Anesthesiology Commons^™

Cardiac Arrest In A Child Following Cranioplasty, Asma Abdus Salam, Fauzia Anis Khan

Department of Anaesthesia

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.

Airway Management In A Patient With Bullous Pemphigoid, Mohammad Yasir, Fauzia Anis Khan

Department of Anaesthesia

Airway management in patients with pemphigoid lesions has anaesthetic implications. We report a case of a 23 years old female with bullous pemphigoid who presented with laryngeal stenosis and critical airway narrowing. The airway was initially managed with jet ventilation. Anaesthesia was maintained with propofol infusion and ventilation was performed by introducing a size 10 French gauge suction catheter through the stenotic laryngeal orifice. Thirty minutes into anaesthesia, she developed subcutaneous emphysema and decreased air entry on right side of the chest but remained hemodynamically stable. The airway was further managed by tracheostomy. This case report highlights complications that can …

Medical Errors Related To Look-Alike And Sound-Alike Drugs, Samina Ismail,, Arshad Taqi

Department of Anaesthesia

Despite recent developments in the inventory management, introduction of electronic drug trolleys and cabinets, color coding of the filled syringes and many more interventions, medication errors could not be eliminated. The most common of these are syringe swap and human errors regarding wrong drug administration due to look-alike drug containers or sound-alike names of the drugs belonging to diverse groups. Many of the fatalities, that occur in third world countries due to these causes, go unnoticed and unregistered. This special article complements two special editorials on the same topic by Professor Joseph D. Tobias et al and Professor Robert Stoelting, …

Comparison Of Hemodynamic Response To Tracheal Intubation With Macintosh And Mccoy Laryngoscopes, Mehtab A. Haidry, Fauzia A. Khan

Department of Anaesthesia

Background: Use of McCoy blade laryngoscope avoids the lifting force in the vallecula and theoretically should lead to a lower hemodynamic response related to laryngoscopy and tracheal intubation. The available literature on the topic is conflicting.MATERIALS AND Methods: We studied the hemodynamic response to laryngoscopy and tracheal intubation in 60 ASA 1 AND 2 adult patients using either Macintosh or McCoy laryngoscopes. The change in systolic, diastolic, mean arterial pressure, and heart rate (HR) was observed for 10 min post intubation. Arrhythmias and ST changes were also observed.Results: The maximum change in HR was 18.7% in the Macintosh and 7.7% …

Induction Position For Spinal Anaesthesia: Sitting Versus Lateral Position, Khurrum Shahzad, Gauhar Afshan

Department of Anaesthesia

Objective: To compare the effect of induction position on block characteristics (sensory and motor nerves) and haemodynamic stability in elderly patients with isobaric bupivacaine. Patient comfort was also looked at.Methods: The randomized single blinded study was conducted at the Aga Khan University Hospital, Karachi, from September 2007 to August 2008. A total of 70 patients aged >60 years of both genders were included. Spinal anaesthesia was performed either in sitting or lateral position according to random allocation. Assessments of sensory, motor block and heart rate, systolic and diastolic blood pressure were recorded for 20 minutes. SPSS 16 was used for …

Pharmacological Agents For Preventing Morbidity Associated With The Haemodynamic Response To Tracheal Intubation, Fauzia A. Khan, Hameed Ullah

Department of Anaesthesia

Background: Several drugs have been used in attenuating or obliterating the response associated with laryngoscopy and tracheal intubation. These changes are of little concern in relatively healthy patients but can lead to morbidity and mortality in the high risk patient population.Objectives: The primary objective of this review was to determine the effectiveness of pharmacological agents in preventing the morbidity and mortality resulting from the haemodynamic changes in response to laryngoscopy and tracheal intubation in adult patients aged 18 years and above who were undergoing elective surgery in the operating room setting.SEARCH Methods: We searched the Cochrane Central Register of Controlled …

Fiberoptic Intubation In A Paediatric Patient With Severe Temporomandibular Joint (Tmj) Ankylosis, Ali Asghar, Faisal Shamim, Asiyah Aman

Department of Anaesthesia

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.

Anaesthetic Management Of A Young Patient With Homocystinuria, Ali Asghar, Faiza Mazhar Ali

Department of Anaesthesia

Homocystinuria is a rare autosomal recessive genetic disease. It is caused by a deficiency in cystathionine-b-synthase leading to a defect in methionine metabolism. High levels of plasma homocysteine are associated with vascular injury via mechanisms of oxidative damage, vascular smooth muscle proliferation, promotion of platelet activation and aggregation,and disruption of normal procoagulant-anticoagulant balance favouring thrombosis. This is a case of 8 years old boy, a known case of homocystinuria, who was scheduled for bilateral lensectomy and intraocular lens placement. The major anaesthetic considerations include the development of thromboembolism, need to avoid nitrous oxide in balanced anaesthesia regimen and hypoglycaemia.

Anaesthetic Management Of Neonatal Primary Hyperparathyroidism, Anwar-Ul-Huda, Sanam Dost Mohammad, Tauseef Ahmed

Department of Anaesthesia

Neonatal primary hyperparathyroidism (NPHP) is a rare disease that presents in the first 6 months of life. It is almost invariably fatal unless a prompt diagnosis is made and urgent surgical intervention is instituted. Patients with hyperparathyroidism require special preoperative considerations. They require proper work-up from cardiac, renal and neurological point of view, correction of intravenous volume and electrolytes irregularities. We are presenting a case of an infant who started to have cyanosis and lethargy at 21st day of life. Initial diagnosis of pneumonia was made but later on diagnosed as hyperparathyroidism. He was planned for parathyroidectomy under general anaesthesia. …

Comparison Of Upper Lip Bite Test With Mallampati Test In The Prediction Of Difficult Intubation At A Tertiary Care Hospital Of Pakistan, Muhammad Asghar Ali, Muhammad Qamar-Ul-Hoda, Khalid Samad

Department of Anaesthesia

Objective: To determine the accuracy of the Upper lip bite test and Mallampati test in predicting difficult endotracheal intubation.Methods: The cross-sectional study was conducted at the Aga Khan University Hospital, a tertiary care facility in Karachi, Pakistan. Between June 1,2007 and May 31, 2008, 324 adult patients undergoing elective surgeries requiring general anaesthesia with endotracheal intubations were enrolled. Pre-operatively upper lip bite test and Mallampati test were performed for the assessment of airway by a specifically trained observer. Laryngoscopic view was rated by using Cormack and Lehane laryngoscopic grading once the patient was fully anaesthetised using standard anaesthesia technique. Completed …

Spinal Anaesthesia For Caesarean Section: Plain Vs Hyperbaric Bupivacaine, Gurmukh Das Punshi, Gauhar Afshan

Department of Anaesthesia

Objective: To compare the clinical characteristics of sensory and motor block as well as haemodynamic stability using plain and hyperbaric bupivacaine in spinal anaesthesia for caesarean section.Methods: Two equal groups were formed from a total of 60 patients who were enrolled in this prospective randomised double-blinded study that was done at tertiary care hospital in Karach, during 2005 to 2006. Equal volume of plain and hyperbaric bupivacaine 10 mg with 25 mcg of fentanyl was used for spinal anaesthesia in the two groups that were formed on the basis of random allocation. Characteristics of sensory and motor block, episodes of …

Effectiveness Of Premedication At The Time Of Separation From Parent And Mask Induction In Paediatric Patients Coming For Congenital Heart Disease Surgery, Mohammad Hamid, Mansoor Ahmed Khan, Aftab Khatri, Irfan Akhtar

Department of Anaesthesia

OBJECTIVE: To compare the effectiveness of oral midazolam and chloral hydrate on anxiety and sedation at various stages of pre-operative period in congenital heart surgery patients.

STUDY DESIGN: Cross-sectional comparative study.

PLACE AND DURATION OF STUDY: Operating rooms of The Aga Khan University Hospital, Karachi, from October 2009 to December 2010.

METHODOLOGY: Sixty-six patients between the ages of 6 months and 6 years received either chloral hydrate (Group C) or midazolam (Group M) pre-operatively. All congenital heart disease patients coming for cardiac surgeries were included while cases of emergency surgery and those patients in whom premedication was not given were …

Rotational Vs. Standard Smooth Laryngeal Mask Airway Insertion In Adults, Dileep Kumar, Mueenullah Khan, Muhammad Ishaq

Department of Anaesthesia

OBJECTIVE: To compare the ease of insertion between rotational laryngeal mask airway (LMA) insertion and Brain's 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 …

Technique Of Anaesthesia For Different Grades Of Caesarean Section: A Cross-Sectional Study, Samina Ismail, Faraz Shafiq, Aliya Malik

Department of Anaesthesia

OBJECTIVE: The percentage use of regional anaesthesia (RA) and failure rate of RA for different grades of caesarean section (CS) has become a marker of quality for obstetric anaesthesia service. The objective of our prospective observational study is to find out the technique of anaesthesia used in different grades of CS, reasons for choosing general anaesthesia (GA) and failure rate of RA in our hospital setting.

METHODS: This prospective cross sectional study was carried in the obstetric unit of Aga Khan University Hospital from 1st January 2010 to 31st May 2011. The anaesthetist performing the procedure filled out the data …

Spontaneous Intracranial Hypotension In A Patient With Marfan's Syndrome Treated With Epidural Blood Patch--A Case Report, Samad Khalid, Punshi Gurmukh Das, Hamid Mohammad, Ullah Hameed

Department of Anaesthesia

Spontaneous intracranial hypotension (SIH) is a well-defined clinical entity that is frequently misdiagnosed. We are reporting a case of 38 years old male who presented with severe headache and an episode of generalized tonic-clonic seizure. He was managed successfully with an epidural blood patch. Understanding of the characteristics, symptomatology, evaluation, treatment options, and prognosis is discussed.

Are We Anesthesiologists, Aware About The Incidence Of Muscle Stiffness Associated With Remifentanil?, Gauhar Afshan

Department of Anaesthesia

No abstract provided.

Anaesthetic Management Of Abdominal Hysterectomy In Patient With Congenital Sinus Node Dysfunction, Dileep Kumar, Faisal Shamim

Department of Anaesthesia

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, …

Magnesium, A Drug Of Diverse Use, Mohammad Irfan Akhtar, Hameed Ullah, Mohammad Hamid

Department of Anaesthesia

Magnesium has evolved as a drug with diverse clinical applications. Mg++ is an important caution and its homeostasis is very important for normal body functioning. The physiological role of Mg is due to its calcium channel blocking properties at smooth muscle, skeletal muscle and conduction system levels. The analgesic properties are due to NMDA receptor blocking action. Mg++ is beneficial in acute Myocardial Infarction, protection during open heart surgery and treatment and prevention of heart rhythm disturbances. Mg has an established role in the management of preeclampsia and eclampsia. Magnesium prevents or controls convulsions by blocking neuromuscular transmission and decreasing …

Anaesthesia As A Career Choice In A Developing Country; Effect Of Clinical Clerkship, Fauzia Khan, Fauzia Nasim Minai, Shahla Siddiqui

Department of Anaesthesia

OBJECTIVE: To explore the fourth year medical student's knowledge regarding anaesthesia as a specialty, their attitude towards anaesthesia as a career choice and the effect of clinical clerkship on these.

METHODS: This survey was conducted in the Department of Anaesthesia of a university medical centre in a developing country. One hundred and fifty year four medical students rotating in anaesthesia were enrolled. They were asked to fill a structured questionnaire before (pre) and after (post) their anaesthesia rotation. The questionnaire sought information on their perception of anaesthesia as a specialty, role of anaesthetists clerkship duration, and reasons for considering or …

Audit On Preoperative Midazolam And Level Of Sedation, Sanam Muhammad, Shahla Siddiqui

Department of Anaesthesia

We wished to observe by carrying out a prospective clinical audit, the level of sedation and time interval of all adult elective surgery patients. We enrolled adult ASA I-III patients who came for elective surgery to the Aga Khan University Hospital preoperative surgery suite for 3 months. Hundred patients were enrolled. The majority of patients got 7.5 mg of PO Midazolam. Our median Ramsay sedation score was 2 and the Median drug to door time was 52.35 minutes. 11 patients were reportedly 'drowsy' in the recovery room one hour after surgery was completed. These were mostly the same patients who …

Knowledge And Attitudes Of Pakistani Women Towards Anaesthesia Techniques For Caesarean Section, Imtiaz Ahmad, Gauhar Afshan

Department of Anaesthesia

OBJECTIVE: To assess knowledge and attitudes of Pakistani women towards different options of anaesthesia techniques for caesarean section and also to identify their sources of information about them.

METHODS: A total of 410 women scheduled for elective caesarean section were enrolled after informed written consent in this hospital based cross sectional survey. The women were interviewed preferably in Urdu (national) language according to structured pre coded questionnaire by one of the investigators and the sequence of questions was strictly followed. This survey included pertinent questions to assess knowledge and attitudes of our women towards choices of anaesthesia techniques. The questionnaire …

Audit Of Postoperative Nausea And Vomiting In Paediatric Day Case Surgery, Fauzia N. Minai, Faraz Shafiq, Azhar Rehman

Department of Anaesthesia

OBJECTIVE: To assess the incidence of PONV, delay in discharge or unplanned admissions in paediatric surgical cases done at the Surgical Day Care Unit at Aga Khan University between January and July 2009.

METHODS: All paediatric ASA 1-2 cases, from 6 months to 18 years of age undergoing day case surgeries at the Surgical day care unit were included in this retrospective audit. Data was collected on a designed form filled with information from preoperative, intraoperative and postoperative recovery forms. Any relevant data was also noted from nurses notes in recovery room and step down unit. Episodes of vomiting, delay …

Anaesthetic Challenges In Emergency Surgical Repair Of Acute Aortic Dissection Rupturing Into The Pericardium In A Pregnant Patient, Mohammad Irfan Akhtar, Khalid Samad

Department of Anaesthesia

Acute aortic dissection in pregnancy is a serious situation, because rapid and appropriate surgical decision making is required to save the life of both mother and baby. Aortic dissection is rare in young women but is likely during pregnancy (third trimester) secondary to the hyperdynamic and hypervolaemic circulatory state associated with pregnancy. A 35 years old 27 weeks pregnant patient weighing 90 kg presented in the emergency with severe chest pain. In the immediate post cardiopulmonary bypass period, the patient started bleeding profusely from the anastamotic sites irrespective of utilization of all the conventional methods of haemostasis including multiple units …

Apache-Ii Score Correlation With Mortality And Length Of Stay In An Intensive Care Unit, Saad Ahmed Naved,, Shahla Siddiqui, Fazal Hameed Khan

Department of Anaesthesia

Objective: To correlate the APACHE-II score system with mortality and length of stay in ICU. Study Design: Cohort study. Place and Duration of Study: The Intensive Care Unit (ICU) of the Aga Khan University Hospital, Karachi, from May 2005 to May 2006. Methodology: All adult patients who were admitted in the ICU were included. APACHE-II score was calculated at the second and seventh days of admission in the ICU. Patients who were discharged alive from the ICU or died after first APACHE-II Score (at 2nd day) were noted as the primary outcome measurement. Second APACHE-II score (at 7th day) was …

Post-Dural Puncture Posterior Reversible Encephalopathy Syndrome, Fauzia N. Minai, Syeda Fauzia Hasan, Mughis Sheerani

Department of Anaesthesia

We report the case of a young patient with 36 weeks pregnancy, and an acute respiratory infection with severe bronchospasm, who developed an occipital headache and neck pain on the third day of inadvertent dural puncture during placement of combined epidural spinal anaesthesia for caesarian section. It was diagnosed as post-dural puncture headache until generalised tonic clonic siezures occurred the next day raising the suspicion of postpartum eclampsia or meningitis. Posterior reversible encephalopathy syndrome was diagnosed on MRI of the brain which showed features of reversible ischemia in the posterior region of the brain. With anticonvulsant therapy and antibiotics there …

Grown Up Congenital Heart Disease Patient Presenting For Non Cardiac Surgery: Anaesthetic Implications, Mohammad Hamid, Mansoor Ahmed Khan, Mohammad Irfan Akhtar, Hameedullah, Saleemullah, Khalid Samad, Fazal Hameed Khan

Department of Anaesthesia

Congenital heart disease patients surviving to adulthood have increased over the years due to various reasons. These patients are admitted in the hospital for non cardiac surgeries and other procedures more often than normal adult population. Management of grown up congenital heart disease patient presents a challenge during perioperative period for cardiologists, surgeons, intensivists and particularly for the anaesthetist. Management issues include psychological and physiological impact on the patient, complexity of defects, presence of previous palliative procedure, impact of anaesthetic agents on shunting and myocardium, endocarditis prophylaxis and associated extra cardiac anamolies.

Chemical Dependency: An Occupational Hazard In The Field Of Anaesthesia, Samina Ismail

Department of Anaesthesia

The medical personnel are vulnerable to substance abuse and dependence due to ready access to substance of abuse. Addiction is considered as an occupational hazard for those involved in the practice of anaesthesia for the same reason. Substance abuse is defined as a psychosocial biogenetic disease, which results from dynamic interplay between a susceptible host and favourable environment. According to the 5th and the last National Survey on Drug Abuse (NSDA) in 1993 by Pakistan Narcotic Control, there are nearly three million drug dependants in Pakistan, but no data is available to determine the prevalence among medical or anaesthesia personnel. …

Emergency Airway Management Of A Patient With Tracheal Stenosis, Anwar-Ul-Huda, Muhammad Qamar-Ul-Hoda, Mohammad Sohail Awan

Department of Anaesthesia

We are presenting a case of a 26 year old healthy male, who came with gradual worsening of dyspnoea following prolonged intubation and ventilation, after a road traffic accident five months back. On arrival in ER, he was hypoxaemic with severe respiratory distress. He was transferred to the operation room (OR) for emergency tracheostomy. During the transfer, he was placed in an upright position with oxygen at 15 L/M. In the OR, anaesthesia was induced with sevoflurane gradually. Direct laryngoscopy was done which revealed normal vocal cords. A size 4.00 mm ID endotracheal tube was impossible to pass more than …

Single Lung Ventilation In A Young Child For Repair Of Coarctation Of Aorta, Mohammad Hamid, Mansoor Ahmed Khan, Muneer Amanullah

Department of Anaesthesia

Single lung ventilation in small children is extremely challenging. In this case, a paediatric bronchial blocker was successfully inserted in a 19-month-old child to provide single lung ventilation using a modified insertion technique. It provided excellent working conditions during thoracotomy and our method of insertion may help in reducing the cost.

Anaesthetic Management Of Two Patients With Beta-Thalassaemia Intermedia, Shahnawaz Ali, Fauzia Khan

Department of Anaesthesia

There is paucity of literature regarding the anaesthetic management of patients with thalassaemia intermedia. In this case study, the anaesthetic management and concerns in two children with thalassaemia intermedia aged eleven and nine years undergoing herniotomy and splenectomy respectively is reported. Both children had unanticipated difficulty in airway management and high intraoperative blood pressure trends. These cases are representative of the range of problems seen in children with thalassaemia intermedia.