Dilated ascending aorta is associated with the difficulty in correct placement of pulmonary artery catheter.

The present case report highlights that a tense mega-sized aortic root and ascending aorta can mechanically resist the passage of fully inflated (1.5 ml air) balloon to wedge-trace position in the pulmonary artery. Any attempt to push the catheter rather predisposed its recoiling and rebutting into the right ventricle and the cardiac arrhythmia. Inflating continuous cardiac output catheter balloon with lesser volume of air (1 ml) is suggested to overcome this problem.

Absenteeism among nurses in a tertiary care hospital in India.

Background. Absence due to sickness among nurses has not been studied in-depth in the Indian setting. Methods. We studied the sickness pattern among 385 nurses during one calendar year and retrospectively compared the absenteeism among nurses in different work areas of a tertiary care hospital. Results. Sickness leave was availed by 68.9% of nurses at least once during the year. Nurses in the ward area were significantly older (43[5.4] years of age) than those in operation theatres (38[6.2] years of age) and intensive care units (39[5.9] years of age). The average annual duration of absenteeism per nurse (index of severity) was 27.7 days/ person. The average sickness leave days/spell (index of duration) was 8.82 days/person. The annual inception rate of nonsickness leave (index of frequency) was 1.57 spells/person and for sickness leave was 1.27 spells/person. While nurses working in the ward area took the highest number of unplanned sickness leave (7.36 days/spell), the planned sickness leaves were highest (64.8 days/spell) among those in operation theatres. About half the episodes of sickness were related to diseases of the respiratory tract, digestive system, infections and injury. Planned sickness leave mainly constituted maternity leave related to childbearing and was highest among younger nurses in operation theatres and intensive care units. Conclusion. Unplanned leave demands greater administrative adjustments and substitution. Inappropriate substitution may compromise patient care and sharing of work by the staff present; it may increase the workload and absenteeism. Occupational welfare services at tertiary care hospitals should work towards decreasing absence due to sickness among nurses.

Evaluation of lung infiltration score to predict postural hypoxemia in ventilated acute respiratory distress syndrome patients and the lateralization of skin pressure sore.

Context: Mechanical ventilation with positive end expiratory pressure (PEEP) is associated with unequal aeration of lungs in acute respiratory distress syndrome (ARDS) patients. Therefore, patients may develop asymmetric atelectasis and postural hypoxemia during lateral positioning. Aims: To validate proposed lung infiltration score (LIS) based on chest x-ray to predict postural hypoxemia and lateralization of skin sores in ARDS patients. Settings and Design: University hospital ICU. Prospective, observational study of consecutive patients. Materials and Methods: Sixteen adult patients of both genders on mechanical ventilation with PEEP for 24 to <48 hours. On chest x-ray, 6 segments were identified on each lung. The proposed LIS points (0- normal; 1- patchy infiltrates; 2- white infiltrates matching heart shadow) were assigned to each segment. Without changing ventilation parameters, supine, left and right lateral positions at 45° tilt were randomly changed. At the end of 20 minutes of ventilation in each position, we observed arterial oxygen saturation, hemodynamic and arterial blood gases. Later, position change protocol (4 hourly) was practiced in ICU, and skin pressure sore grading was noted within a week of ICU stay. Statistical Analysis Used: Nonparametric Bland and Altman correlation analysis, ANOVA and Student t test. Results: Arterial oxygenation (PaO 2 /FiO 2 = 313± 145.6) was significantly (P<0.01) higher in better lung (lower LIS)-down position than supine (PaO 2 /FiO 2 = 199± 70.2) or a better lung-up position (PaO 2 /FiO 2 = 165± 64.8). The positioning-related arterial oxygenation was significant (P< 0.05) at LIS asymmetry ≥3 between two lungs. Conclusions: The LIS mapping on chest x-ray was useful to differentiate between asymmetric lung disease and postural hypoxemia in ICU patients, which predisposed patients to early skin sore changes on higher LIS side.

Naloxone-induced pulmonary edema: a potential cause of postoperative morbidity in laparoscopic donor nephrectomy.

A 28-year-old patient operated for laparoscopic donor nephrectomy (LDN) developed overdose effect of fentanyl leading to poor postoperative recovery. Naloxone (200 microg) treatment was used to reverse fentanyl effects, but it was associated with hypertension. The patient developed pulmonary edema after 2 hours and required overnight mechanical ventilation with positive end-expiratory pressure. Volume overload prescribed in the management of LDN to overcome the immediate poor renal graft functioning probably predisposed this healthy young patient to develop cardiac failure during sympathetic surge associated with naloxone administration. The authors feel that the reversal of overdose effect of opioid by naloxone after intravascular blood volume expansion puts the patient at risk to develop pulmonary edema.

Induced mild hypothermia in post-cardiopulmonary bypass vasoplegia syndrome.

The state of vasoplegia in immediate post-cardiopulmonary bypass period is characterized by severe hypotension, supranormal cardiac output, low systemic vascular resistance (SVR), and resistance to vasoconstrictors. We could successfully use induced mild hypothermia to increase SVR, and could avoid very high doses of nor-epinephrine (>0.3 mcg/kg/min) in the background of severe pulmonary hypertension (systolic pulmonary pressure> 90 mmHg). Its effects such as decreased oxygen demand, positive inotropy and better right ventricle performance probably helped to improve oxygenation in presence of pulmonary oedema.

Butorphanol premedication to facilitate invasive monitoring in cardiac surgery patients before induction of anaesthesia.

Cannulations (peripheral vein, radial artery and jugular vein) performed for invasive monitoring before induction of anaesthesia in cardiac surgery patients may be associated with stress and anxiety. The efficacy and safety of butorphanol premedication was assessed in setting up of invasive monitoring. The study was a prospective, randomized, double blind, placebo controlled one with 70 patients undergoing elective cardiac surgery. In group-1 patients (n = 35) (placebo) intramuscular saline was administered 1-2 hours before the surgery in equivalent volume to butorphanol. In group-2 (n = 35) butorphanol (1, 1.5 and 2 mg for three body weight groups < 40 kg, 41-60 kg and> 60 kg, respectively) was administered 1-2 hours before surgery. Observer blinded for medication recorded the sedation score, pupil size and pain after each cannulation using visual analogue score (VAS). Student's 't' test and Chi-square test for proportions, Mann-Whitney test for non-parametric data was carried out. The median pain score of cannulation in group-2 (butorphanol) in the hand (10 mm) and neck (20 mm) were significantly (P < 0.05) lower than group-1 (placebo) patients (hand = 30 mm and neck = 40 mm). Pain during neck cannulation was significantly (P < 0.05) reduced (VAS < 30 mm) in patients with the pupil size of < 2.5 mm. Since the pain during neck cannulation was more than pain during hand cannulations in both the groups, we conclude that the intensity of pain depends also upon the site of cannulation. Besides the analgesic effect of butorphanol, its sedative effect helped to effectively decrease the pain during neck cannulation in conscious patients.

Chronic pain and cost: an epidemiological study in the communities of Sunsari district of Nepal.

The purpose of the study was to find out the prevalence of chronic pain in economically active population and associated economic loss. This cross-sectional observational study was carried out in 3 VDCs of Sunsari District involving 1730 individuals of 15-64 years age group selected by multistage random sampling. Demographic data, absence or presence of pain, site, severity, duration and relieving measures, approximate expenditure in treating pain and number of days lost due to pain were noted using a preformed questionnaire. Out of 1730 individuals interviewed, 882 (50.1%) had pain of which 93.7% had chronic pain (pain lasting for > 3 months). Backache (25.8%), headache (20.1%) and abdominal pain due to acid peptic disease (12.5%) were the most prevalent painful conditions. About 14.0% of individuals had severe grade pain. Female sex, age e"30 years, lack of formal schooling, smoking habit and dependent status were associated with higher prevalence of pain. Almost 19.0% of individuals with pain were unable to go to work the previous day. Man-days loss due to pain was 1.37 days/month/person in the study population. In terms of cost, pain related losses were Nepalese Rupees (NRs) 1671.89/person/year as against the per capita GDP of NRs 98,640.00 (US$ 1370.0). The money incurred by individuals for therapy on pain was NRs 760.15/person/year. In conclusion, probably first time, we are reporting the prevalence of chronic pain in our communities with people having to spend significant portion of their scarce income (and country's GDP) to treat pain, thus, highlighting it as a public health problem.

Continuous arteriovenous haemofiltration to regulate hyperkalaemia during renal transplantation: a case report.

Progressive hyperkalaemia is common in end stage renal disease patients waiting for renal transplantation. Ventricular tachycardia and ventricular fibrillation due to hyperkalaemia are life-threatening complications in these patients. In live and related renal transplant, after induction and anaesthesia, ventricular fibrillation and pulmonary oedema occurred. After immediate resuscitation by defibrillation and intravenous injection of adrenaline, the patient was put on continuous femoral arteriovenous haemofiltration (CAVH). This improved his pulmonary oedema, controlled hyperkalaemia and surgery could be completed uninterruptedly. After anaesthetising live and related kidney donor for nephrectomy, since it is not prudent to stop recipient surgery because of unforeseen complication, the authors wish to recommend CAVH as an alternative method to prevent life threatening cardiac complication of hyperkalaemia.

Scorpion sting envenomation presenting with pulmonary edema in adults: a report of seven cases from Nepal.

Scorpion sting is a common problem in villages of Eastern Nepal. The life-threatening complications of myocarditis and pulmonary edema is known in red scorpion in India but not reported in Nepal. This condition requires urgent attention and ICU care from few hours to days. Delay in recognition and the hypoxemia increase the morbidity and mortality. Illiteracy, ignorance, poverty, traditional faith healers trying treatment in remote areas, lack of transport in difficult terrains and the non availability of ventilation facility in nearby hospital, add to delay in appropriate treatment. Seven young adult patients admitted in a span of two years with history of scorpion sting presenting with pulmonary edema required ICU care. They were successfully managed with the positive pressure ventilation with PEEP, cardiac support with inotropes and fluid balance. Magnitude of problem, clinical presentation and management done is emphasized.

A randomized controlled double blind study on quick intubation regimen using vecuronium priming infusion technique with the use of patient controlled analgesia pump vs bolus priming technique.

BACKGROUND & OBJECTIVES: Priming principle is implied to hasten intubation with the use of vecuronium. Priming dose is usually injected by bolus and certain side effects have been observed due to acute rise in plasma levels after bolus injection. In the present study priming infusion regimen of vecuronium using patient controlled analgesia (PCA) pump was compared for the intubation dose onset, intubation, and the side effects with the usual bolus priming. METHODS: Adult ASA grade 1 patients of both sexes (n=112) were randomized into four groups of 28 patients each. In group 1 patients, vecuronium (10 microg/kg) was given bolus (30 sec). In group 2, priming infusion (5 microg/kg/min) regimen for vecuronium (1200 microg/kg) was used by setting up the background infusion rate (ml/h) at 1/4th of the patient body weight on PCA pump. Priming infusion for 3 min delivered the priming dose (15 microg/kg). In group 3, higher priming infusion (10 microg/kg/min) was given by setting up the PCA pump at the 1/2 the patient body weight for 1.5 min, to deliver same dose (15 microg/kg). In group 4, the priming infusion (10 microg/kg/min) for 2 min delivered higher priming dose (20 microg/kg). After induction of anaesthesia with fentanyl, propofol, the intubating dose of vecuronium (0.06 mg/kg) was injected by activating patient demand button and grading laryngoscopy/intubation after 1 min in each group. RESULTS: In demographically similar patients, the laryngoscopy/intubation was excellent in 53 per cent (group 3) and in 64 per cent patients (group 4) after 1 min of the intubation dose. While in bolus priming (group 1), 50 per cent patients developed ocular side-effects, none had it on priming infusion in groups 2 or 3. Only 2 patients complained of diplopia at the higher priming dose (20 microg/kg) (group 4). INTERPRETATION & CONCLUSION: PCA pump regimen for vecuronium priming infusion significantly shortened the onset of intubation. Side effects from the smaller priming dose by bolus were not seen in priming infusion regimen.

Silent blast in oral cavity: is the car battery innocuous?

Low voltage energy source is not free from danger. An exceptionally rare and peculiar mode of facial blast injury is reported. The blast took place silently in the mouth of a 15-year-old boy, due to short-circuiting of wires connected to a12-volt car battery while peeling off insulation with the intent of running a musical instrument. Airway compromise due to soft tissue injury produced further problem during tracheostomy. Emergent airway management is discussed. Post-healing sequel resulted in loss of voice and prevented normal oral feeding. The case report emphasizes need for education to public in handling low voltage energy source.

Pulmonary artery catheter insertion in a patient of dextrocardia with anomalous venous connections.

In a young adult patient having situs solitus with dextrocardia the attempted pulmonary artery catheter placement for emergency mitral valve replacement required an unduly long length (50cm) of catheter insertion to get into right ventricle and then into pulmonary artery. Although catheter coiling was suspected initially, chest x-ray taken after successfully placement revealed an uncommon congenital anomalous venous connection i.e. right internal jugular opening into left sided superior vena cava then into inferior vena cava after running all along the left border of the heart. With the result, it required to pass 50cm of PA catheter to get into right ventricle in our patient. This emphasizes the need to look for abnormal venous connections during echocardiography and x-ray screening in congenital heart disease. Fluoroscopy is recommended when an unusual length of pulmonary artery catheter insertion is required to enter the pulmonary artery.

A pharmacodynamic basis for the peak effect of vecuronium: peak twitch versus peak tetanic fade.

Double burst stimulation (DBS), a tetanic test, shows two types of changes during nondepolarising neuromuscular block (NMB) viz, amplitude (D1) suppression and fading of second response (D2), quantified as DBS ratio (D2/D1). During subclinical dose effect of vecuronium bromide both parameters show peak suppression at two distinct intervals. To evaluate, which of the two is the true peak effect of vecuronium, twenty-two ASA 1 patients were given im buprenorphine (5 micro/kg) premedication and iv diazepam (0.1 mg/kg). Vecuronium bromide (0.015 mg/kg) effect was monitored by stimulating ulnar nerve at the wrist. Adductor pollicis response of supramaximal DBS stimuli was recorded on myograph. DBS ratio was calculated with each DBS stimuli, using pocket calculator. In randomly allocated group 1 (n = 11) patients, repeat dose of vecuronium (0.08 mg/kg) was given at the peak D1 suppression and in group 2 (n = 11) at peak DBS ratio suppression. The onset time of repeat dose of vecuronium monitored by one Hz stimuli, to '0' response in group 2 (37.3 +/- 6.65 second) was significantly (p < 0.01) shorter than in group 1 patients (46.8 +/- 9.3 second). It was noteworthy that at the repeat dose of vecuronium while D1 showed recovery in group 2 patients, DBS ratio was concomitantly and significantly lower (0.37 +/- 0.10) (more intense NMB) than in group 1 (0.49 +/- 0.17) patients, with quicker onset of repeat dose. These findings suggest that as the NMB agents show two types of changes during clinical monitoring, DBS test seems to be a better clinical pharmacodynamics-monitoring test for NMB agents. In addition, the peak tetanic fade (peak DBS ratio suppression) correlated with peak effect of vecuronium than the usually measured peak twitch suppression.