Anticipated vs. Experienced Pain at Site of Spinal Needle Insertion in Patients Undergoing Elective Lower Segment Caesarean Section: Perspective from Resource-Limited Region.

Background: Despite significant advantages, approximately 20% of pregnant patients refuse spinal anaesthesia in caesarean section due to fear of spinal needle prick. Studies have shown that the patient's expectation of pain is higher than what they experience in real. The objective was to evaluate the difference between anticipated and actually experienced pain at the spinal needle insertion site in spinal anaesthesia for pregnant women undergoing elective lower segment caesarean section (ELSCS). Method: The cross-sectional study was conducted in a labour room suite of a tertiary care hospital. Results: A total of 50 patients scheduled for ELSCS were included. The median experienced pain at the site of spinal needle insertion was significantly low as compared to anticipated pain (P value < 0.01). For the identification of predictors impacting the anticipated and experienced pain, univariate and multivariate regression models were applied. Amsterdam Preoperative Anxiety and Information Scale ≥11 for anticipated pain showed a statistically significant positive correlation in univariate (coefficient: 2.59; 95% CI: 1.49 to 3.68; P value < 0.001) and multivariable analyses (coefficient: 2.51; 95% CI: 1.36 to 3.67; P value < 0.001). Thus, anxiety was associated with statistically significant higher anticipated pain. Conclusion: In conclusion, there is a remarkable difference in the obstetric population between anticipated and actually experienced pain at the site of spinal needle insertion in ELSCS.

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.

Impact of International Quality Improvement Collaborative on Congenital Heart Surgery in Pakistan.

BACKGROUND: The International Quality Improvement Collaborative (IQIC) was formed to reduce mortality and morbidity from congenital heart disease (CHD) surgeries in low/middle-income countries. OBJECTIVES: We conducted this study to compare the postoperative outcomes of CHD surgeries at a centre in Pakistan before and after joining IQIC. METHODS: The IQIC provides guidelines targeting key drivers responsible for morbidity and mortality in postoperativepatients with CHD. We focused primarily on nurse empowerment and improving the infection control strategies at our centre. Patients with CHD who underwent surgery at this site during the period 2011-2012 (pre-IQIC) were comparedwith those getting surgery in 2013-2014 (post-IQIC). Morbidity (major infections), mortality and factors associated with them were assessed. RESULTS: There was a significant decrease in surgical site infections and bacterial sepsis in the post-IQIC versus pre-IQIC period (1% vs 30%, p=0.0001, respectively). A statistically insignificant decrease in the mortality rate was also noted in post-IQIC versus pre-IQIC period (6% vs 9%, p=0.17, respectively). Durations of ventilation and intensive care unit (ICU) and hospital stay were significantly reduced in the post-IQIC period. Age <1 year, malnutrition, low preoperative oxygen perfusion, Risk Adjustment for Congenital Heart Surgery score >3, major chromosomal anomalies, perfusion-related event, longer ventilation and ICU/hospital stay durations were associated with greater odds of morbidity and mortality. CONCLUSION: Enrolling in the IQIC programme was associated with an improvement in the postsurgical outcomes of the CHD surgeries at our centre.

Feasibility and safety of on table extubation after corrective surgical repair of tetralogy of Fallot in a developing country: a case series.

Fast-track extubation is an established safe practice in pediatric congenital heart disease (CHD) surgical patients. On table extubation (OTE) in acyanotic CHD surgical patients is well established with validated safety profile. This practice is not yet reported in tetralogy of Fallot (TOF) cardiac surgical repair patients in developing countries. Evidence suggests that TOF total correction patients should be extubated early, as positive pressure ventilation has a negative impact on right ventricular function and the overall increase in post-TOF repair complications such as low cardiac output state and arrhythmias. The objective of the case series was to determine the safety and feasibility of OTE in elective TOF total correction cardiac surgical patients with an integrated team approach. To the best of our knowledge, this is the first reported case series. A total of 8 elective male and female TOF patients were included. Standard anesthetic, surgical and perfusion techniques were used in these procedures. All patients were extubated in the operating room safely without any complications with the exception of one patient who continued to bleed for 3 h of postextubation at 2-3 ml/kg/h which was managed with transfusion of fresh frozen plasma at 15 mL/kg, packed red blood cells 10 mL/kg and bolus of transamine at 20 mg/kg. Apart from better surgical and bypass techniques, the most important factor leading to successful OTE was an excellent analgesia. On the basis of the case series, it is suggested to extubate selected TOF cardiac surgery repair patients on table safely with integrated multidisciplinary approach.

Value of real life (in situ) simulation training for tracheal intubation skills in medical undergraduates during short duration anesthesia rotation.

BACKGROUND AND AIMS: Skill of a successful endotracheal intubation needs to be acquired by training and attaining several competencies simultaneously. It becomes more challenging when we have to deliver the key concepts in a limited period of time. The medium fidelity simulator is a valuable tool of training for such scenarios. For this purpose we aim to compare the efficacy of structured training in endotracheal intubation between real life simulation and the conventional teaching method. MATERIALS AND METHODS: The year 4 medical students had their attachment in anaesthesia for a period of 6 months from Jun - Dec 2009 were randomly divided into Group (Gp) A who had conventional teaching and Group B who were taught by four simulated sessions of endotracheal intubation. Performance of both the groups was observed by a person blinded to the study against a checklist on a 7 point rating scale in anaesthetized patient. RESULTS: Total 57 students, 29 in Gp A and 28 in Gp B were rotated in the anaesthesia during the study period. Evaluation of the individual component tasks revealed that simulated group achieved a significant difference in the scoring for laryngoscope and intubation technique. (P = 0.026, 0.012) The comparison of overall competence again showed that the 64.3% of student in Gp B achieved an excellent score in comparison to Gp A in which only 41.4% achieved excellent. (P = 0.049). Similarly the lesser number of students in Gp B (14.3%) require remediation as compared to the Gp A, in which the requirement was 40% (P=0.04). CONCLUSION: We conclude that all essential skills components of tracheal intubation in correct flow and sequence are acquired more efficiently by real life simulated training.

Safety profile of fast-track extubation in pediatric congenital heart disease surgery patients in a tertiary care hospital of a developing country: An observational prospective study.

BACKGROUND AND AIMS: Early extubation after cardiac operations is an important aspect of fast-track cardiac anesthesia. In order to reduce or eliminate the adverse effects of prolonged ventilation in pediatric congenital heart disease (CHD) surgical patients, the concept of early extubation has been analyzed at our tertiary care hospital. The current study was carried out to record the data to validate the importance and safety of fast-track extubation (FTE) with evidence. MATERIALS AND METHODS: A total of 71 patients, including male and female aged 6 months to 18 years belonging to risk adjustment for congenital heart surgery-1 category 1, 2, and 3 were included in this study. All patients were anesthetized with a standardized technique and surgery performed by the same surgeon. At the end of operation, the included patients were assessed for FTE and standard extubation criteria were used for decision making. RESULTS: Of the total 71 patients included in the study, 26 patients (36.62%) were extubated in the operating room, 29 (40.85%) were extubated within 6 h of arrival in cardiovascular intensive care unit and 16 (22.54%) were unable to get extubated within 6 h due to multiple reasons. Hence, overall success rate was 77.47%. The reasons for delayed extubation were significant bleeding in 5 (31.3%) cases, hemodynamic instability (low cardiac output syndrome) in 4 (25%) cases, respiratory complication in 2 (12.5%), bleeding plus hemodynamic instability in 2 (12.5) cases, hemodynamic instability, and respiratory complication in 2 (12.5%) cases and triad of hemodynamic instability, bleeding and respiratory complication in 1 (6.5%) case. There was no reintubation in the FTE cases. CONCLUSION: On the basis of the current study results, it is recommended to use FTE in pediatric CHD surgical patients safely with multidisciplinary approach.

A survey of undergraduate anesthesia rotation in medical colleges of Pakistan.

BACKGROUND: Student perceptions of specialties influence career choice decisions. It is important to expose undergraduates to the scope of rewarding careers in specialties like anesthesia by ensuring a good quality educational experience during anesthesia rotation. Our objective was to survey the curriculum structure and placement of the anesthesia undergraduate rotation in all the medical colleges of Pakistan recognized by the Pakistan Medical and Dental Council. MATERIALS AND METHODS: A standardized survey questionnaire was distributed by direct contact, postal mail or e mail to one identified anesthetist in all recognized medical colleges with enrolment of 100 or more students. The response rate was 75%. We received responses by hand, email and postal mail. RESULTS: We received responses from 15 out of 20 anesthetists contacted. 11 reported undergraduate anesthesia rotation while 4 reported absence of this rotation in their undergraduate curriculum. The rotation placement, duration and curriculum showed a wide variation and lack of standardization. CONCLUSION: Our survey indicates that the inclusion of anesthesia rotation in undergraduate medical education is not mandatory and standardized. The rotation duration, placement and curriculum need to be standardized to enhance the quality of the experience and promote the scope of the specialty for rewarding careers.

Anaesthesia as a career choice in a developing country; effect of clinical clerkship.

OBJECTIVE: To explore the fourth year medical student's knowledge regarding anaesthesia as a specialty, their attitude towards anaesthesia as a career choice and the effect of clinical clerkship on these. METHODS: This survey was conducted in the Department of Anaesthesia of a university medical centre in a developing country. One hundred and fifty year four medical students rotating in anaesthesia were enrolled. They were asked to fill a structured questionnaire before (pre) and after (post) their anaesthesia rotation. The questionnaire sought information on their perception of anaesthesia as a specialty, role of anaesthetists clerkship duration, and reasons for considering or not considering anaesthesia. RESULTS: Prior to anaesthesia clerkship 12 students (8%) included anaesthesia in their first three career choices (2 as first preference). Post clerkship 36 (24%) included it in their first 3 career choices (3 as first preference). There was a change in perception of specialty for 57 participants. CONCLUSION: The findings support the positive influence of anaesthesia clerkship on changing the attitude of medical students towards anaesthesia specialty in a developing country with shortage of anaesthesia personnel.

Audit of postoperative nausea and vomiting in paediatric day case surgery.

OBJECTIVE: To assess the incidence of PONV, delay in discharge or unplanned admissions in paediatric surgical cases done at the Surgical Day Care Unit at Aga Khan University between January and July 2009. METHODS: All paediatric ASA 1-2 cases, from 6 months to 18 years of age undergoing day case surgeries at the Surgical day care unit were included in this retrospective audit. Data was collected on a designed form filled with information from preoperative, intraoperative and postoperative recovery forms. Any relevant data was also noted from nurses notes in recovery room and step down unit. Episodes of vomiting, delay in discharge, or unplanned admission due to PONV were documented. Data was analyzed on SPSS 14. RESULTS: Out of 163 patients only one patient (0.6%) had an episode of vomiting in the recovery room and two patients (1.2 %) had vomiting in the step down unit. There was no delay in discharge or unplanned admission due to PONV in paediatric day cases during the period of our audit. CONCLUSION: The incidence of postoperative vomiting in paediatric day cases at our day care unit does not justify polymodal prophylaxis as a protocol for PONV.

Post-dural puncture posterior reversible encephalopathy syndrome.

We report the case of a young patient with 36 weeks pregnancy, and an acute respiratory infection with severe bronchospasm, who developed an occipital headache and neck pain on the third day of inadvertent dural puncture during placement of combined epidural spinal anaesthesia for caesarian section. It was diagnosed as post-dural puncture headache until generalised tonic clonic seizures occurred the next day raising the suspicion of postpartum eclampsia or meningitis. Posterior reversible encephalopathy syndrome was diagnosed on MRI of the brain which showed features of reversible ischemia in the posterior region of the brain. With anticonvulsant therapy and antibiotics there was complete resolution of neurological symptoms. We highlight the importance of high index of suspicion of this reversible encephalopathy in obstetric cases with intentional or inadvertent dural puncture, with headache similar to post-dural punctural headache, and the essential role of neuroradiology in confirmation of the diagnosis, as placement of an epidural blood patch would be highly detrimental in these cases.

A national survey into desirable personality traits in anaesthesia trainees in a developing country.

OBJECTIVE: To explore personality traits considered to be important in selection of trainees by consultant anaesthetists in a developing country. METHODS: A questionnaire listing 28 traits was sent to 125 consultant anaesthetists. The raters were asked to mark each trait on a scale of 1 to 10, with one being least desirable and 10 as most desirable. Listing of five most desirable and one least desirable trait was also required. RESULTS: The response rate was 79%. The most desirable trait was identified as reliability by 40%, followed by honesty 17%, functionality under stress 9%, punctuality 7%, and discipline 4%. The least desirable trait was considered as resourcefulness (21%), sense of humour (20%), unassuming mannerism (15%), high self esteem (11%), inquisitive (5%) and expedious (5%). CONCLUSION: Some traits have been identified as more desirable than others for trainees in our country. We plan to assess these in structured behavioural interviews in our residency programme.

Anaesthetic management of patient with Ellis Van Creveld syndrome.

A known case of Ellis-Van Creveld Syndrome was scheduled for emergency repair of obstructed paraumblical hernia. We describe the anaesthetic management of the case with special reference to the classic physical and physiological manifestations of this syndrome present in our patient.

Sedation-analgesia in non operative locations: practice trends of anaesthetists.

Sedation/analgesia is a mode of anaesthesia which facilitates an uncomfortable or painful procedure, such as gastrointestinal endoscopy, in a rousable and cooperative patient. The objective of the study was to assess the practice trends for administering sedation analgesia in non operative locations in Aga Khan Hospital, Karachi by anaesthetists. It was a descriptive study which retrospective reviewed anaesthesia records. A total of 41 ASA I-IV cases were reviewed. Non invasive cardiorespiratory monitoring and clinical sedation monitoring were applied. Intravenous Propofol infusion and midazolam boluses were used, singly or in combination with fentanyl boluses. All our patients recovered uneventfully within 5 minutes of the end of procedure. The practice trends for drug regimens are similar to those reported in recent literature. However we need to provide BIS monitoring, target controlled and patient maintained sedation to enhance patient and operator comfort.

Paraneoplastic syndrome of renal cell carcinoma.

We report a case of renal cell carcinoma who presented with the classic triad of flank pain, hematuria and fever as well as progressively developed multisystem disease, including a massive anteroseptal myocardial infarction. This was diagnosed as paraneoplastic syndrome of renal cell carcinoma and the decision to proceed with nephrectomy was taken after 3 weeks of acute myocardial infarction, despite predicted high cardiac risk under general anaesthesia; following removal of tumour, all symptoms and signs regressed. He has remained well till the time of last follow-up 4 months later.

Evaluation of cardiology consultations sought from the anaesthesia clinic.

OBJECTIVE: To evaluate the criteria for cardiology referrals and to assess the perioperative relevance of the cardiology advice given in patients evaluated for non-cardiac surgery. DESIGN: Single center, observational study. PLACE AND DURATION OF STUDY: Outpatient Anaesthesia Clinic at The Aga Khan University Hospital (AKUH), between January 2001- August 2001 and February 2002- August 2002. MATERIALS AND METHODS: A review of case files of 70 patients, scheduled for non-cardiac surgery, who were referred for cardiology consultations from the anaesthesia clinic at AKUH during the study period. The clinical criteria for seeking cardiology advice, the cardiology advice given, its influence on patient management, as well as number of adverse cardiac events in the perioperative period were documented. RESULTS: A history of hypertension, ischemic heart disease, and ECG abnormalities were the major criteria for seeking opinion on cardiac status. Cardiology advice frequently resulted in the ordering of extensive cardiac investigations. Among the patients identified for further tests by the cardiologists, 75% had no evidence of ischemic heart disease or myocardial dysfunction; none of them were monitored invasively intraoperatively or had adverse cardiac events in the perioperative period requiring intensive care or prolonged hospital stay. CONCLUSION: No definite criteria or pattern for referrals was identified. Most of the referrals did not fall within the AHA guidelines. Cardiology advice given had very little influence on the perioperative management.