International Journal of Chronic Obstructive Pulmonary Disease, Sep 1, 2019
We have read the study by Liao et al published in your journal with great interest. 1 The article... more We have read the study by Liao et al published in your journal with great interest. 1 The article evaluates the effects of COPD on the outcome of laparoscopic cholecystectomy. Although COPD is a well-known risk for postoperative pulmonary complications, it is interesting to know this association from this matched study with a relatively larger sample. The authors' findings and conclusions are relevant, but we consider that a few other aspects need to be taken into account from the practical point of view. Firstly, from the methodological point of view, although the cohort was matched for age and gender, their comorbidities were very much different and may have affected the outcome measures like use of supports, ie, vasopressors, hemodialysis (HD), mechanical ventilation (MV), intensive care unit (ICU) stay, etc. Inclusion of patients with only COPD in the COPD group or using multivariate analysis may have helped in determining the real impact caused by COPD. In addition, the time period considered, ie, 1997-2013, is too long and the management strategy, especially for COPD patients, has evolved/changed a lot, diluting the applicability in the current practice. Secondly, the information on intraoperative and postoperative respiratory management is very crucial and is missing. Respiratory management in hypercapnic, emphysema patient during pneumoperitoneum, use of multimodal analgesia, especially regional analgesia techniques, neuromuscular blockade management can impact the postoperative pulmonary conditions and outcome. Similarly, preoperative optimization strategy for risk reduction taken, induction of COPD specific treatment, if any, is also equally important. 2-4 Finally, information on whether the facility of HD, MV, ICU were there in all the hospitals included is critical. It is because, it can lead to a selection bias, management differences, as well as impact in the outcome. A recent meta-analysis indicates that laparoscopic major gastrointestinal surgery in COPD patients is safe and has its own benefits including reduced overall postoperative pulmonary complications. 5 However, proper patient selection is very important. 5 While we very much welcome and accept the conclusion of the authors, we believe that the bad prognosis, ie, increased mortality and mechanical ventilation, shown and attributed to COPD needs to be judged in the
CAUTI in hospitals/centers who follow CDC-NHSN CAUTI definitions will not only have its implicati... more CAUTI in hospitals/centers who follow CDC-NHSN CAUTI definitions will not only have its implications on CLABSI rates, but also put the onus on Candida auris surveillance in India. [5,6]
In response to "positive end-expiratory pressure valve malfunctioning detected by capnographic an... more In response to "positive end-expiratory pressure valve malfunctioning detected by capnographic and airway pressure waveform" improper maintenance and service that led to the excessive moisture accumulation and the stuck PEEP valve disc. Needless to emphasize, the anesthesia machine including PEEP valve should undergo regular maintenance and service as per instructions given in the manual, strict adherence to given recommendations would prevent machine failure as well as the PEEP valve malfunction, and ensure safe conduct of anesthesia and ventilation.
This is an open access article distributed under the terms of the Creative Commons Attribution-No... more This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
This is an open access article distributed under the terms of the Creative Commons Attribution-No... more This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
headache, dizziness and visual disturbances ranging from blurred vision to permanent blindness. [... more headache, dizziness and visual disturbances ranging from blurred vision to permanent blindness. [2] Later manifestations include severe metabolic acidosis, brain edema/necrosis, and cerebral hemorrhage. [3,4] Putaminal necrosis or hemorrhage could be due to these metabolic effects or as a result of direct toxicity from metabolic end products of methyl alcohol. [5] Thus, persistent weakness or unconsciousness in a patient with methanol poisoning should always point toward the possibility of an intracranial complication while managing such cases.
Journal of Clinical Monitoring and Computing, May 4, 2012
Acute left ventricular (LV) or right ventricular (RV) dysfunction during repair of coarctation of... more Acute left ventricular (LV) or right ventricular (RV) dysfunction during repair of coarctation of aorta (CoA) is rare. Well-developed collateral circulation between branches of both the subclavian arteries (SCAs) and upper descending thoracic aorta decompress LV and prevents acute rise in afterload. An adult patient presented for CoA repair. On chest X-ray, rib notching was not seen. Magnetic Resonance Imaging showed about 7 mm long CoA distal to the origin of left common carotid artery. Reconstruction images of distal arch and descending thoracic aorta showed origin of both the SCAs from CoA segment. Transthoracic echocardiography showed 1.3 cm atrial septal defect (ASD), left to right shunt, moderately severe mitral regurgitation (MR), dilated RV, and severe pulmonary artery hypertension (PH). During cardiac catheterization, the peak gradient across CoA was 60 mmHg. On aortic-root angiography, both the common carotids and the distal arch opacified simultaneously, the CoA segment and the distal aorta opacified a little later. Both the SCAs were filling retrograde. A unique anatomy in which aortic-clamping proximal to CoA and both the SCAs would increase flow to spinal-cord as clamping of the SCAs will stop stealing of blood into the CoA but potentially increase LV afterload, MR, left to right shunt across ASD and RV volume and pressure load depending on the magnitude of flow across the CoA. The increases in LV afterload, MR, and RV afterload and volume overload were managed by controlled phlebotomy and fine-tuned by manipulating inhaled isoflurane concentration whereas the Transesophageal echocardiography (TEE) monitored and guided the management.
is a water-soluble, phosphono-O-methyl prodrug of propofol for intravenous (i.v.) injection. It h... more is a water-soluble, phosphono-O-methyl prodrug of propofol for intravenous (i.v.) injection. It has been evaluated for sedation during diagnostic and routine therapeutic procedures. The early evaluation studies were published mostly in Anesthesiology between 2003 and 2005.
Journal of Cardiothoracic and Vascular Anesthesia, Apr 1, 2012
s b a THE SIMULTANEOUS PRESENCE of an aneurysmal main pulmonary artery (MPA) and left pulmonary a... more s b a THE SIMULTANEOUS PRESENCE of an aneurysmal main pulmonary artery (MPA) and left pulmonary artery (LPA), severe right pulmonary artery (RPA) stenosis, and severe pulmonary artery hypertension (PAH) is rare. The aneurysmally dilated and tense MPA can compress the left main coronary artery (LMCA),1-3 whereas a dilated tense LPA can ompress the left main bronchus.4-7 In such a clinical scenario, the consequences of compromise of the LMCA flow and left lung ventilation can be catastrophic. Perioperative issues in a child with severe pulmonary hypertension who presented for MPA and RPA plasty and atrial septal defect (ASD) closure are discussed.
Cardiopulmonary bypass is known to elicit systemic inflammatory response syndrome and organ dysfu... more Cardiopulmonary bypass is known to elicit systemic inflammatory response syndrome and organ dysfunction. This can result in pulmonary dysfunction and deterioration of oxygenation after cardiac surgery and cardiopulmonary bypass. Previous studies have reported varying results on anti-inflammatory strategies and oxygenation after cardiopulmonary bypass. Ketamine administered as a single dose at induction has been shown to reduce the pro-inflammatory serum markers in patients undergoing cardiopulmonary bypass. Therefore we investigated if ketamine can result in better oxygenation in these patients. This was a prospective randomized blinded study. Eighty consecutive adult patients undergoing elective coronary artery bypass grafting under cardiopulmonary bypass were included in the study. Patients were divided into two groups. Patients in ketamine group received 1mg/kg of ketamine intravenously at induction of anesthesia. Control group patients received an equal volume of saline. All patients received standard anesthesia, operative and postoperative care.Paired t test and independent sample t test were used to compare the inter-group and between group oxygenation indices respectively. Oxygenation index and duration of ventilation were analyzed. Deterioration of oxygenation index was noted in both the groups after cardiopulmonary bypass. However, there was no significant difference in the oxygenation index at various time points after cardiopulmonary bypass or the duration of ventilation between the two groups. This study shows that the administered as a single dose at induction does not result in better oxygenation after cardiopulmonary bypass.
Background: Fresh gas flow (FGF) during volatile inhalational agent-based anesthesia is a concern... more Background: Fresh gas flow (FGF) during volatile inhalational agent-based anesthesia is a concern for many reasons. Advancement in anesthesia workstation (WS) and monitoring of anesthesia gas concentrations has led to the feasibility of lower flow safely. However, the practice pattern is not yet well known. The information can help us in better protocol formation. Aim: The survey was aimed to know the prevailing practice pattern of FGF and volatile agent choices and compare them among anesthesiologists of different working setups and experiences. Materials and Methods: With approval, the present cross-sectional survey was conducted using SurveyMonkey® software from January 2018 to May 2018. Anesthesiologists working in different organizations across India were approached through E-mail and WhatsApp. Anonymous responses were collected, expressed in number and percentage scale, as well as compared using INSTAT software and appropriate tests; P < 0.05 was considered statistically significant. Results: A total of 251 (15.2%) responses were received and 249 were analyzed. Overall, 87% of respondents were using anesthesia WS and 71% were using nitrous oxide as balance gas. The FGF of <600 mL/min was highest with desflurane. Minimum alveolar concentration (MAC) monitoring was very poor in nonteaching (NT) hospitals as compared to teaching hospitals; P < 0.0001. The Boyle's machine was more common in use in NT hospitals as compared to medical colleges and corporate hospitals; P < 0.0001. Conclusion: Low-flow anesthesia (LFA) use is still suboptimal, and there are ample opportunities to increase and optimize the FGF used. The use of Boyle's machine is associated with higher flow use. MAC monitoring and LFA use are poor in NTs.
International Journal of Chronic Obstructive Pulmonary Disease, Sep 1, 2019
We have read the study by Liao et al published in your journal with great interest. 1 The article... more We have read the study by Liao et al published in your journal with great interest. 1 The article evaluates the effects of COPD on the outcome of laparoscopic cholecystectomy. Although COPD is a well-known risk for postoperative pulmonary complications, it is interesting to know this association from this matched study with a relatively larger sample. The authors' findings and conclusions are relevant, but we consider that a few other aspects need to be taken into account from the practical point of view. Firstly, from the methodological point of view, although the cohort was matched for age and gender, their comorbidities were very much different and may have affected the outcome measures like use of supports, ie, vasopressors, hemodialysis (HD), mechanical ventilation (MV), intensive care unit (ICU) stay, etc. Inclusion of patients with only COPD in the COPD group or using multivariate analysis may have helped in determining the real impact caused by COPD. In addition, the time period considered, ie, 1997-2013, is too long and the management strategy, especially for COPD patients, has evolved/changed a lot, diluting the applicability in the current practice. Secondly, the information on intraoperative and postoperative respiratory management is very crucial and is missing. Respiratory management in hypercapnic, emphysema patient during pneumoperitoneum, use of multimodal analgesia, especially regional analgesia techniques, neuromuscular blockade management can impact the postoperative pulmonary conditions and outcome. Similarly, preoperative optimization strategy for risk reduction taken, induction of COPD specific treatment, if any, is also equally important. 2-4 Finally, information on whether the facility of HD, MV, ICU were there in all the hospitals included is critical. It is because, it can lead to a selection bias, management differences, as well as impact in the outcome. A recent meta-analysis indicates that laparoscopic major gastrointestinal surgery in COPD patients is safe and has its own benefits including reduced overall postoperative pulmonary complications. 5 However, proper patient selection is very important. 5 While we very much welcome and accept the conclusion of the authors, we believe that the bad prognosis, ie, increased mortality and mechanical ventilation, shown and attributed to COPD needs to be judged in the
CAUTI in hospitals/centers who follow CDC-NHSN CAUTI definitions will not only have its implicati... more CAUTI in hospitals/centers who follow CDC-NHSN CAUTI definitions will not only have its implications on CLABSI rates, but also put the onus on Candida auris surveillance in India. [5,6]
In response to "positive end-expiratory pressure valve malfunctioning detected by capnographic an... more In response to "positive end-expiratory pressure valve malfunctioning detected by capnographic and airway pressure waveform" improper maintenance and service that led to the excessive moisture accumulation and the stuck PEEP valve disc. Needless to emphasize, the anesthesia machine including PEEP valve should undergo regular maintenance and service as per instructions given in the manual, strict adherence to given recommendations would prevent machine failure as well as the PEEP valve malfunction, and ensure safe conduct of anesthesia and ventilation.
This is an open access article distributed under the terms of the Creative Commons Attribution-No... more This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
This is an open access article distributed under the terms of the Creative Commons Attribution-No... more This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
headache, dizziness and visual disturbances ranging from blurred vision to permanent blindness. [... more headache, dizziness and visual disturbances ranging from blurred vision to permanent blindness. [2] Later manifestations include severe metabolic acidosis, brain edema/necrosis, and cerebral hemorrhage. [3,4] Putaminal necrosis or hemorrhage could be due to these metabolic effects or as a result of direct toxicity from metabolic end products of methyl alcohol. [5] Thus, persistent weakness or unconsciousness in a patient with methanol poisoning should always point toward the possibility of an intracranial complication while managing such cases.
Journal of Clinical Monitoring and Computing, May 4, 2012
Acute left ventricular (LV) or right ventricular (RV) dysfunction during repair of coarctation of... more Acute left ventricular (LV) or right ventricular (RV) dysfunction during repair of coarctation of aorta (CoA) is rare. Well-developed collateral circulation between branches of both the subclavian arteries (SCAs) and upper descending thoracic aorta decompress LV and prevents acute rise in afterload. An adult patient presented for CoA repair. On chest X-ray, rib notching was not seen. Magnetic Resonance Imaging showed about 7 mm long CoA distal to the origin of left common carotid artery. Reconstruction images of distal arch and descending thoracic aorta showed origin of both the SCAs from CoA segment. Transthoracic echocardiography showed 1.3 cm atrial septal defect (ASD), left to right shunt, moderately severe mitral regurgitation (MR), dilated RV, and severe pulmonary artery hypertension (PH). During cardiac catheterization, the peak gradient across CoA was 60 mmHg. On aortic-root angiography, both the common carotids and the distal arch opacified simultaneously, the CoA segment and the distal aorta opacified a little later. Both the SCAs were filling retrograde. A unique anatomy in which aortic-clamping proximal to CoA and both the SCAs would increase flow to spinal-cord as clamping of the SCAs will stop stealing of blood into the CoA but potentially increase LV afterload, MR, left to right shunt across ASD and RV volume and pressure load depending on the magnitude of flow across the CoA. The increases in LV afterload, MR, and RV afterload and volume overload were managed by controlled phlebotomy and fine-tuned by manipulating inhaled isoflurane concentration whereas the Transesophageal echocardiography (TEE) monitored and guided the management.
is a water-soluble, phosphono-O-methyl prodrug of propofol for intravenous (i.v.) injection. It h... more is a water-soluble, phosphono-O-methyl prodrug of propofol for intravenous (i.v.) injection. It has been evaluated for sedation during diagnostic and routine therapeutic procedures. The early evaluation studies were published mostly in Anesthesiology between 2003 and 2005.
Journal of Cardiothoracic and Vascular Anesthesia, Apr 1, 2012
s b a THE SIMULTANEOUS PRESENCE of an aneurysmal main pulmonary artery (MPA) and left pulmonary a... more s b a THE SIMULTANEOUS PRESENCE of an aneurysmal main pulmonary artery (MPA) and left pulmonary artery (LPA), severe right pulmonary artery (RPA) stenosis, and severe pulmonary artery hypertension (PAH) is rare. The aneurysmally dilated and tense MPA can compress the left main coronary artery (LMCA),1-3 whereas a dilated tense LPA can ompress the left main bronchus.4-7 In such a clinical scenario, the consequences of compromise of the LMCA flow and left lung ventilation can be catastrophic. Perioperative issues in a child with severe pulmonary hypertension who presented for MPA and RPA plasty and atrial septal defect (ASD) closure are discussed.
Cardiopulmonary bypass is known to elicit systemic inflammatory response syndrome and organ dysfu... more Cardiopulmonary bypass is known to elicit systemic inflammatory response syndrome and organ dysfunction. This can result in pulmonary dysfunction and deterioration of oxygenation after cardiac surgery and cardiopulmonary bypass. Previous studies have reported varying results on anti-inflammatory strategies and oxygenation after cardiopulmonary bypass. Ketamine administered as a single dose at induction has been shown to reduce the pro-inflammatory serum markers in patients undergoing cardiopulmonary bypass. Therefore we investigated if ketamine can result in better oxygenation in these patients. This was a prospective randomized blinded study. Eighty consecutive adult patients undergoing elective coronary artery bypass grafting under cardiopulmonary bypass were included in the study. Patients were divided into two groups. Patients in ketamine group received 1mg/kg of ketamine intravenously at induction of anesthesia. Control group patients received an equal volume of saline. All patients received standard anesthesia, operative and postoperative care.Paired t test and independent sample t test were used to compare the inter-group and between group oxygenation indices respectively. Oxygenation index and duration of ventilation were analyzed. Deterioration of oxygenation index was noted in both the groups after cardiopulmonary bypass. However, there was no significant difference in the oxygenation index at various time points after cardiopulmonary bypass or the duration of ventilation between the two groups. This study shows that the administered as a single dose at induction does not result in better oxygenation after cardiopulmonary bypass.
Background: Fresh gas flow (FGF) during volatile inhalational agent-based anesthesia is a concern... more Background: Fresh gas flow (FGF) during volatile inhalational agent-based anesthesia is a concern for many reasons. Advancement in anesthesia workstation (WS) and monitoring of anesthesia gas concentrations has led to the feasibility of lower flow safely. However, the practice pattern is not yet well known. The information can help us in better protocol formation. Aim: The survey was aimed to know the prevailing practice pattern of FGF and volatile agent choices and compare them among anesthesiologists of different working setups and experiences. Materials and Methods: With approval, the present cross-sectional survey was conducted using SurveyMonkey® software from January 2018 to May 2018. Anesthesiologists working in different organizations across India were approached through E-mail and WhatsApp. Anonymous responses were collected, expressed in number and percentage scale, as well as compared using INSTAT software and appropriate tests; P < 0.05 was considered statistically significant. Results: A total of 251 (15.2%) responses were received and 249 were analyzed. Overall, 87% of respondents were using anesthesia WS and 71% were using nitrous oxide as balance gas. The FGF of <600 mL/min was highest with desflurane. Minimum alveolar concentration (MAC) monitoring was very poor in nonteaching (NT) hospitals as compared to teaching hospitals; P < 0.0001. The Boyle's machine was more common in use in NT hospitals as compared to medical colleges and corporate hospitals; P < 0.0001. Conclusion: Low-flow anesthesia (LFA) use is still suboptimal, and there are ample opportunities to increase and optimize the FGF used. The use of Boyle's machine is associated with higher flow use. MAC monitoring and LFA use are poor in NTs.
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