Anaesthetic management of a patient with pemphigus vulgaris for emergency laparotomy

A 45-year-old man with a long-standing history of duodenal ulcer presented with symptoms and signs of perforation peritonitis. He also had lesions of pemphigus vulgaris throughout the body, involving both skin and mucous membranes. Care was taken to avoid pressure and friction during placement of monitoring devices, intravenous and arterial lines. Since the patient had to undergo exploratory laparotomy, intubation was performed in an atraumatic manner after rapid sequence induction. However, there was minor bleeding from the mucous lesions of the oral cavity, which was controlled by a saline adrenaline throat pack. The patient was extubated at the end of the surgery and steroids were continued in the peri-operative period.     

The anesthetic management of a patient with paroxysmal nocturnal hemoglobinuria

Implications: This case report describes the anesthetic considerations for a patient with paroxysmal nocturnal hemoglobinuria. Specific strategies to be applied in the perioperative period to prevent hemolytic episodes and venous thrombosis are also discussed.     

Sevoflurane for trans-sternal thymectomy in myasthenia gravis

Myasthenic gravis (MG) is an autoimmune disease associated with acetylcholine receptor deficiency. Patients with MG exhibit increased sensitivity to non-depolarising muscle relaxants. In an attempt to avoid neuromuscular blockers, we used sevoflurane in two myasthenic patients undergoing trans-sternal thymectomy. Inhalation of 8% sevoflurane in oxygen using vital capacity technique produced rapid, pleasant and smooth induction and provided good tracheal intubating conditions. In both patients anaesthesia was maintained with 1.5-2% end-tidal concentration of sevoflurane and nitrous oxide in oxygen without adjunctive neuromuscular blocking agents. There were minimal changes in cardiovascular variables and recovery was faster. It is suggested that sevoflurane may be the main anaesthetic for both induction and maintenance in myasthenic patients undergoing trans-sternal thymectomy.     

Effect of COVID-19 lockdown on the pathway of care and treatment outcome among patients with tuberculosis in a rural part of northern India: a community-based study

Objectives: The coronavirus disease 2019 (COVID-19) pandemic affected routine healthcare services across all spectra, and tuberculosis (TB) care under the National Tuberculosis Elimination Program have been affected the most. However, evidence available at the community level is minimal. The clinical features, care cascade pathway, and treatment outcomes of TB patients pre- and during/post-COVID-19 pandemic lockdown in a rural community health block in northern India were assessed and compared.Materials and Methods: This was a retrospective cohort study that included all patients diagnosed with TB and initiated treatment under programmatic settings between January 1 and June 30, 2020, in a rural TB unit in northern India. The periods from January 1 to March 23 and March 24 to June 30 were marked as pre-lockdown and during/post-lockdown, respectively.Results: A total of 103 patients were diagnosed and treated for TB during the study period. A significantly higher proportion of pulmonary TB cases were reported during/post-lockdown (43, 82.7%) compared to that pre-lockdown (32, 62.7%), and a higher diagnostic delay was noted during/post-lockdown (35, 81.4%). Through adjusted analysis, patients diagnosed during/post-lockdown period (adjusted risk ratio [aRR], 0.85; 95% confidence interval [CI], 0.73–0.98) and previously treated (aRR, 0.77; 95% CI, 0.60–0.995) had significantly lower favorable treatment outcomes.Conclusions: The symptom and disease (pulmonary/extrapulmonary) pattern have changed during/post-lockdown. The care cascade delays are still high among TB patients, irrespective of the lockdown status. Lockdown had a significant adverse impact on the outcomes of TB treatment.     

Sports-related pneumothorax in children

Pneumothorax after blunt chest trauma in the absence of rib fractures is uncommon and has only rarely been reported as a result of sporting activity. Presentation may vary from an apparently normal physical examination in the presence of a small pneumothorax to hemodynamic compromise in the presence of a tension pneumothorax. High fitness levels in athletes may result in failure to recognize symptoms and delay diagnosis, potentially increasing morbidity. It is imperative for the emergency physician to exclude pneumothorax in children who present with chest pain after blunt chest trauma from sports injury. We report our experience with and the management of 3 patients with pneumothoraces.     

Preoperative statin intake and morbid events after isolated coronary artery bypass grafting

STUDY OBJECTIVE: To examine the effect of statins on morbidity and mortality in patients after isolated coronary artery bypass grafting (CABG). DESIGN: Observational cohort study. SETTING: Tertiary-care teaching hospital. MEASUREMENTS: Data from 2497 adult patients who underwent isolated CABG between January 2002 and June 2004 were studied. Patient characteristics and intraoperative variables were prospectively collected. End points were major morbid events and in-hospital mortality. A propensity score was estimated for each patient using logistic regression on the probability of statin use. Patients were also classified into 5 quintile groups according to their propensity score. Outcome variables were compared for propensity-matched pairs and quintile groups between those who received and did not receive statin therapy. MAIN RESULTS: Propensity matching resulted in a similar distribution of variables among the 654 matched pairs. Similar perioperative mortality was found between matched pairs with statin therapy vs no statin therapy, 5 (0.76%) and 8 (1.2%), (P = 0.40), respectively. Cardiac, neurologic, renal and respiratory morbidity, occurrence of atrial fibrillation, and length of hospital stay were similar between the matched pairs and among quintiles of propensity scores. CONCLUSIONS: Preoperative statin intake did not reduce the frequency of major perioperative morbid events after isolated CABG.