In patients with anticipated difficult airway, awake fiberoptic intubation (AFOI) is highly indicated. Preparation of the patient for optimal intubating conditions requires adequate anxiolysis while maintaining patient safety with respect to a patent airway and adequate ventilation. The present study compared dexmedetomidine (dex) with propofol–fentanyl (prop–fent) combination in terms of intubation condition and patient safety.
Forty patients were divided randomly into two groups: a prop–fent group, which received continuous infusions of propofol 30 μg/kg/min and fentanyl 0.5 μg/kg/h, and a dex group, which received dex. 1 µg/kg as a loading dose for 10 min, followed by a continuous infusion of 0.7 µg/kg/h. The parameters analyzed included the percentage of patients requiring rescue midazolam, total dose of rescue midazolam, anesthesiologist’s assessment of intubation condition, and patients’ and anesthesiologists’ satisfaction. Other parameters included hemodynamic changes, hypoxia, and state entropy at intubation.
Fewer dex-treated patients compared with prop–fent-treated patients required rescue midazolam to achieve/maintain Ramsay Sedation Scale level 2 (20 vs. 60%; P<0.001), and the supplemental midazolam dose was lower (0.6±0.85 vs. 1±1.05 mg; P<0.001). In terms of adverse hemodynamic effects, more frequent hypotension was observed in the dex group compared with the prop–fent group (20 vs. 10%; P<0.05). Hypertension was reported only in the prop–fent group (15 vs. 0%; P<0.05). Tachycardia was more frequent in the prop–fent group compared with the dex group (10 vs. 5%; P<0.05). Bradycardia was more common in the dex group compared with the prop–fent group (20 vs. 15%; P>0.05). Hypoxia did not occur in any patient in the dex group compared with one only patient in the prop–fent group (0 vs. 5%; P>0.05). Intubation scores were better in the dex group compared with the prop–fent group (P value <0.05) in terms of vocal cord movement. At intubation, it was found that patients in the dex group had lower levels of state entropy than patients in the prop–fent group (67.2±6.3 vs. 87.1±2.7; P value <0.05). Anesthetists rated their satisfaction with the technique as excellent in 90% of patients treated with dex compared with 70% of patients treated with prop–fent (P<0.05). In terms of patients’ satisfaction, it was found that 50% of patients in the dex group rated their satisfaction as excellent compared with 15% of patients in the prop–fent group (P<0.05). Patients’ recall of topical anesthesia, endoscopy, and intubation were generally higher in the prop–fent group (30, 5, and 5%, respectively) compared with the dex group (5, 0, and 0%, respectively) (P<0.05, P>0.05, and P>0.05, respectively).
Both the dex and the prop–fent regimes provided upper airway patency comparable to that of awake patients, satisfactory intubating conditions, and patient and anesthetist satisfaction in the majority of patients undergoing awake fiberoptic intubation. Dex appeared to offer better patient satisfaction, less patient recall of procedure, better anesthetist satisfaction, and a reduced hemodynamic response to intubation.
To evaluate the feasibility and outcome of upper limb orthopedic surgery under an axillary brachial plexus block using either bupivacaine alone or bupivacaine combined with dexmedetomidine (DEX). Patients were divided into two equal groups (n=25).
The patients in group B received 40 ml of 0.25% bupivacaine plus 1 ml normal saline only and the patients in group D received a mixture of 40 ml of 0.25% bupivacaine plus 1 ml DEX (100 mcg). The four main nerves in the axilla (musculocutaneus, radial, median, and ulnar) were identified using neural stimulation by a 1 mA current by a single injection. Sensory block was assessed at 10-min intervals with an ice cube testing the skin areas supplied by the identified nerves, and the motor block was evaluated once at the end of the 30-min period. Block performance data, duration of sensory and motor block, duration of analgesia, and pain severity at the time of request of rescue analgesia were rated using a 10-point visual analog scale (VAS). Patient comfort during the anesthetic procedure was evaluated on a VAS 0–10 scale and surgeon’s satisfaction in terms of intraoperative anesthesia and analgesia and postoperative analgesia.
Axillary block yielded an overall success rate of 100%. There was a nonsignificant difference between both groups in terms of the frequency of complete block, nerves that escaped block, block performance time, or motor block duration. However, the latency time was significantly shorter and the duration of sensory block was significantly longer in group D compared with group B. The mean VAS pain score was significantly lower with a significantly longer duration of postoperative analgesia in group D compared with group B. Moreover, 16 patients did not request rescue analgesia until discharge and 29 patients requested it only once, with a significant difference in favor of group D. The block performance in group D was highly satisfactory for both the patients and the surgical team, with a significantly higher mean satisfaction score compared with group B.
DEX added to bupivacaine for an axillary brachial plexus block shortened the onset time and prolonged the duration of the block and the duration of postoperative analgesia, and allowed upper limb orthopedic surgery to be managed as an outpatient procedure.
The efficacy of peripheral nerve block (PNB) in the form of combined femoral, sciatic, and obturator nerve blocks was compared with epidural anesthesia (EA) in patients undergoing major knee surgery.
The study included 40 patients of American Society of Anesthesiologists physical status I and II (age range 20–60 years) undergoing major knee surgery. The patients were randomly divided into two groups. EA was performed on patients in the EA group (n=20), and the femoral, sciatic, and obturator nerves were blocked in the patients belonging to the PNB group (n=20). For each patient, success in providing adequate anesthesia, onset of sensory and motor block, hemodynamic changes, time to first analgesic request, and patient and surgeon satisfaction with the anesthetic technique were recorded.
Two patients in the EA group and four patients in the PNB group required general anesthesia because of failed blocks. There were no significant differences between the two groups with regard to the success of providing adequate anesthesia. The onset of sensory motor block and the time to first analgesic request were significantly more prolonged in the PNB group than in the EA group. The incidence of hypotension was significantly higher in the EA group. Patient satisfaction was higher in the PNB group because of longer duration of postoperative analgesia, whereas surgeon satisfaction was higher in the EA group because of shorter time to achieve the block.
Femoral, sciatic, and obturator nerve blocks provide effective unilateral anesthesia and may offer a beneficial alternative to EA in patients undergoing total knee surgery.
Awake fiberoptic intubation (AFOI) is an established technique for the management of patients with difficult airways. A number of drugs have been described to provide sedation for this procedure. Benzodiazepines combined with opioids or propofol are commonly used agents. Recently, dexmedetomidine has emerged as an ideal sedative during AFOI.
To compare the efficacy and safety of dexmedetomidine as a sole sedative versus the conventionally used propofol/midazolam and fentanyl/midazolam combinations during AFOI.
Seventy-five patients with anticipated difficult airways who required tracheal intubation for elective surgery were enrolled and randomly allocated to one of three groups: group D (n=25) received a dexmedetomidine infusion, group PM (n=25) received a propofol/midazolam combination, and group FM (n=25) received a fentanyl/midazolam combination. The main outcome measures were fiberoptic intubating conditions and patient tolerance, which were graded using multiple scoring systems. Other parameters including hemodynamic (mean arterial pressure and heart rate) and respiratory changes were recorded.
All the scores that quantified patient tolerability and the fiberoptic intubating conditions were significantly better in group D than both groups PM and FM. Mean arterial pressure and heart rate decreased significantly during sedation in group D and group PM. Meanwhile, there was considerable hemodynamic stability in both group D and PM during intubation. The dexmedetomidine group showed more favorable respiratory changes than the other two groups.
Dexmedetomidine alone appears to be a more suitable agent for sedation during AFOI compared with either propofol/midazolam or fentanyl/midazolam combinations.
Dexmedetomidine is a highly selective α-2 adrenergic agonist with analgesic, sedative, and sympatholytic effects. We designed this prospective, randomized, double-blind study to examine the effects of dexmedetomidine on the hemodynamic changes, analgesic needs, and recovery profile during and after laparoscopic cholecystectomy (LC).
After obtaining written informed consent, 60 ASA I and II patients undergoing LC were recruited and divided equally and randomly into two equal groups. Group D (n=30 patients) received a loading dose of dexmedetomidine 0.5 μg/kg, followed by an intraoperative dexmedetomidine infusion at a rate of 0.5 μg/kg/h. Group C (n=30 patients) received a loading dose of normal saline, followed by saline infusion. The infusions were stopped at the end of surgery at the time of abdominal deflation. The method of administration of the loading doses, volume of infusions, and the rate of infusions were standardized and were identical in both groups. The mean arterial pressure and heart rate were recorded at specific time intervals intraoperatively and during recovery. During recovery, the following data were recorded: the level of sedation, time to eye opening, time to tracheal extubation, incidence of nausea and vomiting, pain scores, time for the first analgesic requirement, and intraoperative and postoperative analgesic requirements in both groups.
The intraoperative mean arterial pressure and heart rate were significantly lower in group D compared with group C at all measurement points, except the baseline. However, there were no significant differences between both groups in the recovery. Also, the intraoperative fentanyl requirements were significantly less in group D, median 2 µg/kg [interquartile range (IR) 2–2], versus median 3 µg/kg (IR 3–4) in group C (P value <0.001). During recovery, the postoperative fentanyl requirements were significantly lower in group D, median 0.5 µg/kg (IR 0.5–1), versus median 1 µg/kg (IR 0.8–1) in group C. Times to first analgesic dose request were significantly longer in group D, 19±3 min, versus 12±3 min in group C (P value <0.001). Sedation scores were significantly higher in group D immediately postoperatively (at 0 h), being median 2 (IR 2–3) in group D versus median 1.5 (IR 1–2) in group C. After 1 h, the sedation scores were 1.5 (1–2) versus 1 (1–1), respectively, P less than 0.001. There were no significant differences between the two groups after 2 h in the sedation scores.
An intraoperative infusion of dexmedetomidine attenuated the hemodynamic changes occurring during LC and reduced the analgesic requirements during and immediately after surgery.
Failure mode and effect analysis (FMEA) is a process in operation management for analysis of the potential failures within a system, and it can be used in healthcare to detect any errors and can find the action plans to prevent errors or risks. The aim of this study was to evaluate whether the FMEA is a useful method to predict anesthesia medication errors, identify those errors and analyze the root causes of failures, and how it can eliminate the risk.
A prospective study was carried out by a multidisciplinary team under the supervision of an anesthesiologist as the team leader and included an anesthesia nurse, pharmacist, and performance improvement coordinator. The FMEA model was implemented in the process of general anesthesia medications. First, the process was divided into three steps of ordering, preparation, and administration of the anesthetics. Second, identification of the failure was made (failure mode). Third, the potential effect of the failure was assessed. Fourth, criticality score was determined to detect the critical failure that was evaluated by root causes analysis, and then final recommendations or action plan were made to eliminate the risk or reduce the failure.
There were three failures in the process of ordering, eight failures in the process of preparation, and four failures in the process of administration, a total of 15 failures; there were eight critical failures that required urgent recommendations to reduce the risk, and the remaining failures were nonhigh risk that required further recommendations. All of them were reviewed and approved by the pharmacy and therapeutic committee and hospital management.
The FMEA model by a multidisciplinary team is a useful method for detecting failures for anesthesia medication errors, and a simple way to analyze the root causes of the errors; it can also find the optimal method to eliminate the risk of failure.
This randomized-controlled study was designed to assess the effect of a patient’s position on lower esophageal pH and ease of intubation during induction of anesthesia in morbidly obese patients.
Sixty-six morbidly obese patients undergoing laparoscopic gastric banding surgery were allocated according to the patient’s position before induction of anesthesia to one of three equal groups: group S (control), ‘sniff’ position with the patient supine, group R, ‘ramp’ position, and group RT 30π reverse-Trendelenburg position. The primary outcome measure was lower esophageal pH. The secondary outcome measures were ease of intubation, laryngoscopic view, and changes in heat rate, mean arterial blood pressure, and arterial oxygen saturation during induction.
Lower esophageal acidity was significantly increased in group S compared with group RT and group R, P less than 0.001, with a significant increase in group R compared with group RT, P less than 0.001. Although the laryngoscopic view was the best in group R, there were no significant differences in intubation time and ease of intubation between group R and group RT, P=0.069. Heart rate was significantly increased in reverse-Trendelenburg 30π (group RT) after induction of anesthesia compared with before induction P less than 0.001. There were statistically significant reductions in the mean arterial blood pressure after induction of anesthesia in group RT and group R compared with before induction, P=0.001 and 0.020, respectively, but it was not clinically significant. Oxygen saturation was significantly higher in group RT and group R compared with group S, P=0.001.
During induction of anesthesia in morbidly obese patients, the reverse-Trendelenburg 30π position is the best as it increases the lower esophageal pH, allows easy laryngoscopy, and provides an adequate laryngoscopic view.
The aim of this study is to compare the role of nitroglycerine, milrinone, and iloprost as pulmonary vasodilators administered through the inhalation route in reducing pulmonary arterial hypertension (PAH) and facilitating weaning from cardiopulmonary bypass (CPB) in cardiac surgical patients.
In total, 75 cardiac surgical patients with preexisting PAH were randomized to receive nitroglycerine (group N; n=25), milrinone (group M; n=25), or iloprost (group I; n=25) by inhalation before the initiation of and during weaning from CPB. Hemodynamic parameters including heart rate (HR), mean systemic and pulmonary arterial pressures, systemic and pulmonary (PVR) vascular resistances, cardiac index, and mixed venous oxygen saturation were measured before drug inhalation (T0), after drug inhalation (T1), after weaning from CPB (T2), and at sternal closure (T3). The incidence of difficult weaning off CPB and the need for pharmacologic and mechanical cardiovascular support were also recorded.
PVR and mean pulmonary arterial pressure were significantly reduced in all groups at all time points compared with the baseline values. This reduction was significantly greater in groups M and I compared with group N at T1, T2, and T3. Cardiac index and mixed venous oxygen saturation were significantly higher in groups M and I at all time points compared with the baseline values and with group N. Heart rate, mean systemic arterial pressure, and systemic vascular resistance were stable in all groups at all time points. The incidence of difficult weaning from CPB, doses of inotropic, vasopressor, and inodilator support, and the incidence of mechanical cardiovascular support were significantly lower in the milrinone and iloprost groups compared with the nitroglycerine group.
Inhaled nitroglycerine, milrinone, and iloprost are effective in reducing PVR and PAP with pulmonary vascular selectivity in high-risk patients with PAH undergoing cardiac surgery under CPB. Aerosolized milrinone and iloprost are superior to nitroglycerine as they increase the cardiac output, facilitating weaning from CPB.
One of the major drawbacks in spinal anesthesia is the hemodynamic and cardiovascular affection. One of the methods used to decrease these side effects is unilateral spinal. Many concentrations of local anesthetics are tried to achieve the best results with the least disturbances. The ccNexfin monitor is a noninvasive monitor used to measure cardiac performance.
This prospective randomized study was carried out on 111 patients scheduled for orthopedic or vascular procedures involving one lower limb; patients were divided into three groups, each including 37 patients. The three groups received unilateral spinal anesthesia using the same technique, but with different doses of bupivacaine 0.5% (7.5, 10, and 12.5 mg for groups I, II, and III, respectively). Hemodynamic changes were measured in the three groups and also the cardiovascular changes using the noninvasive ccNexfin monitor. In addition, sensory level and motor power were recorded in each group at different time intervals. Data were analyzed statistically.
The mean arterial pressure and heart rate showed no clinical decrease at all testing times with a dose of 7.5 mg; yet, there were decreases in both parameters when using the higher doses and the decrease was maximal with 12.5 mg. In terms of the cardiac performance, cardiac output, cardiac index, and stroke volume showed no decrease at all testing times with a 7.5 mg dose, whereas the higher doses showed a decrease at these parameters that was maximal when using a dose of 12.5 mg. Also, there was a decrease in the systemic vascular resistance with time in the three groups and the decrease was greater in group III. In terms of the sensory level, the dependent limb had a sensory level of midthoracic in most of the patients in both group I and II and upper thoracic in group III. For the nondependent limb, unilateral selectivity was maintained in group I (5.4% with no sensory level), but in groups II and III, unilateral selectivity was lost. For the motor power when using the 7.5 mg dose, unilateral selectivity was maintained (89.2% of the nondependent side had a modified Bromage scale of zero) whereas with increasing dose, the selectivity was lost in a dose-dependent manner.
Unilateral spinal anesthesia using a dose of 7.5 mg hyperbaric bupivacaine 0.5% exerts less effects on hemodynamic and cardiac performance with better selectivity than using the higher doses of 10 and 12.5 mg in orthopedic and vascular surgeries of the lower limb.
Multidrug-resistant organisms as a cause of hospital-acquired infections represent a major problem. Here, we report a case of multidrug-resistant Pseudomonas aeruginosa and Klebsiella pneumoniae infections in an ICU-admitted patient. The treatment options for these pathogens are discussed.
To compare the effect of intra-articular (IA) tramadol (100 mg) versus fentanyl (0.1 mg) as postoperative analgesic after arthroscopic meniscectomy.
This was a randomized, double-blind, controlled trial including 60 ASA I–II patients undergoing arthroscopic meniscectomy under general anesthesia. At the end of the surgical procedure, patients were randomly allocated to one of three equal groups using the sealed envelope method. The control group (group C) received an IA injection of methyl-prednisolone acetate 40 mg, the fentanyl group (group F) received fentanyl 0.1 mg and methyl-prednisolone acetate 40 mg, and the tramadol group (group T) received tramadol 100 mg and methyl-prednisolone acetate 40 mg. Postoperative pain was assessed using the visual analogue scale (VAS) at 30 min, 2, 4, 8, 12, and 24 h at rest. Analgesic duration (time to first request for analgesics), analgesic consumption in the first 24 h, and the incidence of postoperative nausea and vomiting were recorded.
The VAS scores were significantly lower in groups F and T compared with group C (P<0.001) at 30 min, 2, 4, 8, 12, and 24 h and in group T compared with group F at 8, 12, and 24 h after the operation (P<0.05). Time to first morphine dose was significantly lower in group C compared with groups F and T (P<0.001), and in group F compared with group T (P<0.001). The frequency of morphine doses in the first 24 h was significantly higher in group C compared with groups F and T (P<0.001), and in group F compared with group T (P=0.003). There were no statistically significant differences between groups in postoperative nausea and vomiting in the first 2 postoperative hours (P=0.766).
An IA injection of tramadol 100 mg following arthroscopic meniscectomy is a good option for postoperative pain control, with superior analgesic properties than fentanyl (0.1 mg) in terms of lower VAS scores and lesser need for postoperative systemic analgesics.
Nutritional support is becoming a cornerstone for the therapeutic approach to patients with chronic diseases. Chronic heart failure and chronic obstructive pulmonary disease are frequently associated with malnutrition. Nutritional support to prevent progressive weight loss should be considered. Oral supplementation and enteral nutrition represent the first choices when cardiopulmonary patients require nutritional support, which explains the lack of clinical trials on the role of parenteral nutrition in chronic heart failure and chronic obstructive pulmonary disease patients.
Nutritional support in the intensive care setting represents a real challenge to intensivists. Its delivery and monitoring can be followed carefully. Parenteral nutrition (PN) represents an alternative or an additional approach when other routes are not safe or successful. The main goal of PN is to deliver a nutrient mixture closely related to the requirements safely and to avoid complications that have been investigated over the past decade. PN carries the huge risk of overfeeding, which can be as deleterious as underfeeding. This review focuses on the indications for PN, calorie targets, the relative importance of the macronutrients and micronutrients, complications, different proportions of different nutrients, and its possible complementary use with enteral nutrition.
The art and science of nutrition has evolved over the past decade, and amino acids play an important role in the nutritional aspect in intensive care units. Glutamine and taurine are considered to be conditioned essential amino acids in the management of critically ill patients. Their presence in the regimen decreases the incidence of sepsis and improves the overall function of the immune system.
The transversus abdominis plane block is a nerve block that provides analgesia to the anterior abdominal wall. The aim of this study was to evaluate the analgesic efficacy of a pre-emptive ultrasound-guided transversus abdominis plane block (US-TAP block) in patients undergoing laparoscopic colectomy through a small lower abdominal skin incision.
Forty patients undergoing laparoscopic colectomy surgery were randomized to undergo standard care such as patient-controlled analgesia (control group) or to receive an additional pre-emptive US-TAP block with standard care (TAP group). A bilateral US-TAP block was performed after induction of general anaesthesia using 0.25% levobupivacaine 20 ml on each side. Postoperative demand of rescue analgesics in the postanaesthesia care unit (PACU) and ward were recorded. Each patient was assessed postoperatively by a blinded observer in PACU and at 2, 12, 24 and 48 h postoperatively to investigate pain at rest and on movement, drowsiness, nausea, itching and shivering.
The US-TAP block reduced the pain score compared with standard care in the PACU (4.1±0.9 vs. 8.6±0.3) and at 24 and 48 h postoperatively (1.3±0.4 vs. 2.7±0.4, 1.3±0.6 vs. 2.6±0.2, respectively). Morphine requirements in PACU in the TAP group versus the control group were reduced (9.3±3.0 vs. 15.2±2.1 mg, P<0.05). In the ward, morphine requirements were reduced at 24 and 48 h (11.8±3.4 vs. 16.6±3.3 mg, 9.5±2.3 vs. 14.4±2.0 mg, respectively, P<0.05).
The US-TAP block with standard care provides more effective analgesia after a laparoscopic colectomy surgery than standard patient-controlled analgesia only, reduces opioid requirements and side effects, promotes early return of bowel activity, promotes early hospital discharge and increases patient satisfaction.
This study aimed to evaluate the value of epidural anesthesia in improving renal functions in preeclamptic patients with early renal impairment.
The study included 60 patients of ASA (American Society of Anesthesiologists) physical status II–III, age range 19–40 years, found to have mild preeclampsia with early renal impairment. The patients were divided randomly into two groups. Epidural anesthesia was administered in the epidural anesthesia (Epi) group (n=30), whereas patients in the control (Cont) group (n=30) were subjected to the same procedure for epidural catheter insertion, but not activated (except after the study time), and then treated by conventional measures according to the protocol of the Obstetric ICU of Ain Shams University Hospitals. For each patient, the following data were collected: hemodynamic changes, urine output, and renal function [detected by cystatin C, serum creatinine, blood urea nitrogen, and then estimation of glomerular filtration rate (GFR)].
There was a statistically significant reduction in blood pressure (systolic blood pressure, diastolic blood pressure, and mean arterial blood pressure) in the Epi group after 15 min of epidural activation on comparing subsequent measures with the baseline value (T0) and also compared with the corresponding values in the Cont group. Also, the Epi group showed a statistically significant increase in urine output after 2 h of epidural activation, in comparison with baseline values and compared with the Cont group. Patients in the Epi group showed a statistically significant decrease in serum cystatin C and increase in estimated GFR (eGFR) on the basis of cystatin C after 2 h of a sympathetic block by epidural activation in comparison with the baseline value and compared with the Cont group, indicating a marked improvement in GFR. However, measurement of the urine protein/creatinine ratio, serum creatinine, blood urea nitrogen, and eGFR on the basis of serum creatinine indicated no significant difference in both groups compared with the baseline of the same group or on comparing both groups together.
Performing a renal sympathetic block by epidural anesthesia helps improve renal function with better control of blood pressure in preeclamptic patients with an early renal impairment detected by the sensitive renal marker cystatin C.
Propofol-Lipuro 1% consists of long-chain triglycerides (LCT) and medium-chain triglycerides that have been reported to cause less injection pain than traditional long-chain triglycerides.
This double-blinded prospective controlled study was designed to assess the effect of 100 mcg fentanyl pretreatment with venous occlusion on pain on injection of Propofol-Lipuro in comparison with lignocaine premixing, pretreatment, or placebo.
In a randomized double-blind controlled trial, 120 patients were assigned to receive one of the following four options: group 1: pretreatment with 2 ml normal saline+18 ml Propofol-Lipuro premixed with 2 ml normal saline; group 2: pretreatment with 2 ml normal saline+18 ml Propofol-Lipuro premixed with 2 ml lignocaine 2%; group 3: pretreatment with 2 ml lignocaine 2%+Propofol-Lipuro premixed with 2 ml normal saline; and group 4: pretreatment with fentanyl 100 mcg/2 ml+Propofol-Lipuro premixed with 2 ml normal saline. Any associated pain or discomfort was categorized using a 4-point verbal rating scale.
Twenty-one patients in group 1, 15 patients in group 2, 13 patients in group 3, and only seven patients reported pain in group 4 (P<0.001). Fourteen patients complained of moderate to severe pain in group 1 (six moderate and eight severe) and four patients complained of moderate to severe pain in group 2 (three moderate and one severe). Six patients complained of moderate to severe pain in group 3 (four moderate and two severe), compared with three patients who had severe pain in the fentanyl pretreatment group. No complications related to the study medications or propofol were reported in any patient for the first 24-h perioperative time period.
Pretreatment with fentanyl incorporated into the anesthesia induction technique is a simple and effective way to alleviate pain during the injection of Propofol-Lipuro in addition to both premixing and pretreatment with lignocaine. All reduced the incidence and severity of pain on intravenous injection of Propofol-Lipuro with high statistical significance than placebo.
Positive end-expiratory pressure (PEEP) and inverse ratio ventilation (IRV) are techniques commonly used in the addition of low tidal volume ventilation in patients with acute lung injury (ALI) to improve oxygenation and reduce associated lung injury. In this study, we have attempted to compare their effects on the oxygenation status and local inflammation in the lung as determined by bronchoalveolar lavage (BAL) levels of tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), and IL-10.
Forty-eight patients diagnosed with ALI with scores ranging from 0.1 to 2.5 were included. They were investigated for 10 days and were randomly divided into two groups: a PEEP group, which included 25 patients who were ventilated with the low tidal volume technique (6 ml/kg) with the addition of high PEEP [lower inflexion point (P flex)+2 cmH2O], and an IRV group, which included 23 patients who received mechanical ventilation with low tidal volume (6 ml/kg) with adjustment of the ventilator setting to deliver IRV (I : E=2 : 1) with a low PEEP (5 cmH2O). Arterial blood gas parameters were reported every 12 h and the oxygenation index (PaO2/FiO2) was recorded every 6 h. Alveolar fluids were aspirated using a fiberoptic bronchoscope and the levels of TNF-α, IL-1β, and IL-10 were measured at the start (basal) and at the third, seventh, and 10th days after enrollment.
The PaO2/FiO2 ratio showed no significant difference in its values during the first 4 days; subsequently, it increased in the IRV group compared with the PEEP group until the end of study, whereas all other arterial blood gas parameters showed no statistical difference between both groups. BAL levels of TNF-α were significantly increased in the IRV group at the third, seventh, and 10th days (43.39±5.52, 52.69±5.78, and 65.65±5.88 pg/dl, respectively) than the baseline level (30.44±2.56 pg/dl) (P<0.001). Similarly, its levels in the PEEP group increased significantly at the third, seventh, and 10th days (33.86±2.14, 35.34±2.02, and 39.15±3.18 pg/dl, respectively) than the baseline value (29.89±3.88 pg/dl) (P<0.001). BAL levels of TNF-α were significantly higher in the IRV group than the PEEP group at all time points of measurements (P<0.001) after the baseline reading. IL-1β levels in the IRV group increased significantly at the third, seventh, and 10th days (65.99±3.67, 85.93±2.47, and 95.13±6.36 pg/dl, respectively) compared with the baseline value (51.71±4.44 pg/dl) (P<0.001). Similarly, in the PEEP group, it increased significantly at the third, seventh, and 10th days (57.93±3.76, 63.80±3.98, and 72.12±5.27 pg/dl, respectively) compared with the baseline level (52.07±4.83 pg/dl). Moreover, IL-1β levels were significantly higher in the IRV group than the PEEP group. The levels of IL-10 increased significantly in the IRV group (P<0.001) at the third, seventh, and 10th days (37.19±5.10, 42.24±7.03, and 49.13±11.51 pg/dl) compared with the baseline level (11.71±2.14 pg/dl); also its levels in the PEEP group increased significantly (P<0.001) at the third, seventh, and 10th days (24.03±4.07, 26.32±8.01, and 27.09±10.62 pg/dl, respectively) compared with the baseline level (12.38±3.51 pg/dl). IL-10 was significantly higher in the IRV group than in the PEEP group at the third (P<0.01), seventh, and 10th days (P<0.001), respectively.
IRV showed better oxygenation than high PEEP when used with low tidal volume ventilation in patients with ALI, and it was associated with higher levels of lung proinflammatory cytokines (TNF-α and IL-1β) and of the anti-inflammatory cytokine IL-10, indicating the presence of balance between the proinflammatory and anti-inflammatory cytokines.
The use of lignocaine to prevent the pain of propofol injection is the most widely studied technique and is the most common method used in everyday practice. Many studies have shown the use of lignocaine to be effective. Two methods have been studied: pretreatment with lignocaine and mixing with propofol. Previous studies have found that lignocaine was associated with a lower incidence of injection pain, but the incidence was still high (31–40%). Our study aimed to investigate whether the incidence of injection pain could be further reduced by pretreatment with dexamethasone 8 mg/2 ml with 1-min venous occlusion.
In a randomized double-blind controlled trial, 120 patients were assigned to receive one of the following four options: group 1: pretreatment with 2 ml normal saline+18 ml Propofol-Lipuro premixed with 2 ml lignocaine 2%; group 2: pretreatment with 2 ml lignocaine 2%+Propofol-Lipuro premixed with 2 ml normal saline; group 3: pretreatment with dexamethasone 8 mg/2 ml+Propofol-Lipuro premixed with 2 ml normal saline; and group 4: pretreatment with 2 ml normal saline+18 ml Propofol-Lipuro premixed with 2 ml normal saline. Patients graded any associated pain or discomfort using a 4-point verbal rating scale.
Eight (26.6%) patients in groups 1 and 2, four (13.3%) patients in group 3, and 23 (76.6%) patients reported pain in group 4 (P<0.001). Five patients complained of moderate to severe pain in the lignocaine pretreatment or premixing groups (three moderate and two severe in group 1 and five moderate and zero severe in group 2). Compared with two patients who had moderate pain in the dexamethasone pretreatment group (group 3), 16 patients complained of moderate to severe pain in group 4 (six moderate and 10 severe).
Pretreatment with, or adding lignocaine, and pretreatment with dexamethasone reduced the incidence and severity of pain on an intravenous injection of Propofol-Lipuro.