The Effect of Different Fluid Therapy Methods on Hemodynamic Parameters, Blood Sugar, Blood Gases, and Blood Electrolytes in Six Months to Four Years Old Children Undergoing Surgery.

Background: Considering the necessity of employing an appropriate fluid therapy for patients during the surgery to have hemodynamic stability and electrolyte balance and the lack of studies addressing children in this regard, the present study aimed at investigating the effect of different fluid therapy methods on hemodynamic parameters, blood sugar (BS), blood gases, and blood electrolytes in children undergoing surgery. Materials and Methods: The current clinical trial was conducted on 105 children aged 6 months to 4 years that were candidates for surgery. These patients were randomly divided into three groups undergoing intraoperative fluid therapy with 1/5-4/5 serum, Ringer's, and 1/3-2/3 serum. The values of hemodynamic parameters, BS, serum electrolytes (sodium, potassium, and chloride), and blood gases (pH, HCO3, and BE) were evaluated and compared among the three groups. Results: The level of BS at the end of the surgery in Ringer's group with mean 166.20 ± 39.46 mg/dl was significantly lower than its level in the other two groups (1/5-4/5 serum: 241.00 ± 51.11 and 1/3-2/3 serum: 189.20 ± 34.23; P value < 0.05). Moreover, pH, HCO3, and BE at the end of the surgery had significant differences between the three groups (P value < 0.05). The amount of urine output at all follow-up times revealed a significant difference between Ringer's group and the other two groups (P value < 0.001). Conclusion: Use of Ringer's serum during anesthesia in children, in addition to maintaining BS and electrolytes within the normal range, has resulted in greater stability of hemodynamic responses and maintenance of the body's acid-base balance.

Comparative evaluation between two methods of induced hypotension with infusion of Remifentanil and Labetalol during sinus endoscopy.

OBJECTIVE: This study aimed to compare two methods of controlled hypotension using labetalol and remifentanil in terms of capability to create controlled hypotension and to investigate the obtained complications, and satisfaction rate of surgeon and patient during functional endoscopic sinus surgery. METHODS: In this prospective clinical trial, 62 patients underwent endoscopic sinus surgery in Al-Zahra and Ayatollah Kashani Hospitals of Isfahan were divided into two groups: in the first group, 20 mg bolus dose of labetalol and then infusion of it, at a rate of 0.5-2.0 mg/min and in the second group, remifentanil with dose of 0.5-1 µg/kg started and then 0.25-0.5 µg/kg/min were prescribed. Hemodynamic parameters during anesthesia and recovery time, surgeon and patient satisfaction, and recovery time were measured and recorded. FINDINGS: Hemodynamics variable were comparable between two groups at different times of the study. The mean of bleeding and the frequency of side effects were higher in labetalol group (P = 0.033 and P < 0.0001, respectively). The median of surgeon satisfaction score in remifentanil group was statistically higher in labetalol group (P < 0.0001). Recovery time, fluid requirement, and pain score in labetalol group reported significantly more than remifentanil group. Richmond Agitation-Sedation Scale status at time points in the postanesthetic care unit showed differences between groups. CONCLUSION: With infusion of labetalol and remifentanil after a bolus dose we can induce effective controlled hypotension under general anesthesia. Remifentanil is a short-acting narcotic drug; then, patient satisfaction was better and recovery time was shorter. From the economic aspect, labetalol prefers to remifentanil.

Evaluation the effect of breathing filters on end-tidal carbon dioxide during inferior abdominal surgery in infants and changes of tidal volume and respiratory rate needs for preventing of increasing end-tidal carbon dioxide.

BACKGROUND: The aim of this study was to prevent of increasing end-tidal carbon dioxide (ETCO2) with changing of vital capacity and respiratory rate when using of birthing filter in infants. MATERIALS AND METHODS: In a randomized clinical trial study, ninety-four infant' patients were studied in three groups. Basic values, such as peak inspiratory pressure, tidal volume, minute ventilation, respiratory rate, and partial pressure of ET CO2 (PETCO2) level had been evaluated after intubation, 10 min after intubation and 10 min after filter insertion. In the first group, patients only observed for changing in ETCO2 level. In the second and the third groups, respiratory rates and tidal volume had been increased retrospectively, until that ETCO2 ≤35 mmHg was received. We used ANOVA, Chi-square, and descriptive tests for data analysis. P < 0.05 was considered statistically significant. RESULTS: Tidal volume 10 min after filter insertion was statistically higher in Group 3 (145.0 ± 26.3 ml) versus 129.3 ± 38.9 ml in Group 1 and 118.7 ± 20.8 ml in Group 2 (P = 0.02). Furthermore, respiratory rate at this time was statistically higher in Group 2 (25.82 ± 0.43) versus Groups 1 and 3 (21.05 ± 0.20 ml and 21.02 ± 0.60 ml, respectively) (P = 0.001). Minute volume and PETCO2 level were statistically significant between Group 1 and the other two groups after filter insertion (P = 0.01 and P = 0.00,1 respectively). CONCLUSION: With changing the vital capacity and respiratory rate we can control PETCO2 level ≤35 mmHg during using of birthing filters in infants. We recommend this instrument during anesthesia of infants.

Comparative evaluation of adding different opiates (morphine, meperidine, buprenorphine, or fentanyl) to lidocaine in duration and quality of axillary brachial plexus block.

BACKGROUND: There is no agreement about the effect of adding opioids to local anesthetics in peripheral nerve blocks. The aim of this study was to investigate the effect of adding different opioids with equipotent doses of lidocaine in axillary brachial plexus block using ultrasonography and nerve locator guidance. MATERIALS AND METHODS: In a prospective, randomized, double-blind clinical trial study, 72 adult patients aged 18-65 years old scheduled for orthopedic surgery of the forearm and hand with axillary brachial plexus block were selected and randomly allocated to four groups. Meperidine (pethidine), buprenorphine, morphine, and fentanyl with equipotent doses were added in 40cc of 1% lidocaine in P, B, M, and F groups, respectively. The onset and duration of sensory and motor blocks, severity of patients' pain, duration of analgesia, hemodynamic and respiratory parameters, and adverse events (such as nausea and pruritus) during perioperative period were recorded. RESULTS: The onset time for the sensory block was similar in the four groups. The onset time for the motor block was significantly faster in morphine and pethidine groups (P = 0.006). The duration of sensory and motor blocks was not statistically different among the four groups. The quality of motor blockade was complete in 100% of patients receiving pethidine or morphine and 77.8% of patients receiving buprenorphine or fentanyl (P = 0.021). CONCLUSION: In the upper extremity surgeries performed under axillary brachial plexus block addition of morphine or pethidine to lidocaine may be superior to other opioids (i.e. fentanyl and buprenorphine) due to better quality and quantity of motor blockade and faster onset of the block.

Comparison of the effects of intravenous premedication: Midazolam, Ketamine, and combination of both on reducing anxiety in pediatric patients before general anesthesia.

OBJECTIVE: In some medical circumstances, pediatric patients may need premedication for transferring to the operating room. In these situations, using intravenous premedication is preferred. We assessed the efficacy and safety of intravenous midazolam, intravenous ketamine, and combination of both to reduce the anxiety and improve behavior in children undergoing general anesthesia. METHODS: In a double-blind randomized clinical trial, 90 pediatric patients aged 6 months to 6 years with American Society of Anesthesiologist grade I or II were enrolled. Before anesthesia, children were randomly divided into three groups to receive intravenous midazolam 0.1 mg/kg, or intravenous ketamine 1 mg/kg, or combination of half doses of both. Behavior types and sedation scores were recorded before premedication, after premedication, before anesthesia, and after anesthesia in the postanesthesia care unit. Anesthesia time, recovery duration, blood pressure, and heart rate were also recorded. For comparing distribution of behavior types and sedation scores among three groups, we used Kruskal-Wallis test, and for comparing mean and standard deviation of blood pressure and heart rates, we used analysis of variance. FINDINGS: After premedication, children's behavior was significantly better in the combination group (P < 0.001). After anesthesia, behavior type was same among three groups (P = 0.421). Sedation scores among three groups were also different after premedication and the combination group was significantly more sedated than the other two groups (P < 0.001). CONCLUSION: Combination of 0.05 mg/kg of intravenous midazolam and 0.5 mg/kg of intravenous ketamine as premedication produced more deep sedation and more desirable behavior in children compared with each midazolam 0.1 mg/kg or ketamine 1 mg/kg.

A randomized controlled trial for the effectiveness of intraarticular versus intravenous midazolam on pain after knee arthroscopy.

BACKGROUND: This double-blinded, randomized clinical trial was designed to evaluate the comparison of intravenous versus intraarticular (IA) administration of midazolam on postoperative pain after knee arthroscopy. MATERIALS AND METHODS: In this study, 75 patients randomized in three groups to receive 75 mc/kg IA injection of midazolam and 10 ml intravenous injection of isotonic saline (Group I), 75 mc/kg intravenous injection of midazolam and 10 cc IA injection of isotonic saline (Group II) or IA and intravenous injection of isotonic saline (Group III) at the end of knee arthroscopy. Pain scores, time until the first request for analgesics, cumulative analgesic consumption, satisfaction, sedation, and complications as studied outcomes were assessed. Patients were observed for 24-h. RESULTS: IA administration of midazolam significantly reduced pain scores in the early postoperative period compared with intravenous injection. Mean of time to first analgesic requirement in Group III (33.6 min) was significantly lower than Group II (288.8 min) and Group I (427.5 min). Cumulative analgesic consumption was increased in Groups II (35.5 mg), and III (70 mg) compared with Group I (16 mg), (P < 0.0001). Complications significantly occurred in 3 of 25 patients in Group I in contrast to 20 of 25 patients in Group III (P < 0.0001). At 2-, 4- and 8-h after arthroscopy pain score significantly decreased in Group I than other groups (P < 0.0001). Patients in Group I were significantly satisfy than other groups (P < 0.0001). CONCLUSION: Results show the greater analgesic effect after IA administration of midazolam than after intravenous injection and hence, IA administration may be is the method of choice for pain relief after knee arthroscopy.

Prophylactic Use of Oral Acetaminophen or IV Dexamethasone and Combination of them on Prevention Emergence Agitation in Pediatric after Adenotonsillectomy.

BACKGROUND: The present study was aimed to evaluate the efficacy of acetaminophen plus dexamethasone on post-operative emergence agitation in pediatric adenotonsillectomy. METHODS: A total of 128 patients were randomized and assigned among four groups as: Intravenous (IV) dexamethasone, oral acetaminophen, IV dexamethasone plus oral acetaminophen, placebo. Group 1 received 0.2 mg/kg dexamethasone plus 0.25 mg/kg strawberry syrup 2 h before surgery. Group 2 received 20 mg/kg oral acetaminophen (0.25 ml/kg) with 0.05 ml/kg IV normal saline. Group 3 received 20 mg/kg acetaminophen and 0.2 mg/kg dexamethasone intravenously. Group 4 received 0.25 ml/kg strawberry syrup and 0.05 ml/kg normal saline. Agitation was measured according to Richmond agitation sedation score in the post anesthetic care unit (PACU) after admission, 10, 20 and 30 min after extubation. Pain score was measured with FACE scale. Nurse satisfaction was measured with verbal analog scale. If agitation scale was 3 ≥ or pain scale was 4 ≥ meperidine was prescribed. If symptoms did not control wit in 15 min midazolam was prescribed. Patients were discharged from PACU according Modified Alderet Score. Data were analyzed with ANOVA, Chi-square, and Kruskal-Wallis among four groups. P < 0.05 was considered statistically significant. RESULTS: A total of 140 patients were recruited in the study, which 12 of them were excluded. Thus, 128 patients were randomized and assigned among four groups. The four treatment groups were generally matched at baseline data. Median of pain score in 0, 10, 20 and 30 min after extubation were different between each study group with the control group (<0.001, 0.003 respectively). Also median of agitation score in 0, 10, 20 and 30 min after extubation were different between each study group with the control group (<0.001). Incidence of pain and incidence of agitation after extubation were not statistically identical among groups (P < 0.001 and P = 0.002 respectively). Mean of recovery time, duration of agitation and 1(st) time to agitation appearance, meperidine and midazolam consumption, nurse satisfaction and complication frequency were not statistically identical among groups (P < 0.001). CONCLUSIONS: Acetaminophen, dexamethasone and combination of them are superior to placebo for prevention of agitation after adenotonsillectomy in children. Furthermore combinations of both drugs are superior to acetaminophen or dexamethasone separately.

The effect of intravenous infusion of paracetamol before anesthesia induction on the core and peripheral temperature changes and post-operative shivering in patients undergoing general anesthesia.

BACKGROUND: Post-operative shivering is an unpleasant complication that various drugs are used to prevent and treat. It is tried to advice a suitable drug with the least side-effects. This study was carried out to examine the effect of intravenous Apotel on the post-operative shivering and core and peripheral body temperature. MATERIALS AND METHODS: This clinical trial conducted in Al Zahra and Kashani Hospitals in Isfahan in 2012 on 64 patients undergoing upper limbs surgery with general anesthesia, which divided in two equal groups. In the first group, before induction, 15 mg/kg and up to 1 g paracetamol was infused in 100 cc normal saline within 20 min and control group was infused 100 cc normal saline during 20 min. Post-operative shivering and pain were recorded in the same time in addition to the core and peripheral temperature. The results were analyzed by SPSS ve.20 software. RESULTS: In patients receiving Apotel, the core and peripheral temperature were significantly lower (P < 0.05). At 10 min after entering in recovery, 10 patients in the control group and 2 in the intervention group suffered from shivering (31.2% vs. 6.2%), which was significantly different (P = 0.02). Nineteen patients (29.7%) suffered from shivering in recovery (14 patients in the control group and 5 patients in the intervention group (43.8% vs. 15.6%)). In Apotel receiving group, the incidence of shivering in recovery was significantly lower (P = 0.014). CONCLUSION: Given the beneficial effects of Apotel in post-operative shivering and pain reduction, using the drug as a pre-drug is recommended in patients undergoing surgery with general anesthesia.

Comparative evaluation of the effects of hydroxyethyl starch on coagulation state of patients during brain tumor surgeries in comparison to crystalloids by thromboelastography.

BACKGROUND: Hypercoagulability has been reported in primary brain tumors which can lead to thrombotic complications. Hydroxyethyl starch (hetastarch) is a synthetic colloid solution with adverse effects on blood coagulation. The aim of this study was to evaluate the protective effect of hetastarch in reducing thromboembolic events in these patients. MATERIALS AND METHODS: In a double-blinded clinical trial, 60 brain tumor surgery patients were randomly divided into two groups and given 10 mL/kg hetastarch or normal saline during surgery. Blood coagulation was compared before and after infusion of these fluids within and between groups by thromboelastography (TEG). RESULTS: There were no significant differences in bleeding (P = 0.126), duration of surgery (P = 0.504), and fluid intake (0.09L) between the two groups. Percentage of changes in R (R: Time to initiate fibrin formation), K (K: Measure of the speed taken to reach a specific level of clot strength), and Ly30 (Ly30: Percent of fibrin distraction after 30 minutes of clot formation) in the crystalloid group were -20.61 ± 26.46, -30.02 ± 49.10, and 1.27 ± 22.63, and that in the colloid group were 22.10 ± 26.11, 41.79 ± 37.15, and 59.09 ± 37.12, respectively. Deterioration in hemostasis during and after surgery was not observed. CONCLUSION: There was a reduction in the speed of clot formation and increase in clot lysis in the hetastarch group. Coagulability was decreased in the colloid group. Infusion of 10 mL/kg hetastarch in brain tumor resection surgeries can probably decrease susceptibility of these patients to deep vein thrombosis (DVT) and thromboembolic events.

Comparing the preventive effect of 2 percent topical lidocaine and intravenous atropine on oculocardiac reflex in ophthalmological surgeries under general anesthesia.

BACKGROUND: The current study aimed to determine preventive effect of 2 percent topical xylocaine on oculocardiac reflex in ophthalmological surgeries except strabismus, including retinal detachment and vitrectomy with scleral buckling under general anesthesia. METHODS: A randomized controlled clinical trial was carried out on 150 patients aged 18-90 years undergoing ophthalmological surgeries under general anesthesia. Samples randomly divided into the experimental group (received four drops of 2 percent topical xylocaine instilled in desired eye) and control group (received 0.5 mg atropine sulfate injection). Systolic, diastolic and mean arterial blood pressure of patients and baseline heart rate were recorded. They were compared regarding the incidence of bradycardia, heart rate less than 60 beats/minute, hypotension and blood pressure less than 90 mm/Hg. Data were analyzed by Statistical Package for the Social Sciences software version 20 using Chi-square and ANOVA. RESULTS: The difference between two groups was not statistically significant regarding demographic and basic variables. The incidence of bradycardia in both groups was respectively (90.7 percent vs. 17.3 percent), heart rate less than 60 beats/minute (40 percent vs. 13.3 percent), hypotension (76 percent vs. 32 percent) and blood pressure less than 90 mmHg was (28 percent vs. 8 percent). Accordingly, the differences between both groups were statistically significant (P > 0.001). CONCLUSIONS: The preventive impact of topical xylocaine upon oculocardiac reflex in ophthalmological surgeries such as retinal detachment and vitrectomy with scleral buckling under general anesthesia was less effective than that of atropine injection. Therefore, to avoid this reflex in high-risk patients, injecting atropine would be safer.

The effect of lidocaine on reducing the tracheal mucosal damage following tracheal intubation.

BACKGROUND: The aim of this study was to investigate the efficacy of lidocaine solution in the cuff of the endotracheal tube in reducing mucosal damage following tracheal intubation. MATERIALS AND METHODS: This was a randomized controlled trial study undertaken in the intensive care unit patients. Participants, who met all eligibility criteria, were randomly assigned to one of two groups of patients, according to whether lidocaine or air was used to fill the tracheal tube cuff. The tracheal mucosa at the site of cuff inflation was inspected by fiberoptic bronchoscopy and scored at the 24 h and 48 h after intubation. RESULTS: In all, 51 patients (26 patients in the lidocaine group and 25 patients in the control group) completed the study. After 24 h, erythema and/or edema of tracheal mucosa were seen in 2 patients (7.7%) of lidocaine group and 6 patients (24%) of air group (P = 0.109). Binary logistic regression analysis showed that lidocaine has a significant protective effect against mucosal damage (odds ratio = 0.72, confidence interval = 0.60-0.87). CONCLUSION: The inflation of the tracheal tube cuff with lidocaine was superior to air in decreasing the incidence of mucosal damage in the 24 h and 48 h post intubation.

A randomized evaluation of intravenous dexamethasone versus oral acetaminophen codeine in pediatric adenotonsillectomy: emergence agitation and analgesia.

BACKGROUND: Adenotonsillectomy is the most frequently performed ambulatory surgical procedure in children. Post operative agitation and inadequate pain control, for children undergoing adenotonsillectomy, can be a challenge. The aim of this study was to assess the effect of intravenous dexamethasone and oral acetaminophen codeine on emergence agitation and pain after adenotonsillectomy in children. METHODS: One hundred and five pediatric patients (3-7 years old), scheduled to undergo adenotonsillectomy under general anesthesia, were enrolled in the study. Thirty minutes before induction, patients were randomized to three groups. Group 1 received 0.2 mg/kg of intravenous dexamethasone and 0.25 ml/kg of oral placebo syrup. Group 2 received 20 mg/kg of oral acetaminophen codeine syrup and 0.05 ml/kg of intravenous saline. Group 3 received 0.25 ml/kg of oral placebo syrup and 0.05 ml/kg of intravenous saline. Emergence agitation and postoperative pain were assessed, recorded and compared. RESULT: Agitation was less frequent in dexamethasone and acetaminophen codeine groups in comparison with placebo group, but there were not significant differences between the two groups. The pain frequencies in the three groups were not significantly different. CONCLUSION: The results of this study suggest that the administration of intravenous dexamethasone (0.2 mg/kg) and oral acetaminophen codeine (20 mg/kg) thirty minutes before anesthesia can significantly decrease the incidence and severity of agitation but does not have an effect on postoperative pain.

Effects of adjunct intrathecal magnesium sulfate to bupivacaine for spinal anesthesia: a randomized, double-blind trial in patients undergoing lower extremity surgery.

PURPOSE: The aim of this study was to evaluate the effect of additional magnesium sulfate (MgSO(4)) 100 mg to intrathecal (IT) isobaric 0.5% bupivacaine 3 ml on spinal anesthesia in patients undergoing lower extremity orthopedic surgery. METHODS: In a double-blind randomized clinical trial, 79 American Association of Anesthesiologists (ASA) I or II adult patients undergoing lower extremity orthopedic surgery were recruited. The patients were randomly allocated to receive 100 mg MgSO(4) 5% (0.2 ml) plus 15 mg of bupivacaine 0.5% (MgSO(4) group) or 15 mg bupivacaine 0.5% combined with 0.2 ml normal saline (control group) intrathecally. Response to treatment was assessed as onset and duration of sensory block, the highest level of sensory block, time to complete motor block recovery, duration of spinal anesthesia, and postoperative analgesic requirement. RESULTS: The onset of the sensory block was slower in the MgSO(4) group than in the control group (13.3 vs. 11.6 min, P = 0.04), and the duration of the sensory blockade was significantly longer in the MgSO(4) group than the control group (106.5 vs. 85.5 min, P = 0.001). Total analgesic requirements for 24 h following surgery were lower in the MgSO(4) group than in the control group (96.8 vs. 138.5 mg, P = 0.001). Mean duration of spinal anesthesia was not significantly different between two groups (178.0 vs. 167.4 min, P = 0.23). CONCLUSION: In patients undergoing lower extremity surgery with spinal anesthesia, the addition of 100 mg IT MgSO(4) to 15 mg bupivacaine without opioid supplement, prolonged the duration of the sensory block, decreased postoperative analgesic consumption, and significantly prolonged the onset of spinal anesthesia.

Comparison of pre- vs. post-incisional caudal bupivacaine for postoperative analgesia in unilateral pediatric herniorrhaphy: A double-blind randomized clinical trial.

INTRODUCTION: This study was designed to evaluate the pre- vs. post-incisional analgesic efficacy of bupivacaine administered caudally in children undergoing unilateral hernia repair. METHODS: Fifty children aged 6 months to 6 years were included in the study. Children were divided blindly between the two groups to receive pre- vs. post-incisional caudal bupivacaine. The preincisional group received 1 ml/kg of 0.125% bupivacaine caudally after induction of anesthesia and the postincisional group received the same dose caudally at the end of surgery. Heart rate, SaO(2), end tidal CO(2), and noninvasive arterial blood pressure were recorded every 10 min. The duration of surgery, extubation time, and duration of recovery period were also recorded. The pain scores were measured with using an Oucher chart in the recovery room, 2, 4, 6, 12, and 24 h after surgery. Time to first analgesia, numbers of supplementary analgesics required by each child in a 24-h period and total analgesic consumptions were recorded. Any local and systemic complications were recorded. Quantitative data were compared using a two-tailed t-test. Sex distribution and frequency of acetaminophen consumption were measured using χ(2) test. P < 0.05 was considered statistically significant. RESULTS: The Oucher pain scale at 4, 6, 12, and 24 h after surgery, the total analgesic consumption and the numbers of demand for supplemental acetaminophen were lower statistically in preincisional group (P < 0.05). Extubation time and duration were higher in preincisional group (P < 0.05). Mean changes of heart rates were statistically lower during the anesthesia period and recovery time in preincisional group (P < 0.05). CONCLUSION: Preincisional caudal analgesia with a single injection of 0.125% bupivacaine is more effective than the postincisional one for postoperative pain relief and analgesic consumption in unilateral pediatric herniorrhaphy.

Efficacy of granisetron in preventing postanesthetic shivering.

BACKGROUND: Recently, 5-hydroxytryptamine 3 (5-HT3) receptor antagonists have been reported to prevent postanesthetic shivering. This placebo-controlled study was performed to evaluate the efficacy of granisetron, a 5-HT3 antagonist, in comparison with meperidine and tramadol in preventing postanesthetic shivering. METHODS: In this prospective, randomized, double-blind study, 132 ASA I and II patients undergoing elective orthopedic surgery under standardized general anesthesia were included. At the end of surgery, patients were randomly assigned to one of four groups (each group n = 33) using a double-blinded protocol. Group T received 1 mg/kg tramadol, group G received 40 microg/kg granisetron (an antiemetic dose), group M received 0.4 mg/kg meperidine, and group P received saline 0.9% as placebo. Shivering was graded according to the following: 0 = no shivering; 1 = piloerection, peripheral vasoconstriction or peripheral cyanosis without other cause; 2 = visible muscular activity confined to one muscle group; 3 = visible muscular activity in more than one muscle group; and 4 = gross muscular activity involving the entire body. The emergence time from anesthesia, defined as the time between withdrawal of isoflurane and tracheal extubation, was documented. RESULTS: The number of patients with observable shivering was 19 in group P, nine in group G, seven in group T and six in group M. Granisetron significantly reduced the incidence of shivering in comparison with placebo (p = 0.013). Although the frequency of shivering was higher with granisetron in comparison to tramadol and meperidine, it was not statistically significant (p > 0.05). The number of patients with a shivering score of 2, 3 and 4 was significantly higher in group P compared with the other groups (p = 0.001). Both meperidine and tramadol caused a significantly prolonged emergence time (20.58 +/- 3.56 and 16.45 +/- 4.13 minutes, respectively) as opposed to granisetron (13.58 +/- 3.41 minutes) and placebo (12.61 +/- 3.31 minutes). CONCLUSION: The prophylactic use of granisetron 40 microg/kg is as effective as meperidine (0.4 mg/kg) and tramadol (0.1 mg/kg) in preventing postanesthetic shivering without prolonging the emergence time from anesthesia.

Supplementing epidural lidocaine with midazolam: effect on sensorymotor block level.

BACKGROUND: Midazolam, the only clinically available water-soluble benzodiazepine, has been reported to have an antinociceptive effect through neuroaxial pathway. Also it can be used epidurally for postoperative analgesia and chronic pain management. In a recent study it was disclosed that when midazolam was added to intrathecal bupivacaine it improved the duration and quality of the spinal anesthesia. In this study the effects of this drug on intraoperative motor and sensory blocks were evaluated. METHODS: We studied 53 adult ASA I and II patients scheduled for elective lower-limb surgery. All patients received epidural anesthesia with 19 ml of lidocaine and l ml additive. Patients were randomly allocated to three groups. Midazolam was administered epidurally in doses of 5 mg (1 ml) and 3 mg (1 ml) in groups land 2 respectively, and group 3 received normal saline Iml as placebo. Patients were evaluated for the onset time and duration of sensory and motor blocks, duration to the first rescue analgesic and hemodynamic changes. RESULTS: Onset of sensory block and time to peak effect was significantly faster and shorter in group one patients who received 5 mg midazolam as compared with those of other two groups (P = 0.002 and P = 0.001, respectively). Also, the durations of motor and sensory blocks were significantly longer in group one compared with those of other two groups (P = 0.004 and P = 0.045, respectively). CONCLUSIONS: Midazolam can improve the durations of sensory and motor blocks of lidocaine in a single epidural administration. It seems that the 5 mg dosage works better than the lower one.

Paradoxical reaction following intravenous midazolam premedication in pediatric patients - a randomized placebo controlled trial of ketamine for rapid tranquilization.

BACKGROUND: Paradoxical reactions to benzodiazepines include restlessness, violent behavior, physical assault, act of self-injury and need for restraints. These may occur at variable times after administration. This study was designed to determine the incidence of paradoxical reactions following intravenous midazolam premedication in pediatric patients and to compare the efficacy of extra doses of midazolam with low-dose intravenous ketamine to rapidly tranquillize them. METHODS: A total of 706 ASA I, II children scheduled for elective surgery were given intravenous midazolam premedication. Children who developed a paradoxical reaction were randomly divided into three equal groups to receive: (i) extra midazolam, (ii) ketamine, or (iii) placebo as the test drug for treatment of paradoxical reaction. Ease of rapid tranquillization and need for a rescue tranquillizer (i.e. ketamine; irrespective of patient group) were compared among the three groups. RESULTS: Twenty-four (3.4%) children developed paradoxical reaction after midazolam premedication. Those who received ketamine as the test drug responded rapidly to ketamine. But the responses of the other two groups to their test drug were poor and the majority of them required ketamine as rescue tranquillizer (six in midazolam, seven in placebo, but no patient in the ketamine group; P < 0.05). CONCLUSIONS: The results of this study demonstrate that ketamine is an effective drug for the treatment of paradoxical reaction following intravenous midazolam premedication. The exact mechanisms of these reactions and how it is aborted by ketamine are not clear.

A randomized, prospective comparison of end-tidal CO2 pressure during laparoscopic cholecystectomy in low and high flow anesthetic system.

BACKGROUND: Low flow anaesthesia has been used in anesthetic practice to prevent operation room pollution and also for econormical reasons. Since the safety of low flow technique has not been clearly determined in previous researches this study was performed to compare the end-tidal CO2 pressure during laparoscopic cholecystectomy in low flow as opposed to high flow anesthesia. METHODS: Forty patients, 30-65 years of age, ASA physical status I or II, scheduled for laparoscopic cholecystectomy under general anesthesia were randomly alloted to low flow and high flow groups. End-tidal CO2 pressure, arterial blood pressure, pulse oximetric oxygen saturation, and heart rate were measured before, during and after insufflation of CO2 into the peritoneal cavity. The data were compared between two groups. RESULTS: Pneumoperitoneum caused a decrease in PaO2 and oxygen saturation together with increases in PaCO2 and end-tidal CO2 pressure in both groups but the differences between two groups were not statistically significant. CONCLUSIONS: The result of this study shows that end-tidal CO2 pressure during laparoscopic cholecystectomy using low flow anesthesia system is comparable to that with high flow system. Therefore it can be concluded that low flow anesthesia can be used with relative safety in anesthetic management of patients during laparoscopic cholecystectoy.

The macroscopic changes of tracheal mucosa following tight versus loose control of tracheal tube cuff pressure.

BACKGROUND: Tracheal mucosal lesions have been reported following intubation anesthesia. This has been mostly attributed to improper cuff pressure leading to ischemic damages of the tracheal mucosa. In this study macroscopic changes of tracheal mucosa at the site of cuff inflation were evaluated endoscopically after "tight method" of cuff pressure control using a special water manometer. METHODS: Eighty ASA I and II patients scheduled for elective operations were evaluated. The severity of macroscopic changes of tracheal mucosa was compared between tight control group and control group in which only "no leak method" of cuff inflation was used (loose control group). RESULTS: The incidence and severity of macroscopic changes in tracheal mucosa were significantly lower in tight control group than that in loose control group. CONCLUSIONS: Tight control of cuff pressure can minimize the incidence and severity of macroscopic lesions of tracheal mucosa at the site of cuff inflation.