Medi News A quarterly Newsletter NEW YEAR SPECIAL EDITION CAPSULE from ISSUE - 15 | JAN 2016 ISSUE - 15 | JAN FLORID HEART FAILURE

SUB MENTAL EMPHYSEMATOUS INTUBATION PYELONEPHRITIS

MANAGEMENT PULMONARY OF UTI SARCOIDOSIS

TELOVELAR THE METHOTREXATE APPROACH TO THE NIGHTMARE 4 TH VENTRICLE

8 AWARD CHOICE OF ANAESTHESIA

NOW WE ARE ON ONLINE VERSION TOO, VISIT www.kauveryhospital.com

This magazine is free circulation for and doctors only, Not for sale. Design and logo of kauvery are property of Kauvery Hospital, To get this magazine copy mail us at: [email protected] If you want to know any other details contact us on Editorial Address My Dear fellow clinicians,

As we step into a fresh year with renewed hopes & a refreshed perspective , I would like to thank each & every one of you for your unstinting support & patronage and playing a vital role in our growth & development.

We have worked together as an extended family and striven to make the best contribution to establish the best possible standards of healthcare delivery in this region.

Kauvery hospital has always worked with a vision of making quality healthcare affordable without compromising on quality. All our units in Trichy have been awarded the NABH certificate of pre-accreditation and this is a standing testimony to our quality quest.

Along with clinical bench-marking we have also focused on process bench-marking & adopted the principles of Lean management in our operational processes. The Platinum award of excellence for 5s practice that we have won recently is an honour we cherish & feel proud of.

I would like to acknowledge & appreciate your contribution in every accomplishment & milestone of ours and wish you all a successful , healthy & happy year ahead.

Warm regards, Dr. S. Chandrakumar, MD Managing Director WISH YOU A HAPPY NEW YEAR AND HAPPY PONGAL THIS " ONLINE VERSION " IS OUR NEW YEAR GIFT TO THE CLINICAL FRATERNITY AND HOPE Dear Doctors, IT WOULD FULFILL Our " Capsule " has been in existence since 2009 and every edition of Capsule has featured YOUR EXPECTATIONS standard articles across all medical specialties with updated information spanning a wide range AS ALWAYS. of interests.

We have consistently tried to match your academic quest and all the editions have received an overwhelming response from you which is indeed heartening and your feedback, appreciation & constructive criticism has motivated us to make it better and value added every time.

As you are aware , Kauvery Hospital has been a front runner in IT enabled healthcare and we have always kept our pace with the advancements in user friendly technology.

Keeping with this trend, we have now launched the " Online version " of Capsule making it portable, easily accessible , user friendly and compatible with all platforms.

This " online version " is our new year gift to the clinical fraternity and hope it would fulfill your expectations as always.

Regards, Dr S. Manivannan, MD., DNB Joint Managing Director N CAPSULE MAGAZINE Capsule Magazine is published TH S by Kauvery Hospital 01 Copyright 2015 © Kauvery Hospital SSUE From the Editor’s Desk DR. S. SENTHILKUMAR

PATRONS Dr. S. Chandrakumar Dr. S. Manivannan 02 03 ADVISORY BOARD Dr. D Senguttuvan Florid heart failure Emphysematous Pyelonephritis Dr. Aravindan Selvaraj BY BY Dr. T. Senthil Kumar DR. R. PREM SEKAR DR. S. SENTHILKUMAR KAUVERY HOSPITAL, DR. N. KARTHICKEYAN KAUVERY KIDNEY CENTER,TRICHY EDITOR Dr. S. Senthil Kumar

EDITORIAL TEAM Dr. S. Velmurugan Dr. S. Aravinda Kumar 05 07 Dr. Iyyappan Ponnuswamy Sub mental Intubation Pulmonary Sarcoidosis BY BY DR.K.SENTHIL KUMAR DR. A. NAGARAJAN TECHNICAL TEAM KAUVERY HOSPITAL, TENNUR, TRICHY PULMONOLOGIST Dr. Ve. Senthil Vel Murugan Dr. A. Subramanian

ADMIN TEAM Mr. A. Madhavan 09 11 Mr. P. Charles Mrs. JPJ. Bindhu Management of UTI The Methotrexate Nightmare BY BY DR. N. PRAHLAD, DR.SHWETHA RAHUL, CO-ORDINATORS KAUVERY HOSPITAL, CHENNAI KAUVERY HOSPITAL, CHENNAI Mrs. Percy Mr. Prakash Ranjith Kumar R.

DESIGN & LAYOUT Mr. Vahid Ali N. 12 13 Telovelar approach to the 4th ventricle CHOICE OF ANAESTHESIA BY BY DR.M.VIKRAM, DR. HEMA KAUVERY HOSPITAL, CANTONMENT, TRICHY KAUVERY HOSPITAL, CHENNAI

EDITORIAL OFFICE Kauvery Hospital 14 15 VI Floor, Administrative Office, #6, Royal Road, Cantonment, IMA Award New Doctors List -620001. CHENNAI KAUVERY IMA BRANCH WELCOMING NEW DOCTORS Call us at (431) 40 77 777 WON 8 AWARDS TO KAUVERY FAMILY Mail us at: [email protected] Visit us at: www.kauveryhospital.com FROM THE EDITOR’S DESK | CAPSULE MAGAZINE

FROM THE

DITOR’S DESK DR. S. SENTHIL KUMAR, M.S., DNB., (URO) SENIOR CONSULTANT UROLOGIST

Dear Friends , one in particular that he asked himself every time he faced a big decision in his life I am pleased to present the first issue of ' What would i do if this was the last night of 2016 capsule, which will serve as an my life? ' additional communication channel between the consultants of Kauvery and the ever growing referral Doctor community. This To live big life it's essential that you take capsule contains information with variety of calculated risks. Steve jobs met his wife that interest to the readers. From the way. He was giving a speech at a university Department of Renal sciences, there are two and spotted her in the audience. He met topics, one covers the entire information her after the event and wanted to take her about urinary tract infections and the other to dinner - but he had an important deals with the 'Emphysematous business meeting. As he walked to his car, Pyelonephritis' which is a highly Fatal he asked himself. " If this was the last night disease. Apart from this there are interesting of my life, what would I do?" . He ran back articles about submental intubation, florid to the auditorium and found her. They were heart failure, pulmonary sarcoidosis and together since. With out daring there can others. be no winning. On the other side of your fear lies your treasure.

The Famous This is a great time to reflect. You are Steve Jobs Question leaving one year and welcoming in another. So think about it. Steve jobs late Apple CEO - is known for his winning ways with i Pod, his transformation I appreciate you taking the time to read our of Apple, his Achievements with Pixar. He newsletter and I would like to thank every was Brilliant, passionate and a philosopher. one who contributed to this edition.

He pondered life's big questions . There is HAPPY NEW YEAR 2016

JANUARY 2016 • CAPSULE MAGAZINE • 01 FLORID HEART FAILURE | CAPSULE MAGAZINE

The child was admitted on was a large shunt through FLORID HEART FAILURE 28/07/2015 with florid heart the device, from left DR. R. PREM SEKAR failure. She was initially ventricle directed into the SENIOR CONSULTANT presented at 7 years of age right atrium. This resulted INTERVENTIONAL PAEDIATRIC CARDIOLOGIST in a different institution in in severe congestion on the KAUVERY HOSPITAL, CHENNAI India, with a very large hole right side of her heart in the heart and severe lung leading to swelling in her hypertension. After detailed legs, face and abdomen. evaluation to ensure that she was fit for undergoing The gravity of her sick open heart surgery to close condition was explained to the hole in the heart, she her parents and she was taken up for surgery. underwent yet another However, in the immediate high risk open heart postoperative period she surgery on 3rd August was found to have a 2015 by Dr.Prashanth Shah, significant residual hole Senior Consultant which needed her to Paediatric Cardiothoracic SUCCESSFUL STRATEGIC MANAGEMENT undergo another open Surgeon. OF A DIFFICULT CARDIAC PROBLEM heart surgery the very next IN A 9 YEAR OLD IRAQI GIRL day. The hole being in a During this surgery, the difficult location, multiple occluder was removed, the MS. BANEEN MUSLIM KHALEEL attempts to close it resulted resultant hole was closed in injury to the nerve in the and the valve was repaired. heart that regulates heart Post operatively, she beat. She then required a showed a dramatic relief of permanent pacemaker the right heart failure with implantation for complete resolution of the swelling heart block. She and breathing difficulties. subsequently returned to She has subsequently Iraq, but presented again at returned to Iraq with advice the same institution in to follow up with the local January 2015 with a large paediatric cardiologist. residual hole again presumably due to the This case report highlights stitches giving way. This is a the importance of the close noted complication in collaboration that is surgical closure of holes in required by the team of the heart located in difficult care givers who provide locations. This time, she care for the children with underwent a nonsurgical heart disease. It also places

Pre operative Picture Pre closure of the residual hole emphasis on the with a plug like occluder meticulous preoperative after which she returned to planning strategy and Iraq. careful execution of the plan for a successful In August 2015, at outcome. 9 years of age, she was referred to Kauvery Hospital with features of florid right heart congestive failure. Echocardiography revealed the occluder to be interfering with the valve on the right side of the heart

Post operative Picture Post causing severe leakage of blood. Additionally, there

02 • CAPSULE MAGAZINE • JANUARY 2016 EMPHYSEMATOUS PYELONEPHRITIS | CAPSULE MAGAZINE

EMPHYSEMATOUS PYELONEPHRITIS AND OUR RECENT EXPERIENCE

DR. S. SENTHILKUMAR, SENIOR CONSULTANT UROLOGIST

DR. N. KARTHICKEYAN, CONSULTANT UROLOGIST

KAUVERY KIDNEY CENTER,TRICHY

factors(eg, thrombocytopenia, elevated EPIDEMIOLOGY IMAGING STUDIES serum creatinine levels, altered EPN is a rare condition. It is six times Xray KUB often reveals gas distribution sensorium, shock) more common in women. All over the region of kidneys. Renal USG documented cases are reported in may reveal hyperechoic areas with adults. Juvenile diabetics are not at risk. dirty shadowing. Hydronephrosis and CONSERVATIVE TREATMENT Left kidney is affected often than right perinephric fluid may be seen. CONSISTS OF THE FOLLOWING: for reasons not known. Ninety five CT is the imaging modality of choice. • Prompt hydration & Systemic percent of patients with EPN have DM. Several gas patterns have been antibiotics = Mainstay of treatment. Obstruction is the main cause of EPN described including streaky, mottled • Relief of obstruction with in persons without diabetes. and bubbly. Perinephric abscess may percutaneous drainage or stent lead to significant gas accumulation in placement the perinephric space. A stone causing •Rapid control of diabetes PATHOPHYSIOLOGY obstruction may be seen in the collecting system. • UTIs are common in DM, but all of these infections do not lead to EPN. • Factors that predispose to EPN in DM SURGICAL TREATMENT (NEPHRECTOMY) MANAGEMENT may include: INDICATIONS • Uncontrolled diabetes Patients with EPN should be treated • High levels of HbA1c with aggressive medical management • No access to percutaneous drainage • Impaired host immune mechanism and prompt surgical intervention if or internal stenting (after patient is indicated. stabilized) • Type 1 or "dry-type" EPN immediate Nephrectomy CLINICAL PRESENTATION • Class 3 and class 4 EPN with ≥ 2 risk CONSERVATIVE TREATMENT/ factors (eg, thrombocytopenia, The classical triad of EPN includes MEDICAL THERAPY elevated serum creatinine, altered Fever, flank pain and vomiting. Altered INDICATIONS sensorium, shock) sensorium and shock are less common. Nephrectomy may be associated with Laboratory findings include: • Patients with compromised renal significant bleeding and injury to • Leukocytosis with a left shift function surrounding structures.The initial • Thrombocytopenia • Early cases associated with gas in the procedure should often be • An elevated creatinine level collecting system alone conservative with care to drain the • Positive culture • Class 1 and class 2 EPN abscess. Surgical intervention should • Class 3 and class 4 EPN: In the be performed only after stabilization of presence of fewer than 2 risk cardio-respiratory status.

JANUARY 2016 • CAPSULE MAGAZINE • 03 EMPHYSEMATOUS PYELONEPHRITIS | CAPSULE MAGAZINE

OUR RECENT EXPERIENCES: CASE 3: With this overview, we now present our A diabetic female was recent experiences from three patients diagnosed to have right with EPN who had variable EPN and was advised presentation and were managed nephrectomy elsewhere in differently. view of uncontrolled sepsis. She came to our OPD with septic shock and was stabilised with CASE 1: antibiotics, IV fluids and 60 year old female with inotropes. Percutaneous DM presented with Left drainage was done under upper abdominal pain & IV sedation. About 500ml fever for 20 days. On of pus mixed with foul arrival she had smelling gas were Leucocytosis with Figure 3: The entire left kidney was drained. Patient gradually HbA1c of 10.4.CT. KUB replaced with gas improved and recovered was done which showed from sepsis. She was multiple air pockets discharged on the 8th within the left kidney, CASE 2: POD without the need for perirenal and nephrectomy. 62 year old female with periureteric areas uncontrolled diabetes came (Figure 1). After initial with fever, vomiting and stabilization,Left DJ flank pain for 1 week CONCLUSION Stenting was done duration. On admission she EPN occurs almost under local anaesthesia had severe left loin exclusively in Diabetics. It (Figure2).Patient tenderness with can have fatal outcome if recovered completely thrombocytopenia and not treated adequately and was discharged with elevated renal parameters. and promptly .Fluid oral antibiotics. The entire left kidney was resuscitation and replaced with gas with no treatment with systemic fluid collection in CT KUB antibiotics are the (Figure 3).ESBL producing mainstays of E.coli was grown in urine management. Surgical culture. Under antibiotic intervention should only cover DJ Stenting was done be performed after initially. Patient ultimately stabilization. required left nephrectomy Nephrectomy, the to remove the septic focus treatment of choice in the following which she made past is only required in an uneventful recovery. few selected patients. Figure 1 –Class III B EPN

Figure 2: Post DJ Stenting - complete resolution of gas collection.

04 • CAPSULE MAGAZINE • JANUARY 2016 SUB MENTAL INTUBATION | CAPSULE MAGAZINE

In this article we are going to discuss SUBMENTAL INTUBATION which is done in our hospital for patients with pan facial fractures who SUB MENTAL INTUBATION need pan DR.K.SENTHIL KUMAR facial fixation. This ANESTHESIOLOGIST procedure consists of KAUVERY HOSPITAL, exteriorizing an oral TENNUR, TRICHY endo tracheal tube through floor of the mouth and submental triangle.

Panfacial fractures involve the nasoendotracheal intubation cranium, midface and the is contraindicated, a mandible. Early cricothyrotomy or reconstruction of patients tracheostomy has been the with panfacial fractures by traditional method of airway open reduction and rigid control. Submental intubation internal fixation is now the technique consists of passing standard of care which gives the tube through the anterior a very good pain relief after floor of mouth, allowing free the surgery. intraoperative access to oral An important consideration cavity and nasal pyramid at the time of surgery is the without endangering patients maintenance of airway with skull base trauma. without interfering with the Submental intubation, thus, reconstruction of fractured as an alternative to segments. Essentially the tracheostomy can be used anaesthesiologist and the when short-term surgeon are competing for postoperative control of the same space. The surgeon airway is desirable with the needs access to an presence of undisturbed unobstructed field; and in access to oral as well as nasal most instances; airways and a good dental maxillomandibular fixation is occlusion. Accordingly, required intraoperatively for unnecessary surgery and adequate reconstruction of potential complications facial fractures. Oral associated with either a intubation may interfere with cricothyrotomy or proper maxillomandibular tracheostomy can be avoided reduction. Surgical correction by using the submental of maxillofacial trauma intubation. Once the frequently requires oroendotracheal intubation is maxillomandibular fixation. In achieved, it can be converted situations where to a submental intubation. maxillomandibular fixation is required and

JANUARY 2016 • CAPSULE MAGAZINE • 05 SUB MENTAL INTUBATION | CAPSULE MAGAZINE

Submental intubation has The curved artery forceps is undergone various modifications introduced through the since its inception and has opening made from external unfolded many indications for it. It aspect to enter into the oral can be used in patients with cavity. First pilot ballon of the midfacial or panfacial fractures with ETT is guided through the oral possible base of the skull fractures cavity and exteriorized through Skin incision involving Nasal, Orbital and the incision made. Next the Ethmoidal ( NOE ) fractures where universal connector of the ETT a routine nasal intubation may lead is disconnected and the ETT is on to life threatening complications also exteriorized with the help as the tube may enter the base of of curved artery forceps (FiO2 the skull through fractured to 100%) cribriform plate of ethmoid. It can also be done in patients Once ETT is exteriorized undergoing elective Le Fort bilateral air entry is checked After a skin incision and thorough dilatation with a curved artery forceps Osteotomies or simultaneous and the tube is fixed through the oral cavity the pathway is elective mandibular orthognathic submentally with silk. dilated with the help of Hegar’s dilator. surgery and rhinoplasty procedure. Note the ETT through the oral route in left At the end of the surgery the angle of mouth decision to extubate was carried out after consultation THE PROCEDURE with the surgeon and also After a routine orotracheal considering the clinical intubation with flexo metallic tube condition of the patient and ( size 7.5 or 8.0 ) and fixing the the duration of the surgical tube on either angle of the mouth procedure. On an average in with soft plasters, the patient is all cases the surgical procedure positioned with a pillow behind the went on for 7 to 8 hours. In our ETT exteriorized from oral route chest to achieve a mild extension at hospital almost every patients the neck level. This position clearly were extubated on table exposes the chin and mentum. The through the incision itself.( not area below the ramus of the converting once again to mandible is drapped after orotracheal positon of the ETT thorough asepsis. 3 cm away from and extubating). After midline just below the ramus of the extubation the incision was mandible ( mind the facial artery closed with appropriate suture nearby ) 3 to 4 ml of lignocaine material. Postoperatively the ETT secured with 1-0 silk firmly. adrenaline is infiltrated. A 3cm scar is usually not visible as the incision is made just parallel to the incision made is just behind the ramus of the mandible. Blunt ramus of the mandible. dissection is made through the incision with the help of curved artery forceps. A finger is kept intraorally inside the floor the CONCLUSION mouth just beneath the tongue. Submental intubation is a The curved artery forceps is felt on useful alternative technique of ETT extubated through the finger kept intra orally. Blunt airway management in patients the submental incision itself. dissection is proceeded with a with panfacial fractures. It control felt by the intra oral finger demands a certain surgical skill, (take care of submandibular duct however, it is safe and quick to opening). Once the forceps reaches execute. It allows intraoperative the oral cavity it is slowly dilated. correction of occlusion and We can even use graded dilator enables surgery for associated like Hegar’s dilator. nasal fracture in the event of concomitant skull base trauma Next step is rerouting the oral tube Submental incision into submental route . sutured after extubation.

06 • CAPSULE MAGAZINE • JANUARY 2016 PULMONARY SARCOIDOSIS | CAPSULE MAGAZINE

PULMONARY SARCOIDOSIS

DR. A. NAGARAJAN CONSULTANT-PULMONOLOGIST KAUVERY HOSPITAL, CANTONMENT, TRICHY

Sarcoidosis is a multisystem disorder of unknown causes, commonly The clinical course and expression of affecting young and middle aged adults. Diagnosis is established on the pulmonary sarcoidosis are variable, may be basis of clinicoradiological features supported by histopathological asymptomatic or can present with severe evidence of non-caseating granulomas after exclusion of known causes. respiratory symptoms and even can cause The typical radiographic feature of sarcoidosis is bilateral hilar death. The resemblance to tuberculosis lymphadenopathy with involvement of right paratracheal lymph nodes compounded by lack of awareness among concomitantly. physicians and pathologists with lack of diagnostic facilities has all been the reasons Transbronchial lung biopsy(TBLB) and Transbronchial needle aspiration for under reporting of the disease in India. (TBNA) are important for diagnosing pulmonary sarcoidosis.

Sarcoidosis is a multisystem disorder of unknown etiology. It’s characteristic feature is the presence of non-caseating granulomas that can affect various body parts; however, pulmonary involvement is seen in more than 90% of CASE PRESENTATION patients. 52 yrs old lady with no significant medical history presented with 2 months history of cough, intermittent fever, and fatigue and weight loss. On examination there was no clubbing, skin rash, lymphadenopathy or organomegaly. Chest examination revealed bilateral fine crepitations and rhonchi. Complete blood count (CBC) was normal except high erythrocyte sedimentation rate (ESR 104 mm/hr). Mantoux test showed a skin reaction of 8X6 mm. Saturation of peripheral oxygen (Spo2) was 95% of room air.

Chest X ray (fig.1) showed bilateral hilar soft tissue prominence due to enlarged lymph nodes with paratracheal soft tissue opacity. Computed tomographic (CT) scan of chest (fig2) showed bilateral massive hilar lymphadenopathy and paratracheal lymph nodes.

Bronchoscopy showed widening of carina and chronic inflammation of bronchial mucosa suggestive of sarcoidosis. Cytopathology of bronchoalveolar fluid (BAL fluid) was done which revealed inflammatory smear. No acid fast bacillus was seen on Ziehl-Neelsen staining. No fungal elements or granuloma or atypical cells seen. Transbronchial needle aspiration

JANUARY 2016 • CAPSULE MAGAZINE • 07 PULMONARY SARCOIDOSIS | CAPSULE MAGAZINE

(TBNA) showed numerous epithelial cells and macrophages. No granuloma DISCUSSION: or atypical cells seen. Histopathological Sarcoidosis is characterized by the formation of non necrotizing epitheloid cell examination of Transbronchial lung granuloma as a result of underlying immune dysregulation and typically shows multi biopsy (TBLB) revealed epitheloid cell organ involvement. Sarcoidosis has propensity to involve multiple systems, but granuloma with Langhans type of giant pulmonary involvement usually dominates. Skin, eyes and peripheral lymph nodes cells consistent with sarcoidosis. are involved in 15% to 30% of patients Involvement of spleen, liver, heart, central nervous system, bone or kidney occurs in 2 to 7% of patients. Patient was treated with methylprednisolone and supportive The typical radiographic feature of sarcoidosis is bilateral hilar lymphadenopathy medications. Patient was reviewed after with involvement of right paratracheal lymph nodes concomitantly. On CT scan, the 2 months, there was good clinical typical features of sarcoidosis are mediastinal and/ or hilar lymphadenopathy, improvement in symptoms and repeat nodular opacities and micronodules along bronchovascular bundles in the form of X ray chest (fig.3) showed fair perilymphatic distribution. radiolological improvement.

The diagnostic yield of flexible THERE ARE FOUR STAGES OF fiberoptic bronchoscopy with PULMONARY SARCOIDOSIS NORMAL transbronchial lung biopsy (TBLB) is AS MENTIONED about 60- 90%, even in radiographic stage I disease. Transbronchial needle 0 aspiration biopsies (TBNA) are diagnostic in 63- 90% of patients with BILATERAL HILAR mediastinal and/or hilar adenopathy EXTENSIVE FIBROSIS WITH LYMPHADENOPATHY on chest CT. DISTORTION OR BULLAE 4 1 WITHOUT PULMONARY INFILTRATES The combination of TBNA and TBLB may have a higher accuracy than either procedure alone. Corticosteroids are PARENCHYMAL 3 2 BILATERAL HILAR the mainstay treatment option for INFILTRATES WITHOUT LYMPHADENOPATHY severe or progressive sarcoidosis BILATERAL HILAR PLUS PULMONARY (pulmonary or extrapulmonary), and LYMPHADENOPATHY INFILTRATES often gives significant regression of the disease. For patients not responding or having adverse effects from corticosteroids, immunosuppressive, cytotoxic or immunomodulatory SUMMARY: agents are preferred. In patients with Fig-2 Sarcoidosis is a multisystem end-stage pulmonary sarcoidosis disorder with predominantly refractory to medical therapy, lung pulmonary involvement. The transplantation is a viable option. clinical and radiological features of sarcoidosis closely resemble Tuberculosis (TB). One should

Fig-1 have a high index of suspicion for diagnosis of this condition.

Fig-3 In countries with high prevalence of TB, like India, sarcoidosis is often misdiagnosed as TB. Hence, patients having bilateral hilar lymphadenopathy with or without infiltrates should be investigated for sarcoidosis.

08 • CAPSULE MAGAZINE • JANUARY 2016 MANAGEMENT OF UTI | CAPSULE MAGAZINE

BLOOD MANAGEMENT OF •Polymorphonuclear Leukocytosis, raised C-reactive protein and elevated URINARY TRACT INFECTION ESR, help in the diagnosis. DR. N. PRAHLAD, CONSULTANT PEDIATRIC NEPHROLOGIST •Renal function is monitored by blood KAUVERY HOSPITAL, CHENNAI urea, serum creatinine and electrolytes. Renal failure can occur with severe acute pyelonephritis when it involves both kidneys and when there is a single functioning kidney. Type IV RTA (Hyperkalemic Metabolic Acidosis) is seen in acute pyelonephritis in a single Urinary Tract Infection (UTI) is one of functioning kidney. the common bacterial infections seen in children. It presents with non-specific symptomatology. It can present as ULTRASOUND (USG) septicemia in infants, and as acute or chronic infections in older children. •USG is done to identify the size, shape Recurrences are common. This is aided and position of the kidney and also to by various urinary tract anomalies and assess underlying anatomical defects voiding dysfunctions. Children with like obstruction, dilated collecting Acute Pyelonephritis are at a high risk system, stone disease, pyelonephritis, of renal scarring and future bladder wall thickening, post void residual urine and turbidity of the complications as proteinuria, MANAGEMENT OF UTI hypertension, pregnancy related urinary tract. complications and end stage renal INVESTIGATIONS: failure. Infancy, delayed, inadequate URINE and improper anti-bacterial treatment, • Rapid tests like Urinary Nitrite and DMSA recurrent UTI, associated vesicouretric Leukocyte Esterase Tests have •Radio nuclide imaging used to identify reflux (VUR) and voiding dysfunction problems of false positivity and acute pyelonephritis and cortical are high risk factors for renal scarring, negativity. Thus more specificity can be scarring. in a growing kidney. Thus any delay in gained by combining a positive test for •Its done during acute stage to diagnosis and management may cause leukocyte esterase and nitrite with clinic diagnose acute pyelonephritis which extensive morbidity in children and biological features of upper UTI. Pyuria helps to complete the treatment for infants. may be absent in more than 50% of acute pyelonephritis UTI. •It is repeated after 6 months to see for The criteria for the diagnosis of UTI, •Gram- Stained Smear is useful as a scarring of the kidney is a positive urine culture. Urine supportive evidence of UTI. It has a samples can be collected by a clean better sensitivity and specificity than all mid-stream urine specimen, supra other rapid tests. MCU pubic aspiration and urethral •A combination of enhanced urine catheterization. Any urine culture taken analysis and rapid tests will suggest UTI •Done after treating UTI adequately by the above methods which grows a in 95% of children. while on chemoprophylaxis single organism of a significant colony •Helps to identify bladder contour, count, confirms the diagnosis of UTI. Thus reiterating that urine culture is the posterior urethral valve and gold standard to diagnose UTI. vesicouretric reflux

JANUARY 2016 • CAPSULE MAGAZINE • 09 MANAGEMENT OF UTI | CAPSULE MAGAZINE

INITIAL MANAGEMENT •Fluoroquinolones (ciprofloxacine) •Infant with febrile UTI pending should not be used as first line agents. imaging studies. Indications for hospitalization are It is best reserved for UTI caused by •Vesicouretric reflux. infants with features of toxicity and paeruginosa or other multi drug •Obstructive uropathy with dehydration, children who are unable resistant organisms. Vesicouretric reflux. to retain oral medicines, clinical •Antibiotic prophylaxis are started only •Cold areas in DMSA without VUR. urosepsis, investigations suggestive of in case of recurrent UTI, complicated •Drugs used – Cephalexin, bacteremia, immunocompromised UTI, UTI with VUR and DMSA with cold Cotrimoxazole and Nitrofurantoine. children and children who fail to areas. •Avoid Chemoprophylaxis in respond to outpatient therapy. neurogenic bladder on CIC, PUV and urolithiasis. These children are managed with IV GUIDELINES IN THE MANAGEMENT •Cyclical chemoprophylaxis has no role. fluids to maintain hydration till oral OF CHILDHOOD LOWER UTI acceptance is restored, paracetamol and parenteral antibiotics. NSAID’s are •Appropriate oral antibiotic therapy is IMAGING EVALUATION best avoided. Pending urine culture sufficient. AFTER FIRST UTI parenteral antibiotics like ceftrioxone, •Duration of therapy is 7 to 10 days. FIRST ATTACK OF FEBRILE UTI cefotaxime, aminoglycoside and •Dysuria and severe bladder spasms co-amoxiclav can be started. are managed with bladder analgesics Subsequently treatment can be and alkalizing agents. AGE < 1 YR modified based on anti microbial •Bladder analgesics like ULTRASOUND sensitivity. With the improvement in the phenazopyridine hydrochloride are MCU general condition and oral acceptance, used. This drug should not be used in DMSA SCINTIGRAPHY oral antibiotics can be started like children with renal failure. Other drugs cefixime, co-amoxyclav and commonly used are flavoxate ciprofloxacin. hydrochloride which has an AGE 1 – 5 YRS anticholinergic and antimuscarinic ULTRASOUND Children with lower UTI and those effect. It is not recommended for DMSA SCINTIGRAPHY above 3 months of age with upper UTI children for less than 10 years of age. (MCU IF ULTRASOUND & can be treated with oral antibiotics. DMSA SCINTIGRAPHY Symptoms and fever reduced by 48 to IS ABNORMAL) 72 hours. Failure to respond may be GUIDELINES IN THE MANAGEMENT due to resistant pathogens and OF CHILDREN WITH ESBL underlying anatomical complications or PRODUCING ORGANISMS AGE > 5 YRS non compliance. These children need ULTRASOUND re-evaluation. Duration of therapy is 7 (IF ULTRASOUND IS to 10 days for a simple UTI and 10-14 Infections due to ESBL producers range ABNORMAL, MCU & days for acute pyelonephritis. Following from uncomplicated UTI to life DMSA SCINTIGRAPHY) treatment of the UTI antibiotic threatening sepsis. It can occur as an prophylaxis are started for children less isolated infection or secondary to than one year of age, pending imaging colonization. studies. PREVENTION OF RECURRENT UTI •In case of colonization, removal of the Adequate hydration, timed voiding, source of infection is vital, eg. Catheter. triple voiding, avoid constipation, •Drug of choice is carbapenems. treatment of thread worms and GUIDELINES IN THE MANAGEMENT •For an uncomplicated nonbacteremic circumscision in case of repeated UTI OF CHILDHOOD UPPER UTI UTI, a 3 day therapy is enough. with high grade reflux are the general •For a complicated UTI, 2 week therapy steps to be followed to prevent •All febrile UTIs are treated as acute is indicated. recurrence of UTI. pyelonephritis. •Quinalone antibiotics are avoided in •For acute pyelonephritis, total the treatment of ESBL infections. As UTI presents variably with duration of treatment is 14 days. 5 days nonspecific symptoms, high index of of parenteral followed by oral drugs. INDICATIONS FOR ANTIBIOTIC suspicion is needed to diagnose UTI by •Modify antibiotic dose basing on PROPHYLAXIS sending a urine culture prior to the serum creatinine. initiation of an antibiotic, as it is the •Serial monitoring of serum creatinine Antibiotic prophylaxis definitely reduces corner stone for early diagnosis and is mandatory when aminoglycocides the incidence of UTI in a child with management. This prevents renal are used. recurrent UTI. scarring and morbidity in children.

10 • CAPSULE MAGAZINE • JANUARY 2016 THE METHOTREXATE NIGHTMARE| CAPSULE MAGAZINE

S BEYOND PEN YO AP UR H P T R A E S H C W R I P

T

I

O

N

THE METHOTREXATE NIGHTMARE !

DR.SHWETHA RAHUL, DERMATOLOGIST AND AESTHETIC PHYSICIAN KAUVERY HOSPITAL, CHENNAI

Methotrexate has been one of the most useful weapons in the immune warfare. But inadvertent use of the drug can lead to life threatening complications as seen below

THE ENTHUSIASTIC OVERDOSER DISCUSSION: HOW CAN WE PREVENT THIS? •An educated 50 year old male The reason for the toxicity in this • Explain your prescription to your suffering from chronic unstable plaque patient was the daily dosing instead of patient psoriasis self medicated himself on the recommended once weekly dosing. - Ban OTC availability of MTX 5-10 mg/day of oral methotrexate daily And the lack of folate supplementation - Regulations to ascertain that old for > 2months while on MTX. prescriptions are not used for repeated purchase of medication by patients •He presented with Chills, bleeding •Once ingested, MTX is converted to gums, hematuria, melena,odynophagia polyglutamate form which is stored in and severe ulceration of psoriatic various tissues including RBCs and plaques and oral mucosa. Multiple hepatocytes. MTX is an antimetabolite WHAT’S THE UPDATE? bleeding ecchymotic patches in the drug; the accumulation of MTXglu in Recent studies have elucidated the role posterior pharyngeal wall were also the tissues viz liver, erythrocytes, etc. of genetic polymorphisms in the seen. reduces the polyglutamation of natural enzyme involved in the conversion of folates and may account for the homocysteine to methionine, •Investigations revealed pancytopenia chronic toxicity associated with MTX methylene tetrahydrofolate reductase with platelets as low as 5000/cu mm MTHFR, in excess methotrexate marrow •The organs that take the major hit in toxicity in patients with rheumatoid MTX toxicity are skin, mucosa, liver ,GIT arthritis (van Ede et al., 2001a; Urano et TREATMENT and the kidneys al., 2002; Kumagai et al., 2003). •Admission in IMCU •Alkalisation of urine to raise urine Ph> • Thus, the results of these studies 7 with sodium bicarbonate (40–50 mEq demonstrate that the C677T sodium bicarbonate per liter of i.v. Fluid THE FOLLOWING ARE THE RISK polymorphism is associated with till Ph >7) FACTORS FOR MTX TOXICITY: enhanced methotrexate mediated •Inj Folinic acid: 15mg i.v every 6 hrs marrow toxicity. for five days • Renal dysfunction •Inj GM CSF(filgrastim): 300 • Presence of infection • Caretakers to administer drugs to micrograms i.v. Daily for five days or • Folic acid deficiency older patients to avoid confusion; until total count exceeded 4000 cells/ • Hypoalbuminemia encourage use of weekly pill boxes cu mm • Concomitant use of drugs such as •Platelet transfusions ( single donor) trimethoprim •Broad spectrum i.v antibiotics • Advanced age •i.v fluids for hydration • Concomitant use of NSAID Following the excellent care given by • Inadvertent use of MTX dose our institution, the patient went home completely recovered.

JANUARY 2016 • CAPSULE MAGAZINE • 11 TELOVELAR APPROACH TO THE FOURTH VENTRICLE | CAPSULE MAGAZINE

SPECIAL POINTS OF INTEREST TELOVELAR APPROACH TO THE FOURTH • Minimally invasive brain surgery is less VENTRICLE & TOTAL EXCISION OF invasion in the brain structures and not at 4TH VENTRICULAR SOL the skin alone

DR.M.VIKRAM • Usage of newer less CONSULTANT NEUROSURGEON, invasive techniques KAUVERY HOSPITAL keeps the functional CANTONMENT, TRICHY aspects of the patient well retained to lead a better Quality of life.

• Less invasion cannot compromosie the quality of excision or mobility, mortality of the patient. Fourth Ventricular tumors fastigium, superolateral are known for its appearance recess, and the superior half in all age groups and posses of the roof. Tumors in the its own problems related to fourth ventricle may stretch approach for excision and and thin these two new deficits in terms of gait semi-translucent membranes PRE OP CASE ! disturbances, dysarthria etc., to a degree that one may not HPE– EPENDY- beyond the damage caused be aware that they are being MOMA GR. I by the tumor per se, with the opened in exposing a fourth advent of the telovelar ventricular tumor. approach the new deficits Four Cases have been incidences decreases approached by this approach dramatically even in the over last 2 years and it was early post op period without found to be very successful PRE OP CASE 2 limiting the quality of with no morbility, no HPE– PILOCYTIC excision and is truly a cerebellar ataxia, cranial ASTROCYTOMA. GR. I minimally invasive approach nerve deficits or other post as it means in the aspect of operative complications and less invasion in the brain with we could discharge the no disturbences of the patient ambulant connecting fibers. independently on 3rd post In the past, operative access operative day itself. The POST OP CASE 1 CONTRAST MRI to the fourth ventricle was approach gave us the TOTAL EXCISION obtained by splitting the opportunity to excise the NO DEFICITS cerebellar vermis or lesion completely as seen removing part of a cerebellar here in the pre and post op hemisphere. It was found images as well without any that opening the tela alone increase in the operative will provide adequate time, or disturbances to the ventricular exposure, in most neural structures. Though two POST OP CASE 2 cases, without splitting the of the benign lesion were CONTRAST MRI vermis. Opening the tela gelatinous to fibrous in its TOTAL EXCISION alone provides access to the nature for dissection, the NO DEFICITS, full length of the floor and lesion could be excised totally the entire ventricular cavity by this approach. except, possibly the

12 • CAPSULE MAGAZINE • JANUARY 2016 CHOICE OF ANAESTHESIA | CAPSULE MAGAZINE

CASE PRESENTATION Case 1, 65 year old man, presented with head ache mild CHOICE OF ANAESTHESIA gait disturbance, visual blurring and occasional vomiting, for 8 SEGMENTAL EPIDURAL ANAESTHESIA months duration initially treated elsewhere and was investigated WITH B/L OBTURATOR NERVE BLOCK and find to have fourth ventricular lesion, in view of fear of surgery DR. HEMA patient postponed treatment KAUVERY HOSPITAL, CHENNAI options, patient was convinced about he minimally invasive procedure on the brain and 92 year old It provides better and a caution not to underwent the procedure with no Mr.Swaminathan, a stable hemodynamics exceed maximum post operative complications or k/c/o DM/SHT on and it avoids allowable dose to new deficits, post op, contrast T.Daonil 5mg/BD, polypharmacy and its avoid L/A toxicity. In imaging showed no residul lesion. Insulin 15units/OD physiological effects on view of extended Histopathology was reported as and T.Amlong a fragile geriatric patient. duration of operating grade 1 ependymoma and did not 5mg/OD was posted It provides optimal hours on an elderly require any further treatment on 6 for TURBT for a huge operating condition for patient, procedure was months followup. tumour involving the surgeon and it can planned as two stages. both lateral walls and be extended for any Epidural catheter was case 2, was a 6 years old girl base of the urinary number of hours. If preserved for II stage presented with head ache, bladder. He had required, the epidural that was planned vomiting and progressive visual undergone truncal catheter can be 3days later. loss on both eyes, initially treated vagotomy for preserved for the During redo TURBT, elsewhere for 1 year by alternative duodenal ulcer and second stage of Epidural anaesthesia medicine, as child lost vision tympanoplasty procedure. was resumed by completely and head ache, earlier. Patient was co-loaded activating epidural vomiting persisted came here for with 500ml of catheter and from further management with not On examination, his Hartmann’s solution. In then on topup was other deficits. Child underwent the pulse rate was sitting posture, under given as and when minimally invasive procedure with 78/min, regular and sterile aseptic required. As there was no new post op deficits and BP was precautions, under L/A, residual growth only improving neurologically with no 184/76mmhg. ECG 17G tuohy needle entry on the right lateral vision improvement as optic nerve showed NSR, RBBB. at T12- L1, epidural wall of the urinary atrophied due to long standing Chest Xray showed space was identified bladder, only right ICP. Pre operatively as the lesion unfolding of aorta. using LOR technique at obturator nerve block was dissectecd Echo confirmed Ef 5cm from skin. Catheter was given using nerve from the medulla oblongata, floor 67%, gr I diastolic was placed 4cm in stimulator. Inj. of the fourth ventricle there were dysfunction. Blood epidural space, Tranexamic acid 1gm severe brady, tachy, high and low reports were Hb – cephalad. 6ml of 2% was given on both the b/p fluctuations within a span of 5 11.4gm/dl, FBS – lignocain with adrenaline occasions to minimize to 10 minutes due to disturbance 139, PPBS – 206, and 1ml of sodium blood loss. Intra op in the medullary control, and was urea – 58, Creatinine bicarbonate was given. hemodynamics were posing a severe surgical challenge – 2 and electrolytes – B/L obturator nerve stable. Patient did not to the managing WNL. Cardiologist block was given to avoid require blood anesthetist along with change opinion was obturator jerk on direct transfusion post op. periodic stopage of dissection, obtained. Patient nerve stimulation that Epidural catheter was change of dissecting area we had b/l basal might happen intraop as removed subsequently could manage the scenario and crackles for which the growth was on both and patient was sent could resect the tumor totally incentive spirometry the lateral walls, close to home after an which was clearly seen in the post was started a week the nerves. Using nerve uneventful hospital operative contrast MRI. before and he was stimulator 20ml of stay. Histopathology was reported as nebulized 0.375% bupivacaine on grade1 pilocytic preoperatively. each side was given with astrocytoma.

JANUARY 2016 • CAPSULE MAGAZINE • 13 CAPSULE MAGAZINE

CONGRATULATION TO CHENNAI KAUVERY IMA BRANCH FOR WINNING 8 AWARDS AT STATE IMA CONFERENCE

Best Branch Best Journal Best CME Best Community Activities Blood Donation Best Membership Contribution Best Secretary Best President.

Capsicum or Peppers are one of 3. Place a Kadai on the stove (low the most versatile vegetables. You heat). Add 2 tablespoons of Oil. Vegetable Pepper Bowls can use them in curries, in fried 4. Once the oil is a bit hot, add the A Healthy Recipe rice, pulaos, in salads and as diced onions and sauté, until the stuffed bowls. The stuffing could be onions turn pink or translucent. cooked or used as a salad. 5. Add the carrots, peas, and Whichever way you use it, it is beans. delicious and colorful. Capsicums 6. Add the Jeera, Turmeric, Chilie come in four different colors – and Garam masala powders. Add Green, Red, Yellow and Orange salt to taste. and each color gives off a different 7. Stir in the Ginger / Garlic paste flavor. and sauté for 5 minutes. Capsicum contains small levels of 8. Once the vegetables are half capsaicin, an alkaloid compound, done, stir in the mashed potatoes, which has anti-bacterial , mix and remove from the stove. anti-carcinogenic analgesic and 9. Next in a small bowl, mix just anti-diabetic properties. They are enough water to make a thick also a rich source of Vitamin C, A, paste of the corn flour. Vitamin B complex and minerals 10. Using a teaspoon or such as manganese, potassium, tablespoon, ladle the vegetable selenium, magnesium, zinc, copper mix into the capsicum bowls. and iron. 11. Once the vegetables are filled Ingredients: to the brim, cover each capsicum • Green, Red, Orange, Yellow Capsicum Nutritional Value in this Recipe: with the corn flour paste to seal Peppers – 6 medium size Per serving – 342 calories; the vegetables. • Potatoes – 4 medium size Carbohydrate – 8g, fat – 11g, 12. In a Kadai, pour some oil for • Onion – 1 small finely diced or sodium 46g, fiber 17g, cholesterol shallow frying. Take each capsicum ¾ cup of finely diced onions – 550mg. bowl filled with vegetables and • Green Peas – ½ cup fresh (can substitute gently fry it in the shallow oil, until with black cow peas / karamani) the capsicum is cooked. • Carrots – 1 finely chopped Preparation: • Green beans – 10 finely chopped 1. Wash the capsicum and cut Serve as a side dish with dal and • Jeera – ½ tsp open at the top. Remove all the rice or any other curry / curd and • Turmeric powder – ¼ tsp seeds and white soft layers from rice. Non-vegetarians can • Red chili powder – ¼ tsp within the capsicum and discard. substitute the beans with minced • Garam Masala – ¼ tsp Arrange the capsicum shells on a meat (beef, lamb or mutton) of • Ginger / Garlic paste – 1 tsp plate and set aside. their choice. • Salt to taste 2. In a pot, boil potatoes with • Corn Flour – 1 cup water. Once cooked, peel and • Oil (Refined) – 1 cup mash. Set aside.

14 • CAPSULE MAGAZINE • JANUARY 2016 KAUVERY HOSPITAL CONTRIBUTION | CAPSULE MAGAZINE

Our touch to cure is a combination of expertise, standard and humanity with a soft touch for care and cure to the Chief Minister’s Relief Fund to help people affectecd by the floods Kauvery Hospital contributed Rs.10 lakh

QUESTION Xray chest taken for a blunt injury abdomen and chest. What are the findings? What is the diagnosis?

Answer the Quiz to Emaill: [email protected] or Whatsapp: 98434 12380 and win Surprize Gift

Please send the answers with your full name and mobile number. The correct answers and winner will be disclosed in the next capsule edition.

Answer for the previous Quiz Barium swallow study showing achalasia cardia

And the winner is Dr. V. M. Manikandan Karur

15 • CAPSULE MAGAZINE • JANUARY 2016 WELCOME TO KAUVERY FAMILY | CAPSULE MAGAZINE

WELCOME TO KAUVERY FAMILY

DR.N.KARTHICKEYAN, MS(GEN.SUR.).,MRCS.,DNB(GEN.SUR.).,M.CH(URO) CONSULTANT UROLOGIST CONTONMENT

DR.D.RAMACHANDRAN, MD.,DM, CONSULTANT - CARDIOLOGIST HEARTCITY

DR.V.RAMU, MBBS.,MD EMERGENCY PHYSICIAN CONTONMENT

DR.T.GOUTHAMAN, MD(GEN. MED.) CONSULTANT - PHYSICIAN CONTONMENT

DR.N.SUGUMAR, MBBS.,MS.,M.CH CONSULTANT CARDIO THORACIC SURGEON HEARTCITY

DR. VELVIZHI, MBBS, (MD) ER DMO CHENNAI

DR.VINOTH RAYAR, MBBS.,MD CONSULTANT RADIOLOGIST TENNUR

DR. RAJA. K,, MBBS.,DNS CONSULTANT GENERAL SURGEON CHENNAI

DR.C.NAVEEN CHANDER, MS.,M.CH(CTS) JR. CONSULTANT - CARDIOTHORACIC SURGEON HEARTCITY

DR. AMALA AROKIARAJ LOUIS, MBBS,FRCP(UK).,CCT ()UK,. CONSULTANT CARDIOLOGIST CHENNAI

DR.N.JOB, MS.,DNB.,M.CH CONSULTANT CARDIO THORACIC SURGEON HEARTCITY

JANUARY 2016 •CAPSULE MAGAZINE • 16 THE NEW AGE FAMILY HOSPITAL

WHAT DOES THIS QUALITY CERTIFICATION MEAN TO YOUR PATIENT?

HAPPY TO • Your patients are taken care ANNOUNCE THAT by well trained doctors and paramedics • A safe environment for an early recovery • Less chance of medication errors and hospital aquired infections • Practice of evidence based medicine • Overall satisfaction of the patient ALL THREE UNITS OF and family is improved. KAUVERY FAMILY AT TRICHY GETS QUALITY CERTIFICATION FROM This certification reiterated kauvery’s NABH goal of providing quality care to your patients

KAUVERY HOSPITAL TENNUR, TRICHY We would be happy to share our experience on quality KAUVERY HOSPITAL certification with your team members. If you require any assistance or training CANTONMENT, TRICHY for your staffs kindly feel free to call our Quality Manager Mr. Vairamuthu - 8973957986 Email: [email protected]

KAUVERY HEARTCITY CANTONMENT, TRICHY