effect of propofol-fentanyl versus sevoflurane-fentanyl on intracranial pressure and cerebral hemodynamics in surgeries for supratentorial mass lesions in children

This study was carried out to compare the effects of sevoflurane-fentanyl versus propofol-fentanyl anesthesia on cerebral hemodynamics and subdural intracranial pressure in children undergoing craniotomy for supratentorial tumors. Forty children, 3-8 years old, with supratentorial tumors resulting in midline shift of 5-10 mm were included in this prospective study. They were randomized into two equal groups. Anesthesia was induced with propofol, fentanyl and atracurium in both groups. In group S anesthesia was maintained with sevoflurane [1-1.5 MAC] in oxygen, while in group p anesthesia was maintained with a continuous intravenous infusion of propofol. Jugular venous bulb blood samples were obtained from a catheter introduced retrogradely into the right internal jugular vein. Intracranial pressure [ICP] was measured through a cannula inserted subdurally and connected via a fluid-filled tubing system to a pressure transducer. Cerebral perfusion pressure [CPP] and arterial- to-jugular venous oxygen difference [AJDO[2]] were calculated. The surgeon manually assessed dural tension prior to dural incision and also assessed the degree of brain swelling after dural incision. Observations were made during normocapnia and moderate hyperventilation. Anesthetic maintenance with propofol-fentanyl resulted in a significantly higher mean arterial pressure [MAP], significantly lower ICP, and significantly higher CPP [p<0.05 for all] compared to sevoflurane-fentanyl. On the other hand, jugular bulb venous oxygen saturation [SjvO[2]] was significantly higher and AJDO[2]] significantly lower in the group S [p<0.05]. Surgeon's assessment of dural tension and brain swelling was significantly more favorable in the group P [p<0.05]. The incidence of probable cerebral hypoperfusion or ischemia tended to be higher in group P but with no significant difference relative to group S. Propofol-fentanyl anesthesia seems to have more favorable effects on cerebral hemodynamics and intracranial pressure than sevoflurane fentanyl anesthesia in children undergoing craniotomy for supratentorial tumors, with no significant side effects on brain oxygenation

Anaesthesia for elective caesarean section: the effect of adding ketamine to epidural ropivacaine/fentanyl on postoperative pain relief and neonatal outcome

Ketamine has been reported to potentiate epidural local anaesthetics in non-obstetric surgery. This study was conducted to investigate the effect of adding ketamine to epidural ropivacaine/fentanyl for caesarean section [CS] on the analgesic profile and neonatal outcome. Thirty full-term females presenting for elective CS were randomized into two equal groups to receive epidural anaesthesia using ropivacaine 0.75% + 2 micro g/ml fentanyl in group C or ropivacaine 0.75% + 2 micro g/ml fentanyl + 0.5mg/kg preservative-free ketamine in group K. Visual analogue score [VAS] of pain, postoperative analgesic consumption [75mg i.m. diclofenac sodium], time to first request [TFR] of postoperative analgesic, heart rate [HR], mean arterial pressure [MAP] and patient sedation using the Observer's Assessment of Alertness/Sedation [OAA/S] score were recorded during the first 24 postoperative hours. Time from skin incision to cord clamping [I-C time] and time from uterine incision to cord clamping [U- C time] were recorded as well as Apgar scores for the neonates at 1 and 5 minutes. The two groups were comparable as regards HR [being slightly higher in group K] and postoperative MAP. Intraoperatively, MAP was significantly lower in group C relative to baseline and to group K. VAS scores were significantly lower in group K than group C at 4, 12 and 16 hours postoperatively. TFR was significantly longer in group K, and the number of postoperative diclofenac doses was significantly lower. Patients were significantly more sedated in group K relative to group C at achievement of surgical anaesthesia and till the end of the operation, but not from 4 hours postoperatively till the end of the study. I-C time, U-C time and Apgar scores at 1 and 5 minutes were comparable between the groups. The addition of 0.5mg/kg preservative-free ketamine to epidural ropivacaine/fentanyl in women undergoing elective CS results in more haemodynamic stability and improves postoperative analgesia with no adverse effects on neonatal outcome