Hemodynamic Side Effects Research Articles

Comparative efficacy of epidural clonidine versus epidural fentanyl for treating breakthrough pain during labor: a randomized double-blind clinical trial

BackgroundBreakthrough pain during neuraxial labor analgesia is typically alleviated with additional administration of epidural local anesthetics, with or without adjuvants. Sometimes avoiding neuraxial opioids may be warranted and clonidine is an alternative. In a randomized double-blind trial we compared the efficacy of clonidine versus fentanyl, added to bupivacaine, for the management of breakthrough pain. MethodsTerm parturients (n=98) receiving bupivacaine 0.0625% with fentanyl 2 μg/mL at 12 mL/h, a patient-administered bolus of 5 mL at lockout 6–10 min and a maximum of four boluses per hour, and experiencing breakthrough pain ≥5/10, were randomized to receive a 10 mL bolus containing 12.5 mg bupivacaine and either clonidine 100 μg or fentanyl 100 μg. The primary outcome was ‘success’ of study drug treatment, defined as a pain score reduction ≥4/10 within 15 min of administration. Maternal hemodynamics and fetal heart rate were documented for two hours after treatment. ResultsThere was no significant difference between groups in success rates (66.0% after clonidine (n=47) vs 74.5% after fentanyl (n=51), P=0.48) or in the incidence of hypotension (systolic blood pressure ≤80% of baseline or <90 mmHg) or sedation at 15 min, with 2/51 and 1/47 subjects in the fentanyl and clonidine groups, respectively, receiving phenylephrine. ConclusionEpidural clonidine 100 μg was not superior to fentanyl 100 μg for decreasing pain scores within 15 min of co-administration with bupivacaine 0.125% for intrapartum breakthrough pain. The analgesic efficacy and hemodynamic side effects did not significantly differ.

Ivabradine as an Adjunct for Refractory Junctional Ectopic Tachycardia Following Pediatric Cardiac Surgery: A Preliminary Study.

Junctional ectopic tachycardia (JET) is a relatively common narrow complex rhythm typically characterized by atrioventricular dissociation or retrograde atrial conduction in a 1:1 pattern. Junctional ectopic tachycardia can be a life-threatening disorder, causing severe hemodynamic compromise and increased morbidity and mortality. The treatment of refractory JET can be very difficult, even with multimodal therapeutic interventions. The purpose of this study was to assess the role of ivabradine in cases of JET refractory to amiodarone and esmolol. A total of 480 congenital heart surgeries were carried out at our center in 2017. Twenty (4.16%) patients had postoperative JET. Among these, five infants, aged 7 to 12 months (median: 8 months), had refractory JET. These patients (three tetralogy of Fallot, one ventricular septal defect, one complete atrioventricular septal defect) were treated with oral ivabradine in the dose range of 0.1 to 0.2 mg/kg/12 h as an adjunct to amiodarone. All five patients achieved rate reduction and eventual conversion to sinus rhythm. Mean duration to achieve heart rate of <140 bpm after initiation of ivabradine therapy was 16.8 hours (±7.2 hours), while mean duration to achieve sinus rhythm was 31.6 hours (±13.6 hours). No patient had any recurrence of JET. No patient exhibited any hemodynamic derangement nor side effects attributable to oral ivabradine. Oral ivabradine has the potential to be used as an adjunct to amiodarone in the treatment of JET in infants after surgery for congenital heart disease.

Choice of anti-hypertensive treatment in HELLP syndrome at ehu Oran

In Africa and Asia, nearly 10% of maternal deaths are associated with hypertensive disorders during pregnancy. Among the hypertensive disorders, HELLP syndrome (Hemolysis Elevated Liver Enzymes, Low Platelets: HS) represents a significant cause of severe morbidity and long-term disability. Our goal was to evaluate the management of antihypertensive treatment in HS syndrome. Our prospective, monocentric study included patient with a HS between January 2013 and December 2016. Our protocol was based on the antihypertensive molecules available in our institution administered orally: alfa methyl-dopa, nicardipine and acebutolol and intravenously: most often nicardipine and magnesium sulfate when pre-eclampsia was diagnosed. One hundred and sixty-five patients with HS were admitted; mean age: 32 ± 6.33 years old, the average parity was 2 ± 1, the average term for onset of pre-partum HS was 32 weeks of amenorrhea. At admission, 112 patients (68%) had epigastric pain in the upper right thoracic quadrant; severe hypertension with arterial pressure values > 160/110 mmHg was found in 116 patients (70.3%), headache in 83 patients (50%), visual disturbances in 27 (16.4%), confusion and hyper-reflexivity in 43 patients (26.1%). Magnesium sulfate was used in 68 patients. 96 patients received nicardipine alone intravenously. The combination of magnesium sulfate and nicardipine was performed in 27 patients, without significant deleterious hemodynamic or respiratory side effects. The management of hypertension was done according to a codified protocol with molecules available in each Maghreb establishment; it requires deep involvement of the paramedical staff.

Transüretral Cerrahide Spinal Anestezide Ropivakain ve Levobupivakainin Karşılaştırılması

Objective. It was aimed to compare the efficacy of levobupivacaine and ropivacaine during transurethral resection of the prostate under spinal anesthesia.Material and Methods: In this prospective, randomized, double-blind trial, 40 patients undergoing elective transurethral resection of the prostate under spinal anesthesia were randomized into two groups. 0.75% levobupivacaine 7.5mg (Group I) and 0.75% ropivacaine 7.5mg (Group II) were used intrathecally.Results: There were no differences the time for sensorial block to reach T10, maximum sensorial block level, the time to reach maximum block level, motor block level at the end of surgery between the groups. The two-segment regression time was 53.75 ± 10.75 minutes in Group I and 73.25 ± 15.50 minutes in Group II (p&amp;lt;0.000), the regression time to reach T12 was 70.25±17.05 minutes in Group I and 88.00 ± 20.42 in Group II (p&amp;lt;0.005), the duration of the motor block was 60.75±36.93 minutes in Group I and 92.00±26.03 minutes in Group II (p&amp;lt;0.004). There was not any significant difference between groups with regard to hemodynamic data and side effects. Conclusions: This study showed that, low-dose levobupivacaine and ropivacaine used in transurethral surgery have similar effects and delivers sufficient and reliable anesthesia. Use of ropivacaine constitutes an advantage since the motor blockage level is shorter with it. As a result, it was concluded that low-dose ropivacaine and levobupivacaine used in transurethral surgery had similar effects, provided adequate and reliable anesthesia, but ropivacaine was an advantage because of the short duration of motor block.

A newly developed anesthetic based on a unique chemical core

Intravenous anesthetic agents are associated with cardiovascular instability and poorly tolerated in patients with cardiovascular disease, trauma, or acute systemic illness. We hypothesized that a new class of intravenous (IV) anesthetic molecules that is highly selective for the slow type of γ-aminobutyric acid type A receptor (GABAAR) could have potent anesthetic efficacy with limited cardiovascular effects. Through in silico screening using our GABAAR model, we identified a class of lead compounds that are N-arylpyrrole derivatives. Electrophysiological analyses using both an in vitro expression system and intact rodent hippocampal brain slice recordings demonstrate a GABAAR-mediated mechanism. In vivo experiments also demonstrate overt anesthetic activity in both tadpoles and rats with a potency slightly greater than that of propofol. Unlike the clinically approved GABAergic anesthetic etomidate, the chemical structure of our N-arylpyrrole derivative is devoid of the chemical moieties producing adrenal suppression. Our class of compounds also shows minimal to no suppression of blood pressure, in marked contrast to the hemodynamic effects of propofol. These compounds are derived from chemical structures not previously associated with anesthesia and demonstrate that selective targeting of GABAAR-slow subtypes may eliminate the hemodynamic side effects associated with conventional IV anesthetics.

A comparative study of ketofol and fentafol for evacuation of retained products of conception (ERPC)

Background: Intravenous balanced anesthesia (IVA) is desirable during the evacuation of retained products of conception (ERPC) to avoid the use of inhalational anesthetics agents that may cause uterus relaxation, the possibility of bleeding, and the risk of uterus perforation. Objectives: The aim of this study was to compare the efficacy and safety of ketofol (a mixture of propofol and ketamine) versus fentafol (a mixture of propofol and fentanyl) during the ERPC. Methods: A double-blind, randomized comparative study was conducted among a total of 60 women of childbearing age categorized as grades I and II according to the American Society of Anesthesiologist (ASA), presented for ERPC. The patients were selected and randomized blindly into two groups (K group and F group), with 30 patients in each group. The K group was given ketofol (1ml containing 5mg of propofol and 5mg of ketamine) and F group was given fentafol (1ml containing 5mg propofol and 5mcg fentanyl). An intravenous loading dose of ketofol or fentafol was given slowly, with doses ranging from 1ml to 2ml/10kg, to reach level 5 or 6 of the Ramsay Scale of Sedation (RSS), followed by small incremental doses which were given when RSS dropped to 4. Hemodynamic parameters, success, and side effects were assessed throughout the procedures. Results: K group demonstrated a significant increase in heart rate (HR) and blood pressure (BP), compared to significant decreases in the F group. Decreases in oxygen saturation (SpO 2 ) and respiratory rate (RR) were observed more in the F group. However, no patients developed hypertension, hypotension, apnea, hypoxemia or serious adverse effects. Ketofol showed less propofol consumption and a short recovery time. Conclusions: Both ketofol and fentafol offer optimum conditions for ERPC. Ketofol is characterized by more stable hemodynamic parameters, a smaller dosage and faster recovery. [ Ethiop.J. Health Dev. 2019; 33(2):88-93] Key words: Propofol, ketamine, fentanyl, retained products of conception (RPC), ketofol, fentafol

A study to compare the haemodynamic stability and side effects when using 0.5 percent levobupivacaine vs combination of 0.5 percent levobupivacaine and hyaluronidase, in ultrasound guided axillary brachial plexus block for forearm and hand surgeries

Background: One key component of enhanced recovery protocols is standardized analgesic and anesthetic regimens. Peripheral nerve blocks in particular help in enhanced recovery of the patient by the possibility of early mobilization of the patient. Local Anesthetics are drugs that prevent conduction of electrical impulses on the membranes of nerve and muscle. Adjutants are pharmacological drugs that when co- administered with local anaesthetic agents may improve speed of onset as well as the quality and duration of analgesia. Hyaluronidase drug works as a spreading factor by increasing tissue membrane permeability and reducing the viscosity. Objective: To find if there are any hemodynamic problems or any side effects when Levobupivacaine is used alone compared to Levobupivacaine when used with Hyaluronidase. Materials and Methods: After institutional ethical committee clearance 60 ASA PS class 1 and 2 adult patients in age group of 18 to 60 years who underwent elective upper limb surgeries in Sridevi Institute of Medical Sciences, Tumkur from October 2017 to October 2019 were included. Any patient with history of bleeding disorders, documented neuromuscular disorders, known allergy to Local anesthetics drugs, Psychiatric patients and if on anticoagulants were excluded from the study. Patients were alternately assigned to two groups Group A and Group B each containing 30 patients. Patients undergoing Ultrasound guided Axillary Brachial plexus block with. Group A: 20 ml of 0.5% Levobupivacaine and Hyaluronidase 300 Units (15U/ml of local anesthetic). Group B: 20 ml of 0.5% Levobupivacaine. The patients were given Ultrasound guided Axillary brachial plexus block. Hemodynamic parameters like pulse rate, non-invasive blood pressure, oxygen saturation was monitored. Mean arterial blood pressure (MAP) and pulse rate (PR), oxygen saturation was recorded before application of the block as well as immediately after block & 3 min intervals until the end of the operation. Any drop-in blood pressure more than 20% from the baseline signifies hypotension and was managed with Inj ephedrine 6 mg. Any decrease in pulse rate of less than 60 beats /min was managed with Inj. atropine 0.6mg. Any other complication other than this was noted. Results: Mean pulse rate was similar in both groups with Group A 81.87 and Group B 81.43. Mean arterial pressure between 2 groups was also similar MAP of Group A 105.3 and Group B 105.07. Conclusion: No significant hemodynamic changes were noted between both the groups. Hyaluronidase used as adjuvants along with local anaesthetics to improve the quality of block has no adverse effect on the hemodynamics, unlike other agents (adrenaline, dexmeditomidine, clonidine). It has a good safety profile.

Comparison of two continuous nebulized albuterol doses in critically ill children with status asthmaticus

Objectives: Continuous nebulized albuterol is frequently used to treat children with status asthmaticus in the pediatric intensive care unit (PICU) but can have cardiovascular side effects. Limited data exist comparing different dosages. The purpose of this study was to compare hemodynamic side effects of two continuous albuterol doses (10 vs. 25 mg/h). Our hypothesis was that lower dose albuterol would be associated with lower toxicity without increased need for adjunctive therapies.Methods: We conducted a retrospective cohort study of all children over 2 years old receiving continuous nebulized albuterol for status asthmaticus in our PICU from 2011 to 2013. Standard initial therapy was intravenous steroids and continuous nebulized albuterol. Patients receiving 10 mg/h albuterol were compared to those receiving 25 mg/h. Clinical outcomes, including the need for additional asthma therapies as well as hypotension requiring fluid resuscitation, were evaluated.Results: About 632 patients were studied (342 received 10 mg/h, 290 received 25 mg/h). Children in the lower-dose group received less fluid resuscitation without increased adjunctive therapies when adjusted for confounders. Those in the 25 mg/h group receiving 17% higher bolus volume. Those receiving lower-dose albuterol had shorter adjusted PICU and hospital lengths of stay.Conclusions: In our PICU cohort of children with status asthmaticus, use of 10 mg/h continuous albuterol was associated with lower fluid bolus resuscitation without more adjunctive therapies. These findings support the safety of lower doses in this population. Prospective studies evaluating the efficacy and toxicity of specific continuous albuterol dosages in critically ill children with status asthmaticus are warranted.

Comparison of intracoronary versus intravenous adenosine-induced maximal hyperemia for fractional flow reserve measurement: A systematic review and meta-analysis.

We sought to perform a systematic review and meta-analysis of the available literature comparing fractional flow reserve (FFR) measurements after administration of adenosine using intracoronary (IC) bolus versus standard continuous intravenous (IV) infusion. FFR is considered the gold standard for invasive assessment of coronary lesions of intermediate severity. IV adenosine is recommended to induce hyperemia; however, IC adenosine is widely used for convenience. The difference between IV and IC administration in lesions assessment is not well studied. We systematically searched MEDLINE and relevant databases for studies comparing IV with IC adenosine administration for FFR measurement. We reviewed data pertaining to adenosine doses, side effects, and FFR values. Eight studies addressing the primary question were identified. Dose of IC adenosine varied between 36 and 600 μg. Compared to IV adenosine infusion, the sensitivity of IC administration is 0.805 (95% confidence interval [95% CI]: 0.664-0.896; p < .001), specificity is 0.965 (95% CI: 0.932-0.983; p < .001), positive likelihood ratio is 24.218 (95% CI: 12,263-47.830; p < .001), negative likelihood ratio is 0.117 (95% CI: 0.033-0.411; p < .01), and diagnostic odds ratio is 274.225 [95% CI: 92.731-810.946; p < .001]. Overall, hemodynamic side effects and symptoms were reported more frequently with IV adenosine. The available literature suggests that IC adenosine is well tolerated and may provide equivalent diagnostic accuracy compared to IV administration. However, variability in dosing regimens does not allow definitive conclusions regarding noninferiority of IC approach compared to IV administration.

Nebulized versus intravenous morphine titration for the initial treatment of severe acute pain in the emergency department: study protocol for a multicenter, prospective randomized and controlled trial, CLIN-AEROMORPH

BackgroundIntravenous morphine titration (IVMT) is the French gold standard for opioid treatment in the emergency department (ED). Nebulized morphine titration (NMT) may represent an alternative without venous access, but it has not been adequately studied in adults. We test the hypothesis that NMT is at least as effective as IVMT to initially manage severe acute pain in the ED.Methods/designWe designed a multicenter (10 French EDs), single-blind, randomized and controlled trial. Adults between 18 and 75 years with visual analog scale (VAS) ≥ 70/100 or numeric rating scale (NRS) ≥ 7/10 will be enrolled. We will randomize 850 patients into two groups to compare two routes of MT as long as VAS > 30 or NRS > 3. In group A (425), patients will receive an initial NMT for 5–25 min associated with titration of an intravenously (IV) administered placebo of physiologic serum (PS). In group B (425), patients will receive IVMT plus nebulized PS placebo.NMT is defined as a minimum of 1 and a maximum of 3 5-min nebulized boluses of 10 mg or 15 mg (weight ≥ 60 kg), at 10-min fixed intervals. IVMT is defined as a minimum of 1 and a maximum of 6 boluses of 2 mg or 3 mg (weight ≥ 60 kg), at 5-min fixed intervals. Nebulized placebo titration will be performed every 10 min. IV titration of PS will be performed every 5 min. In both groups, after 25 min, if VAS > 30/100 or NRS > 3/10, routine IVMT will be continued until pain relief.Pain severity, vital signs, bronchospasm, and Ramsay score will be recorded every 5 min. The primary outcome is the rate of relief obtained 1 h from the start of drug administration. Complete pain relief in both groups will be compared with a non-inferiority design. Secondary outcomes are pain relief at 30 min (the end of NMT) and at 2 h and median pain relief. We will compare final doses, and study the feasibility and tolerance of NMT (protocol deviations, respiratory or hemodynamic depression, sedation, and minor vegetative side effects). Co-analgesia will be recorded. Discharge criteria from the ED and hospital are defined.DiscussionThis trial is the first multicenter randomized and controlled NMT protocol for severe pain in the ED using the titration concept. We propose an original approach of combined titration with an endpoint at 1 h and a non-inferiority design.Trial registrationClinicalTrials.gov, NCT03257319. Registered on 22 August 2017.

An Observational Study on the Use of Intravenous Non-Opioid Analgesics and Antipyretics in Poor-Grade Subarachnoid Hemorrhage: Effects on Hemodynamics and Systemic and Brain Temperature.

Intravenous nonsteroidal anti-inflammatory drugs and nonopioid analgesics are used to achieve normothermia or relieve pain in patients with aneurysmal subarachnoid hemorrhage (aSAH). We investigated the effects of paracetamol (1 g), diclofenac (75 mg) and metamizole (1 g) on systemic and cerebral hemodynamics and temperature during febrile and nonfebrile episodes after aSAH. Prospectively collected data from 77 consecutive poor-grade aSAH patients with invasive neuromonitoring were included. The burden and occurrence of hypotension (mean arterial pressure <70 mmHg), brain tissue hypoxia (PbtO2 < 20 mmHg), high intracranial pressure (>22 mmHg), low cerebral perfusion pressure (CPP <70 mmHg), and cerebral autoregulation pressure (pressure reactivity index [PRx]) during baseline (1 hour before) and 6 hours after medication were analyzed in febrile (core temperature; Tcore ≥ 38.3°C) and nonfebrile episodes. Nine hundred eighty-nine infusions (278 paracetamol, 542 diclofenac, and 169 metamizole) were administered resulting in significant reduction of core and brain temperature during febrile (49%) and nonfebrile (51%) episodes (p < 0.001). In febrile cases, temperature decreased for >1 hour below 37.5°C in 36% of interventions and ≤37°C in 11%. Hemodynamic side effects with hypotension and low CPP occurred in both febrile and nonfebrile episodes (p < 0.001) prompting increased vasopressor support in 31% of cases, even more pronounced during the vasospasm period (4-12 days postictus) (OR 5.4, 95% CI 1.8-16). The magnitude of PbtO2-decrease is directly correlated with the decrease in Tcore (p = 0.002) and higher baseline PbtO2 (p < 0.001). PRx decreased in febrile and nonfebrile episodes (p < 0.001), indicating improvement of cerebrovascular autoregulation. Antipyretics were insufficient to achieve sustained normothermia in poor-grade aSAH patients. Hemodynamic side effects were common even when given as analgesic drugs. Further studies are needed to weigh hemodynamic side effects to benefits (inter alia improved cerebral autoregulation).

Effect of Verapamil Adjuvant with Local Anaesthetic Mixtures in Supraclavicular Brachial Plexus Block

Among the various approaches to block brachial plexus , supraclavicular approach offers a high success rate for elbow, forearm and hand surgery . Various adjuvant drugs have been used with local anesthetics in order to decrease the time of onset and prolong the duration and quality of regional blocks. So efforts were made to combine the adjuvant with local anesthetics to improve patient and surgeon satisfaction. In this randomized study we tried to see the effect of verapamil in brachial plexus block as an adjuvant with local anaesthetic .This randomized study wasconducted in Anaesthesiology department of ShaheedZiaurRahman Medical College Hospital after approved by the ethical review board of this hospital.The study subject were divided into two groups (Group A=only local anaesthetics&amp;Group B=local anaesthetics with Verapamil) , 30 IN numbers in each group. Group-A patients was administered 15ml of 1% lignocaine with 15 ml of bupivacaine 0.25% while in Group-B patients was administered injection verapamil 3.5 ml (3.5 mg) in addition to the above mixture. In this study mean onset time of sensory block was 11.53 ± 1.4 minutes in group - A and 7.12 ± 1.68 minutes in group – B which is not statistically significant (p value = 0.057). The mean onset time of motor block in group A was 15.26 ± 1.96 min, and in group B was 11.58 ± 2.68 min and this difierence isstatistically significant (p value=0.000152). Duration of motor block was 96.30 min and 115.08 min in group A and Group B respectively. Sensory block was 157.26 min and 188.0 min in group A and Group B respectively. Regarding the heart rate, no significant difference was detected between the groups at the time of preanesthesia and at the 5 min after anaesthesia. Compared with group B patients, group A patients shows slight but statistically significant increased heart rate at the 10 min (80, 92 beat/min respectively) after brachial plexus block. At 30 minute after, mean systolic BP was 97.9±4.7 mmHg in group A and 84.3±5.0 mmHg in group B. At 45 minute after, mean systolic blood pressure was 94.6±15.6 mmHg and 84.3±5.0 mmHg in group A and group B respectively. At 60 minutes after, mean systolic blood pressure was 59.6±6.0 mmHg in group A and 61.2±9.4 mmHg in group B. At 15, 30 and 45 minute difference was statistically significant (p&lt;0.05) between two groups. In conclusion, the study revealed that verapamil can be used as an adjuvant to decrease the onset time of sensory and motor blocks of bupivacaine in supraclavicular block. Moreover, verapamil doses in regional blocks did not show any hemodynamic side effects.&#x0D; Bangladesh Med J. 2017 May; 46 (2): 43-47

The use of remifentanil in critically ill patients undergoing percutaneous dilatational tracheostomy: A prospective randomized-controlled trial.

Remifentanil was a μ-agonist, with a rapid onset, a powerful narcotic analgesic activity and a fast nonspecific esterases hydrolyzation and theoretically an ideal opioid for percutaneous dilatational tracheostomy (PDT). The present study discussed use of remifentanil in critically ill patients undergoing PDT. Ninety-nine patients were randomly assigned to the propofol/remifentanil group (PR group, n = 49) or the propofol group (P group, n = 50). Two patients (one in P group and one in PR group) were excluded and transferred to surgical way of tracheostomy because of uncontrolled bleeding. The primary outcomes were critical care pain observation (CPOT) scores during PDT; hemodynamic response and side effects, such as bleeding and muscle rigidity (MR). CPOT scores in P group were significantly higher than in PR group during incision and dilation stages (P < 0.05 and P < 0.01). Systolic blood pressure had a significant drop after a bolus of remifentanil in PR group compared with patients in P group (P < 0.056). The incidence of MR was significantly higher in PR group than in P group (P < 0.05). Recovery time in PR group was significantly shorter than in P group (P < 0.05). The occurrence of tachycardia, bleeding, vomiting, and nausea had no statistically differences in both groups. Patients in PR group were undergoing shorter recovery time and better experience of pain in PDT compared with patients in P group, but MR seemed to be higher in PR group. Remifentanil seemed to be a safe and effective opioid used in critically ill patients undergoing PDT.

Spinal versus General Anaesthesia for Laparoscopic Gynaecological Procedures: A Comparative Study of Haemodynamic Changes and Side Effects

Introduction: Laparoscopic gynaecological procedures are conventionally done under general anaesthesia. Spinal anaesthesia is usually preferred only in patients where general anaesthesia is contraindicated. For laparoscopic gynaecological procedures sub arachnoid block is gaining popularity day by day as it is a good alternative to GA.&#x0D; Objective: To compare haemodynamic changes and side effects between subarachnoid block (SAB) and general anaesthesia (GA) for lower abdominal laparoscopic gynaecological procedures.&#x0D; Materials and Methods: A total number of sixty female patients were considered and divided equally into two groups as per American Society of Anesthesiologists (ASA) grade I and II. All patients underwent short duration (&lt;1hr) laparoscopic gynaecological procedures. Group-I patients received lumber SAB and group-II patients received standard general anaesthesia using Propofol, Halothane and Fentanyl. Peri-operative heart rate, blood pressure, Electro-cardiogram (ECG) and Saturation of Oxygen (SPO2) were monitored. Any intra operative and post operative side effects were also recorded and managed.&#x0D; Results: Intra operative and post operative heart rate, systolic and diastolic blood pressure were significantly higher (P&lt;0.05) in group-II. Preoperative, per operative and post operative mean blood pressure (MBP) were also significantly higher (P&lt;0.05) in group-II. During intraoperative period, the side effects in group-I were mainly discomfort and shoulder tip/neck pain and in group-II were hypertension and arrhythmia. Postoperative side effects were mainly postoperative nausea and vomiting (PONV).&#x0D; Conclusion: Spinal anaesthesia using mixture of bupivacaine and fentanyl can be used as a safe alternative to GA for short duration gynaecological laparoscopic procedures with minimum haemodynamic alterations and reduced post operative side effects. To alleviate shoulder tip/neck pain or discomfort patient needs supplementary sedation and analgesia.&#x0D; Journal of Armed Forces Medical College Bangladesh Vol.11(2) 2015: 20-24

Comparison between position change after low-dose spinal anesthesia and higher dose with sitting position in elderly patients: Block characteristics, hemodynamic changes, and complications

Background:Large numbers of patients are presenting for surgeries with aging-related pre-existing conditions that make them at higher risks of adverse outcomes. Hemodynamic instability due to high sympathetic nerve block largely limits the use of conventional dose spinal anesthesia in high risk elderly patients.Aims and Objectives:We aimed to compare the hemodynamic stability and the block characteristics in low dose spinal anesthesia (5 mg) with immediate position change into supine position versus higher dose of spinal anesthesia (10 mg) with maintaining patient position in sitting position for 3 minutes after the block in elderly high risk population.Settings and Design:This study was a prospective randomized controlled double-blinded clinical study.Materials and Methods:This study was carried on 70 patients of American Society of Anesthesiologists physical status classes I, II, and III aged 50 years old and above, who were scheduled for elective knee and below knee orthopedic surgeries expected to last for 40-60 minutes under spinal anesthesia. Patients were randomly allocated into two groups: group (A) Sitting group n= 35 patients that received 10 mg hyperbaric bupivacaine 0.5% in 2 mL volume intrathecal at level lumbar (L4-5) in sitting position and remained in this position for 3 minutes before turning supine. And, group (B) Supine group n = 35 patients received 5 mg (low dose) intrathecal hyperbaric bupivacaine in 2 mL volume (1 mL hyperbaric bupivacaine 0.5% diluted with 1 ml sterile distilled water) at L4-5 in sitting position then turned supine immediately. The injection will be in the midline over 30 seconds by 25 gauge(G) Quincke needle. We measured the changes of mean arterial blood pressure, heart rate, O2 saturation and the incidence of hypotension and bradycardia intraoperatively as a primary outcome. Also, we measured the characteristics and the duration of the sensory and motor blocks, the duration required till return of bladder function and the satisfaction levels of both the patients and the surgeons as secondary outcomes.Statistical Analysis Used:Student's t-test and Chi-square test were used for analysis.Results:As regards hemodynamics, mean arterial blood pressure and heart rate were significantly lower in group A compared to group B; P-value <0.05, during the intraoperative period, while MABP and HR were significantly decreasing in group A during the initial intraoperative period at 5 min, 10 min, 15 min, 20 min, 25 min, 30 min and 35 min, but in group B these parameters were statistically insignificant throughout the whole procedure P-value >0.05. As regards oxygen saturation, there were no significant differences between both groups or within the same group during the whole intraoperative period. Comparing sensory and motor blocks, sensory block was significantly higher and motor block was significantly dense in group A compared to group B during the first intraoperative period at 5 min, 10 min, 15 min, 20 min and 25 minutes. The recovery times from sensory and motor blocks were significantly longer in group A compared to group B (P-value <0.001). Also, the void recovery time was significantly longer in group A (129.29 ± 5.87 min) compared to group B (114.77 ± 8.24 min). In group B, patient satisfaction was significantly better (25 excellent/ 10 good) compared to group A (10 excellent/25 good). Also, surgeon satisfaction was statistically significantly better in group B (23 excellent/12 good) compared to group A (14 excellent/21 good). As regards side effects, in group A, 3 patients had to receive ephedrine due to significant reduction in MABP while no patients in group B had significant hypotension or bradycardia throughout the intra operative period.Conclusion:We concluded that the use of small dose of heavy bupivacaine 0.5% (5 mg) with immediate patient position changing to supine position provided good spinal block characteristics in elderly population without any hemodynamic side effects, also with better patient and surgeon satisfaction levels compared to higher doses of heavy bupivacaine (10 mg) even if we maintained patient position in the sitting position for 3 min after the block.

Commentary: Role of alpha-2 agonists in regional ophthalmic anaesthesia.

Regional anaesthesia is the most common mode of anaesthesia used in ophthalmic surgical procedures. Among regional blocks, peribulbar anaesthesia is the safest and most commonly employed. However, in procedures with prolonged operating time, such as vitreoretinal surgeries, repeated need for block supplementation and patient anxiety, are a challenge. Adjuvants to peribulbar anaesthetics, namely, hyaluronidase and adrenaline along with preoperative anxiolytics/sedatives have been tried to overcome these challenges.[1] Alpha-2 agonists are drugs which bind selectively to alpha-2 adrenergic receptors in the central, peripheral and autonomic nervous system as well as in vital organs and blood vessels. They produce dose-dependent analgesia, anxiolysis and sedation without causing respiratory depression by acting on the G protein-coupled alpha-2 receptors.[2] Two main alpha-2 agonists that are commercially available include clonidine and dexmedetomidine. Although neither of them is completely selective for alpha-2 receptors, dexmedetomidine is 8-10 times more selective towards these receptors compared to clonidine. Dexmedetomidine has a higher avidity and affinity for alpha-2 receptors, shorter elimination half-life and higher clinical efficacy with a lesser side-effect profile compared to clonidine.[3] The study by Gujral et al. adds credence to the anxiolytic effect of dexmedetomidine which is coupled with hemodynamic safety in patients receiving peribulbar block for vitreoretinal surgery.[4] Clonidine was the first alpha-2 agonist to be used as an adjuvant by Mjahed et al. who found that its addition to peribulbar block decreased intraocular pressure, enhanced anaesthesia, akinesia and intraoperative sedation.[5] However, use of clonidine was associated with hemodynamic side-effects such as bradycardia, arterial and orthostatic hypotension, rebound hypertension and syncope. The long half-life of clonidine meant that the hemodynamic instability was not only seen intra-operatively but also for up to 8 hours in the post-operative period.[6] Dexmedetomidine, a newer alpha-2 agonist, has shown potential with a better safety profile due to its higher selectivity and shorter half-life. Two recent studies have evaluated its efficacy and side-effect profile when used as an adjunct to peribulbar block during vitreoretinal surgery.[78] Ahmed et al.[7] used 20 μg of dexmedetomidine along with lidocaine, bupivacaine and hyaluronidase. They found faster onset of anaesthesia, akinesia, increased duration of anaesthesia and increased patient sedation in comparison to a control group using normal saline. EL-Shmaa et al.[8] compared two doses of dexmedetomidine, 15 and 30 μg, as adjuvants to routine peribulbar anaesthetic agents. They also found similar results in terms of onset and duration of anaesthesia in the dexmedetomidine groups compared with the control group. The two doses did not differ significantly in terms of their efficacy or side-effect profile. The current study in contrast did not find any difference in the time of onset of anaesthesia between the study and the control groups; however, the patient and surgeon comfort were significantly better with dexmedetomidine. This study is also unique in keeping the systemic stability as its primary outcome measure.[4] No significant systemic side-effects have been reported with either of the studies while using this drug in vitreoretinal surgeries. There is increasing evidence that supports the use of dexmedetomidine as an adjunct to regional blocks for ophthalmic anaesthesia. This drug seems to be especially useful in cases with prolonged operating times such as complex vitreoretinal surgeries and for apprehensive patients. However, use of dexmedetomidine in patients with heart block, heart failure, renal/hepatic insufficiency, uncontrolled diabetes, obesity and/or chronic obstructive pulmonary disease is contraindicated. Meticulous pre-operative evaluation by the anaesthesia team is thus essential before subjecting a patient to peribulbar block with dexmedetimidine as an additive. Establishment of standard pre-anaesthetic evaluation and intra-operative monitoring protocols are needed before this drug gains popularity as an adjunct for regional anaesthesia in ophthalmic surgery. Hence, further studies on the requirement of systemic monitoring during surgery and long-term safety profile of these agents are warranted.

Comparing Effects of Intrathecal Adjuvants Fentanyl and Dexmedetomidine with Hyperbaric Ropivacaine in Patients Undergoing Elective Infraumbilical Surgeries: A Prospective, Double-Blind, Clinical Study.

Background:Spinal anesthesia is most commonly used anesthesia technique for infraumbilical surgeries, and it is cost-effective with decreased hospital stay. Intrathecal isobaric ropivacaine has shorter duration of anesthesia than bupivacaine. By making, ropivacaine hyperbaric will help to achieve dense block with good postoperative analgesia.Materials and Methods:Ninety patients with American Society of Anesthesiologists physical status Classes I and II, aged between 18 and 60 years of either sex, undergoing for elective infraumbilical surgeries were randomly allocated into three groups 30 each (n = 30). Group Ropivacaine + Dexmedetomidine (RD) received 2.5 ml of 0.5% hyperbaric ropivacaine (15 mg) + dexmedetomidine 10 μg (0.5 ml), Group Ropivacaine + Fentanyl (RF) received 2.5 ml of 0.5% hyperbaric ropivacaine (15 mg) + fentanyl 25 μg (0.5 ml), and Group Ropivacaine + Normal saline (RC) received 2.5 ml of 0.5% hyperbaric ropivacaine (15 mg) +0.5 ml of normal saline. The onset, extent, and duration of sensory and motor block, duration of rescue analgesia, hemodynamic parameters, and side effects such as nausea, vomiting, pruritus, and shivering were recorded.Results:Time of onset early in RD (1.673 ± 0.567), in RF (1.73 ± 0.520), and in RC (1.763 ± 0.420) min (P = 0.783). Time to achieve maximum level of sensory block in RD (5.94 ± 1.88), in RF (3.86 ± 1.22), and RC (5.99 ± 0.46) min (P < 0.001). The total duration of analgesia in Group RD (356.67 ± 63.022), in RF (255.10 ± 35.626), and in RC (197.67 ± 37.605) min (P < 0.001). The time onset and duration of motor block in Group RD (1.59 ± 0.59, 319.57 ± 64.752), Group RF (1.59 ± 0.53, 236.83 ± 33.797), and Group RC (2.07 ± 0.20, 183.93 ± 35.252) min both are statistically highly significant (P < 0.001).Conclusion:Addition of glucose to ropivacaine makes the block dense. Addition of adjuvants such as dexmedetomidine and fentanyl further hastens the onset; prolong the postoperative analgesia with minimal hemodynamic and other side effects.

Effect of dexmedetomidine or propofol sedation on haemodynamic stability of patients after thoracic surgery.

Dexmedetomidine and propofol are commonly used sedative agents in non-invasive ventilation as they allow for easy arousal and are relatively well controllable. Moreover dexmedetomidine is associated with low risk of respiratory depression. However, both agents are associated with significant hemodynamic side effects. The primary objective of this study is to compare the influence of both drugs on hemodynamic effects in patients after thoracic surgical procedures receiving dexmedetomidine or propofol for noninvasive postoperative ventilation. A prospective, randomised, observational study University Hospital. Interventions: Continuous sedation with dexmedetomidine or propofol for six hours of postoperative non-invasive ventilation after thoracic surgery, with concomitant use of continuous epidural analgesia. A total of 38 patients (20 dexmedetomidine and 18 propofol) were included in the analysis. The primary outcomes of this study is that heart rate, systolic and mean arterial blood pressure did not differ significantly between the groups, but diastolic arterial blood pressure was significantly higher in propofol group. Comparison analysis of epinephrine usage did not reveal significant differences between the groups. Cardiac output (CO) and cardiac index (CI) analysis did not show significant differences between the groups, but there is a clear tendency of lower values of CO/CI in group receiving propofol. We also observed similar tendency in stroke volume index (SVI) and stroke volume variation (SVV) values, but also those differences did not reach statistical significance. Systemic vascular resistance index (SVRI) values were higher in propofol group, exceeding reference values, but similarly, the difference between the groups was not significant. The main finding of this study is that dexmedetomidine and propofol provide similar advantages in haemodynamic stability during short-term sedation for non-invasive ventilation after thoracic surgical procedures in patients receiving continuous epidural analgesia.

Haemodynamic stability after paracervical block: A randomized, controlled, double‐blind study comparing bupivacaine‐adrenaline with bupivacaine

Paracervical block is widely used in gynaecological interventions on cervix and uterus. Many surgeons add adrenaline 100 μg or pitressin 3-5 IU in a total volume of 10-20 mL to reduce total blood loss. We wanted to examine haemodynamic stability in healthy patients given bupivacaine with and without adrenaline. In this randomised, double-blinded, controlled study, 30 healthy women scheduled for cervical conisation got a paracervical block using bupivacaine 50 mg with adrenaline 100 μg (BA-group, n = 14) or without adrenaline (B-group, n = 16) after induction of general anaesthesia. LiDCOplus was used for minimally invasive haemodynamic monitoring. Changes in cardiac output (CO) and systolic blood pressure (SBP) were the primary outcome. Changes in heart rate (HR), stroke volume (SV), and systemic vascular resistance (SVR) were secondary outcome variables. Area under the curve (AUC) ratios and change from baseline to maximal values were used as effect measures comparing the two groups. The AUC-ratio for CO and SBP was 2.50 (P < 0.001) and 1.70 (P = 0.03), respectively. For HR, SV, and SVR the AUC-ratio was 1.59 (P < 0.01), 1.52 (P < 0.001), and 0.90 (P = 0.14), respectively. CO increased 68% (standard deviation (SD) 42%, P < 0.001), HR increased 41% (SD 26%, P < 0.001), and SV increased 26% (SD 17%, P < 0.001) from baseline to maximal values after 70-90 seconds in the BA-group. Paracervical block with bupivacaine 50 mg and adrenaline 100 μg may give haemodynamic instability in healthy females and is not recommended if haemodynamic side effects are to be avoided.

Neuraxial versus Peripheral Nerve Block for Postoperative Pain Management in Drug Abusers Undergoing Orthopedic Surgeries

Background: While all surgical procedures are associated with some degree of pain, it is a well-accepted fact that orthopedic surgeries are some of the most painful. Despite the increasing interest and continuous advancement in postoperative pain management, more than half of the patients who undergo orthopedic surgeries experience inappropriate level of postoperative pain. Poorly treated pain can have negative impact on recovery especially owing to disruption in physiotherapy resulting in stiffness of joints and slow progress in mobility. In order to achieve good quality of postoperative analgesia, careful history should be taken from the patients about any coexisting medical conditions such as substance abuse or withdrawal, anxiety disorder, affective disorder, hepatic or renal impairment and any past history of poor pain management. Aim of the Work: The purpose of this study was to compare efficacy, side effects, opiate consumption and hemodynamic effects of neuraxial blocks versus peripheral nerves blocks placed under ultrasound guidance, for postoperative pain management in drug abusers undergoing orthopedic surgeries. Patients and Methods: Sixty patients presenting to Ain Shams University hospitals for orthopedic surgeries were enrolled in this prospective randomized controlled study after providing written consents. Participants were instructed about the study protocol and visual analogue scale (VAS). Approval was obtained from the research ethics committee of anesthesia and intensive care department, at Ain Shams University. In this study, all patients were preoperatively assessed for evaluation of their medical status, mode of trauma, post-traumatic critical symptoms or signs, hemodynamic stability, evidence of coagulopathy and any previous history or concurrent drug abuse. Results: This study included 60 drug-abuser patients, undergoing orthopaedic surgeries, starting from January 2018 till May 2018 at Ain Shams University Hospitals and randomly distributed within 2 groups, 30 patients each: Group A: EPI group, Group B: PNB group. As regard to age, gender, body weight, height, ASA and duration of surgery, there were no statistically significant differences between both groups (P-value>0.05). Regarding effects on hemodynamics and intraoperative ephedrine administration, the present study found statistically significant difference in the mean arterial blood pressure measured intra operatively with more drop in group A (EPI) than group B (PNB) with a (P value 0.05). Conclusion: The choice of continuous femoral and sciatic block technique placed under ultra-sound guidance for postoperative pain control provides equivalent analgesia, opioid consumption, postoperative rehabilitation and hospital stay with a lower incidence of hemodynamic side effects when compared to continuous epidural analgesia in drug-abuser patients undergoing orthopedic surgeries. It was also associated with decreased risk of postoperative side effects as sedation, dizziness, nausea and\or vomiting and urinary retention.