Morphine versus fentanyl patient-controlled analgesia for postoperative pain control in major hepatic resection surgeries including living liver donors: A retrospective study.

BACKGROUND: Liver resection surgery results in significant postoperative pain. However, it is still not clear which opioids used by patient-controlled analgesia (PCA) provides the best pain control and results in the least side effect in a patient with impaired liver function. Our hypothesis was that fentanyl is a better choice than morphine as it is a potent analgesic that its elimination half-life does not depend on the hepatic uptake and metabolism. THE STUDY PURPOSE: Is to compare morphine and fentanyl PCA in liver resection patients as regards the degree of pain control, the consumption of opioids, and the side effects. METHODS: A retrospective case-control study of hepatic resection patients who received postoperative morphine (Morph) or fentanyl (Fent) PCA. The study compared the pain scores, the morphine equivalent dose (MED), the number of demands requested as recorded by the PCA infusion pump, and the side effects every 12 h for 48 h. RESULTS: This study yielded 40 patients; with the majority were living donor hepatic resection patients. There was no significant difference in the pain scores. However, the MED and the demands were significantly less in the Morph group. The P < 0.000, 0.0001, 0.0005, and 0.003, demands P < 0.002, 0.006, 0.014, and 0.013 at 12, 24, 48, and 36 h, respectively. The overall side effects were not different between the 2 groups at all time intervals measured; however, Morph patients were significantly more sedated in the first 12 h. There was one case of respiratory depression in the Morph group compared to two cases in the in the Fent group that needed treatment with naloxone. CONCLUSIONS: Although both groups had adequate pain control. The Morphine group reached faster pain control with less MED and PCA requests in liver resection patients, although it was more sedating in the first 12 h. However, fentanyl patients were less sedated; both drugs need close monitoring in the immediate postoperative period due to reported respiratory depressive effect and the need to use naloxone. The dosage of the PCA settings needs to be studied further to reach to the best dose with a reduced side effect. Further studies are recommended to reduce PCA dosages by introducing a multimodal approach of pain management relying on other methods with no additional sedative effects as regional anterior abdominal blocks.

Postoperative vision loss after spine surgery: a single-institution case-control comparison.

BACKGROUND: Postoperative vision loss (POVL) after spine surgery is a rare but devastating outcome. We present the first case-control study from a single institution for POVL with the diagnoses of ischemic optic neuropathy or central vision loss after complex spine surgery. METHODS: POVL cases following spine surgeries between December 1995 and December 2010 at the Cleveland Clinic were identified retrospectively using administrative codes. Each instance of POVL was matched to 5 case-control patients based on age, gender, body mass index, systolic blood pressure, diastolic blood pressure, mean arterial pressure, and hematocrit. Duration of anesthesia, fluid volumes, and hemodynamic measurements were then compared between POVL cases and control cases using Wilcoxon rank sum test. RESULTS: Six patients developed POVL. These patients had significantly greater blood loss (P=0.002, Wilcoxon test) and a significantly greater volume of red blood cells transfused (P=0.006) than the control patients. No other intraoperative measures differed significantly after Bonferroni correction for multiple outcomes. CONCLUSION: We found that patients with POVL had significantly greater blood loss and significantly more red blood cell transfusions than their matched controls.

Factors predicting incremental administration of antihypertensive boluses during deep brain stimulator placement for Parkinson's disease.

Hypertension is common in deep brain stimulator (DBS) placement predisposing to intracranial hemorrhage. This retrospective review evaluates factors predicting incremental antihypertensive use intraoperatively. Medical records of Parkinson's disease (PD) patients undergoing DBS procedure between 2008-2011 were reviewed after Institutional Review Board approval. Anesthesia medication, preoperative levodopa dose, age, preoperative use of antihypertensive medications, diabetes mellitus, anxiety, motor part of the Unified Parkinson's Disease Rating Scale score and PD duration were collected. Univariate and multivariate analysis was done between each patient characteristic and the number of antihypertensive boluses. From the 136 patients included 60 were hypertensive, of whom 32 were on angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB), told to hold on the morning of surgery. Antihypertensive medications were given to 130 patients intraoperatively. Age (relative risk [RR] 1.01; 95% confidence interval [CI] 1.00-1.02; p=0.005), high Joint National Committee (JNC) class (p<0.0001), diabetes mellitus (RR 1.4; 95%CI 1.2-17; p<0.0001) and duration of PD >10 years (RR 1.2; 95%CI 1.1-1.3; p=0.001) were independent predictors for antihypertensive use. No difference was noted in the mean dose of levodopa (p=0.1) and levodopa equivalent dose (p=0.4) between the low (I/II) and high severity (III/IV) JNC groups. Addition of dexmedetomidine to propofol did not influence antihypertensive boluses required (p=0.38). Intraoperative hypertension during DBS surgery is associated with higher age group, hypertensive, diabetic patients and longer duration of PD. Withholding ACEI or ARB is an independent predictor of hypertension requiring more aggressive therapy. Levodopa withdrawal and choice of anesthetic agent is not associated with higher intraoperative antihypertensive medications.

Ultrasound-guided supraclavicular brachial plexus block: single versus triple injection technique for upper limb arteriovenous access surgery.

BACKGROUND: Although ultrasound-guided supraclavicular block has a good success rate, it remains unclear whether multiple injections are superior to single injection (SI). We compared the sensory block success rate of SI versus triple injection (TI). METHODS: In this randomized double-blind study, 96 end-stage renal disease patients undergoing arteriovenous fistula creation or superficialization were randomly allocated to receive either SI or TI. The primary outcome was the combined score of sensory blockade of the 5 nerves (median, ulnar, radial, medial cutaneous nerve of the forearm, and musculocutaneous) measured at 5, 10, 15, and 20 minutes after injection. Secondary outcome variables were the time to onset of the blockade, performance time (time to do the block), separate success rate for each of the above nerves, success rate of surgical anesthesia, and the complication rate. RESULTS: The combined success of the sensory block was 20% to 31% higher in the TI group than in the SI group at 10, 15, and 20 minutes after injection (all P < 0.035). The block of the musculocutaneous nerve in the TI group was faster and more successful than in the SI group, at all time points (all P < 0.026). The average time needed to perform the block was significantly longer in the TI than the SI group (6.5 ± 2.1 vs 4.7 ± 2.1 minutes, P = 0.001). The overall success of surgical anesthesia measured at 30 minutes did not differ significantly between the 2 groups (96% in TI vs 87% in SI, P = 0.253). CONCLUSIONS: Although the performance time of the SI technique was shorter, TI had a faster onset and resulted in a more successful block of all nerves in the first 20 minutes.

Asleep-awake-asleep craniotomy: a comparison with general anesthesia for resection of supratentorial tumors.

The anesthetic plan for patients undergoing awake craniotomy, when compared to craniotomy under general anesthesia, is different, in that it requires changes in states of consciousness during the procedure. This retrospective review compares patients undergoing an asleep-awake-asleep technique for craniotomy (group AW: n = 101) to patients undergoing craniotomy under general anesthesia (group AS: n = 77). Episodes of desaturation (AW = 31% versus AS = 1%, p < 0.0001), although temporary, and hypercarbia (AW = 43.75 mmHg versus AS = 32.75 mmHg, p < 0.001) were more common in the AW group. The mean arterial pressure during application of head clamp pins and emergence was significantly lower in AW patients compared to AS patients (pinning 91.47 mmHg versus 102.9 mmHg, p < 0.05 and emergence 84.85 mmHg versus 105 mmHg, p < 0.05). Patients in the AW group required less vasopressors intraoperatively (AW = 43% versus AS = 69%, p < 0.01). Intraoperative fluids were comparable between the two groups. The post anesthesia care unit (PACU) administered significantly fewer intravenous opioids in the AW group. The length of stay in the PACU and hospital was comparable in both groups. Thus, asleep-awake-asleep craniotomies with propofol-dexmedetomidine infusion had less hemodynamic response to pinning and emergence, and less overall narcotic use compared to general anesthesia. Despite a higher incidence of temporary episodes of desaturation and hypoventilation, no adverse clinical consequences were seen.

Evaluation of "no touch" extubation technique on airway-related complications during emergence from general anesthesia.

BACKGROUND AND OBJECTIVES: Awake "no touch" extubation requires performing extubations only when the patient spontaneously wakes up without any kind of stimulation during emergence from general anesthesia. The aim of this study was to evaluate absolutely awake extubation "no touch" technique in adult patients, scheduled for elective nasal and paranasal sinus surgeries under general anesthesia as regard to emergence airway complications. METHODS: A total of 60 adult patients were randomly allocated into one of two equal groups according to the method of extubation: Group I: Standard fully awake, Group II: Absolutely "no touch" awake extubation (absolutely no stimulation no touch was allowed until patients were able to open their eyes). The incidence of laryngospasm and its grade according to a four-point scale was reported. Occurrence of airway events (excessive secretions, breath-holding, coughing, hoarseness, biting, as well as the number and severity of any desaturation episodes), oozing from the wound, and postoperative sore throat were also recorded. The heart rate (HR), systolic (SBP) and diastolic (DBP) blood pressure measured at the end of surgery served as baseline values, and subsequent measurements were taken within 30 minutes after the end of surgery. RESULTS: There was absolutely no case of laryngeal spasm or episode of desaturation among patients who were extubated with the "no touch" technique. On the other hand, there were 3 cases of laryngeal spasm in standard fully awake group. Severity of coughing, excessive secretions and breath holding, hoarseness, biting, and occurrence of non-purposeful movements of the limbs were significantly less in the absolutely "no touch" technique awake technique. The changes in HR, SBP, and DBP during emergence extubation were significantly less in "no touch" technique technique group. However, oozing from the wound was significantly higher with standard fully awake extubation. However, there were no significant differences between the two groups regarding the incidence of postoperative sore throat (39 and 36%, respectively). CONCLUSION: The results of the present study showed that awake "no touch" technique technique for tracheal extubation produces less airway-related complications, as well as minimal hemodynamic response during emergence from general anesthesia in nasal and paranasal surgeries. It could be a safe alternative for tracheal extubation in airway surgery.