Background:Caudal analgesia is the most commonly used technique providing intra- and postoperative analgesia for various pediatric infraumbilical surgical procedures but with the disadvantage of short duration of action after single injection. Caudal dexamethasone and magnesium could offer significant analgesic benefits. We compared the analgesic effects and side-effects of dexamethasone or magnesium added to caudal ropivacaine in pediatric patients undergoing inguinal hernia repair.Materials and Methods:A total of 105 (1-6 years) were randomly assigned into three groups in a double-blinded manner. After a standardized sevoflurane in oxygen anesthesia, each patient received a single caudal dose of ropivacaine 0.15% 1.5 mL/kg combined with either magnesium 50 mg in normal saline 1 mL (group RM), dexamethasone 0.1 mg/kg in normal saline 1 mL (group RD), or corresponding volume of normal saline (group R) according to group assignment. Postoperative analgesia, use of analgesics, and side-effects were assessed during the first 24 h.Results:Addition of magnesium or dexamethasone to caudal ropivacaine significantly prolonged analgesia duration 8 (5-11) h and 12 (8-16) h, respectively compared with 4 (3-5) h with the use of ropivacaine alone. The incidence of postoperative rescue analgesia was significantly higher in group R compared with groups RM and RD. The time to 1st analgesic dose was significantly longer in groups RM and RD (500 ± 190 and 730 ± 260 min) respectively compared with group R (260 ± 65 min). Group R patients achieved significantly higher Children's Hospital of Eastern Ontario Pain Scale and Faces Legs Activity Cry Consolability scores (4th hourly) compared with groups RM and RD patients (8th and 12th hourly, respectively).Conclusion:The addition of dexamethasone or magnesium to caudal ropivacaine significantly prolonged the duration of postoperative analgesia in children undergoing inguinal hernia repair. Also the time to 1st analgesic dose was longer and the need for rescue postoperative analgesic was reduced and without increase in incidence of side effects.

Background:In spite of being the preferred induction agent for LMA insertion, propofol has many undesirable side effects including dose-related cardiorespiratory depression and local pain at injection site. Ketofol as a novel induction agent has been introduced recently with comparable efficacy and improved hemodynamic controlObjective:To investigate ketofol as a suitable induction agent alternative to propofol for insertion of LMA in children considering insertion conditions, hemodynamic stability, local pain at injection site, and recovery.Materials and Methods:In this randomized, double-blind study, 100 children were randomly assigned into two groups of 50 patients each in which induction was performed with either propofol or ketofol. Providers were given one 20 ml syringe [represent either 2 mg/kg of propofol (P group) or 0.75 mg/kg of ketamine and 1.5 mg/kg of propofol (KP group)] and one 10 ml syringe for rescue if needed [represent 1 mg/kg of propofol (P group) or 0.25 mg/kg of ketamine and 0.5 mg/kg of propofol (KP group)]. After monitoring with bispectral index (BIS), general anesthesia was induced by infusion with a syringe perfuser at a constant rate of 250 ml/h with either of the two agents till the BIS values decreased to 40. Mean arterial pressure (MAP), heart rate (HR) were measured every 30 seconds up to 5 minutes after LMA placement. The time till BIS values decreased to 40 was measured. All children were evaluated for incidence of apnea, pain on injection, jaw relaxation, conditions for LMA insertion, and complications such as muscle rigidity, hallucinations, and excessive secretions.Results:Induction time (time to reach BIS of 40) was faster in the KP group (150 ± 23.5 seconds) than in the P group (205 ± 37.4 seconds). The incidence of injection pain was significantly lower in the KP group (10%) than in the P group (80%). Excellent jaw relaxation and full mouth opening were higher in the KP group [45 patients (90%)] than in the P group [38 patients (76%)]. Excellent LMA insertion conditions were observed in 45 patients (90%) in the KP group and 38 patients (76%) in the P group. The KP group showed preserved hemodynamic stability (mean blood pressure, heart rate) with less incidence and duration of apnea compared to the P group.Conclusion:ketofol is a safe and effective alternative induction agent for LMA insertion in children with rapid onset of action and lower incidence of injection pain. It provided better LMA insertion conditions, improved hemodynamic stability with less prolonged apnea when compared with propofol.

Background:Morbidly obese patients are at increased risk of difficult mask ventilation and intubation as well as increased risk of hypoxemia during tracheal intubation. Recently, new video-assisted intubation devices have been developed. The GlideScope® videolaryngoscope and LMA CTrach™ (CT) allows continuous video-endoscopy of the tracheal intubation procedure.Objective:this study is to determine whether the GlideScope® videolaryngoscope (GVL) and the LMA CTrach™ (CT) provide the best airway management, measured primarily in intubation difficulty scale (IDS) scores, time and numbers of intubation attempts, and improvement in the intubation success rate of morbidly obese patients when compared with the direct Macintosh laryngoscope (DL).Materials and Methods:After Ethics’ Committee approval, 90 morbidly obese patients (BMI > 35 kg/m2) scheduled for general, gynecological, and bariatric surgery were included in this prospective study. Patients were randomly assigned in three groups: tracheal intubation using direct laryngoscopy (DL), GlideScope® videolaryngoscope (GVL) or the LMA CTrach™ (CT). Characteristics and consequences of airway management were evaluated. The primary outcome was the intubation difficulty scale score (IDS), Secondary outcomes were theintubation time, overall success rate, number of attempts, Cormack–Lehane grade, subjective difficulty of intubation, desaturation and upper airway morbidity.Results:Difficulty in facemask ventilation was similar in the three groups. IDS scores were significantly lower with GVL and CT than with DL. The mean TTI was 14 s faster in patients intubated with the GVL (86 s, IQR: 68-115) compared with DL (100 s, IQR; 80-150), and was 34 s faster when compared with CT (120 s, IQR; 95-180). The success rate of tracheal intubation was lower with the DL (80%) compared with the GVL (100%) or the CT (100%). Six cases of failed intubation occurred in group DL, four patients from the six patients were intubated successfully with GVL, and two patients were intubated with the CT. Both the GVL and the CTimproved the Cormack and Lehane view obtained at laryngoscopy, compared with the DL. Significantly high percent of patients in DL (43%) and CT (27%) required optimization maneuvers (external laryngeal pressure) compared with GVL (0%). In the CT group, 30% of the patients required laryngeal mask manipulation (for view optimization) compared with (0%) in GVL and CT groups.Conclusion:The GlideScope® videolaryngoscope and the LMA CTrach™ reduced the difficulty, improved laryngoscopic views and overall success rate of tracheal Intubationto a similar extent compared with the Macintosh laryngoscope in morbidly obese patients. The GVL improved intubation time for tracheal intubation compared with the CT and DL but no patient became hypoxic with CT because of prolonged intubation time.

Background:Laparoscopic cholecystectomy became the standard surgery for gallstone disease because of causing less postoperative pain, respiratory compromise and early ambulation.Objective:This study was designed to compare spinal anesthesia, (segmental thoracic or conventional lumbar) vs the gold standard general anesthesia as three anesthetic techniques for healthy patients scheduled for elective laparoscopic cholecystectomy, evaluating intraoperative parameters, postoperative recovery and analgesia, complications as well as patient and surgeon satisfaction.Materials and Methods:A total of 90 patients undergoing elective laparoscopic cholecystectomy, between January 2010 and May 2011, were randomized into three equal groups to undergo laparoscopic cholecystectomy with low-pressure CO2 pneumoperitoneum under segmental thoracic (TSA group) or conventional lumbar (LSA group) spinal anesthesia or general anesthesia (GA group). To achieve a T3 sensory level we used (hyperbaric bupivacaine 15 mg, and fentanyl 25 mg at L2/L3) for LSAgroup, and (hyperbaric bupivacaine 7.5 mg, and fentanyl 25 mg at T10/T11) for TSAgroup. Propofol, fentanyl, atracurium, sevoflurane, and tracheal intubation were used for GA group. Intraoperative parameters, postoperative recovery and analgesia, complications as well as patient and surgeon satisfaction were compared between the three groups.Results:All procedures were completed laparoscopically by the allocated method of anesthesia with no anesthetic conversions. The time for the blockade to reach T3 level, intraoperative hypotensive and bradycardic events and vasopressor use were significantly lower in (TSA group) than in (LSA group). Postoperative pain scores as assessed throughout any time, postoperative right shoulder pain and hospital stay was lower for both (TSA group) and (LSA group) compared with (GA group). The higher degree of patients satisfaction scores were recorded in patients under segmental TSA.Conclusion:The present study not only confirmed that both segmental TSA and conventional lumber spinal anesthesia (LSA) are safe and good alternatives to general anesthesia (GA) in healthy patients undergoing laparoscopic cholecystectomy but also showed better postoperative pain control of both spinal techniques when compared with general anesthesia. Segmental TSA provides better hemodynamic stability, lesser vasopressor use and early ambulation and discharge with higher degree of patient satisfaction making it excellent for day case surgery compared with conventional lumbar spinal anesthesia.

Background:Morbid obesity magnifies the importance of the fat–blood solubility coefficient of the anesthetic in its relation to emergence and recovery. Using bispectral index (BIS) monitoring for the titration of the administration of inhaled anesthetics such as desflurane may permit a less consumption and more rapid recovery from desflurane anesthesia in morbidly obese patients, which enables earlier maintenance of a patent airway, better protection against aspiration, and better oxygenation.Objective:The aim of this study was to investigate the effect of BIS monitoring on postoperative extubation and recovery times, and intraoperative desflurane consumption in morbidly obese patients undergoing laparoscopic sleeve gastrectomy under general anesthesia using desflurane for maintenance.Patients and Methods:Forty morbidly obese patients were randomly enrolled in this study and divided into two groups of 20 patients each: Non-BIS group and BIS group. End-tidal desflurane concentration, mean blood pressure, and heart rate were regularly recorded. Recovery times (eye opening to verbal commands, time to extubation, and orientation to time, place, and person) and the time to achieve a modified Aldrete score of ≥ 9 were recorded by blinded study anesthesia nurse. Desflurane consumption was calculated in milliliters through gas usage option of Datex-Ohmeda S/5 anesthesia machine.Results:The mean end-tidal concentrations of desflurane were significantly decreased in the BIS group compared to the non-BIS group (P < 0.05). The mean desflurane consumption and cost were significantly lower in the BIS group (124.8 ± 5.1 ml/patient) compared to the non-BIS group (150.6 ± 6.5 ml/patient) (P < 0.05). Recovery times were significantly shorter in the BIS group versus non-BIS group (P < 0.05).Conclusion:The use of BIS monitoring was effective in reducing intraoperative desflurane requirement (cost) and in shortening early recovery times after laparoscopic sleeve gastrectomy in morbidly obese patients without compromising the hemodynamic stability, adequacy of anesthesia, or patient outcome.