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Archive for the ‘ CLINICAL ’ Category

SAVE A LIMB – SAVE A LIFE

Wednesday, April 24th, 2019

The Centre for Heart and Vascular Care at Meitra conducted a CME cum workshop on March 20 and 21st 2019 with emphasis on Peripheral Arterial Diseases (PAD) and Interventions. The programme focused on below knee interventions for peripheral arterial disease with deliberations on a novel treatment modality known as Drug Eluting Balloon (DEB) Angioplasty. The scientific session and workshop was part of the ‘Save a Limb, Save a Life’ Campaign kick started by the Heart and Vascular Care team at Meitra. The workshop was conducted under the supervision of Dr. Sven Braunlich from Leipzig University, Germany, who is an expert in this treatment method. Dr. Sven Braunlich opines, “Drug Eluting Balloon Angioplasty is a very safe and effective therapy for Peripheral Arterial Disease and gives long term benefits. The treatment has also resulted in decreasing amputation rates worldwide.”

Peripheral arterial disease is a very common problem affecting the general population and most importantly diabetics and smokers. It is the most common cause for diabetic ulcers, foot amputations and limb loss. Meitra is the only centre in north Kerala that caters to this need. “Such complex cases employing Drug Eluting Balloon Angioplasty are performed routinely with very good results by the Heart and Vascular Care team at Meitra” Dr. Asish Kumar (Chairman of Cardiology Department, Meitra Hospital) commented.

“The aim of ‘Save a Limb, Save a Life’ campaign is to create an awareness among the general public regarding Peripheral Arterial Diseases and enlighten them with the new treatment modality of Drug Eluting Balloon Angioplasty that helps to decrease the burden of amputations and improve quality of life in patients “said Dr. Ali Faizal (Director and Chief of Clinical Services, Meitra Hospital).

Drug Eluting Balloon Angioplasty uses delivery of a drug-coated balloon to the site of blockage in the blood vessels and removing them by dilatation of the balloon. The drug on the balloon helps to prevent re-occurrence of block at the same site and gives long-term relief to the patient. It also helps to improve blood flow in the corresponding limb, enhances ulcer healing and helps to prevent limb amputations.

Vacuum Assisted Closure

Friday, August 3rd, 2018

Vacuum Assisted Closure (VAC) therapy is an advanced wound healing therapy that can be readily integrated into clinicians routine wound healing practice. This advanced wound healing technology makes use of the negative pressure (a vacuum) to promote wound healing by promoting granulation tissue and perfusion and by removing exudate and infectious materials.

VAC was described by Fleischmann et al in 1993 where they reported that the treatment resulted in “efficient cleaning and conditioning of the wound, with marked proliferation of granulation tissue“.
In 1995, a commercial system for promoting vacuum assisted closure (called VAC) was introduced into the United States market.

The components of VAC therapy work as an integrated unit to optimize both the delivery and the benefits of negative pressure wound therapy. An open pore reticulated polyurethane or polyvinyl alcohol foam is cut to fit in the wound which is covered with an adhesive drape. The open cells of the foam enable equal distribution of negative pressure across the surface of the wound while the tubing transfers accumulated fluids to the canister. Depending on the wound type and needs of each patient, the VAC therapy can be used in continuous or intermittent modes. Some of the advanced wound care systems have features which include alarms that signal tubing blockages, a full or missing canister, Inactive therapy, low battery, leaks in the seal of the dressing and low pressure alarms.

VAC therapy is intended to create an environment that promotes wound healing by secondary or tertiary intention by preparing the wound bed for closure, reducing edema, promoting granulation tissue and perfusion and by removing exudate and infectious materials. It is widely used on open wounds like acute traumatic, subacute and dehisced wounds, partial thickness burns, ulcers ( Diabetic, Pressure or Venous), flaps and grafts. The dressing is an effective barrier to bacterial penetration and may help reduce infection in these types of wounds.

How does VAC help in healing of the wounds?
1. Removes edema fluid from the wound through suction
2. Results in increased blood flow to the wound
3. Increases cell proliferation
4. Reduction in bacterial colonization of the wound
5. Decreases the risk of wound infections
6. Enhances the formation of granulation tissue
7. Faster healing compared to other kinds of wound dressings

When used on closed surgical incisions, they are intended to manage an environment that continue to drain following sutured or stapled closure by maintaining a closed environment and removing exudates via the application of negative pressure wound therapy.

VAC therapy is contraindicated in the following situations:
1. Malignancy of the wound
2. Untreated Osteomyelitis
3. Necrotic tissue with eschar
4. Non-enteric and unexplored fistulas
5. Exposed blood vessels, organs, nerves and anastomotic sites.

Patients on anticoagulants and platelet aggregation inhibitors are treated and monitored in a setting deemed appropriated by the treating physician. Utmost care needs to be taken when VAC is being used in such patients with increased risk of bleeding, which, if uncontrolled could cause more harm than good.

Infected wounds should be monitored closely and may require more frequent dressing changes than non-infected wounds. If there are any signs of systemic infection or advancing infection at the wound site the VAC therapy needs to be discontinued.

What are the advantages of VAC over conventional wound dressings?
1. Limiting exposure to the wound results in a lower risk of infection
2. Reduces the need for materials and qualified personnel
3. Reduce the length of a hospital stay
Home care
Faster healing
4. Early return to normal activities
5. Less discomfort and pain for the patient
6. Have a greater sense of well-being

The average duration for which a VAC is applied to a wound depends on several patient factors and was found to be around 3-5 days. Wounds dressed with VAC closed at an average of 0.23 cm2 per day compared with 0.090 cm2 for the controls. Depending upon the size and depth of the wound multiple applications may be necessary.

Awake Craniotomy

Friday, June 29th, 2018

An awake craniotomy is an operation performed in the same manner as a conventional craniotomy( brain surgery) but with the patient awake during the critical part of the procedure.

This is a preferred technique for operations to remove tumours close to, or involving functionally important (eloquent) regions of the brain. Performing the operation in this way allows us to test regions of the brain before they are incised or removed and also to test the patient’s function continuously throughout the operation. The overall aim is to minimise the risks of the operation.

The benefits are considered to be of increased extent of lesion removal, with growing evidence of improved survival benefit, whilst minimizing damage to eloquent cortex and resulting postoperative neurological dysfunction. Other advantages include a shorter hospitalization time, hence reduced cost of care, and a decreased incidence of post-anesthesia complications such as nausea and vomiting.

Not all patients are fit for awake craniotomy. A team of neurologists/ neurosurgeons/ neuropsychologists/ anesthesiologists and neurophysiologists together select the right candidate. Thorough pre-operative assessment of airway and other premorbid conditions like sleep apnea, mental impairment, personality disorder, pre-existing paralysis, brain swelling and profound dysphasia is essential.

The team members,especially the anesthetistist, must gain the patient’s confidence, as the patient will depend on them during the procedure. Prior to surgery, the patient must be informed about realistic description of the operating room, expected discomforts and level of co-operation expected, potential risks, safety measures and stages of the procedure. The anesthesiologist must explain in detail the potential presence of sounds (monitor alarms, cranial drilling, elektroknife, ultrasonic surgical aspirator) or discomforts (unchangeable position, aphasia during cortical mapping) from the patient. The patient must understand that these discomforts are essential for the success of the procedure. A visit to the operating room before surgery in order to familiarize the patient with the sounds and equipment in the rooms is a good idea. The patient should be explained the tasks that will be performed for speech and motor testing. Questions should be encouraged and if possible speaking to a prior patient who has undergone this procedure successfully in the past can be invaluable.

These preoperative visits provide an invaluable opportunity for the multidisciplinary team to create a rapport with the patient and therefore encourage trust and familiarity.

The patients comfort is of utmost importance. The operating room temperature must be appropriate; the surgical table must be covered with soft, thick dressing, and the surgical team must be instructed to speak softly and move only if necessary. It is important to study the position of the instruments in order to minimize unnecessary movements of objects and personnel. The patient’s face must be in a position that allows him to look at the anesthesiologist and at pictures during brain mapping, but must also be accessible for adequate access to airway during emergencies. An audio-video recorder system should be used so that the surgeon can see and hear the patient’s responses during cortical mapping.

The term ‘awake craniotomy’ is misleading as the patient is not fully awake for the entirety of the procedure. The patient has a scalp block applied for pain relief- so that he doesn’t feel pain throughout the procedure. Occasionally the anaesthetic technique of awake with a scalp block alone is utilized, this can be useful in elderly patients. The more surgically stimulating parts of the procedure may require varying levels of sedation, or anaesthesia. The patient is fully awake during the mapping procedure and while lesion resection takes place.

When the brain is exposed the surgeon will perform a procedure called cortical mapping. This involves stimulating the brain surface with a tiny electrical probe. If we stimulate a motor region of the brain it may cause twitching of a limb or face; a sensory area will cause a tingling feeling; the speech areas will prevent speech very briefly. By mapping out the important regions of the brain first we can aim to avoid and protect them during the operation. Whilst the surgeon removes the tumour, the patient’s sensory/ motor/ speech functions, will be continuously tested and if anything changes, the surgeon will be able to stop the tumour resection.

Post-operative recovery is generally much quicker than with a conventional craniotomy.

Transcatheter Aortic Valve Replacement (TAVR)

Friday, June 29th, 2018

TAVR valve with delivery catheter

When we think about treatment of valvular heart disease, till recently, there were no options other than open surgery for replacement or repair of the valve. We had conquered ischaemic heart disease, ie, blocked blood vessels to the heart long back; with keyhole surgery called angioplasty celebrating its 40th anniversary this year, a catheter- based treatment for these valve patients was long overdue. And now it’s a reality.

Transcatheter Aortic Valve replacement or Implantation (TAVR or TAVI) involves passing a valve loaded on to a catheter through the groin artery and delivering it in the correct position in the heart.

The major challenges are identifying the high risk patients who are the right candidates for this treatment, assessing the patient to minimise risk, selecting the right valve type and size, perfect positioning and deployment of the valve and identifying and treating complications, if any.

At Meitra, all these are taken care of by the well- experienced heart team – from planning every step of the procedure beforehand, to precision delivery of the valve with the use of a robotic cath-lab.

At present, only patients who are considered too high risk for open surgery are undergoing this treatment worldwide. In near future, as experience with the procedure grows, TAVR could be offered to a lot more patients with a wider variety of valvular anatomies and risk profiles.

That day is not far when all valvular heart diseases can be treated with a catheter-based approach.

Angina

Thursday, June 28th, 2018

Angina Pectoris Is The Classical Medical Term For The Symptom That Occurs Due To Coronary Occlusion. The Characteristic Feature Of This Pain Is It Occurs Retrosternally With Typical Radiation To The Left Arm And Is Relieved With Medications. Angina Can Be Stable Or Unstable. Stable Angina Is Classically Described As Pain That Remains Stable For At Least 8 Weeks And Typically Occurs With Effort And Relieves With Rest Or Medications. Unstable Angina Is Described As New Onset Angina Or Angina That Occurs At Rest And There Is An Aggravation Of Symptom Class. Whatever May Be The Angina, It Needs Evaluation Or Advise From A Cardiologist. When Angina Occurs In The Setting Of Acute Myocardial Infarction (Mi) It Lasts More Than 30 Minutes And Is Not Relieved Till Any Form Of Intervention Is Undertaken. Patients Have A Feeling Of Impending Doom (Angor Animi) When Angina Occurs During St Elevation Mi. Immediate Advice From A Cardiologist/chest Physician Will Be The Need Of The Hour Then.