Efficacy of Dexmedetomidine vs Morphine as an Adjunct in a Paravertebral Block with Bupivacaine in Postoperative Analgesia Following Modified Radical Mastectomy.

Objective To observe the efficacy of dexmedetomidine vs morphine as an adjunct in a paravertebral block (PVB) with bupivacaine in postoperative analgesia following modified radical mastectomy. Study design This was a randomized controlled trial performed from June 2018 to August 2019 in the Department of Anesthesia, Bakhtawar Amin Medical and Dental College, Ch. Pervaiz Ellahi Institute of Cardiology, Multan, Gurki Hospital, Services Institute of Medical Sciences, and Sheikh Zayed Hospital, Lahore. Methodology Seventy-eight patients were equally divided into group M, which received morphine (3 mg) and group D, which received dexmedetomidine (1 µg/kg), along with 20 cc 0.25% bupivacaine, for PVB. The primary outcome included morphine requirements in the post-anesthesia care unit (PACU). Secondary outcomes included the quality and duration of analgesia, intraoperative doses of fentanyl and propofol, postoperative doses of diclofenac required, postoperative nausea and vomiting (PONV), and the Ramsey sedation score. Data were entered into SPSS version 23 (IBM Corp., Armonk, NY) and analyzed by applying the independent t-test, Mann Whitney U-test, and the chi-square test or Fischer's exact test, as appropriate. P≤0.05 was considered statistically significant. Results The mean time for the first analgesic administration was much shorter in group D as compared to group M (p<0.001). The average doses of ephedrine and morphine used were higher in group D (p-value 0.033 and 0.013, respectively). In the PACU, 33.3% of group D patients as compared to 12.8% of group M patients needed morphine (p=0.032). Postoperatively, diclofenac consumption was higher in group D (p<0.001). Postoperative pain was lower and sedation was higher in group M (p<0.05). Conclusion As an adjunct to bupivacaine in PVB for MRM, morphine is superior to dexmedetomidine.

Intracameral Triamcinolone Acetonide Versus Topical Dexamethasone: A Comparison of Anti-inflammatory Effects After Phacoemulsification.

Study objective and design The objective of this study was to determine the effectiveness of triamcinolone acetonide when used as a single dose as compared to the topical use of dexamethasone to control the inflammation after phacoemulsification. The study was a randomized controlled trial conducted in the Department of Ophthalmology at the District Headquarter (DHQ) Teaching Hospital, Dera Ghazi Khan, from March 1, 2018, to August 31, 2019. Materials and methods Eighty patients were included in the study. All patients were assigned to two groups of 40 patients each using the lottery method. Group A patients were treated with a 1-mg intracameral injection of triamcinolone acetonide postoperatively after phacoemulsification. Group B patients were administered 0.1% dexamethasone eye drops with a dosage of one drop every four hours for four weeks. Postoperative follow-up was planned for day one, day seven, and day 28. Results The postoperative inflammation cell values of Group A on day one, day seven, and day 28 were 1.68 ±0.84, 0.22 ±0.15, and 0.12 ±0.23, respectively, while the postoperative inflammation cell values of Group B on day one, day seven, and day 28 were 1.91 ±0.75, 0.28 ±0.15, and 0.09 ±0.20, respectively. The postoperative inflammation flare values of Group A on day one, day seven, and day 28 were 0.31 ±0.37, 0.03 ±0.44, and 0.00 ±0.22, respectively, while the postoperative inflammation flare values of Group B on day one, day seven, and day 28 were 0.25 ±0.26, 0.22 ±0.46, and 0.02 ±0.18, respectively. Conclusion The efficacy of both modes of treatments is comparable; however, triamcinolone acetonide is preferable to dexamethasone, as its intracameral injection generally results in better compliance than multiple dosages of topical eye drops of dexamethasone.

Recurrence of Pterygium after Pterygium Excision with Stem Cell Graft and Amniotic Membrane Graft: A Comparison.

Study objective The objective of this study was to compare pterygium excision with amniotic membrane graft and that with stem cell graft in terms of pterygium recurrence, using a quasi-experimental study design. This study was conducted at the department of ophthalmology at Nishtar Hospital, Multan, Pakistan from January to September 2019. Methodology and results A total of 214 patients who presented to the outpatient section at the department of ophthalmology were included in this study. A lottery method was used to divide the patients into two equal groups: A and B. Patients in group A underwent pterygium excision with amniotic membrane graft, and patients in group B underwent pterygium excision with stem cell grafts. Follow-ups were planned for the third day, the second week, the first month, the third month, and the sixth month postoperatively. Frequency and percentage were calculated for qualitative variables and for quantitative data. Mean and standard deviation were calculated, and a p-value of <0.05 was considered significant. Postoperative complications (i.e., graft edema, hemorrhage, and recurrence) in group A were observed as n = 0 (0%), n = 11 (10.3%), and n = 15 (14%), respectively. Postoperative complications (i.e., graft edema, hemorrhage, and recurrence) in group B were observed as 15%, 3.7%, and 12.1%, respectively. Statistically, the difference for graft edema was significant (p = 0.000). Conclusion Stem cell grafting after pterygium excision was not associated with any major complications postoperatively. Stem cell grafting is better in terms of cosmetic appearance and has less recurrence rate as compared to amniotic membrane transplantation.

Intravenous Dexmedetomidine Has Synergistic Effect on Subarachnoid Block with Hyperbaric Bupivacaine.

Objective To assess the effect of intravenous dexmedetomidine on subarachnoid anesthesia with the help of hyperbaric bupivacaine when administered as a bolus or as an infusion. Materials and methods This randomized control trial was conducted at the Department of Anesthesia, Nishtar Hospital, Multan, Pakistan, from January 2017 to December 2018. Seventy patients were enrolled in the study. Patients were segregated into three groups. At the T10 level, a sensory blockade was noted. The motor blockade was also periodically measured until a modified Bromage score of three was achieved. The depth of sedation was measured with the help of the Ramsay Sedation Scale score. Oxygen saturation and other factors were also measured and recorded. Nausea, vomiting, diarrhea, and pruritus were the adverse effects noted during the study. To check and compare the statistical differences among the variables from different groups, the Chi-square test and analysis of variance test were performed. A probability (p) value of <.05 was considered statistically significant. Results The duration of the sensory blockade was shortest in the control group receiving only bupivacaine (Group B) and longest in the group receiving bupivacaine plus dexmedetomidine as a single bolus (Group BDexB; p: <.001). The time of complete sensory and motor recovery was longest in Group BDexB and shortest in Group B. The difference was statistically significant (p: <.001). The Ramsay score was >2 (i.e., 3 or 4) in five patients from Group B, 19 from Group BDexB, and 17 from the group receiving intrathecal bupivacaine plus dexmedetomidine as an infusion (Group BDexI). Between these groups, a statistically significant difference was found (p: <.001). Conclusions Intravenous administration of dexmedetomidine as either a bolus or infusion prolonged the duration of the sensory and motor blockade.

Comparing the predicted accuracy of PO2\FIO2 ratio with rapid shallow breathing index for successful spontaneous breathing trial in Intensive Care Unit.

OBJECTIVE: To compare the predicted accuracy of PFR with RSBI for successful spontaneous breathing trial before extubation in intensive care unit. METHODS: This cross sectional study was conducted at the ICU of Ch. Pervaiz Ellahi Institute of Cardiology, Multan Medical and Nishtar Medical University Hospital from July, 2017 to January, 2019.PO2/FIO2 and RSBI was measured by a different investigator, before and 20 minutes after the start of SBT. Heart rate, blood pressure and oxygen saturation were continuously measured throughout the trial. Trial outcome was labeled as unsuccessful or successful by the investigator who was blinded to the rapid shallow breathing index and PO2/FiO2 measurements. Patients with SpO2>85%, stable hemodynamics (HR and BP change <20%), stable respiration (RR change <50%), and the absence of (i) signs of labored breathing, (ii) emergence or worsened discomfort, (iii) change in mental status, were labeled as successful in bearing the SBT. Patients were divided into two groups i.e. successful and unsuccessful, gender, Age, GOLD stage, APACHE II score, pCO2, pO2, FiO2 and RSBI score were compared between the two groups after putting all the data in SPSS version 23. Chi square tests and Student's t-test were used on the continuous data and nominal data, accordingly. The specificity, sensitivity, diagnostic accuracy, negative predictive value and positive predictive value of two threshold values of RSBI and PO2/FiO2 ratio were calculated from the 2X2 contingency tables. RESULTS: RSBI threshold of 130 had 40.4% sensitivity, 51.1% specificity, 55.2% positive predictive value, 36.4% negative predictive value and 44.7% diagnostic accuracy while RSBI threshold of 105 had 94.1% sensitivity, 43.6% specificity, 71.4% positive predictive value, 83.2% negative predictive value and 73.8% diagnostic accuracy. pO2/FiO2>250 had 76.9% sensitivity, 24.5% specificity, 60.4% positive predictive value, 41.5% negative predictive value and 55.9% diagnostic accuracy. CONCLUSION: Even though neither rapid shallow breathing nor the PFR was enough accurate in prediction of successful extubation but rapid shallow breathing index 105 threshold had higher sensitivity and specificity as compared to RSBI threshold 130PFR. Therefore, RSBI105 is more accurate in predicting the outcome of extubation of ICU patients.

Comparing The Functional Outcome Of Different Dose Regimes Of Succinylcholine When Used For Rapid Induction And Intubation.

BACKGROUND: This study was conducted to compare outcomes of different doses of succinylcholine, in terms of intubation condition, onset of action, duration of action and abdominal fasciculation. METHODS: Thus, randomized control trial was conducted in the department of anaesthesia and ICU, Nishter Hospital Multan from April 2016 to November 2016. A total number of 60 patients with ASA status I and II were enrolled. All patients were divided into three groups by lottery method. Data was entered and analysed by computer software SPSS version 23.2. Descriptive variables like age and onset of action were presented as mean and SD and continues statistics like gender, abdominal fasciculation and incubation condition were presented as frequency and percentages. Chi square test and one-way ANOVA was applied to see effect modification and significance of results. The p-value 0.05 was considered as significant. RESULTS: A Total number of 60 patients included in this study and all were female. The mean age of the patients was 28.15±4.5 years. The main outcome variables of this study were the fasciculation, satisfactory intubation, onset time (seconds) and duration of action (in minutes). In group (A) 1mg, abdominal fasciculation was found 80%, 85% and 75% in group A, B, C respectively. It was also observed that satisfactory intubation was found 90%, 80% and 30% in three groups respectively. The mean onset time was 50.95±4.6, 70.7±5.66 and 94.15±8.73 seconds in three groups respectively. Similarly, the mean duration of action was 16.1±3.76, 13.55±3.01 and 8±2.05 minutes respectively. CONCLUSIONS: Results of our clinical trial suggest that succinylcholine in low doses shorter duration of action and low rate of abdominal fasciculation which is desirable for rapid induction but onset of action is prolonged and intubation conditions were not satisfactory predominantly. So, we concluded that low doses of succnylcholine are not so much beneficial that I can replace full doses of succinylcholine when used for rapid induction and intubation.

Comparing the efficacy of Morphine alone with Morphine and mgso4 in pain management after coronary artery bypass surgery.

OBJECTIVE: To compare the effectiveness of Morphine alone and Morphine with MgSo4 in pain management after CABG surgery. METHODS: This randomized control trial was conducted in the department of anesthesia and critical care Choudhary Pervaiz Ellahi Institute of Cardiology, Multan from November 2016 to June 2017. All collected data was entered and analyzed by using computer software SPSS version 23.1. Quantitative data like age, VAS score was analyzed and presented as mean and standard deviation. Similarly qualitative data like gender and ASA status was calculated and presented as frequency and percentages. Independent sample T-test was applied for significance of VAS score. P value ≤0.05 was considered as significant. RESULTS: A total number of 150 patients of both genders were included in this study. The main outcome variables of our study were VAS score. It was observed that, in group (M), the mean VAS score after 4, 12 and 24 hours of operation was 5.24±1.61, 5.8±2.27 and 5.44±2.27 respectively. And in group (MM), the mean VAS score after 4, 12 and 24 hours of operation was 4.36±2.58, 3.48±2.10 and 4.12±1.05 respectively. It was noted that both groups had statically significant difference of VAS score, as group (M) had higher VAS score than group (MM). CONCLUSION: Morphine with Mgso4 has better efficacy as compared to morphine alone when used as analgesic agent after CABG surgery.

Effect Of Midazolam Premedication On Doses Of Propofol For Laryngeal Mask Airway Insertion In Children.

BACKGROUND: Propofol is a widely-accepted medication for the successful insertion of laryngeal mask airway (LMA). When propofol is used alone, larger doses are required which can lead to cardiorespiratory distress resulting in hypotension and prolonged apnoea. The objective of this study was to evaluate the effect of premedication of midazolam on different doses of propofol for LMA insertion. METHODS: In this randomized clinical trial, eighty-six (86) patients who were scheduled to undergo elective surgery is supine position not requiring the need for tracheal intubation from September 2015 to 6 March 2016 were included. In group I (n=43), the LMA was introduced after induction of anaesthesia with Propofol alone. In Group II (n=43, the patient was premeditated with midazolam (0.05 mg/kg) before induction of anaesthesia with propofol. Each group was divided into three subgroups depending upon the dose of propofol used for LMA insertion. RESULTS: In this study, there were 53.5% females in group I and 48.8% females in group II. The mean age of Children in group I was 7.30±2.55 years and 7.47±2.46 years in group II. Incidence of incomplete Jaw relaxation, coughing and limb movements was significantly high in in Group I patients (pvalues <0.001, <0.001 and <0.001 respectively). Effectiveness of anaesthesia was compared among different subgroups. On comparison of subgroup Ia and IIa, the effectiveness rate was significantly high in subgroup IIa 50% versus only 7.1% in subgroup Ia (p-value 0.012). Similarly, in subgroup IIb effectiveness was achieved in 100% patients as compared to only 64.3% patients in subgroup IIb (p-value 0.014). There was no significant difference in effectiveness rate in subgroup Ic and IIc (p-value 0.309). CONCLUSIONS: With midazolam premedication, the dose of propofol for LMA insertion is decreased. The incidence of adverse events during LMA insertion is also low with midazolam premedication.

Comparing the effectiveness of Betamethasone Gel with Lidocaine Gel local application on endotracheal tube in preventing post-operative sore throat (POST).

OBJECTIVE: To see whether betamethasone gel or lidocaine gel is superior in reducing the incidence of post-operative sore throat after tracheal extubation. METHODS: This clinical study was conducted at the Nishtar Hospital and Medical College, Multan, Pakistan, from July to December 2015, and comprised patients who were set to undergo elective surgery under general anaesthesia. The patients were divided into two equal groups. In group 1, endotracheal tube was lubricated with betamethasone gel (0.05%). In group 2, endotracheal tube was lubricated with 4.0% lidocaine gel. SPSS 20 was used for data analysis. Generalised estimating equation was used to see the association between the treatment methods and severity of sore throat over time. RESULTS: Of the 120 patients, there were 60(50%) each in the two groups. The mean intubation time was 5.58±1.31 hours in group 1and 5.43±1.21 hours in group 2. Besides, 7(11.7%) patients developed mild sore throat and 3(5.0%) moderate sore throat in group 1,whereas 13(21.7%) patients developed mild sore throat, 7(11.6%) moderate and 2(3.3%) severe sore throat after one hour of extubation (p=0.04). After 6 hours, there were 2(3.3%) patients with moderate and 1(1.7%) with severe sore throat in group 1 compared to 8(13.3%) with moderate and 4(6.7%) with severe sore throat in group 2. After 24 hours,5(8.3%) patients developed mild and 2(3.3%) moderate sore throat in group 1 compared to 14(23.7%) patients with mild sore throat, 5(8.5%) with moderate and 1(1.7%) with severe throat in group 2. Generalised estimating equation analysis showed a significant positive association between application of lidocaine gel on endotracheal tube and severity of sore throat (p<0.001). CONCLUSIONS: Local application of betamethasone gel was associated with reduced risk of post-operative sore throat as compared to local application of lidocaine gel on the endotracheal tube.

Comparison of Effects of Propofol and Isosorbide Dinitrate during Rewarming on Cardiopulmonary Bypass.

OBJECTIVES: Comparison of effects of propofol and isosorbide dinitrate during rewarming on cardiopulmonary bypass in patients undergoing coronary artery bypasses grafting. METHODS: It was randomized prospective clinical trial. One hundred and twenty patient (120) undergoing CABG surgery were included in this study. Group-I (Study group, n=60): in which only propofol infusion used during rewarming and Group-II (control Group, n=60) in which isosorbide dinitrate and propofol infusion combination was used during rewarming. The data was entered and analyzed through SPSS Version 19. Independent sample T-test and chi-square test were used for data analysis. P value of ≤ 0.05 was taken as significant. RESULTS: Mean arterial pressures during rewarming were 63.41±3.61 mmHg in propofol group versus 60.80±4.86 mmHg in control group (p-value 0.001). Core temperature on weaning from cardiopulmonary bypass was 37.11±0.49 °C in propofol group and 37.00±0.18 °C in control group. After drop in core temperature was little more in propofol group (1.02±0.36 °C) versus 0.96±0.37 °C in control group but this difference was not statistically significant (p-value 0.41). Mean Ventilation time after surgery in propofol group was 4.65±0.65 hours versus 5.03±0.81 hours in control group (p-value 0.006). CONCLUSION: Propofol alone is capable of fulfilling the requirements of adequate rewarming during Cardiopulmonary bypass and can produce more hemodynamic stability and early post-operative recovery.