Arterial blood pH low ph as predictor of prognosis

Arterial blood gas analysis is the most commonly performed investigation in intensive care unit[ICU] as the changes in acid-base balance are common in critically ill patients. Changes in pH are directly related to severity of disease. Keeping in view our clinical experience and literature search, we assume that patients whose pH is less than 7 at any time in the course of disease carries poor prognosis. Quasi experimental study. ICUs of Combined Military Hospital Rawalpindi and Combined Military Hospital Multan. From 1st Jan 2006 to 6th Aug 2007 and 7th Aug 2007 to 31st May 2010 respectively. All the patients having pH less than 7 at any time in the course of disease were considered and patient having otherwise fair state of health before recent insult were included. Moribund terminally ill patient were excluded. All the thirty patients needed intubation and ventilation except one who remained conscious despite having pH. 6.95. Twenty two patients [73.4%] died and eight patients [26.6%] survived. All patients who survived were diabetic except one having tracheal stenosis. All patients who died were non diabetic. Only one non diabetic patient was among the survivor. Survival among diabetic patient as group was 100%[7/7]. Patients having pH below 7 at any time in the course of disease carry poor prognosis especially if they are non diabetic. Diabetic has best prognosis. However it is a small study of thirty cases only, further multi centre studies are needed to demonstrate the co-relation of pH with prognosis prediction

Tracheal stenosis surgery; airway management

To highlight the problems and solutions in airways management in patients with tracheal stenosis undergoing surgical interventions and to highlight the alternative methods of airway control where high frequency ventilatory facility is not available. Case series study. Combined Military Hospital Rawalpindi from 1[st] Jan 2004 to 30[th] June 2007. Twenty nine patients of both sex and all age groups presenting with difficulty in breathing due to tracheal stenosis undergoing surgical intervention on trachea have been included. All the patients were managed under general anaesthesia. Nasogastric tube 10 Fr, suction catheter, laryngeal mask airway or mask ventilation was used for initial ventilation where conventional endotracheal tube of even smallest size did not work. Small size endotracheal tube were used in twenty four patients. Difficulty was faced in five patients. In these patients endotracheal tube of smallest size available could not be passed and we had to provide ventilation by innovative measures like nasogastric tube 10Fr in one, suction catheter 10Fr in two, laryngeal mask airway in one and mask ventilation in one. There was no mortality. Adequate ventilation during tracheal stenosis surgery can be very difficult in some cases. Therefore a thorough understanding, a tier of flexible plans and a variety of ventilating means should be arranged before administering anaesthesia.Nasogastric tube 10Fr or suction catheter of similar size are suitable alternative if facility for high frequency ventilation is not available

Double lumen intubation; reliability of auscultatory method?

Auscultation is well established and most commonly used method for checking of correct placement of Double Lumen Tube[DLT]. Now with widespread availability of fibre optic bronchoscope, confirmation of DLT placement by fibre optic bronchoscope is recommended by many and considered mandatory by some anaesthetist. To discuss method of insertion and reliability of auscultatory method to confirm correct placement of double lumen tubes. Observational. Combined Military Hospital Rawalpindi from 16th Nov 2003 to 13th July 2007. We have performed about one thousand one hundred and fifty double lumen intubation without use of fibreoptic bronchoscope. 85% of patients did not need any tube adjustment during surgical procedure. Only 15% cases required tube adjustment intra-operatively. None of procedures were abandoned due to double lumen tubes problems. We conclude that auscultation is not that unreliable though not perfect method of DLT placement. Use of fibreoptic bronchoscope is recommended but not mandatory for DLT placement. Anatomical malpositioning detected by fibre optic bronchoscope which according to some studies is 70 to 80% does not necessarily translate into physiological malfunctioning

Anaesthestic management in disasters an anaesthetist's experience in "LAMNO" banda ache, Indonesia

The purpose of this study is to highlight the problems faced by the anaesthesiologist in the field and to mention some of the anaesthetic techniques which have proved useful in such adverse circumstances. Responding to the call for help to the victims of Tsunami on December 26 2004, the Pakistan Field hospital [Level II] arrived in Sumatra [Indonesia] and was deployed in a remote island, Lamno, Banda Ache. A total of 11,299 patients were treated including 1164 surgeries, from 12[th] January 2005 to 26[th] February 2005. The main problems were non availability of pressurized oxygen source, hostile and adverse circumstances, language barrier and massive number of tsunami victims requiring immediate medical attention. The Boyle's apparatus could not be used as it requires high pressure gases at 40 to 50 psi. The Oxygen concentrator was the only source of Oxygen. Descriptive. The surgical patients mostly had wounds of extremities which were infected. Majority of the surgical procedures included debridements of the wounds, skin grafting and amputation of the extremities. Most of the surgeries were performed under local and regional anaesthetic techniques. A modified general anaesthetic technique using an oxygen concentrator was devised for those few patients where regional anaesthetics alone were inappropriate. Local anaesthesia was administered to 1055 [90.64%] patients with minor injuries; peripheral regional blocks were administered to 35 [3.0%] patients, spinal anaesthesia to 31 [2.66%] patients and extradural anaesthesia to 17 [1.46%] patients. Eighteen [1.546%] patients were operated under dissociative anaesthesia with Ketamine and 08 [0.687%] patients were administered total intravenous anaesthesia, muscle relaxants, endotracheal intubation, bag valve mask [Ambu's] ventilation, oxygen supplementation from the oxygen concentrator and local anaesthetic infilteration. The incidence of complications was very low and none of the surgical patients had anaesthesia related morbidity or mortality. Most of the Tsunami affected patients could be managed safely under local anaesthesia, regional blocks or dissociative anaesthesia with Ketamine. The oxygen concentrator proved to be highly useful source of oxygen for a modified general anaesthetic technique without using a proper anaesthesia machine

Acute epiglottitis

A case of acute epiglottitis is presented here. The patient was in severe respiratory distress. He was intubated and managed in general ICU. He made good recovery. ICU management and special consideration of this disease are discussed

Brain death and related issues

Concerns about the erroneous diagnosis of death and premature burial have been expressed from times immemorial. Patients with brain stem death have absolutely no chance of recovery. brain death is considered at par with death in most of the countries. General public in most parts of the world shows reluctance to accept this concept due to different social, cultural and religious backgrounds and state of literacy and awareness. The criteria for the diagnosis of brain death have been established which include certain pre-conditions, exclusions and tests of the brain stem function. These criteria are universally accepted. The criteria in children are somewhat different from the adults. The subject is intimately related with organ transplantation. If the patient is registered as organ donor or the family consents, organs can be harvested from brain dead patients for transplantation. Pakistan is amongst the few countries where no legislation exists to accept brain death as being at par with death of an individual, and to facilitate and regulate, cadaveric organ donation and transplantation. This is a review Article