Hypothermia in trauma

The number of polytrauma patients in high energy accidents brought to trauma centers is increasing day by day. For their management we require a multidisciplinary team capable of performing lifesaving maneuvers following the sequence of resuscitation protocols. The physiological response in a patient with trauma is usually hypovolemic shock. The compensatory mechanisms are activated to improve redistribution of the flow and maintain systemic vascular resistance. During the transitional period rational and goal-directed fluid therapy and prevention of inadequate tissue perfusion and impaired metabolic exchange at the microcirculatory level take precedence. Trauma kills by acidosis, hypothermia and coagulopathy- together called the "mortal triad"- which develop as a consequence of the metabolic changes induced by polytrauma. Hypothermia as part of the triad in the polytrauma patient is an indicator of injury severity and is associated with an increase in mortality. In the case of trauma patients, the presence of hypothermia is related to inability of the body systems to maintain temperature in the face of increased heat loss, decreased production and/or alterations in thermoregulation. The hemodynamic response to the decrease in temperature begins with peripheral vasoconstriction, myocardial dysfunction and electrical instability develops as a consequence of the metabolic changes induced by polytrauma. The complications of hypothermia include activation of the coagulation cascade, triggering of acidosis, endothelial dysfunction, inflammatory cascade activation, consumption coagulopathy, hypoxia, cell death, multiple organ dysfunction etc. This review highlights the main aspects of the pathophysiological derangements occurring as a result of trauma

Malignant hyperthermia, dantrolene and apathy

Malignant hyperthermia is a genetically transmitted hypermetabolic syndrome, and thus will always continue to surface and test the wits of the anesthesiologists. This editorial compliments two case reports published in this issue, as well as a brief story on the related topic in the journal's permanent chapter [My Most Unforgettable Experience]. The high rate of mortality due to non-availability of dantrolene, and thus the need to chalk out a well-linked system to make dantrolene available even in the farthest corner of the country, with the help of army aviation, when the need arises, is emphasized.

National anesthesia mentoring program

Pakistan has a big population, with large parts mainly centered in larger cities and towns, although majority of the population is scattered in villages and remote areas. A major part of the healthcare facilities and professionals are thus concentrated in towns and cities. The anesthesiologists who have to serve in peripheral areas remain cut off from the more fortunate and more experienced senior colleagues serving in the larger institutions with better facilities. Hence, they have little access to the opportunities to enhance their professional competence. To fulfil the gap, a WhatsApp group, 'Anesthetists Support Group' was started by some of our Pakistani colleagues currently serving in UK with collaboration of their counterparts in Pakistan. The group has recently conducted a national survey and proposed to have a countrywide mentoring program to provide an opportunity to these peripheral anesthesiologists to enable them to seek help in case of emergencies and enhance their professional competence

Is regional anesthesia safe in children?

There is a long history of using regional anesthesia in children. Even though, majority of the anesthesiologists still prefer general anesthesia [GA], the use of regional techniques is on a rise. Recent advances in regional block techniques and new equipments have enhanced the use of regional anesthesia in children and decreased complications. This brief review stresses that it is better not to prejudge and let us make sure that the regional anesthesia is in fact as safe as GA

comparative study of tracheal intubation using i-gel[TM]and air-Q[TM] intubating LMA

Various supraglottic devices [SGD's] have been used as a conduit for tracheal intubation particularly in difficult airway situations when an endotracheal tube is a must. Various SGD's tried for this purpose include Intubating Laryngeal Mask Airway also called the C-Trach[TM]laryngeal mask, LMA Fastrach[TM] air-Q[TM] intubating LMA and the i-gel[TM] supraglottic airway. In this study we used air-Q[TM] LMA and i-gel[TM] for blind tracheal intubation in patients with normal airways and compared the rates of successful intubation. 100 patients were randomly divided into two groups. For Group A, air-Q™ was used for blind tracheal intubation while for Group B i-gel[TM] LMA was used. Correct placement of ETT was confirmed by capnography. Success rate for blind tracheal intubation through air-Q[TM] was 82% while that for i-gel it was 54% [p-value 0.003]. The success rate for blind tracheal intubation through air-Q[TM] intubating laryngeal mask airway is higher as compared to that for blind tracheal intubation through i-gel[TM]

Transfusion, under-transfusion and over-transfusion

The incidence of transfusion has increased day by day due to many factors, including increasing population, enhanced expertise and facilities to operate once inoperable conditions and the willingness of the public to pay high cost of advanced surgical procedures. Trauma services have been well-organized now and victims may have massive transfusion. Many authors have pointed out the need of protocols and guidelines to be followed to avoid transfusion associated risks and complications. Under-transfusion has been preferred to over-transfusion and a need to have a 'Maximum Surgical Blood Order Schedule' has been stressed

Successful intubation with air-Q in Pierre Robin syndrome

Airway access is particularly difficult in infants and children with some anatomical deformities, usually associated with congenital syndromes. Craniofacial abnormalities are commonly seen in the Pierre Robin Syndrome [PRS], Treacher Collins and Goldenhar syndromes. The Pierre Robin sequence consists of micrognathia and relative macroglossia with or without cleft palate. In the severe case, airway obstruction and feeding difficulties are present. Endotracheal intubation may be difficult, or in some case even impossible. We present a case report of intubation of a child, suffering from PRS, by using air-Q, a new intubating LMA, and use of tongue stitches to maintain airway during recovery

Drug errors: a case of syringe swap

The journal presents this special issue dedicated to drug errors, with just two aspects highlighted; syringe swap and inadvertent wrong drug administration due to look-alike drug containers. This article gives the background of this decision and a victim's vivid narrative of her terrific experience related to drug error during anesthesia

Redefining plagiarism; a friend or a foe?

Plagiarism is a universal phenomenon, not strictly restricted to medical writing, but encompassing almost all fields of life. Over a period of time, it has become customary to talk very loudly about it and even condemn it as a sin. A review of the past and present scientific knowledge as well as literature confirms that plagiarism has been and is still in wide practice in developed as well as undeveloped countries. The availability of scientific knowledge on the internet has made it easier to plagiarise as well as to identify plagiarized material. On the other hand much of the research methodology, reviews, discussion parts of original articles and even larger books and monographs do contain parts of copied material from already published material. This editorial review the prevalence of and the measures to control the plagiarism, and stresses a need to draw fresh lines in between good and bad plagiarism

Job satisfaction in Pakistani anesthesiologists

The purpose of this study is to provide empirically-based evidence about Pakistani anesthesiologists' job satisfaction, upon which recommendations can be made to physicians, managers, and policy makers. A questionnaire based, cross-sectional study. Islamabad; July 2008-January 2010. A questionnaire was designed so as to accumulate evidence about the level of JS, mailed by post to known addresses of all anesthesiologists across the country and was also e-mailed to anesthesiologists via direct e-mailing. All heads of anesthesiology departments of major hospitals were requested to get the questionnaire filled by all the anesthesiologists in their departments. A total of 40 responses were received. A total of 40 responses were received. Mean age of the respondents was 41.77 years [SD = 10.39] with a range of 27-69 years. Among the respondents, 21[52.5%] were higher diploma holders, 12[30%] were lower diploma holders and 7[17.5%] were postgraduate trainees. The respondents ranged from a professor to PG trainees, including 6[15%] senior anesthesiologists, 27[67.5%] junior anesthesiologists and 7[17.5%] PG trainees. Anesthesiology was the first choice specialty of 19[47.5%]. 13 [32.5%] of the respondents repented at some point after joining the specialty. 50% of anesthesiologists were fully satisfied with their job, the great majority of senior consultants were satisfied as compared to juniors 12 [63%] vs. 8[38%]. 20[50%] of the respondents were satisfied with the working conditions in the operating rooms. Only 5[12.5%] of the respondents were satisfied with anesthesia fee paid to them as compared to 35 [87.5%], who were not. 36[90%] including a majority of PG trainees [71%] opined that the anesthesia fee should be based on ASA physical status of the patients. 35[87.5%] of the respondents expressed their dissatisfaction about the public awareness about their role in the operating rooms and the healthcare system. The rating of public awareness about their role in operating rooms, intensive care, pain management and resuscitation was 3.52 +/- .28, 2.92 +/- .26, 2.18 +/- .25 and 2.88 +/- .37 respectively on a scale of 1-10. Various measures suggested to improve it included pre-anesthetic rounds [25%] and media talks [37.5%]. Others favoured public awareness meetings, television programs + writing article in newspapers and proper legislation etc. 33[82.5%] suggested that PSA could play a role in improving public perception. We conclude that JS in anesthesiologists in Pakistan is low as compared to developed countries and correlates with low anesthesia fee as well as low public awareness about the vital role played by them in the patient care in the operating rooms as well as other fields e.g. in intensive care setting, pain management and resuscitation. JS can be improved with more attention to improving working conditions, improving fee structure and public awareness about the specialty and about the players in this specialty

Epidurography

Since its introduction into clinical practice in 1921, millions of epidurals are performed daily around the world. Anesthesiologists were quick to grasp its use for prolonged or continuous analgesia and routinely use it alone or in combination with general anesthesia. It has been found to be associated with less complications as compared to spinal analgesia and has taken a major chunk out of spinal practice. The success of epidural depends upon successful location and deposition of drugs into the epidural space. Blind identification of epidural space by loss of resistance or negative epidural space pressure has resulted in mixed results. The figures vary among the researchers but in about 25-30% cases, drugs are deposited at wrong place [outside epidural space]. Epidurography offers the best method of confirming the needle or catheter tip location in the space, and has evolved itself a standard practice now. Although very rarely adverse reactions to the technique or the contrast media have been reported, the method is highly recommendable and the pain practitioners and anesthesiologists are encouraged to use it more judiciously

Safety of tramadol as a pre-induction agent

To study the safety profile of intravenous use of tramadol immediately before induction of general anesthesia. Prospective, observational study. January 2005 to October 2007. Combined Military Hospital Multan, Military Hospital Rawalpindi and Railway Hospital Rawalpindi. 600 patients of ASA-I to ASA-III, aged 10.-50 years, undergoing elective surgery were selected for the study under convenient sampling. Children less than 10 years were excluded. Morbidly obese and patients with history of syncope, convulsive syncope, panic attacks and other convulsive events were excluded. Ladies undergoing caesarian section were also excluded from the study. The patients were injected 1.5mg/kg body weight, but not exceeding 100mg of tramadol [100mg of the drug diluted to 10 ml] intravenously, slowly over a period of two minutes as a part of pre-induction regimen. Patients were monitored for any untoward signs and symptoms for 10 min and all observations were recorded. The main complications / side-effects observed were nausea / vomiting, sweating, heart sinking and seizures in that order. Out of 600 patients, 47 [7.83%] patients complained of nausea alone and 9 [1.5%] patients had a bout of vomiting, 23 [3.88%] patients were observed to have sweating, 31 [5.17%] female patients complained of heart sinking and 2 [0.33%] patients had had seizure activity. We conclude that although the use of IV tramadol as a pre-induction agent is associated a low risk of side effects, but due to its potential to cause seizure activity, it is best avoided in the environments where adequate resuscitative measures are not available