Observation In Intensive Care Unit Research Articles

Early diagnosis of placenta accreta in case of mid trimester postabortal haemorrhage with previous 3 cesarean sections

: To know the risk and management of postabortal haemorrhage in patients with previous caesarean delivery to prevent maternal mortality. : Placenta accreta is an emergency life threatening obstetric situation may also complicate first trimester and midtrimester abortion and encountered as profuse vaginal bleeding and difficulty in placenta removal at delivery. The incidence of placenta accreta increased from 1 in 30,000 pregnancies in 1960 to 1 in 533 pregnancies in 2000. Placenta accreta developed in 55 of 590 women with placenta previa and 7 of 156080 without placenta previa. Increased incidence of caesarean increases the incidence of placenta accreta. Multiple caesarean deliveries are largest risk factor for placenta accreta. On the basis of a high risk factor, suspected case of placenta accreta spectrum, must be diagnose and be in charge of a multidisciplinary team with better maternal and fetal outcome. A 36 years old patient, P3L3A1 had prior 3 LSCS with retained placenta with profuse bleeding per vaginum with history of expulsion of fetus (18 week) on the way to hospital, presented to labor room. Patient was unbooked and uninvestigated. Initial resuscitation done along with oxytocic given but no sign of placental separation was there and bleeding was continued. On the basis of torrential bleeding and history of previous three caesarean deliveries, patient is immediately shifted to the operation theatre for exploratory laparotomy in view or provisional diagnosis of a morbidly adherent placenta with torrential haemorrhage. On laparotomy, the anterior surface of lower uterine segment of uterus accompanied by numbers of engorged blood vessels. Bladder was spared. Decision of exploratory laparotomy taken into consideration of morbidly adherent placenta, and procedure was ended with Subtotal hysterectomy, haemostasis achieved. 2 units PCV transfused intraoperatively and patient was shifted to intensive care unit for observation postoperatively. Her postoperative duration was uneventful; she got discharged on postoperative day6 under satisfactory condition. The specimen was sent for histopathological examination. Vigilant monitoring and timely intervention in obstetric emergencies can avoid maternal mortality. We wish to highlight the vigilant monitoring and timely decision, active collaboration by multidisciplinary team improve outcomes in patient of postabortal haemorrhage in midtrimester with previous caesarean delivery with placenta accreta spectrum.

Anaesthetic management of foetus in foetu: A rare entity.

Sir, Foetus in foetu (FIF) is a congenital condition in which a malformed, parasitic foetus is located in the body of its twin. The incidence is 1 in 5,00,000 live births.[1] It was first described in the 1800s by Johann Friedrich Meckel. Less than 200 cases of foetus in foetu have been reported till now.[2] During the developmental stages, there is absence of independent circulatory systems, so the parasite undergoes the stage of primitive streak and it develops vertebral body and organ arranged around an axis differentiating it from a foetiform teratoma.[3] Teratoma is a differential diagnosis which is a type of germ cell tumour. Different organs seen in FIF are vertebral column (91%), limbs (82.5%) and central nervous system (55.8%).[4] 1 ½-year-old, 9-kg child presented with palpable mass in abdomen since birth, constipation and difficulty in passing urine since 3 months. Birth history was insignificant, child was immunised and had achieved milestones for age. General and systemic examination were normal except that a large, and painless mass of the size of a sweet lemon was felt per abdomen. Blood investigations, chest X-ray and echocardiography were normal. Beta-human chorionic gonadotropin and alpha-foetoprotein were negative. Abdominal sonography showed a retroperitoneal mass of 12×8×10 cm in the right suprarenal region extending to the right lumbar region, crossing the midline suggestive of teratoma or FIF. Computerised tomography (CT) abdomen showed a FIF in the retroperitoneal aortocaval region—a well-organised teratoma causing compression over the abdomen [Figure 1].Figure 1: CT Abdomen showing massNil by mouth status and consent was checked. Plan was general anaesthesia plus epidural analgesia. All standard American Society of Anesthesiologists (ASA) monitors attached. Pre-oxygenation was done, and premedication was given. Induction was done with intravenous (IV) propofol (2 mg/kg), IV fentanyl (2 µg/kg) and IV atracurium (0.5 mg/kg), intubated with 4.5 mm uncuffed endotracheal tube and maintained on atracurium, sevoflurane using pressure control mode. Right internal jugular vein was cannulated with 5F 8 cm triple lumen under ultrasonography guidance and fixed at 8 cm. Right radial artery was cannulated for arterial blood pressure (ABP). 19G epidural catheter was placed in left lateral position at L1-L2 space, fixed at 5 cm using saline technique. Infusion with Inj. Ropivacaine 0.2% was started at 2 ml/h and adjusted according to haemodynamics for adequate analgesia. 10F Ryles tube was inserted. Intraoperatively, it was found that the mass was adhered to the surrounding structures, inferior vena cava and aorta [Figure 2]. This led to increased blood loss during dissection causing fall in blood pressure and tachycardia. Beat-to-beat monitoring was done with ABP and central venous pressure; accordingly, fluid was replaced. Blood loss was replaced with packed red blood cells 15 ml/kg. Total fluid given was 900 ml crystalloids, blood loss was 200 ml and urine output was 300 ml. Body temperature was kept normal throughout the procedure. After 5 h duration of surgery, arterial blood gases were normal and patient was extubated uneventfully.Figure 2: Mass of foetus in foetuThe child was shifted to the paediatric intensive care unit for observation. Epidural 0.1% ropivacaine infusion was continued for analgesia and the child was discharged on day 15. The histopathology report showed FIF. FIF has been explained by two theories ‘Parasitic twin theory’ states that a normal foetus becomes enveloped inside the twin partner becoming dependent on its blood supply. As per ‘Teratoma theory’, it is a highly differentiated form of mature teratoma.[5] Conjoined twinning happens when the twinning event occurs at the primitive streak stage of development, 13–14 days after fertilisation, and is associated with the monoamniotic monochorionic type of placentation.[3] The presence of vertebral column differentiates between teratoma and FIF, and its presence was confirmed via CT abdomen in our case. FIF should be differentiated from a teratoma as teratoma has malignant potential.[6] According to Willis definition, FIF should have (a) separate vertebral column, symmetrical development around its axis, and (b) the organs should have developed in an organised manner with some degree of maturation,[3] all of which were present in our case. Meticulous preoperative optimisation, vigilant intraoperative monitoring and good post-operative care led to successful outcome of this rare and complicated case. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

A Rare Case of Leech Therapy Induced Right Foot and Leg Cellulitis with Septic Shock

A 57 year old female came to emergency department with complaint ofpain and swelling over right foot and leg distally. On local examination there was multiple scar marks with redness and blisters formation. Patient was also giving complaint of discharge from the site since night yesterday. On further examination the patient was conscious and little drowsy but in arousable state. On further evaluation, the patient was hypotensive with tachycardia andtachypnoea. Patient was known case of Arthritis and Hypothyroidism. On further assessment attendants gave history of Leech therapy over right foot and leg distally since 20 days prior coming to emergency department. The leech therapy was started at an Ayurvedic hospital for detoxification from steroid. Patient was on steroids since long time for arthritis and she was told in ayurvedic hospital that leech therapy will detoxify her blood and remove excess steroids from her body. Patient was immediately taken on to symptomatic supportive treatment with intravenous antibiotics, intravenous fluids and ionotropic support. All relevant investigations sent from emergency department and patient was admitted in Intensive Care Unit for observation. Patient was discharged after 5 days in haemodynamically stable condition.

Rare case of Torsades de Pointes in severe hypothyroidism: literature review and challenges in management

BackgroundHypothyroidism can manifest as several important cardiac abnormalities. There are few reports of ventricular dysrhythmias (VDs) in hypothyroidism. We described a rare case of VDs in severe hypothyroidism and reviewed the literature behind its management.Case presentationA 67-year-old gentleman, with poor compliance to treatment for Hashimoto’s thyroiditis, presented with palpitations to the Emergency Department. He had runs of non-sustained ventricular tachycardia (NSVT). He was treated with intravenous (IV) amiodarone and admitted to the intensive care unit for observation. He then developed recurrent Torsades de Pointes (Tdp) despite treatment with several anti-arhythmics. He required electrical cardioversion and eventual transvenous overdrive pacing (OP). VT recurred while he was on OP. VT resolved and he was weaned off OP only after adequate thyroid hormone replacement.ConclusionsVDs, including NSVT, Tdp, and VT, are rare and potentially lethal in hypothyroidism. Our case demonstrates important challenges in the management of severe hypothyroidism. Here, VDs are often refractory to treatment with drugs and electrical means. The choice(s) of anti-arrhthymics requires careful consideration and can be difficult before thyroid function tests are known. Amiodarone use should be cautioned as it is associated with thyroid dysfunction and QT interval prolongation.There is no literature to guide thyroid hormone replacement in this disease. Aggressive replacement is associated with adverse cardiovascular effects. Our case showed a fine balance between the risk of rapid thyroid hormone replacement and the urgency to terminate VDs. Its administration should be carefully monitored amidst bridging strategies like electrical cardioversion and OP to manage life-threatening VDs.

A 17-Year-Old Girl with a Recent History of Marijuana Use Presented with Pneumomediastinum and Pneumopericardium and Tested Positive for SARS-CoV-2 Infection on Hospital Admission

Patient: Female, 17-year-oldFinal Diagnosis: Pneumomediastinum • pneumopericardiumSymptoms: Abdominal pain • diarrhea • nausea • vomitingMedication: —Clinical Procedure: Recovered • symptomatic and supportive careSpecialty: Pediatrics and NeonatologyObjective:Unusual clinical courseBackground:Pneumomediastinum and pneumopericardium have been reported to occur in people who regularly smoke marijuana and have also been reported in patients with COVID-19 pneumonia due to infection with SARSCoV-2. This report is of a 17-year-old girl with a history of marijuana use who presented with pneumomediastinum and pneumopericardium and was found to be positive for SARS-CoV-2 infection on hospital admission by Abbott ID NOW testing.Case Report:A 17-year-old girl presented to the emergency room with a 3-day history of abdominal pain, nausea, and vomiting and a 1-day history of diarrhea. She had a history of daily marijuana use and lived with her grandmother who was presumed to be positive for COVID-19, based on symptoms. Her admission laboratory results were unremarkable except for pyuria, which was suspicious for urinary tract infection. The patient’s nasopharyngeal swab was positive for SARS-CoV-2 infection. Owing to abdominal pain, a computed tomography (CT) scan of the abdomen and pelvis was obtained, which was concerning for pneumomediastinum and pneumopericardium. A CT scan of the thorax confirmed the findings. A contrast-enhanced barium esophagogram was performed and was unremarkable. The patient was admitted to the pediatric intensive care unit for observation and supportive care.Conclusions:This report shows the importance of current testing for SARS-CoV-2 infection in patients of all ages who present acutely to the hospital. It also highlights the importance of obtaining a full social and medical history so that symptoms and signs from causes other than SARS-CoV-2 infection are not missed.

Human Zinc Phosphide Exposure in Lebanon: A Case Report and Review of the Literature.

IntroductionToxicity from rodenticides such as metal phosphides is common worldwide, particularly in developing countries where consumers have access to unlabeled and uncontrolled insecticides and pesticides.Case ReportWe present the first documentation of a metal phosphide exposure in Lebanon. A middle-aged woman presented to the emergency department following the ingestion of an unknown rodenticide. Spectroscopy analysis of the sample brought by the patient was used and helped identify zinc phosphide. The patient developed mild gastrointestinal symptoms and was admitted to the intensive care unit for observation without further complications.ReviewWe subsequently conducted a literature review to understand the diagnosis, pathophysiology, clinical presentation, and management of metal phosphide toxicity. Multiple searches were conducted on MEDLINE and PubMed, and articles related to the topics under discussion were included in the review. Metal phosphide is associated with significant morbidity and mortality involving all body systems. Patients presenting with metal phosphide intoxication need extensive workup including blood testing, electrocardiogram, and chest radiography. To date there is no antidote for metal phosphide toxicity, and management is mostly supportive. Many treatment modalities have been investigated to improve outcomes in patients presenting with metal phosphide toxicities.ConclusionEmergency physicians and toxicologists in developing countries need to consider zinc and aluminum phosphides on their differential when dealing with unlabeled rodenticide ingestion. Treatment is mostly supportive with close monitoring for sick patients. Further research is needed to better understand metal phosphide toxicity and to develop better treatment options.

S3545 Pneumomediastinum and Pneumopericardium in a Teenager With Coronavirus Disease 2019 (COVID-19)

INTRODUCTION: Coronavirus disease 2019 (COVID-19) has been declared pandemic by the World Health Organization (WHO) with the rapidly increasing number of infectious cases. The current literature is deficient regarding pediatric population data. We report a case of a seventeen-year-old female, known history of marijuana use, presented to the emergency department with complaints of abdominal pain, nausea, and vomiting and was found to have pneumopericardium and pneumomediastinum. CASE DESCRIPTION/METHODS: The patient presented to the emergency room with a three days history of abdominal pain, nausea, and vomiting and one day history of diarrhea. She lived with her grandmother who was presumed to be COVID-19 positive based on symptoms. Her admission labs revealed pyuria suspicious for urinary tract infection. The remainder of her serology was unremarkable. Patient’s nasal swab was PCR positive for SARS-CoV-2. Due to abdominal pain, a CT-Scan of the abdomen and pelvis was obtained which was concerning for pneumomediastinum and pneumopericardium. CT-scan thorax confirmed the findings and revealed extensive subcutaneous emphysema in the neck soft tissue. Contrast Barium Esophagogram was done which was unremarkable, without any extraluminal contrast leakage. The patient was admitted to the pediatric intensive care unit for observation and supportive care. DISCUSSION: The patient recovered to her baseline with the supportive treatment and did not require any respiratory support during the hospital stay.

Approach to Paroxysmal Atrial Fibrillation Type Arrhythmia in a Cardiology Service: A Case Report

Atrial fibrillation is a cardiac arrhythmia of high prevalence in the population, especially in the elderly. Its main electrical characteristics are the interval between two successive irregular R waves, absence of P waves and presence of f waves between QRS complexes. The most common symptoms of atrial fibrillation are irregular palpitations associated with dyspnea, dizziness, feeling tired, fatigue and general malaise, but not all patients have any symptoms. The present report presents the history of an elderly patient who arrived at the hospital’s emergency department with irregular heart rhythm and palpitations. The patient’s symptoms, associated with the electrocardiogram results, indicated paroxysmal atrial fibrillation. Electrical cardioversion was performed, and after, cardiac ablation via the femoral vein at the hospital’s cardiology service. There were no complications during the procedure. As a routine imaging exam after ablation, control esophagogastroduodenoscopy was requested to verify that there was no formation of atrio-esophageal fistula developed by the invasive ablation procedure and electrocardiogram, which showed normal sinus rhythm. The patient remained in the cardiac intensive care unit for observation for 24 hours. After the electrical cardioversion and catheter ablation procedures, the patient improved his clinical picture of atrial fibrillation and was discharged after 24 hours of hospitalization. He received treatment to perform at home, to reduce acid reflux into the esophagus and to prevent thrombosis. He did not present pulmonary thromboembolism after hospital discharge. It is believed, therefore, that this form of treatment and management of paroxysmal atrial fibrillation is effective for the solution of the proposed problem and can also serve as a reference for other professionals within the cardiology service.

Acute Type B dissection and Aortic Coarctation, Now What?

Introduction: Acute type B dissection is a rare complication in patients with aortic coarctation. Medical therapy is the standard therapy for an uncomplicated acute type B dissection. Nowadays aortic coarctation should be treated by endovascular means. We describe a case of a patient with an acute type B dissection and a silent coarctation. Methods: We describe a case of a patient with an acute type B dissection and an underlying coarctation treated with a thoracic endograft. Results: A 58-year old man was admitted to another hospital with acute interscapular thoracic pain radiating to the left shoulder. CT-scan revealed a Stanford type B dissection with secondary dilatation up to 6 cm and a hematoma in the adjacent fatty tissue suspect for impending rupture. Patient was referred to our centre for treatment. A new CT-scan did not show any evolution, there was no malperfusion and the pain was under control. He was admitted to the intensive care unit for observation and antihypertensive therapy. Further investigations with transthoracic echocardiography showed a bicuspid aortic valve, a dilated arch and descending aorta, and a suspicion of aortic coarctation. Because of the impending rupture, the dilated descending aorta and the persisting limited thoracic pain we decided to treat the dissection after 14 days. A thoracic endografting was successfully performed, covering the entry point of the dissection, the coarctation and the dilated part of the descending aorta. Conclusion: In this case we describe a rare case of a patient with an acute type B dissection and an underlying coarctation, treated with a thoracic endograft. We discuss the preoperative work-up and surgical decision making, the technical aspects of thoracic endografting and the results of the procedure.

Acute Pediatric Colchicine Toxicity is Associated with Marked Bradydysrhythmias

BackgroundColchicine ingestion is rare but highly lethal. Patients usually die of multiorgan failure and cardiogenic shock. Colchicine is not only associated with depressed myocardial function but also with fatal heart rhythm disturbances, such as complete heart block, ventricular tachycardia, and asystole. While histologic changes of myocytes are well known, the mechanism by which colchicine affects cardiac impulse generation and conduction is not fully understood. Case ReportWe present a case of colchicine ingestion with sinus bradycardia, marked sinus arrhythmia, and first- and second-degree heart block. A 10-year-old previously healthy boy was brought to the emergency department for the sudden onset of dizziness, abdominal pain, and vomiting after ingesting his grandfather's colchicine and furosemide. His symptoms improved with ondansetron and intravenous normal saline. However, because of the colchicine ingestion, he was admitted to the pediatric intensive care unit for observation. He first developed PR prolongation (∼4–30 h postingestion) followed by marked sinus bradycardia and sinus arrhythmia along with second-degree heart block (∼48–60 hours postingestion). The minimum heart rate was 40 beats/min. Marked sinus arrhythmia was observed, suggesting an increase in parasympathetic activity. His heart rhythm improved initially with less sinus arrhythmia followed by resolution of heart block. He was discharged home without any sequelae. Holter monitoring 1 week after discharge showed normal heart rate variability for age. Why Should an Emergency Physician Be Aware of This?This case provides novel insights into how colchicine may affect the heart's electrophysiology. Colchicine may increase the parasympathetic tone enough to cause sinus bradycardia and different degrees of heart block.

Clinical Risk Factors for Early Seizure Recurrence in Dogs Hospitalized for Seizure Evaluation.

BackgroundEpileptic seizures are a common cause for neurological evaluations in dogs.Hypothesis/ObjectivesTo determine the timing, frequency, and risk factors for early seizure recurrence (ESR) among dogs admitted to the hospital for seizure evaluation and to facilitate rapid decision making about whether dogs should be placed in the intensive care unit (ICU) or day ward.AnimalsNine‐hundred twenty‐two dogs referred for seizure investigation; 214 patients were included.MethodsRetrospective study. Medical records between 2000 and 2017 were reviewed to determine risk factors for ESR. Findings were compared among dogs diagnosed with idiopathic epilepsy (IE), structural epilepsy (StE) and reactive seizures (RS), as well as in all selected cases together.ResultsFifty percent of dogs had a seizure while hospitalized. In the group 53.1 and 52.2% in the StE group, whereas in the RS 40.44% had ESR. The average time to ESR was 7 hours. In IE group, abnormal postictal neurological examination with prosencephalon signs predicted ESR. In StE group, a single generalized or focal seizure 72 hours before hospital admission and abnormal neurologic examination predicted ESR. In the RS group, ERS was predicted by long‐term antiepileptic monotheraphy. When all dogs were analyzed together, abnormal neurological examination, the occurrence of cluster seizures, status epilepticus, or combination of them 72 hours before presentation predicted ESR.Conclusions and Clinical ImportanceEpileptic seizures recurred in 50% of patients within a mean time of 7 hours. In general, when cluster seizures, status epilepticus or both occurred 72 hours before presentation and neurological examination was abnormal upon presentation, the dog should be placed in ICU for observation.

Kawasaki disease and general anaesthesia: The Know - Hows.

Sir, Kawasaki disease (KD) is a mucocutaneous lymph node syndrome of unknown aetiology affecting infants and children. It is characterised with fever, rash, lymphadenopathy and arteritis with specific predilection to the coronary arteries. Administering general anaesthesia in this subset of patients is challenging. Literature describes only a few and sporadic case reports on its anaesthetic management.[12] We present a case of successful anaesthetic management of a 5-year-old male child weighing 17 kg, diagnosed case of KD posted for full-mouth dental rehabilitation, with on table intermittent two-dimensional (2D) echocardiographic monitoring. The patient was diagnosed with KD 5 months back and subsequently treated with Intravenous (IV) immunoglobulin. Twelve-lead electrocardiogram (ECG) was normal. 2D echocardiogram was suggestive of a good ventricular function with ejection fraction 60%, a 2 mm small ventricular septal defect and atrial septal defect of size 5 mm, both with left to right shunts. Valves were structurally normal. Abnormal dilatation of proximal and mid-segment of the left main coronary artery (LMCA) was noted. Computed tomography angiography was performed demonstrating a 4 mm LMCA, prominent in calibre and a very short trunk. Other vessels appeared normal with no plaque or stenosis. It was advised to consider a possibility of congenital variant by clinical correlation. The patient was receiving tablet aspirin since then, but was stopped 1 month ago. A thorough preoperative evaluation was done. 2-D echocardiogram done a month ago did not show any fresh changes. The paediatrician opinion regarding cardiac status was sought and the patient was taken up for anaesthesia and surgery with informed high-risk consent was obtained from the parents. The child was premedicated with 1 mg/kg of oral midazolam, 20 min before procedure. In the OR, monitoring included ECG (lead II and V5), pulse oximetry (SpO2), non-invasive blood pressure and end-tidal carbon dioxide. After adequate preoxygenation, the child was induced with sevoflurane in air and oxygen mixture. IV access was gained; IV fentanyl 3 mcg/kg. Adequacy of mask ventilation was confirmed, IV atracurium1 mg/kg was administered. In addition, IV propofol 2 mg/kg (as graded boluses during airway manipulation) was administered. Nasal intubation was performed with utmost care so as to avoid any haemodynamic response maintaining an adequate depth of anaesthesia. Intraoperatively, IV dexmedetomidine 0.3 mcg/kg as infusion was administered over 30 min. In this case, local infiltration was not used as adrenaline was a concern and our dental team as a protocol does not use bupivacaine. We planned for adequate analgesia, particularly avoided tachycardia at any stage and maintained a stable heart rate. 2-D echocardiography was performed twice intraoperatively and once post-operatively, which showed no signs of any abnormal contractility, thrombus, embolus, filling pressure changes or any untoward changes in the cardiovascular system. We were interested in assessing the global ventricular function, regional wall motion abnormalities if any, and we used the apical four- and two-chamber views. The duration of surgery was 2.5 h. Apart from fentanyl, diclofenac suppository 2 mg/kg and IV paracetamol 20 mg/kg slow infusion over 20 min were given intraoperatively. On completion of the procedure, the trachea was extubated after reversal of neuromuscular blockade. Post-operatively, the patient was shifted to paediatric Intensive Care Unit for observation. Post-operative analgesia regimen was decided as ibuprofen oral suspension 5 mg/kg/dose three times a day. There exist an array of biochemical tests and invasive monitoring described in the limited literature on anaesthesia for KD. The most dreaded complications are cardiac including coronary artery aneurysms, myocardial involvement and pericardial effusion. The goals of successful management include risk stratification, cardiac status assessment, maintaining stable intraoperative haemodynamics and avoiding triggers of myocardial injury (pain, instrumentation under light planes of anaesthesia). Here, we performed an on table 2-D Echocardiography so as to detect any untoward evidence of myocardial contractility, filling pressure, peripheral vascular resistance or thrombus. We also maintained an adequate myocardial supply-demand ratio by providing adequate multimodal analgesia and dexmedetomidine infusion intraoperatively. Our choice of dexmedetomidine was with regard to its favourable sedative, anxiolytic, limited respiratory and haemodynamic effects.[34] Accordingly, the safety profile for administering general anaesthesia in this high-risk population increases many fold. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Increasing the acceptability and rates of organ donation among minority ethnic groups: a programme of observational and evaluative research on Donation, Transplantation and Ethnicity (DonaTE)

BackgroundBlack, Asian and minority ethnic (BAME) groups have a high need for organ transplantation but deceased donation is low. This restricts the availability of well-matched organs and results in relatively long waiting times for transplantation, with increased mortality risks.ObjectiveTo identify barriers to organ donor registration and family consent among the BAME population, and to develop and evaluate a training intervention to enhance communication with ethnic minority families and identify impacts on family consent.MethodsThree-phase programme comprising (1) community-based research involving two systematic reviews examining attitudes and barriers to organ donation and effective interventions followed by 22 focus groups with minority ethnic groups; (2) hospital-based research examining staff practices and influences on family consent through ethics discussion groups (EDGs) with staff, a study on intensive care units (ICUs) and interviews with bereaved ethnic minority families; and (3) development and evaluation of a training package to enhance cultural competence among ICU staff.SettingCommunity focus group study in eight London boroughs with high prevalence of ethnic minority populations. Hospital studies at five NHS hospital trusts (three in London and two in Midlands).Participants(1) Community studies: 228 focus group participants; (2) hospital studies: 35 nurses, 28 clinicians, 19 hospital chaplains, 25 members of local Organ Donation Committees, 17 bereaved family members; and (3) evaluation: 66 health professionals.Data sourcesFocus groups with community residents, systematic reviews, qualitative interviews and observation in ICUs, EDGs with ICU staff, bereaved family interviews and questionnaires for trial evaluation.Review methodsSystematic review and narrative synthesis.Results(1) Community studies: Organ Donor Register – different ethnic/faith and age groups were at varying points on the ‘pathway’ to organ donor registration, with large numbers lacking knowledge and remaining at a pre-contemplation stage. Key attitudinal barriers were uncertainties regarding religious permissibility, bodily concerns, lack of trust in health professionals and little priority given to registration, with the varying significance of these factors varying by ethnicity/faith and age. National campaigns focusing on ethnic minorities have had limited impact, whereas characteristics of effective educational interventions are being conducted in a familiar environment; addressing the groups’ particular concerns; delivery by trained members of the lay community; and providing immediate access to registration. Interventions are also required to target those at specific stages of the donation pathway. (2) Hospital studies: family consent to donation – many ICU staff, especially junior nurses, described a lack of confidence in communication and supporting ethnic minority families, often reflecting differences in emotional expression, faith and cultural beliefs, and language difficulties. The continuing high proportion of family donation discussions that take place without the collaboration of a specialist nurse for organ donation (SNOD) reflected consultants’ views of their own role in family consent to donation, a lack of trust in SNODs and uncertainties surrounding controlled donations after circulatory (or cardiac) death. Hospital chaplains differed in their involvement in ICUs, reflecting their availability/employment status, personal interests and the practices of ICU staff. (3) Evaluation: professional development package – a digital versatile disc-based training package was developed to promote confidence and skills in cross-cultural communication (available at:www.youtube.com/watch?v=ueaR6XYkeVM&feature=youtu.be). Initial evaluation produced positive feedback and significant affirmative attitudinal change but no significant difference in consent rate over the short follow-up period with requirements for longer-term evaluation.LimitationsParticipants in the focus group study were mainly first-generation migrants of manual socioeconomic groups. It was not permitted to identify non-consenting families for interview with data regarding the consent process were therefore limited to consenting families.ConclusionsThe research presents guidance for the effective targeting of donation campaigns focusing on minority ethnic groups and provides the first training package in cultural competence in the NHS.Future workGreater evaluation is required of community interventions in the UK to enhance knowledge of effective practice and analysis of the experiences of non-consenting ethnic minority families.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.

The Case Files

The Case Files

Povidone-iodine toxicity in a child posted for laparoscopic removal of hepatic and renal hydatid cysts.

Sir, Povidone-iodine (PI) is an antiseptic solution consisting of polyvinylpyrrolidone with water and iodine (available iodine 1%). The 10% solution has been used effectively as a scolicidal agent for hydatid cysts. We hereby discuss the case of a child posted for laparoscopic removal of hepatic and renal hydatid cysts, who developed metabolic acidosis with acute renal failure. A 10-year-old child (weight 26 kg) presented with history of pain in epigastrium. Pain was dull, mild to moderate, and there was no radiation. Systemic examination revealed hepatomegaly. Computed tomography scan abdomen revealed well-defined cystic lesion of 12.5 × 8.5 × 11.4 cm in the left lobe of liver extending to lesser sac and perihepatic area along with small cysts in right kidney. Routine blood investigations and liver function tests were normal. Anti-Echinococcus IgG antibody was positive by Enzyme Linked Immunosorbent Assay. Diagnosis of hydatid cyst of liver and kidney was made, and the child was posted for elective laparoscopic removal of hepatic and renal cysts. Baseline haemodynamic parameters were normal for age. Inhalational induction performed with sevoflurane (8%) in oxygen. After administering fentanyl (60 μg) and vecuronium (3 mg), trachea was intubated. A total of 2.5 L of 10% PI (Microwin®10% w/v) was injected into hepatic hydatid cyst. An hour into the procedure, suddenly heart rate increased from 110 to 180/min along with hypercarbia (end-tidal CO255mmHg) and hyperthermia (from 35.1 to 37.4°C). Injection paracetamol (500 mg) and a bolus (0.5 L) of normal saline were infused. An arterial blood gas analysis showed pH 7.14, pCO236.5 mmHg, pO2135 mmHg, SO297.7%, K+7.4 mmol/L, Na+127 mmol/L, Ca+0.81 mmol/L, Cl − 249 mmol/L, lactate 4.3 mmol/L, base deficit - 15 mmol/L, HCO312.7 mmol/L with Hb of 16 gm%. Blood pressure and airway pressures were normal. Urine output decreased and did not improve after first fluid bolus so a further fluid bolus of 0.5 L of balanced salt solution (sterofundin®) and injection frusemide 15 mg intravenous (IV) were administered. Urine output improved and presumptive diagnosis of anaphylaxis due to systemic entry of hydatid cyst fluid was suspected. Injection hydrocortisone and pheniramine maleate were administered. Patient was shifted to intensive care unit (ICU). Investigations revealed haemoglobin 17 g/dL, leukocyte count 49.6 × 103/μL, serum creatinine 0.9 mg/dL, serum albumin 1.9 g/dL, and potassium 5.2 mEq/L in the immediate post-operative period. Liver, renal, and thyroid function tests were in normal range. Severe metabolic acidosis persisted and thus plan for haemodialysis was made. Tachycardia was fluid responsive and Sterofundin®100 ml/h, albumin (20%) 25 ml/h and hydrocortisone 6 mg/h were started. Bedside echocardiography revealed good cardiac contractility, under filled heart chambers and inferior vena cava diameter of 0.4 – 0.8 cm with collapsibility. After 3–4 h of initiation of haemodialysis, acidosis was corrected and heart rate settled. On post-operative day 1, the patient was fully awake and obeying commands. Trachea was extubated after completion of dialysis. Hydrocortisone infusion was tapered and stopped. Patient was kept for another 2 days in ICU for observation before shifting to ward. In its complexed form (i.e. PI), iodine vapour pressure is reduced essentially to zero, and it becomes soluble in water. The available iodine is released at very slow rate from the complex, prolonging germicidal action of free iodine. Povidone-iodine is highly nephrotoxic and due to its renal elimination, iodine intoxication can result in lethal vicious cycle and anuria.[1] Clinically, patients with PI intoxication can present with hypotension, nausea, vomiting, acute renal failure, hypothyroidism, confusion, metabolic acidosis, seizures, blindness, fever, rash, uterine infarction, elevated hepatic enzymes and iodine-induced haemolysis with decreased serum haptoglobin and lactate dehydrogenase levels.[1] Serum iodine levels could not be done as this analysis was not available in our hospital. Labbe et al. reported a case where abnormalities of cardiac conduction, lactic acidosis, acute renal failure, hypocalcaemia and thyroid dysfunction were features of intoxication.[2] In another case report of iodine toxicity in a child with mediastinitis, after median sternotomy, continuous PI irrigation was carried out and the child died due to its toxicity.[3] Iodinated contrast medium (IV) can cause contrast-induced acute kidney injury, but even with non-intravascular use of iodinated compounds, iodine absorption through mucosal, burned skin or interstitial tissues, can cause nephrotoxicity.[4] Early implementation of renal replacement therapy can be lifesaving.

The successful use of sugammadex and uneventful recovery from general anaesthesia in a patient with myotonic dystrophy.

Sir, Myotonic dystrophy is an autosomal dominant multisystem disorder characterised by progressive weakness and wasting of muscles, cardiomyopathy and cardiac conduction defects, restrictive lung disease, sleep apnoea syndrome, slow gastric emptying, endocrine disorders and cataracts. This condition is often associated with prolonged muscle contractions with defective relaxation (myotonia). There are two major types of myotonic dystrophy: Type 1 and type 2. These are caused by mutations in different genes. Anaesthetic management of this condition can be challenging due to the potential for these patients to develop perioperative cardiorespiratory complications and because they may demonstrate abnormal responses to sedative and neuromuscular blocking agents. We present a report of the successful management of a 60-year-old gentleman with myotonic dystrophy type 1, weighing 70 kg, who presented for elective laparoscopic cholecystectomy. His symptoms had included progressive weakness of the upper limbs with dysarthria, soft voice and mild static swallowing impairment. He had dilated cardiomyopathy and had a pacemaker/defibrillator in situ. The patient also had moderate obstructive sleep apnoea and was saturating at 99% in room air. This patient had never undergone general anaesthesia, and all his previous investigations had been performed previously under local anaesthesia with sedation. Pre-operative examination findings included the characteristic facial features of myotonic dystrophy and a modified Mallampati class III. On the day of surgery, no oral pre-medication was given other than his usual medications. Intra-operative monitoring included five-lead electrocardiography, pulse oximetry, capnography, invasive blood pressure monitoring with a right radial artery catheter and bispectral index (BIS). Magnet and external defibrillator pads were placed over his chest. Following adequate pre-oxygenation, induction and maintenance of anaesthesia were carried out with 0.5 mg of midazolam followed by propofol and remifentanil target controlled infusion titrated to BIS between 40 and 60 and haemodynamic status. After the initial administration of 50 mg rocuronium for intubation anticipating approximately 2 h procedure, we had planned to give subsequent doses guided by a peripheral nerve stimulator. A grade II b laryngeal view was obtained with direct laryngoscopy and a size 8.5 endotracheal tube was inserted. The maintenance phase of anaesthesia was uneventful, and no other analgesia was given intra-operatively. Upper and lower body forced air warmers were used throughout. The surgery was uncomplicated and lasted 45 min. At the end of surgery as no twitches were observed with train-of-four (TOF) stimulus after the initial intubating dose of rocuronium, the decision was made to reverse neuromuscular blockade with an initial sugammadex dose of 200 mg and further administer additional doses if necessary. Interestingly with the initial dose, all the four twitches to TOF stimuli appeared with no fade, merely within 30 s. Furthermore, there was no obvious fade with double burst stimulation. The patient was extubated when fully awake after a smooth emergence. His oxygen saturation was 99% with 5 L/min of supplemental oxygen. The patient was admitted to the Intensive Care Unit for observation and had an uncomplicated recovery. Patients with myotonic dystrophy often have respiratory muscle weakness resulting in an ineffective cough. This can co-exist with a decreased ventilatory response to hypoxia and hypercapnia. Pharyngeal muscle weakness and prolonged gastric emptying may increase the risk of aspiration. As a consequence, there is a possibility of increased postoperative pulmonary complications in this patient group.[1] Suxamethonium can result in exaggerated contracture in patients with myotonic dystrophy.[1] It may be difficult to predict the reaction to neostigmine in these patients as it can result in aggravation of paralysis or myotonia.[2,3] Peripheral nerve stimulation itself can also result in a myotonic response that may be misinterpreted, as sustained tetanus.[1] Residual neuromuscular blockade may further increase the risk of postoperative pulmonary complications in these patients. Sugammadex, a modified gamma-cyclodextrin, selectively binds with rocuronium or vecuronium to reverse the neuromuscular blocking effect. It is devoid of the risks of neostigmine and with better efficacy at reversal, has been suggested as a superior alternative.[4,5,6] We had decided to use rocuronium and sugammadex combination, to avoid the possible need for neostigmine to reverse any other relaxant as well as because of lack of quantitative neuromuscular monitoring with which we could ensure complete reversal. In contrast to the previous reports, where sugammadex was either given to avoid the possibility of residual paralysis[4] or less than normal dose of rocuronium was given for intubation,[6] we observed that using sugammadex, we could easily reverse a complete paralysis following the usual intubating dose of rocuronium (approximately 0.6 mg/kg). We therefore suggest that sugammadex, if available, should be considered for reversal of neuromuscular blockade with steroidal non-depolarising muscle relaxants in patients with muscular disorders such as myotonic dystrophy, particularly in facilities where advanced neuromuscular monitoring is unavailable.

Delayed presentation of post tuberculous broncho oesophageal fistula in an adult: Perioperative anaesthetic management.

Sir, A 42-year-old male had a recurrent cough with expectoration for last 6 months more with supine position and aggravated by the intake of food. He was referred for a pre-anaesthetic checkup for left pneumonectomy with repair of broncho oesophageal fistula (BEF). He had a history of parietal lobe abscess, drained twice with residual left-sided hemiplegia and focal seizures and had completed two courses of antituberculous treatment (ATT) 15 years back. The patient could lie down only in left lateral position. His investigations were unremarkable. Pulmonary function testing showed moderate impairment of lung function with moderately reduced vital capacity. X-ray and computerised tomography of the chest showed cystic bronchiectasis in left lower lobe. There were fibrosis and pleural thickening in bilateral lung fields with dilated oesophagus. Communicating tract between the lateral wall of the lower oesophagus and left lower lobe bronchus was seen at D-8 [Figure 1]. Post-inflammatory BEF was suggested in view of surrounding inflammatory changes and mediastinal lymphadenopathy. Barium swallow confirmed the same. Magnetic resonance imaging of the brain revealed post-operative changes with residual ring configuration in right posterior frontal lobe with moderate perilesional oedema. Figure 1 Computed tomography scan chest showing cystic bronchiectasis in left lower lobe and fistulous communication between oesophagus and left lower lobe bronchus The patient was accepted under American Society of Anaesthesiologists grade III. Antibiotics, chest physiotherapy, incentive spirometry, deep breathing exercises and all antiepileptic medications were continued till the morning of surgery. The patient was already on continuous Ryle's tube aspiration. After pre-medication, the thoracic epidural catheter was placed at T6-T7 interspace. Epidural test dose was followed by 3 mg of morphine. Monitoring included continuous electrocardiography, invasive blood pressure, end tidal carbon dioxide, SpO2, temperature, urine output and blood loss. After nasogastric tube aspiration and pre-oxygenation in the left lateral position, injection fentanyl 50 μg and sleep doses of thiopentone were given. As the patient went asleep, he was turned supine, and the cricoid pressure was applied. Injection rocuronium 50 mg was given to felicitate insertion of right sided double lumen tube (DLT) 41F. Intermittent positive pressure ventilation was avoided. Placement of DLT was confirmed clinically and fibreoptically. The left lung was isolated and collapsed immediately to prevent gastric distension and loss of lung volume. The patient was placed in right lateral position. Anaesthesia was maintained with nitrous oxide, oxygen, isoflurane, and rocuronium. Left pneumonectomy with excision of BEF track was done with blood loss of 2.5 L which was adequately replaced. A nasogastric tube was also placed. At closure, 6 ml of 0.125% bupivacaine was given through the epidural catheter. After extubation of trachea, the patient was shifted to intensive care unit for observation and made an uneventful recovery. BEF is rarely reported in the literature.[1] It may be congenital or acquired. Acquired causes include malignancy, trauma, oesophageal diverticulosis, infections such as syphilis, tuberculosis (TB) and actinomycosis. TB is the most common cause of infective BEF. The development of BEF in TB is related to mediastinal lymph node involvement.[2] Infection and subsequent adhesions between tracheobronchial lymph nodes and oesophagus with subsequent development of a traction diverticulum communicating with the respiratory tree are the mechanism for BEF formation. The aim during induction of anaesthesia is to avoid gas flow through the fistula which can cause gastric distension and impaired ventilation.[3] Positive pressure ventilation should be avoided. Spontaneous ventilation should be maintained during induction until gentle ventilation by mask provides an effective gas exchange. Double lumen intubation is required which protects the contralateral lung from contamination and provides the ability to ventilate it without applying positive pressure to the fistula.[3] Keeping the same in mind, rapid sequence induction was planned as insertion of DLT under spontaneous ventilation is difficult. Once placed, the diseased lung was isolated and kept collapsed. A surgical field fire is a known hazard during the surgery for BEF repair.[4] Avoiding the use of electrocautery while the fistula is open, using wet sponges, and decreasing the oxygen concentration in the gases before the division of fistula could reduce this incidence.[4] We instituted one lung ventilation with little loss of gases and a quick repair of the fistula to avoid the same. Post-tuberculous BEF is a rare entity and scarcely reported in the literature. BEF as a complication of TB can present at varied time intervals. There are reports of both immediate as well as a presentation in the chronic healing phase of TB.[1,2] Our patient received two complete courses of ATT 15 years back. BEF developed a decade later during the chronic healing phase of TB. Chronic suppuration not only damaged the left lung but also lead to the development of BEF. To conclude, prompt recognition and meticulous perioperative management lead to the successful outcome of our patient.

Emergency anaesthetic management of penetrating thoracic trauma: Combining skill with fortuity.

The results and management of penetrating thoracic trauma are largely dependent upon the extent of injury to internal organs as well as the skills of the attending clinicians. Thoracic trauma in children may be associated with rib fractures, flail chest, soft tissue injury, intrapleural lesions such as haemothorax and pneumothorax, parenchymal lung injuries such as pulmonary contusion and lung laceration as well as mediastinal lesions, including cardiac injury,[1,2] and yet our patient fortuituously had none of these, despite suffering a major, and what could potentially have been a life-threatening accident. The sources of perioperative morbidity and mortality in subjects suffering penetrating thoracic injuries include airway obstruction, respiratory failure and haemorrhage. Clinicians need to be adequately trained to deal with these problems. Trauma mainly affects the younger population and happens to be the most common cause of mortality in patients in the first three decades of life. The technical difficulties encountered during the perioperative management of the patient with severe penetrating thoracic injury are highlighted here.

The butterfly pattern in a patient with chromosome 7 deletion.

The butterfly pattern in a patient with chromosome 7 deletion.

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Introduction: Clozapine is primarily metabolized via cytochrome P450 (CYP450) 1A2. There is evidence that infection and/or acute inflammatory processes may decrease CYP450 1A2 activity resulting in clozapine toxicity. We report a 49 year-old male admitted for a total hip arthroplasty (THA) due to debilitating hip pain. His past medical history was significant for paranoid schizophrenia and chronic renal insufficiency. Pertinent medications upon admission included total daily doses of aripiprazole 15 mg, clozapine 400 mg, divalproex sodium 500 mg and escitalopram 10 mg. The THA was completed without complication, however during recovery he was found to be unresponsive. Initial naloxone administration produced minimal effect on hypoxemia and somnolence after repeated bolus administration and a continuous infusion. The patient required transfer to an intensive care unit for observation and was placed on noninvasive ventilation for hypoxemia. Naloxone continuous infusion remained ineffective. A trial of flumazenil and discontinuation of a psoas nerve block also had no effect on sedation. A computed tomography scan of the head was negative for any acute process and infection was not suspected. A valproic acid level was found to be subtherapeutic at 19 mg/mL and serum ammonia was below detectable limits. Significant somnolence persisted through post-operative day (POD) 5 at which time the clozapine dose was empirically reduced from 400 mg to 300 mg daily. Sedation continued on POD 7 and at this time the patient was noted to have developed sialorrhea, which may occur with therapeutic doses but also with acute toxicity. A clozapine level was obtained 8 hours after a dose and found to be 1130 ng/mL (usual goal ~350 ng/mL). Given smoking cigarettes can induce CYP450 1A2, cessation of smoking during a hospitalization may result in toxicity. However, information was obtained that the patient had quit smoking 6 months prior and this would not have been a factor. It has been proposed that infectious and/or inflammatory processes may result in cytokine mediated reduction of CYP450 1A2 activity and that up to a 50% reduction of clozapine dose may be needed to minimize the risk for toxicity. Cases involving infection are most notable in the literature and this is the first case in which surgery may have resulted in clozapine toxicity via this suspected mechanism. This case adds to the growing literature that infection and/or acute inflammatory processes are associated with increased clozapine levels and clinical toxicity. Clinicians should suspect clozapine toxicity when there is unexplained sedation and sialorrhea for patients with acute infectious and/or inflammatory processes.