Background: The author analyzed the medical malpractice litigation that was referred to the National Medico-legal Committee in order to evaluate the magnitude and underlying factors of the problem in Saudi Arabia. Patients and Methods: Retrospective analysis of the official records of Medico-legal malpractice claims over the period 1420H-1424H (1999-2003) was performed. The incidence among different medical specialties, location, and final resolution of each claim were identified. Results: Data analysis revealed an increasing trend of the total number of claims over the study period with a sharp increase in the transition between 1422H and 1423H (2001-2002). The distribution of claims over different medical specialties showed that Obstetrical practice took the lead with 27%, followed by general surgery and subspecialties being represented by 17% each, internal medicine 13%, while pediatrics contributes 10% of the claims, being the least of all is dentistry with 2.5%. The majority of claims were referred to Ministry of Health and Private sectors medical facilities. Most claims were from Riyadh region over the period between 1420H - 1422H (1999-2001), while thereafter on 1423 and 1424H (2002 and 2003) the Holy Capital represents the highest number of claims being referred to the Medico-legal Committee. Conclusion: Adherence to the standards of medical practice is by far to the best approach to avoid or reduce the incidence of litigation.

Background : Perioperative blood transfusion is usually given to sickle cell disease patients to reduce or prevent perioperative morbidity. Assessment of such a practice was the subject of our study. Methods : A retrospective one year survey of sickle cell disease patients undergoing surgery at Salmaniya Medical Complex, Bahrain, was conducted. The medical records were reviewed to characterize the surgical procedure, transfusion management and perioperative complications. Results : 85 sickle cell disease patients who underwent surgery were studied. Preoperatively, 21.2% had exchange transfusion (ETX), 24.7% had simple transfusion (STX) and 54.1% had no transfusion (NTX). 14.1% of all patients had postoperative complications and 50% of those who had complications were from the laparoscopic cholecystectomy group. The incidence of sickle cell crisis postoperatively was 22.2% in ETX group, 9.5% in STX group and 4.34% in the NTX group. The incidence of acute chest syndrome postoperatively was found to be 5.55 % in the ETX group, 4.76% in the STX group and 4.34% in the NTX group. No intraoperative complications were recorded in all groups. All patients who had postoperative complications had a preoperative HBSS > 40%. Conclusion : Exchange transfusion doesn't prevent perioperative complications of sickle cell disease. HBSS > 40% carries a higher risk of postoperative complications.

This prospective, double blind placebo controlled study is designed to compare the effects of sublingual melatonin versus midazolam for premedication of adult patients scheduled to undergo cataract surgery under local anaesthesia. Seventy five patients ASA1&2 ranged from 40-70 yr scheduled for cataract surgery procedure were studied. Patients were classified into 3 groups. Group 1 received midazolam, group 2 received melatonin and group 3 received placebo. Patients in group 1 received sublingual 0.5% midazolam solution 0.1mg/kg body weight. Group 2 received sublingual melatonin0.05mg/kg body weight. The control group received sublingual placebo (saline).All drugs were given 100 min before the local block. Sedation, anxiety and orientation were quantified before and 10, 30, 60 min after premedication and 15, 30, 60 min after admission to the recovery room. One way ANOVA and non-parametric Kurskal-wallis test were for statistical analysis. Patients who received premedication with either midazolam or melatonin had significant decrease in anxiety levels compared with control group and midazolam group significant increase in level of sedation before operation was noticed compared with melatonin and control groups (p<0.05). Midazolam produced highest scores of sedation at 30 and 60 min after administration and significant psychomotor impairment in the preoperative period compared with melatonin and placebo groups(p<0.05). Postoperative patients who no significant difference between the groups for anxiety levels or trigger dot testing performance after received midazolam, melatonin premedication showed no increase in level of sedation at all intervals. There was operation compared with control (p>0.05). Amnesia was not significant in both the groups. In conclusion, melatonin can be used effectively for premedication of adult patients without hangover effect compared to midazolam.

Back Ground: Saliva, duodenogastric refluxate and blood due to gastric mucosal entrapment can affect both pH and volume of gastric contents while sampling from stomach. This issue has never been exposed while evaluating the effectiveness of drugs used for the prophylaxis of acid aspiration. We considered all these factors. Methods: This prospective, triple blind, randomized and placebo controlled clinical trial was conducted to explore the effect of single oral dose of Sodium Rabeprazole 20 mg on intragastric pH and volume in 100 adult inpatients of either sex, ASA I-III, and aged 15-70 years. The patients in Group S received (Sodium Rabeprazole 20 mg) while Group C received Placebo orally at 9.00 p.m., a night before elective surgery. Gastric contents were aspirated with a large bore, multi-orifices gastric tube passed through an endotracheal tube placed blindly in esophagus after tracheal intubation and analyzed for the presence of bile salts, pH and volume. Results: Fifteen cases (15.15%) were contaminated with duodenal contents and one with blood (1%). The proportion of the patients considered" at risk" according to the criteria defined (pH ≤ 2.5 and volume ≥ 25 ml) was statistical significant in Group S compared with Placebo (p value 0.0005). Conclusion: Oral Sodium Rabeprazole 20 mg administered a night before elective surgery does improve the gastric environment at the time of induction of anesthesia, should the aspiration of gastric contents occur.

Early and uneventful postoperative recovery of morbidly obese patients remains a challenge for anesthesiologists.However, it could be even more valuable to titrate the administration of inhaled anesthetic such as sevoflurane in morbid obese patients, to shorten emergence using bispectral index (BIS) monitoring. It would be a great advantage if BIS permitted a more rapid recovery and less consumption in morbidly obese patients with a high cost inhaled agent. The aim of the study is to show whether the titration of sevoflurane based on the BIS monitoring would allow shortening of recovery time in morbidly obese patients and to evaluate whether BIS monitoring would contribute to reduce the amount of sevoflurane administered while providing an adequate anesthesia. Patients and Methods . Thirty morbidly obese ASA I&II patients undergoing laparoscopic gastric banding (LAGB) procedures were studied. In the first group (15 patients), patients were anaesthetized without the use of BIS (non BIS) group, and sevoflurane being administered according to standard clinical practice (control group). Second group, sevoflurane was titrated to maintain a BIS value between 40 and 60 during surgery, and then 60-70 during 15 min prior to the end of surgery (BIS group). Recovery times were recorded. Time to extubation was also noted, as well as the time to achieve a modified Aldrete score of 9 were evaluated subsequently at 10-min intervals until 3 h after surgery by nurses who had no knowledge of the study. Sevoflurane consumption was calculated using the vaporizer weighing method. Results. Awakening and extubation times were significantly shorter in the BIS group (P<0.05). In the BIS (vs. non BIS) group, there were no significant differences observed in the time to obtain an Aldrete score of 9. The Sevoflurane consumption and cost in the BIS group were lower than in the non BIS group (P < 0.05). Conclusion. Bispectral index monitoring during anesthesia for morbidly obese patients provides statistically significant reduction in recovery times. It also added advantage in decreasing sevoflurane consumption.

We performed 100 cases of percutaneous tracheostomy with forceps dilatational method in a period of 20 months. 50 cases were performed under bronchoscopic guidance (group A) and other 50 cases without bronchoscopic guidance (group B). 54 patients underwent procedure in Surgical Intensive Care Unit (SICU), 36 patients in operating room and 10 in the other areas of the hospital. Maximum number of patients (37) was neurosurgical. Only 2 patients underwent tracheostomy in first 5 days, whereas 76 of them had tracheostomy done between 11-20 days of endotracheal ventilation. Technical difficulties were encountered during the procedure in both groups. We found that tracheal puncture (25 cases) and forceps dilatation (13 cases) are difficult steps of the procedure requiring multiple attempts and supervision. We did not encounter any life threatening and major complications. However commonest complication during the procedure was minor bleeding (9%). Other complications in both groups were in the similar range and negligible. Absence of bronchoscopic guidance has not increased the morbidity directly but the procedural time was increased significantly in group A (8.76 min) compared to group B (6.04 min) in group B.

Background: This study aimed at evaluating the effect of application of different patterns of positive ventilatory pressure either during or after cardiopulmonary bypass (CPB) on lung functions. Methods: 30 patients undergoing coronary artery revascularisation under the management of CPB were randomly allocated into 3 groups. Group I (VCM) 10 patients were subjected to manual vital capacity manoeuvre (VCM) before weaning off the CPB. Group II (CPAP) 10 patients were subjected to continuous positive airway pressure (CPAP) of 10 cmH ₂ O during CPB. Group III (PEEP) 10 patients were subjected to positive end expiratory pressure (PEEP) of 7 cmH ₂ O after weaning off the CPB. Measurements included the PO ₂ , PCO ₂ , together with derived calculated parameters as the alveolar-arterial oxygen difference [P (A-a) DO2] and shunt fraction, as well as the dynamic lung compliance being recorded directly from the anaesthetic and ventilatory equipments. All readings were taken on closed chest and on FiO ₂ of 0.5. Intraoperative anaesthetic and surgical data as well as postoperative extubation time and length of ICU stay were also evaluated. Results: Statistical analysis of ventilatory parameters showed no significant differences for both PO ₂ and PCO ₂ in between the studied groups. Alveolar-Arterial oxygen difference mean values were comparable in the 3 studied groups. The mean values of intrapulmonary shunt fraction showed a significant difference in relation to the baseline values in Group I (VCM) and Group III (PEEP) at 30 minutes after ICU admission and 4 hours post CPB with estimated P value <0.01 and < 0.05 respectively, while in Group II (CPAP) mean values started to be significant after chest closure with a p value <0.05, but there was no significant intergroup differences with a P value > 0.01. Dynamic lung compliance mean values showed no intergroup statistical significance. Conclusion: Maintenance of Ventilatory parameters was achieved in all the positive pressure ventilatory methods applied, either being applied during or after CPB.