Comparing the Analgesic Efficacy of Intrathecal Bupivacaine Alone with Intrathecal Bupivacaine Midazolam or Magnesium Sulphate Combination in Patients Undergoing Elective Infraumbilical Surgery

Background. Spinal anaesthesia, which is one of the techniques for infraumbilical surgeries, is most commonly criticized for limited duration of postoperative analgesia. Aim of the Work. The aim of this study was to decrease bupivacaine dose used in spinal anesthesia in patients undergoing orthopedic lower limb surgery and reduce its possible side effects. Patient and Methods. Sixty adult patients of both sexes, divided into three. Group C received 2.5 mL bupivacaine and 0.5 mL saline 0.9%. Group A received 2.5 mL bupivacaine and 0.5 mL midazolam. Group B received 2.5 mL bupivacaine and 0.5 mL magnesium sulphate. Results. As regards onset of both motor and sensory blockade, there are a significant decrease in group A and a significant increase in group B as compared to group C, with a significant decrease in duration of motor blockade and significant increase in duration of sensory blockade in both group A and group B, respectively, as compared to group C, with a significant decrease in the duration of sensory blockade in group B as compared to group C. Conclusions. These results suggested that intrathecal midazolam as an adjuvant for bupivacaine increases the duration of both sensory and motor blockade more than that of magnesium sulphate.

Postoperative Etoricoxib versus Ketoprofen Administration for Pain Management after Total Knee Arthroplasty: A Randomized, Double-Blind Controlled Study

Objective. This randomized double-blind study compared the analgesic efficacy and tolerability of etoricoxib versus ketoprofen in 165 patients with elective total primary knee arthroplasty. Methods. After ethical committee approval, 165 patients were randomized in 3 groups: the etoricoxib group (E) receiving etoricoxib 120 mg/day, at the end of surgery and in the first postoperative day; the ketoprofen group (K) receiving ketoprofen 2 pills of 100 mg/day, the first at the end of surgery and then 1 pill every 12 hours in the surgery day and the first postoperative day; the placebo group (P). All groups received postoperatively the same analgesia protocol when NRS is over 3 with IV Perfalgan and morphine. The effectiveness was evaluated by the time from the initiation of spinal anesthesia until the first analgesic dose, the total amount of morphine administered in the surgery day and the first postoperative day, and the frequency of patients with side effects and necessary amount of adjuvant medication. Results. The baseline demographic characteristics were similar among the 3 groups. In both study days etoricoxib provided an analgesic effect superior to placebo and to ketoprofen, the total administered morphine being significantly lower in etoricoxib group. There were no statistically significant differences between groups regarding the side effects.

Singapore General Hospital Experience on Ethnicity and the Incidence of Postoperative Nausea and Vomiting after Elective Orthopaedic Surgeries

Introduction. We explored how ethnicity affects the risk of postoperative nausea and vomiting (PONV) and established the correlation of suggested risk factors of PONV in the multiethnic population of Singapore. Methods. 785 patients who underwent orthopaedic surgery were recruited. These comprised 619 Chinese (78.9%), 76 Malay (9.7%), 68 Indian (8.7%), and 22 other (2.8%) cases. The presence of possible risk factors of PONV and nausea and/or vomiting within 24 h after surgery was studied. Univariate and multivariate logistic regression analyses were performed. Results. The incidence of PONV was 33.2% (261 patients). There was no statistically significant difference of PONV incidence between Chinese, Malay, and Indian cases (34.6% versus 34.2% versus 29.4%, p=0.695). Indian females younger than 50 years were found to have a higher incidence of vomiting (p=0.02). The significant risk factors for this population include females, use of nitrous oxide, and a history of PONV. Conclusion. In the groups studied, ethnicity is not a significant risk factor for PONV except for young Indian females who have a higher risk of postoperative vomiting. We suggest the selective usage of antiemetic for young Indian females as prophylaxis and avoiding nitrous oxide use in high-risk patients.

McGrath Video Laryngoscope May Take a Longer Intubation Time Than Macintosh Laryngoscope

Background. Video laryngoscopes provide better view and can improve ease of intubation compared with standard laryngoscopes. Methods. A prospective randomized study was done on 60 patients, 18 to 65 years old, comparing McGrath video laryngoscope and Macintosh laryngoscope. The aim was to compare the ease, efficacy, and usability of them during routine airway management. The primary endpoint was duration of intubation and the secondary endpoints were Cormack and Lehane grade of laryngoscopic view, number of intubation attempts, and incidence of complications. Results. There was an increase in total duration of intubation with McGrath video laryngoscope with 42.9 ± 19.5 seconds compared to Macintosh laryngoscope with 17.9 ± 4.6 seconds. In Macintosh group, 73.3% had grade I, 20% had grade II, and 6.7% had grade III Cormack Lehane view, while in McGrath group, 83.3% had grade I, 13.3% had grade II, and 3.3% had grade III. In McGrath group, 6 patients (20%) required more than 120 seconds to get intubated and only 73.3% were intubated in 1 attempt, while patients in Macintosh group had 100% successful intubation in 1 attempt. Pharyngeal trauma was seen with McGrath videolaryngoscopy. Conclusion. Duration of laryngoscopy, intubation, and total duration of intubation were significantly higher in McGrath group than in Macintosh group. McGrath group required a higher number of intubation attempts.

The Effects of Intrathecal Fentanyl on Sedation Depth and Postoperative Recovery Room Delirium

Background/Aim. Intrathecal anaesthesia has been shown to increase sedation level. This study aimed to evaluate the effects of intrathecal applied fentanyl with levobupivacaine on intraoperative sedation and recovery room delirium. Materials and Methods. The study included 68 patients, ASA I–III, 55–85 years. One day preoperatively, the Confusion Assessment Method (CAM) and the Mini Mental Status Test (MMST) were applied and patients were separated into two groups. In Group L 2.5 mL levobupivacaine and in Group LF 2 mL levobupivacaine and 0.5 mL fentanyl were applied intrathecally. In a supine position, following a propofol IV 1 mg kg−1 bolus to obtain Bispectral Index (BIS) of 70–85, propofol infusion was started (1 mg kg−1 st−1). With observation of SpO2, BIS, and the Observer Assessment and Alertness/Sedation Scale (OAA/SS) with the haemodynamic values, the total propofol amount was calculated. Evaluations were made of pain severity (VAS), analgesic use, transfusion requirement, and recovery room delirium. Results. In the comparison within the groups, a significant decrease was determined in HR and MAP compared to the initial values (p<0.05). A positive correlation was found between the BIS and OAA/SS values. The amounts of propofol used were similar between the groups. Conclusions. Intrathecal fentanyl and levobupivacaine had the same effect on sedation or BIS and fentanyl did not cause delirium.

Effect of Low Dose Dexmedetomidine on Emergence Delirium and Recovery Profile following Sevoflurane Induction in Pediatric Cataract Surgeries

This randomized trial was conducted to assess the efficacy and recovery profile of low dose intravenous dexmedetomidine in prevention of post-sevoflurane emergence delirium in children undergoing cataract surgery. Sixty-three children aged 1–6 years were included. Anesthesia was induced with sevoflurane and airway was maintained with LMA. They were randomized to group D 0.15 (received intravenous dexmedetomidine 0.15 μg/kg), group D 0.3 (received dexmedetomidine 0.3 μg/kg), or group NS (received normal saline). The incidence of emergence delirium, intraoperative haemodynamic variables, Aldrete scoring, pain scoring, rescue medication, and discharge time were recorded. Emergence delirium was significantly reduced in dexmedetomidine treated groups with incidence being 10% in group D 0.15, none in group D 0.3, and 35% in the NS group (p=0.002). Significantly lower PAED scores were observed in D 0.15 and D 0.3 group compared to the NS group (p=0.004). Discharge time was significantly prolonged in the NS group compared to D 0.15 and D 0.3 (45.1 min ± 4.4 versus 36.8 min ± 3.8 versus 34.4 min ± 4.6), p<0.02. Intravenous dexmedetomidine in low doses (0.3 and 0.15 μg/kg) was found to be effective in reducing emergence delirium in children undergoing unilateral cataract surgery.

Evaluation of Differences between PaCO2 and ETCO2 by Age as Measured during General Anesthesia with Patients in a Supine Position

Objective. The aim of this study was to evaluate the arterial to end-tidal partial pressure gradient of carbon dioxide according to age in the supine position during general anesthesia. Methods. From January 2001 to December 2013, we evaluated 596 patients aged ≥16 years who underwent general anesthesia in the supine position. The anesthetic charts of these 596 patients, all classified as American Society of Anesthesiologists physical status I or II, were retrospectively reviewed to investigate the accuracy of PaCO2 and ETCO2. Results. The a-ETCO2 was 3.0 ± 2.1 mmHg for patients aged 16 to <65 years and 4.1±3.1 mmHg for patients ≥65 years. The a-ETCO2 was 2.4±3.1 mmHg for patients aged 16 to 25 years, 3.1±2.2 mmHg for patients aged 26 to 35 years, 3.0±2.2 mmHg for patients aged 36 to 45 years, 3.4±2.0 mmHg for patients aged 46 to 55 years, 3.2±2.0 mmHg for patients aged 56 to 64 years, 4.3±3.2 mmHg for patients aged 65 to 74 years, and 3.7±2.8 mmHg for patients aged 75 to 84 years. Conclusion. The arterial to end-tidal partial pressure gradient of carbon dioxide tended to increase with increasing age.

Sedation and Regional Anesthesia for Deep Brain Stimulation in Parkinson’s Disease

Objective. To present the conscious sedation and the regional anesthesia technique, consisting of scalp block and superficial cervical plexus block, used in our institution for patients undergoing deep brain stimulation (DBS) for the treatment of Parkinson’s disease (PD). Methods. The study included 26 consecutive patients. A standardized anesthesia protocol was used and clinical data were collected prospectively. Results. Conscious sedation and regional anesthesia were used in all cases. The dexmedetomidine loading dose was 1 μg kg−1 and mean infusion rate was 0.26 μg kg−1 h−1 (0.21) [mean total dexmedetomidine dose: 154.68 μg (64.65)]. Propofol was used to facilitate regional anesthesia. Mean propofol dose was 1.68 mg kg (0.84) [mean total propofol dose: 117.72 mg (59.11)]. Scalp block and superficial cervical plexus block were used for regional anesthesia. Anesthesia related complications were minor. Postoperative pain was evaluated; mean visual analog scale pain scores were 0 at the postoperative 1st and 6th hours and 4 at the 12th and 24th hours. Values are mean (standard deviation). Conclusions. Dexmedetomidine sedation along with scalp block and SCPB provides good surgical conditions and pain relief and does not interfere with neurophysiologic testing during DBS for PD. During DBS the SCPB may be beneficial for patients with osteoarthritic cervical pain. This trial is registered with Clinical Trials Identifier NCT01789385.

Evaluation of Tip Surface Collision Count as a Measure of Fibreoptic Scope Handling Skills: A Randomized, Cross-Over Manikin Study

Background. In this pilot study, we evaluated tip collisions against three commonly used measures of fibreoptic scope handling skills. Methods. Seventy-seven anaesthetists were recruited to perform a standardized task on an Oxford Box and a modified AirSim manikin. Collision count was correlated against time to scope placement, a global rating scale score, and up-to-date fibreoptic experience. Results. Strong and moderate correlations were found between collision count and task completion time for the Oxford Box (ρ = 0.730, P < 0.0001) and AirSim manikin (ρ = 0.405, P < 0.0001), respectively. Moderate correlation was found between collision count and global rating scale score for the Oxford Box (ρ = −0.545, P < 0.0001) and AirSim manikin (ρ = −0.500, P < 0.0001). Mild and moderate correlations were found between collision count and fibreoptic experience on the Oxford Box (ρ = −0.240, P = 0.041) and AirSim manikin (ρ = −0.423, P < 0.0001), respectively. Conclusions. This study infers that collision count may be used as a measure of fibreoptic scope handling skills in simulation training. Using this outcome in addition to other measures of performance may improve accuracy and precision of fibreoptic scope placement.

Ultrasound Guided Stellate Ganglion Block in Postmastectomy Pain Syndrome: A Comparison of Ketamine versus Morphine as Adjuvant to Bupivacaine

Background. The postmastectomy pain syndrome (PMPS) is chronic pain after breast cancer surgery and is reported to influence quality of life. The aim of this study was to provide long term reduction of PMPS, improve range of motion of the shoulder, and decrease the need for postoperative analgesia using ultrasound guided stellate ganglion block. Method. Sixty patients with PMPS were randomly allocated into 1 of 3 groups: bupivacaine group (group 1), bupivacaine plus ketamine group (group 2), and bupivacaine plus morphine group (group 3). Each patient received 3 blocks with an interval of one week in between. Patients were assessed for: pain visual analogue score (VAS), movement of the shoulder, skin temperature, and the need for analgesic drugs. Results. The pain VAS was significantly decreased in group 2 as compared to the other two groups. Shoulder movement improved significantly in the three studied groups with the best results observed after the third block. The need for the analgesic drugs in the form of gabapentin was more in the bupivacaine and bupivacaine plus morphine groups than in bupivacaine plus ketamine group. Conclusion. Treatment of PMPS with ultrasound guided stellate ganglion block using ketamine (0.5 mg/kg) as adjuvant to bupivacaine (0.25%) successfully decreased pain VAS and the need for analgesic drugs.