Respiratory Morbidity and Mortality of Traumatic Cervical Spinal Injury.

BACKGROUND: Traumatic cervical spinal injuries can severely affect respiratory function and cause significant morbidity and mortality. The typical respiratory morbidity in cervical spine injury is Atelectasis, Ventilator-associated pneumonia, acute respiratory distress syndrome and delayed weaning, etc. The study aims to see the prevalence of respiratory morbidity as well as mortality associated with cervical spine injury. METHODS: Cross sectional study based on retrospective data was conducted on the X Sciences with the existing hospital record during the period of 3 years to find out the prevalence respiratory morbidity like Ventilatory Associated Pneumonia, delayed weaning, ARDS, atelectasis of traumatic cervical spine injury, determine the prevalence, type, and impact of respiratory morbidity and mortality in this population. RESULTS: Total no 76 patients data meeting the inclusion criteria included in study. Male patients were more prone to develop traumatic cervical spinal injuries (SCI). The prevalence of respiratory morbidity in term of VAP(57.89), delayed weaning(46.05) and Atelectasis(22.36) was high. Patients with Asia A Neurology has higher association for VAP and delayed weaning, while Asia E Neurology patients had no respiratory morbidity. The study found a significant positive association between respiratory morbidity with hospital stay, and ventilator days (p-value: 0.019 and 0.048). A total of 15 patients died, 28.95% were discharged on request and 40.8% leaving the hospital against medical advice. CONCLUSIONS: The prevalence of respiratory morbidity higher in cervical spine injury. Furthermore, it has associated with prolonged ICU and ventilator days and increase in mortality.

Clinical Outcome for Lumbar Disc Herniation Treatment with Intradiscal Oxygen-ozone Therapy.

BACKGROUND: Low back pain due to disc herniation is a common problem causing frequent hospital visits and loss of working days with major socio-economic impact. Conservative treatments like analgesics, physiotherapy do not work in all patients. Surgical treatment has been the mainstay of treatment when indicated but is associated with anesthetic and surgical complications. Intradiscal oxygen-ozone chemonucleolysis is a minimally invasive procedure done under local anesthesia and has promising role in shrinking the bulged disc and reducing nerve root compression and related symptoms. This retrospective study was done to see how intradiscal oxygen-ozone chemonucleolysis reduces pain severity in patients with discogenic low back pain. METHODS: Retrospective data were retrieved of those patients who underwent fluoroscopy guided intradiscal oxygen-ozone chemonucleolysis with 5-6 ml of an O2-O3 mixture (concentration of 30 microgram/ml) during a period of two years in Nepal pain care and research center. Numerical pain scale (NRS) at various follow ups were compared to preprocedural NRS. RESULTS: Preprocedural NRS was 8± 13. NRS at three hours, one week, one month, three months and six months were 2± 13 (73 percent reduction), 2± 53 (68 percent reduction), 2± 27 (72 percent reduction), 1± 08 (77 percent reduction) and 1± 67 (79 percent reduction) respectively. CONCLUSIONS: Intradiscal oxygen-ozone chemonucleolysis can be a useful modality of treatment for discogenic low back pain in patients who fail to respond to conservative management and in whom surgery is not indicated.

Ileocecal knotting as a rare cause of small bowel obstruction: a case report.

Introduction: Ileocecal knot syndrome, a rare cause of small bowel obstruction where the ileum wraps around the cecum, poses a significant challenge for preoperative diagnosis. Prompt intervention is crucial due to the risk of rapid bowel deterioration and increased mortality. Case presentation: A 45-year-old female presented with central abdominal pain associated with vomiting, abdominal distension, and obstipation. On examination, she was ill-looking with hypotension, tachycardia with a feeble pulse, direct and rebound abdominal tenderness, and absent bowel sounds. Aggressive fluid resuscitation was done. Based on the clinical presentation and abdominal radiograph suggestive of intestinal obstruction, an emergency exploratory laparotomy was done, which showed an ileocecal knot and 130 cm of gangrenous ileum. Peritoneal lavage followed by resection of non-viable ileum with double barrel ileostomy was done. Discussion: Ileosigmoid, appendico-ileal, ileoileal, and ileocecal knotting are the various types of intestinal knotting, with very few cases of ileocecal knotting being reported. Intestinal knotting causes severe bowel obstruction, resulting in reduced mucosal perfusion, progressive ischemia, and peritonitis, leading to high mortality. X-ray findings of multiple air-fluid levels are non-specific, and for definitive diagnosis, laparotomy is required. Assessing bowel viability before definitive surgery is essential. Despite positive outcomes, extensive resection can lead to malabsorption and ileus, with potential risk for developing short bowel syndrome. Conclusion: Despite its rarity, the possibility of ileocecal knotting should be considered in cases of small bowel obstruction due to its potential for rapid deterioration. Prompt resuscitation followed by emergency laparotomy is necessary to prevent mortality.

Ultrasound Guided Nerve Blocks for Anterior Cutaneous Nerve Entrapment Syndrome an Overlooked Cause of Chronic Abdominal Pain: A Case Series.

Entrapment abdominal neuropathy is not a common diagnosis in our context. Chronic Abdominal wall pain is often mistaken for gastritis, gynecological issue, thoracic spinal radiculopathy, rectus sheath hematoma, abdominal muscle injury or psychiatric disorder. Anterior cutaneous nerve entrapment syndrome is one of the frequent causes of abdominal wall pain occurring due to trapped thoracic intercostal nerves between abdominal muscles. History and bedside Carnett's sign can elicit the diagnosis. Injection of the local anesthetics with steroids in the junction between the rectus sheath and abdominal muscle under ultrasound guidance can provide sustained pain relief. We should consider Anterior cutaneous nerve entrapment syndrome as a differential diagnosis while evaluating the abdominal wall pain. Keywords: ACENE; carnett's test; chronic abdominal pain; entrapment neuropathy; hydrodissection.

Metastases after mastectomy for ductal carcinoma in situ of the male breast; A case report.

Introduction: and importance: Male breast cancer is a rare entity. Ductal carcinoma in situ (DCIS), constituting 10% of all male breast cancer, is confined within the breast ducts and lobules, rarely metastasizing and even less so after mastectomy. Case presentation: A 71 years old male with no history of trauma presented with pain, swelling, and deformity of the left arm. He had continuous back pain for 6 months and a history of mastectomy of the right breast. Fracture of shaft of the left humerus was detected on X-ray. Computed tomography (CT) showed multiple vertebral metastases later confirmed to be metastasized from the breast by biopsy. Tumor cells were progesterone receptor (PR) positive, estrogen receptor (ER) negative, and human epidermal growth factor receptor 2 (HER2) negative. The fracture was treated and the patient was kept on Tamoxifen. On follow-up after four months, the patient is doing well with relief of back pain. Clinical discussion: Despite mastectomy and the histopathological diagnosis of pure DCIS, distant metastases can occur even in absence of locoregional recurrence. Therefore, the aggressive phenotype of DCIS rather than diagnostic or treatment variables can be thought to bring worse outcome in the form of metastases. Early hormonal status identification and hormone therapy could result in a better outcome. Conclusion: Skeletal metastases should be strongly suspected in patients presenting with bone pain and having a history of DCIS of the breast, even after mastectomy. Even though distant metastasis after mastectomy is rare, regular follow-up and surveillance is necessary.

Epidemiology of Trauma Patients Presented at Emergency Department of Trauma Center.

BACKGROUND: Emergency Department of National Trauma Center Nepal Center is the only specialized trauma care hospital in Nepal, in operation since 2012. Traumatic injury is one of the major causes for mortality worldwide. This study aims to see the epidemiology, pattern of injuries and outcome of the patients presenting to the emergency room. METHODS: After getting ethical approval, we included all patients presenting to the Emergency Department with at least one injury, between Jan 2018 to Dec 2020. Informations on age, gender, mechanism of injury and outcome was abstracted for all patients presenting to the emergency department. Data were extracted from hospital database with the permission of hospital authority. RESULTS: Total of 49991 patients presented to emergency department with different types of injuries.  Among them 7792 (14.0%) needed hospital admission. Fall and road crashes comprised almost 80% of admitted cases. Mortality was 2.1% of admitted patients, mostly with head injuries followed by multiple injuries. CONCLUSIONS: Among the patient visiting the trauma center during the study period most common mechanism of the injury were fall and road crash with head and neck injury. Majority of the patients were only managed in the ward without surgery.

Clinical Outcome of Cooled Radiofrequency Ablation in Chronic Knee Pain Osteoarthritis: An Initial Experience from Nepal.

BACKGROUND: Cooled Radiofrequency ablation is a newer technique for management of chronic knee pain in osteoarthritis. The aim of the study is to evaluate the clinical outcomes in patients with chronic osteoarthritis in terms of pain scores for first six months of cooled radiofrequency ablation using ultrasound guidance. METHODS: A cross-sectional study with retrospective review of database was evaluated to analyze the change in the Numerical Rating Scale from baseline scores at 1 day, 1 month and 6 months after the Cooled Radiofrequency ablation of genicular nerves around knee in patients with chronic knee osteoarthritis. RESULTS: Median age was 71 years [ 61-73 years (IQR: 25-75)] with more female preponderance. Numerical Rating Scale (Mean ± S.D.) was significantly less at 1 day (1.87 ± 1.22), 1 month (3.03 ± 0.99) and 6 months (3.37 ± 1.098) from baseline values (6.77 ± 1.00). No soreness and numbness were noted. CONCLUSIONS: Cooled Radiofrequency using Ultrasound guidance for management of knee pain in chronic osteoarthritis is promising and reduces Numerical Rating Score significantly from baseline at 1 month and 6 months respectively.

Anaesthesia for Antenatal Diagnosed Duodenal Atresia with Undiagnosed Persistent Pulmonary Hypertension of Neonate.

Conversion of fetal circulation to adult-type occurs immediately after birth but neonates with problems in the development of pulmonary vasculature are prone to revert back to fetal circulation. This phenomenon is known as flip-flop circulation which may be induced perioperatively and as such anesthesiologist are central to its management. We report a case of term neonate planned for repair of duodenal atresia that despite having no respiratory symptom preoperatively developed severe hypoxemia under anesthesia that was even unresponsive to 100% oxygen. The intraoperative hemodynamics of the neonate was managed along with supportive care successfully. A postoperative echocardiogram confirmed the evidence of persistent pulmonary hypertension of the newborn. Keywords: Duodenal atresia; flip flop circulation; neonates; persistent pulmonary hypertension of newborn.

Metachronous penile metastasis from carcinoma rectum: A case report.

Penile secondary malignancies are rare. Clinical suspicious along with imaging gave fair indication of the metastatic rectal cancer in a 58 year male in our institute. The biopsy of penile lesion confirmed the diagnosis in the patient who was treated for stage III rectal cancer with sandwich approach (neadjuvant chemotherapy followed by surgery and then adjuvant therapy).

Ultrasound-Guided Interscalene Brachial Plexus Block for Pathological Humerus Fracture due to Multiple Myeloma with Systemic Manifestation: Useful Option for Management in Low-Income Countries.

Anesthetic management of pathological fracture due to multiple myeloma with systemic manifestation poses a perioperative challenge especially in low-resource setups like Nepal. Regional anesthesia using ultrasound-guided block can improve the accuracy, reduce complications, and improve overall perioperative management of pathological fractures due to malignancy with systemic spread in resource-deprived setups. We present a case of a 53-year-old lady with pathological fracture of left humerus shaft, a diagnosed case of multiple myeloma with compression fracture of multiple lumbar spine with chest wall metastasis with resolving acute kidney injury with chest infections. Ultrasound-guided interscalene brachial plexus block with sedation was done for open reduction internal fixation of humerus shaft fracture taking in consideration the overall high perioperative risk of patient. Intraoperative hemodynamic was uneventful, with no neurological sequelae and good recovery status perioperatively. Ultrasound-guided interscalene brachial plexus block if done cautiously can be a very useful alternative technique for better perioperative outcome in patients with malignancy with systemic spread in areas where expertise is scarce and resource is limited.

Perspective of Doctors for COVID-19 Pandemic Readiness in Government Hospitals of Nepal.

BACKGROUND: The study assesses the perspective of doctors working in government hospitals of Nepal regarding hospital preparedness for infection prevention measures, isolation services provisions, critical care service readiness, and training of staff for COVID-19 pandemic management. METHODS: This cross-sectional study was done in central, provincial, and local level health centers of the Government of Nepal to assess the perspective of medical doctors regarding COVID-19 pandemic readiness in their facility. Nonprobability sampling was used to collect 56 responses from doctors working in different hospitals of Nepal. An online survey was performed using a questionnaire tool, which was adapted from the guidelines of the World Health Organization and the Centers for Disease Control and Prevention. RESULTS: Most of the participants were medical officers with an MBBS degree (32) followed by anesthesiologists (10). Thirteen participants worked in central hospitals (23.2%), 24 in provincial hospitals (42.8%) and 19 in local health centers (33.92%). The availability of adequate facemask was 84% in central hospitals, which was higher than provincial hospitals (66.7%), and local level health centers (77.8%). There were only 53.8% trained critical care providers in central hospitals and 29.2% in provincial hospitals. Nearly 38.5% (5) of central hospitals had measures for airborne isolation in place, whereas this was only found in 8.3% (2) of provincial hospitals surveyed for critical care facilities. Overall, only 2 hospitals had the provision of a negative pressure room with air exchanges. Only 8 participants working in central hospitals (61.5%) and 14 working in provincial hospitals (58.3%) had performed hands-on training for donning and doffing personal protective equipment. CONCLUSIONS: The majority of medical doctors working in government hospitals of Nepal perceive that provision of facemask distribution, airborne isolation rooms, critical care preparedness, and hands-on training to staff were not adequate.

Can Ultrasound Guided Regional Anesthesia Improve Rural Anesthesia Services and Address Safety Issues in Low Income Country? Perspective from Nepal.

Provision of anesthesia services in a deprived area particularly in low income countries is a major challenge all over the globe. Along with issues of manpower, logistics, services, there lies agendas of safety and accuracy while delivering the services. With rise in ultrasound use in regional anesthesia, pain and perioperative care, it is prudent that some of these issues can be addressed with proper training, mentoring and monitoring. The global idea needs to be implemented locally to reach out to huge volume of patients who are inadequately treated for the various painful conditions. A group of regional enthusiasts from Nepal takes the vision and mission in Nepalese context to address the issues. Keywords: Low income country; rural anesthesia; safety; ultrasound guided regional anesthesia.