Anaesthesia at remote location: use of modified Bain circuit (Mapleson D) at Kunri Christian Hospital (KCH)

OBJECTIVE: To develop a safe general anaesthesia technique for remote areas with lack of facilities. METHODS: Four types of anaesthesia techniques using TIVA and modified Bain circuit were planned. Monitoring facility was limited to manual sphygmomanometer, palpation of radial pulse and monitoring of colour of skin and blood. Depth of anaesthesia was assessed using EVANs, RPST scoring system. Patients were asked in recovery room for awareness. RESULTS: Surgeries done were cesarean sections, laparotomies, gynaecological, urological, hernia and burn contractures. Six patients had RPST score of 5 or more and three patients in recovery room complained of awareness. Cost per Anaesthesia was Rs225. CONCLUSION: TIVA with modified Bain circuit provided effective anaesthesia in remote area at low cost

Anxiolytic effect of midazolam premedication assessed by clinical and platelet aggregation profiles

BACKGROUND: It is well documented that surgery is associated with increased anxiety, which has an adverse impact on patient\u27s outcome. This study was designed to assess the anxiolytic effect of midazolam in pre-anaesthetic medication by using clinical and platelet aggregation profiles.METHODS: Sixty ASA I and II female patients aged between 35 and 60 years undergoing elective abdominal hysterectomy were randomly divided into two equal groups. Group I received placebo as pre-medication while group II received 0.15 mg/kg midazolam as pre-medication 1 hour preoperatively. They were monitored for visual analogue scale (VAS) for anxiety, observer\u27s anxiety criteria, sedation score, blood pressure, heart rate and platelet aggregation profile immediately before and 1 hour after pre-medication.RESULTS: There was statistically significant difference with respect to VAS of anxiety, observer\u27s anxiety criteria, sedation scores, systolic and diastolic blood pressure (

Frequency, Indications And Complications Of Pulmonary Artery Catheter Insertion In Adult Open-Heart Surgery Patients Of A Tertiary Care Hospital

Background: Patients presenting for cardiac surgery have unstable cardiovascular disease and haemodynamics with multiple coexisting diseases. Optimal monitoring in the perioperative period is very important for best perioperative outcome. The introduction of the flow-directed pulmonary artery catheter (PAC) into clinical practice is one of the most important and popular advances in the field of cardiac anaesthesia. The objective of the study was to determine the frequency, indications and complications of pulmonary artery catheter insertion in adult open-heart surgery patients.Methods: A Prospective observational study was conducted at cardiac operating rooms and Cardiac Intensive care unit (CICU) of Aga Khan University Hospital for a period of six months from Nov 2015 to April 2016.Two hundred and seven patients were included in this study. PAC was inserted through right/left internal jugular vein or subclavian vein. Complications noted were arrhythmias (atrial and ventricular), right bundle branch block, coiling and knotting, pulmonary artery rupture, and infection up to 72 hours of PAC insertion. Frequency and percentage were computed for gender, comorbids (Hypertension, Diabetes, Chronic kidney disease, Chronic Obstructive Pulmonary Disease) and PAC frequency of insertion, indications and complications were noted.Results: The frequency of PAC insertion was 47.83%. Major indications for PAC insertion were poor left ventricular function, acute coronary syndrome, cardiogenic shock, significant left main disease and valvular heart disease patients. Minor complications were found in 23.22% cases, which included arrhythmia in 19.2% cases and coiling in 4.02%.CONCLUSIONS: TPulmonary artery catheter insertion is a safe technique with useful clinical application in the management of high-risk cardiac surgical patients. The PAC insertion rationale must be standardized to confirm the judicious use

Knowledge, attitude and practice of parturients regarding Epidural Analgesia for labour in a university hospital in Karachi

Objective: To assess the knowledge, sources of knowledge, attitude (fears and misconceptions) regarding Epidural Analgesia (EA) and practices of parturients delivery at Aga Khan University hospital (AKUH).Methods: A hospital based cross sectional study was conducted at the obstetric unit of AKUH, from November to December 2003. A questionnaire was filled through verbal interviews conducted on 448 parturients fulfilling the inclusion criteria.Results: Seventy six percent of the females were aware of epidural analgesia as a labor pain relieving method. However, only 19% availed EA. About 40% had heard about EA from their obstetricians and 64% from friends or relatives. Twenty even percent believed that EA has detrimental effects on the baby while 9% stated that EA can prolong the duration of labour.CONCLUSION: Majority of the pregnant females delivering at Aga Khan University Hospital were aware of epidural analgesia for labour. However, only a small proportion are availing this service, due to fears and misconceptions

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

A nationwide evaluation of bevacizumab-based treatments in pediatric low-grade glioma in the UK: safety, efficacy, visual morbidity, and outcomes

BACKGROUND: Bevacizumab is increasingly used in children with pediatric low-grade glioma (PLGG) despite limited evidence. A nationwide UK service evaluation was conducted to provide larger cohort "real life" safety and efficacy data including functional visual outcomes. METHODS: Children receiving bevacizumab-based treatments (BBT) for PLGG (2009-2020) from 11 centers were included. Standardized neuro-radiological (RANO-LGG) and visual (logMAR visual acuity) criteria were used to assess clinical-radiological correlation, survival outcomes and multivariate prognostic analysis. RESULTS: Eighty-eight children with PLGG received BBT either as 3rd line with irinotecan (85%) or alongside 1st/2nd line chemotherapies (15%). Toxicity was limited and minimal. Partial response (PR, 40%), stable disease (SD, 49%), and progressive disease (PD, 11%) were seen during BBT. However, 65% progressed at 8 months (median) from BBT cessation, leading to a radiology-based 3 yr-progression-free survival (PFS) of 29%. Diencephalic syndrome (P = .03) was associated with adverse PFS. Pre-existing visual morbidity included unilateral (25%) or bilateral (11%) blindness. Improvement (29%) or stabilization (49%) of visual acuity was achieved, more often in patients' best eyes. Vision deteriorated during BBT in 14 (22%), with 3-year visual-PFS of 53%; more often in patients' worst eyes. A superior visual outcome (P = .023) was seen in neurofibromatosis type 1-associated optic pathway glioma (OPG). Concordance between visual and radiological responses was 36%; optimized to 48% using only best eye responses. CONCLUSIONS: BBTs provide effective short-term PLGG control and delay further progression, with a better sustained visual (best > worst eye) than radiological response. Further research could optimize the role of BBT toward a potentially sight-saving strategy in OPG

Management of patients in a dedicated burns intensive care unit (BICU) in a developing country

Background: In Pakistan the practice of managing extensive burns in dedicated intensive care units is not well established. This audit aims to define the characteristics of the victims of major burns and factors that increase mortality and outcome of the protocol-based management in a dedicated burns intensive care unit (BICU).PATIENTS AND Methods: This prospective audit included all patients admitted to the BICU of Suleiman Dawood Burns Unit in Karachi from 1st September 2002 to 31st August 2011. Demographic information, type and place of burn, total body surface area burn (TBSA), type of organ support provided, length of ICU stay, any associated medical diseases, and out outcome were documented.Results: A total of 1597 patients were admitted to the BICU in 9 years. Median age of the patients was 22 (IQR =32-7). 32% victims were children \u3c14 years and only 7% were \u3e50 years old. Male to female ratio was 1.4:1. Fire was the leading cause of burns in adults (64%) and scald burns were most common in (64%) in children. 72.4% of the accidents happened at home, where kitchen was the commonest location (597 cases). Mean TBSA burnt was 32.5% (SD ± 22.95%, 95%CI: 31.36-33.61). 27% patients needed ventilatory support, 4% were dialyzed and split skin graftings were performed in 20% patients. Average length of ICU stay was 10.42 days. Epilepsy, psychiatric illness and drug addiction were not common associations with burns. Overall mortality was 41.30% but it decreased over the years from 75% to 27%.CONCLUSIONS: Groups of people most vulnerable to sustain burn are young females getting burnt in the kitchen, young males getting burnt at work, and small children falling in pots of hot water stored for drinking or bathing. TBSA \u3e40%, age \u3e50 years, fire burn and female gender were associated with a higher risk of death. Carefully planned, protocol based management of burn patients by burn teams of dedicated healthcare professionals, even with limited resources reduced mortality.RECOMMENDATIONS: Burn hazard awareness, prevention and educational programmes targeted at the vulnerable population, i.e. women and young children at home and men at their work place is the single most cost-effective way of reducing the incidence of burns in developing countries

Evaluation of cardiology consultations sought from the anaesthesia clinic

Objective: To evaluate the criteria for cardiology referrals and to assess the perioperative relevance of the cardiology advice given in patients evaluated for non-cardiac surgery.Design: Single center, observational study.PLACE AND DURATION OF STUDY: Outpatient Anaesthesia Clinic at The Aga Khan University Hospital (AKUH), between January 2001- August 2001 and February 2002- August 2002.MATERIALS AND Methods: A review of case files of 70 patients, scheduled for non-cardiac surgery, who were referred for cardiology consultations from the anaesthesia clinic at AKUH during the study period. The clinical criteria for seeking cardiology advice, the cardiology advice given, its influence on patient management, as well as number of adverse cardiac events in the perioperative period were documented.Results: A history of hypertension, ischemic heart disease, and ECG abnormalities were the major criteria for seeking opinion on cardiac status. Cardiology advice frequently resulted in the ordering of extensive cardiac investigations. Among the patients identified for further tests by the cardiologists, 75% had no evidence of ischemic heart disease or myocardial dysfunction; none of them were monitored invasively intraoperatively or had adverse cardiac events in the perioperative period requiring intensive care or prolonged hospital stay.CONCLUSION: No definite criteria or pattern for referrals was identified. Most of the referrals did not fall within the AHA guidelines. Cardiology advice given had very little influence on the perioperative management

What families want - an assessment of family expectations in the ICU.

Introduction: Families of Patients admitted in the intensive care units (ICUs) experience high levels of emotional stress. Access to information about Patient\u27s medical conditions and quality relationships with healthcare staff are high priority needs for these families and meeting these needs of the family members is a primary responsibility of ICU physicians and nurses. Methodology: Our objectives were to assess the expectations of ICU Patients\u27 families that can be fulfilled by physicians and nurses. The design was a descriptive, exploratory questionnaire based study over 6 months in the multidisciplinary ICU of a tertiary care hospital. Results: Of 205 interviews, the median age of the Patient was 28 years. One hundred and nineteen (58%) were male and Eighty six (42%) Patients were female. 163 (79.5%) of the relatives were Next of kin, and 133 (64.9%) were male members. Of the family members, 20 (9.8%) were spouses. One hundred and forty two (69.3%) belonged to Middle income group. Ninety nine (48.3%) were Graduates of high school or above. Relation to Patient, sex of relative, DNR status of Patient and age of relative were statistically significant to make a difference to the satisfaction score. The majority of the relatives reached a score of 22-25. Conclusion: We conclude that families of critically ill Patients were generally satisfied with communication in the ICU, however, our limitations are the cohort in our urban based tertiary care hospital may not adequately represent the majority of our population which is poor and illiterate and many other factors such as misunderstanding of medical knowledge and a more patriarchal attitude of physicians may affect family needs and satisfaction scores