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

Cancellation of surgery in patients attending the preoperative anaesthesia assessment clinic: a prospective audit

OBJECTIVE: To find the causes of operating room cancellation in patients attending preoperative anaesthesia clinic and scheduled for surgery at our institution. METHODS: This audit included all those patients who presented to the pre anaesthesia clinic with their surgeries planned in the main operating rooms of our hospital. The duration of this audit was two months. Cancelled cases were identified from the operating room lists and the reasons for cancellations were categorized into above mentioned four factors. RESULTS: Fifty five (55) cancellations were identified; patient related factors (58%) were the most frequent cause followed by anaesthetic (22%), surgical (18.2%) and administrative (1.8%) factors. In patients related factors, most common causes appeared to be no-shows and patient\u27s financial issues. CONCLUSION: Most of the patient related factors were found to be uncontrollable. Anaesthetic related cancellations might be reduced with better communication between anaesthetist themselves and the surgeons. Overbooking of cases and other administrative issuescan be reduced with better organizational strategie

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 surger

Standardization of Anaesthesia Ready Time and reasons of delay in induction of anaesthesia

Objective: Anaesthesia-Ready Time (ART) is the time taken by the anaesthetist to provide sufficient anaesthetic depth for start of surgery. Our aim was to set benchmark timings for ART and compare it with our current practice.Methods: Benchmark ART time of 15 minutes was set for American Society of Anesthesiologists (ASA) class I and II patients, 30 minutes for ASA III and IV patients, 20 minutes for spinal and 30 minutes for epidural anaesthesia. An additional 15 minutes was added for each invasive procedure.Results: Three hundred elective cases were audited. Seventy eight percent of the cases were within benchmark timings. The main causes of delay included undergraduate students performing procedures (24.6%), teaching invasive lines to postgraduates (21.3%) and paediatric patients (16.4%).CONCLUSION: The introduction of benchmark timings and its regular auditing can help standardize operating room booking time and reducing patient cost

Rotational vs. standard smooth laryngeal mask airway insertion in adults

OBJECTIVE: To compare the ease of insertion between rotational laryngeal mask airway (LMA) insertion and Brain\u27s LMA insertion technique in terms of number of LMA insertion attempts, time duration of LMA insertion and complications: trauma, laryngospasm, and hypoxaemia. STUDY DESIGN: Randomized control study. PLACE AND DURATION OF STUDY: The Aga Khan University Hospital, Karachi, from September 2006 to May 2007. METHODOLOGY: One hundred ASA I and II adults undergoing short elective surgical procedures requiring general anaesthesia with spontaneous breathing were enrolled. Following pre-oxygenation, anaesthesia was induced with propofol 2 mg/kg and fentanyl 2 mug/kg. Patients were randomly assigned into one of the study groups: rotational-(R) and standard-(S). LMA insertion was performed when patients became apnoeic and adequate LMA insertion depth achieved. Successful placement was confirmed by chest expansion, reservoir bag movement and appearance of capnographic tracing in both spontaneously breathing patients and in apnoeic patients with assisted ventilation. RESULTS: Significant differences were not seen in patient\u27s demographics, Mallampati score, ASA status and pre-operative vital signs. Statistically insignificant difference was found for the time duration and number of LMA insertion attempts. The incidence of trauma was significantly noted in standard insertion technique (28%) compared to (6%) in rotational insertion technique (p = 0.003). The hypoxaemia and laryngospasm was not reported among the groups. CONCLUSION: The rotational technique was practically easy while negotiating the back of mouth and it requires little efforts with lowest complication rate. This technique can be considered in adults when encountering difficulty and repetitive failures with standard LMA insertion technique

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

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

Prospective case control evaluation of epidural midazolam for improving pain and ambulation after microdiscectomy

Objective: To evaluate midazolam as an epidural analgesic in patients undergoing single-level microdiscectomy.Methods: This prospective case control study was carried out at the Aga Khan University Hospital, Karachi, from January 20 to September 20, 2007, on patients undergoing microdiscectomy. Cases (group A) received midazolam with saline, while controls (group B) received saline only, placed intra-operatively over involved nerve root. Post-operatively, patients were monitored for various variables. Data was analysed using SPSS 13.0 and groups were compared using student\u27s t-test for continuous variables and chi square for categorical variables. P-value \u3c0.05 was considered significant.Results: Patients in group A ambulated earlier (p = 0.005) and although they did not show significantly better post-operative pain control, but post-operative nausea and vomiting (PONV) score was better at six hours (p = 0.020). There was no difference in other variables such as requirement of analgesics, anti-emetics, hospital stay and complications.Conclusion: Midazolam may improve post-operative nausea and vomiting score, and may lead to earlier ambulation, without affecting patient\u27s vitals, consciousness, lower extremity power or sensations, and is not associated with adverse effects

Unanticipated hospital admission after ambulatory surgery

The unplanned admission rate is considered to be an important measure of the quality of ambulatory surgical units. The objective of our study was to evaluate the unanticipated hospital admission rate from the Surgical Day Care (SDC) unit of our university affiliated teaching hospital and to analyze the reasons for admission. A review of all unanticipated admissions over a one-year period was done. The admission rate was calculated and the reasons for admission were analysed. The overall admission rate was 4.93%. Most of the admissions were ordered by the surgeons (97%). The main reasons for admission were patient observation indicated for various reasons (72%) and patient request (18%). Eighty percent of the admitted patients had received general anaesthesia. Admissions were also related to the male gender (69%), age over 65 years (27%) and surgeries ending in the afternoon (69%). On analyzing the reasons for admission, a large number of admissions were found to be due to preventable causes. We conclude that proper selection of patients, careful scheduling of lists and education of patients and clinical professionals can help to avoid many unanticipated admissions after day care surgical procedures

Perioperative cardiac arrests in children at a university teaching hospital of a developing country over 15 years

To study the incidence, causes, and outcome of perioperative cardiac arrests in children at a university teaching hospital with an aim of improving quality of care.Analysis of anesthesia-related complications is routinely performed by most anesthesia departments to make prevention strategies.All perioperative cardiac arrests in children up to 18 years from induction of anesthesia to postanesthesia care unit discharge or ICU admission during noncardiac surgery from January 1992 to December 2006 were analyzed. Outcome variable was noted as survival to discharge. Anesthesia-related cardiac arrests were identified and their causes analyzed.Ten cardiac arrests occurred among 20216 Patients. Overall incidence was 4.95 per 10000 (95% CI: 1.88-8.01). Six (6.53/10000) were females. Seven (19.44/10000) Patients belonged to the classification III-IV of ASA physical status, eight (18.28/10000) were below 1 year, and two (1.26/10000) above 1 year. Three Patients (6.53/10000) were undergoing emergency surgery. Anesthesia was primarily responsible in four cases. The causes of anesthesia-related arrests were medication-related (two), airway-related (one), and under-replacement of fluids (one). Seven Patients died during the arrest and three were discharged home. The event was considered avoidable in seven (70%) cases.Perioperative cardiac arrests were higher in Patients with poor physical status, in those under 1 year of age, and in female Patients. Anesthesia-related cardiac arrests were mainly due to medication- or airway-related causes. The majority of arrests were avoidable indicating the importance of prevention strategies