Comparison of intraperitoneal instillation of ropivacaine with normal saline in laparoscopic cholecystectomy

Background: Local anesthetics are now widely used, as they have a good safety profile and are available in long acting preparation. They provide the benefit of analgesia without systemic side effects that may result from use of enterally and parenterally administered drugs.Methods: This prospective randomized double-blind study was conducted on 100 patients with symptomatic gall stones disease undergoing laparoscopic cholecystectomy. Patients were randomized to receive either 0.5% of 3mg/kg of Ropivacaine diluted in 100 ml NS, instillation at intraperitoneal space before creation of pneumoperitoneum (group I) or 100 ml NS instillation at intra peritoneal space before creation of pneumoperitoneum (group II). VAS score for pain abdomen as well as shoulder were recorded postoperatively at various time intervals and compared in both the groups. Total analgesic consumption in 24hrs was also noted and compared.Results: The mean postoperative VAS score for abdomen and shoulder pain was significantly (p values<0.05) lower in group I than in group II till 24 hrs postoperatively. The latency time from end of operation to first analgesic requirement was significantly longer in group I than in group II.Conclusions: Intraperitoneal instillation of Ropivacaine before the creation of pneumoperitoneum significantly decreased the total abdominal pain, shoulder tip pain with lower analgesic consumption. As it is safe and without apparent side effects, we believe that intraperitoneal instillation of local anaesthetic in patients undergoing elective laparoscopic cholecystectomy is an effective modality for postoperative pain management.

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A DOUBLE BLIND COMPARATIVE STUDY BETWEEN INTRATHECAL BUPIVACAINE AND INTRATHECAL FENTANYLAS THE INITIAL DOSE OF COMBINED SPINAL EPIDURAL TECHNIQUE FOR LABOUR ANALGESIA

10.36106/ijsr/8921758 ◽

2021 ◽

pp. 48-50

Author(s):

Niraj Kumar Mishra ◽

Sushil Kumar

Keyword(s):

Side Effects ◽

Fetal Distress ◽

Labour Pain ◽

Sampling Procedure ◽

Chi Square ◽

Double Blind ◽

Motor Weakness ◽

Group I ◽

Group Ii ◽

Fetal Oxygenation

Introduction: Labour pain is among the most severe pain a woman can experience in her lifetime. Painful labour has decrimental effects on both mother and fetus leads to severe physical and psychological stress. Maternal hyperventilation in response to pain reduces fetal oxygenation and hypoventilation between contractions combined with decreased blood ow worsens fetal hypoxemia. It has been suggested that conning women to bed during labour may cause the labour to be longer and more painful with increase in abnormal presentation, instrumental deliveries and fetal distress. Aims And Objectives:The onset, quality and duration of their analgesic action. Incidence of unwanted effects like muscle weakness, hypotension, pruritus, nausea/vomiting, fetal bradycardia by the individual drugs. Materials And Methods: The study was conducted in the department of anesthesia, Darbhanga Medical College & Hospital, Laheriasarai, Bihar. Methods of collection of data (including sampling procedure if any) : After institutional committee approval and written informed consent from parturients and their relatives for the procedure the study was conducted and data were collected. Results: Duration of analgesia was found varying widely. It was 55±12.34 minutes in Group I whereas 75 ±14.36 minutes in Group II. The incidence of pruritus almost mild or negligible in both groups. The incidence of motor weakness in group II was 24 (80%) whereas in group I it was 10(33%). There was signicant statistics difference in motor weakness between two groups (p< 0.001) by Chi square test 9 with yate's correction. Other side effects differences between two groups were not statistically signicant. Summary And Conclusion:Both the drugs provided excellent quality of analgesia to the parturient in pain. The difference in duration of analgesia was signicant between the two groups statistically. Mean duration of analgesia lasted for 55 minutes in group I whereas in group II, it lasted for 75 minutes. Main side effects encountered in this study were motor weakness of longer duration in group II than in group I. Other side effects like nausea-vomiting were comparable to each other and were minimal in nature.

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Oral midazolam versus oral triclofos for sedation of children for computed tomography scan - a randomized clinical trial

Journal of Society of Anesthesiologists of Nepal ◽

10.3126/jsan.v2i2.13528 ◽

2015 ◽

Vol 2 (2) ◽

pp. 41-45

Author(s):

Anushu Gupta ◽

Maitree Pandey ◽

Lalita Choudhry ◽

Aruna Jain ◽

Harish Pemde

Keyword(s):

Computed Tomography ◽

Double Blind Study ◽

Computed Tomography Scan ◽

Double Blind ◽

Comparable Rate ◽

Group I ◽

Oral Midazolam ◽

Group Ii ◽

Student’S T ◽

Tomography Scan

Background: Effective and safe pediatric procedural sedation is still a concern especially in areas outside operation theatres. The aim of the study was to compare the efficacy and safety of oral triclofos and oral midazolam in children undergoing computed tomography.Methods: A prospective randomized double blind study was conducted in 100 children aged one to five years. Group-I (n=50) received oral triclofos 100 mg/kg and Group-II (n=50) oral midazolam 0.75 mg/kg. Both groups were given oral atropine 0.03 mg/kg and supplemented with intravenous midazolam upto 0.1 mg/kg in case of inadequate effect. Onset and duration of sedation, success for completion of procedure and time to recovery were noted. Student’s t test and Z test of proportions were used for statistical analysis.Results Majority of children 36(72%) in Group-I achieved Ramsay Sedation Score >4 as compared to 25(50%) in Group-II. Computed tomography scan could be successfully completed at comparable rate (52% vs 56%). Success rate improved to 96% vs 80% after supplementing intravenous midazolam in Group I & II respectively (p< 0.05). Onset (37.91minutes ± 7.96 vs 26 ± 10), duration of sedation ( 117.91minutes ± 72.41 vs 66.2minutes ± 33) were significantly shorter and recovery (98.19minutes ± 72.58 vs 47.4minutes ± 31.42) in Group I & II respectively was faster in children who received oral midazolam (p< 0.05).Conclusion We conclude that both drugs were equally effective and safe for computed tomography scan in children. However better recovery profile of midazolam makes it more suitable for day care procedures.Journal of Society of Anesthesiologists of Nepal 2015; 2(2): 41-45

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PREVENTION OF SHIVERING DURING LOWER SEGMENT CESAREAN SECTION;

The Professional Medical Journal ◽

10.29309/tpmj/2013.20.03.648 ◽

2013 ◽

Vol 20 (03) ◽

pp. 409-415

Author(s):

ASHFAQ AHMED ◽

MOHAMMAD ASLAM

Keyword(s):

Cesarean Section ◽

Spinal Anesthesia ◽

Carbon Dioxide Production ◽

Double Blind Study ◽

Lower Segment ◽

Chi Square ◽

Double Blind ◽

Lower Segment Cesarean Section ◽

Group I ◽

Group Ii

Objectives: To compare the efficacy of low-dose prophylactic use of ketamine with ketamine plus midazolam for theprevention of shivering caused by spinal anesthesia, during lower segment cesarean section. Main Outcome Measures: Heamodynamicmonitoring, avoidance of lactic acidosis/ increased carbon dioxide production and patient satisfaction. Design: Prospective RandomizedControlled trial. Place: Department of Anesthesia and ICU PNS Shifa Karachi. Duration of study: March 2010 to June 2010. Patients andMethods: 100 ASA-I & II consecutive patients who reported for LSCS in PNS Shifa Hospital were studied. In this double-blind study,patients were randomly allocated to receive ketamine alone (Group I, n= 50), and ketamine plus midazolam (Group II, n = 50). Afterstandardized Spinal anesthesia, a shivering was recorded at 5 min intervals for 15 minutes. Results: Shivering was observed in 9/50(18%) patients of group I (Ketamine only) as compared to only 2/50 (4%) patients in Group II (ketamine + midazolam) (p=0.025) whichis statically significant. The two groups were comparable regarding distribution of age (p=0.37), BMI (p=0.27) and duration of surgery.Results were analyzed by using chi square test. Conclusions: The efficacy of i.v. ketamine plus midazolam is better as compared to lowdosei.v. ketamine alone in preventing shivering in lower segment Cesarean Section patients, during spinal anesthesia.

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COMPARATIVE STUDY OF INTRATHECAL FENTANYL WITH HYPERBARIC BUPIVACAINE TO IMPROVE PERIOPERATIVE ANALGESIA IN PATIENT UNDERGOING ORTHOPEDIC SURGERY

10.36106/paripex/5801902 ◽

2021 ◽

pp. 55-58

Author(s):

Rahul Wagh ◽

Swapnil Sangale ◽

Nagesh Jambure

Keyword(s):

Side Effects ◽

Lower Limb ◽

Motor Block ◽

Control Group ◽

Study Group ◽

Hyperbaric Bupivacaine ◽

Analgesic Requirement ◽

Sensory Blockade ◽

Group I ◽

Group Ii

Background: Various methods exist for treating post-operative pain which includes systemic narcotics, NSAIDS, patient-controlled analgesia, regional anaesthesia techniques, epidural local anaesthetic – narcotic mixtures, cryoanalgesia, transcutaneous electric nerve stimulation, psychological methods. Various opioides intrathecally and epidurally have been tried for post-operative analgesia. These include - morphine, pethidine, pentazocine, methadone, tramadol, Fentanyl, sufentanyl. In present study, we tried to find out analgesic effectiveness of intrathecal Fentanyl for post-operative analgesia, combined with 0.5 % Bupivacaine and side effects if any, in patients undergoing lower limb surgeries. Materials and Methods: After approval from the local ethics committee and with written informed consent from patient, a randomized controlled prospective study is carried out in the medical college and hospital.100 patients belonging to American Society of Anesthesiologists (ASA)classification I & II, aged between 18-60 years, posted for elective lower limb surgeries, were randomly allocated for the study. Group-I: 50 patients received intrathecal 3 ml of 0.5 % hyperbaric Bupivacaine only. Group-II : 50 patients received intrathecal 3 ml of 0.5% hyperbaric Bupivacaine and Fentanyl 25 mcg.The patients studied across the group did not vary much with respect to age,height, weight and sex distribution. Results: The onset of sensory blockade was faster by 1.27 min in Group-BF. The perioperative and postoperative hemodynamic parameters were comparable in both the groups. The sensory analgesia in Group II was significantly prolonged by 159 mins, thus increasing the duration of analgesia. The time of first request of analgesics by the patients in group-II is prolonged compared to group-I thus prolonging the duration of analgesia. Analgesic requirement is also reduced in study group in early post-operative period. The onset of motor block was faster when Fentanyl was added to intrathecal Bupivacaine and it was 1.1 min earlier in study group. The duration of motor block to Bromage III was prolonged by almost 22 min in study group as compare to control group. Visual analogue scores were significantly lower in group-II compared to group-I after two hours of surgery thus reducing the frequency of supplemental postoperative analgesics. Conclusion: With the present study we can summarize that intrathecal Fentanyl potentiates the action of Bupivacaine thereby bringing about better quality and longer duration of analgesia, intense motor block, no hemodynamic disturbance and better postoperative outcome with/ minimum side effects.

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High Dose Intrathecal Morphine for Major Abdominal Cancer Surgery: A Prospective Double-Blind, Dose-Finding Clinical Study

January 2018 - Pain Physician ◽

10.36076/ppj.2014/17/255 ◽

2014 ◽

Vol 3;17 (3;5) ◽

pp. 255-264

Author(s):

Hala S. Abdel-Ghaffar

Keyword(s):

Side Effects ◽

Respiratory Rate ◽

Sample Size ◽

Intrathecal Morphine ◽

Double Blind ◽

Group Iii ◽

Group I ◽

The Mean ◽

Group Ii ◽

Peripheral Arterial

Background: Despite 30 years of clinical research, we still do not know the optimal dose of intrathecal morphine (ITM) when used alone. Objectives: A safety investigation and comparison of the analgesic efficacy of ITM 0.2 mg, 0.5 mg, and 1 mg in patients undergoing major abdominal cancer surgery. Study Design: A randomized, double-blind trial. Setting: Academic medical center. Methods: Ninety patients were randomly assigned to receive morphine intrathecally either 0.2 mg (Group I, ITM 0.2 mg, n = 30), 0.5 mg (Group II, ITM 0.5 mg, n = 30), or 1 mg (Group III, ITM 1 mg, n = 30) dissolved in 5 mL physiological saline before general anesthesia. Assessment parameters included hemodynamics, respiratory rate, peripheral arterial oxygenation, sedation score, pain severity, time of first analgesic request, total analgesic consumption, and side effects in the first 72 hours. Results: The mean time to first request for rescue analgesia was significantly prolonged in Group II (22.13 ± 5.21 hours, P < 0.001) and Group III (30.83 ± 4.89 h, P < 0.001), compared with Group I (0.50 ± 0.66 hours). The mean tramadol consumption dose was significantly reduced in Group II (383.33 ± 91.28 mg, P < 0.001) and Group III (300 ± 69.48 mg, P < 0.001) compared with Group I (770 ± 114.92 mg). Patients received 1 mg ITM showed lower VAS scores in the first 48 h postoperative (P < 0.04) compared with Group I and Group II. No significant differences were observed in the mean systolic and diastolic blood pressure values, respiratory rate, and peripheral arterial oxygen saturation between groups. Lower mean heart rate values were observed in Group III patients at 6 hours (P < 0.01) and 12 hours (P < 0.03) postoperative compared with Group I and Group II patients. Six patients (20%) in Group II and 8 (26.7%) in Group III exhibited pruritus compared with 2 patients (6.66%) in Group I (P < 0.01). No intergroup statistical differences were observed for other studied side effects. Limitations: This study is limited by its small sample size. Conclusion: One mg ITM provided superior analgesia for 48 hours postoperative compared with 0.2 mg and 0.5 mg ITM with a nonsignificant difference in the incidence of side effects. Further studies of larger sample size are recommended to confirm these findings. Key words: Anesthesia, analgesia, abdominal cancer, opioids, intrathecal, morphine

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Gabapentin a pre-emptive analgesic in post-operative pain: a randomised double blind placebo controlled study

International Journal of Basic & Clinical Pharmacology ◽

10.18203/2319-2003.ijbcp20172046 ◽

2017 ◽

Vol 6 (6) ◽

pp. 1317

Author(s):

Vikram Bhandari ◽

Geeta Sharma ◽

Dilip C. Dhasmana ◽

Meenakshi Gupta ◽

Jagdish P. Sharma ◽

...

Keyword(s):

Laparoscopic Cholecystectomy ◽

Diclofenac Sodium ◽

Controlled Study ◽

Analgesic Requirement ◽

Serious Adverse Events ◽

Double Blind ◽

Matching Placebo ◽

Group I ◽

Post Operative Pain ◽

Elective Laparoscopic Cholecystectomy

Background: Conventional analgesics, used in peri-operative period cause numerous adverse effects and are not free from interactions with co-administered drugs. Gabapentin has been shown to be effective in various types of neuropathic pain. The primary aim of this study was to evaluate gabapentin as a post-operative analgesic. The study also evaluates the analgesic requirement and safety of gabapentin in post-operative period.Methods: Forty patients undergoing elective laparoscopic cholecystectomy were randomized to receive gabapentin or a matching placebo. The patients of group I received gabapentin 600mg orally 2 hrs before surgery and 12hrs after the first dose. The patients in group II received a matching placebo. Patients in both groups received diclofenac sodium 75mg i.m b.i.d for pain. Additional doses were given on demand and recorded.Results: The present study found that gabapentin significantly reduced pain score and analgesic consumption as compared to a placebo for a period of 24 hours.Conclusions: Gabapentin in the doses used was found to be effective in postoperative pain in patients undergoing planned laparoscopic cholecystectomy. It was found to be safe and no serious adverse events were reported.

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A comparison between palonosetron and ondansetron in prevention of postoperative nausea and vomiting after laparoscopic cholecystectomy

Mediscope ◽

10.3329/mediscope.v2i2.25408 ◽

2015 ◽

Vol 2 (2) ◽

pp. 33-38

Author(s):

A Gafur ◽

L Noor ◽

A Motin ◽

M Alam ◽

M Karim

Keyword(s):

Laparoscopic Cholecystectomy ◽

Side Effects ◽

Postoperative Period ◽

Postoperative Nausea ◽

Adverse Outcome ◽

Postoperative Nausea And Vomiting ◽

Nausea And Vomiting ◽

Double Blind Study ◽

Double Blind ◽

Complete Control

Postoperative nausea and vomiting (PONV) are common complications after anesthesia and surgery and is associated with adverse outcome. This study was designed to compare the effects of palonosetron and ondansetron in preventing PONV in patients with laparoscopic cholecystectomy. This prospective double-blind study included 60 female patients randomly assigned to the palonosetron group (n = 30) or the ondansetron group (n = 30). Palonosetron 0.075 mg was injected intravenously as a bolus in the palonosetron group. Ondansetron 8 mg was injected intravenously as a bolus in the ondansetron group. The incidences of nausea and vomiting and side effects was recorded after 30 min, 60 min, 2 hrs, 8hrs, 24 hrs postoperatively. The incidence of nausea and vomiting was maximal during immediate postoperative period particularly initial 4 hrs of postoperative period. The complete control of postoperative nausea and vomiting was seen in 30% patients of ondansetron group in first 12 hrs of postoperative period and 90% in palonosetron group. Safety profile was more with palonosetron. The effects of palonosetron and ondansetron in preventing PONV were compared in patients undergoing laparoscopic cholecystectomy and it was found that palonosetron was better in preventing postoperative nausea and vomiting.Mediscope Vol. 2, No. 2: July 2015, Pages 33-38

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Intraperitoneal Versus Ultrasound Guided Transversus Abdominis Plane Block by Bupivacaine-Magnesium Sulphate for Pain Relieafter Laparoscopic Cholecystectomy

Journal of Advances in Medicine and Medical Research ◽

10.9734/jammr/2020/v32i1830660 ◽

2020 ◽

pp. 81-90

Author(s):

Nashwa I. Hamoda ◽

Hesham I. El Tatawy ◽

Nagat S. El Shmaa ◽

Mohammad I. Okab

Keyword(s):

Laparoscopic Cholecystectomy ◽

Pain Relief ◽

Transversus Abdominis Plane Block ◽

Transversus Abdominis ◽

Transversus Abdominis Plane ◽

Ultrasound Guided ◽

Rescue Analgesia ◽

Analgesic Consumption ◽

Group I ◽

Group Ii

Background and Aim: Intraperitoneal (IP) administration of local anesthetic is considered a method of control of visceral component of pain. This method cannot be used as sole agent for pain relief after laparoscopic cholecystectomy (LC). Transversus Abdominis Plane block (TAP) becomes a useful anesthetic technique in the treatment of postoperative pain after the LC surgery. The aim of the study was to compare between IP bupivacaine –Magnesiu;m Sulfate (MgSO4) and TAP by bupivacaine- MgSO4 for pain relief after LC. Materials and Methods: This was a randomized double blinded study on sixty patients ASA I &II, age from 18 to 60 years old, undergoing elective LC surgery were randomly classified into two equal groups (30 patients in each group). Group I: IP instillation of 30 ml [15 ml bupivacaine 0.5% (75mg) plus 2.5ml MgSO4 (250 mg) plus 12.5 normal saline].Group II: Ultrasound guided subcostal TAP block was performed by using total volume 20 ml on each side [10 ml bupivacaine %0.5 (50 mg) plus 1.5ml MgSO4 (150 mg) plus 8.5 normal saline]. Heart rate (HR) and Mean Arterial Blood Pressure (MAP) were measured at 5 min before induction and every 15min after induction till the end of operation and then every 5 min for the first 20 mins after administration of study drugs then they recorded at interval of 30mins, 1hr, 2hrs, 4hr and 6hr postoperative. Numeric Rating Scale (NRS) at emergence, 2, 4, 8, 12, 18 and 24hr after recovery, first rescue analgesia time, postoperative analgesic consumption, length of hospital stay(LOS), patients’ satisfaction and post-operative complications were recorded. Results: There were insignificant differences in HR and MAP between the two groups. There was a significant decrease in NRS at 4hr and 8 hr in group II than group I. There was a significant decrease regarding to time of first rescue analgesia, total postoperative analgesic consumption and LOS in group II compared to group I. There was a significant increase of satisfaction in group II compared to group I. There was an insignificant difference between both groups in nausea, vomiting, hypotension, bradycardia, bradypnea or MgSO4 toxicity. Conclusion: TAP by bupivacaine-MgSO4 has superior analgesia, longer duration, less postoperative analgesic consumption and more satisfaction in patients undergoing LC than IP block by bupivacaine-MgSO4.

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COMPARATIVE STUDY OF TRAMADOL WITH THAT OF BUTORPHANOL FOR THE CONTROL OF SHIVERING IN PATIENTS UNDERGOING NEURAXIAL BLOCKADE

10.36106/ijsr/2523867 ◽

2020 ◽

pp. 70-72

Author(s):

Prabhat Kumar Choudhary ◽

Sadab Faisal Ansari ◽

Namita Saraswat ◽

Debarshi Jana

Keyword(s):

Spinal Anesthesia ◽

Lower Limb ◽

Oral Anticoagulant Therapy ◽

Double Blind Study ◽

Double Blind ◽

Neuraxial Blockade ◽

Group I ◽

Lower Limb Surgery ◽

History Of ◽

Group Ii

Aim: To compare the efficacy of Tramadol with that of Butorphanol for the control of shivering in patients undergoing neuraxial blockade. Materials And Methods: A randomized, double blind study of 60 patients undergoing lower abdominal and lower limb surgery under spinal anesthesia who got shivering during intra operative period up to 60minutes. Out of which 60 patients, who will develop shivering after neuraxial blockade will be randomly allocated to one of the following groups. Each group contains 30 patients. Group I: (Tramadol Group) Patients received tramadol intravenously (50mg) Group II: (Butorphanol Group) Patients received butorphanol intravenously (1mg) Inclusion criteria: ASA Grade I Or II, age 18 to 60 years, weight 30 to 70 kg, lower abdominal and lower limb surgery under spinal anesthesia. Exclusion Criteria: Patients not willing to take part in study, ASA grade >2, significant systemic illness, patients with fever, pregnancy, patients with history of seizure, patient on oral anticoagulant therapy, emergency surgeries, conditions where neuraxial blockade will be contraindicated. Result: Time taken to control Shivering was significantly lower in Group I (Tramadol) as compared to group II (Butorphanol), more patients with higher sedation score with Butorphanol group compared to Tramadol Group, Nausea and vomiting higher in Tramadol Group compared to Butorphanol Group. Conclusion: Tramadol is most rapid acting & effective in control of shivering with neauraxial block without any significant side effects and least reappearance of shivering as compared to Butorphanol.

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Effect of dexamethasone with granisetron or ondansetron for prevention of post-operative nausea vomiting in patients undergoing laparoscopic gynaecological surgery

International Journal of Research in Medical Sciences ◽

10.18203/2320-6012.ijrms20201319 ◽

2020 ◽

Vol 8 (4) ◽

pp. 1331

Author(s):

Shailendra Kumar Sharma ◽

Shalendra Singh ◽

Debashish Paul ◽

Nihar Ameta ◽

Priya Taank ◽

...

Keyword(s):

Study Groups ◽

Double Blind Study ◽

Antiemetic Drug ◽

Double Blind ◽

Patient Dissatisfaction ◽

Group I ◽

Significant Difference ◽

Group Ii ◽

High Level ◽

Post Operative Nausea

Background: Post-operative nausea and vomiting (PONV) is generally self-limiting, associated with high level of patient dissatisfaction and may delay hospital discharge. The anaesthetist is usually blamed, despite evidence that PONV results from a variety of factors and variety of antiemetic drug available in market. With this issue we aim to compare the effectiveness of dexamethasone with granisetron or ondansetron in patients undergoing laparoscopic gynaecological surgery.Methods: 120 patients were registered in this prospective, randomized double blind study. Group I (n=60) received ondansetron 4 mg intravenously (IV)+dexamethasone 8mg I/V or II (n=60) received granisetron 1 mg IV+dexamethasone 8 mg I/V prior to anaesthesia. Post-operative data of PONV was recorded at pre-defined intervals.Results: The majority of the patients were of the age group 20-25 years (55.83%). The mean score of Group I subjects was 0.30±0.72 and that of Group II was 0.20±0.57 (p=0.43). There are 3.33% of patients in group-I having vomiting episodes, and 1.67% of patients in group-II having vomiting episodes, none of the patients developed 2nd episodes of vomiting in either group. Thus it appears that dexamethasone in combination with ondansetron and granisetron is effective in decreasing the number of episodes of PONV. The occurrence of sickness episodes within 24 hours of surgery revealed no significant different in both groups. Haemodynamic variables showed no significant difference recorded in postoperative care unit between the study groups. The most common complaint was headache 16.67% in both groups. Conclusions: Dexamethasone 8 mg with either granisetron 1 mg or ondansetron 4 mg showed no significant difference in antiemetic efficacy with minimal side effects and excellent patient satisfaction.

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