Significance of 24 hour Post Operative Lactate Levels in Predicting Mortality and Morbidity in Patients Undergoing Emergency Laparotomy in a Tertiary Centre

INTRODUCTION: Serum lactate levels had shown to increase in acute abdominal conditions like appendicitis and mesenteric ischemia and can used as a marker for mesenteric ischemia and appendicitis. Blood lactate levels had shown to have greater prognostic value than oxygen derived variables like oxygen delivery or oxygen uptake. Obtaining a lactate level is essential to identifying tissue hypo perfusion in patients who are not yet hypotensive but who are at risk for septic shock. The strategy of clearing lactate to normal values was assessed in the 2012 Surviving Sepsis Campaign Guidelines. The campaign suggests targeting resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypo perfusion. Lactate clearance is percentage change in lactate level since admission. High lactate clearance to be associated with better outcome in critically ill patients and low mortality in comparison to low lactate clearance. OBJECTIVES : Primary objective: to compare the ability of the lactate levels to predict postoperative mortality. Secondary objective: to compare the ability to predict postoperative morbidity like wound site infection, length of stay, lower respiratory tract infection, inotropic support, development of AKI, delirium, cardiac morbidity and need for re-exploration. METHODOLOGY : The study is done after obtaining a detailed history, complete general physical examination and systemic examination. The patients are subjected to relevant investigations like x-ray erect abdomen, CXR, USG , CT and routine investigations like Hb, TC, urea, creatinine, serum electrolytes. All investigations and surgical procedures were carried out with proper informed written consent as appropriately. Both Preoperative and Postoperative serum lactate analysis will be done, and the outcome analysis will be evaluated with mortality being the primary outcome. Patients will be followed upto 30 days postoperatively. They will be enquired about survival and complications through telephonic interview. The data regarding patient particulars, diagnosis, investigations, and surgical procedures is collected in a specially designed case recording form and transferred to a master chart subjected to statistical methods like mean, standard deviation, proportion, percentage calculation and wherever necessary chi square test for proportion are used. RESULTS: In the present study, 200 case of patients undergoing emergency abdominal surgeries for various etiology who came to RGGGH emergency department from November 2021 to August 2022 were included. Those patients who were more than 12 years of age were included in this study. There is a significant male preponderance (69.39%). Among those included in the study, 24.5% of patients were found to be hypertensive, 32% of patients were found to be diabetic and 9% of the patients were found to be CAD. Various etiologies including Intestinal obstruction, Perforation, SMA thrombosis, Appendicular perforations has been observed in this study. Based on the above values, both observed and expected values are calculated and entered in tables. By using the values, the Chi Square statistic is calculated. Degree of freedom is found to be 1. Based on the analysis, p-value is calculated to find the significance of the test. Based on the analysis of lactate values for patients with complications and without complications, the following observations are made Chi-square statistic is 18.3911. The p-value is 0.000018. Based on the analysis of lactate values for patients with mortality and without mortality, the following observations are made. Chi-square statistic is 6.4068. The p-value is 0.011369. Significant at p < 0.5 CONCLUSION: Sepsis and septic shock remains a major challenge faced by surgeons in current days scenario. Lactate has been proven as an incredible tool to assess the outcomes of the patient and plan the management accordingly. Increased lactate levels post operatively poses significant high risk in mortality and morbidity of the patient and might help surgeons to as a guide to understand the nature of the disease and its prognosis. Those with normal post operative lactate levels are found to have lower risk of complications and mortality

A Comprehensive study on Conduction Block in Acute Stemi in Thanjavur Medical College

BACKGROUND: Acute myocardial infarction is a grave clinical condition that remains the leading cause of mortality worldwide. World wide around 3 million people suffer from STEMI and another 4 million people develops NSTEMI. Conduction blocks are commonly seen in patients associated with myocardial infarctions. Several studies have shown data that AV and infranodal blocks are present approximately 12 to 25% in acute MI. But this largely varies with studies. Several studies have pointed out that the AV blocks complicating STEMI are associated with increased morbidity and mortality. The prognosis of the patient may vary depending upon the type of AV block and timely intervention as well. OBJECTIVES: To study the prevalence of conduction block in acute STEMI in Thanjavur Medical College and the association with various modifiable and non modifiable risk factors and also the prognosis of the patients. METHODS: The study was conducted as a cross sectional observational study in Thanjavur Medical College from the period of JANUARY 2021 to JANUARY 2022. A total of 100 cases who presented as acute STEMI in Thanjavur Medical College were studies and the prevalence of various heart blocks developed in them where studied and their associations were various risk factors and outcomes were assessed. All the cases were assessed for demographic and clinical presentation b the principal investigator using a pre structured proforma. Patients were followed along the course of treatment ; serial ECG monitoring was done. patient was followed with ECHO and assessed until the patient is discharged or has been expired. Patients were subjected to following investigations to identify the comorbidities : CBC, RBS, RFT, LIPD PROFILE. The data were entered in MS office excel SPFTWARE and analysed using SPSS version 2.0 RESULTS: In our study 100 subjects were taken into consideration and Commonest age group who developed acute STEMI were within the age group of 45 to 60 years males. Incidence of conduction block in our study was 28 %. In literature the conduction blocks in STEMI varies from 12% to 25% depending on various studies. Also the mortality of study subjects was 16% in the study. Age, gender, and comorbidities have no association with conduction block or prognosis of patients. In our study AWMI have the highest incidence being 64% followed by IWMI which is 17%. In our study the most common conduction block was infranodal blocks, of which RBBB more than LBBBB (7%). Conduction blocks and alcoholism has statistically significant association with prognosis of the patient so are the Ejection fraction and killip class at presentation. CONCLUSION: The incidence of heart block in the study was 28% There is significant association between alcoholism and conduction block. RBBB and LBBB are the most common conduction blocks seen. Bundle branch blocks are more seen with AWMI and AV nodal blocks are common with inferior wall MI. There is significant association with mortality of the patient as well as the duration of stay of discharged patients with conduction blocks. There is also association between conduction block and Killip class at the time presentation and reduced Ejection fraction in ECH

Comparison of High Carbohydrate, Whole Food Plant- Based Diet to Standard Mixed Diabetic Diet in the Management of Type 2 Diabetes Mellitus in a Tertiary Care Hospital: A Randomised Controlled Trial

INTRODUCTION: Type 2 diabetes mellitus (T2DM) is a major public health concern. According to the International Diabetes Federation (IDF) as of 2021 there are 537 million adults living with diabetes. T2DM is by far the most common type of diabetes mellitus in adults (>90%). Diabetes mellitus is caused by varying degrees of insulin resistance and defective insulin secretion (beta cell dysfunction) or both. The etiopathogenesis for diabetes is multifactorial and includes genetic predisposition, environment factors, fetal programming, epigenetics and inflammation. Diabetes mellitus is diagnosed in those with a HbA1C of ≥6.5%, fasting plasma glucose ≥ 126mg/dl or a 2-hour plasma glucose of ≥ 200mg/dl. As per the American Diabetic Association (ADA) guidelines, diabetes mellitus should be screened for all adults ≥ 35 years, or even earlier for those with obesity, hypertension. strong family history, dyslipidemia, polycystic ovarian syndrome, past history of gestational diabetes mellitus or other conditions associated with insulin resistance (e.g., acanthosis nigricans). The goals of treatment are to control blood sugars, prevent microvascular and macrovascular complications as well as to ensure a good quality of life. The treatment of diabetes is centered around the patient. AIM OF THE STUDY: The aim of the study is to compare the efficacy of two different types of diabetic diets [a high-carbohydrate (70-75% of the total calorie intake), whole food, plant-based diet and a moderate carbohydrate (50-60% of the total calorie intake) standard, mixed diabetic diet] for their efficacy in improving glycaemic control by lowering of HbA1c levels. OBJECTIVES: Diabetes Mellitus is a disease with a large global burden. Current treatment strategies include medical nutrition therapy, physical activity, oral antidiabetic agents and insulin. At present there is a paradigm shift towards a more holistic approach in diabetic management. We investigated whether there is a difference in the glycaemic control among type 2 diabetics allocated to a high carbohydrate, whole food plant-based diet in comparison to a standard diabetic diet. METHODS: We did a single-center, open-label, assessor blinded, randomised controlled trial to compare the efficacy of two different types of diabetic diets in lowering HbA1c levels. After obtaining informed consent, we randomly allocated 94 participants with type 2 diabetes mellitus to receive either a high carbohydrate, whole food plant-based diet (carbohydrate 70-75%) or a moderate carbohydrate, standard diabetic diet (carbohydrate 50-60%). Participants were followed up for a total of 3 months. At enrollment they were given an intensive dietary education by a certified dietician and were instructed in maintaining a food dairy. During the study period they received weekly telephone calls to ensure compliance, tackle any practical difficulties, motivate participants and ensure they fill the 24-hour food diary. After the completion of 3 months, they underwent repeat testing of the baseline parameters (anthropometry, blood glucose, HbA1c, fasting lipids and a Montreal cognitive questionnaire) to check for difference. RESULTS: Of the total of 50 participants who under randomization, 47 completed the study. The median decrease in HbA1c was -0.2% (-0.5 — 0.2) and -0.2% (-0.9 — 0.2) in the standard diabetic diet and the whole food plant-based diet respectively. Both diets also showed a trend towards a reduction in the body weight and fasting lipid profile. There was no difference between the diets in any of the outcomes assessed. There were no major adverse events noted in our study. CONCLUSION: In patients with type 2 diabetes mellitus, both the standard diabetic diet and the whole food plant-based diets are dietary options that can be advised

A Prospective and Retrospective study on Factors Determining Operative and Non-Operative Management in Blunt Injury Abdomen

INTRODUCTION: The main cause of trauma is Road Traffic Accident which alone accounts for more than 1 million deaths per year and liability of 20-50 million people. In 1982, the trimodal distribution of death has been described for injuries. In case of blunt injury abdomen, the third peak can be prevented with adequate ICU setup, proper and serial patient care. It is due to sepsis and multiple organ dysfunction. This management of blunt injury abdomen is a multimodality approach with early recognition, resuscitation and severity grading with analyzing the clinical status, radiological findings. These combined factors with the presence of ICU care with close monitoring/ tertiary setup may help us in conservative management in blunt injury abdomen in certain hemodynamically stable patients. AIM/ OBJECTIVE OF THE STUDY: The aim of this study is to analyse the various factors involved in and which determines the management in blunt trauma abdomen: 1.operative (surgeries) 2.non-operative (conservative, pigtail insertia, angioembolisation) Management. The various factors analysed are • Age of the patient. • Time of presentation. • Latent period between presentation and resuscitation. • Hemodynamic stability during the course of hospital. • Per abdominal examination findings. • eFAST/ CT severity grating-AAST grading. • Isolated injury or associated with other injuries. • ICU care with close monitoring. • Immobilization followed by restricted mobility. • Initiation of oral diet. METHODOLGY: STUDY DESIGN: Hospital based PROSPECTIVE AND RETROSPECTIVE OBSERVATIONAL STUDY with a sample size of 60. STUDY POPULATION: SINGLE CENTRE- RAJIV GANDHI GOVERNMENT GENERAL HOSPITAL-Patients coming to Trauma ward with Blunt Trauma Abdomen. INCLUSION CRITERIA: • All the patients of age more than 14 years of both male and female sex presenting with blunt injury abdomen. • Patients associated with radiographical documentation of Liver, Spleen, Kidney, Pancreas, Hollow viscus (Bowel and Urinary Bladder). EXCLUSION CRITERIA: • Age less than 14 years. • Penetrating trauma to abdomen. • Patients with major head injury and polytrauma. RESULTS: ➢ In the current study, patients with blunt injury abdomen, most of them were males accounting to 88%. The average age of the participants was 32.62 years, with the vast majority (68%) falling within the age range of 21 to 40. ➢ The commonest mode of injury in our study was RTA (76.7%). ➢ In our study, 33% had Liver injury, 32% had Splenic injury. In the liver injury, 75.07% were managed conservatively and 24.9% non-conservatively. Amongst the Splenic injury, 65.2% were managed non operatively and 34.71% were managed by operative procedures. With positive clinical findings, 6.7% in the current study had grade III splenic injury, 3.3% with grade II liver injury, 3.3% with grade IV liver injury. ➢ When the latent period between presentation after injury and resuscitation is less, more patients are going into conservative management as within 1-5 hours, 71.4% of the patients went into conservative management as compared with 28.5% of the patients who were operated. When the patients were presented after 56 hours nearly 75% of the patients were operated as compared with 25% of the patients who were managed conservatively. ➢ Positive clinical per abdomen findings plays an important role in deciding the line of management. ➢ eFAST was positive in 68% while it was negative in 31%. Out of 60 patients, 13% were managed conservatively and 21% non conservatively. i.e., 38% conservatively and 61.7% by operative methods in eFAST positive patients. ➢ 53% of the individuals were admitted in ICU while 46% were managed in ward who required operative management. 41.17% were admitted in ICU whereas 58.8% were not. ICU admission helps in early identification of operative management. ➢ In conservative management the mean days of immobilization are 8-14 days in which 26% of them were managed. In operative line of management, the mean days of immobilization are 0-7 days in which 18% of them were managed. In conservative management the death is after 15 days and that is after immobilization.i.e., 2%. ➢ 48% of the study respondents were managed conservatively, 5% needed icd insertion for pneumothorax, emergency laparotomy with splenectomy was done in 5%, bladder repair in 1.7%, nephrectomy in 1.7%, emergency laparotomy with packing was done in 3.3%. in total 56.7% were managed with non-operative management and 43.3% were operated. ➢ There is significant mean difference between operative and non-operative procedure when compared with latent period, pulse rate, immobilisation days which is statistically significant with p-value<0.05. The mean pulse rate in conservative management is 96/min, whereas it is 131/min in operative management. CONCLUSION: In Blunt Trauma Abdomen, there is significant relation between the latent period and line of management, initial resuscitation with fluids and blood with close monitoring is crucial to decrease the operative management in solid organ injuries. There is significant relation between tachycardia, hemodynamic instability and operative management. When there is massive hemoperitoneum with hemodynamic instability or activation of massive blood transfusion protocol, then emergency surgical intervention should be considered. Hollow viscus perforation needs prompt and early surgical intervention. Delay in its management increases the morbidity and mortality. Positive per abdominal findings with bedside eFAST in addition to ICU care with close monitoring has a significant role in early decision for surgery

Efficiency of Blunt Abdominal Trauma Severity Score (BATSS) in Predicting the Necessity of Laparotomy in Blunt Abdominal Trauma

INTRODUCTION: Abdominal trauma is one of the most common causes among injuries caused due to road traffic accidents. Motor vehicle accidents account for 75 to 80% of blunt abdominal trauma. Blunt injury of abdomen is also a result of fall from height, assault with blunt objects. Sport injuries and fall from riding bicycle. Blunt abdominal trauma is usually not obvious. The knowledge in the management of blunt abdominal trauma has progressively increased due to the inpatient data gathered from different parts of the world. In spite of the best techniques and advances in diagnostic and supportive care, the morbidity and mortality remain at large. The reason for this could be due to the interval between trauma and hospitalization, delay in diagnosis, inadequate and lack of appropriate surgical treatment, post operative complications and associated trauma especially to head, thorax and extremities. In view of increasing number of vehicles and consequently road traffic accidents, this dissertation has been chosen to study the case of blunt abdominal trauma with reference to the patients presenting at RAJIV GANDHI GOVERNMENT GENERAL HOSPITAL, MADRAS MEDICAL COLLEGE, CHENNAI. AIMS AND OBJECTIVES: Abdominal trauma is the third leading cause of death in trauma patients after head and chest with majority of cases being non penetrating or so called BLUNT ABDOMINAL TRAUMA (BAT). The main causes of BAT are motor vehicle crashes, direct traumas and fall from height. More than 50% of mortalities due to crashes led BAT are preventable and under this circumstance IN TIME LAPAROTOMY plays a major role. However difficulty in diagnosing patients with intraabdominal injuries explains the real need for an accurate and in hand method to evaluate the patients who require further surgical intervention like laparotomy. Frequently FAST is used. Since the ability of FAST in determining the necessity of laparotomy is blurred, a better applicable scoring system for selection of patients suspected with BAT is sought to make easy triage to save time, reduce unnecessary CT scans, radiation exposures and cost for diagnosis and treatment. To obtain blunt abdominal trauma patients signs as well as clinical data and to clarify the accuracy, sensitivity, specificity, negative and positive predictive value of BLUNT ABDOMINAL TRAUMA SEVERITY SCORING (BATSS) and its effectiveness in predicting the need for laparotomy. MATERIAL AND METHODS: The study was carried out in Institute of General Surgery, MADRAS MEDICAL COLLEGE AND RAJIV GANDHI GOVERNMENT GENERAL HOSPITAL. All injured patients were brought to an emergency resuscitation area where primary-survey, resuscitation, and a secondary survey in a standard method were conducted and clinical findings noted. Pulse rate, saturation and blood pressure recorded and all basic blood investigations carried out. The Focused Assessment with Sonography for Trauma (FAST) investigation was performed during primary-survey, after securing airway and establishing adequate oxygenation/ ventilation. The FAST investigation was classified as positive (clearly showing fluid on at least one window), or negative. No quantitative score system will be used for the quantity of fluid seen. CONCLUSION: This scoring will help in better triage of the trauma patient on arrival and reduce the need for further imaging and reduce the time interval between arrival and surgical intervention. With reduction in need for further imaging, it also provides additional benefit by reducing exposure to unnecessary radiation, administration of contrast and reduction in costs, overcrowding of casualty departments and possibility of immediate referral to a tertiary care trauma centre due to inadequate infrastructure to manage a case of blunt abdominal trauma. We conclude by stating that the Blunt Abdominal Scoring System (BATSS) is an excellent predictor of intra-abdominal injury and can be used as a tool by physicians/paramedics in referral/monitoring of high-risk patients in a resource limited setting