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Blast injuries are rare, but life-threatening medical emergencies. We report the clinical presentation and management of four bomb blast victims admitted in Intensive Care Unit of Trauma center of our hospital in 2011. Three of them had lung injury; hemothorax (2) and pneumothorax (1). Traumatic brain injury was present in only one. Long bone fractures were present in all the victims. Presence of multiple shrapnels was a universal finding. Two blast victims died (day 7 and day 9); cause of death was multi-organ failure and septic shock. Issues relating to complexity of injuries, complications, management, and outcome are discussed. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the efficacy of chemoprophylactic dose of oseltamivir in preventing H1N1 by comparing the rates of acute respiratory illness and H1N1 positivity of respiratory specimens between HCP with and without consumption of oseltamivir working in swine flu ICU. Materials and Methods: The study was conducted on HCP posted in "Swine Flu Intensive Care Unit" from October 2009 to March 2010. Data on infection control measures, chemoprophylactic use of oseltamivir, flu-like illness, ADRs to oseltamivir, and contact history in family and neighborhood were collected by face-to-face interview conducted by investigator using a set of prespecified items in a questionnaire. Results: All HCP used infection control measures like using long-sleeved cuffed gown, gloves, cap, shoe cover, and N95 mask, and frequent hand washing. There was no history of any unprotected contact with an H1N1-positive case. Out of 100 HCP, 69% took chemoprophylaxis. There was no significant difference in incidence of flu-like illness between HCP who took chemoprophylaxis (48%) and those who did not (29%, P = 0.18). H1N1 testing was done on 17 HCP, but all tested negative. Incidence of adverse effects to chemoprophylactic dose of oseltamivir was high (57%). The most commonly reported adverse effects were nausea (54%), gastritis (51%), and headache (38%). Conclusion: Chemoprophylaxis with oseltamivir is not recommended for HCP working in areas of high aerosol generation like ICU if infection control measures are adopted as there is no significant difference in the incidence of flu-like illness in HCP with and without intake of oseltamivir. This protects HCP from various adverse effects of the drugs, like nausea, gastritis, and headache. [ABSTRACT FROM AUTHOR]

Background: Hyperbaric oxygen therapy (HBOT) is a treatment option for chronic nonhealing wounds. Transcutaneous oximetry (TCOM) is used for wound assessment. We undertook a randomized prospective controlled trial to evaluate the role of HBOT in healing of chronic nonhealing wounds and to determine whether TCOM predicts healing. Materials and Methods: This study was conducted in 30 consenting patients with nonhealing ulcer. The patients were randomized into group HT (receiving HBOT in addition to conventional treatment) and group CT (receiving only conventional treatment). Duration of treatment in both the groups was 30 days. Wound ulcer was analyzed based on size of the wound, exudates, presence of granulation tissue, and wound tissue scoring. Tissue oxygenation (TcPO2) was measured on 0, 10th, 20th, and 30th day. Results: There was 59% reduction in wound area in group HT and 26% increase in wound area in group CT. Ten patients in group HT showed improvement in wound score as compared to five patients in group CT. Complete healing was seen in three patients in group HT as compared to none in group CT. Surgical debridement was required in 6 patients in group HT and 10 patients in group CT. One patient in group HT required amputation as compared to five patients in group CT. A positive correlation was found between TcPO2 value and various markers of wound healing. Conclusion: HBOT has a definitive adjunctive role in the management of chronic nonhealing ulcers. It decreases the amputation rate and improves patient outcome. Periwound TcPO2 may be used as a predictor of response to HBOT and has a positive correlation with wound healing. [ABSTRACT FROM AUTHOR]

Introduction: Measurement of respiratory quotient (RQ) and resting energy expenditure (REE) has been shown to be helpful in designing nutritional regimens. There is a paucity of the literature describing the impact of a feeding regimen on the energy expenditure patterns. Therefore, we studied the effect of continuous vs. intermittent feeding regimen in head-injured patients on mechanical ventilation on RQ and REE. Methods: After institutional ethical approval, this randomized study was conducted in 40 adult male patients with head injury requiring controlled mode of ventilation. Patients were randomly allocated into two groups. Group C: Feeds (30 kcal/kg/day) were given for 18 h/day, with night rest for 6 h. Group I: Six bolus feeds (30 kcal/kg/day) were given three hourly for 18 h with night rest for 6 h. RQ and REE were recorded every 30 min for 24 h. Blood sugar was measured 4 hourly. Other adverse effects such as feed intolerance, aspiration were noted. Results: Demographic profile and SOFA score were comparable in the two groups. Base line RQ (0.8 vs. 0.86) and REE (1527 vs. 1599 kcal/day) were comparable in both the groups (P>0.05). RQ was comparable in both groups during the study period at any time of the day (P>0.05). Base line RQ was compared with all other RQ values measured every half hour and fluctuation from the base line value was insignificant in both groups (P>0.05). REE was comparable in both the groups throughout the study period (P>0.5). Adequacy of feeding as assessed by EI/MREE was 105.7% and 105.3% in group C and group I, respectively. There was no significant difference in the blood sugar levels between the two groups (P>0.05). Conclusion: We found from our study that RQ, REE, and blood sugar remain comparable with two regimens of enteral feeding - continuous vs. intermittent in neurosurgical patients on ventilator support in a ICU setup. [ABSTRACT FROM AUTHOR]

H1N1 subtype of influenza A virus has clinical presentation ranging from mild flu like illness to severe lung injury and acute respiratory distress syndrome (ARDS). The aim of our study was to compare the demographic characteristics, clinical presentation, and mortality of critically ill patients with (H1N1+) and without H1N1 infection (H1N1-). We retrospectively analyzed medical charts of patients admitted in "Swine Flu ICU" with ARDS from August 2009 to May 2010. Real-time reverse transcriptase polymerase chain reaction (RT-PCR) assay was used for detection of H1N1 virus in the respiratory specimens. Clinical data from 106 (H1N1 , 45; H1N1+, 61) patients was collected and compared. Mean delay in presentation to our hospital was 5.7±3.1 days and co-morbidities were present in two-fifth of the total admissions. Sequential Organ Failure Assessment (SOFA) score of patients with and without H1N1 infection was comparable; 7.8±3.5 and 6.6±3.1 on day 1 and 7.2±4.5 and 6.5±3.1 on day 3, respectively. H1N1+ patients were relatively younger in age (34.2±12.9 years vs. 42.8±18.1, P = 0.005) but presented with significantly lower PaO2:FiO2 ratio (87.3±48.7 vs. 114±51.7) in comparison to those who subsequently tested as H1N1 . The total leucocyte counts were significantly lower in H1N1+ patients during the first four days of illness but incidence of renal failure (P = 0.02) was higher in H1N1+ patients. The mortality in both the groups was high (H1N1+, 77%; H1N1 , 68%) but comparable. There was a mean delay of 5.7±3.1 days in initiation of antivirals. Patients with H1N1 infection were relatively younger in age and with a significantly higher incidence of refractory hypoxia and acute renal failure. Mortality from ARDS reported in our study in both the groups was high but comparable. [ABSTRACT FROM AUTHOR]

Physicians, health care workers, members of the clergy, and laypeople throughout the world have accepted fully that a person is dead when his or her brain is dead. Although the widespread use of mechanical ventilators and other advanced critical care services have transformed the course of terminal neurologic disorders. Vital functions can now be maintained artificially for a long period of time after the brain has ceased to function. There is a need to diagnose brain death with utmost accuracy and urgency because of an increased awareness amongst the masses for an early diagnosis of brain death and the requirements of organ retrieval for transplantation. Physicians need not be, or consult with, a neurologist or neurosurgeon in order to determine brain death. The purpose of this review article is to provide health care providers in India with requirements for determining brain death, increase knowledge amongst health care practitioners about the clinical evaluation of brain death, and reduce the potential for variations in brain death determination policies and practices amongst facilities and practitioners. Process for brain death certification has been discussed under the following: 1. Identification of history or physical examination findings that provide a clear etiology of brain dysfunction. 2. Exclusion of any condition that might confound the subsequent examination of cortical or brain stem function. 3. Performance of a complete neurological examination including the standard apnea test and 10 minute apnea test. 4. Assessment of brainstem reflexes. 5. Clinical observations compatible with the diagnosis of brain death. 6. Responsibilities of physicians. 7. Notify next of kin. 8. Interval observation period. 9. Repeat clinical assessment of brain stem reflexes. 10. Confirmatory testing as indicated. 11. Certification and brain death documentation. [ABSTRACT FROM AUTHOR]

This prospective study was designed to have an insight into critical events occurring in the 13-bedded multidisciplinary intensive care unit (ICU) of our hospital and to report the critical events to evaluate the avoidable/iatrogenic problems so as to improve patient outcome and keep a self-check in the ICU. The errors reported were due to wrong mechanical or human performance. Repeated performance errors of the same kind pointed to the problem area, to which was paid proper attention in the required manner. Some malfunctioning equipments were abandoned and the need for adequate availability of staff was emphasized. Reporting of critical events was done keeping the patients' and doctor's identities anonymous through a proforma designed to report the event. [ABSTRACT FROM AUTHOR]

The article presents a study that describes the clinical and demographic characteristics of patients with H1N1 infection admitted in a hospital from May 2009 to May 2010. The study showed 19,279 patients with flu-like illness but 11.1 percent of them underwent testing for H1N1 using real-time reverse-transcriptasepolymerase-chain-reaction assay.It stresses the need to conduct further studies to assess the nutritional status, serum albumin levels, and immunity on outcome from viral infections.

The article presents a case study of a 23-year-old tourist on a visit to India. For the past seven days, the tourist suffered from fever, vomiting and loose motions, followed by breathlessness and chest pain for the past one day. Using real-time reverse-transcriptase polymerase chain reaction, she was diagnosed of H1N1 infection and treated with hydropneumothorax.

Objective: Magnesium has been used as an adjuvant by various routes, including intravenous, intrathecal, and epidural in different dosage regimens. The effect of single bolus dose of magnesium as an adjuvant to fentanyl for postoperative analgesia has not been studied. This prospective randomized controlled trial was done to evaluate the efficacy of single bolus administration of magnesium epidurally as an adjuvant to epidural fentanyl for postoperative analgesia in patients undergoing total hip replacement under combined spinal epidural anesthesia. Methods: Sixty patients received combined spinal-epidural anesthesia with 2 mL of 0.5% hyperbaric bupivacaine intrathecally. After the surgery, patients were randomized into Group F [epidural fentanyl (1 μg/kg) in 10 mL saline] and Group FM [epidural magnesium (75 mg) along with fentanyl (1 μg/kg) in 10 mL saline]. Supplementary analgesia was provided by 50 mg intravenous tramadol if Verbal Rating Score (VRS) >4. Patient's first analgesic requirement and duration of analgesia were recorded. Results: The duration of analgesia was significantly longer for Group FM, 340±28.8 min, compared with Group F, 164±17.1 min (P=0.001). The frequency of rescue analgesics required in 24-h postoperative period in Group FM (2.3±0.5) was significantly less than that in Group F (4.3±0.5) (P=0.001). VRS was significantly lower in Group FM up to 4 h in the postoperative period (P=0.001). Bromage scale was statistically insignificant at all points of time. Conclusions: The administration of magnesium (75 mg) as an adjuvant to epidural fentanyl (1 μg/ kg) for postoperative analgesia results in significantly lower VRS with prolonged duration of analgesia as compared with epidural fentanyl (1 μg/kg) alone. Concomitant administration of magnesium also reduces the requirement of breakthrough analgesics with no increased incidence of side effects. [ABSTRACT FROM AUTHOR]

Objective: Supraglottic airway devices can be life-saving in the 'cannot intubate, cannot oxygenate' situation. The cricoid pressure (CP) is considered critical in the prevention of aspiration. The aim of this self-controlled study was to evaluate the effect of CP on the bag mask ventilation (BMV), and the placement of and the ventilation through, the ProSeal laryngeal mask airway (LMA). Methods: In 60 adult patients undergoing elective surgery, after induction of anaesthesia, the effect of bimanual CP (≈30N) on BMV, ventilation through the ProSeal LMA, its anatomic position and airway seal pressures were evaluated. CP was released, the ProSeal LMA was reseated (appropriate position), the above assessments were repeated, and the effect of CP on the tidal volume (TV) and peak inspiratory pressure (PIP) was noted. Results: Out of 60 patients, the bag mask ventilation with CP was adequate in 25 (41.7%) patients compared to 59 (98.3%) patients without CP; p<0.001. The ventilation via the ProSeal LMA with CP was excellent, adequate and impossible in 0.0% (0), 49.2% (29) and 50.8% (30) patients, respectively, compared to 93.3% (56), 6.7% (4), 0% (0) patients, respectively, without CP; p<0.001. Releasing CP and advancing the ProSeal LMA to its appropriate position significantly improved the ventilation and anatomic position scores; both p<0.001. Airway seal pressures improved significantly without CP compared to with CP; p<0.001). With the ProSeal LMA in a proper position, the CP application resulted in a significant decrease in the mean expired TV (489.14±91.62 vs. 355.08±104.42 mL) with an increase in PIP (16.72±5.01 vs. 30.71±6.74 cmH2O); both p<0.001. Conclusion: The application of bimanual CP (≈30N) interferes with the bag mask ventilation and prevents both the correct placement and ventilation via the ProSeal LMA in adult patients. [ABSTRACT FROM AUTHOR]

Background: Etomidate injection is often associated with myoclonus. Etomidate injection technique influences the incidence of myoclonus. This study was designed to clarify which of the two injection techniques--slow injection or priming with etomidate--is more effective in reducing myoclonus. Methods: This prospective randomized controlled study was conducted on 189 surgical patients allocated to three study groups. Control group (Group C, n = 63) received 0.3 mg/kg etomidate (induction dose) over 20 s. Priming group (Group P, n = 63) received pretreatment with 0.03 mg/kg etomidate, followed after 1 min by an etomidate induction dose over 20 s. Slow injection group (Group S, n = 63) received etomidate (2 mg/ml) induction dose over 2 min. The patients were observed for occurrence and severity of myoclonus for 3 min from the start of injection of the induction dose. Results: The incidence of myoclonus in Group P (38/63 [60.3%], 95% CI: 48.0-71.5) was significantly lower than in Group C (53/63 [84.1%], 95% CI: 72.9-91.3, P = 0.003) and Group S (49/63 [77.8%], 95% CI: 66.0-86.4, P = 0.034). Myoclonus of moderate or severe grade occurred in significantly more patients in Group C (68.3%) than in Group P (36.5%, P < 0.001) and Group S (50.8%, P = 0.046), but the difference between Groups P and S was not significant (P = 0.106). Conclusions: Priming is more effective than slow injection in reducing the incidence of myoclonus, but their effects on the severity of myoclonus are comparable. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented which discussed a study on the efficacy of Hyperbaric Oxygen Therapy HBOT) in the management of lower extremity ulcer in diabetic patients.

A letter to the editor about clinical occurrences of Bezold-Jarisch reflex (BJR) is presented.

We describe a case of a 17-year-old male who remained drowsy following left temporomandibular joint (TMJ) interposition arthroplasty for TMJ ankylosis. Computed tomography of the head demonstrated an extradural hematoma. The possible cause of this unusual occurrence is discussed. [ABSTRACT FROM AUTHOR]

The article reports a case of green urine in a 45-year-old female patient. She was scheduled for laparotomy for repair of an enterocutaneous fistula by the American Society of Anesthesiologists Physical Status I. The article discusses that chronic accumulation of indigenous medicines can lead to potential toxicity in patients with compromised renal failure.

Despite technological, therapeutic and diagnostic advancements, surgical intervention in pheochromocytoma may result in a life-threatening situation. We report a patient who developed unilateral pulmonary edema during laparoscopic resection of adrenal tumor. [ABSTRACT FROM AUTHOR]

A case study of 30-years-old female is presented who developed massive hydrothorax and was diagnosed postoperatively following percutaneous nephrolithotomy (PCNL) for left renal calculus. It mentions that intraoperatively the old female remained haemodynamically stable and several attempts were required to reach superior calyx. It highlights anaesthetic challenges faced during the PCNL such as dilutional anaemia, blood loss and hypothermia.

The spectrum of presentation of a victim of neurotoxic snake bite can range from mild ptosis to complete paralysis and ophthalmoplegia. We report a case of snake bite in a 10-year-old child who was comatosed with bilateral fixed dilated pupils and absent doll's eye movement that was interpreted as brain death. Physicians need to be aware of the likelihood of snakebite presenting as locked in syndrome. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented about gangrene of hand caused by faulty intravenous cannulation.

Patients with genetic disorders associated with multiple congenital anomalies present unique challenges to the anesthesiologist. We report the successful perioperative management of a child with biliary atresia, situs inversus totalis, and Kartegener syndrome scheduled for corrective biliary surgery. We recommend that patients with multiple congenital anomalies need to be thoroughly and cautiously evaluated. The perioperative management should be individualized based on associated anomalies along with appropriate monitoring. [ABSTRACT FROM AUTHOR]

We describe a 23-year-old man with no history of any other illness contacting H1N1 infection during convalescence from dengue fever. The patient had bilateral pneumonia with renal and hepatic dysfunction. The patient was treated successfully with osaltamivir and noninvasive ventilation along with other supportive measures. Despite multiorgan involvement and severe pulmonary involvement, he had a rapid improvement and did not require invasive ventilation. The possibility of the preceding or concomitant dengue viral infection reducing the severity of H1N1 infection was considered. It may be possible for two viruses to infect the same cell and as such, there may be interaction of the pathologic pathways of the two viruses, leading to change of virulence or altered host response. Such an interaction between the two viruses may be clinically important in the setting of the current H1N1 pandemic and the increased geographic distribution of the dengue virus. [ABSTRACT FROM AUTHOR]

We describe for the first time, the perioperative care of a patient with a rare combination of Eisenmenger syndrome with β-thalassemia major presenting for splenectomy. Patients with Eisenmenger syndrome have polycythemia because of chronic hypoxia but our patient was anaemic and had thrombocytopenia because of thalassemia major. The management of such a case can be challenging for any anaesthesiologist because of severe V/Q mismatch (high shunt fraction and restrictive lung disease because of hypersplenism), decreased oxygen carrying capacity (anaemia) and increased risk of haemorrhage (thrombocytopenia), along with the potential increase in intracardiac shunt during anaesthesia. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in context with perioperative anesthetic complications in a child with Systemic onset Juvenile Idiopathic Arthritis syndrome (SoJIA).

A letter to the editor is presented in response to the article related to the impaction of cuffed tracheal tube in a 9-year-old child.

A case study of one-day-old term male baby is presented with tracheoesophageal fistula and who posted for emergency surgical correction. It mentions that pre-operative examination revealed bilateral crepitations and standard monitoring was established. After analysis the doctors suspected the case of central anticholinergic syndrome (CAS) following general anaesthesia (GA) involving the use of anticholinergic agents in intra-operative care.

A letter to the editor is presented which described two cases of epiglottis downfolding that resulted from conventional laryngoscopic intubation and were discovered incidentally.

A letter to the editor is presented about intubating laryngeal mask airway (ILMA) using transplanted pilot balloon.

A letter to the editor is presented regarding the cardiac and noncardiac surgical burden faced by pediatric physicians with the two-month-old female baby with congenital rubella syndrome (CRS).

The article presents a case study of a 65-year-old male who was taken to the hospital due to progressive swelling over his neck and difficulty in speaking. He was diagnosed of having multinodular goitre and underwent total thyroidectomy. It discusses the application of intubating laryngeal mask airway for the intubation of patient with goitrous thyroid.

A letter to the editor is presented which discusses the risk factors for a pneumothorax during laparoscopic surgery.

A 17-year-old H1N1-positive patient was successfully extubated after 25 days of ventilatory support for treatment of viral pneumonia which was complicated by empyema thoracis due to Candida albicans. Hematogenous spread was suspected as simultaneous culture of ascitic fluid identified Candida species sensitive to flucytosine but resistant to amphotericin B and azole group of antifungals. Monotherapy with flucytosine led to clinical and radiological improvement. [ABSTRACT FROM AUTHOR]