Dexmedetomidine versus nimodipine for controlled hypotension during spine surgery

BackgroundControlled hypotension is a technique that is used to limit intraoperative blood loss, improve operative field, decrease duration of surgery, and thus decrease the amount of blood transfused.ObjectiveThe aim of this double-blind, randomized, controlled study is to compare the effects of sevoflurane combined with dexmedetomidine (DEX) or nimodipine (NIMO) on blood loss in the surgical field, recovery time, and patient tolerability in spine surgery.MethodsForty-eight (48) patients, 20–50 years of age, ASA I-II, randomly divided into DEX group (n = 24) and NIMO group (n = 24). In the DEX group, a loading dose of DEX infused over 10 min at a rate of 1 μg/kg/h, followed by a maintenance rate of 0.4–0.8 μg/kg/h. In the NIMO group, the dose infused at 15 μg/kg/h for 2 h (approximately 1 mg/h). The infusion rates were titrated to maintain mean arterial pressure (MAP) of 60–65 mm. Hg. We recorded MAP, intraoperative blood loss, total recovery time, total fentanyl consumption, incidence of arrhythmia or ischemia, and postoperative nausea and vomiting.ResultsNo significant difference in the amount of blood loss between the two groups was observed. Total fentanyl consumption was significantly higher in the NIMO group (350 ± 8.9 μg) versus (200 ± 5.5 μg) in the DEX group (p = 0.002). Recovery time was shorter in the NIMO group (6.8 min) versus (8.9 min) in the DEX group (p = 0.001).ConclusionsDexmedetomidine and Nimodipine provided effective method of controlled hypotension limiting the blood loss, and NIMO was associated with significantly shorter extubation and recovery times compared with DEX.     

Dexmedetomidine; an adjuvant drug for fast track technique in pediatric cardiac surgery

BackgroundSimple surgical procedures in pediatric open cardiac surgery can be planned for early extubation by using dexmedetomidine alpha2 agonist. Early extubation is associated with shortening of postoperative ventilation and intensive care unit length of stay. The aim of this study was to examine the effects of dexmedetomidine on recovery profile, ICU length of stay, analgesic needs, and hospital stay in pediatric patients undergoing elective correction of congenital heart diseases using CPB.MethodsForty patients with age ranging from 2–10 years of either sex submitted for elective correction of simple congenital heart diseases undergoing CPB. All patients were premedicated in preoperative area with intramuscular 0.1 mg/kg midazolam and 0.015 mg/kg atropine sulfate. Patients were randomly classified into one of two equal groups (n = 20). In the Dex group, patients received an initial bolus dose of dexmedetomidine (0.4 μg/kg) over 10 min, followed by continuous infusion of 0.5 μg/kg/hr. In the control group, patients received an initial bolus dose of saline over 10 min, followed by continuous infusion of 0.5 μg/kg/hr.ResultsMAP, HR, the total dose of intra-operative fentanyl, vasodilator needs, time of extubation, pain score, ICU length of stay and hospital stay were significantly higher in the control group when compared with DEX group. Also in control group these were significant decrease in HR and MAP relative to baseline. There was significant increase in duration of inotropic support in control group than DEX group.ConclusionDexmedetomidine is a short-acting alpha2-adrenoceptor agonist with many desirable clinical benefits that encourage its use in the perioperative period. Dexmedetomidine has anesthesia-sparing effects, it decreases MAP, HR and with reasonable analgesic effect.     

Dexmedetomidine versus propofol for sedation during gastrointestinal endoscopy in pediatric patients

ObjectiveTo compare the sedative, hemodynamic, respiratory and adverse effects of dexmedetomidine versus propofol during gastrointestinal endoscopy (GIE) in pediatrics.MethodsAfter obtaining approval of the research and ethics committee and informed consent of the parents of the patients, eighty pediatric patients ASA I/II aged 1–14 years, scheduled for gastrointestinal endoscopy were randomized into dexmedetomidine group or propofol group. Sedation was achieved with propofol 2 mg/kg bolus then infused at 100 μg/kg/min or dexmedetomidine 2.5 μg/kg over 10 min then infused at 2 μg/kg/h to achieve a Ramsay sedation scale (RSS) ⩾5. HR, MAP, RR and SPO2 were continuously monitored and analyzed at (T0) baseline, (T1) after induction, (T2) after insertion of endoscope, (T3) during procedure, (T4) recovery period. Times of induction, procedure, and recovery were reported together with any adverse effects.ResultsThere were no significant differences in demographic data between the two groups. HR values were significantly lower in dexmedetomidine group at T1, T2 and T3 (83.95 ± 13.79 versus 92.95 ± 12.38, 103.35 ± 15.34 versus 112.75 ± 12.79 and 90.80 ± 13.99 versus 104.05 ± 10.73) beats/min respectively, (p-value < 0.05). No significant differences were found in MAP, RR and SPO2 values between groups at all time points. Induction and recovery times were significantly longer in dexmedetomidine group 10.51 ± 1.75 versus 3.17 ± 0.72 min and 28.55 ± 7.95 versus 13.68 ± 3.35 min (p-value < 0.001). Seven patients in dexmedetomidine group (17.5%) versus one patient in propofol group (2.5%) showed unwanted movement (p-value 0.057), and no cases in dexmedetomidine group demonstrated oxygen desaturation versus 6 patients (15%) within propofol group (p-value 0.026).ConclusionDexmedetomidine sedation during GIE provides more respiratory safety and HR stability presenting itself as a suitable alternative agent especially for the relatively longer procedures.     

A new modality for improving the efficacy of intrathecal injection for cesarean section

BackgroundIntrauterine resuscitation (IUR) is to improve O2 delivery to the placenta and umbilical blood flow, for reversal of foetal hypoxia and acidosis. We evaluated whether maintaining a lateral position after an intrathecal injection of a relatively low dose of hyperbaric bupivacaine and high dose of fentanyl improving the efficacy of spinal anaesthesia, IUR and preventing hypotension during cesarean delivery.MethodsOne hundred and seventy two healthy women undergoing elective cesarean delivery were enrolled in a double blind prospective randomized study. Spinal anesthesia was conducted in the right lateral position which maintained for 6 min for all the patients participated in the study, and then the subjects were turned supine. Patients were randomly allocated to two groups: low-dose spinal bupivacaine (LD) group (n = 86) patients received 6 mg of hyperbaric bupivacaine 0.5% and 15 μg of fentanyl, high-dose spinal bupivacaine (HD) group (n = 86) patients received 10 mg of hyperbaric bupivacaine and 15 μg of fentanyl. The incidence of hypotension and nausea, ephedrine requirement, maximal block height, and Apgar score at 1 and 5 min.ResultsThe authors found significant decrease in MAP in the group that was given the high dose of bupivacaine the incidence of hypotension was 80% but the LD spinal bupivacaine group was hemodynamically stable. The lowest blood pressure, boluses of inj. ephedrine used, or nausea were more significant in the HD group than in LD group. Onset of hypotension was more rapid (8 ± 3 vs. 16 ± 6 min, P < 0.001), and the sensory block level was more cephalad in HD group than in LD group (T2 [C8–T5] vs. T4 [T1–T6], P = 0.001). Apgar scores did not differ between the groups.ConclusionMaintaining the lateral position for 6 min after an intrathecal injection of a relatively low dose of hyperbaric bupivacaine and high dose of fentanyl resulted in improving the efficacy of spinal anaesthesia, IUR by more gradual and higher cephalad sensory block, without an increase in the incidence of maternal hypotension.     

Terlipressin versus norepinephrine to counteract intraoperative paracentesis induced refractory hypotension in cirrhotic patients

Back groundSome of tense ascitic patients with end stage liver disease and portal hypertension were presented to our emergency department with surgical acute abdomen that required urgent abdominal surgery which might be associated with inevitable rapid and relatively complete evacuation of this ascitic fluid with possible occurrence of post-paracentesis-induced hypotension. The aims of this study were to compare between the intraoperative use of terlipressin versus norepinephrine for the management of paracentesis induced refractory hypotension not responding to colloid resuscitation or ephedrine in patients with end-stage liver disease during emergency abdominal surgery.Patients and methodThirty-four patients experienced refractory hypotension during or shortly after the paracentesis process were randomized to receive either bolus dose of terlipressin (1 mg over 30 min) followed immediately by a continuous infusion of 2 μg/kg/h (T group, n = 17) or norepinephrine infusion at starting dose of 0.1 μg/kg/min (N group, n = 17).MeasurementsHemodynamic parameters, cardiac output, systemic vascular resistance, blood gases, lactic acid, liver and kidney functions.ResultsAll patients of both groups showed significant decreases in MAP during or immediately after the paracentesis process to reach mean values of 57 ± 1.4 and 58 ± 1.8 mmHg in terlipressin or norepinephrine groups respectively. This was associated with drop in the SVR that reached mean values of 445 ± 28 and 425 ± 20 dynes/sec/cm⁵ in both terlipressin and norepinephrine groups respectively. At the 2nd day post operative there was significant increase in serum creatinine values in the norepinephrine group.ConclusionTerlipressin and norepinephrine successfully counteracted the post-paracentesis refractory hypotension and the drop of the systemic vascular resistance. It also showed the renal protective effects of terlipressin in the immediate postoperative period.     

A comparison of the haemodynamic effects of lateral and sitting positions during induction of spinal anaesthesia for caesarean section

BackgroundHypotension during spinal anaesthesia occurs commonly in parturients. By influencing spread of local anaesthetic, maternal position may affect the speed of onset of sensory block and thus the haemodynamic effects. The aim of this study was to determine whether inducing spinal anaesthesia for caesarean section using plain bupivacaine in the lateral position would result in less hypotension compared with the sitting position.MethodsOne hundred American Society of Anesthesiologists physical status I and II patients undergoing elective caesarean section were randomised to receive spinal anaesthesia in the lateral position (Group L) or the sitting position (Group S). Using the L3-4 interspace, patients received intrathecal plain bupivacaine, 10 mg or 12 mg according to their height, after which they were placed immediately in the supine position with left uterine displacement. Maternal blood pressure was measured every minute for 10 min, every three min for 20 min and 5-minutely thereafter. Hypotension was defined as a fall in systolic blood pressure >20% or a value <90 mmHg.ResultsThere was no difference in the lowest recorded systolic blood pressure in Group L (99.2 ± 8.9 mmHg) compared with Group S (95.4 ± 12.3 mmHg, P = 0.081). However, the lowest recorded mean arterial pressure was greater in Group L (72.9 ± 11.2 mmHg) than in Group S (68.2 ± 9.6 mmHg; P = 0.025). The incidence of hypotension was lower in Group L (17/50, 34%) than in Group S (28/50, 56%; P = 0.027). Onset of hypotension was similar between groups.ConclusionHypotension occurred less frequently when spinal anaesthesia for caesarean using plain bupivacaine was induced with patients in the lateral compared with the sitting position. Values for the lowest recorded mean arterial pressure were greater but values for the lowest recorded systolic blood pressure were similar for patients in the lateral position group.     

Quality of MRI pediatric sedation: Comparison between intramuscular and intravenous dexmedetomidine

ObjectiveThe study was designed to compare the efficacy of dexmedetomidine whether given intramuscular or intravenous for pediatric MRI sedation.Subjects and methodsNinety children between the ages of 2 and 8 years with ASA physical status I–II, scheduled for elective MRI, were enrolled in a double blind, comparative randomized study. Patients assigned into two equal groups. Group DV, sedation was performed using IV dexmedetomidine hydrochloride; a loading dose of 1 μg/kg administered over 10 min followed by a continuous infusion at 1 μg/kg/h. Group DM where the patient received IM dexmedetomidine 3 μg/kg. Primary endpoints included incidence of failed sedation and the requirement of midazolam supplementation. Secondary endpoints were time to sedation, duration of sedation, discharge time, and hemodynamic status.ResultsThe sedation failure rate was significantly higher in the DV group (40%) in comparison with the DM group (20%) (P = 0.04). Also, the use of rescue midazolam was significantly higher in the VD group (0.37 ± 0.47 mg) in comparison to the DM group (0.17 ± 0.35 mg) (P = 0.025). The onset of satisfactory sedation was significantly shorter in DV group in comparison to DM group (7.93 ± 0.884 vs. 16.87 ± 4.49). Also, the discharge time was significantly less in the DV group (32.27 ± 3.04 min) in comparison to DM group (41.87 ± 5.80 min). Patients in DV group had significantly lower MBP compared to patients in DM group after receiving dexmedetomidine (p < 0.05). Although the HR decreased in both groups during the MRI study, the decrease was statistically significant in the DV group compared to the DM group in the period extended from the 2nd to 35th min (p < 0.05).ConclusionIn pediatric MRI sedation, although IM dexmedetomidine does have a late sedation onset; it reduces the sedation failure rate, the need for supplement sedation and the incidence of hemodynamic instability associated with IV dexmedetomidine.     

Clinical outcome of conventional versus biological fixation of subtrochanteric fractures by proximal femoral locked plate

IntroductionSurgical fixation is the standard management of the subtrochanteric fractures. Proximal femoral locked plating (PF-LCP) provides a strong construct for fixation with a high success rate. However, some studies reported implant failure due to loss of the postero-medial bone support and recommended an anatomical reduction. Other studies reported excellent to good results with indirect (biological) fixation without anatomical reduction. In this study, we reviewed the short-term clinical results of PF-LCP fixation for subtrochanteric fractures using both conventional and biological fixation.Materials and methodsForty six patients (34 males and 12 females) with comminuted subtrochanteric fractures were included aged between 18 and 74 (mean 44.3 years). They were treated in a single-blind random manner by either conventional (open, direct) or biological (indirect) reduction method and internal fixation with PF-LCP. Intra-operative variables including; duration of surgery, blood loss, fluoroscopy time and any complications were recorded. Post-operative differences including; duration of healing, implant failure, complications and the final clinical outcome by Harris Hip Score (HHS) were documented.Results44 cases continued to the final follow-up (23 of the open fixation group and 21 of the biological fixation group). Patients of open group demonstrated greater blood loss (756 ± 151 vs. 260 ± 39 ml; P < 0.0001), longer operative times (129 ± 16.9 vs. 91 ± 8 min; P < 0.0001) and incisions (s) length (20.4 ± 3 vs. 13.4 ± 1 cm; P < 0.0001). More patients needed blood transfusion in open group (11 patients vs. six in closed group; P < 0.0001). Patients of biological group demonstrated longer fluoroscopy time (80.9 ± 7.3 vs. 47.2 ± 5.8 sec.; P < 0.0001). For each group, one case of implant failure was recorded. Low patient compliance was a detrimental factor for the implant failure in both cases. No much difference was demonstrated for the healing rate (open group; 18.3 ± 3.7 vs. biological group16.5 ± 4 weeks; P < 0.058) and for the functional outcome (open group; excellent/good: 54%/37%, biological group; excellent/good: 57%/33%; P = 0.766).ConclusionPF-LCP provided a strong construct for fixation of the comminuted subtrochanteric fractures either by open or biological techniques. Low patient compliance is an influential factor for implant failure in both types.     

Single shot spinal anesthesia with very low hyperbaric bupivacaine dose (3.75 mg) for hip fracture repair surgery in the elderly. A randomized,double blinded study

PurposeSingle shot spinal anesthesia is used worldwide for hip fracture repair surgery in the elderly. Arterial hypotension is a frequent adverse effect. We hypothesized that lowering local anesthetics dose could decrease the incidence of arterial hypotension, while maintaining quality of surgical anesthesia.MethodsIn a randomized double blinded study, 66 patients over the age of 65 years, with hip fracture needing surgical repair, were assigned to B0.5 group 7.5 mg hyperbaric bupivacaine 5 mg/ml (control group), and B0.25 group 3.75 mg hyperbaric bupivacaine 2.5 mg/ml (study group). Sensory and motor block level, and hemodynamic parameters including blood presure, heart rate and vasopressor dose administration were registered, along with rescue anesthesia needs, the feasibility of surgery, its duration, and regression time of sensory anesthesia to T12.ResultsAfter exclusions, 61 patients were included in the final analysis. Arterial hypotension incidence was lower in the B0.25 group (at the 5, 10, and 15 min determinations), and a lower amount of vasopressor drugs was needed (mean accumulated ephedrine dose 1.6 mg vs. 8.7 mg in the B0.5 group, p < 0.002). Sensory block regression time to T12 was shorter in the B0.25 group, mean 78.6 ± 23.6 (95% CI 51.7–110.2) min vs. 125.5 ± 37.9 (95% CI 101.7–169.4) min in the B0.5 group, p = 0.033. All but one patient in the B0.25 group were operated on under the anesthetic procedure first intended. No rescue anesthesia was needed.ConclusionLowering bupivacaine dose for single shot spinal anesthesia for hip fracture repair surgery in elderly patients was effective in decreasing the occurrence of arterial hypotension and vasopressor use, while intraoperative quality remained.     

Predicting the need for blood transfusions in elderly patients with pertrochanteric femoral fractures

ObjectiveThe need exists for perioperative blood management measures aimed at improving patient outcomes and reducing the risks of allogeneic blood transfusion (ABT). Our study aim is to discuss an algorithm to predict the need for perioperative blood transfusion in old patients with pertrochanteric femoral fractures.MethodsWe retrospectively analysed the data from 220 elderly patients with pertrochanteric femoral fractures with regard to the probability of receiving an ABT within 72 h after surgery. The patients were divided into ABT and non-ABT groups. A univariate analysis was used to compare between-group differences with regard to 13 variables. A logistic regression analysis and a probability algorithm to predict the need for an ABT based on independent predictors were used.ResultsThe non-ABT group included 131 patients (55 males and 76 females), with an average age of 77.2 ± 6.8 years; the ABT group included 89 patients (29 males and 60 females), with an average age of 79.7 ± 6.6 years. The total volume of transfused blood was 276 Units; the actual average blood transfusion was 3.1 ± 1.47 Units. Significant between-group differences (P < 0.05) were observed with regard to age, duration of operation, haemoglobin (Hb) at admission, intra-operative blood loss, type of fracture and type of anaesthesia. The mean volume of transfused blood in the proximal femoral nail anti-rotation (PFNA) and Gamma3 group was larger than that of the dynamic hip screw (DHS) group (P < 0.05). A logistic regression analysis revealed that patients with pertrochanteric femoral fractures who were elderly (>81 years), had lower Hb levels at admission (≤124 g/L), longer duration of operations (t > 85 min), underwent intramedullary fixation (Gamma3 and PFNA) and had more intra-operative blood loss were more likely to need an ABT. This regression model predicted 74.1% of the transfused cases.ConclusionsAn algorithm was devised to predict and manage the need for an ABT within 72 h after surgery in patients with pertrochanteric femoral fractures. A reasonable transfusion program might reduce the complications caused by anaemia and effectively avoid the risks associated with ABTs.     

The effects of a resistive warming mattress during caesarean section: a randomised,controlled trial

BackgroundThe adverse effects of inadvertent perioperative hypothermia in the surgical population are well established. The aim of this study was to investigate whether a resistive warming mattress would reduce the incidence of inadvertent perioperative hypothermia in patients undergoing elective caesarean section.MethodsA total of 116 pregnant women booked for elective caesarean section were randomised to either intraoperative warming with a mattress or control. The primary outcome was the incidence of inadvertent perioperative hypothermia, defined as a temperature <36.0°C on admission to the recovery room. Shivering in the perioperative period, severity of shivering and the need for treatment, total blood loss, fall in haemoglobin, incidence of blood transfusion, immediate health of baby, and length of hospital stay were also recorded.ResultsThe incidence of inadvertent perioperative hypothermia in the mattress-warmed group was significantly lower than in the control group (5.2% vs. 19.0%, P = 0.043); mean temperatures differed between the two groups, 36.5°C and 36.3°C, respectively (P = 0.046). There was also a significantly lower mean (± SD) haemoglobin change in the mattress-warmed group at −1.1 ± 0.9 g/dL versus −1.6 ± 0.9 g/dL in the control group (P = 0.007). There was no difference in shivering (P = 0.798).ConclusionsA resistive warming mattress reduced the incidence of inadvertent perioperative hypothermia and attenuated the fall in haemoglobin. The use of resistive mattress warming should be considered during caesarean section.     

Middle cerebral artery blood flow velocity during beach chair position for shoulder surgery under general anesthesia

ObjectivesThe goal of the present study was to examine changes of middle cerebral artery (V_MCA) blood flow velocity in patients scheduled for shoulder surgery in beach chair position.DesignProspective observational study.SettingOperating room, shoulder surgery.PatientsFifty-three consecutive patients scheduled for shoulder surgery in beach chair position.InterventionsTranscranial Doppler performed after induction of general anesthesia (baseline), after beach chair positioning (BC1), during surgery 20 minutes (BC2), and after back to supine position before stopping anesthesia (supine).MeasurementsMean arterial pressure (MAP), end-tidal CO₂, and volatile anesthetic concentration and V_MCA were recorded at baseline, BC1, BC2, and supine. Postoperative neurologic complications were searched.Main ResultsBeach chair position induced decrease in MAP (baseline: 73 ± 10 mm Hg vs lower MAP recorded: 61 ± 10 mm Hg; P < .0001) requiring vasopressors and fluid challenge in 44 patients (83%). There was a significant decrease in V_MCA after beach chair positioning (BC1: 33 ± 10 cm/s vs baseline: 39 ± 14 cm/s; P = .001). The V_MCA at baseline (39 ± 2 cm/s), BC2 (35 ± 14 cm/s), and supine (39 ± 14 cm/s) were not different. The minimal alveolar concentration of volatile anesthetics, end-tidal CO₂, SpO₂, and MAP were not different at baseline, BC1, BC2, and supine.ConclusionBeach chair position resulted in transient decrease in MAP requiring fluid challenge and vasopressors and a moderate decrease in V_MCA.     

Ketamine/propofol versus fentanyl/propofol for sedating obese patients undergoing endoscopic retrograde cholangiopancreatography (ERCP)

ObjectiveThis study was conducted to compare two techniques of sedation for obese patients undergoing ERCP, using either ketofol or fentanyl–propofol as regards propofol consumption, recovery time, patients’ satisfaction, and sedation-related adverse events.Materials and methodsTwo hundred obese patients were randomly allocated to one of two groups; ketamine/propofol (ketofol) group KP (n = 100) or fentanyl/propofol group FP (n = 100). The level of sedation was adjusted to achieve a Ramsay Sedation Scale (RSS) score of 5.ResultsTotal dose of propofol consumed was significantly higher in group FP compared with group KP (97.08 ± 23.31 mg and 57.71 ± 16.97) mg. Recovery time was slightly longer in group KP compared with group FP (11.19 ± 2.59 min and 9.43 ± 1.23 min, respectively), time needed to achieve Aldrete Recovery Scale Score of 9 was comparable in both groups, and sedation-related side effects as hypotension, bradycardia, apnea, and reduction of SpO₂ were more significant in the FP group.In conclusionKetamine/propofol combination 1:4 provided better sedation quality than fentanyl/propofol combination with less side effects and can be safely used for sedating obese patients undergoing ERCP.     

Factores influyentes en la respuesta al rescate con radioterapia tras prostatectomía radical

ObjectiveTo analyze the influential factors in the response in prostatectomized patients with subsequent biochemical relapse (BCR) and treated with salvage radiotherapy (RTP).Material and methodsWe analyzed 313 patients with pT2/pT3 prostate cancer who were receiving salvage therapy due to biochemical relapse (from a series of 1,310 radical prostatectomies between 1989-2012). Of the 313 patients; 159 (50.8%) only received androgen deprivation (AD), 63 (20.1%) Radiotherapy (RTP) plus concomitant AD and 91 (29.1%) only RTP. Of these, 57 (62.6%) have maintained complete response and 34 (37.4%) had failure response with post-RTP BCR.ResultsStudy of the group treated exclusively with salvage RTP. Ninety-one patients were treated with salvage RTP. Median follow-up was 6.4 years and median to recurrence 11 months. Post-RTP biochemical relapse-free survival (PRBRFS) was 68 ± 7% and 30 ± 10% in 5 to 10 years. Median PRBRFS was 7.3 years (6.3-8.3). Initial PSA (HR: 1.08; 95% CI: 1.01-1.1 P = .02) with best PSA cut-off point PSA > 20 ng/ml (HR: 13.6; 95% CI: 2.1-86 P = .005) and PSA pre-RTP (HR: 1.9; 95% CI: 1.2-3.3; P = .009), best PSA cut-off point PSA preRTP 0.92 ng/ml (HR: 4.5; 95% CI: 1.3-15.6; P = .01) showed independent influence in the response in the multivariate study. PRBRFS at 5 years, 81 ± 9% versus 58 ± 9% with initial PSA < 20 or > 20 ng/ml (P = .03). PRBRFS at 5 years, 93 ± 5% versus 53 ± 10% according to PSA pre-RTP < 0.9 or > 0.9 ng/ml (P = .02).ConclusionsIn patients treated with salvage RTP after radical prostatectomy, the preoperative PSA > 20 ng/ml and PSA preRTP > 0.92 ng/ml shows an independent influence on the response.     

A comparative study between propofol and dexmedetomidine as sedative agents during performing transcatheter aortic valve implantation

ObjectiveThe type of sedative drugs could play a major role in providing hemodynamic stability which is crucial during transcatheter aortic valve implantation (TAVI) procedure. The aim of this study is to compare propofol with dexmedetomidine for conscious sedation during TAVI.DesignA prospective randomized pilot study.PatientsFifty patients with a mean age of 74 years, American Society of Anesthesiologists 3-4, complaining from severe aortic stenosis were enrolled in this study to undergo TAVI.InterventionsThe propofol group (group P; n = 25) received a bolus dose of 0.5 mg/kg propofol followed by a continuous intravenous infusion of propofol at a rate of 30 to 50 μg kg^− 1 min^− 1, and the dexmedetomidine group (group D; n = 25) received dexmedetomidine at a loading dose of 1 μg/kg and then a continuous intravenous infusion of dexmedetomidine at a rate of 0.5 μg kg^− 1 h^− 1.MeasurementsHeart rate, mean arterial blood pressure, number of phenylephrine boluses, oxygen saturation, sedation, and satisfaction scores were measured just after the start of infusion of the sedation drugs and at the end of the procedure. Postoperative complications were also recorded.ResultsThere was a statistically significant reduction in the heart rate in group D in comparison to group P where it was 67.28 ± 6.9 beats/min in the first group in comparison to 78 ± 6.9 beats/min in the last one (P < .001). The mean arterial blood pressure was statistically significant lower in group D in comparison to group P (58.12 ± 5.4 mm Hg in group D vs 68.24 ± 11.4 mm Hg in group P; P < .001). Also, the number of phenylephrine boluses was higher in group D than in group P (36.5 ± 7.17 in group D vs 20.6 ± 2.07 in group p; P < .001). No difference between the 2 groups regarding oxygen saturation, sedation, pain, satisfaction scores, and postoperative complications.ConclusionDuring TAVI, dexmedetomidine may be associated with significant hypotension and bradycardia rather than propofol.     

The use of phenylephrine to obtund oxytocin-induced hypotension and tachycardia during caesarean section

BackgroundOxytocin causes clinically significant hypotension and tachycardia. This study examined whether prior administration of phenylephrine obtunds these unwanted haemodynamic effects.MethodsForty pregnant women undergoing elective caesarean section under spinal anaesthesia were randomised to receive either an intravenous 50 μg bolus of phenylephrine (Group P) or saline (Group S) immediately before oxytocin (3 U over 15 s). Systolic blood pressure, diastolic blood pressure, mean arterial pressure and heart rate were recorded using a continuous non-invasive arterial pressure device. Baseline values were averaged for 20 s post-delivery. Between-group comparisons were made of the mean peak changes in blood pressure and heart rate, and the mean percentage changes from baseline, during the 150 s after oxytocin administration.ResultsThe mean ± SD peak percentage change in systolic blood pressure was −16.9 ± 2% in Group P, and −19.0 ± 1.9% in Group S and the estimated mean difference was 2.1% (95% CI −3.5% to 7.8%; P=0.44); corresponding changes in heart rate were 13.5 ± 2.3% and 14.0 ± 1.5% and the mean estimated difference was 0.5% (95% CI −6.0% to 5%; P=0.87). The mean percentage change from the baseline measurements during the 150 s period of measurement was greater for Group S than Group P: systolic blood pressure −5.9% vs −3.4% (P=0.149); diastolic blood pressure −7.2% vs −1.5% (P=0.014); mean arterial pressure −6.8% vs −1.5% (P=0.007); heart rate 2.1% vs −2.4% (P=0.033).ConclusionIntravenous phenylephrine 50 μg immediately before 3 U oxytocin during elective caesarean section does not prevent maternal hypotension and tachycardia.     

Intraocular pressure changes: the McGrath video laryngoscope vs the Macintosh laryngoscope; a randomized trial

Study ObjectiveTo determine the effects of the McGrath Series 5 video laryngoscope on intraocular pressure (IOP) during laryngoscopy.DesignProspective, randomized, double blind.SettingOperating room.PatientsEighty adult patients of American Society of Anesthesiologist physical status 1 scheduled for nonophthalmic elective surgery under general anesthesia.InterventionsThe endotracheal intubation was provided using McGrath series 5 video laryngoscope in MG group (n = 40) or Macintosh laryngoscope in M group (n = 40).MeasurementsThe IOP of the right and left eyes was measured before and after the laryngoscopic process.Main ResultsThe mean arterial blood pressure values just before laryngoscopy and intubation and after intubation were 77.38 ± 6.18 and 97.38 ± 12.77 in the McGrath video laryngoscope group and 75.85 ± 7.88 and 99.12 ± 14.30 in the Macintosh laryngoscope group, respectively. The IOP values of the left eye after intubation and at the 5th and the 10th minutes in the Macintosh laryngoscope group were found to be significantly higher than those in the McGrath video laryngoscope group (P = .019, P = .019, and P = .007, respectively). In addition, the IOP values of the right eye were found to be higher after intubation and at the 5th and the 10th minutes in the Macintosh laryngoscope group, compared to the McGrath video laryngoscope group (P = .009, P = .021, and P = .011, respectively). The mean IOP values for the left eye just before laryngoscopy and intubation and after intubation were 10.65 ± 2.52 and 15.57 ± 3.62 in the McGrath video laryngoscope group, and for the right eye, they were 10.60 ± 1.64 and 17.17 ± 2.38 in the Macintosh laryngoscope group, respectively.ConclusionThe McGrath Series 5 video laryngoscope may provide a lower IOP level compared to the Macintosh laryngoscope in an otherwise healthy, young patient population.     

Single dose spinal analgesia: Is it a good alternative to epidural analgesia in controlling labour pain?

ObjectivesRegional anaesthesia is considered the optimal technique for obstetric patients; nevertheless, the optimal method of regional anaesthesia for delivery remains to be determined. In our study we investigate the safety, efficacy and cost benefits of single-dose spinal analgesia in comparison with epidural analgesia during labour.Study designIn our study women in advanced labour were randomly allocated into two equal groups using a computer-generated randomization table, one group (spinal group = S group) were given 3.75 mg hyperbaric bupivacaine +25 μg fentanyl with 0.75 ml saline, the other group (Epidural group = E group) were given 4 ml bupivacaine with 4 ml saline and 1 ml (50 μg) fentanyl pain intensity was recorded by the parturient on a visual analogue scale. The quality of pain relief was also rated with a verbal score directly after delivery. Side effects, such as hypotension, Pruritus, sedation, nausea and motor block were noted. Obstetric parameters were followed and recorded, Apgar score were noted, and all the results were compared in the two groups.ResultsOnset of sensory block (detected by pin-prick test) was early (4.4 ± 1.5 min vs 12.5 ± 2.3 min, p < 0.001) and duration of sensory block was longer (120.4 ± 15.6 vs 103.2 ± 18.3 min, p < 0.001) in S group compared to E group, time to reach maximum dermatome level of sensory block (T₁₀) was shorter in S than E group (8.3 ± 2.4 min vs 22.4 ± 5.7 min, p < 0.001), two segment regression occur late in S group compared to E group(75.6 ± 12.5 min vs 66.3 ± 9.4 min, p < 0.001). Visual analogue scores after 5, 15, 30, 60, 90, 120 and 150 min were lower in S group compared to E group, all the previous result is statically significant (p < 0.001). 88% of the parturients in S group vs 60% in E group scored the analgesic quality as excellent, the mean duration of analgesia (Mean ± SD) was longer in S group compared to E group. 8% of parturients in S group vs 14% of parturients in E group had hypotension. Motor block, sedation and nausea were 2–6% in both groups. Pruritus was seen in 60% in E group vs 25% in spinal one. No caesarean section was performed. Vacuum extraction was done in 15% vs 25% among S group and E group respectively. Oxytocin augmentation was needed in 48% vs 62% of the parturients among S group and E group respectively. Faetal heart rate disturbances following the spinal block were seen in 2 cases. Apgar score were high and no neonate had Apgar score <7 in both group. The overall cost was lower in S group compared to E group.ConclusionsBased on the results of our study we concluded that single dose spinal analgesia is a good alternative to epidural analgesia in controlling labour pain i.e. spinal compared to epidural is more easy performed, faster, less expensive, and provide effective analgesia.     

Retroperitoneal packing or angioembolization for haemorrhage control of pelvic fractures—Quasi-randomized clinical trial of 56 haemodynamically unstable patients with Injury Severity Score ≥33

AimsBoth retroperitoneal pelvic packing and primary angioembolization are widely used to control haemorrhage related to pelvic fractures. It is still unknown which protocol is the safest. The primary aim of this study is to compare survival and complications of pelvic packing and angioembolization in massive haemorrhage related to pelvic fractures.MethodsPatients with haemodynamically unstable pelvic fractures were quasi-randomized to either pelvic packing (PACK) or angiography (ANGIO) using the time of admission as separator. Physiological markers of haemorrhage, time to intervention, procedure/surgical time, transfusion requirements, complications and early mortality were recorded and analyzed.Results29 patients were randomized to PACK and 27 patients to ANGIO. The Injury Severity Score (ISS) in the ANGIO group was lower than in the PACK group (43 ± 7 vs 48 ± 6) (p < 0.01). The median time from admission to angiography for the ANGIO group was 102 min (range 76–214), and longer than 77 min (range 43–125) from admission to surgery for the PACK group (p < 0.01). The procedure time for the ANGIO group was 84 min (range 62–105); while the surgical time was 60 min (range 41–92) for the PACK group (p < 0.001). The ANGIO group received 6.4 units packed red blood cells (range 4–10) in the first 24 h after angiography. The PACK group required 5.2 units (range 3–10) in the first 24 h after leaving the operating theatre (p = 0.124). 9 patients in the ANGIO group underwent pelvic packing for persistent bleeding. 6 patients in the PACK group required pelvic angiography after pelvic packing for ongoing hypotension following packing (p = 0.353). 5 patients in the ANGIO group died (2 from exsanguination), while 4 in the PACK group died (none from exsanguination) (p = 0.449). Complications occurred without differences in both groups.ConclusionsCompared with angioembolization, pelvic packing has shorter time to intervention and surgical time. Thus pelvic packing is the more rapid treatment of severe pelvic trauma than pelvic angioembolization. It is suitable for patients with haemodynamic instability at centers where the interventional radiology staff is not in-house at all times.RegistrationClinicalTrials.gov (NCT02535624) and ISRCTN registry (ISRCTN91713422).     

The impact of spinal anaesthesia for caesarean delivery on coagulation assessed by thromboelastography

BackgroundPregnancy and puerperium are associated with a hypercoagulable state. The aim of the study was to assess the impact of spinal anaesthesia on coagulation using thromboelastography in healthy term pregnant women undergoing elective caesarean delivery.MethodsThromboelastography was performed on 60 women undergoing elective caesarean delivery under spinal anaesthesia. As spinal anaesthesia has different effects on upper and lower extremity vasculature, venous blood samples were collected from both hand and foot, before and one hour after spinal injection.ResultsIn the hand samples, R and K values decreased significantly from before to one hour after spinal injection (5.7 ± 1.9 min versus 3.6 ± 1.3 min, P < 0.001 and 2.1 ± 0.9 min versus 1.5 ± 0.4 min, P < 0.001, respectively). At the same times, significant increases in the alpha angle (58.6 ± 9.1 degrees versus 65.6 ± 7.5 degrees, P < 0.001), MA (85.1 ± 4.6 mm versus 87.0 ± 3.8 mm, P < 0.001) and CI (2.6 ± 2.1 versus 4.9 ± 1.5, P < 0.001) were seen. No significant changes were found in thromboelastography parameters in samples collected from foot veins before and one hour after spinal injection, with the exception of the alpha angle (62.1 ± 11.5 versus 66.5 ± 8.8 degrees, P < 0.012).ConclusionIn women undergoing caesarean delivery under spinal anaesthesia, enhanced coagulation thromboelastography parameters were observed in blood collected from hand veins. No changes were detected in the majority of parameters collected from the foot. Spinal anaesthesia has different effects on coagulation parameters in the hand and foot in pregnant women undergoing caesarean delivery.