Somrat Charuluxananan

Nalbuphine versus propofol for treatment of intrathecal morphine-induced pruritus after cesarean delivery.

In this prospective, randomized, double-blinded study, we compared the efficacy of nalbuphine and propofol for treating intrathecal morphine-induced pruritus after cesarean delivery. One-hundred-eighty-one parturients who developed moderate to severe pruritus after the administration of intrathecal morphine were randomly allocated into two groups. One group received 3 mg IV nalbuphine (n = 91), and the other received 20 mg IV propofol (n = 90). The improvement of pruritus and other adverse effects was determined at 10 min after study drug administration. The treatment success rate was higher in the Nalbuphine group than in the Propofol group (83% vs 61%;P < 0.001). Among the successfully treated patients, recurrence rates of moderate to severe pruritus within 4 h were not significantly different (nalbuphine 9% versus propofol 7%;P = 0.76). Other side effects, such as decreased analgesia, increased nausea, vomiting, increased sedation, pain on injection, and dizziness, were not significantly different between groups. Sedation and pain on injection, which were the two most common side effects, were minor and clinically inconsequential.

Cardiac arrest after spinal anesthesia in Thailand: a prospective multicenter registry of 40,271 anesthetics.

BACKGROUND AND OBJECTIVES: As part of the Thai Anesthesia Incidents Study of anesthetic adverse outcomes, we evaluated the incidence and factors related to cardiac arrest during spinal anesthesia. METHODS: During a 12-mo period (March 1, 2003, to February 28, 2004), a prospective, multicenter registry of patients receiving anesthesia was initiated in 20 hospitals (7 university, 5 tertiary, 4 general, and 4 district hospitals) across Thailand. Anesthesia personnel reported patient-, surgery-, and anesthetic-related variables and adverse outcomes, including cardiac arrest during spinal anesthesia (defined as the time period from induction of spinal anesthesia until the end of operation). Adverse event specific forms were recorded within 24 h of an anesthetic procedure whenever a specific adverse event occurred. Univariate and multivariate analysis were used to identify factors related to cardiac arrest during spinal anesthesia. A P value <0.05 was considered significant. RESULTS: In the registry of 40,271 cases of spinal anesthesia, there were 11 cardiac arrests, corresponding to an incidence of 2.73 (95% CI: 1.12–4.34) per 10,000 anesthetics. The mortality rate was 90.9% among patients who arrested. Among 11 patients who arrested, there were 5 cases of cesarean delivery and 6 cases of extremity surgery, including hip surgery. In 4 patients (36.3%), the anesthetic contributed directly to the arrest (high sympathetectomy, local anesthetic overdose, or lack of electrocardiography monitoring), whereas some arrests were associated with specific events (cementing of prosthesis, massive bleeding, suspected pulmonary embolism, and suspected myocardial infarction). From multivariate analysis, the risks of cardiac arrest during anesthesia were shorter stature (odds ratio 0.944 [95% CI: 0.938–0.951], P < 0.001), longer duration of surgery (odds ratio 1.003 [95% CI: 1.001–1.005], P = 0.002), and spinal anesthesia administered by the surgeon (odd ratio 23.508 [95% CI: 6.112–90.415], P < 0.001), respectively. CONCLUSION: The incidence of cardiac arrest during spinal anesthesia was infrequent, but was associated with a high mortality rate. If the surgeon performed the spinal anesthetic, this was a significant factor associated with cardiac arrest. Increasing the number of anesthesiologists, improving monitoring guidelines for spinal anesthesia and improving the nurse-anesthetist training program may decrease the frequency of arrest and/or improve patient outcome.

A randomized controlled trial of pentazocine versus ondansetron for the treatment of intrathecal morphine-induced pruritus in patients undergoing cesarean delivery.

BACKGROUND: Ondansetron is effective for the treatment of intrathecal morphine-induced pruritus. There is evidence that &kgr;-opioid receptor agonists have antipruritic activity. Pentazocine is an agonist of &kgr;-opioid receptors and partial agonist at &mgr;-opioid receptors. We therefore performed a randomized, double-blind trial to compare the efficacy of pentazocine and ondansetron for the treatment of pruritus associated with intrathecal injection of morphine in patients undergoing cesarean delivery. METHODS: Two hundred eight parturients who developed moderate to severe pruritus after the administration of intrathecal morphine were randomly allocated to 2 groups: IV pentazocine 15 mg (n = 104) and IV ondansetron 4 mg (n = 104). The successful treatment of pruritus (no or mild pruritus) and other adverse effects were determined 15 min after study drug administration, and patients were observed for recurrence of pruritus for 4 h. RESULTS: The treatment success rate at 15 min was higher in the pentazocine group (96.1%) than in the ondansetron group (80.8%) (95% confidence interval of difference: 7.0%, 23.8%; P = 0.001). The recurrence rate of moderate to severe pruritus within 4 h after treatment in the pentazocine group (12.0%) was lower than in the ondansetron group (32.1%) (P = 0.001). There were no significant differences between groups in nausea/vomiting, sedation, shivering, pain scores, and pain at injection site. No respiratory depression was observed. CONCLUSIONS: Pentazocine 15 mg is superior to ondansetron 4 mg for the treatment of intrathecal morphine-induced pruritus and has a lower recurrence rate. The side effects after treatment are mild.

A Randomized, Double-Blind, Placebo-Controlled Trial of Oral Pregabalin for Relief of Shoulder Pain after Laparoscopic Gynecologic Surgery

STUDY OBJECTIVE To investigate the efficacy of pregabalin for the relief of postoperative shoulder pain after laparoscopic gynecologic surgery. DESIGN Prospective, randomized, double-blind, placebo-controlled trial (Canadian Task Force classification I). SETTING Tertiary referral center, university hospital. PATIENTS Fifty-six women undergoing elective laparoscopic gynecologic surgery between June 2012 and March 2013. INTERVENTIONS Women in the study group received 75 mg pregabalin 2 hours before surgery and then every 12 hours for 2 doses, and women in the control group received an identical capsule and the same dosage of placebo. MEASUREMENTS AND MAIN RESULTS Visual analog scale (VAS) scores for shoulder pain and surgical pain at 24 and 48 hours after surgery were evaluated as primary outcome. Postoperative analgesics used and drug-related adverse events were also monitored. Patients in the pregabalin group had significantly lower postoperative VAS scores for shoulder pain at 24 hours, compared with the placebo group (median, 23.14 [range, 13.67-32.61] vs. 37.22 [27.75-46.64]; p = .04), and required less analgesic (p = .01). There were no significant differences in VAS scores for surgical pain and adverse events between the 2 groups (p = .56). CONCLUSIONS Perioperative administration of 75 mg pregabalin significantly reduced postoperative laparoscopic shoulder pain and amount of analgesic used.

Association of otoscopic findings and hearing level in pediatric patients with otitis media with effusion

OBJECTIVE To find the association between the abnormalities of tympanic membrane characteristics and the hearing level in pediatric patients with otitis media with effusion. METHODS Sixty-three pediatric patients with otitis media with effusion had undergone ear examinations by pneumatic otoscopy to assess the color, transparency, mobility, fluid level and retraction of the tympanic membrane. An audiogram was done in the same setting, average hearing threshold and air-bone gap were measured. Otoscopic findings and the result of the hearing test were analyzed to identify the association between the abnormalities of the tympanic membrane characteristics and elevated hearing threshold. RESULTS Hearing loss was found in 92.1% of the patients. Mean hearing level was 31.7+/-10.3 dB. From linear regression analysis, the patients with dull or opaque tympanic membrane had a significantly higher hearing threshold of 7.2 dB than the patient with translucent ear drum after adjusting for mobility and retraction. The patients with tympanic membrane retraction had a higher hearing threshold of 5.1 dB than the patient who had no retraction after adjusting for transparency and mobility. Mobility had a significant relationship to elevated hearing threshold in the univariate analysis but not in multivariable analysis. CONCLUSION Opacity and retraction were the two characteristics of abnormal tympanic membrane that were associated with elevated hearing threshold in the patients with otitis media with effusion. Hearing test is suggested if opacity or retraction of the tympanic membrane is found.

Fatal maternal outcome of a parturient with Eisenmenger’s syndrome and severe preeclampsia

Abstract Eisenmenger’s syndrome in pregnancy is associated with a high maternal and fetal morbidity and mortality. When it occurs with severe preeclampsia, the morbidity and mortality are higher. We report the case of a 30 weeks’ pregnant woman with Eisenmenger’s syndrome and severe preeclampsia. Cesarean section was performed due to severe preeclampsia and an unfavorable cervix under general anesthesia. The intraoperative period was uneventful and a healthy 1300 g male infant was delivered, but the patient died on the second postoperative day due to a pulmonary embolism. This case confirms the frequently fatal maternal outcome of Eisenmenger’s syndrome in pregnancy. Early termination of pregnancy is the treatment of choice.

Anesthesia for Indian Ocean tsunami-affected patients at a southern Thailand provincial hospital.

Background:  On 26 December 2004, a giant earthquake shook South‐East Asia, triggering deadly flood waves (tsunami) across the Indian Ocean. The Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand joined the Thai Red Cross Society to provide relief in southern Thailand. The objective of this article is to characterize the emergency surgical patients and anesthesia profiles of tsunami victims at Phang‐Nga Provincial Hospital.

Muscular Injury After Succinylcholine and Electroconvulsive Therapy

Both succinylcholine and seizures cause muscular injury during electroconvulsive therapy. We compared the muscular damage in two groups of patients. The psychiatric patient group received succinylcholine for electroconvulsive therapy. The surgical patient group received succinylcholine for endotracheal intubation. Serum myoglobin was measured as a marker for muscular injury and myalgic symptoms were also recorded. Serum myoglobin increased from baseline in both groups at 5 and 20 min. The surgical patients, however, had a higher myoglobin level than the psychiatric patients at 5 and 20 min after the administration of succinylcholine (P < 0.001). The median (range) of myoglobin concentration at 20 min in psychiatric patients was 32.6 (23.1–60.1) ng/mL, compared with 61.2 (31.6–1687.0) ng/mL in surgical patients. The incidence of myalgia was not different between the two groups. In conclusion, we unexpectedly conclude that the psychiatric patients who received electroconvulsive therapy had less effect of muscular damage associated with succinylcholine than the surgical patients did.

Nicardipine versus lidocaine for attenuating the cardiovascular response to endotracheal intubation

AbstractPurpose. The aim of this study was to compare the efficacy of nicardipine and lidocaine in attenuation of cardiovascular responses to endotracheal intubation. Methods. In a randomized, double-blind, controlled trial, 60 unpremedicated (ASA I) patients undergoing elective sur-gery were given either 30 μg·kg−1 nicardipine or 1.5 mg·kg−1 lidocaine intravenously 2 min before intubation. Laryngoscopy and tracheal intubation were performed 1 min after induction of anesthesia with 5 mg·kg−1 thiopentone, followed by administration of 1.5 mg·kg−1 succinylcholine intravenously. Blood pressure and heart rate were monitored at baseline and every minute until 4 min after intubation. Repeated-measures ANOVA, Students t test, the chi-square test, and 95% confidence intervals were used as appropriate. P < 0.05 was considered statistically significant. Results. Baseline hemodynamic variables were not different between the groups. After administration of either agents, diastolic blood pressure and mean blood pressure were significantly lower in the nicardipine group. The heart rate in the nicardipine group was significantly higher. The mean between-group differences in diastolic blood pressure, mean blood pressure, heart rate, and rate-pressure product at baseline and 1 min after starting laryngoscopy were statistically significant. Conclusion. Nicardipine can be used as an alternative to lidocaine in attenuation of cardiovasculars response to tracheal intubation in patients without ischemic heart disease.

Incidence of and Risk Factors for Cardiovascular Complications After Thoracic Surgery for Noncancerous Lesions

OBJECTIVE The purpose of this study was to determine the incidence of and risk factors for cardiovascular complications after thoracic surgery for noncancerous lesions. DESIGN Retrospective cohort study. SETTING A tertiary medical center. PARTICIPANTS All consecutive patients undergoing either thoracotomy or thoracoscopy for noncancerous lesions between 2005 and 2011 were included. MEASUREMENTS AND MAIN RESULTS The primary outcomes were the incidence and types of cardiovascular complications such as cardiac arrhythmias, cardiac arrest, heart failure, and myocardial ischemia during hospitalization. A total of 719 patients were recruited, 60% of whom had infections. The incidence of cardiovascular complications after thoracic surgery was 6.7% (48 of 719), of which cardiac arrhythmia was the most common (25 of 48, 52%). The multivariate risk regression analysis showed that age>55 years (risk ratio [RR]=4.0; 95% confidence interval [CI]=2.1-7.5; p<0.01), diabetes mellitus (RR=3.0; 95% CI=1.7-5.3; p<0.01), coronary artery disease (RR=4.8; 95% CI=2.3-10.2; p<0.01), duration of surgery>180 minutes (RR=2.6; 95% CI=1.3-5.1; p<0.01), intraoperative hypotension (RR=2.6; 95% CI=1.6-4.3; p<0.01), and positive fluid balance>2,000 mL (RR=2.5; 95% CI=1.4-4.5; p<0.01) were independent risk factors for cardiovascular complications. CONCLUSIONS Knowledge of risk factors could help surgical teams to identify high risk patients and adjust modifiable risk factors including optimization of medical conditions, correction of intraoperative hypotension, and appropriate blood and fluid administration in order to reduce perioperative morbidity and mortality.