Liver injury in Siriraj Hospital.

Background : Liver injury is a challenging intraabdominal injury with a high morbidity and mortality rate. We describe details of this interesting injury that was treated at Siriraj Hospital. Objective : To review mechanism of injury, severity of injury, treatment and mortality rate of liver injury at Siriraj Hospital. Methods : A retrospective study of liver injuries that occurred during May 1997 and March 2000 was done. Analysis of the data was made be a simple statistical method using mean and percentage. Results : Sixty-eight patients with liver injury who were admitted of and had completely recorded data from Siriraj Hospital were analyzed, including 56 males and 12 females. Mean age was 28.6 yr. (4.60). Regarding mechanism of injury,39 (57.4%) were affected from blunt ingury,26 (38.2%) were had stab wounds, and 3 (4.4%) had gunshot wounds. Fifty-five patents with liver injury (80.9%) had at least one site of other organ injury (77 sites in 55 patents). The most common other injury was chest in injury (28 sites including 13 sites of diaphragmatic injury) This study included 23 (33.8%), 24 (35.3%), 18 (26.5%), 1 (1.5%) and2 (2.9%) patients who were classified as grade I, II, III, IV and V of liver injury respectively. Surgery was performed in 66 patients whereas only 2 patients were observed and CT scanning for successful nonoperative management. Cauterizaton and suture of injured liver were the two most common procedures that were performed in our hospital, 52.9% and 23.5% of cases respective, had they were limited to only grade I, II and III liver injury. The overall mortality rate was 11.8%, with only 8.5% being grade I and II but markedly increased to 19% in grades III, IV and V. Conclusion : More than half of the liver injuries in this study were from blunt injury, the other 42.6% were from penetrating injury. There was a high rate of associated injury. Most hepatic injuries were minor (69.2%) In this study surgery was per formed in 66 patients whereas only 2 patients were observed. Nonoperative management was not widely used, In case of an operation, one or more surgical procedures were used, including electrocautery, suturing of liver parenchyma or vessels, packing of the liver ligating the hepatic artery and repairing the vena cava. In complex hepatic injury, we prefer the conventional method by perihepatic packing. The overall mortality rate was 11.8%

Risk factors of pressure uIcers in hospitalized elderly.

This study is a hospital based concurrent cohort study with the objectives of investigating the risk factors and the predictive level of the risk factors of pressure ulcers in hospitalized elderly The study was conducted between January 9th and March 12th 2002, in the medical, surgical, and orthopedic wards of Pranangklao Hospital, a 430-bed tertiary hospitsl under the Ministry of Public Health in Nonthaburi Province. The participants in this study were 117 hospitalized elderly patients who were 60 years or older, did not have pressure ulcers on admission, and were hospitalized for at least four days. Data were collected by the researcher and the research assistant who achieved an inter-rater reliability for pressure ulcer risk assessment and skin assessment on the research instrument of 0.905 and 0.954 resprctively. Pressure ulcer risk assessment and skin assessment were conducted daily by utilizing the Braden pressure ulcer risk assessment scale and the Bergstrom’s skin assessment scale throughout the study period. Logistic regres- sion analysis was employrd to analyze the data. The results of the study revealed the greatest frequency of pressure ulcers was found in those aged 70 to 79 years old (41%) and had neurological or spinal problems (30.8%). The assessment of elderly patients’ risk of pressure ulcers on admission correctly predicted 71.8% of pressure ulces. Of the elderly patients who were predicted to have pressure ulcers, 28.2% developed this complication during the hospitalization period. Most pressure ulcers occurred on the second day after admission. Of the elderly who were predicted not to develop this complication, 93.6% were free from pressure ulcers. An increase in friction and shearing (OR=4.592, 95% CI=1.531-13.770) was the risk factor that had the most influence among the participants, where the second most important risk factor was an increase in core temperature (OR=2.760, 95%CI=1.105-6.891). This study indicates the need for pressure ulcer risk assessment at the time of admission and a need for a pressure ulcer education program for the elderly or their caregivers and for all health care providers. In addition, this study also reveals the need for proper management of these elderly patients who are prone to develop pressure ulcers at the time of admission, especially among those who have increases in friction and shear-ing forces and an increase in core temperature.

The study of pressure ulcer risk among activity limited patients.

This study is aims to study the risk levels and the occurrence of pressure ulcers in hospitalized patients with limited activity. The study was conducted in a medical setting at Siriraj Hospital from January 15th to May 31st, 2001. One Hundred patients were enrolled into the study. The data collection procedure included the completion of Braden's pressure ulcer risk assessment form and Bergstrom's skin assessment form on day of admission and this continued throughout the study. The results showed that 28 % of the patients had no risk of pressure ulcer development, while 25 % showed a low risk level, 22 % showed a moderate risk level, and 25 % showed a high risk level. The incidence of pressure ulcer was 40 %. Sixty-five % of those who developed pressure ulcers were age 60 and over and 83 % of them had chronic illnesses such as diabetes or hypertension before hospital admission. There were 96 ulcers found in 40 patients. Of these ulcers, 59 ulcers were stage I while 37 ulcers were stage II. The ulcers most frequently occurred during the first week of hospitalization. The average length of hospital stay of patients who had a pressure ulcer was 14 days while in those who did not have pressure ulcer the stay was only 10 days. The occurrence of pressure ulcers on hospitalization and the number of patients at risk of pressure ulcer development highlight the magnitude of the problem. The results support the need for risk assessment and skin assessment at the time of admission and periodically throughout the hospital stay and could contribute to establishment of a pressure ulcer risk assessment tool as a guideline in nursing practice for predicting and preventing pressure ulcers.

Epidemiological pattern of renal injuries and their evaluation and management.

To determine the epidemiological pattern of renal injuries and to define appropriate methods for their evaluation and management. Material and Methods: We reviewed retrospectively the medical records of 65 patients who were admitted to Siriraj Hospital, between September 1996 and February 2000. Details of patients, mechanism of injury, chief complaint, hematuria, associated injuries, radiographic assessment, management and complications of renal injury were analysed. Results: The study group consisted of 54 men and 11 women with a mean age of 31 years. Blunt and penetrating trauma occurred in 55 (85%) and 10 (15%) patients, respectively. Hematuria was present in 62 patients (95%) and absent in 3 patients (5%). Associated organ injuries were present in 37 patients (57%) and mostly occurred in blunt trauma patients. Chest injuries were the most common cause of associated injuries. Associated abdominal injuries in 17 patients (26%) involved primarily the liver and spleen. In hemodynamically stable patients, preoperative staging was performed in 47 patients (72.3%) with an intravenous pyelogram (IVP). Of 55 patients with blunt renal injuries, 32 (58%) were managed nonoperatively and 23 (42%) underwent exploratory laparotomy. In patient with blunt trauma requiring laparotomy, 6 (26%) underwent renal exploration while the remaining 17 (74%) were treated with expec-tant management and 3 (17.6%) of them had renal complications. Nine out of 10 penetrating trauma patients required laparotomy with renal exploration, but none of them had renal complications. Conclusion: In the evaluation of renal injuries and the accurate staging of these, it is important to define the full extent of the injury in order to decide on the most appropriate management. This will avoid unnecessary surgery in patients with minor injuries and these with limited major injuries, and will avoid the risk of secondary surgery, renal loss and other complications in patients with extensive injuries treated by operation.

Prophylactic antibiotic in minor traumatic wound: Is it worth.

Antibiotics in minor traumatic wounds may not be useful if the wounds are not severely contaminated and received appropriate management since the chance of infection is usually low. Our objective is to determine the value of antibiotics in minor traumatic wounds. A randomized control trial was done in 166 patients (123 males, 43 females), aged between 6 and 60 years, with minor traumatic wounds. Most wounds were located on head and extremity regions. Cultures were done before suturing in all wounds. The wounds were cleaned and sutured as usual, then divided into two groups, group B treated with antibiotics for at least 3 days, group A no antibiotics was used. Antibiotics were given in 83 wounds. One hundred wounds were completely followed up, 50 with oral antibiotic treatment (penicillin v, cloxacillin or erythromycin). Infection rates of those with and without antibiotic treatment were compared using Chi-square test. Initial cultures showed 91 positive wound cultures (54.6%). Staphylococcus coagulase negative was the major organism (69.2%) found. Four wounds were infected though oral antibiotics were given (group B), where as in the non-antibiotic group(group A) 2 wounds were infected. Comparison with Chi-square test showed no statistical significant difference (p>0.05). We conclude that usage of antibiotics in minor traumatic wound does not reduce wound infection rate. Prophylactic antibiotic in minor traumatic wound should be limited because the incidence of infection is too low to justify the expense and risk of antibiotic administration. Wound debridement and cleansing are more advantageous than antibiotic alone.

Measurement of Intra-abdomonal Pressutre (IAP) inn trauma patients.

To study the measurement of intra-abdominal pressure by urinary catheter, we use Y glass tube connected with Foley catheter. The bladder and catheter was filled with 70 ml. NSS. The height of NSS from pubic symphysis was interpreted as intra-abdominal pressure (IAP). We measured IAP of 20 trauma patients with normal abdominal condition. The average IAP was 3.9 cm H2O. The clinical consequences of elevated IAP will be in the future study.

Study of hand injury registry in siriraj hospital during 1993-1995.

Introduction: Trauma is one of the major causes of death among Thai people. In that respect, hand injuries have become an interesting issue during the past three years. Method: Patients with hand injuries (code S60-S69 in ICD 10) were selected from the Siriraj Truama Registry during 1993-1995 and than analyzed with regard to age, occupation, causes of accident and other data. Result: During the part three years, (1993-1995) 13,027 hand-injury patients were serviced by the unit. These included: 9,716 males and 3,311 females, with a ratio of male of 2.9:1. The greatest number of injuries was seen in patients aged 11 to 40 years, two of whom died from causes other than hand injury. Workers, laborers and students were the most common occupations. The sites of the accidents were homes, followed by public places and roads. Most patients arrived at the hospital within 30 minutes of the accident. Lacerated wounds were found to account for 54.4 percent (7,167 patients) of the total cases. Sharp objects and machinery were found to be the main causes of injury (3,397 patients), followed by traffic accidents (2,994 patients). In the traffic accident groups, injuries related to motorcycle accidents were found in 2,472 patients (82.6 percent). Injuries in this group were unintentional. Conclusion: From the incidence of hand injuries, it can be seen that this is the most common type of injury to occur in various types of accidents. Therefore the results of this study can be modified to formulate a prevention program, e.g., training for machine workers before they begin employment. In addition, first aid for hand injuries should be taught, including how to stop bleeding.

Peripherally inserted centeal catheter line for central access, experience in Siriraj Hospital.

Introduction : Central access is important for parenteral nutrition, chemotherapy, some kinds of drugs. Selection of catheter and method of access are also important to ensure that Patients are safe from complications. PICC line (Peripherally Inserted Central Catheter) is made from polyurethane, and is designed for percutaneous insertion through superior vena cava. Methods : We have studied and used the PICC line with patients who need parenteral nutrition or long-term intravenous fluid application in Siriraj Hospital since November 1995. Results : A total of 35 patients received a PICC line, 23 males and 12 females. The average age was 53.6 years. Indication for central access was parenteral nutrition (28 patients) and for longterm IV fluid (7 patients). We used the pericubital fossa vein in 32 patients and the femoral vein in three patients. The methods of insertion were percutaneous puncture in 24 patients, direct puncture in one patient, and venesection with 10 patients. The PICC line can be use for a maximum of 40 days, but 18.5 days on average. At the time of this report, three patients were continuing the use of PICC lines. We found only one accidenetal arterial puncture at the cubital fossa, and no other serious complication. Reasons for removal were cure in 13 patients, clotting in three patients, phleditis in 10 patients, accidental removal in two patients and death from other problems in four patients, but no cases of infection at the tip of the catheter. With regard to nursing care, a PICC line should be filled with fluid at all times, and care should be taken not to draw the blood back and that there is no unnecarrary flexing of the elbow. Conclusion : From this preliminary study, we have shown that a PICC line, made from polyurethane, can be used with patients who need parenteral nutrition, intravenous drugs, or long-term IV fluid for at least 17 days without any problems. The method of insertion for a PICC line is more superior than the conventional method in the view of low risk of anatomical complication.

Burn and cardiac infection: A case report.

A 12-year old child was flame burned 64% of body surface area. During the treatment at Bun Unit, Siriraj Hospital, there were some complications, hyponatremia, water intoxication and pneumothorax. He died on day 16th after admission. From the autopsy, we found pyopericardium (500 ml). Retrospective study was done, cardiac shadow in his chest 7-day seemed to be enlarged. Review of previous studies was performed.

Feeding pharyngostomy in traumatic patients.

The study of enteral feeding via pharyngostomy was performed. Five patients who had head injury and maxillofacial injury, required long term of enteral nutrition. The surgical technique of pharyngostomy was studied. Operative time was average 30 min. The pharyngostomy tube was retained for 1 week to 6 months without complication. Changing the tube was difficult for medical personals, but mouth hygine care for these patients was easy.