Frequency of difficult Intubation in Obese patients with neck circumference to Thyromental distance ratio >/=5.0

Objective: To determine the frequency of difficult intubation in obese patients with neck circumference to thyromental distance ratio [NC/TM] >/=5.0

Study Design: Cross sectional study

Place and Duration of Study: Department of Anaesthesia, Forward Treatment Centre, Kel [Azad Kashmir] and Combined Military Hospital [CMH] Malir. Six months, from Jun 2015 to Nov 2015

Material and Methods: A total of 94 patients between the ages of 18 and 50 years with body mass index [BMI] >/=27.5 kg/m2 and NC/TM >/=5.0 who received general anesthesia requiring tracheal intubation for elective surgery [Orthopaedic, General Sugery, Urology and Gynaecology] were included in the study. Patients were induced general anaesthesia and orotracheal intubation was done by anaesthetist with at least 1 year experience. Number of intubation attempts were recorded in each patient. More than 3 attempts were considered difficult intubation

Results: Eighty two [87.2 percent] out of 94 obese patients with BMI >/=27.5 kg/m2 and NC/TM >/=5 had difficult intubation

Conclusion: The NC/TM >/=5 was found good predictor for difficult intubation in obese patients

Advantages of carotid endarterectomy under local anaesthesia with minimal cerebral monitoring: an experience of 45 cases

To evaluate the benefits, efficacy and safety of local cervical plexus block in the performance of carotid endarterectomy, in the absence of sophisticated cerebral perfusion monitoring. This study was carried out at Combined Military Hospital [CMH] Lahore, Pakistan from January 2012 to May 2013. Quasi-experimental study. A total of 45 cases of ASA II and ASA III physical status were operated for carotid endarterectomy under local block of cervical plexus. After thorough preanaesthetic assessment, the patients physical conditions were optimized before surgery. Premedication was given with midazolam and sedated during operation with small doses of propofol. Local anaesthesia [LA] was completed by injecting bupivacaine in cervical plexuses C2, C3 and C4 areas. During operation vital signs and adequacy of cerebral perfusion were monitored by keeping the patient awake and making clinical neurological observations. Verbal contact was maintained with the patient. Breathing patterns and motor power were assessed in contralateral upper and lower limbs. Postoperatively patients were interviewed and analgesia during operation was assessed with visual analogue scale. Surgeon's satisfaction regarding intraoperative analgesia was also noted. Patients who required added sedation or local anesthetic agent were also noted. Average duration of surgery time was two hours and average stay of the patients in hospital was five days. Out of 45 patients, 37 patients [82%] had smooth and comfortable anaesthesia and analgesia. In only 1 patient [2.2%] LA had to be converted into general anaesthesia [GA]. In 3 cases [7%] LA was supplemented. One patient [2.2%] developed hoarseness and difficulty in breathing and 1 patient [2.2%] developed hemiparesis intra-operatively; while 1 patient [2.2%] developed hypotension in the immediate postoperative period. One patient [2.2%] developed haematoma at infiltration site. Surgeon satisfaction was excellent in 40 [89%] cases. Surgery of carotid endarterectomy can be performed adequately and comfortably under LA. In centers where sophisticated facilities for intraoperative cerebral blood flow measurements are not available, clinical intraoperative assessment of cerebral functions is of immense benefit, which is only possible under LA

Use of neostigmine to augment intravenous regional anesthesia using lignocaine in upper limb surgery

To evaluate the effects of neostigmine on onset and duration of Intravenous regional anesthesia [IVRA] when added to lignocaine. Randomized control trial. Combined Military Hospital Rawalpindi from 21 September 2006 to 23 April 2008. One hundred patients undergoing hand surgery were randomly assigned to two groups to receive IVRA. The control group received 1 mililiter [mL] of saline plus 3 miligram per kilogram [mg/kg] of lignocaine diluted with saline to a total dose of 40 mL, the study group received 0.5 mg [1ml] of neostigmine plus 3 mg/kg of lignocaine diluted with saline to a total dose of 40 mL. Sensory block and motor block onset and recovery were noted. Heart rate, mean arterial blood pressure, and oxygen saturation values were noted before surgery Imin, 5 min, 10 min, 20 min, and 40 min and after tourniquet release. Time to first analgesic requirement was also noted. The mean sensory block onset was 4.14 min as compared to 10.1 min in control group. Mean value of motor block onset was 6.3 min as compared to 13.8 min in control group.similarly mean for sensory recovery was 6.9 min as compared to 3.1 min for control group. Mean value for motor recovery was 5.17 min as compared to 2.17 min in control group. Experiment group had their demand for analgesics after a mean of 35.3 min and control group had their analgesia after 16.5 min. There was highly significant difference in all the variables. We concluded that neostigmine as an adjunct to lignocaine improves quality of anesthesia and is beneficial in IVRA

Patient satisfaction following cataract surgery under loco-regional anaesthesia; a comparison of conscious sedation using proofol infusion versus loco-regional anaesthesia alone

To compare loco-regional anaesthesia alone and its combination with conscious sedation using intravenous propofol infusion, in terms of patient satisfaction following cataract surgery. Randomized controlled trial Conducted in operation theatre complex of Combined Military Hospital Multan during April 2006 to April 2007. One hundred outpatients [n=100], who met inclusion criteria and were scheduled for cataract surgery under loco-regional anaesthesia [Retrobulbar block along with topical anaesthesia], were randomly allocated to group "A" and "B" of 50 patients each. In group A [n=50], patients were also provided conscious sedation using intravenous propofol infusion titrated to the desired effect. While group B [n=50] patients were not provided any sedation in addition to loco-regional anaesthesia. Patient satisfaction of both the groups was assessed by filling a questionnaire, using scoring system modified from Iowa Satisfaction with Anaesthesia Scale [ISAS] at the time of discharge from the hospital. Mean ISAS score of patients in Group A [n=50] was found significantly higher [23.26 +/- 9.52] than mean ISAS score of patients of group B [18.56 +/- 11.20]. Comparison depicted statistically significant difference as the p value was 0.026 [< 0.05]. Conscious sedation with Propofol infusion provided higher patient satisfaction after cataract surgery under loco-regional anaesthesia when compared to surgery under loco-regional anaesthesia alone, as measured by ISAS score. Propofol infusion is recommended to be a novel technique for conscious sedation in outpatient cataract surgery because of propofol's excellent pharmacokinetic profile

Pretreatment with lignocaine: effects on pain of rocuronium injection and withdrawal movements of the arm

To assess the frequency of pain and withdrawal movements after injection of rocuronium and effects of pre-treatment with lignocaine. Double blind study. This study was of six months duration and was carried out from March 2004 to September 2004. Combined Military Hospital Kharian. One hundred and twenty unpremedicated patients with ASA grade I and II, aged between 18-60 years and of both sexes were enrolled in the study. Patients were randomly divided into two groups of 60 patients each. After induction of anaesthesia with thiopentone, patients in group A received 3 ml of lignocaine plain while those in group B, received 3 ml of normal saline as pre-treatment before injection of rocuronium. Their effects on pain on injection and withdrawal movements of the arm were studied. Out of total of 120 patients, only 17 patients [14%] developed withdrawal movements of the arm or wrist. In Group A, who received lignocaine plain before rocuronium injection, only 3 patients out of 60 patients had withdrawal movements while in Group B, who received normal saline as pre-treatment fourteen out of 60 patients developed withdrawal movements of the arm or wrist. Only one patient belonging to Group B experienced pain. Pretreatment with lignocaine plain greatly reduces the chances of withdrawal movements and pain on injection of rocuronium

Neonatal resuscitation; the use of laryngeal mask airway

The key to success in newborn resuscitation is the knowledge about the neonatal physiology and adequate preparation of the staff involved in the resuscitation process. The pulmonary part of the resuscitation can be accomplished with either Endotracheal Tube [ETT] or Face Mask [FM], both of these techniques require expertise and are associated with high rates of failure. Hence a third potential option has been suggested to overcome these problems. To evaluate the efficacy of Laryngeal Mask Airway [LMA] in neonatal resuscitation and artificial ventilation and to compare it with that of ETT and FM. To evaluate LMA's efficiency in situation where endotracheal intubation and facemask ventilation is difficult or not possible. A Non interventional, analytical/ comparative study. Combined Military Hospital Rawalpindi. 20 weeks [1st] January 2002 to 31 May 2002]. A group of 75 neonates born with C-Section were selected on the basis of non-probability convenience sampling. They were subdivided into three sub gps with 25 neonates in each sub gp. 75 neonates born after C-Section, were divided into sub gps i.e. A, B, and C containing a no of 25 neonates in each gp. They were ventilated with ETT, FM and LMA respectively. These newborn babies had an Apgar score < 4. They were resuscitated using a fix protocol. The efficacy of ventilation with either technique was evaluated in terms of placement and ventilation. The LMA emerged, as a valuable and better option in newborn resuscitation. Moreover, it was a successful tool in situations where endotracheal intubation and facemask ventilation was difficult or impossible. The LMA is a potential valuable adjunct for the management of neonatal airway

Effects of pre-treatment with lignocaine on pain of rocuronium injection and withdrawal movements of the arm

The study was carried out to assess the frequency of pain and withdrawal movements after injection of rocuronium and effects of pre-treatment with lignocaine. It was a double blind study. This study was of six months duration and was carried out from March 2004 to September 2004 at Combined Military Hospital Kharian. One hundred and twenty unpremedicated patients with ASA grade I and II, aged between 18-60 years and of both sexes were enrolled in the study. Patients were randomly divided into two groups of 60 patients each. After induction of anaesthesia with thiopentone, patients in group A, received 3 ml of lignocaine plain while those in group B, received 3 ml of normal saline as pre-treatment before injection of rocuronium. Their effects on pain on injection and withdrawal movements of the arm were studied. Out of total of 120 patients, only 17 patients [14%] developed withdrawal movements of the arm or wrist. In Group A, who received lignocaine plain before rocuronium injection, only 3 out of 60 patients had withdrawal movements while in Group B, who received normal saline as pretreatment, fourteen out of 60 patients developed withdrawal movements of the arm or wrist. Only one patient belonging to Group B experienced pain. Pre-treatment with lignocaine plain greatly reduces the chances of withdrawal movements and pain on injection of rocuronium

Field anesthesia - experience in United Nation missions

To communicate the experiences of anaesthesiologists while working in United Nations [UN] peace keeping missions in different parts of the world. Questionnaire based observational study. A questionnaire was sent to anaesthesiologists who had served in UN missions. The response was evaluated by simple percentage. Problems identified in a UN missions are: setup of operating room, high prevalences of HIV, Hepatitis B virus and Hepatitis C virus among the population of host country, different sources of medical stores, short supply of medical gases and problems related to malaria and its prophylaxis. The problems can be overcome by prior planning, use of non conventional practices of anesthesia and vigilance in monitoring in operating rooms and post operative recovery units. Optimal utilization of the equipment can be achieved with the help of non governmental organizations

Thrombocytopenia in critically ill surgical patients; a study evaluating attributable patient's mortality and transfusion requirement

Thrombocytopenia is a well known complication in the surgical intensive care unit [ICU] patients. The influence of thrombocytopenia on patient`s mortality is difficult to assess. Thrombocytopenia results in increased mortality and transfusion requirement of platelets and other blood products, has not been confirmed by previous studies. We performed a case control study in surgical intensive care unit of Combined Military Hospital Rawalpindi in which 119 critically ill surgical patients developed thrombocytopenia of less than 50x10e9 platelets/L. These patients were carefully matched with control patients for the severity of underlying disease and important variables. Purpose of study was to evaluate attributable mortality and transfusion requirement in thrombocytopenic patients at that unit.. Fifty-two [44%] cases died versus forty [33%] control patients. Eighty one [76%] matched pairs had a concordant outcome and in 25% of those pairs, the cases died [exact binomial probabilities 0.036]. The estimated at tributable mortality rate was 18.4% [95% confidence interval 3.12-11.8] and the estimated odds ratio was 2.6 [95% confidence interval 1.02-7.10]. The estimated attributable transfusion requirement was 23% [95% confidence interval 5.3-43.5] and the estimated odds ratio was 1.51. This study suggests that thrombocytopenia of less than 50x10e9/L seems to be a marker of severity the illness and increases risk of death. Thrombocytopenia also leads to more blood product consumption

Facilitated blind nasotracheal intubation in paralysed patients with temporomandibular joint ankylosis

To assess the efficacy of blind nasal intubation technique, in cases of ankylosis of temporomandibular joint [TMJ] without the facility of fiber optic bronchoscope. Analytical study. Maxillofacial Surgery Department, Armed Forces Institute of Dentistry, Rawalpindi, Pakistan, from August 2002 to October 2003. A total of 35 patients of ankylosis of TMJ were included in the study. Blind nasotracheal intubation technique was attempted after induction of anaesthesia and paralyzing the patients. Where blind nasotracheal intubation technique was not successful, one nasotracheal tube was passed into the esophagus and retained. Nasotracheal intubation was attempted through contralateral nares by second tube. Out of 35 patients male to female ratio was 1:1.2. The age of the patients ranged between 5 to 35 years with a mean age of 14.5 years. Blind nasotracheal intubation technique was successful in 23 cases [65.7%], whereas in 12 patients intubation was not successful. The 12 cases of failed blind nasotracheal intubation technique were successfully intubated nasotracheally by prior placement of nasotracheal tube into the esophagus through contralateral nares, which facilitated re-intubation [34.3%]. In the selected patients blind nasotracheal intubation was facilitated by prior placement of the endotracheal tube into esophagus. This technique may be helpful in reducing the psychological trauma and complications of tracheostomy in such patients. However, to-date, fiber optic intubation remains the safest and widely accepted intubation technique in such patients

Nosocomial pneumonia in mechanically ventilated patients

Ventilator associated pneumonia [VAP] is a disease caused by different microorganisms and is associated with high mortality. The objective of this study was to ascertain the causative organisms of VAP and the mortality associated with this disorder. It was a prospective comparative study of 100 patients who underwent ventilatory support at a tertiary care teaching hospital [Combined Military Hospital Rawalpindi] from 1st July, 2000 to 30th June 2001. Patients who developed clinical signs of pneumonia are investigated by bronchoalveolar lavage[BAL] and blood culture. In patients who were diagnosed as a case of VAP, microorganisms were identified by BAL [79%] and blood culture [21%]. Patients who developed VAP were followed as well as the controls that do not developed VAP. Mortality among both groups was recorded. Outcome of the study showed organisms including Pseudomonas aeruginosa [26%], Staphylococcus aureus [20%], Acinetobacter spp. [9%], Proteus spp. [6%], Haemophilus spp. [6%], Escherichia coli [6%], Klebsiella spp. [3%], Streptococcus pneumoniae [3%], Corynebacteria spp. [3%], and Polymicrobial flora [9%]. The mortality among the patients of VAP was 50% compared to 30% among the patients without VAP. But this difference is non-significant. In conclusion VAP is developed by diverse groups of microorganisms with Pseudomonas aeruginosa, Staphylococcus aureus and Acinetobacter spp amongst the commonest pathogens. VAP is associated with higher percentage of mortality