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Acute ascending flaccid paralysis with areflexia were considered as Guillain-Barre Syndrome by medicine and neurology department as tradition. We present two patients 46 years old female and 57 years old male with acute ascending flaccid paralysis admitted in intensive care unit. They developed respiratory paralysis requiring mechanical ventilation. The male patient developed cardiopulmonary arrest during shifting to intensive care unit. Both the patients responded to vitamin d therapy dramatically. Respiratory paralysis on mechanical ventilation responding to vitamin d therapy dramatically were unique events. Vitamin d deficiency is a worldwide problem but its presentation as acute ascending paralysis with areflexia requiring mechanical ventilation is not cited in medical literature. Keywords; Acute ascending flaccid paralysis with areflexia, Respiratory paralysis, Vitamin D deficiency, Vitamin D therapy,

Background & objectives: Spinal anesthesia in children a useful alternative to general anesthesia, is not usually practiced in most of the hospitals of South Punjab. We aimed to evaluate the utilization of spinal anesthesia in children in South Punjab (Pakistan) and to discover the elements preventing its use in children. Methodology: A questionnaire was delivered to all 47 FCPS qualified anesthesiologists working in South Punjab vide e-mail and whatsapp messages to them. Out of 47 anesthesiologists, 38 (80.85%) responded. Questionnaire consisted of 3 components. All participants were asked to fill the first component regarding demographic data, but only those who did not administer spinal in children, needed to fill second and third components. In the second component, structured questions with scale 1 to 5 (strongly disagree to strongly agree). In the third component, the participant had open choice to write three most important factors (most important, second most and third most) prohibiting the practice of spinal anesthesia in children. Results: All of the 47 senior anesthesiologists working in South Punjab were included in this survey. The response rate was 80.85%. Demographic data showed 33/38 (87%) males and 05/38 (13%) females, mean age 44.34 ± 11.06 yrs, mean of total experience in anesthesia 17.03 ± 9.12 yrs and mean experience after postgraduation 8.01 ± 6.85 yrs. The number of respondents administering spinal anesthesia in children was just 3 (7.88%) and 35 (92%) never used spinal in children. Lack of expertise/training/guidance (4.69 ± 0.83) is the most common cause prohibiting the use of pediatric spinal anesthesia followed by risk of high/total spinal (4.14 ± 1.31), lack of cooperation of child (3.83 ± 1.34), risk of spinal cord injury (3.71 ± 1.51), difficulty in assessment of block (3.34 ± 1.64). Less common factors avoiding pediatric spinal include objection by family, objection by surgeon and lack of proper recommendations. The number of participants considering lack of expertise/training/guidance most important factors for avoiding spinal anesthesia in children was 9 (25.71%), followed by uncooperative children 8 (22.86%), risk of spinal cord damage 5 (14.28%), risk of high/total spinal 3 (8.57%) and objection by family 3 (8.57%). Other factors quoted were objection by the surgeon, risk of postdural puncture headache, risk of neurological complications, being short duration, not recommended and not acceptable by society. Conclusion: Pediatric spinal anesthesia is practiced by only three consultants (7.88%) in South Punjab out of a total of 47. There is a need to enhance the expertise level of the anesthesiologists during postgraduate training and to remove the fears / phobias attached with this particular practice. Key words: Pediatric; Anesthesia, Spinal; Barriers; South Punjab Citation: Durrani HD, Sadaf S, Naqvi SAA, Siddique A, Bajwa MH. Factors resulting in underutilization of pediatric spinal anesthesia in South Punjab (Pakistan). Anaesth. pain intensive care 2020;24(6):--- Received: 20 August 2020, Reviewed: 17 October 2020, Revised: 25 October 2020, Accepted: 6 October 2020

Objective: To compare the analgesic efficacy of tramadol wound infiltration with normal saline wound infiltration in patients undergoing Pyelolithotomy. Study Design: Randomized Controlled Trial. Setting: Department of Anesthesia, ICU and Pain Medicine, DG Khan Teaching Hospital, Dera Ghazi Khan. Period: July 2019 to September 2019. Material & Methods: Total 60 patients were included in this study. There were 30 patients in whom normal saline was used for wound infiltration and in other 30 patients tramadol was used for wound infiltration. Analgesic outcomes were noted in terms of Numerical Rating Scale (NRS) of pain in the recovery room, at 06 hours and 24 hours after surgery, mean time of first rescue analgesia and total dose of tramadol within 24 hours after surgery. Results: Mean pain score in the recovery room was 5.20±2.10 in saline group versus 2.60±1.13 in tramadol group (p<0.001). Mean post-operative pain score after 06 hours of surgery was 5.43±1.45 in saline group versus 2.30±1.05 in tramadol group (p<0.001). Pain score was 3.63±1.40 in saline group versus 1.67±0.80 in tramadol group after 24 hours of surgery (p<0.001). Mean time of first rescue analgesia was 6.16±2.47hours in tramadol group versus 0.97±1.46hours in saline group (p<0.001). Total dose of tramadol used for analgesia within 24 hours after surgery was 56.67±70.38mg in tramadol group versus 253.33±73.02mg in saline group (p<0.001). Conclusion: Wound infiltration with tramadol provides better analgesia as compared to normal saline in patients undergoing Pyelolithotomy.

Objectives: Aim of this study was to compare the effects of two different shoulder positions on infraclavicular subclavian venous catheterization in critically ill patients. Study Design: Prospective Comparative study. Setting: Sheikh Zayed Medical College Rahim Yar Khan Pakistan. Period: 1st July 2017 to 30th June 2018. Material & Methods: Enrolling 100 patients thru convenient sampling, divided into two groups, Group A & Group B, 50 in each group. In group A patients were put in supine position, with head turned to contra lateral side and caudal pull was applied on ipsilateral shoulder. While in group B patients were lying supine, head turned to contra lateral side and shoulders were retracted by placing a small pillow vertically under the chest between the scapulae. In both groups, subclavian vein was approached through infra clavicular route. Number of attempts of venous punctures (1st attempt / 2nd attempt), total time spent on procedure (from 1st skin puncture to CVC insertion), complications (arterial puncture, pneumothorax, hydrothorax, malpositioning), any hemodynamic irregularity (ECG changes), radiographic findings to confirm successful CVC insertion was recorded. Results: Number of successful subclavian venous catheterizations was same in both groups (94% vs. 94%) with no significant difference (p= 1.000). 1st attempt success was more in group A  as compared to group B, though statistically this was not significant (p= 0.275). Total time spent on CVC insertion (from 1st skin puncture to catheter insertion) was less than 05 mints in 84% patient in group A and 82% in group B. While more than 05 mints were spent on 16% vs. 18% patients in group A vs. B. This was also not statistically significant (p=0.790). In group A 2/50 (4%) while in group B 1/50 (2%) cases were recorded as malpositioning on post-CVC radiograph. Other complications were not encountered in either group. Conclusion: Lowered shoulder and retracted shoulder positions are equally effective for SVC insertion in terms of success, 1st attempt success, total time spent and number of complications.