Lornoxicam versus tramadol for post-operative pain relief in patients undergoing ENT procedures

Pain following ear-nose and throat surgery is one of the most important complaints for which, several drugs are used. This prospective, randomized, double-blind controlled trial was designed to compare the analgesic effect of tramadol versus lornoxicam for post-operative pain relief in patients undergoing ENT surgical procedures. One hundred and twenty patients of ASA class I-II, who had undergone elective ENT surgical procedures under general anesthesia, were assigned in a randomized manner into three equal groups. Group L received lornoxicam8 mg IV, Group T received tramadol 1 mg/kg IV and Group C received IV saline after induction of anesthesia before the start of the surgery. Post-operative pain was assessed using the visual analogue scale [VAS] and sedation level was evaluated during stay in the post-anesthesia care unit with a four-point sedation scale. Intraoperative blood loss was estimated using the Five-Point Scale. Adverse events in the first 24 h post-operative were recorded. The VAS pain scores were significantly higher in Group C as compared with those in Groups L and T at 30 min and 1, 2, 4and 6 h post-operatively, with no significant difference between Group L and Group T. The amount of morphine consumption post-operatively was significantly lower in Group L [5.2 +/- 2.5 mg] and Group T [5.0 +/- 2.0 mg] as compared with that in Group C [7.4 +/- 2.3 mg] [P = 0.001]. The time for the first analgesic requirement was significantly less in Group L [92.62 +/- 24.23 min] and Group T [88 +/- 21.43 min] as compared with that in Group C [42.82 +/- 25.61 min], with no significant difference between the other two groups. Estimated intraoperative blood loss score by the surgeons showed no significant difference between the three groups. The most frequent side-effects in the three groups were nausea and vomiting, and their incidence was significantly higher in the placebo group as compared with the other two groups. Tramadol 1 mg/kg was comparable to lornoxicam 8 mg for post-operative pain relief in patients undergoing ENT surgical procedures; both drugs helped to reduce the post-operative opioid requirement and consequently minimized the related adverse effects of the opioids

Severe hypertension and pulmonary edema associated with systemic absorption of topical phenylephrine in a child during retinal surgery

Topical phenylephrine solutions are widely used in eye procedures to promote pupil dilation without cycloplegia. We report a case of intraoperative severe hypertension and acute pulmonary edema occurring in a child during retinal surgery after possible systemic absorption of topical phenylephrine eyedrops. Our objective is to discuss the proper treatment and preventive strategies for such a complication. A 4-year-old, male patient, 18.4 kg in weight, physical status ASA I was admitted for right retinal detachment surgery. Anesthesia was induced with sevoflurane in oxygen, followed by glycopyrrolate [5.0 microg/kg], propofol 25 mg, fentanyl 50 microg and cisatracurium 0.15 mg/kg given intravenously. Anesthesia was maintained with sevoflurane 2-2.5% in a mixture of nitrous oxide and oxygen [60%:40%]. After incision, two drops of 10% aqueous phenylephrine were administered topically by the surgeon to the right eye for further pupil dilation. Few minutes later, the noninvasive blood pressure rose to 220/120 mmHg and the heart rate increased to 140 beats/min. Oxygen saturation [SpO[2]] dropped from 99% [with an inspired oxygen concentration [FiO[2]] of 0.4] to 82%. Auscultation revealed crepitations throughout the chest and a blood-stained frothy fluid was aspirated from the trachea with possible development of acute pulmonary edema. Hydralazine [5 mg] and furosemide [10 mg] were administered intravenously. Seven minutes later, the blood pressure returned to normal and the SpO[2] increased to 92% on FiO[2] of 1.0, with decreased intratracheal secretions. After approximately 20 minutes, the SpO[2] had improved to 99%, with a FiO[2] of 1.0 and the blood pressure was 109/63 mmHg and heart rate was 121 beats/min. The FiO[2] gradually reduced back to 0.4 over 30 min with no further desaturation. The patient was discharged from the post anesthesia care unit 5 h after surgery with adequate spontaneous breathing, SpO[2] 99% on room air, normal blood pressure and pulmonary auscultation. Anesthesiologists and ophthalmologists should be aware of the possible cardiovascular side-effects of topical phenylephrine, and it should be used cautiously with appropriate intraoperative monitoring of hemodynamic variables. Moreover, preventive strategies to minimize systemic absorption of the drug should be taken

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