Surya Kumar Dube

Comparison of propofol versus sevoflurane on thermoregulation in patients undergoing transsphenoidal pituitary surgery: A preliminary study

Purpose: General anesthesia causes inhibition of thermoregulatory mechanisms. Propofol has been reported to cause more temperature fall, but in case of deliberate mild hypothermia, both sevoflurane and propofol were comparable. Thermoregulation is found to be disturbed in cases of pituitary tumors. We aimed to investigate which of the two agents, sevoflurane or propofol, results in better preservation of thermoregulation in patients undergoing transsphenoidal excision of pituitary tumors. Methods: Twenty-six patients scheduled to undergo transsphenoidal removal of pituitary adenomas were randomly allocated to receive propofol or sevoflurane anesthesia. Baseline esophageal temperature was noted. Times for temperature to fall by 1°C or 35°C and to return to baseline were also comparable (P>0.05). After that warmer was started at 43°C and time to rise to baseline was noted. Duration of surgery, total blood loss, and total fluid intake were also noted. If any, side effects such as delayed arousal and recovery from muscle relaxant were noted. Results: The demographics of the patients were comparable. Duration of surgery and total blood loss were comparable in the two groups. The time for temperature to fall by 1°C or 35°C and time to return to baseline was also comparable (P>0.05). No side effects related to body temperature were noted. Conclusion: Both propofol and sevoflurane show similar effects in maintaining thermal homeostasis in patients undergoing transsphenoidal pituitary surgery.

Causes of tracheal re-intubation after craniotomy: A prospective study

Background: Re-intubation of neurosurgical patients after a successful tracheal extubation in the operating room is not uncommon. However, no prospective study has ever addressed this concern. This study was aimed at analyzing various risk factors of re-intubation and its effect on patient outcome. Methods: Patients aged between 18-60 yrs and of ASA physical status I and II undergoing elective craniotomies over a period of two yrs were included. A standard anesthetic technique using propofol, fentanyl, rocuronium, and isoflurane/sevoflurane was followed, in all these patients. ‘Re-intubation’ was defined as the necessity of tracheal intubation within 72 hrs of a planned extubation. Data were collected and analyzed employing standard statistical methods. Results: One thousand eight hundred and fifty patients underwent elective craniotomy, of which 920 were included in this study. A total of 45 (4.9%) patients required re-intubation. Mean anesthesia duration and time of re-intubation were 6.3±1.8 and 24.6±21.9 hrs, respectively. The causes of re-intubation were neurological deterioration (55.6%), respiratory distress (22.2%), unmanageable respiratory secretion (13.3%), and seizures (8.9%). The most common post-operative radiological (CT scan) finding was residual tumor and edema (68.9%). Seventy-three percent of the re-intubated patients had satisfactory post-operative cough-reflex. The ICU and hospital stay, and Glasgow outcome scale at discharge were not significantly affected by different causes of re-intubation. Conclusion: Neurological deterioration is the most common cause of re-intubation following elective craniotomies owing to residual tumor and surrounding edema. A satisfactory cough reflex may not prevent subsequent re-intubation in post-craniotomy patients.

Anaphylaxis to artesunate

Artesunate, an artemissin derivative is a highly efficacious and relatively safe antimalarial agent. Common adverse reactions to artemissin derivatives are nausea, vomiting, anorexia and dizziness. More serious but less-frequent toxic effects of artesunate use are neutropenia, anemia, hemolysis, elevated liver enzymes and severe allergic reactions. However, anaphylactic reaction to artesunate is a rare entity. Here, we report a case of anaphylaxis to parenteral artesunate and its successful management in a female patient to whom intravenous artesunate was administered during surgery under general anesthesia.

Comparison of intraoperative brain condition, hemodynamics and postoperative recovery between desflurane and sevoflurane in patients undergoing supratentorial craniotomy

Background: Post operative recovery has been reported to be faster with desflurane than sevoflurane anesthesia in previous studies. The use of desflurane is often criticized in neurosurgery due to the concerns of cerebral vasodilation and increase in ICP and studies comparing desflurane and sevoflurane in neurosurgey are scarce. So we compared the intraoperative brain condition, hemodynamics and postoperative recovery in patients undergoing elective supratentorial craniotomy receiving either desflurane or sevoflurane. Materials and Methods: Fifty three patients between 18-60yr undergoing elective supratentorial craniotomy receiving N 2 O and oxygen (60%:40%) and 0.8-1.2 MAC of either desflurane or sevoflurane were randomized to group S (Sevoflurane) or group D (Desflurane). Subdural intra cranial pressure (ICP) was measured and brain condition was assessed.. Emergence time, tracheal extubation time and recovery time were recorded. Cognitive behavior was evaluated with Short Orientation Memory Concentration Test (SOMCT) and neurological outcome (at the time of discharge) was assessed using Glasgow Outcome Score (GOS) between the two groups. Results: The emergence time [Group D 7.4 ± 2.7 minutes vs. Group S 7.8 ± 3.7 minutes; P = 0.65], extubation time [Group D 11.8 ± 2.8 minutes vs. Group S 12.9 ± 4.9 minutes; P = 0.28] and recovery time [Group D 16.4 ± 2.6 minutes vs. Group S 17.1 ± 4.8 minutes; P = 0.50] were comparable between the two groups. There was no difference in ICP [Group D; 9.1 ± 4.3 mmHg vs. Group S; 10.9 ± 4.2 mmHg; P = 0.14] and brain condition between the two groups. Both groups had similar post-operative complications, hospital and ICU stay and GOS. Conclusion: In patients undergoing elective supratentorial craniotomy both sevoflurane and desflurane had similar intra-operative brain condition, hemodynamics and post operative recovery profile.

Tension pneumoventricle after excision of third ventricular tumor in sitting position

Occurrence of tension pneumoventricle (symptomatic intraventricular air) can result in rapid clinical deterioration in an otherwise stable patient. It is a rare clinical entity, mentioned in relation to cerebrospinal fluid (CSF) diversion procedures, during the late postoperative period. We present a patient with posterior third ventricular tumor who underwent excision by midline suboccipital craniotomy in sitting position. Neurological status of the patient deteriorated rapidly in the immediate postoperative period owing to development of tension pneumoventricle. The condition improved after twist-drill burr-hole evacuation of air under water-seal. Pre-existing gross hydrocephalus, exploration of third ventricle in sitting position, and residual tumor in third ventricle were possibly the factors responsible for this complication.

Comparison of four different methods for detection of biofilm formation by uropathogens.

Context: Urinary tract infection (UTI) is one of the most common infectious diseases encountered in clinical practice. Emerging resistance of the uropathogens to the antimicrobial agents due to biofilm formation is a matter of concern while treating symptomatic UTI. However, studies comparing different methods for detection of biofilm by uropathogens are scarce. Aims: To compare four different methods for detection of biofilm formation by uropathogens. Settings and Design: Prospective observational study conducted in a tertiary care hospital. Materials and Methods: Totally 300 isolates from urinary samples were analyzed for biofilm formation by four methods, that is, tissue culture plate (TCP) method, tube method (TM), Congo Red Agar (CRA) method and modified CRA (MCRA) method. Statistical Analysis: Chi-square test was applied when two or more set of variables were compared. P < 0.05 considered as statistically significant. Considering TCP to be a gold standard method for our study we calculated other statistical parameters. Results: The rate of biofilm detection was 45.6%, 39.3% and 11% each by TCP, TM, CRA and MCRA methods, respectively. The difference between TCP and only CRA/MCRA was significant, but not that between TCP and TM. There was no difference in the rate of biofilm detection between CRA and MCRA in other isolates, but MCRA is superior to CRA for detection of the staphylococcal biofilm formation. Conclusions: TCP method is the ideal method for detection of bacterial biofilm formation by uropathogens. MCRA method is superior only to CRA for detection of staphylococcal biofilm formation.

A simple technique to avoid difficulty in guide wire insertion during pediatric central venous cannulation.

Use of USG is now considered as a standard of care for IJV cannulation.[1] Real-time US guidance has been shown to improve the technical effi ciency and effi cacy of internal jugular venous and has also decreased the frequency of procedure related complications.[2] We agree that use of USG has advantage in terms of identifi cation of the local anatomy, but our problem of displacement of introducer needle persisted in spite of use of USG. So we used the IC to deal with the problem. However, there are two problems with our techniques. First, there is chance of distortion of the IVC sheath during guide wire insertion which can cause extra-vascular migration of the IC sheath (especially during use of smaller IC) and secondly, there is chance of injury to the surrounding structures during introduction of straight end of the guide wire. However, the advancement of sheath of IC completely into the central vein will prevent the distortion and/or extra-vascular migration of the IVC sheath[3] and we introduced the guide wire very gently keeping a close watch on ECG so as to avoid injury to the surrounding structures during guide wire insertion. Our report highlights a common problem encountered during USG guided pediatric IJV cannulation and a simple technique to deal with it.

Metabolic alkalosis: A less appreciated side effect of Imipenem-cilastatin use

Acinetobacter baumannii is a common nosocomial pathogen in our intensive care unit (ICU) for which we use imipenem-cilastatin as the fi rst line antimicrobial agent. Our fi rst patient was a 29-year-old male having cervical spinal cord injury and the second patient was a 37-year-old male having blunt trauma chest. Both of the patients required prolonged mechanical ventilation and eventually had A. baumannii-associated pneumonia which was treated with imipenem-cilastatin. Both of our patients showed clinical improvement with the treatment, but during the treatment both had persistent metabolic alkalosis (after 3 and 4 days of therapy in patient 1 and 2, respectively). There were no signs and/or symptoms of cardiovascular, hepatic or renal abnormality in any of the patient and their serum cortisol, potassium, calcium, and magnesium levels were within normal limits. The urinary chloride levels were 33 mEq/L and 41 mEq/L in patient 1 and 2, respectively. Apart from antimicrobial agents both of the patients were receiving enteral nutrition and multivitamin supplements only and none received any alkaline solution or massive blood transfusions.

Use of the pro-seal laryngeal mask airway facilitates percutaneous dilatational tracheostomy in an intensive care unit.

Purpose: To study the feasibility of using the pro-seal laryngeal mask airway (LMA) for airway maintenance during bronchoscopic-guided percutaneous tracheostomy. Materials and Methods: Observational study of 60 patients in a 16-bed intensive care unit. The patient’s tracheal tube was exchanged for a pro-seal LMA before undertaking percutaneous tracheostomy. Results: Inspiratory pressure and tidal volumes achieved during the procedure were recorded. The median peak inspiratory pressure was 25 (standard deviation 4.4) cm H2O. There was no loss of tidal volume in 30 patients, a loss of less than 100 mL/breath in 27, and loss of more than 100 mL in 3 patients. A pro-seal LMA successfully maintained the airway and allowed adequate ventilation during per-cutaneous tracheostomy in all 60 patients. In all patients, fiber optic bronchoscopy through the pro-seal LMA provided a clear view of the cords and trachea and there was no laryngeal or tracheal soiling at any stage of the procedure. Conclusion: The pro-seal LMA provides a reliable airway and allows effective ventilation during percutaneous tracheostomy. The passage of a fiberscope through the pro-seal LMA and glottis is easy and provides a clear view of the upper trachea.

Perioperative problems in patients with brainstem tumors and their influence on patient outcome

Background and Aims: Patients with brainstem tumors have many associated systemic abnormalities and are prone to develop perioperative complications. We studied the problems associated with brainstem tumors and their influence on the postoperative neurological outcome. Material and Methods: Retrospective review of records of patients who underwent surgery for brainstem tumors over a period of 8 years was done. Preoperative variables, perioperative complications and neurological outcome as assessed by Glasgow Outcome Scale at the time of hospital discharge were noted. Association between perioperative factors and the unfavorable neurological outcome was evaluated. Results: Data of 70 patients were retrieved, 7 patients were excluded from the study because of incomplete data and data analysis was carried out for 63 patients. We found that lower cranial nerve palsies (32%) and hydrocephalus (43%) were common preoperatively. Various intraoperative problems encountered were hemodynamic instability (56%), major blood loss requiring blood transfusion (40%) and venous air embolism (11%), and postoperative problems were meningitis (51%), hypokalemia (38%), chest infection (21%), seizure (11%), deterioration of Glasgow Coma Scale (GCS, 11%), hyponatremia (8%), hydrocephalus (6%), respiratory distress (3%) and operatives site hematoma (3%). Fifty-six (89%) patients had favorable outcome at hospital discharge whereas, 7 (11%) had an unfavorable outcome. There was no association between pre- and intra-operative factors and the neurological outcome. Deterioration of GCS, chest infection, and the need for reintubation and tracheostomy were associated with unfavorable neurological outcome. Conclusion: Patients of brainstem tumors are at increased risk of perioperative complications. Some of the postoperative complications were associated with unfavorable neurological outcome.