Pradipta Bhakta

Peripartum Cardiomyopathy: Review of the Literature

Peripartum cardiomyopathy (PPCM) is a rare but serious form of cardiac failure affecting women in the last months of pregnancy or early puerperium. Clinical presentation of PPCM is similar to that of systolic heart failure from any cause, and it can sometimes be complicated by a high incidence of thromboembolism. Prior to the availability of echocardiography, diagnosis was based only on clinical findings. Recently, inclusion of echocardiography has made diagnosis of PPCM easier and more accurate. Its etiopathogenesis is still poorly understood, but recent evidence supports inflammation, viral infection and autoimmunity as the leading causative hypotheses. Prompt recognition with institution of intensive treatment by a multidisciplinary team is a prerequisite for improved outcome. Conventional treatment consists of diuretics, β blockers, vasodilators, and sometimes digoxin and anticoagulants, usually in combination. In resistant cases, newer therapeutic modalities such as immunomodulation, immunoglobulin and immunosuppression may be considered. Cardiac transplantation may be necessary in patients not responding to conventional and newer therapeutic strategies. The role of the anesthesiologist is important in perioperative and intensive care management. Prognosis is highly related to reversal of ventricular dysfunction. Compared to historically higher mortality rates, recent reports describe better outcome, probably because of advances in medical care. Based on current information, future pregnancy is usually not recommended in patients who fail to recover heart function. This article aims to provide a comprehensive updated review of PPCM covering etiopathogeneses, clinical presentation and diagnosis, as well as pharmacological, perioperative and intensive care management and prognosis, while stressing areas that require further research.

Case Report and Mini Literature Review: Anesthetic Management for Severe Peripartum Cardiomyopathy Complicated with Preeclampsia Using Sufetanil in Combined Spinal Epidural Anesthesia

Peripartum cardiomyopathy (PPCM) is a rare entity, and anesthetic management for cesarean section of a patient with this condition can be challenging. We hereby present the anesthetic management of a patient with PPCM complicated with preeclampsia scheduled for cesarean section, along with a mini review of literature. A 24 year-old primigravida with twin gestation was admitted to our hospital with severe PPCM and preeclampsia for peripartum care, which finally required a cesarean section. Preoperative optimization was done according to the goal of managing left ventricular failure. Combined spinal epidural (CSE) anaesthesia with bupivacaine and sufentanil was used for cesarean section under optimal monitoring. The surgery was completed without event or complication. Postoperative pain relief was adequate and patient required only one epidural top up with sufentanil 6 hours after operation. To the best of our knowledge there is no report in literature of the use of sufentanil as a neuraxial opioid in the anesthetic management of cesarean section in a patient with PPCM. CSE with sufentanil may be a safer and more effective alternative in such cases.

Bone cement implantation syndrome: a delayed postoperative presentation

Bone cement implantation syndrome (BCIS) is a well-known entity but is poorly understood and rarely reported. It is an important cause of perioperative morbidity and mortality in the patient undergoing cemented hip arthroplasty. BCIS is characterized by hypotension, hypoxia, cardiac arrhythmias, and increased pulmonary vascular resistance and can lead to eventual cardiac arrest if not managed properly. We hereby report a case of delayed presentation of BCIS following cemented right hip arthroplasty.

Anaesthesia management of a patient with hereditary angioedema with prophylactic administration of C1 esterase inhibitor: Case report and literature review

Hereditary angioedema (HAE) is a rare disorder caused by a deficiency of C1 esterase inhibitor. Minor trauma and emotional stress are the most common initiating events leading to contact system activation and excessive uncontrolled bradykinin release. This manifests as angioedema, a vascular reaction of the deeper layers of the skin and mucous membranes, with vasodilatation and increased permeability resulting in tissue swelling. Severe angioedema can occur in the perioperative period, leading to fatal airway obstruction. We describe the anaesthetic management of a child with HAE for dental rehabilitation and provide an review of the relevant literature.

Acute pain service: the journey in a developing country setting.

In India, acute pain service (APS) is in nascent stage because of lesser importance given to pain management. After establishing an APS in our hospital, we conducted a prospective audit (2008–2011) with an aim to regularly assess the efficacy of techniques on pain scores, muscle power, and adverse effects.

Esophageal bezoar formation due to solidification of enteral feed administered through a malpositioned nasogastric tube: Case report and review of the literature

Enteral feeding is now standard and routine practice in intensive care. The use of a nasogastric tube for enteral feeding is generally considered to be safe, but tubes with small bores can sometimes lead to aspiration or passage clogging when malpositioned in sedated patients who are on long-term mechanical ventilation. Thus, accurate confirmation of correct placement is mandatory in such patients. This is not always the case, but this faulty practice can lead to serious complications in the absence of potential bezoar-forming medicines or gastrointestinal pathology. We present here one such interesting case of a patient who developed esophageal bezoar due to a malpositioned nasogastric tube for administering a casein-containing feed. In addition, we present a review of the literature.

Development of acute ischemic stroke in a patient with acute respiratory distress syndrome (ARDS) resulting from H1N1 pneumonia

Pneumonia due to H1N1 infection is now very common. We report a case of ischemic stroke which arose subsequently to H1N1 influenza. The patient was a female who developed acute respiratory distress syndrome (ARDS) after H1N1 influenza, was ventilated as per standard protocol and started treatment with oseltamivir. When sedation was stopped during weaning from the ventilator, she was found to have left hemiparesis resulting from multiple infarctions in the brain. Contrary to thrombocytosis usually seen in acute influenza, the platelet counts in our patient actually dropped. We suspected that increased interleukin release or stickiness of the platelets might have caused this ischemic stroke. In the course of time, she had acceptable neurological recovery following treatment with aspirin and neuro-rehabilitation. This case report provides evidence that a rare, debilitating complication like stroke can occur in H1N1 infection. A high index of suspicion of the probability of a cerebrovascular event should be borne in mind and regular neurological assessment should be done in such cases.

Incidence of postoperative nausea and vomiting following gynecological laparoscopy: A comparison of standard anesthetic technique and propofol infusion

OBJECTIVE To determine the safety, efficacy, and feasibility of propofol-based anesthesia in gynecological laparoscopies in reducing incidences of postoperative nausea and vomiting compared to a standard anesthesia using thiopentone/isoflurane. DESIGN Randomized single-blind (for anesthesia techniques used) and double-blind (for postoperative assessment) controlled trial. SETTING Operation theater, postanesthesia recovery room, teaching hospital. PATIENTS Sixty ASA (American Society of Anesthesiologists) I and II female patients (aged 20-60 years) scheduled for gynecological laparoscopy were included in the study. INTERVENTIONS Patients in Group A received standard anesthesia with thiopentone for induction and maintenance with isoflurane-fentanyl, and those in Group B received propofol for induction and maintenance along with fentanyl. All patients received nitrous oxide, vecuronium, and neostigmine/glycopyrrolate. No patient received elective preemptive antiemetic, but patients did receive it after more than one episode of vomiting. MEASUREMENTS Assessment for incidence of postoperative nausea and vomiting as well as other recovery parameters were carried out over a period of 24 hours. MAIN RESULTS Six patients (20%) in Group A and seven patients (23.3%) in Group B experienced nausea. Two patients (6.66%) in Group B had vomiting versus 12 (40%) in Group A (p<0.05). Overall, the incidence of emesis was 60% and 30% in Groups A and B, respectively (p<0.05). All patients in Group B had significantly faster recovery compared with those in Group A. No patient had any overt cardiorespiratory complications. CONCLUSION Propofol-based anesthesia was associated with significantly less postoperative vomiting and faster recovery compared to standard anesthesia in patients undergoing gynecological laparoscopy.

Anaesthetic management of a patient with Weill-Marchesani syndrome complicated with mitral regurgitation.

We read your article with great interest and once again we want to emphasize that the problem of lookalike drugs is still continuing. Recently, we have experienced the potentially disastrous problem of look-alike drugs when an ASA1 patient had nausea while undergoing hernia repair and when asked for inj. Ondansetron, an O.T. technician handed over ampoule of inj. Tramadol; however, because of the vigilance of the anaesthesiologist, wrong drug administration was avoided. Although nothing like life-threatening could have happened other than the exaggeration of patient’s symptoms, but instances are reported when even the life-threatening complications occurred with wrong administration of drugs due to similar looking ampoules.[1] While investigating on close inspection, it was found that both 2 ml ampoules have strikingly similar appearance. Inj ONDOC-2 (Ondansetron) is manufactured by Morepen Laboratories Ltd. with embossed printing in red colour whereas inj TRAMADOC (Tramadol Hydrochloride) is manufactured by Pharma Concepts, also with embossed printing in red colour [Figure 1]. Even the snap off dot is of blue colour in both the ampoules. The last three letters (doc) of commercial names are also similar. Although in the majority of the cases, the human factors are responsible in medication error be it fatigue, haste, stress, mixing of drug ampoules in drug cart, poor light, etc., but similarity of drug ampoules like the above-mentioned drugs definitely needs development of improved standards of drug packaging and labelling.

Sudden near-fatal tracheal aspiration of an undiagnosed nasal foreign body in a small child

Foreign body aspiration is a commonly encountered emergency in children. Foreign body can lodge in any site from supra‐glottis to the terminal bronchioles. Symptoms might range from none to respiratory compromise, cardiac arrest and even death depending on location and size. We report successful management of a child who aspirated a nasal foreign body during physical examination in an outpatient department causing complete airway obstruction with special mention about different management options available for managing near total respiratory arrest from an aspirated foreign body in the ED.