Faisal Shamim

Intraperitoneal lignocaine (lidocaine) versus bupivacaine after laparoscopic cholecystectomy: results of a randomized controlled trial.

BACKGROUND Intraperitoneal local anesthetics have been shown to improve postoperative pain after laparoscopic cholecystectomy (LC). However, the choice of local anesthetic agent is debatable. We compared the analgesic efficacy of intraperitoneal lignocaine (lidocaine) versus bupivacaine after elective LC. METHODS We conducted a double-blind, randomized, controlled trial. We randomized consecutive patients undergoing LC into two groups. Group L received 10 mL 2% lignocaine (lidocaine), whereas Group B received 10 mL 0.5% bupivacaine, each diluted in 10 mL normal saline. All patients underwent standard perioperative anesthesia and analgesia protocol. We assessed patients at 0, 4, 8, 12, and 24 h postoperatively for pain using the visual analogue scale and verbal rating scale, and the need for additional analgesic medications. RESULTS We analyzed a total of 206 patients: 106 in Group L and 100 in Group B. Demographic details were similar between groups (P > 0.05). Abdominal pain decreased significantly with time in both groups, with a similar mean response profile (P < 0.001). There was no statistically significant difference between groups with regard to abdominal or shoulder pain by both visual analogue scale and verbal rating scale at all five time intervals (P > 0.05). There was also no significant difference in the side effect profile of both drugs (P > 0.05). A lower proportion of patients in Group B required additional narcotic analgesia (87%) compared with Group L (94%). This difference was marginally significant (P = 0.057). CONCLUSIONS Bupivacaine and lignocaine (lidocaine) are both safe and equally effective at decreasing postoperative pain after LC.

Postoperative pain assessment using four behavioral scales in Pakistani children undergoing elective surgery

Background: Several measurement tools have been used for assessment of postoperative pain in pediatric patients. Self-report methods have limitations in younger children and parent, nurse or physician assessment can be used as a surrogate measure. These tools should be tested in different cultures as pain can be influenced by sociocultural factors. The objective was to assess the inter-rater agreement on four different behavioral pain assessment scales in our local population. Materials and Methods: This prospective, descriptive, observational study was conducted in Pakistan. American Society of Anesthesiologists I and II children, 3-7 years of age, undergoing elective surgery were enrolled. Four pain assessment scales were used, Children′s Hospital of Eastern Ontario Pain Scale (CHEOPS), Toddler Preschool Postoperative Pain Scale (TPPPS), objective pain scale (OPS), and Face, Legs, Activity, Cry, Consolability (FLACC). After 15 and 60 min of arrival in the postanesthesia care unit (PACU), each child evaluated his/her postoperative pain by self-reporting and was also independently assessed by the PACU nurse, PACU anesthetist and the parent. The sensitivity and specificity of the responses of the four pain assessment scales were compared to the response of the child. Results: At 15 min, sensitivity and specificity were >60% for doctors and nurses on FLACC, OPS, and CHEOPS scales and for FLACC and CHEOPS scale for the parents. Parents showed poor agreement on OPS and TPPS. At 60 min, sensitivity was poor on the OPS scale by all three observers. Nurses showed a lower specificity on FLACC tool. Parents had poor specificity on CHEOPS and rate of false negatives was high with TPPS. Conclusions: We recommend the use of FLACC scale for assessment by parents, nurses, and doctors in Pakistani children aged between 3 and 7.

Comparison between intravenous paracetamol and fentanyl for intraoperative and postoperative pain relief in dilatation and evacuation: Prospective, randomized interventional trial

Background and Aims: Dilatation and Evacuation procedure involves pain, for which pain control measures need to be undertaken. The purpose of this study was to compare paracetamol with fentanyl for pain relief in dilatation and curettage procedures. Materials and Methods: Sixty female patients were randomly included during the period from March 1, 2012 to February 28, 2013. All patients had received oral midazolam 7.5 mg as a premedication 30 min before procedure in the ward. Group P had received intravenous (IV) paracetamol 15 mg/kg in the waiting area of the operating room 15 min before starting the procedure. Group F had received IV fentanyl 2 ug/kg/min at induction of anesthesia. Pain scores on a numerical rating scale at 5, 15, and 30 min intervals after surgery were recorded. Results: Mild pain was commonly observed in both groups, an insignificant difference between groups. Conclusion: The study demonstrates the usefulness of IV paracetamol which may be as effective as fentanyl in dilation and curettage procedures.

Validation of acute physiologic and chronic health evaluation II scoring system software developed at The Aga Khan University, Pakistan

Objective: To assess the predictive performance of Acute Physiologic and Chronic Health Evaluation II (APACHE II) software available on the hospital intranet and analyze interrater reliability of calculating the APACHE II score by the gold standard manual method or automatically using the software. Materials and Methods: An expert scorer not involved in the data collection had calculated APACHE II score of 213 patients admitted to surgical Intensive Care Unit using the gold standard manual method for a previous study performed in the department. The same data were entered into the computer software available on the hospital intranet (http://intranet/apacheii) to recalculate the APACHE II score automatically along with the predicted mortality. Receiver operating characteristic curve (ROC), Hosmer-Lemeshow goodness-of-fit statistical test and Pearson′s correlation coefficient was computed. Results: The 213 patients had an average APACHE II score of 17.20 ± 8.24, the overall mortality rate was 32.8% and standardized mortality ratio was 1.00. The area under the ROC curve of 0.827 was significantly >0.5 (P < 0.01) and had confidence interval of 0.77-0.88. The goodness-of-fit test showed a good calibration (H = 5.46, P = 0.71). Interrater reliability using Pearson′s product moment correlations demonstrated a strong positive relationship between the computer and the manual expert scorer (r = 0.98, P = 0.0005). Conclusion: APACHE II software available on the hospital′s intranet has satisfactory calibration and discrimination and interrater reliability is good when compared with the gold standard manual method.

Anesthetic Management of Conjoined Twins for Computed Tomography Scan

Anesthetic management of the conjoined twins in the radiology suite presents some unique problems for anesthesia. We report a case of 3-month and 10-day-old xiphopagus twins undergoing computed tomography scan under general anesthesia. The issues in their management in radiology included the unknown effects of anesthetic agents on circulation because of sharing of organs, duplication of staff, equipment in a limited space, placing the children on the scan table, airway control and ventilator management, and changeover of equipment during procedure.

Frequency of Intensive Care Unit admission after elective interventional neuroradiological procedures under general anesthesia in a tertiary care hospital

Background: The aim of this study was to determine the frequency of patients admitted to Intensive Care Unit (ICU) after elective interventional neuroradiology (INR) procedures under general anesthesia. Materials and Methods: We retrospectively evaluated 121 patients underwent INR procedures performed with general anesthesia within a 5-year period. Information including demographics, aneurysm/arteriovenous malformations pathology (ruptured or un-ruptured), preoperative neurological status, co-morbidities, complications during procedure and postoperative admission in ICU were recorded on a predesigned form. Results: Elective INR procedure for both ruptured (n = 29, 24%) and un-ruptured (n = 85, 70.25%) aneurysms was performed. Rate of postoperative admission in ICU was significantly high in patients with preoperative ruptured aneurysm (P < 0.01). High rate of neurological deficit, sub-arachnoid hemorrhage (SAH) and hypertension in patients were significant factors of postoperative admission in ICU (P < 0.05). Out of 24 patients, 12 were admitted to ICU postoperatively because of procedure-related complications and 11 were sent due to preexisting significant co-morbidities with added complication of SAH. Conclusion: The authors conclude that patients without major co-morbidities, intraoperative complications, or complex aneurysm morphology can be safely observed in a regular ward rather than being admitted to the ICU.

Outcome of patients with acute pancreatitis requiring intensive care admission: A retrospective study from a tertiary care center of Pakistan

Background and Objective: Acute pancreatitis (AP) is an inflammatory disease. Patients presenting with severe disease may require intensive care unit (ICU) admission. Factors predicting mortality and morbidity need to be identified for improving outcome. The objective of this study was to see the outcome of these patient presented to single center over a period of ten years. The secondary objective was to identify the factors responsible for adverse outcome. Methods: The medical records of adult patients from year 2006 to 2016 requiring ICU admission for AP were reviewed retrospectively. The data was collected on the predesigned Performa for patient’s demographic, etiology, severity of disease and reason of ICU referral. Besides this physiological and biochemical parameters at time of arrival in ICU were also recorded. Management aspects related to disease course including the ICU related complications were also recorded. The outcome was predicted on the basis of mortality and length of stay (LOS) in ICU and hospital. Results: Total 85 patients were identified of having AP requiring ICU admission. 56% of these cases were referred from emergency. Mean Ranson score (RS) was 2.6 and 2.7, at and after 48 hours of admission. Necrosis was present in 48% of cases. Mean APACHE-II score was 23. Sepsis was the commonest complication in ICU. The median LOS in ICU and hospital was six and 12 days respectively. The overall hospital mortality was 52%, out of which 82% died in ICU. RS at admission and APACHE were correlated well with outcome. Similarly associations of factors like need of vasopressors, ARDS, pneumonia, sepsis and AKI requiring intervention were also related to mortality. Likewise development of necrosis or intra-abdominal hypertension showed increased mortality. Biochemical parameters serum blood urea nitrogen (BUN), PH and serum glutamic-oxaloacetic transaminase were also directly linked to adverse outcome. Conclusion: AP patients requiring ICU admission represent severe form of disease. There is a need to develop protocol based care, which should be started immediately after hospital admission. This should have special focus on fluid resuscitation and nutritional therapy. Role of simple bed site parameters like BUN needs to be evaluated.

History conflict and non-formulary medicine: a threat for anaesthesiologist in low and middle-income countries

The practice of complementary and non-formulary medicine has gained tremendous popularity due to their claimed beneficial effects in cardiac, respiratory and chronic diseases, as also other disorders. The most threatening aspect related to these practices pertains to the non-disclosure of its use by patients at the time of their preoperative assessment in elective or emergency setting. We report a case of profound, long-lasting unexplained hypotension during and after anaesthesia in a patient presented for emergency vocal cord surgery (cordectomy). He was taking complementary medicine for last 2 years. Serum cortisol level was sent postoperatively in intensive care unit that was found extremely low.

Anaesthetic management of a child with massive extracranial arteriovenous malformation

Vascular tumors affect the head and neck commonly but arteriovenous malformations are rare. Vascular malformations are often present at birth and grow with the patient, usually only becoming significant later in childhood. Embolization has been the mainstay of treatment in massive and complex arteriovenous malformations. We present a case of massive extracranial arteriovenous malformation in a 7-year-old boy causing significant workload on right heart and respiratory distress. The management of angioembolization under general anaesthesia and anaesthetic concerns are presented.