Intraoperative Fentanyl Consumption Research Articles

Ultrasound Guided PECS II Block versus Thoracic Epidural in Modified Radical Mastectomy for Post-Operative Pain Relief

AbstractBackground: Breast cancer is women's most common malignancy and has steadily increased incidence over the past decade. Despite recent breast cancer surgery advances, this procedure is often associated with postoperative pain, nausea, and vomiting, contributing not only to increased patient discomfort, but also to extended hospital stays and associated costs. A significant risk factor for the development of chronic pain following breast surgery is acute postoperative pain due to insufficient or ineffective pain control.Aim of Study: Assess the effectiveness of ultrasound guided PECS block to thoracic epidural blockage in breast cancer surgery to minimize postoperative pain, analgesic requirements and complications.Patients and Methods: After Ethical Committee at Al-Zahraa University Hospital accepted, 50 female patients, age from 42-67 years, were included in the study with ASA physical status I-II patients scheduled for unilateral modified radical mastectomy and axillary lymph node dissection, randomly blind assigned, split two different groups of 25 patients in each, Thoracic epidural block (TEB group); patients were received a single shot of 15ml of 0.25% bupivacaine between T4 and T5 vertebrae. PECS group: Ultrasound-guided PECS block, the patients were received 0.25% of 10ml bupi-vacaine injected at fiscal plain between the pectoral s major and minor muscles (PECS I) also 0.25% of 20ml of pectoral-minor injection above the Serratus anterior muscle (PECS II). Primary outcome in the form of post-operative visual analogue scale (VAS) to assess pain in density. Secondary outcome in the form heart rate (HR), mean blood pressure (MBP) intra operative fentanyl consumption and, first request of analgesia, total amount of pethidine/24 hrs. were recorded and other any post-operative complication were assessed.Results: The patients of TEB group, the mean heart rate and the mean MAP were highly significant decrease than PECS group. Intra operative fentanyl consumption as statis-tically significant decrease in PECS group compared with TEB group. VAS pain scores was high statistically significant decrease immediately and at 4 hrs. post-operative in PECS group than TEB group. The time for the first request for pethidine was highly significantly longer in the PECS group than in TEB group. Amount of pethidine at 24 hrs. was high significant lower in PECS group in comparison with TEB group. Complications recorded as hypotension and bradycardia post-operative nausea and vomiting (PONV) occurrence in TEB group.Conclusion: PECS blocks provided superior post-operative analgesia, low pain scores and less total pethidine consumption in the early postoperative period and maintained hemodynamic stability compared to TEB.

Ultrasound-guided erector spinae plane block for acute pain management in patients undergoing posterior lumbar interbody fusion under general anaesthesia

Background: The article dealt with evaluating the efficacy of bilateral single shot ultrasound-guided (US-guided) lumbar erector spinae plane block (ESPB) in patients scheduled for L3-L5 posterior lumbar interbody fusion (PLIF) under general anaesthesia (GA). The primary goal of the article was to determine total morphine consumption 24 hours postoperative. Secondary goals included determining total intraoperative and postoperative opioid consumption, length of post-anaesthesia care unit (PACU) stay, and complications. Methods: Sixty patients, American Society of Anesthesiologists (ASA) I and II, aged 18–60 years, undergoing PLIF under GA were enrolled in this prospective, randomised, double-blinded study. Patients were randomised to 2 groups (30 patients each). Group I (control group) received GA only and group II received preoperative bilateral ESPB with 20 ml 0.25% bupivacaine. The primary outcome was postoperative morphine consumption. Secondary measurements were intraoperative fentanyl consumption, time to first analgesic request, static and dynamic visual analogue score (VAS), haemodynamic changes, PACU stay, and complications. Results: Patients who received ESPB showed a significant decrease in intraoperative and postoperative opioid consumption, shortened PACU stay, and haemodynamic stability compared to those who received GA only. Significant increase of VAS was observed in group I compared with group II up to 8 and 12 hours postoperative (static and dynamic VAS respectively). Conclusion: Preoperative bilateral single shot US-guided ESPB provided safe and effective postoperative analgesia for PLIF with reduced opioid consumption and short PACU stay.

Efficacy of Dexmedetomidine Infusion Without Loading Dose as a Potent Hypotensive Agent in Lumbar Fixation Surgery

Background:Dexmedetomidine on the basis of the previous literature can be considered a safe agent for controlled hypotension through its central and peripheral sympatholytic action. Its easy administration and absence of fatal side effect make it a near-ideal hypotensive agent. This study was intended to evaluate the efficacy of dexmedetomidine infusion “without loading dose” as an effective hypotensive agent in lumbar fixation surgery.Methods:In a double-blind study, a total of 60 patients aged 18-65 years, of both genders, belonging to the American Society of Anesthesiologist (ASA) class I - II scheduled for elective lumbar spine instrumentation were included and divided into: Control group (Group C) who received placebo and Dexmedetomidine group (Group D) who received Intravenous (IV) dexmedetomidine. The patients were compared primarily for intraoperative hemodynamics.Results:The study results showed that dexmedetomidine had successfully maintained target mean blood pressure of 65-70 mmHg and only 2 patients out of 30 required rescue therapy (both of propofol and NG). Also, dexmedetomidine had maintained heart rate stability than the control group from the 15thminute after positioning till the end of surgery (P-value < 0.001). Intraoperative fentanyl consumption was significantly low in Dexmedetomidine group 75 ± 25.43 µgversus169.64 ± 34.26 µg in Control group (P-value < 0.001). Finally, more post-operative sedation was noticed during the 1stpostoperative hour in dexmedetomidine group when compared to the control group (P-value < 0.001).Conclusion:Dexmedetomidine infusion without loading dose could be an effective and safe agent in achieving controlled hypotension in adults undergoing elective lumbar spine instrumentation surgery with limited side effects together with intraoperative opioid-sparing effect.

Comparative Evaluation of IV Paracetamol Versus IV Dexmedetomidine in Inpatient Oral and Maxillofacial Surgery: A Double-Blinded Randomized Controlled Study

Reconstructive surgeries following fractures in the maxillofacial region often involve considerable bone manipulation, and paracetamol is a commonly used analgesic medication in both intraoperative and postoperative periods. Dexmedetomidine, an alpha-2 adrenoceptor agonist, has both sedative and analgesic properties with minimal cardiorespiratory effects and has been used primarily for its sedative properties in oral and maxillofacial surgery. To compare the intraoperative analgesic requirements among patients undergoing oral and maxillofacial surgery who receive IV paracetamol versus IV dexmedetomidine. The time to requirement for the first postoperative analgesic dose and safety and adverse events of both medications were also assessed. In total, 64 patients needing primary reconstructive surgery for facial fractures were recruited and divided into two groups for this double-blinded study. Patients were randomized to receive a preinduction dose of either IV paracetamol 1g (Group P) or IV dexmedetomidine 1µg/kg (Group D). Sedation scores (Ramsay sedation scale), maximal interincisal distance and pain scores at maximal mouth opening (visual analogue scale) were assessed in both groups just prior to and after the administration of the study drugs. After induction, Group P and Group D received a maintenance dose of normal saline and dexmedetomidine (0.5µg/kg/h) during the intraoperative period, respectively. Standard noninvasive cardiorespiratory monitoring was done for the entire duration of surgery. Following extubation, postoperative pain scores and the time to request for first analgesic dose in either group were recorded. The time taken to perform the surgery was comparable in both groups. There was a significant difference between the groups in visual analogue scores and interincisal distance after the bolus dose (p < 0.05). Systolic and diastolic blood pressure was significantly lower in Group D at around 150 and 175min of surgery. While the intraoperative fentanyl consumption was comparable in both groups, the time to request for the first analgesic dose in the postoperative period was significantly delayed in Group P (p < 0.05). No adverse cardiopulmonary events were observed in either group. The intraoperative anesthetic and analgesic requirements and hemodynamic stability were comparable in IV paracetamol and dexmedetomidine groups. Dexmedetomidine did not confer any enhanced analgesia effect in the postoperative period. More research examining the role of dexmedetomidine for longer duration inpatient oral and maxillofacial surgery is needed. http://ClinicalTrials.gov (No. CTRI/2017/08/009468).

Effect of Paracetamol and Dexamethasone with Lidocaine in Intravenous Regional Anesthesia of Upper Limb Surgeries

Background: Upper limb surgeries may be done under general anaesthesia or other methods such as nerve block or regional anaesthesia such as intravenous regional anesthesia (IVRA). Intravenous regional anesthesia has many advantages such as cost effectiveness, day case surgeries and reduced hemorrhage risk. Objective: The primary objective was to evaluate the effect of paracetamol and dexamethasone when combined with lidocaine on the depth and duration of IVR anesthesia in upper limbs. The secondary objective was to evaluate the onset of tourniquet-associated pain, time of 1st analgesic request, total opioid consumption and haemodynamic stability. Patients and Methods: Patients of this study were classified into 4 groups, 1 st group received 3 mg/kg lidocaine 2% completed by normal saline to 40 cc total volume without any additives and named as group L. 2 nd group received 3 mg/kg lidocaine 2% plus 8 mg dexamethason completed by normal saline to 40 cc total volume and named as group D. 3 rd group received 3 mg/kg lidocaine 2% plus 250 mg paracetamol completed to 40 cc total volume and named as group P. 4th group received 3 mg/kg lidocaine 2% plus 8 mg dexamethasone plus 250 mg paracetamol completed to 40cc total volume and named as group LDP. These groups were evaluated for haemodynamics and onset of sensory and motor block and time of recovery of sensory and motor block as well as intraoperative VAS score and fentanyl consumption. Results: As regard average values of intraoperative VAS, 4 th group had the lowest numbers then 2nd group, 3 rd group then 1st group which had the highest numbers. As regard the time to 1st analgesic request, the 1 st group showed the shortest time meanwhile the 4 th group showed the longest time to 1st analgesic request while 2 nd and 3rd groups were in between. Total opioid consumption was the least among the 4th group in comparison with the other three groups especially the 1st one, which showed the highest consumption. Finally, 4 th group proved to be the best one as regarding good anaesthesia and analgesia and reduction in intraoperative pain score as well as reduction in opioid consumption. Conclusion: Paracetamol and dexamethasone when combined to lidocaine in intravenous regional anaesthesia in upper limb produce synergistic effect on sensory and motor block, reduce intraoperative pain score and decrease amount of intra operative opioid consumption.

Comparison of intraoperative hemodynamic stability between quadratus lumborum and epidural block in patients who underwent laparoscopic nephrectomy

Laparoscopic nephrectomy has become the standard procedure for living donor renal transplant in Indonesia. The anesthesia technique used for this procedure is general anesthesia combined with regional anesthesia. Among many techniques available, epidural block is often performed. This study aims to compare hemodynamic stability between Quadratus Lumborum (QL) block, as a new alternative block, and epidural block for laparoscopic nephrectomy. Patients were randomized to receive epidural block (n=13) or QL block (n=13) for intraoperative analgesia during laparoscopic nephrectomy. Patients in epidural group received continuous bupivacaine 0.25% infusion 6 ml/hours and patients in QL group received 20 ml of bupivacaine 0.25% bilaterally. Hemodynamic variables consisting of mean arterial pressure (MAP), heart rates (HR), as well as fentanyl consumption between the two groups were compared. There were significant differences in intraoperative MAP between epidural block group and QL block group (p = 0.001). However, there were no significant differences in HR (p = 0.114) and fentanyl consumption (p = 0.593) between two groups. QL block produced a relatively steadier MAP compared to epidural block; however intraoperative HR and fentanyl consumption between two groups had no significant difference.

Effect of Paracetamol and Dexamethasone with Lidocaine in Intravenous Regional Anesthesia of Upper Limb Surgeries

Background: Upper limb surgeries may be done under general anaesthesia or other methods such as nerve block or regional anaesthesia such as intravenous regional anesthesia (IVRA). Intravenous regional anesthesia has many advantages such as cost effectiveness, day case surgeries and reduced hemorrhage risk. Objective: The primary objective was to evaluate the effect of paracetamol and dexamethasone when combined with lidocaine on the depth and duration of IVR anesthesia in upper limbs. The secondary objective was to evaluate the onset of tourniquet-associated pain, time of 1st analgesic request, total opioid consumption and haemodynamic stability. Patients and Methods: Patients of this study were classified into 4 groups, 1 st group received 3 mg/kg lidocaine 2% completed by normal saline to 40 cc total volume without any additives and named as group L. 2 nd group received 3 mg/kg lidocaine 2% plus 8 mg dexamethason completed by normal saline to 40 cc total volume and named as group D. 3 rd group received 3 mg/kg lidocaine 2% plus 250 mg paracetamol completed to 40 cc total volume and named as group P. 4th group received 3 mg/kg lidocaine 2% plus 8 mg dexamethasone plus 250 mg paracetamol completed to 40cc total volume and named as group LDP. These groups were evaluated for haemodynamics and onset of sensory and motor block and time of recovery of sensory and motor block as well as intraoperative VAS score and fentanyl consumption. Results: As regard average values of intraoperative VAS, 4 th group had the lowest numbers then 2nd group, 3 rd group then 1st group which had the highest numbers. As regard the time to 1st analgesic request, the 1 st group showed the shortest time meanwhile the 4 th group showed the longest time to 1st analgesic request while 2 nd and 3rd groups were in between. Total opioid consumption was the least among the 4th group in comparison with the other three groups especially the 1st one, which showed the highest consumption. Finally, 4 th group proved to be the best one as regarding good anaesthesia and analgesia and reduction in intraoperative pain score as well as reduction in opioid consumption. Conclusion: Paracetamol and dexamethasone when combined to lidocaine in intravenous regional anaesthesia in upper limb produce synergistic effect on sensory and motor block, reduce intraoperative pain score and decrease amount of intra operative opioid consumption.

Ultrasound-Guided Erector Spinae Plane Block in Patients Undergoing Open Epigastric Hernia Repair: A Prospective Randomized Controlled Study.

Hernia repair is associated with considerable postoperative pain. We studied the analgesic efficacy of bilateral ultrasound-guided erector spinae plane block in patients undergoing open midline epigastric hernia repair (T6-T9). Sixty patients 18-65 years of age were randomly allocated into 2 groups. Patients in the erector spinae plane block group received bilateral ultrasound-guided erector spinae plane block at the level of T7 transverse process using 20 mL of bupivacaine 0.25% on each side, while the control group received bilateral sham erector spinae plane block using 1 mL of normal saline. All patients underwent general anesthesia for surgery. Pain severity (visual analog scale), consumption of intraoperative fentanyl, time to first request of rescue analgesia, and postoperative pethidine consumption were recorded over the first 24 hours postoperatively. At 2 hours postoperatively, the visual analog scale pain score was significantly lower in the erector spinae plane block group compared to the control group (estimated main effect of 2.53; P < .001; 95% CI, 1.8-3.2) and remained lower until 12 hours postoperatively (P < .001 from postanesthesia care unit admission to 4 hours postoperatively, .001 at 6 hours, .025 at 8 hours, and .043 at 12 hours). At 18 and 24 hours, visual analog scale pain scores were not significantly different between both groups (P = .634 and .432, respectively). Four patients in the erector spinae plane block group required intraoperative fentanyl compared to 27 patients in control group. The median (quartiles) of intraoperative fentanyl consumption in the erector spinae plane block group was significantly lower (0 µg [0-0 µg]) compared to that of the control group (94 µg [74-130 µg]). Ten patients in the erector spinae plane block group required postoperative rescue pethidine compared to 25 patients in control group. The median [quartiles] of postoperative rescue pethidine consumption was significantly lower in the erector spinae plane block group (0 mg [0-33 mg]) compared to that of the control group (83 mg [64-109 mg]). Time to first rescue analgesic request was significantly prolonged in the erector spinae plane block group compared to control group (P < .001). Ultrasound-guided bilateral erector spinae plane block provided lower postoperative visual analog scale pain scores and decreased consumption of both intraoperative fentanyl and postoperative rescue analgesia for patients undergoing open epigastric hernia repair.

Dexmedetomidine versus lidocaine as an adjuvant to general anesthesia for elective abdominal gynecological surgeries

Study objectiveThe current study was conducted to compare the effect of perioperative administration of intravenous dexmedetomidine versus lidocaine on the perioperative hemodynamic changes, anesthetic consumption, anesthesia induction, and recovery times in patients undergoing elective abdominal gynecological surgeries under general anesthesia.Materials and methodsNinety female patients undergoing elective abdominal gynecological surgeries were enrolled in the current study. Patients were randomly distributed to one of three equal groups: group L received lidocaine (1.5 mg/kg loading, 2 mg/kg/h infusion), group D received dexmedetomidine (1 μg/kg loading, 0.5 μg/kg/h infusion), and group C received isotonic saline 0.9% in the same volume and pattern as the study drugs. Hemodynamic parameters including mean arterial pressure (MAP) and heart rate (HR), anesthetic consumption and induction, recovery times, and time to the first postoperative analgesic demand were recorded.ResultsThe MAP and HR after endotracheal intubation and in the subsequent recordings were significantly lower in group L and D when compared with group C with no significant difference between group D and L. The propofol induction dose and mean end-tidal isoflurane concentration were significantly lower in group L and D when compared with group C and were also significantly lower in group D when compared with group L. The intraoperative fentanyl consumption was significantly lower in group L and D when compared with group C with no significant difference between group D and L. The anesthesia induction time was significantly shorter in group L and D when compared with group C; it was also significantly shorter in group D when compared with group L with no significant difference as regards the anesthesia recovery time and the response time between the three study groups. The time to the first postoperative analgesic requirement was significantly longer in group D and L when compared with group C; it was also significantly longer in group D when compared with group L.ConclusionBoth dexmedetomidine and lidocaine could be a useful adjuvant to general anesthesia in patients undergoing abdominal gynecological surgeries. However, dexmedetomidine has a better sparing effect on intraoperative anesthetic consumption and longer time to the first postoperative analgesic demand than that of lidocaine with no significant difference between both agents on intraoperative analgesic demand.

Efficacy of ultrasound-guided transversus abdominis plane block in breast reconstruction surgery with abdominal myocutaneous flap

Background: Ultrasound (US)-guided transversus abdominis plane block (TAPB) provides postoperative analgesic efficacy in abdominal surgery, however evidence of its efficacy in reconstructive breast surgery with transversus rectus abdominis myocutaneous (TRAM) flap is still limited. Our main objective was to assess effectiveness of TAPB in this surgery. Methods: Observational retrospective study conducted in patients undergoing unilateral breast reconstruction with TRAM (surgery 1) and mastectomy (partial or total) followed by TRAM reconstruction (surgery 2) from April 2015 to June 2017. Two anaesthetic plans were analysed: general balanced anaesthesia (GBA) and combined GBA with bilateral TAPB (GBA+TAPB). Primary outcomes were total intraoperative administered fentanyl, total consumed morphine in postoperative anaesthesia care unit (PACU) and time between conclusion of surgery and first requested analgesic (analgesia time). Results: 107 patients were included: 80 submitted to surgery 1 and 27 submitted to surgery 2. In surgery 1, intraoperative fentanyl consumption and administered morphine, during the patients’ stay at PACU, were lower in GBA+TAPB than in GBA group (p Regarding surgery 2, globally no significant differences were identified between both groups. No complications associated to local anaesthetics or TAPB were registered. Conclusion: US-guided bilateral TAPB resulted in lower opioid consumption and better pain control in unilateral breast reconstruction surgery with TRAM.

Role of erector spinae plane block versus paravertebral block in pain control after modified radical mastectomy. A prospective randomised trial.

Background and Aims:Thoracic paravertebral block (TPVB) provides effective analgesia in breast surgery. Recently, use of erector spinae plane block (ESPB) in controlling post-operative pain has proved effective. This study aimed to compare the effect of ESPB with TPVB in post-mastectomy acute pain control.Methods:A prospective, randomised double-blinded study enrolled 70 adult female patients, scheduled for modified radical mastectomy. Patients were randomised into two groups, receiving 20 ml of 0.25% bupivacaine: group I (TPVB) and group II (ESPB). Post-operative 24 h morphine consumption, intra-operative fentanyl consumption, time of the first request for analgesia and post-operative visual analogue scale (VAS), heart rate (HR), mean blood pressure (MBP) and complications were recorded.Results:Post-operative 24 h morphine consumption and time of the first request for analgesia were comparable between both groups (P = 0.32 and 0.075, respectively). There was no significant difference in the intra-operative fentanyl consumption. There was also no significant difference in VAS between both groups over the 24 h of study. Four patients in group I developed pneumothorax with no significant differences between both groups (P = 0.114). Incidence of nausea and vomiting was comparable between both groups. All patients displayed a stable haemodynamic profile.Conclusion:Both TPVB and ESPB can be effectively used in controlling post-mastectomy pain and reduce intra-operative and post-operative opioid consumption.

Effect of magnesium and lignocaine on post-craniotomy pain: A comparative, randomized, double blind, placebo-controlled study.

Background:Lignocaine and Magnesium have an analgesic action and reduce perioperative opioid requirements. We carried out this study to evaluate the effect of magnesium and lignocaine on postoperative pain as assessed using the visual analog scale (VAS) and fentanyl consumption. We also measured S-100 B levels and noted the side effect of drugs if any.Materials and Methods:In this prospective preliminary study, 45 patients undergoing supratentorial craniotomy for tumor surgery were randomized to receive either lignocaine (group I-1.5 mg/kg bolus followed by 2 mg/kg/h infusion), saline (Group II) or magnesium (group III: bolus of 50 mg/kg followed by 25 mg/kg/hr) intraoperatively. The amount of fentanyl required, VAS over first 24 hours and any side effects were noted. S100 B levels were also measured to assess brain protective effect of these drugs, if any. Appropriate statistical tests were applied for analysis of data and a P value < 0.05 was considered statistically significant.Results:None of the patient experienced any adverse hemodynamic effect intraoperatively secondary to the study drugs. The amount of intraoperative fentanyl consumption was comparable among the three groups. The mean VAS score was significantly less in group I and III [Group I (15.3 ± 6.0), Group II (24.8 ± 6.7), Group III (17.9 ± 7.6); (P < 0.01)]. The fentanyl consumed in first 24 hours was significantly less in those patients who received lignocaine and magnesium [Group I (204.4 ± 136.4), Group II (383 ± 168.2), Group III (194 ± 148.9); (P = 0.01)]. S100 value did not differ in the lignocaine and the saline group during the perioperative period. However, a significant decline was noted in the levels of S100 B in the magnesium group.Conclusion:Intraoperative infusion of lignocaine and magnesium results in lower VAS score and decreases the postoperative opioid requirement in patients undergoing craniotomy for excision of supratentorial tumors.

Retrobulbar dexmedetomidine in pediatric vitreoretinal surgery eliminates the need for intraoperative fentanyl and postoperative analgesia: A randomized controlled study

Purpose:This study evaluated the efficacy of retrobulbar ropivacaine plus dexmedetomidine compared with systemic fentanyl in pediatric vitreoretinal (VR) surgery.Methods:This prospective double-blind, randomized controlled study was performed in 60 children undergoing VR surgery, age from 2 to 7 years. After general anesthesia, the following procedure was administrated: (1) retrobulbar block with 0.5% ropivacaine plus dexmedetomidine 1 μg/kg (group RD, n = 20), (2) retrobulbar block with 0.5% ropivacaine (group RB, n = 20), and (3) control group with general anesthesia only (group F, n = 20). Hemodynamics, postoperative pain scores, anesthetics consumption (remifentanil, propofol, fentanyl), and emergence agitation were recorded.Results:Respiratory depression was observed in 7 of the 20 patients in group F after the laryngeal mask airway was removed in the operating room, compared with none in groups RD and RB. All patients in group F required intraoperative rescue fentanyl (average intraoperative fentanyl consumption, 26.6 ± 12.6 μg per patient). Some rescue fentanyl was required in group RB (three patients required one dose of rescue fentanyl). Patients in group RD required none. Groups RD and RB reported lower pain scores than group F at 4 h postoperatively (RD group: P < 0.001; RB group: P =0.002); pain scores in group RD were lower than that in group F at 6 h postoperatively (P < 0.001).Conclusion:Retrobulbar dexmedetomidine as an adjuvant to ropivacaine is a safe and effective alternative to systemic fentanyl. This regimen provides better pain management, hemodynamic stability, and stress response suppression in pediatric VR surgery.

Preventive Multimodal Analgesia Versus Morphine in Cancer Patients Undergoing Major Abdominal Surgeries

AbstractBackground: Opioids are the corner stone for perioperative analgesia in major surgeries. The aim of this study was to compare the efficacy of preventive multimodal analgesia versus morphine on post-operative pain and total morphine consumption.Aim of Study: To compare the efficacy of preventive multimodal analgesia versus morphine in cancer patients undergoing major abdominal surgeries.Patients and Methods: This prospective randomized study was done from March 2018 to September 2018 after approval of the institutional board review of National Cancer Institute. Forty cancer patients were randomly allocated in the study; patients were divided into 2 groups; multimodal group (n=20) received Ketamine, magnesium, ketorolac, paracetamol, with TAB (transverse abdominis plane) block before surgical incision and morphine group (n=20) received morphine sul-phate 0.1mg/kg before surgical incision.Results: There was statistically significant difference in intraoperative fentanyl consumption p-value (<0.001) and total morphine consumption in the first 24 hours postopera-tively p-value (0.001) between the 2 studied groups being higher in the morphine group.Conclusion: Preventive multimodal analgesia has superior analgesic profile than morphine regarding perioperative analgesia and morphine consumption in the first 24 hours post-operatively.

Role of dexamethasone in the para-vertebral block for pediatric patients undergoing aortic coarctation repair. randomized, double-blinded controlled study

BackgroundSurgery for aortic coarctation requires special care during anesthesia due to severe pain during the lateral thoracotomy incision, intraoperative hemodynamic instability and the need for large doses of intra- and postoperative analgesics and vasodilators. Additionally, the postoperative care of patients is very important.AimsWe aimed to compare ultrasound-guided paravertebral block performed using bupivacaine alone and bupivacaine with dexamethasone in terms of the intra- and postoperative analgesic requirements and hemodynamics, postoperative complications and ICU stay.Study designThis was a prospective, randomized, controlled, double-blinded study.MethodsFifty patients aged four to 12 months scheduled for aortic coarctation surgery were randomly divided into two equal groups (n = 25). Patients in group D (dexamethasone) received 0.5 mg/kg bupivacaine 0.25% mixed with 0.1 mg/kg dexamethasone diluted with isotonic saline and those in group C (control) received 0.5 mg/kg bupivacaine 0.25% diluted with isotonic saline (total volume 15 ml in each group). Intraoperative fentanyl consumption and hemodynamics (heart rate, arterial blood pressure) at baseline, 1 min after induction, at skin incision, after 30 min, after clamping, after declamping and at the end of the surgery were recorded, along with the objective pain score (OPS) immediately postoperatively and at 4 h, 8 h, 12 h and 24 h postoperatively and the time to the first request for pethidine. The intra- and postoperative vasodilator doses, time to extubation, ICU stay duration and postoperative complications were also recorded.ResultsThe postoperative OPS was significantly lower at 12 and 24 h in group D than in group C. The time to the first request for analgesia was significantly longer in group D than in group C (3.9 ± 2.23 vs 8.6 ± 0.69). Additionally, the time to extubation was significantly shorter in group D.ConclusionThe use of dexamethasone as an adjuvant in ultrasound-guided paravertebral block in paediatric patients undergoing surgery for aortic coarctation increased the duration of postoperative analgesia with a prolonged time to the first request for analgesics It was also associated with a decreased incidence of postoperative complications.Trial registrationTrial registration number: NCT03074773. (Prospectively registered). The initial registration date was 9/3/2017.

Dexmedetomidine combined with local anesthetics in thoracic paravertebral block: A systematic review and meta-analysis of randomized controlled trials.

BackgroundDexmedetomidine (DEX) improves postoperative pain scores and prolongs the duration of blockage when combined with local anesthetics (LAs) for neuraxial and brachial plexus block; however, there is little information about the effectiveness of DEX as an adjuvant to LAs in paravertebral block (PVB). Therefore, a systematic review and meta-analysis were performed to evaluate the safety and efficacy of DEX combined with LAs in PVB.MethodAn electronic database search from inception date to February 2018 was performed. Randomized controlled trials (RCTs) comparing DEX as an adjuvant to LAs with LAs alone for PVB in adult patients were included. Postoperative pain scores, duration of analgesia, cumulative perioperative analgesic consumption, and adverse events were analyzed.ResultWe identified 7 trials enrolling 350 patients and found that DEX reduced pain scores at rest by standardized mean differences (SMD) −0.86 cm (95% confidence interval [CI] [−1.55, −0.17], P = .01) and SMD −0.93 cm (95% CI [−1.41, −0.26], P =.008) at postoperative 12 hours and 24 hours, respectively. DEX reduced pain scores while dynamic by SMD −1.63 cm (95% CI [−2.92, −0.34], P =.01) and SMD −1.78 cm (95% CI [−2.66, −0.90], P =.007) for postoperative 12 hours and 24 hours, respectively. DEX extended the duration of analgesia by weighted mean differences (WMD) 201.53 minutes (95% CI [33.45, 369.61], P =.02); and reduced cumulative postoperative analgesic consumption by WMD −7.71 mg (95% CI [−10.64, −4.78], P <.001) and WMD −45.64 mg (95% CI [−69.76, −21.53], P < .001) for 24 hours morphine and 48 hours tramadol subgroups, respectively. DEX also increased the odds of hypotension by odds ratio (OR) 4.40 (95% CI [1.37, 14.17], P = .01); however, there was no statistically significant difference for intraoperative fentanyl consumption and the incidence of the bradycardia.ConclusionsDEX combined with LAs in PVB significantly improved postoperative pain scores, prolonged the duration of analgesia, reduced postoperative analgesic consumption, and increased the odds of hypotension. However, we cannot neglect the heterogeneity of the included RCTs. More large-scale prospective studies are needed to further clarify the above conclusions.Systematic review registrationPROSPERO registration number CRD42018090251.

Efficacy of oxycodone combined with thoracic paravertebral block for postoperative analgesia in patients undergoing minimally invasive direct coronary artery bypass grafting

Objective To evaluate the efficacy of oxycodone combined with thoracic paravertebral block (TPVB) for postoperative analgesia in patients undergoing minimally invasive direct coronary artery bypass grafting (MIDCABG). Methods Thirty-two American Society of Anesthesiologists physical status Ⅱ or Ⅲ patients of both sexes, aged 60-75 yr, weighing 50-85 kg, scheduled for elective MIDCABG under general anesthesia, were divided into 2 groups (n=16 each) using a random number table method: morphine plus TPVB group (group MT) and oxycodone plus TPVB group (group OT). Paravertebral catheter was placed at T4, 5 before induction of anesthesia to perform left thoracic paravertebral puncture, patients were tracheally intubated, and 0.375% ropivacaine 15 ml was injected followed by continuous infusion of 0.375% ropivacaine 5 ml/h until 0.5 h before the end of surgery.Both groups received patient-controlled analgesia (PCA) after surgery.The PCA solution contained 1 mg/ml morphine 60 ml in group MT or 1 mg/ml oxycodone 60 ml in group OT, and the PCA pump was set up to deliver a 1 mg bolus dose with a 10-min lockout interval and background infusion at 1 ml/h after a loading dose of 2 mg, with the maximum dose of 20 mg every 4 h. Pethidine 50 mg was intravenously injected as a rescue analgesic to maintain visual analog scale≤4.The intraoperative consumption of fentanyl, consumption of analgesics for PCA within 48 h after surgery, ratio of total to effective pressing times of PCA, consumption of analgesics for rescue analgesia, requirement for rescue analgesia, score of satisfactory analgesia, extubation time, duration of intensive care unit stay and length of hospital stay were recorded.The development of nausea and vomiting, pruritus, respiratory depression, atelectasis and somnolence was recorded within 72 h after surgery. Results Compared with group MT, the intraoperative consumption of fentanyl, consumption of analgesics for PCA, consumption of analgesics for rescue analgesia, requirement for rescue analgesia and ratio of total to effective pressing times of PCA were significantly decreased, the score of satisfactory analgesia was increased, the extubation time and duration of intensive care unit stay were shortened, and the incidence of nausea and vomiting, pruritus, respiratory depression and somnolence was decreased in group OT (P<0.05). Conclusion Oxycodone combined with TPVB provides safe and effective efficacy for postoperative analgesia in patients undergoing MIDCABG. Key words: Oxycodone; Analgesia, patient-controlled; Nerve block; Coronary artery bypass, off-pump

Controlled Hypotension for Functional Endoscopic Sinus Surgery: A Comparative study between Dexmedetomidine versus Esmolol

Background: Functional endoscopic sinus surgery (FESS) requires effective control of bleeding forbetter visibility of the operating field and reduced risk of injury to the optic nerve or the internal carotidartery. Controlled hypotension is a technique used to limit intraoperative blood loss to provide the bestpossible field for surgery. Objectives: Our study is undertaken to evaluate the efficacy of dexmedetomidine as a hypotensive agentin comparison to esmolol in Functional Endoscopic Sinus Surgery (FESS). Method: Sixty (60) patients 20 – 50 years of age, ASA I/II scheduled for FESS were equally randomlyassigned to two equal groups of 30 patients each. Patients of group D received dexmedetomidine 1μg/kgover 10 min before induction of anesthesia followed by 0.4 – 0.8 μg/kg/hr infusion during maintenanceand group E received esmolol loading dose 1mg/kg was infused over one min followed by 0.4 – 0.8 mg/kg/hr infusion during maintenance to maintain mean arterial blood pressure (MAP) between (55 – 65mmHg). The surgical field was assessed using Average Category Scale and average blood loss wascalculated. Hemodynamic variables (MAP, HR); intraoperative fentanyl consumption and total recoveryfrom anesthesia (Aldrete’s score e”9) were recorded. Sedation score was determined at 10, 20, 30, 40 &amp; 60min after tracheal extubation and time to first analgesic demand was also recorded. Results: In both group D and group E reached the desired MAP (55 – 65 mmHg) with no intergroupdifference in MAP or HR. Mean intraoperative fentanyl consumption was significantly lower in group Dthan group E. Recovery time to achieved Aldrete’s score e”9 were significantly lower in group E comparedwith group D. The sedation score were significantly lower in group E compared with group D at 10minutes, 20 minutes and 30 minutes postoperatively. Time to first analgesic demand was significantlylonger in group D. Conclusion: The result of this study showed that both dexmedetomidine and esmolol can be used asagents for controlled hypotension and are effective in providing ideal surgical field during FESS. Butdexmedetomidine offers the advantage of inherent analgesic, sedative and anesthetic sparing effect. JBSA 2018; 31(2): 67-74

Analgesia Nociception Index-guided intraoperative fentanyl consumption and postoperative analgesia in patients receiving scalp block versus incision-site infiltration for craniotomy

Scalp block or local anesthetic infiltration for craniotomy blunts hemodynamic response to noxious stimuli, reduces opioid requirement and decreases postoperative pain. Analgesia Nociception Index (ANI) provides objective information about the magnitude of pain (rated from 0 to 100 with 0 indicating extreme nociception and 100 indicating absence of nociception) and adequacy of intra-operative analgesia. This study compared intra-operative fentanyl consumption guided by ANI and postoperative pain in patients who receive scalp block with those who receive incision-site local anesthetic infiltration for craniotomy. Sixty adult patients undergoing elective supra-tentorial tumor surgery were randomly allocated to receive scalp block or incision-site infiltration after induction of anesthesia. Throughout the intra-operative period, patients received fentanyl 0.5 µg/kg/h and ANI was continuously monitored. Fentanyl 1 µg/kg bolus was administered when ANI decreased to <50. Intraoperative fentanyl consumption was compared using unpaired t-test. Correlation between ANI and postoperative numerical rating scale (NRS) pain score was done using Spearman's rho. The fentanyl consumption (µg/kg/h) was less with scalp block when compared to incision-site infiltration (median [interquartile range]; 1.04 [0.92-1.34] vs. 1.34 [1.18-1.59], P=0.001). Postoperative pain scores were similar [median (interquartile range); 1.5 (0-4) vs. 3 (0-4), P=0.840]. No correlation was observed between postoperative NRS Score and ANI (correlation coefficient = 0.072; P=0.617). ANI-guided analgesic administration during craniotomy demonstrated lower intra-operative fentanyl consumption in patients receiving scalp block as compared to incision-site local anesthetic infiltration. No correlation was seen between postoperative NRS and ANI.

Effect of magnesium sulfate on anesthesia depth, awareness incidence, and postoperative pain scores in obstetric patients. A double-blind randomized controlled trial.

Objectives:To assess the effects of magnesium on the depth of anesthesia and to determine the effects of magnesium on incidence of awareness and postoperative pain after caesarean section.Methods:The study was designed as a double-blind, controlled, randomized study and conducted in Hacettepe University Hospital, Ankara, Turkey between January 2015 and March 2016. A total of 100 pregnant healthy women who were between 17 and 41 years old, ASA II, and scheduled for an elective cesarean section with general anesthesia were included in the study. After induction, sevoflurane was used for maintenance in Group S and desflurane in Group D (control groups). At Group S-M and Group D-M (study groups), magnesium infusion was started with sevoflurane and desflurane anesthesia respectively. Minimum alveolar concentration of sevoflurane and desflurane were kept constant. Bispectral index scores (BIS), fentanyl consumption and postoperative visual analogue scale (VAS) values were recorded. All of the patients had been followed-up for awareness until the postoperative first year.Results:Demographic variables of the patients were similar. BIS values were significantly higher in control groups throughout the operation (p<0.001). No significant difference was detected for intraoperative fentanyl consumption and awareness incidence. VAS values were significantly lower in study groups (p<0.05).Conclusion:Magnesium infusion provided significantly lower intraoperative BIS values and lower postoperative VAS scores. We believe that magnesium can be useful as an adjuvant to general anesthesia.