Adeyemi J. Olufolabi

Dosing study of remifentanil and propofol for tracheal intubation without the use of muscle relaxants

Sixty ASA I and II patients, premedicated with midazolam, were administered propofol 2 mg.kg−1 and remifentanil 3 μg.kg−1 (group R3), remifentanil 4 μg.kg−1 (group R4) and remifentanil 5 μg.kg−1 (group R5). Laryngoscopy and intubation were performed 1 min after the administration of the study drugs and the intubating conditions were assessed. Good to excellent conditions were observed in 12 patients in group R3 compared with 19 patients each in groups R4 and R5 (p = 0.004). Significant reductions in mean arterial pressure (MAP) and heart rate (HR) after administration of the study drug were observed in each group, p < 0.01. There was, however, no difference in mean MAP and HR between the three groups at all time points. We conclude that remifentanil 4–5 μg.kg−1 may reliably provide good to excellent conditions for tracheal intubation when administered after propofol 2 mg.kg−1.

A Preliminary Investigation of Remifentanil as a Labor Analgesic

Implications In this preliminary investigation, we evaluated the safety and analgesic efficacy of IV remifentanil for labor pain. Four women were studied, and then the trial was terminated because administration of this novel synthetic opioid produced significant maternal side effects in the absence of effective pain control.

Iliohypogastric-ilioinguinal peripheral nerve block for post-Cesarean delivery analgesia decreases morphine use but not opioid-related side effects

PurposeTo examine if ilioinguinal-iliohypogastric nerve block could reduce the need for post-Cesarean delivery morphine analgesia and thus reduce the incidence of opioid related adverseeffects.MethodsA multi-level technique for performing the nerve block with bupivacaine was developed and then utilized in this two-part study. Part one was a retrospective assessment of Cesarean delivery patients with and without ilioinguinal-iliohypogastric blocks to determine if the technique reduced patient controlled analgesia morphine use and thus would warrant further study. The second phase was a randomized double-blind placebo-controlled trial to compare post-Cesarean morphine use and the appearance of opioid-related side effects between the anesthetic and placebo-injected groups.ResultsBoth phases demonstrated that our method of ilioinguinaliliohypogastric nerve block significantly reduced the amount ofiv morphine used by patients during the 24 hr following Cesarean delivery. In the retrospective assessment, morphine use was 49 ± 30 mg in the block groupvs 79 ± 25 mg in the no block group (P = 0.0063). For the prospective trial, patients who received nerve blocks with bupivacaine had a similar result, self-administering 48 ± 27 mg of morphine over 24 hr compared to 67 ± 28 mg administered by patients who received infiltrations of saline. However, despite the significant decrease in morphine use, there was no reduction in opioid-related adverse effects: the incidences of nausea were 41 % and 46% (P = 0.70) and for itching were 79% and 63% (P = 0.25) in the placebo and nerve block groups, respectively.ConclusionA multi-level ilioinguinal-iliohypogastric nerve block technique can reduce the amount of systemic morphine required to control post-Cesarean delivery pain but this reduction was not associated with a reduction of opioid related adverse effects in our study group.RésuméObjectifVérifier si l’anesthésie par blocage nerveux ilioinguinal et iliohypogastrique peut réduire ies besoins postcésarienne de morphine et l’incidence des effets indésirables des opioïdes.MéthodeUne technique de blocage nerveux multiniveau, avec de la bupivacaïne, a été mise au point et utilisée pour une étude en deux phases. La première consistait en une évaluation rétrospective des accouchements par césarienne avec et sans biocages ilioinguinal et iliohypogastrique dans le but de déterminer si la technique réduit l’usage de morphine autoadministrée, ce qui pourrait justifier des études plus poussées. La seconde phase était un essai, randomisé et contrôlé en double aveugle contre placebo, réalisé pour comparer l’usage intergroupe de morphine postcésarienne et l’apparition d’effets secondaires reliés aux opioïdes.RésultatsPour les deux phases de l’étude, l’anesthésie par blocage nerveux ilioinguinal et iliohypogastrique a permis de réduire significativement la quantité de morphine iv utilisée pendant les 24 premières heures suivant la césarienne. Dans l’évaluation rétrospective, la morphine utilisée a été de 49 ± 30 mg chez les patientes qui ont reçu un bloc vs 79 ± 25 mg, sans bloc (P = 0,0063). Les résultats de l’essai prospectif sont comparables, l’autoadministration de morphine pendant 24 h étant de 48 ± 21 mg et de 67 ± 28 mg avec et sans bupivacaïne, respectivement. Cependant, il n’y a pas eu de réduction des effets indésirables reliés aux opioïdes: les incidences de nausée ont été de 41 % et de 46 % (P = 0,70) et de prurit, 79 % et 63 % (P = 0,25) chez les patientes avec placebo et bloc nerveux, respectivement.ConclusionUn blocage nerveux ilioinguinal et iliohypogastrique a permis de réduire la quantité de morphine à action générale utilisée pour soulager la douleur postcésarienne, mais cette réduction n’a pas été associée à une baisse des effets secondaires reliés aux opioïdes.

Advancing obstetric and neonatal care in a regional hospital in Ghana via continuous quality improvement

To reduce maternal and neonatal death at a large regional hospital through the use of quality improvement methodologies.

Comparison of remifentanil with alfentanil or suxamethonium following propofol anaesthesia for tracheal intubation.

Sixty ASA physical status I and II, premedicated patients were administered propofol 2 mg.kg−1 and remifentanil 2 μg.kg−1 (group R), alfentanil 50 μg.kg−1 (group A) or suxamethonium 1 mg.kg−1 (group S) as a rapid bolus. One minute after study drug administration, tracheal intubation was performed. Intubation conditions were then scored. Excellent or good conditions were observed in only 35% in group R compared with groups S and A (100% and 85%, respectively; p < 0.001). The haemodynamic response to tracheal intubation was blunted in groups R and A compared with group S (p < 0.001). The mean heart rate in groups R and A was significantly lower than group S (p < 0.001). We conclude that remifentanil 2 μg.kg−1 given as a rapid bolus will not produce intubating conditions as good as those obtained with alfentanil 50 μg.kg−1 or suxamethonium 1 mg.kg−1 if administered after propofol 2 mg.kg−1.

A pilot study to compare the Episure Autodetect syringe with the glass syringe for identification of the epidural space in parturients.

The Episure™ AutoDetect™ syringe, a spring-loaded syringe, is a new loss-of-resistance syringe with an internal compression spring that applies constant pressure on the plunger. In this pilot study, we compared the spring-loaded syringe with the standard glass syringe for identification of the epidural space during initiation of epidural analgesia in parturients. The primary outcome was the incidence of failed epidural analgesia. Three-hundred and twenty-five women were enrolled. Eight residents performed 291 procedures (90%) and two attendings performed 34 procedures (10%). Epidural analgesia failed in five subjects in the glass syringe group and in no subject in the spring-loaded syringe group (P = 0.025).

Subarachnoid Meperidine (Pethidine) Causes Significant Nausea and Vomiting during Labor

Background The combined spinal–epidural (CSE) technique using bupivicaine–fentanyl has become an established method of pain control during parturition. One limitation is the relatively short duration of effective analgesia produced by bupivicaine–fentanyl. In contrast, subarachnoid meperidine has been shown to provide a long duration of anesthesia in nonobstetric patients. Therefore, the authors tested the hypothesis that subarachnoid meperidine produces a significant increase in the duration of analgesia compared with bupivicaine–fentanyl. Methods Based on a power analysis of preliminary data, the authors intended to recruit 90 patients for the study, randomized to three groups: 2.5 mg bupivicaine–25 &mgr;g fentanyl, 15 mg meperidine, or 25 mg meperidine. However, after enrolling 34 patients, the study was discontinued because of a significant increase in nausea or vomiting in the study patients. Results Nausea or vomiting was substantially increased in both meperidine groups compared with the bupivicaine–fentanyl group: 16 with nausea or vomiting in the meperidine groups (n = 21), compared with 1 in the bupivicaine–fentanyl group (n = 11), P = 0.0011. The mean duration of analgesia provided by 25 mg meperidine was 126 ± 51 min, compared with 98 ± 29 min for bupivicaine–fentanyl and 90 ± 67 min for 15 mg meperidine. These data were not significant (P = 0.27). Conclusions Although intrathecal meperidine could potentially prolong subarachnoid analgesia during labor, its use was associated with a significant incidence of nausea or vomiting. These data do not support the use of subarachnoid meperidine in doses of 15 or 25 mg for labor analgesia.

Intrathecal morphine for analgesia after postpartum bilateral tubal ligation

Postpartum bilateral tubal ligation (PPBTL) causes postoperative pain. We designed this study to determine the efficacy of 50 &mgr;g intrathecal morphine for analgesia after PPBTL. Sixty-five women received spinal anesthesia with 12.75 mg hyperbaric bupivacaine, 20 &mgr;g of fentanyl, and either 50 &mgr;g of morphine (morphine group) or 0.05 mL of saline (control group). Postoperative analgesia was provided with regular naproxen 500 mg and oxycodone 5 mg/acetaminophen 325 mg mixture as needed. Overall, satisfaction was higher (P = 0.003) and pain was less intense at rest (P = 0.008) and on movement (P < 0.0001) in the morphine group. There was no significant overall difference in nausea, pruritus, or sedation scores, but vomiting occurred more frequently in the morphine group (21.4% versus 3.5%; P = 0.052). In post hoc comparisons, pain at rest within the morphine group was significantly less at 4 h (P = 0.006), pain on movement was significantly less at 4 h (P = 0.002) and 12 h (P = 0.0004), and pruritus was significantly more frequent at 12 h (P = 0.002) compared with the control group. Oxycodone 5 mg/acetaminophen 325 mg mixture consumption was significantly smaller (P = 0.006) and the time to first request of analgesia was significantly longer (P = 0.006) in the morphine group. We conclude that the addition of 50 &mgr;g of morphine to intrathecal hyperbaric bupivacaine and fentanyl provides improved postoperative analgesia in women undergoing PPBTL.

Effect of head posture on tracheal tube position in children

Changes in the tracheal tube tip to carina distance were measured by radiographic screening following various head postures in 45 children undergoing cardiac catheterisation under general anaesthesia who were intubated via nasal and oral routes. Extension of the head moved the tracheal tube away from the carina and flexion moved it towards the carina in both routes. Endobronchial intubation was noted during neck flexion in a significant proportion of children intubated orally but none occurred during nasal intubation. Extension produced greater upward movement of the tracheal tube tip in the oral route than the nasal route. In contrast, flexion produced greater downward movement in the nasal route in some patients. The direction of movement with lateral rotation and use of a shoulder roll was inconsistent.

Impact of intraoperative dexmedetomidine on postoperative analgesia following gynecologic surgery

Abstract Objective: To assess the impact of intraoperative dexmedetomidine infusion on postoperative analgesia in women undergoing major open and laparoscopic gynecologic surgery under general anesthesia. Research design and methods: A retrospective analysis of patients who underwent major open and laparoscopic gynecologic surgery under general anesthesia from January 2007 to October 2008. Patients who received intraoperative opioids with a dexmedetomidine infusion were compared to those who received opioids alone. Patients who received regional anesthesia, remifentanil, or other analgesic adjuncts were excluded. Data were collected in the postanesthesia care unit (PACU) for all patients, and for 24 hours in the open group. Results: A total of 580 women were included in the analysis (293 open surgery [103 dexmedetomidine, 190 controls] and 287 laparoscopic surgery [101 dexmedetomidine, 186 controls]). In the open group, patients who received dexmedetomidine required less opioids intraoperatively and in PACU. However, there was no difference in the duration of PACU stay, opioid consumption from PACU discharge to 24 h or in the need for rescue antiemetics. Pain scores were not different in PACU. In the laparoscopic group, there was no difference between the groups in intraoperative or PACU opioids, pain scores, or need for rescue antiemetics. Patients in the dexmedetomidine laparoscopic group needed less inhaled agents intraoperatively, but stayed longer in PACU. Conclusions: Intraoperative dexmedetomidine infusion provided an opioid sparing effect intraoperatively and in PACU in women undergoing open gynecologic surgery but did not reduce the need for rescue antiemetics or the duration of PACU stay and did not provide any benefit beyond PACU discharge. For laparoscopic surgery, dexmedetomidine infusion did not provide any analgesic benefit. Limitations of the study include its retrospective non-randomized nature, absence of strict protocol for dexmedetomidine administration and lack of data beyond PACU discharge in patients having laparoscopic surgery.