Vol. 23, No. 3 (263-378)
)Hamlet-Act. III, Sc. ii(
Middle East Journal of Anesthesiology
”For some must watch, while some must sleep“
VOLUME 23, No. 3, October 2015
ISSN 0544-0440
October 2015
MIDDLE EAST JOURNAL OF ANESTHESIOLOGY
Department of Anesthesiology
American University of Beirut Medical Center
P.O. Box 11-0236. Beirut 1107-2020, Lebanon
Editorial Executive Board
Consultant Editors
Editor-In-Chief:
Bikhazi George
Assem Abdel-Razik
(Egypt)
Executive Editors
Mohamad El-Khatib
Editors
Chakib Ayoub
Marie Aouad
Ghassan Kanazi
Sahar Siddik-Sayyid
Mohamad El-Khatib
mk05@aub.edu.lb
Bassam Barzangi
(Iraq)
Izdiyad Bedran
(Jordan)
Dhafir Al-Khudhairi
(Saudi Arabia)
Mohammad Seraj
(Saudi Arabia)
Abdul-Hamid Samarkandi
(Saudi Arabia)
Mohamad Takrouri
(Saudi Arabia)
Bourhan E. Abed
(Syria)
Mohamed Salah Ben Ammar
(Tunis)
Managing Editor Assistant Iman Jaafar
M. Ramez Salem
(USA)
Webmaster
Rabi Moukalled
Elizabeth A.M. Frost
(USA)
Secretary
Alice Demirdjian
ad11@aub.edu.lb
Halim Habr
(USA)
Managing Editor
Founding Editor
Bernard Brandstater
Emeritus Editor-In-Chief Anis Baraka
Honorary Editors
Nicholas Greene
Musa Muallem
The Middle East Journal of Anesthesiology is a publication of the Department of Anesthesiology of the
American University of Beirut, founded in 1966 by Dr. Bernard Brandstater who coined its famous motto:
“For some must watch, while some must sleep” (Hamlet-Act. III, Sc. ii).
and gave it the symbol of the poppy flower (Papaver somniferum), it being the first cultivated flower in the
Middle East which has given unique service to the suffering humanity for thousands of years. The Journal’s
cover design depicts The Lebanese Cedar Tree, with’s Lebanon unique geographical location between East
and West. Graphic designer Rabi Moukalled
The Journal is published three times a year (February, June and October) The volume consists of a two year
indexed six issues. The Journal has also an electronic issue accessed at www.aub.edu.lb/meja
The Journal is indexed in the Index Medicus and MEDLARS SYSTEM.
E-mail: meja@aub.edu.lb
Fax: +961 - (0)1-754249
“For some must watch, while some must sleep”
(Hamlet-Act. III, Sc. ii)
Middle East Journal of Anesthesiology
Vol. 23, No. 3, October 2015
CONTENTS
editorial
Unusual Response To Muscle Relaxants In The Pregnant Woman Undergoing Cesarean Section
��������������������������������������������������������������������������������������������������������������������������������� Anis Baraka
265
scientific articles
Comparison of the Effects of Intrapleural Bupivacaine and Morphine on Post-Thoracotomy Pain
��������������������������������������������������������������� Abdolhossein-Davoodabadi, Mohammad Reza-Fazel,
Hamid Reza-Vafaei, Shohreh Parviz
Rapid Fluid Administration And The Incidence Of Hypotension Induced By Spinal Anesthesia
And Ephedrine Requirement: The Effect Of Crystalloid Versus Colloid Coloading
����������������������������������������������������������Hakki Unlugenc, Mediha Turktan, Ismail Cuneyt Evruke,
Murat Gunduz, Refik Burgut, Hacer Yapicioglu-Yildizdas, Geylan Isik
Opioid Administration as Predictor of Pediatric Epidural Failure
�������������������������������������������������������������������������������������������� James J. Mooney, Ashley McDonell
Comparison of Pre-emptive Effect of Meloxicam and Celecoxcib on Post-Operative Analgesia: A
Double-blind, Randomized Clinical Trial
��������������������������������������������������������������������� Omid Aghadavoudi, Hamid Hajigholam Saryazdi,
Amir Shafa, Alireza Ramezani
Clinical research regarding preemptive analgesic effect of ketamine after transurethral
267
273
283
289
resection of prostate
����������������������������������������������������������������������Na Wang, Yaowen Fu, Haichun Ma, Jinguo Wang
Anesthetic Sparing Effect Of Intraoperative Lignocaine Or Dexmedetomidine Infusion On
Sevoflurane During General Anesthesia
������������������������������������������������������Siddarameshwar S. Harsoor, Devika Rani D., Roopa M. N.,
Lathashree S., Sudheesh K., Nethra S. S.
Submucosal dissection of the retropharyngeal space during nasal intubation
���������������������������������������������������������Mumin Hakim, Richard S. Cartabuke, Senthil G. Krishna,
Giorgio Veneziano, Ahsan Syed, Meredith N. Merz Lind,
Joseph D. Tobias
A Prospective Randomized Comparative Study To Compare The Haemodynamic And Metabolic
Stress Respone Due To Endotracheal Intubation And I-Gel Usage During Laparoscopic
Cholecystectomy
���������������������������������������������������������������������������� Saumya Biswas, Ratan Das, Priyanka Ghosh,
Prof Gauri Mukherjee
Comparative Evaluation Of Plain And Hyperbaric Ropivacaine In Patients Undergoing Lower
Abdominal Surgery Under Spinal Anesthesia
���������������������������������������������������������������������Puneet Dwivedi, Anu Kapur, Sanjay Kumar Gupta
263
295
301
209
315
321
M.E.J. ANESTH 23 (3), 2015
The Beneficial Values Of Transoesophageal Doppler In Intraoperative Fluid Guidance Versus
Standard Clinical Monitoring Parameters In Infants Undergoing Kasai Operation
���������������������������������������������������Eman Sayed Ibrahim, Taha Aid Yassein, Wesam Saber Morad
331
CASE REPORTS
Bilateral Adductor Vocal Cord Palsy: Complication of Prolonged Intraoperative Hypotension
after Endotracheal Intubation’
���������������������������������������������������������������������������������� Rajnish K. Nama,Guruprasad P. Bhosale,
Bina P. Butala, Ankit R. Sharma
Management of anesthesia in an infant with glycogen storage disease type II (Pompe disease)
������������������������������������������������������������� Abdulaleem Al Atassi, Nezar Al Zughaibi, Anas Naeim,
Abdulatif Al Basha, Vassilios Dimitriou
339
343
Recurarization after acute intraoperative normovolemic hemodilution and use of sugammadex
������������������������������������������������������ Bruno L. C. Araujo,Alfredo G. H. Couto, Daniele Theobald
347
Malpositioned LMA Confused As Foreign Body In Nasal Cavity
�������������������������������������������������������������������������� Sidharth Verma, Nitika Mehta, Nandita Mehta,
Satish Mehta, Jayeeta Verma
Optical Laryngoscope for Tracheal Intubation in a Patient with an uncommon Giant Lipoma on
the posterior aspect of neck and additional risk factors of anticipated difficult airway: A
Case Report
���������������������������������������������������������Vassilios Dimitriou, Amr El Kouny, Mohammed Al Harbi,
Freddie Wambi, Nasser Tawfeeq, Aziz Tanweer,
Abdulallem Al Atassi, Georges Geldhof
Diagnosis of Aortic Thrombus After Pelvic Surgery
351
355
�������������������������������������������������������������������������Kenneth S. Tseng, Yan H. Lai, Christina L. Jeng
359
Bilateral Superficial Cervical Blocks As The Primary Anesthetic For The Patient Undergoing
An Evacuation Of Neck Hematoma After Parathyroid Surgery
���������������������������������������������������������������������������������������������������� Benjamin Heller, Adam Levine
363
Extra Corporeal Membrane Oxygenation in Acute Respiratory Distress Syndrome
��������������������������������������������������������������� Manjush Karthika, Farhan Al Enezi, Lalitha V. Pillai,
Salem Al Qahtani and Sami Al Solamy
367
LETTER TO THE EDITOR
Seven-Day Hospital Model: A Futuristic Actuality
������������������������������������������������������������������������������������������������������������������������������Deepak Gupta
371
Does cisatracurium at a clinical dose attenuate the immunosuppression after surgery in smoking
patients with non-small cell lung cancer?
�������������������������������������������������������������������� Wen-qin Sun, Dao-bo Pan, Ai-guo Zhou, Hong Mo
375
264
EDITORIAL
UNUSUAL RESPONSE TO MUSCLE RELAXANTS
IN THE PREGNANT WOMAN UNDERGOING
CESAREAN SECTION
Succinylcholine is usually recommended for tracheal intubation in the pregnant woman
scheduled for Cesarean section under general anesthesia, while nondepolarising relaxant is used to
maintain muscular relaxation throughout surgery. However, the use of both muscle relaxants may
be complicated by the physiological and/or the pathological changes associated with pregnancy.
Because the parturient should be always considered as a patient with a full stomach and a
possible difficult airway, succinylcholine is considered the muscle relaxant of choice for rapid
sequence induction of general anesthesia. During pregnancy, the level of plasma cholinesterase
which hydrolyses succinylcholine is moderately decreased, and hence hydrolysis of succinylcholine
remains within the normal range. Also, the duration of action of succinylcholine will be only
moderately prolonged in the heterozygote atypical parturient. However, in the parturient
inheriting homozygote atypical esterase, hydrolysis of the injected succinylcholine is negligible
with a consequent very prolonged neuromuscular block, which allows the transmission of the
unhydrolysed succinylcholine across the placenta to the fetal circulation. This can be complicated
by neuromuscular block in the fetus who may have inherited a homozygote atypical plasma
cholinesterase if the father is homozygote or heterozygote carrier of the enzyme.
In addition to the possible prolonged neuromuscular block, succinylcholine administration
may result in rare but very serious complications such as anaphylactic reactions. Also, it can trigger
excessive potassium release in the parturients suffering from denervation conditions such as the
quadriplegic patient or patients suffering from neurologic diseases such as guillan Barré syndrome.
The abnormal response to muscle relaxants during pregnancy is not limited to succinylcholine,
but can also complicate nondepolarising muscle relaxants. Administration of nondepolarising
relaxants during repeated Cesarean section can result in seriousIgE-mediated anaphylactic reaction
which may culminate in maternal cardiac arrest. Fortunately, the placenta plays an important role
in protecting the fetus against drug-induced anaphylactic reaction in the parturient. The placental
barrier will prevent crossing of the high molecules-weight IgE antibodies to the fetus. Also, the high
diamine oxidase of the maternal decidua will catalyze the oxidative deamination of histamine and
other related endogenous amines released during anaphylaxis. Several case reports document the
successful resuscitation of pregnant women in cardiac arrest after perimortem Cesarean delivery.
The time interval from cardiac arrest to delivery is probably the single most important factor for
fetal survival. If the fetus is delivered within 5 minutes, intact neurological survival is increased for
both the mother and the newborn.
Abnormal response to nondepolarizing muscle relaxants during pregnancy can also occur in
the undiagnosed myasthenia gravis parturient. Myasthenia gravis is easily missed during pregnancy.
Misdiagnosis might lead to serious complications affecting both the mother and the neonate. The
mother given the normal dose of nondepolarizing muscle relaxant can develop a prolonged and
profound neuromuscular block which cannot be adequately reversed by neostigmine. Also, the
neonate may develop transient myasthenia gravis symptoms. The onset of neonatal myasthenic
265
M.E.J. ANESTH 23 (3), 2015
266
symptoms occur within the first two hours following
delivery in 75% of the cases for a mean duration of
18 days.
Whenever nondepolarising relaxants are used
in ecclamptic patients receiving magnesium sulphate
therapy, its dose should be carefully titrated. The
anticonvulsant effect of magnesium is usually attributed
to both its central depressant action and its peripheral
depressant effect on neuromuscular transmission. At
the neuromuscular junction, magnesium deceases the
presynaptic release of acetylcholine, as well as reduces
the sensitivity of the post-junctional membrane to the
liberated acetylcholine, and decreases the excitability
of the muscle fibers membrane. These effects will
potentiate the action of the neuromuscular blocking
drugs, particularly the neuromuscular block of
nondepolarising relaxants. Also, whenever magnesium
is administered postoperatively to toxemic patients
recovering from general anesthesia including muscle
relaxants, its dose should be carefully titrated to avoid
post operative recurarization.
Anis Baraka
Pheochromocytoma during pregnancy may
mimic the usual symptoms and signs of preeclampsia.
Paroxysmal attacks may be precipitated by postural
changes, the mechanical effect of the gravid uterus in
the last trimester, uterine contractions during labor and
increased fetal movements. These signs and symptoms
may mimic that of preeclampsia and is therefore often
missed, and misdiagnosed as preeclampsia. However,
hypertension associated with pheochromocytoma
is seldom accompanied by oedema or proteinuria,
while glycosuria is often present. Fortunately, the
use of intravenous labetalol or hydralazine as well
established in preeclampsia, and its use in combination
with magnesium sulphate has been recommended in
patients with pheochromocytoma. In this situation,
the interaction of magnesium sulphate with muscle
relaxants must be considered.
Anis Baraka, MD, FRCA (Hon)
Emeritus Professor of Anesthesiology
American University of Beirut
References
1. Baraka A, Haroun S, Bassili M, Abu-Haidar G: Response of the
newborn to succinylcholine in an atypical homozygote mothers.
Anesthesiology; 1975, 43:115.
2. Anis Baraka, Samia Sfeir: Anaphylactic cardiac arrest in a
parturient/Response of the newborn. JAMA; 1980, 243:1745.
3. Nada Usta, Anis Baraka: Undiagnosed myasthenia gravis in a
parturient undergoing Cesarean section-Maternal and neonatal
complications. MEJ Anesth; 1984, 7(4):277-281.
4. Anis Baraka, Aida Dajani, Sahar Tabagi: Magnesium induced
respiratory arrest in a parturient recovering from general anesthesia
– a case report. MEJ Anesth; 1984, 7:437-440.
5. Katz VL, Dorrers DJ, et al: Perimortem Cesarean delivery. Obstet
Gynecol; 1986, 68:571.
6. Anis Baraka, Alex Yazigi: Neuromuscular interaction of magnesium
with succinylcholine-vecuronium sequence in the ectopic parturient.
Anesthesiology; 1987, 67:806-808.
7. Poole JH, Long J: Maternal mortality – a review of current trends.
Crit Care NursClim North Am; 2004, 16:227-230.
8. Mudsmith JG, Thomas CE and Browne PA: Undiagnosed
pheochromocytoma mimicking severe preeclampsia in a pregnant
woman at term. International Journal of Obstetric Anesthesia 15;
2006, pp. 240-245.
9. James MFM, Adrenal Medulla: The anesthetic management of
pheochromocytoma. In Anesthesia for patients with endocrine
disease. Edited by MFM James. Oxford University Press; 2010,
Chapter 8, pp. 149-168.
10.Anis Baraka: Undiagnosed pheochromocytoma complicated with
perioperative hemodynamic crisis and multiple organ failure. In:
Pheochromocytoma – A new view of the old problem. Edited by
Jose Fernando Martin. Intechweb.org 2011, chapter 10, pp. 135-148.
SCIENTIFIC ARTICLES
Comparison of the Effects of
Intrapleural Bupivacaine and Morphine
on Post-Thoracotomy Pain
Abdolhossein-Davoodabadi*, Mohammad Reza-Fazel**,
Hamid Reza-Vafaei*** and Shohreh Parviz****
Background: Post-thoracotomy pain is the most severe types of postoperative pain. This
study compares the effects of intrapleural bupivacaine and morphine on post-thoracotomy pain.
Methods: In a double blind clinical trial study, 30 patients candidate for unilateral thoracotomy
were randomly divided into bupivacaine and morphine groups. Patients in the morphine group
received 0.2 mg/kg morphine and those in the bupivacaine group received 1 mg/kg bupivacaine by
an intrapleural catheter placed at the end of surgery by direct vision. Intrarpleural morphine and
bupivacaine continued every 4 hours for the next 24 hours. If required, systemic analgesia with
morphine (patient-controlled analgesia, PCA) also used as a postoperative analgesic. The amount
of morphine consumption and level of postoperative pain at 2, 6, 12 and 24 hours after surgery
were recorded.
Results: Patients did not differ significantly in terms of age, gender and duration of surgery.
There were no significant differences between the two groups with regard to their mean score
of pain at 2 and 6 hours of the surgery; however, the level of pain was significantly lower in the
bupivacaine group compared to the morphine group at 12 and 24 hours of the surgery. In the
bupivacaine group, the mean level of intravenous opioid used over the 24 hours following surgery
was significantly lower than in the morphine group.
Discussion: Intrapleural injection of bupivacaine can be more effective in reducing postthoracotomy pain compared to intrapleural morphine.
Introduction
Post-thoracotomy pain is the most severe types of post-operative pain and occurs in more
than 70% of patients. Pain control and restoration of proper lung function is a primary objective
in the post-thoracic surgery period1. By creating a vicious cycle of hypoventilation, discharge
accumulation and atelectasis the pain causes hypoxia, hypercapnia and, consequently, progressive
intrapulmonary shunt, and ultimately exacerbates the patient’s problems2. In addition, the failure
to properly improve pain leads to stressful postoperative responses and endocrine and metabolic
* Associated Professor of Surgery, Trauma Research Center. Kashan University of Medical Sciences, Kashan, I.R. Iran
** Associated Professor of Anesthesiology, Trauma Research Center. Kashan University of Medical Sciences, Kashan, I.R.
Iran, E-mail: drmfazel@yahoo.com
*** Surgeon, Shahid Beheshti Hospital, Kashan University of Medical Sciences, Kashan, IR Iran.
****Master of Critical Care, Shahid Beheshti Hospital, Kashan University of Medical Sciences, Kashan, IR Iran.
Corresponding author: Fazel-Mohammad Reza, Trauma Research Center. Kashan University of Medical Sciences,
Kashan, I.R. Iran Matini Hospital-Amirkabir Avenue-Kashan IRAN. Phone: 00989132760380, Fax: 00983615342025.
E-mail: drmfazel@yahoo.com
267
M.E.J. ANESTH 23 (3), 2015
268
disorders3. Given that most patients undergoing
thoracotomy have underlying cardiopulmonary
problems and are usually ASA (American Society of
Anesthesiologists) III and IV, pain control becomes
even more important3. Accordingly, some surgeons
tend to use less harmful techniques such as musclesparing posterolateral thoracotomy or video-assisted
thoracoscopy4,5, while others focus on improving pain
management techniques, such as the use of regional
anesthesia, epidural anesthesia, and intravenous
patient-controlled analgesia. Another pain management
technique used is the intrapleural anesthesia - an
effective simple technique with few side-effects6,7. In
this technique a catheter is placed between the visceral
and parietal pleura, which then exits through the skin
and thus a permanent or intermittent anesthetic infusion
is performed. Numerous studies have confirmed the
effects of intrapleural bupivacaine and morphine on
post-thoracotomy pain as well as their minimal sideeffects7,8,9. Considering the different mechanisms of
these two drugs and the potential side-effects of each,
this study aims to compare the effects of intrapleural
bupivacaine and morphine on post-thoracotomy pain.
Methods
Fazel-Mohammad Reza et. al
0.5%-1% isoflurane and 100% oxygen. Atracurium was
repeated according to neuromuscular monitoring of the
patient while fentanyl dosage was repeated every hour
with the last does given 30 minutes before the end of
surgery. Surgery was performed with a posterolateral
incision on the 5th and 6th intercostal space. At the end
of the surgery, an 18G epidural needle was inserted
through the 1st intercostal space right above the incision
line and a 20 G catheter was inserted into the pleural
space at approximately 15 cm insertion level, the
catheter was fixed to the parietal pleural while sutured
to the skin. Two posterior or anterior chest tubes were
then inserted. At this stage, the patients were divided
into either morphine or bupivacaine group using the
random number table. Prior to extubating the patient,
the chest tube was blocked for about 15 minutes
and the initial dose of both drugs were administered
interpleurally. Patients in the morphine group received
0.2 mg/kg morphine sulfate while patients in the
bupivacaine group received 1 mg/kg bupivacaine.
After reversal of the muscle relaxant with 0.04 mg/
kg atropine and 0.07 mg/kg neostigmine and ensuring
proper ventilation, the patients were extubated and
then transferred to the recovery room followed by
admission to the ICU. Patients who required tracheal
intubation after surgery were excluded from the study.
In a double-blind and random manner, 30
patients of ASA of class I-III aged between 18 and 80
years admitted to Shahid Beheshti hospital of Kashan
for elective unilateral thoracotomy were selected.
Patients with allergic reactions to local anesthetics,
obesity (Body Mass Index greater than 40), significant
central nervous system disease, who have pneumonia,
empyema, or known pleuritic, with a history of
alcohol, drugs, anticonvulsants, antidepressants,
benzodiazepines, antihistamines consumption, as well
as patients with liver and kidney failure were excluded.
After 4 hours from first intrapleural injection,
patients in the morphine group received 0.1 mg/kg
morphine sulfate, while patients in the bupivacaine
group received 1 mg/kg bupivacaine and continued
to receive the drugs every 4 hours for 24 hours. In
both groups, the chest tube was closed for 30 minutes
prior to the administration of the drugs. Syringes
containing equal volumes (40 ml) of drugs were
prepared by trained nurse not involved in the study and
administered by surgeon blinded to the contents and
then the questionnaires were completed.
Following the approval of the university’s Ethics
Committee and after obtaining the patients’ informed
consent, they were admitted to the operating theater
and received 10 mg/kg Ringer’s lactate solution
intravenously. Premedication was performed with
0.05 mg/kg midazolam in addition to 2 µg/kg fentanyl.
General anesthesia was induced using 5 mg/kg
thiopental while 0.5 mg/kg atracurium was used for
facilitating intubation. Anesthesia was maintained with
Patients in both groups received intravenous
patient-controlled analgesia (PCA) with morphine
(0.2mg/ml, 4 ml /hour background infusion, 1ml /
15 min bolus dose, lockout 15 minutes) with a PCA
device for 24 hours postoperatively. Pain scores were
calculated at 2, 6, 12 and 24 hours of the surgery
(from hour zero of recovery) during the rest and deep
breathing, using the Visual Analogue Score (VAS)9.
Fifteen five patients per group was calculated
Post-Thoracotomy Pain Management
269
with a power of 80% for detecting a 50% difference in
pain scores between the 2 study groups at a significance
level of 0.05.
Demographic characteristics of patients, duration
of surgery, the amount of morphine consumption, pain
at 2, 6, 12 and 24 hours after surgery during the rest
and the deep breathing were recorded and analyzed
by SPSS software. Statistical tests of the T-test, and
chi-square test was used. Data are presented as mean±
standard deviation(Mean±SD). A p-value 0.05 was
considered significant.
Results
Patients demographics for both group were not
statistically different (Table1).
There was no significant difference between the
bupivacaine and the morphine group with respect to
the mean scores of pain at rest and deep breathing at 2
and 6 hours after the surgery; however, the level of pain
at rest and deep breathing was significantly lower in
the bupivacaine group at 12 and 24 hours after surgery
compared to the morphine group (Table 2) (Table 3).
Discussion
Effective postoperative pain management is an
integral part of the treatment procedure of patients
undergoing thoracic surgery10. Several methods are
used to relief pain after thoracotomy11-14. In this study
we used intrapleural bupivacaine and morphine on
post-thoracotomy pain The mean scores of pain at rest
and deep breathing at 2 and 6 hours after the surgery
in two groups were equal; however, the level of pain
Table 1
Mean age, duration of surgery and sex in the two groups
group
Bupivacaine
Morphine
P-value
Variable
44.46±15.08
48.02±18.34
0.54
Sex(Male/Female)
Age(Mean±SD)
18/12
16/14
0.1
Duration of surgery
(Mean±SD)
108.4±10.41
105.73±5.71
0.08
Table 2
Visual Analog Scores in the two groups after surgery at rest
group
Postoperative pain
VAS at 2 hrs
Bupivacaine
Morphine
P-value
3.66±0.89
4.06±1.27
0.331
VAS at 6 hrs
3.73±0.79
3.80±0.77
0.81
VAS at 12 hrs
2.53±0.51
3.33±0.81
0.003
VAS at 24 hrs
1.73±0.59
2.53±0.74
0.003
Table 3
Visual Analog Scores in the two groups after surgery with deep breath
group
Postoperative pain
Bupivacaine
Morphine
P-value
VAS at 2 hrs
4.20±0.77
4.66±1.06
0.43
VAS at 6 hrs
4.4±0.73
4.46±0.91
0.82
VAS at 12 hrs
3.13±0.63
4.20±0.56
<0.001
VAS at 24 hrs
2.26±0.45
3.66±0.48
<0.001
Morphine consumption with the PCA device (Mean±SD) was significantly lower in the bupivacaine group compared
to the morphine group during the 24 hours period after surgery (Figure 1).
M.E.J. ANESTH 23 (3), 2015
270
Fazel-Mohammad Reza et. al
Fig. 1
Morphine consumption with the PCA (Mean±SD)
in the two groups during 24 hours after surgery
at rest and deep breathing was significantly lower
in the bupivacaine group at 12 and 24 hours after
surgery compared to the morphine group. Morphine
consumption was significantly lower in the bupivacaine
group compared to the morphine group during 24
hours after surgery. In a study, Mann et al16 used a 50
mg/kg of intrapleural bupivacaine every 4 hours for
post-thoracotomy pain and succeeded in significantly
reducing postoperative pain compared to the negative
control group. In another study conducted by Mansuri
et al17 in order to control post coronary artery bypass
pain, 20 ml 2.5%intrapleural bupivacaine (50 mg)
was used prior to the surgery, which led to a lower
postoperative pain in the bupivacaine group compared
to the control group. In Kadkhodaie et al18 study,
patients received 2 mg/kg bupivacaine through the
thoracic catheter post-thoracotomy and were compared
the group that received intravenous pethidine. Results
showed the same level of pain in both groups but
greater complications in the pethidine group. On
the other hand, other studies have investigated the
effects of intrapleural opioids. Dabir et al19 compared
0.2 mg/kg intrapleural morphine against intravenous
morphine and showed that intrapleural morphine is
more effective. Few studies have compared the effects
of intrapleural opioids and bupivacaine. Esem et al20
evaluated the effects of intermittent paravertebral
intrapleural bupivacaine and morphine on pain
management in patients undergoing thoracotomy
and compared with intermittent systemic analgesia
over a period of 72 hours. Pain score was lower in
the morphine and bupivacaine groups compared with
control group at all postoperative time points. After
6 and 24 hours, the level of pain was lower in the
morphine group compared to the bupivacaine group.
In a study by Dabir et al21 intrapleural morphine
resulted in greater pain reduction compared to the
bupivacaine group. In the present study, however, no
significant difference was observed in the analgesic
effects of morphine and bupivacaine in the first 6
hours after surgery, but after 12 and 24 hours of the
surgery, the level of pain was significantly lower in the
bupivacaine group compared to the morphine group.
For understanding the differences between the results
of the present study compared to results of other
studies, two major. First, a lower dose of morphine was
used in the present study compared to other studies.
The initial dose of intrapleural morphine used was
0.2 mg/kg, which was repeated at a dose of 0.1 mg/
kg every 4 hours; however, in the studies by Dabir et
al19 and Esem et al20, a 0.2 mg/kg dose of intrapleural
morphine was used and repeated every 4 hours so that
their maintenance dose of morphine was twice as in the
current study. In the aforementioned studies, the higher
dose of opioids used can justify the lower degree of pain
in the morphine group compared to the bupivacaine
group. Second, difference can also be attributed to
the direct effects of opioids on pain terminals in the
Post-Thoracotomy Pain Management
pleural space. Many human and animal studies have
shown that in addition to their central effects, opioids
can also develop analgesia in surgery-damaged
tissues by affecting the peripheral pain receptors at
nerve endings. Another point that has been proved
in human and animal studies is that the topical and
systemic use of d, k and m receptor agonists and the
endogenous opioids affect the damaged tissues more
than the healthy tissues22,23. These opioid receptors are
placed on the sensory neurons of small, medium and
large diameters. Inflammation of peripheral tissues
broadly acts as a regulator of opioid receptors in the
sensory neurons, which increases the analgesic effects
of opioids on the inflamed tissues. Therefore, in the
first hours of neuron damaging, both the peripheral and
central opioid receptors play a role in the management
of postoperative pain24.
As such, it seems that in the present study, during
the first hours within surgery, morphine reduced the
level of pain in the patients through both peripheral
and central mechanisms. In the later hours, by reducing
inflammation and eliminating the peripheral effects of
intrapleural morphine, only its central effects remained
involved in pain control. As a result, within 6 hours,
271
the analgesic effect of intrapleural bupivacaine was
greater than morphine’s. This also supported is borne
true by the lower amount of PCA opioid used by
patients in the bupivacaine group.
Conclusion
Results of the present study thus showed that
the injection of intrapleural bupivacaine can be more
effective in reducing post-thoracotomy pain compared
to intrapleural morphine. Given that intrapleural
bupivacaine does not increase the respiratory
depression risk that is often associated with opioids, it
can be a suitable pain management option for thoracic
surgeries.
Acknowledgments
This study supported by Deputy of Research,
Kashan University of Medical Sciences (grant
NO=90086). We would like to thank all of the staff
in the Shahid Beheshti hospital of Kashan University
of Medical Sciences (KAUMS) for their help and
cooperation.
M.E.J. ANESTH 23 (3), 2015
272
Fazel-Mohammad Reza et. al
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Rapid fluid administration and the incidence
of hypotension induced by spinal anesthesia
and ephedrine requirement: the effect
of crystalloid versus colloid coloading
Hakki Unlugenc*, Mediha Turktan*,
Ismail Cuneyt Evruke**, Murat Gunduz*, Refik Burgut***,
Hacer Yapicioglu-Yildizdas****
and G eylan I sik *
Purpose: Spinal anesthesia for caesarean delivery is often associated with hypotension. This
study was conducted to evaluate the effects of rapid crystalloid (Lactated Ringer’s solution; LRS)
or colloid (hydroxyethyl starch; HES) cohydration with a second intravenous access line on the
incidence of hypotension and ephedrine requirement during spinal anesthesia for cesarean section.
Methods: We studied 90 women with uncomplicated pregnancies undergoing elective
cesarean section under spinal anesthesia. Intravenous access was established in all patients with
two peripheral intravenous lines, the first being used for the baseline volume infusion. Immediately
after induction of spinal anesthesia, LRS (Group L) or HES (Group C) infusions were started at the
maximal possible rate via the second line in groups L and C respectively. In the third group (Group
E) , patients received lactated Ringer’s solution at a ‘keep vein open’ rate to maintain the doubleblind nature. The incidence of hypotension, ephedrine requirements, total amount of volume and
side effects were recorded.
Results: The incidence of hypotension was significantly greater in group E than in groups L
and C, and greater in group L than in group C (p<0.03 and p<0.01 respectively ). The total dose
of ephedrine used to treat hypotension was significantly less in groups L and C than in group E
(p<0.001 and p<0.001 respectively). Groups L and C received similar infusion volumes and doses
of ephedrine.
Conclusions: Giving either LR or HES coloading via a second IV line caused less hypotension
and required less use of ephedrine compared to no coloading. There were no maternal or neonatal
side effects.
Keywords: Anesthetic techniques-subarachnoid, Pharmacology-agonists adrenergic, Fluid
Therapy, Fluids iv.
* MD, Cukurova University and Faculty of Medicine, Departments of Anaesthesiology, Adana/Turkey.
** MD, Obstetric & Gynecology, Adana/Turkey.
*** MD, Bioistatistics, Adana/Turkey.
****MD, Paediatrics & Neonatology, Adana/Turkey.
Corresponding author: Dr. Hakki Unlugenc, Cukurova University Faculty of Medicine, Department of Anaesthesiology,
01330, Adana/Turkey. Tel: +90-322-3386742, Fax: +90-322-3386742. E-mail: unlugenc@cu.edu.tr
273
M.E.J. ANESTH 23 (3), 2015
274
Introduction
Spinal anesthesia for cesarean delivery often
causes hypotension, which requires rapid and
aggressive treatment to prevent maternal and neonatal
side effects1. Lateral uterine displacement, the use
of IV fluid preload or coload, vasopressors, and
compression devices on the legs, have all been used
to restore venous return and arterial blood pressure
during spinal anesthesia. Phenylephrine and ephedrine
are used to treat and prevent hypotension induced
by spinal anesthesia; a prophylactic phenylephrine
infusion together with fluid cohydration can
effectively eliminate hypotension1, but maternal
reactive hypertension and bradycardia, may be
a problem, even at slow infusion rates2,3. Unlike
phenylephrine, ephedrine can cause fetal acidosis,
and large doses are associated with maternal nausea
and vomiting. Rapid fluid administration on initiation
of spinal anesthesia offers an alternative technique4,5,
but it can cause hypervolemia, risking pulmonary
edema, decreased oxygen-carrying capacity and poor
wound healing6,7. Thus far, no method has proved
entirely satisfactory.
In this study, we aimed to evaluate the effects
of rapid crystalloid (Lactated Ringer’s solution; LR)
or colloid (hydroxyethyl starch; HES) cohydration
via the second intravenous access line during spinal
anesthesia for cesarean section. The hypothesis was
that cohydration with LR or HES, beginning at the
time of spinal injection, will reduce hypotension and
ephedrine use.
Method
Faculty Ethics Committee approval and informed
parturient consent was obtained. This trial was
registered al Clinical Trials. gov with trial registration
number: NCT01741610.
90 ASA physical status I or II, with a singleton
uncomplicated pregnancy at full-term gestation,
undergoing elective cesarean section under spinal
anesthesia were included in this prospective,
randomized, controlled study. Exclusion criteria
included significant coexisting disease such as preeclampsia and hepato-renal disease, pregnancy
Hakki Unlugenc et. al
preinduced hypertension, being in active labor or
requiring emergency cesarean section, and any
contraindication to regional anesthesia such as local
infection or bleeding disorders.
Parturient were instructed preoperatively on
the use of the verbal rating scale (VRS) for pain
assessment. All were fasted for 6 hours pre-operatively
and no premedication was given. Intraoperative
monitoring included lead II electrocardiogram (ECG),
pulse oximetry and automated blood pressure cuff.
Systolic blood pressure (SBP), heart rate (HR), and
oxygen saturation (SpO2) were monitored before spinal
anesthesia and throughout the operation. Intravenous
access was established with two peripheral
intravenous lines (20 Gauge). The first was used for
the baseline volume infusion; all parturient received
iv 10 ml/kg/h of lactated Ringer’s solution while the
block was being performed.
Using a computer generated sequence patients
were randomly allocated to one of three groups of 30
patients each. Group L received 1000 mL of lactated
Ringer’s solution via the second peripheral intravenous
line with the flow-control clamp fully open. The
Colloid group (Group C), similarly received 1000 mL
of 6 % hydroxyethyl starch (HES) (Voluven®). Group
E received lactated Ringer’s solution at a ‘keep vein
open’ rate as control group. All study solutions were
covered by a non-transparent plastic bag to maintain
the double-blind nature of the study.
The spinal blocks were performed by
experienced, qualified anesthetists using a standard
spinal anesthetic technique. A 26 gauge Pencil
Point spinal needle was inserted at the L3-4 or L4-5
intervertebral level via a midline approach. Following
skin preparation and local infiltration with 1%
lidocaine, the subarachnoid space was then punctured
with the parturient in the sitting position. After
return of clear cerebrospinal fluid a standard spinal
anesthetic consisting of 0.5 % heavy bupivacaine 10
mg combined with 25 mcg fentanyl was given. After
intrathecal injection, the parturient were placed supine
with a 15°-20° left uterine tilt for the prevention of
aortocaval compression. Immediately after induction
of spinal anesthesia, lactated Ringer’s or colloid
infusions were launched at the maximal possible rate
in groups L and C. It was planned that if this 1000
Fluid coloading and incidence of hypotension
mL coloading was complete before the end of surgery,
lactated Ringer’s solution would be launched at a
‘keep vein open’ rate in groups L and C. Oxygen 2–4
L/min was delivered routinely via nasal cannula until
delivery. No additional analgesic was administered
unless requested by the patients.
A T5 sensory dermatome level was obtained
before surgical incision in all parturient. After
delivery, umbilical artery blood gas samples (pH,
PO2, PCO2 and HCO3) were taken and neonatal Apgar
scores were recorded at 1 and 5 min by an attending
pediatrician. Demographic data (age, height, weight,
parity and gravity) and duration of surgery were noted
by an observer blinded to the treatment group. Systolic
and diastolic blood pressures (SBP, DBP), heart rate
275
(HR) and peripheral oxygen saturation (SpO2) were
recorded by an anesthetist blinded to the patient group,
preoperatively and at 1, 3, 5 10, 15, 20, 30, 45 and 60
min after the IT injection and at 5, 15, 30 min and 1, 2,
6, 12, 24 hours postoperatively.
Sensory and motor block levels were assessed
and recorded at 1, 5 15, 30 and 60 min after IT
injection. Sensory block was assessed by pinprick test.
Motor block was assessed by modified Bromage score
(0, no motor loss; 1, inability to flex the hip; 2, inability
to flex the knee; 3, inability to flex the ankle). The
duration of total sensory block (defined as the time for
regression of two segments from the maximum block
height evaluated by pinprick) and of spinal anesthesia
(defined as the period from spinal injection to the
Fig. 1
Flowchart of the patients
M.E.J. ANESTH 23 (3), 2015
276
Hakki Unlugenc et. al
Fig. 2
Perioperative Systolic Blood Pressure variables in
groups
Fig. 3
Perioperative Heart Rate variables in groups
first occasion when the patient complained of pain in
the postoperative period) were also recorded after IT
injection.
Hypotension, defined as systolic blood pressure
less than 80% of baseline (prenatal) or <90 mm Hg,
was treated with IV ephedrine 10 mg. If HR was less
than 50 beats/min, 0.5 mg of atropine sulphate was
given intravenously. Total fluid volumes, ephedrine
requirements, the occurrence of hypotension (defined
as the administration of at least one dose of ephedrine),
bradycardia (heart rate <50 beats/min), hypoxemia
(SpO2 <95 %), excessive sedation, pruritus, dizziness,
nausea and vomiting were recorded. Discharge criteria
for the ward were resolved motor block, stable vital
signs, and absence of nausea, vomiting and pain.
Data Analysis
The primary study endpoint was the ephedrine
requirement (incidence of hypotension). We calculated
that 90 women, 30 for each group would be required to
Fluid coloading and incidence of hypotension
277
Table 1
Demographic data, patient characteristics, duration of surgery, sensory and spinal block in groups
Group L
(n=30)
Group C
(n=30)
Group E
(n=30)
P-value
Age (year)
30.8 ±5.8
31.8±5.2
29.8±4.2
0.3
Height (cm)
162.7±5
163.7±5.5
161±5.8
0.2
Weight (kg)
84.5±11.4
85.7±14.4
79.5±10
0.1
Parity
2.6±1.4
2.5±1.1
2.7±1.5
0.8
Gravidity
2.9±1.7
2.8±1.1
3.1±1.6
0,7
Duration of surgery (min); median(range)
52 (30-120)
47 (25-120)
46 (25-105)
0,1
Duration of sensory block (min); median (range)
58 (25-120)
63 (24-120)
57 (28-120)
0.1
Duration of spinal block (min); median (range)
124(45-180)
134(50-200)
133(45-220)
0.6
Data are presented as mean ± SD or median (range).
Table 2
Neonatal Apgar scores and umbilical artery gas values
Apgar score 1. min median (range)
Apgar score 5. min median(range)
Umbilical artery blood gases
pH
pO2 (mmHg)
pCO2 (mmHg)
HCO3
Group L
(n=30)
Group C
(n=30)
Group E
(n=30)
P-value
8 (4-9)
9 (7-10)
8 (3-9)
9 (7-10)
8 (5-9)
9 (8-10)
0,4
0,5
7.32±0
23.5±9
44.3±9
22.1±2.8
7.32±0
23.1±9.1
46.5±9.4
23.1±4.8
7.34±0
26.9±16
43±8.2
22.5±2
0.5
0.4
0.3
0.5
Data are presented as mean±SD or median (range).
Table 3
Sensory and motor blockade levels
Sensory block level
1 min
5 min
15 min
30 min
60 min
Motor block level (Bomage)
1 min
5 min
15 min
30 min
60 min
Group L
(n=30)
Group C
(n=30)
Group E
(n=30)
P KWallis test
T6 (T3 T12)
T4 (T2 T6)
T4 (T2 T6)
T4 (T2 T6)
T4 (T2 T10)
T6 (T3 T12)
T4 (T3 T10)
T3 (T3 T10)
T4 (T3 T8)
T4 (T3 T6)
T6 (T3 T10)
T4 (T2 T8)
T4 (T3 T8)
T4 (T2 T8)
T5 (T3 T6)
0.3
0.4
0.4
0.1
0.8
2 (0 3)
3 (1 3)
3 (3 3)
3 (2 3)
3 (2 3)
2 (1 3)
3 (3 3)
3 (3 3)
3 (3 3)
3 (3 3)
3 (0 3)
3 (2 3)
3 (3 3)
3 (2 3)
3 (1 3)
0.2
0.2
0.3
0.1
0.3
Data are presented as median (range).
M.E.J. ANESTH 23 (3), 2015
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Hakki Unlugenc et. al
Table 4
Incidence of hypotension and nausea, total amount of volume infused and vasopressor requirements
Group L
(n=30)
Group C
(n=30)
Group E
(n=30)
P-value
Total volume infused (mL)
First IV Line
Second IV Line
2552±572*
1478±490
1074±290*
2233±479*
1336±341
930±185*
1617±297
1541±296
86±40
0.001
0.1
0.001
Total ephedrine dose (mg)
8±14*
8 (2.6 13.3)
3.6±9.2*†
3.6(0.2 7.1)
15.3±17.4
15.3 (8.7 22)
0.003
Incidence of hypotension; n (%)
13/30(43%)*
6/30(20%)*†
20/30 (66%)
0.001
7 (23%)
17 (56%)
0.03
Incidence of nausea; n (%)
10 (33%)
Data are presented as mean±SD, mean (95 % CI) or n (%).
* p<0.05 compared with group E.
† p<0.05 compared with group L.
*
demonstrate a 40 % difference in ephedrine requirement
between groups (beta = 0.1, alpha = 0.05). Normality
was checked for each continuous variable, and normally
distributed values were expressed as mean (SD) or
(95% CI), number (%), others as median (range)
where appropriate. Demographic (gestational age,
maternal age, height and weight) data were analyzed
using one way ANOVA. Clinical data were analyzed
using the Kruskal-Wallis test. If there were significant
differences among the three groups, the analysis was
continued with posthoc comparisons of differences
between pairs of groups by using Mann-Whitney’s
U-test. The incidence of hypotension in the groups was
compared by Chi-square test. If there were significant
differences between groups, a multiple comparison
were applied with Bonferroni’s correction (p<0,05/n;
where n= number of comparisons) and p<0.017
considered statistically significant. Hemodynamic
data were analyzed by repeated measure analyses. The
incidence of intra- and postoperative adverse events
were analyzed using Chi-square tests. Values of p <
0.05 were considered statistically significant. Statistical
analyses were performed using the statistical package
SPSS v 19.0 (Inc, Chicago, USA).
Results
Ninety patients were enrolled and completed the
study. A flowchart of the patients was shown in Figure
1. There were no significant differences between groups
in demographic data, patient characteristics and the
duration of surgery (Table 1). Neonatal Apgar scores
*
after 1 and 5 min and umbilical artery gas samples
were also similar (Table 2). Maternal SpO2 values
remained within the normal range throughout the
perioperative and postoperative study period. Sensory
blockade achieved T5 and above within 10 min in all
parturient, with no significant differences in the level
of sensory or motor blockade between groups (Table
3). Perioperative SBP and HR variables are shown
in Figure 2-3. There were no significant differences
in perioperative and postoperative hemodynamic
variables (SBP and HR) between groups.
Transient hypotension occurred in each
group despite volume coloading. The incidence of
hypotension after spinal anesthesia was 43% (13/30)
in Group L and 20% (6/30) in group C. It was 66%
(20/30) in Group E and significantly greater than in
groups L and C (p<0.03, p<0.01, respectively). There
was less hypotension in Group C than in group L
(p<0.05), (Table 4).
The total amount of volume infused was
significantly greater in groups L and C than in group
E (p<0.001, p<0.001). Significantly less ephedrine
was used in the coloading groups than in group E
(p<0.001). Groups L and group C received similar
total fluid volumes and ephedrine doses (Table 4).
Nausea was experienced by 10 patients (33%)
in group L, by 7 patients in group C (23%) and by
seventeen patients in group E (56%); which was
successfully treated by correcting hypotension. There
was more nausea in group E than in groups L and C
(p<0.01, p<0.03) (Table 4). No major side effects or
Fluid coloading and incidence of hypotension
complications related with spinal anesthesia were
recorded.
Discussion
Depending on the definition used, the incidence
of hypotension caused by spinal block in pregnant
females has been reported as 90%8,9. Current strategy
for avoiding hypotension following spinal anesthesia
would appear to be fluid therapy combined with the
appropriate vasopressor, dependent on patient status10.
However, there is no reliable way to determine how
much volume or vasopressor is required to compensate
for the decrease in systemic vascular resistance caused
by sympathetic blockade. In routine clinical practice,
generally single peripheral intravenous line (18-20
Gauge) is used to treat hypotension during cesarean
section surgery and this frequently cannot compensate
for the decrease in systemic vascular resistance caused
by sympathetic blockade (at T4), even at the flowcontrol clamp fully open rate. Therefore, giving rapid
fluid coloading via second IV line can be an alternative
approach to increase stroke volume while decreasing
vasopressor need. In the present study, regardless of the
fluid used, rapid coloading via second IV line caused
less hypotension and required less use of ephedrine
compared to no coloading.
Rapid and generous fluid administration may
expand the intravascular space and lead to activation
of atrial natriuretic peptide, thereby counteracting
the desired volume-expanding effects11,12. However,
debate has been going on not only as to the optimal
fluid volume and type (crystalloid versus colloid),
and timing of fluid administration but also as to type
and dose of vasopressors used (phenylephrine versus
ephedrine)1,2.
In a recent Cochrane analysis, Cyna et
al investigated 75 trials to assess the effect of
prophylactic interventions for hypotension following
spinal anesthesia for cesarean section and found that
no single or combined prophylactic intervention
avoids the need to treat a proportion of women for
hypotension following spinal anesthesia for cesarean
section. However, no conclusion has been drawn
from the above analysis with respect to the optimum
volume and the infusion rate of fluids needed to restore
13
279
hemodynamic function during spinal anesthesia.
In the present study, fluid infusion was given more
rapidly with the use of two peripheral intravenous
lines to achieve optimum and acute peak expansion of
intravascular volume.
Block height determines the extent of sympathetic
blockade and thus the degree of volume expansion
to be replaced after spinal anesthesia. Sensory block
levels were similar between groups, but the incidence
of hypotension and ephedrine requirements were
significantly greater in group E. The fluid coloading in
groups L and C was probably adequate to compensate
for the decrease in systemic vascular resistance caused
by sympathetic block.
Most studies have attempted to restore venous
return using crystalloids, but colloids remain within
the intravascular space for longer and less is needed to
restore hemodynamic function14. Thus, our parturient
receiving 6% HES experienced less hypotension
than those receiving crystalloid or only ephedrine.
It may not be possible to infuse crystalloids fast
enough to maintain intravascular volume and avoid
hypotension during spinal anesthesia because of the
short intravascular half-life15. Sharma et al16 reported
that patients given 500 mL of hetastarch had a 21%
incidence of hypotension after spinal anesthesia
compared to a 55% incidence in patients given 1000
mL of LR. Zorko et al17 found that hydroxyethyl
starch increased cardiac output during development of
sympathetic block after spinal anesthesia.
Volume kinetic studies suggest that giving fluids
as a coload at the time of onset of spinal anesthesia
might be better than using a preload8. In the present
study, fluid coloading from the second iv access was
started immediately after induction of spinal anesthesia
rather than before. Rapid administration of crystalloid
preload before spinal anesthesia does not decrease
the incidence or severity of hypotension after spinal
anesthesia15. Dyer et al reported that rapid crystalloid
administration after, rather than before the induction of
spinal anesthesia for elective cesarean section, provides
better maternal hemodynamic control and lower
ephedrine requirement prior to delivery4. Kamenik et
al18. found that cardiac output remained elevated above
baseline in patients given coload (11.3%) 30 min after
induction of anesthesia, whereas it returned to baseline
M.E.J. ANESTH 23 (3), 2015
280
Hakki Unlugenc et. al
30 min after spinal anesthesia in those given preload
(20%).
coincided with episodes of hypotension and were
successfully treated by correcting this.
Many clinicians recommend the avoidance
or severe limitation of the use of vasopressors in
parturient, because of their untoward side effects,
but treat the hypotension aggressively after spinal
anesthesia19. A recent review article states that
hemodynamic stability after spinal anesthesia may be
best restored by a low-dose phenylephrine infusion1.
This was confirmed in the last European survey and
phenylephrine administration has been recommended
as the fastest and most effective way of restoring mean
arterial pressure20. Although use of a prophylactic
phenylephrine infusion concurrently with a fluid coload
can virtually eliminate hypotension associated with
spinal anesthesia, maternal reactive hypertension and
bradycardia still occur2,3. Ephedrine has a long history
of use in obstetrics, and is still used21. It may be that
obstetric anesthetists may feel more comfortable with
it than with phenylephrine1. We found the incidence of
hypotension and total dose of ephedrine used to treat
hypotension after spinal anesthesia were greater in
group E than in groups L and C.
The main limitation of this study is that
a non-invasive hemodynamic monitoring (ie.
echocardiography) has not been used to document
cardiac output during the fluid therapy. Non-invasive
cardiac output monitoring in patients undergoing
cesarean section with spinal anesthesia might provide
more accurate determination of fluid responsiveness.
Spinal hypotension often causes nausea
and vomiting, which can be largely avoided by
maintainance of maternal blood pressure.Kee et al
found that maintaining maternal systolic blood pressure
at 100% of baseline was the best way to avoid nausea
and vomiting22. However, we found an incidence of
hypotension after spinal anesthesia of 43% (13/30) in
Group L, 20% (6/30) in Group C, and 66% (13/30) in
Group E. The incidence of nausea was 33% (10/30)
in group L, 23% (7 /30) in group C and 56% (17/30)
in group E. There was a positive correlation between
hypotension and nausea. Most nausea episodes
Our study supports the idea that maintaining
homeostasis by infusing rapid volume coloading
and minimizing the use of vasopressors in pregnant
patients is an acceptable strategy because of the
possible adverse consequences of vasoconstrictors.
Thereby, fluid coloading via a second IV line might be
an alternative approach to compensate for the decrease
in systemic vascular resistance caused by sympathetic
blockade while avoiding untoward side effects of
vasopressors and indicated in parturients for whom
ephedrine or phenylephrine are contraindicated.
In conclusion we found that parturient given either
LR or HES coloading via second IV line experienced
a lower incidence of hypotension and required smaller
doses of ephedrine, without causing maternal or
neonatal side effects compared to parturient given
no coloading. 6% HES was associated with a lower
incidence of hypotension after spinal anesthesia than
crystalloid, although the volumes given were similar
in the two groups.
Acknowledgement
The authors gratefully acknowledge the routine
assistance of nursing staff and surgical colleagues.
Fluid coloading and incidence of hypotension
281
References
1. Veeser M, Hofmann T, Roth R, Klöhr S, Rossaint R, Heesen
M: Vasopressors for the management of hypotension after spinal
anesthesia for elective cesarean section. Systematic review and
cumulative meta-analysis. Acta Anaesthesiol Scand; 2012, 56:8106.
2. Langeseter E, Rosseland LA, Stubhaug A: Continuous invasive
blood pressure and cardiac output monitoring during cesarean
delivery: a randomized, double-blind comparison of low-dose
versus high-dose spinal anesthesia with intravenous phenylephrine
or placebo infusion. Anesthesiology; 2008, 109:856-63.
3. Dyer RA, Reed AR, Van Dyk D, et al: Hemodynamic effects of
ephedrine, phenylephrine, and the coadministration of phenylephrine
with oxytocin during spinal anesthesia for elective cesarean delivery.
Anesthesiology; 2009, 111:753-65.
4. Dyer RA, Farina Z, Joubert IA, et al: Crystalloid preload versus
rapid crystalloid administration after induction of spinal Anesthesia
(coload) for elective cesarean section. Anaesth Intensive Care; 2004,
32:351-7.
5. Mojica JL, Melendez HJ, Bautista LE: The timing of intravenous
crystalloid administration and incidence of cardiovascular side
effects during spinal anesthesia: the results from a randomized
controlled trial. Anesth Analg; 2002, 94:432-7.
6. Lobo DN, Macafee DA, Allison SP: How perioperative fluid
balance influences postoperative outcomes. Best Pract Res Clin
Anaesthesiol; 2006, 20:439-55.
7. Arkilic CF, Taguchi A, Sharma N, et al: Supplemental perioperative
fluid administration increases tissue oxygen pressure. Surgery; 2003,
133:49-55.
8. Montoya BH, Oliveros CI, Moreno DA: Managing hypotension
induced by spinal anesthesia for cesarean section. Rev Col Anest;
Mayo-Julio 2009, Vol. 37 - No. 2:131-140.
9. Reidy J, Douglas J: Vasopressors in obstetrics. Anesthesiol Clin;
2008, (26):75-88.
10.Hahn RG: Volume kinetics for infusion fluids. Anesthesiology;
2010, 113:470-81.
11.Sear JW: Kidney dysfunction in the postoperative period. Br J
Anaesth; 2005, 95:20-32.
12.Pouta AM, Karinen J, Vuolteenaho OJ, Laatikainen TJ: Effect of
intravenous fluid preload on vasoactive peptide secretion during
Cesarean section under spinal Anesthesia. Anesthesia; 1996, 51:12832.
13.Cyna AM, Andrew M, Emmett RS, Middleton P, Simmons SW:
Techniques for preventing hypotension during spinal Anesthesia
for cesarean section. Cochrane Database Syst Rev; 2006 Oct 18,
(4):CD002251.
14.Siddik-Sayyid SM, Nasr VG, Taha SK, et al: A randomized trial
comparing colloid preload to coload during spinal anesthesia for
elective cesarean delivery. Anesth Analg; 2009, 109:1219-24.
15.Rout CC, Akoojee SS, Rocke DA: Rapid administration of
crystalloid preload does not decrease the incidence of hypotension
after spinal Anesthesia for elective cesarean section. Br J Anaesth;
1992, 68:394-7.
16.Sharma S, Sidawi E, Gambling D, et al: Hetastarch versus lactated
Ringer’s preload: prevention of hypotension following spinal
anesthesia [abstract]. Anesth Analg; 1995, 80 (Suppl):S431.
17.Zorko N, Kamenik M, Starc V: The effect of Trendelenburg position,
lactated Ringer’s solution and 6% hydroxyethyl starch solution on
cardiac output after spinal anesthesia.. Anesth Analg; 2009, 108:6559.
18.Kamenik M, Paver-Erzen V: The effects of lactated Ringer’s
solution infusion on cardiac output changes after spinal anesthesia.
Anesth Analg; 2001, 92:710-4.
19.Riley ET: Spinal Anesthesia for Cesarean delivery: keep the pressure
up and don’t spare the vasoconstrictors. Br J Anaesth; 2004, 92:45961. Erratum in: Br J Anaesth; 2004, 92:782.
20.Lirk P, Haller I, Wong CA: Management of spinal Anesthesiainduced hypotension for cesarean delivery: a European survey. Eur
J Anaesthesiol; 2012, 29:452-3.
21.Allen TK, Muir HA, George RB, Habib AS: A survey of the
management of spinal-induced hypotension for scheduled cesarean
delivery. Int J Obstet Anesth; 2009, 18:356-61.
22.Ngan Kee WD, Khaw KS, Ng FF: Comparison of phenylephrine
infusion regimens for maintaining maternal blood pressure during
spinal Anesthesia for Cesarean section. Br J Anaesth; 2004,
92:469-74.
M.E.J. ANESTH 23 (3), 2015
Opioid Administration as Predictor
of Pediatric Epidural Failure
James J. Mooney* and Ashley McDonell**
Background: Increasing use of regional analgesia in pediatric populations requires a better
understanding of when analgesic techniques need revising or supplementation. This study was
conducted to examine intra-operative opioid use as a predictor of post-operative epidural failure.
Methods: Retrospective chart review of patients having epidurals placed intra-operatively.
229 epidurals were placed during the study, with 75 excluded. Dosing and quantity of opioids used
intra-operatively were compared to the primary outcome of epidural failure, as well as duration of
infusions and pain scores.
Results: Opioid use was associated with increased epidural failure, particularly in less than
12 hours. However, no distinct point of certain epidural failure was found..
Conclusions: Opioid use after epidural loading correlates with increasing risk for epidural
failure. Anesthesia providers should consider replacing or supplementing epidurals with increasing
use of opioids.
Keywords: Epidural Analgesia, Epidural Anesthesia, Opioid Analgesics, Outcomes
Assessment, Pediatrics.
Introduction
Reliable prediction of epidural failure in pediatric anesthesia is difficult, and testing of block
adequacy is generally prohibited by placement after induction of general anesthesia. Changing
physiologic parameters, such as blood pressure and heart rate, are used as substitute indicators of
inadequate analgesia.
Unfortunately, there are multiple factors contributing to variation in vital signs during surgery,
including stimuli outside of the surgical area, changing anesthetic levels, and tourniquet related
discomfort. Many of these stimuli may lead to the use of intravenous opioids during anesthesia.
However, this makes it difficult at times to determine the effectiveness of an epidural.
This uncertainty can lead to a patient emerging from anesthesia with an inadequately
functioning epidural and inadequate intravenous analgesia. Additional information that might
improve the ability to predict a failed block would improve patient care. The purpose of this study
was to evaluate the hypothesis that opioid use after initiation (or ‘loading’) of an epidural block
may correlate with the success or failure of an epidural.
∗ MD, Penn State Milton S. Hershey Medical Center Department of Anesthesiology.
** MD, Novant Health Presbyterian, Providence Anesthesiology.
Corresponding author: James Mooney, MD. Penn State Milton S. Hershey Medical Center, Penn State College of
Medicine, Department of Anesthesiology, Mail Code H187, 500 University Drive, P.O. Box: 850, Hershey, PA 17033-0850.
Phone: (717)531-4264, Fax: (717)531-4110. E-mail: mooney.kiddoc@gmail.com.
283
M.E.J. ANESTH 23 (3), 2015
284
Methods
This was a prospective observational study
of routine anesthetic care, without randomization
or control groups. All anesthesia patients between
7/20/2010 and 5/20/2011 were screened for epidural
placement as part of a pre-existing billing/review
process within the Department of Anesthesiology
& Pain Medicine at Seattle Children’s Hospital after
IRB approval and waiver of consent. In patients
receiving epidurals both paper (anesthesia records)
and electronic (Clinical Information System [CIS]
and Pain service database) records were reviewed for
information on epidural loading, intra-operative opioid
use, pain scores and possible failure of epidurals.
Patients were excluded if they were admitted to
the Neonatal ICU or under 6 months old, remained
intubated at the end of procedure, underwent procedures
expected to require more than an epidural for analgesia
or when an epidural could not be evaluated during
or after surgery. Examples of this last group would
include epidurals being placed or removed at the end
of a surgical procedure or unexpected changes in
post-operative care unrelated to the epidural. Other
exclusion criteria included being over 18years of
age, catheter dislodgement, and if an alternative pain
scoring system was used.
The primary outcome variable epidural catheter
failure was defined as epidural removal due to
inadequate analgesia or the regular use of intravenous/
enteral opioids in addition to the epidural infusion.
Determination of inadequate analgesia was made by
the acute pain service per their routine clinical practice
on a case-by-case basis.
Quantity of opioid doses used intra-operatively
was measured as either absolute number delivered, or
doses per hour. The dose of opioids administered was
measured as mcg/kg or mcg/kg/hour. All measures of
opioid administration ignored opioids used prior to
epidural loading, under the assumption that these were
associated with induction of anesthesia. Secondary
outcome measures included the first 24 hours of pain
scores. and the duration of epidural infusion without
removal or supplementation.
Spearman’s rho was used for correlations
between intra-operative opioid use and the outcome
James Mooney et. al
measures of epidural failure, pain scores and infusion
duration. A p value ˂ 0.05 was considered statistically
significant.
Results
After IRB approval and waiver of consent, 229
patients who had epidurals placed were identified.
After exclusion criteria, patient ages ranged from 6
months to 18 years, with a mean of 8.3 years. Patient
weights ranged from 4.49 to 108.2 kg, with a mean of
33.96 kg (Std Dev 23.9).
A total of 75 patients were excluded, most
frequently for being under six months of age or
postoperative care in the NICU (33 patients).
Twenty two patients could not have their epidurals
evaluated due to being placed or removed at the end
of the procedure. Less common reasons for exclusion
included being over 18 years of age (6 patients),
catheter dislodgement (5 patients), remaining intubated
(4 patients), procedures requiring more than an
epidural for analgesia (3 patients) and post-operative
seizures in a patient with a seizure disorder requiring
a highly sedating regimen (1 patient). Due to the low
use of opioids besides fentanyl, all comparisons using
opioid dosing are based exclusively on those patients
receiving only intra-operative fentanyl. The exception
to this is binary state comparison of opioids used/ no
opioids used.
For the primary outcome measure of epidural
failure there were a significant number of measures
that showed significant correlations. No use of opioids
after epidural loading was negatively associated with
epidural failure in less than 12 hours (-0.239p=0.005),
and epidural failure at any time (-0.221p=0.009). The
hazard curve for opioid use is illustrated in Figure
1. Opioid use measured as the number of doses
administered during the procedure (number of doses)
correlated with epidural failure in less than 12 hours
(0.244 p=0.006) and at any time (0.306 p=0.001),
while opioid use measured as number of doses/hour
correlated with epidural failure in less than 12 hours
(0.272 p=0.002) and at any time (0.207 p=0.02). The
hazard curve for number of doses/ hour is illustrated in
Figure 2. Opioid use measured as mcg/Kg correlated
with epidural failure in less than 12 hours (0.324
Opioids as Predictor of Epidural Failure
Fig. 1
Showing the cumulative hazard of epidural failure by groups of
patients who received intra-operative opioids and those who
did not
Fig. 2
Showing the cumulative hazard of epidural failure grouped by
fentanyl doses per hour.
p<0.001), between 12 and 24 hours (0.191 p=0.035)
and at any time (0.282 p=0.001). When measured as
mcg/Kg/Hr, opioid use correlated with epidural failure
in less than 12 hours (0.284 p=0.002) and at any
time (0.232 p=0.009). The hazard curve for opioids
measured in mcg/Kg/Hr is illustrated in Figure 3.
The secondary outcome of pain scores had
285
Fig. 3
Showing the cumulative hazard of epidural failure grouped by
fentanyl dosing in micrograms/ kilogram/hour.
Fig. 4
Showing the distribution of failed and successful epidurals
distributed by patient age and weight in kilograms.
fewer correlations. The first post-operative pain score
correlated only with opioid use measured as mcg/
Kg (0.185, p=0.035), but the third post-operative
pain score correlated with opioids measured in mcg/
kg, mcg/kg/Hr, and number of doses administered
(0.205 p=0.022, 0.180 p=0.043, and 0.186 p=0.038
respectively). Age only correlated with the 5th and
M.E.J. ANESTH 23 (3), 2015
286
6th pain scores (0.214 p=0.013 and 0.201p=0.019
respectively). Similarly, weight correlated with the 5th
and 6th pain scores (0.219 p=0.01 and 0.195 p=0.024
respectively). Figure 4 illustrates the age and weight
distribution, with epidural failures and successes.
Discussion
Intra-operative opioid use did correlate with
epidural failure, particularly within the first 12 hours.
Post-operative pain scores were not as well correlated
with opioid use. The failure of epidurals in the first 12
hours supports the idea that opioid use intra-operatively
is often masking the sympathetic response to surgical
stimulation, i.e. pain.
Perhaps the strongest statistical predictor is
opioids measured as mcg/Kg, with correlations to
epidural failure in less than 12 hours, between 12 and
24 hours and at any time. The cumulative hazard of 1
before 16 hours at a fentanyl dose of 1 mcg/kg/hour
suggests this may be the clearest indicator of epidural
failure for clinical practice.
The relative lack of correlation between postoperative pain scores and opioid use is not surprising.
Strong correlation would seem surprising to the
authors, given the inherent variability in pain score in
and between individuals, as well as the fact that rarely
are epidurals used without adjuncts (acetaminophen,
or non-steroidals) at Seattle Children’s. Additional
variability in pain scores of ‘working’ epidurals can
come from insufficient infusion rates and changes in
activity.
No report was found in the literature of using
opioid administration to predict success or failure of
regional analgesia. There have been prior attempts, with
limited success, using other techniques. Non-invasive
attempts have included changes in baseline heart rate 1,
monitoring skin temperature2, and plethysmography3.
Unfortunately, these techniques do not report
successful coverage of the surgical area specifically1-3,
or require special equipment2. More invasive measures
have included evaluation of anal sphincter tone4 and
papillary response to electrical stimulation5. These
techniques require special equipment5 or were only
evaluated at the end of surgery4.
James Mooney et. al
The findings of this study demonstrate another
avenue for evaluating epidural success and failure,
but do not provide definitive criteria for predicting
epidural failure. No opioid administration was
negatively associated with failure, but even in that
group there were epidural failures. How many of
these failures were due to factors within anesthesia
staff control (poor placement choices, unrealistic
expectation of epidural coverage, etc.) or generally
out of their control (patchy blocks, one sided blocks,
catheter migration) cannot be evaluated. Given
the variable nature of surgical interventions and
anesthetics administered to the subjects of this study,
we believe these results are broadly applicable to
other pediatric populations.
This study had several potential limitations,
including the observational design. Lack of information
on patient gender, specific surgical procedures and
epidural placement locations limited some avenues
of analysis, while variations in anesthetic practice
were not controlled for. These data points may have
provided further analysis, but that is uncertain given
the subject group size. The limited data set was chosen
with the intention to maximize applicability to general
pediatric anesthesia practice.
Not requiring systemic opioids for management
during anesthesia is a predictor of a successful
epidural. Each use of systemic opioids adds to the
risk of a failed epidural as well. Unfortunately, only
the relatively high dose of 1mcg/kg/hour fentanyl
produced a clear indication of failure. Future studies
can examine this issue with specific surgical types,
such as orthopedic procedures and abdominal
procedures (with the contribution of visceral responses
being examined) or specific epidural regimens (such as
thoracic placement). Perhaps a larger study population
will be able to identify a specific point of significantly
increased risk for failure, directing anesthesia care
providers to address analgesic inadequacy before the
patient leaves the operating suites.
Acknowledgements
The authors would like to thank Dr. Nathalia
Jiminez for her advice on statistical analysis in this
project.
Opioids as Predictor of Epidural Failure
287
References
1. Ghai B, Makkar JK, Behra BK, et al: Is a fall in baseline heart rate
a reliable predictor of a successful single shot caudal epidural in
children? Paediatr Anaesth; 2007, 17:552-6.
2. Stevens MF, Werdehausen R, Hermanns H, et al: Skin temperature
during regional anesthesia of the lower extremity. Anesth Analg;
2006, 102:1247-51.
3. Arakawa M, Aoyama Y, Ohe Y: The prediction of effect of lumbar
epidural anesthesia. Can J Anaesth; 2001, 48:1168-9.
4. Verghese ST, Mostello LA, Patel RI, et al: Testing anal sphincter
tone predicts the effectiveness of caudal analgesia in children.
Anesth Analg; 2002, 94:1161-4.
5. Larson MD, Sessler DI, Ozaki M, et al: Pupillary assessment of
sensory block level during combined epidural/general anesthesia.
Anesthesiology; 1993, 79:42-8.
M.E.J. ANESTH 23 (3), 2015
Comparison of Pre-emptive Effect of Meloxicam
and Celecoxcib on Post-Operative Analgesia:
A Double-blind, Randomized Clinical Trial
Omid Aghadavoudi*, Hamid Hajigholam Saryazdi*,
Amir Shafa** and Alireza Ramezani***
Introduction: Pre-emptive analgesia may reduce pain, accelerate recovery and shorten the
duration of hospitalization. The present study aims to compare the preemptive analgesic effects of
meloxicam and celecoxib in patients undergoing lower limb surgery.
Method: In this double blind randomized clinical trial, 70 patients, undergoing lower
extremity surgery, entered in the study; thirty five patients were randomly allocated to either group
using random allocation software. Meloxicam (15mg) was administered orally to one group two
hours before the surgical onset. The other group was treated with oral celecoxib (400 mg) two
hours before the operation. Pain severity was compared between the two groups.
Results: Upon admission to Recovery Room, the mean pain severity was not significantly
different between the two groups. At one and two hours following surgery the mean pain severity
was significantly higher in celecoxib group. However, 6 hours following surgery mean pain severity
was higher with meloxicam administration. Pain severity was not significantly different in the two
groups, 12 and 24 hours following surgery.
Conclusion: The analgesic effect of celecoxib seems to cover longer duration than meloxicam;
but, meloxicam appears to be a stronger analgesic in shorter time interval.
Keywords: postoperative pain, preemptive analgesia, celecoxib, meloxicam.
Introduction
Pain can deeply influence the level of satisfaction and quality of life. Diverse measures have
been taken to reduce pain through quick, cheap, accessible and safe methods1.
Post-operative uncontrolled pain has different acute and chronic adverse effects on
patients. Pre-emptive analgesia may reduce pain, accelerate recovery and shorten the duration of
hospitalization which eventually diminishes the overall cost and burden, and increases the level of
satisfaction2-5. One aim is to decrease the need for analgesic medications, and therefore, to lower
analgesic induced side effects6.
Preemptive analgesia requires pre-operative administration of analgesic medication, which
yields reduced post-operative pain and less need for post-operative analgesic administration7-9.
There is growing tendency towards the use of new agents without narcotic properties resulting
in respiratory depression, cardiac and urinary side effects10,11. Some studies have shown that
*
Associate professor of anaesthesiology, Anesthesiology and critical care research center, Isfahan University of Medical
sciences (IUMS).
** Assisstant professor of anaesthesiology, Anesthesiology and critical care research center, Isfahan University of Medical
sciences (IUMS).
*** MD, Isfahan University of Medical sciences (IUMS).
Corresponding author: Amir Shafa, MD. Assisstant professor of anaesthesiology, Anesthesiology and critical care research
center, Isfahan University of Medical sciences (IUMS). E-mail: amir_shafa@med.mui.ac.ir
289
M.E.J. ANESTH 23 (3), 2015
290
efficacy of such agents are similar to that of narcotics.
Moreover, combination of these agents with narcotic
analgesics is far more effective than narcotic
analgesics alone12,13.
Surgical procedures damage the tissue which leads
to prostaglandin secretion by means of cyclooxygenase
enzyme (COX), and increases inflammation and the
sensitivity of nociceptors. By blocking COX activity,
non-steroid anti inflammatory drugs (NSAIDs) inhibit
the production of prostaglandins14. Specific COX-2
inhibitors can also lead to same effect while causing
fewer side effects15. Celecoxib is a COX-2 inhibitor
agent that has been shown to be effective in postoperative analgesia16,17. Meloxicam is an NSAID
which selectively inhibits COX-2 over COX-1 at low
therapeutic doses and has been used to manage pain in
human and animals18,19. Meloxicam and robenacoxib,
which have similar pharmacologic profiles, have been
used in veterinary medicine to reduce pain in cats, and
robenacoxib has been shown to be more effective20.
The aim of the current study is to compare the preoperative analgesic effects of meloxicam and celecoxib
in patients undergoing lower limb surgeries.
Materials and Methods
This is a double blind randomized clinical trial,
conducted in 2014 at Alzahra Hospital, Isfahan, Iran.
It was approved by the ethics committee of Isfahan
University of Medical Sciences (IUMS). Written
informed consents were obtained from all patients.
The sample was randomly selected among
patients undergoing lower limb surgery under general
anesthesia.
Inclusion criteria were patients of age 18-65 years,
ASA-I and II, candidates of lower extremity surgery,
with absence of coagulopathy, not having any history
of peptic ulcer disease, gastrointestinal bleeding,
substance dependence or seizure disorder. Patients
were excluded from the study if there were deviations
in their surgical or anesthetic plan or they received
treatment for dysrhythmias, or had an un expected
decline in blood pressure. Using a random allocation
software 70 patients were randomly allocated to
receive either meloxicam (n=35) or celecoxib (n=35).
Meloxicam (15mg) in water (5cc) was administered
Amir Shafa et. al
orally to one group two hours before the operation.
The other group received oral celecoxib (400 mg) in
water (5cc) two hours before the operation. To ensure
the blinding process, both celecoxib and meloxicam
were identically packed and alphabetically labeled by
the pharmaceutical laboratory. Neither the patients nor
the clinician who evaluated the patients and collected
the data was aware of the patient group allocation.
Standard monitoring, including blood pressure,
electrocardiogram, pulse rate and O2 saturation, was
performed for all patient before, during and after the
surgery. Following pre-oxygenation, induction of
anesthesia was similarly performed in groups using
identical doses of intravenous sodium thiopental
(6mg/kg), atracurium0.6 mg/kg, and fentanyl (100
µg). Maintenance of anesthesia was achieved with
isoflurane (1.2%), O2 50% and N2O 50%. After
induction, intravenous morphine (0.15 mg/kg) was
administered to provide analgesia. Extubation and
recovery time was registered for each patient. Patients
were discharged from recovery room based on Aldrete
score and assessment of consciousness level.
Pain severity was assessed and registered, using
Visual Analogue Scale (VAS), on admission to recovery,
and at 1, 2, 6, 12 and 24 hours post-operatively. In
case of VAS score ≥4, intravenous pethidine (0.5 mg/
kg) was administered. Consciousness was evaluated
and registered at 1, 2, 6, 12 and 24 hours following
surgery. The dosage of medication and side effects
were registered for each patient. Time and dosage of
first additional analgesic were also registered.
A power analysis considering a confident interval
(CI) of 0.95, a power of 80%, a standard deviation
of 1.17 for post-operative pain score and a minimum
significant clinical difference of 0.8 in the VAS showed
that 70 patients will be needed (35 patients in each
group). Data were analyzed with Chi-square, Student
t-test and repeated measure ANOVA by SPSS 16.0.2.
(SPSS Inc. Released 2007. SPSS for Windows, Version
16.0.2 Chicago, SPSS Inc.). Level of significance was
considered at p ˂0.05.
Results
Baseline data are presented in table 1 and showed
no significant differences between the two groups.
Pre-emptive effect of meloxicam and celecoxcib
Table 1
Demographic data presented as mean±SD
Meloxicam
(n=33)
Celecoxib
(n=35)
p-value
Age (yrs)
37.8±14.0
36.9±10.5
0.76
Body weight
(kg)
71.7±6.7
69.3±8.3
0.2
26/9
0.78
Gender
27/8
(M/F)
SD: Standard Deviation.
Comparison
of
mean
intra-operative
hemodynamic parameters revealed that mean systolic
and diastolic blood pressure in both groups was not
significantly different. However, pulse rate was
significantly higher in patients receiving meloxicam (p
= 0.01). Also, O2 saturation was significantly higher
in patients receiving celecoxib (p = 0.035) (Table 2).
There was no difference in the mean extubation
time between the two groups (Table 2). Frequency
291
of confusion, vomiting, and additional analgesic
administration in recovery room and in the first
postoperative 24 hours are presented in table 3. There
was no significant difference in incidence of confusion
between the two groups in the 1st hour following
surgery. However, in patients receiving meloxicam
the incidence of confusion was significantly higher
two hours post-operatively. All patients in both groups
were completely oriented six to 24 hours following
surgery (Table 3).
Frequency of vomiting was not significantly
different between the two groups in the recovery room
and in the 1st, 2nd, 6th, 12th and 24th hours following the
operation (Table 3). During the study, two patients in
the celecoxib group and none of the patients in the
meloxicam required intravenous metoclopramide.
Frequency of additional analgesic administration
in the first two hours after the operation was
significantly higher in participants receiving celecoxib
Table2
Comparison of intra-operative hemodynamic parameters as mean±SD
Meloxicam
(n=35)
Celecoxib
(n=35)
p-value
Heart rate (beats/min)
79.4±4.2
76.3±6.4
0.01
Systolic blood pressure (mmHg)
115.7±5.6
116.1±5.6
0.75
Diastolic blood pressure (mmHg)
78.9±3.2
77.7±6.1
0.33
SPO2 (%)
97.1±1.5
97.8±1.1
0.035
Mean Extubation Time (minutes)
7.83.4±
7.53.8±
0.16
SD: Standard Deviation.
On admission to
recovery
1h after surgery
2h after surgery
6h after surgery
12h after surgery
24h after surgery
Table 3
Frequency of postoperative confusion, vomiting and additional analgesic administration during
the first 24 hours following surgery
Confusion
Vomiting
Additional Analgesic Administration
n(%)
n(%)
n(%)
meloxicam celecoxib p-value meloxicam celecoxib
p-value meloxicam celecoxib
p-value
0(0)
0(0)
1
2(5.7)
0(0)
0.61
0(0)
0(0)
1
7(20)
5(14.3)
0.53
2(5.7)
0(0)
0.61
0(0)
5(14.3)
0.054
6(17.1)
0(0)
0.025
1(2.9)
0(0)
0.99
0(0)
7(20)
0.011
0(0)
0(0)
1
1(2.9)
2(5.7)
0.99
16(45.7)
10(28.6)
0.14
0(0)
0(0)
1
1(2.9)
3(8.6)
0.61
24(68.6)
16(45.7)
0.053
0(0)
0(0)
1
1(2.9)
3(8.6)
0.61
10(28.6)
6(17.1)
0.025
M.E.J. ANESTH 23 (3), 2015
292
Amir Shafa et. al
(Table 3). However the frequency of additional
analgesic administration was higher in patients
receiving meloxicam during 24 hours postoperatively
(Table 3).
Mean severity of pain was approximately similar
in both groups on admission to recovery room. (Table
4). The severity of pain was higher in participants
receiving celecoxib at the 1st and 2nd hour following
the operation; however, the severity of pain was higher
in patients receiving meloxicam at the 6th hour postoperatively. There was no significant difference in the
severity of pain, between the two groups, at the 12th
and 24thhours following surgery (Table 4).
Discussion
In the present study, we found that both groups
had similar levels of blood pressure, although patients
receiving meloxicam had significantly higher heart
rates. Blood O2 saturation was significantly higher
in patients receiving celecoxib. However, both
differences do not seem to be of clinical significance.
Adverse hemodynamic effect including hypotension
and bradycardia were not detected in either group.
Therefore, both medications seem to be safe in
this regard. Patients receiving celecoxib had better
consciousness states. Celecoxib administration was
associated with decreased post-operative nausea
and vomiting, during the first two hours after the
operation, in comparison to meloxicam. Hawkey
et al in their study concluded that meloxicam was
significantly better tolerated in terms of dyspepsia,
nausea and vomiting, abdominal pain and diarrhea
comparing with diclofenac in investigating tolerability
of the two drugs in a setting of over a 28-day period
oral administration16. However we could not find any
study comparing the gastrointestinal tolerability of
meloxicam and celecoxib in perioperative period.
Meloxicam was associated with decreased
severity of pain in the first two postoperative hours.
This may be due to the fact that celecoxib reaches
peak plasma concentrations after approximately
2-3 hours but meloxicam reaches maximum plasma
concentration (Cmax) at 2.5-7 hours after a 15mg
dose17, 18 and our patients had their administration two
hours before surgery. The total mean severity score
of pain in both groups was not significantly different
during the whole 24 hours post-operatively. Although
the mean VAS scores had been nearly the same at 24th
hour, the additional analgesic administration has been
more in meloxicam group statistically. This might be
based on the violence of nurses from following the
current survey protocol in administering analgesic in
the ward.
Al-Sukhun et al indicated that preemptive
administration of low dose celecoxib was associated
with significant postoperative analgesia in minor oral
surgery19. They administered a standard oral dose of
200 mg celecoxib, preemptively 1 h before surgery and
this may explain the efficacy of celecoxib in recovery
Table 4
Comparison of pain severity between meloxicam and celecoxib receiving groups during
the first 24 hours following surgery as mean±SD
VAS score
Meloxicam
(n=35)
Celecoxib
(n=35)
p-value
On admission to recovery
1.03±1.3
1.03±1.2
1
1h after surgery
2.1±1.2
3.1±1.7
0.007
2h after surgery
2.3±1.2
3.2±1.7
0.008
6h after surgery
4.5±2.0
3.4±1.7
0.022
12h after surgery
4.9±2.0
4.0±2.2
0.07
24h after surgery
3±1.5
2.6±1.6
0.29
Pre-emptive effect of meloxicam and celecoxcib
period according to peak plasma concentrations and
surgery duration. Boonriong et al concluded in their
study that celecoxib showed no significantly difference
from placebo at any time points in reducing postoperative pain20. Aoki et al concluded that in the setting
of surgery with local anesthesia, premedication with
meloxicam was effective in reducing postoperative
pain in oral outpatient surgery21.
Our study was limited in some aspects. In the
current study, small sample size and restriction of
population to candidates of lower extremity surgery
can interfere with generalizability. Also, capability of
293
participants to understand and follow the instruction of
VAS may confound the observation.
It is concluded that celecoxib and meloxicam have
similar effects on postoperative pain in lower extremity
surgery. However, because of more rapid Cmax of
celecoxib, it should be administered more closely
to the surgery. Both medications are well-tolerated
and can be selected based on clinical indications
and surgery duration. Further studies comparing
the gastrointestinal tolerability of meloxicam and
celecoxib in perioperative period is recommended.
M.E.J. ANESTH 23 (3), 2015
294
Amir Shafa et. al
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meta-analysis. Anesth Analg; 100:757, 2005.
2. Vadivelu N, Mitra S, Schermer E, Kodumudi V, Kaye AD, Urman
RD: Preventive analgesia for postoperative pain control: a broader
concept. Local Reg Anesth; May 29, 7:17-22, 2014.
3. Lee SK, Lee JW, Choy WS: Is multimodal analgesia as effective
as postoperative patient-controlled analgesia following upper
extremity surgery? Orthop Traumatol Surg Res; Dec., 99(8):895901, 2013.
4. Recart A, Duchene D, White PF, Thomas T, Johnson DB, Cadeddu
JA: Efficacy and safety of fast-track recovery strategy for
patients undergoing laparoscopic nephrectomy. J Endourol; Dec.,
19(10):1165-9, 2005.
5. Isiordia-Espinoza MA, Sánchez-Prieto M, Tobías-Azúa F, ReyesGarcía JG, Granados-Soto V: Pre-emptive analgesia with the
combination of tramadol plus meloxicam for third molar surgery: a
pilot study. Br J Oral Maxillofac Surg; Oct., 50(7):673-7, 2012.
6. Zavareh SM, Kashefi P, Saghaei M, Emami H: Pre emptive
analgesia for reducing pain after cholecystectomy: Oral tramadol
vs. acetaminophen codeine. Adv Biomed Res; Mar 6, 2:12, 2013.
7. Saeidi M, Aghadavoudi O, Sadeghi MM, Mansouri M: The
efficacy of preventive parasternal single injection of bupivacaine
on intubation time, blood gas parameters, narcotic requirement,
and pain relief after open heart surgery: A randomized clinical trial
study. J Res Med Sci; Apr., 16(4):477-83, 2011.
8. Kelly DJ, Ahmad M, Brull SJ: Preemptive analgesia I: physiological
pathways and pharmacological modalities. Can J Anaesth; 48:1000,
2001.
9. Gurney MA: Pharmacological options for intra-operative and
early postoperative analgesia: an update. J Small Anim Pract; Jul.,
53(7):377-86, 2012.
10.Duellman TJ, Gaffigan C, Milbrandt JC, Allan DG: Multi-modal,
pre-emptive analgesia decreases the length of hospital stay following
total joint arthroplasty. Orthopedics; Mar, 32(3):167, 2009.
11.Mardani-Kivi M, Karimi Mobarakeh M, Haghighi M, NaderiNabi B, Sedighi-Nejad A, Hashemi-Motlagh K, Saheb-Ekhtiari
K: Celecoxib as a pre-emptive analgesia after arthroscopic knee
surgery; a triple-blinded randomized controlled trial. Arch Orthop
Trauma Surg; Nov., 133(11):1561-6, 2013.
12.Keita A, Pagot E, Prunier A, Guidarini C: Pre-emptive meloxicam
for postoperative analgesia in piglets undergoing surgical castration.
Vet Anaesth Analg; Jul., 37(4):367-74, 2010.
13.Ochroch EA, Mardini IA, Gottschalk A: What is the role of
NSAIDs in pre-emptive analgesia? Drugs; 63(24):2709-23, 2003.
14.Emmanuel Marret, OkbaKurdi, Paul Zufferey, Francis Bonnet,
MD: Effects of Nonsteroidal Antiinflammatory Drugs on Patient
controlled Analgesia Morphine Side Effects. Anesthesiology;
102:1249-60, 2005.
15.Fong WP, Yang LC, Wu JI, Chen HS, Tan PH: Does celecoxib have
pre-emptive analgesic effect after Caesarean section surgery? Br J
Anaesth; Jun, 100(6):861-2, 2008.
16.Hawkey C, Kahan A, Steinbruck K, et al: On behalf of the
International MELISSA Study Group. Gastrointestinal tolerability
of meloxicam compared to diclofenac in osteoarthritis patients. Br J
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17.Davies NM, Skjodt NM: Clinical pharmacokinetics of meloxicam:
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drug. Clin Pharmacokinet; 36:115-26, 1999.
18.Davies NM, McLachlan AJ, Day RO, Williams KM: Clinical
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19.Al-Sukhun J, Al-Sukhun S, Penttilä H, Ashammakhi N, Al-Sukhun
R: Preemptive analgesic effect of low doses of celecoxib is superior
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20.Boonriong T, Tangtrakulwanich B, Glabglay P, Nimmaanrat S:
Comparing etoricoxib and celecoxib for preemptive analgesia for
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H, Kaneko A: Premedication with cyclooxygenase-2 inhibitor
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clinical research regarding preemptive
Analgesic effect of preoperative ketamine
after transurethral resection of prostate
Na Wang*, Yaowen Fu**, Haichun Ma***
and J inguo Wang ****
Objective: To investigate whether a single intravenous dose of ketamine before transurethral
resection of prostate (TURP) led to reduced postoperative pain and tramadol consumption.
Methodology: Sixty patients undergoing elective TURP were randomized into one of
two groups: the ketamine group (Group K, n=30) received intravenous 0.5 mg/kg ketamine 10
min before surgery, and the control group (Group C, n=30) received an equivalent volume of
normal saline 30 min before surgery. A standardized general anesthesia method was used with a
laryngeal mask airway device in all patients. Data on pain intensity, incidence of lower urinary tract
discomfort, time to the first analgesic requirement, tramadol analgesia and consumption, overall
patient satisfaction and side effects were recorded for 24 h after extubation of the patients.
Results: Group K had significantly decreased postoperative pain scores at 1, 2, 6, and 12
h. The number of patients who required postoperative analgesia was fewer and postoperative
tramadol consumption was significantly less in Group K as compared with Group C. There was no
significant difference in the incidence of lower urinary tract discomfort or any of side effects. The
patients in Group K were more satisfied.
Conclusion: Preemptive 0.5 mg/kg ketamine has a definitive role of preemptive analgesia for
TURP without influence of LUT discomfort or an increase of adverse effects.
Keywords: Ketamine, Transurethral resection of prostate, Preemptive analgesia.
Introduction
Preemptive analgesia is a pretreatment that prevents the establishment of central sensitization,
which amplifies upcoming pain. Various drugs have been used for this analgesic method, but
treatments that can prevent the development of central sensitization may have the greatest benefit.
It has been shown that central sensitization could be attenuated by 4, 9 N-methyl d-aspartate
receptor antagonists1. Ketamine, a NMDA receptor antagonist, is an interesting choice for
preemptive analgesia. Previous studies indicated that a single small dose of preoperative ketamine
can decrease postoperative pain and analgesic requirement in minor surgeries such as outpatient
*
Na Wang, MD, PhD. Department of Anaesthesiology, the First Hospital of Jilin University, No. 71 Xinmin Street, Changchun,
China, 130021. Phone number: +86-13578899126. e-mail address: lilyly12345@163.com
** Yaowen Fu, MD, PhD, professor. Department of Urology, the First Hospital of Jilin University, No. 71 Xinmin Street,
Changchun, China, 130021. Phone number: +86-13756661667. e-mail address: fuyaowen@medmail.com.cn
*** Haichun Ma, MD, PhD, professor. Department of Anaesthesiology, the First Hospital of Jilin University, No. 71 Xinmin
Street, Changchun, China, 130021. Phone number: +86-13578927386. e-mail address: polly-sd@sina.com
****Jinguo Wang, MD, PhD, associated professor. Department of Urology, the First Hospital of Jilin University, No. 71 Xinmin
Street, Changchun, China, 130021. Phone number: +86-13756861656. E-mail address: wangjinguolily@163.com
Corresponding author: Jinguo Wang, Department of Urology, the First Hospital of Jilin University. Phone number: +8613756861656. E-mail address: wangjinguolily@163.com. Address: No. 71 Xinmin Street, Changchun City, Jilin Province,
China, 130021.
Source of funding: the First Hospital of Jilin University.
295
M.E.J. ANESTH 23 (3), 2015
296
surgery, knee arthroscopy, gynecological laparoscopic
surgery and laparoscopic cholecystectomy, which
cause less tissue trauma2-6. Conceivably, small dose
ketamine can’t lead to obvious hemodynamic variation
and additional psychotomimetic effects6. Transurethral
resection of prostate (TURP) is associated with less
pain and disability; nonetheless several components
contribute to pain after TURP such as tissue trauma at
the surgical site, pelvic organ nociception, stimulation
due to irrigation and low urinary tract (LUT)
discomfort. Most patients scheduled for TURP are
elderly, frequently presented with cardiopulmanory
comorbidities, increased pain threshold and decreased
pain tolerance7; as such the improvement in pain
control is necessary.
The aim of this study is to evaluate preemptive
analgesic efficacy of preoperative intravenous 0.5 mg/
kg ketamine after TURP under general anesthesia.
Materials and Methods
Amir Shafa et. al
for measuring postoperative pain.
After shifting the patients to the operating
theatre, electrocardiogram (ECG), heart rate (HR),
blood pressure (BP), Narcotrend index (NI), endtidal CO2 (ETCO2) and oxygen saturation (SpO2)
were monitored throughout the surgical procedure.
All patients received 5 ml/kg normal saline over 20
min before anesthetic induction. The intravenous
infusion was minimally maintained during the surgical
procedure to avoid fluid overload. Anesthesia was
induced with 0.3 mg/kg etomidate, 3 µg/kg fentanyl
and 0.15 mg/kg cisatracurium. After preoxygenation
for 3 min, intubation using a proper-sized LMA was
performed.
Anesthesia was maintained with 6 to 8 mg/
kg/h propofol and 0.008 mg/kg/h remifentanil, and
intermittent administration of cisatracurium as needed.
Intravenous 1 µg/kg fentanyl was given to all patients
about 10 min before the completion of the surgery.
Patients who were allergic to tramadol or
ketamine, with a history of drug abuse, with psychiatric
illness and communication difficulties and morbidly
obese patients were excluded from the trial.
After extubation, the patients were shifted to
the recovery room where the continuing observations
were made and recorded by an independent anesthesia
registrar who was unaware of the group situation. The
pain intensity was evaluated and recorded at 0.5, 1, 2,
6, 12 and 24 h after extubation of the patients at rest.
The time 0 h was taken as the time of extubation of
the patient. Postoperative analgesia consisted of 1.5
mg/kg intravenous tramadol, which was administered
intravenously when the patient complained of pain and
the VAS score was more than 3. The time to the first
analgesic request, the number of tramadol doses given
and patients who required tramadol analgesia were
recorded.
Randomization was performed with a computergenerated sequence of numbers and sealed envelopes
were used to allocate patients into two groups. Group
K patients received 0.5 mg/kg ketamine (Jiangsu
Hengrui Medicine CO., LTD, Lianyungang, China)
10 min before the surgery, and Group C received an
equivalent volume of normal saline. The study drugs
were drawn and diluted to a fixed volume of 10 ml
by an anesthesiologist who was not involved in the
management of anesthesia. The other researchers and
patients were blinded to the grouping allocation. All
the patients were instructed on the visual analog scale
(VAS) preoperatively and instructed of its use as a tool
The pain intensity was assessed by a linear 10 cm
VAS (0- no pain; 1, 2, 3- mild pain; 4, 5, 6- moderate
pain; 7, 8, 9- severe pain; 10- worst imaginable pain)
and the sedation score was evaluated with Ramsay
sedation scale (RSS: 1- anxious and agitated; 2cooperative and tranquil; 3- drowsy but responds to
command; 4- asleep but responds to tactile stimulation;
and 5- asleep and no response). The incidence of lower
urinary tract (LUT) discomfort was recorded. The
overall satisfaction degree for postoperative analgesia
was also measured at the end of the study. The overall
satisfaction degree was divided as follow: poor,
moderate, good, excellent.
After obtaining the approval from the local
Ethics Committee and written informed consent from
the patients, the present study was conducted in a
randomized and double-blinded manner on a total of
60 patients with American society of anesthesiologists
(ASA) physical status Ⅰ-Ⅱ, scheduled for elective
TURP using a standardized general anesthesia
technique with a laryngeal mask airway (LMA) device.
Preoperative ketamine for TURP
297
Adverse effects associated with ketamine, such
as nausea, vomiting, and hallucinations were evaluated
with a “yes” or “no” survey. Hallucination was defined
as a false sensory experience in which the patients
reported they saw, heard, smelled, tasted, or felt
something that was non-existent. The study ended at
the 24th hour after extubation of the patient.
The time to the first analgesic request was the
primary endpoint of this study. According to clinical
experiences and previous studies, we assumed that
preoperative intravenous ketamine would prolong time
to the first analgesic request by 30 min, 23 subjects
were required in each group with two-sided α of 5%
and β of 10%. We decided to enroll 30 patients per
group for possible dropouts.
Data were analyzed with the SPSS 17.0 (SPSS
Inc, Chicago, IL, USA). Data of the two groups
were compared by unpaired Student›s t-test for
normally distributed data, Mann–Whitney U-test for
nonnormally distributed data (the number of tramadol
doses, VAS and RSS scores), and Chi-square or Fisher’s
exact test for qualitative data. A value of P<0.05 was
considered as a statistically significant.
The VAS scores at 1, 2, 6 and 12 h were
significantly higher in Group C as compared with the
VAS scores at the same time point in Group K. At 0.5
and 24 h the VAS scores were comparable between the
two groups (Fig. 1).
Table 2 summarizes the use of postoperative
Table 2
Postoperative tramadol use
Group K
(n=30)
Time to the first
tramadol request
(min)
Number of doses of
tramadol (n)
Table 1
Demographic data and surgical characteristics
Group K
(n=30)
Group C
(n=30)
P-value
Age (years)
67.2±9.5
64.9±10.3
0.372
Weight (kg)
63.2±11.1
66.3±9.6
0.252
Height (cm)
168.4±9.4
165.3±12.2
0.274
15/15
18/12
0.604
Duration of
operation
(min)
45.9±13.7
51.7±16.1
0.138
Prostate
volume (g)
55.6±12.1
ASA Ⅰ/Ⅱ(n)
58.4±15.6
0.440
ASA: American Society of Anesthesiologists. Values are
presented as mean±standard deviation and number of patients.
P-value
114.6±32.2 66.4±22.7
0.0001
1.8±0.7
1.4±0.6
0.031
Number of patients
requiring tramadol
analgesia: n (%)
18(60%)
27(90%)
0.015
Values are presented as mean±standard deviation and number
of patients (%).
Table 3
Patient satisfaction
Group K
(n=30)
Group C
(n=30)
Poor
1(3.3%)
5(16.7%)
Moderate
6(20.0%)
10(33.3%)
Good
10(33.3%)
11(36.7%)
Excellent
13(43.3%)
4(13.3%)
Results
The demographic data and surgical characteristics
were comparable with no significant differences
between the two groups (Table 1).
Group C
(n=30)
P-value
0.037
Values are presented as number of patients (%).
Table 4
The incidence of lower urinary tract (LUT) discomfort and
adverse effects
Group K
(n=30)
Group C
(n=30)
P-value
LUT
discomfort
8 (26.7%)
14 (36.7%)
0.179
Nausea
5 (16.7%)
3 (10.0%)
0.706
Vomiting
2 (6.7%)
0(0.0%)
0.491
Hallucination
0 (0.0%)
0(0.0%)
Values are presented as number of patients (%).
1.000
M.E.J. ANESTH 23 (3), 2015
298
Amir Shafa et. al
Fig. 1
Visual analog scale (VAS)
scores at various time points
postoperatively. Box plots of
postoperative VAS scores.
Results are expressed in median.
The top and bottom of each box
indicate 75th and 25th percentiles
and the error bars minimum and
maximum. *p<0.05 compared
with Group C.
Fig. 2
Ramsay sedation scale (RSS)
scores at various time points
postoperatively. Box plots of
postoperative RSS scores.
Results are expressed in median.
The top and bottom of each box
indicate 75th and 25th percentiles
and the error bars minimum and
maximum.
tramadol analgesia. In Group K, the time to the first
tramadol request was significantly longer, and the
patients who required tramadol analgesia and the
number of tramadol doses given were significantly
fewer.
the study period (93-100% for SpO2 and 12-16 breath/
min for respiration rate) in both groups.
The overall patients’ satisfaction degree is shown
in Table 3. Patients in Group K were more satisfied
compared to patients in Group C.
Surgical stimulation leads to release of glutamate
which can activate postsynaptic NMDA receptors
in the central nervous system. Activation of NMDA
receptor is involved in development and exacerbation
of hyperalgesia. Analgesic intervention before surgical
stimuli, for example, preoperative administration of
ketamine which is an NMDA receptor antagonist may
attenuate or block sensitization and hence reduce acute
pain8.
No statistically significant difference was noted
on RSS scores between the two groups at all time
points during the study (Fig. 2).
There were no significant differences between the
two groups for the incidence of LUT discomfort or any
of the adverse events (Table 4). All data of SpO2 and
respiration rate were within the normal range during
Discussion
The role of preoperative intravenous ketamine
has been previously reported in outpatient surgeries,
Preoperative ketamine for TURP
gynecological laparoscopic surgery and laparoscopic
cholecystectomy which are all minor surgeries with
less tissue damage compared with other types of
surgeries4,5,6. Singh et al have reported that VAS
scores in the three groups receiving different doses of
ketamine were comparable and 0.5 mg/kg ketamine
had similar effect to 1.00 mg/kg. According to their
study, 1.00 mg/kg ketamine was associated with higher
incidence of side effects6. Therefore, the lowest dose
of 0.5 mg/kg ketamine was chosen as the study dose
in our study.
Our study demonstrated that the patients in Group
K had significantly less postoperative pain. The result
was consistent with the published researches mentioned
above. Whereas some studies have demonstrated no
beneficial effect of preoperative ketamine9,10,11. These
negative findings could be ascribed to major surgeries
in those studies. Major surgeries were usually
associated with severe postoperative pain and maybe
preoperative ketamine was not potent enough to block
central sensitization in this kind of surgeries.
In the present study, intravenous administration
of fentanyl 10 min before completion of the surgery
might contribute to the comparable VAS scores at
the time point of 0.5 h between the two groups. No
significant difference was found on the incidence of
299
LUT discomfort between the two groups. It might be
associated with the result that ketamine had no function
on muscarinic receptor.
The RSS scores were assessed as an indirect
reflection of the adverse effect of ketamine. Patients in
the two groups had comparable RSS scores at various
time points. It implied that preoperative ketamine did
not affect sedation status which should be attached
attention to in the elder patients after general anesthesia.
In our study, no patients experienced hallucination
in Group K. It corresponded to the incidence reported
in the literature with the same dosage of ketamine6.
The incidence of nausea and vomiting was comparable
between the two groups and similar to the previous
research6. It was not noted in this clinical trial that a
small dose of ketamine could decrease postoperative
nausea and vomiting12.
There are limitations about this study. Ketamine
is known to alter the neuroplasticity and reduce the
development of chronic pain13. We didn’t follow up the
patients or evaluate whether chronic pain was reduced
with 0.5 mg/kg ketamine. Further studies in this area
are suggested.
We conclude that preoperative 0.5 mg/kg
ketamine can reduce postoperative pain in patients
undergoing TURP without an increase of side effects.
M.E.J. ANESTH 23 (3), 2015
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Amir Shafa et. al
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5. Truta E, Vartic M, Cristea A: Clinical study regarding preemptive
analgesic effect of ketamine and remifentanyl in laparoscopic
cholecystectomy. Farmacia; 59:239-45, 2011.
6. Singh H, Kundra S, Singh Rm, Grewal A, Kaul TK And
Sood D: Preemptive analgesia with ketamine for laparoscopic
cholecystectomy. J Anaesthesiol Clin Pharmacol; Oct-Dec,
29(4):478-84, 2013.
7. Rivera R and Antognini J: Perioperative drug therapy in elderly
patients. Anesthesiology; 110:1176-81, 2009.
8. Warncke T, Stubhaug A and Jorum E: Ketamine, an NMDA
receptor antagonist, suppresses spatial and temporal properties of
burn-induced secondary hyperalgesia in man: A double-blind, crossover comparison with morphine and placebo. Pain; 72:99-106,
1997.
9. Ong C, Lirk P, Seymour R and Jenkins B: The efficacy of
preemptive analgesia for acute postoperative pain management: A
meta-analysis. Anesth Analg; 100:757-73, 2005.
10.Dullenkop F, Muller R, Dillmann F, Wiedemeier P, Hegi T
and Gautschi S: An intraoperative pre-incision single dose of
intravenous ketamine does not have an effect on postoperative
analgesic requirements under clinical conditions. Anaesth Intensive
Care; 37:753-7, 2009.
11.Carstensen M and Moller A: Adding ketamine to morphine for
intravenous patient-controlled analgesia for acute postoperative
pain: A qualitative review of randomized trials. Br J Anaesth;
104:401-6, 2010.
12.Chandrakantan A And Glass P: Multimodal therapies for
postoperative nausea and vomiting, and pain. Br J Anaesth;
107(Suppl 1):127-40. PMID:22156268, 2011.
13.Voscopoulos C and Lema M: When does acute pain become
chronic? Br J Anaesth; 105(suppl 1):169-85, 2010.
“ANESTHETIC SPARING EFFECT OF INTRAOPERATIVE
LIGNOCAINE OR DEXMEDETOMIDINE INFUSION
ON SEVOFLURANE DURING GENERAL ANESTHESIA”
Siddarameshwar S. Harsoor*, Devika Rani D**, Roopa M.N***,
Lathashree S****, Sudheesh K***** and Nethra S.S******
Background: Lidocaine and Dexmedetomidine are known to blunt the stress response to
surgery, and have anesthetic sparing activity. This study was designed to evaluate and compare
the anesthetic sparing effect of intravenous lidocaine with Dexmedetomidine infusion during
sevoflurane based general anesthesia and also to assess their effects on hemodynamic parameters.
Methods: Forty-eight ASA I−II patients aged between 18−55 yr, scheduled for abdominal
surgery lasting less than 2 h, performed under general anesthesia were enrolled and they were
randomly allocated to Lidocaine(L), Dexmedetomidine (D) and Saline (S) groups of 16 each.
Group L received Inj. Lidocaine at 1.5 mg/kg bolus over 10 min followed by infusion at 1.5 mg/
kg/hr, and Group D received Inj. Dexmedetomidine at 1 µg/kg over 10 min, followed by 0.5 µg/
kg/hr infusion till the end of surgery. Group S received similar volume of normal saline. Anesthesia
was induced with Inj. Propofol and maintained with N2O in O2 and sevoflurane, keeping entropy
between 40−60. The hourly sevoflurane requirements and hemodynamic parameters were recorded.
Results: Demographic parameters, entropy and duration of surgery were comparable. Mean
sevoflurane requirement at 1st h in group L and D were 11.6 ± 1.5 ml, and 10.2 ± 1.3 ml respectively,
while it was 16.7 ± 4.1 ml in Saline group (P < 0.001). Sevoflurane requirements were significantly
lesser in group D compared to group L (P = 0.009). The Mean ETsevo concentrations in Group L, D
and S were 0.8 ± 0.3, 0.8 ± 0.4 and 1.2 ± 0.5 (P = 0.021), respectively.
Conclusions: Both drugs produce significant anesthetic sparing effect during sevoflurane
based general anesthesia, but dexmedetomidine has better sparing effect than lignocaine.
Keywords: Dexmedetomidine, Intraoperative, Lidocaine, Sevoflurane.
*
MD, Professor, Department of Anaesthesiology, Bangalore Medical College and Research Institute, Bangalore. E-mail:
harsoorss@hotmail.com
** MD, Professor, Department of Anaesthesiology, Bangalore Medical College and Research Institute, Bangalore. E-mail:
devikard@gmail.com
*** DA, Resident, Ganga Hospital, Coimbatore. E-mail: dr.mnroopa@gmail.com
****MD, Resident, Department of Cardiac Anaesthesia, Sri Jayadeva Institute of Cardiology, Bangalore. E-mail: lathashree0110@
gmail.com
*****MD, Associate Professor, Department of Anaesthesiology, Bangalore Medical College and Research Institute, Bangalore.
E-mail: drsudhi@rediffmail.com
******MD, Professor, Department of Anaesthesiology, Bangalore Medical College and Research Institute, Bangalore. E-mail:
nethra.surhonne@gmail.com
Corresponding author: Dr. Sudheesh K. 314/2/5 Durganjali Nilaya, 1st H. Cross, 7th Main, Subbannagarden, Vijayanagar
Bangalore - 560040, Karnataka, INDIA. Phone: +91-80-23393535, Mobile number: +91-9900134694. E-mail: drsudhi@
rediffmail.com
301
M.E.J. ANESTH 23 (3), 2015
302
Introduction
Intravenous (IV) Lidocaine can be used to
provide symptomatic relief from cancer pain1, diabetic
neuropathies2,3, and chronic pain4,5 without producing
any toxic side effects. This analgesic efficacy was
attributed to selective depression of pain transmission
in the spinal cord4,5, and a reduction in tonic neural
discharge of active peripheral nerve fibers6,7. Because
of its NMDA receptor antagonist activity, lidocaine
can reduce volatile anesthetic requirements during
general anesthesia. Dexmedetomedine, a highly
selective α-2 adrenergic receptor agonist has sedative,
analgesic, anesthetic-sparing properties without any
respiratory depression8. The hypnotic and supraspinal
analgesic effects are mediated by the hyperpolarization
of noradrenergic neurons, which suppresses neuronal
firing in the locus ceruleus due to decreased
norepinephrine and histamine release9.
There are very few studies that compare
intravenous lidocaine and dexmedetomidine with
regard to anesthetic sparing effect, specially when
objective tools like BIS or entropy were used to guide
the depth of anesthesia.
Hence this clinical study was designed to compare
the effects of IV lidocaine and dexmedetomedine
on sevoflurane requirements during entropy guided
general anesthesia.
Materials and Methods
After obtaining approval from institutional
ethical committee, a randomized, prospective, double
blind, controlled, clinical study was formulated, and
conducted at our hospital from March 2013 to October
2013.
Forty eight patients were randomly allocated into
three groups as Group L (Lidocaine group), Group D
(Dexmedetomedine) and Group S (Saline group) using
computer based random number generation technique.
Informed written consent was obtained from
all patients. The patients with American society of
Anesthesiologists (ASA) physical status I and II,
aged 18-55 yr, scheduled for elective open abdominal
surgery expected to last less than 2 hours, under general
Sudheesh K et. al
anesthesia were included in the study. Hypertensive
patients, patients on psychoactive medication, and
those allergic to local anesthetics were excluded from
the study.
A minimum fasting state of 6-8 hours before
anesthesia was ensured in all patients. In the operating
theatre IV access was obtained and the standard
monitoring consisted of electrocardiography, pulse
oximetry, noninvasive blood pressure, entropy
sensor, neuromuscular transmission indicator
(NMT) and capnography. Midazolam 0.05 mg/kg IV,
glycopyrrolate 0.005 mg/kg IV, Fentanyl 2 μg/kg IV
were used for premedication. The response entropy
was measured with Datex Ohmeda entropy S/5
module. All patients were pre-oxygenated with 100%
oxygen for 3 minutes.
Group L received a loading dose of lidocaine1.5
mg/kg IV made to 20 ml with normal saline, over 10
minutes followed by similar volume every hour till
the end of surgery. In group D, patients received 1 μg/
kg of dexmedetomidine, made to 20 ml, in 10 minutes
followed by an infusion of dexmedetomidine 0.5 μg/
kg made up to 20 ml, every hour. Group S received
similar volume of normal saline. The drug solutions
were prepared by anesthesiologists who were not
involved in the management of the case. Anesthesia
was induced with Propofol until RE reached 50, and
confirmed with loss of response to verbal commands.
Atracurium 0.5 mg/kg IV was used to facilitate
tracheal intubation. Anesthesia was continued with
60% nitrous oxide in oxygen and sevoflurane, and
ventilated to maintain ETCO2 between 35-40 mmHg.
Sevoflurane concentration was adjusted to ensure
adequate depth of general anesthesia as guided by
entropy (40-60) and also by clinical variables like
HR, systolic and diastolic blood pressures (SBP &
DBP), and mean arterial pressure (MAP). Adequate
muscle relaxation was guided by NMT monitor. The
monitored data were recorded continually at baseline,
before induction, after induction, 1 minute after
intubation and every 5 minutes thereafter, till the end
of surgery. Initially fresh gas flow (FGF) of 6 L/min
was used until the difference between end inspiratory
and end expiratory sevoflurane concentration was
nearly equal and later the FGF was reduced to 2 L/min.
Infusion of test drug and sevoflurane administration
Sevo use-dexmedetomidine & Lidocaine
303
was cut off on the beginning of skin closure and the
fresh gas flow was increased to 6 L/min oxygen. At
the end of the skin closure, residual neuromuscular
blockade was reversed with neostigmine 0.5 mg/
kg and glycopyrrolate 0.01 mg/kg and trachea was
extubated after satisfactory recovery. The duration of
sevoflurane usage and duration of anesthesia (min)
were recorded. The hourly sevoflurane requirements
and total consumption of sevoflurane at the end of
the procedure were recorded directly from anesthetic
agent monitoring module of Datex Ohmeda Avance
S5™ anesthesia workstation. The Minimum alveolar
anesthetic concentration (MAC) was derived from end
tidal concentration of sevoflurane using a nomogram
by Nickalls and Mapleson11.
Intraoperatively, occurrence of bradycardia
and hypotension episodes were noted. Bradycardia
was defined as heart rate less than 50 beats/ min and
hypotension was defined as more than 25% decrease in
mean arterial pressure from the baseline. Bradycardia
and hypotension if noticed, were treated with atropine
0.5 mg i.v, and fluid boluses and ephedrine 6 mg i.v
boluses respectively. Tachycardia was defined as heart
rate (HR) more than 110 beats/ min and hypertension
defined as increase in mean arterial pressure greater
than 25% from the baseline and treated with esmolol
infusion. If time from discontinuation of anesthetic
to spontaneous eye opening exceeded 30 min, it was
considered as delayed recovery and recorded.
Statistical Analysis
Sample size was calculated based on the pilot
study done on 10 patients. We hypothesized that
dexmedetomidine would have greater anesthetic
sparing effect compared to Lidocaine. By keeping the
confidence limits at 95% and power at 80%, to detect
a 15% reduction in sevoflurane consumption assuming
an equal standard deviation and normal distribution
of values, the required sample size was 13 patients in
each group. However for better validation of results
we increased the sample size to 16 in each group. All
parametric data were presented as mean + SD, and
nominal data were tabulated. One way ANOVA and
post hoc analysis with Benferroni’s correction and
Dunell’s correction was applied for all parametric
data, chi-square test and Fisher exact test applied for
nominal data. Furthermore, independent t-test was
applied for intergroup comparison of mean values.
P value of less than 0.05 was considered statistically
significant. Statistical analysis was conducted with
SPSS (Version 17) for windows statistical package.
Results
Demographic parameters such as age, gender,
weight, duration and type of surgery and anesthesia,
basal vital parameters and entropy values were similar
in all the groups (Table 1). Sevoflurane was used for
slightly longer time in group D patients (P = 0.04).
Table 1
Demographic Characteristics
Parameters
Lidocaine
(n = 16)
Dexmedetomidine
(n = 16)
Saline
(n = 16)
P-value
Age(yrs)
41.2 ± 12.5
48 ± 9.01
46.68 ± 12.48
0.21
Sex (M:F)
7:9
6:10
7:9
Weight(kg)
55.60 ± 9.08
51.40 ± 5.08
53.87 ± 6.55
0.25
Duration of surgery(min)
76.88 ± 15.15
89.33 ± 30.93
74.38 ± 18.52
0.14
Duration of Anesthesia(min)
92.18 ± 14.94
111.67 ± 38.44
91.88 ± 18.79
0.06
72.8 ± 15.2
93.67 ± 33.57
77.19 ± 19.15
0.043
Open cholecystectomy
12
9
11
Open cholecystectomy with common bile
duct exploration
2
4
2
Gastric surgeries
2
3
3
Duration of Sevoflurane Usage(min)
*
Types of surgeries
0.7
M.E.J. ANESTH 23 (3), 2015
304
Sudheesh K et. al
Table 2
Sevoflurane Consumption
Parameters
Group L
Group D
Group S
P value
Mean EtSevo
0.78 ± 0.3
0.83 ± 0.42
1.18 ± 0.53*
0.021
11.63 ± 1.58
10.20 ± 1.32¥
16.75 ± 4.07*
< 0.0001
Mean Sevoflurane Consumption in 1st hour
Intraoperatively adequate depth of anesthesia was
maintained in all the patients with the help of entropy
(Fig. 1) and clinical parameters such as heart rate and
blood pressure (Figs. 2 and 3).
Mean Sevoflurane requirement at 1st hour in
Group S was 16.75 ± 4.07 ml compared to 11.63 ±
1.58 ml in Group L (30.5% reduction), and 10.20 ±
1.32 ml in Group D (39% reduction)(P < 0.01). Post
hoc analysis showed significantly lower consumption
of sevoflurane in group D compared to group L
Fig. 1
Response Entropy values mean±SD
in 3 groups
Fig. 2
The trend in heart rate
(P < 0.01) in the first hour. The end tidal concentration
of sevoflurane (EtSevo) was significantly lower in
groups L and D compared to group S (P = 0.02). The
intergroup comparison indicates that there was no
statistically significant difference between Group L
and Group D with respect to mean end tidal sevoflurane
concentration, although duration of sevoflurane usage
was significantly longer in group D (Table 2).
The average MAC was 1.02 ± 0.2, 1.05 ± 0.1, and
1.16 ± 0.2 in Group L, D and group S respectively(P =
Sevo use-dexmedetomidine & Lidocaine
305
Fig. 3
Trend in systolic and diastolic blood
pressures
0.08). Post hoc analysis did not reveal any statistically
significant difference between the groups.
During first hour of anesthesia, the heart rates
were significantly lower in Group D compared to
other two groups. The mean heart rates in group D
were comparable to groups L and S after 1st hour. The
systolic and diastolic blood pressure was comparable
in all the three groups initially, but was significantly
higher in group S compared to other two groups after
1st hour. None of the patients in any of the three groups
had heart rate or blood pressure instability requiring
intervention. There was no incidence of delayed
recovery in any of the three groups.
Discussion
The present study shows that intraoperative
infusions of lidocaine and dexmedetomidine reduces
the sevoflurane consumption during entropy guided
general anesthesia. Dexmedetomidine caused greater
decreases in sevoflurane consumption compared to
lidocaine infusion. Degree of surgical stimulus may
influence anesthetic consumption and all attempts were
made to maintain uniformity in surgical stimulus in the
present study, by recruiting patients undergoing upper
abdominal surgeries of duration less than 2 hours.
Following systemic administration, lidocaine,
a sodium channel blocker, attenuates skin pain in
response to mechanical or chemical stimuli through
peripheral and central mechanisms in preclinical
human volunteer tests12-14. It was observed that IV
lidocaine infusion reduced BIS guided propofol
requirement15,16. The BIS read zero when lidocaine
was inadvertently administered at a dose of 100 mg
per minute for 7-8 min17 indicating that cerebral
cortical activity was decreased by systemic lidocaine
administration. During the study conducted to explore
the effect of lidocaine on MAC, Hodgson and Liru18
found that during general anesthesia with BIS less than
50, epidural lidocaine reduced sevoflurane requirement
by 34%, probably due to rostral migration of lidocaine
to the brain cerebrospinal fluid. It was observed that,
intraoperative lidocaine infusion reduced sevoflurane
requirement by 5% during BIS monitored general
anesthesia19,20. During 60% nitrous oxide in oxygen
anesthesia, in the current study, it was observed that
there was 30.5% reduction in sevoflurane requirement
during 1st hour of anesthesia when lidocaine was
infused. The greater reduction in consumption noticed
in the present study compared to previous ones may be
attributed to the use of nitrous oxide.
Edno Magalhaes and others observed that
dexmedetomedine infusion at a rate of 0.5 µg/kg over
10 min before the induction of anesthesia and when
later maintained with 0.2-0.7 µg/kg/hr until skin closure
attenuated sympatho-adrenal response to tracheal
intubation21. Uyar et al22 observed that administration
of single IV bolus dose of dexmedetomedine 1 µg/kg
over 10 minutes before induction of anesthesia resulted
in attenuation of hemodynamic and neuroendocrinal
responses to skull pin insertion in patients undergoing
M.E.J. ANESTH 23 (3), 2015
306
craniotomy. Keniya et al23 showed that 1 µg/kg bolus
followed by 0.2-0.7 µg/kg/hr of dexmedetomedine
infusion not only blunted the sympathoadrenal
response to tracheal intubation but also reduced the
consumption of fentanyl and isoflurane; however,
their measurement were based on the inspired
concentration of isoflurane. Patel et al24 reported that
dexmedetomidine infusion when given as bolus of 1
µg/kg followed by 0.2-0.8 µg/kg infusion, reduced
end-tidal sevoflurane concentration by 21%. In the
present study, using bolus IV dexmedetomedine 1 µg/
kg combined with infusion of 0.5 µg/kg/hr resulted in
39% reduction in sevoflurane requirements during 1st
hour of anesthesia. However, end-tidal concentration
of sevoflurane in patients receiving dexmedetomidine,
in the current study, were lower compared to those
reported by Patel et al which may be attributed to
the use of fentanyl in the current study. Action of
dexmedetomidine at both supraspinal and spinal levels
may have attributed to greater reductions in sevoflurane
Sudheesh K et. al
consumption compared to lidocaine. Though patients
receiving dexmedetomidine exhibited significant
reduction in heart rate intraoperatively, none of these
patients required any treatment.
The main limitations of the study are the fact
that the MAC was a derived factor from end-tidal
concentration. Also, the serum levels of test drugs
were not estimated during this clinical study and hence
dose response relationship could not be established.
Conclusion
IV lidocaine and dexmedetomedine used for
preanesthetic and intraoperative infusions produce
30.5% and 39% anesthetic sparing effect respectively
during sevoflurane based general anesthesia when
compared to normal saline. However dexmedetomedine
was found to be significantly more effective than IV
lidocaine.
Sevo use-dexmedetomidine & Lidocaine
307
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16.Altermatt FR, Bugedo DA, Delfino AE, Solari S, Guerra I,
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M.E.J. ANESTH 23 (3), 2015
Submucosal dissection of the retropharyngeal
space during nasal intubation
Mumin Hakim1, Richard S. Cartabuke1,2, Senthil G. Krishna1,2,
Giorgio Veneziano1,2, Ahsan Syed1,2, Meredith N. Merz Lind3
and Joseph D. Tobias 1,2,4*∗
Various complications have been reported with nasal endotracheal intubation including
bleeding, epistaxis, bacteremia, damage to intranasal structures, and even intracranial penetration.
We present two cases that required general anesthesia for dental surgery. Submucosal dissection
of the retropharyngeal tissues occurred during attempted nasal endotracheal intubation. Previous
reports of this complication are reviewed, treatment strategies presented, and potential maneuvers
to prevent this complication suggested.
Introduction
Endotracheal intubation via the nasal route is performed in various clinical scenarios including
intraoperative care of patients undergoing oromaxillary or dental surgery. Although generally safe,
nasal endotracheal intubation has a greater potential for trauma to the mucosa of the nasopharynx
than does routine oral endotracheal intubation. Various complications have been reported including
bleeding, epistaxis, bacteremia, damage to intranasal structures, and even intracranial penetration1,2.
We present a pediatric patient presenting for dental surgery in whom submucosal dissection of the
retropharyngeal tissues occurred during attempted nasal endotracheal intubation. Previous reports
of this complication are reviewed, treatment strategies presented, and potential maneuvers to
prevent this complication suggested.
Case Report
Institutional Review Board approval is not required at Nationwide Children’s Hospital
(Columbus, Ohio) for the presentation of case reports involving two patients.
Patient #1: The patient was a 4-year-old, 20.5 kg girl who presented for oral rehabilitation
under general anesthesia for the treatment of dental caries. Her past medical history was significant
for recurrent acute otitis media. Her past surgical history included adenotonsillectomy for tonsillar
hypertrophy. There were no associated co-morbid conditions. The patient was not on any home
medications. Preoperative physical examination revealed a well-appearing girl in no acute distress
and a normal systemic examination with dental caries in the oral cavity. On the day of surgery,
the patient was held nil per os for 6 hours. She was transported to the operating room and routine
1
2
3
4
MBBS, Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, Ohio.
MD, Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio.
MD, Department of Otolaryngology and Head & Neck Surgery, Nationwide Children’s Hospital and The Ohio State
University, Columbus, Ohio.
MD, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio.
Corresponding author: J. D. Tobias, MD, Chairman, Department of Anesthesiology & Pain Medicine, Nationwide
Children’s Hospital, 700 Children’s Drive, Columbus, Ohio 43205. Phone: (614) 722-4200, Fax: (614) 722-4203. E-mail:
Joseph.Tobias@Nationwidechildrens.org
309
M.E.J. ANESTH 23 (3), 2015
310
American Society of Anesthesiologists’ monitors were
applied. Anesthesia was induced with the inhalation
of sevoflurane in nitrous oxide and oxygen. After
the induction of anesthesia, a 22 gauge peripheral
intravenous catheter was placed in the left hand and
propofol was administered to deepen the level of
anesthesia. Bag-valve-mask ventilation was provided
without difficulty. Following lubrication of the right
nare, a 4.5 mm cuffed endotracheal tube (ETT)
was passed through the nare in preparation of nasal
endotracheal intubation. Direct laryngoscopy was
performed and blood was noticed in the supraglottic
area and the oropharynx. The patient’s oropharynx was
suctioned and a submucosal bulging was noted in the
retropharyngeal space. Pediatric otolaryngology was
consulted as it was thought that the nasal ETT had caused
a blind submucosal tract. With the nasal ETT in place,
an oral 4.5 mm cuffed ETT was placed into the trachea
without difficulty under direct vision using a Miller
2 blade. The patient was kept in the supine position
and anesthesia was maintained with sevoflurane in
air and oxygen. The pediatric otolaryngologist noted
a submucosal dissection of the retropharyngeal
space. Based on their recommendation, the ETT was
removed and prophylactic antibiotics (clindamycin)
administered. The dental procedure was then completed
without problems. During the procedure, the patient
experienced an episode of bronchospasm and mild
hypotension which was attributed to an anaphylactoid
reaction to the clindamycin infusion. The bronchospasm
was treated with albuterol administered via the ETT
using a metered dose inhaler and a single intravenous
dose of epinephrine (30 µg). Additional medications
during the procedure included dexamethasone (4 mg),
ondansetron (2 mg), and fentanyl (35 µg). Following
completion of the procedure, the patient’s trachea was
extubated when awake. She was transferred to the Post
Anesthesia Care Unit (PACU) in a stable condition. The
patient was kept for observation in the general pediatric
overnight. Postoperative pain control was provided by
intermittent, as needed doses of oral ibuprofen. A 7 day
course of oral antibiotics (amoxcillin-clavulanate) was
completed. Her postoperative period was uneventful
and she was discharged the next day. No complications
related to the submucosal dissection were noted.
Patient #2: The patient was a 6-year-old, 22
kg boy who presented for oral rehabilitation under
J. D. Tobias et. al
general anesthesia for the treatment of dental caries
at the ambulatory surgery center. There was no past
surgical or medical history. There were no associated
co-morbid conditions. The patient was not on any
home medications. Preoperative physical examination
revealed a well-appearing boy in no acute distress
and a normal systemic examination with dental caries
in the oral cavity. On the day of surgery, the patient
was held nil per os for 6 hours. He was transported to
the operating room and routine American Society of
Anesthesiologists’ monitors were applied. Anesthesia
was induced with sevoflurane in oxygen and nitrous
oxide. After the induction of general anesthesia, a 22
gauge peripheral intravenous cannula was inserted.
After achieving topical vasoconstriction with 4 drops
of 0.05% oxymetazoline, a softened and lubricated
5.0 mm cuffed nasal RAE ETT was inserted into
the right nostril with minimal resistance. Under
direct laryngoscopy, the ETT was advanced further;
however, the tip of the ETT was not visualized in the
oropharynx. The ETT was noticed advancing under
the mucosa of the right posterior pharyngeal wall.
The procedure was abandoned, the nasal ETT was
left undisturbed and an oral ETT was placed without
difficulty. A pediatric otolaryngology consultation
was obtained. The nasal ETT was removed under
direct visualization of the ENT surgeon; however,
a posterior pharyngeal hematoma was noted and a
CT scan of the neck was recommended. The dental
procedure was cancelled and the subsequent CT scan
revealed no vascular injury or posterior pharyngeal
hematoma. The patient was admitted for overnight
observation. Antibiotic prophylaxis was provided by
oral Augmentin (amoxicillin-clavulanate potassium).
He was discharged home the next day with instructions
to follow up in the otorhinolaryngology clinic in 6
weeks.
Discussion
Although required to facilitate various
oromaxillary and dental surgical procedures, there
is a higher incidence of adverse events related to
nasotracheal intubation when compared to standard
oral endotracheal intubation. A complication rate of
3% to 16% has reported with nasotracheal intubation
Nasal intubation
with many being noted during prolonged attempts
due to a higher failure rate when compared with oral
intubation. One way of classifying involves separation
into adverse events related to: 1) stimulation of
the sympathetic nervous system and physiological
changes related to pain; 2) occlusive problems
related to the presence of an endotracheal tube in the
nasaopharynx; and 3) traumatic problems. Physiologic
changes related to pain and stimulation of the
sympathetic nervous system includes hypertension,
tachycardia, arrhythmias, and increased intracranial
pressure. Occlusive problems include from long
term placement of a nasal endotracheal tube and can
result in otitis media secondary to the obstruction of
nasal and pharyngeal ostiae and maxillary sinusitis4,5.
Problems from direct trauma during passage of the
endotracheal tube through the nasopharynx include
bleeding, damage to the nasal turbinates, bacteremia,
dislodgement of adenoids, or even rare reports of
penetration of the cranial vault with intracranial
placement of the endotracheal tube6-13 Epistaxis is the
most common of the traumatic complications with a
reported incidence varying from 10 to 80% based on
the technique and definitions used. Posterior epistaxis
can result in a significant hemorrhage while anterior
epistaxis generally resolves on its own.
As noted in our two patients, another albeit
rare yet potential complication of nasal endotracheal
intubation is the submucosal passage of the ETT. The
first report in the literature regarding this complication
appeared in 1975 with the description of 3 cases are of
retropharyngeal dissection as a complication of nasal
endotracheal intubation14. In all three of the cases,
after introduction of the ETT through the nare, the tip
could not be visualized in the oropharynx during direct
laryngoscopy. Palpation revealed that the ETT was
in the submucosal plane. As noted from the patients
reported herein, the initial report from 1975, and others
from the literature, retropharyngeal dissection may
occur from trauma to the pharyngeal wall during nasal
placement of an ETT (Table 1)15-20. Fortunately, this
complication is generally benign if recognized early.
The literature has reported no long term complications
related to the creation of the false passage and no
reports of significant bleeding although localized
hematomas as noted in our second patient have been
reported in the literature. However, there remains
311
a risk of morbidity and even mortality if positive
pressure is administered as subcutaneous emphysema,
pneumothorax, and pneumomediastinum can develop.
This complication can potentially be prevented
or its incidence at least decreased by a systematic
approach with appropriate preparation of the nare and
the ETT prior to its passage through the nostril. Careful
selection of the more patent nare can also be helpful.
Comparing the airflow or probing with a swab used to
apply a topical vasoconstrictor can help in selecting
the most patent naris. Alternatively, the nare can be
progressively opened by the passage of progressing
larger lubricated nasal trumpets. As the ETT is
advanced, excessive force should be avoided and the
ETT should never be advanced against resistance. The
ETT should be advanced in a plane that is parallel to
the floor of the hard palate, generally perpendicular
to the bed when the patient is supine. Additionally,
trauma can be limited by the use of lubrication of the
ETT, the application of topical vasoconstrictors, and
thermosoftening or warming of ETT1,21-24. Although
various topical vasoconstrictors such as epinephrine,
phenylephrine, oxymetazoline, and cocaine have been
shown to effective, they may be associated with lifethreatening cardiovascular complications including
cardiac arrhythmias as well as systemic and pulmonary
hypertension25-30.
The bevel of an ETT is left-facing which may
favor its advancement through the left nare along the
nasal septum with the bevel facing outward thereby
potentially limiting trauma. However, a recent
study demonstrated no advantage to either the left
or right nare regarding success rates and untoward
events31. Kihara et al compared a silicone-based wirereinforced ETT with a hemispherical bevel is superior
to a polyvinyl chloride (PVC)-based pre-curved tube
with a conventional diagonal bevel for nasotracheal
intubation in adults22. Although the pharyngeal and
tracheal placement phases of nasotracheal intubation
required fewer attempts with the silicone ETT than
the PVC ETT, the glottic placement phase required
more attempts. No difference in intubation times was
noted between the two groups. The frequency (32%
versus 80%; P<0.0001) and severity of epistaxis
were less with the silicone ETT. In a similar study to
assess the potential impact of ETT design on trauma
M.E.J. ANESTH 23 (3), 2015
312
J. D. Tobias et. al
Table 1
Previous reports of submucosal dissection during nasotracheal intubation
Authors and
reference
Patient demographics
Intraoperative findings and management
Peña MT et al15
A 6-year-old girl for elective
surgery.
Positive pressure ventilation after attempted nasotracheal intubation
resulted in subcutaneous emphysema. Procedure was deferred and
clindamycin administered for antibiotic prophylaxis. Computed
tomography imaging demonstrated air within retropharyngeal tissues
and along the right carotid artery. No long term sequelae.
8-year-old boy with Noonan
syndrome with respiratory failure.
Four centimeter laceration of the posterior trachea, developing
pneumomediastinum after nasotracheal intubation.
Ghaffari S et al16
7-year-old girl for tonsillectomy.
Uncuffed nasal tube was inserted by the surgeon through the right nare.
No problem was noted and endotracheal intubation was completed.
During the procedure, it was noted that the nasotracheal tube pierced the
posterior pharyngeal mucosa and then re-entered oropharynx.
Bozdogan N et al17
67-year-old man for
uvulopalatopharyngoplasty.
During the surgery, it was noted that the nasotracheal tube had penetrated
the oropharyngeal mucosa in the retropharyngeal space and then reentered the oropharynx. The ETT was left in place during surgery to
prevent bleeding. After surgery, a vertical incision was made through
the mucosa surrounding the tube from the inferior pouch up to the
nasopharynx to explore the site.
Krebs MJ et al18
A 54-year-old, 95-kg woman for
excision of a
mandibular ossifying fibroma.
After passage of the ETT through the nare, direct laryngoscopy could not
identify the tip of the nasotracheal tube in the oropharynx. A longitudinal
submucosal bulge was noted in the posterolateral wall of the pharynx.
Digital palpation confirmed that the tip of the ETT had made a false
passage into the nasopharyngeal submucosa. The nasotracheal tube was
removed and a standard orotracheal ETT was placed without difficulty.
The right-sided nasopharyngeal cavity was packed with sterile gauze for
prophylactic tamponade. Clindamycin was administered for antibiotic
prophylaxis.
Chait DH et al19
33-year-old woman.
Retropharyngeal dissection during nasotracheal intubation was
immediately noted during direct laryngoscopy and digital palpation.
There was brief epistaxis, which spontaneously stopped. Penicillin was
administered for antibiotic prophylaxis.
Landess WW.20
90-year-old woman for repair of
femoral fracture.
Nasotracheal intubation attempted when oral intubation and direct
laryngoscopy failed. Resistance was noted with passage of the
nasotracheal tube.
during nasotracheal intubation, although thermossoftening effectively reduced the severity of epistaxis
for both types of conventional types of ETT, there
was no difference in the severity of epistaxis and the
incidence of nasal injury and pain between the Magilltipped, non-thermo-softened ETT and Murphy-tipped,
thermos-softened ETT32.
What is generally accepted is that gentle warming
of the ETT reduces the incidence and severity of
trauma. The technique is commonly referred to as
“thermosoftening”23,24. However, excessive heating
can make the ETT too soft thereby making successful
passage of the ETT and endotracheal intubation
more difficult. In our practice, the ETT is placed in
sterile normal saline which is kept in a warmer with
the temperature carefully controlled to prevent overheating.
In a prospective comparison, it has been
Nasal intubation
demonstrated that trauma can be reduced by placing
a red rubber catheter over the ETT prior to advancing
it through the nasal passage33. The tip of the ETT is
passed into the flange of the red rubber catheter and
the taper end is then advanced into the nasal passage.
Direct laryngoscopy is performed and the red rubber
catheter is removed as the ETT is advanced once
it is visualized in the oropharynx. Although the
intubation process took longer with the red-rubber
catheter technique, there was less trauma and less
bleeding. Similar findings were reported by Enk et
al21. A finger cot has also been used to protect the
advancing end of the ETT and thereby limit trauma;
however, these smaller devices can potentially be lost
in the nasopharynx or airway and are therefore not
recommended34. Alternatively, other items such as
suction catheters, gum elastic bougies or nasogastric
tubes can be passed through the nasal passage to act as
a guide for the ETT35-38.
The suggestions made above for the atraumatic
passage of a nasal endotracheal tube intranasally can
be divided into 3 categories:
Never advance the ETT with against resistance. The
ETT should be passed in a plane that is parallel to
the hard palate. As there has been an increased use of
cuffed ETTs in infants and children, this allows the use
of a smaller ETT which may pass more easily through
the nasal passages and limit the incidence of trauma.
.The cuff can then be inflated to seal the airway
The nasopharynx should be prepared prior to the procedure with a vasoconstrictor. Although there may be
significant hemodynamic effects with excessive dosing, the topical application of a vasoconstrictor such as
313
oxymetazoline is suggested. This should be done with
careful attention to recent dosing and administration
recommendations29,30. The nasal passage can also be
progressively dilated by the passage of progressively
.larger, well-lubricated nasal trumpets
The distal end of the endotracheal tube can be covered
in order to minimize trauma from the leading edge the
ETT with a red-rubber catheter or advanced over a suction catheter or nasogastric tube that has been placed
.through the nasal passage
Should submucosal dissection occur, we would
recommend the following treatment algorithm:
Leave the ETT in place and secure the airway
.with oral endotracheal intubation if possible
.1
Obtain otolaryngology consultation for direct inspec.tion of the site
While there is no evidence-based medicine to demonstrate efficacy, the majority of reports and the patients
reported herein were treated with antibiotics (intravenous and then oral) with either clindamycin or penicillin to provide appropriate coverage for oral flora in.cluding anaerobes
Never attempt positive pressure ventilation unless the
ETT is in the trachea. An unnoticed retropharyngeal
dissection can worsen with an attempt to ventilate with
the tube or any additional force resulting pneumome.diastinum or pneumothorax
If there is a concern for hematoma formation or dam.age to vital structures, a CT scan should be obtained
Postoperative inpatient observation is suggested as late
bleeding with hematoma formation may compromise
.the airway
M.E.J. ANESTH 23 (3), 2015
314
J. D. Tobias et. al
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A PROSPECTIVE RANDOMIZED COMPARATIVE
STUDY TO COMPARE THE HEMODYNAMIC AND
METABOLIC STRESS RESPONE DUE TO ENDOTRACHEAL
INTUBATION AND I-GEL USAGE DURING
LAPAROSCOPIC CHOLECYSTECTOMY
Saumya Biswas*, Soumen Mandal**, Tapobrata Mitra***,
Suprio De Ray****, Ranabir Chanda***** and Debajyoti Sur******
Background: Surgery and endotracheal intubation both causes an increase in metabolic
stress response.. This is further aggravated during laparoscopic surgeries. In this study we aimed
at comparing hemodynamic and metabolic parameters which are reflective of intraoperative stress
response while using I-GEL against endotracheal tube (ETT) during laparoscopic cholecystectomy.
Material and Methods: This is a prospective randomized comparative study among 64
cases of American Society of Anesthesiologists(ASA) physical status class I and II, undergoing
laparoscopic cholecystectomy who were randomly allocated into two groups of 32 each using
computer generated random number table. Patients were put under general anesthesia using
standard protocol.. After anesthesia induction and 20 minutes afterinduction venous blood samples
were obtained for measuring adrenalin, noradrenalin, dopamine and cortisol levels. Hemodynamic
and respiratory parameters were recorded at the 1st, 5th, 15th, 30th and 45th minutes after the insertion
of airway device.
Results: Although there was no significant difference regarding ventilatory parameters there
was significant increase in heart rate at 1st and 45th minutes(p=0.02 and 0.034) respectively and
increase in mean arterial pressure at 15th and 30th minutes(p=0.034 and 0.026) respectively in the
ETT group compared to I-GEL group. Stress hormone intergroup analysis revealed significant
increase in serum cortisol 20 minutes after induction in ETT group as compared toI-GEL group
(p=0.03).
Conclusion: I-GEL usage is a suitable, effective and safe alternative to ETT in laparoscopic
cholecystectomy patients with lower metabolic stress response.
Keywords: Endotracheal Tube, I-GEL, Hemodynamic Response, Metabolic Response,
Laparocsopy.
∗ Dr. Saumya Biswas, MD, ASTT. Professor, Dept. of Anesthesiology, Malda Medical College (MMCH), Malda, India.
** Dr. Soumen Mandal, MD, Clinical Tutor, Dept of Anesthesiology, Burdwan Medical College, Burdwan, India.
*** Dr. Tapobrata Mitra, Astt. Professor, Mursidabad Medical College, Mursidabad, India.
****Dr. Suprio De Ray, Md, ASTT. Professor, Dept of Anesthesiology, Malda Medical College, Malda.
*****Dr. Ranabir Chanda, MD, ASTT. Professor, Dept of Anaesthesiology, Burdwan Medical College, Burdwan, India.
******Dr. Debajyoti Sur, MD, Clinical Tutor, Mursidabad Medical College, Mursidabad, India.
Institution Where The Sudy Was Conducted: Malda Medical College Hospital (MMCH).
Corresponding author: Dr. Saumya Biswas, Address: 815/C Block-A, Laketown. Kolkata, 700089. Phone number:
9433127430. E-mail: saumya.biswas@gmail.com Source(s) of support: NIL, Conflict of Interest: NIL.
315
M.E.J. ANESTH 23 (3), 2015
316
Introduction
Endotracheal intubation has been shown to
impose the most intense stress response to organism
under general anesthesia1,2. Opioids, inhalational
agents fails to prevent release of chatecholamines
which causes significant hemodynamic response
after laryngotracheal manipulation3,4,5. Surgical stress
response further leads to activation of sympathetic
nervous system and release of catabolic and
hormones6. Carboperitoneum itself cause significant
hemodynamic and metabolic changes. These stress
responses may be life threatening in patients with
co-morbidities likehypertension, diabetes mellitus,
ischemic heart disease. Airway devices which evokes
less stress response would be beneficial in these
circumstances. This study assess the hemodynamic
and metabolic alterations caused with the use of
I-GEL and endotracheal tube (ETT) in laparoscopic
cholesystectomy where carboperitoneum is created
with increase in intraabdominal pressure.
Material and Methods:
After approval of institutional ethics committee
of Malda Medical College and obtaining patients
informed consents, 70(seventy) ASA (American
Physical Status) I and II patients aged between 20-60 yrs
scheduled for elective laparoscopic cholecystectomy
were included in the study. Exclusion criteria were
a known predicted difficult airway, hypertension,
diabetes mellitus, chronic obstructive pulmonary
disease, cardiac disease, history of allergic reaction
and body mass index greater than 35 kg/m2. Excluding
those who failed to satisfy the selection criteria the
remaining patients were randomly allocated into two
groups of thirty two (n=32) patients each using a
computer generated random number table.
Patients were premedicated with diazepam,
ranitidine, and metaclopropamide the evening before
and in the morning of the day of surgery. Consent
and fasting status were confirmed and an intravenous
line was obtained. Routine monitoring including
electrocardiogram (ECG), noninvasive blood pressure
(NIBP), pulse oxymetry (SpO2) and end-tidal
carbondioxide (EtCO2) were applied to each patient in
SAUMYA BISWAS et. al
the operating room. Anesthesia was induced in both
groups using propofol 2 mg/kg, fentanyl 2 microgram/
kg, and airway placement was facilitated by atracurium
0.5 mg/kg.
In the ETT group (Group-E) (n=32) cuffed ETT
of internal diameter (I.D.) 7.0 mm for females and 8.0
mm I.D. for males were used. The cuff pressure of
ETT was maintained in the range of 25-30 cm of H2O
using a cuff manometer. In the other group (Group-I)
(n=32) I-GEL: size 4.0 were used for both males
and females as recommended by the manufacturer.
Difficult intubation cases and more than one attempt
of airway manipulation were excluded from the study.
Anesthesia was maintained with 1-2% Isoflurane
and 50% NO2 & 50% O2. Patients were mechanically
ventilated with a tidal volume of 8ml/kg and a
respiratory rate of 12 breaths/min. SpO2 and EtCO2
were maintained >95% and < 45mm of Hg respectively.
Intra-abdominal pressure was maintained < 15mm
of Hg during the operation. Mean arterial blood
pressure (MAP), heart rate(HR), SpO2, peak airway
pressure, EtCO2 and tidal volume were recorded at
the 1st, 5th, 15th, 30th and 45th minutes after insertion
of airway devices. Side effects like bronchospasm,
laryngospasm, coughing, gagging, hoarseness,
aspiration were evaluated. Hemodynamic alterations
like hypotension (<25% decrease in MAP from the
baseline), hypertension (>25% increase in MAP
from the baseline), tachycardia (heart rate >120/min),
bradycardia (heart rate<50/min) were recorded and
manipulated by titration of inhalational anesthetics at
0.5% concentrations and administration of intravenous
0.5mg atropine sulphate.
After induction of anesthesia and 20 mins after
CO2 insufflation, venous blood samples were obtained
for measuring adrenaline, noradrenaline, dopamine
and cortisol levels. Blood samples were centrifuged
immediately and plasmas were stored at -80°C until
hormonal analysis. For analyzing catecholamine
levels, high pressure liquid chromatography (HPLC)
method was applied using eureka kits (Enrico Fermi
25 60033 Chiaravalle (An) Italy).
Statistical analysis was performed by SPSS11.5
(Statistics Package for Social Sciences) for Windows.
Data was presented as mean, median and standard
deviation. Comparison between groups were
Hemodynamic and Metabolic stress due to ET intubation
performed by unpaired student-t-test and MannWhiteny U-test for continuous variables and chi-square
test for intermittent variables. Paired sample t-test and
Wilcoxon test were used for comparisons within each
group. A p value less than 0.05 was considered as
statistically significant.
device respectively in the ETT group. Comparison
of mean arterial pressure between the two groups
revealed statistically significant differences between
the two groups at 15th and 30th minutes after airway
insertion (Table-3).
Serum cortisol level 20 minutes after induction of
anesthesia was significantly lower in the I-GEL group
than the ETT group (Table-4). When serum cortisol
levels were compared within groups, cortisol levels 20
minutes after induction of anesthesia were significantly
higher than cortisol levels after anesthesia induction in
both groups (Table-5).
Results
No statistically significant differences were found
in demographic variables between the two groups
(Table-1). SpO2, peak airway pressure, EtCO2, and
minute ventilation were not statistically significantly
different when compared between and within groups
at all evaluation times (Table-2). Optimal ventilation
was maintained in both groups before and after
carboperitoneum as indicated by EtCO2 <45mm of Hg
in all patients of both groups.
Discussion
Laparoscopic surgeries present a challenge
for the anesthesiologist as there are hemodynamic
and ventilatory changes due to pneumoperitonium
which may further be aggravated in patients with
obesity and chronic systemic illness. Safe airway
management remains the principal aim of the
anesthesiologist during laparoscopic surgeries as
there is increased intra-abdominal pressure which
may lead to gastroesophageal and biliary reflux. ETT
although commonly used has also some postoperative
disadvantages like laryngospasm, hoarseness, and
sore throat. In addition laryngoscopy itself induces
hemodynamic stress response due to supraglottic
manipulation which causes release of chatecholamine
and cortisol5,7. Newer second generation supraglottic
airway device like I-GEL made of thermoplastic
elastomer may be used as an effective and safe
alternative to ETT in elective surgeries.
Table-1
Demographic data. Data is expressed
in mean ± SD or numbers.
PARAMETER
ETT
(n=32)
I-GEL
(n=32)
P-value
AGE (yrs)
47.84±10.23
46.02±8.68
0.868
BMI(kg/m²)
27.89±8.42
28.90±8.42
0.732
ASA PS(I/II)
28/4
30/2
0.989
44.54±10.12
42.13±9.81
0.865
OPEARTION TIME
(MINUTES)
317
ETT = Endotracheal Tube; ASA PS = American Society of
Anesthesiologists.
There was a significant increase in the heart rate
at 1 minute and 45th minutes after insertion of airway
st
Table-2
ventilator parameters. Data is expressed as mean ± SD.
SpO2(%)
Time
Peak Airway Pressure(cm
of H₂O)
EtCo2
(mm of Hg)
MV(Lit)
ETT
I-GEL
ETT
I-GEL
ETT
I-GEL
ETT
I-GEL
1 min
98.16±1.21
98.45±0.97
19.45±3.45
18.36±3.75
30.39±3.54
31.24±3.76
5.06±1.67
5.14±1.67
5th min
99.23±1.45
99.28±0.45
20.21±2.34
20.13±3.56
31.23±2.43
32.45±3.24
5.13±1.08
5.00±1.34
15 min
98.14±1.13
97.28±0.34
20.19±3.24
19.86±2.45
33.23±2.35
34.76±2.56
5.07±3.07
5.23±1.34
30th min
97.45±1.24
98.23±1.16
22.45±1.34
21.27±2.34
31.34±3.34
32.56±2.67
5.45±3.06
5.67±1.34
45th min
98.23±1.17
98.05±0.98
20.76±2.35
22.34±2.65
32.45±3.56
33.56±2.58
5.08±3.45
5.34±1.46
st
th
SpO2 = Oxygen saturation; EtCo2 = End tidal carbon di-oxide; MV = Minute Ventilation; ETT = Endotracheal Tube.
M.E.J. ANESTH 23 (3), 2015
318
SAUMYA BISWAS et. al
Table-3
Haemodynamic Parameters. Data is expressed as mean ± SD.
Mean Arterial Pressure
P value
Heart Rate
P value
TIME
ETT
I-GEL
ETT
I-GEL
1 min
90.85±31.23
89.68±23.13
0.867
98.46±12.57
79.23±12.30
0.002
5th min
102.36±20.16
100.73±18.68
0.840
82.70±13.26
83.47±13.60
0.845
15th min
98.64±13.63
79.23±16.18
0.034
85.67±12.31
84.32±17.45
0.945
30th min
90.32±20.56
76.14±15.28
0.026
86.32±16.71
87.45±10.04
0.856
45th min
100.23±16.86
89.82±13.68
0.762
98.23±12.06
82.32±12.10
0.034
st
ETT = Endotracheal Tube.
Table-4
Comparison of stress hormones between groups. Data is expressed as Mean (range).
Parameter
ETT
I-GEL
P-value
73(4-545)
80(4-210)
0.621
261(84-815)
288(89-1056)
0.504
30(7-345)
35(12-500)
0.435
11.35(2.84-90.32)
15.23(4-45.30)
0.124
At Induction:
Adrenaline
Noradrenaline
Dopamine
Cortisol
20 min after induction:
Adrenaline
47.16(5-370)
68(8-206)
0.846
Noradrenaline
260(80-798)
263(90-1043)
0.764
34(2-210)
27(3.2-412.4)
0.856
48.2(9.8-168.9)
22(8.6-98.6)
0.030
Dopamine
Cortisol
ETT = Endotracheal Tube.
Table-5
Comparison of stress hormones within groups. Data is expressed as mean.
ETT
I-GEL
After induction
of anesthesia
20 mins after
induction of anesthesia
P-value
After induction
20 mins after
of anesthesia induction of anesthesia
Adrenaline
7(3-500)
30(5-484)
0.632
84.6(4-200)
78.6(9-210)
0.986
Noradrenaline
255(82-812)
263(52-918)
0.416
280(87-1276)
260(68-910)
0.874
Dopamine
32(9-316)
36(3-210)
0.826
36(10-610)
30(4-410)
0.423
48.3(8-168)
0.002
15(4-44)
38(9-121)
0.002
Cortisol
10.6(3-94.6)
ETT = Endotracheal Tube.
Maltby et al compared classic LMA (Laryngeal
Mask Airway) and Proseal LMA (PLMA) as
alternatives to tracheal intubation in laparoscopic
gynaecological procedures with respect to pulmonary
ventilation. There was no significant difference with
respect to airway pressure, oxygen saturation, and
end tidal carbon dioixide before and after peritoneal
P-value
insufflations. They recommended that tracheal tube
could safely be substituted with correctly placed LMA
and Proseal LMA during gynaecological laparoscopy8.
Sinha et al compared ETT and PLMA in pediatric
laparoscopy patients by means of EtCO2, peak
inspiratory pressure and SpO2. They did not report
any statistically significant difference in SpO2, EtCO2
Hemodynamic and Metabolic stress due to ET intubation
and peak inspiratory pressure between the groups.
They concluded that the two devices had comparable
ventilator efficacy in laparoscopic pediatric surgeries9.
Won Jung Shin et al made a comparative study among
I-GEL, proseal LMA, classic LMA, during general
anesthesia and didn’t find any significant difference in
ventilator response10. Maharjan et al found the I-GEL
to be as effective as ETT in laparoscopic surgeries.
There was no difference in leak volume, leak fraction
and airway pressure between the two study groups11.
In this study I-GEL was used effectively as ETT
during laparoscopic cholecystectomy and ventilator
parameters between the two groups were similar.
Jindal P et al compared haemodynamic effects
of three supraglottic airway devices I-GEL, LMA and
streamlined pharyngeal airway(SLIPA) during general
anesthesia with controlled ventilation I-GEL revealed
least haemodynamic changes during device use12.
Ismail SA et al compared intraocular pressure, heart
rate, blood pressure before and after I-GEL, LMA,
and tracheal tube. Use of LMA and ETT resulted
in significant increase in intraocular pressure and
haemodynamics compared to I-GEL13. Oczenski et
al reported that cardiovascular responses induced by
laryngoscopy and intubation were more than twice as
high as those produced by insertion of an LMA7. In the
present study I-GEL usages showed significantly less
haemodynamic perturbation when compared to ETT
(Table-3) as indicated by heart rate and mean arterial
pressure.
Walder
and
Aitkenhead
evaluated
if
pneumoperitoneum affected haemodynamic and stress
responses in laparoscopic cholecystectomy patients.
They observed that plasma vasopressin concentration
significantly increased during peumoperitoneum,
noradrenalin and adrenalin concentrations and rennin
activity did not change14. Carbon dioxide(C02)
insufflation for pneumoperitoneum in long periods may
cause stress hormone increase due to carbon dioxide
diffusion. In our study mean duration of operation
was nearly 45 minutes in both groups. Therefore it is
considered that the reason of increase in cortisol level in
the ETT group was not CO2 insufflation. Lentschener
et al found that both humoral and hemodynamic
319
responses initiated in the pneumoperitoneum by
contact with CO2 have been prevented by continuous
adequate depth of anaesthesia and normovolaemia15.
In the current study, the patients were operated in
elective circumstances and depth of anaesthesia
and volume were controlled easily and strictly so
humoral and hemodynamic responses caused by
pneumoperitoneum were lower than the estimations.
We observed a significant increase in serum cortisol in
both the groups 20 minutes after induction. But inter
group analysis revealed the increase in ETT group was
greater than I-GEL group. As dopamine, adrenalin and
noradrenalin have short duration of activity with the
plasma half time shorter than 2 minutes, they were
not efficient enough for reflecting the metabolic stress
response in our study.
Present study evaluated hemodynamic and
ventilator parameters along with definitive stress
hormone markers like catecholamine and cortisol but
we were unable to take in consideration leak pressure
of individual airway devices and other unwanted
effects like sore throat, trauma, gastric distension and
aspiration. Hence a large scale study is needed to draw
a definitive conclusion.
Conclusion
Correctly placed I-GEL is a safe and efficient
airway option to ETT and PLMA in laparoscopic
cholecystectomy operations with lower incidence of
metabolic stress responses. It can be used in selected
elective surgical cases where these stress responses
may be undesirable and better avoided.
Acknowledgements
The authors are grateful to the doctors of Dept.
of Surgery and nursing staff of OT complex of Malda
Medical College for the help rendered during the data
collection of this study. A special note of thanks for
DR RITA PAL, Dept of Biochemistry, Malda Medical
College for the help in the analysis of blood sample
which formed a crucial part of our study.
M.E.J. ANESTH 23 (3), 2015
320
SAUMYA BISWAS et. al
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patients. J Anesthesiol Clin Pharmacol; 28:326-9, 2012.
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tube and prosealLMA in laparoscopic cholecystectomy. J Res
MedSci; 17(2)148-53, 2012.
6. Ledowski T, Bein B, Hanss R, Paris A, Fudickar W, Scholz J, et
al: Neuroendocrine stress response and heart rate variability: a
comparison of total intravenous versus balanced anesthesia. Anesth
Analg; 101(6):1700-5, 2005.
7. Oczenski W, Krenn H, Dahaba AA, Binder M, Jellinek H, Schwarz
S, et al: Hemodynamic andcatecholamine stress responses to
insertion of the Combitube, laryngeal mask airway or tracheal
intubation. Anesth Analg; Jun, 88(6):1389-94, 1999.
8. Maltby JR, Berault MT, Watson NC: LMA classic and LMA
proseal are effective alternatives to endotracheal intubation for
gynaecologica laparoscopy. Can J Anesth; 50(1)71-7, 2003.
9. Sinha A, Sharma B, Sood J: ProSeal as an alternative to endotracheal
intubation in pediatric laparoscopy. Paediatr Anaesth; 17(4):32732, 2007.
10.Shin WJ, Cheon YS: The supraglottic airway I-gel in comparison
with proseal LMA and classic LMA in anesthetized patients. Eur J
anesthesiol; 27:598-601, 2010.
11.Maharjan SK: I-gel for positive pressure ventilation. JNMA J Nepal
Med Assoc; 52:255-9, 2013.
12.Jindal P, Aslam R, Sharma JP: Is I gel a new revolution among
supraglottic airway devices? A comparative evaluation. MEJ
anaesthesia; 20(1), 2009.
13.Ismail SA, Bisher NA, Kandil HW, Mowafi HA, Atawia HA:
Intraocular pressure and hemodynamic response to I gel, LMA or
endotracheal tube. Eur JAnesthesiol; 28(6):443-8, 2011.
14.Walder AD, Aitkenhead AR: Role of vasopressin in the
haemodynamic response to laparoscopic cholecystectomy. Br J
Anaesth; 78(3):264-6, 1997.
15.Lentschener C, Axler O, Fernandez H, Megarbane B, Billard
V, Fouqueray B, et al: Haemodynamic changes and vasopressin
release are not consistently associated with carbon dioxide
pneumoperitoneum in humans. Acta Anaesthesiol Scand; 45(5):52735, 2001.
Comparative evaluation of plain and hyperbaric
ropivacaine in patients Undergoing lower
abdominal surgery under Spinal Anesthesia
Puneet Dwivedi*, Anu Kapur**
and S anjay K umar G upta ***
Background: Preliminary work has shown that ropivacaine provides spinal anesthesia of
shorter duration with greater sensory motor dissociation than bupivacaine, and may be of particular
use in the day care surgery. Hypothetically, hyperbaric solution of ropivacaine could improve and
shorten both sensory and motor block.
Material and Methods: This prospective, randomized, double blind study was conducted
on 80 patients undergoing lower abdominal surgeries. Patients either received 20.25 mg of plain
ropivacaine (group A) or 20.25 mg of hyperbaric ropivacaine in 5% dextrose (group B). The extent
and duration of sensory and motor block, haemodynamics, time to home readiness, and the time to
first rescue analgesia were recorded.
Results: All patients in group B achieved sensory block at or above T10 dermatome in
comparison to only 87.5% patients of group A. Analgesia at T10 was reached in 4 min (4-6 min) in
group B vs. 10 min (6-16 min) in group A (p<0.001). Patients in group B had a longer duration of
analgesia at T10; 126 min (97-146 min) vs. 110 min (90-128 min) (p=0.047). Median duration of
sensory block from injection of the anesthetic to complete recovery (regression to S2 dermatome)
was shorter in Group B than Group A, 273.5 min (258 - 289 min) vs. 300 min (290 - 312 min)
(p<0.001), as was the time to 2 segment regression 80 min (63-90 min) vs. 102 min (82-124 min)
(p<0.001). Duration of complete motor block (mean ± SD) was significantly less in group B, 93.06
± 17.38 min compared to 139.89 ± 25.17 min (p<0.001) in group A, as was the total duration of
motor block (181.83 ± 30.21 min in group B vs. 254.91 ± 25.34 min in Group A; p<0.001). Patients
in Group B attained discharge criteria earlier as indicated by a shorter time to home readiness.
Cardiovascular changes were unremarkable throughout, and similar in the two groups. There
were no major sequelae.
Conclusion: Addition of dextrose 5% to ropivacaine increases the speed of onset, block
reliability, duration of useful block for surgery and speed of recovery. Plain solutions are less
reliable for surgery above a dermatomal level of T10.
Keywords: block characteristics; home readiness; lower abdominal surgery; ropivacaine;
spinal anesthesia.
*
Dr. Puneet Dwivedi, DA, DNB, Medical Officer, Department of Anaesthesiology and Critical Care, Deen Dayal Upadhyay
Hospital, Hari Nagar, Delhi = 110064.
** Dr. Anu Kapur, MD, Senior Specialist, Department of Anaesthesiology, Critical Care and Perioperative Medicine, Hindu
Rao Hospital, Malka Ganj, Delhi = 110007.
*** Dr. Sanjay Kumar Gupta, DNB, Chief Medical Officer, Department of Anaesthesiology, Critical Care and Perioperative
Medicine, Hindu Rao Hospital, Malka Ganj, Delhi = 110007.
Corresponding author: Dr. Sanjay Kumar Gupta, Address: Flat No. D-14, MCD Medical Complex, Kalidas Marg, Gulabi
bagh, Delhi, India, Pin Code-110007. Tel: +91 9810655949, Fax: +911123641676. E-mail: drskgupta4u@gmail.com.
321
M.E.J. ANESTH 23 (3), 2015
322
Sanjay Kumar Gupta et. al
Introduction
injection of 20.25 mg of plain Ropivacaine (2.7 ml of
0.75% plain Ropivacaine + 0.3 ml normal saline).
Spinal anesthesia is a safe, reliable and
inexpensive technique with the advantage of providing
surgical anesthesia and post-operative pain relief.
It not only alleviates operative pain but also blunts
autonomic, somatic and endocrine responses1.
Group B: Hyperbaric group (n = 40) received
intrathecal injection of 20.25 mg of Ropivacaine with
5% glucose (2.7 ml of 0.75% plain Ropivacaine + 0.3
ml dextrose 50%).
Ropivacaine, a pure S (-) enantiomer, is well
tolerated after intrathecal use and has been found to
have a shorter duration of action than bupivacaine,
making it a possible alternative to lidocaine because of
the low incidence of transient neurological symptoms2.
Due to its property of sensory motor dissociation
(ability to block sensory nerves to a greater degree
than motor nerves), it allows a faster recovery of motor
function that occurs after the use of bupivacaine3.
Tradionally baricity of local anesthetics has
been known to influence the spread of intrathecal
local anesthetic solutions and characteristics of the
subarachnoid block4,5. However, very few studies
have compared the clinical efficacy of hyberbaric and
plain solutions of ropivacaine. Much of the published
work is focused on intrathecal anesthesia with
plain ropivacaine in lower limb, obstetric, perineal,
urological and anal procedures.
We hypothesized that, intrathecal anesthesia with
hyperbaric ropivacaine may be useful for procedures
where a sensory and motor block of adequate duration
for the procedure and a fast regression of motor block
is required, resulting in faster discharge time6. The aim
of the current study is to compare the intraoperative
characteristics and recovery profile of plain and
hyberbaric solutions of ropivacaine in lower abdominal
surgeries.
Methods
This randomized, double blind study was
approved by the hospital ethical committee and written
informed consent was obtained from each patient.
Eighty patients (ASA 1 and 2) between 18-60 yrs of
age, weighing between 45-80 kg, with height between
150 -180 cm, scheduled for elective lower abdominal
surgery were randomly divided into two groups
according to computer generated random numbers.
Group A: Plain group (n =40) received intrathecal
Exclusion criteria included patients belonging to
ASA class III, IV and V, unwilling patients, emergency
surgeries, history of anaphylaxis to ropivacaine or any
other aminoamide local anesthetic drug, pregnant and
lactating females, patients with coagulation disorders
or on anticoagulant therapy, local infection at the site
of proposed puncture for spinal anesthesia, elective
surgery more than 2 hours duration, surgeries requiring
patient position other than supine, patient with medical
complications like raised intracranial tension, anemia,
heart disease, severe hypovolemia, shock, septicemia,
and hypertension.
A detailed pre-anesthetic check up was done in
all patients. Routine hematological, biochemical and
radiological investigations were carried out in all
patients. The special investigations were done as per
the co-morbid condition of the patient.
All patients were asked to remain nil per oral intake
for 6 hours before the planned surgical procedure and
to be accompanied by an escort on the day of surgery.
The anesthetic procedure was explained to the patient
in detail. All patients were given tablet alprazolam 0.5
mg, the night before the surgery to have an adequate
sound sleep. However, patient received no sedatives
before arrival in the operating room.
In the operation theatre, baseline parameters were
recorded (pulse rate, noninvasive blood pressure, heart
rate). Intravenous access was secured with an 18G IV
cannula and 10 ml/kg of ringer lactate was infused as
a co-loading fluid. Patients were placed in the lateral
decubitus position. Wide area of the back was cleaned
and draped. L3-L4 intervertebral space was identified
by palpation and infiltrated with 2% lidocaine. 26 G
spinal needle (Quincke’s) was inserted into the desired
interspace in the midline with the bevel facing upwards.
After confirming free flow of CSF, needle was rotated
so that the bevel faces cephalad and the study drug was
injected over 15-20 seconds without any barbotage.
Study drug was prepared aseptically just before
intrathecal injection by an anesthesiogist, who was not
Plain vs. Hyperbaric ropivacaine during spinal anesthesia
involved in the study and had no clue about the group
allocation. Therefore the investigator was blinded to
the drug administered for intrathecal injection. Patient
was placed supine immediately after the injection with
the table maintained horizontally. Time of intrathecal
injection was recorded. Vital parameters were
monitored at 5 minute intervals till the end of surgery.
Criteria for tachycardia, bradycardia and hypotension
were more than 20% increase or decrease more than
20% from the baseline values, but treatment was given
only if clinically indicated (systolic blood pressure <80
mmHg or heart rate <50 beats per minute). Injection of
mephentermine 3 mg intravenous aliquots was given
for hypotension and injection of atropine sulphate
0.6mg intravenous was given for bradycardia. Patients
were given supplementary oxygen at 2-4 liters/min if
saturation at room air was ≤ 92%.
Sensory block was assessed by loss of sensation
to pin prick with a blunt 27 G needle bilaterally
along the mid-axillary line every two minutes till two
consecutive readings of sensory block remained the
same (i.e. when highest cephalad spread of sensory
block has occurred), after which it was assessed at ten
minute intervals till the end of surgery.
Motor block was assessed by Modified Bromage
Scale by Breen et al7 (MBS 1-6 with MBS 1 =
Complete motor block, 2 = Almost complete motor
blockade: patient is able to move the feet, 3 = Partial
motor blockade: patient is able to move the knees, 4
= Detectable weakness of hip flexion: patient is able
to raise the leg but is unable to keep it raised, 5 = No
detectable weakness of hip flexion: patient is able to
keep the leg raised for at least 10 seconds, MBS 6 = no
motor weakness; patient is able to perform partial knee
bend while supine).
As in sensory block, motor block was assessed
every two minutes till two consecutive readings
remained the same, (highest level of motor block) after
which it was assessed every ten minutes till the end of
surgery.
If sensory block at T10 dermatome was not
attained even at twenty minutes after intrathecal
injection of the drug, patient was given general
anesthesia. In patients undergoing surgery under spinal
anesthesia, no analgesia was given during the surgery
unless the patient complained of pain. Inj. fentanyl
323
2µg/kg intravenously was given as a rescue analgesic
if patient complained of pain intraoperatively. If patient
still complained of pain, then no more analgesics were
given and patient was given general anesthesia.
All the patients were monitored in the operative
room for at least 60 minutes after the subarachnoid
block to a keep close watch on the hemodynamics and
block characteristics, even if the surgery ended earlier.
After completion of surgery, levels of sensory blocks
and motor blocks were recorded with the patient still
on the operating table. The patients were shifted to
the Post Anesthesia Care Unit (PACU) and they were
assessed every 30 minutes for motor block by Modified
Bromage Scale till they attain complete motor recovery.
Sensory block was also assessed every 30 minutes by
the same technique which was used during the intraoperative period until regression of sensory block
to S2 dermatome (total duration of sensory block).
Patients were assessed half hourly by Post Anesthesia
Discharge Scoring System8 (PADSS) until a score of ≥
9 was achieved, to check their readiness for discharge.
Time of request for the first analgesic was
noted. Visual analogue scale (VAS) was used to
assess postoperative pain at 0, 1, 2, 4 and 6 hour after
completion of surgery. Inj. diclofenac sodium 75 mg by
IV infusion was given for rescue analgesia once VAS
score was ≥ 4 (0 = no pain, 10 = most severe pain).
Bladder catheterization was performed when surgically
indicated, but time to micturition was recorded in all
other patients. On the day after the surgery patients
were asked about any persistent symptoms like pain,
nausea, vomiting, headache, backache, delayed
voiding and neurologic symptoms such as tingling,
numbness etc. and were treated accordingly. Follow
up calls were made on telephone at 24 hrs and 3-7 days
later to identify any sequelae.
Sample size
The primary outcome variable was complete
recovery from motor block and results of Khaw et
al9 were used to estimate the sample size. When
extrapolated from their study to our study with
hyperbaric and plain solutions of ropivacaine, the mean
time to complete motor recovery could be calculated
M.E.J. ANESTH 23 (3), 2015
324
Sanjay Kumar Gupta et. al
Table 1
Patient characteristics, duration and type of surgery performed. Data are mean ± SD or frequencies (n).
P-value
Group B
Variable
Group A
(n=40)
(Plain ropivacaine)
(n=40)
Age (yr)
39.35 ± 2.20
40.35 ± 2.17
0.747
Weight(kg)
60.53 ± 1.48
62.13 ± 1.47
0.446
Height(cm)
165.83 ± 1.10
167.55 ± 1.00
0.251
Sex (M/F)
33/7
34/6
0.762
53.17 ± 15.29
54.40 ± 13.16
0.702
36/4
37/3
1.000
Inguinal hernia
27
28
0.689
Incisional hernia
4
3
0.692
Femoral hernia
1
0
0.314
Interval appendectomy
4
4
1.000
Vesical calculus
3
3
1.000
Undescended testis
1
2
0.556
Duration of surgery (min)
ASA (I/II)
Type of Surgery
as 117.45 and 177.39 min. The difference between the
means was 59.94 min and SD was estimated to be 42.5
min from their study. With an α risk 0.05, and a power
(β risk ≤ 0.03) of more than 97%, we calculated the
sample size to be 40 in each group.
Statistical analysis
Statistical analysis was performed using the
SPSS version 17.0 program for Windows (SPSS Inc.,
Chicago, IL, USA). We conducted a Shaipro Wilk test
to verify the distribution of the data. All data were
summarized as the mean ± standard deviation, while
those with a skewed distribution were described as
a median with an interquartile range (IQR). The chisquare test was used to compare the differences in
variables between the two groups. Student’s t-test was
used for continuous, normal variables. The MannWhitney test was used to test independent relationships
between the variables that did not demonstrate
normality. A two-sided P value less than 0.05 was
considered statistically significant.
Results
Demographic profile
The two groups were comparable with respect to
age, weight, height, sex, ASA status and duration of
surgery (Table 1). Various types of lower abdominal
surgical procedure were almost equally distributed
amongst the two groups.
Hemodynamic parameters
The groups did not differ in hemodynamics
in the operative and the recovery rooms (Table 2).
In Group A (plain ropivacaine), only 4 out of 40
patients (10%) developed hypotension and 2 patients
(5%) developed bradycardia. In Group B (hyperbaric
ropivacaine), only 5 out of 40 patients (12.5%) patients
developed hypotension and 3 patients (7.5%) developed
bradycardia. Patients who developed bradycardia in the
operative room were a subset of patients developing
intraoperative hypotension. Patients in both groups were
administered sympathomimetics or anticholinergics in
the operating room as per protocol.
Plain vs. Hyperbaric ropivacaine during spinal anesthesia
325
Table 2
Baseline Hemodynamics in the operating room and the recovery room of the hyperbaric ropivacaine (Group A) and the plain
ropivacaine (Group B). Data are expressed in mean ±SD or numbers of patients and percentages
Group A
(n=40)
Group B
(n=40)
P-value
70.17 ± 8.32
72.62 ± 12.21
0.298
Maximum heart rate
80.88 ± 11.93
78.35 ± 11.18
0.332
Minimum heart rate
60.33 ± 10.05
61.00 ± 8.55
0.935
2
3
0.644
Operating room
Heart rate
Anticholinergic for bradycardia, n (%)
Systolic blood pressure
123.70 ± 12.23
127.25 ± 11.77
0.190
Maximum systolic blood pressure
128.10 ± 8.97
129.38 ± 7.31
0.488
Minimum systolic blood pressure
99.00 ± 9.80
96.93 ± 10.78
0.306
4
5
0.724
Maximum heart rate
77.91 ± 6.85
76.19 ± 9.90
0.839
Minimum heart rate
71.43 ± 9.02
70.58 ± 10.79
0.714
0
0
1.000
Sympathomimetics for hypotension, n (%)
Recovery room
Anticholinergic for bradycardia, n (%)
Maximum systolic blood pressure
124.42 ± 7.07
126.55 ± 7.08
0.235
Minimum systolic blood pressure
97.11 ± 10.47
100.73 ± 11.65
0.214
0
0
1.000
Sympathomimetics for hypotension, n (%)
In the recovery room, 2 patients (5%) in both
plain and hyperbaric ropivacaine groups developed
hypotension but none of the patient in either group
developed bradycardia. There was no need for
sympathomimetics or anticholinergics in both groups
in the recovery room.
Sensory block characteristics
Sensory block reached T10 dermatomal level
or above in all patients of group B, but there were 5
patients (12.5%) in group A in whom block failed to
reach T10 dermatomal level (Table 3). Out of these
5 patients, 3 patients (7.5%) achieved a maximum
sensory level at T12 dermatome and 2 patients (5%) at
L1 dermatome (Figure 1).
Fig. 1
Maximum upper level of sensory block in the two groups.
Each point refers to one patient, and the horizontal
line refers to the median. Patients with upper sensory
level below T10 were given general anesthesia. Empty
symbols indicate patients requiring intraoperative rescue
analgesia to complete the surgery.
M.E.J. ANESTH 23 (3), 2015
326
Sanjay Kumar Gupta et. al
Table 3
Intraoperative Details. Data are represented as frequency (n) and percentage (%)
Group A
Plain ropivacaine (n=40)
Group B
Hyperbaric ropivacaine
(n=40)
Frequency
%
Frequency
%
Sensory block at or above T10 dermatome
35
87.5%
40
100%
Sensory block below T10 dermatome
5
12.5%
0
0%
Patients requiring general anesthesia
5
12.5%
0
0%
Intraoperative pain
4
10%
1
2.5%
Modified Bromage grade 1 (Complete motor block)
40
100%
33
82.5%
Modified Bromage grade 2
0
0%
1
2.5%
Modified Bromage grade 3
0
0%
2
5%
Modified Bromage grade 4
0
0%
2
5%
Modified Bromage grade 5
0
0%
2
5%
Table 4
Sensory block characteristics. Data are represented as median with interquartile range (IQR)
Group A
Plain ropivacaine (n=40)
Group B
Hyperbaric ropivacaine
(n=40)
P-value
Median
IQR
Median
IQR
Time to onset at T10 (min)
10a
6 - 16
4
4-6
<0.001
Total duration at T10 (min)
110
90 - 128
126
97 - 146
0.047
a
Time to max. Cephalic Spread (min)
16
12 - 30
14
10 - 25
0.454
Time to 2 segment regression (min)
102a
82 - 124
80
63 - 90
<0.001
Total duration of sensory block (min)
300
290 - 312
273.5
258 - 289
<0.001
a: n = 35 as 5 patients in Group A did not achieve sensory block at T10 dermatome.
Table 5
Distribution of various grades of motor block (modified Bromage scale by Breen et al7).
Data are represented as frequency (n).
Time to onset at modified Bromage
score
Group A
Plain ropivacaine
Frequency (n)
Median time to onset
(IQR)
Group B
Hyperbaric ropivacaine
Frequency (n)
Median time to onset
(IQR)
2
P value
Grade 5
0
Grade 4
29
4 (2-7)
20
2 (2-4)
0.021
Grade 3
38
6 (2-9)
31
4 (2-4)
0.017
Grade 2
40
8 (4-12)
34
6 (4-8)
0.019
Grade 1 (complete motor block)
40
12 (10-16)
33
12 (8-16)
0.566
Total
40
40
0.494
Plain vs. Hyperbaric ropivacaine during spinal anesthesia
327
Table 6
Motor block characteristics. Data are represented as mean ± SD.
Group B
Hyperbaric ropivacaine
(n = 40)
Group A
Plain ropivacaine
(n = 40)
P value
Mean ± SD
Range
(Min-Max)
Mean ± SD
Range
(Min-Max)
Duration of
complete motor
block (min)
139.89 ± 25.17
80 - 198
93.06 ± 17.38
70 - 158
<0.001
Total duration of
motor block (min)
254.91 ± 25.34
104 - 240
<0.001
(n=35)
a
b
208 - 310
(n=33)
181.83 ± 30.21
a (n=35): (5 patients in Group A did not achieve sensory block at T10 dermatome and thus, these patients were given general anesthesia
and therefore were not assessed for the duration of complete motor block).
b (n=33): (7 patients in Group B did not achieve complete motor block [grade 1]).
Table 7
Postoperative recovery. Data are represented as mean ± SD or median (range)
Group A
Plain ropivacaine
(n=40)
Group B
Hyperbaric ropivacaine (n=40)
Pvalue
Time to first micturitiona (min)
377.68 ± 51.15
383.78 ± 61.93
0.649
Time to home readiness
(min)
340.46 ± 35.53
285.95 ± 31.40
<0.001
Time to first Rescue Analgesia
230 (20 – 337)
200 (15 – 270)
<0.001
(min)
a: (n = 37) in both the groups, as 3 patients in both the groups were operated for vesical calculus and therefore, urinary catheter was
inserted intraoperatively in these patients and thus, time to first micturition in these patients could not be assessed.
Hyperbaric ropivacaine produced a more rapid
onset of more extensive, but less variable sensory
block, which regressed faster than in plain group (Table
4). The onset of analgesia to pinprick at T10 was faster
(4 min vs. 10 min in plain group), and the maximum
block height (median T6 vs T10) was greater (Figure.
1), but less variable. Median time to maximum sensory
block height (14 min vs. 16 min in plain group) was
slightly faster in the hyperbaric group; however the
difference was not statistically significant. Median
time to regression of sensory block to T10 dermatome
was longer in the hyperbaric group (126 min vs 110
min in plain group), but median times 2 segment
regression (102 min in plain vs 80 min in hyperbaric)
and regression of sensory block to S2 dermatome (300
min in plain vs 273.5 min in hyperbaric)were longer in
the plain group.
Motor block characteristics
The onset of motor block at grade 4, 3 and 2
was significantly faster in Group B than in Group
A and the differences amongst the two groups were
statistically significant (Table 5). However, the
median time to onset of grade 1 motor block was
comparable in the two groups with no statistically
significant difference. The mean duration of complete
motor block (Duration of motor block at modified
Bromage 1) was significantly shorter in the hyperbaric
ropivacaine group (93.06 ± 17.38 min vs 139.89 ±
25.17 min in plain group), as was the total duration of
motor block (181.83 ± 30.21 min vs 254.91 ± 25.34
min in plain group) (Table 6).
M.E.J. ANESTH 23 (3), 2015
328
Need for general anesthesia/ rescue
analgesia
All the hyperbaric blocks were adequate for
surgery while 5 patients in the plain group were given
general anesthesia due to inadequate block height.
These 5 patients in the plain group achieved complete
motor block indicating that the inadequate block
height was probably, a result of lesser cephalic spread
of the drug and not a result of block failure. Also, the
median time to reach complete recovery from sensory
block (S2 dermatome) was approximately 300 min in
these patients, which did not differ from the rest of the
patients in Group A.
In Group A, 4 patients(10%) complained
of intraoperative pain in comparison to only 1
patient(2.5%) in Group B (Table 3 and Figure 1).
Majority of these patients experienced pain at the
end of prolonged surgery and required supplemental
analgesia with fentanyl 2µg/kg.
Postanesthesia care and discharge
parameters
Patients in Group B complained of postoperative
pain requiring rescue analgesic significantly earlier
than patients in Group A (Table 7). None of the
patients in the two groups experienced postoperative
urinary retention and the time to first micturition was
comparable in the two groups (table 7).
Patients in the hyperbaric ropivacaine group
achieved criteria for home readiness (PADSS score ≥
9) earlier than patients in the plain ropivacaine group
(285.95 ± 31.40 min vs. 340.46 ± 35.53 min, respectively;
p<0.001).
Two patients (5%) in both plain and hyperbaric
ropivacaine group complained of mild backache at
the puncture site, a day after the surgery, which was
managed with non-steroidal anti-inflammatory drugs
(NSAIDS). None of the patients in either group
complained of persistence of these symptoms.
Discussion
This prospective, randomized, double blind
comparative study conducted between plain and
Sanjay Kumar Gupta et. al
hyperbaric ropivacaine has shown that hyperbaric
solution of ropivacaine produces a more consistent
block with a greater success rate and less frequent
incidence of intraoperative pain than a plain solution.
Addition of glucose 50 mg/ml led to a more rapid
spread to a higher median dermatomal level and with
less variation in maximum height of sensory block.
We chose a dextrose concentration of 50mg/ml
(5%) in the hyperbaric solution for two reasons. First, a
previous study by Whiteside et al10 has demonstrated the
clinical efficacy of a solution of ropivacaine containing
glucose 50 mg/ ml. In the absence of a commercially
available glucose preparation, this solution can be
easily prepared before spinal anesthesia using readily
available solutions, and provides a solution that is
sufficiently hyperbaric for its purpose. Second, previous
works by Bannister et al5 and Chambers et al12 with
bupivacaine have suggested that lower concentrations of
glucose than are present in the commercially available
hyperbaric solution (8.3%) may be sufficient to provide
the previously stated benefits over plain solutions.
When a hyperbaric solution is injected in the
left lateral position, the tendency for it would be to
spread in the cephalad direction, gravity presumably
encouraging spread of the bolus of drug down the slopes
of the lumbar curve when the patient is placed supine
after injection resulting in a more even distribution
of the local anesthetic solution13. In contrast, a plain
solution being marginally hypobaric would not
have such gravity- assisted spread and thus would
concentrate in the lower lumbar segments. This would
explain the less reliability of the block for abdominal
surgery but prolonged sensory and motor block in the
lower limbs due to dense blockade of the lumbar and
sacral segments. This would also explain the 12.5%
failure rate to achieve analgesia at T10 in the plain
ropivacaine group and also higher number of patients
requiring intraoperative supplemental analgesia (4
patient in plain vs. 1 patient in the hyperbaric group).
In agreement with previous work, in our study,
the sensory block with the plain solution of local
anesthetic spread unpredictably; 5 patients (12.5%) in
Group A did not reach sensory block at T10 dermatone
and the highest extent of sensory block varied widely.
This is also in accordance with the results of Khaw
et al9, who reported that all patients in the hyperbaric
Plain vs. Hyperbaric ropivacaine during spinal anesthesia
329
group had sufficient analgesia for Caesarean section,
but 25% of patients in Group plain needed rescue
medication.
al14, both of which stated that spinal anesthesia with
hyperbaric ropivacaine was associated with early
mobilization and faster discharge times.
The cephalic spread of sensory block was
significantly greater with hyperbaric ropivacaine
T6than in group plain T10 and this trend, is similar to
earlier study by Kallio et al4, with (15mg) ropivacaine
having a median cephalad spread of T4 and T9 in the
hyperbaric and plain groups, respectively. Whiteside et
al6 studied hyperbaric ropivacaine 15 mg and reported
a median maximum cephalic spread of sensory block
at T7 dermatome, which is somewhat lower but
comparable to our study with hyperbaric ropivacaine
20.25mg (T6).
In a recent Cochrane systematic review15, authors
have suggested that pain in the lower back is a very
common complication after spinal anesthesia with
any local anesthetic. Its etiology is unknown but no
connection to neurologic pathology has been suggested
in the literature. Data from previous studies16,17,18
suggests that ropivacaine is not associated with an
increased risk of neurologic symptoms. We also did not
find any evidence of transient neurological symptoms
in our study. However, the available data is not enough
to make definitive conclusions.
In our study, the 126 min regression of the
sensory block to the T10 level was comparable with
that (115.8 min) inan earlier study by Chung et al13
with a slightly lower dose of hyperbaric ropivacaine
(18 mg). The median time to 2 segment regression of
sensory block was faster with hyperbaric ropivacaine
(80 min) in comparison to plain ropivacaine (102 min).
These findings were in accordance with Kallio et al4,
who found median time to 2 segment regression of
sensory block with 15mg ropivacaine to be 90 min and
60 min in the plain and hyperbaric ropivacaine group,
respectively.
Faster recovery from both sensory and motor
block with an increase in the useful duration of sensory
block translated into faster mobilization in the patients
of hyperbaric group. Similar findings were also seen
in two previous studies by Kallio et al4 and Essam et
Conclusion
In conclusion, hyperbaric ropivacaine produced
a more predictable and reliable sensory and motor
block, with faster onset and recovery than a plain
solution. Not only the duration of useful block for
surgery was increased, but also patients mobilized
more quickly after spinal anesthesia with hyperbaric
ropivacaine, something that may be particularly useful
for ambulatory surgery and any procedure where
prolonged immobilization is undesirable. However
further studies are necessary to evaluate the role of
hyperbaric ropivacaine in comparison to the plain
solution for surgical procedures of short duration,
particularly day care surgery.
M.E.J. ANESTH 23 (3), 2015
330
Sanjay Kumar Gupta et. al
References
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anaesthesia with bupivacaine. Br J Anaesth; Mar, 53(3):279-82,
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spinal ropivacaine for cesarean delivery: a comparison to hyperbaric
bupivacaine. Anesth Analg; Jul, 93(1):157-61, 2001.
14.Eid Essam A, Alsaif Faisal: Plain versus hyperbaric ropivacaine for
spinal anesthesia in cirrhotic patients undergoing ano-rectal surgery.
Alex J Anaesth Intensive Care; 10(1):11-18, 2007.
15.Zaric D, Pace NL: Transient neurologic symptoms (TNS) following
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The beneficial values of transoesophageal Doppler
in intraoperative fluid guidance versus standard
clinical monitoring parameters in infants
undergoing Kasai operation
Eman Sayed Ibrahim*, Taha Aid Yassein**
and W esam S aber M orad ***
Abstract
Background: Fluid overload in infants can result from inappropriate volume expansion
(VE). The aim of this work was to evaluate the beneficial values of Transoesophageal Doppler
TED in intraoperative fluid guidance versus standard clinical monitoring parameters in infants
undergoing Kasai operation.
Methods: Forty infants scheduled for Kasai procedure were randomly allocated into two
groups (Doppler and clinical group). In Doppler group decided to provide VE (10-30 ml/kg of
Hydroxyethyl starches HES) when the index stroke volume decreased by ≥15% from the baseline
value, in clinical group, hemodynamic variables triggering colloid administration mean arterial
blood pressure (MAP) less than 20% below baseline or central venous pressure (CVP) <5 cmH2O
in both groups: Ringer’s acetate was infused at constant rate (6 m l/kg/h). Standard and TEDderived data were recorded before and after VE. Follow up the postoperative outcome and hospital
stay.
Results: There were significantly lower mean volume of HES (42.85 ± 3.93 versus 84 ±
14.29 ml) and percent of infants required it (30% versus 90%) associated with earlier tolerance to
oral feeding (2 ± 0.66 versus 3.4 ± 0.51), shorter hospital stay (5.30 ± 0.47 versus 6.7 ± 0.92 days)
and lower rate of chest infection (15% versus 30%) in Doppler group than clinical group. There
was no difference between the two studied groups regarding heart rate, MAP.
Conclusions: TED guided intraoperative fluid intake in infants undergoing Kasai operation
optimize fluid consumption and improve outcome associated with shorter hospital stay.
Keywords: Infants, Kasai operation, Transoesophageal Doppler, volume expansion.
*
**
***
MD, Lecturer of anesthesia (National Liver Institute)-Menoufia University.
MD, lecturer of hepatobilliary surgery (National Liver Institute) Menoufia university.
MD, lecturer of public health (National Liver Institute) Menoufia university.
Corresponding author: Eman Sayed Ibrahim MD, Lecturer of anesthesia (National Liver Institute)-Menoufia University.
Phone: 01282271464 - 0123548537. E-mail: emansayed825@gmail.com. Address: 18 Hassan Abdel Latif, Maleka, Fesal,
Giza, Egypt.
331
M.E.J. ANESTH 23 (3), 2015
332
Eman Sayed Ibrahim et. al
Introduction
Methods
Extrahepatic biliary atresia (EHBA) is an
inflammatory, progressive, fibrosclerosing cholangiopathy of infancy, affecting both the extrahepatic
and intrahepatic bile ducts to a variable extent that
results in destruction and obstruction of the biliary
tract1. Without medical and surgical intervention,
disease progression leads to hepatic fibrosis, cirrhosis
with portal hypertension, liver failure, and death within
2 to 3 years. It classically presents in 1 in 8,000 to 1
in 18,000 live births, during the neonatal period, with
cholestatic jaundice, acholic stools, and hepatomegaly,
in an otherwise apparently healthy infant2. Current
treatment of EHBA is surgical hepatoportoenterostomy
(Kasai procedure) for the relief of biliary obstruction
in these infants3.
After receiving approval from Ethical Committee
and informed consent from patient’s parents, this
prospective cohort study enrolled 40 infants who were
randomly assigned into two groups using a random
number generator in sealed envelopes of 20 each: the
Doppler group and the clinical group. Infants aged
≤3 months, weighing <10 kg, without myocardial
dysfunction, American Society of Anaesthesiologists
(ASA) grade I/II, who required general anesthesia
and tracheal intubation for hepatoportoenterostomy
for biliary atresia (BA) were included in the study.
Exclusion criteria were ASA class >II, preoperative
hemodynamic instability or catecholamine infusion,
known congenital heart disease with hemodynamic
consequences and esophageal malformation, any
patient with history of bleeding tendency, and no
written informed consent. All infants received an
oral intake of 15 ml/kg of 10% glucose 2 h before
surgery. Patients were optimized before operation
and deemed hemodynamically stable and clinically
euvolemic before the induction of anesthesia. After
denitrogenation, general anesthesia was induced by
inhalation of 100% oxygen and 8% sevoflurane until
the patient lost consciousness and then the sevoflurane
concentration was decreased to 4%. An IV cannula
was inserted and fentanyl (1 µg/kg) and atracurium
(0.5 mg/kg) were administered to facilitate tracheal
intubation. Anesthesia was then maintained with
50% oxygen, air and sevoflurane (1 MAC end-tidal
concentration). Mechanical ventilation was performed
in all patients using a semi closed system adjusted to
keep SaO2>95% and end tidal CO2 between 25 mmHg
and 35 mmHg (GE Datex Ohmeda S/5 Anesthetic
Delivery Unit System). Arterial pressure was measured
using a standard non-invasive cuff applied to the upper
limb. Nasopharyngeal temperature was monitored
and maintained in a normal range with a forced-air
warmer (Bair Hugger Temperature Management Unit,
Arizant, USA). Following induction of anesthesia,
data of patients in the Doppler group (age, weight,
and height) were registered in the Doppler monitor. A
4 MHz, flexible TED probe specific for single-patient
pediatric use (KDP n-Kinder Doppler Probe®) was
greased with a lubricating gel and passed orally into
the mid esophagus until aortic blood flow signals were
Perioperative fluid optimization is essential in
Kasai procedures for reducing morbidity. Hypovolemia
is associated in particular with improper organ
perfusion and increased length of hospital stay, while
excessive fluid administration produces the clinical
picture of pulmonary peripheral and gut edema with
associated morbidity and mortality4.The assessment of
perioperative hypovolemia and the trigger for volume
expansion (VE) in pediatric anesthesia are based on
the interpretation of multiple variables and clinical
endpoints such as arterial pressure, heart rate (HR),
pulse pressure, urine output, type of surgery, surgical
events (e.g. bleeding), and laboratory findings (e.g.
hematocrit, lactate). Fluid requirements when based
only according to these variables can be inappropriate5.
Minimally invasive tools that could predict patient
responsiveness to VE would be extremely useful.
Transoesophageal Doppler (TED) has been shown
to effectively measure CO in newborns and children
and therefore, could allow for better assessment of the
efficacy of VE6.
We therefore designed a prospective, randomized,
controlled trial to evaluate the effectiveness of TED
on intraoperative fluid optimization versus standard
clinical monitoring parameters in infants undergoing
Kasai operation.
Transoesophageal Doppler in Kasai operation
best identified. The optimal position of the probe was
suggested by an audible, maximal pitch and a sharply
defined velocity waveform with minimal spectral
dispersion. The monitoring system used (Cardio
QPTM, Deltex Medical TM, Chichester, UK) which
shows all the needed hemodynamic variables both
in numerical and graphical forms... The probe was
rotated to display the best aortic blood flow signal
before each measurement. Cardiac index (CI), index
stroke volume (ISV), corrected flow time (CFT)
(length of time of systolic blood flow adjusted for HR,
that is, divided by the square root of the heart cycle
time), peak velocity (PV) (maximal velocity during
systole), of the descending aorta velocity waveform
were recorded. TED measurements pre- and post-VE
were completed and averaged In the clinical group (A
4- to 5.5-Fr central venous catheter AMECATH single
lumen central venous catheter) was placed through the
right internal jugular vein by ultrasound guided method
(Sonosite-Nano Max ultrasound system-USA).
In Doppler group. Boluses of colloid were
administered, guided by an algorithm depending on the
Doppler estimations of ISV, when the ISV decreased
by ≥15% from the baseline value.VE consisted of
an infusion of 10-30 ml/ kg of colloid (Voluven
hydroxyethyl starch 130/0.4 6%). Over a period of 2040 min, repeated by other boluses only if ISV is not
increased by ≥15% this algorithm was similar to that
used by Roux et al.7, In clinical group, hemodynamic
variables triggering colloid administration based on
clinical appreciation and standard monitoring data
that involves either a decrease in mean arterial blood
pressure less than 20% below baseline or CVP<5
mmHg.VE was the same of that used in TED group.
In both groups, Ringer’s acetate solution was infused
intraoperative at approximately constant rate (6 m l/
kg/h) via an infusion pump (Fresenius Kabi, Germany)
to cover fluid deficit and basal fluid requirements.
Four sets of data were recorded and each set included:
heart rate (HR), mean arterial pressure (MAP), end
tidal CO2 (ETCO2), ISV, CFT, PV and cardiac output
(CO). The measurements were obtained at 10 min after
induction of anesthesia when hemodynamicaly stable
with controlled ventilation established, (To) before VE
(T1), T2: after VE (T2) and at the end of surgery (T3).
The primary out-come was to evaluate the
333
beneficial values of TED in intraoperative fluid
guidance versus standard clinical monitoring
parameters in infants undergoing Kasai operation
regarding volume of colloid administered. Secondary
outcomes included evaluation of complications such
as vomiting, post-operative pulmonary complications,
return of bowel function and the length of intensive
care and hospital stay.
20 patients in arm 1 (Doppler group) and 20
patients in arm 2 (clinical group) were recruited based
on the following assumptions: with the power of 80 %,
α = 0.05 and the ratio of cases to controls = 1:1. The
required sample size was determined using (power and
sample size calculation) software.
The sample size was determined as regard
patients attending our institute meeting the inclusion
and exclusion criteria which are 40/year. Normally
distributed data were analyzed using t-test, and
categorical data were analyzed using the Chi-square
test. Continuous data are presented as mean and
standard deviation, whereas categorical data are
presented as number of patients and percentage. Data
were analyzed using IBM SPSS statistics 20.0 software.
P <0.05 was considered statistically significant.
Results
Data is presented at baseline, before and after
VE (Table 1). There were no differences in the
demographic data between Doppler and clinical
groups (Table 1). The percentage of patients who
required volume expansion was significantly lower in
the Doppler group (Table 1). Furthermore, the volume
of HES needed was also significantly smaller I the
Doppler group (Table 1). There was no statistically
significant difference between both groups regarding
Ringer’s acetate requirements (Table 1). There were no
differences between the two studied groups regarding
heart rate, mean blood pressure (MAP) (Table 2). The
TED group demonstrated significant hemodynamic
changes in post fluid boluses, increase of ISV and
cardiac output associated with an increase in CFT
and PV (Table 4). There was statistically significant
decreased in mean heart rate post vs. pre- VE (123 ±
6.548 versus 136.8 ± 10.04 beat /min; p <0.05) and
(112.2 ± 5.20 versus 132 ± 8.67 beat /min; p <0.05) in
M.E.J. ANESTH 23 (3), 2015
334
Eman Sayed Ibrahim et. al
Table 1
Patient characteristic data, and characteristics of VE differences between groups.
Variables
Clinical group
(n=20)
Doppler group
(n=20)
P-value
Age ( days)
73.40 ±18.06
74.40 ± 19.06
0.87
Weight (gm.)
4.77 ± 0.71
5 ±0.62
0.28
Height (cm)
65.70±65.70
65.20±5.28
0.97
Sex :male/ female
13/7
12/8
0.74
ASA I/II
18/2
17/3
0.63
202±54
186±44
0.31
Colloids (%pts)
18 (90%)
6 (30%)
0.00#
Volume (ml)
84±14.29
42.85±3.93
< 0.01*
Total RA (ml)
290±39.44
274±39.44
0.20*
Operative time (min)
Volume expansion
TED – Transoesophageal Doppler; ASA – American society of anaesthesia
RA- Ringer acetate
Table 2
Hemodynamic data for both groups.
Variable
HR (beat/min)
T0
T1
T2
T3
MAP (mmHg)
T0
T1
T2
T3
Clinical
(n=20)
Doppler
(n=20)
P-value
125.4±10.57
136.8±10.04
123±6.54
123.5 ±8.07
123.2±8.67
132±8.67
122.2±5.20
122.5 ±12.14
0.48
0.11
0.67
0.76
54.2±3.42
43.4±2.72
58.1±2.64
56.5±2.95
55.5±4.22
44.6±4.50
61.2±4.04
56.8±5.37
0.29
0.31
0.05
0.82
Values are presented as mean (SD); HR – Heart rate; MBP – Mean blood pressure; TED – Transoesophageal Doppler; T0 – 10 min after
induction of anesthesia; T1– before fluid bolus ; T2 – After fluid bolus ; T3– At end of operation .
the clinical and Doppler group respectively, associated
with statistically significant increase in MAP post VE
compared to before it (58.10 ± 2.64365 versus 43.40 ±
2.71 mm Hg; p <0.01) and (61.20 ± 4.049 versus 44.60
± 4.50 mm Hg; p <0.01) in the control and TED group
respectively. These changes associated with stable
CVP with no statistically significant changes after fluid
bolus in it Table 3. There was no mortality reported
during the study period in any case involved in the
study. There were earlier tolerance to oral feeding (2
± 0.66 versus 3.4 ± 0.51 days), shorter hospital stay
(5.30 ± 0.47 versus 6.7 ± 0.92 days) and lower rate of
chest infection (15% versus 30%) and oral intolerance
(10% versus 40%) in Doppler group than clinical
group (Table 5). Eight patients in the clinical group
needed antiemetic in comparison to two patients in
the Doppler guided group. All patients were extubated
immediately postoperative in the operating room and
admitted to the intermediate care unit for the first 24 h.
Discussion
The results of this study demonstrate that
TED was able to predict responsiveness to fluid
Transoesophageal Doppler in Kasai operation
335
Table 5
Postoperative outcome.
Table 3
Central venous pressure changes for the clinical group.
Variable
To
T1
T2
T3
Doppler
Clinical
P-value
group (n=20) group (n=20)
Variable
CVP(cmH2o) 4.10 ±0.99 4.10± 0.87 3.80±0.63 3.87±0.44
Values are presented as mean (SD);CVP- Central venous
pressure T0 – 10 min after induction of anesthesia; T1– before
fluid bolus(VE) ; T2 – After fluid bolus(VE) ; T3– At end of
operation . Data compared by paired t test
and optimize intraoperative fluid consumption, as
indicated by significant lower mean volume of colloid
(HES) received and percent of infants requiring
volume expanders.. In a study by Lee, et al.8, FTC and
PPV (Pulse Pressure Variation) of Doppler were found
to be better than CVP and LVEDAI (left ventricular
end end-diastolic area index) in predicting fluid
responsiveness and that changes in the stroke volume
index caused by fluid loading correlated significantly
with the FTC values. Estimation of intravascular
volume status in critically ill infants and neonates is
a particular challenge as traditional indices, such as
blood pressure and heart rate, may not reflect mild to
moderate blood loss and because, in the majority of
cases, invasive monitoring is not used9. In our study,
fluid boluses based on standard clinical monitoring
data was shown to be inappropriate in the patients
as CVP was stable after fluid boluses in spite of
significant changes in heart rate and MAP. MAP
and HR did not reliably reflect CO in anesthetized
pediatric patients10,11. Kumar et al and Marik et
al found that CVP is not able to indicate changes
Chest infection n (%)
3(15%)
6 (30%)
0.26
Oral intolerance
2(10%)
8(40%)
0.03
Hospital stays (days)
5.30 ± 0.47
6.7 ± 0.92
< 0.01
Day of oral feeding
(days)
2± 0.66
3.4 ± 0.51
< 0.01
in intravascular volume and fluid responsiveness
accurately12,13. Value of CVP is influenced by the
diastolic compliance of the right ventricle, intraabdominal pressure, positive end expiratory pressure,
and forced expiration. Indeed, CVP does not predict
fluid responsiveness and only poorly reflects preload
in adults, children, and pediatric animal models14. The
hypotensive effect of sevoflurane is well described
and is especially significant in the youngest pediatric
patients15.This effect, mostly attributable to a decrease
in systemic vascular resistance, may explain the arterial
hypotension among our patients before fluid bolus.
The increase in MAP observed in control patient’s
post-fluid bolus, without an improvement in CVP may
be explained by other factors such as the subsequent
reduction in sevoflurane during the period of arterial
hypotension. Our study was able to demonstrate the
ability of minimally invasive TED to reduce fluid
therapy when compared to standard clinical monitor
parameter guided fluid management associated with
earlier tolerance to oral feeding, shorter hospital stay
Table 4
TED variables for the Doppler group.
Variable
To
T1
T2
T3
1.19±0.21
0.76±0.05*
1.16±0.16#
1.09±0.16
333.74±31.88
311.3±11.73*
350.4±11.08#
338.2±6.72**
ISV(ml/beat/m2)
30.13±2.31
25.52±2.22*
32.88±1.83#
33.2±2.24
PV (cm/sec)
111.3±8.18
84.44±5.08*
109.80±7.32#
100.50±3.62*
COP(ml/min)
CFT(m/sec)
Values expressed as mean (SD); COP( Cardiac output); ISV (index Stroke volume); CFT ( Corrected flow time); PV (Peak velocity );
T0 –10 min after induction of anesthesia; T1– before fluid bolus(VE) ; T2 – After fluid bolus(VE) ; T3– At end of operation.* P ˂ 0.05
vs. To
# P ˂ 0.05 vs. T1
** P ˂ 0.05 vs. T2
M.E.J. ANESTH 23 (3), 2015
336
and lower rate of chest infection and oral intolerance.
Recent randomized trials and meta-analyses have
confirmed that intraoperative fluid optimization using
TED improve outcome8,16 Absi et al17 reported that
the application of esophageal Doppler guided fluid
management has produced a similar improvement
in outcome for patients undergoing cardiac surgery.
Roche et al18 studied Goal-directed fluid management
with trans-esophageal Doppler and found a significant
reduction in hospital stay. In the current study, chest
infection and post-operative vomiting and intolerance
to oral feeding were significantly less reported in the
Doppler guided fluid group. This was also supported
by Mythen and Webb study, which demonstrated
that the esophageal Doppler guided plasma volume
optimization significantly reduced the incidence
of gastric mucosal hypoperfusion leading to a
significant reduction in complication rates and length
of hospital stay following cardiac surgery19. Increase
extravascular lung water from excessive intravascular
volume may predispose patients to pneumonia and
respiratory failure. It can lead to edema of the gut,
which may inhibit gastrointestinal motility and
prolong postoperative ileus and intolerance for enteric
alimentation. The potential for bacterial translocation
and development of sepsis and multiorgan failure
Eman Sayed Ibrahim et. al
is also increased. Increase cutaneous edema may
decrease tissue oxygenation, which can lead to
delayed wound healing20. Previous literatures suggest
that perioperative goal-directed therapy (GDT) based
on flow-related hemodynamic parameters improve
patient outcome21,22. Clinical studies have mostly
shown outcome benefits only within postoperative
nausea and vomiting, ileus, morbidity, and hospital
stay23,24. However, only limited pathophysiological
data are available to explain this benefit. Lopes et al.25,
in their work revealed that there is reduced morbidity
and hospital stay by GDT and this also associated with
a reduced interleukin-6 response. Other studies on
perioperative changes of the vascular barrier suggest
that the endothelial gly-cocalyx plays a key role26,27.
The limited number of cases enrolled in our
study was related to the limited number of cases of
biliary atresia selected for kasai surgery in our national
liver institute. The use of TED for intraoperative fluid
guidance in infants undergoing Kasai operation need
to be studied in further planned research work.
In conclusion: TED guided intraoperative fluid
management in infants undergoing Kasai operation
optimizes fluid consumption and improve outcome
associated with shorter hospital stay.
Transoesophageal Doppler in Kasai operation
337
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6. Tibby SM, Hatherill M, Murdoch IA: Use of transesophageal
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7. Raux O, Spencer A, Fesseau R, Mercier G, Rochette A, Bringuier
S, lakhal K, Capdevila X and Dadure C: Intraoperative use of
transoesophageal Doppler to predict response to volume expansion
in infants and neonates. Br J Anaesth; 108(1):100-7, 2012.
8. Lee JH, Kim JT, Yoon SZ, Lim YJ, Jeon Y, Bahk JH and Kim CS:
Evaluation of corrected Flow time in oesophageal Doppler as a
predictor of fluid responsiveness. Br J Anaesth; 99:343-8, 2007.
Richardson JR, Ferguson J, Hiscox J and Rawles J: Noninvasive 9.
assessment of cardiac output in children. J Accid Emerg Med;
15(5):304-307, 1998.
10.Osthaus WA, Huber D, Beck C, Roehler A, Marx G, Hecker H and
Sümpelmann R: Correlation of oxygen delivery with central venous
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11.Kluckow M and Evans N: Relationship between blood pressure and
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13.Marik PE, Baram M and Vahid B: Does central venous pressure
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M.E.J. ANESTH 23 (3), 2015
CASE REPORTS
Bilateral Adductor Vocal Cord Palsy:
Complication of Prolonged
Intraoperative Hypotension
after Endotracheal Intubation
Rajnish K. Nama*, Guruprasad P. Bhosale**,
Bina P. Butala*** and Ankit R. Sharma****
Endotracheal intubation for general anesthesia is usually a safe procedure. However,
postoperative sore throat and mild hoarseness may occur due to laryngeal edema but bilateral
vocal cord paralysis as a result of recurrent laryngeal nerve injury is a rare complication. We report
a case of bilateral adductor vocal cord palsy following general anesthesia for abdominal surgery.
Clinical presentation was hoarseness, aspiration pneumonia and hypoxemia requiring ventilatory
support. Neuropraxia of recurrent laryngeal nerve due to prolong intra-operative hypotension, even
with normal endotracheal tube cuff pressure was the likely mechanism.
Keywords: Endotracheal intubation, Adductor vocal cord palsy, Prolong intraoperative
hypotension.
Introduction
Endotracheal intubation is essential part of anesthesia practice but rarely result in vocal cord
paralysis which is a most serious complication resulting in vocal disability and aspiration1,2,3. Direct
surgical trauma, quality of tracheal intubation and high cuff pressure are some common risk factors
for this complication. In our current case, we report an incident of uncommon cause for vocal cords
palsy.
Case History
A 50-year-old 60 kg male presented with abdominal pain in abdomen and hematuria and
was diagnosed to have renal cell carcinoma with thrombus in inferior vena cava (IVC). He was
posted for right radical nephrectomy with IVC thrombectomy. Patient had no comorbidities. His
preoperative examination and laboratory investigations were insignificant. Airway assessment was
normal with mallampati score grade-I.
* DNB Anaesthesiology, Assistant Professor.
** MD Anaesthesiology, Professor.
*** MD Anaesthesiology, Professor.
****DA Resident in Anaesthesiology.
Department of Anaesthesia and Critical Care, Smt. K.M. Mehta and Smt. G.R. Doshi Institute of Kidney Diseases and
Research Center Dr. H.L. Trivedi Institute of Transplantation Sciences, Civil Hospital Campus, Asarwa, Ahmedabad-380016,
Gujarat-INDIA.
Corresponding author: Dr. Rajnish Kumar Nama, A 501 Umiyateerth avenue, Opp. Lomash bunglows, Sona cross roads,
New CG Road, Chandkheda, Ahmedabad 382424, Gujarat-INDIA. Mob.: +919825976818. E-mail: names.raj@gmail.com
339
M.E.J. ANESTH 23 (3), 2015
340
Rajnish K Nama et. al
Balanced general anesthesia was given and
trachea was intubated with 8.0 mm cuffed portex
endotracheal tube a in single attempt without any
trauma. Cuff of the endotracheal tubewas inflated
with room air till no apparent leak. Endotracheal
tube (ETT) cuff pressure was measured with aneroid
manometer and it was less than 25 mmHg and was
maintained throughout the procedure. Anesthesia
proceeded with oxygen, air, isoflurane, and atracurium
with IPPV. Unexpectedly there was massive blood
loss as tumour was adherent to surrounding structures.
Intra-operatively patient received 14 unit of packed
cells volume (PCV), 6 unit of fresh frozen plasma
(FFP), colloids and crystalloids even vasopressors
were started to maintain blood pressure but most of
time mean arterial pressure was less than 65 mmHg.
Surgery lasted for 8 hours. After completion of surgery
extubation was accomplished in the operating room
with neostigmine and glycopyrrolate. Patient was
shifted in stable hemodynamic condition.
to ICU for observation.
On the next day patient had hoarseness, coughing
on swallowing liquids, breathlessness and hypoxemia.
For protection of airway and reversing severe
breathlessness, the trachea was smoothly intubated and
patient was put on mechiancal ventilator. During direct
laryngoscopy sluggish movement of vocal cords were
noted. Chest x-ray was done and it was suggestive of
bilateral aspiration pneumonia (figure 1). Patient was
treated with antibiotics and supportive management.
Patient was weaned off ventilator gradually and
extubated under fiberoptic bronchoscopy (FOB)
guidance. During extubation both the vocal cords were
seen lying in intermediate position with a gap. Reduced
movements of both vocal cords were also noted and on
coughing vocal cords failed to approximate completely
(figure 2). Adductor vocal cord palsy due to possible
recurrent laryngeal nerve injury was suspected. The
patient was started nasogastric feed and transfered to
his room. After 10 days mild hoarseness and coughing
on swallowing liquid still persisted. ENT opinion was
sought and indirect laryngoscopy was done by ENT
specialist which showed bilateral bowing with reduced
movement of vocal cords more on right side then
left. Beside speech therapy no active treatment was
prescribed and after 25 days the nasogastric tube was
removed as patient could tolerate oral intake of liquid
orally and by 40 days his voice recovered completely.
Fig. 1
Chest X-Ray showing bilateral opacities
Fig. 2
Fiberoptic bronchoscopy view of larynx. Vocal cords failed
to approximate completely during forced coughing
Discussion
Acute hoarseness and sore throat after
endotracheal intubation is common and is usually due
to mucosal injury. Prolong or permanent hoarseness
occurs in approximately 1%4 but postoperative vocal
cord paralysis following endotracheal intubation,
Complication of prolonged inta-operative hypotension
leading to aspiration pneumonia and requiring
mechanical ventilation is a rare occurrence.
Several risk factors for laryngeal injury have
been identified including the size of the ETT, the
cuff pressure and the quality and duration of tracheal
intubation5,6. Kikura et al found that the risk of vocal
cord paralysis was increased three folds in patients
aged older than 50 years, 15-fold in patient intubated
6 h or more and two folds in patients with diabetes or
hypertension7. In other cases, the cause of vocal cord
paralysis still remains undetermined.
Minuck suggested that increasing endotracheal
tube cuff pressure and asymmetrical cuff inflation
might be the principle mechanism of recurrent
laryngeal nerve palsy associated with endotracheal
anesthesia8. According to Cavo John, the probable
site of injury is the subglottic region where anterior
branch of recurrent laryngeal nerve is vulnerable to
compression between expanded cuff and overlying
thyroid cartilage9.
General guidelines state that endotracheal tube
cuff pressure should be not more than 25 mmHg
(Possible maximal range of 15-30 mmHg) to maintain
tracheal mucosa perfusion and thereby prevent
mucosal ischemia, tracheal necrosis, rupture, stenosis,
laryngeal nerve palsy and tracheoesophageal fistula10.
As far as our patient is concerned direct injury
to recurrent laryngeal nerve is unlikely. Trachea
was intubated without trauma in single attempt with
341
adequate size of ETT. Although surgery lasted for 8
hours but N2O was not used and cuff pressure was
kept below 25 mmHg all the time; as such excessive
cuff pressure could not be the reason for nerve injury.
Our patient remained hypotensive (MAP less than 65
mmHg) for most of the time during the surgery and
received vasopressors to maintain blood pressure.
Prolonged intra-operative hypotension could have
affected microcirculation of the larynx and led to
the neuropraxia of the bilateral recurrent laryngeal
nerve. Efrati et al suggested that when the patient is
hemodynamically unstable and is being treated with
vasoconstrictors the perfusion pressure in the tissue
(tracheal mucosa) is significantly reduced. In this
condition tissue hypoperfusion and hypoxia can happen
even at lower cuff pressures (less than 25 mmHg)10.
Conclusion
Severe and Prolonged intraoperative hypotension
may adversely affect the microcirculation of larynx even
with normal cuff pressure and can lead to neuropraxia
of recurrent laryngeal nerve. We emphasize on keeping
endotracheal tube cuff pressure in normal range and
whenever patient is hypotensive and on vasopressors,
ETT cuff pressure should be decreased as low as
possible to maintain adequate tissue perfusion and
prevent possible injuiry to recurrent laryngeal nerve
and bilateral vocal cords palsy.
M.E.J. ANESTH 23 (3), 2015
342
Rajnish K Nama et. al
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important part of a big issue. J Clin Monit Comput; 26:53-60, 2012.
ANESTHESIA MANAGEMENT IN AN INFANT WITH
GLYCOGEN STORAGE DISEASE TYPE II
(POMPE DISEASE)
Abdulaleem Al Atassi*, Nezar Al Zughaibi**, Anas Naeim**,
Abdulatif Al BashA*** and Vassilios Dimitriou****
Abstract
Pompe or Glycogen Storage Disease type II (GSD-II) is a genetic disorder affecting both
cardiac and skeletal muscle. Historically, patients with the infantile form usually die within the
first year of life due to cardiac and respiratory failure. Recently a promising enzyme replacement
therapy has resulted in improved clinical outcomes and a resurgence of elective anesthesia for
these patients. Understanding the unique cardiac physiology in patients with GSD-II is essential to
providing safe general anesthesia. Additional care in maximizing coronary perfusion pressure and
minimizing arrhythmia risk must be given. For these reasons, it is recommended that anesthesia for
infantile Pompe patients should specifically avoid propofol or high concentrations of sevoflurane
and, instead, use an agent such as ketamine as the cornerstone for induction in order to better
support coronary perfusion pressure and to avoid decreasing diastolic blood pressure (DBP) with
vasodilatory agents. We present the anesthetic technique in a case of infantile type Pompe disease.
Keywords: metabolic disorders, Pompe disease, anesthesia.
Introduction
Pompe disease, also known as glycogen storage disease type II or acid maltase deficiency, is an
autosomal recessive disorder caused by a deficiency of the lysosomal enzyme acid a-glucosidase1,2.
For the infantile-onset subtype specifically, the birth prevalence is reported to range between 1: 40
000 and 1: 138 000 among different nations3. The early-onset, infantile subtype is typically fatal
because of rapid intracellular accumulation of glycogen, which causes infiltrative pathology of
the myocardium and skeletal muscle. Common presenting signs include cardiomegaly, hypotonia,
macroglossia, failure to thrive and hepatomegaly. Without treatment, sequelae include rapidly
progressive hypertrophic cardiomyopathy, arrhythmias, systolic and diastolic heart failure and
chronic respiratory failure, followed by death usually within the first year of life1,2. During the
last decade a promising enzyme replacement therapy, with recombinant human acid aglucosidase
(rhGAA), has resulted in improved clinical outcomes in the treatment of infantile-onset Pompe
*
MBBS FRCPC, Assistant Professor, Department of Anesthesiology, King Saud University for Health Sciences, Riyadh,
Saudi Arabia. E-mail: atassia@ngha.med.sa
∗ MBBS FRCPC, Assistant Professor, Deputy Chairman, Department of Anesthesiology, King Saud University for Health
Sciences, Riyadh, Saudi Arabia. E-mail: zughaibin@ngha.med.sa
** Staff Physician, Department of Anesthesia, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
*** Consultant, Department of Anesthesia, King Abdulaziz Medical City, Riyadh, Saudia Arabia. E-mail: abdulrima@yahoo.
co.uk
****Professor of Anesthesia, Consultant, Department of Anesthesia, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
Corresponding author: Vassilios Dimitriou, Professor of Anesthesia, Consultant, Department of Anesthesia, King
Abdulaziz Medical City, Riyadh, Saudi Arabia. Tel: +966596508911. E-mail: vaskdimi58@gmail.com
343
M.E.J. ANESTH 23 (3), 2015
344
disease4. For this reason after early diagnosis, it is
imperative for the infant to start as soon as possible
enzyme replacement therapy (ERT) using rhGAA. We
present the anesthetic management of an infant with
Pompe disease.
Case Description
This is the case of a 2-month-old male (4.7 kg),
with uncomplicated pregnancy and full term normal
vaginal delivery. After birth the infant presented
hypotonic and cyanotic. He was admitted to the NICU
and remained 4 days under supplemental oxygen
support and investigation. Electrocardiogram showed
normal sinus rhythm, biventricular hypertrophy, ST
depression and inverted T wave in inferior leads.
Echocardiography demonstrated non obstructive
hypertrophic cardiomyopathy with severe biventricular
hypertrophy. The estimated left ventricular mass
index (LVMI) on echocardiography was 169.6 g/m2
(normal 48.8 ± 8). LVMI was calculated by Devereux′s
formula5 considering the diastolic measurements of left
ventricular internal diameter (LVID), interventricular
septal thickness (IVST) and posterior wall thickness
(PWT): LVMI (g/m2) = (1.04 [(IVST+LVID+PWT)3LVID3]-14 g)/ Body surface area. The above findings
led to an eventual diagnosis of infantile-onset Pompe
disease. Diagnosis was confirmed in specialized
laboratory centre in Germany, using whole blood and
lymphocyte samples5,6. The infant was then scheduled
to undergo general anesthesia for the placement of a
central venous catheter prior to starting rhGAA therapy.
Standard monitoring was applied. Baseline
heart rate ranged from 140 to 160 b/min) and blood
pressure was 85/49 mmHg. The patient had a history
of hypotonia, small mouth opening, macroglossia,
and gastroesophageal reflux disease with adequate
weight gain. Intravenous induction with ketamine (1
mg/kg) and fentanyl (2.0 mcq/kg) was performed.
The patient was successfully intubated at the second
attempt (Cormack and Lehane grade 3) without
muscle relaxant. Following induction and after the
fentanyl administration the heart rate transiently
decreased to 110 b/min (>20% from baseline) and
resolved spontaneously. Anesthesia was maintained
with sevoflurane 1-2% and 50% nitrous oxide in
Vassilios Dimitriou et. al
oxygen. Maintenance intravenous fluids D5% LR
were infusing at a rate on 100 ml/hr. About 10 minutes
after induction, blood pressure decreased to 55⁄20
(>30% from baseline systolic and diastolic pressures,
respectively) and restored with a fluids bolus of 5ml/
kg. Postoperatively, the patient was transferred to the
intensive care unit and discharged home 2 days later
without incident.
Discussion
Pompe or Glycogen Storage Disease type II
(GSD-II) is a genetic disorder affecting both cardiac and
skeletal muscle. The intracardiac buildup of glycogen
in infantile onset Pompe disease leads to a progressive
hypertrophic
cardiomyopathy
characterized
by abnormal diastolic function. Therefore, the
hypertrophic cardiomyopathy in infantile-onset Pompe
disease requires a delicate hemodynamic balance
during induction and early maintenance of anesthesia.
A noncompliant left ventricle predisposes these infants
to diastolic heart failure with elevated left ventricular
end-diastolic pressure (LVEDP), at lower ventricular
volumes and an increased potential for subendocardial
ischemia, necessitating adequate hydration and preload
to maintain cardiac output. At the same time, diastolic
blood pressure (DBP) must remain sufficiently higher
than LVEDP to maintain adequate coronary perfusion
pressure7.
Glycogen accumulation can also be present
in the cardiac conduction system, as evidenced
by the glycogen infiltration of the sinoatrial and
atrioventricular nodes8. Coupled with a hypertrophied
heart and an already labile coronary perfusion pressure,
infantile Pompe patients become especially sensitive
to the development of ventricular and supraventricular
arrhythmias9. As such, patients suspected of having
Pompe disease should routinely undergo extensive
preoperative evaluation, conservative intraoperative
management and have appropriate postoperative
disposition. Preoperatively, it is essential to obtain,
in addition to an ECG, echocardiography to assess
ventricular cavity volume. In particular, measurement
of LV mass index (LVMI) is imperative to help stratify
risk. There is strong evidence for an association
between LVMI and mortality risk9. Deaths resulting
ANESTHESIA IN AN INFANT WITH POMPE DISEASE
from arrhythmias appeared to correlate with LVMI
>350 g/m2 9.
Propofol, should be avoided specifically for
infantile Pompe patients, given its known rapid
reduction in systemic vascular resistance and DBP.
The use of propofol during induction or maintenance
of anesthesia, has resulted in severe and even fatal
arrhythmias and has been associated with negative
outcomes9. Although sevoflurane is an acceptable
anesthetic in these infants, the concentrations must be
kept low to avoid hypotension, and therefore should
only be used if other agents allow the sevoflurane to
have an additive effect in an infant where immobility is
difficult to obtain with a single agent. Sevoflurane does
not appear to be a safe option as the sole anesthetic for
this purpose.
345
In our case ketamine, known for its stable
cardiovascular profile, was used for induction in
combination with fentanyl and low concentration
of sevoflurane. According to the current literature
ketamine is suggested as the first choice in this group of
patients9. Additionally, regional anesthetic techniques
have been used successfully as alternative to general
anesthesia for infants with Pompe disease10.
Conclusion
With the availability of enzyme replacement
therapy (ERT) using rhGAA, increased survival is
anticipated and more infantile Pompe patients will
likely present for surgical procedures. Additional
care in maximizing coronary perfusion pressure and
minimizing arrhythmia risk must be given.
M.E.J. ANESTH 23 (3), 2015
346
Vassilios Dimitriou et. al
References
1.KISHNANI PS, HOWELL RR: Pompe disease in infants and children.
J Pediatr; 144:S35-S43, 2004.
2.VAN DEN HOUT HM, HOP W, VAN DIGGELEN OP, SMEITINK JA,
SMIT GP, POLL-THE BT, BAKKER HD, LOONEN MC, DE KLERK JB,
REUSER AJ, VAN DER PLOEG AT: The natural course of infantile
Pompe’s disease: 20 original cases compared with 133 cases from
the literature. Pediatrics; 112:332-340, 2003.
3.KISHNANI PS, HWU WL, MANDEL H, NICOLINO M, YONG F, CORZO
D: A retrospective, multinational, multicenter study on the natural
history of infantile onset Pompe disease. J Pediatr; 148:671-676,
2006.
4.KLINGE L, STRAUB V, NEUDORF U, SCHAPER J, BOSBACH T,
GÖRLINGER K, WALLOT M, RICHARDS S, VOIT T: Safety and
efficacy of recombinant acid alpha-glucosidase (rhGAA) in patients
with classical infantile Pompe disease: results of a phase II clinical
trial. Neuromuscul Disord; 15:24-31, 2005.
5.DEVEREUX RB, REICHEK N: Echocardiographic determination of
left ventricular mass in man: anatomic validation of the method.
Circulation; 55:613-619, 1997.
6.JACK RM, GORDON C, SCOTT CR, KISHNANI PS, BALI D: The use
of acarbose inhibition in the measurement of acid alpha-glucosidase
activity in blood lymphocytes for the diagnosis of Pompe disease.
Genet Med; 8:307-312, 2006.
7.ZHANG H, KALLWASS H, YOUNG SP, CARR C, DAI J, KISHNANI PS,
MILLINGTON DS, KEUTZER J, CHEN YT, BALI D: A comparison of
maltose and acarbose as inhibitors of maltase-glucoamylase activity
in assaying acid alpha-glucosidase activity in dried blood spots for
the diagnosis of infantile Pompe disease. Genet Med; 8:302-306,
2006.
8.ING RJ, COOK DR, BENGUR RA, WILLIAMS EA, ECK J, DEAR GDE
L, ROSS AK, KERN FH, KISHNANI PS: Anaesthetic management
of infants with glycogen storage disease type II: a physiological
approach. Pediatr Anesth; 14:514-519, 2004.
9.LUKE Y, WANG J, ROSS A, LI J, DEARMEY S, MACKEY J, WORDEN M,
CORZO D, MORGAN C, KISHANI P: Cardiac arrhythmias following
anesthesia induction in infantile-onset Pompe disease: a case series.
Pediatric Anesth; 17:738-748, 2007.
10.WALKER RW, BRIGGS G, BRUCE J, FLETCHER J, WRAITH ED:
Regional anesthetic techniques are an alternative to general
anesthesia for infants with Pompe’s disease. Paediatr Anaesth;
17:697-702, 2007.
Recurarization after acute intraoperative
normovolemic hemodilution and use
of sugammadex
Bruno LC Araujo*, Alfredo GH Couto**
and D aniele T heobald ***
Acute normovolemic hemodilution (ANH) is a blood conservation procedure that can be
used in cases of refusal of blood transfusion for religious reasons. Herein, we describe a case
of recurarization after reinfusion of collected blood. A combination of rocuronium/sugammadex
has the potential to increase the safety of patients if ANH is done after induction. Prospective
controlled studies evaluating this unique indication for sugammadex use are thus warranted.
Keywords: Advance Directives; Hemodilution; Jehovah’s Witnesses; Neuromuscular Blocking Agents;
Bloodless Medical and Surgical Procedures.
Introduction
The Jehovah’s Witness religious community is remembered by health professionals for its
refusal to receive blood products as part of the therapeutic arsenal1. Minor fractions of blood and
other transfusion alternatives, such as acute normovolemic hemodilution (ANH), are optional
depending on the follower’s personal beliefs1.
The perioperative management of patients who refuse to receive blood products requires
interaction between various medical specialties as well as experience with blood conservation
procedures. This case report presents the use of ANH in gynecological oncology surgery with
recurarization after the infusion of collected blood and the use of sugammadex for reversal.
To our knowledge, this is the first reported case on the indication for and use of sugammadex
for reversal of recurarization after ANH.
Case
The patient was a 76-year-old woman with arterial hypertension and type 2 diabetes mellitus.
The operation proposed was a total abdominal hysterectomy associated with para-aortic pelvic
lymphadenectomy, omentectomy, and biopsies because of an endometrial adenocarcinoma.
Laboratory tests revealed the following: hemoglobin: 13.0 g/dL; hematocrit, 38.5% : urea: 24 mg/
dL; glucose: 145 mg/dL; and normal coagulation tests. The patient refused to receive the 4 main
blood products under any circumstances owing to her religious conviction (Jehovah’s Witness).
*
MD, Supervisor, Department of Anesthesiology, Hospital do Câncer II - Instituto Nacional do Câncer José Alencar Gomes
da Silva.
** MD, Anesthesiologist, Department of Anesthesiology, Hospital do Câncer II - Instituto Nacional do Câncer José Alencar
Gomes da Silva.
*** MD, Anesthesiologist, Department of Anesthesiology, Hospital do Câncer II - Instituto Nacional do Câncer José Alencar
Gomes da Silva.
Corresponding author: Bruno Luís de Castro Araujo, Instituto Nacional do Câncer José Alencar Gomes da Silva, Rua do
Equador, 831, 7º andar. Santo Cristo. CEP: 20.220-410. Rio de Janeiro. RJ. Brazil. Tel: 55-21-32072915; 55-21-88400944.
E-mail: brunoaraujomed@yahoo.com.br; baraujo@inca.gov.br
347
M.E.J. ANESTH 23 (3), 2015
348
Bruno LC Araujo et. al
Fig. 1
Temporal relationship between evaluation of neuromuscular function by train-of-four (TOF)
stimulation, infusion of the collected blood, administration of rocuronium and sugammadex.
# - Anesthetic induction with rocuronium 0.6 mg/kg.
* - Start of the surgical procedure.
#1 - Rocuronium 0.15 mg/kg at the beginning of the closure of the abdominal wall.
*1 - End of the surgical procedure.
#2 - Sugammadex 4 mg/kg.
X - Extubation.
During anesthesia, the patient was monitored
with electrocardiography cardioscopy, pulse oximetry,
capnography, esophageal temperature, bispectral index,
train-of-four (TOF) stimulation, urine output, invasive
blood pressure measurement with cardiac output and
central venous oxygen saturation measurement. The
anesthesic technique was general anesthesia with
sevolurane, remifentanil and rocuronium associated
with a lumbar epidural puncture (L2–L3) using a
catheter. The blood collection was started 5 min after
the induction of anesthesia and 1,030 mL was obtained
over 1 h. The hematocrit was 26% after collection.
Volume replacement was performed with continuous
monitoring of changes in stroke volume. A total of 1,500
mL of colloids (0.6% hydroxyethylamide, 130/0.4) and
1,000 mL of crystalloids were administered through
anesthesia. The operating time was 3 h, 15 min with
an estimated bleeding of 1,000 mL. Monitoring of the
neuromuscular junction, rocuronium and sugammadex
administration occurred as shown in Figure 1.
The patient was admitted to the intensive care
unit in the immediate postoperative period without
pain or other complaints. On the first postoperative
day (POD) she presented with 33% hematocrit and
11.5% hemoglobin. Her pain was controlled using
an epidural until the second postoperative day. The
postoperative recovery was uneventful and the patient
was discharged on the fifth postoperative day.
Discussion
ANH is usually well accepted by Jehovah’s
Witnesses, and it is important to note that there is no
religious prohibition to its use. For this, it is necessary
to guarantee that the collected blood will remain in
contact with the patient during all stages of the process,
thus maintaining a closed system1.
We chose to collect blood after anesthesia
induction. A very important technical aspect is the
recirculation of drugs during the transfusion of
collected blood. The drugs present in plasma at the time
of collection will perform their action on the effector
organs at the time of reinfusion. Neuromuscular
blockers deserve special attention.
We opted to administer rocuronium for
neuromuscular blockade because of the safety
associated with rocuronium/sugammadex versus the
other nondepolarizing neuromuscular blockers and
succinylcholine. Cases of recurarization with the use of
atracurium, vecuronium, mivacurium, and rocuronium
have been described2. Sugammadex has been proven to
be a safer reversal agent than neostigmine, particularly
in moderate and deep blockade3. Thus, proper planning
to prevent residual curarization is crucial when one
opts for blood collection after induction.
The use of the combination of rocuronium and
sugammadex offers a unique opportunity to perform
a suitable neuromuscular blockade at all stages of
the surgical procedure without increasing the risk of
postoperative residual paralysis.
Consent Statement
The patient provided written informed consent
and the paper was accepted by the hospital’s research
ethics committee.
Recurarization after ANH and sugammadex
349
References
1.Hughes DB, Ullery BW, Barie PS: The contemporary approach to
the care of Jehovah’s witnesses. J Trauma; 65:237-47, 2008.
2. Rohling RG, Rentsch KM, Beck-Schimmer B, Fuchs-Buder T:
Risk of recurarization during retransfusion of autologous blood
withdrawn after injection of muscle relaxants: a comparison of
rocuronium and mivacurium. J Clin Anesth; 15:85-90, 2003.
3. Karalapillai D, Kaufman M, Weinberg L: Sugammadex. Crit Care
Resusc; 15(1):57-62, 2013.
M.E.J. ANESTH 23 (3), 2015
Malpositioned LMA confused as foreign
body in nasal cavity
Sidharth Verma*, Nitika Mehta**, Nandita Mehta***,
Satish Mehta**** and Jayeeta Verma*****
We present a case of confusing white foreign body in the nasal cavity detected during
Endoscopic Sinus Surgery (ESS) in a 35-yr-old male which turned out to be a malposition of
classic laryngeal mask airway (LMA). Although malposition of LMA is a known entity to
the anesthesiologist, if ventilation is adequate, back folded LMA in nasal cavity might not be
recognized by the surgeon and lead to catastrophic consequences during endoscopic sinus surgery.
In principle, misfolding and malpositioning can be reduced by pre usage testing, using appropriate
sizes, minimizing cuff volume, and early identification and correction of malposition.
Introduction
Laryngeal mask airway (LMA) is now the airway of choice in nasal surgeries. Due to its
blind technique of insertion, LMA carries inherent risk of malposition and misfolding which may
compromise patient safety. Early recognition and corrective actions are therefore imperative for
risk reduction.
Case History
A 35 year old male patient presented with history of bilateral nasal obstruction, post nasal drip
and headache for last 4 years. Patient had a history of previous endoscopic sinus surgery 2 yrs back
but his symptoms were persistent. He was a non-smoker, non-alcoholic and his medical history
included no other comorbid condition. A CT scan revealed sinusitis along with bilateral polyps. He
was then scheduled for Endoscopic Sinus Surgery (ESS) for polypectomy.
On examination, he had a Mallampati class I airway, poor dentition, and no artificial teeth or
dentures. He was 161 cm tall and weighed 65 kg. His heart rate was 76 bpm and regular and arterial
blood pressure was 128/76 mm Hg. The lungs were clear by auscultation.
On the day of surgery, after sedation with midazolam the patient was taken to the operating
room (OR), where routine monitors were attached for monitoring blood pressure (systolic, diastolic
and mean), SpO2, heart rate and ECG. An eighteen G venous cannula was inserted. Induction of
anesthesia was accomplished with 2.5 mg/kg propofol and 0.8 mg/kg rocuronium. A size 4 LMA
*
Dr. Sidharth Verma, Senior Resident, (PDCC Pain Management) Department of Anaesthesiology, IMS, BHU, Varanasi, UP
(India) - 221005.
** Dr. Nitika Mehta, PG Resident, SRSIMS Bareilly-Nainital Road, Bhojipura, Bareilly, Uttar Pradesh 243202 (India).
*** Dr. Nandita Mehta, Professor and Head of the Department of Anaesthesiology, Acharya Shri Chander College of Medical
Sciences and Hospital, Sidhra Jammu (India).
****Dr. Satish Mehta, Consultant ENT Surgeon, Jammu (India).
***** Emergency Medicine and Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences, King
Abdullah International Medical Research Center, Riyadh, Saudi Arabia: SolamyS@ngha.med.sa
Corresponding author: Dr. Sidharth Verma, 524-25, Colonel’s Colony, Talab Tillo Bohri, Jammu - 180002 INDIA,
Presently PDCC Pain Management (Deptt of Anesthesiology) at IMS, BHU, Varanasi, INDIA. Tel: 09918300497,
09419200497. E-mail: sidharth2008@gmail.com
351
M.E.J. ANESTH 23 (3), 2015
352
Sidharth Verma et. al
was inserted in the first attempt and showed good
chest rise with adequate oxygenation (SpO2 of 100%
throughout the surgery). There were no evidence of air
leaks.
Towards the end of the surgical procedure which
lasted two and a half hours, a white rubbery mass was
seen in the nasopharynx which the surgeon thought
to be some foreign material left during the previous
surgery. The mass had a cystic consistency and was
unlike any lesion of the nasopharynx. On positioning
the nasal endoscope closer to the foreign body, the
anesthesiologist recognized it to be the tip of the
folded malpositioned LMA (figure 1). This was then
confirmed by oral examination while the LMA was still
in place. Endoscopy clearly revealed a folded distal
cuff which was going into the nasopharynx (figure 1,
2). Despite this, the patient was being ventilated all
through the surgical procedure without any air leak or
fall in saturation.
After completion of surgery, proper suctioning
was done and the LMA was removed and examined
for the presence of any blood on the ventral part. Blood
was present only on the dorsal part of the LMA whereas
ventral aspect was absolutely clean. Patient had no
signs and symptoms suggestive of any aspiration.
Patient was fully conscious, with good cough reflex
and there was no hoarseness of voice and sore throat
in the immediate post-op period of 24 hours. Patient
was closely monitored for any signs or symptoms of
aspiration post-operatively. Thereafter the patient was
discharged on the next day.
Discussion
LMA has gained widespread acceptance
throughout the world as airway management device
across a spectra of clinical situations. Because the
larynx is not directly stimulated, respiratory and
cardiovascular reflex responses to placement1,2,3 and
removal4 of the LMA are reduced compared with those
after tracheal intubation. These properties make awake
removal of LMA a preffered technique after surgery5,6.
In nasal surgery, rapid rises in blood pressure can
enhance bleeding and are best avoided. A smooth
anesthesia induction, maintenance and emergence
are required7. The avoidance of coughing and return
of airway reflexes to prevent aspiration is needed at
the same time. This makes LMA a suitable option
for airway management in nasal surgery. But due to
the blind insertion technique, difficulty in ventilation
through an LMA is not uncommon even in experienced
hands. It commonly results from malposition and is
often corrected by repositioning8. Whereas difficulty
in ventilating through an LMA may be the result of
malposition, it can also be the result of pathological
anatomy8. Conversely, it is prudent to emphasize that
adequate ventilation does not rule out malposition per
se as aptly demonstrated by this case and may lead to
complications in the intra and post-operative period. It
has been found that a malpositioned LMA was 26 times
more likely to be associated with gastric insufflation
and subsequent aspiration9.
In our case, the patient was being ventilated
Fig. 1
Showing fibreoptic views of nasal cavity (I, II) and oral cavity/ oropharynx (III)
A: Malpositioned cuff of the LMA, B: Nasal Septum, C: Turbinate (inferior), D: Uvula, E: Hard Palate,
F: Faucial Pillars, G: Airway Tube of LMA, H: LMA Cuff in pharynx.
Malpositioning of LMA
353
Fig. 2
Line diagram showing folded
distal cuff in the nasopharynx
in spite of the malpositioned LMA which was
incidentally noticed during the procedure. The surgeon
mistook it for a foreign body in the nasal cavity left
by the previous surgery. The point of concern however
remains that the patient was at considerable risk of
aspiration throughout the procedure. Although the
chances of aspiration were minimal due to fasting
status and low pressure used for the positive pressure
ventilation, they were still present. Previous research
recommends certain signs to ascertain the correctness
of LMA placement10,11. These include slight outward
movement of the tube upon LMA inflation, presence
of a small oval swelling in the neck around the thyroid
and cricoid area, no cuff visible in the oral cavity and
expansion of chest wall on bag compression. This case
emphasizes that, in spite of fulfilling all these criteria,
the LMA may still be malpositioned or misfolded or
both. The facts illustrated by this case, therefore raise
a concern scarcely addressed by the literature till date.
Although the risk of aspiration from LMA has been
found to be only 2 per 10,00012, it is still present and may
often be preventable if proper positioning of LMA is
ensured. Fibreoptic confirmation of the LMA position
can be of immense benefit but may not be possible in
all the cases routinely and in all the settings due to time
and financial constraints. The grade of fiberoptic view
has been graded in literature as: 1=glottis only seen,
2=epiglottis and glottis seen, 3=epiglottis impinging
on grille, glottis seen, 4=epiglottis down folded, glottis
not seen13. A grade of 3 or more may need repositioning
and reinsertion as it might be associated with increased
risk of aspiration.
Another point of concern is that since the reusable
LMA can be reused up to 40 times as per manufacturer’s
recommendations, does the chance of misfolding and
malposition increase with usage or not. The answer
to this is not known and needs further studies in
this regard but it has been found that the material in
reusable classic LMAs does not lose its strength after
100 uses to the extent that its manufacturer claims.
At least 100 uses may be considered safe for these
devices14. Another safeguard may be the manufacturer
recommended pre use performance tests consisting of
visual inspection, 180 degree tube flexion test, cuff
overinflation test, airway connector examination,
checking for discolouration, inflation line testing
and mask aperture testing15. These may significantly
decrease the chances of misfolding and malposition
due to device related issues. In our case, the LMA was
being used for the thirty first time and pre use check
had not revealed any obvious abnormality.
It is pertinent to mention improper technique
of insertion as one of the causes of a malpositioned/
misfolded LMA. In our case, we inserted the LMA
using the classic technique as per manufacturer’s
recommendations15 with a fully deflated cuff and were
able to achieve adequate ventilation satisfying the
aforementioned criteria in the very first attempt by an
experienced anesthesiologist using the LMA for past
ten years.
The most common causes of reported
complications of LMA usage including sore throat,
laryngospasm, voice hoarseness, hypoglossal,
lingual nerve injuries16, bilateral vocal cord palsy17,
sialadenopathy18 and arytenoid dislocation19 have been
documented to be either a faulty insertion technique,
or using an undersized LMA with an overinflated cuff
or malposition/misfolding or a combination of these
M.E.J. ANESTH 23 (3), 2015
354
factors20-25.
This case demonstrates that the LMA might be
malpositioned or misfolded in spite of patient being
adequately ventilated and whenever possible, a
fibreoptic view grading should be done to ascertain
the proper position. Further safeguards to prevent
complications include limiting the peak airway
pressures (below 20 cm of water12), using recommended
pre use testing and proper insertion technique. Since
economic considerations cannot be used when reducing
risks: any risk has to be reduced as far as possible
Sidharth Verma et. al
whatever the economic cost26, a possible approach in
minimizing the patient risk might be to use single usage
devices like the LMA Unique. The cost effectiveness
and practicality of doing so may, however, be guided
by the regional and institutional factors. Moreover,
further high power studies are needed to actually
quantify the amount of risk reduction achieved with
these single use devices. The change in the incidence
of malposition and misfolding with increasing number
of uses of LMA also needs to be studied.
References
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and laryngeal mask insertion: a comparison with tracheal intubation.
Anaesthesia; 44:551-4, 1989.
2. Hickey S, Cameron AE, Asbury AJ: Cardiovascular response to
insertion of Brain’s laryngeal mask. Anaesthesia; 45:629-33, 1990.
3. Wilson IG, Fell D, Robinson SL, et al: Cardiovascular responses to
insertion of the laryngeal mask. Anaesthesia; 47:300-2, 1992.
4. Brain AIJ: The laryngeal mask airway: a new concept in airway
management. Br J Anaesth; 55:801-5, 1983.
5. Brain AIJ, Denman WT, Goudsouzian NG: Laryngeal mask airway
instructional manual. San Diego, CA: Gensia Inc., 1995.
6. Brimacombe JR, Brain AIJ: The laryngeal mask airway: a review
and practical guide. London: WB Saunders, 85-95, 1997.
7. Niall Jefferson, Faruque Riffat, John McGuinness, Charlotte
Johnstone: The Laryngeal Mask Airway and Otorhinolaryngology
Head and Neck Surgery. DOI: 10.1002/lary.21768. Laryngoscope
121, 2011.
8. Daniel d’Hulst, John Butterworth, Sebron Dale, Timothy Oaks,
Brian Matthews: Polypoid Hyperplasia of the Larynx Misdiagnosed
as a Malpositioned Laryngeal Mask Airway. Anesth Analg; 99:15702, 2004.
9. Richards JT: Pilot tube of the laryngeal mask airway. Anaesthesia;
49:450-1, 1994.
10.Brimacombe JR: In: Laryngeal Mask Anesthesia-Principles and
Practice (2nd Edn), Saunders, Philadelphia 2005.
11.Khan RM (ed): Supraglottic airway devices. In: Airway
Management-Made Easy. A manual for Clinical Practitioners and
Examinees. Paras Medical Publishers; Hyderabad, 12:82-95, 2005.
12.Brimacombe JR, Berry AM: The Laryngeal Mask Airway. In: The
Difficult Airway I. Anesthesiol Clin N Am; June, 13(2):411-37,
1995.
13.Kundra P, Deepak R, Ravishankar M: Laryngeal mask insertion in
children: a rational approach. Paediatr Anaesth; 13:685-90, 2003.
14.Evan J Goodman, Elizabeth Christenson, Allen M, E. Jane
Ziegler, Bradley R Lewis: Reusable Laryngeal Mask Airways can
be used more than 40 times. Journal of Clinical Anesthesia; 20:10915, 2008.
15.The Laryngeal Mask Company Limited: Instructions for use - LMA
Classic, LMA Flexible, LMA Flexible single use and LMA Unique.
As on http://www.lmana.com/viewfu.php?ifu=15 assessed on 15
March 2014.
16.Ogata J, Minami K, Oishi M, Tamura H, Shigematsu A: The influence
of the laryngeal mask airway on the shape of the submandibular
gland. Anesth Analg; 93:1069-72, 2001.
17.Kazuhira Endo, Youzou Okabe, Yumiko Maruyama, Toshiaki
Tsukatani, Mitsuru Furukawa: Bilateral vocal cord paralysis caused
by laryngeal mask airway. American Journal of Otolaryngology Head and Neck Medicine and Surgery; 28:126-9, 2007.
18.J HyunBaek Ah, T Mirza, JR Gallagher: Transient Bilateral
Submandibular Sialadenopathy secondary to Laryngeal Mask
Airway Placement. Face Mouth & Jaw Surgery: International
Trainee Journal of Oral & Maxillofacial Surgery; 4(1):36-9, 2014.
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European Standards Committee (CEN). Medical Devices Application of Risk Management to Medical Devices (EN IS
14971:2012). Brussels: CEN, 2012.
AIRTRAQ® OPTICAL LARYNGOSCOPE FOR TRACHEAL
INTUBATION IN A PATIENT WITH AN UNCOMMON GIANT
LIPOMA ON THE POSTERIOR ASPECT OF NECK AND
ADDITIONAL RISK FACTORS OF ANTICIPATED DIFFICULT
AIRWAY: A CASE REPORT
Vassilios Dimitriou*, Amr El Kouny***, Mohammed Al Harbi**,
Freddie Wambi***, Nasser Tawfeeq****, Aziz Tanweer***,
Abdulallem Al Atassi**** and Georges Geldhof*****
Patients with restricted neck movement present a difficult airway situation because of
improper positioning and inadequate extension of the atlanto-occipital joint. The Airtraq optical
laryngoscope is a new single use device that permits an indirect view of the glottis without the
need to achieve a direct line of sight by conventional use of the ‘sniffing position’. We present and
discuss a case of uncommon giant lipoma (16x12X10 cm) in the posterior aspect of the neck in
addition with other independent factors of anticipated difficult airway, intubated successfully in the
semi-lateral position with the use of Airtraq®.
Keywords: Intubation, Difficult airway, Lipoma, Laryngoscopes.
Introduction
The Airtraq® optical laryngoscope (AL) (Prodol Ltd. Vizcaya, Spain) is a relatively new
disposable tracheal intubation device, developed to facilitate tracheal intubation in patients with
normal or difficult airways1-5. It is designed to provide a view of the glottis without alignment
of the oral, pharyngeal and tracheal axes. This is due to the exaggerated curvature of the blade
and a series of lenses, prisms and mirrors that transfer the image from the illuminated tip to a
proximal viewfinder. A guiding channel on the right side of the blade acts as a conduit holding
and directing the tracheal tube through the glottis opening when the vocal cords are visualized.
AL is commercially available in three sizes. The larger size 3 utilizing tube sizes 7.0-8.5 internal
diameter (ID), the size 2 utilizing tube sizes 6.0-7.5 ID and the pediatric size utilizing sizes 4.0-5.5
ID according to the manufacturer. The width of the guiding channel in size 3 is 14 mm and in size
2 12 mm. The length of the guiding channel in size 3 and size 2 is 20 and 19 cm, respectively. The
angle between the guiding channel and the blade is 93° in all AL sizes. The extreme curvature of
the blade and the optical components help to visualize the glottis without the need for aligning the
three airway axes, i.e. oral, pharyngeal and laryngeal. It also does not obstruct the endoscopic view
* Professor of Anesthesia, Consultant, Department of Anesthesia, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
** FRCPC, Assistant Professor, Department of Anesthesiology, King Saud University for Health Sciences, Deputy Chairman,
Department of Anesthesia, King Abdulaziz Medical City, Riyadh, Saudi Arabia. E-mail address: harbimk@ngha.med.sa
*** Consultant, Department of Anesthesia, King Abdulaziz Medical City, Riyadh, Saudi Arabia. E-mail address: E-mail address:
azizt@ngha.med.sa, amrkouny@hotmail.com, wambifr@ngha.med.sa
****FRCPC, Assistant Professor, Department of Anesthesiology, King Saud University for Health Sciences, Department of
Anesthesia, King Abdulaziz Medical City, Riyadh, Saudi Arabia, tawfeeqn@ngha.med.sa, aaatassi@yahoo.com
*****Chairman, Department of Anesthesia, King Abdulaziz Medical City, Riyadh, Saudi Arabia, georgesgeldhof@gmail.com
Corresponding author: Vassilios Dimitriou, Professor of Anesthesia, Consultant, Department of Anesthesia, King
Abdulaziz Medical City, Riyadh, Saudi Arabia. Tel: +966596508911. E-mail: vaskdimi58@gmail.com
355
M.E.J. ANESTH 23 (3), 2015
356
Vassilios Dimitriou et. al
of the vocal cord during laryngoscopy because of its
inbuilt conduit for endotracheal tube.
Fig. 2
Restricted head extension represents an important
independent risk factor during laryngoscopy and
tracheal intubation. We present and discuss a case of
restricted head extension due to an uncommon giant
lipoma located in the posterior aspect of the neck and
anticipated difficult airway, intubated with the use of
AL.
Case Report
A female, 42 years old (height: 150cm, weight:
108 kg, BMI: 46 kg/m2), American Society of
Anesthesiologists class II, presented to the surgical
outpatient department with a history of gradually
progressive swelling mass on the posterior aspect of
neck for the last 12 years. On clinical examination and
investigations the diagnosis of lipoma was made and
the patient was planned for excision. Cervical spine CT
showed a giant neck lipoma (16X12X10 cm) without
bony or articular abnormality (Figure 1 and 2).
During preoperative airway assessment, the
morbidly obese patient presented with severely
restricted head extension (45°) due to the giant lipoma,
leading to a very short thyromental distance (4.9 cm).
Mouth opening was small (interincisor distance 3.5
cm) with protruding incisors, leading to Mallampati
scale III. Additionally, the patient reported history of
gastroesophageal regurgitation and obstructive sleep
apnea, without previous history of surgical procedure
under general anesthesia during the last 12 years. An
anticipated difficult airway was confirmed.
Fig. 1
Awake fibreoptic intubation was recommended
for airway management of the anticipated difficult
airway. However, the patient denied to give consent
for awake intubation and so general anesthesia was
planned. The night before the procedure the patient
was given 40mg of esomeprazole and 2h before
surgery metoclopramide 10mg orally. On the table,
standard monitoring was applied and the patient was
put to lie in a semi-lateral position with the back
appropriately supported, in a way to achieve maximal
neck extension and to avoid compression of the
lipoma. After preoxygenation, anesthesia was induced
with i.v. fentanyl 1µg.kg-1 and propofol 2 mg.kg-1.
After confirmation of adequate bag mask ventilation
neuromuscular relaxation was achieved with 1.5
mg.kg-1 of succinylcholine. Cricoid pressure was
applied soon after loss of consciousness and during
intubation, without distorting the laryngoscopy and
view of glottis.
Tracheal intubation was performed by an
experienced anesthetist (instructor in national and
international airway courses) in the use of Airtraq.
An Airtraq® size 2 blade was introduced into the oral
cavity in the midline, over the base of the tongue. The
view of glottis was optimized on the first attempt, which
required vertical lift adjusting maneuver. A 7.5 mm ID
conventional polyvinyl chloride (PVC) endotracheal
tube the tracheal tube was passed through the vocal
cords and the cuff inflated. The tube was then held
in place while the AL was removed. Anesthesia was
maintained with nitrous oxide (66%) and sevoflurane
(1-2%) in oxygen. The intraoperative course was
uneventful and lasted 70min. The lipoma removed
weighted 1.3kg.
USE OF AIRTRAQ LARYNGOSCOPE IN UNCOMMON ANTICIPATED DIFFICULT AIRWAY
Discussion
Airway management is fundamental for safe
anesthetic practice and anesthetists need to be skilled
in airway management techniques. We report a case of
tracheal intubation with the Airtraq® laryngoscope in a
patient with giant neck lipoma and anticipated difficult
airway. The patient presented with a significant number
of independent risk factors indicating anticipated
difficult airway management. These included severely
restricted head extension, decreased mouth opening,
morbid obesity, history of gastroesophageal reflux and
obstructive sleep apnea.
Management of the potential difficult airway
still remains a major challenge. Awake fibreroptic
intubation is considered to be the gold standard and
the safest option in patients of anticipated difficult
airway6. However, this is technically more difficult
and requires adequate experience6. Alternatively,
awake tracheal intubation using the Airtraq® could
be an option7,8. However, even if there were no
technical limitations like in our case, some patients
remain apprehensive about the procedure and refuse
to remain awake. Supraglottic airway devices (SAD)
are of proven value in difficult airway situation.
Nevertheless, the 4th National Audit Project (NAP4)
from the United Kingdom, documented cases of
inappropriate use of SAD to avoid tracheal intubation
resulted in patient morbidity9. In our patient there
were two important limitations for the SAD to be the
primary airway management device. First, the history
of morbid obesity combined with gastroesophageal
reflux and the possible risk of aspiration and second
the site of operation in close proximity with the airway,
that possibly could lead to inadvertent SAD misspositioning during anesthesia9.
Recent reports have demonstrated that the use
of the AL is superior to the Macintosh laryngoscope
in patients at low or increased risk for difficult
intubation3-5. Additionally, the AL has been used
successfully in a number of cases with difficult airway
management, including patients with cervical spine
immobilization10-12, morbid obesity13-14, following
failed tracheal intubation15 in anesthetized patients as
well as in cases where AL was used successfully for
awake tracheal intubation7,8.
357
Head extension is an important point during
laryngoscopy and an adequate extension of the
atlantooccipital joint is important to align the three
axes i.e. oral, pharyngeal and laryngeal. Intubation
in patients with restricted neck movements like
ankylosing spondylitis or in patients with cervical
spine immobilization, therefore present a difficult
airway situation because of improper positioning and
non-alignment of the three axes. The AL is a new
single use device that permits an indirect view of the
glottis without the need to achieve a direct line of sight
by conventional use of the ‘sniffing position’. Actually,
in our case sniffing position was impossible due to the
giant lipoma, restricting severely the head extension.
For this reason the patient was put to lie in a left semilateral position on the table, in order to achieve the
maximal head extension. Additionally, AL has been
used successfully for tracheal intubation in the lateral
position16. Another similar case has been reported
recently with the patient in supine position17.
Following the induction of general anesthesia
and before administering the neuromuscular
blocking agent, adequate face mask ventilation was
confirmed. Prior significant clinical experience with
the use of Airtraq demonstrated that in cases when
tracheal tube was not possible to be directed into the
trachea, optimization maneuvers were attempted7,18.
Optimization maneuvers included extension, rotation
or vertical lift of the AL, with the latter to be used most
commonly like in our case7,18.
The operation site was at the same level and in
close proximity with the airway while the patients’
head was covered. For these reasons, someone
should argue that it should be reasonable to choose a
reinforced tracheal tube. However, conventional PVC
tracheal tube was used instead, taking into account the
increased failure rate with reinforced tracheal tubes
during tracheal intubation, when using Airtraq optical
laryngoscope18.
In conclusion, this case of uncommon giant
lipoma (16x12X10 cm) in the posterior aspect of the
neck in addition with other independent factors of
anticipated difficult airway, was intubated successfully
in the semilateral position with the use of Airtraq®.
M.E.J. ANESTH 23 (3), 2015
358
Vassilios Dimitriou et. al
References
1.SARACOGLU KT, ETI Z, GOGUS FY: Airtraq optical laryngoscope:
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2.NISHIYAMA T: Comparison of the Airtraq, Airway Scope,
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3.MAHARAJ CH, O’CROININ D, CURLEY G, HARTE BH, LAFFEY JG: A
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4.FORD PN, HAMER C, MEDAKKAR S: Use of the Airtraq in the
difficult airway. Eur J Anaesthesiol; 24:730-1, 2007.
5.MAHARAJ CH, COSTELLO JF, HARTE BH, LAFFEY JG: Evaluation
of the Airtraq and Macintosh laryngoscopes in patients at increased
risk for difficult tracheal intubation. Anaesthesia; 63:182-8, 2008.
6.COOK TM, MCDOUGALL-DAVIS SR: Complications and failure of
airway management. Br J Anaesth; 109(51):68-85, 2012.
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using the Airtraq laryngoscope: a case series. Acta Anaesthesiol
Scand; 53:964-7, 2009.
8.SUZUKI A, TOYAMA Y, IWASAKI H, HENDERSON J: Airtraq for awake
tracheal intubation. Anaesthesia; 62:746-7, 2007.
9.COOK T: Supraglottic airway devices. In: Cook T, Woodall N,
Frerk C, editors. 4th National Audit Project of the Royal College of
Anaesthetists and the Difficult Airway Society Major Complications
of Airway Management in the United Kingdom. London: The Royal
College of Anaesthetists; 86-95, 2011.
10.AMOR M, NABIL S, BENSGHIR M, MOUSSAOUI A, KABBAJ S,
KAMILI ND, MAAZOUZI W: A comparison of Airtraq™ laryngoscope
and standard direct laryngoscopy in adult patients with immobilized
cervical spine. Ann Fr Anesth Reanim; 32:296-301, 2013.
11.MAHARAJ CH, BUCKLEY E, HARTE BH, LAFFEY LG: Endotracheal
intubation in patients with cervical spine immobilization.
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Anesthesiology; 107:53-59, 2007.
12.BASARANOGLU G, SUREN M, TEKER GM, OZDEMIR H, SAIDOGLU
L: The Airtraq laryngoscope in severe ankylosing spondylitis. JR
Army Med Corps; 154:77-8, 2008.
13.NDOKO SK, AMATHIEU R, TUAL L, POLLIAND C, KAMOUN W, EL
HOUSSEINI L, CHAMPAULT G, DHONNEUR G: Tracheal intubation of
morbidly obese patients: a randomized trial comparing performance
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14.DHONNEUR G, NDOKO S, AMATHIEU R, HOUSSEINI LE, PONCELET
C, TUAL L: Tracheal intubation using the Airtraq in morbid obese
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106:629-30, 2007.
15.MAHARAJ CH, COSTELLO JF, MCDONNELL JG, HARTE BH, LAFFEY
JG: The Airtraq as a rescue airway device following failed direct
laryngoscopy: a case series. Anaesthesia; 62:598-601, 2007.
16.PENTILAS N, ZOGOGIANNIS I, DOUMA A, LIOTIRI D, DIMITRIOU V:
Tracheal intubation in the right lateral position. A comparative study
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17.ALI QE, SIDDIQUI OA, AMIR SH, AZHAR AZ, ALI K: Airtraq®
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18.DIMITRIOU V, ZOGOGIANNIS I, DOUMA A, PENTILAS N, LIOTIRI
D, WACHTEL M, KARAKITSOS D: Comparison of standard
polyvinyl chloride tracheal tubes and straight reinforced tracheal
tubes for tracheal intubation through different sizes of the Airtraq
laryngoscope in anesthetized and paralyzed patients: a randomized
prospective study. Anesthesiology; 111:1265-70, 2009.
Diagnosis of Aortic Thrombus
After Pelvic Surgery
Kenneth S. Tseng*, Yan H. Lai*
and C hristina L. J eng **
We describe the case of a patient who was found to have an aortic thrombosis while in the
recovery room after an abdominal perineal resection. If not treated early, aortic thrombosis can be
a devastating complication, leading to paralysis, need for amputation, or death. Understanding the
risk factors that pre-dispose patients to thrombosis can allow the anesthesiologist to make an earlier
diagnosis in the recovery room. In addition, patients at high risk of intraoperative thrombosis
may benefit from an anesthetic plan that includes particular attention to patient positioning and
hemodynamic stability.
Case Description
A 62-year-old gentleman with a recto-urethral fistula after radiation for prostate cancer
presented to the operating room for an abdominal perineal resection. His past medical history
included hypertension, diabetes mellitus, chronic renal insufficiency, and tobacco use. His previous
surgeries included a radical cystectomy with an ileal conduit and ureteral stent placement.
The patient was induced with general anesthesia and placed into lithotomy position with
steep Trendelenburg for the duration of the six-hour surgery. The intra-operative blood loss was
approximately 750 mL. Soon after tracheal extubation, the patient began complaining of right leg
pain. He was also unable to move his leg. Both legs were cold to the touch: the right leg was pale,
and the left leg was cyanotic. Dorsalis pedis pulses were not palpable in either leg. Suspecting
acute limb ischemia, the anesthesiologist immediately consulted a vascular surgeon. When multiple
attempts to locate a pulse with Doppler were unsuccessful, the patient was taken for a computed
tomography angiogram, which confirmed the diagnosis of an aortic thrombus beginning above the
bifurcation and extending into both iliac arteries (figure 1). The patient was taken emergently to the
operating room for a thromboembolectomy, approximately five hours after the end of his original
procedure. Three months later, the patient was discharged to a subacute rehabilatation facility,
although he was unable to stand without assistance.
* MD, MPH.
**MD.
Department of Anesthesia, Critical Care & Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
(KST); Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA (YHL, CLJ).
Corresponding author: Kenneth S. Tseng, MD, MPH, Department of Anesthesia, Critical Care & Pain Medicine,
Massachusetts General Hospital, 15 Parkman St WACC 330. Boston, Massachusetts 02114-3117, USA. Phone: 443-5703549, Fax: 617-724-6981. E-mail: kennethtsengmd@gmail.com
359
M.E.J. ANESTH 23 (3), 2015
360
Fig. 1
Computed tomography angiogram (CTA) showing an aortic
thrombus beginning above the bifurcation
(A) and extending into both iliac arteries (B, C).
Kenneth S. Tseng et. al
Discussion
To our knowledge, only one other case report
has described a post-operative aortic thrombosis after
pelvic surgery1. That patient experienced progressive
weakness and decreased sensory function of both
legs after undergoing a low anterior resection. These
symptoms were initially mis-attributed to the patient’s
epidural analgesia. The diagnosis of aortic occlusion
was not made until postoperative day one, when a
femoral pulse could not be palpated in either groin.
Despite successful surgical restoration of blood flow
to salvage the lower extremities, the patient was unable
to ambulate afterwards.
A similar clinical scenario was seen in two other
patients who had post-operative thrombosis of their
indwelling aortic endo-grafts after pelvic surgery2.
Both patients had undergone endovascular repair of
an abdominal aortic aneurysm one week prior to their
colectomy. After the colectomy, both patients had
loss of palpable lower extremity pulses. However,
because the diagnosis was made within two hours
and re-vascularization was performed immediately,
neither patient experienced neurologic or vascular
sequelae. The anecdotal evidence from this limited
number of cases suggests that the avoidance of adverse
consequences requires early diagnosis in the recovery
room and prompt treatment. Studies of spontaneous
acute aortic occlusion have also shown that patients
who have motor or sensory deficits at the time of
diagnosis have a higher chance of adverse events3.
Therefore, it may be prudent to identify patients
preoperatively who are at higher risk of thrombosis
and pre-emptively perform postoperative vascular
checks before motor or sensory symptoms develop.
Acute aortic occlusion often presents with the
signs and symptoms of acute limb ischemia: pain,
pallor, poikilothermia, paresthesia, paralysis, and
pulselessness. In order to avoid mistaking a patient’s
symptoms for a neurologic deficit and delaying
appropriate intervention, physical examination of
the patient with any of the first five “P’s” should
also include a thorough pulse (including Doppler4)
examination, which may be the first indication that
the underlying symptoms are caused by a vascular
etiology and not a neurologic one3.
Aortic thrombosis after pelvic surgery
Spontaneous aortic thrombosis has been
associated with smoking, diabetes, coronary artery
disease, hypertension, hyperlipidemia, chronic renal
insufficiency, atherosclerosis, peripheral artery disease,
cancer, hypercoagulable states, radiation therapy, and
male gender1,3,5-10. Some authors have hypothesized
that thrombosis occurs during low-flow states, such
as with low cardiac output or hypovolemia6, both of
which can occur during surgery.
Patients who present to the hospital on the day
of surgery may be hypovolemic from NPO status or
bowel preparation. Additional intra-operative factors
include extensive surgical dissection or retraction
leading to vascular injury11; prolonged lithotomy
and Trendelenberg position; and compression of legs
from stirrups or serial compression devices. Both of
these latter two factors - lithotomy positioning12 and
serial compression devices13 - have been implicated
361
in compartment syndrome of the lower extremities,
leading to decreased circulation. Although there
have not been any reports of ureteral stents causing
thrombosis, it is also possible that turbulent blood flow
through the common iliac arteries at the point over
which the ureters and stents cross could contribute to
thrombosis.
Some authors have advocated certain measures
to improve circulation to the lower extremities.
Confirming the presence of distal pulses when the
patient is first positioned in the lithomy position
may prevent unnecessary compression of the lower
extremities2. In prolonged procedures in the lithotomy
or Trendelenberg position, intermittently placing the
patient into supine position14 or tilting the table so that
the legs are below the level of the left atrium12,15 may
decrease the duration of time that the lower extremities
are hypoperfused16.
M.E.J. ANESTH 23 (3), 2015
362
Kenneth S. Tseng et. al
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Bilateral superficial cervical blocks as
the primary anesthetic for the patient
undergoing an evacuation of neck
hematoma after parathyroid surgery
Benjamin Heller* and Adam Levine**
Abstract
This is the case of an 80-year-old female who presented for evacuation of a neck hematoma
on POD#3 after a parathyroidectomy. Her medical history included coronary artery disease with
a drug-eluding stent, off aspirin for 2 weeks. She had a significant hematoma from the hyoid bone
extending down to below the suprasternal notch. She reported hoarseness. The anesthesiology
team provided regional anesthesia with bilateral superficial cervical blocks, supplemented with
minimal sedation for patient compliance. The surgical team used no adjuvant local anesthetic. A
deep exploration was performed and significant clot was evacuated. The patient went home safely
from the PACU.
Introduction
Parathyroidectomy is a surgery commonly performed on a daily basis in many hospitals
throughout the United States. The complications of this surgery have been well described and
include postoperative bleeding resulting in hematoma, laryngeal edema, unilateral or bilateral
recurrent laryngeal nerve injury, and hypocalcemia1. Patients may return to the operating room
as a result of these complications, and the anesthesiologist must be prepared to manage these
cases in both an urgent and emergent fashion. Furthermore, otolaryngological surgery is commonly
associated with airway fire risk, and these cases are no exception. For a fire to occur, there needs to
be fuel, oxygen, and an ignition source2. The ASA has released a practice advisory for the prevention
and management of operating room fires3, which includes an operating room fire algorithm for both
the prevention and treatment of this complication.
There are a variety of issues that must be addressed when creating an anesthetic plan for
the patient undergoing evacuation of a neck hematoma. Airway patency is of utmost importance,
but the risk of airway fire and the mangement of co-morbid medical conditions must always be
taken into account. The anesthesiologist’s main duty to the patient is to safely manage the patient
during the intra-operative period, however, if one is able to minimize the risk of post-operative
complications and improve long term patient outcomes, that must be taken into consideration as
well.
*
**
MD, Resident, Icahn School of Medicine at Mount Sinai. E-mail: Benjamin.Heller@mountsinai.org
MD, Professor, Icahn School of Medicine at Mount Sinai. E-mail: adam.levine@mountsinai.org
Institution: Icahn School of Medicine at Mount Sinai.
Corresponding author: Benjamin Heller, MD, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, New
York, NY, 10029. Phone: 212-241-1518, Fax: 212-426-2009. E-mail: Benjamin.Heller@mountsinai.org
363
M.E.J. ANESTH 23 (3), 2015
364
This patient signed written surgical consent
which included a statement regarding publication of
the surgery/treatment/procedure for medical, scientific,
or educational purposes, provided the patient’s identify
is not revealed. Furthermore, the patient was consented
separately for the explicit goal of presentation of the
anesthetic management of this case. The authors of this
case have the original copy of the patient’s consent to
the presentation of this case. Both authors contributed
to the care of this patient.
Case Description
Our case is an 80-year-old female who is
presenting for an evacuation of a neck hematoma. The
patient underwent parathyroid exploration and removal
of right inferior parathyroid adenoma three days prior.
Approximately 36 hours after the surgery, the patient
reported she had a coughing fit and then noticed she
began to have swelling in her neck and hoarseness.
She presented to her surgeon, who performed a flexible
fiberoptic endoscopy. This demonstrated moderate
laryngeal edema, some slight ecchymosis of the left
aryepiglottic fold, normal vocal cord motion, but an
overall clear airway. She was admitted to the hospital
and scheduled for surgery the following morning.
The patient’s medical history was significant
for coronary artery disease with a stent in the left
anterior descending artery, placed 6 years ago. She had
been off of her aspirin for 14 days on the day of this
surgery. Her other medical co-morbidities included
anxiety, non-insulin dependent diabetes mellitus,
hypertension, former smoker, and hyperlipidemia.
She had been NPO since the previous evening, and
had no complications with prior anesthetics. She was
a mallampati 2. Physical exam was significant for a
significant hematoma extending from the hyoid bone
down to below the suprasternal notch (Figure 1).
A discussion was had with the patient, the
anesthesiology team, and the surgical team. The
patient noted that she was a singer, and manipulation
of her vocal cords was of concern to her. The patient
was motivated, and was amenable to a regional
technique. The risks and benefits were explained to
the patient, and it was emphasized that conversion to
general anesthesia would be at the discretion of the
anesthesiology team.
Benjamin Heller, et. al
The patient was brought into the operating room
and standard ASA monitors were applied. A fiberoptic
tower was in the room, along with an arterial line setup.
Glycopyrolate 0.2mg was given in case conversion to
general anesthesia was required. The patient was given
a bolus of 20mcg of remifentinil for comfort during
block placement. Bilateral superficial cervical blocks
were placed, with 15ml of 0.5% bupivacaine injected
on each side. A low dose remifentinil infusion was
started at 0.05mcg/kg/min for patient compliance and
to prevent movement during the surgery. A bolus of
30mcg of remifentinil was given before the start of
surgery to assist with immobility.
Surgery was performed successfully with a deep
exploration of the neck and evacuation of a significant
amount of clot (Figure 2). No supplemental local
anesthetic was given by the surgical team, and no
adjuvant bolus sedation was required. The infusion
of remifentinil was maintained between 0.02mcg/kg/
min and 0.05mcg/kg/min. The patient was awake,
responding appropriately to commands, breathing
spontaneously, and comfortable throughout the
procedure.
Of note, as demonstrated in figure 3, we created
a unique apparatus designed to provide the patient
with oxygen but to minimize the risk of airway fire.
The nasal cannula provided the oxygen, the face tent
provided the barrier, and the suction at the top of the tent
eliminated risk of oxygen pooling. The combination of
entrapped oxygen and electrocautery was concerning;
therefore, this apparatus was created, and the surgical
team used minimal cautery.
Discussion
This case presents multiple issues that the astute
anesthesiologist must consider. The most concerning is
the patient’s airway. The patient had a significant neck
hematoma, and reported new hoarseness. However,
she had been stable on the floor overnight, with no
acute changes. Since this patient was off of aspirin for
2 weeks, it is possible her risk of cardiac complications
was increased, as at least one randomized, double
blind, placebo-controlled study has shown in highrisk patients undergoing non-cardiac surgery that
perioperative aspirin reduces the risk of major adverse
Bilateral superficial cervical blocks as the primary anesthetic for the patient
undergoing an evacuation of neck hematoma after parathyroid surgery
365
Fig. 1
Demonstrates the extent of the hematoma in this
patient, extending from the hyoid bone down to
below the suprasternal notch.
Fig. 2
A deep exploration of the neck and evacuation of
a significant amount of clot was performed.
Fig. 3
We created a unique apparatus designed to
provide the patient with oxygen but to minimize
the risk of airway fire. The nasal cannula
provided the oxygen, the face tent provided the
barrier, and the suction at the top of the tent
eliminated risk of oxygen pooling.
M.E.J. ANESTH 23 (3), 2015
366
cardiac events4. While the surgical stress is not
attenuated with this technique, general anesthesia may
incur increased risk from variations in blood pressure
and manipulation of the airway. The authors had to
weigh this risk against the risk of having to convert
to general anesthesia intra-operatively. Our patient was
motivated, and preferred as little airway manipulation
as possible. We have good rapport with our surgeon,
who was confident the surgery could be performed in
a short period of time. We decided to proceed with a
regional anesthetic, and had all the materials necessary
to convert to a general anesthetic if it was required.
Furthermore, we were aware of the risk of airway
fire in this surgery. Typically, in a general anesthetic it
is possible to turn the oxygen down to minimize the
Benjamin Heller, et. al
oxidative source. Our patient was awake, and although
there was minimal risk of an accumulation of oxygen,
we made a unique apparatus that applied suction
near the patient, minimizing oxygen building and the
rebreathing of carbon dioxide. This decreased the risk
of operating room fire in this head and neck monitored
anesthetic care case.
In conclusion, this case was unique in that a
regional anesthetic was given to prevent manipulation
of a possibly tenuous airway, and to possibly lower the
cardiac risk that this patient was likely incurring having
been off aspirin for 2 weeks. Careful planning between
the anesthesiology and surgical teams, combined with
thorough preparation, contributed to the success of this
plan, and a positive outcome for this patient.
References
1. Porter Steven Schwartz, Andrew De Maria, Samuel Jr and Eric M
Genden: 14 Thyroid, Parathyroid, and Parotid Surgery. In: Levine,
Adam I., Satish Govindaraj, and Jr Samuel De Maria. Anesthesiology
and Otolaryngology; Dordrecht: Springer, 217-40, 2011.
2. Cohen Neal H, Ronald D Miller, Lars I Eriksson, Lee A Fleisher,
Jeanine P Wiener-Kronish and William L Young: Miller’s
Anesthesia. 8th edition. Philadelphia: Elsevier/Saunders, 2015.
Accessed via Icahn School of Medicine at Mount Sinai online
library on March 14, 2015.
3. Practice Advisory for the Prevention and Management of Operating
Room Fires. Anesthesiology 118.2 (2013): n. pag. Committee
on Standards and Practice Parameters. Web. Available at: http://
www.asahq.org/~/media/Sites/ASAHQ/Files/Public/Resources/
standards-guidelines/practice-advisory-for-the-prevention-andmanagement-of-operating-room-fires.pdf. Accessed March 14,
2015.
4. Oscarsson A, Gupta A, Fredrikson M, Järhult J, Nyström M,
Pettersson E, Darvish B, Krook H, Swahn E, Eintrei C: To continue
or discontinue aspirin in the perioperative period: a randomized,
controlled clinical trial. Br J Anaesth; Mar, 104(3):305-12. doi:
10.1093/bja/aeq003, 2010.
Extra Corporeal Membrane Oxygenation in
Acute Respiratory Distress Syndrome
Manjush Karthika*, Farhan Al Enezi**,
Lalitha V. Pillai***, Salem Al Qahtani****
and S ami A l S olamy *****
Abstract
A young female presented with pneumonitis and worsened acute respiratory distress syndrome
(ARDS) failed all the conservative ventilator management, was managed with extra corporeal life
support technology, and was successfully discharged.
Keywords: Extra Corporeal Membrane Oxygenation (ECMO); Acute Respiratory Distress
Syndrome (ARDS).
The Case
A 15 year old female, known case of chronic inflammatory demyelinating polyneuropathy,
presented to emergency room (ER) on 02/01/2013 with chief complaints of shortness of breath,
chest pain, fever, vomiting and diarrhea for 3 days. Her condition worsened in the ER due
to respiratory distress, hypoxia and shock. Eventually she was intubated and mechanically
ventilated. Post intubation chest x-ray (CXR) showed right upper zone pneumonia and she was
shifted to intensive care unit (ICU) where she was managed with lung protective ventilation,
antibiotics, antivirals and all other supportive critical care measures. Initial Ventilator settings
were assist- pressure control mode with inspiratory pressure set between 26 - 30 cmH2O,
fraction of inspired oxygen (FiO2) of 0.9, positive end expiratory pressure (PEEP) of 12 cmH20,
respiratory frequency of 22 with an I:E of 1:2. Her ideal body weight (IBW) was 46 kg. Tidal
volume generated was 160-200, which was just adequate. The patient was severely hypoxemic
with oxygen saturation (SpO2) of 85-88%. Arterial blood gas (ABG) reported P/F ratio of 90 with
mild acidosis. Repeat CXR revealed worsening of right lung opacity and bronchoscopy was done
to rule out any collapsed segment. Lung recruitment maneuvers with CPAP of 35 - 40 cmH2O for
40 seconds were performed in view of recurrent severe oxygen desaturation and hypoxemia. The
same management continued on 03/01/2013, and the frequency of recruitment maneuvers was
increased. Recruitment maneuvers resulted in transient improvement of SpO2. On 04/01/2013
*
Faculty of Health and Biomedical Sciences, Symbiosis International University, Pune, India. King Saud Bin Abdulaziz
University for Health Sciences, Riyadh, Saudi Arabia: manjushnair@hotmail.com
** King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia: farhan03@yahoo.com
Corresponding author: Dr. Farhan Al Enezi, ICU Consultant, Department of Intensive Care Medicine, King Abdulaziz
Medical City, King Saud Bin Abdulaziz University of Health Sciences, Ministry of National Guard Health Affairs, Riyadh,
Saudi Arabia. Tel: 0555944877. E-mail: farhan03@yahoo.com
*** Department of Critical Care Medicine, Aundh Institute of Medical Sciences, Pune, India. Faculty of Health and Biomedical
Sciences, Symbiosis International University, Pune, India: lalithapillai29@rediffmail.com
****King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia: s2alrubaii@yahoo.com
***** Emergency Medicine and Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences, King
Abdullah International Medical Research Center, Riyadh, Saudi Arabia: SolamyS@ngha.med.sa
367
M.E.J. ANESTH 23 (3), 2015
368
Farhan Al Enezi et. al
Chest X-rays
Fig. 1
02/01/2013- Initial CXR
Fig. 2
04/01/2013- Worsened CXR
Fig. 3
04/01/2013 CXR Post ECMO cannulation
Fig. 4
08/01/2013-CXR improving
Fig. 5
14/01/2013-CXR, Post ECMO decannulation
Fig. 6
24/01/2013-CXR, 3 days after extubation
ECMO in ARDS
hypoxia and shock worsened and vasopressors
were stepped up. CXR also worsened with bilateral
infiltrates. High frequency oscillatory ventilation
(HFOV) was initiated with FiO2 of 1.0; Frequency of
6.0 Hz.; amplitude ensured adequate chest wiggle and
continuous distending pressure (CDP) of 35 cmH2O.
In spite of this, hypoxemia was persistent. The patient
suffered a cardiac arrest (pulseless electrical activity
for 3 minutes, secondary to severe hypoxia) and was
resuscitated. Mean arterial pressure (MAP) of >65
mmHg was achievable with maximal vasopressor
support. All conventional lung protective strategy,
recruitment maneuvers and HFOV failed to improve
oxygenation. The decision to initiate Veno-Venous
Extra Corporeal Membrane Oxygenation (VV ECMO)
was made in view of severe refractory hypoxemia.
The circuit was primed with crystalloid, plasma and
heparin. The right internal jugular vein (Rt. IJV) was
cannulated with 19F cannula and right femoral vein
with 25F cannula. The cannulation procedure was
uneventful. Settings were as follows: ECMO Flow:
4.5 to 5.5 LPM (120-150 ml/kg/min); Targeted ACT:
180-220 sec; FiO2: 100%; Sweep Gas: 4 LPM;
Temperature: 360 C. The patient was kept on minimal
ventilator settings with a minimal PEEP of 5 cmH2O,
low tidal volume (4-6 ml/kg IBW) and respiratory
rate of 18. On 05/01/2013, patient’s oxygenation
status started to improve with stable hemodynamics,
and subsequently the inotropic support was stepped
down. Virology panels were negative for H1N1.
There were no clear improvement in CXR and
hence bronchoscopy was done again to rule out lung
collapse. Infection control practices and nutritional
support were strictly followed. On 08/1/2013, the
CXR started to improve and Glasgow coma scale
(GCS) was 9/15T. A pig tail catheter was inserted for
right pleural effusion on 09/01/2013. The following
days were uneventful with steady improvement
in oxygenation. On 13/01/2013 morning, CXR
revealed that Rt. IJV cannula was slipped out about
6 cm, and was reinserted with no adverse events. On
14/01/2013, weaning from ECMO was initiated, as
the patient showed significant clinical improvements.
CXR showed significant clearance of lung fields and
patient was maintaining a SpO2 of 95% on ECMO
FiO2 of 0.6, Arterial blood gas parameters were
acceptable with a partial pressure of arterial oxygen
369
(PaO2) of 102 mmHg and a MAP of >80 mmHg with
no vasopressors. On the morning of 15/01/2013,
oxygen challenge test was performed. Ventilator FiO2
was increased to 1.0 for 15 minutes and a subsequent
ABG showed a PaO2 of 180, which marked oxygen
challenge test as satisfactorily positive. ECMO FiO2
was decreased to 0.21 and eventually the ECMO
machine was stopped and later the patient was
decannulated. The patient was hemodynamically
stable and maintained good oxygenation on minimal
ventilator setting. The patient was successfully
liberated and extubated on 21/01/2013 and post
extubation phase was uneventful. On 04/02/2013,
patient was shifted out to ward and rehabilitation
phase was started. The patient was discharged home
on 17/03/2013.
Discussion
There are many conservative adjuncts in
treating patients with severe ARDS like recruitment
maneuvers, prone positioning, aggressive diuresis,
high frequency ventilation, shunt reduction
techniques and extra corporeal life support as a last
resort. ECMO is a re-evolving life support technology
which has been in use for 40 years. There is a general
consensus about the use of extra corporeal life support
in neonatal and pediatric population with reversible
cardiorespiratory failure1. The supportive evidence
for its extensive use in adults has only emerged in
the recent past, with the publication of the CESAR
(Conventional ventilatory support vs extracorporeal
membrane oxygenation for severe adult respiratory
failure) trial2 and a report of large number of H1N1
ARDS patients treated with ECMO3. Currently
ECMO has become more reliable across the world
with improved technology and increased experience,
which has reflected in improved outcome. The
Australian and CESAR studies suggest that ECMO
can indeed save lives as a rescue therapy when
conventional methods fail2,3. Of note ECMO can be
considered as a supportive therapy rather than disease
modifying treatment and best results are obtained if
we choose the right patient, with the right mode and
configuration at the right time.
M.E.J. ANESTH 23 (3), 2015
370
Farhan Al Enezi et. al
References
1. Mugford M, Elbourne D, Field D: Extracorporeal membrane
oxygenation for severe respiratory failure in newborn infants.
Cochrane Database Syst Rev; 3:CD001340, 2008.
2. Giles J Peek of Glenfield Hospital, Leicester, U.K, and his
associates in the Conventional Ventilation or ECMO for Severe
Adult Respiratory Failure (CESAR) trial. Lancet; Sept., 16, 2009.
3.Andrew Davies, John Beca, Rinaldo Bellomo, et al: Extracorporeal
membrane oxygenation for 2009 influenza A (H1N1) acute
respiratory distress syndrome. JAMA; Oct., 12:302(17), 2009.
LETTER TO THE EDITOR
Seven-Day Hospital Model: A Futuristic
Actuality
Deepak Gupta MD*
As medicine realizes and accepts that it has been theoretically and financially surviving on
corporate business menu card for some time now, it will have to eventually imbibe the futuristic
actuality of seven-day hospitals that will run full-fledged round-the-clock (a full-fledged
advancement on New York University Langone Medical Center’s concept of working weekends)1.
Firstly, it is time to understand that there has been a lot of data2-10 suggesting that patients may
be likely to face higher risks of in-hospital morbidity and mortality during weekends most likely
secondary to the fewer human resources during weekends. Then there is the other side of the
coin wherein hospitals are potentially losing money1 because of non-functioning to minimally
functioning weekends suggesting hospital infrastructures are primarily-to-exclusively utilizing
5-out-of-7 days in each week with personnel’s vacationing/weekending forcing worksites’ major
shutdowns on weekends every week. To complicate it further, there is constant non-resolving
debate about deeming appropriateness to electivity of procedures/interventions11 and separating
elective procedures-from-emergency procedures12. Finally, there is innovative/creative concept of
doing “free” elective surgeries/procedures on Sundays and Saturdays13-14 for non-insured or poorly
insured patients so as to avoid the costs borne by the hospitals in the event of elective surgeries/
procedures deteriorating into emergencies and presenting into emergency rooms for non-covered/
insured immediate-mandated medical management.
The futuristic seven-day MODEL should be based on the “Three Patterns for all” (each and
every personnel working in the hospital): Mon-Fri AND Tue-Sat AND Sun-Thu. For non-biased
rotation across the three patterns, the personnel will be mandated to follow monthly change: MonFri THEN Tue-Sat THEN Sun-Thu. If somebody is only working four-days-a-week, then they will
have to choose similarly but the monthly rotation will have to include at least one true weekend day
per rotation cycled over every four months rather than the cycled rotation every three months in
the case of five-days-a-week workers. So four-days-a-week workers will have to follow Mon-Thu
THEN Tue-Fri THEN Wed-Sat THEN Sun-Wed. This will ensure that each person has one true
weekend day. Additionally, mandatory monthly rotation will have to accommodate annual rotation
so as to take long weekends’ months into consideration. Moreover, if a person is working less than
7-days in a month due to any reason (like long vacations), that month will have to be excluded from
the monthly rotation’s account.
*
Department of Anesthesiology, Wayne State University/Detroit Medical Center Detroit, Michigan, United States.
Corresponding author: Dr. Deepak Gupta. Box No. 162,3990 John R, Detroit, MI 48201, United States. Tel: 1-313-7457233, Fax: 1-313-993-3889. E-mail: dgupta@med.wayne.edu
371
M.E.J. ANESTH 23 (3), 2015
372
As all seven-days will be deemed as weekdays
for hospital personnel, there will not be be any
requirements for extra incentives/payments for
working on true weekend days. The rationale behind
this is that each personnel will be mandated to have
2-contiguous-days off each week (their personal
“weekend” each week) plus their annual job-specific
vacation days. Now the situation may arise that despite
opening the scheduling for all seven days-a-week for
elective admissions/procedures/surgeries, the true
weekend days (Saturdays and Sundays) may see less
patient/clientele traffic in the hospitals if patients
want to enjoy their own weekends instead of being
in a hospital; however, that will not preclude those
true weekend days from acting as weekdays for the
hospital personnel’s staffing. The only thing that can be
accommodated irrespective of it being a true weekday
or true weekend day will be the option of paying per
hour across the board so that when relieved from
duty due to paucity of clientele traffic, the hospital
personnel can enjoy home. Coming to work and going
home early will not mean that it was NOT a holiday
because there will be a mandatory personal weekend
per week anyway. As far as immovable infrastructure
of the hospitals is concerned, the only true holidays
for them will be for regularly mandated maintenance
(and an additional bonus of vacations for the personnel
during that maintenance periods if those time periods
are NOT miniscule).
Alternately in terms of limitations of the
seven-day hospital MODEL, it may happen that true
weekend days may see increased footfalls of the
patients in the hospitals to take advantage of the fully
functioning hospitals being open on true weekend days
so that patients can avoid wasted sick-leave days in the
event of elective procedures being scheduled on true
weekdays. Moreover, the additional reasons why true
weekends may not be considered and may not evolve
as weekdays for the hospital personnel is that though
the equipment costs will be the same, the personnel
costs may be demanded higher because true weekends
were invented to accommodate the humane need for
“weekly” break off the work-routine (some may even
Deepak Gupta
say that they could have been invented to match to
even out with the seven-day lunar phases of waxing
crescent, waxing gibbous, waning gibbous and waning
crescent) and simultaneous advent of weekend social
activities to rejuvenate exhausted personnel for their
next weekly work-routine. So even though personal
weekends will ensure the “weekly” break off for the
hospital personnel but these personal weekends may
frequently fall on non-Saturdays-non-Sundays when
everyone else is working and they are “holidaying”
and vice-a-versa. How hospital personnel will enjoy
“weekends” with paucity of week-end activities as
week-end activities will not be planned according
to the hospital personnel’s working patterns until
and unless “Three Patterns for all” percolates into
all business activities of the societies so that there
are always long weekends’ activities from Fridays
to Mondays round-the-year for accommodating the
work-schedules of Sun-Thu AND Mon-Fri AND TueSat across the societies. The pro-business aptitude of
the society may further want to envisage a future of
opening even night-times for scheduling the elective
admissions/procedures/surgeries (converting fully
functioning seven-day hospitals to fully functioning
24x7 hospitals). However, this model or any model
for that matter will NOT be able AND should NOT
be allowed to override the physiological needs of
maintaining daily circadian rhythms of the human
beings including the patients themselves because even
the inanimate equipment and infrastructure needs a
daily downtime (nighttime that is by nature devoid of
sunlight) for proper functioning day-in-day-out and
human brains and bodies are no different from the
computerized brains and robotic hands.
In summary, the time may be ripe to consider
this futuristic actuality of seven-day hospitals model
wherein complete hospital’s infrastructure is functional
round the year with each day being non-unique as far
as for catering/welcoming the patients/clientele while
accommodating and non-compromising the provisions
of weekly personal “weekends” of the hospitals’
personnel.
Seven-Day Hospital Model: A Futuristic Actuality
373
References
1. NYTimes.com [homepage on the Internet]. New York City, New
York: The New York Times Company c 2015 [updated 2010
October 3; cited 2015 March 13]. Health care’s lost weekend (By
Peter Orszag) [about 1 screen]. Available from: http://www.nytimes.
com/2010/10/04/opinion/04orszag.html?_r=1&
2. McIsaac DI, Bryson GL, Van Walraven C: Elective, major
noncardiac surgery on the weekend: a population-based cohort study
of 30-day mortality. Med Care; 52:557-564, 2014.
3. Aylin P, Alexandrescu R, Jen MH, Mayer EK, Bottle A: Day
of week of procedure and 30 day mortality for elective surgery:
retrospective analysis of hospital episode statistics. BMJ; 346:f2424,
2013.
4. Palmer WL, Bottle A, Davie C, Vincent CA, Aylin P: Weekend
admissions and increased risk for mortality: less urgent treatments
only?- Reply. JAMA Neurol; 70:132-133, 2013.
5. Palmer WL, Bottle A, Davie C, Vincent CA, Aylin P: Dying for the
weekend: a retrospective cohort study on the association between
day of hospital presentation and the quality and safety of stroke care.
Arch Neurol; 69:1296-1302, 2012.
6. Mohammed MA, Sidhu KS, Rudge G, Stevens AJ: Weekend
admission to hospital has a higher risk of death in the elective setting
than in the emergency setting: a retrospective database study of
national health service hospitals in England. BMC Health Serv Res;
12:87, 2012.
7. Dasenbrock HH, Pradilla G, Witham TF, Gokaslan ZL, Bydon
A: The impact of weekend hospital admission on the timing of
intervention and outcomes after surgery for spinal metastases.
Neurosurgery; 70:586-593, 2012.
8. Freemantle N, Richardson M, Wood J, Ray D, Khosla S,
Shahian D, Roche WR, Stephens I, Keogh B, Pagano D: Weekend
hospitalization and additional risk of death: an analysis of inpatient
data. J R Soc Med; 105:74-84, 2012.
9. Aylin P, Yunus A, Bottle A, Majeed A, Bell D: Weekend mortality
for emergency admissions. A large, multicentre study. Qual Saf
Health Care; 19:213-217, 2010.
10.Clarke MS, Wills RA, Bowman RV, Zimmerman PV, Fong KM,
Coory MD, Yang IA: Exploratory study of the ‘weekend effect’
for acute medical admissions to public hospitals in Queensland,
Australia. Intern Med J; 40:777-783, 2010.
11.Ghomrawi HM, Schackman BR, Mushlin AI: Appropriateness
criteria and elective procedures-total joint arthroplasty. N Engl J
Med; 367:2467-2469, 2012.
12.Surgeons.org [homepage on the Internet]. East Melbourne, Victoria,
Australia: Royal Australasian College of Surgeons c2011 [updated
2011 May; cited 2015 March 13]. The case for the separation of
elective and emergency surgery [about 1 screen; 12 pages]. Available
from: https://www.surgeons.org/media/307115/sbm_2011-05-24_
separating_elective_and_emergency_surgery.pdf
13.
MarketPlace.org [homepage on the Internet]. Los Angeles,
California: American Public Media c2015 [updated 2014 May 6;
cited 2015 March 13]. Hospitals save money by doing surgery for
free (By Adam Ragusea) [about 1 screen]. Available from: http://
www.marketplace.org/topics/health-care/hospitals-save-moneydoing-surgery-free
14.
SurgeryOnSunday.org [homepage on the Internet]. Lexington,
Kentucky: Surgery On Sunday c2015 [updated 2015 January 16;
cited 2015 March 13]. Homepage [about 1 screen]. Available from:
http://www.surgeryonsunday.org/
M.E.J. ANESTH 23 (3), 2015
Does cisatracurium at a clinical dose
attenuate the immunosuppression after
surgery in smoking patients with
non-small cell lung cancer?
Wen-qin Sun*, Dao-Bo Pan*, Ai-Guo Zhou*
and H ong M o *
Immunosuppression is a feature of the postoperative stress response and is associated with
anesthesia, blood transfusion, hypothermia, mechanical ventilation, and the patient’s underlying
disease1-2. There is a shift from a T helper cell 1 (Th1) to a Th2 immune response in those patients
with non-small cell lung cancer after surgery, which appears to be associated with infections,
sepsis, and cancer formation and progression3.
Cisatracurium is a benzyl isoquinoline non-depolarizing muscle relaxant, which is widely
used during anesthesia due to its Hofmann degradation independent of liver and kidney functions,
no release of histamine and its intermediate duration4. It is well known that nicotine can inhibit
immune function and attenuate systemic inflammatory responses via activating α7 nicotinic
acetylcholine receptors (nAChRs), which is termed the cholinergic anti-inflammatory pathway5.
Besides blocking muscle nAChRs, non-depolarizing muscle relaxants, such as d-tubocuratine, can
also block α7 nAChRs expressed on multiple-type cells in vitro6, but limited data is available in
clinical settings.
The hypothesis
Cisatracurium at clinical dose may be useful in attenuating postoperative immunosuppression
in smoking patients with non-small cell lung cancer.
Evaluation of the Hypothesis
Nicotinic acetylcholine receptors (nAChRs) are composed of five receptor subunits,
including α1 to α10, β1 to β4, γ, δ, and ε, which form ligand-gated ion channels7. According to
their physiological distribution, nAChRs are classified as either muscle or neuronal nAChRs8. In
neurons, α7 nAChR assembles as a homopentamer composed of five individual α7 subunits that
form a central pore with ligand binding at subunit junctions. α7 nAChR also widely expressed
in human immune cells, including T lymphocytes, B lymphocytes, dendritic cells, monocytes,
macrophages, neutrophils, and microglia cells9-12. These receptors play an important role in
controlling angiogenesis, apoptosis of T cells, and the development and antibody secretion of B
cells as well as down-regulating proinflammatory cytokine synthesis in macrophages and glial
cells13-14.
*
MD, Department of Anesthesiology, The First People’s Hospital of Changde, Changde, China.
Corresponding author: Dr. Sun, Department of Anesthesiology, The First Affiliated Hospital of Changde, 388# People’s
East Road, Changde 415003, China. Tel & Fax: +86 7367788088. E-mail: 15873666967@ 163.com
375
M.E.J. ANESTH 23 (3), 2015
376
Nicotine, the main addictive component of
tobacco, binds to various subtypes of nicotinic
acetylcholine receptors that are expressed on
neurons and some non-neuronal cells, such as α7
nAChRs in immune cells. Activation of α7 nAChRs
by nicotine leads to elevated intracellular calcium
levels sufficient to active signal transduction
pathways that suppress innate and adaptive immune
responses15. Nicotine reduces T cell proliferation
and the production of Th1 and Th17 cytokines16 and
enhances immunosuppressive function of CD4+CD25+
Tregs via α7 nAChR17. There are also reports on the
inhibition of antigen presentation of dendritic cells
and disruption of their ability to induce Th1 lineage
differentiation by nicotine18-19. It has been reported that
chronic exposure to nicotine up-regulates expression
of α7 nAChRs on circulating monocytes in humans
and CD4+ T cells in mice16,20. Therefore, smoking
deteriorates the immune system function in patients
with lung cancer. The effects of cisatracurium on the
immune response in patients with lung cancer after
surgery has not been well established. Cisatracurium is
able to block α7 nAChRs on immune cells because it
has a similar chemical structure and more potent effect
compared with d-tubocuratine which is conformed
to block α7 nAChRs6. We hypothesize that nicotine
induced immunosuppression may be attenuated due to
antagonizing α7 nAChRs on human peripheral blood
Wen-qin Sun et. al
mononuclear cells by cisatracurium, thus protecting
against the postoperative immunosuppression in
smoking patients with lung cancer.
Consequences of the Hypothesis and
Discussion
If α7 nAChRs on peripheral immune cells
are blocked by cisatracurium at clinical dose, it
would very likely affect systemic immunity, such as
enhancing Th1-type cytokines production, inducing
Th1-type lymphocyte differentiation and proliferation,
weakening CD4+CD25+ regulatory T cells suppressive
activity. Therefore, the administration of cisatracurium
or other non-depolarizing muscle relaxants to smoking
patients with non-small cell lung cancer during surgery
should be given great importance and a continuous
infusion with a deeper level of neuromuscular blockade
is recommended.
In
conclusion,
the
postoperative
immunosuppression in smoking patients with nonsmall cell lung cancer may be attenuated by continuous
infusion of cisatracurium during surgery. Nondepolarizing muscle relaxants may play an important
role in regulating postoperative immue response in
smoking patients with non-small cell lung cancer and
may lower the risk for tumor development and enhance
the clinical outcome of surgical treatment.
Cisatracurium and immunosuppression in smokers
377
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Cholinergic agonists inhibit HMGB1 release and improve survival
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M.E.J. ANESTH 23 (3), 2015
GUIDELINES FOR AUTHORS
The Middle East of Anesthesiology publishes original
work in the fields of anesthesiology, intensive care, pain, and
emergency medicine. This includes clinical or laboratory
investigations, review articles, case reports and letters to the
Editor.
Submission of manuscripts:
The Middle East Journal of Anesthesiology accepts
electronic submission of manuscripts as an e-mail attachment
only.
Manuscripts must
attachment to:
be
submitted
via
email
Editor-In-Chief,
Department of Anesthesiology,
American University of Beirut Medical Center
Beirut, Lebanon
E-mail: meja@aub.edu.lb
Human Subjects
Manuscripts describing investigations performed in
humans must state that the study was approved by the appropriate
Institutional Review Board and written informed consent was
obtained from all patients or parents of minors.
Language:
Articles are published in English.
Manuscript Preparation
Manuscript format required:
Double-spaced lines
Wide margins (1.5 inches or 3.8 cm)
Page numbers start on title page
Word count should reflect text only (excluding abstract,
references, figures and tables).
Editorial
1500
Abstract
250 (General articles)
100 (Case Reports)
Clinical or laboratory investigations:
The following structured format is required:
1. Cover Letter
7. Discussion
2. Title page
8. Acknowledgements
3. Abstract
9. References
4. Introduction
10. Tables
5. Methods
11. Figures
6. Results
1. Cover Letter
Manuscripts must be accompanied by a cover letter,
signed by all authors and stating that:
- All authors have contributed intellectually to the
manuscript and the manuscript has been read and
approved by all the authors.
- The manuscript has not been published, simultaneously
submitted or accepted for publication elsewhere.
2. Title Page
Starts at page 1 and includes:
- A concise and informative title (preferably less than 15
words). Authors should include all information in the
title that will make electronic retrieval of the article both
sensitive and specific.
- Authors listing: first name, middle initial and last name
with a superscript denoting the academic degrees as
footprints.
- The name of the department(s) and institutions(s) to
which the work should be attributed.
- The name, address, telephone, fax numbers and e-mail
address of the corresponding author.
- Disclose sources of financial support (grants, equipment,
drug etc…).
- Conflict of interest: disclosure of any financial
relationships between authors and commercial interests
with a vested interest in the outcome of the study.
- A running head, around 40 characters.
- Word count of the text only (excluding abstract,
acknowledgements, figure legends and references).
Review article
4000
Original article
3000
Case Reports
800
3. Abstract
Letter to Editor
500
Abstract should follow the title page. It should be
structured with background, methods, results and conclusion.
M.E.J. ANESTH 23 (3), 2015
It should state, the specific purpose of the research or
hypotheses tested by the study, basic procedures, main findings
and principal conclusions.
Provide separate word count for the abstract.
4. Introduction
Provide the nature of the problem and its significance.
State the specific purpose or research objectives or hypothesis
tested. Provide only directly pertinent references and do not
include data or conclusions from the work being reported.
5. Methods
A. Selection and description of participants:
- Describe selection of participants (including controls)
clearly, including eligibility and exclusion criteria.
B. Technical information:
-Identify the methods, apparatus (give the
manufacturer’s name and address in parentheses),
and procedure in sufficient detail to allow others
to reproduce the results. Give references to
established methods. Provide references and brief
descriptions for methods that have been published.
Identify precisely all drugs and chemicals used,
including generic names(s), dose(s) ands routes(s)
of administration.
C. Statistics-describe statistical methods with enough
detail to enable a knowledgeable reader with access to
the original date to verify the reported results. Define
statistical terms, abbreviations and most symbols.
Specify the computer software used. Provide a power
analysis for the study.
6. Results
Present your results in logical sequence in the text, tables
and illustrations, giving the main or most important findings
first. Do not repeat all the data in the tables or illustrations
in the text: emphasize or summarize only the most important
observations. Extra or supplementary materials and technical
details can be placed in an appendix.
7. Discussion
Emphasize the new and important findings of the study
and the conclusions that may be drawn.
Do not repeat in details data or other information given
in the Introduction or the Results sections. For experimental
studies, it is useful to begin the discussion by summarizing
briefly the main findings, then explore possible mechanisms or
explanations for these findings, compare and contrast the results
with other relevant studies. State the limitations of the study,
and explore the implications of the findings for future research
and for clinical practice. Link the conclusions with the goals of
the study, but avoid unjustified statements and conclusions not
adequately supported by the data.
8. Acknowledgements
They should be brief. Individuals named must be given
the opportunity to read the paper and approve their inclusion in
the acknowledgments.
9. References
- References should be indicated by Arabic numerals in
the text in the form of superscript and listed at the end
of the paper in the order of their appearance. Please be
accurate, giving the names of all authors and initials, the
exact title, the correct abbreviation of the journal, year of
publication, volume number and page numbers.
- The titles of journals should be abbreviated according
to the style used in the list of Journals Indexed for
MEDLINE.
Example: (1) from a journal (2) from a book.
1.SHAWW: AND ROOT B: Brachial plexus anesthesia
Comparatives study of agents and techniques. Am. J.
Surg.; 1951, 81:407.
2. ROBINSON JS: Modern Trends in Anaesthesia, Evans
and Gray Ch. 8, Butterworth Pub. Co., London 1967.
10. Tables
Tables capture information concisely and display it
efficiently: They also provide information at any desired level
of details and precision. Including data in tables rather than text
frequently makes it possible to reduce the length of the text.
- Type or print each table with double spacing on a separate
sheet of paper.
- Number tables consecutively in the order of their first
citation in the text.
- Supply a brief title for each.
- Place explanatory matter in footnotes, not in the
heading.
- Explain all nonstandard abbreviations in footnotes.
- Identify statistical measures of variations, such as
standard deviation and standard error of the mean.
11. Figures
- Figures should be submitted in JPEG or TIFF format
with a minimum of 150 DPI in resolution.
- Colored data if requested by author is chargeable.
- If a figure has been published previously, acknowledge
the original source and submit written permission from
the copyrights holder to produce the figure.
Abbreviations and symbols:
- Use only standard abbreviations.
- Avoid abbreviations in the title of the manuscript.
-The spelled-out abbreviations followed by the
abbreviation in parenthesis should be used in first
mention.
Vol. 23, No. 3 (263-378)
)Hamlet-Act. III, Sc. ii(
Middle East Journal of Anesthesiology
”For some must watch, while some must sleep“
VOLUME 23, No. 3, October 2015
ISSN 0544-0440
October 2015