Hemodynamic Side Effects Research Articles

Intrathecal Isobaric 1% 2-Chloroprocaine versus Hyperbaric 0.5% Bupivacaine in Parturients Undergoing Lower Segment Cesarean Section

Background: Cesarean sections are usually done under spinal anesthesia (SA) using local anesthetics. This study is aimed to compare the efficacy of intrathecal isobaric 1% 2-chloroprocaine (CP) and hyperbaric 0.5% bupivacaine in parturients undergoing lower segment cesarean section (LSCS). Materials and Methods: One hundred parturients aged 18–35 years with the American Society of Anesthesiologists physical status I or II undergoing LSCS were randomly allocated into two groups. Group A (n = 50) received intrathecal isobaric 1% 2-CP 5 ml (50 mg), while Group B (n = 50) received intrathecal hyperbaric 0.5% bupivacaine 2 ml (10 mg) in SA. Onset and duration of both sensory and motor block, highest dermatomal level achieved, time to achieve highest dermatomal level, two-segment regression, duration of analgesia, hemodynamic changes, and side effects were noted. Results: The onset of sensory blockade was significantly faster in Group A (1.66 ± 0.49 min) compared to Group B (3.00 ± 0.58 min) (P < 0.05). Duration of sensory block was significantly shorter in Group A (P < 0.05). The time of two-segment regression was also significantly faster in Group A (41.44 ± 5.41 min) compared to Group B (70.24 ± 10.38 min) (P < 0.05). The onset time of the motor block was significantly faster in Group A (P < 0.05). Duration of motor blockade was significantly shorter in Group A (95.7 ± 9.8 min) as compared to Group B (186.26 ± 13.5 min) (P < 0.05). Duration of analgesia was significantly shorter in Group A (97.22 ± 11.82 min) when compared to Group B (191.58 ± 37.06 min) (P < 0.05). No significant hemodynamic changes and side effects were noted (P > 0.05). Conclusion: Intrathecal 1% 2-CP (50 mg) appears to be a safe and effective alternative, preferably in elective and uncomplicated LSCS, as it has faster onset and predictable sensory block height with shorter but adequate duration of motor block and analgesia.

Relationship between hemodynamic parameters and portal venous pressure in cirrhosis patients with portal hypertension.

Cirrhosis caused by viral and alcoholic hepatitis is an essential cause of portal hypertension (PHT). The incidence of PHT complication is directly proportional to portal venous pressure (PVP), and the clinical research of PVP and its hemodynamic indexes is of great significance for deciding the treatment strategy of PHT. Various techniques are currently being developed to decrease portal pressure but hemodynamic side effects may occur. In this article, the hemodynamic indexes of cirrhotic PHT patients were studied to explore the correlation between the index and PVP and to evaluate the clinical value of Doppler ultrasound in measuring PVP in patients with PHT. This was achieved by selecting 90 cirrhotic PHT patients who underwent transjugular intrahepatic portosystemic shunt in our hospital from June 2015 to September 2019. Fifty healthy people who had a physical examination in the hospital in the same period were selected as the control group. The liver hemodynamic parameters of two groups were measured by Doppler ultrasound, and the cirrhotic PHT patients were graded by the Child–Pugh grading method to evaluate the liver function and measure the PVP value. The results showed that both the central portal vein velocity (PVV) and splenic vein velocity (SVV) of the PHT group were lower than those of the control group. Also, the portal vein diameter (PVD), portal venous flow and splenic vein diameter (SVD) were higher than those of the control group (all Ps < 0.05). Among liver function graded PHT patients, the PVD, PVV, SVD and SVV were significantly different (all Ps < 0.05). Furthermore, the PVP of patients with liver function grades A, B and C was 38.9 ± 1.4, 40.6 ± 5.1 and 42.5 ± 4.8 cmH2O, respectively, with a significant difference. It can be concluded from this study that Doppler ultrasound can be used as a tool for clinical assessment of PHT in cirrhosis patients. Doppler ultrasound showed a good prospect in noninvasive detection of PHT in cirrhosis; however, this technique needs application on large sample population study to validate the results.

Bupivacaine-Fentanyl vs Ropivacaine-Fentanyl: Evaluation of two Spinal Anesthesia Protocols for Emergency Cesarean Section

Objective: Evaluation of the hemodynamic, respiratory and fetal side effects of two protocols for spinal anesthesia (P1: bupivacaine-fentanyl; P2: ropivacaine-fentanyl).&#x0D; Material and Method: Prospective pseudo-randomized study comparing two spinal anesthesia protocols for emergency cesarean section conducted in the operating room of the regional hospital center of Saint Louis in Senegal. Study duration was 4 months. We studied, age, indication for Caesarean section, medical and surgical history, P1 and P2 protocols, hypotension, bradycardia, Apgar scores at birth and at 5min. Univariate and bivariate analysis was performed on the R software.&#x0D; Result: A total of 115 patients were collected, with a mean age of 27.1 years (E: 15 - 45) and a standard deviation of 7.6. Indications for Caesarean section were maternal and fetal dystocia for 67 patients (58%), fetal distress for 39 parturients (34%), and pre-eclampsia for 5 patients (4%). The P1-Bupi spinal protocol was used in 42 patients (36.5%) and the P2-Ropi spinal protocol was used in 73 patients (63.5%). Anesthetic complications such as low blood pressure, bradycardia and desaturation were found in a total of 30 patients, i.e. in 26% of cases. The mean Apgar score at birth for newborns from the P1-Bupi protocol was 8 (Extremes: 7, 9); the mean Apgar score at birth for newborns from the P2-Ropi protocol was 7.5 (Extremes: 2, 10). There was a significantly negative correlation between the P1-bupi protocol and the appearance of hypotension with p-value: 0.04 and a significantly positive correlation between the P2-ropi protocol and the appearance of hypotension with p-value: 0.04.&#x0D; Discussion/ Conclusion: Ropivacaine certainly has a better cardiovascular and neurological tolerance and a better efficacy in terms of analgesia. However, during caesarean sections, it is important to consider the risk of hypotension and possible fetal complications related to its use.&#x0D; Keywords: Ropivacaine - Bupivacaine - Spinal anesthesia - Caesarean section

Intraoperative sedation during regional anaesthesia (Caudal epidural anaesthesia) in paediatric patients: Role of intravenous dexemedetomidine

Introduction: To avoid adverse effects of general anaesthesia, regional anaesthesia (RA) techniques are increasingly being practiced in children for different surgeries. These RA techniques are often combined with moderate degree of sedation to remain child calm and immobile. With limited literature available, we planned a prospective study to evaluate the effectiveness of dexemedetomidine as an intraoperative sedative agent with RA considering its short term sedation and least respiratory depression property. Materials and Methods: Fifty children of 1-8 year of age, ASA grade 1&2 undergoing below umbilical surgery under RA (caudal epidural anaesthesia) were selected and studied. After giving Inj. Ketamine (1mg/kg) intravenously, RA was performed with Inj. Bupivacaine. Then inj. Dexemedetomidine (1mcg/kg) IV was administered as bolus over 10 min followed by continuous infusion (0.4 mcg/kg/hr) till completion of surgery. Perioperative sedation score, vital parameters, peripheral oxygen saturation, respiratory rate and surgeon's satisfaction were observed. The Study was considered complete till stay of patient in PACU for 2hrs. Recovery time and any complications were noted. Results: The quality of sedation and surgeon's satisfaction were good in all children except three children who needed extra dose of sedative. The only adverse effects reported were bradycardia and hypotension in 3 patients which were well managed by reducing the infusion rate. Conclusion: Dexemedetomidine offers an adequate level of sedation in most of the children without haemodynamic or respiratory side effects when used intraoperatively with RA. Keywords: Dexemedetomidine, Ketamine, Regional anaesthesia, Caudal epidural anaesthesia.

Clonidine as an Adjuvant to Bupivacaine for Suprazygomatic Maxillary Nerve Blocks in Cleft lip and Palate Repair: A Randomized, Prospective, Double-Blind Study.

Does clonidine, as adjuvant to bupivacaine for suprazygomatic maxillary nerve blocks, reduce emergence agitation in patients undergoing cleft lip and cleft palate surgery? Randomized, controlled, and double-blind study. Guwahati Comprehensive Cleft Care Center, Guwahati (Assam, India). A total of 124 patients; with a median age of 5 years in the clonidine group (CLG) and 7 years in the control group (CG), who underwent cleft lip or cleft palate surgery were included. Exclusion criteria included lack of consent from patients or their guardians, allergy to local anesthetics, coagulation disorders, local infection at the puncture site before performing the block, and language difficulties or cognitive disorders. Patients were randomized into 2 groups to receive bilateral suprazygomatic maxillary nerve blocks with either a bupivacaine/clonidine mixture for the CLG or bupivacaine alone in the CG. The primary end point was the incidence of emergence agitation. There was a statistically significant difference in the incidence of emergence agitation (30.2% in the CG compared to 15.2% in the CLG; difference of incidences: 15%, 95% CI: 0.1-30.1). The percentage of patients requiring intraoperative Fentanyl was lower in the CLG (10.6% compared to 26.4%; difference of incidences: 15.8%, 95% CI: 1.8-29). No other differences were observed. Further research in a more typically aged children population undergoing cleft surgery is needed. The use of clonidine as an adjuvant to bupivacaine in maxillary nerve block reduces the incidence of emergence agitation and intraoperative opioid consumption without hemodynamic or sedative side effects in patients undergoing cleft lip and palate surgery.

A COMPARATIVE STUDY BETWEEN DEXMEDETOMIDINE AND MIDAZOLAM AS AN ADJUVANT TO INTRATHECAL BUPIVACAINE

Background: Subarachnoid block(SAB) is the common mode of anaesthesia. To prolong its action various adjuvants are being added to local anaesthetics(LA). In this study we compared the efficacy and safety of midazolam and dexmedetomidine as an adjuvant to intrathecal 0.5% hyperbaric (H) bupivacaine. Material &amp; Methods: 80 ASA grade I or II patients of either sex scheduled for lower limb or lower abdominal surgeries were randomly allocated into two groups, Group D &amp; Group M. In group D, patients received 3ml of 0.5% (H) bupivacaine + dexmedetomidine 5mcg in 0.5ml normal saline(NS). While group M received 3ml of 0.5% (H) bupivacaine + 2mg midazolam ( 0.4ml of 5mg/ml) + 0.1ml of NS. Onset of sensory &amp; motor block and duration of sensory &amp; motor block were recorded. Patients were monitored for any haemodynamic changes and side effect. Result: Duration of both sensory &amp; motor blockade was significantly prolonged in group D as compared to group M. There was no clinically significant difference observed among both the groups in respect to hemodynamic parameters, sedation and side effect. Conclusion: Dexmedetomidine as an adjuvant to intrathecal bupivacaine (H) was better as compared to midazolam. It significantly prolongs the duration of analgesia postoperatively without any significant side effect.

Comparison of the benefits and hemodynamic side effects of oxytocin between intravenous infusion with and without bolus injection during caesarean section

The aim of this study was to compare the benefits and hemodynamic side effects of oxytocin between intravenous infusion with and without a bolus injection during a caesarean section. Women with singleton pregnancies who underwent caesarean sections under spinal anaesthesia were included. Oxytocin was administered by an iv bolus injection (5 U) followed by an intravenous infusion (10 U of oxytocin in 500 mL normal saline); this was switched to just an intravenous infusion. The amount of blood loss did not differ between the groups. In a multivariate analysis, the adjusted odds ratios for the risk of hypotension (≥20% reduction of systolic BP) and tachycardia (heart rate ≥100 bpm) were 4.5 (95% confidence interval [CI], 1.6–12.5) and 3.7 (95%CI 1.9–7.2) in the iv bolus group, respectively, compared with the just the infusion group. The oxytocin administration by iv bolus injection did not decrease blood loss and increased the rate of hemodynamic side effects. Impact statement What is already known on this subject? Oxytocin is used as the first-line uterotonic treatment to prevent a postpartum haemorrhage in women undergoing Caesarean Sections. Oxytocin is known to relax vascular smooth muscle, which can cause hypotension and tachycardia. The protocols for administering oxytocin during CS vary by institution. What do the results of this study add? Combined treatment with oxytocin by iv bolus injection (5 U) followed by iv infusion (10 U of oxytocin in 500 mL normal saline) during CS increased the risk of developing adverse hemodynamic side effects, including hypotension, tachycardia, and the need for vasopressors, without any benefit in the control of intraoperative blood loss in comparison to iv infusion alone. What are the implications of these findings for clinical practice and/or further research? We should abandon the iv bolus injection of oxytocin during CS, especially for women undergoing an elective CS who are not in labour.

Comparison of Tramadol and Pethidine for Control of Shivering Following Central Neuraxial Blockade

Background: Central neuraxial blockade is associated with shivering in 40-60% of the patients. A popularly used drug to control shivering is pethidine. The present study was conducted to evaluate the effect of tramadol on shivering and compare it with the efficacy of pethidine. The study was also intended to compare the haemodynamics, complications and recurrence of shivering with the use of pethidine and tramadol. Subjects and Methods: This prospective comparative study was conducted in Department of Anaesthesiology, Akash Institute of Medical Sciences and Research Centre, Devanahalli, Bengaluru. In this study, 80 consenting patients of either gender, aged between 20-60 years, in American Society of Anesthesiologists (ASA) Grades 1, 2 and 3 according to ASA who experienced shivering during or immediately after elective surgeries under central neuraxial blockade (spinal, epidural and combined spinal and epidural) were randomized to receive either pethidine 1mg/kg or tramadol 1 mg/kg for control of shivering. The time interval for the onset of shivering after regional anaesthesia, onset of disappearance of shivering after drug administration, complete disappearance of shivering, hemodynamics, recurrence of shivering and complications were recorded. Results: There was no statistical difference in the onset of disappearance between the 2 groups (p=0.615). Time taken for complete disappearance of shivering after 5 minutes interval period was statistically more in Group T (17.5% vs 5% in Group P) with p= 0.154. Recurrence of shivering occurred more in the tramadol group as compared to pethidine group which was strongly significant statistically (27.5% vs 5.0%) with p=0.006. However the incidence of complications was higher with pethidine with a greater drop in mean blood pressure, increased indicators of respiratory depression, more sedation, greater nausea, vomiting and itching. Conclusion: The present study results may conclude that tramadol is an effective drug in the control of shivering with more stable hemodynamic and fewer side effects such as sedation, respiratory depression, nausea, vomiting and itching. However one must be prepared for a slight delay in the onset of its action and expect a recurrence of shivering which may require further therapy. Pethidine, with its equal efficacy may be advocated in patients allergic to tramadol and where sedation is desirable.

A comparative study of epidural ropivacaine 0.2% with nalbuphine and ropivacaine 0.2% with fentanyl in unilateral total knee replacement surgeries

Background: Total knee replacement (TKR) is associated with intense early postoperative pain. Epidural opioids have unique advantages over conventional, intermittent IV/ IM administration, in that sooner in the postoperative period. Materials and methods: This is prospective, double blind study where twenty patients in group A received Ropivacaine 0.2% with Nalbuphine and twenty patients in group B received Ropivacaine 0.2% with Fentanyl. Patients were assessed for hemodynamic changes, VAS scores, sedation scores and side effects. Result: There was no statistically significant difference in the baseline parameters between the two groups. Rescue analgesics required in the first 24 hours of postoperative period in group A were significantly higher (p < 0.01) when compared with group B. Nalbuphine group had a good sedative action than Fentanyl group (P=0.04). Conclusion: Fentanyl group is better in terms of quality of postoperative analgesia, lesser incidence of side-effects and patient satisfaction.

Comparison of intrathecal dexmedetomidine and intrathecal fentanyl as an adjuvant with hyperbaric bupivacaine for spinal anaesthesia in lower limb surgeries: A prospective randomized clinical trial

Subarachnoid block is the most common technique employed for lower limb surgeries. When used as an adjuvant to intrathecal local anaesthetic, both fentanyl and dexmedetomidine have the ability increase perioperative analgesia. This study aimed to compare and evaluate the effective profile of dexmedetomidine and fentanyl as an adjuvant to intrathecal bupivacaine in lower limb surgeries.In this clinical trial, 90 patients undergoing elective lower limb surgeries under spinal anaesthesia were randomly allocated to two groups. In group BD, the patients received 0.5% hyperbaric bupivacaine 12.5 mg + dexmedetomidine 5 mcg. In group BF, the patients received 0.5% hyperbaric bupivacaine 12.5 mg + fentanyl 25 mcg. Onset, duration, regression of sensory and motor blockade along with haemodynamic variations and side effects were compared between both the groups.The onset of sensory block was earlier in Group BD, while the onset of motor block was earlier in Group BF. However, the differences with the onset of sensory and motor block remained statistically insignificant (P = 0.4988 and 0.4918). The mean time for two-segment sensory regression, time for regression to L1 dermatome and duration of motor block was significantly less in Group BF. The analgesic requirement in the early postoperative period and the haemodynamic variation remained statistically insignificant in both the groups. Intrathecal dexmedetomidine provided prolonged sensory as well as motor blockade thereby enhancing postoperative analgesia.

Ultrasound guided Erector Spinae Plane block versus thoracic epidural for post-mastectomy analgesia

Background: Thoracic epidural analgesia (TEA) was considered as the gold standard for postoperative analgesia in thoracic surgeries, particularly in bilateral procedures. However, it isn't routinely used as it is associated with some haemodynamic side effects. Erector spinae plane (ESP) block is recognized as a promising post-operative analgesia technique. Aim of the study: Primary outcome was to compare post-mastectomy pain control in TEA and ESP block groups, and secondary outcomes were to compare post-operative hypotension, number of morphine boluses and patient satisfaction. Patients and Methods: Sixty female patients scheduled for elective mastectomy were enrolled in this study. Patients were allocated into 2 groups, 30 patients each. Group (TE) patients underwent ultrasound guided single shot TEA, while group (ES) were handled with ultrasound guided single shot ESP block. Peri-opertaive details, Post-operative hypotension, visual analogue scale (VAS) assessment of pain, number of post-operative morphine boluses, and patient satisfaction were recorded. Results: Time needed to give block was shorter in group (ES) (p < 0.001). Group (ES) patients reported significantly lower pain scores according to VAS (P<0.001). Hypotension was more recorded in group (TE) patients, with statistical significance at 0 point (p < 0.001). Required post-operative morphine boluses were significantly lower in group (ES), as 3.3% of patients received 3 boluses compared to 27% in group (TE) (p=0.01). More patients were highly satisfied in group ES (60%) than group TE (30%) (p=0.037). Conclusion: Ultrasound-guided ESP block is a choice with better outcome in patients undergoing elective mastectomy as regards lower frequency of hypotension, better efficiency and patient satisfaction.

Effect of intravenous versus intrathecal dexmedetomidine on the characteristic of spinal anesthesia in patients undergoing infra umbilical surgeries

Background: Dexmedetomidine have been used as an adjuvant to local anaesthetic in subarachnoid block and as intravenous medication for postoperative pain relief and sedation. In higher doses, it may produce adverse effect on haemodynamic. Aim: This study compares the effects of low-dose intravenous (IV) dexmedetomidine or Intrathecal dexmedetomidine with hyperbaric bupivacaine on spinal characteristic, total duration of analgesia, and sedation. Objective: the primary objective of our study evaluate the total duration of analgesia and a secondary objective was to assess and compare the onset time and duration of sensory block, changes in hemodynamic parameter and side effect. Materials and Methods: In this prospective, randomised, double-blinded study, 240 American Society of Anaesthesiologist Status I and II patients were randomly allocated into two groups: Group IV: Patients received dexmedetomidine 0.5 μg/kg body weight diluted up to 10 ml with normal saline intravenously by infusion pump and 3 ml of 0.5% hyperbaric bupivacaine diluted in 0.5 ml of normal saline intrathecally.Group IT: Patients received 10 ml of normal saline intravenously by infusion pump and 3 ml of 0.5% hyperbaric bupivacaine with 0.5 ml (5 μgm) of dexmedetomidine intrathecally. Onset and duration of sensory and motor block, first request for analgesia, hemodynamic, VAS score, and sedation score were assessed. Results: Time to two segment regression was more in group IT (127.7 ± 16.69 min) as compared to group IV (116 ± 16.2 min). Total duration of analgesia was also prolonged in group IT (274.68 ± 58.21 min) than group IV (211.37 ± 32.87 min)(P

Pretreatment with Nalbuphine Prevents Sufentanil-Induced Cough During the Anesthesia Induction: A Randomized Controlled Trial.

BackgroundSufentanil-induced cough is frequent during the induction of anesthesia. The aim of this research was to assess the influence of pretreatment with nalbuphine on sufentanil-induced cough.Patients and MethodsA total of 210 American Society of Anesthesiologists (ASA) I–II patients who are 18–70 years old and scheduled for elective surgery were randomly divided into two groups. Group N was pretreated with 0.3 mg/kg nalbuphine at 150 s before induction with sufentanil, and Group C received the same volume of normal saline as the placebo. We assessed the incidence and severity of cough 2 minutes after sufentanil administration. We also recorded the hemodynamic changes and side effects of sufentanil after sufentanil administration.ResultsNo patients had cough in group N, and 30 patients had cough in group C (degree of cough: mild 8; moderate 10; severe 12). The incidence and severity of cough in group N were significantly lower than those in group C.ConclusionPretreatment with 0.3 mg/kg nalbuphine significantly suppressed the incidence and intensity of sufentanil-induced cough.

Impact of General Anesthesia Guided by State Entropy (SE) and Response Entropy (RE) on Perioperative Stability in Elective Laparoscopic Cholecystectomy Patients-A Prospective Observational Randomized Monocentric Study.

Laparoscopic cholecystectomy is one of the most frequently performed interventions in general surgery departments. Some of the most important aims in achieving perioperative stability in these patients is diminishing the impact of general anesthesia on the hemodynamic stability and the optimization of anesthetic drug doses based on the individual clinical profile of each patient. The objective of this study is the evaluation of the impact, as monitored through entropy (both state entropy (SE) and response entropy (RE)), that the depth of anesthesia has on the hemodynamic stability, as well as the doses of volatile anesthetic. A prospective, observational, randomized, and monocentric study was carried out between January and December 2019 in the Clinic of Anesthesia and Intensive Care of the “Pius Brînzeu” Emergency County Hospital in Timișoara, Romania. The patients included in the study were divided in two study groups: patients in Group A (target group) received multimodal monitoring, which included monitoring of standard parameters and of entropy (SE and RE); while the patients in Group B (control group) only received standard monitoring. The anesthetic dose in group A was optimized to achieve a target entropy of 40–60. A total of 68 patients met the inclusion criteria and were allocated to one of the two study groups: group A (N = 43) or group B (N = 25). There were no statistically significant differences identified between the two groups for both demographical and clinical characteristics (p > 0.05). Statistically significant differences were identified for the number of hypotensive episodes (p = 0.011, 95% CI: [0.1851, 0.7042]) and for the number of episodes of bradycardia (p < 0.0001, 95% CI: [0.3296, 0.7923]). Moreover, there was a significant difference in the Sevoflurane consumption between the two study groups (p = 0.0498, 95% CI: [−0.3942, 0.9047]). The implementation of the multimodal monitoring protocol, including the standard parameters and the measurement of entropy for determining the depth of anesthesia (SE and RE) led to a considerable improvement in perioperative hemodynamic stability. Furthermore, optimizing the doses of anesthetic drugs based on the individual clinical profile of each patient led to a considerable decrease in drug consumption, as well as to a lower incidence of hemodynamic side-effects.

Comparative study of outcome in epidural bupivacaine with buprenorphine and bupivacaine with fentanyl in lower limb surgeries

Pain is a complex subjective experience which has been proved difficult to measure in reproducible way. It is found that operative pain is more severe after surgery and thereafter gradually diminishes over next 24 hours. Providing effective analgesia for patients undergoing major surgery is a daily challenge for most anesthetists. The treatment of acute postoperative pain is a major health care issue. Epidural anesthesia /analgesia is one of the best accepted techniques for lower limb surgeries as it provides good sensory and motor block, decreases adverse physiologic responses to surgery such as autonomic hyperactivity, cardiovascular stress, tissue breakdown, increased metabolic rate, pulmonary dysfunction, and immune system dysfunction. Intraoperatively, sensory and motor blockade, quality and duration of Postoperative analgesia, hemodynamic and respiratory parameters, side effects like nausea, vomiting, respiratory depression, urinary retention. In this observational study an effort was made to study the peri operative analgesic efficacy of Inj. buprenorphine and Inj. fentanyl with 0.5 % Bupivacaine epidurally for lower limb surgeries. There were no significant hemodynamic and respiratory side effects in either of the groups. The postoperative analgesia was definitely of a longer duration with the Buprenorphine group. So it is concluded that epidural Buprenorphine is better in providing prolonged satisfactory postoperative analgesia as compared to Inj. Fentanyl. Regarding the side effects, the incidence of nausea and vomiting was more in buprenorphine as compared to fentanyl group, which could be easily treated with antiemetic’s like Ondansetron. Both buprenorphine and fentanyl along with bupivacaine 0.5% can be given epidurally as a single shot injection for perioperative analgesia obviating the need for epidural catheter.

Efficacy of dexmedetomidine used as an adjuvant to 0.5% ropivacaine in ultrasound-guided supraclavicular brachial plexus block for upper limb surgeries

Background: Supraclavicular brachial plexus block (SCBPB) has gained popularity with the addition of various adjuncts to local anesthetics. This study aimed to evaluate the efficacy of dexmedetomidine as an adjuvant to 0.5% ropivacaine in ultrasound-guided (USG) SCBPB. Materials and Methods: One hundred patients of either sex, belonging to the American Society of Anesthesiologists physical status I or II, aged between 15 and 65 years and scheduled for elective upper arm surgery under USG SCBPB were enrolled. Patients were randomly allocated into two groups (n = 50). Both groups received 16 ml (120 mg) 0.75% ropivacaine with 1 μg/kg dexmedetomidine diluted in 8 ml normal saline (NS) (Group Ropivacaine Dexmedetomidine [RD]) or with 8 ml NS only (Group R). The primary outcome measure was the duration of analgesia, whereas secondary outcome measures were onset and duration of sensory and motor block, quality of anesthesia, sedation score, hemodynamic changes, and side effects. Statistical analysis was performed using unpaired Student's t-test or nonparametric Mann–Whitney test and Chi-square test. Results: The duration of analgesia was significantly prolonged in Group RD (730.70 ± 51.62 min) compared to Group R (388.30 ± 41.66 min), (P 0.05). Conclusion: Dexmedetomidine provides the prolonged duration of analgesia along with faster onset as well as prolonged duration of both sensory and motor block without any significant hemodynamic changes and side effects.

A study on compare the efficacy of epidural, bupivacaine with buprenorphine and bupivacaine with fentanyl in lower limb surgeries

Background and Objectives: Pain is a complex subjective experience which has proved difficult to measure in reproducible way. It is found that operative pain is more severe after surgery and thereafter gradually diminishes over next 24 hours. Providing effective analgesia for patients undergoing major surgery is a daily challenge for most anaesthetists. Methods: 60 patients in the age group 20-60 years belonging to ASA I-II posted for elective lower limb surgeries were studied. The patients were divided in to two groups of 30 each. Group A- 0.5% Bupivacaine 15ml (75mg) with 0.5ml (150 ug) Buprenorphine (preservative free) Group B- 0.5% Bupivacaine 15ml (75mg) with 1ml (50ug) Fentanyl(preservative free) Intraoperatively, sensory and motor blockade, quality and duration of Postoperative analgesia, hemodynamic and respiratory parameters, side effects like nausea, vomiting, respiratory depression, urinary retention, pruritus were studied. Patients were monitored for 48 hours postoperatively to look for any delayed complications. Results: Addition of 50 mcg fentanyl to 0.5 % bupivacaine (group B) resulted in faster onset of sensory and motor blockade which was statistically insignificant compared to 150mcg buprenorphine with 0.5% bupivacaine (group A). Duration of analgesia was significantly longer in Group A with mean duration of 766.6 minutes as compared to 471 min in Group B. Both the groups provided a good hemodynamic stability. There was no significant respiratory depression in both the groups. The incidence of Nausea and vomiting was more in group A (40 %) compared to group B (10 %) and mild pruritus which did not require any treatment was more in group B (10%) compared to none in group A. Conclusion: In this comparative study an effort was made to study the peri operative analgesic efficacy of Inj. Buprenorphine and Inj. Fentanyl with 0.5 % Bupivacaine epidurally for lower limb surgeries. There were no significant hemodynamic and respiratory side effects in either of the groups. Both buprenorphine and fentanyl along with bupivacaine 0.5% can be given epidurally as a single shot injection for perioperative analgesia obviating the need for epidural catheter

Effectiveness of an oral versus sublingual loading dose of nifedipine for tocolysis.

To determine the effectiveness of an oral versus sublingual loading dose of nifedipine for tocolysis. An open, randomized clinical trial conducted between March 1, 2013, and April 31, 2014. Participants were pregnant women with a diagnosis of premature labor, single live fetus, topical pregnancy, gestational age 24-36weeks, normal fetal vitality, cervical dilatation less than or equal to 4cm, cervical effacement less than or equal to 80%, and intact amniotic membranes. They were randomized into two groups, oral and sublingual nifedipine, 20mg loading dose, repeated every 30minutes (maximum dose of 60mg). The primary endpoint was the time until tocolysis and the secondary endpoints were the effectiveness of tocolysis within 90minutes, 12hours, and 48hours; premature delivery within 48hours; and maternal hemodynamic parameters and side effects. There were 80 patients randomized to oral (n=40) and sublingual (n=40) nifedipine. The time required for tocolysis was significantly less with sublingual nifedipine (160minutes vs 340minutes; P=0.0003). Sublingual nifedipine was also more successful than oral nifedipine at inhibiting premature labor within 90minutes (n=8 [20.0%] vs n=1 [2.5%], P=0.014). There was no statistically significant difference between the groups for the other secondary endpoints. Compared with oral administration, a sublingual loading dose of nifedipine resulted in faster tocolysis in patients with premature labor. Brazilian Clinical Trials Registry (ReBEC): U1111-11566186.

The Cushing reflex and the vasopressin-mediated hemodynamic response to increased intracranial pressure during acute elevations in intraabdominal pressure

BackgroundAbdominal compartment syndrome has been linked to detrimental hemodynamic side effects that include increased intracranial pressure and diminished renal function, but the mechanisms behind this continue to be elucidated. In this study, we sought to investigate any direct association between acute elevations in intra-abdominal pressure and intracranial hypertension during experimentally induced abdominal compartment syndrome and between acutely elevated intracranial pressure and the hemodynamic response that might be elicited by a vasopressin-induced Cushing reflex affecting urine osmolality and urine output. The aim of this study is to explain the Cushing reflex and the vasopressin-mediated hemodynamic response to intracranial pressure during acute elevations in intra-abdominal pressure. MethodsWe measured intra-abdominal pressure, intrathoracic pressure, optic nerve sheath diameter as an indirect sign of intracranial pressure, vasopressin levels in blood, urine osmolality, and urine output at 4 time points during surgery in 16 patients undergoing sleeve gastrectomy for morbid obesity. Values for the 4 time points were compared by repeated-measures analysis of variance. ResultsMore than 50-fold elevations in serum vasopressin paralleled increases in optic nerve sheath diameter, rising throughout prepneumoperitoneum and tapering off afterward, in conjunction with a marked decrease in urine but not serum osmolality. Mean arterial pressure rose transiently during pneumoperitoneum without elevated positive end-expiratory pressure but was not significantly elevated thereafter. ConclusionsThese findings support our hypothesis that the oliguric response observed in abdominal compartment syndrome might be the result of the acutely elevated intra-abdominal pressure triggering increased intrathoracic pressure, decreased venous outflow from the central nervous system, increased intracranial pressure, and resultant vasopressin release via a Cushing reflex.

Interleukin 1 alpha administration is neuroprotective and neuro-restorative following experimental ischemic stroke

BackgroundStroke remains a leading cause of death and disability worldwide despite recent treatment breakthroughs. A primary event in stroke pathogenesis is the development of a potent and deleterious local and peripheral inflammatory response regulated by the pro-inflammatory cytokine interleukin-1 (IL-1). While the role of IL-1β (main released isoform) has been well studied in stroke, the role of the IL-1α isoform remains largely unknown. With increasing utilization of intravenous tissue plasminogen activator (t-PA) or thrombectomy to pharmacologically or mechanically remove ischemic stroke causing blood clots, respectively, there is interest in pairing successful cerebrovascular recanalization with neurotherapeutic pharmacological interventions (Fraser et al., J Cereb Blood Flow Metab 37:3531–3543, 2017; Hill et al., Lancet Neurol 11:942–950, 2012; Amaro et al., Stroke 47:2874–2876, 2016).MethodsTransient stroke was induced in mice via one of two methods. One group of mice were subjected to tandem ipsilateral common carotid artery and middle cerebral artery occlusion, while another group underwent the filament-based middle cerebral artery occlusion. We have recently developed an animal model of intra-arterial (IA) drug administration after recanalization (Maniskas et al., J Neurosci Met 240:22–27, 2015). Sub groups of the mice were treated with either saline or Il-1α, wherein the drug was administered either acutely (immediately after surgery) or subacutely (on the third day after stroke). This was followed by behavioral and histological analyses.ResultsWe now show in the above-mentioned mouse stroke models (transient tandem ipsilateral common carotid artery (CCA) and middle cerebral artery occlusion (MCA) occlusion, MCA suture occlusion) that IL-1α is neuroprotective when acutely given either intravenously (IV) or IA at low sub-pathologic doses. Furthermore, while IV administration induces transient hemodynamic side effects without affecting systemic markers of inflammation, IA delivery further improves overall outcomes while eliminating these side effects. Additionally, we show that delayed/subacute IV IL-1α administration ameliorates functional deficit and promotes neurorepair.ConclusionsTaken together, our present study suggests for the first time that IL-1α could, unexpectedly, be an effective ischemic stroke therapy with a broad therapeutic window.