Chapter 15
Swine Flu in Pregnancy
Dr. Vasanthi Vidyasagaran*
Department of Anaesthesiology, Kauvery Hospital, Chennai, Tamilnadu, India
*Correspondence: Vasanthi.vidyasagaran@gmail.com
A 34-year-old, primiparous woman at 37 weeks’ gestation, well-built weighing 84 kg was brought to the outpatient department for consultation. She complained of cough, cold and fever for the past 4 days. No history of any comorbidity in the past. Pregnancy had been normal so far.
Clinical examination showed PR-130 beats/min, BP-90/60, tachypnoea with a RR of 30 breaths/min. Auscultation revealed bilateral crepitations. She began feeling giddy and suddenly became unconscious even while being examined. Immediately she was turned to the left lateral position and vitals were reassessed. Pulse was feeble and BP was 80/50.
An IV line was started and fluids were administered, but she was drowsy and not responding to commands. Due to persistent low level of consciousness, she was shifted to the ICU and intubated in controlled environment for ventilatory support and further management. A Dopamine infusion was started. CTG showed foetal bradycardia. These were unexpected turn of events. The family was counselled and she was immediately taken up for an emergency LSCS.
Since the patient was already intubated, Fentanyl 70 microgram and Succinylcholine 100 mg were administered for surgical relaxation. Anaesthesia was maintained with Oxygen / Nitrous Oxide, and 0.2
% Isoflurane as her level of consciousness could not be assessed.
The baby had to be intubated by the paediatrician as the Apgar score was only 4 and was shifted to the NICU. At the end of surgery, she continued to be unconscious, without any respiratory effort. Pulse rate=120 beats/min, and saturation was 95% with 100% oxygen. BP was 100/60 with Dopamine support. She was shifted to the ICU with the endotracheal tube in-situ for elective ventilation.
A post-operative x-ray revealed extensive bilateral infiltrates and haziness in all areas corresponding to ARDS. Cultures of the endotracheal tube, blood and urine were sent along with all the basic investigations. Infections like malaria, dengue, leptospirosis and swine flu were investigated for. Broad spectrum antibiotics were started.
She was mechanically ventilated as there was no improvement in her condition. She required pressor support with noradrenaline and Dopamine. Eventually she tested positive for swine flu. Her ARDS worsened. Urine output began to drop, Urea-147, Creatinine-8.9. She developed multi organ failure. In spite of all resuscitative efforts, she suffered a cardiac arrest on the 7th day and could not be revived. Her baby was doing well and got discharged.
Discussion
Administering anaesthesia for an unconscious, already decompensated patient is difficult. The outcome of surgery or the prognosis of such a patient cannot be predicted. But we should try our best to maintain haemodynamics and cardiorespiratory status and strive not to worsen the condition. Anaesthesia in presence of fever and infection is challenging especially if it has not been diagnosed yet, even more so in a pregnant patient with altered physiology. Attention has to be paid to perfusion of every organ system, as we may not be aware of what complication to expect.
Also, since the source of the infection is not identified, we should take all safety measures to protect ourselves. Double gloves, aprons and eye protection should be used. Blood and blood products should be handled carefully. The theatre should be fumigated post-surgery before allowing any other procedure.
While managing a critically ill pregnant patient where chances of survival may be grim, it is all the more important to explain the situation to relatives. It may be very difficult for the relatives to accept, and they may be in state of denial. However, counselling them every few hours with update of the patient status is necessary. Time may be a constraining factor, still efforts must be taken.
When there is a critically ill obstetric patient the following should be quickly reviewed:
1. Conditions related to pregnancy – eclampsia, severe pre-eclampsia, haemorrhage, amniotic fluid embolus, acute fatty liver, peri partum cardiomyopathy, aspiration syndromes, and infections
2. Medical diseases that may be aggravated due to pregnancy – congenital heart diseases, rheumatic and non-rheumatic valvular diseases, pulmonary hypertension, anaemia, renal failure etc.
3. Conditions that are not related to pregnancy – sepsis, trauma, asthma, diabetes, autoimmune diseases
In a critically ill pregnant patient, it is important to understand that mother is the priority. Delivery of the baby in the decompensating mother must be done alongside resuscitation as pregnancy worsens her condition. Some of the illnesses may take a very rapid course with no response to treatment.
Perimortem caesarean section is an important topic that is being discussed in recent obstetric anaesthesia meetings.
References
- Trikha A, Singh PM. The critically ill obstetric patient – Recent concepts Indian J Anaesth. 2010;54(5):421–7.
- Shanker N, Aneja S, Jayalalitha MV, et al. Perioperative management of a parturient for caesarean section with confirmed H1N1 influenza. J Obst Anaesth Crit Care 2013; 3(2).
There is no failure…. It is an experience… to enhance future performance.
Chapter 16
Table modified to accommodate a Neck Lipoma
Case 1
An 80-year-old man presented with a huge mass in the nape of the neck. He had been having the lesion for over 30 years, slowly increasing in size. There was an ischemic ulcer at the tip which had started bleeding, and that brought him to the hospital. The mass was measuring 10 inches x 12 inches. It was diagnosed as a lipoma with ischemic ulcer due to the stretch of the skin. The mass was as big as his head. Considering the size of the swelling, it was planned to take him up under general anaesthesia. He had no other known comorbidities and not on any drugs. He was maintaining himself in lateral position only.
Challenges in this patient were:
- Geriatric patient with restricted neck movement and associated complications.
- Positioning the patient was a major concern: he was unable to lie flat, and neck extension was not possible.
- Airway problems particularly Intubation
- Risk of malignancy, due to age and bleeding
The plan was to modify the operating table to enable positioning of the head and neck, so that intubation was possible. The head end of the table was removed and replaced with a horse shoe attachment that is used in neuro surgery. The patient was made to lie in such a way that the swelling passed through the centre of the horse shoe and he could lie supine. Difficult airway trolley was made available.
Anaesthesia was induced slowly and carefully titrated. Bag mask ventilation was confirmed and then muscle relaxant was administered. Intubation was successful in the first attempt using Macintosh size 4.0 blade. Flexo-metallic endotracheal tube size 8.0 was used and secured well. He was then repositioned into the prone position. Pressure areas were protected. Surgery lasted about 3 hours. He required 3 units of packed cells. Fluids were titrated appropriately. Recovery was uneventful.
Case 2: Position of patient modified to enable intubation.
A 45-year-old man was posted for excision of a huge lipoma on the nape of his neck. The lipoma had been present for over 5 years, but now he developed pressure symptoms and pain. He found it difficult to lie down supine. The mass measured 8 x 10 inches, it restricted his neck extension. Examination revealed an obvious airway difficulty. His neck was flexed from the weight of the lipoma and there was no neck movement. In addition, he had 2 dentures in place of his upper incisors.
Airway management was the challenge as he was to be operated under general anaesthesia. The plan was to perform an awake intubation in the sitting position, from the front of the patient with a video laryngoscopy commonly used by ENT surgeons for direct laryngoscopy.
Patient was prepared with mild sedation using Dexmedetomidine. Upper airway was adequately anaesthetized with Lignocaine 10% spray, glossopharyngeal and superior laryngeal nerve block. In the sitting position, under standard monitoring, oxygen was administered through nasal prongs at 4 litres/min, Direct video laryngoscope was used to visualize the larynx.
With the video laryngoscope, the larynx could be visualised. ENT surgeon held the tongue forward, and it was possible to intubate the trachea successfully. A flexo-metallic 7.5 cuffed endo tracheal tube was used. After ensuring the position of the tube with end tidal capnography trace, anaesthesia was induced with Propofol and atracurium the cuff was then inflated. Surgery was completed in two hours and recovery was uneventful.
(whenever awake intubation is done, the cuff should be inflated only after administering muscle relaxant, or the patient may have a violent cough reflex, and this will lead to very high airway pressures) This was the first and only time, intubation, facing the patient, in the sitting position has been attempted by me.
Fibre optic scope was not available and hence other techniques had to be applied. It was also informed that if intubation was not feasible he would be referred to a higher centre where FOB was available. Blind nasal intubation would have also been difficult as there was no movement in the neck. LMA may not be the right choice as the procedure had to be done in the prone position. We wanted to try something new. Steps of the plan were thought through efficiently and applied in a strategic manner to ensure success at first attempt. Repeated manoeuvres make it very inconvenient for the patient and frustrating for the scopist, resulting in unsuccessful attempts and loss of airway specially if excess sedation is also given. Hence the plan A becomes important! Also, it is important to have a fall-back plan
B. It must be noted that a definitive tracheostomy may be impossible in cases with mass in front or back of the neck.
This was a surgery done before the introduction if all the modern airway gadgets. It may still be relevant in today’s practice in certain centres!
Discussion
Appropriate thought process and certain degree of innovation is required in special cases to make life easy for patient, anaesthetist and surgeon for efficient anaesthetic management of a difficult scenario.
Various case reports of loss of airway and catastrophic situations have been reported due to inappropriate positioning and inadequate planning in that perspective. This case highlights the importance of such preplanning to ensure safety and efficiency.
In addition to positioning, concerns here are the anatomical and pathophysiological changes in airway and neck in an elderly patient.
- Stiff neck due to osteoarthritis, leading to limited range of neck movement
- Tooth decay, edentulous, loss/atrophy of airway muscles leading to loss of normal airway contour. Bag mask ventilation may be difficult.
- Common pulmonary issues in elderly like COPD and obstructive sleep apnoea
- Reduced oxygen reserve capacity leading to early desaturation, hence quick control of airway and constant vigilance in prone position in essential.
- Achalasia and gastrointestinal reflux disease increase the risk of aspiration. When rapid sequence intubation is applied, drugs to obtund hemodynamic stress response are essential. At the same time, hemodynamic stability must be maintained.
- Cognitive changes related to age are associated with increased risk of airway problems in the postoperative period, this must be borne in mind.
Several modified positions have been reported in literature in difficult cases.
- Ramped up/head elevated position for morbidly obese patients
- Sniffing position is described as classical ‘win with the chin’ position. New jaw elevating device has been described in the west causing guarded forced extension of the mandible to optimize mouth opening
- Beach chair/sitting position helps prevention of airway collapse, helpful in obese patient, useful technique for fibre optic intubation
Availability of adequate support staff and equipment with team understanding and cooperation makes the process successful.
The whole team including the patient was extremely receptive in this case.
References
- Johnson KN, Botros DB, Groban L, et al. Anatomical and pathophysiological changes affecting the airway of the elderly patient: implications for geriatric focused airway management. Clin Interv Aging 2015;10:1925-34.
- Frank C, Heyland DK, Chen B, et al. Determining resuscitation preferences of elderly inpatients: a review of the literature. CMAJ 2003;169:795.
- Langeron O, Masso E, Huraux C, et al. Prediction of difficult mask ventilation. Anesthesiology 2000;92:1229.
- Cattano D. Airway management and patient positioning: A clinical perspective. Anesthesiology news guide to airway management 2010.
- Takenaka I, Aoyama K, Iwagaki T, et al. Approach combining the airway scope and the bougie for minimizing movement of the cervical spine during endotracheal intubation. Anesthesiology 2009;110(6):1335-40.
Innovation – keeping in mind the safety of the patient is exciting and rewarding.
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- Battle of two drugs: Who won? – An unusual presentation
- Return of the native and a resurrected foe: A case of Rhinocerebral Mucormycosis
- Covert invader- atypical presentation of neuronal migration disorder
- Fragile heart: an unusual cause of chest pain
- Goldberger’s ECG sign in Left Ventricular Aneurysm
- Congenital absence of bilateral Internal Carotid Artery: A case report
- The Power of Purple
- Beads of Nature’s Rattle
- Case Report
- Diagnostic Image
- EDITORIAL
- Kauverian eMedical Journal
- Modification of Management Strategies, And Innovations, During SARS Cov2 Pandemic Improved the Quality, Criticality and Outcomes in In-Patients “Rising to the occasion”, the mantra for success in the COVID -19 pandemic
- Time in Range (TIR) In Diabetes: A Concept of Control of Glycemia, Whose Time Has Come
- Kauvery Heart Failure Registry- A Concept
- Shorter Course of Remdesivir In Moderate Covid-19 is as Efficacious as Compared to Standard Regime: An Observational Study
- CASE REPORT
- Lymphoepithelial Carcinoma: A Case Report of a Rare Tumour of The Vocal Cord
- Diabetic Keto Acidosis (DKA), Associated with Failed Thrombolysis with Streptokinase in Acute Myocardial Infarction
- EARNING FROM EXPERIENCE – CHAPTERS 1 AND 2
- The Consultation Room
- Journal scan
- Recommended Reading
- DIAGNOSTIC IMAGE
- Notes to Nocturne
- Editorial
- Kauverian eMedical Journal
- Caring for nobody’s baby
- Special Report
- Research Article
- The curious case of a migrating needle on the chest wall
- Foreign body: A boon at times
- Cardiorenal Syndrome
- What My Grandmother Knew About Dying
- Endovascular Therapy for Acute Stroke with a Large Ischemic Region. N Engl J Med. 2022
- Letter to the Editor
- Clinical outcomes of Coronary Artery Disease in Octogenarians
- Diagnostic Image
- Learning from Experience – Intra Operative, Chapters 11 and 12
- The Consultation Room
- Journal Scan
- Recommended Reading
- colours
- Editorial
- Author Instruction
- Ultrashort Case Report
- Cochlear Implantation: Expanding candidacy and Cost Effectiveness
- Spontaneous Pneumomediastinum in COVID 19 – Tertiary Care Centre Experience in South India
- Amoxycillin Induced Anaphylactic Shock: A Case Report
- An Unusual Cause of Seizures: A Case Report
- Case Report
- Educational Strategies to Promote Clinical Diagnostic Reasoning
- Rheumatic Rarities
- Types of sampling methods in statistics
- Diagnostic Image
- Learning from Experience – Intra Operative, Chapters 21 and 22
- The Consultation Room
- Journal Scan
- Recommended Readings
- Editorial
- Author Instruction
- Journal Scan
- Myeloma
- Posterior Reversible Encephalopathy Syndrome (PRES)
- Prophylactic orthopaedic surgery
- Subclavian steal: An interesting imaging scenario
- Spondylo-epi-metaphyseal dysplasia (SEMD)
- The bleeding windpipe
- Learning from Experience – Intra Operative, Chapters 23 and 24
- The Consultation Room
- Diagnostic Image
- Recommended Readings
- Editorial
- Editorial Board
- Physician, Protect thyself
- Foetal Medicine, the Future is here!
- Japanese Encephalitis: A common menace
- Carpometacarpal dislocation with impending compartment syndrome
- Heterotopic pregnancy
- Femoral Trochantric and Proximal Humerus Fracture, from Diagnosis to Rehabilitation
- My Father’s Heart Block
- EPS page
- CRT CSP Cases
- Journal scan
- Learning from Experience – Intra Operative, Chapters 25 and 26
- The Consultation Room
- Recommended Readings
- Editorial
- Editorial Board
- Multiple Sclerosis: An overview
- A flower born to blush unseen
- Guest Editorial
- Radio-frequency ablation as an effective treatment strategy in a case of VT storm post STEMI
- Lymphatic malformation of tongue
- Bilateral anterior shoulder dislocation in epilepsy: A case report and review of literature
- An unusual cause of Stridor
- Monoclonal Antibodies (mAbs) – the magic bullets: A review of therapeutic applications and its future perspectives
- Write the Talk
- Press release and Comments
- Probability Distribution of Bernoulli Trials
- Journal Scan
- Recommended Readings
- poem-v4i4
- Editorial
- Editorial Board
- Research
- Research
- Lambda-cyhalothrin and pyrethrin poisoning: A case report
- Good Enough
- The Monoclonal antibodies (mAbs): the beginning
- Comprehensive trauma course 2022: Trauma Management & Kauvery
- Comprehensive trauma course 2022: Introduction to Comprehensive trauma course
- Diagnostic Image
- Learning from Experience – Intra Operative, Chapters 27 and 28
- The Consultation Room
- Recommended Readings
- Poem
- Editorial
- The Brave New World of Anaesthesia
- Anesthetic considerations in Wilson’s disease for fess: A case report
- The painful story behind modern anaesthesia
- Anesthesia considerations for Ankyslosing Spondylitis
- Total intravenous anaesthesia: An overview
- Risk stratification for cardiac patients coming for non-cardiac surgeries
- The Anaesthesiologist’s role in fluoroscopic guided epidural steroid injections for low back pain
- Awake Craniotomy
- Malpositioned central venous catheter: Step wise approach to avoid, identify and manage
- Benefits outweighing risk: Neuraxial anaesthesia in a patient with Spina Bifida with operated Meningomyelocele
- Pain free CABG: newer horizon of minimally invasive cardiothoracic surgery a walk through anaesthesiologist perspective
- Stellate Ganglion Block: A bridge to cervical sympathectomy in refractory Long QT Syndrome
- Venous Malformation in Upper Airway – Anesthetic Challenges and Management: A Case Report
- Editorial
- USG guided peripheral nerve block in surgery for hernia
- Anaesthesia and morbid obesity: A systematic review
- Patient-Controlled Analgesia
- Parapharyngeal abscess of face and neck: Anesthetic management
- 3D TEE, a boon for the diagnosis of Left Atrial Appendage thrombus!
- Anaesthetic management of difficult airway due to retropharyngeal abscess and cervical spondylosis
- Expect the unexpected – Breach in continuous nerve block catheter
- Lignocaine nasal spray: An easy remedy for Post Dural Puncture Headache
- Potassium permanganate poisoning and airway oedema
- Angioedema following anti-snake venom administration
- Editorial
- Editorial Board
- Ra Fx ablation of Atrioventricular nodal reciprocating tachycardia
- Pace and Ablate Strategy: Conduction system pacing with AV junction ablation for drug refractory atrial arrhythmia – A novel approach
- Why Cardiac Resynchronization Therapy (CRT) For complete heart block? A case discussion
- Pacemakers and Bradyarrhythmias in Diabetic Mellitus
- Outcomes of Total Knee Arthroplasty in patients aged 70 years and above
- An approach to CBC for practitioners
- Acute cerebral sinus venous thrombosis with different presentations and different outcomes: A case series
- Diet and nutritional care for DDLT: A case study
- Vaccine for Dengue (Dengvaxia CYD-TDV)
- Diagnostic Image
- Learning from Experience – Intra Operative, Chapters 31 and 32
- Recommended Readings
- காவிரித்தாய்
- ATLAS OF HAEMATOLOGY AND HEMATOONCOLOGY
- Editorial
- Editorial Board
- Case reports and Case series:
- Usefulness of NEWS 2 score in monitoring patients with cytokine storm of COVID-19 pneumonia
- Treatment approach for extensively Drug-Resistant Tuberculosis (XDR-TB)
- Modified Lichtenstein mesh repair, for a patient of Coronary Artery Disease, Heart Failure and with Implanted Cardioverter- Defibrillator
- Fever-induced Brugada Syndrome
- Pulmonary Thrombo Embolism: When to Thrombolyse?
- Ultra-Short Case Report
- Learning from the failure of Nebacumab
- Journal scan
- Learning From Experience Intra Operative Chapters 29 and 30
- Recommended Readings
- Poem
- Editorial
- Editorial Board
- Heart transplantation: Life beyond the end of life
- Azithromycin to Prevent Sepsis or Death in Women Planning a Vaginal
- Medial retropharyngeal nodal region sparing radiotherapy versus standard radiotherapy
- Proximie: Patient safety in surgery – the urgent need for reform
- Analysis of femoral neck fracture in octogenarians and its management
- Adult Immunisation in Clinical Practice: A Neglected Life Saver
- “Icing” The Eyes
- Doppler vascular mapping in Arterio Venous Fistula (AVF)
- Cosmesis and cure: Radiotherapy in basal cell carcinoma of the dorsum of nose – A case report
- Pulmonary Hypertension and Portal Hypertension
- Comprehensive review of Drug-Induced Cardiotoxicity
- Statistics – Data Collection – Case Study Method
- Atlas of Haematology and Hematooncology
- PRE-OPERATIVE Chapters 1 and 2 – Learning from Experience
- Chapter 2. Uncertainties in medicine in spite of advances
- No Splendid Child
- Editorial
- Editorial Board
- A Young Girl Lost in the Storm
- ECMO as a bridge to Transplant: A case report
- Renal anemia – from bench to bedside
- Mission Possible
- New kids on the block – Update on diabetic nephropathy therapy
- Infections – Trade off in Transplants
- To Give Or Not to Give – Primer on Bicarbonate Therapy
- Sialendoscopy: Shifting paradigms in treatment of salivary gland disease
- Gait imbalance in a senior due to Chronic Immune Sensory Polyneuropathy (CISP)
- Statistics – Mcnemar Test
- Atlas Of Haematology And Hematooncology
- PRE-OPERATIVE Chapters 3 and 4 – Learning from Experience
- Changing trends a challenge to the already trained
- Journal scan
- Recommended Readings
- EDITORIAL
- EDITORIAL BOARD
- PREGNANCY POST-RENAL TRANSPLANT
- BALLOON-OCCLUDED RETROGRADE TRANSVENOUS OBLITERATION
- REVERSE SHOULDER ARTHROPLASTY FOR ROTATOR CUFF ARTHROPATHY
- THE AMBUSH A TEAM APPROACH
- ENDOSCOPIC TRANS-SPHENOID APPROACH FOR PITUITARY ADENOMA EXCISION
- A STUDY ON PRESENTATION AND OUTCOME OF BULL GORE INJURIES IN A GROUP OF TERTIARY CARE HOSPITALS
- A CASE OF INTERNUCLEAR OPHTHALMOPARESIS AS THE FIRST MANIFESTATION OF MULTIPLE SCLEROSIS
- GRANULOMATOSIS WITH POLYANGITIS AND LUNG INVOLVMENT (WEGENER’S DISEASE)
- RITUXIMAB (RITUXAN, MABTHERA) IN THE TREATMENT OF B-CELL NON-HODGKIN’S LYMPHOMA
- STATISTICAL SIGNIFICANCE
- Atlas Of Haematology And Hematooncology
- PRE-OPERATIVE CHAPTERS 5 AND 6 – LEARNING FROM EXPERIENCE
- Chapter 4: Diagnostic process often reversed
- Journal scan: A review of 25 recent papers of immediate clinical significance, harvested from major international journals
- Recommended Readings
- ஆரோக்கியம் நம் கையில்
- வெற்றியின் பாதை
- Editorial
- Editorial Board
- Prevalence of vitamin D deficiency in a multi-speciality hospital orthopaedic outpatient clinic
- Esomeprazole induced Hypoglycemia
- Dynamic external fixator for unstable intra articular fractures of Proximal Interphalangeal Joint (PIP): “Suzuki” frame
- How to Practice Academic Medicine and Publish from Developing Countries? A Practical Guide, Springer Nature, 2022
- WINTNCON 2022 – Scientific Program
- Pulmonary Thrombo Embolism: A state of the art review
- Role of Artificial Intelligence in improving EHR/EMR and Medical Coding and billing
- Monoclonal Antibodies: Edrecolomab and Abciximab
- Atlas of haematology and hematooncology
- Journal scan
- Learning from Experience – Intra Operative, Chapters 31 and 32
- What doctors must learn: Doctor, look beyond science
- Recommended Readings
- I Whisper Secrets In My Ear
- EDITORIAL
- Instructions for Authors
- Mismatched Haploidentical Bone Marrow Transplantation in a 10-year-old boy with relapsed refractory acute lymphoblastic leukemia, at Trichy
- ST-Segment Elevation is not always Myocardial Infarction
- Acyanotic Congenital Heart Disease, repaired, evolves into a Cyanotic Congenital Heart Disease and presents with an atrial tachycardia
- Family medicine – caring for you for the whole of your life. A Lost and Found Art
- The Principles and Practice of Family Medicine
- Complete Heart Block
- Sick Sinus Syndrome (SSS)
- The First Ever National Award Comes to Kauvery Hospital Chennai & Heart City for Safety and Workforce Category in IMC RBNQA Milestone Merits Recognition 2022
- Diagnostic Image
- PRE-OPERATIVE CHAPTERS 7 AND 7 – LEARNING FROM EXPERIENCE
- Chapter 5: Super-specialist – boon or bane
- Journal scan: A review of 42 recent papers of immediate clinical significance, harvested from major international journals
- RECOMMENDED READINGS
- நேரம் ஒதுக்கு
- மருத்துவரின் மகத்துவம்
- EDITORIAL
- Instructions for Authors
- Surgical Management of Covid-19 Associated Rhino-Orbito-Cerebral-Mucormycosis (Ca-Rocm) – A Single Centre Experience
- Knee Joint Preservation Surgeries
- Guest Editorial Comments
- Ventricular Septal (VSR) closure with ASD device
- Newer Calcium Debulking Angioplasty technique of Orbital Atherectomy
- An hour-long CPR to restart the heart
- VT or SVT with aberrancy?
- Pituitary Neuroendocrine Tumor (PitNET)
- VSD Device Closure
- PDA Device Closure
- Iron Deficiency Anemia, Post MVR
- Torsades de Pointes
- Quality improvement project to Reducing the Malnutrition Rate of ICU patients from 43% to 20%
- Long term use of Amiodarone in Cardiac patients: A Clinical Audit
- Statistical Independent Events and Probability
- PERI-OPERATIVE Chapters 9 and 10 – Learning from Experience
- Journal scan: A review of 40 recent papers of immediate clinical significance, harvested from major international journals
- EDITORIAL
- Kauverian Medical Journal
- First da Vinci Robotic Surgery in Carcinoma Prostate: A Case Report
- Black burden or Taylor the saviour: A case report
- Analysis of differences in Oncology practice between the United Kingdom and India
- A Case of Takayasu Arteritis
- Idiopathic Dilated Pulmonary Artery (IDPA)
- ECG Atlas
- Unusual cause of Dysphagia: A case report
- Tu Youyou: The scientist who discovered artemisinin
- Continuing Nursing Education (CNE) on Risk assessment tools, to assess vulnerable patients at Kauvery Hospital, Tennur
- DIAGNOSTIC IMAGE
- PRE-OPERATIVE CHAPTERS 11 AND 12 – LEARNING FROM EXPERIENCE
- OLD AND NEW – MAKE THE BEST OF THE TWO
- Journal scan: A review of 30 recent papers of immediate clinical significance, harvested from major international journals
- Recommended Readings
- EDITORIAL
- INSTRUCTION TO AUTHORS
- A pregnant patient with DKA, septic shock and a lactate mystery
- Radical Thymectomy in Myasthenia Gravis through Partial Sternotomy approach: A report on three patients
- In-utero blood transfusion in two etiologically distinct anaemic fetus
- RARE CAUSE OF PULMONARY HYPERTENSION
- Acute Rheumatic fever is still an enigma
- A remarkable journey: Managing LQTS in a 43-year-old female with recurrent syncope and seizure
- An unusual case of Acute Coronary Syndrome
- Reversible cause of severe LV Dysfunction in Left Bundle Branch Block
- A case study on Rhino-Orbital-Cerebro- Mucormycosis
- Snakebite and its management
- Total Elbow arthroplasty in Post Traumatic arthritis
- Wellens Syndrome: An ECG finding not to miss!
- Dr. C.R. Rao Wins Top Statistics Award a look back at his pioneering work
- PRE-OPERATIVE Chapters 13 and 14 – Learning from Experience
- Chapter 7. Doctor-patient relationship
- Journal scan: A review of 30 recent papers of immediate clinical significance, harvested from major international journals
- EDITORIAL
- INSTRUCTION TO AUTHORS
- FROZEN ELEPHANT TRUNK (FET) PROCEDURE IN A 52 YEARS OLD CHRONIC AORTIC DISSECTION PATIENT
- DIAGNOSING AND MANAGING EISENMENGER SYNDROME IN A YOUNG MALE
- STEMI EQUIVALENT BUT STEMI!
- TEMPORARY HEAL CAN POSSIBLY KILL!
- UNDERSTANDING PUBERTY
- THE IMPORTANCE OF STATISTICS IN HEALTHCARE
- JOURNAL SCAN: A REVIEW OF 44 RECENT PAPERS OF IMMEDIATE CLINICAL SIGNIFICANCE, HARVESTED FROM MAJOR INTERNATIONAL JOURNALS
- DIAGNOSTIC IMAGE
- PRE-OPERATIVE CHAPTERS 15 AND 16 – LEARNING FROM EXPERIENCE
- CHAPTER 8. DOCTOR-DOCTOR RELATIONSHIP
- EDITORIAL
- GUEST EDITORIAL
- CLINICAL AUDIT: AN INTRODUCTION
- YOUNG ACS AUDIT
- CLINICAL AUDIT: ANAESTHESIA
- CLINICAL OUTCOME IN ICU PATIENTS
- RATE OF MALIGNANCY IN INDETERMINATE OVARIAN CYST – A PROCESS AUDIT
- PATTERNS OF NEEDLE DISPOSAL AMONG INSULIN USING PATIENTS WITH DIABETES MELLITUS: AN AUDIT
- CONTINUOUS PATIENT MONITORING – LIFE SIGNS
- AGE IS JUST A NUMBER!
- SVT WITH LEFT BUNDLE BRANCH BLOCK FOLLOWING GASTRECTOMY
- COMPLEX AORTIC DISSECTION WITH MULTIFACETED CLINICAL PRESENTATIONS
- EDITORIAL
- POST-OPERATIVE SORE THROAT IN GA: A CONCERN
- NEONATAL HLH: OUR EXPERIENCE
- CLINICAL REVIEW MEET 16TH NOV 2023: CHALLENGES IN SETTING UP A NEW HSCT CENTRE IN A TIER-2 CITY IN INDIA
- CARDIAC BIOMARKERS: CLINICAL UTILITY
- HIRAYAMA DISEASE: A CLINICAL-RADIOLOGICAL REVIEW
- ECG AS A WINDOW OF OPPORTUNITY: FOR HYPERKALEMIA
- EFFECTIVENESS OF ROOD’S APPROACH BASED PAEDIATRIC OCCUPATIONAL THERAPY MANAGEMENT: ON CHILDREN WITH CONGENITAL MUSCULAR TORTICOLLIS
- ELTROMBOPAG, A NOVEL THROMBOPOIETIN (TPO) RECEPTOR AGONIST: AN OVERVIEW
- HENOCH-SCHONLEIN PURPURA
- SUBMANDIBULAR GLAND SIALADENITIS SECONDARY TO SUBMANDIBULAR CALCULUS
- LEAN HOSPITALS
- STATISTICS BLACK-SCHOLES MODEL
- PERI-OPERATIVE CHAPTERS 17 AND 18 – LEARNING FROM EXPERIENCE
- CHAPTER 9. BUILDING BLOCKS OF PATIENT CARE
- JOURNAL SCAN: A REVIEW OF 30 RECENT PAPERS OF IMMEDIATE CLINICAL SIGNIFICANCE, HARVESTED FROM MAJOR INTERNATIONAL JOURNALS
- EDITORIAL
- INSTRUCTIONS TO AUTHORS
- ROTATHON-SERIES OF SUCCESSFUL ROTA CASES LAST 2 MONTHS: AN AUDIT
- OUTCOMES OF AKI AUDIT IN KAUVERY
- ETIOLOGY, CLINICAL CHARACTERISTICS AND OUTCOMES OF PATIENTS WITH ACUTE PANCREATITIS IN KAUVERY CANTONMENT HOSPITAL (KCN), TRICHY
- USE OF BLOOD PRODUCTS AND STEROIDS IN THE MANAGEMENT OF DENGUE AT KAUVERY TRICHY HOSPITALS: A CLINICAL AUDIT
- A CLINICAL AUDIT: ON THE MANAGEMENT OF ECTOPIC PREGNANCY
- DIABETIC KETOACIDOSIS WITH HIGH ANION GAP METABOLIC ACIDOSIS
- HYPOKALEMIC PARALYSIS FROM DISTAL RENAL TUBULAR ACIDOSIS (TYPE-1)
- DELAYED PRESENTATION OF INTERMEDIATE SYNDROME IN A PATIENT WITH ORGANOPHOSPHORUS POISONING: A CASE REPORT
- SCAPULA FRACTURES: DO WE NEED TO FIX THEM?
- SPONTANEOUS CSF RHINORRHEA
- DANCING WITH DIABETES: AN UNUSUAL CASE OF CHOREA HYPERGLYCEMIA BASAL GANGLIA SYNDROME
- CONVALESCENT RASH OF DENGUE
- ECG ATLAS 2
- MI MIMICKER
- PERFORATION PERITONITIS-A CASE REPORT
- APPLICATION OF EVIDENCE BASED PRACTICE CARE FOR INDIVIDUALS WITH SPINAL CORD INJURY WITH FUNCTIONAL DIFFICULTIES: ROLE OF THE OCCUPATIONAL THERAPY PRACTICE GUIDELINES
- METHOTREXATE INDUCED MUCOSITIS AND PANCYTOPENIA: A CONSEQUENCE OF MEDICATION ERROR IN A PSORIASIS PATIENT
- POST OPERATIVE CHAPTERS 1 AND 2 – LEARNING FROM EXPERIENCE
- CHAPTER 10. NURTURING SELF
- விடாமுயற்சி வெற்றி தரும்
- JOURNAL SCAN: A REVIEW OF 26 RECENT PAPERS OF IMMEDIATE CLINICAL SIGNIFICANCE, HARVESTED FROM MAJOR INTERNATIONAL JOURNALS
- EDITORIAL
- EDITORIAL BOARD
- LIMB SALVAGE IN EXTREMITY VASCULAR TRAUMA: OUR EXPERIENCE
- MANAGEMENT OF URETHRAL CATHETER RELATED PAIN IN RENAL TRANSPLANT RECIPIENTS: A CLINICAL AUDIT
- NO PAIN VEIN GAIN WITH PRILOX IN PAEDIATRIC POPULATION
- GUIDELINE-DIRECTED MEDICAL TREATMENT (GDMT) OF HEART FAILURE AT KAUVERY HOSPITALS: A CLINICAL AUDIT
- PATIENTS STORY: DIGNITY MATTERS
- PATIENTS STORY: DIGNITY MATTERS
- VIDEO PRESENTATION- CT CORONARY ANGIOGRAPHY
- DRUG INDUCED HYPERKALEMIA
- ADULT NEPHROTIC SYNDROME
- EXPLORING COMPLEX CARDIAC CASES: INSIGHTS FROM DIVERSE PRESENTATIONS IN MID-AGED WOMEN
- EFFECTIVENESS OF ACTIVITY CONFIGURATION APPROACH BASED OCCUPATIONAL THERAPY INTERVENTION FOR CHILDREN WITH CONGENITAL MUSCULAR TORTICOLLIS: A CASE STUDY
- CARDIOMYOPATHY AND ITS ECHO FINDINGS
- THE STRESS TEST ON THE TREADMILL
- POST OPERATIVE CHAPTERS 3 AND 4 – LEARNING FROM EXPERIENCE
- CHAPTER 11. BALANCE IN LIFE BEYOND BANK BALANCES
- JOURNAL SCAN: A REVIEW OF 30 RECENT PAPERS OF IMMEDIATE CLINICAL SIGNIFICANCE, HARVESTED FROM MAJOR INTERNATIONAL JOURNALS
- காணும் பொங்கலும் மனித மன மாற்றமும்
- EDITORIAL
- INSTRUCTIONS TO AUTHORS
- PREVALENCE OF STREPTOCOCCUS PNEUMONIAE SEROTYPES IN AND AROUND TRICHY AND ITS CLINICAL RELEVANCE
- ANAESTHETIC MANAGEMENT OF A PATIENT WITH HUGE GOITER: A CASE REPORT
- EUGLYCEMIC DIABETIC KETOACIDOSIS A RARE CAUSE FOR DELAYED EXTUBATION
- SUCCESSFUL PREGNANCY IN ASD PATIENT – COMPLICATED BY SEVERE PULMONARY ARTERIAL HYPERTENSION
- ENDOCRINE COMPLICATION OF GROWTH HORMONE SECRETING TUMOR: A CASE REPORT
- EFFICACY OF EARLY DIAGNOSIS AND DEVELOPMENT APPROACHES OF PAEDIATRIC OCCUPATIONAL THERAPY ON ACUTE DISSEMINATED ENCEPHALOMYELITIS: A CASE REPORT
- POST OPERATIVE CHAPTERS 5 AND 6 – LEARNING FROM EXPERIENCE
- CHAPTER 12. MILES TO GO – BEFORE TEACHING BECOMES LEARNING
- JOURNAL SCAN: A REVIEW OF 26 RECENT PAPERS OF IMMEDIATE CLINICAL SIGNIFICANCE, HARVESTED FROM MAJOR INTERNATIONAL JOURNALS
- காவேரி – 25
- POEM – மண்ணில் பிறந்தது சாதிப்பதற்குத்தான்
- EDITORIAL
- EDITORIAL BOARD
- Audit Appraisal: An overview
- Intra Ventricular antibiotics: Our experience
- Transfusion Reactions: A clinical audit
- Postoperative pain management
- Rising concerns of Carbapenem resistant Enterobacteriaceae and the options available: An overview
- Ultrashort case report on VF storm in immediate Post CABG Period—‘Angry Purkinje Syndrome’
- Lynch syndrome, diagnostic challenges and management: A case report
- Bilateral posterior shoulder fracture – dislocation due to seizure, an uncommon injury: A case report
- Navigating amlodipine overdose: A multi-disciplinary approach in a 23 year old female
- Exploring the interplay between sleep patterns and behavioural characteristics in individuals with Autism Spectrum Disorder (ASD)
- POST OPERATIVE Chapters 7 and 8 – Learning from Experience
- Chapter 13. Art of communication and counselling
- Journal scan: A review of 20 recent papers of immediate clinical significance, harvested from major international journals
- மருத்துவமனையின் தேவதையே
- மருத்துவ சிந்தனை விருந்து
- Editorial
- Instructions for Authors
- Cardiac surgery in an octogenarian Indian population
- Mycotic Aortoiliac Aneurysm: A case series
- The Scorpion Block—A Sting operation
- Arterial Thoracic Outlet Syndrome: A case report
- Infective endocarditis in adult congenital heart disease: A case report
- Takotsubo cardiomyopathy: A case report
- Cerebral Venous Thrombosis (CVT): A case report
- Hemophagocytic Lymphohistiocytosis in Dengue
- A prospective observational study on the prescription of Guideline Directed Medical Treatment (GDMT) for Heart Failure at Kauvery Heart City
- Guideline-Directed Medical Treatment (GDMT) of Heart Failure at Kauvery Hospitals: A clinical audit
- POST OPERATIVE Chapters 9 and 10 – Learning from Experience
- Chapter 14. How to keep updated in busy medical practice?
- Journal scan: A review of 15 recent papers of immediate clinical significance, harvested from major international journals
- சிந்தனையே சிறப்பு
- தோல்வியே வெற்றியின் பாதை
- Editorial
- Results of Mechanical Thrombectomy in acute stroke: A case study in a Tier 2 city in India
- A clinical audit—cost effective way of managing superficial chest wound infections post sternotomy
- Dental implants: Our experience and expertise
- A non-randomized retrospective study on the management of pediatric septic arthritis
- Analysis of femoral neck fracture in octogenarians and its management
- Airway management of a huge thyroid: A case report
- Cardiac Arrhythmias in the ER setting
- Effectiveness of tactile-spatial oriented approach based paediatric occupational therapy intervention for children with Infantile Hemiplegia
- Corporate citizenship in healthcare: Nurturing social responsibility
- Guillain-Barré syndrome: A case report
- POST OPERATIVE Chapters 11 and 12 – Learning from Experience
- Chapter 15. How to be rational in practice?
- Journal scan: Elsevier’s Medicine, Current Issue, Volume 52 Issue 6, June 2024, Seminar on Poisoning
- Recommended Readings
- இயற்கை சொல்லும் செய்தி
- Editorial
- Instructions for Authors
- A rare organism causing septic arthritis of hip joint
- ICD implant in 6 year old with Jervell and Lange-Nielsen (JLN) syndrome
- A clinical audit on Bariatric/Metabolic surgery
- Clinical audit on Nil per Oral (NPO)
- A non-randomized clinical study on heat stroke
- Stress cardiomyopathy with posterior reversible encephalopathy syndrome in Eclampsia
- Intro-Reversible Cerebral Vasoconstriction Syndrome (RCVS): An ultra-short case report
- A 2 am Tamponade: Critical call to action
- Immune Checkpoint Inhibitors, and in combination with JAK inhibitors: The modelling for the future
- Optimizing the patient journey in hypertrophic cardiomyopathy—Patient and clinician perspectives: Summary of CME from Medscape
- ER Intervention
- Diagnostic Images/Videos
- A randomized controlled trial: Different types of blinding
- Journal scan – June
- Journal scan – July
- Post-Operative Chapters 13, 14
- Chapter 16. How to enjoy medical practice?
- Driving business growth with 5S and lean strategies: A transformative session for corporations in the Trichy region
- Poem: 25 – வருடங்களாக காவேரி
- Editorial
- A Data Audit: Tool for Good Clinical Practice
- Ortho rehab audit at Kauvery Hospital, Trichy
- Endovascular Thrombectomy in young patient with a stroke – surgical procedure decompressive craniotomy
- Secondary HLH (Hemophagocytic Lymphohistiocytosis): An ultra-short case report
- Prone ventilation: A case series
- Dermatologic Emergencies: A case series
- Managing DKA at the ER
- Podcast – Managing DKA at the ER
- Insertion of tunneled hemodialysis catheter through the collateral vein adjacent to the thrombosed right jugular vein.
- Access failure with dysfunctional tunnelled haemodialysis catheter in the presence of exit-site infection
- Video – A multidisciplinary approach to preventing sudden cardiac death
- Dasatinib in pediatric Chronic Myeloid Leukemia: An overview
- Dyslipidemia management: Indian perspective
- Pharmacological stress testing: Assessing heart health without exercise
- Journal scan: A review of 15 Ethics with clinical significance, harvested from a major international journal
- Post-Operative Chapters 15 and 16
- Chapter 17. How to find time for the family
- Poem – உனக்காக நீ
- Editorial
- An audit: A silent disease-Osteoporosis
- An approach to antibiotic therapy: A primer for all specialties
- Audit on pediatric Cholesteatoma
- Clinical audit: ER to ICU transit time
- A case report on Multiple myeloma: Value of pre and post-treatment MRI
- Unrelated donor bone marrow transplantation in 3 year old with Acute Myeloid Leukemia
- Infective endocarditis: A case series
- A Retrospective observational study on Scrub typhus paediatric population in Kauvery Hospitals, Trichy
- Clinical Pharmacy Approach: To a patient on multiple anticonvulsants for “Difficult to control’’ seizure disorder
- An analysis of the Urea to Creatinine Ratio (UCR) in different cardiac surgeries
- Journal scan – 1
- Journal Scan – 2
- Post-Operative Chapters 17 and 18
- Chapter 18. How to be legally safe in medical practice?
- Poem – காவேரியின் மாரத்தான்
- Poem – ஆரோக்கியம் என்னுடையது
- Editorial
- Clinical audit on antibiogram
- Renal transplantation in marrow dysfunction: A case series
- Empowering lifesavers: Impact of BLS and PALS training for PICU and critical care nurses
- Myotonia congenita: A case series
- Utilization of Inj. Sovateltide: A novel injectable formulation
- Retroperitoneal sarcoma: A report of two cases
- Traumatic simultaneous bilateral femur and tibia shaft fracture in an 8-year-old male child: An unusual case report
- Echocardiography in the assessment of shock
- Plasma combats angioedema: A case report
- A case report and video presentation on a 9-year-old boy who underwent PAPVC
- Interventional Radiology: Large gastric varices
- Interventional Radiology: A case of active PV bleeding post-D and C day 12
- Diagnostic Images: Exencephaly
- A short case report on Hyperdontia (extra teeth)
- Post-Operative Chapters 19 and 20
- Chapter 19. How to deal with incurable disease?
- CII CFO Excellence award: A recognition of exceptional leadership
- Journal scan
- Poem – மறுக்காதே மறவாதே
- Extraordinary Edition of the Kauverian