Background: To compare oral midazolam (0.5 mg/kg) versus oral clonidine (4 μg/kg) as a premedication in pediatric patients aged between 2-12 years with regard to sedation and anxiolysis. Methods: Sixty pediatric patients belonging to the American Society of Anesthesiologists class I and II between the age group of 2-12 years scheduled for elective surgery were randomly allocated to receive either oral midazolam (group I) 30 min before induction or oral clonidine (group II) 90 min before induction of anesthesia. The children were evaluated for levels of sedation and anxiety at the time of separation from the parents, venepuncture, and at the time of mask application for induction of anesthesia. Results: After premedication, the percentage of children who were sedated and calm increased in both the groups. The overall level of sedation was better in the children in the clonidine group, but children in the midazolam group had a greater degree of anxiolysis at times of venepuncture and mask application. In addition, midazolam did not cause significant changes in hemodynamics unlike clonidine where a significant fall in blood pressure was noted, after premedication, but preinduction. Conclusion: We conclude that under the conditions of the study, oral midazolam is superior to clonidine as an anxiolytic in pediatric population. Clonidine with its sedative action especially at the time of separation from parents along with its other perioperative benefits cannot be discounted.

Purpose: General anesthesia causes inhibition of thermoregulatory mechanisms. Propofol has been reported to cause more temperature fall, but in case of deliberate mild hypothermia, both sevoflurane and propofol were comparable. Thermoregulation is found to be disturbed in cases of pituitary tumors. We aimed to investigate which of the two agents, sevoflurane or propofol, results in better preservation of thermoregulation in patients undergoing transsphenoidal excision of pituitary tumors. Methods: Twenty-six patients scheduled to undergo transsphenoidal removal of pituitary adenomas were randomly allocated to receive propofol or sevoflurane anesthesia. Baseline esophageal temperature was noted. Times for temperature to fall by 1°C or 35°C and to return to baseline were also comparable ( P>0.05). After that warmer was started at 43°C and time to rise to baseline was noted. Duration of surgery, total blood loss, and total fluid intake were also noted. If any, side effects such as delayed arousal and recovery from muscle relaxant were noted. Results: The demographics of the patients were comparable. Duration of surgery and total blood loss were comparable in the two groups. The time for temperature to fall by 1°C or 35°C and time to return to baseline was also comparable ( P>0.05). No side effects related to body temperature were noted. Conclusion: Both propofol and sevoflurane show similar effects in maintaining thermal homeostasis in patients undergoing transsphenoidal pituitary surgery.

Background: Thoracic epidural anesthesia (TEA) improves analgesia and outcomes after a cardiac surgery. As aging is a risk factor for postoperative pulmonary complications, TEA is of particular importance in elderly patients undergoing coronary artery bypass graft (CABG). Methods: Fifty patients aged 65-75 years; ASA II and III scheduled for elective CABG were included in the study. Patients were randomized to receive either general anesthesia (GA) group alone or GA combined with TEA group. Heart rate (HR), mean arterial pressure (MAP), and central venous pressure were recorded. Total dose of fentanyl ΅g/kg, aortic cross clamping, cardiopulmonary bypass (CPB) time, time to first awaking and extubation, arterial blood gases, visual analog scale (VAS) score in intensive care unit were reported. Postoperative pulmonary function tests were done. Results: TEA showed a significant HR and lower MAP compared with the GA group. The total dose of intraoperative fentanyl and nitroglycerine were significantly lower in the TEA. Patients in TEA group have statistically significantly higher PaO ₂ , lower PaCO ₂ , increase in Forced Vital Capacity (FVC) and Forced Expiratory Volume in one second (FEV ₁ ) Conclusions: TEA reduced severity of postoperative pulmonary function and restoration was faster in TEA group in elderly patients undergoing CABG. Also, it resulted in earlier extubation and awakening, better analgesia, lower VAS.

Background: We evaluated the anesthetic efficacy and the postoperative analgesic effects of 0.75% levobupivacaine versus 0.75% ropivacaine for peribulbar anesthesia in patients undergoing primary vitreoretinal surgery. Methods: We investigated 120 patients subjected to vitreoretinal surgery under peribulbar anesthesia. They were randomized into two equal groups according to the local anesthetic (LA) used, namely, 0.75% levobupivacaine or 0.75% ropivacaine, both with the addition of hyaluronidase. Nerve block was carried out by injection of 5-7 mL of the LA using single injection percutaneous peribulbar anesthesia with a short needle. Results: When compared with 0.75% ropivacaine, 0.75% levobupivacaine provided more successful akinesia at 10 min after block (P=0.026), fewer supplementary injections (P=0.026), and less volume (mL) was used (P=0.031). Also, levobupivacaine provided significantly longer motor block duration (342±27 min versus 206±40 min, P=0.001) and significantly longer sensory block duration (513±24 min versus 394±11 min, P=0.001) when compared with ropivacaine. In the postoperative period, the patients in the levobupivacaine group achieved lower values of verbal numeric rating scale of pain compared with patients in the ropivacaine group among the period from 4 to 12 h. Also, there were significantly (P=0.001) lower diclofenac consumption (mg) and the percentage of patients who required tramadol rescue medication were significantly less (P=0.034) in the levobupivacaine group compared with the ropivacaine group. Conclusion: We are concluding that, at equipotent doses and concentrations, 0.75% levobupivacaine provides more effective peribulbar anesthesia and more effective postoperative analgesia for vitreoretinal surgery compared with 0.75% ropivacaine.

Background: Laparoscopy is one of the most common surgical procedures and is the procedure of choice for most of the elective abdominal surgeries performed preferably under endotracheal general anesthesia. Technical advances in the field of laparoscopy have helped to reduce surgical trauma and discomfort, reduce anesthetic requirement resulting in shortened hospital stay. Recently, regional anaesthetic techniques have been found beneficial, especially in patients at a high risk to receive general anesthesia. Herewith we present a case series of laparoscopic appendectomy in eight American Society of Anaesthesiologists (ASA) I and II patients performed under spinal-epidural anaesthesia. Methods: Eight ASA Grade I and II adult patients undergoing elective Laparoscopic appendectomy received Combined Spinal Epidural Anaesthesia. Spinal Anaesthesia was performed at L ₂ -L ₃ interspace using 2 ml of 0.5% (10 mg) hyperbaric Bupivacaine mixed with 0.5ml (25 micrograms) of Fentanyl. Epidural catheter was inserted at T ₁₀ -T ₁₁ interspace for inadequate spinal anaesthesia and postoperative pain relief. Perioperative events and operative difficulty were studied. Systemic drugs were administered if patients complained of shoulder pain, abdominal discomfort, nausea or hypotension. Results: Spinal anaesthesia was adequate for surgery with no operative difficulty in all the patients. Intraoperatively, two patients experienced right shoulder pain and received Fentanyl, one patient was given Midazolam for anxiety and two were given Ephedrine for hypotension. The postoperative period was uneventful. Conclusion: Spinal anaesthesia with Hyperbaric Bupivacaine and Fentanyl is adequate and safe for elective laparoscopic appendectomy in healthy patients but careful evaluation of the method is needed particularly in compromised cardio respiratory conditions.

Aim: The aim of this study was to demonstrate that APACHE II scores can be used as a predictor of the cardio-pulmonary resuscitation (CPR) outcome in hospitalized patients. Methods: A retrospective chart review of patients admitted, from 2002 to 2007, at the Aga Khan University Hospital, Karachi, was done for this study. Information was collected on 738 patients, constituting all adults admitted in general ward, ICU, CICU and SCU during this time, and who had under-went cardiac arrest and received cardiopulmonary resuscitation during their stay at the hospital. Patient characteristics, intra-arrest variables such as event-witnessed, initial cardiac rhythm, pre arrest need for intubation and vasoactive drugs, duration of CPR and survival details were extracted from patient records. The APACHE II score was calculated for each patient and a descriptive analysis was done for demographic and clinical features. The primary outcome of successful CPR was categorized as survival >24 h after CPR versus survival <24 h after CPR. Multivariable logistic regression was used to assess the association between the explanatory variables and successful CPR. Results: Patients with APACHE II scores less than 20 had 4.6 times higher odds of survival compared to patients with a score of >35 (AOR: 4.6, 95% CI: 2.4-9.0). Also, shorter duration of CPR (AOR: 2.9, 95% CI: 1.9-4.4), evening shift (AOR: 2.1, 95% CI: 1.3-3.5) and Male patients (AOR: 0.6, 95% CI: (0.4-0.9) compared to females were other significant predictors of CPR outcome. Conclusion: APACHE II score, along with other patient characteristics, should be considered in clinical decisions related to CPR administration.

Background: Epidural analgesia is claimed to result in prolonged labor. Previous studies have assessed epidural analgesia vs systemic opioids rather than to parturients receiving no analgesia. This study aimed to evaluate the effect of epidural analgesia on labor duration compared with parturients devoid of analgesia. Methods: One hundred sixty nulliparous women in spontaneous labor at full term with a singleton vertex presentation were assigned to the study. Parturients who request epidural analgesia were allocated in the epidural group, whereas those not enthusiastic to labor analgesia were allocated in the control group. Epidural analgesia was provided with 20 mL bolus 0.5% epidural lidocaine plus fentanyl and maintained at 10 mL for 1 h. Duration of the first and second stages of labor, number of parturients receiving oxytocin, maximal oxytocin dose required for each parturient, numbers of instrumental vaginal, vacuum-assisted, and cesarean deliveries and neonatal Apgar score were recorded. Results: There was no statistical difference in the duration of the active-first and the second stages of labor, instrumental delivery, vacuum-assisted or cesarean delivery rates, the number of newborns with 1-min and 5-min Apgar scores less than 7 between both groups and number of parturients receiving oxytocin, however, the maximal oxytocin dose was significantly higher in the epidural group. Conclusion: Epidural analgesia by lidocaine (0.5%) and fentanyl does not prolong labor compared with parturients without analgesia; however, significant oxytocin augmentation is required during the epidural analgesia to keep up the aforementioned average labor duration.

Background: Tranexamic acid has been used to reduce bleeding and the subsequent need for blood transfusion in many surgeries. Because orthognathic surgery can be associated with significant bleeding, this study evaluated the efficacy of prophylactic intravenous (IV) tranexamic acid on blood loss during bimaxillary osteotomy. Methods: Thirty-two consecutive patients, scheduled for elective bimaxillary osteotomy, were included in the study and 16 were randomly assigned to each group. They received tranexamic acid (20 mg/kg) or equal volume of placebo (normal saline) intravenously just before induction of anesthesia. Intraoperative blood loss, pre and post operative hemoglobin (Hb) and hematocrit (Hct) concentration, duration of surgery, hospital stay time, and rate of blood transfusion were recorded for each patient. Results: Intraoperative blood loss in the tranexamic group and control group were 585.9 and 790 mL respectively (P=0.008). Postoperative Hb concentration at the 6 ^th hour was greater in the tranexamic group (P=0.008). There was no significant difference in the Hct concentration between the study groups. There was no significant difference in blood transfusion rate, hospital stay time and duration of surgery between the study groups. Conclusion: Preoperative IV administration of tranexamic acid reduces the amount of blood loss during bimaxillary osteotomy.

Background: Anesthesiology may be stressful and most anesthesiologists develop mechanisms for coping. However, inexperienced trainee anesthesiologists seem to be vulnerable. We studied stress perception and job burnout in trainee anesthesiologists. Methods: Responses to perceived stress scale (PSS) and Maslach Burnout Inventory (MBI) were evaluated in 159 trainee anesthesiologists. Results: In our results, when perceived stress was increased, emotional exhaustion and depersonalization increased but personal accomplishment decreased, as expected. Perceived stress was very high in the early years of training. There was a negative correlation between age and emotional exhaustion and depersonalization, but positive correlation with personal accomplishment. Female anesthesiologists had higher personal accomplishment, but lower depersonalization points than male anesthesiologists in our study. There was no statistical association between marital status, PSS, and MBI; ≥2 children group had a significant high personal accomplishment but low depersonalization and emotional exhaustion scores. Line regression analysis showed a statistically significant relationship between PSS and emotional exhaustion and between age and depersonalization. Conclusions: Social factors such as gender and number of children affect the work life of our trainees.

Aims: The aim of our study was to compare the effects of suprascapular nerve block in patients with frozen shoulder and diabetes mellitus unresponsive to intraarticular steroid injections. Settings and Design: Ten patients without improvement of sign and symptoms after intraarticular injections were made a suprascapular nerve block. Methods: Pain levels and active range of movement of patients were recorded at initial attendance and after 1, 4, and 12 weeks. All patients' simple pain scores, total pain scores, and range of motion of their shoulders were improved significantly after suprascapular nerve block. Statistical Analysis: In this study, the statistical analyses were performed by using the SPSS 8.0 program (SPSS Software, SPSS Inc., USA). To compare pre- and post-injection results of simple pain score, total pain score, shoulder abduction and external rotation, Wilcoxon test was used. Results: Patient's simple pain scores, total pain scores also abduction, external rotation and internal rotation angles were improved significantly after suprascapular nerve block. Conclusion: Effective results after suprascapular nerve blockage was obtained for the treatment of refractory frozen shoulder cases.

Background: This prospective double-blind randomized study aims to study the hemodynamic changes following fluid preloading with Hydroxyethyl starch (HES) 6% (130/0.4) compared with normal saline (NS) in cardiac surgery patients. Methods: Forty patients undergoing coronary artery bypass grafting (CABG) were enrolled in this study, then they were divided in 2 equal groups, HES and NS. After fast administration of 10 mL/kg from either solutions over 5 min only, hemodynamic parameters, such as heart rate, mean arterial pressure (MAP), central venous pressure (CVP), pulmonary artery occlusion pressure (PAOP), mean pulmonary artery pressure, systemic vascular resistance, and pulmonary vascular resistance were measured every 5 min for the total duration of 40 minutes. Results: There were significant differences in the cardiac index measurements between both groups at 15 min onward; also PAOP was significantly higher in HES group at 10 min onward. CVP was higher in HES group but statistically significant at 10 min only. MAP was higher in HES group, but that was statistically significant at 40 min only. On the other hand PAP was significantly higher at 10 and 40 min. Conclusion: Fluid preloading with HES led to a significant increase in filling pressure of the left ventricle (PAOP) and cardiac index compared with NS. We believe that HES (130/0.4) could be a suitable solution for fluid preloading in CABG surgery patients. However, further studies are needed on different fluid preloading modalities with different dosing regimens.

We report here the management of glass fragment buried in the soft tissue close to the ulnar nerve. Also discuss how ultrasound provides real-time guidance without radiation exposure and emphasize the importance of this evolving and exciting imaging field.

We present an unusual diagnosis of a permanent third-degree atrioventricular block under general anesthesia in an otherwise healthy and asymptomatic child. This diagnosis of unclear causality represented a serious rare finding, requiring judicious management and resulting in the placement of a permanent pacemaker.

Heroin use is associated with several well described respiratory complications, including noncardiogenic pulmonary edema, aspiration pneumonitis, acute respiratory distress syndrome,pneumonia, lung abscess, septic pulmonary emboli, and atelectasis. We describe an interesting case of a young female patient, an intravenous heroin user who presented with progressive dyspnea, hypoxia, and left lung consolidation.

Tracheobronchial disruption is a potentially life-threatening airway challenge for all the anesthesiologists. Carinal rents, although rare, if not timely managed can be catastrophic. We describe a patient with carinal rent being managed successfully by prompt diagnosis, use of low pressure ventilation, and bronchoscopic sealing using tissue glue.

Cholecystectomy represents the second most common surgery during pregnancy. Both general and regional anesthetic techniques have been successfully used for cholecystectomy in pregnant patients. Authors present here a case of a pregnant patient carrying twin gestation who underwent cholecystectomy, which is not frequently encountered by the anesthesiologists. This report enumerates the perioperative issues relating to anesthesia given to a pregnant patient in addition to emphasizing the importance of multidisciplinary approach when such a case is encountered.