feasibility of spinal anesthesia with sedation for laparoscopic general abdominal procedures in moderate risk patients

One of the major advantages of laparoscopic surgery is minimizing postoperative morbidity. The previous limitations to the use of spinal anesthesia in laparoscopic surgery were the limited work space, high failure rate, more intra-operative morbidity and significant arterial blood gas alterations. However, the addition of a small-dose Ketamine infusion to propofol might provide a suitable sedative combination to be used with high spinal anesthesia, producing titerable sedation, increased hemodynamic stability, and minimal respiratory depression. At KFSH and RC Hospital, after Ethical Committee approval and informed written consent, 18 ASA III patients scheduled for various laparoscopic abdominal procedures were enrolled. Exclusion criteria consisted of ejection fraction below 45% and or peak expiratory flow rate and forced vital capacity of less than 65% of predicted values. Following oral premedication with midazolam 7.5-10 mg 30 min preoperatively, spinal anesthesia was conducted by bupivicaine 0.75% 3-3.5 ml at L3-4, in the lateral position to reach a sensory level at T4. Sedation was started by intravenous injection of 0.4 mg/kg propofol and 0.1 mg/kg ketamine prior to spinal anesthesia. This was followed by infusion of 1.0-1.5 mg/kg/h and 0.3-1.0 mg/kg/h. of the same drugs respectively. The sedation requirements were adjusted to keep the patient sleepy with conservation of airway reflexes at level 3 on a 5 point sedation score. Heart rate, respiratory rate and SpO[2] were monitored, together with direct arterial blood pressure monitoring and arterial blood gas analysis through arterial cannulation. Postoperative first time call for analgesia, total morphine consumption during the first hour and incidence of complications were recorded. Twenty Four hours later, surgeons' and patients' satisfaction were obtained and recorded. Heart rate and mean arterial blood pressure were significantly decreased after spinal anesthesia and intra-peritoneal insufflations of CO[2], with significant increase in arterial carbon dioxide tension accompanied by increase in the respiratory rate. The increase in respiratory rate led to gradual decrease of CO[2] level down to near the pre-operative PaCO[2] values. However, there was insignificant decrease in oxygen saturation throughout the intra-operative time. Postoperatively there were excellent surgeon and patient's satisfaction. Only one patient regained sensation before completion of surgery and sedation was deepened to level 5 sedation score. The mean surgical time was 98.5 +/- 21.4 min while the mean anesthesia time was 117.7 +/- 20.1 min. First mean time call for analgesia was 50 +/- 8 min. 7/18 patients required single dose of morphine of 4 mg during the 1[st] hour postoperatively. The addition of a sedative combination of ketamine and propofol to spinal anesthesia was found to be safe and efficient from both the anesthetic and surgical point of view, especially for sick patients with intermediate clinical predictors

Thoracic para vertebral block in mastectomy: role of adjuvants

This study was designed to investigate whether the addition of ketamine or neostigmine to bupivacaine would enhance the quality of intra- and postoperative analgesia for thoracic paravertebral block in breast surgery. 45 patients, scheduled for mastectomy were randomly divided into three equal groups using sealed envelops technique to receive one of the three study drugs. Group B received 2mg.kg[-1] [max 150 mg] bupivacaine 0.5% with epinephrine [2.5 mcg-mI[-1]]. Group K, received bupivacaine as group B plus Ketamine 0.5mg.kg[-1] and Group N received bupivacaine as group B plus Neostigmine 2 mcg.kg[-1]. All patients received midazolam premedication 5-10 mg orally 45 min before surgery and 1 mg IV Granisetron [Kytril] as prophylactic anti-emetic. Thoracic Para-vertebral Block [TPVB] was applied at levels of 1st [1/3 of the dose] and 4[th] [2/3of the dose] thoracic vertebra. All patients received general anesthesia with LMA after induction with propofol 2-3 mg/kg, and patients were kept spontaneously breathing. All patients received 75mg Diclofenac IV infusion over 30 min and Ranitidine 50 mg IV. Intra-operative rescue analgesia was fentanyl 1-2 micro g.kg[-1] as required. In Post Anesthesia Care Unit [PACU], fentanyl 0.25-0.50 mcg.kg[-1] IV as a rescue medication, every 10 minutes as needed to control postoperative pain. Postoperative patient controlled fentanyl analgesia [PCA] was used. Heart rate [HR] and Mean Blood Pressure [MBP] were measured pre-operatively [baseline], 30 min after incision, on admission to Post Anesthesia Care Unit [PACU], and on discharge from PACU [2 hours postoperatively]. Postoperative Pain evaluated by Numerical Rating Scale [NRS] was assessed on admission to PACU, on discharge from PACU and every 2 hours postoperatively for 24 hours. Intraoperative fentanyl consumption and 24 hour postoperatively was recorded patient satisfaction: was evaluated using a 5- points verbal score. Demographic and clinical characteristics were comparable in the study groups. There was significant decrease in MBP in group B compared to the base line, while there were insignificant changes in MBP in all groups during the rest of measured time interval. There were insignificant changes in HR in all groups during the study period. There was significant increase in the total amount of ephedrine in group B compared to groups K and N. A similar small number of TPVB patients in each group required intraoperative fentanyl suggesting inadequate or block failure. The mean 24 hour rescue fentanyl consumption was significantly decreased in Group K and Group N Versus Group B. Pain scores were significantly reduced in groups K and N compared to group B. There were no incidence of nausea or vomiting occurred during the study period. No patient in the study groups experienced hypotension, hypertension or bradycardia at any measured time interval postoperatively. Overall, patient satisfaction was significantly higher in groups K and N versus Group B. Addition of ketamine or neostigmine to bupivacaine in paravertebral block would enhance the quality of intra- and postoperative analgesia for mastectomy surgery with excellent patient satisfaction

Living donor hepatectomy [LDH]: comparative study between two different anesthetic techniques

Living donor hepatectomy [LDH] is now widely used to meet the need for liver grafts due to the shortage of cadaveric livers. Donor safety and perioperative anesthetic management are our major concern. The aim of our study was to compare two anesthetic techniques for management of living donor hepatectomy. After ethical committee approval and informed written consent, 20 donors ASA I physical status undergoing hepatectomy for living-relative liver transplant were allocated randomly to one of two groups. Group A where anesthesia was induced with fentanyl 2 micro g/kg and propofol 2-3 mg/kg -1, and maintained with isoflurane 0.8-1.2% and fentanyl infusion 1-2mcg/kg -1/h -1. In group B anesthesia was induced with sufentanyl 0.2mcg/kg -1, and propofol 2-3mg/kg -1, and maintained with propofol infusion 6-12 mg/kg -1/h -1, and sufentanyl infusion 0.2-0.4mcg/kg -1/h -1. Atracurium was the muscle relaxant for intubation and maintenance in both groups. There were no perioperative mortality in both groups, no significant statistical differences between both groups as regard demographic data, duration of surgery, duration of anesthesia, hospital stay, intraoperative hemodynamics, blood loss, liver function tests [PT, AST, and ALT] measured in the first, third, and seventh days postoperative. In conclusion, our study demonstrated that both anesthetic techniques were well tolerated for living donor hepatectomy, with no blood transfusion required, with short and safe discharge from PACU and short hospital stay, but with significant laboratory changes reflecting transient impairment in metabolic liver function. These procedures have proven useful as an important alternative to the cadaveric liver transplantation. Both techniques can be used as fast tract technique for living donor hepatectomy

Low molecular weight hydroxyethyl starch 130/0.4 versus albumin 5% in pediatrics undergoing abdominal tumor excision

Hydroxyethyl starchs [HES] have the advantage of a higher plasma-expanding effect and an infrequent incidence of allergic reactions, but they have more pronounced effects on emostasis. A new HES with a lower in vivo molecular weight [HES 130/0.4] has been introduced

The aim of this study was to compare the effect of hypervolemic haemodilution of the ecently available low molecular weight hydroxyethyl starch 130/04 and albumin 5% on the hemostatic function, renal function and blood loss during laparotomy for abdominal tumor excision Forty six children with age range between 3 and 5 years were enrolled in the study. Patients were randomly allocated after induction into two groups ; Group I patients received either 6% HES 130/0.4 as a hypervolemic hemodilution with a dose of 25 ml/kg over one hour oreoperativly. Group II [control group] patients received Albumin 500 as a hypervolemic hemodilution with a dose of 25 ml/kg

Measurements: hemoglobin and hematocrit, PT, partial thromboplastin time [PTT], platelet count, serum creatinine, urine out put were measured. Blood losses at the end of surgery were calculated using the equations developed by Mercuriali and lnghilIeri, considering sex, preoperative body weight and hemotocrit and volume of blood transfusion

Results: The mean intra-operative blood loss in group I was 362.8 +/- 4.5 ml, whereas it was 374.1 +/- 3.2 ml in group II, there was no statistically significant differences in the mean blood loss in both groups .There was no statistically significant difference in all other measurements in both groups

Conclusion: The new low molecular weight hydroxyethyl starch 130/0.4 up to 25 ml/kg hypervolemic hemodilution have similar blood loss without effect on hemostatsis and renal function similar to albumin 5% during laparotomy for abdominal tumor Excision in Pediatrics abdominal tumor excision in pediatrics

Perioperative anesthetic management of liver transplantation: a retrospective analysis of King Faisal Hospital experience

Background: Liver transplantation is the accepted standard of care for patients with End Stage Liver Disease [ESLD]. Since the liver transplant programme restarted in King Faisal Specialist Hospital and Research centre in 2001 and results have been improving. We review the overall results of liver transplantation over the last 6 years

Patients and Methods: Characteristic of patient population: Data retrospectively reviewed between April 2001 to January 2007 years, our center performed 122 liver transplantations, 77 from deceased donors [DDL T], and 45 from living donors [LDLT], in 118 patients 4 cases were retransplanted. Perioperative Management: All patients were evaluated preoperatively according to the institute protocol. All patients received general anesthesia according to our protocol. Swan Ganz‘catheterization and Rapid Infusion System [RIS] only used when clinically indicated most of the patients were assisted by mechanical ventilation in Medical Surgical Intensive Care Unit [MSICU] postoperatively. Fluid therapy and vasoactive agents were managed according to haemodynamic parameters

Results: The patients were 68 male and 54 female. Their median age was 43 years, ranging from 2 to 63 years. 111 patients were adult and 11 patients were pediatrics. In DDLT the median operating and anesthesia time were 8 hours [range 4-19], and 9 hours [range 5-20] respectively, median MSICU discharge time 15 hours [range 9-85] and hospital stay was 13 days [range, 6-183]. After a median fol/ow-up period of 760 days [range, 2-2085], the overall patient and graft survival rates was 86%. Deaths were due to primary non-function in 4 patients, central pontine myelinolysis in one patient, chronic rejection in one patient, recurrent malignancy in 2 patients, and recurrent HCV infection in 3 patients. In the LDLT group; median operating and Anesthesia time were 11 hours [range, 7-17] and 12 [range 818] respectively. Median MSICU discharge time was 16 hours [range 4-76] and median hospital stay was 15 days [range, 7-127]. After follow-up period of 685 days [range, 26-1540], the overall patient and graft survival rates were 90% and 80% respectively. Graft failure and deaths were due to hepatic an‘ery thrombosis in 2 cases, biliaIy complication in one patient, uncontrollable bleeding in one patient, portal vein thrombosis in 2 cases, and smalI-for-size-syndrome in 3 patients. Four patients were successfully retransplanted using cadaveric organs. The median intraoperative packed red blood cells [PRBCs] transfused was 6 units [range 0-40] and 4 units [range 0-65] in DDLT and LDLT groups respectively

Conclusions: Both DDLT and LDLT are being successfully performed at KFSH and RC with good outcomes. Our early experience indicates higher rate of biliary and vascular complications in the LDLT group. Intraoperative Packed Red cells, blood products, fluid replacement and estimated blood loss in both groups were matching the international centers results

Comparative study to evaluate three different techniques to attenuate haemodynamic response to propofol in patients with end stage renal disease [ESRD]

Propofol is the most common induction agent used in anaesthesia practice. However, it has some properties that limit its usefulness when used in critically ill patients. The aim of the present study is to compare the efficacy of pre-induction administration of ephedrine 200 mcg.kg-1, phenylephrine 1 mcg.kg-1 or ketamine 500 mcg.kg-1 against the anticipated hypotensive effect of propofol in patients with end stage renal disease [ESRD]. Eighty patients ASA physical status III -IV scheduled for creation of Arterio-Venous fistula [A-V Fistula] under general anesthesia with laryngeal mask airway [LMA] were included in the study. Patients were randomly allocated to one of four groups of 20 patients each to receive 2 ml of normal saline [Control group], 200 mcg.kg-1 of ephedrine [Group E], phenylephrine 1mcg.kg-1 [Group P], or ketamine 500 mcg.kg-1 [Group K] IV diluted in 2ml of normal saline one min before the induction of anesthesia. After haemodynamic baseline measurements, fentanyl 0.5 1.0 mcg.Kg-1 was given IV as a bolus. Anesthesia was induced 2 min later by using propofol 1.5 mg/kg over 30 s. If required, further increments of propofol 0.5 mg.kg-1 were given at 1 min and repeated every 30 s until loss of consciousness. Rescue medications with ephedrine 100 mcg.kg-1 was given if the SAP decreased to <80 mm Hg. Atropine 0.5 mg was given if the HR decreased to <45 bpm. Systolic Blood Pressure [SBP], Mean Arterial Pressure [MAP], and Diastolic Blood Pressure [DBP] at 3, 1, and 0 min before and 2, 5, and 10 min after induction of anaesthesia. Total fentanyl consumption in Post Anesthesia Care Unit [PACU] was recorded. There were no differences among studied groups in the distribution of age, sex; body weight; duration of surgery and duration of anesthesia .There were significant decrease in MBP in Control Group [C] 2 min after propofol induction and significant increase in MBP in Ephedrine Group [E] 10 min after induction. There were short-lived changes in HR 2min after induction in groups [E] and [P], with significant increase and decrease receptively. While, there was short-lived increase in HR 5min after induction in Control group [C] .Number of patients required rescue ephedrine was 16, 5, 2, and 1 in group C, E, P and K respectively with significant statistical increase in Control Group [Group C] [P<0.01]. Fentanyl consumption in PACU was significantly decreased in Ketamine group [K] in comparison to other groups. In conclusion, our study shows that Pre-induction IV injection of ephedrine, phenylephrine or ketamine are equally effective in maintaining haemodynamic during propofol induction in ESRD patients undergoing Arterio-Venous Fistula Creation. In addition ketamine not only has stable haemodynamic effect but also, has analgesic effect and reducing the post operative analgesia requirement

influence of bilateral superficial cervical plexuses block [BSCBs] as pre-emptive analgesia on patient satisfaction after thyroid surgery

Superficial cervical nerve block may reduce post-thyroidectomy pain. The aim of this study was to evaluate the influence of BSCBs as pre-emptive analgesia on patient satisfaction post- thyroidectomy surgery. Fifty adult patients were randomly allocated to one of the two groups, to receive either 20 mL isotonic sodium chloride solution [Saline group] or 20 mL bupivacaine 0.25% [Bupivacaine group] as BSCBs before induction of general anesthesia. Thyroid surgery was performed according to a standardized procedure by the same surgeon. Patients were transferred to the PACU where they stayed for 2 h, then were transferred to the ward. Morphine was administered in PACU following a standardized protocol [1-2 mg repeated every 10 minutes until the pain was controlled] if the VAS score was >/= 40 mm. Postoperative pain: was assessed by visual analogue scale [VAS], with 100 being the worst pain and 0 being no pain, by a nurse trained in pain assessment when patient is fully awake and extubated [H0], before discharge from the PACU [H+2], and every 4 h until 24 h after the end of surgery. Was evaluated the day after surgery by the anaesthetist using a 5- point verbal score [0: poor; 1: moderate; 2 good; 3: very good; 4 excellent. Total amount of morphine used in PACU and after 24hours. All adverse effects were recorded. There were no significant statistical differences between both groups as regard demographic data, duration of anesthesia and duration of surgery. The main outcome variables were pain scores [VAS], the proportion of patients given morphine at PACU and 24-h after surgery as well as the amount of morphine required. The Bupivacaine group had a smaller proportion of patients given morphine [24% vs. 72%; P = 0.0016] and [40% vs. 84%] in PACU and 24 hour after surgery respectively. Patients given BSCBs had significantly lower VAS with excellent satisfaction. We conclude that bilateral superficial cervical plexus blocks significantly reduce pain intensity and Opioids requirement in the postoperative period after thyroid surgery with excellent patient satisfaction

Intra-peritoneal bupivacaine alone or in combination with morphine patients undergoing vertical bypass gastroplasty

Intra-peritoneal instillation of local anesthesia and morphine has been used to alleviate post-operative pain in laparoscopic surgery. Controversy exists about the efficacy of this technique. We studied 48 patients scheduled for Vertical Bypass Gastroplasy [VBG]. All of them received the same technique of general anesthesia [GA]. Patients were randomly allocated into four equal groups. They received equal volumes of the test drug instilled in the peritoneal cavity at the end of laparoscopy, 50 ml of normal saline [Group S]: 50 ml of bupivacaine 0.25% [Group B], 50 ml of bupivacaine 0.25%, plus morphine 40 mcg.kg-1 [maximum of 5 rug] Group M or [Group D] patients received the same regimen as Group M in addition, they received 75 mg intra-muscular diclophenac after induction of general anesthesia. Wound edges were infiltrated with 10 ml bupivacaine 0.25% in all patients. Morphine 25-50 mcg.kg-1 was given intravenously every 10 mm as a rescue analgesic to control postoperative pain in Post Anesthesia Care Unit [PACU]. Post operative pain was evaluated using Visual Analogue Scale [VAS]. vital signs and morphine consumption, and time to receive rescue analgesia were measured at different intervals. The incidence of post-operative complications [respiratory depression. oxygen de-saturation. arid nausea and vomiting] was recorded as well as hospital stay. There was significant decrease in VAS, HR. MBP and morphine consumption in Groups M and D when compared to Groups S and B on admission and on discharge from PACU. There were significant decrease in time to receive rescue analgesia as well as significant reduction in hospital study in Groups M and D when compared to Groups S and B. However, there was no significant difference between group S and B regarding the same parameters. The presented technique is safe and easy to use with good postoperative morphine sparing analgesia, excellent patient satisfaction and short hospital stay