ABSTRACT

Background: Intra-articular drugs and local anaesthetics are the most popular methods for pain relief after arthroscopic knee procedure. Many drugs, including opioids, non-steroidal antiinflammatory drugs, ketamine, clonidine, and neostigmine, have been used intra-articularly. Objectives: The aim of our study was to compare the analgesic effect of intraarticular injection of ketamine bupivacaine and neostigmine bupivacaine in patients undergoing arthroscopic knee surgery under intra-thecal anaethesia. Design: a randomized controlled trial included 100 Patients were randomly divided into two groups 50 patients each, setting: the study was conducted in Assuit university tertiary hospital, Egypt. Intervevtions: Neostigmine group received intra-articular 0.5mg/dose neostigmine + 20 ml 0.25% bubivacaine and ketamine group received intra-articular 0.5 mg/kg ketamine + 20 ml 0.25% bubivacaine. VAS score was used for post-operative evaluation of pain every 4 hours over a 24 hour period. The total analgesic dose and any side effects were also recorded. Results: There were no significant differences in VAS score between the two studied groups but Time to rescue analgesia was significantly longer in the ketamine group (447.70± 48.109 minutes) than in the neostigmine group (257.60± 47.243 minutes) with P value ≤ 0.000. There was a significant difference in the analgesic dose of ketorolac between ketamine group and neostigmine group. Conclusion: Injection of intra-articular ketamine bupivacaine provided better postoperative analgesia, less side effects and low supplementary analgesic dose than intra-articular neostigmine bupivacaine. Trial registration: This study is registered by the local research ethics committee and its Approval Number: IRB00008788 and registered at www.clinicaltrials.gov under number NO: NCT02720705. Key words: analgesic dose, intra-articular, ketamine, neostigmine

Abstract

Background: Microcirculatory function is the main prerequisite for adequate tissue oxygenation and organ function. It transports oxygen and nutrients to tissue cells, ensure adequate immunological function and, in disease, delivers therapeutic drugs to target cells. Recruiting microcirculation, i.e., non-perfused or intermittently perfused capillaries might improve tissue perfusion, mitigating the progression to organ failure and death. Nitroglycerin has been used in different shock states particularly in sepsis. The effect is variable and debatable suggesting an improvement of microcirculation.

Patients and Methods: 60 adult patients with hemorrhagic shock admitted to the Emergency Department within 6 hours of trauma event, resuscitation immediately started according to advanced trauma life support ATLS® protocol 2016 with control of the bleeding source. Nitroglycerine patch 5mg applied to patients after the first hour of resuscitation. The study period corresponded to the outcome of the first 48 hours of trauma unit or ICU resuscitation. Patients considered successfully resuscitated if they had normal lactate levels (≤2mmol/L).

Results: 60 patients enrolled in this study, 10 patients were excluded; 3 of them due to uncontrolled bleeding and 7 due to marked hypotension. 50 patients continued in the study (38 men, 12 women) with mean age was (29.1 ± 10.8ys); of them 45 survived (90%) and 5 did not survive (10%). Patients received mean crystalloid volume (6100 ± 1410.67ml), mean colloid volume (490 ±457.25ml), mean packed RBCs (4.34± 1.33 units), mean fresh frozen plasma (3.08± 1.65 units) and mean nor-adrenaline dose (7.94± 10.55µg/kg/minute). Baseline perfusion index was (0.37±0.21), mean heart rate (128.46± 18.18 beat/minute), systolic blood pressure (78.08 ± 7.47mmHg), diastolic blood pressure (40.20±7.39mmHg), mean arterial pressure (53.44±6.43mmHg), central venous pressure (–1 .46±2.77cmH2O) and baseline modified shock index was (2.45±0.56). Baseline serum lactate was (8.61 ± 1.86 mmol/L), base deficit was (–12.59±5.57). Perfusion index showed statistically significant increase in survivors than non survivors at 12, 18, 24, 30, 36, 42, 48 hours (p<0.001). Serum lactate level was significantly higher in non survivors group than survivor group (p<0.001). Base deficit was significantly higher in non survivors than survivors (p<0.001).

Correspondence to: Dr. Medhat Sayed Ali, E-Mail: medhat_sayed69@yahoo.com

Conclusion: Use of nitroglycerin patch 5mg improved PI at 6 to 48 hours post resuscitation and reduce mortality rate (in this study was 10%) while in other previous studies with the same sample size of hemorrhagic shock patients without use of nitroglycerin it was higher (about 30%).

This study is registered at www.clinicaltrials.gov under number NCT03235921.

Key Words: Base deficit – Nitroglycerin – Perfusion index – Serum lactate.

Introduction

Trauma is the main cause of death in age group less than 45 years. A lot of clinical parameters including heart rate, pulse rate, blood pressure, shock index (SI), and modified shock index (MSI) are used to predict the severity of hemorrhage in trauma patients. In 2012 Choi and colleagues proposed for the first time a new index (NI) based on lactate concentration and peripheral perfusion index for assessment of shock in a rat model. In this trial, we propose for the first time a new severity predicting index (NI) based on lactate concentration/peripheral perfusion ratio as an indicator of hemorrhage-related mortality in humans.

Materials and methods

This prospective trial is a single-center study of 122 consecutive adult polytraumatized patients with hemorrhagic shock admitted to trauma center within 6 h of the trauma, and underwent resuscitation according to the advanced trauma life support protocol (2016). Protocol-related measurements were obtained immediately after admission and over 48 h postresuscitation for metabolic perfusion parameters, serum lactate, perfusion index, and other hemodynamic parameters. The period of the study corresponds to the outcome after 48 h of admission. Resuscitation measures were considered successful when lactate levels were less than or equal to 2 mmol/l in addition to stable macrohemodynamic parameters at the end of this period.

Results

Characteristically, the survivors had NI of 40 ± 2.7 on admission, compared with 87.1 ± 13 of nonsurvivors with highly significant difference. MSI showed a significant difference (nearly doubled) between survivors and nonsurvivors. SI showed nearly the same change, nearly doubled. NI showed lower prediction value for mortality than MSI and SI (P = 0.05) 0.884, 0.905, and 0.908, respectively.

Conclusion

This study confirms, for the first time in humans, the validity of severity index as independent parameter in prediction of mortality in comparison with MSI.

Keywords:

hemorrhagic shock, lactate and perfusion index, modified shock index, severity index, shock index

ABSTRACT

Background: Shoulder pain secondary to laparoscopic interventions may cause more discomfort to the patient than the incision site pain, with a reported incidence varies from 35% to 80%. Aim of the study:–To evaluate the effect of intrathecal dexmedetomidine on incidence and severity of laparoscopy-triggered shoulder tip pain.

Methods: Sixty patients, 1st patient recruited on the 1 July 2017, undergoing elective laparoscopic ovarian cystectomy under spinal anesthesia were randomly allocated to one of the two groups. Group C received intrathecal hyperbaric Bupivacaine 3.5 ml plus 0.5 ml normal saline. Group D received intrathecal hyperbaric Bupivacaine 3.5 ml plus 10 μg dexmedetomidine (0.5 ml). Measurements: Data on the severity of intraoperative shoulder pain were collected using a visual analogue scale.

Results: Twenty-four patients in Group C complained of intraoperative shoulder tip pain, 16 patients (53.3%) required fentanyl which was given in 25 μg increments, and total fentanyl consumption for 16 patients was 875 μg. Two patients were converted into general anaesthesia as pain was intolerable (≥ 4). In Group D, five patients (16.7%) experienced shoulder pain intraoperative with a mean VAS score 0.37 ± 0.9.

Conclusion: Intrathecal dexmedetomidine can effectively decrease the incidence and severity of shoulder tip pain during laparoscopic ovarian cystectomy under spinal anesthesia.

Abstract

a B s t r a c t

BacKgroUND: Post-dural puncture headache (PDPH) is one of the most common complications of neuraxial anesthesia after an accidental dural puncture. this study aimed to test non-interventional alternatives to treat PDPH. our goals were to compare the effectiveness of nebulized dexmedetomidine (DeX) versus neostigmine/atropine in the conservative management of PDPH.

MetHoDs: a randomized double-blind controlled study of ninety (90) women divided into three equal groups: group c (given nebulization of saline 0.9% placebo in four ml), group N (given nebulization of 20 µ/kg neostigmine and 10 µ/ kg atropine diluted in four ml normal saline), and group D (given nebulization of dexmedetomidine 1 µg/kg diluted in four ml normal saline). Nebulization was done twice daily for three days, and a Visual analogue scale pain score (Vas) was recorded for seventy-two hours after the intervention for the three groups with a Vas score equal or less than three being the cutoff value.

RESULTS: VAS was significantly decreased in dexmedetomidine, and neostigmine/atropine groups compared to the

control group at six hours (median Vas: 5, 2, and 2 for groups c, N, and D respectively [P=0.001]). there was a significant difference in VAS trends between the three groups (at six, twelve, twenty-four, thirty-six, and forty-eight hours [P=0.001], and at seventy-two hours [P=0.003]). No patients in group D, but one patient in group N and seven patients in group c needed an epidural blood patch.

coNclUsioNs: Nebulized dexmedetomidine and neostigmine/atropine had a rapid effect on relieving PDPH after cesarean section.

Abstract:

Background: In everyday pediatric anesthesia practice, clinicians frequently exchange an already inserted endotracheal tube because of a leak or resistance causing significant morbidity. We investigated the accuracy of two ultrasound measurements; the transverse cricoid diameter and epiphyseal diameter of the distal radius in the prediction of endotracheal tube size that best fits in children compared to age-based formulas.

Patients: One hundred children (1–6 years) who underwent elective surgery with endotracheal tube whether cuffed (n=50) or uncuffed (n=50) were enrolled. The primary endpoint was the agreement between the reference tube size for which its outer diameter selected based on transverse cricoid diameter and the final Best-Fit-ETT. The Correlation and Bland Altman agreement tests were conducted between Best-Fit-ETT outer diameter and ultrasound measured outer diameter, and between Best-Fit-ETT inner diameter and inner diameter calculated by agebased formulas.

Results: The agreement rate between transverse cricoid diameter based endotracheal tube size and Best-Fit-ETT size was 88% in cuffed group compared to 90% in uncuffed group. A significant positive correlation was reported between the outer diameter of Best-Fit-ETT, and the outer diameter measured by the two ultrasound methods. A lower degree of positive correlation was reported between the inner diameter of Best-Fit-ETT, and the inner diameter calculated by age-based formulas. Bland Altman's analysis showed agreement between Best-Fit-ETT outer diameter and epiphyseal diameter of the distal radius in both groups and with transverse cricoid diameter in the cuffed group, with no agreement with age-based formulas in either group.

Conclusions: Both transverse cricoid diameter and epiphyseal diameter of the distal radius are reliable predictors of the size of Best-Fit-ETT pediatric endotracheal tube compared to age-based formulas. To save time and effort, we recommend the US measurement of the epiphyseal diameter of distal radius in the preoperative visit and documenting the predicted tube size with the preoperative assessments.  

Key Words: Children, Endotracheal tube size, prediction, ultrasound, subglottic, distal radius.

Trial registration: ClinicalTrials.gov (Identifier: NCT03560895).

Background

Audit is an attempt to improve the quality of medical care by measuring the performance in relation to desired standards, whereas re‑audit demonstrates improvements that have been made.

Patients and methods

A prospective study was performed through a medical audit of 100 patients at the endoscopy unit of El‑Rajhi Hospital University between January and December 2017. Revision of upper endoscopy, including indications, preparations, and complications, was done.

Results

The mean age was 59 years. The most frequent comorbidities were liver cirrhosis (70%) and diabetes mellitus (25%). All patients were indicated for endoscopy, as the majority (70%) of patients required urgent upper endoscopy secondary to upper gastrointestinal tract bleeding

in contrast to the previous study as 4% of patients were not indicated. There was an increase in the percentage of complications in our study owing to the increased percentage of postband ulcers (92%) in comparison with the previous study (90%).

Conclusion

Improvement in our practice was noticed after recommendations of the previous audit regarding preparation and indications. It is important that a re‑audit takes place following the implementation of changes.