Intracranial Hypertension

Tracheal Tube Introducers, Stylets, Exchange Catheters, and Staged Extubation Sets in Airway Management

Introducers and stylets are two very useful devices for overcoming difficulties in airway management. In fact, they are the first option in many difficult airway algorithms. The design and use of these tools have evolved over the years, and several introducers and stylets are currently available on the market, with different indications and applications in daily clinical practice. Anaesthetists should be familiar with the different devices, characteristics and indications in order to ensure correct application in each situation [1].

SICU Update

Since the field of critical care is constantly changing, it is important for anesthesiologists to stay knowledgeable of these changes in order to provide optimal care to critically ill patients in the perioperative period. The purpose of this chapter is to provide an update for clinicians on ICU issues relevant to clinical practice. Topics which will be discussed include: modes of mechanical ventilation, renal replacement therapy, antibiotic prophylaxis, nutritional support, sedation management, transport of patients, and transfer of care.

Pediatric Hematological Malignancies – Clinical Manifestation, Treatment and Follow-Up

Hematological malignancies are the forms of cancer that begin in the cells of the blood- forming tissue, such as the bone marrow. Childhood blood cancers are relatively rare but are still found to be the major cause of death in children aged 1-14. Early detection increases the chances of successful treatment which paves the way to reduce the rate of mortality. Leukemias and lymphomas account for more than one half of new cancer cases in children. Despite major advances – from an overall survival rate of 10 percent to nearly 90 percent today, for many rare cancers, the survival rate is much lower. Enhancement of anti-leukemic efficacy and reduction of treatment related morbidity or mortality can be achieved by targeted therapy, but requires detailed understanding of pathways and genetic defects involved in leukemogenesis.

The Menace of Malaria: An Overview

Malaria remains one of the most dreadful diseases affecting millions of people across the world. It is an infectious disease spread through the (female anopheles) mosquito caused by the parasitic protozoans belonging to genus Plasmodium. The most lethal species is Plasmodium falciparum which if left untreated, may cause organ failures (severe malaria) or may accumulate in brain (cerebral malaria) causing coma and finally leading to the death. The disease is mostly prevalent in Sub-Saharan Africa. Children under the age of 5 years, pregnant women and travellers to the malaria prone area are particularly at higher risk of getting malaria. It is typically diagnosed by microscopic examination of blood using blood film or antigen-based rapid diagnostic tests. The treatment of malaria comprises various synthetic, natural analogues administered orally or parenterally. The choice of therapeutic agents depends on the species of parasite, pattern of resistance and the seriousness of the infection. Emergence and spread of the multidrug resistant strains of the causative organisms has extremely limited the choice of antimalarial chemotherapeutics. Only limited treatment options are currently available due to the resistant species highlighting the need of efficient research for developing newer broad spectrum antimalarial drugs. The discovery of potent vaccine against malaria still remains a major challenge amongst scientific community, with only limited success achieved till now. The choice of the delivery system plays a vital role in determining fate of the drug as it’s not only important for delivering the right drug at the right site, but also it can minimize the untoward effects of drugs. Nano-carriers or nanosystems are useful tools that are particularly gaining distinctive attention in malaria chemotherapy because of their ability to minimize the side effects, improve bioavailability and the selectivity of the drugs by altering the biopharmaceutics and pharmacokinetic property of the drug molecules. Discovery of potent drugs like Arteether (ART) and Bulaquin have been some major breakthroughs in antimalarial research. However; the major challenge in management of malaria in the current scenario is to combat drug resistance and to develop new potent drugs in order to completely irradiate this fatal disease. This chapter is intended to highlight on some basic aspects of malaria, challenges in current chemotherapy, current investigations towards malaria chemotherapy and vaccine, and the use of nanotechnology as a promising strategy for malaria treatment.

The Endocrinology and Iatrogenesis

Iatrogenicity is inherent to endocrinology, being a consequence of treatment (e.g., use of thyroid hormones in large doses to suppress thyroid stimulating hormone [TSH] in thyroid cancer) or occurring due to a lack of patient compliance (e.g., lack of adequate controls in chronic diseases, such as Hashimoto’s chronic thyroiditis). Quite often, it is induced as a side effect of medicines (e.g., long-lasting use of antithyroid agents or glucocorticoids). In this chapter, we review the most important iatrogenic effects, according to the main features of endocrinology. We present certain drugs that can trigger particular syndromes, such as the syndrome of inappropriate antidiuretic hormone secretion (SIAHS), along with preparations with pitressin and complications of treatment performed for pituitary adenomas, potential complications of drugs used to treat pituitary insufficiency in children and other specific features constituting required knowledge for medical practitioners. All therapeutic modalities of hyperthyroidism (medical, surgical, radioiodine) can cause iatrogenic pathology. For example, the euthyroid state is a sine qua non condition of thyroid surgery (except the thyrotoxic storm in advanced stages). Radioiodine treatment, in turn, has its own contraindications. Iodine-containing preparations can activate thyroid autonomies and aggravate autoimmune thyroiditis and overt hyperthyroidism. In hypothyroid elderly and cardiac patients, the thyroid hormone substitution must be applied only after initial cardiovascular treatment, in small, gradually increasing doses. In Addison’s disease, indication of dietary salt reduction alongside glucocorticoid substitution, or the lack of increase in glucocorticoid dose in acute injuries, are serious iatrogenic complications.

Iatrogenic Lesions in Neurology

Iatrogenic neurological disorders can be induced by several factors, such as pharmacological agents prescribed for treatment or prevention (drug-induced neurological disorders [DIND]), complications of diagnostic and treatment procedures, like cerebral angiography or lumbar puncture, organ transplantation (related to the surgical procedure of transplantation, post-transplant immunosuppression, opportunistic infection or the inherent disorders that lead to transplantation), radiation therapy, etc. Iatrogenic neurological effects may be devastating due to the higher potential irreversibility of central nervous system, peripheral nervous system, neuromuscular junction (NMJ) and/or muscular system involvement. DIND represent the majority of iatrogenic neurological disorders. Drugs may directly induce neurological damage (through primary neurotoxicity, such as damage to the bloodbrain barrier [BBB], disturbances of brain energy metabolism, ion channels/neurotransmitters disturbances, mitochondrial dysfunction, metabolitemediated toxins, drug-induced selective cell death) or do so indirectly (cardiovascular, hematological or renal effects). Identification of DIND is important because early recognition and drug withdrawal can prevent irreversible damage. The numerous intrinsic risk factors for DIND should be well known by medical practitioners.

Subject Index

Von Hippel-Lindau Disease

A Case of Superior Sagittal Sinus Thrombosis Presented with Papilledema

This is a case report of superior sagittal sinus thrombosis (SSST), with bilateral papilledema as the initial manifestation.

A 65-year-old male was referred to us with bilateral decreased vision and recurrent blackouts associated with postural change. Although his intracranial pressure was increased, an intracranial space-occupying lesion was not detected by computed tomography (CT). Magnetic resonance imaging (MRI) with a fluid-attenuated inversion recovery (FLAIR) technique and magnetic resonance venography (MRV) findings revealed a thrombosed superior sagittal sinus. Anticoagulation therapy with heparin was started and recurrent blackouts disappeared one month thereafter. Thoracoabdominal CT examination revealed an infiltrative shadow in the right inferior lobe of the lungand was diagnosed as squamous cell carcinoma from biopsy by bronchoscopy. Bilateral papilledema gradually decreased over an 18-month observation period after anticoagulation therapy.

MRV was useful in the diagnosis of SSST in this case of bilateral papilledema with increased intracranial pressure.