Bupivacaine scalp nerve block: hemodynamic response during craniotomy, intraoperative and post-operative analgesia

Background: Noxious stimuli during craniotomy may induce hypertension and tachycardia, giving rise to morbidity in patients with intracranial hypertension. Craniotomy is followed by moderate level of postoperative pain. Objective: Evaluate the effectiveness of scalp block on hemodynamic response to noxious stimuli, intraoperative fentanyl requirement and post-operative analgesia. Methods: Sixty patients undergoing elective craniotomy were randomly assigned to receive a scalp block with either 0.5% bupivacaine or 0.25% bupivacaine and 1:200,000 adrenaline (group A and B) or normal saline with 1:200,000 adrenaline (group C). Fentanyl 0.5 mcg/kg was administered for hemodynamic control. Intraoperative mean arterial blood pressure (MAP), heart rate (HR), fentanyl doses, and post-operative pain scores were recorded. Post-operative analgesia was provided by patient-controlled analgesia (PCA) morphine for 24 hours. Results: MAP was greater in group C than group A during pinning and incision (p <0.05), and was greater in group C than group B during pinning, incision and craniotomy (p <0.05). HR differences were not statistically significant between all groups (p >0.05). Intraoperative fentanyl requirement was significantly greater in group C compared with group A and B (p < 0.05). Pain score, time to the first morphine administration and total morphine consumption were not significantly different between all groups. Conclusion: Pre-incision scalp blocks using either 0.25% or 0.5% bupivacaine with 1:200,000 adrenaline were effective to prevent rising of MAP, but not HR in response to cranial pinning and skin incision, causing less intraoperative fentanyl requirement. However, they did not reduce post-craniotomy pain and morphine consumption.

Learning manual skills in spinal anesthesia and orotracheal intubation: is there any recommended number of cases for anesthesia residency training program?

Wide variability exists in the number of anesthetic procedures to which anesthesia residents are exposed during their training. The number of attempts at various procedures before a trainee becomes proficient at performing each anesthetic procedure is not known. To determine the learning process of 150 attempts of spinal anesthesia and 100 attempts of orotracheal intubation, the two most frequent anesthetic procedures, we evaluated 9 first-year anesthesia residents according to their rate of success or failure. The learning curves of both procedures revealed an initial rapid improvement of success during the first 20 attempts. Spinal anesthesia was more difficult to learn (p=0.0002) but the learning curves of spinal anesthesia and orotracheal intubation reached a nondifferent high success rate of 82 per cent and 88.9 per cent respectively (p=0.13). According to this study the institutional recommended number of cases for spinal anesthesia and orotracheal intubation were 112 and 27 cases respectively.

Intubating conditions after three different doses of rocuronium.

This randomized controlled trial study evaluated the intubating conditions at 1 minute after 0.3, 0.6 and 0.9 mg/kg of rocuronium in 108 Thai patients who were enrolled for elective surgery under general anesthesia with fentanyl, thiopental and isoflurane at King Chulalongkorn Memorial Hospital. Excellent or good conditions were observed in 77.8 per cent (p < 0.05) with rocuronium 0.3 mg/kg compared to 94.4 and 97.2 per cent at 0.6 and 0.9 mg/kg of rocuronium, respectively but the excellent condition was 16.7 (p < 0.05), 52.8 (p < 0.05) and 77.8 per cent (p < 0.05) from each dose. In females, the excellent condition was 33.3 (p < 0.05), 83.3 and 88.9 per cent while it was only 0, 22.2 and 66.7 per cent (p < 0.05) in males. Therefore, rocuronium > or = 0.6 mg/kg should be adequate for intubation. Furthermore, in a situation where an excellent condition is very important, a dose of > or = 0.9 mg/kg of rocuronium is recommended especially in male patients.

Effect of national seminar on AIDS and anesthesia upon knowledge, attitude and practice concerning HIV among Thai anesthesia personnel.

In the national seminar of AIDS and Anesthesia which was a short course educational program in all aspects of HIV medicine, 195 questionnaires about knowledge, attitude and practice concerning HIV were distributed among the participants (anesthesiologists and nurse anesthetists) in 3 periods, pretest, post test (at the end of 2 days seminar) and post test 2 (at 4 months after the seminar). There were 177 (90.76%) respondents who completed both pretest and post test 1 questionnaires. About 12 questions of knowledge; mean scores were statistically significantly increased; 7.95 (0.98) vs 9.5 (0.78), P < 0.001. Two thirds (8 out of 12 questions) were answered correctly in post test 1 more than in the pretest by Mc Nemar Chi-square test; P < 0.05. About attitude; 2 out of 5 answers changed significantly by Mc Nemar Chi-square test; P < 0.05. The post test 2 questionnaires were mailed to all 177 participants twice asking to reply only once. All questionnaires were to be completed anonymously. The post test 2 with a response rate of 65.5 per cent revealed that universal precautions were frequently used among Thai anesthesia personnel but not universally followed. At least one-third of the respondents admitted recapping before disposal of used needles. Fifty six per cent of respondents (vs 22.8% in pretest) admitted re-using one syringe for more than one patient. In conclusion, this study showed that a short course educational program may improve knowledge about HIV and partly change attitude, but can not change behaviour. Changing the practice of anesthesia health care workers needs continual education and appropriate training.

Comparison of ondansetron and placebo for preventing postoperative nausea and emesis in gastrointestinal tract surgery: a multicenter randomized controlled trial.

BACKGROUND: Nausea and emesis are undesirable events that may cause discomfort and suffering in the postoperative period. This study was carried out to evaluate the efficacy and safety of ondansetron for preventing postoperative nausea and vomiting in patients undergoing gastrointestinal tract surgery. METHODS: Using a randomized double-blind study design, 408 surgical patients (163 male and 245 female) receiving general endotracheal anesthesia were studied at five medical centers in Bangkok. Ondansetron (4 mg) or placebo was administered prior to induction of anesthesia. Episodes of nausea and vomiting, adverse events and laboratory tests (complete blood count and liver function test) were evaluated during 24 hours after study drug administration. RESULTS: The incidence of postoperative nausea and vomiting in the placebo group (42.7 and 35.2%) were significantly higher than the ondansetron group (23.9 and 15.4%). However, no significant differences occurred in the incidence of adverse events or changes in laboratory tests in the ondansetron group compared to the placebo group. CONCLUSIONS: Ondansetron 4 mg given intravenously before surgery is safe and effective for preventing postoperative nausea and emesis following gastrointestinal tract surgery.

Maternal and neonatal effects of single-dose epidural anesthesia with lidocaine and morphine for cesarean delivery.

Two per cent lidocaine (18-20 ml) with epinephrine 1:200,000 plus 4 mg of morphine was given as a single epidural injection over 3 minutes for elective cesarean section in 60 healthy mothers at term. It provided effective, safe and adequate analgesia in the postoperative period. There was no evidence of neonatal depression related to the epidural morphine as judged by Apgar scores at 1 and 5 minutes and umbilical venous pH at birth. Maternal and umbilical venous levels of morphine were measured and found to be low at birth. However, this study was done only in healthy mothers not in labor and having a term fetus. We do not recommend using this technique in complicated obstetric patients.

Blood glucose concentration in pediatric outpatient surgery.

Blood glucose concentration was measured in 84 pediatric patients who were scheduled for outpatient surgery at Chulalongkorn Hospital. They were allocated into 3 groups according to their ages, group 1:less than 1 year of age, group 2:1 to 5 years of age and group 3:over 5 years. The fasting times were approximately 8-12 hours. All patients received standard general anesthesia under mask. No glucose solution was given during operation. Preoperative mean blood glucose were 91.09 +/- 17.34, 89.55 +/- 18.69 and 82.14 +/- 16.14 mg/dl in group 1, 2 and 3 while the postoperative mean glucose values were 129.07 +/- 37.90, 115.62 +/- 29.63 and 111.53 +/- 23.07 mg/dl respectively. The difference between pre- and post-operative values were statistically significant difference (P < 0.01). None of the children had hypoglycemia even when fasting longer than expected. Increased postoperative glucose values may be due to stress response from surgery and anesthesia. We would suggest that the parents give the fluid to their children according to our instructions in order to prevent dehydration and hypoglycemia especially in small infants.

Cardiovascular and respiratory changes in laparoscopic cholecystectomy.

Although laparoscopic cholecystectomy has several advantages over the traditional open cholecystectomy, it may however cause some adverse cardiovascular and respiratory effects associated with intraperitoneal insufflation of CO2. It is, therefore, recommended that appropriate hemodynamic and respiratory monitorings should be used routinely in order to prevent deleterious complications, especially in high risk patients.