the specialist ezine :clinical knowledge series

8/14/2019 The Specialist Ezine :Clinical Knowledge Series

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Wockhardt Hospitals - Mumbai Bangalore Kolkata Hyderabad Nagpur Rajkot Surat

Intracranial aneurysms and vascular head ache Thrombolysis in stroke Total knee replacement in severelydeformed

rheumatoid knee VATS Congenital Diaphragmatic Hernia (CDH) ARDS Toxic shock syndrome News Roomn s i d e

Vol 1, Issue 2, April 2007

imultaneous carotid endarterectomy and

off pump coronary arterybypass surgery (Awake)

S

S

ome patients with

coronary artery disease

are diagnosed as having

additional carotid arterydisease. This subset of patients has

been identified as a high-risk group

for cardiac and cerebral complications

following surgical intervention.

The incidence of significant carotid

artery disease in patients undergoing

CABG varies from 8-14% and coronary

artery disease is present in more than

40% of patients who meet the

indications for carotid endarterectomy.

Combined procedures steadily

increased since Bernhardt andcolleagues initial report of 16 such

cases in 19721.This combined surgery

when done awake under High Thoracic

Epidural Anesthesia (HTEA) offers an

absolute neurological monitoring & fast

tracking. Presently there are no reports

of awake combined carotid

endarterectomy (CEA) with Offpump

CABG (OPCAB) under HTEA as the

sole anesthetic.

At Wockhardt Hospitals Bangalore

from Jan 2006 to Jan 2007 we have

performed combined CEA-OPCAB in

10 patients. Age varied from 65yrs to

CCA Vein patch

ECA

ICA

Post endartectomy picture

Picture of endartectomy specimen

74yrs. There were 3 females & 7 males.

Four patients had symptoms of TIA and

one off them had a cerebral infarct on

CT brain. All patients underwent a

carotid MRI to access the nature &

extent of block. Those who had more

than 90% stenosis with no symptoms

& symptomatic patients underwent

CEA with OPCAB. All required triple

vessel bypass. All underwent CAE

with OPCAB under high Thoracic

Epidural Anesthesia, which is the best

monitor for brain function during

carotid endarterectomy. We have

already reported 520 awake cardiac

surgeries done under HTEA as sole

anesthetic7, 8. Hence the anesthesia

protocols have been well

standardised.

RESULT

None of these patients had any

neurological events or mortality. One

female patient needed a rexploration

of the neck wound for hematoma.

There were no perioperative

myocardial infarctions. Average

hospital stay was 6 days. All patients

remained in the ICU for one day.

There were no major wound infections.

DISCUSSION

Combined procedures steadily

increased since Bernhardt and

colleagues initial report of 16 such

cases in 19721. The incidence of CVA

in patients undergoing combined CEA-CABG surgery is equivalent to those

with asymptomatic patients

undergoing isolated CABG, but much


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lower than that of patients with

symptomatic carotid stenosis

undergoing isolated CABG surgery.

Combined CEA-CABG surgery shouldbe reserved for those patients who

have symptomatic or asymptomatic

severe carotid artery stenosis and

require coronary revascularisation2.

There continues to be a dilemma

regarding the best means ofsurgical

management of significant carotid

artery disease in patients requiring

coronary artery bypass surgery.

A combined approach of coronary

artery bypass and carotid

endarterectomy

has shown goodresults in patients with concomitant

carotidand coronary artery disease and

off pump techniques3.

The incidence of significant carotid

artery disease in patients undergoing

CABG varies from 8-14% and coronary

artery disease is present in more

than 40% of patients who meet

the indications for carotid

endarterectomy4. Kallikazaros et al.

found that the frequency of significant

carotid artery disease increased from5% in patients with 1- vessel disease

to 25% in 3-vessel disease and

reached 40% in patients with left main

stem stenosis5. Pre-operative stroke

risk is considered to be less than 2%

when carotid stenosis are below 50%,

10% when stenosis are 5080% and

1119% in patients with stenosis over

80%. Patients with untreated bilateral

high-grade stenosis and/ or occlusions

have a 20% chance of stroke. Thus,

the American College of Cardiology(ACC) and the American Heart

Association (AHA) guidelines for

CABG recommend carotid

Bispectral indexBispectral indexBispectral indexBispectral indexBispectral index

correlates with

clinical measures of

hypnosis, sedation,

reduced cerebral

metabolic rate, and

also cerebral

hypo-perfusion.

endarterectomy in asymptomatic

patients with severe carotid

artery disease6.

Neurological monitoring is an

important part of safe CEA.

The various methods of monitoring

are electroencephalography (EEG),

somatosensory-evoked potential

(SSEP), transcranial doppler (TCD),

ICA stump pressure, regional cerebral

O2 saturation (rSO2), bispectral index

(BIS) and serial neurologic

assessments during regional

anesthesia. Detection of cerebral

hypo-perfusion by any of these

methods will guide for immediate

placement of intra-luminal shunt. BIS

is a single number that incorporates

information of EEG power and frequency, and also includes

information regarding activation, burst

suppression, and bicoherence. It can

provide more information regarding

interactions between cortical and sub-

cortical neuronal generators.

BIS correlates with clinical measures

of hypnosis, sedation, reduced

cerebral metabolic rate, and also

cerebral hypo-perfusion.

The best possible monitoring of the

brain would be the patient, where heis conscious, responds to commands,

there by moving his arms and legs at

command, or he would become

restless due to hypo-perfusion of brain

or would develop weakness of contra-

lateral side when a shunt could be

placed immediately only to observe

full recovery of motor power, which

are the added benefits of awake CEA

and OPCAB. None of our patients had

a stroke during immediate

postoperative period or during follow

up. There was no mortality or

morbidity due to the procedure.

CONCLUSION

Combined procedure does not add any

significant extra risk on mortality or

morbidity as compared to stage

procedure and is cost effective. The

same when done under Continuous

High Thoracic Epidural Analgesia

(Awake) offers absolute neurological

monitoring and aids fast tracking.This is worlds initial experience of

awake off pump CABG combined with

Carotid endarterectomy.

REFERENCE

1. Bernhard V M,Johnson W D, Peterson J J Carotid

A Stenosis Associates with surgery for CAD Arch

Surg 1972 105:837-40

2. Cannadian Cardiovascular CongressPoster

Session: Surgery 413 Is combined carotid

endarterectomy and CABG justifiable in patientswith symptomatic carotid stenosis? MC Moon, DH

Freed, ML Brown, EA Pascoe, G Louridas Winnipeg,

Manitoba

3. Concomitant Carotid Endarterectomy and

Coronary Bypass Surgery: Outcome of On-Pump

and Off-Pump Techniques Yugal Mishra, PhD,

Harpreet Wasir, MCh, Vijay Kohli, MCh, Zile Singh

Meharwal, MCh, Rajneesh Malhotra, MCh, Yatin

Mehta, MD, Naresh Trehan, MD Ann Thorac Surg

2004; 78:2037-2042

4. Borger MA, Fremes SE, Weisel RD, et al. Coronary

bypass andcarotid endarterectomy: Does a

combined approach increase risk? Ameta-

analysis. Ann Thorac Surg 1999; 68:14-21.

5. Kall ikazaros I, Tsioufis C, Sideris S,

Stefanadis C, Toutouzas P. Carotid

artery disease as a marker for the

presence of severe coronary artery

disease in patients evaluated for chest

pain. Stroke 1999; 30:1002-7.

6. Eagle KE, Guyton RA, Davidoff R, et al. ACC/AHA

guidelines for coronary artery bypass graft

surgery: Executive summary and

recommendations: A report of the ACC/AHA task

force on Practice Guidelines (Committee to

revise the 1991 guidelines for Coronary Artery

Bypass Graft Surgery). Circulation 1999;

100:1468-80.

7. High thoracic epidural anesthesia as soleanesthetic for redo off-pump coronary artery

bypass surgery. J Cardiothoracic Vasc Anesth:

2003 Feb; 17:84-6

8. Conscious Off-Pump Coronary Artery Bypass

Surgery Indian Heart Journal Jan - Feb 2005; 57:

(1) 49-53

Courtesy:

Dr. Vivek Jawali,

M.S., M.Ch., DNB, FIACS

Chief Cardiovascular and Thoracic Surgeon

Dr. Ganeshakrishnan Iyer,

M.S., M.Ch.

Dr. Devananda N S,

M.S., M.Ch.

Dr. K N Srinivasan,

M.S., M.Ch.

Dr. Murali Manohar V,

M.S, DNB (CVTS), FIACS

Department of Cardiovascular

and Thoracic Surgery.

Wockhardt Hospitals, Bangalore

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3/12

ntracranial aneurysms and

vascular head ache

IMRI WITH MRA

Showed well delineated berryaneurysm at the bifurcation of left

Middle Cerebral Artery (MCA)

CT ANGIOGRAPHY

A multislice spiral CT angiography notonly confirmed the aneurysm but gavea three dimensional picture of thevascular anatomy which is useful forsurgical intervention. With the possibilityof reconstruction of image, and imagerotation in 360 in all the planes, the

invasive DSA could be avoided.

SURGERY

Electively she was taken up for leftpterional craniotomy and microsurgically

the aneurysm was clipped successfully.

Fig 2: CT Angiography

Headache remains the

most common pain for

which an adult seeks

medical attention and

vascular (migraine) headache is one of

the most common varieties. It is not

very unusual for individuals suffering

from common varieties of chronic

headache like migraine to have or

develop other structural lesions like braintumor, cerebral aneurysms and AVMS

or meningitis as a cause for worsening

or change in pattern of headache. The

intracranial aneurysms usually present

with subarachnoid haemorrhage (SAH)

causing sudden onset intense headache

associated with nausea, vomiting and

most often unconsciousness.

Subsequent events following a major

SAH lead to a neurological status

demanding immediate hospitalisation.

In a small (


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hrombolysis in stroke

Time is BrainT

CASE REPORT

Mr J presented to the casuality with

the history of acute onset blurring of

vision in left eye followed by

unresponsiveness of 45 minutes

duration. He was a known

hypertensive on regular treatment.

There were no previous episodes of

IHD/ Stroke/ TIA. BP was150/90 mmHg and other vital parameters were

stable. He was drowsy and was noted

to have paucity of movements of right

upper limb and lower limb. In addition,

left gaze preference was present along

with equivocal plantar response. CT

scan of head which was done within

an hour of the ictus was normal. GRBS

was 142 mg %. ECG, platelet count

and coagulation parameters were

within normal limits. The risks, benefits

and cost of thrombolysis therapy with

rtPA (recombinant tissue plasminogen

activator) were explained to the family

members.

After obtaining the informed consent

of the family, rtPA was administered

intravenously at a dosage of 0.9 mg/

kg body weight, 10% of the total

dosage was given as a bolus and

remaining as an infusion over one

hour. We were able to accomplish this

within two hours of ictus MRI of brain

done within six hours of ictus revealedleft middle cerebral artery (mca)

territory stroke with a tiny speck of

hemorrhage. There was no

deterioration in the neurological status

at this point of time. Anti platelet

agents and citicholine were introduced

24 hours after the thrombolysis. CT

scan of head was repeated on fourth

day revealing mild mass effect. It was

treated with antioedema measures.

Patient improved gradually and was

conscious by fifth of ictus. He was

shifted to the ward after a stay of eight

days in MICU. He regained

comprehension for simple verbal

commands and power of hemiplegic

limbs improved to grade 3/5.

Physiotherapy and speech therapy was

continued. He was discharged after a

ten-day stay in the ward. At the time of

discharge, he was able to sit with minimal

support, walk with one persons support

and had got motor aphasia.

DISCUSSION

Thrombolysis in stroke using rtPA is an

accepted practice for certain types of

ischemic stroke. The critical part of

management of stroke is to bring the

patient within three hours of ictus for

thrombolysis (the golden period). This

window period is three hours for

intravenous thrombolysis and six hours

for intra-arterial thrombolysis. It is well

known that the benefits of thrombolysis

are apparent as reduction of disabilitythree months after the stroke.

Strict inclusion and exclusion criteria

are available (table). This case

illustrates the importance of the

Golden Hour in stroke and also the

importance of coordination between

neurologist, intensivist and emergency

room physician The Stroke Team.

CONCLUSION

1) Brain attack is as lethal anddebilitating as heart attack.

2) Awareness and education of

public and medical fraternity

regarding the need for urgency in

potential cases of thrombolysis is

important.

3) Thrombolysis with rtPA should be

used carefully by trained experts

in the field after careful

consideration in a tertiary care

centre.

4) The costs involved should be

within the reach of common man.

Courtesy:

Dr. Udaya Shankar, M.D., D.M

Consultant Neurologist

Dr. Ravindra Mehta, MD, FCCP,

American Board Certified Critical Care

Medicine, Pulmonary Medicine,Sleep disorder medicine

Intensivist and Pulmonologist

Dr. Prabhakara Reddy, MD., FACP,

American Board Certified Internal Medicine

Consultant Emergency Medicine


TABLE

Characteristics of patients who could be

treated with rtPA (intravenous)

1) Ischemic stroke causing measurable

neurological deficit

2) The neurological signs should not be

clearing spontaneously

3) The neurological signs should not beminor and isolated

4) Onset of symptoms - three hours

before beginning treatment

5) Time of onset should not be vague

6) No head trauma or prior stroke in

previous three months

7) No GI or urinary tract hemorrhage in

previous 21 days

8) No major surgery in previous 14 days

9) No arterial puncture at a non

compressible site in the previous

seven days

10) No h/o previous intracranial

hemorrhage

11) BP < 185/110 mm Hg

12) Not on oral anticoagulants or if on oral

anticoagulants INR < 1.7

13) Platelet count > 100000/ mm3

14) RBS > 50ms/dl and < 450 mm/dl

15) If receiving heparin in previous 48

hours, a PTT must be in normal range

16) No h/o seizure

17) CT Scan should not show multilobar

infarction (hypodensity < 1/3 cerebralhemisphere)

18) The patient or family understand the

potential risks and benefits of

treatment.

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5/12

severely deformed Rheumatoid knee

TShe was a known case of rheumatoid

arthritis on medical treatment. She was

unable to stand or walk and had severe

pain on bending the knee.

On examination she was moderately

built but poorly nourished and anemic.

Local examination of both knees

revealed that she has wind-swipe

deformity. Right knee was in 30 varusdeformity and range of movement

was 0-90. Left knee was in 40 valgus

and further valgus till 70. Range of

movement was 0-30. Investigation:

Hb -8.2 mg %, R A factor - positive,

CRP - positive, ESR- 89mm/hr. X-ray

of right knee showed severe varus

deformity with medical tibial condyle

defect and lateral subluxation of tibia.

Left knee - severe valgus deformity

with central tibial bone defect and

lateral patellar subluxation.

Patient was admitted and complete

pre-operative work done. The team of

Orthopaedic surgeons headed by Dr.

Sanjay Pai, Rheumatologist and

Anaesthetist got involved to give her a

comprehensive team care.

We performed total knee replacement

in staged manner. First the right knee

with varus deformity was operated

using a revision total knee

replacement implants. After five days,

the left knee with severe valgus

deformity was operated. Postoperative period was uneventful.

The patient was mobilised on the third

day with walker and was discharged

on the sixth day. On the 12th day, the

patient was able to walk without

support, able to climb stairs and do her

daily activities.

Thanks to the surgical expertise now

available in India and good hospitals to

support, these patients can get back

their normal daily life style which was

thought impossible in the past.

otal knee replacement in

Rheumatoid arthritis is a

well known systematic

inflammatory disease

wherein arthritis of synovial

joints is a major component.

This disease is common in females and

affects during third, fourth and fifth

decades of the life. Initially the disease

starts with pain and joint stiffness in

small joints of hand and later involvesbig joints like hip, knee, shoulder and

elbow. In an advanced rheumatoid

arthritis all the joints of the body are

involved.

Treatment of rheumatoid arthritis is

ideally to be done by rheumatologist.

Start with NSAIDS and later go on to

combination therapy of DMARDS

(steroids, methotrexate, leflunomide,

sulfasalazine chloroquine and oral gold

salts). An Orthopaedicians role comes

only after joint pain/ swelling anddeformity are not controlled by

medical treatment.

Indication of joint replacement in

rheumatoid arthritis.

1. Severe pain in joints

2. Inability to do daily activities

3. Progressing deformity

4. Joint stiffness

Advantages of joint replacement

1. Painless and stable joints

2. Good functional movements ofjoints

3. Improvement in quality of life

4. Better disease control after

surgery

With advent of new implants, good

operation theatres, laminar flow and

surgical expertise, it is possible to

perform joint replacements even in

severely deformed joints which was

thought impossible previously.

CASE REPORT

58 year old female patient consulted

us with severe knee pain for four years.

Pre-operative picture

Pre-operative x-ray

12 days, post-operative picture

Courtesy:

Dr. Sanjay Pai, M.S.

Dr. Srinivas J V, M.S.

Dr. Vasudev N Prabhu, M.S.

Department of Orthopaedic Surgery


4


6/12

CASE REPORT

A 45-year old Pakistani patient

presented with progressive

weakness of both lower limbs of six

months duration. He had been

bedridden for the past two months.

He had been diagnosed to have

Thoracic Cord Compression in

Karachi five years ago for which he

underwent decompressive

laminectomy at that time. The

symptoms of lower limb weakness

reappeared after a few months for

which he was reexplored. And he

improved partially. He had five such

recurrences and had undergone

surgery five times in Pakistan. Each

time the same wound at the posterior

midline was explored. The latest MRI

showed that there was both anterior

and posterior compression at the levelof T9-T10. The spinal canal was very

narrow at that level. There was no

evidence of infiltration. He underwent

surgery in two stages in our hospital.

Stage 1:

Video-assisted thoracoscopic

corpectomy and cage fixation

The patient was positioned left lateral

under GA using a double lumen

endotracheal tube intubation.

Typically, four key holes were made,through which various instruments

are passed: one for the thoracoscope

(video camera), one for the retractor,

one for suction, and one for other

surgical instruments. Under general

anesthesia, using single lung

ventilation special thoracoscopic

corpectomy instruments were

utilised to achieve adequate bone

removal of the T9 and T10 bodies.

A 60 mm cage (Medtronics) was then

used to fixate the spine from T8 to

T11. At the end of the procedure, the

holes were typically closed with an

absorbable suture and the deflated

Video-assisted thoracoscopic (VATS)

anterior spine fixation

lung is reinflated. A chest tube was

used post-operatively for three days.

Stage 2:

Laminectomy T9, T10 and unilateral

pedicle fixation T8-T11

The posterior wound was reexplored.

It was found that the laminectomy was

inadequate. Therefore, it was

completed using drills. The dura and

the exiting nerve roots at the foramina

were freed from the scar tissue,

ligaments and bone. Pedicle screw

fixation was performed unilaterally on

the right as the pedicles on the left

side did not hold the screws properly.

Post-operatively, the patient had

reduced spasticity with some recovery

of the lower limb power.

DISCUSSION

Surgery for spinal disorder has seendramatic progress in the methods of

treatment. The surgical incision is most

Opening of pleura with hook MRI spine pre-operative

Fixation of 60mm cage Post-operative x-ray

commonly performed posteriorly, on

the back of the spine, but there are

specific circumstances when an

incision is needed to approach the

front of the spine (anterior approach).

Historically, anterior surgery was

performed through an open

thoracotomy. This required a large

incision through the chest wall and

chest cavity. Technological advances

TTTTTechnological advancesechnological advancesechnological advancesechnological advancesechnological advances

have allowed spine

surgeons to perform the

same procedures through

small incisions in the chest

wall using video

technology with small

cameras as well as

endoscopic instruments.

5


7/12


8/12

on day 10 of age, but he developed

feeding intolerance due to suspected

necrotising enterocolitis. Feeds were

withheld for a week and was

Fig 2: Chest X-ray after CDH repair.

Smal lSmal lSmal lSmal lSmal l

intest ineintest ineintest ineintest ineintest ine

(Left(Left(Left(Left(Left

thoracicthoracicthoracicthoracicthoracic

cavi ty)cavi ty)cavi ty)cavi ty)cavi ty)

Fig 3: Small intestines in thoracic cavity

Fig 4: Small & Large intestine pulled down to

abdominal cavity.

Small & largeSmall & largeSmall & largeSmall & largeSmall & large

intest ineintest ineintest ineintest ineintest ine

(Abdomina l(Abdomina l(Abdomina l(Abdomina l(Abdomina l

cavi ty)cavi ty)cavi ty)cavi ty)cavi ty)

recommenced again and slowly

upgraded to attain to full feeds. At the

time of discharge from hospital, he

was saturating > 98% in room air and

was feeding directly at breast and

started to gain weight. He was

discharged from the hospital on day25 of age with complete recovery

from CDH.

The most important factors which

played significant role for good long

term survival in our case are-

1. Antenatal diagnosis (by

ultrasonagraphy).

2. Planning of delivery (high- risk

pregnancy).

3. Timing of surgery.

4. Not associated other structural

anomalies.

5. Prevention of secondary lung

injury after birth.

6. Management of pulmonary

hypertension.

7. Nutrition supplementation.

8. Multidisciplinary team approach.

Fig 5: Diaphragmatic Hernia repaired using Gortex

patch.

Fig 1: Loops of intestine in the left side of chest

G o rG o rG o rG o rG o r t et et et et exxxxx

pa t chpa t chpa t chpa t chpa t ch

Left Lung

Hypoplastic

Fig 6: Left lung hypoplasia

Baby in ICU ventilated

Baby in ICU prior to discharge

CASE REPORT

A newborn was diagnosed

antenatally to have left sided CDH at

35 weeks of pregnancy. Parents were

counselled about the nature of the

disease prior to delivery of their

newborn. The baby was delivered byelective caesarean section at 37

weeks, the birth weight was 3.8 kgs.

He was immediately transferred to

neonatal-paediatric intensive care for

further care and management.

He developed respiratory distress

requiring respiratory support at three

hours of age (Fig 1 and 2). The

pulmonary pressures were monitored

by echocardiography during the first

week of life. The small and large bowel

which had herniated on left side of

diaphragm was repaired using a

Gortex patch by combined thoracic

and abdominal approach on day four

of age once the pulmonary pressures

dropped to normal levels (Fig 3, 4, and 5).

The left lung was hypoplastic

(Fig 6). The baby was on respiratory

support for seven days and requiredoxygen supplement for the next 15

days. Expressed breast milk feeds

were commenced by nasogastric tube

Courtesy:

Dr. Prakash Vemgal, DCH (Paediatrics),

MRCPCH, Fellowship in Neonatology

(Australia), Fellowship in Paediatric Intensive

Care (Canada)

Consultant Neonatologist & Paediatric

Critical Care

Dr. Devananda N S,M.S., M.Ch.

Paediatric Cardiac Thoracic Surgeon

Dr. Ramesh R, M.D.

Consultant Anaesthesiologist

Dr. Anuradha S, M.D.

Consultant Obs & Gynaec


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7


9/12

A20 year old male patient

with an alleged history of

suicidal ingestion of 40

tablets of Atenolol 50mg,

40 tablets of Metformin and th of a

cake of Mortein Rat Killer

(Bromodiolone 0.005%w/w). He was

given a stomach wash at a nursing

Home. As his general condition

deteriorated with progressive

respiratory distress, he was intubated

and ventilated. CVC was attempted,

with repeated punctures at the nursing

home unsuccessfully. Progressive

respiratory distress followed with

bilateral worsening opacities, and hewas diagnosed to have ARDS

secondary to aspiration pneumonia,

and shifted to Wockhardt Hospitals for

further management.

On arrival in the ER, he was

hemodynamically stable. Initial

evaluation revealed reduced air entry

on the right side, multiple puncture

marks present over right

supraclavicular area, right anterior

chest wall and fullness over the right

neck with no crepitus. Patient was

drowsy, opening eyes to call and

moving all 4 limbs. Central nervous

examination was normal. Chest

radiograph revealed bilateral dense

opacities, right > left [Fig 1]. Other

investigations were normal.

Chest tube was inserted into the right

side and drained about 2.5 liters ofblood tinged fluid. Despite drainage,

chest XRay showed a large

opacification on right side with non

expansion of the lungs, and CT scan of

the thorax was done (Figure 2). CT

revealed a right loculated effusion

compressing the right lung suggestive

of loculated hemothorax, additional

large left sided pleural effusion and

pseudoaneurysm in relation to right

subclavian artery. Doppler of the right

upper limb arterial system with right

n unusual case of

Adult Respiratory Distress Syndrome (ARDS)

A

RITICAL CARE

Fig 1: Initial Chest Radiograph showing

opacification of the right hemithorax with smaller

left opacification

Fig 2. Contrast enhanced high resolution CT scan

showing the presence of bilateral hemothorax at

multiple levels

common carotid artery revealed a small

hematoma near the bifurcation of right

innominate artery and absence of any

pseudoaneurysm. Chest tube was

inserted on the left side and drained

about 1.5 liters of hemorrhagic fluid,

with good lung expansion (figure 3).

In view of persistent loculated

hematoma in the right chest after chest

tube insertion with respiratory

compromise, Video Assisted

Thoracoscopic Surgery was advised.

Intra- operatively, the pleural cavity

showed no evidence of residual

hematoma, and the opacity was found

to be a large, non-pulsatile

EXTRAPLEURAL hematoma. Limited

muscle sparing thoracotomy was done

to drain the extrapleural hematoma.

Thoracic drain was placed in the

hematoma cavity. Following this, the

lung completely re-expanded (see

figure 4). Patient was weaned off the

Fig 3. Chest Radiograph showing partial resolution

of opacity in right hemithorax

A properproperproperproperproper

diagnosisdiagnosisdiagnosisdiagnosisdiagnosis and

appropriateappropriateappropriateappropriateappropriate

treatmenttreatmenttreatmenttreatmenttreatment of a

complicated

condition can

save lives.save lives.save lives.save lives.save lives.

Fig 4. Chest Radiograph showing complete

resolution of the pathology

8


10/12

T

oxic shock syndrome is a rare

but potentially fatal toxin

mediated acute febrile

illness. Although classicallyassociated with tampon use, it is now

known that many non-menstrual

conditions are related to this syndrome.

Case fatality rates for menstrual related

STSS have ranged from 5.5% in 1980

to 1.8% in 1996. Mortality rates for

streptococcal TSS are in the range of

30-70%. Early onset of shock and

multi-organ failure contribute to the

high morbidity and mortality

associated with this condition. The

condition can mimic several common

diseases. Hence, patients with fever

and rash and a toxic condition out of

proportion to local findings should have

the diagnosis of toxic shock syndrome

in their differential diagnosis.

CASE REPORT

A 26-year-old female, who had

undergone LSCS 40 days ago,

presented to us with h/o fever of seven

days and rash of five days duration. She

had a high-grade fever, not associated

with chills and rigors. The rash, which

developed two days after the onset of

fever, began on the face and progressed

to involve the palms and the soles. One

day prior to admission, the patient had

developed sore throat and loose stools.

The caeserian section wound appearedto be healing except for an area of

induration in the central portion. She

had no prior h/o fever with rash and no

other prior medical or surgical illnesses.

On examination, a generalised macular

erythrodermal rash was noted which

also involved the palms, soles and oral

mucosa. She had mild puffiness of the

face with fine scaling of skin over the

malar area. Her heart rate was 90/min;

BP- 100/70 mm Hg and temperature

103 deg F. Systemic examination was

normal except for minimal induration

and discharge from the caeserian

section scar.

The total count was 5,300; Platelet

count, Renal Function Test, Liver

Function Test were normal. CRP was

positive.

With a tentative clinical diagnosis of

toxic shock syndrome, the patient was

started on IV Reflin 500 mg thrice daily,

IV Clindamycin 600mg thrice daily, on

admission. Throat C/S, Vaginal discharge

C/S and Blood C/S were negative.

However, wound discharge C/S grew

Staph. aureus resistant to Methicillin,

sensitive to Clindamycin. The

temperature, which was 103 deg F on

admission, decreased progressively

and patient was afebrile on day four.

The skin lesions began to desquamate

by day 12 of illness and the patient

was discharged in a stable state.

What you need to know about toxic

shock syndrome

Toxic shock syndrome is a toxin

mediated multisystem disease

precipitated by staphylococcus aureusor Group A streptococcus

(streptococcus pyogenes). The

condition was first described in 1978

INTERNAL

MEDICINEsyndromeToxic shock

Immediate treatmentImmediate treatmentImmediate treatmentImmediate treatmentImmediate treatment

should be aimed

at aggressive

management of

hypovolaemic shockhypovolaemic shockhypovolaemic shockhypovolaemic shockhypovolaemic shock

caused by capillary

leakage and vasodilation

Courtesy:

Dr. Ravindra Mehta, M.D., FCCP,

American Board Certified Critical Care

Medicine, Pulmonary Medicine,

Sleep disorder medicine

Intensivist and pulmonologist

Dr. U Shabeer Ahmed, M.S.,FRCS (UK), MMAS (Dundee)

Consultant Laparoscopic surgeon

Dr. K N Srinivasan,M.S., M.Ch.

Cardiovascular and Thoracic Surgeon

Dr. Deepak Tauro,M.D.Fellow - Critical care

Dr. Madhusudan K A, M.D.

Intensivist


ventilator and extubated on the next

day. He had an uneventful recovery

and was discharged 5 days later.

Presence of bilateral large hemothorax

and an extrapleural hematoma on one

side is an unusual clinical presentation.

Central Venous Catheterisation (CVC)

is otherwise a safe and uncomplicated

procedure in experienced hands. This

was a rare complication of CVC done

outside, and labeled as ARDS. This

case demonstrates that proper

diagnosis and appropriate treatment of

a complicated condition can save lives.

Admission of a patient to a centre

having the required Critical Care

expertise and adequate facilities to

treat such patients will go a long way

in saving lives.

9


11/12

Courtesy:

Dr. Manjunath K N,

M.D., ABIM (USA), FACP (USA)

Consultant Internal Medicine

Dr. Aashish R Shah,

M.S., DNB, FRCS

Consultant GI and Laparoscopic Surgeon

Dr. Poonam Arya,

M.B.B.S., DNB

Surgical Registrar

Dr. Lingaraj B Patil,

M.B.B.S., DNB

Surgical Registrar


in children. Subsequently in 1980 it

was identified in association with

tampon use.

Non-menstrual cases of TSS were

also reported in the early 80s in

association with several surgical

procedures (e.g. rhinoplasty,

augmentation mammoplasty,

liposuction, chemical peeling, nasal

packing, post partum procedures)

and medical conditions (e.g.

pneumonia, influenza, unidentified

bacteraemia, septic arthrit is,

thrombophlebitis, meningitis, pelvic

infection, endophthalmitis).

Non-menstrual conditions

predisposing to STSS include -

surgical wound infection, postpartuminfections, focal cutaneous and

subcutaneous lesions, deep

abscesses, empyema, peritonsillar

abscesses, sinusitis, and

osteomyelitis. Necrotising fascitis,

myositis, cellulitis caused by Group

A streptococci are also known to

cause TSS.

Risk factors described with STSS

include HIV infection, diabetes, cancer,

ethanol abuse, recent h/o varicella

infection, NSAID use.

STSS should be suspected in any

patient with fever, rash, hypotension

and systemic evidence of toxicity.

The CDC criteria for diagnosis of TSS

include the following:

Fever - which is the most

common presenting sign.

However patients in shock

may be hypothermic.

Rash - classically describedas a diffuse macular

erythroderma.

Desquamation - which begins

1-2 weeks after the

onset of illness and involves

the palms and soles.

Hypotension (systolic

BP twice the upper

limit of normal

Hepatic - total bilirubin,

SGOT, SGPT at least twice

the upper limit of normal

Hematological - Platelets lessthan 100,000

Central nervous system -

disorientation or alteration in

consciousness without focal

signs.

DIFFERENTIAL DIAGNOSIS

Diseases, which may be confused

with TSS, include:

Rocky Mountain SpottedFever- in which the rash is

petechial

Leptospirosis, Kawasaki

Disease - mucocutaneous

lymph nodes enlargement

Meningococcemia - in

which the rash is petechial

or purpuric

Toxic Epidermal Necrolysis

and Steven Johnson

Syndrome.

TREATMENT

Immediate treatment should be

aimed at aggressive management of

hypovolaemic shock caused by

capillary leakage and vasodilation.

Rapid infusion of large volumes of

crystalloid solutions is the mainstay

of treatment. At times 8 to 20L of fluid

over 24 hrs may be required to

maintain pressures. Placement of a

central venous line or pulmonary

arterial catheter is recommended for

haemodynamic monitoring.

TTTTToxic shockoxic shockoxic shockoxic shockoxic shock

syndromesyndromesyndromesyndromesyndrome is a

rare but potentially

fatal toxinfatal toxinfatal toxinfatal toxinfatal toxin

mediated acute

febrile illness.febrile illness.febrile illness.febrile illness.febrile illness.

10


12/12

Doctors use a 4 mm endoscope to

remove brain tumour through

patients nose

Bangalore, February 23, 2007: In a

unique path-breaking surgery the

neuro-surgery team at Wockhardt

Hospitals, Bangalore, performed a

pioneering technique by which a brain

tumor was removed using a 4 mm

endoscope that was guided through

the patients nasal cavity. The surgery,

which demands exceptional skill and

specialised equipment, wasconducted by Dr. D V RajaKumar, on a

40-year old lady who was diagnosed

with a brain tumour measuring 2

centimetres. While endoscopes have

been previously used for brain

surgeries related to cavities within the

brain and occasionally to remove the

tumours from the pituitary gland

through the nose, this is the first

reported case in the country where an

endoscope was used to remove a brain

tumor without open surgery.

Wockhardt hospitals expands super-

speciality care to Womens Health on

International Womens Day

Bangalore, March 8, 2007: Wockhardt

Hospitals officially launched a

dedicated Womens Care Speciality on

the occasion of International Womens

Day 2007. The Wockhardt Hospitals

Womens Health Speciality,

comprising of well-equipped delivery

suites, operating theatres, a 12-bed

neo-natal ICU, a nursery, 13 LDR

(labour, delivery and recovery) rooms

and consultation suites, was formally

launched at a special event by Priyanka

Upendra, film star and wife of Kannada

film star Upendra.

Wockhardt launches E-ONE, the

Wockhardt Emergency Care

Network (1057-11)

E-ONE is not just an ambulance

service, but a holistic coordinated

effort involving mobile critical careunits with advanced life saving

equipments, qualified emergency

care trained paramedics, a network

of ICUs within easy proximity,

backed by a team of critical care

specialists.

E-ONE facility is available across the

Wockhardt network of ICUs located at

Bannerghatta Road, Cunningham

Road, Rajajinagar and Nagarbhavi in

Bangalore.

Innovative surgery replaces

degenerated cervical disc

Latest therapy in cervical disc

replacement designed to preserve

motion and flexibility

Bangalore, March 28, 2007:

Dr. D V Rajakumar, Consultant Neuro

Surgeon at Wockhardt Hospitals Brain

& Spine care, with his team hassuccessfully performed a total disc

replacement in the cervical spine of

26-year old Gautam Kher, a software

engineer, thus opening up a new area

of treatment for patients who suffer

from Cervical Degenerative Disc

Disease (DDD). Through the new

technique, an artificial disc replaces

the degenerated disc and allows

movement at that level. The diseased

disc was replaced using a PRESTIGE

LP Cervical Disc implant, rather than

to remove it through disectomy or

bone graft.

Launch of Wockhardt Hospitals ICU

and Community care, at Rajajinagar,

Bangalore

Wockhardts first regional hospital was

launched on February 17th 2007. The

hospital is designed to deliver high

standards of secondary healthcare

services supported by sophisticatedtechnology and experienced medical

professionals.

This is a 50 bed (including 10 ICU beds)

and one operation theatre, expert

medical professionals, dedicated

specialists and the latest technology.

The hospital is located at West of

Chord Road, opposite to Rajajinagar

first block, Bangalore.

News

We look forward to hearing from you. Send in your views and suggestions [email protected]

Wockhardt Hospitals

154/9, Bannerghatta Road, Opp IIM, Bangalore 560076 India. Tel:91-80 6621 4444/254 4444 Fax: 91-80 6621 4242/2254 4242

14 Cunningham Road, Bangalore 560052 India. Tel:91-80 4199 4444 / 2226 1034 Fax: 91-80 2228 6530

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