The analgesic efficacy of ultrasound-guided transversus abdominis plane block vs. local anesthetic infiltration technique in major gynecologic surgery: A randomized controlled trial.

Background and Aim: Transversus abdominis plane (TAP) block and local anesthetic infiltration (LAI) technique are used as part of the multimodal analgesic regimen after abdominal surgery. Postoperative opioid consumption and analgesic efficacy was compared using TAP and LAI techniques in patients undergoing gynecologic surgery in a randomized, controlled clinical trial. Material and Methods: Total of 135 patients scheduled for major gynecological surgeries were allocated into three groups: group T received bilateral TAP block with bupivacaine 0.25%; group I received LAI with 0.25% bupivacaine with epinephrine 5 µ/mL in the peritoneum and abdominal wall, and group C was control group. Anesthesia and postoperative analgesia were standardized. Outcome measures were cumulative and rescue tramadol consumption, numerical rating score (NRS) for pain and side effects in post-anesthesia care unit (PACU) at 4, 8, 12 hours postoperatively. Results: Tramadol consumption, need for rescue analgesia, and NRS for pain between three groups at 4, 8, and 12 hours postoperatively had no statistically significant difference (P < 0.05). In PACU, median tramadol consumption used for rescue analgesia between group T (15 (15-30)) and group C (30 (15-45)) (P = 0.035), and between group T (15 (15-30)) and group I (30 (15-52)) was statistically significant (P = 0.034). In PACU, the percentage of patients having NRS >4 on movement in group C (72%) compared to group T (46.5%) and group I (46.5%) was significant (P = 0.034). No statistically significant difference was observed in the incidence of side effects among study groups (P > 0.05). Conclusion: Except for the immediate postoperative period, neither TAP block nor LAI had added benefit to the multimodal analgesia regimen in patients undergoing gynecological surgeries.

Mid-axillary transversus abdominis plane block and stress response after abdominal hysterectomy: A randomised controlled placebo trial.

BACKGROUND: The hormonal response to surgical trauma can have detrimental effects on patients. Transversus abdominis plane (TAP) block, which can improve analgesia after total abdominal hysterectomy (TAH) might attenuate the peri-operative stress response. OBJECTIVE: To evaluate the ability of the TAP block to reduce stress response, opioid consumption and pain following TAH and multimodal analgesia. DESIGN: Randomised, placebo-controlled double-blind study. SETTING: The current study was conducted at a university hospital from July 2016 to September 2017. PATIENTS: Fifty patients scheduled for TAH were included. Anaesthesia and postoperative analgesia were standardised. INTERVENTION: After induction of anaesthesia, patients were allocated into two groups: ultrasound-guided bilateral mid-axillary TAP block with 20 ml of bupivacaine 0.25% (Group T) or 0.9% saline (Group C). MAIN OUTCOME MEASURES: Levels of free serum cortisol, metanephrine and normetanephrine at 60 min and 6, 12 and 24 h after surgical incision. Pain scores and opioid consumption during the first 24 h after surgery. RESULTS: There was no statistically significant difference between the median [IQR] peri-operative levels of stress hormones and pain scores between groups. Compared with baseline value 9.90 [4.2 to 23.1], free serum median cortisol levels were significantly high at 6 h in Group T, 23.6 [10.1 to 42.9] P = 0.015 and Group C 23.6 [9.9 to 46.3] P = 0.014. Only Group C showed significant elevation from the baseline median levels of plasma metanephrine at 60 min, 52.8 [33.4 to 193.2] P = 0.001, 6 h, 92.70 [2.4 to 202.6] P = 0.005 and normetanephrine at 60 min 83.44 [28.98 to 114.86] P = 0.004, 6 h 78.62 [36.6 to 162.31] P = 0.0005 and 24 h 80.96 [8.6 to 110.5] P = 0.025. Mean ±â€ŠSD opioid consumption was similar in both groups: 39.60 ±â€Š14.87 in Group T vs. 43.68 ±â€Š14.93 in Group C (P = 0.338). CONCLUSION: Mid-axillary TAP block does not improve stress response and analgesia in patients undergoing TAH receiving multimodal analgesia. TRAIL REGISTRATION: ClinicalTrial.gov identifier: NCT03443271.

Failure rate of labor epidural: An observational study among different levels of trainee anesthesiologists in a university hospital of a developing country.

CONTEXT: Frequent use of labor epidural has also led to a corresponding increase in failed epidural analgesia (FEA). AIMS: This study aims to identify the overall rate of FEA and evaluate its association with trainee anesthesiologist at different years/levels of anesthesia residency training. SETTINGS AND DESIGN: Prospective observational study was conducted for one year in the labor room suit of a university hospital. METHODS AND MATERIAL: After university ethics committee approval, full-term parturient receiving labor epidurals and consenting for the study were included. FEA was identified by the presence of one or more set criteria of failure including; pain of numeric rating scale of >4 at 45 minutes after epidural placement, accidental dural puncture, need to re-site the epidural, abandoning the procedure, and maternal dissatisfaction with labor pain relief. STATISTICAL ANALYSIS USED: A binary logistic regression was used to assess the association between failure rate of labor epidural and grades of anesthesiologists. Odds ratio (OR) and 95% confidence interval (CI) were reported. P value ≤0.05 was considered significant. RESULTS: Out of 500 women included, 76 (15.2%) had FEA, which was significantly high in 2nd and 3rd year residents compared to 5th year and above level anesthesiologists [OR = 2.08; 95% CI: 1.17 to 3.67; P = 0.012]. Failure rate was also high but insignificant in 4th year residents compared to senior level anesthesiologists [OR = 1.78; 95%CI: 0.89 to 3.53; P = 0.098]. CONCLUSIONS: The incidence of FEA is comparable to those quoted in literature from developed countries and shows association to experience and year of training of anesthesia residents.

Postoperative pain management practices and their effectiveness after major gynecological surgery: An observational study in a tertiary care hospital.

BACKGROUND AND AIMS: Despite advances in postoperative pain management, patients continue to experience moderate to severe pain. This study was designed to assess the strategy, effectiveness, and safety of postoperative pain management in patients undergoing major gynecological surgery. MATERIAL AND METHODS: This observational study included postoperative patients having major gynecological surgery from February 2016 to July 2016. Data collected on a predesigned data collection sheet included patient's demographics, postoperative analgesia modality, patient satisfaction, acute pain service assessment of numeric rating scale (NRS), number of breakthrough pains, number of rescue boluses, time required for the pain relief after rescue analgesia, and any complication for 48 h. RESULTS: Among 154 patients reviewed, postoperative analgesia was provided with patient-controlled intravenous analgesia in 91 (59.1%) patients, intravenous opioid infusion in 42 (27%), and epidural analgesia in 21 (13.6%) patients with no statistically significant difference in NRS between different analgesic modalities. On analysis of breakthrough pain, 103 (66.8%) patients experienced moderate pain at one time and 53 (51.4%) at two or more times postoperatively. There were 2 (0.6%) patients experiencing severe breakthrough pain due to gaps in service provision and inadequate patient's knowledge. Moderate-to-severe pain perception was irrespective of type of incision and surgery. Vomiting was significantly higher (P = 0.049) in patients receiving opioids. CONCLUSION: Adequacy of postoperative pain is not solely dependent on drugs and techniques but on the overall organization of pain services. However, incidence of nausea and vomiting was significantly higher in patients receiving opioids.

A double-blind randomized control trial to compare the effect of varying doses of intrathecal fentanyl on clinical efficacy and side effects in parturients undergoing cesarean section.

BACKGROUND AND AIMS: It is a common practice to add intrathecal lipophilic opioids to local anesthetics to improve the quality of subarachnoid block. This study was designed to find a dose of intrathecal fentanyl, which can improve the quality of surgical anesthesia with minimal side effects in parturients undergoing cesarean section under spinal anesthesia with intrathecal bupivacaine. MATERIAL AND METHODS: In a prospective randomized double-blind study, 243 parturients undergoing cesarean section under spinal anesthesia were randomly allocated to receive 10, 15, or 25 µg of intrathecal fentanyl with 10 mg of 0.5% hyperbaric bupivacaine. Patients were assessed for clinical efficacy by measuring pain score, need for rescue analgesia, conversion to general anesthesia, and complaints of inadequacy of surgical anesthesia by the surgeon. The side effects assessed were pruritus, nausea, vomiting, dizziness, and decrease in saturation and respiratory rate. In addition, neonatal APGAR score, patients' hemodynamics, need for vasopressors, onset and duration of sensory, and motor block were measured. RESULTS: Patients receiving 25 µg of fentanyl had a significantly higher incidence of pruritus, nausea, and dizziness in addition to a significantly prolonged sensory and motor block (P < 0.001). All patients in three groups had adequate surgical anesthesia with no statistically significant difference in the onset of block, quality of surgical anesthesia, pain scores, neonatal APGAR score, hemodynamic variables, and need for vasopressor. CONCLUSION: For patients undergoing cesarean section, 10 or 15 µg of intrathecal fentanyl with 10 mg of bupivacaine provided adequate surgical anesthesia and analgesia with minimal side effects.

Factors associated with choice of delivery with or without epidural analgesia among laboring women: a cross-sectional survey at a tertiary care hospital of a developing country.

AIMS: The aim of this study was to evaluate the factors responsible for epidural analgesia (EA) refusal among parturient patients. METHODS: In this prospective cross-sectional study of six months, we included all consenting postpartum patients having a non-operative delivery in the obstetric unit of our hospital. Data were collected on a predesigned questionnaire and included information such as parity, education, reasons for delivering with or without EA, source of information and patient satisfaction. Knowledge regarding EA was assessed from patients delivering without EA. RESULTS: From 933 patients enrolled, 730 (78.2%) delivered without EA, and 203 (21.7%) with EA. Only 11 (1.5%) patients refused EA for the reason of having natural birth process. Otherwise common reasons were misconceptions (65.9%) and lack of awareness about EA (20.5%); 70.5% had no knowledge of common side effects of EA. Among patients delivering with EA, 92.6% were offered EA by health care providers and had obstetricians and anesthesiologists as their sources of information. CONCLUSIONS: Patients in developing countries are laboring without EA, even in centers where there is a provision for it. The main reasons for not availing themselves of EA are lack of awareness and knowledge and misconceptions, rather than the desire to have un-medicated natural birth.

Reliability and validity of a tool to assess airway management skills in anesthesia trainees.

BACKGROUND AND AIMS: Gaining expertise in procedural skills is essential for achieving clinical competence during anesthesia training. Supervisors have the important responsibility of deciding when the trainee can be allowed to perform various procedures without direct supervision while ensuring patient safety. This requires robust and reliable assessment techniques. Airway management with bag-mask ventilation and tracheal intubation are routinely performed by anesthesia trainees at induction of anesthesia and to save lives during a cardiorespiratory arrest. The purpose of this study was to evaluate the construct validity, and inter-rater and test-retest reliability of a tool designed to assess competence in bag-mask ventilation followed by tracheal intubation in anesthesia trainees. MATERIAL AND METHODS: Informed consent was obtained from all participants. Tracheal intubation and bag-mask ventilation skills in 10 junior and 10 senior anesthesia trainees were assessed by two investigators on two occasions at a 3-4 weeks interval, using a procedure-specific assessment tool. RESULTS: Average kappa value for inter-rater reliability was 0.91 and 0.99 for the first and second assessments, respectively, with an average agreement of 95%. The average agreement for test-retest reliability was 82% with a kappa value of 0.39. Senior trainees obtained higher scores compared to junior trainees in all areas of assessment, with a significant difference for patient positioning, preoxygenation, and laryngoscopy technique, depicting good construct validity. CONCLUSION: The tool designed to assess bag-mask ventilation and tracheal intubation skills in anesthesia trainees demonstrated excellent inter-rater reliability, fair test-retest reliability, and good construct validity. The authors recommend its use for formative and summative assessment of junior anesthesia trainees.

Preoperative anxiety in patients selecting either general or regional anesthesia for elective cesarean section.

BACKGROUND AND AIMS: We aimed to measure the frequency of preoperative anxiety in patients undergoing elective cesarean section (CS) and its impact on patients decision regarding the choice of anesthesia. MATERIAL AND METHODS: This cross-sectional study included 154 consecutive patients, who were scheduled for elective CS. Visual analog scale (VAS) for anxiety was the study tool, and VAS ≥50 was considered as significant anxiety. Enrolled patients were interviewed by the primary investigator the day before the surgery and their VAS score and choice of anesthesia technique either general anesthesia (GA) or regional anesthesia (RA) were recorded. Additional data included demographics, parity, educational status, previous anesthesia experience and source of information. RESULTS: Preoperative anxiety (VAS ≥ 50) was seen in 72.7% of patients, which was significantly higher (P < 0.005) in patients selecting GA (97.18%, n = 71/154) as compared to those selecting RA (51.81%, n = 83/154) for elective CS. Statistically significant association of anxiety (P < 0.005) was seen with age <25 years, nulli and primiparous, higher education status, previous anesthesia experience and source of information from nonanesthetist. CONCLUSION: Patients scheduled for elective CS were found to have high frequency of anxiety (72.7%), and GA was observed to be the choice of anesthesia technique in anxious patients.

Incidence of cesarean section and analysis of risk factors for failed conversion of labor epidural to surgical anesthesia: A prospective, observational study in a tertiary care center.

BACKGROUND AND AIMS: This study aimed to analyze the effect of labor epidural (LE) on the incidence of cesarean section (CS) and assess the risk factors involved in failed conversion of LE to surgical anesthesia for CS. MATERIAL AND METHODS: A prospective observational study of 18 months from January 2012 to June 2013 was conducted on all patients who had delivered in the labor room suit of our hospital. The data collected for all 4694 patients included their demographics, parity and mode of delivery. In addition a predesigned proforma, with additional information was used for 629 parturient with LE. RESULTS: During the study period, total numbers of deliveries performed in our hospital were 4694, with an epidural rate of 13.4% (629/4694). No significant difference (P = 0.06) was observed in the rate of CS among women with or without LE (28 % [n = 176/629] vs. 31.7 % [n = 1289/4065]), however, a statistically significant difference (P < 0.01) was observed in the rate of assisted delivery in patients receiving LE as compared to those delivering without it (8.7% [n = 55/629] vs. n = 3.7% [154/4065]). For 176 patients requiring CS, LE utilization for surgical anesthesia was 52.8% (93/176) and factors identified for not utilizing LE in 47% (83/176) were; failure to achieve surgical anesthesia in 6.8% (12/176), emergency CS in 28.4% (50/176), patient preference in 6.8% (12/176) and inadequate labor pain relief with LE in 5.1% (9/176) patients. Non-obstetric anesthesiologists were involved in 59% (49/83) of cases where LE was not used for CS. CONCLUSION: LE had no effect on the rate of CS; however it significantly increased (P < 0.01) the rate of assisted delivery. Factors like inadequate LE, emergency situations and non-obstetric anesthesiologists can all be responsible for failed conversion of LE to surgical anesthesia for CS.

Caesarean Section for Placenta Previa: A Retrospective Cohort Study of Anaesthesia Techniques.

OBJECTIVE: Placenta previa is associated with maternal and neonatal morbidity and mortality. This study aims to add to the limited literature from the developing world on the association of different anaesthetic techniques with blood loss, the need for blood transfusion, and maternal/ neonatal outcomes among women undergoing caesarean section with placenta previa. METHODS: This retrospective study was conducted at Aga University Hospital, Karachi, Pakistan. The patient population included parturients undergoing caesarean section for placenta previa from January 1, 2006, through December 31, 2019. RESULTS: Out of 276 consecutive cases of placenta previa progressing to caesarean section during the study period, 36.24% were performed under regional anaesthesia and 63.76% under general anaesthesia. When compared to general anaesthesia, significantly less regional anaesthesia was used for emergency caesarean section (26% vs. 38.6%, P = .033) and for grade IV placenta previa (50% vs. 68.8%, P = .013). Blood loss was found to be significantly low with regional anaesthesia (P = .005) and posterior placenta (P = .042), while it was found to be high in grade IV placenta previa (P = .024). The odds of requiring blood transfusion were low in regional anaesthesia (odds ratio = 0.122; 95% CI = 0.041-0.36, P = .0005) and posterior placenta (odds ratio = 0.402; 95% CI = 0.201-0.804, P = .010), while they were high in grade IV placenta previa (odds ratio: 4.13; 95% CI = 0.90-19.80, P = .0681). The rate of neonatal deaths and intensive care admission was significantly lower in regional anaesthesia than in general anaesthesia (7% vs. 3% and 9% vs. 3%). The maternal mortality was zero; however, intensive care admission was less in regional anaesthesia compared to general anaesthesia (<1% vs. 4%). CONCLUSION: Our data demonstrated less blood loss, need for blood transfusion, and better maternal and neonatal outcomes with regional anaesthesia for caesarean section in women with placenta previa.

Anaesthetic Management and Peripartum Outcomes for Parturients With Valvular Heart Disease in a Tertiary Care Hospital of Pakistan.

Introduction Parturients with valvular heart disease are at increased risk of maternal cardiac and neonatal complications. We aim to observe maternal cardiac complications in relation to the type of anaesthesia and mode of delivery as our primary objective and neonatal complications as the secondary outcomes. Methods We retrospectively reviewed all parturients with valvular heart disease undergoing delivery over a five-year period at the Aga Khan University Hospital, Karachi, Pakistan. to identify maternal cardiac and neonatal complications occurring during the peripartum period. Results Of 83 patients with valvular heart disease, 79.5% had rheumatic heart disease. Caesarian section (CS) was performed in 79.5% of patients and regional anaesthesia (RA) was given to 62.1%. Patients with cardiac risk index > 2 were delivered by CS and 64.5% received RA. One maternal and three neonatal deaths were reported with a complication event rate of 9.64% in parturients and 40.9% in neonates. Incidence of maternal cardiac events was one in 17 (5.8%) for vaginal deliveries versus seven in 66 (10.6 %) for CS. Maternal events for CS under RA was 5/66 (7.5 %) vs 2/66 (3%) under general anaesthesia. The incidence of peripartum maternal cardiac events when stratified by severity of cardiac disease was similar to a previously derived cardiac risk index for pregnant women with cardiac disease with no statistical difference in the adverse events rate from the estimated rates (p-value= 0.42). Conclusion Elective CS with RA was a common approach for high-risk parturients; however, the benefits cannot be ascertained. Despite low maternal and neonatal mortality, significant maternal cardiac and neonatal complications were observed.

Perceptions of Advocacy in High School Students: A Pilot Study.

Assessing perceptions and attitudes of advocacy in adolescent populations is an important area of research. Previous studies have shown that advocacy programs in high schools are well-received and help promote health advocacy. This pilot study took place at the University of Central Florida College of Medicine Health Leaders Summer Academy hosted by medical students of the Student National Medical Association. A one-hour interactive workshop was administered to high school students interested in the healthcare field. Pre- and post-survey data were collected to assess participants' perceptions, methods, and barriers to engaging in advocacy. A total of 29 students were included in this study. Results indicated that students' definitions of advocacy changed after completing the workshop, as a higher percentage of students indicated that they practiced advocacy (pre-survey, 82.76% versus post-survey, 95.45%). There was a statistically significant difference in perceptions of the importance of advocacy in the student's future career (pre-survey, 3.82 versus post-survey, 4.15, p = .035). Social media was the most effective and common form of advocacy used (post-survey 72.73%). The most common barrier to practicing advocacy was a lack of education on a particular topic (31.82% post-survey). Overall, the workshop increased participants' interest in engaging in advocacy. Future directions include expanding the study to a larger population sample throughout the Orlando community and researching the use of social media as a tool for advocacy.

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.

Technique of anaesthesia for different grades of caesarean section: a cross-sectional study.

OBJECTIVE: The percentage use of regional anaesthesia (RA) and failure rate of RA for different grades of caesarean section (CS) has become a marker of quality for obstetric anaesthesia service. The objective of our prospective observational study is to find out the technique of anaesthesia used in different grades of CS, reasons for choosing general anaesthesia (GA) and failure rate of RA in our hospital setting. METHODS: This prospective cross sectional study was carried in the obstetric unit of Aga Khan University Hospital from 1st January 2010 to 31st May 2011. The anaesthetist performing the procedure filled out the data collection proforma .Suggested Indicators were percentages of Grade 1-4 CS done under RA and GA, percent of failed regional, percent of failed regional in different grades of CS. RESULTS: A total of 407 patients having undergone Caesarian Section (CS) were reviewed. General Anaesthesia (GA) was used in 201(49%) patients and Regional Anaesthesia (RA) in 206 (51%) patients. There was no significant difference between the use of GA and RA for grade 2-4 CS {grade 2: GA 42 (51%), RA 40 (49%), grade 3: GA 43 (46%), RA 39 (53%), grade 4: GA 81 (44%), RA 101 (55%) with a slight increase margin of difference for grade 1 CS (GA 44 (63%) vs RA 26 (37%)}. Patient preference 42 (45%)was the most common reason for choosing General Anaesthesia.. Fourteen (6.7%) patients required conversion from regional technique to GA. Of these 11 patients had Grade 1-3 CS and three patients had grade 4 or elective CS. CONCLUSION: A large percentage (49%) of patients preferred general anaesthesia for CS which is of the International standards. This calls for guidelines regarding the use of Regional Anaesthesia for different grades Caesarian Section. Patient education regarding the use and benefits of Regional Anaesthesia needs to enforced.

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.

Anaesthetic Challenges in a Paediatric Patient with Escobar Syndrome-Difficult Airway and Postoperative Pneumothorax.

Escobar syndrome (ES) is an autosomal recessive disorder characterised by the presence of pterygia in cervical, antecubital and popliteal regions. Anaesthesiologist encounter notable challenges in this syndrome, especially airway management due to associated malformations like cleft lip/palate, micrognathia, syngnathia, ankyloglossia, neck contracture, cervical spine fusion, limited neck extension and craniofacial dysmorphism. In addition to difficult airway, anaesthesiologist may encounter other perioperative challenges. Here, we report a paediatric patient with ES, who required general anaesthesia for laparoscopic inguinal hernia repair and orchidopexy. Initial attempt with video laryngoscope failed due to inability to visualise epiglottis. Subsequent attempt with fibreoptic bronchoscope also failed due to rapid decrease in oxygen saturation. He was finally intubated with fibreoptic bronchoscope along with oxygen insufflation with a 3mm internal diameter polyvinylchloride endotracheal tube inserted nasally and connected to oxygen supply. Further perioperative challenges faced were intraoperative hyperthermia and postoperative pneumothorax with mediastinal shift. To the best of our knowledge, this is the first case reporting pneumothorax with mediastinal shift as a postoperative complication and use of oxygen insufflation through nasal tube during fibreoptic intubation in paediatric patient with ES.

Chemical dependency: an occupational hazard in the field of anaesthesia.

The medical personnel are vulnerable to substance abuse and dependence due to ready access to substance of abuse. Addiction is considered as an occupational hazard for those involved in the practice of anaesthesia for the same reason. Substance abuse is defined as a psychosocial biogenetic disease, which results from dynamic interplay between a susceptible host and favourable environment. According to the 5th and the last National Survey on Drug Abuse (NSDA) in 1993 by Pakistan Narcotic Control, there are nearly three million drug dependants in Pakistan, but no data is available to determine the prevalence among medical or anaesthesia personnel. In order to handle the rising trend of chemical abuse, we need to have more surveys and studies on this subject, written policy and educational programme in postgraduate training with proper control and frequent checking of narcotic dispensing. Reporting of drug abuse and rehabilitation of affected doctors are areas which need to be worked upon.

A Prospective Observational Study to Determine the Predictors of Increased Number of Attempts at Labour Epidural Placement.

OBJECTIVE: Multiple attempts at labour epidural placement result in patient discomfort and high incidence of complications. Identifying the factors that lead to more than one attempt would help anaesthesiologists prepare in advance such as getting expert help and additional equipment, patient counselling or planning alternative management. METHODS: This prospective observational study was conducted on 500 patients from July 2017 to June 2018 after obtaining approval from the institutional Ethics Review Committee. The study patients consisted of full-term parturient women who were admitted in the labour room suite of Aga Khan Hospital requesting for labour epidural and consented to participate in the study. A predesigned form was used to collect the following data: number of attempts at epidural insertion and factors such as patients' demographics, cervical dilatation, anatomical grading of spine according to visibility and palpation of spinous process and vertebral interspace, experience level of the anaesthesiologist, patient satisfaction and pain score during labour. RESULTS: The average age of the patients was 28.11±4.02 years. The total number of epidural attempts varied between one and four; the median number of attempts was 1 [IQR=1-2]. Anatomical grade of the spine was the only factor that was significantly associated with more than one attempt at epidural insertion (p=0.0005). Patient satisfaction was negatively associated with the number of attempts (p=0.04), but mean pain difference at different time points during the course of labour was not statistically significant between patients with one attempt and those with more than one attempt. CONCLUSION: Determining the anatomical grade of the spine is the most reliable method for predicting a technically difficult neuraxial block that requires more than one attempt at epidural insertion.

Accuracy of Tuffier's Line Identification by Palpation Method: Cross-Sectional Comparative Study Among Obese, Pregnant and Control Groups.

OBJECTIVE: Performance of safe central neuraxial blocks requires identification of accurate vertebral interspace. This study aimed to evaluate the accuracy of palpation method by confirmation with ultrasound in high-risk groups like obesity and pregnancy. METHODS: This cross-sectional comparative study was conducted after approval from the hospital ethics committee and written informed consent from participants. Participants were enrolled into four groups: normal weight non-pregnant (N), full-term pregnant (P), obese (O) and obese full-term pregnant (PO). Tuffier's line at L4-L5 interspace was determined by palpation method and marked as P-line. Another examiner blinded to the marking done by palpation method confirmed it by ultrasound. The primary endpoint was to determine the accuracy of the palpation method, defined as true identification of Tuffier's line at the L4-L5 interspace by confirming it with ultrasound among four groups. Proportion and percentage were computed and analysed the true identification of Tuffier's line at L4-L5 by chi-square test at 0.008 adjusted level of significance for multiple comparisons. RESULTS: Tuffier's line identification by palpation method was confirmed by ultrasound scanning at L4-L5 interspace in 75.3% (226/300) of participants. Proportion difference of true identification of Tuffier's line at L4-L5 by palpation and ultrasound was statistically significant among the groups (p=0.0005). True identification was significantly lower in group PO [36.4%; p=0.0005<0.008] and group O [34%; p=0.0005<0.008] as compared to that in group N. CONCLUSION: Palpation method was found to be the inaccurate surrogate for the L4-L5 vertebral interspace for obesity with or without pregnancy.