What is new in postoperative analgesia?

The rate of Caesarean sections is on an increase and with it an increased awareness among the mothers to remain pain free during and after the surgery. This has put anesthesiologists to explore possibilities and options other than the routine methods of surgical analgesia. The cons and pros of using opioids, NSAID’s, nerve blocks and regional techniques, all have been scrutinized and the associated disadvantages and side effects discussed

Chemical dependency: an occupational hazard in the field of Anaesthesia

The medical personnel are vulnerable to substance abuse and dependence due to ready access to substance of abuse. Addiction is considered as an occupational hazard for those involved in the practice of anaesthesia for the same reason. Substance abuse is defined as a psychosocial biogenetic disease, which results from dynamic interplay between a susceptible host and favourable environment. According to the 5th and the last National Survey on Drug Abuse (NSDA) in 1993 by Pakistan Narcotic Control, there are nearly three million drug dependants in Pakistan, but no data is available to determine the prevalence among medical or anaesthesia personnel. In order to handle the rising trend of chemical abuse, we need to have more surveys and studies on this subject, written policy and educational programme in postgraduate training with proper control and frequent checking of narcotic dispensing. Reporting of drug abuse and rehabilitation of affected doctors are areas which need to be worked upon

Practice of use of antiemetic in patients for laparoscopic gynaecological surgery and its impact on the early (1st two hrs) postoperative period

There is no agreed technique for minimizing PONV (Postoperative Nausea and Vomiting) although some techniques are associated with low rate. Best practice involves identifying high risk patients and surgeries and use of prophylactic antiemetic where appropriate. Laparoscopic gynaecological surgery has high incidence of PONV (54-92%). An audit on the practice of antiemetic use in diagnostic laparoscopic gynaecological surgery was done in the department of anaesthesia of Aga Khan University Hospital from 1st January to 30th June 2006. We included all the patients scheduled for this procedure lasting less than 90 minutes. Anaesthetist involved in the audit identified the patient falling into the predetermined risk factors. The following facts about antiemetic were noted; whether the patients received any antiemetics or not, if it was prophylactic or rescue, type, dose route and timing of antiemetic. Patients were rated for any signs of nausea and vomiting (retching) after extubation in the operating room by the anaesthetist and in the recovery room or surgical day care unit (SDC) by the nurse who was briefed about it and was cross checked by the anaesthetist involved in the audit. This was done for two hours postoperatively. Our results showed that only 75% of patients with risk factors received an antiemetic. The most commonly used antiemetic was Metoclopramide. Eight percent of the patients had vomiting and all of them had received a prophylactic antiemetic. They received the same rescue antiemetic. This audit recommended institutional guidelines for the management of PONV. These should be based on evidence obtained from the published peer-reviewed studies. These guidelines could be communicated to health care workers involved in postoperative management of patients to help them achieve an optimal management strategy for this uncomfortable postoperative complication

Obstetric patients requiring critical care: Retrospective study in a tertiary care institute of Pakistan

Background: The outcome of obstetric patients admitted to the intensive care unit (ICU) depends on the number of factors. The objective of this study is to review the outcomes of these patients with regard to pregnancy status, source of admission, and their presenting illness at time of admission to ICU. Materials and Methods: A retrospective study was undertaken for all obstetric patients admitted to the ICU of a private tertiary care hospital of Pakistan from 2014 to 2018. The data were reviewed thorough ICU log sheet, electronic medical records, and online laboratory data. The data included patient demographics, pregnancy status, mode of admission, length of stay, laboratory investigation, presenting disease, and outcomes in terms of death or survival. Results: Obstetric patients accounted for 3.8% for all ICU admission with overall mortality of 11.1%. There was no statistically significant difference in the mortality rate with respect to presenting illness; however, morality was highest (37.5%) in patients with pre-eclampsia. A majority (54.2%) of the ICU admission were due to hemorrhagic/hematological causes followed by cardiovascular causes (33.1%). A statistically significant increase in mortality rate was observed in patients admitted through emergency compared with patients from within hospital (P \u3c 0.0005). Conclusion: Patients coming through emergency as referral patients were found to have the highest mortality. There is dire need to uplift the primary and secondary tertiary care centers in developing countries, where early treatment can be provided and high-risk cases can be picked up with early referral to tertiary care center

Medical errors related to look-alike and sound-alike drugs

Despite recent developments in the inventory management, introduction of electronic drug trolleys and cabinets, color coding of the filled syringes and many more interventions, medication errors could not be eliminated. The most common of these are syringe swap and human errors regarding wrong drug administration due to look-alike drug containers or sound-alike names of the drugs belonging to diverse groups. Many of the fatalities, that occur in third world countries due to these causes, go unnoticed and unregistered. This special article complements two special editorials on the same topic by Professor Joseph D. Tobias et al and Professor Robert Stoelting, a case report, a patient’s perspective and a ‘Cliniquiz’ being published in the current issue of the journal. It discusses salient features of this issue as well as preventive measures and recommendations. Key words: Medications; Medications errors; Adverse drug events; Look-alike drugs; Sound-alike drugs Tall man lettering; Medication Errors Reporting Program; Anesthesia Patient Safety Foundation Citation: Ismail S and Taqi A. Medical errors related to look-alike and sound-alike drug

Management of parturient with triplet pregnancy and placenta percreta: Importance of multi-disciplinary approach

Obstetric conditions like placenta percreta and multiple pregnancies can be extremely challenging as they pose a high risk for both the mother and infants. In placenta percreta, placental villi penetrate through the wall of uterus into the surrounding organs including the bladder and carry a risk of massive maternal bleeding. Multiple pregnancies have greater complication rate than that in singleton pregnancy. Successful management of such challenges are best done by a multidisciplinary teamwork, where all members of a perinatal team are involved in decision making and management. We report the successful management of a triplet gestation associated with placenta percreta

Adequacy of postoperative pain relief after discharge

Day care surgery has shown a remarkable development over the last two decades, comprising approximately 60-70% of all surgical procedures. Therefore major proportions of surgical patients are recovering at home and have little or no assessment of the adequacy of their pain relief. The aim of our audit was to compare suggested postoperative pain indicators with targets for best practice. This audit was done at the Aga Khan University Hospital day care unit for a period of three months. On the day of surgery patients having the contact numbers were informed about the telephone call 24 hrs after the surgery inquiring about their pain relief. Patients were shown and explained the visual analogue score from 0 to 10. The data was collected by one of the investigators on the day of surgery. We could assess 63.3% of day care patients. All patients were discharged with analgesia. Only three percent reported severe pain after 24 hrs which is according to the proposed standard for best practice that is \u3c 5 %. Sixty percent of patients had mild or no pain which is less than the proposed standard (\u3e85%) and 84.2% were satisfied which is almost borderline (\u3e85%) according to the standard of best practice

Postoperative pain management practices and their effectiveness after major gynecological surgery: An observational study in a tertiary care hospital

Background and Aims: Despite advances in postoperative pain management, patients continue to experience moderate to severe pain. This study was designed to assess the strategy, effectiveness, and safety of postoperative pain management in patients undergoing major gynecological surgery.Material and Methods: This observational study included postoperative patients having major gynecological surgery from February 2016 to July 2016. Data collected on a predesigned data collection sheet included patient\u27s demographics, postoperative analgesia modality, patient satisfaction, acute pain service assessment of numeric rating scale (NRS), number of breakthrough pains, number of rescue boluses, time required for the pain relief after rescue analgesia, and any complication for 48 h.Results: Among 154 patients reviewed, postoperative analgesia was provided with patient-controlled intravenous analgesia in 91 (59.1%) patients, intravenous opioid infusion in 42 (27%), and epidural analgesia in 21 (13.6%) patients with no statistically significant difference in NRS between different analgesic modalities. On analysis of breakthrough pain, 103 (66.8%) patients experienced moderate pain at one time and 53 (51.4%) at two or more times postoperatively. There were 2 (0.6%) patients experiencing severe breakthrough pain due to gaps in service provision and inadequate patient\u27s knowledge. Moderate-to-severe pain perception was irrespective of type of incision and surgery. Vomiting was significantly higher (P = 0.049) in patients receiving opioids.Conclusion: Adequacy of postoperative pain is not solely dependent on drugs and techniques but on the overall organization of pain services. However, incidence of nausea and vomiting was significantly higher in patients receiving opioids