Effect of preemptive intramuscular diclofenac on minimal effective-dose bupivacaine saddle block for minor perianal surgeries.

Background: Preemptive analgesics are commonly used to increase analgesic efficacy and patient satisfaction. The aim of this study was to evaluate the preemptive analgesic effect of intramuscular diclofenac on minimal effective dose spinal anesthesia for perianal surgeries. Materials and Methods: Fifty patients ASA I&II were divided randomly into two groups, control group (GC N = 25) and Diclofenac group (GD N = 25), both groups received saddle block with 5% hyperbaric bupivacaine 0.5 mL (2.5 mg). Thirty minutes before the saddle block, patients in GD received 75 mg (3 mL) diclofenac intramuscularly, whereas patients in GC received 3 mL saline intramuscularly. The differences in the time for the first analgesic request, postoperative analgesic consumption as well as, visual analog scale, were our primary outcomes. Results: Fifty patients (25 in each group) undergoing perianal surgery completed the study successfully. The time to the first request of analgesia was significantly longer in GD 511.8 (108.07) min. compared to the GC 179.56 (49.24) min with P = 0.00001, as well as the total consumption of rescue analgesic (tramadol hydrochloride) was significantly less in GD 66 (23.8) mg compared to 104 (28.5) mg in the GC with P = 0.00001. Conclusion: Preemptive intramuscular diclofenac sodium with minimal dose bupivacaine saddle block significantly minimized the postoperative analgesic consumption and delayed the first analgesia request after perianal surgery.

Preoperative mannitol infusion improves perioperative cerebral oxygen saturation and enhances postoperative recovery after laparoscopic cholecystectomy.

OBJECTIVES: To test the effect of preoperative mannitol infusion on perioperative decreased cerebral oxygen saturation (rSO2) during laparoscopic cholecystectomy. METHODS: Forty patients scheduled for laparoscopic cholecystectomy were enrolled in this study conducted at Dammam Hospital of the University, Dammam, Kingdom of Saudi Arabia from December 2013 to June 2014. Patients received either 0.5 g/kg of 20% intravenous mannitol infusion over 10 minutes before induction of anesthesia (group M), or an equal volume of normal saline instead (group C). Primary outcome variable was rSO2. Other variables included extubation time, clinical assessment of consciousness recovery using the Modified Observer's Assessment of Alertness/Sedation Scale (OAA/S), and the mini-mental state examination (MMSE) for cognitive evaluation. RESULTS: Anesthesia induction increased rSO2 in both groups. Pneumoperitoneum decreased rSO2 in group C, but not in group M. This drop in rSO2 in the group C reached its maximum 30 minutes after extubation, and was significantly less than the preinduction value. Time to extubation in group M was significantly shorter compared with group C (p=0.007). The OAAS in group M at 10 min after extubation was significantly higher compared with group C. No differences were found between the 2 groups in cognitive function as measured by MMSE score. CONCLUSION: Preoperative mannitol infusion maintains perioperative rSO2 during laparoscopic cholecystectomy and shortens extubation time with earlier resurgence of OAAS.

The optimal effect-site concentration of sufentanil for laryngeal mask insertion during induction with target-controlled propofol infusion at 4.0 µg/mL.

OBJECTIVE: The objective of this study is to determine the optimal effect-site concentration (Ce) of sufentanil for satisfactory insertion of laryngeal mask airway (LMA) when administered with a target-controlled infusion (TCI) of propofol at 4.0 µg/mL. MATERIALS AND METHODS: A total of 25 adult patients scheduled for minor elective surgery were enrolled in this study. All patients received induction with a combination of propofol and sufentanil TCI. The TCI of sufentanil was started at a target Ce of 0.1 ng/mL. After equilibrium with the plasma concentration, the TCI of propofol was initiated, targeting a preset Ce of 4.0 µg/mL. After the loss of consciousness, LMA was inserted and assessed by an experienced Anesthesiologist. The Ce of sufentanil for the next patient was guided by modified Dixon's up-and-down method using 0.05 ng/mL as a step size. The Ce of sufentanil required for successful LMA insertion in 50% of adults (EC50) was determined by calculating the midpoint concentration of all independent pairs of patients after at least seven crossover points. RESULTS: The optimal Ce (EC50) of sufentanil for LMA insertion during propofol induction using target Ce of 4 µg/mL was 0.16 ng/mL (95% confidence interval [CI] = 0.12-0.20). There was a significant reduction in propofol induced pain score P = 0.0275 and insignificant hemodynamic changes. CONCLUSION: Ce of sufentanil required for successful LMA insertion in 50% of patients (EC50) using propofol target Ce of 4.0 µg/mL was 0.16 ng/mL (95% CI = 0.12-0.20) with a significant reduction in the propofol induced pain and hemodynamic stability.

Isometric force dynamometer is superior to bromage score in prediction of patients' ambulation after spinal anesthesia in ambulatory surgeries.

BACKGROUND: The aim of our study was to use a quantitative measure of muscle strength to identify the muscle power at which the patient can safely ambulate unassisted after spinal anesthesia. METHODS: Twenty ASA physical status I and II patients undergoing elective perineal or lower abdominal surgery under spinal anesthesia were enrolled in the study. Spinal anesthesia was conducted using 10 mg heavy bupivacaine. The regression of motor block was assessed both qualitatively using the Bromage score and quantitatively by measuring the isometric contraction of the knee, hip, and ankle flexors every 15 minutes until the patient was able to ambulate unassisted. RESULTS: The rate of regression of the Bromage score was faster than regression of the isometric forces at all tested joints. As the median Bromage score reached 0 (no motor blockade), the mean±SD motor power recoveries at the knee, hip, and ankle were 28.2%±16%, 45.5%±24%, and 56.3%±28 %, respectively, and only 6 of 20 patients (30%, 95% confidence interval 10%-53%) were able to walk unassisted. After 75 minutes passed, 90% of the patients (95% confidence interval 56%-99%) were able to walk unassisted with mean motor power recovery of 63.6%±20%, 82.1%±27%, and 90.2%±24% at the knee, hip, and ankle, respectively. The area under the receiver operating characteristic curves was significantly higher with isometric contraction at different joints than the Bromage score (P<0.001). In addition, isometric contraction at different joints was effective in predicting the patients' ability to walk unassisted after subarachnoid block with prediction probabilities of 0.901, 0.948, and 0.958 for the knee, hip, and ankle, respectively, as compared with 0.752 for the Bromage score (P<0.001). CONCLUSION: Quantitative measurement of the degree of recovery of the motor power of the knee, hip, or ankle flexors is more accurate and superior to the qualitative Bromage score, as a predictor of the patient's ability to safely ambulate after spinal anesthesia. This may be recommended when assessing motor block when small-dose anesthetic solutions are used.

Is sealing cuff pressure, easy, reliable and safe technique for endotracheal tube cuff inflation?: A comparative study.

OBJECTIVE: To compare the three common methods of endotracheal tube cuff inflation (sealing pressure, precise standard pressure or finger estimation) regarding the effective tracheal seal and the incidence of post-intubation airway complications. METHODS: Seventy-five adult patients scheduled for N(2) O free general anesthesia were enrolled in this study. After induction of anesthesia, endotracheal tubes size 7.5 mm for female and 8.0 mm for male were used. Patients were randomly assigned into one of three groups. Control group (n=25), the cuff was inflated to a pressure of 25 cm H(2)O; sealing group (n=25), the cuff was inflated to prevent air leaks at airway pressure of 20 cm H(2)O and finger group (n=25), the cuff was inflated using finger estimation. Tracheal leaks, incidence of sore throat, hoarseness and dysphagia were tested. RESULTS: Although cuff pressure was significantly low in the sealing group compared to the control group (P<0.001), the incidence of sore throat was similar in both groups. On the other hand, cuff pressure as well as the incidence of sore throat were significantly higher in the finger group compared to both the control and the sealing group (P<0.001 and P=0.008). The incidence of dysphagia and hoarseness were similar in the three groups. None of the patients in the three groups developed air leak around the endotracheal tube cuff.. CONCLUSIONS: In N(2)O, free anesthesia sealing cuff pressure is an easy, undemanding and safe alternative to the standard technique, regarding effective sealing and low incidence of sore throat.

Gentle chest compression relieves extubation laryngospasm in children.

PURPOSE: Extubation laryngospasm is frequently encountered in children undergoing upper airway surgery. Different drugs and techniques have been used for its treatment. The objective of this study was to examine gentle chest compression as an alternative to standard practice for relief of laryngospasm. METHODS: This study was conducted over 4 years on all children scheduled for elective tonsillectomy. During the first 2 years, extubation laryngospasm was managed with 100% O2 with gentle positive pressure ventilation via a tight-fitting face mask (Standard-Practice Group), whereas in the following 2 years; laryngospasm was managed with 100% O2 and concurrent gentle chest compression (Chest-Compression Group). In both groups, if the spasm was not relieved and oxygen saturation decreased to 85%, IV succinylcholine was administered with subsequent manual ventilation. RESULTS: During the 4-year study period, 1226 children aged 3-12 years were studied. In the chest-compression group, 46/594 children (7.8%) developed laryngospasm compared with 52/632 children (8.2%) in the standard group (P = 0.84). Significantly more children who developed laryngospasm were successfully treated by chest compression 34/46 (73.9%) compared with those managed by the standard method 20/52 (38.4%); (P < 0.001). None of the children in the chest-compression group developed gastric distension compared with 45/52 (86.5%) in the standard group. CONCLUSION: Gentle chest compression with 100% oxygen is a simple and effective technique for immediate management of post extubation laryngeal spasm in children.

Double-lumen tube placement using a retractable carinal hook: a preliminary report.

BACKGROUND: Proper placement of a double-lumen tube (DLT) is vital for its optimal functioning. We modified the standard blind method of left-sided DLT placement using a retractable carinal hook. The aim of this study was to determine whether this modified method could improve the success rate of correct initial tube positioning compared with the conventional method. METHODS: Forty patients scheduled for general anesthesia requiring left-sided DLTs in a prospective, randomized, controlled trial were studied. The incidence of malpositions and time required for proper placement of a DLT using either the conventional method (conventional group, n = 20) or a modified method using a retractable carinal hook (hook group, n = 20) were recorded. The hook is a modified gum elastic bougie. Correct positioning was confirmed by fiberoptic bronchoscopy (FOB). RESULTS: After initial DLTs placement, clinical finding alone detected malpositions in 3 of 20 (15%) and 1 of 20 (5%) patients in the conventional and hook groups, respectively. Subsequent FOB revealed a significantly lower incidence of tube malposition in the hook group 2 of 20 (10%), compared with the conventional group 9 of 20 (45%) (P = 0.03). The time for clinical placement of DLTs was comparable in the two groups (P = 0.63), and the time for FOB confirmation and adjustment was significantly shorter in the hook group (88.9 +/- 35.7 s) compared with the conventional group (152.3 +/- 40.3 s) (P < 0.0001). CONCLUSION: The use of a retractable carinal hook increased the success rate and shortens the time for correct DLT positioning. Further, larger studies are required to confirm its safety and reliability.

Plethysmographic pulse wave amplitude is an effective indicator for intravascular injection of epinephrine-containing epidural test dose in sevoflurane-anesthetized pediatric patients.

BACKGROUND: Plethysmographic pulse wave amplitude (PPWA) was effective in detecting intravascular injection of epidural test dose with 100% sensitivity and specificity in adults. We evaluated the efficacy of PPWA in detecting intravascular injection of a simulated epidural test dose during sevoflurane anesthesia in pediatric patients. METHODS: Eighty infants and children were randomized to receive either 0.5 minimal alveolar concentration (MAC) or 1 MAC sevoflurane and nitrous oxide in oxygen. Patients in each anesthesia group were further randomized to receive either 0.1 mL/kg of 1% lidocaine with 1:200,000 epinephrine (0.5 mug/kg of epinephrine) IV to simulate the intravascular injection of epidural test dose or saline. Heart rate (HR), systolic blood pressure (SBP), and PPWA were monitored for 5 min after injection. A positive test response was defined as HR increase > or =10 bpm, SBP increase > or =15 mm Hg, and PPWA decrease > or =10%. RESULTS: Injecting the test dose resulted in an average maximum PPWA decrease by 69% +/- 18% and 58% +/- 14% at 79 +/- 22 and 80 +/- 19 s in the 0.5 MAC and 1 MAC sevoflurane groups, respectively. The sensitivity, specificity, positive predictive, and negative predictive values for PPWA were 100% in both sevoflurane groups, whereas by using HR and SBP criteria, the sensitivity was 90% and 95% respectively during 0.5 MAC sevoflurane anesthesia and 85% for both during 1 MAC sevoflurane anesthesia. CONCLUSION: PPWA is effective for detection of an intravascular injection of a simulated epidural epinephrine-containing test dose in pediatric patients.

Lipomatosis of the parotid gland in children.

Parotid lipomatosis is extremely rare in children. Only 4 cases have previously been reported in the English language medical literature. Surgical excision is frequently complicated by recurrence. We report, a fifth case, on a 5-month-old girl with rapidly progressive parotid lipomatosis. Emphasis is laid on the importance of preserving the unusually delicate tumor capsule to prevent tissue spillage and recurrence. The creation of an appropriate cleavage between the mass and the expanded skin with sparse subcutaneous fat, safeguarding the tumor capsule on one side and the skin blood supply on the other, represents a rewarding technical challenge.