Journal Scan

Journal Scan McHenry CR, Berguer R, Ortega RA, Yowler EJ, Recognition, management and prevention of specific operating room catastrophe. Journal of the American College of Surgeons, Volume-198, Number 5, May 2004,810-21. Operating room (OR) catastrophes and intraoperative emergencies are rare, but delays in their recognition and treatment may be devastating. In this article, some of the most important emergencies and potential operating room catastrophes have been examined, including latex induced anaphylaxis, malignant hyperthermia, thyrotoxic crisis, cardiovascular collapse, transfusion reaction, coagulopathy, the difficult airway and mechanical hazard in the operating room. All of these entities represent conditions in which early recognition and aggressive treatment are necessary to prevent fatal outcome and in which prevention is the cornerstone of management. Surgeons, anaesthesiologists and OR personnel should be familiar with these entities and appropriate institutional protocols should be developed for their management. Contributed by: Brig Gurjit Singh Commandant, Artificial Limb Centre, Pune-40. Dubick MA, Atkins JL. Small-volume fluid resuscitation for the far-forward combat environment: current concepts. J Trauma 2003;54:S43-5. Hemorrhage remains the primary cause of death on the battlefield in conventional warfare. With modern combat operations leading to the likelihood of significant time delay in air evacuation of casualties and long transport times, the immediate goals of the Army’s Science and Technology Objectives in Resuscitation are to develop limited or small volume fluid resuscitation strategies, including permissive hypotension, for the treatment of severe hemorrhage, to improve battlefield survival and prevent early and late deleterious sequelae. As an example, the U.S. Army Institute of Surgical Research, San Antonio, Texas, USA has invested much effort in the evaluation of hypertonic saline dextran (HSD) as a plasma volume expander, at one tenth to one twelfth the volume of conventional crystalloids, in numerous animal models of hemorrhage. These studies have identified HSD as a potentially useful field resuscitation fluid. In addition, preliminary studies have used HSD under hypotensive resuscitation conditions, and it has been administered through intraosseous infusion devices for vascular access. This research suggests that many of the difficulties and concerns associated with fluid resuscitation for treating significant hemorrhage in the field can be overcome. For the military, such observations have important implications toward the development of optimal fluid resuscitation strategies under austere battlefield conditions for stabilizing the combat casualty. Contributed by: Lt Col MM Harjai Classified Specialist (Surgery and Paediatric Surgery), Department of Paediatric Surgery, Army Hospital (R&R), Delhi Cantt –10

Cyr SJ, Hensley D, Benedetti GE. Treatment of field water with sodium hypochlorite for surgical irrigation. J Trauma 2004;57:231-5. Early irrigation and surgical debridement of high-energy wounds and open fractures effectively prevents infection. Rapid wound care has been maximized by the United States military’s “forward surgical teams”. However, the volume of sterile irrigant required to treat multiple patients with multiple wounds presents a significant logistical burden. Using ground-derived field water could eliminate this burden. The authors from Lackland Air Force Base, Texas, USA collected 100 water samples from five sources. An initial bacterial count (CFU/mL) was determined before treatment. 5% sodium hypochlorite was then added to each sample to derive a concentration of 0.025%. After treatment, a final bacterial colony count was performed. They found no bacterial growth in 99/100 samples. One post-treatment sample grew a single colony of a Bacillus species not present in the pretreatment culture and was determined to be an air contaminant. The authors conclude that their field-expedient modification of Dakin’s solution could substitute for sterile irrigation fluid when it is neither available nor logistically feasible. Contributed by: Lt Col MM Harjai Classified Specialist (Surgery and Paediatric Surgery), Department of Paediatric Surgery, Army Hospital (R&R), Delhi Cantt –10

Intrapartum exposure to Nevirapine and subsequent maternal responses to Nevirapine-based antiretroviral therapy. Jourdain G, Ngo-Giang-Huoun N, Pharm D, Le Coeur S, Bowonwatanuwong C, Kantipong P, et al. N Engl J Med 2004;351(3):229-40. After participating in a placebo-controlled trial of antiviral regimens to reduce mother-to-child transmission of the human immunodeficiency virus (HIV) in Thailand, some of the women began taking a Nevirapine-containing regimen. After six months, the rate of viral suppression was lower among the mother who had received intrapartum Nevirapine than among those who had not received it (49% vs 68%, P=0.03). These observational data suggest that intrapartum exposure to a single dose of Nevirapine may lead to selection for resistant mutations that can adversely affect a woman’s subsequent antiviral treatment. Contributed by: Lt Col VK Agrawal Associate Professor, Department of Preventive and Social Medicine, Armed Forces Medical College, Pune -40