Comparison of large antecubital vein versus small vein on dorsum of hand for the prevention of propofol injection pain

Objective: To evaluate the effectiveness of using two different sizes of veins on upper limb for the prevention of propofol intravenous injection pain

Methodology: This prospective randomized clinical trial was conducted at Department of Anesthesia, King Saud University, Riyadh [KSA] from May 1, 2013 - May 31, 2014. A total of 160 patients, ages between 20-50 years, both male and female, American Society of Anesthesiologist [ASA] class I and II, posted for elective surgery under general anesthesia [GA] were included in the study and were divided into two groups. Patients with known history of allergy to lidocaine or propofol, obese patients, anticipated difficult intubation, already on any analgesics and pregnant patients were excluded from the study. Both groups received an admixture of propofol [1%] - lidocaine [2%] on induction of anesthesia through antecubital vein [Group-1] or through a vein on dorsum of hand [Group-2]. Pain was assessed as none, mild, moderate or severe

Results: Moderate to severe pain on intravenous injection of propofol-lidocaine admixture through antecubital vein and small vein on dorsum of hand was 20% vs 71%

Conclusion: There is marked reduction of pain when propofol - lidocaine admixture was injected through antecubital vein as compared to small vein on dorsum of hand

Routine use of Glidescope and Macintosh laryngoscope by trainee anesthetists

Objective: to compare intubating conditions, success rate, and ease of intubation by anesthesia trainees using Glidescope Videolaryngoscope [GVL] compared to Macintosh laryngoscope [MCL]

Study Design: comparative study

Place and Duration of Study: king Khalid University Hospital, Riyadh, Saudi Arabia, from January 2012 to February 2015

Methodology: eighty adult patients ASA I and II with normal airway, scheduled to undergo elective surgery requiring endotracheal [ET] intubation were enrolled. Patients were randomly divided into 2 groups: GVL and MCL. All intubations were performed by trainee residents having experience of more than 1 year and who had successfully performed more than 50 tracheal intubations with each device. Glottic view based on Cormack and Lehane's [C and L's] score and percentage of glottis opening [POGO] score, time to successful intubation, need of external pressure, and overall difficulty scores were compared using either GVL or MCL

Results: view of glottis based on C and L's classification was better [p < 0.001] and POGO score was higher [88.25 +/- 22.06 vs. 57.25 +/- 29.26, p < 0.001] with GVL compared to MCL. Time to intubate in seconds was [32.90 +/- 8.69 vs. 41.33 +/- 15.29, p = 0.004] and overall difficulty score was less 2.78 +/- 1.39 vs. 4.85 +/- 1.75 [p < 0.001] using GVL compared to MCL

Conclusion: residents found ET intubation to be faster and easier with superior glottic view using GVL compared to MCL in patients with normal airway

Preload Versus Coload and Vasopressor requirement for the prevention of spinal anesthesia induced hypotension in non-obstetric patients

Objective: To compare the effectiveness of preload and coload for the prevention of Spinal Induced Hypotension [SIH] and vasopressor requirements

Study Design: Randomized trial

Place and Duration of Study: Department of Anesthesia, The Aga Khan University Hospital, Karachi, Pakistan, from June 2007 - June 2010

Methodology: Sixty patients were randomly divided into preload and coload group of 30 each. Patients with ASA 1 - 3, aged 20 - 60 years were included. Patients with history of IHD, COPD, BMI > 30 and surgical procedure TURP were excluded. All patients received crystalloid 10 ml/kg before induction of spinal anesthesia in preload group and at the time of spinal anesthesia in coload group. Blood pressure and heart rate were recorded at different time intervals till 45 minutes. Patients received ephedrine 5 mg when systolic blood pressure dropped below 90 mmHg and heart rate was less than 60 beats/minute and/or phenylephrine 50 micrograms when systolic blood pressure dropped below 90 mmHg and heart rate was more than 60 beats/minute

Results: There was no statistically significant difference at different time intervals in heart rate, systolic and mean arterial pressure between the groups. Diastolic blood pressure was significantly different in both groups at 6 - 15 minutes after spinal anesthesia. SIH occurred [21] 70% and [15] 50% in preload and coload groups, respectively [p=0.187]. Ephedrine requirement for SIH was significantly high in preload group [p=0.017]. Phenylephrine requirement for SIH was high in preload group which was statistically non-significant [p=0.285]

Conclusion: Coload group has lower incidence of spinal induced hypotension and significantly less vasopressor requirement than the preload group

Comparison of the effect of pre-operative single oral dose of Tramadol and Famotidine on gastric secretions pH and volume in patients scheduled for laparoscopic cholecystectomy

To evaluate and compare the effects of pre-operative single oral dose of tramadol and famotidine on gastric secretions pH and volume in patients electively scheduled for laparoscopic cholecystectomy. Randomized control trial. Department of Anaesthesia, King Saud University Riyadh, Saudi Arabia, from August 2011 to June 2013. Ninety adult, ASA-I and II patients scheduled for laparoscopic cholecystectomy were included in the study. Patients were randomly assigned to receive pre-operatively either placebo [Group-C, n=30], oral tramadol 100 mg [Group-T, n=30] or famotidine 40 mg [Group-F, n=30]. After induction of general anaesthesia, gastric fluid was aspirated through orogastric tube. The gastric secretions volume and pH was measured using pH meter. There was no statistically difference between groups in age, weight and gender. The gastric secretions mean pH was 2.06 +/- 0.22,2.04 +/- 0.20, 5.79 +/- 0.77 and volume was 0.59 +/- 0.17, 0.59 +/- 0.14 and 0.28 +/- 0.16 ml/kg in Group-C, Group-T and Group-F respectively. There was a significant statistical difference in the mean pH values between Group-C vs. Group-F [p < 0.001] and Group-Tvs. Group-F [p < 0.001]. Statistically significant difference was also found in the mean gastric secretions volume between Group - C vs. Group-F [p < 0.001] and Group-Tvs. Group-F [p < 0.001]. There was no significant difference in the mean gastric fluid pH values [p=0.99] and mean gastric secretions volume [p=0.99] between Group-Tand Group-C. As compared to famotidine, pre-operative single oral dose of tramadol was unable to elevate the desired level of gastric fluid pH [> 2.5] and decrease in gastric secretions volume [< 0.4ml/kg]

Endotracheal intubation in patients with unstable cervical spine using LMA-fastrach and gum elastic bogie

To evaluate the success of alternative technique of ET- intubation in patients with unstable cervical spine with Philadelphia collar around the neck. Case series. The Department of Anaesthesia, College of Medicine, King Saud University, Riyadh, Saudi Arabia, from June 2009 to June 2012. Adult patients of either gender with unstable cervical spine wearing Philadelphia collar electively scheduled for cervical spine decompression and fixation more than one level were included. Those with anticipated difficult intubation, mouth opening < 25 mm and BMI > 27 kg/m2 were excluded. After induction of anaesthesia FT-LMA was inserted. Correct position of FT-LMA was confirmed then soft straight end of gum elastic bogie was passed through FTLMA into trachea. FT-ILMA was removed on bogie. Reinforced silicon ET- tube was rail road on bogie. The bogie was pulled out and position of ET- tube was confirmed with ETCO2, chest movement and auscultation on bag ventilation. The ease of insertion of FT-LMA, ET- intubation and maximum time taken for successful intubation was noted. 26 patients were studied with mean age of 59.3 A +/- 2.93 years and M: F ratio of 7:3. The mean time taken from the insertion of gum elastic bogie to the ET intubation was 38.9 A +/- 1.20 seconds. The success rate of ET- intubation in the first attempt was 88.4% and 7.6% in two attempts. Intubation failed in one patient. The mean ease of insertion of FT-LMA and ET- intubation in all patients was 46.7 A +/- 2.59 and 46.5 A +/- 2.66 respectively on VAS [0-100]. No complication was noted in any patient. This technique is safe and reliable for achieving adequate ventilation and intubation in patients with unstable cervical spine with Philadelphia collar in place

Ruptured ectopic pregnancy with APLA syndrome - a case report

All means to reduce blood loss in liver resection and to decrease blood loss and a need of blood transfusion would be of benefit to the patient as well as the surgeon. We report two cases in which different strategies were applied in order to achieve the low central venous pressure. We also compared in these cases surgical time, blood loss and blood transfusion requirements during liver resection

Strategies to lower the central venous pressure during liver resections

All means to reduce blood loss in liver resection and to decrease blood loss and a need of blood transfusion would be of benefit to the patient as well as the surgeon. We report two cases in which different strategies were applied in order to achieve the low central venous pressure. We also compared in these cases surgical time, blood loss and blood transfusion requirements during liver resection

Is there a role for TENS application in the control of diabetes mellitus in insulin-dependent patients?

An 80-year-old man with insulin-dependent diabetes mellitus presented to the hospital with low back pain. He was initially managed with non-steroidal anti-inflammatory drugs, tramadol and epidural steroid injection. Transcutaneous electrical nerve stimulation (TENS), applied on the back and buttocks, was subsequently advised. Initially, TENS was applied once every 24 hours. On improvement of pain symptoms, it was increased to thrice every 24 hours. The patient then complained of symptoms of hypoglycaemia (blood sugar level < 4 mmol/L). Discontinuation of TENS resulted in raised blood sugar level. When TENS was restarted, the same hypoglycaemic response was noted. The insulin dosage was adjusted to half of the patient's routine daily requirement with continued application of TENS. This incidental finding has alerted us to hypoglycaemic episodes following TENS application, which may be due to effective pain control, decreased sympathetic stimulation, enhanced insulin sensitivity or altered muscle metabolism due to electrical stimulation.

Anaesthesia related mortality in ASA-1 and 2 patients as a quality improvement indicator

Quality and safety in anesthesia is usually monitored by analysis of perioperative mortality-morbidity and incidents. Clinical quality indicator, death within 48 hours of anaesthesia exposure is considered to be a flag that can alert to possible problems in individual patient care. The measurement of perioperative mortality as a quality indicator is a continuous peer reviewed quality improvement activity. Medical records and morbidity and mortality files were reviewed to see the trends and finding the benchmark of mortality in ASA-1 and 2 patient who died between 1992-2006 within 48 hours of anaesthesia exposure. Mortality in class 1 was nil. Anaesthetic mortality in ASA-1 and 2 patients was 0.35 per 10,000 and 0.74 per 10,000 of ASA-2 patient's volume. Anaesthesia-related mortality was 0.17 per 10,000 and 0.37 per 10,000 of ASA-2 patient's volume which is almost double of the overall calculated incidence. We suggest continuing monitoring of anaesthesia related mortality as a continuous quality indicator in developing countries. The reporting and analyzing of data according to the ASA status volume should be taken as a denominator. The available benchmark will help in evaluating the confounding factors and perioperative care of a particular group of patients