Indu Lata

Simulation in resuscitation teaching and training, an evidence based practice review.

In the management of a patient in cardiac arrest, it is sometimes the least experienced provider giving chest compressions, intubating the patient, and running the code during the most crucial moment in that patient’s life. Traditional methods of educating residents and medical students using lectures and bedside teaching are no longer sufficient. Today’s generation of trainees grew up in a multimedia environment, learning on the electronic method of learning (online, internet) instead of reading books. It is unreasonable to expect the educational model developed 50 years ago to be able to adequately train the medical students and residents of today. One area that is difficult to teach is the diagnosis and management of the critically ill patient, specifically who require resuscitation for cardiac emergencies and cardiac arrest. Patient simulation has emerged as an educational tool that allows the learner to practice patient care, away from the bedside, in a controlled and safe environment, giving the learner the opportunity to practice the educational principles of deliberate practice and self-refection. We performed a qualitative literature review of the uses of simulators in resuscitation training with a focus on their current and potential applications in cardiac arrest and emergencies.

Gossypiboma, a rare cause of acute abdomen: A case report and review of literature

Gossypiboma or textiloma is used to describe a retained surgical swab in the body after an operation. Inadvertent retention of a foreign body in the abdomen often requires another surgery. This increases morbidity and mortality of the patient, cost of treatment, and medicolegal problems. We are reporting case of a 45-year-old woman who was referred from periphery with acute pain in abdomen. She had a surgical history of abdominal hysterectomy 3 years back, performed at another hospital. On clinical examination and investigation, twisted ovarian cyst was suspected. That is a cystic mass further confirmed by abdominal computerized tomography (CT). During laparotomy, the cyst wall was opened incidentally which lead to the drainage of a large amount of dense pus. In between pus, there was found retained surgical gauze that confirmed the diagnosis of gossypiboma.

Estimation of the Incidence of Bacterial Vaginosis and other Vaginal Infections and its Consequences on Maternal/Fetal Outcome in Pregnant Women Attending an Antenatal Clinic in a Tertiary Care Hospital in North India

Aims: This study was undertaken to estimate the incidence of bacterial vaginosis (BV) and other vaginal infections during pregnancy and its association with urinary tract infections (UTI) and its consequences on pregnancy outcome, maternal and fetal morbidity and mortality. Settings and Design: Prospective cohort study. Materials and Methods: The present prospective cohort study was conducted on 200 women attending the antenatal clinic (ANC) of a tertiary hospital. All pertinent obstetric and neonatal data covering antenatal events during the course of pregnancy, delivery, puerperium and condition of each newborn at the time of birth were collected. BV was detected by both Gram stain and gold standard clinical criteria (Amsel’s composite criteria). Statistical analysis used: Data were analyzed using SPSS version 9. Fischer’s exact test, chi square tests and Student’s’ test has been used for analysis. The probability of 5% was considered as significant for continuous variables such as age, period of gestation and birth weight. Odds ratio (OR) and confidence interval (CI) with 95% probability were determined. Results: The incidence of bacterial vaginosis was 41 in 200 patients. Adverse outcomes such as preterm labor, PROM and fetal complications were found more in pregnant women who had bacterial vaginosis (N=41), bacterial vaginosis with UTI (N=14) as compared to those without bacterial vaginosis (N=118). Conclusions: The incidence of poor pregnancy outcome was higher in bacterial vaginosis with UTI. Prevention of BV and UTI is cost effective to minimize the pregnancy-related complications and preterm labor to decrease in perinatal and maternal mortality and morbidity. We recommend all antenatal patients should be screened for the presence of bacterial vaginosis, other infections and UTI.

Management of pregnant female with meningioma for craniotomy

Intracranial meningioma during pregnancy challenges the skill of obstetricians, neurosurgeons and neuroanesthesiologists in resection of the tumor and to secure delivery of the baby. Advances in fetal and maternal monitoring, neuroanesthesia, and microsurgical techniques allow safe neurosurgical management of these patients. Urgent neurosurgical intervention is reserved for the management of malignancies, active hydrocephalus, and benign brain tumors associated with signs of impending herniation or progressive neurological deficit. Particular attention is given to maintain stable maternal hemodynamics to avoid uterine hypo perfusion and fetal hypoxia intraoperatively. Therefore, the major challenge of neuroanesthesia during pregnancy is to provide an appropriate balance between competing, and even contradictory, clinical goals of neuroanesthesiology and obstetric practice.

Management of paroxysmal hypertension due to incidental pheochromocytoma in pregnancy.

A 25-year-old, full-term pregnant woman diagnosed with pre-eclampsia was referred to our tertiary care hospital with severe resistant hypertension. Her blood pressure remained labile despite the usual medications, which led to the suspicion of an underlying endocrinological problem. Further biochemical and radiological investigations confirmed the diagnosis of pheochromocytoma. The patient was invasively monitored and treated with alpha blockade, beta blocker, and vasodilators. The primary goals for the management of pheochromocytoma in pregnancy are early diagnosis, avoidance of a hypertensive crisis during delivery, and definitive surgical treatment. This case illustrates that one needs to be cautious when such a presentation of paroxysmal hypertension is present. With a multidisciplinary team approach, proper planning, and adequate preoperative medical management, pheochromocytoma in pregnancy can be managed successfully.

Revisiting hemophilia management in acute medicine.

The World Federation of Hemophilia estimates that more than 350,000 people globally have a form of the disease. Hemophilia A is a bleeding disorder that has a spectrum of manifestations ranging from persistent bleeding after minor trauma to spontaneous hemorrhage. We report a case of a male patient with hemophilia A who received general anesthesia for removal of foreign body from the nose. There was no excessive blood loss during surgery. Perioperatively, the patient received recombinant factor VIII coverage. Rest of the postoperative course was uneventful. Literature on the clinical management of patient with hemophilia A are reviewed and considerations for perioperative preparation and management of hemophilic patient are presented.

Anaesthetic management of Wolff-Parkinson-White syndrome for hysterectomy

Wolff–Parkinson–White syndrome (WPW) is an uncommon cardiac disorder having an aberrant pathway between atria and ventricles. We are reporting a known case of WPW syndrome for hysterectomy under combined spinal epidural anaesthesia. Management of the present case is an important pearl to revisit management of WPW syndrome. The perioperative management should be tailored according to the nature of surgery and the clinical presentation of the patient.

Better outcome after pediatric resuscitation is still a dilemma.

Pediatric cardiac arrest is not a single problem. Although most episodes of pediatric cardiac arrest occur as complications and progression of respiratory failure and shock. Sudden cardiac arrest may result from abrupt and unexpected arrhythmias. With a better-tailored therapy, we can optimize the outcome. In the hospital, cardiac arrest often develops as a progression of respiratory failure and shock. Typically half or more of pediatric victims of in-hospital arrest have pre-existing respiratory failure and one-third or more have shock, although these figures vary somewhat among reporting hospitals. When in-hospital respiratory arrest or failure is treated before the development of cardiac arrest, survival ranges from 60% to 97%. Bradyarrthmia, asystole or pulseless electric activity (PEA) were recorded as an initial rhythm in half or more of the recent reports of in-hospital cardiac arrest, with survival to hospital discharge ranging from 22% to 40%. Data allowing characterization of out of hospital pediatric arrest are limited, although existing data support the long-held belief that as with hospitalized children, cardiac arrest most often occurs as a progression of respiratory failure or shock to cardiac arrest with bradyasystole rhythm. Although VF (Ventricular fibrillation, is a very rapid, uncoordinated, ineffective series of contractions throughout the lower chambers of the heart. Unless stopped, these chaotic impulses are fatal) and VT (Ventricular tachycardia is a rapid heartbeat that originates in one of the ventricles of the heart. To be classified as tachycardia, the heart rate is usually at least 100 beats per minute) are not common out-of-cardiac arrest in children, they are more likely to be present with sudden, witnessed collapse, particularly among adolescents. Pre-hospital care till the late 1980s was mainly concerned with adult care, and the initial focus for pediatric resuscitation was provision of oxygen and ventilation, with initial rhythm at the time of emergency medical services arrival being infrequently recorded. In the 1987 series, pre-hospital pediatric cardiac arrest demonstrated asystole in 80%, PEA in 10.5% and VF or VT in 9.6%. Only 29% arrests were witnessed, however, and death in many victims was caused by sudden infant death syndrome.

Hepatobiliary diseases during pregnancy and their management: An update

Liver diseases in pregnancy although rare but they can seriously affect mother and fetus. Signs and symptoms are often not specific and consist of jaundice, nausea, vomiting, and abdominal pain. Although any type of liver disease can develop during pregnancy or pregnancy may occur in a patient already having chronic liver disease. All liver diseases with pregnancy can lead to increased maternal and fetal morbidity and mortality. It is difficult to identify features of liver disease in pregnant women because of physiological changes. Physiological changes of normal pregnancy can be confounding with that of sign and symptoms of liver diseases. Telangiectasia or spider angiomas, palmar erythema, increased alkaline phosphatase due to placental secretion, hypoalbuminemia due to hemodilution. These normal alterations mimic physiological changes in patients with decompensated chronic liver disease. Besides all these pathological changes however, blood flow to the liver remains constant and the liver usually remains impalpable during pregnancy. The diagnosis of liver disease in pregnancy is challenging and relies on laboratory investigations. The underlying disorder can have a significant effect on morbidity and mortality in both mother and fetus, and a diagnostic workup should be initiated promptly. If we see the spectrum of liver disease in pregnancy, in mild form there occur increase in liver enzymes to severe form, where liver failure affecting the entire system or maternal mortality and morbidity. It can not only complicate mothers life but also poses burden of life of fetus to growth restriction. Most of the times termination is only answer to save life of mother but sometimes early detection of diseases, preventive measures and available active treatment is helpful for both of the life. Extreme vigilance in recognizing physical and laboratory abnormalities in pregnancy is a prerequisite for an accurate diagnosis. This could lead to a timely intervention and successful outcome.

Emergency central venous catheterization revisited

between transverse process fractures and abdominal injury has been reported.[5] Although transverse fracture of the lumbar vertebra can be a marker of associated visceral injuries including trauma to the abdominal viscera, retroperitoneum, spine, long bones and cranium,[3,5] the fractures of the transverse processes of the lumbar spine can occur in the absence of other vertebral and visceral damage.[6] In literature, in patients with isolated transverse fractures, the detailed investigations are recommended to exclude these associated visceral injuries. Classically, the conventional lumbar radiographs are used for evaluation of patients who are at risk of injury from blunt trauma; however, it is relatively insensitive in detecting the fractures as well as associated visceral injuries.[3,7] This insensitivity of conventional radiographs, especially in the setting of acute trauma can be due to the presence of overlying bowel gas, hence the full assessment and extent of fractures and associated injuries is not possible. [1,5,7] With the widespread use of whole-body CT scanning in trauma patients, the isolated transverse process fractures has been increasingly recognized and apart form this, the CT scan can detect the associated injuries in detail.[3,5,8] As in the present case, the transverse processes of the lumbar spine, not associated with neurological deficits or structural instability, can be managed conservatively without neurosurgical or orthopedic intervention.[8] The detailed radiological investigations should be performed wherever facilities and resources permit.[3,8,9] In a large retrospective review at Level I trauma center, it was found that where no other vertebral fracture is seen on an adequate screening CT scan, investigation may reasonably end. Also further imaging and consultations can lead to prolonged log-roll precautions, which delay the mobilization and can be potentially deleterious to overall patient care.[9] This can be followed in a setting with limited resources (either the resources are not available, e.g. CT scan or inability to perform recommended investigation in all the cases, e.g. financial constraints and poor affordability) and clinically stable patients can be carefully observed over an extended period.