Less invasive management of deep neck infection and descending necrotizing mediastinitis: A single-center retrospective study

By a 7-year retrospective review, we reported our experience in management of descending necrotizing mediastinitis (DNM) and deep neck infection (DNI). A retrospective design was used to reveal the clinical characteristics of DNI and DNM. The clinical outcome was analyzed to validate less invasive management. We reviewed 82 patients between 2009 and 2016, 12 of which were diagnosed as DNM by clinical and computed tomography findings. A total of 35 patients had relevant systemic conditions, mainly diabetes mellitus (19 patients). Most cases were secondary to oropharyngeal or dental infections. All patients underwent transcervical drainage, and 10 DNM patients were treated with additional closed thoracic drainage simultaneously. Twenty patients accepted more than 1 operation. Seven patients died as a result of sepsis and/or multiple organ failure. The mortality rate in our study was similar to that in other studies. In our opinion, less invasive therapies are useful to most patients. Transcervical drainage alone is optimal management for all DNI cases and some DNM cases. Additional closed thoracic drainage is enough for type I and IIA DNM with pleural effusion or empyema.

Emergency Surgery in a Critically Ill Patient with Major Drug-Induced Bleeding and Severe Ischaemic Heart Failure

Introduction

Anticoagulant overdose frequently occurs in elderly populations especially in remote areas where medical services are scarce. When emergency surgery is required, such patients offer major anaesthetic challenges.

Case presentation

We describe the case of an elderly patient admitted to a surgical ward with acute abdominal pain, on dual anti-platelet therapy and acenocoumarol for a recent acute myocardial infarction treated percutaneously with two drug-eluting stents. Laboratory tests showed severe anticoagulant overdose with uncoagulable INR. The decision was made to use of both light transmission aggregometry [LTA] for platelet function testing and thromboelastography to aid in the management of perioperative haemostasis in order to prevent both severe bleeding and stent thrombosis. Surgery revealed haemoperitoneum, volvulus of the ileum and a venous mesenteric infarction. Intraoperative blood loss was minimal and no blood products were administered. Postoperative course was uneventful without either thrombotic or haemorrhagic complications and the patient was discharged from the Postanaesthesia Care Unit on postoperative day two.

Conclusion

The use of aggregometry and thrombography helped in both evaluation and management of haemostasis of a high-risk patient by goal-directed administration of pro-and anti-coagulants.

Perioperative Considerations in a Patient with Hemophilia A: A Case Report and Review of Literature

Classic hemophilia or hemophilia A is a congenital bleeding diathesis in which the affected individual may present with spontaneous hemorrhage or persistent bleeding even after minor trauma. Knowledge about the disease process, multidisciplinary team approach, and timely management can lead to favorable outcome in these patients. We report management of a child with hemophilia A for suturing of lacerated upper lip mucosa following trauma. A review of literature with recommendations for perioperative management, especially in the setting of emergency surgery, is also provided.

Patent Ductus Arteriosus Banding for Circular Shunting After Pulmonary Valvuloplasty

We report two cases of newborns with critical pulmonary stenosis having intact ventricular septum, who underwent pulmonary valve balloon valvuloplasty followed by banding of a patent ductus arteriosus. Transcatheter pulmonary valvuloplasty was performed one week after delivery. Following the procedure, both developed "circular shunting" as a consequence of left-to-right ductal flow and pulmonary regurgitation. This in turn caused increased blood flow into a dysfunctional right ventricle and low systemic cardiac output syndrome. The PDA banding was performed urgently as a rescue measure in order to restore systemic flow while still maintaining some duct-dependent pulmonary blood flow. This approach resolved the circular shunting. Outcome was favorable in both the patients.

Perioperative risk factors for in-hospital mortality after emergency gastrointestinal surgery

Few studies have evaluated the risk factors for in-hospital mortality in critically ill surgical patients who have undergone emergency gastrointestinal (GI) surgery. The aim of this study was to identify the risk factors associated with in-hospital mortality in critically ill surgical patients after emergency GI surgery.The medical records of 362 critically ill surgical patients who underwent emergency GI surgery, admitted to intensive care unit between January 2007 and December 2011, were reviewed retrospectively. Perioperative biochemical and clinical parameters of survivors and nonsurvivors were compared. Logistic regression multivariate analysis was performed to identify the independent risk factors of mortality.The in-hospital mortality rate was 15.2% (55 patients). Multivariate analyses revealed cancer-related perforation (odds ratio [OR] 16.671, 95% confidence interval [CI] 2.629-105.721, P = 0.003), preoperative anemia (hemoglobin <10 g/dL; OR 6.976, 95% CI 1.376-35.360, P = 0.019), and preoperative hypoalbuminemia (albumin <2.7 g/dL; OR 9.954, 95% CI 1.603-61.811, P = 0.014) were independent risk factors of in-hospital mortality after emergency GI surgery.The findings of this study suggest that in critically ill patients undergoing emergency GI surgery, cancer-related peritonitis, preoperative anemia, and preoperative hypoalbuminemia are associated with in-hospital mortality. Recognizing risk factors at an early stage could aid risk stratification and the provision of optimal perioperative care.

Acute lupus pneumonitis followed by intestinal pseudo-obstruction in systemic lupus erythematosus: A case report

Intestinal pseudo-obstruction (IpsO) and acute lupus pneumonitis (ALP) are uncommon severe complications of systemic lupus erythematosus (SLE). The present study reports the case of a 26-year-old female who presented with abdominal pain, nausea and vomiting as initial symptoms. Computed tomography (CT) scanning revealed the jejunal wall was thickened and streaky, mimicking the presentation of intestinal obstruction. Following emergency surgery, the patient's general condition was aggravated, with evident limb erythematous rashes. A series of laboratory examinations revealed SLE, and combined with patient's medical history IpsO was diagnosed, with a disease Activity Index score of 10. During the therapeutic period, high fever, dyspnea and oxygen saturation (SaO₂) reductions were detected, and CT scans indicated lung infiltration, excluding other causes through a comprehensive infectious work-up and a bronchoalveolar lavage examination. ALP was confirmed and treated with high-dose methylprednisolone and gamma globulin supplement. The patient responded well and was discharged in 2 weeks. In the one-year tapering period and after stopping corticosteroids, the patient recovered well with no relapse detected. In conclusion, the manifestation of IpsO in SLE is rare and represents a challenge for the surgeon to establish the correct diagnosis and avoid inappropriate surgical intervention. ALP may be the consequence of emergency surgery, and immediate high-dose glucocorticoid therapy is recommended.

Changing models of care for emergency surgical and trauma patients in Singapore

The last 15 years have seen changing patterns of injury in emergency surgery and trauma patients. The ability to diagnose, treat and manage these patients nonoperatively has led to a decline in interest in trauma surgery as a career. In addition, healthcare systems face multiple challenges, including limited resources, an ageing population and increasing subspecialisation of medical care, while maintaining government-directed standards and managing public expectations. In the West, these challenges have led to the emergence of a new subspecialty, 'acute care surgery', with some models of care providing dedicated acute surgical units or separating acute and elective streams with the existing manpower resources. The outcomes for emergency surgery patients and efficiency gains are promising. In Singapore, Khoo Teck Puat Hospital has implemented its first dedicated acute surgical unit. This article outlines the evolution of acute care surgery and its relevance to Asia.

Self-expanding metallic stent improves histopathologic edema compared with transanal drainage tube for malignant colorectal obstruction

AIMS

To compare the usefulness of the self-expanding metallic stent (SEMS) with that of the transanal drainage tube (TDT) and emergency surgery after failure of decompression (ESFD) in patients with malignant colonic obstruction (MCO), and to evaluate post-decompression histopathologic changes.

METHODS

From January 2010 to June 2015, 39 patients with MCO received SEMS, TDT, and ESFD. We evaluated the outcomes including success rates of placement, clinical outcomes after decompression, and histopathologic findings of the resected specimens.

RESULTS

Technical success rates were 100% for SEMS and 78.9% for TDT. Clinical success rates were 100% for SEMS and 80.0% for TDT. Postoperative ileus was significantly less frequent after SEMS than after TDT (p = 0.014). Histopathologic edema grade was significantly lower for SEMS than for TDT and ESFD (p < 0.0001). There was no significant difference between edema grade and duration of decompression in the TDT group (p = 0.629), while all patients with SEMS were classified in a low edema grade (grade 0-2). The rate of stoma creation was significantly higher in patients with a high edema grade (grade 3) than in those with a low edema grade (grade 0-2) (p = 0.003). There was no microscopic perforation in any group.

CONCLUSION

Significantly greater resolution of histopathologic edema was achieved after placement of SEMS than after placement of TDT. These findings provide an indication of favorable clinical outcomes of SEMS in comparison with TDT and ESFD. This article is protected by copyright. All rights reserved.

Emergency surgery for hemorrhagic shock caused by a gastrointestinal stromal tumor of the ileum: A case report

In this report, a case of hemorrhagic shock caused by a gastrointestinal stromal tumor (GIST) of the ileum, which was successfully treated by emergency surgery, is presented. A 67-year-old male patient presented to the Ibaraki Medical Center, Tokyo Medical University (Ami, Japan) in July 18, 2014, with dizziness and blood in the stool. Upper endoscopy and colonoscopy failed to reveal the source of the hemorrhage, although abdominal contrast-enhanced computed tomography revealed extravasation of the contrast medium into the small intestine. The patient developed hemorrhagic shock; thus, double-balloon enteroscopy (DBE) was performed, which revealed a Meckel's diverticulum and a submucosal tumor with excessive bleeding at 60 and 100 cm proximal to the ileocecal valve, respectively. Subsequent emergency partial resection of the ileum, including the tumor and the Meckel's diverticulum, was performed in July 20, 2014. Histological examination of the excised tumor revealed proliferation of spindle-shaped cells, and immunohistochemical staining of the tumor was positive for CD34, KIT and α-smooth muscle actin, but negative for S-100 protein. These immunohistological results supported the diagnosis of GIST of the ileum. The patient had an uneventful recovery and has been monitored at our outpatient clinic for 14 months after surgery. This case demonstrated the efficacy of DBE for the diagnosis of small intestinal bleeding, and immediate emergency surgery should be considered for cases of small intestinal GISTs with excessive bleeding.

A Statewide Analysis of the Incidence and Outcomes of Acute Mesenteric Ischemia in Maryland from 2009 to 2013

Introduction

Acute mesenteric ischemia is a surgical emergency that entails complex, multi-modal management, but its epidemiology and outcomes remain poorly defined. The aim of this study was to perform a population analysis of the contemporary incidence and outcomes of mesenteric ischemia.

Methods

This was a retrospective analysis of acute mesenteric ischemia in the state of Maryland during 2009–2013 using a comprehensive statewide hospital admission database. Demographics, illness severity, comorbidities, and outcomes were studied. The primary outcome was inpatient mortality. Survivors and non-survivors were compared using univariate analyses, and multivariable logistic regression analysis was performed to evaluate risk factors for mortality.

Results

During the 5-year study period, there were 3,157,499 adult hospital admissions in Maryland. A total of 2,255 patients (0.07%) had acute mesenteric ischemia, yielding an annual admission rate of 10/100,000. Increasing age, hypercoagulability, cardiac dysrhythmia, renal insufficiency, increasing illness severity, and tertiary hospital admission were associated with development of mesenteric ischemia. Inpatient mortality was high (24%). After multivariate analysis, independent risk factors for death were age >65 years, critical illness severity, mechanical ventilation, tertiary hospital admission, hypercoagulability, renal insufficiency, and dysrhythmia.

Conclusion

Acute mesenteric ischemia occurs in approximately 1/1,000 admissions in Maryland. Patients with mesenteric ischemia have significant illness severity, substantial rates of organ dysfunction, and high mortality. Patients with chronic comorbidities and acute organ dysfunction are at increased risk of death, and recognition of these risk factors may enable prevention or earlier control of mesenteric ischemia in high-risk patients.

Predictors of Mortality Up to 1 Year After Emergency Major Abdominal Surgery in Older Adults

OBJECTIVES

To identify factors associated with mortality in older adults 30, 180, and 365 days after emergency major abdominal surgery.

DESIGN

A retrospective study linked to Medicare claims from 2000 to 2010.

SETTING

Health and Retirement Study (HRS).

PARTICIPANTS

Medicare beneficiaries aged 65.5 enrolled in the HRS from 2000 to 2010 with at least one urgent or emergency major abdominal surgery and a core interview from the HRS within 3 years before surgery.

MEASUREMENTS

Survival analysis was used to describe all-cause mortality 30, 180, and 365 days after surgery. Complementary log-log regression was used to identify participant characteristics and postoperative events associated with poorer survival.

RESULTS

Four hundred individuals had one of the urgent or emergency surgeries of interest, 24% of whom were aged 85 and older, 50% had coronary artery disease, 48% had cancer, 33% had congestive heart failure, and 37% experienced a postoperative complication. Postoperative mortality was 20% at 30 days, 31% at 180 days, and 34% at 365 days. Of those aged 85 and older, 50% were dead 1 year after surgery. After multivariate adjustment including postoperative complications, dementia (hazard ratio (HR) = 2.02, 95% confidence interval (CI) = 1.24-3.31), hospitalization within 6 months before surgery (HR = 1.63, 95% CI = 1.12-2.28), and complications (HR = 3.45, 95% CI = 2.32-5.13) were independently associated with worse 1-year survival.

CONCLUSION

Overall mortality is high in many older adults up to 1 year after undergoing emergency major abdominal surgery. The occurrence of a complication is the clinical factor most strongly associated with worse survival.

Emergency Major Abdominal Surgical Procedures in Older Adults: A Systematic Review of Mortality and Functional Outcomes

OBJECTIVES

To systematically review the current literature on mortality and functional outcomes after emergency major abdominal surgery in older adults.

DESIGN

Systematic literature search and standardized data collection of primary research publications from January 1994 through December 2013 on mortality or functional outcome in adults aged 65 and older after emergency major abdominal surgery using PubMed, EMBASE, Web of Science, Cochrane, and CINAHL. Bibliographies of relevant reports were also hand-searched to identify all potentially eligible studies.

SETTING

Systematic review of retrospective and cohort studies using Preferred Reporting Items for Systematic reviews and Meta-Analyses, Meta-analysis Of Observational Studies in Epidemiology, Strengthening the Reporting of Observational Studies in Epidemiology, and A Measurement Tool to Assess Systematic Reviews guidelines.

PARTICIPANTS

Older adults.

MEASUREMENTS

Articles were assessed using a standardized quality scoring system based on study design, measurement of exposures, measurement of outcomes, and control for confounding.

RESULTS

Of 1,459 articles screened, 93 underwent full-text review, and 20 were systematically reviewed. In-hospital and 30-day mortality of all older adults exceeded 15% in 14 of 16 studies, where reported. Older adults undergoing emergency major abdominal surgery consistently had higher mortality across study settings and procedure types than younger individuals undergoing emergency procedures and older adults undergoing elective procedures. In studies that stratified older adults, odds of death increased with age. None of these studies examined postoperative functional status, which precluded including functional outcomes in this review. Differences in exposures, outcomes, and data presented in the studies did not allow for quantification of association using metaanalysis.

CONCLUSION

Age independently predicts mortality after emergency major abdominal surgery. Data on changes in functional status of older adults who undergo these procedures are lacking.

Surgical outcomes in native valve infectious endocarditis: the experience of the Cardiovascular Surgery Department - Cluj-Napoca Heart Institute

Background and aims

The introduction of Duke’s criteria and the improvement of imaging methods has lead to an earlier and a more accurate diagnosis of infectious endocarditis (IE). The options for the best therapeutic approach and the timing of surgery are still a matter of debate and require a close colaboration between the cardiologist, the infectionist and the cardiac surgeon.

Methods

We undertook a retrospective, descriptive study, spanning over a period of five years (from January 1st, 2007 to December 31st, 2012), on 100 patients who underwent surgery for native valve infectious endocarditis in our unit.

Results

The patients’ age varied between 13 and 77 years (with a mean of 54 years), of which 85 were males (85%). The main microorganisms responsible for IE were: Streptococcus Spp. (21 cases – 21%), Staphylococcus Spp. (15 cases – 15%), and Enterococcus Spp. (9 cases – 9%). The potential source of infection was identified in 26 patients (26%), with most cases being in the dental area (16 cases – 16%). The lesions caused by IE were situated in the left heart in 96 patients (96%), mostly on the aortic valve (50 cases – 50%). In most cases (82%) we found preexisting endocardial lesions which predisposed to the development of IE, most of them being degenerative valvular lesions (38 cases – 38%). We performed the following surgical procedures: surgery on a single valve - aortic valve replacement (40 cases), mitral valve replacement (19 cases), mitral valve repair (1 case), surgery on more than one valve – mitral and aortic valve replacement (20 cases), aortic and tricuspid valve replacement (1 case), aortic valve replacement with a mechanical valve associated with mitral valve repair (5 cases), aortic valve replacement with a biological valve associated with mitral valve repair (2 cases), and mitral valve replacement with a mechanical valve combined with De Vega procedure on the tricuspid valve (1 case). In 5 patients (5%) the bacteriological examination of valve pieces excised during surgery was positive. In 3 cases it matched the germ identified in the hemocultures, and in 2 cases it evidenced another bacterium.

Conclusion

The overall mortality of 5% is well between the limits presented in literature, being higher (30%) in patients who required emergency surgery. For the patients who return into our clinic with prosthetic valve endocarditis, the mortality after surgery was even higher (50%).

Open Surgical Bypass for Superficial Femoral Artery Occlusion Caused by Blunt Trauma

Blunt vascular trauma of the lower extremities brings about a high amputation rate, because other organ injuries disturb revascularization. We experienced a case of a superficial femoral artery occlusion caused by blunt trauma. The patient also had a femoral bone fracture and a large skin defect with deep muscular injuries of the thigh. We performed a femoropopliteal (FP) bypass using a saphenous vein which was routed through the contaminated wound. Postoperative vacuum-assisted closure therapy was used to prevent graft infection. Surgical bypasses using saphenous veins are approved treatments for arterial occlusions from blunt trauma if the grafts go through contaminated wounds.

The anesthetic considerations while performing supraclavicular brachial plexus block in emergency surgical patients using a nerve stimulator

Regional anesthesia is favored in patients who undergo emergency extremity (limb) surgery, and specifically so in the absence of fasting status. In the absence of ultrasonic guidance, the nerve stimulator still remains a valuable tool in performing a brachial block, but its use is difficult in an emergency surgical patient and greater cautious approach is essential. We identified the supraclavicular plexus by the nerve stimulation-motor response technique as follows. Anterior chest muscles contractions, diaphragmatic contraction, deltoid contractions, and posterior shoulder girdle muscle contractions when identified were taken as “negative response” with decreasing stimulating current. A forearm muscle contraction, especially “wrist flexion” and “finger flexion” at 0.5 mA of current was taken as “positive response.” If no positive response was identified, the “elbow flexion” was considered as the final positive response for successful drug placement. The series of patients had difficulty for administering both general and regional anesthesia and we considered them as complex scenarios. The risk of the block failure was weighed heavily against the benefits of its success. The described series includes patients who had successful outcomes in the end and the techniques, merits, and risks are highlighted.

Emergency surgery in the elderly: challenges and solutions

Elderly patients frequently present with surgical emergencies to health care providers, and outcomes in this group of patients remain poor. Contributing factors include frailty, preexisting comorbidity, polypharmacy, delayed diagnosis, and lack of timely and consultant-led treatment. In this review, we address common emergency surgical presentations in the elderly and highlight the specific challenges in caring for these patients. We summarize 20 years of reports by various medical bodies that have aimed to improve the care of these patients. To improve morbidity and mortality, several aspects of care need to be addressed. These include accurate and timely preoperative assessment to identify treatable pathology and, where possible, to consider and correct age-specific disease processes. Identification of patients in whom treatment would be futile or associated with high risk is needed to avoid unnecessary interventions and to give patients and carers realistic expectations. The use of multidisciplinary teams to identify common postoperative complications and age-specific syndromes is paramount. Prevention of complications is preferable to rescue treatment due to the high proportion of patients who fail to recover from adverse events. Even with successful surgical treatment, long-term functional decline and increased dependency are common. More research into emergency surgery in the elderly is needed to improve care for this growing group of vulnerable patients.

Outcomes after emergency abdominal surgery in patients with advanced cancer: Opportunities to reduce complications and improve palliative care

BACKGROUND

There is increasing emphasis on the appropriateness and quality of acute surgical care for patients with serious illness and at the end of life. However, there is a lack of evidence regarding outcomes after emergent major abdominal surgery among patients with advanced cancer to guide treatment decisions. This analysis sought to characterize adverse outcomes (mortality, complications, institutional discharge) and to identify factors independently associated with 30-day mortality among patients with disseminated cancer who undergo emergent abdominal surgery for intestinal obstruction or perforation.

METHODS

This is a retrospective cohort study of 875 disseminated cancer patients undergoing emergency surgery for perforation (n = 499) or obstruction (n = 376) at hospitals participating in the American College of Surgeons' National Surgical Quality Improvement Program from 2005 to 2012. Predictors of 30-day mortality were identified using multivariate logistic regression.

RESULTS

Among patients who underwent surgery for perforation, 30-day mortality was 34%, 67% had complications, and 52% were discharged to an institution. Renal failure, septic shock, ascites, dyspnea at rest, and dependent functional status were independent preoperative predictors of death at 30 days. When complications were considered, postoperative respiratory complications and age (75-84 years) were also predictors of mortality.Patients who had surgery for obstruction had a 30-day mortality rate of 18% (n = 68), 41% had complications, and 60% were discharged to an institution. Dependent functional status and ascites were independent predictors of death at 30 days. In addition to these predictors, postoperative predictors of mortality included respiratory and cardiac complications. Few patients (4%) had do-not-resuscitate orders before surgery.

CONCLUSION

Emergency abdominal operations in patients with disseminated cancer are highly morbid, and many patients die soon after surgery. High rates of complications and low rates of preexisting do-not-resuscitate orders highlight the need for targeted interventions to reduce complications and integrate palliative approaches into the care of these patients.

LEVEL OF EVIDENCE

Prognostic study, level III; therapeutic study, level IV.

An evaluation of treatment results of emergency versus elective surgery in colorectal cancer patients

OBJECTIVE

Colorectal cancer is still one of the most common causes of cancer related deaths in the world despite improvements in diagnosis and treatment modalities, and application of community-based screening methods. Symptoms of colorectal cancer are non-specific and usually manifest following local progression. A number of patients with advanced stage colorectal cancer present to emergency departments with obstruction as the first sign of disease without any previous symptoms. This presentation is an indication for emergency surgery that has a high rate of morbidity and mortality. In this study, we aimed to determine the factors associated with early diagnosis and survival by comparing postoperative results of colorectal cancer patients who underwent surgery under emergency or elective situation.

MATERIAL AND METHODS

Files of colorectal patients treated between 2009-2013 were retrospectively analyzed. Data on patient age, gender, operation type, intraoperative results, length of hospital stay, co-morbidities, postoperative complications and pathological results were evaluated and compared.

RESULTS

There was no statistical difference between groups in terms of age, gender, and pathology results (p>0.05). The difference between groups in terms of postoperative length of hospital stay, presence of co-morbid diseases, pathological stage, and postoperative complications was statistically significant (p<0.05). Length of hospital stay, advanced stage on admission, complications such as surgical site infection, evisceration, and anastomosis leakage rates were higher in patients in the emergency surgery group.

CONCLUSION

Risk groups should be determined in order to diagnose colorectal cancer patients at an early stage while they are still asymptomatic, and this information should be incorporated into effective screening programs. This approach will be beneficial to treatment outcomes, complication rates, length of hospital stay, and survival and treatment results.

Volvulus and bowel obstruction in ATR-X syndrome-clinical report and review of literature

Alpha thalassemia-mental retardation, X-linked (ATR-X) syndrome is a rare genetic disorder with a variety of clinical manifestations. Gastrointestinal symptoms described in this syndrome include difficulties in feeding, regurgitation and vomiting which may lead to aspiration pneumonia, abdominal pain, distention, and constipation. We present a 19-year-old male diagnosed with ATR-X syndrome, who suffered from recurrent colonic volvulus that ultimately led to bowel necrosis with severe septic shock requiring emergent surgical intervention. During 1 year, the patient was readmitted four times due to poor oral intake, dehydration and abdominal distention. Investigation revealed partial small bowel volvulus which resolved with non-operative treatment. Small and large bowel volvulus are uncommon and life-threatening gastrointestinal manifestations of ATR-X patients, which may contribute to the common phenomenon of prolonged food refusal in these patients.

Overcrowding of accident & emergency units: is it a growing concern in Nigeria?

BACKGROUND

The inability of the Nigeria's Accident and Emergency Departments (AED) to meet current demands is growing among the public and health care professionals. The data supporting perceptions of insufficient capacity are limited. Therefore, this study was intended to determine the prevalence, causes, and effects of overcrowding AEDs in Nigeria.

MATERIALS AND METHODS

This was a cross sectional, descriptive study carried out among AED staff of 3 referral teaching hospitals in Nigeria, using a pre-tested and validated structured questionnaire.

RESULTS

The analysis of the 267 AED staff revealed 20-56 years (36.40+5.1 mean) age range. One hundred and twenty eight (47.9%) were males, 139 (52.1%) females. Two hundred and fifty nine (97%) agreed that an AED should have a bed capacity of 21-30. Agreement to AED overcrowding in Nigeria was quite considerable. The frequency of AED overcrowding per week was 4-7 times. The average bed occupancy level was 3.25. Agreed common causes of prolonged AED admissions were to be a high volume of critically ill patients, Delayed transfer of patients to the wards, delay in theatre operation, delay in radiological investigations and exceptionally high proportion of patients requiring admission in AED. Also, long pre-review waiting time and haematological delays were more causes. The average waiting time for victims to be seen was 29.7 minutes.

CONCLUSION

There are many causes of AED overcrowding in this environment. However, improving AED bed management, better organized and diligent discharge planning, and reducing access block should be a priority to reduce AED overcrowding.

Idiopathic mitral valve chordae rupture in an infant: importance of rapid diagnosis and surgery

Mitral valve chordae rupture in infancy is a rare, but life-threatening disease. The progression of acute cardiac failure has been reported, with emergency surgery being required in most cases. Mitral valve chordae rupture typically occurs at the age of 4-6 months. Echocardiography is needed to diagnose this disease, and accurate diagnosis is difficult for general pediatricians. We herein describe the case of an acutely ill 4-month-old infant, who was saved and discharged without neurological sequelae due to the early diagnosis of mitral valve chordae rupture, life support, and surgery. We confirm the importance of acute pre-surgery treatment and immediate surgery for the survival and good outcome of infants.

Open surgical repair for a ruptured abdominal aortic aneurysm with a horseshoe kidney

Horseshoe kidney is a congenital anomaly characterized by medial fusion of the bilateral kidneys. Treatment for an abdominal aortic aneurysm (AAA) with a horseshoe kidney is a technical challenge because of the complex anatomy. We report a successful open surgical repair for a ruptured AAA with a horseshoe kidney. An aortic grafting was performed with division of the renal isthmus through a transperitoneal approach. In the case of a ruptured AAA, quick open surgery is the most reliable treatment. If a horseshoe kidney coexists, transperitoneal approach with division of the renal isthmus provides good surgical field for an aortic grafting.