Dexmedetomidine during suprazygomatic maxillary nerve block for pediatric cleft palate repair, randomized double-blind controlled study

Background@#For children with cleft palates, surgeries at a young age are necessary to reduce feeding or phonation difficulties and reduce complications, especially respiratory tract infections and frequent sinusitis. We hypothesized that dexmedetomidine might prolong the postoperative analgesic duration when added to bupivacaine during nerve blocks. @*Methods@#Eighty patients of 1-5 years old were arbitrarily assigned to two equal groups (forty patients each) to receive bilateral suprazygomatic maxillary nerve blocks. Group A received bilateral 0.2 mL/kg bupivacaine (0.125%; maximum volume 4 mL/side). Group B received bilateral 0.2 mL/kg bupivacaine (0.125%) + 0.5 µg/kg dexmedetomidine (maximum volume 4 mL/side). @*Results@#The modified children’s hospital of Eastern Ontario pain scale score was significantly lower in group B children after 8 hours of follow-up postoperatively (P < 0.001). Mean values of heart rate and blood pressure were significantly different between the groups, with lower mean values in group B (P < 0.001). Median time to the first analgesic demand in group A children was 10 hours (range 8-12 hr), and no patients needed analgesia in group B. The sedation score assessment was higher in children given dexmedetomidine (P = 0.03) during the first postoperative 30 minutes. Better parent satisfaction scores (5-point Likert scale) were recorded in group B and without serious adverse effects. @*Conclusions@#Addition of dexmedetomidine 0.5 μg/kg to bupivacaine 0.125% has accentuated the analgesic efficacy of bilateral suprazygomatic maxillary nerve block in children undergoing primary cleft palate repair with less postoperative supplemental analgesia or untoward effects.

Intravenous propacetamol as postoperative analgesia in cesarean section. Comparative study with intra-thecal morphine

The Provision of optimal analgesia after cesarean section remains a challenge, as satisfactory pain relief must be balanced with the ability of the mother to care for her newborn. [Cohen et al., 1992] Paracetamol is a non NSAID commonly used in multimodal post-operative pain management [Flouvat et al, 2004]. The recent availability of propacetamol an injectable pro-drug of paracetamol has prompted the use of this well known and safe analgesic in many clinical settings when the par enter al route is required [Van Aken et al., 2004]. of this study was to evaluate the safety and efficacy of intravenous propacetamol in comparison with intrathecal morphine for postoperative analgesia following cesarean section. The present study was carried out in Assiut University Hospital Eighty parturients undergoing elective cesarean section under spinal anesthesia were included. The parturients were allocated randomly into four equal groups: Group I is the control group and received intrathecal bupivacaine 0.5%, 10-12.5 mg alone. Group II received intrathecal bupivacaine 0.5% 10-12.5 mg combined with morphine 0.4 mg. Group III received intrathecal bupivacaine 0.5% 10-12.5 mg followed by i.v. propacetamol 2g /l00mL saline after delivery of the baby and after 6 hours. Group IV received intrathecal bupivacaine 0.5% 10-12.5 mg combined with morphine 0.2 mg followed by i.v. propacetamol 2g /l00mL saline after delivery of the baby and after 6 hours. All patients in the four groups received I. M. 75 mg diclofenac at the end of surgery and after 8 hours. When the Visual Analogue Scale [VAS] was 4cm or more, an additional postoperative I.M. meperidine 50 mg as rescue medication was given. Hemodynamic data were recorded immediately after induction and every 10 min till the end of the operation. Neonatal outcome was assessed by Apgar score at one and 5 minutes. Pain intensity score was assessed by VAS every hour and for 12 hours. There were no significant differences between the four groups as regard demographic data, hemodynamics and the neonatal outcome. The pain intensity was more in the control group, the 1. V. propacetamol group was better than the control group but less than the intrathecal morphine group and the pain intensity was the least in the combined group. The combined group was the best one, regarding the quality of pain relief and less side effects due to reduction in morphine dose. The control group required more supplemental analgesia than the propacetamol group and no supplemental analgesia was required in groups II and IV. Complications and side effects were minor. Conclusion: This study may be too small to detect the analgesic effect of propacetamol. The study is also too small to detect a reduction in side effects using multimodal therapy, if there is such a reduction. Therefore, the role of propacetamol is still unknown and a further investigations, with sample sizes large enough to quantify side effects and patient safety, still need to be performed

Comparison between Nalbuphine and propofol for Treatment of intrathecal morphine-induced pruritus after cesarean section

Intrathecal opioids are frequently used in management of postoperative pain, but may be associated with many adverse effects such as pruritus, nausea, vomiting, urinary retention, and respiratory depression, which may limit their use. Our study was done to compare between nalbuphine [a mixed opioid agonist antagonist] and propofol [2-6 di-isopropylphenol] in treating intrathecal morphine-induced pruritus after cesarean delivery. It included one hundred forty one parturients undergoing elective cesarean section with spinal anesthesia and post-operative analgesia by intrathecal morphine [0.3 mg]. Ninty four parturients were reported to have moderate to severe pruritus. Without pre-medications, all women were hydrated with 500 to 1000 ml of normal saline before intrathecal injection of 7.5-10 mg of bupivacaine for spinal anesthesia and morphine 0.3 mg for postoperative pain control. Heart rate, mean blood pressure, respiratory rate and oxygen saturation were monitored. The degree and onset of pruritus were also recorded. Those parturients whose pruritus scores was >/= 3 or those who requested antipruritic treatment were assigned to receive either 3mg nalbuphine IV, 20mg propofol IV or placebo. The degree of success was reported when pruritus score decreased to 1 or 2 after treatment and then women were evaluated every 15 minutes for up to 4 hours to determine the duration of antipruritic response. The patients who continued to have pruritus scores >/= 3 were considered treatment failure after only a single dose of the study medicine. Any side effects from spinal anesthesia or from the drugs used were recorded. we were able to demonstrate that the success rate after treatment with 3 mg of nalbuphine was significantly greater than with 20 mg of propofol. Among the successfully treated patients, [8%] in the Nalbuphine group and [5.3%] in the Propofol group reported the recurrence of moderate to severe pruritus [pruritus score >/= 3] within 4 hours after administration of the study drug. Among all the treated patients, [21.9%] in the Nalbuphine group and [40.6%] in the Propofol group reported failure of success [moderate to severe pruritus [pruritus score >/= 3]] within 15 minutes after administration of the study drug. our study showed that nalbuphine [3 mg] was superior to propofol [20 mg] in the treatment of intrathecal morphine induced pruritus after cesarean delivery

Pulmonary effects of thoracic epidural analgesia for cardiac valve replacement surgery

The study was performed on forty patients [ASA physical status II: III] with symptomatic mitral valve disease underwent mitral valve replacement surgery. The patients where criteria were randomly allocated into two equal groups [20 patients each] 1- General anesthesia group [GA] ['control group]. 2- General anesthesia with thoracic epidural analgesia group [TEA group]. Anesthetic technique and management of cardiopulmonary bypass were standardized for all patients. Spirometric data: [FVC, FEV1, FEV1/FVC% and PEFR,], and respiratory rate were measured at the night before surgery, after extubation by 1h, 12h, 24h, 48h, 72h and [6th postoperative day Arterial Blood Gases: PaO2, PaCO2 and pH were measured after induction of GA by 15 min., after extubation by 48h, 72h and 6th postoperative day. Visual analogue scale [VAS] score for assessment of pain was measured after extubation by 1h, 6h, 12h, 18h, 24h, 48h, 72h and 6th postoperative day. Total dose of fentanyl analgesia was calculated in each group. There were some improvement in respiratory function [FVC, FEV 1 and PEFR.] started at the 3rd to the 6th post operative days.There were insignificant changes in FEV1/FVC all over the study period RR decreased significantly in the epidural group than control group in all readings. There was a significant decrease in VAS in TEA group than the control group throughout the study period. PaO 2 was significantly decreased in both groups at all readings. 1. Intensive Care Unit [ICU] stay: There was insignificant difference between the two groups. 2. Time to first awake /hour was significantly decreased in thoracic epidural group than general anesthesia group [1.3 +/- 0.3 vercus 2.5 +/- 0.6]. 3. Time to extubation /hour was significantly decreased in thoracic epidural group than general anesthesia group [3.5 + 0.2 versus 7.3 +/- 0.3]. 4. Total postoperative fentanyl consumption in 1st 24h was a significant decrease in TEA than GA group [p<0. 00] [677.9 +/- 26 in TEA group versus 1203.4 +/- 44 in general anesthesia group] perioperative epidural infusion of 0.125% bupivacaine and fentanyl, started before induction of anesthesia in valve replacement surgery reduces the total requirements of intraoperative narcotics, without cm appreciable delay in extubation. There was slight improvement in pulmonary function, but not to expected values and far less than control reading indicating multifactorial bases of pulmonary dysfunction in cardiac surgery using CBP

Does low dose of aprotinin influence haemostatic profile in-patients under going mitral valve replacement?

Aprotinin [Trasylol], a non-specific serine protease inhibitor, is successful used to reduce excessive postoperative bleeding during cardiopulmonary bypass. The aim of our study was to verify the hypothesis whether aprotinin used during cardiopulmonary bypass procedure affects hemostatic parameters, which might be crucial for the elevated risk of thromboembolic complications. Patients and methods: Thirty patients undergoing open heart surgery for valve replacement were divided into two equal groups. Group 1[Aprotinin group, AP] [N = 15] a loading dose of 1,000,000 u was given over 20 minutes before sternotomy followed by a constant infusion of 500,000 U/h and 1,000.000 U was added to the priming. Group 2 [Control group] [N = 15] no antifibrinolytic medications were given to this group of patients. Anesthesia and cardiopulmonary bypass protocol were standard for all patients. Plasma level of [Hemoglobin, Hematocrit, Platelet], and Coagulation profile were measured. All blood samples were withdrawn in all patients at 6 times, before induction of anesthesia [basal], post CPB, at ICU arrival, after 6, 12 and 24 hours from ICU arrival. Postoperative, blood loss from the mediastinal chest tubes was collected and reported at 6, 12, and 24 hours from the time of arrival to ICU The percentage of patients received transfusion and the number of transfused units of packed red blood cells [PRBC], platelet and fresh frozen plasma were estimated and recorded at the end of CPB and at the time of discharge from the hospital. At the end of CPB, the thrombin time decreased in group I but this decrease was with in normal range [38-54 seconds] and elevated to exceed the normal range in group [2], This change in thrombin time returned gradually to the baseline value at the end of the study [24hours from ICU arrival] in groups [1], but still exceeded the normal range in group [2] till the end of the study. The fibrinogen level was decreased at the end of CPB in all the studied groups. It began to return to the baseline value in groups [1] at 12 and 24 hours from ICU arrival but the level still lower in group [2] till the end of the study. The D-dimer level was elevated at the end of CPB in all the studied groups and began to return to the normal value in groups [1] at 12 and 24 hours from ICU arrival but the level was markedly elevated and exceeded the normal value in group [2] till the end of the study. The amount of blood loss was significantly reduced [P < groups [1] when compared with group [2] at all the time of study. The amount of transfused [PRBC] units, FFP and Platelet were significantly decreased [P < 0.05] in group [1] when compared to control group. Low dose aprotinin during mitral valve replacement surgery decreased perioperative blood loses and the need for allogenic transfusion together with improvement the haemostatic profile

Immunological effects of parenteral nutrition on traumatized patients

Nutrition is one of the most important treatment for the traumatized patients, improving body protein and immune function, reducing rate of infection and shortening hospitalization. The aim of this work is to study the effect of early parenteral nutrition on the immunological and inflammatory variables. Thirty poly-traumatized patients with Injury Severity Score [ISS] 20-40 and within 6 hours after trauma were enrolled sequentially into a conventional [n = 15] and an parenleral [n = 15] groups. Conventional group was received intravenous regimen and hospital oral diet as soon as the bowel function returned. Parenteral nutrition plans were designed individually for the TPN group, based on their calculated caloric and protein requirement [25 k cal/kg] day. Laboratory investigations included blood sample for blood picture, serum total proteins, albumin, and C-reactive protein. Immunological parameters included interleukin 10 [IL-10], interleukin 6 [IL-6], immunoglobulins [IGA], CD4 and CD8 were determined by immunoassy kit. In the TPN group, the mean values of serum protein, 1st day was significantly increase [P < 0.01] versus 10th day, also the mean value of serum albumin was significantly increased on the 10th day. In relation to C-reactive protein CRP: The mean values for conventional and TPN groups, on the 1st day showed significantly decrease versus 10th day in both groups. There were no significant changes as regard [IL-10] and [IL-6] all studied times in the conventional group. While in the TPN, [IL-10] showed significantly decrease at 10th day. Also IL-6 showed significantly decrease on 1st day and 10th day. Concerning immunoglobulins [IGA]: In TPN group showed significantly increase in the 10th day. In the TPN group CD4 showed significantly increase between 1st day and 10th day. As regard CD8 in the TPN group show significantly decrease between 1st day and 10th day. In conclusion nutritional support of the traumatized patient is critically important to decrease the immunosuppression associated with injury

Studies on alkyl heterocyclic aromatic compounds new routes for the synthesis of azanaphthalene

Synthesis of pyridine derivatives via reaction of 2-amino-1,1,3-tricyanoprop-1-ene with trichloroacetonitrile or diethyl-malonomonoimidate hydrochloride has been achieved. Compounds 3a,b coupled with aryldiazonium chloride to yield the corresponding coupling products 4a-d. Compounds 4c-d could be converted into 6a-b on treated with acetic acid. The reaction of 3b with acetic hydrochloric acid mixture and trichloro acetonitrile are reported