Comparison of the effect of caudal ropivacaine, ropivacaine-clonidine and ropivacaine-magnesium on postoperative analgesia and stress response in children

Caudal analgesia is widely used for various surgical procedures in children. In order to decrease intra and postoperative analgesic requirements after caudal blockade, various additives can be added with local anesthetics. The aim of this study was to compare the efficacy of pre-emptive caudal blockade using ropivacaine 0.25% alone or combined with clonidine, or magnesium sulfate-on stress response and postoperative pain relief in children. We performed a prospective, randomized study on 60 children, aged 4-10 years, undergoing hypospadius surgery. Patients were randomly assigned into three groups to receive either caudal ropivacaine alone [group R], caudal ropivacaine + clonidine [group RC] or caudal ropivacaine + magnesium sulfate [group RM] prior to a standardized sevoflurane anesthetic. Postoperative pain and analgesic requirements, postoperative sedation, catecholamines plasma levels, as well as hemodynamic parameters were compared among the three groups. Group RC had significantly lower objective pain scale [OPS] scores than group R and group RM in the first six postoperative hours. Fewer patients in group RC required postoperative analgesics than in groups R and RM. The time to 1[st] analgesic dose and number of analgesic doses in each group were significantly less in group RC than in groups R and RM. The sedation score was significantly higher only during the first 2 postoperative hours in group RC than groups R and RM. There was a significant decrease in the mean values of plasma epinephrine [E] and norepinephrine [NE] at the end of surgery and 1 hour after recovery compared to pre-block values in all groups. The addition of clonidine to ropivacaine 0.25% significantly increases the duration of caudal analgesia and decreases postoperative analgesic requirements in children. The addition of magnesium to ropivacaine is comparable to the effect of ropivacaine alone. Caudal analgesia resulted in a significant reduction in catecholamine levels

Validity of fetal pulse oximetry in predicting fetal outcome in patients with non-assuring external fetal heart rate monitoring

To assess the sensitivity and predicitive values of fetal pulse oximetry in predicting fetal outcome in patients with non-assuring CTG. Women with singleton fetus and non-assuring fetal heart rate pattern during active phase of the first stage of labor were randomised into two groups; case and control. All fetuses had umbilical artery sampling when the baby was born. Fetuses in study group were additionally evaluated using fetal pulse oximetry. The study showed statistically significant correlation between the fetal pulse oximetry measurements and the umbilical artery pH, PO2, PCO2 and Apgar scores. The sensitivity of fetal pulse oximetry in this study was 77.3%. Its specificity was 95%. Positive predictive value was 89.5% and the negative predictive value was 88.4%. Fetal pulse oximetry is a successful intrapartum monitoring tool to be applied in fetuses with non-assuring fetal heart rate patterns. FPO may help obstetricians in the process of decision making and the use of FPO may help avoid unnecessary cesarean sections performed due to abnormal FHR tracing

Ringer acetate versus ringer lactate cardioplegia: a comparative study in mitral valve surgery

Background: ringer lactate has long been used in many surgical procedures as one of the isotonic solutions. However, with the development of Ringer acetate, it becomes the crystalloidof cholce owing to its main metabolism in muscles unlike lactate which is mainly in liver, also it corrects acidosis more rapidly than lactate and it needs less O[2] and produces less CO[2]. Ringer acetate has also a great utility during cardiovascular surgery with cardiopulmonary bypass. We compared efficacy and safety of Ringer acetate versus lactate in preparing cardioplegic solution during mitral valve surgery

Methods: 42 adult patients undergoing mitral valve replacement using CPB were randomly divided into two groups. Patients in group A received antegrade cold Ringer Acetate cardioplegic solution at a rate of l0ml/kg followed after 20 minutes by 5ml/kg retrogradely in the coronary sinus. Patients in group B received cold Ringer Lactate cardioplegic solution in a similar regimen to group A

Results: troponin I level from coronary sinus during reperfusion, was higher in group B than A [4.4+/-l.6ng/ml and 3.4+/-1.49ng/ml respectively] and after 4 and 24 hours postoperatively there was a significant increase in the serum Troponin I level in group B than In group A [p<0.05]. Lactate in the coronary sinus was higher in group B than A during rewarming [2.8+/-1.9ng/ml and 1.6+/-1.8ng/ml respectively]. The serum level was always higher in group B than A in the postoperative period [p<0.05]. There was no significant difference between both groups as regards the post-bypass ischemic changes as detected by TEE examination. Also, there were no differences in the duration of inotropic support, ventilation time, intensive care unit or hospital stay in the two groups

Conclusion: both Ringer Acetate and Lactate cardioplegia provide adequate myocardial protection, however the recovery of the heart from ischemia after the Ringer Acetate cardioplegia is better than Ringer Lactate

Natural history of hepatitis C virus among apparently normal schoolchildren: follow up after 7 years

In November 1994, we started a community-based study upon 294 rural, randomly selected school children, aged 6-75 years. Anti-Hepatitis C virus antibodies [HCV-Ab] were tested for all children with Enzyme Linked immunosorbent Assay [version III] and positive cases were confirmed by Polymerase Chain Reaction [PCR]. Liver function tests, Hepatitis B surface antigen [HBsAg], Hepatitis B core antibodies [HbcAb], urine, stool analysis for parasite ova as well as abdominal ultrasonography were done. The overall prevalence of anti-HCV Ab, HBsAg, HBcAb, Schistosoma [S] mansoni infection and periportal thickening detected by ultrasonography was 5.8%, 1%, 3.7%, 45% and 58% respectively. Active S. mansoni infection and its intensity were the risk factors significantly correlated to anti-HCV seropositivity [P<0.04, Odd's ratio [OR] 3, 95% confidence interval [CI] 0.95-10.1. The PCR confirmed viremia in 41% of anti-HCV seropositive cases which was significantly correlated with elder children, [P=0.03, 95% CI 0.3-5.8], past history of schistosomiasis [SCH] P<0.05, OR 12, S. mansoni infection [P0.03] and raised aspartate aminotransferase level [AST] [P< 0.001]. No significant past history of the mode of acquisition of HCV infection was detected among our cases. We followed up our apparently normal schoolchildren for 7 years, positive [15 cases] and negative [8 cases] for anti-HCV antibody. The above laboratory investigations were repeated in November 2001 [the seventh year of follow up]. All of them still had no risk factor for HCV infection nor abnormal findings by clinical examination and abdominal sonar. Cases and controls were negative for HbsAg. One case out of six became PCR negative comprising 17% spontaneous clearance of viremia. Six cases out of nine [67%] of PCR negative, anti-HCV positive cases lost their antibody positivity after 7 years

Conclusion: intestinal SCH may be a risk factor for the development of viremia and to the rise of AST level in HCV infection. The persistently high prevalence of SCH infection in our community was confirmed. It could be suggested that the natural history of community acquired hepatitis C virus in asymptomatic children may be more benign than previously thought