Sujay Samanta

Pneumothorax following flexible fiberoptic bronchoscopy: A rare occurrence.

Sir, Pneumothorax following flexible fibreoptic bronhoscopy is rare. It occurs 1 in 450 bronchoscopy.[1] We report a case of such event in a trauma victim. A 34-year-old male patient with alleged history of road traffic accident admitted in our trauma center. On initial examination, his airway was patent, he was breathing at the rate of 22 breaths/min with air entry diminished over the right lung. Initial hemodynamics were stable with heart rate of 96 beats/min and blood pressure of 126/88 mmHg. Contrast-enhanced computed tomography scan chest revealed the fracture of 1st, 2nd, 3rd, and 7th ribs on the right side with hemopneumothorax and multifocal contusions in all lobes of the right lung. A right-sided intercostal tube drain (ICD) was placed. Pneumothorax and hemothorax resolved subsequently. He was shifted to the general ward. After 4 days of admission, patient developed acute respiratory distress with fall in oxygen saturation (90%) and was transferred to trauma intensive care unit (ICU). On initial evaluation, his chest X-ray showed [Figure 1] right lung collapsed with mediastinal shift toward the right side. A flexible bronchoscopy was contemplated in view of provisional diagnosis of mucus plug obstructing the major airways. A flexible bronchoscopy was carried out and a large mucus plug was aspirated from the right bronchus thereby clearing the airway. The patient was kept on positive pressure ventilation after the procedure. Immediately following the flexible bronchoscopy a large air leak became apparent in right-sided ICD. A follow-up chest X-ray showed a new large pneumothorax and collapse whole lung [Figure 2]. Ventilatory settings were adjusted to minimize the leak and the ICD was connected to negative pressure of 15 mmHg. A second ICD was inserted in order to control the leak and expand the lung. After 2 days, air leak controlled and lung got expanded. Patient was shifted to high dependency unit for further care. Figure 1 Chest X-ray showed collapsed right lung with mediastinal shift toward the right side Figure 2 Chest X-ray demonstrated a new large pneumothorax and collapse of whole the right lung Flexible fiberoptic bronchoscopy is a safe procedure carried out in patients admitted to ICUs. Its indication varies between diagnostic to therapeutic interventions including regular bronchoalveolar lavage for microbiological sampling, diagnosis of pulmonary hemorrhage, use in cases of difficult intubation, as a control in percutaneous tracheostomies, and aspirations of secretions.[2] Its use in clearing the airway because of mucus plug is considered as a standard practice particularly in patients where physiotherapy has failed to do so. However, its complications are infrequent. Most frequent complications cited in the literature are supraventricular tachycardia (3.8%), transient hypoxemia (6.7%), and slight bleeding of the bronchial mucosal membrane (2.4%).[2] Pneumothorax following flexible bronchoscopy has been reported infrequently in literature. Pue et al. have reported pneumothorax following flexible bronchoscopy in 0.16% of cases. Predominantly, it followed transbronchial biopsy procedure.[3] de Blic et al. analyzed prospectively in 1328 flexible bronchoscopy procedures in children and noted 0.1% incidence of pneumothorax.[4] In both the above analysis, none has reported pneumothorax following aspiration of secretion or mucus plug in case of chest injury following trauma. Moreover, flexible fiberoptic bronchoscopy was used here as a diagnostic modality to identify the cause of persistent pneumothorax and bronchial injuries. Mechanism that might have led to pneumothorax in our patient can be attributed to initial lung injury. Probably, the mucus plug had sealed the existent bronchial rent underlying lacerated lung and corrected the initial hemopneumothorax. As soon as the mucus plug got aspirated during flexible bronchoscopy the lung laceration got expose to high airway pressures and caused escaping of air into the pleural cavity. To conclude, although flexible bronchoscopy is a safe procedure, it mandates close monitoring during and after the procedure. It is important to have a high index of suspicion and a follow-up chest X-ray to identify a potentially dangerous complication.

A unique anesthesia approach for carotid endarterectomy: Combination of general and regional anesthesia.

Carotid endarterectomy (CEA), a preventable surgery, reduces the future risks of cerebrovascular stroWke in patients with marked carotid stenosis. Peri-operative management of such patients is challenging due to associated major co-morbidities and high incidence of peri-operative stroke and myocardial infarction. Both general anesthesia (GA) and local regional anesthesia (LRA) can be used with their pros and cons. Most developing countries as well as some developed countries usually perform CEA under GA because of technical easiness. LRA usually comprises superficial, intermediate, deep cervical plexus block or a combination of these techniques. Deep block, particularly, is technically difficult and more complicated, whereas intermediate plexus block is technically easy and equally effective. We did CEA under a combination of GA and LRA using ropivacaine 0.375% with 1 mcg/kg dexmedetomidine (DEX) infiltration. In LRA, we gave combined superficial and intermediate cervical plexus block with infiltration at the incision site and along the lower border of mandible. We observed better hemodynamics in intraoperative as well as postoperative periods and an improved postoperative outcome of the patient. So, we concluded that combination of GA and LRA is a good anesthetic technique for CEA. Larger randomized prospective trials are needed to support our conclusion.

Recurrent central venous malposition caused by severe lower airway distortion.

Correct placement of central venous catheter (CVC) should be confirmed radiologically before using it. It is always a challenge to place CVC at a right anatomical position. Malposition of CVC varies widely, ranging from less than 1% to more than 60% [1]. Cannulation by the right subclavian vein is associated with the highest risk of malposition of approximately 9.1%, most commonly in the ipsilateral internal jugular vein [2]. We had encountered a case where we failed to insert the catheter through the right internal jugular vein, and it went into ipsilateral internal jugular vein when cannulation tried by the right subclavian vein. All our measures to correct the malposition of CVC failed probably because of distortion by severe airway deformity. We wish to report such a malposition of CVC caused by severe tracheobronchial deformity after obtaining consent from the patient. A 56-year-old male patient who was a known smoker for the last 20 years presented in our emergency department with fever and shortness of breath. He also was diagnosed to have chronic obstructive pulmonary disease and chronic kidney disease (without any dialysis) since the last 10 years. His history revealed pulmonary tuberculosis 15 years back and received antitubercular therapy for 6 months. On examination, he was conscious but slightly tachypnic (respiratory rate, 25 breaths/min), with pulse oxymetry showing 96% on oxygen by venturi mask (40%). His blood pressure was 86/48 mm Hg on noninvasive measurement with heart rate of 120 beats/min, even after fluid resuscitation with 1 L of normal saline. Coagulation profile was within normal limits. We decided to put CVC through right internal jugular vein, but we failed to insert the guidewire beyond 10 cm only after 2 to 3 attempts with the help of ultrasound. Then we changed the approach through right subclavian vein, and we were able to insert the CVC. However, post-CVC radiology showed catheter in ipsilateral internal jugular vein. His chest x-ray also showed severe tracheobronchial deformity toward the right side, with changes suggestive of chronic bronchitis and old tuberculosis (Fig.). Then we tried to readjust the catheter with the help of guidewire toward the right atrium while occluding the right internal jugular vein manually at the same time. Again, we failed thrice, each time the catheter was going only toward the right internal jugular vein as confirmed by

Postpartum pulmonary edema in twin parturient: beyond the fluids

Pulmonary edema (PE) after postpartum hemorrhage (PPH) resuscitation is mainly due to fluid overload or transfusion-related acute lung injury. Here we present the case of a 30-year-old primigravida having uncomplicated twin pregnancy. She developed PPH and PE simultaneously during the early postpartum period. Chest radiography was inconclusive to exclude fluid overload. Echocardiography and lung ultrasound ruled out volume overload. PE could be due to adverse effects of drugs, or negative pressure from laryngospasm originating from incisional pain during uterine manipulation. Caution should be exercised while administering methylergometrine or carboprost for atonic PPH, with continued vigilance for detection of signs of PE, especially in high-risk pregnancy. Moreover, the risk versus benefit ratio should be considered for performing abdominal uterine massage as it may be more harmful than beneficial in such subset of patients.

Emphysematous pancreatitis predisposed by Olanzapine.

A 32-year-old male presented to our intensive care unit with severe abdominal pain and was diagnosed as acute pancreatitis after 2 months of olanzapine therapy for bipolar disorder. His serum lipase was 900 u/L, serum triglyceride 560 mg/dL, and blood sugar, fasting and postprandial were 230 and 478 mg/dL, respectively on admission. Contrast enhanced computed tomography (CECT) of abdomen was suggestive of acute pancreatitis. Repeat CECT showed gas inside pancreas and collection in peripancreatic area and patient underwent percutaneous drainage and antibiotics irrigation through the drain into pancreas. We describe the rare case of emphysematous pancreatitis due to development of diabetes, hypertriglyceridemia and immunosuppression predisposed by short duration olanzapine therapy.

Maternal and foetal outcome after epidural labour analgesia in high-risk pregnancies.

Background and Aims: Low concentration local anaesthetic improves uteroplacental blood flow in antenatal period and during labour in preeclampsia. We compared neonatal outcome after epidural ropivacaine plus fentanyl with intramuscular tramadol analgesia during labour in high-risk parturients with intrauterine growth restriction of mixed aetiology. Methods: Forty-eight parturients with sonographic evidence of foetal weight <1.5 kg were enrolled in this non-randomized, double-blinded prospective study. The epidural (E) group received 0.15% ropivacaine 10 ml with 30 μg fentanyl incremental bolus followed by 7–15 ml 0.1% ropivacaine with 2 μg/ml fentanyl in continuous infusion titrated until visual analogue scale was three. Tramadol (T) group received intramuscular tramadol 1 mg/kg as bolus as well as maintenance 4–6 hourly. Neonatal outcomes were measured with cord blood base deficit, pH, ionised calcium, sugar and Apgar score after delivery. Maternal satisfaction was also assessed by four point subjective score. Results: Baseline maternal demographics and neonatal birth weight were comparable. Neonatal cord blood pH, base deficit, sugar, and ionised calcium levels were significantly improved in the epidural group in comparison to the tramadol group. Maternal satisfaction (P = 0.0001) regarding labour analgesia in epidural group was expressed as excellent by 48%, good by 52% whereas it was fair in 75% and poor in 25% in the tramadol group. Better haemodynamic and pain scores were reported in the epidural group. Conclusion: Epidural labour analgesia with low concentration local anaesthetic is associated with less neonatal cord blood acidaemia, better sugar and ionised calcium levels. The analgesic efficacy and maternal satisfaction are also better with epidural labour analgesia.

Sustained Ventricular Tachycardia after Electroconvulsive Therapy: Can it be Prevented?

Electroconvulsive therapy (ECT) is an important nonpharmacological intervention effective as treatment for patients suffering from certain severe neuropsychiatric disorders. Various cardiological side effects such as conduction abnormalities, especially asystole have been reported during or after ECT.[1] Ventricular tachycardia arising as a side effect of ECT has been seldom reported in the literature. Here we report such a case after obtaining consent from the relative.

Should intensivist do routine abdominal ultrasound

Roundworm infestation is common in tropical climate population with a low socioeconomic status. We describe a case of a young male with polytrauma accident who presented with small bowel dysfunction with a high gastric residual volume during enteral feeding. While searching the etiology, the intensivist performed bedside abdominal ultrasound (USG) as a part of whole body USG screening along with clinical examination using different frequency probes to examine bowel movement and ultimately found ascariasis to be the cause. This case report will boost up the wide use of bedside USG by critical care physicians in their patient workup.

Chest ultrasonography in emergency Cesarean delivery in multi-valvular heart disease with pulmonary edema during spinal anesthesia

Valvular heart disease in a parturient presenting for Cesarean section is challenging. A 25 year old primigravida parturient with severe mitral stenosis, mild mitral regurgitation, mild aortic regurgitation, and mild pulmonary arterial hypertension required Cesarean delivery after developing pulmonary edema. Low-dose spinal with hyperbaric bupivacine 0.5% 1.8 mL plus 25 μg of fentanyl was used for anesthesia. Chest ultrasonography (US) and transthoracic echocardiography (TTE) were used for monitoring purposes. Spinal-induced preload reduction improved the pulmonary edema, as evidenced by chest US. Chest US and TTE helped in fluid management.

Angiographic catheter as airway exchange device through laryngeal airway mask in unanticipated difficult airway in emergency department

Sir, Angiographic catheter (AC) is commonly used in intervention cardiology, but its application outside cardiac catheterization laboratory (CCL) is seldom reported. AC has been used for nasogastric tube insertion.[1] We used AC as an airway exchange catheter through ProSeal laryngeal airway mask (PLMA) in an unanticipated difficult airway in emergency department (ED). A 42-year-old man admitted at midnight to our ED with diagnosis of severe acute pancreatitis with respiratory failure with apparent normal airway. After preoxygenation rapid sequence intubation was tried with cricoid pressure but unable to intubate even after removal of cricoid pressure for a moment. Immediately airway was secured with size 4 PLMA. The patient needs definite airway for prolonged mechanical ventilation. But we did not have sophisticated airway gadgets in our resuscitation kit. Then we used a 9 Fr sterile AC (Medtronic, Minnesota, USA) with guide wire [Figure 1] lubricated with lignocaine 2% gelly as airway exchange catheter in airway port of PLMA [Figure 2] keeping suction catheter in gastric port. It passed smoothly into trachea and a tactile sensation was felt by keeping the palm on trachea. After 35 cm of insertion, PLMA was removed. Apnea oxygenation was supplied to the patient through the angiographic catheter after removing guide wire and an 8 mm internal diameter endotracheal tube (ET) was exchanged. ET confirmed with capnometry and 5-point chest auscultation. Figure 1 Angiographic catheter with guidewire Figure 2 Angiography catheter inside ProSeal laryngeal airway mask Repeated attempts of laryngoscopy for tracheal intubation in difficult airway are associated with decreased success, increase complications, and morbidities. Alternative airway devices like gum elastic bougies, rigid or flexible fiberoptic bronchoscope, intubating laryngeal mask airway (LMA), video laryngoscope, light wand, and cricothyroidotomy are very effective in this situation.[2]. Airway management in ED is often more difficult than operation theater due to unavailability of difficult airway gadgets, improper environment, and untrained medical stuff. As an intubation conduit LMA is used in different way like blind ET passage after proper LMA placement, using a premounted ET in LMA, bougie-aided intubation via LMA, light wand-aided intubation through LMA, fiberscope aided intubation via LMA, and so on. PLMA having narrower airway tube will not allow to pass larger ET, but absence of aperture bar allow smooth passage of AC. Above all, PLMAs have gastric drainage tube to reduced incidence of aspiration, prevent gastric insufflation, and allow ventilation with higher pressure as it was required in our patient. People used fiberoptic aided intubation through the LMA-Supreme using an Aintree Intubating Catheter (AIC) in manikin.[3] Cook et al.,[4] reported seven case of difficult intubation via PLMA using AIC. AIC are long length, atraumatic, ability to oxygenate, and ventilate during exchange process. But the guidewire in it is too thin and soft for support. We used sterilized AC with atramatic guide wire which have same function as AIC but minimum cost and easily available from CCL. This AC was previously used for angiography but sterilized with 2% glutaraldehyde for 10 min before use in this patient.[5] In conclusion, emergency resuscitation and airway kit must contain classic LMA and LMA for rescue ventilation and oxygenation, while a resterilized AC can also be a useful gadget in difficult airway situation with limited resource.