Ventilatory performance of BASKA mask as an alternative to endotracheal intubation in short-term gynecologic laparoscopic procedures: a prospective randomized clinical trial.

BACKGROUND: Using laryngeal mask airways (LMAs) in laparoscopic surgery is still controversial because of the risk of insufficient ventilation and gastric overinflation. We investigated the use of BASKA LMA as an alternative to endotracheal intubation in low-risk females undergoing short-term gynecologic laparoscopic surgeries in Trendelenburg position under general anesthesia and positive pressure ventilation. METHODS: Sixty-five females (19-43 years), ASA (I-II) were scheduled to receive endotracheal tube (ETT group, N.=32) or BASKA mask (BASKA group, N.=33) for airway management. Assessments included insertion time and score, intraoperative lung mechanics, oropharyngeal leak pressure (OLP), ventilatory score, leak fraction, perioperative lung spirometry, and adverse effects. Timepoints were after device insertion, pneumoperitoneum inflation, Trendelenburg position, at 15, 30, 45 minutes intraoperatively and at end of surgery. RESULTS: The median insertion time was shorter in BASKA group (21.0 [18-38] s), compared with ETT group (27.0 [24-33] s, P=0.000). First-time success rate for insertion of BASKA mask was 87.9% (29 patients). The peak inflation pressure, calculated dynamic compliance, ventilatory score and lung spirometry data showed no significant difference between the two groups. The median leak fraction was higher in BASKA group after insertion (P=0.012) and after Trendelenburg position (P=0.032), with no significant differences afterwards. The median OLP after insertion was 32.0 (29-35) cmH2O which decreased after pneumoperitoneum inflation (31.0 [27-33] cmH2O, P=0.000), and after Trendelenburg position (30.0 [27-32] cmH2O, P=0.000) and remained stable at this range. CONCLUSIONS: BASKA mask can be considered as a safe alternative to ETT with comparable ventilatory performance in low-risk females undergoing short-term gynecologic laparoscopic surgeries.

Development of Sedative Dexmedetomidine Sublingual In Situ Gels: In Vitro and In Vivo Evaluations.

Intravenous dexmedetomidine (DEX) is currently approved by the FDA for the sedation of intubated patients in intensive care units to reduce anxiety and to augment postoperative analgesia. Bradycardia and hypotension are limitations associated with the intravenous administration of DEX. In this study, DEX sublingual in situ gels were developed and assessed for their pH, gelling capacity, viscosity, mucoadhesion and in vitro drug release. The optimized gelling system demonstrated enhanced mucoadhesion, superior gelling capacity, reasonable pH and optimal rheological profile. In vivo, compared to the oral solution, the optimal sublingual gel resulted in a significant higher rate and extent of bioavailability. Although the in situ gel had comparable plasma levels to those observed following intravenous administration, significant amelioration of the systemic adverse reactions were attained. As demonstrated by the hot plate method, a sustained duration of analgesia in rats was observed after sublingual administration of DEX gel compared to the intravenously administered DEX solution. Furthermore, no changes in systolic blood pressure and heart rate were recorded in rats and rabbits, respectively, after sublingual administration of DEX. Sublingual administration of DEX in situ gel provides a promising approach for analgesia and sedation, while circumventing the reported adverse reactions associated with intravenous administration of DEX.

Device stability and quality of ventilation of classic laryngeal mask airway versus AIR-Q and I-gel at different head and neck positions in anesthetized spontaneously breathing children.

BACKGROUND: Since its introduction into clinical practice, the use of laryngeal mask airway (LMA) has been dramatically increasing. We aimed to investigate the clinical performance of single use LMA classic, AIR-Q and I-gel at different head and neck positions and during the operative procedure in pediatric elective day case surgery. METHODS: One hundred sixty-eight generally anesthetized spontaneously breathing children (2-9 years) were randomized to receive either LMA classic (N.=56), I-gel (N.=58) or AIR-Q (N.=54). The oropharyngeal leak pressure (OLP), exhaled tidal volume (TV), peak inspiratory pressure (PIP), ventilation score and fiberoptic glottis view score were assessed at neutral position then at maximum flexion, extension and left rotation. Afterwards, the ventilation and fiberoptic view scores were assessed in neutral position at fixed time-points until end of surgery. RESULTS: Compared to neutral position, maximum neck flexion increased OLP (P=0.000) and compromised the ventilation leading to increased PIP, decreased TV, worsening of ventilation score and fiberoptic glottis view. OLP mildly decreased with extension and left lateral rotation with mild effect on ventilation parameters (P<0.05). At all neck positions, the OLP was higher (P=0.000) and ventilation parameters were better with I-gel (P=0.000). Gradual worsening of ventilation score and fiberoptic view grade was recorded intraoperatively with the three devices, with the least deterioration observed in I-gel group (P=0.000). CONCLUSIONS: Having the highest increase in OLP at neck flexion, the I-gel LMA exhibited the best ventilation parameters and fiberoptic view grade at different head and neck positions and throughout the intraoperative period.

[Oral trans-mucosal dexmedetomidine for controlling of emergence agitation in children undergoing tonsillectomy: a randomized controlled trial]. / Dexmedetomidina transmucosa oral para controle da agitação ao despertar em crianças submetidas a amigdalectomia: ensaio clínico randomizado.

OBJECTIVES: Emergence agitation is a negative behavior commonly recorded after pediatric tonsillectomy. We investigated the efficacy of preoperative premedication with oral transmucosal buccal dexmedetomidine on the incidence and severity of emergence agitation in preschool children undergoing tonsillectomy under sevoflurane anesthesia. METHODS: Ninety patients aged (3-6 years), ASA I-II were enrolled into three groups (n = 30) to receive oral transmucosal dexmedetomidine 0.5 µg.kg-1 (Group DEX I), 1 µg.kg-1 (Group DEX II) or saline placebo (Group C). Our primary endpoint was the Watcha agitation score at emergence in PACU. Secondary outcomes were preoperative sedation score, intraoperative hemodynamics, postoperative Objective Pain Scale (OPS) and adverse effects. RESULTS: The patients' demographics, preoperative sedation scores and extubation time showed no difference between groups. Significant differences between groups in incidence and frequency distribution of each grade of Watcha score were evident at 5 minutes (p = 0.007), 10 minutes (p = 0.034), 30 minutes (p = 0.022), 45 minutes (p = 0.034) and 60 minutes (p = 0.026), postoperatively with significant differences between DEX I and II groups. DEX groups showed lower OPS scores at 5 minutes (p = 0.011), 10 minutes (p = 0.037) and 30 minutes (p = 0.044) after arrival at PACU, with no difference between DEX I and II groups. Patients in DEX II group exhibited lower intraoperative mean heart rate at 15 minutes (p = 0.020), and lower mean arterial pressure at 30 minutes, (p = 0.040), 45 minutes (p = 0.002) and 60 minutes (p = 0.006) with no significant differences between groups in other time points. CONCLUSION: This study demonstrates the clinical advantage and the simple technique of oral transmucosal DEX premedication for emergence agitation in preschool children undergoing tonsillectomy under sevoflurane anesthesia compared with saline placebo. TRIAL REGISTRATION: Clinical Trials.gov trial registry: NCT02720705.

Oral trans-mucosal dexmedetomidine for controlling of emergence agitation in children undergoing tonsillectomy: a randomized controlled trial / Dexmedetomidina transmucosa oral para controle da agitação ao despertar em crianças submetidas a amigdalectomia: ensaio clínico randomizado

Abstract Objectives: Emergence agitation is a negative behavior commonly recorded after pediatric tonsillectomy. We investigated the efficacy of preoperative premedication with oral transmucosal buccal dexmedetomidine on the incidence and severity of emergence agitation in preschool children undergoing tonsillectomy under sevoflurane anesthesia. Methods: Ninety patients aged (3-6 years), ASA I‒II were enrolled into three groups (n = 30) to receive oral transmucosal dexmedetomidine 0.5 µg.kg-1 (Group DEX I), 1 µg.kg-1 (Group DEX II) or saline placebo (Group C). Our primary endpoint was the Watcha agitation score at emergence in PACU. Secondary outcomes were preoperative sedation score, intraoperative hemodynamics, postoperative Objective Pain Scale (OPS) and adverse effects. Results: The patients' demographics, preoperative sedation scores and extubation time showed no difference between groups. Significant differences between groups in incidence and frequency distribution of each grade of Watcha score were evident at 5 minutes (p= 0.007), 10 minutes (p= 0.034), 30 minutes (p= 0.022), 45 minutes (p= 0.034) and 60 minutes (p= 0.026), postoperatively with significant differences between DEX I and II groups. DEX groups showed lower OPS scores at 5 minutes (p= 0.011), 10 minutes (p= 0.037) and 30 minutes (p= 0.044) after arrival at PACU, with no difference between DEX I and II groups. Patients in DEX II group exhibited lower intraoperative mean heart rate at 15 min (p= 0.020), and lower mean arterial pressure at 30 minutes, (p= 0.040), 45 minutes (p= 0.002) and 60 minutes (p= 0.006) with no significant differences between groups in other time points. Conclusion: This study demonstrates the clinical advantage and the simple technique of oral transmucosal DEX premedication for emergence agitation in preschool children undergoing tonsillectomy under sevoflurane anesthesia compared with saline placebo. Trial registration Clinical Trials.gov trial registry: NCT02720705.

Resumo Objetivos: A agitação ao despertar da anestesia é um comportamento negativo comumente registrado após amigdalectomia pediátrica. Avaliamos a eficácia da pré-medicação com dexmedetomidina via transmucosa oral no pré-operatório sobre a incidência e gravidade da agitação ao despertar em crianças pré-escolares submetidas à amigdalectomia sob anestesia com sevoflurano. Métodos: Noventa pacientes entre três e seis anos e estado físico ASA I-II foram incluídos em três grupos (n = 30) para receber 0,5 µg.kg-1 ou 1 µg.kg-1 de dexmedetomidina via transmucosa oral (Grupo DEX I e Grupo DEX II, respectivamente) ou solução salina (Grupo C). O desfecho primário foi o escore de agitação ao despertar medido com a escala de Watcha na SRPA. Os desfechos secundários foram escore de sedação pré-operatória, hemodinâmica intraoperatória, escore OPS (Objective Pain Scale) e efeitos adversos no pós-operatório. Resultados: A demografia dos pacientes, os escores de sedação pré-operatória e o tempo de extubação não apresentaram diferença entre os grupos. Diferenças significativas entre os grupos na distribuição da incidência e frequência de cada grau do escore de Watcha foram evidentes aos 5 minutos (p = 0,007), 10 minutos (p = 0,034), 30 minutos (p = 0,022), 45 minutos (p = 0,034) e 60 minutos (p = 0,026) no pós-operatório, com diferenças significativas entre os grupos DEX I e II. Os grupos DEX apresentaram escores OPS mais baixos aos 5 minutos (p = 0,011), 10 minutos (p = 0,037) e 30 minutos (p = 0,044) após a chegada à SRPA, sem diferença entre os grupos DEX I e II. Os pacientes do grupo DEX II apresentaram menor frequência cardíaca média aos 15 minutos de intraoperatório (p = 0,020) e menor pressão arterial média aos 30 minutos, (p = 0,040), 45 minutos (p = 0,002) e 60 minutos (p = 0,006), sem diferenças significativas entre os grupos em outros momentos. Conclusão: Este estudo demonstra a vantagem clínica e a técnica simples da pré-medicação com DEX por via transmucosa oral para agitação ao despertar em crianças pré-escolares submetidas à amigdalectomia sob anestesia com sevoflurano, comparado à solução salina. Registro do estudo: Clinical Trials.gov trial registry: NCT02720705.

Analgesic and Respiratory Effects of Two Doses of Morphine as an Adjunct to Bupivacaine in Ultrasound-Guided Transversus Abdominis Plane Block in Upper Abdominal Surgery.

BACKGROUND: Opioid receptors are present at the terminals of afferent peripheral nerves; therefore, administration of opioids peripherally might provide a significant analgesic effect. OBJECTIVES: We investigated the analgesic efficacy of 2 different doses of morphine in bilateral subcostal single-injection ultrasound-guided transversus abdominis plane (TAP) block in abdominal surgery. STUDY DESIGN: Randomized, controlled, double-blind trial. SETTING: University hospital. METHODS: We enrolled 90 patients (aged 18-60 years) who were scheduled for elective upper abdominal surgeries and received TAP block for postoperative analgesia. Patients received 20 mL bupivacaine 0.5% (group B) only or combined with 10 mg morphine (group BM10) or 15 mg morphine (group BM15). Study drugs were diluted with saline solution 0.9% to 40 mL volume and bupivacaine concentration of 0.25% and injected 20 mL on each side. Primary outcome was the verbal rating pain scale (VRS) over the first 24 hours postoperatively. Secondary outcomes were time to first request for analgesics, total analgesic consumption, lung spirometry, and adverse effects. RESULTS: Compared with group B, patients in BM10 and BM15 groups showed significantly lower postoperative VRS scores at rest and during cough. Patients in BM15 group had lower VRS scores at the 24th hour postoperatively at rest (P = 0.034) and during cough (P = 0.040), compared with group BM10, with no significant difference at other timepoints. The median time to first request for intravenous patient controlled analgesia (PCA) nalbuphine was 10 hours (range, 6-12 hours) in group B versus 15 hours (8-18 hours; P = 0.000) and 16 hours (10-23 hours; P = 0.000) in BM10 and BM15 groups, respectively. Total consumption of nalbuphine PCA in BM15 group was 12 mg (6-18 mg) compared with 26 mg (20-34 mg; P = 0.000) and 18 mg (12-24 mg; P = 0.000] in groups B and BM10, respectively, with a significant difference between BM10 and BM15 groups (P = 0.000) and without significant adverse effects. LIMITATIONS: A limitation was a small sample size. CONCLUSIONS: Addition of morphine to bupivacaine in single-injection subcostal TAP block controlled pain and reduced opioid requirements after abdominal surgery in a dose-dependent manner. KEY WORDS: Abdominal surgery, analgesia, transversus abdominis plane block, morphine.

[Preemptive nebulized ketamine for pain control after tonsillectomy in children: randomized controlled trial]. / Uso preventivo de cetamina nebulizada para controle da dor após amigdalectomia em crianças: estudo randômico e controlado.

OBJECTIVES: The administration of ketamine as nebulized inhalation is relatively new and studies on nebulized ketamine are scarce. We aimed to investigate the analgesic efficacy of nebulized ketamine (1 and 2mg.kg-1) administered 30min before general anesthesia in children undergoing elective tonsillectomy in comparison with intravenous ketamine (0.5mg.kg-1) and saline placebo. METHODS: One hundred children aged (7-12) years were randomly allocated in four groups (n=25) receive; Saline Placebo (Group C), Intravenous Ketamine 0.5mg.kg-1 (Group K-IV), Nebulized Ketamine 1mg.kg-1 (Group K-N1) or 2mg.kg-1 (Group K-N2). The primary endpoint was the total consumption of rescue analgesics in the first 24h postoperative. RESULTS: The mean time to first request for rescue analgesics was prolonged in K-N1 (400.9±60.5min, 95% CI 375.9-425.87) and K-N2 (455.5±44.6min, 95% CI 437.1-473.9) groups compared with Group K-IV (318.5±86.1min, 95% CI 282.9-354.1) and Group C (68.3±21.9min, 95% CI 59.5-77.1; p<0.001), with a significant difference between K-N1 and K-N2 Groups (p<0.001). The total consumption of IV paracetamol in the first 24h postoperative was reduced in Group K-IV (672.6±272.8mg, 95% CI 559.9-785.2), Group K-N1 (715.6±103.2mg, 95% CI 590.4-840.8) and Group K-N2 (696.6±133.3mg, 95% CI 558.8-834.4) compared with Control Group (1153.8±312.4mg, 95% CI 1024.8-1282.8; p<0.001). With no difference between intravenous and Nebulized Ketamine Groups (p=0.312). Patients in intravenous and Nebulized Ketamine Groups showed lower postoperative VRS scores compared with Group C (p<0.001), no differences between K-IV, K-N1 or K-N2 group and without significant adverse effects. CONCLUSION: Preemptive nebulized ketamine was effective for post-tonsillectomy pain relief. It can be considered as an effective alternative route to IV ketamine.

Preemptive nebulized ketamine for pain control after tonsillectomy in children: randomized controlled trial / Uso preventivo de cetamina nebulizada para controle da dor após amigdalectomia em crianças: estudo randômico e controlado

Abstract Objectives The administration of ketamine as nebulized inhalation is relatively new and studies on nebulized ketamine are scarce. We aimed to investigate the analgesic efficacy of nebulized ketamine (1 and 2 mg.kg-1) administered 30 min before general anesthesia in children undergoing elective tonsillectomy in comparison with intravenous ketamine (0.5 mg.kg-1) and saline placebo. Methods One hundred children aged (7-12) years were randomly allocated in four groups (n = 25) receive; Saline Placebo (Group C), Intravenous Ketamine 0.5 mg.kg-1 (Group K-IV), Nebulized Ketamine 1 mg.kg-1 (Group K-N1) or 2 mg.kg-1 (Group K-N2). The primary endpoint was the total consumption of rescue analgesics in the first 24 h postoperative. Results The mean time to first request for rescue analgesics was prolonged in K-N1 (400.9 ± 60.5 min, 95% CI 375.9-425.87) and K-N2 (455.5 ± 44.6 min, 95% CI 437.1-473.9) groups compared with Group K-IV (318.5 ± 86.1 min, 95% CI 282.9-354.1) and Group C (68.3 ± 21.9 min, 95% CI 59.5-77.1; p < 0.001), with a significant difference between K-N1 and K-N2 Groups (p < 0.001). The total consumption of IV paracetamol in the first 24 h postoperative was reduced in Group K-IV (672.6 ± 272.8 mg, 95% CI 559.9-785.2), Group K-N1 (715.6 ± 103.2 mg, 95% CI 590.4-840.8) and Group K-N2 (696.6 ± 133.3 mg, 95% CI 558.8-834.4) compared with Control Group (1153.8 ± 312.4 mg, 95% CI 1024.8-1282.8; p < 0.001). With no difference between intravenous and Nebulized Ketamine Groups (p = 0.312). Patients in intravenous and Nebulized Ketamine Groups showed lower postoperative VRS scores compared with Group C (p < 0.001), no differences between K-IV, K-N1 or K-N2 group and without significant adverse effects. Conclusion Preemptive nebulized ketamine was effective for post-tonsillectomy pain relief. It can be considered as an effective alternative route to IV ketamine.

Resumo Objetivos A administração de cetamina por via inalatória através de nebulizador é relativamente nova e os estudos sobre este assunto são escassos. Nosso objetivo foi investigar a eficácia analgésica da cetamina nebulizada (1 e 2 mg.kg-1) administrada 30 minutos antes da anestesia geral em crianças submetidas à amigdalectomia eletiva, em comparação com cetamina intravenosa (0,5 mg.kg-1) e placebo (soro fisiológico). Métodos Cem crianças entre 7-12 anos foram randomicamente alocadas em quatro grupos (n = 25) e receberam: soro fisiológico para controle (Grupo C); 0,5 mg.kg-1 de cetamina intravenosa (Grupo C-IV); 1 mg.kg-1 de cetamina nebulizada (Grupo C-N1); 2 mg.kg-1 de cetamina nebulizada (Grupo C-N2). O desfecho primário foi o consumo total de analgésicos de resgate nas primeiras 24 horas de pós-operatório. Resultados O tempo médio para a primeira solicitação de analgésicos de resgate foi prolongado nos grupos C-N1 (400,9 ± 60,5 min, IC 95% 375,9-425,87) e C-N2 (455,5 ± 44,6 min, IC 95% 437,1-473,9) em comparação com o Grupo C-IV (318,5 ± 86,1 min, IC 95% 282,9-354,1) e o Grupo C (68,3 ± 21,9 min, IC 95% 59,5-77,1; p < 0,001), com uma diferença significativa entre os grupos C-N1 e C-N2 (p < 0,001). O consumo total de paracetamol IV nas primeiras 24 horas de pós-operatório foi reduzido no Grupo C-IV (672,6 ± 272,8 mg, IC 95% 559,9-785,2), Grupo C-N1 (715,6 ± 103,2 mg, IC 95% 590,4-840,8) e Grupo C-N2 (696,6 ± 133,3 mg, IC 95% 558,8-834,4) em comparação com o Grupo C (1153,8 ± 312,4 mg, IC 95% 1024,8-1282,8; p < 0,001). Não houve diferença entre os grupos de cetamina intravenosa e nebulizada (p = 0,312). Os pacientes dos grupos de cetamina intravenosa e nebulizada apresentaram escores VRS pós-operatórios menores, em comparação com o Grupo C (p < 0,001), sem diferenças entre os grupos C-IV, C-N1 ou C-N2 e sem efeitos adversos significativos. Conclusão A administração preventiva de cetamina nebulizada foi eficaz no alívio da dor pós-amigdalectomia. Cetamina nebulizada pode ser considerada como uma via alternativa eficaz à cetamina IV.

Post-extubation continuous positive airway pressure improves oxygenation after pediatric laparoscopic surgery: A randomized controlled trial.

BACKGROUND: Effects of intraoperative recruitment maneuvers (RMs) on oxygenation and pulmonary compliance are lost during recovery if high inspired oxygen and airway suctioning are used. We investigated the effect of post-extubation noninvasive CPAP mask application on the alveolar arterial oxygen difference [(A-a) DO2 ] after pediatric laparoscopic surgery. METHODS: Sixty patients (1-6 years) were randomly allocated to three groups of 20 patients, to receive zero end-expiratory pressure (ZEEP group), RM with decremental PEEP titration only (RM group), or followed with post-extubation CPAP for 5 minutes (RM-CPAP group). Primary outcome was [(A-a) DO2 ] at 1 hour postoperatively. Secondary outcomes were respiratory mechanics, arterial blood gas analysis, hemodynamics, and adverse events. RESULTS: At 1 hour postoperatively, mean [(A-a) DO2 ] (mm Hg) was lower in the RM-CPAP group (41.5 ± 13.2, [95% CI 37.6-45.8]) compared to (80.2 ± 13.7 [72.6-87.5], P < 0.0001] and (59.2 ± 14.6, [54.8-62.6], P < 0.001) in the ZEEP and RM groups. The mean PaO2 (mm Hg) at 1 hour postoperatively was higher in the RM-CPAP group (156.2 ± 18.3 [95% CI 147.6-164.7]) compared with the ZEEP (95.9 ± 15.9 [88.5-103.3], P < 0.0001) and RM groups (129.1 ± 15.9 [121.6-136.5], P < 0.0001). At 12 hours postoperatively, mean [(A-a) DO2 ] and PaO2 were (9.6 ± 2.1 [8.4-10.8]) and (91.9 ± 9.4 [87.5-96.3]) in the RM-CPAP group compared to (25.8 ± 5.5 [23.6-27.6]) and (69.9 ± 5.5 [67.4-72.5], P < 0.0001) in the ZEEP group and (34.3 ± 13.2, [28.4-40.2], P < 0.0001) and (74.03 ± 9.8 [69.5-78.6], P < 0.0001) in the RM group. No significant differences of perioperative adverse effects were found between groups. CONCLUSIONS: An RM done after pneumoperitoneum inflation followed by decremental PEEP titration improved oxygenation at 1 hour postoperatively. The addition of an early post-extubation noninvasive CPAP mask ventilation improved oxygenation at 12 hours postoperatively.

Prophylactic granisetron for post-spinal anesthesia shivering in cesarean section: A randomized controlled clinical study.

BACKGROUND: The serotonergic system is known to be involved in control of post-anesthetic shivering. Our hypothesis was that prophylactic granisetrone (serotonin antagonist) might reduce incidence of post-spinal anesthesia shivering in cesarean section. METHODS: Parturient scheduled for elective cesarean delivery under spinal anesthesia were allocated to receive 0.9% saline (Group I, n = 71), 1 mg granisetron (Group II, n = 69), or 0.7 mg granisetron (Group III, n = 72) before the spinal block. Assessment parameters included; hemodynamics, tympanic membrane temperature, neonatal Apgar score, shivering score, patient satisfaction scores about shivering prophylaxis and adverse effects. RESULTS: Clinically significant shivering was recorded in 55/71 patients (77.5%) in group I, 11/69 (15.9%) in group II and 21/72 (29.2%) in group III (P = 0.000). The intensity of shivering was significantly lower in patients who received granisetron 1 mg compared with granisetron 0.7 mg or saline (P = 0.000). Patients who received prophylactic granisetron 1 mg reported lower mean intraoperative arterial pressure and heart rate values and consumed higher doses of iv ephedrine compared with 0.7 mg granisetron or saline placebo (P < 0.05). Pruritus significantly decreased from (22.5%) in control group to (0%) in granisetron groups (P = 0.000). Nausea was reported in 8 vs 10 and four in group I, II and III, respectively (P < 0.03). Sixteen vs eight and six patients vomited in group I, II, and III, respectively (P < 0.03). Higher patient satisfaction scores were recorded in group II (9.83 ± 0.29, P < 0.03) and III (9.14 ± 1.04, P < 0.04), compared with control group (8.23 ± 1.14). CONCLUSION: Prophylactic granisetron effectively reduced incidence and severity of perioperative shivering in a dose dependent manner, compared to placebo controls.

Efficacy of ketamine as an adjunct to lidocaine in intravenous regional anesthesia.

BACKGROUND: This study aims to compare and evaluate the effect of adding ketamine as an adjunct to lidocaine for intravenous regional anesthesia (IVRA) on intraoperative and postoperative analgesia, the onset and recovery times of sensory and motor block, and tourniquet pain. METHODS: Forty patients undergoing surgery of the hand or forearm under IVRA were randomly assigned to receive lidocaine 3 mg/kg (group 1) or lidocaine 3 mg/kg plus ketamine 50 mg (group 2) diluted to 40 mL with normal saline. Assessment parameters included the onset and recovery times of sensory and motor block, tourniquet pain, intraoperative hemodynamics, surgeon and patient satisfaction, postoperative pain, time of first analgesic request, total analgesic consumption, and adverse effects in the first 24 hours postoperatively. RESULTS: Groups 1 and 2 were comparable in demographic and surgical parameters. There were no differences between groups in intraoperative hemodynamics, onset and recovery times of sensory and motor block, or surgeon satisfaction index. Compared with group 1, group 2 patients showed less tourniquet pain, prolonged time to first request for postoperative rescue analgesia (5.5 ± 1.3 vs 20.4 ± 3.7 hours, P < 0.001), lower postoperative diclofenac consumption (120.00 ± 45.23 vs 55.1 ± 0.00 mg, P < 0.001), lower scores for postoperative pain as measured by the Verbal Rating Scale, higher patient satisfaction index, and a nonsignificant difference in the incidence of postoperative adverse effects between groups. CONCLUSIONS: The addition of ketamine to lidocaine in patients receiving IVRA significantly reduced intraoperative and postoperative analgesic requirements and improved patient satisfaction without causing significant adverse effects.

Intercostal nerve transfer in infants with obstetric brachial plexus palsy.

The use of intercostal nerve (ICN) transfer to repair brachial plexus lesions associated with root avulsions is a well known procedure in adults. However, there is a paucity of reports on the use of ICN in infants with obstetrical brachial plexus palsy (OBPP). This study included 46 infants with obstetric brachial plexus palsy who underwent 62 neurotization procedures. Clinically, 2 cases had upper trunk injury, 19 had upper-middle trunk injury, 3 had lower trunk injury, and 22 had total palsy. The average age at surgery was 14 months. Twelve patients underwent surgery younger than 6 months of age, 11 patients at 6 to <9 months, 9 patients at 9-12 months, and 14 patients at >12 months. The average follow-up period was 49 months. ICN transfer resulted in 76% satisfactory (good and excellent) outcome, and was best for restoration of elbow flexion (93.5%). Functional results were best when the operation was done before the age of 9 months; however, the difference between age groups was statistically insignificant. Functional results were also independent of the extent of the original injury. Nine children had preoperative and postoperative CT chest scans. All the nine children developed basal pulmonary atelectasis postoperatively. Pulmonary atelectasis was mostly ipsilateral and was not correlated to the patient age (months), or the duration of anesthesia (in minutes). We conclude that, intercostals nerve transfer is an effective procedure for restoration of function in infants with OBPP and root avulsions. The procedure is associated with variable degree of ipsilateral pulmonary atelectasis.