Anesthesiology Commons^™

Developing Local Guidelines For Management Of Sepsis In Adults: Sepsis Guidelines For Pakistan (Sgp), Madiha Hashmi, Fazal Hameed Khan, Sarwar Zubairi, S. Tipu Sultan, Saeeda Haider, Sadqa Aftab, Javed Husain, Anwar Ul Haq, Zahid Akhtar Rao, Amin Khuwaja, Syed Farjad Sultan, Zunairah Rais, Roohina Baloch, Naseem Salahuddin, Aslam Khan, Faisal Sultan, Kamran Chima, Amjad Ali, Gohar Ali

Department of Anaesthesia

Background: The purpose of developing ‘Sepsis Guidelines for Pakistan’ (SGP) is to provide clinicians practicing in local hospitals with a framework to aid timely recognition and management of adult patients in sepsis by adopting evidence-based recommendations of Surviving Sepsis Campaign (SSC) tailored to available resources. These recommendations are not meant to replace the SSC Guidelines.
Methodology: SGP is an initiative of Pakistan Society of Critical Care Medicine (PSCCM). Four key decision points to be addressed in the guidelines were identified by a thirteen member multidisciplinary committee i.e., grading the hospitals in the country, recognition of sepsis and associated organ dysfunction, …

Job Stress Among Female Residents During Postgraduate Training At A University Hospital In Karachi, Pakistan, Madiha Hashmi, Fauzia A. Khan, Khan S, Ali S. K

Department of Anaesthesia

Background: Postgraduate medical training is a stressful experience for both male and female doctors but previous studies have shown that stress might be more prevalent amongst female residents. Since women make up 70-80% of medical graduates in Pakistan we conducted this study to determine the prevalence of stress among female residents during postgraduate training and identify the most common stressors.

Methodology: All female residents enrolled in postgraduate training programmes at the Aga Khan University meeting the inclusion criteria were recruited and informed written consent was obtained. Job Stress Inventory (JSI) was used to identify symptoms and sources of job stress. …

Perioperative And Acute Care Transesophageal Echocardiography (Toe), Madiha Hashmi

Department of Anaesthesia

In Pakistan perioperative transoesophageal echocardiography (TOE) during cardiac surgery is available in a few centers with reliance on cardiologists and cardiac technicians and its use in noncardiac surgery and intensive care units is very limited. In view of the increasing popularity of TOE based on obvious benefits this review is presented with an aim to evaluate the current indications and potential benefits of using TOE during anesthesia for cardiac and non-cardiac surgery and the intensive care units and compare TOE with pulmonary artery catheter (PAC) and transthoracic echocardiography (TTE) as an hemodynamic monitor in the acute care setting.

Planning A Safe Exit: A Multidisciplinary Approach, Srijaya K. Reddy, Nina Deutsch

E-Learning Modules

This resource is a problem-based learning discussion (PBLD) case addressing the challenges and approach to planning and safely executing an EXIT procedure. It is primarily aimed at pediatric anesthesiologists but also applies to healthcare providers in fetal medicine and surgery.

The clinical scenario involves a fetus with a large cervical neck mass requiring an EXIT procedure for tracheal obstruction. This case highlights the challenges and implications of a procedure involving a multidisciplinary team. After presentation of the case stem, the instructor moderates a student-focused group discussion using a series of questions that build upon the case and a review of …

Malignant Hyperthermia, Chase Contri

Nursing Student Class Projects (Formerly MSN)

Although very rare, occurring one out of every 100,000 anesthesia cases, malignant hyperthermia is a hypermetabolic disorder that anesthesia providers screen and interrogate patients prior to every case they are administering anesthesia. Many research studies about anesthesia induced malignant hyperthermia have explored new methods of testing for the genetic susceptibility for malignant hyperthermia and into hospital based protocols when a patient starts to show the signs and symptoms of the metabolic disorder. This new knowledge and understanding has decreased patient mortality of anesthesia induced malignant hyperthermia from eighty percent to five percent over the past three decades (Rosenberg et al, …

Malignant Hyperthermia, Devin Poncsak

Nursing Student Class Projects (Formerly MSN)

A crisis of malignant hyperthermia is a medical emergency, and must be treated immediately with a coordinated, multidisciplinary team response in order to give the patient the highest chance for a successful recovery (Dirksen, Van Wicklin, Mashman, Neiderer, & Merritt, 2013). Malignant hyperthermia is defined by Bandschapp & Girard (2012), as “a disturbance of the skeletal muscle calcium homeostasis, triggered by volatile anaesthetics and depolarizing muscle relaxants.” Once a vulnerable patient is exposed to one of these triggering agents, a pathologic hypermetabolic response ensues, and the patient has a rapid increase in oxygen consumption and expired carbon dioxide, hyperthermia, acidosis, …

Pseudocholinesterase Deficiency, Ross Gerken

Nursing Student Class Projects (Formerly MSN)

Pseudocholinesterase deficiency is a rare genetic or acquired variation in the metabolism of choline esters such as the neuromuscular blockers succinylcholine, mivacurium, and ester local anesthetics. Pseudocholinesterase deficiency genetically is transmitted in an autosomal recessive pattern with the frequency of apnea from a genetic abnormality of pseudocholinesterase between 1:480 and 1:3200 people (Ok et al., 2013). An extended period of neuromuscular blockade results from these medications than what is clinically expected. The signs and symptoms which occur are apnea and paralysis hours longer. This condition is rare but must be known and understood by the clinician in order to provide …

Cesarean Sections, Buprenorphine, Intrathecal Opioids & Pain Control – What To Do?, Madeel A. Abdullah, Md, Michelle Beam, D.O., H. Jane Huffnagle, D.O., Suzanne Huffnagle, D.O., Michelle Mele, Md, Eugene R. Viscusi, Md

Department of Anesthesiology Faculty Papers

Introduction

Suboxone^® is becoming a popular alternative to methadone maintenance in opioid abstinence. This population will likely expand in the future presenting a challenge for perioperative analgesia. Conventional pharmacology suggests that buprenorphine has a high binding affinity for the mu-opioid receptor (MOR), displacing any other opioid; and, only overcome by extremely high opioid doses. Hence recommendations are usually that buprenorphine should be discontinued before surgery so the MOR is available perioperatively. Buprenorphine is considered to have a “ceiling” analgesic effect rather than a classic opioid dose-response curve; it should not be effective for postoperative analgesia. This case supports an …

Secondhand Smoke Exposure As A Risk Factor For Perioperative Airway Complications In Pediatric Outpatient Procedures, Ashlee Denise Loudin

Theses, Dissertations and Capstones

Abstract: The purpose of this study is to assess the risk of perioperative airway complications, analyze extubation times, and PACU Length Of Stay (LOS), and their association with secondhand smoke exposure in pediatric populations receiving outpatient procedures that require general anesthesia.

Introduction: Tobacco Smoke Exposure (TSE), is well documented to cause physiologic changes in lung tissue that are associated with decreased lung function, increased risk of lower and upper respiratory tract illness, exacerbation of asthma or increased risk of asthma, increased prevalence of non-allergic bronchial hyperresponsiveness, sudden infant death syndrome, and a host of other respiratory complications in adult and …

Attenuating The Systemic Inflammatory Response To Adult Cardiopulmonary Bypass: A Critical Review Of The Evidence Base, R. Clive Landis, J. R. Brown, D. Fitzgerald, D. S. Likosky, L. Shore-Lesserson, R. A. Baker, J. W. Hammon

Journal Articles

A wide range of pharmacological, surgical, and mechanical pump approaches have been studied to attenuate the systemic inflammatory response to cardiopulmonary bypass, yet no systematically based review exists to cover the scope of anti-inflammatory interventions deployed. We therefore conducted an evidence-based review to capture "self-identified" anti-inflammatory interventions among adult cardiopulmonary bypass procedures. To be included, trials had to measure at least one inflammatory mediator and one clinical outcome, specified in the "Outcomes 2010" consensus statement. Ninety-eight papers satisfied inclusion criteria and formed the basis of the review. The review identified 33 different interventions and approaches to attenuate the systemic inflammatory …

The Effect Of A Preanaesthesia Clinic Consultation On Adult Patient Anxiety In Aga Khan University Hospital; A Cohort Study, Anthony Kamau

Master of Medicine in Anaesthesiology

Background: Preoperative anxiety is a common perioperative complication, according to studies done it is seen in approximately 11-80% of adults undergoing surgery. Various pharmacological and non pharmacological techniques have been used to reduce preop anxiety. One of the goals of the preanaesthesia clinic is to allay anxiety. Literature shows that a preanaesthesia clinic evaluation reduces anxiety however b current studies done on anxiety and the preanaesthesia clinic have not quantified this reduction. Objective: To determine the reduction in anxiety in patients evaluated in the clinic versus those evaluated in the ward. Study Design: A cohort and before – after study …

A Randomized Control Trial Comparing Weight Adjusted Dose Versus Fixed Dose Prophylactic Phenylephrine Infusion On Maintaining Systolic Blood Pressure During Caeserean Section Under Spinal Anaesthesia, Lucy Wambui Mwaura

Master of Medicine in Anaesthesiology

Background: Spinal anaesthesia is the standard of care for elective caesarean delivery. Its advantages over general anaesthesia include: decreased blood loss, reduced postoperative pain and faster recovery time. Despite these advantages, the sympathetic blockade induced by spinal anaesthesia results in 80 percent incidence of hypotension without prophylactic management. This hypotension can cause: nausea, vomiting, cardiovascular collapse or even loss of consciousness in the mother, and fetal acidosis. Current evidence supports co-loading with intravenous fluids in conjunction with the use of vasopressors as the most effective way to prevent and treat the hypotension. Phenylephrine is the accepted vasopressor of choice in …

Continuous Subglottic Suctioning Of Intubated Patients In The Icu, Dan Deutsch

Physician Assistant Scholarly Project Posters

Ventilator associated pneumonia (VAP) is a common complication in mechanically ventilated patients. It causes substantial morbidity and mortality, as well as substantial cost to the patients and healthcare systems. One of the major risk factors identified for risk of VAP is the aspiration of secretions from the oropharynx. One intervention aimed at decreasing the incidence of secretion aspiration is an endotracheal tube (ETT) that can be hooked up to suction, providing continuous subglottic suctioning. The purpose of this paper was to explore the use of continuous subglottic suctioning and its effects on the incidence of ventilator-associated pneumonia. Review of literature …

In Children And Elderly Patients, What Are The Effects Of General Anesthesia On Neurological Health Compared With Procedural Sedation?, Taylor G. Caldwell

Theses and Dissertations

Anesthesia has been a necessity in the field of health care since it was discovered in the early to middle 1800s. Before anesthesia, many procedures and surgeries that are now considered an easy fix were life-threatening and patients often chose the inevitable death over the pain of surgery. The idea was stumbled upon when "laughing gas," nitrous oxide, was inhaled and credited in "produc[ing] a state of intoxication during which people became highly amused and insensitive to pain" (Palo Alto, 2013, para. 2). Anesthesia has come an unbelievably long way since the first surgery under anesthesia was performed by Dr. …

Increasing Practitioner Knowledge Of Ketamine As An Adjunct Analgesic For Postoperative Pain, Allison Goldfarb

UNF Graduate Theses and Dissertations

Postoperative pain is of serious concern to patients and anesthesia providers alike. Management of a patients’ pain is a central component of anesthesia care. Ketamine as an anesthetic agent has been available for 50 years. It has been utilized as a general anesthetic and selectively as an anesthetic agent for high-risk patients. Due to dysphoric side effects associated with the dosage required to render general anesthesia, anesthesia providers may be reluctant to utilize this medication to its full potential. Recently there has been a resurgence of interest in ketamine as an analgesic agent. The researcher for this project performed a …

Anesthesia Safety: Filter Needle Use With Glass Ampules, Debran L. Harmon

UNF Graduate Theses and Dissertations

Glass particle contamination of medication occurs when opening ampules which may cause patient harm. The use of filter needles reduces this risk. Many anesthesia providers use ampules daily, but do not use filter needles when aspirating medications from ampules. In addition, filter needles may not be readily available at the anesthesia medication preparation site. Not using filter needles or having them available for use can increase the risk of patient harm by glass particle contamination. The purpose of this project was to increase anesthesia provider’s knowledge thereby improving compliance with evidence-based standards when preparing medications from ampules. The goal is …

Improving Anesthesia Professional Adherence To Hand Hygiene, Martha E. Seneca

UNF Graduate Theses and Dissertations

Performance of hand hygiene is among the most effective means of preventing healthcare associated infections (HAI) among patients. Deaths resulting from HAIs are one of the top ten leading causes of death in the United States. Any improvement in the frequency of hand hygiene among healthcare professionals may have a direct impact on patient mortality and associated costs. While anesthesia professionals have been found to have low rates of hand hygiene adherence, few targeted studies seeking to improve hand hygiene adherence among this group exist. Studies conducted to improve hand hygiene among health care professionals have reported limited improvement, with …

To Compare The Accuracy Of Prayer's Sign And Mallampatti Test In Predicting Difficult Intubation In Diabetic Patients, Mirza Mudassir Ali Baig, Fazal Hameed Khan

Department of Anaesthesia

Objective: To determine the accuracy of Prayer's sign and Mallampatti test in predicting difficult endotracheal intubation in diabetic patients.
Methods: The cross-sectional study was performed at Aga Khan University Hospital, Karachi, over a period from January 2009 to April 2010, and comprised 357 patients who required endotracheal intubation for elective surgical procedures. Prayer's sign and Mallampatti tests were performed for the assessment of airway by trained observers. Ease or difficulty of laryngoscopy after the patient was fully anaesthetised with standard technique were observed and laryngoscopic view of first attempt was rated according to Cormack-Lehan grade of intubation. SPSS 15 was …

Apache Ii Analysis Of A Surgical Intensive Care Unit Population In A Tertiary Care Hospital In Karachi (Pakistan), Madiha Hashmi, Ali Asghar, Saima Rashid, Fazal Hameed Khan, Hameedullah

Department of Anaesthesia

Purpose: Performance of prognostic models deteriorates over time by changes in case-mix and clinical practice. This study was conducted to describe the case-mix of a surgical intensive care unit (SICU) and assess the performance of APACHE II scoring system in this cohort.
Methodology: We analyzed 213adult patients admitted to the surgical intensive care unit (SICU) of Aga Khan University Hospital, from January 2011 to December 2012 and the performance of APACHE II scoring system was assessed in this population.
Results: The mean age of patients was 46.31 years (SD ±18.43), 67.1% patients were male and mean length …

Rare Presentation Of Posterior Reversible Encephalopathy Syndrome (Pres) And Neurogenic Stunned Myocardium In A Patient After Emergency Cesarean Section, Ausaf Ahmed Khan, Khalid Samad, Kashif Munshi, Madiha Hashmi

Department of Anaesthesia

Posterior Reversible Encephalopathy Syndrome (PRES) is clinically characterized by seizures, lethargy, nausea and visual impairment. These findings are thought to be due to vasogenic edema, predominantly in the posterior cerebral hemispheres and are reversible with appropriate management. Neurogenicstunned myocardium is a syndrome of reversible left ventricular dysfunction, associated with excessive sympathetic discharge states like pheochromocytoma, high-grade subarachnoid hemorrhage (SAH), status epilepticus and significant emotional stress. Here, we report a case of PRES and Neurogenic-stunned myocardium occurring simultaneously in a 25 year old primigravida at 34 weeks of gestation with twin pregnancy who presented to the emergency department with eclampsia and …