Management of retroperitoneal haematoma

To find out the frequency of different visceral injuries and morbidity and mortality related to different zones in retro peritoneal haematoma due to trauma. D.H.Q Teaching Hospital Rawalpindi. Prospective study. June 1998 to May 1999. There were total 45 patients with retro peritoneal haematoma. The policy for exploration of retro peritoneal haematoma included mandatory exploration of Zone I and selective exploration of Zone II and III. Out of total 45 patients, 40 had associated intra peritoneal injuries and Zone I was most commonly involved [n=21] followed by Zone II [n=13] and Zone III [n=11]. Vascular, genitourinary and pelvic fracture injuries were the common injuries. Overall mortality was 6.5% mainly due to irreversible shock in patients with Zone I vascular injuries. Mandatory exploration of Zone I and selective exploration of Zone II and III is a valid policy in the management of retro peritoneal haematomas. Penetrating Zone I trauma causing vascular injuries is most common of all. Shock is the most common presentation, complication and cause of mortality

Aortic valve replacement for aortic stenosis - 12 Year experience of a single surgeon

Aortic Valve Replacement [AVR] is a standard procedure carried out for severe pathological changes in aortic valve. In our study 30 patients had AVR for aortic stenosis from Dec. 1989 to Dec. 2002. There were 25 male and 5 female. Most of the patients were from poor socioeconomic group. Rheumatic heart disease was the most common cause [72.2%]. Syncope, angina and heart failure were the major indications of surgery. The mean age was 37 years. Starr Edward Valve was most commonly used valve [72.4%]. LV diastolic diameter was associated with increased pre-op NYHA grading, increased inotropic support. Hospital mortality was 5 [16.6%] and late death was 1[3.3%],4 [13.2%] patients were lost to follow up while 20[66.6%] are attending the follow up clinic with most of the cases in NYHA grade 0/I. Bleeding, infarction and postoperative arrhythmias affected the mortality significantly

Comparison and efficacy of different cardioprotective techniques during CABG assessed by metabolic and chemical markers

It was a prospective and randomized study of 124 consecutive patients scheduled for elective surgery at AFIC/NIHD. Patients were assigned to cold crystalloid cardioplegia, warm blood cardioplegia and cold blood cardioplegia groups. Patients were comparable with respect to preoperative data and cardiac status. Biochemical measurements, metabolic indices and post operative morbidity and mortality were evaluated before and after the operation. CPK, CK-MB, AST, LDH and ALT measurements were significant among different groups. Their concentrations were highest after cold crystalloid cardioplegia and least after warm blood cardioplegia. The warm blood cardioplegia appears to confirm best myocardial protection, cold blood cardioplegia lies in the center and cold crystalloid ardioplegia exerts sub-optimal degree of myocardial protection. This study provides guidelines for the selection of a better cardioplegia solution giving optimal results

Euro-scoring for risk stratification in CABG surgery [10 Years experience]

Aim of the study was to evaluate patients pre operatively with Euroscoring System to judge the end point, hospital mortality in CABG done in last ten years by a single surgeon. Form June 1989 to June 1999 the data of 262 cases of CABG done was collected on the data sheet each case was scored pre operatively with Euroscoring System. The different groups were made from this system, Group 1 Score 0-1, Group 2 Score 3-4, Group 3 Score 5-6, Group 4 Score 7-8, Group 5 >9. Another Grouping was Group 1 score 0-5, and Group 2 score 6-10 and Group 3 score 11-15. Pre op data was collected and analyzed by SPSS Version 7.5. The End point was hospital mortality. In this group of 262 patients, the age range was 25-77 with the mean 52.41 years, 248 [94.7 percent] were males and 14 [5.3 percent] were females. In this whole cohort of patients 227 [86.6 percent] were having stable angina pectoris and 35 [13.4 percent] were having unstable angina Pre op angina status was Class 1 in 5 [1.9 percent], Class II 88 [33.6 percent], Class III 132 [50, 4 percent] and Class IV were 37 [14.1 percent]. There were 116 [44.3 percent] hypertensive, 56 [21.4 percent] were diabetics and 9 [3.4 percent] were obese. Recent myocardial Infarction was there in 9 [3.4 percent] of cases, the old non Q- wave infarction was present in 18 [6.9 percent] of cases and Q - wave infarction was present in 42 [16 percent] of cases. Pre op Ejection fraction was good in [EF >50 percent] in 204 [77.9 percent] cases, Fair [EF 30-49 percent] in 50 [19.1 percent] cases, poor [EF<30 percent] in 8 [3.1 percent] cases. Pre op support of intra-aortic balloon counterpulsation [IABP] was used in 3 [1.1 percent], pre operative ventilation was done in 1 [0.4 percent], Inotropic support was present in 4 [1.5 percent], and vasodilators were given in 14 [5.3 percent] cases, Elective surgery was done in 92 percent, urgent in 4 percent, emergency in 3 percent and salvage surgery was done in 1 percent of cases. Mortality in Euroscore Group I [Score 0-1] was 3.1 percent, in Group II [Score 2-3] 9.4 percent, in Group III [Score 4-5] 19 percent, in Group IV [Score 6-7] 25 percent and in Group VI [Score >9] the mortality was 60 percent. The Euro score from 0-5 was having 6.1 percent mortality, the score from 6-10 was having 20 percent and the score from 11-15 was having 80 percent mortality. On Logistic regression overall predictive accuracy of Euroscoring is very good [90 percent]. Predictive accuracy, 37 percent of deaths could be explained on the existing variables, positive predictive value is 19.05 percent and negative predictive value is 99.17 percent. The predictive accuracy of Euroscoring changes with various risk groups, in low risk Groups [Score 0-5] and [Score 6-10] Euroscore predicts survival more accurately. In high risk Group [11-15] Euroscoring better predicts mortality rather than survival. The factors included in permutations of Euroscore explain only 37 percent of the observed mortality. It is noted that the observed mortality is consistently higher than that predicted by logistic regression. Euroscoring is a good tool of risk stratification to predict the out come but not ideally suited to our clinical circumstances. Though we have documented an overall predictive accuracy of 92 percent, it is limited in its usefulness because it does not take into consideration certain risk factors found to be important in our patient population. In addition, the relative weight assigned to various risk factors in scoring needs to be readjusted for our patient population in the light of observations made on our patient population. There is a need to develop a scoring system of our own which could be used for better prediction of outcomes in our clinical circumstances

Multiple valve replacement, a decade's experience

Multiple Valve Replacement is the procedure involving replacement of more than one valve due to pathological changes. It was a prospective and randomized study of 72 patients for Multiple Valve Replacement at Armed Forces Institute of Cardiology [AFIC], by one surgeon. The major cause of multiple valve replacement in our country is Rheumatic heart disease and occurs in younger age group as compared to Caucasians. In this study most of the cases were of Mitral regurgitation with Aortic regurgitation [39.4 percent]. The procedures done were according to the valves involved. Aortic valve replacement [AVR] with Mitral valve replacement [MVR] was maximum in 73.7 percent. Starr Edward Valve was used in the majority of cases [59 percent]. Postoperative complications were present in 54.5 percent of cases. ICU problems were LCO, excessive bleeding, arrhythmias and pulmonary complications. Overall hospital mortality for the whole group was 28.8 percent, late mortality was 15.1 percent. Patients who were lost to follow up were 28.6 percent and 30.4 percent are still having the follow up. The relation of hospital mortality with disease pattern and NYHA grading was significant [p=0.0001]