INTRODUCTION Retinoblastoma is the most common intraocular malignancy of early childhood. At least 9 out of 10 afflicted children will be diagnosed before the age of 5, with the median age at diagnosis being 2 years (1). For retinoblastoma to occur there must be mutational changes in both active copies of the tumor suppressing retinoblastoma (RB1) gene, which maps to the chromosome locus 13q14.2 and is responsible for production of a nuclear protein with regulatory function in the cellular growth cycle (2). According to Knudson et al., the pathogenesis of retinoblastoma follows a “two-hit” model, accounting for differences in the presentations of hereditary and nonhereditary cases. In the hereditary form, the first mutation takes place in germline cells and is present in all cells of the patient; a second “hit” occurs within somatic retinal cells (3). Patients with germline disease more commonly have bilateral and multifocal tumors and appear to be at an increased risk of developing secondary tumors, including soft tissue and bone sarcomas (4, 5). Leukocoria and strabismus are the most common presenting findings in the children with retinoblastoma but do not necessarily have to be present for diagnosis (6, 7). Diagnosis is usually made with dilated indirect fundoscopy under anesthesia and the detection of a white-gray colored retinal mass or several tumors; pathology is needed to confirm the diagnosis (8). Ancillary tests, including MRI and ocular ultrasonography, may be performed to contribute to workup and prognostication (9). In the last decade, intra-arterial (IA) chemotherapy for the treatment of intraocular retinoblastoma has gained wide interest as a treatment modality in patients with advanced disease (Reese Ellsworth ... ... middle of paper ... ...ns, premedication with dexamethasone and benadryl had been given; however, it is important to note that premedication with a corticosteroid and/or H1/H2 antagonist has not proven to preclude anaphylaxis (22, 23). In fact, with the introduction of IA carboplatin, epinephrine doses ranging from 2 mcg to 8 mcg were administered for sharp declines in tidal volumes likely heralding bronchospasm. Neither hypoxia nor bradycardia was documented prior to or following epinephrine treatment. The decision to rechallenge the patient with IA carboplatin was based on its potential clinical benefits of reducing retinoblastoma disease burden, preserving eyesight, and sparing her from an enucleation procedure. Nevertheless, vigilance and a thorough understanding of the pathophysiology and management of anaphylaxis becomes a paramount responsibility of the anesthesiologist.
Inadvertent perioperative hypothermia is a common anesthesia-related complication with reported prevalence ranging from 50% to 90%.(ref 3,4 of 4) The clinical consequences of perioperative hypothermia include tripling the risk of morbid myocardial outcomes and surgical wound infections, increased blood loss and transfusion requirements, and prolonged recovery and hospitalization.(ref 5)
Prior to intubation for a surgical procedure, the anesthesiologist administered a single dose of the neuromuscular blocking agent, succinylcholine, to a 23-year-old female to provide muscular relaxation during surgery and to facilitate the insertion of the endotracheal tube. Following this, the inhalation anesthetic was administered and the surgical procedure completed.
Epinephrine can be added to NE if needed to maintain acceptable BP, or substituted if necessary. Vasopressin (0.03 units/min) can be used as an adjunct to increase MAP,or to lower NE dose; it should not be used as a single agent. Dopamine can be used as an alternative to NE, but only in patients meeting criteria due to risk of arrhythmias; low dose dopamine not to be used for renal protection. Phenylephrine not recommended in most cases; can be utilized if NE leads to serious arrhythmias, CO is known to be high yet BP continues to be low, or as salvage therapy when MAP target is not achieved by other means. An arterial cath should be placed ASAP in patients who require vasopressors. Inotropes can be added to vasopressors or used alone, with a doubatmine trial of up to 20 mcg/kg/min as an option if myocardial dysfunction is suspected by elevated cardiac filling pressures and low CO, or if hypoperfusion is still evident although intravascular volume and MAP are at goal. Bicarbonate should not be used in patients with pH greater than or equal to
The exact cause of hypothalamic tumors is not known. It is likely that they result from a combination of genetic and environmental factors. In children, most hypothalamic tumors are gliomas. Gliomas are a common type of brain tumor that results from the abnormal growth of glial cells, which are a type of cells that support nerve cells. Gliomas can occur at any age
Although there are very less situations which are reported with respect to the dual paracetamol peaks with sustained-release preparations. 2-5 It was studied in very detail. But it was clear-cut from the empty tablet blister packets present at the situation scene that the patient had taken just the basic-preparation paracetamol. The chance of another overdoes being done in the ICU was eradicated after a detail study. The levels of the paracetamol were assessed with the help of Roche Modular PPE using the acetaminophen assay kit K8001, K8002,6 which is famous for its good intra and interessay accuracy. It is a well known fact the increased level of lipids can obstruct with this assay. For this situation, the patient’s lipid profile was in normal range.
In my department Interventional Radiology (IR), nursing staff administers moderate sedation to patient who are undergoing minimally invasive procedures. Interventional Radiology (IR) follows the anesthesia guidelines for administering moderate sedation. The guidelines do not limit the amount of medications that are administered, if the drugs are being ordered by a supervising physician. Most, patients receive doses of fentanyl up to 100 mcg, starting with 25mcg to 50 mcg to start, and versed up to 2 mg starting with 0.25 mg to 50 mg. We have a physician new to our department who ordered higher doses of medications than what our staff is comfortable with as starting doses of the medications. This physician was routinely ordering oral agents pre-procedure and he would order Benadryl be
After a laryngeal mask airway was inserted, sevoflurane was discontinued and anesthesia was maintained using desflurane. The initial desflurane concentration was randomly assigned and ranged between 4.5 and 7.5 end-tidal volume %. Following an equilibration period of 45 minutes, noxious electrical stimulation testing began. Intradermal needles inserted bilaterally into the anterior thighs were used to deliver electrical stimulation for 10 seconds at a time at an intensity of 100 Hz, 60-70 mA. This level of stimulation is not tolerated by unanesthetized patients, but is undetected by those under general anesthesia. Response to the stimulation was evaluated by an independent investigator who was chosen randomly out of a group of four investigators for each session. Investigators were brought into the room just before the stimulation commenced. A response was considered positive if a gross purposeful movement of the arms or legs occurred within the first minute after stimulation. While the investigators were not blinded to the hair color or skin complexion of the volunteers, they were blinded to both the initial desflurane concentration as well as the desflurane concentrations for the duration of the study. Depending on if the volunteer moved or did not move in response to the electrical stimulation, desflurane was increased or decreased by 0.5
Long et al., states that numerous studies indicate that a combination therapy with drugs of different classes is more effective than a single dose treatment (2009). Also, Apfel et al., suggest in their study that increasing the number of antiemetics reduces the incidence of PONV from 52% when no medication is given to 37%, 28%, and 22% when one, two, or three anti-nausea drugs are administered (2004). Use of multiple medications to decrease the incidence of PONV will improve patient outcomes thereby reducing anxiety about surgery and increasing all around patient satisfaction. Failing to utilize such evidence could result in increased incidence of PONV; which leads to other postoperative complications. Pulmonary complications due to aspiration, wound dehiscence, hematoma development, will hurt the patient quality of life, and delay discharge from the post-anesthesia care unit (PACU); ultimately delaying discharge home (Tinsley, M. H., & Barone,
Anesthesiologists face many issues, one of the most important being drug shortages. These drug shortages are on some of the most vital anesthetics, those used on a daily basis. These shortages result in numerous problems not only for the physicians, but also for the patients because it creates different side effects and creates hazards in the hospitals. Although still developing, some solutions have risen that might help alleviate the drug shortages even though they are not as effective as expected.
Webster CS, Merry AF, Larsson L, McGrath KA, Weller J. The frequency and nature of drug administration error during anaesthesia. Anaesth Intensive Care 2001; 29: 494-500.
Previous studies used fentanyl by aerosol for postoperative analgesia and They concluded that inhaled fentanyl is an effective, safe and convenient method of analgesia which merits further investigation into such areas as mode of action and method of administration6. Similarly, we also found good analgesic effect of fentanyl by instillation via intranasal route in doses of 2mcg/kg without any significant adverse effect. J M Malinovsky et al (1996)7did a study in which during halothane anaesthesia, 32 children, aged 2-9 year, weight 10-30 kg were allocated randomly to receive ketamine 3 mg kg-1 nasally (group IN3) or ketamine 9 mg kg-1 nasally (group IN9); ketamine 9 mg kg-1 rectally (group IR9); or ketamine 3 mg kg-1
Childhood cancers are often the result of deoxyribonucleic acid (DNA) changes in cells very early in life, sometimes even before birth (American Cancer Society, 2018). The cause of Wilms’ Tumor has remained virtually unknown to doctors and researchers; nevertheless, they have made great progress in understanding typical and atypical kidney development (American Cancer Society, 2018). The kidneys develop early in the fetal stage of development. Mutations in certain genes in early kidney cells can be problematic during development (American Cancer Society, 2018). Some cells that are to develop fully into mature kidney cells occasionally remain early cells. If the maturation of the cells does not happen, the cells may begin to grow out of control, resulting nephroblastoma (American Cancer Society,
How does one see the symptoms for childhood cancer? First one must know that there are many different types. There are forty different types of children’s cancer, including: Leukemia, Lymphoma, Sarcomas, cancers of the nervous system, liver cancers, kidney cancer, and more. Out of these cancers, the two most common childhood cancers are Leukemia, and brain tumors. What is leukemia? It is a cancer in which the bone marrow and other organs that produce blood produce and increased amount of immature or abnormal white blood cells. The symptoms of leukemia are paleness, excessive bruising, pain in the joints, and fatigue. Brain tumors are formed when a massive amount of cells are produced on the brain. The symptoms for this are frequent headaches, vomiting, seizures, decreased coordination, weakness, and problems concerning vision.
In conclusion, early diagnosis followed by an appropriate airway intervention is essential to prevent cardiac arrest or irreversible brain damage that occurs within minutes of complete airway obstruction. Although the conventional techniques remains standard option, every physician has to be familiar with the process of evaluating a difficult airway and, in the event of the unanticipated difficult airway and be able to use a wide variety of techniques to avoid complications and fatality. Airway management of the patient requires a coordinated effort from other consultants or colleagues, if available, can be the key to success in some circumstances.
Pharmacology is a vital component in the perioperative practice. Medication use is monitored closely during the perioperative period. Preoperatively, there are certain drugs that must be discontinued prior to a surgery as they increase surgical risk, including anticoagulants, tranquillisers, corticosteroids and diuretics (Laws, 2010b). In fact, these drugs can increase the risk of respiratory depression, infection, fluid and electrolyte imbalance and increased risk of bleeding (Hamlin, 2010). Open communication is important in obtaining a medication history, and in identifying the drugs taken prior to the surgery. If any of these medications has be...