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

Comparison of duration of neuromuscular blockade with atracurium in obese patients

Objective: To compare the mean duration of atracurium induced neuromuscular blockade in minutes when dosed according to real body weight [RBW] or ideal body weight [IBW] to obese patients undergoing abdominal surgeries under general anesthesia

Study Design: Randomized controlled trial

Place and Duration of Study: Department of Anesthesiology, National hospital defense Lahore, From March 2015 to March 2016

Material and Methods: One hundred and fifty [150] patients were selected for this study and divided in to two equal groups [75 patients in each group], group-I [experimental group] and group-II [control group]. Sample size was calculated with 80% power of test, 95% confidence interval taking mean and standard deviation of duration of atracurium induced neuromuscular blockade in minutes in both groups i.e. 74.6 +/- 37.56 in real body weight group versus 40.02 +/- 22.5 in ideal body weight group. Non probability consecutive sampling technique was used. SPSS version 16 was used for data analysis. Frequency and percentages were used to present categorical data and mean +/- standard deviation for numerical data. Independent sample t-test was applied to compare the significance of outcome variables. A p-value of <0.05 was considered statistically significant

Results: There was a prolong duration of action in experimental group [real body weight group] 69.64 +/- 3.11 minute versus 46.33 +/- 2.77 minute in control group [ideal body weight group] which suggests that dose of atracurium should be calculated and given on basis of ideal body weight in obese

Conclusion: It was observed in our clinical trial that body weight calculation and dosage of atracurium accordingly has altered duration for recovery from blockade, the results of the study showed that atracurium when used according to ideal body weight as compared to total body weight has reduced duration of action. So atracurium dose should be calculated according to ideal body weight rather than total body weight in obese patients

Prophylactic use of gabapentin to reduce postoperative nausea and vomiting in patients undergoing diagnostic gynecological laparoscopy

Introduction: Postoperative nausea and vomiting [PONV] occurs in patients during the first 24 hours of the surgery. Many drugs have been used for the prevention and treatment of PONV. In this trial, we used gabapentin to evaluate its prophylactic effect in reducing the severity and incidence of PONV in patients undergoing diagnostic laparoscopic gynecological surgery

Methodology: This, double blind randomized controlled trial, was done in operation theatre complex over a period of six months. 140 patients undergoing diagnostic gynecological laparoscopic surgery were selected. Two groups were formed and 70 patients were recruited in each group using lottery method as method of randomization. Group C [control group] was given placebo medication orally two hours before surgery and group G [gabapentin group] received 600 mg of gabapentin orally two hours before the procedure. Standard general anesthesia technique was used in all patients and incidence and severity of postoperative nausea and vomiting [PONV] was recorded in these patients till 24 hours of laparoscopy

Results: Severity of PONV was graded from mild to severe. There was no PONV in 25 patients [35.7%] in group C and 47 patients [67.1%] in group G. It was mild in severity in 8 patients [11.4%] in group C and 5 patients [7.1%] in group G, moderate in 31 patients [44.3%] in group C and 15 patients[21.4%] in group G and severe PONV was seen in 6 patients [8.6%] in group C and 3 patients [4.3%] in group G [P=0.003]. Postoperative nausea and vomiting within 24 hours after procedure was present in 45 patients [64.3%] in group C and 23 patients [32.9%] in group G. Results were significant between two groups after statistical analysis with p value of 0.001

Conclusion: Administration of 600 mg of gabapentin two hours before diagnostic gynecological laparoscopy decreases the frequency and severity of PONV

Use of box simulators for improving intraoperative laparoscopic skills: an essential tool for the surgeon in training

To compare the improvement of intraoperative laparoscopic skills by measuring GOALS score between residents who have undergone simulator training with those who have not received any simulator training. A randomized controlled trial. Department of Surgery, Services Hospital, Lahore, from August 2013 to February 2014. Thirty residents belonging to year 1, 2 and 3 were included in the study. They were randomly divided into 2 groups. Both groups had a baseline evaluation with GOALS score while performing dissection of gallbladder from liver bed during laparoscopic cholecystectomy. Group-A underwent formal training on simulators whereas group-B did not receive any formal training on simulators. After 6 months, a repeat evaluation was done again by measuring GOALS score while performing gallbladder dissection. Baseline GOALS scores of both the groups were similar. Group-A baseline score was 7.66 +/- 0.93 and group-B score was 7.46 +/- 1.04 [p = 0.585]. However repeat scores for group-A showed a significant improvement [an increase of 7.16 +/- 1.48 to 14.76 +/- 1.67, p < 0.001] from baseline scores. Residents in group-B improved their scores by 2.30 +/- 0.99 to 9.76 +/- 0.79 [p < 0.001]. When inter group comparison was done the second score of group-A was significantly higher than that of group-B [14.76 +/- 1.67 vs. 9.76 +/- 0.79, p < 0.001]. Inter-rater reliability was moderately significant [Kappa 0.540]. Training on laparoscopic simulators results in significant improvement of intraoperative laparoscopic skills

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

Frequency of hypothyroxinemia in preterm versus term neonates

To determine the relative frequency of hypothyroxinemia in preterm versus term neonates from 3 to 7 days of age. cross sectional analytic study. special care baby unit Khyber teaching hospital, Peshawar, in collaboration with IRNUM Hospital Peshawar from November 2004 to June 2005. One hundred and one neonates age 3 to 7 days, including 52 preterm and 49 term babies were included in the study. Blood specimens for T4 and TSH assays were collected after taking informed consent from parents and tested in laboratory of IRNUM Hospital for serum T4 and TSH levels by radiommunoassy. Mean values of serum T4 and TSH levels in preterm and serum T4 and TSH levels in hypothyroxinemic preterm and term neonates were compared. Data was entered and analyzed on SPSS version 8. Among 52 preterm neonates, 9 babies [17.3%] had serum T4 levels < 60 n mol/l compared to one baby out of 49 term neonates [2.04%]. Mean values of serum T4 levels were lower in preterm neonates and values of serum TSH were not proportionately increased in these babies, while in one full term baby lower T4 level was associated with increased level of serum TSH. [High level of TSH was defined> 4.0 ulU/ml and low level of serum T4 was defined as < 60 nmol/l]. Among 9 preterm babies with hypothyroxinemia who were called at later ages for follow up, parents of 2 babies agreed to give blood specimen and serum levels of T4 and TSH, which were normal in the babies [reflecting transient hypothyroxinemia of preterm]. Hypothyroxinemia without significant hyperthyropinemia is relatively common in preterm than term neonates during the first weeks of life. It seems to be transient. Further studies are required to determine the risks and benefits of thyroxine therapy in preterm infants