Epidural catheter migration in non-obstetric adult surgical patients: A prospective, observational, cohort study.

Background and Aims: Epidural catheter migration is a well-described complication in the obstetric population, though its significance in the non-obstetric surgical population is not known. The purpose of this study was to explore the incidence of epidural catheter migration in a non-obstetric adult surgical cohort, assess the factors associated with migration and analyse complications among patients with and without catheter migration. Methods: In this single-centre, prospective, observational study, the acute pain services team collected data over 12 months on consecutive, adult non-obstetric surgical patients who received an epidural catheter for postoperative pain management. Details of epidural catheter insertion, fixation, migration and complications were collected from the first to the fourth postoperative day. Results: Of the 510 patients recruited, epidural catheter migration was noted in 233 patients (45.7%), of which 152 (65.2%) migrated outwards and the rest migrated inwards. Also, 72 (30.9%) and 86 (31.05%) complications were noted in the groups with and without catheter migration, respectively. The most frequent complications noted were inadequate analgesia, unilateral sensory block, motor block and hypotension in both groups. We did not find any correlation between the frequency of epidural catheter migration and demographic factors. Conclusions: Epidural catheter migration is a sizeable postoperative occurrence in non-obstetric surgical patients. Factors that might play a role in catheter migration could not be established in this study. There is an almost similar frequency of complications noted among patients with and without catheter migration, with the most common being inadequate analgesia in both groups.

Improving safety in anesthetized patients undergoing magnetic resonance imaging-Concept of time-out in the MRI suite and measures to improve adherence to time-out protocol.

BACKGROUND: The time-out protocol introduced by the Joint Commission is an important tool to prevent adverse events and improve safety in various health-care environments. However, its implementation and utilization involve human, social, behavioral as well as system issues. AIMS: The SMART aim of the current project was to increase the utilization of the time-out protocol to more than 80% from baseline of 13%, over 6-month period in all the magnetic resonance imaging (MRI) procedures performed at a tertiary care, teaching institute in South India. METHODS: The Plan, Do, Study, Act (PDSA) cycle and root cause analysis strategies were utilized in this quality improvement initiative. The time-out protocol was modified for MRI environment and put into practice to improve safety. Six months after the initiation of this safety protocol, our audit showed only a 13% compliance to the time-out protocol. A multimodal strategy was utilized by involving all the stakeholders, educational interventions, and placing reminders for following the time-out protocol, to affect change and achieve improvement in safety. RESULTS: The compliance to time-out protocol increased from 13% to 86% and the run chart showed that a special cause variation indicated by six points above the centerline at 86%. When analyzing individual components of the time-out, the greatest improvement was noted in the ferromagnetic check of the personnel involved, namely, the Anesthesiologist, radiographer, and anesthesia technician. There were no delays in the list because of adherence to the time-out protocol. CONCLUSION: Time-out protocol in an MRI suite provides a final check to the anesthesia team before the anesthetized patient is wheeled into MR gantry. Using quality improvement methodology, we increased the compliance of time-out protocol in the magnetic resonance imaging environment. Our study is an example how other institutions in India and elsewhere can adapt similar improvement strategies to enhance patient safety.

Timeliness of care and adverse event profile in children undergoing general anesthesia or sedation for MRI: An observational prospective cohort study.

BACKGROUND AND AIMS: Anaesthesia for children undergoing magnetic resonance imaging (MRI) ranges from moderate to deep sedation in order to facilitate uninterrupted completion of the scan. While various intravenous and inhalational techniques of anaesthesia have their own merits and demerits, there is a paucity of comparative literature between the two in children undergoing diagnostic MRI. MATERIALS AND METHODS: This prospective observational cohort study was conducted at the Radiology suite of a 2800-bedded tertiary care hospital, wherein 107 unpremedicated children between the ages of 6 months to 15 years received either sedation with propofol infusion (Group GSP, n = 57) or inhalational anaesthesia with a laryngeal mask airway (Group GAL, n = 50). Primary outcome measures included time to induction and time to recovery. Secondary outcomes comprised the incidence of respiratory and non-respiratory adverse events in the two groups. RESULTS: The median time to induction was significantly shorter in GSP than GAL [7.00 (IQR 5.0, 10.0) versus 10.00 minutes (IQR 8.8, 13.0), P < 0.001]; the incidence of desaturation [8 (16.0%) in GAL, 1 (1.8%) in GSP, P = 0.012], laryngospasm [11 (22.4%) in GAL, 1 (1.8%) in GSP, P = 0.001] and emergence delirium (5 (10%) in GAL, 0 in GSP, P = 0.047) were significantly greater in the GAL group. There was no difference in the time to emergence, nausea and vomiting or bradycardia between the two groups. CONCLUSION: Sedation with propofol infusion during paediatric MRI scan offers a short turnover time and favourable adverse event profile when compared to inhalational anaesthesia with an LMA.

Seesawing end-tidal carbon dioxide: portent of critical carbon dioxide embolism in retroperitoneoscopy.

An abrupt increase in end-tidal CO2 (EtCO2; from 35 to 58 mm Hg) followed by a sudden fall (to 18 mm Hg) was noted during retroperitoneoscopic adrenalectomy under general anaesthesia in a 23-year-old patient with adrenal hyperplasia. This was accompanied by hypotension (systolic blood pressure of 60 mm Hg), desaturation (88% SpO2) and ST depression (3.5 mm). The patient was resuscitated with fluids and vasopressor drugs and about 4 mL of air was aspirated through the central venous catheter, confirming the diagnosis of an intraoperative gas embolism. Later, a rent in the adrenal vein extending into the inferior vena cava was discovered and sutured. The blood pressure, EtCO2, ST segment and pulse oximetry returned to normal after 15 min. This case demonstrates that gas embolism may transpire during retroperitoneoscopic adrenalectomy and an acute rise followed by a sharp fall in EtCO2 should alert the anaesthesiologist to this rare but potentially fatal complication.

A Randomized Controlled Trial Studying the Role of Dexamethasone in Scalp Nerve Blocks for Supratentorial Craniotomy.

BACKGROUND: The aim of this double-blinded randomized control study was to examine the role of the steroid dexamethasone as an adjuvant to lignocaine and ropivacaine in scalp nerve blocks in adults undergoing supratentorial craniotomy under general anesthesia. We compared the intraoperative anesthetic and postoperative analgesic requirement with and without the addition of dexamethasone to the local anesthetics. METHODS: The consented 90 patients were randomized into 2 groups: one group received 8 mg (2 mL) of dexamethasone, whereas the other received 2 mL of normal saline along with the local anesthetics in the scalp nerve block administered soon after induction of general anesthesia. All patients received oral/intravenous dexamethasone perioperatively to decrease cerebral edema. The general anesthetic technique for induction, maintenance, and recovery was standardized in the 2 groups. The primary outcome assessed was the time to administration of the first dose of analgesic postoperatively. The secondary outcomes included intraoperative opioid requirement, time to emergence, and incidence of postoperative nausea and vomiting. RESULTS: There was no significant difference between the dexamethasone and saline groups with respect to time to first analgesic requirement, intraoperative fentanyl requirements, time to emergence from general anesthesia, and incidence of postoperative nausea and vomiting. CONCLUSIONS: Addition of dexamethasone as an adjuvant to local anesthetics in scalp nerve blocks in the setting of perioperative steroid therapy does not appear to provide any additional benefit with respect to prolongation of the duration of the block.

Polythene predicament.

BACKGROUND: Hypoxemia complicating care during ventilation is a common problem. OBJECTIVE: To describe an unusual cause of hypoxemia with fluctuating airway pressures in an invasively ventilated, organophosphate-poisoned patient. CASE REPORT: A 40-year-old man being treated for organophosphate poisoning developed episodes of high airway pressure during mechanical ventilation. These episodes initially settled spontaneously. Detailed evaluation failed to reveal any patient-, airway-, or ventilator-related cause for the high airway pressures. On the fourth hospital day, one such episode of high peak airway pressures persisted and was associated with low tidal volumes and oxygen desaturation. Several attempts at suctioning were unsuccessful and the suction catheter could not be advanced. When the endotracheal tube was removed, a piece of polythene was found at the lower end of the endotracheal tube. This polythene probably resulted in this unusual problem by behaving like a flap valve, causing fluctuating airway pressures initially, and high airway pressures subsequently. There were no further episodes of high airway pressure, and a bronchoscopy did not reveal any residual pieces of polythene. On subsequent questioning, it was revealed that the patient was discovered unconscious with a stuffed polythene cover containing the poison in his mouth. It was likely that the polythene was aspirated when the patient was drowsy, or it was pushed into the airway during intubation. CONCLUSION: The importance of careful visualization of the oral cavity before intubation is illustrated in this report. A bronchoscopy may aid in the evaluation of intermittent high airway pressures once pneumothorax and bronchospasm are excluded and should be considered early if an obvious cause for the high airway pressure is not evident.

Distribution analysis of deacetylase SIRT1 in rodent and human nervous systems.

Sirtuins function with other biogenic molecules to promote adaptation to caloric restriction in a broad spectrum of eukaryotic species. Sirtuin pathways also converge in the mammalian brain where they appear to protect neurons from nutrient stress. However, few anatomical studies on sirtuins (e.g., SIRT1) are available, particularly those detailing the spatial distribution and subcellular localization pattern of SIRT1 in the brain parenchyma. Here, we report the characterization of a panel of SIRT1-specific antibodies within rodent (i.e., rat and mouse) and human central nervous systems. Immunocytochemical and Western blot analyses indicate that the subcellular localization of SIRT1 is predominantly nuclear throughout the rodent brain and spinal cord. A similar subcellular distribution pattern of SIRT1 was detected in human central nervous system material. SIRT1 is ubiquitously present in areas of the brain especially susceptible to age-related neurodegenerative states (e.g., the prefrontal cortex, hippocampus and basal ganglia). Further, we show no apparent species-specific differences in the subcellular localization pattern of rodent versus human SIRT1. Finally, we identify the chemical phenotype of SIRT1-containing neurons in a number of brain sites that are strongly compromised by aging. These data provide additional and important anatomical findings for the role of SIRT1 in the mammalian brain and suggest that SIRT1 pathways are broadly distributed in neurons most susceptible to senescence injury. Activating endogenous sirtuin pathways may, therefore, offer a therapeutic approach to delay and/or treat human age-related diseases.

Distribution of constitutively expressed MEF-2A in adult rat and human nervous systems.

Myocyte enhancer factor 2A (MEF-2A) is a calcium-regulated transcription factor that promotes cell survival during nervous system development. To define and further characterize the distribution pattern of MEF-2A in the adult mammalian brain, we used a specific polyclonal antiserum against human MEF-2A to identify nuclear-localized MEF-2A protein in hippocampal and frontal cortical regions. Western blot and immunocytochemical analyses showed that MEF-2A was expressed not only in laminar structures but also in blood vessels of rat and human brains. MEF-2A was colocalized with doublecortin (DCX), a microtubule-associated protein expressed by migrating neuroblasts, in CA1 and CA2 boundaries of the hippocampus. MEF-2A was expressed heterogeneously in additional structures of the rat brain, including the striatum, thalamus, and cerebellum. Furthermore, we found a strong nuclear and diffuse MEF-2A labeling pattern in spinal cord cells of rat and human material. Finally, the neurovasculature of adult rats and humans not only showed a strong expression of MEF-2A but also labeled positive for hyperpolarization-activated, cyclic nucleotide-regulated (HCN) channels. This study further characterizes the distribution pattern of MEF-2A in the mammalian nervous system, demonstrates that MEF-2A colocalizes with DCX in selected neurons, and finds MEF-2A and HCN1 proteins in the neurovasculature network.