944 Re Audit: Maintenance Iv Fluids Prescribing

Aim

Many hospital admissions require intravenous (IV) fluid therapy to prevent or correct fluid status and/or electrolyte disturbances. Within our trust the recommended IV maintenance fluid is 0.18% Saline in Glucose 4%. This Re audit aimed to assess the knowledge and improve understanding of junior clinicians for IV maintenance fluid prescribing at Royal Preston Hospital by comparing our current practice to Trust guidelines/NICE guidelines

Method

A multiple choice knowledge questionnaire was used evaluate the knowledge of foundation doctors, core trainee's and advanced care practitioners (n=21). The trusts electronic system was used to review patients prescribed maintenance fluid. (n=50). 1st audit was conducted in October 2020 followed by re audit in April 2021.

Results

In 1st cycle only 16% of the patients had the recommended maintenance fluid prescribed. We displayed posters and sent email reminders of the trust IV fluid prescribing guidelines. Junior's knowledge of the IV fluid prescribing guidelines improved regarding: recommended maintenance fluid (52% to 80%), Daily fluid requirement in ml/kg/day (66% to 70%) and Recommended monitoring (52% to 100%). This ultimately led to the prescribing of 0.18% Saline in Glucose 4% in 38% of patients. Plasma-Lyte remained the most commonly fluid prescribed in both audit cycles (42% vs 50%).

Conclusion

Changes implemented after 1st cycle led to improvement is prescribing fluid of choice but there is still room for improvement. Juniors report consultant lead decisions influencing their prescribing and the availability of fluids on the wards.

EP.WE.381Daycase Parathyroidectomy for Primary Hyperparathyroidism: Our Experience

Aims

Concerns due to postoperative complications following parathyroid surgery have precluded its consideration as a Daycase procedure. However recent BAETS guidelines have supported Daycase parathyroid surgery. To assess the outcomes of Daycase parathyroidectomy pathway we established in our Hospital since April,2018.

Methods

Retrospective review of all patients who underwent parathyroidectomy for Primary Hyperparathyroidism between April,2018 and October,2020. Patients with ASA 3 and above and patients undergoing total-parathyroidectomies were excluded. Outcome measures include length of stay, prerequisite for overnight stay, complications, and readmission rates. All patients were assessed and counselled for suitability for Daycase in surgical clinic and given detailed information leaflets.

Results

In this period, 40patients underwent surgery for primary hyperparathyroidism. Of these, 30 patients (75%), 8 males and 22 females with a median age of 59years fulfilled the criteria for Daycase surgery. 19 patients (63.3%) were successfully discharged on the day of surgery. 11 patients (36.7%) were discharged the following morning. The reasons for overnight stay are - 5patien ts(16.7%) developed post-anaesthetic nausea and drowsiness; in 5patients(16.7%) surgery started after 2pm and delayed postoperative return to ward lead to inadequate time for safe discharge; 1patient(3.3%) needed hospital transport. The readmission and postoperative complication rates were nil.

Conclusions

Daycase parathyroidectomy is safe in carefully selected patients. Adequate preoperative counselling, robust perioperative management to minimize postop morbidity and clear patient support package upon discharge are vital for wider acceptance. All Daycase patients should be operated first on the list and prior to 2pm to ensure safe discharge allowing adequate time for postoperative recovery.

Distal antral gastropexy - a novel technique to prevent recurrence of giant hiatus hernia in selected cases - a cohort study

INTRODUCTION

The recurrence rate of giant hiatus hernias (GHH) following repair is high (30%) and increases with the hernia size and previous revision surgery. The mechanism of recurrence is poorly understood.

METHODS

This is a retrospective cohort study of all consecutive patients who underwent repair of giant hiatus hernia in a tertiary upper GI referral centre from November 2000 to November 2014. Patients who underwent redo surgery were identified and data on intra-operative findings and procedure performed at primary and redo surgery from their operation notes were collected.

RESULTS

A total of 81 patients underwent primary repair of GHH over the 14 year study period. 10 (12.3%) had symptomatic/radiological recurrence of which 4 were found to have the distal stomach herniating into the chest despite having an intact intra-abdominal wrap/gastropexy. To prevent migration of the distal stomach into the chest, distal gastropexy - fixing the antrum to the anterior abdominal wall, was added to 'conventional' gastropexy in 5 subsequent cases, in whom the antrum was in the chest preoperatively. These cases have no evidence of recurrence at the end of 6 months follow up.

CONCLUSION

Securing the antrum of stomach to the anterior abdominal wall may prevent migration of the distal stomach and other infracolic organs into the chest and thus reduce recurrence of some GHH where antrum had been in chest previously.

The relationship between prosthetic status and the Geriatric Oral Health Assessment Index in a group of institutionalized elderly of an Indian city: a cross-sectional study

AIM

To assess and compare the quality of life and oral health status among institutionalized elderly in Pune.

MATERIALS AND METHODS

A cross-sectional, quantitative exploratory study was conducted in persons 60 years of age in an institutionalized elderly home. The GOHAI questionnaire was completed by a single examiner, who interviewed the patients in their local language. The oral examination was carried out according to WHO oral health survey using the DMFT-index, community periodontal index (CPI), periodontal loss of attachment (PLA), prosthetic use, and needs according to criteria established by the WHO by a calibrated examiner. Descriptive analysis was carried out using absolute and relative frequencies of the qualitative variables and means with respective standard deviations for the quantitative variables. The Student's t-test was applied to compare groups.

RESULTS

Out of the total 110 individuals interviewed for the study, 64% were males and 36% were females. Individuals with up to 20 missing teeth and individuals with more than 20 missing teeth were 20 and 80% respectively. Based on the prosthetic need, 66% individuals needed replacement of teeth by dentures in one or both arches while 34% did not need any replacement by complete denture. The mean value for physical dimension was 5.40 whereas for psychosocial dimension, pain/discomfort and behavioral dimension were 8.02, 4.58 and 7.32.

CONCLUSION

The quality of life was found to be more favorable in individuals with less than 20 teeth missing. The quality of life among complete denture wearers in both the arches was better as compared to the quality of life among nondenture wearers. Prosthetic replacement by complete denture helps the individuals to maintain better oral health.

CLINICAL SIGNIFICANCE

The data obtained from the present study may serve as a reference point for comparisons of the magnitude of quality-of-life indicators relating to oral health.

Peritonitis from an abdominal wall biloma: a unique reason to avoid prophylactic surgical drainage

Prophylactic drainage of the peritoneal space after major surgery is widely practised despite evidence against its efficacy. We describe the case of a 56-year-old woman who underwent a converted cholecystectomy and whose correctly sited abdominal drain resulted in the formation of a biloma between the external and internal oblique musculature. Subsequent leakage from the biloma into the abdominal cavity presented as peritonitis days after surgery, necessitating an emergency laparotomy. This case represents the first reported description of an abdominal wall biloma as a complication of post-cholecystectomy abdominal drainage. The evidence surrounding prophylactic drainage is discussed.

Angelchik prosthesis with oesophageal adenocarcinoma: our surgical approach

The Angelchik prosthesis is an incomplete doughnut-shaped device composed of silicone elastomer used in the treatment of gastro-oesophageal reflux disease (GORD). It is used to encircle the lower oesophagus at the gastro-oesophageal junction (GOJ). The ease of the operation led to the insertion of over 25,000 such prostheses world-wide. However, a variety of major complications including intractable dysphagia, prosthesis migration and gastric erosion required a quarter of these devices to be removed. Development of adenocarcinoma in patients with Angelchik prosthesis is a rare occurrence. This article describes two patients who developed adenocarcinoma above their prosthesis and whose cardio-oesophagectomy was technically challenging due to the formation of a dense inflammatory capsule around the prosthesis. Our surgical approach to curative oesophageal resection with the Angelchik prosthesis in situ is also discussed.

Persistent anterior hip pain in young adults: current aspects of diagnosis

Persistent anterior hip pain, in young adults, presents a diagnostic and treatment challenge to hip surgeons. Diagnosis, in some cases, is difficult because available diagnostic tools are not very reliable, resulting in a difficult decision making process. This article discusses the possible causes, current knowledge of the condition and outlines a method to approach this difficult problem.

Factors influencing length of stay after primary total hip replacement: the role of anaesthesia and the anaesthetist

We studied 121 consecutive total hip replacements (THRs) in 109 patients in order to establish the influence of anaesthetic technique, anaesthetist concerned, age of the patient, and body mass index (BMI) on the length of hospital stay after primary total hip replacement. Patients received either general anaesthesia alone (50 THRs) or a combination of general and local anaesthesia (lumbar plexus block; 71 THRs) from three separate anaesthetists. Our analysis showed that those patients who received a combination of anaesthesia showed shorter median length of hospital stay (three days) than those who received general anaesthesia alone (five days; p<0.0001). The age of the patient was also critical (p=0.003) as was the anaesthetist concerned (p=0.01). BMI was unimportant.

Development and problems of metal-on-metal hip arthroplasty

For over 40 years, the metal-on-polyethylene bearing has dominated the field of total hip replacement. Problems of wear, osteolysis (dissolution of bone), and ultimately failure of prostheses have led to the development of alternative bearing surfaces. Metal-on-metal hip resurfacing has taken current orthopaedic surgery almost by storm. However, metal ion release following metal-on-metal hip resurfacing remains a major cause for concern. This article looks into the development and examines problems and issues surrounding metal-on-metal resurfacing arthroplasty.