Sub-antibiotic doses of erythromycin as a prokinetic in abdominal surgeries: reviving the old

All patients undergoing major abdominal procedures have some degree of gastric atony in the immediate postoperative period, presenting mainly with vomiting. Many prokinetic agents have been used in the past, but none is a universal remedy. Studies showed that subantibiotic doses of erythromycin, a macrolide. antibiotic and motilin agonist, accelerates gastric emptying. This study investigated whether preoperative subantibiotic dose oral erythromycin [250 mg], altered residual gastric volume and postoperative adverse effects in patients scheduled for abdominal surgeries. Erythromycin was compared with the commonly used prokinetic metoclopramide and antiemetic ondansetron, in terms of prokinetic efficacy, cost and adverse effects. In a double-blind study, eighty patients [20 each] were allocated randomly to receive orally, either erythromycin 250 mg [E250] or erythromycin 500 mg [E500], or 10 mg metoclopramide [M], or 4mg ondansetron [Z], an hour pre-induction of anesthesia. Preoperative oral erythromycin in subantibiotic dose 250mg elicited a significantly lower residual gastric volume [P<0.001] and a lower VAS for vomiting, compared with ondansetron. As for metoclopramide and erythromycin 500, residual gastric volume was comparable, but E 250 had a lower VAS for vomiting than both groups. Rescue remedy for vomiting was required for groups E500, M and Z [100, 10 and 10 %] compared to 0% in group E250. Ultimately, subantibiotic oral dose of erythromycin [250 mg], given1 hr preoperatively, is an inexpensive prokinetic alternative with a promising post-operative profile which may be superior to the inexpensive prokinetic metoclopramide with known adverse effects, and the expensive antiemetic ondansetron

non opioid fast track anesthetic regimen for colonic resection

Fast-tracking implies a preoperative patient care paradigm that reduces time to recovery and discharge. The current study adopted fast-track anesthetic techniques, comparing outcome of a multimodal non-opioid and another opioid regimen, on recovery profiles after colonic surgery, with standard anesthetic practice. Seventy five ASA II colectomy patients were randomly assigned to one of three groups. Control group for conventional general anesthetic technique and two fast-track anesthesia groups using combined light general anesthesia and epidural techniques. Epidural maintenance was by infusion cocktail of bupivacaine-fentanyl in opioid-based group, while in non-opioid group by bupivacaine-ketamine which were both continued postoperatively for pain in lower doses and concentrations. Postoperative analgesia in control group was achieved by morphine. Supplemental ketorolac and acetaminophen were added only to non-opioid group. Early and intermediate recovery profiles were compared among the three groups together with recorded side effects. All patients in fast-track groups had significant shorter times to: awakening, extubation, orientation, both PACU arrival and discharge, hospital stay with a significant lower mean VAS for pain at rest, and rescue analgesia, compared to control group. Control group had a significant higher rate of postoperative nausea and vomiting, drowsiness and pruritis. Non-opioid fast-track regimen had a significant shorter PACU and hospital stay with lower side-effects rate than opioid one. Fast-track anesthesia enhanced recovery profile. Non-opioid regimen was superior to opioid-based, having a better recovery profile and a lower rate of side-effects

Role of cholinesterase activity on pharmacodynamics of mivacurium preceded by pancuronium in elderly and young adults

Mivacurium- pancuronium combination proved to be more potent than either drug given alone. The goal of this study was to evaluate the safety and efficacy of this combination in elderly group and its correlation to plasma butyryl cholinesterase [Bche] activity. Forty patients, ASA I or II scheduled for elective open cholecystectomy were allocated into two groups of twenty patients each: young group [18- 55 years] and elderly group [60-75 years]. Anesthesia was induced with midazolam, fentanyl, and propofol then maintained with isoflurane and opioid supplementation. Neuromuscular blockade [NMB] was monitored by train-of-four [TOF] stimulation of the ulnar nerve. After calibration, NMB was achieved by 16 micro g kg[-1] pancuronium followed by 32 micro g kg[-1] mivacurium. The following parameters were recorded: The onset time, clinical duration, recovery index and the total dose of mivacurium and pancuronium together with hemodynamic data. Three blood samples for Bche activity were collected: before pancuronium injection, 3 min. and 30 min. afterwards in both groups. The onset time and the recovery index of NMB were comparable in both groups. The duration of action was significantly prolonged in elderly group [49.8 +/- 10.48 min.] compared to young one [37.13 +/- 7.81 min.]. The total dose of mivacurium was significantly less in the elderly group [22.56 +/- 2.39 micro g kg[-1] hr[-1]] when compared to the young group [25.78 +/- 3.05 micro g kg[-1] hr[-1]]. For all patients, the preoperative Bche activity was within the normal range. After pancuronium injection, it showed a significant reduction in both groups at three and thirty minutes except a non significant value in young at thirty minutes. This reduction showed a significantly higher percent change in the elderly group [30.37 +/- 22.01] than the young group [8.60 +/- 19.19] at thirty minutes. There were significant intra operative variations in the percent changes of hemodynamic data compared to the preoperative values, yet, still within the clinically acceptable range. So, the use of a small dose of pancuronium followed by a small dose of mivacurium with a ratio of 1:2 can produce synergism without affecting either the recovery profile of mivacurium or the clinical hemodynamic stability even in the elderly group