Priyanka Gupta

Fatal Case of Pericardial Effusion Due to Myroides Odoratus: A Rare Case Report.

Myroides spp., previously known as Flavobacterium odoratum, are rare clinical isolates and are often considered non-pathogenic. Natural habitat includes soil, fresh and marine waters, in foods and in sewage treatment plants. We present an unusual case of fatal pericardial effusion due to Myroides odoratus in a patient suffering from chronic kidney disease and undergoing maintenance haemodialysis. This case is presented to show the increasing incidence of rare isolates causing localized and systemic infections and due to their high intrinsic resistance to many antibiotics they can be fatal. Thus isolation of these pathogens is of great clinical importance.

99mTc-DMSA (V) in Evaluation of Osteosarcoma: Comparative Studies with 18F-FDG PET/CT in Detection of Primary and Malignant Lesions

To evaluate the role of 99mTc-DMSA (V) and [18F]FDG PET-CT in management of patients with osteosarcoma, 22 patients were included in our study. All patients underwent both 99mTc-DMSA (V) and whole-body [18F]FDG PET-CT scans within an interval of 1 week. 555–740 MBq of 99mTc-DMSA (V) was injected i.v. the whole-body planar, SPECT images of primary site and chest were performed after 3-4 hours. [18F]FDG PET-CT images were obtained 60 minutes after i.v. injection of 370 MBq of F-18 FDG. Both FDG PET-CT (mean SUVmax = 7.1) and DMSA (V) scans showed abnormal uptake at primary site in all the 22 patients (100% sensitivity for both). Whole-body PET-CT detected metastasis in 11 pts (lung mets in 10 and lung + bone mets in 1 patient). Whole-body planar DMSA (V) and SPECT detected bone metastasis in one patient, lung mets in 7 patients and LN in 1 patient. HRCT of chest confirmed lung mets in 10 patients and inflammatory lesion in one patient. 7 patients positive for mets on DMSA (V) scan had higher uptake in lung lesions as compared to FDG uptake on PET-CT. Three patients who did not show any DMSA uptake had subcentimeter lung nodule. Resuts of both 99mTc-DMSA (V) (whole-body planar and SPECT imaging) and [18F]FDG PET-CT were comparable in evaluation of primary site lesions and metastatic lesions greater than 1 cm. Though 99mTc-DMSA (V) had higher uptake in the lesions as compared to [18F]FDG PET-CT, the only advantage [18F]FDG PET-CT had was that it could also detect subcentimeter lesions.

Comparison between sevoflurane and desflurane on emergence and recovery characteristics of children undergoing surgery for spinal dysraphism

Background and Aims: Rapid recovery is desirable after neurosurgery as it enables early post-operative neurological evaluation and prompt management of complications. Studies have been rare comparing the recovery characteristics in paediatric neurosurgical patients. Hence, this study was carried out to compare the effect of sevoflurane and desflurane anaesthesia on emergence and extubation in children undergoing spinal surgery. Methods: Sixty children, aged 1-12 years, undergoing elective surgery for lumbo-sacral spinal dysraphism were enrolled. Anaesthesia was induced with sevoflurane using a face mask. The children were then randomised to receive either sevoflurane or desflurane with oxygen and nitrous oxide, fentanyl (1 μg/kg/h) and rocuronium. The anaesthetic depth was guided by bispectral index (BIS ®) monitoring with a target BIS ® between 45 and 55. Perioperative data with regard to demographic profile, haemodynamics, emergence and extubation times, modified Aldrete score (MAS), pain (objective pain score), agitation (Cole′s agitation score), time to first analgesic and complications, thereof, were recorded. Statistical analysis was done using STATA 11.2 (StataCorp., College Station, TX, USA) and data are presented as median (range) or mean ± standard deviation. Results: The demographic profile, haemodynamics, MAS, pain and agitation scores and time to first analgesic were comparable in between the two groups (P > 0.05). The emergence time was shorter in desflurane group (2.75 [0.85-12] min) as compared to sevoflurane (8 [2.5-14] min) (P < 0.0001). The extubation time was also shorter in desflurane group (3 [0.8-10] min) as compared to the sevoflurane group (5.5 [1.2-14] min) (P = 0.0003). Conclusion: Desflurane provided earlier tracheal extubation and emergence as compared to sevoflurane in children undergoing surgery for lumbo-sacral spinal dysraphism.

Live foreign bodies in the airway

Upper airway obstruction may rarely complicate anesthesia practice especially in developing nations of the world, leading to disastrous consequences. Reports of endogenous and exogenous foreign bodies in the airway and breathing circuit are available in the literature. Adult worm resides in the gastrointestinal tract, and it may migrate to the esophagus and oropharyngeal cavity when irritated by certain drugs or anesthetic agents. Respiratory obstruction has been reported in a pediatric patient intubated with non-cuffed endotracheal tube who was known case of ascariasis.[1-4] We encountered such a situation during induction of anesthesia in a child resulting in a disastrous complication.

Development of a radiopharmaceutical dose calculator for pediatric patients undergoing diagnostic nuclear medicine studies

Objective: It is important to ensure that as low as reasonably achievable (ALARA) concept during the radiopharmaceutical (RPH) dose administration in pediatric patients. Several methods have been suggested over the years for the calculation of individualized RPH dose, sometimes requiring complex calculations and large variability exists for administered dose in children. The aim of the present study was to develop a software application that can calculate and store RPH dose along with patient record. Materials and Methods: We reviewed the literature to select the dose formula and used Microsoft Access (a software package) to develop this application. We used the Microsoft Excel to verify the accurate execution of the dose formula. The manual and computer time using this program required for calculating the RPH dose were compared. Results: The developed application calculates RPH dose for pediatric patients based on European Association of Nuclear Medicine dose card, weight based, body surface area based, Clark, Solomon Fried, Young and Websters formula. It is password protected to prevent the accidental damage and stores the complete record of patients that can be exported to Excel sheet for further analysis. It reduces the burden of calculation and saves considerable time i.e., 2 min computer time as compared with 102 min (manual calculation with the calculator for all seven formulas for 25 patients). Conclusion: The software detailed above appears to be an easy and useful method for calculation of pediatric RPH dose in routine clinical practice. This software application will help in helping the user to routinely applied ALARA principle while pediatric dose administration.

Complications related to sitting position during Pediatric Neurosurgery: An institutional experience and review of literature

Background: Sitting position is preferred during posterior fossa surgeries as it provides better anatomical orientation and a clear surgical field. However, its use has been declining due to its propensity to cause life-threatening complications. This study was carried out to analyze the perioperative complications and postoperative course of children who underwent neurosurgery in sitting position. Materials and Methods: Medical records of 97 children (<18 years) who underwent neurosurgery in sitting position over a period of 12 years, were retrospectively analyzed. Data pertaining to the perioperative course such as demographics, hemodynamic changes, various complications, duration of intensive care unit (ICU) and hospital stay, and neurological status at discharge were recorded. Statistical analysis was done by chi-square and Mann–Whitney test, and a P value <0.05 was considered as significant. Results: The median age of these children was 12 (3–18) years. Hemodynamic instability was observed in 12 (12.3%) children. A total of 38 episodes of venous air embolism (VAE) were encountered in 21 (21.6%) children; nine experienced multiple episodes. VAE was associated with hypotension in five (23.8%) and desaturation in four (19.1%) children. Six children presented with postoperative tension pneumocephalus; three were managed with twist drill burr-hole evacuation. Brainstem handling was the most common indication (42.5%) for the requirement of elective postoperative ventilation. The duration of ICU and hospital stays were comparable among the children who experienced VAE and those who did not (P > 0.05). Neurological status at discharge was also comparable between these two groups (P = 0.83). Conclusions: This study observed a lesser incidence of VAE and associated complications. Tension pneumocephalus was managed successfully without any adverse outcome. Hence, it is believed that with meticulous anesthetic and surgical techniques, sitting position can safely be practiced in children undergoing neurosurgery.

Fluoroscopic-guided paramedian approach to subarachnoid block in patients with ankylosing spondylitis: A case series

The airway and axial skeleton involvement in ankylosing spondylitis (AS) poses unique challenges to the anaesthesiologists.[1] The spinal manifestations comprise of spondylitis, diskitis, arthritis and enthesitis. These lead to progressive stiffness, ossification of the axial ligaments [Figure 1], obliteration of the intervertebral spaces and syndesmophytes formation; hindering access to the central neuraxial space.[2] Fluoroscopy may aid in identifying the small ‘accessibility window’ [Figure 1]; thereby facilitating subarachnoid block (SAB) in those inaccessible by the landmark technique. However, few anatomical and technical considerations apply. This case series describes the author’s novel technique of fluoroscopic guided paramedian approach to SAB (FPAS) and their experience with the same in six AS patients with severe lumbar spine (LS) involvement.

Comparison of different doses of intravenous lignocaine on etomidate-induced myoclonus: A prospective randomised and placebo-controlled study

Background and Aims: Etomidate-induced myoclonus (EM) is observed in 50%–80% of unpremedicated patients. Low-dose lignocaine has been shown to attenuate but not abolish the EM. The aim of this prospective, randomised controlled study was to compare the different doses of lignocaine on the incidence and severity of EM. Methods: Two hundred adult patients were randomly assigned into four groups to receive saline placebo (Group I) or IV lignocaine 0.5 mg/kg (Group II), 1 mg/kg (Group III) or 1.5 mg/kg (Group IV) 2 min before injection etomidate 0.3 mg/kg IV. The patients were assessed for the EM using a four-point intensity scoring system. Our primary outcome was the incidence of myoclonus at 2 min (EM2). The incidence of myoclonus at 1 min (EM1) and severity of myoclonus constituted the secondary outcomes. ANOVA and Pearson Chi-square test were used for statistical analysis and P < 0.05 was considered as statistically significant. Results: The incidence of EM was significantly reduced in Groups III [(EM1: 32% vs. 60%, P = 0.009); (EM2: 42% vs. 76%, P = 0.001)] and IV (EM2: 54% vs. 76%, P = 0.035) compared with Group I. Lignocaine 1 mg/kg and 1.5 mg/kg significantly reduced the incidence of severe myoclonus at 2 min (14% each) compared to Groups I (42%, P = 0.003) and II (32%, P = 0.032). Conclusion: Lignocaine 1 mg/kg and 1.5 mg/kg IV pretreatment significantly reduces the incidence of EM, with maximum attenuation observed with 1 mg/kg.

Eficácia da pré-oxigenação usando respiração em volume corrente: uma comparação dos sistemas Mapleson A, Bain e Circular

BACKGROUND Efficacy of preoxygenation depends upon inspired oxygen concentration, its flow rate, breathing system configuration and patient characteristics. We hypothesized that in actual clinical scenario, where breathing circuit is not primed with 100% oxygen, patients may need more time to achieve EtO2≥90%, and this duration may be different among various breathing systems. We thus studied the efficacy of preoxygenation using unprimed Mapleson A, Bains and Circle system with tidal volume breathing at oxygen flow rates of 5L.min-1 and 10L.min-1. METHODS Patients were randomly allocated into one of the six groups, wherein they were preoxygenated using either Mapleson A, Bains or Circle system at O2 flow rate of either 5L.min-1 or 10L.min-1. The primary outcome measure of our study was the time taken to achieve EtO2≥90% at 5 and 10L.min-1 flow rates. RESULTS At oxygen flow rate of 5L.min-1, time to reach EtO2≥90% was significantly longer with Bains system (3.7±0.67min) than Mapleson A and Circle system (2.9±0.6, 3.3±0.97min, respectively). However at oxygen flow rate of 10L.min-1 this time was significantly shorter and comparable among all the three breathing systems (2.33±0.38min with Mapleson, 2.59±0.50min with Bains and 2.60±0.47min with Circle system). CONCLUSIONS With spontaneous normal tidal volume breathing at oxygen flow rate of 5L.min-1, Mapleson A can optimally preoxygenate patients within 3min while Bains and Circle system require more time. However at O2 flow rate of 10L.min-1 all the three breathing systems are capable of optimally preoxygenating the patients in less than 3min.

Severe neonatal thrombocytopenia in a case of Cornelia de Lange syndrome

Patients of Cornelia de Lange syndrome (CdLS) may be more susceptible for the development of immune thrombocytopenia than the general population, for which many hypotheses have been generated. However, till date, only a few cases of thrombocytopenia in CdLS have been described; only four reports being from neonates. Here, we describe a case of severe, symptomatic and idiopathic neonatal thrombocytopenia in CdLS from India, which remitted spontaneously without any serious sequel. Diagnostic clinical criteria of CdLS are also discussed.