Bali Journal of Anesthesiology (BJOA)
Not a member yet
82 research outputs found
Sort by
Succinylcholine used for difficult airway lead to difficult airway- a case report
No full textSuccinylcholine (Sch) is usually given for intubation in suspected difficult airway due to its fast onset and short duration of action. We report a case of Masseter Muscle Rigidity (MMR) after giving Sch to a patient for lap cholecystectomy with difficult airway.A healthy, 40 year old female weighing 85 kg was posted for laparoscopic cholecystectomy. She was Mallampatti grade III, mouth opening 4.5 cm, upper lip bite test class I, thyromental distance 6.5 cm and neck circumference 55 cm. She had no medical illness, no previous exposure to anaesthetic agents or family history of myopathy with normal investigations.In operating room (OR), difficult intubation cart was kept ready. Pre-medication was done with glycopyrrolate 0.2 mg intravenous (IV), midazolam 1 mg IV and fentanyl 100 µg IV. After pre-oxygenation with 100% O2, patient was induced with propofol 120mg IV. On confirming adequacy of bag and mask ventilation, Sch 120 mg IV was given. Laryngoscopy was attempted once Sch induced fasciculations were over. However, teeth were tightly clenched and it was impossible to open the mouth to allow advancement of the laryngoscope. Again, after few moments, attempt to open the mouth failed. Keeping masseter spasm in mind, mask ventilation was continued with 100 % oxygen and no further anaesthetics were administered. There was no disproportionate increase in EtCO2 or body temperature during this period. After 5 minutes, jaw started relaxing and patient resumed spontaneous respiration. She was sent to the ICU for observation without surgery being performed.In ICU, after 1st post operative hour, blood test revealed normal ABG, slightly raised serum potassium (5.8meq/l) and creatinine phosphokinase (CPK) levels (188 IU/L). Patient remained afebrile throughout with clear urine. Next day, patient was discharged with a special note regarding not to use Sch and counselling for risk of malignant hyperthermia (MH) in future anaesthesia. Muscle biopsy for halothane caffeine test was advised. The case was done at a later date under Total intravenous anaesthesia uneventfully.Our patient presented with difficult airway on account of Mallampati III, increased body weight and neck circumference. In our institute, Sch is routinely used in suspected difficult airway cases as newer short acting non depolarizing muscle relaxants (NDMR) are not available. A rare adverse effect of Sch is MMR which can occur in isolation or can be an early indicator of malignant hyperthermia (MH).(1) Recent findings state that increased tone in the masseter muscle after giving Sch may be a normal pharmacological response of masseter muscle to Sch.(2). MMR causes difficult or impossible laryngoscopy leading to difficult or failed intubation. Alternative techniques like retrograde endotracheal intubation, fiberoptic nasotracheal intubation, trachlight™, laryngeal mask airway and surgical cricothyroidotomy (3) may be required to secure airway. In our patient, though Sch triggered MMR leading to difficult intubation, we were able to ventilate the patient with bag and mask.Surgery was abandoned and patient monitored as there is a possibility of development of MH even after a lag of 20 -30 min (4). Patient did not develop any signs and symptoms of MH during ICU stay. Mild elevation in CPK and K levels could suggest rhabdomyolysis secondary to MMR.To summarize, this case highlights that Sch may produce isolated MMR leading to difficult laryngoscopy and intubation. In such patients, trigger factors of MH should be avoided during maintenance of anaesthesia and availability of dantrolene in OR ensured. We also suggest that the use of Sch is fraught with too much potential for a disastrous outcome and should not be relied upon in cases where difficult intubation is suspected
Salmonella Typhi – a Quiet Bacteria with a Loud Message: an ICU Case Report
Get PDFTyphoid fever, caused by Salmonella enterica, serovar Typhi, is restricted to humans as its host and evades the human immune system with ease. This quality has been one of the many reasons why it is commonly found as an endemic bacterium in emerging economies. Also, due to a remarkably low yield from blood cultures (median of 1 CFU/mL of blood), Salmonella septicemia is uncommon. New evidence gathered together with clinical investigations have provided insight into the mechanisms that underlie the pathogenesis of typhoid, host restriction as well as antibiotic and vaccine susceptibility. However, very little has been done to curb the persistence of disease and emergence of resistant strains. We discuss a case of Salmonella Septic Shock in the Intensive Care Unit (ICU) that takes us through various aspects in diagnosis, the treatment potential and the problems surrounding prevention
Comparative evaluation of low-dose levobupivacaine and ropivacaine in patients undergoing inguinal herniorrhaphy under walking spinal anaesthesia as daycare surgery
Get PDFBackground: Ropivacaine and levobupivacaine possess the property of sensory-motor dissociation. Hence these drugs allow a faster recovery of motor function and hence, these are potentially useful agents for walking spinal anaesthesia in daycare surgeries.Patients and Methods: This is a prospective, double-blind, randomized study involving 120 adult ASA 1 and 2 patients who were randomly allocated into two groups. Group R (n = 60) received 7.5 mg 0.75% ropivacaine + 25 μg fentanyl + 1.5 ml sterile water. Group L (n = 60) received 5 mg 0.5% levobupivacaine + 25 μg fentanyl + 1.5 ml sterile water. Each solution was made to a total volume of 3 ml, administered intrathecally. Sensory and motor block characteristics, hemodynamic changes and postoperative recovery profile characteristics were noted. Paired/unpaired t-test and chi-square test were used wherever applicable for statistical analysis using SPSS version 15.0. Results: Sensory block onset time and time to reach the maximal cephalic spread were comparable in both the groups, whereas time to the two-segment regression and time to first analgesic requirement were significantly shorter in group RF. Out of 60 patients in each group, 59 patients in group RF and 57 patients in group LF were MBS grade 5. Time to home discharge was also significantly shorter in group RF.Conclusion: We concluded that both local anaesthetics could be used in the walking spinal technique; however, ropivacaine is preferred because of its favourable block characteristics and early ambulation time
Acinetobacter baumannii Is an opportunistic pathogen as an MDRO especially on intensive ward
No full textAcinetobacter baumannii is an opportunistic bacterial pathogen that is associated with hospital acquired infections and is a major cause of nosocomial infections especially in intensive spaces; this is becoming increasingly a widespread concern in various hospitals around the world. Acinetobacter baumannii, which is resistant to many antibiotics, is now recognized as clinically very important. Reports suggest that the spread of A. baumannii in the hospital environment led to an increase in nosocomial outbreaks associated with high mortality rates. However, many other Acinetobacter spp. can also cause nosocomial infections. This review focuses on the role of Acinetobacter spp. as nosocomial pathogens, resistance patterns and epidemiology
The relationship between nutritional status based on nutritional risk index (NRI) and length of stay of digestive surgery patients
No full textABSTRACTBackground: Malnutrition is a common concomitant illness that can be found in digestive surgery patients.The risk of malnutrition in digestive surgery patients is often overlooked even though malnutrition has beenknown to be associated with poor postoperative outcomes. The study aimed to analyze the relationship of nutritional status based on the Nutritional Risk Index (NRI) and length of stay of digestive surgery patientsin Sanglah General Hospital. Patients and Methods: The design of this study is an analytical cross-sectional using secondary data fromthe medical record of the digestive surgery patients in Sanglah General Hospital. Data on body weight andserum albumin level were used to identify the preoperative nutritional status of the patients based on NRI. Results: Of the 42 patients involved in this study, 54.8% of patients have poor nutritional status and the remainder 45.2% of patients have good nutritional status. The result of the statistical analysis showed asignificant relationship between nutritional status and length of stay. The result of the logistic regressiontest showed that the prevalence of long hospitalizations (≥11 days) were 5.2 times greater in digestivesurgery patients with poor preoperative nutritional status compared to patients with good nutritionalstatus. Conclusion: This study shows that poor nutritional status is a significant problem for digestive surgery patients and it is one of the factors that contribute to a longer hospital stay
Continuous caudal analgesia as a safe and effective method for pediatric post - chordectomy analgesia
Get PDFABSTRACTIt brings great satisfaction for medical officers to be able to see children smiling, laughing, and playing without pain after surgery, yet many children still experience inadequate postoperative pain management. This phenomenon could lead to serious immediate and long term effects in the pediatric patient. Disruption of the healing process caused by pain could become the source of morbidity and mortality in the early postoperative period. Opioid side effects and transformation from acute to chronic pain due to inadequate analgesia are other problems met when dealing with postoperative pain management. This is where regional analgesia takes advantage. Caudal analgesia is an old yet very popular method in pediatric anesthesia and has gained widespread use. It can be delivered as a single injection or continuous infusion. The continuous technique provides a longer duration of analgesia than single injection does. We report a satisfying result from using continuous caudal analgesia for post chordectomy pain management in a 5-year-old boy.
Fibreoptic intubation under conscious sevoflurane sedation in anticipated difficult intubation cases with unfavorable conventional airway preparation
Get PDFAirway management in maxillofacial and head and neck cancer patients has remained a challenge even after significant development towards difficult airway management. When such patients have multiple difficult intubation predictors, management becomes more thought-provoking. Mucosal preparation and sedation play a vital role in producing co-operative patient and successful procedure but is not always feasible. On the other hand, intravenous sedation lacks titratability and reversibility. We describe awake fiberoptic intubation in three adult patients having multiple difficult intubation predictors whose airway preparation was not feasible due to obscured surface anatomy and nil mouth opening. The cases were done under titrated conscious sevoflurane sedation of MACage 0.4-0.6 using nasopharyngeal airway and closed circuit. This report highlights that Sevoflurane based conscious sedation is a feasible alternative for awake fiberoptic intubation in patients whose airway anesthesia and blocks are not possible
Antimicrobial susceptibility patterns of Acinetobacter baumanii isolates from ICU and non-ICU wards
No full textABSTRACTIntroduction: Acinetobacter baumanii is the most common agent of hospital-acquired infection with the increasing fatality rate due to multidrug-resistant (MDR) strain infection. The magnitude of the problem in Indonesia is unknown. Here, we provide data regarding susceptibility pattern of A. baumanii isolated from a tertiary referral hospital in Bali, Indonesia between 2012 and 2014.Methods: Data were collected retrospectively from culture-based records in the Clinical Microbiology department, Sanglah General Hospital during 2012-2014. A. baumanii was isolated from clinical specimens. Identification and antimicrobial susceptibility test were conducted using micro-dilution method (Vitek-2 Compact system). Isolates that resistant to ≥ 3 antibiotic classes were categorized as multi-drug resistant (MDR) A. baumanii.Results: A. baumanii collected from sputum in intensive care unit (ICU) wards were 7.9%, 11.1%, and 7.0%, while the isolates from sputum in non-ICU wards were 13.1%, 15.6%, and 19.9% in 2012, 2013, and 2014, respectively. There was a reduced susceptibility of A. baumanii to ciprofloxacin, levofloxacin, ceftazidime, aztreonam, imipenem, ampicillin-sulbactam, and piperacillin-tazobactam in ICU ward. Meanwhile, the susceptibility of A. baumanii to Cotrimoxazole remained high in both ICU and non-ICU ward. MDR A. baumanii is found to be resistant to fluoroquinolones, cephalosporins, aztreonam, aminoglycosides, beta-lactamase inhibitors, and carbapenem. Data were analyzed and presented in a descriptive manner.Conclusion: Three years surveillance showed that the susceptibility of A. baumanii to most common antibiotics was decreasing. MDR A. baumanii was found to be resistant to all classes of common antibiotics mostly from ICU ward isolates.
Role of flow velocity and transient hyperemic response evaluated by transcranial doppler for assesing brain autoregulation in mild traumatic brain injury: a case report
Get PDFHead injuries are a common case throughout the world, based on data from the Centers for Disease Control, emergency cases, hospitalization cases, and also deaths due to head injuries have increased in the decade 2001-2010. Cerebral autoregulation (CA) is a mechanism for cerebral blood flow (CBF) regulation if there is a change from cerebral perfusion pressure (CPP). The mechanism of brain autoregulation is negative feedback that holds back the increase in mean arterial pressure (MAP) by reducing the diameter of blood vessels so that CBF returns to normal, whereas if MAP falls, brain autoregulation tends to widen blood vessel diameter so that CBF is normal. Transcranial doppler examination can be one of the modalities of investigation that is very useful in patients with head injuries. Transcranial doppler in patients with a head injury can be used to measure mean flow velocity of cerebral artery media and transient hyperemic response test, both of which can assess the prognosis of a course of head injury
Anaesthesia management on pregnancy with co-morbid asthma undergoing non-obstetric surgery
Get PDFIn the pregnancy process, there is a significant physiological change in the mother. Physiological changes, pre-pregnancy conditions, or those that arise during the pregnancy process will affect the delivery outcome. Also, it turns out that the presence of this preexisting condition will affect the outcome process, especially the anaesthetic technique used, the chosen anaesthetic technique is determined based on the age of the pregnancy, surgical procedures to be performed, surgery site, and overall patient condition. Whatever technique is selected, it must use the right method based on clinical decisions and accordingly to the existing guidelines. This condition is a challenge for an anesthesiologist