Vijaya Patil

Guidelines for prevention of hospital acquired infections

These guidelines, written for clinicians, contains evidence-based recommendations for the prevention of hospital acquired infections Hospital acquired infections are a major cause of mortality and morbidity and provide challenge to clinicians. Measures of infection control include identifying patients at risk of nosocomial infections, observing hand hygiene, following standard precautions to reduce transmission and strategies to reduce VAP, CR-BSI, CAUTI. Environmental factors and architectural lay out also need to be emphasized upon. Infection prevention in special subsets of patients - burns patients, include identifying sources of organism, identification of organisms, isolation if required, antibiotic prophylaxis to be used selectively, early removal of necrotic tissue, prevention of tetanus, early nutrition and surveillance. Immunodeficient and Transplant recipients are at a higher risk of opportunistic infections. The post tranplant timetable is divided into three time periods for determining risk of infections. Room ventilation, cleaning and decontamination, protective clothing with care regarding food requires special consideration. Monitoring and Surveillance are prioritized depending upon the needs. Designated infection control teams should supervise the process and help in collection and compilation of data. Antibiotic Stewardship Recommendations include constituting a team, close coordination between teams, audit, formulary restriction, de-escalation, optimizing dosing, active use of information technology among other measure. The recommendations in these guidelines are intended to support, and not replace, good clinical judgment. The recommendations are rated by a letter that indicates the strength of the recommendation and a Roman numeral that indicates the quality of evidence supporting the recommendation, so that readers can ascertain how best to apply the recommendations in their practice environments.

Hyperkalemia during surgery: is it an early warning of propofol infusion syndrome?

We present a case of severe hyperkalemia in a 48-year-old man after short-term infusion of an average dose of propofol. We suspected that the hyperkalemia in this patient was a sign of propofol infusion syndrome. The patient was undergoing a video-assisted esophagectomy, for which one-lung ventilation, with air/oxygen, isoflurane, and continuous epidural analgesia was supplemented with propofol infusion. In the intraoperative period, the patient developed severe hyperkalemia with mild acidosis but no cardiovascular failure. There were no other evident causes of hyperkalemia as documented by laboratory data. The procedure was abandoned and the patient was taken to postoperative recovery, where his potassium levels returned to normal at the end of 10 h.

Massive transfusion and massive transfusion protocol

Haemorrhage remains a major cause of potentially preventable deaths. Rapid transfusion of large volumes of blood products is required in patients with haemorrhagic shock which may lead to a unique set of complications. Recently, protocol based management of these patients using massive transfusion protocol have shown improved outcomes. This section discusses in detail both management and complications of massive blood transfusion.

Neuroleptic malignant syndrome: A diagnostic challenge.

We report the case of a 7-year-old girl operated for craniopharyngioma who developed hyperkalemic cardiac arrest in the post-operative period. She was diagnosed as Neuroleptic malignant syndrome (NMS) and the causative drug was carbamazepine. It was essentially a diagnosis of exclusion, and treatment was mainly supportive in form of withdrawal of the neuroleptic medication (carbamazepine) and administration of dantrolene and bromocriptine. Although, relatively uncommon, NMS can be fatal. NMS presents a clinical challenge as the patient outcome depends on its prompt recognition and treatment.

Airway emergencies in cancer

Management of airway obstruction is always challenging but more so in cancer setting, as obstruction can lie at any level right from pyriform fossa to low down in medistinum. Morbidity is significant but if not managed properly leads to frightful death by suffocation. These cases need to be evaluated, diagnosed and managed with care, skill, speed and appropriate intervention. With the advent of technology, it has become much easier to manage such situations with a team of specialists involving anesthetist, thoracic surgeon and intensivist.

Agreement between inferior vena cava diameter measurements by subxiphoid versus transhepatic views.

Context: Correcting hypovolemia is extremely important. Central venous pressure measurement is often done to assess volume status. Measurement of inferior vena cava (IVC) is conventionally done in the subcostal view using ultrasonography. It may not be possible to obtain this view in all patients. Aims: We therefore evaluated the limits of agreement between the IVC diameter measurement and variation in subcostal and that by the lateral transhepatic view. Settings and Design: Prospective study in a tertiary care referral hospital intensive care unit. Subjects and Methods: After Institutional Ethics Committee approval and informed consent, we obtained 175 paired measurements of the IVC diameter and variation in both the views in adult mechanically ventilated patients. The measurements were carried out by experienced researchers. We then obtained the limits of agreement for minimum, maximum diameter, percentage variation of IVC in relation to respiration. Statistical Analysis Used: Bland–Altmans limits of agreement to get precision and bias. Results: The limits of agreement were wide for minimum and maximum IVC diameter with variation of as much as 4 mm in both directions. However, the limits of agreement were much narrower when the percentage variation in relation to respiration was plotted on the Bland–Altman plot. Conclusions: We conclude that when it is not possible to obtain the subcostal view, it is possible to use the lateral transhepatic view. However, using the percentage variation in IVC size is likely to be more reliable than the absolute diameter alone. It is possible to use both views interchangeably.

Feasibility and safety of thoracoabdominal approach in children for resection of upper abdominal neuroblastoma

BACKGROUND A thoracoabdominal incision provides excellent exposure in the upper abdominal region. We present our experience with the use of this approach in children for resection of upper abdominal neuroblastoma. METHODS Fifty-one of the 106 consecutive patients with abdominal neuroblastoma who underwent tumor resection using the thoracoabdominal approach between June 2006 and May 2011 were selected from the prospective database for this interim analysis. RESULTS The median age was 3.1 years (range, 10 months-14 years), with 8 younger than 18 months and 22 younger than 4 years. Gross total resection was achieved in 44 patients. There were no major vascular injuries or perioperative mortality. Forty-two patients could be extubated immediate postoperatively, whereas 9 were extubated within 24 hours. Good pain relief was achieved in all patients, and prolonged analgesia was not required in any patient. There were no pulmonary complications, and wound infection occurred in 2 patients. The 2-year local control was 92%. The 2-year survival for stages 1 and 2 is 100%, 71.6% for stage 3, and 40.4% for stage 4. CONCLUSION The thoracoabdominal incision for difficult upper abdominal neuroblastoma is tolerated well in pediatric patients with no added morbidity. The enhanced exposure facilitates resection and improves local control.

The modern integrated anaesthesia workstation

Over the years, the conventional anaesthesia machine has evolved into an advanced carestation. The new machines use advanced electronics, software and technology to offer extensive capabilities for ventilation, monitoring, inhaled agent delivery, low-flow anaesthesia and closed-loop anaesthesia. They offer integrated monitoring and recording facilities and seamless integration with anaesthesia information systems. It is possible to deliver tidal volumes accurately and eliminate several hazards associated with the low pressure system and oxygen flush. Appropriate use can result in enhanced safety and ergonomy of anaesthetic delivery and monitoring. However, these workstations have brought in a new set of limitations and potential drawbacks. There are differences in technology and operational principles amongst the new workstations. Understand the principles of operation of these workstations and have a thorough knowledge of the operating manual of the individual machines.

Does tranexamic acid reduce blood loss during head and neck cancer surgery

Background and Aims: Transfusion of blood and blood products poses several hazards. Antifibrinolytic agents are used to reduce perioperative blood loss. We decided to assess the effect of tranexamic acid (TA) on blood loss and the need for transfusion in head and neck cancer surgery. Methods: After Institutional Review Board approval, 240 patients undergoing supramajor head and neck cancer surgeries were prospectively randomised to either TA (10 mg/kg) group or placebo (P) group. After induction, the drug was infused by the anaesthesiologist, who was blinded to allocation, over 20 min. The dose was repeated every 3 h. Perioperative (up to 24 h) blood loss, need for transfusion and fluid therapy was recorded. Thromboelastography (TEG) was performed at fixed intervals in the first 100 patients. Patients were watched for post-operative complications. Results: Two hundred and nineteen records were evaluable. We found no difference in intraoperative blood loss (TA - 750 [600–1000] ml vs. P - 780 [150–2600] ml, P = 0.22). Post-operative blood loss was significantly more in the placebo group at 24 h (P - 200 [120–250] ml vs. TA - 250 [50–1050] ml, P = 0.009), but this did not result in higher number of patients needing transfusions (TA - 22/108 and P - 27/111 patients, P = 0.51). TEG revealed faster clot formation and minimal fibrinolysis. Two patients died of causes unrelated to study drug. Incidence of wound complications and deep venous thrombosis was similar. Conclusion: In head and neck cancer surgery, TA did not reduce intraoperative blood loss or need for transfusions. Perioperative TEG variables were similar. This may be attributed to pre-existing hypercoagulable state and minimal fibrinolysis in cancer patients.

Opioid sparing effect of diclofenac sodium when used as an intra-operative analgesic during maxillofacial cancer surgeries

Oral cavity cancers are one of the most common cancers in Indian males. Consequently, maxillofacial cancer surgery constitutes a large part of surgical oncology practice in India. Manipulation and excision of mandible, maxilla and tongue are extremely noxious stimuli and severe hypertension and tachycardia during these procedures is not unusual. Management includes deepening the plane of anaesthesia by increasing the inhalational anaesthetic concentration and addition of intravenous (IV) opioids. Traditionally, strong analgesics such as opioids have been used intra-operatively whereas non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol are most commonly given at the end of surgery as part of multimodal approach to post-operative analgesia.[1,2] NSAIDs are highly effective in controlling bone pain and have analgesic effects in various conditions especially where tissue inflammation contributes to pain.[3,4] Concerns regarding the deleterious effects of NSAIDs on platelet function and renal function in conditions of renal hypoperfusion are some of the reasons why NSAIDs are not preferred as intra-operative analgesics. In cancer patients, many commonly used chemotherapeutic drugs have known nephrotoxic effects. Drugs such as cisplatinum and ifosfamide cause tubular damage whereas bevacizumab and gemcitabine injure renal vasculature. Hence, there is a tendency to restrict use of NSAIDs in these patients. We hypothesized that addition of single dose of diclofenac at the time of induction would exert opioid sparing effect during intra-operative period and reduce surges in blood pressure (BP) and pulse rate during noxious stimuli.