Ahmed M. Omar

Postoperative continuous transversus abdominis plane block vs continuous wound infusion of levobupivacaine in females undergoing open gynecologic procedures

Abstract Introduction Transversus abdominis plane (TAP) block is used as a part of multimodal analgesia in decreasing pain of lower abdominal wall incision. Local anesthetic instillation of wounds through subcutaneous or subfascial catheters is used to treat postoperative pain in different types of surgery. The aim of this randomized controlled trial was to study the opioid-sparing effect of these two techniques (if any) compared to placebo in women undergoing gynecologic procedures through transverse lower abdominal incisions. Methods Seventy-eight ASA I–III patients planned to undergo gynecologic procedures through a transverse lower abdominal incision were randomly divided into three equal groups: Control (C) group (n = 26), Continuous Wound Infusion (CWI) group (n = 26), and continuous transversus abdominis plane block (TAP) group (n = 26). After standardized general anesthetic and before extubation, the patients were given the allocated treatment. A morphine patient-controlled analgesia (PCA) was started postoperatively alongside with the local anesthetic (or placebo) infusion. Cumulative dose of morphine PCA in the first postoperative 48 h was the primary outcome. Secondary outcomes included visual analog pain score (VAS) at rest and on movement and complications of morphine PCA. Results The cumulative dose of morphine PCA in the first postoperative 48 h was higher in control group than in groups CWI and TAP (P < 0.001). However, no significant difference was found between groups CWI and TAP. No significant differences were found among the three groups regarding VAS during rest but TAP group showed less pain scores than groups C and CWI on movement. The three groups were similar regarding morphine side effects. Conclusion Continuous bilateral TAP block and CWI can decrease PCA morphine consumption in the first postoperative 48 h when compared to placebo in women undergoing gynecologic surgery through transverse lower abdominal incision. Continuous TAB block might give better analgesia with movement than CWI.

Role of ketamine and tramadol as adjuncts to bupivacaine 0.5% in paravertebral block for breast surgery: A randomized double-blind study

Abstract Background Use of adjuncts to local anesthetics is believed to enhance the quality and duration of the peripheral nerve blocks. We tested the hypothesis that addition of ketamine or tramadol to bupivacaine 0.5% in PVB for patients undergoing modified radical mastectomy would enhance postoperative analgesia. Methods We prospectively randomized 60 ASA I–III women into three groups: group B (n = 20) who received PVB using plain bupivacaine 0.5% (control group), group K (n = 21) who received ketamine (0.5 mg kg−1) added to bupivacaine 0.5%, and group T (n = 19) who received tramadol (1.5 mg kg−1) added to bupivacaine 0.5%. All the patients were then given a standardized general anesthesia. Primary outcome was the cumulative fentanyl dose given through patient-controlled analgesia (PCA) device in the first 24 h after surgery. Secondary outcomes included dose of fentanyl in the postanesthesia care unit (PACU), time to first dose of fentanyl, and visual analogue scale (VAS) pain scores in PACU and ward. Results The three groups were found to be similar in the cumulative dose of PCA fentanyl in the first 24 h (P = 0.62). They were also similar in terms of doses of fentanyl used in PACU (P = 0.87), time to first dose of fentanyl requested (P = 0.57), and VAS pain scores at all time points (P > 0.05). Conclusion We concluded that addition of ketamine (0.5 mg kg−1) or tramadol (1.5 mg kg−1) to bupivacaine 0.5% in PVB for modified radical mastectomy do not have any analgesia-enhancing effect.

Can systemic lidocaine be used in controlled hypotension? A double-blinded randomized controlled study in patients undergoing functional endoscopic sinus surgery

Abstract Introduction Functional endoscopic sinus surgery (FESS) is one of the operations that need controlled hypotension. Many drugs were successfully used in this purpose, e.g., magnesium sulfate, esmolol, and volatile anesthetics. Hypotension was observed to occur after submucosal injection of lidocaine. Based on this observation, it was hypothesized in this double-blinded randomized controlled study that lidocaine may be effective in producing controlled hypotension. Methods Forty-eight ASA I–II adults planned to undergo FESS were given a standard general anesthetic after which they were divided into 2 equal groups to receive either lidocaine infusion in a dose of 1.5 mg/kg/h (group L, n = 24) or equal volumes of normal saline (group C, n = 24). Primary outcome was the surgical field rating score (0–5 points). Secondary outcomes included hemodynamic parameters, extubation time, end-tidal sevoflurane concentrations, fentanyl consumption, and postoperative visual analog pain scores (VASs). Results Both groups were similar regarding hemodynamic parameters. Surgical field scores were significantly lower in group L than in group C at all intraoperative time points (P < 0.05). Extubation time was significantly longer in group C than in group L [group C: 12.4(2.3) min and group L: 9.1(3) min, P = 0.03]. Intraoperative fentanyl dose was significantly higher in group C than in group L [group C: 172(37) mcg and group L: 149(34) mcg, P = 0.03]. End-tidal sevoflurane concentrations were significantly lower in group L than in group C at most intraoperative time points (P < 0.05). Postoperative VAS pain scores in the PACU were higher in group C than in group L (P < 0.05). Conclusion This study showed the ability of intravenous lidocaine infusion of 1.5 mg/kg/h to produce controlled hypotension in patients undergoing FESS and the superiority of this technique over placebo to achieve favorable surgical field scoring.

Psoas compartment block for acute postoperative pain management after hip surgery in pediatrics: a comparative study with caudal analgesia.

Background: Lower-limb peripheral nerve blocks in pediatrics have gained much more popularity in the last few decades. Our purpose of this study was to compare the postoperative analgesic effects between psoas compartment block (PCB) and caudal block in small children undergoing open hip reduction/osteotomies. Methods: Forty American Society of Anesthesiologists physical status I-II children aged 1 to 6 years planned to undergo open hip reduction/osteotomies were administered general anesthesia and then randomly assigned to receive 1 of 2 regional anesthetics: caudal block (group C, n = 20) or PCB (group P, n = 20). Ropivacaine 0.25% with epinephrine (5 &mgr;g/mL) was used in both blocks. The primary outcome of the study was the total consumption of morphine in the first 24 postoperative hrs. Secondary outcomes included dose of intraoperative fentanyl, occurrence of intraoperative hypotension or bradycardia, postoperative pain scores, time to first morphine analgesia, and occurrence of postoperative vomiting or urine retention. Results: The cumulative dose of morphine administered in the ward in the first postoperative 24 hrs and the time to first rescue morphine dose were higher in group C than in group P (P < 0.001). There were no differences between the 2 groups regarding intraoperative and postoperative complications except for the incidence of urine retention, which was higher in group C than in group P (P = 0.037). Conclusions: Use of single-shot PCB is superior to single-shot caudal block regarding length of postoperative analgesia and cumulative dose of morphine in small children undergoing open hip reduction/osteotomies.

A comparative study between magnesium sulphate and dexmedetomidine for deliberate hypotension during middle ear surgery

Abstract Background This study was designed to compare magnesium sulphate with dexmedetomidine, regarding their efficiency in inducing deliberate hypotension and providing a better surgical field exposure during middle ear surgery. It also compared the influence of their use on postoperative pain and recovery time. Methods Eighty-eight adult patients undergoing middle ear surgery were included. Patients were randomly divided into two equal groups. Patients were assigned to receive either magnesium sulphate (M group) or dexmedetomidine (D group). Anaesthesia was induced by propofol 2 mg/kg iv and fentanyl 1 μg/kg. Patients in the M group received an iv bolus of magnesium sulphate 50 mg/kg in a total of 100 ml saline over 10 min followed by infusion of 15 mg/kg/h until the end of surgery. Similarly, patients in the D group received dexmedetomidine 1 μg/kg over 10 min followed by 0.4–0.8 μg/kg/h until the end of operation. The target MAP during operation was between 60 and 70 mmHg. The surgeon who was blinded of the selected hypotensive agent was asked to assess the quality of the surgical field. In the postanaesthesia care unit (PACU), postoperative pain was assessed and recovery time was recorded. Results Both study drugs succeeded to reach the target MAP. The quality of the surgical field was not different between the two groups. Postoperative pain was not different between the two group and only eight patients in the M group and seven patients in the D group required analgesics. Recovery time was significantly longer for the patients in group D (p < 0.05). Conclusion We concluded that both magnesium sulphate and dexmedetomidine successfully induced deliberate hypotension in patients undergoing middle ear surgery but magnesium sulphate was associated with shorter recovery time and earlier discharge from the PACU.

Effect of intravenous lidocaine infusion on sevoflurane requirements as monitored by bispectral index: A randomized double-blinded controlled study

Abstract Introduction Systemic administration of lidocaine significantly decreased propofol requirements when compared to patients receiving placebo. Several studies conducted on animals have proved that systemic local anesthetics reduced minimum alveolar concentration (MAC) of inhalational anesthetics. The aim of this investigation is to study the effect of intravenous administration of lidocaine on the minimum alveolar concentration of sevoflurane required to keep BIS between 40 and 60 during maintenance of anesthesia in humans. Methods Twenty-eight ASA I–II adults planned to undergo laparoscopic procedures expected to last <2 h under general anesthesia were randomly assigned to 2 groups. After standardized induction of general anesthesia, patients were given IV lidocaine bolus (1.5 mg kg−1) followed by 2 mg kg−1 h−1 infusion (group L, n = 14) or equal volumes of saline (group C, n = 14). Primary outcome of the study was end-tidal sevoflurane at bispectral index (BIS) values of 40–60. Secondary outcomes included doses of opioids, BIS values, and extubation time. Results The median doses of intraoperative fentanyl (range) in group C were similar to group L (P = 0.08). There were no significant differences between the 2 groups regarding BIS at any time point. End-tidal sevoflurane concentrations were significantly higher in group C than in group L at all intraoperative time points (P < 0.05). Extubation time was longer in group L than in group C (P = 0.04). Conclusion In conclusion, intravenous lidocaine administration, during maintenance of general anesthesia, can decrease BIS-guided sevoflurane requirements.

Effect of systemic lidocaine infusion on train-of-four ratios during recovery from general anesthesia

Abstract Introduction In spite of introduction of intermediate-acting neuromuscular blocking drugs (NMBDs), incidence of postoperative residual muscle weakness is still high. The aim of this trial is to study the effect of systemic lidocaine infusion on intraoperative consumption of rocuronium and TOF ratios at extubation and on arrival to postanesthesia care unit (PACU). Methods Forty-six ASA I–III patients aged 16–60 yr were randomly allocated into two groups: lidocaine (L) group (n = 23) and control (C) group (n = 23). After induction of standard endotracheal general anesthesia with fentanyl, propofol and rocuronium, patients of group L were given i.v. lidocaine bolus (1.5 mg kg−1) followed by continuous infusion (1.5 mg kg−1 h−1) till time of endotracheal extubation while patients in group C were given equal volumes of normal saline. Rocuronium was titrated based on clinical signs. On conclusion of surgery, neostigmine was given to reverse the effects of rocuronium if TOF count was two or more. Immediately before extubation, TOF ratio was measured and recorded and considered the primary outcome. Results There were no significant differences between the two study groups regarding intraoperative fentanyl doses or core temperature at the end of surgery. End-tidal sevoflurane concentrations were significantly lower in group L than in group P (P < 0.01). The dose of rocuronium was significantly less in group L than in group C (P = 0.001). Train-of four ratios were significantly higher in group L than in group C either before extubation (P < 0.001) or on arrival to PACU (P = 0.001). Conclusion The current study shows that intraoperative use of i.v. lidocaine infusion in generally anesthetized patients can result in higher TOF ratios at time of extubation and on arrival to PACU when rocuronium was given based on clinical signs.

Does pressure support ventilation improve the postoperative outcome of adeno-tonsillectomy patients? A prospective randomized trial

Abstract Background Spontaneous ventilation (SV) is used for adeno/tonsillectomy in children. However, inhalational anesthetics produce dose dependent decrease in minute ventilation. We tested the impact of PSV on awakening time, and length of PACU stay. Methods 34 patients were randomized into two groups; PS ventilation group and SV group. Premedication and induction were similar in both groups. Patients in PS group were ventilated with Pinsp set to deliver 8 ml/kg VT, keeping ETCO2 between 35 and 45 mmHg. Any episodes of hypoventilation were recorded and corrected by manual support of ventilation. Upon completion of surgery, time-to-extubate was recorded. Length of PACU stay, agitation and CHEOPS scores, PONV and desaturation episodes were also recorded. Results are presented as mean (SD), median (interquartile range), or number of patients as appropriate. A P value < 0.05 was considered significant. Results Extubation time (min) [mean (SD)] was longer in SV group than PS group [7.8 (2.1) vs. 5.5(1.4), P < 0.001]. In the SV group 9 patients had episodes of hypoventilation that necessitated manual assist of ventilation. Pain scores were higher in SV group than PS group. Duration of stay in PACU [mean (SD)] in minutes was longer in SV group than PS group [44.3(7.4) vs. 39.4(5.7), P = 0.02]. All but one patient in the PS group needed postoperative rescue meperidine analgesia. The mean (SD) time needed for rescue meperidine analgesia was 27.1(8.9) in PS group and 21.8(9.4) in SV group (P = 0.04). Conclusion PSV carries the advantages of overcoming the effects of narcotics and inhaled anesthetics on spontaneously ventilated adeno-tonsillectomy patients. They suffer less pain and spend less time in the PACU.

Comparative study between propof, ketamine and their combination (ketofol) as an induction agent

Abstract Introduction: Ketofol is a new combination formed by mixing ketamine and propofol. This mixture was used for procedential sedation. However, little is known about its hypnotic characteristic as an induction agent. Methods: Sixty patients were allocated into three equal groups (20 patients each) subjected to hernia repair surgeries under general anesthesia. These patients were anesthetized using propofol (group P), ketamine (group K) and ketofol (group KP) as induction agents. The time needed for loss of verbal contact, eyelash reflex and their corresponding BIS values were recorded. Mean arterial blood pressure and heart rate were measured. Incidence of apnea, postoperative nausea and vomiting, awareness and hallucination were noted. Results: The time needed for loss of verbal contact and eyelash reflex was earlier in group P followed by group KP and group K, respectively, the difference was statistically significant. After induction, MAP decreased in group P, increased in group K while it remained comparable to baseline in group KP. The difference between groups was statistically significant. After intubation MAP increased in the three groups, it was comparable between KP and P groups but remained significantly higher in K group. After induction, HR decreased in P group, increased in K group while it remained comparable to baseline in KP group. The difference between groups was statistically significant. After intubation HR increased in the three groups, it was significantly higher in group K in comparison to groups P and KP, and as regards KP group HR was significantly higher than P group. Afterwards, HR decreased in the three groups and remained stable and comparable for the rest of the surgical time. The Bispectral index readings of ketofol group showed intermediate values between the other two groups. Conclusion: Ketofol is a safe, effective alternative induction agent that lacks many side effects of its two components.