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   2016| July-September  | Volume 9 | Issue 3  
    Online since August 31, 2016

 
 
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CASE REPORTS
Anaesthetic concerns with intramyometrial vasopressin during myomectomy
Geetanjali Chilkoti, Medha Mohta, Shivika Nath, Ashok Kumar Saxena, Priyanka Khurana
July-September 2016, 9(3):452-454
DOI:10.4103/1687-7934.189089  
Vasopressin, a potent vasoconstrictor, has often been used intramyometrially to prevent blood loss during surgical management of uterine myomas. Various lethal complications reported with its use include bradycardia, unmeasurable blood pressure, loss of palpable peripheral pulse, marked pallor, arrhythmia, pulmonary oedema and cardiac arrest. We herein report a case of uterine myomas in which intramyometrial vasopressin-induced complications such as bradycardia, absent pulse and marked pallor were observed with very low dose and concentration (i.e. 1.5 U and 0.1 U/ml). This could be attributed to the coexistence of hypertension in our patient. Here, we discuss the anaesthetic concerns with the use of intramyometrial vasopressin and reinforce the need for dogmatic guidelines envisaging the recommended safe dose and concentrations of intramyometrial vasopressin and proper patient selection.
  11,659 738 2
ORIGINAL ARTICLES
Methylene blue versus vasopressin in sepsis-induced vasoplegia
Mostafa ElAdawy, Ahmed S Omran
July-September 2016, 9(3):319-324
DOI:10.4103/1687-7934.189091  
Background Septic shock is one of the biggest causes of mortality in intensive care settings, and, despite all the recent advances in pharmacological and mechanical support therapies, is the second leading cause of death among ICU patients. Although vasopressors have been widely used in these situations, where keeping the hemodynamic stability is of utmost importance, a detailed study of their effects is undoubtedly needed. Objective Our study compared the effect of methylene blue (MB) in the vasoplegic situation associated with sepsis with that of vasopressin. Patients and methods We randomized 40 patients into two groups (20 patients each); patients in the first group received MB, whereas patients in the second group received vasopressin as a hemodynamic support. Results In the present study, mean arterial blood pressure was found to be significantly higher in the MB group compared with the vasopressin group, whereas within the MB group, it was significantly higher after 6 h compared with the baseline level. The systemic vascular resistance showed no difference between the two groups at the start but a marked difference only after 2 h, being higher for the MB group — that is, there was a significant decrease in the vasopressors and inotropes needed in the MB group. There was no significant difference between the two groups regarding the ICU length of stay, the central venous pressure, pulmonary artery pressure, and oxygen extraction ratio. Conclusion The use of MB in sepsis-induced refractory vasoplegic situations remains one of the salvage management strategies; however, the practice of its routine use is yet to be established and needs further investigation.
  4,339 635 1
CASE REPORTS
Levofloxacin: a rarely suspected cause of delirium
Vivek Chowdhry, B. B. Mohanty
July-September 2016, 9(3):458-462
DOI:10.4103/1687-7934.189093  
Delirium or psychosis is a common entity in the postoperative period, affecting elderly ands well as middle-aged and young patients. Multiple factors predispose a patient to different forms of delirium. Postoperative delirium is associated with acute alteration in attention and cognitive impairment, which is responsible for significant increase in both morbidity and mortality. A wide range of drugs, including fluoroquinolones, can cause mental status changes in the postoperative period. Thus, a thorough knowledge of various drug actions and interactions as well as various risk factors can help an anesthesiologist counter the possible deleterious effects of delirium during the perioperative period. The side effects of fluoroquinolones on the central nervous system are well documented, although they are rarely suspected as the offending agents for delirium. We report the case of a middle-aged lady who after mitral valve replacement became delirious following levofloxacin administration in the postoperative period.
  3,380 584 -
Ventilator dysfunction: role of graphics in detection
Ramaligam Sripriya, Srinivasan Parthasarathy, Murugesan Ravishankar
July-September 2016, 9(3):465-467
DOI:10.4103/1687-7934.189103  
Analysis of ventilator graphics is useful in a few situations for detecting ventilator dysfunction. However, there is a paucity of literature as to what sort of dysfunctions can be detected. We report two cases in which the graphics enabled us to identify ventilator dysfunction in patients who were on mechanical ventilation. Analysing the graphics and not looking at numbers alone enabled us to take timely corrective actions, thereby preventing morbidity. Both patients ultimately achieved a complete recovery.
  3,214 211 -
ORIGINAL ARTICLES
Prophylactic dexamethasone or pethidine for the prevention of postoperative shivering during transurethral resection of the prostate under spinal anesthesia
Abd El Azeem A El Bakry, Ezzeldin S Ibrahim
July-September 2016, 9(3):349-352
DOI:10.4103/1687-7934.189102  
Background Shivering is a common complication in elderly patients undergoing urologic operations under spinal anesthesia. The present study compares the effect of prophylactic dexamethasone and pethidine on shivering during transurethral resection of the prostate (TURP) under spinal anesthesia. Patients and methods This random prospective double-blinded controlled study was conducted on 90 patients scheduled for TURP operations under spinal anesthesia. Patients were allocated into three groups: in the C group, patients were administered intravenous 10 ml normal saline before spinal anesthesia. In the P group, patients were administered 25 mg pethidine in 10 ml normal saline. In the D group, patients were administered 0.1 mg/kg dexamethasone in 10 ml normal saline. Core body temperature, mean arterial blood pressure, respiratory rate, oxygen saturation, incidence and severity of shivering, nausea, vomiting, and pruritus were recorded. Results The incidence and severity of shivering were low in the pethidine and dexamethasone groups compared with the control group (P < 0.05), with no significant difference between the pethidine and dexamethasone groups (P > 0.05). Conclusion Prophylactic dexamethasone is as effective as pethidine in reducing the incidence and severity of shivering in TURP patients under spinal anesthesia.
  2,914 319 1
The effect of adding magnesium to bupivacaine for popliteal nerve block on anesthesia and postoperative analgesia in achilles tendon repair patients: a randomized double-blinded study
Ayman A El Sayed
July-September 2016, 9(3):409-415
DOI:10.4103/1687-7934.189561  
Purpose The aim of this prospective randomized double-blind study was to investigate the effect of adding magnesium to bupivacaine on the onset and duration of sensory and motor block, postoperative visual analog scale (VAS), and total opioid consumption in patients following Achilles tendon repair surgery with popliteal-sciatic nerve blockade. Patients and methods A total of 60 patients who underwent Achilles tendon repair surgery and were of American Society of Anesthesiologist I or II physical status with age between 18 and 50 years of age were included in the study. The patients were randomly assigned into two groups: group bupivacaine–magnesium (BM) (n=29) received 30 ml of 0.25% bupivacaine and 2 ml of 10% magnesium sulfate, and group bupivacaine (B) (n=28) received 30 ml of 0.25% bupivacaine and 2 ml of normal saline for popliteal-sciatic blockade using the nerve stimulator technique. We evaluated the patients as regards the onset and duration of sensory and motor block, postoperative VAS scores, and total opioid consumption. Results The onset of motor block in group B was significantly longer in comparison with group BM (14.2±2 and 11.9±1.5 min, respectively). At the same time, the duration of sensory and motor block in group BM was significantly longer in comparison with group B (P<0.001). As regards total opioid consumption (tramadol) during the first 12 h postoperatively, it was significantly less in group BM in comparison with group B (190.67±21.8 and 237.86±25.8 mg, respectively). As regards VAS, it was significantly lower in group BM in comparison with group B at 4, 6, 8, 10, and 12 h postoperatively. Conclusion The addition of magnesium to bupivacaine prolonged the motor and sensory block duration without increasing side effects, and enhanced the quality of postoperative analgesia, which was manifested by lower VAS and less total opioid consumption. Moreover, the addition of magnesium speeds up the onset of motor block.
  2,914 227 1
Magnesium sulfate at two different doses as an adjuvant to bupivacaine in infraumblical (below knee) orthopedic surgeries under spinal anesthesia
Sudarshan Kumar Chaudhary, Ravinder Kumar Verma, Shelly Rana, Jai Singh, Amruth Danesh
July-September 2016, 9(3):416-421
DOI:10.4103/1687-7934.189098  
Background The use of magnesium sulfate as an adjuvant in neuraxial block has gained popularity, with the aim of improving and enhancing the quality and duration of anesthesia, delaying the onset of postoperative pain, and thus reducing the demand for postoperative rescue analgesics. However, until today, there has been no consensus as regards the ideal dose of magnesium sulfate as an adjuvant in the subarachnoid block. The present study was designed to examine whether the addition of intrathecal magnesium sulfate (50 and 100 mg) would enhance the analgesic efficacy of intrathecal bupivacaine. We hypothesized that the additive effect of magnesium sulfate as an adjuvant to bupivacaine in subarachnoid block is dose dependent. Materials and methods This study was carried out on 90 American Society of Anesthesiology I and II patients of both sexes in the age group of 20–60 years scheduled for below knee surgeries under subarachnoid block. Group 1 (n = 30) patients received intrathecal 0.5% heavy bupivacaine (2.8 ml) +0.2 ml normal saline; group 2 (n = 30) received intrathecal 0.5% heavy bupivacaine (2.8 ml) +50 mg (0.1 ml) magnesium sulfate +0.1 ml normal saline; and group 3 (n = 30) received intrathecal 0.5% heavy bupivacaine (2.8 ml)+100 mg (0.2 ml) magnesium sulfate. The primary outcome measure was the duration of postoperative analgesia, and secondary outcomes included the number of supplemental analgesic requirements, block characteristics, and hemodynamic stability. Results The onset of sensory and motor block was delayed in the magnesium group (100 mg>50 mg). There was a significant prolongation of postoperative analgesia in the magnesium group in a dose-dependent manner, and total dose of rescue analgesic requirement was found to be significantly delayed in the 100 mg group. Patients in all groups remained hemodynamically stable without any adverse effects. Conclusion Magnesium sulfate (100 mg) as an adjuvant to bupivacaine in subarachnoid block prolongs the duration of analgesia and decreases the demand for rescue analgesics compared with the control and the magnesium sulfate 50 mg group.
  2,564 272 1
Comparative study of intrathecal midazolam versus fentanyl as adjuvants to ropivacaine for lower-limb surgery
Sanaa M Elfawal, Aktham A Shoukry, Walid H Nofal
July-September 2016, 9(3):432-439
DOI:10.4103/1687-7934.189101  
Background The current prospective randomized double-blind study was designed to compare the clinical efficacy of intrathecal midazolam versus fentanyl when added to hyperbaric ropivacaine, evaluating the effect of each on the duration and quality of spinal blockade produced by hyperbaric ropivacaine. Patients and methods The study was conducted on 90 patients of both sexes, aged 20-60 years, of class I or II of the American Society of Anesthesiologists classification, who were undergoing elective lower-limb surgery. Patients were randomly assigned to three groups (30 patients each): group R (control group) received 3 ml (15 mg) of hyperbaric ropivacaine plus 0.5 ml of normal saline (0.9%) at a total volume of 3.5 ml intrathecally, whereas group RF received 3 ml (15 mg) of hyperbaric ropivacaine plus 0.5 ml of 25 μg fentanyl (50 μg/ml) at a total volume of 3.5 ml intrathecally and group RM received 3 ml (15 mg) of hyperbaric ropivacaine plus 0.5 ml of 1 mg midazolam (2 mg/ml) at a total volume of 3.5 ml intrathecally. The onset and duration of sensory and motor blockade, postoperative pain, and the time to first rescue analgesia request were noted. Patients were observed for hypotension, bradycardia, sedation, respiratory depression, pruritus, and postoperative nausea and vomiting. Results The onset times and the duration of motor blockade were comparable among groups, whereas the time to sensory block regression was longer in group RM and group RF as compared with group R (P < 0.001). The duration of postoperative analgesia was significantly longer in group RM and group RF as compared with group R (P < 0.001), whereas there was no difference between group RM and group RF. The incidence of pruritus and vomiting was higher in group RF. Conclusion Adding midazolam to hyperbaric ropivacaine in spinal anesthesia for lower-limb surgeries is considered a good alternative for improving the duration of sensory block and decreasing the analgesic requirement in the early postoperative period with minimal side effects compared with hyperbaric ropivacaine alone or fentanyl combined with hyperbaric ropivacaine.
  2,431 238 -
A comparative study between terlipressin alone and dobutamine and terlipressin in septic shock patients
Waleed Abdalla, F Kamel, Naglaa M Ali, Tarek Shabana
July-September 2016, 9(3):330-336
DOI:10.4103/1687-7934.189565  
Background The use of terlipressin, a long-acting synthetic analog of vasopressin, is associated with reduction in cardiac output and oxygen delivery. The present study was designed to determine whether dobutamine may reverse the terlipressin-induced depression in central venous oxygen saturation (SvO2) in patients with catecholamine-dependent septic shock. Patients and methods This clinical trial was conducted in Ain Shams University hospital’s surgical ICU. In total, 90 septic shock patients requiring a continuous infusion of norepinephrine reaching 0.6 µg/kg/min to maintain mean arterial pressure at greater than or equal to 65 mmHg were randomly allocated to three groups be treated as follows: (i): group I, treated with norepinephrine infusion (control); (ii) group II, treated with a single bolus of terlipressin 1 mg, intravenous; (iii) and group III, treated with a single bolus of terlipressin 1 mg, followed by a dobutamine infusion. Results The use of terlipressin (with and without dobutamine) resulted in maintaining mean arterial pressure above 65 mmHg with reduction in norepinephrine requirements to 0.2 (0.1) µg/kg/min in group II and 0.15 (0.1) µg/kg/min in group III (P in each <0.001 vs. control at 2, 4, and 6 h). The use of terlipressin alone in group II resulted in a drop in central SvO2 to 58 (3)% (P<0.001 vs. control at 2, 4, and 6 h) and a decrease in heart rate to 105 beat/minute (7) (P vs. control=0.013 at 2 h, 0.001 at 4 h, and 0.01 at 6 h). The addition of dobutamine in group III resulted in an increase in central SvO2 to 70 (3)% (P<0.001 vs. group II at 2, 4, and 6 h). Conclusion Administration of terlipressin bolus was effective in increasing mean arterial blood pressure and reducing norepinephrine requirements in catecholamine-dependant septic shock patients. Its use was associated with significant reductions in central SvO2, which was reversed by using dobutamine.
  2,423 234 -
Comparison of the respective effects of paracetamol, pregabalin, and their combination in the treatment of postdural puncture headache following major gynecological surgery
Dipasri Bhattacharya, Swarup Paul, Somnath Naskar, Manasij Mitra, Mohanchandra Mandal
July-September 2016, 9(3):387-392
DOI:10.4103/1687-7934.189104  
Background and objective Postdural puncture headache (PDPH) is a very distressing symptom after spinal anesthesia. It usually resolves spontaneously but may extend the length of hospital stay. Although there are different measures to reduce the incidence, most of the times, none of them are effective. Paracetamol is commonly used for the treatment of PDPH. Pregabalin is recently being used for PDPH with effective results. In this study, our aim was to compare the respective effects of paracetamol, pregabalin, and their combination in the treatment of PDPH. Patients and methods In total, 150 patients who had undergone major gynecological surgery under spinal anesthesia and subsequently developed PDPH (diagnosed by postdural components of the pain) were randomly allocated by using computer-generated random numbers placed in sealed opaque envelopes. The patients were allocated into three equal groups (n = 50, each group) to receive orally either a single dose of 150 mg pregabalin (group 1) or 1000 mg of paracetamol (group 2) or a combined dose of paracetamol 1000 mg plus pregabalin 150 mg (group 3). All the patients received the same drug that they had originally received, if required, and were then followed up for 4 days. A patient's headache was scored using the visual analogue scale. Results Earlier relief from PDPH and favorable adverse event profile (overall and central nervous system-related) were found in for the pregabalin–paracetamol combination compared with either of the drugs being used alone (P < 0.05). Conclusion It was concluded that the pregabalin–paracetamol combination is a better option for the treatment of PDPH compared with both of the drugs when used alone.
  2,150 196 -
Selective spinal anesthesia using low concentration bupivacaine and fentanyl versus ordinary bupivacaine as a prophylaxis against deep venous thrombosis in total hip replacement surgery
Hany K Mickhael, Josef Zekry, Mohamed Abd Elrazek
July-September 2016, 9(3):393-397
DOI:10.4103/1687-7934.189087  
Objective The aim of the present study was to detect the efficacy of early postoperative calf muscle exercise to decrease the risk of deep venous thrombosis achieved by intrathecal 3 ml bupivacaine 0.25% and fentanyl 25 μg instead of 3 ml bupivacaine 0.5%. In total, 40 patients of either sex, aged between 18 and 60 years, with American Society of Anesthesiologists (ASA) I and II were included in the study. Patients and methods A total of 40 ASA I and II patients undergoing elective total hip replacement surgery were randomly assigned to two equal groups of 20 patients each (group A and B). Group A received bupivacaine 0.5% (3 ml) and group B received bupivacaine 0.25% (3 ml)+fentanyl 25 μg. Patients were instructed on how to do cuff muscle exercise once they regained the full strength of the lower limbs muscles postoperatively. Five venous blood samples were taken from each patient for the D-dimer assessment as an indicator for the occurrence of venous thromboembolism. The first sample was taken preoperatively at the time of induction of anesthesia; the rest of samples were then taken at 12, 24, 48 h, and 7 days postoperatively. Results Group B, in which patients received intrathecal bupivacaine 0.25% plus fentanyl, had an earlier recovery of motor power; patients in this group started doing calf muscle exercise earlier than did those in group A, and this group had significantly lower postoperative D-dimer level, denoting less susceptibility to deep venous thrombosis. Conclusion Early postoperative calf muscle exercise decreased the incidence of venous thromboembolism risk as indicated by the results of the D-dimer assessment.
  2,168 112 1
Ultrasound-guided rectus sheath block for pediatric patients undergoing elective abdominal midline operations: a randomized controlled trial
Mostafa M Hussein Khalil
July-September 2016, 9(3):403-408
DOI:10.4103/1687-7934.189570  
Background Under high-resolution ultrasonic guidance, bilateral rectus sheath block (RSB) can be performed with higher success rate and fewer complications. RSB results in blocking the anterior branches of the lower thoracic spinal nerves supplying the central portion of the anterior abdominal wall. Objective The aim of the study was to assess the effectiveness of bilateral ultrasound-guided RSB in children undergoing elective midline abdominal operations. Patients and methods Fifty-six patients of both sexes between 2 and 10 years of age, of American Society of Anesthesiologists physical status I–II, undergoing elective midline abdominal procedures were involved in this randomized controlled trial. Patients were randomly allocated to one of two groups: 27 patients in group R (RSB group) and 29 patients in group C (control group). Both groups received general anesthesia. Group R received bilateral RSB with 0.3/ml/kg bupivacaine 0.25% under ultrasound guidance, and group C received regular analgesics. The primary outcome measure was degree of pain assessed using the Objective Pain Scale. The secondary outcome measures were hemodynamic parameters, intraoperative fentanyl requirement, and postoperative need for analgesia. Results Demographic and hemodynamic parameters were similar in both groups. Total intraoperative fentanyl requirement was significantly lower in group R compared with group C. Group R had a significantly lower pain score up to 24/h postoperatively compared with group C. The mean time to first postoperative rescue analgesia was significantly longer in group R (120.8±4.7/min) than in group C (48±3.6/min). The number of rescue doses of analgesia was significantly lower in group R [1 (0–1)] than in group C [3 (2–3)]. Conclusion Bilateral RSB under ultrasound guidance provides effective intraoperative and postoperative analgesia with more stable hemodynamics in pediatric patients undergoing elective midline abdominal procedures.
  2,069 169 2
The effects of coinduction with sevoflurane–propofol and sevoflurane–ketofol in patients undergoing radiofrequency ablation of hepatocellular carcinoma
Rania M Ali, Marwa A Khairy
July-September 2016, 9(3):343-348
DOI:10.4103/1687-7934.189095  
Background Radiofrequency ablation (RFA) is a minimally invasive and effective method for local tumor destruction in nonsurgical patients with early-stage hepatocellular carcinoma (HCC). General anesthesia (GA) has been used for RFA. GA can decrease the hepatic blood flow and cause more hepatic dysfunction. This study aimed to compare the hemodynamic response, recovery characteristics, and postprocedural analgesia after induction of GA with either sevoflurane–propofol or sevoflurane–ketofol in liver patients undergoing RFA of HCC. Patients and methods Eighty patients with hepatic cirrhosis scheduled for RFA of HCC were randomly allocated into two groups. In group PS, induction of anesthesia was achieved using sevoflurane with propofol (1%). In group KPS, induction of anesthesia was achieved using sevoflurane with ketofol (prepared at a ratio of 1: 2). Results Regarding the induction time, the laryngeal mask airway (LMA) insertion time, the percentage of LMA insertions from the first attempt, time to removal of LMA, and time to emergence were comparable between the two groups. However, the rescue analgesia time was longer in group KPS compared with group PS (P < 0.001). The number of episodes during which blood pressure was below 20% of baseline blood pressure, as well as the highest and the lowest mean arterial pressure, was comparable between the two groups. Postoperative levels of liver enzymes were comparable between the two groups. In the recovery unit, only one patient (2.5%) in group KPS suffered from postoperative emergence agitation, and three patients (7.5%) suffered from nausea. Conclusion Either sevoflurane–propofol or sevoflurane–ketofol may be used as alternatives in liver patients undergoing RFA of HCC as both techniques have favorable anesthetic profiles and provide hemodynamic stability. However, when choosing sevoflurane–ketofol, the advantage of its enhanced analgesic effect must be weighed against the increased risk for postoperative nausea and vomiting.
  2,051 170 1
Preservative-free racemic ketamine with bupivacaine: a desirable option for extended caudal analgesia in pediatric surgery
Deepa Chandramohan, Shirley A DíSouza
July-September 2016, 9(3):426-431
DOI:10.4103/1687-7934.189100  
Introduction Caudal epidural block is a commonly performed procedure in pediatric anesthesia worldwide. Ketamine is used as an adjuvant in single-shot caudal blocks to prolong postoperative analgesia. Aims of the study This randomized double-blind study was carried out to evaluate the effect of the addition of preservative-free racemic ketamine 0.5 mg/kg to 0.25% bupivacaine (1 ml/kg) in caudal block on the duration of postoperative analgesia in pediatric patients and to observe adverse effects, if any. Materials and methods Sixty children, aged 2–9 years, undergoing infraumbilical surgical procedures were assigned randomly to one of two groups, B or BK, to receive 1 ml/kg of 0.25% bupivacaine or a mixture of 0.5 mg/kg of preservative-free racemic ketamine with 1 ml/kg of 0.25% bupivacaine, respectively, for single-shot caudal anesthesia. The postoperative pain score was assessed. Sedation, motor weakness, and other adverse effects were also observed. Observations and results The mean duration of analgesia was significantly longer (P < 0.01) in group BK (12.933 h) than in group B (3.467 h). The incidences of adverse effects such as urinary retention, vomiting, and motor weakness were comparable in the two groups (P > 0.05). Conclusion Preservative-free racemic ketamine at a dose of 0.5 mg/kg may be used as a safe and reliable adjunct to caudal bupivacaine for prolongation of postoperative analgesia in children. As racemic ketamine is less expensive and more easily available than S(+)-ketamine, further studies comparing their cost-effectiveness may help to establish the racemic preparation as an appropriate adjuvant for single-shot caudal analgesia, especially in nations where cost constraints exist.
  2,083 123 1
Human albumin 4% versus hydroxyethyl starch 6% for fluid resuscitation in sepsis
Heba F Toulan, Eman M Kamal
July-September 2016, 9(3):325-329
DOI:10.4103/1687-7934.189097  
Background Early fluid resuscitation is vital to patients with sepsis. However, the choice of fluid has been a hot topic of discussion. The objective of this study was to compare hydroxyethyl starch (HES) 6% (130/0.4) with albumin 4% as a resuscitation fluid in septic patients. Patients and methods In this prospective randomized study, 80 patients aged 20–60 years of both sexes with sepsis were assigned to receive either HES (130/0.4) in 0.9% saline or human albumin 4% as a resuscitation fluid. Mortality rate after 28 days, need for renal replacement therapy, and duration of ICU stay were compared between the two groups. Results The mortality rate in the albumin group (22.5%) was lower than in the HES 6% group (40%) with significant P value (0.033). Also, the need for renal replacement therapy (RRT) and length of ICU stay were significantly higher in the HES 6% group compared with the albumin group. Conclusion Use of human albumin 4% has a significant effect in reducing mortality rates in the ICU in patients with severe sepsis compared with HES 6%.
  1,982 210 -
A randomized study comparing the efficacy and safety of epidural anesthesia versus general anesthesia in patients undergoing percutaneous nephrolithotomy
Tanuj Kumawat, Varsha Kothari, Shivam Priyadarshi, Tuhin Mistry, Sanjay Morwal
July-September 2016, 9(3):353-357
DOI:10.4103/1687-7934.189568  
Background Percutaneous nephrolithotomy (PCNL) is the preferred surgical technique for large renal stones (>2 cm in diameter), which involves keyhole surgery through a 1 cm incision on the skin overlying the kidney. It can be performed under local, regional, as well as general anesthesia (GA). We have compared the efficacy and safety of regional epidural anesthesia (EA) and GA in patients undergoing PCNL. Patients and methods In this prospective study, a total of 112 patients of American Society of Anesthesiologists physical status I and II undergoing PCNL were randomized into two groups. Patients in group A (n=56) received regional EA (with lignocaine and bupivacaine), and group B (n=56) patients received standard GA. The postoperative visual analog scale (VAS) score, amount of postoperative analgesic use, adverse effects, operative time, and blood loss were evaluated and compared between the two groups. Results The mean VAS score at 1 h was 1.25 in group A and 5.21 in group B (P<0.001), at 3 h it was 3.05 in group A and 5.04 in group B (P<0.001), and at 6 h it was 3.04 in group A and 4.79 in group B (P<0.001). Less analgesia was required in the EA group compared with the GA group (P<0.001). Five (8.92%) patients in group A and 21 (37.50%) patients in group B had postoperative nausea (P<0.05). Pain score at 18 and 24 h, operative time, postoperative hemoglobin level, and adverse effects were not significantly different between the two groups. Conclusion EA is a good alternative anesthetic technique for PCNL with less analgesic consumption and fewer complications as compared to GA.
  1,939 171 -
Comparative study between general anesthesia and sciatic–femoral–obturator blockade as regards analgesia and incidence of postoperative cognitive dysfunction in elderly patients undergoing unilateral total knee replacement
Ayman A El Sayed, Marwa Soltan, Mai M Nabil
July-September 2016, 9(3):377-386
DOI:10.4103/1687-7934.189566  
Objectives The aim of this study was to compare the effect of sevoflurane general anesthesia (GA) and sciatic–femoral–obturator blockade as regards analgesia and incidence of postoperative cognitive dysfunction (POCD) in elderly patients undergoing unilateral total knee replacement. Patients and methods The patients were divided in a randomized manner into two groups: the GA group (n=40) received maintenance of anesthesia with inhalational sevoflurane, and the peripheral nerve block (PNB) group (n=40) underwent sciatic nerve block (40 ml), femoral nerve block (20 ml), and obturator nerve block (10 ml) with 0.25% bupivacaine. The following time points were considered: baseline, immediately before induction of anesthesia (T-baseline), immediately after induction of anesthesia (T-induction), at the end of the operation (T-end) and then at 6, 12, 18, and 24 h postoperatively and were represented as T6, T12, T18, and T24, respectively. Results A total of 15 of 40 patients from the GA group developed POCD, whereas six of 38 patients in the PNB group developed POCD at T24. This difference was significant. Moreover, there was a significant decrease in Mini-Mental State Examination score in the GA group after 24 h in comparison with the preoperative value. There was a significantly higher value of Aβ (β-amyloid protein) in the GA group compared with the PNB group 24 h postoperatively. Visual analogue score was significantly lower at T-end, T6, T12, T18, and T24 in the PNB group compared with the GA group. Hemodynamics was significantly lower in the PNB group than in the GA group at T-end, T6, T12, T18, and T24. They were significantly higher in the PNB group than in the GA group at T-induction. Total opioid consumption within 24 h postoperatively and the incidence of nausea were lower in the PNB group compared with the GA group. Induction time was significantly longer in the PNB group than in the GA group. Conclusion The current study demonstrated that PNB with sciatic–femoral–obturator for total knee replacement was accompanied by less POCD, less pain, less nausea, and less opioid consumption within 24 h postoperatively compared with GA with sevoflurane.
  1,872 222 -
Statins attenuate hyperalgesia and inflammation in experimentally induced acute and neuropathic pain in rats
Elsayed M Kamel, Ahmed F Elsaid, Eid A Gumaa, Abd Elhafez M El Sheweal
July-September 2016, 9(3):440-448
DOI:10.4103/1687-7934.189562  
Background Available medications for the treatment of neuropathic pain, such as steroidal anti-inflammatory drugs and NSAIDs, were shown to be of limited therapeutic benefit. Objectives This study aimed to evaluate the analgesic and anti-inflammatory effects of atorvastatin and pravastatin in acute and neuropathic pain in rats. Materials and methods Acute and neuropathic pains were induced in rat models by means of subplantar carrageenan injection and partial sciatic nerve ligation (PSNL), respectively. The anti-inflammatory effect of statins was assessed by the reduction in plantar edema (at 0, 1, 2, and 3 h) and prolongation of paw withdrawal reaction time in response to thermal stimulation (at 0, 0.5, 1, 2, 3, and 4 h) after carrageenan injection. Atorvastatin (2, 4, or 8 mg/kg) and pravastatin (4, 8, or 12 mg/kg) were administered intraperitoneally 30 min before carrageenan injection. The effect of statins on neuropathic pain was assessed by prolongation of paw withdrawal reaction time in response to thermal stimulation evaluated at 0, 3, 6, 9, 12, 15, and 18 days after PSNL. Atorvastatin (2, 4, or 8 mg/kg) and pravastatin (4, 8, or 12 mg/kg) were administered orally for 18 consecutive days after PSNL. In addition, the effect of atorvastatin and pravastatin on total cholesterol and tumor necrosis factor-α levels was also assessed. Results Both atorvastatin and pravastatin ameliorated carrageenan-induced rat paw edema and prolonged withdrawal time in response to thermal-induced pain. Both statins were also effective in ameliorating neuropathic pain induced by PSNL. These effects were independent of statin-induced hypolipidemic action but were concomitant with reduction of serum tumor necrosis factor-α levels. Conclusion Atorvastatin and pravastatin demonstrated effective therapeutic potentials to reduce acute and chronic pain together with the associated inflammation and hyperalgesia independent of their hypolipidemic effect.
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Dexamethasone added to levobupivacaine prolongs ultrasound-guided interscalene brachial plexus blockade: a prospective, randomized, controlled study
Ahmed M Abd El-Hamid, Mohamed A. I. Alrabiey
July-September 2016, 9(3):422-425
DOI:10.4103/1687-7934.189099  
Objectives This study aimed to evaluate the effect of the addition of dexamethasone to levobupivacaine on the duration of analgesia in forearm surgeries under ultrasound-guided interscalene brachial plexus block. Patients and methods This prospective randomized controlled, double-blind clinical trial was conducted on 60 patients who underwent elective forearm surgeries under ultrasound-guided interscalene brachial plexus block. Patients in the levobupivacaine group (group L) received 25 ml of 0.5% levobupivacaine plus 2 ml of normal saline 0.9%. Patients in the levobupivacaine dexamethasone group (group LD) received 25 ml of 0.5% levobupivacaine plus 2 ml of dexamethasone (8 mg). The onset of sensory and motor block, duration of the sensory block, time to first analgesic request, the number of failed block, total morphine consumption, side effects, and complications were recorded and compared. Results Onset of sensory block and motor block was significantly earlier in group LD compared with group L. Duration of sensory block and time to first analgesic request were significantly longer in group LD compared with group L. Total morphine consumption was significantly lower in group LD in comparison with group L. The number of failed blocks was nonsignificantly lower in group LD. The incidence of side effects and complications was low and comparable in both groups. Conclusion Addition of dexamethasone to levobupivacaine significantly shortens the onset of sensory and motor block, prolongs the duration of analgesia, decreases the 24 h morphine consumption, and prolongs the time to first analgesic request with minimal side effects.
  1,858 184 -
CASE REPORTS
Copper and anesthesia − a surprising connection
Pradnya M Bhalerao, Kalpana V Kelkar, Anand H Pande, Bapu P.G. Kakade
July-September 2016, 9(3):455-457
DOI:10.4103/1687-7934.189569  
A 28-year-old female presented with complaints of fever with chills and dizziness on and off for the last 3 months. On admission, she was investigated and found to have anemia and thrombocytopenia. On examination, the patient was pale and had a palpable huge spleen. Past history revealed a diagnosis of Wilson’s disease 15 years ago. This disease, due to altered copper metabolism, may influence the conduct and outcome of anesthesia secondary to abnormalities in hemopoietic, cardiovascular, connective tissue, immune, and nervous systems. In this study, we present a patient, a diagnosed case of Wilson’s disease, with massive splenomegaly posted for splenectomy under general anesthesia and the concerns involved therein.
  1,855 137 -
ORIGINAL ARTICLES
Comparative study evaluating the efficacy of ultrasound-guided transversus abdominis plain block versus intraperitoneal injection of local anesthetics in pain control following laparoscopic colectomy
Aktham A Shoukry, Waleed H Nofal, Sanaa M Elfawal
July-September 2016, 9(3):358-365
DOI:10.4103/1687-7934.189096  
Background Laparoscopic surgeries are being widely conducted nowadays for its well-known advantages such as less postoperative pain, shorter length of hospital stay, decreased morbidity and mortality, and reduced healthcare costs. Many analgesic modalities have been applied for this type of surgery, of which we have chosen the intraperitoneal injection (IP) of local anesthetics and the transversus abdominis plane (TAP) block. We studied the effect of both techniques on postoperative pain scores and their effect on abdominal and shoulder pain after laparoscopic colectomy. Patients and methods Fifty patients were enrolled in the study. All of them were of American Society of Anesthesiology (ASA) physical status I or II and scheduled for elective laparoscopic colectomy surgery. Patients were randomly allocated into one of two groups (25 patients each): the TAP block group (TAP group) and the IP of local anesthetics group (IP group). Pain score using the numerical rating scale (NRS), hemodynamic parameters, amount of consumption of rescue analgesia, shoulder pain, and adverse reactions were recorded. Results The main outcome variable was the pain score in the immediate postoperative period and the next 3 h; the mean NRS scores were lower in the TAP group than in the IP group in the previously mentioned time periods, with a highly significant difference. Also, there was a significant difference in the NRS score at the fourth hour postoperatively; however, the subsequent NRS scores at the different time intervals showed no significant difference until the end of the 24th hour postoperatively. In the TAP group, 20 patients (80%) complained of abdominal pain at least once in the first 24 h after surgery, whereas all the patients in the IP group experienced abdominal pain, with a significant difference between the two groups. The overall analgesic consumption in milligrams and the total number of analgesic doses were found to be less in the TAP group, with a highly significant difference. Conclusion The results of this study demonstrated that the TAP block is a more effective analgesic modality for abdominal pain than the IP local anesthetic during the early postoperative period after laparoscopic colectomy but IP is more effective in relieving postoperative shoulder pain.
  1,828 151 -
Effect of high fractional inspiratory oxygen on postoperative pulmonary function: a randomized–controlled study
Gad S Gad
July-September 2016, 9(3):337-342
DOI:10.4103/1687-7934.189090  
Background Although a high fraction of inspired oxygen (FiO2) could reduce surgical site infection, there is a concern that it could increase postoperative pulmonary complications, including hypoxemia. However, there is an advantage for preoperative high FiO2 before induction of anesthesia as it decreases the incidences of desaturation and wound infection. Our aim was to assess whether different levels of FiO2 affect pulmonary function tests. Patients and methods Ninety patients scheduled for elective abdominal hysterectomy were randomized to receive either preoxygenation with 1.0 FiO2 for 3 min, then continued on 1.0 FiO2 till the end of surgery (group A), or preoxygenation with 1.0 FiO2 for 3 min, then continued on 0.4 FiO2 till the end of surgery (group B), or preoxygenation with 0.4 FiO2 then continued on 0.4 FiO2 till the end of surgery (group C). The oxygenation index (PaO2/FiO2) was measured every 30 min during anesthesia and 2 h after extubation. Pulmonary function test was measured on the morning of surgery and 2 h after extubation. Results Five minutes after intubation, the median PaO2/FiO2 was 483 (371–490) mmHg in group A, 420 (336–490) mmHg in group B, and 450 (350–485) mmHg in group C (P = 0.24). Two hours after extubation, the PaO2/FiO2 was reduced to 333 (314–342) mmHg in group A, 328 (311–357) mmHg in group B, and 342 (303–316) mmHg in group C (P = 0.55). The median functional vital capacity were 1950 (1600–2120), 1850 (1570–2250), and 1900 (1490–2020) ml at baseline and 1650 (1370–1953), 1670 (1340–2350), and 1711 (1412–2410) ml 2 h after extubation in groups A, B, and C, respectively (P = 0.66). Conclusion We found no significant difference in the oxygenation index or pulmonary function tests between patients administered different levels of FiO2.
  1,721 168 -
Dexmedetomidine versus fentanyl as adjuvant to epidural 0.5% levobupivacaine for transurethral prostate resection in elderly patients: a comparative evaluation
Kumkum Gupta, Prashant K Gupta, Bhawana Rastogi, Manish Jain, Deepak Sharma, Mahesh Narayan Pandey
July-September 2016, 9(3):398-402
DOI:10.4103/1687-7934.189092  
Background Regional anesthesia is the technique of choice for patients undergoing transurethral resection of the prostate (TURP), but anesthetic management of elderly patients is challenging due to compromised organ function. The present study aimed to evaluate the relative efficacy and safety of dexmedetomidine versus fentanyl in the enhancement of the quality and duration of epidural anesthesia with 0.5% levobupivacaine and hemodynamic stability during TURP in elderly patients. Patients and methods Sixty elderly consented patients were randomized into two equal groups of 30 patients each in a double-blind manner. They were given 15 ml of 0.5% levobupivacaine (75 mg) either with 1 ml (50 μg) dexmedetomidine (group LD) or with 1 ml (50 μg) fentanyl (group LF) using an epidural catheter. The primary endpoints were the onset and duration of sensory and motor blockade, duration of sensory analgesia, hemodynamic variability, respiratory adequacy, and any adverse effect. Results Demographic data were comparable in both groups. Onset of sensory and motor blockade was faster in patients of group LD than in patients of group LF, with a statistically significant difference (P < 0.05). Duration of motor blockade and sensory analgesia was longer in patients of group LD than in patients of group LF (P < 0.05). Intraoperative heart rate and mean arterial blood pressure were significantly lower in patients of group LD, but no intervention was required. Surgical bleeding was reduced in patients of group LD. Conclusion Dexmedetomidine as an adjuvant to epidural levobupivacaine for TURP has shortened onset time of anesthesia and prolonged duration of sensory analgesia. The surgical field vision was improved due to reduced bleeding.
  1,733 152 1
Evaluation of intraperitoneal levobupivacaine with and without sufentanil for postoperative analgesia after laparoscopic cholecystectomy
Ahmed M.A. Abd El-Hamid, Hatem El-Moutaz, Ahmed T Abdel Moneim
July-September 2016, 9(3):371-376
DOI:10.4103/1687-7934.189564  
Background and objectives Postoperative pain after laparoscopic cholecystectomy (LC) is unpredictable, which explains the need for systematic prevention of pain before the patient wakes up from anesthesia. The study was conducted to evaluate the effect of intraperitoneal levobupivacaine with or without sufentanil for postoperative analgesia after LC. Patients and methods Ninety patients who underwent elective LC completed the study. Group C (n=29) received 50 ml of intraperitoneal normal saline, group L (n=31) received 50 ml of intraperitoneal levobupivacaine 0.25%, and group LS (n=30) received 50 ml of intraperitoneal levobupivacaine 0.25% plus 20 μg sufentanil. Visual analog score was recorded immediately postoperatively, and at 4, 8, and 12 h postoperatively. In addition, time to first rescue analgesia (diclofenac), total diclofenac consumption in 12 h, and complications (pruritus, emesis, shoulder pain, bradycardia, and hypotension) were recorded. Results Visual analog score until 8 h postoperatively was significantly higher in group C compared with groups L and LS. However, the difference was nonsignificant between groups L and LS, except at 8 and 12 h postoperatively. Time to first rescue analgesia was significantly longer in group LS (134.16±36.5) compared with group C (11.96±5.92) and group L (114.83±35.49) (P<0.001). Total diclofenac consumption in the first 12 h postoperatively was significantly lower in group L (92.5±32.26) and group LS (82.5±22.88) compared with group C (152.5±13.69). Conclusion Intraperitoneal instillation of levobupivacaine with sufentanil reduces not only the intensity of postoperative pain but also the total rescue analgesic dose consumption after LC.
  1,641 154 -
EDITORIAL
Global burden of diabetes: action for anesthesia
Sukhminder Jit Singh Bajwa, Sanjay Kalra, Manash Baruah
July-September 2016, 9(3):317-318
DOI:10.4103/1687-7934.189088  
  1,642 147 -
CASE REPORTS
Innovative use of damaged fiberoptic bronchoscope
Senthil Kumar Kaliannan, Khaja Mohideen Sherfudeen, Pavan Kumar Dammalapati
July-September 2016, 9(3):463-464
DOI:10.4103/1687-7934.189094  
Flexible fiberoptic bronchoscope is a delicate instrument that can get damaged due to improper handling. Once damaged, this costly instrument becomes useless. We reported a case in which we used a damaged flexible fiberoptic bronchoscope in overcoming a difficulty in advancing the endotracheal tube after visualization of the vocal cord with TruviewPCD in a patient with cervical spine injury.
  1,645 108 -
Management of perioperative bleeding associated with the use of selective serotonin reuptake inhibitors
Lobna A Saleh, Ahmed N Hassan, Amr Sobhy
July-September 2016, 9(3):449-451
DOI:10.4103/1687-7934.189567  
Increased bleeding tendency is associated with the use of selective serotonin reuptake inhibitors. In this study, we report a case of perioperative bleeding in patient on selective serotonin reuptake inhibitors. The management options for such cases are discussed.
  1,537 108 -
ORIGINAL ARTICLES
The role of granisetron in the enhancement of recovery and home discharge in ambulatory surgery performed under spinal anesthesia
Ayman Kasem
July-September 2016, 9(3):366-370
DOI:10.4103/1687-7934.189563  
Background The popularity of day-care surgery has increased worldwide due to reduced costs and remarkable safety profile. Neuraxial anesthesia is a popular technique for day-case surgeries. Anesthetist should modify his/her techniques to optimize patient’s chance of early discharge. 5-Hydroxytryptamine type 3 receptor antagonists used to prevent and treat postoperative nausea and vomiting may affect the course of spinal anesthesia and prevent its associated hypotension. Aim The aim of this study was to evaluate the effects of granisetron in the reversal of hyperbaric bupivacaine spinal anesthesia and enhancement of home discharge in day surgeries. Patients and methods Sixty adult patients scheduled for elective day surgery under spinal anesthesia were randomly divided into two equal groups to receive either 1 mg of granisetron (the G group) intravenously diluted in 5 ml normal saline over 30 s, 5 min before spinal anesthesia, or an equal volume of intravenous normal saline (the S group) at the same time. Heart rate, mean arterial pressure, oxygen saturation, and sensory and motor block levels were monitored and recorded. Results Time to regression of sensory level by two dermatomes, time to regression of sensory level to S2, time to first void, and time to discharge readiness were significantly lower in group G. Moreover, the incidence of nausea and shivering was significantly lower in group G. Conclusion Administration of 1 mg of granisetron before spinal anesthesia in ambulatory surgeries resulted in a statistically faster sensory regression and earlier home discharge from the day-surgery unit.
  1,498 128 -
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