Chronotherapeutics of intrathecal fentanyl added to bupivacaine for labour analgesia

Chronotherapeutics is the optimization of pharmacotherapies, taking into consideration rhythm-dependence in the kinetics and dynamics of medications plus predictable-in-time variability in the manifestations and severity of human disease. The aim of the present work was to determine whether the efficacy and side-effects of intrathecally administered mixture of a small dose of fentanyl and bupivacaine, to relieve labour pain, is influenced by the hour of administration. One hundred parturients requesting neuroaxial labour analgesia were assigned to one of four equal groups based on the time period when the intrathecal mixture was administered. Group E= evening, group N= night, group M= morning and group AN= afternoon. Maternal demographic and obstetric data, and the characteristics of the intrathecal blocks were recorded Demographic data, gestational age and cervical dilatation were similar in the four groups. The incidence of oxytocin use was lower in E and N groups than M and AN groups. The base-line visual analog pain score [VAPS] was higher in E and N groups than in M and AN groups. The onset of analgesia was delayed in E and N groups than M and AN groups [8.6 [3.4], 8.2 [3.1] Vs 6.5 [2.5], 6.6 [2.6], mm respectively]. There were no significant cant differences between groups as regard the upper sensory level, the number of parturients with detectable motor block or side effects. The duration of analgesia was shorter in groups E and N than in groups M and AN [75 [22] and 71 [19] Vs 108 [33] and 102 [31] mm respectively]. Maternal and midwife satisfaction scores were lower in groups E and N than in groups M and AN but no significant difference at 30 mm and at reinjection. Fentanyl and bupivacaine exhibit a temporal pattern of kinetics and dynamics when administered intrathecally for labour analgesia and this should be considered in future comparative studies and in analysis of previous studies and clinically to administer the suitable dose over the 24 hours of the day

High-resolution ultrasound imaging guidance increases efficacy and safety of supraclavicular brachial plexus block

High frequency ultrasound [12 MHZ] imaging equipped with a digital linear scanhead offers excellent resolution of superficial structures during brachial plexus block. Ultrasound can be used to identify the brachial plexus before block, guide the block needle to reach the target nerves, and visualize the pattern of local anesthetic spread. In the present study we compared the state-of-the-art ultrasound technology for supraclavicular brachial plexus block with the classical technique that depended on the anatomical landmarks as regard efficacy, quality and safety. We found that ultrasonic guidance decreased the time to perform the block, shortened the onset of block, prolonged the duration of postoperative analgesia, increased the proportion of successful blocks, increased patient's satisfaction and reduced the incidence of complications than the classical method of supraclavicular blocks. High resolution ultrasound guided supraclavicular block is easier, more effective, of better quality, and safer than the classical block that depends on the anatomical landmarks

safety, benefits and effectiveness of different intravenous subanesthetic doses of ketamine when combined with small dose of midazolam before combined spinal epidural technique for orthopedic lower extremity surgery

In a double blind, randomized, and controlled study of 100 patients [aged 20-60 years], we compared the effect of intravenous [IV] coadministration of different small doses of ketamine [0.00, 0.15, 0.30, and 0.45 mg/kg] with midazolam 0.03 mg/kg in alleviating patient anxiety and pain during establishment of combined spinal epidural [CSE] technique. Patients received midazolam 0.03 mg/kg with placebo [Group C, n= 25] or ketamine 0.15 mg/kg IV [Group K1, n= 25], 0.30 mg/kg IV [Group K2, n= 25] or 0.45 mg/kg IV [Group K3, n= 25], 5 minutes before local analgesic infiltration at the site of SCE and 10 minutes before performing CSE. Scores for sedation, patient's behavior to CSE puncture, and ease of CSE establishment, the mean arterial blood pressure [MBP], heart rate [HR] and arterial oxygen saturation [SpO2] were recorded; the need for ephedrine, atropine and supplemental O2 inhalation was recorded. The incidence of adverse effects especially of unpleasant emergence reactions were recorded. Lastly, the quality of the CSE technique was assessed by the patient and a blind observer. Patients in Group K2 who received midazolam 0.03 mg/kg with ketamine 0.3 mg/kg IV showed ideal scores for sedation, behavior to CSE puncture, and ease of placement of CSE, and best hemodynamic compensation for the inhibitory cardiovascular effects of spinal anesthesia and also for maintenance of normal SpO2. In addition group K2 showed the best quality of anesthesia when assisted by the patient and the blind observer, without significant unpleasant emergence reactions. We conclude that addition of ketamine 0.3 mg/kg to midazolam 0.03 mg was safe, useful, and effective in alleviating patient's anxiety and pain during placement of CSE