Ventilatory management in a child with bilateral bronchopleural fistula: a challenge for the intensivist

Pneumatoceles have been described as a complication of staphylococcal pneumonia in children. But the management of large [>1 cm] bilateral bronchopleural fistula [BPF] in a child on positive pressure ventilation is a challenge for the intensivist. Bronchoscopy is an efficient method to close small BPFs [1-3 mm]; independent lung ventilation cannot be used in patients with bilateral lung involvements; high frequency ventilation is of limited value in patients with distal and parenchymal disease; surgical management is deferred in patients with severe hypoxia and active chest infection. Extracorporeal membrane oxygenation is the only treatment modality left but its availability is limited to a few centers only

Outcome in patients with head injury: Do extra-cranial injuries worsen prognosis?

Introduction: Patient age and severity of brain injury are validated prognostic indicators in patients with polytrauma. This prospective observational study was conducted to study the influence of extracranial injuries on neurological outcome of patients with traumatic brain injury [TBI]

Methodology: Patients with TBI aged 20-60 years were enrolled and categorized into two groups: Group 1- with extracranial injuries; Group 2- without extracranial injuries. Patients with fixed and dilated pupils, brainstem injuries, delay of more than 24 hours for hospitalization, and patients who developed secondary insults were excluded

Results: Complete follow up and data collection was feasible in 33 patients of Group 1 and in 47 patients of Group 2. Severity of head injury, SOFA score, co-morbid conditions, duration of hospital stay, mortality, GCS scores on admission and delta GCS [GCS on admission - GCS at time of discharge] were comparable between the two groups. The duration of mechanical ventilation and the ISS scores were significantly higher in patients with extracranial injuries. Extracranial injuries did not influence the survival rate. Severity of head injury was the prime determinant of survival. Extracranial injuries were shown to have a synergistic effect on morbidity

Conclusion: Presence of extracranial injuries does not influence the outcome of patients with head injuries in which secondary insults like hypoxia, hypercapnia / hypocapnia, hypotension, hyperpyrexia, hypoglycemia / hyperglycemia and intracranial hypertension are avoided

Brachial plexus block for perioperative analgesia in children with radial club hand: a retrospective audit

Brachial plexus block in combination with general anaesthesia is used for surgical correction of radial dub hand. We carried out this retrospective study to assess the feasibility and efficacy of brachial plexus block in children with radial dub hand. Intraoperative and postoperative analgesic requirements were the primary outcome measures analysed. We conducted a retrospective audit and collected data on the intraoperative and postoperative analgesic requirements in 24 patients anaesthetised for orthopedic treatment of this congenital deformity in our children's hospital over a period of 5 years. Transarterial axillary block was administered to 8 patients; nerve stimulator guided supradavicular block was used in 4 patients; and 12 were administered anesthesia without administration of brachial plexus block. Intraoperative additional supplementation of intravenous opioid was required in 12.5%, 50% and 75% of patients administered axillary block, supradavicular block and no block [only general anesthesia] respectively. The mean time interval for administration of first dose of analgesic in postoperative period was 4.5, 3.6 and 0.75 hours respectively. Permanent diaphragmatic paralysis was reported in one patient with supradavicular block. No complication was reported in the group with axillary block. Supplementation of general anesthesia with transarterial axillary brachial plexus block provides adequate perioperative analgesia in children with radial dub hand operated for centralisation of ulna

Failed intubation in obstetrics

Failed intubation is prevalent in obstetric patients, more so during the last trimester of pregnancy when physiological factors may worsen the problems that lead to difficult intubation. If securing the airway is not managed efficiently it may have disastrous effects on mother and the fetus. During last few years, management of airway in obstetrics and training in this field has undergone numerous changes. The postgraduate students have been getting lesser exposure to intubation in pregnant patients. As regional anesthesia is increasingly popular in obstetrics, acquiring dexterity in conducting general anesthesia is becoming difficult. There should be a methodical approach to train in managing difficult obstetric airway. Various novel airway devices are now being suggested as an alternative to conventional intubation using laryngoscope. In addition, devices such as simulators should be employed to so that difficult or failed intubation may be managed with required skill. Other vital aspects to deal with this situation include a difficult airway cart that contains alternative airway devices, a comprehensive but practically easy algorithm and a regular drill or training to deal with difficult airway in obstetric patients

Incidence and severity of adverse events in laparoscopic Nissen fundoplication; an anesthesiologist's perspective

Laparoscopic fundoplication is surgical treatment of choice for gastroesophageal reflux disease. The primary objective of our study was to determine the incidence and severity of intraoperative and postoperative [up to 48 hours after surgery] complications in laparoscopic Nissen fundoplication. We retrospectively analyzed case files and anesthesia charts of patients operated for this surgery from 2005 to 2011 and recorded the incidence and severity of intraoperative and postoperative [up to 48 hours after surgery] complications. 63 patients undergoing laparoscopic surgery for either a sliding [76%] or paraesophageal hiatus hernia [24%] were included in the study. Mean age was 41.6 +/- 13.3 years and mean surgical duration was 4.5 +/- 1.5 hours. Hypertension [28.5%], bradycardia [22.2%], high mean airway pressures [17.4%], desaturation [17.4%], arrhythmia [15.8%], bronchospasm [9.5%], pleural injury [6.3%] and subcutaneous emphysema [4.7%] were the main intraoperative complications. Abdominal pain [79%], radiological evidence of atelectasis [31.7%], breathlessness [22%], nausea and vomiting [20.6%], chest pain [9.5%] and pneumothorax [3%] were reported in early postoperative period. Pleural effusion [19%], pneumonia [3%], abdominal fluid collection [3%] and bed sore [1.5%] were seen in late postoperative period [after 24 hrs]. There was no mortality and the incidence of mild [grade 1], moderate [grade 2; grade 3] and severe complications [grade 4] was 31.5, 62.3 and 5.26% respectively. Injury to splenic artery, injury to stomach and difficult dissection due to adhesions was the reason for conversion to open surgery in three patients. Hypertension, bradycardia, higrrmean airway pressures and desaturation are the commonest intraoperative complications. Pneumothorax is common but clinically asymptomatic. Monitoring of airway pressure, KtCO2, SpO2 and intermittent chest auscultations is needed to detect it. Multimodal analgesia is needed for abdominal pain. Lung recruitment manoeuvers, chest physiotherapy and early mobilization are needed to prevent atelectasis, pleural effusion and pneumonia in the postoperative period

Non-invasive ventilation is helpful in early weaning and early extubation in H1N1 infected, ventilated patients: a case series

The spread of 2009 pandemic of H1N1 increased the number of patients being admitted to intensive care unit with acute respiratory failure. Conservative approach in extubation in view of severe lung injury leads to prolonged mechanical ventilation and is further complicated by development of superadded bacterial infections. In a developing country with a large population and limited health care resources all attempts need to be made to decrease hospital stay. We present a case series of four patients, confirmed to have H1N1 associated respiratory involvement and who were put on non invasive ventilation [NIV] early in the phase of weaning. The weaning and early extubation was successful in all of these patients. We conclude that NIV in post extubation period facilitates weaning and early extubation in patients with H1N1 viral pneumonia, who were on mechanical ventilation

Occupational infections: a risk for the anesthesiologists

The environment of operating room is familiar workplace for anesthesiologists, as well as, an area replete with various kinds of occupational hazards, such as, stress, 1, 2 exposure to inhalational anesthetics 3, 4 noise pollution5'6 and sleep deprivation7'8.In addition to these hazards there is a serious threat of occupational infections 9, 10 among anesthesiologists. Here is the review of this threat and how to identify and minimize risk, while providing optimal patient care. Though, the work environment of anesthesiologists may be hostile to some extent, they should work more safely by identifying, understanding and hence avoiding these hazards