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.     

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.     

Intrathecal morphine 100 and 200 μg for post-cesarean delivery analgesia: a trade-off between analgesic efficacy and side effects

IntroductionIntrathecal morphine is highly effective for post-cesarean analgesia; however, the optimal dose is yet to be established. The aim of this study was to compare analgesia and side effects after a change in institutional practice to give 200 μg rather than 100 μg.MethodsWe conducted a retrospective chart review of 241 patients who had an elective cesarean delivery and received either 100 or 200 μg of intrathecal morphine. The primary outcome variables were mean and peak verbal pain scores (0–10) and analgesic use (milligram-morphine equivalents). Postoperative administration of antiemetics, antipruritics and episodes of nausea or vomiting were recorded. Data are reported as mean ± SD or percentages with P < 0.05 considered statistically significant.ResultsWomen receiving intrathecal morphine 200 μg had lower pain scores and opioid use compared with morphine 100 μg. Mean verbal pain scores were 1.6 ± 1.1 versus 2.0 ± 1.1 (P = 0.01) and peak verbal pain scores were 4.9 ± 2.0 versus 5.6 ± 1.8, respectively (P = 0.008). The group receiving 200 μg used less opioids in the first 24 h after surgery (44 ± 35 versus 54 ± 35 milligram-morphine equivalents, respectively, P = 0.04) and received less intravenous opioids (18% versus 30%, P = 0.02). However, women receiving intrathecal morphine 200 μg had more nausea (mean number of episodes of nausea 1.9 ± 1.3 versus 1.6 ± 1.3, P = 0.037) and used more antiemetics (52% versus 24%, P < 0.0001).ConclusionsIntrathecal morphine 200 μg provided better analgesia but with more nausea compared with morphine 100 μg. Our results can be used to help guide intrathecal morphine dosing in cesarean delivery based on patient preference for analgesia versus side effects.     

The value of epidural magnesium sulfate as an adjuvant to bupivacaine and fentanyl for labor analgesia

ObjectiveWe conducted this clinical study to assess the adjuvant effects of single dose magnesium sulfate (Mg) when administered epidurally during labor with fentanyl and bupivacaine.MethodsEighty healthy nulliparous women in labor requesting epidural analgesia were divided into two groups. Group 1 received bupivacaine 0.125% with magnesium sulfate 50 mg and fentanyl 50 μg as a loading dose; group 2, received bupivacaine 0.125% and fentanyl 50 μg only. Hemodynamic parameters, motor and sensory evaluation, cervical dilation at time of consenting, the progress of labor, the visual analog pain score (VAS), Apgar score, cord blood acid base status, side effects as nausea, vomiting, itching and respiratory depression were recorded. Fetal heart rate tracings were also documented.ResultsEpidural single dose magnesium sulfate added to bupivacaine and fentanyl in labor resulted in significantly faster onset and longer duration of epidural analgesia (169 ± 50 min) in comparison to those patients who received bupivacaine and fentanyl only (105 ± 41 min), also there was a significant reduction in the number of women requiring additional boluses of bupivacaine when Mg was added (P = 0.016). The two groups had no significant differences as regards maternal satisfaction score, maternal and neonatal adverse effects.ConclusionMagnesium sulfate added to bupivacaine and fentanyl for labor epidural analgesia resulted in faster onset, longer duration of action and reduced the break through pain.     

The effect of bupivacaine with fentanyl temperature on initiation and maintenance of labor epidural analgesia: a randomized controlled study

BackgroundLabor epidural analgesia is highly effective, but can be limited by slow onset and incomplete blockade. The administration of warmed, compared to room temperature, bupivacaine has resulted in more rapid onset epidural anesthesia. We hypothesized that the administration of bupivacaine with fentanyl at 37°C versus 20°C would result in improved initial and ongoing labor epidural analgesia.MethodsIn this prospective, randomized, doubled blinded study, 54 nulliparous, laboring women were randomized to receive epidural bupivacaine 0.125% with fentanyl 2 μg/mL (20 mL initial and 6 mL hourly boluses) at either 37°C or 20°C. Pain verbal rating scores (VRS), sensory level, oral temperature, and side effects were assessed after epidural loading (time 0), at 5, 10, 15, 20, 30, 60 min, and at hourly intervals. The primary outcome was the time to achieve initial satisfactory analgesia (VRS ⩽3). Secondary outcomes included ongoing quality of sensory blockade, body temperature and shivering.ResultsThere were no differences between groups in patient demographics, initial pain scores, cervical dilatation, body temperature or mode of delivery. Epidural bupivacaine at 37°C resulted in shorter mean (±SD) analgesic onset time (9.2 ± 4.7 vs. 16.0 ± 10.5 min, P = 0.005) and improved analgesia for the first 15 min after initial bolus (P = 0.001–0.03). Although patient temperature increased during the study (P < 0.01), there were no differences between the groups (P = 0.09). Six (24%) and 10 (40%) patients experienced shivering in the 37°C and 20°C groups, respectively (P = 0.23).ConclusionsThe administration of epidural 0.125% bupivacaine with fentanyl 2 μg/mL at 37°C versus 20°C resulted in more rapid onset and improved labor analgesia for the first 15 min. There was no evidence of improved ongoing labor analgesia or differences in side effects between groups.     

Contribución del bloqueo del plano transverso abdominal guiado por ultrasonidos a la analgesia postoperatoria tras la cesárea

ObjectiveThe aim of this study was to evaluate the contribution made by ultrasound-guided transversus abdominis plane block (TAP) to the quality of the analgesia with intrathecal opioids obtained in patients undergoing elective caesarean delivery.Material and methodsA prospective, randomized study in patients submitted to elective caesarean section with spinal anaesthesia with 0.5% hyperbaric bupivacaine. The patients were randomized into 3 groups according to the added complementary drug for analgesia: group A morphine 0.1 mg; group B fentanyl 10 μg; group C 10 μg fentanyl + bilateral TAP block. The TAP block with 20 ml of 0.5% levobupivacaine on each side, after surgery. Groups A and B, were injected with 20 ml of saline. Postoperative analgesia was performed with morphine bolus through a system of patient-controlled analgesia (PCA). We studied the pain on a visual analogue scale at 12 and 24 h at rest and movement, the time elapsed to require the first bolus, and morphine bolus in 24 h. Secondary effects such as nausea, vomiting, pruritus, and drowsiness, were also evaluated. The level of patient satisfaction was also recorded.ResultsA total of 90 patients were included. At rest the 12/24 h VAS score was: group A, at 12 h 2.1 ± 1.2, at 24 h 4.7 ± 1.6; group B at 12 h 4.3 ± 2.9, at 24 h 4.8 ± 2; group C at 12 h 1.9 ± 1.09, at 24 h 2.3 ± 1.2 (P<.05). Walking improved analgesia more in group C (P≤.02). The time of asking for the first bolus was lower in group B: group A 9.3 ± 4.9 h (P=.02 compared to group C), in group B 2 ± 1.8 h (P<.001 compared to group C) and group C 13.2 ± 2.1 h. The number of bolus in 24 h in group B was 38 ± 5, in group A 10 ± 2 (P<.05), group C 5 ± 2 (P<.001). Delayed nausea was increased in group B (36.6%) and pruritus was greater in group A (36.6%).ConclusionsUltrasound (US)-guided TAP block improves spinal opioid analgesia, with a decrease in VAS scores in the first 24 h, and reduces opioid requirement and secondary effects after caesarean delivery.     

Chronobiology of parturients receiving neuraxial labour analgesia with ropivacaine and fentanyl: a prospective cohort study

BackgroundThe circadian variation in biologic rhythm has been known to affect labour pain. The duration of action of ropivacaine or fentanyl used in treatment of labour pain has been demonstrated to vary with different times of the day. The aim of this study is to find whether the need for epidural supplementation for breakthrough pain is significantly affected by the time of day, in patients who are on a continuous epidural infusion of these drugs.MethodsIn this prospective cohort study, parturients with spontaneous onset of labour were given a combined spinal-epidural technique with spinal ropivacaine 2 mg + fentanyl 15 μg followed by an epidural infusion of ropivacaine 0.1–0.125% with fentanyl 2 μg/mL at 10 mL/hour. A total of 1657 patients were divided into four groups: (1) morning: analgesia request: 7:01 to 13:00, delivery before 19:00; (2) afternoon: analgesia request: 13:01 to 19:00, delivery before 1:00; (3) evening: analgesia request: 19:01 to 1:00, delivery before 7:00 and (4) night: analgesia request: 1:00 to 7:00, delivery before 13:00. Pain scores before epidural analgesia, need for additional epidural supplementation, side effects and patient satisfaction scores were compared between the groups.ResultsThe pain scores before epidural analgesia were significantly higher in evening and night groups than in morning and afternoon groups (6.95 ± 2.4, 7.38 ± 2.2 compared to 6.67 ± 2.5, 6.49 ± 2.7 respectively, P < 0.001). Incidence of breakthrough pain, side effects and parturient satisfaction scores were not significantly different between groups.ConclusionParturients with labour onset and neuraxial analgesia request in the evening and night experienced higher pain scores. However, no significant differences in the incidence of breakthrough pain or the quality of analgesia were observed with the provision of commonly used concentrations of ropivacaine with fentanyl via continuous epidural infusion.     

Analgesic effects of intrathecal tramadol in patients undergoing caesarean section: a randomised,double-blind study

BackgroundIntrathecal tramadol combined with local anaesthetics has been used for postoperative analgesia following lower abdominal and perineal surgery. The present study evaluated the effect of intrathecal tramadol on spinal block characteristics and neonatal outcome after elective caesarean section.MethodsEighty full-term parturients scheduled for elective caesarean section were randomly divided into two groups. In the fentanyl group, patients received intrathecal 0.5% bupivacaine 10 mg with fentanyl 10 μg; in the tramadol group, patients were given the same dose of bupivacaine with tramadol 10 mg. Sensory and motor block characteristics, duration of postoperative analgesia, maternal side effects, and neonatal outcome were compared.ResultsOne patient in the tramadol group and two patients in the fentanyl group were excluded from data analysis. Median [interquartile range] duration of postoperative analgesia in the tramadol and the fentanyl groups was 300 [240–360] min and 260 [233–300] min respectively (P = 0.02). The incidence of shivering was lower in patients who received tramadol (5%) than those who had fentanyl (32%) (P = 0.003). Apgar scores, umbilical cord acid–base measurement and neurologic and adaptive capacity scores were comparable between the two groups.ConclusionCompared to intrathecal fentanyl 10 μg, tramadol 10 mg, as an adjunct to bupivacaine for subarachnoid block for caesarean section, showed a longer duration of analgesia with a reduced incidence of shivering.     

Ketamine–propofol versus ketamine fentanyl for anesthesia in pediatric patients undergoing cardiac catheterization: A prospective randomized study

ObjectiveThe aim of the study was to assess, compare the safety and efficacy of continuous IV administration of a combination of ketamine–propofol versus ketamine fentanyl for anesthesia in children undergoing cardiac catheterization procedures with RT to Lt Shunt.MethodsThirty-six children aged from 1 to 8 years, with RT to Lt Shunt scheduled for Cardiac catheterization in Mansoura Children Hospital were included in this study. Patients in group KP (n = 18) received ketamine (1 mg/kg) and propofol (2 mg/kg) as induction agents followed by combination of ketamine (25 μg/kg/min) and propofol (25 μg/kg/min) for maintenance of anesthesia. On other hand, patients in group KF (n = 18) received ketamine (1 mg/kg) and fentanyl (1 μg/kg) as induction agents followed by combination of ketamine (25 μg/kg/min) and fentanyl (0.75 μg/kg/min) for maintenance of anesthesia. Hemodynamic, oxygenation, recovery variables and side effects were recorded.ResultsThere were no statistical significant differences with age, sex, duration of anesthesia. There were statistical significant decreases in mean arterial blood pressure (MAP), systemic vascular resistance (SVR), pulmonary to systemic vascular resistance ratio in KP group. Additionally, Sao₂ and Pao₂ after anesthesia in KF group were statistically significant higher than the other group. Also there was significant prolongation of time to full recovery in KF group compared with KP group.ConclusionWe concluded that a combination of ketamine–fentanyl is safer and more efficacious than ketamine–propofol for pediatric cardiac catheterization although it was associated with prolonged recovery time.     

Efficacy of ultrasound-guided transversus abdominis plane blocks for post-cesarean delivery analgesia: a double-blind,dose-comparison,placebo-controlled randomized trial

BackgroundThe analgesic benefit of TAP (transversus abdominis plane) blocks for cesarean delivery pain remains controversial. We compared the analgesic efficacy of two doses of local anesthetic for TAP blocks after cesarean delivery.MethodsSixty women having cesarean delivery under spinal anesthesia were randomized to receive ultrasound-guided TAP blocks using either high-dose ropivacaine (3 mg/kg), low-dose ropivacaine (1.5 mg/kg) or placebo. Patients received intrathecal 0.75% bupivacaine 10–12 mg, fentanyl 10 μg and morphine 150 μg and standard multimodal analgesia. The primary outcome was the difference in pain with movement using a numeric rating scale at 24 h. Other outcomes included time to first request for analgesia, pain scores at 6, 12, 36, 48 h and at 6 and 12 weeks, opioid consumption, adverse effects, quality of recovery, and satisfaction.ResultsThere were no differences between groups in the primary outcome. Mean ± SD pain scores (0–10) with movement at 24 h were: high-dose ropivacaine 3.6 ± 1.5, low-dose ropivacaine 4.6 ± 2.1 and placebo 4.1 ± 1.7. With respect to secondary outcomes, the mean ± SD pain scores at 6 h were lower in the high-dose group 2.0 ± 1.8 compared to the low-dose 3.4 ± 2.7 and placebo groups 4.2 ± 2.0 (P = 0.009). Pain scores at 12 h were also lower in the high-dose group 2.2 ± 2.0 compared to the low-dose group 4.1 ± 2.7 and placebo group 4.0 ± 1.3 (P = 0.011). There was no difference in other outcomes between groups.ConclusionsNeither high- or low-dose TAP blocks as part of a multimodal analgesia regimen including intrathecal morphine improved pain scores with movement at 24 h after cesarean delivery when compared to placebo TAP blocks. High-dose TAP blocks may improve pain scores up to 12 h after cesarean delivery.     

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.     

Onset of labor epidural analgesia with ropivacaine and a varying dose of fentanyl: a randomized controlled trial

BackgroundThis study was conducted to investigate the onset of labor epidural analgesia using 0.17% ropivacaine with a varying dose of fentanyl. We hypothesized that the onset of analgesia would be shortened in proportion to an increase in fentanyl dose.MethodsWomen requesting labor epidural analgesia were enrolled in this randomized controlled clinical trial. Each woman was randomly assigned to receive fentanyl 0, 50, 75, or 100 μg with 0.17% ropivacaine 12 mL. The onset and duration of analgesia, the incidence of side effects and patient satisfaction were measured.ResultsData from 102 women were analyzed. The onset of analgesia (mean ± SD) was shortened with an increasing dose of fentanyl (14.3 ± 5.4, 14.2 ± 6.5, 12.1 ± 5.1, and 8.7 ± 3.8 min with fentanyl 0, 50, 75, or 100 μg, respectively, P = 0.001). The duration of analgesia was prolonged with an increasing dose of fentanyl (87.4 ± 20.8, 112.3 ± 19.5, 140.8 ± 18.8, and 143.6 ± 18.6 min with fentanyl 0, 50, 75, or 100 μg, respectively, P < 0.001). The incidence of pruritus increased with an increasing dose of fentanyl (P = 0.027) but there were no differences for other maternal side effects. There was a significant difference in satisfaction score among groups (P = 0.009).ConclusionThe addition of increasing doses of fentanyl to 0.17% ropivacaine contributed to shortened onset as well as prolonged duration of labor epidural analgesia and improved patient satisfaction.     

Low-dose butorphanol alleviates remifetanil-induced hyperalgesia in patients undergoing laparoscopic cholecystectomy

ObjectiveTo evaluate the effects of low-dose butorphanol on hyperalgesia induced by high-dose remifetanil in patients undergoing laparoscopic cholecystectomy.DesignRandomized double-blind clinical trial.SettingIntraoperative.PatientsSeventy-five patients scheduled for laparoscopic cholecystectomy were enrolled.InterventionsRandomly allocated into 3 groups, low dose of remifentanil (LR) group and high dose of remifentanil (HR) group received low (0.1 μg kg^− 1 min^− 1) or high (0.3 μg kg^− 1 min^− 1) doses of remifentanil, respectively, and butorphanol combined with remifentanil (BR) group received remifentanil (0.3 μg kg^− 1 min^− 1) and butorphanol (0.2 μg/kg).MeasurementsThe visual analog scale scores and cumulative consumption of fentanyl were recorded.Main resultsVisual analog scale scores were significantly higher in the HR group than in the LR and BR groups (P < .001). The dose of intravenously given fentanyl was significantly higher in the HR group than in the LR and BR groups (P < .001). In addition, the HR group showed a significantly higher cumulative consumption of fentanyl during 5 to 8 hours after the operation (P < .001).ConclusionsA high dose of remifentanil induces postoperative hyperalgesia, which could be prevented by a continuous intravenous administration of a low dose of butorphanol.     

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.     

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.     

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.     

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.     

Dexmedetomidine as a hypotensive agent: Efficacy and hemodynamic response during spinal surgery for idiopathic scoliosis in adolescents

BackgroundThis study was designed to evaluate the efficacy of dexmedetomidine as a hypotensive agent in comparison to sodium nitroprusside in scoliosis surgery.MethodForty patients ASA I or II aged (12–16) year scheduled for scoliosis surgery were randomly assigned to receive either dexmedetomidine 1 μg/kg over 10 min before induction of anesthesia followed by 0.2–0.5 μg/kg/h infusion during maintenance (DEX group) or sodium nitroprusside 1–10 μg/kg/min infusion after induction of anesthesia (SNP group) to maintain mean arterial blood pressure between (60–65 mmHg). Mean arterial pressure (MAP), heart rate (HR), cardiac index (CI), systemic vascular resistance index (SVRI) and stroke index (SI) were recorded. The two groups were compared with reference to reversibility of hypotensive state, intraoperative blood loss and transfusion requirement.ResultsDexmedetomidine administration resulted in significant reduction in MAP, HR and CI. During the steady state hypotension SNP group showed significant increase in HR and CI compared to baseline and to DEX group (P < 0.05). SVRI was significantly lower during controlled hypotension in SNP group compared to DEX group (P < 0.001). Time to restoration of baseline MAP was longer with DEX group (10.21 ± 1.52 min) than SNP group (4.87 ± 0.86 min) (P < 0.001). Blood loss and transfusion requirement were significantly lower in DEX group than SNP group [1095.62 ± 128.9 6 ml versus 1287.50 ± 182.54 ml, P = 0.0013] and [855.42 ± 140.23 versus 1006.00 ± 154.66 ml, P = 0.0026], respectively.ConclusionDexmedetomidine is a safe and effective drug for controlled hypotension in scoliosis surgery. It may offer the significant advantage of reducing blood loss and transfusion requirement.     

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.     

Dexmedetomidine decreases the required amount of bupivacaine for ultrasound-guided transversus abdominis plane block in pediatrics patients: a randomized study

BackgroundThe effect of dexmedetomidine on the potency of bupivacaine for transversus abdominis plane (TAP) block in pediatric patients has not been investigated.Study objectiveThe primary objective of this study was to assess the effectiveness of dexmedetomidine to decrease the concentration of bupivacaine needed for analgesia for ultrasound-guided TAP block in a pediatric patient undergoing hernia repair or hydrocelectomy.DesignThis is a randomized, double-blind, up-down, dose-finding study.SettingOperating room.PatientsSixty American Society of Anesthesiologists I and II patients aged 1-4 years scheduled for elective unilateral herniorrhaphy or hydrocelectomy.InterventionsPatients were randomly assigned to 1 of the 2 groups: group B (0.125% bupivacaine, 1 mL/kg) TAP block or group BD (0.125% bupivacaine plus 2 μg/kg dexmedetomidine, 1 mL/kg) TAP block.MeasurementsThe response of each child was observed for 60 seconds after skin incision and evaluated as ‘unsuccessful’ when skin incision caused a change in hemodynamic parameters (heart rate and mean blood pressure) 20% more than the preincision values. If the response was determined to be unsuccessful, the concentration of bupivacaine administrated to the next patient was increased by 0.02%. If it was successful, the concentration of bupivacaine administrated to the next patient was decreased by 0.02%.ResultsThe minimum local anesthetic concentration of bupivacaine was 0.0839% (0.0137) in the B group and 0.0550% (0.0169) in the BD group. The difference was statistically significant (t = 7.165, P = .0001). The total postoperative analgesic dosage of morphine was significantly higher in the B group (0.17 ± 0.04 mg/kg) than the BD group (0.11 ± 0.02 mg/kg, P = .001).ConclusionsThe addition of 2 μg/kg of dexmedetomidine reduced the minimum local anesthetic concentration of bupivacaine used for a TAP block and improved postoperative analgesia in children undergoing surgery for inguinal hernia repair or hydrocelectomy.