Neostigmine intrathecal and transdermal nitroglycerine augment intrathecal bupivacaine-fentanyl postoperative analgesia following lower limb surgery

Sixty patients were scheduled for lower limb operations. Their age ranged from 24 to 49 years [mean 41.7 +/- 6.4]. Patients were divided into four groups each group included 15 patients. All patients were given intrathecal bupivacaine - fentanyl, plus group [I] was given [non transdermal nitroglycerine patch] as placebo, group [II] transdermal nitroglycerine patch 5mg /24 hours, group [III] intrathecal neostigmine 10 ug and [non transdermal nitroglycerine patch] as placebo and group [IV] transdermal nitroglycerine patch 5mg /24 hours plus intrathecal neostigmine 10 ug. All groups were assessed for intraoperative and a period of postoperative 24 hours for vital parameters, postoperative analgesia and duration of effective analgesia as time from intrathecal drug administration to the patients first requested for analgesic medication, adverse side effects and total dose to control pain in 24 hours postoperative. Results of this study revealed multiple drug combination may be useful in extending postoperative analgesia of spinal bupivacaine - fentanyl associated with transdermal nitroglycerine patch and neostigmine intrathecal .Suggesting that transdermal nitroglycerine patch and neostigmine may enhance each other's antinociceptive effects at the dose studied

Comparative study between hyperbaric spinal levobupivacine and racemic bupivacaine in orthopaedic surgery

Levobupivacaine is the isolated Senantiomer of bupivacaine and may be a favorable alternative to spinal bupivacaine. However, its clinical efficacy relative to bupivacaine and its dose-response characteristics, in spinal anesthesia, must first be known. This, double-blinded randomized, study was designed to compare the clinical efficacy of hyperbaric levobupivacaine and bupivacaine for spinal anesthesia. Forty patients undergoing elective lower limb orthopaedic surgeries received either 3.5 mL levobupivacaine 0.5% hyerbaric or 3.5 mL bupivacaine 0.5% hyerbaric. Sensory blockade was assessed with the pinprick test; motor blockade was documented by using a modified Bromage score. Haemodynamic variables [e.g., blood pressure, heart rate, pulse oximetry] were also recorded as well as time for discharge criteria. In both groups sensory and motor block were similar between the same doses of levobupivacaine and bupivacaine [P > 0.06]. The duration of motor block at the quadriceps was 281 +/- 48 versus 284 +/- 4.2 min levobupivacaine and racemic bupivacaine respectively. Intergroup differences between levobupivacaine and bupivacaine were insignificant both in respect to the onset time and the duration of sensory and motor blockade [11.8 +/- 1.4 versus 12 .4 +/- 1.1 min; 10 +/- 3 versus 9 +/- 3 min; 225 +/- 50 versus 235 +/- 47min; 281 +/- 48 versus 284 +/- 42 min]. There were no statistically significant differences between the two groups except for the fact that the transition from Bromage scale 0 to 2 was significantly faster in the Levobupivacaine [4 +/- 1 min] than in the Bupivacaine group [7 +/- 2 min]. By comparison, there was no significant difference in first VAS scores at the PACU [3.1 +/- 0.5] in the Levobupivacaine versus [3.4 +/- 0.8] in the bupivacaine group. In both groups slight reductions in heart rate and mean arterial pressure were recorded, but there was no intergroup statistical difference haemodynamic parameters. There was no significant difference with regards time until achievement of discharge criteria. We conclude that intrathecal levobupivacaine is equal in efficacy to racemic bupivacaine

Prognostic values of intracranial pressure monitoring in severe closed head injury

The increased intra cranial pressure is the most significant factor determining morbidity and mortality in patients with severe closed head injury. The continuous monitoring of the ICP is very useful in assessing the ICP dynamics. The purpose of this study was to assess the effect of continuous ICP monitoring in determining the outcome of severe head injury. And how far ICP monitoring can limit the indiscriminate use of therapies to control ICP which themselves can he potentially harmful. Forty patients with severe head injury, with Glasgow Coma Scale [GCS] 8 or less, were involved in this study. On arrival to casualty unit, resuscitation started, general examination was done to assess cardiopulmonary system, and to detect any other associated injuries. All patients were intuhated, sedated, and ventelated. Intubation was facilitated with succinyl choline. Intracranial pressure [ICP] monitoring is done via ventricular catheter using hemodynamic monitor. Monitoring was continued for 48 hrs in controlled cases, and it was contintied when ICP was not controlled. Control of intracranial pressure was done by: I] -Brain dehydrating measures. II]-Dexamethason. III]-Cerebrospinal fluid drainage, and If ICP was still persistently elevated, trials were made to elevate mean arterial pressure [MAP] by using volume expansion and inotropics. These measures used to maintain cerebral perfusion pressure [CPP]. CT scan was done for all patients. Mean arterial pressure [MAP] and cerebral perfusion pressure [CPP] were measured and the injury admission time was recorded for all patients. The outcome was assessed according to Glasgow Outcome Scale. The outcome was divided into two groups: favorable outcome group and unfavorable outcome group. As regard to ICP, it's found that: 35% of cases had ICP<20 mm Hg. 64% of this group had favorable outcome while 36% had unfavorable outcome, Glasgow Coma Scale was >5 in 71% of cases and CT scan finding was normal and defuse lesion [N and D] in 64%. The intracranial pressure was >/= 20 mmHg in 65% of cases. 23% of this group had favorable outcome while 77% had unfavorable outcome GCS was > 5 in 38% of cases and CT scan findings were normal and defuse brain lesions [N and D] in 35% of cases. ICP was significantly higher in the unfavorable group [P<0.01] and injury admission time was significantly longer in the unfavorable group [<0.05], while the mean arterial pressure and cerebral perfusion pressure were significantly lower in the unfavorable group [P<0.05 and P<0.07 respectively]. Osmotherapy reduced the intracranial pressure 22.3 +/- 27%and the duration of reduction was 4.79 +/- 2.1 hours while the CSF drainage reduced the ICP 50.2 +/- 9.6% and the duration of reduction was 5.3 +/- 6.3 hours .The incidence of complication was slipped catheter in two cases. No cases of infection from the catheter were recorded. Mean duration of monitoring was 5 days [maximum 14 days]. The mortality rate was 35%[15 patients]. Intracranial pressure monitoring:[l] helps in early detection of intracranial pressure changes, [2] It can limit the indiscriminate use of therapies to control ICP which themselves can be potentially harmful[3] It can reduce ICP by CSF drainage directly and thus improve cerebral perfusion, [4] It helps in determining prognosis, and [5] It helps to improve the outcome. In prolonged monitoring [>4 days], daily bacteriological examination of CSF for early detection of contamination is recommended