Background: Nalbuphine is a derivative of 14-hydroxymorphine which is a strong analgesic with mixed k agonist and µ antagonist. Nalbuphine was studied several times as adjuvant to local anesthetics in spinal, epidural and local intravenous block. The aim of this study was to evaluate the effect of nalbuphine as an adjuvant to local anesthetics in supraclavicular brachial plexus block. Patients and Methods: Fifty-six patients undergoing elective forearm and hand surgery under supraclavicular brachial plexus block were allocated randomly into one of two groups of 28 patients each to receive either 25 ml (0.5%) bupivacaine with 1 ml of NS or 25 ml (0.5%) bupivacaine with 1 ml (20 mg) nalbuphine. Onset time and duration of both sensory and motor block, and post-operative analgesia were observed. Result: Nalbuphine group showed significant increase in the duration of motor block (412.59 ± 18.63), when compared to control group (353.70 ± 29.019) p-value < 0.001, also, there was significant increase in sensory duration in nalbuphine group (718.14 ± 21.04) when compared to control group (610.18 ± 26.33) p-value < 0.001, without affecting the onset time of the blockade. And also, there was a significant increase in the duration of analgesic effect in nalbuphine group (835.18 ± 42.45) when compared to control group (708.14 ± 54.57) p-value < 0.001. Conclusion: The present study demonstrates that addition of 20 mg nalbuphine to bupivacaine in supraclavicular brachial plexus block is associated with significant increase in the duration of both sensory and motor block and also prolong the duration of analgesia.

Objectives. To compare dexmedetomidine versus magnesium during laparoscopic colectomy. Patients and Methods. 51 patients were randomly allocated into 3 groups: group C (control) received saline infusion, group D dexmedetomidine 1 g/kg and then 0.4 g/kg/hr, and group M MgSO4 2 g and then 15 g/kg/min. Intraoperative hemodynamics were measured before and 1 min after intubation (T1 and T2), before and 5 min after peritoneal insufflation (T3 and T4), before and 5 min after 30° Trendelenburg position (T5 and T6), 5 min after resuming flat position (T7), 5 min after peritoneal deflations (T8), after extubation (T9), and at time of admission to PACU (T10). Recovery time and degree of sedation were assessed. Results. HR and MAP were significantly higher in T2, T4, and T6 compared to T1, T3, and T5, respectively, in all groups with lower measurements in groups D and M compared to group C. Mean of collective measurements was significantly higher in group C. Recovery time and sedation score were significantly higher in groups D and M. Time to Aldrete score of ≥9 was significantly longer in groups D and M. Conclusion. Both drugs ameliorate the pressor responses during LC with a nonsignificant difference. This study is registered with PACTR201602001481308.

Background: Poor management of postoperative pain results in physiological and psychological side effects with higher morbidity. Erector spinae plane block (ESPB) has shown efficacy in controlling pain in many surgeries. Dexmedetomidine has improved the quality of analgesia in many regional techniques. This study aimed to assess the analgesic outcome of adding dexmedetomidine to bupivacaine in ultrasound (US) guided ESPB for perioperative analgesia for thoracic cancer surgeries. Patients and Methods: In this randomized controlled, double-blind study, 42 patients aged 18-65 years, ASA (American Society of Anesthesiologists) physical status II, scheduled for thoracotomy for cancer surgeries under general anesthesia were included. Patients were allocated into two equal groups: group 1 (ESPB by 28 ml bupivacaine 0.25% + 2 mL saline) and group 2 (ESPB 28 ml bupivacaine 0.25% + 2 mL dexmedetomidine 0.5 µg/kg). Blocks were performed before anesthesia induction. Results: Group 2 consumed lower intraoperative fentanyl and postoperative morphine and had a lower pain score at rest and cough compared to group 1. Group 2 had prolonged time to first request of rescue analgesia compared to group 1. Postoperative nausea and vomiting, and sedation were comparable between both groups. No block-related complications were observed. Conclusions: Adding dexmedetomidine to bupivacaine in US-guided ESPB provided more effective and safe analgesia in thoracotomy.

Objectives: Tracheostomy is a very common clinical intervention in critically ill adult patients. The indications for tracheostomy procedures in pediatric patients with complex conditions have increased dramatically in recent years, but there are currently no guidelines on the optimal timing of tracheostomy in pediatric patients undergoing prolonged ventilation. Data Sources: We performed a systematic search of the existing literature in MEDLINE via PubMed and Embase databases and the Cochrane Library to identify clinical trials, observational studies, and cohort studies that compare early and late tracheostomy in children. The date of the last search was August 27, 2018. Included articles were subjected to manual searching. Study Selection: Studies in mechanically ventilated children that compared early with late tracheostomy were included. Data Extraction: Data were extracted into a spreadsheet and copied into Review Manager 5.3 (The Cochrane Collaboration, Copenhagen, Denmark). Data Synthesis: Data were meta-analyzed using an inverse variance, random effects model. Continuous outcomes were calculated as mean differences with 95% CIs, and dichotomous outcomes were calculated as Mantel-Haenszel risk ratios with 95% CIs. We included eight studies (10 study arms). These studies were all retrospective cohort studies. Early tracheostomy was associated with significant reductions in mortality, days on mechanical ventilation, and length of intensive care and total hospital stay, although the lack of randomized, controlled trials limits the validity of these findings. Although variance was imputed for some studies, these conclusions did not change after removing these studies from the analysis. Conclusions: In children on mechanical ventilation, early tracheostomy may improve important medical outcomes. However, our data demonstrate the urgent need for high-quality, randomized controlled trials in the pediatric population.

BACKGROUND: Although invasive monitoring is the standard method for intracranial pressure (ICP) measurement, it is not without potential for serious complications. Noninvasive methods have been proposed as alternatives to invasive ICP monitoring. The study aimed to investigate the diagnostic accuracy of the currently available noninvasive methods for intracranial hypertension (ICH) monitoring. METHODS: We searched 5 databases for articles evaluating the diagnostic accuracy of noninvasive methods in diagnosing ICH in PubMed, Institute of Science Index, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), and Embase. The quantitative analysis was conducted if there were at least 2 studies evaluating a specific method. The accuracy measures included the sensitivity, specificity, likelihood ratios, and diagnostic odds ratio. RESULTS: We included 134 articles. Ultrasonographic optic nerve sheath diameter (US ONSD) had high diagnostic accuracy (estimated sensitivity of 90%; 95% confidence interval [CI], 87–92, estimated specificity of 88%; 95% CI, 84–91) while the magnetic resonance imaging (MRI) ONSD had estimated sensitivity of 77%; 95% CI, 64–87 and estimated specificity of 89%; 95% CI, 84–93, and computed tomography (CT) ONSD had estimated sensitivity of 93%; 95% CI, 90–96 and estimated specificity of 79%; 95% CI, 56–92. All MRI signs had a very high estimated specificity ranging from 90% to 99% but a low estimated sensitivity except for sinus stenosis which had high estimated sensitivity as well as specificity (90%; 95% CI, 75–96 and 96%; 95% CI, 91–99, respectively). Among the physical examination signs, pupillary dilation had a high estimated specificity (86%; 95% CI, 76–93). Other diagnostic tests to be considered included pulsatility index, papilledema, transcranial Doppler, compression or absence of basal cisterns, and ≥10 mm midline shift. Setting the cutoff value of ICH to ≥20 mm Hg instead of values <20 mm Hg was associated with higher sensitivity. Moreover, if the delay between invasive and noninvasive methods was within 1 hour, the MRI ONSD and papilledema had a significantly higher diagnostic accuracy compared to the >1 hour subgroup. CONCLUSIONS: Our study showed several promising tools for diagnosing ICH. Moreover, we demonstrated that using multiple, readily available, noninvasive methods is better than depending on a single sign such as physical examination or CT alone.