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1.  Endocrine anesthesia: A rapidly evolving anesthesia specialty 
PMCID: PMC3950431  PMID: 24665230
2.  When place and time matter: How to conduct safe inter-hospital transfer of patients 
Saudi Journal of Anaesthesia  2014;8(1):104-113.
Inter-hospital transfer (IHT) of patients is often needed for diagnostic or therapeutic interventions. However, the transfer process carries its own risks as a poorly and hastily conducted transfer could lead to adverse events. In this article, we have reviewed literature on the key elements of IHT process including pre-transfer patient stabilization. We have also discussed various modes of transfer, physiological effects of transfer, possible adverse events and how to avoid or mitigate these. Even critically ill-patients can be transported safely by experienced and trained personnel using appropriate equipment. The patient must be maximally stabilized prior to transfer though complete optimization may be possible only at the receiving hospital. Ground or air transport may be employed depending on the urgency, feasibility and availability. Meticulous pre-transfer check and adherence to standard protocols during the transfer will help keep the entire process smooth and event free. The transport team should be trained to anticipate and manage any possible adverse events, medical or technical, during the transfer. Coordination between the referring and receiving hospitals would facilitate prompt transfer to the definitive destination avoiding delay at the emergency or casualty. Documentation of the transfer process and transfer of medical record and investigation reports are important for maintaining continuity of medical care and for medico-legal purposes.
PMCID: PMC3950432  PMID: 24665250
Ambulance; inter-facility; inter-hospital; transfer; transport
3.  Use of oral tramadol to prevent perianesthetic shivering in patients undergoing transurethral resection of prostate under subarachnoid blockade 
Saudi Journal of Anaesthesia  2014;8(1):11-16.
Under regional anesthesia, geriatric patients are prone to shivering induced perioperative complications that Anesthesiologists should prevent rather than treat.
We investigated the prophylactic efficacy of oral tramadol 50 mg to prevent the perioperative shivering after transurethral resection of prostate (TURP) surgery under subarachnoid blockade (SAB). Shivering is usually overlooked in patients undergoing urological surgery under spinal anesthesia and may result in morbidity, prolonged hospital stay and increased financial burden. Use of prophylactic measures to reduce shivering in geriatric patients who undergo urological procedures could circumvent this. Oral formulation of tramadol is a universally available cost-effective drug with the minimal side-effects.
Settings and Design:
Prospective, randomized, double-blinded, placebo-controlled study.
Patients and Methods:
A total of 80 patients who were scheduled for TURP surgery under subarachnoid block were randomly selected. Group I and II (n = 40 each) received oral tramadol 50 mg and placebo tablet respectively. After achieving subarachnoid block, the shivering, body temperature (tympanic membrane, axillary and forehead), hemodynamic parameters and arterial saturation were recorded at regular intervals.
Statistical Analysis Used:
T-test, analysis of variance test, Z-test and Fisher exact test were utilized while Statistical Product and Service Solutions, IBM, Chicago (SPSS statistics (version 16.0)), software was used for analysis.
Incidence of shivering was significantly less in patients who received tramadol (7.5% vs. 40%; P < 0.01). The use of tramadol was associated with clinically inconsequential side-effects.
We conclude that the use of oral tramadol 50 mg is effective as a prophylactic agent to reduce the incidence, severity and duration of perioperative shivering in patients undergoing TURP surgery under SAB.
PMCID: PMC3950433  PMID: 24665233
Shivering; subarachnoid blockade; tramadol; transurethral resection of prostate; urology
4.  Pre-hospital and initial management of head injury patients: An update 
Saudi Journal of Anaesthesia  2014;8(1):114-120.
Most of the bad outcomes in patients with severe traumatic brain injury (TBI) are related to the presence of a high incidence of pre-hospital secondary brain insults. Therefore, knowledge of these variables and timely management of the disease at the pre-hospital period can significantly improve the outcome and decrease the mortality. The Brain Trauma Foundation guideline on “Prehospital Management” published in 2008 could provide the standardized protocols for the management of patients with TBI; however, this guideline has included the relevant papers up to 2006.
A PubMed search for relevant clinical trials and reviews (from 1 January 2007 to 31 March 2013), which specifically discussed about the topic, was conducted.
Based on the evidence, majority of the management strategies comprise of rapid correction of hypoxemia and hypotension, the two most important predictors for mortality. However, there is still a need to define the goals for the management of hypotension and inclusion of newer difficult airway carts as well as proper monitoring devices for ensuring better intubation and ventilatory management. Isotonic saline should be used as the first choice for fluid resuscitation. The pre-hospital hypothermia has more adverse effects; therefore, this should be avoided.
Most of the management trials published after 2007 have focused mainly on the treatment as well as the prevention strategies for secondary brain injury. The results of these trials would be certainly adopted by new standardized guidelines and therefore may have a substantial impact on the pre-hospital management in patients with TBI.
PMCID: PMC3950434  PMID: 24665251
Evidence; pre-hospital management; secondary brain injury; traumatic brain injury
5.  Delayed Horner's syndrome following ultrasound- guided interscalene brachial plexus block 
Saudi Journal of Anaesthesia  2014;8(1):121-123.
We describe a case of Horner's syndrome that occurred shortly after post-operative bolus administration of interscalene brachial plexus analgesia.
PMCID: PMC3950435  PMID: 24665252
Bupivacaine; interscalene block; ultrasound regional block
6.  Anesthesia for tracheostomy for huge maxillofacial tumor 
Saudi Journal of Anaesthesia  2014;8(1):124-127.
Providing sedation for patients with compromised upper airway is challenging. A 19-year-old female patient with huge maxillofacial tumor invading the whole pharynx scheduled for elective tracheostomy under local anesthesia due to compromised airway. The patient had gastrostomy tube for feeding. Venous cannulation was totally refused by the patient after repeated trials for exhausted sclerosed veins. Pre-operative mixture of dexmedetomidine with ketamine was administered through the gastrostomy tube with eutectic mixture of local anesthetics cream application over the planned tracheostomy site. The patient was sedated with eye opening to command. Local infiltration followed by tracheostomy was performed without patient complaints or recall of operative events.
PMCID: PMC3950436  PMID: 24665253
Airway; oral dexmedetomidine; oral ketamine; sedation
7.  Airway management in a patient with Le Fort III Fracture 
Saudi Journal of Anaesthesia  2014;8(1):128-130.
Maxillofacial fractures present unique airway problem to the anesthesiologist. Patients with LeFort III fractures are at great risk of requiring emergent airway control due to midface instability and oropharyngeal airway obstruction. We present a case where difficult intubation was managed with close cooperation between the anesthesiologist and the surgeon.
PMCID: PMC3950437  PMID: 24665254
Difficult intubation; Le Fort III fracture; maxillofacial trauma
8.  Spontaneous migration of central venous catheter tip following extubation 
Saudi Journal of Anaesthesia  2014;8(1):131-133.
Migration of the tip of central venous catheters is not an uncommon event and the mechanism for this is not clear. Increased intrathoracic pressure due to coughing, sneezing or weight lifting, changing the body position or physical movements such as abduction or adduction of the arms is thought to be the cause of such migration. We present here a case of a patient with a port catheter tip that migrated from the left subclavian to the superior vene cava following extubation.
PMCID: PMC3950438  PMID: 24665255
Central venous catheterization; extubation; migration
PMCID: PMC3950439  PMID: 24665256
10.  Anesthetic management of a 2-day-old with complete congenital heart block 
Saudi Journal of Anaesthesia  2014;8(1):134-137.
Maternal connective tissue disorders such as Systemic Lupus Erythematosus (most common), Sjogren's syndrome, mixed connective tissue disorders may lead to the rare condition of complete congenital heart block in the neonate. Rare fetal syndromes such as myocarditis, 18p syndrome, mucopolysaccharidoses and mitochondrial diseases are other causes. The mortality rate of this condition is inversely propotional to the age of presentation being 6 % in the neonatal age group. As the cardiac output in the neonate is heart rate dependent, it is crucial to maintain the heart rate in these patients. Pharamacological interventions with dopamine, isoprenaline, epinephrine and atropine are known for their variable response. Although permanent pacing is the most reliable mode of management, the access to it is often not readily available, especially in the developing countries. In such cases temporary pacing methods become lifesaving. Of all the modalities of temporary pacing (transcutaneous, transesophageal and transvenous) transcutaneous pacing is the most readily available and immediate mode. In this case report we present a two day old neonate with isolated complete congenital heart block and a resting heart rate of 50-55/min in immediate need of palliative surgery for trachea-esophageal fistula (TEF). With pharmacological intervention the heart rate could only be raised to 75-80/min. The surgery was successfully carried out using transcutaneous pacing to maintain a heart rate of 100/min.
PMCID: PMC3950440  PMID: 24665257
Anesthetic implications; complete congenital heart block; transcutaneous pacing
15.  Hyperhomocysteinemia: Anesthetic concerns 
Saudi Journal of Anaesthesia  2014;8(1):143-144.
PMCID: PMC3950445  PMID: 24665262
16.  Comparison of nasal Midazolam with Ketamine versus nasal Midazolam as a premedication in children 
Saudi Journal of Anaesthesia  2014;8(1):17-21.
This study was done to compare effects of intranasal midazolam and intranasal midazolam with ketamine for premedication of children aged 1-12 yrs undergoing intermediate and major surgeries.
Midazolam and Ketamine have already been used as premedicants in children. Our aim was to find out advantage of combination of midazolam with ketamine over midazolam by nasal route.
Sixty children of age group 1-12 yrs of American Society of Anesthesiologists (ASA) grade 1 and 2 were selected. Group A- midazolam (0.2 mg/kg), Group B- midazolam (0.15 mg/kg + ketamine 1 mg/kg). Both groups received drug intranasally 30 min before surgery in recovery room with monitored anesthesia care. Onset of sedation, sedation score, emotional reaction, intravenous cannula acceptance, and mask acceptance were studied.
Statistical Analysis:
Unpaired t test and chi square test.
Sedation score, anxiolysis, attitude, reaction to intravenous cannulation, face mask acceptance, and emotional reaction were significantly better in midazolam with ketamine group. Intra operatively, in both groups, pulse rate, oxygen saturation, and respiratory rate had no significant difference; also, post operatively, no significant difference was observed in above parameters, post operative analgesia was significantly better in midazolam with ketamine group.
Intra nasal premedication allows rapid and predictable sedation in children. Midazolam as well as combination of Midazolam with ketamine gives good level of sedation and comfort. But quality of sedation, analgesia, and comfort is significantly better in midazolam with ketamine group. No significant side effects were observed in both groups.
PMCID: PMC3950446  PMID: 24665234
Intranasal; Ketamine; midazolam; pediatric anesthesia
17.  Albumin and fibrinogen levels’ relation with orthopedics traumatic patients’ outcome after massive transfusion 
Saudi Journal of Anaesthesia  2014;8(1):22-24.
Severe bleeding is common during limb trauma. It can lead to hemorrhagic shock required to massive blood transfusion. Coagulopathy is the major complication of massive transfusion-induced increased mortality rate. Aim of this study was evaluation of fibrinogen and albumin levels association with orthopedics traumatic patients’ outcome who received massive transfusion.
In a cross sectional study, 23 patients with severe limb injury admitted to orthopedic emergency department were studied. All the patients received massive transfusion, that is, >10 unit blood. Albumin and fibrinogen levels are measured at admission and 24 h later, and compared according to final outcome.
Twenty-three traumatic patients with severe limb injuries were studied, out of which ten (43.2%) died and 13 (56.8%) were alive. There was significant difference between patients outcome in fibrinogen level after 24 h, but no difference was observed in albumin levels. Based on regression model, fibrinogen after 24 h had a significant role in determining the final outcome in traumatic patients who received massive transfusion (odds ratio 0.48, 95% confidence interval 0.15–0.92, P = 0.02).
According to our results, fibrinogen level is the most important factor in determination of orthopedics traumatic patients when received massive transfusion. However, serum albumin does not play any role in patients’ outcome.
PMCID: PMC3950447  PMID: 24665235
Albumin; coagulopathy; fibrinogen; massive blood transfusion
18.  PONV in Ambulatory surgery: A comparison between Ramosetron and Ondansetron: a prospective, double-blinded, and randomized controlled study 
Saudi Journal of Anaesthesia  2014;8(1):25-29.
postoperative nausea and vomiting (PONV) frequently hampers implementation of ambulatory surgery in spite of so many antiemetic drugs and regimens.
the study was carried out to compare the efficacy of Ramosetron and Ondansetron in preventing PONV after ambulatory surgery.
Setting and Design:
it was a prospective, double blinded, and randomized controlled study.
124 adult patients of either sex, aged 25-55, of ASA physical status I and II, scheduled for day care surgery, were randomly allocated into Group A [(n=62) receiving (IV) Ondansetron (4 mg)] and Group B [(n=62) receiving IV Ramosetron (0.3 mg)] prior to the induction of general anesthesia in a double-blind manner. Episodes of PONV were noted at 0.5, 1, 2, 4 h, 6, 12, and 18 h postoperatively.
Statistical Analysis and Results:
statistically significant difference between Groups A and B (P <0.05) was found showing that Ramosetron was superior to Ondansetron as antiemetic both regarding frequency and severity.
it was evident that preoperative prophylactic administration of single dose IV Ramosetron (0.3 mg) has better efficacy than single dose IV Ondansetron (4 mg) in reducing the episodes of PONV over 18 h postoperatively in patients undergoing day-care surgery under general anesthesia.
PMCID: PMC3950448  PMID: 24665236
Ambulatory (day care) surgery; American Society of Anaesthesiologists; Ondansetron; postoperative nausea and vomiting; Ramosetron; visual analogue score
19.  A comparison between over-the-head and lateral cardiopulmonary resuscitation with a single rescuer by bag-valve mask 
Saudi Journal of Anaesthesia  2014;8(1):30-37.
mask fixation in the lateral position is difficult during CPR.
the aim of this study is to compare the lateral CPR for the use of bag-valve mask by single paramedic rescuer as well as over-the-head CPR on the chest compression and ventilation on the manikin.
Settings and Design:
Mazandaran University of Medical Sciences. The design of this study was a randomized cross-over trial.
participants learned a standardized theoretical introduction CPR according to the 2010 guidelines. The total number of chest compressions per two minutes was measured. Total number of correct and wrong ventilation per two minutes was evaluated.
Statistical Analysis:
we used Wilcoxon signed-rank test to analyze the non-normally distributed data in dependence groups A. P-value of more than 0.05 was considered to show statistical significance.
there were 100 participants (45 women and 55 men) who participated in the study from September to March, 2011. The compression and ventilation rate in lateral CPR was lower than OTH CPR. Around 51% of participants had correct chest compression rate more than 90 beats per minute in lateral CPR and 65% of them had equal or more than ten correct ventilations per minute.
in conclusion, this study confirmed that in a simulated CPR model over-the-head position CPR led to a better BLS than the lateral position CPR by a single paramedic student with a BVM device. We also concluded that by this new BVM fixation method on the face of the patients in the lateral position CPR can be a good alternative over-the-head mask fixation by a single trained rescuer.
PMCID: PMC3950449  PMID: 24665237
Bag-valve mask ventilation; lateral CPR; over-the-head CPR; standard CPR; single rescuer
20.  Lornoxicam versus tramadol for post-operative pain relief in patients undergoing ENT procedures 
Saudi Journal of Anaesthesia  2014;8(1):38-44.
Pain following ear-nose and throat surgery is one of the most important complaints for which, several drugs are used. This prospective, randomized, double-blind controlled trial was designed to compare the analgesic effect of tramadol versus lornoxicam for post-operative pain relief in patients undergoing ENT surgical procedures.
One hundred and twenty patients of ASA class I-II, who had undergone elective ENT surgical procedures under general anesthesia, were assigned in a randomized manner into three equal groups. Group L received lornoxicam8 mg IV, Group T received tramadol 1 mg/kg IV and Group C received IV saline after induction of anesthesia before the start of the surgery. Post-operative pain was assessed using the visual analogue scale (VAS) and sedation level was evaluated during stay in the post-anesthesia care unit with a four-point sedation scale. Intraoperative blood loss was estimated using the Five-Point Scale. Adverse events in the first 24 h post-operative were recorded.
The VAS pain scores were significantly higher in Group C as compared with those in Groups L and T at 30 min and 1, 2, 4and 6 h post-operatively, with no significant difference between Group L and Group T. The amount of morphine consumption post-operatively was significantly lower in Group L (5.2 ± 2.5 mg) and Group T (5.0 ± 2.0 mg) as compared with that in Group C (7.4 ± 2.3 mg) (P = 0.001). The time for the first analgesic requirement was significantly less in Group L (92.62 ± 24.23 min) and Group T (88 ± 21.43 min) as compared with that in Group C (42.82 ± 25.61 min), with no significant difference between the other two groups. Estimated intraoperative blood loss score by the surgeons showed no significant difference between the three groups. The most frequent side-effects in the three groups were nausea and vomiting, and their incidence was significantly higher in the placebo group as compared with the other two groups.
Tramadol 1 mg/kg was comparable to lornoxicam 8 mg for post-operative pain relief in patients undergoing ENT surgical procedures; both drugs helped to reduce the post-operative opioid requirement and consequently minimized the related adverse effects of the opioids.
PMCID: PMC3950450  PMID: 24665238
ENT procedures; lornoxicam; post-operative pain relief; tramadol
22.  Ring block with levobupivacaine 0.25% and paracetamol vs. paracetamol alone in children submitted to three different surgical techniques of circumcision: A prospective randomized study 
Saudi Journal of Anaesthesia  2014;8(1):45-50.
circumcision in children is a painful procedure. We aim compare the intraoperative and postoperative efficacy of three different surgical procedures of the ring block using levobupivacaine 0.25% combined with rectal paracetamol as opposed to rectal paracetamol alone.
the study included 106 boys scheduled to undergo circumcision. The patients were randomly assigned within two groups to receive either ring block with levobupivacaine 0.25% and rectal paracetamol 30 mg/kg, or rectal paracetamol 30 mg/kg alone. The following surgical procedures were performed: sutureless proctoplasty, preputial plasty, and conventional circumcision. The efficacy of intraoperative analgesia was estimated on the basis of increases in heart rate and mean arterial pressure. Postoperatively, children were assessed for pain, pain-free (PF) period, and the total doses of analgesics administered during hospitalization, on the day after discharge, and on the first and second postoperative days.
all children remained stable during anesthesia. Postoperatively, the mean pain score did not show statistical differences between the groups. Children who received combined analgesia had a longer PF period (P < 0.001). However, the total doses of paracetamol administered during the observational period showed no differences. Children undergoing sutureless prepuceplasty received lower doses of paracetamol postoperatively (P < 0.001).
subcutaneous ring block either with levobupivacaine 0.25% plus rectal paracetamol or rectal paracetamol alone provides adequate intraoperative and postoperative analgesia in circumcised children. However, combined analgesia allows a longer PF period. The need for less analgesic administration in children undergoing sutureless prepuceplasty could mean that the circumcision techniques might be a mitigating factor in terms of pain.
PMCID: PMC3950452  PMID: 24665239
Circumcision; levobupivacaine; paracetamol
23.  A comparison of the analgesic efficacy of transforaminal methylprednisolone alone and with low doses of clonidine in lumbo-sacral radiculopathy 
Saudi Journal of Anaesthesia  2014;8(1):51-58.
Although transforaminal epidural steroid injections under fluoroscopic guidance have become a common mode of treatment of lumbosacral radiculopathy due to herniated disc, the efficacy of steroid with low doses of clonidine has not been compared yet.
Comparison of the analgesic efficacy of methylprednisolone alone and with low doses of clonidine for transforaminal injection in lumbosacral radiculopathy.
Study Design:
A randomized, double-blind trial.
This study was performed at the Pain Clinic under the Department of Anaesthesiology, Jawaharlal Nehru Medical College Hospital, Aligarh Muslim University, Aligarh, India.
One hundred and eighty ASA grade I and II patients aged between 18 and 55 years were allocated into groups I, II and III to receive methylprednisolone 60 mg alone or methylprednisolone 60 mg with or without low doses of clonidine (0.5 mcg/kg or 1 mcg/kg) as transforaminal epidural injection. Pain relief and patient's satisfaction were evaluated with the global pain scale. Follow-up visits were advised at 1, 2, 4, 6 and 12 weeks and then at 6 months after injection. Associated complications were recorded.
Maximum pain relief was observed at 2 weeks after injection in all the three groups, with no difference in complication rate among the three groups. The most common complication observed was paresthesia in the nerve distribution. Greater than 60% improvement in pain scores was seen in 40% of the patients in group I, 50% of the patients in group II and 75% of the patients in group III.
This study is limited by the lack of a placebo group.
Adding 1 mcg/kg clonidine to 60 mg methylprednisolone in transforaminal epidural injections provided better pain relief than 60 mg methylprednisolone with 0.5 mcg/kg clonidine or 60 mg methylprednisolone alone in patients suffering from lumbosacral radiculopathy, with practically no significant side-effects.
PMCID: PMC3950453  PMID: 24665240
Epidural; lumbosacral radiculopathy; sciatica; transforaminal
24.  A randomized clinical trial comparing the efficacy and safety of ramosetron versus ondansetron in patients undergoing abdominal surgery under general anesthesia 
Saudi Journal of Anaesthesia  2014;8(1):59-63.
Post-operative nausea and vomiting is one of the most common and distressing complications after anesthesia and surgery. It may lead to serious post-operative complications. Ramosetron is a newer 5-HT3 receptor antagonist and has more potent and longer duration of antiemetic effects compared to first generation 5HT3 receptor antagonists. The purpose of this study was to compare the efficacy of Ramosetron for the prevention of post-operative nausea and vomiting with that of Ondansetron in patients undergoing abdominal surgeries under general anesthesia.
In this randomized, double-blind study, 60 patients, 18-60 years of both genders falling under ASA I-II category scheduled for abdominal surgery were included. Group I received I.V ramosetron 0.3 mg while group II received I.V Ondansetron 4 mg at the time of extubation. The standard general anesthetic technique was used throughout. Postoperatively the incidences of nausea, vomiting, and safety assessments were performed at 1, 2, 6, and 24 h during the first 24 h after surgery.
There were no differences between groups with respect to patient demographics. The percentage of patients who had complete response (no PONV, and no need for another rescue antiemetic) from 0 to 24 h after anesthesia was 56% with ramosetron and 33% with ondansetron. The corresponding rates at 1, 2, 6, and 24 h after anesthesia were 76% and 63%, 76% and 50%, 100 and 83%, 100 and 93%, respectively. Safety profiles of the two drugs were comparable, as no clinically serious adverse effects caused by study drugs were observed in either of the groups.
Our study concludes that prophylactic therapy with ramosetron is highly efficacious than ondansetron in preventing PONV in patients undergoing abdominal surgery under general anesthesia.
PMCID: PMC3950454  PMID: 24665241
General anesthesia; ondansetron; postoperative nausea; post-operative vomiting; ramosetron
25.  Low-dose ketamine infusion for labor analgesia: A double-blind, randomized, placebo controlled clinical trial 
Most primary and secondary level hospitals in developing countries provide inadequate labor analgesia due to various medical, technical and economic reasons. This clinical trial was an effort to study the efficacy, safety and feasibility of intravenous (IV) ketamine to provide labor analgesia.
Materials and Methods:
A total of 70 parturients were consented and randomly assigned to receive either IV ketamine or 0.9% saline. A loading dose of ketamine (0.2 mg/kg) was followed-by an infusion (0.2 mg/kg/h) until the delivery of the neonate. Similar volume of saline was infused in the placebo-group. Intramuscular meperidine was the rescue analgesic in both groups. The pain score, hemodynamic parameters of mother and fetus and the anticipated side-effects of ketamine were observed for. The newborn was assessed by the Neonatologist.
The pain score showed a decreasing trend in the ketamine group and after the 1st h more than 60% of women in the ketamine group had pain relief, which was statistically significant. There was no significant clinical change in the maternal hemodynamics and fetal heart rate. However, 17 (48.5%) of them had transient light headedness in the ketamine group. All the neonates were breast fed and the umbilical cord blood pH was between 7.1 and 7.2. The overall satisfaction was significantly high in the intervention group (P = 0.028).
A low-dose ketamine infusion (loading dose of 0.2 mg/kg delivered over 30 min, followed-by an infusion at 0.2 mg/kg/h) could provide acceptable analgesia during labor and delivery.
PMCID: PMC3950455  PMID: 24665232
Ketamine infusion; labor analgesia; light headedness; low-dose ketamine; meperidine

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