Enhanced recovery after surgery is a multimodal, multidisciplinary, evidence-based approach, aiming to control postoperative pathophysiology and rehabilitation. The aim of this article is to review current literature in pediatric cardiac practice, implementing the ERAS approach, to identify peri-operative strategies that are associated with enhanced recovery after pediatric cardiac surgery.

Sedation and analgesia following pediatric cardiac surgery is of paramount importance. Individualized sedation and analgesia strategies starting in the operative theater and continuing in the postoperative period need to be recognized as an important aspect of perioperative care. This aims toward speeding recovery, minimizing PICU length of stay, and avoiding the development of postsurgical stress syndrome. Patient-tailored protocols should be implemented based on validated pain/sedation scores. Understanding the pharmacological aspects and side effects of various sedative/analgesic drugs, as well as continuous dose adjustment according to follow-up scoring system and variable patient hemodynamic state and response, is mandatory.

Context Inhaled milrinone has short-acting selective pulmonary vasodilator effect. Aims The aim of the study was to investigate the cardiovascular effects of prolonged inhalation of nebulized milrinone on patients with pulmonary hypertension undergoing mitral valve replacement. Settings and design This is a controlled, randomized, double-blinded study. Patients and methods Forty patients were divided into two groups: the milrinone group and the control group. The milrinone group received milrinone nebulization before cardiopulmonary bypass (CPB) as the loading dose at 50 mg/kg, followed by a maintenance dose of 0.5 mg/kg/min, which was continued for 2 h after tracheal extubation. The control group received an equivalent volume of 0.9% sodium chloride. The measured and calculated variables included heart rate, mean arterial blood pressure, central venous pressure, mean pulmonary artery pressure (mPAP), pulmonary capillary wedge pressure, cardiac index (CI), pulmonary vascular resistance (PVR), and systemic vascular resistance. The time points of measurements and calculations were as follows: at T ₀ - after anesthesia induction and before sternotomy; at T ₁ - 20 min after CPB cessation; at T ₂ - 1 h after CPB cessation; at T ₃ - 3 h after CPB cessation; at T ₄ - 1 h after tracheal extubation; and at T ₅ - 1 h after milrinone discontinuation. The duration of CPB and time of tracheal extubation were recorded. Results The milrinone group showed significant reduction in mPAP (T ₂ to T ₄ readings), pulmonary capillary wedge pressure (T ₃ reading), and PVR (T ₂ to T ₄ readings), increase in CI (T ₃ and T ₄ readings), and shorter CPB duration and tracheal extubation time. Conclusion Prolonged inhalation of nebulized milrinone proved to be feasible in patients with pulmonary hypertension (PAH) undergoing mitral valve replacement. It decreased PVR and mPAP while increasing CI. This helped shorter CPB duration and earlier tracheal extubation.

Background Diffuse microvascular bleeding remains a common problem after myocardial revascularization with cardiopulmonary bypass. Objectives The efficacy of locally administered tranexamic acid (topical application) was compared with systemically administered tranexamic acid to reduce postoperative bleeding after cardiopulmonary bypass in elective nonredo coronary artery bypass grafting (CABG). Methods The study included 60 patients of both sexes, aged between 35 and 65 years, and scheduled for elective CABG; patients were randomly assigned to two groups: group I (the intravenous tranexamic acid group; 30 patients) and group II (the topical tranexamic acid group; 30 patients). For each patient in each group, postoperative blood loss, number of units of packed red blood cells (RBCs) and fresh frozen plasma (FFP) transfused, frequency of resternotomy, duration of hospital and ICU stay, and mortality were recorded. Results There were statistically significant differences between the two groups with regard to total postoperative blood loss and need for packed RBCs and FFP transfusion, being much greater in group I than in group II. There was no mortality in either group. Frequency of resternotomy was higher in group I than in group II, although the difference was statistically nonsignificant. The duration of hospital and ICU stay revealed no statistically significant differences between the two groups. Conclusion Intraoperative topical administration of tanexamic acid into the pericardial cavity before sternal closure during CABG surgery has reduced the incidence of postoperative blood loss and the need for postoperative packed RBCs and FFP transfusion.

Purpose The current study evaluates the efficacy of perioperative intravenous use of NAC as a pharmaco-protective agent in liver transplant recipients. Methods One hundred patients undergoing living donor liver transplantation (LDLT) were included in this prospective, randomized, double-blind, two parallel groups placebo-controlled trial; Group N (50 patients) received 150mg/kg of IV NAC infusion IV over 15 min before surgery, followed by12.5 mg/kg/h NAC for 4 h after induction of general anesthesia and a subsequent dose of 6.25 mg/kg/h continuous infusion for 3 postoperative days and Group C (50 patients) received equal volume of 0.9% saline IV continuous infusion at the same rate and volume for 3 postoperative days. Both groups will be followed for 14 days after their LT. Primary outcome include postoperative acute kidney injury (POAKI) assessed using RIFLE criteria on admission, day 7 and day 14. Secondary outcomes include severity of the post reperfusion syndrome (PRS) and the incidence of primary graft non-function (PGNF), renal functions test, total dose of loop diuretics and dopamine, adverse events, survival, as well as the length of ICU and hospital stays. Results There was no significant difference (P = 0.8) in the incidence of mild PRS, but the incidence of severe PRS was significantly reduced (P = 0.03) in Group N. RIFLE classification was significantly reduced on admission (P = 0.001), day 7(P = 0.002), and day 14(P = 0.003) respectively in Group N compared to Group C. PGNF was significantly reduced (P = 0.03) in Group N [1 (2%)] than Group C [7(14%)]. During 14 days there was a significant decrease in total dose of loop diuretics, need for dopamine, hospital length of stay, ICU length of stay, renal replacement therapy and the incidence of complications (5 vs. 14 P = 0.02) in Group N than Group C. But there was no significant difference in mechanical ventilator days, and patient survival among groups. Conclusions Perioperative intravenous NAC administration in patients undergoing living donor liver transplantation decreased incidence of postoperative acute kidney injury, severity of PRS and PGNF along with decreased length of ICU and hospital stay with no adverse events , But did not significantly reduce mechanical ventilator days and mortality.

Background Postcardiac arrest syndrome has a unique pathophysiological process involving multiple organs. Pentoxifylline can modulate inflammation, oxidative stress, and endothelial function, and may thus reduce multiple organ dysfunction in postcardiac arrest patients and affect the outcome. The aim of this study was to evaluate the effect of intravenous pentoxifylline on organ functions and outcome in postcardiac arrest patients. Materials and methods Forty-two patients admitted to the ICU after inhospital cardiac arrest of both cardiac and noncardiac origin were included in this prospective double-blinded randomized two parallel-group study. Group P received a first dose of intravenous pentoxifylline 5 mg/kg over 5 min, followed by a 1.5 mg/kg/day infusion with a maximum of 1800 mg/day for 3 days, whereas group C received an equal volume of saline over 5 min and then infusion for 3 days as well. The primary outcome was the number of organ dysfunction-free and organ failure-free days, whereas the secondary outcome included time to initial acceptable blood pressure and systemic perfusion, number of acceptable blood pressure and systemic perfusion days, arterial lactate, Cerebral Performance Category score, duration of inotropic support, duration of mechanical ventilation, length of ICU stay, ICU survival, and adverse events. Results There was a significant increase in the number of organ dysfunction-free days [9 (3) vs. 6 (3), P = 0.003] and organ failure-free days [9 (3) vs. 7 (3), P = 0.008], accompanied by an increased number of acceptable blood pressure and systemic perfusion days [8 (3) vs. 6 (4), P = 0.01], with a shorter time to reach initial acceptable blood pressure and systemic perfusion [68 (51) vs. 38 (36), P = 0.03 ] and a significant improvement in the Cerebral Performance Category score on days 6, 7, and 14 in group P compared with group C. The arterial lactate level, duration of mechanical ventilation, duration of inotropic support, and ICU length of stay were significantly reduced in group P, along with an improvement in ICU survival that did not reach statistical significance. Conclusion We conclude that administration of intravenous pentoxifylline in postcardiac arrest patients improved organ function and decreased length of ICU stay, with no adverse effects.

Background Severe pre-eclampsia (PE) is a potentially life-threatening multisystem disease that requires urgent management. Delivery of the fetus is the definitive treatment for PE. However, effective and safe control of severe hypertension is the most important aspect of critical care management. This study aimed to compare the effectiveness and safety profile of hydralazine infusion versus nitroglycerin infusion as antihypertensive therapy in the acute management of patients with severe PE. Patients and methods A total of 180 patients with severe PE admitted to Ain Shams Obstetric ICU to stabilize blood pressure before delivery were randomly assigned to one of two equal groups: group H and group N. Group H received hydralazine infusion (1 mg/ml) and group N received nitroglycerin infusion (1 mg/ml). The infusion rate (5 ml/h) was adjusted to maintain systolic blood pressure at 130-140 mmHg and diastolic blood pressure at 80-100 mmHg. Results As regards hemodynamic parameters, the time to achieve blood pressure control was significantly shorter in the N group compared with the H group. However, the number of cases of severe persistent hypertension and the number of attacks of hypotension were comparable between the two groups. Maternal side effects and fetal and neonatal complications were comparable between the two groups, except for maternal headache and tachycardia, which were significantly higher in the H group compared with the N group. Concerning the mode of delivery, the rate of cesarean section delivery was significantly higher than the rate of vaginal delivery in both groups. Meanwhile, the rate of cesarean section after induction of labor was significantly higher in the N group compared with the H group. Conclusion Nitroglycerin could be a good alternative option for the acute management of patients with severe PE. It is an effective antihypertensive with minimal side effects.

Introduction Tracheostomy is one of the most common procedures performed in the ICU. Tracheostomy decreases the dead space and the effort of breathing, and facilitates suction and chest drainage. The easy placement of the tracheostomy tube makes it the only acceptable method for home ventilation. Tracheostomy can be performed either through percutaneous dilatation using the Seldinger technique in the ICU or surgically by an ENT surgeon in the operating room (OR). The approach for tracheostomy, whether percutaneous or surgical, remains a point of debate. Aim This an observational (prospective cohort) study to compare percutaneous dilatation tracheostomy (PDT) with surgical tracheostomy (ST) with regard to both perioperative and late postoperative complications. Patients and methods A total of 200 patients admitted to King Abdulaziz Specialist Hospital between February 2010 and December 2013 were allocated to two groups: group A included 100 patients who had undergone PDT, and group B included 100 patients who had undergone ST. Both perioperative and late postoperative complications were recorded and compared between the two groups. Changes in blood gases, atelectasis, emphysema, pneumothorax, failure to cannulate the trachea or false passage, tracheal ring fractures, wrong site, and tracheal wall injury were considered perioperative complications, whereas bleeding, infection, stenosis, and tracheoarterial and tracheoesophageal fistula were considered late postoperative complications. Results PDT resulted in a significantly higher perioperative complication rate as regards blood gas changes, false passage, and tracheal wall injury, but there was no significant difference with regard to atelectasis, tracheal ring fractures, wrong site, emphysema, and pneumothorax. However, PDT resulted in a significantly lower postoperative complication rate as regards bleeding and infection, but no statistically significant difference was found in the incidence of stenosis. Tracheoarterial and tracheoesophageal fistula were not reported in either PDT or ST. Conclusion PDT is a safe and reliable method for tracheostomy in all ICU cases and is associated with lower incidence of postoperative complications in terms of bleeding and stomal infection.

Background The role of supraglottic airway devices in general anesthesia for cesarean section (CS) has been controversial, although there is increasing evidence for their use in the difficult obstetric airway, especially in those with esophageal drains as the I-gel. Objective The aim of this study was to evaluate safety of the I-gel as an effective airway compared with the traditional use of cuffed endotracheal tube (ETT) in elective CS. Materials and methods Eighty parturient women, ASA I-II, scheduled for elective CS were randomly selected in this study. Under general anesthesia, the I-gel was compared with ETT as regards ease of insertion, insertion time, and success rate of insertion after first attempt, bucking at the end of surgery, and complications, which included trauma and laryngeal spasm. Other measurements included regurge and/or aspiration and air lack during ventilation using I-gel. Results I-gel was significantly better compared with ETT in terms of the ease of insertion (P = 0.016), success rate after first attempt (P = 0.044), bucking before removal (P = 0.043), laryngeal spasm (P = 0.044), and postoperative complications, which included sore throat and trauma (P = 0.003). Conclusion I-gel is an easy, safe, and effective alternative airway device compared with the traditional use of cuffed ETT in elective CS

Background Double-lumen tube (DLT) is usually performed using blind placement followed by bronchoscopic position confirmation, which is time consuming and complications may occur. We assume that bronchoscopic-guided DLT placement and position confirmation will save time and complications may be less. Patients and methods A total of 31 patients included in this study were randomly allocated into either the conventional group (n = 15) or the bronchoscopic group (n = 16) on the basis of DLT placement; in the conventional group the DLT was inserted blindly, whereas in the bronchoscopic group the DLT was inserted under guidance of the flexible bronchoscopy passed into the bronchial lumen. Thereafter, clinical assessment was performed followed by bronchoscopic assessment in both groups. Clinical findings and bronchoscopic assessment as well as time needed for each were recorded. Hemodynamic response, oxygen saturation, and arrhythmias were also recorded. Results Both groups were comparable with respect to demographic data. There was significant difference when comparing time needed for placement and confirmation of DLT in both groups. The clinical assessment was satisfactory in 12 as against 16 patients, whereas the bronchoscopic assessment revealed proper positioning in seven as against 13 patients and misplacement in eight as against three patients in the conventional and bronchoscopic groups, respectively. Hemodynamic response, oxygen saturation, and arrhythmias did not show any differences. Conclusion Flexible fiberoptic bronchoscopy could be used safely as an initial guide for placement and position confirmation; time needed for placement and confirmation as well as complications were reduced.

Background I-gel is the second generation of supraglottic airway devices with a noninflatable cuff that has several potential advantages over other supraglottic airway devices. Objective The aim of this study was to compare I-gel with proseal laryngeal mask airway (PLMA) and endotracheal tube (ETT) during elective minor surgical procedures using controlled ventilation. Design and setting A prospective, randomized, comparative study. Patients and methods A total of 60 adult female patients ASA I-II scheduled for elective breast lumpectomy surgery under general anesthesia with positive pressure ventilation were divided equally into three groups (20 patients each): group I used I-gel, group II used PLMA, and group III used ETT for airway maintenance. The three devices were compared with regard to the insertion characteristics, the ease of gastric tube insertion, tidal volumes, leak volumes, airway sealing pressures, hemodynamics, gas exchange parameters, and postoperative airway complications. Results The mean insertion time for I-gel (9.8 ± 2.5 s) was significantly shorter than that of PLMA (15.4 ± 3.2 s) and ETT (14.1 ± 2.1 s) (P < 0.001). The I-gel group (19/20) and the ETT group (18/20) showed a significantly easier insertion compared with the PLMA group (13/20) (P < 0.05). There was a significant increase in the mean arterial blood pressure after the insertion of the airway device in the ETT group (110 ± 13 mmHg) compared with the I-gel group (100 ± 10 mmHg) and the PLMA group (102 ± 11 mmHg) (P < 0.05). There was a significantly lower incidence of hoarseness, nausea, regurge, vomiting, and dysphagia in the I-gel and the PLMA groups when compared with the ETT group. Conclusion I-gel is an effective alternative device to PLMA and ETT during minor surgical procedures using controlled ventilation as it produces minimal hemodynamic changes, less airway morbidity, and is rapid and easy to insert.

Introduction The occurrence of emergence agitation (EA) in pediatric patients who received sevoflurane anesthesia is a common postoperative problem. Purpose This study aimed to compare the efficacy of propofol versus fentanyl to decrease the incidence of EA using an emergence behavior scale - pediatric agitation emergence delirium (PAED). Patients and methods This study was performed on three patient groups undergoing the same surgical procedure, under sevoflurane anesthesia: the first received saline as a control, the second received propofol, and the third received fentanyl. Thereafter, we compared the efficacy on incidence and severity of EA using an emergence behavior scale - PAED. Results Regarding the frequency of agitation, the highest frequency was observed in the control group followed by the propofol group and then the fentanyl group (46.9, 18.8, and 12.5%, respectively). The onset of agitation was delayed in the propofol and fentanyl groups when compared with the control group (P < 0.01 and 0.02, respectively). There was no statistically significant difference between the three groups regarding the duration of agitation. The PAED scoring revealed no significant difference between the propofol and fentanyl groups (P = 0.239), but a highly significant difference between both of them and the control group was found (P < 0.001). Conclusion Both propofol and fentanyl decrease the incidence and the severity of EA, but there is no reliable significance when comparing both drugs. We recommend further studies to declare other drugs that have potency to decrease the incidence and to treat the EA.

Background Increase in middle ear pressure (MEP) (mmH ₂ O) is an undesirable condition because of its potential complications. The aim of this randomized study was to compare the effects of isoflurane and sevoflurane on MEP. Patients and methods Patients in American Society of Anesthesiologists (ASA) group I-II between 6 and 14 years of age undergoing tonsillectomy operation were randomized into two groups. Group 1 received isoflurane and group 2 received sevoflurane for maintenance of anesthesia after induction with thiopental and suxamethonium in both groups. MEPs were measured and recorded 1 day before the operation (T0), with the patient lying supine on the operating table (T1), after the induction of anesthesia and endotracheal intubation (T2), and soon after withdrawal of anesthesia (T3). Finally, MEP values were compared intragroup with the baseline value (T0) and between groups. Results In comparison with the baseline value in T0, MEP was significantly increased in T1, T2, and T3 in the two groups. There were no differences between groups at all times, but at the end of anesthesia at T3, the increase in MEP was significantly lower in group 1 (isoflurane group) than in group 2 (sevoflurane groups) (103 ± 68 vs. 138 ± 99, P < 0.01 in the right ear and 112 ± 82 vs. 141 ± 101, P < 0.01 in the left ear). Conclusion There was an increase in MEP after anesthesia with both the inhalational anesthetics, but the increase in MEP was significantly lower during isoflurane anesthesia, which makes it more suitable during middle ear surgery.

Background The aim of this study was to assess whether total intravenous anesthesia (TIVA) offers an alternative anesthetic technique to inhalational anesthesia for patients undergoing radiofrequency (RF) ablation for hepatic focal lesions. Patients and methods A total of 100 American Society of Anesthesiologist (ASA) physical status II patients were included and divided into two groups: the first group underwent RF ablation of hepatic focal lesions under sevoflurane inhalational anesthesia with a laryngeal mask airway applied, whereas the second group was under TIVA with propofol infusion and face mask was applied. The hemodynamic changes, as well as the changes in Spo ₂ , were recorded during the procedure and in the recovery room. The time to speak and the occurrence of postoperative nausea and vomiting (PONV) in the recovery room were also recorded. Results The two groups were comparable as regards the changes in arterial blood pressure values from the baseline. The TIVA group showed reductions in Spo ₂ values after propofol loading, which was corrected with the application of an oropharyngeal airway. The time to speak was longer in the TIVA group than in the sevoflurane group, but it did not prolong the time of discharge from the postanesthesia care unit. The sevoflurane group showed higher incidence of PONV in the recovery room. Conclusion TIVA with propofol infusion offers an alternative anesthetic technique for RF ablation of hepatic focal lesions with the advantages of hemodynamic stability, avoiding instrumentation of the airway in a day-case patient without the development of PONV with the same technical success offered by sevoflurane anesthesia.

Background This randomized, double-blind, prospective-controlled study was designed to assess magnesium sulfate, an N-methyl-D-aspartate receptor blocker, as an anesthetic adjuvant decreasing emergence delirium/agitation, pain, postoperative analgesic requirement, and adverse events. Patients and methods Forty-seven patients undergoing an adenotonsillectomy were included in two parallel groups: the magnesium group received magnesium sulfate 40 mg/kg intravenously after induction of anesthesia, followed by 15 mg/kg/h by a continuous intravenous infusion during the operation. The same volume of isotonic solution was administered to the control group. Primary outcome measures were emergence delirium/agitation assessed by pediatric anesthesia emergence delirium scale. Secondary measures included intraoperative sevoflurane concentration, recovery time, pain assessed by objective pain score, time to first postoperative rescue analgesic, the total dose of rescue fentanyl required, need for rescue antiemetic, postanesthetic care unit (PACU) stay, postoperative total analgesic required, and postoperative adverse events. Results In the magnesium group, there was a reduction in the incidence and severity of pediatric anesthesia emergence delirium [(13 vs. 39%) and (8 vs. 14)], objective pain score (1 vs. 3), sevoflurane concentration (0.0001), time to discharge from the PACU (P = 0.04), postoperative analgesic requirement, and adverse events compared with the control group. Conclusion Magnesium sulfate as an anesthetic adjuvant decreased the incidence and severity of postoperative emergence agitation and pain, intraoperative sevoflurane concentration, time in PACU, and postoperative analgesic requirement.

Context Ambulatory surgery has a target of rapid recovery and discharge. Esmolol has sparing effects on inhalational anesthetics and opioids. Aim The aim of the study was to demonstrate effects of esmolol infusion on recovery profile and discharge from postanesthesia care unit (PACU). Settings and design This study was a randomized, double-blind, and controlled study. Patients and methods Sixty female patients scheduled for elective gynecologic laparoscopic surgery under general anesthesia were divided into two groups. Patients were given either esmolol loading and maintenance doses (the esmolol group) or equivalent volume of normal saline (the control group). Esmolol was given as a loading dose of 1 mg/kg just before induction of anesthesia followed by an infusion of 30 mg/kg/min. Depth of anesthesia was controlled by bispectral index monitoring and variable dose propofol infusion, whereas fentanyl and sevoflurane doses were fixed throughout the procedure. Times denoting recovery from anesthesia were recorded. Patients who reached White-Song score of 12 plus pain numerical rating scale below 4 were discharged from PACU. Time needed for PACU discharge was recorded. Results Compared with the control group, the esmolol group had following statistically significant results: lower blood pressure and heart rate, less fluctuant bispectral index values, lower amount of propofol infusion used, shorter times for immediate postoperative eye opening, extubation, tongue protrusion, and ability of the patient to mention her name, lower pain scores, fewer patients needed analgesics and earlier discharge from PACU. Conclusion Intraoperative esmolol infusion is associated with hemodynamic stability and antinociceptive properties. Recovery profile was excellent and helped early discharge from PACU.

Background Esmolol is the first intravenous, short-acting, titratable b-blocker for use in critical care and surgical settings. It influences core components of an anesthetic regimen, such as analgesia, hypnosis, and memory function. Aims To investigate whether perioperative esmolol infusion as an adjuvant to total intravenous anesthesia could affect the total anesthetic and analgesic requirements in adult patients undergoing arthroscopic shoulder surgery. Settings and design A randomized, double-blinded, prospective study. Materials and methods Eighty adult ASA I and II patients scheduled for elective arthroscopic rotator cuff repair were randomized into the esmolol group (n = 40) and the control group (n = 40). In the esmolol group, 1 mg/kg esmolol was given as a bolus over 30 s, followed by 15 mg/kg/min as an intravenous infusion, and in the control group, the same volume of normal saline was given during the same time period. The heart rate, the mean arterial blood pressure, the depth of anesthesia, the duration of anesthesia, the recovery time, total anesthetic requirements, the postoperative pain score (VAS), and the total postoperative analgesic requirements were monitored and calculated during the perioperative period. Results There was no significant difference between both groups regarding the demographic data using the unpaired t-test. There was a significant difference between both groups (P < 0.05) regarding different parameters, except the duration of anesthesia, using the unpaired t-test. Preoperative mean values of heart rate (beats/min) and the mean arterial blood pressure (mmHg) were comparable between the two groups (P > 0.05). However, after induction of anesthesia and thereafter, there was a significant reduction in heart rate and mean arterial blood pressure mean values in the esmolol group when compared with the control group (P < 0.05). A significant change in bispectral index was noticed within each group in comparison with the baseline using the paired t-test. However, there was no significant difference between both groups. Postoperative pain assessments by VAS (0-100 mm) showed significantly lower pain scores in the esmolol group compared with the control group by the paired t-test (P < 0.05). There was a highly significant reduction (P < 0.001) in the total cumulative doses of morphine consumption by PCA during the first 24 h in the esmolol group compared with the control group. Conclusion Perioperative esmolol infusion reduces the total anesthetic and analgesic requirements and postoperative pain. Hence, esmolol can be considered as safe and suitable adjuvant to total intravenous anesthesia.

Introduction The objective of anesthesia has always been to enable correction of surgical pathology with the best technique and minimum risk to the patient. The aim of the present study was to determine clinically, without using a peripheral nerve stimulator, whether continuous infusion or intermittent bolus dosing of rocuronium bromide yielded a better clinical condition during general anesthesia. Patients and methods The study was carried out on 60 adult patients. A common technique of general anesthesia was used in all patients. Patients were randomized to receive either a continuous infusion (group I, n = 30) or intermittent bolus dosing (group II, n = 30) of rocuronium bromide. Intraoperatively (a), hemodynamic parameters (heart rate and arterial pressure), (b) clinical relaxation by a grading technique, (c) total drug requirement, (d) recovery status by modified Steward score were assessed and were compared between the two groups. Results The mean heart rate and mean arterial pressure at different time intervals after intubation with rocuronium were not significantly different between the two groups. The total drug requirement was significantly greater in patients who received an intermittent bolus dose of rocuronium than those who received a continuous infusion. Clinical relaxation and recovery status in patients receiving rocuronium infusion were significantly better. Conclusion Rocuronium infusion offers a better and stable degree of relaxation compared with intermittent bolus dosing for intermediate duration of operation, which can be assessed using the clinical relaxation grading system. Rocuronium is a rapidly acting and hemodynamically stable nondepolarizing muscle relaxant with fewer drug requirements and provides better quality of recovery status during a continuous infusion.

Context Sedation is commonly used to improve patients' tolerance and comfort during flexible bronchoscopy (FB). Dexmedetomidine is a relatively novel sedative for use in FB. Aims The aim of this study was to compare dexmedetomidine and propofol as sole sedative agent in terms of hemodynamics, efficacy, safety and tolerance to the procedure among patients undergoing FB. Settings and design This study was carried out in a tertiary care teaching hospital, and was a double-blind randomized-controlled trial. Patients and methods Sixty patients were analyzed. Group 1 received propofol (1 mg/kg bolus, then 5 mg/kg/h infusion); group 2 received dexmedetomidine (1 mg/kg bolus, followed by 0.7 mg/kg/h infusion). Intraoperative (IOP) SpO ₂ , heart rate, mean arterial pressure, and respiratory rate were recorded at nine time points. Primary outcome variables were hemodynamic variables, level of sedation, and recovery time (to reach an Aldrete score 10/10). Results The dexmedetomidine group showed significantly lower mean heart rate than the propofol group at IOP ₀ , IOP ₂ , and IOP ₄ . The mean arterial pressure was significantly higher throughout the procedure in the dexmedetomidine group compared with the propofol group (P < 0.001). A significant decrease in respiratory rate was noted in the dexmedetomidine group at IOP ₄ and IOP ₆ (P < 0.001). The lowest mean SpO ₂ was noted in the dexmedetomidine group (97.0 ± 1.1). Incidences of bucking and coughing were significantly higher in the dexmedetomidine group. Bronchoscopist visual analogue scale scores for coughing and satisfaction were significantly lower in the propofol group (P < 0.001). Recovery time was shorter in the propofol group [3 (1.2) vs. 4.5 (1.1) min] (P < 0.001). Conclusion Propofol showed superiority over dexmedetomidine in terms of safety, efficacy, adverse-effect profile, and tolerance to the procedure in patients undergoing diagnostic flexible bronchoscopy.

Context Anxiety and pain are common responses to surgery and can negatively affect patient outcomes. Music is increasingly being used as a nonpharmacological intervention perioperatively, to improve patient outcomes and to avoid polypharmacy. Aims The aim of this study was to evaluate the impact of intraoperative music on the anesthetic requirement and stress response for laparoscopic surgeries under general anesthesia. Settings and design This was a prospective, randomized, double-blinded study. Materials and methods After approval of the hospital ethical committee, 60 ASA I patients were randomly assigned to the music and the no-music group. In the music group, classical instrumental music was played after the induction of anesthesia until the skin closure. In the no-music group, patients wore headphones but no music was played. We established three sample times for measurement of capillary blood sugar level during the procedure and one in the recovery room. Hemodynamic data were recorded. There was no statistically significant difference with respect to demographic profile, baseline hemodynamic variables, and duration of surgery. Results There was no statistically significant difference in the intraoperative hemodynamics between the two groups. The bispectral (BIS) value, end-tidal isoflurane concentration, and fentanyl requirement were comparable in the two groups. There was no significant difference in the blood sugar levels between the two groups. Conclusion In this study, we could not demonstrate the beneficial effects of intraoperative music as a nonpharmacological intervention under general anesthesia on stress response and anesthetic requirement.

Background The well-known toxic effects of bupivacaine on central nervous system and cardiovascular system were a base for the development of new long-acting local anesthetics. Levobupivacaine is the pure S(-)-enantiomer of racemic bupivacaine. This study compares the efficacy of levobupivacaine as against bupivacaine by epidural clinical study and by different routes in animal study. Materials and methods Evaluation of the analgesic activities by the hot plate method was carried out in nine groups of mice. Each four groups were injected intraperitoneally with either levobupivacaine or bupivacaine. The control group received saline. The hemodynamic effects of levobupivacaine and bupivacaine were carried out on the isolated rabbit's heart and anesthetized cats for carotid blood pressure and ECG. Thirty patients undergoing limb surgery were randomized to receive 15 ml of 0.5% levobupivacaine or bupivacaine through epidural needle. Intraoperative blood pressure and heart rate were recorded. Onset time of sensory and motor block, time to T₁₀ sensory block, complete motor block, quality of analgesia, and times for two segment regressions were detected. Results Experimentally, the intensity and duration of analgesia produced by levobupivacaine was more than that of bupivacaine. Both drugs induced significant dose-dependent negative inotropic effect, but it was lesser in levobupivacaine than in bupivacaine. An amount of 2 mg/kg levobupivacaine produced a significant rise in blood pressure and 4 mg/kg significantly decreased it, whereas 1 and 2 mg/kg bupivacaine produced a significant decrease in blood pressure. The ECG pattern of levobupivacaine showed no abnormalities, but bupivacaine at a dose of 2 mg/kg produced significant bradycardia and ECG changes. Cardiac arrest and death of cats occurred when 4 mg/kg of bupivacaine was injected. Clinically, the onset time of sensory block, time to T ₁₀ sensory block and time to complete motor block are lower with bupivacaine than with levobupivacaine. Conclusion We found, based on the current pharmacodynamics evidence from this experimental and clinical study, that levobupivacaine has good analgesic activity and less cardiodepressant effect, and it offers advantages over bupivacaine.

Background Perineal and anorectal surgeries performed on an outpatient basis under spinal block lead to a shorter postoperative hospital stay. Spinal anesthesia has better cost efficacy and is very well accepted by patients. Ropivacaine is less toxic with rapid motor recovery. Clonidine provides dose-dependent analgesia. Intrathecal opioids decrease nociceptive afferent input without affecting dorsal root axons. Objective The aim of this study was to compare the onset, the level, and the duration of sensory and motor blockade occurring after the administration of low-dose hypobaric ropivacaine (0.1%) either alone or with clonidine or fentanyl as adjuvants in spinal anesthesia for anorectal surgeries in the jack-knife position. Study design A prospective, randomized, double-blind, comparative, case-control study. A total of 75 ASA grade I-III patients were randomized into three groups. Results There was a significant difference in the heart rate among the three groups. The plain ropivacaine group had a significantly higher heart rate. The addition of fentanyl resulted in a stable heart rate, but with the addition of clonidine, there was a decrease in the heart rate from the baseline. Mean arterial pressure (MAP) in the ropivacaine group was significantly higher in comparison with the clonidine or the fentanyl groups. None of the patients in any of the groups had complete motor blockade (Bromage score ≥ 3) at any time. After 2 h, there was complete regression (Bromage score = 1) in all the patients in all the groups. The majority of cases, irrespective of their group, achieved a T10 level of sensory blockade. The time taken for two-segment regression of sensory block and the time required for the first analgesic dose was significantly higher (P < 0.001) in the clonidine group. Conclusion Hypobaric ropivacaine provides adequate surgical conditions for anorectal surgeries. Also, intrathecal clonidine with 0.1% hypobaric ropivacaine is a better adjuvant than fentanyl as it prolongs the duration and improves the quality of the sensory block and provides postoperative analgesia for longer periods.

Objective To assess the effect of intrathecal midazolam with bupivacaine-fentanyl in elderly patients undergoing endourologic procedures. Materials and methods This prospective, randomized, double-blind study involved 60 ASA physical status II-III patients aged over 60 years scheduled for elective endoscopic urologic procedures under spinal anesthesia with hyperbaric bupivacaine 0.5% (5 mg/ml). They were randomized into one of three equal groups of 20 patients each: the first group, control group (group C), received 7.5 mg hyperbaric bupivacaine 0.5% in a volume of 1.5 ml; the second group, fentanyl group (group F), received 7.5 mg hyperbaric bupivacaine 0.5% in a volume of 1.5 ml and 10 mg fentanyl (0.1 ml); and the third group, fentanylmidazolam group (group FM), received 7.5 mg hyperbaric bupivacaine 0.5% in a volume of 1.5 ml and 10 mg fentanyl (0.1 ml) plus 1.0 mg of midazolam (0.2 ml). Sensory and motor effects were assessed. Postoperative pain, sedation, and adverse effects were also recorded. Results The three studied groups were comparable in demographic and clinical characteristics. They were hemodynamically stable. There was no significant difference between the three groups in the onset of sensory (P = 0.721) and motor block (P = 0.342), duration of motor block (P = 0.286), and sedation score (P = 0.229). Duration of sensory block was prolonged in group F compared with the control group (P < 0.001) and prolonged more in group FM compared with the F group (P = 0.065). Time to first request of rescue analgesic was significantly longer in group F compared with the C group (P = 0.033) and in FM compared with the F group (P < 0.001). All patients reported excellent or good degree of satisfaction with anesthetic procedure (P = 0.547). Conclusion Adjuvant intrathecal midazolam resulted in intraoperative hemodynamic stability and safely potentiates postoperative analgesic effect of bupivacainefentanyl spinal anesthesia in elderly patients undergoing endourologic procedures.

Objective This study aimed to assess the clinical efficacy of levobupivacaine in spinal anesthesia for day-case brachytherapy for carcinoma of the cervix. Study design A prospective, randomized, double-blind study was conducted at the Anesthesia Department of Al-Azhar University Hospitals over a period of 6 months. Patients and methods Between July 2013 and January 2014, 40 female patients were included in the study after approval of the Local Ethics Committee of Anesthesia and Intensive Care Department of Al-Azhar University. Informed consent was taken from the patients who were randomized into two groups. Bupivacaine group, which included 20 patients who received intrathecal 7.5 mg of 0.5% hyperbaric bupivacaine; and levobupivacaine group, which included 20 patients who received intrathecal 7.5 mg of 0.5% levobupivacaine. About 25 mg fentanyl was added to the local anesthetic solution in both groups through the L3/L4 interspace. The upper level of sensory blockade, two-segment sensory regression, S2 regression, side effects of the local anesthetic used, urination, ambulation, and the duration of hospital stay were assessed. Results There were no significant differences between both groups regarding the level of sensory blockade, the onset of sensory blockade to the T10 dermatome, and side effects of the local anesthetic. The time to two-segment regression, S2 regression, ambulation, and the duration of hospital stay were significantly shorter in the levobupivacaine group (P < 0.05). Conclusion The mixture of 7.5 mg of 0.5% levobupivacaine+25 mg fentanyl given intrathecally was more effective as it provided sensory and surgical blockade with minimal side effects and early home discharge in ambulatory brachytherapy for carcinoma of the cervix compared with 7.5 mg of 0.5% hyperbaric bupivacaine+25 mg fentanyl.

Background Hyperbaric ropivacaine provides adequate sensory and motor block for short duration surgical procedures, safe hemodynamic profile, rapid recovery, early ambulation, and less side effects. Aim and objective The aim of this study was to evaluate the clinical efficacy and safety of subarachnoid block with 0.5% hyperbaric ropivacaine compared with 0.5% hyperbaric bupivacaine in elective gynecological surgeries. Methods Fifty female patients of ASA physical status I and II were randomly selected and divided into two groups: group R and group B. Group R was given 3 ml of 0.5% hyperbaric ropivacaine (15 mg) and group B was given 3 ml of 0.5% hyperbaric bupivacaine (15 mg) during subarachnoid block. Preoperative and intraoperative hemodynamic variables such as heart rate, blood pressure, and SpO ₂ were recorded. Sensory and motor block were also assessed at regular intervals. Results The mean time to achieve the highest level of sensory block was 13.1 min in group R and 12.2 min in group B (P < 0.05). Maximum sensory level was T8 and T7 in group R and group B, respectively (P < 0.05). The onset time for motor block was 6.16 min with bupivacaine versus 9.04 min with ropivacaine (P < 0.05). The duration of motor block (grade I) was longer (162.8 min) with bupivacaine than (131.7 min) with ropivacaine (P < 0.05). Despite adequate hydration, 40% of patients developed hypotension in group B compared with 16% in group R. Conclusion Hyperbaric ropivacaine has lower level of cephalad spread of sensory block, takes more time for maximum spread of analgesia, has early regression of sensory block to L5, has longer onset time for motor block, shorter duration of motor block, and causes less hypotension and other side effects compared with hyperbaric bupivacaine.

Background The purpose of this study was to evaluate the effect of transdermal nitroglycerine patch as a coadjuvant to intrathecal nalbuphine with bupivacaine in patients undergoing lower abdominal surgery. Patients and methods A total of 120 patients (ASA I or II) were randomized into two equal groups in this double-blind, placebo-controlled trial. The control group (group C) received intrathecal 0.5% hyperbaric bupivacaine 15 mg (3 ml) plus 0.8 mg (0.4 ml) preservative-free nalbuphine plus transdermal placebo patch, and the study group (group NG) received intrathecal 0.5% hyperbaric bupivacaine 15 mg (3 ml) plus 0.8 mg (0.4 ml) preservative-free nalbuphine plus transdermal nitroglycerine patch (5 mg). The transdermal patch (either nitroglycerine or placebo) was applied on the chest 20 min after spinal injection. Pain intensity, hemodynamics, and adverse effects were evaluated. Results Patients in group NG had longer duration of effective analgesia with subsequent longer time for the first rescue analgesic (482.6 ± 16.3 min) compared with group C (334.2 ± 15.6 min) (P < 0.05). Moreover, group NG required less rescue analgesics in 24 h compared with group C (P < 0.05) and had lesser overall 24-h pain visual analogue scale scores. The incidence of perioperative adverse effects was similar between the two groups (P > 0.05). Conclusion Transdermal nitroglycerine (5 mg) significantly prolonged the analgesic effect of intrathecal nalbuphine and provided effective postoperative analgesia after lower abdominal surgery.

Context Epidural bupivacaine remains the most widely used local anesthetic for postoperative pain relief, but ropivacaine is increasingly being used as it has less cardiac toxicity. Aim To compare the analgesic efficacy and safety of epidural bupivacaine with fentanyl versus ropivacaine with fentanyl during abdominal surgery and in the immediate postoperative period. Materials and methods One hundred patients undergoing abdominal surgeries under general anesthesia with supplementary epidural analgesia were studied. Group B received an epidural infusion of 0.2% bupivacaine with fentanyl 2 mcg/ml at 6 ml/h intraoperatively and 0.1% bupivacaine with fentanyl 2 mcg/ml at 6 ml/h postoperatively. Group R received an epidural infusion of 0.2% ropivacaine with fentanyl 2 mcg/ml at 6 ml/h intraoperatively and 0.1% ropivacaine with fentanyl 2 mcg/ml at 6 ml/h postoperatively. Results Intraoperative and postoperative heart rate and mean arterial pressure in both groups were comparable. Pain scores were significantly higher in group B postoperatively up to 24 h. The number of epidural topups required was comparable intraoperatively, but in the postoperative period, group B needed significantly more number of epidural topups. The requirement of rescue analgesia showed no significant difference intraoperatively and postoperatively between groups. Conclusion An epidural infusion of ropivacaine 0.2% with fentanyl provides better intraoperative and postoperative analgesia compared with bupivacaine 0.2% with fentanyl.

Background Caudal anesthesia (CA) is used in pediatrics to avoid the possible side effect of postoperative opioids and allows for smooth and rapid emergence from anesthesia. Opioids were added to the injection in CA to prolong the effect of anesthesia. Objective To compare the effect of bupivacaine alone and with nalbuphine in CA. Patients and methods A total of 40 patients scheduled for operations under general anesthesia combined with CA were divided into two groups: in group B, CA was carried out by injection of bupivacaine 0.25% in a dose of 1 ml/kg, and in group NB, CA was carried out by injection of bupivacaine 0.25% 1 ml/kg with nalbuphine 0.1 mg/kg. Hemodynamic changes, oxygen saturation, pain score at 2, 4, 6, 12, 24 h postoperative, sedation score, incidence of postoperative urine retention, and duration of motor block were compared in both groups. The respiratory depression effect of nalbuphine was also recorded. Results There were no significant differences between the two groups regarding the hemodynamic changes. There were significant differences in postoperative pain score and sedation as group NB had prolonged analgesia and prolonged sedation time than group B. There were no significant differences in urine retention and motor block between both groups. Conculsion Nalbuphine added to bupivacaine in CA provides longer postoperative analgesia and sedation without respiratory depression.

Objectives The aim of this randomized, double-blinded study was to compare the duration of postoperative analgesia and sedation, and the incidence of any side effect of single-dose caudal dexmedetomidine with bupivacaine versus ketamine with bupivacaine in pediatric patients undergoing inguinoscrotal surgeries. Patients and methods A total of 60 pediatric patients, 2-5 years of age, American Society of Anesthesiologists physical status I or II, scheduled for inguinoscrotal surgeries were included in the study. The patients were divided into two equal groups: group A patients (n = 30) received dexmedetomidine with bupivacaine, whereas group B patients (n = 30) received ketamine with bupivacaine. For each patient, postoperative sedation score, pain score, duration of analgesia, and postoperative complications were recorded. Results The duration of postoperative analgesia was longer in group A than in group B, and sedation score was lower in group B than in group A, which was statistically significant. No significant postoperative complications were recorded in both groups. Conclusion The use of dexmedetomidine, as an additive to the local anesthetic bupivacaine in caudal epidural analgesia, during single-dose injection, prolonged the duration of postoperative analgesia following inguinoscrotal surgery compared with caudal administration of ketamine with bupivacaine, but with more sedation compared with ketamine. Both groups showed few side effects.

Objective The aim of this study was to study the implication of volume change of bupivacaine in the duration of motor and sensory blocks for early ambulation of the patient and in the rate of complications among patients. Patients and methods A total of 80 adult patients of ASA I, II, or III status, scheduled for lower limb surgery under regional anesthesia by femoral and sciatic nerve blocks, were included in this randomized prospective study. Patients were randomly divided into two equal groups (group I and group II). A total volume of 40 ml of bupivacaine 0.3% was used for peripheral nerve blockade in group I: 20 ml for femoral nerve blockade and 20 ml for sciatic nerve blockade; and a total volume of 60 ml of bupivacaine 0.3% was used in group II: 30 ml for femoral nerve blockade and 30 ml for sciatic nerve blockade. Assessment of the sensory and the motor blocks was carried out including onset of anesthesia and duration of both sensory and motor blocks. The assessment was carried out intraoperatively at 10, 20, and 30 min after the establishment of the procedure, and then at 6, 12, and 24 h after performing the block. Results The onset of the block was significantly shorter in group II. The sensory block was significantly denser in group II at 12 h. The motor block was less dense in group II at 12 and 24 h. The pain scale was less in group II at 6 and 12 h. Conclusion This study revealed that increasing the volume of the local anesthetics hastened the onset of the anesthesia and increased the duration and the density of the sensory block.

Objective This prospective study compares the pain control after total knee replacement using a single-shot femoral nerve block (FNB) against local infiltration analgesia (LIA). Patients and methods Sixty-four patients were included the study. A total of 29 patients received single-shot ultrasound-guided FNB at the end of the procedure, whereas 35 patients received LIA. Both groups were compared as regards pain at 2 and 4 h after surgery, pain before and after physical therapy on the first postoperative day, early flexion of the knee to 90°, total opiate use, and length of stay in the hospital. Results All patients completed the study. The group that received LIA showed significantly less pain at 4 h postoperatively, on the first postoperative day, and after physical therapy. The LIA group also showed significantly better rehabilitation and less hospital stay. Patients who received FNB used significantly more opiate compared with the LIA group. Conclusion LIA gives better pain control compared with single-shot FNB after total knee replacement.

Context Cesarean section is one of the most commonly performed surgical procedures. Intrathecal morphine is a popular and effective option for pain management following cesarean section. It is associated with side effects such as nausea, vomiting, pruritus, urinary retention, reactivation of oral herpes, and, rare but life-threatening, respiratory depression. The interest in transversus abdominis plane (TAP) block as a post-cesarean-delivery analgesic modality has surged in the past few years, and many studies have evaluated and compared its efficacy with intrathecal morphine. Aim The aim of the study was to compare spinal morphine and bilateral TAP block in cesarean section in morbidly obese parturients with respect to their postoperative analgesic efficacy and narcotic consumption. Settings and design This was a prospective randomized, double-blinded study. Materials and methods Parturients, 20 years or older, with BMI greater than 35 kg/m ² , who were scheduled to undergo elective cesarean section were recruited for the study. They were assigned to receive either intrathecal morphine (the ITM group) 0.1 mg or TAP block (the TAP group) using ropivacaine 0.5% 20 ml on each side. The primary outcome was pain on movement, from supine to sitting position. The secondary outcomes were the presence and severity of nausea and pruritus and the presence of respiratory depression. Results We enrolled 60 patients, of whom 59 were analyzed. The numeric rating scale score for pain was less in the ITM group than in the TAP block group, and this difference was statistically significant. Both pruritus and nausea happened in more patients in the ITM group than in the TAP block group, and this difference was statistically significant in both the 8 and 16 h observations. Conclusion In morbidly obese parturients, intrathecal morphine has superior post-cesarean-delivery analgesic efficacy compared with the TAP block.

Objective Transversus abdominis plane (TAP) block is a new, rapidly expanding technique. This study was designed to evaluate the efficacy of ultrasound-guided TAP block in comparison with epidural analgesia in pain management following lower abdominal surgery. Setting and duration The present study was conducted on 60 patients aged 20-75 years, who were admitted at Al-Azhar University Hospitals from February 2013 to March 2014. Patients and methods These patients were allocated to either group I (TAP, 30 cases) or group II (epidural block, 30 cases) using a randomized central computer-generated sequence held by an investigator not involved with the clinical management or data collection. The primary outcome was the proportion of participants who used more than 200 mg/kg of morphine in the first 24 h on arrival at the recovery ward. Secondary outcomes included the following: morphine consumption 24 h after operation; pain measured using the visual analog score in the recovery ward and at 2, 6, 10, 14, 18, and 24 h after operation; and postoperative nausea and vomiting measured with the total number of vomits during the first 24 h. Results The most important finding in our study was that TAP block provided highly effective postoperative analgesia in the first 24 h, especially in the neurofascial plane in the muscles and the skin but not the visceral pain, and that the TAP block reduced the mean intravenous morphine requirements by more than 70%. This reduction in opioid requirement resulted in fewer opioid side effects. In the present study, there was no significant difference between the studied groups as regards time spent in the recovery room, need for paracetamol during the first 8 h after surgical intervention, postoperative nausea and vomiting, and duration of hospital stay. In contrast, the total morphine consumption during the first 8 h was significantly less in group I than in group II, and the time to first analgesic request was significantly longer in group I than in group II. Finally, the number of cases that required more than 200 mg of morphine during the first 24 h was significantly less in group I than in group II. Conclusion Ultrasound-guided TAP block is an effective alternative for providing postoperative analgesia after lower abdominal surgery in comparison with epidural analgesia, but further studies in larger population are necessary.

Background Providing efficient postoperative analgesia for pediatric herinorrraphy is essential for surgical success. Different ultrasound (US)-guided techniques have been developed for pediatric nerve blocks. Aim This study aimed to compare US-guided ilioinguinal/iliohypogastric (II/IH) nerve block and US-guided transversus abdominis plane (TAP) block for pediatric unilateral inguinal herniorraphy with respect to postoperative analgesic efficacy by considering the time to first rescue analgesic as the primary outcome. Secondary outcomes included average pain scores, assessment of analgesic drug requirement, and incidence of postoperative vomiting. Patient and methods Fifty children scheduled to undergo unilateral herniorraphy were included in the study. After induction of general anesthesia patients were randomly allocated to one of two groups: group A or group B. Group A received US-guided II/IH nerve block with 0.2 ml/kg of 0.25% levobupivacaine and group B received US-guided TAP block with 0.2 ml/kg of 0.25% levobupivacaine. Fentanyl was given intravenously in case of failed block; failure was seen in one child (4%) in group A and in two children (8%) in group B and their postoperative data were not included in the statistical analysis. Time to first rescue analgesic, pain scores (FLACC score), the number of children who required postoperative analgesics, and incidence of vomiting were recorded. Results Time to first rescue analgesic was longer and the duration of analgesia was more stable in group A (273 ± 41.7 min) as compared with group B (209.6 ± 98.4 min) (P < 0.001). The average FLACC pain score for group A was 2 (1-2) compared with 3 (2.25-3.5) in group B, with statistically significant difference between the two groups (P < 0.001). The total number of patients who required paracetamol as a rescue analgesic in group A was 8 (33.3%) compared with 14 (60.9%) in group B (P < 0.001). Two patients in group B required morphine and both suffered from vomiting. Conclusion US-guided II/IH nerve block provides longer and more efficient postoperative analgesia compared with TAP block for pediatric inguinal herniorraphy.

Background Intravenous regional anesthesia (IVRA) is a simple and reliable type of regional anesthesia. However, it has some limitations such as tourniquet pain, lack of postoperative analgesia, and local anesthetic toxicity in case of tourniquet malfunction. Various additives to local anesthetics, such as opioids, NSAID, ketamine, and clonidine, are used. Aim The aim of this study was to evaluate the addition of dexmedetomidine to a safe intravenous dose of lidocaine for IVRA. Patients and methods a total of 50 patients undergoing elective superficial hand surgery were assigned into two groups: the L group and the LD group. In the L group, IVRA was achieved using 2 mg/kg lidocaine 2% alone, diluted with saline to a volume of 25 ml. In the LD group, IVRA was achieved using 2 mg/kg lidocaine 2% along with 0.5 mg/kg dexmedetomidine diluted with saline to a volume of 25 ml. The motor and sensory block onset and recovery times were assessed. Tourniquet pain and sedation score were assessed intraoperatively and postoperatively. The quality of anesthesia and the duration of analgesia were also recorded. Results Sensory and motor block onset times were shorter and recovery times were prolonged in the LD group. The quality of anesthesia was better in the LD group, and the fentanyl dose required intraoperatively was also lower in the LD group. The duration of postoperative analgesia was longer and the doses of lornoxicam required were lower in the LD group. Conclusion A safe intravenous dose of lidocaine can be used for IVRA for superficial hand surgery, and the addition of 0.5 mg/kg dexmedetomidine shortened the onset times for both sensory and motor blockade and improved the quality of anesthesia, with prolonged postoperative analgesia time.

Background and aims Adding dexmedetomidine to local anesthetics in intravenous regional anesthesia has been found to produce effective anesthesia and analgesia for minor hand surgery. The aim of this study was to compare hemodynamic changes, adverse effects, patient satisfaction, and anesthetic, analgesic, and sedation qualities in patients who received lidocaine only versus those who received dexmedetomidine with lidocaine during minor hand surgery. Methods One hundred patients scheduled for minor hand surgery were randomly allocated into two equal groups: group L and group DL. Patients in group L received 3 mg/kg lidocaine 0.5% (maximum dose 200 mg), and patients in group DL received 3 mg/kg lidocaine 0.5% (maximum dose 200 mg) + 0.5 mg/kg dexmedetomidine; the total volume was diluted to 40 ml with normal saline 0.9% in both groups and injected at a rate of 20 ml/min. Anesthesia, analgesia, and sedation qualities, hemodynamic changes, patient satisfaction, and adverse effects were recorded. Results The studied groups showed no significant difference in demographic data. In hemodynamics, mean arterial blood pressure and heart rate showed a statistically significant difference during and up to 30 min after tourniquet release (P < 0.001), and oxygen saturation showed no statistically significant difference during and after surgery (P > 0.05). There were statistically significant differences between the two groups (P < 0.05) as regards the quality of anesthesia, time of regression of sensory and motor blocks, and patient satisfaction. There were more patients who reported excellent satisfaction in the DL group (76%) compared with the L group (20%). Intraoperative and postoperative analgesic requirements were greater in the lidocaine group than in the dexmedetomidine group, and postoperative pain score (visual analog scale) was lower in the DL group compared with L group. Sedation score after release of tourniquet was significantly higher in the DL group compared with the L group except in the first 5 min. Conclusion On the basis of the results in this study we concluded that dexmedetomidine is a good adjuvant anesthetic, analgesic, and sedative agent in intravenous regional anesthesia.

Here, we present a case of difficult airway after patient consent. A young male patient presented with painless difficult mouth opening of 0.5 cm for 2 years, restricting him to only liquid diet. He was diagnosed as having bilateral temporomandibular joint ankylosis and was posted for release. The patient was classified as difficult for intubation with Mallampathi IV grade; systemic examination was within normal limits. Computed tomography (CT) of the temporomandibular joint showed gross bilateral osteoarthritic changes. He was planned for awake fiberoptic nasal intubation. The patient was given a detailed explanation about the procedure. The airway was prepared with topical and nebulized lignocaine. The fiberoptic bronchoscope was mounted with a 7.0 mm cuffed armored tube and inserted through the nostrils, proceeding until the vocal cords were visualized. After confirming with auscultation and by Capnography, patient was paralysed. Surgery was performed and the patient was extubated awake. Mouth opening improved to 2 cm. The use of the fiberoptic intubating bronchoscope in case of bilateral temporomandibular joint ankylosis with a high risk of airway control due to restricted mouth opening, a gift of modern technology, circumvents this difficulty without compromising on patient safety, with the patient being awake too, and should be considered a safe procedure.

Takayasu's arteritis (TA), also known as pulseless disease, is a rare disease involving the aorta and its main branches. Anesthesia for cesarean section in patients with TA is complicated by associated hypertension, end organ dysfunction, stenosis of major blood vessels, and overall vasculopathy. We report a pregnant patient with TA with common carotid artery involvement with a history of two abortions. She had also undergone bilateral renal artery angioplasty for stenosis. We discuss the anesthetic considerations with emphasis on appropriate monitoring for a favorable outcome in pregnancy complicated with TA.

Crouzon syndrome is a rare hereditary disorder, characterized by craniosynostosis. Management of difficult airway is challenging because of craniofacial abnormalities. Presentation during adulthood is rare. We describe the case of a 37-year-old man with a known case of Crouzon syndrome who was posted for fixation of humerus fracture. The patient was unique because of the presence of kyphoscoliosis with severe restrictive lung functions, atlantoaxial dislocation, and mental retardation, having almost all features of the syndrome. Anesthesia plan A was to use laryngeal mask airway proseal as the patient had adequate mouth opening. Nasal fiberoptic bronchoscopy was contraindicated and regional nerve block was not a feasible option. Plan A was not successful because of obstructed breathing pattern. Plan B of oral fiberoptic bronchoscopy-guided intubation with good airway anesthesia and sedation was successfully managed in the next attempt.