Browsing by Author "Shrestha, KR"
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Publication A prospective randomized study of goal oriented hemodynamic therapy in cardiac surgical patients(Institute of Medicine, 2015) Shrestha, KR; Pradhan, B; koirala, BAbstract Introduction: Approximately 10% of patients require prolonged care after cardiac surgery because of hemodynamic instability, organ dysfunction or multi organ failure. Increased levels of oxygen delivery and consumption in early postoperative period are associated with improved outcome and early recovery. The aim of the study was to evaluate early post- operative outcome in cardiac surgery patients with adoption of goal oriented hemodynamic therapy. Methods: This is a prospective randomized controlled trial of 12 months period, of adult patients undergoing cardiac surgery in a tertiary level teaching hospital. In the control group, standard postoperative monitoring was done, while in the study group FloTrac TM cardiac output sensor with Vigileo monitor and central venous oxygen saturation monitoring was done to reach a set goal within 8 hrs postoperatively. Findings were analysed using SPSS software version 17. Results: 100 patients were enrolled in the study with 50 in each group. Both groups were comparable by baseline characteristics, body surface area (BSA) and duration of surgery, cardiopulmonary bypass (CPB) and aortic cross-clamp (AoX) time. But the average age was statistically higher in study group. Yet, the ventilator time and duration of use of ionotropes were significantly less in study group. The duration of intensive care unit (ICU) and hospital stay were less in study group but did not reach statistical significance. Conclusion: This study has shown that the use of goal oriented hemodynamic therapy in cardiac surgical patients improves immediate outcome. Mortality, ICU and hospital stay also tend to be lower. Keywords: cardiac surgery, goal orientedhemodynamic therapy, FloTrac system, hemodynamic monitoringPublication Endovascular Treatment for Traumatic Thoracic Aortic Injury: A Case Report(Institute of Medicine, 2018) Shrestha, UK; Shrestha, KR; Gurung, D; Upreti, MR; Adhikari, A; Gurung, AAbstract As majority of blunt traumatic injury with aortic tear die, we see limited numbers of survival in the hospital. Thoracic endovascular treatment for traumatic aortic injury is rare. Endovascular treatment, where available, is the trend for traumatic aortic injury for all age group. Both morbidity and mortality are significantly decreased with endovascular intervention. Twenty nine years old male patient driving a car collided with truck and had thoracic aortic pseudoaneurysm with multiple skeletal fractures that underwent successful endovascular stent graft along with fixation of all fractured bones. Key words: Endovascular stent graft, Thoracic aortic injury, Thoracic aortic pseudoaneurysm, Thoracic endovascular aortic repairPublication Frequency of Bile Bacteria in Gallstone Disease(Institute of Medicine, 2014) Shrestha, KR; Adhikary, S; Koirala, R; Amatya, RAbstract Introduction: Gallstone disease is among the bread and butter surgery for most general surgeons but role of bacteria in its formation is still an enigma. Methods: Bile was obtained during cholecystectomy from the patients admitted for uncomplicated cholecystectomy which was cultured in standard culture medium. Demographic profile and nature of stones obtained were also compared. Results: This study involved micro biological analysis of bile obtained from 528 patients undergoing cholecystectomy without other complication for duration of one year in BP Koirala institute of health sciences, Dharan. Study showed that incidence biliary infection was 4.8% with commonest organism being E coli followed by K pneumonia. Among various types of stones pigment stone were mainly found to be associated with infection than other types of stones. Conclusion: The study shows that though biliary infection in patients with gallstone disease is not uncommon but its exact role in the pathogenesis of gallstone disease is not elusive. Keywords: gallstone disease, biliary infection, pigment stonesPublication Management of Pseudoaneurysms in IV Drug Users(Institute of Medicine, 2011) Sapkota, R; Sapkota, S; Thapa, B; Shrestha, KR; Rajbhandari, N; Shrestha, UKAbstract Introduction: Pseudoaneurysms are major vascular complications in intravenous drug abusers. They are potentially fatal, often infected and require urgent management. Method: This is a retrospective study of the prevalent practice of their management in our center. The inpatient medical charts of the patients spanning 5 years (Sep 2006 to Aug 2011) were reviewed. Data were obtained on their demographic, clinical, management and outcome parameters. Result: Among the thirty intravenous drug users presenting with pseudoaneurysms (excluding one who bled to death before surgery), 28 had their femoral artery involved. Most of them (90%) were infected. Nearly half of the patients (45%) were seropositive for HIV and/or HCV. All were operated, with no mortality. Ligation and debridement was the technique used almost exclusively (83%). One brachial artery wasrepaired primarily, whereas 3 femoral and 1 brachial pseudoaneurysms were managed with autologous saphenous vein bypass. Five patients had neurological complications, and 5 others had non-limb threatening claudication which got better with medical management. Mean follow up period was 11 months. Conclusion: Ligation and debridement appears to be a simple, safe and effective procedure in infected pseudoaneurysms in IV drug users. Keywords: Claudication, IV Drug Users, Infected Pseudoaneurysms, LigationPublication Open Surgical Management of Abdominal Aortic Aneurysm at a Community Based University Hospital in Nepal(Kathmandu University, 2020) Bhandari, N; Karmacharya, RM; Devbhandari, M; Shrestha, B; Singh, AK; Ranjit, S; Shrestha, KRABSTRACT Aortic aneurysms are abnormal dilatation of aorta. The risk factors include male sex, age > 65, smoking, coronary artery disease and hypertension. Here we report a case of infra-renal abdominal aortic aneurysm (AAA) of diameter 6 cm. The patient sucessfully underwent aorto-biiliac bypass surgery using Dacron Y graft. During abdominal aortic aneurysm surgery anesthetic challenge is also of paramount importance and should be considered. KEY WORDS Abdominal aortic aneurysm, Aorto-biiliac bypass, Dacron graft, Vascular surgeryPublication Retrospective study on extracranial neck schwannomas in tertiary care hospital in Nepal(Institute of Medicine, 2014) Shrestha, UK; Shrestha, KRAbstract Introduction: Schwannomas are relatively rare tumors arising from Schwann cells that ensheath the peripheral nerves. The study aim was to identify extracranial neck schwannomas treated in a tertiary care hospital in Nepal. Methods: We reviewed medical records of all patients with extracranial head and neck schwannomas treated at our department from July 2004 to June 2014. Results: Ten such patients consisted of 7 males and 3 females were identified, with a mean age of 37.8 +/- 10.7 years (range: 20 to 54 years) with solitary schwannomas. Mean size of tumor was 5 cm (range: 2-10 cm). Most of the patients (60%) presented with asymptomatic palpable mass. Of these ten, 50% had a left sided neck mass. Seven originated from vagus nerve while three from sympathetic chain. The average duration of symptoms ranged from one month to two and half years. In all cases, tumor was completely resected through cervical approach. All tumors were enucleated keeping nerve of origin intact. In all cases, the tumor was completely resected surgically. The average follow up period ranged from one month to 108 months (median: 24 months). No major postoperative complications were noted. Two patients (20%) developed Homer's syndrome and one (10%) had temporary hypoglossal nerve palsy which recovered within three months. Conclusion: Non-vestibular extracranial head and neck schwannomas most frequently present as an innocuous longstanding unilateral neck mass. The mainstay of treatment is complete excision preserving the nerve of origin. Early recognition of Schwannomas is key to optimal treatment. Keywords: cranial nerves, Horner's syndrome, Schwannoma