Introduction:Patients admitted into a medical Intensive Care Unit (ICU) have varying illnesses and risk factors. An electrocardiogram (ECG) is a useful tool to assess the cardiac status. The aim of the study was to determine the prevalence of QT prolongation of the ECG in patients admitted to a medical ICU in a tertiary hospital, to assess outcomes in terms of mortality, cardiovascular events, and duration of ICU stay.Materials and Methods:Prospective observational study, 6 months duration, assessing the prevalence of prolonged corrected QT interval (QTc) at admission into a medical ICU. A QTc calculated by Bazett's formula, of >440 ms for males and >460 ms for females was considered prolonged. Details of illness, clinical and lab parameters were monitored.Results:The total number of patients screened was 182. There was a high prevalence of prolonged QTc (30%) on admission to the ICU. This reduced to 19% on day 3 (P = 0.011). In patients with a prolonged QTc the odds ratio of adverse outcome from ICU was 3.17 (confidence interval [CI]: 1.52–6.63) (P = 0.001) and of adverse outcome for hospital stay was 2.27 (CI: 1.11–4.66) (P = 0.014). In the study, 35% of all patients received drugs with QT prolonging action. Of patients with a prolonged QTc at admission 18 (35%) received a QT prolonging drug.Conclusions:We found that prolonged QTc is common (30%) in our medical ICU at admission and a large proportion (35%) received drugs capable of prolonging QT interval. These patients with QTc prolongation have a higher odds ratio for adverse outcomes.

Manipulation of the shoulder to facilitate passage of J-wires past the clavicle during external jugular vein catheterization was tested prospectively in III adult patients undergoing cardiac surgery. On 10 of 25 occasions when the wire would not pass into the thorax, manipulation of the shoulder then allowed the wire to pass.

BackgroundSerine-threonine inhibitors, such as vemurafenib, are being used increasingly in cancer treatment, and the toxicity and therapeutic benefit need to be balanced carefully both before and during treatment.Case presentationA patient with metastatic melanoma and end stage renal failure who was on peritoneal dialysis was treated with the serine-threonine kinase inhibitor, vemurafenib. After 5 months of treatment, a substantial response to vemurafenib was observed using imaging, but when he developed a prolonged QTc interval (common toxicity criteria (CTC) grade 3), treatment was interrupted. Vemurafenib was restarted at a reduced dose when the QTc interval returned to normal. The patient has had a significant response to vemurafenib and continued on treatment for 12 months after beginning the therapy.ConclusionThis is the first reported case of end stage renal failure in a patient who is taking vemurafenib. Although the patient developed QTc prolongation, it appears to be asymptomatic, and was managed with dose reduction. This case highlights the need for closer QTc monitoring at the start and during treatment.

Background and Aims:Around the world, the use of the laryngeal mask airway (LMA) is becoming more common for different surgeries accounting for it being the dominant choice of airway in numerous surgeries. Although propofol is known to blunt the laryngeal reflexes often patient movement, coughing, and gagging occur on insertion. This study aims to identify the optimum dose of succinylcholine required to facilitate LMA insertion comparing placebo, 0.1 mg/kg and 0.25 mg/kg of succinylcholine. Further objectives were to compare (a) the overall insertion conditions of the LMA, (b) the number of insertion attempts, (c) the amount of propofol consumption, and (d) the hemodynamics in the three groups.Setting and Design:This is a prospective, double-blinded, randomized control trial of 283 patients randomized into three groups-placebo, 0.1 mg/kg and 0.25 mg/kg of succinylcholine. It was done in the day case theatres of a tertiary hospital in Southern India.Subjects and Methods:Patients were induced with 2 mg/kg of propofol, after 2 μg/kg of fentanyl. The study drug was given after loss of consciousness. After 60 s, a classic LMA was inserted by the standard method by a single investigator. Jaw relaxation, coughing, gagging, movement, laryngospasm, ease of insertion, number of attempts, propofol usage, and hemodynamics were assessed.Statistical Analysis:Statistical methods used were analysis of variance with Bonferroni's t-test, Chi-square test, and Fisher's test. P < 0.05 was considered statistically significant.Results:Jaw relaxation was significantly better in the 0.25 mg/kg succinylcholine group. There was no significant difference in coughing and gagging in the groups, but patient movement was more in the placebo group. Two patients in the placebo group experienced partial laryngospasm. Overall insertion conditions were significantly better in the 0.25 mg/kg group compared to the other two groups. Propofol consumption was significantly more in the placebo group.Conclusions:The study concludes that 0.25 mg/kg succinylcholine facilitates insertion of the LMA.

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Background and Aims: The coronavirus disease 2019 (COVID-19) pandemic has initiated modified protocols for aerosol-generating procedures. A simulation study using dye was conducted to highlight contamination at intubation and extubation and to encourage adherence to the new COVID-19 protocol among anaesthesia personnel in our institution. Methods: A video demonstrating the new COVID-19 protocols was circulated in the Department of Anaesthesiology a week prior to the study. Thirty teams, each comprising an anaesthesia resident and a staff technician, were enroled. Each team was asked to demonstrate the steps of preparation, intubation and extubation on a mannequin in a COVID-19 scenario. Checklists were used to assess points of contamination and adherence to the protocols. Following debriefing, a repeat simulation was conducted. The use of a dye highlighted the points of contamination. The study subjects provided feedback on the usefulness of the session and practical difficulties encountered in adapting to the new protocols. Results: The average contamination scores decreased by 3.4 (95% confidence interval (CI): 2.4–4.4, P < 0.001) in the post-debrief session. Adherence to the steps of the modified protocol improved by a score of 2.7 (CI: 3.6–1.83) among anaesthesiologists and by 4.3 (CI: 5.3–3.3) among technicians. Further, 93% felt that the use of the colour indicator reinforced awareness of the possible points of contamination. Conclusion: Simulation with a low-fidelity mannequin by using colour indicator for secretions is an effective teaching tool to reduce health hazards during airway management in COVID-19 times.

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The point of our paper was not to focus on peri-operative mortality but more on the actual benefit one might expect from postoperative ventilation. As mentioned in the paper, there are other studies that have questioned the need for postoperative ventilation and, providing patients are, kept in a high dependency unit with full monitoring and critical care support, we do not feel that prolonged postoperative ventilation for 18 h, as suggested by Forshaw and colleagues, provides any advantage to the patient. Forshaw and colleagues suggest that these patients are kept in the recovery area until the following morning, although in many hospitals postoperative ventilation would necessitate the patient being admitted to the intensive care unit. We identify in our paper that this might well result in a significant number of patients having their oesophagectomy cancelled for lack of an intensive care bed when this was not necessary. The results from our initial study, and these have been supported by our more recent data (as shown above), demonstrate that there appears to be no benefit from prolonged ventilation providing all physiological parameters are closely monitored in a critical care environment. Although the mortality in the early part of our own series was higher than later years, we did not identify any problems that were directly related to early postoperative extubation. We wish to commend the authors for high-lighting an extremely important aspect in managing patients after oesophagectomy. However, no indication was given regarding the type of resection performed in the centres surveyed. In Exeter, we currently offer minimally invasive oesophagectomy (MIO) to all patients suitable for resection and, this procedure has specific diet-related issues which are important to high-light: COMMENT ON1. In the absence of significant postoperative discomfort and morbidity following MIO, patients were inadvertently taking large portions of hospital food when commenced on oral intake after the fifth postoperative day. This resulted in excessive gastric distension, and subsequent anastomotic leak in two patients. As a consequence, we have now introduced an enforced, structured postoperative diet with no further problems.2. The authors do not mention the route of postoperative jejunal feeding used. We use fine bore nasojejunal feeding tubes placed endoscopically during surgery. These are well tolerated, and rapidly weaned after the commencement of oral intake on postoperative day 5/6 by virtue of the rapid restoration of gastrointestinal function after MIO. This avoids the inherent morbidity associated with percutaneous jejunostomy tubes.1 Reference 1. Pearce CB, Duncan HD. Enteral feeding. Nasogastric, nasojejunal, percutaneous endoscopic gastrostomy, or jejunostomy: its indications and limitations.