BackgroundThis prospective, randomized, double blinded, controlled study was designed to compare effects of intravenous co-administration of clonidine, magnesium, or ketamine on anesthetic consumption, intraoperative hemodynamics, postoperative analgesia and recovery indices during Bispectral Index (BIS) guided total intravenous anesthesia (TIVA).MethodsAfter ethical committee approval and written informed consent, 120 adult patients ASA I and II scheduled for open cholecystectomy were randomly assigned to one of 4 equal groups. Group CL received clonidine 3 µg/kg and maintained by 2 µg/kg/h. Group MG received magnesium sulphate 50 mg/kg and maintained by 8 mg/kg/h. Group KET received racemic ketamine 0.4 mg/kg and maintained by 0.2 mg/kg/h. Control group (CT) received the same volume of isotonic saline. Anesthesia was induced and maintained by fentanyl, propofol and rocuronium. Propofol infusion was adjusted to keep the BIS value between 45-55. Intraoperative hemodynamics, induction time, anesthetic consumption, recovery indices, and PACU discharge were recorded.ResultsInduction time, propofol requirements for induction and maintenance of anesthesia, intraoperative fentanyl and hemodynamic values were significantly lower with Groups CL and MG compared to Groups KET and CT (P < 0.05). Patients in Group MG showed significantly lower muscle relaxant consumption, delayed recovery and PACU discharge than other groups (P < 0.05). First, analgesic requirement was significantly longer and total postoperative analgesic consumption was significantly lower in the adjuvant groups versus Group CT (P < 0.05).ConclusionsClonidine, magnesium, and ketamine can be useful adjuvant agents to BIS-guided TIVA. Pharmacokinetic studies of such drug combinations were recommended to investigate their interaction.

Background: Cirrhotic patients have impaired hemostasis with variable incidence of hypersplenism necessitating splenectomy. Rotation thromboelastometery (ROTEM) facilitates diagnosis and guides management. This study evaluates perioperative effects of desflurane versus propofol on hemostasis in cirrhotic patients undergoing splenectomy guided by ROTEM and laboratory hemostatic tests. Methods: Thirty hepatic Child A patients, ASA II-III, of either sex, aged 25-55 years, undergoing splenectomy were randomly allocated into two equal groups: Group D; anesthetized with desflurane 1 MAC (6%) and Group P; with propofol Target Controlled Infusion 2-5 µg/ml. Six blood samples were collected; preoperatively, after splenic artery ligation, immediately, first, third postoperative day then one month later. The samples were handled to measure complete blood picture, liver and kidney functions, screening coagulation tests (INR, PT and PTT), specific hemostatic factors (P-Selectin/CD62P, fibrinogen and D-dimer) as well as ROTEM criteria; clotting time (CT), clot formation time (CFT) and maximum clot firmness (MCF) via EX-TEM, IN-TEM and FIB-TEM commercial kits. Results: This study displayed postoperative hemoglobin reduction; however, platelet and WBCs as well as CT, CFT and MCF increased versus baseline. Screening and specific hemostatic factors as all other changes were within reference range and comparable between both groups. Conclusions: The current study concluded comparable effects of desflurane and propofol anesthesia on coagulation parameters within acceptable range as monitored by ROTEM and laboratory coagulation tests in cirrhotic patients with hypersplenism. Thus both anesthetics are considered safe in such patients who have high incidence of coagulopathy.

Background: Dexmedetomidine is an a-2 adrenoceptor agonist with sedative and analgesic properties. Desflurane is the most rapidly washed volatile anesthetic agent allowing rapid recovery with minimal metabolism. Having a MAC of 6 vol % made it important to look for an adjuvant that would minimize its consumption. This study was undertaken to analyze desflurane consumption when combined with dexmedetomidine infusion guided by bispectral index as well as calculating intraoperative fentanyl requirements and recording hemodynamic changes associated with this technique. Methods: Forty adult patients ASA class I and II of either sex scheduled for elective laparoscopic cholecystectomy were included in this study. Patients were randomized to one of two groups: Group 'D' (Dexmedetomidine group) receiving 1g/kg over 10 minutes followed by an infusion at 0.5 lg/kg/hr and Group 'P' (Placebo group) who received same volumes of normal saline. Desflurane was started at a concentration of 6% then adjusted to keep BIS level within the range of 40-50. Desflurane consumption, fentanyl requirements as well as hemodynamics were either calculated or recorded. Results: Desflurane consumption and total fentanyl usage were significantly lower in group D versus group P with P value < 0.001. As regards hemodynamics, group D showed statistically significant lower readings versus the preoperative levels (P<0.05) as well as versus group P at the same timings (P<0.05) for most of the readings. Conclusions: Continuous intravenous administration of dexmedetomidine resulted in significant reduction of desflurane consumption and intraoperative fentanyl requirements with attenuation of hemodynamic response to intubation, pneumoperitoneum and extubation.

Background: This study compared haemodynamics of continuous Wiley SpinalÒ anaesthesia with continuous epidural anaesthesia in elderly patients undergoing transurethral resection of prostate (TURP). Methods: After Institutional Review Board approval, thirty elderly male patients undergoing TURP classified as ASA physical status II or III were assigned into either the following: Continuous Epidural Anaesthesia group (Group CEA) receiving fentanyl 50 lg with plain bupivacaine 0.5% in 5 ml boluses or Wiley SpinalÒ Anaesthesia group (Group WSA) receiving fentanyl 5 lg with plain bupivacaine 0.5% given as 0.5 ml boluses until reaching sensory level of T10. Sensory and motor block onset and recovery, haemodynamics, time to first analgesia and adverse events were documented. Results: On reviewing WSA and CEA groups, onset of T10 sensory block [2 (1-8) vs. 5 (3-20) min], and motor block [9 (2-25) vs. 12 (5-40) min], with sensory recovery [161.7 ± 28.3 vs. 253.3 ± 52.7 min] and motor block duration [100.0 ± 27.4 vs. 130.7 ± 19.5 min] respectively (P < 0.05) being shorter in Group WSA. Haemodynamics revealed significant reduction in mean arterial pressure after three and five minutes of injection of local anaesthetic and heart rate after fifteen minutes in Group WSA when compared with Group CEA (P < 0.05). Time to first analgesia and adverse events were non-significant. Conclusion: In elderly patients undergoing TURP, continuous Wiley SpinalÒ anaesthesia showed nearly comparable haemodynamics as continuous epidural anaesthesia with minimal adverse effects. This technique also provided good anaesthetic profile as well as fast sensory and motor block onset and recovery.

Objective: Cisatracurium is approximately 3 times more potent than atracurium, devoid of histamine release and cardiovascular side effects and mainly eliminated by Hofmann degradation. Patients with liver disease exhibit abnormal response to most of muscle relaxants. This study was designed to evaluate the dose-response of cisatracurium in patients with mild-moderate liver impairment in comparison with healthy subjects. Methods: Eighty ASA physical status I-II patients of both sexes, scheduled for elective surgical procedures under general anesthesia, were divided according to their preoperative hepatic status and laboratory investigations into two groups; Group I (control group with normal liver functions, n = 40) and Group II (Liver dysfunction group, Child-Pugh Score A or B, n = 40). The doseresponse curve was constructed, ED 50 and ED 95 were estimated. Results: The preoperative laboratory parameters showed statistically significant differences between the two groups regarding serum albumin, total bilirubin, ALT, AST, PT, PC and INR. The operative data showed statistically insignificant difference between the two groups regarding the 1st dose response (p = 0.152), the estimated ED 80 (p = 0.886) and the calculated 2nd dose (p = 0.886) and statistically significant differences between the two groups regarding the 2nd dose response (p = 0.006), the measured ED 50 (p = 0.010) and the measured ED 95 (p = 0.001). In conclusion, the measured ED 50 and ED 95 through two-dose dose-response curve technique were clinically insignificant from using the single-dose technique. The dose-response curve of cisatracurium in patients with chronic liver disease was clinically insignificant in comparison with healthy subjects.