Medication Error in Anaesthesia – A Review

Medication error is a major cause of morbidity and mortality in medical profession . There is an increasing recognition that medication errors are causing a substantial global public health problem, as many result in harm to patients and increased costs to health providers.Anaesthesia is now safe and routine, yet anaesthetists are not immune from making medication errors and the consequences of their mistakes may be more serious than those of doctors in other specialties. Steps are being taken to determine the extent of the problem of medication error in anaesthesia. In this review, incidence, types, risk factors and preventive measures of the medication errors are discussed in detail.Journal of Bangladesh Society of Anaesthesiologists 2014; 27(1): 31-35

TAP Block in Postoperative Analgesia, A First Time Clinical Trial In Bangladesh

Background: In perioperative care, a reliable pain management is a vital appeal. Over recent years, Transversus Abdominis Plane (TAP) block is introduced as an important component of multimodal analgesia.Objective: To evaluate efficacy of TAP block in postoperative analgesia for Total Abdominal Hysterectomy (TAH) with subarachnoid block (SAB) in comparison of morphine consumption and VAS score.Methods: 60 patients were randomly allocated into 2 groups (TAP group-A & control group-B). Standard SAB was applied to all patients for elective TAH. Immediate after operation classical TAP block was performed through both Lumber Triangle Of Petit (LTOP) of group A patients. Both groups were placed in Post Anesthesia Care Unit (PACU), arranged a common standard postoperative analgesic regimen for all, observed periodically and documented it accordingly in pre-designed data sheet.Results: TAP block prolonged the mean time of 1st required I/V morphine (TAP vs control, mean±SD 271.23±40.34 vs 195.33±22.16 min., p=0.001HS). Morphine requirement was also reduced (17.4±5.4 vs 26.2±4.4 mg, p=0.001HS). Pain VAS scores at rest and movement were also reduced at all time period (p? 0.01 to 0.001). There was no complication attributed to the TAP block.Conclusion: TAP block provided considerably effective postoperative analgesia in first 24 hours after major abdominal surgery like TAH.Journal of Bangladesh Society of Anaesthesiologists 2014; 27(1): 3-11

Separation Time of Children From Parents: A Randomized Comparison Between oral versus Atomized Intranasal Administration of Midazolam

Background: Sedation has become more common for children undergoing procedures in the emergency department, dentistry, and day care surgery. A desirable sedative agent has a rapid onset with short duration of action and is effective and safe. Midazolam as a sedative agent that fulfills these criteria. However controversy surrounds regarding its route of administration, particularly with respect to its ease of administration and patient acceptance. Although the oral route of administration is the most popular among pediatric surgeons and dentists, confrontation and frustration often arise when children refuse to accept the sedative medication.Objectives: To evaluate the outcome (satisfactory anxiolysis and smooth early parental separation) between oral midazolam (OM) and intranasal midazolam(INM)spray in children for conscious sedation before general anaesthesia.Methods: Children aged 1 – 6 years scheduled for routine elective surgery were included to receive midazolam as premedication drug. A total of 80 children were recruited consecutively. Of them 40 were randomly assigned to either single dose of 0.5 mg/kg via oral route (OM0) or 0.5 mg/kg of body weight by intranasal spray(INM). The outcome variables were smooth separation of children from their parents at the level of conscious sedation and time to smooth separation.Results: No change in sedation score was evident in first 3 minutes following midazolam administration. Then the sedation score of INM group increased sharply to assume a mean score of 2 at 9 minutes. No demonstrated change was further noted up to the end of observation. Meanwhile the sedation score of OM group began to increase steadily up to the end of observation when it assumed a mean score of 1.5. The INM group attained a good level of sedation much earlier than its OM counterpart. The mean sedation scores were significantly higher in the former group than those in the latter group. During the first 3 minutes of midazolam administration no change in anxiolysis was noted. Then the score began to increase in both the INM and OM groups, but INM group experienced a much faster increase than the OM group so that the former group reached a mean score of almost 3 and the latter group to a mean score of nearly 2 at 15 minutes interval. The levels of anxiolysis attained by the intranasal group were significantly higher compared to those attained by the oral midazolam group (table II).All but 1 children (97.5%) in the INM group were separated from their parents smoothly as opposed to 90% in the OM group (p = 0.148). In the INM group 12.8% of children were separated at 9 minutes, 69.2% from 10 – 12 minutes (over two-thirds) and 18% from 15 – 18 minutes. In the OM group 13.9% were separated at 15 minutes, about 39% at 18 – 21 minutes, 22.3% at 24 minutes and the rest 11.1% at 27 minutes after premedication. Overall more than 80% of the children in the INM group were separated at 9 – 12 minutes following midazolam administration when none of the children in the OM group was separated (p < 0.001). Complications like nasal irritation was staggeringly higher in the INM group shown on table IV.Conclusion: Despite the intranasal route causes a substantial proportion of children to suffer from nasal irritation, it is the preferred route over oral route, because intranasal route induces much faster sedation and anxiolysis and helps easy and smooth separation of children from their parents.Journal of Bangladesh Society of Anaesthesiologists 2014; 27(1): 17-23

Mass Casualty in A Building Collapse: Techniques of Anaesthesia in Mass Casualty Management (Rana Plaza Collapse at Savar, Bangladesh)

Background: Management of mass casualties in a disaster like situation needs much of discussion. Proper planning and preparation can markedly change the mortality and morbidity following these events. Similarly right use of special skill of anesthesiologists in the management of mass casualty is of immense value.Objectives: This study was aimed to investigate general injury profile, pattern of operations and anesthesia performed during mass casualty management of patients treated in the department of Anesthesia and Intensive care unit of Combined Military Hospitals, Savar.Methods: This study retrospectively investigated the clinical records of 155 patient’s files registered by many different doctors. We used discharge diagnosis, and when available objective x-ray or CT scan used for verification of fractures.Results: Among 431 patients reported to emergency and casualty department, 407 (94.431%) is admitted to hospital. Among 431 patients only 155 (35.962%) is treated in the department of Anesthesia and Intensive care. Among 155 patients of ICU, most of the injuries were blunt trauma soft tissue, rest of the injuries were fractures, head injuries, crush injuries etc, which accounts 95 (61.29%) patients. Majority of surgical procedure included wound debridment, fasciotomy, amputation and external fixation; constituted 51(33%) patients. 132(84%) surgical procedure performed under TIVA with ketamine, 22 (15%) under different regional techniques and only one patient received general anesthesia.Conclusion: Bangladesh is situated in a seismically active zone; fortunately no major earthquake has striken since 1940. Accelerated urbanization and high population densities in all cities are increasing the vulnerability of Bangladesh to catastrophic number of death and injuries. Ninety percent of casualties after earthquake result directly from the collapse of buildings in urban areas. The special skills of the anesthesiologist are of tremendous value in contributing mass casualty management in ICU and operating room. Our study concludes that surgical services can be maximized with the judicious and intelligent use of ketamine and regional anesthetic technique; rather than general anesthesia. Definitely it has strong value in maximizing use of scare resource in country like Bangladesh.Journal of Bangladesh Society of Anaesthesiologists 2014; 27(1): 12-16

A Comparative Randomised Clinical Study Between Nebulised Fentanyl and Intravenous Fentanyl For Post Operative Pain Relief

Background and Aim: Intravenous (IV) route for fentanyl administration is very effective for postoperative pain relief, but complications such as respiratory depression, bradycardia and hypotension have limited this route. The aim of this randomised clinical trial was to compare the efficacy of nebulised fentanyl with IV fentanyl for post-operative pain relief after lower abdominal surgery. Methods:In the post-operative wards, at the time of first onset of pain( visual analogue scale- VAS score > 5) patients were randomised into two groups and either fentanyl IV 2 ìg/kg or by nebulisation of solution containing 4 ?g/kg fentanyl over 6-8 min in 120 patients divided into two groups of 60 each. Observation were made for pain relief by visual analogue scale score 0-10. Adverse effects such as respiratory depression, bradycardia and hypotension were also recorded. Statistical analysis was performed using Medcalc software version 12, 2012. (MedCalc Software, Ostend, Belgium). Results: In the nebulisation group, it was observed that the analgesic efficacy of fentanyl had little delayed onset (10 min vs. 5 min). Nebulisation with 4 ?g/kg fentanyl produced analgesia at par to 2 ?g/kg IV fentanyl with prolonged duration (90 min vs. 30 min) and with significantly less adverse effects. Conclusions:This study shows that nebulisation with 4 ìg/kg fentanyl may be used as an alternative to IV 2 ìg/kg fentanyl for adequate post-operative pain relief.Journal of Bangladesh Society of Anaesthesiologists 2014; 27(1): 27-30

Emergency Cesarean Delivery in a Guillain- Barre Syndrome Patient

Guillain-Barré syndrome is an acute inflammatory demyelinating polyradiculopathy characterized by progressive motor weaknes, areflexia, and ascending paralysis. Guillain-Barré syndrome is extremely rare in pregnant patients, and there are no established guidelines for delivery or safest anesthetic methods. We report an emergency Cesarean delivery in the case of a 25-year old woman who was diagnosed as Guillain-Barré syndrome at her 26 weeks gestation. Tracheostomy was performed as prolonged ventilatory support was required in the intensive care unit. The respiratory difficulty was exacerbated by the growth of the fetus, necessitating emergency Cesarean delivery. The delivery was successfully performed under general anesthesia, and the patient recovered without neurological sequelae.Journal of Bangladesh Society of Anaesthesiologists 2014; 27(1): 39-42

The Challenge of Multi Drug Resistant Bacteria in Intensive Care Patient Management in Bangladesh

not availableJournal of Bangladesh Society of Anaesthesiologists 2014; 27(1): 24-26

Monitored Anaesthesia Care in An One Hundred Years Old Man in NIO&H

A hundred years old man was admitted in NIO&H with the diagnosis of cataract in right eye.He was scheduled for operation under local anaesthesia, but on the O.T. table he became restless, non cooperative. So, the surgical team planned to do the operation under general anaesthesia. Necessary investigations for GA done and the patient was found nondiabetic but had anterolateral ischaemia and had cardiomegaly in X-ray chest. Our anaesthetic plan was to do the surgery under sedation with local anaesthetic block (MAC). We provided the patient monitored anaesthesia care (MAC) by giving Inj. Fentanyl, Inj.Midazolam and Inj. Propofol. The operation took twenty five minutes. Initially after the administration of drugs,his SPO2 fell down.Oxygen given and SPO2 increased to 99% within 90 seconds. Throughout the peroperative period patient remained haemodynamically stable. Within 10 minutes,he opened his eyes,responded to vocal command and after one hour, he was shifted from postoperative ward to general ward.Journal of Bangladesh Society of Anaesthesiologists 2014; 27(1): 36-38

Anaesthesia for the Stroke Patients – New Challenges for Anaesthesiologist

not availableJournal of Bangladesh Society of Anaesthesiologists 2014; 27(1): 1-2

Safe Circumcision Anaesthesia – A Review

Circumcision of Neonate, Infant, Children as well as adult is done for many purposes of them religious, disease process and to prevent some diseases. Pain is the main problem of circumcision. Infant and Children will not allow local analgesia. General anaesthesia needed for them. Neonate and adult may allow local anaesthesia. So, local anaesthesia, general anaesthesia, combination of local and general anaesthesia can be given. It is a minor procedure but anaesthesia for circumcision is not easy and should not be taken lightly. Complications related to circumcision anaesthesia can be minimized by proper selection of patient and type of anaesthesia. In our country circumcision done for religious purpose so a large number of circumcisions done by professional hazzam (non doctor). Doctors including general practitioners and surgeons are also doing this procedure. Complications related to anaesthesia are mainly laryngospasm and hypoxia and ultimately cardiac and cerebral complications. Some of them are highlighted in the media and newspapers but unknown cases are not less. If we can prevent and manage the complications like laryngospasm then this procedure can be done safely. DOI: http://dx.doi.org/10.3329/jbsa.v26i1.19817 Journal of Bangladesh Society of Anaesthesiologists 2013; 26(1): 52-53