randomized comparison of ultrasound guided versus direct palpation method of radial artery cannulation techniques in adult patients undergoing open heart surgery

Background and Objective: The use of two dimensional ultrasound technique allows radial artery cannulation to take place under real time visualization and may increase the success rate of first time pass of the needle and reduce the complications of the invasive procedure compared to traditional palpation and trial method

We aimed to compare the success rate of radial arterial catheter insertion at first attempt and average time for successful first attempt by traditional palpation method with ultrasound guided technique in adult patients undergoing open heart surgery

Methodology: A randomized study was conducted at our hospital during a 12 months period from 1st January 2014 to 31st December 2014. After taking permission from hospital ethical committee, one hundred adult patients were enrolled in whom radial artery cannulation was required prior to open heart surgical procedures including CABG, valvular heart disease, atrial septal and ventricular septal defect repairs and total correction. Patients were divided in two equal groups. In Group I radial artery cannulation was performed by ultrasound guidance and in Group II it was done by palpation method; in both groups Seldinger technique was used

Demographic and medical data were recorded in both groups. Heart rate, and invasive blood pressure monitoring was done in the arm in which the catheter was going to be inserted. Alien test with the help of pulse oximeter was also performed in all patients for detecting adequacy of ulnar artery flow. Time to first successful cannulation and the number of attempts were noted

Computer software SPSS 19.0 was used for data statistical analysis, the Chi-square/Fisher's exact test used for the comparison of qualitative/categorical variable in between groups. Student's t-test used for comparison of quantitative / continuous variables in between groups

Results: Average time to first successful attempt was 72.4 +/- 23.0 sec vs. 94.6 +/- 13.7 sec in Group I and II respectively [p=0.001]. Average number of attempts at same radial artery was significantly less in ultrasound group [1.4 +/- 1.0] as compared to palpation group [2.0 +/- 0.7] [p=0.001]. Ultrasound group [Group 1] had successful insertion at the first attempt in 36 [72%] patients, as compared to 32 [64%] patients in [Group II], but the difference was statistically not significant [p = 0.391]

Conclusion: Average time for successful first attempt was significantly less for radial artery cannulation performed by two dimensional ultrasound guidance as compared to palpation method; however, it did not significantly increase the success rate of first time cannulation of radial artery

Developing local guidelines for management of sepsis in adults: sepsis guidelines for Pakistan [SGp] endorsed by global sepsis alliance

The purpose of developing [Sepsis Guidelines for Pakistan] [SGP] is to provide clinicians practicing in local hospitals with a framework to aid timely recognition and management of adult patients in sepsis by adopting evidence-based recommendations of Surviving Sepsis Campaign [SSC] tailored to available resources. These recommendations are not meant to replace the SSC Guidelines. SGP is an initiative of Pakistan Society of Critical Care Medicine [PSCCM]. Four key decision points to be addressed in the guidelines were identified by a thirteen member multidisciplinary committeei.e., grading the hospitals in the country, recognition of sepsis and associated organ dysfunction, essential interventions to manage sepsis, and general measures for provision of a comprehensive care to patients in sepsis according to the level of education and training of healthcare providers and facilities and resources available in different levels of hospitals. The draft was presented at the 3[rd] Sepsis Symposium held on13[th] September, 2014 in Karachi. The final document was approved by a panel of experts from across the country, representatives of relevant societies and Global Sepsis Alliance [GSA]. Hospitals are divided into basic, intermediate and tertiary depending on the availability of diagnostic facilities and training of the medical personnel. Modified definitions of sepsis,severe sepsis, and septic shock are used given the lack of facilities to diagnose sepsis according to international definitions and criteria in Pakistan. Essential interventions include fluid resuscitation,vasopressors to support the circulation, maintaining oxygen saturation >/= 90% with oxygen, non-invasive ventilation or mechanical ventilation with lung protective strategies, prompt administration of antibiotics as recommended by the Medical Microbiology and Infectious Diseases Society of Pakistan [MMIDSP] and early source control. It is recommended to avoid starvation, keep an upper blood glucose 7.20, avoid fresh frozen plasma in the absence of bleeding, transfuse platelets if indicated, not use intravenous immunoglobulins and avoid neuromuscular blocking agents [NMBAs] in the absence of ARDS, target specific titration endpoints when continuous or intermittent sedation is required in mechanically ventilated patients and use continuous renal replacement therapy [CRRT] to facilitate management of fluid balance in hemodynamically unstable septic patients in tertiary care centers. In addition a comprehensive, meticulous and multidisciplinary general care is required to improve outcome of sepsis by reinforcing hand hygiene and other infection control measures, adequate monitoring and documentation tailored to the available resources. Goals of care and prognosis should be discussed with patients and families early and either shifting the patient to a hospital with better facilities or limiting or withdrawing therapy in case of poor prognosis should be considered

Walking epidural with low dose bupivacaine plus tramadol on normal labour in Primipara

To determine the obstetric outcome in terms of duration of labour and mode of delivery between the walking epidural analgesia with 0.1% Bupivacaine + 0.5% tramadol and routine labour practice. Non-randomized controlled trial. Department of Anaesthesia, Military Hospital, Rawalpindi, from August 2004 to July 2007. Consecutive 50 primiparous patients, ASA-I, coming to antenatal clinic for routine delivery were included in control group-A, and consecutive 50 primiparous ASA-I, coming to antenatal clinic and requesting for painless delivery were included in group-B. In group-A, only injection Nalbuphine 10 mg intramuscular was given when pain was unbearable, on patient's request as a routine practice. In group-B epidural analgesia was given with 15 ml of 0.1% Bupivacaine + 0.5 mg/ml Tramadol. First stage, second stage and total duration of labour were noted. Mode of delivery was also recorded in both groups. Patient satisfaction was assessed by interviewing the parturient ast evening round after delivery. In group-A, fist stage duration of labour was 3.72 +/- 1.16 hours and in group-B, it was 4.03 +/- 1.00 hours, [p < 0.001]. Second stage of labour in group-A was 0.55 +/- 0.35 hours and in group-B it was 0.67 +/- 0.33 hours; [p = 0.072]. Total duration of labour, group-A was 7.57 +/- 1.13 hours and in group-B it was 4.77 +/- 1.21 hours, [p < 0.001]. In group-A 46/50 [92%] patients were delivered spontaneously, while 4/50 [8%] required instrumental assistance, In group B 36/50 [72%] patients were delivered spontaneously and instrumental deliveries were 13/50 [26%] [p = 0.015]. One patient developed fetal distress and went through cesarean section in group B. Patient satisfaction was excellent in 88% of group-B parturients. Epidural analgesia with combination of low concentration of Bupivacaine, injection Tramadol and ambulation markedly reduce the duration of labour

Evaluation of the analgesic and adverse effects of tramadol in combination with low dose bupivacaine for painless epidural delivery

To evaluate the analgesic and adverse effects of Tramadol in combination with low dose Bupivacaine for painless epidural delivery. Quasi-experimental study. Place and Duration of Study: The study was carried out at department of anaesthesiology Military Hospital Rawalpindi from August 2004-July 2007. Material and Fifty ASA-I uncomplicated full term primiparous were selected. Epidural analgesia was given with 15ml of 0.1% Bupivacaine plus 0.5% Tramadol when labour was established and was repeated on patient's demand. Pain was assessed by using verbal analogue scale 0-10 in first stage as well as in second stage of labour. Adverse effects on mother and baby were noted. Overall satisfaction about the procedure was also assessed. Forty two [84%] rated first stage of labour pain free [VAS-0] and Eight patients [16%] rated it as good pain relief [VAS-3]. Thirty four [68%] patients in second stage of labour rated it pain free while sixteen [32%] patients rated it as good pain relief [VAS-3]. One patient developed hypotension. Two patients complained of nausea. No patient complained of vomiting and none of them developed sedation. Three [6%] newborns had Apgar score nine and forty seven [94%] had ten after five minutes of delivery. Forty four patients described the experience as excellent; five described it as good and one as satisfactory. Tramadol used in epidural painless delivery in combination with low dose Bupivacaine is very effective analgesic with less adverse effects on mother and baby and can be used as an alternative to fentanyl/pethedine

Frequency of hepatitis B and C in gynaecological patients

To determine the hospital based prevalence of hepatitis B and C in elective surgical patients of Gynaecology and Obstetrics. A descriptive study. The study was conducted in Military Hospital Rawalpindi from 25 Aug 2004 to 19 Dec 2005. A total of 1502 patients ranging from 20 to 70 years [Mean age 37 SD +/- 12], admitted for elective surgery in Gynaecology department, were screened for hepatitis B and C. Hepatitis C was positive in 156[10.39%] patients, while hepatitis B was positive in only 20 [1.33%] patients and both hepatitis B and C were positive in 5 [0.33%] patients. Overall hepatitis viruses were positive in 181[12.5%] patients. Conclusion: Seroprevalence of hepatitis, especially hepatitis C is high in Gynaecology/obstetric patients. All patients undergoing surgical/invasive procedure should be screened for Hepatitis B and C

experience of percutaneous tracheostomy in twenty obesity patients with short neck in a tertiary care hospital in Pakistan

To evaluate the success rate, procedure time and per-operative complications of percutaneous dilational tracheostomy in obese patients with short neck. Case series, descriptive study. Military Hospital Rawalpindi, from Jan 2006 to July 2007. Twenty obese patients with short neck were referred from intensive care unit [ICU] to operation theatre for open surgical tracheostomy [ST]. Before doing open procedure, all the patients were reassessed and an attempt was made by a team of experienced ENT surgeon and anaesthetist, to do percutaneous dilational tracheostomy [PDT] as first option. The success rate, procedure time and per-operative complications were noted. Data was collected over a period of one and half year. Twenty patients [12 F and 8 M], mean age 53 [34-80] years, mean body mass index [BMI=40] [34-45] were studied. The successful PDT was performed in 18 patients and in two patients procedure was converted to open surgical tracheostomy. Average time taken was 15 min. per-operative complications noted were, false passage, bleeding and leakage of air due to cuff puncture. In obese patients with short neck, if percutaneous dilational tracheostomy is performed by an experienced operator, in operation theatre [OT] with full preparation, good light and proper positioning, the procedure can be performed with in 15 min, the success rate is high with little complications

Comparison of haemodynamic effects of unilateral versus bilateral spinal anaesthesia

A comparative study was carried out to determine whether the unilateral spinal block produces comparatively less hemodynamic disturbances as compared to bilateral spinal block or not. Fifty male patients of age 25- 40 years of comparable weight and height, and ASA status I and II were selected and divided into two groups, Group A and Group B. Each group was assigned 25 patients by convenience sampling. Blood loss was comparable in both groups. All patients were assessed pre-operatively a night before operation. Two variables i.e. pulse and blood pressure was measured a night before operation, just before spinal injection and every thirty minutes for a total period of 180 minutes after the spinal injection. Average duration of surgical procedures was 57 +/- 13 minutes. Each patient was premedicated with tablet "Diazepam 10 mg" a night before operation and injection Diazepam 05 mg IV just before spinal injection and pre- loaded with 5% Dextrose Saline 500 ml. All patients were injected "abocaine spinal" 0.75% [heavy] 1.5 ml at L4-5 or L3-4 interspace intradurally with the help of 23G spinal needles under aseptic measures. Group-A patients were kept supine in flexed position for 10 minutes and Group B patients were kept in lateral decubitus position with surgical side down, for 10 minutes. Block was achieved up to T10-11 level. Contra lateral side was checked for block. Two groups were clinically comparable as regard to patient characteristics and methods of study e.g. dose and type of drug used and level of anaesthesia achieved. There was no significant hypotension or bradycardia in any group; rather there was an increase in blood pressure and heart rate in few patients signifying sympathetic over activation in younger patients. In younger age group haemodynamic changes were negligible in either group of study most probably due to active sympathetic system at the unblocked area. Unilateral block could be a more useful concept in older age group and autonomically compromised patients