Evaluation of "no touch" extubation technique on airway-related complications during emergence from general anesthesia

Awake "no touch" extubation requires performing extubations only when the patient spontaneously wakes up without any kind of stimulation during emergence from general anesthesia. The aim of this study was to evaluate absolutely awake extubation "no touch" technique in adult patients, scheduled for elective nasal and paranasal sinus surgeries under general anesthesia as regard to emergence airway complications. A total of 60 adult patients were randomly allocated into one of two equal groups according to the method of extubation: Group I: Standard fully awake, Group II: Absolutely "no touch" awake extubation [absolutely no stimulation "no touch" was allowed until patients were able to open their eyes]. The incidence of laryngospasm and its grade according to a four-point scale was reported. Occurrence of airway events [excessive secretions, breath-holding, coughing, hoarseness, biting, as well as the number and severity of any desaturation episodes], oozing from the wound, and postoperative sore throat were also recorded. The heart rate [HR], systolic [SBP] and diastolic [DBP] blood pressure measured at the end of surgery served as baseline values, and subsequent measurements were taken within 30 minutes after the end of surgery. There was absolutely no case of laryngeal spasm or episode of desaturation among patients who were extubated with the "no touch" technique. On the other hand, there were 3 cases of laryngeal spasm in standard fully awake group. Severity of coughing, excessive secretions and breath holding, hoarseness, biting, and occurrence of non-purposeful movements of the limbs were significantly less in the absolutely "no touch" awake technique. The changes in HR, SBP, and DBP during emergence extubation were significantly less in "no touch" technique group. However, oozing from the wound was significantly higher with standard fully awake extubation. However, there were no significant differences between the two groups regarding the incidence of postoperative sore throat [39 and 36%, respectively]. The results of the present study showed that awake "no touch" technique for tracheal extubation produces less airway-related complications, as well as minimal hemodynamic response during emergence from general anesthesia in nasal and paranasal surgeries. It could be a safe alternative for tracheal extubation in airway surgery

Procedural sedation analgesia

The number of noninvasive and minimally invasive procedures performed outside of the operating room has grown exponentially over the last several decades. Sedation, analygesia, or both may be needed for many of these interventional or diagnostic procedures. Individualized care is important when determining if a patient requires procedural sedation analgesia [PSA]. The patient might need an anti-anxiety drug, pain medicine, immobilization, simple reassurance, or a combination of these interventions. The goals of PSA in four different multidisciplinary practices namely; emergency, dentistry, radiology and gastrointestinal endoscopy are discussed in this review article. Some procedures are painful, others painless. Therefore, goals of PSA vary widely. Sedating management can range from minimal sedation, to the extent of minimal anesthesia. Procedural sedation in emergency department [ED] usually requires combination of multiple agents to reach desired effects of analgesia plus anxiolysis. Howeverm in dental practice, moderate sedation analgesia [known to the dentists as conscious sedation] is usually what is required. It is usually most effective with the combined use of local anesthesia. The mainstay of success for painless imaging is absolute immobility. Immobility can be achieved by deep sedation or minimal anesthesia. On the other hand, moderate sedation, deep sedation, minimal anesthesia and conventional general anesthesia can be all utilized for management of gastrointestinal endoscopy

Antemortem and postmortem estimation of skin wound age in rats: biochemical study

Inflammatory mediators play an important role in the mediation of inflammation and trauma. There for they could be usefulfor the determination of vitality and wound age. In the present study, interleukin-6 [IL-6], fibronectin [Fn] and lipoxinA[4] [LXA[4]] were estimated in extracts of antemortem skin wounds in rats. Moreover, we extended our measurements to include the levels of these mediators in rat skin wounds in the early postmortem period aiming to test for their practical usefulness in the estimation of wound vitality and the duration after its infliction. Thirty two rats were divided into 4 groups of rats [8 animals in each group] and were assigned for collection of wound samples at the indicated time intervals. The wound samples were taken 30 mm [group I], 3 hours [group II], 6 hours [group III] and 24 [group IV] hours after infliction of the incised wounds. The specimens as control group were excised from uninjured rats [8 animals] in the same region as wounded groufrs. The rats in group IV were sacrificed by cervical dislocation and kept at room temperature to be used in assessment of postmortem changes on different parameters. Postmortem wound samples were then collected 24 hours after sacrifice of group IV rats and the postmortem control samples were taken from intact skin of the same rats. A special group of rats [n-8] was used to explore the influence of supravital injuries on mediator release from postmortem inflicted wounds. All wound and control specimens were homogenated and assayed for the level of IL. 6, Fn and LXA[4] using quantitative ELISA analysis. Analysis of the changes of the studied parameters in different times revealed that Fn is the first mediator to increase, in 30 mm, after wound infliction. In the following 3 and 6 hours after wounding both Fn and IL-6 were increased. At 24 hours of wounding LXA[4] increases to join Fn and IL-6, at that time Fn and IL-6 were still high. This pattern of increased level of the three mediators was maintained for at least 24 hours postmortem. We can conclude that the combined assay of IL-6, Fn and LXA[4] may be a useful tool in determination of the probable duration lapsed since antemortem wound inflection. Moreover, this pattern of time dependent increase of the three parameters may be also useful in age determination of multiple inflicted wounds at variable intervals in the same victim. We can also conclude that vital reactions are essential for release of the assayed parameters. This can be documented by the lack of significant increase of these parameters in postmortem-inflicted wounds

Emergence agitation in uncooperative children undergoing complete dental rehabilitation: a comparison between sevoflurane and desflurane anesthesia

The issue of emergence agitation [EA] following the administration of short-acting anaesthetic agents, sevoflurane and desflurane, has become a controversial issue. The aim of the present study was to evaluate the influence of desflurane versus sevoflurane anaesthesia on EA in behaviorally uncooperative children undergoing complete dental rehabilitation using PAED scale. Thirty eight healthy children [ASAI and II] aged between 2 to 6 years, Frankl behavior category scales 1 or 2 scheduled for complete dental rehabilitation [CDR] under general anaesthesia were enrolled in the study protocol. Children were randomly allocated in a double-blind fashion to one of two groups according to the inhalational anaesthetic used for maintenance of anesthesia. Group S: Sevoflurane [1.0 +/- 0.2 MAC, age adjusted, n = 19] or Group D: Desflurane [1.0 +/- 0.2MAC, age adjusted, n = 19]. Paediartric Anesthesia Emergence Delirium [PAED] scale was used, a 5-point rating scale with 5 gradations for each item that has been validated to assess EA in children. Scoring was obtained multiple times and the peak was recorded for evaluation. Time to tracheal extubation, emergence behavior, recovery complications, and pain scores were assessed. PAED score at 15 min in the PACU was significantly higher [P < 0.05] in sevoflurane group. Similarly, as regards the peak PAED scale reached, children who received sevoflurane had a significant higher value 10 [3-19] min comparison to those who received desflurane 6 [2 - 14] min. Time to tracheal extubation was shorter in children who received desflurane. One case of vomiting in sevoflurane group and two cases in the desflurane group were encountered. The three cases were considered as grade 1 according to the 4-degree scale No differences were found between the study groups with respect to peak pain, time to discharge from PACU. The need for rescue medication was required for two children in sevoflurane group. In conclusion, maintenance of anaesthesia with desflurane resulted in less severe agitation with faster time for tracheal extubation than sevoflurane anesthesia in behaviorally uncooperative pre-school children undergoing complete dental rehabilitation. Although the time of PACU stay did not differ significantly, a more rapid immediate recovery from anaesthesia could be an additional benefit in such cases in a day-case surgery setup

Effect of atorvastatin and ascorbic acid on the gastrocnemius muscle of hyperlipidemic rats: histological, histochemical and biochemical study

Atorvastatin is a member of statins family which are widely used for the treatment of hyperlipidemia and coronary heart disease. Unfortunately, it induces muscle toxicity that limits its use. The present work was performed to evaluate the extent of these toxic effects and to clarify the role of high dose of vitamin C [ascorbic acid] in controling hyperlipidemia and as a protective against statin myotoxicity. This study was conducted on forty adult male albino rats divided into one control group [eight rats] and four experimental groups [eight rats each]. Animals of the control group received normal standard diet while the experimental groups were fed hyperlipidemic diet alone [Group I], or with an additional i.p 200 mg vitamin C [Group II], oral 2.5 mg atorvastatin [Group III] and both vitamin C and atorvastatin [Group IV]. After three months, total lipids and creatine phosphokinase were measured. Histological and histochemical changes in gastrocnemius muscle were also evaluated. The biochemical results established efficacy of both drugs [atorvastatin and vit C] either alone or combined in the treatment of hyperlipidemia by a highly significant reduction of total cholesterol, triglycerides [TG], low-density lipoprotein [LDL] and elevation of high-density lipoprotein [HDL]. CPK showed a highly significant increase in group III only. This group [Group III] showed variable degrees of cellular affection and myopathic changes in the form of splitting, fragmentation, loss of transverse striations, and focal areas of degeneration with vacuoles and cellular infiltration. Peripheral accumulation of glycogen and an apparent decrease in succinic dehydrogenase activity were also seen. Electron microscopy revealed that the myofibrils were not in register and showed many vacuoles, irregular nuclei and mitochondrial affection. Active fibroblasts and an apparent increase in collagen fibers were also seen. The last group [IV] which received vit. C in addition to atorvastatin showed few degenerated muscle fibers with many new regenerating ones. The regenerating fibers showed numerous, central or peripheral nuclei. The glycogen content was patchy among muscle fibers and there was an apparent increase in succinic dehydrogenase enzyme activity. From the above findings, it could be concluded that vitamin C is a safe and effective lipid-lowering drug alternative to statins. It can also protect against statin myotoxicity

Evaluation of endoscopic band ligation plus argon plasma photocoagulation versus scleroligation for eradication of esophageal varices: a prospective randomized controlled study

Bleeding from esophageal varices is the most severe and lethal complication of portal hypertension. The aim of this work was evaluation of the technique of endoscopic band ligation plus argon plasma photocoagulation versus scleroligation as a new method used for eradication of esophageal varices. This study was conducted on 200 patients out of 294 studied patients. Patients who fulfilled the inclusion criteria were randomized to four groups, Group I: comprised of 50 patients who were subjected to endoscopic injection sclerotherapy, Group II. comprised of 50 patients who were subjected to variceal band ligation, Group III comprised of 50 patients who were subjected to combined endoscopic sclerotherapy and band ligation, Group IV comprised of 50 patients who were subjected to endoscopic band ligation plus argon plasma photocoagulation. Comparison of the endoscopic number of therapeutic session between different studied groups showed that group III was significantly lower in number of sessions. As regard post treatment complications during the follow up period, Group I showed the high incidence of transient pyrexia, transient dysphagia and/or retrosternal pain and ulceration, while group II showed the higher incidence of re-bleeding was demonstrated. The higher incidence of recurrence rate of esophageal varices after eradication during the follow up was detected in group II, while the higher mortality incidence was detected in group I and II, In this study the follow up incidence did not significantly differ between the different studied groups. Scleroligation allows very rapid eradication of varices, low recurrence rate, avoided the disadvantage of high recurrence of band ligation alone, and did not require special skill over sclerotherapy or band ligation but the total cost is higher than that required for sclerotherapy. Also, Band ligation plus argon plasma photocoagulation allows very rapid eradication of varices, and low recurrence rate, with no obvious recorded complications, but it has the disadvantage of being the most expensive technique and requires special machine which is not available except in few endoscopic centers

Spinal ropivacaine in fast-track TURP

The addition of fentanyl to spinal ropivacaine anaesthesia has been shown to improve the quality of block, increase duration of sensory block, and provide postoperative analgesia without affecting motor function. in a randomized controlled, double blind study, we examined the efficacy and the adverse effects of three different regimen of spinal anesthesia Forty-five patients scheduled for transuretherai resection of the prostate [TURP] under sudarachnoid anesthesia. Patients were randomly assigned to Group I [G I] hyperbaric bupivacaine 10 mg. Group II [G II] 15 mg heavy ropivacaine, and Group III [G III] ropivacaine 10 mg with 20 micro g fentanyl. Evaluation of the block and side effects were performed after spinal anaesthesia. Three patients in bupivacaine group, three patients in ropivacaine group and one patient in fentanyl group required sedative / analgesic supplementations. Patients of fentanyl group showed significant prolonged sensory block and significant decrease in the motor block. Time to walk was significantly shortened in fentanyl group, it was 150 mm versus 197 and 162 mm in bupivacaine and ropivacaine groups respectively. The visual analogue score for pain at 3, 6 and 12 hours after jntrathecal anaesthesia in G II and III were significantly less than G I. No patient experienced respiratory depression, hypoxemia. hypotension or bradycardia dunng the postoperative penod Pruritus was reported in 12 patients [80%] of fentanyl group, but it was mild and did not necessitate medical treatment. Shivering was significantly less in the patients of fentanyl group. Intratnecal ropivacaine 10 mg plus 20 micro g fentanyl resulted in sufficient analgesia comparable to 15 mg ropivacaine or 10 mg bupivacaine with better analgesia and discharge criteria for fast-track TURP

Propofol versus remifentanil patient controlled sedation for awake craniotomy during epileptic surgeries

Anaesthesia for neurosurgical procedures, specificaity craniotomies requiring patient participation presents a challenge to both the neuroanaesthesiologist and the neurosurgeon Despite the popularity of general anaesthesia for these procedures, there has been a renewed interest in this technique of awake craniotomy due to its definite advantages m specific patient populations. This study evaluate two anaesthetic regimens for propofoi and remifentanil for awake craniotomy in epileptic surgeries. Total drug administered, incidence of complications, sedation score and patient satisfaction were assessed in 20 patients, randomely assigned into 2 equal groups, aged 18-55 years undergoing awake craniotomy for epileptic surgeries. Sedation was induced vis propofol patient controlled sedation in group I and via remifentanil patient controlled sedation in group II. five patients in the remifentanil group versus two patients in propofol group experienced nausea and /or vomiting. Respiratory rate depression, desturation were more frequent in remifentanil group while pain and hypotension were more frequent in propofoi group Both groups achieved a good level of sedation and patient satisfaction. Propofol and remifentanil are almost ideal drugs for conscious sedation during avjake craniotomy

Low central venous pressure anesthesia in major hepatic resection

Blood loss and transfusion requirements are major determinants of morbidity and mortality following liver resection. This study evaluates the association of low central venous pressure [LCVP] with blood loss and blood transfusion during liver resection. Thirty consecutive hepatic resections were studied prospectively concerning CVP, volume of blood loss and volume of blood transfusion and renal outcome. Data were analyzed for those with a CVP 5 mmHg. A multivariate analysis assessed potential confounding factors in the comparison. The mean blood loss in patients with a CVP of 5 mmHg or less was <500 ml and that in those with a CVP >5 mmHg was >2000 ml. [p <0.001]. Only two patients with a CVP of 5 mmHg required transfusion. No incidences of air embolism or permanent renal shutdown have been reported. It is concluded that the volume of blood loss and blood transfusion during liver resection correlates with the CVP during parenchymal transection. Lowering the CVP to less than 5 mmHg is a simple and effective technique to reduce blood loss during liver resection and delete the need for blood transfusion with its hazards

Role of antioxidant compounds during cardiopulmonary bypass

The aim of the present study was to determine the role of antioxidant compounds on haemodynamics during coronary artery bypass grafting using cardiopulmonary bypass. Twenty Two patients of ASA physical status III, who were scheduled to have non-urgent aortocoronary bypass grafting with a preoperative ejection fraction 0.5. Patients were randomly assigned into one of two groups [11 patients each]. Group I: Patients received one gm.h[-1] of N-acetyl cysteine [Mucomyst] infusion after induction of anaesthesia and continuously till the skin closure. One gram of ascorbic acid [Vitamin C] and 400 IU of J-tocopherol [Vitamin E] were administered intravenously over 10-15 minutes at the time of rewarming. Group II: Patients received placebo, equal volumes of normal saline during the same periods. Anesthetic management was the same in all patients and performed by the same surgeon. A 4- lumen, 7 F thermo-dilution pulmonary artery catheter was inserted. Hemodynamic variables: Heart rate [HR], mean arterial pressure [MAP], pulmonary capillary wedge pressure [PCWP] and cardiac output [COP] were measured after induction of anaesthesia and establishment of monitoring [baseline], five minutes after coming off bypass, and at skin closure. The choice and dose of inotrops given was left to the decision of the attending anesthetist. Five minutes after coming off hypass, both MAP and COP decreased significantly in the placebo group in comparison to the treatment group. There was statistically significant decrease in MBP in the placebo group in comparison to antioxidants group, with a mean of 57.1 +/- 3.2 mmHg and 74.7 +/- 4.0 mmHg respectively. Similarly, there was statistically significant decrease in the COP in the placebo group in comparison to antioxidants group, with a mean of 3.77 +/- 0.2 and 4.33 +/- 0.3 respectively. Other variables [HR, PCWP, and SVR] did not significantly differ between both groups. At skin closure the mean HR was the only variable that showed significant change between the two groups. It was significantly higher in placebo group [82.3 +/- 9.2bpm], in comparison to antioxidant group [69.4 +/- 7.6 bpm]. The inotropic requirements were generally increased in the placebo group. Most patients in the antioxidants group [72%] required only low dose dopamine [3 micro.kg[-1.]min[-1]]. On the other hand, in the placebo group, requirements of moderate doses of dopamine [3-10 micro.kg[-1].min[-1]] and dobutamine [3-10 micro.kg[-1].min[-1]] were significantly higher. Similarly, percentage of patients who required combination of dopamine and dobutamine were high in the placebo group in comparison to treatment group. The current study proved that the combination of antioxidant compounds is beneficial to ameliorate haemodynamic changes and decrease the inotropic requirements during cardiopulmonary bypass, and would be very beneficial if used as routine therapy, especially with the high-risk surgical patients

Inhaled furosemide ameliorates wheezes in asthmatic patients during induction of anesthesia

Fifty asymptomatic asthmatic patients of ASA physical status, I and II, with a history of active asthma scheduled for elective surgery were enrolled in the study. Anesthetic management was the same in all patients. Five minutes post-intubation an independent blinded observer assessed wheezing. The presence of wheezing was determined through auscultation during controlled ventilation. A simple "yes" or "no" was obtained, and no grading was done. Patients who wheezed after 5 min were subsequently treated by the random administration of the study medication either albuterol [5 mg in 2-4 ml 0. 9%NaCl, salbutamol sulphate I mg /ml] or furosemide [lasix 40 mg in 2-4 ml 0.9% NaCl]. Wheezes were assessed again. 5 minutes post-medication. Twenly-three out of 50 patients included in the study developed wheezes, 5 minutes after intubation. The incidence of wheezes was 46% and the mean peak inspiratory pressure [PIP] was 26.1 +/- 2.6 cm H2O The patients who wheezed were randomly allocated into one of two groups to receive either albuterol [n =11] or furosemide [n=12]. There was no statistically significant difference in the percentage of patients who responded to albuterol [82%] in comparison to furosemide [75%]. The peak inspiratory pressure [PIP] declined significantly [P= 0.001], 5 minutes after treatment in both groups. Heart rate was significantly higher [P= 0.001], 5 minutes after treatment, in the albuterol group [104.1 +/- 11.25 bpm] in comparison to furosemide group [82.3 +/- 7.53 bpm]. Inhaled furosemide has definitely a role in ameliorating wheezes in asthmatic patients during general anesthesia. It is equally effective to inhaled albuterol however, it unduces no tachyarrythmias. Those who are suffering complications from the adverse effects of beta 2-agonists may benefit from the use of inhaled furosemide

Neuromuscular and haemodynamic effects of mivacurium in patients with hepatic cirrhosis

Forty patients who underwent intermediate elective surgeries were included in the present study. Ten patients were free from hepatic disease [group A], and thirty patients had evident hepatic cirrhosis, [group B]. Using Child-Pugh score, group B patients were further subdivided into three equal subgroups, group B1 was Child A, group B2 patients were Child B and group B3 patients were Child C. Induction of anesthesia was carried out by propofol, fentanyl NO2-O2 and isoflurane. After stabilization of control response using a force displacement transducer and neuromuscular function analyzer, all patients received a bolus of mivacurium 0.15 mg/ kg over 15 seconds [2x ED95] and spontaneous recovery was recorded. Mivacurium infusion was started at T1 of 10% [first response of TOF] and the block was maintained at T1 depression of 95%. Haemodynamic changes were recorded before start of anesthesia and throughout surgery. After bolus injection of mivacuirium, both lag time and onset time didn't show any significant change among groups. Recovery indices were comparable between group A and sub group BO1 [Child A], whereas, there were significant increase of T1 to 10%, 25%, 75% and 90% of control in patients with moderate to severe liver cirrhosis [group B2 and B3] in comparison to group A. TOF ratio of 0. 7 showed the same pattern of change, it was significantly higher in subgroups B2 and B3 in comparison to control group A. Similarly, recovery index was significantly higher in subgroups B2 and B3. The mean infusion requirements of mivacurium were generally less in group B in comparison to group A. Steady state infusion rates were achieved over 10 mm in all groups. Differences in mean mivacurium requirements from 10 min and forward were significantly less in subgroups B2 and B3 in comparison to control A. At end of surgery, residual neuromuscular blockade was antagonized and a TOF ratio of 0.7 was reached in about 7 minutes. None of patients experienced any signs of recurarization in the recovery room. In conclusion, mivacurium has a stable neuromuscular and haemodynamic profile in patients free from hepatic disease and patients of child score A. However, in child score B and C patients the drug profile is unstable and even unpredictable. Therefore, the use of mivacurium is only recommended, if ever, for short procedures in cases of mild liver cirrhosis

Anatomical variations of the arterial component of hepatic pedicle in Egyptians

The structure of organs in the people varies considerably. The course and relations of the arterial component of hepatic pedicle are highly variable. Frequency of variations often differs among various human groups and variations seen in one population cannot be assumed to apply to members of another population. Hence, this study was intended to investigate the types of variations commonly encountered among Egyptians and analyze whether there might be sex difference in the variations. The study was carried out in 55 autopsy specimens [31 male and 24 females] collected from Egyptians. The human extrahepatic biliary parts for this stud] were dissected and any arterial variations in the hepatic pedicle were recorded. Arterial variations were encountered in 80% of specimens. The presence of aberrant hepatic and cystic arteries and the abnormal origin and course of these arteries were found to be common arterial variations. Higher percentage of arterial variations was found in females than in males. Whether or not these differences have some contributions to higher rate of biliary tract diseases in females than in males has to be further investigated

Neuromuscular and eye changes among workers exposed to mercury vapour

This work was conducted on fifty workers exposed to mercury vapour and twenty five control workers from the same factory not exposed to such vapour. Neuromuscular and eye changes were studied and correlated to duration of exposure

Complications of posterior chamber intraocular lenses with special emphasis on cystoid macular edema

Posterior chamber intra-ocular lens has become an important tool for visual rehabilitation after cataract surgery. We have studied the incidence of the post-operative complications in our department. We have selected 35 eyes to receive posterior chamber lens after extracapsular surgery and 35 eyes with no implant, that underwent the same procedure, were taken so control, Fluorescein angiography was done for every case at 6 weeks and 3 months postoperatively or if there is an unexplained change in visual acuity. We have found a low incidence of both anterior and posterior segment complications also the incidence of cystoid macular oedema was low compaired to the control group