Harkant Singh

Nifedipine attenuates the intraocular pressure response to intubation following succinylcholine

Forty patients without eye disease, undergoing elective nonophthalmic surgery, were studied to evaluate the efficacy of sublingual nifedipine in attenuating the intraocular pressure response to succinylcholine administration, laryngoscopy and intubation. The patients were randomly given either nifedipine 10 mg or placebo sublingually 20 minutes before induction of anaesthesia. Intraocular pressure (IOP) and systolic blood pressure (SBP) were recorded before and after induction of anaesthesia. The IOP response to succinylcholine administration, laryngoscopy and intubation was significantly less in patients receiving nifedipine (P > 0.01). The mean maximum rise in IOP above basal level at one minute postintubation was 7.82 mmHg in the control group compared with 0.15 mmHg in the nifedipine pretreated group. These results suggest that sublingual nifedipine is effective in attenuating the IOP response after succinylcholine administration, laryngoscopy and intubation.RésuméNous avons évalué le role de la nifédipine sub-linguale dans la prevention de l’augmentation de la pression intra-oculaire suivant l’injection de succinylcholine et l’intubation chez 40 patients aux yeux normaux. Le hasard déterminait s’ils allaient recevoir 10 mg de nifédipine ou un placebo 20 minutes avant l’induction de leur anesthésie pour chirurgie non-ophtalmique. Nous mesurions les pressions intra-oculaire (PIO) et artirielle systolique (PAS) avant et apres cette induction. L’augmentation maximale moyenne de la PIO une minute après l’intubation a ete de 7.82 mmHg dans le groupe placebo et de 0.15 mmHg dans le groupe nifédipine (P < 0.01). Donc, la nifédipine sublinguale semble capable de limiter l’augmentation de la PIO suivant la séquence succinylcholine-laryngoscopie-intubation trachéale.

Intrapericardial teratoma presenting as recurrent pericardial tamponade: Report of a case

Intrapericardial teratomas are rare after infancy. An accurate diagnosis can only be made with a high index of suspicion. Most of the time, a mediastinal teratoma ruptures/perforates the pericardial cavity, thus causing either pericardial effusion or life-threatening tamponade. These factors emphasize the importance of an early surgical excision even for extrapericardial locations. This report presents the case of a 16-year-old girl with intrapericardial teratoma who presented with cardiac tamponade which is a rare complication of this rare tumor with only eight cases reported so far beyond infancy. This patient presented with recurrent tamponade, and underwent multiple procedures of pericardiocentesis and developed pyopericardium and polyserositis. This intrapericardial teratoma was not detected by imaging modalities.

Closed mitral valvotomy for mitral restenosis: Experience in 113 consecutive cases☆☆☆★★★

The costs of heart operations and the problems related to anticoagulation after prosthetic valve replacement are among the limitations faced by patients in nonindustrialized countries with mitral stenosis caused by chronic rheumatic heart disease. The young age at which these patients are seen also compels the surgeon to preserve the native valve. The least costly and optimal way to achieve this objective is by closed mitral valvotomy. After closed mitral valvotomy, mitral restenosis is commonly encountered. We report here our 10-year experience with operation on 113 consecutive patients with mitral restenosis. Closed transventricular revalvotomy was performed with Tubbs dilator in 105 of 113 patients. Mean age was 343 years, with a male to female ratio of 1:1.5. Most patients were in New York Heart Association functional classes III and IV (74.3% and 19.4%, respectively). Mean interval between first and second valvotomy was 9.4 years, Hospital mortality rate was 2.8%, trivial postoperative mitral regurgitation occurred in 16.1%, and moderately severe regurgitation occurred in 1.9%. Early postoperative systemic embolism occurred in 3.8% of the cases. Moderate to excellent symptomatic improvement was noted in 89.4% of the cases and poor results were seen in 10.2%. Late follow-up of 76 patients ranged from 2 to 10 years (mean 3.8 years), with 39.4% patients in New York Heart Association class I and 50% in class II. Close mitral revalvotomy is thus an economical, simple, and safe palliative procedure that carries good long-term results.

Post-myocardial infarction giant left ventricular pseudoaneurysm presenting with severe heart failure.

Left ventricle (LV) pseudoaneurysm is a late mechanical complication of myocardial infarction. A giant LV pseudoaneurysm is a rare presentation. We report a case of giant LV pseudoaneurysm in a post-MI patient who presented with gross congestive heart failure. The patient had a successful surgical repair of the aneurysm and had a favorable 3-mo outcome. The imaging modality and surgical treatment of the pseudoaneurysm are discussed.

CEREBROSPINAL FLUID PRESSURE CHANGES DURING THE INDUCTION PHASE OF ANAESTHESIA

Cerebrospinal fluid pressure (CSFP) by lumbar puncture, systemic blood pressure (BP) and pulse rate (PR) were measured for 15 minutes during the induction phase of general anaesthesia in seven groups of six healthy female patients each.Intravenous drugs, thiopentone 5mg.kg-1 alfathesin 50μl . kg-1 and diazepam 0.5 mg. kg-1 given in 10 to 20 seconds caused a fall of CSFP and BP, whereas ketamine 2 mg. kg-1 and a three-minute induction with halothane three per cent, trichloroethylene one percent, or methoxyflurane0.75 percent caused a sharp highly significant but short-lived rise of CSFP. Unlike ketamine, trichlorethylene and methoxyflurane, halothane caused a simultaneous significant fall of BP.To rule out apprehension as the cause of the rise of CSFP with inhalation agents a second challenge was given with similar concentrations of the vapours while patients were asleep. These still produced a sharp and significant rise of CSFP.RéSUMéOn a mesuré la pression du liquide céphalo-rachidien (par ponction lombaire), ainsi que la pression artérielle et la fréquence cardiaque durant 15 minutes lors de l’induction de 1’anesthésie chez 42 patientes en bonne santé. Pour les conditions de l’étude, on avait formé sept groupes de six patients chacun, chaque groupe étant assigné àa un agent différent. Le thiopental à la dose de 5mg.kg-1, l’alfathésin a 50μl.kg-1, ainsi que le diazépam à 0.5 mg. kg1- administrés en 10 à 20 secondes, produisaient une chute de pression du LCR et de la pression artérielle, alors que la kétamine à la dose de 2 mg- kg-1, de même qu’une induction par inhalation de trois minutes à l’halothane à 3 pour cent, au trichloroéthylène a 1.0 pour cent ou au methoxyflurane à 0.75 pour cent, amenaient une élévation aiguä et hautement significative, mais de courte durée, de la pression du liquide céphalo-rachidien. Le trichloroéthylène, l’halothane et le méthoxyflurane provoquaient une chute simultanée significative de la pression artérielle. Dans le but d’éliminer l’appréhension comme cause de l’élévation de tension du LCR chez les patientes induites avec un agent d’inhalation, on a réepété 1’administration de ces mêmes agents d’inhalation, aux mêmes concentrations, après stabilisation de 1’anesthésie. On a pu observer la même élévation aiguä et transitoire de la pression du LCR.

Pulmonary Gangrene Due to Rhizopus spp., Staphylococcus aureus, Klebsiella pneumoniae and Probable Sarcina Organisms.

Pulmonary gangrene is a life-threatening condition, which represents the fulminant end of the infectious lung diseases usually caused by polymicrobial infection. Aerobic and anaerobic bacteria act synergistically to produce massive tissue necrosis which might be augmented by the angioinvasive nature of fungi like Mucor. We report a successfully treated case of pulmonary gangrene in a poorly controlled diabetic patient, which was associated with polymicrobial infection. It was caused by Rhizopus spp., Staphylococcus aureus, Klebsiella pneumoniae and unusual anaerobic organism Sarcina. This is the first report describing the presence of Sarcina organisms in a case of pulmonary gangrene. Adequate glycemic control, treatment of coexisting polymicrobial infection and prompt antifungal therapy along with surgical intervention were useful in the index patient. This case also highlights the effectiveness of combined medical and surgical intervention in a case of pulmonary gangrene.

Traumatic sternocostal lung hernia

We report the case of a 6‐year‐old child who fell from a height of almost 10 metres. He had a large wound in the anterior chest wall with herniation of the lung through a defect produced by dysjunction of costo‐chondral/sterno‐chondral cartilages of the second to the fifth right ribs. Successful reduction and surgical repair was performed through a right anterolateral thoracotomy.

Simple and Inexpensive Technique for Internal Mammary Artery Harvest

A simple, inexpensive, and easy-to-use method for exposure of the left internal mammary artery is described. Two blades of the conventional four-blade sternal spreader hooking the Adson forceps, which passes through the loops of sternal wires, provides excellent exposure of the IMA. The same retractor is used for the rest of the procedure.

Multiple intrathoracic hydatids.

A 37-year-old woman with persistent dry cough and recurrent pleural effusion, developed empyema after 10 months of antitubercular treatment. Chest radiography revealed an opacity in the left lateral chest wall (Figure 1). Computed tomography showed multiple fluid collections with enhancing pleura and septa in the left pleural cavity, extending along the costal, mediastinal, and diaphragmatic pleura, with partial collapse of the left lung and central mediastinum, suggestive of left-sided multiloculated empyema and cystic pleural metastasis from adenocarcinoma/ mesothelioma (Figure 2). On attempting decortication and drainage of the empyema through a standard left posterolateral thoracotomy, it was difficult to Figure 1. Chest radiograph in posteroanterior view, showing a broad-based loculated homogenous opacity along the left lateral chest wall, extending from the apex to the costophrenic angle, with crowding of the ribs along the lower chest wall, and multiple nodular opacities in the upper, mid, and lower zones of the left lung.

Proliferation marker (ki67) in sub-categorization of neuroendocrine tumours of the lung

OBJECTIVE The 2015 WHO classification classifies neuroendocrine tumours (NET) of the lung into typical carcinoid, atypical carcinoid, large cell neuroendocrine carcinoma and small cell carcinoma based on morphology alone. Mitosis is the major parameter for this classification, and thus several studies have focused on the role of Ki67 in these tumours but without conclusive results. The aim of the study was to categorize neuroendocrine tumours of the lung based on morphology and to assess the utility of Ki67 in diagnosis. MATERIAL AND METHOD The study included 42 cases (23 biopsies and 19 lobectomy specimens) of neuroendocrine tumours (excluding small cell carcinoma). Haematoxylin & eosin stained sections, immunohistochemistry for neuroendocrine markers and Ki67 were studied. RESULTS Based on WHO criteria, cases were classified as typical carcinoids (83.3%), atypical carcinoids (12%) and large cell neuroendocrine carcinomas (4.7%). The Ki67 index ranged between 1%-10% (mean 2.6%), 10%-30% (mean 19%), 35%-50% (mean 42.5%) in typical carcinoid, atypical carcinoid and large cell neuroendocrine carcinoma respectively. Using the ROC curve, the cut off value of Ki67 for typical and atypical carcinoids was 7.5% (P value < 0.001), and for atypical carcinoid/large cell neuroendocrine carcinoma was 32.5% (P value=0.051). On comparing the size and infiltration pattern (both local and lymphovascular invasion) of tumours in resected specimens, there was no association with the proliferation index (P value > 0.05). CONCLUSION Morphological features are the gold standard for subtyping of neuroendocrine tumours. Ki-67 is a potentially meaningful marker for sub-categorization of lung NETs, especially in small biopsies. However, the size and infiltrative pattern of the tumours are independent of the proliferation index.