The best vein to be accessed based on descriptive study of dorsal metacarpal vein / 대한해부학회지

Anesthetic management of simultaneous coronary artery bypass grafting with cardiopulmonary bypass and extended thymectomy in a patient with myasthenia gravis

A 61-yr-old male having myasthenia gravis MG [Osserman IIB], Hypertension HTN, hyperlipidemia, type II diabetes mellitus DM II, a single pelvic kidney, chronic obstructive pulmonary disease COPD with a positive history of smoking and coronary artery disease, was admitted for uncontrolled myasthenic symptoms, cardiology team was consulted, cardiac catheterization was performed and revealed a three vessel coronary artery disease. All the findings dictated the management, a combined coronary artery bypass graft CABG and an extended thymectomy was performed. Optimization of the patient was achieved preoperatively. Total intravenous anesthesia using propofol and remifentanyl was applied to this patient. Continuous monitoring of the neuromuscular transmission NMT was maintained throughout the perioperative period. Although neither muscle relaxants nor inhalational agents were used in the anesthetic management of this patient; the patient developed postoperative atelectasis and lung collapse; which was managed successfully, and extubation of the trachea was done after ensuring adequate recovery of the NMT and respiratory function. Myasthenic therapy was continued throughout the perioperative period

Intravenous dexmedetomidine or propofol adjuvant to spinal anesthesia in total knee replacement surgery

The purpose of this study was to compare the effect of intravenous dexmedetomidine with the intravenous propofol adjuvant to spinal intrathecal anesthesia on the duration of spinal anesthesia and hemodynamic parameters during total knee replacement surgery. Seventy five patients were enrolled into this randomized study from the 1[st] of April 2008 till the 30[th] of August 2009 for total knee replacement surgery under spinal anesthesia. They were randomly assigned into three groups, group D, group P and group C. Following intrathecal injection with bupivacaine 12.5 mg in all patients in the three groups, patients in group D received intravenous loading dose of microg/kg/hr dexmedetomidine over 10 minutes and a maintenance dose of 0.2 to 0.5 p,g/kg/hr. Patients in group P received intravenous propofol 4 mg/Kg/hr over 10 min and a maintenance dose of 0.5-2 mg/Kg/hr. Patients in group C [control group] received nothing extra to the regular IV fluid. The regression times to reach SI sensory level and Bromage 0 motor scale, the hemodynamic parameters, the Bispectral Index level of Sedation [BIS], and arterial CO[2] level were recorded. The regression time to reach SI dermatome was 149.4 +/- 14.6 min in group C, 152.8 +/- 16.6 min in group P and 209.6 +/- 25.9 min in group D. The regression to Bromage 0 was!84.6 +/- 22.8 min in group C, 190.0 +/- 21.0 min in group P, and 255.8 +/- 36.7 min in group D. Statistical analysis of regression of sensory and motor block was significant among groups [C vs. D, P vs. D, P < 0.05]. The heart rate was significantly decreased in group D in comparison to groups C and P. Sedation levels were within accepted ranges in groups D and P and not affected in the control group. Minimal respiratory depression occurred in group P and D, clinically it was not significant. Supplementation of spinal anesthesia with intravenous dexmedetomidine or propofol produces good sedation levels without significant clinical hemodynamic changes. Adding dexmedetomidine produces significantly longer sensory and motor block than propofol

impact of long-lasting preemptive epidural analgesia before total hip replacement on the hormonal stress response. a prospective, randomized, double-blind study

Recent studies suggest that preemptive analgesia may be effective in reducing postoperative pain. One physiologic explanation may be interference with the endogenous opioid response. We investigated whether long-lasting preoperative preemptive analgesia may have an effect on the hormonal stress response after total hip replacement. 42 patients scheduled for elective hip replacement for coxarthrosis were randomized to receive, on the day before the operation, either 5 ml*h[-1] ropivacaine 0.2% [study group, n=21] or 5 ml*h[-1] saline [control group, n=21]. Postoperative analgesia was achieved in both groups by patient-controlled epidural analgesia [PCEA] with ropivacaine 0.2%. The main outcome measure was the concentration of authentic beta-endorphin [1-31] in plasma up to 4 days after surgery. Additional parameters included concentrations of adrenocorticotrope hormone and cortisol. Both groups were comparable concerning preoperative parameters and pain scores. Epidural blocks were sufficient in all patients for operative analgesia. Preemptive analgesia was performed for 11-20 hours in both groups and led to significantly decreased pain scores before surgery. Preemptive analgesia with epidural ropivacaine did not lead to decreased concentrations of beta-endorphin [1-31] before the start of surgery or in the postoperative period. Furthermore, no differences could be detected in the time course of beta-endorphin and adrenocorticotrope hormone after surgery. However, cortisol concentrations differed significantly between groups before the operation, but showed a comparable rise after surgery. Differences in postoperative pain after preemptive analgesia do not seem to be due to an altered endogenous opioid response

Horner's syndrome after lumbar epidural analgesia during labor

Horner's syndrome is rarely reported after epidural analgesia during labor. The use of Top-Up local anesthetic for controlling labor pain in the first stage of labor, or to dense the block in caesarean deliveries can result in this complication. We reported a cases of Horner's syndrome during epidural analgesia in labor in spite of not giving any Top-Up dose. The case was clinically evident and was successfully managed by stopping the epidural infusion, and reassuring the parturient as well as the family; until the disappearance of the signs and symptoms. The infusion was then restarted, delivery was uneventful and no consequent neurological or psychological problems were noticed after a one-month follow-up

Evaluation of mechanical valve replacement at Jordan University Hospital

To investigate the operative mortality and mid-term [up to eight years] results of mechanical valve replacement. Retrospective data analysis of 118 consecutive patients who underwent mechanical valve replacement. The early and late morbidity and mortality were analyzed at our institution, from January 2001 to December 2008. Hospital mortality was 2.5% [3 patients]. Complications recorded during the follow up study include: prosthetic valve endocarditis [3.4%], bleeding [3.4%], stroke [3.1%], and reoperation [.8%]. No structural valvular dysfunction and no valvular thromboses were reported. Our data show that valves replacement with mechanical valve may be performed with low morbidity and mortality

Effects of sevoflurane on postoperative liver functions in morbidly obese as compared to the non-obese patients

To assess the effect of sevoflurane anesthesia on hepatic function in morbidly obese versus non-obese patients undergoing abdominal surgeries. We prospectively evaluated the levels of the serum concentration of liver enzymes aspartate aminotransferase [AST], alanine aminotransferase [ALT], lactate dehydrogenase [LDH], gamma glutamyl transferase [GGT], alkaline phosphatase [ALP], and total bilirubin [TBil], in 42 morbidly obese and 40 non obese patients who were scheduled for elective abdominal surgery under sevoflurane anesthesia at the Jordan University Hospital, Amman, Jordan. Measurement of liver enzymes was done in the recovery room, and on the first, 3 and 7 days after sevoflurane anesthesia, and the results were compared between the morbidly obese and non obese patients. ALT, AST, GGT and LDH increased significantly in the morbidly obese than they did in non obese patients. In morbidly obese patients TBil increased gradually peaking 7 days after anesthesia, LDH increased in the recovery room, AST and ALT increased in the recovery room and first day, while GGT increased 7th day after anesthesia. In non obese patients, AST, LDH increased in the recovery. ALP did not change in both groups. Sevoflurane induces elevation of the serum liver enzymes in morbidly obese patients with variable onsets

Intravenous dexmedetomidine prolongs bupivacaine spinal analgesia

The prolongation of spinal anesthesia by using clonidine through the oral, intravenous and spinal route has been known. The new ?2 agonist, dexmedetomidine has been proved to prolong the spinal anesthesia through the intrathecal route. We hypothesized that dexmedetomidine when administered intravenously following spinal block, also prolongs spinal analgesia. 48 patients were randomly allocated into two equal groups following receiving spinal isobaric bupivacaine 12.5 mg. Patients in group D received intravenously a loading dose of 1 microg/kg dexmedetomidine over 10 min and a maintenance dose of 0.5 microg/kg/hr. Patients in group C [the control group] received normal saline. The regression times to reach S1 sensory level and Bromage 0 motor scale, hemodynamic changes and the level of sedation were recorded. The duration of sensory block was longer in intravenous dexmedetomidine group compared with control group [261.5 +/- 34.8 min versus 165.2 +/- 31.5 min, P < 0.05]. The duration of motor block was longer in dexmedetomidine group than control group [199 +/- 42.8 min versus 138.4 +/- 31.3 min, P < 0.05]. Intravenous dexmedetomidine administration prolonged the sensory and motor blocks of bupivacaine spinal analgesia with good sedation effect and hemodynamic stability

Incidental invasive thymoma during coronary artery bypass surgery

We encountered 2 incidental cases of invasive thymomas at Jordan University Hospital, Amman, Jordan; during routine coronary artery bypass graft surgery between 2005 and 2008 with an incidence of 0.6%. Both patients presented with angina pain. None of the 2 patients had pressure symptoms cough, shortness of breath or superior vena cava syndrome or Myasthenia Gravis symptoms. Total thymectomy with dissection of perithymic fat was performed on both cases. No radiotherapy was given. No recurrence of the tumor was seen in 2 years follow up. These cases are presented to emphasize the occurrence of this tumor

balanced anesthesia with dexmedetomidine decreases postoperative nausea and vomiting after laparoscopic surgery

To evaluate the effect of adding dexmedetomidine to a balanced anesthetic technique on postoperative nausea and vomiting after laparoscopic gynecological surgeries. A prospective double-blind randomized study was designed at Jordan University Hospital, Amman, Jordan between December 2008 and February 2009. Eighty-one female patients in their child-bearing age [17-48 years]; American Society of Anesthesiologists [ASA] clinical status I, who were scheduled for elective diagnostic laparoscopic surgeries under general anesthesia were divided into 2 groups. Group D [n=42] received dexmedetomidine infusion, while group P [n=39] received 0.9% sodium chloride infusion along with the balanced anesthesia. The incidence of early [up to 24 hours] postoperative nausea, vomiting, nausea and vomiting, and the need for postoperative rescue anti-emetic medications were recorded. The total incidence of postoperative nausea and vomiting decreased significantly in group D; 13 out of 42 patients [31%], compared to group P; 23 out of 39 patients [59%], vomiting alone did not significantly change, the incidence of postoperative nausea, and the use of rescue anti-emetic medications were significantly different. A significant drop in overall consumption of fentanyl and sevoflurane was also noted in group D. Combining dexmedetomidine to other anesthetic agents, results in more balanced anesthesia and a significant drop in the incidence of postoperative nausea and vomiting after laparoscopic gynecological surgeries

Duration of venous occlusion with lidocaine for preventing propofol induced pain

To study the effect of the venous occlusion duration using lidocaine on the incidence and severity of propofol induced pain. A prospective double-blind randomized study was designed at Jordan University Hospital, Amman, Jordan between October 2007 and November 2007. One hundred and fifty patients aged 14-70 years, American Society of Anesthesiologists [ASA] clinical status I and II who underwent elective surgeries under general anesthesia, were divided into 3 groups. All 3 groups had propofol 1% infusion at a constant rate after applying venous occlusion with lidocaine. The occlusion was applied for 15 seconds [group I, n=50], 30 seconds [group II, n=50] and 60 seconds [group III, n=50]. Pain was assessed during injection according to a verbal pain score. Fourteen patients 28% had pain in group I, compared to 16 patients 32% in group II, and 9 patients 18% in group III. This difference did not reach statistical significance p>0.05 for the incidence and severity of pain. While venous occlusion with lidocaine is an effective method in relieving propofol induced pain, we found no difference when the duration of venous occlusion was 15, 30, or 60 seconds

Rapid sequence induction and intubation with 1 mg/kg rocuronium bromide in cesarean section, comparison with suxamethonium

To demonstrate that Rocuronium Bromide can be used for rapid sequence induction in emergency conditions. Our study was performed between December 2005 and May 2006 in Jordan University Hospital, Jordan. We studied the efficacy and intubating conditions after administrating of Rocuronium Bromide 1 mg/kg at 60 second in group of 60 pregnant women undergoing elective or emergency cesarean section and compared the results with those obtained after giving Suxamethonium 1 mg/kg at 60 seconds in a group of patients similar to the Rocuronium group. Intubating conditions after 1 mg /kg of Rocuronium Bromide were found to be acceptable [good and excellent] in 95% of patients and were similar to the Suxamethonium group [97%]. The endotracheal tube could be passed through the vocal cards of all patients enrolled in the study. Rocuronium Bromide 1 mg/kg can be safely used for rapid sequence induction in cesarean section and the intubating conditions are similar to those of Suxamethonium

Bupivacaine with Meperidine versus Bupivacaine with Fentanyl for continuous epidural labor analgesia

To compare the efficacy of bupivacaine-meperidine and bupivacaine-fentanyl mixtures when continuously infused epidurally to relief the labor pain. We performed this prospective double-blinded study at Jordan University Hospital, Amman, Jordan between October 2005 and April 2006. Sixty-seven American Society of Anesthesia physical status I parturients were randomly divided into 2 groups, Group M [n=34] received a continuous infusion of 1 mg/ml of bupivacaine mixed with 1 mg/ml meperidine, and Group F [n=33] received a continuous infusion of 1 mg/ml bupivacaine mixed with 2 micrometer/ml fentanyl. Efficacy of analgesia, degree of motor block, hemodynamic variability, incidence of nausea and vomiting, pruritus, sedation, and the neonatal outcome were all compared between the 2 groups. A p value<0.05 was considered to be significant. Highly effective analgesia was achieved in both groups with a similar incidence of motor block, sedation, pruritus, and neonatal outcome. The only significant difference was in the incidence of nausea and vomiting. Group M had 8 parturients with nausea, compared with only 2 parturients in Group F [p=0.003]. Bupivacaine-meperidine in a continuous epidural infusion is as efficient as bupivacaine-fentanyl for pain relief during labor, but associated with a higher incidence of nausea and vomiting

Venous occlusion with lidocaine for preventing propofol induced pain. A prospective double-blind randomized study

Pain is a well-known complication of intravenous administration of propofol, and to find out the optimal method to decrease this pain, we studied 4 methods of delivering propofol. The study took place at Jordan University Hospital, Amman, Jordan between November 2004 and March 2005 on 200 patients. The patients were divided into 4 groups, group I [n=50], the control group, propofol 1% was given alone. Group II [n=50], patients received propofol 1% premixed with 40 mg of lidocaine. Group III [n=50], patients received propofol 1% 60 seconds after giving 40 mg of lidocaine. Group IV [n=50], patients had venous occlusion for 60 seconds with the use of lidocaine 1% [40 mg], followed by release of the occlusion and administration of the propofol. Pain was assessed during injection and categorized into: no pain, pain, and pain with behavioral changes. In group I [control], 35 patient complained of pain, compared to 26 in group II, 23 in group III, and 7 patients in group IV, with a significant reduction in the incidence and intensity of pain in group II, III, and IV compared with the control [p<0.005]. The best reduction of intensity and incidence was achieved in group VI, when compared with groups I, II and III [p<0.005], with no statistical difference between group II and III when compared with each other. Of the 4 methods studied, the optimal method to decrease the incidence and intensity of pain resulting from propofol injection is to inject lidocaine while applying venous occlusion for 60 seconds prior to administering propofol