Tau protein and brain derived neurotropic factor profile in patient undergoing sevoflurane anaesthesia

Objective: Sevoflurane is commonly and widely used inhalational agent in general anaesthesia. The sevoflurane will be used in general anesthesia to ensure patients are not aware during the operation. Generally, anaesthesia using sevoflurance is safe but some study showed that the usage of sevoflurane can cause cognitive impairment post operatively in susceptible patient. The use of sevoflurane may cause deterioration in neurocognitive function resulting from tau hyperphosphorylation and perhaps reduced level of brain derived neurotropic factor. The purpose of this study is to investigate the effects of sevoflurane anaesthesia on the level of tau protein and brain derived neurotropic factor. Methodology: This was a cross-sectional observational study from June 2013 until October 2014 done in operation theatre Hospital Universiti Sains Malaysia (USM). 39 patients scheduled to undergo elective surgery in orthopaedic cases requiring general anaesthesia were included. Blood was obtained for baseline tau protein and BDNF before induction of anaesthesia using sevoflurane. Maintenance of anaesthesia using sevoflurane with the target minimum alveolar concentration (MAC) 1.5 -2.0 in oxygen: air, 70:30 mixture and to achieved BIS reading of 40 – 60. Throughout the surgery body temperature are maintained within normal range (T° 36- 37.5 ). Duration of anaesthesia was planned for at least 60 and up to 180 min. Once operation is finished, patient will then be extubated and observed in recovery room & will be discharged to the respective wards once they met the ALDRETE & PADSS score & reviewed by anaesthetist. Blood investigation for Tau Protein and BDNF will be repeated 24-48 hours postoperatively. ELISA assay for the plasma Tau protein and BDNF were performed to obtain the blood level for these biomarkers. Results: The mean level of pre Tau Protein was 18.63 ± SD 18.84 and the mean level post Tau Protein was 10.52 ± SD 18.52. The mean level of pre BDNF was 1.63 ± SD 1.71 and the mean level of post BDNF was 1.40 ± SD 2.06. There were no significant changes in the level of Tau Protein or Brain Derived Neurotropic Factor before or after undergoing anaesthesia using sevoflurane. Postoperatively, there were no significant differences in the level of Tau Protein or Brain Derived Neurotropic Factor after first time exposure to sevoflurane anaesthesia. Conclusions: There were no significant differences on the level of both Tau Protein and Brain Derived Neurotropic Factor after first time exposure to sevoflurane anaesthesia

Case report: Unusual cause of difficulty in intubation and ventilation with asthmatic-like presentation of Endobronchial Tuberculosis

Endobronchial Tuberculosis is hazardous in causing circumferential narrowing of tracheobronchial tree despite the eradication of tubercle bacilli in the initial insult from Pulmonary Tuberculosis. They may present as treatment resistant bronchial asthma and pose challenge to airway management in the acute setting. We present a 25 year-old lady who was newly diagnosed bronchial asthma with a past history of Pulmonary Tuberculosis that had completed treatment. She presented with sudden onset of difficulty breathing associated with noisy breathing for 3 days and hoarseness of voice for 6 months. Due to resistant bronchospasm, attempts were made to secure the airway which led to unanticipated difficult intubation and ventilation. Subsequent investigations confirmed the diagnosis of Endobronchial Tuberculosis and patient was managed successfully with anti TB medication, corticosteroids and multiple sessions of tracheal dilatation for tracheal stenosis. This case highlights the unusual cause of difficulty in intubation and ventilation due to Endobronchial Tuberculosis, which required medical and surgical intervention to improve the condition

Significance of a clean-tip catheter closed suctioning system in a high-setting ventilated, super morbidly obese patient with profuse respiratory secretions

Introduction: Closed suctioning is commonly used in the context of high-setting mechanical ventilation (MV), given its ability to prevent lung volume loss that otherwise accompanies open suctioning. However, closed suctioning systems (CSS) are not equivalent regarding components and capabilities, and thus this technique may be differentially effective to adequately clear patient secretions from an endotracheal tube (ETT), which is of paramount importance when the tube size makes the ETT particularly vulnerable to block by patient secretions. Case presentation: A 25-year-old super morbidly obese female (body mass index = 55 kg/meter2) presented with worsening shortness of breath. For MV, pairing of a 6 mm (mm) diameter ETT to accommodate the patient's vocal cord edema, with a CSS not designed to maintain a clean catheter tip, precipitated ETT blockage and respiratory acidosis. Replacement of these devices with a 6.5 mm ETT and a CSS designed to keep the catheter tip clean resolved the complications. After use of the different ETT and CSS for approximately one week, the patient was discharged to home. Discussion: The clean-tip catheter CSS enabled a more patent airway than its counterpart device that did not have this feature. Use of a clean-tip catheter CSS was an important care development for this patient, because this individual's super morbidly obese condition minimized tolerance for MV complications that would exacerbate her pre-existing tenuous respiratory health status. Conclusion: Special attention should be given to the choices of ETT size and CSS to manage super morbidly obese patients who have a history of difficult airway access

Case report: Unusual cause of difficulty in intubation and ventilation with asthmatic-like presentation of Endobronchial Tuberculosis

Endobronchial Tuberculosis is hazardous in causing circumferential narrowing of tracheobronchial tree despite the eradication of tubercle bacilli in the initial insult from Pulmonary Tuberculosis. They may present as treatment resistant bronchial asthma and pose challenge to airway management in the acute setting. We present a 25 year-old lady who was newly diagnosed bronchial asthma with a past history of Pulmonary Tuberculosis that had completed treatment. She presented with sudden onset of difficulty breathing associated with noisy breathing for 3 days and hoarseness of voice for 6 months. Due to resistant bronchospasm, attempts were made to secure the airway which led to unanticipated difficult intubation and ventilation. Subsequent investigations confirmed the diagnosis of Endobronchial Tuberculosis and patient was managed successfully with anti TB medication, corticosteroids and multiple sessions of tracheal dilatation for tracheal stenosis. This case highlights the unusual cause of difficulty in intubation and ventilation due to Endobronchial Tuberculosis, which required medical and surgical intervention to improve the condition

Undiagnosed chicken meat aspiration as a cause of difficult-to-ventilate in a boy with traumatic brain injury.

Introduction: Bronchoscopy is a commonly used procedure in the context of aspiration in the Intensive Care Unit setting. Despite its ability to remove mucus plug and undigested gastric contents, aspiration of gastric content into the trachea is one of the most feared complications among anesthesiologist. Discussion:The scenario is made worst if the aspiration causes acute hypoxemic respiratory failure immediately post intubation. However, in the event of desaturation, the quick decision to proceed with bronchoscopy is a challenging task to the anesthesiologist without knowing the causes. Case presentation:We present a case of a 12-year-old boy who had a difficult-to-ventilate scenario post transferring and immediately connected to ventilator in operation theatre (OT) from portable ventilator from the emergency department. She was successfully managed by bronchoscopy. Conclusion:Special attention should be given to the difficult-to-ventilate scenario post intubation of traumatic brain injury patient prior to operation. Prompt diagnosis and bronchoscope-assisted removal of foreign body was found to be a successful to reduce morbidity and mortality

Undiagnosed chicken meat aspiration as a cause of difficult-to-ventilate in a boy with traumatic brain injury

Introduction: Bronchoscopy is a commonly used procedure in the context of aspiration in the Intensive Care Unit setting. Despite its ability to remove mucus plug and undigested gastric contents, aspiration of gastric content into the trachea is one of the most feared complications among anesthesiologist. Discussion: The scenario is made worst if the aspiration causes acute hypoxemic respiratory failure immediately post intubation. However, in the event of desaturation, the quick decision to proceed with bronchoscopy is a challenging task to the anesthesiologist without knowing the causes. Case presentation: We present a case of a 12-year-old boy who had a difficult-to-ventilate scenario post transferring and immediately connected to ventilator in operation theatre (OT) from portable ventilator from the emergency department. She was successfully managed by bronchoscopy. Conclusion: Special attention should be given to the difficult-to-ventilate scenario post intubation of traumatic brain injury patient prior to operation. Prompt diagnosis and bronchoscope-assisted removal of foreign body was found to be a successful to reduce morbidity and mortality. Keywords: Foreign body, Aspiration, Chicken meat, Difficult ventilatio

Post-partum streptococcal toxic shock syndrome associated with necrotizing fasciitis

We report a fatal case of post-partum streptococcal toxic shock syndrome in a patient who was previously healthy and had presented to the emergency department with an extensive blistering ecchymotic lesions over her right buttock and thigh associated with severe pain. The pregnancy had been uncomplicated, and the mode of delivery had been spontaneous vaginal delivery with an episiotomy. She was found to have septicemic shock requiring high inotropic support. Subsequently, she was treated for necrotizing fasciitis, complicated by septicemic shock and multiple organ failures. A consensus was reached for extensive wound debridement to remove the source of infection; however, this approach was abandoned due to the patient’s hemodynamic instability and the extremely high risks of surgery. Both the high vaginal swab and blister fluid culture revealed Group A beta hemolytic streptococcus infection. Intravenous carbapenem in combination with clindamycin was given. Other strategies attempted for streptococcal toxic removal included continuous veno-venous hemofiltration and administration of intravenous immunoglobulin. Unfortunately, the patient’s condition worsened, and she succumbed to death on day 7 of hospitalization