Anesthesiology Commons^™

Blended Learning In Anesthesia Education: Current State And Future Model, Jaya Kannan, Viji Kurup

Jandrisevits Faculty Publications

Purpose of review: Educators in anesthesia residency programs across the country are facing a number of challenges as they attempt to integrate blended learning techniques in their curriculum. Compared with the rest of higher education, which has made advances to varying degrees in the adoption of online learning anesthesiology education has been sporadic in the active integration of blended learning. The purpose of this review is to discuss the challenges in anesthesiology education and relevance of the Universal Design for Learning framework in addressing them.

Recent findings: There is a wide chasm between student demand for online education and the …

Root Causes Of Intraoperative Hypoglycemia: A Case Series., Eric S. Schwenk, Boris Mraovic, Ryan P. Maxwell, Gina S. Kim, Jesse M. Ehrenfeld, Richard H. Epstein

Department of Anesthesiology Faculty Papers

STUDY OBJECTIVE: To describe the root causes of intraoperative hypoglycemic events.

DESIGN: Retrospective analysis.

SETTING: Large academic teaching hospital.

MEASUREMENTS: Data from 80,379 ASA physical status 1, 2, 3, 4, and 5 surgical patients were reviewed. Blood glucose values, insulin, oral hypoglycemic medication doses, and doses of glucose or other medications for hypoglycemia treatment were recorded.

MAIN RESULTS: Hypoglycemia in many patients had multiple etiologies, with many cases (8 of 17) involving preventable errors. The most common root causes of hypoglycemia were ineffective communication, circulatory shock, failure to monitor, and excessive insulin administration.

CONCLUSION: Intraoperative hypoglycemia was rare, but often …

Influence Of Body Mass Index And Antibiotic Dose On The Risk Of Surgical Site Infections In Pediatric Clean Orthopedic Surgery., Jeffrey J Cies, Shannon Chan, Jobayer Hossain, B Randall Brenn, M Cecilia Di Pentima

Department of Anesthesiology Faculty Papers

OBJECTIVE: To evaluate body mass index (BMI) and antimicrobial dose as risk factors for surgical site infections in pediatric patients.

PATIENTS AND METHODS: Children between 2 and 19 years of age undergoing clean orthopedic procedures and receiving at least one dose of perioperative antibiotics (cefazolin, vancomycin, or clindamycin) were studied. The retrospective case-controlled study was conducted at the Alfred I. duPont Hospital for Children, a 180-bed tertiary-care academic pediatric hospital in Wilmington, DE. Data were collected from January 1, 2002, to December 31, 2005.

RESULTS: Underweight children had a higher risk for SSIs than overweight and normal-weight children. American Society …

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.

Pain Assessment And Management In Different Wards Of A Tertiary Care Hospital, Anwar Ul Huda, Mohammad Hamid, Saboor Ahmed, Syed Muhammad Baqir, Aysha Almas

Department of Emergency Medicine

OBJECTIVE:

To assess the pain management by medical team, emergency room (ER) team and Acute Pain team in a tertiary care hospital.

METHODS:

The cross-sectional study was done in Medical Ward, Surgical Ward and Emergency Room of Aga Khan University, Karachi, in March-April 2010. The assigned research medical officer visited the three locations every day and selected patients by way of convenient sampling. The study comprised 75 patients; 25 each in three groups. Information was collected on patient's demographics, general characteristics, type of drugs and modalities used. Specific queries about pain were sorted out like adequacy of pain assessment done …

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 …

Unintentional, Paediatric Domestic Injury In A Semi Rural Area Of Karachi., Emaduddin Siddiqui, Kiran Ejaz, Uzma Siddiqui

Department of Emergency Medicine

OBJECTIVE:

To identify the characteristics of unintentional domestic injury in children living in a semi-rural area of Karachi.

METHODS:

This retrospective descriptive study was carried out at a private hospital located at the northern outskirts of Karachi, Pakistan, from January 2005 to January 2007. We enrolled 271 out-patient children of either gender with a positive injury history. A questionnaire inquiring socio-demographic characteristics, timing of injury, monthly variation, injury pattern and factors was filled out. Descriptive analysis and Chi-square test were applied to find out the statistically significant differences.

RESULTS:

Among the 271 patients, the male-to-female ratio was 1.2:1. Fall from …

Prospective Case Control Evaluation Of Epidural Midazolam For Improving Pain And Ambulation After Microdiscectomy, Muhammad Shahzad Shamim, S. Ather Enam, Muhammad Zubair Tahir, Mueenullah Khan

Section of Neurosurgery

Objective: To evaluate midazolam as an epidural analgesic in patients undergoing single-level microdiscectomy.
Methods: This prospective case control study was carried out at the Aga Khan University Hospital, Karachi, from January 20 to September 20, 2007, on patients undergoing microdiscectomy. Cases (group A) received midazolam with saline, while controls (group B) received saline only, placed intra-operatively over involved nerve root. Post-operatively, patients were monitored for various variables. Data was analysed using SPSS 13.0 and groups were compared using student's t-test for continuous variables and chi square for categorical variables. P-value <0.05 was considered significant.
Results: Patients in group A ambulated earlier (p = 0.005) …

A Randomised Controlled Trial Comparing Haemodynamic Stability In Elderly Patients Undergoing Spinal Anaesthesia At L5,S1 Versus Spinal Anaesthesia At L3,4 At The Aga Khan University Hospital, Nairobi, Karen Nkatha Mbaya

Master of Medicine in Anaesthesiology

Background: Spinal anaesthesia is a routinely used anaesthetic technique for elderly patients undergoing operations involving the lower limbs, lower abdomen, pelvis and the perineum. Spinal anaesthesia has several advantages over general anaesthesia and these include stable haemodynamic variables, less blood loss, less post operative pain, faster recovery time and less post operative confusion. However, despite these advantages, the sympathetic blockade induced by spinal anaesthesia can result in hypotension, bradycardia, dysrhythmias and cardiac arrests. Conventionally, spinal anaesthesia is performed at the level of L3,4 interspace; with a reported incidence of hypotension in the elderly ranging between 65% and 69%. A possible …

Influence Of The Menstrual Cycle On The Incidence Of Nausea And Vomiting After Laparoscopic Gynecological Surgery: A Pilot Study., Tatjana Simurina, Boris Mraovic, Neven Skitarelić, Tatjana Andabaka, Zdenko Sonicki

Department of Anesthesiology Faculty Papers

STUDY OBJECTIVE: To investigate whether the phase of menstrual cycle influences the incidence of postoperative nausea and vomiting (PONV) in women undergoing general anesthesia for elective laparoscopic gynecological surgery.

DESIGN: Prospective, observational, blinded study.

SETTING: General hospital, Postanesthesia Care Unit, and gynecologic floor room.

PATIENTS: 111 ASA physical status 1 and 2 women, aged 18 to 53 years.

INTERVENTIONS: Patients were classified into three groups according to the phase of menstrual cycle at the time of anesthesia: Group F1: follicular phase (menstrual days 1-8; n = 34); Group O2: ovulatory phase (days 9-15; n = 40); and Group L3: luteal …

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 …

Ketamine As An Adjunct For The Long-Term Sedation And Analgesia Of A Patient With A Left Ventricular Assist Device (Lvad) And An Open Chest, Avni Gupta, Charles S. Kato, Eugene R. Viscusi

Department of Anesthesiology Faculty Papers

Conclusion:

A multimodal sedative and analgesic regimen that incorporates ketamine offers important therapeutic advantages in select patients who require very high doses of opioids and benzodiazepines, but warrants futher study.

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 …

Effects Of Preoperative Aspirin On Cardiocerebral And Renal Complications In Non-Emergent Cardiac Surgery Patients: A Sub-Group And Cohort Study., Longhui Cao, Scott Silvestry, Ning Zhao, James Diehl, Jianzhong Sun

Department of Anesthesiology Faculty Papers

BACKGROUND AND OBJECTIVE: Postoperative cardiocerebral and renal complications are a major threat for patients undergoing cardiac surgery. This study was aimed to examine the effect of preoperative aspirin use on patients undergoing cardiac surgery.

METHODS: An observational cohort study was performed on consecutive patients (n = 1879) receiving cardiac surgery at this institution. The patients excluded from the study were those with preoperative anticoagulants, unknown aspirin use, or underwent emergent cardiac surgery. Outcome events included were 30-day mortality, renal failure, readmission and a composite outcome - major adverse cardiocerebral events (MACE) that include permanent or transient stroke, coma, perioperative myocardial …

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.

Factors That Motivate Certified Registered Nurse Anesthetists To Practice Independently In The Appalachian Region, Michael Lee Frame Jr.

Theses, Dissertations and Capstones

Introduction: Independent Certified Registered Nurse Anesthetists (CRNAs) provide anesthesia services without the supervision or medical direction of anesthesiologists in healthcare facilities throughout the United States. The present literature is limited concerning the factors that motivate CRNAs to choose employment in rural independent practice.

Research Hypothesis: In a sample of CRNAs who practice independently in one of the 13 states of the Appalachian region there will be no differences between the CRNAs from Appalachian and Non-Appalachian counties in their responses to the motivation factors of achievement, recognition, responsibility, advancement, work itself, salary, working conditions, company and administrative policies, supervision, and …

Risk Factors For Ventilator-Associated Pneumonia In The Adult Trauma Patient: A Retrospective Case-Control Study From A Level I Trauma Center, Summer L. Chapman

Theses, Dissertations and Capstones

Introduction: Ventilator-Associated Pneumonia (VAP) continues to be a common complication among the adult trauma population. Little advancements have been made to decrease the incidence, suggesting further research is needed to establish modifiable risk factors. The purpose of this study was to test for an associated link between prehospital intubation and the development of VAP in the adult trauma patient.

Methodology: A retrospective, case-control study design was utilized. The sample included 494 adult trauma patients who required endotracheal intubation and mechanical ventilation for a minimum of 24 hours. All patients presented as a priority one or two trauma to the Charleston …

Our Experience With Two Cardioplegic Solutions: Dextrose Versus Non-Dextrose In Adult Cardiac Surgery, R. Lessen, J. Dicapua, R. Pekmezaris, R. Walia, K. Bocchieri, L. Jahn, M. Akerman, M. L. Lesser, A. Hartman

Journal Articles

Intraoperative hyperglycemia has been observed to be associated with increased morbidity and mortality after cardiac surgery. Dextrose cardioplegia is used for its cardioprotective effects but may lead to intraoperative hyperglycemia and more postoperative complications. This was a retrospective observational study. Patient records (n = 2301) were accessed from a large database at a tertiary care facility. The two groups (dextrose vs. nondextrose) were then matched using preoperative variables of age, sex, body mass index, wound exposure time, preoperative HbA1c levels, renal failure, hypertension, and prior cerebrovascular disease. The following outcomes were recorded: 30-day mortality, sternal wound infection, stroke, and highest …

(1s, 3s)-3-Amino-4-Difluoromethylenyl-1-Cyclopentanoic Acid (Cpp-115), A Potent Gamma-Aminobutyric Acid Aminotransferase Inactivator For The Treatment Of Cocaine Addiction, Y. Pan, M. R. Gerasimov, T. Kvist, P. Wellendorph, K. K. Madsen, E. Pera, H. Lee, A. Schousboe, S. L. Dewey, R. B. Silverman, +6 Additional Authors

Journal Articles

No abstract provided.

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

Department of Anaesthesia

No abstract provided.

Acute Hypotensive Transfusion Reaction: A Case Report, Waleed Shah, Elia S. Elia

Department of Anesthesiology Faculty Papers

Introduction:

Acute hypotensive transfusion reactions are characterized by an abrupt and early onset of hypotension. This is often severe and lacks other signs of symptoms associated with more common causes of hypotension or transfusion reactions. Once the transfusion is stopped, the hypotension rapidly resolves, usually without the need for therapy.

Case Report detailed in poster.

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 …

Postoperative Glycemic Variability In Diabetic And Non Diabetic Patients, Boris Mraovic, Md, Brian Hipszer, Md, Zvi Grunwald, Md, David Gratch, Do, Charles J. Yeo, Md, Jennifer Lessin, Rn, Kathleen O'Malley, Rn, Angela Gulino, Md, Peter Simpson, Meng, Jeffrey Joseph

Department of Anesthesiology Faculty Papers

Objectives: Glycemic variability increases oxidative stress and may trigger the inflammation and coagulation cascades. Variability may be associated with increase morbidity and mortality in ICU patients. We analyzed glycemic variability after major surgery in diabetic (DM) and non-diabetic (NDM) patients using an automated intravenous blood glucose monitor (IVBG).

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 …