Arshad Chanda - Academia.edu (original) (raw)

Papers by Arshad Chanda

IntechOpen eBooks, Apr 3, 2023

Critical Care Medicine, 2005

To summarize the pathophysiology and treatment of acute lung injury and acute respiratory distres... more To summarize the pathophysiology and treatment of acute lung injury and acute respiratory distress syndrome (ARDS) during pregnancy. Data Source: Review of select articles from MEDLINE, including published abstracts, case reports, observational studies, controlled trials, review articles, and institutional experience. Data Summary: ARDS occurs in pregnancy and may have unique causes. Despite extensive clinical research to improve the management of ARDS, mortality remains high, and few strategies have shown a mortality benefit. Furthermore, in most published studies, pregnancy is an exclusionary criterion, and thus, few treatments have been adequately evaluated in obstetric populations. The treatment of ARDS in pregnancy is extrapolated from studies performed in the general ARDS patient population, with consideration given to the normal physiologic changes of pregnancy. In general, the best support of the fetus is support of the mother. From the age of viability (24-26 wks at most institutions) until full term, decisions regarding delivery should be made based primarily on the standard obstetric indications. Conclusions: Little evidence exists regarding the management of ARDS specifically in pregnancy, and thus, treatment approaches must be drawn from studies performed in a general patient population. A multidisciplinary approach involving maternal-fetal medicine, neonatology, anesthesiology, and intensivist clinicians is essential to optimizing maternal and fetal outcomes.

Respiratory Medicine Case Reports, 2022

Qatar Medical Journal, 2021

Pneumocephalus is air in the cranium commonly seen in postcraniotomy and in head injury patients.... more Pneumocephalus is air in the cranium commonly seen in postcraniotomy and in head injury patients. When this air causes an increase in intracranial pressure leading to neurological deterioration, it is called tension pneumocephalus. Similarly, intraventricular air causing compression on vital centers and increasing intracranial pressure is called tension pneumoventricle, and this causes expressive aphasia, which is rarely described in the literature. This study reported a case of a traumatic cerebrospinal fluid (CSF) leak leading to tension pneumoventricle and aphasia. Case: A young male patient sustained severe head injury and had extradural hematoma (EDH) and multiple skull and skull base fractures. EDH was drained, and he recovered and was discharged with a Glasgow coma scale score of 15. He presented to neurosurgical outpatient with CSF leak, aphasia, and loss of bowel and bladder control for a duration of three days. Computed tomography brain scan showed tension pneumoventricles...

Esophagitis and Gastritis - Recent Updates, 2021

Gastrointestinal endoscopy has become fundamental procedure for diagnosis and treatment of gastro... more Gastrointestinal endoscopy has become fundamental procedure for diagnosis and treatment of gastrointestinal tract diseases. Generally, the gastrointestinal endoscopy is minimally invasive procedure. However, it can cause considerable amount of discomfort and pain which make the procedure unsafe, complicated and refusal of follow up procedures if done without safe sedation. The sedation is required to alleviate anxiety, provide analgesia, amnesia and to improve endoscopic performance specifically in therapeutic procedures. The safe administration of sedative and analgesic medications, irrespective of the regimen used, requires knowledge of the individual needs of patients. The combination of benzodiazepines and opioids is now the most widely used sedation regimen for sedation in gastrointestinal endoscopic procedures. Generally, sedation for gastrointestinal endoscopy is considered safe, however, it has the potential for serious complications. Therefore, endoscopist should assess the...

Virtual Endoscopy and 3D Reconstruction in the Airways, 2019

Virtual endoscopy (VE) is a computer simulation from the imaging anatomical studies. It is noninv... more Virtual endoscopy (VE) is a computer simulation from the imaging anatomical studies. It is noninvasive, and hence avoids all the complications of invasive conventional endoscopy. VE does not require a pre-procedural patient preparation and had a shorter procedural time. It is a very useful technique in the diagnosis and management of trachea-bronchial injuries and stenosis; placement of tracheostomy cannula in patients with abnormal anatomy; diagnosis of tracheoesophageal and laryngeal traumatic injuries, bronchopleural fistulas, and foreign body in tracheobronchial tree; and diagnosis of inhalational injury and epiglottis.

Severe acute pancreatitis (SAP) is a severe form of acute pancreatitis, which requires often inte... more Severe acute pancreatitis (SAP) is a severe form of acute pancreatitis, which requires often intensive care therapy. The common aetiology varies with geographic locations. In Middle East, biliary pancreatitis is the commonest type. Initial phase of the disease is due to profound release of the proinflammatory marker, then the organ dysfunction takes over. It mainly divided into three types depending upon the pathological changes that are oedematous, necrotic and haemorrhagic. The common clinical presentation is typical abdominal pain radiating to the back and relieved by typical positioning i.e. sitting or leaning forwards. Raised pancreatic amylase and lipase with imaging will help to diagnose the SAP. The outcome of SAP is dictated by various criteria and scores. The commonly used scoring systems are Ranson’s and Glasgow scores, whereas the local complication is diagnosed and predicted by the Balthazar’s score. The management of SAP is mainly analgesia, prevention of complications...

Management of Subarachnoid Hemorrhage, 2021

Management of Subarachnoid Hemorrhage, 2021

Pulmonary Embolism [Working Title], 2021

COVID-19 infection affects many systems in the body including the coagulation mechanisms. Imbalan... more COVID-19 infection affects many systems in the body including the coagulation mechanisms. Imbalance between pro-coagulant and anticoagulant activities causes a roughly nine times higher risk for pulmonary embolism (PE) in COVID-19 patients. The reported incidence of PE in COVID-19 patients ranges from 3 to 26%. There is an increased risk of PE in hospitalized patients with lower mobility and patients requiring intensive care therapy. Obesity, atrial fibrillation, raised pro-inflammatory markers, and convalescent plasma therapy increases the risk of PE in COVID-19 patients. Endothelial injury in COVID-19 patients causes loss of vasodilatory, anti-adhesion and fibrinolytic properties. Viral penetration and load leads to the release of cytokines and von Willebrand factor, which induces thrombosis in small and medium vessels. D-dimers elevation gives strong suspicion of PE in COVID-19 patients, and normal D-dimer levels effectively rule it out. Point of care echocardiogram may show righ...

Frontiers in Medical Case Reports, 2020

Burns are devastating and debilitating injuries leading to high morbidity and mortality, emotiona... more Burns are devastating and debilitating injuries leading to high morbidity and mortality, emotional stress and they add to the financial burden. Severely burned patients should preferably be managed in burn centre with dedicated intensive care unit (ICU). Severity of burns are classified according to the degree of burns and total body surface area (TBSA) with burns. Rule of nine is used for calculation of TBSA with burn. Severe burns will cause cellular leak, hypovolemia, storm of proinflammatory markers and cardiovascular impairment leading to the burn shock and multiple organ dysfunction. Intensive care management of severe burns includes resuscitation and organ supportive care. There are number of formulae for fluid resuscitation in these patients, these formulas give initial guidance for fluid resuscitation and further fluid therapy should be guided by dynamic preload parameters. The opioids and benzodiazepines are frequently used for analgesia and sedation respectively whereas ketamine and dexmedetomidine have added advantage of opioid and benzodiazepine sparing effects. In these patient's hyperglycaemia and hypercatabolism should be controlled. ARDS (acute respiratory distress syndrome) occurs in up to 50% of the ventilated burns patient. High frequency percussive ventilation and use of ARDS adjuvant therapies will have better outcome. Acute kidney injury occurs in 30% of severe burns, renal replacement therapy should be started early. Early enteral feeds, gastric ulcer prophylaxis and adequate fluid resuscitation will prevent the GI dysfunction. Burns shock will improve with adequate fluid resuscitation and supportive care. The common neurological dysfunction in burns is delirium. Delirium should be managed with pharmacological and non-pharmacological therapies. There is a decreasing trend in the mortality of severely burns patients and it is around 10%.

Case Reports in Obstetrics and Gynecology, 2020

Eclampsia is associated with high maternal and fetal morbidity and mortality. The mortality in ec... more Eclampsia is associated with high maternal and fetal morbidity and mortality. The mortality in eclampsia is reported to be secondary to cerebrovascular accidents, neurogenic pulmonary edema, or acute kidney injury leading to cardiac arrest. A rarely reported etiology is sudden cardiac arrest (SCA) immediately after the seizure activity. We report a case of morbidly obese multigravida, complicated into postnatal eclampsia developing postseizure SCA due to apnea. Case. A 35-year-old woman in 38 weeks of gestation presented to the women’s hospital emergency with hypertension and proteinuria and had lower section caesarean section under epidural anesthesia and required labetalol infusion. She developed convulsions in the 1st postoperative day, and she was started on magnesium sulphate therapy. After a few minutes, the patient had a 2nd episode of convulsions, apnea, cyanosis, and cardiac asystole requiring cardiopulmonary resuscitation and spontaneous circulation returned in 3 minutes. ...

Intensive Care, Jul 12, 2017

International Journal of Case Reports, 2020

Haemophilia is a disorder that affects the ability of the blood to form clots. The congenital for... more Haemophilia is a disorder that affects the ability of the blood to form clots. The congenital form of the disease is the most prevalent, is inherited as X-linked recessive and it causes deficiency of clotting Factor VIII or IX. clinically it presents with joint bleeding. Its counterpart, acquired haemophilia is a rare condition that usually presents with cutaneous, soft tissue or internal bleeding. The pathophysiology of the disease is centred on the formation of auto antibodies which inactivate factor VIII. Haematologically this is reflected as a prolonged aPTT with normal PT and failure of mixing studies to correct aPTT to more than 50%. To confirm the diagnosis Bethesda assay has to be performed to detect the presence of factor inhibitors. In half of the cases it is associated with an underlying condition such as autoimmune diseases, malignancy, pregnancy or infections. The mainstay treatment is to control the bleeding with bypassing agents such as recombinant factor VIIa or Factor VIII inhibitor bypassing agent as well as eradicating the inhibitor with immunosuppressive and/or cytotoxic agents. Here we report a patient with idiopathic acquired haemophilia who presented with a thigh compartment syndrome. He was successfully treated with fasciotomy, bypassing agents and immunosuppressive therapy.

Qatar Medical Journal, 2020

Necrotizing fasciitis (NF) is a surgical emergency characterized by a fulminant course and high m... more Necrotizing fasciitis (NF) is a surgical emergency characterized by a fulminant course and high mortality rate.1,2 NF is a severe form of soft-tissue infection. When NF is complicated with acute myocardial infarction (AMI), acute respiratory distress syndrome (ARDS), and acute kidney injury (AKI), the patient's chance of survival are diminished significantly.3,4 We present a case of NF of the abdominal wall with acute non-ST segment elevated myocardial infarction (NSTEMI). No such case has previously been reported according to our review of the literature. Case: A 52-year-old female with a known case of hypothyroidism presented to the emergency department with severe abdominal pain for two days. She gave the history of abdominal hernia repair ten days back. She had sinus tachycardia but other vitals were normal, with no fever or leucocytosis. Computed Tomography (CT) of the abdomen showed anterior abdominal wall collections. Septic workup was done, cefuroxime and metronidazole were started. Her abdominal wall collection was drained under image guidance. After a few hours, her blood pressure dropped and was not responding to fluid challenges so a noradrenaline infusion was started and she was transferred to the surgical intensive care unit (SICU). Her blood work showed lactic acidosis. Her abdomen was tender all over with swelling and induration of the abdominal wall. Antibiotics were changed to meropenem and clindamycin to broaden the spectrum in view of the septic shock and she was immediately taken for exploratory laparotomy. The operative findings were suggestive of necrotizing fasciitis of the anterior abdominal wall and a bold and thorough debridement was done. She was kept intubated and ventilated for a second look and further debridement was conducted after 24 hours. Six-hours post-surgical debridement, electrocardiographic (ECG) changes were noticed, 12-lead ECG showed ST-segment depression in leads II, III, aVF, and V5-6, with raised cardiac biomarkers and lower cardiac index (Figures 1 & 2), diagnosed as NSTEMI. Heparin infusion, aspirin, and clopidogrel were started. Echocardiogram showed moderate left ventricular systolic dysfunction (ejection fraction: 45%) with septal dyskinesia. Dobutamine infusion (guided by the PiCCO study) was started, which improved her hemodynamic parameters. CT coronary angiography was inconclusive. These findings suggested that she suffered Type II myocardial infarction due to the stress. She developed oliguria which improved with the restoration of hemodynamics. Her lung condition also deteriorated (PaO2/FiO2 ratio dropped to 100), requiring maximum ventilatory support and she was managed as per ARDS guidelines.5 Blood culture showed growth of Group F Streptococci and Prevotella melaninogenica. Meropenem was continued as the growths were sensitive to it. By day six, she started to be weaned off from the ventilator and vasopressors. She was extubated on day nine and transferred to the ward on day ten. She was later discharged home to be followed up in the surgical outpatient clinic. Her length of stay was 15 days. On a six-month follow-up, she was functionally independent, on aspirin, clopidogrel, and thyroxin therapy. Conclusion: Our patient had NF of the anterior abdominal wall leading to septic shock and complicated by NSTEMI, ARDS, and AKI. Timely source control, close monitoring, quick, and effective interventions appear to have resulted in her excellent recovery.

Qatar Medical Journal, 2019

Background: For the last three decades propofol has been used in anaesthesia and as a sedation te... more Background: For the last three decades propofol has been used in anaesthesia and as a sedation technique. Several reports have warned about its use in higher doses for prolonged durations as it can have severe side effects such as propofol related infusion syndrome (PRIS), which can be fatal.1,2,3 PRIS is a rare and complex clinical condition characterized by severe metabolic acidosis, rhabdomyolysis, cardiac, liver and kidney dysfunction, and lipidemia. In its advanced stage PRIS can lead to severe refractory bradycardia and asystole.4,5 Propofol and remifentanil total intravenous anaesthesia (TIVA) is a popular anaesthesia technique. The target controlled infusion (TCI) gives predicted and controlled drug concentration and has added to the increased use of TIVA. Not much literature is available about the use of propofol and remifentanil TIVA and occurrence of PRIS. We report a case of PRIS in a neurosurgical patient with history of dyslipidemia. Case presentation: A 46-year old man weighing 68 kg, with a known case of hyperlipidemia, presented with decreased hearing on the left side, headache, and perioral numbness. Computerized tomography (CT) of the head showed left cerebropontine angle cystic lesion. His home medications were oral sodium chloride 1200 mg three times daily and pravastatin 20 mg once daily. He was electively scheduled for surgery under general anaesthesia, which lasted for seven hours. He received a TCI with propofol and remifentanil. He remained hemodynamically stable throughout the procedure. Over 7 hours the patient received a total of 3332 mg of 1% propofol, remifentanil TCI 3–4 mcg/ml, ephedrine 18 mg, mannitol 20%–250 ml, pancuronium 16 mg, vecuronium 25 mg, cefazoline 2 g, dexamethasone 16 mg, neostigmine 5 mg, glycopyrolate 1 mg, and labetalol 25 mg. He received 2 liters of crystalloid and one liter of colloid during the surgery. Intra-operative blood sugar remained around 6–7 mmol/L and his central venous pressure was maintained between 8–11 mmHg. His first arterial blood gas showed increasing lactate and metabolic acidosis after two hours of anaesthesia and it continued to rise till the end of surgery. He was extubated and shifted to the surgical intensive care unit (SICU) with a Glasgow Coma Score of 15, spontaneously breathing and with stable hemodynamics. The serum lactate continued to rise in SICU for the first 12 hours and then slowly started to decline (Figure 1). A graph of the trends of carbon dioxide and serum bicarbonate levels is shown in Figure 2. The triglycerides level reached 11.46 (Figure 3), creatine kinase 1852 U/L and myoglobin 474 ng/ml which showed decline within the next 24 hours. He remained hemodynamically stable with adequate urine output. On day one we resumed atorvastatin 20 mg, labetalol prn, bicarbonate infusion. After 24 hours, his lactate levels were normalized and acidosis resolved. The patient was discharged without any complications. Conclusion: Propofol TIVA with TCI is a common anesthesia practice. In a known dyslipidemic patient it will increase the risk for PRIS. In our patient, other risk factors for development of PRIS were higher dose, neurosurgical procedure, and extended duration of propofol infusion. The authors believe it is the first case of PRIS in a dyslipidemic patient undergoing neurosurgery with TIVA.

Qatar Medical Journal, 2019

Background: Dexmedetomidine (Dex) is a sedative agent with analgesic property.1,2 A recent review... more Background: Dexmedetomidine (Dex) is a sedative agent with analgesic property.1,2 A recent review of the literature has shown clear advantages over the traditional sedation namely lesser respiratory depression, less delirium, better sedation, analgesia, organ protection and anti-shivering effect.3,4 Optimal sedation in critically ill patients is of vital importance, under sedation will raise work of breathing and causes adverse hemodynamic effects. Whereas over sedation will lead to increased number of imaging studies and higher morbidity and mortality.4,5 The aim of our study was to investigate the efficacy of dexmedetomidine (Dex), its use in intubated patients and post-extubation period, rescue sedation, safety and analgesic sparing effect in critically ill surgical patients. Patients and Methods: All patients sedated with dexmedetomidine (Dex) in the surgical intensive unit of a tertiary healthcare facility were included prospectively in the study. Patients' demographic data, diagnosis, surgical interventions, traditional sedation, Dex dosage and days, post-extubation Dex use, general adverse effects, adverse effects associated with lower or higher Dex doses, analgesic, and rescue sedation requirements were recorded. Patients were intubated and ventilated, the initial dose of Dex infusion was 0.5 mcg/kg/hr along with either fentanyl or remifentanil infusion. Dex infusion was titrated to keep the Ramsay sedation score of 3 to 4. Analgesia was titrated according to the NRS (numeric rating scale) in extubated patients and the Critical-Care Pain Observation Tool (CPOT) score in intubated patients. The infusion of fentanyl and remifentanil were titrated and decreased according to the CPOT score. Some of the patients extubated required continuation of the Dex infusion in the post-extubation period to maintain analgesia and to keep them calm. Chi-square test was performed to compare among the groups. P-value ≤ 0.05 was considered as statistically significant. Results: A total of 428 patients were enrolled in the study. The majority of patients were male (73.3%). The most common diagnosis was acute abdomen and frequently the performed surgery was laparotomy (28.9%) (Figure 1a). The duration of Dex treatment ranged from 2 to 28 days; the most commonly used dose was 0.5 to 1.4 μg/kg/hours (Figure 1b). Seventy-eight percent (78%) of patients required Dex in the post-extubation period at a dose of 0.2 μg /kg/hours. There was significant reduction in the analgesic requirements in the post-Dex period (p < 0.001) (Table 1(a)). Adverse effects such as bradycardia 6.1%, hypertension 4% and hypotension 1.6% were observed (Figure 2) and there was no significant difference in lower and higher dose of Dex and occurrence of adverse effects (p < 0.82). Patients administered a higher dose of Dex required significantly higher rescue traditional sedation (p < 0.01) (Table 1(b)). Conclusion: We used dexmedetomidine in different surgical critical patients. The occurrence of adverse effects such as bradycardia, hypotension and hypertension were comparable to that mentioned in the literature. There was a significant analgesia sparing effect of dexmedetomidine. We continued Dex in the post-extubation period and the effective dose used was 0.2 mcg/kg/hour. There was no significant difference in occurrence of adverse effects with lower and higher range of Dex. The patients on a higher dose of Dex needed more rescue traditional sedation.

Qatar Medical Journal, 2019

Background: Renal transplant recipients (RTR) have a comparatively lower risk of acute myocardial... more Background: Renal transplant recipients (RTR) have a comparatively lower risk of acute myocardial infarction (AMI) than wait-list patients. Cardiovascular diseases especially AMI are the leading cause of morbidity and mortality in post-renal transplant patients.1,4 They account for up to 50% of the deaths in RTR. The incidence of AMI in RTR is about 0.2% but it is on the rise. Meticulous pre-operative assessment of cardiac status, appropriate pre-operative cardiac management, and post-operative cardiac monitoring will prevent mortality.2 Recently it has been emphasized and there is ample evidence to use cardiac troponins from day zero in the post-operative period to diagnose peri-operative cardiac events like AMI.3 We report a case of post-operative myocardial infarction in a live renal donor transplant patient. This case report will serve to increase the awareness of the cardiovascular event in RTR. Case Report: A 62-year-old obese male patient known to have Type II diabetes mellitus, dyslipidemia, hypertension, end-stage renal disease (ESRD) on peritoneal dialysis, presented for live non-related donor renal transplant. In the pre-operative evaluation, his comorbidities were well controlled. His electrocardiogram (ECG) was normal and an echocardiogram revealed left ventricular enlargement and grade 1 diastolic dysfunction. Induction of anesthesia and intra-operative periods were smooth and he remained hemodynamically stable. The patient did not consent for epidural catheter insertion. Intra-operatively his iliac arteries showed multiple plaques, and his renal vessels were anastomosed with difficulty. After a 6-hour surgery, he was admitted to the surgical intensive care unit (SICU) sedated, intubated, and ventilated. In SICU initially, his hemodynamics were stable, passing 20 to 30 ml of urine per hour, and started on 100% renal replacement with IV Ringer's Lactate. The central venous pressure was between 12 to 14 mmHg. He was rapidly weaned from the ventilator and extubated after 8 hours. Post-extubation, he was awake, stable, and resumed his oral medications. On day 2, during physiotherapy, he complained of shortness of breath and developed severe bradycardia (24 beats/minute). Twelve-lead ECG showed ST-segment depression in the anterior-lateral leads. Within a few minutes, he went into cardiac arrest requiring CPR (cardio-pulmonary resuscitation) for 1 minute. Cardiac biomarkers were elevated (Figure 1) and chest x-ray showed pulmonary congestion (Figure 2). An echocardiogram revealed left ventricular ejection fraction of 58% and mild hypokinesia of the anterior wall. CT coronary angioram or conventional coronary angiogram was not done to avoid constrast induced injury to the transplanted kidney. He was started on aspirin and heparin infusion. His newly grafted kidney was functioning well and he was passing 50-100 ml of urine per hour. He was hemodynamically stable and transferred to the ward on day three. From there, he was discharged home and followed in the transplant and cardiac outpatient clinics. After three months of follow-up, his kidney was functioning well and his echocardiogram became normal. Conclusion: RTR are at greater risk of cardiovascular events, particularly AMI though significantly less than the wait-list patients. Cardiac troponins should be monitored in the post-operative period as early detection of acute coronary syndrome improves their outcome.3

Qatar Medical Journal, 2019

Background: Child fever or puerperal sepsis is a significant cause of maternal morbidity and mort... more Background: Child fever or puerperal sepsis is a significant cause of maternal morbidity and mortality. It is a preventable maternal postpartum complication.1 Group A streptococcus (GAS) infection remains a significant cause for postpartum sepsis as it causes septic shock and multiple organ dysfunction (MODS). There has been a resurgence of severe puerperal GAS infections over the past two decades, although rare, it must be recognized early and treated aggressively. GAS is a common bacteria causing necrotizing fasciitis (NEF) in our region,2 but it caused NEF in only one postpartum patient which is a rarity.3,4,5 We report a case of puerperal GAS infection-causing NEF where the patient underwent multiple surgical debridements complicated with septic shock and MODS, and had a fairly positive outcome. Case presentation: A 26-year old female presented to the emergency department 5 days postpartum with fever, tachycardia, tachypnea, borderline blood pressure, vaginal discharge, and severe pain in the right leg. Her physical examination revealed reddish discoloration of the right lower leg, which was edematous, warm, and extremely tender. The episiotomy wound looked dirty and infected. She had leukocytosis (29.2 × 103/μL), thrombocytopenia (44 × 103/μL), C-Reactive protein was elevated (322 mg/L), and serum lactic acid was 3.8 mmol/L. Her hepatic and renal parameter were elevated. She had a deranged coagulation profile. Post-partum sepsis was suspected and blood cultures were done. She was started on Tazocin® (Tazobactum+piperacillin), supplemented with oxygen, and resuscitated with intravenous fluids. She was immediately taken for emergency surgical intervention, right leg debridement, and fasciotomy with exploration of the episiotomy wound was performed. Surgical findings were dirty colored fluid collection and loss of facial resistance which corroborated with NEF. Necrotic tissues were sent for histopathology and cultures, and clindamycin was started. Intraoperatively the patient became unstable, requiring double vasopressor (noradrenaline and vasopressin) to maintain the hemodynamics. Postoperatively the patient was kept sedated and ventilated in the intensive care unit (ICU). She required four debridements in the next two days despite which her right leg was not improving. Magnetic resonance imaging showed necrotizing fasciitis of the right thigh and leg. Tissue biopsy confirmed the diagnosis. Her blood and tissues showed growth of group A streptococcus. With family agreement, she underwent above right knee amputation, lateral and medial thigh compartment fasciotomy, and debridement on day five. She was oozing from the fasciotomy wounds and needed resuscitation with blood and blood products. She started to show signs of improvement and was weaned off from vasopressors and ventilator. Hepatic and renal functions improved (Figure 1 and Table 1). She was extubated on day 12, awake, hemodynamically stable, tolerated oral feeding, and was transferred to the surgical ward on day 19. She was discharged home on day 24 and was followed in surgical outpatient clinics. Conclusion: Despite developments in infection control and strict aseptic precautions, GAS puerperal sepsis remains a potentially life-threatening infection especially when they present with rare conditions like NEF in the postpartum period. Early diagnosis, aggressive surgical management, and supportive medical care are important for a positive outcome.

IntechOpen eBooks, Apr 3, 2023

Critical Care Medicine, 2005

To summarize the pathophysiology and treatment of acute lung injury and acute respiratory distres... more To summarize the pathophysiology and treatment of acute lung injury and acute respiratory distress syndrome (ARDS) during pregnancy. Data Source: Review of select articles from MEDLINE, including published abstracts, case reports, observational studies, controlled trials, review articles, and institutional experience. Data Summary: ARDS occurs in pregnancy and may have unique causes. Despite extensive clinical research to improve the management of ARDS, mortality remains high, and few strategies have shown a mortality benefit. Furthermore, in most published studies, pregnancy is an exclusionary criterion, and thus, few treatments have been adequately evaluated in obstetric populations. The treatment of ARDS in pregnancy is extrapolated from studies performed in the general ARDS patient population, with consideration given to the normal physiologic changes of pregnancy. In general, the best support of the fetus is support of the mother. From the age of viability (24-26 wks at most institutions) until full term, decisions regarding delivery should be made based primarily on the standard obstetric indications. Conclusions: Little evidence exists regarding the management of ARDS specifically in pregnancy, and thus, treatment approaches must be drawn from studies performed in a general patient population. A multidisciplinary approach involving maternal-fetal medicine, neonatology, anesthesiology, and intensivist clinicians is essential to optimizing maternal and fetal outcomes.

Respiratory Medicine Case Reports, 2022

Qatar Medical Journal, 2021

Pneumocephalus is air in the cranium commonly seen in postcraniotomy and in head injury patients.... more Pneumocephalus is air in the cranium commonly seen in postcraniotomy and in head injury patients. When this air causes an increase in intracranial pressure leading to neurological deterioration, it is called tension pneumocephalus. Similarly, intraventricular air causing compression on vital centers and increasing intracranial pressure is called tension pneumoventricle, and this causes expressive aphasia, which is rarely described in the literature. This study reported a case of a traumatic cerebrospinal fluid (CSF) leak leading to tension pneumoventricle and aphasia. Case: A young male patient sustained severe head injury and had extradural hematoma (EDH) and multiple skull and skull base fractures. EDH was drained, and he recovered and was discharged with a Glasgow coma scale score of 15. He presented to neurosurgical outpatient with CSF leak, aphasia, and loss of bowel and bladder control for a duration of three days. Computed tomography brain scan showed tension pneumoventricles...

Esophagitis and Gastritis - Recent Updates, 2021

Gastrointestinal endoscopy has become fundamental procedure for diagnosis and treatment of gastro... more Gastrointestinal endoscopy has become fundamental procedure for diagnosis and treatment of gastrointestinal tract diseases. Generally, the gastrointestinal endoscopy is minimally invasive procedure. However, it can cause considerable amount of discomfort and pain which make the procedure unsafe, complicated and refusal of follow up procedures if done without safe sedation. The sedation is required to alleviate anxiety, provide analgesia, amnesia and to improve endoscopic performance specifically in therapeutic procedures. The safe administration of sedative and analgesic medications, irrespective of the regimen used, requires knowledge of the individual needs of patients. The combination of benzodiazepines and opioids is now the most widely used sedation regimen for sedation in gastrointestinal endoscopic procedures. Generally, sedation for gastrointestinal endoscopy is considered safe, however, it has the potential for serious complications. Therefore, endoscopist should assess the...

Virtual Endoscopy and 3D Reconstruction in the Airways, 2019

Virtual endoscopy (VE) is a computer simulation from the imaging anatomical studies. It is noninv... more Virtual endoscopy (VE) is a computer simulation from the imaging anatomical studies. It is noninvasive, and hence avoids all the complications of invasive conventional endoscopy. VE does not require a pre-procedural patient preparation and had a shorter procedural time. It is a very useful technique in the diagnosis and management of trachea-bronchial injuries and stenosis; placement of tracheostomy cannula in patients with abnormal anatomy; diagnosis of tracheoesophageal and laryngeal traumatic injuries, bronchopleural fistulas, and foreign body in tracheobronchial tree; and diagnosis of inhalational injury and epiglottis.

Severe acute pancreatitis (SAP) is a severe form of acute pancreatitis, which requires often inte... more Severe acute pancreatitis (SAP) is a severe form of acute pancreatitis, which requires often intensive care therapy. The common aetiology varies with geographic locations. In Middle East, biliary pancreatitis is the commonest type. Initial phase of the disease is due to profound release of the proinflammatory marker, then the organ dysfunction takes over. It mainly divided into three types depending upon the pathological changes that are oedematous, necrotic and haemorrhagic. The common clinical presentation is typical abdominal pain radiating to the back and relieved by typical positioning i.e. sitting or leaning forwards. Raised pancreatic amylase and lipase with imaging will help to diagnose the SAP. The outcome of SAP is dictated by various criteria and scores. The commonly used scoring systems are Ranson’s and Glasgow scores, whereas the local complication is diagnosed and predicted by the Balthazar’s score. The management of SAP is mainly analgesia, prevention of complications...

Management of Subarachnoid Hemorrhage, 2021

Management of Subarachnoid Hemorrhage, 2021

Pulmonary Embolism [Working Title], 2021

COVID-19 infection affects many systems in the body including the coagulation mechanisms. Imbalan... more COVID-19 infection affects many systems in the body including the coagulation mechanisms. Imbalance between pro-coagulant and anticoagulant activities causes a roughly nine times higher risk for pulmonary embolism (PE) in COVID-19 patients. The reported incidence of PE in COVID-19 patients ranges from 3 to 26%. There is an increased risk of PE in hospitalized patients with lower mobility and patients requiring intensive care therapy. Obesity, atrial fibrillation, raised pro-inflammatory markers, and convalescent plasma therapy increases the risk of PE in COVID-19 patients. Endothelial injury in COVID-19 patients causes loss of vasodilatory, anti-adhesion and fibrinolytic properties. Viral penetration and load leads to the release of cytokines and von Willebrand factor, which induces thrombosis in small and medium vessels. D-dimers elevation gives strong suspicion of PE in COVID-19 patients, and normal D-dimer levels effectively rule it out. Point of care echocardiogram may show righ...

Frontiers in Medical Case Reports, 2020

Burns are devastating and debilitating injuries leading to high morbidity and mortality, emotiona... more Burns are devastating and debilitating injuries leading to high morbidity and mortality, emotional stress and they add to the financial burden. Severely burned patients should preferably be managed in burn centre with dedicated intensive care unit (ICU). Severity of burns are classified according to the degree of burns and total body surface area (TBSA) with burns. Rule of nine is used for calculation of TBSA with burn. Severe burns will cause cellular leak, hypovolemia, storm of proinflammatory markers and cardiovascular impairment leading to the burn shock and multiple organ dysfunction. Intensive care management of severe burns includes resuscitation and organ supportive care. There are number of formulae for fluid resuscitation in these patients, these formulas give initial guidance for fluid resuscitation and further fluid therapy should be guided by dynamic preload parameters. The opioids and benzodiazepines are frequently used for analgesia and sedation respectively whereas ketamine and dexmedetomidine have added advantage of opioid and benzodiazepine sparing effects. In these patient's hyperglycaemia and hypercatabolism should be controlled. ARDS (acute respiratory distress syndrome) occurs in up to 50% of the ventilated burns patient. High frequency percussive ventilation and use of ARDS adjuvant therapies will have better outcome. Acute kidney injury occurs in 30% of severe burns, renal replacement therapy should be started early. Early enteral feeds, gastric ulcer prophylaxis and adequate fluid resuscitation will prevent the GI dysfunction. Burns shock will improve with adequate fluid resuscitation and supportive care. The common neurological dysfunction in burns is delirium. Delirium should be managed with pharmacological and non-pharmacological therapies. There is a decreasing trend in the mortality of severely burns patients and it is around 10%.

Case Reports in Obstetrics and Gynecology, 2020

Eclampsia is associated with high maternal and fetal morbidity and mortality. The mortality in ec... more Eclampsia is associated with high maternal and fetal morbidity and mortality. The mortality in eclampsia is reported to be secondary to cerebrovascular accidents, neurogenic pulmonary edema, or acute kidney injury leading to cardiac arrest. A rarely reported etiology is sudden cardiac arrest (SCA) immediately after the seizure activity. We report a case of morbidly obese multigravida, complicated into postnatal eclampsia developing postseizure SCA due to apnea. Case. A 35-year-old woman in 38 weeks of gestation presented to the women’s hospital emergency with hypertension and proteinuria and had lower section caesarean section under epidural anesthesia and required labetalol infusion. She developed convulsions in the 1st postoperative day, and she was started on magnesium sulphate therapy. After a few minutes, the patient had a 2nd episode of convulsions, apnea, cyanosis, and cardiac asystole requiring cardiopulmonary resuscitation and spontaneous circulation returned in 3 minutes. ...

Intensive Care, Jul 12, 2017

International Journal of Case Reports, 2020

Haemophilia is a disorder that affects the ability of the blood to form clots. The congenital for... more Haemophilia is a disorder that affects the ability of the blood to form clots. The congenital form of the disease is the most prevalent, is inherited as X-linked recessive and it causes deficiency of clotting Factor VIII or IX. clinically it presents with joint bleeding. Its counterpart, acquired haemophilia is a rare condition that usually presents with cutaneous, soft tissue or internal bleeding. The pathophysiology of the disease is centred on the formation of auto antibodies which inactivate factor VIII. Haematologically this is reflected as a prolonged aPTT with normal PT and failure of mixing studies to correct aPTT to more than 50%. To confirm the diagnosis Bethesda assay has to be performed to detect the presence of factor inhibitors. In half of the cases it is associated with an underlying condition such as autoimmune diseases, malignancy, pregnancy or infections. The mainstay treatment is to control the bleeding with bypassing agents such as recombinant factor VIIa or Factor VIII inhibitor bypassing agent as well as eradicating the inhibitor with immunosuppressive and/or cytotoxic agents. Here we report a patient with idiopathic acquired haemophilia who presented with a thigh compartment syndrome. He was successfully treated with fasciotomy, bypassing agents and immunosuppressive therapy.

Qatar Medical Journal, 2020

Necrotizing fasciitis (NF) is a surgical emergency characterized by a fulminant course and high m... more Necrotizing fasciitis (NF) is a surgical emergency characterized by a fulminant course and high mortality rate.1,2 NF is a severe form of soft-tissue infection. When NF is complicated with acute myocardial infarction (AMI), acute respiratory distress syndrome (ARDS), and acute kidney injury (AKI), the patient's chance of survival are diminished significantly.3,4 We present a case of NF of the abdominal wall with acute non-ST segment elevated myocardial infarction (NSTEMI). No such case has previously been reported according to our review of the literature. Case: A 52-year-old female with a known case of hypothyroidism presented to the emergency department with severe abdominal pain for two days. She gave the history of abdominal hernia repair ten days back. She had sinus tachycardia but other vitals were normal, with no fever or leucocytosis. Computed Tomography (CT) of the abdomen showed anterior abdominal wall collections. Septic workup was done, cefuroxime and metronidazole were started. Her abdominal wall collection was drained under image guidance. After a few hours, her blood pressure dropped and was not responding to fluid challenges so a noradrenaline infusion was started and she was transferred to the surgical intensive care unit (SICU). Her blood work showed lactic acidosis. Her abdomen was tender all over with swelling and induration of the abdominal wall. Antibiotics were changed to meropenem and clindamycin to broaden the spectrum in view of the septic shock and she was immediately taken for exploratory laparotomy. The operative findings were suggestive of necrotizing fasciitis of the anterior abdominal wall and a bold and thorough debridement was done. She was kept intubated and ventilated for a second look and further debridement was conducted after 24 hours. Six-hours post-surgical debridement, electrocardiographic (ECG) changes were noticed, 12-lead ECG showed ST-segment depression in leads II, III, aVF, and V5-6, with raised cardiac biomarkers and lower cardiac index (Figures 1 & 2), diagnosed as NSTEMI. Heparin infusion, aspirin, and clopidogrel were started. Echocardiogram showed moderate left ventricular systolic dysfunction (ejection fraction: 45%) with septal dyskinesia. Dobutamine infusion (guided by the PiCCO study) was started, which improved her hemodynamic parameters. CT coronary angiography was inconclusive. These findings suggested that she suffered Type II myocardial infarction due to the stress. She developed oliguria which improved with the restoration of hemodynamics. Her lung condition also deteriorated (PaO2/FiO2 ratio dropped to 100), requiring maximum ventilatory support and she was managed as per ARDS guidelines.5 Blood culture showed growth of Group F Streptococci and Prevotella melaninogenica. Meropenem was continued as the growths were sensitive to it. By day six, she started to be weaned off from the ventilator and vasopressors. She was extubated on day nine and transferred to the ward on day ten. She was later discharged home to be followed up in the surgical outpatient clinic. Her length of stay was 15 days. On a six-month follow-up, she was functionally independent, on aspirin, clopidogrel, and thyroxin therapy. Conclusion: Our patient had NF of the anterior abdominal wall leading to septic shock and complicated by NSTEMI, ARDS, and AKI. Timely source control, close monitoring, quick, and effective interventions appear to have resulted in her excellent recovery.

Qatar Medical Journal, 2019

Background: For the last three decades propofol has been used in anaesthesia and as a sedation te... more Background: For the last three decades propofol has been used in anaesthesia and as a sedation technique. Several reports have warned about its use in higher doses for prolonged durations as it can have severe side effects such as propofol related infusion syndrome (PRIS), which can be fatal.1,2,3 PRIS is a rare and complex clinical condition characterized by severe metabolic acidosis, rhabdomyolysis, cardiac, liver and kidney dysfunction, and lipidemia. In its advanced stage PRIS can lead to severe refractory bradycardia and asystole.4,5 Propofol and remifentanil total intravenous anaesthesia (TIVA) is a popular anaesthesia technique. The target controlled infusion (TCI) gives predicted and controlled drug concentration and has added to the increased use of TIVA. Not much literature is available about the use of propofol and remifentanil TIVA and occurrence of PRIS. We report a case of PRIS in a neurosurgical patient with history of dyslipidemia. Case presentation: A 46-year old man weighing 68 kg, with a known case of hyperlipidemia, presented with decreased hearing on the left side, headache, and perioral numbness. Computerized tomography (CT) of the head showed left cerebropontine angle cystic lesion. His home medications were oral sodium chloride 1200 mg three times daily and pravastatin 20 mg once daily. He was electively scheduled for surgery under general anaesthesia, which lasted for seven hours. He received a TCI with propofol and remifentanil. He remained hemodynamically stable throughout the procedure. Over 7 hours the patient received a total of 3332 mg of 1% propofol, remifentanil TCI 3–4 mcg/ml, ephedrine 18 mg, mannitol 20%–250 ml, pancuronium 16 mg, vecuronium 25 mg, cefazoline 2 g, dexamethasone 16 mg, neostigmine 5 mg, glycopyrolate 1 mg, and labetalol 25 mg. He received 2 liters of crystalloid and one liter of colloid during the surgery. Intra-operative blood sugar remained around 6–7 mmol/L and his central venous pressure was maintained between 8–11 mmHg. His first arterial blood gas showed increasing lactate and metabolic acidosis after two hours of anaesthesia and it continued to rise till the end of surgery. He was extubated and shifted to the surgical intensive care unit (SICU) with a Glasgow Coma Score of 15, spontaneously breathing and with stable hemodynamics. The serum lactate continued to rise in SICU for the first 12 hours and then slowly started to decline (Figure 1). A graph of the trends of carbon dioxide and serum bicarbonate levels is shown in Figure 2. The triglycerides level reached 11.46 (Figure 3), creatine kinase 1852 U/L and myoglobin 474 ng/ml which showed decline within the next 24 hours. He remained hemodynamically stable with adequate urine output. On day one we resumed atorvastatin 20 mg, labetalol prn, bicarbonate infusion. After 24 hours, his lactate levels were normalized and acidosis resolved. The patient was discharged without any complications. Conclusion: Propofol TIVA with TCI is a common anesthesia practice. In a known dyslipidemic patient it will increase the risk for PRIS. In our patient, other risk factors for development of PRIS were higher dose, neurosurgical procedure, and extended duration of propofol infusion. The authors believe it is the first case of PRIS in a dyslipidemic patient undergoing neurosurgery with TIVA.

Qatar Medical Journal, 2019

Background: Dexmedetomidine (Dex) is a sedative agent with analgesic property.1,2 A recent review... more Background: Dexmedetomidine (Dex) is a sedative agent with analgesic property.1,2 A recent review of the literature has shown clear advantages over the traditional sedation namely lesser respiratory depression, less delirium, better sedation, analgesia, organ protection and anti-shivering effect.3,4 Optimal sedation in critically ill patients is of vital importance, under sedation will raise work of breathing and causes adverse hemodynamic effects. Whereas over sedation will lead to increased number of imaging studies and higher morbidity and mortality.4,5 The aim of our study was to investigate the efficacy of dexmedetomidine (Dex), its use in intubated patients and post-extubation period, rescue sedation, safety and analgesic sparing effect in critically ill surgical patients. Patients and Methods: All patients sedated with dexmedetomidine (Dex) in the surgical intensive unit of a tertiary healthcare facility were included prospectively in the study. Patients' demographic data, diagnosis, surgical interventions, traditional sedation, Dex dosage and days, post-extubation Dex use, general adverse effects, adverse effects associated with lower or higher Dex doses, analgesic, and rescue sedation requirements were recorded. Patients were intubated and ventilated, the initial dose of Dex infusion was 0.5 mcg/kg/hr along with either fentanyl or remifentanil infusion. Dex infusion was titrated to keep the Ramsay sedation score of 3 to 4. Analgesia was titrated according to the NRS (numeric rating scale) in extubated patients and the Critical-Care Pain Observation Tool (CPOT) score in intubated patients. The infusion of fentanyl and remifentanil were titrated and decreased according to the CPOT score. Some of the patients extubated required continuation of the Dex infusion in the post-extubation period to maintain analgesia and to keep them calm. Chi-square test was performed to compare among the groups. P-value ≤ 0.05 was considered as statistically significant. Results: A total of 428 patients were enrolled in the study. The majority of patients were male (73.3%). The most common diagnosis was acute abdomen and frequently the performed surgery was laparotomy (28.9%) (Figure 1a). The duration of Dex treatment ranged from 2 to 28 days; the most commonly used dose was 0.5 to 1.4 μg/kg/hours (Figure 1b). Seventy-eight percent (78%) of patients required Dex in the post-extubation period at a dose of 0.2 μg /kg/hours. There was significant reduction in the analgesic requirements in the post-Dex period (p < 0.001) (Table 1(a)). Adverse effects such as bradycardia 6.1%, hypertension 4% and hypotension 1.6% were observed (Figure 2) and there was no significant difference in lower and higher dose of Dex and occurrence of adverse effects (p < 0.82). Patients administered a higher dose of Dex required significantly higher rescue traditional sedation (p < 0.01) (Table 1(b)). Conclusion: We used dexmedetomidine in different surgical critical patients. The occurrence of adverse effects such as bradycardia, hypotension and hypertension were comparable to that mentioned in the literature. There was a significant analgesia sparing effect of dexmedetomidine. We continued Dex in the post-extubation period and the effective dose used was 0.2 mcg/kg/hour. There was no significant difference in occurrence of adverse effects with lower and higher range of Dex. The patients on a higher dose of Dex needed more rescue traditional sedation.

Qatar Medical Journal, 2019

Background: Renal transplant recipients (RTR) have a comparatively lower risk of acute myocardial... more Background: Renal transplant recipients (RTR) have a comparatively lower risk of acute myocardial infarction (AMI) than wait-list patients. Cardiovascular diseases especially AMI are the leading cause of morbidity and mortality in post-renal transplant patients.1,4 They account for up to 50% of the deaths in RTR. The incidence of AMI in RTR is about 0.2% but it is on the rise. Meticulous pre-operative assessment of cardiac status, appropriate pre-operative cardiac management, and post-operative cardiac monitoring will prevent mortality.2 Recently it has been emphasized and there is ample evidence to use cardiac troponins from day zero in the post-operative period to diagnose peri-operative cardiac events like AMI.3 We report a case of post-operative myocardial infarction in a live renal donor transplant patient. This case report will serve to increase the awareness of the cardiovascular event in RTR. Case Report: A 62-year-old obese male patient known to have Type II diabetes mellitus, dyslipidemia, hypertension, end-stage renal disease (ESRD) on peritoneal dialysis, presented for live non-related donor renal transplant. In the pre-operative evaluation, his comorbidities were well controlled. His electrocardiogram (ECG) was normal and an echocardiogram revealed left ventricular enlargement and grade 1 diastolic dysfunction. Induction of anesthesia and intra-operative periods were smooth and he remained hemodynamically stable. The patient did not consent for epidural catheter insertion. Intra-operatively his iliac arteries showed multiple plaques, and his renal vessels were anastomosed with difficulty. After a 6-hour surgery, he was admitted to the surgical intensive care unit (SICU) sedated, intubated, and ventilated. In SICU initially, his hemodynamics were stable, passing 20 to 30 ml of urine per hour, and started on 100% renal replacement with IV Ringer's Lactate. The central venous pressure was between 12 to 14 mmHg. He was rapidly weaned from the ventilator and extubated after 8 hours. Post-extubation, he was awake, stable, and resumed his oral medications. On day 2, during physiotherapy, he complained of shortness of breath and developed severe bradycardia (24 beats/minute). Twelve-lead ECG showed ST-segment depression in the anterior-lateral leads. Within a few minutes, he went into cardiac arrest requiring CPR (cardio-pulmonary resuscitation) for 1 minute. Cardiac biomarkers were elevated (Figure 1) and chest x-ray showed pulmonary congestion (Figure 2). An echocardiogram revealed left ventricular ejection fraction of 58% and mild hypokinesia of the anterior wall. CT coronary angioram or conventional coronary angiogram was not done to avoid constrast induced injury to the transplanted kidney. He was started on aspirin and heparin infusion. His newly grafted kidney was functioning well and he was passing 50-100 ml of urine per hour. He was hemodynamically stable and transferred to the ward on day three. From there, he was discharged home and followed in the transplant and cardiac outpatient clinics. After three months of follow-up, his kidney was functioning well and his echocardiogram became normal. Conclusion: RTR are at greater risk of cardiovascular events, particularly AMI though significantly less than the wait-list patients. Cardiac troponins should be monitored in the post-operative period as early detection of acute coronary syndrome improves their outcome.3

Qatar Medical Journal, 2019

Background: Child fever or puerperal sepsis is a significant cause of maternal morbidity and mort... more Background: Child fever or puerperal sepsis is a significant cause of maternal morbidity and mortality. It is a preventable maternal postpartum complication.1 Group A streptococcus (GAS) infection remains a significant cause for postpartum sepsis as it causes septic shock and multiple organ dysfunction (MODS). There has been a resurgence of severe puerperal GAS infections over the past two decades, although rare, it must be recognized early and treated aggressively. GAS is a common bacteria causing necrotizing fasciitis (NEF) in our region,2 but it caused NEF in only one postpartum patient which is a rarity.3,4,5 We report a case of puerperal GAS infection-causing NEF where the patient underwent multiple surgical debridements complicated with septic shock and MODS, and had a fairly positive outcome. Case presentation: A 26-year old female presented to the emergency department 5 days postpartum with fever, tachycardia, tachypnea, borderline blood pressure, vaginal discharge, and severe pain in the right leg. Her physical examination revealed reddish discoloration of the right lower leg, which was edematous, warm, and extremely tender. The episiotomy wound looked dirty and infected. She had leukocytosis (29.2 × 103/μL), thrombocytopenia (44 × 103/μL), C-Reactive protein was elevated (322 mg/L), and serum lactic acid was 3.8 mmol/L. Her hepatic and renal parameter were elevated. She had a deranged coagulation profile. Post-partum sepsis was suspected and blood cultures were done. She was started on Tazocin® (Tazobactum+piperacillin), supplemented with oxygen, and resuscitated with intravenous fluids. She was immediately taken for emergency surgical intervention, right leg debridement, and fasciotomy with exploration of the episiotomy wound was performed. Surgical findings were dirty colored fluid collection and loss of facial resistance which corroborated with NEF. Necrotic tissues were sent for histopathology and cultures, and clindamycin was started. Intraoperatively the patient became unstable, requiring double vasopressor (noradrenaline and vasopressin) to maintain the hemodynamics. Postoperatively the patient was kept sedated and ventilated in the intensive care unit (ICU). She required four debridements in the next two days despite which her right leg was not improving. Magnetic resonance imaging showed necrotizing fasciitis of the right thigh and leg. Tissue biopsy confirmed the diagnosis. Her blood and tissues showed growth of group A streptococcus. With family agreement, she underwent above right knee amputation, lateral and medial thigh compartment fasciotomy, and debridement on day five. She was oozing from the fasciotomy wounds and needed resuscitation with blood and blood products. She started to show signs of improvement and was weaned off from vasopressors and ventilator. Hepatic and renal functions improved (Figure 1 and Table 1). She was extubated on day 12, awake, hemodynamically stable, tolerated oral feeding, and was transferred to the surgical ward on day 19. She was discharged home on day 24 and was followed in surgical outpatient clinics. Conclusion: Despite developments in infection control and strict aseptic precautions, GAS puerperal sepsis remains a potentially life-threatening infection especially when they present with rare conditions like NEF in the postpartum period. Early diagnosis, aggressive surgical management, and supportive medical care are important for a positive outcome.