Atef Kamel Salama

Comparative study of intra-articular dexmedetomidine versus ketamine as adjuvant analgesics after knee arthroscopy

Abstract Background Knee arthroscopy is one of the day case procedures which may be diagnostic or therapeutic. Postoperative analgesia is important for early ambulation and short hospital stay. This prospective randomized study was designed to compare the analgesic effect of intra-articular dexmedetomidine versus ketamine as adjuvant to bupivacaine following knee arthroscopy. Method 75 patients ASA physical status I and II undergoing knee arthroscopy under general anesthesia were included in this study. Patients were divided into three groups according to intra-articular injected combination at the end of the arthroscopy. Group B/D received 25 ml 0.25% bupivacaine and dexmedetomidine 1 μg/kg, group B/K received 25 ml 0.25% bupivacaine and ketamine 1 mg/kg, and control group B received 25 ml 0.25% bupivacaine only. Postoperative pain using visual analogue score (VAS), the time to the first postoperative analgesic request, the total dose of postoperative analgesia during the first 24 h, and possible side effects were recorded. Results Visual analogue score (VAS) was significantly less in B/D group in comparison with B/K group after the 1st hour and thereafter. Also VAS was higher in B group compared to the other two groups (P < 0.05). Time to first postoperative analgesic request was longer in the B/D group (479.2 ± 34.9 min) than in B/K group (356.7 ± 39.2 min), but in both groups it was longer than in B group (312.4 ± 18.8 min), (P < 0.05). The total dose of postoperative analgesia (paracetamol consumption) during the first 24 h was significantly low in B/D group (758.0 ± 153.0 mg) compared to both B/K and B groups (1041.2 ± 178.6 mg and 1368.0 ± 227.2 mg) respectively (P < 0.05). Conclusion Intra-articular bupivacaine/dexmedetomidine provides better analgesia compared to bupivacaine/ketamine and both are superior to bupivacaine alone following knee arthroscopy.

Multimodal analgesia with pregabalin and dexmedetomidine in morbidly obese patients undergoing laparoscopic sleeve gastrectomy: A prospective randomized double blind placebo controlled study

Abstract Background and objectives Sleeve gastrectomy has become a popular and effective treatment for morbidly obese patients. The aim of this prospective randomized study was to assess the efficacy of multimodal analgesia using pregabalin and dexmedetomidine in morbidly obese patients undergoing laparoscopic sleeve gastrectomy. Materials and methods After ethical approval 60 American Society of Anesthesiologists (ASA) physical status II patients were enrolled in this study and allocated randomly into 2 groups: group A received 75 mg oral pregabalin 2 h before surgery and dexmedetomidine infusion 0.4 μg/kg/h and group B (control group) received placebo capsule 2 h before surgery and saline infusion intraoperatively. Intraoperative fentanyl consumption, hemodynamics and postoperative opioid consumption, pain scores, level of sedation and any side effects were evaluated. Results There was a significant decrease in heart rate, mean arterial blood pressure, pain score, intraoperative fentanyl use, postoperative morphine consumption and nausea verbal rating scale in group A compared to group B. There was a significant increase in sedation score in group A compared to group B. Conclusions The combination of preoperative oral pregabalin and intraoperative dexmedetomidine infusion decreased intraoperative fentanyl use and ensured postoperative better pain control and less postoperative opioid consumption.

Effects of preincisional analgesia with surgical site infiltration of ketamine or levobupivacaine in patients undergoing abdominal hysterectomy under general anesthesia; A randomized double blind study

Context: Postoperative pain management remains a cornerstone in patients management to ensure a better quality of life. Preemptive analgesia is reported to inhibit the persistence of postoperative pain. Aims: The aim of this study is to assess the analgesic effectiveness of preincisional infiltration of ketamine following elective abdominal hysterectomy as compared to levobupivacaine. Settings and Design: This was a prospective, randomized, double-blind study. Subjects and Methods: This study included 48 patients undergoing abdominal hysterectomy under general anesthesia. They were randomized into two equal groups; Group K received subcutaneous infiltration of 20 ml containing ketamine 2 mg/kg and Group L received subcutaneous infiltration of 20 ml of levobupivacaine 0.25% along the Pfannenstiel incision 5 min before incision. Postoperative pain was assessed using visual analog scale (VAS) at rest and on coughing with evaluation of additional opioid analgesic requirements. Statistical Analysis Used: Numerical variables were presented as mean and standard deviation or median and range as appropriate. The intergroup differences were compared using the independent-sample Students t-test or Mann–Whitney test for numerical variables. Results: VAS score decreased significantly in Group L from 10 to 24 h and in Group K from 8 to 24 h as compared to the immediate postoperative reading. VAS score in ketamine group was significantly lower than that in the levobupivacaine group 8, 10, and 24 h postoperatively. Ketamine group showed delayed request of additional opioid analgesia (P < 0.001) with significantly less opioid consumption (P < 0.001) as compared to levobupivacaine. The total dose of meperidine consumed during the 24 postoperative h was significantly smaller in ketamine group (P < 0.001). Conclusion: Surgical site infiltration of ketamine is a promising preemptive analgesic method in the lower abdominal surgery with minimal sedation and adverse effects.

Comparison between caudal levobupivacaine versus levobupivacaine–nalbuphine for postoperative analgesia in children undergoing hernia repair: A randomized controlled double blind study

Abstract Objectives Caudal analgesia is widely used in children; the aim of this trial was to evaluate the efficacy of adding nalbuphine to local anesthetic in pediatric patients undergoing hernia repair. Patients and methods This randomized double-blind controlled trial was done in department of anesthesia, Cairo University hospitals, and 40 patients with ASA physical status classification I–II, aged 2–7 years were enrolled in this study and randomly assigned into 2 groups; group L received caudal levobupivacaine 1 ml/kg with concentration of 0.25% and group LN received caudal 0.125% levobupivacaine with volume of 1 ml/kg plus 0.2 mg/kg nalbuphine. Pain was evaluated immediately after emergence (FLACC 0 h), after 1 h in the PACU, after 2, 3, 4, 5, 6 and 12 h by the FLACC pain score (Face, Leg, Activity, Crying, Consolability). First time of rescue analgesic, total dose of rescue analgesic and side effects were observed for 12 h. Results FLACC pain scores were much less in LN group compared to L group (p value < 0.001) after the second hour. The first time for postoperative analgesic requirement was significantly longer in LN group (384 ± 23.1 min) compared to L group (202.20 ± 23.42 min) (p value > 0.001). The total dose of postoperative supplementary analgesia (intravenous paracetamol infusion) in the first 12 h was significantly lower in LN group (200.5 ± 65.5 mg) in comparison with L group (355.25 ± 69.9 mg) (P < 0.05). Conclusions Combining caudal anesthesia using levobupivacaine and nalbuphine provided prolonged time of analgesia with no reported side effects.

Does nebulized dexamethasone decrease the incidence of postextubation sore throat?: a randomized controlled study

Objective and aim of study Postoperative sore throat (POST) is a common complaint in about 21-65% of patients undergoing general anesthesia with endotracheal intubation. The aim of this randomized controlled study was to evaluate the efficacy of preoperative nebulized dexamethasone in decreasing the incidence of postextubation sore throat. Patients and methods A total of 120 American Society of Anesthesiologists (ASA) physical status I-II patients of both sexes aged 25-60 years sexes were included in this study. Patients were randomly assigned into one of the two groups of 60 patients each: group D received dexamethasone 8 mg in 5 ml nebulization and group S (the control group) received normal saline in 5 ml nebulization 15 min before general anesthesia and endotracheal intubation. The intensity of sore throat and hemodynamic variables were monitored before nebulization, on arrival to the postanesthesia care unit (0 h), and at 2, 4, 8, 12, and 24 h postoperatively. Results The incidence and severity of POST were significantly reduced in the dexamethasone group than in the saline group at the following time intervals: 2 h after extubation (P = 0.009), 4 h after extubation (P = 0.000), 8 h after extubation (P = 0.000), and 12 h after extubation (P = 0.002). There was no complication associated with dexamethasone nebulization. Conclusion Preoperative nebulization with dexamethasone 8 mg reduces the incidence and severity of POST in patients receiving general anesthesia with endotracheal intubation.

Management for failed back surgery syndrome: three-in-one procedure versus percutaneous spinal fixation alone

Objectives: To evaluate the short-term outcome of a 3-in-1 procedure including percutaneous facet radiofrequency, percutaneous spinal fixation and steroid with hyaluronidase enzyme injection versus percutaneous spinal fixation alone for cases with failed back surgery syndrome (FBSS). Patients and methods: The study included 50 patients who had had previous spinal surgery since a mean duration of 39.7 ± 8.5 months and developed recurrent back pain since a mean duration of 10 ± 2.1 months. Patients were randomly allocated into two groups; group A underwent percutaneous spinal fixation only and group B underwent the 3-in-1 procedure. Outcome was evaluated at the end of six months postoperatively (PO) using a pain numeric rating scale (NRS), the Oswestry Disability Index (ODI) and Odom’s criteria for evaluation of surgical outcome with evaluation of patients’ satisfaction by outcome. Results: All patients showed progressive decrease of NRS pain and ODI scores compared with preoperative scores. However, patients in group B showed significantly lower postoperative NRS pain scores and ODI with significantly higher frequency of patients having had > 50% reduction of both scores compared with patients in group A. PO analgesic consumption rate in both groups was significantly lower than the preoperative rate with a significant reduction of mean total scoring compared with preoperative scoring. The frequency of patients who found the provided therapeutic procedure satisfactory and its outcome good-to-excellent was significantly higher among patients in group B compared with group A. Conclusion: Short-term outcomes of the applied 3-in-1 procedure are promising for improvement of symptoms secondary to FBSS and may ultimately prove to be recommended as the therapeutic modality for such a challenging clinical problem.

Intrathecal dexmedetomidine in TURP operations: A randomised controlled study

http://dx.doi.org/10.1016/j.egja.2017.08.006 1110-1849/ 2017 Publishing services by Elsevier B.V. on behalf of Egyptian Society of Anesthesiologists. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Peer review under responsibility of Egyptian Society of Anesthesiologists. ⇑ Corresponding author. E-mail address: looly24@gmail.com (A. Taha). Alaa Taha ⇑, Ahmed Shash, Hala Goma, Atef Salama, Norhan Aly

Maternal care bundle: The effect of a multimodal approach on the prevention of maternal hypotension following spinal anesthesia in parturients undergoing elective or urgent cesarean section

Abstract Background and Aim Many techniques to prevent spinal induced hypotension in cesarean section have been advocated; but no one technique proved to be totally effective. The aim of this cohort interventional study was to investigate the efficacy of application of multimodal approach to decrease the incidence of hypotension (defined as mean arterial blood pressure ⩽60 mmHg) following spinal anesthesia in parturients undergoing elective or urgent cesarean section. Patients and Methods In this prospective cohort interventional study, 159 American Society of Anesthesiologists (ASA) classification I–II parturients undergoing elective or urgent cesarean section were enrolled. All patients received maternal care bundle which consisted of; fixed low dose of bupivacaine (7.5 mg + fentanyl 25 μg), coloading with 15 ml/kg lactated Ringer’s, placement of the patient in the supine wedged position, administration of 9 mg ephedrine sulphate IV after intrathecal injection and placement of graduated compression stockings (GCS) in the elevated leg position >45° and maintaining leg elevation at 20° following application of GCS. Demographic data, spinal anesthetic technique variables, fluid intake and urine output were documented. Mean arterial blood pressure, heart rate and oxygen saturation were recorded at baseline T0 (before spinal anesthesia administration), T1 (5 min following intrathecal injection of local anesthetics), T2 (15 min), T3 (30 min) and at T4 (end of procedure prior to PACU transfer). Total dose of ephedrine and any complication was documented. Results Incidence of hypotension after 5 min (T1) was 17.6%, at 15 min (T2) was 3.8% and at 30 min (T3) was 5%. Conclusions The application of a maternal care bundle had significantly decreased the incidence of spinal induced hypotension in parturient undergoing elective or urgent Cesarean delivery.

Comparative study of hyoscine doses as antisialagogue for patients receiving ketofol sedation undergoing colonoscopy procedures

Objective: To compare the effects of different regimens of hyoscine as antisialagogue in patients undergoing ketofol sedation for colonoscopy procedures. Patients and Methods: In this prospective double-blind randomized controlled trial 200 American Society of Anesthesiologists I-II aged 20–60-year-old undergoing colonoscopy were randomly assigned into four equal groups, group A received 5 mg hyoscine intravenous, group B received 10 mg, group C received 20 mg intravenous, and control group (D) that was received saline. All patients were sedated using ketofol titrated to achieve Ramsey Sedation Score 4, hemodynamic variables and occurrence of increased secretions were evaluated and recorded. Results: Hyoscine in a dose of 10 mg was the optimum dose to achieve least salivation with the least side effect while hyoscine 5 mg was not efficient to achieve dry field or good surgical conditions. However, hyoscine 20 mg achieved dry field and fair surgical conditions in expenses of tachycardia. Conclusion: Hyoscine 10 mg was the least effective dose that significantly reduced hypersalivation in patients receiving ketofol sedation for colonoscopy procedures, this dose was as effective as 20 mg in draying secretion but with significantly less tachycardia.

Fluid preloading versus ephedrine in the management of spinal anesthesia-induced hypotension in parturients undergoing cesarean delivery: a comparative study

Introduction and objectives Spinal anesthesia-induced hypotension in parturients undergoing cesarean delivery is a very common complication that has detrimental effects on both the mother and the fetus. The objective of our study was to compare the two therapeutic modalities, fluid preloading and ephedrine, in the management of spinal anesthesia-induced hypotension in parturients undergoing elective cesarean delivery. Patients and methods A total of 50 ASA I-II parturient women who presented for cesarean section under spinal anesthesia were enrolled in this study. They were randomly assigned into two groups: the F group (n = 25) (the fluid preloading group), which received 15 ml/kg of lactated Ringer′s solution 10 min before spinal anesthesia, and the E group (n = 25) (the ephedrine group), which received prophylactic 5 mg ephedrine first and second minute and 1 mg every minute until 15 min after the block. Hemodynamic variables and any postoperative complication were recorded. Results Demographic data and duration of procedures were comparable. Systolic blood pressure was generally higher in the E group than in the F group. However, the result was not statistically significant, except at 4 and 22 min after spinal anesthesia. Heart rate was higher in the E group than in the F group; however, it was not statistically significant. The incidence of hypotension and rescue boluses of ephedrine was significantly higher in the fluid group. Conclusion The use of ephedrine is superior to that of fluid preloading in maintaining blood pressure after spinal anesthesia in cesarean section.