Rajeev Uppal

Biliary Obstruction in Gall Bladder Cancer Is Not Sine Qua Non of Inoperability

BackgroundThe presence of biliary obstruction in patients with gallbladder cancer (GBC) is generally viewed as an indicator of advanced disease, inoperability and poor prognosis.MethodsData was collected from patients with GBC with obstructive jaundice who underwent resection during the period January 2001 to October 2003. Systematic analysis of prospective data was undertaken; patients were analyzed for resectability, post-operative morbidity, mortality and disease-free survival.ResultsDuring this period 14 patients with GBC with biliary obstruction underwent resection with curative intent. In these jaundiced patients, the resectability rate was 27.45% (14 of 51). In the jaundiced group the mortality was 7.14% the morbidity rate 50%, the mean disease free survival was 23.46 months (median 26 months and range of 2 to 62 months). Seven patients (50%) survived more than two years.ConclusionBiliary obstruction in gall bladder cancer is not sine qua non of inoperability and resection results in meaningful prolongation of survival.

Influence of non-surgical risk factors on anastomotic leakage after major gastrointestinal surgery: Audit from a tertiary care teaching institute.

Context: The occurence of anastomotic leakage after gastointestinal resection and anastomosis is associated with significant mortality and morbidity. Aims: There is dearth of evidence in the literature on the influence of various non-surgical factors in causing anastomotic leakage although many studies have identified their possible role. Materials and Methods: A retrospective audit of all the anastomotic leakages occurring between September 2009 and April 2012 in our institute was performed to identify the potential non-surgical factors that can influence anastomotic leakage. A total of 137 out of 1246 patients who developed anastmotic leak were analyzed. All the potential non-surgical causes of anastomotic leakage available in the literature were analyzed by univariate analysis and stepwise multiple logistic regression analysis was done after adjusting for the type of surgery. An intergroup comparison among the patients based on the type of surgery was also performed. Results: The following factors were found to be independently associated with increased risk of anastomotic leak: (1) albumin <3.5 g/dl, (2) anemia <8 g/dl, (3) hypotension (4) use of inotropes, and (5) blood transfusion. The majority of anastomotic leaks occurred after pancreatic surgeries followed by esophagectomies and occurred least after colonic resections. The risk for anastomotic leak was four times more in patients who required inotropic support in the perioperative period and three times more in patients who developed hypotension. Conclusions: Our study is the first retrospective audit to identify the influence of non-surgical factors for anastomotic leakage and the need for further observational studies in this direction.

Beware of “curare cleft” like changes during unilateral capnothorax

Capnography is a standard monitoring tool during general anaesthesia. Diaphragmatic movement with the weaning of muscle relaxant effect produces the characteristic “curare cleft” on capnography. Various artefacts can mimick this trace intraoperatively. Cautious interpretation and identification of these is essential to avoid any undue overdosing of the patients with muscle relaxants. We report “curare cleft” like artefact during ventilation with a single lumen tube in a patient with unilateral capnothorax undergoing minimally invasive esophagectomy.

Predictors of postoperative pulmonary complications after liver resection: Results from a tertiary care intensive care unit.

Background: Postoperative pulmonary complication (PPC) is a serious complication after liver surgery and is a major cause of mortality and morbidity in the intensive care unit (ICU). Therefore, the early identification of risk factors of PPCs may help to reduce the adverse outcomes. Objective: The aim of this retrospective study was to determine the predictors of PPCs in patients undergoing hepatic resection. Design: Retrospective, observational. Methods: The patients admitted after hepatic resection in the gastrosurgical ICU of our institute between October 2009 and June 2013 was identified. The ICU charts were retrieved from the database to identify patients who developed PPCs. A comparison of risk factors was made between the patients who developed PPC (PPC group) against the patients who did not (no-PPC group). Results: Of 117 patients with hepatic resection, 28 patients developed PPCs. Among these, pneumonia accounted for 12 (42.8%) followed by atelectasis in 8 (28.5%) and pleural effusion in 3 (10.7%). Among the patients developing PPCs, 16 patients were over a 70-year-old (57.1%), 21 patients were smokers (75%) and 8 patients (28.5%) had chronic obstructive pulmonary disease (COPD). The requirement for blood transfusion and duration of mechanical ventilation were greater in the patients developing PPC (2000 ± 340 vs. 1000 ± 210 ml; 10 ± 4.5 vs. 3 ± 1.3 days). Conclusion: Old age, chronic smoking, COPD, increased blood product transfusion, increased duration of mechanical ventilation and increased length of ICU stay increased the relative risk of PPC, presence of diabetes and occurrence of surgical complications (leak, dehiscence, etc.) were independent predictive variables for the development of PPC.

A comparison between intravenous paracetamol plus fentanyl and intravenous fentanyl alone for postoperative analgesia during laparoscopic cholecystectomy.

Purpose: our study compared the effect of fentanyl alone with fentanyl plus intravenous Paracetamol for analgesic efficacy, opioid sparing effects, and opioid-related side effects after laparoscopic cholecystectomy. Materials and Methods: eighty patients undergoing laparoscopic cholecystectomy were randomized into two groups, who were given either an IV placebo or an IV injection of 1g paracetamol just before induction. Both groups received fentanyl during induction and IM diclofenac for pain relief every 8 hourly for 24 h after surgery. The postoperative pain relief was evaluated by a visual analog scale (VAS) and consumption of fentanyl as rescue analgesic in the postoperative period for 24 h after surgery was measured. The incidence of PONV and sedation scores was also measured in the postoperative period. Results: the mean VAS score in first and second hour after surgery was less in the group receiving IV Paracetamol (3.3±0.4* vs. 5.2±0.9; 3.1±0.4* vs. 4.3±0.3); the fentanyl consumption over first 24 h was also less in the group receiving IV paracetamol (50±14.9 vs. 150±25.8). The time requirement of first dose of rescue analgesic in the postoperative period was also significantly prolonged in the group receiving IV paracetamol (76±24.7 vs. 48±15.8). There was no difference in the sedation scores and in the incidence of PONV in the two groups. Conclusion: The study demonstrates the usefulness of intravenous paracetamol as pre-emptive analgesic in the treatment of postoperative pain after laparoscopic cholecystectomy.

Use of single-lumen tube for minimally invasive and hybrid esophagectomies with prone thoracoscopic dissection: case series.

Minimally invasive and hybrid minimally invasive esophagectomy (MIE) is a technically challenging procedure. Anesthesia for the same is equally challenging due to special requirements of the video-assisted thoracoscopic technique used and shared operative and respiratory fields. Standard ventilatory strategy for this kind of surgery has been 1-lung ventilation with the help of a double-lumen tube. Prone positioning for thoracoscopic dissection facilitates gravity-dependant collapse of the operative side lung induced by a unilateral capnothorax, thus making the use of single-lumen endotracheal tube a feasible option for this surgery. We report our experience of 10 consecutive cases of minimally invasive esophagectomy conducted in prone position at our center and the use of single-lumen endotracheal tube for ventilation.

Unexpected cause of leak in a modern anesthesia workstation

Anesthesia workstation circuit leaks have been reported earlier. Various “hidden” causes of gas leaks have been reported in the literature which may not be easily detected while checking the machine [1,2]. We report a leak in a Datex Ohmeda S/5 Avance anesthesia workstation (GE Healthcare, Madison, WI, USA) due to the stuck “EZchange” canister mode valve during change of absorbent intraoperatively. Routine daily check of the workstation as per the displayed stepwise checkout menu of the anesthesia workstation was done. After successful completion of the circuit and workstation check, the first case (laparoscopic cholecystectomy) was started. The patient’s ventilation posed no problem for the first 30 minutes of surgery. A change in color of more than half of the absorbent canister prompted us to change the absorbent. The absorbent was changed as per manufacturer’s recommendation, with the absorber canister being put on EZchange mode. The message, “CO2 absorber out of circuit”, was displayed on the monitor. After changing the absorbent and switching the canister back on, the bellows collapsed and the message, “Unable to drive bellows”, was displayed on the monitor screen. No message regarding the CO2 absorber was displayed. The circuit, endotracheal tube, and ventilator assembly were checked throughout their length for any disconnections or leaks. Placement of vaporizers and connections of the absorbent canister assembly also was thoroughly checked, as misalignment of the absorbent canister assembly (also undetected by machine self-check) also leads to similar problems. None of the above-described situations caused the leak. Manual ventilation was not possible using the closed circuit loop, even with high fresh gas flows. It was difficult to ventilate now with the canister being engaged or disengaged from the anesthesia workstation. The patient was then ventilated manually with the auxiliary common gas outlet (ACGO) until completion of the case. The machine self-test after completion of the case did not show

Epidemiology and characteristics of nosocomial infections in critically ill patients in a tertiary care intensive care unit of Northern India

Background and Aims: The prevalence of nosocomial infection is higher in the Intensive Care Unit (ICU) than other areas of the hospital. The present observational study was undertaken to describe the epidemiology and characteristics of nosocomial infections acquired in a tertiary care ICU and the impact of the various risk factors in their causation. Materials and Methods: A retrospective study was conducted on the prospectively collected data of 153 consecutive patients admitted in a tertiary care ICU between July 2014 and December 2015. The primary objective was to assess the epidemiology of ICU-acquired bacterial infections in terms of the incidence of new infections, causative organism, and site. The secondary end point was to assess the risk factors for developing ICU-acquired infections. Results: Out of the 153 patients enrolled in the study, 87 had an ICU-acquired nosocomial infection (58.86%). The most common organism responsible for infection was Klebsiella pneumoniae (37%), and the most common infection was pneumonia (33%). The duration of mechanical ventilation and length of ICU stay were significantly prolonged in patients developing nosocomial infections. There was no difference in mortality between the groups. The multivariate analyses identified intubation longer than 7 days, urinary catheterization >7 days, duration of mechanical ventilation more than 7 days, and ICU length of stay longer than 7 days as independent risk factors for nosocomial infections. Conclusion: The study demonstrated a high incidence of nosocomial infection in the ICU and identified the risk factors for acquisition of nosocomial infections in the ICU.

Influence of admission source on the outcome of patients in an intensive care unit

Aim of the study: The admission in the Intensive Care Unit (ICU) occurs from various sources, and the outcome depends on a complex interplay of various factors. This observational study was undertaken to describe the epidemiology and compare the differences among patients admitted in a tertiary care ICU directly from the emergency room, wards, and ICUs of other hospitals. Materials and Methods: A retrospective study was conducted on 153 consecutive patients admitted from various sources in a tertiary care ICU between July 2014 and December 2015. The primary endpoint of the study was the influence of the admission source on ICU mortality. The secondary endpoints were the comparison of the duration of mechanical ventilation, length of ICU stay, and the ICU complication rates between the groups. Results: Out of the 153 patients enrolled, the mortality of patients admitted from the ICUs of other hospital were significantly higher than the patients admitted directly from the emergency room or wards/operating rooms (60.5% vs. 48.2% vs. 31.9%; P = 0.02). The incidence of ventilator-associated lung injury was lower in the patients admitted directly from the emergency room (23.4% vs. 50% vs. 50%; P = 0.03). Multivariate logistic regression analysis revealed higher age, increased disease severity, longer duration of mechanical ventilation, and longer ICU stay as independent predictors of mortality in the patients shifted from the ICUs of other hospitals. Conclusion: The study demonstrated a higher risk of ICU mortality among patients shifted from the ICUs of other hospitals and identified the independent predictors of mortality.

Entanglement of Nasogastric Tube and Nasopharyngeal Temperature Probe During Surgery

Nasogastric tube (NGT) insertion and nasopharyngeal temperature probe (NTP) insertion are routine procedures in patients scheduled for gastric pull or colonic pull surgeries for corrosive esophageal strictures. Although intra-gastric and intra-esophgeal knotting of NGT is described in the literature, there is no report of entanglement of NTP with the NGT in a knot in the nasopharynx. We report entanglement of NGT and NTP in a 17-year-old female scheduled for gastric pull-up surgery and discuss the possible causes and preventive measures. The preventive measures discussed may improve patient safety and quality of care by preventing misplacements of NGT and NTP which can cause such entanglement.