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ERAS has been responsible for reducing surgical stress, maintaining postoperative physiological function, and for enhancing mobilization after surgery. It has been ultimately shown to reduce the rates of morbidity, hastening recovery, and reducing the length of hospital stay. The objective of this study was to compare the outcome between the implementation of enhanced recovery after surgery program vs. traditional care in elective abdominal surgeries. METHODSThis retrospective study was carried out in the General Surgery Department of Government Medical College, Kottayam, Kerala. This is a tertiary care centre that caters to the needs of nearly five districts in the state. The hospital has excellent critical care and surgical facilities. Patients were grouped as ERAS and Non-ERAS. 78 patients were included in each group. A standard questionnaire was formulated. The clinical outcomes, functional recovery, and patient experience in ERAS and conventional methods of recovery after surgery were analyzed and compared. RESULTSDuration of hospital stay, complications, and costs incurred were found to be almost 60 % less as compared to the non-ERAS group and patient satisfaction was high in the ERAS group. By using ERAS, we have been able to reduce the duration of hospital stay by more than 30 % and the post-operative complications by up to 50 %. CONCLUSIONSThe ERAS programme has definite advantage over traditional methods in terms of hospital stay, treatment cost, complications, readmission rates and overall patient satisfaction. We have to analyse the avoidable factors leading to substandard care or any missed opportunities. Patient education must also be given utmost importance.
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Dengue fever is endemic India and the prevalence of dengue is on the rise owing to various social and economic factors. Prevalence of asymptomatic dengue infection varies widely from less than 1 % to 80 % in India. Transfusion transmissible dengue has been reported in different parts of the word. Prevalence of subclinical dengue among blood donor poses a threat to the blood supply leading to transfusion transmissible dengue. We wanted to estimate the prevalence of IgG antibodies for Dengue in the blood donor population. METHODSSix hundred and eight whole blood donors were included in the study during the period January 2017 to October 2018. Donor registration and education was done as per the national guidelines. Donors who gave a history of previous dengue or symptoms consistent with dengue were excluded from the study. Serum samples from whole blood donors were tested for IgG antibodies using ELISA technology. RESULTSOf the total of 608 donors, 602 were male donors and 55 % of the donors were in the age group 21 - 30 years. Majority (69 %) of the donors were from urban locations. Anti IgG antibodies for dengue were present in 4.14 % of donors of which 38 % of donors were in the age group 31 - 40 years. Three hundred and eighty-four donors revealed history of fever, myalgia and headache in the past one year. No statistical significance was found between fever, myalgia and the presence of IgG anti-dengue antibodies. CONCLUSIONSThe subclinical or asymptomatic prevalence of dengue infection is low when compared to other studies in other parts of the country. Enquiring into donor history for history of dengue or symptoms of dengue and deferring such donors for a recommended period will prevent transfusion transmissible dengue.
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Background: Surgical site infections are one of the most common complications in the postoperative period leading to increased morbidity, prolonged hospital stay and reduced quality of life. The present study aims to identify the incidence of surgical site infection (SSI), risk factors, causative organisms, and their sensitivity patterns in patients who have undergone elective abdominal surgeries.Methods: A prospective study containing 200 patients who have undergone elective abdominal surgeries from May 2018 to January 2020 were evaluated. A thorough history was taken in all the patients. A detailed clinical examination and routine investigations were done. Parameters such as body mass index (BMI), diabetic status, type of surgery, wound grading, culture, and sensitivity patterns were considered. The patients underwent treatment based on their investigatory reports.Results: In the present study, 54 patients developed surgical site infection, and among them, 22 are diabetics. Only ten patients with normal BMI developed SSI, whereas the other 44 patients who developed SSI had abnormal BMI. The incidence of SSI was higher in clean-contaminated surgeries comprising up to 89% of cases. Staphylococcus aureus was the most commonly isolated organism, and cefoperazone plus sulbactam was the most sensitive on antibiogram.Conclusions: The surgical site infections are on rising trend due to the emergence of antibiotic-resistant microorganisms. Treatment of the underlying risk factors, regular wound dressings, and antibiotics, according to sensitivity patterns, are the mainstay.
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Background: Surgical team always tries to provide consistently low incidence of major complications for patient undergoing any operation. Clavien-Dindo (CD) classification is the simplest way of reporting all complications. The main aim of this study was to test the usefulness of Clavien-Dindo classification in patients undergoing the abdominal surgery. In this study Clavien-Dindo classification has been used for assessment of postsurgical complications after major abdominal surgery.Methods: A total of 50 patients admitted to surgical wards for major abdominal surgery were evaluated through history, co-morbid condition and thorough clinical examination based on inclusion and exclusion criteria along with necessary investigations. Post-operative complications and management were recorded, and then postsurgical complication was classified based on Clavien-Dindo classification and assessed.Results: Most of the patients who developed complications were in the age group of 40-50 years. Most of the patients (32%) belonged to grade 2 complications. Serum creatinine, blood urea and post-operative stay were found to have direct relation with Clavien-Dindo grade of complications.Conclusions: The Clavien-Dindo classification represents an objective and simple way of reporting all complications in patients undergoing major abdominal surgeries and comparing the various complications between different surgeries. However, a definite statement on the clinical value of this classification system is not yet possible due to the small case number in this study, but the promising results should encourage further evaluation in larger cohort with the goal to possibly establish its validity as a standard clinical practice.
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Ropivacaine, a long acting amide local anaesthetic, has reduced potential for neurotoxicity and cardiotoxicity and is considered to block sensory nerves to a greater degree than motor nerves. In today’s world, faster recovery along with minimal side effects and early ambulation after surgeries under spinal anaesthesia are very important. So, this prospective randomized study was aimed at evaluating and comparing the efficacy and safety of intrathecally injected isobaric ropivacaine and intrathecally injected hyperbaric bupivacaine in patients posted for lower abdominal surgeries under spinal anaesthesia.METHODS90 patients belonging to ASA physical status I & II scheduled for lower abdomen surgeries were randomly selected for the study and were divided into two groups of 45 each. Group B received 3 ml of 0.5% hyperbaric (15 mg) bupivacaine intrathecally. Group R received 3 ml of 0.75% isobaric (22.5 mg) ropivacaine intrathecally. Onset and extent of sensory block, onset and duration of motor block, maximum height of sensory block, duration of analgesia, hemodynamic parameters and adverse effects if any were studied. SPSS 20.0 and GraphPad Prism 6.0 were used for the analysis of the data.RESULTSThe mean time for onset of sensory block was significantly faster in group B as compared to group R (8.28±2.2 min v/s 7.98±2.2 min). There was no significant difference between the groups regarding the time for two segment regression. Mean time of onset of motor block was significantly faster in group B. The mean duration of motor blockade was 146.89±14.11 min in group R and 208.91±14.62 min in group B. The mean duration of analgesia was comparable in both the groups. Hemodynamic parameters and side effects were comparable in both the groups.CONCLUSIONS0.75% isobaric ropivacaine provided similar duration of analgesia with a shorter duration of motor block as compared to hyperbaric 0.5% bupivacaine and it also provided adequate level of sensory block for the surgery with minimal intraoperative and postoperative side effects and stable haemodynamics throughout the surgery.
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Background: Surgical Site Infections (SSI) afterelective/emergency laparotomy contributes topostoperative morbidity, mortality and resourceutilization. Risk factors related to abdominal SSIs arewell known. Nevertheless, National data guide effortsto improve efficiency, which cannot identify specificorganizational risk factors. Aim and Objectives: Todescribe the prevalence and risk factors associated withSSI in patients undergoing laparotomy. Material andMethods: Descriptive, observational study of elective/emergency laparotomy patients uses institutional datafrom 2017-2019. Univariate and Multivariable logisticregression identified risk factors associated with SSIdevelopment. Results: Of 393 patients studied. 88developed SSI (superficial 19.60%, deep 2.30%, organspace 0.50%), age (40-60 years), males, Body MassIndex (BMI) >25, smoking, diabetes, alcohol, higherwound class, low hematocrit, low serum albumin,Longer duration of surgery were associated withincreased SSI rate. Associated co-morbidities, Lowhematocrit and higher duration of surgery weresignificant independent risk factors (p<0.05).Conclusion: Institutional SSI modeling shows thatmany previously suggested nationally defined riskfactors do not contribute to SSI, at our institution.Identifying SSI's institutional contextual predictors,rather than relying on external data assumptions, is avital endeavor to promote quality improvements andmaximize the value of quality investments.
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Epidural analgesia has been the gold standard, preferred technique for providing postoperative analgesia in lower abdominal, lower limb, pelvic and vascular surgeries. Combination of local anaesthetic agents when used along with opioids, as an adjuvant in epidural analgesia, was found to be effective and synergistic. Ropivacaine is associated with less central nervous system toxicity and cardiotoxicity, and produces less motor blockade. Nalbuphine is an opioid with mixed kappa (κ) agonist and mu (µ) antagonistic properties, when mixed with other opioids, attenuates the µ opioid effect and enhances the κ opioid effect. We wanted to compare the post-surgical analgesic efficacy of epidural nalbuphine (10 mg) when added as an adjuvant to epidural ropivacaine (0.2%-9 ml) in patients undergoing lower abdominal surgeries. Primary objective was to compare the duration of postoperative analgesia and number of rescue analgesics required in 24 hours. Secondary objectives were to compare postoperative haemodynamic variation, quality of analgesia, Visual Analogue Score and side effects if any in both the groups.METHODSIt was prospective observational study conducted after obtaining ethical committee clearance. Sixty patients of ASA class I & II, fulfilling inclusion criteria posted for elective lower abdominal surgeries preferably abdominal hysterectomies divided into two groups, each comprising of 30 patients; group R- Ropivacaine- 0.2% - 9 ml with 1 ml normal saline and group R+N - 0.2%- 9 ml with nalbuphine 1 ml - 10 mg, under spinal anaesthesia with epidural catheter insertion. Parameters like duration of analgesia, number of rescue analgesia, quality of analgesia by patient rated quality of pain management, haemodynamic variation was assessed. Assessment of pain was done by VAS scale, side effects like sedation was assessed by modified Ramsay sedation scale.RESULTSNo demographic variation was found in any group. Mean duration of analgesia was found more in group R+N. Number of rescue analgesia was reduced in group R+N with improved quality of analgesia which was statistically significant. Mean HR was significant in group R+N. No change was noted in SBP, RR, SpO2 in either group. DBP and MAP showed statistically significant difference at 30, 60 min and 15, 30, 60 min respectively. None of the patients in either group had sedation; one episode of vomiting was noted in group R+N with statistically non-significant results.
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Background: Surgical site infection (SSI) is defined as those infections presenting up to 30 days after a surgical procedure if no prosthetic is placed and up to 1 year if prosthesis is implanted in the patient. SSI contributes to increasing morbidity, mortality and cost related to surgeries and continues to be a major problem even in tertiary care modern hospitals following standard protocols of peri operative preparation and antibiotics prophylaxis. Objective of this study was to study and analyse the pattern of pathogen causing SSI in abdominal surgeries in a tertiary care hospital.Methods: Descriptive study on patients undergoing abdominal surgery in the department of surgery. Patients satisfying inclusion criteria will be assessed on 2nd postoperative day and then daily for surgical site pain, redness, warmth, discharge and swelling of surgical site till the patient gets discharged and followed up after discharge every 7 days up to 1 month. If SSI is detected, swab will be taken and sent for culture and sensitivity.Results: At the end of the study, after analysing the pattern of pathogens and antibiotic susceptibility, we intend to conclude the safe usage of empirical antibiotic prophylaxis to prevent the incidence of SSI’s in our hospital.Conclusions: Appropriate prophylactic therapy for any open abdomen surgeries reduces incidence of surgical site infection thereby reducing morbidity, mortality and cost burden in patients undergoing abdominal surgeries.
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Background: An evaluation of intrathecal hyperbaric ropivacaine without adjuvant and with adjuvant magnesium for lower abdominal surgeries.Methods: This was a prospective, randomized, double-blind study conducted among the patients aged 18 to 60 years planned for lower abdomen surgeries under spinal anaesthesia and ASA grade I or II. Patients were randomly allocated to two groups (30 in each): ropivacaine Group (R group): spinal anesthesia with 3ml of 0.6% hyperbaric ropivacaine (18mg )+ 0.5ml NS. hyperbaric ropivacaine + Magnesium Group (R+M group ): spinal anesthesia with 3ml of 0.6% hyperbaric ropivacaine (18mg) + 0.5ml magnesium sulphate (50 mg). All the patients scheduled for operation were given oral tablets ranitidine 150 mg and Alprazolam 0.25mg in the night before surgery.Results: There was no significant difference in the basic characteristics between the groups. The mean HR, MAP and SpO2 in both the groups decreased over the periods as compared to baseline. However, the trend of HR over the periods remains similar in both R and R+M groups. The bromage levels were significantly (p=0.0001) higher among the patients of Group R compared with R+M. The 2 segment sensory regression (min), Sensory regression S2 (hr), motor recovery (hrs) and long term mobilization after spinal anesthesia were significantly (p=0.0001) lower among the patients of Group R compared with R+M. The complications were lower in Group R+M than R.Conclusions: Magnesium may be more suitable drug in surgeries in which muscle relaxation has greater value in lower abdominal surgeries.
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Background: Surgical care has a role in treating a broad spectrum of diseases in the alleviation of human suffering. Upper abdominal surgery included gastrectomy, pancreatectomy, hepatic resection, cholecystectomy and splenectomy. Maximal inspiratory pressure (Pimax) is an important indicator for assessing the strength of inspiratory muscles. Respiratory muscle training devices enhance respiratory muscle strength, endurance and exercise capacity. Pressure Threshold IMT devices are usually handheld devices with a spring load that is impeded with different intensities. Incentive Spirometer is a form of ventilatory training that emphasis sustained maximum inspiration. Therefore, the present study aims to assess the effect of Threshold Inspiratory Muscle Training versus Incentive spirometry in participants with upper abdominal surgeries. Materials and Methods: A prospective cross-sectional comparative study was done with 30 participants with upper abdominal surgeries in the age group of 20 to 65. On Day 1 and after 2 weeks the maximal inspiratory pressure was measured using Hand Held Pressure Manometer Device (Pimax). Group A participants received Threshold Inspiratory Muscle Training (IMT) and Group B participants received Incentive spirometry. The intervention was given for 5 days in a week for 2 weeks. The duration for each session was of 15-30 minutes which also includes rest periods. Data was analyzed using student Paired ‘t’ test and Unpaired ‘t’ test. Result: There was extremely significant difference (p<0.0001) in Maximal Inspiratory Pressure (Pimax) in both the groups but Group A showed slightly more improvement were Threshold Inspiratory Muscle Training (IMT) was given as an intervention after 2 weeks. Conclusion: The study shows extremely significant improvement in Maximal Inspiratory Pressure (PImax) in both the groups. This study concluded that Threshold IMT has more effect than Incentive Spirometry in participants with upper abdominal surgeries.
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Background: Bupivacaine when used alone produces analgesia for 2.5 to 3 hours, making it unsuitable in cases where the duration of surgery is longer and in cases which require further analgesia during post-operative period. Present study is intended to evaluate the effect of addition of intrathecal midazolam to bupivacaine to prolong the post-operative analgesia.Methods: Present clinical study was conducted in Kamineni Institute of Medical Sciences, Narketpally, Nalgonda District, Andhra Pradesh, India. After obtaining approval from institutional ethical committee, present clinical study was undertaken to evaluate the effects of addition of intrathecal midazolam to bupivacaine 0.5% (heavy). The study was conducted on 60 patients undergoing lower abdominal surgeries.Results: Mean onset of analgesia was 190.5 with SD 21.3 in group-C whereas in group-M, mean onset of analgesia was 185.3 with SD 26.81. Mean difference between the groups not showing statistical significance. In the present study the Maximum height of sensory blockade in control and midazolam group was T7 (T6-T8) compared to T7 (T6-T8) midazolam group. Mean duration of sensory blockade was 130.4 with SD 36.36 in group-C whereas in group-M, mean duration of sensory blockade was 191.9 with SD 36.4. Mean difference between the groups showing statistical significance. Mean duration of motor blockade was 176.3 with SD 23.7 in group-C whereas in group-M, mean duration of motor blockade was 208.1 with SD 18.21. Mean difference between the groups showing statistical significance.Conclusions: Midazolam is a useful adjuvant to bupivacaine in subarachnoid block. Intrathecal midazolam combined with intrathecal bupivacaine produces a longer and more effective anaesthesia and analgesia. It also prolongs post-operative analgesia without increasing adverse effects.
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Aim: To compare epidural 0.25% bupivacaine with 0.25% ropivacaine for post operative pain relief in cases of abdominal surgeries. Methods: 60 patients belonging to ASA physical status I & II of both sexes (each group 30 patients n=30) were randomly selected for the study. The sensory and motor block, analgesia, hemodynamic status, complications and need for rescue analgesia were compared in both the groups. Group B patients received 0.25% Bupivacaine as continuous epidural. Group R patients received 0.25% Ropivacaine as continuous epidural. Results: The sensory block was almost similar in both groups. No significant association is observed between the ASA class, age and sex of the groups (P>0.05). The difference in mean VAS between Bupivacaine and Ropivacaine was found to be statistically significant at 24 hours (P<0.05). Motor block was significantly more (17%) in group B than group R (3%) (P< 0.05). Haemodynamic changes did not differ in patients of either group (P >0.05). The rescue analgesia requirement were minimal in group R compared to group B. Complications were less in group R. Conclusion: Our study compared clinical efficacy of 0.25% Ropivacaine and 0.25%Bupivacaine in respect to analgesia, motor blockade, hemodynamic stability, requirement of rescue analgesia and complications. Sensory block and hemodynamic stability was comparable in the two groups. Ropivacaine group had significantly less motor block than Bupivacaine group.
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The gastro-omental artery is one of the branches of the common hepatic artery. Alterations in the embryonic development of the ventral splanchnic arteries can cause marked variations. A rare variant of the right gastro-omental artery was observed during dissection of a 50-year-old male cadaver. The occurrence of this variant has not been reported in the specialized literature. This case of a different origin of the gastro-omental artery is described in detail in order to provide information that may contribute to upper abdominal surgeries.
La arteria gastro-omental es una de las ramas de la arteria hepática común. Las alteraciones en el desarrollo embrionario de las arterias ventrales pueden causar variaciones marcadas. Se observó una variante rara de la arteria gastro-omental derecha durante la disección de un cadáver de un hombre de 50 años de edad. La presencia de esta variante no se ha informado en la literatura especializada. Este caso de origen diferente de la arteria gastro-omental se describe detalladamente con el fin de proporcionar información que pueda contribuir a la cirugía abdominal superior.
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Humans , Male , Middle Aged , Anatomic Variation , Arteries/anatomy & histology , Omentum/blood supply , Stomach/blood supply , CadaverABSTRACT
Objective: To evaluate the feasibility and character of laparoscopic cholecystectomy (LC) in patients with histories of multiple upper abdominal surgeries(≥2 ). Methods: We retrospectively analyzed the results of 21 LC operations in patients who had previously accepted two or three upper abdominal surgeries . Results: LC were successfully performed in 13 of all the patients (61.9%). The success rate of LC in patients with 2 upper abdominal surgeries was 66.7%. It was only 33.3% in patients with 3 upper abdominal surgeries. Eight of the patients (38.1%) were transformed to open cholecystectomies. The mean operation time was 72.1 minutes. The transform rate was higher, and the mean operation time was longer than those without previous upper abdominal surgery at the same period in our department. Conclusion: History of multiple upper abdominal surgeries should not be regarded as the contraindication to laparoscopic cholecystectomy. But these operations were difficult with higher transform rate and longer operation time.