Mg Of Bupivacaine Research Articles

Super-refractory status epilepticus, rhabdomyolysis, central hyperthermia and cardiomyopathy attributable to spinal anesthesia: a case report and review of literature

BackgroundThere are only six past reports of super-refractory status epilepticus induced by spinal anesthesia. None of those patients have died. Only < 15 mg of bupivacaine was administered to all six of them and to our case. Pathophysiology ensuing such cases remains unclear.Case presentationA 27 year old gravida 2, para 1, mother at 37 weeks of gestation came to the operating theater for an elective cesarean section. She had no significant medical history other than controlled hypothyroidism and one episode of food allergy. Her current pregnancy was uneventful. Her American Society of Anesthesiologists (ASA) grade was 2. She underwent spinal anesthesia and adequate anesthesia was achieved. After 5–7 min she developed a progressive myoclonus. After delivery of a healthy baby, she developed generalized tonic clonic seizures that continued despite the induction of general anesthesia. She had rhabdomyolysis, one brief cardiac arrest and resuscitation, followed by stress cardiomyopathy and central hyperthermia. She died on day four. There were no significant macroscopic or histopathological changes in her brain that explain her super refractory status epilepticus. Heavy bupivacaine samples of the same batch used for this patient were analyzed by two specialized laboratories. National Medicines Quality Assurance Laboratory of Sri Lanka reported that samples failed to confirm United States Pharmacopeia (USP) dextrose specifications and passed other tests. Subsequently, Therapeutic Goods Administration of Australia reported that the drug passed all standard USP quality tests applied to it. Nonetheless, they have detected an unidentified impurity in the medicine.ConclusionsAfter reviewing relevant literature, we believe that direct neurotoxicity by bupivacaine is the most probable cause of super-refractory status epilepticus. Super-refractory status epilepticus would have led to her other complications and death. We discuss probable patient factors that would have made her susceptible to neurotoxicity. The impurity in the drug detected by one laboratory also would have contributed to her status epilepticus. We propose several possible mechanisms that would have led to status epilepticus and her death. We discuss the factors that shall guide investigators on future such cases. We suggest ways to minimize similar future incidents. This is an idiosyncratic reaction as well.Graphical

The Relationship of Spinal Anesthesia Dosing Based on Thecal Sac Area to Anesthetic Failure in Lumbar Surgery.

Greater thecal sac volumes are associated with an increased risk of spinal anesthesia (SA) failure. The thecal sac cross-sectional area accurately predicts thecal sac volume. The thecal sac area may be used to adjust the dose and prevent anesthetic failure. We aim to assess the rate of SA failure in a prospective cohort of lumbar surgery patients who receive an individualized dose of bupivacaine based on preoperative measurement of their thecal sac area. A total of 80 patients prospectively received lumbar spine surgery under SA at a single academic center (2022-2023). Before surgery, the cross-sectional area of the thecal sac was measured at the planned level of SA injection using T2-weighted MRI. Patients with an area <175 mm2, equal to or between 175 and 225 mm2, and >225 mm2 received an SA injection of 15, 20, or 25 mg of 0.5% isobaric bupivacaine, respectively. Instances of anesthetic failure and adverse outcomes were noted. Incidence of SA failure was compared with a retrospectively obtained control cohort of 250 patients (2019-2022) who received the standard 15 mg of bupivacaine. No patients in the individualized dose cohort experienced failure of SA compared with 14 patients (5.6%) who experienced failure in the control cohort (P = .0259). The average thecal sac area was 187.49 mm2, and a total 28 patients received 15 mg of bupivacaine, 42 patients received 20 mg of bupivacaine, and 10 patients received 25 mg of bupivacaine. None of the patients experienced any adverse outcomes associated with SA. Patients in the individualized dose cohort and control cohort were comparable and had a similar distribution of lumbar procedures and comorbidities. Adjusting the dose of SA according to thecal sac area significantly reduces the rate of SA failure in patients undergoing lumbar spine surgery.

Cis-2-Decenoic Acid and Bupivacaine Delivered from Electrospun Chitosan Membranes Increase Cytokine Production in Dermal and Inflammatory Cell Lines.

Wound dressings serve to protect tissue from contamination, alleviate pain, and facilitate wound healing. The biopolymer chitosan is an exemplary choice in wound dressing material as it is biocompatible and has intrinsic antibacterial properties. Infection can be further prevented by loading dressings with cis-2-decenoic acid (C2DA), a non-antibiotic antimicrobial agent, as well as bupivacaine (BUP), a local anesthetic that also has antibacterial capabilities. This study utilized a series of assays to elucidate the responses of dermal cells to decanoic anhydride-modified electrospun chitosan membranes (DA-ESCMs) loaded with C2DA and/or BUP. Cytocompatibility studies determined the toxic loading ranges for C2DA, BUP, and combinations, revealing that higher concentrations (0.3 mg of C2DA and 1.0 mg of BUP) significantly decreased the viability of fibroblasts and keratinocytes. These high concentrations also inhibited collagen production by fibroblasts, with lower loading concentrations promoting collagen deposition. These findings provide insight into preliminary cellular responses to DA-ESCMs and can guide future research on their clinical application as wound dressings.

A Comparative Study of Intrathecal Fentanyl and Nalbuphine as an Adjuvant to Hyperbaric Bupivacaine for Spinal Anesthesia in Lower Limb Orthopedic Surgeries: A Prospective, Double-Blind, Randomized Controlled Study.

Spinal anaesthesia is the most commonly used technique for lower limb orthopaedic surgeries as it is economical and easy to administer. Opioids as adjuvants to local anaesthetics during spinal anaesthesia have played a vital role in reducing post-operative pain qualitatively and effectively. This prospective randomised study was conducted on 100 patients divided into two groups scheduled for lower limb orthopaedic surgeries. Group bupivacaine fentanyl (BF) received 25 mcg of fentanyl with 15 mg of bupivacaine and Group bupivacaine nalbuphine (BN) received 1 mg of nalbuphine and 15 mg of 0.5% bupivacaine. The aim of the study was to compare the analgesic efficacy of intrathecal fentanyl and nalbuphine as an adjuvant to hyperbaric bupivacaine for spinal anaesthesia. Duration of effective analgesia, haemodynamic parameters, onset and duration of sensory and motor block, adverse effects, and visual analogue scale (VAS) score were assessed. Duration of effective analgesia was 388±24.88 minutes in the BN group and was higher (p-value <0.001) in comparison to the BF group, which was 304.70±15.76 minutes. Nalbuphine was more effective than fentanyl in providing post-operative analgesia when used as an adjuvant to hyperbaric bupivacaine.

Analgesic effects of intrathecal morphine and bupivacaine during robotic-assisted surgery: A prospective randomized controlled study.

Limited data exist concerning the management of postoperative pain after robotic-assisted surgery. The present study was performed to investigate the efficacy of intrathecal morphine and bupivacaine to treat postoperative pain in adult women undergoing robot-assisted laparoscopic hysterectomy. The primary outcomes of this study were opioid consumption and pain scores during and after robotic surgery. 96 patients were prospectively enrolled and randomized to a nonspinal group (n = 48) and a spinal group (n = 48). The intrathecal regimen consisted of 100 μg morphine and 15 mg of bupivacaine. The numeric rating scale scores (NRS) were assessed every 15 min in the postoperative care unit (PACU) and pain was treated with iv fentanyl or morphine when NRS was above 5 and orally oxycodone when NRS was 3-5. Cumulative iv opioid-consumption and NRS scores were compared. Intrathecal morphine and bupivacaine resulted in a significantly lower cumulative total iv opioid (morphine equivalents) consumption (9.4 ± 3.9 vs. 22.8 ± 6.1 mg equivalents). Highest recorded NRS scores in the PACU were also significantly lower in the spinal group (2.0 ± 2.6 vs. 5.3 ± 3.2). Intrathecal morphine and bupivacaine to treat postoperative pain after robotic-assisted laparoscopic hysterectomy decrease total opioid consumption and NRS pain scores. This might be of great importance to diminish the rate of other serious disadvantages related to opioids.

Effect ofclonidine on heart rate variability during spinal anaesthesia: randomized clinical trial.

Spinal anaesthesia consists of administering a local anaesthetic in the subarachnoid space, thus causing sensory, motor, and autonomic nerve conduction block. Currently, recovery from spinal anaesthesia is evaluated by the return of motor function, without considering the autonomic blockade, which is responsible for most complications of the technique. Heart rate variability (HRV) is an indirect method to measure the autonomic nervous system and may be useful in assessing autonomic recovery after spinal anaesthesia. The study objective was to evaluate the autonomic function, through HRV, at the moment of return of motor function in patients who received spinal anaesthesia when clonidine is used as an adjuvant. This was a randomised, double-blind clinical trial. The sample consisted of 64 ASA I-II patients who underwent spinal anaesthesia and were divided into 2 groups. Group C received 20 mg of bupivacaine with 75 mcg of clonidine, and group B received 20 mg of bupivacaine. HRV was evaluated at rest (T1) and at the time of motor function recovery (T2). Data were collected using a Polar V800® heart rate monitor and then analysed and filtered using Kubios 3.0® software. There was no difference in the values of the low-frequency/high-frequency (LF/HF) ratio, Poincaré plot standard deviation (SD2/SD1), detrended fluctuation analysis (DFAα1, DFAα2), or correlation dimension (D2) indices in any of the groups between the 2 moments. In the clonidine group, there was a difference only in approximate entropy (ApEn), where a P of 0.0124 was obtained considering a 95% confidence interval ranging from 17.83 to 141.47. There was no significant difference between the duration of sympathetic blockade and motor blockade in spinal anaesthesia.

Administration of Nebulised Ketamine for Managing Pain in the Intensive Care Unit of Obstetrics and Gynaecology

Introduction: The use of inhaled ketamine to manage a variety of painful conditions has been endorsed by the American College of Emergency Physicians and the American Academy of Emergency Medicine. Nebulized analgesia has multiple benefits, including rapid, effective and titratable analgesic delivery. The aim of our study is to assess the efficacy and safety of intranasal analgesic-dose ketamine compared to multimodal analgesia in patients presenting with acute postoperative pain or headache after a spinal anaesthetic in the intensive care unit of obstetrics and gynaecology. Materials and Methods: This was a prospective descriptive study, with hospital Ethics Committee approval and written informed consent from study participants. We compared the effect of nebulized ketamine and multimodal analgesia postoperatively in 120 patients belonging to the physical status I - II of the American Society of Anesthesiologists, in the intensive care unit of obstetrics and gynaecology, at the Ibn Rochd University Hospital Center in Casablanca from June 2021 to June 2022. Results: We included 120 patients in our study divided into two groups of 60 patients: the average age was 35 years, with extremes ranging from 18 to 45 years, All patients were hospitalized for postoperative care: all women underwent locoregional anaesthesia with a standard dose according to the service protocol (10 mg of bupivacaine, 25γ of fentanyl, 100γ of morphine), where pain was the common denominator. Among these patients, 59 were admitted for management of postpartum haemorrhage, 43 for postoperative monitoring, 15 for post-spinal anaesthesia headache and 3 for pelviperitonitis. The results of the pain assessment 30 minutes after the ketamine nebulization were marked by a request for analgesia in 12 patients, which is 20% of group A, including 5 patients, whose visual analogue scale (VAS) on admission was between 5 and 7, and 7 patients whose VAS at admission was ≥8; all these patients received a second dose of ketamine by nebulization; the evaluation 30 min after the second dose was marked by a request for analgesia in 4 patients, which is 7% of Group A; in all these patients the VAS at admission was ≥8. Of the total number of patients of Group A, only 4 received morphine when they were requested for analgesia after the second dose of nebulized ketamine. Conclusion: The primary outcome of nebulized ketamine use is a significant reduction in VAS pain score. We believe that nebulized ketamine has a potential effect of reducing pain in the intensive care unit of obstetrics and gynaecology; this may be an additional analgesic modality for clinicians to provide rapid, effective and non-invasive pain relief.

Synergistic effect of inthrathecal fentanyl and bupivacaine in spinal anesthesia for cesarean section in Baghdad city

Background: Potentiating the effect of intrathecal local anesthetics drugs by addition of intrathecal opiods for intra-abdominal surgeries had been used lately. In this study by addition of fentanyl, we tried to minimize the dose of bupivacaine thereby reducing the side effect caused by higher doses of intrathecal bupivacaine in cesarean section, and to improve the quality of block.Methods: Study was performed on sixty patients underwent cesarean section they were divided into 6 groups as B10, B 12.5, B15 mg of bupivacaine and FB10, FB12.5, FB15 received a combination of 25 µg intrathecal fentanyl respectively, the parameter taken into consideration were visceral pain, hemodynamic stability (hypotension and bradycardia) intra operative sedation, nausea, vomiting and post-operative pain. Results: Onset of sensory block to T6 occurred faster with increasing bupivacaine doses in bupivacaine only groups and bupivacaine fentanyl combination groups. Alone lower concentration of bupivacaine could not completely remove the visceral pain. Blood pressure declined with increasing the concentration of bupivacaine and fentanyl. The incidence of nausea and vomiting was reduced significantly while post-operative pain relief and hemodynamics stability increased by adding fentanyl. Pruritis, maternal respiratory depression and changes in APGAR score of babies did not occur with fentanyl. Conclusions: Spinal anesthesia among the neuro axial blocks in obstetric patients’ needs strict dose calculation because minimal dose changes results in more complications and side effects Here the synergistics potentiating effects of fentanyl (an opiod) on bupivicaine (local anesthetic) in spinal anesthesia for cesarean section is presented. Fentanyl is able to reduce a dose of bupivicaine and therefore its harmful effect.

Anesthesia Management for Section Cesarean Delivery in Patient with Severe Mitral Stenosis

&lt;p&gt;&lt;strong&gt;Background&lt;/strong&gt;: Heart defects in pregnancy is one main nonobstetric factor causing morbidity and mortality in pregnant women. Mitral stenosis is common in pregnancy. The choice of anesthetic management has to consider hemodynamics, type of heart disease, and drugs used. Neuraxial anesthesia has been significantly used because it is considered safer than general anesthesia&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Case&lt;/strong&gt;: A 26-year-old woman with gestational age 32-34 weeks with severe mitral stenosis, moderate mitral regurgitation, severe tricuspid regurgitation, pulmonary hypertension, pericardial effusion, and atrial fibrillation underwent cesarean section with a low dose of spinal anesthesia using 5mg bupivacaine heavy 0.5% and Fentanyl 50 mcg. The sensory and motoric block was achieved in 5 minutes. Hemodynamic was stable during the perioperative phase. There was no heart failure or postoperative hemodynamic deterioration.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusion&lt;/strong&gt;: Low-dose spinal anesthesia using 5 mg of bupivacaine and fentanyl adjuvant can be used in cesarean section in patients with severe mitral stenosis due to rapid onset, adequate block level, stable hemodynamic, block duration, and healthy born babies.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Keywords&lt;/strong&gt;: Pregnancy; mitral stenosis; C-section; neuraxial block; low dose&lt;/p&gt;

Spinal, Epidural, and General Anesthesia for Knee Joint Arthroscopy: Diversity, Equity, and Inclusion - Comparison Study.

Knee arthroscopic surgery is a commonly performed procedure for diagnosing and treating knee joint problems. This procedure can be achieved under various types of anesthesia, general; or by applying regional anesthesia or even local. Epidural anesthesia and peripheral nerve blockage have been utilized in short procedures and provided a shorter length of hospital stay than general anesthesia in many former articles; however, spinal anesthesia including bupivacaine infusion has also offered a shorter length of hospital stay compared to general anesthesia. While the literature has not compared optimal techniques for these valid options. This review was conducted to challenge the hypothesis: What would be of choice for local anesthesia agents (either epidural or spinal anesthesia) that would be comparable to short-acting general anesthesia agents in terms of patient satisfaction and discharge times?! The review was conducted as a prospective, randomized study. Patients were randomized using a sealed envelope method to be selected to one anesthesia technique (general, epidural, or spinal anesthesia). During the period between January 2019 and December 2020, 198 patients underwent unilateral knee joint arthroscopy. Seventy-seven patients refused anesthesia randomization and opted for one option directly. One hundred and twenty-one patients were qualified for the final recruitment stage of this analysis to contribute to the anesthesia randomization and they were assigned into three groups. Demographical analysis showed no significant differences between cohorts. No major surgical or anesthetic adverse effects were reported. Anesthesia reported satisfactory for incision among three groups. For regional anesthesia cohorts, sphincteric control (voiding) considered a mandatory parameter for discharge, was shorter in the epidural group compared to the spinal anesthesia cohort (154 ± 28 vs. 189 ± 47 min, P < 0.0013). Time to discharge for the three cohorts was also significantly shorter for general anesthesia and epidural cohorts as compared to spinal cohort (general, 106 ± 29 min; epidural, 90 ± 18 min; spinal, 151 ± 48 min, P < 0.003). A total of 114 patients stated that they would select the same anesthetic method over again. This review revealed that regional epidural anesthesia using 2-chloroprocaine and general anesthesia using short-acting agents were similarly successful in terms of perioperative conditions and duration of hospital stay in our center. Whereas spinal anesthesia using 10 mg of bupivacaine combined with fentanyl in the same setting lacked behind in terms of extended discharge time and showed a higher prevalence of adverse effects.

Assessment of the Magnitude and Risk Factors of Post Spinal Relevant Hemodynamics Associated with Caesarean Section in Bahirdar University Hospital, Northwest Ethiopia, 2020

Background: Maternal hemodynamics is a common clinical problem for caesarean section under spinal anesthesia. The main objective of this study was to determine magnitude of post spinal hemodynamics and factors associated with relevant maternal hypotension during caesarean section. Materials and Methods: This cross-sectional clinical study was conducted among 143 pregnant mothers who underwent caesarean section from January 29 to April 15, 2020. Simple random sampling technique was conducted with fulfilling the inclusion criteria. Maternal hemodynamic changes and the severity were assessed within 60 minutes after spinal injection. The systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) of parturient were recorded during the perioperative period. These times of recording were including the admission to operating room (preanaesthetic baseline), immediately after anesthesia (displayed as 0 time), and minutes of 3, 5, 15, 20, 25, 30, 35, and 60 after spinal injection. Results: The incidence of relevant maternal hypotension was 55.9 %. From these, 31patients (21.7%) were connected with sever hypotension. There was a highly significant relationship to sensory block height above T4, at 10 minutes of post spinal anesthesia P &lt; 0.001 (AOR= 5.340; 95% CI: 2.235 - 12.762), Elective degree of urgency involved P_ 0.038 (AOR=0.207; 95% CI: 0.047 - 0.918) and Dose of local anesthetic more than 2.5 ml or &gt; 12.5 mg of bupivacaine, P_0.001 (AOR= 7.815; 95% CI: 2.338 – 26.12). Conclusion and Recommendation: Lowering the intrathecal dose of spinal anesthesia seems to be a useful technique to reduce the incidence of hypotension and better preserves maternal hemodynamic stability. The study showed that the incidence of relevant hypotension will increase when the analgesic block level become higher than T4 dermatome within 10 minutes. Depending on the degree of urgency, a parturient with an emergency base for caesarean delivery may be a useful tool to predict relevant hypotension during spinal anesthesia. The hospital management and responsible clinicians of GUH need to minimize the incidence of post spinal relevant hypotension by adquate preotimization and taking to account avaliable options.

Comparison of epidural, spinal, and saddle block for holmium laser enucleation of prostate (HoLEP): A prospective randomized, comparative study.

Background:Holmium laser enucleation of the prostate (HoLEP) has become an important treatment modality for benign prostate hypertrophy. The aim of the present study was to compare regional anesthesia methods for HoLEP operation and to determine the optimal technique.Methods:Sixty patients with American Society of Anesthesiologists scores of I-III were randomly allocated into 3 groups. Patients in group E received an epidural block with 75 mg of bupivacaine plus 50 μg of fentanyl. In group S, 15 mg of bupivacaine and 50 μg fentanyl were used for spinal anesthesia. In group SA, patients received saddle block with 15 mg of bupivacaine and 50 μg of fentanyl.Results:Time to T10 dermatome block and to maximal level block were longest in group E (P < .05), and maximal sensorial block level was higher in group E than group SA (P < .05). There was a significant difference in postoperative motor block, but no difference in systolic blood pressure and heart rate.Conclusion:Among 3 techniques, saddle block might be preferable in HoLEP because an adequate sensorial level was achieved with lower motor block and stable hemodynamics.

Effects of the Sufentanil and Dexmedetomidine Combination on Spinal Anesthesia in Patients Undergoing Lower Abdominal or Lower Extremity Surgery: A Double-Blind Randomized Controlled Trial.

Background: Intrathecal additive drugs are becoming increasingly common in anesthesia practice. We aimed to evaluate the additive effects of dexmedetomidine on spinal anesthesia with sufentanil in patients undergoing lower abdominal or lower limb surgery.Methods: This double-blind randomized controlled trial was performed in Mashhad, Iran, between 2017 and 2018. Sixty patients undergoing lower abdominal or lower limb surgery were randomly divided to receive 15 mg of bupivacaine and 3 μg of sufentanil (control group; n=30) or 15 mg of bupivacaine, 3 μg of sufentanil, and 10 μg of dexmedetomidine (intervention group; n=30). Outcomes, comprised of the onset and regression of sensory and motor blocks, the duration of analgesia, analgesic use, hemodynamic parameters, and side effects, were assessed. The data were analyzed in the SPSS software (version 22), using different statistical tests. A P value of less than 0.05 was considered significant.Results: The times of sensory and motor blocks reaching T10 and Bromage 3, respectively, were significantly shorter, while the times of sensory and motor regressions to S1 and Bromage 0, correspondingly, were significantly longer in the intervention group than in the control group (P<0.001). Both the frequency (P=0.006) and the dose (P<0.001) of postoperative analgesic use were significantly lower, and the duration of analgesia was significantly longer in the intervention group (P<0.001). The frequency of side effects and changes in hemodynamic parameters had no significant differences between the groups.Conclusion: The sufentanil and dexmedetomidine combination in spinal anesthesia caused the earlier onset and later regression of sensory and motor blocks, longer postoperative analgesia, and lower analgesic use without significant side effects or hemodynamic changes, which appears to be due to the combined effects of sufentanil and dexmedetomidine. Trial Registration Number: IRCT2017082833680N3.

In vitro evaluation of loaded chitosan membranes for pain relief and infection prevention.

Wounds resulting from surgeries, implantation of medical devices, and musculoskeletal trauma result in pain and can also result in infection of damaged tissue. Up to 80% of these infections are due to biofilm formation either on the surface of implanted devices or on surrounding wounded tissue. Bacteria within a biofilm have intrinsic growth and development characteristics that allow them to withstand up to 1,000 times the minimum inhibitory concentration of antibiotics, demonstrating the need for new therapeutics to prevent and treat these infections. Cis-2-decenoic acid (C2DA) is known to disperse preformed biofilms and can prevent biofilm formation entirely for some strains of bacteria. Additionally, local anesthetics like bupivacaine have been shown to have antimicrobial effects against multiple bacterial strains. This study sought to evaluate hexanoic acid-treated electrospun chitosan membranes (HA-ESCM) as wound dressings that release C2DA and bupivacaine to simultaneously prevent infection and alleviate pain associated with musculoskeletal trauma. Release profiles of both therapeutics were evaluated, and membranes were tested in vitro against Methicillin-resistant Staphylococcus aureus (MRSA) to determine efficacy in preventing biofilm infection and bacterial growth. Results indicate that membranes release both therapeutics for 72 hr, and release profile can be tailored by loading concentration. Membranes were effective in preventing biofilm growth but were toxic to fibroblasts when loaded with 2.5 or 5mg of bupivacaine.

Comparative Study between Analgesic Effects of Intrathecal Administration of Midazolam Versus Tramadol with Bupivacaine for Infra-Umbilical Surgeries

Background: The administration of bupivacaine intrathecally as a regional anesthesia is commonly used to provide anesthesia for lower abdominal surgeries. The motor blockage of bupivacaine provides adequate blockage, which allows the surgeons to do their work comfortably and also provides effective postoperative analgesia in early postoperative period. However, adding adjuvants to the local anesthetics to prolong the period of postoperative analgesia after fading of the spinal anesthesia was tried in many studies. These supplements as regard to postoperative pain relief are beneficial as they decrease or abolish the need for the administration of analgesics and their associated complications. Objective: To compare the analgesic effect of intrathecal midazolam versus intrathecal tramadol when added to bupivacaine during spinal anesthesia after infra-umbilical surgeries. Patients and methods: In our study we included 80 patients scheduled for elective surgeries in the lower abdomen and lower limbs (infra-umbilical surgeries) under spinal anesthesia. They were randomly divided to one of two groups. Group M received 10 mg of hyperbaric bupivacaine + 2 mg midazolam, and group T received 10 mg of bupivacaine + 20 mg of tramadol (total is 3cc in both groups). The comparison was done by using the visual analogue scale (VAS) for assessing postoperative pain score and recording the duration of postoperative analgesia. Results: The postoperative analgesia duration was significantly higher in the tramadol group than midazolam group (P<0.05). Conclusion: Addition of 20 mg tramadol to bupivacaine during spinal anesthesia provides longer duration of analgesia when compared to intrathecal midazolam 2.0 mg.

Comparative Study between Analgesic Effects of Intrathecal Administration of Midazolam Versus Tramadol with Bupivacaine for Infra-Umbilical Surgeries

Background: The administration of bupivacaine intrathecally as a regional anesthesia is commonly used to provide anesthesia for lower abdominal surgeries. The motor blockage of bupivacaine provides adequate blockage, which allows the surgeons to do their work comfortably and also provides effective postoperative analgesia in early postoperative period. However, adding adjuvants to the local anesthetics to prolong the period of postoperative analgesia after fading of the spinal anesthesia was tried in many studies. These supplements as regard to postoperative pain relief are beneficial as they decrease or abolish the need for the administration of analgesics and their associated complications. Objective: To compare the analgesic effect of intrathecal midazolam versus intrathecal tramadol when added to bupivacaine during spinal anesthesia after infra-umbilical surgeries. Patients and methods: In our study we included 80 patients scheduled for elective surgeries in the lower abdomen and lower limbs (infra-umbilical surgeries) under spinal anesthesia. They were randomly divided to one of two groups. Group M received 10 mg of hyperbaric bupivacaine + 2 mg midazolam, and group T received 10 mg of bupivacaine + 20 mg of tramadol (total is 3cc in both groups). The comparison was done by using the visual analogue scale (VAS) for assessing postoperative pain score and recording the duration of postoperative analgesia. Results: The postoperative analgesia duration was significantly higher in the tramadol group than midazolam group (P<0.05). Conclusion: Addition of 20 mg tramadol to bupivacaine during spinal anesthesia provides longer duration of analgesia when compared to intrathecal midazolam 2.0 mg.

Comparative analysis of effects of three different doses of fentanyl and standard dose of bupivacaine on a spinal block in patients with hip endoprosthesis surgery

Introduction/Objective. Spinal anesthesia is often used for hip endoprosthesis surgery. Significant surgical stress response consisting of hormonal, metabolic and inflammatory changes can be initiated by the hip replacement surgery. Intrathecal opioids, as adjuvants to local anesthetics, make spinal block sufficient even with lower doses of the local anesthetics, and the incidence of the side effects reduce to minimum. Methods. This study included 162 patients of either sex, American Society of Anesthesiology classification (ASA) 1?2, scheduled for total hip arthroplasty. The patients had spinal anesthesia with 10 mg of 0.5% bupivacaine with 20 ?g (Group I), or 25 ?g (Group II) or 30 ?g fentanyl intrathecally (Group III). Results. Mean time to achieve maximum motor and sensory blockade was with no significant difference among the groups. Time of motor block duration was shorter in the Group III. Four hours after the operation, patients in the Group I had significantly higher cortisol serum levels. Blood glucose levels were with no significant difference among the groups. Levels of CRP increased remarkably postoperatively in the Group I. Incidence of hypotension, bradycardia, nausea and vomiting was significantly higher in the Group III. Pruritus and shevering were not recorded among the groups. The first time an analgetic was needed postoperatively was the longest in the Group III. Conclusion. The dose of 10 mg of bupivacaine combined with 25 ?g fentanyl was the optimal option to achieve hemodynamic stability, sufficient sensory and motor blockade, and reduce the stress response and incidence of the opioids side effects such as vomiting, nausea, pruritus etc.

Periarticular Injection of Ketorolac Augmenting Intravenous Administration of Ketorolac for Postoperative Pain Control: A Randomized Controlled Trial in Simultaneous Bilateral Total Knee Arthroplasty.

Adequate postoperative pain control with minimal side effects is necessary for patients undergoing total knee arthroplasty (TKA). Ketorolac is a frequently used nonsteroidal anti-inflammatory drug due to its excellent disposition in all administration routes; however, it possesses an "analgesic ceiling," which means that higher doses of the drug have no additional analgesic effect. Alternatively, increasing the local concentration of ketorolac via periarticular injection may provide additional pain relief to parenteral administration of ketorolac, but evidence demonstrating the benefits and safety of this approach is limited. Therefore, this study assesses whether local ketorolac injection could yield additional pain reduction to intravenous administration of ketorolac. A total of 54 patients who underwent simultaneous bilateral TKA were enrolled. Randomization was performed to determine whether 50 mg of bupivacaine plus 30 mg of ketorolac (ketorolac group), or only 50 mg bupivacaine (bupivacaine group) would be periarticularly injected into the first knee operated on (more painful), and then the contralateral knee would receive another mixture. Ketorolac (30 mg) was intravenously given every 8 hours for the first 48 hours. Visual analog scales (VASs) were used to assess pain, knee recovery function, and patients' preferred knee. Postoperative VAS pain scores in the ketorolac group were lower than those in the bupivacaine group 6 to 96 hours postoperatively and reached statistical significance 12 (4.25 ± 2.38 vs. 5.06 ± 2.48, respectively; p = 0.04) and 24 hours (4.22 ± 1.94 vs. 5.30 ± 2.12, respectively; p < 0.01) postoperatively. The ketorolac group had higher degrees of knee flexion and straight leg raise. No patient experienced adverse effects of ketorolac. On the day of discharge, 61.11% of the patients favored the knee that received local ketorolac injection (p < 0.01). Adjunct local ketorolac injection to systemic administration is well tolerated and may improve its analgesic effect as determined by the patients' perception.

A randomized controlled trial comparing the efficacies of ketorolac and parecoxib for early pain management after total knee arthroplasty

BackgroundNonsteroidal anti-inflammatory drugs (NSAIDs) are widely used to reduce pain after orthopedic surgery. Currently, selective COX-2 inhibitors can provide effective pain reduction with less platelet inhibition compared with conventional NSAIDs. We aimed to compare the analgesic effect and perioperative blood loss (PBL) after total knee arthroplasty (TKA) between ketorolac and parecoxib administration. MethodsWe conducted a prospective randomized controlled study of 100 unilateral TKAs. The ketorolac group of 50 patients received an intraoperative periarticular injection (PAI) with 100 mg of bupivacaine and 30 mg of ketorolac. Afterwards, 30 mg of ketorolac was intravenously injected every 12 h until 48 h. In the parecoxib group of 50 patients, 20 mg of parecoxib was added to PAI, and the first intravenous dose was 20 mg followed by 40 mg every 12 h. The primary outcomes were visual analog scales (VASs) of postoperative pain, amount of morphine consumption, PBL, and blood transfusion rate. ResultsThe ketorolac group had a significantly lower VAS pain score than the parecoxib group at 6 h after TKA (2.38 ± 2.52 vs. 4.12 ± 2.86, P < 0.01). Thereafter, the VAS of both groups and total morphine consumption at 24 and 48 h were comparable. The PBLs of the ketorolac and parecoxib groups were 529.72 ± 263.02 and 402.40 ± 191.47 ml, respectively (P = 0.01). However, the blood transfusion rates between groups were not different. ConclusionParecoxib provides comparable analgesic effects to ketorolac. Additionally, perioperative use of parecoxib is safe and is associated with significantly less blood loss after TKA.

A prospective randomized trial comparing liposomal bupivacaine vs standard bupivacaine wound infiltration in open gynecologic surgery on an enhanced recovery pathway

Value in healthcare is reflected by patient-centered outcomes of care per health dollar expended. Although liposomal bupivacaine is more expensive, it has been shown to provide prolonged analgesia (up to 72 hours). This study aimed to evaluate whether the addition of liposomal bupivacaine to standard bupivacaine could decrease opioid intake and improve pain control after laparotomy for gynecologic surgery compared with standard bupivacaine alone in an enhanced recovery after surgery pathway. A prospective randomized controlled single-blinded trial of wound infiltration with liposomal bupivacaine plus 0.25% bupivacaine (study arm) vs 0.25% bupivacaine (control arm) was performed at a National Cancer Institute-designated tertiary referral cancer center. Participants were patients aged ≥18 years undergoing exploratory laparotomy for a gynecologic indication. All patients were treated on an enhanced recovery pathway including local wound infiltration before closure. In this study, 266 mg of liposomal bupivacaine (free base; equal to 300 mg bupivacaine HCL)+150 mg of bupivacaine mixed in the same syringe was used in the study arm, and 150 mg of bupivacaine was used in the control arm. The primary outcome was the proportion of patients who were opioid-free within 48 hours after surgery. Secondary outcomes included number of opioid-free days from postoperative day 0 to postoperative day 3, days to first opioid administration, morphine equivalent daily dose, and patient-reported outcomes collected with the MD Anderson Symptom Inventory. The MD Anderson Symptom Inventory was administered as a preoperative baseline, daily while hospitalized, and at least weekly for 8 weeks after discharge. All outcomes were prespecified before data collection. In this study, 102 patients were evaluated. Among them, 16.7% of patients in the study arm received no opioids up to 48 hours compared with 14.8% in the control arm (P=.99). There were no significant differences in the amount of intraoperative opioids administered or days to first opioid use. There was no significant difference between the 2 arms in median cumulative morphine equivalent daily dose (21.3 [study arm] vs 33.8 [control arm]; P=.36) or between the groups in morphine equivalent daily dose per individual day. There were no significant differences in patient-reported pain or interference with walking between the 2 arms or other patient-reported outcomes. Within an enhanced recovery after surgery pathway, adding liposomal bupivacaine to 0.25% bupivacaine wound infiltration did not decrease the proportion of patients who were opioid-free within 48 hours after surgery, did not decrease opioid intake, or did not improve patient's self-reported pain and functional recovery compared with standard bupivacaine.