Comparison of success rate of abducted and neutral arm position for right infraclavicular subclavian vein cannulation under real-time ultrasound guidance in patients undergoing elective neurosurgery under general anesthesia.

Background: Classically subclavian vein catheterization is done in neutral arm position; recently, it has been done in different arm positions to compare success rate and catheter misplacement. There is a paucity of literature for comparing abducted and neutral arm position for right infraclavicular subclavian vein cannulation. Aim: Comparison of success rate of abducted and neutral arm position for right infraclavicular subclavian vein cannulation under real-time ultrasound guidance in patients undergoing elective neurosurgery under general anesthesia. Design: Randomized comparative study. Materials and Methods: After approval from Institutional Review Board and Ethical Committee, 100 patients of 18-70 years of age, of either sex, posted for elective neurosurgery under general anesthesia, requiring right subclavian vein cannulation were included in our study. They were randomly divided into two groups: abducted arm position (group 1-AG) and neutral arm position (group 2-NG) using sealed envelope technique. Results: First attempt success rate was higher in AG group compared to NG group (P value- 0.741). Times taken (seconds) for cannulation in NG and AG group, catheter misplacement and hematoma (P value- 0.37, P value- 0.37, P value- 1, respectively) were lesser in AG Group. Conclusion: For USG-guided infraclavicular subclavian vein cannulation, abducted arm position, and neutral arm position in terms of first attempt success rate, number of attempts and associated complications has comparable results; however, further studies with larger group of patients are required to assess the overall advantage of abducted arm position over neutral arm position.

Comparison of Haemodynamic Response to Inhalational Bolus with Desflurane in Normotensive and Hypertensive Patients Undergoing Laparoscopic Cholecystectomy.

OBJECTIVE: Desflurane causes sympathetic stimulation at high end-tidal concentrations. We conducted this study to compare the haemodynamic response to inhalational bolus with desflurane in normotensive and hypertensive patients undergoing laparoscopic cholecystectomy. METHODS: In this prospective, clinical trial, 40 patients aged 18-60 years and undergoing laparoscopic cholecystectomy were divided into normotensives (Group N; n=20) and hypertensives (Group H; n=20). Heart rate (HR), mean arterial pressure (MAP) and bispectral index (BIS) were measured at baseline and every 60 s for 5 min after induction, intubation, initiation and inhalational bolus of desflurane. The primary objective was to compare haemodynamic response, and the secondary objective was to assess the need for inhalational boluses and to compare the number of overcorrections and undercorrections in BIS value after each inhalational bolus. An independent t-test was used to compare the means of the study parameters between the groups, and a dependent t-test was used to compare the percentage change in the means of the study parameters within the same group. Statistical significance was defined as p<0.05. RESULTS: No statistically significant difference in the percentage of patients responding with a decrease, increase or no change of HR or MAP were seen between the two groups after inhalational bolus of desflurane. An overcorrection of BIS (value <45) was seen in 60% of the patients in Group H and 15% of the patients in Group N (p=0.003). None of the patients in either group had an undercorrection (BIS>55). CONCLUSION: BIS-guided desflurane administration and BIS-triggered inhalational boluses of desflurane is safe, feasible and does not cause sympathetic stimulation in either normotensive or hypertensive patients.

Use of metabolic monitors in a multidisciplinary Intensive Care Unit: A prospective pilot study of 20 patients.

INTRODUCTION: Caloric intake of critically ill patients are usually calculated using predictive equations. Recent advances in gas exchange measurements have the potential to estimate energy expenditure at the bedside and at different time periods. MATERIALS AND METHODS: Energy needs of critically ill patients were estimated over a period of 3 months using simplistic formula of 25 kcal/kg/day estimated energy expenditure (EEE), Harris-Benedict equation (HBE) (Basal energy expenditure [BEE]) and M-COVX™ metabolic monitor resting energy expenditure (REE) on day 4 of Intensive Care Unit (ICU) admission. Calculations based on HBE were taken as standard, and percentage errors (PE) were calculated for each patient for values derived from simplistic formula and metabolic monitor. Adequacy of nutritional intake in ICU was also assessed. RESULTS: Metabolic monitor could be used in only 20/70 patients. The mean age of patients was 40 years, 65% were males, and average body mass index was 23.69 kg/m(2). Intermittent intolerance to feeds was reported in 50%. Values of REE and EEE were greater than BEE in 70% of patients. A significant difference was reported in values of PE of ≤20% and ≥30%; P = 0.0003 and 0.0001, respectively estimated using REE and EEE. CONCLUSIONS: It is not feasible to use metabolic monitors in all patients. Variability in readings is large and further studies are needed to establish the validity of its measurements. Calculations using simplistic formulas are much closer to values obtained using HBE.

Anaesthesia for emergency ventriculo-peritoneal shunt in an adolescent with Noonan's syndrome.

A 15-year-old boy with Noonan's syndrome was admitted for emergency ventriculo-peritoneal shunt. Intraoperative course was complicated by hypertensive urgency, which was effectively managed with high doses of esmolol (500 µg/kg/min). Difficult airway was anticipated due to presence of webbed neck and facial dysmorphism. Tracheal intubation was however successfully accomplished with the aid of a bougie. This report thus highlights the unique anaesthetic problems encountered during anaesthetic management of such a case, which is worth sharing.

Anesthetic management in a patient with Wolff-Parkinson-White syndrome for laparoscopic cholecystectomy.

Wolff-Parkinson-White syndrome is an electrophysiological disorder of heart. Patients with such disorder may be asymptomatic or present with cardiac symptoms like palpitation and dyspnea. These patients may present with serious cardiac complication like atrial fibrillation and PSVT intraoperatively. We report a case of a 30-year-old female with WPW syndrome posted for laparoscopic cholecystectomy under general anesthesia. We took all the precautions necessary to avoid tachycardia and arranged drugs necessary to treat any complications together with stringent monitoring which is very important for favorable outcome in these patients. Management of the case offers an opportunity to relearn the important considerations on WPW syndrome.

Repeated surgeries in a patient with Behçet's disease, what changes to expect?

Behçet's disease is a multisystem inflammatory disorder of unknown etiology characterized by vasculitis of large and smaller vessels. Most common features are appearance of oral ulcers which later heal by scarring and ocular involvement leading to glaucoma requiring surgical treatment. Here, we report a case of child suffering from Behçet's disease undergoing repeated ocular surgery for uncontrolled glaucoma and found that with the usual risk involved in such patients there are important changes in the airway when the patient is exposed to repeated surgery under general anesthesia.

Evaluation of the efficacy of hyperbaric oxygen therapy in the management of chronic nonhealing ulcer and role of periwound transcutaneous oximetry as a predictor of wound healing response: A randomized prospective controlled trial.

BACKGROUND: Hyperbaric oxygen therapy (HBOT) is a treatment option for chronic nonhealing wounds. Transcutaneous oximetry (TCOM) is used for wound assessment. We undertook a randomized prospective controlled trial to evaluate the role of HBOT in healing of chronic nonhealing wounds and to determine whether TCOM predicts healing. MATERIALS AND METHODS: This study was conducted in 30 consenting patients with nonhealing ulcer. The patients were randomized into group HT (receiving HBOT in addition to conventional treatment) and group CT (receiving only conventional treatment). Duration of treatment in both the groups was 30 days. Wound ulcer was analyzed based on size of the wound, exudates, presence of granulation tissue, and wound tissue scoring. Tissue oxygenation (TcPO(2)) was measured on 0, 10(th), 20(th), and 30(th) day. RESULTS: There was 59% reduction in wound area in group HT and 26% increase in wound area in group CT. Ten patients in group HT showed improvement in wound score as compared to five patients in group CT. Complete healing was seen in three patients in group HT as compared to none in group CT. Surgical debridement was required in 6 patients in group HT and 10 patients in group CT. One patient in group HT required amputation as compared to five patients in group CT. A positive correlation was found between TcPO(2) value and various markers of wound healing. CONCLUSION: HBOT has a definitive adjunctive role in the management of chronic nonhealing ulcers. It decreases the amputation rate and improves patient outcome. Periwound TcPO(2) may be used as a predictor of response to HBOT and has a positive correlation with wound healing.

Filgrastim as a rescue therapy for persistent neutropenia in a case of dengue hemorrhagic Fever with acute respiratory distress syndrome and myocarditis.

Pathogenesis of dengue involves suppression of immune system leading to development of characteristic presentation of haematological picture of thrombocytopenia and leucopenia. Sometimes, this suppression in immune response is responsible for deterioration in clinical status of the patient in spite of all specific and supportive therapy. Certain drugs like steroids are used for rescue therapy in conditions like sepsis. We present a novel use of filgrastim as a rescue therapy in a patient with dengue hemorrhagic fever (DHF) with acute respiratory distress syndrome (ARDS), myocarditis, and febrile neutropenia and not responding to standard management.

Flucytosine for treatment of Candida albicans in H1N1-positive patient.

A 17-year-old H1N1-positive patient was successfully extubated after 25 days of ventilatory support for treatment of viral pneumonia which was complicated by empyema thoracis due to Candida albicans. Hematogenous spread was suspected as simultaneous culture of ascitic fluid identified Candida species sensitive to flucytosine but resistant to amphotericin B and azole group of antifungals. Monotherapy with flucytosine led to clinical and radiological improvement.