Pramila Chari

Comparative evaluation of midazolam and ketamine with midazolam alone as oral premedication

Background : Oral premedication with midazolam and ketamine is widely used in pediatric anesthesia to reduce emotional trauma and ensure smooth induction. However, various dosing regimens when used alone or in combination have variable efficacy and side effect profile. The aim of our study was to investigate and compare the efficacy of oral midazolam alone with a low‐dose combination of oral midazolam and ketamine.

Dose response study of caudal neostigmine for postoperative analgesia in paediatric patients undergoing genitourinary surgery

Background: Neostigmine given through the neuraxial route has been found to have analgesic properties. In this clinical trial, we evaluated for the first time the efficacy of a varying dose of caudal neostigmine for postoperative analgesia in children undergoing genitourinary surgery.

Caudal neostigmine with bupivacaine produces a dose-independent analgesic effect in children

PurposeTo evaluate the analgesic efficacy and duration of varying doses of caudal neostigmine with plain bupivacaine and its side effects in children undergoing genito-urinary surgery.MethodsIn a randomized double-blind prospective study 80 boys aged two to eight years scheduled for surgical repair of hypospadias were allocated randomly to one of four groups (n = 20 each) and received either only caudal 0.25% plain bupivacaine 0.5 mL · kg−1 (Group 1) or 0.25% plain bupivacaine 0.5 mL · kg−1 with neostigmine (Groups II-IV) in doses of 2, 3 and 4βg · kg−1 respectively. Postoperative pain was assessed for 24 hr using an objective pain score. Blood pressure, heart rate, oxygen saturation, total amount of analgesic consumed and adverse effects were also recorded.ResultsThe duration of postoperative analgesia in Group I (5.1 ± 2.3 hr) was significantly shorter than in the other three groups (II–16.6 ± 4.9 hr; III — 17.2 ± 5.5 hr; IV-17.0 ± 5.8 hr; P < 0.05). Total analgesic (paracetamol) consumption was significantly more in Group 1 (697.6 ± 240.7 mg) than in the groups receiving caudal neostigmine (II — 248.0 ± 178.4; III — 270.2 ± 180.8 and IV − 230.6 ± 166.9 mg; P < 0.05). Groups II, III and IV were comparable with regards to duration of postoperative analgesia and total analgesic consumption (P > 0.05). Incidence of nausea and vomiting were comparable in all four groups. No significant alteration in vital signs or any other adverse effects were observed.ConclusionsCaudal neostigmine (2, 3 and 4μg · kg−1) with bupivacaine produces a dose-independent analgesic effect (≈ 16–17 hr) in children as compared to those receiving caudal bupivacaine alone (approximately five hours) and a reduction in postoperative rescue analgesic consumption without increasing the incidence of adverse effects.RésuméObjectifÉvaluer l’efficacité analgésique et la durée de différentes doses de néostigmine caudale avec bupivacaïne simple et ses effets secondaires chez des enfants qui subissent une intervention génito-urinaire.MéthodeDans une étude randomisée, prospective et à double insu, 80 garçons de deux à huit ans devant subir la réparation chirurgicale d’un hypospadias ont été répartis au hasard en quatre groupes (n = 20 chacun) et ont reçu: seulement de la bupivacaïne caudale simple à 0,25 % (0,5 mL · kg−1 Groupe I) ou de la bupivacaïne simple à 0,25 % avec néostigmine (0,5 mL · kg−1, Groupes II-IV) en doses respectives de 2, 3 et 4 μg · kg−1. La douleur postopératoire a été évaluée pendant 24 h selon des scores de douleur objectifs. La tension artérielle, la fréquence cardiaque, la saturation du sang en oxygène, la quantité totale d’analgésiques consommés et les effets secondaires ont été aussi enregistrés.RésultatsLa durée de l’analgésie postopératoire a été significativement plus courte dans le Groupe I (5,1 ± 2,3 h) que dans les autres groupes (II — 16,6 ± 4,9 h; III — 17,2 ± 5,5 h; IV-17,0 ± 5,8 h; P < 0,05). La consommation totale d’analgésique (paracétamol) a été significativement plus élevée dans le Groupe I (697,6 ± 240,7 mg) que dans les groupes avec néostigmine caudale (II — 248,0 ± 178,4; III-270,2 ± 180,8 et IV — 230,6 ± 166,9 mg; P < 0,05). La durée de l’analgésie postopératoire et la consommation totale d’analgésique (P > 0,05) étaient comparables dans les groupes II, III et IV. Lincidence de nausées et de vomissements a été similaire dans les quatre groupes. Aucune modification significative des signes vitaux ou tout autre effet indésirable n’ont été observés.ConclusionChez des enfants, la néostigmine caudale (2, 3 et 4 μg · kg−1) avec bupivacaïne, comparées à la bupivacaïne caudale seule (≈ 5 h), produit une analgésie non reliée à la dose (≈ 16–17 h) et une réduction de la consommation postopératoire d’analgésique de secours sans augmenter l’incidence d’effets indésirables.

Comparison of Ondansetron With Ondansetron Plus Dexamethasone for Antiemetic Prophylaxis in Children Undergoing Strabismus Surgery

BACKGROUND Children undergoing strabismus surgery have a high incidence of postoperative nausea and vomiting. Ondansetron plus dexamethasone is effective in reducing its incidence in many surgical procedures. PURPOSE To examine the efficacy of ondansetron plus dexamethasone in children undergoing strabismus surgery. PATIENTS AND METHODS A randomized, placebo-controlled, double blind study of 100 children 2 to 12 years old, in American Society of Anesthesiologists classes I and II, and undergoing strabismus surgery with the use of general anesthesia was conducted. Children received normal saline (n = 31), an injection of 0.15 mg/kg of ondansetron (n = 39), or an injection of 0.15 mg/kg of ondansetron and 0.2 mg/kg of dexamethasone (n = 30). Postoperatively, children were monitored for the number of emetic episodes, Steward recovery score, and need for a rescue antiemetic. RESULTS The incidence of vomiting was 64.5% in the group receiving saline, 33.3% in the group receiving ondansetron, and 10% in the group receiving ondansetron plus dexamethasone (P < .001). The incidence of early vomiting (0 to 4 hours) and the need for a rescue antiemetic were significantly lower in the groups receiving ondansetron (P < .01) and ondansetron plus dexamethasone (P < .001) compared with the group receiving saline; however, the former two groups were comparable in this regard. In the late postoperative period (4 to 24 hours), the incidence of vomiting and the need for a rescue antiemetic were not significantly different among the groups. Vomiting was significantly more severe in the group receiving saline compared with the groups receiving ondansetron and ondansetron plus dexamethasone at all times (P < .01 and P < .001, respectively). However, the latter two groups were comparable in this regard. CONCLUSION Ondansetron and ondansetron plus dexamethasone were equally effective in preventing early nausea and vomiting in children following strabismus surgery. However, the efficacy of dexamethasone in late postoperative nausea and vomiting could not be demonstrated. Further studies with a large population and different doses of dexamethasone may be warranted.

Addition of midazolam to continuous postoperative epidural bupivacaine infusion reduces requirement for rescue analgesia in children undergoing upper abdominal and flank surgery

STUDY OBJECTIVE To investigate the effect of adding midazolam to continuous epidural infusion of bupivacaine for postoperative analgesia in children. DESIGN Prospective, randomized, double-blind, controlled study. SETTING Tertiary-care center. PATIENTS 44 ASA physical status I and II children in age groups of two to 10 years, undergoing elective upper abdominal and flank surgery. INTERVENTIONS At the end of surgery, patients were randomly allocated to receive epidural infusion of 0.125% bupivacaine alone (Group B) or with 20 microg/kg/hr midazolam (Group BM) for 12 hours at the rate of 0.2 mL/kg/hr. MEASUREMENTS Pain, motor block, and sedation were assessed at predetermined times over 24 hours. Intravenous fentanyl was used as rescue analgesic for the first 12 hours, and tramadol for next 12 hours. Patients were followed at one week, one month, and one year for any neurological deficits. MAIN RESULTS The number of patients requiring rescue analgesia during infusion was significantly lower in Group BM (7 vs. 17 in Group B; P < 0.001). Time to first rescue analgesia was significantly prolonged in Group BM compared with Group B (P < 0.001). Frequency of fentanyl (P < 0.001) and tramadol (P = 0.001) administration as rescue analgesia was significantly less in Group BM. Significantly lower median pain scores were obtained in Group BM than Group B at all time intervals (P < 0.05). Greater sedation scores were noted in Group BM at all time intervals postoperatively except at 4 hours (P < 0.05). No motor block was observed in any child during the study. No neurological deficit was reported in any child in the one year of follow-up. CONCLUSION Addition of 20 microg/kg/hr of midazolam to postoperative continuous epidural infusion of 0.125% bupivacaine reduces the requirement for rescue analgesia in children following upper abdominal and flank surgery.

Epidural butorphanol-bupivacaine analgesia for postoperative pain relief after abdominal hysterectomy

STUDY OBJECTIVE To determine the efficacy of epidural butorphanol with and without bupivacaine in providing postoperative analgesia following abdominal hysterectomy. DESIGN Randomized, double-blinded study. SETTINGS Postoperative recovery area of a university-affiliated medical center. PATIENTS 60 ASA physical status I and II women, aged 20-65 years, undergoing abdominal hysterectomy. INTERVENTIONS Patients were randomly allocated to three groups during the postoperative period to receive one of three epidural regimens: two mg of butorphanol in 10 mL of normal saline (Group 1), two mg of butorphanol in 10 mL of 0.125% bupivacaine (Group 2), or two mg of butorphanol in 10 mL of 0.25% bupivacaine (Group 3). MEASUREMENTS Onset and duration of analgesia were recorded. Hemodynamic variables, pain scores, sedation scores, and respiratory rate were monitored for 24 hours. Frequency and severity of respiratory depression, sedation, pruritus, nausea, and vomiting were recorded. MAIN RESULTS The addition of butorphanol to bupivacaine resulted in significantly (P < 0.05) faster onset of pain relief. The duration of analgesia was prolonged in patients receiving butorphanol with bupivacaine combination (8.68 +/- 0.82 hrs, 9.82 +/- 0.54 hrs) as compared with butorphanol alone (4.35 +/- 0.66 hrs; P < 0.05). The differences between Groups 2 and 3 were not significant. CONCLUSIONS Addition of two mg of butorphanol to 0.125% of epidural bupivacaine resulted in rapid onset and longer duration of analgesia than did butorphanol alone.

Post-Enteric Mycotic Aneurysm of Abdominal Aorta with Total Disruption

We report an extremely rare case of suprarenal mycotic aneurysm of the abdominal aorta below the origin of the superior mesenteric artery, secondary to Salmonella infection in a 3-year-old boy, which was associated with total disruption of the aortic wall. This case was successfully managed surgically with debridement and interposition of a double velour Dacron graft in the involved segment of aorta. A high degree of suspicion, angiographic evaluation supported by noninvasive investigations, and a planned surgical approach are required for a successful outcome.