Anaesthetic management of abdominal hysterectomy in patient with congenital sinus node dysfunction

A 45 years old woman having dysfunctional uterine bleeding was scheduled for total abdominal hysterectomy with bilateral salpingo-oophorectomy under general anaesthesia. On pre-operative anaesthesia assessment, she was found to have junctional rhythm at rate of 44 beats/minute with bigeminies and pre-mature ventricular contractions on ECG. On further evaluation, she was diagnosed as having congenital sinus node dysfunction on the basis of 24 hours Holter monitoring. She was asymptomatic, no prior comorbidity and belonged to functional class one. General anaesthesia was successfully managed by vigilance, invasive monitoring, standby transcutaneous and transvenous pacemakers; use of cardiostable and vagolytic anaesthetic agents like Etomidate, Atracurium and Pethidine during the procedure and for postoperative pain management. Transcutaneous external pacing pads were placed just after induction of anaesthesia, their functional apability was confirmed and was ready for use if needed. The transcutaneous and transvenous pacemakers were on backup and both were not required. Patient was successfully managed and was discharged home on third postoperative day with uneventful hospital course. The elective pacemaker implantation was therefore not required

Anaesthetic management of patient with Ellis Van Creveld syndrome

A known case of Ellis-Van Creveld Syndrome was scheduled for emergency repair of obstructed paraumblical hernia. We describe the anaesthetic management of the case with special reference to the classic physical and physiological manifestations of this syndrome present in our patient

Fiberoptic Intubation in a Paediatric Patient with Severe Temporomandibular Joint (TMJ) Ankylosis

Craniofacial abnormalities are associated with mandibular hypoplasia, reduced mandibular space with overcrowding of soft tissues and maxillary hypoplasia. Decreased mouth opening and limitation in jaw protrusion are independent predictors of difficult airway in such patients. The relative difficult problem becomes even graver in the paediatric age group because of their small mouth opening and un-cooperativeness. A child with severe temporomandibular joint (TMJ) ankylosis presented with negligible mouth opening and required surgical correction under general anaesthesia. Successful intubation was performed with endotracheal tube size 5.5 mm using an adult 4.3 mm fiberoptic bronchoscope under inhalational as well as topical anaesthesia

Bomb Blast and Its Consequences: Successful Intensive Care Management of Massive Pulmonary Embolsim.

A suicide bomb blast in 2013 at a distant city of Pakistan killed 84 and wounded more than 150 people. Some patients were transferred to our tertiary care hospital because of extreme load on medical services there. This patient arrived at the Aga Khan Hospital, 2 days after the bomb blast injury and underwent an orthopedic procedure. Next day, he developed sudden tachypnea, desaturation, and circulatory collapse. After initial cardiopulmonary resuscitation, he was immediately transferred to surgical intensive care unit. Based on history, echocardiography findings and patient parameters, a clinical diagnosis of massive pulmonary embolism was made and immediate thrombolytic therapy with alteplase was started. The immediate improvement in hemodynamic status was evident following 2 hours of alteplase infusion. This case also highlights the aggressiveness of resuscitation, decision making in initiating thrombolytic therapy on clinical grounds, importance of deep venous thrombosis prophylaxis, and exhaustion of health resources due to blast related mass destruction

Laser treatment of laryngeal papillomatosis in a young child: anaesthetic and surgical management

Abstract The authors report the case of a 4-year boy who required anaesthetic and surgical care during LASER excision of laryngeal papillomatosis. He presented with hoarseness and stridor and underwent emergency tracheostomy after confirmation of laryngeal papillomas on CT scan. He required LASER treatment under general anaesthesia with a requirement of paediatric LASER-safe endotracheal tube but unfortunately, this was not available in the country. Balanced anaesthesia technique using inhalational anaesthetic, muscle relaxant and narcotic is used with modifications. After three successful surgical sessions, the airway became patent and tracheostomy was de-cannulated. The perioperative issues surrounding this process are discussed including anaesthetic induction in the patient with a compromised airway, maintenance anaesthetic techniques, methods used for ventilation during LASER surgery of the upper airway, surgical implications and hazards of LASER to the operating room personnel

How Individual Investors Select Stocks: A Case of Karachi Stock Exchange

The research named as “How Individual Investors Select Stocks: A Case of Karachi Stock Exchange” will examine the individual investor’s views regarding making the decision while selecting the stock. This research will comparatively relate the influencing factors that are technical and fundamental analysis, financial statement information, valuation models, yield and profitability ratio analysis, and referral considered by the individual investors while making decision for the stocks that is to be bought or sell from the stock market. The main objective of this research is to find out the influence of the factors that are mostly concerned by the individual investors while stocks selection from the equity market. And to determine the result and analysis of the research the quantitative method has been used as it deals with the numeric facts and numbers and the data is being collected via survey i.e. questionnaire and deductive approach is applied as conclusion of the report is drawn stepwise i.e. starting from theory construction then building up hypothesis then further observation and finally leading to the conclusion. The result of the five independent and one dependent variables are drawn via the Pearson’s Correlation. The results of the Pearson correlation eventually determine that the all the results of the hypothesis on the bottom line is that the approach for the selecting the stocks varies between the individual investors. But, the most and dominating result in terms of percentage of the Pearson’s correlation test suggest that the financial statements information, yield and profitability ratio analysis and technical and fundamental analysis are mostly concerned and had the greater influence; while valuation models and referrals does not have that much influence on the individual investors while selecting the stocks from the Karachi Stock Exchange

Management of difficult airway in a pregnant patient with severely reduced mouth opening

Pregnancy is associated with a wide variety of oral and dental changes ranging from gingivitis to odontogenic infections. If left untreated, severe dental abscess can progress to Ludwig\u27s angina, which is a potentially lethal cellulitis that rapidly extends to the neck region and may lead to life-threatening upper airway obstruction. We report the case of a pregnant woman who presented with intense throbbing pain, trismus and severely reduced mouth opening due to dental abscess for the last one week. She required incision and drainage of abscess with extraction of third molar under general anaesthesia. There are some significant challenges to anaesthesiologist like the risk of aspiration and failed intubation in patients with pregnancy and anticipated difficult airway. With counselling and proper preparation, we were able to manage this case with awake intubation. The potential merits of securing airway in conscious state with necessary steps in preparation are particularly discussed with emphasis of creating awareness among local healthcare practitioners