Effect of two different doses of dexmedetomidine on the incidence of emergence agitation after strabismus surgery: a randomized clinical trial / Efeito de duas doses diferentes de dexmedetomidina na incidência de agitação ao despertar após cirurgia para correção de estrabismo: um ensaio clínico randômico

Abstract Background and objective: Emergence agitation is a postoperative negative behavior that affects mainly children. We studied the effect of two different doses of dexmedetomidine on the incidence and degree of EA in children undergoing strabismus surgery. Methods: 90 patients were allocated into three equal groups; patients received 0.5 µg.kg−1 of dexmedetomidine in high Dex group, 0.25 µg.kg−1 of dexmedetomidine in low Dex group, or normal saline in the placebo group. All drugs were received with the closure of the conjunctiva before the end of the surgery. Pediatric Anesthesia Emergence Delirium (PAED) scale was used to evaluate the agitation, and Face, Legs, Activity, Cry, Consolability (FLACC) scale was used for pain assessment. Adverse effects of dexmedetomidine and recovery times were recorded. Results: The incidence of agitation was significantly lower in high Dex group compared to other groups and it was significantly lower in low Dex group compared to placebo group. The median (range) of FLACC score was significantly lower in both Dex groups compared to placebo group. Recovery times; time from removal of laryngeal mask to eye opening and time stay in post anesthesia care unit was significantly longer in high Dex group compared to other groups. No significant bradycardia or hypotension was recorded. Recovery time was significantly longer in high Dex group compared to the other two groups. Conclusion: Dexmedetomidine (0.5 µg.kg−1) before emergence from general anesthesia resulted in a reduction in the incidence of emergence agitation compared to a dexmedetomidine (0.25 µg.kg−1) but on the expense of recovery times without adverse effects.

Resumo Justificativa e objetivo: A agitação ao despertar é um comportamento pós-operatório negativo que afeta principalmente as crianças. Avaliamos o efeito de duas doses diferentes de dexmedetomidina na incidência e no grau de agitação ao despertar em crianças submetidas à correção de estrabismo. Métodos: Noventa pacientes foram alocados em três grupos iguais: receberam 0,5 µg.kg−1 de dexmedetomidina (grupo Dex-alta), 0,25 µg.kg−1 de dexmedetomidina (grupo Dex-baixa) ou solução salina normal (grupo placebo). Todos os medicamentos foram administrados com o fechamento da conjuntiva antes do fim da cirurgia. A escala pediátrica de delírio ao despertar da anestesia (PAED - Pediatric Anesthesia Emergence Delirium) foi usada para avaliar a agitação e a escala dos padrões de face, pernas, atividade, choro e consolabilidade (FLACC - Face, Legs, Activity, Cry, Consolability) para avaliar a dor. Os efeitos adversos de dexmedetomidina e os tempos de recuperação foram registrados. Resultados: A incidência de agitação foi significativamente menor no grupo Dex-alta em comparação com os outros grupos, foi significativamente menor no grupo Dex-baixa em comparação com o grupo placebo. A mediana (variação) do escore FLACC foi significativamente menor em ambos os grupos Dex em comparação com o grupo placebo. O tempo de recuperação, o tempo transcorrido desde a remoção da máscara laríngea até a abertura dos olhos e o tempo de permanência na sala de recuperação pós-anestesia foram significativamente maiores no grupo Dex-alta em comparação com os outros grupos. Não houve registro de bradicardia ou hipotensão significativa. O tempo de recuperação foi significativamente maior no grupo Dex-alta em comparação com os outros dois grupos. Conclusão: Dexmedetomidina (0,5 µg.kg−1) antes do despertar da anestesia geral resultou em uma redução da incidência de agitação ao despertar em comparação com dexmedetomidina (0,25 µg.kg−1), mas em detrimento dos tempos de recuperação sem efeitos adversos.

The impact of caudally administrated tramadol on immune response and analgesic efficacy for pediatric patients: a comparative randomized clinical trial

BACKGROUND: Immune responses appear to be affected by anesthetics and analgesics. We investigated the effects of caudal tramadol on the postoperative immune response and pain management in pediatric patients. METHODS: Sixty ASA-I pediatric patients aged 3–10 years undergoing lower abdominal surgery. Patients were randomly assigned either to a caudal bupivacaine (0.25%) group (group B), or a group that received caudal tramadol (1 mg/kg) added to the bupivacaine (0.25%) (group T). Both were diluted in a 0.9% NaCl solution to a total volume of 1ml/kg. The systemic immune response was measured by collecting blood samples preoperatively, at the end of anesthesia, and at 24 and 72 hours postoperatively, and studied for interleukin IL-6, C-reactive proteins (CRP) cortisol levels, and leucocytes with its differential count. Postoperative pain was assessed along with sedation scales. RESULTS: Postoperative production of IL-6 was significantly higher in group B at the end of anesthesia, than at the 24th hour, and at the 72nd hour in group B and group T, respectively. The immune response showed leukocytosis with increased percentages of neutrophil and monocytes, and a decreased lymphocyte response rate within both groups with no significant differences between the groups. Cortisol and CRP were significantly higher in group B. CONCLUSIONS: Adding tramadol to a caudal bupivacaine block can attenuate the pro-inflammatory cytokine response, Cortisol, and CRP in children undergoing lower abdominal surgery.

Pain alleviation in patients undergoing cardiac surgery; presternal local anesthetic and magnesium infiltration versus conventional intravenous analgesia: a randomized double-blind study

BACKGROUND: Magnesium is one of the effective, safe local anesthetic adjuvants that can exert an analgesic effect in conditions presenting acute and chronic post-sternotomy pain. We studied the efficacy of continuous infusion of presternal magnesium sulfate with bupivacaine for pain relief following cardiac surgery. METHODS: Ninety adult patients undergoing valve replacement cardiac surgery randomly allocated into three groups. In all patients; a presternal catheter was placed for continuous infusion of either 0.125% bupivacaine and 5% magnesium sulfate (3 ml/h for 48 hours) in group 1, or 0.125% bupivacaine only in the same rate in group 2, versus conventional intravenous paracetamol and ketorolac in group 3. Rescue analgesia was iv 25 µg fentanyl. Postoperative Visual Analog Scale (VAS) and fentanyl consumption during the early two postoperative days were assessed. All patients were followed up over two months for occurrence of chronic post-sternotomy pain. RESULTS: VAS values showed high significant differences during the first 48 hours with the least pain scale in group 1 and significantly least fentanyl consumption (30.8 ± 7 µg in group 1 vs. 69 ± 18 µg in group 2, and 162 ± 3 in group 3 respectively). The incidence of chronic pain has not differed between the three groups although it was more pronounced in group 3. CONCLUSIONS: Continuous presternal bupivacaine and magnesium infusion resulted in better postoperative analgesia than both presternal bupivacaine alone or conventional analgesic groups.

Dexamethasone alone versus in combination with intra-operative super-hydration for postoperative nausea and vomiting prophylaxis in female patients undergoing laparoscopic cholecystectomy: a randomized clinical trial / 대한마취과학회지

BACKGROUND: Dexamethasone has a prophylactic effect on postoperative nausea and vomiting (PONV) and perioperative hydration is believed to play a role in PONV prophylaxis. This study was performed to examine the combined effects of pre-induction dexamethasone plus super-hydration on PONV and pain following laparoscopic cholecystectomy (LC). METHODS: A total of 100 female patients undergoing LC were enrolled and randomized equally into two groups. Group DF received 5 mg dexamethasone (pre-induction) plus 30 ml/kg Ringer's lactate (intraoperative) and group D received 5 mg dexamethasone (pre-induction) alone. Anesthetic and surgical managements were standardized for all patients. The incidence and severity of PONV, and intra and post-operative analgesic and postoperative antiemetic consumption, were assessed during the first 24 h postoperatively. Post-anesthesia care unit (PACU) stay and aggregated 24 h pain scores were calculated. RESULTS: Group DF had significantly lower PONV than group D (P = 0.03). The number of patients with the lowest PONV score was significantly increased in group DF (P = 0.03). Ondansetron consumption was significantly lower in group DF (P < 0.0001). The mean accumulated 24 h pain scores were significantly lower in group DF compared to group D (P < 0.0001). The time to first analgesic request was significantly longer in group DF than group D (P < 0.0001). In addition, total meperidine consumption during the first postoperative 24 h was significantly lower in group DF than group D (P = 0.002). CONCLUSIONS: In female patients undergoing LC, pre-induction with 5 mg dexamethasone plus intraoperative 30 ml/kg Ringer's lactate solution decreased PONV and pain during the first 24 h postoperatively compared to 5 mg dexamethasone alone.

The impact of magnesium sulfate as adjuvant to intrathecal bupivacaine on intra-operative surgeon satisfaction and postoperative analgesia during laparoscopic gynecological surgery: randomized clinical study

BACKGROUND: Surgeon satisfaction and patient analgesia during the procedure of laparoscopic surgery are important issues. The aim of this work was to study if an intrathecal (IT) Bupivacaine combined with Magnesium sulfate may or may not provide good surgeon satisfaction in addition to improvement of intraoperative and postoperative analgesia. METHODS: Sixty female patients were enrolled in this prospective, randomized, double-blind controlled clinical trial study. All patients were operated for gynecological laparoscopic surgery under spinal anesthesia. Patients were divided into two groups (Bupivacaine and Magnesium). Group Bupivacaine (30 patients) received intrathecal Bupivacaine 0.5% only (15 mg), while 30 patients in group Magnesium received intrathecal Bupivacaine (15 mg) in addition to intrathecal Magnesium sulfate (50 mg). The sensory block level, the intensity of motor block, the surgeon satisfaction, the intraoperative visual analog scale (VAS) for pain assessment, the postoperative VAS, and side effects were recorded during the intraoperative period and within the first 24 hours after surgery in the post-anesthesia care unit. RESULTS: Surgeon satisfaction, intraoperative shoulder pain, postoperative pain after 2 h, and perioperative analgesic consumption (ketorolac) were significant better in group Magnesium than in group Bupivacaine. (P < 0.05). The onset of motor and sensory blocks was significant longer in group Magnesium than the other one. The incidence of PONV, pruritus and urinary retention was insignificant statistically between both groups. CONCLUSIONS: Magnesium sulfate if used intrathecally as an adjuvant to Bupivacaine would provide a better surgeon satisfaction and would improve the analgesic effect of spinal anesthesia used for gynecological laparoscopic surgery.

Effect of slow versus rapid rewarming on jugular bulb oxygen saturation in adult patients undergoing open heart surgery

A debate has appeared in the recent literature about the optimum rewarming strategy [slow vs. rapid] for the best brain function. This study was designed to compare the effect of slow versus rapid rewarming on jugular bulb oxygen saturation [SjO2] in adult patients undergoing open heart surgery. A total of 80 patients undergoing valve and adult congenital heart surgery were randomly allocated equally to rapid rewarming group 0.5 [0.136] [degree]C/min and slow rewarming group 0.219 [0.055][degree]C/min in jugular bulb sampling was taken before, during and after surgery. Surgery was done at cardiopulmonary bypass [CPB] temperature of 28-30[degree]C and rewarming was performed at the end of the surgical procedure. CPB time, rewarming period were significantly longer in the slow rewarming group. Significant difference was observed in the number of the desaturated patients [SjO[2]

Coronary artery bypass graft operation: the start and early experience of Assiut university hospital

Coronary artery bypass grafting [CABG] surgery has been successfully introduced at Assiut university hospital. The purpose of this study was to encourage recommend other starting centers to do this by pass. In the initial feasibility trial 60 patients were selected to receive CABG, between January 2009 and December 2010, 55 of them underwent CABG with cardiopulmonary bypass and 5 patients were submitted to beating heart CABG. All patients were symptomatic for angina before surgery and had single or multivessel coronary artery disease. Overall the calculated preoperative risk for both groups was indicated by EUROSCORE. The patients were evaluated during operation, immediately postoperative during hospital stay by hemodynamic monitoring, serial ECGs, cardiac enzymes and echocardiography. Among 130 distal anastomoses, 55 were fashioned with single internal thoracic artery to bypass Left anterior descending artery [LAD] and 5 with radial artery to bypass left coronary branches. Saphenous vein was used in the remaining 70 anastomoses. A complete myocardial revascularization was achieved; an average of 2 grafts/patient was performed. There were two postoperative strokes [3%] and one case of renal impairment [1.7%]. Mean ICU and in patient-hospital length of stay were 3.4 +/- 2.2 and 11.9 +/- 5.8 days, respectively. Off pump coronary artery bypass grafting is an alternative method to conventional bypass grafting. As it is indicated in single vessel coronary disease, renal impairment and calcified aorta. In the overall, CABG surgery significantly had low incidence of complications resulting in a shorter ICU stay, hospital stay and lower mortality. Coronary artery bypass graft surgery in Assiut university hospital is well established technique with accepted results. The doctors at the hospital are dedicated to introduce new procedures for better treatment and quick recovery

study of some nontraditional risk factors for the development of coronary heart disease in patients with insulin dependent diabetes mellitus

Megjor risk factors explain much of the excess risk for coronary heart disease produced by diabetes, but nontraditional factors may also relate to incident coronary heart disease. This study was conducted on 35 patients with IDDM and coronary heart disease [CHD] [10 females and 25 males, aged 45-70 years], 35 patients with IDDM and without CHD [17 females and 18 males, aged 35-65 years] as well as 20 age and sex matched apparently healthy individuals as a control group. Every individual was subjected to clinical evaluation including history taking and clinical examination with special stress on the presence of risk factors as well as measurement of: fasting and postprandial blood glucose levels, lipid profile, serum albumin level glycosylated hemoglobin [HbA[1]], C-reactive protein [CRP], fibrinogen level von Willebrand factor antigen level [vWF Ag], total leucocyte count and albumin excretion rate [AER] in urine. Insulin dependent diabetics with CHD had higher levels of total cholesterol LDL-c and triglycerides and had lower levels of HDL-c when compared with diabetics without CHD and with controls. They also showed higher levels of fibrinogen, vWFAg level, CRP and total leucocyte count and lower levels of serum albumin. Microalbuminuria was present in 71.4% of diabetics who developed CHD while it was present in 31.4% of diabetics without CHD. In diabetics with CHD, fibrinogen was correlated with vWF at r=0.52 and P< 0.05. vWF Ag level is weakly correlated to lipid parameters, being significantly correlated to triglycerides. It was also positively correlated toAER [microalbwninuria] [r=0.84, P< 0.003], while it was negatively correlated to serum albumin [r = -0.4, P< 0.05]. In the type I diabetic group with CHD C-reactive protein correlated significantly with vWF [r=0.43, P< 0.005] and with fibrinogen [r=0.60, P< 0.001]. In conclusion levels of fibrinogen, von Willebrand factor, CRP, albumin and leucocyte count were predictors of coronary heart disease among patients with IDDM. These associations may reflect the underlying inflammatory reaction or microvascular injury related to atherosclerosis and a tendency toward thrombosis