Vol 1, Issue 2, April 2007
Wockhardt Hospitals - Mumbai Bangalore
Intracranial aneurysms and vascular head ache
I n sid e rheumatoid knee VATS
S
imultaneous carotid endarterectomy and
S
ome patients with
coronary artery disease
are diagnosed as having
additional carotid artery
disease. This subset of patients has
been identified as a high-risk group
for cardiac and cerebral complications
following surgical intervention.
The incidence of significant carotid
artery disease in patients undergoing
CABG varies from 8-14% and coronary
artery disease is present in more than
40% of patients who meet the
indications for carotid endarterectomy.
Combined procedures steadily
increased since Bernhardt and
colleague’s initial report of 16 such
cases in 19721.This combined surgery
when done awake under High Thoracic
Epidural Anesthesia (HTEA) offers an
absolute neurological monitoring & fast
tracking. Presently there are no reports
of awake combined carotid
endarterectomy (CEA) with Offpump
CABG (OPCAB) under HTEA as the
sole anesthetic.
At Wockhardt Hospitals Bangalore
from Jan 2006 to Jan 2007 we have
performed combined CEA-OPCAB in
10 patients. Age varied from 65yrs to
Kolkata Hyderabad Nagpur Rajkot Surat
Thrombolysis in stroke Total knee replacement in severely deformed
Congenital Diaphragmatic Hernia (CDH) ARDS Toxic shock syndrome News Room
off pump coronary artery
bypass surgery (Awake)
74yrs. There were 3 females & 7 males.
Four patients had symptoms of TIA and
one off them had a cerebral infarct on ECA
CT brain. All patients underwent a
carotid MRI to access the nature & CCA Vein patch
ICA
extent of block. Those who had more
than 90% stenosis with no symptoms
& symptomatic patients underwent
CEA with OPCAB. All required triple
vessel bypass. All underwent CAE Post endartectomy picture
with OPCAB under high Thoracic
Epidural Anesthesia, which is the best
monitor for brain function during
carotid endarterectomy. We have
already reported 520 awake cardiac
surgeries done under HTEA as sole
anesthetic7, 8. Hence the anesthesia
protocols have been well
standardised.
Picture of endartectomy specimen
RESULT
DISCUSSION
None of these patients had any
neurological events or mortality. One Combined procedures steadily
female patient needed a rexploration increased since Bernhardt and
of the neck wound for hematoma. colleague’s initial report of 16 such
There were no perioperative cases in 19721. The incidence of CVA
myocardial infarctions. Average in patients undergoing combined CEA-
hospital stay was 6 days. All patients CABG surgery is equivalent to those
remained in the ICU for one day. with asymptomatic patients
There were no major wound infections. undergoing isolated CABG, but much
 Bispectral index
correlates with
clinical measures of
hypnosis, sedation,
reduced cerebral
metabolic rate, and
also cerebral
hypo-perfusion.
lower than that of patients with
symptomatic carotid stenosis
undergoing isolated CABG surgery.
Combined CEA-CABG surgery should
be reserved for those patients who
have symptomatic or asymptomatic
severe carotid artery stenosis and
require coronary revascularisation2.
There continues to be a dilemma
regarding the best means of surgical
management of significant carotid
artery disease in patients requiring
coronary artery bypass surgery.
A combined approach of coronary
artery bypass and carotid
endarterectomy has shown good
results in patients with concomitant
carotid and coronary artery disease and
3 2003 Feb; 17:84-6
off pump techniques .
The incidence of significant carotid
artery disease in patients undergoing
CABG varies from 8-14% and coronary
artery disease is present in more
than 40% of patients who meet
the indications for carotid
4 and OPCAB. None of our patients had
endarterectomy . Kallikazaros et al.
found that the frequency of significant
carotid artery disease increased from
5% in patients with 1- vessel disease
to 25% in 3-vessel disease and
reached 40% in patients with left main
5
stem stenosis . Pre-operative stroke
risk is considered to be less than 2%
when carotid stenosis are below 50%,
10% when stenosis are 50–80% and
11–19% in patients with stenosis over
80%. Patients with untreated bilateral
high-grade stenosis and/ or occlusions
have a 20% chance of stroke. Thus,
the American College of Cardiology
(ACC) and the American Heart
Association (AHA) guidelines for
CABG recommend carotid
1
endarterectomy in asymptomatic
patients with severe carotid
6
artery disease .
Neurological monitoring is an
important part of safe CEA.
The various methods of monitoring
are electroencephalography (EEG),
somatosensory-evoked potential
(SSEP), transcranial doppler (TCD),
ICA stump pressure, regional cerebral
O2 saturation (rSO2), bispectral index
(BIS) and serial neurologic
assessments during regional
anesthesia. Detection of cerebral
hypo-perfusion by any of these
methods will guide for immediate
placement of intra-luminal shunt. BIS
is a single number that incorporates
information of EEG power and
frequency, and also includes
information regarding activation, burst
suppression, and bicoherence. It can
provide more information regarding
interactions between cortical and sub-
cortical neuronal generators.
BIS correlates with clinical measures
of hypnosis, sedation, reduced
cerebral metabolic rate, and also
cerebral hypo-perfusion.
The best possible monitoring of the
brain would be the patient, where he
is conscious, responds to commands,
there by moving his arms and legs at
command, or he would become
restless due to hypo-perfusion of brain
or would develop weakness of contra-
lateral side when a shunt could be
placed immediately only to observe
full recovery of motor power, which
are the added benefits of awake CEA
a stroke during immediate
postoperative period or during follow
up. There was no mortality or
morbidity due to the procedure.
CONCLUSION
Combined procedure does not add any
significant extra risk on mortality or
morbidity as compared to stage
procedure and is cost effective. The
same when done under Continuous
High Thoracic Epidural Analgesia
(Awake) offers absolute neurological
monitoring and aids fast tracking.
This is world’s initial experience of
awake off pump CABG combined with
Carotid endarterectomy.
REFERENCE
1. Bernhard V M,Johnson W D, Peterson J J Carotid
A Stenosis Associates with surgery for CAD Arch
Surg 1972 105:837-40
2. Cannadian Cardiovascular CongressPoster
Session: Surgery 413 Is combined carotid
endarterectomy and CABG justifiable in patients
with symptomatic carotid stenosis? MC Moon, DH
Freed, ML Brown, EA Pascoe, G Louridas Winnipeg,
Manitoba
3. Concomitant Carotid Endarterectomy and
Coronary Bypass Surgery: Outcome of On-Pump
and Off-Pump Techniques Yugal Mishra, PhD,
Harpreet Wasir, MCh, Vijay Kohli, MCh, Zile Singh
Meharwal, MCh, Rajneesh Malhotra, MCh, Yatin
Mehta, MD, Naresh Trehan, MD Ann Thorac Surg
2004; 78:2037-2042
4. Borger MA, Fremes SE, Weisel RD, et al. Coronary
bypass and carotid endarterectomy: Does a
combined approach increase risk? Ameta-
analysis. Ann Thorac Surg 1999; 68:14-21.
5. Kallikazaros I, Tsioufis C, Sideris S,
Stefanadis C, Toutouzas P. Carotid
artery disease as a marker for the
presence of severe coronary artery
disease in patients evaluated for chest
pain. Stroke 1999; 30:1002-7.
6. Eagle KE, Guyton RA, Davidoff R, et al. ACC/AHA
guidelines for coronary artery bypass graft
surgery: Executive summary and
recommendations: A report of the ACC/AHA task
force on Practice Guidelines (Committee to
revise the 1991 guidelines for Coronary Artery
Bypass Graft Surgery). Circulation 1999;
100:1468-80.
7. High thoracic epidural anesthesia as sole
anesthetic for redo off-pump coronary artery
bypass surgery. J Cardiothoracic Vasc Anesth:
8. Conscious Off-Pump Coronary Artery Bypass
Surgery Indian Heart Journal Jan - Feb 2005; 57:
(1) 49-53
Courtesy:
Dr. Vivek Jawali,
M.S., M.Ch., DNB, FIACS
Chief Cardiovascular and Thoracic Surgeon
Dr. Ganeshakrishnan Iyer,
M.S., M.Ch.
Dr. Devananda N S,
M.S., M.Ch.
Dr. K N Srinivasan,
M.S., M.Ch.
Dr. Murali Manohar V,
M.S, DNB (CVTS), FIACS
Department of Cardiovascular
and Thoracic Surgery.
Wockhardt Hospitals, Bangalore
 I ntracranial aneurysms and
vascular head ache
H
eadache remains the
most common pain for
which an adult seeks
medical attention and
vascular (migraine) headache is one of
the most common varieties. It is not
very unusual for individuals suffering
from common varieties of chronic
headache like migraine to have or
develop other structural lesions like brain
tumor, cerebral aneurysms and AVMS
or meningitis as a cause for worsening
or change in pattern of headache. The
intracranial aneurysms usually present
with subarachnoid haemorrhage (SAH)
causing sudden onset intense headache
associated with nausea, vomiting and
most often unconsciousness.
Subsequent events following a major
SAH lead to a neurological status
demanding immediate hospitalisation.
In a small (<25%) of there may be minor
warning leak and in some cases several
episodes which may be often
mistakenly passed of as vascular
headache or migraine. This may lead to
a catastrophic SAH within three months,
which is very much preventable if
diagnosed and treated early. Here we
present an illustrative case of left Middle
Cerebral Artery (MCA) bifurcation
aneurysm presenting as probable
warning leak spread over 2 years with
background history of classical migraine.
CASE REPORT
Mrs S, 36 year -old, non diabetic, non
hypertensive IT professional presented
with a history of vascular type of headache
since the age of 15. She had two
episodes of sudden onset intense head
ache – leading to brief loss of
consciousness with vomiting and, dazed
status persisting over next 48hrs – in the
past two years. Subsequent to these
episodes she was getting periodical
hemicranial headaches for which
neurological consultation was sought and
investigated. At this point of time she had
no neurological deficits or meningial signs.
MRI WITH MRA
Fig 1
Showed well delineated berry
aneurysm at the bifurcation of left
Middle Cerebral Artery (MCA)
CT ANGIOGRAPHY
Fig 2: CT Angiography
Fig 3: 3D view of CT Angiography
A multislice spiral CT angiography not
only confirmed the aneurysm but gave
a three dimensional picture of the
vascular anatomy which is useful for
surgical intervention. With the possibility
of reconstruction of image, and image
rotation in 360° in all the planes, the
invasive DSA could be avoided.
SURGERY
Electively she was taken up for left
pterional craniotomy and microsurgically
the aneurysm was clipped successfully.
Fig 4: Intra operative picture of Aneurysm
Fig 5: Aneurysm after clipping the neck
Post operatively, the patient did very well.
She was cured of the aneurysm and
discharged on the fifth post-operative day
THE MESSAGE
1. ‘Warning leaks’ (minor, SAH) from
Cerebral Aneurysms should be
recognised and investigated.
2. Change in intensity, periodicity and
pattern of chronic headache demands
further investigation.
3. MRI brain with MRA is a non invasive
and most useful investigation of choice
in evaluating these headaches.
4. Multislice spiral CT has enabled
viewing multiplanar picture and
delineation of vascular anatomy to
minute details, eliminating the need of
invasive, technically demanding Digital
Subtraction Angiography in most cases.
5. The treatment of choice for even
unruptured aneurysm is still the gold
standard microsurgery which is one time,
curative and also economical compared
to endovascular therapy in most cases.
Courtesy:
Dr. K N Krishna, M.Ch.
Consultant Neurosurgeon
Wockhardt Hospitals, Bangalore
2
 T hrombolysis in stroke –
Time is Brain
CASE REPORT
Mr J presented to the casuality with
the history of acute onset blurring of
vision in left eye followed by
unresponsiveness of 45 minutes
duration. He was a known
hypertensive on regular treatment.
There were no previous episodes of
IHD/ Stroke/ TIA. BP was150/90 mm
Hg and other vital parameters were
stable. He was drowsy and was noted
to have paucity of movements of right
upper limb and lower limb. In addition,
left gaze preference was present along
with equivocal plantar response. CT
scan of head which was done within
an hour of the ictus was normal. GRBS
was 142 mg %. ECG, platelet count
and coagulation parameters were
within normal limits. The risks, benefits
and cost of thrombolysis therapy with
rtPA (recombinant tissue plasminogen
activator) were explained to the family
members.
After obtaining the informed consent
of the family, rtPA was administered
intravenously at a dosage of 0.9 mg/
kg body weight, 10% of the total
dosage was given as a bolus and
remaining as an infusion over one
hour. We were able to accomplish this
within two hours of ictus MRI of brain
done within six hours of ictus revealed
left middle cerebral artery (mca)
territory stroke with a tiny speck of
hemorrhage. There was no
deterioration in the neurological status
at this point of time. Anti platelet
agents and citicholine were introduced
24 hours after the thrombolysis. CT
scan of head was repeated on fourth
day revealing mild mass effect. It was
treated with antioedema measures.
Patient improved gradually and was
conscious by fifth of ictus. He was
shifted to the ward after a stay of eight
days in MICU. He regained
3
comprehension for simple verbal
commands and power of hemiplegic
limbs improved to grade 3/5.
Physiotherapy and speech therapy was
continued. He was discharged after a
ten-day stay in the ward. At the time of
discharge, he was able to sit with minimal
support, walk with one person’s support
and had got motor aphasia.
DISCUSSION
Thrombolysis in stroke using rtPA is an
accepted practice for certain types of
ischemic stroke. The critical part of
management of stroke is to bring the
patient within three hours of ictus for
thrombolysis (the golden period). This
window period is three hours for
intravenous thrombolysis and six hours
for intra-arterial thrombolysis. It is well
known that the benefits of thrombolysis
are apparent as reduction of disability
three months after the stroke.
Strict inclusion and exclusion criteria
are available (table). This case
illustrates the importance of the
‘Golden Hour’ in stroke and also the
importance of coordination between
neurologist, intensivist and emergency
room physician – ‘The Stroke Team’.
CONCLUSION
1) ‘Brain attack’ is as lethal and
debilitating as heart attack.
2) Awareness and education of
public and medical fraternity
regarding the need for urgency in
potential cases of thrombolysis is
important.
3) Thrombolysis with rtPA should be
used carefully by trained experts
in the field after careful
consideration in a tertiary care
centre.
4) The costs involved should be
within the reach of common man.
TABLE
Characteristics of patients who could be
treated with rtPA (intravenous)
1) Ischemic stroke causing measurable
neurological deficit
2) The neurological signs should not be
clearing spontaneously
3) The neurological signs should not be
minor and isolated
4) Onset of symptoms - three hours
before beginning treatment
5) Time of onset should not be vague
6) No head trauma or prior stroke in
previous three months
7) No GI or urinary tract hemorrhage in
previous 21 days
8) No major surgery in previous 14 days
9) No arterial puncture at a non
compressible site in the previous
seven days
10) No h/o previous intracranial
hemorrhage
11) BP < 185/110 mm Hg
12) Not on oral anticoagulants or if on oral
anticoagulants INR < 1.7
13) Platelet count > 100000/ mm3
14) RBS > 50ms/dl and < 450 mm/dl
15) If receiving heparin in previous 48
hours, a PTT must be in normal range
16) No h/o seizure
17) CT Scan should not show multilobar
infarction (hypodensity < 1/3 cerebral
hemisphere)
18) The patient or family understand the
potential risks and benefits of
treatment.
Courtesy:
Dr. Udaya Shankar, M.D., D.M
Consultant Neurologist
Dr. Ravindra Mehta, MD, FCCP,
American Board Certified Critical Care
Medicine, Pulmonary Medicine,
Sleep disorder medicine
Intensivist and Pulmonologist
Dr. Prabhakara Reddy, MD., FACP,
American Board Certified Internal Medicine
Consultant Emergency Medicine
Wockhardt Hospitals, Bangalore
 T otal knee replacement in
severely deformed Rheumatoid knee
R
heumatoid arthritis is a
well known systematic
inflammatory disease
wherein arthritis of synovial
joints is a major component.
This disease is common in females and
affects during third, fourth and fifth
decades of the life. Initially the disease
starts with pain and joint stiffness in
small joints of hand and later involves
big joints like hip, knee, shoulder and
elbow. In an advanced rheumatoid
arthritis all the joints of the body are
involved.
Treatment of rheumatoid arthritis is
ideally to be done by rheumatologist.
Start with NSAIDS and later go on to
combination therapy of DMARDS
(steroids, methotrexate, leflunomide,
sulfasalazine chloroquine and oral gold
salts). An Orthopaedician’s role comes
only after joint pain/ swelling and
deformity are not controlled by
medical treatment.
Indication of joint replacement in
rheumatoid arthritis.
1. Severe pain in joints
2. Inability to do daily activities
3. Progressing deformity
4. Joint stiffness
Advantages of joint replacement
1. Painless and stable joints
2. Good functional movements of
joints
3. Improvement in quality of life
4. Better disease control after
surgery
With advent of new implants, good
operation theatres, laminar flow and
surgical expertise, it is possible to
perform joint replacements even in
severely deformed joints which was
thought impossible previously.
CASE REPORT
58 year old female patient consulted
us with severe knee pain for four years.
She was a known case of rheumatoid
arthritis on medical treatment. She was
unable to stand or walk and had severe
pain on bending the knee.
On examination she was moderately
built but poorly nourished and anemic.
Local examination of both knees
revealed that she has wind-swipe
deformity. Right knee was in 30 varus
deformity and range of movement
was 0-90. Left knee was in 40 valgus
and further valgus till 70. Range of
movement was 0-30. Investigation:
Hb -8.2 mg %, R A factor - positive,
CRP - positive, ESR- 89mm/hr. X-ray
of right knee showed severe varus
deformity with medical tibial condyle
defect and lateral subluxation of tibia.
Left knee - severe valgus deformity
with central tibial bone defect and
lateral patellar subluxation.
Pre-operative picture
Pre-operative x-ray
Patient was admitted and complete
pre-operative work done. The team of
Orthopaedic surgeons headed by Dr.
Sanjay Pai, Rheumatologist and
Anaesthetist got involved to give her a
comprehensive team care.
We performed total knee replacement
in staged manner. First the right knee
with varus deformity was operated
using a revision total knee
replacement implants. After five days,
the left knee with severe valgus
deformity was operated. Post
operative period was uneventful.
The patient was mobilised on the third
day with walker and was discharged
on the sixth day. On the 12th day, the
patient was able to walk without
support, able to climb stairs and do her
daily activities.
12 days, post-operative picture
Thanks to the surgical expertise now
available in India and good hospitals to
support, these patients can get back
their normal daily life style which was
thought impossible in the past.
Courtesy:
Dr. Sanjay Pai, M.S.
Dr. Srinivas J V, M.S.
Dr. Vasudev N Prabhu, M.S.
Department of Orthopaedic Surgery
Wockhardt Hospitals, Bangalore
4
 V ideo-assisted thoracoscopic (VATS)
anterior spine fixation

CASE REPORT lung is reinflated. A chest tube was Technological advances

A 45-year old Pakistani patient
presented with progressive
weakness of both lower limbs of six
months duration. He had been
bedridden for the past two months.
He had been diagnosed to have
‘Thoracic Cord Compression’ in
Karachi five years ago for which he
underwent decompressive
laminectomy at that time. The
symptoms of lower limb weakness
reappeared after a few months for
which he was reexplored. And he
improved partially. He had five such
recurrences and had undergone
surgery five times in Pakistan. Each
time the same wound at the posterior
midline was explored. The latest MRI
showed that there was both anterior
and posterior compression at the level
of T9-T10. The spinal canal was very
narrow at that level. There was no
evidence of infiltration. He underwent
surgery in two stages in our hospital.
used post-operatively for three days.
Stage 2:
Laminectomy T9, T10 and unilateral
pedicle fixation T8-T11
The posterior wound was reexplored.
It was found that the laminectomy was
inadequate. Therefore, it was
completed using drills. The dura and
the exiting nerve roots at the foramina
were freed from the scar tissue,
ligaments and bone. Pedicle screw
fixation was performed unilaterally on
the right as the pedicles on the left
side did not hold the screws properly.
Post-operatively, the patient had
reduced spasticity with some recovery
of the lower limb power.
have allowed spine
surgeons to perform the
same procedures through
small incisions in the chest
wall using video
technology with small
cameras as well as
endoscopic instruments.
commonly performed posteriorly, on
the back of the spine, but there are
specific circumstances when an
incision is needed to approach the
front of the spine (anterior approach).

Stage 1:
Video-assisted thoracoscopic
corpectomy and cage fixation

The patient was positioned left lateral Opening of pleura with hook MRI spine pre-operative
under GA using a double lumen
endotracheal tube intubation.
Typically, four key holes were made,
through which various instruments
are passed: one for the thoracoscope
(video camera), one for the retractor,
one for suction, and one for other
surgical instruments. Under general
anesthesia, using single lung
ventilation special thoracoscopic
corpectomy instruments were
utilised to achieve adequate bone Fixation of 60mm cage Post-operative x-ray
removal of the T9 and T10 bodies.
A 60 mm cage (Medtronics) was then Historically, anterior surgery was
DISCUSSION
used to fixate the spine from T8 to performed through an open
T11. At the end of the procedure, the Surgery for spinal disorder has seen thoracotomy. This required a large
holes were typically closed with an dramatic progress in the methods of incision through the chest wall and
absorbable suture and the deflated treatment. The surgical incision is most chest cavity. Technological advances

5
 have allowed spine surgeons to
perform these same procedures
through small incisions in the chest
wall using video technology with small
cameras as well as endoscopic
instruments.
Video-assisted thoracoscopy requires
a surgical team that should include an
experienced anesthesiologist, an
‘access’ surgeon (thoracic or general
surgeon), the spine surgeon, and an
experienced scrub nurse.
INDICATIONS
Video-assisted thoracoscopic spine
surgery (VATS) is typically used in
those conditions in which a
thoracotomy would be needed. For
example an anterior release for scoliosis
or Scheuermann’s kyphosis, correction
KEY HOLE ACCESS
ADVANTAGES VS
DISADVANTAGES
With any surgery, there are advantages
and disadvantages with newer
techniques. Advantages of VATS
include: smaller incisions, no spreading
open of the chest wall, less muscle
cutting/ scarring, minimal open/ closing
time, cosmetically appealing, and
improved visualisation of the spine
secondary to camera magnification.
Disadvantages include: the need for
additional training and experience to
Courtesy:
become efficient, risk of bleeding
requiring a thoracotomy, and the need Dr. D V Rajakumar, M.Ch.
for single lung ventilation for adequate Consultant Neurosurgeon
visualisation, which requires an Dr. U Shabeer Ahmed, M.S.,
experienced anesthesiologist. FRCS (UK), MMAS (Dundee)
Consultant Laparoscopic surgeon
CONCLUSION
Wockhardt Hospitals, Bangalore

of instability, neural decompression for The VATS technique is a safe and

the treatment of infection or tumor
through biopsy, debridement, drainage
of an abscess, resection of a tumour, or
corpectomy. It is also useful for
symptomatic spondylosis.
comparable alternative to open
thoracotomy. Although there is a
learning curve for VATS, greater
experience could show an advantage
in this approach to the anterior spine.

The previous issue of ‘The Specialist’ featured a case study on Minimal Access Surgery for Giant pulmonary bullae.
Dr. U Shabeer Ahmed name was inadvertently missed out from the list of contributors. We regret the error.

NEONATOLOGY

C ongenital Diaphragmatic Hernia

& PEDIATRICS
(CDH)

INTRODUCTION
Diaphragm is a muscular layer which
separates thorax from abdomen and its
formation is completed as early as 8th
week of fetal life. CDH can occur in 1 in
2-3,000 live births and over the past 20
years (1970-90), the overall postnatal
survival was relatively poor with only
approximately 50% survival if a
diagnosis is made during pregnancy.
The high mortality is due to various
factors, and we now realise that the
anomaly is far more complex. The most
important is the herniation of abdominal
contents (stomach and intestine into
the left side of chest which constitutes
85% of cases) leading to failure of
development of pulmonary alveoli and
capillaries of the left lung and to some
varying degree affecting the right lung.
There is a reported incidence of 40-50%
of other malformations in association
with CDH, the most common of which
are those involving the brain
and heart.
In 1848 Czech anatomist Dr. Vincent
Bochdalek described bowel herniation
through the posteriolateral part of
diaphragm and in 1946 Dr. Gross
reported the first successful repair of a
neonatal diaphragmatic hernia. The
mortality rate of CDH was very high
with most of the newborns dying soon
after birth or during the first few weeks
of life. In 1960s, Dr. Areechon and
Dr. Reid observed that the high death
rate was directly related to the degree
of development of lungs at birth.
Over the last 10 years, the
understanding of the disease along
with the advances in the antenatal
diagnosis by ultrasound and postnatal
intensive care management in the
best of the centres around the world,
has up to 90% survival rate. Expertise
therefore needs to be focussed on
timing of surgical repair and on
techniques of mechanical ventilation
and manipulating pulmonary vascular
reactivity.

6
 CASE REPORT
A newborn was diagnosed
antenatally to have left sided CDH at
35 weeks of pregnancy. Parents were
counselled about the nature of the
disease prior to delivery of their
newborn. The baby was delivered by
elective caesarean section at 37
weeks, the birth weight was 3.8 kgs.
He was immediately transferred to
neonatal-paediatric intensive care for
further care and management.
Tracheal
deviation
to right
Cardiac
shadow on
right side
of chest
Gaseous
bowel loops
- Left
thoracic
cavity
Fig 1: Loops of intestine in the left side of chest
Small left
lung
volume, no
bowel
loops in
left chest,
no
mediastinal
shift.
Fig 2: Chest X-ray after CDH repair.
He developed respiratory distress
requiring respiratory support at three
hours of age (Fig 1 and 2). The
pulmonary pressures were monitored
by echocardiography during the first
week of life. The small and large bowel
which had herniated on left side of
diaphragm was repaired using a
Gortex patch by combined thoracic
and abdominal approach on day four
of age once the pulmonary pressures
dropped to normal levels (Fig 3, 4, and 5).
The left lung was hypoplastic
(Fig 6). The baby was on respiratory
support for seven days and required
oxygen supplement for the next 15
days. Expressed breast milk feeds
were commenced by nasogastric tube
7
Small
intestine
(Left
thoracic
cavity)
Fig 3: Small intestines in thoracic cavity
Baby in ICU prior to discharge
Small & large
intestine recommenced again and slowly
(Abdominal upgraded to attain to full feeds. At the
cavity) time of discharge from hospital, he
was saturating > 98% in room air and
was feeding directly at breast and
started to gain weight. He was
discharged from the hospital on day
25 of age with complete recovery
Fig 4: Small & Large intestine pulled down to from CDH.
abdominal cavity.
The most important factors which
played significant role for good long
Gor t ex
term survival in our case are-
patch
1. Antenatal diagnosis (by
ultrasonagraphy).
2. Planning of delivery (high- risk
pregnancy).
3. Timing of surgery.
Fig 5: Diaphragmatic Hernia repaired using Gortex
4. Not associated other structural
patch.
anomalies.
5. Prevention of secondary lung
injury after birth.
6. Management of pulmonary
hypertension.
Left Lung 7. Nutrition supplementation.
Hypoplastic
8. Multidisciplinary team approach.
Fig 6: Left lung hypoplasia
Courtesy:
Dr. Prakash Vemgal, DCH (Paediatrics),
MRCPCH, Fellowship in Neonatology
(Australia), Fellowship in Paediatric Intensive
Care (Canada)
Consultant Neonatologist & Paediatric
Critical Care
Dr. Devananda N S, M.S., M.Ch.
Paediatric Cardiac Thoracic Surgeon
Dr. Ramesh R, M.D.
Consultant Anaesthesiologist
Baby in ICU ventilated
on day 10 of age, but he developed Dr. Anuradha S, M.D.
Consultant Obs & Gynaec
feeding intolerance due to suspected
necrotising enterocolitis. Feeds were Wockhardt Hospitals, Bangalore
withheld for a week and was
 A
CRITICAL CARE
n unusual case of
Adult Respiratory Distress Syndrome (ARDS)
A
20 year old male patient
with an alleged history of
suicidal ingestion of 40
tablets of Atenolol 50mg,
40 tablets of Metformin and ¼th of a
cake of ‘Mortein Rat Killer’
(Bromodiolone 0.005%w/w). He was
given a stomach wash at a nursing
Home. As his general condition
deteriorated with progressive
respiratory distress, he was intubated
and ventilated. CVC was attempted,
A proper
diagnosis and
appropriate
treatment of a
complicated
condition can
save lives.
with repeated punctures at the nursing
home unsuccessfully. Progressive
respiratory distress followed with
bilateral worsening opacities, and he
was diagnosed to have ARDS
secondary to aspiration pneumonia,
and shifted to Wockhardt Hospitals for
further management.
On arrival in the ER, he was
hemodynamically stable. Initial
evaluation revealed reduced air entry
on the right side, multiple puncture
marks present over right
supraclavicular area, right anterior
chest wall and fullness over the right
neck with no crepitus. Patient was
drowsy, opening eyes to call and
moving all 4 limbs. Central nervous
examination was normal. Chest
radiograph revealed bilateral dense
opacities, right > left [Fig 1]. Other
investigations were normal.
Fig 1: Initial Chest Radiograph showing
opacification of the right hemithorax with smaller
left opacification
Chest tube was inserted into the right
side and drained about 2.5 liters of
blood tinged fluid. Despite drainage,
chest XRay showed a large
opacification on right side with non
expansion of the lungs, and CT scan of
the thorax was done (Figure 2). CT
revealed a right loculated effusion
Fig 2. Contrast enhanced high resolution CT scan
showing the presence of bilateral hemothorax at
multiple levels
compressing the right lung suggestive
of loculated hemothorax, additional
large left sided pleural effusion and
pseudoaneurysm in relation to right
subclavian artery. Doppler of the right
upper limb arterial system with right
common carotid artery revealed a small
hematoma near the bifurcation of right
innominate artery and absence of any
pseudoaneurysm. Chest tube was
inserted on the left side and drained
about 1.5 liters of hemorrhagic fluid,
with good lung expansion (figure 3).
Fig 3. Chest Radiograph showing partial resolution
of opacity in right hemithorax
In view of persistent loculated
hematoma in the right chest after chest
tube insertion with respiratory
compromise, Video Assisted
Thoracoscopic Surgery was advised.
Intra- operatively, the pleural cavity
showed no evidence of residual
hematoma, and the opacity was found
to be a large, non-pulsatile
EXTRAPLEURAL hematoma. Limited
muscle sparing thoracotomy was done
to drain the extrapleural hematoma.
Thoracic drain was placed in the
hematoma cavity. Following this, the
lung completely re-expanded (see
figure 4). Patient was weaned off the
Fig 4. Chest Radiograph showing complete
resolution of the pathology
8
 ventilator and extubated on the next
day. He had an uneventful recovery
and was discharged 5 days later.
Presence of bilateral large hemothorax
and an extrapleural hematoma on one
side is an unusual clinical presentation.
Central Venous Catheterisation (CVC)
is otherwise a safe and uncomplicated
procedure in experienced hands. This
INTERNAL
MEDICINE
T oxic shock
syndrome
T
oxic shock syndrome is a rare
but potentially fatal toxin
mediated acute febrile
illness. Although classically
associated with tampon use, it is now
known that many non-menstrual
conditions are related to this syndrome.
Case fatality rates for menstrual related
STSS have ranged from 5.5% in 1980
to 1.8% in 1996. Mortality rates for
streptococcal TSS are in the range of
30-70%. Early onset of shock and
multi-organ failure contribute to the
high morbidity and mortality
associated with this condition. The
condition can mimic several common
diseases. Hence, patients with fever
and rash and a toxic condition out of
proportion to local findings should have
the diagnosis of toxic shock syndrome
in their differential diagnosis.
CASE REPORT
A 26-year-old female, who had
undergone LSCS 40 days ago,
presented to us with h/o fever of seven
days and rash of five days duration. She
had a high-grade fever, not associated
with chills and rigors. The rash, which
developed two days after the onset of
fever, began on the face and progressed
9
was a rare complication of CVC done
outside, and labeled as ARDS. This
case demonstrates that proper
diagnosis and appropriate treatment of
a complicated condition can save lives.
Admission of a patient to a centre
having the required Critical Care
expertise and adequate facilities to
treat such patients will go a long way
in saving lives.
to involve the palms and the soles. One
day prior to admission, the patient had
developed sore throat and loose stools.
The caeserian section wound appeared
to be healing except for an area of
induration in the central portion. She
had no prior h/o fever with rash and no
other prior medical or surgical illnesses.
On examination, a generalised macular
erythrodermal rash was noted which
also involved the palms, soles and oral
mucosa. She had mild puffiness of the
face with fine scaling of skin over the
malar area. Her heart rate was 90/min;
BP- 100/70 mm Hg and temperature
103 deg F. Systemic examination was
normal except for minimal induration
and discharge from the caeserian
section scar.
The total count was 5,300; Platelet
count, Renal Function Test, Liver
Function Test were normal. CRP was
positive.
With a tentative clinical diagnosis of
toxic shock syndrome, the patient was
started on IV Reflin 500 mg thrice daily,
IV Clindamycin 600mg thrice daily, on
admission. Throat C/S, Vaginal discharge
C/S and Blood C/S were negative.
Courtesy:
Dr. Ravindra Mehta, M.D., FCCP,
American Board Certified Critical Care
Medicine, Pulmonary Medicine,
Sleep disorder medicine
Intensivist and pulmonologist
Dr. U Shabeer Ahmed, M.S.,
FRCS (UK), MMAS (Dundee)
Consultant Laparoscopic surgeon
Dr. K N Srinivasan, M.S., M.Ch.
Cardiovascular and Thoracic Surgeon
Dr. Deepak Tauro, M.D.
Fellow - Critical care
Dr. Madhusudan K A, M.D.
Intensivist
Wockhardt Hospitals, Bangalore
Immediate treatment
should be aimed
at aggressive
management of
hypovolaemic shock
caused by capillary
leakage and vasodilation
However, wound discharge C/S grew
Staph. aureus resistant to Methicillin,
sensitive to Clindamycin. The
temperature, which was 103 deg F on
admission, decreased progressively
and patient was afebrile on day four.
The skin lesions began to desquamate
by day 12 of illness and the patient
was discharged in a stable state.
What you need to know about toxic
shock syndrome
Toxic shock syndrome is a toxin
mediated multisystem disease
precipitated by staphylococcus aureus
or Group A streptococcus
(streptococcus pyogenes). The
condition was first described in 1978
in children. Subsequently in 1980 it
was identified in association with
tampon use.
Non-menstrual cases of TSS were
also reported in the early 80s in
association with several surgical
procedures (e.g. rhinoplasty,
augmentation mammoplasty,
liposuction, chemical peeling, nasal
packing, post partum procedures)
and medical conditions (e.g.
pneumonia, influenza, unidentified
bacteraemia, septic arthritis,
thrombophlebitis, meningitis, pelvic
infection, endophthalmitis).
Non-menstrual conditions
predisposing to STSS include -
surgical wound infection, postpartum
infections, focal cutaneous and
subcutaneous lesions, deep
abscesses, empyema, peritonsillar
abscesses, sinusitis, and
osteomyelitis. Necrotising fascitis,
myositis, cellulitis caused by Group
A streptococci are also known to
cause TSS.
Risk factors described with STSS
include HIV infection, diabetes, cancer,
ethanol abuse, recent h/o varicella
infection, NSAID use.
STSS should be suspected in any
patient with fever, rash, hypotension
and systemic evidence of toxicity.
The CDC criteria for diagnosis of TSS
include the following:
Fever - which is the most
common presenting sign.
However patients in shock
may be hypothermic.
Rash - classically described
as a diffuse macular
erythroderma.
Desquamation - which begins
1-2 weeks after the
onset of illness and involves
the palms and soles.
Hypotension (systolic
BP<90mmHg, orthostatic
drop in diastolic BP<15
mmHg, orthostatic syncope
and dizziness)
Evidence of multisystem involvement
in three or more of the following
systems:
Gastrointestinal - vomiting or
diarrhea at the onset of
illness
Musculoskeletal - severe
myalgia or creatinine kinase
elevation (> twice the
normal upper limit)
Mucous membrane -
vaginal, oropharyngeal or
conjunctival erythema
Renal - BUN or serum
creatinine > twice the upper
limit of normal
Hepatic - total bilirubin,
SGOT, SGPT at least twice
the upper limit of normal
Hematological - Platelets less
than 100,000
Central nervous system -
disorientation or alteration in
consciousness without focal
signs.
DIFFERENTIAL DIAGNOSIS
Diseases, which may be confused
with TSS, include:
Rocky Mountain Spotted
Fever- in which the rash is
petechial
Leptospirosis, Kawasaki
Disease - mucocutaneous
lymph nodes enlargement
Meningococcemia - in
which the rash is petechial
or purpuric
Toxic Epidermal Necrolysis
and Steven Johnson
Syndrome.
TREATMENT
Immediate treatment should be
aimed at aggressive management of
hypovolaemic shock caused by
capillary leakage and vasodilation.
Rapid infusion of large volumes of
crystalloid solutions is the mainstay
of treatment. At times 8 to 20L of fluid
over 24 hrs may be required to
maintain pressures. Placement of a
central venous line or pulmonary
arterial catheter is recommended for
haemodynamic monitoring.
Toxic shock
syndrome is a
rare but potentially
fatal toxin
mediated acute
febrile illness.
A detailed search should be made for
possible sites of infection. Surgical
wounds should be examined for
evidence of infection. Infected
wounds should be opened and
debrided.
Culture specimens from mucous
membranes, wounds, blood, urine
should be taken.
High dose beta lactamase resistant
antibiotics singly or in combination
should be started. Nafcillin and first
generation cephalosporins are also
agents of first choice. In patients
allergic to penicillin, vancomycin may
be used. Clindamycin has been
recommended for use in combination
with a beta lactamase resistant anti-
staphylococcal agent at least in the
initial phase of treatment, to decrease
the synthesis of the toxin.
Recommended duration of treatment
may extend up to 10-15 days in the
absence of bacteraemia and other
complications.
Courtesy:
Dr. Manjunath K N,
M.D., ABIM (USA), FACP (USA)
Consultant Internal Medicine
Dr. Aashish R Shah,
M.S., DNB, FRCS
Consultant GI and Laparoscopic Surgeon
Dr. Poonam Arya,
M.B.B.S., DNB
Surgical Registrar
Dr. Lingaraj B Patil,
M.B.B.S., DNB
Surgical Registrar
Wockhardt Hospitals, Bangalore
10
 ROOM

News
Doctors use a 4 mm endoscope to Bannerghatta Road, Cunningham
remove brain tumour through Road, Rajajinagar and Nagarbhavi in
patient’s nose Bangalore.

Bangalore, February 23, 2007: In a Innovative surgery replaces

unique path-breaking surgery the degenerated cervical disc
neuro-surgery team at Wockhardt
Hospitals, Bangalore, performed a Latest therapy in cervical disc
pioneering technique by which a brain replacement designed to preserve
tumor was removed using a 4 mm motion and flexibility
endoscope that was guided through Bangalore, March 28, 2007:
the patient’s nasal cavity. The surgery, Dr. D V Rajakumar, Consultant Neuro
which demands exceptional skill and Surgeon at Wockhardt Hospitals Brain
Women’s Health Speciality,
specialised equipment, was & Spine care, with his team has
comprising of well-equipped delivery
conducted by Dr. D V RajaKumar, on a successfully performed a total disc
suites, operating theatres, a 12-bed
40-year old lady who was diagnosed replacement in the cervical spine of
neo-natal ICU, a nursery, 13 LDR
with a brain tumour measuring 2
(labour, delivery and recovery) rooms 26-year old Gautam Kher, a software
centimetres. While endoscopes have
and consultation suites, was formally engineer, thus opening up a new area
been previously used for brain
launched at a special event by Priyanka of treatment for patients who suffer
surgeries related to cavities within the
Upendra, film star and wife of Kannada from Cervical Degenerative Disc
brain and occasionally to remove the
film star Upendra. Disease (DDD). Through the new
tumours from the pituitary gland
through the nose, this is the first technique, an artificial disc replaces
Wockhardt launches E-ONE, the
the degenerated disc and allows
Wockhardt Emergency Care
movement at that level. The diseased
Network (1057-11)
disc was replaced using a PRESTIGE®
LP Cervical Disc implant, rather than
to remove it through disectomy or
bone graft.

Launch of Wockhardt Hospitals ICU

and Community care, at Rajajinagar,
Bangalore

Wockhardt’s first regional hospital was

reported case in the country where an
endoscope was used to remove a brain
tumor without open surgery.
Wockhardt hospitals expands super-
speciality care to Women’s Health on
International Women’s Day
Bangalore, March 8, 2007: Wockhardt
Hospitals officially launched a
dedicated Women’s Care Speciality on
the occasion of International Women’s
Day 2007. The Wockhardt Hospitals
E-ONE is not just an ambulance
service, but a holistic coordinated
effort involving mobile critical care
units with advanced life saving
equipments, qualified emergency
care trained paramedics, a network
of ICUs within easy proximity,
backed by a team of critical care
specialists.
E-ONE facility is available across the
Wockhardt network of ICUs located at
launched on February 17th 2007. The
hospital is designed to deliver high
standards of secondary healthcare
services supported by sophisticated
technology and experienced medical
professionals.
This is a 50 bed (including 10 ICU beds)
and one operation theatre, expert
medical professionals, dedicated
specialists and the latest technology.
The hospital is located at West of
Chord Road, opposite to Rajajinagar
first block, Bangalore.

We look forward to hearing from you. Send in your views and suggestions to
thespecialist@wockhardthospitals.com

Wockhardt Hospitals
154/9, Bannerghatta Road, Opp IIM, Bangalore 560076 India. Tel:91-80 6621 4444/254 4444 Fax: 91-80 6621 4242/2254 4242
14 Cunningham Road, Bangalore 560052 India. Tel:91-80 4199 4444 / 2226 1034 Fax: 91-80 2228 6530
E-mail: care@wockhardthospitals.com Visit us:www.wockhardthospitals.net