Comparison of lidocaine and a combination of lidocaine and ketorolac pretreatment on withdrawal movement induced by rocuronium injection

Introduction: Rocuronium is a widely used monoquaternary aminosteroid nondepolarizing muscle relaxant of intermediate duration with a rapid onset to achieve optimal conditions for endotracheal intubations. The injection of rocuronium bromide during induction of anesthesia has often been associated with pain-induced withdrawal movement near the site of injection. It has been hypothesized that addition of ketorolac and Lidocaine in combination as pretreatment drugs among patients undergoing general anesthesia with rocuronium injection provides a better control of withdrawal movements in comparison to patients who receive only lidocaine. The objective of this study was to compare the efficacy of pretreatment of combination of ketorolac and Lidocaine and Lidocaine alone in the frequency of withdrawal movement associated with rocuronium injection in peripheral veins during intubation

Methodology: This study was conducted on 90 patients undergoing elective surgeries under general anesthesia in operation theater complex of our hospital. Patients were randomly divided in group A and B by lottery method. Group A received 20 mg lidocaine IV prior to rocuronium. Group B received lidocaine 20 mg and ketorolac 10 mg IV. General anesthesia was administered by induction via 5 mg/kg thiopental sodium in a separate peripheral intravenous line. Withdrawal movements were observed as mild, moderate and severe, and recorded on a well-structured performa. Efficacy was defined as no withdrawal movement on injecting rocuronium

Results: The differences in age and gender of patients were not significant in both groups and these were not associated with efficacy of treatment in the groups. However ASA status of the patients was significantly associated with efficacy of treatment groups. In Group-A 27[60%] and in Group-B 36[80%] patients had no withdrawal movement while mild movement was observed in 12[26.7%] patients in Group-A, and in 7[15.6%] patients in Group-B. Moderate movement was seen in 6[13.3%] patients in Group-A, and in 2[4.4%] patients in Group-B. The number of patients who had withdrawal movement was 18[40%] vs. 9[20%] in Group-A and Group-B respectively [p = 0.0384]. The criterion of efficacy was fulfilled by 27[60%] Group-A patients, compared to 36[80%] patients in Group-B

Conclusion: Results of this study showed that combination of intravenous lidocaine and ketorolac prior to rocuronium injection is more effective that lidocaine alone for preventing withdrawal movements for general anesthesia

Single scrotal incision orchidopexy for palpable undescended testis

To retrospectively asses the results of single scrotal incision orchidopexy [SSIO] performed at our centre with ligation of the patent processus vaginalis in children having palpable undescended testes [UDT]. Quasi-experimental with retrospective data. Department of Paediatric surgery Military Hospital Rawalpindi, from April 2007 to December 2011. After making a single transverse incision at superior scrotal border, the testis was identified; gubernaculum and the sac were dissected to the highest level and divided. The testis was places into the scrotum and fixed to the scrotal fascia/skin. All patients were assessed at 2 weeks, 2 months and 6 months post operatively, and then yearly. A total of 38 orchidopexies were performed in 33 patients. The patients' age ranged from 14 months to 7 years [mean: 2.1 years]. Bilateral UDT were found in 5 patients [15.1%]. Operative time ranged from 20 to 45 minutes [mean: 36 minutes]. The single scrotal incision technique was successful in all 38 cases [100%]. All testes were easily fixed in the scrotum. Two patients [5.2%] developed scrotal haematoma and one patient [2.6%] developed stitch abscess. All showed good anatomical and cosmetic results up to a minimum of six months of follow-up. Single scrotal incision orchidopexy for palpable undescended testis is a simple and safe technique. It has shown to consume shorter time and give good cosmetic results

Should we routinely expose recurrent laryngeal nerve[s] during thyroid surgery?

To compare the frequency of recurrent laryngeal nerve[s] [RLNs] palsy after various thyroid procedures with and without identification of recurrent laryngeal nerve during the operation. Randomized controlled trial. Department of Surgery, Military Hospital, Rawalpindi, from August 2008 to April 2010. Patients undergoing indirect laryngoscopy with normal vocal cords and those with carcinoma and re-do surgery having normal vocal cord were included in the study. Patients with hoarseness of voice, abnormal vocal cord movements and with solitary nodule in the isthmus were excluded. These patients were randomly divided into 2 groups of 50 each using random number tables. RLN was identified by exposing the inferior thyroid artery and traced along its entire course in group-A. Whereas, in group-B, nerves were not identified during the operations. Immediate postoperative direct laryngoscopy was performed by a surgeon with the help of an anaesthesiologist for the assessment of vocal cords. Patients with persistent hoarseness of voice were followed-up with indirect laryngoscopy at 3 and 6 months. Temporary unilateral recurrent laryngeal nerve palsies occurred in 2 [4%] patients in group-A where the voice and cord movements returned to normal in 6 months. In group-B, it occurred in 8 [16%] patients, 2 bilateral [4%] injuries requiring tracheostomy and 6 unilateral injuries [12%]. Among the 2 bilateral recurrent laryngeal nerve injuries, the tracheostomy was removed in one case after 6 months with persistent hoarseness of voice but no respiratory difficulty during routine activities. Tracheostomy was permanent in the other case. Among the 6 cases of unilateral nerve injuries, the voice improved considerably in 4 cases within 6 months but in 2 cases hoarseness persisted even after 6 months. Frequency of recurrent laryngeal nerve palsies was significantly lower in group-A as compared to group-B [p = 0.046]. For safe thyroid surgery, recurrent laryngeal nerve[s] should be routinely exposed in its entire course

Prevention of post spinal hypotension; comparison between preloading with and without intramuscular ephedrine in elderly patients undergoing inguinal hernia surgery

Objective of the study is to evaluate the efficacy of intramuscular ephedrine along with preloading in prevention of post spinal hypotension in elderly patients undergoing inguinal hernia surgery. This is a quasi experimental study. The study was conducted at the department of Anaesthesia and Intensive Care Combined Military Hospital, Peshawar over a period of one year. In a double-blind, randomized study, 80 elderly patients undergoing inguinal hernia surgery under spinal anaesthesia divided into two equal groups of A and B. Forty patients received i/m inj of ephedrine 45mg deep in the paravertebral muscles immediately after injection of bupivacaine, and 40 received an equal volume of saline. Patients in both groups were given the same volumes of fluid before anaesthesia. The incidence of hypotension [Systolic arterial pressure <90mmHg or <80% of baseline] were recorded. and incidence of fall in the heart rate was recorded. Systolic arterial pressure during the first 60 min after anaesthesia remained significantly more stable in the ephedrine-treated group, and there was also a significantly smaller number of patients in this group who had decreases in pressure of more than 30% of pre-block levels and fewer required rescue i.v. Ephedrine. An increase in heart rate or systolic pressure of > 20% from baseline was found in two patients in the ephedrine group and in one patient in the placebo group. We conclude that ephedrine 45mg administered in the paravertebral muscles immediately after plain bupivacaine spinal anaesthesia is a simple and effective means of reducing the incidence of hypotensive episodes in the elderly patient

Comparison of haemodynamic changes following tracheal intubation by using laryngoscope with intubating laryngeal mask airway

To compare haemodynamic changes following tracheal intubation using direct laryngoscopic technique with intubating laryngeal mask airway technique. Randomized control trail [RCT]. Military Hospital Rawalpindi from Jan 2008 to Dec 2008. After approval by the hospital ethics committee, 100 patients admitted for elective surgery from OPDs were randomly distributed equally in groups I and II for either direct laryngoscopy or laryngeal mask airway intubation respectively, as a part of general anaesthesia. A uniform protocol of general anaesthesia was followed. Heart rate and mean blood pressure were recorded before and at 1, 3 and 5 minutes after intubation. It was observed that increase in mean arterial blood pressure and heart rate at 1 and 3 minute was significant in patients intubated with laryngoscope as compared to patients intubated with Intubating laryngeal mask airway [ILMA]. Intubation with ILMA produces less haemodynamic response as compared to direct laryngoscopy

Tracheal intubation; direct laryngoscopic oral intubation vs fiberoptic bronchoscopic nasal intubation haemodynamic response

Haemodynamic response to direct laryngoscopy and tracheal intubation has always been concern especially in cardiac patients. The use of fiberoptic bronchoscope for endotracheal tube placement may reduce the haemodynamic changes associated with intubation. To compare haemodynamic changes [pulse and mean arterial pressure] following tracheal intubation, using direct laryngoscopic technique with fiberoptic bronchoscopic technique. Randomized Controlled Trial [RCT]. Department of Anaesthesiology, Intensive Care and Pain management Military hospital Rawalpindi. The study was of six months duration starting from April 2008 to October 2008. ASA-I and II patients [n=160] undergoing surgery meeting the inclusion and exclusion criteria.Informed consent was taken from all the patients undergoing the study. Patients were divided in two groups. Patients assigned to Group A got endotracheal intubation through direct laryngoscopic technique and Group B through fiberoptic bronchoscopic technique after induction of general anaesthesia. Pulse and Mean arterial pressure were recorded before induction of anaesthesia and three minutes after the intubation. One hundred and sixty patients were studied. Eighty patients intubated through direct laryngoscopy [Group A] and eighty patients intubated through fiberoptic bronchoscope and it was observed that fiberoptic bronchoscopic intubation is haemodynamically safer as compared to conventional laryngoscopic intubation. The study concluded that bronchoscopic intubation provides better haemodynamic stability than direct laryngoscopic intubation

Post operative analgesia following open cholecystectomy; is intermittent epidural bupivacain bolus administration more effective than continuous administration?

Pain following surgery is a universal phenomenon; it is often underestimated and undertreated. Epidural analgesia is considered to be the best method of pain relief after subcostal cholecystectomy. Epidural is effective technique that offers comparable analgesia and better side effect profile. Quasi Experimental study. Jan2010 to June 2010. Military Hospital Rawalpindi. This is a prospective, randomized control trial. The main objective of this study was to compare the number of rescue doses for postperative pain relief, after subcostal cholecystectomy under epidural anesthesia, in patients receiving continuous epidural infusion of bupivacain 0.125% with those receiving intermittent boluses. Thoracic epidural catheter was placed for post operative pain relief. Patients were divided into two equal groups. Patient receiving continuous epidural anaesthesia were placed in group A and those receiving intermittent doses were included in group B. Purposive [non probability] sampling. Patient who received intermittent boluses [group B] required less rescue doses of nalbuphine as compared to the patients who received continuous infusion of 0.125 bupivacain. Intermittent boluses of 0.125% bupivacain are considered a better method of postoperative pain relief than continuous infusion of 0.125% bupivacain

Epidural analgesia in labour; maternal and fetal outcome

To evaluate the effects of epidural analgesia on the pain relief and maternal and fetal outcome. Comparative and analytical study. In Military Hospital Rawalpindi from Oct 1998 to Oct 1999. 100 full term healthy primigravida admitted for induction of labour. Fifty patients were given epidural analgesia and 50 served as control to whom no analgesia was given. Outcome measures observed were duration of labour, mode of delivery; Apgar score of the newborn; untoward reaction and intra-partum complications. The data analysis revealed that epidural analgesia significantly prolonged labour time and was associated with increased instrumental delivery rate. Significant reduction in intra-partum fetal complications was seen, while C-section rate was not effected by epidural analgesia. Apgar scores were higher in analgesia group as compared to control. Although accused of prolonging labour time, it's benefits in terms of great maternal satisfaction and reduced intra-partum complications still makes it an option for labouring patients

Circumcision; caudal epidural block with single dose bupivacaine compared with tramadol for post operative analgesia in children

To compare the quality of postoperative analgesia with single dose Bupivacaine and that of Tramadol in caudal epidural block for circumcision in children. Interventional experimental study. This study was carried out in the department of anaesthesia and pain management at Combined Military Hospital Peshawar. Jun 30, 2004 to Mar 2005 and then from Dec 2006 to Feb 2007. Sixty [60] children between the ages of 2-6 year were included in study. They were divided into two groups by convenience non- probability technique and each group had 30 children. Group A [n=30] was given 1.25mg/kg Bupivacaine, 0.25% solution, whereas Group B [n=30] received 2mg/kg of Tramadol. The volume of drug in each group was 0.5ml/kg. Standard monitoring was done perioperatively. The analgesic effects were evaluated by using Hannallah pain score scale6, which had maximum score of 10 arid mininium of 0 [zero]. The score of 3 or <3 was considered as adequate analgesia. Sedation was assessed by using 5-point sedation test. 0 - Awake, 1 - mild sedation, 2 - feeling sleepy, 3- sleepy but able to wake, 4 - Deep sleep difficult to wake. Both the groups were comparable with respect to age, sex and duration of surgery. Insufficient pain control was observed in 4 patient's in-group B [Tramadol group], 13% and 7 patient's in-group A [Bupivacaine group], 23%, 30 minutes atter caudal administration of drug. Adequate postoperative analgesia was maintained in all other patients for 12 hrs. Only 6 patients in Tramadol group had light sedation [p=0.012]. Weakness of lower limbs was found in 4 patient's in-group A there was no difference in vital signs and there was no complication related to technique in both groups. Caudal administration of Tramadol in the dose of 2mg/kg when compared with 0.25% Bupivacaine in children under going circumcision provided similar quality of analgesia for 12 hours with out any requirement of rescue analgesic

Anaesthetic technique in paediatric patients with ankylosed temporomandibular joint

This study was carried out to evaluate the anaesthesia technique in 50 cases of severe trismus because of ankylosed temporo-mandibular joint. Patients managed successfully between years 1999-2002 are reported. A technique for securing the airway by blind nasal intubation, a combination of halothane, oxygen and nitrous oxide through a facemask and ventilation through a nasopharyngeal airway or nasotracheal tube was used. Increments of propofol mixed with lignocaine plain 2% were used to obtain adequate depth of anaesthesia.The technique was studied to find out the difficulties and failure rate in achieving the nasotracheal intubation. By applying gentleness in manipulation and patience, airway was secured in 1-3 attempts. Tube position was confirmed by chest auscultation and capnography. Only ten patients [20%] could be intubated in first attempt, while thirty patients [60%] could be intubated in second attempt and remaining ten [20%] in third attempt. There was no failure, no patient required preoperative tracheostomy. Adequate mouth opening was achieved in 100% cases at the end of surgery. Although we achieved a 100% success in intubation on multiple attempts, the expertise is definitely required. However the need of a fiberoptic laryngoscope cannot be overlooked