Introduction: Cardiac surgery‑associated kidney injury (CSA‑AKI) is common but relatively less
is... more Introduction: Cardiac surgery‑associated kidney injury (CSA‑AKI) is common but relatively less is known about its progression. The present study is aimed at evaluating the incidence and course of CSA‑AKI and its relationship with the different durations of cardiopulmonary bypass (CPB) and cross clamp times. Materials and Methods: Occurrences of CSA‑AKI are evaluated as per the Akin Kidney Injury Network (AKIN) criteria over the course of 5 postoperative day (POD) in 100 patients. The relationship of different durations of CPB and aortic cross clamp time with CSA‑AKI is analyzed by Chi‑squared test for trend and other appropriate tests using INSTAT software. Results: One hundred (43 male, 57 female; mean age of 37.01 ± 12.28 years, and baseline mean serum creatinine 0.99 ± 0.20 mg %) patients undergone mostly valve replacement, and congenital heart disease correction was evaluated. Nearly 49% suffered CSA‑AKI (81.63% AKIN Class I) with maximum numbers on 2nd POD. Serum creatinine followed a falling trend 3rd POD onward except in 8.16% cases of CSA‑AKI. Oliguria was absent even in AKIN Class II. The CPB time >70 min and cross clamp time >60 min increase CSA‑AKI risk by an OR of 4.76 and 2.84, respectively (P < 0.05). Conclusion: CSA‑AKI is very prevalent; mostly of AKIN Class I and increases with increasing CPB and cross clamp time. Urine output is not a reliable indicator of CSA‑AKI. The AKIN Class II on the very 1st POD or increasing trend of serum creatinine beyond 3rd POD should alert for early intervention.
International Journal of Biomedical Research, Dec 30, 2016
Background and aim: Coexisting cardiovascular disease in pregnancy is associated with high matern... more Background and aim: Coexisting cardiovascular disease in pregnancy is associated with high maternal morbidity and mortality. These patients pose a great challenge to both anesthesiologist and obstetrician. Present study was aimed at reviewing the perioperative management and outcome of obstetrical surgeries in women who had coexisting cardiovascular disease in a tertiary care teaching institute. Materials and Methods: Departmental database of all pregnant patients with coexisting cardiovascular diseases who underwent obstetrical surgeries during January 2011 to August 2016 were reviewed. Patients functional status, obstetrical history, stage of labor, type of anaesthesia, monitoring, hemodynamics, post operative care and baby outcome were noted. Data are expressed in absolute number and percentage scale and INSTAT software was used for measuring central tendencies and dispersion. Results: A total of 22 women (mean ± Standard deviation: SD age 26.18 ± 4.78 years) were found eligible and included for analysis. 21(95.45%) patients underwent cesarean section and one medical termination of pregnancy. 68.18% cases were done under subarachnoid block. Most of the patient needed post operative high dependant unit care, one patient developed mild pulmonary edema and no maternal and fetal deaths were noted. All the babies were born with APGAR > 7 at 1 min. No patient was managed using pulmonary artery catheter or continuous cardiac output monitoring. Conclusion: Pregnant patients with coexisting cardiovascular disease need multidisciplinary approach, timely delivery and intensive therapy in perioperative period. They can be safely delivered under subarachnoid blocks. Pulmonary artery catheterization is probably not an essential for hemodynamics management of such patients in perioperative management.
Maxillofacial injuries affect theairway in many ways. Knowing the factors which may lead to airwa... more Maxillofacial injuries affect theairway in many ways. Knowing the factors which may lead to airway management other than Macintosh laryngoscopy will help emergency medical team in decision making and thus avoid any fatal situation. The present retrospective observational study was aimed to evaluate fractures and airway management patterns in cranio-maxillofacial injury patients with fracture of the mandible. It was also aimed to assess the clinical findings which predict airway management by other than Macintosh laryngoscopy. Anaesthesia management record, critical care assessment record and surgical team notes were evaluated in all cranio-maxillofacial injury patients with mandible fracture who required anaesthesia, critical care and ENT specialty services. The duration of the study was between 2009-10 to 2013-14 and the collected data was evaluated by using INSTAT software.Fifty nine (64.13%) out of 92 cranio-maxillofacial injury patients (with at least one head and neck or facial bone fracture) presented with mandibular fracture. The mean age was 27.25 years with 94.8% male patients. Laryngoscopy was expected not to be helpful in 38.33% cases. Video laryngoscopy appeared to be better or preferred over Machintosh laryngoscopy. Awake fiberoptic intubation was done in 30%, elective tracheostomy in 6.67% and retrograde intubation in 1.67% cases. Multiple facial bone fractures and mouth opening < 2 cm was independently associated with airway management other than laryngoscopy (p < 0.0001). Airway management is deviating towards video laryngoscopy from Macintosh laryngoscopy. Awake Fiberoptic intubation still plays a big role. Submental and blind intubations are becoming less prevalent.
Background and objectives: The shortage of medical teachers and quality teaching is felt greatly ... more Background and objectives: The shortage of medical teachers and quality teaching is felt greatly in the current medical education system. The Medical Council of India (MCI) has initiated faculty development programs to reduce this deficiency. However, this program doesn’t include residents, who are actually involved in teaching to a great extent. The present study was aimed to evaluate the efficacy of adapted Medical Education Technology (MET) workshop for resident doctors in changing their perception as teachers of medicine. Methods: After obtaining the informed consent regarding this study and data collection, the resident doctors participating in the MET workshop were given a set of question papers designed to quantify their own perception (a 0 to 10 scale) about themselves as a medical teacher both for pre workshop and post workshop time. Data thus collected were analyzed by paired t test using INSTAT software and a p value of <0.05 was taken as statistically significant. Results: Thirty two (94.11%) participants responded to the questionnaire. The mean self score on the knowledge of the teaching-learning process, curriculum and assessment were significantly higher for the post workshop (p <0.0001). All of the participants responded that the workshop had changed their perception as a medical teacher and more than 65% responded that it had changed very much. Interpretation and conclusion: MET workshop is an effective tool for improving knowledge on medical education as well as changing the perception of a teacher (regarding the quality of teachers and teaching) among the resident doctors (future faculties).
Introduction: Low Cardiac Output Syndrome (LCOS) following Cardiopulmonary Bypass (CPB) is common... more Introduction: Low Cardiac Output Syndrome (LCOS) following Cardiopulmonary Bypass (CPB) is common and associated with increased mortality. Maintenance of adequate cardiac output is one of the primary objectives in management of such patients.
Aim: To compare Levosimendan, Milrinone and Dobutamine for the treatment of LCOS after CPB in patients who underwent valve replacement surgeries.
Materials and Methods: Sixty eligible patients meeting LCOS were allocated into three treatment groups: Group A-Levosimendan (loading dose 10µg/kg over 10 minutes, followed by 0.1µg/kg/min); Group B-Milrinone (loading dose 50 mcg/kg over 10 minutes followed by 0.5mcg/kg/min) and Group C-Dobutamine @ 5µg/kg/min to achieve target cardiac index (CI) of > 2.5 L/min/m2. In case of failure, other drugs were added as required. Hemodynamic parameters were monitored using EV1000TM clinical platform till 30 minutes post CPB. INSTAT software was used for statistics and p<0.05 was considered significant.
Results: The mean±standard deviation of time taken by Dobutamine, Levosimendan and Milrinone to bring the CI to target were 11.1 ± 8.79, 11.3± 6.34 and 16.62 ± 9.33 minutes respectively (p=0.064). Levosimendan was equally effective in increasing and maintaining adequate CI as compared to Dobutamine (p>0.05). Levosimendan and Milrinone increased MAP (Mean Arterial Pressure) equally while Dobutamine was more effective as compared to both Levosimendan and Milrinone 20th minute onwards (p<0.01). Milrinone was less effective in increasing the stroke volume as compared to Dobutamine and Levosimendan while Dobutamine and Levosimendan were equally effective. There was no difference in the HR (Heart Rate) achieved with all these three drugs.
Conclusion: Levosimendan is equally effective to Dobutamine and better than Milrinone for the treatment of LCOS following CPB in patients undergoing valve replacement surgeries.
Background: Desflurane is relatively newer volatile anesthetic in clinical practice with many adv... more Background: Desflurane is relatively newer volatile anesthetic in clinical practice with many advantages. Unfortunately, it is comparatively costlier. The present observational study is aimed to evaluate the consumption pattern and cost of Desflurane based minimal flow anesthesia with regards to different durations of anesthesia. Methods: Twenty adults of American Society of Anesthesiologists’ class I and II of either sex were enrolled for the study with informed consent during November 2015 to January 2016. Anesthesia was performed using Intermed Penlon sigma Alfa Desflurane vaporizer and Penlon Prima SP2 workstation. Age and opioid compensated minimum alveolar concentration was fixed for each patient and was monitored using Penlon SP M8 monitor and its attached anesthesia gas monitoring system. Bispectral index was used in affordable patients to monitor depth of anesthesia. Data of Desflurane consumption was collected from the digital numerical display on the vaporizer screen. Statistical analysis was done using INSTAT software and cost was calculated from maximum retail price. Results: Data from 20 patients consisting 60% male (mean + standard deviation age of 39.8 + 16.9 years and weight of 59.7 + 12.52 kilograms) were analyzed. Gender had no effect on consumption of Desflurane. Older patients (>60 years) consumed less than the younger (p<0.05). Mean Desflurane consumption was highest during first 5 minute (6.2 ml) and followed decreasing trend till 45 minute of anesthesia (p<0.05) followed by a near steady consumption. Cost of Desflurane reduced from Indian Rupees 22/minute for 15 minute anesthesia to Indian Rupees 6/minutes for 3 hours anesthesia. Conclusions: Desflurane consumption and cost do not depend on sex but on age, flow and time. It becomes more cost-effective for relatively longer duration of minimal flow anesthesia.
Introduction: Perioperative procedures are stressful and lead to haemodynamic instability with po... more Introduction: Perioperative procedures are stressful and lead to haemodynamic instability with potentially devastating consequences. Dexmedetomidine is found to have many of the desired characteristics that are required in perioperative period. Aim: To evaluate the ability of pre and intraoperative dexmedetomidine to attenuate stress induced haemodynamic responses, quantifying the anaesthetic agents sparing as well as its cost-effectiveness in patients undergoing laparoscopic cholecystectomy. Materials and Methods: The present single blind randomized study was conducted with 120 ASA I and II consented patients who underwent laparoscopic cholecystectomy. Patients were randomly divided into 2 groups (i.e., group D and group N). Prior to induction, group D received 1 μg/kg of Dexmedetomidine and group N received Normal saline infusion over 20 minutes. Group D also received maintenance Dexmedetomidine intraoperatively. Bispectral index and minimum alveolar concentration monitoring was done in both the groups. Haemodynamic parameters were noted till 100 minutes post laryngoscopy. Opioid and anaesthetic agent consumptions were also noted and cost analysis was done. Medcalc –Version 12.5.0.0 software was used for statistics and p <0.05 was considered significant. Results: Dexmedetomidine attenuated the stress induced haemodynamics responses and produced stable, relatively non fluctuating haemodynamics throughout. The MAC requirement and the consumptions of Fentanyl and Isoflurane were significantly less in the Dexmedetomidine group (p<0.0001). However, despite anaesthetic dose sparing effect the anaesthetic technique was not cost-effective. Conclusion: Dexmedetomidine is effective in attenuating haemodynamic responses in laparoscopic surgery and having dose sparing effect on Fentanyl, Propofol and Isoflurane. However, overall this technique is not cost-effective.
Existing Medical Education Technology Workshop of the Medical Council of India was adapted for re... more Existing Medical Education Technology Workshop of the Medical Council of India was adapted for residents, run it as a pilot project and evaluated the pre- and post-workshop knowledge along with feedback with regard to the usefulness of the 2-day workshop as a tool for developing the residents knowledge on the teaching–learning process. This article reports the findings and suggests a new a step towards development of new faculties.
Background and Aims: Pre‑operative investigations are often required to supplement information fo... more Background and Aims: Pre‑operative investigations are often required to supplement information for risk stratification and assessing reserve for undergoing surgery. Although there are evidence‑based recommendations for which investigations should be done, clinical practice varies. The present study aimed to assess the pre‑operative investigations and referral practices and compare it with the standard guidelines. Methods: The present observational study was carried out during 2014–2015 in a teaching institute after the approval from Institute Ethical Committee. A designated anaesthesiologist collected data from the completed pre‑anaesthetic check‑up (PAC) sheets. Investigations already done, asked by anaesthesiologists as well as referral services sought were noted and compared with an adapted master table prepared from standard recommendations and guidelines. Data were expressed in frequencies, percentage and statistically analysed using INSTAT software (GraphPad Prism software Inc., La Zolla, USA). Results: Seventy‑five out of 352 patients (42.67% male, 57.33% female; American Society of Anesthesiologists physical status I to III) were included in this study. Nearly, all patients attended PAC with at least 5 investigations done. Of them, 89.33% were subjected to at least one unnecessary investigation and 91.67% of the referral services were not required which lead to 3.5 ( SD ±1.64) days loss. Anaesthesiologist‑ordered testing was more focused than surgeons. Conclusion: More than two‑third of pre‑operative investigations and referral services are unnecessary. Anaesthesiologists are relatively more rational in ordering pre‑operative tests yet; a lot can be done to rationalise the practice as well as reducing healthcare cost.
Scrub typhus and malaria can involve multiple organ systems and are notoriously known for varied ... more Scrub typhus and malaria can involve multiple organ systems and are notoriously known for varied presentations. However, clinical malaria or scrub typhus is unusual without fever. On the other hand, altered sensorium with or without fever, dehydration, hemorrhage and hemolysis may lead to low blood pressure. Presence of toxic granules and elevated band forms in such patients can even mimic sepsis. When such a patient is in the peripartum period, it creates a strong clinical dilemma for the physician especially in unbooked obstetric cases. We present such a case where a 26-year-old unbooked female presented on second postpartum day with severe anemia, altered sensorium, difficulty in breathing along with jaundice and gum bleeding without history of fever. Rapid diagnostic test for malaria was negative and no eschar was seen. These parameters suggested a diagnosis of HELLP (Hemolysis, Elevated Liver enzymes, Low Platelet) syndrome with or without puerperal sepsis. Subsequently she was diagnosed as having asymptomatic malaria and scrub typhus and responded to the treatment of it. The biochemical changes suggestive of HELLP syndrome also subsided. We present this case to emphasize the fact that mere absence of fever and eschar does not rule out scrub typhus. It should also be considered as a differential diagnosis in patients with symptoms and signs suggesting HELLP syndrome. Asymptomatic malaria can complicate case scenario towards puerperal sepsis by giving false toxic granules and band form in such situations.
Background: Basic life support (BLS) is an integral part of emergency medical care. Studies have ... more Background: Basic life support (BLS) is an integral part of emergency medical care. Studies have shown poor knowledge of it among health care providers who are usually taught BLS by lecture‑based teachings in classes.
Extravasations of many drugs can lead to phlebitis to soft tissue necrosis. Phenytoin sodium has ... more Extravasations of many drugs can lead to phlebitis to soft tissue necrosis. Phenytoin sodium has also been implicated for such events in a few case reports with varying success of treatments. We present a case with due consent from the patient party where a single loading dose phenytoin sodium leads to phlebitis and rapidly progressed to gangrene of the hand in a critically ill patient ultimately requiring amputation despite providing possible treatments. The intention of presenting the case is to share our bad experience along with a point to ponder which probably would give an opportunity to critical care physicians to get rid of such avoidable traumatic problem while managing such patients in future.
Objective: The present study was aimed at exploring the patient profile and the unmet needs of la... more Objective: The present study was aimed at exploring the patient profile and the unmet needs of labour analgesia in relation to caesarean delivery on maternal request (CDMR) as a reason for it. Methodology: The departmental electronic database was searched for all the CDMR cases and was included. The anaesthetic management chart, pre-anaesthetic assessment chart, verbal interview records were reviewed for the study to complete the data as far as possible. Data were analyzed as percentage and mean and standard deviation as applicable using INSTAT software. Results: There were 38 (2.64%) CDMR among the 1437 LSCS evaluated. Twenty four out of 38 (63.16%) of the patients were primigravida. 57.89% of CDMR had reason related to pain, fear and anxiety. Medical comorbidity was associated and probably contributed as a reason for choosing CDMR in association with pain in 48.57% cases. 5.26% had received antenatal counselling for painless labour and 23.68% had prior knowledge of labour analgesia while only 2.63% asked voluntarily for it. Conclusion: Lack of knowledge about painless delivery & facilities, fear, anxiety and previous bad experience are major reason for choosing “knife” than normal route of delivery. Higher education, parturients related to health care services and primigravida are more inclined to CDMR and needs to be targeted both for labour analgesia and for psychological counselling.
Background: Basic life support (BLS) is an integral part of health care. However, teaching of BLS... more Background: Basic life support (BLS) is an integral part of health care. However, teaching of BLS is not yet a part of protocolized curriculum and uniform throughout. The present study is designed to assess the knowledge, attitude and practice of BLS and compare it among trained and untrained medical students and junior doctors in a medical institute. Methods: After approval from Institute Ethical Committee and informed consent from the participant, the present study was conducted among the undergraduate-level medical and nursing students and junior doctors. A questionnaire consisting of 30 questions based on knowledge, attitude and practice of BLS was used to collect data which is evaluated as per scale defined for this study. Statistical significance was assessed using INSTAT software (GraphPad Software, Inc., La Zolla, USA). Results: Only 16.41% of all participants and 52% of doctors have received class and/or hands on training. The untrained participants have scored poorly as compared to trained participants in theoretical knowledge and practice of BLS (24.36 % and 53.45% versus 9.25 % and 24.07%) respectively. The mean score for both theoretical knowledge and practice of BLS for trained students was higher than that of the untrained participants and the statistical difference was highly significant - p<0.0001. Most of the participants of both trained and untrained group were having very good attitude towards BLS. Conclusions: Knowledge and practice skills of BLS/CPR are poor in medical and nursing students. A significant portion of trainees do not acquire adequate knowledge in a single session of training. An organised curriculum for BLS and its protocolized training is the need of the hour in medical education.
A 19-year-old soldier was referred to our Intensive Care Unit (ICU) with a diagnosis of pyrexia o... more A 19-year-old soldier was referred to our Intensive Care Unit (ICU) with a diagnosis of pyrexia of unknown origin in
a state of deep coma (GCS 6/15) and shock with severe anaemia at presentation without any evidence of external or
internal bleeding. He was subsequently diagnosed as a case of Scrub Typhus with Multi Organ Dysfunction (MODS).
Clinical evidence of massive Gastrointestinal (GI) bleeding (melaena and clotted blood per rectum) was found next
day. Despite aggressive supportive treatment we lost the patient next morning. We are presenting the case to share our
experience for better management of such cases in future along with a point to ponder which probably would give an
opportunity to critical care physicians to save such patients
Background
Hyperoxia exerts variable effects on multiple cellular and immunologic parameters and... more Background
Hyperoxia exerts variable effects on multiple cellular and immunologic parameters and offers potential benefits from use of supplemental oxygen. Supplementation with high concentration of O 2 has been shown to reduce colorectal anastomotic leakage by 50% and subsequently its use has been recommended to reduce surgical site infection (SSI) by surgical associations of America and Canada. We designed this randomized controlled trial to determine the impact of O 2 supplementation on the incidence of SSI in urological surgeries performed under neuraxial anaesthesia.
Aim
The aim of the study was to evaluate whether use of supplemental high-concentration perioperative oxygen decreases the risk of post-uro-SSI as it did after colorectal surgery in previous studies.
Settings
The study was conducted in the Department of Anaesthesiology and Critical Care in collaboration with the Department of Urology at our institute after obtaining clearance from the Institute of Ethical Committee and written informed consent from patients enrolled in this study.
Patients and methods
Eighty ASA grade I and II patients, aged between 15 and 60 years, undergoing selected urological surgeries were randomly assigned to two equal groups after they had fulfilled inclusion and exclusion criteria. One group received 8-10 l O 2 /min through a non-rebreathing face mask during the intraoperative period, which was continued in the postoperative period for about 6 h, whereas the other group continued breathing room air. Data were collected by physicians from the Department of Urology who were blinded to the intervention and were analysed using INSTAT software with appropriate statistical tools.
Results
Demographic, physical, preoperative, intraoperative and postoperative haemodynamic parameters in both groups were comparable (P > 0.05). Although our study showed a tendency towards reduction in SSI (17.5 vs. 12.5%), compared with the control group, the difference was not statistically significant (P > 0.05).
Conclusion
Perioperative high-concentration oxygen supplementation does not reduce SSI in clean contaminated types of wounds in urological surgeries.
... Article Outline. Collapse Box Author Information. Division of Gastroenterology, Mount Sinai H... more ... Article Outline. Collapse Box Author Information. Division of Gastroenterology, Mount Sinai Hospital, New York, New York. Reprints: Ethan O. Bryson, MD, Department of Anesthesiology, Mount Sinai Hospital, New York, New York, E-mail: ethan.bryson@mountsinai.org. ...
This chapter (chapter 11) of Handbook for Practice of Research Methodology 1st edition (c) 2015, ... more This chapter (chapter 11) of Handbook for Practice of Research Methodology 1st edition (c) 2015, published by the Department of Medical Education, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, India is aimed at providing basic information on how to design, conduct, report a randomized controlled trial.
This chapter (chapter 14) of Handbook for Practice of Research Methodology 1st edition (c) 2015, ... more This chapter (chapter 14) of Handbook for Practice of Research Methodology 1st edition (c) 2015, published by the Department of Medical Education, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, India is aimed at providing basic information on ethical principles to be followed while conducting clinical researches with human subjects.
Introduction: Cardiac surgery‑associated kidney injury (CSA‑AKI) is common but relatively less
is... more Introduction: Cardiac surgery‑associated kidney injury (CSA‑AKI) is common but relatively less is known about its progression. The present study is aimed at evaluating the incidence and course of CSA‑AKI and its relationship with the different durations of cardiopulmonary bypass (CPB) and cross clamp times. Materials and Methods: Occurrences of CSA‑AKI are evaluated as per the Akin Kidney Injury Network (AKIN) criteria over the course of 5 postoperative day (POD) in 100 patients. The relationship of different durations of CPB and aortic cross clamp time with CSA‑AKI is analyzed by Chi‑squared test for trend and other appropriate tests using INSTAT software. Results: One hundred (43 male, 57 female; mean age of 37.01 ± 12.28 years, and baseline mean serum creatinine 0.99 ± 0.20 mg %) patients undergone mostly valve replacement, and congenital heart disease correction was evaluated. Nearly 49% suffered CSA‑AKI (81.63% AKIN Class I) with maximum numbers on 2nd POD. Serum creatinine followed a falling trend 3rd POD onward except in 8.16% cases of CSA‑AKI. Oliguria was absent even in AKIN Class II. The CPB time >70 min and cross clamp time >60 min increase CSA‑AKI risk by an OR of 4.76 and 2.84, respectively (P < 0.05). Conclusion: CSA‑AKI is very prevalent; mostly of AKIN Class I and increases with increasing CPB and cross clamp time. Urine output is not a reliable indicator of CSA‑AKI. The AKIN Class II on the very 1st POD or increasing trend of serum creatinine beyond 3rd POD should alert for early intervention.
International Journal of Biomedical Research, Dec 30, 2016
Background and aim: Coexisting cardiovascular disease in pregnancy is associated with high matern... more Background and aim: Coexisting cardiovascular disease in pregnancy is associated with high maternal morbidity and mortality. These patients pose a great challenge to both anesthesiologist and obstetrician. Present study was aimed at reviewing the perioperative management and outcome of obstetrical surgeries in women who had coexisting cardiovascular disease in a tertiary care teaching institute. Materials and Methods: Departmental database of all pregnant patients with coexisting cardiovascular diseases who underwent obstetrical surgeries during January 2011 to August 2016 were reviewed. Patients functional status, obstetrical history, stage of labor, type of anaesthesia, monitoring, hemodynamics, post operative care and baby outcome were noted. Data are expressed in absolute number and percentage scale and INSTAT software was used for measuring central tendencies and dispersion. Results: A total of 22 women (mean ± Standard deviation: SD age 26.18 ± 4.78 years) were found eligible and included for analysis. 21(95.45%) patients underwent cesarean section and one medical termination of pregnancy. 68.18% cases were done under subarachnoid block. Most of the patient needed post operative high dependant unit care, one patient developed mild pulmonary edema and no maternal and fetal deaths were noted. All the babies were born with APGAR > 7 at 1 min. No patient was managed using pulmonary artery catheter or continuous cardiac output monitoring. Conclusion: Pregnant patients with coexisting cardiovascular disease need multidisciplinary approach, timely delivery and intensive therapy in perioperative period. They can be safely delivered under subarachnoid blocks. Pulmonary artery catheterization is probably not an essential for hemodynamics management of such patients in perioperative management.
Maxillofacial injuries affect theairway in many ways. Knowing the factors which may lead to airwa... more Maxillofacial injuries affect theairway in many ways. Knowing the factors which may lead to airway management other than Macintosh laryngoscopy will help emergency medical team in decision making and thus avoid any fatal situation. The present retrospective observational study was aimed to evaluate fractures and airway management patterns in cranio-maxillofacial injury patients with fracture of the mandible. It was also aimed to assess the clinical findings which predict airway management by other than Macintosh laryngoscopy. Anaesthesia management record, critical care assessment record and surgical team notes were evaluated in all cranio-maxillofacial injury patients with mandible fracture who required anaesthesia, critical care and ENT specialty services. The duration of the study was between 2009-10 to 2013-14 and the collected data was evaluated by using INSTAT software.Fifty nine (64.13%) out of 92 cranio-maxillofacial injury patients (with at least one head and neck or facial bone fracture) presented with mandibular fracture. The mean age was 27.25 years with 94.8% male patients. Laryngoscopy was expected not to be helpful in 38.33% cases. Video laryngoscopy appeared to be better or preferred over Machintosh laryngoscopy. Awake fiberoptic intubation was done in 30%, elective tracheostomy in 6.67% and retrograde intubation in 1.67% cases. Multiple facial bone fractures and mouth opening < 2 cm was independently associated with airway management other than laryngoscopy (p < 0.0001). Airway management is deviating towards video laryngoscopy from Macintosh laryngoscopy. Awake Fiberoptic intubation still plays a big role. Submental and blind intubations are becoming less prevalent.
Background and objectives: The shortage of medical teachers and quality teaching is felt greatly ... more Background and objectives: The shortage of medical teachers and quality teaching is felt greatly in the current medical education system. The Medical Council of India (MCI) has initiated faculty development programs to reduce this deficiency. However, this program doesn’t include residents, who are actually involved in teaching to a great extent. The present study was aimed to evaluate the efficacy of adapted Medical Education Technology (MET) workshop for resident doctors in changing their perception as teachers of medicine. Methods: After obtaining the informed consent regarding this study and data collection, the resident doctors participating in the MET workshop were given a set of question papers designed to quantify their own perception (a 0 to 10 scale) about themselves as a medical teacher both for pre workshop and post workshop time. Data thus collected were analyzed by paired t test using INSTAT software and a p value of <0.05 was taken as statistically significant. Results: Thirty two (94.11%) participants responded to the questionnaire. The mean self score on the knowledge of the teaching-learning process, curriculum and assessment were significantly higher for the post workshop (p <0.0001). All of the participants responded that the workshop had changed their perception as a medical teacher and more than 65% responded that it had changed very much. Interpretation and conclusion: MET workshop is an effective tool for improving knowledge on medical education as well as changing the perception of a teacher (regarding the quality of teachers and teaching) among the resident doctors (future faculties).
Introduction: Low Cardiac Output Syndrome (LCOS) following Cardiopulmonary Bypass (CPB) is common... more Introduction: Low Cardiac Output Syndrome (LCOS) following Cardiopulmonary Bypass (CPB) is common and associated with increased mortality. Maintenance of adequate cardiac output is one of the primary objectives in management of such patients.
Aim: To compare Levosimendan, Milrinone and Dobutamine for the treatment of LCOS after CPB in patients who underwent valve replacement surgeries.
Materials and Methods: Sixty eligible patients meeting LCOS were allocated into three treatment groups: Group A-Levosimendan (loading dose 10µg/kg over 10 minutes, followed by 0.1µg/kg/min); Group B-Milrinone (loading dose 50 mcg/kg over 10 minutes followed by 0.5mcg/kg/min) and Group C-Dobutamine @ 5µg/kg/min to achieve target cardiac index (CI) of > 2.5 L/min/m2. In case of failure, other drugs were added as required. Hemodynamic parameters were monitored using EV1000TM clinical platform till 30 minutes post CPB. INSTAT software was used for statistics and p<0.05 was considered significant.
Results: The mean±standard deviation of time taken by Dobutamine, Levosimendan and Milrinone to bring the CI to target were 11.1 ± 8.79, 11.3± 6.34 and 16.62 ± 9.33 minutes respectively (p=0.064). Levosimendan was equally effective in increasing and maintaining adequate CI as compared to Dobutamine (p>0.05). Levosimendan and Milrinone increased MAP (Mean Arterial Pressure) equally while Dobutamine was more effective as compared to both Levosimendan and Milrinone 20th minute onwards (p<0.01). Milrinone was less effective in increasing the stroke volume as compared to Dobutamine and Levosimendan while Dobutamine and Levosimendan were equally effective. There was no difference in the HR (Heart Rate) achieved with all these three drugs.
Conclusion: Levosimendan is equally effective to Dobutamine and better than Milrinone for the treatment of LCOS following CPB in patients undergoing valve replacement surgeries.
Background: Desflurane is relatively newer volatile anesthetic in clinical practice with many adv... more Background: Desflurane is relatively newer volatile anesthetic in clinical practice with many advantages. Unfortunately, it is comparatively costlier. The present observational study is aimed to evaluate the consumption pattern and cost of Desflurane based minimal flow anesthesia with regards to different durations of anesthesia. Methods: Twenty adults of American Society of Anesthesiologists’ class I and II of either sex were enrolled for the study with informed consent during November 2015 to January 2016. Anesthesia was performed using Intermed Penlon sigma Alfa Desflurane vaporizer and Penlon Prima SP2 workstation. Age and opioid compensated minimum alveolar concentration was fixed for each patient and was monitored using Penlon SP M8 monitor and its attached anesthesia gas monitoring system. Bispectral index was used in affordable patients to monitor depth of anesthesia. Data of Desflurane consumption was collected from the digital numerical display on the vaporizer screen. Statistical analysis was done using INSTAT software and cost was calculated from maximum retail price. Results: Data from 20 patients consisting 60% male (mean + standard deviation age of 39.8 + 16.9 years and weight of 59.7 + 12.52 kilograms) were analyzed. Gender had no effect on consumption of Desflurane. Older patients (>60 years) consumed less than the younger (p<0.05). Mean Desflurane consumption was highest during first 5 minute (6.2 ml) and followed decreasing trend till 45 minute of anesthesia (p<0.05) followed by a near steady consumption. Cost of Desflurane reduced from Indian Rupees 22/minute for 15 minute anesthesia to Indian Rupees 6/minutes for 3 hours anesthesia. Conclusions: Desflurane consumption and cost do not depend on sex but on age, flow and time. It becomes more cost-effective for relatively longer duration of minimal flow anesthesia.
Introduction: Perioperative procedures are stressful and lead to haemodynamic instability with po... more Introduction: Perioperative procedures are stressful and lead to haemodynamic instability with potentially devastating consequences. Dexmedetomidine is found to have many of the desired characteristics that are required in perioperative period. Aim: To evaluate the ability of pre and intraoperative dexmedetomidine to attenuate stress induced haemodynamic responses, quantifying the anaesthetic agents sparing as well as its cost-effectiveness in patients undergoing laparoscopic cholecystectomy. Materials and Methods: The present single blind randomized study was conducted with 120 ASA I and II consented patients who underwent laparoscopic cholecystectomy. Patients were randomly divided into 2 groups (i.e., group D and group N). Prior to induction, group D received 1 μg/kg of Dexmedetomidine and group N received Normal saline infusion over 20 minutes. Group D also received maintenance Dexmedetomidine intraoperatively. Bispectral index and minimum alveolar concentration monitoring was done in both the groups. Haemodynamic parameters were noted till 100 minutes post laryngoscopy. Opioid and anaesthetic agent consumptions were also noted and cost analysis was done. Medcalc –Version 12.5.0.0 software was used for statistics and p <0.05 was considered significant. Results: Dexmedetomidine attenuated the stress induced haemodynamics responses and produced stable, relatively non fluctuating haemodynamics throughout. The MAC requirement and the consumptions of Fentanyl and Isoflurane were significantly less in the Dexmedetomidine group (p<0.0001). However, despite anaesthetic dose sparing effect the anaesthetic technique was not cost-effective. Conclusion: Dexmedetomidine is effective in attenuating haemodynamic responses in laparoscopic surgery and having dose sparing effect on Fentanyl, Propofol and Isoflurane. However, overall this technique is not cost-effective.
Existing Medical Education Technology Workshop of the Medical Council of India was adapted for re... more Existing Medical Education Technology Workshop of the Medical Council of India was adapted for residents, run it as a pilot project and evaluated the pre- and post-workshop knowledge along with feedback with regard to the usefulness of the 2-day workshop as a tool for developing the residents knowledge on the teaching–learning process. This article reports the findings and suggests a new a step towards development of new faculties.
Background and Aims: Pre‑operative investigations are often required to supplement information fo... more Background and Aims: Pre‑operative investigations are often required to supplement information for risk stratification and assessing reserve for undergoing surgery. Although there are evidence‑based recommendations for which investigations should be done, clinical practice varies. The present study aimed to assess the pre‑operative investigations and referral practices and compare it with the standard guidelines. Methods: The present observational study was carried out during 2014–2015 in a teaching institute after the approval from Institute Ethical Committee. A designated anaesthesiologist collected data from the completed pre‑anaesthetic check‑up (PAC) sheets. Investigations already done, asked by anaesthesiologists as well as referral services sought were noted and compared with an adapted master table prepared from standard recommendations and guidelines. Data were expressed in frequencies, percentage and statistically analysed using INSTAT software (GraphPad Prism software Inc., La Zolla, USA). Results: Seventy‑five out of 352 patients (42.67% male, 57.33% female; American Society of Anesthesiologists physical status I to III) were included in this study. Nearly, all patients attended PAC with at least 5 investigations done. Of them, 89.33% were subjected to at least one unnecessary investigation and 91.67% of the referral services were not required which lead to 3.5 ( SD ±1.64) days loss. Anaesthesiologist‑ordered testing was more focused than surgeons. Conclusion: More than two‑third of pre‑operative investigations and referral services are unnecessary. Anaesthesiologists are relatively more rational in ordering pre‑operative tests yet; a lot can be done to rationalise the practice as well as reducing healthcare cost.
Scrub typhus and malaria can involve multiple organ systems and are notoriously known for varied ... more Scrub typhus and malaria can involve multiple organ systems and are notoriously known for varied presentations. However, clinical malaria or scrub typhus is unusual without fever. On the other hand, altered sensorium with or without fever, dehydration, hemorrhage and hemolysis may lead to low blood pressure. Presence of toxic granules and elevated band forms in such patients can even mimic sepsis. When such a patient is in the peripartum period, it creates a strong clinical dilemma for the physician especially in unbooked obstetric cases. We present such a case where a 26-year-old unbooked female presented on second postpartum day with severe anemia, altered sensorium, difficulty in breathing along with jaundice and gum bleeding without history of fever. Rapid diagnostic test for malaria was negative and no eschar was seen. These parameters suggested a diagnosis of HELLP (Hemolysis, Elevated Liver enzymes, Low Platelet) syndrome with or without puerperal sepsis. Subsequently she was diagnosed as having asymptomatic malaria and scrub typhus and responded to the treatment of it. The biochemical changes suggestive of HELLP syndrome also subsided. We present this case to emphasize the fact that mere absence of fever and eschar does not rule out scrub typhus. It should also be considered as a differential diagnosis in patients with symptoms and signs suggesting HELLP syndrome. Asymptomatic malaria can complicate case scenario towards puerperal sepsis by giving false toxic granules and band form in such situations.
Background: Basic life support (BLS) is an integral part of emergency medical care. Studies have ... more Background: Basic life support (BLS) is an integral part of emergency medical care. Studies have shown poor knowledge of it among health care providers who are usually taught BLS by lecture‑based teachings in classes.
Extravasations of many drugs can lead to phlebitis to soft tissue necrosis. Phenytoin sodium has ... more Extravasations of many drugs can lead to phlebitis to soft tissue necrosis. Phenytoin sodium has also been implicated for such events in a few case reports with varying success of treatments. We present a case with due consent from the patient party where a single loading dose phenytoin sodium leads to phlebitis and rapidly progressed to gangrene of the hand in a critically ill patient ultimately requiring amputation despite providing possible treatments. The intention of presenting the case is to share our bad experience along with a point to ponder which probably would give an opportunity to critical care physicians to get rid of such avoidable traumatic problem while managing such patients in future.
Objective: The present study was aimed at exploring the patient profile and the unmet needs of la... more Objective: The present study was aimed at exploring the patient profile and the unmet needs of labour analgesia in relation to caesarean delivery on maternal request (CDMR) as a reason for it. Methodology: The departmental electronic database was searched for all the CDMR cases and was included. The anaesthetic management chart, pre-anaesthetic assessment chart, verbal interview records were reviewed for the study to complete the data as far as possible. Data were analyzed as percentage and mean and standard deviation as applicable using INSTAT software. Results: There were 38 (2.64%) CDMR among the 1437 LSCS evaluated. Twenty four out of 38 (63.16%) of the patients were primigravida. 57.89% of CDMR had reason related to pain, fear and anxiety. Medical comorbidity was associated and probably contributed as a reason for choosing CDMR in association with pain in 48.57% cases. 5.26% had received antenatal counselling for painless labour and 23.68% had prior knowledge of labour analgesia while only 2.63% asked voluntarily for it. Conclusion: Lack of knowledge about painless delivery & facilities, fear, anxiety and previous bad experience are major reason for choosing “knife” than normal route of delivery. Higher education, parturients related to health care services and primigravida are more inclined to CDMR and needs to be targeted both for labour analgesia and for psychological counselling.
Background: Basic life support (BLS) is an integral part of health care. However, teaching of BLS... more Background: Basic life support (BLS) is an integral part of health care. However, teaching of BLS is not yet a part of protocolized curriculum and uniform throughout. The present study is designed to assess the knowledge, attitude and practice of BLS and compare it among trained and untrained medical students and junior doctors in a medical institute. Methods: After approval from Institute Ethical Committee and informed consent from the participant, the present study was conducted among the undergraduate-level medical and nursing students and junior doctors. A questionnaire consisting of 30 questions based on knowledge, attitude and practice of BLS was used to collect data which is evaluated as per scale defined for this study. Statistical significance was assessed using INSTAT software (GraphPad Software, Inc., La Zolla, USA). Results: Only 16.41% of all participants and 52% of doctors have received class and/or hands on training. The untrained participants have scored poorly as compared to trained participants in theoretical knowledge and practice of BLS (24.36 % and 53.45% versus 9.25 % and 24.07%) respectively. The mean score for both theoretical knowledge and practice of BLS for trained students was higher than that of the untrained participants and the statistical difference was highly significant - p<0.0001. Most of the participants of both trained and untrained group were having very good attitude towards BLS. Conclusions: Knowledge and practice skills of BLS/CPR are poor in medical and nursing students. A significant portion of trainees do not acquire adequate knowledge in a single session of training. An organised curriculum for BLS and its protocolized training is the need of the hour in medical education.
A 19-year-old soldier was referred to our Intensive Care Unit (ICU) with a diagnosis of pyrexia o... more A 19-year-old soldier was referred to our Intensive Care Unit (ICU) with a diagnosis of pyrexia of unknown origin in
a state of deep coma (GCS 6/15) and shock with severe anaemia at presentation without any evidence of external or
internal bleeding. He was subsequently diagnosed as a case of Scrub Typhus with Multi Organ Dysfunction (MODS).
Clinical evidence of massive Gastrointestinal (GI) bleeding (melaena and clotted blood per rectum) was found next
day. Despite aggressive supportive treatment we lost the patient next morning. We are presenting the case to share our
experience for better management of such cases in future along with a point to ponder which probably would give an
opportunity to critical care physicians to save such patients
Background
Hyperoxia exerts variable effects on multiple cellular and immunologic parameters and... more Background
Hyperoxia exerts variable effects on multiple cellular and immunologic parameters and offers potential benefits from use of supplemental oxygen. Supplementation with high concentration of O 2 has been shown to reduce colorectal anastomotic leakage by 50% and subsequently its use has been recommended to reduce surgical site infection (SSI) by surgical associations of America and Canada. We designed this randomized controlled trial to determine the impact of O 2 supplementation on the incidence of SSI in urological surgeries performed under neuraxial anaesthesia.
Aim
The aim of the study was to evaluate whether use of supplemental high-concentration perioperative oxygen decreases the risk of post-uro-SSI as it did after colorectal surgery in previous studies.
Settings
The study was conducted in the Department of Anaesthesiology and Critical Care in collaboration with the Department of Urology at our institute after obtaining clearance from the Institute of Ethical Committee and written informed consent from patients enrolled in this study.
Patients and methods
Eighty ASA grade I and II patients, aged between 15 and 60 years, undergoing selected urological surgeries were randomly assigned to two equal groups after they had fulfilled inclusion and exclusion criteria. One group received 8-10 l O 2 /min through a non-rebreathing face mask during the intraoperative period, which was continued in the postoperative period for about 6 h, whereas the other group continued breathing room air. Data were collected by physicians from the Department of Urology who were blinded to the intervention and were analysed using INSTAT software with appropriate statistical tools.
Results
Demographic, physical, preoperative, intraoperative and postoperative haemodynamic parameters in both groups were comparable (P > 0.05). Although our study showed a tendency towards reduction in SSI (17.5 vs. 12.5%), compared with the control group, the difference was not statistically significant (P > 0.05).
Conclusion
Perioperative high-concentration oxygen supplementation does not reduce SSI in clean contaminated types of wounds in urological surgeries.
... Article Outline. Collapse Box Author Information. Division of Gastroenterology, Mount Sinai H... more ... Article Outline. Collapse Box Author Information. Division of Gastroenterology, Mount Sinai Hospital, New York, New York. Reprints: Ethan O. Bryson, MD, Department of Anesthesiology, Mount Sinai Hospital, New York, New York, E-mail: ethan.bryson@mountsinai.org. ...
This chapter (chapter 11) of Handbook for Practice of Research Methodology 1st edition (c) 2015, ... more This chapter (chapter 11) of Handbook for Practice of Research Methodology 1st edition (c) 2015, published by the Department of Medical Education, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, India is aimed at providing basic information on how to design, conduct, report a randomized controlled trial.
This chapter (chapter 14) of Handbook for Practice of Research Methodology 1st edition (c) 2015, ... more This chapter (chapter 14) of Handbook for Practice of Research Methodology 1st edition (c) 2015, published by the Department of Medical Education, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, India is aimed at providing basic information on ethical principles to be followed while conducting clinical researches with human subjects.
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Papers by Md Yunus
is known about its progression. The present study is aimed at evaluating the incidence and course
of CSA‑AKI and its relationship with the different durations of cardiopulmonary bypass (CPB) and
cross clamp times. Materials and Methods: Occurrences of CSA‑AKI are evaluated as per the Akin
Kidney Injury Network (AKIN) criteria over the course of 5 postoperative day (POD) in 100 patients.
The relationship of different durations of CPB and aortic cross clamp time with CSA‑AKI is analyzed
by Chi‑squared test for trend and other appropriate tests using INSTAT software. Results: One
hundred (43 male, 57 female; mean age of 37.01 ± 12.28 years, and baseline mean serum creatinine
0.99 ± 0.20 mg %) patients undergone mostly valve replacement, and congenital heart disease
correction was evaluated. Nearly 49% suffered CSA‑AKI (81.63% AKIN Class I) with maximum
numbers on 2nd POD. Serum creatinine followed a falling trend 3rd POD onward except in 8.16%
cases of CSA‑AKI. Oliguria was absent even in AKIN Class II. The CPB time >70 min and cross
clamp time >60 min increase CSA‑AKI risk by an OR of 4.76 and 2.84, respectively (P < 0.05).
Conclusion: CSA‑AKI is very prevalent; mostly of AKIN Class I and increases with increasing
CPB and cross clamp time. Urine output is not a reliable indicator of CSA‑AKI. The AKIN Class II
on the very 1st POD or increasing trend of serum creatinine beyond 3rd POD should alert for early
intervention.
taken as statistically significant.
Results: Thirty two (94.11%) participants responded to the questionnaire. The mean self score on the knowledge of the teaching-learning process, curriculum and assessment were
significantly higher for the post workshop (p <0.0001). All of the participants responded that the workshop had changed their perception as a medical teacher and more than 65% responded that it had changed very much.
Interpretation and conclusion: MET workshop is an effective tool for improving knowledge on medical education as well as changing the perception of a teacher (regarding the quality of teachers and teaching) among the resident doctors (future faculties).
Aim: To compare Levosimendan, Milrinone and Dobutamine for the treatment of LCOS after CPB in patients who underwent valve replacement surgeries.
Materials and Methods: Sixty eligible patients meeting LCOS were allocated into three treatment groups: Group A-Levosimendan (loading dose 10µg/kg over 10 minutes, followed by 0.1µg/kg/min); Group B-Milrinone (loading dose 50 mcg/kg over 10 minutes followed by 0.5mcg/kg/min) and Group C-Dobutamine @ 5µg/kg/min to achieve target cardiac index (CI) of > 2.5 L/min/m2. In case of failure, other drugs were added as required. Hemodynamic parameters were monitored using EV1000TM clinical platform till 30 minutes post CPB. INSTAT software was used for statistics and p<0.05 was considered significant.
Results: The mean±standard deviation of time taken by Dobutamine, Levosimendan and Milrinone to bring the CI to target were 11.1 ± 8.79, 11.3± 6.34 and 16.62 ± 9.33 minutes respectively (p=0.064). Levosimendan was equally effective in increasing and maintaining adequate CI as compared to Dobutamine (p>0.05). Levosimendan and Milrinone increased MAP (Mean Arterial Pressure) equally while Dobutamine was more effective as compared to both Levosimendan and Milrinone 20th minute onwards (p<0.01). Milrinone was less effective in increasing the stroke volume as compared to Dobutamine and Levosimendan while Dobutamine and Levosimendan were equally effective. There was no difference in the HR (Heart Rate) achieved with all these three drugs.
Conclusion: Levosimendan is equally effective to Dobutamine and better than Milrinone for the treatment of LCOS following CPB in patients undergoing valve replacement surgeries.
Methods: Twenty adults of American Society of Anesthesiologists’ class I and II of either sex were enrolled for the study with informed consent during November 2015 to January 2016. Anesthesia was performed using Intermed Penlon sigma Alfa Desflurane vaporizer and Penlon Prima SP2 workstation. Age and opioid compensated minimum alveolar concentration was fixed for each patient and was monitored using Penlon SP M8 monitor and its attached anesthesia gas monitoring system. Bispectral index was used in affordable patients to monitor depth of anesthesia. Data of Desflurane consumption was collected from the digital numerical display on the vaporizer screen. Statistical analysis was done using INSTAT software and cost was calculated from maximum retail price.
Results: Data from 20 patients consisting 60% male (mean + standard deviation age of 39.8 + 16.9 years and weight of 59.7 + 12.52 kilograms) were analyzed. Gender had no effect on consumption of Desflurane. Older patients (>60 years) consumed less than the younger (p<0.05). Mean Desflurane consumption was
highest during first 5 minute (6.2 ml) and followed decreasing trend till 45 minute of anesthesia (p<0.05) followed by a near steady consumption. Cost of Desflurane reduced from Indian Rupees 22/minute for 15 minute anesthesia to Indian Rupees 6/minutes for 3 hours anesthesia.
Conclusions: Desflurane consumption and cost do not depend on sex but on age, flow and time. It becomes more cost-effective for relatively longer duration of minimal flow anesthesia.
Aim: To evaluate the ability of pre and intraoperative dexmedetomidine to attenuate stress induced haemodynamic responses, quantifying the anaesthetic agents sparing as well as its cost-effectiveness in patients undergoing laparoscopic cholecystectomy.
Materials and Methods: The present single blind randomized study was conducted with 120 ASA I and II consented patients who underwent laparoscopic cholecystectomy. Patients were randomly divided into 2 groups (i.e., group D and group N). Prior to induction, group D received 1 μg/kg of Dexmedetomidine and group N received Normal saline infusion over 20 minutes. Group D also received maintenance Dexmedetomidine intraoperatively. Bispectral index and minimum alveolar concentration monitoring was done in both the groups. Haemodynamic parameters were noted till 100 minutes post laryngoscopy. Opioid and anaesthetic agent consumptions were also noted and cost analysis was done. Medcalc –Version 12.5.0.0 software was used for statistics and p <0.05 was considered significant.
Results: Dexmedetomidine attenuated the stress induced haemodynamics responses and produced stable, relatively non fluctuating haemodynamics throughout. The MAC requirement and the consumptions of Fentanyl and Isoflurane were significantly less in the Dexmedetomidine group (p<0.0001). However, despite anaesthetic dose sparing effect the anaesthetic technique was not cost-effective.
Conclusion: Dexmedetomidine is effective in attenuating haemodynamic responses in laparoscopic surgery and having dose sparing effect on Fentanyl, Propofol and Isoflurane. However, overall this technique is not cost-effective.
Methods: The present observational study was carried out during 2014–2015 in a teaching institute after the approval from Institute Ethical Committee. A designated anaesthesiologist collected data from the completed pre‑anaesthetic check‑up (PAC) sheets. Investigations already done, asked by anaesthesiologists as well as referral services sought were noted and compared with an adapted master table prepared from standard recommendations and guidelines. Data were expressed in frequencies, percentage and statistically analysed using INSTAT software (GraphPad Prism software Inc., La Zolla, USA).
Results: Seventy‑five out of 352 patients (42.67% male, 57.33% female; American Society of Anesthesiologists physical status I to III) were included in this study. Nearly, all patients attended PAC with at least 5 investigations done. Of them, 89.33% were subjected to at least one unnecessary investigation and 91.67% of the referral services were not required which lead to 3.5 ( SD ±1.64) days loss. Anaesthesiologist‑ordered testing was more focused than surgeons.
Conclusion: More than two‑third of pre‑operative investigations and referral services are unnecessary. Anaesthesiologists are relatively more rational in ordering pre‑operative tests yet; a lot can be done to rationalise the practice as well as reducing healthcare cost.
analgesia in relation to caesarean delivery on maternal request (CDMR) as a reason for it. Methodology:
The departmental electronic database was searched for all the CDMR cases and was included. The
anaesthetic management chart, pre-anaesthetic assessment chart, verbal interview records were reviewed
for the study to complete the data as far as possible. Data were analyzed as percentage and mean and
standard deviation as applicable using INSTAT software. Results: There were 38 (2.64%) CDMR among
the 1437 LSCS evaluated. Twenty four out of 38 (63.16%) of the patients were primigravida. 57.89% of
CDMR had reason related to pain, fear and anxiety. Medical comorbidity was associated and probably
contributed as a reason for choosing CDMR in association with pain in 48.57% cases. 5.26% had received
antenatal counselling for painless labour and 23.68% had prior knowledge of labour analgesia while only
2.63% asked voluntarily for it. Conclusion: Lack of knowledge about painless delivery & facilities, fear,
anxiety and previous bad experience are major reason for choosing “knife” than normal route of delivery.
Higher education, parturients related to health care services and primigravida are more inclined to CDMR
and needs to be targeted both for labour analgesia and for psychological counselling.
protocolized curriculum and uniform throughout. The present study is designed to assess the knowledge, attitude and
practice of BLS and compare it among trained and untrained medical students and junior doctors in a medical
institute.
Methods: After approval from Institute Ethical Committee and informed consent from the participant, the present
study was conducted among the undergraduate-level medical and nursing students and junior doctors. A questionnaire
consisting of 30 questions based on knowledge, attitude and practice of BLS was used to collect data which is
evaluated as per scale defined for this study. Statistical significance was assessed using INSTAT software (GraphPad
Software, Inc., La Zolla, USA).
Results: Only 16.41% of all participants and 52% of doctors have received class and/or hands on training. The
untrained participants have scored poorly as compared to trained participants in theoretical knowledge and practice of
BLS (24.36 % and 53.45% versus 9.25 % and 24.07%) respectively. The mean score for both theoretical knowledge
and practice of BLS for trained students was higher than that of the untrained participants and the statistical difference
was highly significant - p<0.0001. Most of the participants of both trained and untrained group were having very good
attitude towards BLS.
Conclusions: Knowledge and practice skills of BLS/CPR are poor in medical and nursing students. A significant
portion of trainees do not acquire adequate knowledge in a single session of training. An organised curriculum for
BLS and its protocolized training is the need of the hour in medical education.
a state of deep coma (GCS 6/15) and shock with severe anaemia at presentation without any evidence of external or
internal bleeding. He was subsequently diagnosed as a case of Scrub Typhus with Multi Organ Dysfunction (MODS).
Clinical evidence of massive Gastrointestinal (GI) bleeding (melaena and clotted blood per rectum) was found next
day. Despite aggressive supportive treatment we lost the patient next morning. We are presenting the case to share our
experience for better management of such cases in future along with a point to ponder which probably would give an
opportunity to critical care physicians to save such patients
Hyperoxia exerts variable effects on multiple cellular and immunologic parameters and offers potential benefits from use of supplemental oxygen. Supplementation with high concentration of O 2 has been shown to reduce colorectal anastomotic leakage by 50% and subsequently its use has been recommended to reduce surgical site infection (SSI) by surgical associations of America and Canada. We designed this randomized controlled trial to determine the impact of O 2 supplementation on the incidence of SSI in urological surgeries performed under neuraxial anaesthesia.
Aim
The aim of the study was to evaluate whether use of supplemental high-concentration perioperative oxygen decreases the risk of post-uro-SSI as it did after colorectal surgery in previous studies.
Settings
The study was conducted in the Department of Anaesthesiology and Critical Care in collaboration with the Department of Urology at our institute after obtaining clearance from the Institute of Ethical Committee and written informed consent from patients enrolled in this study.
Patients and methods
Eighty ASA grade I and II patients, aged between 15 and 60 years, undergoing selected urological surgeries were randomly assigned to two equal groups after they had fulfilled inclusion and exclusion criteria. One group received 8-10 l O 2 /min through a non-rebreathing face mask during the intraoperative period, which was continued in the postoperative period for about 6 h, whereas the other group continued breathing room air. Data were collected by physicians from the Department of Urology who were blinded to the intervention and were analysed using INSTAT software with appropriate statistical tools.
Results
Demographic, physical, preoperative, intraoperative and postoperative haemodynamic parameters in both groups were comparable (P > 0.05). Although our study showed a tendency towards reduction in SSI (17.5 vs. 12.5%), compared with the control group, the difference was not statistically significant (P > 0.05).
Conclusion
Perioperative high-concentration oxygen supplementation does not reduce SSI in clean contaminated types of wounds in urological surgeries.
Books by Md Yunus
is known about its progression. The present study is aimed at evaluating the incidence and course
of CSA‑AKI and its relationship with the different durations of cardiopulmonary bypass (CPB) and
cross clamp times. Materials and Methods: Occurrences of CSA‑AKI are evaluated as per the Akin
Kidney Injury Network (AKIN) criteria over the course of 5 postoperative day (POD) in 100 patients.
The relationship of different durations of CPB and aortic cross clamp time with CSA‑AKI is analyzed
by Chi‑squared test for trend and other appropriate tests using INSTAT software. Results: One
hundred (43 male, 57 female; mean age of 37.01 ± 12.28 years, and baseline mean serum creatinine
0.99 ± 0.20 mg %) patients undergone mostly valve replacement, and congenital heart disease
correction was evaluated. Nearly 49% suffered CSA‑AKI (81.63% AKIN Class I) with maximum
numbers on 2nd POD. Serum creatinine followed a falling trend 3rd POD onward except in 8.16%
cases of CSA‑AKI. Oliguria was absent even in AKIN Class II. The CPB time >70 min and cross
clamp time >60 min increase CSA‑AKI risk by an OR of 4.76 and 2.84, respectively (P < 0.05).
Conclusion: CSA‑AKI is very prevalent; mostly of AKIN Class I and increases with increasing
CPB and cross clamp time. Urine output is not a reliable indicator of CSA‑AKI. The AKIN Class II
on the very 1st POD or increasing trend of serum creatinine beyond 3rd POD should alert for early
intervention.
taken as statistically significant.
Results: Thirty two (94.11%) participants responded to the questionnaire. The mean self score on the knowledge of the teaching-learning process, curriculum and assessment were
significantly higher for the post workshop (p <0.0001). All of the participants responded that the workshop had changed their perception as a medical teacher and more than 65% responded that it had changed very much.
Interpretation and conclusion: MET workshop is an effective tool for improving knowledge on medical education as well as changing the perception of a teacher (regarding the quality of teachers and teaching) among the resident doctors (future faculties).
Aim: To compare Levosimendan, Milrinone and Dobutamine for the treatment of LCOS after CPB in patients who underwent valve replacement surgeries.
Materials and Methods: Sixty eligible patients meeting LCOS were allocated into three treatment groups: Group A-Levosimendan (loading dose 10µg/kg over 10 minutes, followed by 0.1µg/kg/min); Group B-Milrinone (loading dose 50 mcg/kg over 10 minutes followed by 0.5mcg/kg/min) and Group C-Dobutamine @ 5µg/kg/min to achieve target cardiac index (CI) of > 2.5 L/min/m2. In case of failure, other drugs were added as required. Hemodynamic parameters were monitored using EV1000TM clinical platform till 30 minutes post CPB. INSTAT software was used for statistics and p<0.05 was considered significant.
Results: The mean±standard deviation of time taken by Dobutamine, Levosimendan and Milrinone to bring the CI to target were 11.1 ± 8.79, 11.3± 6.34 and 16.62 ± 9.33 minutes respectively (p=0.064). Levosimendan was equally effective in increasing and maintaining adequate CI as compared to Dobutamine (p>0.05). Levosimendan and Milrinone increased MAP (Mean Arterial Pressure) equally while Dobutamine was more effective as compared to both Levosimendan and Milrinone 20th minute onwards (p<0.01). Milrinone was less effective in increasing the stroke volume as compared to Dobutamine and Levosimendan while Dobutamine and Levosimendan were equally effective. There was no difference in the HR (Heart Rate) achieved with all these three drugs.
Conclusion: Levosimendan is equally effective to Dobutamine and better than Milrinone for the treatment of LCOS following CPB in patients undergoing valve replacement surgeries.
Methods: Twenty adults of American Society of Anesthesiologists’ class I and II of either sex were enrolled for the study with informed consent during November 2015 to January 2016. Anesthesia was performed using Intermed Penlon sigma Alfa Desflurane vaporizer and Penlon Prima SP2 workstation. Age and opioid compensated minimum alveolar concentration was fixed for each patient and was monitored using Penlon SP M8 monitor and its attached anesthesia gas monitoring system. Bispectral index was used in affordable patients to monitor depth of anesthesia. Data of Desflurane consumption was collected from the digital numerical display on the vaporizer screen. Statistical analysis was done using INSTAT software and cost was calculated from maximum retail price.
Results: Data from 20 patients consisting 60% male (mean + standard deviation age of 39.8 + 16.9 years and weight of 59.7 + 12.52 kilograms) were analyzed. Gender had no effect on consumption of Desflurane. Older patients (>60 years) consumed less than the younger (p<0.05). Mean Desflurane consumption was
highest during first 5 minute (6.2 ml) and followed decreasing trend till 45 minute of anesthesia (p<0.05) followed by a near steady consumption. Cost of Desflurane reduced from Indian Rupees 22/minute for 15 minute anesthesia to Indian Rupees 6/minutes for 3 hours anesthesia.
Conclusions: Desflurane consumption and cost do not depend on sex but on age, flow and time. It becomes more cost-effective for relatively longer duration of minimal flow anesthesia.
Aim: To evaluate the ability of pre and intraoperative dexmedetomidine to attenuate stress induced haemodynamic responses, quantifying the anaesthetic agents sparing as well as its cost-effectiveness in patients undergoing laparoscopic cholecystectomy.
Materials and Methods: The present single blind randomized study was conducted with 120 ASA I and II consented patients who underwent laparoscopic cholecystectomy. Patients were randomly divided into 2 groups (i.e., group D and group N). Prior to induction, group D received 1 μg/kg of Dexmedetomidine and group N received Normal saline infusion over 20 minutes. Group D also received maintenance Dexmedetomidine intraoperatively. Bispectral index and minimum alveolar concentration monitoring was done in both the groups. Haemodynamic parameters were noted till 100 minutes post laryngoscopy. Opioid and anaesthetic agent consumptions were also noted and cost analysis was done. Medcalc –Version 12.5.0.0 software was used for statistics and p <0.05 was considered significant.
Results: Dexmedetomidine attenuated the stress induced haemodynamics responses and produced stable, relatively non fluctuating haemodynamics throughout. The MAC requirement and the consumptions of Fentanyl and Isoflurane were significantly less in the Dexmedetomidine group (p<0.0001). However, despite anaesthetic dose sparing effect the anaesthetic technique was not cost-effective.
Conclusion: Dexmedetomidine is effective in attenuating haemodynamic responses in laparoscopic surgery and having dose sparing effect on Fentanyl, Propofol and Isoflurane. However, overall this technique is not cost-effective.
Methods: The present observational study was carried out during 2014–2015 in a teaching institute after the approval from Institute Ethical Committee. A designated anaesthesiologist collected data from the completed pre‑anaesthetic check‑up (PAC) sheets. Investigations already done, asked by anaesthesiologists as well as referral services sought were noted and compared with an adapted master table prepared from standard recommendations and guidelines. Data were expressed in frequencies, percentage and statistically analysed using INSTAT software (GraphPad Prism software Inc., La Zolla, USA).
Results: Seventy‑five out of 352 patients (42.67% male, 57.33% female; American Society of Anesthesiologists physical status I to III) were included in this study. Nearly, all patients attended PAC with at least 5 investigations done. Of them, 89.33% were subjected to at least one unnecessary investigation and 91.67% of the referral services were not required which lead to 3.5 ( SD ±1.64) days loss. Anaesthesiologist‑ordered testing was more focused than surgeons.
Conclusion: More than two‑third of pre‑operative investigations and referral services are unnecessary. Anaesthesiologists are relatively more rational in ordering pre‑operative tests yet; a lot can be done to rationalise the practice as well as reducing healthcare cost.
analgesia in relation to caesarean delivery on maternal request (CDMR) as a reason for it. Methodology:
The departmental electronic database was searched for all the CDMR cases and was included. The
anaesthetic management chart, pre-anaesthetic assessment chart, verbal interview records were reviewed
for the study to complete the data as far as possible. Data were analyzed as percentage and mean and
standard deviation as applicable using INSTAT software. Results: There were 38 (2.64%) CDMR among
the 1437 LSCS evaluated. Twenty four out of 38 (63.16%) of the patients were primigravida. 57.89% of
CDMR had reason related to pain, fear and anxiety. Medical comorbidity was associated and probably
contributed as a reason for choosing CDMR in association with pain in 48.57% cases. 5.26% had received
antenatal counselling for painless labour and 23.68% had prior knowledge of labour analgesia while only
2.63% asked voluntarily for it. Conclusion: Lack of knowledge about painless delivery & facilities, fear,
anxiety and previous bad experience are major reason for choosing “knife” than normal route of delivery.
Higher education, parturients related to health care services and primigravida are more inclined to CDMR
and needs to be targeted both for labour analgesia and for psychological counselling.
protocolized curriculum and uniform throughout. The present study is designed to assess the knowledge, attitude and
practice of BLS and compare it among trained and untrained medical students and junior doctors in a medical
institute.
Methods: After approval from Institute Ethical Committee and informed consent from the participant, the present
study was conducted among the undergraduate-level medical and nursing students and junior doctors. A questionnaire
consisting of 30 questions based on knowledge, attitude and practice of BLS was used to collect data which is
evaluated as per scale defined for this study. Statistical significance was assessed using INSTAT software (GraphPad
Software, Inc., La Zolla, USA).
Results: Only 16.41% of all participants and 52% of doctors have received class and/or hands on training. The
untrained participants have scored poorly as compared to trained participants in theoretical knowledge and practice of
BLS (24.36 % and 53.45% versus 9.25 % and 24.07%) respectively. The mean score for both theoretical knowledge
and practice of BLS for trained students was higher than that of the untrained participants and the statistical difference
was highly significant - p<0.0001. Most of the participants of both trained and untrained group were having very good
attitude towards BLS.
Conclusions: Knowledge and practice skills of BLS/CPR are poor in medical and nursing students. A significant
portion of trainees do not acquire adequate knowledge in a single session of training. An organised curriculum for
BLS and its protocolized training is the need of the hour in medical education.
a state of deep coma (GCS 6/15) and shock with severe anaemia at presentation without any evidence of external or
internal bleeding. He was subsequently diagnosed as a case of Scrub Typhus with Multi Organ Dysfunction (MODS).
Clinical evidence of massive Gastrointestinal (GI) bleeding (melaena and clotted blood per rectum) was found next
day. Despite aggressive supportive treatment we lost the patient next morning. We are presenting the case to share our
experience for better management of such cases in future along with a point to ponder which probably would give an
opportunity to critical care physicians to save such patients
Hyperoxia exerts variable effects on multiple cellular and immunologic parameters and offers potential benefits from use of supplemental oxygen. Supplementation with high concentration of O 2 has been shown to reduce colorectal anastomotic leakage by 50% and subsequently its use has been recommended to reduce surgical site infection (SSI) by surgical associations of America and Canada. We designed this randomized controlled trial to determine the impact of O 2 supplementation on the incidence of SSI in urological surgeries performed under neuraxial anaesthesia.
Aim
The aim of the study was to evaluate whether use of supplemental high-concentration perioperative oxygen decreases the risk of post-uro-SSI as it did after colorectal surgery in previous studies.
Settings
The study was conducted in the Department of Anaesthesiology and Critical Care in collaboration with the Department of Urology at our institute after obtaining clearance from the Institute of Ethical Committee and written informed consent from patients enrolled in this study.
Patients and methods
Eighty ASA grade I and II patients, aged between 15 and 60 years, undergoing selected urological surgeries were randomly assigned to two equal groups after they had fulfilled inclusion and exclusion criteria. One group received 8-10 l O 2 /min through a non-rebreathing face mask during the intraoperative period, which was continued in the postoperative period for about 6 h, whereas the other group continued breathing room air. Data were collected by physicians from the Department of Urology who were blinded to the intervention and were analysed using INSTAT software with appropriate statistical tools.
Results
Demographic, physical, preoperative, intraoperative and postoperative haemodynamic parameters in both groups were comparable (P > 0.05). Although our study showed a tendency towards reduction in SSI (17.5 vs. 12.5%), compared with the control group, the difference was not statistically significant (P > 0.05).
Conclusion
Perioperative high-concentration oxygen supplementation does not reduce SSI in clean contaminated types of wounds in urological surgeries.