Shalini Nair

Distribution of ABO and Rh-D blood groups among blood donors in a tertiary care centre in South India.

The distribution of ABO and Rh-D blood groups was studied among 150 536 blood donors screened at the Dr John Scudder Memorial Blood Bank, Christian Medical College Hospital, Vellore, over a period of 11 years (April 1988 to March 1999). The most common blood group was found to be group O [58 330 (38.75%)], followed by group B [49 202 (32.69%)], and group A [28 372 (18.85%)]. The least common blood group was AB group [7930 (5.27%)]. A2 or A2B groups were found in 3.01% and 1.43% of donors, respectively. The prevalence of Rh-D negative group was found in 8225 (5.47%) donors. Bombay group (H negative non-secretor, genotype hh phenotype Oh) was found in six donors (0.004%). Although the incidence of Rh-D negative group was identical to previously published data from North India, the most common blood group was O group in our study as opposed to B group.

Decompressive craniectomy in cerebral venous thrombosis: a single centre experience

Background Cerebral venous thrombosis (CVT) is an important cause for stroke in the young where the role for decompressive craniectomy is not well established. Objective To analyse the outcome of CVT patients treated with decompressive craniectomy. Methods Clinical and imaging features, preoperative findings and long-term outcome of patients with CVT who underwent decompressive craniectomy were analysed. Results Over 10 years (2002–2011), 44/587 (7.4%) patients with CVT underwent decompressive craniectomy. Diagnosis of CVT was based on magnetic resonance venography (MRV)/inferior vena cava (IVC). Decision for surgery was taken at admission in 19/44 (43%), within 12 h in 5/44 (11%), within first 48 h in 15/44 (34%) and beyond 48 h in 10/44 (22%). Presence of midline shift of ≥10 mm (p<0.0009) and large infarct volume (mean 146.63 ml; SD 52.459, p<0.001) on the baseline scan influenced the decision for immediate surgery. Hemicraniectomy was done in 38/44 (86%) and bifrontal craniectomy in 6/44 (13.6%). Mortality was 9/44 (20%). On multivariate analysis (5% level of significance) age <40 years and surgery within 12 h significantly increased survival. Mean follow-up was 25.5 months (range 3–66 months), 26/35 (74%) had 1 year follow-up. Modified Rankin Scale (mRs) continued to improve even after 6 months with 27/35 (77%) of survivors achieving mRs of ≤2. Conclusions This is the largest series on decompressive craniectomy for CVT in literature to date. Decompressive craniotomy should be considered as a treatment option in large venous infarcts. Very good outcomes can be expected especially if done early and in those below 40 years.

Role of quantitative endotracheal aspirate and cultures as a surveillance and diagnostic tool for ventilator associated pneumonia: a pilot study.

BACKGROUND Accurate diagnosis and appropriate treatment of ventilator associated pneumonia (VAP) is crucial for good outcomes. Endotracheal suctioning is performed in ventilated patients as part of routine care and for tracheal toileting. AIM We evaluated if quantitative endotracheal aspirate (ETA) was a suitable alternative to bronchoalveolar lavage (BAL) for suspected VAP. In addition we assessed if surveillance ETA guided antibiotic selection for subsequent VAP. SETTING AND DESIGN Prospective study in the surgical intensive care unit (ICU) of a tertiary hospital in India. MATERIALS AND METHODS Two hundred consecutive patients with mean (standard deviation) APACHE II score of 12.3+/-5 and requiring mechanical ventilation beyond 48 hours underwent surveillance ETA cultures. A second ETA and BAL were performed if the patient developed features of VAP. The threshold for microbiological diagnosis of VAP was taken as 10 5 colony forming units/ml (cfu/ml) for ETA and 10 4 cfu/ml for BAL. STATISTICAL ANALYSIS The sensitivity and specificity of surveillance and concurrent ETA aspirate cultures were compared with BAL cultures. RESULTS VAP was suspected clinically and corroborated radiologically in 27/177 patients (15.3%). Although microbiological support for VAP was obtained by ETA in 19 patients, bronchoscopy was possible only in 13 patients, 8 of whom had isolates at significant threshold. Of the 16 organisms isolated from BAL, 11 were of significant threshold with 9/11 (82%) BAL isolates having a similar antibiogram to a concurrent ETA. Only one BAL isolate (9%), at significant threshold, was not isolated on a concurrent ETA. On the other hand just 6/11 BAL isolates (55%) had an identical antibiogram to surveillance ETA. BAL had 3 additional isolates (27%) at significant threshold not isolated on surveillance ETA. CONCLUSIONS Concurrent quantitative ETA could substitute BAL cultures for VAP. Surveillance ETA at 48 hours of ventilation does not appear to assist with antibiotic selection for a subsequent VAP.

Evaluation of pain following supratentorial craniotomy.

Background. Craniotomy is considered less painful than other surgical procedures and supratentorial surgeries are thought to be the least painful among them. We studied the intensity of pain in the postoperative period following a supratentorial craniotomy while using oral paracetamol as the sole analgesic. The effect of temporalis muscle incision on the intensity of pain was also studied. Methods. In a prospective study over 6 months, 43 patients with a pre-operative Glasgow coma scale (GCS) score 15/15, aged >16 years who underwent a supratentorial craniotomy and were admitted to neurosurgical ICU were included in the study. Patients with a postoperative GCS score of <15 on admission to the ICU were excluded from the study. All patients received oral paracetamol for pain relief. Postoperative pain scale was used in the first hour to assess pain objectively. Visual analogue scale was used thereafter to record pain at 8, 12, 24 and 48 h post-craniotomy. Patients were familiarised with these scales preoperatively. Postoperative pain scores were compared with preoperative scores using paired T test, whereas significance of temporalis muscle involvement in incision for increased post-craniotomy pain was evaluated using Fischers exact test. Results. Inadequate analgesia was complained of by 63% (n = 27) patients in the first 12 h postoperatively. However, severe pain was present only in 12% (n = 5) of patients. Incidence of pain decreased thereafter at 24 and 48 h. Twenty-seven percent (n = 12) patients were free of pain at all study periods. Fifty percent (n = 3) of patients who complained of significant pain beyond 12 h developed postoperative complications. Incision of temporalis muscle was not associated with a significant increase in severity of postoperative pain. Conclusion. Pain following craniotomy is adequately addressed in only about 27% of patients with oral paracetamol. However, the long-term analgesic effect is satisfactory. Persistence of pain of moderate or severe intensity 24 h after a craniotomy could suggest an impending postoperative complication.

Underlying prothrombotic states in pregnancy associated cerebral venous thrombosis

BACKGROUND The exact pathogenesis of pregnancy associated cerebral venous thrombois is still unsettled. Aims : To identify possible inherited and acquired prothrombotic risk factors and also identify the factors associated with mortality in pregnancy associated CVT. SETTINGS AND DESIGN Prospective cohort study to identify prothrombotic risk factors and case control study of influence of local traditional practice of puerperal water restriction on postpartum CVT. MATERIALS AND METHODS Consecutive patients with pregnancy associated CVT seen over a period of three years. Thrombotic workup included genetic markers, protein assays, and other factors. STATISTICAL ANALYSIS Univariate and chi-square analysis. RESULTS Of the 41 patients studied during the study period, 71% of patient had a single and 34% had multiple prothrombotic risk factors. Methylene tetrahydro-folate reductase (MTHFR) heterozygosity (19.5%) and factor V Leiden heterozygous (7.3%) were the commonest genetic markers. Hyperhomocysteinemia (34%) and elevated factor VIII levels (14.6%) were the other important risk factors. In this cohort the mortality was 17%. Mortality increased by odds of 1.3 for every additional prothrombotic marker. The factors associated with increased mortality included: status epileptics (P = 0.05, OR 13.2, 95% CI 1.002 - 173), deep venous system involvement (P = 0.016, OR 9.64, 95% CI 1.53 - 60.6), presence of midline shift (P = 0.012, OR 24.7, 95% CI 2.05 - 29.8) and diffuse cerebral edema (P = 0.006, OR 14.5, 95% CI 2.18- 96.4). The traditional practice of decrease intake of water during puerperium was significant in woman with pregnancy associated CVT when compared to control subjects (P < 0.02). CONCLUSION In patients with pregnancy associated CVT, prothrombotic markers can be multiple and are associated with increased odds of mortality. Deep venous system involvement, presence of midline shift and diffuse cerebral edema increased mortality. Peuperial water restriction may be a modifiable risk factor.

Pulmonary Distress Following Attempted Suicidal Hanging

OBJECTIVE To assess the incidence of post-hanging pulmonary distress in cases of attempted suicidal hanging and predictors of outcome among these patients. DESIGN Five-year retrospective analysis. SETTING Tertiary care center in south India. PATIENTS A total of 335 patients who attempted suicidal hanging, aged above 16 years, were admitted during this period. Thirty-eight of them with pulmonary distress established clinically and with radiological evidence of pulmonary injury post hanging met the inclusion criteria. MEASUREMENTS Data from ICU records of 5 years, X-rays and laboratory investigations were reviewed. In patients identified to have post-hanging pulmonary distress, the neurological status, chest x-rays, arterial blood gas values and outcome data were collected and analyzed. RESULTS Eleven percent (n = 38) of the 335 patients admitted following attempted suicidal hanging were diagnosed to have post-hanging pulmonary distress. The overall mortality among post-hanging patients was 5%, which increased to 34.2% (n = 13) in the presence of pulmonary distress (P < or = 0.001). Among the prognostic factors evaluated, a PaO 2 / FiO 2 (P/F) ratio of < 100 at admission predicted a poor outcome (P < or = 0.001). CONCLUSION Post-hanging pulmonary distress is a relatively common complication of hanging and is associated with increased mortality. P/F ratio from arterial blood gas at admission was the only significant predictor of outcome in this group of patients.

Clinicopathological correlates of primary central nervous system lymphoma: experience from a tertiary care center in South India.

BACKGROUND Primary central nervous system lymphomas (PCNSL) constitute a rare group of extranodal non-Hodgkins lymphomas (NHLs). AIM To study the clinical and immunophenotypic profile of patients with a PCNSL who presented between the years 2000 and 2013 in a tertiary care center in South India. MATERIALS AND METHODS This was a retrospective study. Demographic and clinical data were obtained from the clinical case records. INCLUSION CRITERIA Cases of PCNSL involving brain. EXCLUSION CRITERIA Cases of PCNSL involving the spinal cord, meninges and orbit as well as intravascular large B-cell lymphoma, lymphomas with evidence of systemic disease or secondary lymphomas. Archived slides and tissue blocks were retrieved. All cases had hematoxylin and eosin stained sections and immunohistochemistry for CD20, CD3, and MIB-1. Additional immunohistochemistry was performed for CD10, BCL6, and MUM1 on paraffin blocks with sufficient tissue. RESULTS There were a total of 73 cases with the mean age of presentation being 45.9 years (range 8-71 years) and with a male predominance (male: female (M:F) = 2.3:1). Headache was the commonest presenting complaint. The mean duration of symptoms was 10.6 weeks. All patients were immunocompetent. Most tumors were supratentorial in location. Out of 73 cases, 70 presented with a diffuse large B-cell lymphoma (DLBCL), two with a Burkitts lymphoma, and one with a lymphomatoid granulomatosis. Only 51 of the DLBCL cases had sufficient tissue for additional studies. Non-germinal center was the most common phenotype seen in 65.7% (33/51) of cases. Germinal center B-cell (GCB) phenotype was seen in 18/51 cases (34.3%). CONCLUSION DLBCL constituted the majority of PCNSLs and although non-germinal center was the predominant phenotype, more than a third of the cases were of the GCB phenotype. As the germinal center phenotype is known to have a better prognosis, further studies to explore its relevance in the Asian population are indicated.

Hyponatremia in Traumatic Brain Injury: A Practical Management Protocol

BACKGROUND Hyponatremia (defined as serum sodium <135 mEq/L) is the most common electrolyte abnormality in traumatic brain injury (TBI) and is also an independent predictor of poor neurologic outcome. The reported incidence of hyponatremia varies widely in literature reports, and there is continuing difficulty in clearly differentiating between the 2 common causes of hyponatremia with natriuresis: the syndrome of inappropriate antidiuretic hormone secretion (SIADH) and cerebral salt wasting (CSW). We encounter hyponatremia frequently in our practice, and we therefore decided to review data from our center to estimate the incidence of hyponatremia and the results of our management strategies, and attempt to formulate simple guidelines for the correction of hyponatremia in TBI. METHODS A retrospective analysis of 1500 consecutively admitted patients with TBI was performed by the use of electronic records and radiographic review. Hyponatremia was defined as serum sodium <135 mEq/L, and natriuresis as a urine spot sodium of more than >40 mEq/L. The incidence of TBI, its management, and the effect of fludrocortisone were evaluated. RESULTS The incidence of hyponatremia was 13.2%. Early therapy with fludrocortisone significantly reduced the duration of hospital stay (P < 0.05). Traumatic subarachnoid hemorrhage was the most common abnormality on the admission computed tomographic scan in patients who experienced hyponatremia. CONCLUSION Early initiation of fludrocortisone in the setting of hyponatremia with natriuresis decreases the hospital stay. This protocol is probably safer in a tropical country where fluid restriction might be harmful. It also eliminates the need to differentiate between SIADH and CSW.

Importance of fibrinogen in dilutional coagulopathy after neurosurgical procedures: A descriptive study

Background and Aims : The routine management of coagulopathy during surgery involves assessing haemoglobin, prothrombin time (PT), activated partial thromboplastin time (aPTT) and platelets. Correction of these parameters involves administration of blood, fresh frozen plasma and platelet concentrates. The study was aimed at identifying the most common coagulation abnormality during neurosurgical procedures and the treatment of dilutional coagulopathy with blood components. Methods : During 2 years period, all adult patients undergoing neurosurgical procedures who were transfused two or more units of red cells were prospectively evaluated for the presence of a coagulopathy. PT, aPTT, platelet count and fibrinogen levels were estimated before starting a component therapy. Results : After assessing PT, aPTT, platelet count and fibrinogen levels following two or more blood transfusions, thirty patients were found to have at least one abnormal parameter that required administration of a blood product. The most common abnormality was a low fibrinogen level, seen in 26 patients; this was the only abnormality in three patients. No patient was found to have an abnormal PT or aPTT without either the fibrinogen concentration or platelet count or both being low. Conclusion : Low fibrinogen concentration was the most common coagulation abnormality found after blood transfusions for neurosurgical procedures.

An unusual toxicity with beta blocker and calcium channel blocker.

The increasing use of beta and calcium channel blockers for management of cardiac comorbidities has led to more frequent complications in the postoperative period. Anesthetic interaction with these drugs can lead to delayed manifestations of features of toxicity, even when administered in therapeutic doses. We report a case with an uneventful intraoperative period but profound bradycardia and hypotension postoperatively, only relieved with high-dose insulin therapy.