Postoperative nausea and vomiting in patients undergoing total abdominal hysterectomy under subarachnoid block: a randomized study of dexamethasone prophylaxis.

BACKGROUND: Postoperative nausea and vomiting is a common distressing problem in patients undergoing gynaecological surgery under anaesthesia including central neuraxial blockade, which requires frequent medical interventions. OBJECTIVES: We aimed to find out the antiemetic effect of prophylactic dexamethasone for prevention of postoperative nausea and vomiting in patients undergoing total abdominal hysterectomy under subarachnoid block. Influences of dexamethasone on patient satisfaction and postoperative analgesia were also observed as secondary objectives. METHODS: This was a prospective, randomized, double blind, placebo controlled study conducted in BPKIHS, from January 2009 to April 2009. This study involved 80 American Society of Anaesthesiologist Physical Status I and II patients undergoing total abdominal hysterectomy under subarachnoid block. Patients were divided into two groups of 40 each to receive either 4 mg of dexamethasone (group D) or normal saline (group N) in volume of 2 ml intravenously 1 hour prior to subarachnoid block. Surgery was allowed to start with block height of at least T8 dermatome. Intraoperative and postoperative nausea and vomiting was observed using nausea and vomiting scale every 4 hour for 24 hours. RESULTS: Seven (17.4%) patients in group D and 11 (27.5%) patients in group N had nausea and vomiting in the intraoperative period (P=0.284). Sixteen (40%) patients in group D experienced nausea and vomiting in the postoperative period as compared to 27 (67.5%) in group N (P =0.0136). Accordingly, the mean requirement of rescue antiemetic was less in group D compared to Group N (P=0.042). Further, only 15 (37.5%) patients in group D required postoperative supplemental analgesic as compared to 23 (57.5%) in group N (P=0.058). After 24 hrs of surgery, 26 (65%) patients expressed satisfaction in group D as compared to 16 (40.0%) in group N (P =0.025). CONCLUSIONS: Use of dexamethasone prior to subarachnoid block in patients undergoing total abdominal hysterectomy significantly reduces the incidence of nausea and vomiting and the requirement of antiemetic in the postoperative period, with better patient satisfaction.

Serogroup distribution and virulence characteristics of sorbitol-negative Escherichia coli from food and cattle stool.

AIMS: To (i) study the serogroup distribution and virulence characteristics of non-sorbitol-fermenting Escherichia coli isolates from foods of animal origin and cattle faeces and (ii) re-examine the true sorbitol and beta-D-glucuronidase (GUD) reactions of sorbitol-negative (Sor(-)) strains from MacConkey sorbitol agar (SMAC) to assess their phenotypic similarity with E. coli O157. METHODS AND RESULTS: One hundred and thirty Sor(-)E. coli were isolated from 556 food samples and 177 cattle stool samples using cefixime tellurite-supplemented SMAC (CT-SMAC) and chromogenic HiCrome MS.O157 agar respectively. Based on typing of somatic antigen, the isolates were classified into 38 serogroups. PCR results identified about 40% strains, belonging to O5, O8, O20, O28, O48, O60, O78, O82, O84, O101, O110, O123, O132, O156, O157, O-rough and OUT as Shiga toxigenic. Majority of O5, O84, O101, O105, O123, O157, O-rough and OUT strains were enterohaemolytic. Further, 39.2% and 63.1% of Sor(-) isolates from CT-SMAC fermented sorbitol in phenol red broth and hydrolysed 4-methylumbelliferyl-beta-D-glucuronide (MUG) respectively. Members of serogroups O5, O28, O32, O81, O82, O84, O101, O-rough lacked both the sorbitol fermentation (broth test) and GUD activity and might create confusion in phenotypic identification of E. coli O157. CONCLUSIONS: Sor(-)E. coli isolates from raw meat, milk, shrimp and cattle stool belonged to 38 serogroups, with E. coli O157 constituting only 14.6% of the isolates. Many of these nonclinical Sor(-) strains were potentially pathogenic. Nearly 39% of these Sor(-)E. coli from CT-SMAC fermented sorbitol in broth, indicating the need for confirmation of sorbitol reaction in broth. SIGNIFICANCE AND IMPACTS OF THE STUDY: Classical sorbitol utilization and GUD tests are not likely definitive tests for E. coli O157. Further improvement of differential media based on these phenotypic properties is necessary for detection of pathogenic serotypes from foods and environmental samples.

Percutaneous dilational tracheostomy: an initial experience in community based teaching hospital.

UNLABELLED: Percutaneous dilational tracheostomy (PDT) is frequently performed in the intensive care unit to prevent the long term complications associated with prolonged endotracheal intubation. OBJECTIVE: To report the analysis of our experience with percutaneous dilation tracheostomy. STUDY DESIGN: A prospective documentation of 40 patients who received percutaneous dilational tracheostomy in a multidisciplinary intensive care unit during a 12-month period. METHOD: The patients demographic, indications of intubation and PDT, time required to perform the procedure, complications and the outcome of these patients in the intensive care unit were noted. RESULT: Among 425 patients, 40 underwent percutaneous dilational tracheostomy that included 22 females and 18 males with the median age of 35 years. Prolonged ventilatory support was the most common indication for tracheostomy. The average duration of intubation before PDT was 5 days. Median procedure time was 20 minutes. Complications included minor bleeding in two (5%), subcutaneous emphysema with pneumothorax in two patients (5%), tracheal stenosis in three (7.5%), tracheo-esophageal fistula and glottic granuloma in one patient each (2.5%). Among forty patients, 28 (70%) were discharged to the ward, 8 died in intensive care unit and 4 left hospital against medical advice. CONCLUSION: Percutaneous dilational tracheostomy is a safe, quick and effective way for long term airway management in critically ill patients.

Groundwater arsenic contamination in Bangladesh and West Bengal, India.

Nine districts in West Bengal, India, and 42 districts in Bangladesh have arsenic levels in groundwater above the World Health Organization maximum permissible limit of 50 microg/L. The area and population of the 42 districts in Bangladesh and the 9 districts in West Bengal are 92,106 km(2) and 79.9 million and 38,865 km(2) and 42.7 million, respectively. In our preliminary study, we have identified 985 arsenic-affected villages in 69 police stations/blocks of nine arsenic-affected districts in West Bengal. In Bangladesh, we have identified 492 affected villages in 141 police stations/blocks of 42 affected districts. To date, we have collected 10,991 water samples from 42 arsenic-affected districts in Bangladesh for analysis, 58,166 water samples from nine arsenic-affected districts in West Bengal. Of the water samples that we analyzed, 59 and 34%, respectively, contained arsenic levels above 50 microg/L. Thousands of hair, nail, and urine samples from people living in arsenic-affected villages have been analyzed to date; Bangladesh and West Bengal, 93 and 77% samples, on an average, contained arsenic above the normal/toxic level. We surveyed 27 of 42 districts in Bangladesh for arsenic patients; we identified patients with arsenical skin lesions in 25 districts. In West Bengal, we identified patients with lesions in seven of nine districts. We examined people from the affected villages at random for arsenical dermatologic features (11,180 and 29,035 from Bangladesh and West Bengal, respectively); 24.47 and 15.02% of those examined, respectively, had skin lesions. After 10 years of study in West Bengal and 5 in Bangladesh, we feel that we have seen only the tip of iceberg.

Cardiovascular responses to scalp infiltration with reduced concentration of adrenaline.

A prospective randomized controlled study was carried out in 41 adult neurosurgical patients to find out the hemodynamic effects following scalp infiltration with 0.5% lignocaine with or without adrenaline. The patients were divided randomly into two groups. Group I patients (n=21) received 0.5% lignocaine with adrenaline (1:8,00,000) for scalp infiltration and group II patients (n=20) received 0.5% lignocaine without adrenaline. Continuous monitoring of ECG, heart rate and arterial blood pressure was carried out every minute for 20 minutes following scalp infiltration. Blood loss while raising the scalp flap was assessed by the neurosurgeon who was unaware of the study. No significant hemodynamic disturbances were observed in either group. However, Group I patients had significantly (p=0.001) less bleeding on incision. From this study, we conclude that 0.5% lignocaine with adrenaline (1:8,00,000) does not give rise to any cardiovascular disturbances during and following scalp infiltration. Rather, it minimises blood loss while raising the craniotomy flap.

Analgesic effects of intrathecal tramadol in patients undergoing caesarean section: a randomised, double-blind study.

BACKGROUND: Intrathecal tramadol combined with local anaesthetics has been used for postoperative analgesia following lower abdominal and perineal surgery. The present study evaluated the effect of intrathecal tramadol on spinal block characteristics and neonatal outcome after elective caesarean section. METHODS: Eighty full-term parturients scheduled for elective caesarean section were randomly divided into two groups. In the fentanyl group, patients received intrathecal 0.5% bupivacaine 10 mg with fentanyl 10 µg; in the tramadol group, patients were given the same dose of bupivacaine with tramadol 10 mg. Sensory and motor block characteristics, duration of postoperative analgesia, maternal side effects, and neonatal outcome were compared. RESULTS: One patient in the tramadol group and two patients in the fentanyl group were excluded from data analysis. Median [interquartile range] duration of postoperative analgesia in the tramadol and the fentanyl groups was 300 [240-360] min and 260 [233-300] min respectively (P = 0.02). The incidence of shivering was lower in patients who received tramadol (5%) than those who had fentanyl (32%) (P = 0.003). Apgar scores, umbilical cord acid-base measurement and neurologic and adaptive capacity scores were comparable between the two groups. CONCLUSION: Compared to intrathecal fentanyl 10 µg, tramadol 10 mg, as an adjunct to bupivacaine for subarachnoid block for caesarean section, showed a longer duration of analgesia with a reduced incidence of shivering.

Prevention of hypotension during propofol induction: a comparison of preloading with 3.5% polymers of degraded gelatin (Haemaccel) and intravenous ephedrine.

The present study compared the efficacy of preloading with colloid "Haemaccel" with vasoconstrictor (intravenous ephedrine sulphate) in preventing hypotension during propofol induction. This prospective, randomized study included 120 patients of Amercan Society of Anaesthesiologists (ASA) physical status I and II ageing 21 to 50 years of both gender coming for routine surgery. Patients were randomly allocated into three groups with 40 patients in each. Group A (control) did not receive any study medication, group B received Haemaccel (10 ml/kg intravenously over 10-15 minutes) and group C received injection ephedrine (0.2 mg/kg iv) prior to induction of anaesthesia. Propofol (2.5 mg/kg iv) was used for induction of anaesthesia. Heart rate and blood pressure were recorded before induction (baseline) and then every minute for 5 minutes after administering propofol. Anaesthesia was continued with standard technique thereafter. Hypotension was defined as fall in systolic blood pressure more than 20% from the basal value. The incidence of hypotension in Haemaccel (23.1%) or ephedrine group (22.5%) was significantly less than the control group (67.5%, P<0.01). We conclude that though preloading with colloid (Haemaccel) or prior injection of sympathomimetic (ephedrine) are not fully efficacious in preventing hypotension caused by propofol induction, both decrease the incidence in significant number of patients with heart rate less than baseline value in the colloid group.

Fluoroscopy guided chemical lumbar sympathectomy for lower limb ischaemic ulcers.

The purpose of this study was to assess the effectiveness of chemical lumbar sympathectomy in relieving pain and healing ischaemic ulcers in patients with peripheral vascular diseases. Thirty-one consecutive patients with ischaemic/ gangrenous lower limb ulcers, referred to the BPKIHS, Pain Clinic were observed prospectively after chemical lumbar sympathectomy using modified Reid Technique with 3 ml of 70% alcohol each at L2 and L3 level under fluoroscopic guidance. Pain relief and ulcer healing were noted in the follow up. Moreover, patients' abilities to resume at least part of their day to day work were also noted at three months follow up. Of the total 31 patients, 16 had Buerger's disease and the remaining 15 had non-Buerger's ischaemic ulcers of which 7 were diabetic. There was significant decrease in the pain score from mean+/-SD of 8.3+/-0.9 (pre-block) to 4.2+/-2.5 (post-block after 3 days) in zero to 10 Numerical Analogue Scale (NAS). By 3 months, 6 patients declined for follow up; 19(76%) of the remaining 25 patients reported pain relief, 18(72%) reported healing or decrease in the size of ulcers and 11(44%) were able to resume at least part of their usual work. Minor complications occurred in 5 patients and amputation was needed in 6 patients. Fluoroscopy- guided chemical lumbar sympathectomy is feasible, safe and effective in relieving pain and promoting ulcer healing in patients with ischaemic lower limb ulcers due both to Buerger's disease and non-Buerger's peripheral vascular diseases.

Intubating laryngeal mask for airway management in lateral decubitus state: comparative study of right and left lateral positions.

BACKGROUND: The intubating laryngeal mask has been used for the emergency management of the airway in patients placed in the lateral decubitus position. We have conducted this prospective study to compare the feasibility of placement of an intubating laryngeal mask and blind tracheal intubation guided by the intubating laryngeal mask in patients placed in the right and the left lateral positions. METHODS: A total of 82 adults of both sexes with normal airways, scheduled for cholecystectomy, were allocated randomly to be placed in either the right (n=41) or left (n=41) lateral position for the insertion of an intubating laryngeal mask and blind tracheal intubation guided by the intubating laryngeal mask under balanced general anaesthesia. A sequence of standard manoeuvres was performed after each failed attempt at intubating laryngeal mask placement and intubation. RESULTS: The intubating laryngeal mask was placed in all patients at the first attempt. Ventilation of the lungs through the intubating laryngeal mask was possible in 40 patients (97.5%) from each group after the first attempt at insertion (P=1). Following adjustments, adequate ventilation could be achieved in all patients. The first attempt success rates of blind tracheal intubation were 85.3% (35/41) and 87.8% (36/41) in the right and left lateral groups, respectively (P=1). The remaining patients from both groups (except for one patient in the left lateral group who had a failed intubation) were intubated at the second attempt. CONCLUSION: Insertion of the intubating laryngeal mask and blind tracheal intubation through it in the lateral position is feasible in patients with normal airways. These procedures have a high and comparable success rate when patients are placed in the right and left lateral positions.

Fluoroscope-aided retrograde placement of guide wire for tracheal intubation in patients with limited mouth opening.

Passing a retrograde catheter/wire into the pharynx through a cricothyroid puncture can facilitate tracheal intubation in difficult situations where either a flexible fibre-optic bronchoscope or an expert user of such a device is not available. Some mouth opening is essential for the oral and/or nasal retrieval of the catheter/wire from the pharynx. Two patients with temporo-mandibular joint (TMJ) ankylosis and extremely limited mouth opening required gap arthroplasty of the TMJ under general anaesthesia. Because we did not have a flexible fibre-optic bronchoscope, we performed fluoroscopy-assisted nasal retrieval of the guide wire passed up through a cricothyroid puncture and subsequently accomplished wire-guided naso-tracheal intubation. In the absence of a flexible fibre-optic bronchoscope, this technique is a very useful aid to intubation in patients with limited mouth opening.

Retrieval of a retrograde catheter using suction, in patients who cannot open their mouths.

In difficulty, tracheal intubation can be facilitated by passing a retrograde catheter, but the mouth has to be opened for the retrieval of the catheter from the pharynx. Two patients with ankylosis of a temporomandibular joint were unable to open their mouth, and required general anaesthesia for gap arthroplasty. Because we did not have a flexible fibreoptic laryngoscope, we used a suction catheter to retrieve an epidural catheter from the pharyngeal cavity, which had been passed retrogradely from a cricothyroid puncture. Catheter-guided tracheal intubation was done without complication. A suction catheter can assist retrograde retrieval of a catheter to aid intubation in patients who cannot open the mouth.

Chronic arsenic toxicity in Bangladesh and West Bengal, India--a review and commentary.

Fifty districts of Bangladesh and 9 districts in West Bengal, India have arsenic levels in groundwater above the World Health Organization's maximum permissible limit of 50 microg/L. The area and population of 50 districts of Bangladesh and 9 districts in West Bengal are 118,849 km2 and 104.9 million and 38,865 km2 and 42.7 million, respectively. Our current data show arsenic levels above 50 microg/ L in 2000 villages, 178 police stations of 50 affected districts in Bangladesh and 2600 villages, 74 police stations/blocks of 9 affected districts in West Bengal. We have so far analyzed 34,000 and 101,934 hand tube-well water samples from Bangladesh and West Bengal respectively by FI-HG-AAS of which 56% and 52%, respectively, contained arsenic above 10 microg/L and 37% and 25% arsenic above 50 microg/L. In our preliminary study 18,000 persons in Bangladesh and 86,000 persons in West Bengal were clinically examined in arsenic-affected districts. Of them, 3695 (20.6% including 6.11% children) in Bangladesh and 8500 (9.8% including 1.7% children) in West Bengal had arsenical dermatological features. Symptoms of chronic arsenic toxicity developed insidiously after 6 months to 2 years or more of exposure. The time of onset depends on the concentration of arsenic in the drinking water, volume of intake, and the health and nutritional status of individuals. Major dermatological signs are diffuse or spotted melanosis, leucomelanosis, and keratosis. Chronic arsenicosis is a multisystem disorder. Apart from generalized weakness, appetite and weight loss, and anemia, our patients had symptoms relating to involvement of the lungs, gastrointestinal system, liver, spleen, genitourinary system, hemopoietic system, eyes, nervous system, and cardiovascular system. We found evidence of arsenic neuropathy in 37.3% (154 of 413 cases) in one group and 86.8% (33 of 38 cases) in another. Most of these cases had mild and predominantly sensory neuropathy. Central nervous system involvement was evident with and without neuropathy. Electrodiagnostic studies proved helpful for the diagnosis of neurological involvement. Advanced neglected cases with many years of exposure presented with cancer of skin and of the lung, liver, kidney, and bladder. The diagnosis of subclinical arsenicosis was made in 83%, 93%, and 95% of hair, nail and urine samples, respectively, in Bangladesh; and 57%, 83%, and 89% of hair, nail, and urine samples, respectively in West Bengal. Approximately 90% of children below 11 years of age living in the affected areas show hair and nail arsenic above the normal level. Children appear to have a higher body burden than adults despite fewer dermatological manifestations. Limited trials of 4 arsenic chelators in the treatment of chronic arsenic toxicity in West Bengal over the last 2 decades do not provide any clinical, biochemical, or histopathological benefit except for the accompanying preliminary report of clinical benefit with dimercaptopropanesulfonate therapy. Extensive efforts are needed in both countries to combat the arsenic crisis including control of tube-wells, watershed management with effective use of the prodigious supplies of surface water, traditional water management, public awareness programs, and education concerning the apparent benefits of optimal nutrition.