Ondansetron for treatment of intrathecal morphine-induced pruritus after cesarean delivery.

BACKGROUND AND OBJECTIVES: Pruritus induced by intrathecal morphine is a concern in many obstetric patients after cesarean delivery and may detract from the benefit of postoperative pain relief. This study was performed to investigate the efficacy of ondansetron (5-HT3 receptor antagonist) in treatment of pruritus following intrathecal morphine. METHODS: Eighty parturients developing moderate to severe pruritus following intrathecal morphine were randomly allocated into 2 groups. One group received 4 mg ondansetron while the other group received placebo (normal saline). The improvement of pruritus and other adverse effects such as pain scores, nausea, vomiting, sedation, hallucination, and respiratory depression were determined at 30 minutes after study drugs' administration. RESULTS: The treatment success rate was higher in the ondansetron group than in the placebo group (80% v 36%, P < .001). Among the successfully treated patients, the recurrence rates of moderate to severe pruritus within 4 hours after administration of ondansetron and placebo were 12% and 70%, respectively (P < .001). The number of patients with decreased nausea and vomiting score was also higher in the ondansetron group (11 v 1, P < .006). CONCLUSION: Ondansetron treats intrathecal morphine-induced pruritus after cesarean delivery, particularly in patients suffering from both nausea/vomiting and pruritus.

Learning manual skills in spinal anesthesia and orotracheal intubation: is there any recommended number of cases for anesthesia residency training program?

Wide variability exists in the number of anesthetic procedures to which anesthesia residents are exposed during their training. The number of attempts at various procedures before a trainee becomes proficient at performing each anesthetic procedure is not known. To determine the learning process of 150 attempts of spinal anesthesia and 100 attempts of orotracheal intubation, the two most frequent anesthetic procedures, we evaluated 9 first-year anesthesia residents according to their rate of success or failure. The learning curves of both procedures revealed an initial rapid improvement of success during the first 20 attempts. Spinal anesthesia was more difficult to learn (p=0.0002) but the learning curves of spinal anesthesia and orotracheal intubation reached a nondifferent high success rate of 82 per cent and 88.9 per cent respectively (p=0.13). According to this study the institutional recommended number of cases for spinal anesthesia and orotracheal intubation were 112 and 27 cases respectively.

Hypotension in spinal anesthesia for cesarean section: a comparison of 0.5% hyperbaric bupivacaine and 5% hyperbaric lidocaine.

Hypotension is a common side effect associated with spinal anesthesia. However, there is no previous report comparing the incidence of hypotension between two commonly used local anesthetic agents, bupivacaine and lidocaine. The objective of this study was to compare the incidence of spinal hypotension induced by bupivacaine and lidocaine in parturients undergoing cesarean section. A double blind, randomized controlled trial was conducted in 142 parturients scheduled for cesarean section. The patients were randomized into two groups, 71 each. After receiving 10 ml/kg of normal saline intravenously, patients in the first group were given 2.2 ml of 0.5 per cent hyperbaric bupivacaine plus 0.2 mg of morphine as a spinal anesthetic agent while in the other group, 1.2 ml of 5 per cent hyperbaric lidocaine plus 0.1 mg of epinephrine and 0.2 mg of morphine were administered. Hypotension, defined as 30 per cent less systolic blood pressure than baseline value, was recorded and the patients were treated with 6 mg of ephedrine every 2 minutes until normotension was achieved. There was no statistically significant difference of incidence, onset, duration, and severity of hypotension between the two groups (p > 0.05). The amount of ephedrine used in both groups was also not significantly different. Late onset hypotension occurred after delivery (20-22 minutes after spinal anesthesia was performed) in 17 patients (12%). As such, the rate of hypotension in lidocaine group was comparable to bupivacaine group. Delayed onset hypotension occurring after delivery was noted and these events have never been described. However, the mechanism of late onset hypotension remains unidentified. Thus, bupivacaine and lidocaine can be used interchangeably for spinal anesthesia for elective cesarean section without significant difference in the incidence of hypotension.

Anesthetic management of cerebral aneurysm clipping using the deep hypothermic circulatory arrest technique: a case report.

Deep hypothermic circulatory arrest may prove advantageous during surgery of some technically difficult brain lesions. This technique was first applied in one patient with a large intracavernous aneurysm which had failed standard neurosurgical techniques. For this technique to be successful the cooperation of neurosurgeons, cardiovascular surgeons, anesthesiologists, perfusionists and nurses is essential. Techniques aimed at improving the outcome include a short period of circulatory arrest, the depth of hypothermia, barbiturate administration, coagulation management and well-controlled blood glucose levels. The total time of circulatory arrest and the thiopentone dosage were 61 minutes and 1,700 mg respectively. The lowest core temperature was 13.9 degrees C. The positive outcome supports the use of this technique in selected patients with complex intracranial vascular lesions who may not be operable by standard techniques.

Cardiovascular and respiratory changes in laparoscopic cholecystectomy.

Although laparoscopic cholecystectomy has several advantages over the traditional open cholecystectomy, it may however cause some adverse cardiovascular and respiratory effects associated with intraperitoneal insufflation of CO2. It is, therefore, recommended that appropriate hemodynamic and respiratory monitorings should be used routinely in order to prevent deleterious complications, especially in high risk patients.

Comparison of ondansetron and placebo for preventing postoperative nausea and emesis in gastrointestinal tract surgery: a multicenter randomized controlled trial.

BACKGROUND: Nausea and emesis are undesirable events that may cause discomfort and suffering in the postoperative period. This study was carried out to evaluate the efficacy and safety of ondansetron for preventing postoperative nausea and vomiting in patients undergoing gastrointestinal tract surgery. METHODS: Using a randomized double-blind study design, 408 surgical patients (163 male and 245 female) receiving general endotracheal anesthesia were studied at five medical centers in Bangkok. Ondansetron (4 mg) or placebo was administered prior to induction of anesthesia. Episodes of nausea and vomiting, adverse events and laboratory tests (complete blood count and liver function test) were evaluated during 24 hours after study drug administration. RESULTS: The incidence of postoperative nausea and vomiting in the placebo group (42.7 and 35.2%) were significantly higher than the ondansetron group (23.9 and 15.4%). However, no significant differences occurred in the incidence of adverse events or changes in laboratory tests in the ondansetron group compared to the placebo group. CONCLUSIONS: Ondansetron 4 mg given intravenously before surgery is safe and effective for preventing postoperative nausea and emesis following gastrointestinal tract surgery.

Anesthesia for Indian Ocean tsunami-affected patients at a southern Thailand provincial hospital.

BACKGROUND: On 26 December 2004, a giant earthquake shook South-East Asia, triggering deadly flood waves (tsunami) across the Indian Ocean. The Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand joined the Thai Red Cross Society to provide relief in southern Thailand. The objective of this article is to characterize the emergency surgical patients and anesthesia profiles of tsunami victims at Phang-Nga Provincial Hospital. METHODS: Available records from the operating room and anesthesia unit of Phang-Nga Provincial Hospital, together with laboratory and administrative data, during the period 26-31 December 2004 were collected and analyzed using descriptive statistics. RESULTS: Thai Red Cross teams provided surgical emergency services for 107 cases during 28-30 December 2004. Ninety-three cases (86%) were Caucasian, one (0.9%) was Japanese and nine (8.4%) were Thai. ASA physical status classifications of 1, 2 and 3 were present in 87.8%, 8.4% and 0.4%, respectively. The majority of injuries comprised multiple soft tissue wounds with severe infection. Eighty-five per cent of cases received debridement and 14.0% tendon or nerve repair or fixation of bone. The anesthesia choices were general endotracheal with rapid sequence induction and intubation (69.2%), general under mask (19.6%), total intravenous anesthesia (4.7%), spinal anesthesia (3.7%) and local anesthesia (2.8%). Anesthesia-related problems included a lack of pre-operative laboratory investigation, hypovolemia, severe wound infection with early sepsis and aspiration pneumonia. Common intra-operative complications included hypotension and oxygen desaturation from pulmonary aspiration or lung contusion. There was one case of post-operative reintubation and no peri-operative mortality. CONCLUSION: Anesthesia-related problems in tsunami victims included pulmonary aspiration, hypovolemia, sepsis and lack of pre-operative laboratory investigation. General anesthesia was the most common anesthetic technique. Common intra-operative complications included hypotension and oxygen desaturation.

Nicardipine versus lidocaine for attenuating the cardiovascular response to endotracheal intubation.

PURPOSE: The aim of this study was to compare the efficacy of nicardipine and lidocaine in attenuation of cardiovascular responses to endotracheal intubation. METHODS: In a randomized, double-blind, controlled trial, 60 unpremedicated (ASA I) patients undergoing elective surgery were given either 30 microg.kg(-1) nicardipine or 1.5 mg.kg(-1) lidocaine intravenously 2 min before intubation. Laryngoscopy and tracheal intubation were performed 1 min after induction of anesthesia with 5 mg.kg(-1) thiopentone, followed by administration of 1.5 mg.kg(-1) succinylcholine intravenously. Blood pressure and heart rate were monitored at baseline and every minute until 4 min after intubation. Repeated-measures ANOVA, Student's t test, the chi-square test, and 95% confidence intervals were used as appropriate. P < 0.05 was considered statistically significant. RESULTS: Baseline hemodynamic variables were not different between the groups. After administration of either agents, diastolic blood pressure and mean blood pressure were significantly lower in the nicardipine group. The heart rate in the nicardipine group was significantly higher. The mean between-group differences in diastolic blood pressure, mean blood pressure, heart rate, and rate-pressure product at baseline and 1 min after starting laryngoscopy were statistically significant. CONCLUSION: Nicardipine can be used as an alternative to lidocaine in attenuation of cardiovascular response to tracheal intubation in patients without ischemic heart disease.

Nalbuphine versus propofol for treatment of intrathecal morphine-induced pruritus after cesarean delivery.

UNLABELLED: In this prospective, randomized, double-blinded study, we compared the efficacy of nalbuphine and propofol for treating intrathecal morphine-induced pruritus after cesarean delivery. One-hundred-eighty-one parturients who developed moderate to severe pruritus after the administration of intrathecal morphine were randomly allocated into two groups. One group received 3 mg IV nalbuphine (n = 91), and the other received 20 mg IV propofol (n = 90). The improvement of pruritus and other adverse effects was determined at 10 min after study drug administration. The treatment success rate was higher in the Nalbuphine group than in the Propofol group (83% vs 61%; P < 0.001). Among the successfully treated patients, recurrence rates of moderate to severe pruritus within 4 h were not significantly different (nalbuphine 9% versus propofol 7%; P = 0.76). Other side effects, such as decreased analgesia, increased nausea, vomiting, increased sedation, pain on injection, and dizziness, were not significantly different between groups. Sedation and pain on injection, which were the two most common side effects, were minor and clinically inconsequential. IMPLICATIONS: Nalbuphine was superior to propofol for the treatment of intrathecal morphine-induced pruritus after cesarean delivery.