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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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 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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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 Local anesthetic adjuvants have been studied previously to prolong the duration of analgesia after peripheral nerve block and thus reduce postoperative adverse reactions associated with excessive systemic analgesic intake. The aim of this study was to compare the addition of MgSO ₄ against dexamethasone to bupivacaine in the prolongation of ultrasound-guided interscalene brachial plexus block (ISPB) for shoulder arthroscopy. Patients and methods A total of 63 patients, ASA I and II grades, undergoing arthroscopic rotator cuff repair were enrolled in this study. The ISPB was performed with 0.5% bupivacaine 20 ml plus either 5 ml of 10% MgSO ₄ (group M) or 5 ml of normal saline containing dexamethasone 8 mg (group D) or 5 ml of 0.9% NaCl (group C). The following data were collected: the onset of sensory block, the analgesic duration (time of the first call for analgesics), the occurrence of satisfactory motor block, the motor block duration, and postoperative analgesic consumption. Results The magnesium sulfate group and the dexamethasone group patients showed significantly higher analgesic duration values and significantly lower total meperidine consumption values than control group patients. Conclusion The addition of either magnesium sulfate or dexamethasone to bupivacaine in ISPB prolongs the analgesic duration significantly and also decreases the postoperative analgesic consumption.

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Introduction The objective of anesthesia has always been to enable correction of surgical pathology with the best technique and minimum risk to the patient. The aim of the present study was to determine clinically, without using a peripheral nerve stimulator, whether continuous infusion or intermittent bolus dosing of rocuronium bromide yielded a better clinical condition during general anesthesia. Patients and methods The study was carried out on 60 adult patients. A common technique of general anesthesia was used in all patients. Patients were randomized to receive either a continuous infusion (group I, n = 30) or intermittent bolus dosing (group II, n = 30) of rocuronium bromide. Intraoperatively (a), hemodynamic parameters (heart rate and arterial pressure), (b) clinical relaxation by a grading technique, (c) total drug requirement, (d) recovery status by modified Steward score were assessed and were compared between the two groups. Results The mean heart rate and mean arterial pressure at different time intervals after intubation with rocuronium were not significantly different between the two groups. The total drug requirement was significantly greater in patients who received an intermittent bolus dose of rocuronium than those who received a continuous infusion. Clinical relaxation and recovery status in patients receiving rocuronium infusion were significantly better. Conclusion Rocuronium infusion offers a better and stable degree of relaxation compared with intermittent bolus dosing for intermediate duration of operation, which can be assessed using the clinical relaxation grading system. Rocuronium is a rapidly acting and hemodynamically stable nondepolarizing muscle relaxant with fewer drug requirements and provides better quality of recovery status during a continuous infusion.

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Context Anxiety and pain are common responses to surgery and can negatively affect patient outcomes. Music is increasingly being used as a nonpharmacological intervention perioperatively, to improve patient outcomes and to avoid polypharmacy. Aims The aim of this study was to evaluate the impact of intraoperative music on the anesthetic requirement and stress response for laparoscopic surgeries under general anesthesia. Settings and design This was a prospective, randomized, double-blinded study. Materials and methods After approval of the hospital ethical committee, 60 ASA I patients were randomly assigned to the music and the no-music group. In the music group, classical instrumental music was played after the induction of anesthesia until the skin closure. In the no-music group, patients wore headphones but no music was played. We established three sample times for measurement of capillary blood sugar level during the procedure and one in the recovery room. Hemodynamic data were recorded. There was no statistically significant difference with respect to demographic profile, baseline hemodynamic variables, and duration of surgery. Results There was no statistically significant difference in the intraoperative hemodynamics between the two groups. The bispectral (BIS) value, end-tidal isoflurane concentration, and fentanyl requirement were comparable in the two groups. There was no significant difference in the blood sugar levels between the two groups. Conclusion In this study, we could not demonstrate the beneficial effects of intraoperative music as a nonpharmacological intervention under general anesthesia on stress response and anesthetic requirement.

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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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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 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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Background End-stage liver disease is characterized by severe coagulopathy, and bleeding is common during liver transplantation (Ltx). Previous studies reported a depressant effect of some inhalational anesthetics on platelet function in normal patients. None of them investigated this effect in Ltx recipients with end-stage liver disease. In this study, we evaluated the effects of sevoflurane versus isoflurane on coagulation function, blood loss, and transfusion requirements in living donor liver transplantation recipients. Patients and methods A total of 32 patients of either sex, with MELD score between 12 and 18 scheduled for living donor liver transplantation, were randomly allocated into either the sevoflurane group (N = 18) or the isoflurane group (N = 14), based on the inhalational anesthetics used. Standard hemodynamic monitoring was applied. All operations were performed by the same anesthesia and surgery teams. All patients were administered propofol/fentanyl and rocuronium bromide for induction, followed by continuous infusion of fentanyl for analgesia and rocuronium bromide for muscle relaxation. Samples for INR, prothrombin time, bleeding time, Factor V, Factor VII, serum fibrinogen, complete blood picture, and aPTT were collected before the induction of anesthesia, end hepatectomy, 60 min after reperfusion, and 6, 12, 24 h in the ICU. Amounts of blood loss and blood components transfusion were also recorded at the end of operation and first postoperative day. Results Both the groups had comparable demographics, coagulation profiles, and MELD scores. Bleeding time was significantly longer in the sevoflurane group (P = 0.04), starting at end hepatectomy and persisted till the sixth hour postoperative reading, compared with the isoflurane group. INR, aPTT, PT, Factor V and Factor VII, and Hg were comparable in both groups. Platelet count was also not significantly different between both groups. Blood loss and transfusion requirements were comparable in both groups. No outcome difference was observed between groups. Conclusion In Ltx recipients, sevoflurane induced prolongation of the bleeding time compared with the isoflurane group. Yet, no clinically significant impact was encountered regarding blood loss and transfusion requirements either during intraoperative or the early postoperative period.

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Background Penile block is recommended for analgesia during and after surface operation on the penis, for example circumcision, phimosis, meatal stenosis, and hypospadias repair. Objective To evaluate the effect of penile block versus caudal block using bupivacaine on the quality of analgesia, and the surgeon's and parents' satisfaction after penile pediatric surgery. Patients and methods This study was conducted on 80 healthy boys aged 1-7 years, of American Society of Anesthesiologists (ASA) I and II health classes, scheduled for hypospadias repair, circumcision and meatal stenosis under general anesthesia. The patients were randomly divided into two equal groups: group P (penile block, 0.25% bupivacaine, 0.5 mg/kg; n = 40) and group C (caudal block, 0.25% bupivacaine, 0.5 mg/kg; n = 40). The heart rate (HR), the mean arterial blood pressure (MAP) and oxygen saturation were measured perioperatively. Postoperative pain evaluated by the FLACC pain scale of five categories, (F) Face, (L) Leg, (A) Activity, (C) Cry, (C) Consolability, was assessed on admission to and on discharge from the PACU and 2, 4, 8, 12, 16 and 24 h postoperatively. Also, the time to first rescue analgesic request and doses of analgesic requirements were recorded. The surgeon's and parents' satisfaction were evaluated on the first day of the operation using a five-point verbal score. Results In group P, there was no significant decrease in the HR and the MAP compared with the baseline, but in group C, there was a significant decrease in HR and MAP compared with the baseline. FLACC pain scores were significantly lower in group P compared with group C (P < 0.05). Also, the time to first need for analgesia was significantly (P < 0.05) lower in group P compared with group C. The total analgesic requirement was also significantly lower (P < 0.05) in group P compared with group C. Conclusion Single-injection penile block is superior to caudal epidural block for relief of postoperative pain in children undergoing penile surgery with more satisfaction to the surgeon and the parents, without significant increase in the rate of adverse events.

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Background The effect of deliberate hypothermia and hypocapnia on brain protection during neurosurgical procedures has been studied for many years, but in this study, the combination of deliberate hypothermia and hypocapnia was analyzed to detect their effects on cerebral oxygenation by the assessment of SjvO ₂ and cerebral metabolism by the measurement of both jugular bulb lactate and pyruvate. Patients and methods Sixty patients scheduled for excision of supratentorial space-occupying lesions were randomly allocated into two groups. In group I, hypocapnia was induced combined with hypothermia, and in group II, normocapnia was maintained combined with hypothermia. Hypothermia was induced using a water blanket under the patient controlling the tympanic membrane temperature at 35°C. Jugular bulb venous and arterial blood gas analyses were performed before the induction of hypothermia ± hypocapnia (baseline), and then every 20 min till closure of the dura. The arterio-jugular venous oxygen content difference (AJDO ₂ ) and the cerebral oxygen extraction ratio (COER) were calculated. Jugular bulb lactate and pyruvate levels were measured before the induction of hypothermia ± hypocapnia (baseline) and then every 30 min till closure of the dura. Results There was a significant increase in pjH and significant decreases in both PjCO ₂ and SjvO ₂ in the hypocapnic group after the induction of hypocapnia. SjvO ₂ reached 80.32 ± 4.59% in the normocapnic group, whereas it reached 75.3 ± 4.02% in the hypocapnic group. AJDO ₂ and COER started to decrease after induced hypothermia in both groups compared with readings before induced hypothermia, but the hypocapnic group had a significantly higher AJDO ₂ and COER than the normocapnic group during the period of induced hypothermia (AJDO ₂ reached 3.98 ± 0.47 ml/dl and COER reached 25.93 ± 4.13% in comparison with the hypocapnic group, where AJDO ₂ reached 4.58 ± 0.51 ml/dl and COER reached 31.96 ± 4.01%).Jugular bulb lactate and pyruvate levels were significantly higher during hypocapnia than during normocapnia. Conclusion Cerebral oxygenation and metabolism were better during hypothermia combined with normocapnia as reflected by relative ͽͽSjvO ₂ and ͿͿAJDO ₂ and COER as well as ͿͿjugular bulb lactate and pyruvate.

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Background Despite its strategic role in health-care delivery, anesthesia does not attract medical manpower in developing countries, more so among medical trainees. This has resulted in an alarming lack of physician anesthetists. This study aims to determine the rate of selection of anesthesia as a specialty choice and factors that influence medical students when choosing specialties. Patients and methods A cross-sectional study was conducted on final-year medical students in the University of Calabar. A semistructured self-administered questionnaire was distributed to a total of 105 final-year students who had undergone their posting in anesthesia. Summarization of data was done using frequencies/proportions and graphs, and significance level was set at P-value less than 0.05. Results The mean age of respondents was 27.2 ± 4.15 years. Of the students, 72 (69%) were male, whereas 33 (31%) were female. Of them, 96 (91%) indicated interest in specializing, 34 (32%) preferred obstetrics and gynecology, 20 (19%) wanted pediatrics, 13 (12%) preferred family medicine and three (3%) preferred anesthesia. Factors that influenced choice of specialty among the graduating students included: personal interests in 85 students (81%), future job opportunities in the field in 66 students (63%) and requirement of specialized skill in 65 students (62%). In all, 46 respondents (44%) reported that their anesthesia posting experience was interesting, whereas 27 respondents (28%) reported it as very educative. The duration of the posting was rated very short by 25 students (24%). Conclusion With less than 5% of the graduating medical students indicating interest in anesthesia specialization, improvement in training facilities and provision of incentives to intending trainees are strongly recommended.

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Context Femoral nerve block (FNB) provides effective analgesia after total knee arthroplasty (TKA) but has been associated with delayed ambulation due to quadriceps muscle weakness. Adductor canal block (ACB) may be a promising alternative, with less effect on the quadriceps muscle and comparable analgesic efficacy. Aim The aim of the study was to compare ACB with FNB regarding the quadriceps muscle strength and its analgesic efficacy in patients following TKA. Settings and design This was a prospective, randomized, controlled, double-blinded study. Patients and methods The patients were randomized to receive either ACB or FNB. The primary outcome was the effect on quadriceps muscle and early ambulation as determined by the timed up and go test and 10-min walk test. The secondary outcome was to compare the analgesic efficacy as determined by numeric rating scale, opioid consumption, and hospital length of stay. Results We enrolled 110 patients, of whom 107 were analyzed. The timed up and go test and the 10-m walk test were significantly shorter in the ACB group than in the FNB group on the postoperative day 1 with P-value of 0.002 and 0.005, respectively, whereas the difference between both study groups was statistically nonsignificant on the postoperative day 2. There was no significant difference between the study groups regarding the numeric rating scale, morphine consumption, or length of stay. Conclusion ACB may promote early ambulation after TKA without a reduction in analgesia when compared with FNB.

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Background NSAIDs inhibit platelet aggregation and prolong bleeding time, which may augment the risk of postoperative bleeding. We investigated the effects of pre-emptive analgesia with intravenous ketorolac on intraoperative and postoperative hemorrhage with pediatric tonsillectomy. Patients and Methods A total of 147 children, aged 2-7 years, scheduled for tonsillectomy with or without adenoidectomy were randomized to receive a slow intravenous infusion of either ketorolac 1 mg/kg (ketorolac group, n = 74) or paracetamol 15 mg/kg (paracetamol group, n = 73) after induction of anesthesia. Noninvasive hemoglobin was assessed preoperatively and several times after surgery. Bleeding times were measured before and after surgery. Intraoperative blood loss was estimated. Intensity of postoperative pain was measured using an objective pain score. The incidence and severity of post-tonsillectomy bleeding were recorded until the seventh postoperative day. Results There was no statistically significant difference in the estimated intraoperative blood loss between ketorolac and paracetamol groups (2.4 ± 1.1 vs. 2.1 ± 0.8 ml/kg, respectively; P = 0.061). Bleeding time increased between preoperative and postoperative assessments in both groups, with significant postoperative elevation in the ketorolac group (P = 0.001). Both groups were comparable regarding the perioperative noninvasive hemoglobin measurements. The overall incidence of post-tonsillectomy bleeding was 5.4%, with no statistically significant difference between ketorolac and paracetamol groups [5 (6.75%) vs. 3 (4.1%) patients, respectively; P = 0.705]. Postoperative objective pain score were significantly lower in the ketorolac group on postanesthesia care unit admission and at 1, 2, and 6 postoperative hours (P < 0.05). Conclusion Pre-emptive ketorolac infusion during pediatric tonsillectomy provides superior postoperative analgesia with no effect on intraoperative or postoperative clinical bleeding.

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Background Regional techniques using either epidural or intrathecal routes are currently the most popular methods of pain relief during labor and delivery. Aim The aim of the study was to compare efficacy and duration of analgesia produced by adding magnesium sulfate to intrathecal bupivacaine (10 mg) plus midazolam (1 mg) in patients undergoing cesarean section. Patients and methods In our study, 60 patients aged 18-35 years of American Society of Anesthesiologists (ASA) class I and II were scheduled for a cesarian section under an intrathecal block and divided randomly into two groups: midazolam group (group M): A total of 30 patients received 10 mg/2 ml intrathecal 0.5% hyperbaric bupivacaine, midazolam (1 mg/0.2 ml), and 0.8 ml normal saline and magnesium midazolam group (group MM): A total of 30 patients received 10 mg/2 ml intrathecal 0.5% hyperbaric bupivacaine, midazolam (1 mg/0.2 ml), magnesium sulfate (50 mg/0.5 ml), and 0.3 ml normal saline. The onset and duration of both sensory and motor block, the total dose of analgesia, and adverse effects were recorded. Results The onset of sensory block was significantly delayed in the MM group compared with the M group (6.05 ± 1.1 vs. 3.5 ± 0.45 min, P = 0.024); the duration of sensory block was longer in the MM group compared with the M group (132.4 ± 7.8 vs. 115.3 ± 6.60 min, P = 0.018). In addition, the onset of motor block was delayed in the MM group (7.05 ± 1.3 min) compared with the M group (5 ± 0.65 min, P = 0.028) as well as its duration (149.9 ± 8.67 vs. 126.3 ± 5.35 min, P = 0.005). Conclusion The addition of magnesium sulfate to intrathecal bupivacaine plus midazolam led to a significant delay in the onset of both sensory and motor blockade, and also prolonged their duration without side effects.

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Context Although spinal anesthesia avoids the risks involved in managing the airway of the parturient, an undesired side effect often seen is hypotension. Prophylactic intravenous (i.v.) administration of vasopressors such as ephedrine or of serotonin receptor antagonists such as granisetron and ondansetron has been used to overcome this problem. Aims The aim of the study was to compare granisetron and ondansetron with the traditionally used vasopressor 'ephedrine' in reducing hypotension following spinal anesthesia and their effect on sensory and motor blockade in parturients undergoing cesarean section. Settings and design This study was designed as a randomized, prospective, double-blind, placebo-controlled trial. Materials and methods Eighty parturients of ASA I or II grade, aged 2040 years, scheduled for elective cesarean section were randomly allocated into four equal groups (G, O, E, and C). 'Group G' received 1 mg i.v. granisetron, 'group O' received 4 mg i.v. ondansetron, 'group E' received 10 mg i.v. ephedrine, and 'group C' received 10 ml normal saline. All of the studied drugs were diluted in 10 ml normal saline and administered over a period of 1-5 min before induction of spinal anesthesia. Mean arterial blood pressure, heart rate, sensory and motor blockade, nausea, shivering, bradycardia and vasopressor need were assessed. Results The reduction in mean arterial pressure was significantly lower in the therapeutic groups, with the best results recorded in the O group and nearly comparable results in G and E groups. Heart rate was statistically different only at 10 and 15 min. No significant difference was seen in motor block or in the incidence of bradycardia. Significantly faster recovery of sensation was detected in the G group. Groups G, O, and E had significantly less vasopressor need and lower incidence of nausea. Conclusion In the cesarean section, prophylactic use of i.v. granisetron, ondansetron, or ephedrine reduced the severity of spinal-induced hypotension, nausea, and vasopressor need, but faster recovery of sensory block was noticed with granisetron.

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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 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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