RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA

ANNEXURE-II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. / NAME OF THE CANDIDATE
AND ADDRESS /
Dr. MEDHA SUGARA
d/o K. S. Sugara
Kalpataru, no.8-C, blk-7,
14 C cross, 1 B main,
sector 6, HSR layout
Bangalore-560102
2. / NAME OF THE INSTITUTION / BANGALORE MEDICAL COLLEGE AND RESEARCH INSTITUTE
3. / COURSE OF STUDY & SUBJECT / MS (GENERAL SURGERY)
4. / DATE OF ADMISSION TO THE COURSE / 03-05-2010
5. / TITLE OF THE TOPIC
“PREDICTION OF OUTCOME IN PERFORATION PERITONITIS USING APACHE-II SCORING SYSTEM”

6. BRIEF RESUME OF THE INTENDED WORK

6.1 NEED FOR THE STUDY:

Perforation peritonitis is one of the most common surgical emergencies in India1. The prognosis of peritonitis and intra-abdominal sepsis, particularly when multiorgan dysfunction develops, remains poor despite improvement in diagnosis, surgical and medical management of this condition. Early classification of patients with peritonitis by means of scoring systems provides adequate selection for surgical and therapeutic procedures and comparison of different therapies.

Several scoring systems have been developed for this purpose such as Acute Physiology and Chronic Health evaluation (APACHE-II) score, Sepsis severity score, Ranson score and Mannheim’s peritonitis index.

Prospective assessment of the Acute Physiology and Chronic Health Evaluation-II(APACHE-II) scoring system has been shown to provide objective discrimination between low-risk and high-risk groups of patients with intra-abdominal sepsis2. This study aims to evaluate the performance of APACHE-II score in prediction of mortality risk in patients with peritonitis due to hollow viscous perforation.


6.2 REVIEW OF LITERATURE:

The APACHE (acute physiology and chronic health evaluation) prognostic scoring system was developed in 1981, by Knaus et al, at the George Washington University Medical Centre as a method to measure disease severity3. The APACHE score was found to correlate directly with hospital mortality. Because of the complicated method of obtaining physiological data, a simplified refinement of the original scoring system, i.e. APACHE-II, was introduced in 1985, allowing calculating of probability of death4.The APACHE-II score measures 12 physiological variables and yields a number between 0 and 71 that correlates in a graded fashion with the predicted risk of hospital mortality. The specific risk of death can be calculated using an equation that integrates the patient’s physiologic data with the patient’s underlying diagnosis 5, 6.

Ohmann et al in their review of the various prognostic systems in peritonitis found that evaluation of treatment policies and monitoring in peritonitis can best be performed with APACHE-II 7. Borisov et al compared APACHE-II with the Manheim’s Peritonitis Index (MPI) and Simplified Acute Physiology Score-II (SAPS-II) scoring system and found it to be most accurate in patients with bacterial peritonitis 8.

However, Kulkarni et al reported that APACHE-II predicted mortality did not correlate with observed mortality in patients with scores of 1 to 10 and greater than 20, although a score between 11 and 20 was a better predictor of mortality in patients with hollow viscous perforation 9.

6.3 AIMS AND OBJECTIVES OF THE STUDY:

Ø  To evaluate the performance of APACHE-II scoring system in predicting mortality in patients with perforation peritonitis

7. MATERIAL AND METHODS

7.1 SOURCE OF DATA:

Patients presenting to Victoria hospital and Bowring and Lady Curzon Hospital attached to Bangalore Medical College and Research Institute with features suggestive of perforation peritonitis (minimum 30 cases) from October 2010 to September 2012.

7.2 METHOD OF COLLECTION OF DATA:

Data will be collected by meticulous history taking, careful clinical examination, appropriate radiological, histopathological and serological investigation, operative findings and follow up of the cases.

Sampling method:

Patients presenting to the hospital with features of perforation peritonitis meeting the following inclusion and exclusion criteria will be included in the study after taking their informed consent.

Inclusion criteria:

a.  Patients with features of perforation peritonitis (secondary peritonitis)

b.  Both sexes.

Exclusion criteria:

a.  Patient less than 18 years

b.  Primary and tertiary peritonitis

c.  Traumatic perforation

d.  Peritonitis due to ruptured liver abscess, appendicular abscess.

Statistical methods:

Data will be analysed using parametric or non parametric tests based on the distribution of the values obtained.

7.3 Does the study require any investigation or intervention to be conducted on patients or other humans or animals? If so please describe briefly.

YES (only on patients)

Investigations and intervention required

The following investigations which are components of the APACHE-II will be done.

  1. Arterial pH and Partial pressure of oxygen
  2. Serum electrolytes
  3. Serum creatinine
  4. Hematocrit
  5. Leucocyte count
  6. Erect X ray abdomen
  7. Ultrasound abdomen

7.4 Has ethical clearance has been obtained from your institution in case of 7.3?

YES

8. LIST OF REFERENCES:

1. Jhobta RS, Attri AK, Kaushik R, Sharma R, Jhobta A. spectrum of perforation peritonitis in India –review of 504 consecutive cases. World Journal of Emergency Surgery 2006, 1:26.

2. Kulkarni SV, Naik AS, Subramnian N Jr. APACHE-II scoring system in perforative peritonitis. Am J surg: 2007 Oct; 194(4):549-52.

3. Knaus WA, Zimmerman JE, Wagner DP, Draper EA, Lawrence DE. APACHE- acute physiology and chronic health evaluation: a physiologically based classification system. Crit Care Med 1981; 9:591-7.

4. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med 1985; 13:818-29.

5. Norton JA, Bollinger RR, Chang AE, Surgery- basic science and clinical evidence. Springer Publisher; p. 308-309

6. Paul Marino, Kenneth Sutin. The Icu book. Lippincott Williams and Wilkins, 3rd Ed.p.997-1001

7. Ohmann C, Hau T. Prognostic indices in peritonitis. Hepatogastroenterology 1997 Jul-Aug; 44(16):937-46.

8. Borisov D, Kirov M, Kuzkov V, Uvarov D, Nedashkovsky E. A validation of different prognostic scoring systems in the prediction of outcome in peritonitis. Critical Care 2005, 9(Suppl 1):p 224
9. Williams NS, Bulstrode CJK, O’Connell R. Bailey and Love’s short practice of Surgery. Edward Arnold Publishers, 2008 Ed.p. 992-995
10. Townsend, Beauchamp, Evers, Mattox. Sabiston textbook of surgery. Elsevier, 18 Ed. p. 266-267
9. / Signature of the candidate /
(Dr. MEDHA SUGARA)
10. / Remarks of the Guide / Perforation peritonitis is commonly encountered in our hospital. APACHE-II will be a good indicator in perforation peritonitis. Hence, it will be a useful clinical study.
11
11.1
11.2 / Name and designation
of Guide
Signature /
Dr. SHASHIKALA C.K. MS
Assistant Professor
Department of Surgery
BMC&RI
11.3
11.4 / Co-Guide if any
Signature
11.5
11.6 / Head of the Department
Signature /
Dr. B.S.SHIVASWAMY MS
Professor and Head
Department of Surgery
BMC&RI
12.1
12.2 / Remarks of the Chairman and Principal
Signature / Dr. G T SUBHAS
Director and Dean
Bangalore Medical College and Research Institute
Bangalore

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