Kartik Munta

End-tidal capnography and upper airway ultrasonography in the rapid confirmation of endotracheal tube placement in patients requiring intubation for general anaesthesia

Background and Aims: Confirmation of correct endotracheal tube placement is essential immediately after intubation for general anaesthesia. In this study, we have compared upper airway ultrasonography (USG) with reference to capnography for rapid confirmation of endotracheal tube placement after general anaesthesia. Methods: A prospective, single centre, observational study was conducted on 100 patients requiring tracheal intubation for general anaesthesia. Both capnography and upper airway USG were performed immediately after intubation to confirm the endotracheal tube (ETT) placement. Sensitivity, specificity, and positive and negative predictive values of upper airway USG were determined against capnography as the reference method. Agreement between the methods and time required to determine ETT placement by the two methods were assessed with kappa statistics and Students t-test. Results: Upper airway USG detected all five cases of oesophageal intubation, but could not detect five patients with correct tracheal intubation. Upper airway USG had a sensitivity of 96.84% (95% confidence interval [CI]: 94.25%–96.84%), specificity of 100% (95% CI: 50.6%–100%), positive predictive value of 100% (95% CI: 97.3%–100%) and negative predictive value of 62.5% (95% CI: 31.6%–62.5%). Kappa value was found to be 0.76, indicating a good agreement between upper airway USG and capnography for confirmation of ETT placement. Time taken for confirmation of ETT by capnography was 8.989 ± 1.043 s vs. 12.0 ± 1.318 s for upper airway USG (P < 0.001). Conclusion: Both capnography and upper airway USG may be used as primary procedures for the confirmation of ETT placement.

Stress levels of critical care doctors in India: A national survey.

Background: Doctors working in critical care units are prone to higher stress due to various factors such as higher mortality and morbidity, demanding service conditions and need for higher knowledge and technical skill. Aim: The aim was to evaluate the stress level and the causative stressors in doctors working in critical care units in India. Materials and Methods: A two modality questionnaire-based cross-sectional survey was conducted. In manual mode, randomly selected delegates attending the annual congress of Indian Society of Critical Care Medicine filled the questionnaire. In the electronic mode, the questionnaires were E-mailed to critical care doctors. These questionnaires were based on General Health Questionnaire-12 (GHQ-12). Completely filled 242 responses were utilized for comparative and correlation analysis. Results: Prevalence of moderate to severe stress level was 40% with a mean score of 2 on GHQ-12 scale. Too much responsibility at times and managing VIP patients ranked as the top two stressors studied, while the difficult relationship with colleagues and sexual harassment were the least. Intensivists were spending longest hours in the Intensive Care Unit (ICU) followed by pulmonologists and anesthetists. The mean number of ICU bed critical care doctors entrusted with was 13.2 ± 6.3. Substance abuse to relieve stress was reported as alcohol (21%), anxiolytic or antidepressants (18%) and smoking (14%). Conclusion: Despite the higher workload, stress levels measured in our survey in Indian critical care doctors were lower compared to International data. Substantiation of this data through a wider study and broad-based measures to improve the quality of critical care units and quality of the lives of these doctors is the need of the hour.

Invasive aspergillosis in near drowning nonneutropenic patient

Invasive aspergillosis in immunosuppressed people has been well documented, but to diagnose and treat in an immunocompetent individual after near drowning, it requires early suspicion and proper empirical treatment. We report a case diagnosed to have invasive aspergillosis with systemic dissemination of the infection to the brain, gluteal muscles, and kidneys after a fall in a chemical tank of a paper manufacturing company. He was ventilated for acute respiratory distress syndrome and managed with antibiotics and vasopressors. Due to nonresolving pneumonia and positive serum galactomannan, trans-tracheal biopsy was performed which confirmed invasive aspergillosis and was treated with antifungals. With the availability of galactomannan assay and better radiological investigative modalities, occurrence of such invasive fungal infections in cases of drowning patients should be considered early in such patients and treated with appropriate antifungals.

PHENYTOIN AND SODIUM VALPROATE INTOXICATION AND MANAGEMENT, A CASE REPORT

Dr. Surya Prakash Yarramalle 1 , Dr. Kartik Munta 1 , Dr. S. Manimala Rao 1 , Dr. Hemanth. C 2 , Dr. Dhanalakshmi 2 and Dr. Sohal Parate 1 . 1. Department Of Critical Care Medicine, Yashoda Multi-Speciality Hospital, Somajiguda, Hyderabad, India. 2. Department Of General Medicine, Yashoda Multi-Speciality Hospital, Somajiguda, Hyderabad, India 3. Department Of Nephrology, Yashoda Multi-Speciality Hospital, Somajiguda, Hyderabad, India. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History

Severe hypothermia causing ventricular arrhythmia in organophosphorus poisoningkartik munta, Paiullah Santosh, Manimala Rao Surath

Organophosphorus poisoning cases are routinely treated across all Intensive Care Units adjoining the rural areas where agriculture is the main source of income. We present a unique case of severe hypothermia seen in a case of organophosphorus poisoning, which led to electrocardiogram disturbances and life-threatening arrhythmias.

Secondary Sjogren's syndrome presenting with distal tubular acidosis and quadriparesis

A 52-year-old female patient was admitted to Intensive Care Unit with complaints of quadriparesis. Investigations revealed distal renal tubular acidosis (DRTA) secondary to Sjogrens syndrome with involvement of the parotid and thyroid glands. Laboratory investigations showed hyperchloremic metabolic acidosis and an alkaline urine pH with clinical signs of sicca syndrome. Sjogrens syndrome is associated with DRTA and occurrences of quadriparetic hypokalemia, nephrolithiasis, and osteomalacia can be prevented with early diagnosis and lifelong treatment with potassium and alkali replacement.

Prone position and pressure control inverse ratio ventilation in H1N1 patients with severe acute respiratory distress syndrome

Aim: To observe the 28 and 90 days mortality associated with prone position and assist control-pressure control (with inverse ratio) ventilation (ACPC-IRV). Materials and Methods: All patients who were admitted to our medical Intensive Care Unit (ICU) who are positive for H1N1 viral infection with severe acute respiratory distress syndrome (ARDS) and requiring invasive mechanical ventilation in prone position were included in our prospective observational study. Six patients who are positive for H1N1 required invasive ventilation in prone position. These patients were planned to ventilate in prone for 16 h and in supine for 8 h daily until P/F ratio >150 with FiO2 of 0.6 or less and positive end-expiratory pressure <10 cm of H2 O. Results: At admission, among these six patients the mean tidal volume generated was about 376.6 ml which was in the range of 6–8 ml/kg predicted body weight. The mean lung injury score was 3.79, mean PaO2 /FiO2 ratio was 52.66 and mean oxygenation index was 29.83. The mean duration of ventilation was 9.4 days (225.6 h). The ICU length of stay was 11.16 days. There was no mortality at 28 and 90 days. Conclusion: Early prone combined with ACPC-IRV in H1N1 patients having severe ARDS can be used as a rescue therapy and it should be confirmed by large observational studies.

A Comparative Study of Ropivacaine Alone Versus Ropivacaine With Dexmedetomidine in Supraclavicular Brachial Plexus Block

Background and Aims: Supraclavicular brachial plexus block is frequently used procedure to provide anaesthesia and good post-operative analgesia for surgery on upper limb. The purpose of this study was to compare the hemodynamic, sedative and analgesic effects of ropivacaine alone versus ropivacaine given along with dexmedetomidine. Materials and Methodology: This prospective, randomized and double-blinded study included total 60 patients of either sex with age between 18-60 years posted for various elective upper limb surgery and randomly allocated into 2 equal groups of 30 each. Control Group-R received injection ropivacaine (0.75%) 30 ml plus 1 ml normal saline and Group-RD received injection ropivacaine (0.75%) 30 ml plus dexmedetomidine 25 μg (1 ml) for supraclavicular brachial plexus block using the peripheral nerve stimulator. Sensory and motor block, monitoring of vitals (systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR)), presence of any side effect, Ramsay sedation score and visual analogue scale or visual analog scale (VAS) score were determined every 5 mins in 1st 30 mins and then every 15 mins during 1st hr followed by every 2nd hourly during 24 hrs. Results: There was no significant difference in the study groups with regards to demographic profile and duration of surgery. The onset of sensory and motor blockade was faster in Group-RD than Group-R. {Onset of sensory block: (Group-R=14.133±1.676 min and Group-RD=12.667± 1.213 min) (p=0.000), Onset of motor block: (Group-R=25.967±2.748 min and Group-RD=23.333±3.467 min) (p=0.002). Also total duration of sensory blockade {Group-R=547.833±26.152 mins, Group-RD=811.667±25.405 mins (p value=0.000)}, motor blockade {Group-R=509.667±24.703 mins, Group-RD=760.667±28.062 mins (p value=0.000)} and number of rescue injections in 24 hrs {Group-R=2.733±0.450, Group-RD=1.400±0.498 (p value=0.000)} was significantly different in 2 groups. There was good haemodynamic stability in both groups. SBP and DBP in Group-R and Group-RD with p values 0.416 and 0.784 were comparable between the groups. The difference was statistically not significant. There was no incidence of any side effects like hypotension and bradycardia in any of the 60 patients. Conclusion: Dexmedetomidine in a dose of 25 μg added to ropivacaine in supraclavicular brachial block for upper limb surgery significantly shortens the onset time and prolongs the duration of sensory and motor block without producing sedation in patients.

The role of noninvasive ventilation in mild to moderate acute respiratory distress syndrome

Sir, We read with great interest the research article, “A study on the role of NIV in mild to moderate acute respiratory distress syndrome,” published in the previous issue.[1] It was alarming to note that only 44% had successful noninvasive ventilation (NIV) use while the rest of the patients had to be intubated. The mortality quoted for NIV failure group was 46.3% (19 out of 23), which is rather high in the present scenario. The mortality of moderate adult respiratory distress syndrome (ARDS) in a study done by Thille et al. was only 32%.[2] The author suggests high APACHE scores and delay in intubations as the reasons of the high mortality. The mortality rate is unacceptable and could have been reduced if they were not subjected to further trial of NIV after 1 h. A retrospective study of NIV role in moderate ARDS in esophagectomy patients concluded that it would be an effective option to consider invasive mechanical ventilation in those with P/F ratio 150.[2] Patients who have P/F ratio of 1.5 have to be taken into consideration to go for invasive ventilation.[4] We manage large number of ARDS patients in our department. ARDS patients (P/F ratio >150) can be treated with NIV while moderate to severe ARDS (P/F ratio <150) should be managed with pressure-controlled mechanical ventilation. Our mortality rates have been 11.4% in the past 3 years.[4] NIV for ARDS has to be chosen cautiously and needs vigilant monitoring as it can lead to high mortality, even when one makes a decision to shift from NIV to invasive ventilation quickly. I entirely agree with editorial remarks that the acute inflammation of lung can spread very quickly making the recruitment process slow and delayed. One has to be extremely careful when you choose NIV for ARDS. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Accidental placement of central venous catheter tip into internal mammary vein

Sir, Central venous catheter (CVC) plays an important role in the management of critically ill patients in terms of central venous pressure (CVP) monitoring, administration of vasopressors, inotropes, blood products, and parenteral nutrition. The ultrasound guided central venous cannulation has become a routine practice in recent years due to its lower complication rates and lesser errors during insertion. The ultrasound-guided catheter insertion does not prevent or help in the detection of misplaced catheter tips. We present a case of a 25-year-old male, known case of fungal sinusitis and mycotic aneurysm of right internal carotid artery admitted to our tertiary care Intensive Care Unit following surgery (craniotomy) at an outside hospital. He was shifted for evaluation and management of shortness of breath and sepsis. It was decided to remove his old left subclavian central line in view of sepsis and replace it with a new left internal jugular vein (IJV) cannulation with the help of ultrasound guidance. Left internal jugular site was selected as all other sites were cannulated previously. The CVC on chest X-ray looked as if the catheter was entering the left atrium [Figure 1]. Flush tests on two-dimensional echo with agitated saline through the left jugular catheter showed that the catheter was draining into right atrium [Figure 2]. When patient was taken for computed tomography cerebral angiography, the neck vessel angiography was also done which on venous reconstruction showed that there were no anomalies in the venous system, but the catheter tip was seen entering the left internal mammary vein (IMV) [Figure 3]. Later the central line was removed and replaced at a different location (since it was not showing CVP trace, and there was no backflow of blood through the port). Figure 1 Central venous catheter in the left internal jugular vein appears to be entering left atrium Figure 2 Agitated saline flush through the central port of the catheter showing bubbles in the right atrium Figure 3 Angiogram of neck showing left central venous catheter entering into left internal mammary vein The incidence of CVC malposition during IJV cannulation is around 2%.[1] There have been very few reported cases of accidental left IMV cannulation in the past.[2] CVC, which are misdirected into tributaries of central veins, are more common during central venous cannulation of the left side.[3] Reason may be due to the left brachiocephalic vein, which is anatomically longer and left smaller tributaries anastomose with the brachiocephalic vein opposite to the orifice of the left jugular vein.[4] Internal mammary vein receives the anterior intercostal veins and some abdominal branches, later drain into the brachiocephalic vein behind the sternal end of the clavicle and the first costal cartilage. Portal hypertension and portal to systemic collateral circulation dilates the IMV causing a higher risk of malpositioning of the catheter, which in our patient did not have any of these complaints. Complication related to IMV placement includes laceration of IMV with massive hemothorax and altered patency of the vein.[2,5] Ultrasound might reduce the complications associated with insertion, but chest X-ray would be needed to confirm the tip of catheter positioning.