The Role of Preoperative Educational Intervention in Reducing Parental Anxiety.

Background and objective The parents of pediatric patients admitted for elective surgery exhibit significant levels of anxiety. The reduction in parental anxiety is directly proportional to the information and counseling provided to the parents preoperatively. The parenting style in South Asian culture is different from that of western cultures and may influence the response to these interventions. In this study, we aimed to compare the mean anxiety levels between parents of children (aged three to eight years) undergoing outpatient infraumbilical surgery equipped with standardized preoperative parental education and those without. Methods This was a randomized, controlled, and blinded trial. Parents of 72 pediatric patients (aged three to eight years) undergoing elective infraumbilical daycare surgery were enrolled and were divided into two groups: an intervention (Group I) and a non-intervention (Group NI) group. Both groups received routine verbal counseling at the preoperative clinic, but a standardized brochure was provided only to Group I. Parental anxiety was measured by using the Visual Analog Scale (VAS) at three different time points: in the outpatient surgery suite on the day of surgery, in the preoperative area 10 minutes before shifting the child to the operating room, and finally in the recovery room. Results The baseline mean VAS score was significantly higher in Group I compared to Group NI (p=0.017). After the intervention, the mean pain score significantly decreased from baseline in Group I as compared to Group NI (mean ±SD: 4.08 ±1.6 vs. 6.08 ±1.66; p=0.0005). Conclusion The information provided through standardized written material to the parents on the day of surgery before anesthesia helped to significantly attenuate preoperative parental anxiety.

Anesthesia Patient Safety: Next Steps to Improve Worldwide Perioperative Safety by 2030.

Patient safety is a core principle of anesthesia care worldwide. The specialty of anesthesiology has been a leader in medicine for the past half century in pursuing patient safety research and implementing standards of care and systematic improvements in processes of care. Together, these efforts have dramatically reduced patient harm associated with anesthesia. However, improved anesthesia patient safety has not been uniformly obtained worldwide. There are unique differences in patient safety outcomes between countries and regions in the world. These differences are often related to factors such as availability, support, and use of health care resources, trained personnel, patient safety outcome data collection efforts, standards of care, and cultures of safety and teamwork in health care facilities. This article provides insights from national anesthesia society leaders from 13 countries around the world. The countries they represent are diverse geographically and in health care resources. The authors share their countries' current and future initiatives in anesthesia patient safety. Ten major patient safety issues are common to these countries, with several of these focused on the importance of extending initiatives into the full perioperative as well as intraoperative environments. These issues may be used by anesthesia leaders around the globe to direct collaborative efforts to improve the safety of patients undergoing surgery and anesthesia in the coming decade.

Challenges of Pediatric Anesthesia Services and Training Infrastructure in Tertiary Care Teaching Institutions in Pakistan: A Perspective From the Province of Sindh.

BACKGROUND: Pakistan is a lower middle-income country located in South Asia with a population of nearly 208 million. Sindh is its second largest province. The aim of this survey was to identify the current setup of pediatric services, staffing, equipment, and training infrastructure in the teaching hospitals of Sindh. METHODS: The survey was conducted between June 2018 and September 2018. A questionnaire was designed with input from experts and pretested. One faculty coordinator from each of 12 of the 13 teaching hospitals (7 government and 5 private) completed the form. Information was exported into Statistical Package for the Social Sciences (SPSS) version 22. Frequency and percentages were computed for all variables. Confidentiality was ensured by anonymizing the data. RESULTS: Anesthesia services are provided by consultants with either membership or fellowship in anesthesia of the College of Physicians and Surgeons of Pakistan (CPSP). All drugs on the World Health Organization (WHO) essential medication list were available, although narcotic supply was often inconsistent. Weak areas identified were absence of standardization of practice regarding premedication, preoperative laboratory testing, pain assessment, and management. No national practice guidelines exist. Pulse oximeters and capnometers were available in all private hospitals but in only 86% and 44% of the government hospitals, respectively. Some training centers were not providing the training as outlined by the CPSP criteria. CONCLUSIONS: Several gaps have been identified in the practice and training infrastructure of pediatric anesthesia. There is a need for national guidelines, standardization of protocols, provision of basic equipment, and improved supervision of trainees. One suggestion is to have combined residency programs between private and government hospitals to take advantage of the strengths of both. Recommendations by this group have been shared with all teaching hospitals and training bodies.

First-Pass Success of Tracheal Intubation With Videolaryngoscopy in Head and Neck Cancer Patients: A Registry-Based Retrospective Cohort Study.

Background The incidence of difficult airway is higher in head and neck oncological surgery than in other surgeries. Limited evidence is available on the use of videolaryngoscopes in this cohort. A registry database on perioperative management of these patients was set up in our department in 2017. Methods Data from 2018 to 2019 were retrieved from this database. In 128 patients, videolaryngoscopy was used as the initial airway management of choice. Ease of intubation by first-pass success, its association with accessory manoeuvres, and complications were noted. Results Of the patients, 87% (n = 111) were successfully intubated with a videolaryngoscope in the first attempts. There was a strong association between the use of external laryngeal manipulation and successful first-pass intubation with videolaryngoscope. In patients with reduced inter-incisor distance, videolaryngoscope has shown greater benefit. There were very few complications including bleeding from the tumour site and a transient decrease in oxygen saturation to 88% in two patients. Conclusion Videolaryngoscopy was associated with high first-attempt intubation success and we recommend its use as the initial choice for airway management in head and neck cancer patients.

Pediatric Anesthesia Severe Adverse Events Leading to Anesthetic Morbidity and Mortality in a Tertiary Care Center in a Low- and Middle-Income Country: A 25-Year Audit.

BACKGROUND: The analysis of adverse events, including morbidity and mortality (M&M), helps to identify subgroups of children at risk and to modify clinical practice. There are scant data available from low- and middle-income countries. Our aim was to estimate the proportion of pediatric patients with various severe adverse events in the perioperative period extending to 48 hours and to describe the clinical situations and causes of those events. METHODS: We reviewed the M&M database of the Department of Anesthesiology between 1992 and 2016. A data collection tool was developed, and the outcomes were standardized. Each case was reviewed independently and subsequently discussed between 2 reviewers to identify a major primary causative factor. RESULTS: The total number of pediatric cases during this period was 48,828. Seventy-six significant adverse events were identified in 39 patients (8 patients [95% confidence interval {CI}, 5.7-10.9] per 10,000). Thirteen patients had multisystem involvement, and hence the total number of events exceeded the number of patients. Respiratory events were the most common (33.5%). Thirteen patients had perioperative cardiac arrest within 48 hours of surgery (2.6 [95% CI, 1.3-4.3] per 10,000), 7 of these were infants (54%), 5 of whom had congenital heart disease (CHD). Eleven of these 39 patients died within 48 hours (2.0 [95% CI, 1.1-4.0] per 10,000).In 13 cases, anesthesia was assessed to be the predominant cause of morbidity (2.6 per 10,000), whereas in 26 cases, it contributed partially (5.32 per 10,000). There was only 1 death solely related to anesthesia (0.2 per 10,000), and this death occurred before the start of surgery. CONCLUSIONS: Adverse events were uncommon. Respiratory complications were the most frequent (33%). Infants, especially those with CHD, were identified as at a higher risk for perioperative cardiac arrest, but this association was not tested statistically. Twenty-eight percent of the patients who suffered events died within 48 hours. Increased access to anesthesia drugs and practice improvements resulted in a decline in perioperative cardiac arrests.

Evaluation of Job Stress and Burnout Among Anesthesiologists Working in Academic Institutions in 2 Major Cities in Pakistan.

Work stress is an integral part of anesthetic practice and has been a subject of many studies. Persistent stress can lead to burnout. There is limited published literature from lower- and middle-income countries where job stressors may be different from high-income countries. The aim of this study was to find out the level of burnout in a cohort of anesthesiologists working in academic institutions in 2 major cities of Pakistan, a low middle income country. We conducted an anonymous survey based on the Maslach Burnout Inventory scale with 3 major components: emotional exhaustion; depersonalization; and burnout in personal achievement. The demographic and other work-related details were collected in a standardized manner. Our response rate was 74.5%. Seventy-seven percent of the participants were residents and 23% consultants. Gender distribution was 66.9% males and 33.1% females. Thirty-nine percent (95% CI, 34.8%-44.1%) showed moderate- to high-level emotional exhaustion, 68.4% (95% CI, 63.9%-72.7%) showed a moderate to high level of depersonalization, and 50.3% (95% CI, 45.6%-55.07%) showed a moderate to high level of burnout in personal achievements. On multivariable analysis, anesthesia not being the primary career choice was significantly associated with all 3-dimensional scales for the whole cohort. Factors significantly associated with emotional exhaustion were Lahore as city of work, >2 nights on call per week, and >40 h/wk work inside the operating room. Depersonalization burnout was again associated with Lahore as city of work, >40 h/wk work inside the operating room, and personal achievement burnout with >2 on-call nights per week. No association was observed for gender, marital status, or having children. In conclusion, a high rate of burnout was identified in anesthesiologists working in 2 major cities in Pakistan. Some new associated factors such as initial choice of specialty and city of work were highlighted. Based on these findings, preventive and coping strategies need to be introduced at institutional and national levels.

Effect of Pharmacological Agents Administered for Attenuating the Extubation Response on the Quality of Extubation: A Systematic Review.

Background Several drugs have been tried to obtund the hemodynamic extubation response but all have variable side effects that may affect the quality of short-term recovery. Objective Our primary objective was to evaluate the effect of pharmacological agents, such as dexmedetomidine, local anesthetics, and so on, administered for attenuating the extubation response on the quality of extubation, as judged by the presence or absence of cough, sedation, and laryngospasm/bronchospasm in adult patients who had undergone general anesthesia. A secondary objective was to evaluate the effect of these drugs on other immediate post-extubation complications such as respiratory depression, desaturation, bradycardia, hypotension, and nausea and vomiting (PONV). Methods This is a systematic review of (randomized controlled trials) RCTs with meta-analysis. The Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched for RCTs on the effect of pharmacological agents on both the hemodynamic extubation response as well as the quality of extubation. Results Fourteen out of 24 included studies were subjected to a meta-analysis. The risk of cough was less likely in the intervention group as compared to control groups (OR 0.26, 95% CI 0.15 to 0.46, p<0.00001, I2=35%). Sedation, hypotension (OR= 10.47; 95% CI: 1.86, 58.80, p=0.008, I2=0%), and bradycardia (OR= 6.57; 95% CI: 2.09, 20.64, p=0.001, I2=0%) were reported with dexmedetomidine. Only one study reported laryngospasm with dexmedetomidine and two studies with opioids. Conclusion Dexmedetomidine 0.4 to 0.5 ug/kg was associated with smooth extubation, minimal coughing, no laryngospasm/ bronchospasm, and with stable hemodynamics, without causing respiratory depression, PONV, and desaturation. However, in higher doses (more than 0.5 ug/kg), it caused bradycardia, hypotension, and sedation. Other pharmacological agents, such as local anesthetics, calcium channel blockers, and opioids, did not attenuate cough associated with extubation.

Improving Anesthesia Safety in Low-Resource Settings.

The safety of anesthesia characteristic of high-income countries today is not matched in low-resource settings with poor infrastructure, shortages of anesthesia providers, essential drugs, equipment, and supplies. Health care is delivered through complex systems. Achieving sustainable widespread improvement globally will require an understanding of how to influence such systems. Health outcomes depend not only on a country's income, but also on how resources are allocated, and both vary substantially, between and within countries. Safety is particularly important in anesthesia because anesthesia is intrinsically hazardous and not intrinsically therapeutic. Nevertheless, other elements of the quality of health care, notably access, must also be considered. More generally, there are certain prerequisites within society for health, captured in the Jakarta declaration. It is necessary to have adequate infrastructure (notably for transport and primary health care) and hospitals capable of safely carrying out the "Bellwether Procedures" (cesarean delivery, laparotomy, and the treatment of compound fractures). Surgery, supported by safe anesthesia, is critical to the health of populations, but avoidable harm from health care (including very high mortality rates from anesthesia in many parts of the world) is a major global problem. Thus, surgical and anesthesia services must not only be provided, they must be safe. The global anesthesia workforce crisis is a major barrier to achieving this. Many anesthetics today are administered by nonphysicians with limited training and little access to supervision or support, often working in very challenging circumstances. Many organizations, notably the World Health Organization and the World Federation of Societies of Anaesthesiologists, are working to improve access to and safety of anesthesia and surgery around the world. Challenges include collaboration with local stakeholders, coordination of effort between agencies, and the need to influence national health policy makers to achieve sustainable improvement. It is conceivable that safe anesthesia and perioperative care could be provided for essential surgical services today by clinicians with moderate levels of training using relatively simple (but appropriately designed and maintained) equipment and a limited number of inexpensive generic medications. However, there is a minimum standard for these resources, below which reasonable safety cannot be assured. This minimum (at least) should be available to all. Not only more resources, but also more equitable distribution of existing resources is required. Thus, the starting point for global access to safe anesthesia is acceptance that access to health care in general should be a basic human right everywhere.

Tramadol-Paracetamol Combination for Postoperative Pain Relief in Elective Single-level Microdisectomy Surgery.

BACKGROUND: The tramadol and paracetamol combination is used frequently for postoperative pain management. The literature on the use of this combination for vertebral surgery is limited. Our objective was to compare a combination of paracetamol 1 g and a lower dose of tramadol (1 mg/kg: group 1T) with a combination of paracetamol 1 g and a higher dose of tramadol (1.5 mg/kg: group 1.5T) for postoperative pain after microdisectomy surgery. Our main outcome measure was Visual Analogue Scale pain scores for 4 hours postoperatively. METHODS: This prospective randomized triple-blind clinical trial was conducted at Aga Khan University Hospital, Karachi. Ninety-four patients aged between 18 and 50 years scheduled for elective single-level microdisectomy were allocated randomly into 1 of 2 groups. Twenty minutes before the end of the surgery, patients received the study drugs. RESULTS: There was no significant demographic difference between groups. None of the patients experienced severe pain (VAS>6). There was no significant difference in the mean pain score between groups. The mean score at 4 hours was 2.17 (1.38) in group 1.5T and 1.74 (1.37) in group 1T. The difference was not statistically significant (P=0.14). In group 1.5T, 13 patients reported having nausea and vomiting compared with 2 patients in group 1T. This was a statistically significant difference (P=0.004). The sedation score was similar between groups. CONCLUSIONS: The combination of low-dose tramadol (1 mg/kg) and paracetamol has comparable analgesia and a decreased incidence of nausea and vomiting compared with the higher dose of tramadol (1.5 mg/kg) and paracetamol combination.

Mortality in Sepsis and its relationship with Gender.

BACKGROUND AND OBJECTIVE: Sepsis remains a leading cause of death across the world, carrying a mortality rate of 20-50%. Women have been reported to be less likely to suffer from sepsis and to have a lower risk of mortality from sepsis compared to men. The objective of this study was to determine the relationship between gender and mortality in sepsis, and compare cytokine profiles of male and female patients. METHODS: This was a prospective case series on 97 patients admitted with sepsis. Clinical and microbiological data was gathered, blood samples were collected for cytokine (IL-10, IL-6 and TNFα) levels and patients were followed up for clinical outcome. RESULTS: There were 54% males and 46% females, with no significant difference of age or comorbids between genders. Respiratory tract infection was the commonest source of sepsis, and was more common in females (60%) compared to males (39%) (p=0.034). Males had a higher mortality (p=0.048, RR 1.73) and plasma IL-6 level(p=0.040) compared to females. Mean IL-6 plasma level was significantly (p<0.01) higher in patients who died vs. who recovered. CONCLUSION: Our study shows that males with sepsis have a 70% greater mortality rate, and mortality is associated with a higher IL-6 plasma level.

Postoperative pain assessment using four behavioral scales in Pakistani children undergoing elective surgery.

BACKGROUND: Several measurement tools have been used for assessment of postoperative pain in pediatric patients. Self-report methods have limitations in younger children and parent, nurse or physician assessment can be used as a surrogate measure. These tools should be tested in different cultures as pain can be influenced by sociocultural factors. The objective was to assess the inter-rater agreement on four different behavioral pain assessment scales in our local population. MATERIALS AND METHODS: This prospective, descriptive, observational study was conducted in Pakistan. American Society of Anesthesiologists I and II children, 3-7 years of age, undergoing elective surgery were enrolled. Four pain assessment scales were used, Children's Hospital of Eastern Ontario Pain Scale (CHEOPS), Toddler Preschool Postoperative Pain Scale (TPPPS), objective pain scale (OPS), and Face, Legs, Activity, Cry, Consolability (FLACC). After 15 and 60 min of arrival in the postanesthesia care unit (PACU), each child evaluated his/her postoperative pain by self-reporting and was also independently assessed by the PACU nurse, PACU anesthetist and the parent. The sensitivity and specificity of the responses of the four pain assessment scales were compared to the response of the child. RESULTS: At 15 min, sensitivity and specificity were >60% for doctors and nurses on FLACC, OPS, and CHEOPS scales and for FLACC and CHEOPS scale for the parents. Parents showed poor agreement on OPS and TPPS. At 60 min, sensitivity was poor on the OPS scale by all three observers. Nurses showed a lower specificity on FLACC tool. Parents had poor specificity on CHEOPS and rate of false negatives was high with TPPS. CONCLUSIONS: We recommend the use of FLACC scale for assessment by parents, nurses, and doctors in Pakistani children aged between 3 and 7.

Continuous interscalene brachial plexus block versus parenteral analgesia for postoperative pain relief after major shoulder surgery.

BACKGROUND: Postoperative pain may lead to adverse effects on the body, which might result in an increase in morbidity. Its management therefore poses a unique challenge for the clinician. Major shoulder surgery is associated with severe postoperative pain, and different modalities are available to manage such pain, including opioid and non-opioid analgesics, local anaesthetics infiltrated into and around the shoulder joint and regional anaesthesia. All of these techniques, alone or in combination, have been used to treat the postoperative pain of major shoulder surgery but with varying success. OBJECTIVES: The objective of this review was to compare the analgesic efficacy of continuous interscalene brachial plexus block (ISBPB) with parenteral opioid analgesia for pain relief after major shoulder surgery. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 12), MEDLINE (1950 to December 2012), EMBASE (1980 to December 2012), Web of Science (1954 to December 2012), CINAHL (1982 to December 2012) and bibliographies of published studies. SELECTION CRITERIA: We included randomized controlled trials assessing the effectiveness of continuous ISBPB compared with different forms of parenteral opioid analgesia in relieving pain in adult participants undergoing elective major shoulder surgery. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial quality and extracted outcome data. MAIN RESULTS: We included two randomized controlled trials (147 participants). A total of 17 participants were excluded from one trial because of complications related to continuous ISBPB (16) or parenteral opioid analgesia (one). Thus we have information on 130 participants (66 in the continuous ISBPB group and 64 in the parenteral opioid group). The studies were clinically heterogeneous. No meta-analysis was undertaken. However, results of the two included studies showed better pain relief with continuous ISBPB following major shoulder surgery and a lower incidence of complications when interscalene block is performed under ultrasound guidance rather than without it. AUTHORS' CONCLUSIONS: Because of the small number of studies (two) relevant to the subject and the high risk of bias of the selected studies, no reasonable conclusion can be drawn.

Effect of gender on pain perception and analgesic consumption in laparoscopic cholecystectomy: An observational study.

BACKGROUND: Evidence regarding gender affecting the response to pain and its treatment is inconsistent in literature. The objective of this prospective, observational study was to determine the effect of gender on pain perception and postoperative analgesic consumption in patients undergoing laparoscopic cholecystectomy. MATERIALS AND METHODS: We recruited 60 male and 60 female patients undergoing elective laparoscopic cholecystectomy. Patients were observed for additional intraoperative and postoperative analgesia. Numerical rating scale was documented at 10 min interval for 1 h in post-anesthesia recovery room and at 4, 8, and 12 h postoperatively. Boluses of tramadol given as rescue analgesia were also noted. There were no dropouts. RESULTS: The mean pain scores were significantly higher in female patients at 20 and 30 min following surgery. Mean dose of tramadol consumption was significantly higher in female patients for the first postoperative hour (P = 0.002), but not in the later period. CONCLUSION: Female patients exhibited greater intensity of pain and required higher doses of analgesics compared to males in in the immediate postoperative period in order to achieve a similar degree of analgesia.

Comparison of hemodynamic response to tracheal intubation with Macintosh and McCoy laryngoscopes.

BACKGROUND: Use of McCoy blade laryngoscope avoids the lifting force in the vallecula and theoretically should lead to a lower hemodynamic response related to laryngoscopy and tracheal intubation. The available literature on the topic is conflicting. MATERIALS AND METHODS: We studied the hemodynamic response to laryngoscopy and tracheal intubation in 60 ASA 1 AND 2 adult patients using either Macintosh or McCoy laryngoscopes. The change in systolic, diastolic, mean arterial pressure, and heart rate (HR) was observed for 10 min post intubation. Arrhythmias and ST changes were also observed. RESULTS: The maximum change in HR was 18.7% in the Macintosh and 7.7% in the McCoy group, and in systolic arterial pressure was 22.9% in the Macintosh and 10.3% in the McCoy group. This difference between groups was significant (P < 0.0001). The change lasted for a lesser duration in the McCoy group. No arrhythmias or ST changes were observed in either group. CONCLUSION: Hemodynamic changes with use of McCoy laryngoscope were lesser in magnitude and of shorter duration.

Pharmacological agents for preventing morbidity associated with the haemodynamic response to tracheal intubation.

BACKGROUND: Several drugs have been used in attenuating or obliterating the response associated with laryngoscopy and tracheal intubation. These changes are of little concern in relatively healthy patients but can lead to morbidity and mortality in the high risk patient population. OBJECTIVES: The primary objective of this review was to determine the effectiveness of pharmacological agents in preventing the morbidity and mortality resulting from the haemodynamic changes in response to laryngoscopy and tracheal intubation in adult patients aged 18 years and above who were undergoing elective surgery in the operating room setting. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2011, Issue 6), MEDLINE (1950 to June 2011), EMBASE (1980 to June 2011), and the bibliographies of published studies. We reran our search from June 2011 to December 2012 and will deal with these studies when we update the review. SELECTION CRITERIA: We included randomized controlled trials (RCTs) that compared a drug used as an intervention for preventing or attenuating the haemodynamic response to tracheal intubation to a control group, and that mentioned mortality, major morbidity, arrhythmia or electrocardiogram (ECG) evidence of ischaemia in the methodology, results, or discussion section of the reports. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial quality and extracted the outcome data. MAIN RESULTS: We included 72 RCTs. The included trials studied the effects of 32 drugs belonging to different pharmacological groups. Only two trials mentioned the primary outcome of morbidity and mortality related to the haemodynamic response to tracheal intubation. Of the secondary outcomes, 40 of the included trials observed arrhythmia only, 11 observed myocardial ischaemia only and 20 observed both arrhythmias and myocardial ischaemia. Arrhythmias were observed in 2932 participants and myocardial ischaemia in 1616 participants. Arrhythmias were observed in 134 out of 993 patients in the control group compared to 80 out of 1939 in the intervention group. The risk of arrhythmias was significantly reduced with pharmacological interventions in the pooled data (Peto odds ratio (OR) 0.19, 95% CI 0.14 to 0.26, P < 0.00001, I(2)= 47%). Local anaesthetics, calcium channel blockers, beta blockers and narcotics reduced the risk of arrhythmia in the intervention group compared to the control group. Myocardial ischaemia was observed in 21 out of 604 patients in the control group compared to 10 out of 1012 in the treatment group; the result was statistically significant (Peto OR 0.45, 95% CI 0.22 to 0.92, P = 0.03, I(2) = 19%). However, in subgroup analysis only local anaesthetics significantly reduced the ECG changes indicating ischaemia, but this evidence came from one study. The majority of the studies had a negative outcome. Hypotension and bradycardia were reported with 40 µg kg(-1) intravenous alfentanil, chest rigidity with 75 ug kg(-1) alfentanil, and increased bronchomotor tone with sympathetic blockers.There were 17 studies which included high risk patients. Pharmacological treatment in this group resulted in the reduction of arrhythmias when the data from nine trials looking at arrhythmias were pooled (Peto OR 0.18, 95% CI 0.05 to 0.59, P = 0.005, I(2) = 80%). The analysis from four studies was not included. Three of these trials looked at the effect of sympathetic blockers but arrhythmias or myocardial ischaemia was observed throughout the perioperative period in two studies and some patients had arrhythmias due to atropine premedication in the third study. In the fourth study the authors mentioned myocardial ischaemia in the objectives section but did not report it in the results. AUTHORS' CONCLUSIONS: The risk of arrhythmias associated with tracheal intubation was significantly reduced with pre-induction administration of local anaesthetics, calcium channel blockers, beta blockers and narcotics compared to placebo. Pharmacological intervention also reduced the risk of ECG evidence of myocardial ischaemia in the pooled data. Lignocaine pretreatment showed a significant effect but evidence came from one study only. The data suggested that there may be a reduction in ECG evidence of myocardial ischaemia with beta blocker pretreatment but this difference was not statistically significant. There is a need to focus on outcomes rather than haemodynamic measurements alone when studying this response in future trials.

Effect of one minimum alveolar concentration sevoflurane with and without fentanyl on hemodynamic response to laryngoscopy and tracheal intubation.

BACKGROUND: Drug combinations can be used for optimum obtundation of the hemodynamic response to tracheal intubation. The objective of this trial was to compare the hemodynamic response to laryngoscopy and tracheal intubation after administration of 2 µg/kg fentanyl bolus or a placebo with 2% end tidal sevoflurane at induction of anesthesia. MATERIALS AND METHODS: A total of 70 surgical patients of either gender, age 18-45 years were selected for this double blind, randomized, placebo controlled trial, with 35 in each group. All patients received a standardized induction with thiopentone, atracurium, and an end tidal concentration of 1 minimum alveolar concentration (MAC) sevoflurane. Heart rate and noninvasive blood pressure were compared to the baseline post induction and for seven minutes post intubation. Some adverse events were noted. RESULTS: The maximum heart rate response was significantly less in the sevoflurane fentanyl group (15% vs. 22%). Significant difference between groups was observed in the systolic blood pressure at six minutes post intubation. Hemodynamic adverse events recorded were similar. CONCLUSION: Addition of 2 µg fentanyl bolus to 1 MAC sevoflurane anesthesia at induction attenuated the hemodynamic response to a maximum of 15% above baseline values.

Comparison of analgesic effect of tramadol alone and a combination of tramadol and paracetamol in day-care laparoscopic surgery.

BACKGROUND AND OBJECTIVE: To compare the analgesic efficacy of tramadol alone (1.5 mg kg(-1)) with a tramadol (1 mg kg(-1)) and paracetamol combination in day-care laparoscopic patients. METHODS: The analgesic efficacy of intravenous tramadol alone (1.5 mg kg(-1)) (group T) was compared with a combination of intravenous tramadol (1 mg kg(-1)) and oral paracetamol 1 g (group TP) in 60 day-care laparoscopic patients in a prospective randomized double-blind clinical trial in a tertiary care hospital. Intraoperative haemodynamic responses and postoperative visual analogue scores were used to assess the analgesic efficacy. RESULTS: Only one patient (in group T) received a single dose of rescue analgesia intraoperatively. The highest pain scores were recorded at 30 min postoperatively in both groups, and rescue analgesia was needed in eight patients in group T and in 13 patients in group TP (P = 0.08). The incidence of moderate-to-severe nausea was high in group T (P = 0.001). CONCLUSION: We conclude that reducing the dose of tramadol to 1 mg kg(-1) and combining it with paracetamol 1 g orally decreased the incidence of side effects of tramadol without reducing analgesic efficacy.

Effect of diclofenac suppository on tramadol consumption in posthysterectomy pain.

OBJECTIVE: To determine reduction in dose of tramadol and side effects in posthysterectomy patients on addition of diclofenac on rectal suppository. STUDY DESIGN: Randomized double blinded placebo controlled study. PLACE AND DURATION OF STUDY: The Aga Khan University Hospital, Karachi, Pakistan, from August 2004 to January 2006. METHODOLOGY: Seventy ASA I and II females, aged 20 and above, who underwent elective abdominal hysterectomy, were included in this study. Patients received identical looking suppository of either 100 mg diclofenac sodium or placebo after induction of anaesthesia and then 12 hourly for 24 hours. General anaesthesia was standardized and tramadol was given by patient controlled intravenous analgesia delivery system in the recovery. RESULTS: The mean dose + SD of tramadol used in first 24 hours was found to be 317 +153 mg in the placebo-tramadol group compared to 258 +192 mg in the diclofenac-tramadol group (p = 0.15, 95% CI = 1.24 to -1.34, 6.63). Seventeen (49 %) patients in the placebo-tramadol group and 14 (40%) in the diclofenac-tramadol group used rescue analgesia (p=0.47). Sedation score was similar in both the groups and there was no difference in the incidence of nausea and vomiting and use of antiemetics between the groups. CONCLUSION: This study did not show any reduction in tramadol consumption, given via patient controlled intravenous analgesia when rectal suppository of 100 mg diclofenac was added.