Ravindra Chaturvedi

Incidence of healthcare associated infection in the surgical ICU of a tertiary care hospital

BACKGROUND Healthcare associated infections (HAI) have taken on a new dimension with outbreaks of increasingly resistant organisms becoming common. Protocol-based infection control practices in the intensive care unit (ICU) are extremely important. Moreover, baseline information of the incidence of HAI helps in planning-specific interventions at infection control. METHODS This hospital-based observational study was carried out from Dec 2009 to May 2010 in the 10-bedded surgical intensive care unit of a tertiary care hospital. CDC HAI definitions were used to diagnose HAI. RESULTS A total of 293 patients were admitted in the ICU. 204 of these were included in the study. 36 of these patients developed HAI with a frequency of 17.6%. The incidence rate (IR) of catheter-related blood stream infections (CRBSI) was 16/1000 Central Venous Catheter (CVC) days [95% C.I. 9-26]. Catheter-associated urinary tract infections (CAUTI) 9/1000 urinary catheter days [95% C.I. 4-18] and ventilator-associated pneumonias (VAP) 32/1000 ventilator days [95% confidence interval 22-45]. CONCLUSION The HAI rates in our ICU are less than other hospitals in developing countries. The incidence of VAP is comparable to other studies. Institution of an independent formal infection control monitoring and surveillance team to monitor & undertake infection control practices is an inescapable need in service hospitals.

Operative hysteroscopy intravascular absorption syndrome: A bolt from the blue

Operative hysteroscopy has emerged as an effective alternative to hysterectomy and has become standard surgical treatment for varied gynaecological conditions like abnormal uterine bleeding and uterine myomas. This procedure requires distention of the uterine cavity for adequate visualization of the operative field. 1.5% glycine is a widely used distention medium because it has good optical properties and is non-conductive. However, the intraoperative absorption of this electrolyte-free fluid can cause hyponatraemia, hypoosmolality, hyperglycinaemia and volume overload, including pulmonary oedema. We report a case of operative hysteroscopy intravascular absorption (OHIA) syndrome, presenting abruptly during hysteroscopic myomectomy, employing 1.5% glycine as the fluid distention medium. Successful management of the case and prevention strategies are discussed.

Antiphospholipid syndrome, cardiac surgery and cardiopulmonary bypass

of APLS are cerebrovascular accident, transient ischemic attack, seizures, chorea, migraine, pseudotumor cerebri, visual disturbances and dementia. Cutaneous features include livedo reticularis, ulcers, infarcts and superficial thrombophlebitis. These patients may develop renal arterial or venous thrombosis, acute or chronic renal failure, hemolytic anemia or thrombocytopenia.[15-17] Catastrophic APLS is a distinct entity that results in simultaneous multiple small vessel thromboses. Factors precipitating this ‘thrombotic storm’ include surgical trauma, infection, any change in anticoagulation therapy, or oral contraceptives. It is associated with nearly 50% mortality.[18-20]

Diagnostic and therapeutic challenge of heart failure after liver transplant: Case series

Heart failure (HF) following liver transplant (LT) surgery is a distinct clinical entity with high mortality. It is known to occur in absence of obvious risk factors. No preoperative workup including electrocardiogram, echocardiography at rest and on stress, reasonably prognosticates the risk. In patients of chronic liver disease, cirrhotic cardiomyopathy, alcoholic cardiomyopathy, and stress induced cardiomyopathy have each been implicated as a cause for HF after LT. However distinguishing one etiology from another not only is difficult, several etiologies may possibly coexist in a given patient. Diagnostic dilemma is further compounded by the fact that presentation and management of HF irrespective of the possible underlying cause, remains the same. In this case series, 6 cases are presented and in the light of existing literature modification in the preoperative workup are suggested.

Multimodal temperature management during donor hepatectomy under combined general anaesthesia and neuraxial analgesia: Retrospective analysis

Background and Aims: Unintended hypothermia (UIH) during surgery under general anaesthesia has adverse implications. A retrospective analysis of the perioperative temperature records of healthy voluntary liver donors was done to evaluate the efficacy of a multimodal protocol for temperature management. Methods: Records of 50 American Society of Anesthesiologists physical status Class 1 patients operated for Donor Hepatectomy lasting >2 h under combined general and epidural anaesthesia were analysed. Ambient temperature was maintained 24°C–27°C before induction of GA and during insertion of epidural catheter. Active warming was done using warming mattress set to temperature 38°C, hot air blanket with temperature set to 38°C and fluid warming device (Hotline™) with preset temperature of 41°C. Nasopharyngeal temperature was continuously monitored. After induction of GA and draping of the patient, ambient temperature was decreased and maintained at 21°C–24°C and was again increased to 24°C–27°C at the conclusion of surgery. During surgery, for every 0.1°C above 37°C, one heating device was switched off such that at 37.3°C all the 3 devices were switched off. Irrigation fluid was pre-warmed to 39°C. Results: Baseline temperature was 35.9°C ± 0.4°C. Minimum temperature recorded was 35.7°C ± 0.4°C. Mean decrease in temperature below the baseline temperature was 0.2°C ± 0.2°C. Temperature at the end of surgery was 37.4°C ± 0.5°C. Conclusion: Protocol-based temperature management with simultaneous use of resistive heating mattress, forced-air warming blanket, and fluid warmer along with ambient temperature management is an effective method to prevent unintended perioperative variation in body temperature.

Anaesthetic management of an esophageal stent perforation of the left main bronchus

The self-expandable oesophageal prosthesis has helped in palliation of dysphagia in advanced esophageal cancer. However, the prevalence of complications and mortality are reported to be increased when there is inherent weakness of the tissues. This report describes the anaesthetic management in a patient presenting with an oesophageo bronchial fistula.

Lung protective ventilation in the intraoperative period.

To the Editor: We read with interest the article titled “A Description of Intraoperative Ventilator Management in Patients with Acute Lung Injury and the Use of Lung Protective Ventilation Strategies.” It was also discussed in detail during our journal club as part of the departmental training program. The concept and the idea behind the article are very interesting and thought-provoking and we congratulate the authors on the same. We have a few observations, however. First, current information systems being used in hospitals are programmed to a large extent not to accept values of parameters that are invalid. It was noted that a large number of patients were excluded (320 265 31) because of invalid tidal volume, height, and weight. A total 616 of 2,652 patients, approximately 23.23% of cases, were excluded. This reflects poorly on the reliability of the database and of the entries considered as valid and included in the study. Second, in the materials and methods section all patients undergoing surgery who had at least one preoperative arterial blood gas assessment were included in the study. There exists a possibility that there were some patients with hypoxia who had not undergone preoperative arterial blood gas assessment and so were not included in the study. This situation also would have an effect on the final analysis. Third and most important, the mode of ventilation used intraoperatively has not been mentioned. Because only peak inspiratory pressures were monitored in the “post lung protective ventilation strategy era” it is evident that pressurecontrolled mode of ventilation may have been used. As a result, the findings of the ARDSnet study cannot be applied because that was carried out exclusively using volume control ventilation. This has also been discussed by Slutsky et al. However, if volume-controlled ventilation was used, the plateau pressures (Pplat) would have been lower than the peak inspiratory pressures. Whether the trend of peak inspiratory pressures would have accurately reflected the trend of Pplat as is the authors’ contention is a moot point. Moreover, if that was the case, Pplat would not have been universally used as a surrogate of pressures at the level of the alveolus and peak inspiratory pressures, which is actually an indicator of airway resistance would have sufficed. Thus, it may not be appropriate for the authors to conclude that lung protective ventilation strategy was not used intraoperatively in patients with acute lung injury in their hospital. Lung protective ventilation strategy by definition is use of low tidal volumes in volume-controlled mode of ventilation targeting a tidal volume of 6 ml/kg predicted body weight and plateau pressures of 25 cm of water. Fourth, the authors have concluded that the tidal volume settings appear to mirror the ventilator settings provided to the patients in the intensive care unit, which is borne out by the fact that table 5 shows that the tidal volume being delivered in the preoperative setting in the intensive care unit to the patients with acute lung injury is 8.25 ml/kg predicted body weight, compared with 8.58 ml/kg predicted body weight in the intraoperative period. Is it, therefore, to be inferred that even in the intensive care unit these patients were not being ventilated with a lung protective ventilation strategy using tidal volumes of 6 ml/kg predicted body weight? Finally, there are a number of typographical errors where PaO2 has been repeatedly substituted by PaCO2 in the abstract. In table 1 and figure 1, P/F has been mentioned as PaOC/FiO2. In tables 3, 4, and 5, Fio2 has not been mentioned as a fraction but probably as the percentage of inspired oxygen.

Ether day: an intriguing history

doi: 10.1016/S0377-1237(11)60098-1 1772 was known always as “laughing gas.” The euphoric properties of the gas were well known and Sir Humphry Davy of England had speculated about its possible use in surgery as early as 1800. Yet both nitrous oxide and ether were used as nothing but an entertaining intoxicant till middle of 19th century. There is no good answer to the puzzle of why it took physicians so long to banish pain from their surgeries. It may have been largely that the jolly highs produced by ether and nitrous oxide obscured any potential for practical use. For a small fee, balloons filled with nitrous oxide would be made available to the guests to take a snort and then more money would be charged for exhibiting the frolics of the intoxicated to an audience. Samuel Colt used the money from such a venture to start his revolver factory. In 1844 Gardener Quincy Colton, a doctor turned exhibitor, brought laughing gas to Hartford where a local dentist, Horace Wells (1815–1848) tried it on 10 December 1844 and according to his wife made himself ridiculous in public assembly. A friend of Wells, Samuel A. Cooley got intoxicated, went berserk on stage and banged up his knees against a settee but felt nothing despite a bleeding knee until the gas wore off. Wells made the connection from stage amusement to clinical tool, and, on 11 December 1844 inhaled nitrous oxide from an oil-silk bag provided by Colton and had his dental partner John M Riggs pull out a troublesome tooth. After waking, Wells proclaimed, “It is the greatest discovery ever made. I didn’t feel so much as the prick of a pin!” Wells learnt from Colton how to make nitrous oxide and after successfully using it on some of his patients he was ready to announce his discovery to the Medical fraternity. He approached John Collins Warren, a leading surgeon, who arranged for a lecture demonstration at the Massachusetts General Hospital in Boston in January 1845. Unfortunately, during the demonstration the gas bag was removed early and the patient cried out before the tooth was extracted. Wells was booed out amidst cries of “humbug.” A broken man, Wells returned to Hartford, suffered a debilitating illness followed by a mental depression that was exacerbated by the controversy that followed Morton’s successful demonstration on Ether Day. He experimented with chloroform, which was an effective anaesthetic but more dangerous than ether, and became addicted to it. Arrested for throwing acid onto prostitutes while he was chloroformed, Wells killed himself in jail. It was in 1842 that the then 23-year-old Morton met Horace Wells for the first time in Hartford. Before that time, he had tried his hands at business in the cities of Baltimore, St. Louis, and Cincinnati. He would forge letters of recommendation, buy goods on credit, sell them, and abscond with the money to the Ether da y: an intriguing history