Effect of intravenous lidocaine infusion on sevoflurane requirements as monitored by bispectral index: A randomized double-blinded controlled study

IntroductionSystemic administration of lidocaine significantly decreased propofol requirements when compared to patients receiving placebo. Several studies conducted on animals have proved that systemic local anesthetics reduced minimum alveolar concentration (MAC) of inhalational anesthetics. The aim of this investigation is to study the effect of intravenous administration of lidocaine on the minimum alveolar concentration of sevoflurane required to keep BIS between 40 and 60 during maintenance of anesthesia in humans.MethodsTwenty-eight ASA I–II adults planned to undergo laparoscopic procedures expected to last <2 h under general anesthesia were randomly assigned to 2 groups. After standardized induction of general anesthesia, patients were given IV lidocaine bolus (1.5 mg kg^?1) followed by 2 mg kg^?1 h^?1 infusion (group L, n = 14) or equal volumes of saline (group C, n = 14). Primary outcome of the study was end-tidal sevoflurane at bispectral index (BIS) values of 40–60. Secondary outcomes included doses of opioids, BIS values, and extubation time.ResultsThe median doses of intraoperative fentanyl (range) in group C were similar to group L (P = 0.08). There were no significant differences between the 2 groups regarding BIS at any time point. End-tidal sevoflurane concentrations were significantly higher in group C than in group L at all intraoperative time points (P < 0.05). Extubation time was longer in group L than in group C (P = 0.04).ConclusionIn conclusion, intravenous lidocaine administration, during maintenance of general anesthesia, can decrease BIS-guided sevoflurane requirements.     

A randomized study of maternal serum cytokine levels following cesarean section under general or neuraxial anesthesia

BackgroundCytokines are significant mediators of the immune response to surgery and also play a role in parturition. The aim of the study was to investigate the impact of the anesthetic technique for cesarean section on plasma levels of cytokines IL-6 and TNF-α.MethodsThirty-five parturients scheduled for elective cesarean section were randomly assigned to general (n = 18) or neuraxial (n = 17) anesthesia. The general anesthesia group received thiopental 4 mg/kg, succinylcholine 1–1.5 mg/kg and 1% end-tidal concentration of sevoflurane in nitrous oxide and 50% oxygen. The neuraxial anesthesia group received intrathecal 0.5% levobupivacaine 1.8–2.2 mL and epidural fentanyl 1 μg/kg. Blood samples were taken for IL-6 and TNF-α immediately after positioning the parturient on the operating table, after uterine incision and before the umbilical cord clamping and 24 h after surgery (T₁, T₂ and T₃ respectively).ResultsThe two groups did not differ in IL-6 (P = 0.15) or TNF-α (P = 0.73) serum concentrations at any time point. In the general and neuraxial anesthesia groups, IL-6 serum concentrations were significantly higher in the third blood sample, T₃ (12.2 ± 5.0 and 15.2 ± 4.3 pg/mL), than in T₁ (0.41 ± 0.38 and 0.29 ± 0.10 pg/mL) and T₂ (0.37 ± 0.47 and 0.24 ± 0.05) respectively (P < 0.001). Within each group, serum TNF-α concentrations did not differ significantly over time (P = 0.44).ConclusionsUnder the present study design anesthetic technique did not affect IL-6 or TNF-α concentrations in parturients undergoing elective cesarean section. Serum IL-6 levels increased 24 h postoperatively independently of anesthetic technique.     

Ultrashort acting remifentanil is not superior to long-acting sufentanil in preserving cognitive function—a randomized study

Study objectivePostoperative cognitive dysfunction (POCD) is a well-known complication after cardiac surgery and may cause permanent disabilities with severe consequences for quality of life. The objectives of this study were, first, to estimate the frequency of POCD after on-pump cardiac surgery in patients randomized to remifentanil- or sufentanil-based anesthesia and, second, to evaluate the association between POCD and quality of recovery and perioperative hemodynamics, respectively.DesignRandomized study.SettingPostoperative cardiac recovery unit, University Hospital.PatientsSixty patients with ischemic heart disease scheduled for elective coronary artery bypass grafting ± aortic valve replacement.Interventions and handlingRandomized to either remifentanil or sufentanil anesthesia as basis opioid. Postoperative pain management consisted of morphine in both groups.MeasurementsCognitive functioning evaluated preoperatively and on the 1st, 4th, and 30th postoperative day using the cognitive test from the Palo Alto Veterans Affairs Hospital. Perioperative invasive hemodynamics and the quality of recovery was evaluated by means of invasive measurements and an intensive care unit discharge score.Main resultsNo difference between opioids in POCD at any time. A negative correlation was found between preoperative cognitive function and POCD on the first postoperative day (r = − 0.47; P = .0002). The fraction of patients with POCD on the first postoperative day was statistically greater in patients with more than 15 minutes of Svo₂ < 60 (P = .037; χ² test). Among patients with postoperative ventilation time exceeding 300 minutes, more patients had POCD on postoperative day 4 (P = .002).ConclusionsWe could not demonstrate differences in POCD between remifentanil and sufentanil based anaesthesia, but in general, the fraction of patients with POCD seemed smaller than previously reported. We found an association between POCD and both perioperative low Svo₂ and postoperative ventilation time, underlining the importance of perioperative stable hemodynamics and possible fast-track protocols with short ventilation times to attenuate POCD.     

Preoperative use of gabapentin decreases the anesthetic and analgesic requirements in patients undergoing radical mastectomy

Background/aimGabapentin is an anticonvulsant drug that is safe and effective for the treatment of neuropathic pain syndrome, as well as postoperative pain with good results. This prospective randomized study was done to evaluate the effects of preoperative administration of oral gabapentin (1200 mg) on the intraoperative fentanyl and isoflurane consumption, postoperative analgesic requirements and postoperative pain in patients undergoing radical mastectomy.MethodsSixty ASA I and II patients were randomly allocated into two equal groups to receive oral gabapentin 1200 mg, 2 h before surgery (G group) or control (C group). General anesthesia was induced and maintained at bispectral index value between 40 and 60. During surgery the end-tidal isoflurane concentrations required to maintain adequate depth of anesthesia and the required incremental doses of intraoperative fentanyl were recorded. Postoperative pain was assessed using visual analogue scale (VAS) at rest for 24 h. Postoperatively, whenever visual analogue scale (VAS) was more than 5 or on patients’ demand, analgesia in both groups was provided with diclofenac sodium (1 mg/kg IM) or tramadol hydrochloride (1 mg/kg IV) as needed. VAS, analgesics requirements, and side-effects were assessed for 24 h postoperatively.ResultsIntraoperative fentanyl and postoperative analgesic consumption were significantly lower in G group than C group (P < 0.001). Patients in the G group had significantly lower end-tidal concentrations of isoflurane required to maintain adequate depth of anesthesia (P < 0.05). VAS was significantly lower in G group than C group at the first three measurement times (P < 0.01). The incidence of postoperative nausea and vomiting was significantly lower in G group than C group (30% versus 60% of patients, respectively, P < 0.05). The incidence of dizziness was significantly higher in the G group than C group (26% versus 3.3% of patients, respectively, P < 0.05).ConclusionGabapentin (1200 mg) administered orally 2 h before surgery decreased the intraoperative fentanyl and isoflurane consumption, postoperative analgesic requirements, postoperative pain, and the incidence of postoperative nausea and vomiting, but increased dizziness.     

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.     

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.     

The effect of sevoflurane compared to propofol maintenance on post-surgical quality of recovery in patients undergoing an ambulatory gynecological surgery: A prospective,randomized, double-blinded,controlled, clinical trial

ObjectiveThe main objective of the current investigation was to evaluate the effect of propofol used as anesthetic maintenance compared to sevoflurane on global post-surgical quality of recovery in female patients undergoing ambulatory gynecological surgery.DesignThe study was a prospective randomized double blinded, controlled, clinical trial.InterventionsHealthy female subjects were randomized to receive propofol or sevoflurane as anesthetic maintenance.MeasurementsThe primary outcome was the Quality of Recovery 40 (QOR-40) questionnaire at 24 h after surgery. Other data collected included opioid consumption, pain scores and time to hospital discharge. P < 0.05 was used to reject the null hypothesis for the primary outcome.Main resultsNinety subjects were randomized and sixty seven completed the study. Patient's baseline characteristics and surgical factors were not different between study groups. There was not a clinically significant difference in the global QoR-40 scores between the sevoflurane and the propofol groups, median (IQR) of 175 (163 to 181) and 176 (163 to 184), respectively, P = 0.97. There was an inverse relationship (ρ = − 0.42) between the opioid consumption in PACU (IV morphine equivalents) and 24 h postoperative quality of recovery (P < 0.001) and an inverse relationship (ρ = − 0.48) between the oral opioid consumption at home (oral morphine equivalents) and 24 h postoperative quality of recovery, P < 0.001.ConclusionsOur current results do not support the use of total intravenous anesthesia as an efficacious strategy to improve global quality of recovery after ambulatory surgery. Opioid consumption in the PACU is an earlier surrogate that can be utilized to identify ambulatory patients with a high likelihood to develop poor global quality of recovery and who may benefit from more efficacious strategies to improve global quality of recovery.Trial registration: ClinicalTrial.gov; url: http://www.clinicaltrials.gov; registration identified: NCT 01755234.     

Effects of inhalational anaesthesia with low tidal volume ventilation on end-tidal sevoflurane and carbon dioxide concentrations: prospective randomized study

ObjectiveWe investigated how ventilation with low tidal volumes affects the pharmacokinetics of sevoflurane uptake during the first minutes of inhaled anaesthesia.MethodsForty-eight patients scheduled for lung resection were randomly assigned to three groups. Patients in group 1, 2 and 3 received 3% sevoflurane for 3 min via face mask and controlled ventilation with a tidal volume of 2.2, 8 and 12 ml kg⁻¹, respectively (Phase 1). After tracheal intubation (Phase 2), 3% sevoflurane was supplied for 2 min using a tidal volume of 8 ml kg⁻¹ (Phase 3).ResultsEnd-tidal sevoflurane concentrations were significantly higher in group 1 at the end of phase 1 and lower at the end of phase 2 than in the other groups as follows: median of 2.5%, 2.2% and 2.3% in phase 1 for groups 1, 2 and 3, respectively (P < 0.001); and 1.7%, 2.1% and 2.0% in phase 2, respectively (P < 0.001). End-tidal carbon dioxide values in group 1 were significantly lower at the end of phase 1 and higher at the end of phase 2 than in the other groups as follows: median of 16.5, 31 and 29.5 mmHg in phase 1 for groups 1, 2 and 3, respectively (P < 0.001); and 46.2, 36 and 33.5 mmHg in phase 2, respectively (P < 0.001).ConclusionWhen sevoflurane is administered with tidal volume approximating the airway dead space volume, end-tidal sevoflurane and end-tidal carbon dioxide may not correctly reflect the concentration of these gases in the alveoli, leading to misinterpretation of expired gas data.     

Quality of recovery from anesthesia of patients undergoing balanced or total intravenous general anesthesia. Prospective randomized clinical trial

Study objectivesThe aim of the present study was to assess the quality of recovery from anesthesia of patients subjected to otorhinolaryngological (ORL) surgery under balanced or total intravenous general anesthesia by means of Quality of Recovery-40 (QoR-40) questionnaire.DesignProspective randomized clinical trial.SettingThe setting is at an operating room, a postoperative recovery area, and a hospital ward.PatientsOne-hundred thirty American Society of Anesthesiologists physical status I or II patients scheduled to undergo general anesthesia for ORL interventions under remifentanil, in combination with sevoflurane (balanced technique) or propofol (total intravenous anesthesia).MeasurementsOccurrence of nausea, vomiting, body temperature less than 36°C, and length of stay in the postanesthesia care unit were recorded. The QoR-40 was administered by an investigator blind to group allocation 24 hours after surgery. The quality of recovery, as assessed by the score on the QoR-40, was compared between the groups.Main resultsThere is no difference regarding the QoR-40 score among intravenous and inhalation anesthesia groups (190.5 vs 189.5, respectively; P = .33). Similarly, among the 5 dimensions of the QoR-40, the scores were comparable between the groups. Incidence of hypothermia (P = .58), nauseas or vomits (P = .39), and length of surgery (P = .16) were similar among groups. The evaluation of pain intensity (P = .80) and dose of morphine use in the postanesthesia care unit (P = .4) was also comparable between groups.ConclusionsThe quality of recovery from anesthesia assessed based on the patients' perception did not differ between the ones subjected to either inhalation or intravenous general anesthesia for ORL surgery based on QoR-40 questionnaire assessment.     

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.     

Nível de S100B e disfunção cognitiva após prostatectomia radical laparoscópica assistida por robô: estudo observacional prospectivo

BackgroundThe present study investigated the association between Postoperative Cognitive Dysfunction (POCD) and increased serum S100B level after Robotic‐Assisted Laparoscopic Radical Prostatectomy (RALRP).MethodsThe study included 82 consecutive patients who underwent RALRP. Serum S100B levels were determined preoperatively, after anesthesia induction, and at 30 minutes and 24 hours postoperatively. Cognitive function was assessed using neuropsychological testing preoperatively and at 7 days and 3 months postoperatively.ResultsTwenty‐four patients (29%) exhibited POCD 7 days after surgery, and 9 (11%) at 3 months after surgery. Serum S100B levels were significantly increased at postoperative 30 minutes and 24 hours in patients displaying POCD at postoperative 7 days (p  =  0.0001 for both) and 3 months (p = 0.001 for both) compared to patients without POCD. Duration of anesthesia was also significantly longer in patients with POCD at 7 days and 3 months after surgery compared with patients without POCD (p = 0.012, p = 0.001, respectively), as was duration of Trendelenburg (p = 0.025, p = 0.002, respectively). Composite Z score in tests performed on day 7 were significantly correlated with duration of Trendelenburg and duration of anesthesia (p = 0.0001 for both).ConclusionsS100B increases after RALRP and this increase is associated with POCD development. Duration of Trendelenburg position and anesthesia contribute to the development of POCD.Trial Registry NumberClinicaltrials.gov (N° NCT03018522).     

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.     

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.     

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.     

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.     

Dexmedetomidine is an effective adjuvant to subtenon block in phacoemulsification cataract surgery

BackgroundResearches to find a better adjuvant in regional anesthesia are still continued until now.Dexmedetomidine prolongs anesthesia and analgesia of local anesthetics in various neural blocks as well as the onset of sensory and motor block. The objective of the present study was to evaluate the effect of adding dexmedetomidine to local anesthetics on the sensory and motor block of the subtenon block in patients undergoing phacoemulsification cataract surgery.MethodsSixty patients of American Society of Anaesthesiologists (ASA) grade I–III, aged between 18 and 70 years, scheduled for phacoemulsification cataract surgery were randomly assigned to two equal groups. Group C (control group) received 2 ml of a mixture of 2% lidocaine and 0.5% bupivacaine and Group D (dexmedetomidine group) received 2 ml of a mixture of 2% lidocaine and 0.5% bupivacaine plus dexmedetomidine (0.5 μg/kg). Onset and duration of sensory and motor block was recorded. Pain during administration of anesthesia and during surgery was graded using the verbal analogue scale and recorded. Intraocular pressure, hemodynamic, and sedation parameters were recorded before and after surgery.ResultsOnset of both sensory and motor block was significantly decreased in group D (P < 0.001, P = 0.004 respectively), and duration of sensory and motor block was more prolonged in group D than in group C (P < 0.001, P = 0.961). Pain during administration of anesthesia was significantly lower in group I compared with group II, and more patients in group I compared with group II were pain free, without a significant difference between the two groups. Intraocular pressure was significantly decreased in group D (P < 0.001). More sedation score was observed in group D (P = 0.022). Heart rate and mean arterial blood pressure were insignificantly decreased in group D more than in group C.ConclusionDexmedetomidine is a safe and effective adjuvant to subtenon block in phacoemulsification cataract surgery.     

Magnesium sulfate or diltiazem as adjuvants to total intravenous anesthesia to reduce blood loss in functional endoscopic sinus surgery

Study objectiveThis study was designed to know whether addition of magnesium sulfate (MgSO₄) or diltiazem to total intravenous anesthesia (TIVA) (propofol) aided reduction in blood loss during functional endoscopic sinus surgery (FESS). The secondary outcomes measured were surgeon's assessment of the surgical field and hemodynamics.DesignRandomized, double-blinded, placebo-controlled trial.SettingOperating room.PatientsForty-five American Society of Anesthesiologists I and II adult patients (18-60 years) undergoing FESS.InterventionsAll groups received propofol-fentanyl TIVA. Patients were randomly allocated to 1 of the 3 groups (MgSO₄ group, n = 15; diltiazem group, n = 15; saline group, n = 15).MeasurementsIntraoperative bleeding was quantified, and quality of surgical field was graded. Hemodynamic parameters were recorded.Main resultsAddition of both MgSO₄ and diltiazem significantly reduced blood loss (240 and 350 mL) in comparison to control group (415 mL) (P = .003). The surgical field was significantly better in the MgSO₄ group compared with the diltiazem (P = .028) and saline groups (P = .0001).ConclusionIt was concluded that the addition of both MgSO₄ and diltiazem to TIVA propofol results in significant reduction in blood loss and significant improvement in the quality of surgical field during FESS without causing any adverse effects on the hemodynamics or on the recovery from anesthesia. The surgical field in the MgSO₄ group was significantly better than that in the diltiazem group (P = .04).     

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.     

A randomized comparative study between selective walking spinal anesthesia and general anesthesia for anorectal surgeries in outpatient settings

BackgroundSpinal anesthesia is gradually increasing in ambulatory setting. The limiting factor to the more widespread use of spinal anesthesia in the outpatient setting refers to the effect of residual block. Selective spinal anesthesia (SSA) with low dose lidocaine was compared with modern general anesthesia (GA) technique in day care anorectal surgeries.ObjectiveOur objectives in this study was to compare SSA with propofol and fentanyl based modern GA as regard to 1 – operating conditions 2 – patients’ and surgeon’s satisfaction, 3 – intraoperative, postoperative adverse events and 4 – recovery profiles in ambulatory anorectal surgeries.MethodsProspective randomized clinical study was conducted on 60 patients undergoing elective day case anorectal surgery. The patients were randomly allocated into one of two groups (GA and SSA groups) of 30 patients each. In GA group anesthesia was induced with intravenous fentanyl (2 μg/kg) and propofol (2–3 mg/kg). Airway was secured with I-gel supraglottic airway. Anesthesia was maintained by sevoflurane 1.5–2%, nitrous oxide 60% in oxygen mixture. SSA group patients received spinal anesthesia with lidocaine 20 mg and fentanyl 25 μg to a total volume of 3 ml with sterile water for injection. Intraoperative, postoperative and home adverse events, time to ambulate, time to home discharge, patients’ and surgeon’s satisfactions were statistically compared between both groups.ResultsBoth anesthetic techniques showed acceptable operating conditions and high rate of patients’ satisfaction. Low pain intensity, shorter time to ambulate and home discharge in SSA compared to GA with a p value < 0.001. Intraoperative hemodynamic stability was reported in both groups. No major postoperative or home adverse events in both groups.ConclusionsSSA with low dose lidocaine may be suitable alternative and competitive for modern GA in ambulatory anorectal surgery.     

Preoperative paracetamol infusion reduces sevoflurane consumption during thyroidectomy under general anesthesia with spectral entropy monitoring

BackgroundIntravenous (IV) paracetamol has a significant opioid-sparing effect. We investigated the effect of paracetamol infusion on sevoflurane consumption during entropy monitored general anesthesia.MethodsSixty-two ASA I and II patients undergoing thyroidectomy under general anesthesia were included in a prospective, randomized, double-blind and placebo controlled study. The patients were randomized to receive a slow infusion of either 1 g paracetamol (paracetamol group, n = 31) or saline (control group, n = 31) just before induction of anesthesia. Sevoflurane concentration was titrated to keep the state entropy value between 40 and 50. End-tidal sevoflurane concentration, sevoflurane consumption, recovery characteristics, time to first analgesic request and meperidine consumption during the first 6 postoperative hours were recorded.ResultsThe mean ± SD estimated sevoflurane consumption was significantly lower in the paracetamol treated patients (36.2 ± 15 vs 44.9 ± 13.9 ml, in the control group; p = 0.021). Patients receiving paracetamol had a faster post-anesthetic recovery profile (extubation time, time to eye opening to command and time to state name and mention his/her home address) than the other group (p < 0.05). Mean ± SD time to first analgesic request was significantly prolonged in paracetamol group compared to control group (48.4 ± 14.0 vs 40.7 ± 11.5 min, respectively; p = 0.021). Meperidine consumption was higher in control group than in paracetamol group (28.7 ± 10.2 vs 23.1 ± 9.0 mg, respectively; p = 0.025).ConclusionPreoperative IV paracetamol infusion improved consumption and emergence from entropy monitored sevoflurane anesthesia with enhancement of the early postoperative analgesia.