Quality assurance audit in adult cardiac anaesthesia.

OBJECTIVE: To assess different anaesthesia-related quality indicators during adult cardiac surgery. METHODS: The prospective clinical audit was conducted at the Aga Khan University Hospital, Karachi, from October 2016 to March 2017, and comprised all adult patients scheduled for cardiac surgery. Different anaesthesia-related quality indicators were observed during the pre-induction phase, before the cardiopulmonary bypass, during the procedure, and post-surgery till the transfer from the operating room to the cardiac intensive care unit. Data was analysed using SPSS 19. RESULTS: Of the 264 patients, 217(82.2%) had complete record; 160(73.7%) males and 57(26.3%) females. The overall mean age was 56.56±12.46 years. In the pre-induction phase, difficult intravenous and invasive line access was seen in 42(19.3%) patients. Inappropriate information in the preoperative form was found in 6(2.8%) patients, and preoperative drugs for anxiolysis were used in 145(66.8%) patients. Haemodynamic issues were significant during the surgery in 15(6.9%) patients. In the post-surgery period, abnormal activated clotting time was found in 17(7.8%) patients, while monitoring problems were faced in 7(3.2%) cases during transfer to cardiac intensive care unit. CONCLUSIONS: It will help to develop quality improvement policies to enhance patient safety, satisfaction and better outcome.

Paediatric Thoracic Tumour Resection: Challenge For An Anaesthesiologist.

Paediatric thoracic tumours resection is one of the most difficult procedure for any anaesthetist. Paediatric population is different from adults in many aspects, as they have small thoracic volume and more compressible mass effect on their airway and vascular structures. we are reporting a case of a huge paediatric thoracic tumour resection occupying the left thoracic cavity. The possible mechanism, consequences, prevention and management discussed in this report.

Misplaced Central Venous Catheter in Carotid Artery during Emergency Surgery for the Total Correction of Tetralogy of Fallot of an Adolescent Boy.

Ultrasound-guided central venous cannulation is now considered as the standard of care, and this has largely replaced blind central venous cannulation using anatomical landmarks. We are reporting a case of inadvertent placement of central venous catheter in the right common carotid artery with the use of ultrasound guidance during emergency surgery for the total correction of Tetralogy of Fallot (ToF). This patient luckily had a favourable outcome despite this inadvertent catheter placement which was not recognised even after completion of surgery .The patient also received drug infusions of inotropes and vasopressors through this malplaced central line into the aorta. The possible mechanism, consequences, prevention and management of this inadvertent cannulation are discussed in this report.

Comparison between Intravenous Boluses versus Infusion of Tranexamic Acid (TXA) to Reduce Bleeding in Paediatric Cyanotic Congenital Heart Disease (CHD) Surgeries.

OBJECTIVE: To compare the intravenous boluses and intravenous continuous infusion of tranexamic acid (TXA) to reduce postoperative bleeding in cyanotic congenital heart disease surgeries. STUDY DESIGN: Single-blinded randomised clinical trial. PLACE AND DURATION OF STUDY: Anaesthesia Department, The Aga Khan University Hospital, Karachi, from July 2016 to April 2017. METHODOLOGY: Sixty patients of cyanotic congenital heart disease, undergoing either palliative or corrective surgery involving cardiopulmonary bypass (CPB), were recruited. These 60 patients were divided randomly into two groups. The infusion group received intravenous infusion of TXA at 5 mg/kg/hour while the bolus group received three intravenous boluses of 10 mg/kg after induction, after going to bypass and after protamine reversal. Data was collected through predesigned proforma. There were two primary outcomes: postoperative bleeding in the first 24 hours, and chest closure time. RESULTS: Postoperative bleeding was 13.94 (10.27-20.18) ml/kg in the first 24 hours in infusion group and 15.05 (9.0423.50) ml/kg in the bolus group. Chest closure time was 38.5 (25-45) in infusion group and 30 (20-46.25) minutes in the bolus group. There was no statistically significant and clinical difference between both groups regarding postoperative bleeding in the first 24 hours and chest closure time. CONCLUSION: These infusion and bolus groups had comparable postoperative bleeding and chest closure time.

Manual Trans-Tracheal High Frequency Positive Pressure Ventilation for Left Main Bronchus and Carinal Mass Surgical Resection in a Child.

Inflammatory myofibroblastic tumor (IMT), also called pseudo-tumor, is a very rare condition and accounts for less than 1% of primary lung tumor. It is most common benign tumor of lung in children. This case is reported with the objective of highlighting the role of manual trans-tracheal high frequency positive pressure ventilation (HFPPV) in facilitating surgical resection with maintenance of adequate oxygenation and a little compromised ventilation. A9-year boy, weighing 21 kg, was diagnosed as a case of IMTof left main bronchus on biopsy and was successfully treated by surgical excision through left thoracotomy. HFPPV through improvised technique was used for ventilation and oxygenation during surgery. Total Intravenous anaesthesia with propofol infusion and increments of fentanyl was used during HFPPV. After the completion of the surgery, conventional positive pressure ventilation (PPV) was continued through the endotracheal tube (ETT) to check any bronchial stump leak. After the surgery, patient was weaned and extubated in the operating room. Hospital course remained uneventful and the patient was discharged after 6 days. HFPPV with manually improvised technique is applicable in carinal surgery for optimization of oxygenation, ventilation, and uninterrupted surgical resection.