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ANAESTHESIA FOR PATIENTS WITH TRANSPLANTED HEART
Letters to the Editor
274 infection of the perineal and genital fascia, with gangrene of the overlying skin. It is a rare disease but a life-threatening condition. Inspite of newer diagnostic techniques, the etiology remains unclear in one-fourth of cases [1]. Anorectal, genitourinary traumatic infections are the most common causes of Fournier's gangrene. The infecting organisms comprise both aerobic and anaerobic organisms such as Escherichia coli, Streptococcus pyogenes, Pseudomonas aeruginosa, Klebsiella pneumonia. Proteus mirabilis, Enterococci. Bacteroides fragilis and anaerobic Streptococcus. The early detection, extensive surgical debridement, parenteral broad-spectrum antibiotics, intravenous metronidazole, haemodynamic resuscitation and nutritional support are crucial to survival in this potentially lethal disease. Sometimes multiple surgical procedures may be necessary to bring the infection under control. In a report from literature, the surgical resection and antibiotic treatment failed to halt progression of the disease in one case but complete remission in the disease was achieved by high dose corticosteroid therapy [2]. The response to steroids suggests that Fournier's gangrene represents a local schwartzman phenomenon. Diversion of faecal and urinary streams may not always be necessary but should be considered on a case by case basis. In the present case a diverting colostomy was performed to avoid contamination of the perineal wound. The Fournier's gangrene has also been found as the presenting sign in an undiagnosed human immunodeficiency virus infection [3]. The
value of hyperbaric oxygenation in Fournier's gangrene remains unproven [4]. The reported mortality rates in different series range between 22 and 60% [5]. To summarize, it is a polymicrobial synergistic infection and the aggressive surgical debridement. broad spectrum antibiotics and plastic reconstructive techniques have all contributed to a better survival of these patients in the recent years.
References 1. Stephens BJ. Lathrop JC, Rice WT, Gruenberg JC. Fournier's gan-
2.
3. 4. 5.
grene: Historic(1764-1978) versuscontemporary (1979-1988) differences in etiologyand clinical importance. Am Surg 1993;59: 149-54. SchultzES, Diepgcn TL, Von Den Driesch P, HornsteinOP. Systemic corticosteroids are important in the treatmentof Fournier's gangrene: A case report.Br J Derrnatol 1995;133:633-5. HolterJT. Fornier's gangreneas the presenting sign of an undiagnosed human immunodeficiency virusinfection. J UroI1996;155:291-2. LaucksSS. Fournier's gangrene. Surg Clin North Am 1994;74:133952. Ben-Aharon U, Borenstein A, Eisenkraft S, Lifschitz 0, Leviav A. Extensive necrotizing soft tissue infection of the perineum. Isr J Med Sci 1996;32:745-9.
Lt Col MAN MOHAN HARJAI Reader, Paediatric Surgeon, Department of Surgery, Armed Forces Medical College, Pune 411 040.
ANAESTHESIA FOR PATIENTS WITH TRANSPLANTED HEART Dear Editor, Heart transplantation is now an accepted treatment for end-stage cardiac disease. The chief indications for orthotopic heart transplantation in children are congenital abnormalities such as hypoplastic left heart syndrome, endocardiac fibroelastosis, cardiomyopathies and poor results from cardiac surgeries. The Royal children Hospital, Melbourne has an ongoing heart transplantation programme and has a large number of patients dependent on it for long term care. Recently, three patients between the age group of 18-38 months who had undergone heart transplantation previously, were subjected to general anaesthetic for endomyocardial biopsy which is a routine follow-up procedure in such cases. All the patients had a normal echocardiagram and 12 lead electrocardiogram. Their exercise tolerance was satisfactory and there was no evidence of graft rejection or cardiac failure. The biochemical parameters with special reference to liver function tests and urea, creatinine were within normal range. They were receiving cyclosporine as immunosuppressant drug and appeared to be free of its toxic effects. Midazolam (0.4 mglkg) was given orally about 45 minutes prior to the commencement of anaesthetic. In the induction room adjacent to the theatre, the patients were induced using a mixture of oxygen, air and sevoflurane and tracheal intubation was facilitated with atracurium. Fentanyl was added in the dosages of 1 J.lglKg.Thereafter anaesthesia was maintained using oxygen, air and isoflurane and the lungs were mechanically ventilated in pressure controlled ventilation mode. The right sided internal jugular vein was cannulated in one case whereas in others, the biopsy was performed through right femoral vein. Monitoring consisted of pulse oximeter, non invasive blood pressure, end tibial carbon-dioxide, electrocardiogram, spirometry, respiratory mechanics and nasopharyngeal temperature. Intraoperatively haemodynamic parameters were noted to remain stable however events such as threading of the catheter and performance ofbiopsy, were marked with innocuous premature ventricular contractions. Spontaneous respiration was allowed to return at the end of the procedure and no anticholinesterases were used. Preoperative assessment in children with heart transplantation, is
aimed at detecting early evidence of cardiac failure and signs of rejection of graft such as failure to thrive or poor appetite. The other indicators are episodes of arrhythmia, low voltage complexes on ECG and low ejection fraction on echocardiography. The ECG may also point towards any underlying ischaemia since these patients have an accelerated tendency to develop coronary atherosclerosis which could be as high as 15%. The other important consideration is risk of infection because of long term immunosuppression. Commonly used drugs are cyclosporin-A, azathioprin, antilymphocyte globulin, FK506 and steroids. Usually these patients are on lifelong cyclosporin and other drugs are added only if there are signs of rejection Cyclosporin-A is known to have toxic effects on liver as well on the kidney and may also induce hypertension. Aseptic methods should be followed scrupulously and prophylactic antibiotics are mandatory. Cephazolin in the dosages of20 mg/kg is given at this institute. Blood transfusion if required should be given through a white cell filter so as to destroy 't' cells which may provoke graft versus host (GVH) disease. During anaesthesia, usually there is no cardiovascular response to intubation due to denervation of heart. For similar reasons, tachycardiac response to light plane of anaesthesia or hypovolemia is blunted and heart is unresponsive to atropine. However, direct effects of sympathomimetic drugs are maintained and heart responds well to exogenous catecholamines. Hence, isoprenaline or adrenaline should be readily available to control the heart rate in case of bradycardia [1). A technique such as described above consisting of inhalational induction or intravenous induction with propofol and maintenance with isoflurane in oxygen and atracurium appears to be safe and acceptable [2). The analgesic regimes have not been shown to be different and fentanyl or morphine are equally effective. The heart is preload dependent and therefore there is need to ensure adequate hydration. Dangerous arrhythmias during anaesthesia are uncommon, however all the antiarrhythmic drugs function normally on the transplanted heart except perhaps digoxin which needs integrity of autonomic nervous system for its action. Occasionally, these patients are the recipients of lungs as well and they are subjected to endobronchial biopsy. In such children it is prudent to avoid nitrous oxide as it may increase MiAFl. VOL 56, NO.3. 2000
275
Letters to the Editor incidence of pneumothorax. The cough reflex is absent and postoperatively there is less active cough. Bronchial anastomoses heal poorly and are often fragile. Hence airway pressures should be kept low during mechanical ventilation. As a consequence of refined technique and better care, these patients have a long survival rate and they often return to the operating theatre for cardiac catheterisation, angiography and other incidental surgeries such as appendicectomy, herniotomy or dental procedures. A careful assessment and attention to the aspects highlighted above, may aid in successful anaesthetic management of
these cases. References 1. Dash A. Anaesthesia of a patient with previous heart transplant. Int Anesthesiol Clin 1995;33(2):1-9. 2. Black AE. Anaesthesia for a paediatric patient who has had a transplant. Int Anesthesio! Clin 1995:33(2):107-23.
Maj DK SREEVASTA VA Graded Specialist (Anaesthesia), On Study Leave, The Royal Children Hospital, Melbourne, Victoria 3052. Australia.
UTILISING RESIDUAL 2% METHYL CELLULOSE Dear Editor, I would like to disseminate through this letter a simple way to utilize leftover 2% Methylcellulose. Most anterior chamber (AC) intraocular surgeries, mainly cataract removal with intraocular lens implantation, involve use of viscoelastics. Viscoelastics are critically essential to any procedure involving AC manipulations as they help maintain AC, protect corneal endothelium and assist in breaking synechae, if any. 2% Methylcellulose, though not strictly a viscoelastic, is used most frequently for this purpose and comes pre-filled in a syringe. Almost invariably some of it remains unspent at the end of the surgery and has to be discarded. I have been autoclaving this residual 2% Methycellulose and
accumulating it over 3-4 surgical sessions. This viscous transparent 2% solution can be diluted with equal or three-fourth volume of 4% lignocaine, commonly used as topical anaesthetic. The resultant solution is an excellent coupling fluid for application of contact lenses e.g. Goldmann-3-mirror and Abraham's lens. Not only can one tailor the viscosity of the solution according to one's preference, there is also a distinct advantage ofconstant topical anaesthesia. This becomes important in cases of laser photocoagulation where prolonged topical anaesthesia is required. Of course, preventing a wastage has its own charm. Maj RAKESH MAGGON Graded Specialist (Ophthalmology), 153 General Hospital, C/o 56 APO.
MULTIPLE MENINGIOMA Dear Editor, This refers to article 'Multiple Meningiomas' published in Medical Journal Armed Forces India 1999;55:263-4. Firstly the lady was 50 years old as known to us and as seen on CT scan (Fig lA) of the case report. Secondly the patient had presented with severe headache and vomiting due to raised intra cranial pressure even CT Scan (Fig IB) shows severe hydrocephalus. Lastly I had the opportunity to operate this lady, two of her three
lesions were operated, the one arising from tentorium (not cerebellum) on left, was confirmed histopathologically to be meningioma. The right CP angle tumour was found to be schwannoma on histopathology. The third seen in the falx was too small to be operated, so histopathologically not confirmed. I fail to understand, how this case can be labelled a case of multiple meningioma. Lt Col PRAKASH SINGH Command Hospital (NC), C/o 56 APO.
REPLY Dear Editor, This refers to article 'Multiple Meningiomas' published in Medical Journal Armed Forces India 1999;55:263-4. The lady was 50-years old mother of a serving soldier, age typed as 28 years is wrong and deeply regretted. Hydrocephalous was associated due to primary pathology of intracranial ~OL's and hence not emphasized. All the 3 lesions showed similar CT findings and Imaging diag-
nosis of multiple meningioma was offered on the basis of CT imaging as the case report was essentially depicting the imaging aspect. It is after surgery that the lowermost lesion came out to be a schwanoma which shows similar finding on CT as meningioma. Col HARIQBAL SINGH Senior Adviser (Radiodiagnosis), Command Hospital, Pune 411 040.
SAY NO TO MMR; EPIDEMIOLOGICAL REASONS Dear Editor, There are some practitioners who advocate Measles, Mumps and Rubella (MMR) vaccinations among infants. The epidemiological impact of this in our country can have adverse consequences. The following c1inico-epidemiological factors have to be considered. Measles is a severe disease in infancy and milder in older children and adults. therefore measles vaccine has a well earned placed in the Universal Immunisation Programme (UIP). Mumps on the other hand, is a mild disease in infancy and more MJAFJ. VOL 56. NO.3. 2000
severe during adulthood. Orchitis occurs in about one in four males who develop mumps after puberty and may lead to sterility [1]. In developed countries, 85% of infections occurred in children younger than 15 years prior to widespread childhood immunisation-now disease occurs in young adults, producing epidemics in cQIleges/workplace [2]. Why should we repeat the mistakes of developed countries? More so as we cannot afford immunisation at puberty/adulthood as advocated by Western medical literature [3]. Having the disease in childhood is preferable to escaping it then and possibly acquiring it in adult life when protection afforded by
274 infection of the perineal and genital fascia, with gangrene of the overlying skin. It is a rare disease but a life-threatening condition. Inspite of newer diagnostic techniques, the etiology remains unclear in one-fourth of cases [1]. Anorectal, genitourinary traumatic infections are the most common causes of Fournier's gangrene. The infecting organisms comprise both aerobic and anaerobic organisms such as Escherichia coli, Streptococcus pyogenes, Pseudomonas aeruginosa, Klebsiella pneumonia. Proteus mirabilis, Enterococci. Bacteroides fragilis and anaerobic Streptococcus. The early detection, extensive surgical debridement, parenteral broad-spectrum antibiotics, intravenous metronidazole, haemodynamic resuscitation and nutritional support are crucial to survival in this potentially lethal disease. Sometimes multiple surgical procedures may be necessary to bring the infection under control. In a report from literature, the surgical resection and antibiotic treatment failed to halt progression of the disease in one case but complete remission in the disease was achieved by high dose corticosteroid therapy [2]. The response to steroids suggests that Fournier's gangrene represents a local schwartzman phenomenon. Diversion of faecal and urinary streams may not always be necessary but should be considered on a case by case basis. In the present case a diverting colostomy was performed to avoid contamination of the perineal wound. The Fournier's gangrene has also been found as the presenting sign in an undiagnosed human immunodeficiency virus infection [3]. The
value of hyperbaric oxygenation in Fournier's gangrene remains unproven [4]. The reported mortality rates in different series range between 22 and 60% [5]. To summarize, it is a polymicrobial synergistic infection and the aggressive surgical debridement. broad spectrum antibiotics and plastic reconstructive techniques have all contributed to a better survival of these patients in the recent years.
References 1. Stephens BJ. Lathrop JC, Rice WT, Gruenberg JC. Fournier's gan-
2.
3. 4. 5.
grene: Historic(1764-1978) versuscontemporary (1979-1988) differences in etiologyand clinical importance. Am Surg 1993;59: 149-54. SchultzES, Diepgcn TL, Von Den Driesch P, HornsteinOP. Systemic corticosteroids are important in the treatmentof Fournier's gangrene: A case report.Br J Derrnatol 1995;133:633-5. HolterJT. Fornier's gangreneas the presenting sign of an undiagnosed human immunodeficiency virusinfection. J UroI1996;155:291-2. LaucksSS. Fournier's gangrene. Surg Clin North Am 1994;74:133952. Ben-Aharon U, Borenstein A, Eisenkraft S, Lifschitz 0, Leviav A. Extensive necrotizing soft tissue infection of the perineum. Isr J Med Sci 1996;32:745-9.
Lt Col MAN MOHAN HARJAI Reader, Paediatric Surgeon, Department of Surgery, Armed Forces Medical College, Pune 411 040.
ANAESTHESIA FOR PATIENTS WITH TRANSPLANTED HEART Dear Editor, Heart transplantation is now an accepted treatment for end-stage cardiac disease. The chief indications for orthotopic heart transplantation in children are congenital abnormalities such as hypoplastic left heart syndrome, endocardiac fibroelastosis, cardiomyopathies and poor results from cardiac surgeries. The Royal children Hospital, Melbourne has an ongoing heart transplantation programme and has a large number of patients dependent on it for long term care. Recently, three patients between the age group of 18-38 months who had undergone heart transplantation previously, were subjected to general anaesthetic for endomyocardial biopsy which is a routine follow-up procedure in such cases. All the patients had a normal echocardiagram and 12 lead electrocardiogram. Their exercise tolerance was satisfactory and there was no evidence of graft rejection or cardiac failure. The biochemical parameters with special reference to liver function tests and urea, creatinine were within normal range. They were receiving cyclosporine as immunosuppressant drug and appeared to be free of its toxic effects. Midazolam (0.4 mglkg) was given orally about 45 minutes prior to the commencement of anaesthetic. In the induction room adjacent to the theatre, the patients were induced using a mixture of oxygen, air and sevoflurane and tracheal intubation was facilitated with atracurium. Fentanyl was added in the dosages of 1 J.lglKg.Thereafter anaesthesia was maintained using oxygen, air and isoflurane and the lungs were mechanically ventilated in pressure controlled ventilation mode. The right sided internal jugular vein was cannulated in one case whereas in others, the biopsy was performed through right femoral vein. Monitoring consisted of pulse oximeter, non invasive blood pressure, end tibial carbon-dioxide, electrocardiogram, spirometry, respiratory mechanics and nasopharyngeal temperature. Intraoperatively haemodynamic parameters were noted to remain stable however events such as threading of the catheter and performance ofbiopsy, were marked with innocuous premature ventricular contractions. Spontaneous respiration was allowed to return at the end of the procedure and no anticholinesterases were used. Preoperative assessment in children with heart transplantation, is
aimed at detecting early evidence of cardiac failure and signs of rejection of graft such as failure to thrive or poor appetite. The other indicators are episodes of arrhythmia, low voltage complexes on ECG and low ejection fraction on echocardiography. The ECG may also point towards any underlying ischaemia since these patients have an accelerated tendency to develop coronary atherosclerosis which could be as high as 15%. The other important consideration is risk of infection because of long term immunosuppression. Commonly used drugs are cyclosporin-A, azathioprin, antilymphocyte globulin, FK506 and steroids. Usually these patients are on lifelong cyclosporin and other drugs are added only if there are signs of rejection Cyclosporin-A is known to have toxic effects on liver as well on the kidney and may also induce hypertension. Aseptic methods should be followed scrupulously and prophylactic antibiotics are mandatory. Cephazolin in the dosages of20 mg/kg is given at this institute. Blood transfusion if required should be given through a white cell filter so as to destroy 't' cells which may provoke graft versus host (GVH) disease. During anaesthesia, usually there is no cardiovascular response to intubation due to denervation of heart. For similar reasons, tachycardiac response to light plane of anaesthesia or hypovolemia is blunted and heart is unresponsive to atropine. However, direct effects of sympathomimetic drugs are maintained and heart responds well to exogenous catecholamines. Hence, isoprenaline or adrenaline should be readily available to control the heart rate in case of bradycardia [1). A technique such as described above consisting of inhalational induction or intravenous induction with propofol and maintenance with isoflurane in oxygen and atracurium appears to be safe and acceptable [2). The analgesic regimes have not been shown to be different and fentanyl or morphine are equally effective. The heart is preload dependent and therefore there is need to ensure adequate hydration. Dangerous arrhythmias during anaesthesia are uncommon, however all the antiarrhythmic drugs function normally on the transplanted heart except perhaps digoxin which needs integrity of autonomic nervous system for its action. Occasionally, these patients are the recipients of lungs as well and they are subjected to endobronchial biopsy. In such children it is prudent to avoid nitrous oxide as it may increase MiAFl. VOL 56, NO.3. 2000
275
Letters to the Editor incidence of pneumothorax. The cough reflex is absent and postoperatively there is less active cough. Bronchial anastomoses heal poorly and are often fragile. Hence airway pressures should be kept low during mechanical ventilation. As a consequence of refined technique and better care, these patients have a long survival rate and they often return to the operating theatre for cardiac catheterisation, angiography and other incidental surgeries such as appendicectomy, herniotomy or dental procedures. A careful assessment and attention to the aspects highlighted above, may aid in successful anaesthetic management of
these cases. References 1. Dash A. Anaesthesia of a patient with previous heart transplant. Int Anesthesiol Clin 1995;33(2):1-9. 2. Black AE. Anaesthesia for a paediatric patient who has had a transplant. Int Anesthesio! Clin 1995:33(2):107-23.
Maj DK SREEVASTA VA Graded Specialist (Anaesthesia), On Study Leave, The Royal Children Hospital, Melbourne, Victoria 3052. Australia.
UTILISING RESIDUAL 2% METHYL CELLULOSE Dear Editor, I would like to disseminate through this letter a simple way to utilize leftover 2% Methylcellulose. Most anterior chamber (AC) intraocular surgeries, mainly cataract removal with intraocular lens implantation, involve use of viscoelastics. Viscoelastics are critically essential to any procedure involving AC manipulations as they help maintain AC, protect corneal endothelium and assist in breaking synechae, if any. 2% Methylcellulose, though not strictly a viscoelastic, is used most frequently for this purpose and comes pre-filled in a syringe. Almost invariably some of it remains unspent at the end of the surgery and has to be discarded. I have been autoclaving this residual 2% Methycellulose and
accumulating it over 3-4 surgical sessions. This viscous transparent 2% solution can be diluted with equal or three-fourth volume of 4% lignocaine, commonly used as topical anaesthetic. The resultant solution is an excellent coupling fluid for application of contact lenses e.g. Goldmann-3-mirror and Abraham's lens. Not only can one tailor the viscosity of the solution according to one's preference, there is also a distinct advantage ofconstant topical anaesthesia. This becomes important in cases of laser photocoagulation where prolonged topical anaesthesia is required. Of course, preventing a wastage has its own charm. Maj RAKESH MAGGON Graded Specialist (Ophthalmology), 153 General Hospital, C/o 56 APO.
MULTIPLE MENINGIOMA Dear Editor, This refers to article 'Multiple Meningiomas' published in Medical Journal Armed Forces India 1999;55:263-4. Firstly the lady was 50 years old as known to us and as seen on CT scan (Fig lA) of the case report. Secondly the patient had presented with severe headache and vomiting due to raised intra cranial pressure even CT Scan (Fig IB) shows severe hydrocephalus. Lastly I had the opportunity to operate this lady, two of her three
lesions were operated, the one arising from tentorium (not cerebellum) on left, was confirmed histopathologically to be meningioma. The right CP angle tumour was found to be schwannoma on histopathology. The third seen in the falx was too small to be operated, so histopathologically not confirmed. I fail to understand, how this case can be labelled a case of multiple meningioma. Lt Col PRAKASH SINGH Command Hospital (NC), C/o 56 APO.
REPLY Dear Editor, This refers to article 'Multiple Meningiomas' published in Medical Journal Armed Forces India 1999;55:263-4. The lady was 50-years old mother of a serving soldier, age typed as 28 years is wrong and deeply regretted. Hydrocephalous was associated due to primary pathology of intracranial ~OL's and hence not emphasized. All the 3 lesions showed similar CT findings and Imaging diag-
nosis of multiple meningioma was offered on the basis of CT imaging as the case report was essentially depicting the imaging aspect. It is after surgery that the lowermost lesion came out to be a schwanoma which shows similar finding on CT as meningioma. Col HARIQBAL SINGH Senior Adviser (Radiodiagnosis), Command Hospital, Pune 411 040.
SAY NO TO MMR; EPIDEMIOLOGICAL REASONS Dear Editor, There are some practitioners who advocate Measles, Mumps and Rubella (MMR) vaccinations among infants. The epidemiological impact of this in our country can have adverse consequences. The following c1inico-epidemiological factors have to be considered. Measles is a severe disease in infancy and milder in older children and adults. therefore measles vaccine has a well earned placed in the Universal Immunisation Programme (UIP). Mumps on the other hand, is a mild disease in infancy and more MJAFJ. VOL 56. NO.3. 2000
severe during adulthood. Orchitis occurs in about one in four males who develop mumps after puberty and may lead to sterility [1]. In developed countries, 85% of infections occurred in children younger than 15 years prior to widespread childhood immunisation-now disease occurs in young adults, producing epidemics in cQIleges/workplace [2]. Why should we repeat the mistakes of developed countries? More so as we cannot afford immunisation at puberty/adulthood as advocated by Western medical literature [3]. Having the disease in childhood is preferable to escaping it then and possibly acquiring it in adult life when protection afforded by