Cardiac arrest in a child following cranioplasty

Craniofacial surgery in paediatric patients is associated with several complications, including severe bleeding and venous air embolism. We present a case of an 18 months, 10 kilogramme weight child who had cardiac arrest after completion of surgery, but before extubation. Possibility of both haemorrhage and venous air embolism is discussed

Safety and effectiveness of ultrasound guided peripheral nerve blocks: Audit at tertiary care hospital

Objective: To assess the safety and effectiveness of peripheral nerve blocks using ultrasound.Methods: The retrospective study was conducted at the Aga Khan University Hospital, Karachi, and comprised data of all patients who received peripheral nerve blocks as part of anaesthesia care between January 2015 and January 2017. The data included outcomes of peripheral nerve block effectiveness, complications and limb conditions after the block. Peripheral nerve block effectiveness was assessed by monitoring pain scores at rest and on movement, and the requirement of co-analgesia. Complications, like numbness, motor block, metallic taste, hypotension and respiratory depression, were also assessed. Data was analysed using SPSS 19.Results: There were 299 patients who received ultrasound-guided peripheral nerve blocks. The overall mean age was 44.57±16.64 years. Of the total, 140 (47%) received transversus abdominis plane block, followed by supraclavicular block 49(16.7%). The most common complication in the recovery room was numbness 19 (6.2%). Overall, 70% patients remained pain-free, while 16% had moderate pain on movement 12 hours postoperatively.Conclusions: Ultrasound-guided regional anaesthesia was found to provide effective analgesia during and after surgery. Nerve blocks proved to be safe when used with ultrasound

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Patient refusal for regional anesthesia in elderly orthopedic population: A cross-sectional survey at a tertiary care hospital

Background and Aims: Improvements in pain management techniques in the last decade have had a major impact on the practice of orthopedic surgeries, for example, total hip arthroplasty and total knee arthroplasty. Although there are a number of treatment options for postoperative pain, a gold standard has not been established. In our institution, both general anesthesia and regional anesthesia (RA), are being offered to the elderly orthopedic population but RA is not frequently accepted by elderly population. The objective of this study was to determine the frequency of various reasons for refusal of RA in elderly patients undergoing orthopedic surgeries.MATERIAL AND Methods: A prospective study conducted over a period of 1 year, had 549 patients with ages above 60 years who underwent different types of elective orthopedic procedures 182 patients who refused RA were interviewed according to a structured questionnaire designed to assess the reasons of refusal.Results: Most common reason for the refusal of RA was surgeon\u27s choice (38.5%), whereas 20.3% of the patients were unaware about the RA. There was a significant association between female gender and refusing RA due to backache (17.2%) and fear of being awake during the operation (24.1%) respectively.CONCLUSION: This survey showed that the main reasons among elderly female population were the fear of remaining awake and backache. However, overall it was the surgeon\u27s choice which made patients refuse RA, and the anesthesiologists were the main source of information

Effect of tramadol on extubation response and quality of emergence following Supratentorial surgery: a randomised controlled trial

Objectives: To observe the effect of a single dose of tramadol 1mg/kg on haemodynamic changes related to extubation, and to assess the quality of emergence as judged by incidence of cough, laryngospasm and bronchospasm. Method: The double-blind randomised controlled trial was conducted at the Department of Anaesthesiology, Aga Khan University Hospital, Karachi, from 2016 to 2017, and comprised patients of either gender aged 18-65 years scheduled for elective supratentorial craniotomy under general anaesthesia. The patients were randomised to two Tramadol and Saline groups. The drug was given 45 minutes before extubation at the time of dura closure. The patients were extubated after resumption of adequate spontaneous breathing. Invasive blood pressure and heart rate were recorded one minute before reversal, at 1 minute interval for five minutes and then every 10 minute for 30 minutes after extubation. Cough, laryngospasm and bronchospasm were noted. Pain, post-operative nausea, vomiting, convulsions and conscious levels were also noted till 6 hours post-operatively. Data was analysed using SPSS 19. Results: Of the 80 patients enrolled, 79(98.75%) completed the study. Of them, 38(48%) were in the Tramadol group; 27(71.1%) males and 11(28.9%) females with a mean age of 43.42+/-13.2 years. The remaining 41(52%) patients were in the Saline group; 28(68.3%) males and 13(31.7%) females with a mean age of 45.9+/-15.9 years. Intergroup comparison showed no significant difference in the extubation response (p>0.05), but the changes in blood pressure and heart rate were shorter in magnitude and duration in the Tramadol group compared to the baseline. Significant rise in blood pressure and heart rate was observed in the Saline group at 5 minutes after extubation (p=0.046). There was no difference in the quality of emergence as judged by cough or secondary complications (p>0.05). Conclusion: Tramadol 1mg/kg was considered superior in attenuating the duration and magnitude of haemodynamic response in the shape of hypertension and tachycardia during extubation, but did not affect other parameters in patients undergoing craniotomy. Clinical Trial Number: Clinical Trials.gov PRS: NCT02964416 https://clinicaltrials.gov/ct2/show/NCT02964416 Key Words: Craniotomy, Endotracheal extubation, Haemodynamics, Opioid, Cough

Research and Reviews: Journal of Pharmaceutical Quality Assurance Simultaneous Estimation of Antihypertensive and Antidiabetic Drugs by HPLC *For Correspondence

ABSTRACT A simple, fast and economic reversed phase high performance liquid chromatographic (HPLC) method has been successfully developed and validated for simultaneous determination of an antihypertensive and an antidiabetic drug namely, valsartan and glimepiride in pure form (as API). Before the method development with HPLC, a complexation study was carried out with these drugs by DSC which demonstrated no complexation among these drugs. Therefore, a simple HPLC method was developed and validated according to the guidelines of ICH, FDA and USP with respect to accuracy, precision and linearity. For method development a C-18 bonded silica column (250 x 4.6 mm, 5 μ, Phenomenex, Inc.) and the mobile phase comprising 3% aqueous acetic acid in acetonitrile (60:40, v/v) at a flow rate of 0.7 ml/min were used. For accuracy, the recovery was found to be more than 99% for each of valsartan and glimepiride. Intra-day and interday precisions of the new method were less than the maximum allowable limit (RSD% ≤2.0) according to FDA guidelines. The method showed linear response with correlation coefficient of 0.9993 for valsartan and 0.9981 for glimepiride. Therefore, the developed method was found to be simpler, accurate, reproducible, efficient and less time consuming and can be successfully applied for the simultaneous estimation of valsartan and glimepiride

SARS-CoV-2 vaccination modelling for safe surgery to save lives: data from an international prospective cohort study

Background: Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine numbers are limited so this study aimed to inform their prioritization by modelling. Methods: The primary outcome was the number needed to vaccinate (NNV) to prevent one COVID-19-related death in 1 year. NNVs were based on postoperative SARS-CoV-2 rates and mortality in an international cohort study (surgical patients), and community SARS-CoV-2 incidence and case fatality data (general population). NNV estimates were stratified by age (18-49, 50-69, 70 or more years) and type of surgery. Best- and worst-case scenarios were used to describe uncertainty. Results: NNVs were more favourable in surgical patients than the general population. The most favourable NNVs were in patients aged 70 years or more needing cancer surgery (351; best case 196, worst case 816) or non-cancer surgery (733; best case 407, worst case 1664). Both exceeded the NNV in the general population (1840; best case 1196, worst case 3066). NNVs for surgical patients remained favourable at a range of SARS-CoV-2 incidence rates in sensitivity analysis modelling. Globally, prioritizing preoperative vaccination of patients needing elective surgery ahead of the general population could prevent an additional 58 687 (best case 115 007, worst case 20 177) COVID-19-related deaths in 1 year. Conclusion: As global roll out of SARS-CoV-2 vaccination proceeds, patients needing elective surgery should be prioritized ahead of the general population