Anaesthesiology at Narayana Hrudayalaya

TEE Quiz..

2009-10-23T10:04:00.000-07:00

I invite all of you take this little quiz that I have put together. Please don't forget to leave a comment.. it is immensely valuable for me. If you cannot see the pictures clearly, use the "full screen" button at the bottom of the quiz. It will take you to the website where I have created the quiz. Wish you fun quizzing !!

TEE quiz » fun quizzes

2009-07-08T18:13:00.000-07:00

I read an essay on the NY times.thought its a must to share it with you all

A Doctor by Choice, a Businessman by Necessity By SANDEEP JAUHAR, M.D.

To meet the expenses of my growing family, I recently started moonlighting at a private medical practice in Queens. On Saturday mornings, I drive past Chinese takeout places and storefronts advertising cheap divorces to a white-shingled office building in a middle-class neighborhood.

I often reflect on how different this job is from my regular one, at an academic medical center on Long Island. For it forces me, again and again, to think about how much money my practice is generating.

A patient comes in with chest pains. It is hard not to order a heart-stress test when the nuclear camera is in the next room. Palpitations? Get a Holter monitor — and throw in an echocardiogram for good measure. It is not easy to ignore reimbursement when prescribing tests, especially in a practice where nearly half the revenue goes to paying overhead.

Few people believed the recent pledge by leaders of the hospital, insurance and drug and device industries to cut billions of dollars in wasteful spending. We’ve heard it before. Without fundamental changes in health financing, this promise, like the ones before it, will be impossible to fulfill. What one person calls waste, another calls income.

It is doubtful that doctors and other medical professionals would voluntarily cut their own income (even if some of it is generated by profligate spending). Most doctors I know say they are not paid enough. Their practices are like cars on a hill with the parking brake on. Looking on, you don’t realize how much force is being applied just to maintain stasis.

I recently spoke with a friend who dropped out of medical school 20 years ago to pursue investment banking. Whenever we meet, he finds a way to congratulate me on what he considers my professional calling. He often wonders whether he should have stuck with medicine. Like many expatriates, he has idealistic notions of the world he left.

At our most recent meeting, we talked about the tumult on Wall Street. Like many bankers, he was worried about the future. “It is a good time to be a doctor,” he said yet again, as I recall. “I’d love a job where I didn’t have to constantly think about money.”

I didn’t bother to disillusion him, but the reality is that most doctors today, whether in academic or private practice, constantly have to think about money. Last January, Dr. Pamela Hartzband and Dr. Jerome Groopman, physicians at Beth Israel Deaconess Medical Center in Boston, wrote in The New England Journal of Medicine that “price tags are being applied to every aspect of a doctor’s day, creating an acute awareness of costs and reimbursement.” And they added, “Today’s medical students are being inducted into a culture in which their profession is seen increasingly in financial terms.”

The rising commercialism, driven in part by increasing expenses and decreasing reimbursement, has obvious consequences for the public: ballooning costs, fraying of the traditional doctor-patient relationship. What is not so obvious is the harmful effects on doctors themselves. We were trained to think like caregivers, not businesspeople. The constant intrusion of the marketplace is creating serious and deepening anxiety in the profession.

Not long ago, a cardiology fellow who had been interviewing for jobs came to my office, clearly disillusioned. “I was naïve,” he said. “I never thought of medicine as a business. I thought we were in it to take care of patients. But I guess it is.”

I asked him how he felt about going into private practice. “I’ll be too busy vomiting for the first six months — I won’t have much time to think about it,” he replied.

Of course, there has always been a profit motive in medicine. Doctors who own their own imaging machines order more imaging tests; to take an example from my moonlighting work, a doctor who owns a scanner is seven times as likely as other doctors to refer a patient for a scan. In regions where there are more doctors, there is more per capita use of doctors’ services and testing. Supply often dictates demand.

But financial considerations have never been as prominent as they are today, probably because so many hospitals and doctors, especially in large metropolitan areas, are in financial trouble. More and more doctors are trying to sell their practices, or are negotiating with hospitals for jobs, equipment or financial aid.

At hospitals, uncompensated care is increasing as patients suffering from the economic downturn lose health insurance. Admissions and elective procedures — big moneymakers — are declining. Hospitals are cutting administrative costs, staff and services.

“More and more you’ll see people in medicine get M.B.A.’s,” a doctor told me at a seminar, in a prediction borne out in my experience. “We are in a total crisis, and I don’t know the answer.”

I must admit that part of me wants to see doctors master the business side of our profession. When I hear about executives at health companies getting tens of millions of dollars in bonuses, I am nauseated by the blatant profiteering. As a loyal member of my guild, I want to see doctors exert more control over our financial house.

And yet the consequences of this commercial consciousness are troubling. Among my colleagues I sense an emotional emptiness created by the relentless consideration of money. Most doctors went into medicine for intellectual stimulation or the desire to develop relationships with patients, not to maximize income. There is a palpable sense of grieving. We strove for so long, made so many sacrifices, and for what? In the end, for many, the job has become only that — a job.

Until I went into practice, I never had an interest in the business side of medicine. I sometimes yearn to be a resident or fellow again, discussing the intricacies of a case rather than worrying about the bottom line. “You need to learn a little of the private-practice mind-set,” a doctor friend recently advised me. “You can’t survive with your head in the clouds.”

But something fundamental is lost when doctors start thinking of medicine as a business. In their essay, Dr. Hartzband and Dr. Groopman talk about the erosion of collegiality, cooperation and teamwork when a marketplace environment takes hold in the hospital. “The balance has tipped toward market exchanges at the expense of medicine’s communal or social dimension,” they write.

How this battle plays out will determine to a great extent what medicine will look like in 20 years. This is about much more than dollars and cents. It is a battle for the soul of medicine.

Sandeep Jauhar is a cardiologist on Long Island and the author of the recent memoir “Intern: A Doctor’s Initiation.”

Smiling Child.. Finally

2009-03-26T08:22:00.000-07:00

You could never see a smile on her face. Lagmavva, a cute little 8 year old from North Karnataka hardly ever sported a grin on her face for all the 15 days that she was under our care. She was one of the bluest 'tets' that has been operated on in MSR-NH so far. Surgery was uneventful but for some confusion regarding the exact RV/LV pressure ratio post CPB( we all agreed finally that it was less that 0.75..). Nevertheless, child was successfully weaned off the CPB with stable hemodynamics with minimal inotropic supports and normal sinus rhythm. We extubated her on first POD, since all the necessary parameters were within acceptable limits. All of us, members of the surgical team, rejoiced secretly for this favorable outcome. But our joy was to be only shortlived since, much to our disappointment and dismay, the cardiologist found residual VSD with'sizeable' shunt on post op echo. How ever, she also suggested that, since all the pieces are not really fitting approriately in the jigsaw puzzle it would be prudent to do a catheterisation study to grade the VSD and measure Qp/Qs. Cath was done and fortunately proved that VSD wasn't all that significant and Qp/Qs is 1. So, with her cardiac problem sorted out, we heaved a sigh of relief and proceeded with her futher management so that she can be discharged from the ICU. But then, she had different plans for us !

She refused to take anything orally except coffee( a lots of coffee.. sometimes 6 cups straight!). If forcibly fed, she used to vomit everything with in few minutes. Her past history revealed similar problem since almost 2 months along with history of intermittent abdominal pain. We sought evaluation by pediatrician, pediatric surgeon and pediatric cardiologist. They didn't find anything grossly abnormal with her and one of them even suggested that it could be because of some psychiatric problem. The latter opinion looked more plausible to us also, since the child hardly used to smile, always used to be withdrawn from her surroundings and used to be hyper irritable. This repeated vomiting episodes soon after food intake continued for almost a week after discharge from our post op ICU. So. we decided to get an endoscopy done for the child. We had the dubious honour of anesthetising the child for the fourth time( Cath study, surgery, cathstudy again and finally for the endoscopy !). This turned out to be a very wise move.. it was found on endoscopy that the child had a stricture oesophagus because of reflux oesophagitis due to hiatus hernia! The stricture was dilated with balloon and child was shifted to ward. After a really long time she could eat a meal and retain it too.

She started smiling after that. And it was a wonderful sight ! I wanted to share it with you all and hence this post..

2009-02-12T09:19:00.001-08:00

Pediatric cardiology is one of the most active departments in our hospital. like us they have entered into blogosphere. here is the link.

http://narayanapediatriccardiology.blogspot.com/2008/12/welcome-to-pediatric-cardiology-blog.html

For the travelling anaesthetist..

2009-01-31T09:49:00.000-08:00

No, this post is not about "Travelling Fellowship"! Its for all those my dear brotheren who are bitten by "Travel Bug", who have a mandatory requirement for taking off atleast once in 3-6 months on a vacation so that they can come back to this dreary world, rejuvenated. These two links will help you plan your travel, especially if you are planning to drive down to that place.

Both links are best loaded by Internet Explorer 6.0 onwards.. There are interactive maps with some very useful features. Hope it will be of use to you..

http://www.mapxl.in/path-finder/map_routing.phtml?config=routing

http://www.mapsofindia.com/driving-directions-maps/

Neuroanaesthesia Quiz

2008-12-20T03:10:00.001-08:00

Recently I conducted a neuroanaesthesia test for our DNB students. It was designed to test their depth of understanding of fundamental concepts of anaesthesia for neurosurgery. By the way, Chintan, the topper got a prize from our HOD, Dr. Muralidhar.

If you want the answer key to this quiz, you will have to leave a comment.

NEUROANAESTHESIA QUIZ

Answer all questions. There is no negative marking. MCQs can have more than one correct answer and all the answer should be correct to get a mark.

Time: 45 mins

Brain represents ___ % of body weight and receives about ____ % of cardiac output. Oxygen consumption of brain is about ___ ml/ 100 gms of brain tissue per minute, so total brain oxygen consumption constitutes about ____ % of total body oxygen utilization.

3. Normal ICP is __________

4. What can you understand by the illustration shown below

5. Two components of cerebral metabolic activity are

6. CMR decreases by _____ per °C of temperature reduction

7. Why isn’t it a good idea to rapidly normalize PaCO2 in a patient who has had a prolonged period of hyperventilation?

8. What do these different waveforms represent?(Name the different waveforms)

9. Main energy substrate used for energy production is ________

10. What is inverse steal phenomenon?

11. Complete the following table which shows the effects of anesthetics on CBF and CMRO2( Increase = ‘+’ , decrease = ‘–‘ and No change = '0' )

	CBF	CMRO2
Halothane
Isoflurane
Sevoflurane
Propofol
Thiopentone
Midazolam
Fentanyl
N20 with IV agents

12. “Pulsatality index” is measured by which monitoring modality _____________

13. What do you know about Near Infrared Spectroscopy?

14. Rationale of using beta blockers as premedication in neuroanaesthesia ____________

15. The following monitoring techniques are used to detect venous air embolism. Arrange them in decreasing order of sensitivity

a. Pulmonary artery catheter

b. ETCO2

c. TEE

d. Precordial Doppler

e. Mass spectrometry of ETN2

16. During preanaesthetic evaluation of a head injury patient you notice that he has flexion withdrawal response and is making some incomprehensible sounds. He doesn’t open his eyes even on painful stimulus. What is his GCS score?

17. Methods to control intracranial hypertension (at least four).

18. All the following are true about GABA except

a. GABA is inhibitory neurotransmitter

b. There are two major types of GABA receptors- GABA_A and GABA_B

c. GABA_Aacts by opening chloride channels and GABA_B acts by opening potassium channels

d. Barbiturates and Benzodiazepines act by enhancing action at GABA_B

19. All are true about cerebral autoregulation except

a. It occurs between 50-150 mm Hg

b. It is a Myogenic response

c. Occurs immediately after the pressure change

d. Range of autoregulation is shifted to a higher pressure in hypertensives

e. Abolished by trauma, hypoxia, and inhalational anesthetics

20. All the following are true about CSF except

a. It is formed at a rate of 0.3-0.4ml /min allowing complete replacement 3-4 times a day

b. One of the three major components that occupy the space in skull, with other two being brain(neurons and glia) and Blood perfusing the brain

c. Furosemide and acetazolamide doesn’t decrease CSF production

d. Formed by choroid plexus epithelial cells

e. Has a higher protein concentration than serum

21. When the brain is stiff (low compliance) and enlarged, ICP

a. rises only minimally when the patient coughs

b. rises significantly with a small increase in arterial CO2

c. is unaffected by arterial desaturation (hypoxia)

d. falls if the patient is put in the head-down position

e. rises if the head is twisted to the left or right

22. Cerebral perfusion pressure (CPP)

i. is satisfactory if more than 70 mmHg in a patient with a head injury

ii. is calculated by adding mean arterial pressure (MAP) and ICP

iii. falls if arterial BP falls following induction of anaesthesia

iv. can be calculated by “guessing” ICP to be 20 mmHg after a head injury causing 5 min unconsciousness

b. when low should be treated by infusing dextrose-saline solution

23. All the following processes protect against ischemic damage of brain except,

a. Maintaining normal blood flow

b. Reducing metabolic rate, thereby maintaining ATP levels

c. Scavenging free radicals

d. Increasing intracellular concentration of sodium and calcium

e. Facilitating release of excitatory amino acids

24. Following a severe head injury, ICP will rise to damaging levels if

a. the patient develops airway obstruction

b. the patient becomes severely hypertensive

c. the patient is allowed to breathe halothane spontaneously during an anaesthetic

d. arterial hypoxemia occurs

e. the patient suffers severe pain from other injuries which is not treated

25. All the following are true with respect to focal ischemia of brain tissue except.

a. There are three regions in the ischemic zone

b. “Penumbra” is a region of normal blood flow

c. Inverse steal is beneficial in focal ischemia of brain tissue

d. Apoptosis occurs at less compromised region of ischemia and necrosis occurs at the core of ischemic area

26. All the following are true about effects of inhalational anesthetics on CBF except

a. Isoflurane and sevoflurane are the ideal volatile anesthetics for neurosurgery

b. Desflurane is recommended for space occupying lesions

c. Induction doses of sevoflurane( 1.5-2 MAC) causes epileptiform seizures in some patients

d. Volatile agents abolish PCO2 reactivity of CBF

27. Concerning intravenous agents

a. ketamine has no effect on ICP

b. thiopentone reduces ICP by direct cerebral vasoconstriction

c. a moderate fall in arterial BP following thiopentone in a patient with cerebral decompensation (raised ICP) need not be treated immediately

d. propofol does not effect cerebral metabolic rate

e. the patient will recover rapidly when anaesthesia has been maintained by a thiopentone infusion

28. EEG

a. Generated by pyramidal cells of granular cortex

b. Deep sleep and deep anaesthesia produce delta waves

c. Theta waves are high frequency, low amplitude waves seen in awake adults

d. Indicated intraoperatively in detection of cerebral ischemia, assessment of pharmacologic interventions(burst suppression) and brain death, diagnosis and management of intractable epilepsy

e. Plot of voltage against time

f. Frequency increased by high dose of intravenous agents like thiopentone, propofol, BZDs and etomidate

29. All the following are true about Sensory evoked potentials except,

a. There are three modalities – SSEPs, BAEPs, VEPs

b. Individual peaks are described in terms of amplitude, latency and polarity

c. For SSEP – 50% reduction in amplitude is clinically significant

d. Evoked potential of brainstem origin are more vulnerable anesthetic influence when compared to those of cortical origin

e. VEPs arise from the brain stem

f. Volatile agents cause dose dependent increase in latency and decrease in amplitude of cortical evoked potentials

30. Mannitol

a. Given IV in the dose of 0.25 – 1 gm/kg; action begins within 10-12 minutes and lasts for 2 hours

b. Larger doses produce longer duration of action

c. Is effective only when BBB is intact

d. Should be given rapidly for it to attain its peak onset of action early

e. Can cause a rebound increase of ICP

f. Prolonged use of mannitol may produce dehydration, electrolyte disturbances, hyperosmolality, and impaired renal function

31. About jugular bulb venous oximetry all are true except,

a. Estimates balance between cerebral oxygen demand and supply

b. Normal SjVO2 is 60-70%

c. Changes in oxygenation of systemic blood influences SjVO2

d. SjVO2 increases to >75% during ischemic injury

e. It doesn’t detect focal ischemia

32. Wakeup test

a. Commonly used in scoliosis surgery to identify reversible damage to CNS by spinal distraction

b. Patient is woken up after complete reversal of muscle relaxation

c. Patient “awareness” is one of the adverse effects of the test

d. TIVA is the anesthetic technique of choice

33. In semi sitting position all are true except

a. Reduced venous return to the heart

b. Increased chances of venous air embolism due to sub atmospheric pressures in cerebral veins and dural sinuses

c. Pressure transducer should be kept at the level of external auditory meatus

d. Spontaneous ventilation is better than controlled, since the latter further reduces the venous return

e. Provides very good access to posterior fossa tumors

34. White matter receives more blood than grey matter, since it plays a crucial role in the normal functioning of grey matter – T / F

35. Optimum burst suppression is obtained more commonly by thiopentone when compared to other anaesthetic agents. T / F

36. Cerebral oxygen consumption decreases above 42⁰ C. T/ F and why?

37. The magnitude of CBF reduction with Hypocapnia is greater during volatile anaesthetic. T / F and why?

38. Resting membrane potential of a neuron is nearer to the equilibrium potential of sodium. T/F

39. Children have higher CMRO2 than adults. T/F

40. Muscle relaxant can be given in just adequate doses while monitoring cranial nerves. T/F

41. Mill wheel murmur is one of the very useful early signs of venous air embolism. T/F

Anaesthesia for awake craniotomy

2008-12-13T22:25:00.000-08:00

Awake craniotomy is performed for the surgical treatment of intractable seizures and tumors on the eloquent areas of the brain. Mapping of the normal areas of the brain is done to delineate them from the tumor intraoperatively. This involves stimulating the brain with small voltage ad high frequency currents and assessing patients verbal, motor and sensory response. Thus, an awake and alert patient is the fundamental requirement of this procedure. One can easily understand that keeping the patient awake and responding, pain free and comfortable during the surgery is quite a difficult task and you can say that, awake craniotomy is more of an anaesthetic challenge than surgical. Recently, we performed an awake craniotomy for the first time in our institution for a tumor which was close to the motor areas of right cerebral hemisphere.
Medical literature is replete with numerous original articles and case reports on anaesthesia for awake craniotomy and thank god for that. It was invaluable for us to plan our anaesthetic. When you go through this knowledge bank on awake craniotomy, you will realise that there are mainly two techniques commonly used for anaesthetizing these patients – conscious sedation with scalp blockade and “asleep-awake-asleep” (general anaesthesia (LMA with or without IPPV) and scalp blockade-awakening- general anaesthesia (LMA with or without IPPV). The latter technique supposedly ensures better patient comfort and outcome. Craniotomy involves performing scalp blockade (multiple injections), stabilizing the patient’s head on sharp-pinned frames (Mayfield, Sugita’s etc), raising the scalp flap, drilling and removing a piece of skull bone and lying down in quite uncomfortable position for a long time. No wonder it can be quite a traumatic experience for an awake patient to go through all this for the entire duration of the surgery. So, ours was also a version of “asleep-awake-asleep” technique.
Our patient was a 35 year old male(weighing 61 Kgs) with a glioma over the right parietal sub cortical area measuring about 15 x 15 mm. He had presented with seizures and slurring of speech three months before the day of surgery. He did not have any focal neurological deficits and the speech had also normalized. He had developed allergic bronchial asthma two months before the date of operation, which was attributed to exposure to cold and dusty climate. He was being treated with bronchodilators and inhalational steroids for the same and had become asymptomatic at the time surgery. He was a very cooperative and highly motivated gentleman and had fully understood the need for the procedure and various steps involved. A thorough and patient explanation and showing a video of the procedure helped a great deal in preparing the patient for the procedure. During preanaesthetic examination his upper incisors were found to be significantly mobile and were extracted.
I will give our anaesthesia plan now. I hope it will be of use to somebody. I eagerly welcome all kinds of comments.

Premedication

All his medications (anticonvulsants, bronchodilators) were continued till the morning of the surgery.
T. Clonidine 150 mcg, T. Diazepam 10 mg, T. Pantoprazole 40 mg, inj. Dexamethasone 8 mg, T. Ondansetron 4mg – one hour before the surgery
Salbutamol and Ipratropium bromide nebulisations just before shifting him to operation theatre

Monitoring

Pulse oximetry, ECG, Noninvasive Blood Pressure, ETCO2, Bispectral Index monitor, Invasive Blood Pressure and urine output ( both after induction).

Induction

Intravenous line (16 G) was secured in left hand dorsum under local anaesthesia. Preoxygenated with 100% oxygen and induced with inj. Fentanyl 100 mcg, inj. Propofol 100mg. Size 4 Intubating Laryngeal Mask Airway (ILMA) was inserted and patient was allowed to breathe spontaneously. Anaesthesia was maintained with propofol infusion (50 mcg/kg/min) and sevoflurane (End tidal concentration of 1-1.5%) to BIS of about 50.
Right radial artery was cannulated with 20 G catheter to monitor invasive blood pressure.

Scalp Blockade

Total amount of solution used – 80ml
0.5% Bupivacaine – 40ml
2% Lidocaine – 20ml
Adrenaline – 400 mcg(in 4ml saline)
Saline – 16ml

Nerves blocked – supraorbital, supratrochlear, zygomatico temporal, auricuculotemporal, posterior auricular, lesser occipital and greater occipital on both sides with 2-3ml of drug mixture for each nerve.

Landmarks for the nerves-

a. Supraorbial and supratrochear - above eyebrow at the midpoint, needle inserted perpendicular to the skin. Also at the medial margin of the orbit

b. Auriculotemporal - 1.5cm anterior to the tragus; needle inserted perpendicular to skin.

c. Zygomatico temporal - midway between supraorbital ridge and post margin of Zygoma; deep infiltration with in the temporalis muscle and fascia

d. Post auricular branches( of greater auricular nerve) - 1.5 cm posterior to th ear at the level of tragus between skin and bone

e. Greater and lesser occipital nerves - along the superior nuchal line approximately halfway between occipital protruberance and mastoid process; infiltration done with 22 G spinal needle.( all other blocks done with 23G 4cm needle)

Remaining soultion used to infiltrate over the pin sites(3) and along the line of incision.

Block was done 15 mins before the procedure and we hoped that it would last for atleast 4-5 hours.

Success of the block was noted by observing that there was no hemodynamic response to pin insertion and to the skin incision. Also, patient was completely pain free through out the procedure which lasted for 6 hours. Only 175 mcg of Fentanyl was used through out the procedure.

Draping for the procedure

Draping for this procedure was little different from that for usual craniotomies. A transparent screen separated head end and the operating site from the rest of the body so that we had unhindered access to the same.

Maintenance and awakening

Anaesthesia was maintained with propofol infusion (50mcg/kg/min) and sevoflurane (end tidal concentration of 1.5-2%). BIS was maintained around 50. Patient received 0.5 gm/kg mannitol before craniotomy along with Furosemide (20 mg). Surgeon infiltrated dura with 6 cc of 1% lidocaine before incising it. Twenty minutes before planned awakening, sevoflurane was discontinued and propofol infusion was decreased to 25 mcg/kg/min. Patient started moving his limbs when the BIS was about 75. Propofol infusion was fully stopped. LMA was removed after suctioning, when the BIS was between 75 – 80 and patient responsive to oral commands. Another 5 mins was allowed for the patient to fully regain consciousness. Patient became fully awake and responsive when the BIS was around 90.

Cortical mapping and tumor excision was done, to which patient cooperated fully. Excision was completed in about 45 minutes. Patient kept complaining about desire to pass urine, in spite of being told that his bladder had been catheterized. Probably, the patient would have been much more comfortable if only we could somehow abolish the sensation of catheter in the urethra.

He also had mild generalized head ache towards the end of excision, which he felt was quite tolerable. There were no complaints from the surgeon about bulging of the brain. Hemodynamics was maintained at patient’s normal levels through out the procedure and they remained stable through out.

“Asleep” again

Patient was anaesthetized again with propofol 2mg/kg and fentanyl 75mcg and ILMA was reinserted. There was not much difficulty in accomplishing this. Patient was allowed to breathe spontaneously and anaesthesia was maintained with sevoflurane (2%) and propofol infusion at 50 mcg/kg/min. Surgeon started closing the dura. Patient received Morphine 6 mg for post operative pain relief. Five minutes after this, the breathing became strenuous with reduced rate along with Inspiratory sound similar to stridor. Anaesthesia was deepened further by increasing both propofol infusion and sevoflurane concentration. There was no improvement, rather breathing seemed to worsen, ETCO2 started increasing (to >45 mm Hg) and surgeon complained of bulging of brain out of the craniotomy site. We suspected displacement of LMA and reinserted the same. Meanwhile we reduced the depth of anaesthesia, which increased the respiratory rate with improvement in patient’s breathing. Rest of the surgery was completed uneventfully.

Post operative period

Post surgery, we removed the ILMA when patient was fully awake. The post operative period was uneventful. Patient was awake, alert and comfortable through out. There were no neurological deficits. He was kept in neurosurgery intensive care unit overnight and was shifted to the ward the next day. He was discharged from the hospital after two days of surgery.

P S :

This was our first experience with awake craniotomy. It was indeed a very interesting and learning experience. Please leave comments before you surf away from this page..

India's first live donor simultaneous pancreas kidney transplant

2008-11-24T01:10:00.000-08:00

Hi All,

With great pride I wish to inform all that our team at NH performed the first living donor simultaneous pancreas kidney transplant in India. The patient, Neerja, has since been discharged and is doing well. Feels great to be a part of this team and also see our pictures in the newspapers. Three cheers for the Anaesthesia team at NH. Fortunately we did not have much issues during the procedure, but let me caution you that the surgery is not without considerable risk - to both donor & recipient. Having spoken to my classmate who is a multiorgan transplant surgeon in the US, I realised that complications for the donor can arise even 2 years post surgery. But as of now we can say that a very needy patient has really benefited from this procedure following an act of great personal sacrifice on the part of the father. What more can I say about parents ---- they always give their children throughout their lifetime. My deepest & sincerest thanks to all parents in this world.

Live donor SPK ( simultaneous pancreas kidney ) is extremely rare in the world. In the US some 18 - 20 cases only have been reported. The major stress there is on live kidney & cadaveric pancreas done simultaneously. I am sure that with more awareness we will see more & more of cadaveric transplants in the near future.

I have never celebrated World Anaesthesia Day in a more rewarding fashion, having done this pathbreaking case on 16th October this year.

TEE Quiz

2008-10-31T20:02:00.000-07:00

What is this "thing " in LA ?

Before Bypass

After Bypass

Inspiring Subrato..

2008-10-19T06:41:00.000-07:00

Thanks to the benevolence of Dr.Thimmappa, we were all gifted with a feast of inspiring talks by Mr. Subrato and his colleagues of MindTree consultancy on "Vision building" on a lovely saturday. This wonderful present came bundled with a healthy and sumptuous lunch from e-inn and a personally autographed book,"Go kiss the world", of the great, Mr.Subrato. It was very interesting and informative session, with some highly motivating and spiritually uplifting movies served in between. I particularly liked the one by Mr. Dewitt Jones, ace photographer of NatGeo.
All the speakers were very eloquent and seem to be well aware of how to captivate the crowd. They elaborated on the importance of having a vision and motivating your team members to share that vision and collectively work towards realising that vision. Systematic thinking and tools to acheive that, were wonderfully presented by Mr. Kalyan in a very cheerful and joyful way. The guy just grows on you and you can't just help but liking him. Though we couldn't hear much of Mr. Raja, since Mr.Subrato kept interrupting him very often, I found the guy very friendly and as someone with whom you can talk about just anything. I guess its the smile.I found the idea of "Communication real estates" quite interesting.. I guess it's one of the very important facilitators for any team to work cohesively and succeed. I wish we had something similar in our institution also. I personally feel that here in NH, much thought hasn't been given to any such concepts. It was nice to see many big heads of our institution actively participate in all the discussions and it will be really interesting to see how much of it will be really applied into practice here in NH.
There's no doubt that its necessary to attend such meetings, but what is more important is to stay inspired..

Kidney plus Pancreas transplant

2008-10-10T11:31:00.000-07:00

Hi All,

It is with great pride I inform that we will be doing our first kidney plus pancreas transplant on a young 25 year old girl on Monday 12/10/08. This is going to be a great challenge for our team and I am sure that we will come out with flying colours. Under the able guidance of our HOD Dr. K.Muralidhar we have crossed many frontiers and this will add another feather to our cap.

Welcome Freshers!!

2008-10-02T09:09:00.000-07:00

This spring has been eventful in our department. Along with some really noteworthy changes like Prashanth quitting( he is in the greener pastures now!), three of my colleagues being thrusted with paternal responsibilities and me successfully spending a full month on the "floor", we have had a whiff of fresh air in the department now. We saw an addition of 8 DNB students and 4 clinical assistants to our growing family. First of all, let me take this oppurtunity to welcome them all to our beloved group.
But, with bigger family comes bigger problems. There have been some adjustment problems in the initial few days and from what i foresee the difficult and disturbing phase is over already. I hope there will be more comraderie and good will amongst the junior members of our kinfolk.

F. IACTA

2008-10-01T20:08:00.000-07:00

It is a two year fellowship course offered by the lone CardioThoracic Anaesthesiology organisation in India, Indian Association of CardioThoracic Anaesthesiologists. The association is striving hard to set rigorous and high quality assessment stangards before awarding the fellowship. This is being reflected in the passing percentage of the fellowship exams in the last two years. In the first year of its inception(that is last year), the percentage of successful candidates was about 42% and this year it has been a miserly 33.3%.
There were five candidates from our institution and we are glad to announce that our pass percentage is a tad better than the overall figure, a handsome 40%. Our successful candidates are Dr. Anil Kumar H R and Dr. Madhu. M

2008-07-26T23:26:00.000-07:00

Holiday IQ!

Stress busting is an important factor in our lives. One of the methods used to kill stress is a vacation. I would like to start a new thread where we can post weekend getaways or places where we can have a nice time without bothering Dr. Sanjay much. Holiday IQ is a site that offers a great insight to many holidays. considering the fear factor due to the recent blasts it would be better to avoid crowded areas in the city. this is not exactly a getaway but a shop/fill/enjoy routine.

I came across a dhaba recently on the highway to krishnagiri(5kms away from hosur). Its a dhaba(veg)/petrol bunk/Adyar Ananda Bhavan/Play area. Not only you get cheaper fuel, but enjoy a good drive+kids have a blast+shopping on the way at hosur=goodtimes+value for the buck!

some pics from my recent visit.

2008-07-23T07:13:00.000-07:00

CONTINUOUS CARDIAC OUTPUT MONITORING

Review article by DR. MURALIDHAR. K , DIRECTOR (ACADEMIC), SENIOR CONSULTANT & PROFESSOR ANAESTHESIA AND INTENSIVE CARE , NARAYANA HRUDAYALAYA INSTITUTE OF MEDICAL SCIENCES, BANGALORE – 560 099, INDIA
Ph: 080-27835000 To 27835018; Fax: 080-27835222/27832648E-mail: kanchirulestheworld@gmail.com / kanchi_rules_300a@lycos.com

Cardiac performance is commonly conceptualized in terms of cardiac output (CO). This value is found by multiplying left ventricular stroke volume by heart rate (CO=SV x HR). However, different sized individuals have different cardiac outputs, so the preferred measure is cardiac index (CI), calculated by dividing cardiac output by body surface area (BSA); that is CI=CO/BSA. If patient’s height and weight are known, their body surface area (in m2) can be obtained using the Dubois surface chart. The normal cardiac index is 2.8-3.6 L/minute/m2.

Factors affecting cardiac output
i. The blood volume available for ejection – the venous return or preload.
ii. The resistance to ejection – the afterload.
iii. The strength of ventricular myocardial contractility
(Ventricular preload, afterload and contractility together determine the stroke volume).
iv. The heart rate and rhythm.

Indications/uses of Cardiac output monitoring:
A. Diagnosis
i). Assessment of myocardial function following a cardiac event likely to produce a low output state e.g. myocardial infarct;

ii). Assessment of cardiac function where there may be a high output state e.g. in septic shock;

iii). Measurement of pulmonary and systemic vascular resistances; oxygen delivery and consumption

B. Therapy:
i). Monitoring the effects of medical interventions on cardiac output, e.g. colloid or inotropic therapy and the effect of drugs on vascular resistances, e.g. to reduce systemic vascular resistance in septic shock; measurement of the efficacy of oxygen delivery manipulations.

The cardiac output could be measured intermittently or continuously: invasively or non-invasively: this discussion limits to continuous measurement of cardiac output.

Properties of the ideal continuous cardiac output monitor:
· Minimally invasive and therefore widely applicable
· Accurate
· Real time beat to beat CO
· Real time: preload + after load
· Real time oxygen delivery
· Nurse driven
· Easy data interpretation
· Beside information management
· Neonates to adults

Benefits of continuous cardiac output monitoring:
· True monitor = early warning of deterioration
· Weight of scientific evidence for improved outcome
· Optimum fluid management
· Rational drug administration (e.g. inotropes)
· Optimizing patient – ventilator interaction
· Patient ‘condition’ communication to clinical staff
· Reduced work of health care staff
· Decreased procedural complications (e.g. bolus injections)

The continuous measurement of cardiac output can be performed using one of the following methods:
1. Continuous thermodilution cardiac out put
2. PiCCO
3. LiDCO
4. NiCCO
5. Doppler techniques
6. Thoracic Bioimpedance

CONTINUOUS CARDIAC OUTPUT USING THERMODILUTION TECHNIQUE

Continuous Cardiac output Catheter features:
Continuous cardiac output (CCO) is measured by the thermodilution method using a modified pulmonary artery catheter. The continuous cardiac output (CCO) catheter is similar to a standard thermodilution Pulmonary artery catheter; certain models include a venous infusion (VIP) lumen. This flow directed pulmonary artery catheter is designed to monitor hemodynamic pressures and to provide for continuous and bolus measurement of cardiac output. It has the following features;

Swan-Ganz Continuous Cardiac Output Thermodilution Catheter

a. Proximal injectate lumen: The blue lumen, or proximal injectate lumen terminates at a port located 26 cm from the distal tip of the catheter. When the distal tip is correctly positioned within the pulmonary artery, the proximal injectate port will reside in the right atrium, allowing for bolus cardiac output injections, right atrium pressure monitoring, infusion of IV solutions and blood sampling.
b. VIP Lumen: If present, the clear VIP lumen terminates at a port located 30 cm from the distal tip of the catheter. This port allows for infusion of IV solutions, right atrial pressure monitoring and blood sampling.
c. Distal Lumen: The yellow distal lumen terminates at the distal tip of the catheter. During insertion, this port is used monitor catheter location, via transitional pressure measurements, as the catheter is advanced forward. At full insertion, this port will reside in the pulmonary artery, allowing for measurement of pulmonary artery pressure and mixed venous blood sampling.
d. Balloon inflation valve: The red balloon inflation lumen terminates in a latex balloon at the distal tip of the catheter. When the catheter is properly positioned in the in the pulmonary artery, the balloon is inflated intermittently for the measurement of pulmonary artery wedge pressure (PAWP). The balloon is inflated by syringe, with air or CO2.
e. Thermistor Lumen: The thermistor lumen contains the electrical leads for the thermistor bead, which is positioned at the catheter surface 4 cm from the distal tip of the catheter. The thermistor is used to measure pulmonary artery blood temperature and generates the thermal curve, which is used to calculate cardiac output.
f. Thermal filament: The thermal filament is 10 cm in length and is located between 14-25 cm from the distal tip of the catheter. When positioned correctly within the heart, it lies between the RA and the RV. The thermal filament emits as energy signal, which is used to cardiac output continuously.
Continuous cardiac output methodology:

Swan-Ganz Thermodilution Catheter in place
It is now possible to obtain cardiac output at the bedside on a continuous basis. The same general principles of thermodilution that apply to intermittent bolus are used to measure continuous cardiac output. The difference is the indicator that is used. The intermittent bolus technique uses a cool, fluid injectate as the indicator. CCO technology uses small energy impulses (warming of blood) that are emitted directly into the blood stream as the indicator. Unlike the intermittent bolus technique, no fluid bolus is required.
Small energy impulses are emitted directly into the blood via the thermal filament in a random on-off pattern. When the thermal filament is in the “on” sequence, the surface temperature of the catheter is increased by approximately 4-7O C. This random on-off pattern (pseudo-random-binary sequence) is repeated very 30-60 seconds. The subsequent change in blood temperature is measured by the thermistor, which lies in the pulmonary artery. The overall increase in blood temperature sensed at the thermistor in the pulmonary artery is typically less than 0.05o C above the baseline blood temperature. The vigilance monitors internal algorithm cross correlates the input signal with the resultant change in temperature measured by the thermistor, and a “wash-out” curve is generated. CCO is calculated from the area beneath the curve.

Pulse Contour cardiac output (PiCCO)
PiCCO is a Transpulmonary indicator dilution technique in combination with pulse contour analysis. It is a method that offers new and exciting hemodynamic information to the bedside physician caring for the critically ill patient. PiCCO quantifies the global end-diastolic volume (GEDV) and estimates the intra thoracic blood volume (ITBV) and extravascular lung water (EVLW).
ITBV consists of pulmonary blood volume (PBV) and the global end-diastolic volume (GEDV). In the figure global end-diastolic volume is the sum of the volumes of all heart chambers.
PiCCO also delivers a cost – effective thermodilution cardiac output (COa) measurement by injecting a cold bolus (isotonic saline or dextrose) into a central vein through any central venous catheter. The indicator is detected by a specially developed thermistor catheter placed in a larger artery (femoral axillary, or brachial artery). Transpulmonary thermodilution cardiac output is used as a reference for calibration of pulse contour cardiac output (PCCO).
PiCCO monitors continuously:
1. Pulse contour cardiac output - PCCO
2. Heart rate - HR
3. Arterial pressure - AP
4. Stoke volume / variation - SV/SVV
5. Systemic vascular resistance - SVR
PiCCO quantifies
1. Cardiac output, arterially measured - COa
2. Global end-diastolic volume - GEDV
3. Cardiac function index - CFI
4. Intrathoracic blood volume - ITBV
5. Extravascular lung water - EVLW

The striking advantages of the Pulsion PiCCO are:
1. Continuous pulse contour monitoring
2. Volumetric monitoring
3. Flexible use without a pulmonary artery catheter
4. Less invasive than a pulmonary artery catheter
5. Real beat-to-beat signal
6. Short response time
7. Also applicable in paediatric patients
8. Rapidly set up and easily used
9. Reduction of intensive care costs

Lithium dilution Cardiac output (LiDCO)
The LiDCO / pulse CO device represents a combination of a simple indicator dilution technique used to calibrate an arterial waveform analysis algorithm. Theoretically this combination should provide beat-by-beat measurement of cardiac output, with little clinical increment of risk, assuming that in these critically ill patients arterial and venous lines would already be in situ.
The LiDCOTM/PulseCOTM system. Blood is sampled from the arterial line via the three-way tap in the manometer line.

The use of lithium as an alternative indicator for the estimation of cardiac output was first described in 1993 and has now been extensively validated. In brief, isotonic lithium chloride (150 mM) is injected as bolus (0.002-0.004 mmol/kg) via the central, or peripheral, venous route and a concentration – time curve generated by an ion-selective electrode attached to the arterial line manometer system. The cardiac output is calculated from the lithium dose and the area under the concentration – time curve prior to re circulation using equation1:
Cardiac output = Lithium dose (mmol) x 60 / Area x (1-PCV) (mmol/second);
where the area is the integral of the primary curve, and PCV is packed cell volume (Hb (g/dl).

Comparison (n=318) of LiDCOTM vs bolus thermodilution in adults, paediatric and horses.

Pulse CO
The pulse CO monitor calculates continuous cardiac output following LiDCO calibration, by analysis of the arterial blood pressure trace. The arterial blood pressure trace undergoes a three-step transformation namely (1) arterial pressure transformation into a volume – time waveform (2) deriving normal stroke volume and the heart-beat duration (3) nominal stroke volume and calibration

Non invasive Cardiac output (NICO)
NICO is a non-invasive cardiac output monitor from Novametrix. It uses a method know as partial CO2 re-breathing, which is based on the well-accepted Fick principle. With this method the cardiac output is proportional to the change in CO2 elimination divided by the resulting in end tide CO2. These changes are accomplished and measured by the proprietary NICO sensor, which periodically adds a re-breathing volume into the breathing circuit.

DOPPLER TECHNIQUES
a. Pulmonary artery catheter Doppler
A PAC (no longer commercially available) that incorporates an ultrasonic transducer has been developed. The catheter is curved in such a way as to maintain contact with the wall of the PA. Using the Doppler principle, instantaneous SV is calculated from the mean velocity of blood flow in the main. The accuracy of this technique was favorable compared with an electromagnetic flow probe when tested in a compared well with the Fick and thermodilution methods in patients during cardiac catheterization.

b. Transtracheal Doppler
Doppler CO may be determined transtracheally. The equipment consists of a 5 – mm ultrasonic transducer bonded to the distal end of an endotracheal tube. The shape of the cuff is ellipsoidal to ensure contact between the transducer and the anterolateral wall of the trachea. The technique is similar to transesophageal Doppler techniques in that the calculation of CO is based on approximations of aortic cross-sectional area (CSA), the angle of incidence between the ultrasound beam and direction of blood flow within the aorta, the integral of the systolic velocity-time curve, and the heart rate. The theoretical advantages of this method over the transesophageal approach are that measurement of blood flow is in the ascending aorta (proximal to the arch vessels), which allows for the more constant anatomic relationship between the trachea and the ascending aorta. Disadvantages include the potential for compromising ventilation during positioning of the ultrasonic probe, the possibility that the probe might damage airway structures, and frequent manipulations to maintain correct probe placement.

The technique correlated well with intermittent thermodilution CO determinations in both animal and human studies. The transtracheal Doppler CO monitor revealed a small underestimation of the CO, appeared to perform much better in patients whose Doppler signal required minimal manipulation of the probe, and had a high correlation with the ability to track trends in CO. In another study there was not such a high correlation between transtracheal Doppler CO and intermittent thermodilution Co measurements. The authors point out that this may have been secondary to the investigator’s experience and the fact that the patients enrolled were undergoing cardio thoracic surgery where manipulation of the aorta may interfere with the transtracheal probe.

c. Transesophageal and Suprasternal Doppler:
Specialized Doppler probes may also be placed in the suprasternal notch to interrogate the ascending aorta or in the esophagus adjacent to the descending aorta. Again, the flow within the vessel is proportional to the integral of the systolic velocity-time curve, the aortic CSA, and the heart rate. A number of studies have found good correlations among the aortic ultrasound techniques and other CO monitoring systems. There remains, however, a question whether the degree of accuracy is sufficient when favorable clinical reports are critically examined using the method of bland a Altman statistical analysis. Limitations of these systems include the need for frequent probe repositioning, decreased accuracy during aortic manipulation, and the calibration procedures. Furthermore, Kamal et al demonstrated that the esophageal Doppler CO monitor tended to be inconsistent during periods of acute blood loss.

TRANSESOPHAGEAL ECHOCARDIOGRAPHY

Echocardiography may also be used for the measurement of CO by measuring flow through the heart valves. Using TEE, the velocity-time integral of flow through the mitral valve is multiplied by the calculated valve area and constant. This is then multiplied by HR to determine the CO. While the calculations are time-consuming at present, the degree of accuracy has been promising.

OTHER TECHNIQUES
Pulse Contour
Another method of CO measurement is the aortic pulse contour analysis. This technique requires a central aortic catheter and makes assumptions concerning the distensibility of the systemic arterial bed that may not be valid with wide variations in SVR. The notion that SV can be quantified from the pulse pressure dates back to observations by Erlanger and Hooker in 1904. In a critical review of the numerous pulse pressure contour methods of measuring CO, Kouchoukos et al found an overall correlation coefficient of 0.928 with a standard error of the estimate of 17.4 percent for Warner’ method. Weissman et al were able to show that arterial pulse contour was able to trend CO correctly in patients subjected to esmolol induced hypo tension and phenylephriene-induced hypertension. Using a noninvasive technique to measure pulse contour and continuous CO with the Finapres device, Gratz et al observed a modest correlation with this device compared to the intermittent thermodilution method(r=0.75, p=<0.01)>

THORACIC BIOIMPEDANCE
The first attempts at measuring CO by thoracic electrical impedance date back to 1966, when Kubicek et al presented an empiric equation for the calculation of left ventricular stroke volume. To measure thoracic electrical impedance, and alternating current of low amplitude and high frequency is introduced and simultaneously sensed by two sets of electrodes placed around the neck and xyphoid process. Changes in thoracic impedance are induced by ventilation and pulsatile blood flow. For the measurement of SV, only the cardiac-induced pulsatile component of the total change in electrical impedance is analyzed (dZ/dt) as the respiratory component is filtered out.

Donovan et al compared CO measurements obtained by transthoracic impedance and by thermodilution in 27 critically ill patients, using the standard Kubicek equation. They were unable to find a satisfactory correlation between the two CO methods. Bernstein’s modification of the Kubicek equation was evaluated in critically ill patients. This improved the overall correlation with intermittent thermodilution CO(r=0.88), and 85 percent of the data points fell within 20 percent of the intermittent CO. The greatest disparity between the two techniques was observed at very low flows (<2l/min).>

F. IACTA Question Paper

2008-06-09T06:18:00.000-07:00

The written test was for 100 marks, out of which 40 was for multiple choice questions and the remaining 60 for 2 main questions(15 marks each) and 6 short notes(5 marks each). This post is only about the latter part of the written test.
Main Questions.
1. A 35 year old female patient with mitral stenosis and aortic incompetence is posted for double valve replacement. The patient had closed mitral commissurotomy 10 years ago and belongs to Jehova's faith. Discuss the management strategies for this patient[8 Marks] and also the current guidelines for blood conservation in cardiac surgery.[7 Marks]
2. Mention the factors influencing myocardial oxygen demand and supply.[3 Marks]. Describe various techniques of myocardial preservation during cardiopulmonary bypass.[8 Marks]. How will you monitor ischemia during cardiac surgery[3 Marks]
Short Notes.
3. Diagnosis and management of right ventricular dysfunction.
4. Platelet function assessment.
5. Anesthetic management for carotid endarterctomy.
6. Organ preservation following harvest of heart.
7. Pulmonary hypertensive crisis in a child after VSD closure.
8. Methods of assessing mitral regurgitation using TEE.

IACTA fellowship exams..

2008-05-05T09:26:00.000-07:00

IACTA offers a fellowship in cardiac anaesthesiology. The eligibility criteria for appearing for the fellowship exams are , you should have finished your MD/DNB in Anesthesiology and you should have worked in a recognised cardiac center without a break for two years. Their criteria for recognising a center for training candidates in cardiac anaesthesia in not very clear though. But IACTA being the only official body of CardioThoracic anaesthesiologists in India, I feel it is worth while considering this fellowship as an option if you are planning a career in Cardiac Anaesthesiology and are looking for some kind of recognised and acceptable qualification in the specialty.
Five candidates from our institution are appearing for the exam this year, which is going to be conducted at Sri Ramachandra Medical College, Chennai on June 7th and 8th. The exam consists of both written and practical components along with viva voce. The written test consists of three parts - MCQs(40 of 1 mark each), 5 short notes( 6 marks each ) and two essays ( of 15marks each). The practical will have two case scenarios followed by vivavoce.
Those who are interested to take the exam can contact either the president or the secretary of IACTA. By the way the examination fees is Rs.5000 to be paid in the form of a DD drawn in the favour of IACTA payable in Chennai.

MISERY ACQUAINTS A MAN WITH STRANGE BEDFELLOWS

2008-04-16T09:20:00.000-07:00

by Malcolm Fisher (World Medicine October 1976)

Surgeons and anaesthetist have a curious sadomasochistic relationship. Roland and Oliver, Laurel and Hardy, Tristan and Isolde, Lillee and Thompson have been dissected, analysed and lauded. The equally temptuous relationship between surgeon and anaesthetist is less lauded, and sometimes less laudable.

The love-hate aspects of the relationship are governed by two historical truths: without surgeons, anaesthetists would be unemployed (hence the diversification into intensive care, pain clinics, hyperalimentation, and the like), and, because all surgical progress has been made possible by anaesthesia, without anaesthetists, most patients would rather keep their gallbladders, prepuces, and ugly noses.

As surgery has progressed and become more horrendous the function of the anaesthetist has changed from providing good operating conditions for the surgeon to saving the patient from the surgeon. As one cynic put it: "They will do brain transplant one day, just as soon as I can work out which bit to wake up".

I was a little taken aback but I soon learnt that these rules, like many other things he told me, were essential for survival. On my second day, he initiated me into the inner circle which knows the Cook's three laws of surgery:
1.Surgery begets surgery.
2.The adjustment of an operating light is an immediate signal for the surgeon to place his head at the focal point.
3.No substance is more opaque than a surgeon's head.

After three weeks I believed I had anaesthesia mastered, much so that I asked a surgeon what the difference was between a three week resident anaesthetic and a twenty year consultant anaesthetic.

"Very little," he informed me brutally. "the only major difference is that when something goes wrong and a junior is anaesthetising, I know, and when a consultant is anaesthetising I find out in the tea roomwhen it is all over."

I confronted the anaesthetic philosopher with this disturbing information and learnt the next most important lesson. "Never tell the surgeon anything. There is nothing he can do and he will only get in a flap."
There were only four things he said to tell surgeon in time of
crisis.
1."Please get the retractor off the heart."
2."Could you stop a few bleeders and give me time to catch up."
3."Could you give cardiac massage."
4."You can stop now – he's dead."

I then went on and learned the complexities of the surgeon-anaesthetist relationship. I heard of the famous Jones technique of anaesthesia where the anaesthetist stands at the foot of the table and tells the surgeon how to operate while the surgeon's assistant hold the patient on the table. I learned that fitness for anaesthesia was a meaningless term; anyone who could lie down was fit,
but fitness for surgery was a different matter entirely.

Fitness for surgery can be decided over the telephone by asking who the surgeon is, where the patient is going after, and what the operation is. All the pre-operative examination tells you is how and when.

I learned to understand the prima donna complexities of the surgeon and to recognise when the operation was not going well.
All surgeons follow the same procedure.
* Adjust retractors
* Reposition assistants
* Make bigger hole
* Change sides
* Order multiple light adjustments
* Ask for more relaxation
* Curse scrub nurse, resident, registrar, health commission, government, anaesthetist, and deity
* Remove alternative organ and close.

Over a few further years I learned the two other important things that every anaesthetist must know. Surgical textbooks always list causes of excessive bleeding during surgery. They include incompatible blood transfusion, massive transfusion, poor position, halothane, ether, patient too light, patient too deep, hypoxia, hypercarbia, straining, and so on. They never mention scalpels, tearing vessels or swabbing away clots !
In fact when a surgeon glares " Can you do anything about the bleeding?" the best reply is "Certainly, but who will mind the patient while I scrub?"
There is also a list of great surgical lies which every anaesthetist
will recognise.
* "Put him to sleep, I'll be down in five minutes."
* "He is old but he is fit."
* "You will like her, she's and old dear."
* "I haven't cross matched blood, we don't need any."
* "Don't put a tube down, it's just a quick snatch."
* "I'm just going to open, have a look, and close her."
* "She will die if I do nothing."
* "I'll be finished in ten minutes."
Surgeons appreciate a reciprocal number of anaesthetics lies as they appreciate the law that fitness for surgery is universally proportional to time of day.
And let surgeons beware when they hear:
* "The blood pressure is 123/72."
* "The patients is maximally relaxed and won't breathe for a week
if I give any more."
* "It's not cyanosis, it's just the bloody lighting."
* "Don't go away, it will be two minute turn around."

Liver Transplantation

2008-04-11T06:17:00.000-07:00

In our center we have done about 12 Orthotopic Liver Transplantaions. I was fortunate to be a part of the Liver Transplantation team recently. I have tried to capture some of the important stages of the perioperative period
here

Blood conservation in cardiac surgery

2008-04-11T03:54:00.000-07:00

In our day to day anesthetic practice, we are so busy saving lives, reviving arrests, that we spare little thought to improving our methods. Blood transfusion is one such intervention which needs to be looked at carefully. It can be harmful. It is more often than not unnecessary. This talk was given with a view to educate our fraternity that bloodless cardiac surgery is very much a possible thing, not just a pipe dream.

PHIOSOPHY OF ACHIEVING BLOODLESS SURGERY IN CARDIAC PATIENTS

2nd National TOE workshop under the banner of IACTA, between 15th to 17th October 2008

2008-04-11T02:40:00.000-07:00

The second national TEE workshop is being conducted at Narayana Hrudayalaya in October this year from 15th to 17th. Like the previous one it is going to be a hands on workshop. Registrations are limited to 25 only.Those who are interested may contact at the addresses given in the poster below.

Allowable Blood Loss Calculator

2008-04-10T12:11:00.000-07:00

Check out this ABL calculator.. I don't know how useful it is in our OR scenario, but I found this guy's effort to create something like this very interesting!

Workshop on Transoesophageal Echocardiography

2008-04-10T10:12:00.000-07:00

Recently we conducted a IACTA( Indian Association of CardioThoracic Anesthesiologists) certified national level workshop on Transoesophageal Echocardiography. It was a first of its kind effort by Cardiac Anaesthesiologists in India. It was a three day workshop, with eminent faculty members from all over India and abroad. Since the idea was to give as much hands on exposure as possible to the delegates, the registrations were limited to thirty eight only which left many more who very keen to particpate,disappointed. The workshop included a lecture series on important and relevant topics in TEE, porcine heart dissection by each participant and total of three hours of hands on TEE training in the OR over two days. The workshop was not only well attended but also well appreciated.
I was privileged to be one of the faculty members in the workshop( and also one of the participants!). What you see below is my presentation.

Basic physics of Transoesophageal echocardiography for the workshop2

You can download the presentation here..

Grievance of a patient in ITU..

2008-04-05T13:02:00.000-07:00

I happened to stumble upon this review on our hospital. Not very amusing at all.. Music in ITU! I only hope the reviewer has been satisfactorily replied to and all the necessary clarifications have been given.

About Narayana Hrudayalaya

2008-04-05T11:53:00.000-07:00

Narayana Hrudayalaya is one of the biggest cardiac care centers in Asia with about 25 cardiac surgeries in its 12 fully equipped state-of-the-art cardiac ORs and close to 50 cardiac interventional procedures in its four cathterisation labs being performed every day. "Caring with compassion" being the motto of the hospital, it is striving hard to provide highly affordable and quality health care to the masses. The hospital has grown remarkably in the past few years and has been highly successful in achieving its goal. In an attempt to duplicate this success in other specialties of health care, Centres for Neural Sciences, Trauma care and Orthopaedics and Advanced Surgery including Liver and Kidney Transplants have been started under the aegis of NH. A 1000 bedded Cancer Hospital is also on the anvil. For more information about the hospital please visit our official web site here.