Vol. VI Issue I July 2014

LIGNITE LIFE LINE

INSIDE1

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45

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Inauguration of Upgraded Facilities Diabetes, Hypertension and Kidney DiseaseHypotensive AnaesthesiaSkin Manifestations of Diabetes

Obesity & Anaesthetic Challenges Continuing to learn & EventsObstructive Sleep Apnoea

A to G in the Management of DiabetesFetal Tissue Implantation

Anaesthesia for Intraocular Surgery

PROVEN VALUES. POWERFUL VISION

The renovated and upgraded spacious Emergency Department was Inaugurated on April 07, 2014 by our beloved

CMD Shri B. Surender Mohan, in the presence of Shri Sarat Kumar Acharya, Director (HR), Shri Rakesh Kumar, Director

(Finance), Shri S.Boopathy, Director (P&P), Shri S.Rajagopal, Director (Power), Shri M.S.Ravindranath, Director (Mines)

and Dr.K.Janardhan, CGS/Medical. The renovated Clinical Laboratory was also inaugurated on this occasion.

Inauguration of Upgraded Facilities

Obstructive Sleep Apnoea

Dr. A.Malarvizhi Department of Anaesthesia

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Obstructive Sleep Apnoea is a disorder in which there will be brief pauses in respiration while you sleep. Then the normal respiration starts again. When the pause occurs, that will disrupt your sleep because of low oxygen levels in the blood.Causes:3 Old age 3 Brain injury 3 Decreased muscle tone3 Drugs3 Alcohol3 Neurological problem3 Increased soft tissue around the airway as in obesity3 Structural features that give rise to a narrowed

airway Symptoms3 Day-time sleepiness or fatigue

3 Dry mouth3 Headache3 Irritability, forgetfulness3 Night sweatEffects:OSA may lead to high blood pressure diabetesheart attack strokearrhythmias insulin resistancedepression anxietyGastro Oesophageal Reflex Disease (GERD)Cognitive impairment (memory problem)Even sudden death can occur.Diagnosis:3 The person with OSA does not know it as it occurs

during sleep. Only the bed partner or family member may notice this first

3 Loud snoringTreatment:3 Losing weight3 Stop alcohol, Stop Smoking3 An exercise programme may be adopted3 Change of sleeping Position Sleep on their side Sleep on slightly propped up position3 Mouth-pieces3 Breathing devices 3 Surgery

DESCRIPTION IDEAL LEVELHOW OFTEN

Dr. Subramaian Department of Internal Medicine

A to G in the Management of Diabetes

Blood Pressure Control

Cholesterol (LDL) Level

Diabetes Kidney Mocroalbumin Test

Goals For Self-management

HbA1C

Lowering your Blood Pressure Reduces Complications

Eye ExaminationFundus Eye (Retina) Examination

Lowering your LDL Level Reduces Complications

- Observe the Feet

- Check Pulses

- Test Sensation

Foot Examination

Every 3 Months Less than 7%

Every Year Less than 135 / 80

Every Year Less than 100 mg / dl.

Every Year Less than 30 pg / g

Every Year

Every Year

Every Year

Every Visit

Every Day

Diabetes, Hypertension and Kidney Disease

Dr. C.Dharini Mouli Renal Care Unit

Diabetic Nephropathy is defined as a progressive

decline in renal function with rise in urine albumin

excretion and increasing blood pressure resulting in

reduced glomerular filtration rate and eventually ESRD

(End Stage Renal Disease).

Pathophysiology of diabetic nephropathy involves

hyperglycemia, enhanced activity of Renin –

Angiotensin – Aldosterone System (RAAS) and

increased intraglomerular and systemic blood pressure.

ESRD is associated with heightened cardiovascular

mortality. There is an enhanced risk of coronary heart

disease among people without manifest vascular

disease even at the earliest stages of CKD. Also the

relative risk of fatal coronary artery disease associated

with diabetes has been shown to be 50% higher in

women than in men.

Treatment strategies:

It is proven that the risk of diabetic Nephropathy is

higher in patients with poor metabolic control and that

hyperglycemia is imperative for diabetic nephropathy

Scabies is a skin infestation caused by an ecto-parasite

sarcoptes scabei (itch mite). It is common among

inmates of hostel, old age homes, prisons etc., where

there is close contact among people. It is not transmitted

from animals.

It causes pimple - like rash over wrist, elbow, axilla,

between fingers, waist, genitals and buttocks. It can

cause intense itching at night. When a person is infected

for the first time, the onset of symptoms may be delayed

up to two months, but for the second

time, he develops itching very early.

Itching is due to allergy to the mite

and its feaces. In elderly, debilitated

p e r s o n s a n d t h e i m m u n o -

suppressed, thick crusts form in the

skin with large number of mites called

crusted or Norwegian scabies.

Scabies can lead to secondary

bacterial skin infections, scabies is

transmitted from person to person by

close skin contact or through

contaminated items like clothing,

and impaired renal function to develop. Intensive

glycemic control substantially reduces the risk of

development of microalbuminuria in type I & type II DM.

Target HbA1C is recommended to be <7%.

Newer drugs prevent the progression of cardiovascular

disease complicating diabetes and improve renal

function by decreasing albuminuria.

Systolic blood pressure has a significant association

with progressive decline in kidney function in diabetics.

The risk of developing albuminuria decreased with

lowering of Blood Pressure. Tight Blood Pressure

control led to risk reduction in diabetes related end

points, deaths, strokes and in microvascular end points

when compared to less tight control.

Diuretic therapy also improves the antiproteinuric

effects of RAAS blocking agents. However, use of

thiazides is plagued with increased incidence of

Dyslipidemia. Treatment with decreases the risk statins

of cardiovascular events and also delays the

progression of diabetic nephropathy.

Dr J. Ilango Department of Internal Medicine

Scabies

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bedding and furniture.

The itch mite lives in the upper layers of the skin

(epidermis), making small burrows where the female mite

(0.3 to 0.4mm) lays eggs.

Scabies is treated with or like scabicidal creams lotions

permethrin lindane ivermectin. and and oral drugs like

All contacts of the infected persons are to be treated at the

same time. Clothing should be cleaned in hot water and

dried in the hot sun.

A fetus is an implanted human embryo from eight weeks

after conception until birth. Fetal tissue or stem cell is

derived from legal abortions and is used for scientific

research into fundamental biological processes and

human development. In addition, transplantation

For clinical applications, fetal tissue transplantation is

considered an approach with great potential for patients

with illnesses such as Parkinson's, diabetes or heart

disease. Transplanted fetal cells elicit less of an immune

response than do adult cells, lowering the risk of tissue

rejection. In addition, early fetal cells are not as

developed as adult cells and are more able to

accommodate to the host.

research uses fetal tissue to study potential treatment of

life threatening diseases.

Fetal tissue research is legal in the United States.

Scientists have used fetal tissue in research since the

1930s. Fetal cells hold unique promise for biomedical

research due to their ability to rapidly divide, grow and

adapt to new environments. This makes fetal tissue

research relevant to a wide variety of diseases and

medical conditions.

Researchers use fetal tissue to explore normal

fetal development and to study its potential for

transplantation into other humans as a way to prevent or

treat disease and injury.

Devaratna Gladis Department of Nursing

Fetal Tissue Implantation

Yet fetal tissue transplantation is still not a proven

technology. In 2001, a clinical trial to treat Parkinson's

was halted after some patients developed severe

neurological side effects. Scientific progress is not

always a straight line. But without continuing this

research, we will never gain the wider understanding of

fetal cell processes that will lead to new clinical

techniques.

Courtesy : www.marymeetsdolly.com, www.nature.com

4

Add4OHT

l Growth factors encourage celldivision

l Retrovirus carrying c-mycER gene added

l Cells are growthenhanced andstabilised withc-mycER regulated by achemical in the culturemedium

l Removal of growthfactors and controlchemical enablesgrowth arrest anddifferentiation

l Stable cell linesremoved from culture and stores in vials

l Cells transplantedin simple one-offsurgical procedure

l Stems cells integrate into hostorgans aftergrafting

l Fetal tissuedissected and cellsreleased

l Dividing somaticstem cells moved totissue culture

l Isolate cellsexpressingc-mycER gene inpresence of 4OHT

l Culture cells toproduce stable celllines

Retroviruswith c-mycERgene Remove

4OHT

Sinus Surgery), Septoplasty, head and neck surgeries.

This method of anaesthesia is adopted by our anaesthesiologists in our hospital since years for ENT surgeries. Drugs like nitroglycerine, clonidine, esmolol, dexmedetomidine are being used as infusion to induce clear, lucid hypotensive field by bringing the blood pressure to 90/70 mm of Hg without affecting blood supply to target organs like brain, heart, kidney and liver.

Limitations to this specialized anaesthesia are the patients with :

1 Diabetes mellitus

2 Severe hypertension

3 Coronary artery disease

4 Kidney and liver disease

5 Anaemia and polycythemia

Selection of patient, proper drug and fluid infusion, meticulous monitoring of patients by anaesthesiologists in our hospital creates a path for successful ENT surgeries like FESS and Septoplasty

Hypotensive anaesthesia or induced hypotension is a method by which blood pressure is reduced in a predictable and deliberate manner in order to create bloodless dry field for the surgeon to do surgery. This facilitates surgeon for better visualization of structures, less damage to structures and fewer sutures needed.

Even though this method was introduced in the year 1917 for brain surgery, it has come in to vogue popularly in the past decade for FESS (Functional Endoscopic

Dr.N.Premkumar Department of Anaesthesiology

Hypotensive Anaesthesia

Skin Manifestations of DiabetesDr. P.Kavitha Department of Dermatology

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SKIN MAINFESTATIONS OF DM

n Diabetic Bullae

n Acanthosis nigricans

n Necrobiosis lipoidica

DIABETIC BULLAE

3 Dermatoses associated with DM

3 Present as small, dull, red papules with superficial scales. When it resolves it leaves small brown depressed scars

3 Site - shins

ACANTHOSIS NIGRICANS

3 Present as velvety hyper pigmented plaques with feathered edges

3 Sites - axillae, neck, groin and inframammary folds

3 Associated with insulin resistant diabetes

NECROBIOSIS LIPOIDICA

3 Present as well demarcated shiny, non tender atrophic plaques of yellowish orange colour

3 Telangiectatic vessels may be visible within the lesions

3 Older lesions may develop ulcers following even minor trauma

3 Site – shins

3 Most patients with necrobiosis have DM but less than 2 % of DM have necrobiosis lipoidiaca

TREATMENT

3 Control of Diabetes

3 Topical corticosteroids

3 In case of Necrobiosis lipoidica – intra lesional steroids can be injected

3 Ulcerated lesions need local wound care and oral antibiotics

Dr. Sundaravadivelu Department of Anaesthesia

Obesity & Anaesthetic Challenges

DEFINITION : Presence of excess body fat or body weight more than 20% of Ideal Body Weight Morbid obesity - body weight more than twice that of Ideal Body Weight

IBW

(Ideal Body Weight) = Height in Cm – 100 in Males.

Height in Cm – 105 in Females.

Based on BMI : BMI less than 18 Lean

18 to 24 Normal

25 to 29 Over-weight

30 to 34 Mild to Moderate obesity

35 to 39 Moderate to Severe obesity

More than 40 - Morbid obesity

More than 50 - SUPER OBESITY.

OBESITY is commonly associated with an increased incidence of

Hypertension

Coronary Artery Disease

Cerebro Vascular Accident

Diabetes Mellitus / IRS (Insulin Resistance Syndrome)

Liver Disease

Gallbladder Disease

Deep Vein Thrombosis/Pulmonary Embolism

Causes : Multifactorial

Genetic

Environmental

Psycho Social

ANAESTHETIC IMPLICATIONSPRE OPERATIVE : Emotional, Passive to Aggressive

Behaviour, Anxiety, Depression

Aspiration prophylaxis

Difficulty in mobilising the patient

INTRA-OPERATIVE:Difficulty in placing the patient on operating room table

Difficulty in getting IV access

Difficulty in non-invasive monitoring eg., NIBP CUFF Placing

Difficulty in invasive monitoring eg., Arterial BP, Central Venous Pressure

Difficult facemask ventilation

Fibreoptic intubation may be required

Technical difficulty with regional anaesthesia

IV induction dose to be calculated on actual body weight

Drug bio-transformation & metabolism may be altered due to excess body fat

Decreased cardio-pulmonary reserve

POST-OPERATIVE:Risk of hypoventilation

Risk of hypoxemia/hypercarbia

Risk of basal atelectasis

Risk of Deep Vein Thrombosis / Pulmonary Embolism being the commonest cause for post-operative mortality Risk of wound infection

June 6, 2014 - Dr. K. Janardhan, CGS/

Medical, gave a presentation on “Screening,

Prevention & Management of Diabetes at

Neyveli Lignite Corporation Ltd.,” at the

Bangalore Regional Round Table on NCDs

organised by Confederation of Indian

Industry.

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Round Table on Diabetes

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Dr. C.D. Venmal Devi Department of Ophthalmology

Anaesthesia for Intraocular Surgery

Abstract

The first recorded use of local anaesthesia for surgery

was the instillation of cocaine into the conjunctival sac in

1884 by an Austrian ophthalmologist, Karl Koller

(1858–1944), at the suggestion of Sigmund Freud.

Drugs

n Lidocaine 2%

n A mixture of lidocaine 2% and bupivacaine 0.75%

n Prilocaine 3% with felypressin.

n Hyaluronidase may improve local drug distribution.

n Some anaesthetists use epinephrine 1:200 000 to

prolong the duration of local anaesthesia.

Contra-indications to local anaesthesia

Absolute contra-indications are:

(i) patient refusal

(ii) local anaesthetic allergy

(iii) Infection/marked orbital inflammation.

Needles

25G sharp needles are commonly used. Various lengths

of needle (16–50 mm) are available. Needles >25 mm in

length may be associated with a greater risk of damage

to the optic nerve, but shorter needles do not abolish the

risk completely.

Topical anaesthesia

Topical application of local anaesthetics, instillation

should be made into the conjunctival sac

Proxymetacaine 0.5% and oxybuprocaine 0.4% are

less irritant than other agents. Topical anaesthesia

either alone or combined with direct intracameral

injection of small volumes of local anaesthetic is

sufficient to provide anaesthesia for cataract surgery in

co-operative individuals.

Local anaesthetic blocks

Any needle placed behind the globe is, by definition,

within the retrobulbar space and could therefore

endanger the optic nerve. A retrobulbar injection can be

achieved with a 16 mm needle.

Modified retrobulbar block

Topical local anaesthetic is a useful adjuvant to this

technique.

Peribulbar anaesthesia: The injections have

theoretical advantages over retrobulbar blocks but

scleral perforation can occur, larger volumes of injectate

are required.

Sub-Tenon's (episcleral) block

Sub-Tenon's block may have advantages, especially in

myopic or anticoagulated patients. The optic nerve

should not be at risk with this technique.

Complications of local anaesthesia

1. The risk of globe perforation is greater in

myopic patients. This leads to retinal detachment.

Perforation may result in soft eye and there may be

bleeding into the vitreous.

2. The use of longer needles may be associated with

increased risk of optic nerve damage.

3. Cardiorespiratory arrest is a consequence of

inadvertent intradural injection.

4. Retrobulbar haemorrhage (1–2% incidence)

5. Optic nerve damage (<1% incidence)

6. Local anaesthetic toxicity (uncommon)

Local anaesthetic may be inadvertently injected directly

into the cerebrospinal fluid via the dural sheath of the

optic nerve or into a branch of the inferior orbital vein.

This can lead to unconsciousness and cardiorespiratory

collapse. For this reason full resuscitation facilities

should be available.

LIGNITE LIFE LINENews Letter of NLC General Hospital

(for private circulation only)Published by Neyveli Lignite Corporation Limited, ‘Navratna’ - A Govt. of India Enterprise

Neyveli 607 801, Tamil Nadu. Website : www.nlcindia.com

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May 03, 2014 - Day Care Surgery in Clinical Practice, Dr. Patta Radhakrishna, SRM Insititute, Chennai

May 13, 2014 - Advances in Radiation Oncology Dr. Rathna Devi, Apollo Speciality, Chennai

May 23, 2014 - Endoscopic Brain Surgery, Dr.Natarajan, Gogulam Hospital, Salem

June 07,2014 - Parenteral Fluid Therapy, Dr. P.C.Vijayakumar, Suriya Hospital, Chennai

May 28, 2014 – Visit to NLC GH by Shri. P.K.Sarkar, DDGMS, Bangalore and Shri. A.K.Meghraj, DMS, Chennai

May 19, 2014 – Nurses Day Celebration at NLC General Hospital

Continuing to learn...

Events