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This is a single case report documenting effcacy of Ulcerative cutaneous polyarteritis nodosa treated with infiximab buy 17mg duetact mastercard diabetes dyslipidemia definition. Kluger N duetact 17 mg with visa diabete 2 dieta, Guillot Cutaneous polyarteritis nodosa: therapy and clinical B purchase 16mg duetact visa diabetes in dogs last stages, Bessis D buy 17 mg duetact with visa diabetes symptoms metformin. Misago N, Mochizuki Y, Sekiyama-Kodera This is a single case report and combines a second-line and H, Shirotani M, Suzuki K, Inokuchi A, et al. Intravenous immunoglobulin E Use of warfarin therapy at a target international nor Pentoxifylline E malized ratio of 3. Intern Med J 2012; 42: experienced resolution of skin manifestations on sustained war- 459–62. The acantholysis is suprabasal Skin swab for bacterial and viral culture if infection is suspected Darier-White disease: a review of the clinical features in 163 patients. Fourteen percent of patients in this series had herpes simplex complicating their disease. Painful blisters arising in a patient with Darier disease are usually due to secondary infection with Staphylococcus aureus or herpes simplex. Genetic counselling can be helpful and written information is often The warty, keratotic papules, which usually appear before the age appreciated. The fexures can be a particular problem, as plaques here are fre- Linear Darier’s disease successfully treated with 0. Simple emollients, soap substitutes, Barbagallo T, Vassallo C, Agozzino M, Borroni G. Sunblock is Linear Darier disease affecting the trunk was treated with taz- recommended for those with a history of photoaggravation. The addition of a topical corticosteroid (alternating with the retinoid) may alleviate some of the side effects. Super- Successful treatment of Darier’s disease with adapalene infection with viruses and bacteria is frequent, so combined gel. The usual starting dose of acitretin is Oral retinoids B 10–25 mg daily, but this can be increased gradually. Clinical and ultrastructural effects of acitretin in Darier’s The rare vesiculobullous form of the disease may respond disease. Vulval Darier’s disease treated successfully with cyclospo- Isotretinoin treatment of Darier’s disease. A previously therapy-resistant case was treated with cyclospo- J Am Acad Dermatol 1982; 6: 721–6. Some patients A patient with the vesiculobullous form of the disease were maintained on alternate-day or alternate-week regimens. Br J Dermatol Extensive recalcitrant Darier disease successfully treated 1997; 136: 368–70. Two patients with Darier disease unresponsive to acitretin Br J Dermatol 2010; 162: 227–8. Effcacy and safety of oral retinoids in different psoriasis Disease cleared in two patients, but follow-up was less than subtypes: a systematic literature review. J Eur Acad Successful treatment of Darier disease with the fashlamp- Dermatol Venereol 2011; 25: 28–33. Submammary disease improved at 8 weeks post treatment, X-ray screening is not necessary for asymptomatic patients on long- with no progression at 15 months. Liver function, cholesterol, and triglycerides should Six patients received photodynamic therapy with topical be monitored during treatment. One patient could not tolerate the treatment, but fve experienced sustained improve- Effcacy and risks of topical 5-fuorouracil in Darier’s ment, with initial infammatory response lasting 2 to 3 weeks. Botulinum toxin type A: an alternative symptomatic man- Topical 5-fuorouracil initially proved effective in three cases, agement of Darier’s disease. A case of Darier’s disease successfully treated with topical Submammary disease was treated with botulinum toxin as tacrolimus. Rubegni P, Poggiali S, Sbano P, Risulo M, Fimiani adjuvant therapy: 100 U were injected, with improvement sus- M. Electron beam radiation therapy to the inframammary folds resulted in initial severe local dermatitis, followed by complete Cyclosporine E resolution sustained for 18 months. Electron beam radiation E Electrosurgery was effective in two cases unresponsive to Dermabrasion E etretinate. Five patients with severe disease were treated by dermabrasion Darier’s disease: severe eczematization successfully down to and including the papillary dermis. Shahidullah H, Humphreys F, Bev- treated skin remained disease free 6 months later. J Dermatol Surg Oncol 1985; 11: treated using tissue expanders inserted 20 days prior to wide 420–3. Recalcitrant, hypertrophic lesions were debrided under local An effective surgical treatment for nail thickening in anesthesia. The surgical treatment of hypertrophic intertriginous One-third of the distal nail matrix was removed, with wound Darier’s disease. If they t 52 Decubitus ulcers are associated with immobility, sustained pressure, and the loss of pain sensibility, then these problems can and should be Joseph A. In practice, successful prevention is often foiled by our limited understanding of the pathogenesis, as well as by compli- Caren Campbell, Jennifer L. There is also some evidence that many deep ulcers are initiated by multiple microthromboses of deep tissues. This indicates that dehydration, along with any factor that might increase blood coagulability, should be addressed. Management The management of skin lesions caused by pressure is based on four principles: Elimination of relative pressure Removal of necrotic debris Maintenance of a moist wound environment Correction of the underlying contributing factors Elimination of sustained pressure The patient should not lie on the ulcer. A patient who is at risk for developing additional ulcers and can assume a variety of posi- tions without lying on the ulcer should be placed on a static support surface, i. If the patient cannot assume various positions without lying on the ulcer or bottoms out while on a static surface, or if the ulcer does not heal after 2 to 4 weeks of optimal care, place the patient on a dynamic support surface when possible, i. The decubitus ulcer represents a defect in the skin that can extend through the subcutaneous tissue and muscle layer onto the Removal of necrotic debris underlying bone. An Prevention eschar on the heel should be excised only if it is fuctuant, drain- ing, or surrounded by cellulitis, and if the patient is septic. A patient in an ordinary bed who is at risk of developing a decu- Major debridement is performed in the operating room, but bitus ulcer, also referred to as pressure ulcer or bed sore, should serial sharp debridement can be performed at the bedside. The be repositioned at frequent intervals; however, the correct timing use of systemic antimicrobials should be considered to prevent for turning has never been established. A bone biopsy is rec- mined by the level of risk of developing an ulcer and the duration ommended while debriding ulcers when bone is exposed and for of blanchable erythema.
Multivitamin and mineral • proximal small intestinal fistulae supplements can be used to ensure there are • severe pancreatitis (unless fed distal sufficient micronutrients in the diet (Table 13 purchase duetact 17mg line diabetic vitamins. High gastric residuals and gastric distension predispose to vomiting or regurgitation and aspiration buy duetact 16 mg line blood glucose 62. In the fed state generic duetact 17mg without a prescription diabetes type 2 control, the stomach can pylorus purchase 16 mg duetact free shipping diabetes mellitus hemoglobin a1c, endoscopic placement or the use of produce up to 2500 ml of secretions (in addition specially designed tubes that are propelled to receiving 1500 ml of saliva). Prokinetic drugs such as residual volume is between 50–100 ml, which erythromycin and metoclopramide that promote represents the equilibrium between secretion, gastric motility may also be given to encourage and emptying plus absorption. For example, tube jejunostomy the tube and aspirating at 2-, 4- or 6-hourly should be considered in patients undergoing intervals will give a better indication of whether oesophagectomy, total gastrectomy or the stomach is emptying adequately. Most stresses pancreaticoduodenectomy or a laparotomy for and illnesses, plus some drugs, increase gastric abdominal trauma. For other patients, insertion residual volume, but may not necessarily lead to of feeding tubes should be considered when it is a degree of impaired emptying that would prevent clear that enteral nutritional support is indicated feeding. Feeding can be commenced through a and is going to be required for more than 6 standard, large-bore nasogastric drainage tube, weeks. Tube gastrostomy can be fashioned using but a fine-bore tube is better tolerated once the either the Stamm (pure-string suture) or Witzel need for drainage has passed. Tube jejunostomy fluid through a fine-bore tube is much more can also be accomplished using a catheter difficult, and confirmation of tube position is introduced over a fine needle, passed submucosally mandatory because of the devastating consequences before entering the bowel. In all cases, the bowel of instilling feeding solution into the lung (as should be sutured to the abdominal wall deep to highlighted by the National Patient Safety Agency). Tube position must be confirmed either by checking Minimal access techniques can also be used. Diarrhoea is one of a number increase, bearing in mind that some aspiration of of potential complications of all modes of enteral gastric contents is normal. Such agents include loperamide, – Wound infection codeine or kaolin–pectin mixtures, and can be – Peritonitis very effective, especially after extensive small – Displacement and catheter migration bowel resection. Related to delivery of nutrient to gastrointestinal tract – Aspiration and hospital-acquired pneumonia Exclude infectious causes (especially if feed contaminated) Send stool for culture, including C. Difficile toxin – Feed intolerance Send feed for culture – Diarrhoea Reduce feeding load on the gut On a daily basis, surgeons should review the Reduce rate of delivery of feed (try 20 ml/hr) indications for feeding, nutritional requirements Consider jejunal rather than gastric feeding and the chosen route of supplementation. In In patients with short bowel, consider omeprazole particular, patients receiving parenteral nutrition to reduce gastric hypersecretion should be switched to the enteral route as soon as gut function returns or underlying abdominal problems settle. Other contributory factors include loss of intestinal absorptive surface because of villous atrophy or resection. In many cases, adaptation will is inserted in the subclavian vein, or internal eventually permit enteral nutrition alone. Inability to use the gastrointestinal tract The exit site should be protected carefully with an for other reasons occlusive dressing and full aseptic technique used – For example, pancreatitis with when dressings are changed or the line handled. The most – Mechanical – blockage, central vein common source of infection in catheter-related thrombosis, migration, fracture, sepsis is the hub of the catheter. Strict aseptic dislodgement technique is essential at all times, cleaning the – Infective – exit-site infection, line sepsis, hub with chlorhexidine whenever used. Also, fluid overload induction from amino acid imbalance and can occur, usually as a result of inappropriate excessive calorie administration, with fat continuation of other intravenous fluids, and deposition in liver electrolyte disturbances are relatively common – Hypoglycaemia – too rapid cessation of though are usually predictable and preventable. The major source of glucose from starvation due to fasting, but surgery and for the brain shifts to glycogen stored in the liver sepsis also cause a systemic metabolic response (of which there is approximately 200 g). This that contributes significantly to the clinical breakdown of glycogen to provide glucose picture and to nutritional management. Though Feeding and fasting skeletal muscle contains a larger amount of In health, feeding replenishes fuel stores and the glycogen (500 g), this cannot directly contribute oxidative metabolism of fuel generates energy to the provision of glucose for other tissues. The normal daily Instead, glucose is converted to lactate within resting energy expenditure of a 70 kg man is muscle, which is exported to the liver for conversion approximately 1800 kcal. Glucose is also converted carbohydrate as its sole fuel in the fed state and to lactate within haemopoietic tissues. Muscle derives approximately one-third of its Any glucose not consumed by the brain is used energy from the oxidation of glucose and the rest to restore liver carbohydrate stores (glycogenesis) from the oxidation of fatty acids derived from and the rest is converted to fat (lipogenesis). Amino acids are used to replenish those lost in Muscle protein breakdown begins to contribute the normal daily turnover of protein (including amino acids (alanine and glutamine) for hepatic skeletal and cardiac muscle, liver and intestinal gluconeogenesis. After about 48 hours of starvation, structural proteins and liver export proteins such approximately 75 g of muscle protein is being as albumin) while the rest are metabolised in the broken down each day. Glycerol and triglycerides liver, converting the carbohydrate component from fat depots are used to make up the shortfall into fuel (gluconeogenesis) and the nitrogenous in energy requirements and fatty acids provide component to urea for excretion. Lipid is stored primarily as triglyceride within With more prolonged fasting, a series of adipose tissue. Lipid cannot be directly converted metabolic adjustments develop in order to into either amino acids or glucose. For example, the liver The hormonal environment associated with recent gradually increases its capacity to produce ketone feeding (high insulin levels and low glucagon bodies from fatty acids. The brain adapts to use levels) allows the storage of nutrients as described ketone bodies, reducing muscle breakdown by above. These metabolic adjustments are There is a modest increase in the metabolic rate associated with low levels of insulin and high to approximately 2000 kcal/day and lipid is the plasma glucagon concentrations. Muscle decline in the conversion of inactive thyroxine protein breakdown increases and glycogenolysis (T4) to active triiodothyronine (T3) results in and gluconeogenesis result in an increased a fall in energy requirements to approximately availability of glucose. This usually coincides with the – Hepatic gluconeogenesis resumption of eating and of increasing mobility, – Lipolysis both of which are required to restore muscle mass. Release of noradrenaline, adrenaline, – Resistance of tissues to effects of insulin glucagon, growth hormone and cortisol occurs. The key changes are a markedly An assessment of the patient’s nutritional status increased metabolic rate (hypermetabolism) and should form part of every physical examination. There may be marked Gross degrees of malnutrition such as obvious glucose intolerance with the development of a wasting are easily recognised but more subtle diabetes-like state. Despite this hyperglycaemia, degrees of deficit may not be, particularly in the glucose utilisation and storage are impaired and obese patient. Muscle skinfold thickness and mid–arm circumference) and visceral protein is thus consumed for the allow estimation of muscle mass (protein reserves) generation of glucose, despite the frequently and fat mass (energy reserves) but are often elevated plasma glucose concentration. Like renal failure, intestinal failure is the end result of many different disease processes. It is also a continuum ranging from temporary mild dysfunction to complete and irreversible failure needing chronic ‘replacement therapy’. Intestinal failure is a clinical the cardiovascular and respiratory systems of diagnosis based on a history and examination, critically ill patients is based on an understanding laboratory investigations and, in some cases, of the altered physiology associated with radiological investigations. Establishing a diagnosis disease, nutritional intervention is based on an of intestinal failure is important because attempts understanding of the metabolic processes in the to provide enteral nutritional support alone are critically ill. The ultimate goals of nutritional likely to be ineffective and early parenteral nutrition support in the surgical patient are to ensure that should be considered, possibly with referral to the patient is optimally prepared for the stress a specialised unit. Use the expertise available to you on the surgical and high dependency wards, from nursing staff, dieticians and dedicated nutritional teams.
During anaesthesia and surgery a series of hormonal changes (as a response to stress) can signiﬁcantly affect the diabetic patient’s metabolic control buy 17 mg duetact with visa lipodystrophy diabetes definition. The most important changes are: increased secretion of compensatory hormones (they promote hepatic glucose production and decreased clearance of glucose from periph- eral tissues); decreased secretion of insulin; decreased activity of insulin (increased insulin resistance) buy cheap duetact 17mg on-line diabetes mellitus type 2 controlled. These alterations result in hyperglycaemia buy 17mg duetact amex diabetes mellitus long term effects, ketosis and increase in metabolic rate and catabolism of the body buy duetact paypal metabolic disease in animals. General principles for achieving metabolic control in diabetic patients who are going to be operated on are as follows: 1. Metabolic control should be evaluated and its improvement opti- mized on an outpatient basis for non-urgent surgeries. This dehydration is accompanied by electrolyte abnormalities and low intravascular volume, which lead to haemodynamic instability. If the patient is treated with metformin or sulfonylureas, they are discontinued at noon of the previous day before the operation. If it is a minor surgery (as was the case described above) the usual diet and treatment is followed. If the patient is already in the hospital, blood glucose is measured every 4–6 hours and insulin is administered subcutaneously based on an empiric sliding scale, on condition that after insulin administration small meals are offered, mainly containing carbohydrates. The authors of the present book frequently use continuous intravenous infusion of a glucose solution 5 percent (more rarely 10 percent) with the necessary electrolytes, depending on each patient’s needs. Capillary blood glucose is measured with the use of portable meters every six (sometimes four) hours and supplemental rapid-acting insulin is injected subcuta- neously, based on an individualized sliding scale. When the patient is able to receive solid food by mouth, the intravenous infusion is discon- tinued, while the six-hourly subcutaneous injections are continued with small meals. According to this scheme, glucose, insulin and potassium are administered together in the same solution. The ﬂuid is dextrose þ 10 percent in 500 ml and contains 10 mmol K as well as 15 units of rapid-acting insulin. The necessary insulin quantity varies to some degree, depending on the state of the patient and the coexistent conditions. For these reasons, the above-mentioned proposals are an 98 Diabetes in Clinical Practice initial approach and later insulin quantity (per gram of glucose) is adjusted as follows: i. Alternatively one could administer insulin in a continuous intravenous infusion (4–6 i. Occasionally, it may be necessary for some patients to measure a blood glucose level at 3 a. Some authors, especially in Intensive Care Units, prefer to administer rapid-acting insulin with an intravenous infusion pump (1 i. The insulin infusion rate is per hour 1/24th of the previously total daily need in subcutaneous insulin. Blood glucose is measured every hour and the glucose infusion rate is adjusted so that its level will range from 120 mg/dl (6. If the previous insulin dose is unknown, we Surgery in diabetes 99 start the infusion at 0. Since this is an urgent situation for surgery, buThat the same time the patient has intense hyperglycaemia, a period of 12–16 hours of stabiliza- tion is proposed, if possible. In patients with serious metabolic derange- ment (ketoacidosis or hyperosmosis) who need emergency surgical treatment, an intensive management of blood glucose for 6–8 hours signiﬁcantly improves the metabolic state and the general condition. Furthermore, when they are going to undergo a major surgery (see above), the administration of an insulin and glucose solution is recom- mended preoperatively in all Type 1 diabetic patients, in insulin-treated Type 2 diabetics and in patients with Type 2 diabetes with poor metabolic control. For well-controlled patients who are going to have minor surgery under local anaesthesia, surgery is usually planned early in the morning, with frequent measurements of blood glucose (every two hours). The patient should be given a third to a half of the morning isophane (intermediate- acting) insulin dose (the rest of the dose is administered after the surgery), whereas for people using glargine insulin, the dose remains unchanged. Diabetic persons, just like non-diabetic ones, frequently have common infections, mild or more serious, during which many questions regarding the treatment of blood glucose arise. It is essential that appropriate instructions be given beforehand, so that patients do not panic and treatment of the acute condition is timely, appropriate and effective. It should always be kept in mind that possible inappropriate management can lead to a signiﬁcantly poor metabolic control that could increase the risk of an acute complication, such as diabetic ketoacidosis or hyperglycaemic hyperosmolar coma. Even when there is a feeding problem (nausea, vomiting), it is more likely that additional insulin will be needed (due to the stress that the acute illness has caused) rather than reduction of insulin. Frequency of capillary blood glucose measurements is recommended to increase (at least every 3–4 hours). Good communication between the patient and his or her treating physician is essential, so that proper instructions for coping with any special situation can be given at any time. What changes should be made in the insulin regimen during periods of an acute illness? Basically, the intensive insulin regimen is followed, as it is, provided the patient is normally fed. Sometimes it may be necessary to administer rapid- acting insulin (or even better a rapid-acting insulin analogue) between meals. If the patient is unable to receive food, the dose of basal insulin is administered normally and, if needed, rapid-acting insulin is administered every 4–6 hours, or a rapid- acting analogue every 3–4 hours. At the same time, intake of carbohy- drates in the form of liquid or semi-solid food (i. Insulin dose is empirically deter- mined each time as 1/10th of the usual total daily dose when blood glucose is > 150 mg/dl (8. When insulin is administered as a twice a day regimen (intermediate acting or a mixture of rapid-acting (or analogue) and intermediate- acting, in the morning and evening), and if the patient eats normally, this scheme is initially preserved and additional rapid-acting (or rapid- acting analogue) insulin is possibly administered in between, based on blood glucose measurements. If the patient is unable to eat (for example due to nausea or vomiting), a decrease in the insulin dose by 30–50 percent is recommended initially, as well as close monitoring of the blood glucose levels, intake of carbohydrates in the form of liquid or semi-solid food and possibly administration of rapid-acting (or analo- gue) insulin. If the condition persists, it may be necessary to admit the patient to hospital (see below). Acute illness in diabetes 105 How is an acute illness managed in patients who receive antidiabetic pills? When diabetes is under good control and small doses of pills are received (monotherapy or combination), no signiﬁcant problem usually arises. During the period of the acute illness, blood glucose can have a mild or moderate increase and later return to the previous levels. In people who receive maximum doses of oral antidiabetic medicines, a problem of poor glycaemic control can ensue, and in this case a temporary period of insulin treatment may be needed. The patient called his primary physician in the morning because during the previous night he had four episodes of vomiting, abdominal pains and three episodes of diarrhoea. He continued to feel intense nausea and when attempting to drink water, he vomited again.
Prevalence of cognitive dysfunction after conventional computer-assisted total knee replacement cheap 16 mg duetact with amex diabetes diet and watermelon. The use of bone cement induces an increase in serum astroglial S-100B protein in patients undergoing total knee arthroplasty trusted duetact 16mg managing diabetes diet exercise,” Anesth Analg generic duetact 17 mg on line diabete xilitolo. Biomarkers for the clinical differential diagnosis in traumatic brain injury-a systematic review generic duetact 16mg without a prescription diabetes symptoms for type 1. It was hypothesised that postoperative pulmonary and other complications as well as mortality is less with inhalational agents in cardiac and noncardiac surgery. It was concluded by the authors that in cardiac surgery, use of volatile agents as compared to total intravenous anesthesia, resulted in less pulmonary or other complications, as well as mortality. The similar results of reduction in mortality and pulmonary/nonpulmonary complications were not observed after noncardiac surgical procedures. The authors have suggested undertaking further studies to observe the efects and outcome of volatile agents in noncardiac surgery. Also, a network meta-analysis has been incorporated to assess the contribution of individual inhalational agent. In case of cardiac surgery, reduced mortality with volatile agents has been observed in an earlier analysis, too. The length of stay in cardiac surgery patients was not affected, possibly due to protocol of minimal stay in hospital in such procedures. In the patients undergoing noncardiac surgery, mortality was not reduced by volatile agents. It may be due to the fact that protective effects of volatile agents are related to cardiac preconditioning. Same is the reason of lack of reduction in pulmonary and other complications in noncardiac population. There was less length of stay in hospital in patients receiving volatile anesthetics but only a few trials reported hospital stay. Therefore, the noncardiac surgery population could not have been effectively represented, and this finding should be inferred with prudence. The practical inference of this review and meta-analysis is that volatile anesthetics should be preferred in patients undergoing cardiac surgery, unless there is any obvious contraindication. In case of noncardiac surgery population, there was higher mortality with volatile anesthetics that may be attributed to selection of high risk of patients. The majority of the trials were small and number of events reported, too was limited that could jeopardize the predictability of mortality. Nevertheless, the authors made adjustment for the effect size with respect to small sample size and Peto odds ratio method was used that provides more accurate statistical analysis for rare events. The publication bias may also influence the evaluation since the studies with negative results are less likely to be published. The pulmonary and other complications were included irrespective of their severity. The postoperative complications largely 280 Yearbook of Anesthesiology-6 depend on the kind and extent of surgery which may affect the role of anesthetic agents. There is no mention of use of opioids in this meta-analysis that could have added up to cardiac protection. Hence, more studies are required in noncardiac surgery to further assess the effects and outcome of volatile anesthetics. An estimation of the global volume of surgery: A modelling strategy based on available data. Effects of anesthetic regimes on inflammatory responses in a rat model of acute lung injury. A comparison of volatile and non volatile agents for cardioprotection during on-pump coronary surgery. Landoni G, Greco T, Biondi-Zoccai G, Nigro Neto C, Febres D, Pintaudi M, Pasin L, Cabrini L, Finco G, et al. Anesthetic and survival: A Bayesian network meta analysis of randomized trials in cardiac surgery. Potential synergy of antioxidant N-acetylcysteine and insulin in restoring sevoflurane postconditioning cardioprotection in diabetes. Isoflurane activates intestinal sphingosine kinase to protect against bilateral nephrectomy-induced liver and intestine dysfunction. Sevoflurane protects against renal ischemia and reperfusion injury in mice via the transforming growth factor-β1 pathway. Statistical aspects of the analysis of data from retrospective studies of disease. Mazo V, Sabaté S, Canet J, Gallart L, Gama de Abreu M, Belda J, Langeron O, Hoeft A, Pelosi P. Prospective external validation of a predictive score for postoperative pulmonary complications. This question is being posed by some of our colleagues from surgical specialities. The positive outcome of this doubt is the surge of studies evaluating the practice of anesthesiologists that can increase or decrease the likelihood of perioperative infections. This awareness is also leading to a slow albeit definite changes in the practice of anesthesiologists. The present study evaluates whether bolus injection of drugs by anesthesiologists poses the threat of injection of potentially harmful microbes into patients’ circulation. The fushed content from these flters and the residual drug in the syringes used to load the drugs were cultured at the end of the anesthetic. Isolated organisms were Staphylococcus capitis,Staphylococcus warneri,Staphylococcus epidermidis,Staphylococcus haemolyticus, Micrococcus luteus/lylae, Corynebacterium, and Bacillus species. The authors concluded that potentially infectious microorganisms are being injected into patients during bolus intravenous injections by anesthesiologists. The entire study is formulated on the findings of a simulated study where microorganisms could be isolated from 13% of collected injectate during simulated anesthetic injections. But considering the turnover of the modern day operating rooms, logistic availabilities and the attitudes of the anesthesiologists does this ideal turn into practice? So we have no clue about the standard practice of drawing the drugs and injection and to what extent it was adhered to. Since there was no way by which the filter membranes could be extracted out from the filters the authors devised their ingenious technique of backflushing the filters to extract the trapped microbes in the filters. It was validated by the laboratory experiment which confirmed that backflushing could successfully extract the trapped microbes from the filters. This flush had to be done in this study every time the drug was injected through the filter assembly. Repeated connections and disconnections of syringes at stop cocks does provide more chance for infection. It is not clear whether the findings of this audit from one hospital can be generalized to all settings especially since the authors have not mentioned the aseptic protocol followed in their hospital to load and administer the drugs.