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Summary: The authors present a low-cost simulation technique to discuss the airway management, the surgical technique, the problems to be faced by the anesthesia and the operating teams, and how to proceed with the operative surgery to separate the conjoined twins. Key words: Conjoined twins; Simulation Citation: Shamim F, Syed R, Siddiqui K, Khan FA. Low-cost simulation technique in planning and preparing perioperative team for conjoined twins separation surgery. Anaesth. pain intensive care 2022;26(2):833−834. DOI: 10.35975/apic.v26i6.2059

Objectives: To observe the effect of a single dose of tramadol 1mg/kg on haemodynamic changes related to extubation, and to assess the quality of emergence as judged by incidence of cough, laryngospasm and bronchospasm. Method: The double-blind randomised controlled trial was conducted at the Department of Anaesthesiology, Aga Khan University Hospital, Karachi, from 2016 to 2017, and comprised patients of either gender aged 18-65 years scheduled for elective supratentorial craniotomy under general anaesthesia. The patients were randomised to two Tramadol and Saline groups. The drug was given 45 minutes before extubation at the time of dura closure. The patients were extubated after resumption of adequate spontaneous breathing. Invasive blood pressure and heart rate were recorded one minute before reversal, at 1 minute interval for five minutes and then every 10 minute for 30 minutes after extubation. Cough, laryngospasm and bronchospasm were noted. Pain, post-operative nausea, vomiting, convulsions and conscious levels were also noted till 6 hours post-operatively. Data was analysed using SPSS 19. Results: Of the 80 patients enrolled, 79(98.75%) completed the study. Of them, 38(48%) were in the Tramadol group; 27(71.1%) males and 11(28.9%) females with a mean age of 43.42+/-13.2 years. The remaining 41(52%) patients were in the Saline group; 28(68.3%) males and 13(31.7%) females with a mean age of 45.9+/-15.9 years. Intergroup comparison showed no significant difference in the extubation response (p>0.05), but the changes in blood pressure and heart rate were shorter in magnitude and duration in the Tramadol group compared to the baseline. Significant rise in blood pressure and heart rate was observed in the Saline group at 5 minutes after extubation (p=0.046). There was no difference in the quality of emergence as judged by cough or secondary complications (p>0.05). Conclusion: Tramadol 1mg/kg was considered superior in attenuating the duration and magnitude of haemodynamic response in the shape of hypertension and tachycardia during extubation, but did not affect other parameters in patients undergoing craniotomy. Clinical Trial Number: Clinical Trials.gov PRS: NCT02964416 https://clinicaltrials.gov/ct2/show/NCT02964416 Key Words: Craniotomy, Endotracheal extubation, Haemodynamics, Opioid, Cough.

Objective: To evaluate the contribution of member countries of the South Asian Association for Regional Cooperation towards anaesthesia research. Method: The retrospective study was conducted at Department of Anaesthesia, Aga Khan University from January 2018 to June 2018 and comprised literature search to identify published articles related to anaesthesia, critical care and pain research contributed by authors from member countries of the South Asian Association for Regional Cooperation region and published in Pakistani indexed journals between January 2007 and December 2016. Data was analysed using SPSS 19. Results: Of the 183 articles extracted, 179(97.8%) were contributed from Pakistan and 4(2.2%) from India. Overall, there were 50(27%) randomised controlled trials, 38((20%) case reports and 36(19.5%) observational studies. There was 1(0.5%) collaborative study involving researchers from two member countries. Conclusions: The contribution to anaesthesia, critical care and pain research was not ideal from the member countries of the South Asian Association for Regional Cooperation. Key Words: South Asia, Research, Anaesthesiology, Pakistan.

Central venous (CV) lines are widely used for anything from rapid fluid resuscitation, to drug administration, to parenteral nutrition, and even for administering hemodialysis. Central lines come in different sizes, types, and sites of administration. Sometimes their use can be associated with complications as well. Our patient is an 85 years old hypertensive, diabetic female presenting with post COVID fibrosis with aspiration pneumonia with septic shock. After admissions in ICU, CV line was inserted through right sub-clavian venous route for administration of essential medications including inotropes. However, forceful backflow of blood was noticed after insertion of CV line raising the suspicion of arterial insertion. It was later confirmed by CXR, ABG and duplex arterial study. Taking appropriate precautions, we were able to remove the CV line safely without any complications. Sometimes minor and easy things like CV like insertion can become life threatening. But with proper knowledge and planning we can overcome any complications. Cardiovasc j 2021; 14(1): 73-75

Background The analysis of adverse events, including morbidity and mortality (M&M), helps to identify subgroups of children at risk and to modify clinical practice. There are scant data available from low- and middle-income countries. Our aim was to estimate the proportion of pediatric patients with various severe adverse events in the perioperative period extending to 48 hours and to describe the clinical situations and causes of those events. Methods We reviewed the M&M database of the Department of Anesthesiology between 1992 and 2016. A data collection tool was developed, and the outcomes were standardized. Each case was reviewed independently and subsequently discussed between 2 reviewers to identify a major primary causative factor. Results The total number of pediatric cases during this period was 48,828. Seventy-six significant adverse events were identified in 39 patients (8 patients [95% confidence interval {CI}, 5.7-10.9] per 10,000). Thirteen patients had multisystem involvement, and hence the total number of events exceeded the number of patients. Respiratory events were the most common (33.5%). Thirteen patients had perioperative cardiac arrest within 48 hours of surgery (2.6 [95% CI, 1.3-4.3] per 10,000), 7 of these were infants (54%), 5 of whom had congenital heart disease (CHD). Eleven of these 39 patients died within 48 hours (2.0 [95% CI, 1.1-4.0] per 10,000). In 13 cases, anesthesia was assessed to be the predominant cause of morbidity (2.6 per 10,000), whereas in 26 cases, it contributed partially (5.32 per 10,000). There was only 1 death solely related to anesthesia (0.2 per 10,000), and this death occurred before the start of surgery. Conclusions Adverse events were uncommon. Respiratory complications were the most frequent (33%). Infants, especially those with CHD, were identified as at a higher risk for perioperative cardiac arrest, but this association was not tested statistically. Twenty-eight percent of the patients who suffered events died within 48 hours. Increased access to anesthesia drugs and practice improvements resulted in a decline in perioperative cardiac arrests.

Electronic health records have brought about vast improvement in all aspects of healthcare. ‘Anesthesia Information Management System’ is a specialized form of electronic health record system that is used to record all of the events taking place during the perioperative period, such as clinical procedures performed, physiologic changes that may happen and the medications administered. Based on anesthetic data many databases have been developed internationally for quality improvement in anesthesiology and to know the research outcomes. At an individual clinical level, big anesthesia data is not yet present, unless waveforms and continuous numerical data of intraoperative physiologic variables is recorded. Though the initiative for big data has taken up by some healthcare institutions in the health data management but our country is still far behind in this field. This editorial is aimed to highlight the necessity of this system and to draw the attention of the concerned authorities to plan provision of electronic record keeping in operating rooms. Key words: Electronic Health Records; Data; Data Science; Anesthesiology Citation: Abbasi S, Ahmed U, Khan FA. Data science and its application in anesthesiology. Anaesth. pain intensive care 2021;26(1):1–3; DOI: 10.35975/apic.v26i1.1757 Received: January 11, 2022, Accepted: January 14, 2022

There is a paucity of literature on anesthetic drug shortages and their impact on patient safety in lower-middle-income countries. We sought to determine the magnitude of the problem, the effect on patient care and safety, and the adverse patient outcomes witnessed by anesthesiologists in Pakistan METHODS: We conducted a nationwide, multicentre, cross-sectional survey of a representative sample of anesthesiologists in Pakistan (January 2021 to June 2021). The survey questionnaire was adapted from the American Society of Anesthesiologists (ASA) survey on drug shortages and was modified based on the national essential medication list 2018 of Pakistan. It was distributed through Google Forms to anesthesiologists practicing in both the private and government sector. The names of hospitals or the identity of anesthesiologists was not required. The questionnaire consisted of 20 items and focused on the anesthesiologists' experience of drug shortages, the availability of drugs, and the impact of drug shortages on their individual practice.Two hundred and forty-six responses were received. Approximately 50% (122/246) of anesthesia practitioners in Pakistan reported anesthetic drug shortages. Fifty-seven percent of respondents mentioned using an inferior drug that may have significantly affected the delivery of anesthetic care. Four participants mentioned severe morbidity and another four mentioned observing a mortality associated with drug shortage.Anesthetic drug shortages are common in anesthetic practice in Pakistan and they appear to affect patient care and outcomes.RéSUMé: OBJECTIF: Il existe peu de littérature sur les pénuries de médicaments anesthésiques et leur impact sur la sécurité des patients dans les pays à revenu intermédiaire ou faible. Nous avons cherché à déterminer l’ampleur du problème, l’effet sur les soins et la sécurité des patients ainsi que les issues indésirables observées par les anesthésiologistes au Pakistan. MéTHODE: Nous avons mené une enquête transversale multicentrique à l’échelle nationale auprès d’un échantillon représentatif d’anesthésiologistes au Pakistan (janvier 2021 à juin 2021). Le questionnaire de l’enquête a été adapté de l’enquête de l’American Society of Anesthesiologists (ASA) sur les pénuries de médicaments et a été modifié en fonction de la liste nationale des médicaments essentiels 2018 du Pakistan. Il a été distribué via Google Forms aux anesthésiologistes exerçant dans les secteurs privé et gouvernemental. Les noms des hôpitaux et l’identité des anesthésiologistes n’étaient pas demandés. Le questionnaire comprenait 20 éléments et portait sur l’expérience des anesthésiologistes en matière de pénuries de médicaments, la disponibilité des médicaments et l’impact des pénuries de médicaments sur leur pratique individuelle. RéSULTATS: Deux cent quarante-six réponses ont été reçues. Environ 50 % (122/246) des praticiens anesthésistes au Pakistan ont signalé des pénuries de médicaments anesthésiques. Cinquante-sept pour cent des répondants ont mentionné avoir utilisé un médicament de qualité inférieure qui pourrait avoir eu une incidence significative sur la prestation des soins anesthésiques. Quatre participants ont mentionné une morbidité grave et quatre autres ont mentionné avoir observé une mortalité associée à une pénurie de médicaments. CONCLUSION: Les pénuries de médicaments anesthésiques sont courantes dans la pratique anesthésique au Pakistan et semblent affecter les soins aux patients et les devenirs.

BackgroundIdentifying medication errors is one method of improving patient safety. Peri operative anesthetic management of patient includes polypharmacy and various steps prior to drug administration. Our objective was to analyze the medication errors reported in our critical incident reporting system (CIRS) database over the last 15 years (2004-2018) and to review measures taken for improvement based on the reported errors.MethodsAll Critical incidents (CI) reported during January 2004 till December 2018 were retrieved from CIRS database. Medication errors were identified and entered on a data extraction form which included reporting year, patients age, surgical specialty, ASA status, time of incident, phase and type of anesthesia and drug handling, type of error, class of medicine, level of harm, severity of adverse drug event (ADE) and steps taken for improvement.Results 311 medication errors were reported. Fifty two percent errors occurred in ASA II and III patient, and 43% during induction. Sixty % occurred during administration phase and 65 % were due to human error. Thirty seven percent were ADE, 58 of which were significant, 23 serious and five life-threatening errors. Majority errors involved neuromuscular blockers (32%) and opioids (13%).Conclusion Sharing of CI and a lesson to be learnt e-mail, colour coded labels, change in medication trolley lay out, decrease in floor stock and high alert labels were the low-cost steps taken to reduce incidents.Medication errors were more frequent during administration. Twenty eight percent resulted in significant, serious, or life-threatening events.

Anesthesiologists have been at the forefront of COVID-19 pandemic and are particularly at risk of suffering both physical and emotional effects. There have been several individual and organizational strategies that can be put in place to tackle their well-being. Self-strategies that are recommended are adequate rest and sleep, consistent work breaks, help seeking behavior, emotional control and acceptance of limitations of their own competence and healthcare systems. Several online training programs are available for individual guidance. Organizations can also support their staff in different ways. It is important to recognize those who are more vulnerable physically and emotionally. Institution should implement stress reduction strategies, provide adequate PPE, should be able to communicate with their employees in a clear and honest manner and enforce infection control policies. In addition, institutions must take other physical measures where resources permit, like provision of negative pressure rooms and to provide updated and accurate information. Both personal and psychological support is needed. Several different models have been suggested for emotional support. One particularly vulnerable group that requires additional assistance are those in quarantine. Last but not least, in addition to the implementation of all these measures it is imperative to sustain these activities. Key words: Anesthesiology; Anesthesiologists; COVID-19; Stress, Psychological Citation: Khan FA. Anesthesiologists’ occupational wellbeing and support during COVID-19 pandemic. Anaesth. pain intensive care 2021;25(2):122-125. DOI: 10.35975/apic.v25i2.1459 Received: 21 February 2021, Accepted: 25 February 2021

The Lancet Commission report in 2015 highlighted the role of safe surgery and anaesthesia. They also gave a framework of recommendations, indicators and targets to achieve universal access to safe surgery. This article explores the applicability of these indicators in Pakistan namely; access to timely surgery, specialist surgical workforce diversity, surgical volumes, perioperative mortality rate, protection against impoverishing expenditure and protection against catastrophic expenditure.

Anesthetic management in neonates, infants and young children is always a challenge. Both esophageal and precordial stethoscopes are used for continuous monitoring of heart and breath sounds in this age group. Recent (2018) publication of Standards for Safe Practice of Anesthesia by World Health Organization-World Federation of Societies of Anesthesiologists (WHO-WFSA) have also recommended monitoring with a precordial or esophageal stethoscope. Citation: Kumar D, Ali S, Khan FA, Suleman M. An alternative approach for continuous monitoring of heart and breath sounds in pediatric patients. Anaesth pain & intensive care 2019;23(4):__ Received: 30 December 2019; Reviewed & Accepted: 31 December 2019

Drug shortage is now a universal problem; but shortage of anesthetic drugs particularly can have wide implications on patient safety. The available data on the magnitude of the problem in lower and middle income countries (LMIC) is very limited. Several factors, e.g. manufacturing and regulatory issues, supply chain issues, hoarding and smuggling can cause shortage of these drugs. Drug shortage results in substitution, increased side effects and medication errors. It also has cost implications. Different models have been recommended to handle these shortages. Innovative solutions require action at all levels, ranging from individuals, institutions, pharmaceutical companies, professional societies, and the governments.

The International Standards for a Safe Practice of Anesthesia were developed on behalf of the World Federation of Societies of Anaesthesiologists (WFSA), a nonprofit organization representing anesthesiologists in 150 countries, and the World Health Organization (WHO). The recommendations have been approved by WHO and the membership of WFSA. These Standards are applicable to all anesthesia providers throughout the world. They are intended to provide guidance and assistance to anesthesia providers, their professional organizations, hospital and facility administrators, and governments for maintaining and improving the quality and safety of anesthesia care. The Standards cover professional aspects; facilities and equipment; medications and intravenous fluids; monitoring; and the conduct of anesthesia. HIGHLY RECOMMENDED standards, the functional equivalent of mandatory standards, include (amongst other things): the continuous presence of a trained and vigilant anesthesia provider; continuous monitoring of tissue oxygenation and perfusion by clinical observation and a pulse oximeter; intermittent monitoring of blood pressure; confirmation of correct placement of an endotracheal tube (if used) by auscultation and carbon dioxide detection; the use of the WHO Safe Surgery Checklist; and a system for transfer of care at the end of an anesthetic. The International Standards represent minimum standards and the goal should always be to practice to the highest possible standards, preferably exceeding the standards outlined in this document.

The primary aim of this systematic review was to assess the effect on neonatal outcome of pharmacological interventions used for attenuation of the haemodynamic response to tracheal intubation in patients undergoing caesarean Section under general anaesthesia. A systematic search of randomised controlled trials from 1990 to 2015 was conducted. The primary outcome measure was the Apgar score at five minutes and secondary outcomes were umbilical arterial blood gas parameters and neurological adaptive capacity scores. Twenty-seven randomised controlled trials (1,689 patients) were included in the qualitative synthesis. Only five studies using opioids (383 patients) and five studies using non-opioid analgesics (358 patients) were subjected to meta-analysis. The Apgar score at five minutes was significantly lower in neonates of opioid-treated mothers (mean difference: −0.29, 95% confidence interval −0.56 to −0.02, P-value=0.03) compared to mothers in the control group; the umbilical arterial pH was lower and there was a higher requirement for tactile stimulation in neonates. No difference was seen in Apgar scores of neonates of mothers administered non-opioid analgesics compared to placebo. No difference was observed in other parameters between opioid- or non-opioid-treated mothers. This review suggests that opioid interventions for attenuation of the haemodynamic response to tracheal intubation in pregnant patients under general anaesthesia affect neonatal Apgar scores at five minutes in neonates but the difference did not appear to be clinically meaningful. We were unable to demonstrate any difference in safety.

Context: The South Asian region is comprised of eight countries, i.e., Pakistan, India, Bangladesh, Sri Lanka, Afghanistan, Bhutan, Nepal, and Maldives. There is dearth of literature documenting anesthesia research in this region. Aim: The aim of this audit was to look at research productivity in the region by examining the volume and the type of anesthesia publication in five high-index anesthesia journals. Settings and Design: The study design was a survey of literature in the top five high-impact anesthesiology journals carried out at a tertiary care hospital. Materials and Methods: The journal citation report 2016 was accessed to identify the top five anesthesia journals based on their impact factor. We identified articles published in these journals between January 2000 and December 2015. Statistical Analysis: Microsoft Excel 2003 worksheet was used for data collection from extracted articles. Results: The highest number of publications came from India (n = 487) 95.9%; 58.5% of these were correspondence, 21% were original articles, 12.8% were case reports and case series, 1.2% reviews, and 1% editorials. Fourteen articles were published from Pakistan, with 1.2% original articles, 0.8% letter to editor, 0.6% audits, and 0.2% case reports. Nepal and Sri Lanka contributed seven publications. There were no publications in these journals from authors from Bangladesh, Afghanistan, Bhutan, and Maldives in the reviewed journals. The highest number of publications was equally distributed between two journals, i.e., “Anesthesia and Analgesia” (29.5%) and “Anesthesia” (28.9%). Conclusion: We found that scientific contributions from the South Asian region in terms of original anesthesiology research in five high index anesthesiology journals was suboptimal and has not shown an increasing trend over the last 16 years.

Background and Aims: The role of critical incident (CI) reporting is well established in improving patient safety but only a limited number of available reports relate to pediatric incidents. Our aim was to analyze the reported CIs specific to pediatric patients in our database and to reevaluate the value of this program in addressing issues in pediatric anesthesia practice. Material and Methods: Incidents related to pediatric population from neonatal period till the age of 12 years were selected. A review of all CI records collected between January 1998 and December 2012, in the Department of Anaesthesiology of Aga Khan University hospital was done. This was retrospective form review. The Department has a structured CI form in use since 1998 which is intermittently evaluated and modified if needed. Results: A total of 451 pediatric CIs were included. Thirty-four percent of the incidents were reported in infants. Ninety-six percent of the reported incidents took place during elective surgery and 4% during emergency surgery. Equipment-related events (n = 114), respiratory events (n = 112), and drug events (n = 110) were equally distributed (25.6%, 25.3%, and 24.7%). Human factors accounted for 74% of reports followed by, equipment failure (10%) and patient factors (8%). Only 5% of the incidents were system errors. Failure to check (equipment/drugs/doses) was the most common cause for human factors. Poor outcome was seen in 7% of cases. Conclusion: Medication and equipment are the clinical areas that need to be looked at more closely. We also recommend quality improvement projects in both these areas as well as training of residents and staff in managing airway-related problems in pediatric patients.

OBJECTIVE To assess the controllable factors in preventing undue cancellation of elective surgical cases and to suggest measures to address the issue. METHODS The retrospective audit was conducted at the Aga Khan University Hospital, Karachi, and comprised all cancellations of elective surgery from 2011 to 2015. The cases reviewed had been cancelled primarily due to hypertension. A three-member committee regularly reviewed files regarding case cancellations and data was gathered. RESULTS Of the 42,242 surgical cases scheduled during the period, 2903 (6.8%) were cancelled. In 11(0.37%) of these cases, hypertension was the primary reason. Of them, 10(91%) were men and 1(9%) woman. Overall age range was 30-77 years. Among the cancelled cases, 3(27.3%) each belonged to neurosurgery and general surgery, 2(18%) each to orthopaedic and urology, and 1(9%) to ear, nose and throat surgery. CONCLUSIONS Hypertension as the primary reason for cancellation was low. Further reductions in these cancellations can be done by emphasis on following guidelines and their dissemination through continuing medical education.

Introduction: Vallecular cyst is a rare occurring often encountered incidentally, which may compromise the airway during induction of anesthesia. There is a high risk for cyst rupture and soiling of the airway during manipulation of the airway. Case Report: We report a case of a young 23-year-old female with a history of difficulty in breathing and swallowing for the past 1½ years. She underwent emergency tracheostomy and excision of some oral swelling 10years back. She was electively booked for excision of the cyst. Various techniques and instruments have been described in the past. We used a tongue depressor to gently push the cyst aside and successfully rail loaded a reinforced endotracheal tube over a gum elastic bougie. Conclusion: Intubation in a patient with oropharyngeal cyst poses a significant risk in view of complete airway obstruction or aspiration of the contents in case rupture of the cyst. Various techniques for intubation have been reported, either awake or under general anesthesia. We successfully used a tongue depressor to shift the cyst away as an aid for intubation. This technique has so far not been reported in the literature. Keywords: Vallecular cyst, induction, tongue depressor.

Background Several drugs have been tried to obtund the hemodynamic extubation response but all have variable side effects that may affect the quality of short-term recovery. Objective Our primary objective was to evaluate the effect of pharmacological agents, such as dexmedetomidine, local anesthetics, and so on, administered for attenuating the extubation response on the quality of extubation, as judged by the presence or absence of cough, sedation, and laryngospasm/bronchospasm in adult patients who had undergone general anesthesia. A secondary objective was to evaluate the effect of these drugs on other immediate post-extubation complications such as respiratory depression, desaturation, bradycardia, hypotension, and nausea and vomiting (PONV). Methods This is a systematic review of (randomized controlled trials) RCTs with meta-analysis. The Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched for RCTs on the effect of pharmacological agents on both the hemodynamic extubation response as well as the quality of extubation. Results Fourteen out of 24 included studies were subjected to a meta-analysis. The risk of cough was less likely in the intervention group as compared to control groups (OR 0.26, 95% CI 0.15 to 0.46, p

Work stress is an integral part of anesthetic practice and has been a subject of many studies. Persistent stress can lead to burnout. There is limited published literature from lower- and middle-income countries where job stressors may be different from high-income countries. The aim of this study was to find out the level of burnout in a cohort of anesthesiologists working in academic institutions in 2 major cities of Pakistan, a low middle income country. We conducted an anonymous survey based on the Maslach Burnout Inventory scale with 3 major components: emotional exhaustion; depersonalization; and burnout in personal achievement. The demographic and other work-related details were collected in a standardized manner. Our response rate was 74.5%. Seventy-seven percent of the participants were residents and 23% consultants. Gender distribution was 66.9% males and 33.1% females. Thirty-nine percent (95% CI, 34.8%-44.1%) showed moderate- to high-level emotional exhaustion, 68.4% (95% CI, 63.9%-72.7%) showed a moderate to high level of depersonalization, and 50.3% (95% CI, 45.6%-55.07%) showed a moderate to high level of burnout in personal achievements. On multivariable analysis, anesthesia not being the primary career choice was significantly associated with all 3-dimensional scales for the whole cohort. Factors significantly associated with emotional exhaustion were Lahore as city of work, >2 nights on call per week, and >40 h/wk work inside the operating room. Depersonalization burnout was again associated with Lahore as city of work, >40 h/wk work inside the operating room, and personal achievement burnout with >2 on-call nights per week. No association was observed for gender, marital status, or having children. In conclusion, a high rate of burnout was identified in anesthesiologists working in 2 major cities in Pakistan. Some new associated factors such as initial choice of specialty and city of work were highlighted. Based on these findings, preventive and coping strategies need to be introduced at institutional and national levels.

Background and Aims: General anesthesia and airway management of patients for head and neck cancer surgery is a challenge for the anesthesiologist. Appropriate assessment and planning are essential for successful airway management. Our objectives were to review airway management strategies in patients undergoing head and neck cancer surgery in our tertiary care institution and also to observe the effect of airway management techniques on postoperative length of hospital stay (PLOS). Material and Methods: A retrospective medical record review of 400 patients who underwent major head and neck cancer surgery in our institution was conducted. A special form was used, and records were searched for airway and anesthetic management in the operating room and recovery room, and for PLOS. Results: 289 (72.25%) of the patients were male, and 111 (27.75%) female. 49.8% of patients had Mallampati score of 3 and 4. Airway was managed with tracheostomy in 81 (20.25%) patients; nasal intubation was performed in 177 (44.25%) and oral intubation in 142 (35.5%) patients. Postoperative emergency tracheostomy was not done in any of the patients. Conclusion: Median postoperative hospital stay was significantly longer (P = 0.0005) in patients who had a tracheostomy performed compared with those where the airway was managed without it.

Bartter syndrome is a rare disorder characterized by reduced sodium chloride transport in the distal nephrons of the kidney. Its clinical features are renal salt wasting, hypokalemic metabolic alkalosis, elevated renin and aldosterone levels with normal or low blood pressure, polyuria, hypercalciuria and malnutrition. The pathophysiologic and biochemical changes in these patients should be kept in mind when considering anaesthetic management. This case report describes our management in a nineteen months old, 3.6 kg weight male child with Bartter's syndrome who underwent elective repair of hiatal hernia and gastrostomy.

The objective of study was to determine the pre-anaesthetic status of intracranial pressure (ICP), using ultrasonographic measurement of optic nerve sheath diameter (ONSD) inpatient scheduled for elective tumour craniotomy. The secondary objective was to compare the diagnostic accuracy of ONSD guided rise in ICP with clinical and radiographic parameters. This is prospective observational study, conducted at single neurosurgical theatre of The Aga Khan University over a period of one year.After getting ethical approval and informed consent patient fulfilling inclusion criteria and planned for elective tumour craniotomy were enrolled in study. The clinical and radiographic signs predicting the status of ICP were recorded. The ultrasonographic measurement of ONSD was done using liner array probe. Value more than 5 mm was considered as abnormal.Total 26 cases were enrolled. Seventy percent patients showed rise in ICP based on clinical parameters, while 65% diagnosed to have raised ICP on the basis of radiographic findings. The ultrasonographic measurement of ONSD predicted this rise in 61% of cases. The diagnostic accuracy of ONSD in detecting raised ICP in comparison to clinical and radiographic evidence was 87.5% respectively.The ultrasonographic-guided ONSD was used successfully for predicting the status of ICP in pre-induction phase of anaesthesia. It also showed good correlation in diagnosing rise in ICP as compared to clinical and radiographic parameters, which indicates that test can be used reliably in preoperative period for patients planned for tumour craniotomy.

The safety of anesthesia characteristic of high-income countries today is not matched in low-resource settings with poor infrastructure, shortages of anesthesia providers, essential drugs, equipment, and supplies. Health care is delivered through complex systems. Achieving sustainable widespread improvement globally will require an understanding of how to influence such systems. Health outcomes depend not only on a country's income, but also on how resources are allocated, and both vary substantially, between and within countries. Safety is particularly important in anesthesia because anesthesia is intrinsically hazardous and not intrinsically therapeutic. Nevertheless, other elements of the quality of health care, notably access, must also be considered. More generally, there are certain prerequisites within society for health, captured in the Jakarta declaration. It is necessary to have adequate infrastructure (notably for transport and primary health care) and hospitals capable of safely carrying out the "Bellwether Procedures" (cesarean delivery, laparotomy, and the treatment of compound fractures). Surgery, supported by safe anesthesia, is critical to the health of populations, but avoidable harm from health care (including very high mortality rates from anesthesia in many parts of the world) is a major global problem. Thus, surgical and anesthesia services must not only be provided, they must be safe. The global anesthesia workforce crisis is a major barrier to achieving this. Many anesthetics today are administered by nonphysicians with limited training and little access to supervision or support, often working in very challenging circumstances. Many organizations, notably the World Health Organization and the World Federation of Societies of Anaesthesiologists, are working to improve access to and safety of anesthesia and surgery around the world. Challenges include collaboration with local stakeholders, coordination of effort between agencies, and the need to influence national health policy makers to achieve sustainable improvement. It is conceivable that safe anesthesia and perioperative care could be provided for essential surgical services today by clinicians with moderate levels of training using relatively simple (but appropriately designed and maintained) equipment and a limited number of inexpensive generic medications. However, there is a minimum standard for these resources, below which reasonable safety cannot be assured. This minimum (at least) should be available to all. Not only more resources, but also more equitable distribution of existing resources is required. Thus, the starting point for global access to safe anesthesia is acceptance that access to health care in general should be a basic human right everywhere.

Nesidioblastosis is the most common cause of non-transient, recurrent and persistent hypoglycaemia in neonates and infants. It is a disorder of diffuse proliferation of beta cells of the pancreas leading to hyperinsulinemia and hypoglycaemia. The main aim is to prevent the severe episodes of hypoglycaemia which can cause damage to the brain and/or mental retardation. In this case report we present two cases of nesidioblastosis and their perioperative anaesthetic course for near-total pancreatectomy. First case was a 7 months old female who had repeated episodes of convulsions since birth. Second case was a 4-month-old female child who again presented with seizures. The challenges faced in the perioperative period were the management of perioperative blood glucose levels and haemodynamic stability.

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.

Objective Several non-pharmacological techniques, such as parental presence and behavioral preparation, are used to decrease children's anxiety at anaesthesia induction. We compared the mean anxiety score in children at the time of anaesthesia induction with two different physical techniques of parental interaction and a control group with no parent present. The secondary objective was to determine the face mask acceptance during induction. Methods This study recruited 123 ASA I & II children, aged 1 to 8 years, undergoing day care surgery, who were randomly allocated to three groups. Children either went to the operating room (OR) alone (Gp C), or one parent sat next to the child at induction (Gp PS), or the child sat in parent's lap (Gp PH). The anxiety score on the modified Yale Preoperative Anxiety Scale (mYPAS) was recorded in the preinduction area of OR and at the induction of anaesthesia before the face mask application. A cut-off value of less than 30 indicated low anxiety. The face mask acceptance was also rated. Results All patients had the mYPAS scores higher than 30 in the preinduction area with no significant difference between groups. Prior to induction, the Gp C score was significantly high as compared to Gp PS (p=0.016) and Gp PH (p=0.001), but it was not different between the Gp PS and PH (p=1.00). The face mask acceptance was easy in 4.9 % patients in Gp C, 26.8% in Gp PS, and 56% in Gp PH. Conclusion Parental presence during induction did not prevent children's anxiety, but it reduced it, irrespective of the physical technique used. The face mask acceptance was better in Gp PH.

Anesthesia for pituitary surgery is challenging because of the diverse endocrinological abnormalities associated with the disease process. Close collaboration is required between anesthesiologists, neurosurgeons, and endocrinologists during the perioperative period. There is a strong association of pituitary tumors with disorders like acromegaly/gigantism and Cushing’s disease. Preoperative optimization and identification of systemic involvement in terms of hypertension, diabetes, and obstructive sleep apnea is required. Airway abnormalities are common. Intraoperative anesthetic management should be based upon tumor size and associated physiological disturbances. Trans-nasal excision of tumor has benefits in terms of mortality and recovery profiles. Newer anesthetic agents like dexmeditomidine and remifentanil are excellent for maintaining hemodynamic stability during the intraoperative period. Postoperative period requires strict monitoring and a high suspicion for complications such as cerebrospinal fluid leak and diabetes insipidus.

Clinical criteria for prediction of difficult airway in adults may not be applicable in children and available literature on the topic is limited. The objective of this prospective observational study was to assess the usefulness of Mallampati classification, thyromental distance (Tm) and distance from tragus to nares (Tn) in two groups of pediatric patients, those who are less than five and above five years of age, and to correlate these assessments with different grades of Cormack and Lehane (C&L) classification. One hundred and ninety six pediatric patients from one month to eight years of age, ASA grade I and II and planned for elective surgery under general anesthesia with tracheal intubation were recruited. Age, gender, weight (kg), BMI, distance between tragus and nares (cm), Mallampati grades and thyromental distance (cm) were noted preoperatively. Relationship of these variables with C&L grading at the time of laryngoscopy was recorded. C&L grades 2 & 3 was observed in 28 patients in younger age group (n = 120) as compared to two children above 5 years (n = 76) (p p p = 0.025) in younger age group. In conclusion, this study showed that distance between tragus to nares, Mallampati classification (if applicable) and thyromental distance can be useful for assessment of difficult airway in children less than five years of age.

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.

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% in the McCoy group, and in systolic arterial pressure was 22.9% in the Macintosh and 10.3% in the McCoy group. This difference between groups was significant ( P < 0.0001). The change lasted for a lesser duration in the McCoy group. No arrhythmias or ST changes were observed in either group. Conclusion: Hemodynamic changes with use of McCoy laryngoscope were lesser in magnitude and of shorter duration.

The primary aim of this review was to assess the effect of pharmacological agents administered to attenuate the haemodynamic response to tracheal intubation in paediatric patients up to 16 years of age undergoing elective surgery. Secondary aims were to identify adverse effects related to these agents, and the agents' roles in decreasing arrhythmias. A systematic search was conducted for articles listed in PubMed, CINAHL or the Cochrane database between January 1980 and June 2014. We included randomised controlled trials where the stated aim of the study included observing the effects of pharmacological agents on the haemodynamic response to tracheal intubation. The outcome measures were changes in mean, systolic and diastolic blood pressure and heart rate, adverse effects of drugs and arrhythmias. Sixteen publications with a total of 1408 children (ages two to 15 years) were identified. These studies varied in methodology and quality. Opioids were the commonest agents used and appeared to obtund the response in a dose-related manner. Fentanyl 2 μg/kg, remifentanil 1 μg/kg, sufentanil 0.1 and 0.2 μg/kg and alfentanil 25 μg/kg blunted the haemodynamic response. Remifentanil 3 μg/kg and sufentanil 0.3 μg/kg were the most effective in obliterating the response but led to hypotension in unstimulated patients. Opioid-related side-effects and arrhythmias were observed in few patients. We recommend that when required, the safe and effective doses identified in this review be used to obtund the haemodynamic response to intubation in paediatric patients, with close observation for the uncommon but recognised side-effects.

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.

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.