m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 6 9 ( 2 0 1 3 ) 3 1 1 e3 1 4
Contributed by Lt Col Tripti Agrawal Commanding Officer, 136 Station Health Organization, C/o 56 APO, India E-mail address: [email protected]
313
DOI of original article: http://dx.doi.org/10.1016/ j.mjafi.2013.06.004 0377-1237/$ e see front matter ª 2013, Armed Forces Medical Services (AFMS). All rights reserved. http://dx.doi.org/10.1016/j.mjafi.2013.07.001
A curious case of blocked catheter mount Failure in properly checking the equipment is a factor in many critical events. Proper checking of equipment can help prevent equipment-related morbidity and mortality, improve preventive maintenance, and educate the critical care provider about equipment. Unfortunately, failure to perform a proper check before use is common.1 57-year-old male underwent a 15 h long surgery for mandibulectomy with tibial graft. He had an uneventful intra-operative period. Tracheostomy was done just before neuromuscular block was reversed. He was planned for partial ventilatory support overnight. The ventilator was checked and kept ready in the ICU. The patient suddenly developed respiratory distress when ventilator was connected to him. On auscultation the air entry at both inspiration and expiratory phase was reduced. His ventilatory parameters showed markedly decreased inspiratory and expiratory flow, increased airway resistance throughout the ventilatory cycle and raised airway pressures. Immediately the reason for this sudden crisis was sought and ventilatory circuit was subjected to a visual test. A paper-thin opaque block in the catheter mount was noticed only allowing tip of toothpick to go across the blocked mount (Figs. 1 and 2). The catheter mount was immediately changed, a cockpit drill was carried out and the patient was put back on ventilator. A re-look into the whole incident suggested that an accidentally dislodged catheter mount was replaced with the blocked one, without a repeat cockpit drill. There are numerous reports of obstruction of anaesthesia breathing circuits by different foreign bodies.2 In 2004 Scotland Yard conducted “Operation Orcadian”3 where they reported two hundred fifty seven incidences of mechanical problems leading to complications. They divided all the incidences into three categories.
Fig. 2 e A schematic diagram showing the blocked catheter mount.
1. “soft” anaesthetic related e concerned with occlusions within the anaesthetic circuit (catheter mount, valve, mask, connector and endotracheal (ET) tube); 2. “hard” anaesthetic related e concerned with problems in the anaesthetic machine and other supporting equipment (used as part of the anaesthetic process); 3. other e concerned with malicious or reckless conduct and rule violation. Soft cases constituted 61% of all the cases. Of these only 4 cases were analysed to be with manufacturing defect where the tube lumen was occluded/blocked. There has been no case report so far in literature, where there was a mechanical defect present. We recommend a complete cockpit drill to be conducted just before putting the patient on ventilator even if conducted earlier.
references
1. Dorsch JA, Dorsch SE. Equipment checking and maintenance. In: Dorsch JA, Dorsch SE, eds. Understanding Anaesthesia Equipment. 5th ed. New Delhi: Lippincott Williams and Wilkins a Wolters Kluwer Business; 2008:931e954. 2. Foreman MJ, Moyes DG. Anaesthetic breathing circuit obstruction due to blockage of tracheal tube connector by foreign body-two cases. Anaesth Intensive Care. 1999;27:73e75. 3. Protecting the Breathing Circuit in Anaesthesia and ICU. Report to the Chief Medical Officer of an Expert Group on Blocked Anaesthetic Tubing. 2004:6e8.
Fig. 1 e Blocked catheter mount allowing only the tip of tooth-pick.
Wg Cdr Parli R. Ravi* Classified Specialist (Anaesthesiology), Command Hospital (Air Force), Bangalore 560007, India
314
m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 6 9 ( 2 0 1 3 ) 3 1 1 e3 1 4
Gp Capt Sachin Shouche Senior Adviser (Anaesthesiology and Cardiac Anaesthesiology), Command Hospital (Air Force), Bangalore 560007, India *Corresponding author. Tel.: þ91 8105425508. E-mail address: [email protected] (P.R. Ravi)
Available online 21 June 2013 0377-1237/$ e see front matter ª 2013, Armed Forces Medical Services (AFMS). All rights reserved. http://dx.doi.org/10.1016/j.mjafi.2013.03.012
Detection of IgG antibodies to donor specific HLA class I & II antigens in post renal transplant cases Renal transplants are now a well establish mode of treatment offered to the patients of chronic kidney disease manifesting as chronic renal failure. With ever decreasing surgical complications, the management of post-transplant cases is becoming a challenging task. This has been reduced to such extent by the availability of HLA typing and effective immunosuppressive drugs. A well matched graft does not give rise much complications during post-transplant period. Many times a well-matched transplant is not available and unrelated or spousal or cadaveric kidney is offered for transplantation. A positive T-cell cross match is an absolute contraindication to renal transplantation. Early trials in kidney transplantation showed that the presence of donor-specific antibodies (DSA) before engraftment almost invariably produced the clinical syndrome of hyperacute rejection with allograft lost.1,2 Among these antibodies against HLA class I and class II are probably the most important. Several studies in past have evaluated the prevalence of HLA specific antibodies after renal transplant and their clinical relevance in terms of risk of acute or chronic rejection. It has been estimated that the overall incidence of acute humoral rejection (AHR) after transplantation is 2%e10%, that is approximately 20%e30% of all acute rejection episodes have a humoral component.3,4 We tested the recipient sera for donor specific antibodies at three months, six months and at 12 months interval. A total 25 cases were studied and followed up. Twenty-three post renal transplant cases received kidney transplants at Army Hospital (R&R) Delhi, during 2007e08 and two received during 2005. These were followed up for one year. Anti-donor antibodies were screened at three, six and twelve months interval. Anti-donors antibody screening was done by ELISA technique using commercially available kit manufactured by GTI MICROAMS (class I and class II), Waukesha, USA. Donor antigens panel were prepared from donor lymphocyte by solubilizing the cells with a non-ionic detergent. The sensitivity and specificity of the kit is 100% at 95% confidence level when 101 samples were tested. All these patients had donor specific cross match negative. Among 25 cases studied there were 17 males and 8 females recipients with mean age of 31 years (range12e53 years). The mean age of donors was 44 years (range 22e71 years). 12 were male donors and 13 were female donors. Out of 25 donors 15 were live related, 9 spousal donors, and 1 cadaveric transplant. There were total seven rejection episodes and one of the recipients showed donor specific antibody production after 3 months. Further, thirteen patients received multiple blood transfusion and out of them ten received more than three units
of packed cells but none had developed other blood group antibodies. Though only small number of cases were studied, but result does correlate with the other studies done for post renal transplant follow up. Cardarelli et al using ELISA assay found that 11% had developed circulating anti-HLA antibodies in their serum after six months of transplantation, however, only 4.4% of patients had DSA.4 The development of DSA occurs well in advance. Detection of DSA and AHR is clinically important as this carries a poor prognosis and require different modality of treatment e.g. plasma pharesis. Monitoring of the DSA by ELISA is a useful tool for tailoring immunosuppression after kidney transplantation. New interventions for preventing acute antibody mediated rejection, such as anti-C5 antibody mediated complement blockade and proteasome inhibitor mediated plasma cell depletion, are promising therapeutic avenues currently under investigation.5
references
1. Ceppellini R, Mattiuz PL, Scudelller G, Visetti M. Experimental allotransplantation in man: I. the role of the HLA system in different genetic combinations. Transplant Proc. 1969;1069(1):385. 2. Ram McKenna, Takemoto SK, Terakasaki PI. Anti-HLA antibodies after solid organ transplantation. Transplantation. 2000;69:319e326. 3. Jeannet M, Pinn VW, Flax MH, et al. Humoral antibodies in renal allotransplantation in man. N Engl Med. 1970;282:111e117. 4. Cardarelli F, Pascual M, Tolkoff-Rubin N, et al. Prevalence and significance of anti-HLA and donor specific antibodies in longterm after renal transplantation. Transpl Int. 2005;18:532e540. 5. Gloor J, Stegall MD. Sensitised renal transplant recipients: current protocols and future directions. Nat Rev Nephrol. 2010 May;6(5):297e306.
Contributed by Col Lavan Singh Classified Specialist (Pathology & Microbiology), Command Hospital (Southern Command), Pune 40, India E-mail address: [email protected] Available online 22 June 2013 0377-1237/$ e see front matter ª 2013, Armed Forces Medical Services (AFMS). All rights reserved. http://dx.doi.org/10.1016/j.mjafi.2013.04.007
Contributed by Lt Col Tripti Agrawal Commanding Officer, 136 Station Health Organization, C/o 56 APO, India E-mail address: [email protected]
313
DOI of original article: http://dx.doi.org/10.1016/ j.mjafi.2013.06.004 0377-1237/$ e see front matter ª 2013, Armed Forces Medical Services (AFMS). All rights reserved. http://dx.doi.org/10.1016/j.mjafi.2013.07.001
A curious case of blocked catheter mount Failure in properly checking the equipment is a factor in many critical events. Proper checking of equipment can help prevent equipment-related morbidity and mortality, improve preventive maintenance, and educate the critical care provider about equipment. Unfortunately, failure to perform a proper check before use is common.1 57-year-old male underwent a 15 h long surgery for mandibulectomy with tibial graft. He had an uneventful intra-operative period. Tracheostomy was done just before neuromuscular block was reversed. He was planned for partial ventilatory support overnight. The ventilator was checked and kept ready in the ICU. The patient suddenly developed respiratory distress when ventilator was connected to him. On auscultation the air entry at both inspiration and expiratory phase was reduced. His ventilatory parameters showed markedly decreased inspiratory and expiratory flow, increased airway resistance throughout the ventilatory cycle and raised airway pressures. Immediately the reason for this sudden crisis was sought and ventilatory circuit was subjected to a visual test. A paper-thin opaque block in the catheter mount was noticed only allowing tip of toothpick to go across the blocked mount (Figs. 1 and 2). The catheter mount was immediately changed, a cockpit drill was carried out and the patient was put back on ventilator. A re-look into the whole incident suggested that an accidentally dislodged catheter mount was replaced with the blocked one, without a repeat cockpit drill. There are numerous reports of obstruction of anaesthesia breathing circuits by different foreign bodies.2 In 2004 Scotland Yard conducted “Operation Orcadian”3 where they reported two hundred fifty seven incidences of mechanical problems leading to complications. They divided all the incidences into three categories.
Fig. 2 e A schematic diagram showing the blocked catheter mount.
1. “soft” anaesthetic related e concerned with occlusions within the anaesthetic circuit (catheter mount, valve, mask, connector and endotracheal (ET) tube); 2. “hard” anaesthetic related e concerned with problems in the anaesthetic machine and other supporting equipment (used as part of the anaesthetic process); 3. other e concerned with malicious or reckless conduct and rule violation. Soft cases constituted 61% of all the cases. Of these only 4 cases were analysed to be with manufacturing defect where the tube lumen was occluded/blocked. There has been no case report so far in literature, where there was a mechanical defect present. We recommend a complete cockpit drill to be conducted just before putting the patient on ventilator even if conducted earlier.
references
1. Dorsch JA, Dorsch SE. Equipment checking and maintenance. In: Dorsch JA, Dorsch SE, eds. Understanding Anaesthesia Equipment. 5th ed. New Delhi: Lippincott Williams and Wilkins a Wolters Kluwer Business; 2008:931e954. 2. Foreman MJ, Moyes DG. Anaesthetic breathing circuit obstruction due to blockage of tracheal tube connector by foreign body-two cases. Anaesth Intensive Care. 1999;27:73e75. 3. Protecting the Breathing Circuit in Anaesthesia and ICU. Report to the Chief Medical Officer of an Expert Group on Blocked Anaesthetic Tubing. 2004:6e8.
Fig. 1 e Blocked catheter mount allowing only the tip of tooth-pick.
Wg Cdr Parli R. Ravi* Classified Specialist (Anaesthesiology), Command Hospital (Air Force), Bangalore 560007, India
314
m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 6 9 ( 2 0 1 3 ) 3 1 1 e3 1 4
Gp Capt Sachin Shouche Senior Adviser (Anaesthesiology and Cardiac Anaesthesiology), Command Hospital (Air Force), Bangalore 560007, India *Corresponding author. Tel.: þ91 8105425508. E-mail address: [email protected] (P.R. Ravi)
Available online 21 June 2013 0377-1237/$ e see front matter ª 2013, Armed Forces Medical Services (AFMS). All rights reserved. http://dx.doi.org/10.1016/j.mjafi.2013.03.012
Detection of IgG antibodies to donor specific HLA class I & II antigens in post renal transplant cases Renal transplants are now a well establish mode of treatment offered to the patients of chronic kidney disease manifesting as chronic renal failure. With ever decreasing surgical complications, the management of post-transplant cases is becoming a challenging task. This has been reduced to such extent by the availability of HLA typing and effective immunosuppressive drugs. A well matched graft does not give rise much complications during post-transplant period. Many times a well-matched transplant is not available and unrelated or spousal or cadaveric kidney is offered for transplantation. A positive T-cell cross match is an absolute contraindication to renal transplantation. Early trials in kidney transplantation showed that the presence of donor-specific antibodies (DSA) before engraftment almost invariably produced the clinical syndrome of hyperacute rejection with allograft lost.1,2 Among these antibodies against HLA class I and class II are probably the most important. Several studies in past have evaluated the prevalence of HLA specific antibodies after renal transplant and their clinical relevance in terms of risk of acute or chronic rejection. It has been estimated that the overall incidence of acute humoral rejection (AHR) after transplantation is 2%e10%, that is approximately 20%e30% of all acute rejection episodes have a humoral component.3,4 We tested the recipient sera for donor specific antibodies at three months, six months and at 12 months interval. A total 25 cases were studied and followed up. Twenty-three post renal transplant cases received kidney transplants at Army Hospital (R&R) Delhi, during 2007e08 and two received during 2005. These were followed up for one year. Anti-donor antibodies were screened at three, six and twelve months interval. Anti-donors antibody screening was done by ELISA technique using commercially available kit manufactured by GTI MICROAMS (class I and class II), Waukesha, USA. Donor antigens panel were prepared from donor lymphocyte by solubilizing the cells with a non-ionic detergent. The sensitivity and specificity of the kit is 100% at 95% confidence level when 101 samples were tested. All these patients had donor specific cross match negative. Among 25 cases studied there were 17 males and 8 females recipients with mean age of 31 years (range12e53 years). The mean age of donors was 44 years (range 22e71 years). 12 were male donors and 13 were female donors. Out of 25 donors 15 were live related, 9 spousal donors, and 1 cadaveric transplant. There were total seven rejection episodes and one of the recipients showed donor specific antibody production after 3 months. Further, thirteen patients received multiple blood transfusion and out of them ten received more than three units
of packed cells but none had developed other blood group antibodies. Though only small number of cases were studied, but result does correlate with the other studies done for post renal transplant follow up. Cardarelli et al using ELISA assay found that 11% had developed circulating anti-HLA antibodies in their serum after six months of transplantation, however, only 4.4% of patients had DSA.4 The development of DSA occurs well in advance. Detection of DSA and AHR is clinically important as this carries a poor prognosis and require different modality of treatment e.g. plasma pharesis. Monitoring of the DSA by ELISA is a useful tool for tailoring immunosuppression after kidney transplantation. New interventions for preventing acute antibody mediated rejection, such as anti-C5 antibody mediated complement blockade and proteasome inhibitor mediated plasma cell depletion, are promising therapeutic avenues currently under investigation.5
references
1. Ceppellini R, Mattiuz PL, Scudelller G, Visetti M. Experimental allotransplantation in man: I. the role of the HLA system in different genetic combinations. Transplant Proc. 1969;1069(1):385. 2. Ram McKenna, Takemoto SK, Terakasaki PI. Anti-HLA antibodies after solid organ transplantation. Transplantation. 2000;69:319e326. 3. Jeannet M, Pinn VW, Flax MH, et al. Humoral antibodies in renal allotransplantation in man. N Engl Med. 1970;282:111e117. 4. Cardarelli F, Pascual M, Tolkoff-Rubin N, et al. Prevalence and significance of anti-HLA and donor specific antibodies in longterm after renal transplantation. Transpl Int. 2005;18:532e540. 5. Gloor J, Stegall MD. Sensitised renal transplant recipients: current protocols and future directions. Nat Rev Nephrol. 2010 May;6(5):297e306.
Contributed by Col Lavan Singh Classified Specialist (Pathology & Microbiology), Command Hospital (Southern Command), Pune 40, India E-mail address: [email protected] Available online 22 June 2013 0377-1237/$ e see front matter ª 2013, Armed Forces Medical Services (AFMS). All rights reserved. http://dx.doi.org/10.1016/j.mjafi.2013.04.007
