Preoperative assessment and optimization in periampullary and pancreatic cancer.

Perioperative management of pancreatic and periampullary cancer poses a considerable challenge to the pancreatic surgeon, anesthesiologist, and the intensive care team. The preoperative surgical evaluation of a pancreatic lesion aims to define the nature of the lesion (malignant or benign), stage the tumor, and to determine resectability or other non-surgical treatment options. Patients are often elderly and may have significant comorbidities and malnutrition. Obstructive jaundice may lead to coagulopathy, infection, renal dysfunction, and adverse outcomes. Routine preoperative biliary drainage can result in higher complication rates, and metal stents may be preferred over plastic stents in selected patients with resectable disease. Judicious use of antibiotics and maintaining fluid volume preoperatively can reduce the incidence of infection and renal dysfunction, respectively. Perioperative fluid therapy with hemodynamic optimization using minimally invasive monitoring may help improve outcomes. Careful patient selection, appropriate preoperative evaluation and optimization can greatly contribute to a favorable outcome after major pancreatic resections.

Efficacy of intravenous ketoprofen for pre-emptive analgesia.

AIM: To determine whether intravenous ketoprofen is effective as pre-emptive analgesia for breast surgery. DESIGN: Randomised, controlled, double blind study. PATIENTS AND METHODS: 50 patients undergoing breast surgery under general anaesthesia randomised to receive either 100 mg intravenous ketoprofen 30 minutes before (Group I), or immediately after surgical incision (Group II). Postoperatively, pain scores (Visual Analogue Scale, VAS) and time to rescue analgesic were recorded by an independent, blinded observer. The study was terminated when rescue analgesic was required (VAS > or =4 or demand for analgesic). STATISTICAL ANALYSIS: Continuous variables were analysed by the unpaired 't' test, discrete variables with the chi square test, and survival curves by the log-rank test. RESULTS: Pain scores were significantly lower in Group I till 10 hours after surgery. The number of patients requiring analgesia at 4, 6, 8 and 10 hours was significantly lower in group I (0% vs. 47% [P <0.0001], 0% vs. 44% [P <0.003], 0% vs. 80% [P <0.0001], 0% vs. 100% [P <0.0001] respectively). The mean time for rescue analgesic was 15.47 -/+ 2.87 hours in group I versus 4.22 -/+ 2.55 hours in group II (P <0.0001). CONCLUSION: Pre-emptive analgesia with Intravenous ketoprofen (100mg) produces better postoperative pain-relief in patients undergoing breast surgery.

Awareness of post-exposure prophylaxis guidelines against occupational exposure to HIV in a Mumbai hospital.

BACKGROUND: Exposure to the human immunodeficiency virus (HIV) is a matter of concern for healthcare workers. We conducted a survey to determine the level of awareness amongst operating room personnel regarding post-exposure prophylaxis in case of needlestick injuries from confirmed or suspected cases of HIV. METHODS: A structured questionnaire was presented to 39 anaesthetists and 31 surgical residents. Questions were related to identification of high risk fluids, risk of transmission, drugs, costs and procedure to be adopted for post-exposure prophylaxis. RESULTS: Fourteen respondents (20%) were aware of the true risk of transmission. About one-third identified all high risk fluids correctly. Fifty-five respondents (78%) correctly stated that washing the site with soap and water was the initial measure, but less than a third knew whom to contact immediately after a needlestick injury. Though 45 respondents (64%) correctly stated that prophylaxis should be initiated within 1 hour of injury, none knew exactly which drugs were to be used. Thirty respondents (42%) were aware of the use of zidovudine but none were aware of the second or third drugs used for post-exposure prophylaxis. Only 4 respondents (6%) knew the correct duration of post-exposure prophylaxis. Five respondents (7%) knew that the drugs were available in medical stores and 7 knew the approximate cost of therapy. CONCLUSION: There is surprisingly poor knowledge of post-exposure prophylaxis against HIV. Ongoing awareness and training programmes are necessary to improve the same.

Cardiomediastinal tamponade and shock following three-stage transthoracic oesophagectomy.

Massive gastric tube dilatation causing cardiomediastinal tamponade is an unusual cause of obstructive shock after transthoracic oesophagectomy. A 55-year-old female was operated for total transthoracic oesophagectomy. Twelve hours after the surgery, she developed hypotension and raised central venous pressure unresponsive to fluid infusion and ionotropes. X-ray chest showed a massively dilated stomach, which was causing intrathoracic tamponade. Suction applied to the nasogastric tube led to aspiration of 150-200 ml of fluid and a large volume of air, which led to resolution of the haemodynamic instability. A simple manoeuvre like nasogastric suction in postoperative case of oesophagectomy can serve as a diagnostic as well as therapeutic tool. It must be performed before resorting to invasive and expensive examination or intervention.