combined effect of ketamine and remifentanil infusions as total intravenous anesthesia for scoliosis surgery in children

This study was designed to assess the effect of combination of ketamine and remifentanil infusions as total intravenous anesthesia [TIVA] during scoliosis surgery in children. Thirty two children, 8-14 yr of age, scheduled for posterior spinal fusion, were randomly allocated into two equal groups to receive either remifentanil infusion in a dose of 0.2 micro g/kg/minutes or same dose of remifentanil infusion combined with ketamine infusion in a dose of 1 micro g/kg/minutes after induction of general anesthesia. During surgery, hemodynamics, surgical bleeding, and electrophysiology monitors were recorded. After completion of surgery, recovery score, recovery time and rescue analgesia were assessed in post-anesthesia care unit [PACU] for 24 hours. The two groups were similar for age, weight, duration of surgery, and time to extubation. Intraoperative heart rate and arterial blood pressure were significantly decreased in remifentanil group when compared to remifentanil-ketamine group. The surgical bleeding and electrophysiological monitoring were not significantly affected by remifentanil-ketamine combination in second group. Recovery score and recovery time were not significantly increased in remifentanil-ketamine group. First pain scores recordings in arrival to [PACU] were significantly less in remifentanil-ketamine group than remifentanil group and the time passed to first patient controlled analgesia [PCA] demand dose was increased in remifentanil-ketamine group. The first 24 h morphime consumption was 38 +/- 17 and 28 +/- 10 mg [mean +/- SD] in remifentanil and remifentanil-ketamine groups, respectively. These data demonstrate that during posterior spinal fusion surgery in children, the combination of ketamine and remifentanil infusions as TIVAmay provide hemodynamic stability, satisfactory surgical requirements with reliable electrophysiological monitoring and adequate post operative pain relief supplemented by PCA morphine

Early graft function and carboxyhemoglobin level in liver transplanted patients

Heme-Oxygenase-1 catalyzes hemoglobin into bilirubin, iron, and carbon monoxide, a well known vasodilator. Heme-Oxygenase-1 expression and carbon monoxide production as measured by blood carboxyhemoglobin levels, increase in end stage liver disease patients. We hypothesized that there may be a correlation between carboxyhemoglobin level and early graft function in patients undergoing liver transplant surgeries. In a descriptive retrospective study, 39 patients who underwent liver transplantation between the year 2005 and 2006 at KFSH and RC, are included in the study. All patients received general anesthesia with isoflurane in 50% oxygen and air. Levels of oxyhemoglobin, carboxyhemoglobin and methemoglobin concentration in percentage were recorded at preoperative time, anhepatic phase, end of surgery, ICU admission and 24 hr after surgery. The level of lactic acid, prothrombin time [PT], partial thrombin time [PTT], serum total bilirubin and ammonia were also recorded at ICU admission and 24 hr after surgery. The numbers of blood units transfused were recorded. 39 patients were included in the study with 13/39 for living donor liver transplant [LDLT] compared to 26/39 patients scheduled for deceased donor liver transplant [DDLT]. The mean age was 35.9 +/- 16.9 years while the mean body weight was 60.3 +/- 20.9 Kg. Female to male ratio was 21/18. The median packed red blood cell [PRBC] units was 4 [Range 0-40]. There was a significant increase in carboxyhemoglobin level during the anhepatic phase, end of surgery and on ICU admission compared with preoperative value [p < 0.005]. However, there was insignificant changes in methemoglobin level and significant decrease in oxyhemoglobin levels throughout the study period compared to the preoperative value [p < 0.005]. The changes in carboxyhemoglobin level on ICU admission and 24 hrs postoperatively were positively correlated with the changes in serum total bilirubin and prothrombin time [R = 0.35, 0.382, 0.325 and 0.31] respectively p < 0.05] but not with the changes in serum lactic acid. The same strong correlation was found when analysing LDLT and DDLT patients separately between carboxyhemoglobin concentration and PT and total bilirubin while still the correlation with lactic acid was weak. There was no correlation between average perioperative carboxyhemoglobin concentration during different timing of measurements and average units of transfused blood [R = -0.02] p > 0.05. The changes in carboxyhemoglobin level significantly correlate with the changes in graft functions particularly prothrombin time and serum total bilirubin and may be used as an early, rapid and simple test for early evaluation of graft function

Remifentanil by patient controlled analgesia compared with epidural analgesia for pain relief in labour

Epidural analgesia has been established as the gold standard for labour analgesia. However, clinical contraindications and personnel or institutional limitations preclude some parturients from receiving an epidural. Remifentanil has been suggested as an ideal opioid for patient controlled analgesia [PCA] in labour. In our study we compared the use of PCA remifentanil to epidural analgesia in labour as regard pain relief, safety of the mother and the fetus, side effects, and overall parturient's satisfaction. After ethical committee approval and informed written consent 30 healthy pregnant women ASA I or II, with no obstetric complications or contraindication to remifentanil or epidural analgesia were included in the study randomly allocated into one of two equal groups, in [Group EP] epidural infusion of bupivacain 1% plus 2 micro g/ml of fentanyl was given and in [Group R] the women received PCA remifentanil with a bolus of 0.4 micro g kg[-1] over 20 seconds and a lockout period of 1 min as an analgesia for labour. There was significant decrease in [VAS] of pain in both groups with significantly more decrease in [Group EP]. There were no significant difference between both groups as regard arterial blood pressure, heart rate, oxygen saturation, nausea, and overall patient's satisfaction. Sedation scores were significantly higher in [Group R], there were no serious bradycardia, hypotension, or desaturation, and all the parturients were easily arousable. There were no fetal heart rate changes that required interference. The median 1 and 5 minutes Apgar scores were 9 in both groups, and the mean umbilical cord gases, and lactate levels were within normal limits with no difference between both groups. Our study demonstrated that epidural infusion gives superior analgesia for labour than PCA remifentanil, however PCA remifentanil is a good, safe, and could be an alternative method of analgesia for labour

Role of antioxidant compounds during cardiopulmonary bypass

The aim of the present study was to determine the role of antioxidant compounds on haemodynamics during coronary artery bypass grafting using cardiopulmonary bypass. Twenty Two patients of ASA physical status III, who were scheduled to have non-urgent aortocoronary bypass grafting with a preoperative ejection fraction 0.5. Patients were randomly assigned into one of two groups [11 patients each]. Group I: Patients received one gm.h[-1] of N-acetyl cysteine [Mucomyst] infusion after induction of anaesthesia and continuously till the skin closure. One gram of ascorbic acid [Vitamin C] and 400 IU of J-tocopherol [Vitamin E] were administered intravenously over 10-15 minutes at the time of rewarming. Group II: Patients received placebo, equal volumes of normal saline during the same periods. Anesthetic management was the same in all patients and performed by the same surgeon. A 4- lumen, 7 F thermo-dilution pulmonary artery catheter was inserted. Hemodynamic variables: Heart rate [HR], mean arterial pressure [MAP], pulmonary capillary wedge pressure [PCWP] and cardiac output [COP] were measured after induction of anaesthesia and establishment of monitoring [baseline], five minutes after coming off bypass, and at skin closure. The choice and dose of inotrops given was left to the decision of the attending anesthetist. Five minutes after coming off hypass, both MAP and COP decreased significantly in the placebo group in comparison to the treatment group. There was statistically significant decrease in MBP in the placebo group in comparison to antioxidants group, with a mean of 57.1 +/- 3.2 mmHg and 74.7 +/- 4.0 mmHg respectively. Similarly, there was statistically significant decrease in the COP in the placebo group in comparison to antioxidants group, with a mean of 3.77 +/- 0.2 and 4.33 +/- 0.3 respectively. Other variables [HR, PCWP, and SVR] did not significantly differ between both groups. At skin closure the mean HR was the only variable that showed significant change between the two groups. It was significantly higher in placebo group [82.3 +/- 9.2bpm], in comparison to antioxidant group [69.4 +/- 7.6 bpm]. The inotropic requirements were generally increased in the placebo group. Most patients in the antioxidants group [72%] required only low dose dopamine [3 micro.kg[-1.]min[-1]]. On the other hand, in the placebo group, requirements of moderate doses of dopamine [3-10 micro.kg[-1].min[-1]] and dobutamine [3-10 micro.kg[-1].min[-1]] were significantly higher. Similarly, percentage of patients who required combination of dopamine and dobutamine were high in the placebo group in comparison to treatment group. The current study proved that the combination of antioxidant compounds is beneficial to ameliorate haemodynamic changes and decrease the inotropic requirements during cardiopulmonary bypass, and would be very beneficial if used as routine therapy, especially with the high-risk surgical patients

Inhaled furosemide ameliorates wheezes in asthmatic patients during induction of anesthesia

Fifty asymptomatic asthmatic patients of ASA physical status, I and II, with a history of active asthma scheduled for elective surgery were enrolled in the study. Anesthetic management was the same in all patients. Five minutes post-intubation an independent blinded observer assessed wheezing. The presence of wheezing was determined through auscultation during controlled ventilation. A simple "yes" or "no" was obtained, and no grading was done. Patients who wheezed after 5 min were subsequently treated by the random administration of the study medication either albuterol [5 mg in 2-4 ml 0. 9%NaCl, salbutamol sulphate I mg /ml] or furosemide [lasix 40 mg in 2-4 ml 0.9% NaCl]. Wheezes were assessed again. 5 minutes post-medication. Twenly-three out of 50 patients included in the study developed wheezes, 5 minutes after intubation. The incidence of wheezes was 46% and the mean peak inspiratory pressure [PIP] was 26.1 +/- 2.6 cm H2O The patients who wheezed were randomly allocated into one of two groups to receive either albuterol [n =11] or furosemide [n=12]. There was no statistically significant difference in the percentage of patients who responded to albuterol [82%] in comparison to furosemide [75%]. The peak inspiratory pressure [PIP] declined significantly [P= 0.001], 5 minutes after treatment in both groups. Heart rate was significantly higher [P= 0.001], 5 minutes after treatment, in the albuterol group [104.1 +/- 11.25 bpm] in comparison to furosemide group [82.3 +/- 7.53 bpm]. Inhaled furosemide has definitely a role in ameliorating wheezes in asthmatic patients during general anesthesia. It is equally effective to inhaled albuterol however, it unduces no tachyarrythmias. Those who are suffering complications from the adverse effects of beta 2-agonists may benefit from the use of inhaled furosemide