Optimal Site for Precordial Stethoscope Placement in Pediatric Patients Younger than Two Years: A Preliminary Cross-sectional Study

Background: The precordial stethoscope is a traditional and non-invasive monitoring method during pediatric general anesthesia. In this preliminary cross-sectional study, we aimed to investigate the characteristics of lung and heart sounds via precordial stethoscope and determine the optimal site for auscultation in children below 2 years of age. Methods: This study involved 68 patients who underwent general anesthesia with tracheal intubation. Auscultation sounds via precordial stethoscope were recorded in MP3 format at the following three sites: Site A-region between the clavicle and nipple on the left midclavicular line; Site B-region between the nipple and costal arch on the left midclavicular line; and Site C-point on the left midaxillary line that was horizontally leveled with Site B. Eight blinded evaluators individually and randomly scored lung and heart sounds on a 10-point scale (0: cannot hear at all and 10: can hear clearly). Results: Lung sound scores at Sites A, B, and C were 8.0 (7.0–9.0), 4.5 (2.9–6.0), and 7.0 (5.5–8.5), respectively, while heart sound scores at Sites A, B, and C were 3.5 (2.0–6.0), 6.5 (4.0–8.0), and 1.0 (0.4–2.0), respectively. Statistically significant differences were found in all pairs of sites. Conclusion: We suggest that Site A, where anesthesiologists can hear both the lung and heart sounds, is the optimal site of precordial stethoscope attachment during general anesthesia for intubated children below 2 years of age.

Right axillary minithoracotomy: An alternative access to close an ASD

A vertical right axillary thoracotomy is a favorable alternative to a median sternotomy for surgical correction of common congenital heart defects in patients of all ages. The right-sided heart structures can be approached through a 4- to 5-cm vertical incision in the midaxillary line. In contrast to a midline sternotomy, osseous thoracic structures can be preserved through a muscle-sparing approach simply by retracting the ribs. Consequently, recovery is usually faster, and the resulting scar is completely hidden under the resting arm. In addition, there is no need for special equipment. The entire operation can be performed with established techniques. Operative outcome and long-term results have been shown by several research groups to be comparable to those obtained with a median sternotomy. This tutorial demonstrates the stepwise performance of an axillary thoracotomy and the extracorporeal circulation setup by the example of the closure of an atrial septal defect.

Comparison of Diaphragmatic Stretch Technique and Manual Diaphragm Release Technique on Diaphragmatic Excursion in Chronic Obstructive Pulmonary Disease: A Randomized Crossover Trial

Background. Chronic Obstructive Pulmonary Disease (COPD) impairs the function of the diaphragm by placing it at a mechanical disadvantage, shortening its operating length and changing the mechanical linkage between its various parts. This makes the diaphragm’s contraction less effective in raising and expanding the lower rib cage, thereby increasing the work of breathing and reducing the functional capacity. Aim of the Study. To compare the effects of diaphragmatic stretch and manual diaphragm release technique on diaphragmatic excursion in patients with COPD. Materials and Methods. This randomised crossover trial included 20 clinically stable patients with mild and moderate COPD classified according to the GOLD criteria. The patients were allocated to group A or group B by block randomization done by primary investigator. The information about the technique was concealed in a sealed opaque envelope and revealed to the patients only after allocation of groups. After taking the demographic data and baseline values of the outcome measures (diaphragm mobility by ultrasonography performed by an experienced radiologist and chest expansion by inch tape performed by the therapist), group A subjects underwent the diaphragmatic stretch technique and the group B subjects underwent the manual diaphragm release technique. Both the interventions were performed in 2 sets of 10 deep breaths with 1-minute interval between the sets. The two outcome variables were recorded immediately after the intervention. A wash-out period of 3 hours was maintained to neutralize the effect of given intervention. Later the patients of group A and group B were crossed over to the other group. Results. In the diaphragmatic stretch technique, there was a statistically significant improvement in the diaphragmatic excursion before and after the treatment. On the right side, p=0.00 and p=0.003 in the midclavicular line and midaxillary line. On the left side, p=0.004 and p=0.312 in the midclavicular and midaxillary line. In manual diaphragm release technique, there was a statistically significant improvement before and after the treatment. On the right side, p=0.000 and p=0.000 in the midclavicular line and midaxillary line. On the left side, p=0.002 and p=0.000 in the midclavicular line and midaxillary line. There was no statistically significant difference in diaphragmatic excursion in the comparison of the postintervention values of both techniques. Conclusion. The diaphragmatic stretch technique and manual diaphragm release technique can be safely recommended for patients with clinically stable COPD to improve diaphragmatic excursion.

Comparison Between Wrist-Worn and Waist-Worn Accelerometry

Objective:To use the most recent ActiGraph model (GT9X) to compare counts per minute (CPM) estimates between wrist-worn and waist-worn attachment sites.Methods:Participants completed 2 conditions (laboratory [N = 13] and free-living conditions [N = 9]), in which during both of these conditions they wore 2 ActiGraph GT9X accelerometers on their nondominant wrist (side-by-side) and 2 ActiGraph GT9X accelerometers on their right hip in line with the midaxillary line (side-by-side). During the laboratory visit, participants completed 5 treadmill-based trials all lasting 5 min: walk at 3 mph, 3.5 mph, 4 mph, and a jog at 6 mph and 6.5 mph. During the free-living setting, participants wore the monitors for 8 hours. Paired t test, Pearson correlation and Bland-Altman analyses were employed to evaluate agreement of CPM between the attachment sites.Results:Across all intensity levels and setting (laboratory and free-living), CPM were statistically significantly and substantively different between waist- and wrist-mounted accelerometry.Conclusion:Attachment site drastically influences CPM. As such, extreme caution should be exercised when comparing CPM estimates among studies employing different attachment site methodologies, particularly waist versus wrist.

A rare gigantic primary epithelial cyst of spleen in an adolescent boy

Cysts arising from spleen are a rare clinical entity, with their discovery usually being incidental. We present a case of the largest reported primary epithelial cyst of spleen. In present study a 16-year-old child presented with abdominal distension for 1 month associated with abdominal pain for 2 weeks. On examination, a mass was felt in the epigastrium, left hypochondrium and left flank, extending across from the right midclavicular line to the left midaxillary line, and extended inferiorly till 6cm caudal to umbilicus. CT abdomen revealed a unilocular cyst of 17x20x24cm arising from the spleen with a volume of 3700ml. Splenectomy was performed; intra-operatively there was a huge splenic cyst measuring 30x30x30cm. Histopathological examination was diagnostic of Primary congenital epithelial cyst of the spleen. Till date the largest congenital splenic cyst documented in literature is 20 cm × 13 cm × 21 cm, as reported by Valentina et al, in 2014. Present specimen bests this previous case considerably.

Spontaneous Esophagopleural Fistula in A High Risk Individual (Trumpet Blower)

A middle aged male patient, trumpet blower by occupation presented with progressive dyspnea with chest heaviness for 2 weeks and low grade fever for 1 week. It started with sudden severe retrosternal chest discomfort and episodic vomiting during practicing trumpet blowing. Patient was toxic with high fever, tachycardia and tachypnoea. Clinicoradiologically patient was diagnosed as left sided hydropneumothorax. Intercostal chest tube was inserted at left 5th. intercostal space at midaxillary line following which pus and air came out. Pleural fluid was acidic with high amylase level and polymicrobial growth. Repeat chest x-ray showed partial resolution of left sided hydropneumothorax. From 4th. day food particles were noticed in the drainage bag. For screening 0.1% sterile methylene blue was given orally which came in ICD tube and bag within 24 hours. Subsequently barium swallow esophagus, CT thorax with oral and intravenous contrast and upper gastrointestinal endoscopy confirmed left sided esophagopleural fistula.Bangladesh J Medicine Jan 2017; 28(1) : 41-45

Pneumothorax in a Patient Posted for Cervical Spine Surgery

ABSTRACT A 54-year-old female posted for cervical laminectomy was started on antihypertensive drugs on admission. Magnetic resonance imaging showed cervical degeneration with posterior disk herniation at C3—C4 and disk bulge at L5—S1. After attaching the monitors, patient was premedicated and anesthetized. During mask ventilation, abdomen gradually distended. After intubation under vision, reduced air entry on right side and increased resistance was felt during manual ventilation. Salbutamol puff was given through endotracheal tube. Still air entry remained decreased on right side. X-ray and C-arm showed right-sided pneumothorax. Inter-costal drainage (ICD) was inserted in right 5th intercostal space in midaxillary line. Post-ICD X-ray showed significant expansion of right lung. Patient was ventilated and extubated after 4 hours. Highresolution computerized tomography confirmed the diagnosis. Surgery was rescheduled. On the 8th day, patient developed purulent drainage through ICD in the ward. She was diagnosed to have pulmonary Koch's and was treated successfully. How to cite this article Dalvi NP, Virkar ND. Pneumothorax in a Patient Posted for Cervical Spine Surgery. Res Inno Anaesth 2016;1(1):32-34.