Haider Abbas

Increased myeloperoxidase enzyme activity in plasma is an indicator of inflammation and onset of sepsis

INTRODUCTION Circulating lipopolysaccharides released from bacteria may activate both neutrophils and monocytes. The activated neutrophils release myeloperoxidase (MPO), a specific enzyme with strong oxidative activity. The aim of this study was to evaluate MPO enzyme activity in plasma of critically ill patients and to check the hypothesis that these concentrations in plasma would be higher in sepsis and systemic inflammatory conditions, as neutrophils release their contents before proliferating in response to stress. MATERIAL AND METHODS Blood samples were collected from 105 critically ill patients admitted to the intensive care unit, consisting of those with systemic inflammatory response syndrome (n = 42), sepsis (n = 37), and septic shock (n = 26). Plasma MPO enzyme activity was determined by o-dianisidine-H(2)O(2) method, modified for 96-well plates. RESULTS The plasma MPO enzyme activity in sepsis patients was significantly higher than that in the control group (mean, 2.4 ± 1.8 in sepsis and 1.86 ± 1.2 nmol per milligram protein per 10 minutes in systemic inflammatory response syndrome vs 0.32 ± 0.11 nmol per milligram protein per 10 minutes in healthy controls). Mean plasma lactate levels in sepsis (7.8 ± 1.2 mmol/L) and shock patients (9.5 ± 1.2 mmol/L) and cytokines like tumor necrosis factor-α, interleukin-8, and interleukin-1β were simultaneously evaluated to establish onset of inflammation and sepsis. These results show that neutrophil activation occurring during inflammation and sepsis could be detected by plasma MPO concentration. CONCLUSION The plasma MPO concentrations may be a marker of the neutrophil proliferation and severity of inflammation.

Tumor necrosis factor gene polymorphism results in high TNF level in sepsis and septic shock.

INTRODUCTION Systemic sepsis releases several cytokines among which tumor necrosis factor alfa (TNFα) has emerged as key cytokine causing septic shock. Single Nucleotide Polymorphisms (SNPs) at positions -238, -308, -376 and +489 in the promoter region of TNF gene exhibit differential association to inflammation and increased TNF production in sepsis. MATERIALS AND METHODS This research work was carried out in 278 critically ill patients and 115 controls. The patients were divided into four groups: Healthy controls, SIRS, Sepsis and Septic shock. Plasma cytokine level was evaluated by ELISA. Specific sequences of TNF gene (-238, -308, -376, +489) were amplified using polychromase chain reaction (PCR). SNP detected by BamHiI, NcoI, FokI, TaiI restriction enzymes. RESULTS Mean plasma TNFα level in healthy Control group was 8.37 ± 2.23 pg/ml, in SIRS group, the mean plasma TNFα level was 77.99 ± 5.51 pg/ml, in Sepsis patients 187.1 ± 14.33 pg/ml and in septic shock 202.2 ± 14.85 pg/ml; range 56.17-417.1 pg/ml. SNP was studied among different patient groups, which showed a higher frequency of mutants among sepsis and shock patients as compared to control. CONCLUSION Plasma TNF alpha level was significantly high in patients with sepsis and septic shock. SNP of TNF gene showed significant association between polymorphism and development of severe sepsis and septic shock, this would help us in evaluating patients at high risk for septic shock and such patients needed to obtain a rational basis for therapy.

Hypokalemic periodic paralysis

Hypokalemic periodic paralysis is a rare genetic disorder characterized by recurrent attacks of skeletal muscle weakness with associated hypokalemia which is precipitated by stress, cold, carbohydrate load, infection, glucose infusion, hypothermia, metabolic alkalosis, anesthesia, and steroids. We encountered one such incidence of prolonged recovery after general anesthesia, which on further evaluation revealed a case of hypokalemic paralysis. The key to successful management of such a patient was vigilant pre-operative evaluation, perioperative monitoring, and aggressive treatment of hypokalemia when it occurs.

Comparative study of ropivacaine with ropivacaine-fentanyl and ropivacaine-fentanyl- magnesium sulfate in epidural anesthesia for lower limb surgeries

Epidural anesthesia presently is one of the most useful techniques in modern Anesthesiology. Its versatility, gives anesthesiologist the opportunity to provide surgical anesthesia along with post-operative analgesia. As a sole regional anesthesia technique it is routinely used for abdominal and lower limb surgeries. For achieving desired per-operative anesthetic effect and to reduce the deleterious hemodynamic response of large volumes of local anesthetic agents, opioids and adjuvant drugs are routinely used in epidural space, but the exact volume and concentration required has not been validated yet. ABSTRACT

Evaluation of intubating conditions using stylet by conventional through-tube technique and through Murphy's eye in patients with high Mallampati scores

Background: Difficult intubation is always a nightmare for an Anaesthetist. This study was planned to study the alternative method of stylet use during difficult oro-tracheal intubation. Outcome measures assessed were ease of intubation, hemodynamic stability and reducing complications. Materials and Methods: A cohort of 60 patients of Mallampati class III patients was formed and patients were divided into two groups. In group 1 patients, conventional through tube method was used for inserting stylet, whereas, in group 2 patients, Murphy′s eye was used for inserting malleable flexi tip stylet. Results: Hemodynamic stability in terms of mean arterial blood pressure and heart rate was observed in group 2. Intubating time, number of attempts of successful intubation and post operative pharyngo-laryngeal complications was also low in group 2 patients. Conclusion: The use of Murphy′s eye to pass stylet during difficult airway manoeuvre is a safe alternative over conventional rail-road technique.

Whipple's Operation Under Lumber Epidural Analgesia and Sedation

Whipples operation can be carried out either under general anaesthesia or continuous epidural anaesthesia with sedation. We report three cases that were managed successfully and we found that the combination of lumbar epidural analgesia with sedation is safer and beneficial as compared to those who undergo Whipples operation under general anaesthesia. For the last three decades epidural analgesia has been the part of anaesthesia practice. Epidural analgesia can be a useful method of pain management various situations. It facilitates early mobilization and also avoids perioperative pulmonary complications especially after major thoracic or upper abdominal surgeries. The combination of continuous epidural analgesia with sedation has many advantages in prolonged major upper abdominal surgeries. Keywords- Whipples operation, general anaesthesia, continuous epidural anaesthesia, sedation, upper abdominal surgery. I. Case Report We present 3 cases where regional anaesthesia technique combined with sedation for whipples operation was employed successfully. Three patients with obstructive jaundice secondary to periampullary carcinoma posted for whipples surgery. The diagnosis was confirmed by blood biochemistry, CT scan, ERCP and biopsy. General physical and systemic examination and vital parameters was essentially the same in all the patients. On pre-anaesthetic examination, an informed consent was taken and patients were thoroughly explained about the procedure and technique of lumbar epidural anaesthesia. After taking the patients in operation theater, patient were monitored for HR, BP, ECG, SpO2 and temperature. Intra Venous access was secured with 18 G cannula on the dorsum of hand and preloading was done with ringers lactate solution 10-15ml kg-1. under full aseptic precaution an epidural catheter was inserted in the epidural space at L1-L2 level. The tip of catheter was advanced to T4. A test dose of 3 ml of 2% xylocaine with adrenaline 5 µg ml-1 was given after insuring correct placement the bolus dose of local anaesthetics (10ml of 2% lignocaine and 10ml of 0.5% bupivacaine and 50 micro g of fentanyl) was given followed by bolus dose of 6ml 0.5% bupivacaine hourly. Central venous cannulation was done and CVP maintained between 8-10 cm of normal saline. Opioids were not used. Urine output monitoring was done and maintained between 1.5-2 ml kg-1 hr-1. Blood loss was adequately replaced by PRBCs, FFPs and other IV fluids. Average blood loss in all 3 cases was 2-3 liters. The duration of surgery was approximately 8 hours. Propofol infusion 10ml hr-1 was used in all cases for sedation along with midazolam @ 2 ml/hour. Vital signs were monitered and maintained through out intraoperative period. All patients were fully conscious, oriented and with stable vitals. Postoperative x-ray Chest was normal in all cases. Postoperative pain relief was given with lumber epidural infusion. Bowel sounds were audible on 3rd postoperative day. Biochemistry, haematological and Blood Gas parameters was within normal limits. Patients remained comfortable, without pain and were discharged on 3-4th postoperative day from the ICU. epidural catheter was removed before discharge. All the 3 patients were ambulatory and with no complaint of pain.

Evaluation of access to adrenaline in different non-operative clinical areas-A Blind Study

Introduction: The impulse for carrying out this study stemmed from the fact that there was an observational variation in responding to and conducting the management of critical incidents by residents (senior house officers) in different wards of the hospital. Following an incident where intravenous adrenaline was not available in adequate time during sudden cardiac arrest; the present study was done to objectively evaluate the access to the prototype emergency drug,adrenaline injection.Material and Method: Ten teams were sent to five different wards to simultaneously check the response of duty doctors to pick up Adrenaline injection in any form (pre-filled syringes or ampoules) at the nursing station and hand it over to the auditor. Results: The time to access the adrenaline in ampoule form was least in Accident & Emergency (24.33 ± 3.67 sec) unit while highest in Medicine ward (32.17 ± 3.66 sec). The time to access the adrenaline in pre-filled syringes was least in Accident & Emergency (19.00 ± 2.71 sec) unit while highest in Obstetrics ward (23.50 ± 1.00 sec). Conclusion: Time to access adrenaline injection was shorter in the Accident & Emergency unit but was significantly higher(p<.05) in other wards; also the access to pre-filled syringes was quicker than the ampoules.