uses of melatonin in anesthesia and surgery

Melatonin is a hormone secreted by the pineal gland. It is available as a dietary supplement, taken primarily for the relief of insomnia. Increasing evidence from human and animal studies suggests that melatonin may be efficacious as a preoperative anxiolytic, a postoperative analgesic, and a preventative for postoperative delirium. It has also been reported to decrease intraocular pressure. Melatonin's high efficacy, wide safety profile in terms of dose, and virtual lack of toxicity make it of interest in anesthetic and surgical practice. This review examines clinical trial data describing the efficacy and safety of melatonin in the perioperative anesthetic and surgical settings. We shall, also, focus attention on animal and human experimental studies that concern these issues

Tramadol as an adjuvant to intravenous regional anesthesia with lignocaine

To assess the effect of different doses of tramadol when added to lignocaine during intravenous regional anesthesia [IVRA]. Sixty patients, scheduled for hand surgery under IVRA in King Fahd University Hospital, Al-Khobar, Saudi Arabia from January 2006 to January 2007 were randomly allocated into 3 groups [20 patients each] in a double blind controlled study. All patients received 0.5% lignocaine, 40ml plus 2ml of a study solution containing either isotonic saline control group, or tramadol 50mg [group T50] or tramadol 100 mg [group T100]. Hemodynamic changes, sensory and motor block onset and recovery times, tourniquet tolerance time, the quality of intraoperative anesthesia and the duration of postoperative analgesia were assessed. All patients, 20 in each group completed the study period. Patients who received tramadol had earlier onset of sensory block [5.2 +/= 1.2; 4.9 +/= 1.2 min in the T50; and T100 groups] compared with the control group [7.6 +/= 1.4 min]. Patients who received 100mg of tramadol had better tolerance of tourniquet [p=0.011], and less intraoperative fentanyl supplementation [p=0.042]. They had also a longer time to the first postoperative analgesic request [p=0.001] compared with the control group. Tramadol 100 mg is a beneficial additive to lignocaine for IVRA since it shortened the onset of sensory block, enhanced the tourniquet tolerance and improved the perioperative analgesia

effect of etoricoxib premedication on postoperative analgesia requirement in orthopedic and trauma patients

We hypothesized that etoricoxib premedication would reduce the need for additional opioids following orthopedic trauma surgery. A double blind, controlled study, conducted in King Fahd University Hospital, King Faisal University, Dammam, Kingdom of Saudi Arabia. After obtaining the approval of the Research and Ethics Committee and written consent, 200 American Society of Anesthesiology grade I and II patients that underwent elective upper limb or lower limb fracture fixation surgeries during the period from August 2005 to October 2007 were studied. Patients were randomly premedicated using 120 mg of etoricoxib or placebo n=100, each. To alleviate postoperative pain, a patient controlled analgesia device was programmed to deliver one mg of morphine intravenously lockout time, 6 minutes. Visual analog scale and total postoperative morphine consumption over 24 hours and the adverse effects were recorded. One hundred patients in each group completed the study period. Etoricoxib premedication provides a statistically significant postoperative morphine sparing effect over 24 hours postoperatively. Total morphine consumption was 44.2 [8.2] in the placebo and 35.17.0mg in the etoricoxib groups p<0.001. The incidence of nausea and vomiting requiring treatment was lower in the etoricoxib group, p=0.014. The postoperative blood loss was similar in both groups. Etoricoxib is a suitable premedication before traumatic orthopedic surgery as it enhanced postoperative analgesia and reduced the need for morphine

Intrathecal sufentanil added to small-dose hyperbaric bupivacaine for transurethral resection of the prostate

The hypothesis of this study was that the addition Intrathecal sufentanil 5 micro g to 6 mg of hyperbaric bupivacaine could give reliable spinal block and prolong postoperative analgesia with minimal hypotension in elderly patients undergoing transurethral resection of prostate [TURP] surgery. Forty patients were randomly assigned into two groups [20 patients each]. In the control group, the patients received intrathecal 11 mg hyperbaric bupivacaine, while in the sufentanil group; they received intrathecal 6 mg hyperbaric bupivacaine and 5 micro sufentanil. In both groups, the hemodynamic changes, the peak sensory level and time to achieve it, the degree and duration of motor block as well as the time to SI sensory regression were studied. The duration of effective analgesia and incidence of side effects were also evaluated. The spinal block was adequate as regard the quality and duration in all patients. The highest level of sensory block and the time taken to reach it, in addition to, regression to S1 were similar in the two groups. A lower degree and faster duration of motor blockade were observed in the sufentanil group [p < 0.001]. The duration of effective analgesia was significantly longer in the sufentanil group compared with the control group [p < 0.001]. Hypotension occurred more frequently with higher total rescue doses of ephedrine in the control group [p = 0.004]. The frequency of pruritus was significantly higher in the sufentanil grdup [p < 0.001]. Addition of sufentanil 5 micro g to hyperbaric bupivacaine 6 mg for spinal anesthesia in patients undergoing TURP induced an adequate spinal block with a lower incidence of hypotension and prolonged the duration of postoperative analgesia, with few side-effects

Melatonin premedication for patients undergoing phacoemulsification cataract surgery under topical anesthesia

We hypothesized that melatonin premedication in adult patients undergoing cataract surgery could produce anxiolysis, Improve analgesia and reduce intraocular pressure. Forty patients were randomly allocated into two equal groups [20 patients each]. Ninety minutes before surgery, each patient received sublingual 5 mg melatonin tablet [melatonin group] or placebo tablet [control group]. Anxiety and pain scores, heart rate [HR], mean arterial pressure [MAP], and intraocular pressure [IOP] changes were evaluated. Following premedication, the anxiety scores were lower in the melatonin group [p < 0.05]. There were also significantly lower intraoperative verbal pain scale [VPS] scores at 10 and 30 minutes during surgery and postoperatively with less intraoperative fentanyl consumption in the melatonin group [33.6 +/- 18.4 vs. 68.8 +/- 32.4 micro g, p < 0.001] IOP decreased significantly after melatonin premedication and at the end of surgery in the melatonin group compared to the control group [p < 0.05]. Sublingual 5 mg melatonin premedication in patients undergoing phacoemulsification cataract surgery under topical anesthesia reduced anxiety, and enhanced intraoperative and early postoperative analgesia. It also results in ocular hypotensive effects and better operating conditions

Autoclaved gelatin [haemagel] versus 6% hydroxyethyl starch 200/0.5 [Haes-steril] for plasma volume expansion in critically-ill patients

Synthetic colloids are used to optimize hemodynamics in the critically ill patients and a debate about the most suitable one is still present. The influence of short term infusion of autociaved gelatin [Haemagel] and 6% hydroxyethyi starch 200/0.5 [Haes-steril] on hemodynamic, respiratory, coagulation, renal and oncotic parameters were examined in a prospective randomized study. Thirty patients suffering from systemic hypoperfusion due to sepsis in ICU of Suez Canal University Hospital were assigned into 2 equal groups. In GEL group; 1000 ml of Haemagel was infused within an hour, while in HES group: 1000 ml of 6% Haes-steril 200/0.5 was given within an hour The hemodynamic, respiratory, hematological. coagulation, renal and colloidal osmotic pressure parameters were recorded before and after infusion of both colloids. There was a significant similar increase in hemodynamic variables [Mean arterial pressure, central venous pressure, cardiac index, stroke volume index and left ventricular stroke work index] in both groups. Also, a significant improvement in tissue perfusion as judged by decreased arterial lactate was found. There were no significant differences in any of the measured respiratory parameters [respiratory rate, arterial oxygen saturation, arterial blood gases and intrapulmonary shunt] in the studied groups. No significant intergroup difference in any haemodynamic or respiratory variable was demonstrated. A significant expansion in plasma volume as indicated by the significant reduction in haematocrit was detected. There were insignificant changes in coagulation profile [prothrombin time, activated partial thrombopiastin time, bleeding time and fibrinogen] in either group except the platelet count which was significantly reduced in both groups without any recorded bleeding complications. Creatinine, blood urea nitrogen, sodium and potassium didn't change and were comparable in the two groups Colloidal osmotic pressure and urine output increased significantly in either group. Anaphylactic reactions were not observed in any of the patients However, no significant differences between both groups in haematological. coagulation, renal and oncotic parameters were found. Both autoclaved gelatin [Haemagel] and 6% hydroxyethyl starch 200/0.5 [Haes-steri!] are safe and equally effective colloids for plasma volume expansion tn critically ill patients without apparent adverse effects on respiration, coagulation and renal functions

Bilateral sphenopalatine ganglion block in functional endoscopic sinus surgery under general anaesthesia

The purpose of this study was to examine the effects of bilateral sphenopalatine ganglion block on the surgical conditions, haemodynamics, intraoperative blood loss, consumption of anaesthetics, recovery characteristics and postoperative pain relief during functional endoscopic sinus surgery under general anaesthesia. A double-blinded randomised controlled trial was performed to evaluate the efficacy of bilateral sphenopalatine ganglion block in 60 patients undergoing functional endoscopic sinus surgery [FESS]. They were categorized into 2 equal groups [30 patients each]. In group I [block group], bilateral sphenopalatine ganglion block was performed after induction of general anaesthesia while group II [non-block group] received no similar injection. Anaesthesia was maintained with N2O-O2, fentanyl and sevoflurane. Urapidil was administered to induce hypotension as needed. Observed variables included haemodynamic parameters, visibility of the surgical field and intraoperative blood loss. Also, the requirements of sevoflurane, fentanyl and urapidil to provide optimal surgical field were assessed. Moreover, recovery characteristics, postoperative analgesia and any complication related to the technique used were recorded. Patients in group I [block group] had more stable haemodynamics with no fluctuations, better visibility of the surgical field and decreased blood loss as compared with non-block group. Also, less fentanyl, sevoflurane and urapidil doses were consumed in the block group. In addition, there were significant differences between both groups as regards the recovery criteria, the time to first rescue pain medication and analgesic requirements. Minimal postoperative complications occurred. It could be concluded that bilateral sphenopalatine ganglion block is a useful adjunct in patients undergoing endoscopic sinus surgery. It provided more stable haemodynamics, good operative conditions and lower blood loss. Also, it decreased consumption of sevoflurane, fentanyl and urapidil. Moreover, it improved recovery characteristics and postoperative pain relief with minimal recorded complications

Preferential COX-2 inhibitors -Do they add for post-operative analgesia?

The preemptive use of nonsteroidal antiinflammatory drugs [NSAIDs] for postoperative analgesia is controversial because of a questionable benefit against increased risk of haemorrhagic complications. Meloxicam is a new NSAID with a pereferential COX-2 inhibitory activity and a better safety profile. In the present study, the efficacy of meloxicam and ketorolac, a nonselective commonly used NSAID, in relieving postoperative pain when given either before or after the operation and their effect on platelet function were compared. The study was conducted on 80 patients undergoing peripheral orthopedic surgery of 1-2 hours duration. In a randamized double blind fashion, patients received either I.M. meloxicam 15mg/day [Group M], or I.M. ketorolac 30mg 6 hourly [Group K], starting 30 min before the operation [subgroups M[1] and K[1] respectively] or just after closure of surgical wound [subgroups M[2] and K[2] respectively]. Pain scores [10 cm visual analogue scale] [VAS] were obtained for all the patients immediately after recovery and at 1/2, 1, 2, 4, 8 and 24 hours after recovery. Time latency to the first request of additional analgesic and the amount of the first 24 hours consumption of pethedine analgesia were also recorded. In order to evaluate the effect of the drugs on intraoperative hemostasis, bleeding time and platelet aggregation studies were obtained before and one hour after giving the premedication drugs in the subgroups M[1] and K[1] and also in M[2] as a control. There was no significant difference in VAS, in the amount of first day consumed pethedine or in the time latency to the first request for additional analgesic between patients who received either meloxicam or ketorolac, whether they received the drugs before or after the operation. However, patients who received either of the drugs before the operation has significantly less pain scors during the first 8 hours [in meloxicam subgroups] and 4 hours [in ketorolac subgroups], and consumed less pethedine than those who received the drugs after the completion of surgery. Intra-operative bleeding time was significantly prolonged relative to the preoperative values in the three tested subgroups. However, there was no significant difference in the changes that occurred in bleeding time between patients who received meloxicam and placebo. Patients who received ketorolac had significantly more prolonged bleeding time than those who received meloxicam or placebo. Ketorolac also induced significant depression in platelet aggregation while meloxicam and placebo did not. Equal levels of post-operative analgesia can be obtained by either meloxicam or ketorolac. Preoperative administration of either drugs provides better post-operative analgesia during the first few hours after recovery. In contrast with ketorolac, meloxicam does not affect intraoperative platelet function if given before the operation. Meloxicam is equally effective, but can be more safely administered preoperatively than ketorolac

Ondansetron and tramadol for the treatment of post-extradural shivering

Sixty patients suffering from post-extradural shivering were randomly divided into three equal group. Group I, each patient received intravenous [IV] 0.5 mg /kg tramadol, and in group II, each patient was given 0.1 mg /kg IV ondansetron. while group III patients, received IV saline. The efficacy of both drugs on suppression of post-extradural shivering was compared. Onset at effect, the response rate and arrest time of shivering, heart rate, mean arterial pressure, blood gas changes, the level of plasma catecholamines and the incidence of adverse effects including recurrence of shivering were evaluated. Ondansetron could be considered an effective alternative to tramadol in aborting post-extradural shivering with high safety profile and no adverse effect

Vaginal misoprostal: comparison of two regimens for termination of early pregnancy failure

Two hundred patients were included in this trial. They had data of diffuse peritonitis proved surgically. Information specific to peritonitis and variables necessary for the calculation of APACHE II, MPI and PIAII scores were recorded. The three scoring systems were compared as regards the discriminatory ability, sharpness and reliability. It was found that APACHE II score is more superior than both MPI and PIA II as it produces reliable predications and can define more precisely the risk groups. Additional antibiotic trial was performed using APACHE II score to look for the impact on wound sepsis, augmenting which proved to be the best, followed by unasyn and lastly zinnat

use of intracervical Foley catheter for preinduction cervical ripening

A randomized prospective study was conducted and included 100 primigravid and multigravid pregnant inpatients admitted for induction of labor with a modified bishop score of [0 <7] and fulfilling the inclusion. Sixty patients were randomized to receive intracervical Foley catheter and forty patients to receive prostin E2 vaginal tablets. Oxytocin drip was then given if necessary. The results showed that the two groups were comparable with respect to age, parity, gestational age, indications for induction and initial pelvic scoring. Both prostin E2 vaginal tablets and Foley catheter were found to be effective for inducing cervical ripening. However, prostin E2 vaginal tablets were found to be more efficient in inducing cervical ripening in multiparae and cases with low initial pelvic score. They were also found to be more efficient in establishing vaginal delivery within a short time, but were more liable to be associated with intrapartum complications

Clinical and laboratory evaluation of immediate post operative oral hydration after caesarean section

This study included 147 unpremedicated women undergoing elective and emergency CS under general endotracheal anesthesia. Cases were randomly assigned into two groups: In group I [n = 72], only IV fluids were given and nothing was allowed per mouth until the appearance of intestinal sounds and at least for 24 hours and group II [n = 75]received only oral fluids freely after recovery. The two groups were comparable as regards age, parity, duration of pregnancy and indications for CS. The two groups were compared for onset of peristalsis, first passage of flatus, first bowel motion and for the occurrence of abdominal distension and vomiting. Sodium and potassium levels and hematocrit value were determined 24 hours postoperative. The results revealed that immediate oral hydration group had earlier onset of peristalsis, rectal gas emission and first bowel motion. There was no significant difference between the two groups as regards the occurrence of postoperative vomiting, distension or electrolyte levels

Transvaginal sonographic study of the endometrium in postmenopausal women

To study endometrial thickness [ET] and echogenicity by transvaginal ultrasound [TVS] in a group of normal postmenopausal women another group with postmenopausal bleeding [PMB] and to correlate ultrasonic findings with histopathologic diagnosis in the latter group. The study included 100 normal postmenopausal women and 52 women with PMB scheduled for curettage. ET [double layer technique] was measured for both groups with TVS, and for patients with PMB before curettage was performed. The ultrasonographic findings were correlated with age, age at menopause, parity and postmenopausal period for all cases. In addition, it was correlated with weight and body mass index [BMI] of normal cases, and histological diagnosis of cases with bleeding. In normal postmenopausal women, the ET ranged between 1.3 and 4.9 mm; with a mean [ +/- SD] of 3.34 +/- 0.99 mm, and the most determining factors were weight and age. Women older than 60 years had significantly thinner endomteria compared to women younger than 50 years [mean ET was 3.1 VS 4.4 mm respectively, p< 0.05]. Women with PMB had a mean ET of 11.7 mm [range 1.5-48 mm]. However, patients with ET < 5 mm had no evident athologic lesions at histology; while patients with endometrial thinckness > 20 mm had either atypical endometrial hyperplasia or endometrial carcinoma. TVS measurement of et was found to be a valiable method for discriminating normal from pathologic endometrial, as well as being from malignant endometrial with a high degree of precision. TVS is highly recommended for evaluating patients with PMB. It seems possinle that, in expert hands, it may save many women from an unneeded endometrial curettage. ET < 5 mm is assuring necessitating not more adequate not more than adequate follow up with repeated TVS. On the other hand, denometria thicker than 20 mm at TVS justify meticulous histopathological assessment of the endometrium for the high probability of malignancy

Eclampsia: a retrospective clinical and demographic hospital based study in Sohag city

A retrospective hospital-based study on the deliveries conducted in three main hospitals of Sohag City, Egypt, between the years 1991-1994. Of 7361 deliveries, 157 cases of eclampsia were reported [2.13% incidence]. There was a significant correlation between the occurrence of eclampsia and season, so that eclampsia occurred more frequently in winter for all age groups and parities. Antepartum eclampsia was more frequent [66%] than intrapartum and postpartum eclampsia; and it commonly occurred before term [60%], with no significant correlation with fetal sex. 58% of eclamptic cases were primiparae. There was unacceptable rates of maternal deaths [9.6%] and perinatal deaths [35%]. Maternal deaths was highest in both young and old women, and was most frequent with postpartum eclampsia and in cases delivered vaginally. Perinatal deaths were commonest in premature deliveries and amongst those who delivered vaginally. Eclampsia is still a major problem in our community and may have seasonal prevalence particularly in winter, and represents one of the main contributors of maternal and perinatal losses. Improvement of antenatal care and hospital facilities for better management is badly needed to improve maternal and fetal outcome of this serious obstetric tragedy

Study of risk factors for Ischaemic heart disease in middle aged women

This is a prospective study conducted to examine the relationships of obesity, lipids and apolipoproteins, menopausal status, prior combined oral contraceptive [COC] use, and parity with the risk for ischemic heart disease [IHD] among middle aged women. A total of 160 women, aged 35 to 59 years were recruited, 100 cases with IHD, and 60 healthy women as controls. High apolipoprotein-B [Apo-B], low density lipoprotein cholesterol [HDL-C], and high triglyceride [TG] levels, were found to have independent influence on the risk of developing IHD in the studied cases. Other risk factors that were found to have significant relation to IHD were increased body mass index [BMI], postmenopause particularly before 50 years, increased low- density lipoprotein cholesterol [LDL-C], increased total cholesterol [TC], decreased apolipoprotein-A-I [Apo-A-I]. Parity and prior combined oral contraceptive use were not found to be significant risk factors. An equation including all the studied factors was suggested to be used for prediction of IHD in middle-aged women