Comparison of large antecubital vein versus small vein on dorsum of hand for the prevention of propofol injection pain

Objective: To evaluate the effectiveness of using two different sizes of veins on upper limb for the prevention of propofol intravenous injection pain

Methodology: This prospective randomized clinical trial was conducted at Department of Anesthesia, King Saud University, Riyadh [KSA] from May 1, 2013 - May 31, 2014. A total of 160 patients, ages between 20-50 years, both male and female, American Society of Anesthesiologist [ASA] class I and II, posted for elective surgery under general anesthesia [GA] were included in the study and were divided into two groups. Patients with known history of allergy to lidocaine or propofol, obese patients, anticipated difficult intubation, already on any analgesics and pregnant patients were excluded from the study. Both groups received an admixture of propofol [1%] - lidocaine [2%] on induction of anesthesia through antecubital vein [Group-1] or through a vein on dorsum of hand [Group-2]. Pain was assessed as none, mild, moderate or severe

Results: Moderate to severe pain on intravenous injection of propofol-lidocaine admixture through antecubital vein and small vein on dorsum of hand was 20% vs 71%

Conclusion: There is marked reduction of pain when propofol - lidocaine admixture was injected through antecubital vein as compared to small vein on dorsum of hand

Routine use of Glidescope and Macintosh laryngoscope by trainee anesthetists

Objective: to compare intubating conditions, success rate, and ease of intubation by anesthesia trainees using Glidescope Videolaryngoscope [GVL] compared to Macintosh laryngoscope [MCL]

Study Design: comparative study

Place and Duration of Study: king Khalid University Hospital, Riyadh, Saudi Arabia, from January 2012 to February 2015

Methodology: eighty adult patients ASA I and II with normal airway, scheduled to undergo elective surgery requiring endotracheal [ET] intubation were enrolled. Patients were randomly divided into 2 groups: GVL and MCL. All intubations were performed by trainee residents having experience of more than 1 year and who had successfully performed more than 50 tracheal intubations with each device. Glottic view based on Cormack and Lehane's [C and L's] score and percentage of glottis opening [POGO] score, time to successful intubation, need of external pressure, and overall difficulty scores were compared using either GVL or MCL

Results: view of glottis based on C and L's classification was better [p < 0.001] and POGO score was higher [88.25 +/- 22.06 vs. 57.25 +/- 29.26, p < 0.001] with GVL compared to MCL. Time to intubate in seconds was [32.90 +/- 8.69 vs. 41.33 +/- 15.29, p = 0.004] and overall difficulty score was less 2.78 +/- 1.39 vs. 4.85 +/- 1.75 [p < 0.001] using GVL compared to MCL

Conclusion: residents found ET intubation to be faster and easier with superior glottic view using GVL compared to MCL in patients with normal airway

Comparison of the effect of pre-operative single oral dose of Tramadol and Famotidine on gastric secretions pH and volume in patients scheduled for laparoscopic cholecystectomy

To evaluate and compare the effects of pre-operative single oral dose of tramadol and famotidine on gastric secretions pH and volume in patients electively scheduled for laparoscopic cholecystectomy. Randomized control trial. Department of Anaesthesia, King Saud University Riyadh, Saudi Arabia, from August 2011 to June 2013. Ninety adult, ASA-I and II patients scheduled for laparoscopic cholecystectomy were included in the study. Patients were randomly assigned to receive pre-operatively either placebo [Group-C, n=30], oral tramadol 100 mg [Group-T, n=30] or famotidine 40 mg [Group-F, n=30]. After induction of general anaesthesia, gastric fluid was aspirated through orogastric tube. The gastric secretions volume and pH was measured using pH meter. There was no statistically difference between groups in age, weight and gender. The gastric secretions mean pH was 2.06 +/- 0.22,2.04 +/- 0.20, 5.79 +/- 0.77 and volume was 0.59 +/- 0.17, 0.59 +/- 0.14 and 0.28 +/- 0.16 ml/kg in Group-C, Group-T and Group-F respectively. There was a significant statistical difference in the mean pH values between Group-C vs. Group-F [p < 0.001] and Group-Tvs. Group-F [p < 0.001]. Statistically significant difference was also found in the mean gastric secretions volume between Group - C vs. Group-F [p < 0.001] and Group-Tvs. Group-F [p < 0.001]. There was no significant difference in the mean gastric fluid pH values [p=0.99] and mean gastric secretions volume [p=0.99] between Group-Tand Group-C. As compared to famotidine, pre-operative single oral dose of tramadol was unable to elevate the desired level of gastric fluid pH [> 2.5] and decrease in gastric secretions volume [< 0.4ml/kg]

Novel management of methylene blue extravasation: a case report and review of literature

Methylene blue is a highly irritant drug and has been used intraoperatively. Its accidental extravasation can lead to tissue necrosis. In this report, a unique management is described, and the patient recovered without any morbidity

Preload Versus Coload and Vasopressor requirement for the prevention of spinal anesthesia induced hypotension in non-obstetric patients

Objective: To compare the effectiveness of preload and coload for the prevention of Spinal Induced Hypotension [SIH] and vasopressor requirements

Study Design: Randomized trial

Place and Duration of Study: Department of Anesthesia, The Aga Khan University Hospital, Karachi, Pakistan, from June 2007 - June 2010

Methodology: Sixty patients were randomly divided into preload and coload group of 30 each. Patients with ASA 1 - 3, aged 20 - 60 years were included. Patients with history of IHD, COPD, BMI > 30 and surgical procedure TURP were excluded. All patients received crystalloid 10 ml/kg before induction of spinal anesthesia in preload group and at the time of spinal anesthesia in coload group. Blood pressure and heart rate were recorded at different time intervals till 45 minutes. Patients received ephedrine 5 mg when systolic blood pressure dropped below 90 mmHg and heart rate was less than 60 beats/minute and/or phenylephrine 50 micrograms when systolic blood pressure dropped below 90 mmHg and heart rate was more than 60 beats/minute

Results: There was no statistically significant difference at different time intervals in heart rate, systolic and mean arterial pressure between the groups. Diastolic blood pressure was significantly different in both groups at 6 - 15 minutes after spinal anesthesia. SIH occurred [21] 70% and [15] 50% in preload and coload groups, respectively [p=0.187]. Ephedrine requirement for SIH was significantly high in preload group [p=0.017]. Phenylephrine requirement for SIH was high in preload group which was statistically non-significant [p=0.285]

Conclusion: Coload group has lower incidence of spinal induced hypotension and significantly less vasopressor requirement than the preload group

Flying blind in anesthesia: a safety concern

We describe two cases of sudden loss of display of all the monitors of Zeus anesthesia work station during operation, which is a major safety concern. Flying blind in anesthesia could be devastating. These cases attempt to highlight the need for greater vigilance by anesthesiologists and have implications for improvement in technology

Ruptured ectopic pregnancy with APLA syndrome - a case report

All means to reduce blood loss in liver resection and to decrease blood loss and a need of blood transfusion would be of benefit to the patient as well as the surgeon. We report two cases in which different strategies were applied in order to achieve the low central venous pressure. We also compared in these cases surgical time, blood loss and blood transfusion requirements during liver resection

Strategies to lower the central venous pressure during liver resections

All means to reduce blood loss in liver resection and to decrease blood loss and a need of blood transfusion would be of benefit to the patient as well as the surgeon. We report two cases in which different strategies were applied in order to achieve the low central venous pressure. We also compared in these cases surgical time, blood loss and blood transfusion requirements during liver resection

study of stress response to endotracheal intubation ;comparing glidescope and flexible fiberoptic bronchoscope

Objective: To compare hemodynamic stress response [HDSR] to ET intubation using Glidescope [GLS] and Flexible fiberoptic laryngoscope [FFB]

Methods: This prospective randomized comparative study was conducted at King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia from June 2011 - November 2013. Eighty ASA 1 and 2 patients with normal airway undergoing elective surgical procedure requiring ET intubation were included in the study. Patients were randomly assigned in two groups GLS or FFB. General anesthesia was induced with propofol and fentanyl. Muscle relaxation was achieved with cisatracurium and ET intubation was performed using either GLS or FFB. Noninvasive hemodynamic data was recorded [HR, systolic, diastolic and mean blood pressure] as pre-induction, baseline and after ET intubation at one minute intervals for successive five minutes. End tidal Sevoflurane and C02 at the time of intubation, need of external neck pressure, time to successful intubation and number of attempts were recorded; and rate pressure product was calculated

Results: Induction of anesthesia resulted in significant fall in blood pressure in both the groups. ET intubation resulted in similar rise of BP in both groups [for 3-4 minutes] from their baseline values; however the rise was not significantly different from their respective pre-induction values. Time to intubation was longer with FFB compared to GLS however, need for external neck manipulation was more with GLS

Conclusion: There was no difference in HDSR due to ET intubation using either GLS or FFB in healthy adult patients with normal airway. Rate pressure product remained within the acceptable range

simple solution to unexpected kinking of endotracheal tube

We report a case of unexpected kinking of endotracheal [ET] tube in an infant who was being operated in supine position and positioned away from the anesthetist. The usual management mentioned in the literature was unsuccessful. So, a simple and unique solution that can be useful in unanticipated kinking of ET tube is described

Comparison of the impact of powerpoint and chalkboard in undergraduate medical teaching: an evidence based study

To compare the impact of the PowerPoint multimedia presentation and chalkboard in teaching by assessing the knowledge based on the marks obtained. Cross-sectional study. Department of Physiology, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia, from December 2007 - June 2009. Three-hundred male medical students were divided into three groups and a selected content-based lecture in physiology was delivered. For one group lecture was delivered using PowerPoint presentation, for second group using chalkboard and for third group the lecture was delivered by using both PowerPoint as well as chalkboard. Single-best Multiple Choice Questions [MCQs] paper was used for assessing the knowledge gained. The same exercise was repeated in another medical science school for the confirmation of validity and reliability of the results. Students who attended the class on both PowerPoint and chalkboard obtained significantly higher score in single best MCQ examination compared to those students who attended the same content based lecture on the PowerPoint or chalkboard alone [p = 0.05]. The integrated [PowerPoint and chalkboard] method of teaching was found more suitable tool of teaching and learning than PowerPoint or chalkboard alone

Hemodynamic stress response to reinforced endotracheal tube placement using Upsher scope and Macintosh laryngoscope: a comparative study

Endotracheal intubation leads to hemodynamic stress response that can be deleterious. The purpose of this study was to compare the intubation response to reinforced [R] endotracheal tube [ETT] placement using Upsher scope and Mcintosh laryngoscope. Eighty ASA I patients scheduled to undergo surgery under GA, requiring use of R ETT were enrolled. Time to successful intubation, need for external neck manipulation; and end tidal concentration of sevoflurane and carbon dioxide at the time of intubation were recorded. Heart rate, systolic and diastolic BP were recorded as baseline, after induction of anesthesia and at one minute interval for five minutes after intubation. Time to intubation was significantly longer in Upsher scope group [64 v.s 23 seconds] compared to Mcintosh group [P < 0.05]. There was significantly more rise in heart rate, systolic and diastolic BP after intubation in Upsher scope group compared with Mcintosh group [P < 0.05] and the rise persisted for 4, 3 and 4 minutes in respective parameters. Significantly more number of patients in Upsher scope group required external neck manipulation in an attempt to align the tip of the ETT and the glottis. Time required for successful ET intubation of R ETT using Upsher scope and the need for external neck manipulation was more compared with Mcintosh laryngoscope; and it resulted in significant increase in BP and HR in patients with normal airway and without any comorbidity

Acute respiratory failure after endoscopic third ventriculostomy: a case report and review of the literature

Endoscopic third ventriculostomy [ETV] is a relatively safe procedure. However, postoperative acute respiratory failure may be fatal. The authors report an 8-month-old patient with obstructive hydrocephalus secondary to posterior fossa cyst, and Chiari malformation. After ETV he developed difficulty in breathing, and had to be reintubated and ventilated. The infant recovered fully after craniocervical decompression and insertion of cystoperitoneal shunt. We speculate that respiratory failure is related to relative expansion of the posterior fossa arachnoid cyst, causing significant compression on the brain stem. Supportive care with mechanical ventilation and brain stem decompression were the mainstay of treatment

Is preemptive analgesic effect of ketamine dose dependent? Effect of increasing dose on post septorhinoplasty pain

To find out the effect of increasing the dose of preemptive ketamine on ketoprofen requirement in first 24 hours after surgery. 120 patients, scheduled for elective septorhinoplasty were randomly divided in to four groups. At the time of induction of general anesthesia one test drug was given. Group 1 received placebo, group 2, 3 and 4 received I.V ketamine, 0.5 mg kg[-1], 1.0 mg kg[-1] and 1.5 mg kg[-1] respectively. The total postoperative consumption of ketoprofen and pethidine as rescue analgesia in 24 hours was recorded. The incidence of common side effects was recorded. There was no difference in ketoprofen requirement between group 1 and 2[P=0.108].Patients in group 1 and 2 required more ketoprofen than patients in group 3 and 4 [P=0.00]. Group 4 patients required significantly less ketoprofen compared to group 3 patients [P=0.01]. Time to first request analgesia was longer in the groups 2, 3 and 4 compared to group 1 [P=0.00]. Time to discharge from PACU was found to be longer in patients where ketamine was used [P=0.018]. No patient in any group required pethidine as rescue analgesia. There was no significant difference in the common side effects among the groups. Ketamine in the doses of 0.5 mg kg[-1] failed to produce reduction in ketoprofen requirement. However, the dose of 1.0 mg kg[-1] and 1.5 mg kg[-1] resulted in reduction in post operative ketoprofen requirement and prolonged the time to first request analgesia without any increase in side effects

Safety concerns start well before anesthesia machine

We report a case of sudden onset of an unfamiliar, continuous sound in the operating room during an elective surgical procedure, which was found to be due to leakage of nitrous oxide from a hole in the ballooned up part of the flexible hose pipeline of the anesthesia machine. A slowly leaking hose pipe may be hazardous to the safety of patients as well as staff; a sudden burst of a hose pipe can result in confusion among the busy staff. A need to have guidelines regarding routine checking of hose pipes and printing date of expiry indicating life span of these pipes is stressed

Dental braces bracing a throat pack to cause difficulty in its removal

We present an unusual case of dental braces entangled into a throat pack, thus making it impossible to remove it from the mouth cavity of a patient. The patient, who was emerging from anesthesia, had to be reanesthetised, to enable removal of the pack

Effect of two different doses of fentanyl on intubating conditions with sevoflurane inhalation without neuromuscular blocking agents in adults

To compare the effect of two different doses of fentanyl on intubating conditions, after inhalational induction with sevoflurane in adults, without using neuromuscular blocking agents. In this prospective, randomized, double blind study, fifty six adult patients with ASA status I-II, without any airway problem and scheduled to undergo elective surgical procedures under general anesthesia requiring endotracheal intubation were selected. Patients with allergy to any of the drugs used, body mass index > 30 kg/m2 and anticipated difficult airway were excluded from the study. Patients were premedicated with midazolam 0.1mg/kg and ranitidine 150 mg PO two hours prior to surgery and received 0.2 mg of glycopyrrolate intravenously just before the start of inhalational induction. The patients were randomly divided into two groups. Group-I patients received fentanyl 2 micro g/kg and those in Group-Il received 3 micro g/kg intravenously one minute after the start of inhalational induction with 8% sevoflurane in 50% nitrous oxide and oxygen. After 4 minutes of start of inhalational induction, conditions for tracheal intubation were assessed based upon a set of criteria. Tracheal intubation was successful in all patients. Mean time to loss of consciousness was 47 sec in Group-I and 46 sec in Group-Il. Optimal intubating conditions were higher in the Group-II [89% vs. 54% P <0.01].The incidence of post-intubation coughing was lower in the Group-II as compared to Group-I [11% vs.39%] with P <0.02. We conclude that both doses of fentanyl along with inhalational induction with sevoflurane nitrous oxide mixture provided adequate conditions for tracheal intubation without using neuromuscular blocking agents. However, increasing the dose to fentanyl to 3 micro g/kg further improved the intubating conditions. Tracheal intubation using sevoflurane and fentanyl may be an alternative to traditional tracheal intubation with neuromuscular blocking agents

Comparative study of tramadol and propacetamol for postoperative pain management in patients undergoing nasal surgeries

To compare the analgesic and side effects of propacetamol and tramadol after nasal surgeries. King Abdul Aziz University Hospital, Riyadh [KSA]. From January 2006 to February 2007. A total number of 40 surgical patients were prospectively randomized into two equal groups of 20 and were entered into single blinded clinical trial. Anaethesta. protocol was similar for all patients. Pain intensity was measured based on a 4-point verbal rating scale [VRS]. VRS was obtained before analgesic administration [T0] and at 0.5, 1.5, 3, 4.5, 6, 12, 18 and 24 hours, Patients received either tramadol 100 mg I/V or propacetamol 2 gm I/V at T0 and then 50 mg tramadol or 1.5 gm propacetamol at 6, 12, 18 and 24 hours if pain was present. The results of this study showed that propacetamol is less effective as analgesic in severe pain requiring more supplementary morphine as compared to tramadol. On the other hand tramadol is associated with higher incidence of nausea and or vomiting than with parcetamol. It was concluded from the study that propacetamol is less effective as analgesic in severe pain receiving more supplementary morphine as compared to tramadol

Is it a diabetic hand?

This is a prospective study conducted in the department of surgery from 1-04-1999 to 31-012002 at BVH Bahawalpur. All the diabetic patients of both types [IDDM or NIDDM] of any age or sex, suffering from infection of hand or Foot were included in the study. A total of 36 diabetic patients had hand infection [Group A] as compared to 207 patients with Diabetic Foot [Group B]. Average age of the patients in Group A was 39.6 years which was quite younger as compare to 57.5 years in Group B. Pain was the dominant presenting complaint [100%] in Group A patients. All these patients were manual workers [Tailors, Carpenters, Farmers, Blacksmiths, Embroidery workers or Housewives] and had minor trauma to their digits during work; which they had neglected for few days or received first aid treatment from a family member or quack. In Hand Group, no patient was in Grade 0, I, or III. During the course of treatment, all the patients [100%] of Hand Group required amputation of one or more digits of the dominant hand including amputation of the thumb in 22 patients. No patient required amputation of the whole hand or forearm. The involvement of thumb or index finger alone or along with other digits in almost all the patients of Hand Group, reflects their common use, in manual work and their more susceptibility to repeated minor trauma. The loss of thumbs in 22 patients reflected high morbidity in terms of loss of hand function though thumb reconstruction is a valid option. Morbidity in terms of hospital stay was quite less in Hand Group but it was 100% in terms of loss of crafted digits. Mortality in Hand Group patients was nil in contrast to 9[4.3%] in the Foot Group. Infection of the hand in Diabetics can be named as DIABETIC HAND without any ambiguity. This can lead to opening up of new era of research for better management of this entity in terms of DIABETIC HAND CLINICS. Surgical management of infection in diabetics should be early, aggressive and specialized to avoid poor outcome in the form of loss of vital craft hand