Vishal Sehgal

Polypharmacy and potentially inappropriate medication use as the precipitating factor in readmissions to the hospital.

Background and Aim: Readmission to the hospital within 30 days of discharge from the hospital is a common occurrence. Congestive heart failure is the most common cause of readmissions in the hospital. We hypothesized that irrespective of the admission diagnosis polypharmacy and potentially inappropriate use of medications (PIM) leads to readmissions within 30 days of discharge from the hospital. Materials and Methods: A retrospective study was carried out by reviewing the hospital records of 414 patients who were readmitted to the hospital within 30 days of discharge from the hospital between January 2008 and December 2009. The data was stratified to see which patients were on polypharmacy and/or on PIM. Polypharmacy was defined as use of more than 5 medications. PIM was defined as per the modified Beers criteria. Day 0 was defined as the day of discharge and day1 was defined as the day-after Admission to the hospital. Statistical analysis was carried out using a two-way analysis of variance (ANOVA) on the data to see if polypharmacy and/or PIM was related to readmission within 30 days of discharge irrespective of admission diagnosis. Results: Polypharmacy was related to hospital readmission at day 1 and day 0, however inappropriate drug use was found to be not related at any day. Polypharmacy and PIM combined had a positive correlation to readmission only on days 1 and 0 and it was statistically significant. The use of minimal and appropriate use of drugs was statistically significant compared to polypharmacy and PIM use. Conclusions: Polypharmacy and PIM are under recognized cause of readmissions to the hospital.

Efficacy of noninvasive ventilation after planned extubation: A systematic review and meta-analysis of randomized controlled trials

The objective our meta-analysis is to update the evidence on the efficacy of noninvasive ventilation (NIV) compared with conventional oxygen therapy after planned extubation. We did a systematic literature review of database, including Pubmed, EMBASE, and Cochrane. We included randomized controlled trials comparing NIV with conventional oxygen therapy after planned extubation in medical intensive care unit (ICU) in our analysis. The results of our meta-analysis is consistent with the results of previous reviews and show that NIV decreased reintubation rate significantly as compared to conventional oxygen therapy in chronic obstructive pulmonary disease (COPD) and patients at high risk for extubation failure; COPD (RR, 0.33; 95% CI, 0.16-0.69; I2 = 0), high risk (RR, 0.47; 95% CI, 0.32-0.70; I2 = 0). However, in a mixed medical ICU population, there was no statistical difference of reintubation rate between the two groups (RR, 0.66; 95% CI, 0.25-1.73; I2 = 68%). Our study suggests that use of NIV after planned extubation significantly decreases the reintubation rate in COPD patients and patients at high risk for extubation failure, confirming the findings of previous reviews. There is no difference in the reintubation rate between the two groups in the mixed medical ICU population.

Anesthesia and thyroid surgery: The never ending challenges

Thyroidectomy is the most common endocrine surgical procedure being carried out throughout the world. Besides, many patients who have deranged thyroid physiology, namely hyperthyroidism and hypothyroidism, have to undergo various elective and emergency surgical procedures at some stage of their life. The attending anesthesiologist has to face numerous daunting tasks while administering anesthesia to such patients. The challenging scenarios can be encountered at any stage, be it preoperative, intra-op or postoperative period. Preoperatively, deranged thyroid physiology warrants optimal preparation, while anticipated difficult airway due to enlarged thyroid gland further adds to the anesthetic challenges. Cardiac complications are equally challenging as also the presence of various co-morbidities which make the task of anesthesiologist extremely difficult. Thyroid storm can occur during intra-op and post-op period in inadequately prepared surgical patients. Postoperatively, numerous complications can develop that include hemorrhage, laryngeal edema, nerve palsies, tracheomalacia, hypocalcemic tetany, pneumothorax, etc., The present review aims at an in-depth analysis of potential risk factors and challenges during administration of anesthesia and possible complications in patients with thyroid disease.

Clinical and critical care concerns in severely ill obese patient

The incidence of obesity has acquired an epidemic proportion throughout the globe. As a result, increasing number of obese patients is being presented to critical care units for various indications. The attending intensivist has to face numerous challenges during management of such patients. Almost all the organ systems are affected by the impact of obesity either directly or indirectly. The degree of obesity and its prolong duration are the main factors which determine the harmful effect of obesity on human body. The present article reviews few of the important clinical and critical care concerns in critically ill obese patients.

Management of diabetes in the elderly with canagliflozin: A newer hypoglycemic drug on the horizon

Canagliflozin is the first available oral inhibitor of sodium/glucose cotransporter 2 (SGLT2) in the market. At the outset it sounds excellent for the use in the elderly diabetic population, because of its minimal tendency to cause hypoglycemia. However, the clinician needs to exercise caution as it needs to be dosed renally. The clinician needs to be circumspect about potential drug interactions, especially when there is an underlying chronic kidney disease (CKD) and congestive heart failure (CHF). Also its use is best avoided in people who are predisposed to genital mycotic and urinary tract infections (UTI).

Management of diabetes mellitus type-2 in the geriatric population: Current perspectives

The prevalence of diabetes mellitus (DM) has increased exponentially throughout the world and there is rapid increase in elderly diabetics. DM is associated with increased mortality and considerable morbidity including stroke, heart disease, and diminished quality of life in the elderly. However, the unique features of geriatric diabetes have not been given due a prominence in medical literature. Hypoglycemia remains the biggest complicating factor and needs to be avoided in the elderly. Most people in the geriatric age group have some degree of renal insufficiency and medications need to be adjusted wisely with changing renal profile. Because safer and more effective pharmacological therapy is available, an individual approach to DM in the elderly is essential.

New orally active anticoagulants in critical care and anesthesia practice: the good, the bad and the ugly.

With the adoption of dabigatran, rivaroxaban, and apixaban into clinical practice, a new era has arrived in the practice of oral anticoagulants. Venous thromboembolism (VTE) has traditionally been underdiagnosed and under treated in Asia. With increasing longevity, the diagnosis and the need for management of atrial fibrillation (AF) and VTE is likely to increase significantly. The new orally active anticoagulants (NOACs) have reasonably filled the lacunae that clinicians traditionally faced when treating patients with vitamin K antagonist (VKA). Unlike VKA, NOACs do not need frequent monitoring. Therefore, more patients are likely to get therapeutic effects of anticoagulation and thus reduce morbidity and mortality associated with VTE and AF. However, the clinicians need to be circumspect and exercise caution in use of these medications. In particular (in geriatric population), the clinicians should look out for drug-drug interactions and underlying renal insufficiency. This would ensure therapeutic efficacy and minimize bleeding complications. Here, it is important to note that the antidote for NOACs is not available and is a major concern if emergency surgical procedure is required in their presence.

Anesthetic management of primary hyperparathyroidism: A role rarely noticed and appreciated so far

Endocrine surgeries have been on the rise for the last few years. During surgery, endocrine disorders present unique challenges to the endocrinologist and to the attending anesthesiologist. The endocrine, electrolyte and metabolic disturbances resulting from such disorders can have a profound effect on the normal human physiological milieu. Surgery of parathyroid glands is no exception and is associated with a multiple challenges during pre-, intra-, and post-operative period. Pre-op examination and optimization is essential so as to prevent any intra-op or post-op complications. The most striking electrolyte disturbance during parathyroid surgery is the imbalance of calcium levels in the body and the main emphasis during the entire peri-operative period revolves around the maintenance of normal serum calcium levels. The present article review in depth the various anesthetic considerations and implications during parathyroid surgery with an emphasis on pre-op preparation for elective and emergency surgery.

Predictors of Acute Kidney Injury in Geriatric Patients Undergoing Total Knee Replacement Surgery

Background: Few studies have focused on patients’ characteristics that affects acute kidney injury (AKI) after total knee replacement surgery (TKR). Objectives: The primary objective of this retrospective study was to identify patients’ characteristics associated with AKI after TKR. Patients and Methods: Between January 2008 and December 2009, 659 patients with a mean age of 67.1 years (range, 39-99) underwent TKA at Regional Hospital Knee and Hip Institute. Retrospective chart review was done to identify patients’ characteristics that were associated with AKI after TKR. Logistic regression was used to evaluate AKI. Results: AKI occurred in 21.9% of patients. AKI risk decreased between 2008 and 2009 (odds ratio, 0.55; 95% CI, -0.37 to 0.82) but increased with age (P < 0.001), diabetes mellitus (DM), and angiotensin converting enzyme inhibitors (ACEI)/angiotensin receptor blockers (ARB) use (OR, -1.6; 95% CI, -1.0 to 2.5; and OR, -1.5, 95% CI, -1.0 to 2.3, respectively). However, the effects of DM and ACEI/ARB use were not independent; when both were included in the regression model, neither was statistically significant, and both ORs were smaller than combined OR. Conclusions: When examined separately, both DM and preoperative ACEI/ARB use increased the risk of AKI; however these factors were correlated and were not independent predictors of significantly increased risk. Patients with DM have higher tendency to develop AKI and hence, preoperative renal risk stratification should be done in all patients with DM.

Clinical conundrums in management of sepsis in the elderly

Abstract In 2012, surviving sepsis campaign came out with updated international guidelines for management of severe sepsis and septic shock. Paradoxically, there are no specific guidelines for management of sepsis in the elderly, although the elderly are more predisposed to sepsis, and morbidity and mortality related to sepsis. Sepsis in the elderly is, more often than not, complicated by clinical conundrums such as congestive heart failure (CHF), atrial fibrillation (AF), chronic kidney disease (CKD), acute kidney injury (AKI), delirium, dementia, ambulatory dysfunction, polypharmacy, malglycemia, nutritional deficiencies, and antibiotic resistance. Also, with recurrent admissions to the hospital and widespread use of antibiotics, the elderly are more susceptible to Clostridium difficile colitis.