Ultrasound-guided supraclavicular brachial plexus block: single versus triple injection technique for upper limb arteriovenous access surgery.

BACKGROUND: Although ultrasound-guided supraclavicular block has a good success rate, it remains unclear whether multiple injections are superior to single injection (SI). We compared the sensory block success rate of SI versus triple injection (TI). METHODS: In this randomized double-blind study, 96 end-stage renal disease patients undergoing arteriovenous fistula creation or superficialization were randomly allocated to receive either SI or TI. The primary outcome was the combined score of sensory blockade of the 5 nerves (median, ulnar, radial, medial cutaneous nerve of the forearm, and musculocutaneous) measured at 5, 10, 15, and 20 minutes after injection. Secondary outcome variables were the time to onset of the blockade, performance time (time to do the block), separate success rate for each of the above nerves, success rate of surgical anesthesia, and the complication rate. RESULTS: The combined success of the sensory block was 20% to 31% higher in the TI group than in the SI group at 10, 15, and 20 minutes after injection (all P < 0.035). The block of the musculocutaneous nerve in the TI group was faster and more successful than in the SI group, at all time points (all P < 0.026). The average time needed to perform the block was significantly longer in the TI than the SI group (6.5 ± 2.1 vs 4.7 ± 2.1 minutes, P = 0.001). The overall success of surgical anesthesia measured at 30 minutes did not differ significantly between the 2 groups (96% in TI vs 87% in SI, P = 0.253). CONCLUSIONS: Although the performance time of the SI technique was shorter, TI had a faster onset and resulted in a more successful block of all nerves in the first 20 minutes.

Effect of tidal volume on extravascular lung water content during one-lung ventilation for video-assisted thoracoscopic surgery: a randomised, controlled trial.

BACKGROUND: The use of low tidal volume during one-lung ventilation (OLV) has been shown to attenuate the incidence of acute lung injury after thoracic surgery. OBJECTIVE: To test the effect of tidal volume during OLV for video-assisted thoracoscopic surgery on the extravascular lung water content index (EVLWI). DESIGN: A randomised, double-blind, controlled study. SETTING: Single university hospital. PARTICIPANTS: Thirty-nine patients scheduled for elective video-assisted thoracoscopic surgery. INTERVENTIONS: Patients were randomly assigned to one of three groups (n = 13 per group) to ventilate the dependent lung with a tidal volume of 4, 6 or 8 ml  kg(-1) predicted body weight with I:E ratio of 1:2.5 and PEEP of 5 cm H2O. MAIN OUTCOME MEASURES: The primary outcomes were perioperative changes in EVLWI and EVLWI to intrathoracic blood volume index (ITBVI) ratio. Secondary outcomes included haemodynamics, oxygenation indices, incidences of postoperative acute lung injury, atelectasis, pneumonia, morbidity and 30-day mortality. RESULTS: A tidal volume of 4 compared with 6 and 8 ml  kg(-1) after 45 min of OLV resulted in an EVLWI of 4.1 [95% confidence interval (CI) 3.5 to 4.7] compared with 7.7 (95% CI 6.7 to 8.6) and 8.6 (95% CI 7.5 to 9.7) ml  kg(-1), respectively (P < 0.003). EVLWI/ITBVI ratios were 0.57 (95% CI 0.46 to 0.68) compared with 0.90 (95% CI 0.75 to 1.05) and 1.00 (95% CI 0.80 to 1.21), respectively (P < 0.05). The incidences of postoperative acute lung injury, atelectasis, pneumonia, morbidity, hospitalisation and 30-day mortality were similar in the three groups. CONCLUSION: The use of a tidal volume of 4 ml kg during OLV was associated with less lung water content than with larger tidal volumes of 6 to 8 ml kg(-1), although no patient developed acute lung injury. Further studies are required to address the usefulness of EVLWI as a marker for the development of postoperative acute lung injury after the use of a low tidal volume during OLV in patients undergoing pulmonary resection. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT01762709.

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.

Intravenous lornoxicam is more effective than paracetamol as a supplemental analgesic after lower abdominal surgery: a randomized controlled trial.

BACKGROUND: The aim of this prospective, randomized, double-blind study was to determine the more effective supplemental analgesic, paracetamol or lornoxicam, for postoperative pain relief after lower abdominal surgery. METHODS: Sixty patients scheduled for lower abdominal surgery under general anesthesia were randomly allocated to receive either isotonic saline (control group), intravenous paracetamol 1 g every 6 h (paracetamol group), or lornoxicam 16 mg then 8 mg after 12 h (lornoxicam group). Additionally pain was treated postoperatively with morphine patient-controlled analgesia. Postoperative pain scores measured by the verbal pain score (VPS), morphine consumption, and the incidence of side effects were measured at 1, 2, 4, 8, 12, and 24 h postoperatively. RESULTS: Morphine consumption at 12 and 24 h was significantly lower in the lornoxicam group (19.25 ± 5.7 mg and 23.1 ± 6.5 mg) than in the paracetamol group (23.4 ± 6.6 mg and 28.6 ± 7.6 mg). Both treatment groups had less morphine consumption than the control group (28.5 ± 5 mg and 38.1 ± 6.6 mg) at 12 and 24 h, respectively. Additionally, VPS was reduced in the paracetamol and the lornoxicam groups compared with the control group both at rest and on coughing. Further analysis revealed that VPS in the lornoxicam group was significantly lower than that in the paracetamol group only during coughing. Drug-related side effects were comparable in all groups. CONCLUSIONS: Lornoxicam is superior to paracetamol for postoperative analgesia after lower abdominal surgery. However, paracetamol could be an alternative supplemental analgesic whenever an NSAID is unsuitable. TRIAL REGISTRATION: clinicaltrials.gov.identifier:NCT01564680.

Intraocular pressure and haemodynamic responses to insertion of the i-gel, laryngeal mask airway or endotracheal tube.

CONTEXT: We hypothesised that the effects of insertion of an i-gel supraglottic airway management device on intraocular pressure (IOP) and haemodynamic variables would be milder than those associated with insertion of a laryngeal mask airway (LMA) or an endotracheal tube. OBJECTIVES: This study evaluated IOP and haemodynamic responses following insertion of an i-gel airway, LMA or endotracheal tube. DESIGN AND SETTING: This was a randomised controlled study in a tertiary care centre in which 60 adults scheduled for elective non-ophthalmic procedures under general anaesthesia were allocated to one of three groups. Patients with pre-existing glaucoma, cardiovascular, pulmonary or metabolic diseases or anticipated difficult intubation were excluded. INTERVENTIONS: Following induction of general anaesthesia, an endotracheal tube, LMA or i-gel device was inserted. MAIN OUTCOME MEASURES: IOP, SBP, DBP, heart rate (HR) and perfusion index were measured before induction of anaesthesia and before and after insertion of the airway device. RESULTS: Insertion of the i-gel did not increase IOP. Insertion of an endotracheal tube increased IOP from 11.6 ± 1.6 to 16.5 ± 1.7 mmHg (P < 0.001). The post-insertion IOP exceeded the pre-induction value (P < 0.05). Insertion of the LMA increased IOP from 13.0 ± 1.5 to 14.7 ± 1.8 mmHg (P < 0.01), but this did not exceed the pre-induction value. Tracheal intubation significantly increased HR, SBP and DBP. Insertion of the LMA significantly increased HR and SBP. These increases were significantly higher than those which followed insertion of the i-gel device. Insertion of the endotracheal tube or LMA resulted in a significant decrease in perfusion index which was maintained for 5 min following tracheal intubation and for 2 min after insertion of the LMA. Insertion of the i-gel device did not change perfusion index significantly. CONCLUSION: Insertion of the i-gel device provides better stability of IOP and the haemodynamic system compared with insertion of an endotracheal tube or LMA in patients undergoing elective non-ophthalmic surgery.

Brief reports: nerve stimulator evoked motor response predicting a successful supraclavicular brachial plexus block.

BACKGROUND: We examined the success rate of supraclavicular brachial plexus block after the different evoked motor responses to nerve stimulation. METHODS: This multicenter observational study included 377 patients. For each block, the evoked motor response elicited at 0.25 mA for 2 milliseconds was recorded, 30 mL bupivacaine 0.25% was injected, and the block was observed for success or failure. RESULTS: Complete anesthesia occurred in 317 cases (84.1%). The success rate was 100% when the evoked motor response was simultaneous flexion of the third and fourth digits or flexion of all 4 digits (digits 2-5) with or without thumb opposition. CONCLUSION: Simultaneous flexion of the third and fourth digits with or without other digits is associated with the highest success rate of supraclavicular brachial plexus block.

Preoperative peritonsillar lornoxicam infiltration is not superior to intravenous lornoxicam for pain relief following tonsillectomy in adults.

BACKGROUND AND OBJECTIVE: Nonsteroidal anti-inflammatory drugs have peripheral analgesic effects. We compared the efficacy of peritonsillar infiltration versus intravenous (i.v.) lornoxicam on pain relief after tonsillectomy in adults. METHODS: Sixty adult patients scheduled for tonsillectomy were randomly assigned into three groups in a double-blind placebo-controlled study. In the control group, the patients received i.v. and peritonsillar saline infiltration; in the infiltration group, they received i.v. isotonic saline and peritonsillar lornoxicam infiltration, whereas in the i.v. group they received i.v. lornoxicam and peritonsillar saline infiltration. Pain verbal analogue scale at rest and on swallowing, the time to the first postoperative analgesic request, the total postoperative analgesic consumption during the first 24 h, intraoperative blood loss and postoperative bleeding were evaluated. RESULTS: Preoperative lornoxicam administration resulted in a significant reduction in pain scores postoperatively in the infiltration and i.v. groups with no significant difference between them. The time to first postoperative analgesic request was 143 +/- 138 min in the control group compared with 684 +/- 328 and 750 +/- 316 min in the i.v. and infiltration groups, respectively; P value is less than 0.05. Similarly a higher total paracetamol consumption (2632 +/- 1065 mg) during the first postoperative day was recorded in the control group than in both the lornoxicam groups (1300 +/- 733 and 1600 +/- 754 mg), with no significant differences between the i.v. and infiltration groups. Comparable intraoperative blood losses with no posttonsillectomy bleeding were recorded in the three study groups. CONCLUSION: Peritonsillar infiltration or i.v. lornoxicam enhanced postoperative analgesia after tonsillectomy in adults. However, the analgesic efficacy of locally applied lornoxicam is not superior to the i.v. administration.

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.

Melatonin provides anxiolysis, enhances analgesia, decreases intraocular pressure, and promotes better operating conditions during cataract surgery under topical anesthesia.

BACKGROUND: Melatonin has anxiolytic and potential analgesic effects. In this study, we assessed the effects of melatonin premedication on pain, anxiety, intraocular pressure (IOP), and operative conditions during cataract surgery under topical analgesia. METHODS: Forty patients undergoing cataract surgery under topical anesthesia were randomly assigned into two groups (20 patients each) to receive either melatonin 10 mg tablet (melatonin group) or placebo tablet (control group) as oral premedication 90 min before surgery. Anxiety scores, verbal pain scores, heart rate, mean arterial blood pressure, and IOP were recorded. In addition, the surgeon was asked to rate operating conditions. RESULTS: Melatonin significantly reduced the anxiety scores (median, interquartile range) from 5, 3.5-6 to 3, 2-3 after premedication and to 3, 2-3.5 during surgery (P = 0.04 and P = 0.005 compared with the placebo group, respectively). Perioperative verbal pain scores were significantly lower in the melatonin group with less intraoperative fentanyl requirement (median, interquartile range) compared with the control group, 0, 0-32.5 vs 47.5, 30-65 microg, respectively, P = 0.007. Melatonin also decreased IOP (mean +/- sd) significantly from 17.9 +/- 0.9 to 14.2 +/- 1.0 mm Hg after premedication and to 13.8 +/- 1.1 mm Hg during surgery (P < 0.001). It also provided better quality of operative conditions. CONCLUSION: We concluded that oral melatonin premedication for patients undergoing cataract surgery under topical anesthesia provided anxiolytic effects, enhanced analgesia, and decreased IOP resulting in good operating conditions.

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.

The efficacy of perfusion index as an indicator for intravascular injection of epinephrine-containing epidural test dose in propofol-anesthetized adults.

BACKGROUND: Perfusion index (PI) is a noninvasive numerical value of peripheral perfusion obtained from a pulse oximeter. In this study, we evaluated the efficacy of PI for detecting intravascular injection of a simulated epidural test dose containing 15 mug of epinephrine in adults during propofol-based anesthesia and compared its reliability with the conventional heart rate (HR) (positive if >or=10 bpm) and systolic blood pressure (SBP) (positive if >or=15 mm Hg) criteria. METHODS: Forty patients scheduled for elective general surgery under total IV anesthesia were randomized to receive either 3 mL of lidocaine 15 mg/mL with epinephrine 5 microg/mL or 3 mL of saline IV (n = 20 each). HR, SBP, and PI were monitored for 5 min after injection. RESULTS: Injecting the test dose resulted in an average maximum PI decrease by 65% +/- 13% at 39 +/- 15 s. Moreover, maximal increases in HR and SBP were 19 +/- 8 bpm at 49 +/- 25 s and 17 +/- 7 mm Hg at 102 +/- 34 s after test dose injections, respectively. Using the PI criterion for intravascular injection (positive if PI decreases >or=10% from the preinjection value) the sensitivity, specificity, positive predictive, and negative predictive values were 100% (95% confidence interval [CI]; CI = 83%-100%). On the contrary, sensitivities of 95% (CI = 76%-99%) and 90% (CI = 70%-97%) were obtained based on HR and SBP criteria, respectively. CONCLUSION: PI is a reliable alternative to conventional hemodynamic criteria for detection of an intravascular injection of epidural test dose in propofol-anesthetized adult patients.

Melatonin improves tourniquet tolerance and enhances postoperative analgesia in patients receiving intravenous regional anesthesia.

BACKGROUND: Melatonin has anxiolytic and potential analgesic effects. We assessed the efficacy of melatonin premedication in reducing tourniquet-related pain and improving analgesia in patients receiving IV regional anesthesia (IVRA). METHODS: Forty patients undergoing elective hand surgery under IVRA were randomly assigned into two groups (20 patients each) to receive either melatonin 10 mg (melatonin group) or placebo (control group) as oral premedication. IVRA was achieved with lidocaine, 3 mg/kg, diluted with saline to a total volume of 40 mL. Anxiety scores, hemodynamic changes, sensory and motor block onset and recovery times, tourniquet pain, the quality of intraoperative anesthesia, time to first analgesic request, and 24 h analgesic requirements were recorded. RESULTS: After premedication, the anxiety scores were significantly reduced in the melatonin group (P=0.023). During surgery, patients who received melatonin premedication had better tourniquet tolerance (lower verbal pain scores at 30, 40, and 50 min after tourniquet inflation, P<0.05), lower rescue fentanyl requirements (15.6+/-21.9 vs 45.7+/-33.4 microg, P=0.002), longer time to the first postoperative analgesic request (145.4+/-20.2 min vs 74.6+/-12.8, P<0.001) and lower postoperative diclofenac consumption at 24 h (86.3+/-27.5 mg vs 116.3+/-38.3 mg, P=0.007) compared with the control group. CONCLUSIONS: Melatonin is an effective premedication before IVRA since it reduced patient anxiety, decreased tourniquet-related pain, and improved perioperative analgesia.

The effects of intravenous granisetron on the sensory and motor blockade produced by intrathecal bupivacaine.

BACKGROUND: We hypothesized that pretreatment with i.v. granisetron would affect the sensory and motor components of spinal blockade through 5-HT(3) receptor blockade. METHODS: Forty unpremedicated patients scheduled for elective knee arthroscopy under spinal anesthesia were randomly allocated to receive either i.v. granisetron 1 mg (granisetron group) or saline (control group) on arrival to the operating room. Two and half milliliters (12.5 mg) of hyperbaric bupivacaine 0.5% was injected intrathecally. Regression of the sensory level and motor blockade, and the hemodynamic changes were evaluated. RESULTS: There were no significant differences between the two groups in the maximum cephalad spread of sensory block or the time to maximum sensory level. Compared with the control group, patients who received granisetron had significantly faster sensory regression times by two segments (69.8 +/- 25.5 min vs 88.0 +/- 27.8 min, P = 0.036), to segment T12 (105.5 +/- 25.1 min vs 127.0 +/- 30.5 min, P = 0.019) and to segment S1 (162.8 +/- 41.1 min vs 189.8 +/- 39.8 min, P = 0.041), respectively. In contrast, motor block did not differ between the two groups at any study time. No significant differences were detected between the two study groups in the hemodynamic data. CONCLUSION: We concluded that i.v. granisetron facilitated a faster recovery of sensory block after bupivacaine subarachnoid anesthesia.

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.

Tramadol as an adjuvant to intravenous regional anesthesia with lignocaine.

OBJECTIVE: To assess the effect of different doses of tramadol when added to lignocaine during intravenous regional anesthesia (IVRA). METHODS: Sixty patients, scheduled for hand surgery under IVRA in King Fahd University Hospital, Al-Khobar, Saudi Arabia from January 2006 to January 2007 were randomly allocated into 3 groups (20 patients each) in a double blind controlled study. All patients received 0.5% lignocaine, 40ml plus 2ml of a study solution containing either isotonic saline control group, or tramadol 50mg (group T50) or tramadol 100 mg (group T100). Hemodynamic changes, sensory and motor block onset and recovery times, tourniquet tolerance time, the quality of intraoperative anesthesia and the duration of postoperative analgesia were assessed. RESULTS: All patients, 20 in each group completed the study period. Patients who received tramadol had earlier onset of sensory block (5.2 +/= 1.2; 4.9 +/= 1.2 min in the T50; and T100 groups) compared with the control group (7.6 +/= 1.4 min). Patients who received 100mg of tramadol had better tolerance of tourniquet (p=0.011), and less intraoperative fentanyl supplementation (p=0.042). They had also a longer time to the first postoperative analgesic request (p=0.001) compared with the control group. CONCLUSION: Tramadol 100 mg is a beneficial additive to lignocaine for IVRA since it shortened the onset of sensory block, enhanced the tourniquet tolerance and improved the perioperative analgesia.

The effect of etoricoxib premedication on postoperative analgesia requirement in orthopedic and trauma patients.

OBJECTIVE: We hypothesized that etoricoxib premedication would reduce the need for additional opioids following orthopedic trauma surgery. METHODS: A double blind, controlled study, conducted in King Fahd University Hospital, King Faisal University, Dammam, Kingdom of Saudi Arabia. After obtaining the approval of the Research and Ethics Committee and written consent, 200 American Society of Anesthesiology grade I & II patients that underwent elective upper limb or lower limb fracture fixation surgeries during the period from August 2005 to October 2007 were studied. Patients were randomly premedicated using 120 mg of etoricoxib or placebo n=100, each. To alleviate postoperative pain, a patient controlled analgesia device was programmed to deliver one mg of morphine intravenously lockout time, 6 minutes. Visual analog scale and total postoperative morphine consumption over 24 hours and the adverse effects were recorded. RESULTS: One hundred patients in each group completed the study period. Etoricoxib premedication provides a statistically significant postoperative morphine sparing effect over 24 hours postoperatively. Total morphine consumption was 44.2 (8.2) in the placebo and 35.17.0mg in the etoricoxib groups p<0.001. The incidence of nausea and vomiting requiring treatment was lower in the etoricoxib group, p=0.014. The postoperative blood loss was similar in both groups. CONCLUSION: Etoricoxib is a suitable premedication before traumatic orthopedic surgery as it enhanced postoperative analgesia and reduced the need for morphine.

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.

Five-year experience with the peri-operative goal directed management for surgical repair of traumatic aortic injury in the eastern province, Saudi Arabia.

CONTEXT: Traumatic aortic injury (TAI) accounts for 1/3 of all trauma victims. AIM: We aimed to investigate the efficacy of the adopted standardized immediate pre-operative and intra-operative hemodynamic goal directed control, anesthetic technique and organs protection on the morbidity and mortality in patients presented with TAI. SETTINGS AND DESIGN: An observational retrospective study at a single university teaching hospital. MATERIALS AND METHODS: Following ethical approval, we recruited the data of 44 patients admitted to the King Fahd Hospital of the University, Al Khobar, Saudi Arabia, with formal confirmation of diagnosis of blunt TAI during a 5-year period from February 2008 to April 2013 from the hospital medical records. STATISTICAL ANALYSIS: descriptive analysis. RESULTS: A total of 44 victims (41 men, median (range) age 29 (22-34) years) with TAI who underwent surgical repair were recruited. Median (range) post-operative chest tube output was 700 (200-1100) ml necessitated transfusion in 5 (11.4%) of cases. Post-operative complications included transient renal failure (13.6%), pneumonia (6.8%), acute lung injury/distress syndrome (20.5%), sepsis (4.5%), wound infection (47.7%) and air leak (6.8%). No patient developed end stage renal failure or spinal cord injury. Median intensive care unit stay was 6 (4-30) days and in-hospital mortality was 9.1%. CONCLUSION: We found that the implementation of a standardized early goal directed hemodynamic control for the peri-operative management of patients with TAI reduces the post-operative morbidity and mortality after surgical repair.

The use of laryngeal mask airway during transesophageal echocardiography in pediatric patients.

BACKGROUND: Transesophageal echocardiography (TEE) in the cardiac lab is usually performed in pediatric patients under general anesthesia with an endotracheal intubation (ET). This study was performed to investigate the safety and efficacy of using the laryngeal mask airway (LMA) as an alternative to ET to maintain pediatric airway during the general anesthesia for TEE. MATERIALS AND METHODS: A total of 50 pediatric patients undergoing TEE in the cardiac lab were randomized to have their airway maintained during the procedure with either LMA (LMA group) or ET (ET group). Hemodynamic, respiratory parameters, time to extubation, recovery time, the incidence of complication and operator satisfaction were compared between the two groups. RESULTS: There were no differences between both groups in hemodynamic and respiratory parameters. Laryngeal spasm was reported in one patient in the LMA group and two patients in the ET group. TEE operators were equally satisfied with the procedure in groups. The time to extubation was shorter in the LMA group (P < 0.01). The mean recovery time was also significantly shorter in the LMA than in the ET group (44 ± 8 min and 59 ± 11 min, respectively; P < 0.001). CONCLUSION: The LMA is safe and effective in securing the airway of children undergoing diagnostic TEE.

Spectral entropy as an objective measure of sedation state in midazolam-premedicated patients.

CONTEXT: Objective assessment of sedation depth is a valuable target. Spectral entropy is an anesthetic depth monitor based on the analysis of the electroencephalogram signal. AIMS: To evaluate the performance of spectral entropy as an objective measure of sedation state in midazolam-premedicated patients and to correlate it with a clinically assessed sedation score. SETTINGS AND DESIGN: This prospective double-blind placebo-controlled study was performed in King Fahd Hospital of the university. METHODS: Eighty adult ASA I-II patients were randomly assigned into 4 groups. Patients were premedicated using 0.02, 0.04, or 0.06 mg/kg midazolam or saline intramuscularly. The effect of these doses on the Observer's Assessment of Alertness and Sedation (OAA/S) scale, hemodynamic variables, response entropy (RE), and state entropy (SE), was evaluated at 10, 20, and 30 min after premedication. STATISTICAL ANALYSIS: Spearman Rank-order correlation analysis to examine the relation between OAA/S and entropy. The ability of spectral entropy to predict the depth of sedation was evaluated using Smith prediction probability. RESULTS: Midazolam doses ≥0.04 mg/kg produced significant decreases in RE, SE, and OAA/S scores. There was a strong correlation between midazolam dose and OAA/S scale, RE, and SE since Spearman Rank R values were 0.792, 0.822, and 0.745, respectively (P<0.001). In addition, RE and SE were strong predictors of OAA/S level during midazolam sedation with no significant difference in prediction between the 2 entropy components. CONCLUSIONS: Spectral entropy is a reliable measure for the sedative premedication. It may be used to objectively assess the adequacy of midazolam premedication and to determine the dose requirement.