Challenges of Pediatric Anesthesia Services and Training Infrastructure in Tertiary Care Teaching Institutions in Pakistan: A Perspective From the Province of Sindh.

BACKGROUND: Pakistan is a lower middle-income country located in South Asia with a population of nearly 208 million. Sindh is its second largest province. The aim of this survey was to identify the current setup of pediatric services, staffing, equipment, and training infrastructure in the teaching hospitals of Sindh. METHODS: The survey was conducted between June 2018 and September 2018. A questionnaire was designed with input from experts and pretested. One faculty coordinator from each of 12 of the 13 teaching hospitals (7 government and 5 private) completed the form. Information was exported into Statistical Package for the Social Sciences (SPSS) version 22. Frequency and percentages were computed for all variables. Confidentiality was ensured by anonymizing the data. RESULTS: Anesthesia services are provided by consultants with either membership or fellowship in anesthesia of the College of Physicians and Surgeons of Pakistan (CPSP). All drugs on the World Health Organization (WHO) essential medication list were available, although narcotic supply was often inconsistent. Weak areas identified were absence of standardization of practice regarding premedication, preoperative laboratory testing, pain assessment, and management. No national practice guidelines exist. Pulse oximeters and capnometers were available in all private hospitals but in only 86% and 44% of the government hospitals, respectively. Some training centers were not providing the training as outlined by the CPSP criteria. CONCLUSIONS: Several gaps have been identified in the practice and training infrastructure of pediatric anesthesia. There is a need for national guidelines, standardization of protocols, provision of basic equipment, and improved supervision of trainees. One suggestion is to have combined residency programs between private and government hospitals to take advantage of the strengths of both. Recommendations by this group have been shared with all teaching hospitals and training bodies.

Comparison of intra-cuff lidocaine vs alkalinized lidocaine effects for prevention of post-operative sore throat.

OBJECTIVE: To compare the effect of intra-cuff lidocaine versus alkalinized lidocaine in the prevention of post-operative sore throat. Methods: The cross-sectional study was conducted from June 15 to July 15, 2019, at the Department of Anaesthesiology, Liaquat National Hospital and Medical College, Karachi, and comprised patients of either gender aged 15-50 years classified as American Society of Anaesthesiologist class 1-2 and undergoing general anaesthesia with endotracheal intubation expected to last more than one hour. The patients were randomised into Group L and Group LA. General anaesthesia was given using induction dose of propofol 2-3mg/kg, nalbuphine 0.1mg/kg and atracurium 0.5mg/kg and female patients were intubated with 7.0mm size endotracheal tube and males patients with 8.0mm. All intubations were performed by an anaesthesiologist with minimum of two-year experience. The endotracheal tube cuff was inflated by using plain lidocaine 2% in group L and 2% lidocaine with 8.4% sodium bicarbonate in LA group till the air leak diminished. Post-surgery, the patients were assessed on extubation for any emergence phenomenon and were re-assessed at 1st, 6th, 12th and 24th hour. The assessment was done by the on-call anaesthesiology resident who was blinded to the study group. Data was collected using a proforma. The analysis was done using software IBM SPSS Statistics 23.0. Chi-Square Test was applied to analyse the data. RESULTS: Of the 58 patients, 33(56.9%) were male and 25(43.1%) were female. There were 26(44.8%) patients aged 25-36 years, while 12(20.7%) each were aged 36-45 years and 46-55 years. There were 29(50%) patients in each of the 2 groups. After 24 hours, 44(75.9%) patients in Group L did not complain of any pain, while in group LA the corresponding number was 56(96.6%). Both in terms of cough and hoarseness at 24 hours, 56(96.6%) patients in Group L did not have complaints, while in Group LA there were no such complaints. In Group L, heart rate 60-80 was noted in 20(69%) patients and 81-100 in 9(31%). In Group LA, the corresponding values were 17(58.6%) and 12(41.4%). Conclusion: Alkalinized lidocaine was found to be highly effective in preventing post-operative throat complications compared to lidocaine.

Comparison of efficacy of ondansetron and dexamethasone combination and ondansetron alone in preventing postoperative nausea and vomiting after laparoscopic cholecystectomy.

OBJECTIVE: To compare the efficacy of ondansetron alone and combination of ondansetron and dexamethasone in preventing post-operative nausea and vomiting in patients undergoing laparoscopic cholecystectomy. METHODS: The randomised control trial was conducted from April 23 to August 22, 2009, at the Liaquat National Hospital, Karachi, and comprised 100 American Society of Anaesthesiology I and II patients undergoing laparoscopic cholecystectomy. Half of the subjects comprised Group A and received ondansetron alone, while Group B received combination of ondansetron and dexamethasone. They were randomised by opaque envelope method. Group A received ondansetron 4 mg while Group B received ondansetron 4 mg with dexamethasone 8 mg, 1 minute before induction. Post-operatively patients were observed for six hours for any episode of nausea or vomiting, or whether the patients required any rescue anti emetic. SPSS 19 was used for statistical analysis. RESULTS: Patients receiving ondansetron alone showed 14 (28%) with incidence of nausea or vomiting while the other group showed 6 (12%). This difference was statistically significant (p < 0.046). CONCLUSION: Combination of ondansetron and dexamethasone was more efficacious compared to ondansetron alone in the prevention of postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy.

Effectiveness Of Intrathecal Dexmedetomidine In Combination With Hyperbaric Bupivacaine For Lower Abdominal Surgeries And Its Postoperative Analgesic Characteristic.

Background: Intra-thecal anaesthesia is the commonly preferred, block for surgeries of lower abdomen, perineal and lower limb. It is easy to administer and very economical but needs skills. Intrathecal use of local anaesthetics possesses a short duration of action and needs early use of rescue analgesia postoperatively. Objective was to assess the efficacy of Dexmedetomidine in adjuvant with bupivacaine for neuraxial anaesthesia and postoperative analgesic characteristics. It was a prospective comparative study, conducted at Anaesthesia Department, Liaquat National Hospital, Karachi from January to July 2020. Methods: Overall 100 patients conveniently recruited who underwent lower abdominal procedures were allocated into two groups by randomization, i.e., 50 in each group and were labelled as Group N and Group D10. Group N consist of 0.5% bupivacaine 10 mg (2 ml) + diluted with 0.5ml normal saline dilution and group D10 consist of 10 µg Dexmedetomidine + 0.5% bupivacaine 10 mg (2 ml) with 0.5 ml normal saline dilution, total 2.5 ml dose in each group. The duration of block and regression was evaluated. . Results: The study showed significant differences in sensory and motor block to reach T10 and Bromage 3 respectively. Patients who were assigned in Group D reported short onset of sensory to reach T10 (5.4±1.17) and motor to reach Bromage 3 (10.4±1.03) as compared to Group N (9.9±2.12 and 17±22) respectively. Participants of Group D required rescue analgesia in less amount throughout intervals as compare to group N. Conclusion: The usage of 10ug Dexmedetomidine adjuvant with 0.5% bupivacaine significantly reduced the onset on sensory T10 and motor Bromage 3 and also prolong duration of sensory and motor regression, moreover minimal adverse effects and less use of rescue analgesic drugs were observed.

To asses the effects of rocuronium pretreatment on succinylcholine induced fasciculations and postoperative myalgias.

OBJECTIVE: To asses the effects of Rocuronium pretreatment on Succinylcholine induced Fasciculations and postoperative Myalgias. METHODS: A randomized double blind case control study was conducted in Department of Anaesthesia and Surgical Intensive Care Unit, Liaquat National Hospital, Karachi from October 2003 - April 2004. Sixty adults ASA I or II patients who presented for elective general surgical procedures were included in the study. The patients were divided in two groups of thirty each by a simple lottery method. Group "A" received placebo and group "B" received Rocuronium 0.1 mg/kg, one minute prior to induction with Pentothal Sodium 5 mg/kg, Suxamethonium, 1.5 mg/kg and Nalbuphine 10 mg / 70 kg. Fasciculations and intubation condition was assessed immediately after the induction of anaesthesia while post operative myalgias were assessed 6, 12 and 24 hours after surgery. RESULTS: Fasciculations were noticed in group "A" as 100% (mild to severe) and in group "B" 13.3% (mild). Post operative myalgias at 6 and 12 hours after surgery were 76.66 % in group "A" and 16.66 in groups "B". After 24 hours in group "A' post operative myalgias were 93.33% and group "B" 23.33%. CONCLUSION: It is concluded that pretreatment with Rocuronium reduced the incidence of myalgias, fasciculations and produced rapid precurarization in one minute thereby saving time on busy operating lists. They also allowed the early ambulation of patients in minor surgeries.

Comparison of haemodynamic changes in patients undergoing unilateral and bilateral spinal anaesthesia.

OBJECTIVE: To assess the haemodynamic changes in patients receiving unilateral and bilateral spinal anaesthesia with their pre-anaesthesia recordings. STUDY DESIGN: Quasi-experimental study. PLACE AND DURATION OF STUDY: Main Operation Theater, Liaquat National Hospital, Karachi, from May 2006 to February 2007. METHODOLOGY: Sixty patients meeting the inclusion criteria were randomly allocated in two groups of 30 patients each. One and a half ml of 0.75% hyperbaric bupivacaine was injected with free flow of cerebrospinal fluid using a 23 gauge quincke needle. Lumbar puncture was performed in the sitting position at 3 - 4 or 4 - 5 lumbar interspace. Patients were then assigned to the supine or lateral decubitus position for 10 minutes. Heart rate, systolic, mean and diastolic blood pressures of patients were recorded with their pre-anaesthesia readings in the 1st, 5th, 15th, 30th and then at every 15th minute till the end of procedure. Recovery room readings were also taken. RESULTS: The systolic, mean and diastolic blood pressure changes were significant in both groups. But from 1st minute to recovery room, statistically significant difference (p < 0.05) was found at each time interval, the unilateral groups (group A) being more stable with respect to pre-anaesthesia readings. The decrease in heart rate was comparable in both groups. CONCLUSION: Unilateral spinal anaesthesia was associated with a more stable cardiovascular profile, therefore, it is a valuable technique for high risk patients.