Comparison Of Total Intravenous Anaesthesia, Spinal Anaesthesia And Local Block For Day Care Inguinal Herniorrhaphy

– Local anaesthesia has a rapid turnover time but it is the least preferred technique. TIVA and spinal anaesthesia are comparable in terms of clinical efficacy however, spinal anaesthesia is the most economical and preferred technique.

A Study of Perioperative Hyperglycemia in Patients With Diabetes Having Colon, Spine, and Joint Surgery

Patients with diabetes often have impaired wound healing and an increased rate of postoperative complications with surgery. Most research has focused on the effect of hyperglycemia in the postoperative period, but there is limited evidence to guide blood glucose (bG) control throughout the perioperative period. This retrospective study explored the effect of hyperglycemia in the PACU on postoperative complications, length of stay (LOS), and in-hospital mortality in patients with diabetes undergoing spine, colon, or joint surgery. Findings revealed that the total LOS for patients with a PACU bG >200 mg/dL was significantly longer than for patients with a maximum bG of 140 to 200 mg/dL. Further, the rate of total complications increased significantly as bG levels increased. More prospective, controlled studies on the management of perioperative hyperglycemia are recommended for consideration.

Single dose of preoperative analgesia with gabapentin (600 mg) is safe and effective in monitored anesthesia care for nasal surgery

– Monitored anesthesia care combined with preoperative analgesia with a low dose of (600 mg) oral gabapentin is an efficient option with tolerable side effects for patients undergoing ear, nose and throat ambulatory surgery.

Obstetric analgesia: a comparison of patient-controlled meperidine, remifentanil, and fentanyl in labour

Douma MR et al. – The efficacy of meperidine, fentanyl, and remifentanil patient–controlled analgesia (PCA) for labour analgesia varied from mild to moderate. Remifentanil PCA provided better analgesia than meperidine and fentanyl PCA, but only during the first hour of treatment. In all groups, pain scores returned to pre–treatment values within 3 h after the initiation of treatment.

Intensive insulin treatment

1Department of Intensive Care Medicine, Royal North Shore Hospital of Sydney, St Leonards, Australia; 2Faculty of Medicine, University of Sydney, Sydney, Australia; 3Department of Critical Care and Trauma, The George Institute for International Health,Sydney, Australia

Hyperglycaemia is common in acute illness and more severe hyperglycaemia is associated with worse outcomes in critically ill patients in general and after acute myocardial infarction, stroke, and trauma. Normalization of blood glucose by intensive insulin therapy has been shown to reduce morbidity and mortality in one study in surgical intensive care patients; a subsequent study in medical intensive care patients resulted in reduced morbidity but not a reduction in mortality. Multicentre studies and current meta-analyses in the critically ill have not demonstrated improved outcomes when normalization of blood glucose was targeted; furthermore all studies to date have detected an increased risk of hypoglycaemia in patients subjected to intensive insulin therapy. At present, universal treatment guidelines or recommendations to target strict normoglycaemia must be considered premature. Further data will be available after the completion of the NICE-SUGAR study which has recruited 6103 patients; the NICE SUGAR study will add significant power to future meta-analyses and may help define the role of intensive insulin therapy in critically ill patients.

Post-operative nausea and vomiting

Post-operative nausea and vomiting (PONV) is a common clinical problem with widespread effects on morbidity, patient satisfaction and cost. Although a myriad of risk factors have been postulated as having the potential to increase its incidence, a risk scoring system using four factors – female sex, non-smoking status, past history of PONV and use of post-operative opioids – identifies most at-risk individuals. Prevention and treatment is multi-factorial and aimed at risk-reduction, pharmacological and non-pharmacological techniques.

Titrated propofol induction vs. continuous infusion in children undergoing magnetic resonance imaging

Background: Propofol is the popular intravenous (i.v.) anaesthetic for paediatric sedation because of its rapid onset and recovery. We compared the efficacy and safety of a single dose and conventional infusion of propofol for sedation in children who underwent magnetic resonance imaging (MRI).

Methods: This was a double-blind, randomized-controlled study. One hundred and sixty children were assigned to group I (single dose) or II (infusion). Sedation was induced with i.v. propofol 2 mg/kg, and supplemental doses of propofol 0.5 mg/kg were administered until adequate sedation was achieved. After the induction of sedation, we treated patients with a continuous infusion of normal saline at a rate of 0.3 ml/kg/h in group I and the same volume of propofol in group II. In case of inadequate sedation, additional propofol 0.5 mg/kg was administered and the infusion rate was increased by 0.05 ml/kg/h. Induction time, sedation time, recovery time, additional sedation and adverse events were recorded.

Results: Recovery time was significantly shorter in group I compared with group II [0 (0–3) vs. 1 (0–3), respectively, P<0.001]. Group I (single dose) had significantly more patients with recovery time 0 compared with group II (infusion) (65/80 vs. 36/80, respectively, P<0.001). Induction and sedation times were not significantly different between groups. There was no significant difference in the frequency of additional sedation and adverse events between groups.

Conclusion: A single dose of propofol without a continuous infusion can provide appropriate sedation in children undergoing MRI for <30 min.

Surgery in the Patient with Renal Dysfunction

Preoperative evaluation of patients with renal dysfunction often requires the collaborative efforts of the primary care physician, nephrologist, surgeon, and anesthesiologist. Renal dysfunction is typically a spectrum of disease with multisystem effects. Optimization of preexisting medical issues is the key, as is a thorough understanding of the potential perioperative risks for further renal injury. Surgical or anesthetic techniques may require alteration for the patient with significant renal dysfunction. Identification of those at risk for renal injury may allow for preventative therapies in the perioperative period. This article focuses on defining the population at risk, a framework for preoperative evaluation, and developments in the area of perioperative renal protection.

Surgery in the Patient with Liver Disease

Liver dysfunction is a prominent entity in Western medicine that has historically affected patients suffering from chronic viral or alcoholic hepatitis. The incidence of these conditions has not changed dramatically in recent years but the overall number of patients with liver dysfunction has increased considerably with the emergence of the obesity epidemic. Nonalcoholic fatty liver disease (NAFLD) has become increasingly recognized as the most common cause of chronic liver disease in the United States. Although the rate of progression of NAFLD to overt cirrhosis is low, the high prevalence of this condition, combined with the moderate degree of liver dysfunction it engenders, has resulted in a significant increase in the number of patients with liver disease that can be encountered by a surgical practice. Any degree of clinically evident liver disease in a prospective surgical patient should raise concern for the entire surgical team. This particularly applies to intraabdominal surgery whereby the presence of hepatomegaly, portal hypertension, variceal bleeding, and ascites can turn even the most routine operation into a morbid and life-threatening procedure. Nonabdominal surgery avoids some of the technical challenges presented by liver disease but the anesthetic management of a cirrhotic patient still makes any operation potentially more dangerous. In this article, approaches to minimize the risk when surgery becomes necessary in the presence of liver disease are discussed.

Perioperative management of diabetes: Translating evidence into practice

Glycemic control before, during, and after surgery reduces the risk of infectious complications; in critically ill surgical patients, intensive glycemic control may reduce mortality as well. The preoperative assessment is important in determining risk status and determining optimal management to avoid clinically significant hyper- or hypoglycemia. While patients with type 1 diabetes should receive insulin replacement at all times, regardless of nutritional status, those with type 2 diabetes may need to stop oral medications prior to surgery and might require insulin therapy to maintain blood glucose control. The glycemic target in the perioperative period needs to be clearly communicated so that proper insulin replacement, consisting of basal (long-acting), prandial (rapid-acting), and supplemental (rapid-acting) insulin can be implemented for optimal glycemic control. The postoperative transition to subcutaneous insulin, if needed, can begin 12 to 24 hours before discontinuing intravenous insulin, by reinitiation of basal insulin replacement. Basal/bolus insulin regimens are safer and more effective in hospitalized patients than supplemental-scale regular insulin.

Effect of different anesthetic agents on oculocardiac reflex in pediatric strabismus surgery

Abstract

Purpose The oculocardiac reflex (OCR) occurs frequently during pediatric strabismus surgery. The aim of this study was to assess the effects of various anesthetic regimens on the incidence of OCR during the surgery.

Methods Two hundred and eighty children, 1 to 9 years old, undergoing elective strabismus surgery, were randomly assigned to eight groups; ketamine-sevoflurane (KS), ketamine-desflurane (KD), ketamine-propofol (KP), ketamine-remifentanil (KR), midazolam-sevoflurane (MS), midazolam-desflurane (MD), midazolam-propofol (MP), and midazolam-remifentanil (MR). No premedication was given. Anesthesia was induced using ketamine 1 mg·kg⁻¹ or midazolam 0.15 mg·kg⁻¹ with 66% N₂O in O₂. Laryngeal mask airways (LMAs) were placed with rocuronium 0.5 mg·kg⁻¹. Anesthesia was maintained with sevoflurane 2–3 vol. %, desflurane 5–6 vol. %, propofol 7–8 mg·kg⁻¹·h⁻¹, or remifentanil 0.75 µg·kg⁻¹ over 1 min, followed by a continuous infusion of remifentanil 0.5 µg·kg⁻¹·min⁻¹ with 66% N₂O in O₂. Heart rate (HR) was recorded during extraocular muscle (EOM) manipulation. OCR was defined as a reduction in HR of more than 20% induced by the traction of an EOM.

Results In patients given ketamine, OCR occurred more frequently in the KP (65.7%) and KR (62.9%) groups than in the KD (29.4%) and KS (37.1%) groups (P <>P <>

Conclusion Propofol or remifentanil anesthesia was associated with a higher incidence of OCR during pediatric strabismus surgery than sevoflurane and desflurane anesthesia, when either ketamine or midazolam was used as an induction agent.

A comparison of intra-articular magnesium and/or morphine with bupivacaine for postoperative analgesia after arthroscopic knee surgery

Purpose Both magnesium and morphine provide enhanced patient analgesia after arthroscopic knee surgery when administered separately via the intra-articular route. Magnesium sulfate amplifies the analgesic effect of morphine. This study was designed to compare the analgesic effects of intra-articular magnesium and morphine, with bupivacaine, when used separately and in combination.
Methods Eighty patients undergoing arthroscopic menisectomy were randomized blindly into four intra-articular groups: group B+Mor+Mg received 20 ml 0.25% bupivacaine, morphine 2 mg, and magnesium 150 mg; group B+Mor received 20 ml 0.25% bupivacaine and morphine 2 mg; group B+Mg received 20 ml 0.25% bupivacaine and magnesium 150 mg; and group B received 20 ml 0.25% bupivacaine. Pain scores at rest and during movement, analgesic duration, and total analgesic consumption were recorded.
Results Group B+Mor and group B+Mg patients had equally effective postoperative analgesia. Group B+Mor+Mg patients had significantly reduced visual analogue scale (VAS) values both at rest and during movement and significantly increased time to first postoperative analgesic request, as well as significantly reduced total analgesic consumption, compared with the other groups.
Conclusion Intra-articular administration of magnesium sulfate or morphine, with bupivacaine, had comparable analgesic effects in the doses used. Their combination provided more effective postoperative analgesia than either drug alone.

Presurgical fentanyl vs caudal block and the incidence of adverse respiratory events in children after orchidopexy

Background: There is controversy about the etiology of early postoperative hypoxemia. Age, weight, intubation, surgical procedure, use of muscle relaxants, and/or administration of opioids may affect the incidence of early postoperative hypoxemia. In this prospective, randomized, and single-blinded study, we evaluated whether the administration of caudal analgesia vs i.v. fentanyl affected the number of children who develop postextubation adverse upper airway respiratory events, (upper airway obstruction, laryngospasm) and/or early postoperative hypoxemia.

Methods/materials: Institutional approval and written parental informed consents were obtained. Thirty-eight healthy outpatient boys, aged 1–6 years, scheduled for elective orchidopexy were randomized to receive pain relief either with a presurgical caudal block or by i.v. fentanyl. The primary outcome of the study was the number of children who developed postextubation adverse upper airway respiratory events and/or early postoperative hypoxemia.

Results: The number of boys who developed postextubation adverse upper airway respiratory events and/or early postoperative hypoxemia in the caudal group was less compared with those in the fentanyl group (P = 0.04).

Conclusions: Compared to fentanyl, placement of a presurgical caudal block in boys scheduled for orchidopexy was associated with a lower incidence of postextubation adverse upper airway respiratory events and/or early postoperative hypoxemia.

Epidural steroid injections: An update on mechanisms of injury and safety

Epidural steroid injections (ESIs) are the most commonly performed intervention in the United States to manage chronic and subacute low back and neck pain with radiculopathy. ESIs have been used for decades for the treatment of discogenic and osteoarthritic radicular conditions originating from the cervical, thoracic, and lumbar spine, as well as spondylosis, nonspecific radiculitis, and spinal stenosis.

With the ever-increasing use of epidural steroids, there has been a disproportionate increase in popularity of transforaminal ESIs in particular. Since 2002, there has been a growing body of largely transforaminal epidural steroid case report literature that describes paralysis, stroke, and death that immediately follows the performance of these procedures. These complications are thought to be related to a combination of factors, which may include the technique used, underlying pathophysiology that is being treated, anatomical variations in the blood supply, as well as the specific injectate used.

This article discusses the pathogenesis of these complications and puts the role of steroids in their causation into perspective.

Management of back pain in pregnancy

Back pain during pregnancy is a common problem experienced by many pregnant women. Physiological changes during pregnancy are a contributing factor for the development of back pain. Laxity of the sacroiliac joints causes instability and development of sacroiliac pain. The pain may be severe and can interfere with daily activities. Neurological examination is usually normal. A positive straight leg-rising test may indicate herniated disc, which is rare during pregnancy. Noncontrast magnetic resonance imaging is safe in pregnancy. To date, there are no identified adverse effects of the magnetic resonance on the developing fetus, but long-term effects need to be examined. Most back pain in pregnancy can be treated conservatively. Acetaminophen is the drug of choice to treat pain during pregnancy. Epidural steroid injection (ESI) may be considered in certain cases. Data in the literature are deficient regarding the use of ESI in pregnancy, but it appears to be safe based on expert clinical experience. More work is needed to examine the long-term effect of ESI on the mother and the fetus. Surgery is usually postponed until the postpartum period, unless there is progressive neurological deficits or cauda equina syndrome.

Ultrasound guidance for epidural steroid injections

– Ultrasound (US) guidance is practiced widely in regional anesthesia. It is becoming increasingly used for pain medicine interventions. US–guided neuraxial analgesia has also been demonstrated despite many technical challenges. The applicability of US guidance for neuraxial steroid injections adds the dimension of complications secondary to particulate steroids. This review will discuss the available evidence for the use of US in neuraxial analgesia and for epidural steroid injections (ESIs), the technique and limitations, and the potential uses of US for ESIs.

The Efficacy and Safety of Continuous Intravenous Administration of Remifentanil for Birth Pain Relief: An Open Study of 205 Parturients

OBSTETRIC ANESTHESIOLOGY
In an observational study, we prospectively evaluated the efficacy and safety of remifentanil in 205 parturients. Remifentanil was administered as a continuous infusion. The initial infusion of 0.025 µg · kg–1 · min–1 was increased in a stepwise manner to a maximum dose of 0.15 µg · kg–1 · min–1. Maternal pain, other maternal and fetal variables, side effects, and satisfaction were recorded. The mean (±sd) visual analog score before the start of the infusion was 9.4 ± 1.2 cm and decreased to 5.1 ± 0.4 cm after 5 min and 3.6 ± 1.5 cm after 30 min. The maternal side effects were minimal and no fetal or neonatal side effects were noted.

Time course of rocuronium-induced neuromuscular block after pre-treatment with magnesium sulphate: a randomised study

Background: A previously published study suggested that pre-treatment with magnesium sulphate (MgSO4) had no impact on the speed of onset of rocuronium-induced neuromuscular block. We set out to verify this assumption.

Methods: Eighty patients (18–60 years) were randomly allocated to MgSO4 60 mg/kg or placebo (saline). Study drugs were given intravenously for 15 min before induction of anaesthesia with propofol, sufentanil and rocuronium 0.6 mg/kg. Anaesthesia was maintained with a target-controlled propofol infusion. Neuromuscular transmission was measured using train-of-four (TOF)-Watch SX® acceleromyography.

Results: Onset was analysed in 37 MgSO4 and 38 saline patients, and recovery in 35 MgSO4 and 37 saline patients. Onset time (to 95% depression of T1) was on average 77 [SD=18] s with MgSO4 and 120 [48] s with saline (P<0.001). The total recovery time (DurTOF0.9) was on average 73.2 [22] min with MgSO4 and 57.8 [14.2] min with saline (P<0.003). The clinical duration (Dur25%) was on average 44.7 [14] min with MgSO4 and 33.2 [8.1] min with saline (P<0.0002). The recovery index (Dur25–75%) was on average 14.0 [6] min with MgSO4 and 11.2 [5.2] min with saline (P<0.02). The recovery time (Dur25%TOF0.9) was on average 28.5 [11.7] min with MgSO4 and 24.7 [8.4] min with saline (P=0.28).

Conclusion: Magnesium sulphate given 15 min before propofol anaesthesia reduces the onset time of rocuronium by about 35% and prolongs the total recovery time by about 25%.

Malignant Hyperthermia - Diagnostics, Treatment and Anaesthetic Management

In malignant hyperthermia (MH) susceptible individuals volatile anaesthetics and the depolarizing muscle relaxant succinylcholine may induce a potentially lethal hypermetabolic syndrome of skeletal muscle due to an uncontrolled sarcoplasmic calcium release. Immediate discontinuation of triggering agents, oxygenation, correction of acidosis and electrolyte abnormalities and dantrolene application are essential for MH treatment. This article reviews the clinical symptoms of MH, the diagnostic criteria and the actual guidelines for treatment and management of anaesthesia in susceptible individuals.

Ketamine, but not priming, improves intubating conditions during a propofol–rocuronium induction

Purpose Both ketamine and priming may shorten the onset time of rocuronium. This study investigates the effects of ketamine and priming as components of a propofol induction on intubating conditions and onset of neuromuscular block.
Methods This prospective randomized double-blind study was performed in 120 American Society of Anesthesiologists (ASA) I–II patients who were assigned to one of four groups of 30 patients each: control, priming, ketamine, and ketamine-priming. Ketamine 0.5 mg ∙ kg−1 or saline was given before priming and induction. Rocuronium 0.06 mg ∙ kg−1 or saline was injected 2 min before propofol 2.5 mg ∙ kg−1. This was followed by rocuronium 0.6 mg ∙ kg−1 or by rocuronium 0.54 mg ∙ kg−1 if priming was given. Intubation was performed one minute later. Intubating conditions were graded as excellent, good, or poor. Heart rate, noninvasive blood pressure, and train-of-four (TOF) response were monitored.
Results Intubating conditions were graded excellent in 20% of the control group, 30% of the priming group, 47% of the ketamine group, and 57% of the ketamine-priming group. Analysis using forward stepwise regression indicated that ketamine improved intubating conditions (P = 0.001) but priming did not (P = 0.35). Time to reach a TOF count of zero was shortened by ketamine (P = 0.001) but not by priming (P = 0.94): 216 ± 20 s in the control group, 212 ± 27 s in the priming group, 162 ± 18 s in the ketamine group, and 168 ± 22 s in the ketamine-priming group.
Conclusion A low-dose ketamine used with a propofol–rocuronium induction improved intubating conditions and shortened onset time. Priming did not influence intubating conditions or onset time.

Tracheal intubation in patients with rigid collar immobilisation of the cervical spine: a comparison of Airtraq® and LMA CTrach™ devices*

The aim of this study was to evaluate the effectiveness of the Airtraq® and CTrach™ in lean patients with simulated cervical spine injury after application of a rigid cervical collar. Eighty-six consenting adult patients of ASA physical status 1 or 2, who required elective tracheal intubation were included in this study in a randomised manner. Anaesthesia was induced using 1 μg.kg−1 fentanyl, 3 mg.kg−1 propofol and 0.6 mg.kg−1 rocuronium, following which a rigid cervical collar was applied. Comparison was then made between tracheal intubation techniques using either the AirTraq or CTrach device. The mean (SD) time to see the glottis was shorter with the Airtraq than the CTrach (11.9 (6.8) vs 37.6 (16.7)s, respectively; p < 0.001). The mean (SD) time taken for tracheal intubation was also shorter with the Airtraq than the CTrach (25.6 (13.5) and 66.3 (29.3)s, respectively; p < 0.001). There was less mucosal damage in the Airtraq group (p = 0.008). Our findings demonstrate that use of the Airtraq device shortened the tracheal intubation time and reduced the mucosal damage when compared with the CTrach in patients who require cervical spine immobilisation.

Comparison of the laryngeal mask airway Supreme and laryngeal mask airway Classic in adults

Background and objective: The laryngeal mask airway (LMA) is an important airway device that was developed in 1983. From the first classic LMA models up to now, LMA models have been developed that are easily and quickly inserted, provide ventilation at higher airway pressures, have lower cuff pressure, a reduced risk of gastric aspiration and cause fewer stress responses. We aimed to compare the LMA Classic with the LMA Supreme in assessing the success rate and time for insertion, number of attempts and leak pressure.

Methods: A total of 70 patients of ASA group I or II were included in our study. Regarding the airway device used during surgery, the patients were randomly assigned into two groups: the LMA Supreme group and the LMA Classic group. In order to provide common conditions for inserting the laryngeal mask, insertion was made while the bispectral index was between 50 and 60 and T1 was 0. The success rate of inserting the LMA, the duration of insertion, the number of attempts, the insertion complications, ventilation parameters, haemodynamic parameters and postoperative adverse effects were recorded for each group.
Results: In the LMA Classic group and the LMA Supreme group, the LMA was successfully inserted in 27 (88.5%) and 34 (97%) patients, respectively. The duration of insertion in the LMA Supreme group was shorter and the cuff pressure was lower than that in the LMA Classic group (P < 0.001).

Conclusion: The LMA Supreme is superior to the LMA Classic because of its ease of insertion with low cuff pressure and high oropharyngeal leakage pressure

Sexuality During Pregnancy

Introduction. Sexuality is an important part of health and well-being. Sexual behavior modifies as pregnancy progresses, influenced by biological, psychological, and social factors.

Aim. To evaluate changes in sexual perceptions and activities during pregnancy and to determine sexual dysfunctions in that period.

Main Outcome Measures. Sexual perceptions (desire from the partner, feelings of attractiveness, and fear of sexual intercourse), sexual activities during pregnancy (sexual intercourse frequency, the most frequent sexual intercourse trimester, sexual activity during the birth week, type(s) of sexual intercourse, changes in sexual satisfaction and desire compared with the pre-pregnancy period, and changes in sexual intercourse frequency during each trimester compared with the pre-pregnancy period), and sexual dysfunctions.

Methods. Puerperal women were asked to anonymously complete a self-administered and structured questionnaire at the day of discharge from hospital.

Results. One hundred and eighty-eight women, aged between 17 years and 40 years with a mean age of 28.9 years, were analyzed. The first trimester was considered the most frequent period of sexual intercourse (44.7%), followed by the second trimester (35.6%). Fifty-five percent reported a decrease of sexual activity during the third trimester. Fear of sexual intercourse was referred by 23.4% of the women questioned. Sexual satisfaction was unchanged in 48.4% of the subjects and decreased in 27.7% (P < 0.0001); sexual desire is reported to be unchanged in 38.8% and decreased in 32.5% (P = 0.196) of the population. Vaginal, oral, anal sex, and masturbation were performed by 98.3%, 38.1%, 6.6%, and 20.4% of the women, respectively.

Conclusions. We determined in our study that sexual satisfaction do not change in pregnancy compared with the pre-pregnancy patterns despite a decline of sexual activity during the third trimester. A discussion of expected changes in sexuality should be routinely done by the doctor in order to improve couples' perception of possible sexual modifications induced by pregnancy. Pauleta JR, Pereira NM, and Graça LM. Sexuality during pregnancy. J Sex Med **;**:**–**.

The effect of intrathecal fentanyl on Cerebral State Index-guided sedation during spinal anaesthesia*

This study investigated the effect of intrathecal fentanyl on the dose of propofol during sedation guided by Cerebral State Index monitoring. Seventy patients were randomly assigned to receive either fentanyl 25 μg (n = 35) or normal saline (n = 35) with hyperbaric bupivacaine 12.5 mg for spinal anaesthesia. Propofol was infused to maintain a Cerebral State Index value of 65–75 for 30 min. The propofol infusion time and dose required to reach a Cerebral State Index value of 75 were recorded together with the time required to reach a Cerebral State Index value higher than 90 after cessation of sedation. The onset time for sedation was faster and the recovery time was slower in the fentanyl group compared to those in the saline group (p = 0.018 and 0.027, respectively). The propofol doses required for onset and maintenance of sedation were significantly lower in the fentanyl group compared to those in the control group (p = 0.018 and < 0.001, respectively). In conclusion, adding intrathecal fentanyl 25 μg during spinal anaesthesia significantly reduced the dose of propofol required for sedation and prolonged the subsequent recovery time.

Perioperative pain management in the patient treated with opioids: Continuing Professional Development

Purpose The objective of this continuing professional development module is to describe the perioperative anesthesia and pain management of patients taking opioids because of chronic pain or drug addiction.
Principal findings The number of patients under opioid treatment is increasing. Pain management is problematic in these patients, because regular opioid intake is associated with mechanisms of tolerance and dependence. More recently, opioid-induced hyperalgesia phenomena have been brought to light. As a rule, the usual opioid dose should be administered with the appropriate conversions, and additional requirements should be anticipated because of the surgical procedure. Local and regional anesthesia, and multimodal analgesia are indicated whenever possible. For the patient addicted to heroin or other opioids, the perioperative period is not a suitable time to initiate weaning.
Conclusion The physiological and pharmacological changes caused by chronic opioid intake must be understood in order to provide optimal pain management with respect to each individual and the type of procedure.

Inotrope and Vasopressor Therapy of Septic Shock

When fluid administration fails to restore an adequate arterial pressure and organ perfusion in patients with septic shock, therapy with vasoactive agents should be initiated. The ultimate goals of such therapy in shock are to restore effective tissue perfusion and to normalize cellular metabolism. The efficacy of hemodynamic therapy in sepsis should be assessed by monitoring a combination of clinical and hemodynamic parameters. Although specific end points for therapy are debatable, and therapies will inevitably evolve as new information becomes available, the idea that clinicians should define specific goals and end points, titrate therapies to those end points, and evaluate the results of their interventions on an ongoing basis remains a fundamental principle.

Depth of anesthesia

– The present review article provides a summary of the recent literature evaluating the technology for monitoring depth of anesthesia and patient outcomes associated with its use. The goal of precisely dosed general anesthesia guided by brain monitoring remains elusive.

Ultrasound-guided arterial catheterization: a narrative review

– A description of the procedure is provided, along with an online supplemental video. Most studies indicate that first–pass success will be improved with US–guided (USG) arterial catheterization. The technique is easy to learn, particularly if one is already familiar with USG for central venous catheter placement. More research, including formal analyses of cost effectiveness, is needed.
Abstract Arterial catheterization is the second most common invasive procedure performed in the intensive care unit. Despite the ubiquity of the procedure, complications including failure to place the catheter occur. While many clinicians are familiar with the use of ultrasound (US) guidance to decrease complication rates of central venous catheter insertion, fewer are familiar with the use of ultrasound to guide arterial catheterization. This manuscript reviews the evidence for the utility of ultrasound for this indication. Technical aspects of the procedure and limitations of the existing evidence are reviewed. A description of the procedure is provided, along with an online supplemental video. Most studies indicate that first-pass success will be improved with US-guided (USG) arterial catheterization. The technique is easy to learn, particularly if one is already familiar with USG for central venous catheter placement. More research, including formal analyses of cost effectiveness, is needed.
Electronic supplementary material The online version of this article (doi:10.1007/s00134-009-1699-6) contains supplementary material, which is available to authorized users.
Keywords Catheterization - Artery - Ultrasonography - Review

Use of oral ketamine in chronic pain management: A review

The analgesic effect of ketamine is primarily based on the antagonism of the N-methyl-D-aspartate (NMDA) receptor. Activation of NMDA receptors may play a crucial role in the pathogenesis of chronic pain. Little formal research has been performed on the efficacy and safety of ketamine in chronic pain, especially concerning long-term oral administration. This review provides an overview of the available clinical data on the use of oral ketamine in chronic pain management. A literature search was performed in MEDLINE, EMBASE and the Cochrane Library, resulting in 22 relevant articles. Because most retrieved articles were of a descriptive nature (e.g. case reports and case series) a quantitative analysis was not possible. There was no consistent dose–response relation. A recommended starting dosage in ketamine-naive patients is 0.5mg/kg racemic ketamine or 0.25mg/kg S-ketamine as a single oral dose. The dosage is increased by the same amount if required. For a continuous analgesic effect it is usually given 3–4 times daily. The injection fluid can be taken orally. When parenteral ketamine is switched to oral administration the daily dosage can be kept equal and, depending on clinical effect and/or adverse effects, is slowly increased. The pharmacologically active metabolite norketamine is believed to contribute to the analgesic effect of oral ketamine. Lack of evidence regarding efficacy, and the poor safety profile, do not support routine use of oral ketamine in chronic pain management. Oral ketamine may have a limited place as add-on therapy in complex chronic pain patients if other therapeutic options have failed.

Total intravenous anaesthesia techniques for ambulatory surgery

-Purpose of review: The purpose of the present review is to provide an updated discussion on the use of total intravenous anaesthesia (TIVA) for ambulatory surgery, based on results from recent studies put into the context of issues already known.

Recent findings: The current use of TIVA for ambulatory surgery seems to be abundant. It is encouraged by the simplicity of the method, increased experience and declining costs with the propofol and remifentanil combination. The TIVA methods are well tolerated and perceived to give good quality patient care; with rapid, clear-headed emergence and low incidence of postoperative nausea and vomiting. Cost-efficacy and other benefits of recovery from TIVA versus alternative techniques of anaesthesia seem to depend more on the patient and the individual perioperative setting than on the TIVA concept per se. Further development of TIVA will include the refinement of target control systems, the introduction of new drugs and adjuvants and advanced equipment for automatic drug delivery, as well as improved effect monitoring.

Summary: TIVA is well tolerated and simple. It is associated with less postoperative nausea and vomiting than inhalational anaesthesia and has no residual paralyses as are possible with locoregional techniques. Propofol with remifentanil seems to be the dominating TIVA technique, delivered either by conventional pumps or by target control systems.

Anesthésie locorégionale pour la chirurgie esthétique de la face et du cou

-La chirurgie plastique connaît un développement important, c’est un domaine d’application des blocs de la face. Les indications chirurgicales sont multiples, dont un nombre important peut être pratiqué en ambulatoire. Après quelques rappels anatomiques, les techniques d’anesthésie locorégionale appliquées à chaque type de chirurgie sont détaillées. La réalisation de ces blocs obéit aux règles générales de toute anesthésie, en particulier en ce qui concerne la surveillance clinique et l’asepsie.

Ambulatory hernia surgery under local anesthesia is feasible and safe in obese patients

– The authors conclude that ambulatory abdominal wall hernia repair under local anesthesia is feasible in obese patients. Because of the increased length of surgery in these patients, monitored sedation and prophylactic antibiotic cover should be used. The slight decrease in patient satisfaction is balanced by the lower risks and higher costs associated with full general anesthetic.

Spinal mepivacaine with fentanyl for outpatient knee arthroscopy surgery: a randomized controlled trial

– When compared with 45 mg isobaric mepivacaine 1.5%, an intrathecal dose of 30 mg isobaric mepivacaine 1.5% plus 10 microg fentanyl produces reliable anesthesia, hastens block regression, shortens stay in Phase I recovery, and enables earlier ambulation for patients undergoing unilateral knee arthroscopy.

Comparison of Local Anesthetic Effects of Tramadol With Prilocaine During Circumcision Procedure

– A combination of tramadol 5% plus adrenaline can provide a safe and effective local anesthesia during circumcision procedure and postoperative period in children.
Objectives

To compare the local anesthetic effects of tramadol hydrochloride with prilocaine for circumcision procedure.
Methods

This study included 40 patients with American Surgical Association-I scores. Patients were randomly allocated to receive either 5% tramadol (2 mg/kg) plus adrenaline (0.0125/mL) (group 1, n = 20) or 2% prilocaine plus adrenaline (0.0125/mL) (group 2, n = 20). The degree of burning sensation and pain at the injection site were documented. Sensory block was assessed 1 minute after injection and the patients were asked to grade touch and pinprick sensation. Five minutes after drug administration, incision was performed and intensity of pain, felt by the patient was evaluated on a 4-point scale (0-3). Pain at the injection site and local skin reactions were also recorded.
Results

Mean ages were 9.7 and 10.3 years for groups 1 and 2, respectively. Mean duration of surgery was 19.6 minutes. In control visit, 2 of 20 (10%) in group 1 and 10 of 20 (50%) children in group 2 reported extra need for oral ibuprofen (P <.05). First analgesic medication time was 9.5 (± 2.1) hours in group 1 and 8.7 (± 3.1) hours in group 2 (P >.05). Total postoperative ibuprofen consumptions were 10 and 50 mg for groups 1 and 2, respectively (P <.05).
Conclusions

A combination of tramadol 5% plus adrenaline can provide a safe and effective local anesthesia during circumcision procedure and postoperative period in children.

Transient neurological symptoms after spinal anaesthesia with levobupivacaine 5 mg/ml or lidocaine 20 mg/ml

– After spinal anaesthesia with levobupivacaine, the incidence of TNS was much less than after lidocaine. However, it appears that TNS may occur in association with levobupivacaine.
Transient neurological symptoms (TNS) after spinal anaesthesia have been reported most commonly in association with lidocaine, but have been observed with other local anaesthetics. The aim of this prospective, randomized, double-blind study was to investigate the incidence of TNS after spinal anaesthesia with either levobupivacaine or lidocaine.

Methods: Patients undergoing inguinal hernia, appendectomy, varicose vein or minor orthopaedic operations were included in the study (60 patients; 47 male, 13 female, overall mean age 30 years). All patients had an American Society of Anesthesiologists score of I or II. The patients were randomly assigned to receive spinal anaesthesia with either 20 mg isobaric levobupivacaine (5 mg/ml) or 80 mg isobaric lidocaine (20 mg/ml). Onset of sensory and motor block and side effects were recorded. On post-operative days 1, 2, and 3, patients were interviewed by an investigator blinded to the spinal anaesthetic used. The patients were classified as having TNS if, following recovery from anaesthesia, there was pain in the buttocks, thighs and/or lower limbs.

Results: In the levobupivacaine group, one patient (3.33%) experienced TNS, whereas in the lidocaine group, eight (26.6%) experienced TNS (P=0.002). Maximum times to arrival of sensory blocks were shorter with lidocaine (P<0.001). The levobupivacaine and lidocaine groups did not differ significantly in terms of the highest dermatome included in sensory block or motor block grade.

Conclusion: After spinal anaesthesia with levobupivacaine, the incidence of TNS was much less than after lidocaine. However, it appears that TNS may occur in association with levobupivacaine.

ANALGESIA Ropivacaine Spinal Anesthesia Is Not Antagonized by Ondansetron Pretreatment

– The authors investigated a possible effect of ondansetron on the duration of sensory and motor block produced by ropivacaine. Ondansetron had no effect on the subarachnoid sensory or motor block produced by ropivacaine.

Use of intra-articular lidocaine as analgesia in anterior shoulder dislocation: a review and meta-analysis of the literature

– Based on the current literature, it appears that the intra–articular lidocaine (IAL) method provides, at a minimum, the same level of pain control and reduction success as the procedural sedation method, while markedly reducing the time spent by the patient in the emergency department and the cost of treatment. The likelihood of complications is arguably less with the use of IAL. Although more research is this area is merited, physicians may consider IAL as an alternative to procedural sedation and analgesia (PSA) in the management of anterior shoulder dislocations.

A Randomized Comparison of Low Doses of Hyperbaric Bupivacaine in Combined Spinal-Epidural Anesthesia for Cesarean Delivery

– The lowest dose of hyperbaric bupivacaine (7 mg) provided equally rapid onset and effective anesthesia for cesarean delivery while reducing the incidence of hypotension compared with 8 and 9 mg. However, because of its shorter duration of anesthesia, it may be feasible only when the block can be reinforced using a functional epidural catheter.

A Comparison of Gabapentin and Ketamine in Acute and Chronic Pain After Hysterectomy

– Gabapentin and ketamine are similar in improving early pain control and in decreasing opioid consumption; however, gabapentin also prevented chronic pain in the first 6 postoperative months.

INNOVATIVE LIGHTED STYLET

– Intubation of trachea using lighted stylet is easy, safe, effective and rapid alternative method of airway management. The innovative lighted stylet has an added advantage that it can be used to intubate trachea with RAE tube where conventional lighted stylet fails.

Pediatric Pain After Ambulatory Surgery: Where's the Medication?

– A large proportion of children receive little analgesic medication after surgery and research efforts should be directed to the discrepancy between high ratings of postoperative pain provided by parents and the low dosing of analgesics they use for their children.

Three concentrations of levobupivacaine for ilioinguinal/iliohypogastric nerve block in ambulatory pediatric surgery

– The aim is to compare the postoperative analgesia of three different concentrations of levobupivacaine for ilioinguinal/iliohypogastric (II/IH) block in children undergoing inguinal hernia repair. II/IH nerve block using 0.4 mL kg^–1 of 0.25% levobupivacaine provided satisfactory postoperative pain relief after inguinal herniorraphy.

CT Scans Identify Patients With Severe H1N1 at Risk for Developing Pulmonary Emboli

LEESBURG, Va -- October 14, 2009 -- Utilising computed tomography (CT) scans, researchers have found that patients with severe cases of the influenza A(H1N1) are at risk for developing severe complications, including pulmonary emboli (PE).

The study is published online, ahead of print, in the American Journal of Roentgenology. The study will be published in the December print issue of the journal.

The study included 66 patients diagnosed with the H1N1. Two study groups were formed. Group 1 consisted of 14 patients who were severely ill and required admission to the intensive care unit (ICU) and group 2 consisted of 52 patients who were not severely ill and did not require ICU admission.

All 66 patients underwent chest x-rays for the detection of H1N1 abnormalities. Ten patients from the ICU group and 5 patients from the largely outpatient group, underwent CT scans.

"Pulmonary emboli were seen on CT in 5 of 14 ICU patients," said lead author Prachi P. Agarwal, MD, University of Michigan, Ann Arbor, Michigan.

"Our study suggests that patients who are severely ill with H1N1 are also at risk for developing PE, which should be carefully sought for on contrast-enhanced CT scans," she said.

"With the upcoming annual influenza season in the United States, knowledge of the radiologic features of H1N1 is important, as well as the virus's potential complications, said Dr. Agarwal.

"The majority of patients undergoing chest x-rays with H1N1 have normal radiographs. CT scans proved valuable in identifying those patients at risk of developing more serious complications as a possible result of the H1N1 virus, and for identifying a greater extent of disease than is appreciated on chest radiographs," she said.


SOURCE: American Roentgen Ray Society

Bispectral Index Monitoring of Midazolam Sedation During Flexible Bronchoscopy

– The authors suggest that the BIS value during flexible bronchoscopy is associated with the satisfaction of patients and they may be able to predict patients' satisfaction.

Perioperative Use of β-Blockers in the Elderly Patient

– This article examines common comorbidities in the elderly who may benefit from the chronic use of beta–blockers, prophylactic perioperative use of beta–blockers including timing, dosage, and choice of beta–blocker, the pharmacologic effects of aging, and recommendations on the use of beta–blockers.

THE ‘BEST FIT’ ENDOTRACHEAL TUBE IN CHILDREN

– The age–based and 5th fingernail width–based predictions of ETT size are more accurate than length–based and multivariate–based formulae in terms of mean value and case matching.

Obstructive Sleep Apnea Is Not a Risk Factor for Difficult Intubation in Morbidly Obese Patients

– In MO patients undergoing bariatric surgery in the "ramped position," there was no relationship between the presence and severity of OSA, BMI, or NC and difficulty of intubation or laryngoscopy grade. Only a Mallampati score of 3 or 4 or male gender predicted difficult intubation.

A prospective, randomised, cross-over trial comparing the EndoFlex® and standard tracheal tubes in patients with predicted easy intubation

– Patients with a grade 2 (19/50) or 3 (6/50) laryngoscopic view had shorter intubation times, easier intubation and reduced insertion attempts with the EndoFlex. The EndoFlex is a satisfactory alternative to a standard–type tracheal tube, even with an anterior larynx.

How do pediatric anesthesiologists define intraoperative hypotension?

– There is great variability in the BP parameters used and the threshold used for defining and treating IOH among pediatric anesthesiologists. The majority of respondents considered a 20–30% reduction from baseline in SBP as indicative of significant hypotension. Lack of a consensus definition for a common clinical condition like IOH could have implications for patient care as well as future clinical research.

Ultrasound guidance for peripheral nerve blockade

– The review authors searched the medical literature for controlled clinical trials comparing ultrasound with another nerve–locating technique in adult patients. They found 18 studies including a total of 1344 patients. Most of the studies compared ultrasound with electrical nerve stimulators. Most of the studies were of moderate quality. As the methods used in the included studies were very varied, the review authors were unable to pool the results using statistical tests. The findings of the review are based on the interpretation of individual studies. The use of ultrasound was not found to make a significant difference to whether a nerve block was successful or not. Using ultrasound reduced bruising. Ultrasound may reduce the time taken to do the block and also resulted in the block working more quickly. Two studies found ultrasound allowed a reduction in the amount of local anaesthetic. No differences were found in length of time the nerve block lasted. No serious complications were reported in any of the studies and there was no evidence of adverse effects from ultrasound itself.

Comparative Evaluation of Ketamine,Midazolam and Combinatin of Both as Oral Premedicants in chirldren

– Oral Midazolam and Ketamine alone and in combination were acceptable and effective premedication in children and their combination in lower dosage, 3 mg kg^–1 and 0.3 mg kg^–1 respectively was superior than their alone administration in higher dosage.

Single dose oral tiaprofenic acid for acute postoperative pain in adults

– Not one of eleven studies identified by the searches and examined in detail studied oral tiaprofenic acid against placebo in patients with established postoperative pain and therefore no results are available. In the absence of evidence of efficacy for oral tiaprofenic acid in acute postoperative pain, its use in this indication is not justified at present. Because trials clearly demonstrating analgesic efficacy in the most basic of acute pain studies is lacking, use in other indications should be evaluated carefully. Given the large number of available drugs of this and similar classes which are effective, there is no urgent research agenda for this particular drug.

Single dose oral lornoxicam for acute postoperative pain in adults

– A high level of pain relief is experienced by about 45% of those with moderate to severe postoperative dental pain after a single dose of lornoxicam 8 mg, compared to about 10% with placebo. This is comparable to the proportion experiencing the same level of pain relief with ibuprofen 200 to 400 mg. Adverse events were generally mild and did not differ from placebo in these singe dose studies. There were insufficient data to assess duration of action, but it is likely to be similar to ibuprofen 200 mg.

Equipment for airway management

– The authors describe the ‘RAW’ approach (Ready, Able, Willing) and list five phases of airway management in which equipment is used. These are: facemask ventilation with adjuncts, airway clearance with suction or foreign body removal, use of supraglottic airway devices, tracheal intubation with a variety of laryngoscopes including the flexible fibre–optic bronchoscope and subglottic management using cricothyroidotomy or tracheostomy. Tracheal tubes and aids for placement are described.

Parent-assisted or nurse-assisted epidural analgesia: is this feasible in pediatric patients?

– Parent–assisted or nurse–assisted epidural analgesia (PNEA) can be safely administered to children undergoing surgery who are physically or cognitively unable or unwilling to self–activate a demand dose. Additional studies are needed to compare the efficacy of PNEA with other modalities for postoperative pain control in children.

Efficacy of a low-dose spinal morphine with bupivacaine for postoperative analgesia in children undergoing hypospadias repair

– Spinal anesthesia provided by hyperbaric bupivacaine is adequate for distal hypospadias repair in children, but adding 2 microg·kg^?1 intrathecal morphine provides better postoperative pain control when compared to placebo in these children.

Spinal Analgesia in Cardiac Surgery: A Meta-analysis of Randomized Controlled Trials

– This analysis indicated that spinal analgesia does not improve clinically relevant outcomes in patients undergoing cardiac surgery, discouraging further randomized controlled trials on this topic even if changes in techniques, devices, and drugs could modify the outlook of the comparison between spinal and standard anesthesia in this setting.

"Tapentadol" A Novel Anagegic

– Tapentadol is a new analgesic drug with a dual mode of action, hence has efficacy in a broad spectrum of acute and chronic pain models and possibly an improved tolerability profile. It combines moderate mu–opioid agonist activity with NE reuptake inhibition in a single, nonracemic molecule. No metabolic activation of tapentadol is necessary for analgesia, and it has no active metabolites. Further RCTs are needed to establish its routine use in postoperative patients.

Effective anesthetic volumes in sciatic nerve block: comparison between the parasacral and infragluteal-parabiceps approaches with 0.5% bupivacaine wi

Effective anesthetic volumes in sciatic nerve block: comparison between the parasacral and infragluteal-parabiceps approaches with 0.5% bupivacaine with adrenaline and 0.5% ropivacaine
Effective anesthetic volumes in sciatic nerve block: comparison between the parasacral and infragluteal-parabiceps approaches with 0.5% bupivacaine with adrenaline and 0.5% ropivacaine. Rev. Bras. Anestesiol. [online]. 2009, vol.59, n.5, pp. 521-530. ISSN . doi: 10.1590/S0034-70942009000500001.

BACKGROUND AND OBJECTIVES: The volume and mass of local anesthetics (LA) affect the success rate of peripheral nerve blocks. Thus, the main objective of this study was to determine the volumes of local anesthetics in parasacral and infragluteal-parabiceps sciatic nerve block (SNB). METHODS: One hundred and one patients undergoing infragluteal-parabiceps or parasacral SNB with 0.5% ropivacaine or 0.5% bupivacaine with 5 �g.mL-1 of adrenaline were randomly divided into 4 groups. Success was defined as complete sensitive and motor blockades of the sciatic nerve 30 minutes after the administration of the LA. Volumes were calculated by the up-and-down method. RESULTS: In the parasacral approach, the mean effective volume of ropivacaine was 17.6 mL (95% CI: 14.9-20.8) and of bupivacaine it was 16.4 mL (95% CI: 12.3-21.9). In the infragluteal-parabiceps approach, the mean effective volume of ropivacaine was 21.8 mL (95% CI: 18.7-25.5), and that of bupivacaine was 20.4 mL (95% CI: 18.6-22.5). Volumes were significantly lower (p < 0.01) in the parasacral than in the infragluteal-parabiceps approach. In Probit regression, the estimated effective volume in 95% of the patients in the parasacral approach was 21.8 mL for ropivacaine, and 20.5 mL for bupivacaine; in the infragluteal-parabiceps approach the volumes were 27.2 mL for ropivacaine and 25.5 mL for bupivacaine. The effective volume in 99% of the patients in parasacral SNB was 24 mL for ropivacaine, and 24 mL for bupivacaine; and in the infragluteal-parabiceps approach, 29.9 mL for ropivacaine, and 28.0 mL for bupivacaine. CONCLUSIONS: In sciatic nerve block, significantly smaller volumes were necessary in the parasacral than in the infragluteal-parabiceps approach, but volumes did not differ between both LAs.

Keywords : ANESTHETIC, Local [bupivacaine]; ANESTHETIC, Local [ropivacaine]; ANESTHETIC TECHNIQUES, Regional [sciatic nerve block].

Pediatric Pain After Ambulatory Surgery: Where's the Medication?

– A large proportion of children receive little analgesic medication after surgery and research efforts should be directed to the discrepancy between high ratings of postoperative pain provided by parents and the low dosing of analgesics they use for their children.

Prevalence of Delirium with Dexmedetomidine Compared with Morphine Based Therapy after Cardiac Surgery: A Randomized Controlled Trial (DEXmedetomidine

– Dexmedetomidine reduced the duration but not the incidence of delirium after cardiac surgery with effective analgesia/sedation, less hypotension, less vasopressor requirement, and more bradycardia versus morphine regimen.

Continuous intra-articular infusion of bupivacaine for post-operative pain relief after total hip arthroplasty: A randomized, placebo-controlled, doub

– Continuous intra–articular infusion of 0.5% bupivacaine at 2 mL/h via a PCIP does not provide sustained post–operative pain relief in patients undergoing THA. Methods

• 92 patients undergoing THA were randomized to receive continuous intra–articular infusion of either 0.5% bupivacaine or 0.9% normal saline at a flow rate of 2 mL/h via a PCIP for 48 h.
• The primary outcome measure was pain intensity on Visual Analogue Scale (VAS) scores in the first 72 h.
• Other measures included time to first rescue dose of narcotics, amount of narcotic use, presence of adverse events, length of hospital stay, and hip function evaluated with the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index.

Results

• Despite a longer time to first narcotic rescue (56 versus 21min, p<0.0001) p="0.54).
• A lower VAS score was found only at time 0 and 2 h; no difference in VAS score was noted at any other time point.
• Additionally, no difference was found in terms of amount of narcotic use, incidence of adverse events, hospitalization days, and the WOMAC score.

Magnesium sulphate has beneficial effects as an adjuvant during general anaesthesia for Caesarean section

– Preoperative i.v. magnesium sulphate attenuated BIS and arterial pressure increases during the pre–delivery period. Magnesium sulphate can be recommended as an adjuvant during general anaesthesia for Caesarean section to avoid perioperative awareness and pressor response resulting from inadequate anaesthesia, analgesia, or both.

Laryngeal mask airways – to inflate or to deflate after insertion?

– This study demonstrates that LMAs, particularly when using small–sized LMAs or LMAs with a more rigid PVC surface, need to be deflated following insertion of the device rather than inflated to avoid cuff hyperinflation. Hence, cuff pressures should be measured routinely using a manometer to minimize potential pressure–related airway complications.

Histoires droles(កំប្លែងចុងសប្តាហ៍)

> Numéro 6 :
>
> Un ex va au mariage de son ancienne femme.
> Durant la soirée, l'ex va voir le nouveau marié et lui demande d'un air
arrogant :
> - Comment tu trouves ça, de rentrer dans du stock usagé
> Le nouveau marié le regarde droit dans les yeux et, inébranlable(!!!),
> Il lui répond :
> - C'est stupéfiant !! ... Passé les 6 premiers centimètres, c'est flambant neuf
!!!...
>
> Numéro 5 :
<>>
> Un homme se cogne contre une femme dans un hall d'hôtel.
Durant la collision son coude butte contre la poitrine de celle-ci.
> Ils sont tout deux surpris.
> L'homme se tourne vers elle et dit :
> "Madame, si votre coeur est aussi doux que votre poitrine, je
sais que vous me pardonnerez."
> Ce à quoi elle répond :
> " Si votre queue est aussi dure que votre coude, je suis dans la
chambre 221".
>
>
Numéro 4 :
>
> Un homme d'affaire monte à bord d'un train et se retrouve
assis à côté d'une superbe femme.
> Il remarque qu'elle est en train de lire un livre sur les
statistiques sexuelles.
> Il l'interroge sur ce sujet, et elle répond :
> " C'est un livre très intéressant. Ainsi les Indiens sont ceux
dont le pénis est le plus long, et les bretons sont ceux qui savent
le mieux s'en servir. Au fait je m'appelle Florence. Et vous "
> "Géronimo LE GENNEC ! Enchanté de vous rencontrer."
>
>
Numéro 3 :
>
> ; Un soir, alors qu'un couple se couche, le mari commence à
caresser le bras de sa femme.
> Elle se retourne et lui dit :
> " Je suis désolée chéri, j'ai un rendez-vous chez le
gynécologue demain et je veux rester fraîche".
> Le mari déçu se retourne.
> Quelques minutes plus tard, il se tourne de nouveau vers sa
femme.
> " Est-ce que tu as aussi un rendez-vous chez le dentiste
demain ?"
>
> <>Numéro 2 :
>
> Un prêtre et une nonne sont dans une tempête de neige. Après
un moment, ils trouvent une petite cabane. Exténués, ils se
préparent à dormir.
> Il y a une pile de couvertures et un duvet sur le sol, mais
seulement un lit.
> Gentleman, le prêtre dit :
> " Ma soeur, vous dormirez dans le lit, et je dormirai sur le sol,
dans le duvet".
> Alors qu'il venait juste de fermer son duvet et commençait à
s'endormir, la nonne dit :
> " Mon père, j'ai froid ".
> Il ouvre la fermeture de son duvet, se lève, prend une
couverture et la pose sur elle. De nouveau, il s'installe dans le
duvet, le ferme et se laisse
> sombrer dans le sommeil, quand la nonne dit encore :
> " Mon père, j'ai toujours très froid".
> Il se lève a nouveau, met une autre couverture sur elle et
retourne se coucher.
> Juste au moment ou il ferme les yeux, elle dit :
> "Mon père, j'ai siiiiii froid ".
> Cette fois, il reste couché et dit :
> "Ma soeur, j'ai une idée : nous sommes ici au milieu de nulle
part, et personne ne saura jamais ce qui s'est passé. Faisons
comme si nous
> étions mariés".
> Enfin exaucée, la nonne répond :
> " Oui, c'est d'accord ".> Et le prêtre crie :
> " Alors tu lèves ton cul et tu prends toi même ta putain de
couverture, conasse !!!"
>
> Numéro 1 :
>
> Un couple a était marié pendant 50 ans.
> Un matin au petit déjeuner, la femme déclare :
> " Rappelle - toi comme 50 ans en arrière, nous étions
probablement assis à cette même table ensemble."
> "Je sais," dit le vieil homme
> "nous étions probablement assis, complètement nus."
> " Eh, bien, " dit la vielle femme " revivons un peu du
passé."
> Alors les 2 se déshabillent entièrement et se rassoient.
> " Tu sais chéri, " dis la petite vieille toute excitée " mes
tétons sont toujours aussi chauds aujourd'hui qu'ils l'étaient
il y a 50 ans! "
> "Ca ne m'étonne pas, " répondit le grand-père " Il y en a
un dans le grille-pain et l'autre qui t rempe dans ton café.

Outpatient intravenous ketamine for the treatment of complex regional pain syndrome: A double-blind placebo controlled study

– The results of this study warrant a larger randomized placebo controlled trial using higher doses of ketamine and a longer follow–up period. Methods

• Randomized double–blind placebo controlled trial.
• Before treatment, after informed consent was obtained, each subject was randomized into a ketamine or a placebo infusion group.
• Study subjects were evaluated for at least 2 weeks prior to treatment and for 3 months following treatment.
• All subjects were infused intravenously with normal saline with or without ketamine for 4 h (25 ml/h) daily for 10 days. The maximum ketamine infusion rate was 0.35 mg/kg/h, not to exceed 25 mg/h over a 4 h period.
• Subjects in both the ketamine and placebo groups were administered clonidine and versed.

Results

• Intravenous ketamine administered in an outpatient setting resulted in statistically significant reductions in many pain parameters.
• Subjects in the placebo group demonstrated no treatment effect in any parameter.

Ventilator-associated pneumonia and mortality: A systematic review of observational studies *

There is no evidence of attributable mortality due to ventilator–associated pneumonia in patients with trauma or acute respiratory distress syndrome. However, in other nonspecified patient groups, there is evidence for attributable mortality due to ventilator–associated pneumonia, but this could not be quantified due to heterogeneity in study results. More detailed studies, allowing subgroup analyses, are needed to determine the attributable mortality of ventilator–associated pneumonia in these patient populations.

ថ្នាំសណ្តំ ឬ អវិញ្ញាណកម្ម

នៅស្រុកខ្មែរគេទម្លាប់ហៅ Anesthésiste ថាអ្នកដាក់ថ្នាំសណ្តំខ្ញុំក៏ជាអ្នកដាក់ថ្នាំសណ្តំម្នាក់ដែរ
តែខ្ញុំស្តាប់ទៅវាដូចជាមិនទំនងសោះ ព្រោះថាថ្នាំសណ្តំវាគ្រាន់តែជាផ្នែកមួយនៃAnesthésie ប៉ុណ្ណោះ។
ខ្ញុំធ្លាប់បានឃើញសំណៅបកប្រែរបស់លោក វ៉ាន់ឌី កាអុន កាលដែលលោកធ្វើការនៅស្រុកខ្មែរ
សម័យរដ្ឋកម្ពុជា លោកបកប្រែរពាក្យ Anesthésie ថា អវិញ្ញាណកម្ម ។
នៅក្នុងវចនានុក្រមខ្មែររបស់សម្តេចជួន ណាត ខ្ញុំក៏បានរកឃើញពាក្យ
អវិញ្ញាណក ៖ អៈវិញ-ញា ណៈកៈ បា। ឬ សំ। ( គុ। ) (អវិញ្ញាណក, អវិជ្ញានក) ដែល​ឥត​វិញ្ញាណ ។ ន। អ្វី​ៗ​ដែល​ឥត​វិញ្ញាណ; អនុបាទិន្នក​រូប ។ ព। ផ្ទ. សវិញ្ញាណកៈ ។ អវិញ្ញាណក​ទ្រព្យ ទ្រព្យ​ឥត​វិញ្ញាណ : មាស, ប្រាក់, ត្បូង, ផ្តិល, ចាន, ទូ, តាំង, តុ, កៅអី,... ជា​អវិញ្ញាណក​ទ្រព្យ ។ ព. ផ្ទ. សវិញ្ញាណក​ទ្រព្យ ។ អវិញ្ញាណក​រូប រូប​ឥត​វិញ្ញាណ ។ល។
ខ្ញុំយល់ថា​ នេះជាឬសគល់នៃពាក្យខ្មែរដែលយើងអាចបំបែកចេញជាមែកធាងយ៉ាង
ច្រើនដូចជា៖អវិញ្ញាណកម្ម អវិញ្ញាណកម្មវិទ្យា អវិញ្ញាណកម្មវិទូ
អវិញ្ញាណកម្មបណ្ឌិត ។ល។ ហាស់ហា!!
ដូចពាក្យ Anesthésie វាចែកចេញជាច្រើនផ្នែកណាស់គឺមាន Anesthésie générale,Anesthésie locale,Anesthésie​ loco-régionale,។ល។
ដូច្នេះ Anesthésie générale គួរតែជា ការដាក់ថ្នាំសណ្តំឯ Anesthésie locale ការដាក់ថ្នាំស្ពឹក។ល។
ទាំងការដាក់ថ្នាំស្ពឹក ទាំងការដាក់ថ្នាំសណ្តំ គឺសុទ្ធសឹងតែការធ្វើ៎ឲ្យបាត់បង់វិញ្ញាណទាំងអស់
(អវិញ្ញាណកម្ម)មានការបាត់បង់ការឈឺចាប់ ការកំរើក មិនដឹងរស់ជាតិ ក្លឹន ការមើលឃើញ។ល។ រហូតដល់បាត់បង់វិញ្ញាណទាំងស្រុង លើកលែងតែ ចលនាបេះដូង និង ដង្ហើម តែប៉ុណ្ណោះ ។
ឯចំណែកអ្នកដាក់ថ្នាំសណ្តំគាត់ក៏ជាអ្នកដាក់ថ្នាំស្ពឹកដែរដូច្នេះគួរហៅគាត់ថា៖
អ្នកឯកទេសអវិញ្ញាណកម្ម និង​ប្រពោធនកម្ម ។
From Wikipedia

Le mot anesthésie provient du grec aïsthêsis (αισθησις: faculté de percevoir par les sens) combiné à l'alpha (α) privatif et du nu (ν) euphonique. L'anesthésie peut viser un membre, une région ou l'organisme entier (anesthésie générale). L'anesthésie est la suppression de la douleur. Elle vise à permettre une procédure médicale qui autrement serait trop douloureuse. L'anesthésie loco-régionale est aussi pratiquée dans les cas de douleurs chroniques.

Le domaine de la médecine qui étudie et pratique l'anesthésie est l'anesthésiologie. Cette spécialité médicale est récente, et elle a révolutionné la médecine en permettant une chirurgie de qualité.

Anesthesia, or anaesthesia (see spelling differences; from Greek αν-, an-, "without"; and αἲσθησις, aisthēsis, "sensation"), has traditionally meant the condition of having sensation (including the feeling of pain) blocked or temporarily taken away. This allows patients to undergo surgery and other procedures without the distress and pain they would otherwise experience. The word was coined by Oliver Wendell Holmes, Sr. in 1846.^[1] Another definition is a "reversible lack of awareness", whether this is a total lack of awareness (e.g. a general anaesthetic) or a lack of awareness of a part of the body such as a spinal anaesthetic or another nerve block would cause. Anesthesia is a pharmacologically induced reversible state of amnesia, analgesia, loss of consciousness, loss of skeletal muscle reflexes and decreased stress response.

Characteristics of patients with chronic back pain who benefit from acupuncture

– Overall, the strongest predictors of improvement in back function and symptoms were higher baseline levels of these measures, receipt of an acupuncture treatment, and non–use of narcotic analgesics. Benefit from acupuncture compared to usual care was greater with worse pre–treatment levels of back dysfunction (interaction p< 0.004 for the functional outcome, Roland Morris Disability Scale at 8 weeks). No other consistent interactions were observed. This secondary analysis found little evidence for the existence of subgroups of patients with chronic back pain that would be especially likely to benefit from acupuncture. However, persons with chronic low back pain who had more severe baseline dysfunction had the most short–term benefit from acupuncture.

Thinking beyond low-density lipoprotein cholesterol: strategies to further reduce cardiovascular risk

Some trials have highlighted the significance of residual cardiovascular risk after treatment of LDL–C to target levels. This residual risk is partially due to low HDL–C and high triglycerides (TG) despite achievement of LDL goals with statin therapy. The NCEP ATP III guidelines reported that low HDL–C is a significant and an independent risk factor for coronary heart disease (CHD) and is inversely related to CHD. Epidemiologic studies have also shown a similar inverse relationship of HDL–C with CHD. High–density lipoprotein cholesterol (HDL–C) may directly participate in the anti–atherogenic process by promoting efflux of cholesterol of the foam cells of atherogenic lesions. Many studies have demonstrated multiple anti–atherogenic actions of HDL–C and its role in promoting efflux of cholesterol from the foam cells. The residual risk by increased TG with or without low HDL–C can be assessed by calculating non–HDL–C and a reduction in TG results in decreased CHD.

Relative potencies of bupivacaine, levobupivacaine, and ropivacaine for neonatal spinal anaesthesia

– Comparing the relative potency of new local anaesthetics such as levobupivacaine and ropivacaine with bupivacaine by the minimum local analgesic concentration model has not been described for neonatal spinal anaesthesia. This information is important to compare agents and to determine the most effective spinal dose. Appropriate doses for infant spinal anaesthesia are 1 mg kg^–1 of isobaric 0.5% bupivacaine and ropivacaine and 1.2 mg kg^–1 of isobaric 0.5% levobupivacaine.

Obstructive Sleep Apnea Is Not a Risk Factor for Difficult Intubation in Morbidly Obese Patients

– In MO patients undergoing bariatric surgery in the "ramped position," there was no relationship between the presence and severity of OSA, BMI, or NC and difficulty of intubation or laryngoscopy grade. Only a Mallampati score of 3 or 4 or male gender predicted difficult intubation.

Blind intubation device for nasotracheal intubation in 100 oral and maxillofacial surgery patients with anticipated difficult airways: a prospective e

The authors have demonstrated the safe and effective use of the blind intubation device in 100 adult patients with anticipated difficult airways. The overall success rates of the oesophagus airway placement, the light–guiding catheter insertion and nasotracheal intubation over the light–guiding catheter were really satisfied. This technique could improve the success of blind nasal intubation, especially in situations in which fibreoptic equipment was unavailable. However, further studies are still required.

Overweight/Obesity and Gastric Fluid Characteristics in Pediatric Day Surgery: Implications for Fasting Guidelines and Pulmonary Aspiration Risk

– Twenty–seven percent of pediatric day surgery patients are overweight/obese. These children may be allowed clear liquids 2 h before surgery as GFV(IBW) averages 1 mL/kg regardless of BMI and fasting interval. Rare emetic episodes were not associated with shortened fasting intervals in this population.

Intensive care adult patients with severe respiratory failure caused by Influenza A (H1N1)v in Spain

– Over a 5–week period, influenza A (H1N1)v infection led to ICU admission in 32 adult patients, with frequently observed severe hypoxemia and a relatively high case–fatality rate. Clinicians should be aware of pulmonary complications of influenza A (H1N1)v infection, particularly in pregnant and young obese but previously healthy persons.

9thWorldCongressForNurseAnesthetists

Adenosine-An Old Drug Newly Discovered

At present, pharmacological approaches to modulate extracellular adenosine signaling are evaluated for their potential use in perioperative medicine, including attenuation of acute lung injury; renal, intestinal, hepatic and myocardial ischemia; or vascular leakage. If these laboratory studies can be translated into clinical practice, adenosine receptor–based therapeutics may become an integral pharmacological component of daily anesthesiology practice.

Acute Severe Arterial Hypertension:Therapeutic Options

– Treatment for hypertensive crisis should achieve a progressive control of blood pressure, avoiding any abrupt decrease in organ blood supply. Therapeutic options are many and different in terms of pharmacokinetics and pharmacodynamic profiles. The best option should be based upon the characteristics of the patient and the pathophysiology of the hypertensive crisis . Of particular interest, some agents are metabolized by blood esterase and have a very short half life (e.g., clevidipine). This allows tight titration of their effect, which is advisable when carefully lowering blood pressure. This is of particular importance when treating hypertensive crisis in surgical patients both intra–operatively or in critical care.

Epidural analgesia in the latent phase of labor at cervical dilation of 1.0 cm or more does not prolong the progression of labor and does not increase

Epidural analgesia in the latent phase of labor at cervical dilation of 1.0 cm or more does not prolong the progression of labor and does not increase the rate of Cesarean in nulliparous women compared with the delayed analgesia at the cervical dilation of 4.0 cm or more.

Infraclavicular brachial plexus blocks

Successful brachial plexus block requires a thorough knowledge of anatomy, both to decide on the appropriate approach and to locate the nerves. The plexus is traditionally found at specific anatomical points by using bony or vascular landmarks, whereas ultrasound allows block of the plexus at any point along its length.

General anaesthesia for Caesarean section

General anaesthesia for Caesarean section is still decreasing in incidence.
General anaesthesia may be indicated due to urgency, maternal refusal of regional techniques, inadequate regional block, or regional contraindications.
Obstetric indications, which were once considered absolute indications for general anaesthesia, such as placenta praevia, are now being routinely performed under regional anaesthesia.
Major complications include failed intubation, aspiration of gastric contents, increased blood loss, and awareness.
Difficulty in intubation is encountered 10 times more often than in the non-obstetric population.