Evaluation of "no touch" extubation technique on airway-related complications during emergence from general anesthesia

Awake "no touch" extubation requires performing extubations only when the patient spontaneously wakes up without any kind of stimulation during emergence from general anesthesia. The aim of this study was to evaluate absolutely awake extubation "no touch" technique in adult patients, scheduled for elective nasal and paranasal sinus surgeries under general anesthesia as regard to emergence airway complications. A total of 60 adult patients were randomly allocated into one of two equal groups according to the method of extubation: Group I: Standard fully awake, Group II: Absolutely "no touch" awake extubation [absolutely no stimulation "no touch" was allowed until patients were able to open their eyes]. The incidence of laryngospasm and its grade according to a four-point scale was reported. Occurrence of airway events [excessive secretions, breath-holding, coughing, hoarseness, biting, as well as the number and severity of any desaturation episodes], oozing from the wound, and postoperative sore throat were also recorded. The heart rate [HR], systolic [SBP] and diastolic [DBP] blood pressure measured at the end of surgery served as baseline values, and subsequent measurements were taken within 30 minutes after the end of surgery. There was absolutely no case of laryngeal spasm or episode of desaturation among patients who were extubated with the "no touch" technique. On the other hand, there were 3 cases of laryngeal spasm in standard fully awake group. Severity of coughing, excessive secretions and breath holding, hoarseness, biting, and occurrence of non-purposeful movements of the limbs were significantly less in the absolutely "no touch" awake technique. The changes in HR, SBP, and DBP during emergence extubation were significantly less in "no touch" technique group. However, oozing from the wound was significantly higher with standard fully awake extubation. However, there were no significant differences between the two groups regarding the incidence of postoperative sore throat [39 and 36%, respectively]. The results of the present study showed that awake "no touch" technique for tracheal extubation produces less airway-related complications, as well as minimal hemodynamic response during emergence from general anesthesia in nasal and paranasal surgeries. It could be a safe alternative for tracheal extubation in airway surgery

Procedural sedation analgesia

The number of noninvasive and minimally invasive procedures performed outside of the operating room has grown exponentially over the last several decades. Sedation, analygesia, or both may be needed for many of these interventional or diagnostic procedures. Individualized care is important when determining if a patient requires procedural sedation analgesia [PSA]. The patient might need an anti-anxiety drug, pain medicine, immobilization, simple reassurance, or a combination of these interventions. The goals of PSA in four different multidisciplinary practices namely; emergency, dentistry, radiology and gastrointestinal endoscopy are discussed in this review article. Some procedures are painful, others painless. Therefore, goals of PSA vary widely. Sedating management can range from minimal sedation, to the extent of minimal anesthesia. Procedural sedation in emergency department [ED] usually requires combination of multiple agents to reach desired effects of analgesia plus anxiolysis. Howeverm in dental practice, moderate sedation analgesia [known to the dentists as conscious sedation] is usually what is required. It is usually most effective with the combined use of local anesthesia. The mainstay of success for painless imaging is absolute immobility. Immobility can be achieved by deep sedation or minimal anesthesia. On the other hand, moderate sedation, deep sedation, minimal anesthesia and conventional general anesthesia can be all utilized for management of gastrointestinal endoscopy

Emergence agitation in uncooperative children undergoing complete dental rehabilitation: a comparison between sevoflurane and desflurane anesthesia

The issue of emergence agitation [EA] following the administration of short-acting anaesthetic agents, sevoflurane and desflurane, has become a controversial issue. The aim of the present study was to evaluate the influence of desflurane versus sevoflurane anaesthesia on EA in behaviorally uncooperative children undergoing complete dental rehabilitation using PAED scale. Thirty eight healthy children [ASAI and II] aged between 2 to 6 years, Frankl behavior category scales 1 or 2 scheduled for complete dental rehabilitation [CDR] under general anaesthesia were enrolled in the study protocol. Children were randomly allocated in a double-blind fashion to one of two groups according to the inhalational anaesthetic used for maintenance of anesthesia. Group S: Sevoflurane [1.0 +/- 0.2 MAC, age adjusted, n = 19] or Group D: Desflurane [1.0 +/- 0.2MAC, age adjusted, n = 19]. Paediartric Anesthesia Emergence Delirium [PAED] scale was used, a 5-point rating scale with 5 gradations for each item that has been validated to assess EA in children. Scoring was obtained multiple times and the peak was recorded for evaluation. Time to tracheal extubation, emergence behavior, recovery complications, and pain scores were assessed. PAED score at 15 min in the PACU was significantly higher [P < 0.05] in sevoflurane group. Similarly, as regards the peak PAED scale reached, children who received sevoflurane had a significant higher value 10 [3-19] min comparison to those who received desflurane 6 [2 - 14] min. Time to tracheal extubation was shorter in children who received desflurane. One case of vomiting in sevoflurane group and two cases in the desflurane group were encountered. The three cases were considered as grade 1 according to the 4-degree scale No differences were found between the study groups with respect to peak pain, time to discharge from PACU. The need for rescue medication was required for two children in sevoflurane group. In conclusion, maintenance of anaesthesia with desflurane resulted in less severe agitation with faster time for tracheal extubation than sevoflurane anesthesia in behaviorally uncooperative pre-school children undergoing complete dental rehabilitation. Although the time of PACU stay did not differ significantly, a more rapid immediate recovery from anaesthesia could be an additional benefit in such cases in a day-case surgery setup

Low central venous pressure anesthesia in major hepatic resection

Blood loss and transfusion requirements are major determinants of morbidity and mortality following liver resection. This study evaluates the association of low central venous pressure [LCVP] with blood loss and blood transfusion during liver resection. Thirty consecutive hepatic resections were studied prospectively concerning CVP, volume of blood loss and volume of blood transfusion and renal outcome. Data were analyzed for those with a CVP 5 mmHg. A multivariate analysis assessed potential confounding factors in the comparison. The mean blood loss in patients with a CVP of 5 mmHg or less was <500 ml and that in those with a CVP >5 mmHg was >2000 ml. [p <0.001]. Only two patients with a CVP of 5 mmHg required transfusion. No incidences of air embolism or permanent renal shutdown have been reported. It is concluded that the volume of blood loss and blood transfusion during liver resection correlates with the CVP during parenchymal transection. Lowering the CVP to less than 5 mmHg is a simple and effective technique to reduce blood loss during liver resection and delete the need for blood transfusion with its hazards

Spinal ropivacaine in fast-track TURP

The addition of fentanyl to spinal ropivacaine anaesthesia has been shown to improve the quality of block, increase duration of sensory block, and provide postoperative analgesia without affecting motor function. in a randomized controlled, double blind study, we examined the efficacy and the adverse effects of three different regimen of spinal anesthesia Forty-five patients scheduled for transuretherai resection of the prostate [TURP] under sudarachnoid anesthesia. Patients were randomly assigned to Group I [G I] hyperbaric bupivacaine 10 mg. Group II [G II] 15 mg heavy ropivacaine, and Group III [G III] ropivacaine 10 mg with 20 micro g fentanyl. Evaluation of the block and side effects were performed after spinal anaesthesia. Three patients in bupivacaine group, three patients in ropivacaine group and one patient in fentanyl group required sedative / analgesic supplementations. Patients of fentanyl group showed significant prolonged sensory block and significant decrease in the motor block. Time to walk was significantly shortened in fentanyl group, it was 150 mm versus 197 and 162 mm in bupivacaine and ropivacaine groups respectively. The visual analogue score for pain at 3, 6 and 12 hours after jntrathecal anaesthesia in G II and III were significantly less than G I. No patient experienced respiratory depression, hypoxemia. hypotension or bradycardia dunng the postoperative penod Pruritus was reported in 12 patients [80%] of fentanyl group, but it was mild and did not necessitate medical treatment. Shivering was significantly less in the patients of fentanyl group. Intratnecal ropivacaine 10 mg plus 20 micro g fentanyl resulted in sufficient analgesia comparable to 15 mg ropivacaine or 10 mg bupivacaine with better analgesia and discharge criteria for fast-track TURP

Propofol versus remifentanil patient controlled sedation for awake craniotomy during epileptic surgeries

Anaesthesia for neurosurgical procedures, specificaity craniotomies requiring patient participation presents a challenge to both the neuroanaesthesiologist and the neurosurgeon Despite the popularity of general anaesthesia for these procedures, there has been a renewed interest in this technique of awake craniotomy due to its definite advantages m specific patient populations. This study evaluate two anaesthetic regimens for propofoi and remifentanil for awake craniotomy in epileptic surgeries. Total drug administered, incidence of complications, sedation score and patient satisfaction were assessed in 20 patients, randomely assigned into 2 equal groups, aged 18-55 years undergoing awake craniotomy for epileptic surgeries. Sedation was induced vis propofol patient controlled sedation in group I and via remifentanil patient controlled sedation in group II. five patients in the remifentanil group versus two patients in propofol group experienced nausea and /or vomiting. Respiratory rate depression, desturation were more frequent in remifentanil group while pain and hypotension were more frequent in propofoi group Both groups achieved a good level of sedation and patient satisfaction. Propofol and remifentanil are almost ideal drugs for conscious sedation during avjake craniotomy

Inhaled furosemide ameliorates wheezes in asthmatic patients during induction of anesthesia

Fifty asymptomatic asthmatic patients of ASA physical status, I and II, with a history of active asthma scheduled for elective surgery were enrolled in the study. Anesthetic management was the same in all patients. Five minutes post-intubation an independent blinded observer assessed wheezing. The presence of wheezing was determined through auscultation during controlled ventilation. A simple "yes" or "no" was obtained, and no grading was done. Patients who wheezed after 5 min were subsequently treated by the random administration of the study medication either albuterol [5 mg in 2-4 ml 0. 9%NaCl, salbutamol sulphate I mg /ml] or furosemide [lasix 40 mg in 2-4 ml 0.9% NaCl]. Wheezes were assessed again. 5 minutes post-medication. Twenly-three out of 50 patients included in the study developed wheezes, 5 minutes after intubation. The incidence of wheezes was 46% and the mean peak inspiratory pressure [PIP] was 26.1 +/- 2.6 cm H2O The patients who wheezed were randomly allocated into one of two groups to receive either albuterol [n =11] or furosemide [n=12]. There was no statistically significant difference in the percentage of patients who responded to albuterol [82%] in comparison to furosemide [75%]. The peak inspiratory pressure [PIP] declined significantly [P= 0.001], 5 minutes after treatment in both groups. Heart rate was significantly higher [P= 0.001], 5 minutes after treatment, in the albuterol group [104.1 +/- 11.25 bpm] in comparison to furosemide group [82.3 +/- 7.53 bpm]. Inhaled furosemide has definitely a role in ameliorating wheezes in asthmatic patients during general anesthesia. It is equally effective to inhaled albuterol however, it unduces no tachyarrythmias. Those who are suffering complications from the adverse effects of beta 2-agonists may benefit from the use of inhaled furosemide

Neuromuscular and haemodynamic effects of mivacurium in patients with hepatic cirrhosis

Forty patients who underwent intermediate elective surgeries were included in the present study. Ten patients were free from hepatic disease [group A], and thirty patients had evident hepatic cirrhosis, [group B]. Using Child-Pugh score, group B patients were further subdivided into three equal subgroups, group B1 was Child A, group B2 patients were Child B and group B3 patients were Child C. Induction of anesthesia was carried out by propofol, fentanyl NO2-O2 and isoflurane. After stabilization of control response using a force displacement transducer and neuromuscular function analyzer, all patients received a bolus of mivacurium 0.15 mg/ kg over 15 seconds [2x ED95] and spontaneous recovery was recorded. Mivacurium infusion was started at T1 of 10% [first response of TOF] and the block was maintained at T1 depression of 95%. Haemodynamic changes were recorded before start of anesthesia and throughout surgery. After bolus injection of mivacuirium, both lag time and onset time didn't show any significant change among groups. Recovery indices were comparable between group A and sub group BO1 [Child A], whereas, there were significant increase of T1 to 10%, 25%, 75% and 90% of control in patients with moderate to severe liver cirrhosis [group B2 and B3] in comparison to group A. TOF ratio of 0. 7 showed the same pattern of change, it was significantly higher in subgroups B2 and B3 in comparison to control group A. Similarly, recovery index was significantly higher in subgroups B2 and B3. The mean infusion requirements of mivacurium were generally less in group B in comparison to group A. Steady state infusion rates were achieved over 10 mm in all groups. Differences in mean mivacurium requirements from 10 min and forward were significantly less in subgroups B2 and B3 in comparison to control A. At end of surgery, residual neuromuscular blockade was antagonized and a TOF ratio of 0.7 was reached in about 7 minutes. None of patients experienced any signs of recurarization in the recovery room. In conclusion, mivacurium has a stable neuromuscular and haemodynamic profile in patients free from hepatic disease and patients of child score A. However, in child score B and C patients the drug profile is unstable and even unpredictable. Therefore, the use of mivacurium is only recommended, if ever, for short procedures in cases of mild liver cirrhosis