ObjectivesBowel dysfunction is a major complication following open surgery for invasive cancer of the bladder that results in significant discomfort; complications and can prolong the length of stay. The incidence of postoperative ileus following open radical cystectomy has been reported as 23–40%. The median length of hospital stay after this surgery in the United Kingdom is 11 days. Standard analgesic techniques include wound infusion analgesia combined with systemic morphine or thoracic epidural analgsia. Combined erector spinae plane and intrathecal opioid analgesia is a novel technique that has been reported to be an effective method of providing perioperative analgesia thereby enhancing recovery after open radical cystectomy.MethodsWe performed a prospective study on the effectiveness of the novel analgesic technique (combined erector spinae plane and intrathecal opioid analgesia) in reducing the incidence of postoperative ileus, thereby facilitating early discharge following open radical cystectomy when compared to a contemporaneous control group receiving standard analgesia. Twenty-five patients received the novel analgesia while 31 patients received standard analgesia as a part of enhanced recovery programme. Standard analgesia arm included 14 patients who recived thoracic epidural analgesia (14/31, 45%) and 17 patients who received combined wound infusion analgesia and patient controlled analgesia with morphine (17/31, 55%). Primary outcome was the incidence of postoperative ileus. Secondary outcomes included length of hospital stay, tramadol consumption and time to bowel opening.ResultsCombined erector spinae plane and intrathecal opioid analgesia was associated with a reduced incidence of postoperative ileus (16 [4/25] vs. 65% [20/31], p<0.001), reduced time to first open bowel (4.4 ± 2.3 vs. 6.6 ± 2.3, p<0.001) and reduced median (IQR) length of hospital stay (7[6, 12] vs. 10[8, 15], p=0.007). There was no significant difference in rescue analgesia (intravenous tramadol) consumption. Complete avoidance of systemic morphine played a key role in improved outcomes.ConclusionsESPITO was successful in reducing postoperative ileus and length of hospital stay after open radical cystectomy when compared to standard analgesia within an enhanced recovery programme.
COVID-19 has been declared a pandemic since March 2020 and it has been responsible for millions of deaths worldwide. The SARS-CoV-2 causes a spectrum of diseases mainly affecting the respiratory system. It can also complicate other systems causing thromboembolic phenomena and myocardial ischaemia. An entity of hypoxia has been described in these patients which show no clinical signs and symptoms of respiratory distress despite being extremely hypoxic. This is called silent or happy hypoxia. The exact mechanism for this is not known. We report 4 cases which had similar presentations of silent hypoxia but had different course of illness and different outcomes. All 4 patients did not show any signs of respiratory distress, but had oxygen saturation less than 82%. 3 of them needed intensive care unit support for oxygen therapy and subsequently needed noninvasive ventilation. Only one required invasive ventilation. The fourth patient did not require intensive care support. The patient who required invasive ventilation succumbed due to severe COVID pneumonia whereas the other 3 patients were discharged from the hospital. Silent hypoxemia can go undetected in COVID-19 patients particularly in the time of a pandemic. This case series highlights the importance of meticulous clinical examination including oxygen saturation measurements in suspected or confirmed patients with COVID-19. The course of illness can be different in different populations, and this needs further clinical evidence.
BackgroundThe adult population in Sri Lanka is having high level of susceptibility for Varicella Zoster Virus (VZV) infection. Among medical undergraduates, 47% are VZV seronegative. The purpose of the present study was to determine the incidence of VZV infection in medical undergraduates in Sri Lanka, and to describe the effects of VZV infection on their academic activities.MethodsA retrospective cohort of medical undergraduates' susceptible for VZV infection was selected from the University of Peradeniya, Sri Lanka. Data on the incidence of VZV infection (Chickenpox) during their undergraduate period was collected using a self-administered structured questionnaire. A second questionnaire was administered to collect data on the details of VZV infection and the impact of it on their academic activities. VZV incidence rate was calculated as the number of infections per 1,000 person years of exposure. Descriptive statistics were used to describe the impact of VZV infection on academic activities.ResultsOut of the 172 susceptible cohort, 153 medical undergraduates were followed up. 47 students reported VZV infection during the follow up period and 43 of them participated in the study. The cumulative incidence of VZV infection during the period of five and half years of medical training was 30.7%. Incidence density of VZV infection among medical undergraduates in this cohort was 65.1 per 1,000 person years of follow-up. A total of 377 working days were lost by 43 students due to the VZV infection, averaging 8.8 days per undergraduate. Total academic losses for the study cohort were; 205 lectures, 17 practicals, 13 dissection sessions, 11 tutorials, 124 days of clinical training and 107 days of professorial clinical appointments. According to their perception they lost 1,927 study hours due to the illness (Median 50 hours per undergraduate).ConclusionsThe incidence of VZV infection among Sri Lankan medical undergraduates is very high and the impact of this infection on academic activities causes severe disruption of their undergraduate life. VZV immunization for susceptible new entrant medical undergraduates is recommended.
Difficult airway is a common problem encountered in oro-maxillo-facial surgeries. We describe a case where a displaced mandibular reconstruction plate obstructing the access to oral cavity. The airway was further compromised by previous tracheostomy, and limited neck extension owing to previous surgeries and radiotherapy. The inability of the patient to swallow increased the risk of pulmonary aspiration. The first line of airway management in such patient should be fibro-optic laryngoscopy. However, one must have alternative plans for securing airway if there are expected difficulties with fiberoptic laryngoscopy. Such plans were made considering her clinical presentation. We believe this case highlights the importance of pre-planning the strategies for airway management according to the presentation. Key words: Difficult airway; Oro-maxillary-facial surgeries; Fiberoptic intubation; Mandibular reconstruction Citation: Ratnayake A, Nanayakkara S, Herath M. A case of displaced mandibular reconstruction plate and the airway. Anaesth. pain intensive care 2022;27(1):139−141; DOI: 10.35975/apic.v27i1.2126 Received: September 24, 2022; Reviewed: November 15, 2022; Accepted: November 15, 2022
A very few cases with Coronavirus disease inducing Diabetic ketoacidosis in non-diabetic patients are reported. Hyperglycaemia caused by transient damage to pancreatic cells by the virus and cytokine storm is identified as the underlying pathophysiology. Here, we present a patient who presented with transient Diabetic ketoacidosis while being treated for COVID-19 pneumonia and is the first reported case in Sri Lanka as per literature. We highlight the approach to diagnosis, monitoring and management of this patient which was challenging for the treating physician.Case: A 34-year-old previously well Sri Lankan male presented with severe covid pneumonia. He was found to have diabetic ketoacidosis and managed as per protocol with fluid and insulin. His glycosylated haemoglobin was normal. Even though his Covid pneumonia worsened leading to death, he recovered from diabetic ketoacidosis and did not require exogenous insulin later in the course of the illness. Conclusion:Transient hyperglycemia with ketoacidosis, such as in our patient, associated with Covid infection has been reported very rarely in the literature. The treating physician should have a high index of suspicion to diagnose these types of patients and to manage them timely. Otherwise, it will be an added but a preventable factor to increase mortality in patients with Covid pneumonia.
As of February 2021, cumulative high-certainty data shows that Tocilizumab decreases the risk of mechanical ventilation in hospitalized patients with Covid-19 [1]. COVID-19 patients receiving tocilizumab may have a theoretical risk of acquiring a secondary infection due to immunosuppression [2]. Here we present a series of chest radiographs of a patient presented with severe Covid pneumonia who improved rapidly with tocilizumab but died of secondary infection later on.
Congenital diaphragmatic hernia a rare congenital malformation which often requires surgical interventions. The surgery is not an emergency, and it can be done within days with planned preoperative optimisation. We present a case of a premature neonate presented with co-existence of left side diaphragmatic hernia with imperforate anus. Presence of imperforate anus prevents the passage of meconium leading to distention of bowel increasing the resistance inside the left hemithorax. Therefore, an urgent repair of the diaphragmatic hernia with colostomy formation was done under general anaesthesia after 48 hours of birth. Patient was managed in a paediatric intensive care unit both pre and post operative period. Even though the post operative period was complicated with a broncopneumonia and a pleural effusion, he was discharged from ICU 20 days after the procedure.
Background Video laryngoscopy is recommended for critically ill COVID-19 patients due to safety concerns and to avoid complications. It is not available in some places forcing the operator to rely on conventional laryngoscope. Intubations in critically ill COVID is challenging and may lead to adverse complications and this may be affected by the laryngoscope used. The aim of the study was to analyse predictors of difficult intubation, complexity of intubation and complications of using conventional laryngoscopy in emergency intubations of COVID- 19 patients. Methods A prospective observational study was done in COVID Intensive care unit of Base Hospital- Teldeniya, Sri Lanka from 1st of January 2021 to August 2021. Data was collected using a performa filled by operator at the end of the intubation. Apart from demographic data and clinical parameters, data related to intubation including MACOCHA score which is a validated score predicting difficult intubation in ICU(3) and Intubation difficulty scale (IDS) which measures actual complexity of intubation(4) were collected. The complications related to intubation were also analysed. Results 84 out of 91 emergency intubations were done using conventional laryngoscope. Out of them 50.72% were male and 49.27% Were female. Mean age was 50.75 years. First pass success rate was 83.3%. 25% had MACOCHA score more than 3. Most patients scored on the desaturation component of the score. Despite this only 50% of the predicted difficult intubations actually had major difficulty in intubation. The commonest complication was hypotension. 12 had suffered cardiac arrest, and 4 of them were fatal. Conclusions Intubation of Critically ill COVID-19 patients are challenging, but can be done successfully with conventional laryngoscope. However, one must prepare for complications including cardiac arrest.
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