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Objective: To evaluate the renal resistive index (RI) and serum creatinine correlation in patients with diabetic nephropathy. Study Design: Cross-sectional study Place and Duration of Study: Department of Radiology, Pakistan Institute of Medical Sciences, Islamabad Pakistan, from Nov 2020 to Apr 2021. Methodology: This study was conducted on 80 patients. Doppler renal artery sonography was carried out, and for all the individuals with controlled blood pressure, gender, age, urinary protein, serum creatinine and HBA1c were recorded. Results: In our study, 42(52%) patients were females, whereas the remaining 38(48%) were males. The mean age was observed to be 49.15±11.91 years. A significant positive correlation (r=0.53) was found between Resistive Index and Serum Creatinine.The correlation co-efficient values between Resistive Index and Serum Creatinine in female and male patients were r=0.58 and r=0.47, respectively. Conclusion: The present study concluded that RI had no significant statistical correlation with albuminuria, proteinuria and HbA1c levels. However, a statistical correlation between RI and creatinine level was reported.

Objective In this study, we aimed to assess the diagnostic accuracy of carotid Doppler ultrasound (CDU) in detecting anechoic carotid artery thrombus when compared to CT angiography (CTA) as the gold standard. Materials and methods This prospective comparative study was conducted at the Radiology Department of the Pakistan Institute of Medical Sciences, Islamabad from January 2022 to May 2022. The study enrolled 32 patients who met the inclusion criteria. We evaluated patients admitted to the neurology ward/OPD who were referred to radiology as part of a stroke workup based on their clinical examination and medical history. In all patients, CDU was used to detect free-floating thrombus (FFT)/anechoic thrombus. CTA was used as the gold standard to assess the diagnostic accuracy of CDU. Results The mean age of the study participants was 45.63 ± 7.05 years (range: 33-59 years). Out of 32 patients, 19 (59.4%) were male and 13 (40.6%) were female. The results of CDU were confirmed by CTA in all patients. The diagnostic accuracy of CDU was 53.12% for detecting FFT. The values for sensitivity (54.55%), specificity (50%), positive predictive value (PPV, 70.59%), and negative predictive value (NPV, 33.33%) were also calculated. Conclusion Despite the limited sample size, the study concludes that CDU has a diagnostic accuracy of 53%. CTA still remains the gold standard imaging modality for anechoic thrombus if strong clinical suspicion is present.

Introduction Bone tumors are a common pathology of the musculoskeletal system being frequently encountered by clinicians. Radiological workup is a mainstay in the diagnostic workup of bone tumors. This study aimed to highlight the importance of plain radiography and MRI in the diagnosis of bone tumors keeping histopathology as a gold standard. It is a descriptive validation study conducted in the Radiology Department of Pakistan Institute of Medical Sciences Islamabad. Methodology The study included 92 patients with suspected bone lesions. After taking a complete history and receiving informed written consent. X-rays radiographs and magnetic resonance imaging were performed. X-ray radiograph and magnetic resonance imaging parameters were recorded and compared with the histopathology of lesions as a standard. Results The mean age of patients was 30.50 ± 8.95 years. Of 92 patients examined on X-ray, 51 (55.4%) had lytic lesions, 34 (37.0%) had sclerotic lesions, and seven (7.6 %) had mixed lesions. MRI revealed the location of the lesion. There were 25 (27.2%) bone lesions in diaphysis, 19 (20.7%) in metaphysis, nine (9.8%) at meta-diaphysis, and 32 (34.8 %) in the meta-epiphyseal region. These findings were later on confirmed with histopathological results. Conclusion MRI can differentiate soft-tissue components and periosteal reactions. An X-ray radiograph can provide information about bony matrix and calcifications within tumors. After analysis of imaging findings and histopathological results, it is concluded that these modalities can be used to diagnose bone tumors with high diagnostic accuracy.

Background The hormonal response to surgical trauma can have detrimental effects on patients. Transversus abdominis plane (TAP) block, which can improve analgesia after total abdominal hysterectomy (TAH) might attenuate the peri-operative stress response. Objective To evaluate the ability of the TAP block to reduce stress response, opioid consumption and pain following TAH and multimodal analgesia. Design Randomised, placebo-controlled double-blind study. Setting The current study was conducted at a university hospital from July 2016 to September 2017. Patients Fifty patients scheduled for TAH were included. Anaesthesia and postoperative analgesia were standardised. Intervention After induction of anaesthesia, patients were allocated into two groups: ultrasound-guided bilateral mid-axillary TAP block with 20 ml of bupivacaine 0.25% (Group T) or 0.9% saline (Group C). Main outcome measures Levels of free serum cortisol, metanephrine and normetanephrine at 60 min and 6, 12 and 24 h after surgical incision. Pain scores and opioid consumption during the first 24 h after surgery. Results There was no statistically significant difference between the median [IQR] peri-operative levels of stress hormones and pain scores between groups. Compared with baseline value 9.90 [4.2 to 23.1], free serum median cortisol levels were significantly high at 6 h in Group T, 23.6 [10.1 to 42.9] P = 0.015 and Group C 23.6 [9.9 to 46.3] P = 0.014. Only Group C showed significant elevation from the baseline median levels of plasma metanephrine at 60 min, 52.8 [33.4 to 193.2] P = 0.001, 6 h, 92.70 [2.4 to 202.6] P = 0.005 and normetanephrine at 60 min 83.44 [28.98 to 114.86] P = 0.004, 6 h 78.62 [36.6 to 162.31] P = 0.0005 and 24 h 80.96 [8.6 to 110.5] P = 0.025. Mean ± SD opioid consumption was similar in both groups: 39.60 ± 14.87 in Group T vs. 43.68 ± 14.93 in Group C (P = 0.338). Conclusion Mid-axillary TAP block does not improve stress response and analgesia in patients undergoing TAH receiving multimodal analgesia. Trail registration ClinicalTrial.gov identifier: NCT03443271.

Objective To assess knowledge and practice trends in managing acute pain in patients infected with human immunodeficiency virus (HIV+) or having acquired immunodeficiency syndrome (AIDS) among emergency physicians of four tertiary care hospitals. Acute pain management in such patients is complex because of multiple concomitant painful conditions related to their disease. After obtaining ethical approval and written informed consent, emergency physicians were requested to fill out a questionnaire. Results Out of 84 physicians who participated, 49 had managed HIV+/AIDS patients during the preceding year. Out of the 49, 30 (61.2%) physicians stated that they used a combination of analgesics for acute pain in these patients. Forty-two (50%) out of the 84 participants believed that routine doses of opioids were adequate for pain relief, while 42 (50%) agreed that pain management was more complex in these patients mainly due to presence of multiple coexisting problems and psychological issues. Only 26 (31%) respondents considered that pain was under-reported and under-treated in these patients, mainly because physicians were more focused on patients’ other disease related complications and issues. Formulation of guidelines are recommended for effective acute pain management in these patients encompassing associated issues, including concomitant painful conditions, opioid dependence, psychiatric problems, etc.

Objective: To assess the safety and effectiveness of peripheral nerve blocks using ultrasound. Methods: All patients who received peripheral nerve blocks (PNB) as a part of their anaesthesia care, in two years were analysed retrospectively. The data included outcomes of PNB effectiveness, complications and limb conditions after block. PNB effectiveness was assessed by monitoring pain scores at rest and on movement and the requirement of co- analgesia. Complications like numbness, motor block, metallic taste, hypotension, respiratory depression were also assessed. Results: A total of 299 patients received ultrasound guided peripheral nerve blocks. Most common block performed was transversus abdominus plane block (TAP) block (46.5%) followed by supraclavicular block (16.7%). Most common complication observed in the recovery room after PNB was numbness 6.2%. Approximately 70% patients remained pain free; however 16% of the patients had moderate pain on movement at 12 hour post-operatively. Sedation score, sensory block and skin conditions were observed to be normal. Conclusion: This study shows that the complications associated with ultrasound guided regional anaesthesia (UGRA) are very few. With advancements in ultrasound guided technique, further studies are required to evaluate benefits and complications in comparison to conventional techniques. Keywords: Regional anesthesia, ultrasound guided blocks, peripheral nerve blocks Continuous....

BackgroundUnrelieved postoperative pain afflicts millions each year in low and middle income countries (LMIC). Despite substantial advances in the study of pain, this area remains neglected. Current systematic review was designed to ascertain the types of clinical trials conducted in LMIC on postoperative pain management modalities over the last decade.MethodsA comprehensive search was performed in June 2019 on PubMed, Cochrane Library, CINAHL Plus, and Web of Science databases to identify relevant trials on the management of postoperative pain in LMIC. Out of 1450 RCTs, 108 studies were reviewed for quality evidence using structured form of critical appraisal skill program. Total of 51 clinical trials were included after applying inclusion/exclusion criteria.ResultsResults are charted according to the type of surgery. Eleven trials on laparoscopic cholecystectomy used multimodal analgesia including some form of regional analgesia. Different analgesic modalities were studied in 4 trials on thoracotomy, but none used multimodal approach. In 11 trials on laparotomy, multimodal analgesia was employed along with the studied modalities. In 2 trials on hysterectomy, preemptive pregabalin or gabapentin were used for reduction in rescue analgesia. In 13 trials on breast surgical procedures and 10 on orthopaedic surgery, multimodal analgesia was used with some form of regional analgesia.ConclusionWe found that over the past 10 years, clinical trials for postoperative pain modalities have evolved in LMIC according to the current postoperative pain management guidelines i.e. multi-modal approach with some form of regional analgesia. The current review shows that clinical trials were conducted using multimodal analgesia including but not limited to some form of regional analgesia for postoperative pain in LMIC however this research snapshot (of only three countries) may not exactly reflect the clinical practices in all 47 countries.Post Operative Pain Management Modalities Employed in Clinical Trials for Adult Patients in LMIC; A Systematic Review.

Distance learning achieved academic recognition in 1892 when the first college level program was introduced. Later, due to rapid technological advancements in the late nineteenth century, the most prestigious institutions across the world introduced distance learning. The Covid-19 pandemic has expedited distance learning in the education landscape following a sudden closure of academic institutions and almost overnight, online delivery of courses was initiated at all levels of education. In the current scenario, distance learning is very likely to stay beyond the covid era, and authors envision a “hybrid” model of education with blended learning i.e. a combination of face-to-face and online teaching. The necessity to follow social distancing will force us to limit the class room activities as well as hands-on practical training sessions to a reduced number of students. It will require the void to be filled through distance learning education. Key words: Distance learning, Covid -19 pandemic, online courses, hybrid model, blended learning Citation: Afshan G, Ahmed A. Distance learning is here to stay: Shall we reorganize ourselves for the post-covid-19 world? Anaesth. pin intensive care 2020;24(5): Received: 27 September 2020, Reviewed: 30 September 2020, Accepted: 2 October 2020

Background: Research has shown that more than 50% of patients have insufficient postoperative pain relief despite the use of multiple pain management modalities. Insufficient pain relief leads to several pathophysiological effects. One of the barriers to optimal pain relief is patient’s lack of knowledge regarding the options available for pain management and their potential side effects. In this survey, we evaluated surgical patients’ knowledge about postoperative pain and its management in patients undergoing major upper abdominal surgeries at a tertiary care hospital. Methods and Material: This was a cross-sectional survey. A total of 155 patients (18-60 years of age) scheduled to undergo elective major upper abdominal surgery were included after ethical approval and informed consent. Preoperatively, patients were interviewed through a questionnaire regarding knowledge about postoperative pain and its management. Results: The average age of the patients was 42.97 ± 13.05 years. Excellent and good knowledge were observed in 11.61% and 21.94% patients, respectively, whereas fair and poor knowledge were seen in 42.58% and 23.87%, respectively. Inadequate knowledge was more marked regarding analgesic side effects and addiction risk. Education level, history of surgery, and adequate information provision about pain management plan by surgeons preoperatively were significantly associated with a higher level of knowledge about pain and its management (p-value 0.0005, 0.002, and 0.0005, respectively). Conclusion: A considerable proportion of patients have inadequate knowledge about their postoperative pain and its management, particularly in areas of side effects and addiction risk.

Background and aims Persistent post-surgical pain (PPSP) is significant issue following breast cancer treatment. Primary aim of this study was to determine the frequency of persistent pain in patients after breast cancer surgery while the secondary aim was to observe the distribution and characteristics of pain in these patients. Methods This prospective observational single cohort study was conducted in the Department of Anaesthesiology and the Breast Surgery Clinic of the Department of Surgery, Aga Khan University. Adult female patients with biopsy proven carcinoma of breast who were scheduled for elective definitive breast cancer surgery were enrolled in this study. Total 120 patients were followed for up to 3 months after surgery and those who had persistent pain were followed up for 6 months after operation. Results Of the 120 patients, 26 (21.7%) patients developed persistent post-surgical pain for up to 3 months while in 17 (14.2%) patients pain continued for up to 6 months after operation. Of 26 patients with PPSP, 11 (42.3%) had burning pain, 10 (38.5%) had throbbing pain, 3 (11.5%) patients had numbness and 2 patients had mixed character of pain. 11 patients developed pain at more than one site. Pain was distributed in axilla, chest wall, upper arm and surgical scar area. 15 of 26 patients (57.7%), had pain in axilla. Conclusions Persistent pain following breast cancer surgeries was found to be 21.7% in this study; 15 of 26 patients had pain in axilla.

All laparoscopic cholecystectomy (LC) patients in our hospital setting are admitted overnight. This article assesses the contribution of factors like postoperative nausea and vomiting (PONV), postoperative pain and surgical complications to overnight stay after elective LC. This 1-year observational study included patients having normal liver functions undergoing elective LC before 1400 h. The collected data included patient demographics, co-morbidities, PONV, pain scores, complications, surgical time, anesthesia technique, use of prophylactic antiemetics, analgesics, patient satisfaction and desire to have this surgery as day case or in-patient procedure. From 930 LC done per annum, 45.2 % (430/950) patients were included in this study. Prophylactic antiemetic was given in 91.6 %, intraoperative narcotics in 94.2 % patients and multimodal analgesia in 85.3 %. The mean pain score in the recovery and ward was maintained to

Background: Imaging technologies like x-ray and computed tomography used in study of paranasal sinuses plays an important role in managing multiple pathologies. Modern imaging technologies such as X-ray, CT-scan and MRI play a vital role to diagnose paranasal disorders more accurately than the normal conventional x-rays. This comparative study was conducted at PIMS Hospital Islamabad during from 3rd Jan 2018 to May 15 2018 to examine the diagnostic accuracy of x-ray and CT-Scan of paranasal sinuses. Objective: The aim of this study is to evaluate the accuracy between modern imaging technologies (X-rays and CTScan) of paranasal sinuses in clinically observed sinusitis patients. Materials and Methods: In this comparative/observational study, 55 patients of both genders who have resulted acute and chronic sinusitis disorder through clinically examination were included according to inclusion criteria and those patients were excluded from this study who had previously getting any nasal passage surgery or having normal and sinus problems and infections. All patients were referred to department of radiology at Pakistan Institute of Medical Science, Islamabad (PIMS) for examine the diagnostic accuracy of paranasal sinuses under x-ray and CTscan. Radiological results of x-ray were associated with CT-scan in both chronic and acute sinusitis resulted patients. Results: In this research 55 patients who had ages of 20 to 55 years were included. 33 (60%) patients were male while rest 22 (40%) were female. 12 (21.82%) patients were aged between 20 to 29 years, 13 (23.64%) patients had ages of 30 to 39 years, 18 (32.72%) patients were aged between 40 to 49 years and 12 (21.82%) patients were ages >49 years. From all 55 patients 26 (47.27%) had found acute sinusitis while 29 (52.73%) had found chronic sinusitis by clinically normal x-ray observation, when these patients were diagnosed by CT-Scan, from 26 acute sinusitis patients, 18 (69.23%) patients had found acute sinusitis while 8 (30.77%) had found no positive result. From 29 chronic patients, 22 (75.86%) had found positive results while 7 (24.14%) had not found chronic sinusitis. Conclusion: It is concluded that, In past researches X-rays plays an important role for diagnosing of paranasal sinuses, but now a days, modern and advanced CT-Scan and MRI provide an accurate findings for diagnosing paranasal sinuses of sinusitis patients.

Objective: To decide the number of punctures in a biopsy procedure, Fine Needle Aspiration (FNA), needed for secured cytological evaluation of thyroid nodules. Materials and Methods: This cross-sectional analysis was carried out at Pakistan Institute of Medical Science, Islamabad (PMIS) during the period from January to December, 2016. A total of 94 patients participated in the population study according to the inclusion criteria. The diagnosis was the focal point of the research. Results: The participants in the study group aged around 51 years, while 86.2% among the patients were females. Since punctures were considered as an independent event, the first puncture produced decisive results in 77.5% of cases. The second and third puncture produced results in 82.1% and 73.2% of all cases relatively. With a view to increase the conclusive analysis at each puncture, two punctures have demonstrated indisputable results in 87.2% of cases, and three punctures, in 91.2% of cases with no less than one decisive result. Conclusion: Two punctures in fine-needle desire biopsies of thyroid nodules have prompt determination in 86.2% of cases in the evaluation recommending that there is no requirement for further punctures to securely acquire the analysis of thyroid nodules.

Multiple anaesthesia books are available about the state-of-art anaesthetic management, including management of the obstetric patient. There has been considerable advancement in the field of anaesthesiology in recent years; however, incidents of morbidity and mortality continue to be reported from resource limited settings. The current ebook is aimed to describe safe practice of safe anaesthesia in resource-limited situations. The authors are well aware about the available resources in different parts of their country and other countries with similar resources, are capable of suggesting a safe standard of care that can be applicable in resource limited situations, while at the same time describing the standard of care in the developed world. Format of the eBook: • Typical descriptive case scenarios • Current standards of care in the best institutes of the world • Suggested standards of care in resource limited situations

OBJECTIVE To determine the correlation of trainee selection scores (TSS) with subsequent performance in anesthesiology trainees at a university hospital. STUDY DESIGN Descriptive analytical study. PLACE AND DURATION OF STUDY The Aga Khan University Hospital, Karachi, from August 2016 to January 2017. METHODOLOGY Data were collected on 44 anesthesiology trainees completing their training between 2009 and 2015. TSS consisted of entrance test, final-year medical school scores, and interviews. Assessment included written tests, viva voce, and clinical assessment. Non-parametric Spearman rank correlation coefficient was computed to assess the relationship between scores. RESULTS Weak correlation was found between TSS and overall assessment scores for first three years of training. Correlation of TSS with clinical component of assessment was weak throughout training, while it was moderately significant with cognitive component of assessment in third and fourth years of training. Correlation between interview scores and cognitive as well as clinical assessment was non-significant. TSS showed weak correlation with success in exit level examination. CONCLUSION Correlation between overall TSS and assessment scores was weak for first three years of training, and becoming moderately positive in later years of training. Cognitive component of TSS had moderately positive correlation with cognitive assessment, but not with clinical performance. Anesthesiology training programmes need to strengthen their selection criteria; and development of structured interviews might prove useful. Future research should focus upon identifying most useful traits in selecting high performers in anesthesiology training.

OBJECTIVE To assess the effectiveness of intravenous dexamethasone along with caudal block in improving analgesia following inguinal hernia repair in children. METHODS The double-blind randomised controlled trial was conducted over a 6-month period from June 01, 2016 to November 30, 2016 at the Aga Khan University Hospital, Karachi, and comprised patients aged 1-5 years, scheduled for elective inguinal hernia repair. The subjects were randomised into two groups using the sealed envelope technique. Group D patients received 0.5mg/kg dexamethasone intravenous in 5ml, and group P was given placebo (5ml 0.9% saline). Assessment of postoperative pain was made through the faces, legs, activity, cry and consolability tool at 30 minutes and hourly for 4 hours. Rescue analgesia was given at pain score 3 or more with intravenous pethidine 0.5 mg/kg. SPSS 19 was used for data analysis. RESULTS Of the 64 patients, there were 55(85.9%) boys and 9(14.1%) girls. The overall mean age was 29.8}13.8 months. The mean postoperative pain score was significantly higher in group P (p

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.

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 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.

This article was migrated. The article was marked as recommended. Introduction: Inadequate acute pain relief is a significant healthcare problem. In developing countries acute pain services are still few in number, mainly due to insufficient resources. Adequately trained nurses can play a pivotal role in provision of pain management services. Method: A 5-day course was conducted for 30 nurses involved in care of surgical patients at six tertiary care hospitals as a first step towards development of anaesthesia-supervised nurse-based acute pain services in the participating hospitals. Teaching methodologies included lectures, problem-based discussions, workshops, and practicums. Pre and post-tests were conducted. A telephonic interview of the participants was conducted one year after the course. Results: The overall rating given to the course was 4.35 on the scale of 5. All nurses affirmed that they experienced a change in their practice after attending the course. Pain assessment is now performed routinely by them while recording vital signs and they are able to assess and manage side effects of pain medication in a more effective manner. All participants are involved in informal teaching of their peers. Conclusion: Similar courses need to be conducted on a regular basis to strengthen the workforce and improve the effectiveness of acute pain management in developing countries.

Background 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. Methods In this prospective cohort study, we determined the effect of menstrual cycle phase on pain perception and analgesic requirements following total abdominal hysterectomy. Sixty women with regular menstrual cycles undergoing elective surgery were recruited and divided into ‘follicular’ and ‘luteal’ groups according to their menstrual history. Post-operative pain was managed with intravenous patient-controlled analgesia using tramadol. Intravenous morphine was used for rescue analgesia, and pain was assessed for 24 h. Results Pain scores in the recovery room and ward six and 24 h post-operatively were similar in the groups at rest and on coughing. Pain scores at rest 12 h post-operatively were significantly higher in the luteal group (P = 0.043), while they were similar on coughing. There was no significant difference in the total tramadol requirement. Number of patients requiring rescue analgesia and the amount of morphine used was also similar. Conclusion There was no difference in pain scores or analgesic requirements between the two groups except for rest pain at 12 h, which was significantly higher in the luteal group. As pain was assessed at 13 different time points, a significant difference seen only at one point could be due to random chance. We suggest that future research should concentrate on studying this issue in patients of relatively younger age groups with more pronounced hormonal variations during the cycle.

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.

Background: Management of postoperative pain after caesarean section (C/S) requires a balance between pain relief and undesirable side effects of drugs and technique. In order to improve postoperative pain management after caesarean section, we compared intravenous patient controlled analgesia (IV-PCA) with our current hospital practice, which is continuous opioid infusion. Method: We enrolled one hundred and twenty patients in our prospective randomized trial after an uneventful elective caesarean section under spinal anaesthesia. All patients received 0.5 mg/kg bolus of pethidine on first complaint of pain or at 120 minutes after institution of spinal anaesthesia. Depending upon the randomization, Group P received IV-PCA with 0.15 mg/kg bolus pethidine with 10-minute lockout and Group C received continuous pethidine infusion at a rate of 0.15 mg/kg/hr. Statistical analysis: For qualitative variables means and standard deviations were computed and analyzed by T-test, Mann Whitney U test and repeated measures ANOVA. Frequency and percentages were computed for qualitative data and analyzed by Chi-Square and Fischer exact test. A p-value of less than 0.05 was treated as significant. Results: The numeric rating score for pain, need for rescue analgesia and incidence of nausea and vomiting was significantly lower (p-value < 0.001) in IV-PCA group as compared to continuous infusion group at 6, 12 and 24 hours postoperatively, 98% of the patients were satisfied with pain management in Group P as compared to 70% (p < 0.001) in Group C. Conclusion: Our results showed improved pain control, less need for rescue analgesia for breakthrough pain, lower incidence of nausea and vomiting and greater patient satisfaction with IV-PCA. In the absence of preservative free narcotics for intrathecal use, postoperative pain management can be significantly improved by using IV-PCA instead of continuous opioid infusion in patients undergoing caesarean section.

John Gray presents interesting metaphor for men and women in his best seller title “Men are from Mars and Women are from Venus” as men are warrior; protector of fields and territory while women are the symbols of love, beauty and fertility in a society. If summed up the characteristics of men and women in single word for each, explained by Gray, most probably the men are ‘tuff’ and women are ‘fragile’. Are they really so? The claim of Gray can not be out rightly rejected. Although most of the researches in the field of ‘gender and management’ did not endorse the Gray’s analogy but accepted a few differences in the management and leaderships styles of men and women at the work place. In Pakistan too, gender equality or inequality is being debated like anywhere in the world. Pakistani organizations are predominantly managed by men. Few women can be seen at the top slot of management in the Pakistani corporate organizations. It is generally perceived that management is a masculine role, though management role is not a single role rather management roles are further classified into various sub roles, whereas some are perceived masculine and others are perceived as feminine roles. Being an active part of the corporate world, the researchers have observed differences in the managerial styles between men and women and wanted to find out through scientific method whether in Pakistani corporate culture, is management still associated with men only or its sub roles are more/less associated with men and women; both?

Summary Objective/Aim: 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. Background: Analysis of anesthesia-related complications is routinely performed by most anesthesia departments to make prevention strategies. Methods: All perioperative cardiac arrests in children up to 18 years from induction of anesthesia to postanesthesia care unit discharge or ICU admission during noncardiac surgery from January 1992 to December 2006 were analyzed. Outcome variable was noted as survival to discharge. Anesthesia-related cardiac arrests were identified and their causes analyzed. Results: Ten cardiac arrests occurred among 20216 patients. Overall incidence was 4.95 per 10000 (95% CI: 1.88–8.01). Six (6.53/10000) were females. Seven (19.44/10000) patients belonged to the classification III–IV of ASA physical status, eight (18.28/10000) were below 1 year, and two (1.26/10000) above 1 year. Three patients (6.53/10000) were undergoing emergency surgery. Anesthesia was primarily responsible in four cases. The causes of anesthesia-related arrests were medication-related (two), airway-related (one), and under-replacement of fluids (one). Seven patients died during the arrest and three were discharged home. The event was considered avoidable in seven (70%) cases. Conclusion: Perioperative cardiac arrests were higher in patients with poor physical status, in those under 1 year of age, and in female patients. Anesthesia-related cardiac arrests were mainly due to medication- or airway-related causes. The majority of arrests were avoidable indicating the importance of prevention strategies.

To assess the frequency and types of adjustments that acute pain service makes to postoperative analgesic regimes to improve pain relief or treat side effects.The prospective observational study was conducted at the Aga Khan University Hospital, Karachi, from December 1, 2012, to March 31, 2013. Data was collected from Acute Pain Service register four hours after the pain rounds by a Service member not involved in rounds. Data was collected on a standardised form and analysed using SPSS 19.Of the 323 patients, 209(65%) were receiving epidural infusions and 114(35%) were receiving intravenous patient-controlled analgesia. Overall, 114(35%) required action by Acute Pain Service; 76(66.6%) with epidural infusions and 38(33.3%) intravenous analgesia. Besides, 98(85.9%) had inadequate pain relief, 61(62%) with epidural and 37(38%) with analgesia. Post-intervention, motor block occurred in 13(11.4%) patients, who were managed by change of patient\'s position and/or lowering the concentration of epidural solution. Improvement was seen in all patients after the adjustments.Acute Pain Service played an important role in improving the quality of postoperative pain relief and management of analgesia-related side effects. Regular feedback to the primary anaesthesiologist can lead to improved practices.

Objective: To determine the mean induction dose of propofol with ketamine-propofol and midazolam-propofol co-induction. Methods: A total of sixty patients with American Society of Anaesthesiologist (ASA) physical status I and II, aged 20-50 years, of either sex, undergoing daycare surgeries requiring general anaesthesia were included in this study. The patients were randomly allocated into two equal groups. Group K received ketamine-propofol and group M received midazolam-propofol for induction of anaesthesia. All the patients received pethidine 0.8 mg/kg. Two minutes after the administration of co-induction agent, each patient received 20 mg of lignocaine and injection propofol was given 10 mg every five seconds until patient stopped counting and does not respond to a reminder to continue counting. The level of sedation and alertness was targeted to an observer’s assessment of alertness/ sedation score of 2. Results: Mean induction dose of propofol in the two groups was compared by student’s T test. The mean induction dose was 53.67 (30-120) mg in group K and 52.33 (30-110) mg in group M. The difference between the mean inductions doses of propofol in the two groups were statistically insignificant (P-value of 0.78). Mann Whitney test was also used to compare the mean induction doses of propofol between the two groups. The difference in mean induction doses of propofol was statistically insignificant (P-value of 0.57). Conclusion: There is no difference in the mean induction dose of propofol with ketamine-propofol and midazolam- propofol co-induction.

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 ­new-generation device usually requires MAC with conscious sedation only.