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Presentation of a thymoma during pregnancy means that safe delivery becomes more challenging. We present a 33-year-old pregnant woman who was diagnosed with a large thymoma causing marked compression of the tracheobronchial tree and right atrium. After various multidisciplinary meetings she presented for elective caesarean section delivery at 31 weeks of gestation. A combined spinal-epidural anaesthesia was performed, along with colloid pre-and co-loading, and vasopressor support. The delivery was uneventful. The possibility of catastrophic complications was foreseen. Therefore, all requirements for the possibility of airway or haemodynamic collapse were planned carefully, including the possibility of emergent cardiopulmonary bypass.Copyright © 2023, College of Anaesthesiologists of Sri Lanka. All rights reserved.
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BackgroundPenetrating injury of the oropharynx occurs frequently in children, however, anesthetic management is seldom described in such cases.Case presentationA 2-year old child came to the emergency room with a toothbrush impacted in the gingivobuccal sulcus making airway management difficult. We used a simple yet unique approach to secure the airway safely given the lack of pediatric size fibreoptic and videolaryngoscopes in our emergency operation theatre. The patient was kept in Pediatric ICU and watched for any complications and discharged on the 4th postoperative day.ConclusionsThus, ingenious non-invasive techniques to secure the airway can prevent the patient from undergoing surgical tracheostomy.
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Background Recently, several cases of mucormycosis in people with coronavirus disease 2019 (COVID-19) have been increasingly reported worldwide, in particular from India. As an increasing number of post-COVID patients with mucormycosis are presenting for surgical management, the onus is on the anaesthesiologists to adequately evaluate and optimise such patients.Case presentationWe present three cases to highlight the anaesthetic challenges in patients undergoing functional endoscopic sinus surgery (FESS) with debridement surgery for mucormycosis through a series of three cases. In our manuscript, two cases had comorbidities as a challenge uncontrolled diabetes and hypertension. The third case had difficult intubation due to a small mouth opening which was probably due to swelling and tenderness as a result of rhino orbital mucormycosis.ConclusionsProper anticipation, optimization and timed promptness to deal with the anaesthetic challenges pertaining to the multisystemic involvement and sequelae of mucormycosis should be done.
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By 2022, publishing has already returned to the standard. This means that the global SARS-CoV-2 pandemic for anaesthesiologists is all but forgotten, and the safety of anesthesia is again the dominant issue. However, in addition to the traditional search for answers to whether we should prefer regional or general anesthesia and for which procedures and what is the best prevention of PONV, there is now another associated topic - postoperative delirium and postoperative cognitive dysfunction. Although both entities are crucial to the overall perioperative course, they still need more attention. This is even though, especially in elderly patients, they have already been shown to significantly affect perioperative morbidity and mortality. Moreover, to the surprise of many, recent data show that their incidence is not so much dependent on the type of anesthesia but on the quality of its administration. This text aims to briefly summarize some key publications in the field of anesthesiology and to highlight papers that should not escape attention.Copyright © 2022, Czech Medical Association J.E. Purkyne. All rights reserved.
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BackgroundThere has been a rise in cases of sino-nasal mucormycosis in patients who contracted the COVID-19 virus and were on steroids. Population at risk includes diabetics and on immunosuppressant therapy and/or immunocompromised state. Perioperative management becomes challenging due to residual pulmonary disease secondary to COVID pneumonia and complication following systemic antifungal therapy. Such patients often have other associated illnesses like hypertension, obesity, and deranged renal functions, either as a part of metabolic syndrome or post-systemic antifungal therapy.Case presentationWe report a case of a 64-year-old female, a poorly controlled hypertensive, with class 1 obesity, and diabetic on oral hypoglycemic agents, hypothyroid on oral medications, and post-COVID pneumonia with recently diagnosed sino-nasal mucormycosis who was posted for debridement of the sino-nasal fungal mass. The gamut of co-morbid conditions along with post-COVID pneumonia status presents an anesthetic challenge apropos the optimization of the clinical conditions and timing of the surgery considering the emergent nature of the surgery.ConclusionsThe timing of operative intervention for such patients is imperative and the treating team of anesthesiologist and the otorhinolaryngologist should aim to strike a balance between timely intervention to negate the spread of the infection to the orbit and brain causing potential irreparable damage and optimizing the cardio-respiratory and renal functions.
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From the Evidence-based medicine (EBM) point-of-view, the year 2022 due to the slowly subsiding world SARS-CoV-2 pan-demic, brought the whole complex of articles, publications, and guidelines once again. The aim of the article Year 2022 in pediatric anesthesia and intensive care is to highlight the important publications that should not be missed due to their impact on daily clinical practice.Copyright © 2022, Czech Medical Association J.E. Purkyne. All rights reserved.
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Objective We aimed to compare the effect of tocilizumab and itolizumab in terms of PaO2/FiO2 ratio (P/F ratio), interleukin 6 (IL-6) level, serum ferritin, C-reactive protein, and a reduction in mortality. Our primary objective was to compare P/F ratio at various time intervals: baseline (before administering the drug), 12 h after drug administration, once a day for the next 7 days, and on the 14th day. Our secondary objective was to evaluate serum level of biomarkers like IL-6, ferritin, and C-reactive protein before start of drug infusion and following drug infusion at 72 h and on 7th day. Patients and methods A total of 50 patients, age between 18 and 60 years, having moderate Acute Respiratory distress syndrome (ARDS) following coronavirus disease 2019 infection were recruited. Patients of group I received a single dose of injection of tocilizumab 8 mg/kg intravenously (i.v.) via infusion over 1–2 h. Group II patients received premedication with hydrocortisone 100 mg and pheniramine 30 mg and a single dose of injection itolizumab 1.6 mg/kg dissolved in 250 ml of 0.9% normal saline infusion over 5–6 h. Results We observed significantly higher P/F ratio in the itolizumab group (239.18±97.31) than in the tocilizumab group (104.87±75.25) on the 3rd day following drug administration (P<0.001). Similarly, the IL-6 level was lower in the itolizumab group (72±100) in comparison with the tocilizumab group (682±1360), and the differences were statistically significant (P<0.05). We identified adverse effects of the drugs in 10 patients who have received itolizumab. Conclusion We observed an increasing trend in P/F ratio on the 3rd day following itolizumab administration in comparison with tocilizumab, and the difference was statistically significant (P<0.001).
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Mucormycosis is a progressive, opportunistic fungal infection with high risk of mortality. Rampant use of steroids in the treatment coronavirus disease 2019 creates a fertile environment for mucor growth. Perioperative challenges for the anesthesiologist in a patient having post-coronavirus disease mucormycosis include increased risks of arterial and venous thromboembolism, poor glycemic control and myocardial dysfunction, adrenal insufficiency from corticosteroid use, pulmonary dysfunction, and residual neuromuscular weakness. So, a complete biochemical workup of renal functions, hypothalamic–pituitary–adrenal axis, electrolyte, coagulation profile, optimization of blood glucose, and pulmonary function should be done.
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Background Inflammatory markers like interleukin-6 (IL-6) are linked to the worse outcome in coronavirus disease 2019 (COVID-19) cases. Other markers such as C-reactive protein are not as reliable as IL-6 in predicting respiratory failure. Aim To assess the function of IL-6 as a predictor of COVID-19 severity. Patients and methods A total of 50 severe and critical patients with PCR-confirmed COVID-19 were included. All enrolled patients followed the case definition for confirmed cases of Egyptian national protocol for COVID-19 issued by MOHP. Clinical assessment, imaging, and laboratory data were recorded at admission. Pulmonary function was evaluated by SpO2/FiO2 ratio. Outcomes included hospital stay, prognosis of the disease, complications, death rate, and discharge, which were recorded during the follow-up. Results The elevated IL-6 group showed a significantly higher critical rate (87.1%) than the normal IL-6 group (26.3%) (P<0.0001), and the improvement rate was higher in the normal IL-6 group (73.7%). Moreover, the death rate was significantly greater in the elevated IL-6 group (38.7%) than the normal IL-6 group (10.5%) (P=0.033). The cutoff value of IL-6 levels in prediction of severity and mortality of COVID-19 was assessed. Our receiver operating characteristic results revealed that IL-6 cutoff value is higher than 50.27 for severity and the cutoff value is greater than 120.83 for mortality. The sensitivity values of IL-6 for severity and mortality were 93.3 and 90.5%, respectively, and the specificity values were 90.0 and 86.7%, respectively. Conclusion Elevated levels of serum IL-6 in COVID-19-infected patients were related with a variety of adverse outcomes, including severe illness, mechanical ventilation, and acute respiratory distress syndrome. When it came to accurately predicting the severity and mortality of COVID-19, the optimum IL-6 cutoff levels were 50.27 and 120.83 pg/ml, respectively.
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Since the outbreak of the Coronavirus Disease-2019 (COVID-19) pandemic many elective cases were postponed worldwide. But emergency Lower Segment Caesarean Sections (LSCS) is one surgery which can't be postponed at any cause since two lives are at risk. This case series reports 16 symptomatic COVID-19 patients in whom emergency LSCS was performed. The aim of presenting the series was to analyse how far the clinical and laboratory findings were deranged in such patients and to find out whether the current anaesthetic techniques were safe in these patients. Out of a total of 157 COVID-19 positive patients who had undergone LSCS in the study, 16 presented with symptoms such as fever, cough, dyspnoea, rhinitis, headache and palpitation. Six (37.5%) were preterm. Seven patients had elevated C-Reactive Protein (CRP) (> 5 mg/L). Liver function tests abnormalities were seen in five (31.25%). Most of the patients had elevated D-dimer of which (> 1500 ng/mL) were seen in seven. The most common indication was foetal distress. COVID pneumonia was an indication for LSCS in three (18.75%). All the surgeries were performed under subarachnoid block. Of the four patients who had fall in oxygen saturation two were admitted in Intensive Care Unit (ICU) and one required Non Invasive Ventilation (NIV). There were no mortalities. Thus, LSCS can be done safely under subarachnoid block even in symptomatic COVID-19 parturients. Elevation of D-dimer is common in pregnancy and it does not always indicate severe COVID-19 disease.
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Coronavirus disease 2019 (COVID-19) is a contagious pulmonary infectious disease with respiratory symptoms. The virus, SARS-CoV-2 has shown 85% resemblance to SARS coronavirus (SARS-CoV) and MERS coronavirus (MERS-CoV). The management of a COVID-19 positive mother is challenging as the virus is extremely contagious and can be life threatening to mothers and health-care personnel. Here, we describe the successful anesthetic management of 20 pregnant women with confirmed COVID-19 infection undergoing cesarean section in our hospital. A dedicated operating room was used for cesarean delivery of a parturient with COVID-19. This dedicated operating room was located in the secluded area of our hospital, away from the rest of the operating rooms. The first choice of anesthesia was a single-shot subarachnoid block with 0.5% heavy bupivacaine.
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BackgroundThe purpose of the study was to find out correlation between severity of disease and vaccine in COVID-19 pandemic. Primary objective was to know occurrence of post-vaccination breakthrough infections in hospitalized patients and secondary objective was to know of COVID-19 vaccine to prevent severe infection, morbidity, and mortality of patients. This retrospective observational multicentric study included 325 confirmed COVID-19 patients on NRBM/BIPAP/ventilator admitted in high dependency unit (HDU)/intensive care unit (ICU) were divided into based on severity of symptoms and vaccination status. We included adult patients having positive RTPCR (reverse transcription polymerase chain reaction) COVID-19 test/high-resolution computed tomography scan (HRCT) thorax suggestive of COVID-19 pneumonia. Patients who developed adverse reaction post-vaccination, pregnant patient, and lactating mother were excluded from the study.ResultsTotal 325 confirmed COVID-19-positive patients were studied. Statistical analysis with SPSS version 26 and data were analyzed by chi-square test and P value < 0.05 were considered as significant. Total duration of hospital stay was less in vaccinated patients compared to non-vaccinated patients. Oxygen requirement was also less in vaccinated patients. Vaccinated patients developed less severe infection than non-vaccinated patients.ConclusionsCOVID-19 vaccination is very effective against severity of disease. It reduces hospitalization, oxygen requirement, and mortality.
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BackgroundMethaemoglobinemia (MetHb) is a rare entity in clinical practice which often goes undiagnosed and keeps both the anaesthesiologist and attending surgeon under tension during surgery on seeing dark or chocolate-coloured blood in the surgical field. A low oxygen saturation (SpO2) will further panic us to search for a cause but may end futile. To add further, SpO2 may not rise significantly with adequate oxygenation and may not reach 100 with a fraction of inspired oxygen (FiO2) of 1 which keeps us searching further for a cause. An arterial blood gas (ABG) finally clinches our diagnosis. It is often missed in the pre-anaesthetic evaluation due to its rarity and the patient being asymptomatic most of the time.Case presentationWe present a case of a 61-year-old man, a reformed smoker and hypertensive on regular medication was evaluated for laparoscopic partial nephrectomy for right renal cell carcinoma. MetHb was diagnosed preoperatively in the midst of the COVID pandemic when we had all our patients’ room air SpO2 recorded and thus helped us in the smooth and hassle-free management with vitamin C preoperatively for 5 days and an uneventful perioperative period.ConclusionsMetHb is an uncommon and potentially reversible cause of hypoxia. A simple bedside SpO2 evaluation may give a hint to the diagnosis along with a high haematocrit which urges us to order for an ABG when no other cause is attributable. A preoperative diagnosis can lead to an effective and simple management with vitamin C which often reduces methaemoglobin to significantly low levels and to have a favourable outcome. According to the literature, any level of less than 20% does not have much clinical significance in asymptomatic patients and surgery need not be deferred.
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B415 Table 1 B415 Table 2ConclusionsWe noticed an increase in performing regional anaesthesia after the pandemic in our institute. Although we observed more complications in the pandemic than in 2019;postoperative complications,including pulmonary were lower in patients had regional anaesthesia.
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Background and AimsDifferent descriptions of long COVID have already been proposed, and the most common description includes symptoms lasting for over three months after the first symptom onset. One of the most frequent symptoms identified, besides fatigue and dyspnoea, is a new daily persistent headache.1MethodsWe describe a case of persistent headache associated with COVID-19, which had a poor response to pharmacological treatment. The patient scored a pain of 8 points in Visual Analog Scale (VAS). It was a widespread—affecting frontal, temporal, and occipital area—pulsating quality headache that worsened with mild physical activity.Since Botulinum toxin type A has been used to treat chronic migraine for over a decade, we decided to try this therapeutic option after proving that the response to local anesthetics was positive.ResultsShe responded satisfactorily to bilateral greater occipital nerve block and infiltration of the frontal and temporal muscles with local anesthetic and corticosteroids, with an improvement during approximately 48 hours.Two weeks later, we administered by ultrasound guidance 20 IU of botulinum toxin near the greater occipital nerve, and performed a mapping with botulinum toxin by administering it at different points: both trapezius, splenius, frontal muscles, bilateral orbicularis and bilateral temporal and parietal muscles. After seven days, the patient reported improvement of the symptoms (VAS 3) that were still present one month later.ConclusionsIn conclusion, we propose that botulinum toxin can be a therapeutic option for persistent headaches associated with COVID-19. However, future research studies are required to clarify this possibility.
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B265 Figure 1ResultsContinuous fractional spinal anesthesia offers the advantage of fractionating the doses of local anesthetic in the subarachnoid space and has lesser effect on respiratory and cardiac physiologyConclusionsContinuous spinal anesthesia (CSA) is a safer alternative technique to general anesthesia in patients with severe cardio - respiratory disease in whom general anesthesia could result in prolonged ICU stay.
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Background and AimsThe present survey was designed to ascertain impact of pandemic on regional anaesthesia(RA) practice, the strategies necessary to counter the hinderances and improve its safe utilization.MethodsAfter IRB approval and CTRI, this validated google form based cross-sectional survey was circulated through social-media platforms to various anaesthesiologists using a snowball sampling technique. The participation was voluntary and survey included questions to assess the challenges faced in pursuing RA during COVID era, effect of PPE, effect on training/research activities related to RA and the strategies adopted to overcome challenges.ResultsA total of 532 anaesthesiologists filled the survey and majority(86%) were from a teaching hospital. 68.5% felt there was an increase in RA use post COVID -19. A web-based learning for regional anaesthesia was provided to 61% of respondents. While performing RA in positive patients, majority felt that PPE resulted in poor vision due to fogging(91%), increased attempts( 63%) and performance time(46.9%). Disposable plastic drapes were preferred by most( 75%) and sharps were collected in separate bags for disposal(53%). After surgery, the OR was cleaned using sodium hypochlorite (37.6%), hydrogen peroxide ( 37%) or 75% alcohol ( 55.26%) and a sterile camera cover was used by most (65.8%) respondents.ConclusionsRA was preferred if feasible in COVID-19 patients and its utilization increased during COVID. Use of PPE hindered the performance of blocks. Regarding sterility practices, disposable drapes were preferred, and more stringent measures were used for cleaning the ultrasound machine used and the OT following the case in COVID era.