Effectiveness of intramuscular neostigmine to accelerate bladder emptying after spinal anesthesia.

PURPOSE: Postoperative urinary retention (POUR) is one of the most common complications following spinal anesthesia. Spinal anesthesia may influence urinary bladder function due to interruption of the micturition reflex. Urinary catheterization is the standard treatment of POUR. Urinary catheter insertion is an invasive procedure, which is associated with catheter-related infections, urethral trauma, and patient discomfort. The purpose of this study was to determine the effectiveness of intramuscular (IM) neostigmine to accelerate bladder emptying after spinal anesthesia. PATIENTS AND METHODS: A total of 36 patients undergoing lower abdominal (except for pelvic, urologic, anorectal, and hernia surgery) and lower extremity surgery under spinal anesthesia were divided into two groups randomly (n=18), to either neostigmine (N) group or control (C) group. Neostigmine 0.5 mg (N group) or NaCl 0.9% (C group) was administered intramuscularly when Bromage score 0 and sensory level sacral two have been achieved. The time to first voiding after IM injection and the time to first voiding after spinal anesthesia were measured. RESULTS: The time to first voiding after IM injection was significantly faster (P≤0.05) in the N group than that in the C group, with median time as 40 minutes (20-70 minutes) and 75 minutes (55-135 minutes), respectively. Time to first voiding after spinal anesthesia was also significantly faster (P≤0.05) in the N group than that in the C group (mean of 280.8±66.6 minutes and 364.2±77.3 minutes, respectively). CONCLUSION: IM neostigmine effectively accelerates bladder emptying after spinal anesthesia.

Extended Glasgow Outcome Scale correlates with bispectral index in traumatic brain injury patients who underwent craniotomy.

BACKGROUND: Assessing consciousness in traumatic brain injury is important because it also determines the treatment option, which will influence patients' outcome. A tool used to objectively assess consciousness level is the bispectral index (BIS) monitor, which was originally designed to monitor the depth of anesthesia. Glasgow Outcome Scale-Extended (GOS-E) provides a measuring tool to assess traumatic brain injury (TBI) outcome. The goal of this study was to assess the correlation between GOS-E scores with BIS values in patients with TBI who underwent craniotomy. PATIENTS AND METHODS: A total of 68 patients admitted to the emergency department with decreased consciousness due to TBI who underwent craniotomy were included in the study. BIS value was measured upon admission, then GOS-E score was determined 6 months after the incident took place. Spearman's correlation coefficient was used to assess the correlation between GOS-E score and BIS value. RESULTS: In 68 patients, the GOS-E score was found to have a strong correlation (r =0.921, p<0.01) with BIS values. From this study, the formula to estimate GOS-E score based on BIS value upon admission stands as: GOS-E =0.19 (BIS) - 8.31. CONCLUSION: This study found that there is a strong correlation between GOS-E score and BIS value. These findings suggest that BIS scores upon admission may be used to predict the outcomes in patients with TBI. However, the wide distribution of BIS values for each GOS-E score may limit the use of BIS scores in accurately predicting GOS-E scores.

Jugular bulb oxygen saturation correlates with Full Outline of Responsiveness score in severe traumatic brain injury patients.

BACKGROUND: Maintaining brain oxygenation status is the main goal of treatment in severe traumatic brain injury (TBI). Jugular venous oxygen saturation (SjvO2) monitoring is a technique to estimate global balance between cerebral oxygen supply and its metabolic requirement. Full Outline of Responsiveness (FOUR) score, a new consciousness measurement scoring, is expected to become an alternative for Glasgow Coma Scale (GCS) in evaluating neurologic status of patients with severe traumatic head injury, especially for those under mechanical ventilation. METHODS: A total of 63 patients with severe TBI admitted to emergency department (ED) were included in this study. SjvO2 sampling was taken every 24 hours, until 72 hours after arrival. The assessment of FOUR score was conducted directly after each blood sample for SjvO2 was taken. Spearman's rank correlation was used to determine the correlation between SjvO2 and FOUR score. Regression analysis was used to determine mortality predictors. RESULTS: From the 63 patients, a weak positive correlation between SjvO2 and FOUR score (r=0.246, p=0.052) was found upon admission. Meanwhile, strong and moderate negative correlation values were found in 48 hours (r=-0.751, p<0.001) and 72 hours (r=-0.49, p=0.002) after admission. Both FOUR score (p<0.001) and SjvO2 (p=0.04) were found to be independent mortality predictors in severe TBI. CONCLUSION: There was a negative correlation between the value of SjvO2 and FOUR score at 48 and 72 hours after admission. Both SjvO2 and FOUR score are independent mortality predictors in severe TBI.

Ultrasound-guided bilateral superficial cervical plexus block is more effective than landmark technique for reducing pain from thyroidectomy.

PURPOSE: Thyroidectomy causes postoperative pain and patient discomfort. Bilateral superficial cervical plexus block is a regional anesthesia technique that can provide analgesia during and after surgery. This study aims to compare the effectiveness of ultrasound (US)-guided versus landmark (LM) technique for bilateral superficial cervical plexus block in thyroidectomy. PATIENTS AND METHODS: Thirty-six patients undergoing thyroidectomy were divided into two groups randomly (n=18); either US-guided (US group) or LM technique (LM group) for bilateral superficial cervical plexus block. Patient-controlled analgesia was used to control postoperative pain. Intraoperative opioid rescue, postoperative visual analog scale (VAS) score and opioid consumption were measured. RESULTS: The number of patients who required intraoperative opioid rescue was significantly lower in the US group (p≤0.05). There was no significant difference in postoperative VAS score at 3 hours (p>0.05), but postoperative VAS score at 6 and 24 hours was significantly lower in the US group (p≤0.05). Twenty-four hour postoperative opioid consumption was significantly lower in the US group (p≤0.05). CONCLUSION: Ultrasound-guided bilateral superficial cervical plexus block is more effective in reducing pain both intra- and postoperatively compared with landmark technique in patients undergoing thyroidectomy.

Bispectral index value correlates with Glasgow Coma Scale in traumatic brain injury patients.

BACKGROUND: Accuracy of consciousness level assessment is very important. It may determine and influence further clinical decisions, thus influences patients' outcomes. The widest method in determining the level of awareness is the Glasgow Coma Scale (GCS). Despite its common use, GCS scores obtained by one clinician may differ from others depending on their interpretations and past experience. One of the tools used to assess the level of consciousness objectively is bispectral index (BIS). The aim of this study was to identify the correlation between BIS and GCS score in patients with traumatic brain injury. PATIENTS AND METHODS: A total of 78 patients who were admitted to emergency room for traumatic brain injury were included in this study. One observer evaluated the GCS of all patients to minimize subjectivity. Another investigator then obtained the BIS values for each patient. Spear-man's rank correlation coefficient was used to determine whether GCS correlated with BIS value. RESULTS: In 78 patients, the BIS was found to be significantly correlated with GCS (r=0.744, p<0.01). The BIS values increased with an increasing GCS. Mean BIS values of mild, moderate, and severe head injury were 88.1±5.6, 72.1±11.1, and 60.4±11.7, respectively. CONCLUSION: In this study, a significant correlation existed between GCS and BIS. This finding suggests that BIS may be used for assessing GCS in patients with traumatic brain injury. However, the scatters of BIS values for any GCS level may limit the BIS in predicting GCS accurately.

Effectiveness of low-dose intravenous ketamine to attenuate stress response in patients undergoing emergency cesarean section with spinal anesthesia.

PURPOSE: Cesarean section is a surgical procedure. Surgical procedures will induce stress responses, which may have negative impact on postoperative recovery. Ketamine plays a role in the homeostatic regulation of inflammatory response in order to attenuate stress response. We tried to determine the effectiveness of low-dose intravenous ketamine to attenuate stress response in patients undergoing emergency cesarean section with spinal anesthesia. PATIENTS AND METHODS: Thirty-six pregnant women undergoing emergency cesarean section with spinal anesthesia were randomly divided into two groups (n=18). Ketamine 0.3 mg/kg (KET group) or NaCl 0.9% (NS group) was administered intravenously before the administration of spinal anesthesia. C-reactive protein (CRP) and neutrophil levels were measured preoperatively and postoperatively. RESULTS: Elevation of CRP stress response was lower in the KET group and significantly different (P≤0.05) from that in the NS group. Neutrophil level was elevated in both the groups and hence not significantly different from each other (P>0.05). Postoperative visual analog scale pain score was not significantly different between the two groups (P>0.05), but there was a statistically significant (P≤0.05) positive and weak correlation between visual analog scale and CRP level postoperatively. CONCLUSION: Low-dose intravenous ketamine effectively attenuates the CRP stress response in patients undergoing emergency cesarean section with spinal anesthesia.

The role of intensive insulin therapy in increasing superoxide dismutase (SOD) and normalizing hyperglycemia in critically ill patients.

AIM: To find out the difference between intensive insulin therapy and conventional insulin therapy in influencing the increase of superoxide dismutase (SOD), decrease of cytokine production (TNF-alpha and IL-6), increase of albumin level, and occurrence of SIRS. METHODS: The study design was randomized pre and post control group design involving 40 adult patients admitted to the ICU of Sanglah Hospital, Denpasar. The study subjects were randomly allocated into two groups: the first group to receive intensive insulin therapy in which blood glucose was set at a level between 80 - 110 mg/dL; the second group to receive conventional insulin therapy, which was given if the blood glucose level exceeded 215 mg/dL and to be maintained at the level of between 180 - 200 mg/dL. RESULTS: This study showed: (1) There was a significant increase of SOD in the group receiving intensive insulin therapy as compared to the conventional insulin therapy (370.70 vs. 98.50 U/gHb, p=0.001), (2) There was no significant decrease in the TNF-alpha level, (3) There was a significant decrease of IL-6 level (10.25 vs. 2.02; p=0.023); (4) There was a significant decrease in the event of SIRS (10% vs. 45%, p=0.000) in the intensive insulin therapy group as compared to the conventional insulin therapy group. CONCLUSION: Increase of insulin dose in the intensive insulin therapy can maintain blood glucose at normoglycemic level between 80 - 110 mg/dL faster than that in the conventional insulin therapy. On the other hand, intensive insulin therapy can increase the SOD level, decrease IL-6 level, and decrease the events of SIRS in the ICU critically ill patients compared to conventional insulin therapy.