National board governed post-graduate curriculum: Strengths and scope.

The National Board of Examinations was established to boost the quality of medical education by laying down exclusive norms, uniform standards and a national level evaluation for the postgraduate medical courses. The content and context of the training curriculum is well updated as per advances in the field and current requirements. Diplomate of National Board (DNB) courses are considered to be at par with the postgraduate and post doctorate degrees for all intents and purposes. The introduction of a formative assessment with objective evaluation pattern has improved the scope of the board. Moving on to a competency-based training with emphasis on novel research can maximise the quality of training to international standards. Training DNB teachers and assessors in the newer teaching and assessment methods can improve the calibre of residents. Stringent monitoring and review of the training can increase the credibility of the courses and the board can be expected to cater for students abroad.

Migrated esophageal stent posing a challenge for ventilation.

Self-expandable esophageal stents are being commonly used for palliative treatment in advanced esophageal cancer patients to relieve dysphagia, prevent tracheoesophageal fistula, and facilitate symptomatic betterment. The modern covered stents reduce the ingrowth of the tumor but have seen an increase in the incidence of stent migrations. We report a rather complicated presentation of an esophageal stent for esophageal dilatation and a challenging management of a difficult tracheostomy.

An unusual differential for a pulseless trauma patient.

Hemorrhagic shock is the most common reason to explain the inability to feel pulse in a trauma patient. However, clinicians should always suspect atypical causes for differential pulses in this population and Takayasu's arteritis (TA) is one such example. We report a case of aorto-arteritis in a patient who presented with trauma and was later diagnosed with TA. She had blood pressure discrepancy between upper and lower limbs noted upon her initial trauma evaluation.

When to correct coagulopathy in acute kidney injury?

Incidence of acute kidney injury (AKI) in adult trauma patients is 18% with 70% requiring renal replacement therapy. It is a challenge to treat AKI with coagulopathy since there are no defined transfusion triggers for these patients. We report a case wherein a polytrauma patient developed AKI for which he/she was dialysed and subsequently had an intracerebral bleed. There is a need to develop guidelines to transfusion triggers in AKI patients keeping vigilance on fluid overload, hyperkalemia and uraemia-induced platelet dysfunction.

Analyzing fat embolism syndrome in trauma patients at AIIMS Apex Trauma Center, New Delhi, India.

BACKGROUND: Fat embolism syndrome (FES) is a constellation of symptoms and signs subsequent to orthopedic trauma. MATERIALS AND METHODS: The clinical profile of FES in the trauma population was studied over 2 years and 8 months. RESULTS: The incidence of FES among all patients with long bone and pelvic fractures was 0.7% (12). The mean injury severity score was 10.37 (SD 1.69) (range 9-14). The diagnosis of FES was made by clinical and laboratory criteria. Hypoxia was the commonest presentation (92%). The average days of onset of symptoms were 3.5 (SD1.29) days. Management included ventilator support in 75%, average ventilator days being 7.8 (SD 4.08) days. The average ICU stay and hospital stay were 9.1 days and 29.7 days, respectively. A mortality of 8.3% (1) was observed. CONCLUSION: Fat embolism remains a diagnosis of exclusion and is a clinical dilemma. Clinically apparent FES is unusual and needs high index of suspicion, especially in long bone and pelvic fractures.

Airway management of an unusual case of recurrent rhinoscleroma.

Rhinoscleroma is a rare entity encountered in anesthesia practice. We discuss the management of a patient after its recurrence, involving the upper respiratory tract i.e. nasopharynx and oropharynx, which compromised the airway. The pateint was referred for anesthesia on three different occasions with different presentations owing to the recurrence of symptoms.The presence of an oropharyngeal membrane with a small opening made airway management a challenge. The patient was successfully managed on all three occasions. Imaging facilitated assessment and subsequent airway management.

Start time delays in operating room: Different perspectives.

BACKGROUND: Healthcare expenditure is a serious concern, with escalating costs failing to meet the expectations of quality care. The treatment capacities are limited in a hospital setting and the operating rooms (ORs). Their optimal utilization is vital in efficient hospital management. Starting late means considerable wait time for staff, patients and waste of resources. We planned an audit to assess different perspectives of the residents in surgical specialities and anesthesia and OR staff nurses so as to know the causative factors of operative delay. This can help develop a practical model to decrease start time delays in operating room (ORs). AIMS: An audit to assess different perspectives of the Operating room (OR) staff with respect to the varied causative factors of operative delay in the OR. To aid in the development of a practical model to decrease start time delays in ORs and facilitate on-time starts at Jai Prakash Narayan Apex Trauma centre (JPNATC), All India Institute of Medical Sciences (AIIMS), New Delhi. METHODS: We prepared a questionnaire seeking the five main reasons of delay as per their perspective. RESULTS: The available data was analysed. Analysis of the data demonstrated the common causative factors in start time operative delays as: a lack of proper planning, deficiencies in team work, communication gap and limited availability of trained supporting staff. CONCLUSIONS: The preparation of the equipment and required material for the OR cases must be done well in advance. Utilization of newer technology enables timely booking and scheduling of cases. Improved inter-departmental coordination and compliance with preanesthetic instructions needs to be ensured. It is essential that the anesthesiologists perform their work promptly, well in time . and supervise the proceedings as the OR manager. This audit is a step forward in defining the need of effective OR planning for continuous quality improvement.

Cerebral Fat Embolism: A diagnostic challenge.

Fat embolism syndrome (FES) is a rare but a serious clinical catastrophe occurring after traumatic injury to long bones. Cerebral involvement in the absence of pulmonary or dermatological manifestation on initial presentation may delay the diagnosis of cerebral fat embolism (CFE). We discuss a case series of CFE which posed a challenge in diagnosis. The clinical presentations of these patients did not satisfy the commonly used clinical criteria for aiding the diagnosis of FES. Early MRI brain (DWI and T2 weighted sequences) in patients with neurological symptoms after trauma even in the absence of pulmonary and dermatological findings should be the goal.

Anaesthetic management and implications of a case of chronic inflammatory demyelinating polyneuropathy.

A 60-year-old man with chronic inflammatory demyelinating polyneuropathy (CIDP) was posted for surgery of the neck femur fracture and was successfully managed. We discuss the anaesthetic considerations during regional and general anaesthesia of this patient with CIDP. A brief review of the available literature reveals no consensus on the choice of anaesthetic management.

Comparative study of dexamethasone and ondansetron for prophylaxis of postoperative nausea and vomiting in laparoscopic gynecologic surgery.

OBJECTIVE: To compare intravenous dexamethasone and ondansetron for the prophylaxis of postoperative nausea and vomiting (PONV), a main complaint that affects almost 40%-75% of patients undergoing laparoscopic gynecologic surgery. METHODS: In a prospective study, 93 women were divided into 3 groups receiving 4mg of dexamethasone, 8mg of dexamethasone, or 4mg of ondansetron. PONV score was used for assessment during the first 24hours after surgery. RESULTS: The incidence of PONV during the 24-hour postoperative period was highest in the ondansetron group (61%). In the first 3hours, the incidence of PONV in the ondansetron group was also higher: 51.6% as compared with 22.6% and 36.6% in the dexamethasone 4mg and 8mg groups, respectively. The overall incidence of PONV was highest in the first 3hours as compared with later time periods, and there was a linear trend in decreasing PONV among the groups (P=0.017). In the dexamethasone 4mg group, the request for a rescue antiemetic was significantly lower: 0% as compared with 6.7% and 16.1% in the dexamethasone 8mg and ondansetron 4mg groups, respectively. CONCLUSION: Dexamethasone was found to be an efficacious and cost-effective drug for the prophylaxis of PONV.