Intravenous (IV) dexmedetomidine with excellent sedative properties has been shown to reduce analgesic requirements during general anaesthesia. A study was conducted to assess the effects of IV dexmedetomidine on sensory, motor, haemodynamic parameters and sedation during subarachnoid block (SAB).
A total of 50 patients undergoing infraumbilical and lower limb surgeries under SAB were selected. Group D received IV dexmedetomidine 0.5 mcg/kg bolus over 10 min prior to SAB, followed by an infusion of 0.5 mcg/kg/h for the duration of the surgery. Group C received similar volume of normal saline infusion. Time for the onset of sensory and motor blockade, cephalad level of analgesia and duration of analgesia were noted. Sedation scores using Ramsay Sedation Score (RSS) and haemodynamic parameters were assessed.
Demographic parameters, duration and type of surgery were comparable. Onset of sensory block was 66±44.14 s in Group D compared with 129.6±102.4 s in Group C. The time for two segment regression was 111.52±30.9 min in Group D and 53.6±18.22 min in Group C and duration of analgesia was 222.8±123.4 min in Group D and 138.36±21.62 min in Group C. The duration of motor blockade was prolonged in Group D compared with Group C. There was clinically and statistically significant decrease in heart rate and blood pressures in Group D. The mean intraoperative RSS was higher in Group D.
Administration of IV dexmedetomidine during SAB hastens the onset of sensory block and prolongs the duration of sensory and motor block with satisfactory arousable sedation.
Dexmedetomidine; intravenous; subarachnoid block; supplementation
Day care surgery is still in its infancy in India. Both regional and general anaesthesia can be used for this. Central neuraxial blocks are simple cheap and easy to perform. This study was done to evaluate usefulness of spinal and epidural anaesthesia for day care surgery.
Patients & Method:
100 patients were randomized to either spinal (n=50) or epidural (n=50) group anaesthetized with either 0.5% hyperbaric 2ml bupivacaine or 0.5% 20ml bupivacaine respectively. In spinal group 27 gauze quincke needle and in epidural group 18 gazue tuohy needle was used. Both the groups were compared for haemodynamic stability, side effects, complications, postanaesthesia discharge score (PADS), time taken to micturate, total duration of stay in hospital and patient satisfaction score for technique.
We observed that spinal anaesthesia had significantly early onset of anaesthesia and better muscle relaxation (p<0.05) as compared to epidural block otherwise both groups were comparable for haemodynamic stability, side effects or complications. Although more patients in spinal group (64% vs 48%) achieved PADS earlier (in 4-8 hours) but statistically it was insignificant. Time to micturition (6.02 0.55 v/s 6.03 0.47 hours) and total duration of stay (7.49 1.36 v/s 8.03 1.33 hours) were comparable in both the groups.
Both spinal and epidural anaesthesia can be used for day care surgery. Spinal anaesthesia with 27 gauze quincke needle and 2ml 0.5% hyperbaric bupivacaine provides added advantage of early onset and complete relaxation.
Day Care; Spinal; Epidural; Bupivacaine
Gastroschisis is a congenital anomaly with a high perioperative mortality. Administration of general anaesthesia to these high risk neonates is associated with several problems including postoperative apnoea and the need for mechanical ventilation. Central neuraxial blocks, and more recently, combined spinal epidural have been administered for major abdominal surgery in neonates. We present the case of a neonate posted for gastroschisis repair conducted under combined spinal epidural anaesthesia and discuss the several advantages of this technique.
Gastroschisis; Combined spinal epidural
Many anesthetics reduce lower esophageal sphincter pressure (LESP) and consequently the gastro-esophageal pressure gradient (GEPG); thus they may promote gastro-esophageal reflux and contribute to aspiration pneumonia. Our goals were to evaluate the association between LESP and 2 measures of sedation: bispectral index (BIS) and the responsiveness component of the Observer’s Assessment of Alertness score (OAA/S).
Eleven healthy volunteers were each sedated on 2 separate days. Subjects were given sedative infusions of increasing target plasma concentrations of dexmedetomidine or propofol. LESP and GEPG were recorded after starting each infusion phase. Generalized estimating equation modeling was used to assess the relationship between LESP and, respectively, BIS and OAA/S. The existence of a drug-dependent association was evaluated within these models by testing an interaction term. Wald tests were used to evaluate the relationships within the models.
We found a significant relationship between LESP and BIS (P=0.0043) after adjusting for the main effect of sedative type – a deepening of sedation as measured by a decrease in BIS of 10% was associated with a decrease [Bonferroni-adjusted 95% CI] in LESP of −1.34 [−2.39, −0.29] mmHg. After adjusting for the main effect of sedative drug, LESP significantly declined with declining OAA/S (P=0.001); a unit decrease of OAA/S was associated with a decrease [Bonferroni-adjusted 95% CI] in LESP of −2.01 [−3.20, −0.81] mmHg.
Deeper sedation, as measured by either BIS or OAA/S, significantly reduces LESP.
BIS; lower esophageal sphincter; dexmedetomidine; propofol
Midazolam has analgesic properties. The aim of the present study was to assess the analgesic effect of midazolam when added to lidocaine in intravenous regional anesthesia (IVRA).
Sixty patients undergoing hand surgery were randomly allocated into two groups to receive 3 mg/kg 2% lidocaine diluted with saline to a total volume of 40 mL in the control group (group lidocaine saline ~ LS, n=30) or 50 μg/kg midazolam plus 3 mg/kg 2% lidocaine diluted with saline to a total volume of 40 mL in the midazolam group (group lidocaine midazolam ~ LM, n=30). Before and after the tourniquet application, hemodynamic variables, tourniquet pain, sedation, and analgesic use were recorded.
Shortened sensory and motor block onset time [4.20 (0.84) vs. 5.94 (0.83) min, p = 0.001 and 6.99 (0.72) vs. 9.07 (0.99) min, p = 0.001 in LM and LS groups, respectively], prolonged sensory and motor block recovery times [8.41 (0.94) vs. 5.68 (0.90) min, p = 0.001 and 11.85 (1.18) vs. 7.06 (0.82) min, p = 0.001 in LM and LS groups, respectively], shortened visual analog scale (VAS) scores of tourniquet pain (p < 0.05), and improved quality of anesthesia were found in group LM (p < 0.05). VAS scores were lower in group LM in the postoperative period (p = 0.001). Postoperative analgesic requirements were significantly smaller in group LM (p = 0.001).
The addition of 50 μg/kg midazolam to lidocaine for IVRA shortens the onset of sensory and motor block, and improves quality of anesthesia and perioperative analgesia without causing side effects.
Anaesthetic Techniques; IV Regional Lidocaine; Postoperative; Analgesics; Midazolam; Tourniquet Pain
This study examined the effect of sedation with xylazine on the brainstem auditory evoked potentials (BAEP) of cattle to determine whether sedation causes differences in waveform configuration, peak latencies, interpeak latencies, measurement time of the average count (2000 responses), and clinical signs. There were no significant differences between the sedation and no-sedation groups in peak latency of any stimulus intensities. In the sedation group, the baselines of waveforms were comparatively stabilized. Those in the no-sedation group were unstable, however, because the measurement can be influenced by excessive muscle movement. The present findings suggest that clinically, it is useful to use a sedative when measuring BAEP in cattle to control excessive movement of the cattle without influencing the peak latencies.
Regional anaesthesia has become an important anaesthetic technique. Effective sedation is an essential for regional techniques too. This study compares midazolam and propofol in terms of onset & recovery from sedation, dosage and side effects of both the drugs using Bispectral Index monitoring. Ninety eight patients were randomly divided into two groups,one group recieved midazolam infusion while the other recieved propofol infusion until BIS reached 75. We observed Time to reach desired sedation, HR, MABP, time for recovery, dose to reach sedation and for maintenance of sedation and side effects if any. The time to reach required sedation was 11 min in Midazolam group(Group I) while it was 6 min in Propofol group(Group II) (p=0.0). Fall in MABP was greater with propofol. Recovery in with midazolam was slower than with propofol (18.6 ± 6.5 vs 10.10±3.65 min) (p=0.00). We concluded that both midazolam and propofol are effective sedatives, but onset and offset was quicker with propofol, while midazolam was more cardiostable.
Propofol; Midazolam; Sedation; BIS
Complications of regional anaesthesia has been recognised from very long time. Fortunately serious complication are rare. Safe, effective practice of neuraxial anaesthesia requires a detailed knowledge of potential complications, their incidence and risk factors associated with their occurrence. The incidence of complication were higher for spinal than for epidural anaesthesia. These complications being rare, so existing studies are mainly retrospective, providing information about incidence and their associations but not necessarily demonstrate causality.
There are many areas of controversies regarding the usage of regional anaesthesia i.e. in outpatient surgical procedures, epidural test dose, its safety in infected / febrile / immuno compromised patients, / in patients with neurological disorder and in patients receiving anti-coagulants. Recommendations proposed may be acceptable based on the judgment of the responsible anaesthesiologist. The consensus statements are designed to encourage safe and quality patient care but cannot guarantee a specific outcome.
Regional anaesthesia; Complications; Controversies
To compare the efficacy and safety of local anaesthetics under cervical epidural anaesthesia (CEA) using lignocaine (1%), bupivacaine (0.25%) and ropivacaine (0.5%) for thyroid surgery.
In a prospective, randomized fashion, 81 patients were selected for thyroid surgery under CEA. They were assigned to one of three groups: Group L, B and R to receive 10 mL of 1% lignocaine, 0.25% bupivacaine and 0.5% ropivacaine, respectively. We compared their efficacy in terms of pulmonary and haemodynamic parameters, blockade quality and complications.
Of the total, 74 patients completed the study successfully. Sensory block attained the median dermatomal range of C2-T4/T5 in all the groups. Motor block was more pronounced in the ropivacaine group. Cardiorespiratory parameters decreased significantly in all the groups; however, none of the patients had any major complications except for bradycardia in two patients. Among the measured variables, the decrease in heart rate and peak expiratory force was more in the lignocaine group while forced vital capacity and forced expiratory volume at 1 sec declined to a greater extent in the ropivacaine group. The lignocaine group required significantly more epidural top-ups compared with the other two groups.
We conclude that cervical epidural route can be safely used for surgery on thyroid gland in patients with normal cardiorespiratory reserve, using either of local anaesthetics chosen for our study. Under the selected dose and concentrations, the decrease in cardiorespiratory parameters was lesser with bupivacaine.
Bupivacaine; cervical epidural anaesthesia; lignocaine; ropivacaine; thyroid surgery
Doxorubicin (Dox) is an antineoplastic agent used in a wide variety of malignancies. Its use is limited because of a cumulative, dose-dependent irreversible cardiomyopathy. We report a case of Dox induced cardiomyopathy, posted for modified radical mastectomy. The patient had poor LV function along with moderate pulmonary hypertension. Regional anaesthesia was planned as the risk associated with general anaesthesia was more. A cervical epidural was placed and a block adequate for surgery could be achived. The haemodynamic parameters as measured by esophageal doppler showed a stable trend. The surgery could be managed well under cervical epidural and also provided a good postoperative pain relief.
Adriamycin; cervical epidural; dilated cardiomyopathy; pulmonary arterial hypertension
Background/aims: To assess patient preferences for different anaesthesia management strategies during cataract surgery.
Methods: Cross sectional clinic based study of patient preferences for anaesthesia management strategies. Patients rated their preferences using a linear rating scale from 0 to 100.
Results: Subjects tended to prefer block to topical anaesthesia and oral to intravenous sedation. On a scale from 0 to 100, subjects preferred oral to intravenous sedation and block to topical anaesthesia by about 8 points.
Conclusions: When given the choice of four different anaesthesia management strategies, 72% of the study subjects preferred block anaesthesia to topical anaesthesia. More patients chose to have oral sedation than intravenous sedation. These findings indicate that patients may prefer anaesthesia management approaches other than the ones they are currently being offered.
anaesthesia; cataract surgery
The bispectral index (BIS) monitor records electroencephalogram waveforms and provides an objective measure of the hypnotic effect of a sedative drug on brain activity. The aim of this pilot study was to use the BIS monitor to evaluate the depth of procedural sedation in pediatric dental patients and to assess if the BIS monitor readings correlate with a validated pediatric sedation scale, the University of Michigan Sedation Scale (UMSS), in determining the level of sedation in these patients. Thirty-five pediatric dental patients requiring sedation were studied prospectively. A baseline BIS reading was obtained and during the procedure an independent observer recorded the BIS every 5 minutes. The operator, who was blinded to the BIS results, determined the UMSS scale at the same 5-minute interval. The patients were monitored postoperatively for 1 hour. There was a significant but moderate correlation between BIS values and UMSS scores (Spearman's rank correlation r = −0.574, P < .0001). Percentage of agreement and kappa coefficient using all the observations were also calculated. The percentage of agreement was 37.8%, the kappa coefficient was 0.18 (P < .0001), and the weighted kappa coefficient 0.26 (P < .0001). A lack of correlation was noted between the deeper levels of UMSS sedation scores and BIS values. This study demonstrated a significant correlation between BIS values and the UMSS score in pediatric dental patients undergoing mild to moderate sedation. Based on our results, it appears that the BIS monitor may be useful during mild or moderate sedations to establish the level of sedation objectively without the need to stimulate the patient.
Bispectral index monitor; Pediatric sedation; University of Michigan Sedation Scale; Pediatric dentistry
Background: Regional anaesthesia is widely used and has been considered to pose few risks once the block is established. However, life threatening problems can occur both during the establishment and maintenance phases of a regional block which require prompt recognition and management.
Objectives: To examine the role of a previously described core algorithm "COVER ABCD–A SWIFT CHECK", supplemented by a specific sub-algorithm for regional anaesthesia, in the management of problems arising in association with regional anaesthesia.
Methods: The potential performance of this structured approach was assessed for each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS).
Results: There were 252 incidents involving regional anaesthesia, 6.3% of the first 4000 reports to AIMS. Of these, the majority (78%) involved the use of epidural or spinal anaesthesia. The core algorithm AB COVER CD properly applied, would have accounted for 45% of all problems, and is worth applying to eliminate unexpected problems unrelated to the regional anaesthesia technique itself. Hypotension and dysrhythmias made up over 30% of all incidents and accounted for all six deaths in the 252 incidents. The specific sub-algorithm for regional anaesthetic techniques accounted for 55% of all incidents: problems with delivery to the site of action, 49 cases (19%); problems with the block, 30 cases (12%); local anaesthetic toxicity, 30 cases (12%); trauma, infection, or pain, 14 cases (6%), wrong side or wrong patient, five cases (2%).
Conclusion: Based on an analysis of 252 incidents, the core algorithm and the regional anaesthesia sub-algorithm, properly applied, would lead to swift recognition and appropriate management of problems arising in association with regional anaesthesia.
AIM: To compare deep sedation with propofol-fentanyl and midazolam-fentanyl regimens during upper gastrointestinal endoscopy.
METHODS: After obtaining approval of the research ethics committee and informed consent, 200 patients were evaluated and referred for upper gastrointestinal endoscopy. Patients were randomized to receive propofol-fentanyl or midazolam-fentanyl (n = 100/group). We assessed the level of sedation using the observer’s assessment of alertness/sedation (OAA/S) score and bispectral index (BIS). We evaluated patient and physician satisfaction, as well as the recovery time and complication rates. The statistical analysis was performed using SPSS statistical software and included the Mann-Whitney test, χ2 test, measurement of analysis of variance, and the κ statistic.
RESULTS: The times to induction of sedation, recovery, and discharge were shorter in the propofol-fentanyl group than the midazolam-fentanyl group. According to the OAA/S score, deep sedation events occurred in 25% of the propofol-fentanyl group and 11% of the midazolam-fentanyl group (P = 0.014). Additionally, deep sedation events occurred in 19% of the propofol-fentanyl group and 7% of the midazolam-fentanyl group according to the BIS scale (P = 0.039). There was good concordance between the OAA/S score and BIS for both groups (κ = 0.71 and κ = 0.63, respectively). Oxygen supplementation was required in 42% of the propofol-fentanyl group and 26% of the midazolam-fentanyl group (P = 0.025). The mean time to recovery was 28.82 and 44.13 min in the propofol-fentanyl and midazolam-fentanyl groups, respectively (P < 0.001). There were no severe complications in either group. Although patients were equally satisfied with both drug combinations, physicians were more satisfied with the propofol-fentanyl combination.
CONCLUSION: Deep sedation occurred with propofol-fentanyl and midazolam-fentanyl, but was more frequent in the former. Recovery was faster in the propofol-fentanyl group.
Endoscopy; Deep sedation; Anesthetic administration; Anesthetic dose; Adverse effects
Background: Until recently, midazolam sedation was routinely used in our institution for bone marrow aspirates and lumbar punctures in children with cancer. It has been perceived by many doctors and nurses as being well tolerated by children and their families.
Aim: To compare the efficacy of inhalational general anaesthesia and midazolam sedation for these procedures.
Methods: A total of 96 children with neoplastic disorders, who received either inhalational general anaesthesia with sevoflurane, nitrous oxide, and oxygen (GA) or sedation with oral or nasal midazolam (SED) as part of their routine preparation for procedures were studied. The experiences of these childen were examined during their current procedure and during their first ever procedure. Main outcome measures were the degree of physical restraint used on the child, and the levels of distress and pain experienced by the child during the current procedure and during the first procedure. The family‘s preference for future procedures was also determined.
Results: During 102 procedures under GA, restraint was needed on four occasions (4%) when the anaesthetic mask was first applied, minimal pain was reported, and children were reported as distressed about 25% of the time. During 80 SED procedures, restraint was required in 94%, firm restraint was required in 66%, the child could not be restrained in 14%, median pain score was 6 (scale 0 (no pain) to 6 (maximum pain)), and 90% of the parents reported distress in their child. Ninety per cent of families wanted GA for future procedures. Many families reported dissatisfaction with the sedation regime and raised concerns about the restraint used on their child.
Conclusions: This general anaesthetic regime minimised the need for restraint and was associated with low levels of pain and distress. The sedation regime, by contrast, was much less effective. There was a significant disparity between the perceptions of health professionals and those of families with respect to how children coped with painful procedures.
We report three cases where BiPAP (bi-level positive airway pressure) was used with CSEA (combined spinal epidural anaesthesia) to over come the hypoventilation due to preoperative poor respiratory reserves and additive effect of sedation. Combination of BiPAP with spinal, epidural and CSEA have been used successfully in patients of severe COPD (chronic obstructive pulmonary disease) for various surgical procedures. This combination provides safe alternative to conventional general anaesthesia, as it avoids need for postoperative ventilatory support and its deleterious effects.
BiPAP; COPD; CSEA; Hypoventilation; Laparoscopic cholecystectomy; Propofol sedation
The bispectral (BIS) index has been used to interpret partial EEG recordings to predict the level of sedation and loss of consciousness in patients undergoing general anesthesia. The author has evaluated BIS technology in determining the level of sedation in patients undergoing outpatient deep sedation. These experiences are outlined in this review article. Initially, the correlation of the BIS index with traditional subjective patient evaluation using the Observer's Assessment of Alertness and Sedation (OAA/S) scale was performed in 25 subjects. In a second study, the recovery profile of 39 patients where the BIS was used to monitor sedation was compared with a control group where the monitor was not used. A strong positive relationship between the BIS and OAA/S readings was found in the initial subjects. From the recovery study, it appears that use of the BIS monitor may help titrate the level of sedation so that less drugs are used to maintain the desired level of sedation. A trend to earlier return of motor function in BIS-monitored patients was also demonstrated. BIS technology offers an objective, ordinal means of assessing the depth of sedation. This can be invaluable in comparing studies of techniques. The BIS index provides additional information to standard monitoring techniques that helps guide the administration of sedative-hypnotic agents. The trend to earlier return of motor function in BIS-monitored patients warrants further investigation.
Objective assessment of sedation depth is a valuable target. Spectral entropy is an anesthetic depth monitor based on the analysis of the electroencephalogram signal.
To evaluate the performance of spectral entropy as an objective measure of sedation state in midazolam-premedicated patients and to correlate it with a clinically assessed sedation score.
Settings and Design:
This prospective double-blind placebo-controlled study was performed in King Fahd Hospital of the university.
Eighty adult ASA I–II patients were randomly assigned into 4 groups. Patients were premedicated using 0.02, 0.04, or 0.06 mg/kg midazolam or saline intramuscularly. The effect of these doses on the Observer's Assessment of Alertness and Sedation (OAA/S) scale, hemodynamic variables, response entropy (RE), and state entropy (SE), was evaluated at 10, 20, and 30 min after premedication.
Spearman Rank-order correlation analysis to examine the relation between OAA/S and entropy. The ability of spectral entropy to predict the depth of sedation was evaluated using Smith prediction probability.
Midazolam doses ≥0.04 mg/kg produced significant decreases in RE, SE, and OAA/S scores. There was a strong correlation between midazolam dose and OAA/S scale, RE, and SE since Spearman Rank R values were 0.792, 0.822, and 0.745, respectively (P<0.001). In addition, RE and SE were strong predictors of OAA/S level during midazolam sedation with no significant difference in prediction between the 2 entropy components.
Spectral entropy is a reliable measure for the sedative premedication. It may be used to objectively assess the adequacy of midazolam premedication and to determine the dose requirement.
Monitoring; depth of anaesthesia; observer's assessment of alertness and sedation; premedication; midazolam; sedation
Clonidine is a preferential alpha-2 agonist drug that has been used for over 35 years to treat hypertension. Recently, it has also been used as a preoperative medication and as a sedative/anxiolytic drug. This randomized, double-blind, placebo-controlled crossover clinical trial characterized the effects of oral clonidine pretreatment on intravenous catheter placement in 13 patients. Parameters measured included the bispectral index (BIS), Observer's Assessment of Alertness/Sedation Scale (OAA/S), frontal temporal electromyogram (EMG), 30-Second Blink Count (Blink), Digit Symbol Substitution Test (DSST), State Anxiety Inventory (SAI), fingertip versus forearm skin temperatures, and multiple questionnaires. Oral clonidine significantly decreased SAI scores, OAA/S, EMG, and Blink, but did not cause statistically significant BIS or DSST reductions. Subjects preferred oral clonidine pretreatment prior to venipuncture compared to placebo. Questionnaires also indicated that clonidine provided minimal sedation, considerable anxiolysis, and some analgesia. Fingertip versus forearm skin temperature differentials were decreased. Reduced fingertip versus forearm temperature differentials suggest increased peripheral cutaneous blood flow prior to venous cannulation. Oral clonidine pretreatment not only helped control patient anxiety and pain but also provided cardiovascular stability.
Clonidine; Venous cannulation; BIS; SAI; DSST
This study was undertaken to compare the effects on intrauterine resuscitation by table tilt versus pelvic tilt position after spinal anaesthesia for Caesarian Section.
Patients & Methods:
Fifty ASA I and II patients who fulfilled the eligibility criteria were enrolled in the study and were divided into two groups: group W (Pelvic tilt with wedge under right hip and group L- (150left lateral table tilt) and received spinal anaesthesia. The following parameters were recorded. Heart rate (HR), mean arterial pressure (MAP) at baseline, 2mins, 5 min and then 5 min thereafter. Mean height of block, Total no. of segments blocked, Onset Time of sensory block (in Minutes), ephedrine doses, incidence of hypotension & bradycardia, APGAR score at 1& 5 Minutes.
The decrease in MAP was much more in wedged position as compared to table tilt position also the incidence of hypotension was 40% in wedged position as compared to 12% in table tilt position. Mean height of block, Total no. of segments blocked, and boluses of inj. ephedrine used were more in the wedged position than in table tilt position.
Wedge placement caused increased incidence of hypotension and higher blockade after spinal anaesthesia as compared to left lateral table tilt position, there was no adverse effects on foetus and patients tolerated wedge better than left lateral table tilt position. Also surgery was easier to perform after wedge placement.
Intrauterine Resuscitation (IUR); Table Tilt & Pelvic Tilt Position; Spinal Anaesthesia; Caesarian Section
An appropriate level of sedation and pharmacological assist are essential during percutaneous transluminal balloon angioplasty (PTA). Ketamine provides good analgesia while preserving airway patency, ventilation, and cardiovascular stability with an opioid sparing effect suggesting that it would be ideal in combination with remifentanil and midazolam in spontaneously breathing patients. We evaluated the effect of a small dose of ketamine added to midazolam and remifentanil on analgesia/sedation for PTA procedures.
Sixty-four patients receiving PTA were enrolled. The Control group received midazolam 1.0 mg i.v. and continuous infusion of remifentanil 0.05 µg/kg/min. The Ketamine group received, in addition, an intravenous bolus of 0.5 mg/kg ketamine. Patients' haemodynamic data were monitored before remifentanil infusion, 5 min after remifentanil infusion, at 1, 3, 5, 30 min after incision, and at admission to the recovery room. Verbal numerical rating scales (VNRS) and sedation [OAA/S (Observer's Assessment of Alertness/Sedation)] scores were also recorded.
The VNRS values at 1, 3, and 5 min after incision and OAA/S scores at 5 min after remifentanil infusion, and 1, 3, and 5 min after incision were lower in the Ketamine group than in the Control group. In the Control group, the VNRS value at 1 min after incision significantly increased and OAA/S values at 3, 5, and 30 min after incision significantly decreased compared to baseline values, while there were no significant changes in the ketamine group.
A small dose of ketamine as an adjunct sedative to the combination of midazolam and remifentanil produced a better quality of sedation and analgesia than without ketamine and provided stable respiration without cardiopulmonary deterioration.
Ketamine; Pain scale; Remifentanil; Sedation
Percutaneous radiofrequency ablation (PRFA) of liver tumours performed under local anaesthesia and intravenous sedation can cause severe pain to patients. This prospective study evaluated the efficacy of a right thoracic paravertebral block (TPVB) for anaesthesia and analgesia during PRFA of liver tumours.
20 patients, aged 44–74 years, with liver malignancies received a multiple injection TPVB at the T6–10 levels 30 min before the PRFA. An intravenous infusion of propofol (3–5 mg kg–1 h–1) was administered to patients who requested to be sedated and intravenous fentanyl (25 µg bolus) was administered as rescue analgesia. Pain during the TPVB and PRFA was assessed using a numerical rating scale (NRS; 0, no pain; 10, worst imaginable pain). Patients were also assessed for residual pain and analgesic consumption during the 24 h after the intervention.
The TPVB was well tolerated and produced ipsilateral sensory anaesthesia with satisfactory spread (median (range); 8 (6–11) dermatomes). The PRFA procedure caused mild pain (mean (standard deviation, SD); NRS 1.4 (1.9)) during the insertion of the ablation needle and the peak pain intensity during the therapeutic burn was moderate (mean (SD); NRS 5.0 (3.3)) in severity. During the 24 h after the PRFA, patients reported minimal pain and consumed very few analgesics. The mean (SD) satisfaction score (0, totally dissatisfied; 10, very satisfied) of the patients was 8.9 (1.1) and that of the radiologists was 8.8 (1.4).
A right TPVB is safe and effective for anaesthesia and analgesia during PRFA of malignant liver tumours.
This study compared the odds ratio (OR) of surgical site infection (SSI) within 30 days after operation with general anaesthesia (GA) or neuraxial anaesthesia (NA) in Taiwanese women undergoing Caesarean delivery (CD).
An epidemiologic design was used. The study population was based on the records of all deliveries in hospitals or obstetric clinics between January 2002 and December 2006 in Taiwan. Anonymized claim data from the Taiwan National Health Insurance Research Database (NHIRD) were analysed. Women who received CD were identified from the NHIRD by Diagnosis-Related Group codes. The mode of anaesthesia was defined by order codes. Multivariate logistic regression was used to estimate the OR and associated 95% confidence interval (CI) of post-CD SSIs for GA when compared with NA. The outcome was whether a woman had been diagnosed as having an SSI during the hospitalization or was re-hospitalized within 30 days after CD for the treatment of SSIs using five or 81 International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes.
Among the 303 834 Taiwanese women who underwent CD during the 5 yr observation period, the 30 day post-CD SSI rate was 0.3% or 0.9% based on five or 81 ICD-9-CM codes. The multivariate-adjusted OR of having post-CD SSIs in the GA group was 3.73 (95% CI, 3.07–4.53) compared with the NA group (P<0.001) using five ICD-9-CM codes for the definition of SSI.
GA for CD was associated with a higher risk of SSI when compared with neuraxial anaesthesia.
anaesthesia; Caesarean section; general anaesthesia; neuraxial anaesthesia; surgical site infection
Epidural bleeding as a complication of catheterization or epidural catheter removal is often associated with perioperative thromboprophylaxis especially in adult reconstructive surgery.
We report on a case of a 19 years old male athlete that underwent anterior cruciate ligament reconstruction, receiving low molecular weight heparin for thromboprophylaxis and developed an epidural hematoma and subsequent cauda equina syndrome two days after removal of the epidural catheter. An urgent magnetic resonance imaging scan revealed an epidural hematoma from the level of L3 to L4. Emergent decompression and hematoma evacuation resulted in patient's significant neurological improvement immediately postoperatively.
A high index of clinical suspicion and surgical intervention are necessary to prevent such potentially disabling complications especially after procedures on a day-case basis and early patient's discharge.
A 47-yrs-female patient presented with carcinoma right breast, swelling and allodynia of right upper limb. radical mastectomy with axillary clearance and skin grafting was done under cervical epidural anaesthesia through 18G epidural catheter placed at C6/C7 level. Postoperative analgesia and rehabilitation of affected right upper limb was managed by continuous epidural infusion of 0.125% bupivacaine and 2.5 µg/ml−1clonidine solution through epidural catheter for 5 days and physiotherapy. This case report highlights the usefulness of cervical epidural analgesia in managing a complex situation of carcinoma breast with associated periarthitis of shoulder joint and chronic regional pain syndrome (CRPS) of right upper limb.
Cervical epidural anaesthesia (CEA); CRPS (chronic regional pain syndrome); Carcinoma breast; epidural Clonidine