Challenges of Pediatric Anesthesia Services and Training Infrastructure in Tertiary Care Teaching Institutions in Pakistan: A Perspective From the Province of Sindh.

BACKGROUND: Pakistan is a lower middle-income country located in South Asia with a population of nearly 208 million. Sindh is its second largest province. The aim of this survey was to identify the current setup of pediatric services, staffing, equipment, and training infrastructure in the teaching hospitals of Sindh. METHODS: The survey was conducted between June 2018 and September 2018. A questionnaire was designed with input from experts and pretested. One faculty coordinator from each of 12 of the 13 teaching hospitals (7 government and 5 private) completed the form. Information was exported into Statistical Package for the Social Sciences (SPSS) version 22. Frequency and percentages were computed for all variables. Confidentiality was ensured by anonymizing the data. RESULTS: Anesthesia services are provided by consultants with either membership or fellowship in anesthesia of the College of Physicians and Surgeons of Pakistan (CPSP). All drugs on the World Health Organization (WHO) essential medication list were available, although narcotic supply was often inconsistent. Weak areas identified were absence of standardization of practice regarding premedication, preoperative laboratory testing, pain assessment, and management. No national practice guidelines exist. Pulse oximeters and capnometers were available in all private hospitals but in only 86% and 44% of the government hospitals, respectively. Some training centers were not providing the training as outlined by the CPSP criteria. CONCLUSIONS: Several gaps have been identified in the practice and training infrastructure of pediatric anesthesia. There is a need for national guidelines, standardization of protocols, provision of basic equipment, and improved supervision of trainees. One suggestion is to have combined residency programs between private and government hospitals to take advantage of the strengths of both. Recommendations by this group have been shared with all teaching hospitals and training bodies.

Assessment of atherosclerotic risk among patients with epilepsy on valproic acid, lamotrigine, and carbamazepine treatment.

OBJECTIVE: To compare the long-term effects of carbamazepine (CBZ), valproic acid (VPA), and lamotrigine (LTG) as monotherapy on the markers of vascular risk. METHODS: The present cross-sectional study was carried out at the Department of Neurology, Jinnah Postgraduate Medical Centre (JPMC), Karachi, Pakistan, from 2012 to 2013. We selected 120 adult patients with epilepsy and 40 control subjects. The patients with epilepsy were divided into 3 groups according to the use of antiepileptic drugs (AEDs) (CBZ, n = 40; VPA, n = 40; and LTG, n = 40). All participants` total cholesterol (TC), triglycerides (TG), low-density lipoprotein cholesterol (LDL-c), very low-density lipoprotein cholesterol (VLDL-c), high-density lipoprotein cholesterol (HDL-c), ratio of TC/HDL-c, ratio of LDL-c/HDL-c, body mass index (BMI), and blood pressure was determined. RESULTS: In patients with epilepsy, CBZ and VPA treatment caused a noteworthy increase in the concentrations of TG, TC, and LDL-c compared with LTG treatment and the control group (p<0.001). The HDL-c significantly decreased in CBZ, VPA, and LTG-treated patients as compared with controls (p<0.001). The ratio of LDL-c/HDL-c and TC/HDL-c significantly increased in VPA- and CBZ-treated groups compared with the LTG-treated, and control group, while the ratio was also considerably elevated in patients treated with CBZ as compared with the patients treated with VPA. The weight and BMI of the patients treated with AEDs were higher (p<0.01). CONCLUSION: Patients with epilepsy on CBZ or VPA have changed vascular risk markers that may lead to atherosclerosis, while LTG-treated patients have less alteration in lipid profile.

New single use supraglottic airway device with non-inflatable cuff and gastric tube channel.

OBJECTIVE: To assess ventilatory characteristics and airway complications associated with the use of I-gel in patients undergoing gynaecological surgeries. STUDY DESIGN: Experimental study. PLACE AND DURATION OF STUDY: Department of Anaesthesiology, Surgical Intensive Care Unit and Pain Management, Civil Hospital, Dow University of Health Sciences, Karachi, from July 2008 to June 2009. METHODOLOGY: One hundred adult female patients aged 15 - 75 years, ASA-I and II scheduled for elective gynaecologic surgical procedures under general anaesthesia with controlled ventilation were included in this study. After insertion of device, ease of insertion, time of insertion, peak airway pressure, leak pressure were noted. After proper placement of device, gastric tube was also passed in every patient. Pharyngolaryngeal morbidities (sore throat, dysphagia, dysphonia, neck pain and coughing at 1 hour and 24 hours postoperatively) were also noted. RESULTS: I-gel was inserted in the first attempt in 92% patients while second attempt was required in 8% of patients. Average time of insertion was 9.68 ± 2.69 seconds. Average leak pressure of 22.48 ± 2.07 cm H2O. After removal of I-gel no blood staining was found on any device. Coughing was noted in 6% patients after removal of device and mild sore throat was noted in only one patient after 24 hours of surgery. CONCLUSION: I-gel is a simple and easy to use supraglottic airway device. Its insertion do not require laryngoscopy and airway can be maintained in very short time in adult female patients.

Recovery profile - a comparison of isoflurane and propofol anesthesia for laparoscopic cholecystectomy.

OBJECTIVE: To compare the recovery profile in terms of time of extubation, eye opening, orientation and mobility and frequency of Postoperative Nausea and Vomiting (PONV) between propofol and isoflurane based anesthesia in patients undergoing laparoscopic cholecystectomy with prophylactic antiemetic. STUDY DESIGN: Quasi-experimental study. PLACE AND DURATION OF STUDY: Department of Anesthesia, Civil Hospital and Dow University of Health Sciences, Karachi, from January to April 2007. PATIENTS AND METHODS: After informed consent, a total of 60 ASA I-II patients scheduled for laparoscopic cholecystectomy were divided in two equal groups I and P. Anesthesia in all patients were induced by Nalbuphine 0.15 mg/kg, Midazolam 0.03 mg/kg, Propofol 1.5 mg/kg and Rocuronium 0.6 mg/kg. Anesthesia was maintained with Isoflurane in group I and propofol infusion in group P, while ventilation was maintained with 50% N2O/O2 mixture in both the groups. All patients were given antiemetic prophylaxis. Hemodynamics were recorded throughout anesthesia and recovery period. At the end of surgery, times of extubation, eye opening, orientation (by modified Aldrete score) and mobility (recovery profile) were assessed. PONV was observed and recorded immediately after extubation, during early postoperative period (0-4 hours) and late period (4-24 hours). Antiemetic requirements were also recorded for the same periods in both the groups. RESULTS: Propofol provided faster recovery (extubation and eye opening times) and orientation in immediate postoperative period with statistically significant differences between the groups (p<0.0001). Recovery characteristics were comparably lower in group I. More patients achieved full points (8) on modified Aldrete score at different time until 30 minutes in group P. Postoperative nausea and vomiting in early and late periods were significantly reduced in group P. Moreover, requirement of rescue antiemetic doses were significantly lower in group P in 24 hours (p<0.0001). CONCLUSION: In this series, recovery was much faster with earlier gain of orientation with propofol anesthesia compared to isoflurane in the early recovery periods. Propofol is likely to be a better choice of anesthesia because of its better antiemetic property that persists long into postoperative period and reduces the risk of PONV.

Dexamethasone plus ondansetron for prevention of postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy: a comparison with dexamethasone alone.

OBJECTIVE: To compare the efficacy of combination of dexamethasone plus ondansetron with dexamethasone alone for postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy. STUDY DESIGN: Double blinded randomized controlled clinical trial. PLACE AND DURATION OF STUDY: Department of Anaesthesiology, Surgical Intensive Care Unit and Pain Management, Dow University of Health Sciences and Civil Hospital, Karachi, from March 2007 to September 2007. PATIENTS AND METHODS: One hundred patients, both male and female, age 20 to 50 years, ASA Physical status I and II, scheduled for elective laparoscopic cholecystectomy under general anaesthesia were randomly allocated to two groups. Group A received dexamethasone (2 ml) plus ondansetron 4 mg (2 ml) prepared in two different syringes, and group B received dexamethasone 8 mg (2 ml) and normal saline (2 ml), prepared in two separate syringes just before induction of anaesthesia. Anaesthesia was standardized. For the first 24 hours after anaesthesia, the presence or absence of nausea and vomiting (by simply yes or no) was assessed by anaesthetist blinded to randomization. The rescue antiemetic (metoclopromide 10 mg) i.v., was given, if patient remained nauseous for more than 15 minutes, or experience retching or vomiting during study period. RESULTS: In comparison to dexamethasone group, the frequency of nausea and vomiting was clinically and statistically lower in dexamethasone -- ondansetron group (p=0.035). Use of rescue antiemetic was significantly higher in dexamethasone group (p=0.022). Two patients in group A and one patient in group B experienced peri-anal itching at time of giving dexamethasone, none of our patients experienced headache, flushing or other side effects. CONCLUSION: Combination of dexamethasone plus ondansetron is more effective in preventing postoperative nausea and vomiting than dexamethasone alone when used for prophylaxis of PONV before the induction of anaesthesia in patients undergoing laparoscopic cholecystectomy.

Single dose caudal tramadol with bupivacaine and bupivacaine alone in pediartic inguinoscrotal surgeries.

OBJECTIVE: To determine the postoperative analgesic effect of Tramadol when given with caudally administered Bupivacaine in children undergoing inguinoscrotal surgeries. STUDY DESIGN: Quasi-experimental study. PLACE AND DURATION OF STUDY: Department of Anaesthesia, Dow University of Health Sciences and Civil Hospital Karachi, from July 2005 to March 2006. PATIENTS AND METHODS: A total of 60 children, undergoing inguinoscrotal surgeries, aged from 1 to 12 years, ASA 1 and 2, were included. The patients were divided into two equal groups. The group given Bupivacaine with Tramadol was called 'group BT' and the group which was given only Bupivacaine was labeled as 'group B'. Group BT was given 0.25%,0.8 ml/kg Bupivacaine and Tramadol 2 mg/kg while the other group B was given 0.25%, 0.8 ml/kg Bupivacaine through caudal route after induction of general anesthesia. No other analgesic was given intraoperatively. The postoperative pain was evaluated by using visual analogue scale/Ocher's face scale/CHEOPS and sedation was assessed by 5 points sedation score at immediate postoperative period 1, 2,3,4,6, 12 and 24 hours. Supplemental analgesia in the form of paracetamol suppositories and syrup Ibuprofen was given accordingly. SaO2, pulse, blood pressure, and motor block were monitored in all the patients. RESULTS: Addition of Tramadol with Bupivacaine resulted in meaningfully increased postoperative analgesic period (16.06 +/- 4.04 hours). No other side effects like respiratory depression, pruritus, urinary retention were found in both the groups except for nausea and vomiting. The demand for supplemental analgesia was more in the patients belonging to B group than BT group. The sedation scores were similar in both the groups. CONCLUSION: The use of Tramadol as an additive with local anesthetics can prolong the postoperative analgesic period when administered caudally. Its use is safe in children.

Use of recombinant activated factor VII for massive postpartum hemorrhage.

OBJECTIVE: We hypothesised that patients with massive postpartum hemorrhage (PPH), defined as blood loss >1,500 ml,may benefit from the use of activated recombinant factor VII (rFVIIa). Design. Retrospective cohort study. Setting.Department of Obstetrics & Gynaecology, Dow University of Health Sciences. POPULATION: Thirty-four women with a diagnosis of massive PPH. METHODS: All patients with PPH who were admitted to the Department of Obstetrics &Gynecology and Surgical Intensive Care Unit of Civil Hospital Karachi, Pakistan, were included in the study. From March 2005 to October 2006, 34 patients fulfilled the criteria of massive PPH, of which 18 received rFVIIa to control bleeding, and 16 patients did not. Availability and cost of rFVIIa were the factors in drug allocation. Main outcome measures. Maternal mortality, correction of coagulopathy, the amount of blood products transfused and preservation of fertility. RESULTS: Patients receiving rFVIIa had lower maternal mortality (5/18, 28% versus 8/16, 50%, OR: 0.04 (0.002, 0.83)), and received a lower number of packed red cell transfusions (4.0 ± 4.46 versus 9.61 ± 6.7, p value 0.007), against the comparison group. Patients receiving rFVIIa had lower activated partial thromboplastin (median: 13.0; 25-75th percentile: -25.0, -8.0, signed rank p<0.0001), and lower prothrombin times (median: -8.8; 25-75th percentile: -24.2, -4.8), after administration of drug.There was no significant difference in the rate of hysterectomy between the 2 groups (11/18 (61%) versus 6/16 (38%)). No adverse event attributable to rFVIIa was observed in the study. CONCLUSION: Activated recombinant factor VII can be a lifesaving drug in patients with massive PPH.

Intravenous ketamine attenuates injection pain and arterial pressure changes during the induction of anesthesia with propofol: a comparison with lidocaine.

OBJECTIVE: To compare the effects of lidocaine and ketamine pretreatment on injection pain and hypotension due to propofol induction. DESIGN: Double blinded randomized controlled clinical trial. Place and Duration of the Study: Department of Anesthesiology, Surgical Intensive Care Unit and Pain Management, Dow University of Health Sciences and Civil Hospital, Karachi from February 2005 to December 2005. PATIENTS AND METHODS: One hundred patients, age 20-60 years, of either gender, ASA I and II scheduled for elective gynaecological, urological, orthopedic or general surgical procedures under general anesthesia were randomly allocated into two groups i.e. group A to receive ketamine 0.5 mg/kg in volume of 2 ml with venous occlusion and group B to receive 2 ml of 1% lidocaine with venous occlusion as pretreatment before propofol induction. Venous occlusion was performed using rubber tourniquet after elevating the arm for 30 seconds, which was released 60 seconds after giving the pretreatment bolus and anesthesia was induced with propofol (2 mg/ml). Fifteen seconds after injection of 25%, the calculated dose of propofol and severity of injection pain was evaluated. Heart rate (HR) and noninvasive blood pressure were recorded pre-operatively, just before propofol induction, after propofol induction, immediately after intubation and 3 minutes after intubation. RESULTS: Comparing the lidocaine group, the intensity and incidence of pain after propofol injection was lower in ketamine group but remained statistically insignificant. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were significantly higher in ketamine group after induction with propofol. The maximum fall in SBP from baseline in ketamine group was 16% and 29.1% in lidocaine group, while maximum decrease in DBP in ketamine group was found to be12.66% vs. 26.47% in lidocaine group. There was no significant change in heart rate from baseline in either group. CONCLUSION: Ketamine pre-treatment with venous occlusion is an effective method in reducing pain and providing hemodynamic stability after propofol induction.

Injection dexamethasone in preventing postoperative nausea and vomiting: a comparison with placebo in the patients undergoing laparoscopic cholecystectomy.

OBJECTIVE: To determine the efficacy of intravenous dexamethasone for preventing postoperative nausea and vomiting (PONV) in patients undergoing laparoscopic cholecystectomy (lap-chole) and comparing it with normal saline (placebo). STUDY DESIGN: Single blinded, randomized, placebo controlled, interventional study. PLACE AND DURATION OF STUDY: This study was conducted in the department of Anaesthesiology of Civil Hospital, Karachi and Dow University of Health Sciences, Karachi, from June 2005 to April 2006. PATIENTS AND METHODS: After the approval of the hospital's ethical committee, the study was conducted on 60 patients who were randomly divided into two groups, each group containing 30 patients. All belonged to A.S.A-I and A.S.A-II. Randomization was done by envelope draw method. Injections dexamethasone (8 mg in 2mls) and normal saline ( 2 mls ) were given intravenously to respective groups just before induction of anesthesia. Fisher's exact test was applied to compare proportion of PONV between two groups for the recovery room data, while Chi-square test was applied to compare the proportion of PONV between two groups during first 12 hours and second 12 hours. The p-value was calculated at the level of significance chosen as 0.05. RESULTS: In the recovery room where the patient stayed for one hour 10% of patients in the dexamethasone group in comparison with 33% of the patients in the placebo group experienced PONV (p=0.028). In the ward, during first 12 hours observation period, 27% of the patients in the dexamethasone group in comparison with 43% of the patients in the placebo group experienced PONV (p=0.176). During the second 12 hours observation period, 30% of the patients in the dexamethasone in comparison with 80% of the patients in the placebo group experienced PONV (p < 0.001). CONCLUSION: In this study, the frequency of postoperative nausea and vomiting (PONV) in the dexamethasone administered group was significantly less as compared to placebo group. As the former is freely available, economical and the single dose is not associated with any significant side effects, it should, therefore, be used more frequently in the patients undergoing lap-chole.

Intrathecal fentanyl as adjunct to hyperbaric bupivacaine in spinal anesthesia for caesarean section.

OBJECTIVE: To compare the effect of adding fentanyl to intrathecal bupivacaine on the onset, duration and quality of spinal anesthesia and its effect of mother and neonate. DESIGN: Single blind randomized controlled clinical trial. PLACE AND DURATION OF STUDY: Department of Anesthesiology, Surgical Intensive Care Unit and Pain Management, Dow University of Health Sciences and Civil Hospital, Karachi, from January 2003 to June 2004. PATIENTS AND METHODS: Sixty young adult females, ASA physical status I and II, with singleton pregnancy undergoing elective or emergency cesarean section under spinal anesthesia were randomly allocated to receive spinal anesthesia either by using 0.75% hyperbaric bupivacaine 1.5 ml with 0.25 ml normal saline or 0.75% hyperbaric bupivacaine 1.5 ml with 0.25 ml fentanyl (12.5 microg). Blood pressure, heart rate, respiratory rate, oxygen saturation, sensory level, motor block, pain score and side effects were observed every 2 minutes for first 20 minutes, then at-5 minute interval throughout the surgery, thereafter at 30 minutes interval until the patient complained of pain. RESULTS: Comparing the bupivacaine group, time to achieve highest sensory level was significantly shorter in fentanyl group (*p < 0.05), while the duration of complete analgesia (time from injection to first report of pain) lasted significantly more longer in fentanyl group (184+/-20 minutes) than bupivacaine group (126+/-10 minutes). Duration of effective analgesia was also significantly more prolonged in fentanyl group (p < 0.05). There was no significant difference in the incidence of side effects between the two groups. CONCLUSION: Addition of fentanyl to intrathecal bupivacaine results in faster onset with improved peri-operative anesthesia without increasing the side effects.

Use of recombinant factor VIIa for massive postpartum haemhorrage: case series and review of literature.

Recombinant activated factor VII is indicated mainly for the treatment of patients with haemophilia inhibitors. It has also been found successful in the treatment of platelet disorder Glanzmann's thrombasthenia. Recently, its use in trauma patients and in patients with intracereberal haemorrhage has become well established. We present three cases of massive post partum haemorrhage treated with rFVIIa, following caesarean section. The response of these three patients is discussed along with review of literature.

Comparison of 25-gauge, Quincke and Whitacre needles for postdural puncture headache in obstetric patients.

OBJECTIVE: To compare the frequency of postdural puncture headache (PDPH) and failure rate of spinal anesthesia using 25-gauge Quincke and 25-gauge Whitacre needles in obstetric patients. DESIGN: Single blinded, interventional experimental study. PLACE AND DURATION OF STUDY: This study was conducted at the Department of Anesthesiology, Pain Management and Surgical Intensive Care Unit, Dow University of Health Sciences and Civil Hospital, Karachi from November 1, 2003-April 15, 2004. PATIENTS AND METHODS: One hundred females, aged 18-35 years, ASA physical status I and II, with singleton pregnancy undergoing elective or emergency cesarean section under spinal anesthesia were randomly allocated to receive spinal anesthesia either by using 25-gauge Quincke or 25-gauge Whitacre needles. Patients were followed for 3 days postoperatively. Headache, its relation with posture, onset, duration, severity and response to the treatment were recorded. RESULTS: Compared with the Whitacre group, frequency of postdural puncture headache was significantly higher in Quincke group (*p=0.015), while the overall occurrence of non-postdural puncture headache (NPDPH) did not differ significantly between two groups (p=0.736). Most of PDPH developed on 2nd postoperative day, were mild in nature and resolved within 48 hours of their onset. There was no significant difference in the failure rate of spinal anesthesia in both groups (p=0.149). CONCLUSION: It is suggested that use of 25-gauge Whitacre needle reduces the frequency of PDPH without increasing the failure rate of spinal anesthesia in obstetric patients.

Comparison of caudal bupivacaine and bupivacaine-midazolam for peri and postoperative analgesia in children.

OBJECTIVE: To compare the duration and side effects of postoperative analgesia of caudal bupivacaine and bupivacaine-midazolam mixture. DESIGN: Single blinded, interventional experimental study. PLACE AND DURATION OF STUDY: The Department of Anesthesiology and Surgical Intensive Care Unit, Dow Medical College and Civil Hospital, Karachi from May to November, 2002. SUBJECTS AND METHODS: Sixty children, aged 1-8 years, ASA physical status I and II, undergoing inguinal and urogenital surgery were randomly allocated to receive either 0.25% bupivacaine 0.75 ml/kg (group A) or 0.25% bupivacaine 0.75 ml/kg along with 0.1% midazolam 50mg/kg (group B) by caudal route immediately after induction of general anesthesia. Anesthesia was maintained till the end of surgery. Cardiorespiratory data, sedation and pain score were recorded for 24 hours following recovery from anesthesia. Analgesia was supplemented (diclofenac suppository) whenever the pain score was > or = 4. Duration of analgesia was recorded. RESULTS: The duration of analgesia was 21.41 +/- 2.7 hours in bupivacaine midazolam group and 9.97 +/- 2.25 hours in bupivacaine group, which showed a significant difference (p < 0.001). There was no significant difference in heart rate, respiratory rate, blood pressure and the incidence of side effects in both groups (p = 0.716). The sedation score were significantly higher in bupivacaine-midazolam group during first hour postoperatively (*p = 0.003). CONCLUSION: Addition of midazolam to caudal bupivacaine provides longer duration of postoperative analgesia without having significant side effects but with higher sedation score for 1 hour postoperatively.