Paraphenylenediamine poisoning: clinical presentations and outcomes

Background: Paraphenylenediamine [PPD], also known as Kaala pathar, has become an emerging and life threating source of poisoning in Pakistan as well as in many other Asian and African nations. The aim of this study is to recognize the etiological factors, poisoning

Methodology: This observational prospective analytic study included 32 patients who presented in ICU of Nishtar Hospital, Multan. Patients were first managed conservatively by IV fluids, diuretics, antihistamines and steroids; tracheal intubation or tracheostomy was performed only if needed. Univariate analysis was used to determine the independent variables of mortality after PPD poisoning and odds ratios were calculated

Results: Cervicofacial edema, oral erythema and sore throat were most common clinical presentation of patients at the time of admission in ICU, with incidence rates of 93.8%, 81.3% and 75.0%, respectively. Acute renal failure occurred in 34.4% patients and acute hepatitis in 18.75% patients. The independent predictors of mortality after PPD poisoning were: male gender [odds ratio 16.62], dysphagia [odds ratio 9.92], hyperkalemia [odds ratio 84.0], development of cardiogenic shock [odds ratio 36.75], acute renal failure [odds ratio 16.62] and acute hepatitis [odds ratio 27.50]. Tracheostomy was required in all 30 [93.7%], and 13 [40.6%] patients required mechanical ventilation support. In-hospital mortality was 9 [28.1%]. Mean stay of patients in ICU was 3.47+/- 2.04 days

Conclusion: Paraphenylenediamine [Kaala Pathar] poisoning has become one of the major means of suicide attempts with very high mortality rate. Male gender, dysphagia at the time of presentation, hyperkalemia, cardiogenic shock, acute renal failure and acute hepatitis are the independent predictors of mortality after PPD poisoning

Transversus abdominis plane block offers prolonged postoperative analgesia than surgical incision infiltration by bupivacaine in cesarean section patients

Background and objective: Postoperative pain requires a well-planned analgesia regimen to ensure adequate patient comfort, satisfaction, early mobilization and also to decrease the hospital stay after anesthesia. We conducted this study to compare the transversus abdominis plane block with direct infiltration of bupivacaine into surgical incision in cesarean section to prolong the mean duration of postoperative analgesia

Methodology: This Randomized control trial was conducted in department of anesthesia, Nishtar Hospital, Multan from July 2016 to December 2016. A total of sixty patients were included in the study and randomly divided into two equal groups of 30 each; Group-T and Group-I. Group-T received TAP block with 0.3 ml/kg of 0.25% bupivacaine on each side under double pop technique, and Group-I received 0.6 ml/kg of 0.25% bupivacaine infiltration in surgical incision. Postoperatively all the patients were monitored in PACU. VAS was noted at 1/2, 1, 2, 4 and 6 h intervals. Inj tramadol 1.5 ml/kg was given as rescue analgesia when VAS score >/=4. Time to requirement of first rescue analgesia was noted. Sample size was calculated with 80% power of test, 95 % confidence interval taking mean and standard deviation of rescue analgesia in Group-T 148 +/- 46.7 and in Group-I 85.38 +/- 38.07. Data were analyzed with computer software SPSS version 23. Mean +/- SD was calculated for quantitative variables and frequency [percentage] was calculated for qualitative variables. Student t-test and chi square test were applied. P value 0.05 was considered as significant

Results: Mean VAS score at half hour in Group-T was 3.8 +/- 2.9 and in Group-I was 5.0 +/- 3.0; and mean VAS score at one hour was 4.4 +/- 3.01 in T Group and in Group-I was 5.3 +/- 3.09 respectively; at two hours 4.7 +/- 2.9 and 6.3 +/- 4.2, and at four hours was 5.2 +/- 2.9 and 5.7 +/- 2.8 in Group-T and Group-I respectively. Mean VAS score during six hours was 5.5 +/- 2.8 and 6.1 +/- 2.5 in Group-T and Group-I respectively. Mean time for 1st analgesia in Group-T was 296.3 +/- 37.1 min and in Group-I was 202.0 +/- 34.9 min, by applying t-test P= 0.000 a significant value

Conclusion: TAP block is a promising technique in alleviating postoperative pain in patients' cesarean section. The procedural simplicity of this block, along with reliable level of analgesia [T10-L1], and longer duration makes the TAP block a good option

Spinal anaesthesia; comparison between prophylactic low dose ketamine and ondansetron for prevention of shivering during spinal anaesthesia in patients undergoing lower abdominal surgeries

Perioperative shivering is a common problem during spinal anaesthesia. It causes tremendous deleterious effects on metabolism of body. Despite of re-warming and raising the ambient temperature, several drugs are under research to evaluate their preventive role in shivering during anaesthesia like tramadol, butorphanol, midazolam, ketamine and ondansetron. The present study was conducted to evaluate the effect of prophylactic low dose ketamine and ondansetron for prevention of shivering during spinal anaesthesia. To compare prophylactic low dose ketamine with ondansetron for prevention of shivering during spinal anaesthesia in patients undergoing lower abdominal surgeries. Randomized controlled trial. Department of Anaesthesia, Nishtar Hospital Multan. November 2012 to May 2013. A total of 256 patients were included in the study divided into two equal groups. In this study basic demographics like age, gender, mean weight and height and type of surgery patients underwent were similar, having no significant difference in both groups, while on comparison in both groups, the frequency of shivering revealed 4.69%[n=6] in K Group and 11.72%[n=15] in O Group while remaining 95.31%[n=122] in K and 88.28%[n=113] in O Group had no findings of the morbidity, p value was calculated as 0.03, which showed significant difference. The result of the study concluded that prophylactic intravenous administration of low dose ketamine [0.25mg/kg] is significantly more effective than ondansteron [4 mg] for prevention of shivering during spinal anesthesia in patients undergoing lower abdominal surgeries

Postoperative analgesia; comparison of caudal bupivacaine and bupivacaine - tramadol in children with inguinal hernia repair

To compare the effects after caudal bupivacaine alone and bupivacaine-tramadol in young children with inguinal hernia repair. Department of Paediatric Anaesthesia, Children Hospital Complex, Multan. August 2008 to May 2009. A total of 100 children aged between 2-5 years were included in the study. The duration of analgesia was significantly prolonged in group-A patients [P= 0.001]. A low frequency of postoperative vomiting was observed in both groups i.e. 10% in group-A and 6.7% in group-B [P=0.64]. No respiratory depression, flushing and pruritis were observed. Low dose combination of bypivacaine and tramadol, when administered caudally, had an additive effect and provided prolonged and effective postoperative analgesia with minimal side effects

comparison of pressor respons following laryngeai mask airway vs laryngoscopy and endotracheal tube inserition

To test the hypothesis that laryngeal mask airway [LMA] insertion is associated with less pressor response as Compared to endotracheal intubation. A prospective, comparative study. Department of Anaesthesiology Intensive Care and Path Management, Nishtar Medical Institution Multan [Pakistan] from July 2007 to January 2008. 60 adult, ASA grades land II patients undergoing elective general surgery of less than one hour duration were divided in two groups with 30 patients in each. These patients were operated under general anaesthesia and either endotracheal tube [Group I] or LMA [Group II] was used to maintain the airway. The rise in heart rate, systolic and diastolic blood pressure was recorded before induction of anaesthesia and at one, three, five and ten minutes after insertion of laryngeal mask airway or tracheal tube and the results compared in both groups. A statistically significant rise in heart rate, systolic blood pressure and diastolic blood pressure was seen in group-I while statistically significant rise in heart rate only was seen in group-II subsequent to their insertion. Mean maximum increase was statistically more after laryngoscopy and endotracheal intubation than after laryngeal mask airway insertion. The duration of pressor responses was also longer after endotracheal intubation. Laryngeal mask airway is an acceptable alternative techinque offering advantages in terms of haemodynamic stability compared to tracheal intubation

Post-anaesthetic sore throat in patients with endotracheal tube

It has been noticed in the past that some patients who had undergone surgeries under general anaesthesia regained conscience and complained of sore throat. This study is to determine the ratio of patients under general anaesthesia who will present with post-operative sore throat; and to attempt to reduce that ratio in order to provide a more comfortable recovery to the patients. Sixty four patients eligible to be considered for analysis had follow ups for the next three days and were asked to describe any sore throat feature they might be experiencing after they recovered from anaesthesia. The incidence of sore throat in the patients was 37.5%. An alternative to ETT has to be employed [e.g. LMA]

Comparison of 0.5% lignocaine vs 0.5% lignocaine plus 0.25% tramadol in intravenous regional anaesthesia

To compare the quality, onset and duration of intravenous regional anaesthesia [IVRA] with 0.5% lignocaine plus tramadol and 0.5% lignocaine alone. A comparative, double blind, randomized, prospective study. Orthopaedic operating rooms, Nishtar Medical Institution, Multan, Pakistan, from June 2005 to June 2006. In our of 60 adult ASA class I and II patients undergoing upper limb surgeries in patients were divided in two groups having 30 patients in each. We used tramadol, a weak opioid as a component of IVRA with lignocaine to suppress intra-operative pain and enhance postoperative analgesia. Patients received IVRA with 40ml of 0.5% lignocaine to which either 100mg tramadol or saline was added. The onset of anaesthesia and recovery was compared by loss and regain of sensations. Tramadol with lignocaine was found to be significantly better for rapid onset and quality of anaesthesia compared to lignocaine alone and devoid of opioid related side effects. We conclude that tramadol as a component of IVRA is significantly better adjunct to lignocaine

PONV-A comparative study of meto-clopramide alone and with dexamethasone in strabismus surgery

To determine the efficacy of intravenous metoclopramide alone and in combination with dexamethasone in preventing postoperative nausea and vomiting [PONV] in patients undergoing strabismus surgery. Single blinded, randomized, interventional study. This study was conducted in the department of Anaesthesiology at Nishtar Hospital, Multan from October 2005 to October 2006. After the approval of the hospital's ethical committee, the study was conducted on 60 patients who were randomly divided into two groups, each group containing 30 patients. All of the patients were between 2-14 years of age and were A.S.A-I. Randomization was done by envelope draw method. The patients received either metoclopramide 150 micro g/kg or dexamethasone 150 micro g/kg with metoclopramide 150 micro g/kg combination IV, 30 minutes before the induction of anesthesia. General anesthesia was induced with thiopentone sodium, nalbuphine, succinylcholine and maintained with isoflurane and N[2]O+O[2] in both groups. PONV were evulated postoperatively. Patients in group II who received metoclopramide plus dexamethasone experienced significantly less PONV during the first 24 h after surgery. In this study, a single dose of metoclopramide plus dexamethasone [150 micro g/kg of each drug] produced better antiemetic effects after strabismus surgery than metoclopramide alone

Comparison of incidence of postdural puncture headache with 25[gram] quincke babcock spinal needle versus 27[gram] quincke babcock spinal needle in caesarean section

To compare the incidence of post dural puncture headache by using Quincke Babcock spinal needles of 25 G and 27 G in obstetrical patients. This comparative study was conducted in Obstetrics Units, Nishtar Hospital, Multan during the period. of 6 months i.e. from September 2004 to March 2005. A total of 80 patients were included in the study and divided into two groups. Out of the 80 patients, 9 were complicated by headache post-operatively. The overall incidence of PDPH was 15% in group-A, 7.5% in group-B. The difference in PDPH between groups was not statistically significant. The mean duration of headache was found to be 27.77 hours. In 5 patients out of 9, the duration of headache lasted less than 24 hrs. In 3 patients duration of headache was between 24-48 hours. in only one patient, the duration of headache was more than 48 hours. All the patients who developed PDPH had mild to moderate headache. In 8 patients out of 9 patients who had PDPH in the present study, the site was occipital region. Only one patient had generalized headache. Onset of headache was 24 hours to 72 hours after dural puncture. The incidence was found to be minimum with 27 Gauge Quincke Babcock spinal needle because the smaller the needle diameter the lesser the risk of cost dural puncture headache

Postoperative sore throat after endotracheal intubation of LMA

A prospective, randomized study was conducted to compare the postoperative throat complaints between two groups of patients with the airway managed either with an endotracheal tube [ETT] or a Laryngeal Mask Airway [LMA]. One hundred patients, ages 20-50 years and belonging to [ASA] class I and II were randomly allocated to the two groups. Patients in both groups underwent surgical procedures of less than one hour duration under general anaesthesia. Thirty percent of patients in the LMA group compared to sixty percent in [ETT] group had postoperative throat complaints. The difference was statistically highly significant [P=0.0005]. Moreover the degree of severity of sore throat in [ETT] group was higher than that in LMA group. It was concluded from the results that the use of LMA was associated with a reduced incidence and lower degree of severity of postoperative sore throat when compared to the ETT

Single versus multimodel analgesia in laparoscopic cholecystectomy

Evaluate the analgesic effect of single vs multimodel analgesics in postoperative pain in Laparoscopic Cholecystectomy and investigates whether. Prophylactic treatment with multimodel nociceptive blockade will delay the onset of postoperative pain. Decrease analgesic requirement, speed recovery time, and facilitate same. Day discharge in this surgical population. This experimental comparative study was conducted in General Operation Theatre of Nishtar Hospital, Multan during the period from May 2004 to November 2004. Sixty patients were included in the study and divided in 2 equal groups of 30 each using non-probability convenience sampling technique. Group-A:-Preoperatively at 45 minutes before induction of anesthesia an intramuscular [IM] bolus injection of Ketorolac 0.5mg/kg was given. Group-B:-Preoperatively at 45 minutes before induction of anesthesia, an intramuscular [IM] bolus injection of 0.5mg/kg Ketorolac+2mg/kg body weight of Tramadol [IM]+Local infiltration with 0.5% injection Bupivacaine was done 10 minutes before incision. in Group A, who received Inj. of Ketorolac 0.5 mg/kg, 14 patients [46.7%] had mild pain, 3 patients [10%] had moderate, 6 patients [20%] had severe and 7 patients [23.3%] had no pain. While in group B who received Ketorolac+Tramadol+0.5% of bupivacaine infiltration, the degree of postoperative pain relief I was greater than the Group A in which 14 patients [46.7%] had mild pain, 3 [10%] had moderate and 13 patients [43.3%] had no pain. There was no case having severe postoperative pain in group B. Multimodal analgesia has much more advantage over single analgesia in patients undergoing Laparoscopic Cholecystectomy

Lateral internal anal sphincterotomy for anal fissure: with or without associated anorectal procedures

To confirm or refute the validity of the fear associated with anal sphincterotomy for anal fissure, particularly when performed with other anorectal procedures. Design: Descriptive study. Place and Duration of Study: Surgical Wings - Medicare Hospital and Fatima Medical Center, Multan, over a period of 8 years from January 1994 to December 2001. Subjects and Records of 112 anal fissure patients, 46 [41.0%] males and 66 [58.9%] females, ranging in age from 12-95 years [mean 39] were studied. All patients with acute or chronic anal fissures with or without other anorectal pathologies were included. Seventeen patients who had anal dilatation and 2 recurrent fissures were excluded. 'Open' technique of anal sphincterotomy was employed in all cases. Results were recorded and analyzed. Fissures were acute in 16 [14.2%] and chronic in 96 [85.7%] patients. Anterior fissure was present in 20 [17.8%], posterior in 80 [71.4%], both in 9 [8.0%] and lateral or multiple fissures in 3 [2.6%] cases. Commonest associated pathology was haemorrhoids; encountered in 64 [57.1%] patients. Minor complications, taken together, occurred in 20 [17.8%] patients. Urinary retention was seen in 3 [2.6%] with lateral internal anal sphincterotomy [LIAS], and in 6 [5.3%] where haemorrhoidectomy was added. Haemorrhage in 2 [1.7%], temporary loss of flatus control in 3[2.6%] and soiling of clothes in 2 [1.7%] patients was encountered. No permanent loss of flatus or faecal control and recurrence has been reported to-date. Anal sphincterotomy with or without other anorectal procedures can be safely practiced in properly selected patients. Postoperatively, ablution with mild antiseptic added to plain water is adequate in maintaining hygiene to promote healing

Extra-dural anaesthesia for LSCS; comparison of buprenorphine-0.5 and bupivacaine mixture with plain 0.5 bupivacaine and bupivacaine mixture with plain 0.5 bupivacaine / and bupivacaine mixture with plain 0.5 / bupivacaine

[1] To assess the clinical efficacy of Buprenorphine 0.5% Bupivacaine mixture when given extraduraly for caesarean section. [2] To assess the smallest effective dose of each drug in combination. [3] To reduce side effects, whilst providing optimum analgesia. STUDY DESIGN: Double blind trial. PERIOD: Jan 1997 to Jan 1998. SETTING: Departments of Anaesthesia and Gynaecology and Obstetrics, Nishtar Hospital Multan. PATIENTS AND METHODS: Seventy patients for elective Caesarean section were allocated randomly to receive extra dural block with 20 ml of either 0.5% bupivacaine mixed with 0.3 mg of buprenorphine or 0.5% Bupivacaine. If the block did not reach T6 within 15 min, another 5 ml of solution was given. If needed, a further 5 ml was given 30 min after the main dose. The mean total dose of Bupivacaine was 23.1 ml [n-35] and of Bupivacaine mixed with 0.3 mg of Buprenorphine 23.7 ml [n=35]. There was no significant difference between the groups in the profile of sensory block produced. There was no significant difference in the time of onset, or intensity of motor block between the groups. The patients in the Buprenorphine 0.5% Bupivacaine group indicated greater satisfaction [86% very satisfied, compared with 43% in the control group [P<0.02]. There was no differences in the incidence of hypotension. However patients in the Buprenorphine-Bupivacaine group had pruritus, nausea and vomiting. There was no significant difference in neonatal outcome, as assessed by Apgar score, umbilical cord blood gas tensions at delivery. CONCLUSIONS: Buprenorphine-Bupivacaine and 0.5% bupivacaine plain produced a similar action and duration of sensory analgesia but combination of Bupivacaine and Buprenorphine produced more satisfactory block for caesarean sections

Combined spinal-epidural anesthesia [CSEA] single space technique [SST]

Combined spinal-epidural anaesthesia in a single space has been used since 1981 on 14816 patients. Lumbar [L] 2-3 or L3-4 space was punctured by tuohy needle. Spinal needle [25 or 26G] was then passed through epidural needle while its bevel was in caudal position in the epidural space. After injecting local anaesthetic [3.5 ml bupivacain] through spinal needle once it has pierced the subarachnoid space, spinal needle was taken out. Epidural catheter was passed after turning the bevel of epidural needle cephalad. Segmental spread was assessed by pinprick. Advantages of both spinal-epidural anaesthesia has been obtained by this technique apart from post operative pain relief