Anesthetic deaths in a developing country

It is important to ascertain the contribution of anesthesia to perioperative mortality in order to enable improvement in the safety and quality of care. Scanty literature regarding anesthetic mortality from developing countries is available. We present data regarding anesthesia related mortality in a university hospital in a developing country. We reviewed all patient deaths occurring between 1992-2003 occurring within 24 hours of anesthesia, as part of departmental quality assurance activity. The aim of study was to identify any contributing factors associated with mortality, and to compare our data with similar studies from developed and developing countries. 111,289 cases were handled in this period. Within 24 hours the crude mortality was 35 (3.14: 10,000). 3 patients died at induction, 13 intraoperatively and one at emergence. In the postoperative period 18 (51%) cases of mortality occurred. In 4 (11%) cases anesthesia was found to be solely responsible (0.35 per 10,000), in 8 (23%) cases anesthesia was found to be partially responsible (0.7 per 10,000). In 23 patient disease and surgical factors played a primary role. In 10 (28.5%) cases deaths were considered to be avoidable. Two time periods were also compared. Between 1992-1998 anesthesia mortality was 0.68: 10,000 anesthetics, and from 1999-2003 it was 0.18: 10,000 Higher mortality was observed with advancing age, higher ASA status, emergency and complex surgical procedures. Human factor, human error, inadequate preoperative preparation, inappropriate postoperative care and lack of supervision were identified as preventable factors

Laryngeal mask airway insertion anaesthesia and insertion techniques

Laryngeal Mask Airway has gained wide acceptance for routine airway management, difficult airway and in emergency situations. The classical method of insertion was recommended by Dr Brain. Over the years various induction and insertion techniques have been described with variable results. Combination of induction agents with narcotics, with or without small dose muscle relaxants has been found to be very effective. There is less also lesser incidence of mucosal trauma with partially inflated cuff. Insertion with cuff facing laterally or backwards and rotating it forwards into position has also been described. A review of various options and their advantages and limitations is presented

Comparison of hemodynamic response to tracheal intubation with Macintosh and McCoy laryngoscopes

Background: Use of McCoy blade laryngoscope avoids the lifting force in the vallecula and theoretically should lead to a lower hemodynamic response related to laryngoscopy and tracheal intubation. The available literature on the topic is conflicting.MATERIALS AND Methods: We studied the hemodynamic response to laryngoscopy and tracheal intubation in 60 ASA 1 AND 2 adult patients using either Macintosh or McCoy laryngoscopes. The change in systolic, diastolic, mean arterial pressure, and heart rate (HR) was observed for 10 min post intubation. Arrhythmias and ST changes were also observed.Results: The maximum change in HR was 18.7% in the Macintosh and 7.7% in the McCoy group, and in systolic arterial pressure was 22.9% in the Macintosh and 10.3% in the McCoy group. This difference between groups was significant (P \u3c 0.0001). The change lasted for a lesser duration in the McCoy group. No arrhythmias or ST changes were observed in either group.CONCLUSION: Hemodynamic changes with use of McCoy laryngoscope were lesser in magnitude and of shorter duration

Estimation of blood loss during Caesarean section: an audit

Objective: To evaluate the blood ordering practice and blood transfusion for Caesarean sections at our institution and to compare the estimated blood loss between anaesthetists and obstetricians.Methods: A review of 126 patients undergoing both elective and emergency Caesarean section was undertaken in 2002. Information collected included the number of blood units cross-matched preoperatively, type of surgery (emergency or elective), type of anaesthesia, parity of the patient, estimated blood loss by both anaesthetists and obstetricians, intraoperative and postoperative transfusion within 48 hours and pre and post operative haemoglobin (Hb) and haemocrit (Hct).Results: A total of 215 units were cross-matched for 126 patients undergoing Caesarean section delivery. A small amount (9.5%) were transfused intraoperatively and 5.5% postoperatively. The average blood loss estimated by anaesthetists was 498 +/- 176 ml and that by obstetricians was 592 +/- 222 ml. The calculated blood loss based on patients blood volume and drop in Hct was 787 +/- 519 ml. The cross-match transfusion ratio was 9.7.CONCLUSION: Only 13% of our patients needed blood transfusion. The mean blood loss was estimated to be more by the obstetricians as compared to the anaesthetists. We recommend that the practice of routine cross-match practice prior to Caesarean section should be re-looked by institutions practicing obstetric anaesthesia

Job Stress among Female Residents during Postgraduate Training at a University Hospital in Karachi, Pakistan

Background: Postgraduate medical training is a stressful experience for both male and female doctors but previous studies have shown that stress might be more prevalent amongst female residents. Since women make up 70-80% of medical graduates in Pakistan we conducted this study to determine the prevalence of stress among female residents during postgraduate training and identify the most common stressors. Methodology: All female residents enrolled in postgraduate training programmes at the Aga Khan University meeting the inclusion criteria were recruited and informed written consent was obtained. Job Stress Inventory (JSI) was used to identify symptoms and sources of job stress. A cut-off value of \u3e25 was used to indicate job stress. Results: A total of 154 female residents met the inclusion criteria. The response rate of the survey was 77%. Sixty one residents scored 26 or more on the JSI, indicating the presence of job stress. The three most common causes cited for job stress were, lack of control, environmental factors and workplace politics. Conclusion: Our study indicates a high prevalence of stress among female residents, independent of the marital status, number of children, the chosen specialty or the level of training. We suggest that programme directors and supervising faculty acknowledge the need for change in the training programmes refraining from favoritism and the need for politics towards constructive feedback based on merit and hard work and allow the residents to have more control over their working environment

Effect of diclofenac suppository on tramadol consumption in posthysterectomy pain

OBJECTIVE: To determine reduction in dose of tramadol and side effects in posthysterectomy patients on addition of diclofenac on rectal suppository. STUDY DESIGN: Randomized double blinded placebo controlled study. PLACE AND DURATION OF STUDY: The Aga Khan University Hospital, Karachi, Pakistan, from August 2004 to January 2006. Methodology: Seventy ASA I and II females, aged 20 and above, who underwent elective abdominal hysterectomy, were included in this study. Patients received identical looking suppository of either 100 mg diclofenac sodium or placebo after induction of anaesthesia and then 12 hourly for 24 hours. General anaesthesia was standardized and tramadol was given by patient controlled intravenous analgesia delivery system in the recovery. RESULTS: The mean dose + SD of tramadol used in first 24 hours was found to be 317 +153 mg in the placebo-tramadol group compared to 258 +192 mg in the diclofenac-tramadol group (p = 0.15, 95% CI = 1.24 to -1.34, 6.63). Seventeen (49 %) patients in the placebo-tramadol group and 14 (40%) in the diclofenac-tramadol group used rescue analgesia (p=0.47). Sedation score was similar in both the groups and there was no difference in the incidence of nausea and vomiting and use of antiemetics between the groups. CONCLUSION: This study did not show any reduction in tramadol consumption, given via patient controlled intravenous analgesia when rectal suppository of 100 mg diclofenac was added

Unplanned prolonged postanaesthesia care unit length of stay and factors affecting it

Objective: To identify the factors that prolong the length of stay in the post anaesthesia care unit (PACU). Methods: This audit was conducted in the PACU of a university hospital. A special form was designed and filled for those patients who stayed unplanned in the PACU for more than two hours. All patients who were admitted to the PACU after surgery were included. Patients undergoing cardiothoracic surgery, those directly shifted to ICU and cases done under local anaesthesia were excluded. Data was collected for 20 months by a designated recovery nurse for all included patients including those admitted outside the scheduled surgery hours. Results: The total number of patients who were admitted to the PACU during the audit period were 13644, out of these 1114 (8.1%) stayed in the PACU for more than 2 hours. The percentage of overstay patients on monthly basis ranged from 6.4% to 10%. The commonest reason was the need for postoperative monitoring 578 (51.8%), unavailability of beds in the special care areas 264 (23.7%), pain management 68 (6.1%) and 61 (5.4 %) for postoperative ventilation. Conclusion: Our results show that majority of patients stayed in the PACU for more than two hours either because they needed postoperative monitoring or because of unavailability of bed in the special care areas

Complications of endotracheal intubation in mechanically ventilated patients in a general intensive care unit

During a period of one year, 126 patients were prospectively audited to analyse complications of endotra­cheal intubation in a general intensive care unit setting. A total of 62 complications were observed in 48 patients. The most frequent complications during intubation were hypotension and bradycardia. The blockage of endotracheal tubes significantly increased with the duration of intubation. Sore throat was the commonest (22%) complication following extubation. Other complications like stridor and ulceration of mouth and lips which followed extubation were not related to the duration of intubatio

Premedication in Surgical Day Care Patients

The purpose of this audit was to find out the efficiencyof our system in providing premedication to surgical daycare patients. This audit was conducted in the Surgical DayCare (SDC) Unit of a University Hospital. All patientsanaesthetised in the SDC unit on day care basis were includedin this audit. Nursing notes and preoperative orders of allpatients to be anaesthetised were checked to see whetherpremedication was given or not and was the timing accordingto the orders written. The result showed that out of 205patients scheduled, twenty (9.7%) patients did not receivepremedication. Only 37.2% of our patients were receivingpremedication according to the orders. The majority of theerrors noted in our audit were system errors related to cancellation,rescheduling and admitting the outpatient in theinpatient ward

EVALUATION OF COMMON ORGANISMS CAUSING VAGINAL DISCHARGE

Background: Vaginal discharge is very common problem among females. Alteration in balance of normal vaginal organisms can cause the overgrowth of the bacteria that creates vaginal discharge. It is common among sexually active women yet there still remain gaps in our knowledge of this infectious disorder. Objective: To evaluate the frequency of bacterial vaginosis (BV), vaginal candidiasis (VC), vaginal trichomoniasis and Group B streptococcus in women complaining of vaginal discharge in our setup. Method: A total of 100 women of reproductive age group with the complaint of vaginal discharge were included in the study. After filling proforma patients were examined by speculum examination and two high vaginal swabs (HVS) were collected aseptically from each patient. One swab was used for making wet mount for clue cells, pus cells and for motility of Trichomonas vaginalis. The other swab was used to check pH and Amine test. The growth was confirmed by Gram staining in each case. Results: Gardnerrella vaginalis were isolated in 28%, Group B streptococcus in 5% and T. vaginolis in 4% of women. Conclusion: Gardnerella vaginalis causing BV is the most common cause of vaginal discharge in otherwise healthy women of reproductive age group in our setup