Outcome of patients with acute pancreatitis requiring intensive care admission: a retrospective study from a tertiary care center of Pakistan

Background and Objective: Acute pancreatitis [AP] is an inflammatory disease. Patients presenting with severe disease may require intensive care unit [ICU] admission. Factors predicting mortality and morbidity need to be identified for improving outcome. The objective of this study was to see the outcome of these patient presented to single center over a period of ten years. The secondary objective was to identify the factors responsible for adverse outcome

Methods: The medical records of adult patients from year 2006 to 2016 requiring ICU admission for AP were reviewed retrospectively. The data was collected on the predesigned Performa for patient's demographic, etiology, severity of disease and reason of ICU referral. Besides this physiological and biochemical parameters at time of arrival in ICU were also recorded. Management aspects related to disease course including the ICU related complications were also recorded. The outcome was predicted on the basis of mortality and length of stay [LOS] in ICU and hospital

Results: Total 85 patients were identified of having AP requiring ICU admission. 56 percent of these cases were referred from emergency. Mean Ranson score [RS] was 2.6 and 2.7, at and after 48 hours of admission. Necrosis was present in 48 percent of cases. Mean APACHE-II score was 23. Sepsis was the commonest complication in ICU. The median LOS in ICU and hospital was six and 12 days respectively. The overall hospital mortality was 52 percent, out of which 82 percent died in ICU. RS at admission and APACHE were correlated well with outcome. Similarly associations of factors like need of vasopressors, ARDS, pneumonia, sepsis and AKI requiring intervention were also related to mortality. Likewise development of necrosis or intra-abdominal hypertension showed increased mortality. Biochemical parameters serum blood urea nitrogen [BUN], PH and serum glutamic-oxaloacetic transaminase were also directly linked to adverse outcome

Conclusion: AP patients requiring ICU admission represent severe form of disease. There is a need to develop protocol based care, which should be started immediately after hospital admission. This should have special focus on fluid resuscitation and nutritional therapy. Role of simple bed site parameters like BUN needs to be evaluated

Cumulative fluid balance as a major predictor of clinical outcome in patients admitted to surgical intensive care unit

Objective: Fluid balance remains a highly controversial topic in the critical care field, and there is no consensus about the amount of fluid required by critically ill patients. In this study, the objective was to find the relationship between fluid balance and in hospital mortality in critically ill surgical patients. Our secondary objective was to identify the association between use of colloid and acute kidney injury and use of blood products and development of ARDS

Study Design: The medical records of adult patients admitted to a surgical intensive care unit [ICU] >48 hours, from Aug 2014 to Feb 2016 [18 months] were reviewed retrospectively

Place and Duration of Study: The study was conducted in the surgical intensive care unit of a tertiary care hospital. Medical records of 18 months from Aug 2014 to Feb 2016 were reviewed

Material and Methods: Sampling technique was convenience sampling. A total of 100 patients met the inclusion criteria. Abstracted data of patients admitted to surgical intensive care included body mass index, Acute physiology and chronic health evaluation [APACHE]-II scores, fluid balance during first 5 days of ICU stay, length of ICU stay and in hospital mortality. All statistical analysis was performed using statistical packages for social science version 19 [SPSS Inc., Chicago, IL]. Frequency and percentage were computed for qualitative observation and were analyze by chi-square test. Mean [+/-Standard deviation] and median [IQR] were presented for quantitative variables and analyze by independent sample t-test and Mann-Whitney test. Normality of quantitative data was also be checked by Kolmogorov-Smirnov test. Statistically significant results had a p-value less than 0.05

Results: A total of 100 patients fulfilled the inclusion criteria. The average age of patients was 44.08 +/- 18.14 [years], BMI [kg/m2] 27.84 +/- 5.56 and APACHE II Score 17.28 +/- 6.96. The in hospital mortality was 26 percent, median length of ICU and hospital stay was 6.91 +/- 4.07 and 14.74 +/- 7.78 days. In non-survivors fluid balance was significantly positive on 2nd, 3rd, 4th and 5th day of SICU [p-value: 0.005, 0.0005 and 0.024], APACHE II score [p<0.02], incidence of acute kidney injury [p<0.004] and mechanical ventilation days were significantly more. There was association between the use of colloid and acute kidney injury [p<0.014]. Use of blood products was significantly associated [p<0.03] with development of ARDS

Conclusion: Positive fluid balance, high APACHE II score and acute kidney injury is significantly associated with hospital mortality of non-cardiac surgical ICU patients

Awake fiberoptic intubation in a patient with known difficult airway due to huge thyroid goiter

Thyroid enlargement or goiter has been considered a risk factor for difficulty in airway management during anaesthesia and surgery. Moderate to huge size along with retro-sternal extension makes it an anticipated difficult airway scenario. In this report, we present a case of huge goiter with compression symptoms and patient cannot be intubated by conventional direct laryngoscopy at a district hospital a week ago. CT scan revealed extension of mass into superior mediastinum compressing right brachiocephalic vein and superior vena cava. We successfully performed awake fiberoptic intubation with local/topical anaesthesia of airway. We have discussed the significance of careful approach, planning and preparation in the management of such a case

Postoperative pain assessment using four behavioral scales in Pakistani children undergoing elective surgery

Several measurement tools have been used for assessment of postoperative pain in pediatric patients. Self-report methods have limitations in younger children and parent, nurse or physician assessment can be used as a surrogate measure. These tools should be tested in different cultures as pain can be influenced by sociocultural factors. The objective was to assess the inter-rater agreement on four different behavioral pain assessment scales in our local population. This prospective, descriptive, observational study was conducted in Pakistan. American Society of Anesthesiologists I and II children, 3-7 years of age, undergoing elective surgery were enrolled. Four pain assessment scales were used, Children's Hospital of Eastern Ontario Pain Scale [CHEOPS], Toddler Preschool Postoperative Pain Scale [TPPPS], objective pain scale [OPS], and Face, Legs, Activity, Cry, Consolability [FLACC]. After 15 and 60 min of arrival in the postanesthesia care unit [PACU], each child evaluated his/her postoperative pain by self-reporting and was also independently assessed by the PACU nurse, PACU anesthetist and the parent. The sensitivity and specificity of the responses of the four pain assessment scales were compared to the response of the child. At 15 min, sensitivity and specificity were >60% for doctors and nurses on FLACC, OPS, and CHEOPS scales and for FLACC and CHEOPS scale for the parents. Parents showed poor agreement on OPS and TPPS. At 60 min, sensitivity was poor on the OPS scale by all three observers. Nurses showed a lower specificity on FLACC tool. Parents had poor specificity on CHEOPS and rate of false negatives was high with TPPS. We recommend the use of FLACC scale for assessment by parents, nurses, and doctors in Pakistani children aged between 3 and 7

LASER treatment of laryngeal papillomatosis in a young child: anaesthetic and surgical management

The authors report the case of a 4-year boy who required anaesthetic and surgical care during LASER excision of laryngeal papillomatosis. He presented with hoarseness and stridor and underwent emergency tracheostomy after confirmation of laryngeal papillomas on CT scan. He required LASER treatment under general anaesthesia with a requirement of paediatric LASER-safe endotracheal tube but unfortunately, this was not available in the country. Balanced anaesthesia technique using inhalational anaesthetic, muscle relaxant and narcotic is used with modifications. After three successful surgical sessions, the airway became patent and tracheostomy was de-cannulated. The perioperative issues surrounding this process are discussed including anaesthetic induction in the patient with a compromised airway, maintenance anaesthetic techniques, methods used for ventilation during LASER surgery of the upper airway, surgical implications and hazards of LASER to the operating room personnel

Airway management in a patient with severe Ankylosing Spondylitis causing Bamboo Spine: use of Aintree Intubation Catheter

Management of a case of ankylosing spondylitis can be very challenging as the airway and the central neuraxial blockade are extremely difficult to handle. Fiberoptic intubation may lead to predictable success in the face of difficult airway. We are presenting a new technique of fiberoptic intubation in a young patient, suffering from severe ankylosing spondylitis, came for total hip replacement surgery. There was anticipated difficult airway due to severe limitation in neck movement and it was successfully managed by using Aintree Intubation Catheter [AIC] with intubating fiberoptic bronchoscope

Fiberoptic intubation in a paediatric patient with severe temporomandibular joint [TMJ] ankylosis

Craniofacial abnormalities are associated with mandibular hypoplasia, reduced mandibular space with overcrowding of soft tissues and maxillary hypoplasia. Decreased mouth opening and limitation in jaw protrusion are independent predictors of difficult airway in such patients. The relative difficult problem becomes even graver in the paediatric age group because of their small mouth opening and un-cooperativeness. A child with severe temporomandibular joint [TMJ] ankylosis presented with negligible mouth opening and required surgical correction under general anaesthesia. Successful intubation was performed with endotracheal tube size 5.5 mm using an adult 4.3 mm fiberoptic bronchoscope under inhalational as well as topical anaesthesia

Anaesthetic management of abdominal hysterectomy in patient with congenital sinus node dysfunction

A 45 years old woman having dysfunctional uterine bleeding was scheduled for total abdominal hysterectomy with bilateral salpingo-oophorectomy under general anaesthesia. On pre-operative anaesthesia assessment, she was found to have junctional rhythm at rate of 44 beats/minute with bigeminies and pre-mature ventricular contractions on ECG. On further evaluation, she was diagnosed as having congenital sinus node dysfunction on the basis of 24 hours Holter monitoring. She was asymptomatic, no prior comorbidity and belonged to functional class one. General anaesthesia was successfully managed by vigilance, invasive monitoring, standby transcutaneous and transvenous pacemakers; use of cardiostable and vagolytic anaesthetic agents like Etomidate, Atracurium and Pethidine during the procedure and for postoperative pain management. Transcutaneous external pacing pads were placed just after induction of anaesthesia, their functional capability was confirmed and was ready for use if needed. The transcutaneous and transvenous pacemakers were on backup and both were not required. Patient was successfully managed and was discharged home on third postoperative day with uneventful hospital course. The elective pacemaker implantation was therefore not required

Comparison between tramadol and pethidine in patien controlled intravenous analgesia

To compare the efficacy and side effects related to Tramadol with Pethidine in patient controlled intravenous analgesia [PCIA] after total abdominal hysterectomies. A total of 60 patients were randomized to receive either Tramadol or Pethidine by PCIA [30 in each group] after total abdominal hysterectomy. Pain assessments were recorded one hour after starting the PCIA and then at 6, 12, and 24 hours by using visual analogue scale [VAS]. Nausea vomiting score and sedation score were also recorded. Good attempts, total attempts and total drug consumption was noted from PCIA pump at the end of the study period. The analgesia achieved in Tramadol group was comparable to Pethidine. The incidence of nausea and vomiting was similar in both groups. Tramadol causes significantly less sedation than Pethidine [p < 0.05]. Mean drug consumption, total attempts and good attempts were also significantly less in Tramadol group than Pethidine group [p < 0.05]. Tramadol produces equivalent analgesia and less sedation and can be used as an alternative to Pethidine in Patient Controlled Intravenous Analgesia for postoperative pain relief after Total Abdominal Hysterectomy [TAH]