Insights into obstetric anesthesia practices: a quantitative survey among physicians across Arab countries.

BACKGROUND: Obstetric anesthesia guidelines are essential for standardizing obstetric anesthesia practices globally and ensuring high-quality patient care. However, practices may vary across different settings, and there are limited data from Arab countries. This study aims to gain insights into obstetric anesthesia practices in several major hospitals across Arab countries. METHODS: A questionnaire was emailed to 85 obstetric anesthesiologists/anesthesia chairpersons in major hospitals, including academic medical institutions and central hospitals, across 11/22 Arab countries. This survey gathered data on key structural and process-related obstetric anesthesia indicators. RESULTS: Out of 85 contacted, we had 56 responses (65.8%), with 41 being fully completed, providing insights into obstetric anesthesia indicators. Regarding structure: 31 (76%) hospitals had an operating room adjacent to the delivery room, all had intensive care units, and 22 (54%) had a lead obstetric anesthesiologist. For equipment, 19 (46%) had a video laryngoscope in the delivery suite, and 20 (49%) occasionally used ultrasound for epidurals. Regarding process: 33 (81%) held regular meetings, and 21 (51%) conducted research. Before epidural and spinal procedures, 26 (63%) and 28 (68%) required coagulation studies for patients without a history of hemorrhagic complications, while 38 (93%) and 36 (88%) mandated a platelet count, respectively. For labor analgesia, 34 (83%) primarily used epidurals, and 15 (37%) placed preemptive catheters in high-risk pregnancies. For cesarean delivery, 40 (98%) used spinals, with 16 (39%) using intrathecal morphine and 22 (54%) administering aspiration prophylaxis before general anesthesia. Regarding spinal-induced hypotension, 6 (15%) used prophylactic phenylephrine infusion. CONCLUSION: This survey highlights variations in obstetric anesthesia practices among various major hospitals in several Arab countries, compared to international recommendations. It emphasizes the need for obstetric anesthesia registries in the Arab world for future research. Further studies are required to outline country-specific practices, improve resource allocation, and enhance obstetric population safety and satisfaction.

Dexmedetomidine for Improved Quality of Emergence From General Anesthesia: A Dose-Finding Study.

BACKGROUND: Dexmedetomidine provides smooth and hemodynamically stable emergence at the expense of hypotension, delayed recovery, and sedation. We investigated the optimal dose of dexmedetomidine for prevention of cough, agitation, hypertension, tachycardia, and shivering, with minimal side effects. METHODS: In this prospective, randomized, double-blind trial, 216 adult patients were randomly assigned to dexmedetomidine 1 µg/kg (D 1), 0.5 µg/kg (D 0.5), 0.25 µg/kg (D 0.25), or control (C). During emergence, cough, agitation, hemodynamic parameters, shivering, time to extubation, and sedation scores were recorded. RESULTS: A total of 190 patients were analyzed. The respective incidences for the groups D 1, D 0.5, and D 0.25 versus group C were 48%, 64%, and 64% vs 84% for cough-corrected P < .003 between groups D 1 and C; 33%, 34%, and 33% vs 72% for agitation-corrected P < .003 between group C and each of the study groups; and 4%, 2%, and 7% vs 22% for shivering-corrected P = .03 and corrected P = .009 between groups D 1 and D 0.5 versus group C, respectively. The percent increase from baseline blood pressure on extubation for the 3 treatment groups was significantly lower than group C. Percent increase in heart rate was lower than control in groups D 1 and D 0.5 but not in group D 0.25. Time to extubation and sedation scores were comparable. However, more hypotension was recorded during the emergence phase in the 3 treatment groups versus group C. CONCLUSIONS: D 1 at the end of surgery provides the best quality of emergence from general anesthesia including the control of cough, agitation, hypertension, tachycardia, and shivering. D 0.5 also controls emergence phenomena but is less effective in controlling cough. The 3 doses do not delay extubation. However, they cause dose-dependent hypotension.

Preprocedural ultrasound versus landmark techniques for spinal anesthesia performed by novice residents in elderly: a randomized controlled trial.

BACKGROUND: Spinal anesthesia using the midline approach might be technically difficult in geriatric population. We hypothesized that pre-procedural ultrasound (US)-guided paramedian technique and pre-procedural US-guided midline technique would result in a different spinal anesthesia success rate at first attempt when compared with the conventional landmark-guided midline technique in elderly patients. METHODS: In this prospective, randomized, controlled study, one hundred-eighty consenting patients scheduled for elective surgery were randomized into the conventional surface landmark-guided midline technique (group LM), the pre-procedural US-guided paramedian technique (group UP), or the pre-procedural US-guided midline technique (group UM) with 60 patients in each group. All spinal anesthesia were performed by a novice resident. RESULTS: The successful dural puncture rate on first attempt (primary outcome) was higher in groups LM and UM (77 and 73% respectively) than in group UP (42%; P < 0.001). The median number of attempts was lower in groups LM and UM (1 [1] and 1 [1-1.75] respectively) than in group UP (2 [1, 2]; P < 0.001). The median number of passes was lower in groups LM and UM (2 [0.25-3] and 2 [0-4]; respectively) than in group UP (4 [2-7.75]; P < 0.001). The time taken to perform the spinal anesthesia was not different between groups LM and UM (87.24 ± 79.51 s and 116.32 ± 98.12 s, respectively) but shorter than in group UP (154.58 ± 91.51 s; P < 0.001). CONCLUSIONS: A pre-procedural US scan did not improve the ease of midline and paramedian spinal anesthesia as compared to the conventional landmark midline technique when performed by junior residents in elderly population. TRIAL REGISTRATION: Retrospectively registered at Clinicaltrials.gov, registration number NCT02658058, date of registration: January 18, 2016.

Haloperidol Versus Ondansetron for Treatment of Established Nausea and Vomiting Following General Anesthesia: A Randomized Clinical Trial.

BACKGROUND: Haloperidol is an antipsychotic. At low doses, it is a useful agent for the prophylaxis of postoperative nausea and vomiting (PONV). However, its use for treating established PONV has not been well studied. METHODS: This randomized double-blinded trial tested whether haloperidol is noninferior to ondansetron for the early treatment of established PONV in adult patients undergoing general anesthesia. The primary outcome is whether patients were PONV free during the first 4 hours. The noninferiority margin was set at 15%. One hundred twenty patients with PONV received either haloperidol 1 mg intravenously (n = 60) or ondansetron 4 mg intravenously (n = 60). RESULTS: Data from 112 patients (59 in the haloperidol group and 53 in the ondansetron group) were analyzed. Thirty-five patients (52%) in the haloperidol group received 1 or 2 prophylactic antiemetics compared with 42 (79%) in the ondansetron group. Haloperidol was noninferior to ondansetron for the end point of complete response to treatment (defined as the rate of PONV-free patients) for the early (0-4 hour) and the 0- to 24-hour postoperative periods by both the per-protocol and intention-to-treat analyses. In the per-protocol analysis, complete responses in the early period were noted in 35 of 59 patients (59%) and 29 of 53 patients (55%) for the haloperidol and ondansetron groups, respectively (difference 5%; 95% confidence interval [CI]: -13% to 22 %), and in the 0- to 24-hour period in 31 of 59 patients (53%) and 26 of 53 patients (49%) for the haloperidol and ondansetron groups, respectively (difference 4%; 95% CI of the difference: -15% to 21%). In the intention-to-treat analysis, complete responses in the early period were noted in 35 of 60 patients (58%) and 29 of 60 patients (48%) for the haloperidol and ondansetron groups, respectively (difference 10%; 95% CI of difference: -8% to 27%) and in the 0- to 24-hour period in 31 of 60 patients (52%) and 26 of 60 patients (43%) for the haloperidol and ondansetron groups, respectively (difference 8%; 95% CI of the difference: -9% to 25%). All other PONV secondary outcomes were comparable. Twenty-five percent of patients in the haloperidol group were sedated versus 2% in the ondansetron group (P < .001; difference 23%; 95% CI of the difference: 11%-36%). Pain, satisfaction scores, need for analgesics, and changes in QTc intervals were not different between the 2 groups. CONCLUSIONS: Haloperidol is at worst 13% and 8% less effective than ondansetron by per-protocol analysis and by intention-to-treat analysis, respectively. Thus, it is noninferior to ondansetron for the early treatment of established PONV, but is associated with sedation.

Half dose sugammadex combined with neostigmine is non-inferior to full dose sugammadex for reversal of rocuronium-induced deep neuromuscular blockade: a cost-saving strategy.

BACKGROUND: Sugammadex reverses the effect of rocuronium more rapidly and effectively than neostigmine, at all levels of neuromuscular blockade (NMB). However, its cost is prohibitive. The combination of half dose sugammadex with neostigmine would be non-inferior to full dose sugammadex for the reversal of deep NMB. This approach would reduce the cost of sugammadex while preserving its efficacy. METHODS: Patients were randomly allocated to receive sugammadex 4 mg/kg (Group S) or sugammadex 2 mg/kg with neostigmine 50 µg/kg and glycopyrrolate 10 µg/kg (Group NS) for reversal of rocuronium deep NMB. The primary outcome was the percentage of patients who recovered to 90% Train of Four (TOF) ratio within 5 min. The non-inferiority margin was set at 10%. RESULTS: Twenty eight patients were enrolled in each group. The number of patients who reached 90% TOF ratio within 5 min was 27 out of 28 (96%) in group S versus 25 out of 28 (89%) in group NS by intention-to-treat (difference: 7%, 95% CI of the difference: -9% to 24%). The number of patients who reached 90% TOF ratio within 5 min was 26 out of 26 (100%) in group S versus 23 out of 25 (92%) in group NS by per-protocol (difference: 8%, 95% CI of the difference: -6% to 25%). CONCLUSIONS: Sugammadex 2 mg/kg with neostigmine 50 µg/kg was at worst 9% and 6% less effective than sugammadex 4 mg/kg by intention-to-treat and by per-protocol analysis respectively. Hence, the combination is non-inferior to the recommended dose of sugammadex. TRIAL REGISTRATION: Clinicaltrials.gov NCT 02375217 , registered on February 11, 2015.

Femoral arterial cannulation performed by residents: a comparison between ultrasound-guided and palpation technique in infants and children undergoing cardiac surgery.

BACKGROUND: Percutaneous cannulation of the femoral artery in the pediatric age group can be technically challenging, especially when performed by residents in training. OBJECTIVE: We examined whether the use of real-time ultrasound guidance is superior to a palpation landmark technique for femoral artery catheterization in children undergoing heart surgery. METHODS: Patients were prospectively randomized into two groups. In the palpation group, the femoral artery was cannulated using the traditional landmark method of palpation of arterial pulse. In the ultrasound group, cannulation was guided by real-time scanning with an ultrasound probe. Ten minutes were set as time limit for the resident's trials during which the time taken for attempted cannulation (primary outcome), number of attempts, number of successful cannulations on first attempt, and success rate were compared between the two groups. Adverse events were monitored on postoperative days 1 and 3. RESULTS: A total of 106 patients were included in the study. The time taken for attempted femoral artery cannulation was shorter (301 ± 234 vs 420 ± 248 s; difference in mean: 119; 95% confidence interval (CI) of difference: 26-212; P = 0.012) and the number of attempts was lower [1 (1-10) vs 2 (1-5); difference in median: 1, 95% CI of difference: 0.28-1.72; P = 0.003] in the ultrasound group compared with the palpation group. The number of successful cannulations on first attempt was higher in the ultrasound group compared with palpation group [24/53 (45%) vs 13/53 (25%); odds ratio (OR): 2.54, 95% CI: 1.11-5.82; P = 0.025]. The number of patients who had successful cannulation was 31 of 55 (58%) in the palpation group and 40 of 53 (75%) in the ultrasound group (OR: 2.18, 95% CI: 0.95-5.01; P = 0.06). None of the patients had adverse events at days 1 and 3. CONCLUSIONS: Ultrasound-guided femoral arterial cannulation in children when performed by anesthesia residents is superior to the palpation technique based on the reduction of the time taken for attempted cannulation and the number of attempts, and improvement in first attempt success.

PATIENT-VENTILATION ASYNCHRONY CAUSING NEGATIVE PRESSURE PULMONARY EDEMA IN AN INTUBATED OBESE PATIENT.

Negative pressure pulmonary edema is a potentially life-threatening condition that may occur when a large negative intrathoracic pressure is generated against a 'physically' obstructed upper airway during emergence from anesthesia. We report a 35 year old male patient who is morbidly obese and undergoing laparoscopic gastric bypass who developed negative pressure pulmonary edema without any evidence of a 'physical' upper airway obstruction. In our patient, the negative pressure pulmonary edema occurred after complete reversal of neuromuscular blockade and during manual positive pressure ventilation with the endotracheal tube still in place and in the presence of an oral airway. Since the patient was still intubated and had an airway in place with no possibility for physical obstruction, we speculate that the occurrence of the negative pressure pulmonary edema was mainly due to a 'functional' obstruction secondary to the severe patient-ventilation asynchrony that ensued upon reversal of the neuromuscular blockade.

A randomized controlled trial of variable rate phenylephrine infusion with rescue phenylephrine boluses versus rescue boluses alone on physician interventions during spinal anesthesia for elective cesarean delivery.

BACKGROUND: Phenylephrine infusion is used to reduce hypotension during spinal anesthesia for cesarean delivery. A prophylactic fixed rate infusion regimen may not improve hemodynamic control; a variable rate regimen adjusted in response to changes in arterial blood pressure and heart rate may allow more accurate maintenance of baseline blood pressure. We hypothesized that a combination of crystalloid solution coload with a variable rate phenylephrine infusion and phenylephrine rescue boluses may be associated with fewer physician interventions needed to maintain maternal systolic blood pressure within 20% of baseline and greater hemodynamic stability than crystalloid solution coload with phenylephrine rescue boluses alone. METHODS: In this prospective, double-blind study, 80 patients received a coload with 15 mL/kg lactated Ringer's solution immediately after the initiation of spinal anesthesia. Patients were randomized to receive a prophylactic variable rate phenylephrine infusion starting at 0.75 µg/kg/min (group P) or infusion of normal saline (group S). Maternal systolic blood pressure was maintained within 20% of baseline with rescue phenylephrine boluses using a preset algorithm. During the predelivery period, the number of physician interventions (primary outcome), hemodynamic performance, nausea/vomiting, and umbilical cord blood gas values were compared between the groups. RESULTS: One patient from group S was excluded due to protocol violation. Therefore, group P included 40 patients and group S 39 patients. The median (range) number of physician interventions needed to maintain maternal hemodynamics within the target range (0 [0-6] vs 3 [0-9], difference in median: 3, 95% confidence interval of difference: 2-4) and incidence of hypotension (8/40 [20%] vs 35/39 [90%]) were lower in group P compared with group S (P < 0.001). Group P had a higher incidence of hypertension compared with group S (6/40 [15%] vs 0/39 [0%], P = 0.026). The median performance error was closer to baseline (P < 0.001) with a smaller median absolute performance error (P = 0.001) in group P versus group S. In group P, 4/40 (10%) patients had nausea/vomiting compared with 17/39 (44%) in group S (P = 0.001). The number needed to treat was 1.4 women to prevent 1 case of hypotension, and 3 women to prevent 1 case of nausea/vomiting; the rate of hypertension was 1 case per 6.7 women treated. Neonatal outcomes were not different between the 2 groups. CONCLUSION: Prophylactic variable rate phenylephrine infusion and rescue phenylephrine bolus dosing is more effective than relying on rescue phenylephrine bolus dosing with respect to limiting clinician workload and maternal symptoms during spinal anesthesia for cesarean delivery.

Fentanyl-induced cough--pathophysiology and prevention.

Many reports have demonstrated that intravenous administration of a bolus of fentanyl at induction of anesthesia can cause coughing with varying degrees. This cough can be benign, but sometimes it causes undesirable side effects including an increase in intraabdominal, intracranial or intraocular pressure. Many studies demonstrated that the incidence and severity of fentanyl-induced cough could be related to age, ethnicity, history of smoking, as well as to the rate, route, dose and concentration of fentanyl administered. This cough was described by several mechanisms including an inhibition of central sympathetic system leading to vagal predominance, reflex bronchonstriction after the stimulation of tracheobronchial tree receptors, or histamine release. The efficacy of several measures to avoid fentanyl-induced cough have been demonstrated, and several anesthetics adjuncts can be given prior to fentanyl administration aiming at decreasing this unwanted side effect.

The effect of the addition of nefopam to intraoperative ketoprofen and acetaminophen on postoperative morphine requirements after laparoscopic cholecystectomy: a randomized controlled trial.

BACKGROUND: Few studies investigated the use of nefopam for pain control after laparoscopic cholecystectomy in the context of multimodal analgesia. The aim of this study was to evaluate the effect of adding nefopam to ketoprofen and acetaminophen given before the end of laparoscopic cholecystectomy. METHODS: In this double-blind, controlled study, 90 patients undergoing laparoscopic cholecystectomy during sevoflurane-dexmedetomidine-based anesthesia were randomized to receive either ketoprofen and acetaminophen or nefopam, ketoprofen, and acetaminophen for postoperative pain control before the end of surgery. The primary outcome was total morphine consumption in the Postanesthesia Care Unit (PACU). RESULTS: PACU morphine consumption was significantly lower in the experimental group compared to the control group (0.9±1.8 mg vs. 2.3±2.4 mg, respectively; P=0.004, Cohen's d=0.63). In the experimental group, a smaller proportion of patients received morphine in PACU (24% vs. 60%, respectively; P=0.001), morphine during the first 24 hours after surgery (47% vs. 77%, respectively; P=0.004), and acetaminophen on the floor (76% vs. 93%, respectively; P=0.039) compared with the control group. The average pain score during PACU stay was also significantly lower in the experimental group (1.7±2.0 vs. 2.7±2.0, P=0.01). Median time to first morphine requirement (44.0 minutes, 95% CI [(31.96 to, 52.21)] was shorter in the control group than in the experimental group (higher than the 90 minutes-last time point taken in PACU). CONCLUSIONS: Adding nefopam to ketoprofen and acetaminophen before the end of laparoscopic cholecystectomy provides a reduction in morphine consumption with superior analgesia in PACU.

Harlequin syndrome during peripheral cardiopulmonary bypass in a patient with an obstructing tracheal schwannoma: A case report.

Surgical resection of obstructive tracheal tumors can be challenging to cardiothoracic surgeons and anesthesiologists. It is often difficult in these cases to maintain oxygenation by face mask ventilation during induction of general anesthesia. Also, the extent and location of these tracheal tumors can preclude conventional induction of general anesthesia and subsequent successful endotracheal intubation. Peripheral cardiopulmonary bypass (CPB) under local anesthesia and mild intravenous sedation may be safe to support the patient until securing a definitive airway. We describe a case of a 19-year-old female with a tracheal schwannoma, who developed differential hypoxemia (Harlequin, or North-South, syndrome) after institution of awake peripheral femorofemoral venoarterial (VA) partial CBP.

A comparison between dexamethasone and methylprednisolone for vomiting prophylaxis after tonsillectomy in inpatient children: a randomized trial.

BACKGROUND: The frequent incidence of postoperative vomiting in children undergoing tonsillectomy, in addition to the occurrence of severe pain, may delay postoperative oral intake and lead to increased risk of dehydration. Thus, prophylactic therapy is indicated in this high-risk group. Glucocorticoids, such as dexamethasone and methylprednisolone, have anti-inflammatory and antiemetic properties with dexamethasone being frequently used. We hypothesized that methylprednisolone should be noninferior to dexamethasone for the prevention of vomiting in children after tonsillectomy. METHODS: We designed a randomized double-blind trial to compare the efficacy of a single prophylactic dose of 0.5 mg/kg dexamethasone with a dose of 2.5 mg/kg methylprednisolone on the incidence of postoperative vomiting during the first 24 hours (primary outcome) in children undergoing total or partial tonsillectomy with a noninferiority margin set at 9%. One hundred sixty children undergoing total or partial tonsillectomy under general anesthesia were randomly assigned to receive either IV dexamethasone 0.5 mg/kg (n = 79) or methylprednisolone 2.5 mg/kg (n = 81) after induction of anesthesia. Secondary analysis of all studied outcomes was also performed according to the type of surgery. RESULTS: An intention-to-treat analysis showed an overall incidence of vomiting of 30% in the dexamethasone group and of 22% in the methylprednisolone group (difference: 8%, 95% confidence interval [CI]: -5% to 21%). A per protocol analysis showed an incidence of vomiting of 32% and 23%, respectively (difference: 9%, and 95% CI of the difference: -5 to 23%, P(sup) = 0.28). The time and quality of oral intake and the duration of IV hydration, as well as pain and satisfaction scores and the need for analgesics, were similar between the 2 groups. The incidence of vomiting was also similar in patients who had total versus partial tonsillectomy; however, time to first oral intake, duration of IV hydration, and the need for analgesics were less with better satisfaction scores in partial versus total tonsillectomy patients. CONCLUSION: Methylprednisolone is at worst 5% less effective than dexamethasone by the intention-to-treat analysis, and by the per protocol analysis. Thus, it is noninferior to dexamethasone in preventing vomiting after tonsillectomy in children.

The effect of adjuvant drugs on the quality of tracheal intubation without muscle relaxants in children: a systematic review of randomized trials.

Intubation without prior administration of muscle relaxants is a common practice in children. However, succinylcholine may be considered as the golden standard for optimizing intubating conditions. We conducted a systematic review of the literature to identify drug combinations that included induction of anesthesia with sevoflurane or propofol. Our aim was to select drug combinations that yield excellent intubating conditions ≥80%; we identified six combinations in children aged 1-9 years. Sevoflurane with remifentanil (1 or 2 µg·kg(-1) ), lidocaine (2 mg·kg(-1) ), or propofol (2 mg·kg(-1) ) as the adjuvant shared the following characteristics: premedication with midazolam and/or ketamine, long sevoflurane exposure time, high inspired and endtidal sevoflurane concentration, and assisted ventilation. One combination using sevoflurane with propofol (3 mg·kg(-1) ) without premedication, with shorter sevoflurane exposure time, and spontaneous breathing indicated that propofol may be the adjuvant of choice for a rapid sevoflurane induction. The only adjuvant identified in propofol induction was remifentanil (4 µg·kg(-1) ). No serious adverse events were reported with these combinations.

Factors Associated with Mental Health Outcomes: Results from a Tertiary Referral Hospital in Lebanon during the COVID-19 Pandemic.

Coronavirus Disease (COVID-19) has caused global mental health impacts, and healthcare workers (HCWs) face an increased risk of exposure to the disease when compared to the general population. This study aimed to assess factors associated with mental health among Lebanese HCWs six months after the start of the COVID-19 pandemic. A cross-sectional study was conducted among HCWs at a tertiary hospital, in Lebanon between June and July 2020. The survey included data on demographics, exposure to COVID-19, preparedness to COVID-19 outbreak, risk perceptions of COVID-19, and mental health dimensions. Chi-squared and Fisher's exact tests were used to understand the association among these variables. One hundred and ninety-three of 1,600 Lebanese HCWs participated. More than 80% reported high preparedness levels towards the COVID-19 outbreak, 69% believed that their job was putting them at risk, and 70% altruistically accepted these risks. Anxiety and depression symptomatology were present in 24% and 23% of HCWs; who were more likely to feel more stress at work (83% vs 60%; p = 0.004; 82% vs 61%; p = 0.01, respectively), feel afraid of falling ill (72% vs 55%; p = 0.03; 77% vs 54%; p = 0.01, respectively), fear death (21% vs 7%; p = 0.01; 25% vs 6%; p ≤ 0.001, respectively), and believed that people avoided their families (39% vs 21%; p = 0.01; 35% vs 65%; p = 0.02, respectively). HCWs who reported signs of depression were less likely to altruistically accept the risks of caring for COVID-19 patients, compared to those who did not (57% vs 74%; p = 0.03). This study aimed to detect factors associated with mental health among Lebanese HCWs during the COVID-19 pandemic. Findings suggested that altruistic acceptance of COVID-19 risks is higher among HCWs with positive exposure history to COVID-19 and those with less depressive symptomatology.

The analgesic efficacy of subarachnoid morphine in comparison with ultrasound-guided transversus abdominis plane block after cesarean delivery: a randomized controlled trial.

BACKGROUND: Ultrasound-guided transversus abdominis plane block is an effective method of providing pain relief after cesarean delivery. Neuraxial morphine is currently the "gold standard" treatment for pain after cesarean delivery. In this study we tested the hypothesis that subarachnoid morphine would provide more prolonged and superior analgesia than would transversus abdominis plane block in patients undergoing elective cesarean delivery. METHODS: In this prospective, double-blind study, 57 patients were randomly assigned to receive either subarachnoid morphine (group SAM; n = 28) or transversus abdominis plane block (group TAP; n = 29). Patients received bupivacaine spinal anesthesia combined with morphine 0.2 mg in group SAM and received saline in group TAP. At the end of surgery, bilateral transversus abdominis plane block was performed using saline in group SAM or using bupivacaine 0.375% plus epinephrine 5 microg/mL in group TAP with 20 mL on each side. Postoperative analgesia for the first 24 hours consisted of scheduled rectal diclofenac and IV paracetamol; breakthrough pain was treated with IV tramadol. For the next 24 hours, scheduled rectal diclofenac was given; oral paracetamol and IV tramadol were administered upon patient request. Patients were assessed postoperatively in the postanesthesia care unit (time 0 hours) and at 2, 4, 6, 12, 24, 36, and 48 hours. The primary outcome measure was the time to first analgesic request. RESULTS: Median (range) time to first analgesic request was longer in group SAM than in group TAP [8 (2-36) hours versus 4 (0.5 to 29) hours (P = 0.005)]. Median (range) number of tramadol doses received between 0 and 12 hours was 0 (0-1) in group SAM versus 0 (0-2) in group TAP (P = 0.03). Postoperative visceral pain scores at rest and on movement during first the 4 hours were lower in group SAM than in group TAP, but were not different at any other time points. The incidence of moderate to severe nausea was higher in group SAM than in group TAP [13/28 (46%) versus 5/29 (17%) (P = 0.02)]. More patients developed pruritus requiring treatment in group SAM than in group TAP [(11/28 (39%) versus none (0%) (P < 0.001)]. CONCLUSION: As part of a multimodal analgesic regimen, subarachnoid morphine provided superior analgesia when compared with ultrasound-guided transversus abdominis plane block after cesarean delivery, yet at the cost of increased side effects.

Femoral vein cannulation performed by residents: a comparison between ultrasound-guided and landmark technique in infants and children undergoing cardiac surgery.

BACKGROUND: Percutaneous cannulation of the femoral vein, in the pediatric age group, can be technically challenging, especially when performed by residents in training. We examined whether the use of real-time ultrasound guidance is superior to a landmark technique for femoral vein catheterization in children undergoing heart surgery. METHODS: Patients were prospectively randomized into 2 groups. In group LM, the femoral vein was cannulated using the traditional method of palpation of arterial pulse. In group US, cannulation was guided by real-time scanning with an ultrasound probe. The time to complete cannulation (primary outcome), success rate, number of needle passes, number of successful cannulations on first needle pass, and incidence of complications were compared between the 2 groups. RESULTS: Forty-eight pediatric patients were studied. The time to complete cannulation was significantly shorter (155 [46-690] vs 370 [45-1620] seconds; P = 0.02) in group US versus group LM. The success rate was similar in both groups (95.8%). The number of needle passes was smaller (1 [1-8] vs 3 [1-21]; P = 0.001) and the number of successful cannulations on first needle pass higher (18 vs 6; P = 0.001) in group US compared with group LM. The incidence of femoral artery puncture was comparable between the 2 groups. CONCLUSIONS: Ultrasound-guided cannulation of the femoral vein, in pediatric patients, when performed by senior anesthesia residents, is superior to the landmark technique in terms of speed and number of needle passes, with remarkable improvement in first attempt success.

Establishing a High-Quality Congenital Cardiac Surgery Program in a Developing Country: Lessons Learned.

Background: Developing countries are profoundly affected by the burden of congenital heart disease (CHD) because of limited resources, poverty, cost, and inefficient governance. The outcome of pediatric cardiac surgery in developing countries is suboptimal, and the availability of sustainable programs is minimal. Aim: This study describes the establishment of a high quality in-situ pediatric cardiac surgery program in Lebanon, a limited resource country. Methods: We enrolled all patients operated for CHD at the Children's Heart Center at the American University of Beirut between January 2014 and December 2018. Financial information was obtained. We established a partnership between the state, private University hospital, and philanthropic organizations to support the program. Results: In 5 years, 856 consecutive patients underwent 993 surgical procedures. Neonates and infants constituted 22.5 and 22.6% of our cohort, respectively. Most patients (82.6%) underwent one cardiac procedure. Our results were similar to those of the Society of Thoracic Surgeons (STS) harvest and to the expected mortalities in RACHS-1 scores with an overall mortality of 2.8%. The government (Public) covered 43% of the hospital bill, the Philanthropic organizations covered 30%, and the Private hospital provided a 25% discount. The parents' out-of-pocket contribution included another 2%. The average cost per patient, including neonates, was $19,800. Conclusion: High standard pediatric cardiac surgery programs can be achieved in limited-resource countries, with outcome measures comparable to developed countries. We established a viable financial model through a tripartite partnership between Public, Private, and Philanthropy (3P system) to provide high caliber care to children with CHD.

The effect of low-dose remifentanil on responses to the endotracheal tube during emergence from general anesthesia.

BACKGROUND: Emergence from general anesthesia can be associated with coughing, agitation, and hemodynamic disturbances. Remifentanil may attenuate these responses. METHODS: In a prospective, double-blind, randomized trial, we enrolled 60 adult patients undergoing nasal surgery using remifentanil-based anesthesia. During the emergence phase, the remifentanil group had remifentanil reduced to one tenth of the maintenance rate, whereas the control group had remifentanil discontinued. RESULTS: Times to awakening and tracheal extubation were similar between the two groups. During emergence, the remifentanil group (infusion rate 0.014 +/- 0.011 microg x kg(-1) x min(-1)) had a significantly lower incidence (40% vs 80%, P = 0.002) and less severe coughing compared with the control group, as well as a lower incidence of nonpurposeful movement (3.3% vs 30%, P = 0.006) and slower heart rates. CONCLUSIONS: Low-dose remifentanil during emergence did not prolong wake-up but reduced the incidence and severity of coughing from the endotracheal tube.

A randomized trial comparing colloid preload to coload during spinal anesthesia for elective cesarean delivery.

BACKGROUND: Hypotension after spinal anesthesia for cesarean delivery is common. Previous studies have demonstrated that a crystalloid fluid "coload" (rapid administration of a fluid bolus starting at the time of intrathecal injection) is superior to the conventional crystalloid preload (fluid administered before the intrathecal injection) for preventing hypotension. Colloid preload provides a sustained increase in central blood volume. We hypothesized that, in contrast to crystalloid, a colloid preload may be more effective than colloid coload for reducing the incidence of spinal anesthesia-induced hypotension. METHODS: In this double-blind study, 178 patients were randomly assigned to receive a preload of 500 mL of hydroxyethyl starch over a period of 15-20 min before initiation of spinal anesthesia (n = 90) or an identical fluid bolus of hydroxyethyl starch starting at the time of identification of cerebrospinal fluid (n = 88). Vasopressors (ephedrine or phenylephrine) were administered if systolic arterial blood pressure decreased less than 80% of the baseline pressure and <100 mm Hg, or with smaller decreases in blood pressure if accompanied by nausea, vomiting, or dizziness. The primary outcome was the incidence of hypotension (defined as the administration of at least one dose of vasopressor). RESULTS: There was no significant difference between the groups in the incidence of hypotension (68% in preload group and 75% in coload group, 95% confidence interval of difference -6%-20%; P = 0.28), doses of ephedrine and phenylephrine, and number of vasopressor unit doses. The incidence of severe hypotension (systolic blood pressure <80 mm Hg) was 16% in the preload group and 22% in the coload group (P = 0.30). There were no differences in the incidence of nausea and/or vomiting, or neonatal outcome between the groups. CONCLUSION: There was no difference in the incidence of hypotension in women who received colloid administration before the initiation of spinal anesthesia compared with at the time of initiation of anesthesia. Both modalities are inefficient as single interventions to prevent hypotension.

Excellent intubating conditions with remifentanil-propofol and either low-dose rocuronium or succinylcholine.

PURPOSE: The shortest time to tracheal intubation, the best intubating conditions, and the shortest duration of muscle paralysis are achieved with succinylcholine. During a lidocaine-remifentanil-propofol induction of anesthesia, we compared intubating conditions 90 s after administering low-dose rocuronium (0.3 mg . kg(-1)) with intubating conditions 60 s after administering succinylcholine 1.5 mg . kg(-1). METHODS: The randomized double-blind study included 184 healthy adult patients scheduled for elective surgery. Anesthesia was induced in all patients with lidocaine 1.5 mg . kg(-1), remifentanil 2 microg . kg(-1), and propofol 2 mg . kg(-1) administered over 30 s. In one group, rocuronium 0.3 mg . kg(-1) was administered before the induction sequence, and in the other group, succinylcholine 1.5 mg . kg(-1) was administered after the induction sequence. Laryngoscopy was attempted 90 s after rocuronium administration and 60 s after succinylcholine administration. Intubating conditions were assessed as excellent, good, or poor on the basis of ease of laryngoscopy, position of the vocal cords, and reaction to insertion of the tracheal tube and cuff inflation. RESULTS: There were 92 patients per group. In the rocuronium group, intubating conditions were excellent in 83 patients (90%), good in 8 (9%), and poor in 1 (1%), not significantly different from the intubating conditions in the succinylcholine group, which were excellent in 88 patients (96%), good in 3 (3%), and poor in 1 (1%) (P = 0.3). CONCLUSION: During a lidocaine-remifentanil-propofol induction of anesthesia, rocuronium 0.3 mg . kg(-1) administered before the induction sequence provides intubating conditions comparable to those achieved with succinylcholine 1.5 mg . kg(-1) administered after the induction sequence.