Aliya Ahmed

Perioperative cardiac arrests in children at a university teaching hospital of a developing country over 15 years

Objective/Aim:u2002 To study the incidence, causes, and outcome of perioperative cardiac arrests in children at a university teaching hospital with an aim of improving quality of care.

Post-operative analgesia for major abdominal surgery and its effectiveness in a tertiary care hospital

Background: Post-operative pain is often inadequately treated. Optimal utilization of the available resources is essential for improving pain management. Aims: The aim of our study was to determine pain management strategies employed after major abdominal surgeries at our institute and their efficacy and safety. Settings and Design: Prospective observational study conducted at a tertiary care hospital. Materials and Methods: Patients undergoing elective major abdominal surgeries were included. Post-operative analgesic strategy, co-analgesics used, pain and sedation scores, motor block, nausea and vomiting were recorded and patient satisfaction was determined. Results: Data was collected on 100 patients. Epidural analgesia was used in 61, patient controlled intravenous analgesia (PCIA) in 25 and opioid infusion in 14 patients. Multimodal analgesia was employed in 98 patients. The level of epidural was between L1-L3 in 31, T10-L1 in 20 and T8-T10 in 10 patients. Pethidine was used in 80% of patients receiving PCIA. Patients with epidurals at T8-T10 had lower pain scores. Fifteen patients had motor block, 73% of which were with epidural at L1-L3. Fourteen patients complained of nausea. Ninety nine out of 100 patients were satisfied with their analgesia. Conclusion: Epidural, PCIA and opioid infusions are used for pain relief after major abdominal surgeries at our hospital. Although there is limited drug availability, regular assessments and appropriate dose adjustments by acute pain management service (APMS) and use of multimodal analgesia led to a high level of patient satisfaction. We recommend that feedback to the primary anesthesiologists by APMS is of utmost importance to enable improvement in practice.

Effect of the menstrual cycle phase on post‐operative pain perception and analgesic requirements

Research has shown that menstrual cycle phase may affect pain sensitivity. There is a lack of studies evaluating this effect on post‐operative pain and analgesic needs.

Assessment of patient satisfaction with acute pain management service: Monitoring quality of care in clinical setting

Background and Aims: Assessment of patient satisfaction is an important tool for monitoring the quality of care in hospitals. The aim of this survey was to develop a reliable tool to assess patient satisfaction with acute pain management service (APMS) and identify variables affecting this so that care can be improved. Methods: A questionnaire was developed and administered tou200a patients after being discharged from APMS care by an unbiased person. Data collected from record included patient demographics, surgical procedure, analgesic modality, co-analgesics and dynamic and static pain scores. Questions included pain expected and pain experienced, APMS response time, quality of pain relief with treatment, professionalism of APMS team, overall experience of pain relief and choosing/suggesting same modality for themselves/family/friends again. Five-point Likert scale was used for most of the options. Statistical analysis was done using SPSS 19. Results: Frequency and percentages were computed for qualitative observation and presented on pie chart and histogram. Seventy-one per cent patients expected severe pain while 43% actually experienced it. About 79.4% would choose same analgesia modality in future for self/family/friends. Ninety-nine per cent found APMS staff courteous and professional. About 89% rated their experience of pain management as excellent to very good. Conclusion: The survey of patients′ satisfaction to monitor the quality of care provided by APMS provided positive inputs on its role. This also helps to identify areas requiring improvement in care and as a tool to gauge the quality of care.

Effect of gender on pain perception and analgesic consumption in laparoscopic cholecystectomy: An observational study

Background: Evidence regarding gender affecting the response to pain and its treatment is inconsistent in literature. The objective of this prospective, observational study was to determine the effect of gender on pain perception and postoperative analgesic consumption in patients undergoing laparoscopic cholecystectomy. Materials and Methods: We recruited 60 male and 60 female patients undergoing elective laparoscopic cholecystectomy. Patients were observed for additional intraoperative and postoperative analgesia. Numerical rating scale was documented at 10 min interval for 1 h in post-anesthesia recovery room and at 4, 8, and 12 h postoperatively. Boluses of tramadol given as rescue analgesia were also noted. There were no dropouts. Results: The mean pain scores were significantly higher in female patients at 20 and 30 min following surgery. Mean dose of tramadol consumption was significantly higher in female patients for the first postoperative hour (P = 0.002), but not in the later period. Conclusion: Female patients exhibited greater intensity of pain and required higher doses of analgesics compared to males in in the immediate postoperative period in order to achieve a similar degree of analgesia.

Effects of bispectral index monitoring on isoflurane consumption and recovery profiles for anesthesia in an elderly asian population

Background: Age related limited physiological reserves and associated co-morbidities in elderly patients require careful titration of inhalational anesthetic agents to minimize their side effects. The use of Bispectral index (BIS) monitoring may be helpful in this regard. The objectives of this study were to evaluate the effect of BIS monitoring on Isoflurane consumption during maintenance and recovery profile at the end of anesthesia. This Quasi experimental study was conducted for a 1 year period at the main operating units of a tertiary care hospital. Materials and Methods: Total 60 patients of age 60 years and above were enrolled in either standard practice (SP) or (BIS) group. In the SP group, the anesthesia depth was maintained as a routine clinical practice, while in BIS group it was maintained by monitoring the BIS score between 45 and 55. Standard anesthesia care was provided to all of the patients. Data including demographics, isoflurane consumption, hemodynamic variables and recovery profiles were recorded in both groups. Results: The mean isoflurane consumption was lower (P = 0.001) in the BIS group. The time to eye opening, extubation and ready to shift was shorter (P = 0.0001) in BIS group. The patients in BIS group had higher Post anesthesia recovery score (P = 0.0001) than the SP group. Conclusion: The use of BIS in an elderly Asian population resulted in 40% reduction of isoflurane usage. The patients having BIS monitoring awoke earlier and had better recovery profiles at the end of anesthesia.

Incident reporting by acute pain service at a tertiary care university hospital

Background and Aims: Provision of effective and safe postoperative pain management is the principal responsibility of acute pain services (APSs). Continuous quality assurance is essential for high-quality patient care. We initiated anonymous reporting of critical incidents by APS to ensure continuous quality improvement and here present prospectively collected data on the reported incidents. Our objective was to analyze the frequency and nature of incidents and to see if any harm was caused to patients. Material and Methods: Data were collected from January 1, 2012 to September 30, 2013. An incident related to pain management was defined as An incident that occurs in a patient receiving pain management supervised by APS, and causes or has the potential to cause harm or affects patient safety. A form was filled including incident type, personnel involved, any harm caused, and steps taken to rectify it. Frequencies and percentages were computed for categorical variables. Results: A total of 2042 patients were seen and 442 (21.64%) incidents reported during the study period, including documentation errors (136/31%), noncompliance with protocols (113/25.56%), wrong combination of drugs (56/12.66%), premature discontinuation (74/16.72%), prolonged delays in change of syringes (27/6.10%), loss to follow-up (19/4.29%), administration of contraindicated drugs (9/2.03%), catheter pull-outs (6/1.35%), and faulty equipment (2/0.45%). Steps were taken to rectify the errors accordingly. No harm was caused to any patient. Conclusion: Reporting of untoward incidents and their regular analysis by APS is recommended to ensure high-quality patient care and to provide guidance in making teaching strategies and guidelines to improve patient safety.

Reliability and validity of a tool to assess airway management skills in anesthesia trainees

Background and Aims: Gaining expertise in procedural skills is essential for achieving clinical competence during anesthesia training. Supervisors have the important responsibility of deciding when the trainee can be allowed to perform various procedures without direct supervision while ensuring patient safety. This requires robust and reliable assessment techniques. Airway management with bag-mask ventilation and tracheal intubation are routinely performed by anesthesia trainees at induction of anesthesia and to save lives during a cardiorespiratory arrest. The purpose of this study was to evaluate the construct validity, and inter-rater and test-retest reliability of a tool designed to assess competence in bag-mask ventilation followed by tracheal intubation in anesthesia trainees. Material and Methods: Informed consent was obtained from all participants. Tracheal intubation and bag-mask ventilation skills in 10 junior and 10 senior anesthesia trainees were assessed by two investigators on two occasions at a 3-4 weeks interval, using a procedure-specific assessment tool. Results: Average kappa value for inter-rater reliability was 0.91 and 0.99 for the first and second assessments, respectively, with an average agreement of 95%. The average agreement for test-retest reliability was 82% with a kappa value of 0.39. Senior trainees obtained higher scores compared to junior trainees in all areas of assessment, with a significant difference for patient positioning, preoxygenation, and laryngoscopy technique, depicting good construct validity. Conclusion: The tool designed to assess bag-mask ventilation and tracheal intubation skills in anesthesia trainees demonstrated excellent inter-rater reliability, fair test-retest reliability, and good construct validity. The authors recommend its use for formative and summative assessment of junior anesthesia trainees.

Comparison of ketorolac and low-dose ketamine in preventing tourniquet-induced increase in arterial pressure.

Background and Aims: Application of tourniquet during orthopaedic procedures causes pain and increase in blood pressure despite adequate anaesthesia and analgesia. In this study, we compared ketorolac with ketamine in patients undergoing elective lower limb surgery with tourniquet in order to discover if ketorolac was equally effective or better than ketamine in preventing tourniquet-induced hypertension. Methods: Approval was granted by the Institutional Ethics Review Committee and informed consent was obtained from all participants. A randomised double-blinded controlled trial with 38 patients each in the ketamine and ketorolac groups undergoing elective knee surgery for anterior cruciate ligament repair or reconstruction was conducted. Induction and maintenance of anaesthesia were standardised in all patients, and the minimum alveolar concentration of isoflurane was maintained at 1.2 throughout the study period. One group received ketamine in a dose of 0.25 mg/kg and the other group received 30 mg ketorolac 10 min before tourniquet inflation. Blood pressure was recorded before induction of anaesthesia (baseline) and at 0, 10, 20, 30, 40, 50, and 60 min after tourniquet inflation. Results: The demographic and anaesthetic characteristics were similar in the two groups. At 0 and 10 min, tourniquet-induced rise in blood pressure was not observed in both groups. From 20 min onward, both systolic and diastolic blood pressures were significantly higher in ketorolac group compared to ketamine group. Conclusion: We conclude that ketamine is superior to ketorolac in preventing tourniquet-induced increases in blood pressure.

Anesthesia and Pain Relief for Procedures Performed to Manage Urolithiasis

Anesthetic considerations for extracorporeal shock wave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL), and concepts of pain management are discussed in this chapter. The pain associated with ESWL has cutaneous, somatic, and visceral origins. General anesthesia, regional anesthesia, and several others miscellaneous techniques (e.g., monitored anesthesia care [MAC]) have been used successfully. The continuous monitoring of hemodynamics and oxygenation is of paramount importance in patients undergoing ESWL regardless of anesthesia technique. Currently the patient undergoing lithotripsy with a xadnew-generation device usually requires MAC with conscious sedation only.