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Assessment of role of perioperative melatonin in prevention and treatment of postoperative delirium after hip arthroplasty under spinal anesthesia in the elderly
Sherif S Sultan
September-December 2010, 4(3):169-173
DOI:10.4103/1658-354X.71132  PMID:21189854
Context: Little is known about the relationship between sedative drugs used preoperatively and postoperative delirium. Melatonin is a drug used to sedate patients preoperatively and is hypothesized by recent works to have a curative effect on postoperative delirium. Aims: The incidence of postoperative delirium will be tested if affected by three different sedative drugs including melatonin. Settings and Design: Controlled randomized double-blind study. Patients and Methods: Three-hundred patients aged>65 years scheduled for hip arthroplasty under spinal anesthesia were randomly distributed to one of the four groups. Group 1 (control) received nothing for sedation. Group 2 (melatonin) received 5 mg melatonin. Group 3 (midazolam) received 7.5 mg midazolam. Group 4 (clonidine) received 100 μg clonidine. These medications were given orally at sleep time at night of operation and another dose 90 min before operative time. Patients who developed postoperative delirium received 5 mg of melatonin 9 pm for three successive days in a trial to treat delirium. Statistical Analysis Used: Statistical analysis was done using the SPSS Software (version 13). Results: Total of 222 patients completed the study. Percentage of postoperative delirium in the control group was 32.65% (16/49 patients). The melatonin group showed a statistically significant decrease in the percentage of postoperative delirium to 9.43% (5/53 patients). Melatonin was successful in treating 58.06% of patients suffered postoperative delirium (36/62 patients) with no difference between different groups. Conclusions: Postoperative delirium is affected with the drug used for preoperative sedation. Melatonin was successful in decreasing postoperative delirium when used preoperatively and in treating more than half of patients developed postoperative delirium when used for three postoperative nights.
  15,087 1,426 35
Negative pressure pulmonary edema revisited: Pathophysiology and review of management
Balu Bhaskar, John F Fraser
July-September 2011, 5(3):308-313
DOI:10.4103/1658-354X.84108  PMID:21957413
Negative pressure pulmonary edema (NPPE) is a dangerous and potentially fatal condition with a multifactorial pathogenesis. Frequently, NPPE is a manifestation of upper airway obstruction, the large negative intrathoracic pressure generated by forced inspiration against an obstructed airway is thought to be the principal mechanism involved. This negative pressure leads to an increase in pulmonary vascular volume and pulmonary capillary transmural pressure, creating a risk of disruption of the alveolar-capillary membrane. The early detection of the signs of this syndrome is vital to the treatment and to patient outcome. The purpose of this review is to highlight the available literature on NPPE, while probing the pathophysiological mechanisms relevant in both the development of this condition and that involved in its resolution.
  14,012 1,086 10
Preanesthetic medication in children: A comparison of intranasal dexmedetomidine versus oral midazolam
Ashraf M Ghali, Abdul Kader Mahfouz, Maher Al-Bahrani
October-December 2011, 5(4):387-391
Background: Relieving preoperative anxiety is an important concern for the pediatric anesthesiologist. Midazolam has become the most frequently used premedication in children. However, new drugs such as the α2 -agonists have emerged as alternatives for premedication in pediatric anesthesia. Methods: One hundred and twenty children scheduled for adenotonsillectomy were enrolled in this prospective, double-blind, randomized study. The children were divided into two equal groups to receive either intranasal dexmedetomidine 1 μg/kg (group D), or oral midazolam 0.5 mg/kg (group M) at approximately 60 and 30 mins, respectively, before induction of anesthesia. Preoperative sedative effects, anxiety level changes, and the ease of child-parent separation were assessed. Also, the recovery profile and postoperative analgesic properties were assessed. Results: Children premedicated with intranasal dexmedetomidine achieved significantly lower sedation levels (P=0.042), lower anxiety levels (P=0.036), and easier child-parent separation (P=0.029) than children who received oral midazolam at the time of transferring the patients to the operating room. Postoperatively, the time to achieve an Aldrete score of 10 was similar in both the groups (P=0.067). Also, the number of children who required fentanyl as rescue analgesia medication was significantly less (P=0.027) in the dexmedetomidine group. Conclusion: Intranasal dexmedetomidine appears to be a better choice for preanesthetic medication than oral midazolam in our study. Dexmedetomidine was associated with lower sedation levels, lower anxiety levels, and easier child-parent separation at the time of transferring patients to the operating room than children who received oral midazolam. Moreover, intranasal dexmedetomidine has better analgesic property than oral midazolam with discharge time from postanesthetic care unit similar to oral midazolam.
  10,796 768 17
Clonidine for management of chronic pain: A brief review of the current evidences
Anil Kumar, Souvik Maitra, Puneet Khanna, Dalim Kumar Baidya
January-March 2014, 8(1):92-96
DOI:10.4103/1658-354X.125955  PMID:24665248
Clonidine, an alpha-2 adrenergic receptor agonist, has well-established role in acute perioperative pain management. However, recently it has found increasing use in chronic pain conditions as well. In this review, we systematically searched and analyzed the clinical studies from "PubMed," "PubMed central" and "Scopus" database for use of clonidine in the chronic pain. Quantitative meta-analysis was not possible as clonidine has been used in various patient populations through different routes. However, qualitative analysis of nearly thirty clinical studies provides some evidence that clonidine administered through epidural, intrathecal and local/topical route may be effective in chronic pain conditions where neuropathy is a predominant component. It may also be effective where opioids are of limited use due to inadequate pain relief or adverse effects.
  11,072 459 3
Reflex bradycardia and asystole during anaesthesia
Stephen Michael Kinsella
January-June 2009, 3(1):35-38
Neurogenically mediated bradycardia that may result in cardiac arrest is a rare but well-recognised complication during anaesthesia. Three cases are described that illustrate certain features. In the first, hidden haemorrhage during laparoscopy under general anaesthesia was revealed during reinsufflation of gas into the peritoneum at the end of the operation. The second case developed asystole when positioned supine with tilt after spinal anaesthesia for caesarean section. This occurred on two occasions separated by ten years. In the third case, asystole developed 95 minutes after a spinal when the patients legs were lowered down from the lithotomy position. All patients were resuscitated with drug treatment and, in the first case, intravenous fluids.
  10,740 718 1
Ultrasound-guided peripheral and truncal blocks in pediatric patients
Mohamed Bilal Delvi
April-June 2011, 5(2):208-216
DOI:10.4103/1658-354X.82805  PMID:21804805
Ultrasound has added a feather in the cap of the anesthesiologists as real-time nerve localization and drug deposition around the nerve structure under real-time guidance is now a reality, as the saying "seeing is believing" has been proven true with the advent of ultrasound in anesthesia. Pediatric patients are a unique group regarding their anatomical and physiological features in comparison with adults; regional blocks in adults with the anatomical landmark and surface marking are almost uniform across the adult population. The landmark technique in pediatric patients is not reliable in all patients due to the variability in the age and size; the advent of ultrasound in assisting nerve localization has changed the way regional blocks are achieved in children and the range of blocks performed on adults can now be performed on pediatric patients; with advances in the technology and dexterity of ultrasound equipment, the chances of success of blocks has increased with a smaller dose of the local anesthetic in comparison to the traditional methods. Anesthesiologists are now able to perform blocks with more accuracy and avoid complications like intravascular injection and injury to the pleura and peritoneum during routine practice with the assistance of high-frequency transducers and top of the range portable ultrasound machines; catheters can be inserted to provide a continuous analgesia in the postoperative period. This review article describes the common peripheral blocks in pediatric patients; the readers are encouraged to gain experience by attending workshops, hands-on practice under supervision, and conduct random controlled trials pertaining to ultrasound-guided blocks in the pediatric age group. The recent literature is encouraging and further research is promising; a wide range of blocks being described in detail by many prominent experts from all over the world.
  10,553 264 -
Paravertebral block can attenuate cytokine response when it replaces general anesthesia for cancer breast surgeries
Sherif S Sultan
October-December 2013, 7(4):373-377
DOI:10.4103/1658-354X.121043  PMID:24348286
Context: Cytokine release is a well-known response to surgery especially when it is linked to cancer. Paravertebral block (PVB) is the suitable regional anesthesia for breast surgery. Aim: We tested the effect of replacing general anesthesia (GA) with PVB on cytokine response during and after surgeries for cancer breast. Settings and Design: Controlled randomized study. Methods: Forty cancer breast patients were divided in two groups; Group I received PVB and Group II received GA during performance of unilateral breast surgery without axillary clearance. Plasma concentrations of interleukin (IL)-6, IL-10, IL-12 and interferon-γ (IFN-γ) were measured and IL-10/IFN-γ were estimated in the following points; before starting PVB in Group I or induction of GA in Group II (Sample A), before skin incision (Sample B), at the end of procedure before shifting out of operating room (Sample C), 4-h post-operatively (Sample D) and 24-h post-operatively (Sample E). Statistical Analysis: unpaired Student t-test. Results: IL-6 increased progressively in both groups with statistically significant lower levels in samples C and D in Group I. IL-10 levels showed progressive increasing in both groups without differences between groups. IL-12 showed progressive decrease in both groups with statistically significant higher levels in samples C and D in Group I. IFN-levels showed significantly higher levels in samples C and D in Group I. IL-10/IFN-γ ratio was significantly lower in Group II in samples C and D. Conclusion: Replacing GA with PVB can attenuate cytokines response to cancer breast surgeries.
  9,263 1,134 1
Comparison of two drug combinations in total intravenous anesthesia: Propofol-ketamine and propofol-fentanyl
Sukhminder Jit Singh Bajwa, Sukhwinder Kaur Bajwa, Jasbir Kaur
May-August 2010, 4(2):72-79
DOI:10.4103/1658-354X.65132  PMID:20927266
Background and Aims: Keeping in consideration the merits of total intravenous anesthesia (TIVA), a genuine attempt was made to find the ideal drug combinations which can be used in general anesthesia. This study was conducted to evaluate and compare two drug combinations of TIVA using propofol-ketamine and propofol-fentanyl and to study the induction, maintenance and recovery characteristics following anesthesia with these techniques. Settings and Design: A case control study was conducted, which included 100 patients, in the department of Anaesthesiology and Intensive care, Government Medical College and Hospital, Patiala. Patients and Methods: A hundred patients between the ages of 20 and 50 years of either gender were divided into two groups of 50 each, and they underwent elective surgery of approximately 1 h duration. Group I received propofol-ketamine while group II received propofol-fentanyl for induction and maintenance of anesthesia. All the results were tabulated and analyzed statistically with student's unpaired t-test and chi-square test. Results : Propofol-fentanyl combination produced a significantly greater fall in pulse rate (PR; 9.28% versus 0.23%) and in both systolic (7.94% versus 0.12%) and diastolic blood pressures (BP; 8.10% versus 0.35%) as compared to propofol-ketamine during induction of anesthesia. Propofol-ketamine combination produced stable hemodynamics during maintenance phase while on the other hand propofol-fentanyl was associated with a slight increase in both PR and BP. During recovery, ventilation score was better in group I while movement and wakefulness score was better in group II. Mean time to protrusion of tongue and lifting of head was shorter in group I. Conclusions : Both propofol-ketamine and propofol-fentanyl combinations produce rapid, pleasant and safe anesthesia with only a few untoward side effects and only minor hemodynamic effects.
  8,327 1,180 8
Patient-controlled sedation with propofol/remifentanil versus propofol/alfentanil for patients undergoing outpatient colonoscopy, a randomized, controlled double-blind study
Sherif S Sultan
November 2014, 8(5):36-40
DOI:10.4103/1658-354X.144068  PMID:25538518
Context: Many techniques are used for sedation of colonoscopies. Patient-controlled sedation (PCS) is utilizing many drugs or drug combinations. Aims: The aim of this study is to compare the safety and feasibility of propofol/remifentanil versus propofol/alfentanil given to sedate patients undergoing outpatient colonoscopies through a patient-controlled technique. Settings and Design: Controlled randomized and double-blind study. Materials and Methods: A total of 80 patients were randomly divided into two groups; PA group received a combination of propofol/alfentanil and PR group received propofol/remifentanil combination. Patients were monitored for heart rate (HR), blood pressure (BP), oxygen saturation, and Ramsay sedation scale (RSS). Times of the following events were recorded; initiation of sedation, insertion and removal of the colonoscope, recovery and discharge. Five intervals were calculated; time to sedation, procedure time, postprocedure time, procedure room time, and postanesthesia care unit (PACU) time. Endoscopist and patient satisfaction scores were obtained. Statistical Analysis Used: Unpaired Student's t-test was used to compare between the two groups. Paired Student's t-test was used to compare baseline readings with readings after 30 min of sedation in the same group when needed. Results: Both groups showed slowing of the HR and decrease in mean arterial BP. HR and mean arterial BP were significantly lower 5 and 10 min after initiation of sedation in PR group when compared with PA group. Both HR and mean arterial BP returned to presedation readings 30 min after initiation of sedation in PR group but not in PA group. No differences between the two groups concerning oxygen saturation, RSS, endoscopist and patient satisfaction scores. Postprocedure and PACU times were significantly prolonged in PA group. Conclusion: PCS with either remifentanil/propofol or alfentanil/propofol for patients undergoing outpatient colonoscopy is safe and feasible. Remifentanil/proofol has more beneficial advantages in this setting secondary to its more rapid clearance.
  8,158 1,055 -
Comparative evaluation of dexmedetomidine and fentanyl for epidural analgesia in lower limb orthopedic surgeries
Sukhminder Jit Singh Bajwa, Vikramjit Arora, Jasbir Kaur, Amarjit Singh, SS Parmar
October-December 2011, 5(4):365-370
Background and Aims: Opioids as epidural adjunct to local anesthetics (LA) have been in use since long and α-2 agonists are being increasingly used for similar purpose. The present study aims at comparing the hemodynamic, sedative, and analgesia potentiating effects of epidurally administered fentanyl and dexmedetomidine when combined with ropivacaine. Methods: A total of one hundred patients of both gender aged 21-56 years, American Society of Anaesthesiologist (ASA) physical status I and II who underwent lower limb orthopedic surgery were enrolled into the present study. Patients were randomly divided into two groups: Ropivacaine + Dexmedetomidine (RD) and Ropivacaine + Fentanyl (RF), comprising 50 patie nts each. Inj. Ropivacaine, 15 ml of 0.75%, was administered epidurally in both the groups with addition of 1 μg/kg of dexmedetomidine in RD group and 1 μg/kg of fentanyl in RF group. Besides cardio-respiratory parameters and sedation scores, various block characteristics were also observed which included time to onset of analgesia at T10, maximum sensory analgesic level, time to complete motor blockade, time to two segmental dermatomal regressions, and time to first rescue analgesic. At the end of study, data was compiled systematically and analyzed using ANOVA with post-hoc significance, Chi-square test and Fisher's exact test. Value of P<0.05 is considered significant and P<0.001 as highly significant. Results: The demographic profile of patients was comparable in both the groups. Onset of sensory analgesia at T10 (7.12±2.44 vs 9.14±2.94) and establishment of complete motor blockade (18.16±4.52 vs 22.98±4.78) was significantly earlier in the RD group. Postoperative analgesia was prolonged significantly in the RD group (366.62±24.42) and consequently low dose consumption of local anaesthetic LA (76.82±14.28 vs 104.35±18.96) during epidural top-ups postoperatively. Sedation scores were much better in the RD group and highly significant on statistical comparison (P<0.001). Incidence of nausea and vomiting was significantly high in the RF group (26% and 12%), while incidence of dry mouth was significantly higher in the RD group (14%) (P<0.05). Conclusions: Dexmedetomidine seems to be a better alternative to fentanyl as an epidural adjuvant as it provides comparable stable hemodynamics, early onset, and establishment of sensory anesthesia, prolonged post-op analgesia, lower consumption of post-op LA for epidural analgesia, and much better sedation levels.
  8,170 1,041 16
Acute epiglottitis: Trends, diagnosis and management
Claude Abdallah
July-September 2012, 6(3):279-281
DOI:10.4103/1658-354X.101222  PMID:23162404
Acute epiglottitis is a life-threatening disorder with serious implications to the anesthesiologist because of the potential for laryngospasm and irrevocable loss of the airway. Acute epiglottitis can occur at any age. Early diagnosis with careful and rapid intervention of this serious condition is necessary in order to avoid life-threatening complications.
  8,314 344 3
Mixed venous versus central venous oxygen saturation in patients undergoing on pump beating coronary artery bypass grafting
Ahmad Alshaer, Mohamed Essam Abdel-Meguid, Osama Ibraheim, Khaled Fawzi, Ibrahim AbdulSalam, Saad Sheta, Khaled M Abdullah, Ahmed El-Demerdash, Raed Al-Satli, Mohamed AbdelAll, Bakir M Bakir, Nezar AlNahal, Yasser Abdulrahman, Hanaa AlHamoud
May-August 2010, 4(2):63-67
DOI:10.4103/1658-354X.65129  PMID:20927264
Objective: To examine the validity of central venous oxygen saturation (ScvO 2 ) as a numerical substitution of mixed venous oxygen saturation (SvO 2 ) in adult patients undergoing normothermic on pump beating coronary artery bypass grafting (CABG). Materials and Methods: Prospective clinical observational study was done at King Khalid University Hospital, King Saud University, Riyadh, Kingdom of Saudi Arabia. Thirty four adult patients scheduled for coronary artery surgery were included. Patients were monitored by a pulmonary artery catheter (PAC) as a part of our routine intraoperative monitoring. SvO 2 and ScvO 2 were simultaneously measured 15 minutes (T1) and 30 minutes (T2) after induction of anesthesia, 15 and 30 minutes after initiation of cardiopulmonary bypass (T3 and T4), and 15 and 30 minutes after admission to intensive care unit (T5 and T6). Results: ScvO 2 showed higher reading than SvO 2 all through our study. Our results showed perfect positive statistically significant correlation between SvO 2 and ScvO 2 at all data points. Individual mean of difference (MOD) between both the readings at study time showed MOD of 1.34 and 1.44 at T1 and T2 simultaneously. This MOD was statistically insignificant, but after on pump beating normothermic bypass was initiated; MOD was 5.2 and 4.4 at T3 and T4 with high statistical significance. In ICU, MOD continues to have high statistical significance, MOD was 6.3 at T5 and at T6 it was 4.6. Conclusions: In on pump beating CABG patients; ScvO 2 and SvO 2 are not interchangeable numerically. ScvO 2 is useful in the meaning of trend; our data suggest that ScvO 2 is equivalent to SvO 2 , only in the course of clinical decisions as long as absolute values are not required.
  8,399 242 1
Comparison of epidural ropivacaine and ropivacaine clonidine combination for elective cesarean sections
Sukhminder Jit Singh Bajwa, Sukhwinder Kaur Bajwa, Jasbir Kaur
May-August 2010, 4(2):47-54
DOI:10.4103/1658-354X.65119  PMID:20927262
Background and Aim: Neuraxial adjuvants augment the action of local anesthetics. The aim is to determine the qualitative and quantitative aspects of epidural block of ropivacaine 0.75% versus ropivacaine 0.75% with clonidine for elective cesarean section . Settings and Design: A randomized double-blind study was conducted among 51 healthy parturients, scheduled for elective cesarean section, at Gian Sagar Medical College and Hospital, Banur, Punjab, India. Materials and Methods: Epidural block was administered with 20 ml of ropivacaine 0.75% (group R) and ropivacaine 0.75% and clonidine 75 μg (group RC) and anesthetic level was achieved minimum until T6-T7 dermatome. Onset time of analgesia, sensory and motor block levels, maternal heart rate and blood pressure, neonatal Apgar scores, postoperative analgesic dose and adverse events were recorded. Results: Fifty one patients were enrolled in this study and were subjected to statistical analysis. Groups were comparable with regard to demographic data, neonatal Apgar scores and incidences of side effects except for the higher incidence of dry mouth in patients of RC group. Onset of analgesia was much shorter in RC group along with prolonged duration of analgesia. The incidence of bradycardia and hypotension was more in RC group as compared to R group which was statistically significant. The dose requirement for postoperative pain relief was significantly lesser in RC group. Conclusions: The addition of 75 μg clonidine to isobaric epidural ropivacaine results in longer, complete and effective analgesia with similar block properties and helped to reduce the effective dose of ropivacaine when compared with plain ropivacaine for cesarean delivery.
  7,596 866 -
A randomized controlled trial to compare pregabalin with gabapentin for postoperative pain in abdominal hysterectomy
Anju Ghai, Monika Gupta, Sarla Hooda, Dinesh Singla, Raman Wadhera
July-September 2011, 5(3):252-257
DOI:10.4103/1658-354X.84097  PMID:21957402
Background: Pregabalin is a potent ligand for alpha-2-delta subunit of voltage-gated calcium channels in the central nervous system, which exhibits potent anticonvulsant, analgesic and anxiolytic activity. The pharmacological activity of pregabalin is similar to that of gabapentin and shows possible advantages. Although it shows analgesic efficacy against neuropathic pain, very limited evidence supports its postoperative analgesic efficacy. We investigated its analgesic efficacy in patients experiencing acute pain after abdominal hysterectomy and compared it with gabapentin and placebo. Methods: A randomized, double-blind, placebo-controlled study was conducted in 90 women undergoing abdominal hysterectomy who were anaesthetized in a standardized fashion. Patients received 300 mg pregabalin, 900 mg gabapentin or placebo, 1-2 hours prior to surgery. Postoperative analgesia was administered at visual analogue scale (VAS) ≥3. The primary outcome was analgesic consumption over 24 hours and patients were followed for pain scores, time to rescue analgesia and side effects as secondary outcomes. Results: The diclofenac consumption was statistically significant between pregabalin and control groups, and gabapentin and control groups; however, pregabalin and gabapentin groups were comparable. Moreover, the consumption of tramadol was statistically significant among all the groups. Patients in pregabalin and gabapentin groups had lower pain scores in the initial hour of recovery. However, pain scores were subsequently similar in all the groups. Time to first request for analgesia was longer in pregabalin group followed by gabapentin and control groups. Conclusion: A single dose of 300 mg pregabalin given 1-2 hours prior to surgery is superior to 900 mg gabapentin and placebo after abdominal hysterectomy. Both the drugs are better than placebo.
  7,527 691 21
Bifid uvula: Anesthetist don't take it lightly!
Sukhen Samanta, Sujay Samanta
October-December 2013, 7(4):482-484
DOI:10.4103/1658-354X.121061  PMID:24348311
  7,883 153 -
Palonosetron: A novel approach to control postoperative nausea and vomiting in day care surgery
Sukhminderjit Singh Bajwa, Sukhwinder Kaur Bajwa, Jasbir Kaur, Veenita Sharma, Amarjit Singh, Anita Singh, SPS Goraya, SS Parmar, Kamaljit Singh
January-March 2011, 5(1):19-24
DOI:10.4103/1658-354X.76484  PMID:21655011
Background: Postoperative nausea and vomiting (PONV) is one of the complications which hamper the successful implementation of day care surgical procedure in spite of the availability of so many antiemetic drugs and regimens for its prevention. The aim was to compare the prophylactic effects of intravenously (IV) administered ondansetron and palonosetron on PONV prevention in patients undergoing laparoscopic gynecological surgery under general anesthesia. Methods: A prospective double-blind study comprised of 60 ASAI/II female patients between the age group of 25 and 40 years was carried out in the Departments of Anesthesiology and Obstetrics and Gynecology of our institute. Patients were randomly divided into two groups of 30 patients each in a double-blind manner. Group I received 8 mg of inj. ondansetron IV while group II received inj. palonosetron 0.075 mg IV 5 minutes before the induction of anesthesia. The need for rescue antiemetics, episodes of PONV and other side effects were observed for 6 hours in the postanesthesia care unit and thereafter complaints were received on phone after the discharge. At the end of study, results were compiled and statistical data was subjected to statistical analysis using Student two-tailed 't' and c2 test and value of P<0.05 was considered significant. Results: The demographical profile of the patients was comparable. Twenty and 13.33% of the patients in group I had nausea and vomiting episodes postoperatively as compared to 6.67% and 3.33%, respectively, in group II which was statistically significant (P<0.05). Twenty percent of the patients in group I experienced significant post-op headache as compared to 6.67% in group II. The mean rescue dose of antiemetic was significantly higher (10.6 mg) in the group I as compared to group II (6.4 mg) (P=0.036). The rest of parameters were comparable and statistically nonsignificant. Conclusions: Palonosetron is a comparatively better drug to prevent the PONV in patients undergoing day care surgical procedures as compared to ondansetron as it has got a prolonged duration of action and favorable side-effects profile.
  7,070 874 24
Ultrasound guidance of uncommon nerve blocks
Ahmed Thallaj
October-December 2011, 5(4):392-394
In the past nerve stimulation was considered the standard tool for anesthesiologists to locate the peripheral nerve for nerve blocks. However, with the recent introduction of ultrasound (US) technology for regional anesthesia, the use of nerve stimulation has become a rarity nowadays. There is a growing interest by most anesthesiologists in using US for nerve blocks because of its simplicity and accuracy. US is now available in most hospitals practicing regional anesthesia and is a popular tool for performance of nerve blocks. Although nerve stimulation became a rarity, however the use of it is now limited to identify small nerve structures, such as greater auricular nerve and medial antebrachial cutaneous nerve of the forearm. However, in this review article we discuss the role of ultrasonography for greater auricular and antebrachial cutaneous nerve blocks, which could replace nerve stimulation technique. We look at the available literature on the role of US for the performance of uncommon nerve blocks and its benefits.
  7,513 423 1
Use of transesophageal Doppler as a sole cardiac output monitor for reperfusion hemodynamic changes during living donor liver transplantation: An observational study
M Hussien, E Refaat, N Fayed, K Yassen, M Khalil, W Mourad
July-September 2011, 5(3):264-269
DOI:10.4103/1658-354X.84099  PMID:21957404
Aims: To report the use of transesophageal Doppler (TED), a minimally invasive cardiac output (COP) monitor, before, during and after reperfusion and study its effect on anesthetic management during living donor liver transplantation (LDLT). Setting and Design: A prospective observational study. Methods: A total of 25 consecutive recipients with a MELD score between 15 and 20 were enrolled. Data were recorded at baseline (TB); anhepatic phase (TA); and post-reperfusion - 1, 5, 10 and 30 minutes. Fluid therapy was guided by corrected flow time (FTc) of the TED. Packed red blood cells (RBCs) were only given when hematocrit was less than 25%. Rotational thromboelastometry (ROTEM) and standard laboratory tests were used to guide component blood products requirements. Results: Post-reperfusion, the COP, Cardiac Index (CI) and stroke volume (SV) increased significantly at all points of measurements; this was associated with a significant decrease in systemic vascular resistance (SVR) ( P <.05). Immediately post-reperfusion, for 5 minutes, mean arterial blood pressure (ABP) dropped significantly (P<.05), and 14 out of the 25 patients required boluses of epinephrine (10 μg) to restore the mean ABP; 3 of the 14 patients required norepinephrine infusion till the end of surgery. Central venous pressure (CVP) and urine output (UOP) at all measures were maintained adequately with FTc-guided fluid replacement. Eight out of the 25 patients required no blood transfusion, and 4 of the 8 patients required no catecholamine support. Conclusion: TED as a sole monitor for COP was able to present significant and reliable changes in the cardiovascular status of the recipients during reperfusion, which could help to guide fluid- and drug-supportive therapy in this population of patients. This preliminary study needs to be applied on a larger scale.
  6,838 760 3
Airway management in a patient with Le Fort III Fracture
Maroun B Ghabach, Myriam A Abou Rouphael, Caroline E Roumoulian, May R Helou
January-March 2014, 8(1):128-130
DOI:10.4103/1658-354X.125974  PMID:24665254
Maxillofacial fractures present unique airway problem to the anesthesiologist. Patients with LeFort III fractures are at great risk of requiring emergent airway control due to midface instability and oropharyngeal airway obstruction. We present a case where difficult intubation was managed with close cooperation between the anesthesiologist and the surgeon.
  7,202 319 1
Ultrasound-guided single injection infraclavicular brachial plexus block using bupivacaine alone or combined with dexmedetomidine for pain control in upper limb surgery: A prospective randomized controlled trial
Amany S Ammar, Khaled M Mahmoud
April-June 2012, 6(2):109-114
DOI:10.4103/1658-354X.97021  PMID:22754434
Background: Dexmedetomidine, is a selective α2-adrenoceptor agonist that is used as an adjuvant mixed with local anesthetics during regional anesthesia. This study was designed to test the efficacy of adding dexmedetomidine to bupivacaine during placement of infraclavicular brachial plexus blockade (ICB). Methods: Sixty adult patients were divided into 2 equal groups of 30 subjects each. Patients in Group I received an ICB using 30 mL of 0.33% bupivacaine and Group II patients received 30 mL of 0.33% bupivacaine mixed with 0.75 μg/kg of dexmedetomidine. The following brachial plexus nerve block parameters were assessed: block success rate, sensory onset time and duration, motor block onset time and duration, analgesic pain scores using the verbal rating scale (VRS) for pain, duration of analgesia, and amount of supplemental intravenous (IV) morphine required. Results: There was a statistically significant shorter time to onset of sensory blockade (13.2 vs 19.4 min, P=0.003), longer duration of sensory block (179.4 vs 122.7 min, P=0.002), shorter onset time to achieve motor block (15.3 vs 22.2 min, P=0.003), longer duration of motor block (155.5 vs 105.7 min, P=0.002), lower VRS pain scores, prolonged analgesia (403 vs 233 min, P=0.002), and lower morphine rescue requirements for 48 h after surgery (4.9 (0-8.0) vs 13.6 mg (4.0-16.0) mg, P=0.005). All patients recovered without evidence of sensory or motor deficit. Conclusion: Adding dexmedetomidine to bupivacaine during the placement of an ICB provides: (1) enhancement of onset of sensory and motor blockade, (2) prolonged duration of analgesia, (3) increases duration of sensory and motor block, (4) yields lower VRS pain scores, and (5) reduces supplemental opioid requirements.
  6,774 585 17
Dexmedetomidine versus propofol for sedation in patients undergoing vitreoretinal surgery under sub-Tenon's anesthesia
Ashraf Ghali, Abdul Kader Mahfouz, Tapio Ihanamäki, Ashraf M. El Btarny
January-March 2011, 5(1):36-41
DOI:10.4103/1658-354X.76506  PMID:21655014
Purpose: The purpose of this study was to evaluate the hemodynamic, respiratory effects, the recovery profile, surgeons, and patients satisfaction with dexmedetomidine sedation compared with those of propofol sedation in patients undergoing vitreoretinal surgery under sub-Tenon's anesthesia. Methods: Sixty patients were enrolled in this prospective, single-blind, randomized study. The patients were divided into two groups to receive either dexmedetomidine (group D) or propofol (group P). Sedation level was titrated to a Ramsay sedation scale (RSS) of 3. Hemodynamic and respiratory effects, postoperative recovery time, analgesic effects, surgeons and patients satisfaction were assessed. Results: Both groups provided a similar significant reduction in heart rate and mean arterial pressure compared with baseline values. The respiratory rate values of the dexmedetomidine group were significantly higher than those in the propofol group. The oxygen saturation values of the dexmedetomidine group were significantly higher than those of the propofol group. The expired CO 2 was similar in both groups. Postoperatively, the time to achieve an Aldrete score of 10 was similar in both groups. Dexmedetomidine patients have significantly lower visual analog scale for pain than propofol patients. The surgeon satisfaction with patients' sedation was similar for both groups. The patients' satisfaction was higher in the dexmedetomidine group. Conclusion: Dexmedetomidine at similar sedation levels with propofol was associated with equivalent hemodynamic effects, maintaining an adequate respiratory function, similar time of discharge from PACU, better analgesic properties, similar surgeon's satisfaction, and higher patient's satisfaction. Thus, dexmedetomidine may prove to be a valuable adjuvant for sedation in patients undergoing vitreoretinal surgery under sub-Tenon's anesthesia.
  6,888 425 9
The effects of warm and cold intrathecal bupivacaine on shivering during delivery under spinal anesthesia
Abdolreza Najafianaraki, Kamran Mirzaei, Zahra Akbari, Philippe Macaire
October-December 2012, 6(4):336-340
DOI:10.4103/1658-354X.105854  PMID:23493460
Background: Shivering associated with neuraxial anesthesia is a common problem that is uncomfortable for patients; it is of unknown ethnology and has no definite treatment. Purpose: The purpose of this study was to compare the effects of warm intrathecal bupivacaine stored at 23°C and cold intrathecal bupivacaine stored at 4°C on shivering during delivery under spinal anesthesia. Methods: Seventy-eight parturient women scheduled for nonemergency cesarean delivery were enrolled in the study and separated into 2 groups. The standard group received 10 mg of heavy bupivacaine 0.5% stored at room temperature (23°C) plus 10 μg of fentanyl intrathecally (warm group), and the case group received 10 mg of heavy bupivacaine 0.5% stored at 4°C plus 10 μg of fentanyl intrathecally (cold group). Data collection, including sensory block level, blood pressure, core temperature, and shivering intensity, was first performed every minute for 10 min, then every 5 min for 35 min and, finally, every 10 min until the sensory level receded to L4. Results: There were no differences between the 2 groups in the amount of bleeding, pulse rate, oxygen saturation, neonatal Apgar, and incidence of vomiting. The incidence and intensity of shivering decreased in the warm group (P=0.002). Conclusion: Warming of solutions can reduce the incidence and intensity of shivering in parturient candidates for cesarean delivery under spinal anesthesia.
  5,894 1,419 1
Comparison of streamlined liner of the pharynx airway (SLIPA TM ) with the laryngeal mask airway Proseal TM for lower abdominal laparoscopic surgeries in paralyzed, anesthetized patients
Ashraf Abualhassan Abdellatif, Monaz Abdulrahman Ali
July-September 2011, 5(3):270-276
DOI:10.4103/1658-354X.84100  PMID:21957405
Context: Supraglottic airway devices have been used as an alternative to tracheal intubation during laparoscopic surgery. Aims: The study was designed to compare the efficacy of Streamlined Liner of the Pharynx Airway (SLIPA) for positive pressure ventilation and postoperative complications with the Laryngeal Mask Airway ProSeal (PLMA) for patients undergoing lower abdominal laparoscopies under general anesthesia with controlled ventilation. Settings and Design: Prospective, crossover randomized controlled trial performed on patients undergoing lower abdominal laparoscopic surgeries. Methods: A total of 120 patients undergoing lower abdominal laparoscopic surgeries were randomly allocated into two equal groups; PLMA and SLIPA groups. Number of intubation attempts, insertion time, ease of insertion, and fiberoptic bronchoscopic view were recorded. Lung mechanics data were collected 5 minutes after securing the airway, then after abdominal insufflation. Blood traces and regurgitation were checked for; postoperative sore throat and other complications were recorded. Statistical Analysis: Arithmetic mean and standard deviation values were calculated and statistical analyses were performed for each group. Independent sample t-test was used to compare continuous variables exhibiting normal distribution, and Chi-squared test for noncontinuous variables. P value <0.05 was considered significant. Results: Insertion time, first insertion success rate, and ease of insertion were comparable in both groups. Fiberoptic bronchoscopic view was significantly better and epiglottic downfolding was significantly lower in SLIPA group. Sealing pressure and lung mechanics were similar. Gastric distension was not observed in both groups. Postoperative sore throat was significantly higher in PACU in PLMA group. Blood traces on the device were significantly more in SLIPA group. Conclusions: SLIPA can be used as a useful alternative to PLMA in patients undergoing lower abdominal laparoscopic surgery with muscle relaxant and controlled ventilation.
  7,057 186 12
General anesthesia for repair of omphalocele in a pair of conjoined twins in Enugu, Nigeria
HA Ezike, VO Ajuzieogu, AO Amucheazi, SO Ekenze
September-December 2010, 4(3):202-204
DOI:10.4103/1658-354X.71579  PMID:21189860
Conjoined twins have been viewed with fascination since antiquity. There are numerous reports in the literature documenting anesthetic management strategies for the separation of conjoined twins. There are also reports in the literature detailing anesthetic approaches for surgical procedures not involving separation. This is the first report of the anesthetic management of a set of omphalagous presenting for palliative repair of omphalocele in Nigeria.
  7,006 225 -
Procedural sedation: A review of sedative agents, monitoring, and management of complications
Joseph D Tobias, Marc Leder
October-December 2011, 5(4):395-410
Given the continued increase in the complexity of invasive and noninvasive procedures, healthcare practitioners are faced with a larger number of patients requiring procedural sedation. Effective sedation and analgesia during procedures not only provides relief of suffering, but also frequently facilitates the successful and timely completion of the procedure. However, any of the agents used for sedation and/or analgesia may result in adverse effects. These adverse effects most often affect upper airway patency, ventilatory function or the cardiovascular system. This manuscript reviews the pharmacology of the most commonly used agents for sedation and outlines their primary effects on respiratory and cardiovascular function. Suggested guidelines for the avoidance of adverse effects through appropriate pre-sedation evaluation, early identification of changes in respiratory and cardiovascular function, and their treatment are outlined.
  6,673 546 16