survey of obstetric anesthesia practices in district level and government teaching hospitals in Punjab, Pakistan

Objectives: Maternal mortality rate remains unacceptably high in Pakistan. Nearly 200 women die in Pakistan for every 100000 live births as compared to 8 in Europe. According to Pakistan Demographic and Health Survey [PDHS] 2006-2007, anesthesia is one of the contributing factors to this high mortality rate. The aim of this survey was to find out what standards and guidelines in obstetric anesthesia are followed by anesthesiologists in teaching and district hospitals in Punjab, which is the largest province of Pakistan

Methodology: From January 2016 to March 2016, seventeen teaching hospitals and twenty-four district hospitals in Punjab were asked to take part in telephonic or face-to face survey. Questions were asked regarding the availability of internationally acceptable guidelines and protocols for managing obstetric emergencies like massive hemorrhage and failed intubation. Questions were also asked about the availability of equipment for difficult airway, blood products and regional anesthetic techniques used for cesarean sections. Data were collected in Microsoft Excel format and analyzed using simple statistics

Results: Overall availability of guidelines was lowest for massive hemorrhage [12%] and highest for managing difficult intubation [29%]. For the management of difficult airway only 36% had endotracheal tube introducers. For major obstetric hemorrhage, 68% of the hospitals could get blood in 30 min and 24% could get fresh frozen plasma [FFP] in 30 min. Regional anesthesia was the preferred technique in all the government hospitals. For performing spinal anesthesia all of the anesthesiologists used sterile gloves while 51% used masks and gowns and only 39% washed their hands before spinal. Sensation of pain and leg raising were the main modalities used to test the spinal block with 41% anesthesiologists considering block up to T8 a good level to start cesarean section. 85% anesthesiologists used 25G Quincke spinal needle

Conclusion: Our survey showed a grim state of affairs as far as obstetric anesthesia in government hospitals of Punjab is concerned. However; a comprehensive survey is needed to draw final conclusions and make further recommendations

Hypertrophic cardiomyopathy in a patient of klinefelter syndrome - a rare association

A 36-year-old man presented with exertional dyspnoea and chest pain. He also had sexual dysfunction with poorly developed secondary sex characteristics. Echocardiography and thorough cardiac evaluation revealed obstructive hypertrophic cardiomyopathy. Hormonal profile suggested primary hypogonadism and cytogenetics report suggested a karyotype, 47, XXY, in all counted cells, consistent with the diagnosis of Klinefelter syndrome. He is being managed with beta-blocker and androgen replacement therapy

Acute myocardial infarction; significance of 1 [st] set of CK-MB in diagnosis

To assess the reliability of the first set of CK-MB in establishing diagnosis of acute myocardial infarction in different subgroups of the patients according to their time of presentation after symptom onset. Prospective observational study was carried out in Armed Forces Institute of Cardiology/National Institute of Heart Diseases [AFIC/NIHD] Rawalpindi, from April to September 2005. We studied 300 consecutive cases presenting with typical electrocardiographic changes of acute ST Elevation Myocardial Infarction of the Emergency and Reception department of AFIC/NIHD [confirmed later on as acute STEMI with raised serial serum cardiac enzymes levels]. We documented values of CK-MB at the time of presentation in different subgroups of the patients according to duration of symptom onset. This study was predominantly male dominated [approximately 78%], with a mean age of 58 +11 years. Majority of patients i.e. 216 [72%] presented within first 6 hours of onset of symptoms, 60 [20%] within 6-12 hrs, 6[2%] within 12-24 hrs and 18 [6%] after 24 hrs of onset of symptoms. Overall serum cardiac enzymes sent at the time of presentation revealed that 126 [42%] patients had normal CK-MB [<24U/L] and another 66 [22%] had a minimal rise in CK-MB [25-49U/L]. Only 108 [36%] patients 3 had serum CK-MB levels more than double the normal value. Amongst the patients presenting within the first 6 hours of onset of symptoms, 104 [48%] had normal CK-MB values, 48 [22%] had a minimal rise [<49 U/L] and only 64 [30%] had a significant rise in CK-MB levels i.e. more than double the normal values or more than 5% of CK value. Out of 60 patients who presented within 6-12 hours of onset of symptoms, 54 [90%] had more than double the normal value of CK-MB and 6 [10%] had mild rise in CK-MB. All the patients [100%] who presented within 12-24 hours of onset of symptoms i.e. 6 [2%] and more than 24 hours 18 [6%] had significant rise in CK-MB. This study shows that the first set of CK-MB alone has very little value in diagnosing acute myocardial infarction especially in the patients who presented within 6 hours of onset of symptoms. Reliability of CK-MB in diagnosing acute myocardial infarction greatly improves to the maximum in those patients who present more than six hours after symptom onset

Deployment of inferior vena cava filters; efficacy and safety

Objective: to study the patient's profile, indications and procedural success of placement of Inferior Vena Cava [IVC] filters at AFIC/NIHD Rawalpindi, Pakistan

Design: a retrospective observational study

Place and Duration of Study: the patients were studied in the department of Interventional Cardiology of AFIC/NIHD from May 2004 to Jun 2005

Material and Methods: 16 patients of either sex who revealed clinical and investigative evidence of recurrent pulmonary embolism [PE] due to deep vein thrombosis [DVT] of lower limbs were selected. All efforts including history, physical examination and laboratory investigations were carried out in order to ascertain the etiology. A note was made of the associated conditions, past and family history of DVT and PE. IVC filter was deployed through femoral vein in all patients as a lifesaving treatment modality. The procedure was uncomplicated and all patients had smooth post procedural recovery

Results: through femoral vein, IVC filters [Trap Ease Cordis J and J] were successfully deployed below the renal veins. In one patient, another filter was deployed immediately below the tricuspid valve

Conclusion: IVC filter placement is a simple, safe and effective procedure in stabilizing patients who have recurrent pulmonary embolism

Morphological changes in coronary arteries in cases of sudden cardiac death at high altitude

To determine the changes in coronary arteries in patients dying at high altitude. Observational descriptive study was carried out at Armed Forces Institute of Pathology and Army Medical College Pathology Laboratory, Rawalpindi form 2002 to 2004 on autopsy of 58 cases dying at high altitude. In 53 out of 58 cases, death was attributed to coronary atherosclerosis. The majority of cases were less than 40 years as also observed in people dying below high altitude. However triple vessel coronary atherosclerosis was seen in 67% cases and left anterior descending coronary artery was involved in almost 100% cases. Coronary atherosclerosis remains the major cause of death at high altitude in acclimatized individuals. Accelerated coronary atherosclerosis with triple vessel involvement in patients without prior history of ischemic heart disease points to specific indicators. Dietary modifications with high carbohydrate diet are recommended at high altitudes