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  Address:  39 Daryacha, Hauz Khas Villege, New Delhi, India. e-Mail: drkk@ijcp.com , Website: http://www.ijcpgroup.com 

Dr K K Aggarwal

Dr KK Aggarwal
Dr BC Roy Awardee
Sr Physician and Cardiologist,
Moolchand Medcity
President, Heart Care
Foundation of India
Gp Editor-in-Chief,
IJCP Group
Member,
Delhi Medical Council
Director, IMA AKN Sinha Institute (08-09)


 

27th October

Dear Colleague,

Breaking news: Start all high risk patients on beta blocker in pre operative phase?
Findings from a huge database at the San Francisco Veterans Administration  Hospital, presented at the American Society of Anesthesiologists 2009 Annual Meeting, confirmed the survival benefits of peri-operative beta blockers for patients with cardiovascular risk.
More than 10 years ago, peri-operative beta blockers were shown to reduce mortality in clinical trials and were therefore adopted as the standard of care by cardiology societies. But the Peri-operative Ischemic Evaluation (POISE) trial ? called into question their benefit and, in fact, found an increased rate of mortality and stroke associated with their use (Devereaux PJ et al. American Heart Association 2007 Scientific Sessions. Abstract LBCT 20825).
The current study from San Francisco, finds flaws in the POISE trial, which could have affected the results, especially the use of metoprolol in a dose that is 8 times higher than the standard.
The current Peri operative Cardiac Risk Reduction Therapy (PCRRT) protocol, uses standard doses.
Protocol: Beta Blockers
1. Oral atenolol 25 mg once daily to start. If heart rate is higher than 60 beats per minute and systolic blood pressure is higher than 120 mm Hg, titrate dose to effect.
2. Atenolol or intravenous (IV) metoprolol on the day of surgery. Atenolol or IV metoprolol postop until taking orally.
3. Oral atenolol 100 mg once daily for 1 week or more post op.
4. If known coronary artery or peripheral vascular disease, continue beta blocker indefinitely.
If Unable to Take Beta Blockers
1. Oral clonidine 0.2 mg tablet the night before surgery.
2. Clonidine TTS 2 patch (0.2 mg/24 hours) the night before surgery.
3. Oral clonidine 0.2 mg tablet the morning of surgery.
Investigators analyzed 38,779 surgical procedures in 20,937 patients (average age, 63 years). For in-patient procedures, metoprolol was most common (75%); for out-patient procedures, atenolol was most common (54%). When compared with no use of beta blockers, the prophylactic addition of beta blockers significantly reduced 30-day and 1-year mortality by approximately 50%. Withdrawal of beta blockers in patients already taking the drugs raised the risk for 30-day mortality almost 4-fold (P < .0001) and nearly doubled 1-year mortality (P > .0001). Clinicians should be aggressive in identifying candidates for beta blockers and starting them on therapy right away. Patients scheduled for surgery start receiving a beta blocker as soon as we identify them as at-risk. {American Society of Anesthesiologists (ASA) 2009 Annual Meeting: Abstract A705. Presented October 19, 2009]

Dr KK Aggarwal
Editor

 


Winter Disorders (Proceedings of CME held at Moolchand Medcity on Sunday 25th)

1. Dengue: It is surprising this year dengue is continuing even after Diwali. In fact, in the last one week, there has been an increase in the number of cases of dengue. One observation ? during this period, we have been organizing Perfect Health Mela for the last 16 years and every time during Mela we encountered an army of  street mosquitoes all around the tube lights for which  every time we had to call  MCD for anti-mosquito fogging. These mosquitoes were short lived and by morning one could see lakhs of them dead on the floor. This year that army of mosquitoes was absent. Has this to do something with rise in dengue mosquito, only the experts can tell?
2.  Treatment of capillary leakage in Dengue: The answer again formula of 20. Give orally or IV 20 ml per kg body weight per hour fluid till the pulse pressure is 40 or the patient passes sufficient urine.
 
3. Winter SAD: or seasonal affective disorder, presents as  early morning depression, letharginess, unwillingness to come out of woolen rajai. Patient is invariably OK by evening. It is usually seen in people who are obese, diabetic or hypothyroid. Most people have a craving for eating sweet, salt or sour food. Treatment is adequate exposure to sunlight or room light. It is due to the imbalance between melatonin and serotonin.

4. Winter Diabetes: During winter, people have more tendency to eat sweet, salt, sour food and hence they may end up with uncontrolled diabetes or blood pressure. Accelerated hypertension, blocks, arrhythmias are more noted in in later half of December and early January. In November, one will see high blood pressure with signs of water retention, LV Dysfunction etc.   

5. Winter smoking and alcohol: It is a general myth that the treatment of cold is drinking alcohol or smoking. If alcohol is consumed more than 150 ml in one hour or more than 180 ml in one day, it is called binge drinking and can precipitate acute MI due to plaque rupture. Smoking if added to it can cause disasters. Smoking itself can increase upper blood pressure by 20 mmHg and also cause plaque rupture. The combination of binge drinking and smoking is dangerous in the early hours of the day, especially, in early January as alpha activity is known to be maximum during that period. If it coincides with full moon, it may be further dangerous.

6. Winter Bronchitis/Asthma: A sudden change in inter day temperature of more than ten degree or a fluctuation of humidity by 10% in a day can precipitate an attack of asthma or COPD. This can happen when one is coming out of heated car or house. In such cases, one should close the warming of the car five minutes before the destination.

7. Winter Pneumonia: It can be H1N1 pneumonia, human flu pneumonia or pneumocoacal pneumonia. The characteristic features of the elderly pneumonia is occurrence of single chills. Quite often in the elderly pneumonia may present atypically with no fever, breathlessness or chest pain and the patient may  complain only of not feeling well. Absence of fever is a bad sign. All patients during winter should consult their doctor for a flu and pneumonia vaccination. Swine flue vaccination is not yet available in the country.

8.  Why no blood transfusion in dengue bleeding?

Because, the culprit is low platelet when bleeding is there. Once you give platelets, the bleeding will stop. Most blood issued by blood banks is not fresh. In fact, the blood issued is the near expiry one as blood can only be kept for 42 days. Tendency for any blood bank is to first exhaust near expiry blood. That blood invariably will be deficient in platelets and would have lost atleast  20% of its quality.

9. What are the two phases of winter?

The first phase of winter is moist winter and the second phase will be dry winter. Dry winter will start around 13 January and will last till 13 March. This description in terms of proneness to diseases is well described in Ayur Veda where moist winter is associated with disorders with water retention like menstrual headache, LVF etc.

Dry winter is associated with accelerated movement disorders which can be seen in accelerated high blood pressure, blocks, acute MI due to plague rupture.

Letter to the editor:
1. Ref DMC decision on weather or not DMC should intervene in subjudice cases.  I personally would not agree with decision of the DMC that matter is subjudice. U see what is expected of the Council is that matter is examined from professional point of view. At the most in such cases decision may not be conveyed to individuals, and kept under cover or may be communicated to the respective court after making a submission that the Council received the complaint and professional view is so & so. Secondly, an undertaking, which could be under oath (on affidavit) whether the complainant has approached any court of Law in the same matter. The Council would lose its credibility, if a routine reply stating that since it is subjudice, council will not examine. What if the matter is referred by court of Law for a professional opinion. I feel this matter needs serious consideration by the Council. Since u r now member of the Council, I expect professional touch with sincerity to the outcome.
2.  I think I am getting enlightened by such info. I have one observation. In the consent forms signed by the patient/relatives, there is one standard statement that complications have been explained to me. This is statement to cover up the doctors and hospitals, but tell me in reality and practice how many times and how many of us do explain or spend time in explaining complications to the patient/relatives. Let us not follow self protective practice. It will be better if major complications- (i) Common, and (ii) Specific related to the specific procedure- are jotted down on consent form itself. There is no need for any Govt. orders on that I think an executive order taken by management of the hospital/s can take such a decision in consultation with specialist physicians/surgeons. Let that be a routine hospital protocol, there is no harm in that but besides safety valve for doctors and hospitals, it will help us contributing a little in reducing number of litigations as well. Let your hospital take the lead and bring other hospitals in the fold for a larger consensus. In addition the people sitting on such matters should be really serious and not just with excuses like, I have to reach in ten minutes / I have to attend to such & such function/meeting, etc. I am willing to devote time on such important issues.
[Dr K K Arora ]

Editors response: 
1. The consent in India is based on informed consent which means it has to contain the following words: I have been informed in my own language in great detail about the treatment, complications and the possible outcome out of it. I have understood what has been told to me.? It has to be written by the patient in his own hand writing and signed by a witness. I agree that most of the consent forms in the hospitals in India are in English and patients sign it blindly without even understanding it which can create problems when such cases come in the Court.
2. I agree with your observation. This is what I have written in my comments also. In India one can approach different courts simultaneously.

SMS of the day
Leukoplakia itself is a benign reactive process, but 1-20% lesions will progress to cancer in 10 years.

Humor
 You know you are a nurse when you start appreciating veins of strangers in a party

Formula to know 

VLDL cholesterol is never done by a lab. It is triglycerides divided by 5.


 



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