Initial Bolus Dose Research Articles

Proposal for a Revised Classification of the Depth of Neuromuscular Block and Suggestions for Further Development in Neuromuscular Monitoring

Proposal for a Revised Classification of the Depth of Neuromuscular Block and Suggestions for Further Development in Neuromuscular Monitoring

A Comparative Study of Bolus Dose of Hypertonic Saline, Mannitol, and Mannitol Plus Glycerol Combination in Patients with Severe Traumatic Brain Injury

This prospective randomized controlled study compared the efficacy of an equiosmolar and isovolumetric dose of 3% hypertonic saline, 20% mannitol, and 10% mannitol plus 10% glycerol combination in reducing the raised intracranial pressure (ICP) in patients with severe traumatic brain injury (TBI). A total of 120 patients of severe TBI with increased ICP were randomized to receive an equiosmolar and isovolumetric dose of 3% hypertonic saline, 20% mannitol, and 10% mannitol plus 10% glycerol combination at a defined infusion rate, which was stopped when ICP was <15 mm Hg. A total of 120 patients with severe TBI (aged >18 years, Glasgow Coma Scale ≤8, and had sustained elevated ICP of >20 mm Hg for more than 5 minutes) were randomized during the study. All data were presented as mean (minimum-maximum). A one-way analysis of variance test was used to analyze the effect across the treatment group, and Tukey's method was used for multiple comparisons. A paired t-test was employed to analyze the effect of the medication within each group. All 3 drugs decreased ICP below 15 mm Hg (P < 0.0001). The maximum change in ICP occurred after a bolus dose of 3% hypertonic saline followed by 10% mannitol plus 10% glycerol combination and then 20% mannitol (60% vs. 57% vs. 55%, respectively). Mean arterial pressure and cerebral perfusion pressure were increased after the bolus dose of study medications. Maximum changes occurred after infusion of 3% hypertonic saline followed by 10% mannitol plus 10% glycerol combination and 20% mannitol (P < 0.0349 and <0.0013, respectively). There was no statistically significant change in the hematocrit value noted after the bolus dose of any of the study medications. Serum sodium and osmolarity were raised significantly after the bolus dose of study medications. Maximum changes in serum sodium and osmolarity occurred after the bolus dose of 3% hypertonic saline. The mean dose required to reduce ICP below 15 mm Hg for 3% hypertonic saline: 1.4 mL/kg, for 10% mannitol plus 10% glycerine: 1.7 mL/kg, and for 20% mannitol: 2.0 mL/kg. The mean time required to reduce ICP below 15 mm Hg for 3% hypertonic saline: 16 minutes, for 10% mannitol plus 10% glycerine: 19 minutes, and for 20% mannitol: 23 minutes. The maximum change in the Glasgow Coma Scale occurred after the bolus dose of 3% hypertonic saline, followed by 10% mannitol plus 10% glycerol combination and then 20% mannitol. All 3 osmotic compounds exhibit comparable effectiveness in reducing ICP when a similar osmotic load is administrated, but 3% hypertonic saline appeared to be more effective followed by 10% mannitol plus 10% glycerol combination and 20% mannitol. A dose of 1.4 mL/kg can be recommended as an initial bolus dose for 3% hypertonic saline. Hypertonic saline can be recommended to treat patients with pretreatment hypovolemia, hyponatremia, or renal failure. There is no clear benefit compared with 20% mannitol in regard to neurologic outcome, even though there is a minor positive trend for 3% hypertonic saline and 10% mannitol plus 10% glycerol combination.

Terlipressin infusion during Whipple procedure: effect on blood loss and transfusion needs – a randomized clinical trial

Context Multivisceral resections including Whipple procedure are among the foremost common oncologic procedures during which massive bleeding and transfusion might happen intraoperatively or postoperatively. Terlipressin is a synthetic vasopressin analog with relative specificity for the splanchnic circulation where it causes vasoconstriction, with a hypothetical reduction in blood loss during abdominal surgeries. Aims We aim to assess the effect of terlipressin infusion on blood loss and blood transfusion requirements during Whipple procedure. Settings and design The current study was a prospective single center randomized placebo-controlled trial. The study was carried out in Al Rajhy Liver Hospital, Assiut University, Egypt between May 2016 and July 2017. Patients and methods In this trial 40 patients scheduled for Whipple procedure were randomly assigned either to receive terlipressin at the beginning of surgery as an initial bolus dose of (1 mg over 30 min) followed by a continuous infusion of 2 μg/kg/h throughout the procedure and gradually weaned over the first 4 h postoperatively (terlipressin group) or to receive the same volume and rate of 0.9% saline for the same duration (control group).The primary outcome was the amount of intraoperative blood loss. Statistical analysis used Statistical analysis was established using SPSS, version 16.0. Results The amount of intraoperative blood loss was significantly lower in the terlipressin group (690.00 ± 449.44) in comparison with the control group (1020.00 ± 284.88). Five (25%) patients received blood transfusion in the terlipressin group compared with 13 (65%) patients in the control group (P = 0.011). Significantly greater number of packed red blood cells units were transfused to the control group (P = 0.013). Conclusion Terlipressin infusion during Whipple procedure was associated with less bleeding and lower rates of blood transfusion requirements compared with placebo.

Therapeutic and maintenance regimens of vitamin D3 supplementation in healthy adults: A systematic review

Studies carried out assessing the effect of different doses of cholecalciferol (vitamin D3) on correcting serum 25-hydroxyvitamin D deficiency in healthy adults are limited and review studies are lacking. Moreover, the maintenance dose and its duration offered by these few studies are inconsistent. We performed a systematic review of randomized clinical controlled trials (RCTs) that assessed the effect of different doses of vitamin D3 on serum 25(OH)D in healthy adults. PubMed database was searched from 2010 to 2018 using the following search terms: "vitamin D deficiency", "Cholecalciferol", "vitamin D3 dose", "vitamin D supplement", "vitamin D therapy". RCTs and original articles that evaluated different doses of vitamin D3 were identified. A total of sixteen (out of 3016) acceptable studies fulfilling our inclusion criteria were included in the current systematic review. Our results revealed that supplementation with vitamin D3 had a significant positive effect in raising serum 25(OH) D concentrations. Our findings indicated that the best regimen of vitamin D3 supplement consisted of an initial large bolus dose either IM injection of 600.000 IU monthly or oral dose of 200.000 IU monthly or 50.000 IU weekly for 8 weeks, followed by a maintenance dose of 50.000 IU monthly or bimonthly. A large bolus therapeutic dose of vitamin D3, frequently or infrequently for 8 weeks, followed by long-term oral maintenance dose of 50.000 IU monthly or bimonthly optimiz and manitain vitamin D serum levels year round.

Improving Medication Timeliness in Pediatric Sickle Cell Disease Population Presenting to the Emergency Department with Vaso-Occlusive Episode

Abstract Background: Vaso-occlusive episode (VOE) is the most common acute complication for individuals with sickle cell disease (SCD) and most common reason to seek medical care. Rapid initiation of analgesia therapy, with timely subsequent doses as needed upon presenting to the emergency department (ED) for VOE are current established guidelines. Our center's initial analgesic approach aligns with NHLBI Guidelines of initial analgesic therapy within 60 minutes of registration and reassessment along with subsequent doses every 15 to 30 minutes if severe pain persists. Our center also recommends initiation of continuous infusion (CI) of pain medication within 60 minutes following third bolus dose of pain medication for those not achieving sufficient analgesia. Objective: This project's aim is to reduce time to initial dose of analgesic therapy in patients with SCD presenting to the ED with VOE to less than 60 minutes from registration in 90% of study population, decrease time interval between first and third dose of opioids to less than 60 minutes in 90% of study population, and initiate CI of pain medication within 60 minutes of third dose of opioids in 75% of individuals requiring further analgesic support. The goal is to achieve these measures within the completion of 6 monthly Plan-Do-Study-Act (PDSA) cycles. Methods: Three initial countermeasures were implemented within our institution to achieve the targeted objectives. (1) An adjustment to current ED order sets was made to include intranasal fentanyl as an initial one time option for a quicker analgesic option upon registration. (2) Another adjustment was made to the initial ED order set used upon presentation of the patient to include CI orders instead of the current system of having separate order sets for initial bolus dosing of analgesic therapy and CI order. (3) Final initial adjustment was made to change nursing prompt within the electronic medical record (EMR) for reassessment following bolus doses of pain medication; prompts were changed to every 20 minutes from every 30 minutes for the nurses with idea to better target goal of &lt;30 minutes between doses for those who are in persistent severe pain. Results: Baseline data was obtained by retrospective chart review over a three month period. A median of 58.8% of patients were receiving an initial dose of analgesic therapy within 60 minutes of registration. Sixty minutes between first and third dose occurred in 53.8% of patients. Initiation of CI was occurring in 8.3% of patients within 60 minutes of the third dose of opioids. Over the first PDSA cycle, improvement has been noted across all 3 aims. For the initial dosing, 68% of patients were receiving within 60 minutes. Time between first and third dosing of less than 60 minutes occurred in 60% of patients. Initiation of CI within 60 minutes of the third dose is occurring in 36.3% of patients. Initial qualitative response from ED staff and nursing has been positive regarding countermeasures and care for the patients. Conclusions: This project identified the need for improvement efforts in patient care. The goal is to provide more efficient analgesic support; with these adjustments, quicker pain control can be achieved, with this leading to improvement in patient care. It is anticipated that with the eventual achievement of the aims, a decreased admission rate will be noted; for those individuals still requiring further analgesic support, it is felt faster initiation of CI will lead to quicker control of VOE and, subsequently, shorter hospitalizations. Additional countermeasures have been discussed in anticipation to adding to the current interventions to further improve the project's efforts; these ideas are currently being vetted to determine feasibility within our center and their ability to maintain the success of this project over time. Plan will be to continue to run monthly PDSA cycles for 6 months to evaluate response of timing to initial adjustments before integrating further interventions. Qualitative data will be obtained formally during quarterly meetings between hematology and ED representatives. Disclosures Woods: Global Blood Therapeutics: Research Funding; Pfizer: Research Funding; Guidepoint: Honoraria; Putman: Honoraria; Children's Mercy Hospital: Employment, Membership on an entity's Board of Directors or advisory committees.

Vitamin D supplementation improves waist-to-hip ratio and fasting blood glucose in vitamin D deficient, overweight or obese Asians: A pilot secondary analysis of a randomised controlled trial

Recent trials do not support a role for vitamin D supplementation in prevention or treatment of type 2 diabetes mellitus, although effects may differ in Asian populations. In this pilot secondary analysis of a placebo-controlled randomised trial of overweight or obese individuals with low 25-hydroxyvitamin D (25(OH)D < 50 nmol/L), we examined whether vitamin D supplementation improved insulin sensitivity or body composition in participants of Asian ethnicity. Amongst 65 trial participants, 33 reported being of Asian descent (mean ± SD age 30 ± 7 years; 67% male). Participants were block randomised to receive vitamin D (n = 14; initial bolus dose of 2500 μg cholecalciferol followed by 100 μg cholecalciferol/d) or placebo (n = 19; identical capsules) for 16 weeks. Primary outcome was change in insulin sensitivity (M-value) assessed by hyperinsulinemic-euglycemic clamp. Secondary outcomes were changes in 25(OH)D (chemiluminescent immunoassay), fasting blood glucose (YSI Stat 2300), and body composition including waist-hip ratio and total body fat percentage (dual-energy X-ray absorptiometry). Questionnaires assessed sun-exposure habits, physical activity, and diet. After the 16-week intervention, 25(OH)D concentrations increased significantly in the vitamin D group with no change in placebo (61.4 ± 21.1 vs −0.4 ± 12.7 nmol/L; P < 0.01). Vitamin D group participants demonstrated significant improvements in waist-hip ratio (-0.02 ± 0.03 vs 0.00 ± 0.02; P < 0.01) and fasting blood glucose (−0.1 ± 0.2 vs 0.2 ± 04 mmol/L; P < 0.04) compared with the placebo group, but changes in insulin sensitivity and other body composition measures did not differ significantly between groups (all P > 0.05). In conclusion, vitamin D supplementation improved waist-hip ratio and fasting blood glucose in overweight and obese Asian-Australians with low vitamin D concentrations. Further research is required to determine whether vitamin D supplementation is potentially more effective in specific ethnic groups.

Effects of terlipressin infusion on blood loss and transfusion needs during liver resection: A randomised trial.

Blood loss and perioperative blood transfusion requirements affect the long-term survival after liver resection for malignant tumours. Terlipressin is a synthetic vasopressin analogue with relative specificity for the splanchnic circulation where it causes vasoconstriction with subsequent reduction of blood loss during abdominal surgeries. We tried to examine the impact of terlipressin on blood loss and blood transfusion needs during liver resection. In this randomised, double-blind placebo-controlled trial 84 patients scheduled for major liver resections were randomly assigned to receive either terlipressin at the onset of surgery as an initial bolus dose of (1 mg over 30 minutes) followed by a continuous infusion of 2 μg/kg/h throughout the procedure (Terlipressin group) or the same volume and rate of 0.9% saline (Placebo group).The primary outcome was the amount of intra-operative blood loss. The mean (SD) of the amount of intra-operative blood loss was 1351 (887) in the terlipressin group versus 1892 (889) mL in the placebo group (P = 0.006). Thirteen (30%) patients received blood transfusion in the terlipressin group compared with t27 (64.2%) in the placebo group (P = 0.002) with a statistically significant difference in the median (range) number of the transfused units of packed RBCs [0 (0-5) units and 1 (0-6) units in the two groups respectively; P = 0.001]. Terlipressin infusion during major liver resection was associated with less bleeding compared to placebo. More studies are required to confirm our results especially in patients with normal portal pressure.

Monthly High-Dose Vitamin D Supplementation and Cancer Risk

Previous randomized clinical trials have reported inconsistent results on the effect of vitamin D supplementation on cancer incidence. To examine whether high-dose vitamin D supplementation received monthly, without calcium, is associated with a reduction in cancer incidence and cancer mortality in the general population. This is a post hoc analysis of data from the Vitamin D Assessment (ViDA) study, a randomized, double-blind, placebo-controlled trial that recruited participants from family practices and community groups in Auckland, New Zealand, from April 5, 2011, through November 6, 2012, with follow-up completed December 31, 2015. Participants were adult community residents aged 50 to 84 years. Of 47 905 adults invited from family practices and 163 from community groups, 5110 participants were randomized to receive vitamin D3 (n = 2558) or placebo (n = 2552). Two participants withdrew consent, and all others (n = 5108) were included in the primary analysis. Data analysis was by intention to treat. Oral vitamin D3, in an initial bolus dose of 200 000 IU and followed by monthly doses of 100 000 IU, or placebo for a median of 3.3 years (range, 2.5-4.2 years). Post hoc primary outcome was the number of all primary invasive and in situ malignant neoplasms (excluding nonmelanoma skin cancers) diagnosed from randomization until the study medication was discontinued on July 31, 2015. Of the 5108 participants included in the analysis, the mean (SD) age was 65.9 (8.3) years, 58.1% were male, and 4253 (83.3%) were of European or another race/ethnicity, with the remainder being Polynesian or South Asian. Mean (SD) baseline deseasonalized 25-hydroxyvitamin D concentration was 26.5 (9.0) ng/mL. In a random sample of 438 participants, the mean follow-up 25-hydroxyvitamin D concentration consistently was greater than 20 ng/mL higher in the vitamin D group than in the placebo group. The primary outcome of cancer comprised 328 total cases of cancer (259 invasive and 69 in situ malignant neoplasms) and occurred in 165 of 2558 participants (6.5%) in the vitamin D group and 163 of 2550 (6.4%) in the placebo group, yielding an adjusted hazard ratio of 1.01 (95% CI, 0.81-1.25; P = .95). High-dose vitamin D supplementation prescribed monthly for up to 4 years without calcium may not prevent cancer. This study suggests that daily or weekly dosing for a longer period may require further study. anzctr.org.au Identifier: ACTRN12611000402943.

Fosphenytoin for control of electrical storm in acute myocardial infarction and Purkinje fiber‐mediated arrhythmias

Purkinje fiber-mediated arrhythmias in the setting of acute myocardial infarction are poorly responsive to conventional antiarrhythmic therapy, increases overall mortality and often requires radiofrequency ablation (RFA) for control. In this study, we report the use of intravenous Fosphenytoin for the control of arrhythmic storm in patients with acute myocardial infarction. Six patients with acute myocardial infarction (5 AW/1 LW) and Purkinje-triggered ventricular arrhythmias refractory to conventional antiarrhythmics were treated with intravenous Fosphenytoin before considering RFA. Arrhythmia control was obtained in all patients after the initial bolus dose. Breakthrough episodes were seen in 5/6 within 24-36hours of the initial bolus, necessitating a second bolus. Complete arrhythmia control was obtained in all patients within 72hours and 5/6 patients were successfully discharged from the hospital. One patient succumbed to sepsis in hospital while another patient succumbed to Sub Dural Hematoma after 3 months. Intravenous Fosphenytoin should be considered before RFA for control of Purkinje fiber-mediated refractory arrhythmias in acute myocardial infarction patients.

Impact of a Nurse-Driven Opioid Titration Protocol on Appropriateness of Orders at End of Life (S710)

•Determine appropriate symptom management for inpatients at end of life.•Describe the impact of a standardized symptom management protocol on the appropriateness of orders at end of life. A nursing-driven opioid titration protocol and symptom management order set were developed at a community teaching hospital to be used to manage pain and dyspnea in patients at the end of life. The aim of this study is to evaluate the impact of the opioid titration protocol and order set on symptom management at the end of life. This is a retrospective study in which medical records of adult patients that received morphine infusions for end of life were analyzed. An order set and nursing-driven opioid titration protocol were implemented in August 2016 following extensive nursing education. Medical records were reviewed during 3-month periods pre and post implementation (PRE-group and POST-group) for the presence of supportive care management and appropriate opioid infusion orders. Morphine orders were considered appropriate if they included an as-needed bolus dose with an objective indication, and specific infusion titration instructions. There were 32 patients included in the PRE-group and 37 patients in the POST-group. In the PRE-group, 6 of 32 orders (18.8%) were considered appropriate compared to 35 of 37 orders in the POST-group (94.6%, p<0.0001 for comparison). Of the orders considered inappropriate in the PRE-group, 12 included a sedation score as a target, 7 listed “comfort” as a target, and 7 did not state any goal or target. Morphine infusion orders in the POST-group were significantly more likely to include a maximum dose (p=0.041) and an initial bolus dose (p<0.0001) compared to the PRE-group. In addition, patients in the POST-group were significantly more likely to receive additional medications to manage other end of life symptoms (p<0.05 for all). In this study, implementation of a standardized opioid titration protocol and symptom management order set led to an improvement in the management of symptoms such as pain and dyspnea at end of life.

Efficacy of Dexmedetomidine versus Ketofol for Sedation of Postoperative Mechanically Ventilated Patients with Obstructive Sleep Apnea

Patients with sleep apnea are prone to postoperative respiratory complications, requiring restriction of sedatives during perioperative care. We performed a prospective randomized study on 24 patients with obstructive sleep apnea (OSA) who underwent elective surgery under general anesthesia. The patients were equally divided into two groups: Group Dex: received dexmedetomidine loading dose 1 mcg/kg IV over 10 min followed by infusion of 0.2–0.7 mcg/kg/hr; Group KFL: received ketofol as an initial bolus dose 500 mcg/kg IV (ketamine/propofol 1 : 1) and maintenance dose of 5–10 mcg/kg/min. Sedation level (Ramsay sedation score), bispectral index (BIS), duration of mechanical ventilation, surgical intensive care unit (SICU) stay, and mean time to extubation were evaluated. Complications (hypotension, hypertension, bradycardia, postextubation apnea, respiratory depression, and desaturation) and number of patients requiring reintubation were recorded. There was a statistically significant difference between the two groups in BIS at the third hour only (Group DEX 63.00 ± 3.542 and Group KFL 66.42 ± 4.010, p value = 0.036). Duration of mechanical ventilation, SICU stay, and extubation time showed no statistically significant differences. No complications were recorded in both groups. Thus, dexmedetomidine was associated with lesser duration of mechanical ventilation and time to extubation than ketofol, but these differences were not statistically significant.

Safety and Efficacy of Dexmedetomidine, Ketofol, and Propofol for Sedation of Mechanically Ventilated Patients

Introduction The Society of Critical Care Medicine recommended using non -benzodiazepine agents as propofol and dexmedetomidine for sedation of the critically ill patients in intensive care units. Aims and objectives This study aimed to evaluate the safety and efficacy of ketofol, dexmedetomidine or propofol for sedation of postoperative mechanically ventilated patients in intensive care unit. Materials and methods The study included ninety postoperative mechanically ventilated patients in the intensive care unit divided randomly into three equal groups. Group A: 30 patients received ketofol an initial bolus dose (500mcg/kg) of ketamine/propofol 1:1 (ketamine 8 mg/ml and propofol 8 mg/ml‏‏ followed by a maintenance dose of (10 mcg/kg/min). Group B: 30 patients received loading dose infusion of dexmedetomidin diluted in 0.9% sodium chloride 1mcg /kg/h over 10min followed by a maintenance infusion of 0.2-0.7mcg/kg/h. Group C: 30 patients received propofol undiluted as an infusion of 1-3mg/kg/h, after a loading dose infusion up to1mg/kg over10 min. Sedation level, bispectral index, systolic and diastolic blood pressure, heart rate, recovery time, complications (hypertension, hypotension, bradycardia). Result RAMSY sedation score was statistically significantly higher in group A than group B at the sixth and twelfth hour; it was statistically significantly higher in group A than group C from the first to the twenty-fourth hour and was statistically significantly higher in group B than group C at first, the sixth and eighteenth hour. The recovery time was longer in group A compared to group B and C, and it was statistically significant, no complications recorded in the three groups. Conclusion Using ketofol, dexmedetomidine or propofol was effective in maintaining sedation without hemodynamic complications in postoperative mechanically ventilated patients in the intensive care unit

Effect of butorphanol, midazolam or ketamine on romifidine based sedation in horses during standing cheek tooth removal

BackgroundStanding surgery, especially dental procedures, are commonly performed in horses. This leads to an increasing demand for reliable sedation protocols. Therefore, it was the purpose of this study to investigate the influence of butorphanol, midazolam or ketamine on romifidine based sedation in horses during cheek tooth removal.MethodsForty horses presented for tooth extraction were divided in four groups using matched pair randomization. Group R was sedated with romifidine (bolus 0.03 mg/kg, followed by a constant rate infusion (CRI) 0.05 mg/kg/h) and group RB with romifidine (same dose) and butorphanol (0.02 mg/kg; CRI 0.04 mg/kg/h). Group RM received romifidine (same dose) and midazolam (0.02 mg/kg; CRI 0.06 mg/kg/h) whereas group RK was administered romifidine (same dose) and ketamine (0.5 mg/kg; CRI 1.2 mg/kg/h). If sedation was not adequate a top up bolus of romifidine (0.01 mg/kg) was administered. The quality of sedation and the conditions for tooth extraction, the level of ataxia, chewing, head and tongue movement were evaluated by using a scoring system. The investigator was blinded to the applied sedation protocol. Furthermore, serum cortisol concentrations before, during and after the procedure were analyzed to gain more information about the stress level of the horses.ResultsHorses in group RM showed significantly less chewing and tongue activity compared to horses sedated with romifidine alone or with butorphanol additionally, but also significantly higher levels of ataxia. The quality of sedation was significantly better if romifidine was administered in combination with ketamine compared to romifidine alone. Furthermore, horses of group RK needed less additional romifidine boli compared to all other groups. Blood cortisol concentrations during surgery in groups RB and RM remained unchanged. Horses of group R showed higher cortisol concentrations during sedation compared to horses of groups RB and RM.ConclusionRomifidine alone at an initial bolus dose of 0.03 mg/kg followed by a constant rate infusion of 0.05 mg/kg/h was insufficient to obtain an adequate level of sedation and led to increased stress levels, whereas the addition of butorphanol inhibited the stress response. The combination of romifidine with either midazolam or ketamine improved sedation quality and surgical conditions.

The Role Of Epidural Fentanyl In Painless Labour

Background: Epidural analgesia for providing Painless normal vaginal deliveries has been developed over the last 20 years,epidural local anaesthetics was the only available option. However, cetain drugs were added with the local anaesthetics to improves the quality of analgesia.Aims : to ascertain the efficiency of fentanyl added to the epidural local anaesthetics in comparison with the use of an epidural local anaesthetics alone.Patient and methods : This study was carried out on 30 parturients prepared for painless normal vaginal delivery under epidural analgesia in Al-khuder general hospital.&#x0D; Anaesthesiologist (ASA) classification were grade 1 between 20-40 of age with length taller than 160 cm.Subjects were allocated into two groups (15 patients in each group): Group A (n=15) received through an epidural catheter 8 ml lidocaine 0.75%+ 2ml normal saline for the first main dose and subsequent top up doses. Group B (n=15) received through an epidural catheter 8ml lidocaine o.75% + 20 microgram fentanyl diluted with normal saline to a total 2 ml volume for the first main dose and subsequent top up doses. Onset of action of local anaesthetic , the interval from initial bolus dose to the maternal request for additional analgesia , the number of top up doses and the neonatal condition in both groups were recorded.Results : the group B is associated with shorter onset of action , longer interval from initial bolus dose to the maternal request for additional dose and a lesser number of top up doses than group A. The effect on neonatal condition manifested by APGAR score at 5 minute after delivery is similar in both groups.conclusions : 20 microgram of fentanyl added to the usual dose of local anaesthetic epidurally is safe , effective and much better than the use of epidural local anaesthetic alone.

Evaluation of an Unfractionated Heparin Pharmacy Dosing Protocol for the Treatment of Venous Thromboembolism in Nonobese, Obese, and Severely Obese Patients.

Despite large interpatient variability in dose response, heparin is utilized for treatment of venous thromboembolism (VTE). Current data on the optimal heparin dosing in obese patients are conflicting. The objective was to evaluate the time and dose required to achieve a therapeutic activated partial thromboplastin time (aPTT) in nonobese, obese, and severely obese patients using a pharmacist-directed heparin dosing protocol. This was a retrospective cohort study in a single-center community hospital inpatient setting. Adult patients receiving heparin for VTE treatment from July 1, 2013, to July 31, 2015, were evaluated. Patients were categorized into 3 groups: nonobese (BMI < 30 kg/m2), obese (BMI = 30-39.9 kg/m2), and severely obese (BMI ≥ 40 kg/m2). Data on height, weight, initial bolus dose, initial infusion rate, time to therapeutic aPTT, and therapeutic infusion rate were collected. Dosing body weight (DBW) was utilized for patients 20% over their ideal body weight (IBW). The primary outcome was time to therapeutic aPTT. Analysis included 298 patients. Median times to therapeutic aPTT (hours:minutes) in the nonobese, obese, and severely obese were 15:00 (interquartile range [IQR] = 8:05-23:21), 15:40 (IQR = 9:22-25:10), and 15:22 (IQR = 7.54-23:40), respectively ( P = 0.506). There was no difference in bleeding among the nonobese (14%), obese (13.9%), or severely obese groups (7.9%; P = 0.453). No adverse thrombotic events occurred during hospitalization. Using a DBW for heparin dosing in patients 20% over their IBW resulted in similar times to therapeutic aPTT and adverse events in the nonobese, obese, and severely obese.

Metastatic Spinal Cord Compression and Steroid Treatment: A Systematic Review.

Systematic review. We conducted a systematic review of the literature to answer the following questions regarding the use of steroid therapy in metastatic spinal cord compression (MSCC): 1. In cases of MSCC, what is the effect of steroid administration before definitive radiotherapy or surgery on ambulatory status, bowel and bladder function and survival? 2. What steroid dosing regimens are associated with the best outcomes concerning neurological symptoms and complication prevention in cases of MSCC? Currently, there is significant variation in the initial bolus dose, daily maintenance dose and duration of treatment when steroids are used as a bridge to definitive therapy for MSCC. A literature search following PRISMA guidelines was conducted in June 2016, using Medline via Ovid SP, Medline via PubMed, Embase, Biosis Previews and the Cochrane Library. Search terms used in each database varied slightly to optimize results. All generic steroid formulations were included along with spinal cord compression or myelopathy combined with metastatic or malignant tumors. Papers discussing acute traumatic causes of spinal cord compression were excluded, as were papers discussing cord compression from nonmetastatic tumors or epidural lipomatosis. Subjects were limited to adult humans undergoing definitive treatment with radiotherapy or surgery. Of the 309 papers retrieved, 66 full text studies were reviewed and 6 papers were found to address the stated questions. There is a paucity of high quality literature evaluating the use of steroids in MSCC. On the basis of the evidence available an initial 10 mg intravenous bolus of dexamethasone followed by 16 mg PO QD has been associated with fewer complications compared with 100 mg bolus and 96 mg QD. Weaning of steroids should occur rapidly after definitive treatment. Risk of gastric bleeding or perforation can be managed with the routine use of proton-pump inhibitors. Level IIIa.

Optimization of initial propofol bolus dose for EEG Narcotrend Index-guided transition from sevoflurane induction to intravenous anesthesia in children.

Sevoflurane induction followed by intravenous anesthesia is a widely used technique to combine the benefits of an easier and less traumatic venipuncture after sevoflurane inhalation with a recovery with less agitation, nausea, and vomiting after total intravenous anesthesia (TIVA). Combination of two different anesthetics may lead to unwanted burst suppression in the electroencephalogram (EEG) during the transition phase. The objective of this prospective clinical observational study was to identify the optimal initial propofol bolus dose for a smooth transition from sevoflurane induction to TIVA using the EEG Narcotrend Index (NI). Fifty children aged 1-8 years scheduled for elective pediatric surgery were studied. After sevoflurane induction and establishing of an intravenous access, a propofol bolus dose range 0-5 mg·kg-1 was administered at the attending anesthetist's discretion to maintain a NI between 20 and 64, and sevoflurane was stopped. Anesthesia was continued as TIVA with a propofol infusion dose of 15 mg·kg-1 ·h-1 for the first 15 min, followed by stepwise reduction according to McFarlan's pediatric infusion regime, and remifentanil 0.25 μg·kg-1 ·min-1 . Endtidal concentration of sevoflurane, NI, and hemodynamic data were recorded during the whole study period using a standardized case report form. Propofol plasma concentrations were calculated using the paedfusor dataset and a TIVA simulation program. Median endtidal concentration of sevoflurane at the time of administration of the propofol bolus was 5.1 [IQR 4.7-5.9] Vol%. The median propofol bolus dose was 1.2 [IQR 0.9-2.5] mg·kg-1 and median NI thereafter was 33 [IQR 23-40]. Nine children presented with a NI 13-20 and three children with burst suppression in the EEG (NI 0-12); all of them received an initial propofol bolus dose >2 mg·kg-1 . Regression equation demonstrated that NI 20-64 was achieved with a 95% probability when using a propofol bolus dose of 1 mg·kg-1 after sevoflurane induction. Decrease in mean arterial blood pressure correlated significantly with propofol bolus dose (P = 0.038). After 25 min of TIVA, children younger than 2 years had a higher NI (median difference 14.0, 95%CI: 6.0-20.0, P = 0.001), higher deviations from the expected Narcotend Index (median difference 4.1, 95%CI: 3.9-4.2, P < 0.001) and lower calculated propofol plasma concentrations (median difference 0.2 μg·ml-1 , 95% CI: 0.1-0.3 μg·ml-1 , P < 0.001) than older children. After sevoflurane induction, a reduced propofol bolus dose of 1 mg·kg-1 followed by TIVA according to McFarlan's regime resulted in a NI within the recommended range in children aged 1-8 years. During the course of TIVA, children younger than 2 years displayed higher NI values and more pronounced interindividual variation. Processed EEG monitoring is recommended to find adequate individual age-dependent doses.

Thoracic Paravertebral Analgesia for Treatment Blunt Chest Trauma with Multiple Rib Fractures

Multiple rib fracture (MRF) causes severe pain that compromise respiratory mechanics. We evaluated the efficacy of thoracic paravertebral block with bupivacaine -fentanyl mixture in patients with unilateral MRF. The study was carried out on 172 blunt chest trauma patients in prospective nonrandomized case series. An initial bolus dose of 0.3 ml/kg of bupivacaine 0.25% plus fentanyl 2 μg/ml was used following by continuous infusion with 0.1 ml/kg/h of bupivacaine 0.125% plus fentanyl 2 μg/ml. Pain severity was assessed by visual analogue scale (VAS) at rest and during coughing; bedside spirometry was measured 5 times in 3 consecutive days after paravertebral block. Traffic accidents (69.1%) was major reason for blunt chest trauma; the number of ribs fracture ranged from 3-5 (76.1%) and 6-8 (23.9%). The rate of hemothorax, pneumothorax and the combination hemothorax-pneumothorax were 64.5%, 7.6% and 27.9% respectively. There was significant improvement in pain score at rest and during coughing, respiratory rate, FVC and FEV1 (p<0.05) 30 min after initial bolus dose, which were sustained during continuous thoracic paravertebral infusion 72 h (p<0.05). The rate of analgesic rescue by paracetamol infusion was 6.4%. No patient had respiratory depression or respiratory failure or signs of local anesthetic toxicity. The result shows that thoracic paravertebral analgesia with bupivacaine and fentanyl provided a good efficacy for pain management in patients with unilateral MRF.

The Use of Thrombolytic Therapy in the Treatment of Frostbite Injury.

Frostbite can lead to severe consequences including loss of digits and limbs. One of the mechanisms of frostbite includes vascular thrombosis. The use of tissue plasminogen activator (tPA) in frostbite has been shown to be effective in case reports and small prospective studies. A retrospective chart review was performed on all patients admitted for frostbite between January 2008 and April 2015, and six patients were identified as having received treatment with intravenous tPA. Patients received an initial bolus dose followed by a 6-hour infusion of tPA. Five patients (83.3%) were treated with continuous infusion heparin following tPA administration. Three patients (50%) were discharged on aspirin 325 mg daily for 30 days and two patients (33.3%) were discharged on warfarin for 28 days. There were no serious complications noted with tPA. In this case series, there were 65 digits at risk for amputation in six patients. Only 16 digits (24.6%) were partially or completely amputated in three (50%) of the patients. After rapid rewarming, the use of tPA is safe and effective at reducing the number of digits amputated. Patients who had less of a response to tPA were those who had an unknown duration of cold exposure along with drug or alcohol intoxication at presentation. Utilizing a guideline with clear criteria will help facilitate determining appropriate patients to safely treat with tPA for frostbite injury.

Fluoroscopically Guided Thoracic Interlaminar Epidural Injection: A Comparative Epidurography Study Using 2.5 mL and 5 mL of Contrast Dye

Background: Thoracic epidural anesthesia (TEA) is frequently used to maintain intraoperative analgesia. After injecting the initial bolus dose of epidural local anesthetics (LA), intermittent injection of LA through an epidural catheter is required to maintain the intraoperative analgesia. For intermittent epidural administration, usually 2 – 5 mL of LA has been used. However, no studies have suggested an optimal volume of LA of TEA for intermittent epidural administration of TEA. Objective: We focused on identifying an optimal volume of LA of TEA using epidurography of the thoracic level with 2 different volumes of contrast dye. Study Design: Prospective, randomized study. Setting: An interventional pain management practice in South Korea. Methods: After Institutional Review Board approval, 70 patients undergoing thoracic epidural catheterization for upper abdominal and thoracic surgery were randomly assigned to one of the 2 contrast dye volume groups of 35 patients each (A, 2.5 mL and B, 5.0 mL). Epidurography was evaluated to confirm how many spinal segments were covered by contrast dye. The spreads in the cephalad and caudad directions were also evaluated. Results: The total number of vertebral segments evaluated by contrast dye were 7.5 ± 2.0, and 8.4 ± 2.6, respectively in groups A and B. The number of patients who showed contrast dye spread of more than 5 vertebral segments was 34/35 (97%) in both groups. Group B resulted in higher contrast dye distribution in the cephalad direction compared to group A (T2.6 vs. T3.6 ). Limitations: We used a test dose of contrast dye to confirm the contrast was in epidural space, not intrathecal or vascular, before injection of the main dose of contrast dye. The present study did not include the volume of test dose. Conclusion: The volume of 2.5 mL for intermittent epidural administration would be enough for the analgesic effect of upper abdominal and thoracic surgery while avoiding excessive upper thoracic and cervical spread. Key words: Thoracic epidural anesthesia, intermittent epidural administration, optimal volume, epidurography, cephalad, caudad, analgesic effect