Enhancing Patient Safety through Education in a Low-to-Middle-Income Country: Training in the Correct Application of Cricoid Pressure.

Background: Cricoid pressure (CP) is applied to occlude the esophagus during endotracheal intubation in patients at an increased risk of aspiration of gastric contents. Evidence shows marked deficiencies in knowledge and skills for CP application among personnel responsible for this task. This study evaluated the effectiveness of CP training in improving knowledge and skills regarding CP application among anesthesiology technicians and critical care nurses and assessed the retention of skills after 2 months. Methods: Five workshops were conducted on effective application of CP. Indications, relevant anatomy, physiology, and correct technique were taught using interactive sessions and videos and hands-on practice on a weighing scale, 50-mL syringe, and trainer model. Pre- and postworkshop tests were conducted for knowledge and skill. An assessment was repeated after 2 months to assess skill retention. Results: Five workshops were conducted for 102 participants. Statistically significant improvements were seen in mean scores for knowledge in postworkshop assessments (12.32 ± 2.12 versus 7.12 ± 2.32; P < .01). Similarly, posttraining mean scores for skill assessment were significantly higher than pretraining scores (6.31 ± 0.96 versus 2.72 ± 2.00; P < .0005), indicating an overall 131% improvement. Seventy-four participants appeared for assessment of the retention of skills. A 20% decrement was observed compared with posttraining scores (5.15 ± 1.71 versus 6.45 ± 0.86; P < .0005). Conclusions: A significant improvement was observed in both knowledge and skills immediately following training. However, this does not ensure long-term retention of clinical skills, as a 20% decrement was observed 2 months after the workshops. Formal training and regular practice are recommended to enable clinicians to perform CP effectively.

Ratio of height to thyromental distance: a comparison with mallampati and upper lip bite test for predicting difficult intubation in Pakistani population.

OBJECTIVE: To compare the accuracy of three diagnostic tests in predicting difficult laryngoscopy using Cormack and Lehane grade as the gold standard. METHODS: The cross-sectional study was conducted at the Aga Khan University Hospital, Karachi, from August 2014 to August 2015, and comprised patients who required endotracheal intubation for elective surgical procedures. The primary investigator used ratio of height to thyromental distance, upper lip bite test and the modified Mallampati test for assessing the airway correlated with laryngoscopic view based on Cormack and Lehane grading. Data was analysed using SPSS 19. RESULTS: Of the 383 patients, 59(15.4%) were classified as difficult cases of laryngoscopy. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of ratio of height to thyromental distance were 84.7%, 90.1%, 60.9%, 97%, 89.3%; and those the corresponding values for the upper lip bite test were 83.1%, 89.2%, 58.3%, 96.7% and 88.3%. The values for the modified Mallampati test were 30.5%, 84.3%, 26.1%, 86.9% and 79.9% respectively. The area under receiver-operating characteristic curve for the first two tests was significantly more than for the modified Mallampati test (p<0.01). CONCLUSIONS: RHTMD and ULBT both are acceptable alternatives for prediction of difficult laryngoscopy as a simple, single bed-side test.

Bladder Distension as a Cause of Abdominal Compartment Syndrome.

Abdominal compartment syndrome (ACS) is increasingly identified in critically ill patient and its harmful effects are well documented. The disparity among the pressure, volume in abdominal cavity and its contents, results in ACS. The actual incidence of ACS is not known. However, it has been observed predominantly in patients with severe blunt and penetrating abdominal trauma, ruptured abdominal aortic aneurysms, retro- and intra-peritoneal hemorrhage, pneumoperitoneum, neoplasm, pancreatitis, ascites and multiple bone fracture. We present a case of 40-year female who underwent emergency cesarean section and developed abdominal compartment syndrome due to urinary bladder distension secondary to blockade of urinary catheter with blood clots. This is a very unusual cause of ACS.

Prospective survey to study factors which could influence same-day discharge after elective laparoscopic cholecystectomy in a tertiary care hospital of a developing country.

All laparoscopic cholecystectomy (LC) patients in our hospital setting are admitted overnight. This article assesses the contribution of factors like postoperative nausea and vomiting (PONV), postoperative pain and surgical complications to overnight stay after elective LC. This 1-year observational study included patients having normal liver functions undergoing elective LC before 1400 h. The collected data included patient demographics, co-morbidities, PONV, pain scores, complications, surgical time, anesthesia technique, use of prophylactic antiemetics, analgesics, patient satisfaction and desire to have this surgery as day case or in-patient procedure. From 930 LC done per annum, 45.2 % (430/950) patients were included in this study. Prophylactic antiemetic was given in 91.6 %, intraoperative narcotics in 94.2 % patients and multimodal analgesia in 85.3 %. The mean pain score in the recovery and ward was maintained to <4. In the ward, 99.1 % patients were able to start oral fluids after 6 h and were started on oral non-steroidal anti-inflammatory drugs and paracetamol, and none required parental opioid. The PONV score of more than 2 was observed in only 3.2 % of patients in the ward requiring parenteral antiemetic. Surgical complications in the form of bleeding, visceral injury and bile duct leak were observed in 2 % of patients, which was treated intra-operatively. Satisfaction was observed in 99.3 % and desire to stay overnight in 87.4 % of patients. Factors like postoperative pain, PONV and surgical complications were well managed and were not associated with significant morbidity to justify routine overnight admission. However, majority of the patients desired to stay overnight, which could be improved by counseling and education.

Prevention of hypotension associated with the induction dose of propofol: A randomized controlled trial comparing equipotent doses of phenylephrine and ephedrine.

BACKGROUND AND AIMS: Propofol, the most commonly used intravenous (IV) anesthetic agent is associated with hypotension on induction of anesthesia. Different methods have been used to prevent hypotension but with variable results. The objective of this study was to evaluate efficacy of equipotent doses of phenylpehrine and ephedrine in preventing the hypotensive response to the induction dose of propofol. MATERIAL AND METHODS: One hundred thirty five adult patients were randomised to one of the study groups: propofol-saline (PS), propofol-phenylephrine (PP) or propofol-ephedrine (PE) by adding study drugs to propofol. Anesthesia was induced with a mixture of propofol and the study drug. Patients were manually mask-ventilated for 5 min using 40% oxygen in nitrous oxide and isoflurane at 1%. A baseline mean arterial pressure (MAP) was recorded prior to induction of anesthesia. Systolic, diastolic and mean blood pressure and heart rate were recorded every minute for up to 5 min after induction. Hypotension was defined as a 20% decrease from the baseline MAP. RESULTS: There were no significant demographic differences between the groups. Overall incidence of hypotension in this study was 38.5% (52/135). Rate of hypotension was significantly higher in group PS than group PP (60% vs. 24.4% P = 0.001) and group PE (60% vs. 31.1% P = 0.005). In contrast, a significant difference in rate of hypotension was not observed between groups PP and group PE. CONCLUSION: In equipotent doses, phenylephrine is as good as ephedrine in preventing the hypotensive response to an induction dose of propofol.

Audit of an acute pain service in a tertiary care hospital in a developing country.

The first anaesthesia based acute pain service (APS) was introduced in Pakistan at the Aga Khan University Hospital in July 2001, with the aim of patient safety and satisfaction. The American Society of Anesthesiologist task force guidelines were used for the introduction of APS. APS has managed 6810 patients during four and half years period. Common analgesic techniques used, were intravenous infusion (50%), patient controlled intravenous analgesia (18%) and epidural infusions (30%). Common reported side effects were nausea and vomiting with intravenous infusion (10%) and PCIA (10%) while motor block was noticed with epidural infusion (29%). This article aims to share experience with the initial setup of APS, difficulties faced after establishment of APS and an audit to show overall APS performance.

Comparison between tramadol and pethidine in patient controlled intravenous analgesia.

OBJECTIVE: To compare the efficacy and side effects related to Tramadol with Pethidine in patient controlled intravenous analgesia (PCIA) after total abdominal hysterectomies. METHODS: A total of 60 patients were randomized to receive either Tramadol or Pethidine by PCIA (30 in each group) after total abdominal hysterectomy. Pain assessments were recorded one hour after starting the PCIA and then at 6, 12, and 24 hours by using visual analogue scale (VAS). Nausea vomiting score and sedation score were also recorded. Good attempts, total attempts and total drug consumption was noted from PCIA pump at the end of the study period. RESULTS: The analgesia achieved in Tramadol group was comparable to Pethidine. The incidence of nausea and vomiting was similar in both groups. Tramadol causes significantly less sedation than Pethidine (p < 0.05). Mean drug consumption, total attempts and good attempts were also significantly less in Tramadol group than Pethidine group (p < 0.05). CONCLUSION: Tramadol produces equivalent analgesia and less sedation and can be used as an alternative to Pethidine in Patient Controlled Intravenous Analgesiafor postoperative pain relief after Total Abdominal Hysterectomy (TAH).

Unusual site of guide-wire entrapment during central venous catheterization.

We are reporting a case of possible entrapment of guide wire in the region of tricuspid valve, which made it impossible to remove the guide wire from internal jugular (IJ) vein for a short while. Awareness about this rare complication is emphasized.