Elvan Erhan

Propofol - not thiopental or etomidate - with remifentanil provides adequate intubating conditions in the absence of neuromuscular blockade.

PurposeAdministration of remifentanii followed by propofol provides adequate conditions for tracheal intubation without muscle relaxants. Other hypnotic drugs have not been thoroughly investigated in this regard. Intubating conditions with remifentanil followed by propofol, thiopentone or etomidate are compared in this study.MethodsIn a randomized, double-blind study 45 healthy males were assigned to one of three groups (n = 15). After iv atropine, remifentanil 3 μg· kg−1 were injected over 90 sec followed by propofol 2 mg· kg−1 (Group I), thiopentone 6 mg· kg−1 (Group II) or etomidate 0.3 mg· kg−1 (Group III), Ninety seconds after the administration of the hypnotic agent, laryngoscopy and intubation were attempted, Intubating conditions were assessed as excellent, good or poor on the basis of ease of ventilation, jaw relaxation, position of the vocal cords, and patient response to intubation and slow inflation of the endotracheal tube cuff.ResultsOne patient in Group I, three patients in Group II and five patients in Group III could not be intubated on the first attempt. Clinically acceptable intubating conditions were observed in 93.3%, 66.7%, 40.0% of patients in Groups I, II and III, respectively. Overall conditions at intubation were significantly (P < 0,05) better, and the frequency of excellent conditions was significantly (P < 0.05) higher in the propofol group compared with the thiopentone and etomidate groups. No patient was treated for hypotension or bradycardia.ConclusionPropofol 2 mg· kg−1 was superior to thiopentone 6 mg· kg−1 and etomidate 0.3 mg· kg−1 for tracheal intubation when combined with remifentanil 3 μg· kg−1 and no muscle relaxant.RésuméObjectifL’administration de rémifentanil suivie de propofol permet des conditions satisfaisantes d’intubation endotrachéale sans myorelaxants. D’autres hypnotiques n’ont pas encore été testés dans ces circonstances. Nous avons donc voulu comparé les conditions d’intubation avec le rémifentanil suivi du propofol, du thiopental ou de l’étomidate.MéthodeL’étude randomisée et à double insu a été réalisée auprès de 45 hommes en bonne santé, répartis en trois groupes (n = 15). Après l’administration iv d’atropine, l’injection de 3 μg· kg−1 de rémifentanil, pendant 90 sec, a été suivie de 2 mg· kg−1 de propofol (Groupe I), de 6 mg· kg−1 de thiopentai (Groupe II) ou de 0,3 mg· kg−1 d’étomidate (Groupe III). Quatre-vingt-dix secondes après l’administration de l’agent hypnotique, la laryngoscope et l’intubation ont été tentées. Les conditions d’intubation ont été évaluées comme excellentes, bonnes ou pauvres d’après la facilité de ventilation, du relâchement de la mâchoire, la position des cordes vocales et la réponse du patient à l’intubation et au gonflement lent du ballonnet du tube endotrachéal.RésultatsUn patient du Groupe I, trois du Groupe II et cinq du Groupe III n’ont pu être intubés au premier essai. Des conditions d’intubation acceptables ont été observées chez 93,3 %, 66,7 % et 40,0 % des patients des Groupes I, II et III. Dans l’ensembie, les conditions d’intubation ont été signifiativement (P < 0,05) meilleures, et la fréquence de conditions excellentes a été signifeativement (P < 0,05) plus élevée, avec le propofol, comparé au thiopentai et à l’étomidate. Aucun patient n’a dû recevoir de traitement pour hypotension ou bradycardie.ConclusionLes conditions d’intubation endotrachéale ont été meilleures avec l’usage de 2 mg· kg−1 de propofoi, comparés à 6 mg· kg−1 de thiopental et à 0,3 mg· kg−1 d’étomidate, combinés à 3 μg· kg−1de remifentanil et sans myorelaxants.

Tracheal intubation without muscle relaxants: remifentanil or alfentanil in combination with propofol

Background and objective: In some situations, the use of muscle relaxants (neuromuscular blocking drugs) are undesirable or contraindicated. We compared intubating conditions without muscle relaxants in premedicated patients receiving either alfentanil 40 μg kg−1 or remifentanil 2, 3 or 4 μg kg−1 followed by propofol 2 mg kg−1. Methods: In a randomized, double-blind study, 80 healthy patients were assigned to one of four groups (n = 20). After intravenous atropine, alfentanil 40 μg kg−1 or remifentanil 2, 3 or 4 μg kg−1 were injected over 90 s followed by propofol 2 mg kg−1. Ninety seconds after administration of the propofol, laryngoscopy and tracheal intubation were attempted. Intubating conditions were assessed as excellent, good or poor on the basis of ease of lung ventilation, jaw relaxation, laryngoscopy, position of the vocal cords, and patient response to intubation and slow inflation of the endotracheal tube cuff. Results: Seven patients who received remifentanil 2 μg kg−1 and one patient who received remifentanil 3 μg kg−1 could not be intubated at the first attempts. Excellent intubating conditions (jaw relaxed, vocal cords open and no movement in response to tracheal intubation and cuff inflation) were observed in those who received either alfentanil 40 μg kg−1 (45% of patients) or remifentanil in doses of 2 μg kg−1 (20%), 3 μg kg−1 (75%) or 4 μg kg−1 (95%). Overall, intubating conditions were significantly better (P < 0.05), and the number of patients showing excellent conditions were significantly higher (P < 0.05) in patients who received remifentanil 4 μg kg−1 compared with those who received alfentanil 40 μg kg−1 or remifentanil 2 μg kg−1. No patient needed treatment for hypotension or bradycardia. Conclusions: Remifentanil 4 μg kg−1 and propofol 2 mg kg−1 administered in sequence intravenously provided good or excellent conditions for tracheal intubation in all patients without the use of muscle relaxants.

The antinociceptive effect of tramadol on a model of neuropathic pain in rats.

The antinociceptive activity of tramadol was investigated on the vocalization threshold to paw pressure in a rat model of unilateral mononeuropathy produced by loose ligatures around the common sciatic nerve. Despite the analgesic activity of tramadol was clearly established in motor and sensory responses of the nociceptive system in rats, the effect of this atypical opioid on experimental neuropathic pain models is not investigated. The intraperitoneally injected tramadol (2.5, 5 and 10 mg/kg) produced a potent and dose-dependent antinociceptive effect on both lesioned and non-lesioned hind paws. However, the analgesic effect on the lesioned paw was significantly more potent than the non-lesioned paw. This effect was partially antagonized by intraperitoneally administered naloxone (0.1 mg/kg) suggesting an additional non-opioid mechanism. Our results suggest that tramadol may be useful for the alleviation of some symptoms in peripheral neuropathic conditions

Remifentanil versus alfentanil in total intravenous anaesthesia for day case surgery.

Background and objective: We assessed the intraoperative haemodynamic responses and recovery profiles of total intravenous anaesthesia with remifentanil and alfentanil for outpatient surgery. Methods: Patients in Group 1 (n = 20) received alfentanil 20 μg kg−1 followed by 2 μg kg−1 min−1 intravenously; patients in Group 2 (n = 20) received remifentanil 1 μg kg−1 followed by 0.5 μg kg−1 min−1 intravenously. Both groups then received propofol 2 mg kg−1 followed by 9 mg kg−1 h−1 intravenously. Five minutes after skin incision, infusion rates were decreased, and at the end of surgery, all infusions were discontinued. Early recovery was assessed by the Aldrete score, whereas intermediate recovery was assessed with the postanaesthetic discharge scoring system (PADS). Results: Perioperative arterial pressure was similar in both groups; heart rate was lower in Group 2 (P < 0.05). The times to spontaneous and adequate respiration, response to verbal commands, extubation and times for Aldrete score ⩾9 were shorter in Group 2 patients (P < 0.05). Pain scores were higher in Group 2 patients (P < 0.05). Overall times for postanaesthetic discharge scores ⩾9 were similar. Conclusions: Early recovery of patients after day surgery is significantly shorter after total intravenous anaesthesia with remifentanil compared with that with alfentanil but postoperative pain management must be planned ahead.

Tension-type headache in children: a clinical evaluation.

Abstract Background : Anxiety and psychological stress are often pre‐existing factors which can trigger pediatric tension‐type headaches.

Tramadol infusion for the pain management in sickle cell disease: a case report

We present the analgesic management of a 4‐year‐old child who suffered from severe abdominal and leg pain during his first vaso‐occlusive crisis with sickle cell disease, diagnosed as β/S disease when he was 1 year old. His mother and father were carriers of β‐thalassemia and hemoglobin S, respectively. He had an upper respiratory tract infection in which a vaso‐occlusive crisis was precipitated. On admission to hospital, fever, severe abdominal and leg pain were noted. Hemoglobin was 4 g·dl−1 with accompanying prominent reticulocytosis and acute spleen enlargement. These findings indicated a sequestration crisis as well as vaso‐occlusive disease. He was transfused with packed red cells. Paracetamol (40–60 mg·kg−1·day−1) and ibuprofen (20 mg·kg−1·day−1) were administered to relieve pain. The child experienced moderate to severe pain (Oucher score 60–80) despite nonopioid analgesics, so a tramadol infusion (0.25 mg·kg−1·h−1) was started. During the tramadol infusion no morphine was required, the intensity of pain gradually decreased (Oucher score 20) and the child was able to move his legs. At the end of 3 days splenomegaly regressed, no fever and pain were observed and the infusion was stopped. In conclusion, tramadol infusion i.v. (0.25 mg·kg−1·h−1) combined with nonopioids was effective to relieve moderate to severe pain due to vaso‐occlusive crisis and can be recommended before using morphine in a pediatric sickle cell crisis.

The Effect of Head Rotation on Intraocular Pressure in Prone Position: a Randomized Trial

BACKGROUND AND OBJECTIVES The increased intraocular pressure (IOP) - which decreases perfusion pressure on the optic nerve - increases by prone positioning (1). The aim of our study was to compare the effect of head rotation 45° laterally in prone position on the increase in IOP of upper placed and lower placed eyes in patients undergoing percutaneous nephrolithotomy (PCNL). METHODS Forty-five patients were randomly divided into 2 Groups. IOP of the patients were recorded bilaterally in supine position before the operation had started. Patients were turned to prone position. The head was placed on a prone headrest without external direct compression to both eyes. Patients in Group I were kept in strictly neutral prone position where as patients in Group II were placed prone with their heads rotated 45° laterally to the right side. At the end of the operation, patients were turned to supine position and their IOP was measured immediately. RESULTS There was no difference related to demographics, duration of surgery, blood loss and fluid input data. IOP values after surgery in prone position increased significantly compared to preoperative values in both groups (p < 0.05). After surgery in prone position IOP values of the upper positioned eyes in Group II were significantly lower than Group I and lower positioned eyes in Group II (p < 0.05). CONCLUSION prone positioning increases IOP. In patients with prone position with a head rotation of 45° laterally, IOP in the upper positioned eye was significantly lower.

Effects of preoperative gabapentin on postoperative pain after radical retropubic prostatectomy.

Objective: The impact of preoperative gabapentin on tramadol consumption using patient-controlled analgesia (PCA) and postoperative pain was assessed in patients undergoing radical retropubic prostatectomy (RRP). Methods: In this prospective, randomized trial, 51 patients undergoing RRP were randomized into two groups: the gabapentin group received 900 mg gabapentin orally 2 h before surgery; the control group did not receive gabapentin. Postoperative analgesia was provided by tramadol PCA. Pain was assessed using a visual analogue scale for 24 h, postoperatively. Results: Mean cumulative tramadol consumption at 24 h was comparable in the two groups. Pain scores at 45 min, 60 min and 2 h postoperatively, and the number of patients who required rescue analgesia, were significantly lower in the gabapentin group than in the control group. Side-effects were similar in the two groups. Conclusions: Preoperative administration of 900 mg gabapentin did not decrease tramadol consumption, but was associated with lower pain scores in the early postoperative phase and a reduced need for rescue analgesia, compared with controls, in patients undergoing RRP.

Comparison of 75 and 150 µg doses of intrathecal morphine for postoperative analgesia after transurethral resection of the prostate under spinal anesthesia

OBJECTIVE The administration of single dose intrathecal (IT) morphine with local anesthetics during spinal anesthesia produces an effective postoperative analgesia. In this study, we evaluated the efficacy and safety of two different doses of IT morphine with bupivacaine for postoperative analgesia after transurethral resection of prostate (TURP). STUDY DESIGN Prospective, randomized study. SETTING Urology Department. PATIENTS, PARTICIPANTS Sixty patients who were scheduled to undergo TURP with spinal anesthesia. METHODS Patients were allocated to receive IT morphine (75 μg) with bupivacaine heavy (group I) and IT morphine (150 μg) with bupivacaine heavy (group II). Postoperative pain was evaluated by Visual Analogous Scale during 24 hours. The need for rescue analgesia, adverse effects and patient satisfaction were recorded. RESULTS Groups were comparable with respect to demographic data. VAS scores were similarly low in both groups. However, the request for analgesia was significantly higher in group I (27 percent) than group II (7 percent; p = 0.04). The incidence of postoperative nausea was similarly low in both groups. No patients reported pruritis in group I where as six patients (20 percent) reported mild pruritis not necessitating treatment in group II (p = 0.036) Patients satisfaction was similarly high in both the groups. CONCLUSIONS IT morphine 150 μg reduced the need for rescue analgesia compared to IT morphine 75 μg in patients undergoing TURP under spinal anesthesia. As the incidence of pruritis was low with no treatment, IT morphine 150 μg may be a suitable dose for postoperative analgesia for patients undergoing TURP under spinal anesthesia.

Sevoflurane vs ketamine-midazolam for the anesthetic management of children undergoing extracorporeal shock wave lithotripsy.

discontinued from the current dose of 0.4 lgÆkgÆh. Tachycardia, hypertension and emesis were observed immediately after discontinuation without any physiological explanation. These symptoms did not subside with lorazepam administration. Drug withdrawal was suspected, hence dexmedetomidine was restarted 3 h later with the loading dose of 1 lgÆkg and followed by continuous infusion at 0.4 lgÆkgÆh with good results (see Figure 1). The following day, the infusion was gradually weaned off by 0.1 lgÆkgÆh every 8 h without incident. The prolonged use of dexmedetomidine in the ICU has been a safe option in pediatric patients. Hammer et al. (1) reported the use of dexmedetomidine in a 9-year-old male for 4 days following a tracheal reconstruction. Their use of dexmedetomidine allowed for a decrease dose in fentanyl and midazolam combined with more periods of controlled wakefulness. Walker et al. (2) reported on prolonged dexmedetomidine infusions in 65 pediatric burn patients. There was an average of 11 days on the agent with a range of 2–50 days. The dosing ranges of dexmedetomidine were 0.1–2 lg kg h. The infusion of dexmedetomidine was weaned off on each patient over 12–24 h. There were no episodes of tachyphylaxis or withdrawals reported in both studies. In addition, Enomoto et al. (3) recently described the use of dexmedetomidine in an infant for more than 2 months following a liver transplant. The pediatric use of dexmedetomidine continues to increase. More research is needed in the prolonged use of dexmedetomidine to determine the safe maximal total dosing in pediatric population. As seen in our patient, protracted use of dexmedetomidine may lead to a physiologic dependence as seen in other classes of drugs. We propose that a gradual weaning is warranted after a prolonged use of dexmedetomidine to prevent withdrawal. Mark D. Weber R N C P N P* Satid Thammasitboon M D M H P E* David A. Rosen M D† *Department of Pediatrics †Department of Anesthesia, West Virginia University Children’s Hospital (email: mweber@hsc.wvu.edu)