Sukhen Samanta

Emergency caesarean delivery in a patient with cerebral malaria-leptospira co infection: Anaesthetic and critical care considerations

Malaria-leptospira co-infection is rarely detected. Emergency surgery in such patients has not been reported. We describe such a case of a 24-year-old primigravida at term pregnancy posted for emergency caesarean delivery who developed pulmonary haemorrhage, acute respiratory distress syndrome, acute kidney injury, and cerebral oedema. Here, we discuss the perioperative management, pain management (with transverse abdominis plane block), intensive care management (special reference to management of pulmonary haemorrhage with intra pulmonary factor VIIa) and the role of plasmapheresis in leptospira related jaundice with renal failure.

Cardiopulmonary resuscitation in undiagnosed situs inversus totalis in emergency department: An intensivist challenge.

Situs inversus totalis is a rare congenital condition. A 34-year-old woman with undiagnosed situs inversus was referred to our emergency department with cardiac arrested state. She underwent cardiopulmonary resuscitation (CPR) and defibrillation with a modified approach. We faced different challenging aspects during intensive care management. Ultrasonography in CPR in our patient was very helpful. We restricted our discussion on special aspect of SIT in emergency and intensive care unit.

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

Unexpected tracheal tube blockage from a semi-dissolved misoprostol tablet

Fig. 1 Distal end of the tracheal tube blocked by a misoprostol tablet through the PLMA. Anaesthesia was maintained with nitrous oxide and isoflurane in 50% oxygen and surgery commenced. The baby was delivered within 5 min, after which intravenous fentanyl and atracurium were given. Umbilical cord blood gases and Apgar scores were satisfactory. A paediatric 3.5 mm fibreoptic bronchoscope was passed through the PLMA and showed the airway was clear of foreign bodies. Maternal perioperative blood gases were satisfactory. After completion of surgery, residual neuromuscular block was reversed and the PLMA was removed after awakening the patient. She was monitored closely for signs of aspiration for the next 24 h and was discharged uneventfully on the fourth postoperative day. Subsequent review of the patient’s treatment chart showed that she had received a sublingual tablet of misoprostol 30 min before anaesthesia induction. The patient in her distressed state had not disclosed its presence. Two previous reports have implicated oral medications in tracheal tube obstruction. Misoprostol is a synthetic prostaglandin E1 analogue used for cervical ripening. Although it can be administered vaginally and orally, the sublingual route avoids vaginal examination, the need for fluid intake and results in higher bioavailability by avoiding hepatic first pass metabolism. Being water soluble, it usually dissolves under the tongue in about 15–20 min. In our patient, we believe that the stress of labour resulted in a dry oral cavity, preventing the tablet from dissolving and then sticking to the underside of the tongue. It was therefore missed during airway examination. We postulate that tongue deflection during laryngoscopy led to its displacement into the pharynx and during attempts at intubation it lodged inside the lumen of the tracheal tube, obstructing ventilation. We recommend specific enquiry about intake of oral or sublingual drugs and their presence in the oral cavity before induction of anaesthesia and would emphasize the importance of meticulous examination of the airway. In obstetric patients, difficulty with tracheal intubation has an incidence of approximately 1 in 30. We report a case where a sublingual misoprostol tablet inadvertently blocked the lumen of a tracheal tube during intubation in a pregnant patient with an unexpected difficult airway. A 29-year-old, 65 kg, nulliparous woman at term presented for an urgent caesarean section for fetal distress following non-progressive labour. The patient was extremely distressed and airway assessment by the anaesthesia resident revealed adequate mouth opening and a Mallampati class III airway. The patient refused neuraxial anaesthesia, so general anaesthesia with a rapidsequence induction was performed using thiopental, succinylcholine and cricoid pressure. The first attempt at intubation failed because of an anteriorly-placed larynx (Cormack and Lehane grade 3). After another attempt using a stylet, the trachea was successfully intubated with a 7.0 mm internal diameter tracheal tube (Portex, Smiths Medical, Hythe, UK) with moderate difficulty. With cricoid pressure maintained, there was unusual resistance to bag ventilation associated with high peak airway pressures of 45–50 cmH2O. Breath sounds and capnographic trace were absent. A check of the breathing circuit revealed no malfunction. A 12 French suction catheter was passed through the lumen of the tube and resistance was encountered at around 30 cm. The tube was removed immediately with cricoid pressure maintained. When the tube was examined, a semi-dissolved tablet was occluding the lumen above the Murphy eye (Fig. 1). The patient started to desaturate (SpO2 <90%), so a size 4 ProSeal laryngeal mask airway (PLMA) was inserted with transient release of cricoid pressure. After optimizing ventilation and oxygenation, gastric drainage was performed using a suction catheter

Global left and right ventricular dysfunction after tranexamic acid administration in a polytrauma patient

305 Annals of Cardiac Anaesthesia  Vol. 16:4  Oct-Dec-2013 mitral valve obstruction mimicking symptoms of rheumatic heart disease,[4] while right‐sided myxomas, being extremely rare, may present with nonspecific signs and symptoms, including right heart failure secondary to right ventricular outflow tract obstruction.[5] Mitral valve myxomas may be localized to the anterior mitral leaflet, posterior mitral leaflet or mitral annulus. Usually the tumor is localized to the atrial side of the mitral valve.[3] The treatment of choice for myxomas is surgical removal. Surgical resection is mandatory, but there has been disagreement on the extent of resection. Simple excision of the tumor is considered adequate by some, while others favor radical approach to prevent local implantation and embolization. We did a radical excision of the tumor along with the anterior leaflet of the mitral valve and part of annulus. The patient is under close follow‐up to check for recurrence of myxoma.

Contemporary social network sites: Relevance in anesthesiology teaching, training, and research

Objective: The phenomenal popularity of social networking sites has been used globally by medical professionals to boost professional associations and scientific developments. They have tremendous potential to forge professional liaisons, generate employment,upgrading skills and publicizing scientific achievements. We highlight the role of social networking mediums in influencing teaching, training and research in anaesthesiology. Background: The growth of social networking sites have been prompted by the limitations of previous facilities in terms of ease of data and interface sharing and the amalgamation of audio visual aids on common platforms in the newer facilities. Review: Contemporary social networking sites like Facebook, Twitter, Tumblr,Linkedn etc and their respective features based on anaesthesiology training or practice have been discussed. A host of advantages which these sites confer are also discussed. Likewise the potential pitfalls and drawbacks of these facilities have also been addressed. Conclusion: Social networking sites have immense potential for development of training and research in Anaesthesiology. However responsible and cautious utilization is advocated.

Intractable Polyuria Mimicking Diabetes Insipidus-Source Traced to Vecuronium Infusion.

Continuous infusion of vecuronium is a commonly used technique for patients requiring prolonged neuromuscular blockade for mechanical ventilation. As compared with older neuromuscular blocking agents, it confers the advantages of rapid excretion and intermediate duration of action. Prolongation of neuromuscular blockade and muscle weakness are the known complications of continuous vecuronium infusion. This report attempts to describe polyuria, as a hitherto unknown complication of vecuronium infusion, which can occur due to the mannitol present in commercially available preparation of vecuronium bromide.

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.

Post-partum sequential occurrence of two diverse transfusion reactions (transfusion associated circulatory overload and transfusion related acute lung injury)

Transfusion associated circulatory overload (TACO) and transfusion related acute lung injury (TRALI) are two dissimilar pathological conditions associated with transfusion of blood products where the time course of the events and clinical presentation overlap leading to uncertainty in establishing the diagnosis and initiating the treatment, which otherwise differs. We encountered a case where a patient of post-partum hemorrhage developed TACO in the immediate post-operative period due to aggressive resuscitative attempts with blood products. The patients condition was appropriately diagnosed and was managed according to the clinical scenario, and the condition abated. Subsequently, on the third post-operative day the patient again required blood product transfusions following which the patient developed TRALI, the diagnosis of which was also established and adequate treatment strategy was undertaken.

Anesthesia for a patient of acromesomelic dysplasia with associated hydrocephalus, Arnold Chiari malformation and syringomyelia

Acromesomelic dysplasias are autosomal recessive osteochondrodysplasias. Acromesomelic dysplasia Maroteaux-type (AMDM), also known as St Helena dysplasia, is of two types: The classical and the mild variety. About 50 cases of AMDM have been reported till date, most of them being the classical variety. There is scarcity of literature on anesthesia for such patients. We are reporting a case of general anesthetic management of AMDM, associated with hydrocephalus, Arnold Chiari malformation type-1 and syringomyelia. The patient was a 10-year-old short-statured boy who presented with symptomatic thoracic kyphoscoliosis, gibbus deformity and back pain. On examination, there was no neurological deficit. Radiology revealed thoracic kyphoscoliosis, mild ventriculomegaly and upper cervical syringomyelia. The patient underwent posterior fossa decompression in the prone position under general anesthesia. We will discuss the anesthetic considerations for such patients and review the pertinent literature.