Assessment of Patient Safety in a Low-Resource Health Care System: Proposal for a Multimethod Study.

BACKGROUND: The high prevalence of adverse events (AEs) globally in health care delivery has led to the establishment of many guidelines to enhance patient safety. However, patient safety is a relatively nascent concept in low- and middle-income countries (LMICs) where health systems are already overburdened and underresourced. This is why it is imperative to study the nuances of patient safety from a local perspective to advocate for the judicious use of scarce public health resources. OBJECTIVE: This study aims to assess the status of patient safety in a health care system within a low-resource setting, using a multipronged, multimethod approach of standardized methodologies adapted to the local setting. METHODS: We propose purposive sampling to include a representative mix of public and private, rural and urban, and tertiary and secondary care hospitals, preferably those ascribed to the same hospital quality standards. Six different approaches will be considered at these hospitals including (1) focus group discussions on the status quo of patient safety, (2) Hospital Survey on Patient Safety Culture, (3) Hospital Consumer Assessment of Healthcare Providers and Systems, (4) estimation of incidence of AEs identified by patients, (5) estimation of incidence of AEs via medical record review, and (6) assessment against the World Health Organization's Patient Safety Friendly Hospital Framework via thorough reviews of existing hospital protocols and in-person surveys of the facility. RESULTS: The abovementioned studies collectively are expected to yield significant quantifiable information on patient safety conditions in a wide range of hospitals operating within LMICs. CONCLUSIONS: A multidimensional approach is imperative to holistically assess the patient safety situation, especially in LMICs. Our low-budget, non-resource-intensive research proposal can serve as a benchmark to conduct similar studies in other health care settings within LMICs. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/50532.

The comparison of the analgesic efficacy of continuous paravertebral block alone compared with continuous paravertebral and intercostal nerve block for thoracotomy in adults: a randomized controlled trial.

PURPOSE: The study aims to compare the analgesic efficacy of two analgesic interventions, continuous paravertebral (PVB) nerve block alone with continuous paravertebral and intercostal nerve block (PVB/ICB) in patients undergoing thoracotomy. METHODS: A total of 70 patients undergoing thoracotomy were randomly enrolled in either continuous paravertebral nerve block (PVB) group or in continuous paravertebral and intercostal nerve block (PVB/ICB) group and received corresponding blocks. Analgesic efficacy measured by Visual Analog Scale (VAS) pain score, hemodynamic effects, total narcotic consumption, sedation score, patient's length of stay in hospital and patient's satisfaction with the analgesic technique were recorded. RESULTS: Demographic characteristics of the patients were similar in both groups. The mean VAS pain score was not statistically significant in both groups at 24 h. The mean pulse rate and blood pressures were comparable in both groups for the first 24 h. Nalbuphine consumption was significantly higher in PVB group as compared to PVB/ICB group at 1 h (p = 0.01), 6 h (p = 0.03) and 12 h (p = 0.009) and 24 h (p = 0.03). The mean total nalbuphine consumption in the PVB group was higher (28.29 mg vs. 22.63 mg) and statistically significant then PVB/ICB group (p = 0.03). The total tramadol consumption as a rescue analgesic was higher in the PVB group (131.42 mg) as compared to PVB/ICB group (120 mg) after 24 h but not statistically significant (p = 0.17). CONCLUSION: Continuous paravertebral nerve block with intercostal nerve block provides effective post-operative pain relief after thoracotomy with reduced narcotic consumption compared to continuous paravertebral nerve block alone. CLINICAL TRIAL REGISTRATION NUMBER: Clinicaltrails.gov NCT04715880.

Pharmacological Interventions for the Treatment and Control of Shivering in Adult Patients Undergoing Elective Surgery Under Regional Anaesthesia: A Systematic Review and Meta-Analysis.

Intraoperative shivering is quite common after regional anaesthesia, which not only increases the total body oxygen requirement but also causes discomfort to the patients. The aim of this systematic review is to determine the effectiveness of pharmacological agents administered intra-operatively for treating shivering in adult patients who are undergoing elective surgery under regional (i.e., central neuraxial) anaesthesia so that an optimal choice of an agent can be recommended for clinical application. A literature search was carried out using PubMed, Cochrane Library, CINAHL databases, and hand searches to identify relevant studies. After literature screening and information extraction, a systematic review was performed. Meta-analysis was performed for the primary outcome. The primary outcome was to evaluate the effectiveness of pharmacological agents used for the treatment and control of intraoperative shivering and the time taken to control shivering. The secondary outcome includes recurrence of shivering after pharmacological intervention and identification of common adverse effects related to them. In total, 10 studies (791 patients) were included. Common interventions were opioids, central α2 receptor agonist, and few other medications like magnesium sulfate, ondansetron, nefopam, and amitriptyline. Tramadol and dexmedetomidine were the most frequently documented drugs compared with other drugs to resolve shivering. The most effective drug with approximately 100% response rate was dexmedetomidine with the dose of 0.5 µg kg-1 intravenously given just after the appearance of shivering. Studies showed that tramadol is also an effective drug used to control shivering in most patients, and its effect is comparable with the pethidine.

Female Representation in Academic Medicine in Pakistan: A 15-Year Overview.

OBJECTIVE: To determine the proportion of female authors publishing in Pakistan and their representation in academic anesthesiology. Design, place, and duration of study: This study was a cross-sectional retrospective analysis. We reviewed all volumes and issues of the Journal of the College of Physicians and Surgeons Pakistan (JCPSP) published from 2007 to 2021. All original articles, clinical practice articles (CPAs), reviews, and editorials were included. The first and last authors publishing in JCPSP were the study subjects. MAIN OUTCOME MEASURES: Gender of the first and last authors was determined by (a) a general review of the author's first, middle, and last names, (b) an internet search of the author's name, and a review of photographs on their social media, or (c) an online search of the author's first name for typical gender assignment. The research field of the first author was noted to determine the contribution of different medical specialties. Article type and the number of citations were noted to determine the relationship with the gender of the author. RESULTS: Around 1549 papers were published by Pakistani authors, of which, 82.6% were original articles, 9.8% were editorials, 5.5% were CPAs, and 2.1% were reviews. Around 56.2% of the first authors and 70.9% of the last authors were males. Most article types had a majority of male first and last authors (<0.001). The median (interquartile range) citation rate was two (0-19), with no difference in citations between gender. Male-male author pairing remained the most common (45.6%). The majority of the papers published belonged to the field of medicine (27.2%) and surgery (21%), with only 3.1% contributed by anesthesiology (females: 41.3%; males: 58.6%). CONCLUSION: Female representation in academia in Pakistan is at par with developed countries. The academic contribution from anesthesiology remains low, which corresponds to a lower percentage of the anesthesia workforce in the country. There is a need for a national indexed journal of anesthesia to evaluate the true representation of female authors in the country.

Incorporating Patient Safety and Quality Into the Medical School Curriculum: An Assessment of Student Gains.

BACKGROUND: Global efforts are being made to improve health care standards and the quality of care provided. It has been shown through research that the introduction of patient safety (PS) and quality improvement (QI) concepts in the medical curriculum prepares medical students to face future challenges in their professional careers. PURPOSE: This study aimed to evaluate how a brief course on QI and PS affects the knowledge, efficacy, and system thinking of medical students. METHODS: A 5-day QI and PS intervention course was implemented at the Aga Khan University medical college for 98 third-year medical students in March 2021. This weeklong course of lectures, interactive sessions, and hands-on skill workshops was conducted before the students began their clinical rotations. Students' knowledge, self-efficacy, and system thinking were assessed with pretest and posttest. Students were also asked to write personal reflections and fill out a satisfaction survey at the end of the intervention. RESULTS: Comparisons of pretest and posttest scores showed that the course significantly improved students' knowledge by a mean of 2.92 points (95% confidence interval, 2.30-3.53; P < 0.001) and system thinking by 0.16 points (95% confidence interval, 0.03-0.29; P = 0.018) of the maximum scores of 20 and 5 points, respectively. The students' self-assessment of PS knowledge also reflected statistically significant increases in all 9 domains ( P < 0.001). Students reported positive experiences with this course in their personal reflections. CONCLUSIONS: The medical students exhibited increases in knowledge, self-efficacy, and system thinking after this weeklong intervention. The design of the course can be modified as needed and implemented at other institutions in low- and middle-income countries. A targeted long-term assessment of knowledge and attitudes is needed to fully evaluate the impact of this course.

Striking the Right Note: Assessing the Recipient for Liver Transplantation in Low- and Middle-Income Countries.

More than 50 years have passed since Starzl et al. did the first liver transplant. Since then the transplant speciality has witnessed enormous growth and at present more than 1 000 000 liver transplants have been performed to date in over 100 liver transplant centers around the world. In Europe and North America, the predominant mode is deceased donor liver transplantation, while in Turkey and most of the Asian countries, the living donor liver transplant or split liver transplantation is the most widely available method for liver transplantation. The etiology of end-stage liver disease is also different in developed and developing countries. Liver recipients usually have multiple comorbidities and in addition, derangements in liver functions also indirectly affect other systems. The anaesthesiologist plays a very crucial role as a perioperative physician concerning liver transplantation. He is the lead person involved, from preoperative workup to intraoperative management and postoperative care in critical care units. Anaesthesiologists are also actively involved in developing organ transplant pathways and protocols for perioperative assessments. Although there are local protocols and pathways for assessing liver transplant recipients, there is a lack of standardization in the literature for such assessments. This article highlights essential aspects in assessing liver transplant recipients and the role of some specific assessment tools and establishes a standardized protocol for selecting and optimizing suitable patients, thereby reducing the mortality and morbidity associated with this major surgery.

Anaesthetic Management of a Child with West Syndrome Associated with Tuberous Sclerosis Complex at a Remote Location: A Case Report.

West syndrome is a rare syndrome that consists of a triad of infantile spasms, hypsarrhythmia pattern on electroencephalogram and mental retardation. Tuberous sclerosis complex (TSC) is one of the disorders that can cause it. Radiology suites are considered as remote locations for anaesthesiologists, and the delivery of anaesthesia becomes challenging if a patient with such a rare disease having multiple anaesthetic implications arrives. We present anaesthetic management for the radiological procedure of the MRI brain of a year old paediatric patient with the West syndrome having suspected TSC based on presenting signs and symptoms. Anaesthetic consideration and management of this rare syndrome are discussed. Detailed preoperative assessment, pre-emptive preparation for possible difficult intubation and difficult intravenous access, careful positioning and prevention of seizures should be the goal. Thorough knowledge of the disease process, its manifestation and its management is the key to the successful management of such cases.

Thyrotoxic Hypokalemic Periodic Paralysis: A Success Story of a Diagnostic Challenge.

Thyrotoxic hypokalemic periodic paralysis (THPP) is a rare but life-threatening complication of hyperthyroidism seen predominantly in males. It is generally characterized by hypokalemia and skeletal muscle paralysis requiring intensive care admission. Hypokalemia occurs due to the massive intracellular shift of potassium because of the hyperactivity of the sodium-potassium adenosine triphosphates pump (Na+ K+ ATPase). Its differential diagnosis from the other common causes of hypokalemic paralysis is essential to provide targeted therapy. We present a rare case of THPP in a female patient with no prior history of thyroid disease. THPP in this patient was precipitated by trauma and emotional stress, which served as a diagnostic challenge. Both hypokalemia and elevated levels of T3 and T4 are important diagnostic features during the acute episode. Treatment of THPP includes nonselective beta-blockade, which prevents the shift of intracellular potassium, and potassium replacement. THPP is curable once a euthyroid state is achieved.

[Comparison of two supraglottic airway devices on postoperative sore throat in children: a prospective randomized controlled trial]. / Comparação entre dois dispositivos supraglóticos de vias aéreas na dor de garganta pós­operatória em crianças: estudo controlado prospectivo randomizado.

BACKGROUND AND OBJECTIVE: Sore throat is well recognized complaint after receiving general anesthesia. This study is conducted to compare the severity and frequency of postoperative sore throat in children undergoing elective surgery - following the use of Ambu laryngeal mask airway) or I-gel® - who are able to self-report postoperative sore throat. METHOD: Seventy children, 6 to 16 years-old, undergoing elective surgery randomly allocated to either Ambu laryngeal mask (Ambu Group) or I-gel® (I-gel Group). After the procedure, patients were interviewed in the recovery room immediately, after one hour, 6 and 24 hours postoperatively by an independent observer blinded to the device used intra-operatively. RESULTS: On arrival in the recovery room 17.1% (n=6) of children of the Ambu Group complained of postoperative sore throat, against 5.7% in I-gel Group (n=2). After one hour, the results were similar. After 6 hours, postoperative sore throat was found in 8.6% (n=3) of the children in Ambu group vs. 2.9% (n=1) in I-gel Group. After 24hours, 2.9% (n=1) of the kids in Ambu Group compared to none in I-gel Group. There was no significant difference found in the incidence of postoperative sore throat in both devices on arrival (p=0.28); after 1 hour (p=0.28); after 6 hours (p=0.30); and after 24 hours (p=0.31). The duration of the insertion was shorter in Ambu Group and it was easier to insert the I-gel® (p=0.029). Oropharyngeal seal pressure of I-gel® was higher than that of Ambu laryngeal mask (p=0.001). CONCLUSION: The severity and frequency of postoperative sore throat in children is not statistically significant in the I-gel Group compared to Ambu Group.

Comparison of two supraglottic airway devices on postoperative sore throat in children: a prospective randomized controlled trial / Comparação entre dois dispositivos supraglóticos de vias aéreas na dor de garganta pós-operatória em crianças: estudo controlado prospectivo randomizado

Abstract Background and objective: Sore throat is well recognized complaint after receiving general anesthesia. This study is conducted to compare the severity and frequency of postoperative sore throat in children undergoing elective surgery, following the use of Ambu laryngeal mask airway or I-gel®, who are able to self-report postoperative sore throat. Method: Seventy children, 6 to 16 years-old, undergoing elective surgery randomly allocated to either Ambu laryngeal mask (Ambu Group) or I-gel® (I-gel Group). After the procedure, patients were interviewed in the recovery room immediately, after one hour, 6 and 24 hours postoperatively by an independent observer blinded to the device used intra-operatively. Results: On arrival in the recovery room 17.1% (n = 6) of children of the Ambu Group complained of postoperative sore throat, against 5.7% in I-gel Group (n = 2). After one hour, the results were similar. After 6 hours, postoperative sore throat was found in 8.6% (n = 3) of the children in Ambu group vs. 2.9% (n = 1) in I-gel Group. After 24 hours, 2.9% (n = 1) of the children in Ambu Group complained of postoperative sore throat compared to none in I-gel Group. There was no significant difference found in the incidence of postoperative sore throat in both devices on arrival (p = 0.28); after 1 hour (p = 0.28); after 6 hours (p = 0.30); and after 24 hours (p = 0.31). The duration of the insertion of Ambu laryngeal mask was shorter and it was easier to insert than I-gel® (p = 0.029). Oropharyngeal seal pressure of I-gel® was higher than that of Ambu laryngeal mask (p = 0.001). Conclusion: The severity and frequency of postoperative sore throat in children is not statistically significant in the I-gel Group compared to Ambu Group.

Resumo Justificativa e objetivo: Dor de garganta é uma queixa bem conhecida após anestesia geral. O presente estudo comparou a gravidade e a frequência da queixa de dor de garganta pós-operatória associada ao uso de máscara laríngea Ambu ou máscara laríngea I-gel® durante cirurgia eletiva, em crianças capazes de autoreferir a queixa no pós-operatória. Método: Setenta crianças, de 6 a 16 anos submetidas à cirurgia eletiva foram alocadas aleatoriamente para o emprego da máscara laríngea Ambu (Grupo Ambu) ou para o emprego da máscara laríngea I-gel® (Grupo I-gel). Após o procedimento, os pacientes foram entrevistados imediatamente após admissão na sala de recuperação pós-anestésica-SRPA, uma hora, 6 e 24 horas após a cirurgia por um observador independente e cego ao dispositivo de vias aéreas utilizado no intraoperatório. Resultados: Na admissão à SRPA, 17,1% das crianças no Grupo Ambu (n = 6) se queixaram de dor de garganta pós-operatória, contra 5,7% no Grupo I-gel (n = 2). Após uma hora, os resultados foram similares. Após 6 horas, houve dor de garganta pós-operatória em 8,6% (n = 3) das crianças no Grupo Ambu vs. 2,9% (n = 1) no Grupo I-gel. Após 24 horas, 2,9% (n = 1) das crianças no Grupo Ambu versus nenhuma criança no Grupo I-gel. Não houve diferença significante na incidência de dor de garganta pós-operatória nos dois dispositivos na admissão na SRPA (p = 0,28); após 1 hora (p = 0,28); após 6 horas (p = 0,30); e após 24 horas (p = 0,31). A duração da inserção foi menor no grupo da máscara laríngea Ambu, e a I-gel® foi mais fácil de inserir (p = 0,029). A pressão de selagem orofaríngea do I-gel® foi maior do que a da máscara laríngea Ambu (p = 0,001). Conclusão: A gravidade e a frequência da dor de garganta pós-operatória em crianças não foram estatisticamente significantes no grupo com máscara laríngea I-gel® em comparação ao grupo com máscara laríngea Ambu.

Ultrasound-guided peripheral nerve blocks in high-risk patients, requiring lower limb (Above and below knee) amputation.

A case series of five high-risk patients with lower limb ischemia, sepsis, altered coagulation, and multi-organ dysfunction requiring emergent or urgent lower limb amputation is presented. Use of peripheral nerve blocks for below and above knee amputations is quite uncommon which provides better hemodynamic stability and pain management, especially in the very sick patients. The surgeries were successfully carried out under ultrasound-guided combined femoral and sciatic nerve blocks. All five patients obtained adequate level of block at the area of amputation. There were no complications related to anesthetic management. Patients remained hemodynamically stable and pain-free during surgery and postoperatively. Combined femoral-sciatic nerve block under ultrasound guidance is safe and satisfactory alternative anesthetic technique for such patients.