Early extubation in adult and pediatric open heart surgery; an experience from a tertiary care hospital of a developing country

Numerous remarkable advances have been made in the perioperative care of both adults and children undergoing cardiac surgery. Improvements in the technology of CPB, advances in the techniques of surgery, a better understanding of the pathophysiology of the postoperative period, and refinements in anesthetic and ICU care have led to changes in the perioperative management of these patients. These changes have resulted in improved outcomes and shortened hospital stay. Fast track strategy [FTS] is one of the major advances in the sub-specialty of cardiac anesthesia practice. FTS is applicable to all moderate to low risk elective open heart adult and pediatric surgeries. The role of anesthesiologist in Fast Track extubation [FTE] is very crucial and decisive as perioperative physician. Teamwork in FTE execution is very important. Every team member should respect the opinion of other team member provided the opinion is in the best interest of the patient. Multiple studies conducted as clinical audits and case series to validate the safety and feasibility of fast track extubation in adult and pediatric open heart surgical patients at our institution. Fast track extubation was practically evolved at our institution in 2007. FTE cannot be predicted in all the cases as it depends upon intra-operative and post-operative course. Safety is the priority in the decision about fast track extubation

Introduction to basic transesophageal echocardiography [TEE] and standard views

Intraoperative use of transesophageal echocardiography [TEE] for monitoring and diagnostic purposes has increased over the years in cardiac surgical patients and anaesthesiologists have taken a lead to develop expertise in performing this examination. TEE has proved to be helpful in the management of non-cardiac surgical and Intensive care unit patients particularly those patients who are haemodynamically unstable. It provides important information about ventricular and valvular anatomy and its function. Certain structures which are difficult to visualize by transthoracic echocardiography can be demonstrated easily by TEE. Several guidelines have been established for performing comprehensive TEE examination and cardiologists and anaesthesiologists follow these guidelines to identify any cardiovascular abnormality. TEE use is limited to very few centres in Pakistan, mainly due to the equipment cost and lack of expertise. In addition, there are no established TEE training institutes. The main purpose of this article is to provide basic information about transesophageal echocardiography machine, TEE probe and how to obtain standard images by probe manipulation

Grown up Congenital Heart Disease patient presenting for non cardiac surgery: anaesthetic implications

Congenital heart disease patients surviving to adulthood have increased over the years due to various reasons. These patients are admitted in the hospital for non cardiac surgeries and other procedures more often than normal adult population. Management of grown up congenital heart disease patient presents a challenge during perioperative period for cardiologists, surgeons, intensivists and particularly for the anaesthetist. Management issues include psychological and physiological impact on the patient, complexity of defects, presence of previous palliative procedure, impact of anaesthetic agents on shunting and myocardium, endocarditis prophylaxis and associated extra cardiac anamolies

Etiology of obstructive jaundice: a comparative study

1. To re-appraise the etiology of obstructive jaundice. 2. To raise high index of suspicion for malignancy in cases of obstructive jaundice. DESIGN: retrospective study. SETTING: department of surgery, Rawalpindi General Hospital. PERIOD: Jan 1990 to Dec 1994. PATIENTS AND METHODS: 360 cases which presented with extra hepatic biliary tract disease, 52 had obstructive jaundice, the etiology of which is evaluated and compared with that of European published data. common bile duct stones accounted for obstruction in 21 patients [40.3%], whereas carcinoma of the pancreas produced obstruction in 14 patients [27%]. Carcinoma of gall bladder presented with obstructive jaundice in 8 patients [15.3%]. Pancreatitis caused obstruction in 4 [7.6%] and secondaries produced obstructive jaundice in 2 patients [3.8%]. The incidence of malignancy was 48.1% in this study in comparison with two studies from United Kingdom which shows an incidence of 59% and 29.45%. Choice of various operative procedures performed is also evaluated. CONCLUSIONS: It is concluded that malignancy accounts to almost half of the cases of obstructive jaundice which is higher than in Western countries

Torsion of testis: R.G.H. experience

A retrospective study of thirty two patients presenting to Emergency department of Rawalpindi General Hospital with acute scrotal pain, all being subjected to surgery. Seventeen [54%] were found to have gangrenous testis with mean time of presentation 9 hours. Nine [28%] patients could be salvaged with bilateral fixation. Seven [22%] were found to have torsion of appendix testis with mean time of presentation being 18 hours. Torsion in undescended testis was encountered in seven [22%] patients. Six[19%] patients had negative explorations and all were above 25 years of age