predictive capability of apache ii score in determining mortality among critically ill surgical population

The APACHE II model has been widely validated and used by many ICUs to classify the severity of illness and to predict hospital mortality, Although the APACHE II model is quite old, and other scoring systems have been developed using more recent cohorts, APACHE II is still widely used for research and clinical audit purposes. It scored the most accurate mortality prediction. Because of the differences between intensive care unit patients, in criteria of admission and type of surgery, we think it is necessary for every intensive care unit to have a prediction system which is validated for its specific kind of patients. This prospective study was done on 680 consecutive patients admitted to surgical intensive care unit [SICU] of Kasr EI-Aini hospital were enrolled from January 2006 to December 2007. For standardization purpose, 54 patients, who remained less than 24 hours, were excluded. Another 75 patients were excluded as their medical files could not provide all required information. The APACHE II score was calculated for the remaining 551 patients, physiological variables, age and chronic disease. The SICU resident filled the APACHE II form which is a routine form of SICU. The least value was used for calculating the physiological variable during the first 24 hours of admission. Patients were classified according to surgical procedure formed, into post-elective and post-emergency, an equation established by Knaus et al. in 1985 was used for the calculation of mortality risk. From the 551 patient enrolled the mean age was 46.93 +/- 17.9 years and the length of SICU stay was 3.77 +/- 3.9 days. The overall median APACHE II score of all SICU patients was 8 with a range of 51 [minimum 0 and maximum 51]. The expected mortality rate was 15.95 +/- 22.0%. The actual mortality rate was 92 patients [16.7%]. There was significant difference among distribution of male: female, survivors: non-survivors and elective: emergency patients enrolled [p=0.03, <0.0001 and <0.0001 respectively] APACHE II score had a strong positive correlation with actual mortality rate. There was good correlation between predicted death risk and actual mortality rate r=0.75 and p<0.0001. We conclude that this study demonstrated a meaningful association between predicted and observed mortality rates in patients in SICU in a tertiary referral university hospital [Kasr EI-Aini hospital] relying on APACHE II score evaluation. APACHE II prognostic index was useful for stratifying patients according to the severity of their health condition

influence of two different hydroxyethyl starch solutions [6 % HES 130/0.4 and 200/0.5] on postoperative pulmonary functions in patients undergoing elective abdominal aortic surgery

Major surgery may alter the physiologic immune balance and initiate systemic inflammatory processes which may progress to severe postoperative complication e.g. multiple organ dysfunction syndrome [MODS] or adult respiratory distress syndrome [ARDS]. The colloid used for intra vascular volume replacement in surgical patients may affect the inflammatory response during major surgery. Thirty six patients scheduled for elective abdominal aortic aneurysm surgery were randomized to receive either 6% hydroxyethly starch HES 200/0.5 or 6% hydroxyethyl starch HES 130/0.4 for colloid replacement. Lung function was assessed with PO[2]/FiO[2]ratio, respiratory compliance, chest X-ray and a score for lung injury. Serum concentrations of interleukin [IL]-6, IL-8 and IL-10 were measured. After aortic cross clamp release the PO[2]/FiO[2] ratio was 354.6 +/- 7.95 mmHg for the HES 130/0.4 compared with318 +/- 9.52 mmHg for the HES 200/0.5 treated patients. Twelve hours after aortic cross clamp release, PO[2]/FiO[2]ratio for the HES 130/0.4 patients was 316 +/- 9.04 compared with 259.44 +/- 6.92 for HES 200/0.5 patients [p<0.001]. In the first postoperative day it was 251.6 +/- 4.2 for HES 130/0.4 patients compared with 217 +/- 9.74 for HES 130/0.4 treated patients. Respiratory compliance was greater for HES 200/0.5 treated patients compared with HES 130/0.4 treated patients. Peak values of IL-6 and IL-8 were significantly lower in HES 200/0.5 treated patients compared with HES 130/0.4 treated patients serum IL-6 were 52.9 +/- 10.2pg/dl in HES 200/0.5 group compared with 46 +/- 11.8pg/dl for HES 130/0.4 group serum IL-8 were 45 +/- 8.9pg/ml in HES 200/0.5 group compared with 37 +/- 9.8pg/ml in HES 130/0.4 group. Intravascular volume replacement with HES 130/0.4 resulted in better perioperative pulmonary function and reduced inflammatory response in patients undergoing abdominal aortic surgery compared with HES 200/0.5

Role of Helicobacter pylori in refractory iron deficiency anaemia

The role of Helicobacter pylori [H. pylori] infection in the development of iron deficiency anaemia has been the focus of attention during the last decade. Confirmation of the relationship between H. pylori infections and iron deficiency anaemia has not confirmed the pathophysiologic mechanisms involved in this phenomenon was to study the levels of fasting gastric acidity [free and total] as well as the level of tumor necrosis factor alpha in refractory iron deficiency anaemic male patients seropositive for H. pylori infection versus those with seronegativity for H. pylori infection. Also, we tried to find the underlying pathophysiologic mechanism for iron deficiency anaemia observed in these patients. This study was conducted on 30 adult male patients having iron deficiency anaemia and gastroduodenitis. They were subdivided into 2 groups of matched age and haemoglobin value. Group I was seropositive for H. pylori infection and refractory to iron therapy. These patients did not receive prior treatment for eradication of H. pylori infection while group II was seronegative for H. pylori infection and was considered a control group. Patients with active bleeding or previous medical problem were excluded from the study. All patients and controls in the present study were subjected to the following at presentation: careful history taking and thorough clinical examination, complete blood picture, reticulocytes%, assessment of serum iron, total iron binding capacity, serum ferritin, IgG antihelicobacter antibody and tumor necrosis factor-alpha [TNF-alpha], stool for occult blood and measurement of gastric acidity [total and free] by chemical method. Upper endoscopy was done and multiple biopsies were taken and tested for expression of cytotoxin associated gene A [cag A] by polymerase chain reaction [PCR]. results revealed statistically significant higher values of free and total gastric acidity as well as tumor necrosis factor-alpha levels in H. pylori seropositive compared with H. pylori seronegative group. Among H. pylori seropositive group, higher value of TNF-alpha level was observed in H. pylori cagA positive [7 patients] than cagA negative patients [8 patients]. Also, haemoglobin values were inversely correlated with tumor necrosis factor-alpha levels. From this study, we can conclude that elevated serum tumor necrosis factor [TNF-alpha] in H. pylori seropositive group may be one of the underlying pathophysiologic mechanism for iron deficiency anaemia observed in these patients

Hyperbaric bupivacaine and fentanyl for elective cesarean section: effect of a height and weight adjusting dose

There are large varieties of dosage regimens which are in use for spinal anesthesia for Cesarean section [3]. All aiming for limiting the dose of Bupivacaine to reduce incidence of maternal hypotension and vasopressor requirements, decreasing nausea and vomiting, reducing time to discharge from post anesthesia unit, and improving maternal satisfaction [4]. This study was designed to assess the validity of adjusting the dosage of intrathecal hyperbaric bupivacaine according to the patient's height and weight would provide adequate surgical anesthesia for elective cesarean section while decreasing the incidence of maternal hypotension and the use of vasopressor to treat hypotension and consequently fetal outcome. Patients were randomly assigned to be involved into two groups. Group 1: The fixed dose group, patients received fentanyl 20 microgram [0.4ml] added to hyperbaric bupivacaine 0.5% 2.4ml. Group 2: The adjusting dosage group, patients receive fentanyl 20 microgram [0.4ml] added to a volume of hyperbaric bupivacaine 0.5% that is determined by referencing to the dosage regimen detailed Table. All the cardiovascular data measured plus the incidence of nausea and vomiting were statistically significantly lower in the adjusted group compared to the fixed one [p<0.05]. Time to loss of cold [T4] and to pinprick sensation to T64 on both sides were significantly slower in the adjusted group [p<0.05]. There were no significant differences as regard the visual analogue scale, number of patients needed supplementary analgesia, or the fetal outcome between the two groups at different time intervals [p>0.05]. Adjusting the intrathecal hyperbaric Bupivacaine dose to patient's height and weight combined with 20 microgram Fenatnyl provide adequate anesthesia with less maternal side effects for patients undergoing elective cesarean section

Combined great auricular nerve block and general anesthesia for tympanomastoid surgery

The effects of the great auricular nerve [GAN] block combined with general anaesthesia [GA] in patients undergoing tympanomastoid surgery have been evaluated with respect to the quality of the surgical field, isoflurance consumption, postoperative pain and recovery profile. Thirty adult patients were randomly allocated to receive GA alone [group I, n=15] or combined GA and GAN block [group II, n=15]. After stabilization of GA with isoflurane, N[2]O/O[2] the patients in group II received GAN block The mean arterial pressure [MAP] intraoperatively was maintained at 60-65 mmHg by adjusting the concentration of isoflurane and the use of hypotensive agent [esmolol]. The consumption of isoflurane, and the frequency of esmolol use were evaluated in both groups. The surgeon evaluated the quality of surgical field. The pain intensity, postoperative morphine consumption and incidence of nausea were evaluated in PACU. Intraoperatively, isoflurane consumption was less in group II than group I [P<0.005]. The number of patients requiring esmolol were significantly higher in group I. The average category scale for quality of surgical field was better in group II than group I in the range of MAP 60-65 mmHg .In the PACU, the total morphine consumption were significantly reduced in group II than group I [P