Tracheal tube cuff inflation guided by pressure volume loop closure associated with lower postoperative cuff-related complications: Prospective, randomized clinical trial

The main function of an endotracheal tube [ETT] cuff is to prevent aspiration. High cuff pressure is usually associated with postoperative complications. We tried to compare cuff inflation guided by pressure volume loop closure [PV-L] with those by just to seal technique [JS] and assess the postoperative incidence of sore throat, cough and hoarseness. In a prospective, randomized clinical trial, 100 patients' tracheas were intubated. In the first group [n = 50], ETT cuff inflation was guided by PV-L, while in the second group [n. = 50] the ETT cuff was infl ated using the JS technique. Intracuff pressures and volumes were measured. The incidence of postoperative cuff-related complications was reported. Demographic data and durations of intubation were comparable between the groups. The use of PV-L was associated with a lesser amount of intracuff air [4.05 [3.7-4.5] vs 5 [4.8-5.5], P < 0.001] and lower cuff pressure than those in the JS group [18.25 [18-19] vs 33 [32-35], P

Addition of dexmedetomidine to bupivacaine in transversus abdominis plane block potentiates post-operative pain relief among abdominal hysterectomy patients: a prospective randomized controlled trial

Dexmedetomidine is an alpha 2 adrenergic agonist, prolongs analgesia when used in neuraxial and peripheral nerve blocks. We studied the effect of addition of dexmedetomidine to bupivacaine to perform transversus abdominis plane [TAP] block. A total of 50 patients scheduled for abdominal hysterectomy were divided into two equal groups in a randomized double-blinded way. Group B patients [n = 25] received TAP block with 20 ml of 0.25% bupivacaine and 2 ml of normal saline while Group BD [n = 25] received 0.5 mcg/kg [2 ml] of dexmedetomidine and 20 ml of 0.25% bupivacaine bilaterally. Time for first analgesic administration, totally used doses of morphine, pain scores, hemodynamic data and side-effects were recorded. Demographic and operative characteristics were comparable between the two groups. The time for the first analgesic dose was longer in Group BD than Group B [470 vs. 280 min, P < 0.001] and the total doses of used morphine were less among Group BD patients in comparison to those in Group B [19 vs. 29 mg/24 h, P < 0.001]. Visual analog scores were significantly lower in Group BD in the first 8 h post-operatively when compared with Group B, both at rest and on coughing [P < 0.001]. In Group BD, lower heart rate was noticed 60 min from the induction time and continued for the first 4 h post-operatively [P < 0.001]. The addition of dexmedetomidine to bupivacaine in TAP block achieves better local anesthesia and provides better pain control post-operatively without any major side-effects.

survey of the practice of regional anesthesia in Saudi Arabia

This survey aimed to assess both the extent of practice and need for training in regional anesthesia among anesthesiologists in Saudi Arabia in 2012. We distributed an electronic survey among 382 anesthesiologists attending the bi-annual meetings of the Saudi Anesthetic Association, enquiring about their practice in regional anesthesia. Questions concerned the practice of regional anesthesia, use of ultrasound guidance, and the need for training workshops. The response rate of anesthetists was 55.2% with most of them were males and had mean age of 25-50 years. Most anesthesiologists [88.2%] were practicing regional anesthesia frequently in the operating rooms [75.3%] rather than designated block room. From the respondents, only 14.2% did fellowship in regional anesthesia, 21.8% and 18.5% were using ultrasound and nerve stimulation guidance, respectively, 11.4% received formal training, and 86.3% were willing to attend training workshops on regional anesthesia. There was a significant negative correlation between the ultrasound users and their institutional positions [r=-0.191] [P=0.026]. We believe that more could be done to improve the practice of regional anesthesia in the Kingdom of Saudi Arabia, including the implementation of formal training and conduction of more frequent specialized courses/workshops in the field of regional anesthesia with special reference to ultrasound regional anesthesia blockade techniques

Adding a conduit to glidescope blade facilitates tracheal intubation. prospective randomized study

To determine the effect of modifying the GlideScope [GVL] blade on the intubation time. This prospective study was conducted at the Department of Anesthesia, King Abdulaziz University Hospital, Jeddah, Saudi Arabia between June 2011 and October 2011. Sixty patients requiring endotracheal tube [ETT] intubation for elective surgery in whom airway was anticipated normal were randomly allocated to one of 2 groups. Group M [n=30]: intubated via a modified GVL blade in which a tube conduit along the side of the GVL blade was created to allow the passage of ETT through the cords. Group C [n=30]: intubated with the conventional GVL blade and rigid intubating stylet. Time to successful tracheal intubation [TTI] was 39.6 +/- 2.1 seconds in Group M versus 66.4 +/- 8.3 seconds in Group C [p=0.0001], tracheal intubation was deemed more easily in Group M than in Group C [VAS2 +/- 1 versus 6 +/- 1, p=0.0001], and all patients in Group M were successfully intubated on the first attempt when compared with 90% in Group C [p=0.009]. The addition of a conduit to the GVL blade made the passage of the ETT easier and TTI shorter without increasing adverse events or intubation failure.

use of botulinum toxin and epidural analgesia for the treatment of spasticity and pain in a patient with maple syrup urine disease

A 7-year-old boy, weighing 18 kg, was diagnosed with maple syrup urine disease [MSUD]. He suffered from spasticity of the lower limbs and pain that did not respond to oral medications. Injections of botulinum toxin A [BTX-A] at 10 sites and epidural analgesia with 0.125% bupivacaine were used to treat spasticity with good results. We conclude that BTX-A combined with epidural analgesia may be a useful treatment option for incapacitating, painful spasticity related to MSUD. This treatment modality allowed a comprehensive rehabilitation program to be completed and it lasted longer than 9 months

Use of pressure volume loop closure to check for endotracheal tube cuff function randomized clinical trial

To assess the efficacy of pressure volume loop [PV-L] closure as an indicator of adequate endotracheal tube cuff [ETTc] function, and to compare this with commonly used methods of checking cuff pressure. We conducted a randomized clinical trial at the Department of Anesthesia, King Abdulaziz University Hospital, Jeddah, Kingdom of Saudi Arabia from October 2011 to February 2012. One hundred and forty patients were intubated, and the ETTc was inflated using one of 3 techniques. The intubating anesthesiologist inflated the cuff at his discretion until he detected no further air leak in the first technique. In the second technique, we maintained the ETTc pressure at 20 centimeter water, while the third technique used PV-L closure. The PV-L technique required lower amounts of air to inflate the ETTc than the other 2 techniques [3.89 +/- 0.26 for PV-L versus 4.4 +/- 0.36 for fixed preset pressure, and 5.26 +/- 0.46 for pilot balloon palpation, p=0.00001] and the mean cuff pressure was lower than other techniques [18.67 +/- 0.72 for PV-L versus 20 for fixed preset pressure, and 33.48 +/- 3.49 for pilot balloon palpation, p=0.00001]. The PV-L closure technique is an alternative way to check for ETTc function with a significantly lower ETTc pressure and volume than those recorded with a manually inflated cuff, or with preset cuff pressure of 20 cm H[2]O

Medical students' knowledge and attitude toward cancer pain management in Saudi Arabia

To assess the final year medical students' knowledge, beliefs, and attitude toward cancer pain, and the need for a formal pain curriculum in medical schools. An epidemiological study was conducted from May 2008 to October 2009 at King Abdulaziz University Hospital, Jeddah, Kingdom of Saudi Arabia to assess the students' knowledge and attitude toward cancer pain management. A survey in the form of self-conducted questionnaire was distributed among them. Response rate was 55% [N=325]. Fifty-four percent of the respondents believed that <40% of cancer patients suffered from pain. Forty-six percent of them considered cancer pain as untreatable, while 41.6% considered pain as a minor problem, and 58.6% considered the risk of addiction is high with legitimate opioids' prescription. There are 23.1% of students believed that patients are poor judges of their pain, 68% of them limited opioids prescription to patients with poor prognosis, and 77.1% believed that drug tolerance or psychological dependence, rather than advanced stages' cancer is the cause of increasing analgesic doses. The students' knowledge on the causes of cancer pain, pain clinic rule, and pain inclusion in the medical curriculum was poor. The correlation between personal life experience and respondents' attitude toward cancer pain management did not reveal any statistical significant. The study revealed poor knowledge and negative attitude of medical students' toward cancer pain. A structured teaching pain program is needed to improve the knowledge and attitude of future doctors toward pain

Use of airtraq, C-Mac, and glidescope laryngoscope is better than macintosh in novice medical students' hands: a manikin study

Obtaining patent airway is a crucial task for many physicians. When opportunities to practice intubations on patients are really limited, skill gaining methods are needed. We conducted a study among novice 6[th] year medical students to assess their ability to intubate the trachea in normal airway in manikin using four airway tools. Prospective, cohort study conducted at simulation center of university-based, tertiary care hospital. Fifty medical students performed either oral or nasal tracheal intubation using the following four intubating tools: C-Mac videolaryngoscope, Glidescope, and Airtraq in comparison with regular Macintosh laryngoscope. Intubation time, visualization of glottic opening, ease of intubation, satisfaction of participants, incidence of dental trauma, and the need for optimization manoeuvres' use among different airway tools were recorded. In oral intubation, Airtraq was better than others in regard to intubation time, glottic opening, ease of intubation, and the need for external laryngeal pressure application, followed by Glidescope, C-Mac, and finally Macintosh laryngoscope [P<0.001]. Airtraq and Glidescope associated with less dental trauma than C-Mac and Macintosh. In nasal route, fastest intubation time was reported with Airtraq followed by Glidescope, C-Mac, and lastly Macintosh. Airtraq, Glidescope, and C-Mac were similar to each other and better than the Macintosh in regard to ease of intubation, satisfaction, and number of attempts [P

Nurses' knowledge of pharmacological measures on acute pain management in Western Saudi Arabia

To assess the nursing knowledge of acute pain management in a tertiary hospital. Three hundred closed-answer questionnaires were distributed in various hospital departments at King Khalid National Guard Hospital in Jeddah, Saudi Arabia in 2007. Three main topics were tested in the questionnaire; nursing opinion on patient self-report of pain as a main indicator of pain intensity, the need to increase opioids dose when the first dose had been safe but ineffective, and nurses' attitude toward the incidence of addiction, tolerance, and physical dependence. Of the respondents, 45.8% used the patient self-report of pain as an indicator of pain intensity in the smiling patient [A], and 55.1% relied on that in the grimacing patient [B]. Fifty percent of respondents in patient A and 30.5% in patient B decided to give no more morphine to both patients despite their pain, while 7.6% and 19.5% of nurses selected the option of giving higher morphine dose to both patients. Only 38.1% of nurses chose the correct answer for risk of addiction [< 1%] and 41.6% selected an exaggerated response range from 25-100% as a chance of addiction. Very few nurses recognized the problem of tolerance and physical dependence and picked the right answers. Nurses' knowledge of acute pain management is deficient in many aspects. Proper education is needed to improve their knowledge of pain

Post-herniorrhaphy infiltration of tramadol versus bupivacaine for postoperative pain relief: a randomized study

Inguinal hernia repair is frequently associated with persistent postoperative discomfort and pain and late discharge from the hospital. We evaluated the postoperative analgesic effect of local wound infiltration with tramadol following herniorrhaphy among adult patients. Forty-three adult male patients were randomly assigned to two groups; group T [n=23] received tramadol 1 mg/kg in 10 mL 0.9% normal saline and group B [n=20] received 10 mL of 0.25% bupivacaine, both as a local wound infiltration prior to skin closure. Postoperatively, pain severity, time to first analgesic requirement, analgesic consumption, and incidence of side effects were recorded. During the first postoperative day, there was a significant difference between the two groups in the recorded visual analog scale rating higher in group B [P < .05] and the time to first analgesic requirement [6.6 +/- 0.99 hours in group B vs 3.7 +/- 0.74 hours in group T; P<.05]. There was no difference in the incidence of side effects among the two groups. Postoperative consumption of fentanyl and diclofenac was higher in group B than group T [65% vs 18% and 80% vs 21.7%, respectively, P<.005]. Locally infiltrated tramadol prior to herniorrhaphy wound closure provides better pain relief compared to bupivacaine in adult patients

Effect of intraoperative magnesium infusion Vs. lidocaine infusion on postoperative pain and morphine consumption in patients undergoing laparoscopic cholecystectomy

This randomized, double-blinded, prospective study was aimed to evaluate and compare the analgesic effect of Magnesium and lidocaine on pain, analgesic requirements, quality of sleep and bowel function in patients undergoing laparoscopic cholecystectomy. Seventy five patients were assigned into three groups [n=25 each]. Group M received magnesium sulphate 50 mg kg[-1] as a bolus dose followed by 25 mg Kg[-1] h[-1] Group L received lidocaine 2 mg kg[-1] as a bolus dose followed by 2 mg kg[-1] h[-1] and those of placebo group received saline infusion in an equal manner. These regimens were started 30 minutes before induction of anaesthesia and were discontinued at the end of surgery. Intraoperative fentanyl, cisatracurium and average end tidal sevoflurane were calculated. Pain scores at rest and upon cough and movement were evaluated 1, 2, 6, 12 and 24 h after surgery. Postoperative morphine consumption were recorded at 2 and 24 h. Time to first flatus and insomnia were evaluated after 24 hours. Magnesuim and lidocaine infusions alter anaesthetic dose requirements. Patients in the Magnesim and lidocaine groups had better pain relief and lower opioid consumption than the placebo group [p<0.001]. In addition, lidocaine was associated with earlier return of bowel function and magnesium caused a better quality of sleep [p<0.05]. Both lidocaine and magnesium reduced intraoperative anaesthetic requirements and improved the quality of postoperative analgesia. Moreover, their opioidsaring effect was maintained in the early postoperative period and after 24 hours during the first postoperative day

Prophylaxis of postoperative nausea and vomiting with ondansetron, metoclopramide, or placebo in total intravenous anesthesia patients undergoing laparoscopic cholecystectomy

To compare total intravenous anesthesia [TIVA] with ondansetron, and metoclopramide in preventing postoperative nausea and vomiting [PONV] in laparoscopic cholecystectomy patients. A prospective randomized double-blinded study was performed at King Abdulaziz University Hospital, Jeddah, Saudi Arabia in 2007. Seventy-five patients scheduled for laparoscopic cholecystectomy under TIVA were randomized to receive either: metoclopramide 10 mg [n=25], 4 mg ondansetron [n=25], or placebo [n=25] at the end of surgery. Postoperative nausea and vomiting episodes, analgesic supply, rescue medication, adverse events, and patient satisfaction were collected over 24 hours. Nineteen patients developed PONV. The frequencies of PONV were equal for the 2 groups [28%], and lower among the ondansetron group [20%] [p>0.05]. Female gender, lengthy surgery, and longer hospital stay were associated with more frequent PONV regardless of the study group [p<0.05]. Patient's satisfaction was more frequent among the ondansetron group [p>0.05]. Morphine consumption was associated with more PONV, but it was statistically significant only in the placebo group. There was no difference between the 3 groups with regard to the VAS pain score, cardiovascular parameters, or oxygen saturation. It is unlikely that a single technique or drug will ever be effective in treating emesis under all surgical circumstances. Therefore, a multimodal regimen incorporating avoidance of emesis triggering factors, and administration of antiemetic medications is recommended

Oral examination in medical sciences: is there any need for preparation?

Undergoing oral medical examination is a stressful situation for any candidate. Fear and anxiety may have an adverse effect on the performance of the candidate. Proper preparation will alleviate this stress. Familiarity with the format and regulations of the examination is the first step in that direction. The second step is frequent performance in a practice setting. This article offers some practical advice and information to aid the candidate in coping with this situation