A Survey of Current Practices and Adherence to Coronavirus Disease Airway Management Guidelines Among Frontline Healthcare Professionals in a Resource-Limited Country.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) has brought anaesthesiologists, intensive care and emergency physicians to the forefront due to their airway management skills. The aim of survey was to determine current practice trends in COVID-19 airway management among frontline healthcare professionals of Pakistan and their adherence to standard principles proposed by most consensus guidelines. METHODS: An online questionnaire was designed based on consensus guidelines from international societies. We contacted consultants and trainees nationwide working in anaesthesia, intensive care, and emergency departments through emails, phone calls, and social media platforms. RESULTS: A total of 285 individuals participated in this cross-sectional descriptive study. Intubations were largely performed by anaesthetists followed by emergency physicians. Deteriorating respiratory failure (89%) was the most frequent indication. Availability of trained staff, use of intubation checklist, limited staff presence during intubation, and use of appropriate personal protective equipment were positive findings. One-third reported that their workplace did not have negative pressure rooms for aerosol-generating procedures, and 63.3% responders do not perform airway assessment before intubation. The device of choice for the first attempt at laryngoscopy was Macintosh laryngoscope (51.6%) followed by videolaryngoscopes with disposable blades (24.2%). Availability of rescue devices in case of unanticipated difficult airway is variable; laryngeal mask airway (70.1%), bougie (82.2%), and stylet (68.7%) were present at majority places. Frequency of airway-related adverse events including hypoxemia (69.8%) and failed first attempt intubation (35.2%) was significant. CONCLUSION: This survey found satisfactory knowledge, comparable practices, and offers some important insights about airway management in COVID-19 patients by healthcare professionals of Pakistan.

A retrospective analysis of peri-operative medication errors from a low-middle income country.

Identifying medication errors is one method of improving patient safety. Peri operative anesthetic management of patient includes polypharmacy and the steps followed prior to drug administration. Our objective was to identify, extract and analyze the medication errors (MEs) reported in our critical incident reporting system (CIRS) database over the last 15 years (2004-2018) and to review measures taken for improvement based on the reported errors. CIRS reported from 2004 to 2018 were identified, extracted, and analyzed using descriptive statistics and presented as frequencies and percentages. MEs were identified and entered on a data extraction form which included reporting year, patients age, surgical specialty, American Society of Anesthesiologist (ASA) status, time of incident, phase and type of anesthesia and drug handling, type of error, class of medicine, level of harm, severity of adverse drug event (ADE) and steps taken for improvement. Total MEs reported were 311, medication errors were reported, 163 (52%) errors occurred in ASA II and 90 (29%) ASA III patient, and 133 (43%) during induction. During administration phase 60% MEs occurred and 65% were due to human error. ADEs were found in 86 (28%) reports, 58 of which were significant, 23 serious and five life-threatening errors. The majority of errors involved neuromuscular blockers (32%) and opioids (13%). Sharing of CI and a lesson to be learnt e-mail, colour coded labels, change in medication trolley lay out, decrease in floor stock and high alert labels were the low-cost steps taken to reduce incidents. Medication errors were more frequent during administration. ADEs were occurred in 28% MEs.

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.

Adverse Respiratory Events After Removal of Laryngeal Mask Airway in Deep Anesthesia Versus Awake State in Children: A Randomized Trial.

Background The advent of the laryngeal mask airway (LMA) has reduced respiratory events in comparison to the conventional endotracheal tubes. Any manipulation under a light plane of anesthesia predisposes to increased airway sensitivity followed by adverse events. The reduced airway sensitivity in the deeply anesthetized state makes LMA removal feasible. In the past, the respective advantages and disadvantages of extubation in two planes of anesthesia have led to conflicting results. The primary objective of this study is to compare the incidence of adverse respiratory events at the time of LMA removal, in deeply anesthetized and awake groups. Our secondary objective was to record the management of complications. Materials and methods We conducted a prospective randomized control trial in 106 American Society of Anesthesiologists (ASA) I and II patients undergoing lower umbilical surgeries over a period of one year. The demographic details and intraoperative and postoperative variables, i.e., airway obstruction, laryngospasm, peripheral oxygen desaturations, cough, straining and vomiting, along with corrective measures were recorded by the primary research assistant in both groups. Regarding the management of peripheral oxygen desaturation (less than 90%), airway obstruction, and laryngospasm, 100% fractional inspired oxygen support and chin lift/jaw thrust were used. Results The average age was 32.58±15.81 months. The demographic characteristics of the patients were not significant between the two groups. The rate of adverse respiratory events like laryngospasm and airway obstruction was relatively high in the deep group but not statistically significant between the groups. A total of 7 (6.6%) patients had laryngospasm, 21 (20%) had airway obstruction, 16 (15%) had a cough and 11 (10%) patients had observed peripheral oxygen desaturation (less than 90%) between both groups.  Conclusion We concluded that adverse respiratory events could happen in both awake and deep planes of anesthesia after the removal of LMA in children. Furthermore, both techniques have an acceptably low frequency of complications, and it does not affect the current clinical practice.

Ultrasound-guided peripheral nerve blocks in high-risk patients, requiring lower limb (Above and below knee) amputation.

A case series of five high-risk patients with lower limb ischemia, sepsis, altered coagulation, and multi-organ dysfunction requiring emergent or urgent lower limb amputation is presented. Use of peripheral nerve blocks for below and above knee amputations is quite uncommon which provides better hemodynamic stability and pain management, especially in the very sick patients. The surgeries were successfully carried out under ultrasound-guided combined femoral and sciatic nerve blocks. All five patients obtained adequate level of block at the area of amputation. There were no complications related to anesthetic management. Patients remained hemodynamically stable and pain-free during surgery and postoperatively. Combined femoral-sciatic nerve block under ultrasound guidance is safe and satisfactory alternative anesthetic technique for such patients.

Pediatric critical incidents reported over 15 years at a tertiary care teaching hospital of a developing country.

BACKGROUND AND AIMS: The role of critical incident (CI) reporting is well established in improving patient safety but only a limited number of available reports relate to pediatric incidents. Our aim was to analyze the reported CIs specific to pediatric patients in our database and to reevaluate the value of this program in addressing issues in pediatric anesthesia practice. MATERIAL AND METHODS: Incidents related to pediatric population from neonatal period till the age of 12 years were selected. A review of all CI records collected between January 1998 and December 2012, in the Department of Anaesthesiology of Aga Khan University hospital was done. This was retrospective form review. The Department has a structured CI form in use since 1998 which is intermittently evaluated and modified if needed. RESULTS: A total of 451 pediatric CIs were included. Thirty-four percent of the incidents were reported in infants. Ninety-six percent of the reported incidents took place during elective surgery and 4% during emergency surgery. Equipment-related events (n = 114), respiratory events (n = 112), and drug events (n = 110) were equally distributed (25.6%, 25.3%, and 24.7%). Human factors accounted for 74% of reports followed by, equipment failure (10%) and patient factors (8%). Only 5% of the incidents were system errors. Failure to check (equipment/drugs/doses) was the most common cause for human factors. Poor outcome was seen in 7% of cases. CONCLUSION: Medication and equipment are the clinical areas that need to be looked at more closely. We also recommend quality improvement projects in both these areas as well as training of residents and staff in managing airway-related problems in pediatric patients.

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.

Anaesthetic consideration in a cannabis addict.

This case report describes the anaesthetic management of a patient addicted to Bhang(cannabis) for 20 years. Cannabis use has implication in the anaesthetic management of a patient because of its effects on the cardiovascular system, respiratory system, and central nervous system and its interaction with anaesthetic drugs.

Prevalence of low back pain experienced after delivery with and without epidural analgesia: A non-randomised prospective direct and telephonic survey.

BACKGROUND AND AIMS: The most frequent concern of patients receiving epidural analgesia for labour pain relief is post-partum back pain. This survey was designed to assess the prevalence of post-partum backache with and without epidural analgesia among post-partum women. METHODS: The study was conducted at a university teaching hospital and women presenting to labour room for labour and delivery formed the target population. A total of 482 women were recruited during the study period. Response rate was 95.4% and these cases were included in our statistical analysis. Two forms were designed for data collection before and after delivery; form I was filled by one of the investigators while form II was filled by a research assistant to prevent bias which included follow-up of back pain. The primary outcome variable was backache quantified with visual analogue scale score. Out of 460 women, 230 women received epidural analgesia for labour and 230 women had not. RESULTS: The prevalence of post-partum back pain in epidural analgesia versus non epidural analgesia groups was 40.9% versus 40% on day one and 32.2% versus 35.2% after 1 week. However, after one and 3(rd) months follow-up, backache prevalence was less in epidural analgesia group (unadjusted odds ratio [OR]: 0.63; 95% confidence interval [CI]: 0.39-0.99) and (unadjustedd OR: 0.32; 95% CI: 0.15-0.69) respectively. The adjusted odd ratio was 0.59 at 1st month and 0.25 at 3rd month. There was no significant difference between the two groups in pain scores. CONCLUSION: There was no association between the epidural analgesia and post-partum back pain.

Standards for labelling and storage of anaesthetic medications--an audit.

OBJECTIVE: To check compliance of anaesthetist to current policies set for the use of medication within operation room and for induction room floor stock. METHODS: The initial audit was conducted from 1st October to 31st November 2006 and reaudit after dissemination and sharing of results within the department repeated in July-August 2007. In each audit four operating rooms were visited twice a week. Syringes were checked for standard drug labelling for narcotic and non narcotic preparations. Drug trolley was checked for any expired drugs and whether the trolley was locked in case of operating room (OR) where list was ended or was on hold. Any unattended drug was noted and Induction room was checked twice weekly for accurate drug inventory and for standard drug storage recommendations. RESULTS: Labels were according to standard in non narcotic drugs on 25% syringes in first audit and 63% in second audit, likewise, narcotics labels were according to standards in 41% in first and 57% in second audit. Unattended drugs were present once in first and twice in second audit. There was 100% compliance in other drug storage policy parameters in both audits. CONCLUSION: Poor compliance of drug labelling standards for both narcotic and non narcotic drugs was present. However, second audit revealed improvement in all areas of drug handling. Dissemination of policies and reminders are important for continuing improvement in use of medication within operation room and within induction room floor stock.

Arterial to end-tidal carbon dioxide difference in neurosurgical patients undergoing craniotomy: a review of practice.

OBJECTIVE: To see if PETCO2 reflects PaCO2 with acceptable accuracy. METHODS: In this audit the.anaesthetic chart of fifty consecutive patients, age 12 years and above undergoing craniotomy for intracranial pathology, were reviewed. RESULTS: The difference between end tidal carbon dioxide (ETCO2) value corresponding to the time of taking the arterial sample and the PaCO2 was calculated. The mean end tidal CO2 was 29.3 +/- 2.8 and the mean PaCO2 was 32.63 +/- 4.5. The mean difference between the two values was calculated as 4.09 +/- 3.0. The regression coefficient was 0.496, which showed a moderate association. A wide variability was observed in the results. CONCLUSION: Based on our results we recommend that arterial samples should be taken to determine PaCO2 in neurosurgical patients where maintenance of cerebral blood flow is crucial e.g. cerebral aneurysm surgery

Intraoperative analgesia for day-care surgery: practice trends.

Our objective was to determine the trends of providing intraoperative analgesia for day-care surgery among the various anaesthesiologists at our university hospital. All patients having surgical procedures under general anaesthesia in the Surgical Day Care Unit (SDC) of the Hospital were included. The study was done over two months and 142 patients were enrolled during the study period. Of these 45% received pethidine for intraoperative analgesia, 24% pethidine and ketorolac, 6% pethidine and paracetamol suppositories, 18% received fentanyl, 2% tramadol and 5% received other analgesic combinations. Of the 22% patients who received pethidine intraoperatively needed rescue analgesia in recovery room, while 12% of those receiving a combination of pethidine and ketorolac needed rescue analgesia. Pethidine was found to be the most commonly used analgesic agent while a combination of pethidine and ketorolac was found to provide a superior quality of analgesia with a lesser need of additional analgesia.

Effect of pre-operative coagulation testing on intra-operative transfusion requirements in surgical patients.

OBJECTIVE: To assess the value of pre-operative coagulation testing in elective surgical patients, to estimate the frequency of abnormality and the outcome in relation to transfusion. DESIGN: Observational study. PLACE AND DURATION OF STUDY: The study was performed at the Aga Khan University Hospital in main operating room over a period of six months from March to September 1999. MATERIALS AND METHODS: All patients scheduled for elective surgery in which the primary physician had ordered PT (prothrombin time), APTT (activated partial thromboplastin time) and PLT (platelet) count were included. Risk groups were made based on history of coagulation disorders and medications altering coagulation. The patients were also stratified according to age and the frequency of abnormality determined in different groups. RESULTS: Five hundred cases were studied. The frequency of abnormalities of PT and APTT were found to have statistically high association with the risk groups based on history. There was significant association between age and abnormal platelets count. Only 8 patients were transfused. CONCLUSION: Pre-operative coagulation tests should only be ordered in high risk groups based on history and examination.