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%.     

Efeitos da ansiedade pré‐operatória na recuperação anestésica e na dor pós‐operatória em pacientes submetidos a nefrectomia para doação

Background and objectivesIt is suggested that 38‐45% of patients experience preoperative anxiety. We observe that patients undergoing living donor nephrectomy suffer from anxiety. Preoperative anxiety may complicate a patient's recovery from anesthesia and postoperative pain control. This study investigates the preoperative anxiety rate and its effect on anesthetic recovery and postoperative pain in patients undergoing donor nephrectomy.MethodsForty‐eight individuals undergoing living‐related renal donor nephrectomy were included in this analytic prospective observational cohort study. Their preoperative anxiety was measured with the STAI‐I and STAI‐II inventories. The relationships between anxiety scores with data regarding demographics, recovery from anesthesia, and postoperative pain scores were investigated.ResultsThe findings were remarkable in that the anxiety scores of living renal donors were significantly correlated with their recovery variables, which are spontaneous respiration time, sufficient respiration time, extubation time, and PACU discharge time (p < 0.01). Anxiety scores were significantly positively correlated with the pain scores of the 30th minute, 1st, 2nd, 4th, 8th, 12th, 24th hours, and the total amounts of analgesic administered in 24 hours (p < 0.05). A significantly negative correlation was also determined between anxiety scores and patients’ satisfaction.ConclusionOur study showed that patients undergoing living‐related donor nephrectomy with high anxiety levels had late recovery times and high postoperative pain scores. Thus, determining those patients with high preoperative anxiety level is crucial to providing patients with satisfactory emerging from anesthesia and the control of their postoperative pain during donor nephrectomy.     

Mirtazapine premedication: Effect on preoperative anxiety and propofol dose requirements at different stages of hypnosis

BackgroundMirtazapine is an antidepressant drug that blocks central 5-HT2 receptors with anxiolytic and sleep-promoting effects and theoretically can be used as a premedication.MethodsSixty ASA I-II patients aged 25–50 yr were randomly allocated according to the premedication received 2 h before induction of anesthesia into two equal groups: group M patients received mirtazapine 30 mg tablet mixed with 20 ml of water and group P patients received 20 ml of plain water. Anxiety level was measured by visual analogue scale (VAS) and bispectral index (BIS) electrodes were connected before induction of anesthesia. Intravenous (i.v) infusion of propofol 1% at a rate of 300 ml h^?1 was started to induce hypnosis till a target BIS value of 45 (BIS45) is reached, and then endotracheal intubation is performed after fentanyl and cis-atracuruim being administered. Propofol dose requirements to achieve loss of response to verbal contact (RVC), loss of eyelash reflex (ELR), and a target BIS45 were recorded. Anesthesia was maintained with sevoflurane titrated to BIS value of 40–50 and oxygen/air mixture. Recovery time was recorded. In postanaesthesia care unit (PACU), VAS for pain and Ramsay sedation score were recorded. Patients were discharged from PACU when two consecutive Aldrete scores of 9 or 10 are obtained, and time of PACU stay was recorded.ResultsPreoperative anxiety by VAS and propofol doses required achieving loss of RVC and ELR, and target BIS45 were significantly lower in mirtazapine group. The two groups were comparable with regard to recovery and PACU stay times as well as postoperative pain and anxiety.ConclusionMirtazapine 30 mg oral tablets can be used as a premedication as it reduces preoperative anxiety and hypnotic dose requirements of propofol, and does not prolong recovery time.     

Effect of oral dextromethorphan versus oral ketamine on sevoflurane related emergence agitation in children undergoing adenotonsillectomy

BackgroundEmergence agitation is a popular phenomenon after sevoflurane anesthesia. Our aim was to study the efficacy of oral dextromethorphan compared to oral ketamine on sevoflurane related agitation.MethodsIn a prospective, randomized, double- blinded study 120, ASA I, aged 4–10 years old children undergoing adenotonsillectomy were randomly divided into three groups to receive oral dextromethorphan 1 mg/kg (Group D, n = 39), oral ketamine 5 mg/kg (Group K, n = 39) or placebo(Group C, n = 38) as premedication 1 h before surgery. Standard general anesthesia was induced and maintained with sevoflurane in N₂O/O₂. The following were recorded by a blinded anesthetist; Child separation and cooperation at induction, duration of operation, duration of anesthesia, duration of extubation, duration of emergence, state of emergence on admission to PACU using emergence agitation scale, number of patients required postoperative fentanyl to control agitation, duration of discharge from PACU, vital signs (heart rate, blood pressure, and Spo₂) in PACU, and side effects (Nausea, vomiting, respiratory depression, and hallucination).ResultsThe agitated patients that required fentanyl treatment were statistically significant low in groups D and K compared to group C (p < 0.05). Child separation and child cooperation at induction from parents was successful in all children in group K with statistical significant difference compared to other groups (p < 0.05). There were increases in duration of anesthesia, extubation, and emergence in group K compared to other groups without increase in the duration of stay in PACU.ConclusionOral premedication with either dextromethorphan 1 mg/kg or ketamine 5 mg/kg were comparable in reducing significantly the incidence of postoperative sevoflurane related emergence agitation in comparison to placebo treated group without reported side effects in children undergoing adenotonsillectomy.     

Fatores de risco associados a delírio no despertar da anestesia em crianças submetidas à cirurgia ambulatorial

IntroductionAnesthesia emergence delirium is a self‐limiting clinical phenomenon very common in children. Although pathophysiology is still uncertain, some factors seem to be involved, such as rapid awakening in an unknown environment, agitation during anesthetic induction, preoperative anxiety, environmental disorders, use of preanesthetic medication, use of inhalational anesthetics, and postoperative pain.ObjectiveTo determine the prevalence and risk factors associated with anesthesia emergence delirium in children undergoing outpatient surgery.MethodsA prospective observational study was carried out with 100 children aged 2 to 10 years, who underwent surgery on an outpatient basis. The study variables were: anesthesia emergence delirium and the associated risk factors (preoperative anxiety, child impulsive behavior, use of pre‐anesthetic medication, traumatic induction, type of anesthesia, and postoperative pain). Multivariate Poisson's logistic regression was used to analyze the possible explanatory variables, where the prevalence ratios were estimated with the respective 95% confidence intervals, considering a significance level of 5%.ResultsDelirium and pain were observed in 27% and 20% of children, respectively. Only postoperative pain after Poisson's regression, was shown to be associated with anesthesia emergence delirium, with a prevalence ratio of 3.91 (p < 0.000).ConclusionThe present study showed 27% prevalence of anesthesia emergence delirium in the study population. The incidence of anesthesia emergence delirium was higher in children who had postoperative pain.     

Preoperative anxiety in surgical patients - experience of a single unit

ObjectivesPreoperative anxiety has a significant effect on the outcome of anesthesia and surgery. At present, there is no published data on the preoperative anxiety levels in Sri Lankan patients. In the West, several validated questionnaires such as The Amsterdam Preoperative Anxiety and Information Scale (APAIS) and State Trait Anxiety Inventory (STAI) are used. To measure the preoperative anxiety levels in patients using APAIS and to analyze the factors affecting anxiety and the role played by the anesthetist in allaying anxiety.MethodsOne hundred patients scheduled for elective surgery were prospectively studied using the APAIS. The internal consistency was checked using Cronbach's alpha.ResultsThe ages varied 25 to 72 years (mean = 48.7 years, SD = 13.6). Reliability of the APAIS was high; Cronbach's alpha = 0.864 in the overall component and 0.84, 0.73 and 0.97 in the anxiety related to surgery, anesthesia and in the information desire components, respectively.Females were more anxious than males (p = 0.02) and those who had never sustained surgery were more anxious than those who previously had surgery (p = 0.05).An anesthetist's visit and premedication reduced total anxiety scores (Z = ?3.07, p = 0.002) and anesthesia related anxiety scores (Z = ?3.45, p = 0.001).ConclusionsThe prevalence of anxiety is high among Sri Lankan patients. Females are more anxious than males and those who have never had surgery are more anxious than those who have had surgery. The anesthetist's visit could reduce anxiety. Sinhala version of the APAIS is highly reliable in assessing the preoperative anxiety levels.     

Role of sugammadex in accelerating postoperative discharge: A meta-analysis

Study objectiveSugammadex has been introduced for reversal of neuromuscular blockade (NMB) induced by rocuronium (or vecuronium). Although its efficacy and safety have been established, data are conflicting as to whether it accelerates discharge to the surgical ward compared with neostigmine, which is traditionally used for reversing NMB. The object of this systematic review and meta-analysis was to review the research comparing sugammadex and neostigmine in the context of patient discharge after general anesthesia.DesignSystematic review and meta-analysis.SettingUniversity medical hospital.PatientsFive-hundred eighteen patients from six studies were included.MethodsA comprehensive search was conducted using PubMed, Web of Science, Google Scholar, and Cochrane Library electronic databases to identify randomized controlled trials written in English. Two reviewers independently selected the studies, extracted data regarding postoperative discharge, and assessed the trials' methodological quality and evidence level. Postoperative discharge time was determined from the operating room (OR) to the postanesthesia care unit (PACU) and from the PACU to the surgical ward. This study was conducted using PRISMA methodology.MeasurementsTime to discharge after NMB reversal with sugammadex or neostigmine.Main resultsCompared with neostigmine, sugammadex was associated with a significantly faster discharge from the OR to the PACU (mean difference [MD] = 22.14 min, 95% CI (14.62, 29.67), P < 0.0001, I² = 0%) and from the PACU to the surgical ward (MD = 16.95 min, 95% CI (0.23, 33.67), P = 0.0469, I² = 98.4%). Similarly, discharge-readiness was shorter for sugammadex than for neostigmine from the OR to the PACU (MD = 5.58 min, 95% CI (3.03, 8.14), P ≤ 0.0001, I² = 0%). However, discharge-readiness was similar in both groups for patients moving from the PACU to the surgical ward (MD = − 1.10 min, 95% CI (− 5.69, 3.50), P = 0.6394, I² = 25.3%).ConclusionsResults from this meta-analysis suggest that sugammadex accelerates postoperative discharge of patients after general anesthesia compared with neostigmine.     

Effect of systemic lidocaine infusion on train-of-four ratios during recovery from general anesthesia

IntroductionIn spite of introduction of intermediate-acting neuromuscular blocking drugs (NMBDs), incidence of postoperative residual muscle weakness is still high. The aim of this trial is to study the effect of systemic lidocaine infusion on intraoperative consumption of rocuronium and TOF ratios at extubation and on arrival to postanesthesia care unit (PACU).MethodsForty-six ASA I–III patients aged 16–60 yr were randomly allocated into two groups: lidocaine (L) group (n = 23) and control (C) group (n = 23). After induction of standard endotracheal general anesthesia with fentanyl, propofol and rocuronium, patients of group L were given i.v. lidocaine bolus (1.5 mg kg^?1) followed by continuous infusion (1.5 mg kg^?1 h^?1) till time of endotracheal extubation while patients in group C were given equal volumes of normal saline. Rocuronium was titrated based on clinical signs. On conclusion of surgery, neostigmine was given to reverse the effects of rocuronium if TOF count was two or more. Immediately before extubation, TOF ratio was measured and recorded and considered the primary outcome.ResultsThere were no significant differences between the two study groups regarding intraoperative fentanyl doses or core temperature at the end of surgery. End-tidal sevoflurane concentrations were significantly lower in group L than in group P (P < 0.01). The dose of rocuronium was significantly less in group L than in group C (P = 0.001). Train-of four ratios were significantly higher in group L than in group C either before extubation (P < 0.001) or on arrival to PACU (P = 0.001).ConclusionThe current study shows that intraoperative use of i.v. lidocaine infusion in generally anesthetized patients can result in higher TOF ratios at time of extubation and on arrival to PACU when rocuronium was given based on clinical signs.     

Combined preoperative femoral and sciatic nerve blockade improves analgesia after anterior cruciate ligament reconstruction: a randomized controlled clinical trial

Study objectiveTo compare preoperative femoral (FNB) with combined femoral and sciatic nerve block (CFSNB) in patients undergoing arthroscopic anterior cruciate ligament (ACL) reconstruction.DesignProspective, randomized clinical trial.SettingAmbulatory surgery center affiliated with an academic medical center.PatientsSixty-eight American Society of Anesthesiology physical status I and II patients undergoing arthroscopic ACL reconstruction.InterventionsSubjects randomized to the CFSNB group received combined femoral and sciatic nerve blocks preoperatively, whereas patients randomized to the FNB group only received femoral nerve block preoperatively. Both groups then received a standardized general anesthetic with a propofol induction followed by sevoflurane or desflurane maintenance. Intraoperative pain was treated with fentanyl. Pain in the postanesthesia care unit (PACU) was treated with ketorolac and opiates. Patients with significant pain despite ketorolac and opiates could receive a rescue nerve block.MeasurementsOur primary outcome variable was highest Numeric Rating Scale (NRS) pain score in PACU. NRS pain scores, opioid consumption, opioid adverse effects, and patient satisfaction were assessed perioperatively until postoperative day 3.Main resultsThe highest PACU NRS pain score was significantly higher in the FNB group compared with the CFSNB group (7 [3-10] vs 5 [0-10], P = .002). The FNB group required significantly larger doses of opioids perioperatively (31.8 vs 19.8 mg intravenous morphine equivalents, P < .001). PACU length of stay was significantly longer in the FNB group (128.2 vs 103.1 minutes, P = .006). There was no significant difference in opioid consumption, pain scores, or patient satisfaction on postoperative days 1-3 between groups.ConclusionsPreoperative CFSNB for arthroscopic ACL reconstruction improves analgesia, decreases opioid consumption perioperatively, and decreases PACU length of stay when compared with FNB alone.     

Utilidad de la consulta preanestésica para disminuir el grado de ansiedad en pacientes programados para intervención quirúrgica

Background and objectivesPreoperative anxiety can alter perioperative evolution, increasing the need for sedatives and analgesics. Information received during the pre-anesthesia consultation could reduce the level of anxiety. The objective of this study was to determine whether preoperative anxiety levels decrease after the pre-anesthesia consultation.Material and methodsObservational, unicentric, prospective study. Sociodemographic and clinical data were recorded. Heart rate, blood pressure and anxiety levels were measured before and after the pre-anesthesia consultation using the abbreviated State-Trait Anxiety Inventory. Results were analyzed using Wilcoxon test and univariate logistic regression. P = .05 was considered significant.ResultsNinety patients were included, with a median age of 62 years; 58% were females, 79% had completed primary-secondary studies, 72% were selected for ambulatory surgery and 72% preferred regional anesthesia. The prevalence of anxiety was 35.6% (State-Trait Anxiety Inventory score 5; IQR 3-9); after the anesthesia consultation the score was reduced to 4 (IQR 2-6), P = .005. There was no significative decrease in hemodynamic values, and no significant relationship between anxiety and sociodemographic or clinical variables.ConclusionsThe pre-anesthesia consultation reduces anxiety levels in surgical patients. This emphasizes the importance of the pre-anesthesia consultation in identifying and managing anxiety.     

Preoperative gabapentin augments intraoperative hypotension and reduces postoperative opioid requirements with functional endoscopic sinus surgery

BackgroundFunctional Endoscopic sinus surgery (FESS) is a delicate and time consuming procedure; it is performed routinely under general anesthesia. Hypotensive techniques should be employed for best visualization of operative field. Gabapentin is a structural analog of gamma amino butyric acid. The aim of this study was to determine the analgesic efficacy of gabapentin and its role in deliberate hypotension during and after FESS.MethodsEighty patients ASA physical status I–II patients were scheduled to undergo elective FESS under general anesthesia. Patients were randomly assigned to one of two groups using a computer-generated table. Patients in the control group (40 patients) received oral placebo capsules and the study group (40 patients) patients received oral gabapentin (Conventin 400 mg; Evapharma Egypt) 1.2 g 1 h before surgery. Intraoperative, mean arterial blood pressure, infusion rates of the hypotensive agent (sodium nitroprusside) were recorded at 15 min interval. Assessments of pain, opioid usage, and side effects were performed at 1 h interval after arrival in the PACU.ResultsGabapentin group patients required significantly lower (p value <0.05) infusion rates and total doses of hypotensive agent (sodium nitroprusside) than the placebo group patients at all measured intervals. Postoperative assessment of pain scores revealed that gabapentin group recorded significantly lower mean values of VAS than the control group (p value <0.05).ConclusionOral gabapentin, 1200 mg decreased dose requirements of intraoperative hypotensive agent (sodium nitroprusside) and postoperative morphine. In addition, patients receiving gabapentin had suffered less from opioid side effects (nausea, vomiting and urinary retention) than those receiving placebo.     

Lateral popliteal block in foot and ankle surgery: Comparing ultrasound guidance to nerve stimulation. A prospective randomized trial

BackgroundThe popliteal block has several benefits in foot and ankle surgery. It reduces postoperative pain, limits the use of narcotics and facilitates early discharge. The aim of this prospective randomized trial was to evaluate whether ultrasound guidance improves block characteristics compared to the nerve stimulation technique in lateral popliteal blocks.MethodsPatients were randomized to receive either a lateral popliteal block using neurostimulation or ultrasound guidance. Block performance time, number of needle pricks, number of redirections were recorded. Pain upon admission to and discharge from post anesthesia care unit (PACU) was recorded. Block duration, patient satisfaction, pain at block site and amount of opioids used in PACU and between subsequent followup visits was recorded. Patients were followed for 12 weeks postoperatively.ResultsThere was no statistically significant difference between the two groups in terms of number of pricks, time for the block to wean, pain upon admission to PACU, amount of opioids received in PACU, pain upon discharge from PACU, pain at the operative site, pain at the block site, toe motor function and toe sensation. There was a statistically significant difference in the block procedure performance time between the two groups, with the control group being faster (P < 0.0001). A significantly larger number of patients in the control group required more than three needle redirections (P = 0.0060).ConclusionsThe lateral sciatic popliteal block using nerve stimulation had similar block characteristics and patient satisfaction with a significantly faster performance time compared to the ultrasound guided technique.Level of evidence: Level I, prospective randomized study.     

Anesthesia for bariatric surgery: 8-Year retrospective study: Are our patients now easier to manage?

ObjectivesTo review the perioperative management of patients who had undergone bariatric surgery in our institution during an 8-year period, with the aim of identifying variables that correlated with improved clinical outcomes and changes in perioperative practice.MethodsThis was a retrospective observational study of 437 patients who had undergone bariatric surgery from January 2005 to June 2013. Of these patients, 163 had undergone open or laparoscopic biliopancreatic diversion (Group 1), and 274 had been managed according to a Tailored Laparoscopic Approach Program (TLAP) (Group 2). We analyzed major cardiocirculatory, pulmonary, and surgery-related complications, mortality rate, intensive care unit (ICU) admissions, post-anesthetic care unit (PACU) length of stay, and perioperative management standards, throughout the study period.ResultsChanges were observed in anesthetic patterns and perioperative care standards during the study period: 25% of patients had combined epidural anesthesia in 2005, compared with none at present; ICU admissions decreased from 28.6% in 2005 to 3.1% at present; and time in PACU declined from a median of 23 h in 2005 to 5.12 h at present. Duration of postoperative opioid therapy was also significantly reduced (from 48 h to 6 h). Group 2 had a significantly lower mortality rate than Group 1 (0.37% versus 4.3%, respectively, P = 0.004).ConclusionsIn our institution, adoption of a TLAP for bariatric surgery has led to changes in perioperative care standards that have been followed by clear improvements according to morbidity, mortality and management indicators.     

Tolerabilidad del paciente durante la cistoscopia y la cauterización de tumores vesicales en consulta: análisis multivariante de los factores de riesgo

ObjectiveCystoscopy and cauterization performed in the operating room is expensive and exposes patients to anesthesia risks. Patient tolerability during office cystoscopy and cauterization is critical to the office management of bladder cancer and other urologic diseases. We evaluated the risk factors for pain of flexible cystoscopy in the office-setting with emphasis on a sub-group of bladder cancer patients who underwent cauterization.Materials and methodsRetrospective analyses of 110 anonymous patient surveys completed after cystoscopy and/or cauterization. Survey information included age, gender, purpose of cystoscopy, number of prior cystoscopies, prior number of office-cauterizations, anxiety prior/during cystoscopy, and pain during cystoscopy and/or cauterization. Univariate/multivariate and linear-regression analyses were performed to evaluate the association of pain with clinical parameters.ResultsAverage pain during cystoscopy (1.75 ± 1.331) was not significantly different when cauterization was also performed (2.37 ± 2.214) (P < .001) (P = .2840). Patients in the lower age group (< 66 years) indicated higher anxiety (P = .0005), more pain at cystoscopy (P = .004) and cauterization (P < .001). Although the patient's overall anxiety level was low (1–3/10), it was associated with some pain during cystoscopy (P = .0005) and cauterization (P < .000). In multivariate analysis, anxiety was the only independent predictor of pain during cystoscopy (P = .03, OR: 6.52, 95%CI: 1.2-35.6) and cauterization (P = .0012, OR: 3.4, 95%CI: 1.6-7.0). In bladder cancer patients, pain scores during cystoscopy and cauterization were not significantly different (P = .4772) but associated with anxiety.ConclusionOffice cystoscopy and cauterization are tolerable with minimal pain. Higher pain during the cystoscopy was associated with procedure anxiety, and pain during cauterization was associated with procedure anxiety and younger age. Younger and more anxious patients may need more counseling before cystoscopy.     

Use of ketofol to control emergence agitation in children undergoing adenotonsillectomy

ObjectiveTo assess the efficacy and safety of ketofol administration in controlling emergence agitation (EA) after sevoflurane-based anesthesia in children undergoing adenoidectomy or adenotonsillectomy.Subjects and methodsThis double-blinded randomized study involved 90 children (3–6 years) scheduled for elective adenotonsillectomy or adenoidectomy. They were randomly assigned to receive 10 ml of normal saline (control group, C) or, 1 mg/kg propofol in 10 ml saline (group P) or ketofol as 1 mg/kg propofol and 0.25 mg/kg ketamine in 10 ml saline (group K) 10 min before the end of surgery. In PACU, sedation, behavior, pain and severity of EA were assessed using modified Aldrete score, Aono’s scale, Objective Pain Score (OPS) and Pediatric Anesthesia Emergence Delirium (PAED) scale, respectively.ResultsIn ketofol group, OPS was significantly lower compared to propofol and control groups. Recovery criteria were in favor of ketofol and propofol groups including longer time to eye opening (p < 0.001) and time to Aldrete score ⩾ 9 (p = 0.001). Time to discharge from PACU was comparable in the three groups (p = 0.079). EA was significantly more frequent in the control group (p < 0.001), but comparable in ketofol and propofol groups. PAED score was significantly higher in control group compared to ketofol and propofol groups. Ketofol and propofol preserved hemodynamic stability.ConclusionKetofol provides a promising new option for controlling emergence agitation with adequate postoperative sedative and analgesic effect, good recovery criteria and hemodynamic stability compared to propofol and control groups in children undergoing adenoidectomy or adenotonsillectomy.     

Dexmedetomidine as supplement to low-dose levobupivacaine spinal anesthesia for knee arthroscopy

AimTo evaluate efficiency of dexmedetomidine compared to fentanyl as supplements to low-dose levobupivacaine spinal anesthesia in patients undergoing knee arthroscopy.Materials and methodsSixty adult patients (ASA I or II) scheduled for knee arthroscopy were randomized to receive plain levobupivacaine (4 mg) plus dexmedetomidine (3 μg) in group D or fentanyl (10 μg) in group F.ResultsDexmedetomidine shortened time to surgery (P = 0.002), time to highest sensory level (P = 0.001), and time to highest Bromage score (P < 0.001). The highest sensory level was comparable in both groups (P = 0.969), but the duration of sensory block was significantly longer in group D (P = 0.009). The highest Bromage score was 2 in both groups. This score was attained in significant higher number of patients in group D (P = 0.038) that showed better muscular relaxation (P = 0.035). At the end of surgery, a residual motor block (Bromage score 1) was observed in significant higher number of patients (P = 0.033) and time to ambulation was significantly longer in group D (P = 0.001). There was no difference in the number of patients bypassed post-anesthesia care unit (PACU) (P = 0.761) or time to hospital discharge (P = 0.357) between groups. The pain free period was more prolonged (P < 0.001), and the visual analog scale (VAS) for pain was lower at the 2nd, 4th, 6th, and 8th postoperative hours (P < 0.001, <0.001, 0.013, 0.030 respectively) in group D.ConclusionDexmedetomidine is a good alternative to fentanyl for supplementation of low-dose levobupivacaine spinal anesthesia for knee arthroscopy.     

Does pressure support ventilation improve the postoperative outcome of adeno-tonsillectomy patients? A prospective randomized trial

BackgroundSpontaneous ventilation (SV) is used for adeno/tonsillectomy in children. However, inhalational anesthetics produce dose dependent decrease in minute ventilation. We tested the impact of PSV on awakening time, and length of PACU stay.Methods34 patients were randomized into two groups; PS ventilation group and SV group. Premedication and induction were similar in both groups. Patients in PS group were ventilated with P_insp set to deliver 8 ml/kg V_T, keeping ETCO₂ between 35 and 45 mmHg. Any episodes of hypoventilation were recorded and corrected by manual support of ventilation.Upon completion of surgery, time-to-extubate was recorded. Length of PACU stay, agitation and CHEOPS scores, PONV and desaturation episodes were also recorded. Results are presented as mean (SD), median (interquartile range), or number of patients as appropriate. A P value < 0.05 was considered significant.ResultsExtubation time (min) [mean (SD)] was longer in SV group than PS group [7.8 (2.1) vs. 5.5(1.4), P < 0.001]. In the SV group 9 patients had episodes of hypoventilation that necessitated manual assist of ventilation. Pain scores were higher in SV group than PS group. Duration of stay in PACU [mean (SD)] in minutes was longer in SV group than PS group [44.3(7.4) vs. 39.4(5.7), P = 0.02]. All but one patient in the PS group needed postoperative rescue meperidine analgesia. The mean (SD) time needed for rescue meperidine analgesia was 27.1(8.9) in PS group and 21.8(9.4) in SV group (P = 0.04).ConclusionPSV carries the advantages of overcoming the effects of narcotics and inhaled anesthetics on spontaneously ventilated adeno-tonsillectomy patients. They suffer less pain and spend less time in the PACU.     

Bilateral sphenopalatine ganglion block as adjuvant to general anaesthesia during endoscopic trans-nasal resection of pituitary adenoma

BackgroundThis study was conducted to investigate the anaesthetic, vasodilator, and post-operative analgesic sparing effect of bilateral sphenopalatine ganglion block (SPGB) in patients undergoing endoscopic endo-nasal trans-sphenoidal surgery.MethodsThirty adult patients of ASA (I, II), aged 20–60 years, were randomly allocated to either the block group or the non-block group (n = 15, for each). After establishment of general anesthesia with sevoflurane and 100% oxygen, the patients received bilateral SPGB with 1.5 ml of either 0.5% bupivacaine (block group) or 0.9% NaCl (non-block group). Intra-operative mean arterial pressure (MAP) was maintained at 60–65 mmHg by using nitroglycerine. End-tidal sevoflurane concentration required to maintain bispectral index values (40–50) throughout the operation was recorded. Nitroglycerine and propranolol consumption, blood loss, recovery profile, perioperative catecholamines, post-operative pain and meperidine consumption were evaluated.ResultsBlock group showed significant decrease in sevoflurane and nitroglycerine consumption, blood loss, emergence time and time needed to achieve ?9 Aldrete score, P < 0.0001. All patients in non-blockade group (100%) were supplemented by nitroglycerine to achieve the target MAP versus 9 patients (60%) in the block group (P < 0.01). Propranolol administration was necessary in 9 patients (60%) in the non-block group versus 3 patients (20%) in the block group, P < 0.05. At PACU, visual analogue pain score and number of patients received meperidine analgesia were significantly less in the block group versus non-block group, P < 0.0001 and P < 0.001, respectively. Intra- and post-operative plasma epinephrine and nor-epinephrine levels were significantly higher in the non-block group than the block group, P < 0.05.ConclusionBilateral SPGB has anaesthetic, vasodilator and analgesic sparing effect when combined with general anaesthesia during endoscopic endo-nasal trans-sphenoidal resection of pituitary adenoma.     

The effect of different drugs on sevoflurane emergence agitation in pediatric patients undergoing hypospadias repair surgery

BackgroundVarious methods are used to decrease the incidence of emergence agitation (EA) in children following general anaesthesia with sevoflurane.ObjectiveThe present study aims to compare the effect of intravenous injection of small dose of propofol, fentanyl or ketamine at the end of surgery, just before the discontinuation of sevoflurane on the incidence and severity of sevoflurane emergence agitation in children undergoing hypospadias repair operations.Patients and methodsEighty patients undergoing elective hypospadias repair under sevoflurane general anaesthesia with caudal block were randomly divided into four groups (20 patients each); group P received intravenous 1 mg/kg propofol, group K received intravenous 0.25 mg/kg ketamine, group F received intravenous 1 μg/kg fentanyl, and group S received intravenous saline as control group. All those injections were given just before the discontinuation of sevoflurane. The emergence agitation was evaluated by emergence agitation scale from awakening every 5 min for 30 min. Complications like laryngospasm, desaturation, cough, and vomiting were recorded. Awakening time and PACU duration were also recorded.ResultsThe incidence of emergence agitation was significantly lower in groups P and F (p < 0.05). The time for awakening was significantly prolonged in groups P, K and F (p < 0.05), while PACU duration was significantly prolonged in group F (p < 0.05). No significant complications occurred except a significantly higher incidence of vomiting in group F.ConclusionThe use of propofol or fentanyl just before the discontinuation of sevoflurane reduces the incidence of emergence agitation in children, on the other hand fentanyl was accompanied with a significantly longer PACU duration and higher incidence of vomiting.