesophageal echocardiogram in the placement of ventriculoatrial shunt has been described by Chuang et al.1 Although it is not a standard practice, we would like to highlight specific benefits of transesophageal echocardiographic guidance for the revision of ventriculoatrial shunt. It confirms the optimal positioning in real time of the new shunt and allows assessment of the position of the previous shunt and visualization of any possible thrombus or vegetations.3 It also guides the safe removal of the preexisting ventriculoatrial shunt and provides an undisturbed surgical field, as compared with the use of transthoracic echocardiogram or repeated C-arm exposures. Although similar objectives may be obtained with fluoroscopic guidance, it risks radiation exposure, especially in a growing child. With more and more anesthesiologists being familiar with transesophageal echocardiogram, we would suggest that the placement of ventriculoatrial shunts, and more so, its revision, be performed under transesophageal echocardiographic guidance.