Background Many elderly hypertensive patients are on cardio/reno protective medications (ACEIs, A... more Background Many elderly hypertensive patients are on cardio/reno protective medications (ACEIs, ARBs, β blockers & K sparing diuretics), which may precipitate or worsen hyperkalemia in them. Given its potential life threatening nature, identifying such patients is imperative. Rarely emergency temporary cardiac pacing may be required to thwart cardiac arrest while K is being lowered by extracorporeal removal. In many resource-constrained settings HD to lower K quickly is not always available. Materials and Methods We describe the profile of 26 patients over a three year period who besides medications & dialysis needed temporary cardiac pacing because of severe hyperkalemia. Results: The mean age of these 26 patients (17 males, 9 females) was 64+/-11 years. 12 (46%) had diabetes mellitus. On admission, the mean serum K was 6.7 ± 1.4 mmol/L, mean serum creatinine was 2.8 ± 1.6 mg/dL, mean arterial pH was 7.1 ± 0.5 and the mean plasma bicarbonate was 12 ± 4 mmol/L. The main causes for acute kidney injury (AKI) and hyperkalemia were dehydration (n = 14) and worsening heart failure (n = 7) with concomitant use of ACEIs, ARBs, β blockers, K sparing diuretics either alone or in combination. 22 patients received PD, two HD, while two received both. Six patients were admitted to the ICU, two of whom died. The duration of hospitalization ranged from 1-12 with a mean of 7 days. The patients in the drug induced hyperkalemia group who required pacing were elderly, had been on a combination of K elevating medications, were more likely to have DM and had a longer hospital stay compared to those who had hyperkalemia but did not require cardiac pacing. Conclusion: A combination of ACEIs, ARBs, β blockers & K sparing diuretics should be used with caution in patients who are elderly, have renal insufficiency, DM or heart failure or are at risk for dehydration. In places with limited availability of emergency HD, PD is an effective alternative for lowering serum K.
Immune check point inhibitors (ICPIs) are a new class of anti-neoplastic agents being increasingl... more Immune check point inhibitors (ICPIs) are a new class of anti-neoplastic agents being increasingly used by oncologists to treat various malignancies. These drugs have been associated with varied side effects and have a nephrotoxic potential. Many cases of ICPI induced acute kidney injury are increasingly being reported. Their use in CKD patients on dialysis as well as in kidney transplant recipients is associated with various challenges. This review discusses the use of ICPIs in CKD, dialysis and renal transplant patients and their nephrotoxic potential
Purpose: Percutaneous nephrolithotomy (PCNL) is the procedure of choice for treating large renal ... more Purpose: Percutaneous nephrolithotomy (PCNL) is the procedure of choice for treating large renal stones. Pneumatic lithotripsy (Lithoclast Ⓡ) is effective regardless of the stones' composition, and ultrasonic lithotripsy allows the aspiration of small debris during lithotripsy. We investigated the efficacy and safety of PCNL via Lithoclast Ⓡ alone or combined with ultrasonic lithotripsy. Materials and Methods: Thirty-five (group A) and 39 (group B) patients underwent Lithoclast Ⓡ PCNL and combination therapy, respectively, from May 2001 to March 2010, and the two groups were compared in terms of stone size, location, and composition; operative time; average number of treatments; hospital days; hemoglobin loss; ancillary procedures; rate of device failure; and initial and total stone-free rates. Results: The two groups did not differ significantly in preoperative stone size, location, or composition; the average number of treatments; or the initial and overall stone-free rates. However, combination therapy was associated with a significantly lower operative time (181±50 vs. 221±65 min, respectively, p=0.004), number of hospital days (11.6±3.8 vs. 14.2±4.4 days, respectively, p=0.009), and average hemoglobin loss (1.12±0.61 vs. 1.39±1.02 g/dl, respectively, p=0.013). Transfusions were required in 6 patients (4 and 2 in each group, respectively), but there were no significant complications related to percutaneous access. There were 2 (5.7%) mechanical failures (Lithoclast Ⓡ probe fracture) in the group A and 5 (12.8%) in the group B (2 cases of suction tube obstruction, 3 cases of overheating). Conclusions: The combination of ultrasonic lithotripter and Lithoclast Ⓡ is more effective than Lithoclast Ⓡ alone because it significantly decreases operative time, hemoglobin loss, and the hospital stay. This may reflect the superior power of Lithoclast Ⓡ and the ability to aspirate the debris during ultrasonic lithotripsy.
The Palonosetron 04-07 Study Group BACKGROUND: We designed this multicenter, randomized, double-b... more The Palonosetron 04-07 Study Group BACKGROUND: We designed this multicenter, randomized, double-blind study to assess the efficacy and safety of three doses of palonosetron, compared with placebo, on the incidence and severity of postoperative nausea and vomiting (PONV) in inpatients for 72 h after surgery. METHODS: Female patients undergoing either elective gynecological or breast surgery were stratified according to two additional PONV risk factors: nonsmoking status and history of PONV and/or motion sickness. Five hundred forty-four patients with one or both of these risk factors were randomized to receive one of the three doses of IV palonosetron (0.025 mg, 0.050 mg, 0.075 mg) or placebo immediately before induction of anesthesia. The primary efficacy end-point was complete response (CR: no emesis and no use of rescue medications) evaluated at the 0-24 and 24-72 h time intervals after surgery. RESULTS: CR rates for placebo and palonosetron 0.075 mg were 36% and 56% for 0-24 h (P ϭ 0.001), 52% and 70% for 24-72 h (P ϭ 0.002) and 36% and 52% (P ϭ 0.010) for the 0-72 h postoperative interval. Palonosetron 0.075 mg was associated with less intense nausea (e.g., toward "mild" or "none") versus placebo during the 0-24 h (P Ͻ 0.001) time interval and significantly delayed median time to emesis (P ϭ 0.002) and treatment failure (P ϭ 0.004). Although CR rates for both the 0.025 mg and 0.050 mg palonosetron doses were not statistically superior to placebo for the 0-24 h or 24-72 h periods, both lower doses reduced nausea severity during the 0-24 h period (P ϭ 0.040 and P ϭ 0.004). CONCLUSION: A single 0.075-mg IV dose of palonosetron effectively reduced the severity of nausea and delayed the time to emesis and treatment failure in the inpatient surgical setting; lower doses were not as effective.
endotracheal intubation and single shot caudal epidural. The child was premedicated with 5 mg of ... more endotracheal intubation and single shot caudal epidural. The child was premedicated with 5 mg of oral midazolam 1 hour prior to induction. After establishing basic monitoring-Electrocardiography (EKG), pulse oximetry and noninvasive blood pressure, inhalational induction with 5% sevoflurane was initiated followed by establishment of intravenous (IV) access with 22G cannula. Rocuronium 6 mg with fentanyl 20 mcg was given to facilitate endotracheal intubation. Endotracheal intubation with size 4.5 uncuffed PVC ETT (Euromedical, single use) was accomplished without difficulty. Correct placement of ETT was confirmed by end-tidal CO 2 trace and auscultation. Chest auscultation revealed bilateral but diminished breath sounds and a high resistance was felt at the first manual ventilation. ETT marking at the incisors remained same at 13 cm. The patient was connected to the anesthesia machine, on pressure control mode at an inspiratory pressure of 13 cm H 2 O and a frequency of 20 breaths/minute. The 13 cm H 2 O pressure generated only 30 mL of tidal volume and end-tidal CO 2 showed an obstructive pattern. There was little chest movement during positive pressure ventilation with no gastric insufflation. Breath sounds were equal but distant. An 8 Fr suction catheter was introduced down the lumen of ETT with resistance. No secretions could be suctioned. Two puffs of aerosolized salbutamol were delivered through ETT for assumed bronchospasm, with no improvement. Oxygenation was maintained at 100% with higher ventilatory pressure. The patient was
The aim of the study was to compare the effect of mannitol (M) and hypertonic saline (HTS) on bra... more The aim of the study was to compare the effect of mannitol (M) and hypertonic saline (HTS) on brain relaxation and electrolyte balance. Prospective, randomized, double-blind study. A total of 114 patients with American Society of Anesthesiologists status II and III, scheduled to undergo craniotomy for supratentorial brain tumor resection were enrolled. Patients received 5 ml/kg 20% mannitol (n = 56) or 3% HTS (n = 58) at the start of scalp incision. Hemodynamics, fluid balance and electrolytes, were measured at 0, 15, 30, and 60 min and 6 h after infusion. Intensive Care Unit (ICU) stay between the two groups was also recorded. The surgeon assessed brain relaxation on a four-point scale (1 = Relaxed, 2 = Satisfactory, 3 = Firm, 4 = Bulging). Appropriate statistical tests were used for comparison; P < 0.05 was considered significant. Brain relaxation conditions in the HTS group (relaxed/satisfactory/firm/bulging, n = 28/20/5/3) were better than those observed in the M group (relaxed/satisfactory/firm/bulging, n = 17/21/11/9). The levels of serum sodium were higher in the HTS group (P < 0.001). The average urine output was higher in the M group (5.50 ± 0.75 L) than in the HTS group (4.38 ± 0.72 L) (P < 0.005). There was no significant difference in fluid input, ICU stay, and hospital days between the two groups. We concluded that HTS provided better brain relaxation than mannitol during elective supratentorial brain tumor surgery, without affecting ICU and hospital stay.
International journal of contemporary medical research, Mar 1, 2019
Introduction: Organophosphorus compounds are widely used as insecticides. Organophosphorus poison... more Introduction: Organophosphorus compounds are widely used as insecticides. Organophosphorus poisoning has a significant morbidity and mortality and is a common occurrence due to their easy accessibility. Study aimed to assess clinicoepidemiological profile of organophosphorus poisoning. Material and methods: Our study was a hospital based prospective study conducted over a period of two years involving all the patients of organophosphorus (OP) poisoning, admitted in the medical emergency of the hospital. These patients were evaluated for demographic and clinical profile and followed till the time of discharge or death. Results: 102 cases of OP poisoning were admitted, majority belonged to the age group of 15-25 years (54.9%) and were of rural origin (84.3%). Females (67.64%) outnumbered males. 97 cases had taken it with suicidal intent. Miosis was the most consistent clinical feature (93.13%). 64 patients (62.7%) needed admission in ICU. Respiratory failure was the most common complication. Mortality rate of 14.7% was observed. Conclusion: OP compounds are ingested mostly with suicidal intent due to their easy availability mostly by young and productive population. Initial management and resuscitation in periphery is invaluable.
Central venous catheterization (CVC) is a commonly performed intraoperative procedure. Traditiona... more Central venous catheterization (CVC) is a commonly performed intraoperative procedure. Traditionally, CVC placement is performed blindly using anatomic landmarks as a guide to vessel position. Real-time ultrasound provides the operator the benefit of visualizing the target vein and the surrounding anatomic structures prior to and during the catheter insertion, thereby minimizing complications and increasing speed of placement. A 22-year-old male underwent open reduction and internal fixation of acetabulum fracture in prone position. Excessive continuous bleeding intraoperatively warranted placement of CVC in right internal jugular vein (IJV), which was not possible in prone position without the help of ultrasound. Best view of right IJV was obtained and CVC was placed using real-time ultrasound without complications. Ultrasound-guided CVC placement can be done in atypical patient positions where traditional anatomic landmark technique has no role. Use of ultrasound not only increases the speed of placement but also reduces complications known with the traditional blind technique.
Background:Pediatric infraumbilical surgeries are often performed under general anaesthesia using... more Background:Pediatric infraumbilical surgeries are often performed under general anaesthesia using different modes of ventilation through Laryngeal Mask Airway .Although controlled ventilation has been successfully used, very less studies have been done to compare them with spontaneous ventilation for short duration surgeries.Aims:We tried to measure quantitave differences in haemodynamic and respiratory parameters and assess the recovery profile between controlled and spontaneous ventilation using Proseal LMA.Settings and Design:This was a prospective, randomized, double-blind study that comprised 90 American Society of Anaesthesiologist (ASA) classes I and II pediatric patients posted for infra umbilical surgery.Materials and Methods:90 paediatric patients undergoing infraumbilical surgeries were included. Three different ventilation strategies: spontaneous , pressure support and pressure-controlled ventilation were applied depending on attending anaesthesiologist's preference. Haemodynamic and respiratory parameters were recorded during the procedure. Post procedure parameters including need for supplementary oxygen, recovery time, complications were recorded.Statistical Methods:Analysis of variance (ANOVA) was employed for inter group analysis and for multiple comparisons, least significant difference (LSD) test was applied. Chi-square test or Fisher's exact test, whichever appropriate, was used for comparison of categorical variables.Results:The mean time interval between end of surgery and removal of LMA was significantly higher in PCV group in comparison to SV and PSV groups. In SV group lesser number of patients required oxygen supplementation and had shorter stay in recovery than PCV group.Conclusion:We conclude that spontaneous mode of ventilation can be used as safely as controlled /assist ventilation mode in short duration surgeries in high turn over settings.
Pain is a common complaint after surgery and seems to be difficult to manage in children because ... more Pain is a common complaint after surgery and seems to be difficult to manage in children because of fear of complications of pain treatment or misconception that infants and small children do not feel pain at all or feel less pain. Physicians often prescribe insufficiently potent analgesics, recommend inadequate doses, or use pharmacologically irrational dosing regimens because of their overriding concern that children may be harmed by the use of these drugs. Realistic aims are to recognize pain in children, minimize moderate and severe pain safely in all children, prevent pain where it is predictable, and bring pain rapidly under control. John Bonica tirelessly pioneered the development of multidisciplinary concept of pain research and treatment from the Second World War until his death in 1994. [1] A major problem in treating pain in children is associated with difficulty in assessment. [2] Generally, two types of assessment Background: Pain is a common complaint after surgery and seems to be difficult to manage in children because of fear of complications of pain treatment or misconception that infants and small children do not feel pain at all or feel less pain. A survey reported that 40% of pediatric surgical patients experienced moderate or severe postoperative pain and that more than 75% had insufficient analgesia. Our study was carried to provide continuous infusion of intravenous (i.v.) tramadol alone using a dedicated infusion device Graseby 2100 syringe pump and compared it to a combination of i.v. tramadol infusion and per rectal paracetamol. Subjects and Methods: A total of 124 children aged 1-8 years selected for the study were randomized into two groups using a table of random numbers. Power calculation had suggested a sample size of 62 in each group with a power of 80% and significance level of 5%. Group A comprising 62 children, received i.v. infusion of tramadol in a dose of 0.25 mg/kg/h for 24 h postoperatively. Group B comprising 62 children, received i.v. infusion of tramadol in a dose of 0.25 mg/kg/h for 24 h postoperatively in addition to per rectal suppository of paracetamol in a dose of 90 mg/kg in 24 h (30 mg/kg as first dose followed by 20 mg/kg every 6 hourly for the next 18 h). Postoperatively, patients were observed for 24 h. Results: A statistically significant difference (P ≤ 0.001) in Face, Legs, Activity, Cry, Consolability pain scores was seen between two groups at 4, 6, and 8 h. Pain scores being less in Group B patients who had received infusion of tramadol and per rectal suppositories of paracetamol compared to Group A patients who received only infusion of tramadol. A statistically significant difference (P < 0.05) was found in mean analgesic consumption during the first 24 h between the groups. Consumption was more in Group A as compared to Group B. In Group A, 13 patients (21%) required rescue analgesia as compared to only 4 patients (6.5%) in Group B. Conclusion: We recommend use of an infusion of tramadol in a dose of 0.25 mg/kg/h in the first 24 h after surgery, in combination with a regular per rectal paracetamol in a daily dose of 90 mg/kg/day in four divided doses for children after major abdominal surgery. However, a close nursing supervision is essential to increase the safety profile.
Abstract Background: Nephron sparing surgery is a well-established surgical procedure for patient... more Abstract Background: Nephron sparing surgery is a well-established surgical procedure for patients with small/bilateral renal masses. During the procedure, hilar control can be achieved by using bulldog clamps individually on the renal vessels, the renal artery alone without clamping the vein, or a laparoscopic Satinsky clamp for en bloc hilar clamping. In our series, we described the outcome of laparoscopic nephron sparing surgery using a Satinsky clamp for hilar control. Materials and methods: All eligible cases with confirmed diagnosis of a renal mass were advised of nephron sparing surgery. The short-term outcomes were evaluated by warm ischemia time (using a Satinsky clamp especially when CT renal angiography was not available), average blood loss, and length of postoperative hospital stay. The oncological outcome was evaluated by noting the surgical margins of histopathological specimen, local recurrence, and distant metastasis. Results: Of 30 cases 20 were male. The mean age was 54.25 years. On preoperative evaluation, 24 cases were T1a stage and the rest were 6 T1b stage. Four tumors were located in the upper pole, 4 in the posterior midpole, and 22 in the lower pole. Twenty-six patients had a low complexity score on RENAL scoring (ie, 4–6) and 4 patients a medium complexity score (ie, 7–9). Three patients were converted to open partial nephrectomy because of technical difficulty in intracorporeal suturing and difficulty in achieving hemostasis. Among these 3 patients, 2 patients had posterior base tumors and 1 had a lower polar tumor. Average blood loss was 350 ml, warm ischemia time was 28.46 minutes, and postoperative stay was 4.55 days. Of 30 specimens for histopathology, 23 (76%) were clear cell renal cell carcinoma (RCC), 4 (13%) were papillary RCC, 1 (3.3%) was chromophobe RCC, whereas 2 (6.6%) were benign (oncocytoma). Margins were free of tumors in all the patients with no recurrence in 2 years of follow-up. Conclusion: Laparoscopic partial nephrectomy by using a Satinsky clamp as a tool for en bloc hilar clamping in the proper axis at the hilum takes care of multiple vessels irrespective of size and number, particularly when renal angiography is not available. This technique of en bloc hilar clamping is quite useful especially in developing countries where robotic facilities are not available. The Satinsky clamp decreases blood loss and intraoperative time.
Neuromonitoring aims to detect harmful physiologic events, early enough to guide the treatment in... more Neuromonitoring aims to detect harmful physiologic events, early enough to guide the treatment instituted. Evidences encourage us to implement multimodal monitoring, as no single monitor is capable of providing a complete picture of dynamic cerebral state. This review highlights the role of intracranial pressure monitoring, cerebral oxygenation (jugular venous oximetry, brain tissue oxygenation, near infrared oximetry, cerebral microdialysis) and cerebral blood fl ow monitoring (direct and indirect methods) in the management of neurologically injured patients. In this context, the recent developments of these monitors along with the relevant clinical implications have been discussed. Nevertheless, the diverse range of data obtained from these monitors needs to be integrated and simplifi ed for the clinician. Hence, the future research should focus on identifi cation of a most useful monitor for integration into multimodal system.
Purpose The Metabolic equivalent of task (MET) score is used in patients’ preoperative functional... more Purpose The Metabolic equivalent of task (MET) score is used in patients’ preoperative functional capacity assessment. It is commonly thought that patients with a higher MET score will have better postoperative outcomes than patients with a lower MET score. However, such a link remains the subject of debate and is yet unvalidated in major urological surgery. This study aimed to explore the association of patients’ MET score with their postoperative outcomes following radical cystectomy. Methods We used records-linkage methodology with unique identifiers (Community Health Index/hospital number) and electronic databases to assess postoperative outcomes of patients who had underwent radical cystectomies between 2015 and 2020. The outcome measure was patients’ length of hospital stay. This was compared with multiple basic characteristics such as age, sex, MET score and comorbid conditions. A MET score of less than four (
Introduction: Patients undergoing urological procedures under spinal anaesthesia are usually elde... more Introduction: Patients undergoing urological procedures under spinal anaesthesia are usually elderly having comorbid conditions. Dexmedetomidine, the new highly selective α-2 agonists is being used as an adjuvant in spinal anaesthesia with improved quality of anaesthesia and analgesia and minimal side effects. The present study was designed to evaluate the effect of intrathecal dexmedetomidine to bupivacaine in spinal anesthesia for urological procedures. Material and Methods: Sixty patients of ASA class I and II were randomly divided into two groups of thirty patients each. The control group received hyperbaric bupivacaine 15 mg + 0.5 ml normal saline (3.5 ml).The study group received hyperbaric bupivacaine 15 mg +10 mcg dexmedetomidine diluted in 0.5 ml normal saline (3.5ml). Results: The time taken to reach the highest sensory level was 8.5 ± 0.5 minutes in control group while 6.2 ± 0.4 minutes in study group. The mean time to reach the bromage 3 was 10.1 ± 2.9 minutes in control...
Background and Aims: This prospective, randomized, double blind study was undertaken to establish... more Background and Aims: This prospective, randomized, double blind study was undertaken to establish the effect of addition of fentanyl or dexmedetomidine, as an adjunct to epidural bupivacaine in lower abdominal surgeries. Materials and Methods: Ninety ASA (American Society of Anesthesiologists) class I and II patients undergoing lower abdominal surgeries were enrolled to receive either saline (Group BS) or fentanyl (Group BF) or dexmedetomidine (Group BD) along with epidural bupivacaine for surgical anesthesia. All the study subjects received an epidural anesthesia with 20 ml of 0.5% bupivacaine along with either saline 2ml (Group BS) or fentanyl 1mcg/kg (Group BF) or dexmedetomidine 1.0 μg/kg (Group BD). The onset of motor and sensory block, duration of block, hemodynamic parameters, and adverse events were monitored. Results: Analgesia in the postoperative period was better in Group BD, together with duration of sensory and motor blockade.However incidence of sedation was more in t...
Background: Organophosphorus poisoning (OPP) is a major global public health problem. Pralidoxime... more Background: Organophosphorus poisoning (OPP) is a major global public health problem. Pralidoxime has been used in a complimentary role to atropine for the management of OPP. World Health Organization (WHO) recommends use of pralidoxime but studies regarding its role have been inconclusive, ranging from being ineffective to harmful or beneficial. Materials and Methods: The present study was undertaken to evaluate the effectiveness of pralidoxime. Eddleston's study was the most compelling factor for our study, as he showed worst outcomes using pralidoxime. Our practice of continuous use of pralidoxime was based on the WHO guidelines and the study by Pawar (2006), which showed better outcome with higher doses of pralidoxime. These conflicting results suggested that a re-evaluation of its use in our clinical practice was indicated. Results: There was no difference in mortality rates, hemodynamic parameters and atropine requirements between the AP and A groups. Mean duration of ventilation (3.6 ± 4.6 in AP group vs. 3.6 ± 4.4 in A group) and Intensive Care Unit stay (7.1 ± 5.4 in AP group vs. 6.8 ± 4.7 in A group) was comparable. Serum sodium concentrations showed a correlation with mortality, with lower concentrations associated with better outcomes. Conclusion: The study suggests that add-on WHO-recommended pralidoxime therapy does not provide any benefit over atropine monotherapy. Adding pralidoxime does not seem to be beneficial and at the same time does not result in increased mortality rates. Our practice changed after completion of this study, and it has proven to be of significant benefit to patients who had to bear the expense of treatment.
Background Many elderly hypertensive patients are on cardio/reno protective medications (ACEIs, A... more Background Many elderly hypertensive patients are on cardio/reno protective medications (ACEIs, ARBs, β blockers & K sparing diuretics), which may precipitate or worsen hyperkalemia in them. Given its potential life threatening nature, identifying such patients is imperative. Rarely emergency temporary cardiac pacing may be required to thwart cardiac arrest while K is being lowered by extracorporeal removal. In many resource-constrained settings HD to lower K quickly is not always available. Materials and Methods We describe the profile of 26 patients over a three year period who besides medications & dialysis needed temporary cardiac pacing because of severe hyperkalemia. Results: The mean age of these 26 patients (17 males, 9 females) was 64+/-11 years. 12 (46%) had diabetes mellitus. On admission, the mean serum K was 6.7 ± 1.4 mmol/L, mean serum creatinine was 2.8 ± 1.6 mg/dL, mean arterial pH was 7.1 ± 0.5 and the mean plasma bicarbonate was 12 ± 4 mmol/L. The main causes for acute kidney injury (AKI) and hyperkalemia were dehydration (n = 14) and worsening heart failure (n = 7) with concomitant use of ACEIs, ARBs, β blockers, K sparing diuretics either alone or in combination. 22 patients received PD, two HD, while two received both. Six patients were admitted to the ICU, two of whom died. The duration of hospitalization ranged from 1-12 with a mean of 7 days. The patients in the drug induced hyperkalemia group who required pacing were elderly, had been on a combination of K elevating medications, were more likely to have DM and had a longer hospital stay compared to those who had hyperkalemia but did not require cardiac pacing. Conclusion: A combination of ACEIs, ARBs, β blockers & K sparing diuretics should be used with caution in patients who are elderly, have renal insufficiency, DM or heart failure or are at risk for dehydration. In places with limited availability of emergency HD, PD is an effective alternative for lowering serum K.
Immune check point inhibitors (ICPIs) are a new class of anti-neoplastic agents being increasingl... more Immune check point inhibitors (ICPIs) are a new class of anti-neoplastic agents being increasingly used by oncologists to treat various malignancies. These drugs have been associated with varied side effects and have a nephrotoxic potential. Many cases of ICPI induced acute kidney injury are increasingly being reported. Their use in CKD patients on dialysis as well as in kidney transplant recipients is associated with various challenges. This review discusses the use of ICPIs in CKD, dialysis and renal transplant patients and their nephrotoxic potential
Purpose: Percutaneous nephrolithotomy (PCNL) is the procedure of choice for treating large renal ... more Purpose: Percutaneous nephrolithotomy (PCNL) is the procedure of choice for treating large renal stones. Pneumatic lithotripsy (Lithoclast Ⓡ) is effective regardless of the stones' composition, and ultrasonic lithotripsy allows the aspiration of small debris during lithotripsy. We investigated the efficacy and safety of PCNL via Lithoclast Ⓡ alone or combined with ultrasonic lithotripsy. Materials and Methods: Thirty-five (group A) and 39 (group B) patients underwent Lithoclast Ⓡ PCNL and combination therapy, respectively, from May 2001 to March 2010, and the two groups were compared in terms of stone size, location, and composition; operative time; average number of treatments; hospital days; hemoglobin loss; ancillary procedures; rate of device failure; and initial and total stone-free rates. Results: The two groups did not differ significantly in preoperative stone size, location, or composition; the average number of treatments; or the initial and overall stone-free rates. However, combination therapy was associated with a significantly lower operative time (181±50 vs. 221±65 min, respectively, p=0.004), number of hospital days (11.6±3.8 vs. 14.2±4.4 days, respectively, p=0.009), and average hemoglobin loss (1.12±0.61 vs. 1.39±1.02 g/dl, respectively, p=0.013). Transfusions were required in 6 patients (4 and 2 in each group, respectively), but there were no significant complications related to percutaneous access. There were 2 (5.7%) mechanical failures (Lithoclast Ⓡ probe fracture) in the group A and 5 (12.8%) in the group B (2 cases of suction tube obstruction, 3 cases of overheating). Conclusions: The combination of ultrasonic lithotripter and Lithoclast Ⓡ is more effective than Lithoclast Ⓡ alone because it significantly decreases operative time, hemoglobin loss, and the hospital stay. This may reflect the superior power of Lithoclast Ⓡ and the ability to aspirate the debris during ultrasonic lithotripsy.
The Palonosetron 04-07 Study Group BACKGROUND: We designed this multicenter, randomized, double-b... more The Palonosetron 04-07 Study Group BACKGROUND: We designed this multicenter, randomized, double-blind study to assess the efficacy and safety of three doses of palonosetron, compared with placebo, on the incidence and severity of postoperative nausea and vomiting (PONV) in inpatients for 72 h after surgery. METHODS: Female patients undergoing either elective gynecological or breast surgery were stratified according to two additional PONV risk factors: nonsmoking status and history of PONV and/or motion sickness. Five hundred forty-four patients with one or both of these risk factors were randomized to receive one of the three doses of IV palonosetron (0.025 mg, 0.050 mg, 0.075 mg) or placebo immediately before induction of anesthesia. The primary efficacy end-point was complete response (CR: no emesis and no use of rescue medications) evaluated at the 0-24 and 24-72 h time intervals after surgery. RESULTS: CR rates for placebo and palonosetron 0.075 mg were 36% and 56% for 0-24 h (P ϭ 0.001), 52% and 70% for 24-72 h (P ϭ 0.002) and 36% and 52% (P ϭ 0.010) for the 0-72 h postoperative interval. Palonosetron 0.075 mg was associated with less intense nausea (e.g., toward "mild" or "none") versus placebo during the 0-24 h (P Ͻ 0.001) time interval and significantly delayed median time to emesis (P ϭ 0.002) and treatment failure (P ϭ 0.004). Although CR rates for both the 0.025 mg and 0.050 mg palonosetron doses were not statistically superior to placebo for the 0-24 h or 24-72 h periods, both lower doses reduced nausea severity during the 0-24 h period (P ϭ 0.040 and P ϭ 0.004). CONCLUSION: A single 0.075-mg IV dose of palonosetron effectively reduced the severity of nausea and delayed the time to emesis and treatment failure in the inpatient surgical setting; lower doses were not as effective.
endotracheal intubation and single shot caudal epidural. The child was premedicated with 5 mg of ... more endotracheal intubation and single shot caudal epidural. The child was premedicated with 5 mg of oral midazolam 1 hour prior to induction. After establishing basic monitoring-Electrocardiography (EKG), pulse oximetry and noninvasive blood pressure, inhalational induction with 5% sevoflurane was initiated followed by establishment of intravenous (IV) access with 22G cannula. Rocuronium 6 mg with fentanyl 20 mcg was given to facilitate endotracheal intubation. Endotracheal intubation with size 4.5 uncuffed PVC ETT (Euromedical, single use) was accomplished without difficulty. Correct placement of ETT was confirmed by end-tidal CO 2 trace and auscultation. Chest auscultation revealed bilateral but diminished breath sounds and a high resistance was felt at the first manual ventilation. ETT marking at the incisors remained same at 13 cm. The patient was connected to the anesthesia machine, on pressure control mode at an inspiratory pressure of 13 cm H 2 O and a frequency of 20 breaths/minute. The 13 cm H 2 O pressure generated only 30 mL of tidal volume and end-tidal CO 2 showed an obstructive pattern. There was little chest movement during positive pressure ventilation with no gastric insufflation. Breath sounds were equal but distant. An 8 Fr suction catheter was introduced down the lumen of ETT with resistance. No secretions could be suctioned. Two puffs of aerosolized salbutamol were delivered through ETT for assumed bronchospasm, with no improvement. Oxygenation was maintained at 100% with higher ventilatory pressure. The patient was
The aim of the study was to compare the effect of mannitol (M) and hypertonic saline (HTS) on bra... more The aim of the study was to compare the effect of mannitol (M) and hypertonic saline (HTS) on brain relaxation and electrolyte balance. Prospective, randomized, double-blind study. A total of 114 patients with American Society of Anesthesiologists status II and III, scheduled to undergo craniotomy for supratentorial brain tumor resection were enrolled. Patients received 5 ml/kg 20% mannitol (n = 56) or 3% HTS (n = 58) at the start of scalp incision. Hemodynamics, fluid balance and electrolytes, were measured at 0, 15, 30, and 60 min and 6 h after infusion. Intensive Care Unit (ICU) stay between the two groups was also recorded. The surgeon assessed brain relaxation on a four-point scale (1 = Relaxed, 2 = Satisfactory, 3 = Firm, 4 = Bulging). Appropriate statistical tests were used for comparison; P &amp;amp;amp;amp;amp;amp;lt; 0.05 was considered significant. Brain relaxation conditions in the HTS group (relaxed/satisfactory/firm/bulging, n = 28/20/5/3) were better than those observed in the M group (relaxed/satisfactory/firm/bulging, n = 17/21/11/9). The levels of serum sodium were higher in the HTS group (P &amp;amp;amp;amp;amp;amp;lt; 0.001). The average urine output was higher in the M group (5.50 ± 0.75 L) than in the HTS group (4.38 ± 0.72 L) (P &amp;amp;amp;amp;amp;amp;lt; 0.005). There was no significant difference in fluid input, ICU stay, and hospital days between the two groups. We concluded that HTS provided better brain relaxation than mannitol during elective supratentorial brain tumor surgery, without affecting ICU and hospital stay.
International journal of contemporary medical research, Mar 1, 2019
Introduction: Organophosphorus compounds are widely used as insecticides. Organophosphorus poison... more Introduction: Organophosphorus compounds are widely used as insecticides. Organophosphorus poisoning has a significant morbidity and mortality and is a common occurrence due to their easy accessibility. Study aimed to assess clinicoepidemiological profile of organophosphorus poisoning. Material and methods: Our study was a hospital based prospective study conducted over a period of two years involving all the patients of organophosphorus (OP) poisoning, admitted in the medical emergency of the hospital. These patients were evaluated for demographic and clinical profile and followed till the time of discharge or death. Results: 102 cases of OP poisoning were admitted, majority belonged to the age group of 15-25 years (54.9%) and were of rural origin (84.3%). Females (67.64%) outnumbered males. 97 cases had taken it with suicidal intent. Miosis was the most consistent clinical feature (93.13%). 64 patients (62.7%) needed admission in ICU. Respiratory failure was the most common complication. Mortality rate of 14.7% was observed. Conclusion: OP compounds are ingested mostly with suicidal intent due to their easy availability mostly by young and productive population. Initial management and resuscitation in periphery is invaluable.
Central venous catheterization (CVC) is a commonly performed intraoperative procedure. Traditiona... more Central venous catheterization (CVC) is a commonly performed intraoperative procedure. Traditionally, CVC placement is performed blindly using anatomic landmarks as a guide to vessel position. Real-time ultrasound provides the operator the benefit of visualizing the target vein and the surrounding anatomic structures prior to and during the catheter insertion, thereby minimizing complications and increasing speed of placement. A 22-year-old male underwent open reduction and internal fixation of acetabulum fracture in prone position. Excessive continuous bleeding intraoperatively warranted placement of CVC in right internal jugular vein (IJV), which was not possible in prone position without the help of ultrasound. Best view of right IJV was obtained and CVC was placed using real-time ultrasound without complications. Ultrasound-guided CVC placement can be done in atypical patient positions where traditional anatomic landmark technique has no role. Use of ultrasound not only increases the speed of placement but also reduces complications known with the traditional blind technique.
Background:Pediatric infraumbilical surgeries are often performed under general anaesthesia using... more Background:Pediatric infraumbilical surgeries are often performed under general anaesthesia using different modes of ventilation through Laryngeal Mask Airway .Although controlled ventilation has been successfully used, very less studies have been done to compare them with spontaneous ventilation for short duration surgeries.Aims:We tried to measure quantitave differences in haemodynamic and respiratory parameters and assess the recovery profile between controlled and spontaneous ventilation using Proseal LMA.Settings and Design:This was a prospective, randomized, double-blind study that comprised 90 American Society of Anaesthesiologist (ASA) classes I and II pediatric patients posted for infra umbilical surgery.Materials and Methods:90 paediatric patients undergoing infraumbilical surgeries were included. Three different ventilation strategies: spontaneous , pressure support and pressure-controlled ventilation were applied depending on attending anaesthesiologist's preference. Haemodynamic and respiratory parameters were recorded during the procedure. Post procedure parameters including need for supplementary oxygen, recovery time, complications were recorded.Statistical Methods:Analysis of variance (ANOVA) was employed for inter group analysis and for multiple comparisons, least significant difference (LSD) test was applied. Chi-square test or Fisher's exact test, whichever appropriate, was used for comparison of categorical variables.Results:The mean time interval between end of surgery and removal of LMA was significantly higher in PCV group in comparison to SV and PSV groups. In SV group lesser number of patients required oxygen supplementation and had shorter stay in recovery than PCV group.Conclusion:We conclude that spontaneous mode of ventilation can be used as safely as controlled /assist ventilation mode in short duration surgeries in high turn over settings.
Pain is a common complaint after surgery and seems to be difficult to manage in children because ... more Pain is a common complaint after surgery and seems to be difficult to manage in children because of fear of complications of pain treatment or misconception that infants and small children do not feel pain at all or feel less pain. Physicians often prescribe insufficiently potent analgesics, recommend inadequate doses, or use pharmacologically irrational dosing regimens because of their overriding concern that children may be harmed by the use of these drugs. Realistic aims are to recognize pain in children, minimize moderate and severe pain safely in all children, prevent pain where it is predictable, and bring pain rapidly under control. John Bonica tirelessly pioneered the development of multidisciplinary concept of pain research and treatment from the Second World War until his death in 1994. [1] A major problem in treating pain in children is associated with difficulty in assessment. [2] Generally, two types of assessment Background: Pain is a common complaint after surgery and seems to be difficult to manage in children because of fear of complications of pain treatment or misconception that infants and small children do not feel pain at all or feel less pain. A survey reported that 40% of pediatric surgical patients experienced moderate or severe postoperative pain and that more than 75% had insufficient analgesia. Our study was carried to provide continuous infusion of intravenous (i.v.) tramadol alone using a dedicated infusion device Graseby 2100 syringe pump and compared it to a combination of i.v. tramadol infusion and per rectal paracetamol. Subjects and Methods: A total of 124 children aged 1-8 years selected for the study were randomized into two groups using a table of random numbers. Power calculation had suggested a sample size of 62 in each group with a power of 80% and significance level of 5%. Group A comprising 62 children, received i.v. infusion of tramadol in a dose of 0.25 mg/kg/h for 24 h postoperatively. Group B comprising 62 children, received i.v. infusion of tramadol in a dose of 0.25 mg/kg/h for 24 h postoperatively in addition to per rectal suppository of paracetamol in a dose of 90 mg/kg in 24 h (30 mg/kg as first dose followed by 20 mg/kg every 6 hourly for the next 18 h). Postoperatively, patients were observed for 24 h. Results: A statistically significant difference (P ≤ 0.001) in Face, Legs, Activity, Cry, Consolability pain scores was seen between two groups at 4, 6, and 8 h. Pain scores being less in Group B patients who had received infusion of tramadol and per rectal suppositories of paracetamol compared to Group A patients who received only infusion of tramadol. A statistically significant difference (P < 0.05) was found in mean analgesic consumption during the first 24 h between the groups. Consumption was more in Group A as compared to Group B. In Group A, 13 patients (21%) required rescue analgesia as compared to only 4 patients (6.5%) in Group B. Conclusion: We recommend use of an infusion of tramadol in a dose of 0.25 mg/kg/h in the first 24 h after surgery, in combination with a regular per rectal paracetamol in a daily dose of 90 mg/kg/day in four divided doses for children after major abdominal surgery. However, a close nursing supervision is essential to increase the safety profile.
Abstract Background: Nephron sparing surgery is a well-established surgical procedure for patient... more Abstract Background: Nephron sparing surgery is a well-established surgical procedure for patients with small/bilateral renal masses. During the procedure, hilar control can be achieved by using bulldog clamps individually on the renal vessels, the renal artery alone without clamping the vein, or a laparoscopic Satinsky clamp for en bloc hilar clamping. In our series, we described the outcome of laparoscopic nephron sparing surgery using a Satinsky clamp for hilar control. Materials and methods: All eligible cases with confirmed diagnosis of a renal mass were advised of nephron sparing surgery. The short-term outcomes were evaluated by warm ischemia time (using a Satinsky clamp especially when CT renal angiography was not available), average blood loss, and length of postoperative hospital stay. The oncological outcome was evaluated by noting the surgical margins of histopathological specimen, local recurrence, and distant metastasis. Results: Of 30 cases 20 were male. The mean age was 54.25 years. On preoperative evaluation, 24 cases were T1a stage and the rest were 6 T1b stage. Four tumors were located in the upper pole, 4 in the posterior midpole, and 22 in the lower pole. Twenty-six patients had a low complexity score on RENAL scoring (ie, 4–6) and 4 patients a medium complexity score (ie, 7–9). Three patients were converted to open partial nephrectomy because of technical difficulty in intracorporeal suturing and difficulty in achieving hemostasis. Among these 3 patients, 2 patients had posterior base tumors and 1 had a lower polar tumor. Average blood loss was 350 ml, warm ischemia time was 28.46 minutes, and postoperative stay was 4.55 days. Of 30 specimens for histopathology, 23 (76%) were clear cell renal cell carcinoma (RCC), 4 (13%) were papillary RCC, 1 (3.3%) was chromophobe RCC, whereas 2 (6.6%) were benign (oncocytoma). Margins were free of tumors in all the patients with no recurrence in 2 years of follow-up. Conclusion: Laparoscopic partial nephrectomy by using a Satinsky clamp as a tool for en bloc hilar clamping in the proper axis at the hilum takes care of multiple vessels irrespective of size and number, particularly when renal angiography is not available. This technique of en bloc hilar clamping is quite useful especially in developing countries where robotic facilities are not available. The Satinsky clamp decreases blood loss and intraoperative time.
Neuromonitoring aims to detect harmful physiologic events, early enough to guide the treatment in... more Neuromonitoring aims to detect harmful physiologic events, early enough to guide the treatment instituted. Evidences encourage us to implement multimodal monitoring, as no single monitor is capable of providing a complete picture of dynamic cerebral state. This review highlights the role of intracranial pressure monitoring, cerebral oxygenation (jugular venous oximetry, brain tissue oxygenation, near infrared oximetry, cerebral microdialysis) and cerebral blood fl ow monitoring (direct and indirect methods) in the management of neurologically injured patients. In this context, the recent developments of these monitors along with the relevant clinical implications have been discussed. Nevertheless, the diverse range of data obtained from these monitors needs to be integrated and simplifi ed for the clinician. Hence, the future research should focus on identifi cation of a most useful monitor for integration into multimodal system.
Purpose The Metabolic equivalent of task (MET) score is used in patients’ preoperative functional... more Purpose The Metabolic equivalent of task (MET) score is used in patients’ preoperative functional capacity assessment. It is commonly thought that patients with a higher MET score will have better postoperative outcomes than patients with a lower MET score. However, such a link remains the subject of debate and is yet unvalidated in major urological surgery. This study aimed to explore the association of patients’ MET score with their postoperative outcomes following radical cystectomy. Methods We used records-linkage methodology with unique identifiers (Community Health Index/hospital number) and electronic databases to assess postoperative outcomes of patients who had underwent radical cystectomies between 2015 and 2020. The outcome measure was patients’ length of hospital stay. This was compared with multiple basic characteristics such as age, sex, MET score and comorbid conditions. A MET score of less than four (
Introduction: Patients undergoing urological procedures under spinal anaesthesia are usually elde... more Introduction: Patients undergoing urological procedures under spinal anaesthesia are usually elderly having comorbid conditions. Dexmedetomidine, the new highly selective α-2 agonists is being used as an adjuvant in spinal anaesthesia with improved quality of anaesthesia and analgesia and minimal side effects. The present study was designed to evaluate the effect of intrathecal dexmedetomidine to bupivacaine in spinal anesthesia for urological procedures. Material and Methods: Sixty patients of ASA class I and II were randomly divided into two groups of thirty patients each. The control group received hyperbaric bupivacaine 15 mg + 0.5 ml normal saline (3.5 ml).The study group received hyperbaric bupivacaine 15 mg +10 mcg dexmedetomidine diluted in 0.5 ml normal saline (3.5ml). Results: The time taken to reach the highest sensory level was 8.5 ± 0.5 minutes in control group while 6.2 ± 0.4 minutes in study group. The mean time to reach the bromage 3 was 10.1 ± 2.9 minutes in control...
Background and Aims: This prospective, randomized, double blind study was undertaken to establish... more Background and Aims: This prospective, randomized, double blind study was undertaken to establish the effect of addition of fentanyl or dexmedetomidine, as an adjunct to epidural bupivacaine in lower abdominal surgeries. Materials and Methods: Ninety ASA (American Society of Anesthesiologists) class I and II patients undergoing lower abdominal surgeries were enrolled to receive either saline (Group BS) or fentanyl (Group BF) or dexmedetomidine (Group BD) along with epidural bupivacaine for surgical anesthesia. All the study subjects received an epidural anesthesia with 20 ml of 0.5% bupivacaine along with either saline 2ml (Group BS) or fentanyl 1mcg/kg (Group BF) or dexmedetomidine 1.0 μg/kg (Group BD). The onset of motor and sensory block, duration of block, hemodynamic parameters, and adverse events were monitored. Results: Analgesia in the postoperative period was better in Group BD, together with duration of sensory and motor blockade.However incidence of sedation was more in t...
Background: Organophosphorus poisoning (OPP) is a major global public health problem. Pralidoxime... more Background: Organophosphorus poisoning (OPP) is a major global public health problem. Pralidoxime has been used in a complimentary role to atropine for the management of OPP. World Health Organization (WHO) recommends use of pralidoxime but studies regarding its role have been inconclusive, ranging from being ineffective to harmful or beneficial. Materials and Methods: The present study was undertaken to evaluate the effectiveness of pralidoxime. Eddleston's study was the most compelling factor for our study, as he showed worst outcomes using pralidoxime. Our practice of continuous use of pralidoxime was based on the WHO guidelines and the study by Pawar (2006), which showed better outcome with higher doses of pralidoxime. These conflicting results suggested that a re-evaluation of its use in our clinical practice was indicated. Results: There was no difference in mortality rates, hemodynamic parameters and atropine requirements between the AP and A groups. Mean duration of ventilation (3.6 ± 4.6 in AP group vs. 3.6 ± 4.4 in A group) and Intensive Care Unit stay (7.1 ± 5.4 in AP group vs. 6.8 ± 4.7 in A group) was comparable. Serum sodium concentrations showed a correlation with mortality, with lower concentrations associated with better outcomes. Conclusion: The study suggests that add-on WHO-recommended pralidoxime therapy does not provide any benefit over atropine monotherapy. Adding pralidoxime does not seem to be beneficial and at the same time does not result in increased mortality rates. Our practice changed after completion of this study, and it has proven to be of significant benefit to patients who had to bear the expense of treatment.
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