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

Termination of ventilatory support of a patient under compulsion, who is not yet brain dead

Clinicians are more comfortable psychologically in withholding a treatment than withdrawing it. Reasons for this are related to the fact that withholding is passive, whereas withdrawing is active and associated with a greater sense of moral responsibility. Withdrawing or terminating ventilation in Intensive Care Unit [ICU], even in a terminally sick patient, needs thoughtful review, particularly in those patients who are not yet brain dead. So many arguments may be offered against termination of ventilatory support. Ventilation is a part of palliative care which is always instituted to improve the quality of life and to relieve physical as well as psychosocial problems. Age is a very important factor as younger patients have a greater chance to improve than elderly, if the brain is not yet dead. Even during end of life care, not only ventilation is continued, but antibiotics, nutrition and care of bed-sores etc is also continued. As far as moral principles are concerned, termination of ventilation or withholding it, are equivalent in terms of medical ethics. Dignity of dying is as vital and important as dignity of living. One can always justify continuation of ventilation on ethical grounds. There is clinical precedence for this practice. In the opinion of the Supreme Court, withdrawing of life support should be considered synonymous as a kind of euthanasia. So, the termination of ventilation under compulsion would stand illegal and unlawful. Discontinuation of ventilation on economic reasons must be considered immoral and irrational. Sometimes the decision of terminating ventilatory support may be taken in the absence of interdisciplinary communication or that with the family of the patient. Many religious beliefs argue against the termination of ventilation. There are some religious groups who even challenge the existing brain death criteria. I would suggest that all these factors should be considered before taking the decision to terminate the ventilatory support under compulsion in a terminally sick patient, whose is not yet brain dead

Incidence of diabetic dermopathy

To assess the incidence of diabetic dermopathy and to correlate the incidence in diabetics and non diabetics. The study was done in 250 patients who attended skin outpatient department of our hospital. Thorough general physical examination and dermatological examination was carried out in each case. All the cases were noted and comparison between the diabetics and non diabetics was done. The incidence of diabetic dermopathy in our study was 21 [16.8%] cases in diabetics and 9[7.2%] cases in non diabetics which was statistically significant. Any obese patient present with multiple shin spots having fasting blood glucose levels towards the higher side of normal along with a positive family history of diabetes mellitus should undergo further investigation to rule out the possibility of early diabetes and other microangiopathies as recognition of this finding is the key to early diagnosis, prevention and treatment of chronic disease like diabetes

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

Induction-intubation response - smokers vs non-smokers

Tobacco smoking has been established to be a hazardous activity. Changing social attitude is bringing a decline in tobacco consumption but a significant proportion of patients presenting for surgery still continues to smoke, putting themselves at risk of perioperative complications. We evaluated induction-intubation response in 40 male patients [ASA-I] divided into two groups of 20, each consisting of smokers and non-smokers. All patients received standard premedication and general anesthesia. Heart rate, blood pressure and rate-pressure product were measured prior to induction, just before intubation and at 1,3,5 and 10 minutes after intubation. Continuous electrocardiography [EKG lead II] monitoring was done. Carboxyhemoglobin and total hemoglobin were estimated at the time of securing venous access. Arterial blood gases were analyzed 5 minutes before and after the tracheal intubation. Incidence of arrhythymias [30%] was higher in smokers compared to non-smokers [10%]. Mean carboxyhemoglobin [COHb] level in smokers was 3.81 +/- 2.17 gdL[-1] as compared to 2.95 +/- 1.33 gdL[-1] in non-smokers. Four patients who continued to smoke till the day of surgery had higher COHb levels [8.2, 5.9, 6, 8.8 gdL[-1]]. PaO[2] and PaCO[2] levels were comparable in both groups. During induction-intubation period, heart rate; systolic, diastolic and mean arterial pressure and rate-pressure product showed more pronounced fluctuations in smokers than in non-smokers [p<0.05]