Misplaced central venous catheter in carotid artery during emergency surgery for the total correction of tetralogy of fallot of an adolescent boy

Ultrasound-guided central venous cannulation is now considered as the standard of care, and this has largely replaced blind central venous cannulation using anatomical landmarks. We are reporting a case of inadvertent placement of central venous catheter in the right common carotid artery with the use of ultrasound guidance during emergency surgery for the total correction of Tetralogy of Fallot [ToF]. This patient luckily had a favourable outcome despite this inadvertent catheter placement which was not recognised even after completion of surgery .The patient also received drug infusions of inotropes and vasopressors through this malplaced central line into the aorta. The possible mechanism, consequences, prevention and management of this inadvertent cannulation are discussed in this report

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

Empyema thoracis in children: clinical presentation, management and complications

To determine the etiology, clinical manifestation, management [medical and surgical] and complications of children with empyema thoracis in a tertiary care hospital from Karachi, Pakistan. Descriptive, analytical study. Department of Surgery, The Aga Khan University Hospital, Karachi, from January 1996 to December 2010. Medical records of admitted children aged > a month to 15 years with discharge diagnosis of empyema thoracis and data was collected on demographic features, clinical manifestation, management and complications. Children managed medically were compared with those managed surgically by using interquartile range and median comparison. Mann-Whitney U test was used to compare age in months, weight [kg] and length of stay in days and presenting complaint, duration of illness; chi-square test was used to compare thrombocytosis in between groups and p-value was calculated. Among the 112 patients, 59 [53%] were younger than 5 years of age. Males [n=83, 74%] were predominant. Fifty [45%] children were admitted in winter. Thirty [27%] children found unvaccinated and one fourth [n=27; 24%] were severely malnourished. Fever, cough, and dyspnea were the major presenting symptoms. Sixty-six [59%] were on some antibiotics prior to admission. Staphylococcus aureus [n=13] and Streptococcus pneumoniae [n=5] were the commonest organism isolated from blood and pleural fluid cultures. Majority of the children required some surgical intervention [n=86]. Surgically managed children were younger [p=0.01]; had less weight [p=0.01] and prolonged fever [p=0.02]; and stayed longer in hospital [p < 0.001] as compared to medically managed children. Requiring readmission [n=8], subcutaneous emphysema [n=5] and recollection of pus [n=5] were the major complications. Staphylococcus aureus was the major organism associated with paediatric empyema thoracis. Early identification and empiric antibiotic as per local data is essential to prevent short and long-term complications. Younger, lower weight children with prolonged fever required surgical management

Frequency of hepatitis B and C in pre-operative patients for elective surgery

Objective: to document frequency of Hepatitis B and C in patients undergoing elective surgery

Design: descriptive case series

Setting: surgical Unit II Civil Hospital Karachi, from June 2005 to May 2006

Methods: all patients undergoing elective surgery were screened for Hepatitis B and C by enzyme immunoassay [EIA]. Risk factors for hepatitis B and C virus infections were also recorded

Results: out of 496 screened patients, HBsAg was found positive in 25 [5.0%] patients. Out of 25 HBsAg positive patients 14 [56%] were females and 11 [44%] were males. Anti-HCV was reported positive in 60 [12.0%] patients in which 38 [63.3%] were females and 22 [36.6%] were males. Overall 19.7% subjects had been vaccinated against HBV

Conclusion: we conclude that the high prevalence of hepatitis B and C in pre-operative patients is present in our population

Laparoscopic inguinal herniorrhaphy: analysis of initial experience

To evaluate our experience with laparoscopic inguinal herniorrhaphy regarding time to full recovery, return to work, complications and recurrence rate. We retrospectively studied a consecutive series of patients who underwent laparoscopic repair of inguinal hernia at our institution. The study cohort consisted of forty patients operated by a single surgeon between 1st Janruary2000 to1st January 2003. For all operations a TEPA [total extra-peritoneal approach] was used. Department of General Surgery, Lahore General Hospital Lahore. Outcome of laparoscopic inguinal herniorrhaphy The study group consisted of 38 male and 2 female patients with a mean age of 45 years [range 30 to 60 years] at the time of operation. During the study period, 50 laparoscopic inguinal hernia repairs were performed in 40 patients. Bilateral hernia repair was done in 10 patients [20%]. Of the 50 procedures; one repair [2%] was done for recurrent hernias. In 20% of the patients the procedure was completed as a day case surgery. A mean follow up of 12 weeks was obtained for 36 patients [>90%]. Minor complications occurred in 28% of patients, whereas major complication occurred in one patient who developed recurrence in the immediate post operative period. The median time to return to work or normal physical activity was 8-12 days for unilateral and 10-14 days for bilateral hernia repair. Laparoscopic herniorrhaphy is a feasible alternative to open hernia repair