Increase in optic nerve sheath diameter predicts early cerebral involvement in fat embolism syndrome / 中华创伤杂志(英文版)

Early diagnosis of cerebral fat embolism in a patient with contradiction to MRI is challenging. Here we report an interesting case, where the raised optic nerve sheath diameter helped us to predict the early cerebral involvement with fat emboli in a left femoral shaft fracture patient. MRI scan could not be performed due to the presence of a metallic implant in the patient from a previous surgery. He was later diagnosed as an atypical presentation of fat embolism syndrome. Optic nerve sheath monitoring also helped us to guide further management of the patient.

Clinical characteristics and management of patients with fat embolism syndrome in level I Apex Trauma Centre / 中华创伤杂志(英文版)

PURPOSE@#Fat embolism syndrome (FES) is systemic manifestation of fat emboli in the circulation seen mostly after long bone fractures. FES is considered a lethal complication of trauma. There are various case reports and series describing FES. Here we describe the clinical characteristics, management in ICU and outcome of these patients in level I trauma center in a span of 6 months.@*METHODS@#In this prospective study, analysis of all the patients with FES admitted in our polytrauma intensive care unit (ICU) of level I trauma center over a period of 6 months (from August 2017 to January 2018) was done. Demographic data, clinical features, management in ICU and outcome were analyzed.@*RESULTS@#We admitted 10 cases of FES. The mean age of patients was 31.2 years. The mean duration from time of injury to onset of symptoms was 56 h. All patients presented with hypoxemia and petechiae but central nervous system symptoms were present in 70% of patients. The mean duration of mechanical ventilation was 11.7 days and the mean length of ICU stay was 14.7 days. There was excellent recovery among patients with no neurological deficit.@*CONCLUSION@#FES is considered a lethal complication of trauma but timely management can result in favorable outcome. FES can occur even after fixation of the fracture. Hypoxia is the most common and earliest feature of FES followed by CNS manifestations. Any patient presenting with such symptoms should raise the suspicion of FES and mandate early ICU referral.

Assessment of hemostatic changes after crystalloid and colloid fluid preloading in trauma patients using standard coagulation parameters and thromboelastography

The choice of an ideal fluid administered post trauma and its subsequent influence on coagulation still poses a clinical dilemma. Hence, this study was designed to assess the influence of in vivo hemodilution with various fluid preparations [4% gelatin, 6% hydoxyethyl starch [HES], Ringer's lactate, 0.9% normal saline] on coagulation using standard coagulation parameters and real-time thromboelastography [TEG] in patients undergoing elective surgery post trauma. In a randomized, double-blind study, 100 patients of either sex and age, belonging to ASA Grades I and II, scheduled for elective surgeries were allocated into four groups of 25 each according to the type of fluid infused. Group G [4% gelatin], Group N [0.9% normal saline], Group R [Ringer's lactate], and Group H [6% HES] received preloading with 1 L of fluid according to the group. The coagulation status of the patients was assessed during perioperative period [before surgery, after fluid preloading, and at the end of the surgery] using both conventional coagulation analysis and TEG. Analysis of variance [ANOVA], post hoc and Pearson Chi-square test were used. In all the patients preloaded with gelatin, there was a significant increase in prothrombin time index [PTI; 14.88 +/- 0.90 vs. 13.78 +/- 3.01, P<0.001] and international normalized ratio [INR; 1.12 +/- 0.09 vs. 1.09 +/- 0.19, P<0.05] compared to the baseline value. An increase was observed in these parameters in the postoperative period also. In the HES group, there was statistically significant increase in PT time [15.70 +/- 1.51 vs. 13.74 +/- 0.75, P=0.01] and INR [1.20 +/- 0.15 vs. 1.03 +/- 0.17, P<0.001] as compared to the baseline. In the intergroup comparisons, the patients preloaded with HES had a significant increase in INR [1.20 +/- 0.15 vs. 1.12 +/- 0.09, P=0.04] and reaction time [R time; 6.84 +/- 2.55 min vs. 4.79 +/- 1.77 min, P=0.02] as compared to the gelatin group. The fall in coagulation time [k time; 2.16 +/- 0.98 vs. 3.94 +/- 2.6, P=0.02], rise in maximum amplitude [MA; 61.94 +/- 14.08 vs. 50.11 +/- 14.10, P=0.04], and rise in A20 [56.17 +/- 14.66 vs. 43.11 +/- 14.24, P=0.05] were more in patients preloaded with RL as compared to the HES group. 100% patients in the gelatin group, 84.2% patients in the NS group, 94.4% patients in the RL group, and 66.7% patients in the HES group had hypocoagulable [R time > 14 min] state in the postoperative period. Crystalloids are optimal volume expanders in trauma, with RL having beneficial effects on coagulation system [decrease in k time and increase in MA and A20]. Among the colloids, HES 6% [130/0.4] affects coagulation parameters [increase in PTI, INR, R time, k time] more than gelatin. Trial registration [protocol number-IEC/NP-189/2011]

Start time delays in operating room: different perspectives

Healthcare expenditure is a serious concern, with escalating costs failing to meet the expectations of quality care. The treatment capacities are limited in a hospital setting and the operating rooms [ORs]. Their optimal utilization is vital in efficient hospital management. Starting late means considerable wait time for staff, patients and waste of resources. We planned an audit to assess different perspectives of the residents in surgical specialities and anesthesia and OR staff nurses so as to know the causative factors of operative delay. This can help develop a practical model to decrease start time delays in operating room [ORs]. Aims: An audit to assess different perspectives of the Operating room [OR] staff with respect to the varied causative factors of operative delay in the OR. To aid in the development of a practical model to decrease start time delays in ORs and facilitate on-time starts at Jai Prakash Narayan Apex Trauma centre [JPNATC], All India Institute of Medical Sciences [AIIMS], New Delhi. We prepared a questionnaire seeking the five main reasons of delay as per their perspective. The available data was analysed. Analysis of the data demonstrated the common causative factors in start time operative delays as: a lack of proper planning, deficiencies in team work, communication gap and limited availability of trained supporting staff. Conclusions: The preparation of the equipment and required material for the OR cases must be done well in advance. Utilization of newer technology enables timely booking and scheduling of cases. Improved inter-departmental coordination and compliance with preanesthetic instructions needs to be ensured. It is essential that the anesthesiologists perform their work promptly, well in time . and supervise the proceedings as the OR manager. This audit is a step forward in defining the need of effective OR planning for continuous quality improvement