Comprehensive overview of analytical and bioanalytical methodologies for the opioid analgesics - Tramadol and combinations.

Synthetic opioids like Tramadol are used to treat mild to moderate pain. Its ability to relieve pain is about a tenth that of morphine. Furthermore, Tramadol shares similar effects on serotonin and norepinephrine to several antidepressants known as serotonin-norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine and duloxetine. The present review paper discusses the recent developments in analytical methods for identifying drugs in pharmaceutical preparations and toxicological materials, such as blood, saliva, urine, and hair. In recent years, a wide variety of analytical instruments, including capillary electrophoresis, NMR, UV-visible spectroscopy, HPTLC, HPLC, LC-MS, GC, GC-MS, and electrochemical sensors, have been used for drug identification in pharmaceutical preparations and toxicological samples. The primary quantification techniques currently employed for its quantification in various matrices are highlighted in this research.

Developing a latent class analysis model to identify at-risk populations among people using medicine without prescription.

INTRODUCTION: There exist limited strategies to address the issue of topical medication without prescription (MWP) use. MATERIAL AND METHODS: A survey with pre-coded questionnaires was conducted with 210 patients following up in the dermatology clinic of a tertiary care center. The knowledge and attitude scores were regressed against demographics and exploratory practice questions, and latent class analysis was carried out to check any particular set of characteristics associated with study subpopulations. RESULTS: Forty-seven (22%) participants were found using topical antimicrobial containing MWP. Participants with good knowledge score had 3.41 (95% C.I. = 1.68-7.33), 2.99 (1.37-6.73), and 2.49 (1.26-5.15) times association with opting of distance as the prime reason for availing topical MWP, habit of always reading the accompanying drug leaflet, and understanding that OTC topical medication may change the effect of the already prescribed drugs. Participants with good attitude score showed 2.76 (1.50-5.13) times association with limiting the use of steroid containing topical MWP. Latent class analysis identified one subset of participants having lesser knowledge and attitude scores and quoted financial reasons for the procurement of MWP; however, it was found to have greater income as compared to remaining participants. CONCLUSION: The strategy to identify the target patient audience so as to deliver patient education intervention programs, regarding safe and effective use of MWP was built.

Women and tobacco: a cross sectional study from North India.

BACKGROUND: Tobacco is a leading risk factor for different types of diseases globally. Tobacco smoking by women is culturally unacceptable in India, but still women smoke tobacco at various times of their life. AIMS: The aim was to estimate the prevalence and pattern of tobacco use among women and to study the associated sociodemographic factors. SETTINGS AND DESIGN: This cross-sectional study was conducted among women aged 30 years or over in an urban resettlement colony for the migrant population at Chandigarh, India. METHODOLOGY: The study included women used tobacco products on one or more days within the past 30 days. Through systematic random sampling, 262 women were studied. As a part of the study 144 bidi smoking women were interviewed using detailed semi-structured questionnaire. STATISTICAL ANALYSIS: Descriptive statistics and hypothesis testing with Chi-squared test and logistic regression were done using SPSS 16.0 version. RESULTS: Overall, the prevalence of tobacco use was 29.4% and that of bidi, zarda and hookah were 19.8%, 8.8%, and 2.7%, respectively. Around 6.2% women used tobacco during pregnancy. Teenage was the most common age of initiation of bidi smoking. Logistic regression analysis showed that the prevalence of tobacco use was high among Hindu unemployed women with no formal education belonged to scheduled caste, and those having grandchildren. CONCLUSIONS: This study highlighted high rates of tobacco use and explored both individual and family factors related to tobacco use among women. Affordable, culturally acceptable, sustainable and gender-sensitive individual and community-specific interventions will reduce the prevalence and effects of tobacco use.

Development and validation of HPTLC method for the determination of mycophenolate mofetil in bulk and pharmaceutical formulation.

AIM: Described in this manuscript is the first ever reported, new, simple, high-performance thin-layer chromatographic method for the determination of mycophenolate mofetil in bulk and tablet dosage form. MATERIALS AND METHODS: The drug was separated on aluminum plates precoated with silica gel 60 F254 with toluene, acetone, and methanol in the ratio of 6:2:2 (v/v/v) as the mobile phase. Quantitative analysis was performed by densitometric scanning at 254 nm. RESULTS: The method was validated for linearity, accuracy, precision, and robustness. The calibration plot was linear in the range of 100-500 ng band(-1) for mycophenolate mofetil. The method was successfully applied to the analysis of the drug in a pharmaceutical dosage form.

Propofol as a sole agent for paediatric day care diagnostic ophthalmic procedures: comparison with halothane anaesthesia.

BACKGROUND: Our aim was to study the feasibility of total intravenous anaesthesia with propofol in spontaneously breathing children undergoing ophthalmic procedures. METHODS: Fifty-five children (aged 6 months to 5 years) were randomly allocated to receive either propofol bolus (until loss of eyelash reflex) followed by infusion [group P (n=29)] or halothane 3-4% for induction, followed by 1-2% in 70% nitrous oxide and oxygen via face mask [group H (n=28)]. Dose for induction and maintenance, intraoperative adverse events, time to recovery (on an Observer's Assessment of Alertness/Sedation Scale, 5 at each level) and duration of procedure were recorded. All children in both groups, were anaesthetized successfully. RESULTS: 4.0 +/- 0.7 mg x kg(-1) and 5.1 +/- 1.0 mg x kg(-1) of propofol were required for loss of eyelash reflex and tolerance of the ophthalmic speculum, respectively. An infusion rate of 8.3 +/- 1.7 mg x kg(-1) x h(-1) was needed for maintenance of anaesthesia; 3.4 +/- 0.5%, 3.6 +/- 0.4% and 1.4 +/- 0.4% halothane was needed for induction, tolerance of the eye speculum and maintenance of anaesthesia, respectively. Induction and recovery were significantly faster with halothane compared with propofol [induction - 38.3 +/- 6.6 s (group H)/60.9 +/- 15.2 s (group P) (P < 0.001); recovery 12.8 +/- 4.6 min (group H)/27.0 +/- 23.3 min (group P) (P < 0.001)]. Apnoea, coughing and breath-holding were seen only in group H. Group P had significantly higher incidence of involuntary movements (minor degree) (n=6) (P < 0.01). CONCLUSIONS: Propofol is a feasible option for paediatric diagnostic ophthalmic procedures with the advantage over halothane of providing complete access to the eye.

Combination of droperidol and ondansetron reduces PONV after pediatric strabismus surgery more than single drug therapy.

BACKGROUND: Pediatric strabismus surgery is associated with a very high incidence of postoperative nausea and vomiting [(PONV) 44-88%]. Droperidol (10-75 microg kg(-1)) and ondansetron (50-150 microg kg(-1)) have shown variable success in reducing the incidence and severity of PONV. Combination of these two drugs has shown promising results. This randomized, double-blind, placebo-controlled clinical trial was conducted to evaluate the efficacy and safety of the combination of these two drugs in reducing the incidence and severity of PONV in pediatric strabismus surgery. METHODS: After institutional approval and parental informed consent, 240 children of ASA physical status I and II of either sex, aged 1-15 years were included in this study. None of the children received any premedication and a standardized anesthesia technique was used for all the children. They were prospectively randomized to one of the four treatment groups. Group PP received normal saline placebo intravenously after induction and at the end of the procedure. Group DP received droperidol 25 microg kg(-1) after induction and normal saline at the end. Group OP received ondansetron 150 microg kg(-1) after induction and saline at the end. Group DO received droperidol 15 microg kg(-1) after induction and ondansetron 100 microg kg(-1) at the end. RESULTS: Combination prophylaxis resulted in a lower incidence of PONV (13%) as compared to placebo (62.5%, P<0.001), ondansetron (37%, P<0.001), or droperidol (32%, P<0.01). CONCLUSION: Droperidol 15 microg kg(-1) in combination with ondansetron 100 microg kg(-1), administered at the induction and end of the operative procedure respectively, is more effective than either drug given individually in reducing the incidence of PONV after strabismus surgery.

Anesthetic management of patients with Takayasu's arteritis: a case series and review.

UNLABELLED: Takayasu's arteritis is a rare, chronic progressive panendarteritis involving the aorta and its main branches. Anesthesia for patients with Takayasu's arteritis is complicated by their severe uncontrolled hypertension, end-organ dysfunction resulting from hypertension, stenosis of major blood vessels affecting regional circulation, and difficulties encountered in monitoring arterial blood pressure. Takayasu's arteritis is an uncommon disease and previous descriptions of the anesthetic management of patients with this disease have been limited to isolated case reports in the anesthetic literature, mostly in women undergoing cesarean delivery. We present our experience in this series of eight patients for various emergency and elective surgical procedures and review their perioperative problems and management. IMPLICATIONS: This case series describes the anesthetic problems and management of patients with pulseless disease.

Effect of prophylactic ondansetron on postoperative nausea and vomiting after elective craniotomy.

This prospective, randomized, placebo-controlled, double-blind study was designed to evaluate the efficacy of ondansetron, a 5-HT3 antagonist, in preventing postoperative nausea and vomiting (PONV) after elective craniotomy in adult patients. The authors also tried to discover certain predictors for postcraniotomy nausea and vomiting. We studied 170 ASA physical status I and II patients, aged 15 to 70 years, undergoing elective craniotomy for resecting various intracranial tumors and vascular lesions. A standardized anesthesia technique and postoperative analgesia were used for all patients. Patients were divided into two groups and received either saline placebo (Group 1) or ondansetron 4 mg (Group 2) intravenously at the time of dural closure. Patients were extubated at the end of surgery and episodes of nausea and vomiting were noted for 24 hours postoperatively in the neurosurgical intensive care unit. Demographic data, duration of surgery, and anesthesia and analgesic requirements were comparable in both groups. Overall, a 24-hour incidence of postoperative emesis was significantly reduced in patients who received ondansetron compared with those who received a saline placebo (39% in Group 1 and 11% in Group 2, P = .001). There was a significant reduction in the frequency of emetic episodes and rescue antiemetic requirement in patients treated with ondansetron; however, ondansetron did not significantly reduce the incidence of nausea alone (14% in Group 2 vs 5% in Group 1, P = .065). Prophylactic ondansetron had a favorable influence on PONV outcome measures such as patient satisfaction and number needed to prevent emesis (3.5). Side effects were similar in both groups. We conclude that ondansetron 4 mg given at the time of dural closure is safe and effective in preventing emetic episodes after elective craniotomy in adult patients.

The anesthetic management of a patient with paroxysmal nocturnal hemoglobinuria.

IMPLICATIONS: This case report describes the anesthetic considerations for a patient with paroxysmal nocturnal hemoglobinuria. Specific strategies to be applied in the perioperative period to prevent hemolytic episodes and venous thrombosis are also discussed.

Effects of intrathecal ketamine added to bupivacaine for spinal anaesthesia.

We prospectively studied 30 healthy female patients undergoing intracavitory brachytherapy applicator insertion for carcinoma of the cervix under spinal anaesthesia. Patients were randomly allocated to receive either intrathecal bupivacaine 10 mg alone or bupivacaine 7.5 mg combined with preservative-free ketamine 25 mg. Spinal block onset, maximum sensory level, duration of blockade, haemodynamic variables, postoperative analgesic requirements and adverse events were recorded. Onset of sensory and motor block and duration of spinal analgesia were comparable between groups. Duration of motor blockade was shorter (p = 0.0416) and requirement for intravenous fluids in the peri-operative period was less (p = 0.0159) in the ketamine group. Significantly more patients in the ketamine group had adverse events, such as sedation, dizziness, nystagmus, 'strange feelings' and postoperative nausea and vomiting. Although the addition of ketamine to spinal bupivacaine had local anaesthetic sparing effects, it did not provide extended postoperative analgesia or decrease the postoperative analgesic requirements. Moreover, the central adverse effects of ketamine limit its spinal application.

Anaesthetic management of a patient with pemphigus vulgaris for emergency laparotomy.

A 45-year-old man with a long-standing history of duodenal ulcer presented with symptoms and signs of perforation peritonitis. He also had lesions of pemphigus vulgaris throughout the body, involving both skin and mucous membranes. Care was taken to avoid pressure and friction during placement of monitoring devices, intravenous and arterial lines. Since the patient had to undergo exploratory laparotomy, intubation was performed in an atraumatic manner after rapid sequence induction. However, there was minor bleeding from the mucous lesions of the oral cavity, which was controlled by a saline adrenaline throat pack. The patient was extubated at the end of the surgery and steroids were continued in the peri-operative period.

Comparison of the Effects of Sevoflurane and Halothane on Arterial Oxygenation during One Lung Ventilation.

We investigated the effect of halothane and sevoflurane on oxygenation during one lung ventilation (OLV) in 24 patients undergoing elective thoracic procedures. After induction with thiopentone, 4-5 mg/kg and morphine 0.1 mg/kg, suxamethonium 2mg/kg was administered to facilitate tracheal intubation with a double lumen tube. Anaesthesia was maintained with 1.5-3% sevolurane (group 1, n = 12) or 1.1.5% halothane (group 2, n = 12) in 02 with N20 (1:1) and pancuronium bromide. Arterial blood gases were recorded before surgery in the lateral position with two lung ventilation (2LV), 10, 20 and 30 minutes after beginning of one lung ventilation. Morphine and endtidal inhalational anaesthetic concentration were titrated to desired anaesthetic depth and haemodynamic variables. Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR) and central venous pressure (CVP) were measured during the study period. In both the groups there was a significant decrease of PaO2 apparent at 10 minutes after initiation of OLV. Thereafter PaO2 remained stable throughout the study period in both the groups. It is concluded that oxygenation did not differ significantly with either sevoflurane or halothane during OLV. It is also concluded that decrease in oxygenation with OLV is complete by 10 minutes of its initiation.

The safety and efficacy of prophylactic ondansetron in patients undergoing modified radical mastectomy.

UNLABELLED: We aimed to evaluate the antiemetic efficacy, safety, and clinical utility of prophylactic ondansetron administered at the end of the surgery for the prevention of postoperative nausea and vomiting (PONV) in a homogenous population of 54 women undergoing modified radical mastectomy (MRM). A standard general anesthetic and perioperative analgesic technique were used. After surgery, patients received either saline placebo or ondansetron 4 mg IV. Episodes of PONV, as well as rescue antiemetic requirements, were recorded for the first 24 h after surgery. The 24-h incidence of PONV (33.3% vs 81.5%; P = 0.0010) was significantly lower in the ondansetron group. The severity of PONV, evaluated by the number of emetic episodes per patient (1.59+/-1.90 vs 0.29+/-0.66; P = 0.0029), and the rescue antiemetic requirement (59.2% vs 14.8%; P = 0.0019) was significantly lower, in the ondansetron group. Patient satisfaction scores and number needed to prevent PONV (2.07) were significantly better and therapeutically more favorable in the ondansetron group. The incidence of adverse events such as headache, dizziness, and increased liver enzyme levels (number needed to harm = infinity) was similar in both groups. Administered at the end of the surgery in adult female patients undergoing general anesthesia for MRM, ondansetron 4 mg is effective and safe in preventing PONV. We recommend the clinical practice of routine prophylactic ondansetron to prevent PONV after MRM, as it significantly improves perioperative patient satisfaction and outcome. IMPLICATIONS: We evaluated the antiemetic efficacy, safety, and routine use of prophylactic ondansetron, a "gold standard" antiemetic, in women undergoing radical breast surgery who were at a high risk of postoperative vomiting. We analyzed more meaningful "true" and "therapeutic" outcome measures, and we conclude that prophylactic ondansetron is safe and effective and that its routine use is justified.

Comparison of perioperative morbidity in patients with ovarian malignancy undergoing radical cancer surgery with or without prior chemotherapy.

Evaluation was undertaken of the effect of chemotherapeutic drugs on the perioperative morbidity of patients with ovarian malignancy undergoing radical surgery. Twenty patients who had received cytotoxic drugs pre-operatively (group I) were compared with 11 patients in whom radical surgery was the first line of treatment (group II). Pre and post-operative cardiac, pulmonary, renal, hepatic and coagulation functions were compared in both groups, as well as the critical intra- and post-operative events like cardiac pump failure, respiratory dysfunction, rhythm disturbances, blood loss, etc. Demographic data, ASA status, biochemical and haematological parameters and cardiac ejection fractions were comparable in the two groups but patients in group I had significantly higher left ventricular end diastolic dimensions (P < 0.01). A higher number of patients in group I had pre-operative respiratory and coagulation factor abnormalities but critical intra- and post-operative events in both groups were comparable. The surgical time was significantly (P < 0.01) longer in group I (5.5 +/- 2.5 h) as compared to group II (4.5 +/- 1.5 h). One patient with extensive tumour spread and pre-operatively deranged coagulation profile (group I) died of disseminated intravascular coagulation in the post-operative period. It is concluded that patients with advanced ovarian malignancy, treated with cytotoxic drugs are more likely to have pre-operative cardiac, respiratory and coagulation abnormalities, which should be managed by thorough pre-operative evaluation and intensive intra- and post-operative monitoring.

Comparison of anti-emetic effects of ondansetron, metoclopromide or a combination of both in children undergoing surgery for strabismus.

This prospective, randomized and double-blinded study was designed to evaluate the anti-emetic efficacy of a combination of ondansetron and metoclopramide in 100 ASA physical status I and II children of either sex and 1-15 years of age undergoing elective surgery for strabismus. A standardized anaesthetic technique and post-operative analgesia were used for all the children. Children were divided into four groups. They received saline, metoclopromide 250 micrograms kg-1, ondansetron 150 micrograms kg-1 or a combination of metoclopramide 150 micrograms kg-1 and ondansetron 100 micrograms kg-1 intravenously immediately after the insertion of an intravenous cannulae. There were no differences between the groups in their age, gender, weight, duration of surgery, number of muscles subjected to surgery or intravenous fluids received. In the first 24 post-operative hours, 18 (72%) patients in the placebo group, 15 (60%) patients in the metoclopramide group, 10 (40%) patients in the ondansetron group and 11 (44%) patients in the combination group had nausea or vomiting. The overall incidence of post-operative nausea and vomiting was significantly (P < 0.05) lower in the combination group and in the ondansetron group compared with the placebo group. Nine (36%) patients in both the placebo and the metoclopramide groups and one (4%) patient in the ondansetron group required rescue anti-emetic treatment. None of the patients in the combination group required rescue anti-emetic and this was significantly less (P < 0.01) when compared with the placebo and the metoclopramide groups. Recovery and sedation scores were comparable in all the four groups. A combination of metoclopramide 150 micrograms kg-1 and ondansetron 100 micrograms kg-1 administered prior to surgery was not found to be more effective than ondansetron 150 micrograms kg-1 alone for the prophylaxis of nausea and vomiting following surgical repair of strabismus in paediatric patients.

Sevoflurane for trans-sternal thymectomy in myasthenia gravis.

Myasthenic gravis (MG) is an autoimmune disease associated with acetylcholine receptor deficiency. Patients with MG exhibit increased sensitivity to non-depolarising muscle relaxants. In an attempt to avoid neuromuscular blockers, we used sevoflurane in two myasthenic patients undergoing trans-sternal thymectomy. Inhalation of 8% sevoflurane in oxygen using vital capacity technique produced rapid, pleasant and smooth induction and provided good tracheal intubating conditions. In both patients anaesthesia was maintained with 1.5-2% end-tidal concentration of sevoflurane and nitrous oxide in oxygen without adjunctive neuromuscular blocking agents. There were minimal changes in cardiovascular variables and recovery was faster. It is suggested that sevoflurane may be the main anaesthetic for both induction and maintenance in myasthenic patients undergoing trans-sternal thymectomy.