Bispectral index for evaluation of recovery after sevoflurane anesthesia

Bispectral index [BIS] is a method of monitoring depth of hypnosis during anesthesia. Guided anesthetic administration using BIS target range may be associated with a reduction in volatile anesthetic and faster recovery. We evaluated recovery profile after sevoflurane anesthesia with and without BIS monitoring. 60 ASA I and II patients, aged 20-60 years, were enrolled in this study. Patients were divided randomly into two groups [n= 30]. In group A [GA] concentration of sevoflurane was adjusted according to clinical data. In group B [GB] concentration of sevoflurane was adjusted to keep BIS reading in range of 50 +/- 5. The following emergency times were evaluated: spontaneous eye opening, responding to verbal command and orientation time. Also, duration of patients stay in post anesthesia care unit [PACU] was determined and all patients were questioned about recall 24 hours after operation. End tidal sevoflurane concentration was significantly high in GA, during maintenance until stop of inhalational agents, compared to GB. Early recovery times are shorter in GB compared to GA, but not significant. When we compared duration of patients stay in PACU to be eligible for transfer to ward, it was significantly shorter in GB. No patient can recall any events during operation. Compared with standard anesthesia monitoring practice, adjunctive use of BIS monitoring can improve titration of sevoflurane during general anesthesia, leading to improved recovery profile and shorten the duration of stay in PACU. But, consideration of hemodynamic parameters is very important to avoid unaccepted change in HR and MBP, especially in cardiac patients

Ultrasound guided continuous femoral nerve sheath block versus continuous epidural analgesia after internal fixation of fractured neck femur

Continuous peripheral nerve blocks provide extended, site specific post-operative analgesia with few side effects. Ultrasound guidance can significantly improve the quality of nerve blocks in almost all types of regional anesthesia. The aim of the present study is to compare continuous femoral sheath block, under ultrasound guidance, with continuous epidural analgesia in terms of analgesic efficacy at rest and during movement, complications, and patients satisfaction. Thirty five ASA physical statuses I to III patients scheduled for internal fixation of fracture neck femur under general anesthesia were included in this study. Patients were divided into two groups in a randomized fashion. During the first 48 h postoperatively, analgesia was provided by using continuous femoral nerve sheath block group A [GA] or continuous epidural analgesia group B [GB]. The intensity of pain at rest and on movement was assessed by the patients using a visual analog scale [0 = no pain, 100 = worst possible pain] at 2, 4, 8 h and every 8 h for 48 h after the operation. If the VAS was >/= 3 the patient could receive additional morphine 2 mg every five to ten minutes; up to 4-6 mg according to age and general condition of patient. Times of catheter insertion and difficulty were significantly high in GA, no vascular puncture happened during procedures in both groups. VAS at rest and on movement present no significant difference between the groups allover the time of study. Cumulative morphine dose over 48 h was not significantly different, but satisfaction was significantly high in GA. Pain at insertion site was high in GA compared to GB where it was 5 and 3 respectively. Local signs of infection present in 2 patients in GA, but no patient had local signs of infection in GB. Inadvertent catheter removal as well as kinked catheter was occurred in one patient in each group. Hypotension, urine retention and need of antiemetic were high in GB. We can concluded that, ultrasound guided continuous femoral nerve sheath block offers a technically easy and safe method, with faster onset and better quality, for providing post-operative analgesia in patients undergoing internal fixation of fractured neck femur. However, it must be done under strict and complete aseptic conditions to avoid local infection which can spread to form psoas abscess

Sumatriptan and gabapentin for treatment of postdural puncture headache

Postdural puncture headache [PDPH] is one of frequent adverse complication of dural puncture. Although, it is a self limiting and non-fatal condition, its postural nature prevents the patient from performing routine activity and may make them anxious and depressed. In this study we evaluate a combination of sumatriptan and gabapentin for treatment of PDPH and compare it with sumatriptan or gabapentin as sole medication. ASA I and II 45 patients age between 20 and 40 years and non-parturient, who's developed PDPH after spinal or epidural neuraxial block was included in the study. Patients were randomized to receive either gabapentin 300 mg orally every 8 hours for one week group I, in group II patient was received sumatriptan 50 mg orally once daily for 3 successive days. In group III, patients received sumatriptan 50 mg orally every day for 3 days and gabapentin 300 mg every 8 hours for 7 days. PDPH was evaluated by using Visual Analog Scale [VAS], measured 20 min after patients assumed upright postures either sitting or standing. It was recorded before start the treatment as baseline and at 12, 24, 36, 48, 72 and 96 hours after. Satisfaction of patients with treatment was asked, after 4 days. Complications such as somnolence, dizziness, seizures, chest pain, nausea, vomiting and dry mouth were recorded. VAS was significantly low and patient satisfaction was high in group III when compared with the other two groups. Number of patients reported somnolence and dizziness were significantly high in group III compared to group I or II. Combination of sumatriptan and gabapentin could be beneficial for treatment of patients with PDPH, more than sumatriptan or gabapentin alone, as it relief the headache and decrease usage of epidural blood patch which is invasive and not safe procedure

Comparative evaluation of alfentanil with propofol or sevoflurane for endotracheal intubation in pediatric without muscle relaxant

Intubation without muscle relaxant may be needed especially in pedi-atric short procedure. Although suxamethonium produces rapid profound neuromuscular block, it have many potential problems. Non-depolarizing neuromuscular blocking agents are an alternative but, slower in onset and have a longer duration of action. Propofol and sevoflurane may provide adequate conditions for intubation without neuromuscular blocking agents in pediatric. We studied 60 ASA I or II children undergoing elective surgery. Patients allocated randomly to one of two groups. Group P [GP] received lignocaine 1mg kg[-1] followed by alfentanil 15micro kg[-1] 2 min before propofol 2.5 mg kg[-1] was given. In group S [GS] patients received lignocaine Img kg[-1] followed by alfentanil 15 microg kg[-1] and induction of anesthesia was done by sevoflurane start by 3% concentration, which increase gradually until end tidal concentration was 3%, Laryngoscopy and intubation was performed, in GP 1 min after propofol and in GS 3min after stabilization of end tidal sevoflurane to 3%. Intubation conditions were assessed and recorded. Duration of induction and intubation were estimated. Complications during induction, intubation, and after extubation were recorded. Patients with acceptable intubation conditions in GP were more by one than GS group, but these results were statistically not significant and unacceptable condition was equal in both groups, impossible intubation conditions happened only in one patient in GS. Induction time was significantly prolonged in GS, but intubation time did not show significant difference between both groups. Adverse effects, hypertension was occurred in one patient in GS. Hypotension and bradycardia were happened in one patient in GP. Only one patient, in GS, expressed laryngospasm and hypoxia which need suxamethonium to facilitate intubation. After extubation. laryngospasm and vomiting occurred in 1 and 2 patients in GS respectively and no patient in GP suffer from vomiting or laryngospasm. We concluded that, Induction with intravenous propofol or inhalational sevoflurane, in addition to intravenous alfentanil and lignocaine equally facilitate endotracheal intubation without muscle relaxant in pediatric patients. Induction time was significantly prolonged with sevoflurane bat intubation time, show; no significant difference

Small doses of rocuronium versus mivacurium for short procedures

Rocuronium bromide is a non-depolarizing muscle relaxant [NDMR]. It has a fast rate of onset of action, intermediate duration and rapid recovery. Mivacurium is a short acting [NDMR] that undergo rapid breakdown by plasma cholinesterase leads to rapid spontaneous recovery. In this study rocuronium, in two small doses 0.3 and 0.45mg/ kg were compared with mivacurium 0.2mg/kg as regard, intubations, onset, clinical duration and reversal either spontaneous or induced, using neostagmine and glycopyrrolate. This study divided into two parts. In part I, quality of neuromuscular block for intubation was studied, 90 patients were allocated randomly to one of three groups [n=30] to receive rocuronium 0.3mg/kg [group 1], rocuronium 0.45mg/kg [group 2] and mivacurium 0.2mg/kg [group 3]. Each group divided into two equal subgroups [a and b]. The trachea was intubated after 60 sec in subgroups la and 2a, after 90 sec in subgroup Ib, 2b and 3a and after 120sec in subgroup 3b. Intubating conditions were graded as excellent, good or poor. In part II, assessment of onset, clinical duration and time for reversal were studied. 90 patients were randomly assigned to one of three groups [n=30], group I received rocuronium 0.3mg/kg, group II received rocuronium 0.45mg/kg and group III received mivacurium 0.2mg/kg. The onset, maximum degree of block and clinical duration were measured. When T[25] was reached, the three groups divided into equal subgroups a and b. Subgroups la, Ila and IlIa undergo spontaneous recovery and subgroups Ib lIb and Illb were received neostagmine 50 micro g/kg and glycopyrrolate 10microg/kg. Results: The frequency of distribution of excellent and good in-tubating conditions were high in subgroups 2b and 3b, but the patients with excellent conditions were more in subgroup 3b, no patient with poor intubating conditions in both subgroups. There were no significant difference between the subgroups Ib, 2a and 3a regarding intubation conditions. The onset was significantly rapid in group II and slow in group III, clinical duration was significantly longer in group II compared with groups I and II. While there were no significant difference, in clinical duration of action, between groups I and II. When spontaneous recovery time TOP [0.7] compared, we found that group III had significantly short spontaneous recovery time. On the other side, group II had significantly long spontaneous recovery time. In groups I and II, the induced recovery time were much rapid than spontaneous. While in group III there was no significant difference between spontaneous or induced recovery. Rocuronium has minimal side effects, provides conditions more suitable for rapid tracheal intubation. With small doses 0.3 and 0.45mg/kg of rocuronium, clinical duration of action became short and recovery, especially induced, became rapid. Rocuronium can be used for short procedures, but a dose of 0.45mg/kg was more accepted as intubating dose especially when intubations were attempted after 90sec. A dose of 0.3mg/kg can be used as intubating dose only under adequate anesthetic depth. Mivacurium as short acting muscle relaxant may be beneficial for short procedures. Also, spontaneous recovery of mivacurium was significantly short while there was no significant difference in induced recovery when compared to rocuronium either 0.3 or 0.45mg/kg, but its delayed onset made it unsuitable for rapid intubations. The principal side effects of mivacurium are facial flushing and transient fall in blood pressure due to moderate histamine release. The duration of action of mivacurium is prolonged in patients with atypical plasma cholinesterase as well as those with end stage liver or renal disease. Mivacurium is indicated for short procedures when anticholinesterase agents must be avoided