Analgesic efficacy of ultrasound guided bilateral transversus thoracis muscle plane block in pediatric cardiac surgery: a randomized,double-blind,controlled study

Study objectiveAdequate perioperative pain control in children undergoing cardiac surgery is mandatory. Intravenous opioids and neuraxial anesthetic techniques have been used but didn't gained any popularity. The aim of the current study was to evaluate the analgesic efficacy of transversus thoracis plane (TTP) block in pediatric cardiac surgery.DesignSuperiority, randomized, double-blind, controlled study.SettingIntraoperative and postoperative in intensive care unit (ICU), Mansoura university children hospital, Egypt.PatientsEighty pediatric patients aged 2–12 years, undergoing cardiac surgery via median sternotomy, were randomly allocated into 2 equal groups, the control group and TTP block group.InterventionsControlled group received only fentanyl for perioperative analgesia, while TTP block was performed in the intervention group (TTP group).MeasurementsThe primary outcome measure was the total dose of fentanyl in the first postoperative 24 h after extubation, while the secondary outcome measures were postoperative pain score, intraoperative fentanyl consumption, time to extubation and ICU length of stay.Main resultsDuring the first postoperative 24 h, total fentanyl consumption was significantly lower (P < 0.05) in the TTP block group (9.892 ± 3.397 μg/kg) than the control group (18.500 ± 3.401 μg/kg) and modified objective pain score was significantly (P < 0.05) lower in TTP block group than the control group all over the time. Total intraoperative fentanyl requirement was significantly (P < 0.05) lower in TTP block group (8.27 ± 1.170 μg/kg) than the control group (13.72 ± 1.186 μg/kg).ConclusionThe use of TTP block decreased perioperative fentanyl consumption and reduced postoperative pain intensity.     

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.     

Pre-operative breathing training based on video learning reduces emergence delirium in preschool children: A randomized clinical trial

Study objectiveEmergence delirium is a common complication in preschool children after general anesthesia and may result in undesirable complications. This study aimed to determine whether breathing training after watching an informative video during the pre-operative visit could reduce the incidence of emergence delirium in preschool children after otorhinolaryngologic surgery under general anesthesia.DesignA single-center, double-blinded, randomized controlled trial.SettingPerioperative care.PatientsA total of 170 children undergoing otorhinolaryngologic surgery, aged 3–7 years, ASA physical status I or II were involved.InterventionsPatients were randomized to receive breathing training during the pre-operative visit (Training group) or to receive pre-operative visit only (Control group) the day before surgery.MeasurementsEmergence delirium was measured by the Pediatric Anesthesia Emergence Delirium score during the anesthesia recovery time. Data regarding extubation time and post-anesthesia care unit stay time were collected.Main resultsChildren who received breathing training during the pre-operative visit had a significantly lower incidence of emergence delirium than those who only underwent the pre-operative visit (10.4% vs. 35.1%, P < 0.001). The awakening time score and the maximum score in the post-anesthesia care unit were significantly lower in the training group compared with the control group [4.4 ± 3.4 vs. 6.9 ± 4.2, P < 0.001 and 5.0 (5.0) vs 7.0 (7.0), P = 0.001, respectively]. We found no differences in the extubation time and post-anesthesia care unit stay time between groups.ConclusionsWe concluded that breathing training based on video learning during the pre-operative visit in preschool children undergoing otorhinolaryngologic surgery could significantly decrease the incidence of emergence delirium.Trial registrationChinese Clinical Trial Registry (Reference number: ChiCTR1900026162); registered on September 24, 2019.     

Effect of real-time binaural music on sedation with dexmedetomidine during spinal anesthesia: A triple-arm,assessor-blind,randomized controlled trial

Study objectiveBinaural audio induces sedation and reduces pain and anxiety in surgical patients. This study tested the hypothesis that dexmedetomidine requirement for adequate sedation during spinal anesthesia would be lower in patients listening to music with binaural sound than that in patients listening to plain or no music.DesignA triple-arm, assessor-blind, randomized controlled study.SettingOperating room.PatientsOne hundred and eighty-nine patients undergoing orthopedic surgery under spinal anesthesia.InterventionsPatients were randomly assigned to music with binaural sound, plain music, or no music groups. Dexmedetomidine was infused for sedation during surgery. The loading infusion rate was 6 μg/kg predicted body weight (PBW)/h, followed by continuous infusion at 0.6 μg/kg PBW/hr. Loading was stopped after achieving adequate sedation, defined as the Observer's Assessment of Alertness/Sedation (OAA/S) scale score of 3. Infusion rate was adjusted every 30 min per the OAA/S scale.MeasurementsPrimary outcomes were the difference in the dexmedetomidine loading dose adjusted for the patient's PBW between (1) the binaural and plain music groups and (2) the binaural and control groups. Secondary outcomes were the total dose and total loading time of dexmedetomidine; Patient State Index; relative powers of the alpha, theta, and delta bands; recovery from sedation; and patient satisfaction score.Main resultsThe final analyses included 184 patients. The PBW-adjusted dexmedetomidine loading dose was significantly lower in patients listening to music with binaural sound (1.15 ± 0.30 μg/kg PBW) than that in patients without music (1.33 ± 0.33 μg/kg PBW; mean difference, 0.18 μg/kg PBW; 95% confidence interval [CI], 0.06 to 0.29; P = 0.002). However, the difference was not statistically significant when compared with the plain music group (1.26 ± 0.36 μg/kg PBW; mean difference, 0.11 μg/kg PBW; 95% CI, −0.01 to 0.23; P = 0.070). Dexmedetomidine total dose, recovery from sedation, and patient satisfaction score showed no difference among the three groups.ConclusionsCompared with no music, music with binaural sound reduced the dexmedetomidine loading dose; however, this sedative-sparing effect of binaural sound was not found when compared to plain music.     

Bilateral erector spinae plane blocks in children undergoing cardiac surgery: A randomized,controlled study

Study objectiveWe aimed to test the hypothesis that erector spinae plane block (ESPB) provides efficient analgesia and reduces postoperative morphine consumption in children undergoing cardiac surgery with median sternotomy.DesignA prospective, blinded, randomized, controlled study.SettingA tertiary university hospital, operating room and intensive care unit.PatientsForty children aged 2–10 years, who underwent cardiac surgery with median sternotomy. The patients were randomly divided into the block group (Group B) and the control group (Group C).InterventionsGroup B (n = 20) were treated with ultrasound-guided bilateral ESPB at the level of the T4-T5 transverse process, whereas no block was administered in Group C (n = 20). In all children, intravenous morphine at 0.05 mg/kg was used whenever the modified objective pain score (MOPS) ≥4 for postoperative analgesia.MeasurementsThe MOPS and Ramsay sedation score (RSS) were assessed at 0, 1, 2, 4, 6, 8, 10, 12, 16, 20 and 24 h postoperatively. Total morphine consumption at 24 h, extubation time and length of intensive care unit (ICU) stay was also evaluated and recorded.Main resultsBilateral ESPB significantly decreased the consumption of morphine in the first 24 h, postoperatively. During the postoperative 24-h follow-up, 11 children in Group C requested morphine and the cumulative dose of morphine was 0.83 ± 0.91 mg, while 4 children in Group B requested morphine and the cumulative dose of morphine was 0.26 ± 0.59 mg (p = 0.043). There was no significant difference between Groups B and C in terms of MOPS and RSS values, extubation time or length of ICU stay.ConclusionUltrasound-guided bilateral ESPB with bupivacaine provides efficient postoperative analgesia and reduces postoperative morphine consumption at 24 h in children undergoing cardiac surgery.     

The role of intravenous paracetamol in conscious sedation during Internal Cardioverter Defibrillator (ICD) insertion in geriatric patients

BackgroundInsertion of Internal Cardioverter Defibrillator in high risk cardiac patients can be performed by many anesthetic techniques including local anesthesia with moderate sedation or general anesthesia. Many studies have proved that intravenous paracetamol infusion is effective in reducing narcotic requirements in many surgical procedures.PurposeThe aim of this study was to assess the effect of paracetamol in reducing pain as well as apnea and upper airway obstruction during conscious sedation for Internal Cardioverter Defibrillator placement.Patients and methodsIn this prospective, randomized study, 100 patients undergoing elective transvenous placement of Internal Cardioverter Defibrillator (ICD) were enrolled in this study. Pain, respiratory events as apnea and airway obstruction in patients receiving intravenous paracetamol infusion 1 g over 30 min have been compared with those receiving fentanyl in a total dose of 1.5 μg/kg.ResultsThe incidence of airway obstruction was lower in the paracetamol group than in the fentanyl one (P < 0.05). There was also a significant difference between the two groups as regards arterial carbon dioxide tension (PCO2), which was significantly higher in Group F (48.9 ± 0.63) in comparison to Group P (45.6 ± 0.64) (P < 0.001) as well as the degree of sedation where the sedation score was 2.2 ± 0.3 in group P. Also, the Visual Analog Scale (VAS) was significantly lower in Group P than in Group F (P < 0.05).ConclusionIntravenous paracetamol infusion was effective in reducing pain as well as the incidence of intraoperative respiratory events as upper airway obstruction in high risk cardiac patients undergoing Internal Cardioverter Defibrillator insertion.     

Effect of the intraoperative wake-up test in sevoflurane-sufentanil combined anesthesia during adolescent idiopathic scoliosis surgery: a randomized study

Study ObjectiveTo investigate the effect of the intraoperative wake-up test on sevoflurane-sufentanil anesthesia for adolescent idiopathic scoliosis (AIS) surgery.DesignRandomized, double-blind, parallel trial.SettingOperating room.Patients30 ASA physical status 1 patients, aged 13 to 20 years, scheduled for AIS surgery.InterventionsPatients were randomized to two groups: Group W patients received sevoflurane-sufentanil combined anesthesia and underwent the intraoperative wake-up test; Group NW received sevoflurane-sufentanil combined anesthesia without the wake-up test. Anesthesia was induced with an intravenous (IV) injection of midazolam, propofol, and sufentanil and maintained with sevoflurane inhalation, a target-controlled infusion (TCI) of sufentanil, and IV infusion of cisatracurium besylate.MeasurementsThe primary outcome was postoperative delirium. Secondary outcomes were duration of surgery, duration of anesthesia, intraoperative blood loss and transfusion, exposure of drugs administered, time to eye opening, extubation, and consciousness.Main ResultsPostoperative delirium occurred in one patient from each group (P > 0.05). There were no significant differences between the two groups in duration of surgery (322 ± 65 min vs 336 ± 72 min), duration of anesthesia (356 ± 76 min vs 368 ± 81 min), intraoperative blood loss (1847 ± 423 mL vs 1901 ± 451 mL) and transfusion (1663 ± 398 mL vs 1649 ± 382 mL), average exposure of drugs (72 ± 13 mg vs 75 ± 15 mg for propofol, 116 ± 28 μg vs 109 ± 25 μg for sufentanil, and 22 ± 5 vs 23 ± 4 mg for cisatracurium), time to eye opening (4.7 ± 1.5 min vs 4.8 ± 1.4 min), extubation (7.5 ± 2.0 min vs 7.3 ± 2.2 min), and consciousness (8.9 ± 1.8 min vs 9.1 ± 2.1 min) (all P > 0.05).ConclusionsSevoflurane-sufentanil combined anesthesia provides hemodynamic stability and rapid recovery from AIS surgery. There is no correlation between the intraoperative wake-up test and postoperative delirium after sevoflurane-sufentanil combined anesthesia.     

Efficacy and safety of Ciprofol for procedural sedation and anesthesia in non-operating room settings

Study objectiveCiprofol, a novel intravenous anesthetic, provides rapid recovery in patients undergoing colonoscopy. We aimed to examine the efficacy and safety of ciprofol in comparison with propofol for sedation or anesthesia in non-operating room settings including endoscopic submucosal dissection, endoscopic retrograde cholangiopancreatography, and flexible bronchoscopy (FB).DesignProspective, randomized, double-blind, parallel-group clinical trial.SettingUniversity-affiliated teaching hospital.PatientsWe recruited 207 patients scheduled for an endoscopic procedure from October 2021 to December 2021.InterventionsPatients were randomized into three groups according to the dose during induction (n = 69 each): 1) ciprofol 6 mg/kg/h, 2) ciprofol 8 mg/kg/h, or 3) propofol 40 mg/kg/h. Ciprofol or propofol was administered throughout the procedure.MeasurementsThe primary outcome was the success rate of sedation or anesthesia for the procedures. Secondary outcomes included induction time, endoscope insertion time, recovery time, discharge time, incidence of drug-related adverse events (AEs), neurological and inflammatory outcomes.Main resultsThe procedure success rates in the three groups were 100%. The induction time in the 6 (3.3 ± 1.0 min) and 8 mg/kg/h (2.9 ± 0.6 min) ciprofol groups was longer than that in the propofol group (2.5 ± 0.6 min) only in patients undergoing FB (p = 0.004). The time for patients to be fully alert and discharged from the post-anesthesia care unit was comparable across the three groups (p > 0.05). The incidence of drug-related AEs in the propofol and 6 and 8 mg/kg/h ciprofol groups was 84.1%, 76.8%, and 79.7%. No pain on injection was reported by ciprofol groups. Neurological outcomes and inflammatory responses were comparable among the three groups.ConclusionsCiprofol induced a level of sedation or anesthesia equivalent to that induced by propofol in non-operating room settings except for a prolonged induction time in patients undergoing FB. Ciprofol had a safety profile similar to that of propofol. No pain on injection was reported by ciprofol.     

Low dose ketorolac infusion improves postoperative analgesia combined with patient controlled fentanyl analgesia after living donor hepatectomy – Randomized controlled trial

BackgroundHepatectomy elaborates significant post-operative pain. Opioids represent cornerstone for post-operative analgesia in such cases. This study examined the therapeutic effect and outcome of adding low dose ketorolac tromethamine infusion to PO intravenous patient controlled fentanyl analgesia IV-PCA.Patients and methodsSixty right lobe donors were randomized into either fentanyl or ketorolac groups (30 patients each). Patients in both groups received fentanyl (2 μg/ml) solution in normal saline as IV-PCA with background infusion in a rate adjusted to deliver 0.25 μg kg h^?1 and boluses of 10 ml with a lock-out time of 20 min. They received 15 mg ketorolac IV bolus in ketorolac group and similar placebo injection in the control. Patients in both groups received a continuous intravenous infusion of 240 ml normal saline solution that is either free in the FENT group or containing 60 mg ketorolac in ketorolac group, adjusted to a rate of 0.2 ml kg h^?1. Visual analogue score (VAS) and hemodynamic profile were recorded at 1, 6, 12, 24, 36 and 48 h while laboratory results were recorded after 48 h and 7 days post-operatively.ResultsVAS was significantly lower in ketorolac group compared to fentanyl group from 6 to 36 h post-operatively while sedation score was significantly higher in fentanyl group compared to fentanyl–ketorolac group between 12 and 36 h post-operatively. Fentanyl consumption was significantly lower in ketorolac group at 24 (318.7 ± 66 vs 468.3 ± 79) and 48 (211.5 ± 59 vs 369.1 ± 68) h. Hemodynamic data and laboratory parameters were comparable in both groups. Nausea had a significantly higher incidence in FENT compared to KETR groups while other complications (vomiting and blood loss) were homogenous in both groups.ConclusionAdding ketorolac to IV PCA fentanyl improved the analgesic state and reduced the dose of fentanyl used without adding any side effects or risks to donors subjected to right lobe hepatectomy.     

Clinical study of midazolam sequential with dexmedetomidine for agitatedpatients undergoing weaning to implement light sedation in intensive care unit

Purpose: To evaluate midazolam sequential with dexmedetomidine for agitated patients undergoing weaning to implement light sedation in ICU. Methods: This randomized, prospective study was conducted in Tianjin Third Central Hospital, China. Using a sealed-envelope method, the patients were randomly divided into 2 groups (40 patients per group). Each patient of group A received an initial loading dose of midazolam at 0.3-3 mg/kg$h 24 h before extubation, followed by an infusion of dexmedetomidine at a rate of 0.2-1 mg/kg$h until extubation. Each patient of group B received midazolam at a dose of 0.3e3 mg/kg$h until extubation. The dose of sedation was regulated according to RASS sedative scores maintaining in the range of -2-1. All patients were continuously monitored for 60 min after extubation. During the course, heart rate (HR), mean artery pressure (MAP), extubation time, adverse reactions, ICU stay, and hospital stay were observed and recorded continuously at the following time points: 24 h before extubation (T1), 12 h before extubation (T2), extubation (T3), 30 min after extubation (T4), 60 min after extubation (T5). Results: Both groups reached the goal of sedation needed for ICU patients. Dexmedetomidine was associated with a significant increase in extubation quality compared with midazolam, reflected in the prevalence of delirium after extubation (20% (8/40) vs 45% (18/40)), respectively (p=0.017). There were no clinically significant decreases in HR and MAP after infusing dexmedetomidine or midazolam. In the group A, HR was not significantly increased after extubation; however, in the group B, HR was significantly increased compared with the preextubation values (p<0.05). HR was significantly higher in the group B compared with the group A at 30 and 60 min after extubation (both, p<0.05). Compared with preextubation values, MAP was significantly increased at extubation in the group B (p<0.05) and MAP was significantly higher at T3, T4, T5 in the group B than group A (p<0.05). There was a significant difference in extubation time ((3.0±1.5) d vs (4.3±2.2)d, p<0.05), ICU stay ((5.4±2.1)d vs (8.0±1.4)d, p<0.05), hospital stay ((10.1±3.0)d vs (15.3±2.6)d, p<0.05) between group A and B. Conclusion: Midazolam sequential with dexmedetomidine can reach the goal of sedation for ICU agitated patients, meanwhile it can maintain the respiratory and circulation parameters and reduce adverse reactions.     

Methadone dosage for prevention of opioid withdrawal in children

BACKGROUND: Opioids are frequently used for sedation in the Paediatric Intensive Care Unit (PICU). With time the dosing often increases because of tolerance. On cessation of the sedation there is a risk of the opioid withdrawal syndrome. The aim of our study was to evaluate methadone dosing as a risk factor for opioid withdrawal and to determine optimal dose and efficacy of methadone to prevent withdrawal. METHOD: We undertook a clinical, retrospective, chart review study. Data were analysed from the quality improvement initiative database of a tertiary-care 18 bed PICU. RESULTS: Data from 30 children who received an opioid infusion for >/=7 days and subsequently received methadone for opioid withdrawal (between January 2000 and July 2001) were analysed. Nurses documented the presence or absence of withdrawal signs daily. Our unit protocol has recommended converting the patient's opioid dose into fentanyl equivalents and a dose of methadone equal to the total daily dose of fentanyl to be given three times a day. Twenty patients had no or minimal withdrawal symptoms and 10 experienced significant withdrawal. Age, weight, PRISM score, lorazepam dose, muscle relaxant use and fentanyl dose were not statistically significantly between these groups. Receiver Operator Characteristics analysis showed that 80% of the suggested methadone dose was effective in minimizing withdrawal symptoms. The odds ratio for withdrawal with <80% of the predicted methadone dose was 21. CONCLUSIONS: Inadequate methadone is a risk factor for opioid withdrawal. A daily starting methadone dose equivalent to 2.5 times the daily fentanyl dose is effective in minimizing withdrawal symptoms.     

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.     

Anterior quadratus lumborum block at the lateral supra-arcuate ligament versus transmuscular quadratus lumborum block for postoperative analgesia in patients undergoing laparoscopic nephrectomy: A randomized controlled trial

Study objectiveThe analgesic efficacy of transmuscular quadratus lumborum block (TQLB) to decrease the need for opioid consumption after laparoscopic nephrectomy has been demonstrated in several studies. However, the effect of an anterior QLB approach at the lateral supra-arcuate ligament (QLB-LSAL) in this surgical context is unclear. Here, we aimed to compare postoperative analgesic effects of the two block approaches in laparoscopic nephrectomy.DesignA single-center, randomized controlled trial.SettingUniversity-affiliated tertiary care hospital.PatientsA total of 106 patients with American Society of Anesthesiologists (ASA) physical status of I–III scheduled to undergo elective laparoscopic nephrectomy under general anesthesia.InterventionsPatients were randomly allocated to receive preoperative TQLB or QLB-LSAL with 0.5% ropivacaine (25 mL). Postoperatively, patient-controlled analgesia with intravenous sufentanil was administered.MeasurementsThe primary outcome was postoperative intravenous morphine equivalent consumption within the first 24 h postoperatively. Secondary outcomes included pain scores, satisfaction scores, levels of sedation, and incidence of nausea or vomiting.Main resultsPatients who underwent preoperative QLB-LSAL used a significantly lower intravenous morphine equivalent dose than those who underwent preoperative TQLB within the initial 24 h after surgery (34.3 ± 6.3 mg vs 23.5 ± 3.2 mg, P < 0.001). No significant differences were observed in pain scores, satisfaction scores, sedation scores, or incidence of nausea or vomiting between the groups.ConclusionsThe results indicate that, compared to TQLB, QLB-LSAL is a beneficial nerve block that can reduce postoperative opioid consumption, making it a potentially superior approach to achieve multimodal analgesia after laparoscopic nephrectomy.     

Effect of Dexmedetomidine as an adjuvant in quadratus lumborum block in patient undergoing caesarean section – A randomised controlled study

Study objectiveThis study was conducted to evaluate the effect of Dexmedetomidine as an adjuvant in quadratus lumborum block (QLB) for postoperative pain relief at rest in patients undergoing caesarean section (CS). The primary objective was to compare the time to the first request of rescue analgesia. Secondary objectives were to compare the amount of rescue analgesia, patient satisfaction, Numeric rating scale (NRS), and Ramsay sedation score (RSS) during the first 24 h.DesignA randomised, double-blinded study.SettingThe study was conducted at AIIMS Bhubaneswar from December 2019 to February 2021in the Operating Theatre complex (for the immediate postoperative follow-up) and in the Obstetric Ward (for follow-up at the later time points).PatientsA total of 70 patients were enrolled with singleton term pregnancies scheduled for CS under spinal anaesthesia after written informed consent.InterventionBilateral QLB was given in the recovery area. Group A received 30 ml of 0.25% Bupivacaine and group B received 30 ml 0.25% bupivacaine with Dexmedetomidine 1 μg/kg. They received inj. Paracetamol 15 mg/kg intravenously TDS and Inj. Tramadol 1 mg/kg as rescue analgesia (if Numeric rating scale (NRS) Score ≥ 4). We also compared the rescue analgesia in the first 24 h, patient satisfaction scores, Ramsay sedation score (RSS), and NRS scores at 2, 4, 6, 8, 12, 18, and 24 h.Main resultsThe time to request the first rescue analgesia was significantly prolonged in group B [Mean ± SD (95% CI)] 880 ± 351 (720–1040) min. vs group A 439 ± 208 (368–510) min., p < 0.001). There was a significant decrease in the amount of rescue analgesia [(Inj. Tramadol (1 mg/ kg)] used in the group with dexmedetomidine [group B Mean ± SD (95% CI) (57 ± 18 (49–65) mg. vs group A - 81 ± 25 (73–90)] mg., p < 0.001]. A significant difference was seen in patient satisfaction scores and pain scores between the groups up to 18 h. (p < 0.05) but not in RSS.ConclusionDexmedetomidine can be considered an effective adjuvant for QLB in CS in the absence of intrathecal morphine.     

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.     

Incidência de delírio ao despertar e fatores de risco após o uso de sevoflurano em pacientes pediátricos para cirurgia ambulatorial,Kingston, Jamaica

Background and objectivesEmergence delirium is a distressing complication of the use of sevoflurane for general anesthesia. This study sought to determine the incidence of emergence delirium and risk factors in patients at a specialist pediatric hospital in Kingston, Jamaica.MethodsThis was a cross‐sectional, observational study including pediatric patients aged 3–10 years, ASA I and II, undergoing general anesthesia with sevoflurane for elective day‐case procedures. Data collected included patients’ level of anxiety pre‐operatively using the modified Yale Preoperative Anxiety Scale, surgery performed, anesthetic duration and analgesics administered. Postoperatively, patients were assessed for emergence delirium, defined as agitation with non‐purposeful movement, restlessness or thrashing; inconsolability and unresponsiveness to nursing and/or parental presence. The need for pharmacological treatment and post‐operative complications related to emergence delirium episodes were also noted.Results145 children were included, with emergence delirium occurring in 28 (19.3%). Emergence delirium episodes had a mean duration of 6.9 ± 7.8 min, required pharmacologic intervention in 19 (67.8%) children and were associated with a prolonged recovery time (49.4 ± 11.9 versus 29.7 ± 10.8 min for non‐agitated children; p < 0.001). Factors positively associated with emergence delirium included younger age (p = 0.01, OR 3.3, 95% CI 1.2–8.6) and moderate and severe anxiety prior to induction (p < 0.001, OR 5.6, 95% CI 2.3–13.0). Complications of emergence delirium included intravenous line removal (n = 1), and surgical site bleeding (n = 3).ConclusionChildren of younger age with greater preoperative anxiety are at increased risk of developing emergence delirium following general anesthesia with sevoflurane. The overall incidence of emergence delirium was 19%.     

Efficacy of preoperative melatonin versus pregabalin on perioperative anxiety and postoperative pain in gynecological surgeries

BackgroundWe compared the efficacy of melatonin and pregabalin on perioperative anxiety and postoperative pain in patients undergoing laparoscopic gynecological surgeries.MethodsIn this randomized double-blind study, 40 patients, 25–35 yr undergoing gynecological surgeries were divided into 2 equal groups to receive either melatonin capsule 6 mg (Group M), or pregabalin capsule 150 mg (Group P) 1 h before induction of general anesthesia. Our primary outcome was preoperative acute anxiety level 1 h after drug administration, 1, 6, and 12 h after operation. The secondary outcomes were postoperative visual analog scale (VAS) for pain, analgesic consumption, sedation level using the inverted observer’s assessment of alertness/sedation scale (OAA/S) scale, and incidence of adverse effects.ResultsThe anxiety scores decreased significantly >50% after premedication in both groups compared to baseline values (p < 0.01) with no statistically significant difference between the two groups (30.4 ± 4.5 in group M versus 31.7 ± 4.2 in group P, p > 0.05). Postoperative VAS for pain, time for first analgesic demand and number of patients requiring postoperative analgesia did not differ between groups, and the sedation score was higher in melatonin group compared to pregabalin group 1 h after drug (3.45 ± 0.7 versus 1.95 ± 0.6, p < 0.001, respectively) and at all the subsequent readings postoperatively with equal incidence of adverse effects in both groups.ConclusionOral melatonin 6 mg or pregabalin 150 mg administered 1 h before operation had reduced perioperative anxiety and postoperative pain in patients undergoing gynecological surgeries, without untoward sedative effects in the pregabalin group compared to melatonin group.     

Procedural sedation for insertion of central venous catheters in children: comparison of midazolam/fentanyl with midazolam/ketamine

Background: There is a lack of studies evaluating procedural sedation for insertion of central venous catheters (CVC) in pediatric patients in emergency departments or pediatric intensive care units (PICU). This study was designed to evaluate whether there is a difference in the total sedation time for CVC insertion in nonintubated children receiving two sedation regimens. Methods: Patients were prospectively randomized to receive either midazolam/fentanyl (M/F) or midazolam/ketamine (M/K) i.v. The Children's Hospital of Wiscosin Sedation Scale was used to score the sedation level. Results: Fifty seven patients were studied (28 M/F and 29 M/K). Group M/F received midazolam (0.24 ± 0.11 mg·kg⁻¹) and fentanyl (1.68 ± 0.83 μg·kg⁻¹) and group M/K received midazolam (0.26 ± 0.09 mg·kg⁻¹) and ketamine (1.40 ± 0.72 mg·kg⁻¹). The groups were similar in age, weight, risk classification time and sedation level. Median total sedation times for M/F and M/K were 97 vs 105 min, respectively (P = 0.67). Minor complications occurred in 3.5% (M/F) vs 20.7% (M/K) (P = 0.03). M/F promoted a greater reduction in respiratory rate (P = 0.005). Conclusions: In this study of nonventilated children in PICU undergoing central line placement, M/F and M/K provided a clinically comparable total sedation time. However, the M/K sedation regimen was associated with a higher rate of minor complications. A longer period of study is required to assess the efficacy and safety of these sedative agents for PICU procedures in nonintubated children.     

The effects of a short-term perioperative duloxetine treatment on post-colectomy pain: A randomized,controlled clinical trial

Study objectiveTo test the hypothesis that duloxetine reduces postoperative morphine consumption and pain intensity in patients undergoing major colonic surgeries.DesignSingle-center, prospective, double-blinded, randomized, controlled trial.SettingTertiary university hospital, from December 2019 to September 2021.PatientsSixty 18–85 years old, ASA I – III patients undergoing elective open major colonic surgeries were randomly allocated into duloxetine (duloxetine) or placebo (placebo) groups (n = 30 per group).InterventionsDuloxetine 60 mg or placebo was administered orally 2 h before and 24 h after surgery.MeasurementsPCA morphine consumption, surgical pain at rest, and movement measured on 10-cm visual analog scales (VAS), Ramsay sedation scores, and the incidence of adverse effects potentially associated with duloxetine were assessed at patients' admission to the post-anesthesia care unit (PACU), 6, 24, and 48 h postoperatively (PO).Main resultsAfter adjusting for age, BMI, ASA physical status, education level, and incision type, no differences were found between groups in PCA morphine consumption 24 PO h (duloxetine = 5.44 ± 2.06 mg; placebo = 10.33 ± 2.06 mg, p = 0.62) or 48 h PO (duloxetine = 9.18 ± 2.06 mg, placebo = 12.93 ± 2.06, p = 1). Pain at rest also did not differ between groups at 24 h PO (duloxetine = 1.76 ± 0.67 cm; placebo = 1 ± 0.67 cm, p = 1) or at 48 h PO (duloxetine = 0.84 ± 0.67 cm; placebo = 0.49 ± 0.67 cm, p = 1). Similarly, groups did not differ regarding pain on movement at 24 h PO (duloxetine = 2.09 ± 0.68 cm; placebo = 1.80 ± 0.68, p = 1) or at 48 h PO (duloxetine = 1.16 ± 0.68 cm; placebo = 0.88 ± 0.68 cm, p = 1). Sedation scores and adverse effects also did not differ between groups.ConclusionUnder this study's conditions, short-term duloxetine did not reduce total opioid consumption or pain intensity during the initial 48 h following major colon surgery.     

Postoperative patientcontrolled epidural analgesia with opioid bupivacaine mixtures

Purpose

To determine the efficacy and safety of patient-controlled epidural analgesia of morphine or fentanyl in combination with bupivacaine for postoperative pain relief.

Methods p]Forty ASA 1–11 patients scheduled for major abdominal surgery were studied. After insertion of a lumbar epidural catheter, patients were given a non-opioid general anaesthetic. After surgery patients complaining of pain, received a loading dose of 2 mg morphine (Group I) or 50 μg fentanyl (Group II). For continuing pain, 1 mg morphine in 4 ml bupivacaine 0.125% (0.25 mg·ml^?1 morphine and 1 mg·ml^?1 bupivacaine, Group I) or 20 μg fentanyl in 4 ml bupivacaine 0.125% (5 μg·ml^?1 fentanyl and 1 mg·ml^?1 bupivacaine Group II) were administered. Blood pressure, heart rate, respiratory rate and SpO₂ were monitored. Assessments of pain (VAS), nausea-vomiting, motor block, pruritus and sedation were recorded for 24 hr.

Results

No difference in pain or sedation was observed between groups, The 24 hr postoperative opioid consumption was 15.50 ± 7.53 mg morphine and 555.10 ± 183.85μg fentanyl. Total bupivacaine 0.125% consumption was 58.00 ± 30.14 ml in Group I and 101.05 ± 36.77 ml in Group II. One patient in Group II complained of motor weakness in one leg. The incidence of nausea (Group I 45%, Group II 10%P < 0.05) and pruritus (Group I 30%, Group II 5%P < 0.05) was less in patients receiving fentanyl. Conclusion: Both methods were effective in the prevention of pain but, because of fewer side effects, fentanyl may be preferable to morphine.