The issue of water quality is becoming ever more serious as freshwater resources are severely degraded across the world. Water quality in rivers, streams, lakes, and subterranean aquifers is deteriorating, posing a threat to human life and ecological sustainability. A proper study of the physico-chemical properties of the water samples give us insight into the quality of life in a specific region, as poor water quality not only affects the aquatic life but the surrounding ecosystem as well. In the present study, 30 different water samples were collected from different regions of district Mardan and they were analyzed for their physico-chemical properties such as pH, total suspended solids, conductivity, total dissolved solids, nitrates concentration, sulphates concentration, chlorides concentration, dissolved oxygen, and biochemical oxygen demand. The results of the analysis show that most of the parameters have significantly higher values than the WHO permissible limits. From the analysis of water samples, the researchers have been able to designate the study area with poor water quality and to propose future advice for sustaining the water quality in the region.

Objectives: In this study we determine the modifiable factors related to bleeding and transfusion in post-cardiac surgery patients who underwent open heart surgery. Methods: This is a retrospective study that include two hundred patients who had undergone open heart surgery (OHS) at Northwest General Hospital and Research Center from December 2018 to July 2021. Platelet count and hemoglobin level were measured in the pre-operative period. Results: This study included both male and female patients. Postoperative platelets were counted as follow: 50-100 x109 L in 3.0% cases, 101-150 x109 L seen in 27.5% cases, and >150 x 109 L in 69.5% cases which required transfusion. We have also reported the increased requirement of transfusion of blood and blood products in patients with pre-operative hemoglobin (Hb) < 10 g/dl. Conclusion: Correction of pre-op Hb, post-op platelet count and total bypass time are the significant and preventable parameters in patients undergoing cardiac surgery if proper pre-op assessment of the patient is performed. doi: https://doi.org/10.12669/pjms.38.4.5685 How to cite this:Khan B, Mujahid Ul Islam, Ahmad I, Mujeeb Ur Rehman. Modifiable Risk Factors associated with Post-Operative Bleeding and transfusion requirements in Cardiac Surgery. Pak J Med Sci. 2022;38(4):---------.  doi: https://doi.org/10.12669/pjms.38.4.5685 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

IntroductionRe-explorations after open-heart surgery are often required if the patient is bleeding or shows features of cardiovascular instability and does not improve with conservative measures. Our study aims to determine whether timely re-exploration of patients who are bleeding has an impact on the morbidity and mortality of the patients. MethodsA retrospective analysis of 75 patients that underwent open-heart surgery and subsequently underwent chest re-exploration for excessive bleeding between March 2018 and March 2020. Patients who were reopened post-op for indications other than excessive bleeding were excluded. ResultsA total number of cases were 700, out of which 75 (9.3%) patients were reopened, as compared to the literature, which shows worldwide 2-11% being reopened. Post-operative drain output was 1000ml to 1500ml in 47 (62.7%) and more than 1500ml in 28 (37.3%) patients before they were reopened. In 67 (89.3%) patients, three to five units of blood were transfused, and in eight (10.7%) patients, more than five units of blood were transfused. We believe our mortality in the reopened patients was low, because of timely intervention and early re-exploration, and is probably the reason why our figures land in a higher range (2-11%) of reopened cases (9.3%). Reopening time was less than five hours in 49 (65.3%) patients and less than 10 hours in 26 (34.7%) patients in our study. We tried to minimize the loss of blood and re-explored the patients before they lose excessive blood, the average time for reopening in our study was less than 10 hours. The average intensive care unit (ICU) stay was 4.2 days (range three to six days). Wound infections were reported in one of three patients. There was no mortality in these patients. Surgical site of bleeding was identified in 54 (72%) patients and no particular site was found in 21 (28%) patients. Suggesting that it is common to have a surgical bleeder than coagulopathy induced bleeding in post-cardiac surgery patients ConclusionsWe believe our low mortality (0%) is due to early reopening in patients who are bleeding excessively after cardiac surgery.

For patients undergoing elective cesarean, spinal anesthesia has been considered a preferred method of anesthesia. Conventionally, Bupivacaine was used but now dexemetomidine, a newer drug as compared to Bupivacaine is being used. Due to short usage tenure of dexemetomidine as a spinal anesthesia, data regarding its afficacy is lacking in Pakistan.Objectives:  To compare the mean duration of spinal anasthesia between hyperbaric bupivacaine 0.5% alone versus hyperbaric bupivacaine 0.5% with dexmedetomidine on first analgesic request for women undergoing elective cesarean section alongwith examining the affect of BMI on Dexemedetomidine. Methods: Spinal anesthesia was administered in the sitting position under sterile conditions with 25G pencil point needle. Patient was positioned in a supine position tilting towards left after successful intra thecal injection. Group A cases received hyperbaric 0.5% BPV (2.25ml) with 5ug DXM (0.25ml) and those in Group B received only 0.5% BPV (2.25ml) with 0.25ml normal saline under full aseptic measures. These patients underwent cesarean section and were assessed in post-operative time after every 30 minutes to first request of analgesia which were given if there was pain of 4 or more on visual analogue scale. Results: In Group A, mean and SDs for duration of analgesia was 359.73+8.021 minutes. In Group B, mean and SDs for duration of analgesia was 182.30+7.720 minutes. Results depicted mean and SD for BMI of the patients to be 25.66+1.52. Conclusion: In this study, hyperbaric bupivacaine 0.5% with DXM in spinal anesthesia for patients undergoing caesarean section significantly prolonged the duration of analgesia in normal to slightly overweight individuals.

Preoperative anemia is associated with increased morbidity and mortality after cardiac surgery, so we looked into the effect of preoperative hemoglobin levels on early outcome of coronary artery bypass grafting (CABG). Objective: To assess the role of preoperative anemia as a predictor of morbidity and mortality among patients who went through coronary artery bypass surgery. Methods: A retrospective study was carried out among patients who suffered from isolated CABG surgery. These patients were considered anemic with hematocrit levels less than 35.0 in females and less than 40.0 in males. The results were evaluated by using SPSS 24.0. Results: Overall mortality rate among patients who went through CABG was 3.9%. The mean hematocrit level among these patients was less than 30. Conclusions: It is concluded that the patients presented with preoperative anemia who have to undergo coronary artery bypass surgery are more likely to encounter co-morbidities and death after the surgery.

Objective: To find the incidence of intra-aortic balloon pump (IABP) induction and factors associated with its insertion in coronary artery bypass grafting (CABG). Methods: This retrospective observational non interventional study was conducted at Cardiac Surgery Department, North West General Hospital and Research Center, Peshawar from December 2018 to March 2020. The total sample size was 360 patients who underwent coronary artery bypass grafting (CABG). The research was piloted in the cardiac operation theatre then cardiac intensive care unit (CICU) of Northwest General Hospital and Research center Hayatabad Peshawar. Data was collected from 360 patients scheduled for CABG. Total numbers of patients in whom IABP was inserted and factors associated with IABP insertions were noted. All the information was collected on a specifically prepared Form. Data was entered and evaluated in statistical package for social sciences form 25. Results: In this study, a total of 360 patients were observed who underwent coronary artery bypass grafting (CABG). We determined the frequency of IABP induction and the factors related to it. Gender distribution among patients who were assisted with IABP was 43% female and 57% male. IABP induction was done for most of moderately to severely reduced ejection fraction patients. Other factors related to patients who required IABP support were previous myocardial infarction 100%, hypertension 86%, diabetes mellitus 64%, coronary end-arterectomy 21% and smoking 7%. The results were analyzed. We have used the (SPSS) version 25 and Chi-square test for analysis in which the P-value less than 0.00001 is statistically significant. Conclusion: Incidence of insertion of IABP among CABG population was 3.9% in our hospital. It is an essential support to post CABG patient with left ventricular dysfunction after cardiopulmonary bypass with moderate to severely reduced ejection fraction, Myocardial infarction, hypertension, diabetes mellitus. Smoking and endarterectomy were not significantly related to IABP induction in our study. Multicenter study is still required to find out the other factors governing the IABP insertion. Abbreviations:CABG: Coronary Artery Bypass Grafting Surgery, EF: Ejection Fraction, CAD: Coronary Artery Disease, PCI: Percutaneous Coronary Intervention, ICU: Intensive Care Unit, IABP: Intra-aortic Balloon Pump, CICU: Cardiac Intensive Care Unit, MI: Myocardial Infarction. doi: https://doi.org/10.12669/pjms.37.2.3614 How to cite this:Ahmad I, Mujahid Ul Islam, Mujeeb Ur Rehman, Khan B. Frequency of intra-aortic balloon pump insertion and associated factors in coronary artery bypass Grafting in a tertiary care hospital. Pak J Med Sci. 2021;37(2):---------.  doi: https://doi.org/10.12669/pjms.37.2.3614 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Spinal anesthesia has been considered preferred method of anesthesia for patients undergoing elective cesarean sections. Dexmedetomidine (DXM) is relatively a newer drug in Pakistan as compared to conventional used drug i.e. Bupivacaine (BPV) and that’s why the local data regarding its efficacy in cesarean section is lacking. Objective: To compare the mean duration of spinal anasthesia between hyperbaric bupivacaine 0.5% alone versus hyperbaric bupivacaine 0.5% with dexmedetomidine on first analgesic request for women undergoing elective cesarean section under subarachnoid block Methods: Spinal anesthesia was performed in the sitting position under sterile conditions with 25G pencil point needle. After successful intra thecal injection, patient was placed in the supine position with left tilt. The cases in Group A received hyperbaric 0.5% BPV (2.25ml) with 5ug DXM (0.25ml) and those in Group B received only 0.5% BPV (2.25ml) with 0.25ml normal saline under full aseptic measures. These patients underwent cesarean section and were assessed in post-operative time after every 30 minutes to first request of analgesia which were given if there was pain of 4 or more on visual analogue scale. Results: In Group A, mean and SDs for duration of analgesia was 359.73+8.021 minutes. In Group B, mean and SDs for duration of analgesia was 182.30+7.720 minutes Conclusions: In this study, hyperbaric bupivacaine 0.5% with DXM in spinal anesthesia for patients undergoing caesarean section significantly prolonged the duration of analgesia

To determine the incidence of endotracheal reintubation, excluding surgical reopening, in post-cardiac surgical patients in a tertiary care hospital. Material and methodsA retrospective descriptive analysis of 408 patients who underwent different cardiac surgeries during this period. Post-operative extubation was performed when patients fulfilled the preset criteria for extubation, which include consciousness (awake and aware), stable vital signs, acceptable arterial blood gases, acceptable respiratory mechanics, a maximum inspiratory force greater than 20-25 cm H 2 O, chest tube drainage less than 100 ml per hour, normal temperature and electrolytes. The total number of patients who were reintubated within 72 hours of extubation was noted. The criteria for reintubation included altered conscious level with Glasgow Coma Score (GCS) of less than 8, respiratory failure, unstable hemodynamics, and arrhythmias such as ventricular tachycardia (VT) and fibrillation. All of the information was collected retrospectively on a specifically prepared form. Data was entered and evaluated in Statistical Package for the Social Sciences.