Narasingam (1)
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This document summarizes the case of a 72-year-old male patient who presented with injection abscess in his left gluteal region, lower limb cellulitis, and sepsis. He had a history of hypertension and diabetes. He underwent incision and drainage of the abscess 10 days prior and then developed fever, pain, swelling, and breathlessness. He was found to have pleural effusion, abdominal collections, and acute kidney injury. He underwent further surgical drainage and was managed in the ICU with antibiotics, fluid resuscitation, oxygen supplementation, and thoracic epidural anesthesia for pain management. His condition stabilized and he was successfully weaned off the ventilator the next day.
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For PPT, Check following link
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- Early identification and treatment of hemorrhage is critical to preventing death, and strategies like damage control resuscitation focusing on blood product administration over crystalloids can improve outcomes for severely injured patients.
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Dr. Bukenya presented a case of a 47-year-old male who presented with neck swelling and was admitted with a suspected diagnosis of lymphoma. His condition deteriorated and he developed respiratory failure and died. Opportunities were identified where earlier intubation, ICU consultation, and multidisciplinary discussion may have improved outcomes. The team recommended improvements in documentation, consultation, identifying deteriorating patients, and discussing management as a team.
Cirrhosis
This document summarizes a 39-year-old male patient who presented with an intertrochanteric fracture of the left hip. He had a history of diabetes, liver disease, splenectomy, and alcohol use. He underwent a closed reduction and internal fixation with a proximal femoral nail. The anesthetic plan addressed his comorbidities and perioperative risks. Intraoperatively, he developed ventricular tachycardia which resolved with medication. He received blood products due to blood loss. Postoperatively, he showed signs of hepatic encephalopathy.
Morning Report Thursday, February 1st 2024.pptx
The morning report summarizes 3 patients scheduled for procedures. The first is a 4 year old boy scheduled for a brain evoked response auditory procedure for delayed speech. The second is a 12 year old boy with transposition of the great arteries scheduled for tracheostomy and stenosis release for impending airway obstruction. The third is a 58 year old man scheduled for diagnostic laryngoscopy and T-tube placement for subglottic stenosis.
Anaesthetic management of a patient with perioperative asthma
1. A 74-year-old female with a history of asthma and hypertension presented for an emergency CBD re-exploration surgery.
2. During induction, the patient aspirated, which precipitated a severe bronchospasm that led to irreversible hypoxia, hypotension, and cardiac arrest.
3. Despite maximal treatment and resuscitation efforts, the patient could not be revived and was declared dead. The case highlights the challenges of managing perioperative bronchospasm and aspiration in a high-risk asthmatic patient.
Haemoptysis
This 81-year-old male presented with a 2-week history of haemoptysis. He had a history of smoking and comorbidities including heart disease and hypertension. Initial workup found a lung mass and CT showed possible liver lesions. Bronchoscopy confirmed squamous cell carcinoma of the right lower lobe. He was discharged after his haemoptysis resolved with follow up by oncology.
Peri-Mortem C-Section in the Emergency Department : Dr Peter Soltau et al.
Grand round presentation on the Emergency Department perspective to the critically ill pregnant patient and the role of peri-mortem C-section.
Emphysematous pyelonephritis- case discussion
A 59-year-old diabetic male presented to the emergency department with left-sided abdominal pain, abdominal distension, and decreased urine output over two days. Imaging revealed gas in the left renal calyces and retroperitoneal spaces, consistent with emphysematous pyelonephritis. The patient was admitted to the ICU for IV fluids, antibiotics, and glycemic control. A nephrostomy tube was placed and aspirated pus and air. Antibiotics were adjusted based on culture results identifying E. coli. The patient's condition improved with treatment and he was later discharged.
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More from Arthi Rajasankar
Presentation1
This document presents the case of a 35-year-old male patient who presented with swelling and pain in the floor of his mouth for 4 days. He was diagnosed with Ludwig's angina and underwent incision and drainage surgery under awake fiberoptic intubation. Post-extubation, the patient experienced airway obstruction and respiratory distress requiring emergency tracheostomy. He developed negative pressure pulmonary edema but stabilized in the ICU. On post-op day 2, the patient exhibited agitated behavior and pulled out his tracheostomy tube due to underlying alcohol dependence syndrome.
Epidural (1)
This document provides information about epidural anaesthesia. It discusses the history and development of epidural techniques. It then describes the anatomy of the spinal cord, meninges, epidural space and sacral canal. It explains the mechanism of action of epidural anaesthesia and factors affecting drug distribution and elimination. Finally, it outlines the physiological effects of epidural anaesthesia on the cardiovascular, respiratory, gastrointestinal, genitourinary and neuroendocrine systems.
Review roleija originalstudy 2
This document provides guidelines for peer reviewers to evaluate original articles submitted to the Indian Journal of Anaesthesia. It includes a checklist of criteria to assess for various sections of the article like the title, abstract, introduction, methods, results, discussion, and references. Reviewers are asked to evaluate if the manuscript includes the necessary components for each section, follows ethical guidelines, and uses appropriate statistical analyses and language. The goal is to promote high-quality scientific writing while maintaining constructive feedback to authors.
Review roleija originalstudy
This document provides guidelines for peer reviewing original articles and clinical investigations submitted to the Indian Journal of Anaesthesia. It outlines key areas to check such as headings, title, abstract, keywords, and main sections of the article including introduction, methods, results, discussion, and conclusion. Reviewers are asked to check that appropriate approvals and consent were obtained, the study design and statistical analysis are sound, results are clearly presented, discussions are supported by citations, and references are formatted correctly. Guidelines also cover reviewing images, illustrations, videos andlegends.
Mcquade2017
This randomized crossover study compared end-tidal oxygen (ETo2) levels during preoxygenation with a bag valve mask (BVM) alone and with supplemental nasal cannula (NC) oxygen at different flow rates. Healthy volunteers underwent 3 minutes of preoxygenation with a BVM alone or a BVM with NC at 0, 5, 10, or 15 liters per minute. The primary outcome was ETo2 after 3 minutes of preoxygenation. NC flows of 0 and 5 L/min resulted in significantly lower ETo2 levels compared to the other groups. There were no differences in ETo2 between the BVM alone, NC 10 L/min, and NC 15 L/
Comp+ breathing
Compliance refers to the change in lung volume for a given change in pressure. It is the reciprocal of elastance. Compliance of the respiratory system (CRS) depends on the interaction of lung compliance (CL) and chest wall compliance (CW). CL is affected by lung volume, surface tension, blood volume, and edema, while CW is affected by posture, obesity, costal cartilage ossification, and scarring. Dynamic compliance includes the effects of resistance and hysteresis during breathing, while static compliance is measured without gas flow at equilibrium. The difference between static and dynamic compliance reflects airway resistance.
Arthi
The document discusses temperature monitoring and thermoregulation in the human body. It explains that body temperature depends on heat production and heat loss. The core body temperature is normally 36-37.5°C and vital organs must operate within this optimal range. When core temperature rises above 37°C, the hypothalamus activates mechanisms like sweating and vasodilation to increase heat loss and cool the body. When core temperature falls below 37°C, shivering and vasoconstriction occur to generate more heat and reduce heat loss. The hypothalamus precisely regulates these responses through negative feedback to maintain core temperature. General anesthesia disrupts all elements of thermoregulatory processing and control, which can lead
Journal 2
1. The document summarizes a journal club presentation which discussed different types of articles published in journals including editorials, review articles, original research articles, case reports, and letters to the editor.
2. It provided details on what constitutes each type of article and their purposes. For example, it stated that an editorial can critique other articles, review recent topics, and deliver concise messages from the editor.
3. The document also discussed other topics like how impact factor is calculated to measure a journal's importance, how to write a literature review, and the components of original research articles and case reports. It provided guidance on writing different types of academic articles and participating in journal club discussions.
Untitled
The study compared two dose regimens of tranexamic acid (TA) for reducing blood loss in hip surgeries: 1) a single 10 mg/kg bolus before incision, and 2) a 10 mg/kg bolus followed by a 1 mg/kg/hr infusion for 4 hours post-op. The bolus+infusion group saw significantly less blood loss at 6 hours post-op and higher hemoglobin levels at 6 hours. Both TA groups required fewer blood transfusions compared to the placebo group. The authors conclude that continuing TA infusion post-op is more effective at reducing early blood loss than a single pre-op bolus alone.
Arthi (1) copy
The document discusses thermoregulation and temperature monitoring. It summarizes that the hypothalamus regulates body temperature through heat production and loss mechanisms like radiation, conduction, convection, and evaporation. General anesthesia affects all aspects of thermoregulation by inhibiting responses like vasoconstriction and shivering that normally maintain core body temperature. This can lead to perioperative hypothermia if not prevented through measures like warmed fluids and surgical drapes.
Untitled
The study compared two dose regimens of tranexamic acid (TA) for reducing blood loss in hip surgeries: 1) a single 10 mg/kg IV bolus before incision, and 2) a 10 mg/kg IV bolus followed by a 1 mg/kg/hr infusion for 4 hours post-op. The infusion group saw significantly less blood loss at 6 hours post-op compared to bolus or placebo groups. Both TA regimens reduced 24-hour drain blood loss and need for blood transfusions compared to placebo. The authors conclude that a bolus plus infusion of TA maintains therapeutic levels longer to more effectively inhibit fibrinolysis and reduce early post-op bleeding in hip surgeries
Indian j anaesth60119-6203009_171350
- The document describes a study that assessed whether the antifibrinolytic drug tranexamic acid (TA) could reduce blood loss in patients undergoing surgery for head and neck cancer.
- 240 patients were randomly assigned to receive either TA or a placebo during surgery. Blood loss, need for transfusions, and coagulation parameters were compared between the groups.
- While post-operative blood loss was lower in the TA group, intraoperative blood loss and need for transfusions were similar between groups. Coagulation parameters indicated a hypercoagulable state in both groups.
Referral pain and phantom pain
1. Referred pain is pain perceived in a location other than where the painful stimulus originated. Common examples include pain from a heart attack referring to the left arm.
2. There are several proposed theories to explain referred pain, including axon reflex theory of shared nerve fibers and convergence-projection theory of shared spinal pathways. More recent theories involve central sensitization in the spinal cord.
3. Phantom limb pain refers to painful sensations felt in an amputated or missing limb. Approximately 60-80% of amputees report phantom limb sensations, with most being painful. Treatment is challenging but may involve drugs, nerve blocks, or spinal/brain stimulation in difficult cases.
Positioning in anaesthesia mgmc
The document discusses various patient positioning techniques used in anaesthesia and their goals, risks, and complications. It describes positions like supine, lithotomy, prone, lateral decubitus, and their effects on cardiovascular and respiratory systems. Common risks include nerve injuries, pressure sores, compartment syndrome, and visual complications. Careful patient assessment, padding of pressure points, monitoring for nerve injuries are emphasized. Position changes should be gradual and extremities checked regularly during long procedures to prevent injuries.
Paediatric breathing systems
- Dr. Phillip Ayre developed the T piece breathing system for children in 1937 after losing his own child to high gas pressures during anesthesia.
- Breathing systems for pediatric use have since undergone many modifications to suit different patients and situations. They aim to minimize resistance, dead space, and work of breathing while allowing for controlled or spontaneous ventilation.
- Common pediatric breathing systems include the T piece, Jackson Rees, Mapleson D and Bain circuits, and pediatric-modified circle systems. Low fresh gas flows can be used with these systems to decrease costs and heat/fluid loss while maintaining normocarbia. Proper selection and setup of the breathing system is important for safe anesthesia in children.
Paediatric anaesthesia practical tips
This document provides an overview of pediatric anesthesia considerations. It discusses key differences in pediatric physiology compared to adults, including higher oxygen consumption and metabolic rate in infants, differences in the cardiovascular and respiratory systems, and immature hepatic and renal function in young children. It also reviews airway anatomy variations, appropriate tube and LMA sizes, and pharmacokinetic considerations for commonly used anesthetic drugs in pediatrics. The principles of maintaining temperature, adequate oxygenation and IV fluids are emphasized for safe pediatric anesthesia.
Oxygen therapy
The patient may be developing CO2 narcosis due to suppression of hypoxic drive by high FiO2. Reduce FiO2 and consider non invasive ventilation. Monitor ABG.
Oxygen dissociation curve
This document discusses the oxyhemoglobin dissociation curve. It provides background on oxygen transport by hemoglobin and factors that influence the curve. Key points include:
- Hemoglobin transports oxygen through cooperative binding of up to 4 oxygen molecules per heme-globin molecule.
- The sigmoidal dissociation curve arises from cooperative binding - as one oxygen binds it increases affinity for others.
- Factors like pH, CO2, temperature can shift the curve left or right, altering oxygen unloading in tissues.
- Fetal hemoglobin has a higher affinity, helping oxygen transfer to the fetus in utero. Myoglobin also has higher affinity and acts as an oxygen storage in muscle.
Pain the basics
Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. It is classified in several ways including by type (nociceptive, neuropathic, psychogenic), duration (acute, chronic), and location. Theories of pain transmission include the specificity, pattern, and gate control theories. Pain signals travel along A-delta and C fibers to the spinal cord and then ascend to the brain via the spinothalamic tract. Descending pathways from the brainstem modulate pain transmission through the release of neurotransmitters like serotonin and norepinephrine.
Pain complex regional pain syndrome
Complex regional pain syndrome (CRPS) is an abnormal response to injury characterized by prolonged pain, vasomotor disturbances, delayed recovery, and trophic changes. It has two types: type 1 has no identifiable nerve injury while type 2 follows a nerve injury. It progresses through three stages - acute, dystrophic, and atrophic. Treatment involves sympathetic blocks, drugs like antidepressants and anticonvulsants, physiotherapy, and electroacupuncture which may help reduce sympathetic drive, inflammation, and pain.
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Narasingam (1)
- 1. A Case of Injection Abscess Left Gluteal Region – B/L lower limb cellulitis- Sepsis Team involved: Dr. Dr. Dr. Arthi (PG) Dr. (PG)
- 2. Brief History : Diagnosis: Surgical Procedure: Comorbidities & Drug history K/C/O SHT – 6 years on regular treatment Recently diagnosed as DM - 3 days • H/O Injection Abscess developed 10 days before(3/12/17) • C/O fever , pain & swelling over left leg x 5days • H/O I&D – Left gluteal region (13/12/17) • On 14/12/17 – pt developed breathlessness • C/O Palpitaion, Abdominal discomfort AGE : 72/M WEIGHT: 75 KG HEIGHT :160 cm BMI:
- 3. Consciousness Orientation No P +I C C L E+ Others- B/L pitting pedal edema PR :102/min RR :40/min NIBP :140/90mmHg SpO2 : 100% room air Temperature : 101F RS – B/L AE + B/L Basal Crepts CVS – S1S2 heard No Murmer P/A – Diffuse tenderness + CNS- NFND Mouth opening : Adequate MPC : 2 Nasal patency : patent Mentohyoid : 3FB Teeth :No loose tooth GPE AIRWAY EXAMINATION VITALS Systemic examination
- 4. Hb :9.9 TC :17,500 DC : N /L /M /E ESR : Blood urea :85 S creatinine:1.15 Na: 129 K:5.0 Cl:103 RBS :156 mg/dl BT: CT: INR: 1.53 CXR : Normal Study ECG : NSR Routine investigations Chest X ray: Normal Study Others :- PusCulture (12/12/17) - Streptococcus Pyogens Which was sensitive Vancomycin, Linezolide , Teicoplanin Urine :Ketone –ve Pus cells – 8-10Bacteria – Ocassional LL venous doppler – No E/O DVT Right Bakers cyst USG Abd: R pleural effusion, Left Paraumblical & L iliac subcutaneous collection Other investigations F Fio2 – 40% Cross consultations Ph PcO2 PO2 Lactate Bicarbonate 7.43 33 120 1.3 21.9
- 5. ANAESTHETIC PLAN Peri-op Risk Factors Old Age - Poor Effort Tolerance Anemia HT DM SEPSIS AKI Coagulopathy DEHYDRATION Stress of Surgery 4- 7 mets Right lateral position • Oxygenation- Low FRC – High Abdominal Pressure, pleural effusion- athelectasis • Prolonged Ventilation post surgery- sepsis • Hypotension Patient factors surgical factors Anaesthesia factors General Anaesthesia Vasopressor support for maintianing hemodynamic stability .
- 6. • Antibiotics changed from Augmenti & ciprofloxacin to Inj.Vancomycin • Oxygen Supplementation • Adequate Fluid Resuscitation PRE-OP OPTIMIZATION
- 7. • Thoracic Epidural was secured at T4-T5 space • Patient Anaesthetic Management
- 10. COURSE IN ICU • Post procedure patient was shifted to icu for ventilator support & Monitoring • Infusion. Noradrenalin was tappered & stopped on the same day • Patinet was weaned off from ventilator on 1 POD • Anterior Erector Spinae catheter was placed for pain management on POD 2 • ABG post Extubation on 40% Venturi Ph PcO2 PO2 Lactate Bicarbonate Na K Hb 7.40 40 121 1.2 28.4 129 3.1 8.4