Perfusion index derived from pulse oximetry versus lactate monitoring for outcome prediction in polytraumatized patients

Perfusion Index is a non-invasive numerical value of peripheral perfusion [PI] obtained from pulse oximetery. Prognostic value of perfusion index and its relation to serum lactate and brain natriuretic peptide [BNP] changes has not been investigated in poly-traumatized patients. Fifty poly-traumatized adult patients with hemorrhagic shock without head injury were studied in a prospective observational study, perfusion index changes in relation to serum lactate, lactate clearance and Brain Natriuretic Peptide in survivors and non survivors and their predictability of mortality was evaluated. Full resuscitation according to the advanced trauma life support guidelines [ATLS] was carried out and the morbidity and mortality were followed up for 48 hours. Perfusion index was included as a target for peripheral perfusion and we compared its sensitivity and specificity with serum lactate and BNP for prediction of mortality. Statistical analysis was done using pearson's correlation and receiver operating curve [ROC]. Perfusion index showed a significant difference between survivors and non survivors after the first 6 hours post resuscitation [p < 0.001], ROC analysis showed that perfusion index /= 2.25 mmol/L provided the optimal cutoff point for predicting mortality with AUC was 0.57, sensitivity 79% and specificity 69%. Lactate clearance showed a significant difference between survivors and non survivors [p < 0.001], ROC curve analysis showed that lactate clearance < 3.0 mmol/L/24 hours provided the optimal cutoff point for predicting mortality with AUC was 0.97, sensitivity 97% and specificity 86%. Brain natriuretic peptide level at 48 hours [BNP-48] was significantly higher in non survivors than in survivors [p < 0.001]. ROC analysis showed that BNP-48 >/= 95.0 pg/ml provided the optimal cutoff point for predicting mortality with AUC was less than 0.5, sensitivity 61% and specificity 32%. Perfusion index is a good prognostic factor of mortality and lactate clearance seems the most accurate predictor of mortality as well. Serum lactate is the least accurate predictor of mortality followed by brain natriuretic peptide

Postoperative epidural analgesia: trials of bupivacaine combined with fentanyl or morphine after spinal fusion surgery

Background: major spinal fusion surgery causes severe postoperative pain, which persists for at least 3 days. Efficient and safe methods for postoperative analgesia after spinal fusion surgery are, therefore, mandatory. This study aimed to compare the analgesic effect of different epidural analgesia combinations and their effects on blood level of Beta-endorphin. We also studied the impact of these analgesic regimens on defined postoperative mobilization maneuvers and on patient satisfaction

Methods: This study was registered in clinical trials number NCT01838707. Sixty patients scheduled for elective posterior lumbar fusion surgery for correction of Spondylolisthesis were enrolled in this study. Patients were randomly allocated into three equal groups [20 each] according to analgesic drugs combinations administered through epidural catheter inserted intraoperatively. All patients received standard general anesthesia. Al the end of posterior instrumentation, the surgeon inserted the epidural catheter under direct vision in the midline. All patients in this study were nursed in a high dependency intensive care facility and received analgesics according to the following protocol. Continuous drug flow will be maintained with a syringe pump. The syringe pump was connected to the epidural catheter [with the reservoir contain either: 0.125% Bupivacaine HCI at flow rate of 4 5 ml/h [5-6.25mg/h bupivacaine]. 0.125% Bupivacaine HCI fentanyl 100 microg at flow rate of 3 5 ml/h [3.75-6.24 mg/h bupivacaine I 6-10 microg /h fentanyl] 0.125% Bupivacaine HCI morphine sulphate 3 mg at flow rate of 3 5 ml/h [3.75-6.24 mg/h bupivacaine 0.18-0.3 mg/h morphine]. Infusion was continued until the third postoperative day. The rate was increased if pain VAS >3 [visual analogue scale] at rest or VAS >6 with movement. The rate was decreased when patients have intolerable relevant motor block [Bromage score >0] or sensory disturbances [numbness], or hypotension [systolic blood pressure <90 mm Hg]. IV rescue analgesia will be Ketrolactromethamine 30 mg. Epidural catheters were removed on the third postoperative day. Pain was assessed using the VAS ranging from "0" [no pain] to "10" [worst imaginable pain]. Pain was evaluated at rest and during mobilization. Maneuvers of particular clinical importance for postoperative mobilization [alone and with help] were chosen: Turning in bed. Standing in front of the bed and walking, and using the toilet without help. The time needed until the patient can first successfully perform these maneuvers was documented. Three venous samples to measure serum B-endorphin level first one preoperative base line, second at first time VAS more three at rest and third sample when VAS less than three at rest. For assessment of patients satisfaction with postoperative pain management a verbal rating score was used. Motor block was quantified with the Bromage scale. Patients will be asked about sensory deficits. Verbal rating scores was used for sedation. Nausea and vomiting and the incidence of pruritus were recorded

Results: There were no significant differences observed between the studied groups regarding patient characteristics [age, sex, ASA status, anesthesia time, surgery duration and number of segments fused]. There were no significant differences in all hemodynamic variables between the three groups, the results of this study showed less pain scores as recorded by VAS all over the study time for group 3 [bupivacaine+ morphine]. Pain scores were lowest for group Ill [bupivacaine + morphine] all over the study time when testing pain during movement. The mean times to turn in bed with and without assistance were lowest in group Ill [bupivacaine morphine]. B-endorphin level, there was no significant differences between means of B-endorphin samples between the groups or within each group. Patients were more satisfied in group 3 all over the study period. The incidence of nausea, vomiting or itching within the observation period was significantly different between the three groups. It was more common in the bupivacaine morphine group

In Conclusion: Epidural analgesia after spine surgery improve pain control and enhance functional recovery, but potential cost issues related to maintenance of the epidural infusion and ICU slay versus potential cost savings in hospital stay and effect on long term outcome must be considered. Also the cost of use B-endorphin as a biomarker of pain severity needs to be revised against the subjective assessment of pain

Intravenous propacetamol as postoperative analgesia in cesarean section. Comparative study with intra-thecal morphine

The Provision of optimal analgesia after cesarean section remains a challenge, as satisfactory pain relief must be balanced with the ability of the mother to care for her newborn. [Cohen et al., 1992] Paracetamol is a non NSAID commonly used in multimodal post-operative pain management [Flouvat et al, 2004]. The recent availability of propacetamol an injectable pro-drug of paracetamol has prompted the use of this well known and safe analgesic in many clinical settings when the par enter al route is required [Van Aken et al., 2004]. of this study was to evaluate the safety and efficacy of intravenous propacetamol in comparison with intrathecal morphine for postoperative analgesia following cesarean section. The present study was carried out in Assiut University Hospital Eighty parturients undergoing elective cesarean section under spinal anesthesia were included. The parturients were allocated randomly into four equal groups: Group I is the control group and received intrathecal bupivacaine 0.5%, 10-12.5 mg alone. Group II received intrathecal bupivacaine 0.5% 10-12.5 mg combined with morphine 0.4 mg. Group III received intrathecal bupivacaine 0.5% 10-12.5 mg followed by i.v. propacetamol 2g /l00mL saline after delivery of the baby and after 6 hours. Group IV received intrathecal bupivacaine 0.5% 10-12.5 mg combined with morphine 0.2 mg followed by i.v. propacetamol 2g /l00mL saline after delivery of the baby and after 6 hours. All patients in the four groups received I. M. 75 mg diclofenac at the end of surgery and after 8 hours. When the Visual Analogue Scale [VAS] was 4cm or more, an additional postoperative I.M. meperidine 50 mg as rescue medication was given. Hemodynamic data were recorded immediately after induction and every 10 min till the end of the operation. Neonatal outcome was assessed by Apgar score at one and 5 minutes. Pain intensity score was assessed by VAS every hour and for 12 hours. There were no significant differences between the four groups as regard demographic data, hemodynamics and the neonatal outcome. The pain intensity was more in the control group, the 1. V. propacetamol group was better than the control group but less than the intrathecal morphine group and the pain intensity was the least in the combined group. The combined group was the best one, regarding the quality of pain relief and less side effects due to reduction in morphine dose. The control group required more supplemental analgesia than the propacetamol group and no supplemental analgesia was required in groups II and IV. Complications and side effects were minor. Conclusion: This study may be too small to detect the analgesic effect of propacetamol. The study is also too small to detect a reduction in side effects using multimodal therapy, if there is such a reduction. Therefore, the role of propacetamol is still unknown and a further investigations, with sample sizes large enough to quantify side effects and patient safety, still need to be performed

Comparative study between tramadol and pethidine when added to lidocaine for intravenous regional anesthesia

Both pethidine and tramadol have a local anesthetic effect and thus can be used for intravenous regional anesthesia [IVRA], is to compare the local anesthetic and analgesic action of lidocaine alone, tramadol added to Lidocaine and pethidine added to lidocaine in IVRA for surgeries on the upper limb. A prospective nonrandoinized case series study included 60 patients ASA physical status I and II scheduled for forearm surgery using IVRA. The patients were classified into three groups:- Lidocaine group [L]:- Included 20 patients, as a control group, and they received lidocaine hydrochloride 200 mg [0.5%] diluted in 40 ml normal saline, Pethidine group [P]:- Included 20 patients who received Pethidine hydrochloride 100 mg [0.25%] added to lidocaine hydrochloride 200 mg [0.5%] diluted in 40 ml normal saline and Tramadol group [T]:- Included 20 patients who received tramadol hydrochloride 100 mg [0.25%] added to lidocaine, hydrochloride 200 mg [0.5%] diluted in 40 ml normal saline. The patients were assessed for onset and recovery of sensory and motor block, visual analogue scale [VAS]] for tourniquet and forearm pain, presence or absence of postoperative pain and time to first analgesic requirement. The onset of pinprick and touch loss was significantly shorter in pethidine and tramadol groups in comparison to lidocaine group [p <0.001], while their recovery was longer [p<0, 001 and p<0.05 respectively]. The onset of pinprick and touch loss in pethidine group was significantly shorter in comparison to tramadol group [p <0.05]. The pinprick recovery in pethidine group was significantly shorter than in tramadol group [p <0.05]. The onset of motor block in tramadol and pethidine groups was significantly shorter in comparison to lidocaine group [p <0.01, p <0.05 respectively]. There was no significant difference in the onset of motor block between tramadol and pethidine groups. The motor recovery in all three groups was comparable and the difference was [statistically non significant. For tourniquet pain VAS was significantly less at 10 min. and 20 min in the pethidine group in comparison to the lidocaine group [p<0.01 and p<0.05 respectively]. For foreann pain, VAS was significantly less in tramadol and pethidine at 10 minutes in comparison to lidocaine group [p <0.01, p < 0 001 respectively]. At 20 min there was no pain in all groups postoperative analgesic requirements The mean time to the first analgesic requirement in pethidine and tramadol groups was greater than in lidocaine group [P < 0 001]. The mean time to the first analgesic requirements in tramadol group was greater than in pethidine group [P <0.05]. Recorded side effects the incidence of tachycardia was more significant in pethidine group [40%] in comparison to the other groups. Our results suggest that, both tramadol and pethidine have a local anaesthetic effect on the peripheral nerves. Both of them enhance the speed of onset of sensory and motor block, induce better anesthesia and analgesia for tourniquet and forearm pain, improve postoperative analgesia and reduce postoperative analgesic requirements after tourniquet deflation when added to lidocaine. But tramadol is considered to be safer than pethidine