Sahar M. Siddik-Sayyid

The Analgesic Efficacy of Subarachnoid Morphine in Comparison with Ultrasound-Guided Transversus Abdominis Plane Block After Cesarean Delivery: A Randomized Controlled Trial

BACKGROUND: Ultrasound-guided transversus abdominis plane block is an effective method of providing pain relief after cesarean delivery. Neuraxial morphine is currently the “gold standard” treatment for pain after cesarean delivery. In this study we tested the hypothesis that subarachnoid morphine would provide more prolonged and superior analgesia than would transversus abdominis plane block in patients undergoing elective cesarean delivery. METHODS: In this prospective, double-blind study, 57 patients were randomly assigned to receive either subarachnoid morphine (group SAM; n = 28) or transversus abdominis plane block (group TAP; n = 29). Patients received bupivacaine spinal anesthesia combined with morphine 0.2 mg in group SAM and received saline in group TAP. At the end of surgery, bilateral transversus abdominis plane block was performed using saline in group SAM or using bupivacaine 0.375% plus epinephrine 5 &mgr;g/mL in group TAP with 20 mL on each side. Postoperative analgesia for the first 24 hours consisted of scheduled rectal diclofenac and IV paracetamol; breakthrough pain was treated with IV tramadol. For the next 24 hours, scheduled rectal diclofenac was given; oral paracetamol and IV tramadol were administered upon patient request. Patients were assessed postoperatively in the postanesthesia care unit (time 0 hours) and at 2, 4, 6, 12, 24, 36, and 48 hours. The primary outcome measure was the time to first analgesic request. RESULTS: Median (range) time to first analgesic request was longer in group SAM than in group TAP [8 (2–36) hours versus 4 (0.5 to 29) hours (P = 0.005)]. Median (range) number of tramadol doses received between 0 and 12 hours was 0 (0–1) in group SAM versus 0 (0–2) in group TAP (P = 0.03). Postoperative visceral pain scores at rest and on movement during first the 4 hours were lower in group SAM than in group TAP, but were not different at any other time points. The incidence of moderate to severe nausea was higher in group SAM than in group TAP [13/28 (46%) versus 5/29 (17%) (P = 0.02)]. More patients developed pruritus requiring treatment in group SAM than in group TAP [(11/28 (39%) versus none (0%) (P < 0.001)]. CONCLUSION: As part of a multimodal analgesic regimen, subarachnoid morphine provided superior analgesia when compared with ultrasound-guided transversus abdominis plane block after cesarean delivery, yet at the cost of increased side effects.

Preoperative caudal block prevents emergence agitation in children following sevoflurane anesthesia

Background:  The frequency of emergence agitation in children is increased following sevoflurane anesthesia. However, controversies still exist concerning the exact etiology of this postanesthetic problem. Although this phenomenon is present with adequate pain relief or even following pain‐free procedures, pain is still regarded as a major contributing factor.

The effect of low-dose remifentanil on responses to the endotracheal tube during emergence from general anesthesia.

BACKGROUND: Emergence from general anesthesia can be associated with coughing, agitation, and hemodynamic disturbances. Remifentanil may attenuate these responses. METHODS: In a prospective, double-blind, randomized trial, we enrolled 60 adult patients undergoing nasal surgery using remifentanil-based anesthesia. During the emergence phase, the remifentanil group had remifentanil reduced to one tenth of the maintenance rate, whereas the control group had remifentanil discontinued. RESULTS: Times to awakening and tracheal extubation were similar between the two groups. During emergence, the remifentanil group (infusion rate 0.014 ± 0.011 &mgr;g · kg−1 · min−1) had a significantly lower incidence (40% vs 80%, P = 0.002) and less severe coughing compared with the control group, as well as a lower incidence of nonpurposeful movement (3.3% vs 30%, P = 0.006) and slower heart rates. CONCLUSIONS: Low-dose remifentanil during emergence did not prolong wake-up but reduced the incidence and severity of coughing from the endotracheal tube.

Propofol is superior to thiopental for intubation without muscle relaxants

PurposeTo compare intubating conditions and cardiovascular changes following induction of anesthesia and tracheal intubation in patients receiving either lidocaine-remifentanil-propofol or lidocaine-remifentanil-thiopental prior to induction.MethodsIn a randomized, double-blind study 76 healthy adult patients were assigned to one of two groups: lidocaine 1.5 mg kg-1, remifentanil 2μg kg-1 and propofol 2 mg kg-1 (Group P) or lidocaine 1.5 mg kg-1, remifentanil 2μg kg-1 and thiopental 5 mg kg-1 (Group T). Ninety seconds after the administration of the hypnotic agent, laryngoscopy and tracheal 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’s response to intubation and slow inflation of the tracheal cuff. The mean arterial pressure (MAP) and heart rate (HR) were measured 45 sec after hypnotic agent administration, immediately after tracheal intubation, two and five minutes after intubation.ResultsExcellent intubating conditions were obtained in 84% of Group P patients and 50% of Group T patients (P < 0.05). The percentage decrease from baseline MAP was significantly higher in Group P than in Group T postinduction (27.4% ± 1 1.6 vs 21.8% ± 10.0) and immediately postintubation (19.0% ± 16.7 vs 11.2% ± 14.9). The percentage change from baseline HR was significantly higher in Group Pthan in Group T postinduction (13.8% ± 9.7 vs 0.5% ± 12.4), immediately postintubation (8.7% ± 13.7 vs 2.1% ± 13.1), and two minutes postintubation (7.04% ± 14.3 vs 3.5% ± 14.3).ConclusionLidocaine-remifentanil-propofol is superior to lidocaine-remifentanil-thiopental for tracheal intubation without muscle relaxants. However, it induces more hypotension and bradycardia.RésuméObjectifComparer les conditions d’intubation et les changements cardiovasculaires suivant l’induction de l’anesthésie et l’intubation endotrachéale chez les patients qui reçoivent un mélange de lidocaïne-rémifentanil-propofol ou de lidocaïne-rémifentanil-thiopental avant l’induction.MéthodeLors d’une étude randomisée et en double aveugle, 76 adultes sains répartis en deux groupes ont reçu : 1,5 mg kg-1 de lidocaïne, 2 μg kg-1 de rémifentanil et 2 mg kg-1 de propofol (Groupe P) ou 1,5 mg kg-1 de lidocaïne, 2 μg kg-1 de rémifentanil et 5 mg kg-1 de thiopental (Groupe T). La laryngoscopie et l’intubation endotrachéale ont été tentées 90 s après l’administration de l’agent hypnotique. Les conditions d’intubation ont été évaluées comme excellentes, bonnes ou pauvres fondées sur la facilité à ventiler, le relâchement de la mâchoire, la position des cordes vocales et la réaction du patient à l’intubation et au gonflement lent du ballonnet trachéal. La tension artérielle moyenne (TAM) et la fréquence cardiaque (FC) ont été mesurées 45 s après l’administration de l’agent hypnotique, immédiatement après l’intubation endotrachéale, deux et cinq minutes après l’intubation.RésultatsDes conditions d’intubation excellentes ont été obtenues chez 84 % des patients du Groupe P et 50 % du Groupe T (P < 0,05). La TAM a été significativement réduite par rapport aux mesures de base, davantage dans le Groupe P que dans le Groupe T après l’induction (27,4 % ± 11,6vs21, 8% ± 10,0) et immédiatement après l’intubation (19,0 % ± 16,7 vs 11,2% ± 14,9). La FC a été modifiée par rapport aux mesures de base, plus dans le Groupe P que dans le Groupe T après l’induction (13,8 % ± 9,7 vs 0,5 % ± 12,4), immédiatement après l’intubation (8,7 % ± 13,7 vs 2,1 % ± 13,1) et deux minutes après l’intubation (7,04% ± 14,3 vs 3,5% ± 14,3).ConclusionLe mélange de lidocaïne-rémifentanil-propofol est supérieur à celui de lidocaïne-rémifentanil-thiopental pour l’intubation endotrachéale sans myorelaxants. Cependant, il induit plus d’hypotension et de bradycardie.

A randomized trial comparing colloid preload to coload during spinal anesthesia for elective cesarean delivery.

BACKGROUND: Hypotension after spinal anesthesia for cesarean delivery is common. Previous studies have demonstrated that a crystalloid fluid “coload” (rapid administration of a fluid bolus starting at the time of intrathecal injection) is superior to the conventional crystalloid preload (fluid administered before the intrathecal injection) for preventing hypotension. Colloid preload provides a sustained increase in central blood volume. We hypothesized that, in contrast to crystalloid, a colloid preload may be more effective than colloid coload for reducing the incidence of spinal anesthesia-induced hypotension. METHODS: In this double-blind study, 178 patients were randomly assigned to receive a preload of 500 mL of hydroxyethyl starch over a period of 15–20 min before initiation of spinal anesthesia (n = 90) or an identical fluid bolus of hydroxyethyl starch starting at the time of identification of cerebrospinal fluid (n = 88). Vasopressors (ephedrine or phenylephrine) were administered if systolic arterial blood pressure decreased less than 80% of the baseline pressure and <100 mm Hg, or with smaller decreases in blood pressure if accompanied by nausea, vomiting, or dizziness. The primary outcome was the incidence of hypotension (defined as the administration of at least one dose of vasopressor). RESULTS: There was no significant difference between the groups in the incidence of hypotension (68% in preload group and 75% in coload group, 95% confidence interval of difference −6%–20%; P = 0.28), doses of ephedrine and phenylephrine, and number of vasopressor unit doses. The incidence of severe hypotension (systolic blood pressure <80 mm Hg) was 16% in the preload group and 22% in the coload group (P = 0.30). There were no differences in the incidence of nausea and/or vomiting, or neonatal outcome between the groups. CONCLUSION: There was no difference in the incidence of hypotension in women who received colloid administration before the initiation of spinal anesthesia compared with at the time of initiation of anesthesia. Both modalities are inefficient as single interventions to prevent hypotension.

Femoral vein cannulation performed by residents: a comparison between ultrasound-guided and landmark technique in infants and children undergoing cardiac surgery.

BACKGROUND: Percutaneous cannulation of the femoral vein, in the pediatric age group, can be technically challenging, especially when performed by residents in training. We examined whether the use of real-time ultrasound guidance is superior to a landmark technique for femoral vein catheterization in children undergoing heart surgery. METHODS: Patients were prospectively randomized into 2 groups. In group LM, the femoral vein was cannulated using the traditional method of palpation of arterial pulse. In group US, cannulation was guided by real-time scanning with an ultrasound probe. The time to complete cannulation (primary outcome), success rate, number of needle passes, number of successful cannulations on first needle pass, and incidence of complications were compared between the 2 groups. RESULTS: Forty-eight pediatric patients were studied. The time to complete cannulation was significantly shorter (155 [46–690] vs 370 [45–1620] seconds; P = 0.02) in group US versus group LM. The success rate was similar in both groups (95.8%). The number of needle passes was smaller (1 [1–8] vs 3 [1–21]; P = 0.001) and the number of successful cannulations on first needle pass higher (18 vs 6; P = 0.001) in group US compared with group LM. The incidence of femoral artery puncture was comparable between the 2 groups. CONCLUSIONS: Ultrasound-guided cannulation of the femoral vein, in pediatric patients, when performed by senior anesthesia residents, is superior to the landmark technique in terms of speed and number of needle passes, with remarkable improvement in first attempt success.

Epidural tramadol for postoperative pain after Cesarean section

PurposeTo compare the post-operative analgesic effect of 100 mgvs 200 mg epidural tramadol and saline in patients undergoing elective Cesarean section.MethodsSixty healthy women undergoing Cesarean delivery with epidural anesthesia were randomly allocated into three groups (n = 20 in each). Patients received, at skin closure via the epidural catheter, 100 mg tramadol (Group I), 200 mg tramadol (Group II) or 10 ml saline (Control group). Pain scores and side effects were evaluated at 1, 2, 4, 8, 12 and 24 hr after surgery. Mean times to the first analgesic administration, as well as the cumulative doses of analgesic requirements over 24 hr postoperatively were compared.ResultsThe mean time to first analgesic administration was longer in patients who received 100 mg tramadol (4.5 ±3.1 hr) and the 200 mg tramadol (6.6 ±3.4 hr) than in those who received placebo (2.8 ± 2 hr). The mean cumulative doses of meperidine over 24 hr were less in the 100 mg tramadol group (0.3 ± 0.3 mg·kg−1) and the 200 mg tramadol group (0.3 ± 0.3 mg·kg−1) than in the control group (0.7 ± 0.4 mg·kg−1). Also, the mean doses of diclofenac over 24 hr were less in the 100 mg tramadol group (156 ± 59 mg) and the 200 mg tramadol group (142 ± 62 mg) than in the control group (214 ± 70 mg). However, no difference was obtained between patients receiving 100 mg and 200 mg tramadol concerning all parameters studied.ConclusionEpidural tramadol 100 mg can provide adequate postoperative analgesia without respiratory depression in patients after Cesarean delivery.RésuméObjectifComparer l’effet analgésique postopératoire de 100 mg vs 200 mg de tramadol épidural ou d’une solution salée chez des patientes qui doivent subir une césarienne.MéthodeSoixante femmes en santé admises pour une césarienne sous anesthésie épidurale ont été réparties au hasard en trois groupes (n = 20 chacun). Elles ont reçu, lors de la fermeture cutanée et au moyen d’un cathéter épidural, 100 mg (groupe I) ou 200 mg (groupe II) de tramadol ou 10 ml de solution salée (groupe témoin). Les scores de douleur et les effets secondaires ont été évalués à 1, 2, 4, 8, 12 et 24 h après l’intervention. On a comparé les temps moyens de la première administration d’analgésique et quelles en étaient les doses cumulatives postopératoires demandées pendant 24 h.RésultatsLe temps moyen pour la première analgésie a été plus long chez les patientes qui ont reçu 100 mg (4,5 ±3,1 h) ou 200 mg (6,6 ± 3,4 h) de tramadol que chez celles qui n’ont reçu que le placebo (2,8 ± 2 h). Pendant 24 h après la césarienne, les doses moyennes cumulatives de mépéridine ont été moindres dans les groupes I et II (0,3 ± 0,3 mg·kg−1; 0,3 ± 0,3 mg·kg−1) que dans le groupe témoin (0,7 ± 0,4 mg·kg−1) et les doses moyennes de diclofénac ont été plus faibles dans les groupes I et II (156 ± 59 mg; 142 ± 62 mg) que dans le groupe témoin (214 ± 70 mg). Cependant, aucune différence n’a été notée entre les patientes des groupes I et II, et ce, pour tous les paramètres étudiés.ConclusionLadministration épidurale de 100 mg de tramadol peut fournir une analgésie postopératoire adéquate sans dépression respiratoire chez des patientes qui ont subi une césarienne.

Haloperidol vs. ondansetron for the prevention of postoperative nausea and vomiting following gynaecological surgery

Background and objective: Ondansetron is widely used for the prophylaxis of postoperative nausea and vomiting, while haloperidol is an antiemetic that lacks recent data on efficacy and adverse effects. Methods: In this prospective, randomized, double‐blinded study involving 93 females undergoing gynaecological procedures under general anaesthesia, we compared the efficacy and adverse effects of prophylactic haloperidol 1 mg intravenous and ondansetron 4 mg intravenous vs. placebo. Results: During the overall observation period (0–24 h), in the haloperidol, ondansetron and placebo groups respectively, the incidence of nausea and/or vomiting was 40.7% (11/27), 48.2% (13/27) and 55.5% (15/27), and the need of rescue antiemetics was 22.2% (6/27), 44.4% (12/27) and 40.7% (11/27), with P values >0.05 among the three groups. During the early observation period (0–2 h), in the haloperidol, ondansetron and placebo groups respectively, the incidence of nausea and/or vomiting was 13.7% (4/29), 26.6% (8/30) and 43% (13/30), and the need for rescue antiemetics was 6.8% (2/29), 26.6% (8/30) and 36.6% (11/30). Between haloperidol and placebo groups, the P value was 0.04 for nausea and/or vomiting, and was 0.01 for rescue antiemetics, in addition to lower nausea scores (P = 0.03). During the late observation period (2–24 h), no significant difference was shown among the three groups. Conclusion: The prophylactic administration of 1 mg intravenous haloperidol or 4 mg ondansetron, in female patients undergoing gynaecological surgery, did not improve the overall incidence of nausea and/or vomiting vs. placebo. However, haloperidol 1 mg proved to be an effective antiemetic in the early observation period without significant adverse effects.

Intrathecal Versus Intravenous Fentanyl for Supplementation of Subarachnoid Block During Cesarean Delivery

Forty-eight healthy parturients scheduled for elective cesarean delivery were randomly allocated to receive intrathecally either 12 mg of hyperbaric bupivacaine plus 12.5 &mgr;g of fentanyl (n = 23) or bupivacaine alone (n = 25). In the latter group, IV 12.5 &mgr;g of fentanyl was administered immediately after spinal anesthesia. We compared the amount of IV fentanyl required for supplementation of the spinal anesthesia during surgery, the intraoperative visual analog scale, the time to the first request for postoperative analgesia, and the incidence of adverse effects. Additional IV fentanyl supplementation amounting to a mean of 32 ± 35 &mgr;g was required in the IV Fentanyl group, whereas no supple- mentation was required in the Intrathecal Fentanyl group (P = 0.009). The time to the first request for postoperative analgesia was significantly longer in the Intrathecal Fentanyl group than in the IV Fentanyl group (159 ± 39 min versus 119 ± 44 min;P = 0.003). The incidence of systolic blood pressure <90 mm Hg and the ephedrine requirements were significantly higher in the IV Fentanyl group as compared with the Intrathecal Fentanyl group (P = 0.01). Also, intraoperative nausea and vomiting occurred less frequently in the Intrathecal Fentanyl group compared with the IV Fentanyl group (8 of 23 vs 17 of 25;P = 0.02).

A randomized controlled trial of variable rate phenylephrine infusion with rescue phenylephrine boluses versus rescue boluses alone on physician interventions during spinal anesthesia for elective cesarean delivery.

BACKGROUND:Phenylephrine infusion is used to reduce hypotension during spinal anesthesia for cesarean delivery. A prophylactic fixed rate infusion regimen may not improve hemodynamic control; a variable rate regimen adjusted in response to changes in arterial blood pressure and heart rate may allow more accurate maintenance of baseline blood pressure. We hypothesized that a combination of crystalloid solution coload with a variable rate phenylephrine infusion and phenylephrine rescue boluses may be associated with fewer physician interventions needed to maintain maternal systolic blood pressure within 20% of baseline and greater hemodynamic stability than crystalloid solution coload with phenylephrine rescue boluses alone. METHODS:In this prospective, double-blind study, 80 patients received a coload with 15 mL/kg lactated Ringer’s solution immediately after the initiation of spinal anesthesia. Patients were randomized to receive a prophylactic variable rate phenylephrine infusion starting at 0.75 &mgr;g/kg/min (group P) or infusion of normal saline (group S). Maternal systolic blood pressure was maintained within 20% of baseline with rescue phenylephrine boluses using a preset algorithm. During the predelivery period, the number of physician interventions (primary outcome), hemodynamic performance, nausea/vomiting, and umbilical cord blood gas values were compared between the groups. RESULTS:One patient from group S was excluded due to protocol violation. Therefore, group P included 40 patients and group S 39 patients. The median (range) number of physician interventions needed to maintain maternal hemodynamics within the target range (0 [0–6] vs 3 [0–9], difference in median: 3, 95% confidence interval of difference: 2–4) and incidence of hypotension (8/40 [20%] vs 35/39 [90%]) were lower in group P compared with group S (P < 0.001). Group P had a higher incidence of hypertension compared with group S (6/40 [15%] vs 0/39 [0%], P = 0.026). The median performance error was closer to baseline (P < 0.001) with a smaller median absolute performance error (P = 0.001) in group P versus group S. In group P, 4/40 (10%) patients had nausea/vomiting compared with 17/39 (44%) in group S (P = 0.001). The number needed to treat was 1.4 women to prevent 1 case of hypotension, and 3 women to prevent 1 case of nausea/vomiting; the rate of hypertension was 1 case per 6.7 women treated. Neonatal outcomes were not different between the 2 groups. CONCLUSION:Prophylactic variable rate phenylephrine infusion and rescue phenylephrine bolus dosing is more effective than relying on rescue phenylephrine bolus dosing with respect to limiting clinician workload and maternal symptoms during spinal anesthesia for cesarean delivery.