Improving outcomes of emergency bowel surgery using NELA model

Objective: To find outcomes of emergency bowel surgery and review the processes involved in the care of these patients on the same template used in National Emergency Laparotomy Audit [NELA]

Study Design: An audit

Place and Duration of Study: Surgery Department, The Aga Khan University Hospital, Karachi, from December 2013 to November 2014

Methodology: Patients undergone emergency bowel surgery during the review period were included. Demographic data, type of admission, ASA grade, urgency of surgery, P-POSSUM score, indication of surgery, length of stay and outcome was recorded. Data was then compared with the data published by NELA team in their first report. P-value for categorical variables was calculated using Chi-square tests

Results: Although the patients were younger with nearly same spectrum of disease, the mortality rate was significantly more than reported in NELA [24% versus 11%, p=0.004]. Comparison showed that care at AKUH was significantly lacking in terms of proper preoperative risk assessment and documentation, case booking to operating room timing, intraoperative goal directed fluid therapy using cardiac output monitoring, postoperative intensive care for highest risk patients and review of elderly patients by MCOP specialist

Conclusion: This study helped in understanding the deficiencies in the care of patients undergoing emergency bowel surgery and alarmingly poor outcomes in a very systematic manner. In view of results of this study, it is planned to do interventions in the deficient areas to improve care given to these patients and their outcomes with the limited resources of a developing country

Duhamel's procedure for adult Hirschsprung's disease

An adult presented with chronic constipation and abdominal mass. Clinical features, abdominal radiographs and barium enema revealed features consistent with Hirschsprung's disease. Full-thickness rectal biopsy was planned, but patient was lost to follow-up and presented 3 years later with intestinal obstruction. Exploratory laparotomy with resection of affected sigmoid colon and end colostomy were performed. Sequential rectal biopsies were obtained during the procedure to confirm the diagnosis. Later, Duhamel's procedure with a diverting loop ileostomy was successfully performed. Ileostomy reversal was done thereafter. There was complete resolution of symptoms and dramatic improvement in bowel function

Three pregnancies with mechanical heart valve and no follow-up in 10 years

Anticoagulation and proper INR [International Normalized Ratio] monitoring is essential for patients having mechanical heart valves; it is vital in these patients in order to prevent lethal complications such as valve thrombosis and systemic embolism. In pregnancy, it becomes even more important as pregnancy itself is a hypercoagulable state. This report describes a female patient having undergone mitral valve replacement with a Starr Edward metallic prosthesis. She came back to the operating surgeon after 10 years of valve replacement with a history of three uneventful healthy deliveries and no follow-up and INR monitoring during this period

audit of head trauma care and mortality

To analyze the factors contributing to deaths from head trauma by using standardized assessment parameters and to provide a peer-review of head injury deaths with focus on identifying deficiencies and analyzing contributory factors. Design: Descriptive study. Place and Duration of Study: The study was carried out at the Emergency, Aga Khan University Hospital during January 1998 to December 1999. Subjects and Method: One hundred and three patients above the age of 15 years presenting alive to the Aga Khan University Hospital [AKUH] emergency with head injury were included in this study. Identified deaths data was reviewed by the Hospital Trauma Peer Review Committee and consensus arrived at for categorization of deaths. The potential deficiencies in care were identified and final recommendations made. The data was computed on CDC Trauma Registry [V 3.0] and SPSS [V 8.0]. Mean age was 31.9 years [n=103] with predominant male population [4:1]. Severe head injury [GCS<8] accounted for 21.3% [n=22] of all cases with a total number of deaths being 12.6% [n=13]. Deaths were categorized preventable in 3 cases with non-preventable and potentially preventable in 4 and 6 cases respectively. Road traffic accidents were the predominant mechanism [n=8] in all deaths [n=13]. The time interval in relation to mortality was biphasic, most deaths occuring either within 24 hours or between 3-7 days of injury. Inappropriate pre-hospital treatment, pre-hospital delays and inappropriate mode of transportation without inter-hospital communication were the process-related defects in pre-hospital care with major determinant of deaths outside AKUH [n=5]. Prolonged emergency stay, delayed intensive care availability were the process-related deficiencies whereas inappropriate initial resuscitation, inappropriate initial head injury management were provider-related deficiencies in in-hospital care. Transfer of inappropriately managed patients, lapses in inter-hospital communications, delayed transfers were identified as the major pre-hospital factors whereas lack of ICU beds, portable ventilators in emergency room, delays in CT scan facilities were the deficiencies in the hospital services. Opportunities for improvement in head trauma care are needed to focus on initial resuscitation and appropriate surgical management