Alaa El-Deeb

Can thoracic paravertebral block replace thoracic epidural block in pediatric cardiac surgery? A randomized blinded study

To compare the outcomes of thoracic epidural block with thoracic paravertebral block for thoracotomy in pediatric patients. A prospective double-blind study. 60 pediatric patients aged 1-24 months, ASA II, III scheduled for thoracotomy were randomly allocated into two groups. After induction of general anesthesia, thoracic epidural catheter was inserted in group E (epidural) patients and thoracic paravertebral catheter was inserted in group P (paravertebral) patients. Post operative pain score was recorded hourly for 24 hours. Plasma cortisol level was recorded at three time points. Tidal breathing analysis was done preoperatively and 6 hours postoperatively. Analgesia, serum cortisol level, and pulmonary function parameters were comparable in the two groups. However, failure rate (incorrect placement of catheter) was significantly higher in epidural group than in paravertebral group (7% versus 0%, respectively). The complications were also significantly higher in epidural group (vomiting 14.8%, urine retention 11.1% and hypotension 14.8%) than paravertebral group (0%, 0%, and 3.6%, respectively). We conclude that both thoracic paravertebral block and thoracic epidural block results in comparable pain score and pulmonary function after thoracotomy in pediatric patients; the paravertebral block is associated with significantly less failure rate and side effects.

The outcome of thoracic epidural anesthesia in elderly patients undergoing coronary artery bypass graft surgery

Background: Thoracic epidural anesthesia (TEA) improves analgesia and outcomes after a cardiac surgery. As aging is a risk factor for postoperative pulmonary complications, TEA is of particular importance in elderly patients undergoing coronary artery bypass graft (CABG). Methods: Fifty patients aged 65–75 years; ASA II and III scheduled for elective CABG were included in the study. Patients were randomized to receive either general anesthesia (GA) group alone or GA combined with TEA group. Heart rate (HR), mean arterial pressure (MAP), and central venous pressure were recorded. Total dose of fentanyl μg/kg, aortic cross clamping, cardiopulmonary bypass (CPB) time, time to first awaking and extubation, arterial blood gases, visual analog scale (VAS) score in intensive care unit were reported. Postoperative pulmonary function tests were done. Results: TEA showed a significant HR and lower MAP compared with the GA group. The total dose of intraoperative fentanyl and nitroglycerine were significantly lower in the TEA. Patients in TEA group have statistically significantly higher PaO2, lower PaCO2, increase in Forced Vital Capacity (FVC) and Forced Expiratory Volume in one second (FEV1) Conclusions: TEA reduced severity of postoperative pulmonary function and restoration was faster in TEA group in elderly patients undergoing CABG. Also, it resulted in earlier extubation and awakening, better analgesia, lower VAS.

Could ephedrine replace meperidine for prevention of shivering in women undergoing Cesarean Section under spinal anesthesia? A randomized study

Abstract Purpose To compare possible unlabeled effect of ephedrine, as shivering prophylaxis, with meperidine during spinal anesthesia for Cesarean Section. Methods After institutional ethical committee approval, 96 parturients scheduled for elective cesarean delivery under spinal anesthesia were randomly allocated according to shivering prophylaxis to receive either 15 mg meperidine (group M, n = 48) or 6 mg ephedrine (group E, n = 48) intravenously before spinal block. Incidence and intensity of shivering as well as side effects of either drug were assessed. Results The incidence shivering in meperidine and ephedrine groups in women undergoing Cesarean Section under spinal anesthesia was comparable (27%, 29% respectively, P = 0.06). Also, intensity of shivering was not different between two groups. Moreover, phenylephrine requirement and incidence of nausea and vomiting were significantly less in ephedrine group (121 ± 2.2% and 4.1% respectively) relative to meperidine group (168 ± 3.2% and 16.6% respectively). Conclusion The prophylactic use of a low dose ephedrine is effective as meperidine for shivering prophylaxis in women undergoing Cesarean Section under spinal anesthesia as meperidine. Moreover, it is associated with less hypotension, nausea and vomiting.

Prophylactic multimodal antiemetic in women undergoing cesarean section under spinal anesthesia

Abstract Background To find out the cost effective antiemetic drug combination as a prophylaxis against nausea and vomiting during regional anesthesia for cesarean section. Methods After the gaining of institutional ethical approval, 240 parturients scheduled for elective cesarean delivery under spinal anesthesia were randomly allocated to receive either 2 mg granisetron plus 8 mg dexamethasone (group II) IV immediately after clamping of the fetal umbilical cord or 2 mg midazolam plus 8 mg dexamethasone (group III) IV or placebo (group I). Results The use of rescue antiemetic medication, which indicates either vomiting or severe nausea, in the post delivery period intraoperatively was 37%, 14%, 23% in group I, II and III, respectively. These values are significantly less than the corresponding values during the first 24 h after surgery which was 20%, 7%, 13%, respectively. No clinically serious adverse events were observed in any of the groups. Conclusion The prophylactic use of a granisetron/dexamethasone combination is better than midazolam/dexamethasone for reducing nausea and vomiting in patients during and after spinal anesthesia for cesarean section.

Evaluation of combination antiemetic prophylaxis in high risk emetogenic patients undergoing thyroid surgery: A randomized double-blind study

Abstract Background This study was designed to find out the effective antiemetic drug for prevention of postoperative nausea and vomiting in high risk emetogenic patients undergoing thyroid surgery. Patients and methods One hundred twenty patients, ASA I, II, subjected to elective thyroid surgery were enrolled in this study. Patients were randomly assigned, according to antiemetic prophylaxis, into three groups, each consisted of 40 patients. Patients received 4 mg ondansetron plus 8 mg dexamethasone (Group II) i.v. or 2 mg midazolam plus 8 mg dexamethasone (Group III) i.v. or saline (Group I) just after induction of anesthesia. Frequency of nausea, vomiting, the use of antiemetics, the complete response (defined as no PONV and no administration of rescue antiemetic drug) were recorded at three time points (6 h, 12 h, 24 h) postoperatively. Results We found that ondansetron/dexamethasone or midazolam/dexamethasone significantly increased the complete response, compared with placebo, with an incidence of 90%, 85%, and 22.5%, respectively at 6 h, 90%, 87.5%, 25%, respectively, at 12 h and 95%, 92.5%, 47.5%, respectively at 24 h postoperatively. Conclusion We conclude that the prophylactic use of ondansetron/dexamethasone or midazolam/dexamethasone, compared with placebo, was effective for reducing nausea and vomiting in patients undergoing thyroid surgery. Midazolam/dexamethasone is preferred due to its cost relative to ondansetron/dexamethasone.

Transversus abdominis plane block versus caudal block for postoperative pain control after day-case unilateral lower abdominal surgeries in children: a prospective, randomized study

Background The transversus abdominis plane (TAP) block is a relatively simple technique that may prove useful in the management of postoperative pain. It decreases the amount of intraoperative and postoperative opioid requirements after surgery. Caudal block is a gold standard technique in pediatric surgeries. Patients and methods Seventy-five children aged 1–7 years with ASA I or II scheduled for day-case unilateral lower abdominal surgeries were randomly allocated to two groups: group C (caudal block) and group T (TAP block). Group C received caudal 0.25% bupivacaine at 1 ml/kg and group T received 0.25% bupivacaine at 1 ml/kg. Time to first analgesic request, total intraoperative fentanyl consumption, postoperative tramadol requirement, sedation level, parent satisfaction scores, pain score, postanesthetic care unit time and day-surgery unit time, and side effects were reported. Results The two groups were comparable in terms of total intraoperative fentanyl consumed, postoperative tramadol requirement, postoperative pain scores, time to first administration of rescue analgesia, and postanesthetic care unit time. Children in the TAP group were discharged home significantly earlier than those in the caudal group (306.8 ± 18 vs. 259 ± 22.4 min with P < 0.001). More children in the caudal group experienced vomiting when compared with the other group. Parent satisfaction score was statistically significantly higher in the TAP group when compared with the caudal group [80 (70–90) vs. 95 (80–95) with P < 0.001]. Conclusion TAP block and caudal block provided adequate relief from postoperative pain after day-case unilateral lower abdominal surgeries in children. However, TAP block resulted in better parent satisfaction and earlier home discharge with fewer side effects when compared with caudal block.

The effects of intravenous lidocaine infusion on hospital stay after major abdominal pediatric surgery. A randomized double-blinded study

Abstract Background Lidocaine attenuates the stress response to surgery when given intravenously. This study investigated the effect of perioperative lidocaine infusion on hormonal responses, bowel function and hospital stay after major abdominal surgeries in pediatrics. Methods After obtaining the Research Ethics Board (REB) approval and written informed parental consent, 80 pediatric patients aged 1–6 years, ASA II, III scheduled for abdominal major surgery were randomly allocated into two groups, each of forty children. Twenty minutes before induction, children in placebo group received saline in a rate of 1.5 ml/kg/h and those in lidocaine group received lidocaine 1.5 mg/kg intravenously then infusion of 1.5 mg/kg/h up to 6 h postoperatively. Length of hospital stay and return of bowel function were reported. Plasma cortisol was recorded at baseline, 10 min after continuous infusion, 5 min after intubation and 10 min after extubation. Serum lidocaine concentrations were recorded 10 min after start of infusion, 10 min and 4 h after extubation. Results Patients in placebo group showed significant higher plasma cortisol concentrations (P = 0.001) in response to induction of anesthesia and extended postoperatively when compared to lidocaine group. Hospital stay was significantly less in lidocaine group (5 ± 2 days) compared to placebo group (7 ± 2 days; P = 0.03). Also, fentanyl (μg/kg/d) requirement was significantly less in lidocaine group (5.4 ± 2.9 on 1st postoperative day and 4.1 ± 2.6 on 2nd postoperative day) compared to placebo group (14.4 ± 2.5 on 1st postoperative day and 12.6 ± 3.3 on 2nd postoperative day). Moreover, return of bowel function was earlier in lidocaine group compared to placebo group (19 ± 6.2 h vs. 23 ± 3.65 h respectively). Conclusion Intravenous lidocaine infusion, started preoperatively and continued for 6 h postoperatively, attenuated stress response to major abdominal pediatric surgery. It also decreased hospital stay, opioid requirement and hastened return of bowel function.