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Summary Opium was the first opioids with sedative and analgesic effects, so was readily adopted by the surgical doctors to be used during surgeries. Later on its natural alkaloid, morphine, was extensively used, till synthetic alkaloids were introduced in the clinical practice. Now many non-narcotic analgesic drugs have been synthesized and proven to be devoid of serious side effects, commonly associated with the opioid use. There have been some staunch advocates of non-narcotic based anesthesia, who claim that the side effects of the opioids outweigh their benefits in the anesthesia. This editorial throws some light on the current and the future trends in analgesic use in anesthesia. Key words: Opioids; Analgesics; Non-opioid analgesics; Perioperative pain; Side effects Citation: Butt MN, Faraz A, Fazal M. Anesthesia without opioids (Editorial). Anaesth. pain intensive care 2021;26(1):4–7; DOI: 10.35975/apic.v26i1.1758 Received: January 10, 2022, Accepted: January 12, 2022

Background & Aims: Laparoscopic surgery has been associated with troublesome postoperative nausea and vomiting (PONV) in patients. Various regimens have been tried by the anesthesiologist to prevent PONV in laparoscopic cholecystectomy (LapChole). The primary objective of this study was to determine the role of stimulation of acupoint P6 for this purpose in patients undergoing LapChole at our institution. Methodology: A randomized clinical trial was conducted at the Aga Khan University Hospital, Karachi, Pakistan. The research setting took place at the Post Anesthesia Care Unit (PACU) of the hospital. A total of 84 participants undergoing LapChole, ASA Status I or II, were enrolled and randomly allocated into two groups: 41 in control and 43 in the intervention group. In the intervention group, a commercially available band – PressureRight™ was applied at the wrist and the beads were placed exactly at P6 point. In the control group, the band was applied at the wrist with the beads placed on the dorsal surface. In both groups, acupressure band was applied before the induction of anesthesia in the waiting area of the operating room and continued during the intraoperative period and six hours postoperatively. Measurements: Postoperatively, patients were monitored for postoperative nausea and vomiting at the time of arrival in post anesthesia care unit [PACU], after half hour, three hour and six hours postoperatively using numerical pain scale [NPS] from 1-10 [1=none, 2-5=mild, 6-7=moderate, 8-10=severe] for PONV separately. Main Results: The results of PONV in PACU, at 30 minutes, three hours and six hours postoperatively showed an insignificant difference in intervention and control group. The frequencies of mild to moderate PONV were gradually reduced in both groups but the reduction was more pronounced in the control group than in the intervention group. There were no reported events of severe PONV at three hours and six hours postoperatively in both groups. The use of rescue antiemetics was statistically insignificant between the two groups [P = 0.744]. Conclusions: Our study reports that acupressure at Neiguan P6 point starting before the induction of anesthesia till 6 hours postoperative has no significant role in preventing PONV in patients undergoing laparoscopic cholecystectomy. Rescue antiemetics were required in both groups with a similar frequency. Key words: Acupoint P6; Acupressure; PONV; Laparoscopic cholecystectomy; Antiemetics; Randomized Clinical Trial Ethical approval: AKU No. 5365-ane-ERC-18, dated July 17, 2018 Citation: Hamid S, Butt MN, Rehman A, Afshan G. Stimulation of acupoint P6 before induction of anesthesia to prevent postoperative nausea and vomiting; a randomized control trial. Anaesth. pain intensive care 2022;26(1):96-101. DOI: 10.35975/apic.v26i1.1774 Received: August 6, 2021, Reviewed: October 22, 2012, Accepted: December 15, 2021

Background: Advance directives are legal documents written or drawn when the person has total mental capacity, noting the requirements of health care when/if he loses the ability to make decisions. The concept has not been explored in Pakistan; hence a valid instrument is not available that addresses the needs of an LMIC. We aimed to develop and validate a tool to assess knowledge, Attitude, and perceptions about advance directives of the adult population availing services at tertiary care hospitals in Karachi, Pakistan. Methodology: We carried out a validation study in three tertiary care hospitals in Karachi. The study was initiated by adapting from an American tool, modified following the Pakistani context. An estimated sample size of 389 using a purposive sampling technique was calculated. We checked the tool's relevancy using content validity. STATA software 16 was used for consistency, reliability, and factorial analysis. Results: All the components of the survey performed well with overall good reliability (α = 0.75), and for individuals, main features, including family support decisions (α = 0.64), sociocultural and religious (α = 0.72), physical health awareness experience (α = 0.93), knowledge (α = 0.99), attitude (α = 0.75), and perceptions (α = 0.64). Conclusion: This was the first validation study done in low-and-middle-income countries to develop a reliable and validated tool with the efforts made to make it contextual and comprehensive for both English and Urdu versions.

Optimum ICU design has pivotal role in critical care delivery that has major impact on physical and psychological health of the patients, physicians and other related staff. Its structure formation is complex and demands the dedicated involvement of not only care providers but also a trained and multi-professional team of architect, engineer and information technologists, etc. This paper tracks the journey from traditional design to recent advances in building the intensive care unit. The limitations in ICU design observed in the lower to middle income countries will also be discussed in this review. Specialist hospital architects are scarce in these countries and the ordinary civil engineering does not impart adequate coaching on matters related to lay-out plans as well as the various minute details about fittings and provisions. Hence, it becomes imperative for the anesthesiologists and other healthcare providers to come to guide and assistance to the architects involved in designing the blue prints. It may only be possible if they have adequate knowledge and professional experience.Citation: Butt MN, Khan MF. Intensive Care Unit design; from advance to basic. Anaesth Pain & Intensive Care 2018;22 Suppl 1:S17-S20

Objective: To assess the knowledge, training, and practices of cricoid pressure (CP) application among the anesthesiologists working in teaching hospitals of a developing country.Methodology: This cross-sectional study was conducted among the consultant anesthesiologists and anesthesia trainees with at least 18 months of anesthesia experience, working in teaching hospitals of four provinces of the country and one teaching hospital of the capital city. The survey was conducted through a validated questionnaire including questions regarding knowledge, training and practice of CP application among anesthesiologist working in teaching hospitals of the capital city and four provinces of Pakistan.Results: A total of 220 questionnaires were distributed, 212 were returned with a response rate of 96%. 36 (16.98%) participants made correct answers to all of the six ‘knowledge’ based questions. With respect to “training”, 116 participants (55.50%) responded that they had supervised instructions on anesthetized patients, 19 participants (9.1%) had training courses using manikins and 74 participants (35.4%) had received knowledge from books only. 210 participants responded to the questions regarding the “practice” of CP application. 197 participants (93.8%) routine practice CP.Conclusion: Based on our survey, the ‘knowledge’ of cricoid pressure application was poor among the anesthesiologists working in teaching hospitals. There are insufficient training opportunities for this important anesthesia-related skill. More specific education and simulation-based training should be made mandatory for enhancing clinical use ofcricoid pressure.Citation: Butt MN, Hoda MQ. Knowledge, training, and practice of cricoid pressure application by the anesthesiologists of teaching hospitals of a developing country: A national survey. Anaesth. pain & intensive care 2019;23(2):151-156

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.

This case report is regarding a 32 years old female with 30 weeks gestation, presented to the obstetric department first time with gestational amenorrhoea. She has history of exertional dysponea, orthopnoea and attacks of syncope on and off from last three years. On further work up, she has got left sided intra atrial mass of about 41×36 mm in size attached to the lateral wall of left atrium, protruding into left ventricle through mitral valve, during diastole causing severe obstruction. Left ventricular systolic function was normal, estimated ejection fraction of 58% and no regional wall motion abnormality. Fetal heart rate and other parameters of fetal wellbeing was assessed, they were within normal limits. Patient and her family were counseled about her critical condition. In the presence of obstetrician within the operating room, cardiac surgery was started with all essential monitoring. A successful excision of atrial mass and mitral valve repair was done with a cross clamp time of 45 minutes and total cardiopulmonary bypass time of 105 minutes. Postoperatively, patient was shifted to cardiac ICU and extubated when met the criteria of extubation and she was kept in cardiac ICU for 48 hours. In CICU, fetal cardiac activity was assessed continuously. All parameters regarding fetus were remained within normal limits and Obstetrician decided to plan for Caesarian section vs. spontaneous vaginal Delivery after four to six weeks, with regular weekly visits to labor suit. At 36th week, patient was admitted for induction of labor or possible caesarean section. The whole of the labor went uneventful and she delivered a male baby with good APGAR score. There were no postpartum complications. Histopathology of the excised mass showed a very rare intra cardiac tumor i.e. Chondrosarcoma.

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.