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postoperative arrhythmias related to an esophagectomy is
13-64% and this is further aggravated by atrial or pulmonary
vein inflammation.[4,5] The presence of organized thrombus in
our patient possibly lead to inflammation and perioperative
arrhythmias. The presence of thrombus in the heart after a
myocardial infarction requires anticoagulation but there are
no recommendations for anticoagulation for an organized
atrial thrombus in absence of history of myocardial infarction
or atrial fibrillation.[6]
To conclude, presence of asymptomatic clot should be taken
seriously and the possibility of all the complications which can
arise should be discussed preoperatively and measures to treat
those complications should be available before anesthetizing
such patients.
Rakesh Garg1, Alka Bhatnagar2,
Sushma Bhatnagar3, Seema Mishra4
1
Assistant Professor, 2Senior Resident, 3Additional Professor and
Head, 4Additional Professor, Department of Anaesthesiology, Pain
and Palliative Care, Dr. BRAIRCH, All India Institute of Medical
Sciences, New Delhi, India
Address for correspondence: Dr. Rakesh Garg,
35, DDA Flats, East Punjabi Bagh, New Delhi - 110 026, India.
E-mail: drrgarg@hotmail.com
References
1. Agmon Y, Khandheria BK, Gentile F, Seward JB. Clinical and
echocardiographic characteristics of patients with left atrial thrombus
and sinus rhythm: Experience in 20 643 consecutive transesophageal
echocardiographic examinations. Circulation 2002;105:27-31.
2. Alexander GR, Reddi A, Reddy D. Idiopathic pulmonary vein
thrombosis: A rare cause of massive hemoptysis. Ann Thorac Surg
2009;88:281-3.
3. Cipriano PR, Guthaner DF. Organized left atrial mural thrombus
demonstrated by coronary angiography. Am Heart J 1978;96:166-9.
4. Hahm TS, Lee JJ, Yang MK, Kim JA. Risk factors for an intraoperative
arrhythmia during esophagectomy. Yonsei Med J 2007;48:474-9.
5. Ma JY, Wang Y, Zhao YF, Wu Z, Liu LX, Kou YL, et al. Atrial
fibrillation after surgery for esophageal carcinoma: Clinical and
prognostic significance. World J Gastroenterol 2006;12:449-52.
6. European Heart Rhythm Association; European Association for
Cardio-Thoracic Surgery, Camm AJ, Kirchhof P, Lip GY, Schotten U,
et al. Guidelines for the management of atrial fibrillation: The task
force for the management of atrial fibrillation of the European
Society of Cardiology (ESC). Eur Heart J 2010;31:2369.
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DOI:
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302 Journal of Anaesthesiology Clinical Pharmacology | April-June 2014 | Vol 30 | Issue 2
The fatigued anesthesiologist:
Improve operating room
climate to minimize effect of
residual anesthetics
Sir,
We read with interest The fatigued Anesthesiologist: A threat
to patient safety? by Sinha et al.[1] Authors have highlighted
in detail professional hazards of prolonged working hours. It
is noteworthy that anesthesiology organizations have come
forward with strategies to cope up with sleepiness and other
fatigue management plans to ensure patient safety. Editorial
Maximum working hours and minimum monitoring standards-
need for both to be mandatory[2] further enlightens us with
the methods to improve attention span of the anesthesiologists
by optimizing working hours per day/per week.
We wish to emphasize upon the need of scavenging facilities
in the operating rooms. Exhaustion after days work is directly
proportional to the operating room environment, surgery
proposed, type of anesthesia required, physical status of the
patient and anesthesia equipment used. Tank et al.[3] used
volatile anesthetic absorbers to detect amount of sevoflurane
absorbed during intracerebral surgery. Authors reported that
absorbers placed in the proximity of patients breathing zone
captured maximum amount of sevoflurane (1.54 0.55
parts per million [ppm]), followed by the detectors placed
near the anesthesiologist (1.14 0.43 ppm). Surgeons
exposure to volatile anesthetics was six-fold less compared to
the anesthesiologist. (0.15 0.05 ppm). This observation
of different risk stratification according to professional work
have been recently verified in a study by Zaffina et al.,[4]
where multi-point sampling method for environmental
monitoring was used. To minimize exposure to inhalational
anesthetics use of double masks or anesthesia hoods has
been suggested.[5,6] Alternatively, use of Total Intravenous
Anesthesia or regional anesthesia techniques (wherever
feasible) should be encouraged.[7] However, these issues have
not been widely addressed in pediatric OR and literature from
developing countries is scanty.[8,9] In 1999, Marsh et al.[10]
conducted a postal survey of consultant Pediatric Anesthetists
to find out anesthesia and scavenging techniques used in
neonates, infants and older children (less than 20 kg). Authors
reported that T-Piece remains the commonest breathing system
used in smaller children and 60% respondents of survey used
scavenging system with T-piece. Thus, an anesthesiologist
working in a poorly ventilated pediatric operating room (OR)
with open/semi-open anesthesia circuit and no scavenging
facilities is more likely to be exposed to waste gas residues
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compared to the one working in an OR with appropriate
facilities for removal of exhaled anesthetics. Similarly, if there
is rapid turn-over of cases requiring inhalational anesthetics,
anesthesia providers are more likely to be dosing themselves
and get exhausted early. Thus, the effect of residual anesthetics
on the occupational performance, driving capabilities and
sleep behavior of pediatric anesthesia providers in developing
countries needs further evaluation. Keeping these in mind,
national societies should take adequate measures to ensure
the safety of one and all working in operating areas.
Indu Sen, Randeep Kaur
Department of Anesthesia and Intensive Care, Post Graduate Institute
of Medical Education and Research, Chandigarh, India
Address for correspondence: Dr. Indu Sen,
Department of Anesthesia and Intensive Care, PO Box No. 1519,
PGI Campus, Sector - 12-A, Chandigarh - 160 012, India.
E-mail: indumohini@gmail.com
References
1. Sinha A, Singh A, Tewari A. The fatigued anesthesiologist:
A threat to patient safety? J Anaesthesiol Clin Pharmacol
2013;29:151-9.
2. Trikha A, Singh PM. Maximum working hours and minimum
monitoring standards-need for both to be mandatory. J Anaesthesiol
Clin Pharmacol 2013;29:149-50.
3. Tank B, Molnr C, Budi T, Peto C, Novk L, Flesdi B. The
relative exposure of the operating room staff to sevoflurane during
intracerebral surgery. Anesth Analg 2009;109:1187-92.
4. Zaffina S, Camisa V, Poscia A, Tucci MG, Montaldi V, Cerabona V, et al.
Occupational exposure to sevoflurane in pediatric operating rooms: The
multi-point sampling method for risk assessment. [Article in Italian].
G Ital Med Lav Ergon 2012;34(Suppl 3):266-8.
5. Kurrek MM, Dain SL, Kiss A. Technical communication: The effect
of the double mask on anesthetic waste gas levels during pediatric
mask inductions in dental offices. Anesth Analg 2013;117:43-6.
6. Panni MK, Corn SB. The use of a uniquely designed anesthetic scavenging
hood to reduce operating room anesthetic gas contamination during
general anesthesia. Anesth Analg 2002;95:656-60.
7. Irwin MG, Trinh T, Yao CL. Occupational exposure to anaesthetic
gases: A role for TIVA. Expert Opin Drug Saf 2009;8:473-83.
8. Bihari V, Srivastava AK, Gupta BN. Occupational health hazards
among operation room personnel exposed to anesthetic gases: A
review. J Environ Pathol Toxicol Oncol 1994;13:213-9.
9. Oliveira CR. Occupational exposure to anesthetic gases residue.
[Article in English, Portuguese]. Rev Bras Anestesiol 2009;59:110-24.
10. Marsh DF, Mackie P. National survey of pediatric breathing systems
use in the UK. Pediatri Anaesth 2009;19:477-80.
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DOI:
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Journal of Anaesthesiology Clinical Pharmacology | April-June 2014 | Vol 30 | Issue 2
Anesthetic management for
patients with perforation
peritonitis
Sir,
We read with interest a recently published review article by
Sharma et al. entitled, Anesthetic management for patients
with perforation peritonitis.[1] There are some issues that
can affect the anesthesia management and outcome hence
need discussion:
1. There is just a passing remark that Abnormalities in
electrolyte balance and acid base balance should be
corrected. The causes of these abnormalities and their
anesthetic implications need elaboration. Hypokalemia
(in addition to chloride loss) may be caused by
vomiting, nasogastric tube (NGT) aspiration, or
prolonged inadequate intake in patients with intestinal
perforation, whereas hyperkalemia could be due to
hypotensive metabolic acidosis or renal insufficiency.[2]
Similarly, metabolic acidosis could be due to shock or
decrease renal functions while prolonged nasogastric
aspiration in such patients may cause mixed metabolic
disorder. Inadvertent intraoperative hyperventilation
can further complicate the picture by worsening the
hypokalemia. As these metabolic and electrolyte
derangements can cause arrhythmias, hemodynamic
disturbances and delayed recover y, preoperative
blood gas and electrolyte estimation and simultaneous
correction is important.
2. The authors have mentioned that hemoglobin (Hb)
should be raised by packed cell infusion and kept close
to 11 g/dl The authors have failed to mention the
source of this statement. In fact this may encourage
unnecessary transfusions and associated complications
(including worsening of sepsis and organ failure). The
intraoperative blood loss in such patients is generally
small and transfusion should be considered only when
the Hb levels are below 7 g/dl as per Surviving Sepsis
guidelines[3] recommendations, with a target to achieve
7-9 g/dl level. Only in patients with myocardial ischemia,
severe hypoxemia or acute hemorrhage, Hb levels are
recommended to be kept above 10 g/dl.
3. The authors have mentioned a lot about the antibiotic
therapy, but have not mentioned anything about fungal
infections. The patients with perforation peritonitis may
also have intra-abdominal fungal infection, which has a
poor prognosis and early recognition and treatment is
advisable which is often difficult due to its nonspecific
presentation.[4]
303