Day-case laparoscopy: a comparison of prophylactic opioid, NSAID or local anesthesia for postoperative analgesia

BACKGROUND: The study was aimed to evaluate the analgesic efficacy, postoperative comfort, recovery characteristics and side effects of three different analgesic agents administered prophylactically. METHODS: Eighty patients undergoing day-case minor operative laparoscopy were randomly allocated into four groups to receive tenoxicam 20 mg i.v. (Group T), fentanyl 100 microg i.v. (Group F), 5 ml of bupivacaine 2.5 mg/ml for infiltration of trocar sites (Group B), 30, 10 and 5 min before incision respectively. Bupivacaine, 35 ml, 2.5 mg/ml was also administered into the pelvic cavity in Group B. Group P received only placebo. Postoperative pain, analgesic requirements, first response to verbal stimulus, first analgesic requirement, ability to walk without help, to drink and to void, blood pressures, SpO2 and respiration rates were recorded in the PACU. Postoperative pain was evaluated by verbal rating scale. Pain scores, analgesic requirements and side effects were evaluated by telephone calls until the 48th postoperative hour. RESULTS: Postoperative pain scores were lower and time to requirement of rescue analgesics was longer in groups F and B compared to Group P. In the PACU, analgesic requirements were lower in Group B, compared to Group P. Nausea and vomiting were increased in Group F. CONCLUSION: Tenoxicam 20 mg i.v. was found to be ineffective whereas bupivacaine was superior to other groups in reducing pain and analgesic requirements. Bupivacaine also increased time to first analgesics and obtained better recovery characteristics, underlining its value in prophylactic pain management compared to the other two agents.     

The effect of intravenous paracetamol for the prevention of rocuronium injection pain

Rocuronium is a nondepolarizing neuromuscular blocking agent used in anesthesia induction and is associated with considerable discomfort and burning pain during injection, which is reported to occur in 50–80% of patients. This study was carried out to investigate the effectiveness of intravenous paracetamol pretreatment compared with lidocaine and normal saline to prevent rocuronium injection pain. The study included 150 ASA I–II patients undergoing elective orthopedic, gastrointestinal, and gynecological procedures under general anesthesia. They were allocated into three groups according to pretreatment drugs: lidocaine (40 mg) (n = 50), paracetamol (n = 50), and normal saline group (n = 50). Before anesthesia induction with propofol, all patients were pretreated with rocuronium. The pain caused by the injection was evaluated. Local signs were assessed on the arm at the end of the injection, as well as 24 hours after recovery from anesthesia. There were no patients with blurred speech or vision and there was no respiratory depression in any group after pretreatment with the study drug. The level of pain on injection was statistically lower in those who had received paracetamol compared to normal saline (p = 0.009). There were more patients in the saline group with severe pain (p < 0.001). Paracetamol relieved the rocuronium injection pain better than normal saline but lidocaine was the best of the three drugs (p < 0.001).     

Biglycan protects cardiomyocytes against hypoxia/reoxygenation injury: Role of nitric oxide

Biglycan, a proteoglycan component of extracellular matrix, has been suspected to contribute to the development of atherosclerosis, but overexpression of biglycan in transgenic mice has been shown to induce cardioprotective genes including nitric oxide (NO) synthases in the heart. Therefore, here we hypothesized if exogenous administration of biglycan exerts cytoprotection. Primary cardiomyocytes from neonatal rats were subjected to 150 min hypoxia and 2 h reoxygenation. Mortality of cardiomyocytes was dose-dependently attenuated by pretreatment with 1-100 nM biglycan. Biglycan enhanced eNOS mRNA and protein, and significantly increased NO content of cardiomyocytes. The NO synthase inhibitor l-nitro-arginine-methyl-ester significantly attenuated the cytoprotective effect of biglycan. This is the first demonstration that biglycan leads to cytoprotection against hypoxia/reoxygenation injury, and that this phenomenon is partially mediated by an NO-dependent mechanism.     

Ketamine sedation during spinal anesthesia for arthroscopic knee surgery reduced the ischemia-reperfusion injury markers

We studied the effect of ketamine sedation on oxidative stress during arthroscopic knee surgery with tourniquet application by determining blood and tissue malonyldialdehyde (MDA) and hypoxanthine (HPX) levels. Thirty ASA I-II patients undergoing arthroscopic knee surgery with tourniquet were randomly divided into two groups. Spinal anesthesia induced with 12.5 mg bupivacaine was administered to all patients. In the ketamine group, after IV administration of 0.01 mg/kg midazolam, a continuous infusion of ketamine (0.5 mg . kg(-1) . h(-1)) was used until the end of surgery whereas the placebo group received a volume-equivalent placebo infusion. Ramsey Sedation Scale (RSS) was used for assessing the sedation level. Venous blood and synovial membrane tissue samples were obtained before ketamine infusion, at 30 min of tourniquet ischemia, and at 5 min after tourniquet deflation for MDA and HPX measurements. Tissue MDA and HPX levels were significantly less in the ketamine group than the control group after reperfusion. RSS scores were higher in the ketamine group without any adverse effect. We conclude that ketamine sedation attenuates lipid peroxidation markers in arthroscopic knee surgery with tourniquet application.     

Remifentanil versus propofol sedation for peribulbar anesthesia

The short onset and offset of remifentanil may allow for accurate dosing of sedative effect with few side-effects and rapid recovery. In this study, remifentanil is compared with propofol for sedation intraocular pressure hemodynamics and oxygen saturation, in patients undergoing cataract surgery with peribulbar block. After ethical committee approval, fifty patients scheduled for one eye cataract surgery were enrolled into the prospective study. Remifentanil infusion was initialized at a rate of 0.04 microg/kg/min, 10 min before peribulbar anesthesia in Remifentanil group (Group R). In Propofol Group (Group P), propofol infusion of 2 mg/kg/h was reduced to 1mg/kg/h. Intraocular pressures of the contralateral eye were measured before and after peribulbar anesthesia and at the end of the operation. Sedation scores (1-5), hemodynamic parameters and saturation were assessed at 5 minute intervals. Heart rate, intraocular pressure, saturation and sedation scores were similar between groups. Intraocular pressures decreased within time in both groups. There were significant changes in mean blood pressure after 5th min between groups (P < 0.05). The infusion of remifentanil or propofol for sedation provided adequate sedation, hemodynamic stability without increasing intraocular pressure during surgery in patients undergoing cataract surgery with peribulbar anesthesia.     

Repeated attacks of venous air embolism during endoscopic sinus tumor surgery: a case report

Repeated attacks of venous air embolism during an operation is a very rare situation. We report a case of multiple venous air emboli during an endoscopic surgery of a sphenoidal sinus tumor.     

Upper cervical vertebrae movement during intubating laryngeal mask, fibreoptic and direct laryngoscopy: a video-fluoroscopic study

BACKGROUND AND OBJECTIVE: Minimizing cervical vertebrae motion during endotracheal intubation is important in patients with cervical instability. The aim of this study was to compare upper cervical spine extension during endotracheal intubation using three different techniques. METHODS: Duration of intubation and movement of upper cervical vertebrae during endotracheal intubation were compared in 33 patients undergoing lumbar laminectomy. Patients requiring tracheal intubation under general anaesthesia and neuromuscular blockade were randomly allocated into three groups - direct laryngoscopy, intubating laryngeal mask (LM) airway and fibreoptic laryngoscopy. The procedure was recorded by video-fluoroscopy and analysed with computer-assisted measurements. The maximum movement of the C1/C2 and C2/C3 vertebrae during intubation were obtained. Data were analysed using one-way analysis of variance with Bonferroni and Kruskal-Wallis tests. RESULTS: We found statistically significant movement between the first and second, but not between the second and third cervical vertebrae. The mean (+/-SD) movement at C1/C2 was 10.2 +/- 7.3 degrees with direct laryngoscopy, 5.0 +/- 6.3 degrees with LM and 1.6 +/- 3.2 degrees with fibreoptic laryngoscopy. This difference was statistically significant (P = 0.01) between the direct and fibreoptic laryngoscopy groups. The maximum movement at C2/C3 was 2.2 +/- 10.1 degrees with direct laryngoscopy, 3.5 +/- 5.1 degrees with LM and 0.5 +/- 3.2 degrees with fibreoptic laryngoscopy. Duration of intubation was significantly longer in the intubating LM group (P < 0.001). CONCLUSION: We conclude that fibreoptic laryngoscopy is the more suitable intubation technique when cervical spine movement is not desired.