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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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 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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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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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 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 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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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 Postanesthetic shivering (PAS) can influence hemodynamic stability and recovery from general anesthesia. We tested the efficacy of intramuscular dexmedetomidine in prevention of PAS in patients undergoing arthroscopic anterior cruciate ligament reconstruction. Materials and methods In this prospective, randomized, and double-blind controlled study, 85 ASA I male patients, aged 18-40 years, scheduled for arthroscopic anterior cruciate ligament reconstruction under general anesthesia were enrolled. Forty-five minutes before the expected end of surgery, the patients were randomized to receive an intramuscular injection in the deltoid muscle of either dexmedetomidine 2.5 μg/kg (group D, n = 43) or isotonic saline (group C, n = 42). Extubation time, the incidence and grades of shivering, pain intensity, degree of sedation, and side effects were recorded. Results The mean ± SD extubation time was prolonged in the dexmedetomidine group than in the control group (8.4 ± 2.3 vs. 7.2 ± 2.6 min, respectively; P = 0.0268). The incidence of shivering was 64.28% in the control group compared with 11.62% in the dexmedetomidine group (P ≤ 0.0001), with lower intensity in group D. Assessment of pain intensity until 2 h postoperatively revealed significantly lower scores in dexmedetomidine-treated patients (P = 0.0239 at the second hour). Sedation scores were higher in the dexmedetomidine group until 4 h postoperatively (P = 0.032 at the fourth hour). The mean heart rates and blood pressure were significantly lower in group D than in group C (P < 0.05) in most of the assessments until 6 h postoperatively. Conclusion Intramuscular dexmedetomidine provides effective prophylaxis against PAS without major side effects.

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Background Caudal block is the most frequently used regional anesthetic technique for pediatric analgesia, with the disadvantage of limited duration of action. Transversus abdominis plane (TAP) block has been reported to provide effective analgesia after lower abdominal surgery, but there are few data comparing caudal block with ultrasound-guided TAP block in pediatric patients undergoing surgical pyeloplasty. Patients and methods Thirty-nine patients (6 months to 6 years) scheduled for elective surgical pyeloplasty were divided into two groups in a double-blinded randomized manner. After sevoflurane in oxygen anesthesia, patients were assigned to one of the two groups: group A (caudal; n = 19 patients) received a single caudal dose of isobaric bupivacaine 0.25% (1.25 ml/kg) and group B (TAP block; n = 20 patients) received isobaric bupivacaine 0.25% (0.3 ml/kg). The primary outcomes were the time to first analgesia in minutes and the analgesic doses (oral acetaminophen and rectal diclofenac) required during the first 24 h postoperatively. The secondary outcome measures included FLACC pain scale score and intraoperative hemodynamic variables. Results Group B had a significantly longer time to first analgesia (602, 705, 748 vs. 250, 280, 365 min) and required significantly lower doses of acetaminophen (301.9 ± 161.26 vs. 635.05 ± 205.42) and rectal diclofenac (0, 0, 0 vs. 0, 0, 12.5 mg) than group A. FLACC pain scale score was significantly lower in group B than in group A (P < 0.05) at 2, 4, 6, 8, 10, 12, 16, 18, 20, and 24 h postoperatively. There was no significant difference between both groups with respect to intraoperative hemodynamic variables. Conclusion Unilateral TAP block provided superior analgesia compared with single caudal block injection in the first 24 postoperative hours after surgical pyeloplasty in infants and children aged 6 months to 6 years.

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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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Objective This study aimed to evaluate the postoperative analgesic efficacy of either preincisional peritonsillar infiltration of ketamine in combination with bupivacaine, or intravenous ketamine combined with infiltration of bupivacaine. Patients and methods A total of 60 patients were randomized into three groups: intravenous group, in which patients received intravenous ketamine (0.5 mg/kg) in 10 ml plus peritonsillar infiltration of bupivacaine 2 ml (5 mg/ml); infiltration group, in which patients received peritonsillar infiltration of ketamine (0.5 mg/kg) in 2 ml plus bupivacaine 2 ml and intravenous 10 ml saline; and placebo group, in which patients received 10 ml intravenous saline and peritonsillar infiltration of 2 ml saline plus 2 ml bupivacaine 2 ml/tonsil. The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and Wilson scale were used to evaluate pain and sedation, respectively. Time to first analgesic request and total analgesic request, total analgesic consumption during 24 h postoperatively, intraoperative blood loss, and adverse effects were evaluated. Results Time to analgesic request was significantly prolonged in the intravenous and infiltration groups (4.3 ± 2.1 and 11.6 ± 3.6 h, respectively) compared with the placebo group (1.2 ± 1.2 h), with significant prolonged time in the infiltration group compared with the intravenous group. Significant lower (CHEOPS) scores and significant lower analgesic consumption were observed in the intravenous and infiltration groups (69 ± 4.1 and 45.1 ± 2.1 mg), respectively, compared with the placebo group (90.6 ± 5.3 mg). Both the intravenous and infiltration groups had comparable pain scores, with statistical significance at 4, 6, and 8 h postoperatively. Dysphagia was significantly higher in the placebo group compared with the intravenous and infiltration groups. No serious complication was reported in the three groups. Conclusion Intravenous or peritonsillar infiltration of ketamine with bupivacaine enhanced post-tonsillectomy analgesia in children. In comparison, the analgesic efficacy of infiltration of ketamine was superior to intravenous administration, without significant side effects.

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Objectives In this paper, we evaluate the effect of adding ketamine to spinal anesthesia in day-case surgery with regard to the time of onset of block, the duration of the block, hemodynamic variables, postoperative time to full motor power, time to walking, and side effects. Materials and methods Sixty patients scheduled for day-case surgeries under spinal anesthesia were studied in a prospective double-blinded randomized manner. Patients were allocated to receive either 3 ml hyperbaric bupivacaine (0.5%) (group I) or 2 ml hyperbaric bupivacaine (0.5%) combined with ΍ ml ketamine (25 mg) + ΍ ml normal saline (group II). Results The onset time and the duration of the block were shorter in group II than in group I. The postoperative time to walking, the time to full motor power recovery, and the duration of spinal analgesia were shorter in group II. There were no significant differences in hemodynamic variables or side effects. Conclusion Ketamine added to hyperbaric bupivacaine in spinal anesthesia provides a shorter time of onset of block, a shorter duration of the block, and a shorter time to full motor power and to walking postoperatively in day-case surgery.

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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 Many adjuvants have been used to improve the quality of intravenous regional anesthesia (IVRA). The aim of this study was to compare the use of dexmedetomidine with that of magnesium sulfate as an adjuvant for IVRA as regards onset and duration of sensory and motor blocks, quality of anesthesia, intraoperative-postoperative hemodynamic variables, and intraoperative and postoperative pain. Patients and Methods This study was a prospective, randomized, double-blinded trial. Sixty patients scheduled for upper hand or forearm surgery were randomly divided into two groups, comprising 30 patients each. Group D received dexmedetomidine at 0.5 μg/kg diluted with saline to 20 ml in addition to 20 ml of 1% lidocaine to reach a total volume of 40 ml, whereas group M received 5 ml of 20% magnesium sulfate and 15 ml saline added to 20 ml of 1% lidocaine to reach a total volume of 40 ml. Sensory and motor block onset, recovery times, anesthesia quality, and hemodynamic variables were recorded and compared between the two groups. Results No statistically significant difference was observed between dexmedetomidine and magnesium sulfate as regards sensory block onset time and motor block onset time (P = 0.102 and 0.206, respectively) as well as intraoperative analgesic requirements (P = 0.76). However, dexmedetomidine showed more favorable hemodynamic variables and less tourniquet pain. Conclusion We concluded that dexmedetomidine seems to be superior to magnesium sulfate as an adjuvant to lidocaine in IVRA regarding tourniquet pain and intraoperative and postoperative hemodynamic stability.

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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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Objective The aim of this study was to determine whether the magnesium sulfate (MgSO ₄ ) used for pre-eclamptic patients affects the oxytocin bolus dose requirement to maintain adequate uterine tone during cesarean section under spinal anesthesia. Materials and methods A total of 80 patients with mild pre-eclampsia were randomized to receive either intravenous MgSO ₄ (group M, n = 40) or matched normal saline (group S, n = 40). After delivery of the baby, oxytocin was injected as an intravenous bolus of 3 IU. The uterine tone was assessed by the obstetrician to be either satisfactory or unsatisfactory at 2, 4, 6, 8, and 10 min. If the tone was assessed as unsatisfactory at any time less than 3 IU of oxytocin were injected as a 'rescue' bolus dose. A maximum of two 'rescue' doses of oxytocin were allowed at two separate recordings of inadequate uterine tone. If the uterine tone was still unsatisfactory after two rescue doses of oxytocin, then other uterotonic drugs were given. The primary endpoint was the number of patients who received rescue doses of oxytocin or other uterotonic medications. Secondary endpoints, including the change in the hematocrit value before surgery and within 30 min after cesarean section, the estimated amount of intraoperative blood loss, and any side effects associated with oxytocin, were recorded. Results The number of patients who required one rescue dose of oxytocin during the study was significantly higher in group M in comparison with group S (P = 0.029). The total number of patients who received both additional oxytocin boluses and other uterotonic agents to achieve a satisfactory uterine tone was also statistically significant between both groups (P = 0.034). Conclusion The use of MgSO ₄ in mild pre-eclamptic patients leads to increased oxytocin requirements in order to maintain a satisfactory uterine tone during cesarean section under spinal anesthesia.

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