Journal Of Anesthesiology MP State Vol 1

ANAESTHESIOLOGY ANAESTHESIOLOGY ANAESTHESIOLOGYM.P.M.P.

Editor: Dr. Meenu ChadhaCo-editor: Dr. Alok Biyani

? October 2015 Volume 1 ? ? issue 1

Anaesthesiology M.P. 1

CONTENTSANAESTHESIOLOGY

M.P.

Dr. Meenu Chadha

Editorial - Pain Physican - Learning Dilemma

21

Dr. Anil K Sharma, Ann Maresca PA-C

Review Article - Chronic Spinal Pain - Diagnosis

32

Prof. Poonam Malhotra Kapoor

Nuances of Social Media in Medical Journalism

103

Dr. Neelima Tandon, Dr. Suman Gupta, Dr. Preeti Goyal,

Dr. Bhanu Choudhary

CASE REPORT - Commencement of Early and Uninterrupted Chest only Compression CPR is the Failsafe technique in Sudden Cardiac Arrest 134

CASE REPORT - Unusual Case of Consecutive Snake bite of three Persons

165

Dr Ashish Sethi, Miltan Debbarma, Neeraj Narang,Anudeep Saxena, Mamta Mahobia

Correlation of Goal- Directed Preoperative Optimization with Clinical outcone in Emergency Abdominal Surgery

196

Dr. Priya Shenwani, Dr. Pradeep Meshram, Dr. Neeraj Narang

CASE REPORT - Case of Uncorrected Tetralogy of Fallot Posted for closed reduction and Hip Spica Application for Fracture of Shaft of Femur 267

Dr. Meenu Chadha, Dr. Dharna Jain

CASE REPORT- Flexometallic Endotrachel Tubes Are They Really Safe?

298

Submission Guidelines

329

EDITOR

Dr. Meenu Chadha

CO-EDITOR

Dr. Alok Biyani

EDITORIAl BOARD

Dr. Mayank Kulshreshtha

Dr. Ashwin Soni

Dr. Suman Gupta

Dr. Ruchi Tandon

Dr. Ashish Sethi

Dr. Harsh Mangal

ADVISORS

Dr. T.C. Kriplani

Dr. V.M. Agnihotri

Dr. R.C. Agarwal

Dr. V.K. Joshi

Dr. M.M. Neema

Dr. Bhanu Ved

Dr. K.G. Vijayan

Dr. K.K. Arora

Dr. Shikha Mehrotra

Dr. Aditya Agarwal

Dr. Dilip Kothari

Dr. Sadhana Sanwatsarkar

Dr. Sudhakar Diwedi

Dr. Manorama Singh

Dr. Rajnish Jain

Dr. S.R. Lad

Dr. Maj USSV Meher, Gradee Specialist (Anesthesiology)

Chief Anaesthetist, Pain Physician & OT SuprintendentVishesh Hospital [email protected] 9977161035

ConsultantApollo Hospitals [email protected]

PAIN PHYSCIAN - LEARNING DILEMMAhe anaesthesiologist has played a primary role since beginning in pain Tmedicine. Late John J Bonica an anaesthesiologist was the first to develop his career

promoting multidisciplinary pain care and formal training of a specialist. The International

Association for the Study of Pain (IASP) was founded in 1974. Interventional pain medicine is evolving as a distinct discipline that requires detailed

knowledge and expertise. Familiarity with radiographic anatomy for image guided injections

and the minor surgical skills needed to implant devices such as spinal cord stimulators and

implanted delivery systems are just a few of the techniques that many of us have master for pain

management. To introduce new interventional techniques to our own pain practice, how can we

ensure that we have been properly trained to conduct these techniques with safety & success?

Adequate exposure to these newer interventions/treatment alternatives is certainly necessary

to ensure its appropriate application & to optimize patient outcomes. We do not have scientific

data to define the average minimum level of experience that will be needed to achieve

competence especially for complex procedures that are associated with significant risks. New techniques are evolving at a staggering rate & we cannot rely solely on pain training

programs to provide all the technical training needed. Higher standards for minimal training are

needed.So the question is where we do stand as pain practitioners. It is time that the parent body

helps in giving insights into formulating some protocols for starting pain practice. In the mean time few considerations that can be kept in the mind of the practitioners are

suggested below:- Study the new techniques- Thoroughly study the published literature to gain a detailed

knowledge of all aspects of the technique.Attend a workshop- Preferably a hands on cadaveric workshop that allows introduction to

the techniques in a realistic setting. Plan and give adequate time for your initial procedure Get help during the initial conduct of the procedure- perhaps another experienced

practitioner ,an invited expert or team up with a colleague in a related discipline.Inform your patients- In detail about the procedure as to what to expect and what would be

the probable outcomes and also obtain written consent for the same.Examine your outcomes- Careful self audit in the initial stages of using any new technique

and comparing them with those of your colleagues or published literature.Hippocratic oath” Primum non nocerum” i.e. First do no harm should be our goal.So need of the hour is that all pain physicians should be involved not only in research and in

publications, but in formulation of protocols for diagnosis, investigation and evidence based

treatment algorithm. Meenu Chadhal

Anaesthesiology M.P.2

E d i t o r i a l

1. President, Spine & Pain Centre NJ & NY. Director, Pain Management Monmouth Medical Centre NJ, USA.

2. Certified Physician Assistant.

Chronic Pain

Spinal Interventional Techniques

Chronic pain is defined as a pain that persists 6

months after an injury and/or beyond the usual

course of an acute disease or a reasonable time for

a comparable injury to heal. It is associated with

chronic pathologic processes that cause

continuous or intermittent pain for months or

years and may continue in the presence or

absence of demonstrable pathology and may not

be amenable to routine pain control methods with 2,7healing never occurring.

However, chronic pain must not be confused 7with chronic pain syndrome which is defined as a

complex pain condit ion with physical ,

psychological, emotional and social components.

While chronic pain and chronic pain syndrome

may appear similar and may at times coexist,

chronic pain syndrome encompasses the added

components of certain psychological ,

socioeconomic influences and psychological

behavioral patterns.

Chronic spinal pain is a complex and

multifactorial phenomenon. There is high

prevalence of chronic spinal pain and there are

numerous modalit ies of treatments in

management of the problem. Despite its

commonality, both in primary care and tertiary

care, it is often difficult to reach a definite diagnosis

of the origin of spinal pain. Interventional Pain

Management techniques are based on the

philosophy of a neurophysiologic and anatomical

basis, in that when present, a structural origin of

pain is important and blocking that structure with

an anesthetic will relieve the pain. A major source

of growth in treatment modalities and their failure

is because of lack of accurate diagnosis. In the

absence of accurate diagnosis, treatment fails

resulting in wasted health care dollars, and

diversion of essential health care resources.

Fundamental to proper treatment is accurate

diagnosis, which is based on the reliability of the

test used to make the diagnosis. There are no

universally accepted gold standards for the

diagnosis of spinal pain, regardless of the 1,2,3,4,5,6,7,8,9,10suspected source. . Controlled studies

have established intervertebral disc, facet joints,

and sacroiliac joints as potential sources of low 2,3,4,9,11,12,13,28back pain. Accurate diagnosis can be

17made by interventional techniques in diagnosing

the source of pain due to intervertebral discs, facet

joints and sacroiliac joint . For some patients there

can be multiple pain generators.

Based on history, physical examination,

imaging, and nerve conduction studies in non-

radicular pain, a precise cause of pain may be

Controlled Diagnostic Injection Techniques

CHRONIC SPINAL PAIN- DIAGNOSIS

l 1 2Dr. Anil K Sharma Ann Maresca PA-C


REVIEW ARTICLE

identified in only approximately 15% of patients.

However, it has been described that with

application of controlled diagnostic interventional

techniques, a diagnosis may become a reality in 3,4,5, 6,9,14,1585% of the patients rather than 15%.

In order to determine the pathophysiology of

clinical pain, the site of nociception, and the

pathway of afferent neural signals, precision

diagnostic blocks are utilized. Provocation

discography, sacroiliac joint injections, and facet

joint injections are part of the armamentarium of

diagnostic techniques with proven accuracy.

Controlled diagnostic blocks have a theoretical

basis that if a patient has legitimate pain from a

specific targeted structure, complete or near

complete relief of that particular pain should be

obtained consistently whenever that structure is

anesthetized. Accuracy can be obtained by

repeating the diagnostic block with different

anesthetizing agents, rendering a consistent

response.

For a diagnostic block to have face validity it

must be shown that the block actually does what it

is supposed to do in an anatomical and a 15, 16physiological sense. The targeted structure

must be proven to have been anesthetized and

that a documented result was either produced or

not produced. Face validity can be tested and

established either by a study whose results can be

replicated in each and every case. Other options to

establish face validity are injecting a contrast

agent utilizing radiographic imaging or by a

physiological approach utilizing a detectable and

testable function other than pain, such as distal

extremity temperature monitoring with a

sympathetic block.

Construct validity establishes if the test

actually achieves what it is supposed to achieve by

measuring the extent to which a test correctly

distinguishes the presence, but also the absence,

of the condition that the test is supposed to detect.

Construct validity measures if the test actually 15,16works or not, and how well it works.

There is no standard criterion for diagnostic

interventional techniques, such as imaging

findings, operative findings, or pathological

findings. For certain types of blocks, long-term

relief, however, may be used to provide standard 15criterion. Thus, Bogduk has developed testing for

construct validity of diagnostic blocks by other

means. Features such as the false-positive rates

can be estimated by determining how often a

diagnostic block is positive in patients who should

not, or demonstrably do not, have the condition in

question. Once the false- positive rates are known,

the specificity of the test can be derived as the

complement of the false-positive rates.

A protocol requiring a series of three blocks

utilizing a placebo may be utilized as one form of

control. The first block must involve an active

agent, in order to establish that the targeted

structure was indeed the pain generator. The other

2 agents are administered on a randomized

double-blind basis. Given these conditions, a true-

positive response would be yielded on every

occasion the active agent was used and no

response when the inactive agent was used.

A second approach, most commonly utilized in

the United States because it is also a more

pragmatic approach, is to use comparative local

anesthetic blocks. The blocks are performed on

separate occasions using local anesthetic agents 15,16,17with different durations of action. The

consistency and duration of the response are

tested in this approach. Inconsistency is

established if there is failure to respond to the

second block, thus indicating a false positive with

the first block. A positive response occurs if the

response is concordant with the expected duration

of action of the anesthetizing agent.


discography screening can decrease the number of

unnecessary operations. The discrepancy in

opinions is based on the lack of positive outcomes

with surgical interventions for discogenic pain.

Proponents of discography also argue that it is

the only diagnostic modality that attempts to

correlate pathology with symptoms. This point is

reasonable given the fact that close to two-thirds

of asymptomatic subjects have been found to have

abnormal findings on MRI and CT scans of their 16,18,27lumbar spines, As a means to reduce the high

false-positive rates associated with provocation

discography in certain subgroups, the use of

anesthetic discography has recently generated

significant interest.

The evidence for provocation discography is

fair. Due to ongoing debate on the accuracy of this

test and the lack of outcome parameters in

patients undergoing surgical interventions, the

evidence is subject to other interpretation. There is

limited evidence supporting functional anesthetic

discography.

Lumbar facet joints are pairs of joints that

stabilize and guide motion in the spine. Lumbar

facet joints are a well-recognized source of low

back and referred pain in the lower extremity

above the knees in patients with chronic low back 2, 3, 11, 12, 13, 28pain. Facet joints are innervated by the

3medial branches of the dorsal rami.

Degenerative spinal changes observed on

radiologic imaging studies, including radiographs,

MRI, CT scanning, single photon emission

computed tomography (SPECT), and radionuclide 28, 30, 31bone scanning are common and do not point

out to a specific pain generator. There is ongoing

debate about whether there is association

between degenerative changes in the lumbar facet

joints and symptomatic low back pain.

Lumbar Facet Joint Pain

Diagnosis of Chronic Low Back Pain

Diagnostic Selective Nerve Root Blocks

Lumbar Discography

Lumbosacral selective nerve root blocks

and/or transforaminal epidural injections are used

for the diagnosis and treatment of different

disorders causing lower extremity pain: however,

a clear consensus on the use of selective nerve

root injections as a diagnostic tool does not 6,20currently exist. Though, if a particular spinal

nerve is thought to be responsible for causing or

mediating a patients' symptoms, then

theoretically anesthetizing that nerve should

provide temporary pain relief, thereby creating

the rationale behind the diagnostic spinal nerve

block. Based on the present comprehensive 6,21,22evaluation of the available literature,

diagnostic selective nerve root blocks may be

recommended with limited evidence.

Discography is a procedure that is used to

characterize the pathoanatomy/architecture of

the intervertebral disc and to determine if the

intervertebral disc is a source of chronic low back 23pain. Basic and clinical studies have shown that

the lumbar discs are innervated and can be a 24source of pain.

Chronic low back pain patients with suspected

discogenic etiology, who are willing to consider

surgery and other less invasive options should be

the only patient population considered for this

invasive diagnostic test. There is data that it can

accelerate the degenerative process as well as can

cause herniation, so this should not be performed

just to find the pain generator.

Opponents of discography contend that

escalating numbers of unnecessary fusions have

been performed in the United States each year for 25,26indications of discogenic pain. However,

proponents argue that when properly utilized,


Standard clinical features and examination are

unreliable in diagnosing lumbar zygapophysial

(facet) joint pain. For the diagnosis of low back

pain, there is no universal gold standard, no

matter what the suspected source, i.e. facet

joint(s), intervertebral disc(s), or sacroiliac joint(s).

Controlled local anesthetic blocks continue to be

the best available tool to identify facet joint(s), or

sacroiliac joint(s) as the source of low back pain.

Controlled diagnostic blocks of a lumbar facet or

zygapophysial joint can be performed by

anesthetizing the medial branches of the dorsal

rami that innervate the target joint, (keeping in

mind that 2 nerves have to be blocked for each

joint). The false-negative rate of diagnostic facet

joint blocks was shown to be 8% due to

unrecognized intravascular injection of local 29anesthetic. The gold standard would include a

placebo-controlled technique, but due to cost

implications and to the ethical and logistical issues

of designing a true placebo, there is limited clinical

utility for this technique.

There was only one study evaluating 50% to 74%

relief as criterion standard with a single block 12showed the prevalence of 48%, 4 studies

evaluated 75% to 100% relief as the criterion

standard with a single block showed a prevalence of 32,3331% to 61%, 5 studies evaluated 50% to 74%

relief as the criterion standard with controlled

diagnostic blocks with the prevalence of 15% to 33 1361%, and studies evaluated 75% to 100% relief as

the criterion standard with controlled blocks with a

prevalence of 25% to 45% in heterogeneous 13,19,34,35 populations. The evidence is good for

utilization of 75% to 100% pain relief with

controlled diagnostic blocks as the criterion

standard with a prevalence of 25% to 45%.

The sacroiliac joint is accepted as a potential

source of low back and /or buttock pain with or

Sacroiliac Joint Pain

13,36without lower extremity pain. The sacroiliac

joint receives innervation from the lumbosacral

nerve roots. There is no universally accepted gold

standard for the diagnosis of low back pain

originating from the sacroiliac joints. A

combination of provocative manipulations tends

to be useful in localizing the sacroiliac joint as the

pain generator for patients with symptoms below

the fifth lumbar vertebra.

38,39The sacroiliac joint is well-innervated with

nociceptors and proprioceptors, even though the

pattern of innervation is the subject of much

controversy. There are no non-invasive tests to

make the diagnosis of sacroiliac joint-mediated

pain, sacroiliac joint blocks appear to be the

evaluation of choice.

There were 2 studies evaluating 50% to 74% 41,44relief with dual blocks. the prevalence of SI joint

pain was 38% with 50% relief and 26.6 % with 70%

relief.

There were a total of 8 studies meeting the

inclusion criteria evaluating sacroiliac joint pain

using a cutoff threshold between 75% and 100% 12,37,40,42,43relief following a single block. The

prevalence in this group ranged from a low of 10%

to a high of 62%.

There were a total of 7 studies meeting the

inclusion criteria with 75% to 100% relief with dual 10,13 blocks, Using the 75% and 100% pain relief with

dual blocks as the criterion standard the

prevalence ranged from 10% to 44.4% and has

been advocated by some as the most rigorous 2, 28means for diagnosing sacroiliac joint pain.

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Interventional techniques in the management

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2000:3:7-42.

2. Manchikanti L, Bosell MV, Singh V, Benyamin

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1. Department of Cardiac Anaesthesia, CNC, AIIMS, New Delhi

NUANCES OF SOCIAL MEDIA IN MEDICAL JOURNALISM *

l 1Prof. Poonam Malhotra Kapoor

o one in today's era of technology wants to be

belonging to past dawns, but wants to move Nahead to the noon of the future. Today, social

media is being used aggressively by medical

publishers to promote knowledge, spread ideas

and create platforms, where they can

communicate their message. Social media helps

guide them to create discussions amongst

colleagues and across the globe on latest topics in

their fields of medicine. It helps journals increase

their scope by broadening the readership with a

larger population viewing the recent journal

articles. Social media has seen rapid growth in

popularity in the last few years. There is

widespread use of sites such as facebook and

twitter amongst medical journals and a growing

number of well-established blogs and internet

forums that are aimed specifically at medical

journals such as that for Circulation, British

Medical Journal, New England Journal of Medicine,

Lancet, JCVA etc. Cobwebbed, by the desires to

reach the masses, most established as well as

upcoming journals, put their best foot forward and

leave no stone unturned in putting the journal

articles for enhanced viewership. None of them,

but don't realize that further down, there is a trap! !

In promoting the journal, we are spending time,

energy, money to be seen online and stay hooked

on to the social media for very fast journal article

updates! But, are we gaining or loosing?

THE PROS OF SOCIAL MEDIA

Explosion of Social Media

It's hard to oppose the social media blitzkrieg

adoption of newer technology all of which are

great drivers of change in medicine. Social Media

is one such technology which has had a massive

effect on making die world increasingly shrink to

become a hub of global knowledge reach more

people and increase readership. This makes us all

medical professionals across the world, sail in the

same boat of social, international knowledge but

which is not without paradoxes! It's hard to

oppose the social media storm, but we need to

focus at least half as much attention on a quietly

worsening viewership crisis!!

The online information environment has

evolved from a world in which users searched

information (web 1 .0) to a world where they are

now able to generate and spread information

themselves (web 2.0). This has shifted the focus

from content-centric to user-centric information

environment, leading to no explicit direction of

information flow, with the reader interacting

through social media with all three namely the

sources, the medium and importantly with each

other and leading to no contact with the direct

supplier!!

A lot of work by the researchers needs to

frame the implications of the explosion of new

REPUBLICATION

* From Annals of Cardiac Anaesthesia ISSN 0971-8561/Volume18/Issue3.


social media and web technologies in the specific

context of risk and benefit to the journal status.

It is important at all times to be aware of the

journals online image and how it can impact its

professional standing.

Social media applications like Facebook.

Twitter. Linkedln. and Youtube are extremely

popular and its use is growing exponentially

[Figure I]. However, it is time-consuming. It has

replaced human meetings and behavior and

interactions. Thus, though being online is an

advertisement, it has led to the offline basic

intricacies woven around human emotions and

bonds going for a toss! "Googling emotions" and

"sharing them online" is weakening human

bonds, and one shudders that the "hard copy"

replaced by a "soft copy" of the journal, brings

about a fission of fear of deterioration in "active

journal" reading without a "hardcopy" in hand.

The budget being used while putting a

medical journal on social media is of utmost

importance. Dr. Ryan in a Google interview on 1"The scope" said about the famous journal

Circulation going on the Facebook and Twitter

with the aim of improving the scope of readership

that most readers felt that a low budget strategy

was not a good platform to read an article. An

article may be hit by thousands, but read only by a

few tweets. The viewers get the message, but the

primary article as it is, is safely stored in their

phones and never read!! And the journal has

spent effort and money to put it on the phone!

Social media opens the era of citizen and

collaborative journalism, wherein professional

journalism can both create new medical news

collaboratively and interactively with the public,

THE CONS OF SOCIAL MEDIA

THE CONS OF SOCIAL MEDIA

SOCIAL MEDIA - A PARADOX

but it also uses the latter as "feat - on the streets"

eye - witness reporters, whether it is with social

bookmarking or twitters hash-tags! Effective

social media communication requires clear

identification and thorough understanding of the

target audiences. It needs appropriate

management of information provision, so that it

optimally enhances the journals status amongst

the readers.

2The American Medical Association and the 3Federation of State Medical Boards provide basic

instructive guidelines for the use of social media,

in which it emphasizes the need to protect patient

privacy and confidentially and to maintain a

professional journalism discipline. It is imperative

for a medical journal to keep professional and

personal activity separate. Facebook users have

no control over what the readers may post about

them! It is important to remain within their

professional ethics and discipline to enhance its

image.

A personal and professional touch to the social

media campaign is required for all "online

MAINTAIN PROFESSIONAL BOUNDARIES ON

SOCIAL MEDIA

FUTURE CHALLENGES IN MEDICAL JOURNALISM

USE OF SOCIAL MEDIA

Figure 1: Networking of social media application


important to establish dual online identities, to

separate personal and professional identities.

An evolved and ethical use of social media will

take medical journalism UP Sky High for as told by

Buddha "Thousands of candles can be lighted from

a single candle, but the life of a candle will not be

shortened."

Medical education shared on social media too

is like the candle that never decreases by being

shared.

1. Dr. Ryan. Health care insider: Surprising

findings from a study about using social media

to promote journal article. An Interview.

2. http://www.ama-assn.org /ama/ pub /

physician-resources / medicalethics / code-

medical-ethics / opinion9124.

3. Model Policy Guidelines for the Appropriate

Use of Social Media and Social Networking in

Medical Practice. Federation of state medical

boards, http://www.fsmb.org/ pdf/pub-

social-media-guidelines.pdf.

4. https://www.wsma.org/Media/Legal-pdfs /

Social_media_WSMA % 20 Statement _

20130821 .pdf.

5. Leiker M. When to "friend" a patient: Social

media tips for health care professionals. WMJ

2011;110: 42e3.

REFERENCES

success" without a personal face to it. Instant

interaction with the "reader's online queries"

whether on the blog or on a tweet is the need of

the hour. Engaging the readers in a journal

accounts conversation involving multiple

organizations helps bring more authors to spread

more research knowledge and take it up also on

public health issues. Involving the public is

important Researches in medical fraternity must

be explained to the masses through social media.

All this is what will make medical journalism savvy 4on the social media.

The mannerism in which one delivers the PDF

on the gadgets is important too! Lengthy pages,

small fonts are not the preferred technique by the

viewers. What is seeked in an article is

minipodcasts through brief interviews, short video

commentaries or through infographics as well.

Most readers follow only much evolved strategies

on social media and most of them, may read the

journal online or in the mailbox. This paradox is

challenging.

Awareness and interest in social media, though

it has hit medical journalism like a bulwak in recent

years, is still in its infancy. A prompt call for social

media guidelines to prevent unprofessional

content and breaches in patient confidentiality is

the need of the hour. Further research is essential

to harmonise the ethical aspects of clinical

manuscripts, being seen on Facebook and other 5sites, for which as suggested by Leiker et al., it is

CONCLUSION


1. Associate Professor Dept. of Anaesthesiology GRMC, Gwalior

2. Assistant Professor Dept. of Anaesthesiology GRMC, Gwalior

3. Associate Professor Dept. of Anaesthesiology GRMC, Gwalior

4. Professor & Head Dept. of Anaesthesiology GRMC, Gwalior

COMMENCEMENT OF EARLY AND UNINTERRUPTED CHEST ONLY

COMPRESSION CPR IS THE FAILSAFE TECHNIQUE IN SUDDEN CARDIAC

ARRESTl

1 2 3 4Dr. Neelima Tandon , Dr. Suman Gupta , Dr. Preeti Goyal Dr. Bhanu Choudhary ,

Case Report

Abstract:

Introduction:

Cardiopulmonary resuscitation is a versatile

term which encompasses so many techniques

which are updated every five years by the American

Heart Association. When suddenly confronted to

do so, it storms one's brain before we actually put

in efforts to do so because of complexity of its steps

and urgency to execute it immediately without

delay for it to be effective. Chest compressions are

the good means to maintain blood flow to victims

brain, heart and other vital organs .Here we

illustrate a true life story of how an out of hospital

cardiac arrest was managed by chest compression

CPR only.

Cardiac arrest is a condition in which the heart 1abruptly stops pumping blood. A Standard

cardiopulmonary Resuscitation (CPR) involves

alternating chest compression with rescue

breathing. For >50 years this combination of chest

compression and rescue breathing has been a 2 standard CPR.

Out of Hospital Cardiac arrest is a major public

health problem, affecting approximately 300,000 3individuals in the united states annually

In India-no definite survey been carried out to

reveal data related to cardiac pulmonary

resuscitation.

It's a great horror when you self visualizes a

faint of heart .At such times, it is better to do some

CPR rather than doing nothing, even if you are not

trained or certified provider .We need to alter the

mind set of trained personnel as well as layman

that chest only compression CPR (COCCPR) can be

executed by anybody whom so ever witnesses

circumstances of sudden cardiac arrest.

Here we report a real life incidence of sudden

cardiac arrest , revived as a result of only chest

compression CPR . A 74 years elderly woman was

about to retire to bed. Suddenly she grumbled

loudly that the bystander rushed to her and found

her to be unresponsive bystander. Bustander being

anaesthesiologist tried to palpate carotid but

failed. Mouth to mouth was difficult as she was

edentulous. She Immediately bared her chest and

Case –report


Discussion-

Multifactorial efforts have been launched to

encourage bystanders to use compression only

CPR (COCCPR) because this approach is easier to

teach ,learn, remember and perform than

conventional CPR with rescue breathing. There are

multiple reasons of COCCPR being advantageous

over conventional CPR technique, including the

rapid deterioration of blood flow that occurs

during even with brief disruptions of chest

compressions, the long ramp up time to return to

adequate blood flow after resuming chest

compression, the complexity of conventional CPR,

the significant time required to perform the

breaths and the critical importance of cerebral and 4coronary circulation during arrest.

When a person has a cardiac arrest because of a

cardiac cause , such individual normally has plenty

of oxygen reserve in the body, thus rescue

breathings aren't as vital to survival as trying to 5keep blood flowing as regularly as possible.

Studies comparing survival rates of cardiac arrest

victims in the light of the kind of rescue efforts

performed by the bystanders has concluded that

chances of leaving the hospital alive were actually 6higher for patients who received COCCPR.

Rescue breathing is so difficult to perform that 7it can interrupt chest compressions. Minimizing

interruptions in chest compressions during

resuscitation attempts by bystanders might be

associated with increase in survival compared with 8conventional CPR. The reduction in venous return

during positive pressure ventilation also can be

associated with a worse outcome in those 9receiving conventional CPR.

Thus for a successful continuous –chest

–compression CPR, a certain steps can be followed 11as shown in the Table

started chest compression hard and fast

simultaneously calling for help ,knowing that it

might take several minutes for help to arrive. Only

chest compression CPR was continued, without

interrupting it for any period of time; until they

reached Intensive Care Unit (ICU) and continued

thereafter also. In ICU trachea was intubated and

ventilation started with 100 % oxygen with

continuing Chest Compression. All the routine

investigations as per ICU Protocol were done

(Arterial Blood Gases , Cardiac markers, Hbgm%,

Total Count, Serum Urea, Creatinine ,blood sugar

etc.).Monitors i.e. Electrocardiogram(ECG) ,Non

invasive blood pressure ( NIBP), Pulse oximeter (

SpO2) were applied and it revealed Asystole in

ECG. Immediately Inj. Adrenaline 1:1000 dilute in

10 ml Normal Saline was administered

intravenously without interruptions of chest

compressions in subsequence she had ventricular

fibrillation following which heart was shocked

with 120 joule biphasically along with CPR. Forty

five minutes elapsed till now, finally she reverted

back to sinus rhythm with occasional Ventricular

prematures contractions (VPC's ) per minute.

Inj.Amiodarone was administered 300 mg I.V

bolus followed by its infusion. She was kept on

ventilator for next two days with supportive

treatment with vasopressors. Slowly she was

weaned off and shifted to High dependency unit

(HDU) for next 5 days for observation and

discharged thereafter. Echocardiography shows

extensive anterior wall Myocardial Infarction with

EF 25% , akinetic and regional wall abnormality.

Coronary angiography done after a month showed

blockade in proximal LAD 80% , Distal LAD 50-60%

and RCA plaque. Stenting was done as mode of

treatment .Now she is asymptomatic and actively

doing her day to day activities . Hence chest

compression only CPR turned out to be the Best

CPR than conventional CPR to help victims of

sudden cardiac arrest.


Table 1. Steps for Continuous Chest

Compression CPR

Conclusion:

1. Call for help on 108 by yourself or ask someone

to do the same.

2. Position the patient on the floor ,face up. Bare

patient chest . Place the heel of one hand on the

center of the chest with the heel of the other

hand on top of the first .Lock your elbows so

that your arms are straight. Position your

shoulders directly above the center of the

patient's chest and fall so that the weight of

your upper body compresses the patient's

chest . Perform fast , forceful chest

compressions at more than 100/ min,

compressing the chest 1.5 to 2 inch. Allow time

for decompression

3. If an automated external defibrillator is

available ,open the patient's shirt and attach

the pads to the skin in the positions indicated

on the automated external defibrillator and

follow the machine's voice instructions .Keep

interruptions of chest compressions to a

minimum.

Hence COCCPR is easy to teach, learn, 7 ,10remember and perform But in our clinical

perspectives , there is nothing like all in one law

in most of the cases where lack of oxygen is the

primary cause of respiratory arrest like drug

overdose, alcohol intoxication, carbon

monooxide poisoning, severe asthma attack

,drowning, choking, conventional CPR with

mouth to mouth breathing remains the 1appropriate rescue technique.

We conclude that COCCPR is more effective

over conventional CPR in conditions of cardiac

arrest .Any interruptions in chest compression ,in

order to attempt rescue breathing will hamper the

blood flow to vital organs and lower the chances of

survival . Also COCCPR is less complex ,easier to

learn and remember, hence it should be

encouraged while doing Basic Life Support.

Note- In the present case report the bystander

was author herself and the victim was her mother.

1. C i r c u l a t i o n . 2 0 0 7 ; 11 6 : e 5 6 6 - e 5 6 8 doi:10.1161/CIRCULATIONAHA.107.740779

2. Safar P,Escarraga L A,Elam J O. N.Engl J.Med.1958:258:671-677

3. http://phys.org/news 205515381.html

4. http://phys.org/News 205515381.html

5. h t t p : / p h y s . o r g / n e w s / 2 0 1 0 - 1 0 - c h e s t -compression-only cpr-survival-cardiac.html

6. cardiopulmonary resuscitation by Bystanders with chest compression only(SOS-KANTO): an observational study: Lanset 2007; 369:920-926

7. Sayre MR, Berg RA, Cave DM , Page RL ,Potts J ,White RD: American Heart Association Emergency Cardiovascular Care Committee H a n d s - o n l y ( c o m p r e s s i o n -only)cardiopulmonary resuscitation :a call to action for bystander response to adults who experience out of hospital sudden cardiac arrest : a science advisory for the public from the American 2167.Heart Association Emergency Cardiovascular Care Committee Circulation.2008;117:2162-

8. Bobrow BJ, Clark LL, Ewy GA, Chikani V. Sanders AB, Berg RA, Richman PB, Kern KB. Minimally interrupted cardiac resuscitation by emergency medical services for out of hospital cardiac arrest JAMA 200;299:1158-1165.

9. AUfderheide TP, Sigurdsson G Pirrallo RG, Yannopoulos D, Mcknite S, von Briesen C, Sparks CW. Conrad CJ, Provo TA, Lurie KG. Hyperventilation-induced hypotension during cardiopulmonary resuscitation. Circulation 2004;109: 1960-1965.

10. 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation.2010-122;5639-5946

REFERENCES:


1. Deparment of Anaesthesia and crtitical care, Military Hospital Gwalior, Morar Cantt.

Abstract:

Background:

A case of Three NCC cadets bitten by the same

snake while sleeping in their tent at their NCC

camp. This interesting and unusual case occurred

in the rural area of Gwalior, M.P, and India. The

uniqueness of the case lies in the fact that all

three boys were bitten by the same snake.

Further, with negligible local signs of

Envenomation, two of the patients presented

with classical signs of neurotoxicity. The third

patient suffered no ill-effects and was kept under

observation in the ICU. Notwithstanding the

numerous superstitions associated with snake

bite, all of them were rushed to our hospital

immediately and made a complete and

uneventful recovery.

Since time immemorial, snakes have inspired

an awe mixed with fear in our mind. In India,

these reptiles are greatly feared and hence

worshipped. In India, snakes are found

everywhere from the icy heights of the Himalayas

down to Andaman island.

India is inhabited by more than 60 species of

venomous snakes out of which only four have

been popularly known to be dangerously

poisonous to man; cobra, common krait, Russell

1viper and Saw Scaled Viper . In India each year

approximately 200,000 number of cases of snake

bite are reported, out of which 45,000 to 50,000 2succumb to death . India is recognized as having

the highest snakebite mortality in the world. Most

of the fatalities are due to the victim not reaching

the hospital in time and are preventable. This

instance of multiple envenomation with

neurotoxicity by the same snake has not been

reported often in scientific journals.

Three NCC cadets aged between 17-20 years

were sleeping in their tent at their campsite on the

outskirts of Gwalior. All three were asleep when

they were allegedly bitten by a snake. The first boy

was bitten on his left ear.by the time he was alert

and pushed it away realizing it was a snake, he was

bitten again on his right hand also. the snake bit

the second boy who was sleeping on his right

upper arm. The third boy was bitten on his right

leg, however, with no fang marks or skin break.

Since they were in an organized camp, an alarm

was raised and the cadets shown to the

paramedical staff (Nursing assistant) present at

the camp site. A loose tourniquet was applied

(handkerchief) and immobilization of the affected

areas of all the three patients was done. The

Case presentation:

UNUSUAL CASE OF CONSECUTIVE SNAKE BITE IN THREE PERSONS

Case Report

l 1Dr. Maj USSV Meher, Graded Specialist (Anesthesiology)


further evaluation.

(b) The second cadet presented with c/o bulbar

symptoms with pupils mid-dilated. Fang marks

were clearly visible on right hand with no local

reaction. ASV 100 ml given over 1 hr. Adjunct

therapy including Dexmedetomidine infusion, IV

antibiotics, PPI inhibitors, Inj Neostigmine with

glycopyrrolate was given as for the first cadet. The

same evening, the patient developed stridor with

acute onset respiratory distress with worsened

bulbar symptoms with pooling of secretions.

ABG showed Co2 retention with fall in SP02. In

view of the above, the patient was placed on

ventilator support. SCMV mode initial FIO2 – 70 %.

He was reassessed after 24 hrs, when he had a

power of grade 4/5 and ptosis was markedly

reduced. He had normal eye opening to command.

He was put on T-piece support. He was extubated

the same evening after 24 hrs of ventilation. He

made a complete recovery and was discharged

after seven days of hospital admission.

(c) The third patient had no signs of

envenomation or any other signs of neurotoxicity.

He was placed in ICU for observation and shifted to

medical ward after 48 hrs.

Snakebites remain a public health problem in

many countries. The snake venom consists of

different enzymatic and non-enzymatic

components. The nature of the symptoms in our

scenario indicates the neurotoxic nature of the

venom. Neurotoxic envenomation has the potency

to cause a broad spectrum presentation ranging

from ptosis and opthalmoplegia to respiratory

arrest. Timely administered anti-venom and

ventilator assistance can prevent the mortality and

morbidity of the victims. The use of anti-

cholinesterase therapy helped accelerate the

clinical recovery by combating post-synaptic toxins

released by the snake venom.

Discussion:

cadets were rushed to the Accident &Emergency

room of Military hospital Gwalior, Morar Cantt.

They reached here at 0420 hrs.

According to the history given by the cadets on

admission the snake managed to crawl away.

Hence the snake was not available to identify its

species.

(a) The first cadet presented with c/o problems

in swallowing and difficulty in opening eyes, pain

and numbness in the body. He had some classic

signs of neurotoxicity, viz.Ptosis, Bulbar symptoms

like drooling of saliva, sluggishness, apathy,

disorientation, slurring of speech, and difficulty in

respiration . GCS 15/15 On examination of bite site,

there was slight redness on left ear without any

features of swelling, bruising, blistering, local

bleeding, etc. Arterial blood gas was normal. ICU

protocol including clott ing profi le was

ordered.ASV was started 5 vials ASV reconstituted

with 100 ml D/W was administered with 5 vials

repeated 6 hrly.over after premedication with Inj

Hydrocortisone/Avil. However, patient had an

attack of severe bronchospasm with rapid

desaturation. He was immediately intubated and

placed on ventilator support on Galileo Gold. He

was put on SCMV mode withFio2 @ 50 %. Inj

Neostigmine 0.05 mg/kg with 0.6 mg Atropine was

given I.M and repeated every6 hrs. he was put on

Dexmedetomidine 0.5 mcg/kg hrly infusion. The

adjunct therapy included antibiotic, PPI inhibitors,

iv. fluids etc. This standard treatment continued for

24 hrs. He was reassessed subsequently Fio2

decreased to 40 %. Power improved to grade 4/5.

He was then put on T-piece with marked

improvement in eye opening and was extubated

after 36 hours and later monitored. The patient

made a remarkable recovery and was discharged

without any sequelae after seven days of hospital

admission. He was asked to report after 1 week for

Signs and symptoms:


Multiple snake bites are relatively common.

However, instances of successive bites by the same

creature at the same instance are relatively

unheard of.

Consent:

Written informed consent was obtained from

the patient for publication of this Case report and

any accompanying images.

Figure 1

Figure 2

Images :- 1& 2: Patient victims of multiple envenomation from a single snake bite, admitted in our ICU

with typical neurotoxic symptoms pre & post convalescence.

References:

1. Mohapatra B,Warreil DA,Suraweera W,Bhatia P,Dhingra N,Jotkar RM,Rodriguez PS,Mishra

K,Whitaker R,Jha P,Million death study.

Collabarators.Snake bite mortality in india:A nationally representative mortality survey, PLoS, Negi

Trop Dis. 2011 Apr 12;5(4):e1018.

2. WHO SEARO (2010): Guidelines on management of Snake-bite New Delhi: WHO Regional office for

South- East Asia.

3. National Snake bite management protocol,2009.

4. Anjum Arshad et al. The Pan African Medical Journal - ISSN 1937-8688: A snake bite on scrotum-a

case report. http://www.panafrican-med-journal.com/content/article/10/25/full/.


1. Department of Anaesthesiology and Critical Care, Netaji Subhash Chandra Bose Medical College, Jabalpur

CORRELATION OF GOAL- DIRECTED PREOPERATIVE OPTIMIZATION WITH CLINICAL OUTCOME IN EMERGENCY

ABDOMINAL SURGERY

l 1Dr. Ashish Sethi, Miltan Debbarma, Neeraj Narang,Anudeep Saxena, Mamta Mahobia.

Peritonitis is inflammation of the peritoneum

and is most commonly due to a localized or

generalized infection. It can be primary, secondary

or tertiary based on the source and nature of

microbial contamination.Secondary Peritonitis which is due to

perforation of the hollow viscus continues to be

one of the most common surgical emergencies.

Risk factors among the general population include

among others, helicobacter pylori infection,

indiscriminate use of steroids and non steroidal

anti inflammatory agents, and enteric fever in

addition to several other less common causes. This

condition most of the times needs an emergency

surgical intervention. Since there is lack of data in

India regarding its prognostic indicators, morbidity 1and mortality patterns, application of a scoring

system, is needed to stratify patients to assess the

type and level of care required for a particular

patient.

The management protocols include surgical

intervention, broad spectrum antimicrobial

therapy and intensive care support. Despite this,

management of peritonitis is highly demanding 2and complex. This group of patients invariably

present with features of sepsis on admission, and

thus the management of sepsis has to be primarily

incorporated in the perioperative management

protocol.

There are various scoring indices such as Acute

Physiology and Chronic Health Evaluation

(APACHE) score (based on 34 Physiological 3,4,5parameters) , the multi organ failure (MOF)

3,4score , and the Mannheim Peritonitis Index 3,6,7,8,9,10(MPI) , for risk stratification in patients of

perforation peritonitis. APACHE II was later

developed as a simplified and clinically useful 11system using 12 physiological variables. The

score can be translated to a mortality risk level that

correlates with observed mortality with

reasonable accuracy.

APACHE II scoring system has been found to be

superior in the prediction of outcome in critically ill

patients with perforation peritonitis in some 12studies. This system is able to stratify a wide

variety of patients prognostically because of the

strong and consistent underlying relationship

between acute physiologic derangement and the

risk of death during acute illness. Acute

Physiological score of APACHE II tends to change in

conditions leading to deranged homeostasis.

This study has taken into account the APACHE II

score and tried to establish a relationship between


goal directed optimization, surgical source

control, changes in serial APACHE II scores and

clinical outcome.

1. Assessment of APACHE II score at

presentation.

AIMS AND OBJECTIVES

2. Assessment of APACHE II scores 24 hours

postoperatively.

3. Evaluation of the extent of change in APACHE

II score after goal directed optimization,

administration of empirical broad spectrum

APACHE II SCORING SYSTEM

Physiologic Variable

0Temperature-rectal ( C)

Mean Arterial

Pressure mmHg

Heart Rate (ventricular

response)

Respiratory Rate (non-

ventilated or ventilated)

Oxygenation A- aDO2 or

PaO (mmHg)2

a.F10 0.5 record2

b.A-aDO2

B. FI0 < 0.5 record PaO2 2

Arterial pH (preferred)

Serum Sodium (mEq/l)

Serum Potassium (mEq/l)

Serum Creatinine (mg/dl)

Double point score for

acute renal failure

Hematocrit(%)

White Blood Count

(total/mm2) (m 1000s)

Glasgow Coma Score

(GCS) Score ± 15 minus

actual GCS

A. Total Acute Physiology Score (sum of 12 above points)

B. Age points (years) < 44 ±1) 45 to 54 ±2) 65 to 74 =5) > 75 = 6

+4 +3 +2 +1 0 +1 +2 +3 +4 Points

o³41

o³16

³180

³50

³500

³7.7

³180

³7

³3.5

³60

³40

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040.9

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038.9

36 to

038.4

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035.9

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033.9

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£

029.9

130 to

0159

110 to

129

70 to

109

50 to

69 £ 49

140 to

0179

110 to

139

70 to

109

55 to

69

40 to

54 £ 39

35 to

049

25 to

34

12 to

24

10 to

11

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9

40 to

54 £ 5

350 to

499

200 to

349

< 200

PO2>70

PO2 61

to 70

PO2 55

to 60

PO2

<55

7.6 to

7.69

7.5 to

7.59

7.33 to

7.49

7.25 to

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7.15 to

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159

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High Abnormal Range Low Abnormal Range


antibiotics and definitive source control.

4. To observe the outcome in terms of duration

of hospital stay and mortality in both the groups.

After obtaining clearance from the institutional

ethics committee and informed consent the study

was carried out in the Department of

Anaesthesiology and Critical Care, Netaji Subhash

Chandra Bose Medical College, Jabalpur.

100 patients 16 years and above, of ASA

physical status I and II E with clinical diagnosis of

perforation peritonitis.

Group I (Case): 50 patients optimized by goal

directed optimization protocol in the pre operative

holding room by anaesthesiology residents.

Group II (Control): 50 patients managed by

surgery residents in the surgical wards without any

fixed algorithm.

* Spontaneous Bacterial Peritonitis

* Malignancy

* Negative Allen's test

* Anticoagulant therapy

* Patients requiring mechanical ventilation

pre or post operatively.

Patients with abdominal emergencies admitted

to general surgery units were prescreened and

were included in the study only after a clinical

diagnosis of perforation peritonitis was made with

reasonable certainty. Assessment of APACHE II

score was done as a first step and patients were

randomly assigned to one of the two groups, case

group(S) and control group (C). Patients of the case

group received standardized, algorithmic

METHODOLOGY

Selection of cases:

Criteria for exclusion:

STUDY PROTOCOL

management in the preoperative holding room.

Central venous cannulation was performed and

goal directed optimization of these patients was

carried out by the anaesthesiology resident on call.

Those in the control group were managed in the

surgery wards by the surgical resident on call.

Patients assigned to the case group were

optimized till the following targets were achieved

central venous pressure (CVP) between 8 and 12

cmH2O, mean arterial pressure (MAP) of 65 mmHg

or above, and urine output equal to or greater than

0.5 ml.kg-1 hr-1.

The protocol for goal-directed optimization

was as follows. Boluses of 0.9% saline (20-30 ml/kg

body weight) were given every 30 minute to

achieve the first goal (CVP 8 to 12 cmH2O). If MAP

was less than 65 mmHg after reaching the first

goal, vasopressor (nor epinephrine infusion) was

given to achieve and maintain the second goal

(MAP > 65 mmHg). Our third goal was to ensure a

urine output of > 0.5 ml/kg/hr.

In contrast, the patients in control group were

managed according to the clinical judgment

without any fixed algorithm. Empirical broad

spectrum antibiotic cover was given to all the

patients in both the groups.

Patients in the case group were taken up for

surgery after objectively achieving all three three

goals (end points of resuscitation) while those in

the control group were taken up for surgery after

subjective hemodynamic stabilization.

All patients received standard general

endotracheal anaesthesia. Intraoperatively

electrocardiogram (ECG), heart rate, oxygen

saturation (SPO2), non invasive blood pressure

(NIBP) and end tidal carbon dioxide (EtCO2), urine

output monitored.

Decision to extubate the patients or to

continue ventilation was based on the patient's


Table 1APACHE II SCORE ON ADMISSION

Group

Case

Control

Mean

6.8

7.1

SD

3.7

2.6

clinical condition and immediate postoperative

blood gas parameters.

Patients were closely monitored in post

operative recovery room for the next 72 hrs.

APACHE II scoring was repeated 24 hr

postoperatively. Patients were shifted to

postoperative ward after 72 hrs and followed up

till discharge from hospital. In hospital mortality

was taken as the outcome.

All case report forms were checked for

completeness and inappropriate or illogical

responses. The forms were entered using

Microsoft 2007 Excel worksheet. The data bases

were validated and all inconsistencies and

differences were resolved. Statistical analyses

were performed using STATA 12 for Windows

(Stata Corp E.P., Texas, USA). Categorical data are

presented as frequency counts (percent) and

compared using the chi-square or Fisher's exact

statistics as appropriate

OBSERVATIONS AND RESULTS

The mean APACHE II score on admission in case

group is 6.8 ± 3.7 and in the control group is 7.1 ±

2.6. There was no significant difference between

the two study groups.

There is a significant lowering of serial APACHE II

scores in case group as compared to control group

(p < 0.001).

There was significant lowering of mean duration

of hospital stay seen in case group (9.8 ± 1.7 days) as

compared to control group (11.26 ± 3.2 days) p <

0.005.

Table 2APACHE II SCORE, 24 HRS

Group

Case

Control

Mean

2.2

4.5

SD

3.2

3.2

Table 3DURATION OF HOSPITAL STAY (DAYS

Study

Case

Control

Mean

9.8

11.26

SD

1.7

3.2

Table 4

TYPE OF OPERATION DONE

Operation done

Primary Repair of ileal perforation withproximal ileostomy

Omentopexy of pre pyloric perforation

Primary repair of ileal perforation

Total

Case

22(44%)

27(54%)

1(2%)

50

Control

18(36%)

27(54%)

27(54%)

50

Total

40(40%)

54(54%)

6(6%)

100


The number of deaths in case group was 4%,

while that in the control group was 16%.

There was significant decline in death rate in

case group as compared to control group.

Majority of perforation peritonitis patients

present late with sepsis which further increases

morbidity and mortality. Both sepsis and third

space loss of fluid due to perforation leads to

imbalance between oxygen demand and delivery

resulting in tissue hypoxia and subsequent

multiple organ failure. Several studies support the

concept that persistent shock has an adverse

impact on survival in a time dependent manner

and therapeutic strategies involving early

recognition and rapid reversal of shock improves

survival.

Perforation peritonitis is a frequently

encountered surgical emergency in tropical

countries like India. It affects mostly the young.1,2

Despite advances in management protocols it

poses a formidable challenge for perioperative

physicians.2 Majority of cases present late with

features of sepsis and septic shock.13 Therefore

for such a setting there is enough justification in

favor of goal directed optimization which has

evidence based role in improving outcomes in

sepsis and septic shock as established after the

landmark study by Rivers et al.16

In this study, we found that majority of

DISCUSSION

patients had upper gastrointestinal tract

perforation; i.e. 54% suffered from pre-pyloric

perforation and rest had ileal perforation. This

concurs with earlier studies of R.S. Jhobta et al2,

and M.L. Ramchandran et al.14 which showed

greater percentage of perforation cases involving

upper gastrointestinal tract in India.

APACHE II (Acute Physiology and Chronic

Health Evaluation II) is a severity of disease

classification system (Knaus et al), 15 among one

of the several ICU scoring systems. It is applied

within 24 hours of admission in an intensive care

unit (ICU), an integer score from 0 to 71 is

computed based on several measurements;

higher scores correspond to more severe disease

and a higher risk of death.

We observed that majority of the patients in

case group showed features of sepsis; notably,

tachycardia (pulse rate > 90/min), tachypnoea

(respiratory rate > 20), hypotension (SBP < 90 0mmHg) and temperature > 38 C. Such patients

underwent a Goal Directed Optimization as per

our study protocol. Boluses of 0.9% saline (20- 30

ml/kg body weight) were given every 30 minutes

to achieve the first goal (CVP 8 to 12cmH2O). If

MAP was less than 65 mmHg after reaching the

first goal, vasopressor (norepinephrine infusion)

was instituted to achieve and maintain the second

goal (MAP > 65 mmHg). Our third goal was to

ensure a urine output of > 0.5 ml/kg/hr.

The initial APACHE II score taken at admission

was comparable in both case and control groups

(6.8 ± 3.7 vs. 7.1 ± 2.6), whereas there was a

significant reduction in APACHE II score 24 hours

post operatively in both the groups (2.2 vs. 4.5) (p

< 0.0001 vs. p < 0.001)

After optimization the surgeon proceeded

with definitive source control. The surgeries

performed in majority of patients were primary

repair of pre-pyloric perforation with omentopexy

Table 5

FINAL OUTCOME

Outcome

Death

Discharge

Total

Case

2(4%)

48(60%)

50

Control

8(16%)

42(84%)

50


(case 54% control 54%). This study is in agreement

with the study of M.L. Ramchandra et al.14

There was unanimity in mean duration of

hospital stay in this study as seen in the past

studies. Rivers E. et al 16 showed that there was

significant reduction in duration of hospital stay

among those who were treated by goal directed

optimization. In accordance, we found that

optimized patients in case group were discharged

early (9.8 ± 1.7) as compared to control group

(11.26 ± 3.2) (p<0.005).

The study of Han et al17 observed that early

shock reversal by adequate fluid resuscitation was

associated with improved outcome and each hour

of delay in resuscitation was associated with 50%

increased odds of mortality.

Another study of Whalen et al18 showed that

aggressive fluid resuscitation early in the

treatment course led to a decreased occurrence of

persistent shock and subsequently improved

survival of patients with septic shock.

In this study we observed a lower mortality

rate in the case group (4%) as compared to the

control group (16%) (p < 0.05). This study is

inspired by and broadly follows the principles

established in the landmark Rivers study, with

variations and modifications such as exclusion of

central venous saturation (ScvO2) measurement

largely due to resource limitations and feasibility

considerations prevalent in the day to day practice

in a government medical college hospital setting.

1. Sharma L, Gupta S, Soin AS, Sikora S,

Kapoor V. Generalised peritonitis in India- the

tropical spectrum. Jpn J Surg. 1991; 21:272-7.

2. Jhobta RS, Attri AK, Kaushik R, Sharma R,

Jhobta A. Spectrum of perforation peritonitis in

India-review of 504 consecutive cases. World J

Emerg Surg. 2006; 1:26.

REFERENCES

3. Notash AY, Salimi J, Rahimian H,

Fesharaki MS, Abbasi A. Evaluation of Mannheim

peritonitis index and multiple organ failure score

in patients with peritonitis. India J Gastroenterol.

2005; 24:197-200.

4. Rogy M, Fugger R, Schemper M, Koss G,

Schulz F. The value of two distinct prognosis score

in patients with peritonitis. The Mannheim

Peritonitis Index versus the APACHE Score,

Chirurg, 1990; 61:297-300.

5. Lee FY, Leung KL, Lai BS, Ng SS, Dexter S,

Lau WY, Predicting mortality and morbidity of

patients operated on for perforated peptic ulcers.

Arch Surg. 2001; 136:90-4.

6. Billing A, Frohlich D, Schildberg FW.

Prediction of outcome using the Mannheim

peritonitis index in 2003 patients. Br. J. Surg. 1994;

81:209-13.

7. Bosscha K,Reijnders K. Hulstacrt PF, Algra

A. van der Werken C. Prognostic scoring systems

to predict outcome in peritonitis and intra

abdominal sepsis. Br. J. Surg. 1987; 4:1532-4.

8. Kologlu M, Elker D, Altun H, Sayek I.

Validation of MPI and PIA II in two different groups

of patients with secondary peritonitis.

Heptogastroenterology. 2001:48:147-51.

9. Goris RJ, Boekhorst TP, Nuytinck JK,

Gimbrare JS. Multiple-organ failure: Generalised

autodestructive inflammation? Arch Surg. 1985;

44:937-46.

10. Makela JT, Kiviniemi H, Ohtonen P,

Laitinen SO. Factors that predict morbidity and

mortality in patients with perforated peptic

ulcers. Eur J Surg. 2002; 168:446-51.

11. Knaus WA, Draper EA, Wagner DP,

Zimmerman JE. APAC HE II acute physiology and

chronic health evaluation: a severity of disease

classification system. Crit Care Med. 1985;


13:818-29.

12. Samir Delibegovic, Dragana Markovic et

al. Apache II Scoring System Is Superior in the

Prediction of the Outcome in Critically III Patients

with Perforative Peritonitis in Pakistan: 300 cases.

Eastern experience. World J Emerg Surg 2008;

3:31.

13. Ersumo T, W/Meskel Y, Kotisso B.

Perforated peptic ulcer in Tikur Anbessa Hospital;

a review of 74 cases. Ethiop Med. J. 2005; 43:9-13.

14. Methikere Lingaiah Ramachandra,

Bellary Jagadesh, Sathees B.C. Chandra: Clinical

Study and Management of Secondary Peritonitis

due to Perforated Hollow Viscous; Arch Med Sci

2007; 3:1:61-68.

15. Knaus WA, Draper EA, Wagner DP,

Zimmerman JE. APAC HE II – acute physiology and

chronic health evaluation: a severity of disease

classification system. Crit Care Med. 1985;

13:818-29.

16. Rivers E, Nguyen B, Havstad S, Ressler J,

Muzzin A, Knoblich B, Peterson E, Tomlanovich M:

Early goal directed therapy in the treatment of

severe sepsis and septic shock. N. Engl J Med

345:1368Y1377, 2001.

17. Han YY, Carcillo JA, Dragotta MA: Early

reversal of pediatric neonatal septic shock by

community physicians is associated with

improved outcome. Pediatrics 112:793-799,

2003.

18. Whalen MJ, Doughty LA, Carlos TM:

Intercellular adhesion molecule-1 and vascular

cell adhesion molecule-1 are increased in the

plasma of children with sepsis induced multiple

organ failure. Crit Care Med 28:2600-2607, 2000.


Abstract:

Introduction

Congenital heart disease is one of the

commonest birth defect.Advancement of

medical and surgical skills have increased the

survival to adulthood. Hence, we encounter many

such children reporting for various disorders

requiring anesthesia for non-cardiac surgical

corrections. They pose a challenge for anesthesia

because perioperative morbidity and mortality is

greater compared with other children. The

anatomy and pathophysiology of defect of each

patient is different resulting in a varied response

during management. Hence, it is arduous to

manage these cases in basic set up without

invasive monitoring. We report a case of

uncorrected Tetralogy of Fallot posted for closed

reduction under anesthesia.

Key-words: uncorrected Tetralogy of Fallot,

shunt operation, right to left shunt, anesthetic

management, phenylephrine

Cyanotic Congenital Heart Disease (cCHD) is

characterized by intracardiac right-to-left

shunting of unsaturated blood and its distribution

into the systemic circulation resulting in arterial 1hypoxemia . Tetralogy Of Fallot is one of the most

common forms of cyanotic congenital heart

1. Department of Anaeshesiology, NSCB Medical College, Jabalpur

CASE OF UNCORRECTED TETRALOGY OF FALLOT POSTED FOR CLOSED

REDUCTION AND HIP SPICA APPLICATION FOR FRACTURE OF SHAFT OF FEMUR

l 1 2 3Dr. Priya Shenwani , Dr. Pradeep Meshram , Dr. Neeraj Narang

2disease . Most patients experience cyanosis at

birth and die in childhood without surgical

intervention. The rate of survival at 40 years 3without surgical correction is only 3% . The main

causes of death are chronic congestive heart

failure, secondary to the long-standing pressure

overload and consequent pathological changes in 4the right ventricle and arrhythmias . The

treatment consists of palliative procedures like

systemic-pulmonary (s/p) arterial shunts and

balloon dilatation of pulmonic valve; or definitive

surgical correction. Central shunt is a type of s/p

shunt in which artificial graft tube is placed in

between aorta and pulmonary artery.

We report a case of 6 year old boy weighing 15

kgs who reported in our hospital for pain and

swelling in right thigh and inability to move the

limb. He gave a history of fall on the ground while

playing. He was diagnosed with closed fracture of

proximal third shaft of femur right side. He was

posted for closed reduction of fracture and

application of hip spica under anesthesia.

The child was examined carefully as he had

marked central cyanosis and grade IV clubbing.

There was presence of loud systolic murmur and

click in the aortic area. Chest X-ray showed an

Case history

Case Report


titrated as per response. We noted that saturation increased after giving phenylephrine, but was fixed at 88%. There was no further rise in SpO2 despite increasing rate of phenylephrine.

After completion of the procedure, child was

shifted to the ICU for recovery and monitoring. He

was discharged from ICU the next day, with

uneventful course of events.

The children suffering from Tetralogy of Fallot,

which is one of the most common type of

congenital cyanotic heart disease, are chronically

hypoxemic. They have easy fatigability and become

breathless. They are also susceptible to recurrent

fever and chest infections. Usually they may have

growth retardation, delayed milestones, severe

metabolic derangements, multi-organ failure, and

major neurological deficits. They are prone for

vascular stroke, brain abscess, arrhythmias, heart 5, 6blocks, and infective endocarditis . Hence, it's

prudent to administer prophylactic antibiotics 6before any intervention in the operating room .

Cases with uncorrected defects are intricate,

but palliative correction makes them relatively

simpler. The ultimate goal of conducting such cases

is maintaining pulmonary blood flow and

hydration. There are many recognized factors

known to affect the direction of shunt flow and the

degree of shunting. Hence the main goal of

induction in a cyanotic patient is to establish

balanced anesthesia without increasing right-to-

left shunt fraction. The main objectives are to

maintain SVR, or even rise in SVR is favorable (by

using adrenergic agonists like phenylephrine) as it 7increases pulmonary blood flow . We should try to

decrease PVR to improve and maintain pulmonary

blood flow by hypocarbia, alkalosis, high oxygen 7concentrations, inhaled nitric oxide, etc .

Ketamine is an excellent inducing agent for

cyanoticheart disease, because it decreases PVR,

Discussion

enlarged boot shaped heart with pulmonary

oligaemia. ECG suggested of right ventricular

hypertrophy and right axis deviation. On

echocardiography, there was dilated right

ventricle, with over-riding of aorta, large VSD and a

shunt was seen in aorta. Detailed history,

examination and investigations revealed that he

was a case of congenital cyanotic heart disease. 3

Hb levels were 16.9 gm%, TLC was 8000 cells/mm , 3and platelet count was 1.95 lac / mm . He was

taking Tab. Aspirin 50 mg and tab. Propanolol

2.5mg daily.

Two years ago, he underwent shunt surgery

(central s/p shunt between aorta and right

pulmonary artery ) for palliation of symptoms as

he suffered from Tetralogy of Fallot with

pulmonary atresia and patent ductus arteriosus.

After explaining high risk and taking a written

informed consent, he was taken in the operating

room. Basic monitors were connected like NIBP,

SpO2, and ECG. Peripheral venous access was

obtained with 22G intracath using aseptic

precautions. We avoided inadvertent flushing and

performed judicious drug administration to

prevent air bubbles from entering the circulation.

Ringer lactate (RL) was administered at 4mL/kg

and prophylactic i.v. antibiotics (inj. Ceftriaxone-

sulbactum) given as per body weight.

On air saturation was 55%, heart rate was 88

beats/min, and NIBP was 98/58 mmHg. Inj. i.v.

glycopyrrolate 0.2mg was given. Induction was

done by using i.m. Ketamine 100mg (7mg/kg)and

100% oxygen was given via facemask using Ayre's

T-piece.

Closed reduction and hip spica application was

done. Vitals were stable and recorded after every

5min.

Saturation increased to 63% after giving 100% oxygen, Heart rate was 106/min. . Phenylephrine infusion at rate of 0.5-5 ìg/kg/min was started and


maintains SVR and is the safest agent for cyanotic 8patients .

The children with Tetralogy of Fallot are at an

increased risk for significant hypoxia (tet spells/

blue spells/ cyanotic spells), characterized by

sudden cyanosis and syncope. This happens by

increased shunting of blood due to decrease in

systemic vascular resistance and increase in

venous return. It can be prevented by

maintaining adequate hydration, avoid exposure

to cold, adequate glucose intake and oral

Propanolol 0.5-1 mg/kg/ 6hrly.

Management of a hypercyanotic spell intra-

operatively should include general measures to

reduce infundibular spasm, improve oxygenation

and increase cardiac output, and specific

measures to reduce right to left shunt and/or

infundibular spasm: Increase inspired oxygen,

fluid bolus 10-20 ml.kg-1, deepen anaesthesia,

fentanyl bolus 1 mcg.kg-1 Phenylephrine 1

mcg.kg-1 bolus up to 5-10mcg.kg-1 can be given.

It is advisable to perform an ABG to rule out

metabolic acidosis pre-operatively, and to treat

the same in case of severe cyanotic spells.

A vigilant eye is required throughout the

procedure to detect and manage any

complications namely hypoxia, hypotension,

acidosis, etc. Good analgesia will reduce

sympathetic stimulation and hemodynamic

instability. Postoperative care includes intensive

monitoring, appropriate fluid management, and 9, 10good control of pain .

We would appreciate your feedback on this

case report. This was done to the best of our

abilities although unavailability of invasive

monitoring was a concern.

1. Abhijeet Raha, Pragati Ganjoo, Amay Singh,

Monica S. Tandon, and Daljit Singh J Pediatr

References

Neurosci. 2012 Jan-Apr; 7(1): 23–26

2..Tanaka K, Kitahata H, Kawahito S, Nozaki J,

Tomiyama Y, Oshita S. Phenylephrine increases

pulmonary blood flow in children with tetralogy of

Fallot. Can J Anaesthe 2003 Nov 50(():926-9

3. Cerebral Abscess in 8 years old with

uncorrected Tetralogy of Fallot: Anesthetic

challenge

Sidharth Sraban Routray, Khageswar Raut ,

Debasis Mishra, Rajib Mishra IJBAR (2013) 04 (11)

4. Kaplan JA, cardiac anesthesia 4thed .

Philadelphia : WB Saunders, 1999:812

5. Anwar AM, Nosir YF, Anjam A, Mushtaq M,

Alama MN, Chamsi-Pasha H: Multivalvular

infective endocarditis in a tetralogy of Fallot.

Echocardiography 2008, 25:88–90.

6. Freed MD: Infective endocarditis in the adult

with congenital heart disease. Cardiol Clin 1993,

11:589–602.

7. Shahani JM. Anesthetic considerations in

children with congenital heart disease undergoing

non-cardiac surgery. Indian J Anaesth

2012;56:491-5.

rd8. Lake CL, pediatric cardiac anesthesia 3 ed.

Stamford, CT :Appleton & Lange, 1998:223-229

9. Yumul R, Emdadi A, Nassim M. Anesthesia

for non cardiac surgery in children with congenital

heart disease. Semin Cardiothorac Vasc Anesth.

2003;7:153–65.

10. White MC. Anesthetic implications of

congenital heart disease for children undergoing

non-cardiac surgery. Anaesth Intensive Care Med.

2009;10:504–9.


ABSTRACT:

INTRODUCTION:

CASE REPORT :

We present a case of 37 years male American

Society Of Anesthesiologists Grade I who

underwent C1 – C2 posterior cervical fusion for

atlanto – axial dislocation under general

anaesthesia with flexometallic endotracheal

tube in prone position. Entire surgical procedure

and anaesthesia was uneventful but before

extubation patient bit the tube and the tube was

cut into two pieces connected only by a thin wire.

Although the lacerated tube was removed using

Magill's forceps without any complications but it

taught us a lesson and made to think – Are these

tubes really safe to use?

Since last few years, anaesthesia has

considerably advanced to safer techniques.

Flexometallic endotracheal tubes are one of

these safer techniques and now are being

increasingly used in routine anaesthetic practice

as a safer and preventive option in certain cases

where kinking and compression of endotracheal

tube intraoperatively is anticipated.1

A 37-year male, American society of

anesthesiologists Grade I, with diagnosis of

atlanto – axial dislocation was posted for C1-C2

posterior fusion. Routine blood investigations

including complete blood count, serum

creatinine, blood urea nitrogen, random blood

sugar, serum electrolytes, bleeding time, clotting

time, Chest X-ray and electrocardiogram were

within normal limits. Preanaesthetic examination

revealed no systemic illness and airway was

Mallampatti Grade I. Patient was premedicated

with intramuscular injection. Glycopyrollate 0.2

mg half an hour before taking to operation

theatre. Patient was taken in operation theatre

after obtaining intravenous access,and was

m o n i t o r e d w i t h p u l s e o x i m e t e r ,

electrocardiogram, non invasive blood pressure

and end tidal carbon-di-oxide. Induction was done

with intraveneous injection fentanyl 2 mcg/kg and

intraveneous injection Propofol 2 mg/kg, muscle

relaxation was achieved with intraveneous

injection Rocuronium 0.9 mg/kg. Patient was

intubated with Flexometallic endotracheal tube of

internal diameter 8.5 mm. After securing the tube

with adhesive tapes along with Guedel's airway,

patient was made prone for surgery. Anesthesia

was maintained with O2 + N2O in 1:1 ratio with

Isoflurane 1% and injection Atracurium 0.1 mg/kg.

Surgical procedure lasted for approx. 3 hours and

the entire intraoperative anaesthesia course was

uneventful. After completion of surgical

procedure, the patient was made supine &

1. Consultant Anesthesiologist, Pain Consultant and OT Superintendent Vishesh Hospital Indore

FLEXOMETALLIC ENDOTRACHEALTUBES - ARE THEY REALLY SAFE?

l 1 2Dr. Meenu Chadha, Dr. Dharna Jain,

Case Report

2. Sr. Resident, Dept. of Anaesthesia, Vishesh Hospital Indore


anaesthesia was reversed using intraveneous

Injection Myopyrrolate . Oral and endotracheal

tube suctioning was done and when reversal

criteria was accomplished we planned to

extubate the patient but to our surprise after

laryngoscopic suction of the oral cavity with

removal of the oral airway our patient tightly

clenched his teeth and bit the tube to the extent

that the tube got lacerated completely (IMAGE 1)

.

Fortunately the lacerated tube was removed

successfully by our team using Magill's forceps

without aspiration or any other complication but

this incidence taught us a big lesson. Patient was

shifted to intensive care unit in stable condition

and discharged by the surgeon after few days.

Flexometallic endotracheal tubes or spiral

embedded tubes or armoured tubes have

advantage of being resistant to kinking and

compression making them useful in surgeries in

prone position, sitting position, head and neck

surgeries, tracheal surgeries, neurosurgical

procedures and cases where head and neck

manipulation is required intra operatively for

better surgical access.3 These tubes have nylon

or metal spiral wound reinforcing wire covered

DISCUSSION:

both internally and externally by rubber, latex,

poly vinyl chloride or silicone.3

Although these tubes are a boon for certain

surgical procedures they do possess some

problems which cannot be overlooked. Like they

require stylet for insertion and may get rotated on

the stylet during the insertion, possess difficulty

for nasotracheal intubation, and cannot be

shortened, 3, 4, . Overuse and repeated

sterilization of reusable spiral embedded tubes

can predispose them to problems Dynamic

kinking of these tubes by compression with a

Dingmans retractor may lead to ventilatory

problems.5 Latex allows greater flexibility of tube

than the red rubber but it is more susceptible to

deformity on inflation. During light plane of

anaesthesia, patient can bite the tube leading to a

serious complication like permanent deformation

of the tube and thus occlusion of lumen leading to

difficulty in endotracheal suction and life

threatening hypoxia and hypoventilation.1,3

Laceration of tube as happened in our case

may lead to aspiration of tube material which

itself may create a life threatening situation,

fortunately we came out without any of such

complication, but this may not be always the case.

This case reasserts some of the valuable standard

teachings :


(a) Keep a bite block /dental prop in place

when a patient has an airway maintaining gadget

in place (endotracheal tube, laryngeal mask

airway etc.

(b) Do not remove bite block/dental prop

during oral suction.

(c) Remove the bite block/dental prop after

removal of the endotracheal tube /laryngeal

mask air way etc

(d) if available, use the tubes with covering at

the bite portion.

1. Dr Dinesh Malhotra, Dr Mehmood Rafiq,

Dr Shagufta Qazi, Dr Satya Dev Gupta-Ventilatory

obstruction with spiral embedded tube- Are they

REFFERNCES:

as safe? IJA 2007;51;5:432-433

2. Dr Sonia Wadhwan, Dr Vibha and Dr

Rakesh Kumar- An uncommon reason for damage

to the intubating laryngeal mask airway (ILMA)

endotracheal tube inflation system. A&A

2004;99:2:624

3. Dr Afzal Azim1, Dr. Prakash Matreja, Dr.

Chandrakant Pandey. Desaturation with

flexometallic endotracheal tube during lumber

spine surgery– A case report. IJA 2003; 47;1:48-49

4. P. Martens: Persistent narrowing of an

armoured tube. Anaesthesia 1992; 47: 716-717

A j a y K u m a r, H . H . D a s h - D y n a m i c

intraoperative kinking of flexometallic tube.

Journal of Neurosurgical Anesthesiology July

2001;13;3:243-245


ll manuscripts must be submitted via email

to [email protected]. AThe submitted manuscripts that are not as per

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they undergo editorial/peer-review. Generally,

the manuscript should be submitted in the form

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1. Title Page/First Page File/covering

letter: This file should provide

a. The type of manuscript (original article,

review article, short communication, Letter to

editor, etc.) title of the manuscript, running title,

names of all authors/ contributors (with their

highest academic degrees, designation and

affiliations) and name(s) of department(s) and/ or

institution(s) to which the work should be

credited, . All information which can reveal your

identity should be here. Use text/rtf/doc files. Do

not zip the files.

b. The total number of pages, total number

of photographs and word counts separately for

abstract and for the text (excluding the

references, tables and abstract), word counts for

introduction + discussion in case of an original

article;

c. Source(s) of support in the form of

grants, equipment, drugs, or all of these;

d. Acknowledgement, if any. One or more

statements should specify 1) contributions that

need acknowledging but do not justify

authorship, such as general support by a

departmental chair; 2) acknowledgments of

technical help; and 3) acknowledgments of

financial and material support, which should

specify the nature of the support. This should be

SUBMISSION GUIDELINESincluded in the title page of the manuscript and

not in the main article file.

e. If the manuscript was presented as part

at a meeting, the organization, place, and exact

date on which it was read. A full statement to the

editor about all submissions and previous reports

that might be regarded as redundant publication

of the same or very similar work. Any such work

should be referred to specifically, and referenced

in the new paper. Copies of such material should

be included with the submitted paper, to help the

editor decide how to handle the matter.

f. Registration number in case of a clinical

trial and where it is registered (name of the registry

and its URL)

g. Conflicts of Interest of each author/

contributor. A statement of financial or other

relationships that might lead to a conflict of

interest, if that information is not included in the

manuscript itself or in an authors' form

h. Criteria for inclusion in the authors'/

contributors' list

i. A statement that the manuscript has

been read and approved by all the authors, that

the requirements for authorship as stated earlier

in this document have been met, and that each

author believes that the manuscript represents

honest work, if that information is not provided in

another form (see below); and

j. The name, address, e-mail, and

telephone number of the corresponding author,

who is responsible for communicating with the

other authors about revisions and final approval of

the proofs, if that information is not included on

the manuscript itself.


2. Blinded Article file: The manuscript

must not contain any mention of the authors'

names or initials or the institution at which the

study was done or acknowledgements. Page

headers/running title can include the title but not

the authors' names. Manuscripts not in

compliance with The Journal's blinding policy will

be returned to the corresponding author. The

main text of the article, beginning from Abstract

till References (including tables) should be in this

file. Use rtf/doc files. Do not zip the files.

3. Images: Submit good quality color

images. Each image should be less than 4 MB in

size. Size of the image can be reduced by

decreasing the actual height and width of the

images (keep up to 1800 x 1200 pixels or 5-6

inches). Images can be submitted as jpeg files. Do

not zip the files. Legends for the figures/images

should be included at the end of the article file.

4. The contributors' / copyright transfer

form (template provided below) has to be

submitted in original with the signatures of all the

contributors within two weeks of submission .

Manuscripts must be prepared in accordance

with "Uniform requirements for Manuscripts

submitted to Biomedical Journals" developed by

the International Committee of Medical Journal

Editors (October 2006).

These include original research work in

Pharmaceutical sciences, Medicinal/analytical

chemistry, Biotechnology and bioallied sciences.

The text of original articles amounting to up to

2500 words (excluding Abstract, references and

Tables) and The manuscript may have about 25 to

30 references should be divided into sections

with the headings Abstract, Key-words,

Preparation of Manuscripts

Types of Manuscripts

Original articles:

Introduction, Material and Methods, Results and

Discussion,Conclusion, References, Tables and

Figure legends.

The review articles are strictly by invitation

from the Editor. It is expected that these articles

would be written by individuals who have done

substantial work on the subject or are considered

experts in the field and are solicited by the

editorial board. A short summary of the work

done by the contributor(s) in the field of review

should accompany the manuscript.

The prescribed word count is up to 3500 words

excluding tables, references and abstract. The

manuscript may have about 40 to 50 references.

The manuscript should have an unstructured

Abstract (250 words) representing an accurate

summary of the article. The section titles would

depend upon the topic reviewed.

The journal expects the contributors to give

post-publication updates on the subject of review.

The update should be brief, covering the advances

in the field after the publication of the article and

should be sent as a letter to editor, as and when

major development occurs in the field.

New, interesting and rare cases can be

reported. They should be unique, describing a

great anaesthetic challenge and providing a

learning point for the readers. Cases with clinical

significance or implications will be given priority.

These communications could be of up to 1400

words (excluding Abstract and references) and

should have the following headings: Abstract

(unstructured), Key-words, Introduction, Case

report, Discussion,Conclusion, References, Tables

and Legends in that order.

The manuscript could be of up to 1400 words

(excluding references and abstract) and could be

Review Articles:

Case reports:


supported with up 10 to 15 references. Case

Reports could be authored by up to four authors.

The manuscript could be of up to 1000 words

(excluding references),without abstract and

could be supported with up 6 to 8 references and

should have the fo l lowing headings :

Introduction, Case report (for Case reports)

( M e t h o d s a n d r e s u l t s f o r c l i n i c a l

i nve st i gat i o n s ) , D i s c u s s i o n , C o n c l u s i o n ,

References, Tables and Legends in that order

These should be short and decisive

observations. They should preferably be related

to articles previously published in the Journal or

views expressed in the journal. They should not

be preliminary observations that need a later

paper for validation. The letter could have up to

600 words and 6 references. It could be generally

authored by not more than four authors.

The comments,addressed to the

Editor,should include reference of the published

article,should be concise (Max.250 words) with

critical comments to the point, with references in

support.Upto 300 words and not more than 4

references,including the first reference of the

article being commented upon to be included.

Response to Comments: The author is

allowed to present his case/response to the

observations made by the reader, in concise,upto

300 words.

R e f e r e n c e s s h o u l d b e n u m b e r e d

consecutively in the order in which they are first

mentioned in the text (not in alphabetic order).

Identify references in text, tables, and legends by

Arabic numerals in square bracket after the

punctuation marks. References cited only in

Brief communications

Letter to the Editor:

Comments on Published Articles:

References

tables or figure legends should be numbered in

accordance with the sequence established by the

first identification in the text of the particular

table or figure.No references to be used in absract

and Conclusion/ Summary. Use the style of the

examples below, which are based on the formats

used by the NLM in Index Medicus. The titles of

journals should be abbreviated according to the

style used in Index Medicus. Use complete name

of the journal for non-indexed journals. Avoid

using abstracts as references. Information from

manuscripts submitted but not accepted should

be cited in the text as “unpublished observations”

with written permission from the source. Avoid

citing a “personal communication” unless it

provides essential information not available from

a public source, in which case the name of the

person and date of communication should be

cited in parentheses in the text. References from

past issues of IJA of related topics encouraged.

The commonly cited types of references are

shown here, for other types of references such as

newspaper items please refer to ICMJE Guidelines

( h t t p : / / w w w . i c m j e . o r g o r h t t p : / /

www.nlm.nih.gov/bsd/uniform_requirements.ht

ml).

a. Standard journal article (for up to six

authors): Shukla N, Husain N, Agarwal GG, Husain

M. Utility of cysticercus fasciolaris antigen in Dot

ELISA for the diagnosis of neurocysticercosis.

Indian J Med Sci 2008;62:222-7.

b. Standard journal article (for more than

six authors): List the first six contributors followed

by et al.

Nozari Y, Hashemlu A, Hatmi ZN, Sheikhvatan

M, Iravani A, Bazdar A, et al. Outcome of coronary

artery bypass grafting in patients without major

risk factors and patients with at least one major

risk factor for coronary artery disease. Indian J

Articles in Journals


Med Sci 2007;61:547-54

c. Volume with supplement:

Shen HM, Zhang QF. Risk assessment of nickel

carcinogenicity and occupational lung cancer.

Environ Health Perspect 1994; 102 Suppl 1:275-

82.

d. Issue with supplement:

Payne DK, Sullivan MD, Massie MJ. Women’s

psychological reactions to breast cancer. Semin

Oncol 1996; 23(1, Suppl 2):89-97.

a. Personal author(s): Ringsven MK, Bond

D. Gerontology and leadership skills for nurses.

2nd ed. Albany (NY): Delmar Publishers; 1996.

b. Editor(s), compiler(s) as author: Norman

IJ, Redfern SJ, editors. Mental health care for

elderly people. New York: Churchill Livingstone;

1996.

c. Chapter in a book: Phillips SJ, Whisnant

JP. Hypertension and stroke. In: Laragh JH,

B r e n n e r B M , e d i t o rs . H y p e r t e n s i o n :

pathophysiology, diagnosis, and management.

2nd ed. New York: Raven Press; 1995. pp. 465-78.

Electronic Sources as reference

Abood S. Quality improvement initiative in

nursing homes: the ANA acts in an advisory role.

Am J Nurs [serial on the Internet]. 2002 Jun [cited

2002 Aug 12];102(6):[about 3 p.]. Available from:

http://www.nursingworld.org/AJN/2002/june/

Wawatch.htm

Foley KM, Gelband H, editors. Improving

palliative care for cancer [monograph on the

Internet]. Washington: National Academy Press;

2001 [cited 2002 Jul 9]. Available from:

http://www.nap.edu/books/0309074029/html/.

Books and Other Monographs

Journal article on the Internet

Monograph on the Internet

Homepage/Web site

Part of a homepage/Web site

Tables

Illustrations (Figures)

Cancer-Pain.org [homepage on the Internet].

New York: Association of Cancer Online

Resources, Inc.; c2000-01 [updated 2002 May 16;

c i t e d 2 0 0 2 J u l 9 ] . A v a i l a b l e f r o m :

http://www.cancer-pain.org/.

American Medical Association [homepage on

the Internet]. Chicago: The Association; c1995-

2002 [updated 2001 Aug 23; cited 2002 Aug 12].

AMA Office of Group Practice Liaison; [about 2

screens]. Available from: http://www.ama-

assn.org/ama/pub/category/1736.html

lTables should be self-explanatory and should

not duplicate textual material.

lTables with more than 10 columns and 25 rows

should be avoided.

lNumber tables, in Arabic numerals,

consecutively in the order of their first citation

in the text and supply a brief title for each.

lPlace explanatory matter in footnotes, not in

the heading.

lExplain in footnotes all non-standard

abbreviations that are used in each table.

lObtain permission for all fully borrowed,

adapted, and modified tables and provide a

credit line in the footnote.

lFor footnotes use the following symbols, in

this sequence: *, †, ‡, §, ||,¶ , **, ††, ‡‡

lTables with their legends should be provided

at the end of the text after the references. The

tables along with their number should be cited

at the relevant place in the text

lUpload the images in JPEG format. The file size

should be within 2 MB in size while uploading.


lFigures should be numbered consecutively

according to the order in which they have

been first cited in the text.

lLabels, numbers, and symbols should be clear

and of uniform size. The lettering for figures

should be large enough to be legible after

reduction to fit the width of a printed column.

lSymbols, arrows, or letters used in

photomicrographs should contrast with the

background and should be marked neatly

with transfer type or by tissue overlay and not

by pen.

lTitles and detailed explanations belong in the

legends for illustrations not on the

illustrations themselves.

lWhen graphs, scatter-grams or histograms

are submitted the numerical data on which

they are based should also be supplied.

lThe photographs and figures should be

trimmed to remove all the unwanted areas.

lIf photographs of individuals are used, their

pictures must be accompanied by written

permission to use the photograph.

lIf a figure has been published elsewhere,

acknowledge the original source and submit

written permission from the copyright holder

to reproduce the material. A credit line should

appear in the legend for such figures.

lLegends for illustrations: Type or print out

legends (maximum 40 words, excluding the

credit line) for illustrations using double

spacing, with Arabic numerals corresponding

to the illustrations. When symbols, arrows,

numbers, or letters are used to identify parts

of the illustrations, identify and explain each

one in the legend. Explain the internal scale

(magnification) and identify the method of

staining in photomicrographs.

lFinal figures for print production: If the

uploaded images are not printable quality, the

publisher office may request for higher

resolution images which can be sent at the

time of acceptance of the manuscript. Send

sharp, glossy, un-mounted, color photographic

prints, with height of 4 inches and width of 6

inches at the time of submitting the revised

manuscript. Print outs of digital photographs

are not acceptable. If digital images are the

only source of images, ensure that the image

has minimum resolution of 300 dpi or 1800 x

1600 pixels in TIFF format. Send the images on

a CD. Each figure should have a label pasted

(avoid use of liquid gum for pasting) on its back

indicating the number of the figure, the

running title, top of the figure and the legends

of the figure. Do not write the contributor/s’

name/s. Do not write on the back of figures,

scratch, or mark them by using paper clips.

lThe Journal reserves the right to crop, rotate,

reduce, or enlarge the photographs to an

acceptable size.

In case of clinical studies which involves patient,

Identifying information should not be published in

written descriptions, photographs, sonograms, CT

scans, etc., and pedigrees unless the information is

essential for scientific purposes and the patient (or

parent or guardian, wherever applicable) gives

written informed consent for publication. Authors

should remove patients' names from figures unless

they have obtained written informed consent from

the patients. When informed consent has been

obtained, it should be indicated in the article and

copy of the consent should be attached with the

covering letter.

Protection of patients Rights to Privacy


Journal Of Anesthesiology MP State Vol 1

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