Stridor: a rare complication of magnesium sulfate therapy in a pregnant patient

Magnesium sulfate is frequently used in severe preeclampsia and eclampsia for the prevention and reoccurrence of seizure activity. Their adverse effects of magnesium sulfate are minor but it cause respiratory depression and tetany. We report a case of stridor due to laryngospasm as result of hypocalcemia in a pregnant patient on magnesium sulfate therapy.A 30 year old gravida5 para 4 had severe preeclampsia started on magnesium sulfate therapy and to control her hypertension she was on labetalol and nifidipine. One hour after the lower segment cesarean section, she developed severe laryngospasm and stridor, no upper airway secretion but found to have hypocalcemia. She responded to immediate intravenous calcium chloride with dramatic clinical improvement. Patients on magnesium sulfate can have life threatening hypocalcemia and stridor. The calcium channel blockers may augment the hypocalcaemic effect of magnesium sulfate

Abdominal Compartment Syndrome: What Is New?

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are continuation of the same pathological and physiological processes that are largely unrecognized in critical patients. From an era of indistinct definitions and recommendations, this condition has been studied extensively and experts have come forward with clear definitions and recommendations for management. IAH is graded in four grades and ACS is IAH above 20 cm H2O with new organ dysfunction. IAH/ACS can present as acute, hyperacute, or chronic and aetiologically can be classified into primary, secondary and tertiary. It affects various body systems including respiratory, cardiovascular, central nervous, gastrointestinal, renal and hepatic systems adversely and results in deleterious consequences. Management of IAH/ACS is based on the evacuation of intra-luminal and extra-luminal contents, improving the abdominal wall compliance. There are various surgical techniques recommended for preventing the development of IAH/ACS and mitigating the negative consequences. New medical therapies such as octreotide, tissue plasminogen activator, melatonin and vitamin C are being investigated and non-pharmacological methods such as continuous negative abdominal pressure (CNAP) have been introduced recently but are still experimental and not recommended for routine use

Acute Pain Management in Intensive Care Patients: Facts and Figures

Pain is an unpleasant experience for all patients including intensive care patients; if it is not treated properly, it has deleterious effects on patients’ acute and chronic well-beings. In ICU patients, it causes sympathetic stimulation leading to adverse hemodynamic effects and after discharge, these patients are at the higher risk for developing chronic pain and post-traumatic stress disorders. Apart from racial and regional factors, sleep deprivation, anxiety, and delirium increase the pain perceptions. Pain assessment is a prerequisite for adequate pain management. The ICU patients are sedated and ventilated, and assessment scales differ depending on whether the patient is able to communicate. There are different pain assessment scales for both groups of patients. The preferred mode of delivery of analgesic medication is intravenous route as intramuscular and subcutaneous route are not reliable for drug delivery in these patients. Patient and nurse controlled analgesia gives better sense of pain control. In the treatment of pain, opioids are the commonly used medications, but paracetamol, dexmedetomidine, and gabapentin are increasingly used. Newer trends are multimodal analgesia, where the combinations of analgesic medications with different mechanism of action are used. Another trend is increasing use of analgosedation; they not only control the pain but also relieve anxiety

Aneurysmal Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage (SAH) is a devastating neurological syndrome, which occurs at a rate of 3–25 per 100,000 population. Smoking and hypertension are the most important risk factors of subarachnoid hemorrhage. Rupture of cerebral aneurysm leads to rapid spread of blood into cerebrospinal fluid and subsequently leads to sudden increase of intracranial pressure and severe headache. Subarachnoid hemorrhage is associated with neurological (such as re‐bleeding and vasospasm) and systemic (such as myocardial injury and hyponatremia) complications that are causes of high mortality and morbidity. Although patients with poor‐grade subarachnoid hemorrhage are at higher risk of neurological and systemic complications, the early and aggressive management of this group of patient has decreased overall mortality by 17% in last 40 years. Early aneurysm repair, close monitoring in dedicated neurological intensive care unit, prevention, and aggressive management of medical and neurological complications are the most important strategies to improve outcome

Moyamoya Disease: A Rare Vascular Disease of the CNS

Moyamoya disease (MMD) is a rare disease affecting the cerebral vasculature of the central nervous system (CNS) with a reported incidence of 0.35–0.94 per 100,000 populations. It was first reported from Japan and later from other parts of the world. The pathology is narrowing of blood vessels supplying anterior circulation and rarely posterior circulation. It was believed that the disease is genetic in origin, but environmental factors also play a role. Patients with this rare disease may present with ischemic or hemorrhagic symptoms. Ischemic symptoms account for the disease in most of the pediatric patients, whereas in adults, hemorrhage is more common. Diagnostic imaging like CT angiogram and magnetic resonance angiogram helps in demonstrating the narrowing or the collateral vessels like “a puff of smoke” (moyamoya) formed at the base of the brain. Moyamoya disease is treated medically and/or surgically. Aspirin is the main medication used. Surgical options are direct or indirect revascularization techniques to bypass the stenosis. The disease is progressive in majority of the patients, but if treated early, they can have good prognosis especially children

Cerebral Arteriovenous Malformations (cAVMs): What Is New?

Cerebral arteriovenous malformations (cAVMs) are rare congenital anomalies of cerebral blood vessels that result from maldevelopment of the capillary bed, permitting direct communication between cerebral arteries and veins. It usually occurs in the supratentorial area of the brain; however, it can occur anywhere in the brain and spinal cord. Most of the patients with cAVMs present with a variety of complaints such as seizures, intracerebral hemorrhage, headache, and progressive focal neurological deficit. Imaging such as CT, MRI, and angiography plays a vital role in diagnosis, grading, risk assessment, and posttherapeutic follow-up. The multidisciplinary team use three therapeutic modalities in the treatment of cAVMs. This chapter reviews the clinical presentations, diagnosis, classification, and treatment of cAVMs

Urosepsis: Flow is Life

Urosepsis is one of the important etiological factors for community as well as hospital-acquired infections. Accordingly, urosepsis is divided into community-acquired and hospital-acquired urosepsis. Obstruction to the flow of urine is a common risk factor for community-acquired urosepsis, whereas the indwelling urinary catheter is the risk for the hospital-acquired urosepsis. E. coli remained the most common bacteria-causing urosepsis. If not treated early and appropriately, urosepsis can complicate into septic shock and multiple organ dysfunction. The cornerstone for the improved outcome of these patients is initial resuscitation and proper antibiotic therapy and restoring the flow of urine or removing the infected urinary catheter. Community-acquired urosepsis can be prevented by removing the obstruction to flow of urine permanently. The hospital-acquired urosepsis can be prevented by strictly following catheter-associated urinary tract infection prevention bundle and removing the catheter as early as possible

Cerebral Arteriovenous Malformation from Classification to the Management

Cerebral arteriovenous malformations (cAVMs) are the rare neurosurgical emergency. cAVM is an abnormal vascular web, composed of nidus, feeding artery and draining veins. It commonly occurs in the supratentorial area of the brain. The common grading system used in cAVM is Spetzler-Martin grading, which takes into consideration the size of nidus, the location of cAVM and the venous drainage. The cAVMs may develop flow and pressure-related aneurysms, which will increase the morbidity and mortality in these patients. cAVMs vary in size and undergo growth, remodeling and rarely regression. Most of the cAVMs are asymptomatic, but the common presentation are headache, seizure, intracerebral hemorrhage or focal neurological deficit. The cerebral angiography remains the gold standard for the diagnosis of cAVM. Management of the cAVM includes medical therapy, surgical excision, radiosurgery and embolization

Peripartum Cardiomyopathy: Facts and Figures

Peripartum cardiomyopathy (PPCM) is a rare clinical entity during pregnancy. PPCM is a diagnosis of exclusion. These patients do not have prior history of heart disease, and there are no other known possible causes of heart failure. It is more common in African countries, may be related to the consumption of kanwa, in the postpartum period. The multiparity, African descent and pregnancy-induced hypertension are a few risk factors for PPCM. The exact etiology of PPCM is not known; possible theories range from myocarditis to the maladaptation to the changes of pregnancy. The clinical manifestation varies from shortness of breath to thromboembolic phenomenon. Echocardiography is essential for diagnosis as well as differential diagnosis of PPCM. These patients preferably are managed in tertiary healthcare facilities. Anticoagulation and antiarrhythmic medications are pillars for the management of PPCM patients. If required, mechanical devices should be used temporarily. PPCM patients may need heart transplant. The beneficial role of bromocriptine and immunosuppression is not clear in PPCM patients. Subsequent pregnancies should be avoided to prevent the PPCM occurrence

Anaesthetic Considerations in Gastrointestinal Endoscopies

Gastrointestinal endoscopy has become fundamental procedure for diagnosis and treatment of gastrointestinal tract diseases. Generally, the gastrointestinal endoscopy is minimally invasive procedure. However, it can cause considerable amount of discomfort and pain which make the procedure unsafe, complicated and refusal of follow up procedures if done without safe sedation. The sedation is required to alleviate anxiety, provide analgesia, amnesia and to improve endoscopic performance specifically in therapeutic procedures. The safe administration of sedative and analgesic medications, irrespective of the regimen used, requires knowledge of the individual needs of patients. The combination of benzodiazepines and opioids is now the most widely used sedation regimen for sedation in gastrointestinal endoscopic procedures. Generally, sedation for gastrointestinal endoscopy is considered safe, however, it has the potential for serious complications. Therefore, endoscopist should assess the patients properly before the endoscopy as well as should be aware of all possible complications and the risk factors. Furthermore, skilled staff and emergency equipment should be available in endoscopy suit. This chapter discuss in details all the aspects of safe procedural sedation during GI endoscopies