Ibraheem Y. Qudaisat

Intraoperative administration of dexmedetomidine reduces the analgesic requirements for children undergoing hypospadius surgery.

Background The present study was designed to assess whether an intraoperative administration of dexmedetomidine would decrease the intraoperative and postoperative analgesic requirements for paediatric patients undergoing hypospadius surgery. Methods Forty-eight children (American Society of Anesthesiologists-1) aged 1–12 years undergoing hypospadius repair under general anaesthesia were randomly assigned into dexmedetomidine or placebo groups, D and P, respectively. Group D received a loading dose of dexmedetomidine 1 μg kg−1 after induction of anaesthesia, followed by a continuous infusion at a rate of 0.7 μg kg−1 h−1. Group P received a volume-matched 0.9% saline. Both groups received fentanyl for intraoperative analgesia and intravenous morphine and oral paracetamol for postoperative analgesia. For both groups, heart rate, blood pressure and fentanyl requirements were recorded intraoperatively. During their stay for 2 h in the recovery room, heart rate, blood pressure, pain scores, behaviour scores and total morphine requirements were recorded. After discharge from postanaesthesia care unit, paracetamol requirements over 24 h were also recorded. Results Intraoperatively, the dexmedetomidine-treated group had significantly fewer fentanyl requirements, slower heart rate and lower mean arterial blood pressure (P < 0.001). In the postanaesthesia care unit, this group also consumed significantly less morphine, had lower pain scores, lower behaviour score in the immediate postoperative period, lower heart rates and mean arterial blood pressures when compared with the placebo group (P < 0.001). Group D consumed significantly less paracetamol than group P in the ward over 24 h. Conclusion Intravenous administration of dexmedetomidine intraoperatively during hypospadius repair in children reduces intraoperative and postoperative analgesic requirements and lowers heart rate and blood pressure.

Short thyromental distance is a surrogate for inadequate head extension, rather than small submandibular space, when indicating possible difficult direct laryngoscopy.

Context Airway research in anaesthesia shows that the thyromental distance (TMD) as a predictor of difficult intubation is subject to variable sensitivity and specificity. Recently, its value in this regard has been questioned with calls for a redefinition of its role. Objective(s) To define the role of TMD as a predictor of possible difficult laryngoscopy. Design A prospective observational study. Setting A tertiary university teaching hospital. Patients or other participants Two hundred and thirty-five consecutive patients (137 men), planned for endotracheal intubation anaesthesia, were enrolled in the study. Those who were edentulous, or had facial asymmetry, teeth protrusion, limited mouth opening, history of head and/or neck radiation therapy or any disorder, were excluded. Nobody was excluded once enrolled. Intervention(s) Preoperative straight-line morphometric measurements of the mandible and submandibular space (SMS) were taken by a measuring device and used to form a three-dimensional model of SMS. Sagittal dimensions of the SMS that determine the TMD were derived using trigonometric laws. Main outcome measures Direct laryngoscopic view, assessed by a senior anaesthetist and classified according to Cormack/Lehane classification. Results Thirty-two patients were reported to have ‘limited laryngoscopic view’. The TMD had a sensitivity of 19% and a specificity of 97% as a predictor of laryngoscopic view. Among the factors that determine the magnitude of TMD, only the degree of head extension was significantly different between the two laryngoscopy groups. The other two factors (sagittal angulomental distance, representing mandibular growth, and sagittal angulothyroid distance, representing laryngeal descent in the neck) did not differ between the two groups. Also, the SMS volume did not differ between the two laryngoscopy groups. Conclusion The role of the TMD in prediction of difficult laryngoscopy should be redefined from a variable representing the SMS volume to one acting as a surrogate for inadequate head extension.

Comparison of caudal bupivacaine alone with bupivacaine plus two doses of dexmedetomidine for postoperative analgesia in pediatric patients undergoing infra‐umbilical surgery: a randomized controlled double‐blinded study

Data are still insufficient about the effects of different concentrations of caudal dexmedetomidine when used to prolong postoperative analgesia in children. The aim of this study was to assess the analgesic efficacy and side effects of two doses of caudal dexmedetomidine (1 and 2 μg·kg−1) co‐administered with bupivacaine in terms of postoperative pain scores and requirement of postoperative analgesia over 24 h in children undergoing infra‐umbilical surgery.

Early vs. late tracheostomy for the ICU patients: Experience in a referral hospital

Objectives: The aim of this study is to present our experience with elective surgical tracheostomy for intensive care unit (ICU) patients who needed prolonged translaryngeal intubation in order to evaluate the proper timing and advantages of early vs. late tracheostomy and to stress upon the risks associated with delayed tracheostomy. Methods: Medical records of all patients, who underwent elective tracheostomy for prolonged intubation from September 2006 to August 2010 at Jordan University hospital, were reviewed. Results: A total of 106 patients (74 males) were included; their age ranged from 2 months to 90 yr with mean age of 46.5 yr. The mean time at which tracheostomy was done after initial tracheal intubation was 23 days (range 3-7 weeks). Trauma was the most frequent cause of ICU admission 38 (35.8%), followed by post-surgery causes 14 (13.2%). An early tracheostomy showed less complication vs late procedure. The length of stay in the ICU for patients who had an early tracheostomy was 26 days while this period for patients who had late tracheostomy was 47 days. Mortality rate among patients who had early tracheostomy was 17.1% while for late tracheostomy patients, it was 36.1%. Conclusion: Proper assessment and early tracheostomy is recommended for patients who require prolonged tracheal intubation in the ICU.

Foreign body aspiration in children: A study of children who lived or died following aspiration

Foreign body aspiration (FBA) is a preventable cause of mortality and morbidity in children. We conducted a chart review of children who presented to a university hospital due to FBA in the period 1999-2014. Children were either managed with bronchoscopy for removal of the foreign body or died due to FBA. A total of 103 children were seen due to FBA including 27 deaths. The majority of children were boys and were less than 3 years old. Most aspirated foreign bodies were food-related, mainly peanuts. The majority of children presented with acute choking incidents, a smaller number presented with recurrent chest infections, and few childrens choking incidents were unwitnessed. X-ray had a high rate of false negatives and bronchoscopy was the gold standard technique for assessment and management. Aspiration of foreign bodies is a preventable, life-threatening condition that calls for increased parent education and awareness.

Remifentanil consumption in septoplasty surgery under general anesthesia. Association with humane mu-opioid receptor gene variants

Objectives: To evaluate the influence of the ORM1 variants in codon 118 on the intra-operative remifentanil consumption under general anesthesia. Methods: A prospective gene association study, performed at the Jordan University Jordan, Amman, Jordan from September 2013 to August 2014. It includes patients who underwent septoplasty surgery under general anesthesia. All patients received standard intravenous anesthesia. Anesthesia maintained with fixed dose of Sevoflurane and variable dose of Remifentanil to keep the systolic blood pressure between 90-100 mm Hg. The Remifentanil dose was calculated and correlated with ORM1 genotype variance. Results: Genotype and clinical data were available for 123 cases. The A118A genotype was seen in 96 patients (78%), the A118G genotype was seen in 25 patients (20.3%), and only 2 patients had genotype G118G (1.6%). The G118G variant was removed from the statistical analysis due to small sample size. There was a significant effect of ORM1 genotype variant and the amount of remifentanil consumed. The A118A genotype received 0.173 ± 0.063 µg kg-1 min-1 and the A118G genotype received 0.316 ± 0.100 µg kg-1 min-1 (p<0.0001). Conclusion: The ORM1 gene has a role in intra-operative remifentanil consumption in patients who underwent septoplasty surgery under general anesthesia. The A118G gene required higher dose of remifentanil compared with the A118A genotype.

The effects of caudal or intravenous dexmedetomidine on postoperative analgesia produced by caudal bupivacaine in children: a randomized controlled double-blinded study

STUDY OBJECTIVES The aim of this study was to compare the effects of caudal and intravenous (IV) dexmedetomidine (1 μg/kg) on postoperative analgesia after caudal bupivacaine in pediatric patients undergoing lower abdominal and perineal surgeries. DESIGN A randomized controlled double-blind study. SETTING University-affiliated teaching hospital. PATIENTS Seventy-five American Society of Anesthesiologists I children, aged 1 to 6 years. INTERVENTION Patients were randomly allocated to 3 groups. All patients received 1 mL/kg caudal 0.25% bupivacaine. In addition, those in group B (n=25) received 10-mL IV saline, those in group B-Dcau (n=25) received 1 μg/kg caudal dexmedetomidine and 10-mL IV saline, and those in group B-DIV (n=25) received 1 μg/kg IV dexmedetomidine in 10-mL saline. MEASUREMENTS Intraoperative mean blood pressure, heart rate, peripheral oxygen saturation, end-tidal sevoflurane, and bispectral index as well as postoperative pain and behavior scores and time to first analgesia were assessed. MAIN RESULTS Group B-Dcau had a significantly longer time to first rescue analgesia than groups B-DIV and B, with mean (SD) values of 14.4 (7.5), 9.18 (2.7), and 6.6 (2.5) hours, respectively (P<.05). Fewer patients in group B-Dcau (n=16) required rescue analgesia during the first 24 hours postoperatively compared to group B (n=24) and group B-DIV (n=20) (P<.05). Groups B-Dcau and B-DIV had lower pain and behavior scores than Group B. Eight patients Group B had agitation compared to 2 in Group B-DIV and 0 in Group B-Dcau. Four patients in Group B-DIV developed bradycardia and hypotension during surgery. CONCLUSIONS Compared to IV administration, caudal administration of dexmedetomidine during caudal bupivacaine anesthesia provided prolonged postoperative analgesia and a greater analgesic sparing effect without significant side effects. This suggests a greater role of neuraxial compared to that of peripheral α-2 adrenoceptors in pain processing.

Coanda effect as an explanation for unequal ventilation of the lungs in an intubated patient

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Ephedrine requirements during spinal anesthesia for cesarean delivery in Jordanian parturients: association with b2 adrenoceptor gene variants.

BACKGROUND Maternal hypotension after spinal anesthesia for cesarean delivery is common. Many studies performed on the β2-adrenoceptor (β2AR) gene variants and their association with vasopressor requirements during and after neuroaxial block have contradictory conclusions. OBJECTIVES The aim of the study was to evaluate the influence of the β2AR in codons 16 and 27 on the incidence of maternal hypotension and ephedrine consumption after spinal anesthesia for cesarean delivery in an Arab ethnic group. DESIGN A prospective gene association study. SETTING Jordan University Hospital from 1 July 2013 to 31 January 2014. PATIENTS AND METHODS We enrolled parturients who underwent cesarean delivery under spinal anesthesia. Spinal anesthesia was performed with 10 mg plain bupivacaine along with 25 μg fentanyl. Hypotension was treated with ephedrine and the amount consumed in the first 30 minutes after spinal anesthesia was calculated. The β2AR genotype at codons 16 and 27 was determined. We studied the correlation between the β2AR genotype and the amount of ephedrine consumption after spinal anesthesia. MAIN OUTCOME MEASURES Amount of ephederine used. RESULTS Of 250 patients enrolled in the study, genotype and clinical data were available for 234 cases. Ephedrine was used in 94% of patients. There was a significant effect of β2AR genotype on ephedrine dose in the first 30 minutes after spinal anesthesia in codon 16 and 27. Arg16 homozygotes received less ephedrine (14.0 [11.2] mg) than Gly16 homozygotes (38.6 [25.7] mg) and Arg16Gly heterozygotes (33.42 [22.70] mg) (P<.0001). Gln27 homozygotes received less ephedrine (18.2 [12.8] mg) than Glu 27 homozygotes (47.5 [27.0] mg) and Gln27Glu heterozygotes (48.2 [23.7] mg). (P<.0001). CONCLUSION In an Arab ethnic group, the β2AR gene has a role in maternal hypotension after spinal anesthesia. The Gly16 and Glu27 alleles have a higher incidence of arterial hypotension and required a greater amount of vasopressor to treat hypotension compared with homozygous Arg16 and Gln27 carriers. LIMITATIONS Fasting time and hydration protocol, the use of a fixed dose of ephedrine, and relatively small sample size.