An analysis of perioperative adverse neurological events associated with anesthetic management at a Tertiary Care Center of a developing country

Background and Aims: Existing literature on neurological complications related to anesthesia is reported from affluent countries but the trends may vary in less affluent countries.MATERIAL AND Methods: The objective was to find the associated factors contributing to neurological adverse events occurring within 48 h of anesthesia and surgery. The existing departmental morbidity and mortality database was reviewed from 1992 to 2012 for major adverse neurological events. A standardized methodology was used in reviewing and classifying the data. All adverse events were predefined and categorized before filling the form into the following headers; meningitis, cord/plexus/peripheral nerve injury, stroke, paraparesis/paraplegia/quadriparesis/or quadriplegia, new onset postoperative seizures, postoperative vocal cord injury, and a miscellaneous group.Results: During this period, 195,031 patients underwent anesthesia and twenty-nine patients had major neurological morbidity within 48 h (1:6700). There were three cases of meningitis/meningism, eight cases of cord, plexus or peripheral nerve injury, seven of stroke, four had new onset seizures, one had quadriparesis, five had vocal cord, and one had cranial nerve palsy. Forty-one percent cases received regional anesthesia alone or in combination with the general. In six cases, anesthesia was considered solely responsible. Human error contributed to 93% of these events.CONCLUSION: This data has helped in identifying areas of concern and can serve as a reference for further audits in the region

Pediatric critical incidents reported over 15 years at a tertiary care teaching hospital of a developing country

Background and Aims: The role of critical incident (CI) reporting is well established in improving patient safety but only a limited number of available reports relate to pediatric incidents. Our aim was to analyze the reported CIs specific to pediatric patients in our database and to reevaluate the value of this program in addressing issues in pediatric anesthesia practice. Material and Methods: Incidents related to pediatric population from neonatal period till the age of 12 years were selected. A review of all CI records collected between January 1998 and December 2012, in the Department of Anaesthesiology of Aga Khan University hospital was done. This was retrospective form review. The Department has a structured CI form in use since 1998 which is intermittently evaluated and modified if needed.Results: A total of 451 pediatric CIs were included. Thirty‑four percent of the incidents were reported in infants. Ninety‑six percent of the reported incidents took place during elective surgery and 4% during emergency surgery. Equipment‑related events (n = 114), respiratory events (n = 112), and drug events (n = 110) were equally distributed (25.6%, 25.3%, and 24.7%). Human factors accounted for 74% of reports followed by, equipment failure (10%) and patient factors (8%). Only 5% of the incidents were system errors. Failure to check (equipment/drugs/doses) was the most common cause for human factors. Poor outcome was seen in 7% of cases.Conclusion: Medication and equipment are the clinical areas that need to be looked at more closely. We also recommend quality improvement projects in both these areas as well as training of residents and staff in managing airway‑related problems in pediatric patients

Anaesthetic management of an infant with epidermolysis bullosa undergoing inguinal hernia repair

Epidermolysis bullosa is a group of inherited disorders characterized by blistering of the skin as a result of minor trauma. We managed an infant with epidermolysis bullosa undergoing inguinal hernia repair. Anaesthesia was induced with oxygen/nitrous oxide mixture and sevoflurane. Oral tracheal intubation was done with a lubricated laryngoscope blade with KY jelly using atracurium 0.5 mg/kg and fentanyl 0.1 microgm/kg. To avoid frictions on the skin, endotracheal tube was tied with ribbon gauze and fixed around the neck. Pulse-oximetry probe and electrocardiogram electrodes were placed, and then attached to the patient\u27s skin covered with KY jelly. Peripheral venous access was secured in the right foot and sutured. These methods were effective to avoid new blisters and useful for infant safety

An orthogonal framework for fault tolerance composition in software systems

Building reliable systems is one of the major challenges faced by software developers as society is becoming more dependent on software systems. The failure of any system can lead to a serious loss, for example serious injury or death in case of safety critical systems and significant financial loss in the case of business-critical systems. As a consequence, fault tolerance is considered as a solution to provide reliability, but the fault tolerance capability is associated with many challenges, such as the right development phase where it needs to be introduced, how it can be composed with the software, and the issues that arise from this composition such as complexity and potential undesirable feature interactions. This thesis presents an orthogonal fault tolerance framework for the composition of design diversity fault tolerance mechanism with the base system. It further ensures the separation of concerns between the ‘base’ system and the fault tolerance mechanisms that are composed with the base system. The composition in this framework is based on operational semantics that describe the behaviour of the underlying components when composed with the fault tolerance mechanisms. A custom-built pre-processor is based on these composition rules, and is used to automatically compose the system component and the fault tolerance mechanisms. The very introduction of different fault tolerance mechanisms to the system may cause interactions with other fault tolerance features or with system components. Logic properties written in CTL and LTL are used in NuSMV to analyse undesirable interactions. To illustrate its applicability, the framework has been applied to the Home Automation and Therac-25 software

The use of solution focused approaches by Special Educational Needs Co-ordinators (SENCos) and school staff in supporting pupils with Behavioural, Emotional and Social Difficulties (BESD): A Collaborative Action Research Approach

Phase one: Children and young people (CYP) who have been identified in school as experiencing behavioural, emotional and social difficulties (BESD) and who present with challenging behaviour are commonly offered interventions as a supportive strategy. Responding to challenging behaviour in school settings may vary between schools and typically may be reflected in the behavioural policy of the school. The question arises as to whether supporting a CYP with BESD and responding to the challenging behaviour they may present, is being done in a consistent manner, or whether the two are distinctly considered as an approach to “managing needs” as they arise. This phase of the CAR approach explored staff views and experiences on supporting and responding to CYP who experience BESD. I sought to explore the current practice of staff members (SENCos, teachers and TAs) so that insights could be gained on how the needs of CYP with BESD are being met in schools. Through a series of semi-structured and focus group interviews with the staff, themes from responses revealed interesting findings regarding staff perceptions relating to the emotional needs of CYP and the impact of a diagnosis and parental anxieties. The teaching assistants’ valuable contribution to supporting CYP experiencing BESD as well as class teachers expressing how challenging behaviour impacts on their self-esteem were also key findings in this study. The salient themes have been discussed in detail with reference to psychological theory, as well as implications for phase two. Phase two: The use of solution focused approaches (SFAs) in educational practice is on the increase, being implemented in a range of contexts. Originally based on solution focused brief therapy (SFBT) (de Shazer, 1985), emphasis is placed upon the solutions and in thinking about the future, steering away from talking about the past and the problem. This paper describes the second phase of the CAR approach. The aim of this phase was to use SFAs with SENCos who participated in phase one of this study. As the Trainee Educational Psychologist (TEP) working within the two learning communities, I facilitated and supported SENCos on implementing SFAs. They did this firstly in relation to their own practice, and secondly with another member of staff (a teacher or a TA) for supporting a CYP identified as experiencing BESD and challenging behaviour. The procedure involved the SENCos attending three sessions which took place between September 2014 and February 2015. Following each session the SENCos were assigned a task, typically involving them to use SFAs on their own practice as well as with other staff members. I visited each SENCo following the sessions to support them in discussing their reflections as well as during the meeting with the other members of staff they intended to support. The final session involved a group evaluation, in which experiences were shared and a plan was formed in preparation of the next cycle of the action research approach. Data collection included semi-structured interviews with each SENCo, a group evaluation as well as an analysis of the SENCos’ individual reflections (accounts kept throughout the study), using thematic analysis (Braun and Clarke, 2006). Higher order themes were then grouped according to context, mechanism and outcome themes, which draws upon elements of realistic evaluations (Pawson and Tilley, 1997). The findings revealed insights into the enabling factors as well as challenges encountered by the SENCos. Implications for future research in this area are also discussed

Hypoglycemic status in low birth weight neonates during first 24 hours of life after birth

Objective: The study aimed to determine the frequency of hypoglycemia in low birth weight neonates during the first 24 hours of life after birth. Materials and Methods: This cross-sectional study was conducted from 1st March 2016 to 31st August 2016 in the NICU and postnatal ward of POF Hospital, Wah Cantt. All the babies with birth weight less than 2.5 kg including preterm and term were included in the study. After the aseptic measure blood, sugar was checked and a value less than 45 mg/dl was labelled as hypoglycemia. Results: Out of 96 neonates,51 (53%) were male and 45 (47%) were female.  The minimum weight of the patient was 1.6kg and the maximum was 2.40 kg. Hypoglycemia was noted in 49 (51%) babies after 2 hours of birth whereas 36 (37.5%) had hypoglycemia at 4 hours and 13 (13.5 %) had at 24 hours. 68 (70.8%) babies included in the study were appropriate for gestational age (AGA) and 28 (29.1%) babies were small for gestational age (SGA). After 2 hours of birth, hypoglycemia was present more in SGA babies i.e.20 (71.4%) as compared to AGA babies i.e. 29 (42.6%) which had statistical significance also (p-value 0.01). Conclusion: Neonatal hypoglycemia is a well-recognized complication in newborns and low birth weight infants are more susceptible to hypoglycemia. Early identification of vulnerable infants and the use of preemptive measures can result in better outcomes

Antivenom production in chicken against Sind krait (Bungarus sindanus) venom and its efficacy assessment using different immunoassays

ABSTRACT: Present study aimed for detection, purification, quantification of Sind Krait (Bungarus sindanus) antivenom from chicken eggs and to determine extracted antivenom efficacy in mice. Hens’ three groups were immunized by sub-lethal doses of Sind Krait venom with adjuvant paraffin oil+lecithin. Booster doses were injected subcutaneously on pectorals muscles at multiple sites after every two weeks upto eight weeks. Antibodies-IgY produced against Sind Krait venom was purified form eggs’ yolk by precipitation method with PEG-6000. Purified antivenom-IgY protein contents were quantified by Nanodrop-photometer, purity accessed by SDS-PAGE, specificity checked by Ochterloneys method and titer estimated by indirect ELISA. Antivenom efficacy was assessed in albino mice. Purified antivnom-IgY exhibited single protein band 180-190 kDa on SDS-PAGE under non-reduced condition and two-bands 63 - 65 kDa and 22 - 25 kDa correspondingly under-reduced condition. Immunodiffusion exhibited sharp precipitation lines of immune-complex (venom and extracted-IgY). In all groups (G1, G2 and G3) antivenom level sharply increase from 3rd to 4th week and maintained thereafter. G2 and G3 presented high titer upto 1:2048 dilutions, while G1 showed upto 1:1024 dilutions, as tested by indirect ELISA. In neutralization assay ED50 dose of G2 and G3 obtained antivenom was 400.23 µg/mice for more than twofold LD50 dose of venom and 100% protection was at 508.84 µg/mice that completely neutralized highly lethal dose of venom. But G1 ED50 was 405.66 µg/mice and provides 100% protection at 554.21 µg/mice. Extracted antivenom, against Sind Krait venom were highly pure, and with high neutralization capacity were produced successfully from eggs yolk first time in Pakistan