Anaesthesia management of a patient with Bethlem Myopathy for elective tonsillectomy: a case report.

BACKGROUND: Bethlem Myopathy is a collagen VI-related myopathy presenting as a rare hereditary muscular disorder with progressive muscular weakness and joint contractures. Despite its milder clinical course relative to other myopathies, anaesthetic management can be challenging. High arched palates and fixed flexion deformities may contribute to a difficult airway. A progressive decline in pulmonary function can present later into adulthood. This respiratory decline can carry secondary cardiovascular consequences due to the progressive nature of restrictive lung disease, including right sided heart disease and pulmonary hypertension. We describe a case of a male patient with Bethlem Myopathy undergoing anaesthesia, to contribute to the limited body of literature on this condition and enhance awareness and guidance amongst anaesthesiologists on approaching patients with this condition. This is the first case report within the literature of its kind. CASE PRESENTATION: This case details a 33-year-old male with Bethlem Myopathy undergoing tonsillectomy. Diagnosed in childhood following developmental delays, the patient had no prior anaesthetic exposure and no family history of anaesthetic complications. Anaesthetic induction was achieved without complications, avoiding depolarizing muscle relaxants and careful airway management. Extreme care was taken in patient positioning to prevent complications. The surgery proceeded without incident and muscle paralysis was reversed with Suggammadex, resulting in no adverse post-operative respiratory complications. The patient was discharged on the first post-operative day without any respiratory or cardiovascular compromise. CONCLUSIONS: Bethlem Myopathy, while often exhibiting a mild clinical course, can present anaesthetic challenges. Awareness of potential complications including a difficult airway, cardiovascular and respiratory implications as well as the need for specialised monitoring and positioning is crucial to ensure a safe peri-operative course.

Adopting the New Norms of Monitoring Postoperative Patients with Wearable Devices in Ireland - Advantages and Challenges.

There has been a growing interest in wearable devices to monitor postoperative patients, providing the healthcare professionals with real-time information on vital signs to detect potential complications and hence, take timely actions to prevent them. Several studies and pilot programme in Ireland and worldwide indicated the effectiveness of wearable devices in monitoring patients, which could result in better patient outcomes and more efficient healthcare system. As more healthcare providers adopt this new technology, better patient outcomes and a more efficient healthcare system can be anticipated. Key Words: Wearable devices, Continuous monitoring, Patient safety.

Pseudo-teams in Healthcare: The Perils of Impersonating a Cohesive Unit.

Teamwork is a critical aspect of healthcare and is widely recognised as a cornerstone of effective patient care. However, not all healthcare teams are created equal, and some teams that appear to work well together on the surface are better described as pseudo-teams rather than true teams. This issue is frequently disregarded and overlooked despite its importance, yet it significantly impacts patient care and staff morale. We wish to describe the concept of pseudo teams in healthcare, their perils, and ways to create true teams characterised by shared goals, open communication, and a commitment to each other's success.

Efficacy and feasibility of awake proning in patients with COVID-19-related acute hypoxemic respiratory failure: an observational, prospective study.

INTRODUCTION: Most of COVID-19 patients present with hypoxemic respiratory failure. Proning is one of the management options proven to improve oxygenation and reduce mortality in non-COVID-19-related acute respiratory distress syndrome. As a response to COVID-19 pandemic surge, a dedicated COVID-19 respiratory ward for the management of mild to moderate ARDS patients who require oxygen therapy, non-invasive ventilation (NIV), or high-flow nasal cannula (HFNC) was established. We adopted a policy of early awake proning in such patients. AIMS: To determine the physiological changes, improvement in  oxygenation, the need for intubation, alongside with the duration, tolerance, and adverse effects of awake proning. STUDY DESIGN AND METHODS: Single-center, prospective observational cohort study. All awake, non-intubated, spontaneously breathing patients with COVID-19, and hypoxemic acute respiratory failure requiring oxygen supplementation, NIV, or HF RESULTS: Fifty patients were enrolled. There was a significant improvement in oxygenation when turning the patients from supine to prone position with mean PFR was 85 (SD 13.76) in supine position which increased to 124 (SD 34.08) in prone position with substantial increase in mean PFR 1-h post proning to 138 (SD 28.01) and P-value 0.0001. Prone positioning was feasible in 41 (82%) patients (mean duration 8.5 (SD 3.13) h), and 38 (76%) patients reported that it was well tolerated. CONCLUSION: Awake proning was feasible, tolerable, and effective in improving oxygenation in patients with COVID-19-related pneumonia and acute hypoxemic respiratory failure in this prospective study.

COVID-19-related Posterior Reversible Encephalopathy Syndrome in an Adult ICU Patient in Ireland.

Radiologically confirmed, novel coronavirus disease 2019 (COVID-19)-related neurological manifestations are being reported with increasing frequency since the outbreak of the disease. We describe a 54-year-old male with COVID-19, who demonstrated radiological and clinical findings of posterior reversible encephalopathy syndrome(PRES). The proposed mechanism suggested for COVID-19-related PRES is a disease induced inflammatory storm, which causes endothelial injury, resulting in endothelialdysfunction (ED), interstitial fluid extravasation and cerebral edema. Key Words: COVID-19, Encephalopathy, Neurological complications, PRES.

Covid-19, Sixteen Months Into The Pandemic: A Narrative Review.

COVID-19, the disease caused by the newly-discovered SARS-CoV-2 virus, has quickly spread from China throughout the world since January 2020. Its potential severity, despite in a minority of cases, has paralysed healthcare systems struggling for adequate resources, as well as entire nations often forced to adopt radical measures, such as lockdowns and surveillance, to contain the disease and restrict its spread. Initially presenting as a respiratory infectious disease, it can not only progress to an acute respiratory distress syndrome, but also have multisystemic consequences. There are many proving theories as regards to the pathophysiology and there are currently no proven definitive treatments. Due to its high transmissibility and the risk of infecting healthcare workers, hospitals also had to rethink their organisation. We have completed a literature review of the sixteen months of the pandemic, with attention to pathophysiology, key epidemiological concepts, hospital organisation, critical care considerations, and finally current and prospective treatments.

Preparing for a Pandemic: Our Plans and Lessons Learnt as a Department in a Tertiary Care Hospital.

This is a descriptive article aiming to present and analyse the steps of preparedness and troubleshooting of problems faced at operating rooms and intensive care unit during the ongoing coronavirus infectious disease 2019 (COVID-19) pandemic in Our Lady of Lourdes Hospital, a tertiary care hospital in Ireland from February 2020 to March 2020. Concerning preparation, we reviewed all aspects of our clinical and potential logistic  issues and their accessible solutions in times of limited resources. Analysing availability of critical care staff and essential escalation of care area capacity during the ongoing pandemic, we observed that there was strong communication, commitment and team work among departmental and other non-critical care staff, and disciplines. Being the only  regional teaching hospital with critical care unit in county Louth, we found ourselves confident and content with our preparation. We found good communication and training as critical factors in the preparation for a pandemic. Key Words: COVID-19, Pandemic, Preparation, Challenges.

Per-cutaneous dilatation tracheostomy (PCTD) in COVID-19 patients and peri-tracheostomy care: A case series and guidelines.

BACKGROUND & OBJECTIVE: COVID 19 patients with severe respiratory failure may require prolonged mechanical ventilation. Placement of a tracheostomy tube often becomes necessary for such patients. The steps of tracheostomy procedure and post tracheostomy care of these patients can be classified as aerosol generating. We wish to highlight our modified technique to address these issues. METHODOLOGY: We performed percutaneous dilation tracheostomy in three clinically challenging COVID-19 patients in our ICU and developed guidelines aiming to minimise aerosolisation during and after the tracheostomy procedure to safeguard healthcare workers. RESULTS: Percutaneous tracheostomy was performed by a team of three experienced anaesthetists and an ICU nurse. CONCLUSION: The decision of surgical or percutaneous tracheostomy should be dependent on the experience of the tracheostomy performer, health-care worker safety, resource availability, and patient-centred care. We believe our modified strategic approach of brief bronchoscopy, minimum PEEP and gas flows and step-wise planned approach for PCDT offers an extra level of safety to healthcare workers.

Hypoglycaemia secondary to labetalol infusion.

A 42-year-old multigravida with severe pre-eclampsia had an emergency caesarean section under spinal anaesthesia. Peri-operatively, her arterial pressure was controlled with oral methyldopa and an intravenous infusion of labetalol. Postoperatively, in the Intensive Care Unit, she had recurrent episodes of hypoglycaemia which required treatment with intravenous glucose. These episodes resolved when the labetalol infusion was stopped. Clinicians should be aware of the potential of labetalol to cause hypoglycaemia.

Anxiolytic effect of midazolam premedication assessed by clinical and platelet aggregation profiles.

BACKGROUND: It is well documented that surgery is associated with increased anxiety, which has an adverse impact on patient's outcome. This study was designed to assess the anxiolytic effect of midazolam in pre-anaesthetic medication by using clinical and platelet aggregation profiles. METHODS: Sixty ASA I and II female patients aged between 35 and 60 years undergoing elective abdominal hysterectomy were randomly divided into two equal groups. Group I received placebo as pre-medication while group II received 0.15 mg/kg midazolam as pre-medication 1 hour preoperatively. They were monitored for visual analogue scale (VAS) for anxiety, observer's anxiety criteria, sedation score, blood pressure, heart rate and platelet aggregation profile immediately before and 1 hour after pre-medication. RESULTS: There was statistically significant difference with respect to VAS of anxiety, observer's anxiety criteria, sedation scores, systolic and diastolic blood pressure (p<0.05). Heart rate was higher in the midazolam group but this was not statistically significant. There was no statistical significant difference in platelet aggregation profile in the two groups. CONCLUSION: Findings of the study suggest midazolam is a good anxiolytic for pre-medication and its effect on platelet aggregation profile needs to be further evaluated.

Evaluation of a blood conservation strategy in the intensive care unit: a prospective, randomised study.

OBJECTIVE AND METHODS: Anemia is a common problem in the ICU population. Most patients are anemic at admission, their hemoglobin concentrations declining further thereafter. The aim of the present study was to evaluate the effect of a combination strategy, involving closed arterial blood gas sampling and the use of pediatric vials for phlebotomy (Group A), on the sampling-induced blood loss and the rate of decline in hemoglobin in adult ICU patients. Combination (Group A) was compared to the current standard technique of arterial line sampling and adult vial phlebotomy (Group B) in a prospective, randomised, ethically-approved trial for the first 72 hours of their ICU stay. Peri-operative, oncology, coagulopathic and uremic patients were excluded. All other ICU patients with arterial cannulae and predicted to stay beyond 3 days, were enrolled. RESULTS: 39 patients entered the study, 20 in Group A, and 19 in Group B. Data collection was complete for all. There was a statistically significant difference in sampling-induced blood loss between the groups over the first 72 hours of treatment (mean +/- standard deviation: 15.16 +/- 5.3 ml Group A vs 45.11 +/- 14 ml Group B, p<0.001). There was a smaller decline in mean hemoglobin level, which was not statistically significant (0.79 +/- 0.6 g/dL vs 1.30 +/- 1.13, p = 0.09). CONCLUSIONS: Overall, this strategy reduced measurable blood losses from phlebotomy. In larger trials it might also preserve hemoglobin levels.

Anaesthesia at remote location: use of modified Bain circuit (Mapleson D) at Kunri Christian Hospital (KCH).

OBJECTIVE: To develop a safe general anaesthesia technique for remote areas with lack of facilities. METHODS: Four types of anaesthesia techniques using TIVA and modified Bain circuit were planned. Monitoring facility was limited to manual sphygmomanometer, palpation of radial pulse and monitoring of colour of skin and blood. Depth of anaesthesia was assessed using EVANs, RPST scoring system. Patients were asked in recovery room for awareness. RESULTS: Surgeries done were cesarean sections, laparotomies, gynaecological, urological, hernia and burn contractures. Six patients had RPST score of 5 or more and three patients in recovery room complained of awareness. Cost per Anaesthesia was Rs225. CONCLUSION: TIVA with modified Bain circuit provided effective anaesthesia in remote area at low cost.

Efficacy of sub-Tenon's block using an equal volume of local anaesthetic administered either as a single or as divided doses. A randomised clinical trial.

BACKGROUND: Sub-Tenon's anaesthetic is effective and reliable in producing both akinesia and anaesthesia for cataract surgery. Our clinical experience indicates that it is sometimes necessary when absolute akinesia is required during surgery to augment the block with 1-2 ml of local anaesthetic. Hypothesis was that after first injection some of the volume injected may spill out and before second injection the effect of hyaluronidase has taken place and second volume injectate will have desired effect. METHODS: A prospective, randomised, control trial in which patients were randomly allocated to one of two groups. In group 1, single injection of 5 ml of local anaesthetic was injected. In group 2, 3 ml of the same anaesthetic solution was injected followed by application of gentle orbital pressure for 2 minutes. A further 2 ml of the same anaesthetic solution was injected through the same conjunctival incision. Measurement of movement in four quadrants of eye was done by the surgeon at 3 and 6 minutes. Intraocular pressure, chemosis, and subconjuctival haemorrhage were also measured. RESULTS: Significant differences at 3 minutes between groups for overall movement, medial, superior, and lateral quadrants occurred. At 6 minutes no significant group differences emerged for the overall movement or for any of four quadrants. CONCLUSION: Single injection of local anaesthesia for sub-Tenon's block with mixture of lignocaine with adrenaline, bupivacaine and hyaluronidase was found to be superior to provide akinesia of ocular muscles compared to divided dose given by two injections. No difference in groups in terms of haemorrhage, chemosis, patient's satisfaction and intraocular pressure was found. TRIAL REGISTRATION: Trial registration no-ISRCTN73431052.