Effect of ketorolac on postoperative pain relief in dental extraction cases--a comparative study with pethidine.

OBJECTIVE: To compare the analgesic efficacy and side effects of ketorolac with pethidine in a day care procedure. STUDY DESIGN: Single dose, double blind, case matched study. METHODS: Sixty patients were divided into group A and group B, who received either ketorolac 30 mg or Pethidine 0.8 mg/kg ( both IN ) respectively at the time of induction of general anaesthesia. Patients were assessed in recovery room for pain according to visual analogue scale and any side effects. Amount of rescue analgesia required by both groups were also recorded. Odds Ratio and and Chi Square test were used for statistical analysis. RESULTS: Statistical analysis showed no significant differences between these two drugs at any time interval, however a significantly decreased incidence of nausea and drowsiness was found in ketorolac group. CONCLUSION: Ketorolac 30 mg intravenously provides similar analgesic effects as Pethidine with much less incidence of nausea and drowsiness.

Improvement in intraoperative fresh frozen plasma transfusion practice--impact of medical audits and provider education.

OBJECTIVE: To determine the practice of anaesthesiologists in our institution for intraoperative transfusion of Fresh Frozen Plasma (FFP) and to see whether provider education can reduce the incidence of inappropriate FFP transfusion. MATERIAL AND METHODS: A retrospective audit was done for 6 months in all patients who received intraoperative FFP transfusion. The result were compared with recommendations by the British Committee for Standards in Haematology. These results were presented in the departmental meeting and guidelines were circulated. Another prospective audit was conducted for six months to see whether there was any effect of provider education on the intraoperative transfusion practice. RESULTS: The first audit showed that 14.6% of the transfusion were definitely indicated, 40.2% were conditionally indicated whereas there was no justification in 45.1%. The subsequent audit showed a significant reduction (23.3%) in the unjustified transfusions of FFP whereas conditional use was significantly increased (69.1%), showing an overall improvement in the intraoperative transfusion practice. CONCLUSION: Further education and a monitoring system to ensure adherence to the recommended guidelines is required to improve transfusion practice.

Cerebral infarct following central venous cannulation.

Inadvertent carotid artery puncture is a well-known complication of internal jugular vein cannulation. A case of cerebral infarct subsequent to carotid artery puncture during internal jugular vein cannulation is reported.

Comparison of nalbuphine and buprenorphine in total intravenous anaesthesia.

Nalbuphine (0.3 mg.kg-1) and buprenorphine (2.5 micrograms.kg-1) were compared as part of a total intravenous anaesthesia regimen using a propofol infusion in 60 patients undergoing laparoscopic cholecystectomy in a randomised double-blind study. Changes in haemodynamic variables greater than 20% from the baseline were noted. No difference was observed in blood pressure but the heart rate was significantly lower in the buprenorphine group. Intra-operative bradycardia (heart rate < 60 beat.min-1) occurred more often in the buprenorphine group. Recovery was fast and comparable with both drugs and no patient reported awareness. Quality of analgesia was similar in both groups. Both drugs provide suitable analgesic supplementation to total intravenous anaesthesia.

Value of routine pre-operative chest X-ray in patients over the age of 40 years.

The overall usefulness of routine chest X-ray, its cost benefit ratio and effect on anaesthetic management in patients over the age of 40 years was assessed. Four hundred and seventy-seven consecutive patients undergoing elective non-cardiopulmonary surgery with no cardiopulmonary diseases, having a routine preoperative chest x-ray were selected at the Aga Khan University Hospital, Karachi. Twenty five (5.2%) were excluded from the study as their chest x-ray were not available at the time of surgery. Twenty eight (8.3%) below and 33 (28.7%) above 60 years of age had abnormalities in chest x-ray but the difference in cardiac abnormalities in two age groups was insignificant. The frequency of lung field abnormalities increased with age from 3.2% in less than 60 to 15.6% in patients above 60 years of age. The difference in frequency of occurrence of lung field abnormalities was statistically significant in case of lung abnormalities. Only one case required change in anaesthetic management based on routine preoperative chest x-ray. Our study showed that the incidence of significant lung field abnormalities increased in patients aged 60 years and above with no history of chronic obstructive airway disease. We recommend routine preoperative chest x-ray be carried out only in patients over the age of 60 years.

Experience with larangeal mask airway in Pakistani patients.

One hundred and thirty seven adult patients undergoing peripheral surgery were studied regarding ease of larangeal mask airway (LMA) insertion, airway maintenance during surgery and complication encountered during insertion, maintenance and in the postoperative period. In a majority (84%) of patients, the airway was positioned correctly at the first attempt, 3% patients had mild laryngospasm at insertion and in 85% a good airway was obtained. No airway related problems were encountered intraoperatively. Two percent patients had laryngospasm on removal of LMA. Postoperatively, the complaint of sore throat and uvular trauma was seen in 4% cases.

Complications of endotracheal intubation in mechanically ventilated patients in a general intensive care unit.

During a period of one year, 126 patients were prospectively audited to analyse complications of endotracheal intubation in a general intensive care unit setting. A total of 62 complications were observed in 48 patients. The most frequent complications during intubation were hypotension and bradycardia. The blockage of endotracheal tubes significantly increased with the duration of intubation. Sore throat was the commonest (22%) complication following extubation. Other complications like stridor and ulceration of mouth and lips which followed extubation were not related to the duration of intubation.

The effect of increasing the dose of buprenorphine on the haemodynamic response associated with tracheal intubation.

The effect of buprenorphine on the haemodynamic response to tracheal intubation was studied at two dose levels, 2.5 micrograms.kg-1 and 5 micrograms.kg-1, in a placebo-controlled double-blind trial in 75 patients undergoing laparoscopic cholecystectomy. The study drugs were administered intravenously 8 min before induction of anaesthesia with thiopentone 5 mg.kg-1 and vecuronium 0.1 mg/kg-1. Buprenorphine 2.5 micrograms.kg-1 caused 50% attenuation of the blood pressure response whereas 5 micrograms/kg-1 caused 70% attenuation compared to the saline placebo. The maximum increase in heart rate was 14% of the control value after 2.5 micrograms.kg-1 and 11% after 5 micrograms/kg-1 of buprenorphine. A significant difference in heart rate was also observed between the two buprenorphine groups at 5 and 10 min after intubation. Blood pressure and heart rate both showed a significant fall from baseline values 10 min after intubation in both buprenorphine groups, with the changes being greater in the 5 micrograms.kg-1 group. We recommend the use of 2.5 micrograms.kg-1 buprenorphine for attenuation of the hypertensive response to intubation in major abdominal surgery.

Effect of general anaesthesia and surgery on neutrophil function.

The effects of general anaesthesia and surgical trauma on neutrophil function were studied in 60 female ASA 1 and 2 patients undergoing anaesthesia for gynaecological surgery. Patients were divided into three groups depending on the degree of trauma and duration of surgery. Group 1 (n = 15) were patients for dilatation and curettage (minor surgical trauma) and were given 2% halothane. Group 2 (n = 30) had laparoscopic surgery (moderate surgical trauma) and received either 0.5% halothane or 1% enflurane. Group 3 (n = 15) were those having hysterectomy (major surgical trauma) and received 0.5% halothane for a longer duration. Venous samples were taken 30 min before anaesthesia (control value), 10 min after induction of anaesthesia, 10 min after the start of surgery, 30 min after the end of anaesthesia and 24 h later. Phagocytic index, nitroblue tetrazolium reduction test, total leucocyte count, and differential leucocyte counts were performed on each sample. Data were analysed by paired t-test to compare findings in the same patient and by unpaired t-test for differences between groups. Anaesthesia with halothane 0.5% to 2% caused a dose-related depressant effect on leucocyte function which reversed. Enflurane 1% on the other hand caused significantly greater depression of leucocyte function compared with 0.5% halothane which persisted during the recovery period and recovered on the first postoperative day. Total leucocyte counts also showed a fivefold increase in the major surgery groups.

Caudal analgesia with buprenorphine for postoperative pain relief in children.

Caudal buprenorphine was investigated as a postoperative analgesic in a randomized double blind study in thirty children aged 5-12 years undergoing lower abdominal and lower limb surgery. Comparison was made between two groups of patients, one group receiving plain bupivacaine and the other a combination of plain bupivacaine with buprenorphine. Postoperative analgesia was assessed using a linear analogue scale, and by the response to direct questioning of children using an illustration of sequence of faces. Any untoward side effects and the need for additional analgesics were recorded. The degree and duration of analgesia was far superior in the buprenorphine group and there was a highly significant difference in the requirement of postoperative analgesia between the two groups. There were no major adverse side effects and no motor weakness in either groups, however the incidence of nausea and vomiting was higher in the buprenorphine group. It is concluded that a combination of bupivacaine with buprenorphine administered through the caudal epidural space is a safe and reliable means of providing postoperative pain relief in children for up to 24 h.

Minimum induction dose (MID) of thiopentone in Pakistani patients.

The thiopentone dose needed for abolition of eyelash reflex was studied in 505 Pakistani patients who were divided in three subgroups, i.e., age less than 16 years, between 16 and 60 years, and over 60 years. The minimum induction dose for thiopentone was then determined in the three groups and the effect of sex, ASA classification, premedication and advancing age were seen. The minimum induction dose in the adult patients (16-60) was 215.8 +/- 66 mgs (3.48 mgs/kg). Both the adult groups and the elderly showed a statistical difference in the dose required by the males and females, but this difference was not seen in children. Thiopentone dose also showed a steady decline as the age progressed. A statistical correlation existed between ASA I and II patients compared to ASA III who required less thiopentone. The premedicated patients required less thiopentone compared to those who did not receive a premedication. Our patients required a lesser dosage for abolition of eyelash reflex than the figures recommended for British population. We recommend a dose of 3.5 mg/kg for adult Pakistani males and 3.3 mg/kg for adult females.

The effects of suxamethonium and pancuronium on the haemodynamic response to endotracheal intubation.

The pharmacological effects of suxamethonium and pancuronium on the cardiovascular system may vary and therefore alter the haemodynamic response to intubation. The arterial blood pressure, the heart rate and the rate pressure product were measured as parameters of haemodynamic change in forty adult ASA. I and II patients undergoing laryngoscopy and endotracheal intubation in a randomised controlled study. The patients were induced with either thiopentone/suxamethonium (Group A) or thiopentone/pancuronium (Group B). There was no significant difference between the groups on comparison of systolic and diastolic blood pressure changes. Pancuronium, however, caused a significantly higher rise in the heart rate after endotracheal intubation compared to suxamethonium. In both groups the maximum rate pressure product occurred one minute after intubation, rising by 56% in the suxamethonium group and 64% in the pancuronium group compared to control values. In conclusion, there were significant and statistically similar increases in systolic and diastolic blood pressures and rate pressure product following intubation in both groups with values significantly above baseline until three minutes post intubation but the increase in heart rate in group A was significantly less than that in group B.

Anaesthetic management for atlanto axial subluxation.

A number of disease processes including congenital anomalies, malunited odontoid fractures, rheumatoid arthritis and tuberculosis can result in atlanto axial subluxation. The patient population presenting for surgery is therefore varied in age and general condition, ranging from fit young men to steroid dependent frail arthritic patients. The degree of instability and the spinal cord compression are also variable. Gauging these parameters has an important bearing on the anaesthetic management. We present management of six patients with atlanto axial subluxation in our institution.

A review of 6978 consecutive admissions to the recovery room at a university hospital.

Recovery from anaesthesia is a time of potential danger to the surgical patients. A retrospective audit of all recovery room admissions over a period of 18 months was carried out at the Aga Khan University Hospital. During this period 6978 patients were admitted to the recovery area and 695 had one or more complications. The complications were recorded by the recovery room nursing staff in a recovery log book. The breakdown of complications according to different physiological systems is discussed. Several surveys have reviewed complications in the western population, but in contrast, no study is available in Pakistani patients. It is recommended that since one in ten patients is likely to have a problem in the early post-operative period, the local hospitals should provide adequate facilities meeting the criteria laid down for the recovery rooms in modern anaesthetic practice.

Total intravenous anaesthesia with propofol and buprenorphine.

A combination of propofol infusion and two bolus doses of buprenorphine, 2.5 or 5.0 micrograms/kg were evaluated in a total intravenous anaesthesia technique in 36 patients of ASA grade 1 or 2 undergoing cholecystectomy. Additional boluses of propofol were given intravenously if needed. Systolic blood pressure after tracheal intubation increased significantly only in those who received the smaller dose of buprenorphine. Patients in both groups remained haemodynamically stable throughout surgery with minimal side effects. Recovery was fast even with prolonged infusions and without major side effects. No patient reported awareness on postoperative questioning.

A comparison of buprenorphine and pethidine in analgesic supplemented anaesthesia.

A randomized trial comparing 2.5 and 5 micrograms/kilogram body weight of buprenorphine and 0.8 milligram/kilogram pethidine, intravenously for intraoperative use in a balanced anaesthetic technique, and for postoperative analgesia was carried out. Compared with pethidine, buprenorphine was shown to be a satisfactory analgesic for preoperative and postoperative use with little difference in the incidence of unwanted effects and much longer duration of action. Increasing the dose of buprenorphine did not give any significant advantage.