Effects of combined prokinetic administration on gastric emptying in critically ill patients

Background and study aims: Combination of prokinetic drugs with different mechanisms of action is frequently used when feeding intolerance is not improved with a single agent. In this study, we evaluated the effect of combined infusion of neostigmine and metoclopramide on gastric passage in critically ill patients in the intensive care unit [ICU]

Patients and methods: This study is a randomized double-blind controlled trial in 90 patients between 20 and 60 years of age who were under mechanical ventilation and had gastric residual volumes [GRVs] >120 mL 3 h after the last lavage. Patients were randomly assigned to one of the following three groups: intravenous neostigmine 2.5 mg, intravenous metoclopramide 20 mg, and combination of both agents at the mentioned doses. Gastric volume aspiration was first performed before starting the study and then at 3, 6, 9, and 12 h after the infusion of study drugs was finished. Increase in gastric lavage was defined as an aspiration volume of >120 mL

Results: In total, 86 cases in the three groups completed the treatment [all 90 patients included in the study were analysed according to an intention-to-treat approach]. There was no significant difference detected at baseline in age, intubation duration, albumin, haemoglobin, haematocrit, total leucocytic count [WBC], Na, K, Mg, and sequential organ failure assessment score between the study groups. In the combination group, 96.7% of patients showed GRV improvement [GRV < 120 cc], whereas in the metoclopramide and neostigmine groups, 50% and 43.3% of the patients, respectively, showed improvement [p < 0.001]. The frequency of overall adverse effects in the metoclopramide, neostigmine, and combination groups were 3.3%, 16.7%, and 10%, respectively [p = 0.28]

Conclusions: The present results suggested that combination therapy with metoclopramide and neostigmine decreases GRV in critically ill patients with a higher efficacy than monotherapies

[Spinal anesthesia in renal transplantation]

Renal transplantation is the preferred therapeutic method for patients with end-stage renal disease. Patients with renal failure have significant associated medical conditions, such as cardiovascular disease. The suitable anesthesia for renal transplantation requires minimal toxicity for the transplanted organ, as well as sufficient pain relief and maintenance of optimal blood pressure and intravascular volume to keep renal functions. The aim of this study was to improve our experience of spinal anesthesia in patients undergoing renal transplantation. Sixty consecutive patients scheduled for elective renal transplantation over a period of two years who consented for spinal anesthesia were enrolled in the study. Intraoperative hemodynamic, intravenous fluids and infused blood products, duration of surgery, urine output and arterial blood gas and intensity of pain score in the recovery room were monitored. We also noted intraoperative and postoperative complications. Spinal anesthesia was satisfactory in all, but in five patients they required supplementation with general anesthesia for excessively prolonged surgery. There were no significant intraoperative hemodynamic changes. The total intravenous fluid used during surgery was 65.15 +/- 7.2 mL/kg, the mean surgical time was 170 +/- 22 min. The mean of mean arterial pressure [MAP] during the operation was 98 +/- 12 mm hg. There was no significant acidosis at the end of the operation [PH=38 +/- 0.03]. Also the mean intensity of pain was 4 +/- 2 in recovery and a few of patients suffered from bladder catheter bladder discomfort in the recovery room [8 patients]. Spinal anesthesia is a successful regional anesthetic technique in well selected patients for renal transplantation. A successful outcome in this technique is dependent on close intra-operative monitoring, optimization of intravascular fluid volume and keep the hemodynamic status in optimal range.

[Trigemino-cardiac reflex during skull-base neurosurgeries: a case report]

The Trigemino-cardiac reflex [TCR] has been studied as a phenomenon including; bradycardia, arterial hypotension, apnea and gastric hypermotility during manipulation of the peripheral or central parts of the trigeminal nerve. We report a case of a 26-year-old man undergoing surgery for a skull base extra axial tumor in right petrous bone suspected to metastasis of a previous renal cell carcinoma which had been treated four years ago. The patient presented with continuous and unilateral headache and difficulty in swallowing, sensory neural hearing loss, nasal speech and tongue deviation to left side. He underwent general anesthesia with standard monitoring and total intravenous anesthetic technique. The first episode of sudden onset bradycardia and hypotension related to surgical manipulation was detected intraoperatively in which the heart rate spontaneously returned to normal level once the surgical manipulation stopped. However, it repeated several times by beginning of tumor resection and manipulation in the region of trigeminal nerve. The intensity of bradycardia in subsequent episodes of TCR was relatively crescendo and had no fatigability. Finally, it was treated by administration of a single dose of atropine [0.5mg/IV] and did not happen again. The risk of TCR should be considered in any neurosurgical intervention involving trigeminal nerve and its branches, especially at the skull base surgeries. The vigilance of the medical team and continuous intraoperative hemodynamic monitoring alerts the surgeons to interrupt surgical maneuvers upon the TCR occurrence, immediately.

Inadvertent intrathecal injection of large dose magnesium sulfate

The case is a 35-year-old man who underwent spinal anesthesia for emergency strangulated inguinal hernia repair. About five minutes after 3 ml intrathecal drug injection, the patient suffered respiratory distress, bradycardia, hypotension and loss of consciousness. The patient was rapidly intubated and crystalloid infusion and epinephrine drip were established. Thereafter, he was admitted in intensive care unit. Search for the cause revealed us that 3 ml of magnesium sulfate [50%] was injected mistakenly for spinal anesthesia. Two days later, he was extubated and on the fifth day, he was discharged from the hospital without an obvious evidence of complication

[Evaluation of patient satisfaction with anesthesia care]

The assessment of patient satisfaction with anesthesia, the balance between expectations and perception of what was received, is an essential component of continuous quality improvement in anesthesiology. In our center there have been few studies conducted in the anesthesia field, which have assessed patient's satisfaction. In this prospective study we have evaluated patient satisfaction with anesthesia in patients 24 h after surgery. This study was performed in Sina hospital in Tehran, Iran on patients aged more than 18 yr. They all underwent elective surgical procedures with anesthesia. One of the anesthesia staff members took the interview one day after surgery and asked the patients questions for the structured questionnaire designed to measure patient satisfaction with anesthesia. At the same time, some specific questions were also asked to find factors that could be associated with such satisfaction. The data was gathered from 500 patients [mean age: 41 +/- 16 yr; and males: 65.2%]. The overall satisfaction [complete and relative] was high [98.8%]; although 6 patients [1.2%] were dissatisfied with their anesthesia care. After analysis of several factors related to the patients' surgery and anesthesia, a strong relation was found between spinal anesthesia and satisfaction [p=0.003].There was not any relation between age, gender, education, duration of anesthesia and kind of surgery with patients' satisfaction. Our study found that patient satisfaction with anesthesia was very high in our center and the only factor that increased patient's satisfaction was spinal anesthesia

Impact of subcutaneous infiltration of 0.5% bupivacaine on postoperative C-reactive protein serum titer after craniotomy surgery

Tissue injuries may provoke neuro-hormonal response which in tum may lead to release of inflammatory cytokines. We hypothesize that block of afferent sensory pathways by infiltration of 0.5% bupivacaine in the scalp may decrease neuro-hormonal response in the neurosurgical patient. After obtaining informed consent, forty ASA physical statuses I, II, or III patients between the ages of 18 and 65 years were emolled randomly into two equal groups to receive either 20 ml of 0.5% bupivacaine [group A] or 20 ml of 0.9% normal saline as a placebo [group B] in the site of pin insertion and scalp incision. As the primary outcome we checked serum C-reactive protein [CRP] levels before implementation of noxious stimulus, 24h, and 48h after the end of surgery to compare these values between groups. In addition, mean arterial pressure [MAP] and heart rate [RR] were checked at baseline [after the induction of anesthesia], one minute after pin fixation and 5, 10, and 15 minute after skin incision and the recorded values were compared between groups. No significant difference was found between serum CRP levels of the two groups. Comparison of mean HR between groups shows no significant difference. The mean of MAP was significantly lower in the group A in comparison with the group B [p< 0.001]. The results of this study confirm that 0.5% bupivacaine scalp infiltration before skull-pin holder fixation and skin incision could not decrease post-operative C-reactive protein level

[Evaluation of oral clonidine effects on prevention of post-anesthesia shivering]

Shivering is a common post anesthesia complication. Intravenous Clonidine administration at induction of anesthesia is a useful drug for decreasing of incidence and severity of post-anesthesia shivering. As Clonidine injection can induce side effects therefore we evaluated the oral Clonidine premedication on post-anesthesia shivering. In a RCT, 60 adult patients in ASA class 1 and 2 scheduled for cholecystectomy were assigned to 2 groups. 2 hours before anesthesia, 0.2 mg oral Clonidine was administrated and to the other group placebo was administered. Surgery room temperature was adjusted for 21-23[degree][c]. At the end of the anesthesia, the patients' shivering was evaluated in the recovery room by "Crossley andMahajan shivering score". There was no difference at decrease of SpO2 and H.R. and MAP between 2 groups. There was no difference in average time of emergence between 2 groups. Overall 75% of the patients shivered after anesthesia. Median shivering score in clonidine group was 1.97 and in placebo were 2.87. It became revealed that there was clear difference at shivering score between 2 groups [less severe or generalized shivering patients in test group]. 0.2 mg Clonidine tablet, 2 hours before anesthesia is similar to injecting drug and is effective in prevention of post-anesthesia shivering but its complication is less. Lack of difference at hemodynamics and SpO2 and emergence in our study may be due to slow absorption of oral Clonidine

Continuous sedation-analgesia delays diagnosis of compartment syndrome in a patient with intra-aortic balloon pump

Compartment syndrome is a rare, devastating complication of coronary artery bypass grafting [CABG] and intra-aortic balloon pump [IABP]. Prompt diagnosis is based on symptoms and signs and is paramount for limb rescue. This report describes a CABG patient with IABP in whom receiving continuous analgesia-sedation obscured the symptoms of compartment syndrome

Loss of consciousness secondary to lead poisoning

Diagnosis of lead toxicity could be difficult in IC setting because of overlap of signs and symptoms with other diseases. This is a report of two Iranian patients [father and son] with severe level of whole blood concentration, developing into unconsciousness

Malposition of central venous catheter in the left internal jugular vein - A case report

Malposition of central venous catheter is a complication of central venous catheterization. A case of left internal jugular catheterization via left external jugular vein is reported. Details of the procedure are described and the literature is reviewed for similar malpositions

evaluation of the possible effect of positive end expiratory pressure [PEEP] on pharmacokinetics of phenytoin in patients with acute brain injury under mechanical ventilation

Positive ventilation has shown to have an influence on pharmacokinetic and disposition of some drugs.Beacause phenytoin with a narrow therapautic range, is the most commonly used drug for prophylaxis and treatment of early seizures after acute brain injuries, in the present study the effect of short term PEEP [5-10 cm H2O for at least 8 hours] on phenytoin serum concentration and pharmacokinetic parameters such as Vmax and clearance in brain injured patients under mechanical ventilation was examined. Ten patients with moderate to severe acute brain injury who were placed on mechanical ventilation with an initial PEEP level of 0-5 cm H2O were included in the study. Patients received phenytoin loading dose of 15 mg/kg followed by a maintenance daily dose of 3-7 mg/kg initiated within 12 hours of loading dose. Sampels were taken on two different occasions before and after PEEP elevation. Total phenytoin serum concentrations were determined by HPLC method. A time invarient Michaelis-Menten pharmacokinetic model was used to calculate Vmax and clearance for each patient.Derrived variables were calculated as follows: Vmax, 3.5-6.8 and 3.7-8.2 mg/kg/day; Clearance, 0.1-0.7 and 0.1-1.2 l/kg/day [before and after PEEP elevation, respectively]. Our data have shown a wide range of variability [2.6-32.5 mg/l] in phenytoin serum concentrations. There were no statistically significant differences in the measured total concentrations [p=0.721] and calculated Vmax and clearance [p=0.285]before and after PEEP elevation. Administration of fluid and inotropic agents, limitation in application of higher levels of PEEP and drug interactions, shall be considered as possible explanations for these findings

Pharmacokinetic behavior of theophylline following PEEP in critically ill patients with acute lung injury

The effect of Positive End Expiratory Pressure [PEEP] on the hepatic elimination of low to moderate extraction ratio drugs has not been clearly defined. We prospectively investigated the effect of PEEP on the clearance of theophylline in 30 [20 males and 10 females] intubated critically ill adult patients with acute lung injury/acute respiratory distress syndrome [ALI/ARDS]. The Mean [ +/- SD] age was 57 +/- 17 years, creatinine clearance 86 +/- 36 ml/min, serum albumin 3.2 +/- 0.57 mg/dl and the median APACHE [acute physiology and chronic health evaluation] two score was 25 [with a range of 16 to 34]. Critically ill patients who had met the diagnostic criteria for ALI/ARDS were enrolled on PEEP in low [5-9 cmH2O] and high [10-15 cmH2O] levels. All patients received the ordered dose of aminophylline infusion [3 mg/kg over 30 min and then 15 mg/h] after 2 h of initiating PEEP. Blood samples were collected after the loading dose, 2 and 6 h the aminophylline continuous infusion. Vital signs were recorded before and after 2 h of PEEP and each blood sampling interval. Cirrhotic patients and those who had received any drug which could interact with the metabolism and clearance of theophylline, were not included. The Mean [ +/- SD] value of the pharmacokinetic key parameters of theophylline in high [n=17] and low [n=13] PEEP groups were as follows: Vd=0.42[ +/- 0.15] L/kg and 0.54[ +/- 0.13] L/kg, clearance = 0.035[ +/- 0.024] L/h/kg and 0.056 [ +/- 0.025] L/h/kg. Mean measured theophylline concentrations following loading dose were 7.08 mg/L and 5.09 mg/L. The calculated volume of distribution [P<0.03], clearance [P<0.05] and theophylline serum concentration [P<0.05], in high versus low peep group, were found to be significantly different. Positive ventilation tends to reduce Vd and clearance of theophylline in critically ill patients