Delayed presentation of missed vascular injuries and pitfalls in primary treatment- experience of a vascular surgery unit in pakistan

Objective: To analyze errors in primary treatment of vascular injuries and delayed presentations of missed vascular injuries as a surrogate indicator of need for improved vascular surgical training of upcoming general surgeons

Materials and methods: This retrospective observational study was carried out at vascular surgery department of two tertiary care hospitals of Armed Forces from Jan 2012 to June 2017. Hospital records of all patients with vascular trauma were analyzed for presence of pitfalls in primary treatment and delayed presentation of missed vascular injuries which resulted in redo surgeries or adverse outcomes

Results: Out of 256 patients with vascular injury sequel 41 had either a problem in primary treatment or presented with delayed complications of missed injuries. The omissions can be divided into: missed injuries [24/41], technical errors in initial repair [12/24], reperfusion of mangled Extremity [3/41] and non availability of a surgeon capable of undertaking vascular repair. The commonest operative fault was failure to debride the vessel adequately and vascular repair under tension. The commonest primary assessment problem was failure to timely appreciate hard signs of vascular injury

Conclusion: With better training and emphasizing the need of thorough clinical examination outcome of vascular trauma can be improved

effective technique of obturator nerve block to prevent adductor reflex during transurethral resection of bladder tumor

Objective: To observe the efficacy of blind obturator nerve block by Labat technique for prevention of obturator jerk during transurethral resection of bladder tumor performed under spinal anesthesia

Study Design: Descriptive Study

Material and Methods: This was a single center based study conducted at tertiary care military hospital for a period of thirty months. Fifty five patients were recruited in the study, after identifying the location of bladder growth in the lateral wall on ultrasound USG and confirming its exact site on cystoscopic examination. Those eliciting obturator jerk during transurethral resection of bladder tumor [TURBT] were included and ONB was performed using 2% lidocaine via blind technique of Labat. TURBT was restarted and presence of obturator jerk was recorded if evoked [primary outcome]

Results: Median age was 67.3 +/- 8 years with majority [72.7%] in the age group between 61 to 80 years. Male female ratio was 7:1. Fifty [90%] patients presented with solitary growth. Mean operating time was 28.8 +/- 12 minutes. ONB was successful in 52 [94.54%] of the cases while failure in 3 [5.45%] resulted in conversion to general anesthesia for the completion of TURBT

Conclusion: Blind obturator nerve block [ONB] by using Labat technique for obturator nerve block has proven to be simple, reliable and easily replicable in any set up and it does not require any time consuming steps or sophisticated equipment

Bilateral emphysematous pyelonephritis

A 63 year old male, known diabetic for 10 years and a known case of Ischemic Heart Disease for almost same duration, on regular treatment presented in a peripheral hospital with 4 days history of jerky movement of left half of body, fever, cough and urinary incontinence. Examination revealed bibasal crackles in chest; tenderness in right lumber region and upper motor neuron type weakness in left half of body. Investigations revealed Hb 15.1, TLC 17.8, platelet count of 28,000, numerous RBCs and Pus cells in urine. LFTs were normal. There was no ketonuria and DIC screen was negative. Serum urea and creatinine done on alternate days showed a rising trend with max serum urea 34.8 mmol/L and serum creatinine 1138 umol/L five days following admission. Hepatitis serology was negative. Culture of urine showed growth of Escherichia coli as well as candida species. CT scan Brain revealed right Parietal lobe infarct. USG Abdomen revealed air lucencies in subcapsular and cortical region of both kidneys suggesting bilateral emphysematous pyelonephritis. CT scan abdomen confirmed bilateral emphysematous pyelonephritis [R>L] with extension of air lucencies in perinephric spaces and prominence of gerota's fascia bilaterally. Right kidney was at the verge of bursting. Case was discussed with Urologist and Anesthetist but patient was unfit for surgery because of existing comorbid conditions. Aggressive conservative management was started including antibiotics [intravenous Tazocin] based on urine c/s and intravenous Fluconazole alongwith alternate