Post operative sore throat: Comparison between Macintosh versus Video Laryngoscope in patients intubated by trainee anaesthetists - A Randomised Control Trial.

OBJECTIVES: Postoperative sore throat (POST) is a common complication related to endotracheal intubation. The aim of this study was to compare the incidence of POST in patients intubated by trainee anaesthetist using Video Laryngoscope™ (VDL) or Conventional Macintosh Laryngoscope (CL). METHODS: Total 110 patient scheduled for elective laparoscopic cholecystectomy were included from main operating room of Aga Khan University Hospital between June 2017-2018. The standardized perioperative protocol was used for general anaesthesia. Selected patients were randomly allocated into conventional laryngoscopy (CL) group or video laryngoscopy (VDL) group. The evaluation of sore throat was done at 1st, 12th and 24th hour postoperatively using a ten-point visual analogue scale. RESULTS: The demographic characteristics, including intubation time, related complications or any other maneuver required were similar between the groups. The incidence of POST at 1st hour was 47% patients in CL group and 38% in VDL group (p=0.335). At 12th hour, 34.5% patients in CL and 38% in VDL reported POST (p=0.692). Similarly at 24th hour, 25% patients in CL and 16% in VDL group reported POST (p=0.669). CONCLUSIONS: There was no significant difference in incidence of POST for patients intubated by trainee anaesthetists using either CL or VDL. Objective evidence of training and laryngoscope technique can impact of POST.

Frequency of early postoperative adverse events (AEs) in adult patients undergoing elective neurosurgical intervention at tertiary care center in Pakistan.

OBJECTIVE: The postoperative period is critical in neurosurgical patients, where the incidence of postoperative AEs is significantly high. Most of events occurs during recovery phase and has got relation to anaesthetic management. The objective of study was to determine frequency of early AEs in elective neurosurgical patients. METHODS: This cross sectional study was conducted at our tertiary care center. The duration of study was one year, from August 2017-July 2018. The data was collected using predesigned proforma. The assessment was done on arrival in recovery room (T1) and then at forty five minutes (T2), twenty-fourth hour (T3) and forty-eighth hour (T4) postoperatively. RESULTS: Total ninety-five patients were included. Overall, five hundred and forty AEs were recorded at T1, T2, T3 and T4. Anaesthesia related events like pain, postoperative sore throat, hoarseness, shivering and hypothermia were the commonest (73%). There was a gradual decline in incidence of these events over period of 48 hours. There was no effect of age, sex, BMI and blood loss on incidence of AEs. CONCLUSIONS: Postoperative pain, PONV and shivering were frequently reported AEs. We did not identify the impact of age, sex, BMI, comorbid or type of surgery in terms of having these events.

Utilization of awake craniotomy for supra-tentorial tumor resection during pregnancy: A technique useful for fetal-maternal wellbeing.

Meningioma is the benign tumor that can also occurs during pregnancy. We are reporting a case of 29 years, 13th weeks pregnant lady, who underwent supratentorial craniotomy using awake through out approach. The case report highlights the challenges we faced during anaesthetic management, which includes psychological preparation, institution of scalp block and successful neurological monitoring. Technique proven to be useful considering pregnancy related physiological and tumor related pathological changes, the impact of which lies directly on maternal & fetal wellbeing.

Potential Barriers amongst Health Care Professionals of Pakistan in managing COVID-19 patients.

OBJECTIVES: To evaluate basic knowledge of Health Care Professionals (HCPs) of Pakistan in managing COVID 19 patients. It includes information regarding infection control measures, administrative and professional support. This was followed by evaluation of psychological factor that can act as a barrier in effective management of these patients. METHODS: The survey was conducted on line using Google Form. After approval from hospital ethical committee survey link was disseminated to HCPs using social media. RESULTS: Four hundred fifteen HCPs were participated. Most of them were younger than 30 years and majority of them were postgraduate trainees. Results showed gaps in the knowledge about basic infection control measure like donning/doffing and understanding about high-risk procedures. On job training, professional and administrative support is compromising. Many of HCPs are anxious nowadays, having symptoms related to burn out with logical reasons behind. Even with all those hurdles they are committed and ready to volunteer themselves. CONCLUSION: The HCPs of Pakistan needs urgent attention for providing them Formal training regarding infection control measure. Administrative and professional support is required from institutions and scientific societies. Online teaching modules and webinar is a suitable option. The symptoms of burn out are significant and would increase with passage of time. This needs to be supported by occupational health committees.

Anaesthetic management of patients undergoing deep brain simulation: A retrospective review of 8 cases from a tertiary care center of Pakistan.

OBJECTIVES: To review anaesthesia related outcome, perioperative complications and overall length of stay (LOS) in hospital for patients who had deep brain stimulation (DBS). METHODS: The study was retrospective review of patients medical records diagnosed with Parkinson disease (PD) and underwent DBS at The Aga Khan University Hospital, Karachi from 2017-2019. Data was reviewed from file notes and patient chart and recorded on predesigned Performa. Frequency and percentages were used to present the data. RESULTS: All patients were anaesthetized using Sleep-Awake-Sleep technique (SAS). Dexmedetomidine was mainly used for conscious sedation. Bispectral index monitor (BIS) was used to monitor the depth of sedation, and kept between 70-85 during sedative phase. All patients had successful intraoperative neurological monitoring, stimulation, and placement of electrodes. Total duration of anesthesia varied significantly in between the patients. Maximum duration was 600 minutes. None of our patient had any intraoperative event related to anaesthetic management. Overall five patients had some adverse events during ward stay. Mean LOS in hospital was four days. CONCLUSION: Anaesthetic management of DBS is well-tolerated. It requires dedicated team. The SAS technique is excellent for intraoperative neurophysiological monitoring. Careful selection of sedative agents and monitoring depth of anaesthesia using BIS would be beneficial in terms of improving related outcomes.

Outcome of patients with acute pancreatitis requiring intensive care admission: A retrospective study from a tertiary care center of Pakistan.

BACKGROUND AND OBJECTIVE: Acute pancreatitis (AP) is an inflammatory disease. Patients presenting with severe disease may require intensive care unit (ICU) admission. Factors predicting mortality and morbidity need to be identified for improving outcome. The objective of this study was to see the outcome of these patient presented to single center over a period of ten years. The secondary objective was to identify the factors responsible for adverse outcome. METHODS: The medical records of adult patients from year 2006 to 2016 requiring ICU admission for AP were reviewed retrospectively. The data was collected on the predesigned Performa for patient's demographic, etiology, severity of disease and reason of ICU referral. Besides this physiological and biochemical parameters at time of arrival in ICU were also recorded. Management aspects related to disease course including the ICU related complications were also recorded. The outcome was predicted on the basis of mortality and length of stay (LOS) in ICU and hospital. RESULTS: Total 85 patients were identified of having AP requiring ICU admission. 56% of these cases were referred from emergency. Mean Ranson score (RS) was 2.6 and 2.7, at and after 48 hours of admission. Necrosis was present in 48% of cases. Mean APACHE-II score was 23. Sepsis was the commonest complication in ICU. The median LOS in ICU and hospital was six and 12 days respectively. The overall hospital mortality was 52%, out of which 82% died in ICU. RS at admission and APACHE were correlated well with outcome. Similarly associations of factors like need of vasopressors, ARDS, pneumonia, sepsis and AKI requiring intervention were also related to mortality. Likewise development of necrosis or intra-abdominal hypertension showed increased mortality. Biochemical parameters serum blood urea nitrogen (BUN), PH and serum glutamic-oxaloacetic transaminase were also directly linked to adverse outcome. CONCLUSION: AP patients requiring ICU admission represent severe form of disease. There is a need to develop protocol based care, which should be started immediately after hospital admission. This should have special focus on fluid resuscitation and nutritional therapy. Role of simple bed site parameters like BUN needs to be evaluated.

Successful management of septic patient with concealed left persistent superior vena cava: anaesthetic perspective.

Surviving sepsis guideline supports the placement of central venous cannulation (CVC) to target the deranged physiology. The placement of CVC is still challenging, which requires detailed knowledge of venous anatomy and orientation of congenital venous anomalies. Double or persistent left superior vena cava (PLSVC) is a common anomaly in thoracic venous system. Our patient had hidden PLSVC, though he was previously asymptomatic with no cardiac disease. We report the successful anaesthetic management of an adult male with septicaemia for emergency laparotomy. CVC was placed in left internal jugular vein under vision by ultrasonography for fluid and vasopressor requirement. The incidental PLSVC was initially diagnosed on routine post procedure chest X-ray. Later it was confirmed by transthoracic echocardiography with an agitated saline micro bubbles contrast media.We conclude that the routine post CVC chest X ray is mandatory not only to identify the correct positioning of CVC placement but also very helpful in identifying the underlying rare anomalies.

Awake craniotomy for brain tumours in Pakistan: An initial case series from a developing country.

Awake craniotomy offers safe resection of brain tumours in eloquent area. Aga Khan University Hospital, Karachi, recently started the programme in Pakistan, and the current study was planned to assess our experience of the first 16 procedures. The retrospective study comprised all such procedures done from November 2015 to May 2016. Pre-operative and post-operative variables were analysed. Of the 16 patients, 11(68.75%) were males and 5(31.25%) were females. The overall median age was 37 years (interquartile range[IQR]: 23-62 years). The most common presenting complaint was seizures 8(50%), followed by headache6(38%). The common pathologies operated include oligodendroglioma and glioblastoma. Pre-operative mean Karnofsky Performance Status score was 76±10, which increased to 96±7 post-operatively at discharge. Besides, 2(12.5%) intra-operative complications were observed, i.e. seizure and brain oedema, in the series. The study had median operative time of 176 minutes (IQR: 115-352) and median length of stay of 4 days (IQR: 3-7).Awake craniotomy was highly effective in maintaining post-operative functionality of the patient following glioma resection. It was also associated with shorter hospital course and so lower cost of management.

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.

Successful Resuscitation and Management of Cardiac Arrest in Pregnancy Due to Undiagnosed Severe Mitral Stenosis: A Case Report.

Maternal collapse is a rare, potentially fatal event with associated feto-maternal morbidity and mortality. We report a case of severe mitral stenosis without any prior symptoms, that presented as acute cardiac decompensation leading to maternal collapse and cardiac arrest. A 35-year-old female in her 28th week of gestation presented to the emergency room with a four-hour history of per-vaginal discharge and leaking of amniotic fluid. Her past history, physical examination, and laboratory workup were unremarkable. An initial diagnosis of pre-term premature rupture of membranes (PPROM) was made and she was managed conservatively. Within four hours of the presentation, she developed shortness of breath, which gradually worsened, and the anesthesia team was requested to assess the patient. Upon arrival, the patient was in severe respiratory distress. She collapsed soon after and started frothing copiously from the mouth. Pulse was absent and cardio-pulmonary resuscitation (CPR) commenced. Endotracheal intubation was performed and the obstetric team was asked to prepare for a perimortem cesarean section, which was completed four minutes after the commencement of CPR and the baby was delivered alive and well with an APGAR score of 7 and 8 at one minute and five minutes of birth, respectively, and birth weight of 1.1 kg. CPR continued for 16 minutes after which a return of spontaneous circulation was achieved. Due to the unavailability of an ICU bed, the patient was shifted to OR where she stayed for the next five hours for further resuscitation. After a two-month-long ICU course, the patient was discharged in stable condition; her baby was discharged after a month of hospital stay. The expertise of anesthesiologists as resuscitators and peri-operative physicians helped in successful resuscitation, saving not just one but two lives in the process.

Intraoperative Seizures During Awake Craniotomy for Brain Tumor Resection.

Background Intra-operative seizures (IOS) can occur during awake craniotomies (AC) for brain tumors. They can potentially result in an increased risk of morbidity; however, literature is scarce on IOS, its risk factors, and predictors. This study aims to ascertain the frequency of IOS in patients undergoing AC and determine possible IOS predictors. Methods In this retrospective study, we reviewed the records of all patients who underwent AC for tumor resection at a single university hospital between January 2016 and December 2020. IOS was defined as any seizure, including partial or generalized, experienced by any patient at any time from the beginning of the procedure till the end of surgery. Results Two hundred patients underwent AC during the study period. Seven (3.5%) patients experienced IOS. Compared to the non-seizure group, no significant correlation existed with any demographic variable. No significant difference was seen between the initial complaints presented by the two groups. In addition, the post-operative course of the seizure group did not significantly differ from the non-seizure group. Due to the low frequency of IOS in our cohort, an extensive analysis to determine predictors could not be performed. Conclusion In this study, we observed a low frequency of IOS (3.5%) during AC. The possible predictors and risk factors must be further investigated in large cohorts; to help limit the consequences of this possible intraoperative complication.

Awake Surgery for Lesional Epilepsy in Resource-Limited Settings: Case Report and Review of Literature.

Epilepsy surgery is a well-established treatment for drug-resistant epilepsy, with awake craniotomy being used in certain cases to remove epileptogenic foci while preserving crucial brain functions. We are presenting the first reported case from Pakistan of a 19-year-old woman who underwent awake epilepsy surgery to treat cortical dysplasia. She had a history of generalized tonic-clonic seizures since her childhood and was referred to our clinic due to an increase in seizure frequency. EEG and MRI identified the epileptogenic focus in the right parieto-temporal region. The patient underwent a neuro-navigation guided awake craniotomy and an excision of the epileptogenic focus in the right parieto-temporal region. The procedure was carried out using a scalp block and dexmedetomidine for conscious sedation, enabling the patient to remain awake throughout the surgery. Intraoperative mapping and electrocorticography were used for complex multidisciplinary care. Post-resection corticography showed no spikes along the resected margins. The patient was discharged without any complications and remained free of symptoms a year after the surgery. Awake epilepsy surgery is a viable option for removing epileptogenic foci while preserving vital cognitive functions. However, it is seldom used in low- and middle-income countries such as Pakistan. The successful outcome of this case underscores the need for greater awareness and availability of epilepsy surgery in resource-limited settings. Cost-effective measures, such as using small subdural strips for intraoperative localization, can be implemented.

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.

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.

Awake Craniotomy for Resection of Intracranial Meningioma: First Case Series From a Low- and Middle-Income Country.

Introduction Awake craniotomy (AC) has emerged as a better modality for resection of intra-axial brain tumors. The advantages are not just related to the preservation of neurological function, but also include early recovery, short hospital stay and possibly lower costs. However, data on AC for meningioma resection is deficient, likely because of concerns related to intra-operative pain and blood loss. Methods All patients who underwent AC, using awake through-out technique for resection of meningioma, during the last five years, were included in the study. Non-probability consecutive sampling technique was employed. Variables for demographics, and details of diagnosis and surgical procedure were recorded. The outcomes measured were length of hospital stay, worsening of neurological function during surgery and significant intra-operative or post-operative pain. Results Seventeen patients underwent AC for resection of meningioma during the study period. Eleven of these were grade I meningioma, and six were grade II meningioma. The mean age was 45.8 ± 10.5 years. Presenting complaints were variable, with seizures being the most common (n = 7; 41.2%). The mean duration of surgery was 180.8 ± 36.2 minutes and median estimated blood loss was 450 ml (IQR: 225 ml - 737.5 ml). The mean length of stay in the hospital was 3.1 ± 1.3 days. Only one patient had a prolonged hospital stay of seven days, because of post-operative seizures. Eleven patients (58.3%) had convexity meningioma, 4 (33.3%) had parasagittal meningioma and 1 each had a parafalcine and anterior skull-base meningioma. Simpson grade I resection was performed in 6 (41.7%) patients, grade II resection in 10 (50%) patients, and grade III resection in 1 (5.9%) patient. None of our patients had deterioration in their neurological deficits after surgery and no one required emergency intubation, conversion of surgery to general anesthesia, or redo exploration. Conclusion AC may be considered a safe modality for surgical resection of convexity and parasagittal meningioma, with no significant risk of intra-operative or post-operative pain, although it requires more evidence. It can be offered to patients who are at higher risk, or are not willing to undergo general anesthesia. Ultimately, it might also be beneficial in terms of reducing overall costs.

Complications and interventions associated with epidural analgesia for postoperative pain relief in a tertiary care hospital.

INTRODUCTION: Epidural analgesia is one of the commonly used methods of postoperative pain control despite its associated complications. Early recognition and intervention is required to minimize the effect of these complications. Present audit was conducted to find out the incidence of complications and type of interventions required to change the outcome. METHODOLOGY: The record of all the patients who had epidural catheter placed for postoperative pain management reviewed from the departmental acute pain management register. Parameters included level of insertion, drugs used, number of days infusion continued and complications like nausea, vomiting, motor block, sedation, dural tap, catheter pull out, hypotension and itching. In addition, the intervention done to manage these complications was also recorded. RESULTS: Total 1706 entries of epidurals were recorded in study period 2001 to 2007. The overall incidence of the complication was 26.6%. The common complications were motor block (13.4%), dural tap (1.2%), ineffective pain control (2.4%), accidental catheter pull outs (3.8%) and problems associated with the delivery system of drug (1.7%). The 12% of patients required intervention for the particular complications. The regime was discontinued in 28%, drug concentration changed in 21.5% while the other modes of pain management were used in 19% of patients. 0.9% of patients required epidural blood patch while 2% of patients required catheterization for urinary retention. CONCLUSION: This audit shows the importance of regular assessment and early intervention to manage epidural related complications in improving outcome.