Effect of addition of tramadol to one MAC sevoflurane on the haemodynamic response to laryngoscopy and tracheal intubation

To evaluate the effect of tramadol 2 mg/kg on haemodynamic response to tracheal intubation where the end tidal concentration of sevoflurane was kept constant at 1 MAC [2%]. study Design: Double blind randomized controlled trial. The Aga Khan University Hospital, Karachi, from January 2009 to April 2009. Thirty-four patients scheduled for surgery under general anaesthesia were randomly allocated to two groups, sevoflurane alone [2%] or sevoflurane [2%] and tramadol [2 mg/kg] combination. Anaesthesia was induced with thiopentone and atracurium and with either tramadol or placebo according to group allocation. Sevoflurane was administrated along with N2O and oxygen through the face mask till end tidal minimum alveolar concentration [MAC] of one [2%] was achieved. Haemodynamic changes were noted at 1, 2 and 3 minutes post induction and every minute upto 7 minutes post-intubation and compared with baseline values. A significant difference in heart rate was seen at 2 and 3 minutes post-induction and 1, 2 and 3 minutes postintubation between two groups with values higher in sevoflurane alone group. No significant difference was seen in systolic, diastolic, and mean blood pressure compared to baseline between the two groups. HR and SBP values following laryngoscopy and tracheal intubation in both groups were less than 20% of baseline. Addition of tramadol 2 mg/kg to 1 MAC sevoflurane displayed further depression of chronotropic response to laryngoscopy and intubation as compared to sevoflurane alone following thiopentone and atracurium induction

Airway management in a patient with bullous pemphigoid

Airway management in patients with pemphigoid lesions has anaesthetic implications. We report a case of a 23 years old female with bullous pemphigoid who presented with laryngeal stenosis and critical airway narrowing. The airway was initially managed with jet ventilation. Anaesthesia was maintained with propofol infusion and ventilation was performed by introducing a size 10 French gauge suction catheter through the stenotic laryngeal orifice. Thirty minutes into anaesthesia, she developed subcutaneous emphysema and decreased air entry on right side of the chest but remained hemodynamically stable. The airway was further managed by tracheostomy. This case report highlights complications that can occur during the anaesthetic management of such cases

Anaesthesia related mortality in ASA-1 and 2 patients as a quality improvement indicator

Quality and safety in anesthesia is usually monitored by analysis of perioperative mortality-morbidity and incidents. Clinical quality indicator, death within 48 hours of anaesthesia exposure is considered to be a flag that can alert to possible problems in individual patient care. The measurement of perioperative mortality as a quality indicator is a continuous peer reviewed quality improvement activity. Medical records and morbidity and mortality files were reviewed to see the trends and finding the benchmark of mortality in ASA-1 and 2 patient who died between 1992-2006 within 48 hours of anaesthesia exposure. Mortality in class 1 was nil. Anaesthetic mortality in ASA-1 and 2 patients was 0.35 per 10,000 and 0.74 per 10,000 of ASA-2 patient's volume. Anaesthesia-related mortality was 0.17 per 10,000 and 0.37 per 10,000 of ASA-2 patient's volume which is almost double of the overall calculated incidence. We suggest continuing monitoring of anaesthesia related mortality as a continuous quality indicator in developing countries. The reporting and analyzing of data according to the ASA status volume should be taken as a denominator. The available benchmark will help in evaluating the confounding factors and perioperative care of a particular group of patients

Preoperative haemodynamic measurements compared to haemodynamic response of Tracheal Intubation. Search for the most appropriate baseline

To measure the variability in blood pressure and heart rate in the pre operative clinic, after admission in the ward, in the holding area of the operating room, and inside the operating room. Our secondary objective was to see which blood pressure and heart rate should be taken as a baseline for clinical monitoring during anaesthesia especially when one is looking at haemodynamic changes associated with tracheal intubation. Thirty consecutive patients meeting the study inclusion criteria were enrolled at the preoperative anaesthesia clinic. Non invasive blood pressures and heart rate were measured at the pre operative anaesthesia clinic, in the ward, in the holding area on morning of surgery, and inside the operating room. The difference between the haemodynamic readings at different locations was not statistically significant for heart rate and diastolic blood pressure however they were statistically significant for systolic and mean arterial pressures with highest pressures recorded in the immediate pre induction period. The change to maximum reading was 17.18%, 11.89% ,7.83%, 3.59% when clinic, ward, holding area or operating room were taken as baseline alternatively. Variability exists in the measurement of systolic blood pressure taken at different hospital locations in surgical patients. Further work needs to be done to define the appropriate baseline for haemodynamic monitoring and research

role of prophylactic intra-aortic balloon pump counterpulsation [IABP] in emergency non-cardiac surgery

Patients with recent myocardial infarction [MI], congestive heart failure, severe angina, or uncorrected multivessel coronary artery disease are at increased risk of cardiac complications after urgent major non-cardiac surgery. Although invasive haemodynamic monitoring and preoperative optimization of cardiac status may lead to some reduction in the rate of perioperative cardiac events, the mortality from such events still remains high. The use of an intra-aortic balloon pump [IABP] may play a role in such patients by improving the function of the injured heart. We report our experience with the use of perioperative IABP in a patient with unstable angina and recent MI who underwent urgent cholecystectomy. There were no perioperative cardiac events while the IABP was in place. The anaesthetic concerns, intraoperative and postoperative monitoring and care and usefulness of IABP will be discussed

Unanticipated hospital admission after andbulatory surgery

The unplanned admission rate is considered to be an important measure of the quality of ambulatory surgical units. The objective of our study was to evaluate the unanticipated hospital admission rate from the Surgical Day Care [SDC] unit of our university affiliated teaching hospital and to analyze the reasons for admission. A review of all unanticipated admissions over a one-year period was done. The admission rate was calculated and the reasons for admission were analysed. The overall admission rate was 4.93%. Most of the admissions were ordered by the surgeons [97%]. The main reasons for admission were patient observation indicated for various reasons [72%] and patient request [18%]. Eighty percent of the admitted patients had received general anaesthesia. Admissions were also related to the male gender [69%], age over 65 years [27%] and surgeries ending in the afternoon [69%]. On analyzing the reasons for admission, a large number of admissions were found to be due to preventable causes. We conclude that proper selection of patients, careful scheduling of lists and education of patients and clinical professionals can help to avoid many unanticipated admissions after day care surgical procedures

Anesthesia for patients with heart block and pacemakers in situ

This article summarises the newer concepts in the anaesthetic management of patients with different degrees of heart block. The preoperative, per-operative, and postoperative management of paced patients and the anticipation of potential problems is discussed