Publications by authors named "Khalid Samad"

27 Publications

  • Page 1 of 1

Anaesthetic Management of Tracheal Injury following Blunt Neck Trauma: An Unusual Late Presentation.

J Coll Physicians Surg Pak 2021 Aug;31(8):992-994

Department of Anaesthesiology, The Aga Khan University Hospital, Karachi, Pakistan.

Tracheal injuries, following blunt neck trauma, are life-threatening surgical emergencies with high risk of mortality. A high index of suspicion is necessary to avoid missing an occult injury because delays in diagnosis and definitive treatment are associated with poorer outcomes. We, herein, report a case of a 28-year man who presented in Emergency Department 15 days after blunt neck trauma from an accident involving electric cable. Anaesthetic challenges, airway management and importance of effective close loop communication, during repair of complex tracheal reconstruction, will be discussed in this case report. Key Words: Blunt trauma, Airway and anesthetic management, Tracheal injury.
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http://dx.doi.org/10.29271/jcpsp.2021.08.992DOI Listing
August 2021

Frequency of Blood Transfusion in Elective Coronary Artery Bypass Grafting and Its Correlation With Acute Kidney Injury at a Tertiary Care Hospital in a Lower Middle-Income Country.

Cureus 2021 May 22;13(5):e15184. Epub 2021 May 22.

Anesthesia, Aga Khan University Hospital, Karachi, PAK.

Background Blood transfusion remains a significant management aspect in various cardiac surgical procedures including coronary artery bypass grafting (CABG). These patients have a reportedly high incidence of transfusion of blood products. It varies considerably amongst different institutions; most variability being seen in the transfusion trigger. This case series enumerate the frequency of administration of blood products in patients during elective CABG and its association with acute kidney injury (AKI) and ascertain whether blood transfusion is justifiable at a tertiary care hospital. Materials and methods Using non-probability consecutive sampling, 172 patients were enrolled in the study. Patient's preoperative hemoglobin and creatinine, intraoperative hemoglobin, transfusion trigger, number of transfusions (whole blood and packed RBCs-PRBCs), postoperative hemoglobin and creatinine in the ICU and number of transfusions in the first 24 hours were recorded. Results Out of the 172 patients, 96 (55.81%) patients received blood transfusion and 73 (42.69%) patients suffered from AKI. 45 (61.64%) patients with AKI received transfusion whereas 28 (38.36%) patients had no transfusion. Of these 96 patients, 45 (46.8%) received transfusion intra-operatively, 24 (25%) patients received both intra-operatively and post-operatively while 27 (28.2%) patients were transfused postoperatively. Majority of the patients, 46 (88.3%), received unjustifiable transfusion (Hb >8 g/dl) during the first 24 hours post-operatively. Conclusion There is marked divergence in the peri-operative use of blood products that remain on a loco-regional as well as international basis. A standardized and a multidisciplinary strategy as well as robust institutional regulation would significantly reduce inappropriate patient exposure to blood products.
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http://dx.doi.org/10.7759/cureus.15184DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8221641PMC
May 2021

Ratio of height to thyromental distance: a comparison with mallampati and upper lip bite test for predicting difficult intubation in Pakistani population.

J Pak Med Assoc 2021 Jun;71(6):1570-1574

Departments of Anaesthesiology,Aga Khan University Hospital, Karachi.

Objective: To compare the accuracy of three diagnostic tests in predicting difficult laryngoscopy using Cormack and Lehane grade as the gold standard.

Methods: The cross-sectional study was conducted at the Aga Khan University Hospital, Karachi, from August 2014 to August 2015, and comprised patients who required endotracheal intubation for elective surgical procedures. The primary investigator used ratio of height to thyromental distance, upper lip bite test and the modified Mallampati test for assessing the airway correlated with laryngoscopic view based on Cormack and Lehane grading. Data was analysed using SPSS 19.

Results: Of the 383 patients, 59(15.4%) were classified as difficult cases of laryngoscopy. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of ratio of height to thyromental distance were 84.7%, 90.1%, 60.9%, 97%, 89.3%; and those the corresponding values for the upper lip bite test were 83.1%, 89.2%, 58.3%, 96.7% and 88.3%. The values for the modified Mallampati test were 30.5%, 84.3%, 26.1%, 86.9% and 79.9% respectively. The area under receiver-operating characteristic curve for the first two tests was significantly more than for the modified Mallampati test (p<0.01).

Conclusions: RHTMD and ULBT both are acceptable alternatives for prediction of difficult laryngoscopy as a simple, single bed-side test.
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http://dx.doi.org/10.47391/JPMA.1215DOI Listing
June 2021

Postoperative Cognitive Dysfunction following General Anaesthesia in Patients Undergoing Elective Non-cardiac Surgery.

J Coll Physicians Surg Pak 2020 04;30(4):417-419

Department of Anaesthesiology, The Aga Khan University Hospital, Karachi, Pakistan.

Objective: To determine frequency of early postoperative cognitive dysfunction (POCD) in patients aged 40 to 60 years, following general anaesthesia in patients undergoing elective, non-cardiac surgery.

Study Design: Descriptive study.

Place And Duration Of Study: Department of Anaesthesiology, The Aga Khan University Hospital (AKUH), Karachi, from December 2015 to May 2016.

Methodology: After obtaining approval from Ethical Review Committee of AKUH and informed consent, ASA I and II patients, aged between 40 to 60 years of either gender, undergoing general anaesthesia for elective non-cardiac surgical procedures, were recruited. Patients were assessed preoperatively by using mini-mental state examination (MMSE); and patients having a score equal to or greater than 23 (maximum 30) were included in the study. All patients were reassessed at 24 hours postoperatively by MMSE. Both the MMSE evaluations were performed by primary investigator on predesigned data collection form.

Results: A total of 150 patients were enrolled in the study. Preoperative MMSE score ranged from 24 to 30 while postoperative MMSE score (at 24 hours) was between 25 and 30. Thus, no patient developed POCD following general anaesthesia for elective, non-cardiac surgery in this study.

Conclusion: Early POCD was not found in the presently studied population of middle aged patients having elective non-cardiac surgery under general anaesthesia. Key Words: Postoperative cognitive dysfunction (POCD), General anaesthesia, Non-cardiac surgery, Mini- mental state examination.
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http://dx.doi.org/10.29271/jcpsp.2020.04.417DOI Listing
April 2020

[Comparison of two supraglottic airway devices on postoperative sore throat in children: a prospective randomized controlled trial].

Braz J Anesthesiol 2020 May - Jun;70(3):240-247. Epub 2020 May 12.

Aga Khan University Hospital, Department of Anesthesiology, Karachi, Pakistan.

Background And Objective: Sore throat is well recognized complaint after receiving general anesthesia. This study is conducted to compare the severity and frequency of postoperative sore throat in children undergoing elective surgery - following the use of Ambu laryngeal mask airway) or I-gel® - who are able to self-report postoperative sore throat.

Method: Seventy children, 6 to 16 years-old, undergoing elective surgery randomly allocated to either Ambu laryngeal mask (Ambu Group) or I-gel® (I-gel Group). After the procedure, patients were interviewed in the recovery room immediately, after one hour, 6 and 24 hours postoperatively by an independent observer blinded to the device used intra-operatively.

Results: On arrival in the recovery room 17.1% (n=6) of children of the Ambu Group complained of postoperative sore throat, against 5.7% in I-gel Group (n=2). After one hour, the results were similar. After 6 hours, postoperative sore throat was found in 8.6% (n=3) of the children in Ambu group vs. 2.9% (n=1) in I-gel Group. After 24hours, 2.9% (n=1) of the kids in Ambu Group compared to none in I-gel Group. There was no significant difference found in the incidence of postoperative sore throat in both devices on arrival (p=0.28); after 1 hour (p=0.28); after 6 hours (p=0.30); and after 24 hours (p=0.31). The duration of the insertion was shorter in Ambu Group and it was easier to insert the I-gel® (p=0.029). Oropharyngeal seal pressure of I-gel® was higher than that of Ambu laryngeal mask (p=0.001).

Conclusion: The severity and frequency of postoperative sore throat in children is not statistically significant in the I-gel Group compared to Ambu Group.
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http://dx.doi.org/10.1016/j.bjan.2020.03.006DOI Listing
July 2021

Paediatric Thoracic Tumour Resection: Challenge For An Anaesthesiologist.

J Ayub Med Coll Abbottabad 2020 Jan- Mar;32(1):132-135

Tabba Heart Institute, Karachi, Pakistan.

Paediatric thoracic tumours resection is one of the most difficult procedure for any anaesthetist. Paediatric population is different from adults in many aspects, as they have small thoracic volume and more compressible mass effect on their airway and vascular structures. we are reporting a case of a huge paediatric thoracic tumour resection occupying the left thoracic cavity. The possible mechanism, consequences, prevention and management discussed in this report.
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October 2020

Factors affecting reintubations after cardiac and thoracic surgeries in cardiac intensive care unit of a tertiary care hospital.

Saudi J Anaesth 2018 Apr-Jun;12(2):256-260

Department of Anaesthesiology, Aga Khan University, Karachi, Pakistan.

Background: Reintubation and readmission after cardiothoracic surgeries are not uncommon, and its reasons are multifactorial. The study goal was to identify the factors that contribute reintubation after cardiac and thoracic surgery in tertiary care hospital and to compare the outcome with international benchmark.

Methodology: A prospective, observational study was planned in Cardiac Intensive Care Unit (CICU). The study included all those patients who required readmission in CICU due to endotracheal intubation following cardiac and thoracic surgeries. The study was conducted from January to December 2016. The primary focus was to identify the reasons for reintubation within 72 h of extubation after CICU discharge and its association with outcome.

Results: Out of 750 patients who shifted out from CICU following successful extubation, only 32 were readmitted and among them in 25 patients (3.33%) were reintubated and their reasons reintubation were noted. Patients underwent a coronary artery bypass grafting (CABG) with valve replacement had a higher incidence of reintubation 3/39 (7.69%) when compared with CABG 13/517 (2.51%) and 4/135 (2.96%) valve procedure alone. Single cause of endotracheal reintubation was observed in 7 patients (28%), in which 5 patients (20%) had respiratory and 2 patients had (8%) cardiac reason while 18 patients (72%) were observed with multisystem involvement, in which 7 patients (28%) had both respiratory and cardiovascular causes, and 2 (8%) had both respiratory and neurological causes. More than 70% cause of endotracheal reintubation was both respiratory and cardiovascular. The CICU stay after reintubations was 12.88 ± 16.88 days and the hospital stay prolonged to 23.84 ± 21.61 days.

Conclusion: Reasons of reintubation were mainly respiratory and cardiac. The rate of reintubations is high when multisystem involvement is there. CICU, hospital stay, and mortality are increases after reintubation.
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http://dx.doi.org/10.4103/sja.SJA_631_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5875215PMC
April 2018

Fast Track Extubation In Adult Patients On Pump Open Heart Surgery At A Tertiary Care Hospital.

J Ayub Med Coll Abbottabad 2016 Oct-Dec;28(4):639-643

Department of Anaesthesiology, Aga Khan University Hospital, Karachi, Pakistan.

Background: Fast-track cardiac surgery programs have been established as the standard of cardiac surgical care. Studies have shown that early extubation in elective cardiac surgery patients, including coronary and non-coronary open-heart surgery patients does not increase perioperative morbidity and mortality. The objective of this observational study was to determine the success and failure profile of fast track extubation (FTE) practice in adult open-heart surgical patients.

Methods: The study was conducted at cardiac operating room and Cardiac Intensive Care Unit (CICU) of a tertiary care hospital for a period of nine months, i.e., from Oct 2014 to June-2015. All on pump elective adult cardiac surgery patients including isolated CABG, isolated Valve replacements, combined procedures and aortic root replacements were enrolled in the study. Standardized anesthetic technique was adopted. Surgical and bypass techniques were tailored according to the procedure. Success of Fast track extubation was defined as extubation within 6 hours of arrival in CICU.

Results: A total of 290 patients were recruited. The average age of the patients was 56.3±10.5 years. There were 77.6% male and 22.4% female patients. Overall success rate was 51.9% and failure rate was 48.1%. The peri-operative renal insufficiency, cross clamp time and CICU stay (hours) were significantly lower in success group. Re-intubation rate was 0.74%.

Conclusion: The perioperative parameters were significantly better in success group and the safety was also demonstrated in the patients who were fast tracked successfully. To implement the practice in its full capacity and benefit, a fast track protocol needs to be devised to standardize the current practices and to disseminate the strategy among junior anaesthesiologists, perfusionists and nursing staff.
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February 2018

ProSeal versus Classic laryngeal mask airway (LMA) for positive pressure ventilation in adults undergoing elective surgery.

Cochrane Database Syst Rev 2017 07 20;7:CD009026. Epub 2017 Jul 20.

Department of Anaesthesiology, Aga Khan University Hospital, Stadium Road, PO Box 3500, Karachi, Pakistan, 74800.

Background: The development of supraglottic airway devices has revolutionized airway management during general anaesthesia. Two devices are widely used in clinical practice to facilitate positive pressure ventilation: the ProSeal laryngeal mask airway (pLMA) and the Classic laryngeal mask airway (cLMA). It is not clear whether these devices have important clinical differences in terms of efficacy or complications.

Objectives: To compare the effectiveness of the ProSeal laryngeal mask airway (pLMA) and the Classic LMA (cLMA) for positive pressure ventilation in adults undergoing elective surgery.

Search Methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 3) in the Cochrane Library; MEDLINE (Ovid SP, 1997 to April 2017); Embase (Ovid SP, 1997 to April 2017); the Institute for Scientific Information (ISI) Web of Science (1946 to April 2017); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO host, 1982 to April 2017).We searched trial registries for ongoing studies to April 2017.We did not impose language restrictions. We restricted our search to the time from 1997 to April 2017 because pLMA was introduced into clinical practice in the year 2000.

Selection Criteria: We included randomized controlled trials (RCTs) that compared the effectiveness of pLMA and cLMA for positive pressure ventilation in adults undergoing elective surgery. We planned to include only data related to the first phase of cross-over RCTs.

Data Collection And Analysis: We used standard methodological procedures expected by the Cochrane Collaboration.

Main Results: We included eight RCTs that involved a total of 829 participants (416 and 413 participants in the pLMA and cLMA groups, respectively). We identified six cross-over studies that are awaiting classification; one is completed but has not been published, and data related to the first treatment period for the other five studies were not yet available. Seven included studies provided data related to the primary outcome, and eight studies provided data related to more than one secondary outcome.Our analysis was hampered by the fact that a large proportion of the included studies reported no events in either study arm. No studies reported significant differences between devices in relation to the primary review outcome: failure to adequately mechanically ventilate. We evaluated this outcome by assessing two variables: inadequate oxygenation (risk ratio (RR) 0.75, 95% confidence interval (CI) 0.17 to 3.31; four studies, N = 617) and inadequate ventilation (not estimable; one study, N = 80).More time was required to establish an effective airway using pLMA (mean difference (MD) 10.12 seconds, 95% CI 5.04 to 15.21; P < 0.0001; I² = 73%; two studies, N = 434). Peak airway pressure during positive pressure ventilation was lower in cLMA participants (MD 0.84, 95% CI 0.02 to 1.67; P = 0.04; I² = 0%; four studies, N = 259). Mean oropharyngeal leak (OPL) pressure was higher in pLMA participants (MD 6.93, 95% CI 4.23 to 9.62; P < 0.00001; I² = 87%; six studies, N = 709).The quality of evidence for all outcomes, as assessed by GRADE score, is low mainly owing to issues related to blinding and imprecision.Data show no important differences between devices with regard to failure to insert the device, use of an alternate device, mucosal injury, sore throat, bronchospasm, gastric insufflation, regurgitation, coughing, and excessive leak. Data were insufficient to allow estimation of differences for obstruction related to the device. None of the studies reported postoperative nausea and vomiting as an outcome.

Authors' Conclusions: We are uncertain about the effects of either of the airway devices in terms of failure of oxygenation or ventilation because there were very few events. Results were uncertain in terms of differences for several complications. Low-quality evidence suggests that the ProSeal laryngeal mask airway makes a better seal and therefore may be more suitable than the Classic laryngeal mask airway for positive pressure ventilation. The Classic laryngeal mask airway may be quicker to insert, but this is unlikely to be clinically meaningful.
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http://dx.doi.org/10.1002/14651858.CD009026.pub2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6483343PMC
July 2017

Outcome Analysis Of Two Different Injection Solutions For Epidural Injection In Radicular Lumbar Backache Syndromes.

J Ayub Med Coll Abbottabad 2016 Oct-Dec;28(4):709-714

Department of Orthopaedic, Batkhela, Pakistan.

Background: Backache is a significant source of disability and suffering in our society. The treatment modalities need continued enhancement in order to achieve the desired goals of lowering morbidity and financial losses while improving the response of the patient.

Methods: This prospective comparative study was conducted at the department of Orthopaedics and Spine Surgery, Khyber Teaching Hospital Peshawar from July 2013 to June 2015. Two interventional groups were designated; Group 1 was comprised of 54 patients who were injected with epidural bupivacaine plus methylprednisolone while Group 2 included 55 patients who were injected with bupivacaine only. Outcome was assessed using the visual analogue scale and Oswestry disability index (ODI).

Results: Fifty-five female and 54 male patients with mean age 49.37 years±10.46 SD, Mean symptoms duration was 15.01 months±9.32 SD. Common presenting symptoms were backache (77.1%), lower limbs pain (66.1%), dermatomal paresthesias (54.1%) and neurogenic claudication in 57.8% patients. The mean visual analogue score (VAS) after injection was 3.18±1.29 while mean ODI after injection was 23.615. There was a statistically significant reduction in VAS scores (2-sided p=0.003, OR =4.03, 95% CI: 1.535-10.60) following the injection.

Conclusions: An epidural spinal injection is a viable option for achieving relief of pain & improves functioning in individuals with radicular backache. However, further research is advised in order to clarify the role of ESI for long-term relief.
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November 2017

Role of intercostal nerve block in reducing postoperative pain following video-assisted thoracoscopy: A randomized controlled trial.

Saudi J Anaesth 2017 Jan-Mar;11(1):54-57

Department of Anaesthesiology, Aga Khan University, Karachi, Pakistan.

Background: The main advantages of video assisted thoracoscopic surgery (VATS) include less post-operative pain, rapid recovery, less postoperative complications, shorter hospital stay and early discharge. Although pain intensity is less as compared to conventional thoracotomy but still patients experience upto moderate pain postoperatively. The objective of this study was to assess the efficacy and morphine sparing effect of intercostal nerve block in alleviating immediate post-operative pain in patients undergoing VATS.

Materials And Methods: Sixty ASA I-III patients, aged between 16 to 60 years, undergoing mediastinal lymph node biopsy through VATS under general anaesthesia were randomly divided into two groups. The intercostal nerve block (ICNB group) received the block along with patient control intravenous analgesia (PCIA) with morphine, while control group received only PCIA with morphine for post-operative analgesia. Patients were followed for twenty four hours post operatively for intervention of post-operative pain in the recovery room and ward.

Results: The pain was assessed using visual analogue scale (VAS) at 1, 6, 12 and 24 hours. There was a significant decrease in pain score and morphine consumption in ICNB group as compared to control group in first 6 hours postoperatively. There was no significant difference in pain scores and morphine consumption between the two groups after 6 hours.

Conclusion: Patients receiving intercostal nerve block have better pain control and less morphine consumption as compared to those patients who did not receive intercostal nerve block in early (6 hours) post-operative period.
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http://dx.doi.org/10.4103/1658-354X.197342DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5292853PMC
February 2017

Prehospital Airway Management in Emergency and Trauma Patients: A Cross-sectional Study of Ambulance Service Providers and Staff in a Low- and Middle-income Country.

Prehosp Disaster Med 2015 Dec 12;30(6):606-12. Epub 2015 Nov 12.

2Department of Emergency Medicine,Aga Khan University,Karachi,Pakistan.

Background: Prehospital airway management (AM) is the first priority in the care of emergency and trauma victims as it has shown to improve survival in these patients.

Objective: The aim of this study was to assess training and knowledge of ambulance staff and availability of AM equipment in ambulances of Karachi, Pakistan.

Methods: This cross-sectional study was conducted from June through September 2014. Interviews were conducted with management of six ambulance service providers and 165 ambulance staff. Data from the management included availability of AM equipment in the ambulances, number and designation of staff sent for emergency calls, and AM training of staff. Ambulance staff were assessed for their awareness, knowledge, and training pertaining to AM.

Results: All the ambulance services (A through F) had basic equipment for AM but lacked qualified and trained staff. All services had solo drivers (98.3%) for emergency calls; however, Ambulance Service A also had doctors and paramedics. Only 35.7% (59/165) of ambulance staff had awareness regarding AM, out of which 77.9% (46/59) belonged to Ambulance Service A. Of these 59 staff, 81.4% received some form of AM training. Staff with AM awareness, when assessed for knowledge pertaining to AM steps and AM equipment, had a mean score of 4.7/5 and 8.4/12, respectively.

Conclusion: Even though ambulances are equipped with basic equipment, due to lack of trained staff, these ambulances only serve the mere purpose of transportation. There is a need to train ambulance staff and increase ambulance to staff ratio to improve prehospital AM and patient survival.
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http://dx.doi.org/10.1017/S1049023X15005385DOI Listing
December 2015

Continuous interscalene brachial plexus block versus parenteral analgesia for postoperative pain relief after major shoulder surgery.

Cochrane Database Syst Rev 2014 Feb 4(2):CD007080. Epub 2014 Feb 4.

Department of Anaesthesiology, Aga Khan University Hospital, Stadium Road, PO Box 3500, Karachi, Pakistan, 74800.

Background: Postoperative pain may lead to adverse effects on the body, which might result in an increase in morbidity. Its management therefore poses a unique challenge for the clinician. Major shoulder surgery is associated with severe postoperative pain, and different modalities are available to manage such pain, including opioid and non-opioid analgesics, local anaesthetics infiltrated into and around the shoulder joint and regional anaesthesia. All of these techniques, alone or in combination, have been used to treat the postoperative pain of major shoulder surgery but with varying success.

Objectives: The objective of this review was to compare the analgesic efficacy of continuous interscalene brachial plexus block (ISBPB) with parenteral opioid analgesia for pain relief after major shoulder surgery.

Search Methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 12), MEDLINE (1950 to December 2012), EMBASE (1980 to December 2012), Web of Science (1954 to December 2012), CINAHL (1982 to December 2012) and bibliographies of published studies.

Selection Criteria: We included randomized controlled trials assessing the effectiveness of continuous ISBPB compared with different forms of parenteral opioid analgesia in relieving pain in adult participants undergoing elective major shoulder surgery.

Data Collection And Analysis: Two review authors independently assessed trial quality and extracted outcome data.

Main Results: We included two randomized controlled trials (147 participants). A total of 17 participants were excluded from one trial because of complications related to continuous ISBPB (16) or parenteral opioid analgesia (one). Thus we have information on 130 participants (66 in the continuous ISBPB group and 64 in the parenteral opioid group). The studies were clinically heterogeneous. No meta-analysis was undertaken. However, results of the two included studies showed better pain relief with continuous ISBPB following major shoulder surgery and a lower incidence of complications when interscalene block is performed under ultrasound guidance rather than without it.

Authors' Conclusions: Because of the small number of studies (two) relevant to the subject and the high risk of bias of the selected studies, no reasonable conclusion can be drawn.
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http://dx.doi.org/10.1002/14651858.CD007080.pub2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7182311PMC
February 2014

Efficacy of tramadol in preventing postoperative shivering using thiopentone or propofol as induction agent: A randomized controlled trial.

J Anaesthesiol Clin Pharmacol 2013 Oct;29(4):521-5

Department of Anesthesia, Al Adan Hospital, Ministry of Health, Kuwait.

Background: Postoperative shivering (POS) is a common and distressing experience occurring in up to 60% patients postoperatively. This study was designed to compare the efficacy of tramadol in preventing POS when used with two different induction agent, propofol or thiopentone.

Materials And Methods: One hundred and twenty-four ASA I and II adult patients, aged between 18-60 years, undergoing general anesthesia of intermediate duration (60-240 min) for orthopedic, gynecological, and general surgical procedures were randomly divided to receive either thiopentone or propofol as induction agent. Each group was further subdivided (31 patients in each group) to receive either tramadol or saline 15 min before wound closure. Presence of POS after extubation till discharge from post anesthesia care unit (PACU) was recorded at six different time intervals.

Results: The highest incidence of POS was observed in thiopentone-saline (TS) group 77.4%, while the lowest (12.9%) was in propofol-tramadol (PT) group (P > 0.001). Total number of shivering episodes was 122 out of which, 35 (28.7%) were of grade 2 and 3 (significant shivering) requiring treatment. The incidence of significant shivering was similar to the episodes of POS, highest in TS group and lowest being in PT group (P > 0.05).

Conclusion: The prophylactic use of tramadol in a dose of 1 mg/kg with propofol as an induction agent significantly reduces the incidence of POS in patients recovering from general anesthesia of intermediate duration.
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http://dx.doi.org/10.4103/0970-9185.119166DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3819848PMC
October 2013

Comparison of upper lip bite test with Mallampati test in the prediction of difficult intubation at a tertiary care hospital of Pakistan.

J Pak Med Assoc 2012 Oct;62(10):1012-5

Department of Anaesthesia, Aga Khan University, Karachi, Pakistan.

Objective: To determine the accuracy of the Upper lip bite test and Mallampati test in predicting difficult endotracheal intubation.

Methods: The cross-sectional study was conducted at the Aga Khan University Hospital, a tertiary care facility in Karachi, Pakistan. Between June 1,2007 and May 31, 2008, 324 adult patients undergoing elective surgeries requiring general anaesthesia with endotracheal intubations were enrolled. Pre-operatively upper lip bite test and Mallampati test were performed for the assessment of airway by a specifically trained observer. Laryngoscopic view was rated by using Cormack and Lehane laryngoscopic grading once the patient was fully anaesthetised using standard anaesthesia technique. Completed data sheets were analysed using SPSS version 10. McNemar test and rank correlation coefficient were used to compare the upper lip bite test and the Mallampati test.

Results: Of the 324 patients, 56 (17.3%) were classified as cases of difficult intubation. Upper lip bite test showed significantly higher accuracy, positive predictive value and negative predictive value than the Mallampati test. Comparison of specificity, however, did not reveal any significant difference between the two tests.

Conclusion: Upper lip bite test is an acceptable alternative as a single test to predict difficult intubation in addition to other tests of airway assessment for the prediction of difficult intubation.
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October 2012

Spontaneous intracranial hypotension in a patient with Marfan's syndrome treated with epidural blood patch--a case report.

Middle East J Anaesthesiol 2012 Feb;21(4):635-8

Department of Anaesthesia and Intensive Care, Aga Khan University, Pakistan.

Spontaneous intracranial hypotension (SIH) is a well-defined clinical entity that is frequently misdiagnosed. We are reporting a case of 38 years old male who presented with severe headache and an episode of generalized tonic-clonic seizure. He was managed successfully with an epidural blood patch. Understanding of the characteristics, symptomatology, evaluation, treatment options, and prognosis is discussed.
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February 2012

Anaesthetic challenges in emergency surgical repair of acute aortic dissection rupturing into the pericardium in a pregnant patient.

J Pak Med Assoc 2011 Jan;61(1):85-7

Department of Anaesthesia, Aga Khan University Hospital, Karachi.

Acute aortic dissection in pregnancy is a serious situation, because rapid and appropriate surgical decision making is required to save the life of both mother and baby. Aortic dissection is rare in young women but is likely during pregnancy (third trimester) secondary to the hyperdynamic and hypervolaemic circulatory state associated with pregnancy. A 35 years old 27 weeks pregnant patient weighing 90 kg presented in the emergency with severe chest pain. In the immediate post cardiopulmonary bypass period, the patient started bleeding profusely from the anastamotic sites irrespective of utilization of all the conventional methods of haemostasis including multiple units of whole blood, fresh frozen plasma, platelets, calcium and cryoprecipitates. As a last resort she was given low dose r FVIIa (1.2 mg containing 60 KIU of Factor VII). This stopped the bleeding and the haemodyramics were stabilized.
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January 2011

Complications and interventions associated with epidural analgesia for postoperative pain relief in a tertiary care hospital.

Middle East J Anaesthesiol 2010 Oct;20(6):827-32

Department of Anaesthesia, Aga Khan University Hospital, Karachi, Pakistan.

Introduction: Epidural analgesia is one of the commonly used methods of postoperative pain control despite its associated complications. Early recognition and intervention is required to minimize the effect of these complications. Present audit was conducted to find out the incidence of complications and type of interventions required to change the outcome.

Methodology: The record of all the patients who had epidural catheter placed for postoperative pain management reviewed from the departmental acute pain management register. Parameters included level of insertion, drugs used, number of days infusion continued and complications like nausea, vomiting, motor block, sedation, dural tap, catheter pull out, hypotension and itching. In addition, the intervention done to manage these complications was also recorded.

Results: Total 1706 entries of epidurals were recorded in study period 2001 to 2007. The overall incidence of the complication was 26.6%. The common complications were motor block (13.4%), dural tap (1.2%), ineffective pain control (2.4%), accidental catheter pull outs (3.8%) and problems associated with the delivery system of drug (1.7%). The 12% of patients required intervention for the particular complications. The regime was discontinued in 28%, drug concentration changed in 21.5% while the other modes of pain management were used in 19% of patients. 0.9% of patients required epidural blood patch while 2% of patients required catheterization for urinary retention.

Conclusion: This audit shows the importance of regular assessment and early intervention to manage epidural related complications in improving outcome.
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October 2010

Mitral valve replacement in a twin pregnancy.

J Obstet Gynaecol Res 2011 Jul 13;37(7):916-8. Epub 2011 Mar 13.

Medical College, Aga Khan University Hospital, Karachi, Pakistan.

A 35-year-old female with twin gestation diagnosed with severe mitral stenosis and pulmonary hypertension was successfully treated with open heart surgery for mitral valve replacement (MVR). She gave birth to twins with good Apgar scores at 33 weeks of gestation by cesarean section. Cardiac surgery in singleton pregnancy has been reported extensively. However, there is only a single reported case of MVR following therapeutic abortion of a twin pregnancy in the second trimester. In contrast, we report the first case of mitral valve replacement for severe mitral stenosis and pulmonary hypertension in an ongoing twin pregnancy with successful outcomes.
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http://dx.doi.org/10.1111/j.1447-0756.2010.01429.xDOI Listing
July 2011

Grown up congenital heart disease patient presenting for non cardiac surgery: anaesthetic implications.

J Pak Med Assoc 2010 Nov;60(11):955-9

Department of Anaesthesia, Aga Khan University Hospital, Karachi.

Congenital heart disease patients surviving to adulthood have increased over the years due to various reasons. These patients are admitted in the hospital for non cardiac surgeries and other procedures more often than normal adult population. Management of grown up congenital heart disease patient presents a challenge during perioperative period for cardiologists, surgeons, intensivists and particularly for the anaesthetist. Management issues include psychological and physiological impact on the patient, complexity of defects, presence of previous palliative procedure, impact of anaesthetic agents on shunting and myocardium, endocarditis prophylaxis and associated extra cardiac anamolies.
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November 2010

Effectiveness of premature epidural catheter termination as a quality indicator in a developing country.

Eur J Anaesthesiol 2010 Jul;27(7):637-41

Department of Anaesthesia, Aga Khan University, Karachi, Pakistan.

Background And Objective: Premature epidural catheter termination in the postoperative period is a common cause of epidural analgesia failure. The incidence varies from 5.7 to 13%. A higher incidence of unplanned epidural catheter termination was observed in our hospital. We took this as a quality improvement project, monitored the causes and applied remedial measures at the same time to reduce the incidence.

Method: An audit was conducted by the Acute Pain Service between January 2004 and December 2007 to find the incidence and different causes of accidental epidural catheter pullout. Different strategies were applied simultaneously to counter the identified causes. A predesigned pro forma was used for audit while remedial measures included change in practice, counselling of the person responsible, group teaching and reinforcement of epidural care policy.

Results: The overall incidence of premature epidural termination was 3.9% during a 4-year period with a higher incidence in 2004 (5.59%), which was reduced in later years. The main reason for premature epidural catheter removal was mishandling of the catheter and filter (64%). The most common site for catheter disconnection was found to be at the filter end of the catheter (54.7%), although 39 (61%) epidural catheters were removed by the Acute Pain Service following disconnection or breakage to avoid danger of infection.

Conclusion: Identification of premature epidural catheter termination as a quality indicator and continuous quality improvement efforts later on proved to be a useful approach in reducing the incidence. The present audit also helped to quantify the improvement in the quality of care.
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http://dx.doi.org/10.1097/eja.0b013e328338d56bDOI Listing
July 2010

Hemodynamic effects of anesthetic induction in patients treated with beta and calcium channel blockers.

Middle East J Anaesthesiol 2008 Jun;19(5):1111-28

Dept. of Anaesthesia, Agha Khan Univ., Karachi, Pakistan.

Background: The response to anesthetic induction and airway manipulation in the presence of cardiovascular disease and antihypertensive therapy has not been adequately investigated.

Methods: The blood pressure, pulse pressure and heart rate changes at induction and following tracheal intubation were compared in patients who were on either preoperative beta-adrenergic blocker therapy (BB group, n = 20) or a combination of beta-adrenergic blocker and calcium channel blocker therapy (BB + CCB group, n = 20). A standardized anesthesia induction protocol was followed, in the two gourps.

Results: No statistical difference was observed in the hemodynamic parameters between the two groups. The total number of hypotensive patients (SAP 90
Conclusion: Hypotension requiring treatment in patients receiving a combination of BB + CCB is more frequent after induction of anesthesia.
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June 2008

Awareness during anesthesia--an update.

Middle East J Anaesthesiol 2008 Feb;19(4):723-35

Dept. of Anaesthesia & Intensive Care, Aga Khan Univ, Karachi,Pakistan.

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February 2008

Comparison between tramadol and pethidine in patient controlled intravenous analgesia.

J Pak Med Assoc 2006 Oct;56(10):433-6

Department of Anaesthesia, Aga Khan University, Karachi.

Objective: To compare the efficacy and side effects related to Tramadol with Pethidine in patient controlled intravenous analgesia (PCIA) after total abdominal hysterectomies.

Methods: A total of 60 patients were randomized to receive either Tramadol or Pethidine by PCIA (30 in each group) after total abdominal hysterectomy. Pain assessments were recorded one hour after starting the PCIA and then at 6, 12, and 24 hours by using visual analogue scale (VAS). Nausea vomiting score and sedation score were also recorded. Good attempts, total attempts and total drug consumption was noted from PCIA pump at the end of the study period.

Results: The analgesia achieved in Tramadol group was comparable to Pethidine. The incidence of nausea and vomiting was similar in both groups. Tramadol causes significantly less sedation than Pethidine (p < 0.05). Mean drug consumption, total attempts and good attempts were also significantly less in Tramadol group than Pethidine group (p < 0.05).

Conclusion: Tramadol produces equivalent analgesia and less sedation and can be used as an alternative to Pethidine in Patient Controlled Intravenous Analgesiafor postoperative pain relief after Total Abdominal Hysterectomy (TAH).
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October 2006

Unplanned prolonged postanaesthesia care unit length of stay and factors affecting it.

J Pak Med Assoc 2006 Mar;56(3):108-12

Department of Anaesthesia and Intensive Care, Aga Khan University, Karachi.

Objective: To identify the factors that prolong the length of stay inthe post anaesthesia care unit (PACU).

Methods: This audit was conducted in the PACU of a university hospital. A special form was designed and filled for those patients who stayed unplanned in the PACU for more than two hours. All patients who were admitted to the PACU after surgery were included. Patients undergoing cardiothoracic surgery, those directly shifted to ICU and cases done under local anaesthesia were excluded. Data was collected for 20 months by a designated recovery nurse for all included patients including those admitted outside the scheduled surgery hours.

Results: The total number of patients who were admitted to the PACU during the audit period were 13644, out of these 1114 (8.1%) stayed in the PACU for more than 2 hours. The percentage of overstay patients on monthly basis ranged from 6.4% to 10%. The commonest reason was the need for postoperative monitoring 578 (51.8%), unavailability of beds in the special care areas 264 (23.7%), pain management 68 (6.1%) and 61 (5.4 %) for postoperative ventilation.

Conclusion: Our results show that majority of patients stayed in the PACU for more than two hours either because they needed postoperative monitoring or because of unavailability of bed in the special care areas.
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March 2006

The role of prophylactic intra-aortic balloon pump counterpulsation (IABP) in emergency non-cardiac surgery.

J Pak Med Assoc 2006 Jan;56(1):42-3

Department of Anaesthesia and Intensive Care, Aga Khan University, Karachi.

Patients with recent myocardial infarction (MI), congestive heart failure, severe angina, or uncorrected multivessel coronary artery disease are at increased risk of cardiac complications after urgent major non-cardiac surgery. Although invasive haemodynamic monitoring and preoperative optimization of cardiac status may lead to some reduction in the rate of perioperative cardiac events, the mortality from such events still remains high. The use of an intra-aortic balloon pump (IABP) may play a role in such patients by improving the function of the injured heart. We report our experience with the use of perioperative IABP in a patient with unstable angina and recent MI who underwent urgent cholecystectomy. There were no perioperative cardiac events while the IABP was in place. The anaesthetic concerns, intraoperative and postoperative monitoring and care and usefulness of IABP will be discussed.
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January 2006
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