Fire Hazard in an Anesthesia Machine: A Case Report.

An operating room (OR) fire is a rare event but may cause critical harm to patients and health care personnel. We present 2 fire incidents in the rear cabinet of an anesthesia machine, not previously reported in the literature. An anesthesia machine in standby mode is considered safer than in use, but in the first case, the fire occurred while the machine was on standby mode. In another case, the fire erupted while surgery was in progress. Here, we discuss the management of an anesthesia machine fire and emphasize the need for improved fire safety in advanced anesthesia machines.

Comparison of Propofol and Ketofol on Transcranial Motor Evoked Potentials in Patients Undergoing Thoracolumbar Spine Surgery.

STUDY DESIGN: This was a double-blind randomized study. PURPOSE: The primary purpose was to compare the effects of propofol and ketofol on amplitudes and latencies of transcranial motor evoked potentials (TcMEPs) during thoracolumbar spine surgery. In addition, intraoperative hemodynamics and muscle power were compared. OVERVIEW OF LITERATURE: Propofol is commonly used during intraoperative TcMEP monitoring. However, propofol inhibits TcMEP amplitudes and causes hypotension in a dose-dependent fashion. METHODS: Amplitude and latency of TcMEPs were recorded bilaterally from the abductor pollicis brevis (APB) and abductor hallucis (AH) muscles in 38 adult American Society of Anesthesiologists I and II patients undergoing thoracolumbar spine surgery. Baseline recordings of TcMEPs in both groups were recorded under propofol infusion. Group X patients then received propofol and fentanyl (1 mcg/kg/hr), and group Y patients received ketofol and fentanyl (1 mcg/kg/hr). Bispectral index was maintained at 40-60 in both groups. Amplitude and latency were recorded at 30 minutes intervals for 2 hours. RESULTS: Propofol caused no significant changes in amplitude and latency in any muscle. In contrast, amplitude increased significantly at all time points in the bilateral APB muscles and 60, 90, and 120 minutes in the left AH muscle without changes in latency in response to ketofol. When the two groups were compared, ketofol induced significantly higher amplitudes at 60, 90, and 120 minutes in the (left) APB, at all time points in the (right) APB, and at 120 minutes in both AH muscles, compared with propofol. Blood pressures were lower and fluid and vasopressor requirements were higher in group X. Muscle power was similar between the two groups. CONCLUSIONS: Ketofol facilitates TcMEP amplitudes without affecting latency. Use of ketofol resulted in a better and more stable hemodynamic profile than did use of propofol.

Acute critical care course for interns to develop competence.

Background All medical graduates must know how to stabilize and manage critically ill patients. A 2-day intensive course, called the acute critical care course (ACCC), was conducted to train interns in technical and non-technical skills for managing a patient whose condition is deteriorating. This analysis aims to assess the feasibility and effectiveness of ACCC for interns. Methods We developed and conducted the ACCC to train interns. It included lectures and skill stations. Twenty-four interns participated in the course. Immediate, post-course, quantitative and qualitative feedback was taken online. Qualitative information was also collected verbally and later by email. These data were analysed both quantitatively and qualitatively. Thematic analysis was used to identify, analyse and report the patterns of responses and behaviour. Results The average score for the utility of the course was 4.7 and for the skill stations it was 4.6 on a scale of 5. The qualitative analysis of the feedback emphasized the need for the course before the clinical posting and more skill-based modules rather than lectures. The interactive style of teaching and training in communication using role-play was appreciated. Few suggestions to improve the course were provided. Conclusions Implementing the ACCC needed simulation, interactive discussions, role-play, modified Pendleton's feedback, and reflective exercise that form the basis of a range of educational principles. The blended learning set of objectives of ACCC were the pillars for this successful internship training programme.

An investigation to the prolonged requirement (>7 days) of vasopressors in cervical spinal cord injury patients-a retrospective analysis.

STUDY DESIGN: Retrospective chart review. OBJECTIVES: The primary aim was to identify the number of patients requiring vasopressors beyond the first week of cervical spinal cord injury (SCI). Secondary objectives were to note the type, duration and doses of vasopressors and any association between prolonged vasopressors use and outcome. SETTING: Neurosurgical intensive care of a tertiary trauma care centre. METHODS: After Ethical approval we retrospectively collected the data of patients of isolated cervical SCI admitted to neurosurgical intensive care from January to December 2017. Vasopressor requirement for sepsis or cardiac arrest was excluded. RESULTS: Out of 80 patients analysed, 54 (67.5%) received vasopressors. The prolonged requirement of vasopressors was observed in 77.7%. Our preferred agent was dopamine (64.8%). We found out that longer requirement (in days) of high dose of dopamine was associated with higher survival (p = 0.03). CONCLUSION: Our results describe a significant portion of cervical SCI patients need ongoing vasopressor to maintain a mean arterial pressure >65 mm of Hg beyond first week. We observed patients who required longer duration of high dose dopamine had a higher chance of survival suggesting some unknown mechanism of high dose of dopamine. This is first such observation, further studies are needed to substantiate.

Communication skills training through 'role play' in an acute critical care course.

Background: . Effective patient-doctor communication is a key component of patient-centred care, which is one of the six pillars of quality healthcare delivery. Structured and effective communication skills training for healthcare providers is the need of hour in medical education. We assessed the efficacy of role play and simulation in developing communication skills. Methods: . As a key component of an acute critical care course (ACCC), communication skills are taught using role play models and simulation. Live feedback is critical in learning during this course as per the principles of adult learning (andragogy). Quantitative and qualitative data were collected to assess the efficacy of ACCC. Results: . The 19th ACCC was introduced to interns at the All India Institute of Medical Sciences, New Delhi in December 2018. The teaching methodology and objective-oriented structured training in ACCC were much appreciated for training in human factors with emphasis on communication. A positive response was obtained from the candidates 3 weeks after they completed the course to assess whether interns are able to make use of this training in their day-to-day clinical practice amounting to a reliable evidence level of Kirkpatrick's 'return of investment'. Conclusion: . The use of 'role play' to teach communication skills is effective and superior to lecture-based teaching. Further structured and interactive programmes in communication skills training will improve patient care, relatives' satisfaction and the image of medical profession.

Device associated infections at a trauma surgical center of India: Trend over eight years.

BACKGROUND: Device-associated infections (DAIs) are an important cause of excessive stay and mortality in ICUs. Trauma patients are predisposed to acquire such infections due to various factors. The prevalence of HAIs is underreported from developing nations due to a lack of systematic surveillance. This study reports the rates and outcomes of DAIs at a dedicated Trauma Center in trauma patients and compares the rates with a previous pilot observation. METHODS: The study reports the finding of ongoing surveillance and the use of an indigenous software at a level-1 trauma center in India. Surveillance for ventilator-associated pneumonia, central line-associated bloodstream infections, and catheter-associated urinary tract infections was done based on standard definitions. The rates of HAIs and the profile of pathogens isolated from June 2010 to December 2018 were analyzed. RESULTS: A total of 7485 patients were included in the analysis, amounting to 68,715 patient days. The rates of VAP, CLABSI, and CA-UTI were respectively 12, 9.8 1st 8.5/1000 device days. There was a significant correlation between device days and the propensity to develop infections. Of the 1449 isolates recovered from cases of DAIs, Acinetobacter sp (28.2%) was the most common isolate, followed by Candida sp. A high rate of multi-resistance was observed. CONCLUSION: Automated surveillance was easy and useful for data entry and analysis. Surveillance data should be used for implementing preventive programs.

Iatrogenic Seizures during Intraoperative Transcranial Motor-Evoked Potential Monitoring.

Intraoperative neurophysiological monitoring (IONM) is an important tool for early detection of inadvertent damage and guide intra-operative manipulation during complex neurosurgical procedures. However trans-cranial stimulation can evoke an iatrogenic seizure and it remains a real concern while using Tc-MEP. We report a case of intra-operative seizure during transcranial electrical stimulation for motor evoked potential monitoring in a patient without seizure disorder, who underwent surgery for thoracic intra-medullary tumor excision.

Does Real Time Ultrasonography Confer Any Benefit During Bronchoscopy Guided Percutaneous Tracheostomy: A Preliminary, Randomized Controlled Trial.

BACKGROUND: There are studies comparing USG guided percutaneous dilatational tracheostomy (PDT) with bronchoscopy guided PDT. We have compared USG guided PDT to conventional landmark guided PDT using bronchoscopy in both the groups. OBJECTIVE: The primary outcome was the time of procedure and the secondary outcome was incidence of complications in USG guided PDT in comparision to the conventional PDT. MATERIALS AND METHODS: Seventy adult patients were randomly allocated in two groups, i.e., conventional landmark percutaneous dilatational tracheostomy (PDT) and ultrasonography (USG) guided PDT. Demographic data, injury severity score, time taken for the procedure, attempts of tracheal puncture, major and minor complications, and outcome were compared. RESULTS: The median time taken for the procedure was 12 minutes [min., max.; 8, 20] in conventional group 1 and 16 minutes [9, 24] in group 2 (USG guided) which was statistically significant. Minor bleeding was seen in 7 (20%) patients in group 1 and only in 4 patients (11.5%) in group 2. The rate of other complications and the long term outcome were similar in both the groups. CONCLUSION: The use of real time USG during PDT may confer advantage over conventional PDT when using bronchoscopy in terms of decreasing the incidence of minor bleeding but duration of the procedure gets prolonged. HOW TO CITE THIS ARTICLE: Aggarwal R, Soni KD, Goyal K, Singh GP, Sokhal N, Trikha A. Does Real Time Ultrasonography Confer Any Benefit During Bronchoscopy Guided Percutaneous Tracheostomy: A Preliminary, Randomized Controlled Trial. Indian J Crit Care Med 2019;23(5):236-238.

Epidemiological investigation and successful management of a Burkholderia cepacia outbreak in a neurotrauma intensive care unit.

OBJECTIVE: The detailed epidemiological and molecular characterization of an outbreak of Burkholderia cepacia at a neurotrauma intensive care unit of a level 1 trauma centre is described. The stringent infection control interventions taken to successfully curb this outbreak are emphasized. METHODS: The clinical and microbiological data for those patients who had more than one blood culture that grew B. cepacia were reviewed. Bacterial identification and antimicrobial susceptibility testing was done using automated Vitek 2 systems. Prospective surveillance, environmental sampling, and multilocus sequence typing (MLST) were performed for extensive source tracking. Intensive infection control measures were taken to further control the hospital spread. RESULTS: Out of a total 48 patients with B. cepacia bacteraemia, 15 (31%) had central line-associated blood stream infections. Two hundred and thirty-one environmental samples were collected and screened, and only two water samples grew B. cepacia with similar phenotypic characteristics. The clinical strains characterized by MLST typing were clonal. However, isolates from the water represented a novel strain type (ST-1289). Intensive terminal cleaning, disinfection of the water supply, and the augmentation of infection control activities were done to curb the outbreak. A subsequent reduction in bacteraemia cases was observed. CONCLUSION: Early diagnosis and appropriate therapy, along with the rigorous implementation of essential hospital infection control practices is required for successful containment of this pathogen and to curb such an outbreak.

Intraoperative Management of a Patient for Deep Brain Stimulation with Severe Dyskinesia and Tremors: Ketamine to the Rescue!

The loss of dopaminergic neurons from the substantia nigra pars compacta characterizes the classical pathology of Parkinson's disease (PD). Deep brain stimulation (DBS) has become an increasingly common treatment for PD. Sometimes excessive tremors due to exacerbated PD hinder the surgery and may almost make it impossible. This is a case report highlights use of IV ketamine for intraoperative sedation of a patient with PD, with severe dyskinesia & tremors, posted for DBS. IV ketamine resulted in prompt abolition of tremors and dyskinesia, which were unresponsive to previous traditional sedative drugs.

Non- Neurological Complications after Traumatic Brain Injury: A Prospective Observational Study.

INTRODUCTION AND AIMS: Recognizing and treating nonneurological complications occurring in traumatic brain injury (TBI) patients during intensive care unit (ICU) stay are challenging. The aim is to estimate various nonneurological complications in TBI patients. The secondary aim is to see the effect of these complications on ICU stay, disability, and mortality. MATERIALS AND METHODS: This was a prospective observational study at the neuro-ICU of a Level-I trauma center. A total of 154 TBI patients were enrolled. The period of the study was from admission to discharge from ICU or demise. Inclusion criteria were patients aged >16 years and patients with severe TBI (Glasgow coma score [GCS] ≤8). Nonneurological complications were frequent in TBI patients. RESULTS: We observed respiratory complications to be the most common (61%). Other complications, in the decreasing order, included dyselectrolytemia (46.1%), cardiovascular (34.4%), coagulopathy (33.1%), sepsis (26%), abdominal complications (17.5%), and acute kidney injury (AKI, 3.9%). The presence of systemic complications except AKI was found to be significantly associated with increased ICU stay. Most of the patients of AKI died early in ICU. Respiratory dysfunction was found to be independently associated with 3.05 times higher risk of worsening clinical condition (disability) (P < 0.018). The presence of cardiovascular complications during ICU stay (4.2 times, P < 0.005), AKI (24.7 times, P < 0.02), coagulopathy (3.13 times, P < 0.047), and GCS <6 (4.2 times, P < 0.006) of TBI was independently associated with significantly increased risk of ICU mortality. CONCLUSION: TBI patients tend to have poor outcome due to concomitant nonneurological complications. These have significant bearing on ICU stay, disability, and mortality.

Comparison of 20% mannitol and 3% hypertonic saline on intracranial pressure and systemic hemodynamics.

Mannitol and hypertonic saline (HS) are most commonly used hyperosmotic agents for intraoperative brain relaxation. We compared the changes in ICP and systemic hemodynamics after infusion of equiosmolar solutions of both agents in patients undergoing craniotomy for supratentorial tumors. Forty enrolled adults underwent a standard anesthetic induction. Apart from routine monitoring parameters, subdural ICP with Codmann catheter and cardiac indices by Vigileo monitor, were recorded. The patients were randomized to receive equiosmolar solutions of either 20% mannitol (5ml/kg) or 3% HS (5.35ml/kg) for brain relaxation. The time of placement of ICP catheter was marked as T0 and baseline ICP and systemic hemodynamic variables were noted; it was followed by recording of the same parameters every 5min till 45min (Study Period). After the completion of study period, brain relaxation score as assessed by the neurosurgeon was recorded. Arterial blood gas (ABG) was analysed every 30min starting from T0 upto one and half hours (T90), and values of various parameters were recorded. Data was analysed using appropriate statistical methods. Both mannitol and HS significantly reduced the ICP; the values were comparable in between the two groups at most of the times. The brain relaxation score was comparable in both the groups. Urine output was significantly higher with mannitol. The perioperative complications, overall hospital stay, and Glasgow outcome score at discharge were comparable in between the two groups. To conclude, both mannitol and hypertonic saline in equiosmolar concentrations produced comparable effects on ICP reduction, brain relaxation, and systemic hemodynamics.

Pain relief can be painful.

Mandibular nerve block is periodically used procedure used to treat neuralgic pain in the distribution of trigeminal nerve. It is a commonly performed block in outpatient settings at our institute. We present a case of an elderly edentulous patient with trigeminal neuralgia who suffered recurrent temporomandibular joint (TMJ) dislocation following mandibular nerve block. The patient presented with complaints of severe pain, inability to close mouth, and eat food since 2 days. Anterior closed reduction of TMJ resulted in reduction of joint and immediate pain relief. However, the maneuver failed due to recurrent dislocation of the joint. A Barton dressing was applied to prevent another dislocation. This was followed by autologous blood injection into the joint. This case focuses on the preponderance of clinical evaluation and accentuates the need for additional forethought to be taken during pain procedures, particularly in the geriatric population.

Anaesthetic consideration of a child with concomitant craniovertebral junction anomaly and arrested hydrocephalus.

Congenital malformations of various sorts account for a large percentage of childhood hydrocephalus but associated Craniovertebral junction (CVJ) anomaly has not been reported earlier. Though the anaesthetic concerns for isolated arrested hydrocephalus and CVJ anomaly has been reported but the concomitant occurrence of both and its anaesthetic implications is not mentioned in literature. Here we present the anaesthetic management of a child with arrested hydrocephalus along with CVJ anomaly leading to compression of cervicomedullary junction and myelopathy scheduled for decompression and fixation of craniovertebral junction.