Ahmed Turkistani

Efficacy and Safety of Prophylactic Large Dose of Tranexamic Acid in Spine Surgery: A Prospective, Randomized, Double-blind, Placebo-controlled Study

Study Design. This is a double blind randomized placebo controlled study, after obtaining approval of ethics committee in the hospital and informed written consent, 64 patients were randomized equally into 2 groups (tranexamic acid (TA) and placebo). Objective. To evaluate efficacy and safety of large doses of TA on blood loss during spinal operations. Summary of Background Data. Blood loss associated with spinal operations is a common potential cause of morbidity and often requires blood transfusion which subject patients to the known risks of blood transfusion including transmission of diseases. TA is used routinely to reduce bleeding in cardiac, orthopaedic, and hepatic surgery, however, its use in neurosurgery is uncommon and only few studies reported the use of antifibrinolytic drugs in spine surgery. Methods. Sixty-four consecutive patients undergoing spinal surgery with expected significant blood loss at King Khalid University Hospital between June 2005 and December 2006 were randomly assigned to 2 groups, TA and placebo. Shortly after the induction of anesthesia, patients received either TA or placebo as a loading dose of 2 g (for adults) or 30 mg/kg (for children), followed immediately by continuous infusion of 100 mg/h (for adults) or 1 mg/kg/h (for children) during surgery and for 5 hours after the operation. Outcome measures included total (i.e., intraoperative and postoperative) blood loss, amount of blood transfusion, as well as postoperative hemoglobin, and hematocrite levels. The data were analyzed by means of Statistical Package for the Social Science Version 12.0. The results were presented as mean ± SD. Independent Student t test was used to compare the 2 groups and differences were considered significant if the P-value was <0.05. Results. There were 39 males and 25 females, ranging in age from 4 to 86 years with a mean of 51 and median of 56 years. Eighteen patients had multilevel anterior cervical discectomies with or without internal fixation, 22 patients had decompressive surgery (12 laminectomies and 10 intersegmental decompressions) for multiseg- ment spinal stenosis, 15 patients had laminectomy with posterior spinal fixation, and remaining 9 patients had laminectomy and excision of spinal tumor. Statistical analysis showed no significant differences between the 2 study groups with regard to age, sex, weight, preoperative hemoglobin, and hematocrite levels, type of surgery, as well as operative time. In contrast, patients who received TA had 49% reduction of blood loss (P < 0.007) and required 80% less blood transfusion (P < 0.008) than patients who received placebo. The hospital stay was shorter in the TA group, but it did not achieve statistical significance. There were no complications related to the use of large doses of TA in this study. Conclusions. Prophylactic use of large doses of TA provides an effective, safe, and cheap method for reducing blood loss during and after spinal operations. Hence, TAmay help in reducing not only transfusion related complications but also operative expenses. Considering the limited number of patients in this study, our results need, however, to be validated on a larger number of patients, probably in a multicenter study.

Anesthesia for thoracic surgery: a survey of middle eastern practice.

Purpose: The main objective of this survey is to describe the current practice of thoracic anesthesia in the Middle Eastern (ME) region. Methods: A prospective online survey. An invitation to participate was e-mailed to all members of the ME thoracic-anaesthesia group. A total of 58 members participated in the survey from 19 institutions in the Middle East. Questions concerned ventilation strategies during one-lung ventilation (OLV), anesthesia regimen, mode of postoperative analgesia, use of lung isolation techniques, and use of i.v. fluids. Results: Volume-controlled ventilation was favored over pressure-controlled ventilation (62% vs 38% of respondents, P<0.05); 43% report the routine use of positive end-expiratory pressure. One hundred percent of respondents report using double-lumen tube (DLT) as a first choice airway to establish OLV. Nearly a third of respondents, 31.1%, report never using bronchial blocker (BB) in their thoracic anesthesia practice. Failure to pass a DLT and difficult airway are the most commonly cited indications for BB use. Regarding postoperative analgesia, the majority 61.8% favor thoracic epidural analgesia over other techniques (P<0.05). Conclusions: Our survey provides a contemporary snapshot of the ME thoracic anesthetic practice.

Laryngeal mask airway vs. uncuffed endotracheal tube for nasal and paranasal sinus surgery: paediatric airway protection.

Background and objective Risks are anticipated for laryngeal mask airway (LMA) anaesthesia during nasal and sinus surgeries because blood can trickle posteriorly into the hypopharynx and contaminate the airway. This study was conducted to determine whether a LMA could provide adequate airway protection from the expected intraoperative bleeding. Methods After obtaining ethics committee approval, 60 children ASA status I or II, 1–12 years of age, and scheduled for nasal and sinus surgery were randomized to one of two groups, endotracheal tube (ETT) or LMA, with 30 patients in each. Topical lidocaine with adrenaline was used in all patients, and throat packs were used for the ETT group. The airway was examined using a fibreoptic endoscope in order to determine whether blood or tissue debris soiled the supraglottic airway or trachea. After extubation, LMAs and ETTs were examined for soiling by blood and graded on a scale of 0–3. For ETT, the grades were 0, none; 1, contamination above the mark for vocal cord depth; 2, contamination below the mark for vocal cord depth; and 3, contamination interiorly. For LMA, they were 0, no staining; 1, staining on the anterior aspect of the cuff of the LMA; 2, staining inside the cup of the LMA; and 3, staining found in the tube. Results Blood stains were found in the larynx of one child in the LMA group. In the ETT group, there were three cases of staining (two supraglottic and one in the trachea, P = 0.161). With the LMA, 12 (40%) and 18 (60%) patients had visual contamination scores of 0 and 1, respectively. With the ETT, 14 (46.7%), 10 (33.3%), and six (20%) patients had visual contamination scores of 0, 1, and 2, respectively (P = 0.0123). Conclusion LMA is a suitable method for paediatric patients undergoing sinonasal surgery because it offers airway protection from blood contamination comparable to that of a standard uncuffed ETT with throat pack.

Effect of fluid preloading on postoperative nausea and vomiting following laparoscopic cholecystectomy.

Background: Postoperative nausea and vomiting (PONV) is a common complication following general anesthesia. Different regimens have been described for the treatment of PONV with few that mention the prevention of it. Therefore, we conducted this study to compare the effect of preloading with either crystalloids or colloids on the incidence of PONV following laparoscopic cholecystectomy (LC), under general anesthesia. Materials and Methods: This study was carried out on 80 patients who underwent LC. The patients were divided into four groups (each 20 patients), to receive preloading of intravenous fluid, as follows: Group 1 received, 10 ml/kg of low-MW tetrastarch in saline (Voluven™), group 2 received, 10 ml/kg medium-MW pentastarch in saline (Pentaspan™), group 3, received 10 ml/kg of high-MW heta-starch in saline (Hespan™), and group 4, received 10 ml/kg Lactated Ringers, and this was considered as the control group. All patients received the standard anesthetic technique. The incidence of PONV was recorded, two and 24 hours following surgery. The need for antiemetics and/or analgesics was recorded postoperatively. Results: The highest incidence of PONV was in group 3 (75% of the patients) compared to the other three groups. Also the same trend was found with regard to the number of patients who needed antiemetic therapy. It was the highest incidence in group 3 (70%), followed by group 2 (60%), and then group 1(35%), and the least one was in the control group (25%). Conclusion: Intravascular volume deficits may be a factor in PONV and preloading with crystalloids showed a lower incidence of PONV.

Metabolic, hormonal and gastric fluid and pH changes after different preoperative feeding regimens

Purpose: To evaluate the metabolic, hormonal and gastric fluid and pH changes after administration of a small volume of different preoperative feeding regimens.Methods: In a prospective, randomized, double-blind study 375 adult patients were allocated to one of five groups. Patients ingested 60 ml honey, glucose-fructose-sucrose-maltose mixture (GFSM), apple juice or water two hours before surgery or continued their overnight fast (controls). Blood samples were obtained from an indwelling venous catheter before the administration of feeding regimens and before induction of anesthesia for determination of glucose, triglycerides, insulin, epinephrine and norepinephrine concentrations. Before anesthesia induction, patients were asked to grade the degree of thirst and hunger. After tracheal intubation residual gastric volume (RGV) was suctioned through an orogastric tube.Results: Administration of honey, GFSM, apple juice or water resulted in increases in RGV without changes in the gastric pH. The median RGV values were 15 ml in controls and 20–25 ml in other groups. Thirst was noted after administration of fluids containing sugars. Hunger was noted in the apple juice group. Plasma concentrations of glucose increased and triglycerides decreased after ingestion of fluids containing sugars. Plasma insulin concentrations decreased in GFSM and apple juice groups. Norepinephrine concentrations increased in the control, apple juice and water groups.Conclusions: Small volumes of fluid increased RGV (P<0.05). Apple juice resulted in increased incidence of thirst and hunger and plasma glucose and norepinephrine concentrations. Compared with GFSM or apple juice, honey had a gentler effect on plasma glucose and insulin concentrations.RésuméObjectif: Évaluer les changements métaboliques et hormonaux ainsi que les modifications des liquides et du pH gastrique suivant l’administration d’un faible volume de différentes prescriptions alimentaires.Méthode: L’étude prospective, randomisée et à double insu a été réalisée auprès de 375 patients adultes répartis au hasard en cinq groupes. Les patients ont pris 60 ml de miel, d’un mélange de glucose-fructose-sucrose-maltose (GFSM), de jus de pomme ou d’eau, deux heures avant une intervention chirurgicale, ou ils sont restés à jeun toute la nuit (témoins). Du sang a été prélevé par cathéter veineux à demeure, avant de donner les liquides et avant l’induction de l’anesthésie, pour déterminer les taux de glucose, de triglycérides, d’insuline, d’adrénaline et de noradrénaline. Les patients ont gradué leur faim et leur soif avant l’induction de l’anesthésie. Après l’intubation endotrachéale, le volume gastrique résiduel (VGR) a été aspiré dans un tube orogastrique.Résultats: L’administration de miel, d’un mélange de GFSM, de jus de pomme ou d’eau a fait augmenter le VGR sans changer l’acidité gastrique. Le VGR moyen a été de 15 ml dans le groupe témoin et de 20–25 ml dans les autres groupes. La soif a été notée après l’administration de liquides socrés et a faim, avec l’ingestion de jus de pomme. Les concentrations plasmatiques de glucose ont augmenté et celles des triglycérides ont diminué après l’ingestion de liquides sucrés. Le taux plasmatique d’insuline a baissé avec le GFSM et le jus de pomme. Celui de la noradrénaline a diminué chez les témoins, et avec le de jus de pomme et l’eau.Conclusion: Des volumes faibles de liquides augmentent le VGR (P <0.05). Le jus de pomme provoque une incidence accrue de faim et de soif et une augmentation des concentrations plasmatiques de glucose et de noradrénaline. Comparé au GFSM ou au jus de pomme, le miel a un effet plus modéré sur les concentrations plasmatiques de glucose et d’insuline.

Variations in dynamic lung compliance during endoscopic thoracic sympathectomy with CO2 insufflation

Abstract.Endoscopic thoracic sympathectomy (ETS) is the preferred surgery for treatment of intractable palmar hyperhidrosis (PH). General anesthesia with onelung collapsed ventilation (OLCV) using single-lumen tracheal tube (SLT), is our preferred anesthetic technique for ETS. Intrapleural CO2 insufflation (capnothorax) was used to ensure lung collapse. The current study examined the effects of capnothorax on dynamic lung compliance (DLC) of the ventilated lung during ETS. After obtaining written informed consent, 10 adult male patients ASA I&II undergoing ETS were studied. Their average age and weight were 25 ± 7 yr and 67 ± 8 kg. General anesthesia with SLT and OLCV technique was used. Capnothorax with intrapleural pressure (IPP) of 10 mmHg was initially used, then it was reduced and maintained at 5 mmHg throughout the operation. Anesthesia delivery unit (Datex Ohmeda type A_Elec, Promma, Sweden) was used where airway pressures and DLC were displayed during OLCV. A computer program (SPSS 9.0 for Windows; SPSS Inc., Chicago, IL) was used for statistical analysis of the data obtained. One way analysis of variance (ANOVA) was used for analysis of data before, during and after OLCV. P<0.05 was considered significant. The mean values of the DLC were 52 ± 6, 30 ± 3, 39 ± 5 and 53 ± 9 ml/cmH2O before, during (at 10 and 5 mmHg IPP) and after OLCV respectively with significant differences before and at 10 and 5mmHg IPP. In conclusions, during OLCV and capnothorax for ETS, DLC tends to decrease with increasing of intrapleural CO2 insufflation pressure. However, in short procedures it has no deleterious postoperative effect. To the best of our knowledge this is the first study performed to investigate DLC changes during OLCV with capnothorax.

Comparison of the outer diameter of the 'best-fit' endotracheal tube with MRI-measured airway diameter at the cricoid level.

Background and objective In this study, we evaluated the ratio of the outer diameter of an uncuffed Mallinckrodt endotracheal tube (ETT, Mallinckrodt Tyco Healthcare UK Ltd) to the MRI-measured internal transverse airway diameter (ITD) at the cricoid level in children. Methods With institutional ethics committee approval and parental consent, we measured the ITD at the cricoid level from MRI images of children undergoing MRI diagnostic procedures requiring general anaesthesia with orotracheal intubation. The ITD at the cricoid level was compared with the outer diameter of the utilized ETT. Linear regression analysis was employed to assess the correlation of tracheal diameter with age, height and weight. For all tests, a P value of less than 0.05 was considered to be statistically significant. Results Fifty patients were studied (21 girls and 29 boys). The difference between the ITD at the cricoid level and the outer tracheal tube diameter ranged from 0.1 to 1.7 mm (median 0.7 mm). The internal transverse tracheal diameters had a strong association with age (r2 = 0.7077, P < 0.001), a moderate association with height (r2 = 0.5928, P < 0.001), and a mild association with weight (r2 = 0.2437, P < 0.001). Conclusion The outer diameter of the ‘best-fit’ ETT was less than the ITD at the cricoid level by 0.1–1.7 mm. The correlation of the outer diameter of the ‘best-fit’ ETT with age was stronger than with height or weight.