survey of the practice of regional anesthesia in Saudi Arabia

This survey aimed to assess both the extent of practice and need for training in regional anesthesia among anesthesiologists in Saudi Arabia in 2012. We distributed an electronic survey among 382 anesthesiologists attending the bi-annual meetings of the Saudi Anesthetic Association, enquiring about their practice in regional anesthesia. Questions concerned the practice of regional anesthesia, use of ultrasound guidance, and the need for training workshops. The response rate of anesthetists was 55.2% with most of them were males and had mean age of 25-50 years. Most anesthesiologists [88.2%] were practicing regional anesthesia frequently in the operating rooms [75.3%] rather than designated block room. From the respondents, only 14.2% did fellowship in regional anesthesia, 21.8% and 18.5% were using ultrasound and nerve stimulation guidance, respectively, 11.4% received formal training, and 86.3% were willing to attend training workshops on regional anesthesia. There was a significant negative correlation between the ultrasound users and their institutional positions [r=-0.191] [P=0.026]. We believe that more could be done to improve the practice of regional anesthesia in the Kingdom of Saudi Arabia, including the implementation of formal training and conduction of more frequent specialized courses/workshops in the field of regional anesthesia with special reference to ultrasound regional anesthesia blockade techniques

Anesthetic considerations of central airway obstruction

Central airway obstruction [CAO] is a serious presentation of lung cancer and associated chest diseases. It presents a real challenge to the anesthesiologist because usually the patient admitted to the hospital as an emergency case with high grade dyspnea scheduled to undergo rigid bronchoscopy for diagnostic and possible therapeutic interventions. In this case report, we described the anesthetic management of a patient who was admitted to our hospital with CAO

Continuous positive airway pressure ventilation during whole lung lavage for treatment of alveolar proteinosis -A case report and review of literature

Pulmonary alveolar proteinosis [PAP] is a rare disease that affects young population usually in the age group of 20-40 years, characterized by the deposition of lipoproteinacious material in the alveoli secondary to abnormal processing of surfactant by macrophages. We report a case of a 15-year-old female who had history of cough with sputum for 3 days along with fever. She was seen in another hospital and was treated as a case of pneumonia where she received antibiotic but with no improvement. Computerized tomography [CT] chest showed diffuse interlobular septal thickening in the background of ground glass opacity giving a picture of crazy paving pattern which was consistent with the diagnosis of PAP. The patient was scheduled to undergo, first right-sided whole lung lavage [WLL] under general anesthesia. Endobronchial intubation using left sided 37 Fr double lumen tube. Continuous positive airway pressure [CPAP] as described in our previously published report was connected to the right lumen of the endobronchial tube. CPAP ventilation was used during the suctioning of lavage fluid phase in order to improve oxygenation. WLL was done using 5 L of warm heparinized saline [500 i.u/litre]. The same procedure was repeated on the left side using 6 L of heparinized normal saline solution. In conclusion, anesthesia in alveolar proteinosis for patients undergoing WLL is challenging to the anesthesiologist. It requires meticulous preoperative preparation with antibiotics, mucolytics and chest physiotherapy. Also it requires careful intraoperative monitoring and proper oxygenation especially during the suctioning phase of the lavaged fluid. With this second case report of successful anesthetic management using the modified CPAP system we recommend with confidence the application of CPAP ventilation to improve oxygenation during WLL

Effect of bispectral index [BIS] monitoring on postoperative recovery and sevoflurane consumption among morbidly obese patients undergoing laparoscopic gastric banding

Early and uneventful postoperative recovery of morbidly obese patients remains a challenge for anesthesiologists. It could be valuable to titrate the administration of inhaled anesthetic, such as sevoflurane, in morbid obese patients, in order to shorten emergence using bispectral index [BIS] monitoring. It would be a great advantage if BIS permitted a more rapid recovery and less consumption in morbidly obese patients with a high cost inhaled agent. The aim of the study is to show whether the titration of sevoflurane based on the BIS monitoring would allow shortening of recovery time in morbidly obese patients and to evaluate whether BIS monitoring would contribute to reduce the amount of sevofLurane administered while providing an adequate anesthesia. Thirty morbidly obese ASA I and II patients undergoing laparoscopic gastric banding [LAGB] procedures were studied. In the first group [15 patients], patients were anesthetized without the use of BIS [non BIS or control group], and sevoflurane being administered according to standard clinical practice [control group]. In the second group [15 patients], sevoflurane was titrated to maintain a BIS value between 40 and 60 during surgery, and then 60-70 during 15 min prior to the end of surgery [BIS group]. Recovery times were recorded. Time to extubation was also noted, as well as the time to achieve a modified Aldrete score of 9 were evaluated subsequently at 10-min intervals until 3 h after surgery by nurses who had no knowledge of the study. Sevoflurane consumption was calculated using the vaporizer weighing method. Awakening and extubation times were significantly shorter in the BIS group [P <0.05]. In the BIS [vs. non BIS] group, there were no significant differences observed in the time to obtain an Aldrete score of 9. The sevoflurane consumption and cost in the BIS group were lower than in the non BIS group [P <0.05]. Bispectral index monitoring during anesthesia for morbidly obese patients provides statistically significant reduction in recovery times. It also has the added advantage in decreasing sevoflurane consumption

Anesthesia for third ventriculostomy-a report of 128 cases

Endoscopic third ventriculostomy [ETV] has become the standard surgical procedure for treatment of non-communicating hydrocephalus. The aim of this study is to report our results over the past ten years with reference to perioperative complications of ETV with a review of some specific anesthetic issues. The computerized database [in the Department of Neurosurgery] and the medical records of 128 patients who underwent ETV between February 1998 and February 2007 at our Hospital, were reviewed. Data collected were, age, sex, weight, height, preoperative biochemical analysis, duration of the procedure, anesthetic drugs used, amount of irrigation fluid used, blood loss, postoperative biochemical analysis and perioperative complications. Preoperative biochemical analysis for all patients was within normal ranges. Normal saline 0.9% was used as irrigation fluid for all patients. The volume during the procedure used ranged from 2 to 6 L [mean 3 L]. When correlating postoperative serum sodium mean values to the volume of irrigation fluid used, it showed non significant correlation [r = 0.07]. Serum potassium level has shown significant decrease postoperatively compared to preoperative levels [P <0.05]. The other biochemical analysis parameters showed non-significant changes postoperatively compared to preoperative data [P > 0.05]. Anesthesiologists should be aware of the intra and postoperative complications secondary to ETV. Intraoperative bradycardia is the commonest arrhythmia occuring during the procedure. Precautions, like alerting the surgeon and pulling out the scope, are enough to revert bradycardia if it occurs. Though postoperative electrolyte imbalance occurs we believe it has no clinical significance. We believe that either normal saline or lactated Ringer solutions could be safely used for intraoperative irrigation with minimal postoperative impact. Though the procedure is a minimally invasive procedure, close observation of vital signs, serum electrolytes as well as volume and temperature of the irrigation fluid and close communication between anesthesiologist and surgeon, are prerequisites for better outcome

Effect of small dose intravenous dexmedetomidine and/or local anaesthetic infiltration on haemodynamic responses to skull pin placement

Fixation of skull pins during craniotomy may cause acute haemodynamic changes. We evaluated, in this randomised double blind placebo controlled trial, the effects of small dose of dexmedetomidine [Dex] infusion in attenuating the haemodynamic profile during skull pin placement. Twenty-eight patients ASA I and II undergoing elective craniotomy were studied. Anaesthesia induced with sufentanil and sodium thiopentone [STP]. Cisatracurium was given to facilitate endotracheal intubation. Patients were randomly allocated to one of four groups [each 7 patients]: dex, lidocaine, dex-lidocaine and placebo [groups I, II, III, and IV respectively]. Groups I and III received intravenous Dex 0.25 meg/kg infusion and local infiltration with normal saline [NS] in group I and with 1% lidocaine in group III. Groups II and IV received intravenous NS and local infiltration at each pin insertion site with 1% lidocaine in group II and NS in group IV. The protocol started with intravenous medications to the assigned groups followed [after 8 min] with local infiltration of the scalp. Two minutes later [10 min after intravenous medication], scalp pinning was performed. Variables recorded were heart rate [HR], systolic blood pressure [SBP] and mean blood pressure [MBP] at different times. After opening the dura, brain status was assessed by the surgeon. Repeated measures of variance of HR, SBP, and MBP showed statistically significant interaction between group assignment and assigned time for groups I and III. In conclusion, our results showed that use of small doses of dex has resulted in obtunding the haemodynamic response to skull pin placement

EEG bispectral index during carotid endarterectomy

Purpose: Carotid endarterectomy [CEA] is an established surgical procedure for the treatment of internal carotid artery stenosis. Stroke is the commonest risk factor during CEA, therefore, cerebral monitoring became essential. Currently the EEG bispectral index [B1S] is used as a monitor of depth of anesthesia and it has shown decreasing trend during cerebral ischemia. We conducted this study to document the changes of the BIS variable during CEA under anesthesia. Ten patients who underwent CEA under general anesthesia were studied. The EEG BIS was measured during the perioperative period where five phases were identified: [A] before induction of anesthesia, [B] before clamping of ICA, [C] during clamping of ICA, [D] after declamping of ICA and [E] during the recovery from anesthesia. The age ranged between 53-69 yr. The mean values of the BIS were 91.4 +/- 5.6, 59.6 +/- 18.7, 44.3 +/- 6.8, 54.7 +/- 8.3 and 72.1 +/- 12.4 during A, B, C, D and E phases respectively with statistical significant low values during B, C, D and E phases versus phase A. The decreasing trend of the EEG BIS was shown during ICA clamping and whether this is an important quantitative variable to determine the adequacy of cerebral perfusion during CEA is yet to be further studied