Patients' expectations of their anesthesiologists.

OBJECTIVES: To determine the patient's perception of the role of an anesthesiologist and the patient's expectations of their anesthesiologist and their anesthesia care. STUDY DESIGN: Questionnaire survey. METHODS: A total of 170 patients attending the preanesthesia clinic answered a survey prior to their clinic interview and another survey the day after their surgery. The questions pertained to their perception of the role of the anesthesia provider, their expectations, and their level of satisfaction. RESULTS: A majority (>75%) of the participants had high expectations of their anesthesia provider. The satisfaction scores were higher among those who felt that their expectations were met and among those who felt that the anesthesiologist explained to them how they would feel after anesthesia. CONCLUSIONS: Because satisfaction is a fulfillment of one's expectations, understanding what the patient expects from their anesthesiologist is the initial step to improve satisfaction scores. The onus is on the anesthesiologist to educate the patient about their role, to set realistic expectations of the postoperative course, and to involve the patient in decisions regarding their anesthesia care.

The effects of propofol and isoflurane on intraoperative motor evoked potentials during spinal cord tumour removal surgery - A prospective randomised trial.

BACKGROUND AND AIMS: Transcranial electrical stimulation (TES) elicited intraoperative motor evoked potentials (iMEPs), are suppressed by most anaesthetic agents. This prospective randomised study was carried out to compare the effects of Isoflurane and Propofol on iMEPs during surgery for spinal cord tumours. METHODS: A total of 110 patients were randomly divided into two groups. In group P, anaesthesia was maintained with intravenous propofol (6.6 ± 1.5 mg/kg/hr) and in group I anaesthesia was maintained with isoflurane (0.8 ± 0.1% minimal alveolar concentration (MAC). An Oxygen- air mixture (FiO2-0.3) was used in both groups. TES-iMEPs were recorded from tibialis anterior, quadriceps, soleus and external anal sphincter muscles in 60 of 90 patients. Statistical analysis was performed with Pearson correlation and Paired 't' tests. RESULTS: Successful baseline iMEPs were recorded in 74% of patients in Group P and in 50% of patients in Group I. Age and duration of symptoms influenced the elicitation of baseline iMEPs under isoflurane (r = -0.71, -0.66 respectively, P < 0.01) as compared to propofol (r = -0.60, -0.50 respectively, P < 0.01). The mean stimulus strength required to elicit the baseline iMEPs were lesser in propofol (205 ± 55Volts) as compared to isoflurane (274 ± 60 Volts). Suppression of the iMEP responses was less under propofol (7.3%) as compared to isoflurane anaesthesia (11.3%) in patients with no preoperative neurological deficits. CONCLUSION: iMEPs are better maintained under propofol anaesthesia (6-8 mg/kg/hr) when compared with isoflurane (0.7-0.9 MAC). in patients undergoing surgery for excision of spinal cord tumours.

What Every Anesthesiologist Should Know About the Manual Resuscitation Bag.

The bag-valve-mask or the manual resuscitation bag is life-saving equipment. This article explains its construction, functioning, and limitations. This article also attempts to clarify some common misconceptions such as whether a resuscitation bag can be used to preoxygenate or provide continuous positive airway pressure or positive end-expiratory pressure and the highest percentage of oxygen that it can deliver.

The Effect of Elevated A1C on Immediate Postoperative Complications: A Prospective Observational Study.

IN BRIEF This study examined whether elevated A1C in patients with diabetes is associated with a higher incidence of postoperative infections and other complications. Researchers followed 50 noncardiac surgical patients for 7 postoperative days. Half of the patients had an A1C <7% and the other half had an A1C ≥7%. The two groups were otherwise comparable except that the higher-A1C group had significantly higher pre-induction and postoperative blood glucose levels, with wider variability in the first 24 hours after surgery. During the first postoperative week, 11 patients developed complications, of whom 10 were in the higher-A1C group. Elevated A1C, unlike a single preoperative blood glucose value, may predict difficult postoperative glucose control and postsurgical complications.

An Uncommon Complication with a Supraglottic Airway: The King LT.

General anesthesia was administered in an 18-year-old man for removal of hardware from his right knee using a King Laryngeal Tube supraglottic airway. An hour after extubation, he reported inability to swallow with no respiratory distress. Examination showed an edematous uvula, which took 3 days to subside with anti-inflammatory medication. During the positioning of the King Laryngeal Tube, it was pulled back to ensure adequate ventilation. The inflated cuff could have dragged the uvula and folded it on itself, leading to venous congestion and edema.

Low-dose ketamine infusion for labor analgesia: A double-blind, randomized, placebo controlled clinical trial.

BACKGROUND: Most primary and secondary level hospitals in developing countries provide inadequate labor analgesia due to various medical, technical and economic reasons. This clinical trial was an effort to study the efficacy, safety and feasibility of intravenous (IV) ketamine to provide labor analgesia. MATERIALS AND METHODS: A total of 70 parturients were consented and randomly assigned to receive either IV ketamine or 0.9% saline. A loading dose of ketamine (0.2 mg/kg) was followed-by an infusion (0.2 mg/kg/h) until the delivery of the neonate. Similar volume of saline was infused in the placebo-group. Intramuscular meperidine was the rescue analgesic in both groups. The pain score, hemodynamic parameters of mother and fetus and the anticipated side-effects of ketamine were observed for. The newborn was assessed by the Neonatologist. RESULTS: The pain score showed a decreasing trend in the ketamine group and after the 1(st) h more than 60% of women in the ketamine group had pain relief, which was statistically significant. There was no significant clinical change in the maternal hemodynamics and fetal heart rate. However, 17 (48.5%) of them had transient light headedness in the ketamine group. All the neonates were breast fed and the umbilical cord blood pH was between 7.1 and 7.2. The overall satisfaction was significantly high in the intervention group (P = 0.028). CONCLUSION: A low-dose ketamine infusion (loading dose of 0.2 mg/kg delivered over 30 min, followed-by an infusion at 0.2 mg/kg/h) could provide acceptable analgesia during labor and delivery.

Oral bisoprolol improves surgical field during functional endoscopic sinus surgery.

BACKGROUND: The success of functional endoscopic sinus surgery (FESS) depends on visual clarity of the surgical field, through the endoscope. The objective of this double-blind, randomized, controlled study was to determine if a pre-operative dose of bisoprolol (2.5 mg) would reduce the bleeding during FESS and improve the visualization of the operative field. MATERIALS AND METHODS: Thirty American Society of Anesthesiologists I or II patients, scheduled for FESS were randomized to receive either a placebo (Group A) or 2.5 mg of bisoprolol (Group B) 90 min prior to the surgery. All the patients received standard anesthesia and monitoring. The aim was to maintain the mean arterial pressure (MAP) of 60-70 mmHg, by titrating dose of isoflurane and fentanyl. The concentration of isoflurane used was recorded every 15 min. At the end of the surgery, the volume of blood loss was measured and the surgeon was asked to grade the operative field as per the Fromme-Boezaart Scale. RESULT: The blood loss was significantly (P < 0.0001) more in the control group (398.67 ± 228.79 ml) as compared with that in the bisoprolol group (110.67 ± 45.35 ml). The surgical field was graded better in those who received bisoprolol as compared with those in the control group (P - 0.0001). The volume percent of isoflurane and the dose of fentanyl used was significantly lower in those who received bisoprolol. During the operative period, the MAPs were 70.0 ± 2.7 (Group A) and 62.6 ± 3.6 mmHg (Group B) and the heart rate was 99.8 ± 5.0/min (Group A) and 69.2 ± 4.4/min (Group B). These differences were statistically significant ( P - 0.001). CONCLUSION: This clinical trial has demonstrated that administration of a single pre-operative dose of bisoprolol (2.5 mg) can significantly reduce the blood loss during FESS and improve the visualization of the operating field.

Low-concentration, continuous brachial plexus block in the management of Purple Glove Syndrome: a case report.

INTRODUCTION: Purple Glove Syndrome is a devastating complication of intravenous phenytoin administration. Adequate analgesia and preservation of limb movement for physiotherapy are the two essential components of management. CASE PRESENTATION: A 26-year-old Tamil woman from India developed Purple Glove Syndrome after intravenous administration of phenytoin. She was managed conservatively by limb elevation, physiotherapy and oral antibiotics. A 20G intravenous cannula was inserted into the sheath of her brachial plexus and a continuous infusion of bupivacaine at a low concentration (0.1%) with fentanyl (2 mug/ml) at a rate of 1 to 2 ml/hr was given. She had adequate analgesia with preserved motor function which helped in physiotherapy and functional recovery of the hand in a month. CONCLUSION: A continuous blockade of the brachial plexus with a low concentration of bupivacaine and fentanyl helps to alleviate the vasospasm and the pain while preserving the motor function for the patient to perform active movements of the finger and hand.

Plasmid-mediated high-level ceftriaxone resistance in a Salmonella enterica serotype typhimurium isolate.

OBJECTIVE: To present the first documented case of acute infectious gastroenteritis caused by high-level ceftriaxone-resistant Salmonella enterica serotype typhimurium in Kuwait. SUBJECT AND METHODS: Isolation from stool specimen and species identification of current enteric pathogen was carried out according to standard methods. Susceptibility to antibiotics was determined by the disc diffusion method on Mueller-Hinton agar. Minimal inhibitory concentrations (MICs) were measured with E-test strips. The production of extended spectrum beta-lactamase (ESBL) was studied by the double disc synergy method and E-test ESBL strips. Plasmid DNA isolation was performed by the rapid alkaline lysis method. Plasmid DNA was transferred by conjugation to a recipient strain of Escherichia coli. RESULTS: The isolate of S. enterica serotype typhimurium was resistant to ceftriaxone (MIC >256 mg/l), cefotaxime and ceftazidime, and produced ESBL. Ceftriaxone and cefotaxime resistance were co-transferred on a 3.2-kb plasmid to the E. coli recipient strain. Loss of the 3.2-kb plasmid from the transconjugant resulted in the co-loss of ceftriaxone and cefotaxime resistance confirming the carriage of ceftriazone resistance on the 3.2-kb plasmid. CONCLUSION: Plasmid-mediated high-level resistance to ceftriaxone and ESBL production in Salmonella serotype typhimurium is an emerging problem among Salmonella that requires closer monitoring of antimicrobial resistance among these bacterial species.

Comparative in vitro activity of PH-027 versus linezolid and other anti-anaerobic antimicrobials against clinical isolates of Clostridium difficile and other anaerobic bacteria.

PH-027 is a new 5-triazole oxazolidinone synthesized in our laboratories, which shows strong activity against gram-positive aerobic bacteria including clinical isolates. The objective of this study was to investigate the in vitro activity of this compound in comparison with linezolid and other antibiotics against gram-positive and gram-negative anaerobes. The in vitro activity of PH-027 in comparison with those of linezolid and other antimicrobial agents was evaluated against 201 clinical isolates of gram-positive and gram-negative anaerobic bacteria by agar dilution and Etest methods. PH-027 showed excellent activity, with minimum inhibitory concentrations (MIC) in the range of 0.12-4.0 microg/ml against all isolates; MIC90s being 4.0, 1.0, 2.0, 2.0 and 2.0 microg/ml against Clostridium difficile, Peptostreptococcus spp., Bacteroides fragilis, Prevotella bivia and Fusobacterium spp. respectively. In comparison, linezolid had MIC in the range of 0.5-4.0 microg/ml against all isolates, with MIC90s of 2.0, 4.0, 4.0, 4.0 and 2.0 microg/ml against the same set of bacteria respectively. PH-027 demonstrated excellent in vitro activity that is superior to linezolid against Peptostreptococcus spp., B. fragilis and P. bivia. However, against C. difficile and Fusobacterium spp, PH-027 and linezolid showed comparable in vitro activity. Against all anaerobes, metronidazole, PH-027 and, to a lesser extent, linezolid had the most potent activity. From the results of in vitro susceptibility testing, both linezolid and PH-027 show promise in the treatment of anaerobic infections.

Hospital-acquired Clostridium difficile infection amongst ICU and burn patients in Kuwait.

OBJECTIVES: To prospectively study the prevalence of nosocomially acquired Clostridium difficile, a major cause of diarrhoea in hospitalized patients, in the intensive care units (ICUs) and burn unit (BUs) of three teaching hospitals in Kuwait. METHODS: During a 1-year prospective study, stool/rectal swabs were obtained from 344 patients admitted into the ICUs of Mubarak Hospital (ICU-1), the Kuwait Cancer Control Centre (ICU-2), and the BU of Ibn Sina Hospital. The presence of C. difficile and/or its toxin was detected by serially culturing the specimens on differential, selective and enriched media and the use of TOX-A/B test, on admission and at subsequent 1-weekly interval until discharge. RESULTS: Out of the 344 patients admitted into these units, over a study period of 1 year, only 263 (77%) were evaluable. All of them had negative stool culture/toxin on admission. Overall, 25 (9.5%) of these 263 patients acquired C. difficile during their hospitalization. Thirteen (7%) of 187 patients acquired C. difficile in ICU-1, 9 (36%) of 25 on ICU-2 and 3 (5.9%) of 51 patients in BU. Eight (32%) developed diarrhoea attributable only to C. difficile and/or toxin, and the remaining 17 (68%) were asymptomatic: none had pseudomembranous colitis. The diarrhoea in these patients was associated with antibiotic use, the main trigger-antibiotics being the third-generation cephalosporins. Acquisition occurred within 4-53 days of admission, with the majority occurring in the first 15 days. CONCLUSION: Overall, the prevalence of hospital-acquired C. difficile infection/colonization was less than 10%. The use of third-generation cephalosporins was high and was related to the development of diarrhoea. Once acquired, diarrhoea developed in about one third of C. difficile-positive cases, an indication that C. difficile infection/colonization endemic in the hospital ICUs studied is usually transmitted among the hospitalized patients.

Influence of in-vivo endotoxin liberation on anti-anaerobic antimicrobial efficacy.

The ability of cefoxitin, clindamycin, imipenem, meropenem, metronidazole and piperacillin-tazobactam to cause gram-negative anaerobic bacteria to release endotoxin and the influence of such liberated endotoxin on antibiotic efficacy were investigated in in-vivo experiments in animal models. Experimental infections in various animal models (mice, hamster and infant rats) with cultures of wild and reference strains of Bacteroides fragilis group and Fusobacterium spp. were carried out by injecting these animals with different inocula (10(6), 10(7) and 10(8) cfu/ml) of the bacterial suspension, Appropriate doses of the test antibiotics were then injected and the plasma lipopolysaccharide (endotoxin) release measured by the Limulus Amoebocyte Lysate (LAL) Assay. Evidence of worsening of the outcome of the infections post-therapy was assessed, including histopathological changes in the internal organs. Infection with generalized septicemia was established with F. nucleatum in the mice and hamster models while with the B. fragilis group, infections only led to intra-abdominal abscess formation. Plasma endotoxin release was higher in animals infected with F. nucleatum than B. fragilis and was unrelated to the bacterial inoculum. Imipenem, meropenem and cefoxitin, in that order, induced the highest levels of endotoxin activities in the animal model, particularly following F. nucleatum infection. Histological examination of the internal organs of various animals showed variation in the pattern of histopathological changes; grades 3-4 inflammatory changes in the liver were observed in the Fusobacterium-infected animals that were treated with the carbapenems and cefoxitin. Therapy with the other antibiotics did not exacerbate anaerobic sepsis. In this study, bacteremia did not lead to massive endotoxin release and antibiotic therapy appeared not to have negatively influenced the outcome of most of the gram-negative anaerobic infections, except for infections caused by Fusobacterium spp. However, it is conceivable that if the gastrointestinal tract is the source of the endotoxin in patients with systemic inflammatory response syndrome, then the obligate anaerobes like Bacteroides and Fusobacterium species, which are members of the gut flora, may play a major role in the unfavorable outcome of antibiotic therapy in some of these infections.

Response to hepatitis B vaccination in high risk population.

Hepatitis B vaccine is well established as very efficacious, but immune response to the vaccine is highly individual specific. A study involving fifty vaccinees was undertaken at the Hepatitis Laboratory, National Institute of Communicable Disease, Delhi. One ml (20 microgram) of Engerix B vaccine (recombinant yeast derived vaccine) was administered in the standard three dose schedule (0, 1 and 6 months). The sero-conversion of the vaccinees was 24%, 66%, 76% and 78% at 1 month, 6 months, 7 months, and 12 months respectively. There was no seroconversion in 22% of the vaccinees. Sero-conversion was assessed using Macro ELISA test (Ausab, Abbott Labs) for Anti HBs reactivity.

Influence of five antianaerobic antibiotics on endotoxin liberation by gram-negative anaerobes.

Endotoxin, a lipopolysaccharide (LPS), has for many years been recognized as a key effector molecule in the pathogenesis of gram-negative sepsis and septic shock. Seven strains of the Bacteroides fragilis group were studied for their ability to liberate endotoxin upon exposure to five anti-anaerobic antibiotics, trovafloxacin, cefoxitin, imipenem, meropenem and piperacillin/tazobactam, in an in-vitro experiment. The minimum inhibitory concentrations (MICs) of the antibiotics were determined by using the broth macrodilution technique. Thereafter, endotoxin liberation was detected in the filtered broth cultures of the anaerobic bacteria by the limulus amebocyte lysate (LAL) assay after exposing the organisms to four different concentrations of the antibiotics in supplemented Brucella broth. Aliquots of the broth cultures were also taken at intervals of 0, 6, 24 and 48 h for viable counts. All seven gram-negative anaerobic bacteria investigated liberated induced cell-free endotoxin in filtered broth culture many times higher than the control. There was noticeable variation in the propensity of some antibiotics to induce endotoxin liberation. At four times the MICs, cefoxitin and piperacillin/tazobactam induced negligible quantities of endotoxin after 48 h exposure, whereas the others induced high levels of endotoxin release. After exposure to all concentrations for 48 h, endotoxin activity in the test system was many times higher with the Bacteroides fragilis sensu stricto than with the rest of the species in the Bacteroides group. To varying degrees, all five antibiotics had the capacity to induce endotoxin liberation by gram-negative anaerobic bacteria. This differential endotoxin release by the B. fragilis group may, in part, explain why B. fragilis sensu stricto, more than the other Bacteroides spp., is usually associated with clinical infections and higher morbidity.

Susceptibility of 497 clinical isolates of gram-negative anaerobes to trovafloxacin and eight other antibiotics.

Trovafloxacin is a novel investigational trifluoronaphthyridone antibiotic with broad-spectrum activity against Gram-positive and Gram-negative organisms. Its in-vitro activity and those of eight other antimicrobial agents were evaluated against 497 clinical isolates of Gram-negative anaerobic bacteria by the agar dilution method. Trovafloxacin had excellent activity, with a minimum inhibitory concentration (MIC) range of <0.03-4 microg/ml, against all species. Out of the 497 isolates tested, 496 (99.5%) were inhibited by a concentration of < or = 2.0 microg/ml of trovafloxacin; the remaining two strains were inhibited by a concentration of 4.0 microg/ml. The MIC50s and MIC90s were 0.12 microg/ml and 1.0 microg/ml, respectively. Meropenem, imipenem and piperacillin/tazobactam were also very active. Overall, at the MIC90s, trovafloxacin was as active as meropenem, slightly more active than metronidazole and imipenem, twice as active as amoxicillin-clavulanic acid, five times more active than piperacillintazobactam and 68 times more active than clindamycin. About 21% of the isolates were resistant to cefoxitin, 30% to clindamycin and 40% to piperacillin. Five species in the Bacteroides fragilis group of isolates were highly resistant to metronidazole (MIC >128 microg/ml). In general, the relatively more resistant species were the B. vulgatus, B. ovatus, B. thetaiotaomicron, and B. fragilis sensu stricto, in that order. All the isolates of the B. fragilis group and about 50% of the Prevotella spp. were beta-lactamase positive. Trovafloxacin certainly holds promise as an alternative drug for therapy of anaerobic infections.

Prevalence of North India of hepatitis B carrier state amongst pregnant women.

The study was undertaken to determine the hepatitis B carrier rate in North India along with the relative infectivity of the carriers. A total of 1,112 pregnant women were investigated for hepatitis B carrier state during their routine visits to antenatal clinics. All three tiers of the health care delivery system were included from four regions of North India. The sera were screened for the presence of hepatitis B surface antigen (HBsAg), hepatitis B "e" antigen (HBeAg), and antibody to hepatitis B "e" antigen (Anti-HBe) by third generation Macro ELISA tests. The average hepatitis B surface antigen carrier rate was 9.5%. The carriers were found to be of relatively low infectivity with HBeAg and Anti-HBe present in 12.0% and 25.3% of the HBsAg carriers respectively, and both these markers absent in 62.7%. It was concluded that in the past decade the hepatitis B endemicity in North India has probably increased, but the relative infectivity of the carriers remains the same.