Comparison of post-dural puncture headache- incidence and severity in obstetric patients after spinal anesthesia for caesarean section with 25G and 27G quincke needle

Background: The use of neuraxial anesthesia for caesarean section has dramatically increased in last 2 decades because it is easier to perform, safe to the mother and the fetus, and has a high degree of success rate. However, post-dural puncture headache is a well-known complication of spinal anesthesia. It is a common and incapacitating compliation following dura-arachnoid puncture and results in increased morbidity, prolonged hospital stay, increased cost, and patient dissatisfaction.Methods: It was a double-blinded comparative study conducted on 75 consecutive pregnant patients meeting the inclusion criteria of the study. Patient and anesthesiologist involved in collection of data were blinded to the gauge of the needle used. Standard anesthesia protocol was followed in all the patients and spinal anesthesia performed using 25G Quincke needle in 38 patients and 27G Quincke needle in 37 patients.Results: we included 75 consecutive patients in the age group 20-35 years in the study. Overall incidence of PDPH was 14.67% (11/75) in present study. 23.68% (9/38) and 5.4% (2/37) patients who received spinal anesthesia with 25G and 27G needles respectively developed PDPH. Difference was statistically insignificant.Conclusions: The incidence of PDPH was less in patients who underwent caesarean section under spinal anesthesia with 27G needle compared to that of patients in whom block was performed using 25G needles. However, there was no definite advantage of 27G Quincke needle over 25G Quincke needle as far as the incidence of PDPH is concerned

A review of the blood transfusion practices in neuroanesthesia in the perioperative period in a tertiary care hospital

Background: Blood transfusion involves the administration of blood and blood components. Neurosurgical procedures are associated with significant blood loss with the need for blood transfusion in the preoperative, intraoperative and postoperative period to maintain optimal hemodynamic and cerebral oxygenation. Various neurosurgical procedures as traumatic brain injury, complex spinal surgeries, and endovascular neurosurgical procedures may need blood transfusions to maintain the optimal physiology.Methods: This study was performed prospectively at a tertiary care hospital in northern India with about a work load of 800 to 1000 elective neurosurgical surgical procedures being done per year. This data was collected prospectively over a period of one year from the patients being operated for elective neurosurgical procedures and later on shifted to the neurosurgical intensive care unit and the neurosurgical wards. The patients operated for emergency procedures for traumatic brain surgery were not included in the study.Results: A total of 455 elective neurosurgical procedures were done during the study period. Out of these 455 patients there were 95 patients who were in the paediatric age group with age less than 12 years. Out of 360 adult patients 85 patients were in need of blood transfusion which constituted 23.6 percent of the operated patients.   Out of these 85 patients 45 patients needed two transfusions in the form of whole blood or packed cells, 40 patients needed a single transfusion.42 units of fresh frozen plasma were transfused to 17 patients with 15 patients receiving platelet transfusions.Conclusions: In conclusion, neurosurgical population is associated with significant blood loss and a requirement of blood transfusion. About 47 percent of paediatric population needed blood transfusion in our study with around 24 percent of adult population. The transfusion requirement was mainly seen in patients with craniostenosis, meningiomas, cerebello pontine tumours and meningiomas

Negative pressure wound therapy: eleven-year experience at a tertiary care hospital

Background: Management of complicated wounds is a reconstructive challenge. A reconstructive surgeon has to be ready to face new challenges every day. Negative pressure wound therapy has revolutionized the management of complex wounds. We are presenting our experience with this wound care modality in the past 11 years.Methods: It was a prospective study conducted from January 2006 to December 2016 on patients having wounds of varied etiologies, who consented to participate in this study. Custom made low cost NPWT was used till definitive wound closure.Results: A total of 568 patients consented to participate in the study during these 11 years. No major complications were seen. Most of these were males (60.73%) in their 3rd and 4th decade. Trauma was the leading cause of wounds in 38.14%, followed by diabetic foot wounds in 21.5%. Ankle and foot was the most common site of wounds (30.92%) followed by leg (24.01%). A total of 322 small, 218 medium and 97 large size dressings were used. Most of the patients improved with the NPWT.  No major complications were seen.Conclusions: NPWT is safe, effective and has proved to be revolutionary in managing difficult wounds. With the use of customized low cost NPWT the benefit can be extended to underprivileged population in under developed nations too

Reconstruction of soft tissue defects in Fournier’s gangrene at a tertiary care centre

Background: Fournier’s gangrene is an acute and potentially lethal multi-bacterial necrotizing infection that primarily involves the scrotum but may extend beyond its confines to perineum and abdominal wall. The disease may result in sepsis and death if treatment is delayed. Management consists of timely diagnosis, aggressive debridement, broad-spectrum antibiotics followed by reconstruction which still remains a surgical challenge.Methods: It is a prospective study conducted from Jan 2006 to Dec 2015 on 29 patients of Fournier’s gangrene who were referred to the department of Plastic and Reconstructive Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, for reconstruction after initial debridement by general surgeon/urologist. The patient’s age, predisposing factors, site and the size of the defects, reconstructive options used and outcome were evaluated. Assessment of testicular function was done at 6 months by sperm count and morphology.Results: A total of 29 patients of Fournier’s gangrene consisting of 28 males and one female were included in the study. The mean age was 37 years and the most common comorbidity was diabetes mellitus in 18 patients (62%). Wounds were allowed to heal by secondary intension in 8 patients. Scrotal advancement flap was done in seven patients. Split thickness skin grafting (STSG) of extensive wounds was done in 11 patients and testes were placed in medial thigh subcutaneous pocket in one patient. Two elderly diabetic patients succumbed to sepsis and multi organ failure. Overall complication rate was 18.5%.Conclusions: Thorough debridement and early wound cover are essential in the management of Fournier’s gangrene for successful rehabilitation. Various reconstructive options are available with no conclusive evidence to support flap rather than skin graft and most of the procedures result in preservation of testicular function in the long term

Two stage flexor tendon reconstruction in hand: our experience

Background: Flexor tendon injuries in the digital flexor sheath area (zone II) are the most difficult to treat and remain a focus of both clinical attention and basic investigations. This prospective study was designed to evaluate the results of staged zone II flexor tendon repair.Methods: Seventy digits in thirty five patients were treated by Two Stage flexor tendon reconstruction and followed for an average of one and a half year. The procedure included placing a silicone catheter (cut to desire size) as an active implant and reconstruction of A2, A4 or both pulleys if damaged in first stage. During the second stage (performed three to eight months later), tendon graft replaced the silicone catheter in the pseudo sheath formed around the catheter. The proximal end of the transplanted tendon was fixed with flexor digitorum profundus tendon of respective finger using the Pulvertaft method, and the distal end of the graft was fixedwith the distal stump of respective flexor digitorum profundus tendon. Early controlled motion protocol was instituted in all cases.Results: As per Buck Gramcko scale total active motion obtained was Excellent in 70%, Good in 20%, Fair in 7.1%, and Poor in 2.9% of patients.Conclusions: Flexor tendon reconstruction using two stage tendon reconstructions is an effective way to restore digital tendon function in delayed zone II flexor tendon injuries

Closure of anterior palatal fistula using tongue flap: our experience

Background: Palatal fistula is one of the most common complications following cleft palate repair. It occurs mostly due to tip necrosis of palatal flaps. Small palatal fistulas are usually closed by transposition of adjacent tissues, however these local tissues are not sufficient for the closure of bigger fistulas. The tongue flap serves as a reliable and most easily obtainable local flap for closure of large sized palatal fistulas.Methods: This is a prospective study conducted from Aug 2006 to July 2015 in the department of Plastic & Reconstructive Surgery, SKIMS, Srinagar, Jammu Kashmir, India. A total of 25 patients with large anterior palatal fistula were treated using anteriorly based tongue flap. Patients were selected on the basis of size of fistula (> 1x1 cm), scarred local palatal tissue or history of fistula recurrence after previous attempts of closure using local palatal tissues.Results: In present study 25 patients of palatal fistula were treated using tongue flap. Eighty percent patients were in the age group of 3 to 5 years. Male-to-female ratio was 2:3. The largest dimension of treated fistula was 4x3 cm. There was partial dehiscence of flap suture line in two patients while remnant fistula was observed in three patients. None of our patients had flap necrosis.Conclusions: Tongue flap is an excellent and versatile option for closure of large palatal fistulas with high success rate and least morbidity

Results of snodgrass repair.

Objectives: Snodgrass repair is fast becoming the procedure of choice in distal penile hypospadias. Multiple series document excellent cosmetic outcome in conjuction with low complication rates. Study Design: Prospective. Material & Methods: A prospective study of 26 patients in whom Snodgrass repair for distal penile hypospadias was done over a period of two and a half years. All patients with hypospadias other than distal penile were excluded from the study. Results: Mean age of the patients was 6.2±3.2years. Mean operative time was 68.7 minutes. Mean hospital stay was 15.4 days. Wound infection, bleeding/haematoma and urethrocutaneous fistula were the three complications seen in our patients with equal incidence (3.8%). Cosmetic as well as functional outcome was very good in our patients. Conclusions: Snodgrass Repair has revolutionised the management of distal penile hypospadias. Meticulous technique coupled with careful patient selection permit a high rate of success with minimal morbidity

Footboards: Indigenous and novel method of screening for diabetes peripheral neuropathy – A pilot study

Background: To validate the effectiveness of indigenously designed “footboard (FB)” in early diagnosis of diabetic peripheral neuropathy (PNP) by comparing it with Semmes–Weinstein monofilament (SWM) and vibration perception (VP). Materials and Methods: Two hundred and forty-four patients with diabetes were examined for PNP using SWM and 128 Hz tuning fork. The findings were compared with indigenously designed FBs with 1, 2, and 3 mm elevations. Results: Out of 108 patients who did not have protective sensation as per SWM, only 10 (9.2%) felt 1 mm board bearings, and out of 72 patients who did not feel vibration, only 8 (11.1%) felt 1 mm board bearings. Out of 136 patients who had protective sensation, 128 (94.11%) felt 2 mm elevated board bearings, and out of 172 patients who had VP, only 152 patients (88.3%) felt 2 mm board bearings. With SWM as standard, the sensitivities and specificities, respectively, were 63% and 90% (1 mm board), and 94% and 60% (2 mm board). With VP, the sensitivities and specificities, respectively, were 59% and 90% (1 mm board), and 88% and 61% (2 mm board). Conclusions: FB, which simultaneously tests touch and pressure sensation, shows a high level of performance in detecting at-risk feet. FB may be simple, time-efficient, and inexpensive test for detection of neuropathy and needs further validation in a larger study

Contralateral lumbo-umbilical flap: A versatile technique for volar finger coverage

Background: While contemplating any difficult soft tissue reconstruction, patient comfort and compliance is of paramount importance. Reconstruction of the volar aspect of fingers and hand by the ipsilateral pedicled flaps (groin flap, abdominal flaps) is demanding as the flap inset is difficult for the surgeon and very uncomfortable for the patient. This often leads to flap complications. For the comfort of the patient, better compliance and ease of complete inset, we planned to manage soft tissue defects of the volar aspect of fingers and hand by a new contralateral pedicled lumbo-umbilical flap. This flap is based on the paraumbilical perforators of deep inferior epigastric artery. Materials and Methods: The contralateral pedicled lumbo-umbilical flap was used in eight patients with high-tension electrical burn injuries involving the volar aspect of fingers and hand. The patients were closely observed for first 6 weeks for any flap or donor site complications and then followed monthly to assess donor and recipient site characteristics for 6 months to 2 years. Results and Conclusion: Large flaps up to 8 cm × 16 cm were raised. All but one flaps survived completely. All patients were mobilised within 48 h and five were discharged in less than a week after initial inset. The flap is reliable, easy to harvest and easy to inset on the volar aspect of fingers. The arm is positioned in a very comfortable position. The main disadvantage, however, is a conspicuous abdominal scar