A B S T R A C TAims: The aim of this study was to evaluate the onset, duration of sensory and motor block, hemodynamic effects (if any), duration and quality of postoperative analgesia, and adverse effects of magnesium or fentanyl given intrathecally with hyperbaric 0.5% bupivacaine in patients with mild preeclampsia undergoing elective caesarean sections. Materials and Methods: A total of 60 women with mild preeclampsia undergoing elective cesarean section were included in a prospective, double-blind, controlled trial. Patients were randomly assigned to receive spinal anesthesia with 2 mL 0.5% hyperbaric bupivacaine with 12.5 µg fentanyl (Group F) or 0.1 mL of 50% magnesium sulfate (50 mg) (Group M) with 0.15 ml preservative free distilled water. Onset, duration and recovery of sensory and motor block, time to maximum sensory block, duration of spinal anesthesia and postoperative analgesia requirements were studied. Statistical comparison was carried out using the Chi-square or Fisher's exact tests and independent Student's t-test where appropriate. Results: The onset of both sensory and motor block was slower in the magnesium group. The duration of spinal anesthesia (246 min ± 11 min vs. 284 min ± 15 min; P < 0.001) and motor block (186.3 ± 12 min vs. 210 ± 10 min; P < 0.001) were significantly longer in the magnesium group. Total analgesic dose requirement was less in Group M. Hemodynamic parameters were comparable in the two groups. Intrathecal magnesium caused minimal side effects. Conclusions: The addition of magnesium sulfate 50 mg to bupivacaine for sub-arachnoid block in patients with mild preeclampsia undergoing elective cesarean section prolongs the duration of analgesia and reduces postoperative analgesic requirements without additional side effects and adverse neonatal outcomes
Central pontine myelinolysis (CPM) is a demyelinating disease of the pons which is also associated with the demyelination of extrapontine areas of the central nervous system. Although the aetiology and pathogenesis are unclear, CPM is usually associated with hyponatremia or its rapid correction. Malnutrition and chronic alcoholism are also the common underlying conditions. Herein, we report a rare presentation of ODS, secondary to hyperosmolar hyperglycaemic state. We observed a 37-year-old female with diabetes type 1 and hypertension who presented with ataxia, dysarthria and pseudobulbar effect which evolved over a duration of few weeks at home with no evidence of hyponatremia or its rapid correction and no history of alcohol abuse or malnutrition.Key words: Central pontine myelinolysis, diabetes mellitus, extrapontine myelinolysis, hyperosmolar hyperglycaemic state, osmotic demyelination syndrome 37-year-old female with type 1 diabetes who developed osmotic demyelination syndrome (ODS) after rapid correction of osmolarity with normal serum electrolyte levels. This would be the first report of ODS in diabetic patient, associated with hyperosmolar hyperglycaemic state (HHS) with normal serum electrolytes. CASE REPORTA 37-year-old female with a history of type 1 diabetes mellitus (DM) and hypertension was admitted with a history of dysarthria, ataxia, behavioural changes which were gradual in onset and progressive with Glasgow Coma Scale (GCS) 12/15 (E4V4M4). Her neurological examination revealed normal cranial nerves, with grade 5/5 power in all 4 limbs with ataxic gait. Detailed history revealed progressively increasing ataxia with dysarthria, clumsiness with emotional lability and
SummaryThis study compares the response of the muscles of the hand to those of the face during non-depolarising neuromuscular blockade. It was found that observation of the facial muscles was misleading both in terms of degree of neuromuscular blockade and adequacy of reversal. Key words Neurornuscular relaxants. Measurement techniques; neuromuscular blockade.The correlation between the response of the hand muscles to those of respiration in relation to the action of nondepolarising muscle relaxants (NMR) is well described. One can expect that the effect of the NMR will have diminished sufficiently, that respiratory function should be adequate and that recurarisation should not occur, if the patient has a sustained response to tetanic stimulation or a train-of-four (TOF) ratio above 0.7. This information was developed using either the flexors of the digits or thc adductor of the thumb. The action of NMRs on facial muscles has not been well studied although it has been demonstrated that not all muscle groups respond to NMRs to the same degree., It is necessary in certain surgical situations to have both hands at the side. It is the practice of many anaesthetists in these circumstances, to stimulate the hcial nerve and observe the response of the facial muscles to determine both the degree of relaxation achieved and the adequacy of reversal. Our clinical experience suggested that observation of facial muscles does not provide adequate information and a study was designed to test this hypo1 hesis. MethodsTwenty patients undergoing elective abdominal surgery consented to participate in this protocol approved by our institutional review board. All patients were premedicated with morphine (0.14.15 mg/kg) and atropine (0.04 mg/kg) 45-60 minutes before surgery and anaesthesia was induced with thiopentone and isoflurane in 70% N,O. Tracheal intubation was accomplished aided by suxamethonium and end tidal anaesthetic concentration monitored using a mass spectrometer and maintained within 0.6 of 1.25 MAC. Both the facial and ulnar nerves were stimulated with a train-offour pattern using separate clinical nerve stimulators. The electromyograph (EMG) was recorded from the thenar eminence (adductor pollicis muscle) and one of the facial muscles (either the circumoral or circumorbital muscle groups). Transcutaneous electrodes were used to stimulate nerves and to record the EMG, which was registered on either an ink jet oscillograph or photographed from an oscilloscope trace. Pancuronium was administered in increments to generate a cumulative dose-response curve for each patient. The train-of-four ratio and the T1:TO ratio were observed in both muscle groups; the anaesthetist was asked to observe both groups and note the occurrence of TOF decrement during onset and reversal of neuromuscular blockade. Values were compared using Student's t-test. (p < 0.05 was accepted as significant). ResultsDecrement of EMG train-of-four ratio develops in both muscle groups at approximately the same dose (p > 0.05) but can be seen much earlier ...
INTRODUCTIONCisatracurium besilate is a cis-cis isomer (51W89:1R-cis 1'R-cis atracurium), one of the 10 stereoisomers of atracurium that constitutes 15% of the atracurium mixture, an intermediate duration non-depolarising neuromuscular blocking drug. It is about three to four times more potent than atracurium and devoid of cardiovascular side effects in doses of upto 8 times of ED95. The ED95 of cisatracurium is 0.05mg/kg. 1-5The rate limiting step in the degradation of cisatracurium is Hoffmann degradation.(organ independent elimination) to form laudanosine and monoquaternary alcohol. 77% of drug is cleared via Hoffmann degradation which is a ph and temperature dependent process, rest 23% of drug get cleared through organ dependent means, and renal elimination accounts for 16% of this. Hydrolysis by non-specific esterases is not an important pathway for cisatracurium degradation. It is not associated with histamine release in humans. Although the liver and kidneys play only a small role in the excretion of cisatracurium besilate, urinary and hepatic elimination pathways are important for the metabolites of laudanosine. 5-8The total body clearance (CL), steady-state Vd and elimination half-life of cisatracurium besilate in patients with normal organ function are approximately 0.27 to 0.34 L/h/kg (4.7 ml/min/kg), 0.11 to 0.16 L/kg and 22 to 35 minutes, respectively. The volume of distribution (Vd) ABSTRACT Background: Cisatracurium is one of the cis-cis isomer of atracurium (51W89:1R-cis 1'R-cis atracurium) an intermediate duration non-depolarising neuromuscular blocking drug and is devoid of histamine release. However, 2× ED95 dose of cisatracurium does not provide satisfactory intubating condition. The recommended intubating dose of cisatracurium is 3 ×ED95. The objective of this study was to evaluate and compare duration of action, hemodynamic effects and any adverse effects for different doses of cisatracurium. Methods: After Institutional Ethical Committee approval and informed patient consent, 80 patients of ASA I and II in the age group of 20-60 years were selected and included in the study. Patients were divided in two groups of 40 each, group A received intravenously 3×ED95 (0.15 mg/kg) loading dose of cisatracurium and group B received intravenously 4×ED95 (0.2 mg/kg) loading dose of cisatracurium. Results: After induction, MAP and HR shows decrease in both groups but neither statistically nor clinically significant. Better hemodynamic stability and longer duration of action was found in group B compared to group A. No adverse effects noted in both groups. Conclusions: 4×ED95 dose of cisatracurium provides longer duration of action and more stable hemodynamic status than 3×ED95. No associated signs of histamine release were detected clinically.
Background: Induction and endotracheal intubation are invariably associated with certain cardiovascular changes during anaesthesia practice and can lead to sudden swings of blood pressure, arrhythmias, MI and cardiovascular collapse especially in geriatric and haemodynamically unstable patients. Therefore it is desirable to use a safer agent with fewer adverse effects to minimise these complications. Present prospective randomized study is designed to compare the haemodynamic alterations and various adverse effects following induction with etomidate and midazolam.Methods: Hundred ASA I and II patients of age group 18-60 years scheduled for elective surgical procedure under general anesthesia were randomly divided into two groups of 50 each receiving etomidate (0.3mg/kg) and midazolam (0.15mgk/kg) as an induction agent. Vital parameters before and after induction and thereafter at specified time interval following laryngoscopy and intubation were recorded for comparison. Adverse effect viz. pain on injection, apnea and myoclonic activity were also carefully watched.Results: Demographic variables in both the groups were comparable. Patients in both the groups showed little change in mean arterial pressure (MAP) and heart rate (HR) from baseline value (p >0.05). Pain on injection and myoclonic activity were seen in etomidate group while delayed awakening was seen with Midazolam group.Conclusions: This study concludes that both etomidate and midazolam provides haemodynamic stability but Midazolam can be preferred as an induction agent in view of fewer side effects.
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