Complex Regional Pain Syndrome (CRPS type-1) in an Adolescent Following Extravasation of Dextrose Containing Fluid-an Underdiagnosed Case

Due to its complex pathophysiology and wide spectrum of clinical manifestations, the diagnosis of CRPS is often missed in the early stage by primary care physicians. After being treated by a primary care physician for 5 months for chronic cellulitis, a 16-year-old girl was referred to our hospital with features of type-1 CRPS of the right upper extremity. Inability to diagnose early caused prolonged suffering to the girl with all the consequence of CRPS. The patient responded well with marked functional recovery from multimodal therapy. Ability to distinguish CRPS from other pain conditions, referral for specialty care at the appropriate time and full awareness of this condition and its clinical features among various healthcare professionals are essential in reducing patient suffering and stopping its progression towards difficult-to-treat situations

Butorphanol in Labour Analgesia

Introduction: Labour is the process where uterine contractions lead to expulsion of product of conception through the vagina into the outer world. Labour pain is one of the most severe pains which has ever been evaluated and its fear is one of the reasons women wouldn’t go for natural delivery. Delivery is a painful experience for all of the women except a few of them. The labor pain results from some physiological-psychological causes. Different pharmacological and non-pharmacological methods have been tried for pain relief in labour. The objective of this study is to see the effect of butorphanol injection in labour pain. Methods: It is a descriptive cross-sectional study conducted in B.P. Koirala institute of health sciences. We observed 200 pregnant women meeting the inclusion criteria and giving the informed consent who were on 1 mg butorphanol i.m. at the onset of active stage of labour every 4 hourly and on demand. Pain assessment was done by Numerical Pain analogue scale measured from 1 to 10. Fetal heart rate monitoring was done according to the hospital protocol. Caesarean section was performed for obstetrical indication. Neonatal outcome was evaluated by on duty pediatrician and APGAR score were noted at 1 and 5 min. Results: The pain scores in first, second, third, fourth hour were (8.83±0.773), (9.84±0.544), (9.94±0.338), (9.6±0.298) respectively, where 1st and 2nd hour is statistically significant. Conclusions: Butorphanol is an effective labour analgesia without significant adverse effects on women and the neonatal outcome

Effect of carbapenem resistance on outcomes of bloodstream infection caused by Enterobacteriaceae in low-income and middle-income countries (PANORAMA): a multinational prospective cohort study

Background Low-income and middle-income countries (LMICs) are under-represented in reports on the burden of antimicrobial resistance. We aimed to quantify the clinical effect of carbapenem resistance on mortality and length of hospital stay among inpatients in LMICs with a bloodstream infection due to Enterobacteriaceae. Methods The PANORAMA study was a multinational prospective cohort study at tertiary hospitals in Bangladesh, Colombia, Egypt, Ghana, India, Lebanon, Nepal, Nigeria, Pakistan, and Vietnam, recruiting consecutively diagnosed patients with carbapenem-susceptible Enterobacteriaceae (CSE) and carbapenem-resistant Entero-bacteriaceae (CRE) bloodstream infections. We excluded patients who had previously been enrolled in the study and those not treated with curative intent at the time of bloodstream infection onset. There were no age restrictions. Central laboratories in India and the UK did confirmatory testing and molecular characterisation, including strain typing. We applied proportional subdistribution hazard models with inverse probability weighting to estimate the effect of carbapenem resistance on probability of discharge alive and in-hospital death, and multistate modelling for excess length of stay in hospital. All patients were included in the analysis. Findings Between Aug 1, 2014, and June 30, 2015, we recruited 297 patients from 16 sites in ten countries: 174 with CSE bloodstream infection and 123 with CRE bloodstream infection. Median age was 46 years (IQR 15–61). Crude mortality was 20% (35 of 174 patients) for patients with CSE bloodstream infection and 35% (43 of 123 patients) for patients with CRE bloodstream infection. Carbapenem resistance was associated with an increased length of hospital stay (3·7 days, 95% CI 0·3–6·9), increased probability of in-hospital mortality (adjusted subdistribution hazard ratio 1·75, 95% CI 1·04–2·94), and decreased probability of discharge alive (0·61, 0·45–0·83). Multilocus sequence typing showed various clades, with marginal overlap between strains in the CRE and CSE clades. Interpretation Carbapenem resistance is associated with increased length of hospital stay and mortality in patients with bloodstream infections in LMICs. These data will inform global estimates of the burden of antimicrobial resistance and reinforce the need for better strategies to prevent, diagnose, and treat CRE infections in LMICs

Chronic pain and cost: An epidemiological study in the communities of Sunsarai district of Nepal

ABSTRACT The purpose of the study was to find out the prevalence of chronic pain in economically active population and associated economic loss. This cross-sectional observational study was carried out in 3 VDCs of Sunsari District involving 1730 individuals of 15-64 years age group selected by multistage random sampling. Demographic data, absence or presence of pain, site, severity, duration and relieving measures, approximate expenditure in treating pain and number of days lost due to pain were noted using a preformed questionnaire. Out of 1730 individuals interviewed, 882 (50.1%) had pain of which 93.7% had chronic pain (pain lasting for >3 months). Backache (25.8%), headache (20.1%) and abdominal pain due to acid peptic disease (12.5%) were the most prevalent painful conditions. About 14% of individuals had severe grade pain. Female sex, age ≥30years, lack of formal schooling, smoking habit and dependent status were associated with higher prevalence of pain. Almost 19% of individuals with pain were unable to go to work the previous day. Man-days loss due to pain was

Adverse Events in Children Receiving General Anaesthesia with Laryngeal Mask Airway Insertion

Introduction: Perioperative adverse events are more common in children compared to adult population. Reporting an adverse event proves effective in identifying problems and helps in prevention and early management. Our objective was to identify the types, incidence, and the time of occurrence of perioperative adverse event. We also aimed to find out whether the occurrence of the types of adverse events differs in children below and above five years. Methods: This was a prospective study in 242, ASA Physical Status I and II children aged day one to 14 years, receiving general anesthesia with laryngeal mask airway for various elective surgeries. Adverse events observed in the perioperative period were recorded. Results: Adverse events related to respiratory system (n=26, 55%) were the most common followed by cardiovascular system (n= 14, 30%). Adverse events were observed in 24(10%) children in the operating room and in 20 (8%) children in the post anaesthesia care unit. In the operating room, majority (14 of 27, 52%) of the events occurred immediately after removal of laryngeal mask airway. Respiratory events were more common in children below five years (p=0.007), whereas cardiac events were more common in children above five years (p=0.02). Conclusions: The commonest adverse event in children is related to respiratory system. Adverse events occur more frequently in the operating room, mostly immediately after removal of laryngeal mask airway. Respiratory events are more frequent in children below five years whereas cardiac events are more frequent in children above five years.  Keywords: adverse events; children; laryngeal mask airway; laryngospasm; perioperative

Anaesthetic Management of Tracheal Agenesis

Tracheal agenesis is a rare but uniformly fatal congenital condition that obstetricians, neonatologists or anaesthesiologists may encounter as an unexpected emergency. Ventilation with bag and mask or through an endotracheal tube placed in the oesophagus may be the only options left for immediate survival and evaluation. Ventilation and maintenance of adequate oxygenation can be difficult during surgical interventions. We report a case of neonate in which ventilation and anaesthesia were maintained through an endotracheal tube in the oesophagus and frequent episodes of drop in oxygen saturation were observed during surgery. Anaesthetic management, airway and other issues are discussed. JNMA J Nepal Med Assoc. 2008 Jul-Sep;47(171):142-144

Prediction of Difficult Airway Among Patients Requiring Endotracheal Intubation in a Tertiary Care Hospital in Eastern Nepal

Introduction: Unanticipated difficult intubation is an undesirable situation. Various bedside screening tests are routinely performed for predicting difficult airway. Although considered a surrogate indicator, difficult laryngoscopy is not the exact measure of intubation difficulty. We aimed to determine the best screening test for predicting difficult laryngoscopy and the association between difficult laryngoscopic view and difficult intubation. Methods: This prospective, observational study involved 314, ASA I/II adult patients requiring endotracheal intubation for various routine surgical procedures. Sternomental distance 3 attempts for insertion of the tracheal tube was defined as ‘difficult intubation’. The association between difficult laryngoscopic view and difficult intubation was determined. Results: The sensitivity of the modified Mallampati class for predicting difficult laryngoscopy was highest (83%). Twelve (3.8%) patients had grade III laryngoscopic view and none had a grade of IV. Intubation was difficult in seven (2.2%) patients. Majority of patients (4 of 7) with difficult intubation had difficult laryngoscopic view (p<0.001). Conclusions: Modified Mallampati test was better for predicting difficult laryngoscopy compared to other bedside screeing tests. Difficult laryngoscopy could significantly predict difficult intubation in our patients.   Keywords: Airway evaluation; difficult intubation; difficult laryngoscopy; modified Mallampati class; Nepalese patients; sensitivity

Effect of long term high altitude exposure on cardiovascular autonomic adjustment during rest and post-exercise recovery

Abstract Background Despite the successful adaptation to high altitude, some differences do occur due to long term exposure to the hypoxic environment. The effect of long term high altitude exposure on cardiac autonomic adjustment during basal and post-exercise recovery is less known. Thus we aimed to study the differences in basal cardiac autonomic adjustment and its response to exercise in highlanders and to compare it with lowlanders. Methods The study was conducted on 29 healthy highlander males who were born and brought up at altitude of 3000 m and above from the sea level, their cardiac autonomic adjustment was compared with age, sex, physical activity and ethnicity-matched 29 healthy lowlanders using Heart Rate Variability (HRV) during rest and recovery from sub-maximal exercise (3 m step test). Intergroup comparison between the highlanders and lowlanders and intragroup comparison between the rest and the postexercise recovery conditions were done. Results Resting heart rate and HRV during rest was comparable between the groups. However, heart rate recovery after 3 min step test was faster in highlanders (p < 0.05) along with significantly higher LF power and total power during the recovery phase. Intragroup comparison of highlanders showed higher SDNN (p < 0.05) and lower LF/HF ratio (p < 0.05) during recovery phase compared to rest which was not significantly different in two phases in lowlanders. Further highlander showed complete recovery of RMSSD, NN50, pNN50 and HF power back to resting level within five minutes, whereas, these parameters failed to return back to resting level in lowlanders within the same time frame. Conclusion Highlanders completely recovered back to their resting state within five minutes from cessation of step test with parasympathetic reactivation; however, recovery in lowlanders was delayed

Anaesthesia and Perioperative Care in Remote Health Camps- Patients’ Concerns

INTRODUCTION: Identifying patients' concerns and expectations regarding anaesthesia and perioperative care in mobile surgical camps is relevant for the camp workers. This prospective observational study was conducted to assess knowledge, concerns, and expectations about anaesthesia and perioperative care in patients undergoing surgery in mobile surgical camps in remote mountainous districts of Eastern Nepal. METHODS: A questionnaire with seven items related to anaesthesia and perioperative care was used for interviewing 80 individuals of age > or = 12 years, 20 from each camp at Solukhumbu, Sankhuwasabha, Khotang and Bhojpur districts. RESULTS: Data of two patients were lost leaving only 78 individuals for analysis. The mean age of the subjects was 30.5 (+/- 14.6) years with the male: female ratio of 43: 35. Fifty-eight (74.4%) patients had some gross idea about the modality of administration of anaesthetics. Twenty-six (33.3%) individuals preferred GA over local anaesthesia, whereas 22 (28.2%) were happy either way if there was no pain. Pain was the main concern for 73.1% of the patients. Of the 25 patients expressing fear of GA, death or not being able to wake up anymore was the main concern for 60.0%. Increasing age was associated with lower fear of GA (p < 0.05). Surgical experience was distressing for 17 (21.8%) patients. The overall experience of the anaesthesia and surgery was worse than expected for 25.6% of the patients. CONCLUSIONS: Patients presenting to these health camps have limited knowledge regarding anaesthesia and perioperative care but have valid concerns and expectations in respect of their safety, comfort and outcome

Large versus Small Dose Magnesium Sulfate Infusion in Tetanus

Introduction: Evidence based guidelines regarding the use of magnesium sulfate in tetanus is lacking. Hence, our objective was to compare two infusion doses of magnesium sulfate to control the tetanic spasms. Methods: Data of 14 adult male patients admitted in the intensive care unit were retrieved. Twelve adult ventilated patients received magnesium infusion as an adjunct to diazepam therapy to control tetanic spasms. We retrospectively divided them into two groups for comparison. Group 1 patients (n=7) received a smaller dose (<1 g.h-1) than group 2 (n=5) (1.5 to 2 g.h-1). Results: The duration of symptoms before arrival to hospital was significantly longer in group 1 than group 2. The Ablett severity grade was II in three patients in group 1 and III in all patients of group 2. In Ablett severity grade III patients, the diazepam dose used was significantly higher in group 1 (n=4) (292±48 mg.d-1) than group 2 (n=3) (106±9 mg.d-1) as magnesium infusion dose was restricted due to hypotension in group 1. Amongst the patients who received MgSO4 for ≥10 days, the requirement of diazepam was significantly reduced in the second week (174.1±59.2 mg/d) than the first week (325.4±105.9 mg.d-1) of infusion in group 2 (n=4) but not in group 1 patients (n=4). Conclusions: The larger dose of MgSO4 infusion was titrated to control tetanic spasms as an adjunct to diazepam in select group of patients without hypotension. Uncontrolled hypotension, cardiac arrhythmia and renal failure were the factors to limit its infusion dose. Keywords: MgSO4; magnesium sulphate; tetanus