Perioperative complications and risk factors of percutaneous nephrolithotomy.

OBJECTIVE: To study the risk factors of perioperative complications of PerCutaneous NephroLithotomy (PCNL). MATERIAL AND METHOD: The present prospective descriptive study was carried out in the first time operation of 128 PCNL patients after general balanced anesthesia and standard surgical technique. Irrigation fluids were 0.9% NSS (24.1 +/- 16.36 liters) at room temperature. Perioperative complications and risk factors were observed, the results were displayed as adjusted Odds Ratio (OR), 95%CI and p value. RESULTS: Intraoperative complications were hypothermia (56.2%), cardiovascular changes (57.1%) and bleeding. The first two complications statistically significantly related to volume of irrigation fluid > 20 liters (7.4, p < 0.05). Postoperative complications were electrolyte changes (but not statistically significant), pleural tear (3 cases), infection and bleeding. Septic shock was found in 4.7% (6/128) and 0.78% (1/128) died. Fever was significantly correlated with postoperative transfusion > or = 1 unit (adjusted OR 4.9, p < 0.05). Risk factors of postoperative bleeding were operation time (adjusted OR 4.4, p < 0.05), intraoperative transfusion (adjusted OR 10, p < 0.01) and postoperative fever (adjusted OR 4.9 p < 0.01). Mean was 7.3 +/- 5.22 days and the mode of Length Of Stay after operation (LOS(PO)) was 5 days. LOS(PO) was significantly related with postoperative fever > 38.5 degrees C (adjusted OR 2.7, p < 0.05). CONCLUSION: Volume of irrigation fluid at room temperature >20 liters significantly increased the rate of intraoperative hypothermia and cardiovascular changes. Infection was the most serious complication of PCNL and increased LOS(PO). Antibiotics started at the beginning of the surgery could not always prevent this event.

Discordant cardiac troponin results in amphetamine - related rhabdomyolysis.

A case of a patient who developed amphetamine-related rhabdomyolysis and acute renal failure after an intestinal operation is reported. He initially had biochemical evidence of myocardial injury, with a concomitant increase in cardiac marker proteins CK-MB, cardiac troponin T (cTnT) and cardiac troponin I (cTnI) during the acute event. Following intensive treatment and improvement in renal function, levels of all myocardial marker proteins fell towards the normal range. Late in the course of the disease, however, there were re-elevations of CK-MB and cTnT, but not of cTnI, to levels exceeding 14 fold and 8 fold the upper limit of the reference range, respectively. Since, at present the possibility of re-expression of both CK-MB and cTnT in damaged and regenerating skeletal muscle can not be ruled out, the late occurrence of increased CK-MB and cTnT in our patient should not be interpreted as evidence of recurrent myocardial injury.

The causes and effects of airway incidents on Post-surgical ICU patients.

Objective : To identify the causes and effects of in airway incident reduction in the post-surgical ICU, Siriraj Hospital. CQI program was gradually implemented to reduce the incidence. Methods : Self-reported of airway incidents ( unplanned extubation, tube dislocation, tube obstruction, unrecognised disconnection etc.) from August 2000-January 2001 were used for data collection and analysis. CQI program was implemented gradually over six months. Results : Among 284 intubated patients in 524 patients admitted to post-surgical ICU, there were 24 episodes of airway incidents during 6 months, 15 episodes in the first trimester and 9 episodes in the second trimester. The incidents happened during afternoon shifts more than other shifts. Five patients experienced moderate cardiopulmonary events (hypoxemia or severe hypo or hypertension) and two resulted in death. Most (23 out of 24) episodes were considered preventable. The causes were; lack of manpower, insecure airways, lack of knowledge, inadequate communication and inadequate sedation. Conclusion : Airways incidents occurred for several different reasons and occasionally resulted in death. Most of the causes were preventable. The CQI program aimed to define preventable causes and improved the quality of care.

Effect of inspiratory flow waves to the patient.

To study the effect of inspiratory flow, we gave 30 postoperative ventilated patients (ASA 1-2) aged 20-60 years old three kinds of inspiratory wave forms as I (square), II (decelerated) and III (sine) were. Each patient received all 3 kinds of wave in on particular order by random. We found these effects on the cardiovascular system. Sine wave: decreased blood pressure more than the others but not significantly (p > 0.01). The best oxygenation was from sine waves than decelerated and finally square (not significant). Ventilation: PaCP2 decreased least with decelerated wave and most with square wave a significantly change comparing the two (p < 0.01). There was no significant change in pH. Airway pressure; PIP, increased significantly in I more than III and II, P plateau was highest in III then I and II and P maw the difference was not significant in I, II and III nut highest in III.