Rajiv Chawla

Current concepts of optimal cerebral perfusion pressure in traumatic brain injury.

Traumatic brain injury (TBI) consists of varied pathophysiological consequences and alteration of intracranial dynamics, reduction of the cerebral blood flow and oxygenation. In the past decade more emphasis has been directed towards optimizing cerebral perfusion pressure (CPP) in patients who have suffered TBI. Injured brain may show signs of ischemia if CPP remains below 50 mmHg and raising the CPP above 60 mmHg may avoid cerebral oxygen desaturation. Though CPP above 70 mmHg is influential in achieving an improved patient outcome, maintenance of CPP higher than 70 mmHg was associated with greater risk of acute respiratory distress syndrome (ARDS). The target CPP has been laid within 50-70 mmHg. Cerebral blood flow and metabolism are heterogeneous after TBI and with regional temporal differences in the requirement for CPP. Brain monitoring techniques such as jugular venous oximetry, monitoring of brain tissue oxygen tension (PbrO2), and cerebral microdialysis provide complementary and specific information that permits the selection of the optimal CPP. This review highlights the rationale for use CPP directed therapies and neuromonitoring to identify optimal CPP of head injured patients. The article also reviews the evidence provided by various clinical trials regarding optimal CPP and their application in the management of head injured patients.

Communication skills of anesthesiologists: An Indian perspective.

Background: Communication failure is a risk factor for mishaps and complaints, which can be reduced by effective communication between operating room team members and patients. Aim: To conduct a survey among anesthesiologists regarding communications skills and related issues like stress in case of communication failure, need for training, music in operation theater, and language barrier at their work place. Materials and Methods: We conducted a survey among anesthesiologists coming for a neuroanesthesia conference in India (n = 110) in February 2011 by questionnaire sent by e-mail to them. Results: The response rate was 61.8% (68/110). Majority (95.5%) of the respondents agreed that good verbal communication leads to better patient outcome, better handling of crisis and is important between surgeons and anesthesiologists (98.5%). A total of 86% of the anesthesiologists felt that failure of communication caused stress to them. The idea of communication by e-mail or phone text messages instead of verbal communications was discouraged by 65.2%. A total of 82% of respondents felt that training of communication skills should be mandatory for all medical personnel and 77.6% were interested in participating in such course. Language barrier at work place was seen as hurdle by 62.7% of the respondents. A total of 80% of respondents felt that playing music in operating theater is appropriate. Conclusion: Results of the survey highlight the need for effective communication in the operating room between team members and need for formal training to improve it.

Acute isoniazid poisoning

We present two cases of acute isoniazid poisoning in patients who ingested 7.5 g and 5.0 g of isoniazid respectively, with the intention of committing suicide. Both were admitted unconscious, with ventilatory insufficiency and convulsions. Hepatic dysfunction and peripheral neuropathy were notable complications.

Successful transdiaphragmatic cardiac resuscitation through midline abdominal incision in patient with flail chest.

This case report describes a transdiaphragmatic approach through an already present vertical midline abdominal incision for performing internal cardiac compressions in a 30-year-old male road accident victim. The patient had a flail chest with haemopneumothorax and haemoperitoneum. Exploratory laparotomy followed by splenectomy was performed under general anaesthesia but the patient developed a witnessed cardiac arrest in postoperative period. Successful resuscitation using internal cardiac compression by a transdiaphragmatic approach through the midline abdominal incision that was not extended proximally is described.

Asymptomatic methaemoglobinaemia and its implications

Anaesthetists are well trained to detect subtle skin signs of life‐threatening situations such as cyanosis in hypoxia. However, cyanosis resulting from drug‐induced, asymptomatic methaemoglobinaemia is rare and is likely to go undetected preoperatively. Patients presenting with asymptomatic methaemoglobinaemia may, therefore, offer a dramatic challenge to the unprepared anaesthetist. We report a case of methaemoglobinaemia secondary to dapsone ingestion that was diagnosed intraoperatively.

Robotic hysterectomy in Trendelenburg position in a severely anaemic JKa alloimmunised patient with impending high-output cardiac failure: An anaesthetic challenge

Kidd blood group alloimmunisation, though extremely rare, may produce considerable morbidity, and even mortality. Severe anaemia and impending high-output cardiac failure requiring blood transfusion should be weighed against the risk of severe transfusion reactions even with fully cross-matched blood. Kidd antibodies are a common cause of delayed haemolytic transfusion reaction (DHTR) since they have a tendency remain undetectable in plasma. A low -grade DHTR (second hit) was grossly amplified by a second DHTR (third hit) superimposed on it in our patient leading to severe haemolysis with serum bilirubin reaching 68 mg%. Indirect antiglobulin test (indirect Coombs reaction) should ideally be performed in all patients (scheduled for major surgery requiring blood transfusion) who have experienced a previous pregnancy or blood transfusion. Non-invasive continuous haemoglobin monitoring and non-invasive cardiac output monitoring can prove invaluable tools in management.

Laryngoscope decontamination techniques: A survey.

Background and Aims: India is a vast country with variable, nonuniform healthcare practices. A laryngoscope is an important tool during general anesthesia and resuscitation. The study aimed to determine the current practices of laryngoscope decontamination in India. Material and Methods: An online survey was conducted amongst 100 anesthesiologists to determine the common methods of laryngoscope decontamination adopted in their settings. The survey was done over 6 months after validating the questionnaire. Results: A total of 73 responses were received out of 100. The result of the survey revealed that there is no uniform technique of laryngoscope decontamination. There is marked variability in techniques followed not only among different institutions, but also within the same institution. Conclusion: There are no fixed protocols adopted for laryngoscope decontamination. Thus, there is a need to develop definitive guidelines on this subject, which can be implemented in India.

The use of caffeine for the treatment of apnea of prematurity and bradycardia in a holoprosencephalic child with cleft lip and palate.

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