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Vascular access, fluid resuscitation, and blood transfusion in pediatric trauma
Nathaniel Greene, Sanjay Bhananker, Ramesh Ramaiah
September-December 2012, 2(3):135-142
DOI:10.4103/2229-5151.100890  PMID:23181207
Trauma care in the general population has largely become protocol-driven, with an emphasis on fast and efficient treatment, good team communication at all levels of care including prehospital care, initial resuscitation, intensive care, and rehabilitation. Most available literature on trauma care has focused on adults, allowing the potential to apply concepts from adult care to pediatric care. But there remain issues that will always be specific to pediatric patients that may not translate from adults. Several new devices such as intraosseous (IO) needle systems and techniques such as ultrasonography to cannulate central and peripheral veins have become available for integration into our pre-existing trauma care system for children. This review will focus specifically on the latest techniques and evidence available for establishing intravenous access, rational approaches to fluid resuscitation, and blood product transfusion in the pediatric trauma patient.
  16,665 488 9
Pediatric airway management
Jeff Harless, Ramesh Ramaiah, Sanjay M Bhananker
January-March 2014, 4(1):65-70
DOI:10.4103/2229-5151.128015  PMID:24741500
Securing an airway is a vital task for the anesthesiologist. The pediatric patients have significant anatomical and physiological differences compared with adults, which impact on the techniques and tools that the anesthesiologist might choose to provide safe and effective control of the airway. Furthermore, there are a number of pathological processes, typically seen in the pediatric population, which present unique anatomical or functional difficulties in airway management. The presence of one of these syndromes or conditions can predict a "difficult airway." Many instruments and devices are currently available which have been designed to aid in airway management. Some of these have been adapted from adult designs, but in many cases require alterations in technique to account for the anatomical and physiological differences of the pediatric patient. This review focuses on assessment and management of pediatric airway and highlights the unique challenges encountered in children.
  8,372 893 16
Trends in trauma transfusion
Sanjay M Bhananker, Ramesh Ramaiah
January-June 2011, 1(1):51-56
DOI:10.4103/2229-5151.79282  PMID:22096774
Trauma is the leading cause of death in young adults and acute blood loss contributes to a large portion of mortality in the early post-trauma period. The recognition of lethal triad of coagulopathy, hypothermia and acidosis has led to the concepts of damage control surgery and resuscitation. Recent experience with managing polytrauma victims from the Iraq and Afghanistan wars has led to a few significant changes in clinical practice. Simultaneously, transfusion practices in the civilian settings have also been extensively studied retrospectively and prospectively in the last decade. Early treatment of coagulopathy with a high ratio of fresh frozen plasma and platelets to packed red blood cells (FFP:platelet:RBC), prevention and early correction of hypothermia and acidosis, monitoring of hemostasis using point of care tests like thromoboelastometry, use of recombinant activated factor VII, antifibrinolytic drugs like tranexamic acid are just some of the emerging trends. Further studies, especially in the civilian trauma centers, are needed to confirm the lessons learned in the military environment. Identification of patients likely to need massive transfusion followed by immediate preventive and therapeutic interventions to prevent the development of coagulopathy could help in reducing the morbidity and mortality associated with uncontrolled hemorrhage in trauma patients.
  8,302 462 10
Perioperative management of traumatic brain injury
Parichat Curry, Darwin Viernes, Deepak Sharma
January-June 2011, 1(1):27-35
DOI:10.4103/2229-5151.79279  PMID:22096771
Traumatic brain injury (TBI) is a major public health problem and the leading cause of death and disability worldwide. Despite the modern diagnosis and treatment, the prognosis for patients with TBI remains poor. While severity of primary injury is the major factor determining the outcomes, the secondary injury caused by physiological insults such as hypotension, hypoxemia, hypercarbia, hypocarbia, hyperglycemia and hypoglycemia, etc. that develop over time after the onset of the initial injury, causes further damage to brain tissue, worsening the outcome in TBI. Perioperative period may be particularly important in the course of TBI management. While surgery and anesthesia may predispose the patients to new onset secondary injuries which may contribute adversely to outcomes, the perioperative period is also an opportunity to detect and correct the undiagnosed pre-existing secondary insults, to prevent against new secondary insults and is a potential window to initiate interventions that may improve outcome of TBI. For this review, extensive Pubmed and Medline search on various aspects of perioperative management of TBI was performed, followed by review of research focusing on intraoperative and perioperative period. While the research focusing specifically on the intraoperative and immediate perioperative TBI management is limited, clinical management continues to be based largely on physiological optimization and recommendations of Brain Trauma Foundation guidelines. This review is focused on the perioperative management of TBI, with particular emphasis on recent developments.
  6,949 822 10
Septic embolism in the intensive care unit
Stanislaw P Stawicki, Michael S Firstenberg, Michael R Lyaker, Sarah B Russell, David C Evans, Sergio D Bergese, Thomas J Papadimos
January-March 2013, 3(1):58-63
DOI:10.4103/2229-5151.109423  PMID:23724387
Septic embolism encompasses a wide range of presentations and clinical considerations. From asymptomatic, incidental finding on advanced imaging to devastating cardiovascular or cerebral events, this important clinico-pathologic entity continues to affect critically ill patients. Septic emboli are challenging because they represent two insults-the early embolic/ischemic insult due to vascular occlusion and the infectious insult from a deep-seated nidus of infection frequently not amenable to adequate source control. Mycotic aneurysms and intravascular or end-organ abscesses can occur. The diagnosis of septic embolism should be considered in any patient with certain risk factors including bacterial endocarditis or infected intravascular devices. Treatment consists of long-term antibiotics and source control when possible. This manuscript provides a much-needed synopsis of the different forms and clinical presentations of septic embolism, basic diagnostic considerations, general clinical approaches, and an overview of potential complications.
  7,252 239 3
Complications of post-injury decompressive craniectomy
Luciano Santana-Cabrera, Guillermo Pérez-Acosta, Cristina Rodríguez-Escot, Rosa Lorenzo-Torrent, Manuel Sánchez-Palacios
September-December 2012, 2(3):186-188
DOI:10.4103/2229-5151.100937  PMID:23181215
Decompressive craniectomy (DC) is a useful technique for the treatment of traumatic brain injuries (TBI) with intracranial hypertension (ICHT) resistant to medical treatment, increasing survival, although its role in the functional prognosis of patients is not defined. It is also a technique that is not without complications, and may increase the patient's morbidity and mortality. We report two cases of patients with TBI who required DC and suffered complications from the technique
  6,988 162 3
Anesthetic considerations in acute spinal cord trauma
Neil Dooney, Armagan Dagal
January-June 2011, 1(1):36-43
DOI:10.4103/2229-5151.79280  PMID:22096772
Patients with actual or potential spinal cord injury (SCI) are frequently seen at adult trauma centers, and a large number of these patients require operative intervention. All polytrauma patients should be assumed to have an SCI until proven otherwise. Pre-hospital providers should take adequate measures to immobilize the spine for all trauma patients at the site of the accident. Stabilization of the spine facilitates the treatment of other major injuries both in and outside the hospital. The presiding goal of perioperative management is to prevent iatrogenic deterioration of existing injury and limit the development of secondary injury whilst providing overall organ support, which may be adversely affected by the injury. This review article explores the anesthetic implications of the patient with acute SCI. A comprehensive literature search of Medline, Embase, Cochrane database of systematic reviews, conference proceedings and internet sites for relevant literature was performed. Reference lists of relevant published articles were also examined. Searches were carried out in October 2010 and there were no restrictions by study design or country of origin. Publication date of included studies was limited to 1990-2010.
  6,326 751 3
Extraglottic airway devices: A review
Ramesh Ramaiah, Debasmita Das, Sanjay M Bhananker, Aaron M Joffe
January-March 2014, 4(1):77-87
DOI:10.4103/2229-5151.128019  PMID:24741502
Extraglottic airway devices (EAD) have become an integral part of anesthetic care since their introduction into clinical practice 25 years ago and have been used safely hundreds of millions of times, worldwide. They are an important first option for difficult ventilation during both in-hospital and out-of-hospital difficult airway management and can be utilized as a conduit for tracheal intubation either blindly or assisted by another technology (fiberoptic endoscopy, lightwand). Thus, the EAD may be the most versatile single airway technique in the airway management toolbox. However, despite their utility, knowledge regarding specific devices and the supporting data for their use is of paramount importance to patient's safety. In this review, number of commercially available EADs are discussed and the reported benefits and potential pitfalls are highlighted.
  6,619 458 1
The 2014 Academic College of Emergency Experts in India's INDO-US Joint Working Group (JWG) White Paper on "Developing Trauma Sciences and Injury Care in India"
Ranabir Pal, Amit Agarwal, Sagar Galwankar, Mamta Swaroop, Stanislaw P Stawicki, Laxminarayan Rajaram, Lorenzo Paladino, Praveen Aggarwal, Sanjeev Bhoi, Sankalp Dwivedi, Geetha Menon, MC Misra, OP Kalra, Ajai Singh, Angeline Neetha Radjou, Anuja Joshi
April-June 2014, 4(2):114-130
DOI:10.4103/2229-5151.134151  PMID:25024939
It is encouraging to see the much needed shift in the understanding and recognition of the concept of "burden of disease" in the context of traumatic injury. Equally important is understanding that the impact of trauma burden rivals that of nontraumatic morbidities. Subsequently, this paradigm shift reinstates the appeal for timely interventions as the standard for management of traumatic emergencies. Emergency trauma care in India has been disorganized due to inadequate sensitivity toward patients affected by trauma as well as the haphazard, nonuniform acceptance of standardization as the norm. Some of the major hospitals across various regions in the country do have trauma care units, but even those lack protocols to ensure that all trauma cases are handled by those units, largely owing to lack of structured referral system. As a first step to reform the state of trauma care in the country, a detailed overview is needed to gain insight into the prevailing reality. The objectives of this paper are to thus weave a foundation based on the statistical and qualitative burden of trauma in the country; the available infrastructure of trauma care centers equipped to deal with trauma; the need and scope of standardized protocols for intervention; and most importantly, the application of these in shaping educational initiatives in advancing emergency trauma care in the country.
  6,804 267 5
Damage control in the injured patient
Jeremy M Hsu, Tam N Pham
January-June 2011, 1(1):66-72
DOI:10.4103/2229-5151.79285  PMID:22096776
The damage control concept is an essential component in the management of severely injured patients. The principles in sequence are as follows: (1) abbreviated surgical procedures limited to haemorrhage and contamination control; (2) correction of physiological derangements; (3) definitive surgical procedures. Although originally described in the management of major abdominal injuries, the concept has been extended to include thoracic, vascular, orthopedic, and neurosurgical procedures, as well as anesthesia and resuscitative strategies.
  6,418 513 6
Rapid-sequence intubation and cricoid pressure
Joshua C Stewart, Sanjay Bhananker, Ramesh Ramaiah
January-March 2014, 4(1):42-49
DOI:10.4103/2229-5151.128012  PMID:24741497
Airway management is the most important clinical skill for anesthesiologist, emergency physician, and other providers who are involved in oxygenation and ventilation of the lungs. Rapid-sequence intubation is the preferred method to secure airway in patients who are at risk for aspiration because it results in rapid unconsciousness (induction) and neuromuscular blockade (paralysis). Application of cricoid pressure (CP) for patients undergoing rapid-sequence intubation is controversial. Multiple specialty societies have recommended that CP is not effective in preventing aspiration; rather it may worsen laryngoscopic view and impair bag-valve mask ventilation. Some experts think that CP should be applied in trauma and patients at risk for aspiration; however CP, if necessary, should be altered or removed to facilitate intubation.
  6,327 551 2
Treatment of an intraoral bleeding in hemophilic patient with a thermoplastic palatal stent - A novel approach
Nidhi Madan, Arun Rathnam, Neeti Bajaj
January-June 2011, 1(1):79-83
DOI:10.4103/2229-5151.79288  PMID:22096778
This is a case report of a 13-year old child diagnosed with hemophilia A. He reported with a bleeding wound in the middle part of the hard palate, due to trauma from a lead pencil. An intraoral palatal stent was planned to provide continuous pressure, stabilize the clot and allow local delivery of hemostatic agent. The stent was fabricated with a thermoplastic silicone rubber (biostar) under vacuum. The hemostatic agent used was one 500 mg capsule of tranxemic acid that was crushed and applied as a paste every 6 hourly. The patient was admitted under supervision for 3 days, where Recombinant factor VIII (rFVIII) intravenous infusion of 15-25 U/kg twice a day was given. Complete healing was observed in the traumatized area within 10 days. This article emphasizes on prenatal diagnosis, carrier screening and counseling of parents born with hemophilic children.
  6,282 185 -
Pediatric burn injuries
Vijay Krishnamoorthy, Ramesh Ramaiah, Sanjay M Bhananker
September-December 2012, 2(3):128-134
DOI:10.4103/2229-5151.100889  PMID:23181206
Pediatric burns comprise a major mechanism of injury, affecting millions of children worldwide, with causes including scald injury, fire injury, and child abuse. Burn injuries tend to be classified based on the total body surface area involved and the depth of injury. Large burn injuries have multisystemic manifestations, including injuries to all major organ systems, requiring close supportive and therapeutic measures. Management of burn injuries requires intensive medical therapy for multi-organ dysfunction/failure, and aggressive surgical therapy to prevent sepsis and secondary complications. In addition, pain management throughout this period is vital. Specialized burn centers, which care for these patients with multidisciplinary teams, may be the best places to treat children with major thermal injuries. This review highlights the major components of burn care, stressing the pathophysiologic consequences of burn injury, circulatory and respiratory care, surgical management, and pain management of these often critically ill patients.
  5,886 458 7
Compliance with the Eastern Association for the Surgery of Trauma guidelines for prophylactic antibiotics after open extremity fracture
Cassie A Barton, Wesley D McMillian, Bruce A Crookes, Turner Osler, Craig S Bartlett
May-August 2012, 2(2):57-62
Context: Prophylactic antibiotics, paired with wound care and surgical intervention, is considered the standard of care for patients with open fracture. Guidelines from the Eastern Association for the Surgery of Trauma (EAST) recommend specific prophylactic antimicrobial therapy based on the type of open fracture. Aims: We quantified adherence to EAST guideline recommendations and documented the incidence of infection in patients with open fracture. Settings and Design: A retrospective, observational study of all patients with open fracture admitted to our facility from January 2004 to December 2008 was conducted. Materials and Methods: Patients were divided into compliant and noncompliant groups according to the EAST guideline recommendations. Compliance was defined as an appropriate spectrum of therapy for guideline suggested duration. We assessed for surgical and non-surgical site infections, and morbidity outcomes. Statistical Analysis: Nominal data were explored using summary measures. Continuous variables were compared using the Student t-test or the Mann-Whitney U-test. Dichotomous data were compared using χ2 statistic or Fisher's exact test. Results: The final analysis included 214 patients. Prophylactic antibiotics were guideline compliant in 28.5% of patients, and ranged from 10.0% in type 3b fractures to 52.7% in type 1 fractures. The most common reason for non-compliance was the use of guideline recommended coverage that exceeded the suggested duration (71.2%). Patients who received non-compliant therapy required prolonged hospital lengths of stay (6 vs. 3 days, P = 0.0001). The overall incidence of infection was similar regardless of guideline compliance (17.0% vs. 11.5%, P = 0.313). Conclusions: Prophylactic antibiotics for open fracture frequently exceeded guideline recommendations in duration and spectrum of coverage, especially in more severe fracture types. Non-compliance with EAST recommendations was associated with increased in-hospital morbidity.
  6,131 113 7
Blunt traumatic abdominal wall disruption with evisceration
Ellen McDaniel, Stanislaw PA Stawicki, David P Bahner
July-December 2011, 1(2):164-166
DOI:10.4103/2229-5151.84807  PMID:22229144
Blunt traumatic abdominal wall disruptions associated with evisceration are very rare. The authors describe a case of traumatic abdominal wall disruption with bowel evisceration that occurred after a middle-aged woman sustained direct focal blunt force impact to the lower abdomen. Abdominal exploration and surgical repair of the abdominal wall defect were performed, with good clinical outcome. A brief overview of literature pertinent to this rare trauma scenario is presented.
  6,096 96 1
Airway management in cervical spine injury
Naola Austin, Vijay Krishnamoorthy, Arman Dagal
January-March 2014, 4(1):50-56
DOI:10.4103/2229-5151.128013  PMID:24741498
To minimize risk of spinal cord injury, airway management providers must understand the anatomic and functional relationship between the airway, cervical column, and spinal cord. Patients with known or suspected cervical spine injury may require emergent intubation for airway protection and ventilatory support or elective intubation for surgery with or without rigid neck stabilization (i.e., halo). To provide safe and efficient care in these patients, practitioners must identify high-risk patients, be comfortable with available methods of airway adjuncts, and know how airway maneuvers, neck stabilization, and positioning affect the cervical spine. This review discusses the risks and benefits of various airway management strategies as well as specific concerns that affect patients with known or suspected cervical spine injury.
  5,603 485 9
Acute ischemic colitis secondary to air embolism after diving
Austin Daniel Payor, Veronica Tucci
January-June 2011, 1(1):73-78
DOI:10.4103/2229-5151.79286  PMID:22096777
Ischemic colitis (IC) secondary to air embolism from decompression sickness or barotrauma during diving is an extremely rare condition. After extensive review of the available literature, we found that there has been only one reported case of IC secondary to air embolism from diving. Although air embolization from diving and the various medical complications that follow have been well documented, the clinical manifestation of IC from an air embolism during diving is very rare and thus far unstudied. Common symptoms of IC include abdominal pain, bloody or non-bloody diarrhea or nausea or vomiting or any combination. Emergency physicians and Critical Care specialists should consider IC as a potential diagnosis for a patient with the above-mentioned symptoms and a history of recent diving. We report a case of IC from air embolism after a routine dive to 75 feet below sea level in a 53-year-old White female who presented to a community Emergency Department complaining of a 2-day history of diffuse abdominal pain and nausea. She was diagnosed by colonoscopy with biopsies and treated conservatively with antibiotics, bowel rest, and a slow advancement in diet.
  5,378 155 3
Infections of the nervous system
Vevek Parikh, Veronica Tucci, Sagar Galwankar
May-August 2012, 2(2):82-97
DOI:10.4103/2229-5151.97273  PMID:22837896
Infections of the nervous system are among the most difficult infections in terms of the morbidity and mortality posed to patients, and thereby require urgent and accurate diagnosis. Although viral meningitides are more common, it is the bacterial meningitides that have the potential to cause a rapidly deteriorating condition that the physician should be familiar with. Viral encephalitis frequently accompanies viral meningitis, and can produce focal neurologic findings and cognitive difficulties that can mimic other neurologic disorders. Brain abscesses also have the potential to mimic and present like other neurologic disorders, and cause more focal deficits. Finally, other infectious diseases of the central nervous system, such as prion disease and cavernous sinus thrombosis, are explored in this review.
  5,050 389 4
Epidemiology and clinical characteristics of traumatic brain injuries in a rural setting in Maharashtra, India. 2007-2009
Amit Agrawal, Sagar Galwankar, Vikas Kapil, Victor Coronado, Sridhar V Basavaraju, Lisa C McGuire, Rajnish Joshi, Syed Z Quazi, Sankalp Dwivedi
September-December 2012, 2(3):167-171
DOI:10.4103/2229-5151.100915  PMID:23181212
Context: Though some studies have described traumatic brain injuries in tertiary care, urban hospitals in India, very limited information is available from rural settings. Aims: To evaluate and describe the epidemiological and clinical characteristics of patients with traumatic brain injury and their clinical outcomes following admission to a rural, tertiary care teaching hospital in India. Settings and Design: Retrospective, cross-sectional, hospital-based study from January 2007 to December 2009. Materials and Methods: Epidemiological and clinical data from all patients with traumatic brain injury (TBI) admitted to the neurosurgery service of a rural hospital in district Wardha, Maharashtra, India, from 2007 to 2009 were analyzed. The medical records of all eligible patients were reviewed and data collected on age, sex, place of residence, Glasgow Coma Scale (GCS) score, mechanism of injury, severity of injury, concurrent injuries, length of hospital stay, computed tomography (CT) scan results, type of management, indication and type of surgical intervention, and outcome. Statistical Analysis: Data analysis was performed using STATA version 11.0. Results: The medical records of 1,926 eligible patients with TBI were analyzed. The median age of the study population was 31 years (range <1 year to 98 years). The majority of TBI cases occurred in persons aged 21 - 30 years (535 or 27.7%), and in males (1,363 or 70.76%). Most patients resided in nearby rural areas and the most frequent external cause of injury was motor vehicle crash (56.3%). The overall TBI-related mortality during the study period was 6.4%. From 2007 to 2009, TBI-related mortality significantly decreased (P < 0.01) during each year (2007: 8.9%, 2008: 8.5%, and 2009: 4.9%). This decrease in mortality could be due to access and availability of better health care facilities. Conclusions: Road traffic crashes are the leading cause of TBI in rural Maharashtra ffecting mainly young adult males. At least 10% of survivors had moderate or more severe TBI-related disabilities. Future research should include prospective, population based studies to better elucidate the incidence, prevalence, and economic impact of TBI in rural India.
  5,009 387 6
Advances in prehospital trauma care
Kelvin Williamson, Ramaiah Ramesh, Andreas Grabinsky
January-June 2011, 1(1):44-50
DOI:10.4103/2229-5151.79281  PMID:22096773
Prehospital trauma care developed over the last decades parallel in many countries. Most of the prehospital emergency medical systems relied on input or experiences from military medicine and were often modeled after the existing military procedures. Some systems were initially developed with the trauma patient in mind, while other systems were tailored for medical, especially cardiovascular, emergencies. The key components to successful prehospital trauma care are the well-known ABCs of trauma care: Airway, Breathing, Circulation. Establishing and securing the airway, ventilation, fluid resuscitation, and in addition, the quick transport to the best-suited trauma center represent the pillars of trauma care in the field. While ABC in trauma care has neither been challenged nor changed, new techniques, tools and procedures have been developed to make it easier for the prehospital provider to achieve these goals in the prehospital setting and thus improve the outcome of trauma patients.
  5,033 357 6
Prevention of hypotension and prolongation of postoperative analgesia in emergency cesarean sections: A randomized study with intrathecal clonidine
Sukhminder Jit Singh Bajwa, Sukhwinder Kaur Bajwa, Jasbir Kaur, Amarjit Singh, Anita Singh, Surjit Singh Parmar
May-August 2012, 2(2):63-69
Background and Context: Different adjuvants been tried out for neuraxial anesthesia in emergency caesarean section so that the dose of the local anesthetic can be reduced and hypotension thereby prevented. Aims and Objectives: The present study was carried out in patients presenting for emergency lower segment caesarean section (LSCS) to establish the dose of intrathecal clonidine that would allow reduction of the dose of local anesthetic (thereby reducing the incidence and magnitude of hypotension) while at the same time providing clinically relevant prolongation of spinal anesthesia without significant side effects. Materials and Methods: This randomized clinical study was carried out in our institution among 100 pregnant females who underwent emergency caesarean section. The participants were divided randomly into four groups: A, B, C, and D, each comprising 25 parturients. Subarachnoid block was performed using a 26G Quincke needle, with 12 mg of hyperbaric bupivacaine (LA) in group A, 9 mg of LA + 30 μg of clonidine in group B, LA + 37.5 μg of clonidine in group C, and LA + 45 μg of clonidine in group D. The solution was uniformly made up to 2.2 mL with normal saline in all the groups. Onset of analgesia at T 10 level, sensory and motor blockade levels, maternal heart rate and blood pressure, neonatal Apgar scores, postoperative block characteristics, and adverse events were looked for and recorded. Statistical analysis was carried out with SPSS® version 10.0 for Windows® , using the ANOVA test with post hoc significance, the Chi-square test, and the Mann-Whitney U test. P<.05 was considered significant and P<.0001 as highly significant. Results: One hundred patients were enrolled for this study. The four groups were comparable with regard to demographic data and neonatal Apgar scores. Onset and establishment of sensory and motor analgesia was significantly shorter in groups C and D, while hypotension (and the use of vasopressors) was significantly higher in groups A and D. Perioperative shivering, nausea, and vomiting were significantly higher in groups A and D, while incidence of dry mouth was significantly higher in group D. Conclusions: The addition of 45 μg, 37.5 μg, and 30 μg of clonidine to hyperbaric bupivacaine results in more prolonged complete and effective analgesia, allowing reduction of up to 18% of the total dose of hyperbaric bupivacaine. From the results of this study, 37.5 μg of clonidine seems to be the optimal dose.
  4,725 460 4
Sedation and analgesia for the pediatric trauma patients
Ramesh Ramaiah, Andreas Grabinsky, Sanjay M Bhananker
September-December 2012, 2(3):156-162
DOI:10.4103/2229-5151.100897  PMID:23181210
The number of children requiring sedation and analgesia for diagnostic and therapeutic procedures has increased substantially in the last decade. Both anesthesiologist and non-anesthesiologists are involved in varying settings outside the operating room to provide safe and effective sedation and analgesia. Procedural sedation has become standard of care and its primary aim is managing acute anxiety, pain, and control of movement during painful or unpleasant procedures. There is enough evidence to suggest that poorly controlled acute pain causes suffering, worse outcome, as well as debilitating chronic pain syndromes that are often refractory to available treatment options. This article will provide strategies to provide safe and effective sedation and analgesia for pediatric trauma patients.
  4,933 190 1
Initial assessment and management of pediatric trauma patients
J Grant McFadyen, Ramesh Ramaiah, Sanjay M Bhananker
September-December 2012, 2(3):121-127
DOI:10.4103/2229-5151.100888  PMID:23181205
Injury is the leading cause of death and disability in children. Each year, almost one in six children in the United States require emergency department (ED) care for the treatment of injuries, and more than 10,000 children die from injuries. Severely injured children need to be transported to a facility that is staffed 24/7 by personnel experienced in the management of children, and that has all the appropriate equipment to diagnose and manage injuries in children. Anatomical, physiological, and emotional differences between adults and children mean that children are not just scaled-down adults. Facilities receiving injured children need to be child and family friendly, in order to minimize the psychological impact of injury on the child and their family/carers. Early recognition and treatment of life-threatening airway obstruction, inadequate breathing, and intra-abdominal and intra-cranial hemorrhage significantly increases survival rate after major trauma. The initial assessment and management of the injured child follows the same ATLS; sequence as adults: primary survey and resuscitation, followed by secondary survey. A well-organized trauma team has a leader who designates roles to team members and facilitates clear, unambiguous communication between team members. The team leader stands where he/she can observe the entire team and monitor the "bigger picture." Working together as a cohesive team, the members perform the primary survey in just a few minutes. Life-threatening conditions are dealt with as soon as they are identified. Necessary imaging studies are obtained early. Constant reassessment ensures that any deterioration in the child's condition is picked up immediately. The secondary survey identifies other injuries, such as intra-abdominal injuries and long-bone fractures, which can result in significant hemorrhage. The relief of pain is an important part of the treatment of an injured child.
  4,690 339 7
A comparison between two different alveolar recruitment maneuvers in patients with acute respiratory distress syndrome
Khaled M Mahmoud, Amany S Ammar
July-December 2011, 1(2):114-120
DOI:10.4103/2229-5151.84795  PMID:22229134
Background: Alveolar recruitment is a physiological process that denotes the reopening of previously gasless lung units exposed to positive pressure ventilation. The current study was aimed to compare two recruitment maneuvers, a high continuous positive airway pressure (CPAP), and an extended sigh in patients with ARDS. Materials and Methods: Forty patients with acute respiratory distress syndrome were randomly divided into two groups, 20 patients each. Group I received a CPAP of 40 cmH 2 O for 40 seconds and group II received extended sigh (providing a sufficient recruiting pressure Χ time). In our study, we assessed the effects of both recruitment maneuvers on respiratory mechanics, gas exchange, and hemodynamics. These data were analyzed using two-way analysis of variance (ANOVA) followed by a Student--Newman--Keuls post hoc comparison test. P < 0.05 was considered statistically significant. Results: Both methods improved the compliance, increased arterial oxygenation (PaO 2 ), increased the PaO 2 /FiO 2 ratio, and reduced the pulmonary shunt fraction (Q s/Q t). However, the extended sigh improved both PaO 2 and PaO 2 /FiO 2 ratios more than continuous positive airway pressure. Also the hemodynamic parameters were better maintained during the extended sigh. Conclusion: Alveolar recruitment maneuvers are effective in management of mechanically ventilated ARDS patients. We conclude that extended sigh is more effective than continuous positive airway pressure as a recruitment maneuver.
  4,489 426 2
Role of music in intensive care medicine
Hans-Joachim Trappe
January-April 2012, 2(1):27-31
The role of music in intensive care medicine is still unclear. However, it is well known that music may not only improve quality of life but also effect changes in heart rate (HR) and heart rate variability (HRV). Reactions to music are considered subjective, but studies suggest that cardio/cerebrovascular variables are influenced under different circumstances. It has been shown that cerebral flow was significantly lower when listening to "Va pensioero" from Verdi's "Nabucco" (70.4+3.3 cm/s) compared to "Libiam nei lieti calici" from Verdi's "La Traviata" (70.2+3.1 cm/s) (P<0,02) or Bach's Cantata No. 169 "Gott soll allein mein Herze haben" (70.9+2.9 cm/s) (P<0,02). There was no significant influence on cerebral flow in Beethoven's Ninth Symphony during rest (67.6+3.3 cm/s) or music (69.4+3.1 cm/s). It was reported that relaxing music plays an important role in intensive care medicine. Music significantly decreases the level of anxiety for patients in a preoperative setting (STAI-X-1 score 34) to a greater extent even than orally administered midazolam (STAI-X-1 score 36) (P<0.001). In addition, the score was better after surgery in the music group (STAI-X-1 score 30) compared to midazolam (STAI-X-1 score 34) (P<0.001). Higher effectiveness and absence of apparent adverse effects make relaxing, preoperative music a useful alternative to midazolam. In addition, there is sufficient practical evidence of stress reduction suggesting that a proposed regimen of listening to music while resting in bed after open-heart surgery is important in clinical use. After 30 min of bed rest, there was a significant difference in cortisol levels between the music (484.4 mmol/l) and the non-music group (618.8 mmol/l) (P<0.02). Vocal and orchestral music produces significantly better correlations between cardiovascular and respiratory signals in contrast to uniform emphasis (P<0.05). The most benefit on health in intensive care medicine patients is visible in classical (Bach, Mozart or Italian composers) music and meditation music, whereas heavy metal music or techno are not only ineffective but possibly dangerous and can lead to stress and/or life-threatening arrhythmias, particularly in intensive care medicine patients.
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