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KG Medi News(English Monthly)

May, 2016 Coimbatore

Volume 1 Issue 19

Retail Price : Rs. 5

Annual Subscription : Rs. 50.00

Volume 1 - Issue 19 KG Medinews - May, 2016, Coimbatore

Dr G.Bakthavathsalam speaks...

A hospital is generally considered to be a safe

place for patients to get treatment for various

kinds of ailments and diseases and to get

back health and life. An ill equipped hospital

would pose health hazards to patients and

the visitors as there would be quite a number

of causes for contracting “hospital acquired

infections,” known in medical parlance as

“Iatrogenic diseases.”

Iatrogenic diseases can be defined as man-

made diseases caused either by error or

negligence or through infection caused by

the presence of micro-organisms that might

abound in a hospital.

Negligence by a physician can happen in the

form of leaving behind scissors or a piece of

gauze inside the operated area or performing

operation on the wrong side or carrying out

m i s m a t c h e d b l o o d t r a n s f u s i o n o r

administering wrong dosage of drugs.

Sources of Infection

An otherwise healthy person can get

infections when he/she comes in contact with

a patient having bouts of cough or sneezing.

Those who eat junk foods, addicted to

smoking and drinking alcohol (whatever be

the quality of liquor consumed) too are

exposed to the risk of infection and develop

physical conditions that might lead to

morbidity and mortality.

Iatrogenic diseases are not uncommon even

in the highly civilized societies. For instance,

25 per cent of patients admitted in US

“The Most Dangerous Place in Town is the Hospital,”

said an American Doctor!

It may be true in India as well?!

hospitals are victims of one or other kind of

infections. Therefore, it is advisable for the

patients to get treatment at the right kind of

hospitals that pay attention to their safety and

facilitate early cure.

Therefore, for standardizing the health care

delivery system the European countries and

the US have formulated stringent norms for

the hospitals and healthcare providers to

follow. Standardization of medical treatment

is being stressed upon with the laudable

objective of giving the best possible care to

patient so as to improve their quality of life.

Indian Scenario

As far as India is concerned there exists the

National Accreditation Board for Hospitals

and Healthcare Providers (NABH) that grants

quality certification to those hospitals which

fulfill the rigorous norms set by the NABH.

Of the 10,000 odd hospitals across the

country, only 400 hospitals, including KG

Hospital, have voluntarily sought to get

NABH cer t i f icat ion. Before granting

accreditation the unbiased team of assessors

of the NABH usually inspects a hospital for the

duration of three days to look into as many as

612 elements in 120 measurable quality

indicators.

Thus, only those hospitals that fulfill all these

criteria are eligible to get accreditation. It can

be said for sure that KG Hospital has done

extremely well in this regard. KG Hospital

had got its first NABH accreditation way back

in 2010, and the second NABH accreditation

in 2013.

Hat-Trick

Now, KG Hospital is all set to get its third

NABH accreditation and such a voluntary

initiative has so far borne fruits owing to the

committed hospital staff, right from the

specialists to the housekeeping workers who

constantly work towards accomplishing the

Mission and Vision set by the hospital.

In KG Hospital the doctors are dedicated, the

nurses are like angels and all the supporting

staff are superb. KG Hospital is unique in this

aspect as it would soon be one among the 76

hospitals that have the honour of getting

NABH accreditation for more than two times.

KG Hospital could clinch such an honour

because it has built up a wonderful team

whose members have passion to deliver

health care services in the best possible

manner. It is a patient-centric hospital known

for its accessibility, affordability, affability,

adaptability and accountability.

And of course, these sterling qualities has

made KG Hospital “one above the crowd.”

Rightly, the NABH team that visited KG

Hospital recently, as part of assessment for

g r a n t i n g t h i r d a c c re d i t a t i o n , h a d

complemented stating that “KG Hospital

stands out in terms of cohesive work culture,

and, excellent infrastructure and patient

care.”

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KG Hospital received appreciation from the

National Accreditation Board for Hospitals

and Healthcare Providers (NABH) team that

recently carried out assessment of the hospital

for giving quality certification for the third

time.

The three-member NABH team has termed

KG Hospital as “an excellent hospital having

good infrastructure, offering good patient care

and adopting good management practices. At

the helm of affairs is its Chairman Dr

G.Bakthavathsalam who has astounding

passion and involvement in the field of

medical care and obviously, in the hospital,

quality percolates from the top.”

Above all, the team has likened KG Hospital

to “a cohesive family unit” that is working in

unison to achieve the common goal of

rendering health care services to the

satisfaction of patients.

The team comprising Principal Assessor

Dr Jayadeep M.Gadhavi and two Assessors

Dr R.K.Ranyal and Ms M.M.Leessamma

examined the medical equipment and the

kind of services provided by al l the

departments, including the Intensive Care

Unit, in the hospital for three days, ie., from

May 12 to 14, 2016.

Unique Hospital

After completing the assessment, Dr Jayadeep

M.Gadhavi told the formal gathering of

doctors, the heads of departments and

managers of the hospital that “overall I am

very much satisfied with the performance of

KG Hospital.” He further said that so far he

had inspected over 75 hospitals across the

coun t r y f o r t he pu rpose o f g i v i ng

accreditation.

But he found KG Hospital to be the first one to

pro-act ive ly put in p lace necessary

infrastructure and adopt the best hospital

management practices. In his opinion the

ambulance service, blood bank, bio-medical

engineering department, endoscopy

department, pharmacy, Central

Sterile Service Department, main

reception, stores, medical records

department and human resource

department were doing good work.

Dr Gadhavi had a special word of

praise for KG Hospital Chairman

Dr G.Bakthavathsalam who he said

remained dedicated to medical

profession even at the age of 73. “If all

the physicians show the same kind of

involvement and passion, KG Hospital can do

wonders and such a situation would help the

hospital in case of litigation too,” he said.

Dr Gadhavi praised the nurses of KG Hospital

for their excellent services which he attributed

to the good training imparted to them.

However, he said that training was not just a

one-time affair but a continuous process. He

was thankful to the medical fraternity, para-

medical staff and all other employees of KG

Hospital for extending their “kind co-

operation” to the NABH team during its visit.

Facilitators as Appreciators

Dr R.K.Ranyal, one of the Assessors, clarified

that “the visit of the NABH is not intended to

be a fault-finding one, but a fact finding one.

The NABH team has come down here as

facilitators to bring out the best in what you

have and also to learn from you.”

He said, “Hats off to the ambulance drivers of

KG Hospital who are well aware of the Code

Blue procedures (medical emergency), Basic

Life Support System (BLS) and the Advanced

Cardiac Life Support System (ACLS).”

It was an indication as to how knowledge

about health care exigencies had percolated

down the line in KG Hospital. Dr Ranyal

suggested that during an emergency situation

or a disaster the hospital staff should remain

alert to locate the patients by calling out “who

is the patient?” as the patients need not

necessar i ly be ly ing down for easy

identification. It would enable the staff to

render timely medical aid to the affected

people.

Dr Ranyal said that the areas of conflict

identified by the team did not mean that it

would take up AK-46 or AK 47 to sort them

out. It held healthy discussions with the

hospital management on how to get things

right. He emphasized the point that quality

assessment was an ongoing process and did

not stop with a single visit.

Appreciating the total involvement of KG

Hospital Chairman Dr Bakthavathsalam and

his passion for rendering health care services,

Dr Ranyal called upon each and every staff of

the hospital to emulate the Chairman.

Assessor Ms Leessamma thanked the

management for i t s hospi ta l i ty and

appreciated the hard work being put in by the

nursing and housekeeping staff.

Good Work Culture

Chairman Dr Bakthavathsalam in his

introductory speech profusely thanked all

doctors, managers, nurses and employees of

the hospital for their tireless efforts in the past

many years to comply with the NABH norms.

Dr Bakthavathsalam emphatically said that

for KG Hospital patients’ interests and safety

came first and in the 42 years of its existence it

had been successfully implementing its

Mission, thanks to the right work culture the

hospital had evolved.

KG Hospital gets kudos from NABH team

Volume 1 - Issue 19 KG Medinews - May, 2016, Coimbatore

3Volume 1 - Issue 19 KG Medinews - May, 2016, Coimbatore

4Volume 1 - Issue 19 KG Medinews - May, 2016, Coimbatore

Case vignette 1:

37 yr old male, married, owns a small cloth

shop, from a nuclear family, resident of

tirupur. He Came with the complaints of

using alprazolam tablets of about 6 mg per

day (0.25 mg tablets). He was apparently

maintaining well till 10 years back when his

friends introduced him to alcohol. He slowly

become dependent on alcohol within 5 years

and was drinking about 750 ml per day with

marked dysfunction. He was admitted in a

de-addiction centre. He remained abstinent

from alcohol for six months and was

maintaining well except for on and off sleep

disturbances for which he was prescribed

with 0.25 mg of alprazolam by a local

practioner. Alprazolam was giving him the

same calming and relaxed feeling as that of

alcohol. He started taking alprazolam

medicines on his own The amount of

alprazolam slowly increased to 6mg day. He

had a strong desire to take tablets, would

have sleep disturbances, heaviness of head,

tremors of hands whenever he takes lesser

tablets or when tablets are not available.

Had two episodes of withdrawal seizures

when he skipped medicines and was not

regularly going for job. Finally he came for

treatment as the medicines were giving him

and he was not able to give up on his own.

He required IP care because of withdrawal

seizures and marital issues which were

maintaining his drug intake. He was shifted

to 120 mg of diazepam, was monitored for

withdrawal symptoms. Marital issues were

addressed through therapy. Slowly the dose of

diazepam was gradually tapered. He is coming

for regular follow up and he had started going for

job. Patient is currently on relapse prevention

counselling and marital therapy.

Practise Of Prescribing Benzodiazepines

And Management Of Benzodiazepine DependenceDr. V. Umamaheswari

Consultant Psychiatrist

& : 96633 35134

Case vignette 2:

About a 65 yr old male, on anti hypertensives for the last 5 years. When

he was diagnosed as having hypertension he was experiencing on and

off sleep disturbances for which he was prescribed 0.25 mg of

alprazolam. Slowly the patient started taking alprazolam on his own

without the knowledge of treating physician and the dose increased to

upto 1 mg per day for the last 6 months without which he was not able

to sleep properly. He was found drowsy during the day time, had

slurring of speech and was slow in his mental function. He revealed the

history of alprazolam intake to the treating physician and was referred

for further management. He didn’t had any comorbid anxiety,

depression or cognitive deficits. Initially the dose of alprazolam was

decreased by 0.25 mg per week but he would again relapse to the

previous dosage as he was not able to tolerate even minor sleep

disturbances. He was given mirtazapine 15 mg along with alprazolam

and slowly over a period of 2 months he is completely off alprazolam

and is on 7.5 mg of mirtazapine. Patient is regularly following sleep

hygiene, has a good activity schedule and is on relaxation exercises.

Further plan is to stop mirtazapine.

Case vignette 3:

A 40 year old male presented to the hospital with the

complaints of sleep disturbances and anxiety symptoms

whenever he tried to stop 0.5 mg of clonazepam. On

further exploration his friend died because of sudden

cardiac arrest 4 months before, since then he had marked

concern and worry about his health, would experience

palpitations, tremors, sweating, chest pain and would

panic that he would get a heart attack and die. He had

consulted various cardiologist whenever he had this

sudden acute episode. ECG and Echocardiogram were

normal and was reassured. Finally one cardiologist

prescribed him with 0.5 mg of clonazepam with which

his sleep was taken care off but the above mentioned

symptoms were increasing. On further exploration he

was found to be having anxious personality, with

marked health anxiety from his childhood. He was

diagnosed as having generalized anxiety disorder and

was prescribed with T. Sertraline upto 200 mg per day,

clonazepam was continued for three weeks and then

slowly tapered and stopped. He is coming for regular

follow up and is on medications and is maintaining well.

5Volume 1 - Issue 19 KG Medinews - May, 2016, Coimbatore

Lessons Learnt From These Patients:

The first case is an example of illicit drug

abuse. He had strong history for addiction.

Had alcohol dependence and prescription of

benzodiazepine made him to switch over to

b e n z o d i a z e p i n e d e p e n d e n c e a n d

unresolved marital discord was the

maintaining factor for his dependence.

The second case is an example of therapeutic

drug over dose, where the pat ient

continuous to abuse the medicine prescribed

to him by a physician and slowly became

dependent on it and had side effects with the

medicines.

The third patient is an example for anxiety

disorder, which was not recognised and

treated promptly.

Dont’s

Avoid prescr ib ing benzodiazepines

particularly in elderly as there is high chance

for sedation, falls, fracture and memory

disturbances.

Avoid benzodiazepines in individuals with

history of addiction / family history of

addiction.

Avoid using psychiatric medicines like

anxiolytic and antidepressants which comes

in combination with benzodiazepines as

people would abuse them.

Low dose of benzodiazepines mask

underlying depression and anxiety, and

prescribing benzodiazepines in such

individuals’ results in increase in severity of

the underlying illness and it becomes difficult

to treat in the long run.

Avoid benzodiazepines in patient with

delirium as it would worsen delirium.

(Benzodiazepines need to be given only in

a l c o h o l w i t h d r a w a l d e l i r i u m a n d

benzodiazepine dependence).

Avoid benzodiazepines in patients with

dementia and head injury as it would worsen

cognitive deficits.

Do’s

Use benzodiazepines only when required.

Make sure that the patient gets medicines only

for the prescribed duration and not more than

that.

Medicines need to be supervised by the family

members.

Risk of continued usage without the treating

physician’s knowledge needs to be explained.

S l e e p d i s t u r b a n c e s a re t h e i n i t i a l

manifestations of majority of the psychiatric

disorders like depression and anxiety disorder.

So all patients presenting with sleep

disturbances and unexplained pain need to be

assessed for underlying psychiatric disorders

and require proper psychiatric help.

Sleep hygiene measures to be told to the

patient when they have only sleep disturbance

as the predominant complaint before

prescribing benzodiazepines.

DrinkWaterComfortable

mattresand bedding

Go to bed and get up at the same time every day

Avoidcaffeine

and alcoholat night

Spend time outside

Read a book in bed

Relaxation exercise

Have an early light dinner

Helps yousleep

Poor quality

bedding

Coffee andchocolatesafter dinner

Hot bedroomwith no aircirculation

Go to bedwhen

you’re nottired

Stress andanxiety

Use a tableor

phone in bed

Stay indoorall day and do

no exercise

Lie in bed for hours getting

stressed

Keeps youAwake

Sleep Hygiene

Volume 1 - Issue 19 KG Medinews - May, 2016, Coimbatore6

‘Hare Krishna’

Stapedotomy at 68

Stapedotomy is the surgical treatment of

choice of Otosclerosis for the ear.

Mr. Ramalingam, 68 years male from Ooty

was suffering from hearing loss and mild

tinnitus both ears for the past 45 years. He has

consulted many ENT doctors at Chennai and

Coimbatore. He was afraid of the ear surgery

since the prognosis of the surgery –

Stapedotomy is ALL (or) None law. He was

told that either he may get back the normal

hearing or may lose the remaining hearing

after the surgery.

He came to us (KG Hospital) to consult me

regarding the treatment. I examined him and

diagnosed as otosclerosis both ears. I

explained him in detail the pros and cons and

the prognosis of the surgery - Stapedotomy

and convinced him for the surgery.

He underwent right Stapedotomy and Teflon

Piston with vein graft interposition. He has

regained his normal hearing during the

surgery on the table itself. He was able to hear

the sounds and noise of the world and the first

sound he heard was HARE KRISHNA, HARE

RAMA Nama Sangeerthan in the recovery

room. He was very much excited and very

happy to hear lord Krishna’s sangeerthan. He

feels he has got a second life with good

hearing at the age of 68 years.

The age 68 with presbyacusis is not an

absolute contraindication for Stapedotomy.

“We dress the wound. He who heals it”

Caution:

Root canal treatment (Dental) with high

intensity drill sound may produce accustic

trauma and sudden sensory normal hearing

in stapedotomy patients.

Result & Conclusion:

Long term followup of 10 years in 500 cases

with vein graft interposition technique

Air bone gap before surgery (AB gap) – 45db

Air bone gap after surgery– 10db (average)

Tinnitus – 50% relieved, 30% remain the

same, 5% increased.

Highly respected and revered Dr G.Bakthavathsalam Sir,

My loveable greetings to you.

I recently read the Tamil book “Idhayam Oru Koil” (“Heart is a Temple”) authored by you

from cover to cover, without leaving even a single sentence. I have read quite a lot of literary

works, including poetry, essays, novels and story books. This is the first time that I have read a

book related to medicine and thoroughly enjoyed it.

The book gives an interesting and tasteful reading on how to lead a healthy life. The Koran,

Holy Book of Islam, says:

“One who does not have the mind to say ‘No’ has got unparalleled kindness;

One who listens to and heeds the distress call of others looks into the thinking and

heart of the sufferer;

One who looks at the external appearance is a human;

But, one who looks at the heart is God.”

The Koran is considered to be a panacea for all ailments and this truth can be understood

from the following lines: “It is but natural for man to fall sick--in such cases, it is the

responsibility of the sick to approach physicians to get medicines—but it is God’s grace that

makes the medicines work.”

The title of each chapter in your book conveys brilliant ideas in a crisp manner. The significant

aspect of the book is the foreword given by my best friend and Health Secretary

Mr V.K.Subburaj, I.A.S, and its release by honourable former President Dr A.P.J.Abdul

Kalam, who was the guiding star of the young generation.

I deem it a pleasure to quote from the book some of the shining lines which have greatly

impressed me:

“If you don’t take proper care of the heart that is beating lakhs of time, you will

lose lakhs (of money).”

“Like a confined air, stuffing the heart with very many unwanted thoughts will

lead to complications.”

“Today’s youth in the name of searching Heaven are heading to Hell.”

“The classic songs would lose their rhythm if re-mixing is improperly done;

similarly, if the rhythm of heart changes the heart will get spoiled.”

Former Chief Minister Doctor Kalaignar (Mr M.Karunanidhi) has stated that: “One who takes

preventive measure is intelligent and one who struggles after getting ailment is unwise.”

You have mentioned in your book how an actor earned crores of rupees by stylishly puffing

cigarettes in movies and how such a mannerism has spoiled the health of many youths who

copied him. It clearly shows that you are not after money but are sincerely propagating health

aspects.

You have stressed the importance of having whole body test and examining the condition of

the heart through the 128 Slice CT Scan.

Therefore, the “Idhayam Oru Koil” book, replete with healthy tips, should be read by every

citizen of India. Though I have a lot more to say, for the sake of brevity I conclude with the

following sentence:

“May Allah bless you with long life and let your health care services grow further.”

V.M.A.Shalappha

Film Director and Script Writer

“All Glory to God” —A Film Director’s encomiums for Dr G.B’s book

Dr. S. Kaliannan

ENT Surgeon

& : 9443425136

Appreciation

Case No.1:

55 years old male, smoker came with complaints of chronic cough with

expectoration for 3 months. He denied history of haemoptysis, fever,

shortness of breath, weight loss or loss of appetite. Chest X-ray showed

left upper zone homogenous opacification suggestive of

consolidation. Blood biochemistry were normal. ECG was normal.

Further evaluation with CT chest revealed left upper lobe complete

collapse consolidation with a mass lesion in the left hilar region

extending to left subcarinal region and engulfing left pulmonary artery

suggestive of bronchogenic carcinoma. Bronchoscopy showed

complete occlusion of left upper lobe bronchus by the extincic mass

with mucosal invasion. No endo bronchial mass lesion was visible.

Hence a transbronchial needle aspiration was done with a special

needle (size 22 G) which can pass through bronchoscope from

subcarinal and left hilar region with a special attention not to puncture

the pulmonary vessels which were very close to the puncture site. Even

though there was a minimal bleed which could be controlled with local

hemostat, no major bleed encountered. The needle aspirate was

prepared in to s l ides and the cy tof ixed s l ides showed

adenocarcinomatous cells on HPE.

TBNA is a minimally invasive procedure that provides a nonsurgical

means to diagnose and stage bronchogenic carcinoma by sampling

the mediastinal lymph nodes. The procedure allows for sampling

tissue through the trachea or bronchial wall, and sampling of tissue

beyond the vision of the dedicated operator. In addition to the

equipment needed for bronchoscopy, the equipment needed

specifically for TBNA include TBNA needles, which are designed to

pass through a bronchoscope without causing damage and to be

flexible enough to facilitate the positioning of the bronchoscope, yet

rigid enough to penetrate the airway wall. Two types of TBNA needles,

cytology needles and histology needles, should be available for the

procedure. The most common potential complications are bleeding,

pneumothorax, or pneumomediastinum. Significant bleeding rarely

occurs even after a major vessel puncture. Fever and bacteremia have

been reported following TBNA, although this may be related to the

bronchoscopic procedure itself rather than this specific technique.

IBNA:

Case No.2:

75 year old male, smoker, was hospitalized with acute respiratory

failure. He had underlying severe LV dysfunction (ejection fraction

25%) and ischaemic cardiomyopathy. He had fever for 1 week along

with cough with expectoration. He had severe hypoxia and

hypercarbia on admission. He was stabilized with non-invasive

ventilation and diuretics along with antibiotics. Chest X-ray showed

features of pulmonary oedema with left upper lobe consolidation with

cavitation. Further CT chest confirmed the above findings. Even

though the patient had an initial improvement, he required continuous

non-invasive ventilation support and oxygen without which he

desaturated significantly down to 75% on room air. An infective focus

was strongly suspected which could be the cause for acute worsening

of LVD and pulmonary oedema. His sputum examination did not

show AFB or any gram stained organisms as he could not bring out

sputum properly. Hence Bronchoscopy with BAL was planned. The

risks of bronchoscopy in hypoxic patient with severe LVD including

sudden cardiorespiratory arrest, cardiac arrhythmias, pulmonary

oedema, pneumothorax and airway bleed were discussed with the

family in detail. Family consented for bronchoscopy with NIV support.

Bronchoscopy under NIV support was successfully done under local

anaesthesia and IV sedation and BAL sample obtained and procedure

was uneventful.

Bronchoscopy in patients with respiratory disorders can be

challenging. The bronchoscope occupies 10 –15% of the normal

tracheal lumen and can increase the work of breathing and decrease

PaO2 by 10 – 20 mm Hg, which can cause respiratory complications

and cardiac arrhythmia. Hypoxemia occurs with insertion of the

bronchoscope through the glottis into the trachea, and becomes worse

when local anesthetics or saline solution is instilled into the lower

airways. Bronchoalveolar lavage is associated with worse oxygen

desaturation than when lavage is not done. Furthermore, suction

Interesting BronchoscopiesDr. S. Santhakumar

Pulmonologist

& : 99946 52670

7Volume 1 - Issue 19 KG Medinews - May, 2016, Coimbatore

LUL Complete Occlusion TBNABronchoscopy with NIV support.

RNI No. TNENG/2014/59720

Published by Dr. G. Bakthavathsalam, on behalf of K. Govindaswamy Naidu Medical Trust (KG Hospital), Published from 5, Govt. Arts College Road, Coimbatore - 641 018. Tamil Nadu and printed by A. Dhanasekaran, at The Safire Offset Printers, Vembakkottai Road, Ayyanar Colony, Sivakasi - 626123. Editor : Dr. G. Bakthavathsalam

Registration No : CB/127/2015-17

8

Volume 1 - Issue 19 KG Medinews - May, 2016, Coimbatore

For the benefit of the poor people who

might need surgeries for various diseases,

KG Hospital has organized a two month-

long “General surgery camp” in the

hospital premises here Started on May

1st. It will go on till June 30, according to

Dr G.Bakthavathsalam, Chairman of the

hospital.

I n a s t a t e m e n t r e l e a s e d h e r e

Dr Bakthavathsalam has stated that

during the camp period free consultation

would be given to the patients. And those

patients who would be identified as the

probable candidates for surgeries, the

diagnosis and operation would be

performed at concessional rates ranging

from 25 to 50 per cent.

Dr. Bakthavathsalam has further stated

that “the 500-bedded multi-specialty

tertial care KG Hospital is equipped with

ultra modern medical equipment for

doing perfect diagnosis for all kinds of

diseases. The specialists in the respective

fields of medicine/surgery would attend

on the patients and perform the surgeries

with utmost clinical precision.”

A team of experts headed by leading

surgeon Dr V. P. Shanmugasundaram,

who is Chief of the General Surgery

Department and Chief Laparoscopic and

KG Hospital performs General Surgeries at 50 % concessional rate

Transplantation Surgeon of the hospital,

would screen the patients and organise the

required surgeries.

The concess ional scheme would be

applicable to the following surgeries

Ÿ Advanced laparoscopic hysterectomy

Ÿ Tumour in the neck

Ÿ Tumour in the uterus

Ÿ Gall bladder

Ÿ Pancreas and liver surgeries

Ÿ Gastroenterology

Ÿ Varicose vein

Ÿ Appendicitis

Ÿ Hernia

Ÿ Piles and Intestinal problems

Ÿ Family planning

Ÿ Tonsillitis

Ÿ Circumcision and surgery for torsion

testicles

and any cancerous growth in the body

during bronchoscopy reduces the end-

expiratory volume and positive end-

expiratory pressure and thus causes alveolar

closure. Though hypoxemia is associated

with cardiac arrhythmias in 11– 40% of

p a t i e n t s w h o u n d e r g o f i b e r o p t i c

bronchoscopy, these cardiac rhythm

disturbances are rarely clinically important.

The American Thoracic Society, however,

recommends avoiding flexible bronchoscopy

and bronchoalveolar lavage in patients with

hypoxemia that cannot be corrected to at

least a PaO2 of 75 mm Hg or to an arterial

oxygen saturation of 90% with supplemental

oxygen. In these higher-risk patients the

traditional alternatives are avoidance of

bronchoscopy and empirical treatment, or

intubation and mechanical ventilation to

assure adequate vent i la t ion dur ing

bronchoscopy.

Endotracheal intubation and mechanical

vent i la t ion have potent ia l ly severe

complications, however, and in many

patients NIV is a valid alternative to

intubation, especially in immuno suppressed

patients and in critically ill patients with

pneumonia. Single and multi center

randomized studies found, however, that in a

heterogeneous group of patients with a

history of cardiac or respiratory disease and

who developed respiratory distress during the

first 48 hours after extubation, the addition of

NIV to standard medical therapy did not

improve re-intubation rate, hospital mortality,

intensive-care-unit stay, or hospital stay. In

fact, in that patient population NIV may be

harmful and increase the risk of death from

cardiac ischemia, respiratory muscle fatigue,

aspiration pneumonitis, or complications of

emergency intubation.

D. Rajesh. &�:� 98433 21803

P. Sheeba &�:� 90476 55121

For details contact :