Prophylactic use of oral acetaminophen or IV dexamethasone and combination of them on prevention emergence agitation in pediatric after adenotonsillectomy

The present study was aimed to evaluate the efficacy of acetaminophen plus dexamethasone on post-operative emergence agitation in pediatric adenotonsillectomy. A total of 128 patients were randomized and assigned among four groups as: Intravenous [IV] dexamethasone, oral acetaminophen, IV dexamethasone plus oral acetaminophen, placebo. Group 1 received 0.2 mg/kg dexamethasone plus 0.25 mg/kg strawberry syrup 2 h before surgery. Group 2 received 20 mg/kg oral acetaminophen [0.25 ml/kg] with 0.05 ml/kg IV normal saline. Group 3 received 20 mg/kg acetaminophen and 0.2 mg/kg dexamethasone intravenously. Group 4 received 0.25 ml/kg strawberry syrup and 0.05 ml/kg normal saline. Agitation was measured according to Richmond agitation sedation score in the post anesthetic care unit [PACU] after admission, 10, 20 and 30 min after extubation. Pain score was measured with FACE scale. Nurse satisfaction was measured with verbal analog scale. If agitation scale was 3 >/= or pain scale was 4 >/= meperidine was prescribed. If symptoms did not control wit in 15 min midazolam was prescribed. Patients were discharged from PACU according Modified Alderet Score. Data were analyzed with ANOVA, Chi-square, and Kruskal-Wallis among four groups. P < 0.05 was considered statistically significant. A total of 140 patients were recruited in the study, which 12 of them were excluded. Thus, 128 patients were randomized and assigned among four groups. The four treatment groups were generally matched at baseline data. Median of pain score in 0, 10, 20 and 30 min after extubation were different between each study group with the control group [<0.001, 0.003 respectively]. Also median of agitation score in 0, 10, 20 and 30 min after extubation were different between each study group with the control group [<0.001]. Incidence of pain and incidence of agitation after extubation were not statistically identical among groups [P < 0.001 and P = 0.002 respectively]. Mean of recovery time, duration of agitation and 1[st] time to agitation appearance, meperidine and midazolam consumption, nurse satisfaction and complication frequency were not statistically identical among groups [P < 0.001]. Acetaminophen, dexamethasone and combination of them are superior to placebo for prevention of agitation after adenotonsillectomy in children. Furthermore combinations of both drugs are superior to acetaminophen or dexamethasone separately

Comparing the preventive effect of 2 percent topical lidocaine and intravenous atropine on oculocardiac reflex in ophthalmological surgeries under general anesthesia

The current study aimed to determine preventive effect of 2 percent topical xylocaine on oculocardiac reflex in ophthalmological surgeries except strabismus, including retinal detachment and vitrectomy with scleral buckling under general anesthesia. A randomized controlled clinical trial was carried out on 150 patients aged 18-90 years undergoing ophthalmological surgeries under general anesthesia. Samples randomly divided into the experimental group [received four drops of 2 percent topical xylocaine instilled in desired eye] and control group [received 0.5 mg atropine sulfate injection]. Systolic, diastolic and mean arterial blood pressure of patients and baseline heart rate were recorded. They were compared regarding the incidence of bradycardia, heart rate less than 60 beats/minute, hypotension and blood pressure less than 90 mm/Hg. Data were analyzed by Statistical Package for the Social Sciences software version 20 using Chi-square and ANOVA. The difference between two groups was not statistically significant regarding demographic and basic variables. The incidence of bradycardia in both groups was respectively [90.7 percent vs. 17.3 percent], heart rate less than 60 beats/minute [40 percent vs. 13.3 percent], hypotension [76 percent vs. 32 percent] and blood pressure less than 90 mmHg was [28 percent vs. 8 percent]. Accordingly, the differences between both groups were statistically significant [P > 0.001]. The preventive impact of topical xylocaine upon oculocardiac reflex in ophthalmological surgeries such as retinal detachment and vitrectomy with scleral buckling under general anesthesia was less effective than that of atropine injection. Therefore, to avoid this reflex in high risk patients, injecting atropine would be safer.

[Comparing 'remifentanil-propofol' and 'fentanyl-propofol' in patients undergoing craniotomy for supratentorial space-occupying lesions]

Control of intracranial pressure [ICP] before, during and after neurosurgical operations is crucially important. Therefore, trying different methods and drug combinations to attain this goal is an ongoing effort in anesthesiology. In this study we compared two combinations of a narcotic agent with propofol in neurosurgical operations to control intracranial pressure. In this prospective randomized double-blind clinical trial, we enrolled 34 patients with supratentorial brain tumors who were candidates for craniotomy in Alzahra Hospital in Isfahan, Iran from April 2008 to April 2009. The patients were randomly divided into two groups of 17, in whom the first and the second group, respectively, received a combination of "propofol and fentanyl" and a combination of "propofol and remifentanyl" as maintenance of anesthesia. The hemodynamic status, ICP during the surgery, and post-surgical complications in recovery unit were observed for and registered in a questionnaire. Hemodynamic status was similar in both groups and they did not differ in recovery complications except for pain which was more prevalent in remifentanil group [P<0.03]. Although the patients in fentanyl group better responded to the drug for lowering ICP than remifentanyl group, but the difference was not statistically significant. There is no difference between these two anesthetic agent combinations and both could be useful in the anesthesia of neurosurgical operations. However combination of propofol and fentanyl seem to be superior because of more pain relief and a smoother recovery period.

Midazolam versus ketamine in the management of emergence agitation in children undergoing lower abdominal and limb surgeries

Emergence agitation [EA] is a post-anesthetic problem which interferes with a child's recovery and presents a challenge in terms of assessment and management. In this study, we compared the effects of midazolam and ketamine as premedication in the management of EA in children aged 1-6 years. In this prospective, randomized clinical trial study, 58 children aged 1-6 years who were undergoing general anesthesia for elective surgery in Alzahra Hospital in Isfahan during 2008 until 2009. The patients were randomly assigned to receive 0.1 mg/kg midozolam [28] or 0.5 mg/kg ketamine [29] by IV route in the premedication room. All patients received a standardized anesthetic regimen and isoflurane was used for the maintenance of anesthesia. The incidence and severity of agitation [agitation score], severity of pain [pain score], anesthesia, recovery and extubation durations were recorded postoperatively. The prevalence of agitation in midazolam [21.4%] was lower than ketamine group [34.5%; P<0.05]. In addition, the duration of agitation in ketamine group [21 +/- 16.67 min] was significantly higher than midazolam group [6.83 +/- 6.55 min], [P<0.05]. However, no significant differences were seen in agitation score, pain score, anesthesia, recovery or extubation durations in the two groups [P>0.05]. The study showed that midazolam could reduce the frequency of agitation better than ketamine but both drugs were able to reduce the severity of agitation after short-time surgeries in young children

[Evaluating the efficacy of extraplural versus epidural analgesia for post-thoracotomy pain]

Thoracotomy is a particularly painful surgery and good pain control is crucial to maximize the ability to cough and breath. The most common methods of post operative pain management are systemic narcotics and epidural administration of local anesthetic agents or narcotics. The purpose of this study was to compare postthoracotomy analgesia of extraplural and epidural catheters. This is a randomized clinical control trial study performed in Alzahra's hospital of medical university of Isfahan. 64 patients were randomized in two groups. In group A, 15cc%0/125 bupivacaine before surgery and in group B, 10cc%0/5 bupivacaine at the end of surgery were injected and repeated every hour post operatively. Visual analog scale in two group collected and compared. VAS in epidural catleter was better than extra plural catheter but this difference is not significant [P<0/05]. No significant respiratory complication was reported in both groups. Due to results this difference is related to position, drainage of chest tube, volume of local anesthetic and type of surgery in the extra plural groups. Because of no significant difference between them we can use this techniques based on experience and preference of anesthesiologist and surgeon

Comparison of pre- vs. post-incisional caudal bupivacaine for postoperative analgesia in unilateral pediatric herniorrhaphy: a double-blind randomized clinical trial

This study was designed to evaluate the pre- vs. post-incisional analgesic efficacy of bupivacaine administered caudally in children undergoing unilateral hernia repair. Fifty children aged 6 months to 6 years were included in the study. Children were divided blindly between the two groups to receive pre- vs. post-incisional caudal bupivacaine. The preincisional group received 1 ml/kg of 0.125% bupivacaine caudally after induction of anesthesia and the postincisional group received the same dose caudally at the end of surgery. Heart rate, SaO 2, end tidal CO 2, and noninvasive arterial blood pressure were recorded every 10 min. The duration of surgery, extubation time, and duration of recovery period were also recorded. The pain scores were measured with using an Oucher chart in the recovery room, 2, 4, 6, 12, and 24 h after surgery. Time to first analgesia, numbers of supplementary analgesics required by each child in a 24-h period and total analgesic consumptions were recorded. Any local and systemic complications were recorded. Quantitative data were compared using a two-tailed t-test. Sex distribution and frequency of acetaminophen consumption were measured using ?[2] test. P<0.05 was considered statistically significant. The Oucher pain scale at 4, 6, 12, and 24 h after surgery, the total analgesic consumption and the numbers of demand for supplemental acetaminophen were lower statistically in preincisional group [P<0.05]. Extubation time and duration were higher in preincisional group [P<0.05]. Mean changes of heart rates were statistically lower during the anesthesia period and recovery time in preincisional group [P<0.05].Preincisional caudal analgesia with a single injection of 0.125% bupivacaine is more effective than the postincisional one for postoperative pain relief and analgesic consumption in unilateral pediatric herniorrhaphy

Comparative evaluation of vital signs stability, sedation and analgesia scores with two methods of sedation: propofol+fentanyl and ketamine+fentanyl during perm cath insertion

The aim of this study was comparison of sedation and analgesia between two drug combinations i.e. propofol+ fentanyl and ketamine+fentanyl, in patients with End stage renal disease, [ESRD] who were candidates for insertion of 'Perm Cath' catheter for the purpose of hemodialysis. Fifty one candidates for 'perm cath' catheter insertion were enrolled in this study. They were divided into three groups: Propofol+fentanyl; ketamine+fentanyl, and placebo. Systolic and diastolic blood pressure, heart rate and respiratory rate were measured before the procedure and then every 5 minute until the end of the procedure. Xylocaine was infiltrated at the site of insertion in all groups. Propofol lmg/kg with fentanyl 1micgr/kg were injected in propofol group, and ketamine 0.5mg/kg with fentanyl 1micgr/kg in the ketamine group. Pain was measured with Ambesh score in the beginning of catheter insertion and sedation was measured with Ramsay score at the beginning of procedure and at insertion of catheter in the heart. Patient satisfaction was measured qualitatively in the PACU. Comparative evaluation of mean heart rate, mean systolic and diastolic blood pressure and mean respiratory rate were different among the three groups, [P<0.05].Frequency distribution of pain was different among groups in the beginning of the procedures [P<0.001]; also sedation score was different in the beginning of the procedures and when the catheter entered the heart among the three groups [P<0.001]. Patients satisfaction score was higher in propofol group, [P=0.001]. Local infiltration of Xylocaine at Perm Cath insertion is insufficient to produce sedation and analgesia, and it is necessary to use sedative drugs in combination. Both methods of sedation: propofol+fentanyl and ketamine+fentanyl provide sedation and analgesia effectively. Propofol appears to be superior in providing stability of vital signs, sedation and patient satisfaction

Minimum effective dose of tramadol in the treatment of postanesthetic shivering

To determine the minimum effective dose of intravenous administration of tramadol on controlling postanesthetic shivering [PAS] and frequency of effects. Seventy five patients who had shivering grade III or IV after general anesthesia with isoflurane in the recovery room were included in the study. The patients were divided randomly among five groups to receive the same dose of tramadol: 0.2 mg/kg, 0.4 mg/kg, 0.6 mg/kg, 0.8 mg/kg and 1 mg/kg. The shivering grades, tympanic temperature immediately prior to administering the treatment, time spent to control shivering, shivering relapse, time interval between the two shivering periods and side effects were registered. Data were analyzed with SPSS software, version 14. Chi-square test, t-student test and analysis of variance were used where they were appropriate. P value<0.05 was considered significant. There were no statistically significant differences among treatment groups with respect to demographic data, duration of anesthesia, room temperature of postanesthesia care unit, shivering grade before treatment and central temperature at the time of treatment. There was no significant difference among the number of patients who stopped shivering with 0.2 mg/kg compared with 1 mg/kg of tramadol. There was no significant difference among the five doses for shivering relapse. Frequency distributions of side effects were not different among the five groups. All patients completely stopped shivering with tramadol 0.4 mg/kg or more in 5 minutes after treatment. With 0.2 mg/kg only 80% of patients stopped shivering. Although the difference between 0.2 mg/kg and 1 mg/kg was not statistically significant, because of the limited number of cases we were not able to reject type two errors. According to this study, we suggest 0.4 mg/kg of tramadol for shivering control

Effect of pre vs. post incision inguinal field block on postoperative pain after pediatric herniorrhaphy, a different approach

The aim of this study was to determine if preemptive local anesthesia yields better postoperative pain control than infiltration of local anesthesia at the time of wound closure. Forty patients aged between 1 and 10 years were randomly allocated to one of the two groups by using a sealed envelope technique. Group 1 received 0.5 mg/kg bupivacaine 20 minutes before the incision of skin and the same volume of normal saline at the end of skin suture. Group 2 received 0.5 mg /kg bupivacaine at the end of skin suture and the same volume of normal saline 20 minutes before the incision of skin. Pain scores of patients in the recovery room, 6, 12 and 24 hours after surgery were measured. If patients complained of post surgical wound pain, 30 mg/kg of acetaminophen was administered by rectal suppository. Data were analyzed by chi-square test, t -test and ANOVA. There were no statistical significance between the two groups for age, weight and sex. The overall mean of pain was 4.6 +/- 2.6 for group 1 and 18.6 +/- 8.7 for group 2 and the difference between the two groups was statistically significant [P<0.001]. The mean dosage of acetaminophen administration was significantly higher in group 2 compared with group 1 [P<0.05]. Pre-surgical infiltration of bupivacaine in the surgical field is a useful method in decreasing both post-surgical wound pain for up to 24 hours and analgesic consumption after inguinal hernia repair