RESUMO
Objectives The primary concern in functional endoscopic sinus surgery (FESS) is maintaining a clear and unobstructed surgical field. Achieving this objective necessitates controlled hypotension, which can aid in the surgical dissection process and reduce the overall duration of the operation. This study aims to evaluate the efficacy of a sole bolus injection of intravenous magnesium sulfate in FESS. The outcomes measured include blood loss, surgical field grading, the additional intraoperative requirement of fentanyl, stress attenuation during laryngoscopy and endotracheal intubation, and extubation time. Methods In this prospective, double-blinded, randomized control trial (CTRI/2021/04/033052), 50 patients scheduled for FESS were randomly divided into two groups: Group M received 50 mg/kg MgSO4 in 100 ml normal saline, and Group N received 100 ml plain normal saline 15 min before induction. The study assessed total blood loss, measured by blood collected from the surgical field and weighing gauze. The surgical field grading was assessed by a six-point Fromme and Boezaart scale. We also observed stress attenuation during laryngoscopy and endotracheal intubation, additional intraoperative fentanyl requirements, and time taken for extubation. The sample size was estimated using the G power calculator 3.1.9.2 (http://www.gpower.hhu.de/). Data were entered in Microsoft Excel (Microsoft Corporation, Redmond, WA) and analyzed using Statistical Package for Social Sciences version 20.0 (IBM Corp., Armonk, NY). Results The demographic data and duration of the surgery were comparable in both groups. The total blood loss in Group M was 100.40 ml ±60.71 ml, which is lower than Group N (133.80 ml ±59.7 ml) with a p-value of 0.016. In addition, the surgical field grading was also better in Group M. The total vecuronium consumption was significantly lower in Group M, which was (7.23±0.84 mg); in Group N, it was (10.64±1.74 mg) with a p-value of 0.0001, respectively. The dosage of additional fentanyl in Group N was 38.46 mcg ± 8.99 mcg, more than in Group M (33.64 mcg ± 11.20 mcg). The time required for extubation was similar in both groups. The duration of the surgery was significantly more significant in Group M (150.0 ±31.36) than in Group N (205.0 ±32.79), with a p-value of 0.0001, respectively. Furthermore, the mean arterial pressure after induction, at 2 min and 4 min after laryngoscopy, was less in Group M, with p=0.001, p=0.003, and p<0.0001, respectively, when compared with Group N. The heart rate after induction, at 2 min and 4 min after laryngoscopy, was also less in Group M, with p=0.016, p=0.003, and p=0.003, respectively, when compared with Group N. The Ramsay Sedation Score was higher in Group M than in Group N's fourth, eighth, and sixteenth hour, with p=0.001, p=0.021, and p=0.001, respectively, in the postoperative period. The sedation score was statistically insignificant after that. No complications were encountered during the study. Conclusion We conclude that a single bolus dose of MgSO4 reduced surgical blood loss more effectively than in the control group. The surgical field grading was also better in Group M, as was the stress attenuation during laryngoscopy and endotracheal intubation. The intraoperative fentanyl requirement was not statistically significant. The time for extubation was similar between the groups. No other adverse effects were encountered during the study.
RESUMO
Objectives Epidural analgesia remains the cornerstone of pain management following laparotomy. Local anesthetics used in epidural analgesia provide good analgesia but may result in hypotension and/or motor blockade. Morphine, a long-acting opioid, can also be used epidurally to provide analgesia. Morphine used epidurally will cause fewer hemodynamic disturbances and no motor blockade. Hence, we compared the efficacy, hemodynamic parameters, and motor blockade between epidural levobupivacaine and morphine for postoperative analgesia following laparotomy. Materials and methods This is a prospective, double-blind, randomized controlled study registered in the Clinical Trials Registry of India (CTRI/2021/04/033102). Ninety patients undergoing elective major abdominal surgery were randomly divided into two groups: levobupivacaine (0.125%/mL) and morphine (0.032 mg/mL) group. All patients received epidural infusion at 6 mL/hour. The visual analog scale (VAS) score at rest and during cough was observed for 24 hours. Heart rate and blood pressure were monitored continuously for 24 hours postoperatively. Additional analgesic requirements, postoperative sedation score, and motor blockade were also compared between the two groups. Statistical analysis was done using the chi-square test, unpaired T-test, and Mann-Whitney test. The sample size estimation was based on a pilot study. Results The demographic data and duration of the procedure were comparable in both groups. The initial median VAS score at rest in the levobupivacaine group was high (interquartile range (IQR): 2-4) when compared to the morphine group (IQR: 1-3) at the fourth, sixth, and eighth hour with a P value of <0.05. The initial median VAS score at coughing in the levobupivacaine group was 4 (IQR: 3-5) and in the morphine group was 3 (IQR: 3-4). The VAS score at rest and at coughing was significantly higher in the levobupivacaine group. Heart rate was stable in both groups, and a significant fall in mean arterial blood pressure was observed in the levobupivacaine group. The sedation score was significantly higher in the morphine group (IQR: 2-2) when compared to the levobupivacaine group (IQR: 1-2) at the fourth hour postoperatively with a P value of <0.05. Motor blockade was found to be stronger in the levobupivacaine group (IQR: 0-2) when compared to the morphine group (IQR: 0-0) at the fourth, sixth, and eighth hour postoperatively with a P value of <0.05. An additional dose of fentanyl was required by 6.7% of the patients in the levobupivacaine group and 8.9% of the patients in the morphine group. In the levobupivacaine group, 11.1% reported headaches, 2.2% reported vomiting, and 4.4% reported hypotension, and no pruritus was reported. In the morphine group, 11.1% reported tachycardia, 6.7% reported nausea and vomiting, 6.4% reported pruritus, and 2.2% reported hypotension. Conclusion We conclude that patients receiving epidural morphine had better pain scores with better hemodynamic stability than the epidural levobupivacaine group following laparotomy. The morphine group had less motor blockade. Sedation was observed in the morphine group. Additional analgesics were required in both groups. The adverse effects observed in the epidural morphine group were tachycardia, nausea, pruritus, and itching. The epidural levobupivacaine group reported headache, vomiting and fever, and hypotension.
