Gynecology and obstetrical conditions requiring intensive care admission.

OBJECTIVE: Gynecological admissions to the surgical intensive care unit vary from the obstetrical cases. Pregnant women are of prime age and can tolerate the pregnancy and delivery well. There are certain rare conditions or complications, which make the pregnant women's life pass through a critical time. These are dealt with in a high dependency area, which is short of the intensive care unit. In King Khalid University Hospital there is no such arrangement, so the mildly affected and critically ill patients together are cared for in the surgical intensive care unit. The objective of this study is to study the gynecological and obstetrical conditions requiring intensive care admission in King Khalid University Hospital, surgical intensive care unit. METHODS: All obstetrical and gynecological patients who were admitted to the surgical intensive care unit were included. The demographic particulars, reason for admission, the course of the surgical intensive care unit stay and outcome were studied. RESULTS: During the study period of 3 years, there were 83, (100%) obstetrical and gynecological admissions to the surgical intensive care unit. Two (2%) cases were due to anesthesia complications. The majority of causes of admissions were due to obstetrical (n=63, 76%) complications or combination of medical and surgical conditions. Gynecological admissions comprised only 18 (22%) cases. There was no mortality in the group studied. CONCLUSION: Management of major obstetrical emergencies and gynaecological patients require an understanding of medical conditions' influence on the patients, and the physiological changes of normal and abnormal pregnancies. Intensive care unit management is an essential part in raising the level of patient care; health personnel training and continuing health care education may be improved.

Anesthetic and surgical factors affecting open heart surgery patients leading to cerebrovascular accident--retrospective study at King Khalid University Hospital.

Stroke after coronary bypass grafting (CABG) is often disabling. The incidence of ischemic stroke may approach 3% to 5%. Several risk factors have been identified including previous history of stroke, prolonged cardiopulmonary bypass time, and postoperative atrial fibrillation. Retrospective study during the period 1992-1995 was undertaken to determine the incidence, risk factors of neurological deficit after open-heart surgery at King Khalid University Hospital, Riyadh, Saudi Arabia. There were 350 patients who were subjected to CABG, 10 patients (2.8%) were found to suffer from cerebrovascular accidents (CVA) following open-heart surgery. In 18 patients, the complaint lasted more than 24 hours (stroke), while 2 patients developed transient ischemic attacks (TIA). Five factors were found to be associated with increased risk of post cardiac surgery CVA. These factors are postoperative atrial fibrillation, carotid bruit, past history of heart failure, past history of CVA and smoking. The authors concluded that it is necessary to start a prospective study to verify the area of improvement with regards to technique, selection of patients and mode of perfusion during cardiopulmonary bypass (CPB).

Essay on modern history of anesthesia in Egypt as reflected in Naguib (Bey) Mahfouz books.

It was already known that Professor Naguib (Bey) Mahfouz (1882-1974) whas the first staff anesthetist at Kasr El-Ainy Hospital (KEAH) in Cairo between the years 1904-1906. It is not well established why he changed his specialty. In a pursuit of this story, a very relevant account was discovered in his books published in 1935 on medical education and in 1966, a biography. Interesting revelations in his biography were revealed: First, he was not the first anesthetist at KEAH, and he was appointed to replace a retired anesthetist called Amin Naseem; second, chloroform was introduced to Egypt by Herbert Milton, the British surgeon at KEAH, toward the end of the last century; third, the reason why he changed his specialty was a fatal case of obstructed labor whom he has been giving anesthesia to- an incident that turned him toward obstetrics; fourth, he used chloroform, ehter and spinal analgesia with stovaine even when he was practicing as a surgeon; fifth, he revealed in his medical education book the names of pioneer doctors working in anesthesia in Egypt.

The incidence of bradycardia during endoscopic third ventriculostomy.

UNLABELLED: The incidence of bradycardia during endoscopic third ventriculostomy (ETV) is unknown. In an attempt to determine that incidence, we studied 49 pediatric patients with obstructive hydrocephalus who underwent ETV during general anesthesia. The median age was 54.5 mo (range 1-108 mo) and the median weight was 12.2 kg (range 2.4-22 kg). The heart rate was measured continuously in which four stages were identified for data analysis. Stage A is the preoperative phase, stage B is 5 min before perforating the floor of the third ventricle, stage C during perforation, and stage D after perforating the floor of the third ventricle. Three readings were recorded at each stage, then averaged. The mean values of the heart rate at stages A, B, C, and D were 146 +/- 27, 151 +/- 26, 87 +/- 32, and 143 +/- 24 bpm respectively. A significant decrease in the heart rate was determined in stage C compared with stage B (P: < 0.05). The incidence of bradycardia was 41%. Alerting the surgeon to perforate the floor of the third ventricle or withdraw the scope away from it was sufficient to resolve the bradycardia. We concluded that serious bradycardia might occur during ETV, mostly because of mechanical factors and can be resolved without medications. IMPLICATIONS: The use of endoscopy for treating pediatric patients with increased intracranial pressure is a new surgical procedure. These patients require general anesthesia with continuous heart rate monitoring. We have observed a high incidence of decrease in heart rate. If a decrease in heart rate occurs, alerting the surgeon to speed the procedure would be an effective treatment.

Spontaneous chylothorax--case report.

A-19-year old male patient complained of shortness of breath. Aspiration of the pleural fluid revealed chylothorax. Right chest tube was inserted. His ABG showed hypoxaemia with relative hypercarbia. He underwent right thoracotomy and thoracic duct ligation under general anaesthesia and double lumen endobroncheal intubation. During surgery he lost 1.5 L of blood and 4 L chyle. He was transferred to the SICU intubated and on mechanical ventilation. On the subsequent days chyle leak was reduced to a minimum of 10 ml/hr. On the 9th postoperative day the patient was extubated. He was receiving TPN 2600 kcal/day. He was transferred to the normal floor on the 15th day. After 7 day he was readmitted, his chest showed severe lung fibrosis and consolidation. His ABG showed severe hypercarbia (PaCO2 = 126 mmHg). The patient was intubated. His condition deteriorated and he was considered for lung transplantation. No donor was available. Later he arrested and died. Anaesthesia and surgical management of spontaneous chylothorax is challenging. The mortality rate is high.

Analgesic effects of intra-muscular ketoprofen (Profenid) and pethidine for squint surgery in children.

Administration of analgesics before surgery can decrease the intra-operative anesthetic requirement and pain during the early post-operative period (pre-emptive analgesia). The objective of this study was to evaluate an intra-muscular preparation of ketoprofen as analgesic in mild to moderate pain in children. In a double-blind placebo-controlled study, 91 healthy ASA I or II children undergoing squint opthalmic surgery was undertaken in the Ophthalmic Services at King Abdel-Aziz University Hospital Riyadh. The postoperative analgesic effects of intra-muscular pethidine and ketoprofen, just after the induction of anesthesia were compared. Patients were randomized to receive ketoprofen (1 mg W kg-1), pethidine (1 mg W kg-1) or saline (0.1 ml W kg-1). Anesthesia was induced and maintained with halothane and nitrous oxide via a facemask. Post-operative pain was assessed by a blinded observer using an objective pain scale. Results revealed that the ketoprofen group had lower post-operative pain scores and required less frequent analgesic therapy in the early postoperative period compared to the pethidine and placebo groups. In contrast, there were no differences in pain scores or analgesic requirements between the pethidine and the placebo groups. It is concluded that the preoperative administration of intramuscular ketoprofen, but not pethidine, provided better postoperative pain control than placebo in children undergoing ophthalmic surgery.

Anesthesia for laparoscopic general surgery. A special review.

Laparoscopy employs highly technical equipment, and the surgeon needs special training in the technique. He should master in-depth knowledge of the use of optics, electrical principles, gas under pressure, and the physiologic changes that occur when carbon dioxide is placed in the abdominal cavity. Above all, the surgeon must adhere rigidly to guidelines for appropriate technique, and deviation will most assuredly result in complications and even death. General surgery application of laparoscopy followed a wealth of medical experience from gynecological laparoscopies, which declared the technique as safe, reduced hospital stay with little pain and disfigurement. Laparoscopic cholecystectomy started to enjoy ever increasing popularity. It retained the advantages of shorter hospital stay, more rapid return to normal activities, less pain, small incisions and less postoperative ileus compared with the traditional open cholecystectomy. Soon many procedures were done using this new technique in adults and children. Anesthesia for laparoscopy has been established with a broad usage of agents and techniques. General anesthesia using balanced anesthesia technique including intravenous induction agents like: thiopentone, propofol, etomidate, and inhalational agents like nitrous oxide, isoflurane, desflurane, has been reported. Variety of muscle relaxants including succinylcholine, mivacurium, atracurium, vecuronium aiming at rapid recovery and cardiovascular stability. Total intravenous anesthesia using agnets like propofol, midazolam and ketamine, alfentanil and vecuronium has been reported also for outpatient laparoscopy. Epidural anesthesia was considered as safe alternative to general anesthesia for outpatient laparoscopy without associated respiratory depression. As for pain relief, many methods have been used. The pain mechanism is variable and analgesia requirement is less than those of open surgery. Cited complications include pneumothorax, cardiovascular collapse, surgical emphysema and pneumo-peritoneum complications. Among the implication for anesthesia care, the importance of preoperative monitoring, careful positioning and observation during the insufflation of carbon dioxide. The drive to have short term admission to hospital would make it imperative to use short acting rapidly eliminated anesthetic drugs, avoidance of vomiting and pain by proper use of modern anti-emetics and NSAID to help in avoidance of narcotics or reduction of the requirement.

Critical incident reports.

We describe a retrospective analysis of critical incident reports in two teaching hospitals. We included significant observations, involving unsafe practices during cardio-pulmonary resuscitation intensive care management and during anesthesia. Of the 143 critical incidents reported, 87% did not lead to negative out-come, out of these 13% were reports on deaths of patient resuscitated by CPR team or emergency department, underwent surgery, and or managed in the intensive care unit. Human errors and lack of communications were common factors for the majority of the incidents. Wrong drug labeling and irresponsible behavior were the most frequent among the human errors. The analysis aimed to regularize the method of reporting and also to determine the causes of complications, offer solutions and prevent occurrence of such incidents in the future.