Dexamethasone with either granisetron or ondansetron for postoperative nausea and vomiting in laparoscopic surgery.

In a prospective randomized double-blind study, we compared the effectiveness of dexamethasone 8 mg with either granisetron 1 mg or ondansetron 4 mg in the prevention of postoperative nausea and vomiting in patients undergoing laparoscopic surgery. Hundred ASA I and II patients scheduled for laparoscopic surgery were enrolled in the study and 84 patients completed it. Following induction of anesthesia, group I (n=42) received granisetron 1 mg and dexamethasone 8 mg, group II (n=42) received ondansetron 4 mg and dexamethasone 8 mg. Nausea and vomiting episodes, pain scores as well as side effects were recorded during the first hour and subsequently during the first 6 and 24 hours postoperatively. Satisfaction scores were obtained at discharge. There was no statistically significant difference between the 2 groups during the 1st 24 hours following surgery in regards to pain scores, satisfaction and side effects manifestations. At 0-1 hour interval, 100% of patients in group I and 97.6% in group II had no vomiting. Total response (no moderate or severe nausea and no rescue antiemetics) was 83.3% in group I and 80.95% in group II, and metoclopramide was used in 7.1% of patients in both groups. At 1-6 hours interval, 97.6% of patients in group I and 100% in group II had no vomiting. Total response was 92.8% in group I and 90.9% in group II, and metoclopramide was used in 4.76% of patients in group I and 2.38% in group II. At 6-24 hours no vomiting occurred in 97.6% of patients in group I and 100% in group II. Total response was 95.2% in both groups, and metoclopramide was used in 2.38% of patients in both groups. In conclusion, the combination of dexamethasone 8 mg with either granisetron 1 mg or ondansetron 4 mg following induction of anesthesia in patients undergoing laparoscopic surgery showed no statistically significant difference in antiemetic efficacy with minimal side effects and excellent patient satisfaction.

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.

Bilateral guided cervical block for Zenker diverticulum excision in a patient with ankylosing spondylitis.

Patients with severe ankylosing spondylitis (AS) have difficulties in tracheal intubation. An 87-year-old man with severe AS was scheduled for Zenker diverticulum (ZD) excision. It was decided to proceed with combined bilateral cervical plexus blockade using a nerve stimulator. The surgery lasted about 3 h, with stable hemodynamics, ECG, and oxygen saturation. The use of a nerve stimulator-guided cervical block minimizes the risk of severe respiratory and/or airway compromise secondary to phrenic nerve or recurrent laryngeal nerve palsy, because it can elicit diaphragmatic muscle response, which helps to avoid the administration of local anesthetic directly to the area of the phrenic nerve, and guides correct needle placement. In conclusion, the nerve stimulatorguided bilateral cervical block in our ZD patient with AS was shown to be a safe and successful alternative anesthetic option.

A comparison of a silicone wire-reinforced tube with the Parker and polyvinyl chloride tubes for tracheal intubation through an intubating laryngeal mask airway in patients with normal airways undergoing general anesthesia.

BACKGROUND: The intubating laryngeal mask airway (ILMA) is used in the management of difficult intubation. Usually, a silicone wire-reinforced tube is inserted for tracheal intubation. Because the silicone wire-reinforced tube is expensive, alternatives, such as polyvinyl chloride (PVC) and posterior beveled Parker tubes, are worth considering. We compared the blind intubation success rates among the silicone wire-reinforced tube, the Parker tube, and the PVC tube, and identified laryngeal structures preventing tracheal intubations through the ILMA. METHODS: Sixty-three adult patients were randomized into three groups: Group I (n = 20) silicone wire-reinforced tube, Group II (n = 21) Parker tube, and Group III (n = 22) PVC tube. Demographic and clinical continuous data were compared with the analysis of variance with the Scheffé test for post hoc analysis. Frequencies and percentages were compared with the chi(2) test. RESULTS: Tracheal intubation was successful from the first attempt in 18 of 20 patients in Group I (silicone wire-reinforced tube), which was significantly higher than the success rate in either Group II (12 of 22 patients) (Parker tube) or Group III (10 of 21 patients) (PVC tube). With clockwise or anticlockwise rotation of the tracheal tube, the number of successful intubations did not change in Group I, but it increased to 19 of 22 patients in Group II and to 12 of 21 patients in Group III. The rate of successful intubation between patients in Group I (90%) and Group II (86%) was not significantly different after manipulation of the tracheal tube (P = 0.72). However, the rate of successful tracheal intubations in patients of Group III (57%) was significantly lower in comparison to patients in both Group I (P = 0.02) and Group II (P = 0.03). In 3 of the 22 patients of Group II and in 9 of the 21 patients of Group III in whom blind intubation was not possible, the obstruction was due to the epiglottis tubercule. CONCLUSIONS: Manipulation improved the success rate of intubation with the Parker tube through the ILMA rendering it a possible alternative to the silicone wire-reinforced tube.

Laryngospasm: review of different prevention and treatment modalities.

Laryngospasm is a common complication in pediatric anesthesia. In the majority of cases, laryngospasm is self-limiting. However, sometimes laryngospasm persists and if not appropriately treated, it may result in serious complications that may be life-threatening. The present review discusses laryngospasm with the emphasis on the different prevention and treatment modalities.

Recurrent postoperative aspiration following jugular foramen tumor resection.

We report a 38 year old male patient who underwent a craniotomy for jugular foramen tumor resection. In the postoperative care unit, the patient developed aspiration accompanied with oxyhemoglobin desaturation. Subsequently, he had several episodes of recurrent aspiration which were attributed to cranial nerves (IX, X) palsy as a complication of the surgery at the jugular foramen. It is suggested that aspiration prophylactic measures should be taken and early assessment of lower cranial nerves function should be done prior to tracheal extubation to decrease post-operative aspiration in patients undergoing base of skull surgery.

Multimodal analgesia to prevent propofol-induced pain: pretreatment with remifentanil and lidocaine versus remifentanil or lidocaine alone.

BACKGROUND: Propofol is well-known for its pain on injection. Premixture with lidocaine or pretreatment with remifentanil reduces injection pain. A multimodal approach might offer additional mitigation of propofol injection pain. METHODS: In a randomized, prospective, double-blind study of 156 patients, we compared the incidence and severity of propofol pain among three groups. Patients in the lidocaine group (n = 54) received 2% lidocaine premixed with propofol (40 mg lidocaine in 180 mg propofol). Patients in the remifentanil group (n = 50), received pretreatment with remifentanil 2 microg x kg(-1) IV over 30 s. Patients in the combination group (n = 52) received both lidocaine and remifentanil. RESULTS: A significant decrease in the overall incidence of propofol pain at induction was achieved in the combination group (9.6%) compared with that in the remifentanil group (36%) and the lidocaine group (35%) (P = 0.003). The incidence of severe and moderate pain was also significantly different in the combination group (0%), compared with that in the remifentanil (18%) and lidocaine groups (12.9%) (P < 0.02). Similar, statistically significant differences among the three groups were achieved concerning recalled pain in the postanesthesia care unit. CONCLUSIONS: The combination of two different analgesic modalities, remifentanil and lidocaine completely abolishes moderate and severe pain associated with propofol injection, and significantly reduces the incidence of mild pain when compared with each drug used alone.

Does ondansetron or granisetron prevent subarachnoid morphine-induced pruritus after cesarean delivery?

BACKGROUND: We compared the efficacy of granisetron and ondansetron for the prevention of subarachnoid morphine-induced pruritus after cesarean delivery. METHODS: The incidence of pruritus was assessed in parturients who were randomly allocated into Group G (granisetron 3 mg IV, n = 45), Group O (ondansetron 8 mg IV, n = 42), and Group S (saline IV, n = 42). RESULTS: The incidence of pruritus was not significantly different among the 3 groups (86.6% in Group S, 83.3% in Group O, and 88% in the Group G). CONCLUSION: Neither prophylactic ondansetron nor granisetron reduced the incidence of subarachnoid morphine-induced pruritus when compared with the saline group.

The effect of injection of two vs 10 mL saline on the subsequent spread and quality of epidural analgesia in parturients.

OBJECTIVE: To determine whether two vs 10 mL of saline injected into the epidural space affects the subsequent spread and quality of epidural analgesia in parturients. DESIGN: Randomized, double-blinded, placebo-controlled study. SETTING: Delivery room. PATIENTS: 105 ASA physical status I and II parturients requesting epidural analgesia. INTERVENTIONS: After identification of the epidural space by the loss-of-resistance technique using normal saline, two mL of saline was then injected into the epidural space in the 2-mL group (n = 53) and 10 mL in the 10-mL group (n = 52). Five minutes after the test dose, patients received 10 mL of bupivacaine (0.1%) with fentanyl two microg mL(-1). MEASUREMENTS: 25 minutes after the initial bolus of bupivacaine and fentanyl, spread of block, subsequent pain relief, and influence of the volume of the injected saline on the ease of epidural catheter insertion and on the incidence of blood vessel trauma and paresthesia were evaluated. RESULTS: The total number of dermatomes blocked for cold and pinprick sensation in the 10-mL group was significantly more than in the 2-mL group (19 [6-29] vs 15 [4-27] for cold sensation, P = 0.000; and 15 [3-29] vs 11.5 [3-26] for pinprick sensation, P = 0.001). However, the visual analog pain scale and need for supplemental analgesia were similar between the two groups. The epidural catheter was easily inserted in 94.2% of the 2-mL group and 100% of the 10-mL group. The incidence of blood vessel trauma was low and the incidence of paresthesia was high without any significant difference between the two groups. CONCLUSIONS: 10 mL saline was associated with a higher total number of dermatomes blocked for both cold and pinprick sensation than the two mL saline. However, the pain relief was adequate in both groups, and two mL saline was as effective as the 10 mL in the ease of catheter insertion and prevention of intravascular cannulation.

Does pancuronium or cisatracurium delay the rate of arousal following remifentanil-based anesthesia?

STUDY OBJECTIVE: The present report investigates the rate of arousal following remifentanil-based anesthesia associated with the coadministration of pancuronium, which inhibits butyrylcholinesterase, or cisatracurium, which is partially metabolized by nonspecific esterases, versus vecuronium that is eliminated independently of ester hydrolysis. DESIGN, SETTING AND PATIENTS: Sixty patients, ASA I-II, scheduled for elective abdominal surgeries were enrolled in a double-blinded prospective study. In fact, patients were equally divided into three Groups with each Group receiving remifentanil and either one of the following three muscle relaxants: pancuronium, vecuronium or cisatracurium. MEASUREMENTS: The rate of arousal following discontinuation of anesthesia was assessed by Modified Aldrete Score. Time to eye opening on verbal command, tracheal extubation, Modified Aldrete Score >9, and time to discharge from the recovery room were recorded. MAIN RESULTS: Time to eye opening on verbal command, tracheal extubation, Modified Aldrete Score >9, and time to discharge from the recovery room were not significantly different between the three groups. CONCLUSION: The results suggest that recovery following remifentanil-based anesthesia is not delayed by the coadministration of pancuronium, cisatracurium versus vecuronium; and by the use of neostigmine for reversal of neuromuscular blockade.

Hypothermia and excessive sweating following intrathecal morphine in a parturient undergoing cesarean delivery.

OBJECTIVE: Intrathecal morphine has been used for the relief of postoperative pain following cesarean delivery. We report a case of postoperative hypothermia down to 33.6 degrees C associated with excessive sweating in patient undergoing elective cesarean delivery under spinal bupivacaine anesthesia who received intrathecal morphine for postoperative pain management. CASE REPORT: A healthy 31-year-old multigravida presented for elective cesarean delivery. Following prehydration with 500 mL hemaccel, she had a subarachnoid block, using hyperbaric bupivacaine 12 mg and morphine 200 microgram, via a 25-gauge Whitacre needle. In the recovery room, 3 hours after induction of spinal anesthesia, the patient's sublingual temperature was 33.6 degrees C and she was noted to be sedated and sweating excessively. During the next 2 hours, the patient was still hypothermic despite active warming. She also complained of severe nausea, vomiting, and moderate pruritus. Following administration of naloxone 400 microgram sedation, vomiting, and pruritus were relieved. Also, the patient experienced excessive shivering, and her body temperature started to increase in association with a concurrent decrease of sweating. The postoperative hypothermia and excessive sweating in our patient may be related to the cephalad spread of the intrathecal morphine within the cerebrospinal fluid (CSF) to reach the level of opioid receptors in the hypothalamus, causing a perturbation of the thermoregulatory center. This effect could be counteracted by administration of naloxone. CONCLUSIONS: Intrathecal morphine may cause disruption of thermoregulation resulting in hypothermia associated with excessive sweating.

End-tidal CO2 for prediction of cardiac output following weaning from cardiopulmonary bypass.

This prospective study included 32 patients undergoing cardiopulmonary bypass (CPB) for elective coronary artery bypass grafting correlates the respiratory end-tidal CO2 (ETCO2) during partial separation from CPB with cardiac output (CO) following weaning from CPB. After induction of general anesthesia, a pulmonary artery catheter was inserted for measurement of cardiac output by thermodilution. Patients were monitored using a 5-lead ECG, pulse oximeter, invasive blood pressure monitoring, rectal temperature probe, and end-tidal capnography. At the end of surgery, patients were weaned from CPB in a stepwise fashion. Respiratory ETCO2 and in-line venous oximetry were continuously monitored during weaning. The ETCO2 was recorded at quarter pump flow and after complete weaning from CPB. Following weaning from CPB, CO was measured by thermodilution. The CO values were correlated with the ETCO2 during partial bypass and following weaning from bypass. Regression analysis of ETCO2 at quarter-flow and post-bypass CO showed significant correlation (r = 0.57, p < .001). Also, regression analysis of ETCO2 after complete weaning from bypass and post-bypass CO showed significant correlation (r = 0.6, p = .002). The correlation between ETCO2 and CO showed that an ETCO2 >30 mm Hg during partial CPB will always predict an adequate CO following weaning from CPB. An ETCO2 <30 mm Hg may denote either a low or a normal cardiac output and hence other predictive parameters such as SvO2 must be added.

Haemodynamic and EKG changes in patients undergoing minimally invasive direct coronary artery bypass.

BACKGROUND AND OBJECTIVES: The objective of the report is to monitor, in patients undergoing minimally invasive direct coronary artery bypass surgery (MIDCAB), the haemodynamic parameters, ST segment changes and the incidence of arrhythmias during clamping of the coronary artery and following reperfusion. METHODS: Twelve patients scheduled for elective MIDCAB surgery during isoflurane anesthesia were enrolled in the study. Patients were monitored by a pulmonary artery thermodilution catheter, an arterial line and 5 leads ECG. The different haemodynamic parameters, the ST segment changes, as well as the occurrence of arrhythmias during coronary clamping and ten minutes following reperfusion were compared to the control values. RESULTS: No significant changes in the cardiac index followed clamping of the coronary artery. However, the ST segment was significantly elevated. Following coronary reperfusion, the ST segment recovered to the baseline values, and the cardiac index significantly increased more than the baseline value (3.5 +/- 1.1 l/min/m2 vs 2.6 +/- 0.7 l/min/m2). However, reperfusion was associated with multiple ventricular extrasystoles in four patients. The elevation of the ST segments during coronary clamping was higher in the four patients who developed reperfusion arrhythmias (0.9 +/- 0.4 mm); one of the patients had preoperative frequent VPBs, two patients had history of unstable angina, while the fourth patient had 70% proximal stenosis of the LAD and recent myocardial infarction. CONCLUSIONS: Coronary occlusion in patients undergoing MIDCAB can result in ST segment elevation, followed by reperfusion ventricular extrasystoles. The reperfusion arrhythmias were observed in patients showing a significant elevation of the ST segment during coronary occlusion; risk factors included a preoperative history of arrhythmia, unstable angina, recent MI, and/or 70% LAD stenosis. The rapid restoration of the control ST segment level and the significant increase of cardiac output following coronary reperfusion suggest that isoflurane anesthesia may have provided a degree of myocardial protection during coronary clamping and reperfusion.