Barriers to safe anaesthesia care in South Asian countries: a virtual focus group discussion.

Objective: To identify barriers to safe anaesthesia practice across the South Asian region. METHODS: The qualitative study was conducted from September 2020 to August 2021 at the Department of Anaesthesiology at a leading medical university after getting exemption from the ethics review committee of the Pakistan Society of Anaesthesiologists. The sample comprised anaesthetists from 6 countries of the South Asian Association for Regional Cooperation. Data was collected through a focus group discussion held virtually using the Zoom app on September 22, 2020. The proceedings were transcribed and the data was subjected to thematic analysis. RESULTS: Of the 12 anaesthetists, 4(33.3%) were from India, 3(25%) from Pakistan, 2(16.7%) from Bangladesh, and 1(8.3%) each from Sri Lanka, Nepal and Afghanistan. There were 2 main themes identified; Safe anaesthesia and barriers to safe anaesthesia. They had 4 and 6 subthemes, respectively. The participants agreed that fresh medical graduates were not choosing anaesthesia as a preferred career specialty. One major concern raised was that qualified anaesthetists were leaving their countries for better-paid jobs abroad. Conclusion: The lack of a definition describing qualified anaesthetists in South Asian countries was pointed out. Lack of basic monitoring and drugs, brain drain, lack of ownership, lack of training programmes, lack of accountability, weak leadership, and disconnect between professional societies and governments were identified as the main barriers to safe anaesthesia.

Pain assessment in intensive care units of a low-middle income country: impact of the basic educational course.

BACKGROUND: Patients admitted to ICU usually have moderate-to-severe pain at rest and during care-related activities. The "Critical Care Pain Observation Tool (CPOT)" is a reliable and validated objective assessment tool for those patients who cannot self-report pain in ICU. The objectives of the educational course were to assess the baseline knowledge, and practice of pain assessment in critically ill patients and reassess the same in all participants of the course by comparing the results of pre and post-test. METHODS: The educational course of six hours of contact time on the use of CPOT for pain assessment in ICU patients was designed and conducted by the authors after approval from the Ethics Review Committee, Aga Khan University. This educational course was delivered at five different tertiary care hospitals in the Sindh province of Pakistan. A pre-test consisting of 25 true/false multiple-choice questions was conducted at the beginning of the course to assess the baseline knowledge, and practice of participants regarding pain assessment in critically ill patients and the same test was taken at the end of the course. RESULTS: A total of 205 critical care physicians and nursing staff attended the courses. Both pre-test and post-test were completed by 149 (72.6%) participants, of which 53 (35.6%) were female and 96 (64.4%) were male. The mean pre-test score of participants was 57.83 ± 11.86 and the mean post-test score of participants was 67.43 ± 12.96 and this was statistically significant (p = < 0.01). In univariate analysis, the effect of training was significantly higher in the female gender (p = 0.0005) and in those participants, who belong to the metropolitan city (p = 0.010). In multivariate analysis, participants from non-metropolitan cities showed less improvement in post-test scores compared to those who come from the metropolitan city (p = 0.038). CONCLUSIONS: The participating physicians and nurses showed a positive impact on the knowledge and clinical skills regarding pain assessment in CIPs. The participants from hospitals in metropolitan cities showed a significant improvement over those who were from non-metropolitan cities.

Pain Treatment Services; A National Survey Of Tertiary Care Hospitals In Pakistan.

OBJECTIVE: To quantify pain services in Pakistan and classify them according to the International Association for the Study of Pain guidelines. METHODS: The study was conducted at the Aga Khan University, Karachi, from January to June 2022, and comprised data of all public and private tertiary care hospitals anywhere in Pakistan that were registered with the Pakistan Medical Council till November 25, 2021. Data was collected using a predesigned Google form. Data was obtained primarily via email and secondarily by a phone call in a structured format. The facilities providing dedicated pain management services were classified according to the International Association for the Study of Pain guidelines. RESULTS: Of 118 hospitals, 45(38.1%) were in the public sector and 73(61.8%) were in the private sector. Overall, 78(65.2%) had no pain treatment services, while 40(34.2%) had such services. Of these 40(34.2%) facilities, 25(62.5%) were classified as pain centres, 11(27.5%) were pain clinics and 4(10%) were pain practices. In terms of per 100,000 population, there were 0.0193 pain services, 0.0351 pain physicians, 0.025 nursing staff and 0.02 administrative staff in the country. Physiotherapy was present in 37(92.5%) hospitals, psychiatry and psychology as allied services were used in 38(95%), acupuncture was integrated into the practice in 25(62.5%), while 39(97.5%) hospitals offered interventional procedures. Also, 9(22.5%) hospitals offered advanced training in pain medicine. CONCLUSIONS: A severe shortage of chronic pain services in Pakistan was found.

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.

Cervical Cancer-Associated Suffering: Estimating the Palliative Care Needs of a Highly Vulnerable Population.

PURPOSE: To enable design of optimum palliative care for women with cervical cancer, we studied the most common types of suffering and their severity, prevalence, and duration. METHODS: We first reviewed the literature on the major types, severity, prevalence, and duration of suffering associated with cervical cancer. We then conducted a modified Delphi process with experts in cervical cancer care to supplement the literature. For each type of suffering, we distinguished between decedents (those who die from cervical cancer in a given year) and nondecedents (those who have cervical cancer in a given year but do not die). By applying the suffering prevalence and duration estimates to the number of decedents, nondecedents, and family caregivers in 2017, we were able to estimate their palliative care needs and the intensity of palliative care needed to respond adequately to this suffering. RESULTS: There is a high prevalence among decedents of moderate or severe pain (84%), vaginal discharge (66%), vaginal bleeding (61%), and loss of faith (31%). Among both decedents and nondecedents, there is a high prevalence of clinically significant anxiety (63% and 50%, respectively), depressed mood (52% and 38%, respectively), and sexual dysfunction (87% and 83%, respectively). Moderate or severe financial distress is prevalent among decedents, nondecedents, and family caregivers (84%, 74%, and 66%, respectively). More than 40% of decedents and nondecedents are abandoned by their intimate partners. Most patients experience some combination of moderate or severe physical, psychological, social, and spiritual suffering. In total, 258,649 decedents and 2,558,857 nondecedents needed palliative care in 2017, approximately 85% of whom were in low- and middle-income countries where palliative care is rarely accessible. CONCLUSION: Among women with advanced cervical cancer, suffering is highly prevalent and often severe and multifaceted.

Essential Package of Palliative Care for Women With Cervical Cancer: Responding to the Suffering of a Highly Vulnerable Population.

Women with cervical cancer, especially those with advanced disease, appear to experience suffering that is more prevalent, complex, and severe than that caused by other cancers and serious illnesses, and approximately 85% live in low- and middle-income countries where palliative care is rarely accessible. To respond to the highly prevalent and extreme suffering in this vulnerable population, we convened a group of experienced experts in all aspects of care for women with cervical cancer, and from countries of all income levels, to create an essential package of palliative care for cervical cancer (EPPCCC). The EPPCCC consists of a set of interventions, medicines, simple equipment, social supports, and human resources, and is designed to be safe and effective for preventing and relieving all types of suffering associated with cervical cancer. It includes only inexpensive and readily available medicines and equipment, and its use requires only basic training. Thus, the EPPCCC can and should be made accessible everywhere, including for the rural poor. We provide guidance for integrating the EPPCCC into gynecologic and oncologic care at all levels of health care systems, and into primary care, in countries of all income levels.

Augmented Package of Palliative Care for Women With Cervical Cancer: Responding to Refractory Suffering.

The essential package of palliative care for cervical cancer (EPPCCC), described elsewhere, is designed to be safe and effective for preventing and relieving most suffering associated with cervical cancer and universally accessible. However, it appears that women with cervical cancer, more frequently than patients with other cancers, experience various types of suffering that are refractory to basic palliative care such as what can be provided with the EPPCCC. In particular, relief of refractory pain, vomiting because of bowel obstruction, bleeding, and psychosocial suffering may require additional expertise, medicines, or equipment. Therefore, we convened a group of experienced experts in all aspects of care for women with cervical cancer, and from countries of all income levels, to create an augmented package of palliative care for cervical cancer with which even suffering refractory to the EPPCCC often can be relieved. The package consists of medicines, radiotherapy, surgical procedures, and psycho-oncologic therapies that require advanced or specialized training. Each item in this package should be made accessible whenever the necessary resources and expertise are available.

Post-operative pain management modalities employed in clinical trials for adult patients in LMIC; a systematic review.

BACKGROUND: Unrelieved postoperative pain afflicts millions each year in low and middle income countries (LMIC). Despite substantial advances in the study of pain, this area remains neglected. Current systematic review was designed to ascertain the types of clinical trials conducted in LMIC on postoperative pain management modalities over the last decade. METHODS: A comprehensive search was performed in June 2019 on PubMed, Cochrane Library, CINAHL Plus, and Web of Science databases to identify relevant trials on the management of postoperative pain in LMIC. Out of 1450 RCTs, 108 studies were reviewed for quality evidence using structured form of critical appraisal skill program. Total of 51 clinical trials were included after applying inclusion/exclusion criteria. RESULTS: Results are charted according to the type of surgery. Eleven trials on laparoscopic cholecystectomy used multimodal analgesia including some form of regional analgesia. Different analgesic modalities were studied in 4 trials on thoracotomy, but none used multimodal approach. In 11 trials on laparotomy, multimodal analgesia was employed along with the studied modalities. In 2 trials on hysterectomy, preemptive pregabalin or gabapentin were used for reduction in rescue analgesia. In 13 trials on breast surgical procedures and 10 on orthopaedic surgery, multimodal analgesia was used with some form of regional analgesia. CONCLUSION: We found that over the past 10 years, clinical trials for postoperative pain modalities have evolved in LMIC according to the current postoperative pain management guidelines i.e. multi-modal approach with some form of regional analgesia. The current review shows that clinical trials were conducted using multimodal analgesia including but not limited to some form of regional analgesia for postoperative pain in LMIC however this research snapshot (of only three countries) may not exactly reflect the clinical practices in all 47 countries. Post Operative Pain Management Modalities Employed in Clinical Trials for Adult Patients in LMIC; A Systematic Review.

Managing acute pain in HIV+/AIDS patients: knowledge and practice trends among emergency physicians of major tertiary care centers of a developing country.

OBJECTIVE: To assess knowledge and practice trends in managing acute pain in patients infected with human immunodeficiency virus (HIV+) or having acquired immunodeficiency syndrome (AIDS) among emergency physicians of four tertiary care hospitals. Acute pain management in such patients is complex because of multiple concomitant painful conditions related to their disease. After obtaining ethical approval and written informed consent, emergency physicians were requested to fill out a questionnaire. RESULTS: Out of 84 physicians who participated, 49 had managed HIV+/AIDS patients during the preceding year. Out of the 49, 30 (61.2%) physicians stated that they used a combination of analgesics for acute pain in these patients. Forty-two (50%) out of the 84 participants believed that routine doses of opioids were adequate for pain relief, while 42 (50%) agreed that pain management was more complex in these patients mainly due to presence of multiple coexisting problems and psychological issues. Only 26 (31%) respondents considered that pain was under-reported and under-treated in these patients, mainly because physicians were more focused on patients' other disease related complications and issues. Formulation of guidelines are recommended for effective acute pain management in these patients encompassing associated issues, including concomitant painful conditions, opioid dependence, psychiatric problems, etc.

Efficacy of Intravenous Paracetamol in Combination with Lidocaine Pretreatment for Reducing Pain During Injection of Propofol.

Introduction The association of pain and discomfort of moderate to high severity and a high incidence with the intravenous (IV) administration of propofol is well known. Various physical and pharmacological methods are used to minimize propofol-induced pain, but the best intervention is still unknown. Therefore, our aim was to determine the analgesic efficacy of IV paracetamol when used in combination with lidocaine pretreatment in reducing propofol injection pain. Materials and methods This double-blind, randomized controlled trial was conducted after receiving the approval of our institutional research ethics board. A total of 74 patients were included after providing informed consent, and participants were placed into two equal groups: group A received IV paracetamol (1 g) in combination with lidocaine pretreatment prior to the injection of propofol, and group B received lidocaine pretreatment alone prior to propofol injection. After propofol injection, all participants were asked to evaluate pain on the visual analog scale. Results Patients who received the lidocaine-paracetamol combination reported significantly more pain-free responses (51.35%) than those from patients who received lidocaine pretreatment alone (8.11%; P<0.05). The analgesic efficacy of group A was positive in 36 patients (97.3%), and for group B, the analgesic efficacy was positive in 24 patients (64.9%). Conclusion The administration of IV paracetamol with lidocaine pretreatment was more effective than lidocaine pretreatment alone in reducing the pain caused by the injection of propofol. Physicians should consider using IV paracetamol in combination with lidocaine pretreatment when patients require IV propofol to ease patient suffering and reduce pain, which may help provide optimal patient care.

Isoflurane alone versus small dose propofol with isoflurane for removal of laryngeal mask airway in children-a randomized controlled trial.

OBJECTIVE: To compare the safety of laryngeal mask airway removal using two different deep anaesthesia techniques in paediatric patients. METHODS: The Randomized Control Trial was conducted at Aga Khan University Hospital, Karachi, from April 2012 to November 2013, and comprised patients aged 2-10 years scheduled for infraumbilical surgeries. Anaesthesia was induced with sevoflurane and later it was maintained by is oflurane, oxygen and nitrous oxide. The laryngeal mask airway was removed in the intervention group-I at 0.4 minimum alveolar concentration of isoflurane with propofol 1mg/kg. In the control group-II, it was removed at 1.2 minimum alveolar concentration of isoflurane alone. SPSS 19 was used for data analysis. RESULTS: Of the 50 patients, there were 25(50%) in each of the two groups. Overall, there were 46(92%) males and 4(8%) females. Incidence of airway obstruction and teeth clenching was significantly higher in group-II (p<0.05 each). Emergence duration was also significantly increased in group-II compared to group-I (p=0.001). The Post-Anaesthesia Care Unit stay timing was not significantly different between the groups (p=0.74). CONCLUSIONS: Laryngeal mask airway removal under deep anaesthetic technique of low-dose propofol with isoflurane was found to be associated with minimal adverse airway events than isoflurane alone in paediatric patients.

Tramadol: a valuable treatment for pain in Southeast Asian countries.

BACKGROUND: The supply of controlled drugs is limited in the Far East, despite the prevalence of health disorders that warrant their prescription. Reasons for this include strict regulatory frameworks, limited financial resources, lack of appropriate training amongst the medical profession and fear of addiction in both general practitioners and the wider population. Consequently, the weak opioid tramadol has become the analgesic most frequently used in the region to treat moderate to severe pain. METHODS: To obtain a clearer picture of the current role and clinical use of tramadol in Southeast Asia, pain specialists from 7 countries in the region were invited to participate in a survey, using a questionnaire to gather information about their individual use and experience of this analgesic. RESULTS: Fifteen completed questionnaires were returned and the responses analyzed. Tramadol is used to manage acute and chronic pain caused by a wide range of conditions. Almost all the specialists treat moderate cancer pain with tramadol, and every one considers it to be significant or highly significant in the treatment of moderate to severe non-cancer pain. The reasons for choosing tramadol include efficacy, safety and tolerability, ready availability, reasonable cost, multiple formulations and patient compliance. Its safety profile makes tramadol particularly appropriate for use in elderly patients, outpatients, and for long-term treatment. The respondents strongly agreed that tighter regulation of tramadol would reduce its medical availability and adversely affect the quality of pain management. In some countries, there would no longer be any appropriate medication for cancer pain or the long-term treatment of chronic pain. CONCLUSIONS: In Southeast Asia, tramadol plays an important part in the pharmacological management of moderate to severe pain, and may be the only available treatment option. If it were to become a controlled substance, the standard of pain management in the region would decline.

An analysis of perioperative adverse neurological events associated with anesthetic management at a Tertiary Care Center of a developing country.

BACKGROUND AND AIMS: Existing literature on neurological complications related to anesthesia is reported from affluent countries but the trends may vary in less affluent countries. MATERIAL AND METHODS: The objective was to find the associated factors contributing to neurological adverse events occurring within 48 h of anesthesia and surgery. The existing departmental morbidity and mortality database was reviewed from 1992 to 2012 for major adverse neurological events. A standardized methodology was used in reviewing and classifying the data. All adverse events were predefined and categorized before filling the form into the following headers; meningitis, cord/plexus/peripheral nerve injury, stroke, paraparesis/paraplegia/quadriparesis/or quadriplegia, new onset postoperative seizures, postoperative vocal cord injury, and a miscellaneous group. RESULTS: During this period, 195,031 patients underwent anesthesia and twenty-nine patients had major neurological morbidity within 48 h (1:6700). There were three cases of meningitis/meningism, eight cases of cord, plexus or peripheral nerve injury, seven of stroke, four had new onset seizures, one had quadriparesis, five had vocal cord, and one had cranial nerve palsy. Forty-one percent cases received regional anesthesia alone or in combination with the general. In six cases, anesthesia was considered solely responsible. Human error contributed to 93% of these events. CONCLUSION: This data has helped in identifying areas of concern and can serve as a reference for further audits in the region.

Patient refusal for regional anesthesia in elderly orthopedic population: A cross-sectional survey at a tertiary care hospital.

BACKGROUND AND AIMS: Improvements in pain management techniques in the last decade have had a major impact on the practice of orthopedic surgeries, for example, total hip arthroplasty and total knee arthroplasty. Although there are a number of treatment options for postoperative pain, a gold standard has not been established. In our institution, both general anesthesia and regional anesthesia (RA), are being offered to the elderly orthopedic population but RA is not frequently accepted by elderly population. The objective of this study was to determine the frequency of various reasons for refusal of RA in elderly patients undergoing orthopedic surgeries. MATERIAL AND METHODS: A prospective study conducted over a period of 1 year, had 549 patients with ages above 60 years who underwent different types of elective orthopedic procedures 182 patients who refused RA were interviewed according to a structured questionnaire designed to assess the reasons of refusal. RESULTS: Most common reason for the refusal of RA was surgeon's choice (38.5%), whereas 20.3% of the patients were unaware about the RA. There was a significant association between female gender and refusing RA due to backache (17.2%) and fear of being awake during the operation (24.1%) respectively. CONCLUSION: This survey showed that the main reasons among elderly female population were the fear of remaining awake and backache. However, overall it was the surgeon's choice which made patients refuse RA, and the anesthesiologists were the main source of information.

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.

A survey of undergraduate anesthesia rotation in medical colleges of Pakistan.

BACKGROUND: Student perceptions of specialties influence career choice decisions. It is important to expose undergraduates to the scope of rewarding careers in specialties like anesthesia by ensuring a good quality educational experience during anesthesia rotation. Our objective was to survey the curriculum structure and placement of the anesthesia undergraduate rotation in all the medical colleges of Pakistan recognized by the Pakistan Medical and Dental Council. MATERIALS AND METHODS: A standardized survey questionnaire was distributed by direct contact, postal mail or e mail to one identified anesthetist in all recognized medical colleges with enrolment of 100 or more students. The response rate was 75%. We received responses by hand, email and postal mail. RESULTS: We received responses from 15 out of 20 anesthetists contacted. 11 reported undergraduate anesthesia rotation while 4 reported absence of this rotation in their undergraduate curriculum. The rotation placement, duration and curriculum showed a wide variation and lack of standardization. CONCLUSION: Our survey indicates that the inclusion of anesthesia rotation in undergraduate medical education is not mandatory and standardized. The rotation duration, placement and curriculum need to be standardized to enhance the quality of the experience and promote the scope of the specialty for rewarding careers.

Induction position for spinal anaesthesia: sitting versus lateral position.

OBJECTIVE: To compare the effect of induction position on block characteristics (sensory and motor nerves) and haemodynamic stability in elderly patients with isobaric bupivacaine. Patient comfort was also looked at. METHODS: The randomized single blinded study was conducted at the Aga Khan University Hospital, Karachi, from September 2007 to August 2008. A total of 70 patients aged >60 years of both genders were included. Spinal anaesthesia was performed either in sitting or lateral position according to random allocation. Assessments of sensory, motor block and heart rate, systolic and diastolic blood pressure were recorded for 20 minutes. SPSS 16 was used for statistical analysis. RESULTS: There was no significant difference for haemodynamic variables heart rate, systolic and diastolic blood pressure. The onset of anaesthesia was faster in the sitting group (4.5 minutes vs 5.4 minutes). The motor block characteristics were similar in both the groups. The majority of patients who reported 'very comfortable' for induction position belonged to the lateral group. CONCLUSION: Both sitting and lateral positions have similar effects on sensory and motor blockade and haemodynamic stability. However, patients generally found lateral position very comfortable.

Knowledge about Pain Clinics and Pain Physician among General Practitioners: A Cross-sectional Survey.

INTRODUCTION: There is an on-going debate about what qualifies one to be called a "pain physician" and who can run the "pain clinic". Currently, the discipline of anesthesiology is producing the majority of pain physicians. A literature search was unable to find data for any Pakistani or other South Asian countries with regards to general practitioner (GP) knowledge about pain clinics and pain physicians. The main objective of this study was to assess the awareness of GPs regarding the existence of the pain clinic and pain physician. METHODS: A total of 411 GPs were included in this cross-sectional survey. A questionnaire consisting of ten questions was designed to identify their knowledge about the existence of pain clinics and pain physicians. Questionnaires were completed in the field and edited for the inconsistencies and in-completeness. RESULTS: The results showed that only 52.6% of GPs were aware of the existence of pain clinics. The survey showed that 37.5% believe neurologists are the pain physicians and only 10.9% know that pain clinics are run by anesthesiologist. The vast majority (85.0%) are unaware of the modern pain relieving methods used in pain clinics. CONCLUSION: The survey indicates that nearly half of the GPs are unaware of the existence of pain clinics and pain physicians, and the majority of GPs are unaware of new pain relieving methods.