Single-shot lumber epidural morphine for open kidney surgery: effects of Co-administration of bupivacaine or ropivacain

Presurgical epidural analgesia can effectively attenuate peripheral and central sensitization to pain. In a blinded randomized study, we investigated the effects of presurgical administration of single-shot epidural morphine alone or with co-administration of bupivacaine or ropivacaine. The outcome measures were postoperative analgesia, side effects and surgical stress. Ninety patients undergoing open kidney surgery were randomly allocated to receive presurgical epidwal analgesia with morphine 3 mg in normal saline [Group MS], morphine 3 mg plus bupivacaine 50 mg [Group MB] or morphine 3 mg plus ropivacaine 75 mg [Group MR]. All epidural solutions were prepared in equal; 20 ml sealed aliquots. Patients were observed during operative period for hemodynamics and the need for deepening anesthesia. During postoperative period, analgesia was assessed with the visual analog scale; VAS. Venous blood samples were withdrawn at the morning of operation and the morning of first postoperative day for measuring serum corttsol level. Patients in MS group needed higher inspired isoflurane concentration than patients in the other two groups. During positioning for surgery, more patients in MB [90%] and MR [93%] groups were treated with ephedrine to treat hypotension compared to MS [20%]. No differences in pain scores were observed among the patients at rest but during cough or mobilization, more patients in MS group reported significantly higher pain scores at 8, 12, 24h postoperatively. Analgesic drug consumption was higher in MS group than the other two groups; P <0.05. Nausea and pruritus showed no significant differences among the three groups. Serum cortisol levels were comparable in all patients and showed no significant differences among the patients before and after operation. Presurgical administration of epidural morphine-alone or with -bupivacaine or -ropivacaine provide effective analgesia during rest and attenuate the stress response to surgery. The addition of either bupivacaine or ropivacaine to epidural morphine improves analgesia during mobilization

Retropharyngeal abscess in children; changes in airway clinical presentation and management

Diagnosis of retropharyngeal abscess [RPA] in children is based on clinical suspicioun with supportive imaging studies RPA is frequently described as acute airway emergency. There is nowadays a change in the clinical presentation and management that has been explored in this study. The study included cases identified by a diagnosis of RPA including infectious and traumatic cases with confirmatory computed Tomography [CT] scan findings. Patients were treated with conservative antibiotics, CT-guided needle aspiration or open transoral drainage under general endotracheal anesthesia. Seventeen patients were identified. The mean age was 5.5 years. The symptoms were in the following order of frequency; posterolateral neck pain in 70.5%, odynophagia and drooling 47%, fever 29.4%, lateral neck mass 23.5%, and lastly respiratory distress in 1 patient [5.8%]. The commonest sign was limitation of neck movement 88.2%; of those, 10 patients [58.8%] had limitation of neck extension, 3 [17.6%] had torticollis, 2 [11.7%] had limitation on flexion. Following signs were, fever 53%, enlarged tender upper cervical lymph nodes 47%, tachypnea 35%, posterior pharyngeal bulge 11.7%, inspiratory stridor 5.8%, posterior pharyngeal wall congestion 5.8%. Conservative medical treatment with IV antibiotics alone was successful in 4 [23.5%], transoral incision drainage done for 5 patients [29.4%] patients, external neck drainage in 2 [11.7%] patients, transoral needle aspiration of pus plus IV antibiotics successful in 6 [35%]. Airway related side effects were self-limited and none of the patients needed tracheostomy. Children with RPA present with manifestations other than respiratory distress or stridor. CT scan is useful in confirming the diagnosis. IV antibiotics alone can be effective in clinically stable patients; transoral needle aspiration of pus covered by IV antibiotics be helpful while transpharyngeal incision drainage can be reserved for clinically unstable or difficult to aspirate patients

Prolonged pneumoperitoneum in exaggerated trendlenburg position; anesthetic implications

Laparoscopic radical cystectomy is a relatively new surgical procedure. Being a procedure of long duration, performed with pneumoperitonium in exaggerated Trendlenberg position; it is expected to pose unfavorable effects. We report pulmonary and haemodynamic changes in addition to postoperative outcome following laparoscopic radical cystectomy in the exaggerated head-down position. A prospective study was conducted on 31 patients anaesthetized with a combination of epidural and total intravenous anaesthesia [using midazolam, fentanyl, ketamine and vecuronium]. Surgery was done while the patient in head down position [40o]. Lungs were ventilated using air-oxygen [FiO2 = 0.35] with a tidal volume of 8 ml kg[-1] at a rate of 12-14 min[-1]. Lung mechanics, gasometric and haemodynamic variables were recorded at different strategic points. Recovery and postoperative outcome were also evaluated. Two patients discontinued because of conversion to open surgery and 29 completed the procedure. Fourteen of 29 patients [48.2%] had preoperative medical diseases and 11 patients [38%] received blood. There were significant decrease in lung compliance and significant increase in peak pressures after pneumoperitoneum and Trendelenburg. Concomitantly, heart rate, arterial pressure and carbon dioxide tension increased significantly. Three patients suffered postextubation airway obstruction and were reintubated. On the first postoperative day, one patient desaturated and one patient suffered severe nausea and vomiting. Laparoscopic radical cystectomy in exaggerated head down position is associated with brisk consequences and potential risks