Knowledge and attitude towards the use of pain medications according to WHO cancer pain analgesic ladder in tertiary care hospitals of Pakistan.

To assess the knowledge and attitude of practicing physicians and surgeons towards the use of pain medication according to the World Health Organisation cancer pain analgesic ladder, the current study was conducted at tertiary care hospitals of the four provinces of Pakistan. Professionals having experience of treating cancer patients for >2 years were included. Data was collected using a self-administered questionnaire sent to each participant using Google Forms. Of the 630 physicians approached, 133(21%) responded. Of them, 74(55.64%) participants were familiar with the World Health Organisation analgesic ladder. There was a significant difference in the frequency of using the ladder based on age (p<0.05). Most participants 31(23%) reported the nonavailability of the recommended drugs as the reason for not following the analgesic ladder. There is a strong need to educate physicians and surgeons about the World Health Organisation analgesic ladder, and to make strategies to improve opioid availability in Pakistan.

Dexmedetomidine as an Adjunct in a Fluoroscopically Guided Stellate Ganglion Block for Complex Regional Pain Syndrome.

Complex regional pain syndrome (CRPS) is a chronic pain disorder characterized by pain that is disproportionate to the inciting event. Autonomic and inflammatory responses predominate, and treatment plans that explicitly target these responses reduce symptoms for longer periods of time, are typically better tolerated, and have more favorable outcomes. Our patient was a young male who presented with a four-month history of a road traffic accident (RTA) that resulted in a fractured left distal radius and scaphoid. His main complaint was pain and discomfort, even after surgical forearm stabilization, as well as hyperesthesia, restricted range of motion, and new-onset tremors. The patient was provisionally diagnosed with complex regional pain syndrome (CRPS) and booked for a fluoroscopically guided stellate ganglion block when the oral medication regime provided minimal relief. A stellate ganglion block was administered using a combination of ropivacaine, methylprednisolone, and dexmedetomidine under fluoroscopic guidance. During our routine outpatient follow-ups, our patient's pain score on the visual analog scale (VAS) fell to zero, the burning, vasomotor, and temperature abnormalities subsided, and he gradually regained the use of his left forearm and hand. The etiology of complex regional pain syndrome is multifaceted. Early identification and therapy typically halt the progression. Long-term outcomes are improved by treatment strategies that target inflammatory and autonomic responses. Dexmedetomidine has a mild anti-nociceptive action when used as an adjuvant in peripheral nerve blocks and ganglion blocks, blocking pain transmission in Aδ and C fibers. We feel that by combining dexmedetomidine and a stellate ganglion block, we could provide immediate and long-term relief to our patient. More research is needed to monitor and analyze the efficacy of dexmedetomidine as a treatment for chronic pain syndromes such as CRPS.

Effective utilization of time for non-operating room anaesthesia services at Aga Khan University Hospital Karachi: A prospective quality improvement audit.

OBJECTIVE: To identify service quality gaps by reviewing out-of-operating-room anaesthesia services in a tertiary care hospital. METHODS: This quality improvement audit was conducted at The Aga Khan University Hospital Karachi from July to September 2019, and comprised procedures conducted outside the operating room under anaesthesia and sedation from 8am to 5pm. A data collection form was designed to collect information related to the non-operating-room anaesthesia services. Data was analysed using SPSS Version 19. RESULTS: A total of 123 radiological procedures were observed in 48 working days and endoscopic/radio-therapeutic procedures observed were 98 over 31 days. The mean anaesthesia coverage time was 2.96±1.71 hours per day for radiological procedures, and 2.59±1.07 hours for endoscopic/radio-therapeutic procedures, indicating underutlisation of resources both human and material. CONCLUSIONS: A multideciplinary team consisting of all stakeholders should be developed to facilitate the patients and enhance healthcare quality.

Association Between Low Back Pain and Body Mass Index in Pakistani Population: Analysis of the Software Bank Data.

BACKGROUND: Obesity is a growing public health concern and is one of the leading causes of human suffering and disability worldwide. The number of overweight and obese people is dramatically increasing, and local data showed that low back pain (LBP) is more common in people with obesity, prolonged sitting jobs, psychological disorders, and lack of exercise. METHODS: This study was conducted in a cohort of 300 adult patients of either gender who visited a pain management clinic with LBP. Patient data were retrieved from the hospital software program and recorded in a pre-designed proforma. The data included the patient's age, gender, weight, height, BMI, comorbidities, site of pain, duration of pain, distribution of pain, severity of pain, history of spinal trauma, previous spinal surgery, and working diagnosis. RESULTS: Out of 300 patients with LBP, 185 (61.7 %) were female and 115 (38.3%) were male, of these, 224 (74.6%) were overweight or obese. One hundred and three (34.3%) had axial back pain and 197 (65.7%) patients had lumbar radicular pain. Linear regression analysis showed that 17% variability in pain scores in both genders can be explained by the increase in BMI. There is a statistically significant relationship, i.e. P=0.0005, exists between pain score and BMI. CONCLUSION: This study showed the strong association between obesity and LBP in the Pakistani population. Approximately, 75% were overweight or obese in our LBP population-based cohort and this association was stronger among women than men.

Hospital based prevalence of smoking among surgical patients in tertiary care hospitals of Karachi Pakistan.

OBJECTIVE: To determine the prevalence of smoking and to evaluate the knowledge about preoperative smoking cessation in patients coming for elective surgery. METHODS: The cross-sectional study was conducted from July 30, 2019, to March 17, 2020, in the preoperative anaesthesia assessment clinic and surgical wards of Aga Khan University Hospital, Civil Hospital Karachi, and Abbasi Shaheed Hospital, Karachi, and comprised all patients of either gender aged >12 years scheduled for elective surgery having American Society of Anaesthesiologists physical status I-IV. Data was analysed using Stata 13. RESULTS: Of the 811 patients, 478(59%) were male and 333(41%) were female. The overall mean age was 43.4±16.4 years and mean BMI was 25.0±5.8kg/m2. There were 164(20.2%) smokers in the sample. The overall knowledge about preoperative smoking cessation was significantly associated with the level of education and gender (p<0.05). CONCLUSIONS: Smoking in surgical patients was about one-fifth of the overall sample, and knowledge related to preoperative smoking abstinence was significantly associated with educational status and gender.

An Awake Throughout Approach for Awake Craniotomy: A Perspective from a Resource-Limited Country.

BACKGROUND: An awake throughout (AT) approach for awake craniotomy is mostly under utilized. The purpose of this study was to review the efficacy of the technique at our tertiary care center. The primary objective was to identify the incidence of perioperative complications. The secondary objective was to review the patients' satisfaction, satisfaction of surgical team, length of stay (LOS) in special care unit (SCU), and overall LOS in the hospital. METHODS: The study was a retrospective review of patients data. All patients were treated with the AT technique. This included preoperative assessment, psychologic preparation, and institution of scalp block. The incidence of perioperative complications, including satisfaction of surgical team was noted. The patients' satisfaction and the LOS in SCU and in the hospital was also recorded. RESULTS: In total, the data from 55 patients were reviewed. Their mean age was 41 years, and 63% were reported to have seizures at presentation. The AT approach was successful in 100% of cases. The incidence of intraoperative seizures was 7.4%, of vomiting was 5.4%, and of conversion to general anesthesia was 0%. The surgical team was able to perform gross total resection in 53% of patients and rated a satisfaction score of 8 out of 10. Postoperative seizures occurred in 5.4% of patients and vomiting in 3.6%. The mean LOS in SCU was 1.2 days, and the overall hospital LOS was 4 days. The patients remained fully satisfied, as evidenced by a mean satisfaction score of 8.6. CONCLUSION: An AT approach might be very useful in resource-limited setups because of the low incidence of complications, the use of resources, and significant surgeon and patient satisfaction.