Pramendra Agrawal

Enteral nutrition practices in the intensive care unit: Understanding of nursing practices and perspectives

Background: Adequate nutritional support is important for the comprehensive management of patients in intensive care units (ICUs). Aim: The study was aimed to survey prevalent enteral nutrition practices in the trauma intensive care unit, nurses’ perception, and their knowledge of enteral feeding. Study Design: The study was conducted in the ICU of a level 1 trauma center, Jai Prakash Narayan Apex Trauma Centre, AIIMS, New Delhi, India. The study design used an audit. Materials and Methods: Sixty questionnaires were distributed and the results analyzed. A database was prepared and the audit was done. Results: Forty-two (70%) questionnaires were filled and returned. A majority (38) of staff nurses expressed awareness of nutrition guidelines. A large number (32) of staff nurses knew about nutrition protocols of the ICU. Almost all (40) opined enteral nutrition to be the preferred route of nutrition unless contraindicated. All staff nurses were of opinion that enteral nutrition is to be started at the earliest (within 24–48 h of the ICU stay). Everyone opined that the absence of bowel sounds is an absolute contraindication to initiate enteral feeding. Passage of flatus was considered mandatory before starting enteral nutrition by 86% of the respondents. Everyone knew that the method of Ryles tube feeding in their ICU is intermittent boluses. Only 4 staff nurses were unaware of any method to confirm Ryles tube position. The backrest elevation rate was 100%. Gastric residual volumes were always checked, but the amount of the gastric residual volume for the next feed to be withheld varied. The majority said that the unused Ryles tube feed is to be discarded after 6 h. The most preferred (48%) method to upgrade their knowledge of enteral nutrition was from the ICU protocol manual. Conclusion: Information generated from this study can be helpful in identifying nutrition practices that are lacking and may be used to review and revise enteral feeding practices where necessary.

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.

Post operative pain relief through intermittent mandibular nerve block

Mandibular nerve block is often performed for diagnostic, therapeutic and anesthetic purposes for surgery involving mandibular region. Advantages of a nerve block include excellent pain relief and avoidance of the side effects associated with the use of opiods or Non-steroidal anti-inflammatory drug (NSAIDs). A patient with maxillo facial trauma was scheduled for open reduction and internal fixation of right parasymphyseal mandibular fracture. The mandibular nerve was approached using the lateral extraoral approach with an 18-gauge i.v. cannula under general anesthesia. He received 4 ml boluses of 0.25% plain bupivacaine for intraoperative analgesia and 12 hourly for 48 h post operatively. VAS scores remained less than 4 through out observation period. The only side effect was numbness of ipsilateral lower jaw line, which subsided after local anesthetic administration was discontinued. Patient was discharged after four days.

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.

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.

An uncommon cause of intraoperative airleak.

DOI: 10.4103/0972-5229.92071 Anesthetic considerations included: difficult mask ventilation, C-spine instability, transoral surgery, shared airway with surgeons, prolonged duration of surgery, prone position, risk of aspiration, bleeding, and postoperative airway edema. Airway management was a major concern in such presentations, because of cervical spine injury and the unpredictable extent of airway damage. Mask ventilation was a challenge due to the nature of the impacted foreign body. Usage of sedatives for premedication and induction were avoided for fear of airway loss. Awake fiberoptic-guided intubation helped in securing the airway safely and minimizing the movement of the cervical spine. Elective ventilation in the postoperative period was planned to ensure smooth recovery, as coughing and straining could have caused a cerebrospinal fluid (CSF) leak[2] and infection. [3] There was considerable facial edema after removal of the foreign body and prolonged surgery in the prone posture.

An unusual cause of carbon dioxide rebreathing in a circle absorber system

To the Editor: Hypercapnia while using a circle absorber system is a known complication. The main reasons of hypercapnia due to rebreathing are exhausted soda lime, malfunctioning unidirectional valves and chamber bypass. We report an unusual cause of chamber bypass causing hypercapnia due to rebreathing. A 30-year-old male patient with a history of a road traffic accident was posted for emergency decompressive craniotomy. Routine check of the anaesthesia machine (in accordance with the recommended pre-anaesthetic check list) was performed. General anaesthesia was administered and maintained using a circle absorber system at low flows (1 l/min). Standard monitoring was performed, and levels were within normal limits. Twenty minutes later, the FiCO2 gradually increased from 0 to 15 mmHg, and the EtCO2 increased from 34 to 50 mmHg with a rebreathing pattern on the capnograph. The soda lime in the canister did not show any colour change, and the unidirectional valves were confirmed to be functioning normally. The fresh gas flows were increased (5 l/min), and manual ventilation was initiated. On closer inspection of the soda lime canister, one of the three rings on which the inner chamber of soda lime canister is seated was found to be missing (Fig. 1). With replacement of the rubber ring, the FiCO2 and EtCO2 normalized. The anaesthesia machine which was being used had been in service for 3 years, and periodic checks were carried out by a maintenance engineer authorised by the company. The circle absorber breathing system used in our patient contained a single chamber of soda lime surrounded by an outer chamber. In such a system, the exhaled gases pass from above, downwards through the soda lime, then further through the holes at bottom of the inner chamber to the space between the outer chamber and inner canister and finally below and then upwards (Fig. 2). In our case, the absence of the rubber ring caused the gases to escape to the outer chamber, thereby bypassing the soda lime and resulting in CO2 rebreathing. The rubber ring was displaced during the change of soda lime or cleaning of the canister; as such it was a human error. The operation theatre technicians have since been specifically instructed to be careful during their handling of the soda lime assembly in the future in order to prevent further potential mishaps. In addition, the anesthesia residents have been made aware of the possibility of a poorly positioned rubber ring in the soda lime canister if other common causes of CO2 rebreathing and hypercapnia has been clinically excluded. Such realignments can occur despite routine checks of the anaesthesia machine. The manufacturer of the machine has also been informed of this incident with the displaced ring in the soda lime assembly, and we have suggested the possibility of permanent fixation of the ring as this would avoid this inadvertent complication. However, permanent fixation may make cleaning of the canister tedious owing to the collection of moisture. Problems have been encountered with the double canister soda lime assembly in which the sealing ring between the two canisters was displaced [1, 2]. We report this case P. Agrawal B. Gupta N. D’souza Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences (AIIMS), New Delhi 110029, India