RESUMO
Background: COVID19 pandemic caused considerable mortality and had a huge impact on the health system and the world economy. In this context, it is important to characterize the demographic and clinical features of the fatal cases and to have a basic understanding on the additional burden caused by COVID19 on the health care system. Methods: Mortality reports of 408 patients who were diagnosed with COVID-19 in Ernakulam district during the period of 28th March 2020 - the day which reported the first COVID19 death in the district- till 28 February 2021 were collected using a uniform reporting format prepared by the district COVID19 surveillance unit. Results: Out of the 408 fatal cases 260 (64%) were males. The mean age of the cases was 69 years (SD:12, IQR:16-102 years). 31% (n=124) of the patients were admitted to more than one facility for treatment before the death. The median duration between the documented date of onset of symptoms to death was 11 days (IQR:0-46). Mean duration between the onset of COVID19 suspected symptoms to the collection of samples for laboratory test was 3 days and the duration up to the admission to a treatment facility was 4.5 days. The median duration between the admission to a facility and death was 7 days (mean 10, SD:7) with a range 0 to 40 days. The mean duration of hospital stay was 10 days for females and 8.5 days for males. Most frequent symptom at presentation was breathlessness 50% (n=211), followed by fever 43% (n=179). 96% of the cases were reported to have any comorbidity and among those most common was Diabetes mellitus and stroke 60%, followed by Hypertension 54%. However, there was no significant difference in duration of hospital stay and survival period across age group, sex or number of comorbidities which may need further analysis. Conclusion: 6 out of 10 of the fatal cases were males and the mean age was 69 years, Though the mean age was similar for both sexes, median age was slightly higher for females. The proportion was found increasing as the age advanced. One third of the patients were admitted and treated at more than one facility and moreover 6 out of 10 utilized government facilities for treatment. Median duration of survival was 11 days while the median duration of hospital stay was 10 days. Symptomatology was found similar to cases reported worldwide. More than 9 out of 10 had reported at least one comorbidity and the most frequent comorbidities reported were Diabetes mellitus and Cerebrovascular accident. Most frequently observed combination was of a triad of Hypertension-Diabetes-Stroke. This data is of prime importance as Kerala is at an advanced level of epidemiological transition and demographic transition compared to other Indian states and emerging infections like COVI19 could be a double burden to the community.
RESUMO
A pregnant patient in second trimester scheduled for posterior fossa craniotomy in prone position is a challenge for the anesthesiologist. Things to consider are physiological changes during pregnancy, non-obstetric surgery in pregnant patients, neuroanesthetic principles, effects of prone positioning, and need for fetal heart rate (FHR) monitoring. We have described the anesthetic management of this case and discussed intra-operative FHR monitoring including controversies about its role, indications, and various options available as per fetal gestational age. In our case we attempted intermittent intra-operative FHR monitoring to optimize maternal positioning and fetal oxygenation even though the fetus was pre-viable. However the attempt was abandoned due to practical difficulties with prone positioning. Patient made good neurological recovery following the procedure and delivered a healthy term baby 4 months later. Decisions regarding fetal monitoring should be individualized based on viability of the fetus and feasibility of emergency cesarean delivery. Good communication between a multidisciplinary team involving neurosurgeon, anesthesiologist, obstetrician, and neonatologist is important for a successful outcome for mother and fetus. We conclude that prone position neurosurgery can safely be carried out in a pregnant patient with pre-viable fetus without FHR monitoring.
