BACKGROUND: Pakistan is a lower middle-income country located in South Asia with a population of nearly 208 million. Sindh is its second largest province. The aim of this survey was to identify the current setup of pediatric services, staffing, equipment, and training infrastructure in the teaching hospitals of Sindh. METHODS: The survey was conducted between June 2018 and September 2018. A questionnaire was designed with input from experts and pretested. One faculty coordinator from each of 12 of the 13 teaching hospitals (7 government and 5 private) completed the form. Information was exported into Statistical Package for the Social Sciences (SPSS) version 22. Frequency and percentages were computed for all variables. Confidentiality was ensured by anonymizing the data. RESULTS: Anesthesia services are provided by consultants with either membership or fellowship in anesthesia of the College of Physicians and Surgeons of Pakistan (CPSP). All drugs on the World Health Organization (WHO) essential medication list were available, although narcotic supply was often inconsistent. Weak areas identified were absence of standardization of practice regarding premedication, preoperative laboratory testing, pain assessment, and management. No national practice guidelines exist. Pulse oximeters and capnometers were available in all private hospitals but in only 86% and 44% of the government hospitals, respectively. Some training centers were not providing the training as outlined by the CPSP criteria. CONCLUSIONS: Several gaps have been identified in the practice and training infrastructure of pediatric anesthesia. There is a need for national guidelines, standardization of protocols, provision of basic equipment, and improved supervision of trainees. One suggestion is to have combined residency programs between private and government hospitals to take advantage of the strengths of both. Recommendations by this group have been shared with all teaching hospitals and training bodies. (Anesth Analg 2022;134:653-60) KEY POINTS• Question: What are the service and training infrastructure facilities for pediatric anesthesia in Sindh province of Pakistan? • Findings: We have identified and documented several gaps in service provision and training of residents in this area. • Meaning: These data can be used to plan improvement both in service and residency training in pediatric anesthesia in the surveyed institutions.

Aim: The purpose of this study was to analyze the postoperative outcome of open cholecystectomy in patients receiving spinal versus general anesthesia. Study design: Analytical cross-sectional study Place and Duration: this studay was conducted in King Abdullah Medical City Makkah Kingdom of Saudi Arabia from January 2020 to January 2021. Methodology: A total of 180 patients that had the surgery of open cholecystectomy under spinal as well as general anesthesia were included in this research. All patients who had pancreatitis, contraindication to spinal anesthesia or general anesthesia, or severe cardiopulmonary diseases were excluded from the study. Patients were randomly distributed into two groups which are SA and GA groups, with each group having 90 patients. The sample size was determined via open epi. After the surgical procedure, patients were followed and analyzed for postoperative outcomes. Results: A total of 140 patients were female while 40 patients were male. Patients in the SA group did not face post-operative pain till 8 hours. But patients in the GA group complained of postoperative pain after an hour of open cholecystectomy. The postoperative outcome included nausea or vomiting which was common in both groups and post-Dural headaches which were more common in patients of the SA group and was cured without giving any medication. The sore throat was more common in patients of the GA group. However, no respiratory depression was found in patients of both the SA as well as GA groups. Conclusion: Spinal anesthesia as compared to general anesthesia reveals longer pain-free hours and fewer adverse effects after open cholecystectomy. Nausea or vomiting was common in both groups, and no respiratory depression was found in patients from SA as well as the GA group. Open cholecystectomy needed training due to the factors that lead to conversion to laparoscopic surgery, such as incorrect anatomy and the onset of complications. Keywords: open cholecystectomy, anesthesia, spinal anesthesia, general anesthesia, postoperative outcome

Objectives: To evaluate the role of pre-operative lidocaine infusion for pain management in laparotomy procedures. Study Design: Prospective double blind randomized control trial. Period: 8 months duration from April 2017 to November 2017. Setting: Tertiary care hospital in Karachi, Pakistan. Method: N= 50 patients belonging to ASA Classification types I and II were selected to be part of this study. All the patients underwent major abdominal surgeries (laparotomy). The study group received lidocaine 2%, 1.5mg/kg IV bolus half an hour before induction, followed by an infusion of 1.5mg/kg/hour. The anesthesia was induced with fentanyl 3ug/kg, propofol 2mg/kg, followed by rocuronium 1mg/kg to intubate the patient. Maintenance was done with using 33% nitrous oxide in oxygen along with 0.8% of isoflurane. Fentanyl was administered as an infusion initiating prior to the procedure with a maximum dose of 1ug/kg/hour and ceasing the infusion half an hour prior to end of procedure. Visual analog scale was used to measure the pain intensity at an interval of twenty minutes during the first hour of the procedure, and at 2,4,8,12,24 and 48 hours after the end of the procedure. If the visual analog scale score was found to be more than 3, 1 to 3mg of Morphine was administered every ten minutes up to a dose of 0.1mg/kg intravenously. A proforma was used to collect data, data was analyzed using IBM SPSS version 21.0. Results: The study was conducted on n=50 patients, with a mean age of 38.35 years in the study group and 36.48 years in the control group. The intensity of pain was found to be significantly less in the case group as compared to the control group having a p value of <0.001 during the first 48 hours of the procedure. Decreased consumption of morphine was observed in patients in the study group, as compared to the control group with a statistically significant difference, having a p value of less than <0.05. In our study we did not observe any side effects related to toxicity levels of lidocaine or morphine. Conclusion: Our study confirms the results of previously done studies, and we found that in our patient population Perioperative lidocaine infusion decreased the post-operative pain experienced by the patient and decreased the need for consumption of analgesics. Thus we conclude that lidocaine infusion perioperatively is an effective pain management modality.

Aim:To assess the difference between laryngeal mask airway versus endotracheal tube for early postoperative recovery following laparoscopic cholecystectomy Study design: A randomized controlled trial Place and Duration: This study was conducted in Liaquat National Hospital and Medical College Karachi from June 2020 to June 2021 Methodology: Overall, 60 individuals were assigned to airway management utilizing either the laryngeal mask airway(LMA) group or endotracheal tube (ETT) group. All the patients went under sevoflurane-based general anesthesia and all of them had a laparoscopic cholecystectomy. Three things were recorded before and after carbo peritoneum that was blood pressure, heart rate and peak airway pressure. The first hour after surgery and the first postoperative day were used to assess postoperative pain and analgesic needs, as well as hoarseness, nausea, sore throat, and dysphonia. Results: Two attempts were made to have a successful Laryngeal mask airway or endotracheal tube placement. During carbo peritoneum, both of the groups, LMA and ETT had similar highest average peak airway pressure (LMA: 17.8 [2.9], ETT: 18.2 [4.1], with a p-value of 0.159). The incidence of bradycardia and elevated systolic blood pressure was higher in the LMA group. The LMA group had lower pain scores one hour postoperatively and on a postoperative day 1 than the ETT group (LMA: 3.9 [2.0], ETT: 5.4 [2.3], with a p-value of 0.017 and LMA: 5.6 [1.9], ETT: 6.7 [1.7], with a p-value of 0.042). Both the groups had the same analgesic requirements. Until postoperative day 1, the LMA group had a lower incidence of nausea than the ETT group (LMA: 4/28 [14%], ETT: 12/28 [43%], with a p-value of 0.032). Conclusion:The Laryngeal Mask Airway Protector proved to be a successful ventilator device which showed lesser intraoperative hemodynamic stress responses. It also enhanced the early recovery standard following laparoscopic cholecystectomy.