Background:Patients’ surgical experiences are influenced by their perception of pain management. Duloxetine (Dulox) and dexamethasone (Dex) are used in multimodal analgesia to reduce opioid use and side effects. Dulox is a selective serotonin and norepinephrine reuptake inhibitor and has efficacy in chronic pain conditions. Dex enhances postoperative (PO) analgesia and reduces PO nausea and vomiting (PONV).Methods:Seventy-five female patients were randomly allocated into one of three equal groups. GI received Dulox 60 mg orally and 100 ml 0.9% sodium chloride (normal saline [NS]) intravenous infusion (IVI) over 15 min, GII: received as GI except Dex 0.1 mg/kg was mixed with NS and GIII received identical placebo for Dulox capsule and Dex IVI, 2 h preoperatively. Patients’ vitals, visual analog scale (VAS), and sedation score were assessed at 30 min, 1 h, 2 h, 6 h, and 12 h postoperatively. Total pethidine requirements, plasma cortisol, PONV, and patients satisfaction were recorded.Results:PO time for 1st rescue analgesic was significantly high in GI and GII compared to GIII and in GII compared to GI. There was a significant less VAS score, heart rate, mean arterial pressure, and a high sedation score in GI and GII compared to GIII at 30 min, 1, 2, and 6 h postoperatively. Total pethidine requirements were significantly less in GI and GII compared to GIII 12 h postoperatively. There was a significant reduction in the 2 h PO serum cortisol (μg/dl) and a significant increase in the PO patients satisfaction score in GI and GII compared to GIII. PONV was decreased significantly in GII compared to GI and GIII.Conclusion:The use of oral Dulox 60 mg combined with Dex 0.1 mg/kg IVI is more effective than oral Dulox 60 mg alone, 2 h preoperatively, for improving PO pain by reducing the requirements for rescue analgesia and PONV.

The Vigileo-FloTrac system High-risk patients Major abdominal surgeries Postoperative Morbidity Mortality a b s t r a c tBackground: This study evaluated impact of intraoperative goal-directed therapy (GDT) judged by changes of stroke volume variation (SVV) and cardiac index (CI) using the Vigileo/FloTrac system on postoperative (PO) morbidities and mortality rates in high risk patients scheduled for major abdominal surgeries in comparison to conventional fluid therapy (CT). Methods: 86 patients were randomly allocated into one of two equal groups: CT group = 43 patients received crystalloid solution and on demand bolus of 250 ml colloids with possible addition of vasopressor or inotrope to target MAP at 60-90 mmHg, CVP at 8-12 mmHg and urine output at >0.5 ml/kg/hr and GDT group = 43 patients received crystalloid fluid therapy (FT) and colloids (3 ml/kg) with possible addition of vasopressor or inotrope according to predefined protocol with a target CI 2.5 L/min/m 2 , SVV < 12% with MAP > 65 mmHg. Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity (POSSUM) was used to predict morbidity and mortality rates. Study outcomes included ICU and total hospital morbidity and mortality rates and length of stay (LOS). Results: Intraoperative GDT reduced ICU morbidity rate (16.3%) than the POSSUM predicted rate (39.78%) and significantly (p = 0.039) than CT group (37.2%), while in CT group ICU morbidity rate coincided with POSSUM predicted rate (42.86%). ICU and total hospital LOS were significantly shorter with GDT group than with CT group. However, mortality rates weren't significantly lower with GDT group than CT group (7% vs. 11.6%). The applied protocol for intraoperative GDT reduced significantly crystalloid infusion and despite of significantly higher amount of received colloids, the total amount of FT was significantly less than CT group. Conclusion: The applied protocol for intraoperative GDT provided significant reduction of PO morbidities, ICU and hospital LOS but couldn't significantly reduce mortality rates in high risk patients scheduled for major abdominal surgeries.

(2016) Comparative study between transdermal fentanyl and melatonin patches on postoperative pain relief after lumber laminectomy, a double-blind, placebo-controlled trial,

Background: Postdural puncture headache (PDPH) is a common complication after lumbar puncture. Anesthesiologists are the most likely to be consulted for the treatment. PDPH may be debilitating for a patient and can interfere with daily activities and quality of life. Methods: Fifty patients of both sexes, aged 18-50 years and ASA I and II undergoing elective lower abdominal and pelvic surgery under spinal anesthesia were included in this randomized double-blind study. Patients were randomly divided into 2 groups 25 each: hydrocortisone group received intravenous hydrocortisone 100 mg every 8 h for 48 h and mannitol group received intravenous infusion of mannitol 20% 100 ml over 30 min followed by 100 ml every 12hours. Mean (±SD) of headache intensity at 0, 6, 12, 24 and 48 h after beginning of treatment was assessed using visual analogue scale. Results: There was no significant difference regarding headache intensity between two groups before beginning of treatment. The VAS was significantly reduced in hydrocortisone group than in mannitol group at 6, 12, 24 h with P-value 0.030, 0.007, 0.004 respectively. At 48 h, both groups had nearly the same VAS of headache intensity, with P-value 0.305. Conclusion: Both intravenous hydrocortisone and mannitol intravenous infusion were efficient in reducing postdural puncture headache within 48 h. Hydrocortisone showed earlier and significant relief of headache.

Background: Optimal fluid management is crucial for patients undergoing surgical repair of abdominal aortic aneurysm (AAA). Persistent hypovolemia is associated with complications but fluid overload is also harmful. Aim: This study evaluates that perioperative fluid restriction would reduce complications and improve outcome through goal-directed strategies in patients undergoing AAA. Methods: Fifty patients, aged from 60 to 75 years undergoing elective surgical repair of AAA were included in this randomized study. Patients were divided into two groups, 25 for each: liberal group (L) receives 12 ml/kg/h and restrictive group (R) receives 4 ml/kg/h. Goal-directed-therapy approach was concerning assessment of tissue oxygenation. Dobutamine and fluid challenges were used to maintain adequate tissue perfusion during surgery. Results: The patients of the (L) group received a significant greater amount of Lactated Ringer's solution (3586.76 ± 473.21) than the (R) group (1219 ± 140.6). The (R) group had 50% lower rate of major postoperative complications than the (L) group (24% vs 48%) and less hospital stay. Conclusion: A restrictive strategy of fluid maintenance during optimization of oxygen delivery with early treatment directed to maintain oxygen extraction ratio estimate (O 2 ERe) at <27% reduces major complications and hospital stay of surgical patients undergo abdominal aortic aneurysm.

Background: This study evaluated the efficacy of transdermal nicotine (TDN) delivery system (15 mg/16 h) or transdermal melatonin (TDM) delivery system (7 mg) 2 h preoperatively for acute postoperative pain after laparoscopic cholecystectomy compared to placebo group (C). Methods: Sixty female non-smoker patients, aged 18-50 years and ASA I and II undergoing elective laparoscopic cholecystectomy under general anesthesia were included in this randomized controlled double-blind study. Patients were randomly divided into 3 groups 20 each, and C group patients received transdermal placebo patch, TDN group (15 mg/16 h) and TDM group (7 mg/8 h). Assessment of postoperative pain, sedation, hemodynamic variables such as HR and MAP, postoperative monitoring of arterial SpO 2 and side effects (e.g. nausea, vomiting, pruritus, respiratory depression and hemodynamic instability) were done 30 min, 1, 2, 6 and 12 h postoperatively. Postoperative Patient's and Surgeons' satisfaction, Intraoperative bleeding and plasma cortisol (lg/dl) 2 h postoperatively were also assessed. Results: There was a significant reduction in the VAS score, total pethidine requirements (mg) and significantly higher patient's satisfaction in TDN and TDM groups when compared with the C group postoperatively. The sedation score and surgeons' satisfaction were significantly higher associated with a significant decrease in MAP and Intraoperative bleeding in TDM group compared to C and TDN groups postoperatively. Significant nausea and vomiting in TDN group and significant sedation in TDM group were recorded. Conclusion: The use of preoperative TDN (15 mg/16 h) or TDM (7 mg/8 h) was an effective and a safe adjuvant for acute pain after surgery.

Background. Coadministration of different antiemetics proved to decrease postoperative nausea and vomiting (PONV) after laparoscopic sleeve gastrectomy (LSG). This trial compared aprepitant/dexamethasone (A/D) combination vs mirtazapine/dexamethasone (M/D) combination vs dexamethasone (D) alone for prevention of PONV in morbidly obese patients undergoing LSG. Methods. Ninety patients scheduled for LSG were randomly allocated to receive 8 mg dexamethasone intravenous infusion (IVI) only in the D group or in addition to 80 mg aprepitant capsule in the A/D group or in addition to 30 mg mirtazapine tablet in the M/D group. Assessment of PONV was carried out at 0–2 h (early) and 2–24 h (late). The primary outcome was the complete response 0‐24 h after surgery. Collective PONV, postoperative pain, side effects and patient satisfaction score were considered as secondary outcomes. Results. The A/D and M/D groups were superior to the D group for a complete response within 0–24 h after surgery (79.3% for the A/D group, 78.6% for the M/D group, and 20.7% for the D group). The D group was inferior to the A/D and M/D groups regarding collective PONV and use of rescue antiemetic 0–24 h after surgery ( P < 0.001 , P < 0.001 , respectively). The peak nausea scores (2–24 h) were significantly reduced in the M/D group in comparison to the D group ( P = 0.005 ). Patients in the M/D group showed high sedation scores, while those in the A/D group showed low pain scores (2–24 h) and less analgesic requirements ( P < 0.001 , P < 0.001 , P < 0.001 , respectively). The A/D and M/D groups were superior to the D group with regard to the patient satisfaction score ( P < 0.001 ). Conclusion. Aprepitant/dexamethasone combination and mirtazapine/dexamethasone combination were superior to dexamethasone alone in alleviating postoperative nausea and vomiting in morbidly obese patients scheduled to undergo laparoscopic sleeve gastrectomy. Trial Registration: ClinicalTrials.gov identifier: NCT04013386.

Background Co-administration of different antiemetics proved to decrease postoperative nausea and vomiting (PONV) following laparoscopic sleeve gastrectomy (LSG). The investigators compared the combination of aprepitant and dexamethasone (A/D) with the combination of mirtazapine and dexamethasone (M/D) for prevention of PONV in morbidly obese patients undergoing LSG. Methods Ninety patients scheduled for LSG were assigned to receive a single preoperative dose of dexamethasone 8 mg IVI (D group), and in addition to oral aprepitant 80 mg (A/D group) or oral mirtazapine 30 mg (M/D group) in a randomized, double-blind trial. Assessment of PONV was done 0–2 h (early) and 2–24 hours (late). Patients’ level of sedation, satisfaction and postoperative pain were also assessed. Results A/D and M/D groups were superior to D group for complete response 0–24 h after surgery (79.3% for A/D group, 78.6% for M/D group and 20.7% for D group). D group was inferior to A/D and M/D groups regarding collective PONV and use of rescue antiemetics (P < 0.001) 0–24 h after surgery. The peak nausea scores 2–24 h were significantly lower in both A/D and M/D groups vs. D group (P = 0.005). Patients in the M/D group showed higher sedation scores while those in A/D groups showed lower pain scores and less analgesic requirements. A/D and M/D groups were superior to D group regarding the patient’s satisfaction score. Conclusion A/D and M/D combinations were superior to D alone regarding the proportion of patients exhibiting a complete response in preventing PONV associated with LSG. Trial Registration: Clinical Trials. gov Identifier: NCT04013386/ prospectively registered: 09/07/2019, http://www.Clinical Trial.gov