Prevalence and antibiotic susceptibility of methicillin resistant Staphylococcus aureus and Acinetobacter baumannii in clinical samples from intensive care unit patients in a tertiary care hospital at Peshawar [Pakistan]

Multi-drug resistance in Staphylococcus aureus and Acinetobacter baumannii [A baumannii] can cause a wide range of infections, including bacteremia, pneumonia, urinary tract infection, peritonitis etc., which can lead to substantial morbidity and mortality, particularly in the ICU settings. These organisms have been shown to be increasingly resistant to a large group of antibiotics, especially [3-lactam antibiotics. The aim of the present study was to determine the prevalence and antibiotic susceptibility of methicillin resistant Staphylococcus aureus [MRSA] and A baumannii in patients admitted in Intensive Care Units [ICUs] of a tertiary care hospital in Peshawar, Pakistan. A total of 518 bacterial isolates were collected from different ICUs during die period from 1st November 2012 to 30 November 2013. Media, reagents and kits used for bacterial culture and analysis included blood agar, MacConkey's agar, mannitol salt agar, DNAase and Api Biomerieux 10s [France]. Antibiotic cefoxitin was used to check whether strains of Staphylococcus aureus were methicillin resistant or sensitive. The antibiotic susceptibility testing was performed by Mueller Hinton agar [MHA] by disc diffusion method. Out of a total of 518 cultures obtained, 42[8.1%] were MRSA positive and 33[6.37%] were positive for A baumannii. Vancomycin [40[95.23%]] and minocycline [33[78.57%]] were the most effective drugs against MRSA, while colistin [33 [100%]] and minocycline [20 [60.6%]] were the most effective against A baumannii. There is an increased frequency of multi-drug resistant Staphylococcus aureus and Acinetobacter baumannii [A baumannii] among patients in the ICU setting which calls for continuous surveillance to determine prevalence and effective antibiotic susceptibility of these bacteria

Comparison of the stylet and the gum elastic bougie in tracheal intubation in a simulated difficult airway

To compare the stylet and the gum elastic bougie in tracheal intubation of a simulated difficult airway. Randomized control trial. The study was conducted in Main Operation Theatre at Rehman Medical Institute, Peshawar from June 2009 to June 2010.6 patients, ASA grades I and II, undergoing elective surgical procedures requiring tracheal intubation were randomly divided in two groups. Difficult intubation scenario was simulated by applying a rigid Philadelphia collar in both groups. Patients in Group-A were intubated with a stylet and patients in Group-B were intubated using a gum elastic bougie. Both groups were then compared in terms of overall success in intubation, and number of intubation attempts. Statistical analysis was done by applying Chi-Square test and Students' T- test. Among the patients of Group-A, only 71.4% patients were successfully intubated using a stylet while 100% patients in Group-B were successfully intubated using a bougie. In the simulated difficult airway, tracheal intubation using a gum-elastic bougie has a higher success rate when compared to stylet assisted intubation and should be preferred in a difficult intubation scenario

Unrecognised peripartum cardiomyopathy will have dire consequences

We report an undiagnosed case of Peripartum cardiomyopathy [PPCM] in our tertiary care hospital, who presented for an elective cesarean section [CS] with cough and orthopnea in her late gestational period. She was treated for upper respiratory tract infection; whereas her heart failure leading to pulmonary edema causing cough and orthopnea, remained unidentified and thus uninvestigated. The disease was only diagnosed during the postoperative period when she suffered from cardiac arrest and had to be ventilated mechanically. She was effectively managed after correct diagnosis; weaned successfully off the ventilator and transferred to the Obstetrics/Gynecology ward in a stable condition

comparative study of supraclavicular versus infraclavicular approach for central venous catheterization

Supraclavicular approach to subclavian vein catheterization is still being employed less often than traditional infraclavicular approach. The purpose of this study was to compare the two techniques regarding number of attempts, success rate of catheterization and complications associated with the procedure. Surgical Intensive Care Unit [SICU] of Rehman Medical Institute, Peshawar [Pakistan]. 1[st] June 2010 to 30[th] December 2010. We included 144 adult patients of either sex undergoing central venous catheterization for various indications, selected by nonrandom sampling, in the study. They were divided into the supraclavicular and infraclavicular groups [72 in each group]. Right subclavian vein of the patient was chosen in all patients for catheterization. Variables for comparison included number of attempts, success or failure of catheterization and complications associated with the procedure in each group. Statistical analysis was done by applying Chi-square test and Student's Independent Samples T-test. The overall success rate was 95.83% for right supraclavicular and 87.50% for right infraclavicular approach [p>0.05]. The number of successful attempts for supraclavicular and infraclavicular approaches were 1.13 +/- 0.42 and 1.35 +/- 0.69 respectively [P=0.029]. The complication rate was higher in the supraclavicular group, but the difference was not statistically significant. The supraclavicular approach to subclavian vein cannulation was found to be a more successful method for adult central venous catheterization with complications comparable to the more commonly used infraclavicular approach

Tension pneumothorax caused by ventilating rigid bronchoscopy for removal of foreign body

Tension pneumothorax during ventilating bronchoscopy for foreign body removal is a rare but life threatening complication, which if not promptly diagnosed and treated can prove fatal. We present a case of tension pneumothorax, due to a laceration in the right main bronchus caused by bronchoscope, in a one year old child, who underwent bronchoscopy for removal of foreign body [bead]. The child was successfully treated and managed by immediate insertion of 14 gauge IV cannula in the pleural cavity followed by chest tube insertion. The laceration was subsequently repaired and foreign body removed by thoracotomy

comparison of the effects of erythromycin and metoclopramide on gastric fluid volume and pH in patients undergoing elective caesarean section

To compare the effects of erythromycin and metoclopramide on gastric fluid volume and pH in patients undergoing elective caesarean section. Randomized, controlled trial. The study was conducted in Gynaecology Ward and Operation Theatre, Rehman Medical Institute Peshawar from July 2009 to June 2010. We recruited 144 patients, ASA grades I and II, scheduled to undergo elective caesarean section and divided them in two equal groups of 72 patients each by simple random sampling. Patients in group A were given tablet erythromycin 250 mg and patients in group B were given tablet metoclopramide 10 mg orally with 10ml of water one hour before surgery. Both groups were then compared in terms of gastric fluid volume and gastric pH according to Robert and Shirleys' criteria, using a cut off value of 25 ml and pH 2.5, respectively. Statistical analysis was done by applying Chi-Square test and Students' T- test. Among the patients of group A 87.5% patients had acceptable volume [25ml] and 62.5% patients had acceptable pH of gastric fluid [pH >= 2.5]. In group B patients 69.4% patients had acceptable gastric fluid volume and 19.4% patients had acceptable pH of gastric fluid. Oral erythromycin reduces gastric fluid volume more effectively than metoclopramide, if given one hour before surgery. Erythromycin increases while metoclopramide has no effect on the pH of gastric fluid

Bronchopulmonary lavage and re-expansion of the atelectatic lung without bronchoscopy

In this case report, we describe the management of a patient with postnatal sepsis caused by retained infected products of conception [POC], who developed lung collapse due to mucus plugs. She had polymodal therapy including frequent hemodialysis. After removal of POC, she was shifted to Surgical Intensive Care Unit [SICU] for critical care including ventilatory support. The next day she was extubated, but on the third day she developed left lung collapse due to mucus plug resulting in ipsilateral lung collapse. Bronchoscopic lavage was considered hazardous by the pulmonologist due to her poor general condition. She was intubated and removal of the mucus plugs was attempted through sterile endobronchial tube suction which resulted in re-expansion of the collapsed lung. The lung remained expanded in her follow up. This method may be used at centers where facilities or expertise for bronchoscopy is not available

Submental intubation in extensive maxillofacial trauma

Surgical repair of complex maxillofacial trauma presents a challenge to the surgeon and anesthesiologist. Where intubations via oral and nasal route cannot be performed, sub-mental route of endotracheal intubation is a very useful alternative. It obviates the need for tracheostomy and its related complications. We are presenting a case where we avoided tracheostomy in a patient with multiple maxillofacial fractures and opted for the sub-mental endotracheal intubation technique

Distally based sural fasciocutaneous flap for soft tissue reconstruction of the distal leg, ankle and foot defects

Soft tissue management around the lower third of the leg and foot presents a considerable challenge to the reconstructive plastic surgeon. The options in this region are limited. A durable flap is the preferred option for coverage of such defects. This descriptive study was conducted at Hayatabad Medical Complex and Said Anwar Medical Centre Peshawar over a period of 4 years to evaluate the efficacy of distally based Sural flap in coverage of the lower third of leg, ankle and foot defects, in 25 patients. A descriptive study was conducted at the department of Plastic and Reconstructive Surgery at Hayatabad Medical Complex and Said Anwar Medical centre Peshawar. 25 patients with soft tissue defects over the distal leg and foot were included in this study. Distally based sural fasciocutaneous flap was used for coverage in all cases and its survival, successful coverage of the defect and donor site morbidity studied. Out of 25 flaps, 20 showed complete survival [80%]. Partial flap loss was found in 2 patients [8%], marginal flap necrosis in 2 patients [8%] and complete loss in 1 patient [4%]. The distally based sural flap is a versatile and reliable flap for the coverage of soft tissue defects of the distal lower extremity. The procedure is done as a single stage; the dissection is easy with short operating time and minimal morbidity

Experience of the treatment of the patients with polio consequences by Ilizarov's method in Pakistan

This study was conducted in the Midciti hospital, Karachi; Tahir Medical Center, Karachi; Majee Hospital, Hyderabad from Dec.2004 to Apr 2006 to show actuality of the problem of rehabilitation of Post Polio patients in Pakistan and efficiency and advantages of Ilizarov's Method in this matter. During the study period 100 patients were operated, all of them by Ilizarov's Method. Of these 62 were male and 38 females. Combined contracture of hip and knee joints with different degree of extremity shortening and foot deformity or instability were found in 26 cases; 62 patients had knee contracture with leg shortening and foot deformity or instability without hip contracture. Almost all of them were not able to walk without additional support. Some of them used orthopedic brace or crutches, others used to lock their knee by hand or by internal or external extremity rotation in combination with hand support. Two patients could move using wheel chair only and were crawling. Three-segment simultaneous surgical intervention was most common. In 90% of cases good and fair results where achieved and patients were satisfied. Deformities were corrected and required lengthening performed. After treatment most of the patients started to walk without any additional support; crawling and wheel chair patients are able to walk by using orthopaedic brace with sticks. It is concluded that Ilizarov's method is very affective and advanced for the treatment of Post-Polio patients and with well-skilled proper approach and application it is not so cumbersome as considered

Simultaneous correction of post-polio hip and knee joints contractue and foot deformity with limb lengthening by Ilizarov's method

We are presenting the case report of twelve years old girl, who had Post-Polio flexionabduction-external rotation contracture of hip joint, flexion contracture of knee joint, equines deformity of foot and limb shortening. She was treated by Ilizarov's Method in one stage and got excellent result

comparative study of caudal epidural block single dose Bupivacaine versus tramadol for postoperative analgesia in children

The management of postoperative pain in paediatric surgery focuses on complete pain relief with no or minimum possible untoward side effects. The effects of single dose caudal tramadol with single dose caudal bupivacaine in controlling the postoperative pain were compared in this randomized double blind study, conducted in children, presented for genital surgery/vesicolithotomy. 50 children ASA I and II between 2-6 years of age were randomly divided into 2 groups and evaluated for pain relief by Hannallah pain score scale while sedation was assessed with a 5 point test. For 24 hours postoperatively, the Hannallah pain score scale value showed no statistically significant difference among groups. Postoperative analgesia was maintained from 12-24 hours in both the groups. In conclusion, Tramadol used caudally as single dose was found to be as effective and safe agent as bupivacaine in reliving postoperative pain in children