Sir, We present a case report of anaesthetic management of a 12-year-old boy with sickle-cell disease (SCD) and congenital heart block (CHB) with pacemaker [Figure 1], undergoing laparoscopic splenectomy.Figure 1: 12-lead electrocardiography of the patientThe child had suffered sickle-cell crisis and pacemaker malfunction a month back. His preoperative investigations were normal and weight was 30 kg. He received intravenous (IV) fluids during fasting period, pneumococcal vaccine, antibiotic prophylaxis and cefotaxime 500 g IV. The cardiologist changed the mode of pacemaker to asynchronous (fixed rate). Standard American Society of Anesthesiologists monitoring, urine output and temperature monitoring were used. Morphine 4.5 mg IV, thiopentone 150 mg IV and atracurium 0.5 mg/kg IV were used for induction and intubation. Anaesthesia was maintained with isoflurane (MAC: 1.0), air and oxygen (FiO2: 0.5). Pneumoperitoneum was created with CO2 and intra-abdominal pressure was kept around 8–10 mmHg. The surgeon used bipolar cautery, blood loss was approximately 800 ml and 1 unit packed red cell was transfused. The patient was given fluid at 60 ml/h intra-operatively as he had been kept hydrated preoperatively. For post-operative analgesia, paracetamol 500 mg IV was given and skin incision was infiltrated with 12 ml 0.2% ropivacaine. Neuromuscular blockade was reversed and trachea was extubated. The patient remained haemodynamically stable, normothermic and had adequate urine output. Post-operative analgesia was maintained with paracetamol 500 mg IV 8th hourly and fentanyl boluses of 30 μg as rescue analgesic whenever visual analogue scale exceeded 3. The child was discharged on the 7th post-operative day after uneventful course. CHB (incidence 1 in 22,000 live births) with no structural abnormality and when diagnosis is established beyond neonatal period has better survival.[1] Intraoperatively, pacemaker mode is advised to be changed to asynchronous, and bipolar electrocautery is to be used. The availability of manual pacing should be ensured to manage pacemaker malfunction.[2] SCD is the disorder of beta-globin chain characterised by haemolytic anaemia, intermittent vascular occlusion, pulmonary compromise and multi-organ damage. Electrocardiogram changes are non-specific and first-degree heart block may be found.[34] Not usually associated with SCD, CHB in our patient is perhaps an additional finding. Splenectomy is recommended in children older than 2 years or after one major or two minor episodes of splenic sequestration crises.[34] When done laparoscopically, the duration of surgery increases, but hospital stay is decreased.[3] Any major surgery is associated with 7% mortality. Preoperatively, the history of episodes of painful crises must be sought.[4] Pre-operative examination should be thorough as SCD involves multiple organ systems. Neurological evaluation rules out the previous cerebrovascular accident as ischaemic infarcts are common in anaemic children.[3] Kidneys may get involved during advanced disease. Presence of rib infarcts can lead to hypoventilation. Perioperative cardiopulmonary manifestations such as acute chest syndrome usually remain undetected in young children.[34] As dehydration precipitates RBC sickling and occlusion of microvasculature at a level of precapillary sphincters, perioperative hydration must be ensured.[34] There is a controversy regarding blood transfusion, benefit being dilution of haemoglobin S and disadvantage being triggering of sickling.[34] Other factors leading to sickling crises are vascular stasis, hypoxia, metabolic acidosis, hypothermia and presence of infection.[3] Previous case reports have emphasised the importance of preventing sickling crisis perioperatively.[5] To conclude, perioperative anaesthetic management of children suffering from SCD and CHB needs meticulous pre-operative and intra-operative management and post-operative vigilance for preventing sickle-cell crisis and associated complications. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
The diffusion of nitrous oxide (N2O) into the air-filled cuff of the classic laryngeal mask airway (LMA) may lead to an increase in cuff pressure (CP) and displacement of LMA affecting its performance. This study was conducted to evaluate the change in optimal position of LMA by fibre-optic bronchoscope, the changes in cuff pressure and oropharyngeal leak pressure (OLP), and post-operative laryngo-pharyngeal morbidity during N2O-oxygen (O2) anaesthesia in children.After ethics committee approval and written informed consent, 84 children, aged 2 to 8 years undergoing lower abdominal surgery using LMA were included. Anaesthesia was induced with sevoflurane and maintained with either 33% O2 in air (Group 1) or with 33% O2 in 67% N2O (Group 2) along with sevoflurane. The position of LMA using fibre-optic bronchoscope, CP and OLP were recorded at 30, 60 and 90 minutes and at the end of surgery. The incidence of post-operative sore throat, hoarseness of voice and dysphagia was assessed for 24 hours.A mild (Grade 1) change in fibre-optic position of LMA was observed in 6 out of 42 children maintained with N2O-O2 anaesthesia. The cuff pressure was higher than baseline in group 2 at all three time points with the maximum at 90 minutes (93.23 ± 14.86 cm H2O vs. 39.78 ± 7.75 cm H2O; P < 0.05). The OLP was comparable between the groups during the initial 60 minutes and then increased in group 2. The incidence of post-operative sore throat was significantly higher in group 2 (P = 0.008).The diffusion of anaesthetic gases into the air-filled cuff does not change the fibre-optic position of the LMA significantly but increases the cuff pressure and incidence of post-operative laryngo-pharyngeal complications in children.
Inappropriate antimicrobial prescribing is considered to be the leading cause of high burden of antimicrobial resistance (AMR) in resource-constrained lower- and middle-income countries. Under its global action plan, the World Health Organization has envisaged tackling the AMR threat through promotion of rational antibiotic use among prescribers. Given the lack of consensus definitions and other associated challenges, we sought to devise and validate an Antimicrobial Rationality Assessment Tool—AmRAT—for standardizing the assessment of appropriateness of antimicrobial prescribing. A consensus algorithm was developed by a multidisciplinary team consisting of intensivists, internal medicine practitioners, clinical pharmacologists, and infectious disease experts. The tool was piloted by 10 raters belonging to three groups of antimicrobial stewardship (AMS) personnel: Master of Pharmacology (M.Sc.) (n = 3, group A), Doctor of Medicine (MD) residents (n = 3, group B), and DM residents in clinical pharmacology (n = 4, group C) using retrospective patient data from 30 audit and feedback forms collected as part of an existing AMS program. Percentage agreement and the kappa (κ) coefficients were used to measure inter-rater agreements amongst themselves and with expert opinion. Sensitivity and specificity estimates were analyzed comparing their assessments against the gold standard. For the overall assessment of rationality, the mean percent agreement with experts was 76.7% for group A, 68.9% for group B, and 77.5% for group C. The kappa values indicated moderate agreement for all raters in group A (κ 0.47–0.57), and fair to moderate in group B (κ 0.22–0.46) as well as group C (κ 0.37–0.60). Sensitivity and specificity for the same were 80% and 68.6%, respectively. Though evaluated by raters with diverse educational background and variable AMS experience in this pilot study, our tool demonstrated high percent agreement and good sensitivity and specificity, assuring confidence in its utility for assessing appropriateness of antimicrobial prescriptions in resource-constrained healthcare environments.
To the Editor Although the intraarterial (IA) injections of anesthetic drugs have been known to cause local ischemia and tissue necrosis, there are drugs that have been given, deliberately or unintentionally, through IA route but without any adverse effect.1–3 We report 2 cases of unintentional IA injection of neostigmine with glycopyrrolate and atropine, occurring without any sequellae. The patients' families reviewed the case report and gave written permission for the authors to publish the report. The first case was an 18-year-old female who, after craniotomy and excision of posterior fossa tumor under general anesthesia, received an IA injection (through a 3-way with 10-cm extension line attached to the left dorsalispedis arterial cannula) neostigmine 2.5 mg and glycopyrrolate 0.5 mg for reversal of the residual vecuronium-induced neuromuscular relaxation. The second case was a 58-year-old female patient who received an IA injection of neostigmine 3.5 mg with atropine 1.4 mg after aneurysmal clipping surgery. The train-of-4 count increased from 0.40 to less than 0.90, in 9 minutes 40 seconds in the first patient, and in 15 minutes in the second patient. In both patients, the adequacy of circulation of the left foot was monitored postoperatively using pulse oximetery, intermittent palpation of left dorsalispedis artery, and tissue ischemia score. No immediate or delayed vascular complications were observed in either patient, and Doppler studies of the involved vessel revealed good bloodflow with no evidence of vasospasm or IA thrombus formation. Considering the reports of intentional use of IA neostigmine as a diagnostic test for myasthenia gravis,4 we assumed that IA neostigmine with atropine should be safe. Aqueous solubility and acidic property of glycopyrrolate might be the reason for the safe IA injection of neostigmine–glycopyrrolate admixture in our first case. This speculation is supported by the fact that the IA use of nonaqueous agents (diazepam, propofol, and etomidate) and highly alkaline drugs (thiopental and phenytoin) has been associated with vascular complications, whereas drugs such as atropine, fentanyl, midazolam, succinylcholine, and pancuronium have been used without untoward side effects.5,6 Nonetheless, the preservative used with glycopyrrolate (benzyl alcohol) may initiate vasospasm.3 In conclusion, although IA administration neostigmine and glycopyrrolate/atropine allowed uneventful and timely recovery from the residual blockade in our patients,7 a definitive statement regarding the safety of the IA administration of these medications cannot be made. Amit Jain, MD Neeru Sahni, MD Sujoy Banik, MD Department of Anaesthesia and Intensive Care Postgraduate Institute of Medical Education and Research Chandigarh, India [email protected] Sohan Lal Solanki, MD Organ Transplant Anaesthesiology Department of Anaesthesia Sanjay Gandhi Postgraduate Institute of Medical Sciences Lucknow, India
Dear Editor, Difficult airway in a critically ill patient with multiorgan dysfunction is a high-risk procedure due to poor oxygen reserve, risk of worsening of shock with anesthetic drugs, and high possibility of cardiac arrest.[1] A disoriented patient in shock is not amenable to awake intubation and surgical airway access is of limited help in presence of thrombocytopenia. We present a case of difficult airway in an obese 27-year-old male with multiorgan dysfunction with a hematoma on the right side of the neck resulting from right internal jugular venous cannulation. His body mass index was 40 kg/m2 and his acute physiology and chronic health evaluation score (APACHE) II was 30. On receiving from triage, patient was restless, hypotensive, tachypnoeic and tachycardic. Initially managed with fluids, vasopressors and noninvasive ventilation (NIV). An ill-defined hematoma was present at the insertion site of CVC and backflow was absent. For inotrope administration, using ultrasound, a new CVC was placed in the right femoral vein. Invasive blood pressure monitoring was established for hemodynamic monitoring. Because of worsening respiratory distress and severe metabolic acidosis, invasive mechanical ventilation was planned. In anticipation of the difficult airway (BMI: 40 kg/m2, mallampati grade IV, and neck circumference 17 inches), the difficult airway cart was kept ready. After preoxygenation using NIV, the patient was given titrated doses of fentanyl midazolam and propofol intravenously. A nonchanneled videolaryngoscope with Macintosh blade size 5 was used for the first attempt and Cormack Lehane grade 3A was visualized along with a large bulge overhanging the right side of epiglottis due to the external hematoma [Figure 1]. Attempt to insert bougie from the right side failed and because of desaturation, immediate bag and mask ventilation was resumed.Figure 1: View of glottis using videolaryngoscopeIn the second attempt using a video-laryngoscope with the right hand by a more experienced anesthesiologist, an attempt to insert bougie from the left side was successful, as this side was normal. The cuffed endotracheal tube of internal diameter of 8.0 was successfully inserted over the bougie and successful ventilation could be resumed. Cricoid pressure was used during both attempts. In a difficult airway scenario, awake videolaryngoscopy is a viable option over awake fiber optic due to lesser time taken for tube placement.[2] The use of videolaryngoscope is now recommended very early (first-line or after a first-attempt failure using direct laryngoscopy) in ICU airway management algorithms.[3] For standard blade style videolaryngoscopes, the blade is inserted in the midline without sweeping the tongue laterally and the endotracheal tube is introduced from the right angle of the mouth.[4] While using videolaryngoscope, there is equal space on both sides for tube insertion. In our patient, when an attempt from the right side failed, inserting endotracheal tube from the left angle of the mouth with the left hand of the laryngoscopist provided a simple lifesaving solution. We could successfully secure the airway in a critically ill patient with multiorgan dysfunction with preoxygenation with NIV, appropriate hemodynamic monitoring, and vasopressor use and inserting bougie from the left side using videolaryngoscope. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
To the Editor We read with interest the recent special article by Bowdle et al1 mentioning key recommendations for appropriate infection prevention precautions for routine anesthesia care during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. We wish to add our perspective and concern regarding the use of gloves—an important personal protective equipment (PPE). Universal gloving—a horizontal intervention of contact precautions—was introduced to decrease the exposure of health care workers (HCW) to infectious pathogens while performing patient care. During current pandemic situation like coronavirus disease 2019 (COVID-19) and Ebola virus epidemics, many HCW prefer to wear the same pair of gloves for the extended time while working in contact with patients in operating rooms and intensive care units (ICU). Bowdle et al1 have also recommended wearing double gloves during airway management, with the first pair to be removed immediately after the procedure to prevent surface contamination.1 As per World Health Organization recommendations (2015), when wearing 2 pairs of gloves, change of outer gloves should be practised between patients and before exiting patient care area.2 Also, application of alcohol-based hand rub (ABHR) is often done over gloves, for example, during doffing PPE and routine patient care. We wish to highlight that the impact of this practice on incidence of health care-associated infections (HAI) needs special attention. A meta-analysis of 8 heterogeneous studies concluded that universal gloving may be associated with minimal protection against HAI and may be implemented only in high-risk settings.3 Universal gloving may pose more difficulty for hand hygiene by adding another barrier.4 Also, it remains unclear how more frequent application of AHBRs on worn gloves will affect the incidence of HAI in operating rooms and ICU, both COVID and non-COVID. The other concern is that multiple applications of ABHR on gloves may alter their physical properties. Gao et al5 observed ABHRs affected the tensile strength of the tested nitrile more than latex gloves. In addition, ethanol-containing ABHR led to minimal changes in tensile strength of gloves compared to isopropanol containing ABHR.5 Birnbach et al,6 however, showed that the application of ABHR on widely available nitrile examination gloves does not hamper glove integrity and allows safe performance of anesthesia practices. The possible changes in glove properties with multiple applications of ABHR need to be addressed. This is especially significant in the context of safety of HCW working in COVID areas. In the current COVID-19 scenario, when HCW are advised to perform patient care along with self-care, these concerns need to be explored to understand the impact of universal gloving and application of ABHR over worn gloves on incidence of HAI while maintaining safety of HCW. Neeru Sahni, MDKomal A. Gandhi, MDDepartment of Anesthesia & Intensive CarePost-Graduate Institute of Medical Education and ResearchChandigarh, India[email protected] Manisha Biswal, MDDepartment of Medical MicrobiologyPost-Graduate Institute of Medical Education and ResearchChandigarh, India
Introduction: Arthroscopic anterior cruciate ligament reconstruction (ACLR) is associated with moderate-to-severe postoperative pain which may delay hospital discharge as well as physiotherapy resulting in poor outcome. The aim of our study was to compare the effect of clonidine or fentanyl as adjuvant to bupivacaine in femoro-sciatic nerve block (FSNB) on the duration of pain-free period and requirement of rescue analgesic postoperatively. Materials and Methods: Sixty adult patients undergoing ACLR of the knee joint received subarachnoid block as anesthesia for surgery and FSNB for postoperative analgesia. Patients in Group C (control group) received 40 ml of 0.25% isobaric bupivacaine (20 ml in femoral and sciatic block each), whereas Group F (fentanyl group) received fentanyl (1 μg/kg) and Group CL (clonidine group) received clonidine (1 μg/kg) with 40 ml of 0.25% isobaric bupivacaine. The duration of pain-free period, rescue analgesic consumption, postoperative pain score, sedation levels and adverse effects were monitored along with hemodynamic parameters for 24 h postoperatively. Results: The patients in the clonidine group had longer pain-free period (10.06 ± 3.62 h) as compared to the fentanyl group (7.94 ± 3.62 h) and control group (4.59 ± 1.20 h) (P < 0.001). Postoperative pain scores were higher in the control group at the 4th, 8th, and 12th h and comparable between the fentanyl and clonidine groups. The total amount of rescue analgesic requirement was less in the clonidine group (71.25 ± 16.77 mg) than the fentanyl group (86.25 ± 36.71 mg) and control group (161.20 ± 50.34 mg) (P < 0.001). No clinically significant adverse effects were observed in any group. Conclusion: Clonidine as an adjuvant to bupivacaine in FSNB provides better postoperative analgesia compared to fentanyl by significantly prolonging the pain-free period and decreasing rescue analgesic requirement in postoperative period without any untoward side effect.
Background: Surveillance for ventilator-associated pneumonia (VAP) has long been a challenge because of the lack of objective, reliable definitions. Hence, National Healthcare Safety Network (NHSN) has introduced ventilator-associated events (VAEs) as a surveillance definition. While VAE identifies all the possible complications in a mechanically ventilated patient, VAP recognises only the infective complications. There are several retrospective studies reporting no concordance between the occurrence of VAE and VAP. A prospective, observational study in medical intensive care unit (ICU) was conducted over 1 year with the objective of comparing all three tiers of VAE, which are ventilator-associated condition (VAC), infection-related ventilator-associated complication (iVAC) and possible VAP (PVAP), along with VAP in terms of predictive value, characteristics and clinical relevance. Materials and Methods: A prospective cohort study was conducted from July 2018 to June 2019 at PGIMER, Chandigarh, in a 12-bedded medical ICU. All patients with more than 48 h of mechanical ventilation (MV) were included. The demographic data, Acute Physiology and Chronic Health Evaluation-II at 24 h of admission, days of MV, length of ICU stay and outcome of patients were recorded. The patients were screened for both VAP and VAE. Results: Out of a total of 405 patients, 274 patients were included with 3945 patient days and 3330 MV days. The incidence of VAP, VAC, iVAC and PVAP was 6.91, 8.41, 5.41 and 1.50/1000 ventilator days, respectively. Kendall's W -test showed that there was no concordance between VAP and VAE. Conclusion: The study concluded no concordance between cases identified as VAE and VAP.
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