The Effect of Gabapentin on Postoperative Pain, Morphine Sparing Effect and Preoperative Anxiety in Patients Going for Sleeve Gastrectomy Surgical Procedure.

OBJECTIVE: To determine the effectiveness of preoperative administration of gabapentin in reduction of acute postoperative pain, morphine consumption and preoperative anxiety and sedation in obese patients undergoing laparoscopic sleeve gastrectomy. STUDY DESIGN: Double-blinded randomised control trial. PLACE AND DURATION OF STUDY: King Khalid University Hospital, King Saud University Riyadh, Saudi Arabia, from July 2014 to January 2017. METHODOLOGY: Fifty patients undergoing sleeve gastrectomy were enrolled in the study. The subjects received either 1200 mg gabapentin or placebo 2 hours before surgery. The amount of morphine consumption and postoperative pain at 4, 8,12,16, 20 and 24 hours of surgery were measured. Preoperative anxiety and sedation were recorded at 2 hours interval after the drug administration. RESULTS: There was no significant difference in patient characteristics in both groups. 24 hours PCA morphine consumption was significantly lower in gabapentin group than in the placebo group, 15.08±4.55 vs. 27.80±2.51 (p=0.001). Preoperative VAS anxiety, pre- verses post-drug, was significantly lower in gabapentin group 5.80±1.11 vs. 3.52±1.00 (p=0.001) than in placebo group 6.08 1.28 vs. 6.28 1.24 (p=0.635). Preoperative sedation score was not different in both groups. CONCLUSION: Preoperative oral gabapentin was effective in reducing the postoperative pain, morphine consumption and preoperative anxiety in morbid obese patients undergone laparoscopic sleeve gastrectomy.

Correction to: Incidence and severity of postoperative sore throat: a randomized comparison of Glidescope with Macintosh laryngoscope.

We are thankful to Dr. Deepak Gupta (Clinical Assistant Professor Anesthesiology, Wayne State University/Detroit Medical Center) for bringing to our attention a typographical error in our manuscript [1].

Incidence and severity of postoperative sore throat: a randomized comparison of Glidescope with Macintosh laryngoscope.

BACKGROUND: Postoperative sore throat (POST) is a common problem following endotracheal (ET) intubation during general anesthesia. The objective was to compare the incidence and severity of POST during routine intubation with Glidescope (GL) and Macintosh laryngoscope (MCL). METHODS: One hundred forty adult patients ASA I and II with normal airway, scheduled to undergo elective surgery under GA requiring ET intubation were enrolled in this prospective randomized study and were randomly divided in two groups, GL and MCL. Incidence and severity of POST was evaluated at 0, 6, 12 and 24 h after surgery. RESULTS: At 0 h, the incidence of POST was more in MCL than GL (n = 41 v.s n = 22, P = 0.001), and also at 6 h after surgery (n = 37 v.s n = 23, P = 0.017). Severity of POST was more at 0, 6 and 12 h after surgery in MCL (P < 0.001, P = 0.001, P = 0.004 respectively). CONCLUSIONS: Routine use of GL for ET tube placement results in reduction in the incidence and severity of POST compared to MCL. TRIAL REGISRATION: ClinicalTrials.gov NCT02848365 . Retrospectively Registered (Date of registration: July, 2016).

Measurement of endotracheal tube cuff pressure: Instrumental versus conventional method.

OBJECTIVE: To evaluate the conventional practice of endotracheal tube (ETT) cuff inflation and pressure measurement as compared to the instrumental method. STUDY DESIGN: Prospective observational study. PLACE AND DURATION OF STUDY: Department of Anaesthesia, King Saud University Hospital, Riyadh, Saudi Arabia (June 2014-July 2014). METHODS: A total of 100 adult patients were observed according to the syringe size used Group-1 (10 ml) and Group-2 (20 ml) for ETT cuff inflation in general anesthesia. Patients with anticipated difficult intubation, risk for aspiration, known anatomical laryngotracheal abnormalities, and emergency cases were excluded. Trachea was intubated with size 8 or 8.5 mm and 7.0 or 7.5 mm ETT in male and female patients respectively. The ETT cuff was inflated with air by one of the anesthesia technician. Cuff pressures were measured using aneroid manometer. ETT cuff pressure of 20-30 cm of water was considered as standard. RESULTS: In 69% of the patients, the cuff pressure measurements were above the standard. Age (P = 0.806), weight (P = 0.527), height (P = 0.850), and gender (P = 1.00) were comparable in both groups. The mean cuff pressure in Group-1 and Group-2 was 32.52 ± 6.39 and 38.90 ± 6.60 cm of water (P = 0.001). The cuff inflation with 20 ml syringe resulted in higher cuff pressure as compared to 10cc syringe 37.73 ± 4.23 versus 40.74 ± 5.01 (86% vs. 52%, P = 0.013). CONCLUSION: The conventional method for ETT cuff inflation and pressure measuring is unreliable. As a routine instrumental cuff pressure, monitoring is suggested.

Anesthetic management of patient with hemophilia a undergoing emergency ventriculoperitoneal shunting: A case report and review of literature.

Hemophilia A is a hemorrhagic trend almost exclusively affecting males (X-related recessive disease). In 85% of cases, it is caused by factor VIII deficiency, called hemophilia A or classic hemophilia. Successful anesthetic management depends on the special care and a multidisciplinary team of health professionals informed about the disease, including qualified hematologist, surgeon, and anesthesiologist.

Routine Use of Glidescope and Macintosh Laryngoscope by Trainee Anesthetists.

OBJECTIVE: To compare intubating conditions, success rate, and ease of intubation by anesthesia trainees using Glidescope Videolaryngoscope (GVL) compared to Macintosh laryngoscope (MCL). STUDY DESIGN: Comparative study. PLACE AND DURATION OF STUDY: King Khalid University Hospital, Riyadh, Saudi Arabia, from January 2012 to February 2015. METHODOLOGY: Eighty adult patients ASAI and II with normal airway, scheduled to undergo elective surgery requiring endotracheal (ET) intubation were enrolled. Patients were randomly divided into 2 groups: GVL and MCL. All intubations were performed by trainee residents having experience of more than 1 year and who had successfully performed more than 50 tracheal intubations with each device. Glottic view based on Cormack and Lehane&#039;s (C&amp;L&#039;s) score and percentage of glottis opening (POGO) score, time to successful intubation, need of external pressure, and overall difficulty scores were compared using either GVL or MCL. RESULTS: View of glottis based on C&amp;L&#039;s classification was better (p &lt; 0.001) and POGO score was higher (88.25 &plusmn;22.06 vs. 57.25 &plusmn;29.26, p &lt; 0.001) with GVL compared to MCL. Time to intubate in seconds was (32.90 &plusmn;8.69 vs. 41.33 &plusmn;15.29, p = 0.004) and overall difficulty score was less 2.78 &plusmn;1.39 vs. 4.85 &plusmn;1.75 (p &lt; 0.001) using GVL compared to MCL. CONCLUSION: Residents found ET intubation to be faster and easier with superior glottic view using GVL compared to MCL in patients with normal airway.

Preload Versus Coload and Vasopressor Requirement for the Prevention of Spinal Anesthesia Induced Hypotension in Non-Obstetric Patients.

OBJECTIVE: To compare the effectiveness of preload and coload for the prevention of Spinal Induced Hypotension (SIH) and vasopressor requirements. STUDY DESIGN: Randomized trial. PLACE AND DURATION OF STUDY: Department of Anesthesia, The Aga Khan University Hospital, Karachi, Pakistan, from June 2007 - June 2010. METHODOLOGY: Sixty patients were randomly divided into preload and coload group of 30 each. Patients with ASA1 - 3, aged 20 - 60 years were included. Patients with history of IHD, COPD, BMI > 30 and surgical procedure TURPwere excluded. All patients received crystalloid 10 ml/kg before induction of spinal anesthesia in preload group and at the time of spinal anesthesia in coload group. Blood pressure and heart rate were recorded at different time intervals till 45 minutes. Patients received ephedrine 5 mg when systolic blood pressure dropped below 90 mmHg and heart rate was less than 60 beats/minute and/or phenylephrine 50 micrograms when systolic blood pressure dropped below 90 mmHg and heart rate was more than 60 beats/minute. RESULTS: There was no statistically significant difference at different time intervals in heart rate, systolic and mean arterial pressure between the groups. Diastolic blood pressure was significantly different in both groups at 6 - 15 minutes after spinal anesthesia. SIH occurred (21) 70% and (15) 50% in preload and coload groups, respectively (p = 0.187). Ephedrine requirement for SIH was significantly high in preload group (p = 0.017). Phenylephrine requirement for SIH was high in preload group which was statistically non-significant (p = 0.285). CONCLUSION: Coload group has lower incidence of spinal induced hypotension and significantly less vasopressor requirement than the preload group.

Comparison of the Effect of Pre-operative Single Oral Dose of Tramadol and Famotidine on Gastric Secretions pH and Volume in Patients Scheduled for Laparoscopic Cholecystectomy.

OBJECTIVE: To evaluate and compare the effects of pre-operative single oral dose of tramadol and famotidine on gastric secretions pH and volume in patients electively scheduled for laparoscopic cholecystectomy. STUDY DESIGN: Randomized control trial. PLACE AND DURATION OF STUDY: Department of Anaesthesia, King Saud University Riyadh, Saudi Arabia, from August 2011 to June 2013. METHODOLOGY: Ninety adult, ASA-I and II patients scheduled for laparoscopic cholecystectomy were included in the study. Patients were randomly assigned to receive pre-operatively either placebo (Group-C, n=30), oral tramadol 100 mg (Group-T, n=30) or famotidine 40 mg (Group-F, n=30). After induction of general anaesthesia, gastric fluid was aspirated through orogastric tube. The gastric secretions volume and pH was measured using pH meter. RESULTS: There was no statistically difference between groups in age, weight and gender. The gastric secretions mean pH was 2.06 ± 0.22,2.04 ± 0.20, 5.79 ± 0.77 and volume was 0.59 ± 0.17, 0.59 ± 0.14 and 0.28 ± 0.16 ml/kg in Group-C, Group-T and Group-F respectively. There was a significant statistical difference in the mean pH values between Group-C vs. Group-F (p < 0.001) and Group-T vs. Group-F (p < 0.001). Statistically significant difference was also found in the mean gastric secretions volume between Group - C vs. Group-F (p < 0.001) and Group-T vs. Group-F (p < 0.001). There was no significant difference in the mean gastric fluid pH values (p=0.99) and mean gastric secretions volume (p=0.99) between Group-T and Group-C. CONCLUSION: As compared to famotidine, pre-operative single oral dose of tramadol was unable to elevate the desired level of gastric fluid pH (> 2.5) and decrease in gastric secretions volume (< 0.4 ml/kg).

Endotracheal intubation in patients with unstable cervical spine using LMA-Fastrach and gum elastic bogie.

OBJECTIVE: To evaluate the success of alternative technique of ET- intubation in patients with unstable cervical spine with Philadelphia collar around the neck. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: The Department of Anaesthesia, College of Medicine, King Saud University, Riyadh, Saudi Arabia, from June 2009 to June 2012. METHODOLOGY: Adult patients of either gender with unstable cervical spine wearing Philadelphia collar electively scheduled for cervical spine decompression and fixation more than one level were included. Those with anticipated difficult intubation, mouth opening < 25 mm and BMI > 27 kg/m2 were excluded. After induction of anaesthesia FT-LMA was inserted. Correct position of FT-LMA was confirmed then soft straight end of gum elastic bogie was passed through FTLMA into trachea. FT-ILMA was removed on bogie. Reinforced silicon ET- tube was rail road on bogie. The bogie was pulled out and position of ET- tube was confirmed with ETCO2, chest movement and auscultation on bag ventilation. The ease of insertion of FT-LMA, ET- intubation and maximum time taken for successful intubation was noted. RESULTS: 26 patients were studied with mean age of 59.3 ± 2.93 years and M: F ratio of 7:3. The mean time taken from the insertion of gum elastic bogie to the ET intubation was 38.9 ± 1.20 seconds. The success rate of ET- intubation in the first attempt was 88.4% and 7.6% in two attempts. Intubation failed in one patient. The mean ease of insertion of FT-LMA and ET- intubation in all patients was 46.7 ± 2.59 and 46.5 ± 2.66 respectively on VAS ( 0-100). No complication was noted in any patient. CONCLUSION: This technique is safe and reliable for achieving adequate ventilation and intubation in patients with unstable cervical spine with Philadelphia collar in place.

Is there a role for TENS application in the control of diabetes mellitus in insulin-dependent patients?

An 80-year-old man with insulin-dependent diabetes mellitus presented to the hospital with low back pain. He was initially managed with non-steroidal anti-inflammatory drugs, tramadol and epidural steroid injection. Transcutaneous electrical nerve stimulation (TENS), applied on the back and buttocks, was subsequently advised. Initially, TENS was applied once every 24 hours. On improvement of pain symptoms, it was increased to thrice every 24 hours. The patient then complained of symptoms of hypoglycaemia (blood sugar level < 4 mmol/L). Discontinuation of TENS resulted in raised blood sugar level. When TENS was restarted, the same hypoglycaemic response was noted. The insulin dosage was adjusted to half of the patient's routine daily requirement with continued application of TENS. This incidental finding has alerted us to hypoglycaemic episodes following TENS application, which may be due to effective pain control, decreased sympathetic stimulation, enhanced insulin sensitivity or altered muscle metabolism due to electrical stimulation.

Noninvasive positive pressure ventilation in hospital setting.

Noninvasive positive pressure ventilation (NPPV) refers to the delivery of mechanical ventilation to the lungs using techniques that do not require an endotracheal intubation. In the past decade NPPV has gained wide acceptance and is now used more frequently after development of portable ventilators, new modes of ventilation and other equipments. This article will provide a comprehensive overview of the current stage of NPPV in acute and chronic settings. It will appraise the evidence based efficacy of NPPV in patients who presented with acute exacerbation of chronic hypercapneic respiratory failure. The main focus of discussion in this article is to provide detailed knowledge regarding choosing appropriate ventilators and interfaces, selecting appropriate patients and initiating NPPV and their weaning.

Anaesthesia related mortality in ASA-1 and 2 patients as a quality improvement indicator.

Quality and safety in anesthesia is usually monitored by analysis of perioperative mortality-morbidity and incidents. Clinical quality indicator, death within 48 hours of anaesthesia exposure is considered to be a flag that can alert to possible problems in individual patient care. The measurement of perioperative mortality as a quality indicator is a continuous peer reviewed quality improvement activity. Medical records and morbidity and mortality files were reviewed to see the trends and finding the benchmark of mortality in ASA-1 and 2 patient who died between 1992-2006 within 48 hours of anaesthesia exposure. Mortality in class 1 was nil. Anaesthetic mortality in ASA-1 and 2 patients was 0.35 per 10,000 and 0.74 per 10,000 of ASA-2 patient's volume. Anaesthesia-related mortality was 0.17 per 10,000 and 0.37 per 10,000 of ASA-2 patient's volume which is almost double of the overall calculated incidence. We suggest continuing monitoring of anaesthesia related mortality as a continuous quality indicator in developing countries. The reporting and analyzing of data according to the ASA status volume should be taken as a denominator. The available benchmark will help in evaluating the confounding factors and perioperative care of a particular group of patients.

Role of psoas compartment and caudal epidural steroid injection in spinal stenosis patients associated with low back pain and lower limb radiculopathy.

OBJECTIVE: To study the efficacy, safety and patient satisfaction of psoas compartment and caudal epidural steroid injection in patients with spinal stenosis and lumbosaccral radiculopathy. METHODS: Patients with a diagnosis of spinal stenosis and lumbosaccral radiculopathy having visual analogue score (VAS) less than five were included in the study. Bilateral psoas compartment and caudal epidural injection was given to all patients. In group-A patients haemodynamics and complications were examined immediately after injection. In group-B the same patients were examined through a questionnaire after eight weeks, for pain relief, duration of pain relief, reduction in painkillers and overall improvement in activities of daily living. RESULTS: Total 106 patients were examined. In group-A change in haemodynamics before and after twenty minutes of injection was less than 15 percent and no immediate complications were reported. In group B more than 90 percent of patients reported relief of pain and VAS remained below three. Relief of pain lasted for 1-2 weeks, 2-4 weeks, 4-6 weeks and 6-8 weeks in 13 percent, 11 percent, 27 percent and 43 percent of patients respectively. More than fifty percent of patients reported up to 70 percent improvement in activities of daily living (ADL) and reduction in weekly intake of supplemental pain killers. Six percent of the (seven) patients reported no response to treatment. CONCLUSION: Psoas compartment and caudal epidural steroid injection could be an alternate option for pain relief in patients with spinal stenosis and lumbosaccral radiculopathy.

Hand washing and gloving practices among anaesthetists.

OBJECTIVE: To assess the complinance of anaesthetists towards gloving on shifting the patients to post anaesthesia care unit and hand hygiene before leaving the PACU. METHODS: The observational study was conducted in a tertiary care hospital. An assigned nurse in the PACU was asked to observe the anaesthetists and mark on a proforma, the wearing of gloves during shifting a patient and later hand washing or using an alcohol rub before leaving the room. RESULTS: A total of 496 observations were made. Overall compliance with wearing gloves during shifting of patients to PACU was 70% and practice of hand hygiene was observed in 62% of anaesthetists CONCLUSION: Implementation of hand hygiene policy and education has positive effects among anaesthetists. Compliance to the policy remained above fifty percent. In order to further improve the situation continuous education and definitive administration measures of hand hygiene practices are suggested.

Haemodynamic response of intravenous tramadol and intravenous morphine during laryngoscopy and endotracheal intubation.

OBJECTIVE: To compare the haemodynamic response of equipotent analgesic doses of morphine and tramadol to laryngoscopy and endotracheal intubation. METHODS: A randomized double blind study of eighty ASA 1 and ASA II patients, age 18-50 years for elective surgery requiring endotracheal intubation was conducted. Forty patients were selected for each group, M (morphine) and T (tramadol). All patients received study drug three minutes prior to induction of anaesthesia RESULTS: Mean heart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial blood pressure (MAP) between the groups and within the groups from base line and from preintubation period was significantly (p<0.05)different at different time intervals.. When compared from base line maximum increase in heart rate in group M and T was 11.86% and 28.92% and maximum decrease was 12.08% and 1.43% respectively. Mean maximum increase in SBP was 8.06% in group T. Decrease was 18%and 10.48% in group M and T respectively. Maximum increase and decrease in DBP and MAP follow the same pattern and increase in blood pressures remained below 15% of the baseline value. CONCLUSION: Morphine is a better drug as compared to tramadol for attenuation of laryngoscopy and endotracheal intubation response.

Role of Stellate ganglion block in post CABG sympathetically mediated chest pain.

Acute chest pain is a common presentation in emergency. After clinical assessment undiagnosed chest pain can become a difficult problem. Sympathetically mediated chest pain is a rare presentation, as it is similar to that of secondary hyperalgesia in the intact skin surrounding an injury site. We are reporting a case of a 62 years old man who presented with atypical chest pain four months after coronary artery bypass grafting (CABG). On investigation no new change was noticed than previous evaluation. On chronic pain assessment he was having hyperalgesia to light touch in addition to the spontaneous chest pain. He was treated as a case of sympathetically mediated chest pain, pain modulators, analgesics and Stellate ganglion block. Patient responded dramatically to Stellate ganglion block and returned to work within two weeks time. This case illustrated the importance of early diagnosis of sympathetically mediated chest pain and role of Stellate ganglion block.

Diagnostic value of chest X-ray and echocardiography for cardiac tamponade in post cardiac surgery patients.

OBJECTIVE: To investigate the effectiveness of X-ray and echocardiography (ECHO) as a diagnostic tool for cardiac tamponade in adult cardiac surgery patients. METHODS: Thirty five coronary artery bypass and graft surgery patients who developed cardiac tamponade at Cleveland clinic foundation, were included in this study. Their diagnosis was confirmed at the time of re-exploration in the operating room. These patients were followed retrospectively for demographics, X-ray and echocardiography findings. Abnormal and enlarged cardiac silhouette which was different from first postoperative X-ray was used as radiological criteria for tamponade while echocardiographic diagnosis was left to the discretion of cardiologist. RESULTS: Twenty four males (69%) and 11 (31%) females with an average age of 60.7 +/- 15.2 years were included in this study. Only 7 (20%) patients met our criteria for radiological diagnosis of tamponade. All 35 patients showed pericardial effusion on ECHO while cardiac tamponade was present in 30 (86%) patients. Tamponade developed on an average on 4th postoperative day. CONCLUSION: Radiological diagnosis of cardiac tamponade based on changes in cardiac silhouette provide limited information while ECHO is a reliable diagnostic tool when combined with clinical findings.