Bacterial colonization of peripheral intravenous cannulas in a tertiary care hospital: A cross sectional observational study.

BACKGROUND: The use of intravenous (IV) cannulas is an integral part of patient care in hospitals. These intravenous cannulas are a potential route for microorganisms to enter the blood stream resulting in a variety of local or systemic infections. Studies showing the actual prevalence of colonization of peripheral IV cannulas and its role in BSI are lacking. Hence, this study was aimed to estimate the prevalence of colonization of the injection ports of peripheral IV cannulas. METHODS: This cross sectional study was conducted on patients admitted in ICU and wards in an 800 bedded tertiary care hospital. Swabs were taken from lumens of peripheral IV cannulas and cultured. Patient demographic data and practices followed for maintenance of IV line were noted. RESULTS: A total of 196 injection port samples were taken, out of which 11 tested positive for microbial growth (5.61%). Staphylococcus aureus was the predominant organism contributing 64% of the microbial growth. A significant association was seen between presence of local signs, old age and positive cultures. Flushing IV cannula every 6 h was associated with negative cultures. CONCLUSION: Peripheral IV cannulation has significant potential for microbial contamination and is largely ignored. Most of the risk factors associated with growth of microorganisms in the injection ports of peripheral intravenous cannulas (which has a potential to cause catheter-related blood stream infections) can be prevented by improving protocols for management. To prevent infection from occurring, practitioners should be educated and trained about the care and management of IV.

Anaesthetic management of forearm fractures using a combination of haematoma block and intravenous regional anaesthesia.

BACKGROUND: Intravenous regional anaesthesia (IVRA) has been successfully used as a sole technique for forearm fractures and has high success rates. However, it is uncomfortable for the patient when the fresh fracture is manipulated for conduct of IVRA. Haematoma block (HB) has also been demonstrated as an effective anaesthetic technique for treatment of radial fractures in the ER. Unfortunately, HB does not provide muscular relaxation and may not be sufficient for operative intervention. METHODS: An observational case series was designed with the hypothesis that a combination of HB and IVRA would overcome the aforementioned drawbacks. A standardized protocol was followed for HB with 0.1 ml/kg of 0.5% bupivacaine preceding the conduct of IVRA, which permitted adequate exsanguination of the extremity (using compression bandage). For IVRA, 0.5% lignocaine at 3 mg/kg was used with an electro-pneumatic tourniquet. Pain scores were noted after the HB, at exsanguination and during surgery. RESULTS: 100 cases were studied. Average time of onset of block after HB was 2 min 18 s. By the time the IVRA procedure was performed, 99% of patients had a pain score of zero. The quality of surgical anaesthesia revealed that 94% of the patients did not have any pain of incision, tourniquet or positioning at any time during surgery. CONCLUSION: The use of dual technique of HB and IVRA improved patient acceptance and compliance, and the safety and efficacy of the IVRA. The combination anaesthesia was found to be easy to administer, effective and safe with no complications.

Posterior reversible encephalopathy syndrome posttransplantation: a case report of possible association with cerebrospinal fluid leak after epidural catheterization.

We have described a case of posterior reversible encephalopathy syndrome (PRES) that developed early in the course of a renal transplant recipient. The patient was on cyclosporine and also had a cerebrospinal fluid (CSF) leak due to migration of an epidural catheter. The possibilities of PRES being associated with administration of cyclosporine and development of a CSF leak are discussed.

Exomphalos Defects : A Review of 15 Cases.

BACKGROUND: The outcome after repair of exomphalos defects has improved significantly with refinements in surgical techniques, multidisciplinary management and monitoring of intra-abdominal pressures. METHODS: A retrospective study of medical records of 15 cases with omphalocele was done. RESULTS: Antenatal diagnosis was available in six cases. There were eight females and seven males with a mean birth weight of 2.2 kg. Nine babies had associated anomalies. There were nine major (defect size> 5 cm) and six minor defects. Immediate closure in neonatal period was carried out in 12 cases. Urinary bladder pressure (UBP) was measured to assess intra-abdominal pressure in cases where primary closure was difficult. Primary closure was omitted in the event of intravesical pressures exceeding 20 mm Hg (~ 25 cms of water). Primary surgical closure was possible in five (56%) major cases. Two cases were subjected to silo repair followed by delayed primary closure whereas the other two required a Goretex mesh closure. Three minor defects could be repaired primarily whereas the remaining three were managed conservatively and closed at age of 9 to 12 months. There were no significant anaesthetic complications. Elective postoperative ventilation was required in one baby. There were three deaths at ages five, nine and ten months due to unrelated causes. CONCLUSION: Satisfactory outcome is possible in cases with exomphalos defects with intra-operative intravesical pressure assessment forming a convenient method for excluding abdominal compartment syndrome.

Anaesthesia for Paediatric Cardiac MRI.

BACKGROUND: General anaesthesia (GA) for cardiac magnetic resonance imaging (MRI) in patients with congenital heart disease (CHD) is challenging for the anaesthesiologist. METHODS: A retrospective review of anaesthesia for cardiac MRI between January 2002 and December 2005 was undertaken. RESULT: 28 children with cardiac disease were subjected to general anaesthesia for cardiac MRI, of which four patients were in ASA Grade I, five in Grade II, seventeen in Grade III and two in Grade IV. Two patients had undergone previous cardiac surgery. All the cases were managed as inpatients, of which 18 had cyanotic cardiac defects (SpO2 between 65 and 85%). On two occasions scans were interrupted because of low oxygen saturation or haemodynamic instability during GA. No patient was admitted to the hospital for complications related to general anaesthesia though all were kept under observation for two hours before being shifted to ward. Five patients had a brief episode of hypotension/desaturation during the MRI and responded quickly to interventions. CONCLUSION: General anaesthesia for cardiac MRI can be administered safely in children with CHD.

Idiopathic Hypertrophie Pyloric Stenosis : Our Experience.

BACKGROUND: A typical infant with idiopathic hypertrophic pyloric stenosis is described as a male child, first in the order of birth with a positive family history. However our experience suggests otherwise which is presented in this report. Methods : A retrospective analysis of medical records of 8 infants, who were diagnosed to be suffering from idiopathic hypertrophic pyloric stenosis and subjected to surgical treatment, was undertaken. RESULTS: There were 5 (62.5%) males and 3 (37.5%) females. There was no family history and only one child (12.5%) was first born in the order of birth. One infant was preterm and one case (12.5%) had associated congenital anomaly (single kidney). Definitive diagnosis was established in 6 (75%) babies at admission whereas, other 2 cases (25%) required further evaluation. All the infants were in a state of moderate dehydration and in a varying state of hypochloremic alkalosis. The pH and serum chloride levels ranged from 7.52 to 7.67 and 86-94 mmol/L respectively. All were subjected to traditional Ramstedt's pyloromyotomy after having undergone vigorous correction of fluids and electrolytes for 24-48 hours. Intraoperatively, there was one iatrogenic mucosal perforation, which was closed with an omental patch. Postoperative feeding was initiated 12 hrs after surgery in 6 (75%) babies. CONCLUSION: Our series suggests a clinical profile of hypertrophic pyloric stenosis in our subset of patients which is different from what is described in literature.

Cochlear Implant : Anaesthesia Challenges.

BACKGROUND: Cochlear implants are now an acceptable therapeutic option for those patients with irreversible hearing loss and deaf-mutism. The surgery is time consuming and complicated. Hence, the technique of anaesthesia plays a crucial role in success of cochlear implant surgery. Cochlear implant patients have various types of syndromes which are important from anaesthetic as well as surgical point of view. Pre-implant preparation requires objective assessment of hearing, plain X-rays of skull and a CT scan of the temporal bone. Anaesthesia is required for objective assessment of hearing in children under five years of age, to obtain X-rays of skull, magnetic resonance imaging (MRI), CT scan, brain evoked response audiometry (BERA) testing and finally for cochlear implant surgery. Anaesthetic considerations include preoperative familiarisation with the patient and his family. Syndromal illnesses have specific anaesthetic significance such as presence of difficult airway or prolonged QT interval. Parental presence is highly desirable during induction of anaesthesia. Electro-surgical instruments especially monopolar ones, should not be used once the cochlear implant is in place. METHODS: In our institution, all cases (15 children) received their cochlear implants under general anaesthesia and formed the study group. Children were administered midazolam orally and inj ketamine during CT scan. Our techniques of general anaesthesia were modified to permit use of nerve stimulators during surgery. To minimise the incidence of vertigo particularly after cochleostomy, postoperative nausea and vomiting, all patients received glycopyrrolate and fentanyl citrate intravenously prior to induction. Other agents used were, thiopentone, suxamethonium and end-tidal 1.3 MAC halothane in 1:2 mixture of oxygen and nitrous oxide (O2 and N2O). Electro diathermy was switched off, before the cochlear device was implanted on the patient. Patients were allowed to breathe spontaneously whenever nerve stimulator was used to locate the facial nerve. Inj Ondansetron 0.1 mg/kg was used as anti-emetic agent. Postoperative pain relief was initially provided with fentanyl 1 µg/kg IV and later with syrup ibuprofen. RESULTS: There were no remarkable anaesthetic or surgical complication in our series except perilymph leakage in two cases.

Correlation of bispectral index and Guedel's stages of ether anesthesia.

UNLABELLED: Bispectral index (BIS) analysis is a method of electroencephalograph (EEG) analysis based on the interfrequency phase relationships of the EEG, designed to quantify anesthetic hypnosis. The BIS was created after concurrent collection of EEG and clinical data from a large number of patients anesthetized with various drugs over a prolonged period and then performing a Fourier analysis followed by a bispectral calculation. The clinical stages of anesthetic depth are very well demonstrated in etherized patients. In this study, we studied the BIS changes during various stages of ether anesthesia and quantified the hypnotic depth during the surgical stage of ether anesthesia. The values for BIS under various stages and planes of ether anesthesia were recorded in 21 patients listed for short surgical procedures. During diethyl ether anesthesia, BIS initially increased and subsequently decreased. During surgical anesthesia, a BIS value of 30 was observed. IMPLICATIONS: For the first time, bispectral index (BIS) has been studied in patients being anesthetized solely with ether. Ether both causes an increase and decrease in BIS during induction and emergence. The index observed during the surgical stage of ether anesthesia is probably the correct value for the depth of hypnosis because no other volatile anesthetic can produce the true anesthetic state when used alone. This value could be taken as the value to be attained when balanced anesthesia is being practiced.

Interscalene brachial plexus block for shoulder surgery in a patient with arthrogryposis multiplex congenita.

A five-year-old child with severe arthrogryposis multiplex congenita and malnutrition underwent surgery for chronic osteomyelitis of the head of the left humerus. The child had typical features of arthrogryposis multiplex congenita, including a difficult airway. Propofol was used for induction and maintenance. Spontaneous respiration was maintained with a nasal airway. Analgesia was provided with an interscalene brachial plexus block placed using a nerve stimulator. No opioid was given. The child had an uneventful recovery with good postoperative analgesia. The anaesthetic implications of arthrogryposis multiplex congenita are discussed.