Postoperative pain assessment using four behavioral scales in Pakistani children undergoing elective surgery

Several measurement tools have been used for assessment of postoperative pain in pediatric patients. Self-report methods have limitations in younger children and parent, nurse or physician assessment can be used as a surrogate measure. These tools should be tested in different cultures as pain can be influenced by sociocultural factors. The objective was to assess the inter-rater agreement on four different behavioral pain assessment scales in our local population. This prospective, descriptive, observational study was conducted in Pakistan. American Society of Anesthesiologists I and II children, 3-7 years of age, undergoing elective surgery were enrolled. Four pain assessment scales were used, Children's Hospital of Eastern Ontario Pain Scale [CHEOPS], Toddler Preschool Postoperative Pain Scale [TPPPS], objective pain scale [OPS], and Face, Legs, Activity, Cry, Consolability [FLACC]. After 15 and 60 min of arrival in the postanesthesia care unit [PACU], each child evaluated his/her postoperative pain by self-reporting and was also independently assessed by the PACU nurse, PACU anesthetist and the parent. The sensitivity and specificity of the responses of the four pain assessment scales were compared to the response of the child. At 15 min, sensitivity and specificity were >60% for doctors and nurses on FLACC, OPS, and CHEOPS scales and for FLACC and CHEOPS scale for the parents. Parents showed poor agreement on OPS and TPPS. At 60 min, sensitivity was poor on the OPS scale by all three observers. Nurses showed a lower specificity on FLACC tool. Parents had poor specificity on CHEOPS and rate of false negatives was high with TPPS. We recommend the use of FLACC scale for assessment by parents, nurses, and doctors in Pakistani children aged between 3 and 7

Airway and obstetric anesthesia: a review

This review highlights the physiological changes in the airway, associated with pregnancy and delivery of the baby, in the parturients. The strategies to address anticipated and unanticipated difficult airway management have been discussed. The need to have comprehensive guidelines and/or algorithms is stressed. The review covers the updates from the recent research studies

Effect of diclofenac suppository on tramadol consumption in posthysterectomy pain

To determine reduction in dose of tramadol and side effects in posthysterectomy patients on addition of diclofenac on rectal suppository. Randomized double blinded placebo controlled study. The Aga Khan University Hospital, Karachi, Pakistan, from August 2004 to January 2006. Seventy ASA I and II females, aged 20 and above, who underwent elective abdominal hysterectomy, were included in this study. Patients received identical looking suppository of either 100 mg diclofenac sodium or placebo after induction of anaesthesia and then 12 hourly for 24 hours. General anaesthesia was standardized and tramadol was given by patient controlled intravenous analgesia delivery system in the recovery. The mean dose +/- SD of tramadol used in first 24 hours was found to be 317 +/- 153 mg in the placebo-tramadol group compared to 258 +/- 192 mg in the diclofenac-tramadol group [p = 0.15, 95% CI = 1.24 to -1.34, 6.63]. Seventeen [49%] patients in the placebo-tramadol group and 14 [40%] in the diclofenac-tramadol group used rescue analgesia [p=0.47]. Sedation score was similar in both the groups and there was no difference in the incidence of nausea and vomiting and use of antiemetics between the groups. This study did not show any reduction in tramadol consumption, given via patient controlled intravenous analgesia when rectal suppository of 100 mg diclofenac was added

Estimation of blood loss during caesarean section: an audit

To evaluate the blood ordering practice and blood transfusion for Caesarean sections at our institution and to compare the estimated blood loss between anaesthetists and obstetricians. A review of 126 patients undergoing both elective and emergency Caesarean section was undertaken in 2002. Information collected included the number of blood units cross-matched preoperatively, type of surgery [emergency or elective], type of anaesthesia, parity of the patient, estimated blood loss by both anaesthetists and obstetricians, intraoperative and postoperative transfusion within 48 hours and pre and post operative haemoglobin [Hb] and haemocrit [Hct]. A total of 215 units were cross-matched for 126 patients undergoing Caesarean section delivery. A small amount [9.5%] were transfused intraoperatively and 5.5% postoperatively. The average blood loss estimated by anaesthetists was 498 +/- 176 ml and that by obstetricians was 592 ± 222 ml. The calculated blood loss based on patients blood volume and drop in Hct was 787 +/- 519 ml. The cross-match transfusion ratio was 9.7. Conclusion: Only 13% of our patients needed blood transfusion. The mean blood loss was estimated to be more by the obstetricians as compared to the anaesthetists. We recommend that the practice of routine cross-match practice prior to Caesarean section should be re-looked by institutions practicing obstetric anaesthesia

Unplanned prolonged postanaesthesia care unit length of stay and factors affecting it

To identify the factors that prolong the length of stay in the post anaesthesia care unit [PACU]. This audit was conducted in the PACU of a university hospital. A special form was designed and filled for those patients who stayed unplanned in the PACU for more than two hours. All patients who were admitted to the PACU after surgery were included. Patients undergoing cardiothoracic surgery, those directly shifted to ICU and cases done under local anaesthesia were excluded. Data was collected for 20 months by a designated recovery nurse for all included patients including those admitted outside the scheduled surgery hours. The total number of patients who were admitted to the PACU during the audit period were 13644, out of these 1114 [8.1%] stayed in the PACU for more than 2 hours. The percentage of overstay patients on monthly basis ranged from 6.4% to 10%. The commonest reason was the need for postoperative monitoring 578 [51.8%], unavailability of beds in the special care areas 264 [23.7%], pain management 68 [6.1%] and 61 [5.4%] for postoperative ventilation. Our results show that majority of patients stayed in the PACU for more than two hours either because they needed postoperative monitoring or because of unavailability of bed in the special care areas

Effect of Pre-operative coagulation testing on intra-operative transfusion requirements in surgical patients

To assess the value of pre-operative coagulation testing in elective surgical patients, to estimate the frequency of abnormality and the outcome in relation to transfusion. Observational study. The study was performed at the Aga Khan University Hospital in main operating room over a period of six months from March to September 1999. All patients scheduled for elective surgery in which the primary physician had ordered PT [prothrombin time], APTT [activated partial thromboplastin time] and PLT [platelet] count were included. Risk groups were made based on history of coagulation disorders and medications altering coagulation. The patients were also stratified according to age and the frequency of abnormality determined in different groups. Five hundred cases were studied. The frequency of abnormalities of PT and APTT were found to have statistically high association with the risk groups based on history. There was significant association between age and abnormal platelets count. Only 8 patients were transfused. Pre-operative coagulation tests should only be ordered in high risk groups based on history and examination

Anaesthetic reasons for cancellation of elective surgical inpatients on the day of surgery in a teaching hospital

A prospect audit was conducted to find out the anaesthetic reasons for cancellation of surgical in patients on the day of surgery, and to plan for future suggestive corrective actions to reduce unnecessary cancellations. The audit was conducted at Aga Khan University Hospital for one year from 1st January to 31st December 2003. Data was collected monthly on a pre-designed form and the files of cases that were cancelled were reviewed by two consultants and labeled as justifiable or not justifiable cancellation. Eight thousand, five hundred and twenty six patients were scheduled for surgery during the study period, 359 [4%] were cancelled on the day of surgery after their names appeared on the operating room schedule. Only 28 [8%] of all cancellation were anaesthetic cancellations, 15 of which fell in nonjustifiable category. Although anaesthetic cancellations were only 0.3% of total elective admissions, this number can be improved further in the interest of the patients by implementing and following the recommendations that have been proposed following this audit

Patients view of the anaesthetist in a developing country

The objective of this study was to assess patients regarding their knowledge and perception of the anaesthetists' role in patient care in a developing country. The audit was conducted at the Aga Khan University Hospital, Karachi. Two hundred surgical and 102 medical out-patients were included in the audit prospectively who filled a detailed questionnaire. Fifty-six% of the patients knew that anaesthetists were medically qualified but only 20% and 27% had an idea about their role in the intraoperative and immediate postoperative period. 14.6% were aware of the anaesthetists role outside the operating room. No difference was observed between the two groups of patients except that a higher percentage of surgical patients were interested in having more information regarding anaesthesia and wanted to choose their anaesthetist if the need arose. Gender difference was observed in answer to two questions only. A higher percentage of males know the role of anaesthetist in the recovery room whereas a greater number of females who had surgery before remembered their anaesthetist postoperatively. The results of this audit show a poor perception of the anaesthetists role both inside and outside the operating room. Although public knowledge surveys have been carried out in developed countries there is a pressing need to repeat these in developing countries since the image as perceived by public may have a direct bearing on the recruitment of young doctors into an already shortage specialty in these less affluent countries

Experience with laryngeal mask airway in Pakistani patients

One hundred and thirty seven adult patients undergoing peripheral surgery were studied regarding ease of larangeal mask airway [LMA] insertion, airway maintenance during surgery and complication encountered during insertion, maintenance and in the postoperative period. In a majority [84%] of patients, the airway was positioned correctly at the first attempt, 3% patients had mild laryngospasm at insertion and in 85% a good airway was obtained. No airway related problems were encountered intraoperatively. Two percent patients had laryngospasm on removal of LMA. Postoperatively, the complaint of sore throat and uvular trauma was seen in 4% cases

Evaluation of oral midazolam as pre-medication in day care surgery in adult Pakistani patients

A placebo controlled randomized double blind study was designed to assess the suitability of oral Midazolam as a premedication in day care surgery in adult Pakistani patients. Fifty ASA I and II patients aged between 20-60 years received either Midazolam 7.5 mg or placebo approximately one hour prior to surgery. Midazolam 7.5 mg produced significant anxiolysis and sedation [p<0.001] in comparison to placebo after one hour of premedication. There was a significant difference [p<0.001] in the mean heart rate and blood pressure in both groups after 1 hour of premedication with a lesser rise in blood pressure and heart rate in the Midazolam group. Psychomotor performance assessed by 'n' deletion test was impaired by Midazolam [p<0.001] and recall of pictures revealed differences [p<0.05] in the groups at one hour after premedication. However, at four hours after surgery there were no differences in both groups. These findings indicate that rapidly acting oral Midazolam in doses of 7.5 mg provided safe and effective premedication in terms of anxiolysis, sedation, amnesia and psychomotor performance and is suitable for day surgery

review of 6978 consecutive admissions to the recovery room at a University Hospital

Recovery from anaesthesia is a time of potential danger to the surgical patients. A retrospective audit of all recovery room admissions over a period of 18 months was carried out at the Aga Khan University Hospital. During this period 6978 patients were admitted to the recovery area and 695 had one or more complications. The complications were recorded by the recovery room nursing staff in a recovery log book. The breakdown of complications according to different physiological systems is discussed. Several surveys have reviewed complications in the western population, but in contrast, no study is available in Pakistani patients. It is recommended that since one in ten patients is likely to have a problem in the early post-operative period, the local hospitals should provide adequate facilities meeting the criteria laid down for the recovery rooms in modern anaesthetic practice

Anaesthetic management for atlanto axial subluxation

A number of disease processes including congenital anomalies, malunited odontoid fractures, rheumatoid arthritis and tuberculosis can result in atlanto axial subluxation. The patient population presenting for surgery is therefore varied in age and general condition, ranging from fit young men to steroid dependent frail arthritic patients. The degree of instability and the spinal cord compression are also variable. Gauging these parameters has an important bearing on the anaesthetic management. We present management of six patients with atlanto axial subluxation in our institution

effects of suxamethonium and pancuronium on the haemodynamic response to endotracheal intubation

The pharmacological effects of suxamethonium and pancuronium on the cardiovascular system may vary and therefore alter the haemodynamic response to intubation. The arterial blood pressure, the heart rate and the rate pressure product were measured as parameters of haemodynamic change in forty adult ASA. I and II patients undergoing laryngoscopy and endotracheal intubation in a randomised controlled study. The patients were induced with either thiopentone/suxamethonium [Group A] or thiopentone/pancuronium [Group B]. There was no significant difference between the groups on comparison of systolic and diastolic blood pressure changes. Pancuronium, however, caused a significantly higher rise in the heart rate after endotracheal intubation compared to suxamethonium. In both groups the maximum rate pressure product occurred one minute after intubation, rising by 56% in the suxamethonium group and 64% in the pancuronium group compared to control values. In conclusion, there were significant and statistically similar increases in systolic and diastolic blood pressures and rate pressure product following intubation in both groups with values significantly above baseline until three minutes post intubation but the increase in heart rate in group A was significantly less than that in group B

Minimum induction dose [MID] thiopentone in Pakistani patients

The thiopentone dose needed for abolition of eyelash reflex was studied in 505 Pakistani patients who were divided in three subgroups, i.e., age less than 16 years, between 16 and 60 years, and over 60 years. The minimum induction dose for thiopentone was then determined in the three groups and the effect of sex, ASA classification, premedication and advancing age were seen. The minimum induction dose in the adult patients [16-60] was 215.8 +/- 66 mgs [3.48 mgs/kg]. Both the adult groups and the elderly showed a statistical difference in the dose required by the males and females, but this difference was not seen in children. Thiopentone dose also showed a steady decline as the age progressed. A statistical correlation existed between ASA I and II patients compared to ASA III who required less thiopentone. The premedicated patients required less thiopentone compared to those who did not receive a premedication. Our patients required a lesser dosage for abolition of eyelash reflex than the figures recommended for British population. We recommend a dose of 3.5 mg/kg for adult Pakistani males and 3.3 mg/kg for adult females