Context Coadministration of adjuvants with bupivacaine for spinal anesthesia is advocated to reduce its dose and improve the quality of intraoperative and postoperative analgesia with the least number of side effects. Aim The aim of the study was to compare the efficacy and safety of three intrathecal regimens for cesarean section. Patients and methods Ninety patients of ASA grade I or II who were scheduled for cesarean section under spinal anesthesia were randomly allocated into three groups of 30 patients each. Group B was injected with 15 mg of 0.5% hyperbaric bupivacaine, group F was injected with 10 mg of 0.5% hyperbaric bupivacaine +10 mg of sufentanil, and group D was injected with 10 mg of hyperbaric bupivacaine +10 mg of dexmedetomidine. Study parameters were as follows: mean arterial blood pressure, heart rate, respiratory rate, oxygen saturation (SpO ₂ ), sedation scores, side effects (such as hypotension, bradycardia, nausea/vomiting, shivering, pruritus, respiratory depression), neonatal outcome, onset and duration of sensory and motor block, intraoperative and postoperative analgesic requirements, and duration of complete and effective analgesia. Results There were no significant differences regarding mean arterial blood pressure, heart rate, respiratory rate, SpO ₂ , and neonatal outcome among the study groups. Sedation scores were higher in group D compared with groups B and S. Onset of motor block was comparable among the three groups, whereas onset of sensory block, time to two-segment regression and regression time to sensory S1, and motor recovery time were longer in groups D and S compared with group B. Intraoperative analgesic requirements showed no significance among the three groups, whereas duration of complete and effective analgesia was longer in groups S and D compared with group B. Further, postoperative 24 h analgesic requirements were higher in group B compared with groups S and D. Side effects such as hypotension, bradycardia, shivering, and respiratory depression were comparable among the study groups, whereas nausea/vomiting and pruritus were higher in group S compared with groups B and D. Conclusion Addition of sufentanil or dexmedetomidine to hyperbaric bupivacaine for intrathecal block prolongs the duration of sensory and motor block and reduces postoperative analgesic requirements. Sufentanil has a higher incidence of nausea/vomiting and pruritus, whereas dexmedetomidine has better analgesic effects and sedation without respiratory depression.

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Background Incorporation of adjuvants into local anesthetics could potentially aid in producing satisfactory prolonged postoperative analgesic duration and reducing postoperative adverse reactions associated with excessive systemic analgesic intake. The aim of this trial was to study the effect of incorporating magnesium sulfate as an adjuvant into lidocaine in an interscalene plexus block (ISPB) for arthroscopic acromioplasty. Materials and methods Sixty ASA I and II grade patients scheduled for elective arthroscopic acromioplasty under ultrasound guidance and peripheral nerve stimulation technique were allocated randomly to two groups: group L, which included patients who received 20 ml of lidocaine 2% with epinephrine 1 : 200 000 plus 5 ml 0.9% NaCl, and group LM, which included patients who received 20 ml of lidocaine 2% with epinephrine 1 : 200 000 plus 5 ml of 10% MgSO ₄ (500 mg MgSO ₄ ). The following data were collected: the onset of sensory block, the occurrence of satisfactory motor block, sensory block duration, Numeric Rating Scale (NRS) at the first analgesic dose, motor block duration, total morphine consumption in the first 24 h, and the presence of any adverse reactions. Results Patients in the magnesium sulfate group showed a prolonged postoperative analgesic duration, the NRS records decreased significantly on the first analgesic dose, and morphine consumption was reduced, and no adverse events related to its use in ISPB were recorded. Conclusion The addition of magnesium sulfate to lidocaine in ISPB significantly prolongs the analgesic duration and reduces the NRS score and postoperative opioid requirements in shoulder arthroscopic acromioplasty without side effects.

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Background Many additives have been added to local anesthetics in PBA to decrease the time of onset and increase the duration of analgesia to suit the relatively long vitreoretinal surgery with limited success. Dexmedetomidine has been added to local anesthetics for such purpose. Patients and methods Sixty consented ASA I-II adult patients undergoing vitreoretinal surgery were enrolled in this randomized, double blind, controlled study. Patients were randomly and evenly assigned to three groups to receive one of three anesthetic solutions for PBA: group C, group D25, and group D50. Patients in group C received 6 ml of 0.5% levobupivacaine with 10 IU/ml hyaluronidase in addition to 1 ml of normal saline. Patients in groups D25 and D50 received the same mixture but with replacement of the normal saline with 25 and 50 mcg dexmedetomidine, respectively. Intraoperative recordings included onset and duration of corneal anesthesia and globe akinesia, hemodynamics, intraocular pressure (IOP), and Ramsay sedation score. Postoperative recordings included time to first rescue analgesia and number of doses required, pain score, and patient and surgeon satisfaction score. Results The onset of corneal anesthesia and globe akinesia was significantly shorter in group D50 than in group C (1.05 ± 0.50 and 6.90 ± 1.94 vs. 1.68 ± 0.78 and 9.10 ± 2.14); in group D25 the onset was insignificantly shorter. Duration of anesthesia was significantly longer in both groups compared with control, as was the time to first rescue analgesia. IOP was also significantly lower in both groups compared with control. Conclusion Addition of two different doses of dexmedetomidine (25 and 50 mcg) to levobupivacaine/hyaluronidase mixture shortened the onset and prolonged the duration of peribulbar block in patients undergoing vitreoretinal surgery. It also lowered the IOP and provided sedation with patient's cooperation, leading to better patient and surgeon satisfaction.

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Introduction The aim of this study was to evaluate the effect of intrathecal compared with intravenous dexmedetomidine as an adjuvant to spinal bupivacaine anesthesia for pregnant women undergoing cesarean section on intraoperative and postoperative analgesia with special emphasis on their sedative properties and on the neonatal outcome. Patients and methods A total of 105 women of ASA physical status I or II at term pregnancy were enrolled randomly into three groups. Patients in group I received spinal anesthesia with hyperbaric bupivacaine. In group II, 5 μg dexmedetomidine was added to bupivacaine. In group III, after administration of spinal anesthesia with bupivacaine and an intravenous infusion of 0.5 μg/kg/h dexmedetomidine throughout the surgery, the incidence of hypotension, bradycardia, the onset, and the duration of sensory and motor block and the postoperative pain score were assessed. Results No differences were observed in the rate of occurrence of hypotension and bradycardia between the three groups. The time to reach the peak sensory level was shorter in group II and group III with a longer duration compared with group I. The duration of motor block was shorter in group I compared with the two other groups with no significant difference between the three groups in the onset of motor block. The onset of postoperative pain was significantly earlier in group I, and more patients in group I needed supplementary analgesia. No significant difference was noted between the three groups regarding the Apgar score and the incidence of maternal side effects such as nausea, vomiting, and dryness of the mouth. Conclusion The use of intrathecal dexmedetomidine or intravenous dexmedetomidine as an adjuvant to spinal bupivacaine in women undergoing elective cesarean section improved the intraoperative condition and the quality of postoperative analgesia without neonatal or maternal side effects.

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Phantom limb pain has been reported in patients with lower limb amputation during subsequent spinal anaesthesia. No therapy has been proven to be uniformly effective. Here, we report a case managed successfully with ketamine and magnesium sulphate.

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Background Functional endoscopic sinus surgery (FESS) requires effective control of bleeding for better visibility of the operating field and reduced risk of injury to the optic nerve or the internal carotid artery. Dexmedetomidine can provide controlled hypotension, analgesia, and sedation. The present study aimed to evaluate the clinical efficacy, safety, and advantages of dexmedetomidine as an anesthetic adjuvant for FESS. Patients and methods Fifty adult consented patients of comparable demographic profile, scheduled for FESS, were assigned randomly to two groups. Patients of group D received a loading dose of dexmedetomidine 1 mg/kg over 10 min, followed by an infusion at 0.4-0.7 mg/kg/h and patients of group C were administered an identical amount of saline solution. During the procedure, hemodynamic changes, intraoperative surgical grade of bleeding (on the basis of the Fromme-Boezaart scale), intraoperative fentanyl consumption, emergence time, and total recovery from anesthesia (Aldrete's score ≥9) were recorded. Results Patients of group D comparatively had a lower intraoperative heart rate and mean arterial blood pressure, along with a significantly lower bleeding score (P < 0.001). The mean intraoperative fentanyl consumption was significantly lower in patients of group D. Emergence time and time to achieve an Aldrete's score 9 or more were significantly lower in group C at 15 and 30 min postoperatively. Conclusion Dexmedetomidine has effectively provided the ideal oligemic surgical field during FESS and offers the inherent advantages of analgesia, sedation, and anesthetic-sparing effects.

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Background Postoperative emergence agitation (EA) is still a problem in sevoflurane-based anesthesia in children. Among the solutions of this problem is giving caudal anesthesia during operations in the lower half of the body. The aim of this study was to evaluate the addition of magnesium sulfate to bupivacaine in caudal block for the prevention of EA. Materials and methods In this prospective, randomized, double-blind study, 80 children aged 1-6 years, ASA I, undergoing unilateral hernia repair/orchiopexy with sevoflurane-based anesthesia were allocated into one of two groups: either bupivacaine 1 ml/kg 0.25% plus magnesium 50 mg (BM group) or bupivacaine 1 ml/kg 0.25% (B group) received in caudal block. EA was evaluated in both groups using the Pediatric Anesthesia Emergence Delirium scale and Aono's scale. The sedation score, the recovery time, and the occurrence of complications were assessed during the stay in the postanesthesia care unit. Results Only 72 children completed the study (36 in each group). There was a statistically significant difference in the Pediatric Anesthesia Emergence Delirium scale, the value being lower in the BM group than in the B group at 5 min [6 (5-17) compared with 8 (5-18)] (P < 0.001) and at 10 min [5 (4-16) compared with 6 (4-13)] (P < 0.001) postoperatively. Aono's scale showed that the incidence of EA was significantly lower in the BM group than in the B group (P = 0.003). The sedation score was significantly higher in the BM group than in the B group at 15 min (P = 0.001). In contrast, the duration of motor block after operation was similar in both groups. Conclusion The use of caudal magnesium sulfate (50 mg) combined with bupivacaine 0.25% was effective in reducing postoperative EA in preschool children undergoing hernia repair/orchiopexy procedures.

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Background Chronic post-thoracotomy pain, which is defined as pain that recurs or persists for more than 2 months, is a common problem affecting the quality of life of patients. We have evaluated the efficacy of perioperative pregabalin for reducing postoperative pain and the incidence of chronic post-thoracotomy pain. Patients and methods Sixty patients aged 30-49 years undergoing thoracotomy were allocated randomly to receive either pregabalin (75 mg oral twice daily for 5 days before and 5 days after the operation) or placebo at corresponding times in a double-blinded manner. Both groups received the same anesthetic technique. Our primary target was to measure the incidence of chronic postsurgical pain using the Leeds Assessment of Neuropathic Symptoms and Signs Pain Scale at 3- and 6-month intervals. Morphine consumption was measured as well as the length of hospital stay and the occurrence of postoperative systemic complications. Results Pregabalin decreased the incidence of chronic postoperative pain at 3 and 6 months from 60 and 40% to 10 and 6.7%, respectively. Also, pregabalin decreased the postoperative acute pain intensity as indicated by lower morphine consumption (P < 0.001). Pregabalin decreased postoperative hospital stay, with a time of discharge of 10 (9-10) days for the control group and 8 (7-8) days for the pregabalin group (P < 0.001). No statistical difference was found in the incidence of complications. Conclusion Perioperative pregabalin reduces the incidence of chronic post-thoracotomy pain, with less postoperative morphine consumption together with early hospital discharge.

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Background Regional anesthesia has been widely practiced with minimal risk of complications. The aim of this study was to compare the efficacy of nalbuphine and tramadol as separate adjuvants to lidocaine in intravenous regional anesthesia (IVRA) (Bier's block). Materials and methods This randomized double-blind controlled study was conducted in the Department of Anesthesia, Kasr Al Ainy Teaching Hospital, Cairo University, Egypt. Sixty patients, aged 20-60 years, ASA I-II, both sexes, scheduled for minor hand surgeries under IVRA were enrolled in the study. The patients were randomly allocated into three equal groups: group L (n = 20) received lidocaine in IVRA, group LT (n = 20) received lidocaine and tramadol mixture, and group LN (n = 20) received lidocaine and nalbuphine mixture. The onset, duration of both sensory and motor blocks, time to first analgesic request postoperatively, and complications related to the drugs or technique were recorded. Results There was a statistically significant acceleration in the mean onsets with significant prolongation of the mean duration of sensory and motor blocks in group LT and group LN compared with group L (P < 0.05). The results observed in both groups were comparable. In addition, there was an increase in the mean time to first analgesic request in group LT and group LN compared with group L (P < 0.001). Group LN had the longest duration time of postoperative analgesia and this was statistically significant compared with group LT (P < 0.001). Complications were minimal and nonsignificant. Conclusion The use of nalbuphine and tramadol as adjuvants to lidocaine in IVRA resulted in significant acceleration of the onset and prolongation of the duration of both sensory and motor blocks, with minimal insignificant complications. Both tramadol and nalbuphine effects were comparable.

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Background Despite the fact that sevoflurane is widely used in pediatric anesthesia due to its fast and well-tolerated inhaled induction and rapid emergence, sevoflurane-induced emergence agitation (EA) in children is not uncommon. This study aims to test the effect of intraoperative magnesium sulfate on reducing the incidence of EA in children anesthetized with sevoflurane. Materials and methods The study included 50 male children, aged 3-6 years, with ASA status I or II, scheduled for elective inguinal herniorrhaphy under GA through laryngeal mask airway (LMA). The patients were allocated into two groups: group M (25 patients) received intravenous magnesium sulfate 10% (0.2 ml/kg), followed by a continuous infusion of 0.1 ml/kg till the end of surgery; group C (25 patients) received a similar volume of intravenous normal saline (0.2 ml/kg), followed by a continuous infusion of 0.1 ml/kg till the end of surgery. Anesthesia was induced using 6 l/min of O ₂ 100% with sevoflurane 8 vol%. Anesthesia was maintained with sevoflurane 1.5-2 vol% in an oxygen-air mixture. After LMA removal, the agitation scoring scale was used for assessing the quality of emergence. Agitation parameters were measured using a four-point scale. Agitated children were managed by giving intravenous midazolam (0.1 mg/kg). Results The study was completed by 42 children. Magnesium concentrations in group M were significantly higher [2.95 (0.50) mg/dl] compared with group C [2.01 (0.42) mg/dl; P < 0.001]. The emergence time was significantly longer in group M [19.11 (7.45) min] compared with group C [15.421 (6.54) min; P < 0.001]. Other recovery characteristics in terms of the time to LMA removal and the time to reach full Aldrete score were comparable between both groups. Heart rate and systolic blood pressure variables were significantly higher in group C compared with group M at the time of LMA removal (P < 0.01). At the postanesthesia care unit, there was no incidence of agitation reported in group M as compared with 11 patients in group C (P < 0.001). In group C, the mean duration of agitation was 16.4 (8.2) min and the mean dose of midazolam administered was 0.09 (0-0.2) mg/kg per child. No patients in group M complained of pain compared with group C at 5, 10, and 30 min after emergence from anesthesia (P < 0.001). Conclusion Intravenous magnesium sulfate infusion significantly reduced the incidence of sevoflurane-induced EA.

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Background Endotracheal intubation is considered as the definitive method of airway management. Difficulty encountered during direct laryngoscopy for the intubation process is one aspect of the overall problems in airway management. Fiberoptic bronchoscopy (FOB) represents a significant advancement in the management of patients with a difficult airway. C-MAC videolaryngoscopes present a new approach for the management of difficult laryngoscopy. Patients and methods Sixty patients, of both sexes, aged 20-50 years, ASA I-II, undergoing an elective uvulopalatopharyngoplasty surgery were included. Patients were allocated randomly to be intubated using FOB (F group) or FOB plus C-MAC videolaryngoscopy (F-CMAC group). Collected data included grades of the Cormack-Lehane laryngeal view, success or failure of the technique, the number of attempts, the duration of the successful attempt, and hemodynamic measurements throughout the intubation procedure. Complications (such as oxygen desaturation, patient distress, soft tissue damage, gagging/vomiting, bradycardia and hypotension, laryngospasm, and bronchospasm) were recorded. Results There was a significant decrease in the duration of the successful attempt, the number of intubation trials, and Cormack-Lehane grades regarding the laryngeal view as well as a decrease in the number of patients who needed facilitating techniques in group F-CMAC compared with group F. No significant difference was found on comparing the heart rate, the mean arterial pressure, and the incidence of complications during intubation between the two groups. Conclusion The C-MAC videolaryngoscope with fiberoptic bronchoscopy allows a significantly faster intubation time, with a decrease in the duration of the successful attempt, fewer intubation trials, and a better grade of laryngeal views assessed by Cormack-Lehane grades, with a decrease in the number of patients who needed facilitating techniques and a comparable incidence of complications during intubation compared with fiberoptic alone for tracheal intubation in patients with a suspected difficult airway undergoing elective uvulopalatopharyngoplasty.

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Background Different additives have been reported to prolong the duration of caudal anesthesia in pediatrics. Although these drugs successfully increased the duration of the block, many of them were associated with undesirable adverse effects. Dexamethasone has been found to effectively increase the duration of an epidural block in adults, with no resulting side effects. Objective The aim of this study was to assess the effect of adding dexamethasone to bupivacaine on the duration of a caudal block in pediatric patients. Patients and methods This was a prospective randomized-controlled study that included 80 children, aged 1-6 years, American Society of Anesthesiologists physical status I, undergoing elective unilateral inguinal herniotomy. Patients were randomized to receive 1 ml/kg bupivacaine 0.25% (group B) or a mixture of dexamethasone 0.2 mg/kg added to 1 ml/kg bupivacaine 0.25% (group BD). In the postoperative period, pain was assessed using a modified Objective Pain Scale (mOPS) score until 24 h after surgery and rescue analgesia (oral paracetamol 15 mg/kg) was administered when mOPS score 4 or more was recorded. The primary outcome measure was the time to first analgesic requirement. The number of analgesic doses required in the first 24 h after surgery, residual motor block, sedation scores, intraoperative and postoperative hemodynamic variables, postoperative nausea and vomiting (PONV), and other adverse effects were recorded. Results Group BD showed a significantly longer time to first analgesic requirement than group B. The number of oral paracetamol doses required in the first 24 h was significantly less in group BD. Group BD showed lower mOPS scores than group B. Modified Bromage scale scores, sedation scores, as well as intraoperative and postoperative hemodynamic variables were comparable in the two groups. Group BD showed significantly fewer incidences of PONV compared with group B. Conclusion Adding dexamethasone to bupivacaine prolongs the duration of postoperative analgesia and decreases the incidence of PONV after a caudal block in pediatric patients.

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Objectives This study was designed as a randomized comparison of postoperative pain after inguinal herniotomy in patients treated with intravenous esmolol and others treated with ropivacaine abdominal wound infiltration. Patients and methods Sixty American Society of Anesthesiologists physical status I-II patients undergoing herniotomy and anesthetized with isoflurane were randomized into one of two groups. Group R received 20 ml of ropivacaine 0.75% in 20 ml of saline 0.9% preincisional wound infiltration and group E patients received a bolus of esmolol 0.5 mg/kg intravenous at induction followed by an infusion of 5-15 mg/kg/min. After surgery, a bolus of pethidine was given according to visual analogue scale for pain intensity. Results Patients in group E had lower pain scores than patients in group R. Median consumption of pethidine was higher in group R than in group E. Conclusion Intravenous esmolol reduces pethidine consumption and provides more analgesia compared with preincisional ropivacaine infiltration in patients undergoing herniotomy.

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Objective The aim of the study was to assess the efficacy and safety of palonosetron versus ondansetron for postoperative nausea and vomiting during middle ear surgery. Patients and methods This study was conducted on 60 patients, ASA I and II, ages ranging between 23 and 48 years, scheduled for middle ear surgery; they were randomly allocated into two equal groups: group 1 received ondansetron (4 mg) intravenously and group 2 received palonosetron (0.25 mg) intravenously. All medications were given over 30 s immediately before induction of general anesthesia. The duration of surgery, hemodynamic parameters, the severity and frequency of nausea, retching, and vomiting, time to recovery, and time to discharge of all patients were recorded. The patient's requests for rescue antiemetics and details of adverse events throughout the study were recorded. Results A total of 28 patients in group 2 and 22 patients in group 1 had complete response to antiemetic drugs. No patient in group 2 needed rescue antiemetic, whereas four patients in group 1 received ondansetron (4 mg) as rescue. With respect to the severity of nausea, group 2 showed significant decrease in nausea score in comparison with group 1. With respect to the complications, four patients in group 2 and one patient in group 1 developed headache. One patient in group 2 had diarrhea. Conclusion Palonosetron is a good antiemetic alternative during anesthesia with minimal side effects.

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Background Usage of airway stents in cases with tracheobronchial stenoses or obstruction has evolved rapidly. General anaesthesia has become less hazardous, particularly with recent developments in total intravenous anaesthetic agents and nondepolarizing neuromuscular blocking drugs. This study aimed at comparing the effectiveness of neostigmine/rocuronium technique to TIVA technique for tracheal stenting and dilatation. Patients and methods This prospective study was carried out on 80 patients scheduled for tracheal dilatation and stenting. Cases were randomly categorized into two equal groups. Group I (TIVA) received fentanyl and propofol with bilateral superior laryngeal nerve block. Group II (muscle relaxant) received rocuronium and sevoflurane 2% in 100% O ₂ . Heart rate, mean arterial pressure and oxygen saturation were assessed, and PaCO ₂ readings were taken through arterial blood gases at regular intervals intraoperatively. Recovery profile, perioperative complications and patient and doctor satisfaction were recorded in both groups. Results Both techniques offered haemodynamic stability. PaCO ₂ readings were significantly higher (P < 0.001) in group II. Earlier recovery was recorded in group I (P < 0.001). Incidence of complications was generally higher in group II (P > 0.05), except hypotension (higher in group I; P < 0.05). Patient and doctor satisfaction were comparable (P > 0.05). Conclusion Both the TIVA and neostigmine/rocuronium techniques were used successfully. The TIVA technique had the advantages of earlier recovery, less hypercapnia, desaturation, distal total obstruction and stridor on recovery, whereas the muscle relaxant technique offered less hypotension and hemoptysis. Thus, we strongly recommend the TIVA technique for such operations.

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Background Tracheal intubation under deep inhalational anaesthesia is a common practice in paediatrics; however, since the introduction of short-acting opioids, intubation has become more successful when these drugs are used in combination with propofol, avoiding the use of neuromuscular blocking agents with their unwanted side effects. Several techniques and adjuvants have been used to improve intubating conditions. We studied the interaction between magnesium sulphate and the anaesthetic agent's propofol and fentanyl to facilitate intubation in paediatrics. Patients and methods A total of 40 preschool and school-aged patients scheduled for short urogenital procedures were randomly assigned in a double-blind study to be administered either a 5-min infusion of magnesium sulphate (30 mg/kg) in 0.9% saline 5 ml/kg (magnesium group, n = 20), or the same volume of saline (control group, n = 20). Anaesthesia was induced (1 μg/kg) fentanyl followed by propofol (2.5 mg/kg). Intubating conditions were assessed by Copenhagen score. Blood pressure, heart rate, respiratory rate and EtCO ₂ were recorded. Serum magnesium was measured, and Aldrete recovery score was assessed. Results The two groups were comparable regarding demographic data. Intubating conditions were better in the magnesium group than in the control group (0 vs. 60%). There were no differences between both groups regarding haemodynamic variables. The duration of intubation was insignificantly shorter in the magnesium group. Aldrete recovery score showed no difference between both groups. Serum magnesium increased from 1.92 to 3.18 mg/dl in the magnesium group, but with no signs of hypermagnesemia. Conclusion Adding magnesium sulphate to propofol and fentanyl improves intubating conditions without the use of muscle relaxants during the start of procedures in paediatrics.

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Background and aim Pain following laparoscopy is mostly because of irritation of the diaphragm and stretching of the peritoneum associated with carbon dioxide insufflation. In this study, we evaluate the effectiveness of periportal xylocaine infiltration and intraperitoneal instillation of l-bupivacaine at the beginning of laparoscopy in pediatrics in reducing postoperative pain, delaying the onset and reducing the total dose of rescue analgesia, and improving perioperative hemodynamics. Patients and methods After receiving ethical committee approval in Kasr Al Ainy University Hospital and parents' consent, 40 ASA I and II children were allocated randomly to two groups. In group I, l-bupivacaine 0.5% instilled into the peritoneal cavity immediately after gas insufflation at a dose 2 mg/kg. In group II, normal saline was instilled instead of l-bupivacaine. All patients were subjected to preincisional periportal lidocaine 1% infiltration. Heart rate (HR) and blood pressure were recorded at 5 min intervals starting from the preoperative period until 6 h postoperatively. The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) score was used, and the onset and dose of pethidine were recorded. Results HR was lower in group I and HR4 was significantly lower (P < 0.001). The mean arterial blood pressure (MAP) was also lower in group I. It was significantly lower in MAP3 and MAP4 (P = 0.049 and 0.004, respectively). The median pain score was significantly lower in group I (P = 0.001). Onset of rescue analgesia demand was longer in group I and the total dose of pethidine was significantly lower in group I (P < 0.001). Conclusion Periportal lidocaine infiltration and intraperitoneal l-bupivacaine instillation in pediatric laparoscopy, after pneumoperitoneum, reduced postoperative pain and improved perioperative hemodynamics.

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Introduction Predictive accuracy of severity scoring systems in Indian ICUs does not fit well owing to differences in case mix from the west. We hypothesized that 24 h is too early to predict the outcome and that the predictive accuracy of these scores might be better at 48 h of ICU admission. Objective The aim of this study was to evaluate and compare Acute Physiology and Chronic Health Evaluation (APACHE) II, Simplified Acute Physiology (SAPS) II, and Sequential Organ Failure Assessment (SOFA) as a predictor of outcome in critically ill patients at 24 and at 48 h in a tertiary care hospital ICU. Patients and methods A prospective cohort study was conducted on 169 patients over 2 years at a single medical surgical ICU. Eighty-five critically ill patients were included. For each patient, APACHE II, SAPS II, and SOFA scores were calculated at two time frames (first at 24 and then at 48 h) after ICU admission. The accuracies and comparisons of outcome prediction by the three scores were assessed with standardized mortality ratio and area under the receiver operating characteristic (AUROC) curves. Results All scoring systems (except SOFA) underestimated the deaths (standardized mortality ratio>1). All scoring systems displayed larger AUROC curves at 48 h than those at 24 h. APACHE II ₄₈ showed the largest AUROC of 0.933. Conclusion All scores performed better when calculated at 48 h rather than at 24 h. Overall, APACHE II ₄₈ is the best predictor of 28-day mortality in critically ill patients. A worsening APACHE II score at 48 h after ICU admission may identify the patients at high risk of mortality.

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Background and aim This study was designed to compare the postoperative analgesic effect of dexmedetomidine administered intravenously or in wound infiltration with bupivacaine in patients undergoing cesarean section. Patients and methods Ninety female patients scheduled for cesarean section were randomly allocated into three equal groups: group I received 100 ml normal saline infusion over 10 min before closure plus wound infiltration with 25 ml of 0.25% bupivacaine at the end of surgery; group II received 1 mg/kg of dexmedetomidine in 100 ml normal saline infusion over 10 min before closure plus wound infiltration with 25 ml of 0.25% bupivacaine at the end of surgery; and group III received 100 ml normal saline infusion over 10 min before closure plus wound infiltration with 1 mg/kg of dexmedetomidine added to 25 ml of 0.25% bupivacaine at the end of surgery. The number of patients requiring rescue analgesia, total morphine consumption during the first 24 h after the operation, and the level of sedation were recorded. Results Morphine consumption was significantly less in patients receiving dexmedetomidine by either route. All patients in group I required supplemental morphine, whereas 14 patients in group II and 16 patients in the wound infiltration group required supplemental morphine. Patients in group II had more hypotension and sedation compared with other groups. Conclusion Dexmedetomidine provided effective postoperative analgesia and reduced morphine consumption when administered intravenously or in wound infiltration with bupivacaine. The incidence of complications was less with wound infiltration.

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Background Ultrasound (US)-guided transversus abdominis plane (TAP) block is an effective technique in providing analgesia for abdominal surgery. This study was designed to evaluate the efficacy of a US-guided TAP block and to compare it with a caudal block in unilateral day-case open inguinal hernia repair in children. Patients and Methods Forty ASA I-II, 1-5-year-old children scheduled for elective unilateral open inguinal herniotomy were studied. All patients received general anesthesia; sevoflurane was used for induction and maintenance of anesthesia and laryngeal mask airway (LMA) was used to secure the airway. After securing an intravenous cannula, patients were randomized to a US-guided TAP block (n = 20) (group T) using 0.5 ml/kg 0.25% bupivacaine, injected on the same side of surgery, and group C received a caudal block using 1 ml/kg 0.2% bupivacaine (n = 20). Surgery was allowed 15 min after administration the block. Block failure was considered in case of gross movement or more than 20% change in heart rate and/or ABP persisting more than 1 min after skin incision. Any adverse events were recorded. After surgery, patients remained for 4 h in the recovery room. Postoperative analgesia was evaluated using Children and Infants Postoperative Pain Scale (CHIPPS). An anesthesiologist, who was not part of the study team, evaluated the need for rescue analgesia in the intraoperative and postoperative period and a recovery nurse collected the data. If the CHIPPS score was greater than 4, a rescue analgesia of 20 mg/kg acetaminophen was administered. Results No difference was found in hemodynamics in both groups. Also, intraoperative fentanyl consumption was not different and no rescue analgesia was required in the postanesthesia care unit. Conclusion A US-guided TAP block is as effective as a caudal block in providing immediate postoperative analgesia in inguinal hernia repair.

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Background Adequate pain control allows early rehabilitation and improves outcome after shoulder arthroscopic procedures. Objective The aim of this study was to compare the interscalene nerve block (ISB) with shoulder block (ShB) (suprascapular and axillary nerve blocks) for postoperative pain relief after arthroscopic shoulder surgery. Design This was a prospective, randomized, comparative study. Patients and methods A total of 75 patients of ASA grade I or II scheduled for shoulder arthroscopic surgery were equally divided into three groups (25 patients each): the general anesthesia (GA)-only group; the GA with ISB group; and the GA with ShB group. The nerve block was guided by both ultrasound and nerve stimulator. Visual analogue scale score was evaluated at the recovery room and 2, 4, 8, 16, and 24 h postoperatively. The time to first call for analgesia, total analgesic requirement for 24 h postoperatively, patient satisfaction, and any complications were recorded. Results The visual analogue scale score was significantly less in the GA + ISB and GA + ShB groups compared with the GA-only group (P < 0.001). The time to first analgesic request was significantly longer in the GA + ISB group [10 (9-10 h)] and GA + ShB group [9 (9-10 h)] compared with the GA-only group [1 (1 h)] (P < 0.001). The total dose of morphine consumption was significantly higher in the GA-only group [10 (9-10 mg)] compared with the GA + ISB group [6 (5-6 mg)] and the GA + ShB group [6 (6-7 mg)] (P < 0.001). Patient satisfaction was significantly higher in the GA + ISB group [9 (9-10)] and in the GA + ShB group [8 (8-9)] compared with the GA-only group [1 (1-2)] (P < 0.001). The incidence of complications was significantly higher in the GA + ISB group compared with the other two groups (P < 0.001). Conclusion ShB was as effective as ISB for postoperative pain relief but with fewer complications. Thus, ShB is a good alternative for patients at high risk for adverse events with ISB.

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Objective The aim of the present study was to detect the efficacy of early postoperative calf muscle exercise to decrease the risk of deep venous thrombosis achieved by intrathecal 3 ml bupivacaine 0.25% and fentanyl 25 μg instead of 3 ml bupivacaine 0.5%. In total, 40 patients of either sex, aged between 18 and 60 years, with American Society of Anesthesiologists (ASA) I and II were included in the study. Patients and methods A total of 40 ASA I and II patients undergoing elective total hip replacement surgery were randomly assigned to two equal groups of 20 patients each (group A and B). Group A received bupivacaine 0.5% (3 ml) and group B received bupivacaine 0.25% (3 ml)+fentanyl 25 μg. Patients were instructed on how to do cuff muscle exercise once they regained the full strength of the lower limbs muscles postoperatively. Five venous blood samples were taken from each patient for the D-dimer assessment as an indicator for the occurrence of venous thromboembolism. The first sample was taken preoperatively at the time of induction of anesthesia; the rest of samples were then taken at 12, 24, 48 h, and 7 days postoperatively. Results Group B, in which patients received intrathecal bupivacaine 0.25% plus fentanyl, had an earlier recovery of motor power; patients in this group started doing calf muscle exercise earlier than did those in group A, and this group had significantly lower postoperative D-dimer level, denoting less susceptibility to deep venous thrombosis. Conclusion Early postoperative calf muscle exercise decreased the incidence of venous thromboembolism risk as indicated by the results of the D-dimer assessment.

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Purpose The aim of this prospective randomized double-blind study was to investigate the effect of adding magnesium to bupivacaine on the onset and duration of sensory and motor block, postoperative visual analog scale (VAS), and total opioid consumption in patients following Achilles tendon repair surgery with popliteal-sciatic nerve blockade. Patients and methods A total of 60 patients who underwent Achilles tendon repair surgery and were of American Society of Anesthesiologist I or II physical status with age between 18 and 50 years of age were included in the study. The patients were randomly assigned into two groups: group bupivacaine–magnesium (BM) (n=29) received 30 ml of 0.25% bupivacaine and 2 ml of 10% magnesium sulfate, and group bupivacaine (B) (n=28) received 30 ml of 0.25% bupivacaine and 2 ml of normal saline for popliteal-sciatic blockade using the nerve stimulator technique. We evaluated the patients as regards the onset and duration of sensory and motor block, postoperative VAS scores, and total opioid consumption. Results The onset of motor block in group B was significantly longer in comparison with group BM (14.2±2 and 11.9±1.5 min, respectively). At the same time, the duration of sensory and motor block in group BM was significantly longer in comparison with group B (P<0.001). As regards total opioid consumption (tramadol) during the first 12 h postoperatively, it was significantly less in group BM in comparison with group B (190.67±21.8 and 237.86±25.8 mg, respectively). As regards VAS, it was significantly lower in group BM in comparison with group B at 4, 6, 8, 10, and 12 h postoperatively. Conclusion The addition of magnesium to bupivacaine prolonged the motor and sensory block duration without increasing side effects, and enhanced the quality of postoperative analgesia, which was manifested by lower VAS and less total opioid consumption. Moreover, the addition of magnesium speeds up the onset of motor block.

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Background Arthroscopic shoulder surgery is often associated with severe postoperative pain that is often significant enough to interfere with initial recovery and rehabilitation − the pain that can be difficult to manage without large-dose opioids. Opioids can cause nausea, vomiting, sedation, and/or failure to control pain. Supplementing general anesthesia with a regional nerve block might improve the quality of postoperative pain relief. The use of interscalene blockade (ISB) is gaining popularity, but it is associated with infrequent but potentially serious complications. Combined suprascapular nerve block and axillary nerve block (SSNB+ANB) can offer a safe alternative to ISB. Objective This study was designed to compare between ISB and SSNB+ANB in arthroscopic shoulder surgery as regards postoperative analgesia Patients and methods Sixty American Society of Anesthesiologist physical status I and II patients, aged between 18 and 40 years, scheduled for arthroscopic shoulder surgery were randomized to receive ISB or SSNB+ANB. After performing the blocks, general anesthesia was standardized in all groups. All the patients in the two groups were compared as regards postoperative pain assessed by the visual analog scale score at postanesthesia care unit, 4, 6, 12, and 24 h, occurrence of complications, and patient’s satisfaction. Results In the postoperative period, there were no statistically significant differences between the two groups as regards visual analog scale and analgesic requirements. Complications such as Horner’s syndrome, hoarseness of voice, major weakness of the upper arm, and dyspnea were recorded in the ISB group. Conclusion For certain procedures of shoulder arthroscopic surgery, SSNB+ANB is a safe and effective alternative to ISB as postoperative analgesia.

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Background and aim Various peripheral nerve block techniques have been described to deliver anesthesia and analgesia that allow better functional recovery and shortened hospital stay following major lower-limb surgeries. We aimed to compare the possible effect of perineural dexamethasone versus systemic dexamethasone after nerve stimulator-guided combined femoral and sciatic nerve blocks in lower-limb vascular surgeries. Patients and methods After obtaining approval from the ethical committee of Kasr Al-Ainy University Hospital and obtaining written informed consent, 63 patients aged 18–70 years were randomly allocated into three equal groups. Group P received perineural dexamethasone plus bupivacaine 0.5%, group I received intravenous dexamethasone plus perineural bupivacaine 0.5%, and group B received perineural bupivacaine 0.5% alone. We compared the onset and duration of sensory and motor blockade, duration of analgesia, and hemodynamic changes. Results Sensory and motor block onset showed nonsignificant difference between the three groups. Sensory block duration was significantly longer in group P than in groups I and B. Motor block duration was significantly prolonged in groups P and I when compared with group B. Motor block duration was longer in group P than in group I; however, the difference was statistically nonsignificant (p-value 0.34). The duration of analgesia was significantly longer in group P than in the other groups, and significantly longer in group I compared with group B. Conclusion The use of equal doses of perineural or intravenous dexamethasone as an adjuvant in single injection combined femoral and sciatic nerve blocks is associated with extended duration of sensory and motor blocks, extension of postoperative analgesia duration, and reduced postoperative analgesic requirements.

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