Biomedical subjects
Publications and source records attributed to Anil Agarwal.
IMPLICATIONS: Nasogastric tube placement can cause ulceration and bleeding from the nose, pharynx, esophagus, and stomach. Its accidental placement into the tracheopulmonary system may lead to pneumothorax, hemothorax, or even death. We report a case of its knotting over the epiglottis, leading to life-threatening respiratory distress.
UNLABELLED: Pain syndromes of Guillain-Barré are neuropathic as well as nociceptive in origin. We aimed to evaluate the therapeutic efficacy of gabapentin in relieving the bimodal nature of pain in Guillain-Barré syndrome in a randomized, double-blinded, placebo-controlled, crossover study in 18 patients admitted to the intensive care unit for ventilatory support. Patients were assigned to receive either gabapentin (15 mg. kg(-1). d(-1) in 3 divided doses) or matching placebo as initial medication for 7 days. After a 2-day washout period, those who previously received gabapentin received placebo, and those previously receiving placebo received gabapentin as in the initial phase. Fentanyl 2 micro g/kg was used as a rescue analgesic on patient demand or when the pain score was >5 on a numeric rating scale of 0-10. The numeric rating score, sedation score, consumption of fentanyl, and adverse effects were noted, and these observed variables were compared. The numeric pain score decreased from 7.22 +/- 0.83 to 2.33 +/- 1.67 on the second day after initiation of gabapentin therapy and remained low during the period of gabapentin therapy (2.06 +/- 0.63) (P < 0.001). There was a significant decrease in the need for fentanyl from Day 1 to Day 7 during the gabapentin therapy period (211.11 +/- 21.39 to 65.53 +/- 16.17 [ micro g]) in comparison to the placebo therapy period (319.44 +/- 25.08 to 316.67 +/- 24.25 [ micro g]) (P < 0.001). IMPLICATIONS: Gabapentin, an antiepileptic drug, has been used effectively for different types of pain management. This study demonstrates that gabapentin has minimal side effects and is an alternative to opioids and nonsteroidal antiinflammatory drugs for management of the bimodal nature of pain of Guillain-Barré Syndrome patients.
UNLABELLED: Percutaneous tracheostomy with single-step dilation technique using Griggs' guidewire dilating forceps (GWDF) is a well-recognized procedure. Recently, Ciaglia has introduced a one-step dilation technique using a curved, gradually tapered dilator, the Ciaglia Blue Rhino (CBR). In a prospective, randomized study, we performed percutaneous tracheostomy in 60 consecutive patients, using either the CBR or the GWDF technique. Postoperatively, all patients had bronchoscopy by a blinded consultant, and stoma characteristics and injuries to the trachea were studied. Mean tracheostomy time (skin incision to insertion of tracheostomy tube) in the two procedures (CBR 7.5 min versus GWDF 6.5 min) was not different (P > 0.05). The GWDF technique was associated with under-dilation and over-dilation of the tracheal stoma, each in almost one-third of patients. In the CBR group, the procedure was associated with a significant increase in peak airway pressure (P < 0.05) in all patients. There were nine cases of tracheal cartilage rupture, three cases of longitudinal tracheal abrasion, and one pneumothorax. Three patients had tracheal in-drawing at the scar site with huskiness of voice at 8 wk after decannulation; however, none had any breathing difficulty. We conclude that the techniques are equally effective in the formation of percutaneous tracheostomy. However, tracheal stoma over-dilation with GWDF and increase in peak airway pressure and rupture of tracheal rings with CBR remain major concerns. IMPLICATIONS: The tracheas of 60 patients were cannulated through an artificial opening by using a single-step dilation technique with Ciaglia Blue Rhino or Griggs' dilation forceps. The techniques were equally effective for cannulation of the trachea. However, Ciaglia Blue Rhino was associated with rupture of tracheal rings in one-third of patients and increased airway pressure in all, whereas the Griggs' technique was associated with under- or over-formation of the tracheal opening, each in one-third of patients.
OBJECTIVE: To report a case of hepatitis E-induced fulminant hepatic failure associated with typhoid fever, diagnosed with the Widal test. DESIGN: Case report. SETTING: Eight-bed medical/surgical intensive care unit of a university hospital. PATIENT: A 15-yr-old, 50-kg male with grade IV hepatic encephalopathy was admitted to the intensive care unit for ventilatory support. On admission to the intensive care unit he had had fever associated with loss of appetite and nausea for 15 days, jaundice for 4 days, and altered sensorium for 2 days. INTERVENTION: He was intubated and kept on elective ventilation. Tracheal aspirate, blood, urine, and stool were sterile. Anti-coma measures were instituted in the form of 20 degrees head elevation; mannitol, lactulose, and ampicillin through a nasogastric tube; and bowel wash. The mainstay of fluid therapy was 20% dextrose. Viral marker was positive for hepatitis E. He showed a favorable recovery but continued to have high-grade fever (39-40 degrees C). On investigation, peripheral blood smear was negative for malarial parasite, and Widal was positive. Fever responded to treatment with Ceftazidime. RESULT: The patient recovered with anti-coma and anti-typhoid therapy. CONCLUSION: In viral hepatitis, fever is usually present in the prodromal phase but subsides before appearance of the icteric phase. In endemic areas, if fever is present in the icteric phase of hepatitis, typhoid also should be considered in the differential diagnosis of fever, even in the absence of positive cultures for Salmonella typhi. The Widal test may be helpful in reaching a diagnosis.
Small-scale industrial enterprises play a highly important role in the development of countries such as India and China since they tend to be labour-intensive, contribute to decentralised industrial development, and are flexible and responsive to emerging demands. However they also often use outdated and highly polluting technologies and, operating in very competitive environments, have very limited financial reserves to invest in "non-productive" pollution control technologies. There has been very little research anywhere into low-cost pollution-control technologies or more applicable pollution control strategies for this sector.
To find out the incidence of self-extubation in intensive care, to evaluate the factors responsible for it and to identify the predictors of need for re-intubation, a retrospective analysis was conducted among 350 patients who were admitted to the intensive care unit over a two-year period and required ventilatory therapy for more than 48 hours. In all patients who self-extubated, the demographic data, ventilatory parameters before self-extubation (mode of ventilation, inspired oxygen concentration, positive end-expiratory pressure), partial pressure of oxygen in arterial blood and inspired oxygen fraction ration (PaO2/FiO2), and the event of re-intubation were noted. These values were compared among patients who were re-intubated and those who were not. Twelve patients out of 350 self-extubated. Of these 12 patients, 7 required re-intubation while 5 did not. Of these 7 patients, 3 died within 48 hours of the episode of self-extubation and one patient's death was directly attributable to self-extubation. Of the remaining 4 patients, 3 died within a span of 7 days. Re-intubation after self-extubation should not be considered mandatory. Patients who required re-intubation had lower PaO2/FiO2 than patients who did not.
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PURPOSE: To compare the efficacy of acupressure wrist bands and ondansetron for the prevention of postoperative nausea and vomiting (PONV). METHODS: One hundred and fifty ASA I-II, patients undergoing elective laparoscopic cholecystectomy were included in a randomized, prospective, double-blind and placebo-controlled study. Patients were divided into three groups of 50. Group I was the control; Group II received ondansetron 4 mg iv just prior to induction of anesthesia; in Group III acupressure wristbands were applied at the P6 points. Acupressure wrist bands were placed inappropriately in Groups I and II. The acupressure wrist bands were applied 30 min prior to induction of anesthesia and removed six hours following surgery. Anesthesia was standardized. PONV were evaluated separately as none, mild, moderate or severe within six hours of patients' arrival in the postanesthesia care unit and then at 24 hr after surgery by a blinded observer. If patients vomited more than once, they were given 4 mg ondansetron iv as the rescue antiemetic. Results were analyzed by Z test. A P value of < 0.05 was taken as significant. RESULTS: The incidence of PONV and the requirement of rescue medication were significantly lower in both the acupressure and ondansetron groups during the first six hours. CONCLUSION: Acupressure at P6 causes a significant reduction in the incidence of PONV and the requirement for rescue medication in the first six hours following laparoscopic cholecystectomy, similar to that of ondansetron 4 mg iv.
In contrast to hemodialysis (HD), peritoneal dialysis (PD) remains an underutilized form of renal replacement therapy in the United States. Although a variety of factors have been deemed responsible, timely insertion of a PD catheter may also be a contributory factor. We conducted a multicenter analysis to examine whether the establishment of a program for PD catheter insertion by nephrologists has a positive impact on the growth in the number of patients using PD. Data for catheter insertion performed by nephrologists were collected from three centers. Any change in the prevalent PD population at each respective center was compared to the number of PD patients during the period having the traditional surgical approach. Nephrologists at the three centers used the peritoneoscopic technique and performed catheter insertion under local anesthesia. In center 1, the PD population remained stable at between 38 and 45 patients (approximately 16% of the total end-stage renal disease [ESRD] population) from 1993 to 2001. Nephrologists initiated a program for PD catheter insertion in 2001. The number of PD patients has increased to 101 (32% of the ESRD population). In center 2, the PD population remained stable at between 70 and 78 patients (approximately 17%) between 1988 and 1990. Catheter insertion by interventional nephrologists began in 1991. The number of PD patients has increased to 125 (22%). In center 3, the PD population remained at 20-30 patients (approximately 18%) between 1988 and 1991. Catheter placement by nephrologists was initiated in 1991. The number of PD patients increased to 97 (27%). Catheter insertion by interventional nephrologists was suspended in 2001. The number of PD patients has gradually declined to 25 (6%). This study suggests that catheter insertion by the nephrologist can have a positive impact on the utilization of PD.
A 14-year-old male presented with abdominal pain, diarrhoea and a sensation of something prolapsing through the anus during defecation, and was found to have diffuse colonic polyposis. There was no evidence of mucocutaneous hyperpigmentation and family history was negative, suggesting a diagnosis of non-familial juvenile polyposis. Histological analysis of multiple endoscopic biopsies showed features typical of juvenile or retention type (hamartomatous) lesions: dilated cystic glands lined by mucocus-secreting epithelium and prominent, inflamed and congested lamina propria. However, admixed with these features, focal areas of atypical adenomatous changes were recognized. Even the intervening normal-looking colonic mucosa showed some dysplastic changes. These findings indicate that hamartomatous and atypical adenomatous epithelial changes can co exist in non-familial juvenile polyposis and the latter may confer a risk of malignant transformation in this otherwise non-neoplastic disease.