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Article in press
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Mucormycosis: A Fungal Rarity Mangling Coronavirus Disease-2019 Patients in India
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Abstract [+]
Mucormycosis is a rare, non-contagious fungal infection with high fatality rates, identified since centuries. It was found that the filamentous fungi of the family Mucoraceae attacks immunocompromised patients on medication due to comorbidities like diabetes, organ transplant or malignancy. The coronavirus disease-2019 (COVID-19) recovering patients especially with diabetes mellitus or high glucose levels due to corticosteroid treatment made them vulnerable to this fungus. This was announced as an epidemic based on the rapidity of spread and the very high death rates. This was due to the fact that COVID-19 made the immune system of the patient so weak and the steroids given to treat corona provided an ambient bed for the speedy growth of the fungus and finally leading to death. The timely diagnosis of the infection can help to manage mucormycosis may it be by antifungal combination therapy, reduced use of steroids, control blood sugar levels, and removal of necrotic cells by surgical debridement. The review
article is an outline of the clinical manifestation, histopathology, mortality rates, diagnosis and treatment of this deadly disease.
Keywords
COVID-19; Mucormycosis; Black fungus; Diabetes; Immunocompromised patients.
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Safety and Efficacy of Rescue Nerve Blocks
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Abstract [+]
Background: The overall incidence of complications following peripheral nerve blocks is very low. Peripheral nerve blocks performed under ultrasound guidance are widely thought to present a lower risk to direct needle trauma than paresthesia and nerve stimulation techniques and have been shown to decrease opioid consumption by providing analgesia directly to the site of injury. Currently, when a nerve block fails altogether or provides inadequate analgesia, pain and opioid consumption increases which in turn decrease patient satisfaction and increases healthcare costs. Concerns remain whether the benefits of opioid reduction outweigh the risk of inadvertent needle trauma and other potential complications when performing a nerve block replacement, or ‘rescue block’.
Objective: Examine whether performing a rescue peripheral nerve block provides adequate analgesia to elicit a decrease in opioid consumption. Analyze the incidence of nerve injury following ultrasound-guided ‘rescue’ continuous peripheral nerve blocks.
Methods: Data was retrospectively collected from patient electronic medical records from a Level 1 academic Trauma Center at Regional One Hospital in Memphis, Tennessee from March 1, 2019 to May 31 2021. Inclusion criteria was patients over 18-years of age at time of admission who received consecutive continuous peripheral nerve blocks in the same relative location during a time when the peripheral nerves were likely partially or fully anesthetized (a rescue block). The primary outcomes assessed were 24-hour opioid consumption prior to the initial continuous nerve block, just prior to and after the ‘rescue’ block. Adverse outcomes potentially due to performing a ‘rescue’ block were also examined, including direct needle trauma, nerve injury related to extended exposure to local anesthetics, and local anesthetic systemic toxicity. Types of nerve blocks performed, range and median number of catheter days, and reason for rescue block was recorded for all patients. All available electronic healthcare records were reviewed to identify potential injury. Nerve blocks were categorized into low and high-risk for direct needle trauma based on the incidence of needle trauma found in the literature and whether the needle was required to be adjacent to a discrete nerve or nerve bundle in order to perform the procedure.
Results: Fifty-five (55) patients were examined. Of the 55 patients, 5 had multiple locations both blocked and rescued, bringing the total rescue procedures examined up to 60. Additionally, 10 patients had their rescue site re-blocked multiple times due to either multiple surgeries, displacements, or duration of analgesia required bringing the total number of rescue blocks performed to 74. Patients that received an initial continuous peripheral nerve block consumed significantly fewer opioids during the 24-hour period following the block than the 24-hour period before the block was performed (p=0.033). Continuous peripheral nerve blocks (CNPB) were replaced or ‘rescued’ for two general reasons: Failed or inadequate analgesia (21) and to extend the utilization of adequately functioning infusions (35). Once a rescue nerve block was performed, there was no significant change in opioid consumption than after the original block (p=0.64). Of the 60 rescue blocks that were recorded, there were 0 adverse outcomes that were attributed to the rescue block procedure.
Conclusion: Following failed CPNB or when performed to extend the utilization of CPNB infusions, ultrasound-guided ’rescue’ nerve blocks result in reduced opioid consumption to a similar level as the initial peripheral nerve block, and do not result in an increase in the incidence direct needle trauma. Given the relatively low incidence of needle trauma and other nerve block-related complications, larger studies are needed to confirm these initial findings, however, ultrasound provides numerous clinical strategies that can be employed that may reduce the incidence of direct needle trauma compared with traditional nerve localization
techniques.
Keywords
Pain; Analgesia; Regional anesthesia; Nerve block; Rescue; Opioid.
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Current Issue
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The Role of Intravenous Lidocaine in Preventing Chronic Post-Operative Pain
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Abstract [+]
Background and Goal of Study
Chronic post-operative pain (CPOP) is an increasing public health issue considering its impact on the patients quality of life and and the associated costs for the healthcare system. The incidence of CPOP can be as high as 75%, depending on the surgical procedure and other factors. Lidocaine is a local anesthetic with anti-inflammatory, analgesic and antihyperalgesic properties. Several studies have shown its use in controlling acute post-operative pain when used intravenously. The goal of this study was to define the role of intravenous lidocaine in preventing CPOP.
Materials and Methods
The PubMed database was searched from 2006 and 2019 with the keywords: “Chronic post-operative pain” or “Chronic post-surgical pain” or “Chronic pain” and “Intravenous lidocaine”. Adequate papers for the purpose of this study were selected.
Results and Discussion
Three randomized controlled trials that met criteria were obtained: two on breast surgery and the other on open nephrectomy. All trials used intravenous lidocaine during surgery, suspending the infusion up to the first 24-hours of the post-operative period. All three of them showed a significant decrease on the incidence of CPOP. There was a 20-fold decrease six months after breast
surgery.
Conclusion
Intravenous lidocaine seems to decrease the incidence of CPOP however, there is limited evidence. More trials are necessary to define the efficacy and safety of intravenous lidocaine. A generally accepted definition of CPOP is needed.
Keywords
Chronic pain; Chronic post-operative pain; Chronic post-surgical pain; Intravenous lidocaine.
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Bipedicular Basi-Vertebral Nerve Ablation: A Case Report
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Abstract [+]
Introduction
Intraosseous ablation of the basivertebral nerve (BVNA) is an emerging minimally invasive treatment to relieve chronic mechanical axial low back pain associated with Modic type 1 or type 2 vertebral end-plate changes. Randomized controlled trials demonstrate improvements in pain and function sustained for up to five-years.
Methods
A 40-year-old woman presented with an eight-year history of central low back with mechanical features. There was minimal response to active physical reconditioning techniques, breast reduction surgery and chronic opioid prescription. Imaging disclosed modic type 1 vertebral end-plate changes at the L5/S1 segment. Following a positive short-term response to bilateral L5/S1 facet joint injections, the L5/S1 facets were treated with radiofrequency ablation of the L4 medial branch and L5 dorsal ramus bilaterally but with minimal benefit. BVNA at L5 and S1 was provided using a bi-pedicular bipolar radiofrequency approach (description attached).
Result
Six-week outcomes data disclosed decreased pain intensity from 8/10 to 3/10 and improved function with a decrease of 22 points on the oswestry disability index (ODI). Measures of depression, anxiety and stress, and quality of life improved significantly. Opioid usage decreased with a weaning plan. Magnetic resonance imaging (MRI) findings demonstrated new sclerosis with surrounding bone marrow oedema of the right and left sides of the L5 and S1 vertebral bodies consistent with the BVNA treatment.
Discussion
This case reports technically successful BVNA using a bipedicular approach. The early result is consistent with the published literature using the uni-pedicular approach. Follow-up plans are in place. A case series will follow. In Brief A bi-pedicular bipolar radiofrequency technique for basivertebral nerve ablation to treat vertebrogenic chronic low back pain is described, including early clinical outcomes and MRI findings.
Keywords
Bipedicular; Radiofrequency; Basivertebral nerve; Vertebrogenic; Modic end-plate changes.
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Anesthetic Considerations in Bilateral Congenital Anophthalmia: A Rare Clinical Entity
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Hardware Causing Hard Times: Use of the SuperNO2VA™ Nasal PAP Device to Address Airway Challenges Caused by Eroding Mandibular Hardware
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Pneumocephalus Caused by an Epidural Ozone Injection for Treatment of Disc Prolapse
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Transcatheter Arterial Embolization in Postpartum Hemorrhage: A Case Report
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An Observational Study to Evaluate Infection Risk in Two Staff Warming Devices and a Review of Current Literature into Thermal Comfort in the Operating Room and Beyond
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Previous Issue
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Cranial and Spinal Subdural Hygroma Following Lumbar Epidural for Labour Analgesia
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Abstract [+]
Intracranial hygroma is a rare and probably missed complication of epidural analgesia secondary to accidental dural breech. The patient presented had a presumed spinal cerebrospinal fluid leak with symptoms of intracranial hypotension. Unusually the patient had both an intracranial subdural hygroma and rarely reported extensive spinal intradural (extra-arachnoid) collection following a lumbar epidural, administered in labour. Given the potential for progression to symptomatic neurological deficits, anesthetists should consider subdural hygroma when encountering patients with features of intracranial hypotension, or altered neurology following epidural. Pathophysiology, imaging and management are discussed.
Keywords
Subdural hygroma; Epidural; Dural puncture.
Anesthetic Considerations in Bilateral Congenital Anophthalmia: A Rare Clinical Entity
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Congenital anomalies planned for ocular surgeries range from the rare to atypical to common. Many of this rare ophthalmopathy are associated with clinical syndromes and have important anesthetic implications. Not only is it important to know the syndrome we are dealing with, but it’s also the more important to understand the systems that are involved, the extent of involvement, potential anesthetic complications, right from the cerebrovascular, cardiovascular, endocrine, metabolic, neuromuscular, genitourinary systems to airway. Understanding these aspects becomes more important in rare clinical scenarios as it helps to plan the case, anticipate and treat the complications. Congenital anophthalmia is one of the rare conditions with an incidence of <3/1000 with microphthalmia reported in up to 11% of blind children, hence we report a rare case of bilateral congenital anophthalmia planned for excision of right ocular swelling.
Keywords
Ophthalmopathies; Congenital anophthalmia; Microophthalmia; Ocular surgery.
Hardware Causing Hard Times: Use of the SuperNO2VA™ Nasal PAP Device to Address Airway Challenges Caused by Eroding Mandibular Hardware
PDF 361.87 KB
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Abstract [+]
Background
Maintenance of the airway and adequate ventilation are essential for the anesthetized patient and may be compromised in patients with pan-facial trauma, abnormal dentition, abnormal mandibular space, or presence of dental hardware. We present an unusual case of a patient with a lack of natural mandibular structure and exposed mechanical hardware with fistula complicating intubation and ventilation prior to surgery.
Case Presentation
A 35-year-old male with a history of a self-inflicted gunshot to the left submandibular region approximately 6 years prior was scheduled for urgent mandibular hardware removal, closure of left facial fistula, and removal of several teeth. Pre-oxygenation and ventilation were complicated by extruding hardware and eroded skin, causing interference with a conventional facemask seal. The patient was pre-oxygenated using the SuperNO2VA™ nasal mask with which an adequate seal was achieved without use of a nasal trumpet and with a modified grip. Tracheal intubation via oral video laryngoscopy was successful, and the case proceeded uneventfully.
Conclusion
Adequate ventilation and airway maintenance can be difficult to achieve in patients with abnormal facial structure or mandibular mechanical hardware using conventional methods. The SuperNO2VA™ nasal mask can address airway issues for these patients peri-operatively.
Keywords
Anesthesiology; Airway management; Difficult airway; Airway devices; Difficult intubation; Ventilation; Oxygenation; Facial trauma; Mask ventilation.
Pneumocephalus Caused by an Epidural Ozone Injection for Treatment of Disc Prolapse
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Abstract [+]
Pneumocephalus is a complication seen either after head trauma or post-neurosurgical procedure. It can be life-threatening if it turns into tension pneumocephalus. The presence of intracranial air indicates the presence of an open communication of cerebrospinal fluid. Air enters dura matter even without connection. Thin air flows upstream along the cerebrospinal fluid (CSF) pathway. Herein, we report a case of pneumocephalus in a 62-year-old female after epidural injection of Bupivacaine and Ozone for the treatment of a prolapsed disc. She was shifted to our hospital post-epidural injection for the management of severe headache. Though it is a rare complication, keeping this in mind will help to quickly diagnose, if need arises.
Keywords
Pneumocephalus; Head trauma; CT; Thunderclap headache.
Transcatheter Arterial Embolization in Postpartum Hemorrhage: A Case Report
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Abstract [+]
Background
Postpartum haemorrhage is the leading cause of maternal mortality and morbidity. The significant impact of postpartum haemorrhage (PPH) on maternal mortality can be reduced if timely measures are implemented. Transcatheter arterial embolisation (TAE) is an alternative therapeutic strategy for PPH.
Case report
We report a case of postpartum haemorrhage which was managed by transcatheter arterial embolization in lieu of hysterectomy to preserve fertility and menstruation in a 27-year-old patient.
Conclusion
The critical role of obstetrician, anaesthesiologist and interventional radiologist as a team, improve the quality of care and patient safety.
Keywords
Postpartum hemorrhage (PPH); Peripartum hysterectomy; Transarterial embolisation.
An Observational Study to Evaluate Infection Risk in Two Staff Warming Devices and a Review of Current Literature into Thermal Comfort in the Operating Room and Beyond
PDF 401.09 KB
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Abstract [+]
Objective
To compare the degree of bacteria dissemination using two currently available operating room (OR) personnel warming devices. The “off-label” use of 3MTM’s Bair HuggerTM vs. a fairly new device, worn around the torso and under a scrub warm-up jacket or surgical gown, the OPERATIONHEATJAC® transformer only (TRO) powered by a transformer and controlled by a 4-level controller, and best for anesthesia providers and perfusionists.
Methods
Initially, staff members in scrubs sat in a room for 3 and 6-hours with agar plates placed in various positions throughout the room. Then staff members sat in the same room under the same conditions for 3 and 6-hours, and placed the hose from 3M’s Bair Hugger under their scrubs. Agar plates were positioned in the room in the same positions as in the control. Then staff members sat in the same room under the same conditions for 3 and 6-hours, wearing the OPERATIONHEATJAC® TRO over their scrub shirt and under a scrub warm-up jacket. Agar plates were again positioned in the room in the same positions as in the control. Bacteria colony counts were compared.
Results
The bacteria colony counts were 43.78% and 46.18% higher at 3 and 6-hours respectively from placement of the hose from 3MTM’s Bair HuggerTM under scrubs vs. the control. There was no significant difference in bacteria colony counts with using the OPERATIONHEATJAC® TRO vs. the control.
Conclusion
ORs are maintained cold, mostly for surgeon comfort. In an attempt to keep comfortable in this environment, peripheral OR staff opt for the “off-label” use of 3M’s Bair Hugger hose placed under scrubs. An increased spread of bacteria throughout the OR can result from this practice. Currently, there are now safer OR personnel warming devices available. In addition, this paper reviews the significance and benefits of keeping staff warm and comfortable.
Keywords
Warming devices; OPERATIONHEATJAC®; surgical site infections (SSIs); Operating room (OR); Temperature.
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