Gamil H. Absood

Epidural ketamine for postoperative analgesia.

T WO factors have increased interest in ketamine for postoperative analgesia. The first was the discovery of the N-Methyl-D-asparrate (NMDA) receptor and its role in central pain processing and spinal cord neural plasticity. 1 Ketamine is one of two clinically useful NMDA receptor antagonists available (the other is dextromethorphan). Ketamine binds non-competitively to the PCI, (phencyclidine) recognition site in the NMDA receptor channel# In addition, interest in the concept of preemptive analgesia makes ketamine a natural candidate for investigation of postoperative pain relief since blockade of the NMDA receptor reduces noxious stimulusinduced allodynia and hyperalgesia. To avoid the well-known psychomimetic effects ofketamine, investigators have focused on the use of smaller doses than are required for general anaesthesia and alternative administration routes for postoperative analgesia. Spinal administration would seem to be especially interesting due to the proximity of the NMDA receptors and the potential for decrease in dose requirements. Reports on intraspinal administration of ketamine include caudal subarachnoid ketamine administration, with or without local anaesthetic agents, lumbar epidural ketamine alone or with local anaesthetic agents and/or opioids and thoracic epidural ketamine with opioids. There are several case reports, comments and uncontrolled studies related to epidural ketamine analgesia 3-s but only a few controlled clinical trials. 6~s Although two observational studies claimed epidural ketamine is effective as a postoperative analgesic s,4 other uncontrolled trials could find little or no postoperative analgesic effect, s Similarly, properly controlled trials using either small (4-8 mg)7or large (30 mg) s,s doses were unable to document effective postoperative epidural analgesia. Epidural ketamine may have an adjuvant effect when added to epidural morphine s or local anaesthetic agents. 9 Wong et al. s administered 10 mg ketamine and 0.5 mg morphine epidurally to patients scheduled for major joint replacement. The kelanainc/morphine combination produced the same degree of analgesia (with movement) as did 2 mg epidural morphine alone. In this study 10% of patients displayed psychomimetic effects requiting treatment. Yanli et aL, 9 in a controlled study, added 25 mg ketamine to a bupivacaine 0.5% with 1;200,000 adrenalin mixture and administered 20 ml epidurally to patients undergoing lower abdominal or orthopaedic surgery. There was a small but significant decrease in onset time to anaesthesia and a slightly higher segmental blockade in the ketamine group. There were no difference between the ketamine group and the non-ketamine group with regard to postoperative analgesic requirements and no adverse psychomimetic effects were seen. There are some claims that epidural ketamine and morphine combinations may have a preemptive analgesic effect. 1~ Choe et al. I1 in a controlled study added a large dose of ketamine (60 mg) to 2 mg epidural morphine and administered the combination before induction of general anaesthesia or 2-3 hr after the start of abdonfinal surgery. The only measure of analgesic efficacy was analgesic duration which was significantly prolonged in the preincisional group. No psychomimetic effects were noted. The comparative roles of the ketamine or the morphine in the possible preemptive effect are unclear. Wong et al. 1~ used a smaller dose of ketamine (20 mg) with 1.5 mg morphine given epidurally before or after incision to patients having knee joint replacement. Both groups received epidural anaesthesia with lidocaine intraoperatively. Postoperatively all patients received epidural ketamme (10 nag) mad morphine (1 mg) in lidocaine every 12 hr and also had additional PCA morphine available for rescue analgesia. Administration of the morphine/ketamine/fidocaine mixture before surgery resulted in less pain and lower PCA requirements than administration 30 rain after surgery had commenced. The preemptive effect of epidural ketamine alone is difficult to evaluate in this study as corn-Thirty-four patients of ASA physical status I or II scheduled for gall bladder surgery were studied in a comparative prospective trial to evaluate the efficacy of epidural and intramuscular ketamine for postoperative pain relief. They were divided randomly into three groups. Group I (11 patients) received 30 mg intramuscular ketamine. Group II (10 patients) and Group III (13 patients) received 10 and 30 mg ketamine in 10 ml saline respectively, through epidural catheters. Pain was evaluated every two hours for the first 24 hours post-operatively by using a linear analogue pain scale from 0-10. Ketamine was given on the patients request and whenever the pain score exceeded three. Ketamine produced analgesia in all patients studied. The reduction of pain score after two and four hours in Group I and III was significant when compared to Group II. Seven patients (54 per cent) in Group III did not require further analgesia after the initial injection. However, following 10 mg epidural ketamine or 30 mg IM ketamine, post-operative pain was more frequent. Four patients who received epidural ketamine complained of transient burning pain in the back during injection. No patient developed respiratory depression, psychic disturbance, cardiovascular instability, bladder dysfunction or neurologic deficit. It is concluded that 30 mg epidural ketamine is a safe and effective method for postoperative analgesia.

Antiemetic efficacy of high-dose dexamethasone: randomized, double-blind, crossover study with high-dose metoclopramide in patients receiving cancer chemotherapy

A double-blind, randomized, crossover study was conducted to compare the efficacy and safety of high-dose dexamethasone and high-dose metoclopramide in the treatment of chemotherapy-induced nausea and vomiting. All entered patients had no prior chemotherapy and all received inpatient emetogenic chemotherapy mainly without cisplatin. Of the 40 evaluable patients, 23 (58%) had no vomiting with dexamethasone compared with only 11 (28%) receiving metoclopramide (P less than 0.025). Dexamethasone was found to have less adverse effect than metoclopramide on patients appetite and activity (P less than 0.025 and P less than 0.01, respectively). Twenty-one patients (53%) developed mild to severe somnolence with metoclopramide compared to only seven (18%) who experienced this adverse effect with dexamethasone (P less than 0.01). Six patients (15%) developed extrapyramidal manifestations with metoclopramide, but none with dexamethasone. Furthermore, during dexamethasone therapy, patients developed less diaphoresis, insomnia, headache and dizziness. Upon questioning patients about their preference to future use of the antiemetic drug therapy, 28 patients (70%) preferred dexamethasone, two (5%) preferred metoclopramide and 10 (25%) found no difference. We conclude that high-dose dexamethasone has a greater antiemetic activity and is more safe than high-dose metoclopramide in patients receiving emetogenic chemotherapy mainly without cisplatin.

Rapid tracheal intubation with atracurium - a comparison of priming intervals

Abstractdetermine the optimal interval between the administration of the priming dose and the intubating dose, atracurium was given to 44 patients either in a single dose of 0.5 mg.kg-1 or in an initial dose of0.06mg.kg-1 followed two, three or five minutes later with 0.44 mg.kg-1.When atracurium was given as a single bolus of 0.5 mg. kg-1 the time to 100 per cent twitch suppression (onset time) was90.9 ± 36 (mean ± SD) seconds. When the priming interval was two minutes, the onset time of the intubating dose was 76.6 ± 42.2 seconds (p = NS). But when the priming interval was three or five minutes, the onset timeswere42.2 ± 16.5(p<0.01)and52.6 ± 28.8(p < 0.05) seconds respectively.Waiting for five minutes after the administration of the priming dose did not improve the intubating conditions. It is concluded that three minutes appears to be the optimal time interval for the administration of atracurium in divided doses. When a priming dose of atracurium is given three minutes before the intubating dose, it can provide an alternative to succinylcholine for rapid endotracheal intubation.RésuméAfin de déterminer l’ interval optimal entre I’administration de la dose d’amorce et de la dose d’intubation, de I’atracurium a été administré è 44 patients soit en une dose unique de 0.5 mg.kg-1, ou en une dose initiale de 0.06mg.kg-1 suivi de deux, trois, ou cinq minutes plus tard de 0.44 mg.kg-1.Quand I’atracurium a été donné comme dose unique de 0.5 mg.kg-1 le temps d’abolition à 100 pour cent de la réponse au twitch (temps d’installation) était de 90.0 ± 36 (moyenne ± SD) secondes. Lorsque I’intervalle d’amorce etait de deux minutes, le temps d’installation de la dose d’intubation était de 76.6±42.2 secondes (p = NS). Et lorsque I’intervalle d’amorce était de trois ou cinq minutes, les intervalles d’installation étaient de 42.2 ± 16.5 (p<0.01) et 52.6±28.8 (p<0.05) secondes respectivement.Une attente supérieure à cinq minutes après I’administration de la dose d’amorce n’a pas amélioré d’avantage les conditions d’intubation.Il est conclu que trois minutes apparaissent comme étant I’intervalle de temps optimal pour Vadministration de iatracurium à dose divisée. Quand une dose d’amorce d’atracurium est donnée trois minutes avant la dose d’intubation elle peut fournir une alternative à la succinyl-choline pour une intubation endotrachéal rapide.

Obesity in a primary health care centre: A retrospective study.

In a retrospective study, the heights and weights of 1072 Saudis (477 men and 595 women), aged 18 to 74 years, were studied to determine the prevalence of obesity in Saudi patients attending the primary health care center of King Fahd Hospital of the University, Al-Khobar, in the Eastern Province of Saudi Arabia. Of the total group, 51.5% (95% confidence interval, 46.5 to 56.0) of the men and 65.4% (95% confidence interval, 61.5 to 69.2) of the women were considered obese, using as the criterion a body mass index (wt/ht(2)) of greater than 25 kg/m(2). Significantly more women were obese than men. An active detection program and campaign against obesity must be mounted in the community, and this should include advice on diet and the better education of patients with regard to obesity and its complications.

Priming with atracurium: improving intubating conditions with additional doses of thiopental.

The effects of different intubating doses of atracurium on the time of onset, and the effect of an additional dose of thiopental on intubating conditions, were studied in 72 patients divided into six groups (n = 12 in each). Stratified sampling was used to obtain an even sex distribution. Groups I, III, and V (controls) received atracurium as a single bolus dose of 0.4, 0.5 or 0.6 mg/kg respectively. Groups 11, IV, and VI received an initial (priming) dose of 0.05 mg/kg followed 3 min later by 0.35, 0.45, or 0.55 mg/kg respectively. The time of onset, that is the time from the intubating dose to complete suppression of the train-of-four (TOF) response, was significantly accelerated after administration of atracurium in divided doses. Increasing the intubating dose of atracurium after an initial 0.05 mg/kg from 0.35 to 0.55 mg/kg did not result in further significant acceleration of the onset time, but resulted in prolongation of the duration of neuromuscular blockade. When divided doses of atracurium were given, administration of 2 mg/kg thiopental (in addition to the 5 mg/kg used for induction) before the injection of the intubating dose resulted in improvement of intubating conditions as reflected by statistically significant changes in intubating scores. This result was probably due to the increase by thiopental in the depth of anesthesia. Therefore, when thiopental is given as supplement, the priming technique can be made to provide better conditions for tracheal intubation in less than 90 sec.

The optimal priming dose for atracurium.

To determine the optimal priming dose for administration in divided doses, atracurium was given to 77 patients either in a single dose of 0.5 mg·kg-11 or in an initial dose of 0.04, 0.05, 0.06, 0.07, 0.08 or 0.09 mg·kg-1,. followed three minutes later by the remainder of the 0.5 mg·kg-1 dose. Patients were anaesthetized throughout the study. When atracurium was given as a single bolus of 0.5 mg·kg-1, the mean time to complete neuromuscular block was 141.5 seconds. Administration in divided doses accelerated the onset time (p < 0.01), that is the time from the intubating dose to the complete suppression of train-of-four (TOF) response. The TOF ratio decreased slightly but statistically significantly following the priming doses. When the priming dose was 0.05 mg·kg-1, the mean onset time was 70.9 seconds and priming with larger doses did not add any further advantage. It is concluded that 0.05 mg·kg-11 appears to be the optimal priming dose for the administration of atracurium in divided doses. When0.05 mg·kg-1 is given three minutes before the intubating dose, tracheal intubation can be accomplished in less than 90 seconds.RésuméAfin de déterminer la dose optimale d’amorce (priming dose) pour une administration à doses filées, l’atra-curium a été donne à 77 patients soit en une seule dose de 0.5 mg·kg-1 ou en une dose initiale de 0.04, 0.05, 0.06, 0.07, 0.08 ou 0.09mg·kg-1 suivi trois minutes plus tard par le restant de la dose de 0.5mg·kg-1. Les patients etaient anesthésiés tout au long de l’étude. Quand l’atracurium était donné en une dose unique de 0.5 mg·kg-1 le temps moyen nécessaire pour un bloc neuromusculaire complet était de 141.5 secondes. L’administration à dose filée a accéléré le temps d’installation (p < 0.01), ce temps est calculé à partir de l’administration de la dose d’intubation jusqu’à la suppression complète de la réponse à l’ndée-de-quatre (TOF). Le ratio de l’ondée-de-quatre a diminué légèrement mais d’une façon statistiquement significative après les doses d’amorce. Quand la dose d’amorce était de O.05 mg·kg-1 le temps d’installation moyen était de 70.9 secondes et l’amorçage avec des doses plus grandes n’a pas ajouté d’autres avantages. II est conclut que 0.05 mg·kg-1 apparaît comme étant la dose d’amorce optimale pour l’administration de l’atracurium à doses filées. Quand 0.05 mg·kg-1 était administré trois minutes avant la dose d’intubation, l’intubation pouvait etre accomplie en moins de 90 secondes.

Atropine-Edrophonium Mixture: A Dose-Response Study

The dose-response and the doses required to prevent bradycardia in 50% (ED50) and 95% (ED95) of patients were determined for atropine after antagonism of pancuronium-induced neuromuscular blockade in 72 patients with edrophonium-atropine mixtures. Edrophonium 0.67 mg/kg (group A, n = 37) or 1.0 mg/kg (group B, n = 35) was randomly mixed with one of seven doses of atropine (ranging from 0.0125 to 0.0215 mg/kg in group A and from 0.02 to 0.04 mg/kg in group B); with dose-response curves for atropine being constructed for both groups 5 and 10 minutes after the injection of the mixture. These dose-response curves were found to be parallel in both groups. The calculated ED50 values of atropine were 1.6–2 times greater in group B, compared with those in group A. The estimated ED50 doses of atropine in groups A and B at 5 minutes were 0.018 and 0.029 mg/kg, respectively, and at 10 minutes, the ED50 doses were similar, being 0.016 and 0.032 mg/kg, respectively. The calculated ED95 doses of atropine in groups A and B at 5 minutes were 0.024 and 0.055 mg/kg, and at 10 minutes, the ED95 doses were also similar, being 0.027 and 0.05 mg/kg, respectively.

Hepatocellular Carcinoma in Saudi Arabia: Evaluation of Prognostic Factors

ABSTRACT The medical records and pathologic materials of 41 Saudi patients (22 males and 19 females) with confirmed diagnosis of hepatocellular carcinoma were reviewed retrospectively. None of the ...

The pattern of train-of-four fade after atracurium: influence of different priming doses

This study was designed to investigate the effect of three different priming doses of atracurium—0.06, 0.07, and 0.08 mg/kg—followed 3 min later by the remainder of a 0.5 mg/kg dose on the relationship between the depression in the first twitch of the train-of-four (T1) and train-of-four (TOF) fade. This relationship was studied after the administration of the full dose of the relaxant in all groups. Of all the priming doses, 0.08 mg/kg atracurium, when followed 3 min later by 0.42 mg/kg atracurium, had a significantly greater fade in the TOF ratio at any given T1 value. This may indicate significant prejunctional activity. Acceleration of the onset of neuromuscular blockade was, however, evident in all groups that received atracurium in divided doses. The implication is, therefore, that prejunctional activity may not contribute significantly to the acceleration of onset of neuromuscular blockade after administration of atracurium in divided doses, as described in this study.

Pulmonary Function Tests in Normal Saudi School Children

Pulmonary function tests were done in normal Saudi children (215 boys, 130 girls) ranging in age from 6 to 17 years. The children were selected at random from various primary and secondary schools ...