Ponv; dexamethasone effect on post operative nausea and vomiting in laparoscopic cholecystectomy

Background: Postoperative nausea and vomiting is reduced if inj Dexamethasone is given preoperatively in patient undergoing Laparoscopic Cholecystectomy. The aim of this prospective randomized, controlled trial was to look into effectiveness of dexamethasone before surgery may improve nausea, vomiting after surgery in patients undergoing laparoscopic cholecystectomy

Study Design: Prospective randomized study

Setting: Department of Surgery, King Edward Medical University, Lahore - Pakistan. Period: Nov 2010 to April 2012

Methods: 138 Patients with Laparoscopic Cholecystectomy were randomized to receive 08 mg Dexamethasone [n=66] or placebo [n=72] intravenously before surgery. Seven patients were excluded on account of already on steroid treatment due to various reason. Vomiting and nausea were seen in next 24 hours after operation. Dexamethasone has minimal side effect after single dose administration. Six patients [12%] has nausea and vomiting in treatment group while 26 [47%] in the control group [p<0.001]. Patient having dexamethasone, five [10%] need antiemitics as compare to 24 [44%] of those receiving placebo [p<0.001]

Conclusion: Single dose of Inj Dexamethasone given preoperatively reduce nausea and vomiting markedly in Laparoscopic Cholecystectomy and may be routinely used in Laparoscopic procedure

Sensitivity and resistance of microorganisms in infected surgical wounds on surgical floor of Mayo hospital

There is an overwhelming concern around the world regarding the increasing number of resistant strains of microorganisms in all sorts of wounds. There is hardly any information about the prevalence and incidence of such resistance pattern in our local hospitals This study was done to probe into the common microorganisms and their culture sensitivities to antibiotics in surgical wound infections in general surgery wards of Mayo hospital. The study material included the pus specimens sent to pathology lab from general surgical wards. There culture sensitivity results were interpreted to find out the prevalence of individual microorganisms in surgical wounds and sensitivities and resistance to different antibiotics. Staphylococcus aureus was the most common organism cultured [54.87%], followed by E.Coli [10%], pseudomonas[10%], proteus [7.9%] and kleibsiella [5.3%]. 20 percent of wounds had mixed growth of organisms. Mixed growth of microorganisms was seen in 20% of cases. Most of the bacteria cultured were resistant to routinely used antibiotics

Xeroderma pigmentosum

Xeroderma pigmentosum comprises of a heterogeneous group of autosomal recessive hereditary diseases, which are characterized by a number of clinical characteristics and abnormal DNA repair mechanism. These patients are prone to multiple cutaneous malignancies at an early stage in life. We present 2 cases of xeoderma pigmentosum with malignant melanoma and conclude that such cases must be identified at an early stage and properly educated to protect themselves from malignancies

Primary repair Vs ileostomy in patients with typhoid perforation

This is prospective study conducted in the department of Surgery, Mayo Hospital, Lahore over the period of four years. Comparative data was compiled on 100 patients divided in two equal groups. Efficacy of two operations was assessed in terms of morbidity and mortality. The final results were conclusive enough to show the benefits of ileostomy over the primary repair in cases of typhoid perforation

Misses and near misses: drug administration errors

Mistakes made during administration of drugs to patients can be lethal. In order to analyse these mishaps we need to study the particular circumstances of each accident and define the reasons behind the mistake or lapse. This paper reports the findings of a confidential pilot study designed to highlight the frequency of such unfortunate incidences and formulate recommendations applicable in our society to prevent some of these tragic outcomes. Sixty doctors and nurses from different hospitals were randomly enquired about the personal knowledge of pharmacological mistakes with which they were either closely associated or they had first hand information of the incident. All data was collected in confidence on condition of anonymity. We discovered 21 instances of drug administration errors. Dispensation of wrong drug to a patient was the commonest mistake discovered. Nurses gave majority of these injections during the night. Half the victims of these mishaps lost their lives. From this confidential inquiry, we have found that tragedies with loss of life are not infrequent in our set up: Typical scenario involved muscle relaxant given instead of narcotic analgesic by a student nurse during the night. When the mistake was not detected in time it frequently ended in tragic loss of life. It is disturbing to note that minimum basic facilities of proper cardiopulmonary resuscitation were not available in some hospitals. Recommendations: Only senior nurses / doctors should give IV injections. Conscious effort should be made to minimise the use of IV medication, drugs should be used only with proper indications when suitable oral alternatives are not feasible. The nurses' training as well as nurse patient ratio needs to be improved. Muscle relaxants should not be available outside operating rooms and critical care units. We need to set up a central confidential data-reporting centre for voluntary [anonymous

Role of iodine-131 MIBG scanning in the management of paediatric patients with neuroblastoma

To evaluate the role of iodine-131 metoiodobenzylguanidine [iodine-131 MIBG] scanning in the management of paediatric patients with neuroblastoma. Subjects and Forty-three iodine-131 MIBG scans were performed on 26 children, 18 male and 8 female, ranging in age from 8 months to 11 years. Bone scan, computed tomography [CT] images and findings of bone marrow biopsy were compared with the iodine-131 MIBG scan findings. Of the 26 patients, 18 [69%] showed abnormal iodine-131 MIBG avidity and were proven to have a neural crest tumour on histology. The remaining 8 [31%] patients had normal iodine-131 MIBG scans, and histology showed a malignancy other than a neural crest tumour. Iodine-131 MIBG scans showed the primary site in 16 of 17 patients while CT showed 14 primary sites. In follow-up studies, the results were as follows: iodine-131 MIBG showed no evidence of disease in 4 compared with 3 on CT, persistent disease in 2 on iodine-131 MIBG and 4 on CT; recurrence in 1 on iodine-131 MIBG and 0 on CT; MIBG scans detected double the number of bony lesions compared with bone scans. The findings on iodine-131 MIBG scans and bone marrow biopsy were in agreement in 16/18 cases. Patients in whom iodine-131 MIBG scans showed disease resolution had better clinical outcomes. The findings indicate that iodine-131 MIBG scanning is useful for the diagnosis, staging, evaluation of response to therapy and detection of recurrences in patients with neuroblastoma. It exhibited a clear advantage over CT in detecting the primary site and soft issue metastases and was also superior to bone scanning in detecting skeletal metastases. It also reliably demonstrated bone marrow involvement

effect of residual ventricular septal defects on early clinical outcome: Initial experience

Residual ventricular septal defect [VSD] after repair of isolated VSD or Fallot's tetrology is one of the main causes of morbidity and re-operations. In this paper we have presented the results of our initial experience regarding the management of this problem. The data consists of 71 patients [22 isolated VSD and 49 Fallot's tetrology] operated during January, 1991 to July, 1993. The incidence of residual VSD as shown by colour doppler study at the time of discharge from hospital and at three month's follow-up was 43 out of 60 patients [73%] and 12 out of 60 [20%] respectively. Six out of these 12 patients were NYHA class III-IV who underwent cardiac catheterization which revealed patch dehiscence in two patients and residual right ventricular outflow tract obstruction in four patients. The two patients, with patch dehiscence, were reoperated successfully with very good outcome. Simple colour doppler mapping tends to over-diagnose residual VSDs since it can pick up small hemodynamically insignificant leaks around stitches and needle holes which seal off in due course. The findings of colour doppler should, therefore, be correlated with actual clinical outcome in order to proceed with further investigations and re-operation

Surgical approaches to the mitral valve: a prospective comparative study of the trans-septal approach vs standard left atrial approach

Surgical exposure of the mitral valve can be achieved through various approaches depending upon various pathological features of individual case. Each of these approaches has its own merits and demerits. The criteria for selection are not well defined. The left atrial approach is standard and most commonly used approach. The next commonest approach is right atrial trans-septal approach. There is theoretical possibility of rhythm problems following tyhe trans-septal approach as it can damage the atrioventricular conduction system located in the inter-atrial-sepum. We did a comparative prospective study to evaluate the safety of trans-septal approach against the gold standard of left atrial approach. All planned mitral valve operations done between January 1991 to May 1993 were included in the study, which included 237 cases operated through left atrial and 25 through trans-septal approach. The patient characteristics and the operative procedures were similar in both groups. All patients in left atrial group were followed for four years and those in trans-septal group could not be followed beyond two years due to various reasons. The results of both groups were compared statistically. We found no statistically significant differences in post-operative characteristics between both groups. There were no conduction block or arrhythmia in trans-septal group and we therefore consider this approach as useful, safe and convenient

Critical pathway, cardiac surgery in the third world

To set up a protocol in order to provide an efficient, cost effective system for Cardiac Surgery and to reduce the waiting list in straight forward Cardiac Surgical Operations. A prospective study in all patients with Patent Ductus Arteriosus [PDA] following the Critical Care Methodology. Department of Cardiac Surgery, Punjab Institute of Cardiology, Lahore. Main outcome measures: Effectiveness of critical care methodology, reduction of cost to hospital and patient and reduction in waiting list time for PDA surgery. From June 1994 till June 1999, one hundred and fifty consecutive patients of PDA had their operation planned as day case cardiac surgery. There were 90 females and 60 males. Their mean age was 6.55 +/- 0.56 years. 134 patients were less than 18 years, mean age 4.9 +/- 0.39 years. These patients were seen in the outpatient and were accessed by the surgeon, anesthetist and intensive care sister. The parents of the children were fully briefed about the preoperative preparation, operation and post operative course. The patients were admitted on the day of the operation and kept in the ICU for 6 hours and then shifted to the high dependency unit [HDU] and discharged on the second post operative morning. We found this method of day case surgery beneficial for the patient. In that it reduced the cost of the hospital stay, surgery and led to a reduction in the waiting list time for PDA. This did not lead to an increase in the morbidity as the patients were sent home to the community early. In third world countries like Pakistan where resources are limited this method is ideal provided everyone is willing to participate

Role of surgery in portal hypertension

To evaluate and compare the benefits of surgical shunts/procedures in cirrhotic and non-cirrhotic portal hypertension. Department of Cardiovascular Surgery and Clinical Medicine, K.E. and FJ. Medical Colleges/Mayo Hospital, Lahore, Pakistan. A retrospective study of patients with portal hypertension who underwent various surgical procedures. The results were statistically analysed and significance of distribution of age and sex was tested by using chi square test with one degree of freedom. One hundred and eighty one [181] patients with portal hypertension referred from various teaching hospitals of Lahore and other major cities of Punjab for surgical intervention between 1977-1994. Effectiveness of various surgical shunts in different subgroups of portal hypertension [CPH and NCPH] in recurrent variceal bleeding and ascites. There was a male preponderance among patients undergoing shunt operations. The mean age of noncirrhotics was significantly less as comapred to cirrhotics. Thirty days postoperative mortality was 11.6%. Role of various shunt operations in patients with portal hypertension is mainly palliative. It is of some help in patients with cirrhotic portal hypertension but it is certainly much more beneficial in NCPH for prevention of recurrent oesophageal bleeding with improved survival

Mitral valve repair for pure mitral regurgitation and mixed mitral valve disease

Out of all mitral valve salvage cases done at the Punjab Institute of Cardiology, Lahore between 1991 and April 1994, 60 cases operated upon by one surgeon were selected for study. There were 4 [6.67%] hospital and 2 late deaths. Three patients including one late death underwent mitral valve replacement at a later stage. Six patients were lost to follow up. The remaining 46 patients are being followed up to assess the success of the repair or otherwise in terms of the New York Heart Association [NYHA] functional class of the patients and echocardiographic findings. All our patients dad rheumatic involvement of the mitral valve. The associated cardiac lesions were ASD in 2 [3.33%], tricuspid regurgitation in 40 [66.67%] and aortic regurgitation in 23 [38.33%] patients. The age range was between 10 and 50 years. The follow up period was 3-43 months. Forty [86.96%] patients are in functional class I or II while 6 [13.04%] patients are in functional class III or IV. Twenty-five [54.35%] patients have trivial or mild mitral regurgitation on post operative echocardiogram while 14 [30.43%] have moderate mitral regurgitation. We conclude that satisfactory results can be obtained with repair even in cases with rheumatic mitral valve disease

Surgery for partially calcified mitral valve stenosis experience at Mayo hospital, Lahore

Seven hundred and thirty five patients with partially calcified mitral valve were operated from July 1988 to July 1993. Two hundred and eighty five [38.7%] patients underwent mitral valve repair [conservative surgery] and 450 [61.2%] patients had replacement with synthetic valves. Three hundred and twenty three [71.7%] patients had Starr-Edward and 127 [28.3%] Carpentier-Edward biological valves. Two hundred and forty four [33.2%] patients required a De Vega tricuspid annuloplasty in addition to the above procedures. 28 [9.8%] patients in group A and 44 [9.7%] patients in group B had post-operative complications. Thromboembolic complications were four times more common in patients with mitral valve replacement. Perioperative mortality was 2.45% in group A and 2.8% in group B. Analysis of the data shows conservative surgery to be better tolerated with fewer complications as compared to replacement of Mitral valve

Management of displaced supracondylar fractures of humerus in children

Thirty children with displaced Supracondylar fractures of humerus were studied between the ages of 3-16 years. Group I included 8 children who reported soon after injury and were treated by open reduction and internal fixation. Group II patients [10] had presented 2 weeks after injury and were managed by callusoclasis and POP in extension. The patients in group III [12] sought advice after 6 months of injury with cubitus varus deformity and were treated with osteotomy. The group I revealed excellent functional and cosmetic results. The children in group II mostly developed some limitation of movements while patients in group III had satisfactory correction of cubitus varus deformity. In conclusion, the treatment of Supracondylar fractures of humerus gives proper results only after sound clinical judgment, correct surgical approach and good team work between orthopaedic and medical rehabilitation departments

TBAs role in promotion of family health

TBAs [Traditional Births Attendents] role in relation to Perinatal and Neonatal mortality, maternal mortality and family planning services is reviewed. About 65% of women who suffered perinatal and neonatal mortality were receiving antenatal care from TBAs and 71% of deliveries were conducted by them. In maternal mortality TBAs were conducting 27% of cases, and 9% of deaths were definitely avoidable at TBAs level. TBAs played important role in family planning services and contraceptives prevalence increased from 12.1% to 41.7% in Faisalabad

Epidural stimulation for lower abdominal operations

To evaluate the efficacy of epidural stimulation of the dorsal column of spinal cord as a method for pain relief fifty two patients undergoing lower abdominal surgery were studied. Two acupuncture needles, one at 2-3 lumbar intervertebral space and the other in the caudal space, were placed in epidural space. They were stimulated by acupuncture stimulator. The frequency and voltage were set according to the patient's maximum tolerance. Out of 52 patients 23 had comfortable surgical procedure without any analgesic drugs, 16 required adjuvant drugs like diazepam or morphine. In 13 cases this technique totally failed and general anaesthesia had to be administered. We found that epidural stimulation provides segmental analgesia which is helpful in minor surgical procedures