The Efficacy of World Society of Emergency Surgery Classification in the Management of Splenic Injury: An Observational study

INTRODUCTION: • The spleen is the most frequently damaged organ in trauma to the abdomen of any cause • An unrecognized splenic injury is a very preventable cause of severe hypovolemic shock and traumatic death • It is the most vascular organ in the body, hence bleeding from splenic injuries is arterial, and can cause significant hemoperitoneum. Bleeds from the spleen are mainly intraperitoneal. • Any lower left chest or upper left abdominal trauma has the propensity to carry the risk of injury to the spleen. It is highly vulnerable to injury during trauma due to its juxtaposition in tge left upper abdomen to the 9th, 10th and 11th ribs. The trauma can be penetrating, blunt, or indirect trauma (tear in the splenic capsule during traction exerted on the splenocolic ligament) • The spleen is a very important organ in terms of its function in the immunity process, and lymphopoeisis. The normal splenic function is essential for carrying out opsonisation of encapsulated organisms and in the subsequent immune response mounted by the body against them. AIMS AND OBJECTIVES: Primary objective: To assess the efficacy of the WSES (World society of Emergency surgery) classification in becoming a heralded standard algorithm for the management of splenic injury. Secondary objective: To assess effect on patient morbidity and mortality following the use of this algorithm To employ the WSES classification in order to: - Categorize patients suffering from splenic injury - Guide the management of said patients as per the category they are placed under - To assess the morbidity and mortality data. MATERIALS AND METHODS: Sample size : 65 cases. Study design : Observational study (Prospective & Retrospective). Study population : 65 cases. Study period : August 2021 to August 2022 (1 year). Study Centre : Institute of General Sugery, Madras Medical College, Rajiv Gandhi Government General hospital, Chennai SUBJECT SELECTION: Inclusion criteria: 1. Age more than 15 years. 2. Patients of blunt trauma to the abdomen. Exclusion criteria: 1. Paediatric population (age less than 15 years). 2. Patients who died before complete diagnostic workup. 3. Patients with penetrating trauma to the abdomen. RESULTS: The data collected during the study was formulated into a master chart in Microsoft office excel and statistical analysis was done with help of computer using statistical software package SPSS V.21 for windows. Using this software, frequencies, range, mean, standard deviation and ‘p’ value were calculated through independent sample ‘t’ test and also univariate analysis was done using chi square test to find out the association between the variables. p value of < 0.05 was taken as statistically significant. CONCLUSION: The aim of this study was to suggest the WSES classification as a standard in trauma centers for the stratification of splenic injuries and their subsequent management. From the results of the study discussed above, it can be inferred that age of the patient, systolic blood pressure at arrival, number of packed cells transfused, AAST grade, as well as the WSES category were all influencers of the ultimate outcome of the patient and the success of whichever line of management was decided upon in the emergency room. It can be said with a degree of confidence that in the present day, the failure of non-operative management has drastically reduced and that it is no longer associated only to the AAST grade of the lesion. The physiopathological status of the patient, rather than the anatomy of the splenic injury, should guide the therapeutic decision making. From the study, it is learnt that all the factors that related to operative management and failure of non-operative management were in relation to the physiopathological status of the patient rather than the anatomy. This brings the WSES classification to the forefront, as it considers the physiological parameters from the beginning, and hence influences the stratification of patients differently. The current school of thought is to embrace non-operative management rather than perform rampant splenectomies, and in order to avoid unnecessary surgery, it is imperative to know what to do for which patient as a standard protocol that can be employed by all trauma centers with adequate facilities to undertake non-operative management. According to our study, WSES IV represents the only factor related to proceeding with operative management immediately, thus proving that the hemodynamic status is the only determinant of the necessity to proceed to the operating room. The large-scale application of the WSES classification has the potential to realistically increase the rate of non-operative management and improve and standardize management of splenic injury. It also allows to reduce the rate of splenectomy and thus improve the short and long-term survival of the patient

Association Between Blood Urea Nitrogen (Bun) to Creatinine Ratio and Outcome in Patients with Upper Gastrointestinal Bleed at a Tertiary Care Hospital in Chennai

INTRODUCTION: Upper Gastrointestinal bleeding (UGIB) is one of the most common gastrointestinal presentation in Emergency Department. Several risk factors for UGI bleed have been identified to assist physicians for managing and predicting treatment outcomes. Some parameters such as Age, Albumin, level of consciousness, Heart rate and Systolic Blood Pressure and INR can be used to predict risk of mortality prior to Endoscopy. Early identification of high risk patients and urgent interventions like use of medications, blood transfusions, urgent endoscopic therapy improves outcomes. AIM OF THE STUDY: To determine if Blood Urea Nitrogen to creatinine ratio is associated with short term outcomes in patients admitted with Upper GI bleed. OBJECTIVE OF THE STUDY: Is Blood Urea Nitrogen to Creatinine ratio associated with short term outcomes in patients admitted with upper GI bleed. MATERIALS AND METHODS: using pretested proforma, patient details, history and clinical findings and investigations were documented. Descriptive study was conducted for a duration of 6 months from approval of study. RFT repeated at 24 hrs. BUN calculated from blood urea by dividing by a factor of 2.14. The BUN/Cr ratio was then calculated. The patient were followed up during the entire hospital stay. The intervention received by the patient, the endoscopic findings, and their clinical course in the hospital were noted. RESULTS: In our study patients, 53 (55.2%) were observed with less than 30 BUN/CR ratios whereas 43 (44.8%) patients were reported with a BUN/CR ratio of more than 30. In our study of all 50 patients with a BUN/CR ratio of more than 30, the majority of patients 31 (62%) were reported with mortality. Whereas of 46 patients having a BUN/CR ratio less than 30, only 7 (15.2%) patients were found with mortality. In our study 57 (59.4%) required ICU care and 39 (40.6%) patients recorded no ICU care requirement. When ICU care was correlated with the BUN/CR ratio it was found that of all 57 patients requiring ICU care 38 (88.4%) patients were recorded with a BUN/CR ratio of more than 30. Whereas in patients with no requirement of ICU care majority 34 (64.2%) reported with BUN/CR ratio of less than 30. CONCLUSION: In our study, a BUN/Cr ratio of >27.5 was identified as an independent risk factor for mortality and upper GI bleeding and may be useful for pre-endoscopic evaluation

A Study of Serum Fibrinogen Level and Its Prognostic Significance in Patients with Acute Ischemic Stroke

INTRODUCTION: One of the leading causes of illness and mortality worldwide is acute ischemic stroke. The incidence seems to always be on the rise due to changing lifestyles. The patient must receive prompt attention and the proper care to survive. Serum fibrinogen level is a prognostic biomarker for acute ischemic stroke patients because they had a higher mortality rate when they admitted with high levels of fibrinogen. Plasma fibrinogen level is a simple marker which can be used to identify patients who are at risk. OBJECTIVES: To study the prognostic importance of serum fibrinogen in acute ischemic stroke in a series of 70 cases. METHODOLOGY: This is a Prospective cross-sectional study, among 70 patients both male and female presenting as Acute Stroke, admitted under the Department of Internal Medicine, Thanjavur Medical College and Hospital, Thanjavur. Relevant clinical history, clinical examinations, biochemical parameters especially the serum fibrinogen levels were compared with the outcomes of the study population. Prognostic value of the serum fibrinogen levels were analysed. RESULTS: The mean Serum Fibrinogen (mg/dl) among the subjects was 396.36 (± 114.68) mg/dl ranging from 60 to 649 mg/dl. The mean Serum Fibrinogen (mg/dl) among Death was significantly higher compared to the subjects who Discharged. Age, smoking, alcoholism, blood pressure, hypertension status, blood sugar, Diabetic status were not associated with Serum Fibrinogen level. Female gender, ischemic stroke, severe cases in Scandinavian Stroke Scale, higher Modified Ranking Score at discharge and admission, had significantly higher levels of Serum Fibrinogen level. The cut off for predicting Outcome is 505 which had a sensitivity of 75%, specificity of 98.39%, positive predictive value of 85.71%, negative predictive value of 96.83% and a diagnostic accuracy of 95.71%. The area under the curve for Serum Fibrinogen (mg/dl) in predicting Outcome is 0.864 (0.637 - 1). CONCLUSION: Serum fibrinogen levels can be used to predict the prognosis in patients affected with acute ischemic stroke

Serum Chloride Level as a Prognostic Indicator in Acute Decompensated Heart Failure

BACKGROUND: Chloride plays a critical role in plasma electroneutrality, acid-base homeostasis, and the stimulation of neurohormone systems like the RAAS. The effects of serial changes in serum chloride, however, on morbidity and mortality in ADHF patients during hospitalisation have not been thoroughly documented. Diuretics are recommended in clinical guidelines for the treatment of HF, however not to reduce mortality but rather to lessen symptoms and hospitalizations. The mainstay of the early management of acute HF is systemic diuretic decongestion. Due to the increase of sodium and water uptake in the loop of Henle, low blood chloride levels can result in impaired diuretic response. With these factors in mind, this study was carried out to determine the relationship between serum sodium levels and the influence of admission serum chloride concentrations on the length of hospital stay in HF patients. OBJECTIVES: To study the impact of admission Sr. Chloride levels on stay duration in ADHF and to assess the outcome, morbidity, mortality in patients presenting with ADHF. METHODS: This study was conducted as observational cross sectional study in the department of General medicine in Thanjavur Medical College among cases with ADHF during November 2021 to August 2022. A total of 170 cases with ADHF were included in the study. Ethical committee approval was obtained for this study from the Institutional Human Ethics Committee Principal investigator assessed the detailed history of the participants and clinical examination was done. Sr. electrolytes were done on the patients on the day of their admission. Patients are followed up till discharge from the hospital and assessment was done on stay duration in hospital, mortality outcomes also assessed in association with Sr. Cholride level. The data was entered in excel sheet and analyzed using SPSS (Version 19). RESULTS: In the present study among the study participants Dilated CM was diagnosed among 31.8% of the study cases while 50.6% of the cases had Ischemic CM. Chloride level at the time of admission was noted to be 101 meq/L among 27.6%, 52.4% and 20% of the cases respectively in this study. On assessing the difference between admission serum Cl levels with other clinical parameters, age, SBP, DBP, Serum Sodium, LVEF, duration of stay in hospital and mortality were found to be significantly differs with serum chloride levels where as the parameters like gender, BMI, presence of DM, hypertension, dyslipidemia, previous history of MI, CKD, COPD, habit of amoking, alcohol consumption, medications, type of cardiomyopathy, Hemoglobin, Serum Urea, Serum Creatinine, Serum potassium and AF were found to be similar in all groups of serum chloride without any significant difference. CONCLUSION: We conclude that admission serum chloride among the cases with ADHF had a strong impact on the prognosis and duration of hospital stay. Hence it is important to assess the serum chloride levels during the time of admission, with which we can assess the likely duration of hospital stay and the prognosis also