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  Citation statistics : Table of Contents
   2009| January-June  | Volume 3 | Issue 1  
    Online since July 18, 2009

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Preliminary experience with transversus abdominis plane block for postoperative pain relief in infants and children
Joseph D Tobias
January-June 2009, 3(1):2-6
Background. In the adult population, analgesia following lower abdominal surgery and laparoscopic procedures can be provided by a transversus abdominis plane (TAP) block where local anesthetic is placed between the internal oblique and the tranversus abdominis muscles using an injection in the triangle of Petit. We present preliminary experience with the postoperative analgesic efficacy of TAP block in pediatric patients. Patients and Methods. Ten pediatric patients, ranging in age from 10 months to 8 years were reviewed. Using ultrasound guidance, a TAP block was placed on both sides with 0.3 mL/kg of 0.25% bupivacaine with epinephrine 1:200,000 after the completion of the surgical procedure. The surgical procedures included ureteral reimplantation (n=3), colostomy takedown (n=2), pelvic laparoscopy for evaluation of abdominal pain (n=2), laparoscopic appendectomy (n=2), and bilateral inguinal hernia repair (n=1). Results. In 8 of 10 patients, the TAP block was judged to be successful as no postoperative analgesic agents were required for the initial 7-11 postoperative hours. Four patients required no intravenous opioids postoperatively and were treated with oral opioids as outpatients. The other 4 patients required 0.15 ± 0.04 mg/kg of morphine during the first 24 postoperative hours. The TAP block was judged to be unsuccessful in 2 patients who required intravenous opioids during their immediate postoperative course, starting at 2 and 3 hours postoperatively. These two patients required 0.3-0.4 mg/kg of morphine during the first 24 postoperative hours. No adverse effects related to TAP block were identified. Conclusion. Our preliminary experience suggests that TAP block provides effective analgesia following umbilical and lower abdominal surgery in infants and children.
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Assessment of different concentrations of ketofol in procedural operations
Mohamed Daabiss, Medhat Elsherbiny, Rashed Al Otaibi
January-June 2009, 3(1):15-19
Background. Propofol is an intravenous anesthetic that is often used as an adjuvant during monitored anesthesia care, the addition of ketamine to propofol may counteract the cardiorespiratory depression seen with propofol used alone. Ketofol (ketamine/propofol combination) was used for procedural sedation and analgesia. However, evaluation of the effectiveness of different concentrations of Ketofol in procedural operation regarding changes in haemodynamics, emergence phenomena, recovery time, the doses, and adverse effects was not yet studied, so this randomized, double blinded study was designed to compare the quality of analgesia and side effects of intravenous different concentrations of ketofol Patient and Methods. One hundred children of both sex undergoing procedural operation, e.g. esophgoscopy, rectoscopy, bone marrow aspiration and liver biopsy participated in this. Patients received an infusion of a solution containing either combination of propofol: ketamine (1:1) (Group I) or propofol: ketamine (4:1) (Group II). Subsequent infusion rates to a predetermined sedation level using Ramsay Sedation Scale. Heart rate, noninvasive arterial blood pressure (NIBP), oxygen saturation (SpO2), end tidal carbon dioxide (Etco 2 ) and incidence of any side effects were recorded. Results. There were no significant hemodynamic changes in both groups after induction. However, there was an increase in postoperative nausea, psychomimetic side effects, and delay in discharge times in group I compared to group II. Conclusion. The adjunctive use of smaller dose of ketamine in ketofol combination minimizes the psychomimetic side effects and shortens the time of hospital discharge.
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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.
  1 12,835 759
Use of continuous subglottic suction in established ventilator associated pneumonia
Ahmed A Alsaddique
January-June 2009, 3(1):20-24
Background. Pneumonia is the most common nosocomial infection in intensive care units. Most of ICU­acquired pneumonias occur during mechanical ventilation; about half of them develop in the first four days after intubation. Ventilator-associated pneumonia (VAP) can be a lethal complication as it carries a mortality that may approach 50%. Methods. Continuous subglottic suction was utilized in seventeen post cardiac surgery patients with established VAP as part of the management protocol. These patients were compared with a group of 12 patients who did not have continuous subglottic suction part of their management. Results. Institution of continuous subglottic suction in patients with established ventilator associated pneumonia is of value in reducing the number of ventilator dependent days. It also decreases the likelihood of further deterioration in the pulmonary function and reduces the need for antimicrobial agents. Conclusion. Continuous subglottic suction is beneficial in case of established VAP. It prevents further soilage of the airways, speeds up convalescence and shortens the ICU stay. Ideally, it should be instituted early on in case of prolonged mechanical ventilation as one of the effective measures for the prevention of this kind of pneumonia.
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Comparing oral gabapentin versus clonidine as premedication on early postoperative pain, nausea and vomiting following general anesthesia
Sussan Soltani Mohammadi, Mirsadegh Seyedi
January-June 2009, 3(1):25-28
Background. Prevention and treatment of postoperative pain and postoperative nausea and vomiting (PONV), continue to be a major challenge in the postoperative care. This study was designed to compare the effects of small dose of oral gabapentin versus clonidine as premedication on early postoperative pain and on PONV in patients undergoing elective abdominal surgery under general anesthesia. Methods. In a randomized placebo controlled study, 120 ASA I and II patients scheduled for elective abdominal surgery were randomly assigned to receive either 0.2mg oral clonidine (n=40) or 300mg gabapentin (n=40) or placebo (n=40) 1hr before surgery. They were anesthetized using the same technique. Demographic data, post operative visual analogue scale (VAS), PONV and total morphine consumption by PCA pump were recorded in the recovery room and during first 6 hr after surgery. Results. Two patients in gabapentin compared with 13 patients in clonidine group (p<0.05) and 29 patients in placebo group (p<0.05) had VAS >3 in recovery room. The mean morphine consumptions were 4.75±7.5, 1.95±5.51 and 1.56±1.5mg in placebo, clonidine and gabapentin group with significant differences (P<0.05). These measurements were 18±15.8, 13.1±12.6 and 12.1±12.9 mg respectively during first 6 hr after surgery with significant differences (P<0.05). PONV was not statistically different between the study groups in the recovery room and during first 6 hr after the surgery. Conclusion. This study showed that oral premedication with 300mg gabapentin reduces postoperative pain and total morphine consumption but not PONV during recovery and in the first 6 hr after abdominal surgery.
  1 3,090 518
Respiratory difficulties encountered during posterior fossa exploration
Mohamad Said Maani Takrouri, Mohammad Ismail Saqer, Ayman Al-Banyan
January-June 2009, 3(1):39-40
This report describes an unusual case of obstruction of a reinforced endotracheal tube during posterior Fossa exploration to excise glioma tumor. An 11-year-old male child, scheduled for excision of a glioma in the prone position. The trachea was intubated using a 5.0-mm nylon reinforced latex endotracheal tube (TT). The anesthesiologist ventilated his lungs with a mixture of isoflurane 1.0 MAC in oxygen (35%) and medical air. It was observed that his peak airway pressure was 21 cm H2O at the beginning of anaesthesia, increased to 26 cm H2O over three hours. After that and over 30 min, the peak reached 35 cm H2O, while the end-tidal CO2 pressure was 45 mmHg then gradually increased to 100 mmHg. The anesthesiologists suspected partial obstruction of the tracheal tube (TT). However, the anesthesiologists could not pass a suction catheter through the TT. The anesthesiologist could not advance a suction catheter beyond 8 cm. Re-intubation of the trachea with a 5.5 mm PVC TT relieved the airway obstruction. The termination of surgery allowed to take a chest x­ray which revealed unimpressive marginal pneumothorax which was drained but did not relieved the difficulties. The recording of tissue oxygen saturation and end tidal CO2 were consistent with gradual subtotal obstruction which allowed oxygenation, and delivering inhalational agent but retention of carbon dioxide. In this report we described an unusual incidence of tracheal tube obstruction complicated by presence of small pneumothorax which was successfully treated.
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Ultrasound guided tap block - Have we found the "Gold Standard"?
AA El-Dawlatly
January-June 2009, 3(1):1-1
  - 3,136 446
Bis-guided evaluation of dexmedetomidine vs. midazolam as anaesthetic adjuncts in off-pump coronary artery bypass surgery (OPCAB)
Emad El-Din Mansour
January-June 2009, 3(1):7-14
Background. To assess the efficacy of midazolam and dexmedetomidine as induction agents and adjuncts to anaesthesia during OPCAB surgery. Patients and Methods. 107 patients scheduled for elective OPCAB surgery between 1st of January 2005 to 31 st of December 2007 were enrolled. Patients were randomly allocated into two groups Midazolam group (Group M, n=57) and Dexmedetomidine group (Group D, n=50). Patients in Group D (Dexmedetomidine group) received dexmedetomidine as initial i.v loading dose of 1 µg kg -1 over 1 minute (min) before induction of anaesthesia and 60 µg hr -1 continuous infusion thereafter until the end of surgery. Patients in group M (Midazolam group) received midazolam 0.1 mg kg -1 over 1 min before induction of anaesthesia and 2.5mg hr­ 1 continuous infusion thereafter until the end of surgery. Anaesthesia was maintained with continuous i.v infusion of sufentanil 0.2 µg kg -1 h -1 , study drug infusion at a rate of 10 ml h -1 , and rocuronium 0.5 mg kg-1 h -1 supplemented with sevoflurane as required. Induction doses as well as anaesthetic maintenance supplementation doses were guided by the BIS reading near 50. Data collection included haemodynamic parameters (HR, MAP, CI & SVR), BIS readings (T0-T7) and sevoflurane concentrations (T3-T7) were recorded at the following data points, T0= baseline pre-induction, T1= immediately post-induction T2= during laryngoscopy & intubation, T3= skin incision, T4= sternotomy, T5= during revascularization of the left anterior descending (LAD) artery, T6= during revascularization of the obtuse marginal (OM) artery, T7= with chest closure at conclusion of surgery. Results. 5 patients in Group M and 3 patients in group D were excluded due to diversion to on pump technique. All baseline parameters were comparable among both groups. In group M (52 patients) SVR and BP had significantly decreased following induction (T1) compared to baseline (T0, p<0.0001), while HR and CI had significantly increased during T1 compared to baseline (T0, p<0.0001). Also parameters recorded thereafter were comparable to baseline values. In Group D (47 patients) all parameters recorded were comparable to baseline values with exception of HR that decreased significantly from T1-T7 compared to T0. BIS values recorded were comparable among both groups, however sevoflurane concentrations was significantly higher in Group M compared to group D (P<0.0001). Conclusion. Midazolam can alter hemodynamic response following induction of anaesthesia; however such changes are reversible and returned to baseline. Dexmedetomidine is more haemodynamic stable and more potent anaesthetic adjuvant compared to midazolam in patients undergoing OPCAB surgery.
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Update in anaesthesia service and residency training programme in KSA how far from the target?
Mohammed Abdullah Seraj
January-June 2009, 3(1):29-34
The Kingdom of Saud Arabia provides one of the best health care delivery systems in the Arab world. Both government and private sector have spent vast sums of money to establish, maintain and provide medical facilities all over the Kingdom, Primary, Secondary and Tertiary. The health care system is provided by the ministry of health hospitals (MOHH), the private sector hospitals (PSH) and other government hospitals (OGH). In (2005 G), the total numbers of anaesthetists in all hospitals were 1449 (688, 350 and 411 respectively). The workload of anaesthetist/year was 735 cases, while in (2007 G), the total numbers of anaesthetists were increased to 1640 (806,344 and 490 respectively). The workload of anaesthetist/year was 479 (average 467,313 and 739 cases).There is a slight increase in the numbers of anaesthetists in total but it is still beyond the international recommended number of 1 anaesthetist: 10000 populations The residency training programmes started in the late eighties and the early nineties. Several modern programmes were established in the Arab world. They are:
  1. The first was King Saud fellowship started in 1989 by the author
  2. The second was King Faisal Fellowship in 1993 but the programme ceased.
  3. The Arab Board for the specialty of anaesthesia and intensive care in 1993
  4. The Saudi scientific council for the speciality in anaesthesia and intensive care in 1998.
Recently four post-anaesthetic fellowships were approved. They are cardiac anaesthesia, critical care, paediatrics anaesthesia and pain management.
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