Doaa Rashwan

Levobupivacaine patient controlled analgesia: Epidural versus blind fascia iliaca compartment analgesia – A comparative study

Abstract This study was designed to compare the analgesic efficacy of levobupivacaine patient controlled analgesia epidural versus patient controlled analgesia with fascia lliaca compartment block. In patients undergoing fixation of fracture neck femur. Methods Sixty patients ASA II&III undergoing fixation of fracture neck femur were randomly allocated into two groups (n = 30). Group E Epidural group given levobupivacaine 0.25% 15 ml before induction of general anesthesia, followed by postoperative PCEA with levobupivacaine (0.125%). Group F Fascia iliaca block group given levobupivacaine 0.25% 30 ml through the catheter before induction of general anesthesia, followed by postoperative patient controlled fascia illiaca analgesia with levobupivacaine (0.125%). Severity of postoperative pain at rest in 24 h using VAS, number of patients required additional analgesia (tramadol) in 24 h, doses of postoperative 24 h tramadol consumed, postoperative mean arterial blood pressure and heart rate were recorded. Results The severity of postoperative pain was statistically significantly less in E group, number of patients required tramadol in 24 h were statistically significantly less in E group than F group, postoperative tramadol consumed was statistically significantly less in E group than F group. Conclusion PCEA with levobupivacaine (0.125%) was associated with satisfactory analgesia than patient controlled analgesia with fascia iliaca block in patients undergoing fixation of fracture neck femur.

The efficacy of preoperative pregabalin on reduction of the incidence and severity of postdural puncture headache after spinal anesthesia

Abstract Objective The aim of this study was to evaluate the efficacy of prophylactic pregabalin on postdural puncture headache incidence and severity after spinal anesthesia. Method 86 ASA I-II male and female patients age 20–50 years old, undergoing elective general surgeries below the umbilicus under spinal anesthesia with 3 ml heavy bupivacaine 0.5% (15 mg), patients were randomly allocated into one of two groups (Group C, n = 43) (control group) received a placebo capsule 2 h preoperatively (Group P, n = 43) received 150 mg pregabalin capsule 2 h preoperatively, number of attempts for spinal block, sensory level, motor block grade, postoperative time to first analgesic requirement, the incidence, onset and intensity of PDPH and adverse events were recorded for 72 h. Results The peak sensory level in C group and P group showed no statistical significant difference, the time to peak sensory block was significantly earlier in P group than group C, the time to reach the modified Bromage motor block grade 3 was significantly earlier in P group than C group, time to two segment regression of sensory level to S1 and motor block regression to modified Bromage grade 0 were statistically insignificant between the studied groups. Group P had a significantly longer time to first analgesic requirements than group C, and there was no significant difference in VAS (visual analogue scale) of pain between the studied groups. There was significant increase in sedation score in P group compared to C group at 2 h and 6 h postoperatively, and there was statistically significant reduction in the incidence rate and severity of PDPH in P group compared to group C. There were no recorded cases of dizziness, visual disturbances, or PONV. Conclusions preoperative oral pregabalin 150 mg reduced the incidence and severity of PDPH, beside the earlier onset of peak sensory and motor block with increase duration of analgesia in patients undergoing elective surgeries under spinal anesthesia.

Effect of parecoxib on remifentanil induced postoperative shivering

Abstract Remifentanil based anesthesia was found to be associated with high incidence of postoperative shivering. This study was designed to evaluate the effect of preoperative administration of IV parecoxib sodium (a selective COX 2 inhibitor) on remifentanil induced shivering during the first 2 h following surgery. Method In a randomized, placebo-controlled, double blind study, sixty-seven patients with ASA physical status I, aged 20–60 years underwent elective lumber discectomy, were randomly allocated to receive either parecoxib sodium 40 mg IV (group P, n = 33) or saline IV (group S, n = 34) 30 min before induction of anesthesia which was induced with remifentanil 0.5 ug/kg/min, propofol, and cisatracurium and was maintained with remifentanil 0.1–0.3 ug/kg/min, sevoflurane, O2/N2O and cisatracurium. The incidence and grades of postoperative shivering were evaluated for 2 h. Results The incidence of postoperative shivering was 36% in parecoxib group which was significantly less than that of saline group 64% (p < 0.05). Number of patients who developed grade 3 shivering, number of patients received meperidine to treat shivering and postoperative morphine requirement were significantly less in group P than that of group S (p < 0.05). Conclusion Administration of parecoxib sodium 40 mg IV 30 min before induction of general anesthesia significantly reduced the incidence and severity of remifentanil induced shivering compared to placebo in patients underwent elective lumber discectomy under general anesthesia.

Pulse co-oximetry perfusion index as a tool for acute postoperative pain assessment and its correlation to visual analogue pain score

Background A painful stimulus can produce vasoconstriction and a decrease in perfusion index (PI). The visual analogue scale (VAS) is the most common pain assessment scale. However, it is affected by psychometric instability. This study was designed to evaluate the correlation between VAS as a subjective indicator of pain and PI as an objective indicator of pain. Patients and methods At postanesthesia care unit, a Masimo pulse co-oximetry perfusion index was attached to 70 adult patients of ASA I who underwent lumbar spine discectomy. At the time of the first request for analgesia (T1) VAS was recorded together with the PI, heart rate (HR), mean arterial blood pressure (MAP), peripheral oxygen saturation, and axillary temperature, following which analgesia was given. Thirty minutes thereafter (T2) second measurements for the mentioned parameters were taken. Results The PI was significantly higher at T2 than at T1 (mean increase% = 94.3 ΁ 82.7%). This increase was associated with a statistically significant decrease in VAS, HR, and MAP. The mean decrease% was 70.5 ΁ 19.88%, 11.1 ΁ 7.2%, and 3.96 ΁ 5.01% in VAS, HR, and MAP, respectively. This means that the PI increases with adequate relief from pain, as indicated by a decrease in VAS, HR, and MAP. A decrease in VAS was associated with an increase in PI, but the correlation was not statistically significant as the degree of the increase in PI in relation to the decrease in VAS was variable among patients. Conclusion PI can be added to other indicators of pain assessment in the postanesthesia care unit.

Multimodal analgesia after upper limb orthopedic surgeries: Patient controlled intravenous low dose tramadol analgesia with or without intravenous acetaminophen – A comparative study

Abstract This study was designed to evaluate the effects of addition of acetaminophen to a low dose tramadol patient controlled intravenous analgesia after unilateral upper limb orthopedic surgeries under general anesthesia. Methods 120 Adult patients ASA I and II undergoing unilateral upper limb orthopedic surgeries under general anesthesia were randomly allocated into two groups: Group TA (n = 60): received postoperative iv tramadol PCA boluses of 10 mg and iv acetaminophen1 g/8 h. Group T (n = 60): received postoperative iv tramadol PCA boluses of 10 mg. Volume of tramadol (mg)consumed ,severity of postoperative pain at rest using VAS, postoperative systolic, diastolic arterial blood pressure and heart rate in 24 h, patient satisfaction ,adverse effects (sedation, nausea, vomiting, hypotension, respiratory depression) were recorded. Results Volume of tramadol (mg) consumed, severity of postoperative pain at rest using VAS 24 h were statistically significantly higher in group T, postoperative systolic , diastolic arterial blood pressure and heart rate, adverse events showed no statistical significant differences between the two groups, patient satisfaction was more in group TA. Conclusion The addition of acetaminophen to a low dose tramadol iv PCA as a multimodal analgesic approach provided satisfactory pain control than tramadol iv PCA alone after unilateral upper limb orthopedic surgeries under general anesthesia.

Efficacy of Dexmedetomidine versus Ketofol for Sedation of Postoperative Mechanically Ventilated Patients with Obstructive Sleep Apnea

Patients with sleep apnea are prone to postoperative respiratory complications, requiring restriction of sedatives during perioperative care. We performed a prospective randomized study on 24 patients with obstructive sleep apnea (OSA) who underwent elective surgery under general anesthesia. The patients were equally divided into two groups: Group Dex: received dexmedetomidine loading dose 1 mcg/kg IV over 10 min followed by infusion of 0.2–0.7 mcg/kg/hr; Group KFL: received ketofol as an initial bolus dose 500 mcg/kg IV (ketamine/propofol 1 : 1) and maintenance dose of 5–10 mcg/kg/min. Sedation level (Ramsay sedation score), bispectral index (BIS), duration of mechanical ventilation, surgical intensive care unit (SICU) stay, and mean time to extubation were evaluated. Complications (hypotension, hypertension, bradycardia, postextubation apnea, respiratory depression, and desaturation) and number of patients requiring reintubation were recorded. There was a statistically significant difference between the two groups in BIS at the third hour only (Group DEX 63.00 ± 3.542 and Group KFL 66.42 ± 4.010, p value = 0.036). Duration of mechanical ventilation, SICU stay, and extubation time showed no statistically significant differences. No complications were recorded in both groups. Thus, dexmedetomidine was associated with lesser duration of mechanical ventilation and time to extubation than ketofol, but these differences were not statistically significant.

Tourniquet-induced cardiovascular responses in anterior cruciate ligament reconstruction surgery under general anesthesia: Effect of preoperative oral amantadine

Abstract Objective The aim was to test the effect of amantadine, an NMDA antagonist, on tourniquet induced cardiovascular responses under general anesthesia. Method In a randomized, double blind, placebo-controlled study; thirty adult male patients with ASA physical status I or II, aged 18–50 years underwent anterior cruciate ligament reconstruction with a tourniquet under general anesthesia, were divided to receive either oral amantadine 200 mg capsule in the evening before surgery and 200 mg capsule 60 min before surgery (group A) or placebo capsules (group P). Heart rate, systolic and diastolic blood pressures were recorded (before induction of anesthesia, every 15 min after tourniquet inflation, before tourniquet deflation, and 10 min after tourniquet deflation). Incidence of tourniquet-induced hypertension, and postoperative tramadol consumption were also recorded. Results Systolic and diastolic pressures significantly increased in both groups compared to baseline values (P < 0.05) at 15, 30, 45, 60, 75 min after tourniquet inflation, and before tourniquet deflation with significantly lesser increase with amantadine compared to placebo at 45, 60, and 75 min after tourniquet inflation (P < 0.05). Heart rate significantly increased at 45, 60, and 75 min after tourniquet inflation in both groups compared to baseline values (P < 0.05) with significantly lesser increase with amantadine compared to placebo (P < 0.05). Development of tourniquet induced hypertension was less with amantadine (5 out of 15) than with placebo (8 out of 15).The total tramadol consumed during the first 24 h postoperative was significantly less with amantadine compared to placebo (P < 0.05). Conclusion Preoperative oral amantadine reduced tourniquet induced hypertension and postoperative analgesic requirements in anterior cruciate ligament reconstruction surgery under general anesthesia.

Intravenous dexmedetomidine infusion in adult patients undergoing open nephrolithotomy: Effects on intraoperative hemodynamics and blood loss; a randomized controlled trial

Abstract Objective The aim of this study was to evaluate the effect of intravenous infusion of dexmedetomidine on intraoperative hemodynamics and blood loss during open nephrolithotomy under general anesthesia in adult patients. Method 50 male and female patients, ASA physical status I and II aged 20–60 years old scheduled for open nephrolithotomy under general anesthesia were randomly allocated into two equal groups: Group D (n = 25): received a bolus dose of IV dexmedetomidine. 1 μg/kg over 10 min before induction of anesthesia and then IV infusion of 0.1–0.5 μg/kg/h guided by the hemodynamics. Group P (n = 25): received a bolus dose of 10 ml Ringer lactate solution before induction of anesthesia, and infusion was continued during surgery. General anesthesia was induced in all patients using fentanyl, propofol and atracurium. The following parameters were recorded: heart rate and systolic and diastolic arterial blood pressure: before and after induction of anesthesia and then every 15 min intraoperatively, volume of blood loss (ml), laboratory hemoglobin % and hematocrit concentration: preoperative, intraoperative and immediate postoperative and number of the transfused units of PRBCs. Results Intraoperative heart rate and systolic and diastolic arterial blood pressure were statistically significantly lower in group D than in group P. The intraoperative blood volume lost was statistically significantly higher in group P than in group D. A number of the transfused units of PRBCs, intraoperative and postoperative hemoglobin % and hematocrit concentration were statistically significantly lower in group P than in group D. Conclusion Dexmedetomidine infusion in patients undergoing open nephrolithotomy under general anesthesia was associated with intraoperative hemodynamic stability, which decreases intraoperative blood loss and the need for intraoperative blood transfusion.

Efficacy of preoperative hydrocortisone versus tramadol for attenuation of postoperative shivering after percutaneous nephrolithotripsy: A randomized controlled trial

Abstract Background Percutaneous nephrolithotripsy is a technique used for the treatment of renal stones during which an irrigation fluid is used which may cause hypothermia and shivering if not prevented. The aim of this prospective randomized placebo controlled double blinded study was designed to evaluate the efficacy of preoperative hydrocortisone versus tramadol for attenuation of postoperative shivering after percutaneous nephrolithotripsy under general anesthesia Method 90 ASA I males and females patients aged 20–50 years, planned for percutaneous nephrolithotripsy under general anesthesia were randomly divided into three groups: Group S (n = 30) received 10 ml normal saline IV before induction of general anesthesia Group H (n = 30) received IV hydrocortisone 2 mg/kg before induction of general anesthesia Group T (n = 30) received IV tramadol hydrochloride 1 mg/kg before induction of general anesthesia The following parameters were recorded: Core temperature, heart rate and mean arterial blood pressure before induction of anesthesia, then every 15 min after induction of anesthesia, and every 30 min in the PACU, shivering intensity in the first 2 h postoperative, the incidence of shivering, the number of patients required meperidine and side effects. Results The number of patients who had shivering was statistically significantly higher in S group (12) than in H group (8) and in T group (7) with no statistically significant differences between H and T groups. Intraoperative heart rate, mean arterial blood pressure and side effects showed no statistically significant difference between the study groups. Conclusion Preoperative IV hydrocortisone and tramadol were effective in attenuation of postoperative shivering compared to placebo after percutaneous nephrolithotripsy without increasing the incidence of side effects.

Effect of fiberoptic intubation on myocardial ischemia and hormonal stress response in diabetics with ischemic heart disease

Abstract Background Diabetic patients with ischemic heart disease can greatly benefit from decreasing the stress response to intubation with its metabolic sequelae. The use of fiberoptic bronchoscopy will eliminate the response to direct laryngoscopy while lubrication of ETT with lidocaine gel 2% will decrease the response to endotracheal intubation. This study was conducted to compare the stress response hormones (glucose, cortisol and c-peptide) and the hemodynamic responses to intubation between direct laryngoscopy and fiberoptic bronchoscopy in diabetic ischemic patients. Patients and methods Forty-four adult diabetic patients with ischemic heart disease, ASA II, with a blood glucose level between 120 and 180 mg/dL, requiring orotracheal intubation under general anesthesia were divided into 2 equal groups. The laryngoscopic group (n = 22) and the fiberoptic group (n = 22). Ovassapian airway was used to facilitate fiberoptic intubation with avoidance of jaw thrust maneuver. Blood glucose, cortisol and c-peptide were recorded before induction and 10 min after intubation and compared between both groups. The hemodynamic parameters were recorded and compared between both groups. Automated ST segment monitoring was used to detect ischemia. Results There was statistically significant increase in HR, SBP and DBP in laryngoscopic group than in fiberoptic group. However, the incidence of ECG ST-segment changes was comparable with no statistically significant difference between groups. There were no statistically significant differences regarding glucose, cortisol and c-peptide levels between the study groups pre and post-induction. The intubation time in the fiberoptic group showed a statistically significant increase in comparison with the laryngoscope group (39 ± 12.04 vs. 29.3 ± 8.54 s; P < 0.05). Conclusion The optimum use of fiberoptic bronchoscope with avoidance of jaw thrust maneuver attenuates the hemodynamic response to intubation which is beneficial in diabetic patients with ischemic heart disease. Stress response hormones showed no statistically significant difference between groups.