Comparison of priming versus slow injection for reducing etomidate-induced myoclonus: a randomized controlled study / 대한마취과학회지

BACKGROUND: Etomidate injection is often associated with myoclonus. Etomidate injection technique influences the incidence of myoclonus. This study was designed to clarify which of the two injection techniques—slow injection or priming with etomidate—is more effective in reducing myoclonus. METHODS: This prospective randomized controlled study was conducted on 189 surgical patients allocated to three study groups. Control group (Group C, n = 63) received 0.3 mg/kg etomidate (induction dose) over 20 s. Priming group (Group P, n = 63) received pretreatment with 0.03 mg/kg etomidate, followed after 1 min by an etomidate induction dose over 20 s. Slow injection group (Group S, n = 63) received etomidate (2 mg/ml) induction dose over 2 min. The patients were observed for occurrence and severity of myoclonus for 3 min from the start of injection of the induction dose. RESULTS: The incidence of myoclonus in Group P (38/63 [60.3%], 95% CI: 48.0–71.5) was significantly lower than in Group C (53/63 [84.1%], 95% CI: 72.9–91.3, P = 0.003) and Group S (49/63 [77.8%], 95% CI: 66.0–86.4, P = 0.034). Myoclonus of moderate or severe grade occurred in significantly more patients in Group C (68.3%) than in Group P (36.5%, P < 0.001) and Group S (50.8%, P = 0.046), but the difference between Groups P and S was not significant (P = 0.106). CONCLUSIONS: Priming is more effective than slow injection in reducing the incidence of myoclonus, but their effects on the severity of myoclonus are comparable.

Evaluation of single epidural bolus dose of magnesium as an adjuvant to epidural fentanyl for postoperative analgesia: a prospective, randomized, double-blind study

Magnesium has been used as an adjuvant by various routes, including intravenous, intrathecal, and epidural in different dosage regimens. The effect of single bolus dose of magnesium as an adjuvant to fentanyl for postoperative analgesia has not been studied. This prospective randomized controlled trial was done to evaluate the efficacy of single bolus administration of magnesium epidurally as an adjuvant to epidural fentanyl for postoperative analgesia in patients undergoing total hip replacement under combined spinal epidural anesthesia. Sixty patients received combined spinal-epidural anesthesia with 2 mL of 0.5% hyperbaric bupivacaine intrathecally. After the surgery, patients were randomized into Group F [epidural fentanyl [1 microg/kg] in 10 mL saline] and Group FM [epidural magnesium [75 mg] along with fentanyl [1 microg/kg] in 10 mL saline]. Supplementary analgesia was provided by 50 mg intravenous tramadol if Verbal Rating Score [VRS] > 4. Patient's first analgesic requirement and duration of analgesia were recorded. The duration of analgesia was significantly longer for Group FM, 340 +/- 28.8 min, compared with Group F, 164 +/- 17.1 min [P=0.001]. The frequency of rescue analgesics required in 24-h postoperative period in Group FM [2.3 +/- 0.5] was significantly less than that in Group F [4.3 +/- 0.5] [P=0.001]. VRS was significantly lower in Group FM up to 4 h in the postoperative period [P=0.001]. Bromage scale was statistically insignificant at all points of time. The administration of magnesium [75 mg] as an adjuvant to epidural fentanyl [1 microg/ kg] for postoperative analgesia results in significantly lower VRS with prolonged duration of analgesia as compared with epidural fentanyl [1 microg/kg] alone. Concomitant administration of magnesium also reduces the requirement of breakthrough analgesics with no increased incidence of side effects

Comparison of respiratory quotient and resting energy expenditure in two regimens of enteral feeding - continuous vs. intermittent in head-injured critically ill patients

Measurement of respiratory quotient [RQ] and resting energy expenditure [REE] has been shown to be helpful in designing nutritional regimens. There is a paucity of the literature describing the impact of a feeding regimen on the energy expenditure patterns. Therefore, we studied the effect of continuous vs. intermittent feeding regimen in head-injured patients on mechanical ventilation on RQ and REE After institutional ethical approval, this randomized study was conducted in 40 adult male patients with head injury requiring controlled mode of ventilation. Patients were randomly allocated into two groups. Group C: Feeds [30 kcal/kg/day] were given for 18 h/day, with night rest for 6 h. Group I: Six bolus feeds [30 kcal/kg/day] were given three hourly for 18 h with night rest for 6 h. RQ and REE were recorded every 30 min for 24 h. Blood sugar was measured 4 hourly. Other adverse effects such as feed intolerance, aspiration were noted. Demographic profile and SOFA score were comparable in the two groups. Base line RQ [0.8 vs. 0.86] and REE [1527 vs. 1599 kcal/day] were comparable in both the groups [P>0.05]. RQ was comparable in both groups during the study period at any time of the day [P>0.05]. Base line RQ was compared with all other RQ values measured every half hour and fluctuation from the base line value was insignificant in both groups [P>0.05]. REE was comparable in both the groups throughout the study period [P>0.5]. Adequacy of feeding as assessed by EI/MREE was 105.7% and 105.3% in group C and group I, respectively. There was no significant difference in the blood sugar levels between the two groups [P>0.05]. We found from our study that RQ, REE, and blood sugar remain comparable with two regimens of enteral feeding - continuous vs. intermittent in neurosurgical patients on ventilator support in a ICU setup

Periosteal nociceptors induced hypotension and bradycardia under spinal anesthesia: A report of two cases / 대한마취과학회지

The sudden hemodynamic disturbance in the perioperative period can occur because of various surgical and anesthetic reasons but hemodynamic collapse due to noxious stimulus of periosteum stripping has not been described. We report two cases of severe hypotension and bradycardia during periosteum stripping in orthopedic surgery under subarachnoid block even though the block level was adequate. In our patients, hemodynamic collapse occurred specifically at a moment when surgeons manipulated periosteum and fall in blood pressure and heart rate was sudden in onset. The hemodynamic disturbance did not appear to be related to vagally mediated or due to blockade of sympathetic fibers but appeared to be related to periosteal nociceptors.

Non-invasive ventilation is helpful in early weaning and early extubation in H1N1 infected, ventilated patients: a case series

The spread of 2009 pandemic of H1N1 increased the number of patients being admitted to intensive care unit with acute respiratory failure. Conservative approach in extubation in view of severe lung injury leads to prolonged mechanical ventilation and is further complicated by development of superadded bacterial infections. In a developing country with a large population and limited health care resources all attempts need to be made to decrease hospital stay. We present a case series of four patients, confirmed to have H1N1 associated respiratory involvement and who were put on non invasive ventilation [NIV] early in the phase of weaning. The weaning and early extubation was successful in all of these patients. We conclude that NIV in post extubation period facilitates weaning and early extubation in patients with H1N1 viral pneumonia, who were on mechanical ventilation