Ultrasound prediction for vocal cord dysfunction in patients scheduled for anterior cervical spine surgeries: a prospective cohort study.

Prediction of vocal cord dysfunction is essential after anterior cervical spine surgeries. This study aimed to detect the validity of transcutaneous laryngeal ultrasonography by both anterior and novel lateral approaches for prediction of vocal cord edema and paralysis after anterior cervical spine surgeries. A prospective cohort study conducted on 90 patients scheduled for anterior cervical spine surgeries underwent consecutive pre and postoperative vocal cord examination for edema and paralysis by both anterior and lateral approaches laryngeal ultrasonography. Rigid laryngoscopy was the standard confirmatory tool. For postoperative vocal cord edema, the anterior ultrasonography approach diagnostic sensitivity = 88.2%, specificity = 78.9% with PPV = 78.9% and NPV = 88.2% and the novel lateral ultrasonography approach diagnostic sensitivity = 88.2%, specificity = 94.7% with PPV = 93.75% and NPP = 90%. While for paralysis, the anterior ultrasonography approach diagnostic sensitivity = 86.7%, specificity = 85.7% with PPV = 81.25% and NPV = 90% and the novel lateral ultrasonography approach diagnostic (sensitivity, specificity with PPV and NPP) = 100%. The diagnostic accuracy of the novel lateral approach was more correlated to rigid laryngoscopy (91.7% and 100%) compared to anterior approach for vocal cord edema and paralysis (83.3% and 80.6%). Overall incidence of vocal cord paralysis was 16.6%. Risk of vocal cord paralysis was statistically significant more in female, multiple disc herniation, lower and mixed disc levels, Langenbeck retractor, cage and plate and duration of surgery ≥ 1.5 h. Transcutaneous Laryngeal ultrasound is a valid comfortable tool for prediction of vocal cord edema and paralysis after anterior cervical spine surgeries with superiority of the novel lateral over anterior approach.

Bilateral Ultrasound-Guided Erector Spinae Plane Block Versus Transversus Abdominis Plane Block on Postoperative Analgesia after Total Abdominal Hysterectomy.

BACKGROUND: Transversus abdominis plane (TAP) blocks provide postoperative pain relief after various abdominal surgeries. Recently, erector spinae plane (ESP) block has obtained vast attention due to its simplicity and usage in truncal procedures. OBJECTIVES: This study aims to compare the ultrasound-guided bilateral ESP block versus bilateral TAP block on postoperative analgesia after open total abdominal hysterectomy. STUDY DESIGN: A prospective, double-blinded, randomized, controlled, clinical trial. SETTING: Zagazig University Hospitals. METHODS: After ending of surgical procedure and before reversing of the muscle relaxant, 48 women were randomly allocated into 2 equal groups: erector spinae (ES) group received bilateral ultrasound-guided ESP block with 20 mL of bupivacaine 0.375% plus 5 ug/mL adrenaline (1:200000) in each side at the level of T9, and transversus abdominis (TA) group received bilateral ultrasound-guided TAP block with the same volume of bupivacaine plus adrenaline. RESULTS: Visual Analog Scale scores at 30 minutes, 2, 4, 6, 8, 12, 16, 20, and 24 hours were statistically significantly lower in the ES group compared with the TA group. The time for requirement of first morphine was highly statistically significantly prolonged in the ES group (14.81 ± 3.52 hours) compared with the TA group (10.58 ± 2.35 hours). The total amount of morphine consumption in 24 hours postoperatively was statistically significantly decreased in the ES group; P = 0.01. Incidence of postoperative nausea and vomiting was higher but statistically insignificant in the TA group than the ES group. There were statistically significant numbers of unsatisfied patients (4) in the TA group compared with the ES group (no patient). LIMITATIONS: Sensorial evaluation of patients was not performed because both blocks had been done under general anesthesia but did not affect outcome. Therefore we recommend further studies comparing between both blocks. CONCLUSIONS: Bilateral ultrasound-guided ESP block provides more potent and longer postoperative analgesia with less morphine consumption than TAP block after open total abdominal hysterectomy. KEY WORDS: Abdominal hysterectomy, transversus abdominis plane block, erector spinae plane block, postoperative analgesia.

Nalbuphine versus Midazolam as an Adjuvant to Intrathecal Bupivacaine for Postoperative Analgesia in Patients Undergoing Cesarean Section.

BACKGROUND AND PURPOSE: Adding adjuvants to intrathecal hyperbaric bupivacaine provides long analgesic duration with less adverse effects. The aim of this study was to compare intrathecal nalbuphine versus midazolam in patients undergoing cesarean section. CLINICAL TRIAL ID: NCT03918187. PATIENTS AND METHODS: This was a prospective randomized controlled study conducted on 90 females undergoing cesarean section under spinal anesthesia who were randomly allocated to three equal groups of 30 patients each: group C received hyperbaric bupivacaine 12.5 mg plus 0.5 mL saline, group N received hyperbaric bupivacaine 12.5 mg plus 1 mg nalbuphine, group M received hyperbaric bupivacaine 12.5 mg plus 2.5 mg midazolam. The onset and duration of sensory and motor block, effective analgesic time, analgesic requirements, adverse effects, sedation, and Apgar scores were recorded. RESULTS: There was significant rapid onset of sensory and motor block (1.95±.44 and 3.50±0.43 min) with slower regression of sensory block and time to bromage I (211.6±13.2 and 219.8±20.2 min) in group N compared to groups M, C (p < 0.001), with statistically significant rapid onset and long duration of both blocks in group M compared to C (p<0.001). The effective analgesic time was significantly prolonged in group N (263.7±16.3) compared to groups M and C (224.2 ± 18.6, 185.5±17.45), respectively, (p<0.001) and prolonged in group M compared to C (p<0.001), with increase in analgesic requirement in group C compared to groups N and M (p<0.001) and no significant difference between groups N and M. There was higher sedation score in groups N, M (1.78±0.63, 2.75±0.54), respectively, compared to group C (0.61±0.12) (p<0.001) with lower Apgar score in group M (6.9±0.73) at one minute than in groups N, C (7.1±0.91, 7.7±0.84) (p<0.001). There was no significant difference between groups regarding the adverse effects. CONCLUSION: Adding 1 mg nalbuphine to 12.5 mg hyperbaric bupivacaine provided more effective postoperative analgesia than adding 2.5 mg midazolam, with less non-significant adverse effects in midazolam group in patients undergoing elective cesarean section.

Analgo-Sedative Effects of Oral or Nebulized Ketamine in Preschoolers Undergoing Elective Surgery: A Comparative, Randomized, Double-Blind Study.

BACKGROUND: Premedication in children with ketamine is useful to produce mild sedation, decrease anxiety, help the child separation from parents, and provide postoperative pain relief with no or little adverse effects. OBJECTIVES: The aims of this study were to compare the level of sedation, parental separation, successful venous cannulation, and postoperative analgesia of oral or nebulized ketamine in preschoolers undergoing elective surgery. STUDY DESIGN: A prospective, comparative, double-blind, randomized study. SETTING: Zagazig University Hospitals. METHODS: In the preparation room, 30 minutes before induction of anesthesia, 62 children were randomly divided into 2 groups: group O (n = 31) received oral ketamine 10 mg/kg in 2 mL apple juice, and group N (n = 31) received nebulized ketamine 3 mg/kg plus 2 mL isotonic saline solution by a standard hospital jet nebulizer via a mouth mask with a continuous 6 L/min flow of 100% oxygen. RESULTS: At 10 minutes after premedication, sedation score was 3 in group O (34.4%) compared with group N (0%), and at 20 minutes in group O (93.5%) compared with group N (9.6%) (P < 0.001 ). However, at 30 minutes, 51.6% of group O showed a sedation score of 1 versus 0% of group N (P < 0.001 ). There were 70.9% of group O versus 6.4% of group N who showed an Emotional State Score of 1 (P < 0.0001), and 29.03% of group O versus 19.3% of group N who showed an Emotional State Score of 2 (P = 0.37), with statistically nonsignificant adverse effects in both groups. Low mean modified Children's Hospital of Eastern Ontario Pain Scale score in group O compared with group N at 30, 60, 90 minutes (P < 0.0001). LIMITATIONS: In this study, although the dose of nebulized ketamine was 3 mg/kg, which was more than the optimum dose investigated in previous studies, it was not adequate, so we recommend conducting more studies investigating higher doses. CONCLUSIONS: Oral ketamine 10 mg/kg as premedication 30 minutes before induction of anesthesia is more effective than 3 mg/kg nebulized ketamine in producing more sedation, satisfactory separation from parents, successful venous cannulation, and effective postoperative analgesia, as it is more tolerable and accepted by preschoolers undergoing elective surgery. KEY WORDS: Nebulized ketamine, oral ketamine, preschooler, elective surgery.