hemodynamic effects and complications of tracheal intubation with intubating laryngeal mask airway: a comparison with direct laryngoscopy

The intubating laryngeal mask airway [ILMA] is designed to facilitate blind tracheal intubation. Direct laryngoscopy, to facilitate tracheal intubation, produces a marked pressor response. This randomized, controlled study -was undertaken to compare the complications of insertion and hemodynamic effects following tracheal intubation through intubating laryngeal mask airway [ILMA] with that of conventional Macintosh laryngoscope. One hundred adult patients undergoing elective surgery were randomly allocated into two equal-sized groups. All patients received general anesthesia using a standard balanced anesthesia technique. Tracheal intubation was performed using either intubating laryngeal mask airway or Macintosh laryngoscope. The intubation time, number of attempts required for successful intubation, the problems encountered during intubation, hemodynamic changes and postoperative pharyngolaryngeal complications were recorded. Time to intubation was comparatively longer in ILM.4 group than laryngoscopy group [58.6 +/- 8.2 sec. versus 29.2 +/- 5.6 sec. p <0.001]. The overall intubation success rate was comparable among the two study groups. The changes-in mean blood pressure were significantly less in ILMA group as compared to laryngoscope group [p <0.05]. The incidence of postoperative sore throat and hoarseness of voice was comparable among groups. Our results suggest that ILMA offers advantage over laryngoscope in minimizing the hemodynamic effects to intubation. Therefore, it can be used as a suitable alternative to laryngoscopy for tracheal intubation

Do antibiotic-coated central venous catheters reduce catheter-related bloodstream infection in intensive care patients?

Central venous catheters [CVCs] are a major cause of nosocomial bloodstream infections, which are difficult to control Catheters bonded with either antiseptics or antibiotics that constantly and slowly release antimicrobial substances are assumed to be beneficial in reducing rates of colonization and catheter-related infections. This prospective, randomized clinical trial was designed to evaluate the efficacy of catheters coated with either chlorhexidine and silver sulfadiazine [CHSS], or minocycline and rifampin [M/R] in reducing catheter-related colonization and bloodstream infections [CR-BSIs] in intensive care patients. 90 adult inpatients with CVCs, for 3 days or more, were conducted in this clinical trial [classified into three equal groups]. According to the type of the catheter, the patients were assigned to undergo insertion of triple lumen polyurethane CVCs either in standard version [unimpregnated] [Group I], or impregnated with either CHSS [on the extraluminal surface only] [Group II], or M/R [on the extraluminal and intraluminal surfaces] [Group III]. Microbiological evaluation was done for the insertion site before catheterization and at removal of the catheter, CVCs [tips and subcutaneous parts] and peripheral blood after removal of the catheter if accompanied by clinical signs of infection. 114 patients were assigned to undergo CVC insertion but dropouts with missing evaluation totalled 24 cases leaving 90 catheters with complete data and final microbiological evaluation. Clinical characteristics as well as clinical diagnoses of patients enrolled were similar in all study groups. Regarding colonization of the insertion site before catheterization, there were no significant differences between the three groups. Impregnated catheters showed a highly significant reduction in colonization of insertion site at removal of the catheter when compared to unimpregnated ones [P <0.001]. Impregnated catheters [groups II and III] were dramatically less likely to be colonized as unimpregnated version [group I] [4/30 [13.3%]; 2/30 [6.6%] vs. 10/30 [33.3%]]; respectively [P < 0.001]. Only one case of CR-BSIs [3.3%] was detected among catheters impregnated with CHSS vs. 4 cases [13.3%] among the unimpregnated ones. No cases of CR-BSIs [0%] were detected in the group of M/R-impregnated catheters. The use of CVCs coated with either M/R or CHSS is associated with a reduction in the rate of catheter colonization and catheter-related bloodstream infection compared to standard [uncoated] catheters in intensive care patients. In addition, the anti-infective efficacy of catheters impregnated with M/R was higher than that of catheters impregnated with CHSS

Axillary brachial plexus block with clonidine or verapamil

The ability of a[2]-agonists to enhance central and peripheral neural blockade. when added to local anesthetic, has been demonstrated for more than a decade. Calciumions also have an important role in the analgesia mediated by local anesthetics, and clinical investigation have shown that verapamil can potentiate the analgesic effect of local anesthetics. Seventy five unpremedicated patients ASA physical status I or II undergoing upper extremity surgery received axaillary brachial plexus block with 40 ml lidocaine 1.5% solution. Patients were randomized to 3 groups. Group I [control group] received only 40 ml of 1.5% lidocaine solution. Group 2 [clonidine group] received 40 ml 1.5% lidocaine solution to which 150 ug clonidine was added. Group 3 [verapamil group]: received 40 ml 1.5% lidocaine solution to which 2.5 mg verapamil was added. Onset of sensory block, duration of anesthesia and analgesia were recorded. Postoperatively patients rated their pain on integer verbal pain score [0-10] at 1, 3, 6, 12 and 24 hour. Postoperatively patients were instructed to take paracetamole [500 mg increments every 6 h up to 4 gm / day] when pain score exceeded 3. The onset of sensory block was similar among the three groups. Duration of sensory anesthesia was significantly increased P<0.01 in group [3] compared to group [1]. The duration of analgesia significantly increased in group [2] P<0.01 compared to group 1 and 3. We conclude that addition of clonidine to lidocaine during axillary brachial plexus block prolong the duration of analgesia. While addition of verapamil to lidocaine during axillary brachial plexus block significantly increase the duration of anesthesia

Effect of remifentanil compared with fentanyl on the haemondynamic response to orotracheal intubation

Laryngoscopy and tracheal intubation can cause tachycardia, hypertension, arrhythmias, increased plasma catecholamine concentration and myocardial ischemia in susceptible individuals. To compare the relative efficacy of remifentanil with that of fentanyl in modifying the haemodynamic response to orotracheal intubation. 60 patients ASA physical status I or II were enrolled in the study. Patients were allocated to one of three groups in randomized double - blind manner each consists of 20 patients. Group [1] received glycopyrolate 200 ug IV followed by a bolus dose of remifentanil 0.5 ug kg[-1] over 30 s immediately before induction of anesthesia followed by infusion of remifentanil 0.25 ug kg[-1] min[-1]. Group [2] received glycopyrolate 200 ug IV followed by a bolus dose of fentanyl 2 ug kg[-1] over 30 s followed by infusion of saline. Group [3] received 200 ug glycopyrolate IV followed by a bolus dose of saline over 30 s then infusion, of saline [control group]. SAP decreased with induction of anesthesia and did not increase after intubation in group 1, while it increased significantly after intubation in group 3. DAP decreased after induction and was significantly lower after intubation in group 1. Also the heart rate increased significantly after intubation in group 2 and 3 compared to group 1. we conclude that remifentanil 0.5 ug kg[-1] bolus dose over 30 s before induction of anesthesia followed by infusion of 0.25 ug kg[-1] min[-1] was more effective than a bolus dose of fentanyl 2 up kg[-1] in controlling the haemodynamic response to orotracheal intubation

Potentiation of post operative morphine analgesia by Ketamine or magnesium sulphate

We designed this study to compare the analgesic and haemodynamic effects of ketamine and magnesium sulphate given intravenously before intravenous morphine. [60] female patients undergoing open cholecystectomy were randomized into 4 groups [n=15], group I [control] patients received 20 ml saline 3 min before induction and 10 ml every 6 hsfor 24 hs postoperatively [p.oj, group II patients received 25 mg/kg magnesium sulphate in 20 ml saline 3 min before induction and 1 gm in 10 ml saline every 6 hs for 24 p.o, group III received 50 mg /kg magnesium sulphate in 20ml saline 3 min. before induction and 1 gm in 10 ml saline every 6 hsfor 24 hs p.o, group IV received 25 mg ketamine in 20 ml saline 3 min before induction and 25 mg in 10 ml saline every 6 hsfor 24 hs p.o. After surgery patients stayed in the recovery room for 24 hs. Morphine requirements, 24 h p.o, which keep visual analogue scale [VAS] at 30 or less were calculated, also, need for nasal oxygen to maintain capillary oxygen saturation above 95% was recorded, heart rate and mean blood -pressure were monitored continuously and recorded every 3 hsfor 24 hs ip.o. Pain at rest, peak flow rate and discomfort were evaluated after 6, 12, 18 and 24 hs p.o. Quality of sleep was evaluated in the morning after the first p.o night. In magnesium sulphate groups [II and III] we found that the morphine requirement during the p.o period was significantly less [22.2 mg +/- 2.6, 20.3 +/- 3.2, 16.8 +/- 2.1 for the control. 25 mg magnesium, 50 mg magnesium group succisively] but 50 mg/kg magnesium 'sulphate was better as it improved quality of sleep and discomfort but this dose was associated with a significant decrease in mean blood pressure. In the ketamine group analgesic requirement of intravenous morphine reduced from 22.2 mg +/- 1.6 to 15.6 mg +/- 1.6 through 24 hs p.o, also quality of sleep and discomfort were improved with ketamine. When magnesium sulphate is compared with ketamine, we found that ketamine was better because it improved discomfort, sleep qualtiy and reduced dose of morphine more than magnesium sulphate 25 mg /kg. When dose of magnesium sulphate was increased to 50 mg/kg this difference became insignificant but decrease in blood pressure became apparent

Effect of sufentanil on epidural ropivacaine for labour analgesia

Epidural analgesia for labour has been accepted in most obstetric centers because of its effectiveness and safety. Minimizing the degree of motor blockade, decreases the incidence of instrumental deliveries without decreasing analgesic quality and can be achieved by adding an opioid to the local anesthetic. 60 primigravid parturients ASA physical status I in stablished labour were class [fled into 4 groups, in group I we used ropivacaine 0.2%, in group II ropivacaine [0.1%, in group III ropivacaine 0.1% plus sufentanil 10 ug and in group IV ropivacaine 01% plus- 20 ug sufentanil The severity of pain was measured using visual analogue scale 'VAS" also sensory level and degree of motor blockade, onset and duration of analgesia, satisfaction of analgesia, duration of 2[nd] stage, instrumental deliveries, incidence of cesarean section, as well as side effects were also assessed. Visual analogue scale [VAS] shows significant decrease in groups [I and IV] compared to groups [II and III] also VAS in group III significantly decrease when compared to group II. Duration of analgesia was prolonged in group IV compared to other groups- Motor power affection was significant in group I compared to other groups- Satisfaction of analgesia significantly increased in group IV. It can be concluded that addition of sufentanil to ropivacain for epidurat analgesia during labour improves quality of analgesia and gives more satisfaction with prolonged duration and less affection of motor power