Letters to Editor

compared to the one working in an OR with appropriate facilities for removal of exhaled anesthetics. Similarly, if there is rapid turn-over of cases requiring inhalational anesthetics, anesthesia providers are more likely to be dosing themselves and get exhausted early. Thus, the effect of residual anesthetics on the occupational performance, driving capabilities and sleep behavior of pediatric anesthesia providers in developing countries needs further evaluation. Keeping these in mind, national societies should take adequate measures to ensure the safety of one and all working in operating areas. Indu Sen, Randeep Kaur Department of Anesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India Address for correspondence: Dr. Indu Sen, Department of Anesthesia and Intensive Care, PO Box No. 1519, PGI Campus, Sector - 12-A, Chandigarh - 160 012, India. E-mail: [email protected]

References 1.

Sinha A, Singh A, Tewari A. The fatigued anesthesiologist: A threat to patient safety? J Anaesthesiol Clin Pharmacol 2013;29:151-9. 2. Trikha A, Singh PM. Maximum working hours and minimum monitoring standards-need for both to be mandatory. J Anaesthesiol Clin Pharmacol 2013;29:149-50. 3. Tankó B, Molnár C, Budi T, Peto C, Novák L, Fülesdi B. The relative exposure of the operating room staff to sevoflurane during intracerebral surgery. Anesth Analg 2009;109:1187-92. 4. Zaffina S, Camisa V, Poscia A, Tucci MG, Montaldi V, Cerabona V, et al. Occupational exposure to sevoflurane in pediatric operating rooms: The multi-point sampling method for risk assessment. [Article in Italian]. G Ital Med Lav Ergon 2012;34(Suppl 3):266-8. 5. Kurrek MM, Dain SL, Kiss A. Technical communication: The effect of the double mask on anesthetic waste gas levels during pediatric mask inductions in dental offices. Anesth Analg 2013;117:43-6. 6. Panni MK, Corn SB. The use of a uniquely designed anesthetic scavenging hood to reduce operating room anesthetic gas contamination during general anesthesia. Anesth Analg 2002;95:656-60. 7. Irwin MG, Trinh T, Yao CL. Occupational exposure to anaesthetic gases: A role for TIVA. Expert Opin Drug Saf 2009;8:473-83. 8. Bihari V, Srivastava AK, Gupta BN. Occupational health hazards among operation room personnel exposed to anesthetic gases: A review. J Environ Pathol Toxicol Oncol 1994;13:213-9. 9. Oliveira CR. Occupational exposure to anesthetic gases residue. [Article in English, Portuguese]. Rev Bras Anestesiol 2009;59:110-24. 10. Marsh DF, Mackie P. National survey of pediatric breathing systems use in the UK. Pediatri Anaesth 2009;19:477-80. Access this article online Quick Response Code:

Website: www.joacp.org

DOI: 10.4103/0970-9185.130134

Anesthetic management for patients with perforation peritonitis Sir, We read with interest a recently published review article by Sharma et al. entitled, “Anesthetic management for patients with perforation peritonitis.”[1] There are some issues that can affect the anesthesia management and outcome hence need discussion: 1. There is just a passing remark that “Abnormalities in electrolyte balance and acid base balance should be corrected.” The causes of these abnormalities and their anesthetic implications need elaboration. Hypokalemia (in addition to chloride loss) may be caused by vomiting, nasogastric tube (NGT) aspiration, or prolonged inadequate intake in patients with intestinal perforation, whereas hyperkalemia could be due to hypotensive metabolic acidosis or renal insufficiency.[2] Similarly, metabolic acidosis could be due to shock or decrease renal functions while prolonged nasogastric aspiration in such patients may cause mixed metabolic disorder. Inadvertent intraoperative hyperventilation can further complicate the picture by worsening the hypokalemia. As these metabolic and electrolyte derangements can cause arrhythmias, hemodynamic disturbances and delayed recover y, preoperative blood gas and electrolyte estimation and simultaneous correction is important. 2. The authors have mentioned that “hemoglobin (Hb) should be raised by packed cell infusion and kept close to 11 g/dl” The authors have failed to mention the source of this statement. In fact this may encourage unnecessary transfusions and associated complications (including worsening of sepsis and organ failure). The intraoperative blood loss in such patients is generally small and transfusion should be considered only when the Hb levels are below 7 g/dl as per Surviving Sepsis guidelines[3] recommendations, with a target to achieve 7-9 g/dl level. Only in patients with myocardial ischemia, severe hypoxemia or acute hemorrhage, Hb levels are recommended to be kept above 10 g/dl. 3. The authors have mentioned a lot about the antibiotic therapy, but have not mentioned anything about fungal infections. The patients with perforation peritonitis may also have intra-abdominal fungal infection, which has a poor prognosis and early recognition and treatment is advisable which is often difficult due to its nonspecific presentation.[4]

Journal of Anaesthesiology Clinical Pharmacology | April-June 2014 | Vol 30 | Issue 2

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Letters to Editor

4. Routine nasogastric decompression postoperatively should be done only selectively and not in all cases as it could lead to increased incidence of pneumonia, atelectasis, ileus and causes persistent sense of irritation and foreign body in the throat.[5] It does not reduce postoperative nausea and vomiting or reduce anastomotic or other complications.[6] Avoidance of NGTs is one component of the Enhanced Recovery After Surgery protocols.[7] 5. In order to decrease the incidence and duration of ileus in the postoperative period, there is an important role of epidural analgesia, opioid-sparing analgesia, fluid restriction, early enteral feeding, and prokinetic drugs.[8] 6. We agree with authors that enteral feeding should be started as early as possible. The ESPEN guidelines on enteral nutrition: Surgery including organ transplant[7] suggests that oral intake, including clear liquids, can be initiated within hours after surgery to most patients undergoing colon resections. Limited data are available regarding immediate oral nutrition in patients with anastomoses in the proximal gastrointestinal tract but many studies have shown the benefits and feasibility of feeding via jejunostomy, or nasojejunal tube. 7. We regret to state that a large part of the text of “Intraoperative management” in the article has been lifted verbatim from an article published in the BJA,[9] which is unethical. Pradeep Bhatia, Vandana Sharma Department of Anaesthesiology & Critical Care, AIIMS, Jodhpur, Rajasthan, India Address for correspondence: Dr. Vandana Sharma, Vishwkarma Udyog, Ladnu House, Bagar Chowk, Jodhpur - 342 001, Rajasthan, India. E-mail: [email protected]

References 1.

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Sharma K, Kumar M, Batra UB. Anesthetic management for patients with perforation peritonitis. J Anaesthesiol Clin Pharmacol 2013;29:445-53. Miller RD, Eriksson LI, Fleisher LA,Wiener-Kronish JP, Young WL. Anesthetic implications of concurrent diseases. In: Roizen MF, Fleisher LA, editors. Miller’s Anesthesia. 7th ed. Churchill Livingstone Elsevier Inc.; 2010. p. 1122-4. Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock:2012. Crit Care Med 2013;41:580-637. Prakash A, Sharma D, Saxena A, Somashekar U, Khare N, Mishra A, et al. Effect of Candida infection on outcome in patients with perforation peritonitis. Indian J Gastroenterol 2008;27:107-9.

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Nelson R, Tse B, Edwards S. Systematic review of prophylactic nasogastric decompression after abdominal operations. Br J Surg 2005;92:673-80. Cheatham ML, Chapman WC, Key SP, Sawyers JL. A meta-analysis of selective versus routine nasogastric decompression after elective laparotomy. Ann Surg 1995;221:469-76. Weimann A, Braga M, Harsanyi L, Laviano A, Ljungqvist O, Soeters P, et al. ESPEN guidelines on enteral nutrition: Surgery including organ transplantation. Clin Nutr 2006;25:224-44. Luckey A, Livingston E, Taché Y. Mechanisms and treatment of postoperative ileus. Arch Surg 2003;138:206-14. Eissa D, Carton EG, Buggy DJ. Anaesthetic management of patients with severe sepsis. Br J Anaesth 2010;105:734-43. Access this article online Quick Response Code:

Website: www.joacp.org

DOI: 10.4103/0970-9185.130135

In Reply: Anesthetic management of patients with perforation peritonitis Sir, We, thank the author(s) for their keen interest in the article and for making very useful observations. The comments made by them are complementary to our article and we agree with the remarks regarding electrolyte abnormalities, selective nasogastric decompression and factors to decrease ileus in the postoperative period. Though, we, agree with authors’ note for hemoglobin levels as per surviving sepsis guidelines, we want to reiterate that hemoglobin levels in perforation peritonitis patients should be maintained at a reasonable levels, since, anemia in postsurgery patients of perforation peritonitis may lead to inadequate oxygen delivery and ischemia at the anastomotic site, causing its dehiscence. Iancu et al.[1] in their retrospective analysis of host related prognostic factors and their predictive value for anastomotic leakage after colorectal resections, found hemoglobin levels

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