Attenuating the Pressor Response to Laryngoscopy and Endotracheal Intubation in Controlled Hypertensives: The Effect of Combining Lidocaine and Magnesium Sulphate.

BACKGROUND: Laryngoscopy and intubation result in a pressor response which may be deleterious especially in hypertensives, resulting in potentially harmful effects. Many drugs have been used to attenuate this undesirable pressor response to laryngoscopy and intubation in hypertensives; amongst them are magnesium alone in different doses or in combination with lidocaine. However, drug combinations have been found to be more effective than single drug therapy. OBJECTIVE: This study compared the different doses of magnesium sulphate and its combination with lidocaine for the attenuation of the pressor response. METHODS: A prospective, randomized, double-blinded study. Nighty-six controlled hypertensives (ASA physical status II) scheduled for elective surgery under general anaesthesia and who required endotracheal intubation were recruited and randomized into either Group I (they received 30mg/kg of IV MgSO4 plus 1.5mg/kg of 2% lidocaine) or Groups II and III who received 30mg/kg and 40mg/kg of IV MgSO4 alone, respectively. The outcome was the change in the systolic blood pressure (SBP) from the baseline following administration of study medication and after laryngoscopy and endotracheal intubation. The side effects of study medication and changes in serum magnesium level prior to and after 30 minutes of administering study medication were documented. RESULTS: The post-intubation SBP was attenuated in patients in groups I and III only. However, five patients in group III had hypotension. Serum magnesium levels were higher than their respective baseline values in all the groups. CONCLUSION: The combination of 1.5 mg/kg of 2% lidocaine and 30 mg/kg of MgSO4 is more effective than 30 mg/kg of MgSO4 alone and even MgSO4at the higher dose of 40 mg/kg.

CONTEXTE: La laryngoscopie et l'intubation entraînent une réponse pressive, qui peut être délétère, surtout chez les hypertendus, entraînant des effets potentiellement dangereux. De nombreux médicaments ont été utilisés pour atténuer cette réponse pressive indésirable à la laryngoscopie et à l'intubation chez les hypertendus, parmi lesquels le magnésium seul à différentes doses ou en association avec la lignocaïne. Cependant, les associations de médicaments se sont avérées plus efficaces qu'un traitement médicamenteux unique. OBJECTIF: Cette étude a comparé les différentes doses de sulfate de magnésium et son association avec la lidocaïne pour l'atténuation de la réponse pressive. MÉTHODES: Une étude prospective, randomisée, en double aveugle. Six hypertendus contrôlés (statut physique ASA II) prévus pour une chirurgie élective sous anesthésie générale et nécessitant une intubation endotrachéale ont été recrutés et randomisés dans le groupe I, ils ont reçu 30mg/kg de MgSO4 1V plus I,5mg/kg de lidocaïne à 2%, les groupes II et III ont reçu respectivement 30mg/kg et 40mg/kg de MgSO4 IV seul. Les résultats étaient les changements de la pression artérielle systolique (PAS) par rapport à la ligne de base après l'administration du médicament étudié et après la laryngoscopie et l'intubation endotrachéale. Les effets secondaires du médicament à l'étude et les changements du taux de magnésium sérique avant et après 30 minutes d'administration du médicament à l'étude ont été documentés. RÉSULTATS: La PAS après intubation a été atténuée chez les patients des groupes I et III seulement. Cependant, cinq patients du groupe III ont présenté une hypotension. Les niveaux de magnésium sérique étaient plus élevés que leurs valeurs de base respectives dans tous les groupes. CONCLUSION: L'association de 1,5 mg/kg de lidocaïne à 2 % et de 30 mg/kg de MgSO4 est plus efficace que 30 mg/kg de MgSO4 seul et même à la dose supérieure de 40 mg/kg. Mots clés: Sulfate de magnésium, Lidocaïne, Laryngoscopie et intubation endotrachéale, Réponse hémodynamique, Taux sériques de MgSO4.

A comparative study of ketamine gargle and lidocaine jelly application for the prevention of postoperative throat pain following general anaesthesia with endotracheal intubation.

BACKGROUND: Postoperative throat pain is an established complication of general anaesthesia with endotracheal intubation. We thus sought to determine the incidence of postoperative throat pain and the efficacy of lidocaine jelly and ketamine gargle in the prevention of postoperative throat pain. MATERIALS AND METHOD: One hundred and fifty ASA I or II, male: female ratio of 1:2 patients, aged18 -64 year, scheduled for elective general surgery requiring general anaesthesia with endotracheal intubation were randomly recruited into two groups, ketamine (K group) and lidocaine (L group). Group K received ketamine gargle (40 mg in 30 ml normal saline) for 30 sec, five minutes before induction of anaesthesia, while Group L received 2% lidocaine jelly applied to the ETT cuff and 30 ml normal saline was gargled for 30 sec, five minutes before induction of anaesthesia. RESULTS: Postoperative throat pain was defined as pain present with swallowing and it was assessed using verbal rating scale. Time from extubation to onset of postoperative throat pain was significantly longer for patients in K group compared to the lidocaine group, P<0.01. Group L patients recorded a higher occurrence of moderate to severe pain (44.1% vs. 23.5%) as against group K with 58.3% no pain and 36.5% mild pain, P< 0.01. The overall incidence of postoperative throat pain for the study was 55.4%. CONCLUSION: The study demonstrated that ketamine gargle has more protection against moderate to severe postoperative pain as compared to topical lidocaine jelly. Patients undergoing surgery under general anaesthesia with endotracheal intubation will benefit from ketamine gargle five minutes before induction of anaesthesia as prophylaxis against postoperative throat pain.

Evolving pattern of spinal anaesthesia in stable eclamptic patients undergoing caesarean section at University of Benin Teaching Hospital, Benin, Nigeria.

BACKGROUND: Eclampsia is still associated with high maternal and perinatal and perinatal morbidity and mortality, especially in resource poor countries with limited access to perinatal and critical care facilities. The ideal method of anaesthesia for caesarean section in eclamptics is not generally agreed upon. METHODS: Review of the patients' case notes as well as records of the institution's Labour Ward Theatre, Intensive Care Unit and Postnatal Ward was carried out between January 2011 and December 2012. Patients' clinical and demographic data, anaesthetic management methods, maternal and perinatal outcome measures were evaluated and analysed. RESULTS: Ninety-nine cases of eclampsia were reviewed, of which 87 had Caesarean section. After excluding five patients who had intercurrent medical ailments, 82 patients were finally analyzed. Of these, 65 (79.3%) had spinal anaesthesia while 17 (20.7%) had general anaesthesia. Out of the 19 (23.2%) who were transferred to the intensive care unit, 12 (70.6%) had general anaesthesia while 7 (10.8%) had spinal anaesthesia. Of the 17 patients who had general anaesthesia, 10 (58.8%) were ventilated post operatively versus only 2 (3.1%) in spinal anaesthesia. Nine of the 17 general anaesthesia patients (52.9%) versus only 1 of 65 spinal anaesthesia (1.5%) died in ICU. Apgar was two fold better in the spinal anaesthesia group at 5 minutes.There was a higher risk ratio for stillbirths in the general anaesthesia patients. CONCLUSION: maternal and perinatal survival and well being are better in eclamptics who had spinal anaesthesia for caesarean section compared to those who had general anaesthesia.

The effects of dexamethasone and metoclopramide on early and late postoperative nausea and vomiting in women undergoing myomectomy under spinal anaesthesia.

BACKGROUND: Post-operative nausea and vomiting (PONV); early or late, has detrimental effects on surgical patients such as surgical wound disruption, esophageal tear and delayed discharge from the post anesthetic care unit. This study evaluated the effects of dexamethasone-metoclopramide (DM) in the prevention of early and late PONV in women undergoing myomectomy under subarachnoid block. MATERIALS AND METHODS: Following approval from the Research and Ethics Committee of the Hospital, informed consent was obtained from each prospective patient. Patients were randomly allocated to either the DM group, metoclopramide only (MO) group or dexamethasones only (DO) group using the computer-generated random numbers in sealed envelopes. Immediately after the induction of spinal anesthesia, the DM group received intravenous (i.v.) dexamethasone 8 mg and metoclopramide 10 mg, the MO group received metoclopramide 10 mg i.v and the DO group received dexamethasone 8 mg i.v. The incidence of early and late PONV formed the primary outcome. RESULTS: A total of 90 patients, with aged range between 21-64 years were studied. Dexamethasone alone group had the highest incidence of 40% for early but no for late PONV ( P = 0.003) Metoclopramide alone group had an incidence of 29.97% for early PONV and 26.6% for late PONV. There was reduced incidence of both early and late PONV in the DM group, but of lesser magnitude than DO or MO respectively. CONCLUSION: Dexamethasone protects against the incidence of late PONV with a minimal effect on early PONV. The combination of dexamethasone and metoclopramide had comparable effect on both and of better magnitude than metoclopramide alone.

Comparison of intravenous colloid and colloid-crystalloid combination in hypotension prophylaxis during spinal anesthesia for cesarean section.

CONTEXT: Many studies comparing different intravenous fluid types usually do not use equipotent volumes of three to one crystalloid to colloid ratio in such comparisons. Conflicting results emanate from such studies. AIM: This study was designed to compare the efficacy of equipotent volumes of colloid and crystalloid-colloid combination in spinal anesthesia-induced hypotension prophylaxis during cesarean section. SETTINGS AND DESIGN: A prospective randomized double blinded experimental study carried out in a tertiary hospital in Nigeria. MATERIALS AND METHODS: Pregnant women scheduled for elective cesarean section were prospectively randomized into two groups to receive either 1000 ml of crystalloid/colloid (750/250 ml) combination or 500 ml colloid intravenous fluid preload, before spinal anesthesia. Hemodynamic variables were monitored till the end of surgery. The results were collated, analyzed, and rational conclusions deduced. STATISTICAL ANALYSIS USED: Data collected and analyzed with Statistical Package for Social Sciences (SPSS) version 16 and rational deductions derived. RESULTS: In the first 10 min, the crystalloid-colloid combination showed better efficacy in hypotension prophylaxis over the colloid only regimen. In the next 30 min; however, there was no significant difference between both groups in hemodynamic parameters. CONCLUSION: Beyond 10 min the crystalloid-colloid combination has no advantage over colloid alone in hypotension prophylaxis, as used in this study.

Intrathecal tramadol versus intrathecal fentanyl for visceral pain control during bupivacaine subarachnoid block for open appendicectomy.

CONTEXT: Profound side-effects following intrathecal use of local anesthetics as the sole drugs of choice make spinal anesthesia for open appendicectomy uncommon. AIM: The aim of this study was to evaluate the effectiveness of intra-operative analgesia produced by intrathecal tramadol and fentanyl during bupivacaine spinal anesthesia for open appendicectomy. SETTINGS AND DESIGN: A prospective randomized study was performed. MATERIALS AND METHODS: A total of 186 American Society of Anesthesiologists 1 or 11 patients scheduled for emergency open appendicectomy were analyzed. Group FB ( n = 62) received intrathecal fentanyl 25 µg plus 3 ml of 0.5% hyperbaric bupivacaine, Group SB ( n = 62) received 0.5 ml normal saline plus 3 ml of 0.5% hyperbaric bupivacaine and Group TB ( n = 62) received intrathecal tramadol 25 mg plus 3 ml of 0.5% hyperbaric bupivacaine. Visual analog scale scores and frequency of subjective symptoms among patients in the three groups formed the primary outcome measure of this study. RESULTS: Effective intraoperative sensory block was achieved in 100% of patients in group FB and TB while 29 (46.8%) patients in group SB had ineffective sensory block ( P = 0.0001). The pain free period was significantly longer in patients in Group FB than Group SB and TB. Mean time for Group FB with regard to first analgesic request was 304.73 ± 67.91 min, Group SB was 146.59 ± 36.62 and Group TB was 238.39 ± 61.28 min. Incidence of complications were comparable among the three groups. CONCLUSION: This study showed that intrathecal tramadol (25 mg) can safely replace intrathecal fentanyl (25 µg) in the management of visceral pain and discomfort during subarachnoid block for appendicectomy.

Evolving pattern of anaesthesia for caesarean section experience at the University of Benin Teaching Hospital.

BACKGROUND: The WHO puts caesarean section rate in Nigeria at 1.8%. This is much higher in teaching, specialist and referral hospitals. In our centre University of Benin Teaching Hospital (UBTH), the average annual rate is 33.4%. General anaesthesia is the predominant choice for caesarean section (C/S) in most centres. The trend is increasing towards regional anaesthesia. Many studies have reported the trend in several centres. This study examined the evolving pattern in our centre. OBJECTIVE: To examine the evolving pattern of anaesthetic technique for caesarean section, at the University of Benin Teaching Hospital. MATERIALS AND METHODS: A ten-year retrospective period (2001-2010), data were pooled from the computerized data system of the department of obstetrics and gynaecology. Also, anaesthetic chart and staff records from the department of anaesthesiology were studied. Information about C/S, anaesthetic method and anaesthetist profile were derived from these sources. The data were analysed and presented as simple frequency and nominal data. RESULTS: Six thousand, six hundred and eleven C/S were done over the 10-year period. Emergency C/S was 82%, while 12% were elective cases. Average annual rate of anaesthetic technique used was regional anaesthesia 76.5% and general anaesthesia 23.5%. The use of regional anaesthesia grew from 30% in 2001, to 89% in 2010. Number of anaesthetists increased from 22 in 2001 to 37 in 2010. CONCLUSION: The study shows an increasing use of regional anaesthesia for C/S, predominantly subarachnoid blockade.

Effects of position and phonation on oropharyngeal view and correlation with laryngoscpic view.

OBJECTIVE: To evaluate the effects of phonation and various head and body positions on oropharyngeal view (Mallampati score), and the correlation of these with laryngoscopic view, using the Cormack and Lehane score. METHODOLOGY: Four hundred (390) consecutive patients were evaluated in the wards during preoperative anaesthetic review. During airway assessment, the patients were placed in various head and body positions to determine oropharyngeal structures visualized, with and without phonation, according to the Mallampati test score. In the operating theatre, laryngoscopic view scores (according to Cormack and Lehane) were recorded, and the various scores analyzed. RESULTS: Phonation consistently improved the Mallampati scores in all the head and body positions. The scores were better in the supine position compared to the sitting position. The best correlation of the Mallampati score with the Cormack and Lehane score was in the sitting, head maximally extended position, without phonation. Extention of the head improved the score in the sitting position, but not in the supine position. Phonation reduced the correlation of the scores in all the positions. CONCLUSION: We conclude that the best position to conduct the Mallampati test is sitting, head maximally extended, without phonation. This correlated best with laryngoscopic view score in our study.

A study of the work and home domain characteristics of anaesthetists in Nigeria.

OBJECTIVES: To examine the work and home domain characteristics of anaesthetists in Nigeria, and the impact of these on work and family life. MATERIALS AND METHODS: A total of 200 self-administered questionnaires were distributed to anaesthetists in various health institutions in Nigeria. Of these, 114 (57%) were returned. Information contained in the questionnaire included demographic characteristics, qualification, rank and years spent in the specialty, spouse occupation and details of work and family life. RESULTS: The 114 respondents consisted of 86 males (77%) and 28 females (22.8%), aged between 30 and 59 years. The average weekly working hours were 58.4 hours. About half of the respondents could study anaesthesia at home sometimes, while 25% each could do so always or not at all. About 41% of the respondents could respond to emergencies at home immediately, while 45% could only do so after first reporting to work. Respondents' recommendation to enhance work and family life included reduced work load, more flexible work schedule, accommodation close to place of work, among others. CONCLUSION: Positive impact on service output as well as enhanced job satisfaction will ensue if the recommendations in this study are implemented by the relevant authorities.

Hypnosis and its place in modern pain management - review article.

This is an evidence-based review of the efficacy of hypnosis in pain management. Hypnosis is as old as mankind. It is reported in the Ebers Papyrus in ancient Egyptian cures. It went into decline in the Middle Ages with the rise of Christianity, being erroneously associated with witchcraft. There was resurgence of interest in the 19th century. In the early 1950s, the British Medical Association endorsed the teaching of hypnosis in all medical schools. The literature is replete with anecdotal and controlled studies of the efficacy of hypnotherapy in pain management. Not much is found of the effectiveness in acute pain conditions. Nevertheless, in spite of some methodological flaws in many reports, there seems to be sufficient clinical evidence of sufficient quality, to conclude that hypnosis has demonstrable efficacy in the treatment of chronic pain.

Operating Room Deaths

A ten-year retrospective survey of the rate and pattern of death of patients within the operating theatre suites was carried out at the University of Benin Teaching Hospital; Benin City; Nigeria. Of the 12;743 patients who were admitted to the operating theatre suites in the period; excluding obstetric cases; 47 (i.e. 0.37) deaths were recorded; consisting of 24 males and 23 females; aged between 5 months and 72 years. Thirty-two (68) of the deaths were associated with emergency procedures; and fifteen (32) were elective. Thirty-six of the patients (76.6); had general anaesthesia. The patients' medical condition contributed to 51of the deaths; followed by anesthesia (38.3) and surgery (8.5). Twenty-four of the deceased (51.1); were booked for abdominal surgery; while head/neck procedures accounted for 14 (29.8). The death rate of 37 per 10;000 seems high; when compared to western values; but is akin to figures from similar institutions in developing countries like ours

Spinal (Intrathecal) Ketamine Anaesthesia for Upper Abdominal Surgery : Case Report

Intravenous ketamine is usually administered for the induction of general anaesthesia. Spinal ketamine for lower abdominal and lower limb surgery is sporadically reported in the literature. However; the use of spinal ketamine for upper body surgery is rare. We describe the case of a 35-year old man; with a retroperitoneal tumour and severe intercurrent cardiovascular morbidity; that had exploratory laparotomy and tumour biopsy with Intrathecal ketamine administered through the L4/L5 interspace. The patient had good surgical analgesia; with stable vital signs throughout the surgery. After surgery; the spinal catheter was left in place; and withdrawn 48 hours later. The patient did well in the immediate postoperative period; although he gradually succumbed to the primary illness (malignant retroperitoneal cancer) on the 15th postoperative day

A comparison of sphygmomanometric and oscillometric methods of blood pressure measurements in adult in-patients.

The study compared two non-invasive methods of blood pressure measurements used in the anaesthetic management of patients, the conventional sphygmomanometric and the oscillometric methods. One hundred adult in-patients were involved, and 400 blood pressure measurements were done with the two devices. The sphygmomanometric measurements were higher in systolic, diastolic and mean arterial pressure values. Correlation coefficient values between the two methods were r = 0.97, 0.81, 0.95 for systolic, diastolic and mean arterial pressures respectively, (p < 0.05). We conclude that there is a statistically significant difference in haemodynamic values determined by the two devices. This difference is however, not clinically significant to warrant a recommendation of adjustment when comparing values determined by the two devices.