Saurabh Mittal

Endobronchial ultrasound-guided transbronchial needle aspiration of thyroid: Report of two cases and systematic review of literature

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive and safe technique for a sampling of mediastinal lesions. Indications for EBUS-TBNA have gradually expanded since its introduction. The usual approach to cytological sampling of the thyroid gland is percutaneous ultrasound-guided fine needle aspiration (US-FNA) performed under local anesthesia. US-FNA may be risky or not feasible in intrathoracic/substernal thyroid location. Feasibility of aspirating thyroid lesions with EBUS-TBNA has been occasionally reported. We report two patients wherein EBUS-TBNA was utilized for thyroid lesion aspiration and definitive diagnosis. We highlight the utility and safety of EBUS-TBNA in the evaluation of intrathoracic thyroid lesions wherein image-guided percutaneous aspiration may be risky/sometimes impossible to perform. A systematic review of literature has also been performed summarizing and discussing the issues pertaining to EBUS-TBNA of the thyroid gland.

Intra- and inter-observer reliability of quadriceps muscle thickness measured with bedside ultrasonography by critical care physicians

Background: Muscle wasting is common among critically ill patients with sepsis and has a significant effect on clinical outcome. However, appropriate tool for measurement of muscle loss is debatable. Ultrasonography (USG) has been used for objective assessment of quadriceps muscle thickness among these patients; however, there is limited data on its reliability. Aims and Objective: This study was aimed to assess the reliability of quadriceps muscle thickness as measured by critical care physicians. Methodology: This cross-sectional study included twenty patients with sepsis. Quadriceps muscle thickness was measured on right mid-thigh at a predefined point by two critical care fellows using bedside USG. Intra- and inter-observer reliability of the measurements was assessed by intra-class correlation coefficient (ICC). Results: Hundred and twenty quadriceps muscle thickness measurements, three by each of the two critical care fellows, were done in twenty patients with sepsis. First, second, and third measurements (mean ± standard deviation) taken by the first observer (RK) were 35.030 ± 3.546 mm, 35.055 ± 3.307 mm, and 35.245 ± 3.027 mm, respectively. The three values recorded by the second observer (AD) were 35.585 ± 3.746 mm, 35.1 ± 3.006 mm, and 34.89 ± 2.556 mm, respectively. ICC for observer 1 and 2 was 0.925 (95% confidence interval [CI]: 0.851–0.967) and 0.835 (95% CI: 0.689–0.925), respectively. The mean difference of measurement between two observers was 0.082 mm (95% CI: −1.194–1.031). The mean ICC (95% CI) for inter-observer reliability was 0.992 (0.979–0.997); P < 0.001. Conclusions: This study shows that ultrasound is a reliable tool for the measurement of quadriceps muscle thickness by critical care physicians with excellent inter- and intra-class reliability.

A 44-year-old man with hemoptysis

A 44-year-old man with background history of diffuse cutaneous systemic sclerosis and dilated cardiomyopathy receiving immunosuppressive medications, presented with a 2-month history of cough and streaky hemoptysis. Clinicoradiological features were consistent with an endotracheal mass. Subsequently, the patient developed nodular skin lesions and the tracheal mass increased in size causing central airway obstruction. This clinicopathologic conference discusses the clinical and radiological differential diagnoses of such a clinical presentation and their management options.

Paediatric Endobronchial Ultrasound-guided transbronchial needle aspiration: Anaesthetic and procedural considerations

This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms. How to cite this article: Singh S, Chowdhary NK. Erector spinae plane block an effective block for post‐operative analgesia in modified radical mastectomy. Indian J Anaesth 2018;62:148-50.

Difficult intubation: ‘Beyond the vocal cords’

How to cite this article: Senthilkumaran S, Senthilraj MP, Jena NN, Thirumalaikolundusubramanian P. Methaemoglobinaemia: Recognition and realisation at bedside. Indian J Anaesth 2018;62:475-6.

Comparison of Sedation Regimens during Flexible Bronchoscopy

We read with keen interest the recent article comparing different sedation regimens during flexible bronchoscopy, by Riachy et al. Authors conducted a randomised controlled trial comparing three regimens for sedation in flexible bronchoscopy using lidocaine alone, Alfentanil and Dexmedetomidine and concluded similar efficacy between the three groups. However, certain issues with the methodology and applicability of result findings need discussion. The mean topical lidocaine dose used in all three groups ranged from 8.60 mg/kg to 9.58 mg/kg with maximum dose reaching up to 19.23 mg/kg. Most experts shall consider (also highlighted in bronchoscopy guidelines previously published) these dose ranges to be well above the safe limits of topical lignocaine. Even in ‘No-Sedation’ bronchoscopy, feasibility of performing the procedure easily (with good procedure related operator rated satisfaction) with mean lignocaine dose ranging between 5.7 mg/kg and 7.1 mg/kg has been described in a large study including 500 patients. Administration of high doses of topical anaesthesia nearing possible toxic range can be a major limiting factor in a study aimed at looking effects of additive sedation. Therefore, we believe that in presence of such a high baseline lignocaine administration, the comparative results of sedation regimens are unlikely to be representative of the real-life scenario at most centres. It shall also be interesting to know the numbers/proportion of the various diagnostic procedures (like bronchoalveolar lavage, endobronchial biopsy, transbronchial lung biopsy, airway inspection alone) performed in the three groups and whether these were comparable. This is important as the procedure duration is likely to be shorter and consequent patient comfort greater in lavage or endoscopic inspection alone. This information is also important to ascertain the applicability of the findings. As the loading dose of Dexmedetomidine was not employed, there is a possibility that adequate therapeutic effect of the drug may not have been achieved at the time of initiation of the procedure. It is recommended that for optimal action, a loading dose of this agent should be administered and there are studies that have specifically looked at various loading dose regimens for sedation. This is important while comparing the agent with Alfentanil which has an immediate onset of action without any loading dose. The parameters for vocal cord mobility assessment and limb movement grading used as part of calculation of the proposed bronchoscopy score are very subjective and likely to have high inter individual variability in scoring.

A 26-year-old man with dyspnea and chest pain

A 26-year-old smoker male presented with a history of sudden onset dyspnea and right-sided chest pain. Chest radiograph revealed large right-sided pneumothorax which was managed with tube thoracostomy. High-resolution computed tomography thorax revealed multiple lung cysts, and for a definite diagnosis, a video-assisted thoracoscopic surgery-guided lung biopsy was performed followed by pleurodesis. This clinicopathologic conference discusses the clinical and radiological differential diagnoses, utility of lung biopsy, and management options for patients with such a clinical presentation.

Rapid Diagnosis of Infection in Critically Ill: Is Molecular Diagnosis the Magic Bullet?

e314 www.ccmjournal.org May 2016 • Volume 44 • Number 5 The authors reply: We thank Moorman et al (1) for their interest in our study (2) and their appreciation for the necessity of advance in evaluation of organ system network. We agree multidisciplinary collaborations with more sophisticated mathematical analysis will further develop our understanding for the complexity and dynamics of each organ system function in sepsis and that time-series evaluation of the organ system network is necessary for improvement of our clinical management of sepsis. As Moorman et al (1) pointed out, our study (2) demonstrated more disrupted organ system network in nonsurvivors just at the moment of ICU admission with the specific combination of representative variables. Certainly, a new analytical strategy incorporated with network physiology (3), which focuses on dynamical aspects of organ system network, will enable to identify disruption of network in sepsis with more sensitivity. We agree that real-time continuous monitoring can predict exacerbation of septic state before clinical symptoms appear and may tell us the optimal timing of certain therapeutic interventions. Godin and Buchman (4) indicated that inappropriate and excessive secretion of cytokines and inflammatory mediators, recognized as systemic inflammatory response syndrome, might provoke organ system network deterioration. In addition to sepsis, these changes in humeral mediators accompany with other critical conditions such as surgery, trauma, burn, and pancreatitis (5, 6). Even commonly performed medical interventions including mechanical organ support and blood transfusion may cause inflammatory response (7, 8). Thus, continuous monitoring of networked organ system interactions will have great merits for evaluation of critically ill patients. Further investigation incorporating multidisciplinary approach by intensive care medicine and network physiology is expected to provide more clear view of clinical course of illness and contribute to develop novel diagnostics and therapeutics in the fight against critical illnesses including sepsis. The authors have disclosed that they do not have any potential conflicts of interest.