Nita D'souza

Management of a massive thoracoabdominal impalement: a case report

A 26 year old male was impaled through his chest and upper abdomen with an iron angle, one and half meter long and five centimeters thick. The iron angle entered the chest, through the epigastrium and exited posteriorly just inferior to the angle of left scapula. The patient was transported to hospital with the iron angle in situ. Positioning the patient for intubation proved a major challenge. An unconventional position for intubation allowed a successful airway management. Paucity of time prevented us from gauging the nature and extent of injury. The challenges posed by massive impalement could be successfully managed due to rapid pre-hospital transfer and co-ordinated team effort.

Comparative study of dexamethasone and ondansetron for prophylaxis of postoperative nausea and vomiting in laparoscopic gynecologic surgery

To compare intravenous dexamethasone and ondansetron for the prophylaxis of postoperative nausea and vomiting (PONV), a main complaint that affects almost 40%–75% of patients undergoing laparoscopic gynecologic surgery.

Start time delays in operating room: Different perspectives

Background: Healthcare expenditure is a serious concern, with escalating costs failing to meet the expectations of quality care. The treatment capacities are limited in a hospital setting and the operating rooms (ORs). Their optimal utilization is vital in efficient hospital management. Starting late means considerable wait time for staff, patients and waste of resources. We planned an audit to assess different perspectives of the residents in surgical specialities and anesthesia and OR staff nurses so as to know the causative factors of operative delay. This can help develop a practical model to decrease start time delays in operating room (ORs). Aims: An audit to assess different perspectives of the Operating room (OR) staff with respect to the varied causative factors of operative delay in the OR. To aid in the development of a practical model to decrease start time delays in ORs and facilitate on-time starts at Jai Prakash Narayan Apex Trauma centre (JPNATC), All India Institute of Medical Sciences (AIIMS), New Delhi. Methods: We prepared a questionnaire seeking the five main reasons of delay as per their perspective. Results: The available data was analysed. Analysis of the data demonstrated the common causative factors in start time operative delays as: a lack of proper planning, deficiencies in team work, communication gap and limited availability of trained supporting staff. Conclusions: The preparation of the equipment and required material for the OR cases must be done well in advance. Utilization of newer technology enables timely booking and scheduling of cases. Improved inter-departmental coordination and compliance with preanesthetic instructions needs to be ensured. It is essential that the anesthesiologists perform their work promptly, well in time . and supervise the proceedings as the OR manager. This audit is a step forward in defining the need of effective OR planning for continuous quality improvement.

Pseudo loss of resistance in epidural space localization

Loss of resistance (LOR) is the most commonly used technique to locate the epidural space.[1] LOR to air or saline is often used and is accurate in identifying epidural space in most of the patients. False positive or pseudo-LOR can occur if the needle enters paraspinous muscles or a small cyst in the ligamentum flavum or the interspinous ligaments.[2] However, the exact incidence of false positive LOR is not reported in the literature. We encountered a false positive LOR in a patient with subcutaneous emphysema secondary to chest trauma.

Cerebral fat embolism: A diagnostic challenge

Fat embolism syndrome (FES) is a rare but a serious clinical catastrophe occurring after traumatic injury to long bones. Cerebral involvement in the absence of pulmonary or dermatological manifestation on initial presentation may delay the diagnosis of cerebral fat embolism (CFE). We discuss a case series of CFE which posed a challenge in diagnosis. The clinical presentations of these patients did not satisfy the commonly used clinical criteria for aiding the diagnosis of FES. Early MRI brain (DWI and T2 weighted sequences) in patients with neurological symptoms after trauma even in the absence of pulmonary and dermatological findings should be the goal.

Anaesthetic management and implications of a case of chronic inflammatory demyelinating polyneuropathy

A 60-year-old man with chronic inflammatory demyelinating polyneuropathy (CIDP) was posted for surgery of the neck femur fracture and was successfully managed. We discuss the anaesthetic considerations during regional and general anaesthesia of this patient with CIDP. A brief review of the available literature reveals no consensus on the choice of anaesthetic management.

Migrated esophageal stent posing a challenge for ventilation

Self-expandable esophageal stents are being commonly used for palliative treatment in advanced esophageal cancer patients to relieve dysphagia, prevent tracheoesophageal fistula, and facilitate symptomatic betterment. The modern covered stents reduce the ingrowth of the tumor but have seen an increase in the incidence of stent migrations. We report a rather complicated presentation of an esophageal stent for esophageal dilatation and a challenging management of a difficult tracheostomy.

An unusual differential for a pulseless trauma patient

Hemorrhagic shock is the most common reason to explain the inability to feel pulse in a trauma patient. However, clinicians should always suspect atypical causes for differential pulses in this population and Takayasus arteritis (TA) is one such example. We report a case of aorto-arteritis in a patient who presented with trauma and was later diagnosed with TA. She had blood pressure discrepancy between upper and lower limbs noted upon her initial trauma evaluation.

Catheter malposition in infants: A preventable complication

We discuss a case of a 1-month-old baby (length 57 cm, weight 4.8 kg) undergoing decompressive craniotomy for acute subdural haematoma. A 4,5 Fr multicath (Vygon Gmb H and Co. KG, Germany) central line was inserted in the right IJV for intra-operative central venous pressure monitoring. The catheter was inserted using the anatomic landmark technique and was fixed at the 7 cm mark on the skin after confirming backflow in all the lumens. Post-central line, chest roentgenogram (CXR) showed the tip of the catheter in the right subclavian vein by about 2.5 cm [Figure 1a]. Because it was difficult to reposition the original line, we planned ultrasound (USG)-guided left IJV cannulation. The J-tip of the guidewire was directed caudally and towards the right. The catheter was fixed at the 6 cm mark on the skin. Check CXR showed the catheter going to the right innominate vein by 1 cm [Figure 1b]. The catheter was refixed after pulling it out by 1 cm, and a repeat CXR confirmed its correct placement.

When to correct coagulopathy in acute kidney injury

Incidence of acute kidney injury (AKI) in adult trauma patients is 18% with 70% requiring renal replacement therapy. It is a challenge to treat AKI with coagulopathy since there are no defined transfusion triggers for these patients. We report a case wherein a polytrauma patient developed AKI for which he/she was dialysed and subsequently had an intracerebral bleed. There is a need to develop guidelines to transfusion triggers in AKI patients keeping vigilance on fluid overload, hyperkalemia and uraemia-induced platelet dysfunction.