1
|
Júnior GS, Comassetto F, Conterno GB, Victor de Souza J, de Souza Ferreira W, Griebeler LB, Oleskovicz N. The effect of intravenous magnesium sulphate infusion on total intravenous anesthesia with propofol in adult dogs: A randomized, blinded trial. Vet Anaesth Analg 2024:S1467-2987(24)00131-4. [PMID: 39181818 DOI: 10.1016/j.vaa.2024.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 07/14/2024] [Accepted: 07/14/2024] [Indexed: 08/27/2024]
Abstract
OBJECTIVE To evaluate cardiopulmonary, arterial blood gas and propofol-sparing effects of magnesium sulfate (MgSO4) constant rate infusion (CRI) in mechanically ventilated dogs maintained under total intravenous anesthesia with propofol. STUDY DESIGN Blinded, randomized, clinical trial. ANIMALS A total of 24 healthy adult dogs. METHODS Dogs were premedicated with intramuscular acepromazine (0.05 mg kg-1) and morphine (0.5 mg kg-1), followed by an intravenous (IV) bolus of saline or MgSO4 (50 mg kg-1 over 15 minutes) and propofol (given to effect to induce anesthesia). Anesthesia was maintained with an IV propofol infusion (beginning at 0.3 mg kg-1 minute-1, adjusted as necessary). Concurrently, one of three IV infusions were administered: GS (0.9% NaCl), GM30 (MgSO4, 30 mg kg-1 hour-1) or GM80 (MgSO4, 80 mg kg-1 hour-1). Propofol induction and maintenance doses were recorded. The following variables were recorded at baseline (T0), after bolus treatment (T1), after beginning mechanical ventilation (T5) and every 15 minutes until the end of the procedure (T15-T120): mean arterial pressure, heart rate, peripheral oxygen saturation, end-tidal partial pressure of CO2, temperature, blood gas variables, indirect calorimetry and extubation time. Values of p < 0.05 were considered significant. RESULTS Propofol induction bolus dose was lower in GM30 (31.2%, p = 0.04) and GM80 (38.9%, p = 0.003) than in GS. The maintenance propofol infusion rate in GM80 was 16.9% lower (p = 0.03), resulting in fewer propofol CRI rescues during the perioperative period. GM30 and GM80 exhibited faster extubation times than GS (46.2%, p = 0.002 and 48.9%, p = 0.001, respectively). CONCLUSIONS AND CLINICAL RELEVANCE Infusion of a 50 mg kg-1 bolus, followed by CRI of MgSO4 (30 and 80 mg kg-1 hour-1), reduces the propofol induction and maintenance (CRI) requirement, maintaining cardiorespiratory stability and reducing the time required to extubation.
Collapse
Affiliation(s)
| | - Felipe Comassetto
- Department of Veterinary Medicine, Center for Agro-Veterinary Sciences (CAV), Santa Catarina State University (UDESC), Lages, Santa Catarina, Brazil
| | | | | | - William de Souza Ferreira
- Veterinary Clinical Pathology, São Paulo State University (UNESP/Botucatu), Botucatu, São Paulo, Brazil
| | | | - Nilson Oleskovicz
- Department of Veterinary Medicine, Center for Agro-Veterinary Sciences (CAV), Santa Catarina State University (UDESC), Lages, Santa Catarina, Brazil
| |
Collapse
|
2
|
Dauterman L, Khan N, Tebbe C, Li J, Sun Y, Gunderman D, Liu Z, Adams DC, Sessler DI, Meng L. Efficacy and safety of intraoperative controlled hypotension: a systematic review and meta-analysis of randomised trials. Br J Anaesth 2024:S0007-0912(24)00350-7. [PMID: 39003203 DOI: 10.1016/j.bja.2024.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 05/26/2024] [Accepted: 06/07/2024] [Indexed: 07/15/2024] Open
Abstract
BACKGROUND Intraoperative controlled hypotension improves surgical field visibility by reducing blood loss (efficacy) but poses potential risks linked to organ hypoperfusion (safety). The use of controlled hypotension persists despite increasing evidence of associations between intraoperative inadvertent hypotension and adverse outcomes. Therefore, we tested the hypothesis that the focus and results of intraoperative controlled hypertension research differ across anaesthesia and surgery investigators because of differing priorities. METHODS We systematically reviewed randomised trials comparing controlled hypotension with usual care with trials categorised by investigators' affiliation. RESULTS We identified 48 eligible trials, of which 37 were conducted by anaesthesia investigators and 11 by surgery investigators. For the primary outcome, 54% of the anaesthesia-led trials focused on safety, whereas all (100%) surgery-led trials focused on efficacy (P=0.004). Compared with usual care, mean arterial pressure in controlled hypotension was 23% (95% confidence interval [CI] 17-29%) lower in anaesthesia trials and 30% (95% CI 14-37%) lower in surgery trials; estimated blood loss was 44% (95% CI 30-55%) less in anaesthesia trials and 38% (95% CI 30-49%) less in surgery trials. Overall, blood loss was reduced by 43% (95% CI 32-53%), and trial sequential analysis supported an efficacy conclusion. Mean arterial pressure and estimated blood loss reductions were associated (R2=0.41, P=0.002). All trials were underpowered for safety outcomes, and none adequately evaluated myocardial or renal injury. CONCLUSIONS Anaesthesia researchers prioritised safety outcomes, whereas surgery researchers emphasised efficacy in controlled hypotension trials. Controlled hypotension significantly reduces blood loss. In contrast, safety outcomes were poorly studied. Given increasing observational evidence linking inadvertent hypotension to myocardial and renal injury, the safety of controlled hypotension remains to be addressed. SYSTEMATIC REVIEW PROTOCOL PROSPERO (CRD42023450397).
Collapse
Affiliation(s)
- Leah Dauterman
- Indiana University School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Nabia Khan
- Indiana University School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Connor Tebbe
- Indiana University School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Jiangqiong Li
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Yanhua Sun
- Department of Anesthesiology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - David Gunderman
- Indiana University School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Ziyue Liu
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, USA
| | - David C Adams
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Daniel I Sessler
- Outcomes Research Consortium, Department of Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Lingzhong Meng
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN, USA.
| |
Collapse
|
3
|
Mieszczanski P, Gorniewski G, Janiak M, Trzebicki J. The effect of pre-emptive oral pregabalin on opioid consumption in patients undergoing laparoscopic sleeve gastrectomy with an analysis of intraoperative hemodynamic stability and quality of recovery: study protocol for a randomized, prospective, double-blind study. Trials 2024; 25:367. [PMID: 38849875 PMCID: PMC11157713 DOI: 10.1186/s13063-024-08225-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 06/03/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND Obese patients undergoing laparoscopic sleeve gastrectomy (LSG) are particularly at risk of opioid-related side effects. To reduce patient exposure to opioids, multimodal analgesia, which involves the use of drugs of different classes, may be utilized. One of the drugs under consideration is pregabalin. Despite an opioid-sparing potential, few studies assess the role of pregabalin as an element of multimodal analgesia in LSG. Considering the limited number and inconsistent results of available studies, we decided to conduct a randomized, prospective study on the effect of preemptive pregabalin administration in obese patients on opioid consumption, pain scores, the incidence of opioid side effects, and hemodynamical stability. METHODS The study is designed as a prospective randomized controlled trial with double-blinding. Randomization will be performed in a block with a parallel 1:1 allocation. The intervention will involve receiving a pregabalin 150 mg capsule 1-2 h before the surgery, whereas the control group will receive an identically looking placebo. The primary outcome measure will be total oxycodone consumption in the first 24 h following surgery. Secondary outcome measures will be pain severity assessed using the Numerical Rating Scale (NRS) 1, 6, 12, and 24 h after surgery, postoperative sedation on the Ramsay scale, PONV impact scale, the incidence of desaturation episodes < 94%, and episodes of blurred vision at 1, 6, 12, and 24 h after surgery, intraoperative hemodynamic parameters such as heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean blood pressure (MBP), total fluid volume, and total ephedrine dose. Patient comfort will be additionally assessed using the QoR-40 questionnaire at discharge. DISCUSSION The study will explore the efficacy and safety of preemptive pregabalin in a dose of 150 mg as a co-analgesic used in multimodal analgesia for LSG. As studies on opioid-sparing regimes concern the safety of obese patients, we aim to contribute objective data with a relatively large study sample size. The result of the present clinical trial may support the reassessment of recommendations to use pregabalin in the studied population. TRIAL REGISTRATION ClinicalTrials.gov NCT05804591. Registered on 07.04.2023.
Collapse
Affiliation(s)
- Piotr Mieszczanski
- 1St Department of Anesthesiology and Intensive Care, Medical University of Warsaw, Lindleya 4, Warsaw, 02-005, Poland.
| | - Grzegorz Gorniewski
- 1St Department of Anesthesiology and Intensive Care, Medical University of Warsaw, Lindleya 4, Warsaw, 02-005, Poland
| | - Marek Janiak
- 1St Department of Anesthesiology and Intensive Care, Medical University of Warsaw, Lindleya 4, Warsaw, 02-005, Poland
| | - Janusz Trzebicki
- 1St Department of Anesthesiology and Intensive Care, Medical University of Warsaw, Lindleya 4, Warsaw, 02-005, Poland
| |
Collapse
|
4
|
Mieszczański P, Kołacz M, Trzebicki J. Opioid-Free Anesthesia in Bariatric Surgery: Is It the One and Only? A Comprehensive Review of the Current Literature. Healthcare (Basel) 2024; 12:1094. [PMID: 38891169 PMCID: PMC11171472 DOI: 10.3390/healthcare12111094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 05/13/2024] [Accepted: 05/23/2024] [Indexed: 06/21/2024] Open
Abstract
Opioid-free anesthesia (OFA) is a heterogeneous group of general anesthesia techniques in which the intraoperative use of opioids is eliminated. This strategy aims to decrease the risk of complications and improve the patient's safety and comfort. Such potential advantages are particularly beneficial for selected groups of patients, among them obese patients undergoing laparoscopic bariatric surgery. Opioids have been traditionally used as an element of balanced anesthesia, and replacing them requires using a combination of coanalgesics and various types of local and regional anesthesia, which also have their side effects, limitations, and potential disadvantages. Moreover, despite the growing amount of evidence, the empirical data on the superiority of OFA compared to standard anesthesia with multimodal analgesia are contradictory, and potential benefits in many studies are being questioned. Additionally, little is known about the long-term sequelae of such a strategy. Considering the above-mentioned issues, this study aims to present the potential benefits, risks, and difficulties of implementing OFA in bariatric surgery, considering the current state of knowledge and literature.
Collapse
Affiliation(s)
- Piotr Mieszczański
- 1st Department of Anaesthesiology and Intensive Care, Medical University of Warsaw, Lindleya 4 Str., 02-005 Warsaw, Poland; (M.K.); (J.T.)
| | | | | |
Collapse
|
5
|
Hua X, Chen Y, Wu Z, Zheng G, Yang D, Li J, Wu Q, Fan W. Effects of intra-operative magnesium sulfate infusion on orthognathic surgery: A prospective and randomized controlled trial. Heliyon 2024; 10:e30342. [PMID: 38707412 PMCID: PMC11066664 DOI: 10.1016/j.heliyon.2024.e30342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 04/20/2024] [Accepted: 04/24/2024] [Indexed: 05/07/2024] Open
Abstract
Purpose To comprehensively understand the effects of intra-operative infusion of magnesium sulfate on patients who underwent orthognathic surgery, including remifentanil consumption, postoperative pain, postoperative nausea and vomiting (PONV), inflammatory response, and serum magnesium levels. Methods Seventy-five adult patients undergoing orthognathic surgery under general balanced anesthesia were randomly divided into two groups. One group (Group M) received 50 mg/kg of magnesium sulfate in 20 mL 0.9 % saline after intubation, followed by a continuous infusion at a rate of 15 mg/kg/h until 30 min before the anticipated end of surgery. The other group (Group C) received an equal volume of isotonic saline as a placebo. (Clinical trial registration number: chiCTR2100045981). Results The primary outcome was remifentanil consumption. The secondary outcomes included the pain score assessed using the verbal numerical rating scale (VNRS) and PONV assessed using a Likert scale. Remifentanil comsumption in Group M was lower than Group C (mean ± SD: 0.146 ± 0.04 μg/kg/min vs. 0.173 ± 0.04 μg/kg/min, P = 0.003). At 2 h after surgery, patients in Group C suffered more severe PONV than those in Group M (median [interquartile range, IQR]: 1 [3] vs. 1 [0], mean rank: 31.45 vs. 42.71, P = 0.040). At post-anesthesia care unit (PACU), postoperative pain in Group C was severe than Group M (3 [1] vs. 3 [0], mean rank: 31.45 vs. 42.71, P = 0.013). Changes in haemodynamics and surgical field scores did not differ between the groups (all P > 0.05). The levels of cytokines (IL-4, IL-6, IL-8, IL-10, TNF-a, and MIP-1β) were not significantly different between the groups after surgery (all P > 0.05). Postoperative serum magnesium levels in Group C were lower than those in Group M (0.74 ± 0.07 mmol/L vs. 0.91 ± 0.08 mmol/L, P = 0.000) and the preoperative level (0.74 ± 0.07 mmol/L vs. 0.83 ± 0.06 mmol/L, P = 0.219). Conclusions In orthognathic surgery, magnesium sulfate administration can reduce remifentanil requirement and relieve PONV and postoperative pain in the early postoperative phase.
Collapse
Affiliation(s)
- Xiaoxiao Hua
- Department of Anesthesiology, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-Sen University, 74 Zhongshan Rd 2, Guangzhou, 510080, China
- Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, China
| | - Yanling Chen
- Department of Anesthesiology, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-Sen University, 74 Zhongshan Rd 2, Guangzhou, 510080, China
| | - Zhi Wu
- Department of Anesthesiology, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-Sen University, 74 Zhongshan Rd 2, Guangzhou, 510080, China
| | - Guangsen Zheng
- Department of Oral and Maxillofacial Surgery, Guanghua School of Stomatology, Hospital of Stomatology, Sun Yat-sen University, Guangzhou, China
| | - Dongye Yang
- Department of Oral and Maxillofacial Surgery, Guanghua School of Stomatology, Hospital of Stomatology, Sun Yat-sen University, Guangzhou, China
| | - Jing Li
- Department of Anesthesiology, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-Sen University, 74 Zhongshan Rd 2, Guangzhou, 510080, China
| | - Qiaomei Wu
- Department of Anesthesiology, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-Sen University, 74 Zhongshan Rd 2, Guangzhou, 510080, China
| | - Wenguo Fan
- Department of Anesthesiology, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-Sen University, 74 Zhongshan Rd 2, Guangzhou, 510080, China
- Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, China
| |
Collapse
|
6
|
Abdel Rady MM, Osman AM, Abo Elfadl GM, Ahmed HM, Sayed S, Abdallah AO, Ali WN. Effects of intravenous single-bolus lidocaine infusion versus intravenous single-bolus magnesium sulfate infusion on postoperative pain, emotional status, and quality of life in patients undergoing spine fusion surgery: a randomized study. Minerva Anestesiol 2024; 90:397-408. [PMID: 38771164 DOI: 10.23736/s0375-9393.24.17868-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND We assessed the efficiency of intravenous adjuvants in decreasing opioid intake and pain scores after spine fusion surgery. METHODS This study included 120 patients aged 18-60 listed for spine fusion surgery under general anesthesia. Patients were randomly assigned to four groups: Group (Lidocaine): received IV lidocaine 4 mg/kg in 50 mL volume over 30 min. Group (Magnesium): received IV magnesium sulfate 30mg/kg in 50 mL volume over 30 min. Group (combined Lidocaine and Magnesium): received IV lidocaine 4 mg/kg in 50 mL volume over 30 min.+IV magnesium sulfate 30mg/kg in 50 mL volume over 30 min. Group (Control): received IV saline 50 mL. The time to the first request analgesia, the postoperative pain score, total analgesic use, patient satisfaction, anxiety, depression, mental state, quality of life, and side effects were measured. RESULTS The combined group had more extended time for the first analgesic request and fewer rescue analgesia doses than the other groups. NRS scores at rest or movement were statistically significantly lower in the lidocaine group and the combined group compared to the control group (P1, P3<0.05) at almost all times. This combination reduces anxiety and depression and improves overall health up to three months after a single infusion. The combined group had higher patient satisfaction. CONCLUSIONS A synergistic effect of a combination of lidocaine and magnesium sulfate on perioperative pain was found. It reduces analgesic consumption, depression, and anxiety and improves overall health up to three months after a single infusion dose.
Collapse
Affiliation(s)
- Marwa M Abdel Rady
- Faculty of Medicine, New Valley University, Kharga, Egypt -
- Department of Anesthesia and Intensive Care, Assiut University Hospital, Assiut, Egypt -
| | - Ayman M Osman
- Department of Anesthesia and Intensive Care, Assiut University Hospital, Assiut, Egypt
| | - Ghada M Abo Elfadl
- Department of Anesthesia and Intensive Care, Assiut University Hospital, Assiut, Egypt
| | - Haitham M Ahmed
- Department of Anesthesia and Intensive Care, Assiut University Hospital, Assiut, Egypt
| | - Sherif Sayed
- Department of Anesthesia and Intensive Care, Assiut University Hospital, Assiut, Egypt
| | - Ahmed O Abdallah
- Department of Anesthesia and Intensive Care, Assiut University Hospital, Assiut, Egypt
| | - Wesam N Ali
- Department of Anesthesia and Intensive Care, Assiut University Hospital, Assiut, Egypt
| |
Collapse
|
7
|
Dahake JS, Verma N, Bawiskar D. Magnesium Sulfate and Its Versatility in Anesthesia: A Comprehensive Review. Cureus 2024; 16:e56348. [PMID: 38633961 PMCID: PMC11021848 DOI: 10.7759/cureus.56348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 03/17/2024] [Indexed: 04/19/2024] Open
Abstract
In the field of general anesthesia, magnesium sulfate (MgSO4) has become a valuable adjunct because it provides a range of benefits that enhance and optimize conventional aesthetic procedures. This review highlights the various intra-anesthetic benefits of MgSO4 while examining its complex function in the treatment using anesthesia. Magnesium inhibits the release of acetylcholine at the motor endplate and blocks calcium channels at presynaptic nerve terminals. This reduces the amplitude of endplate potential and the excitability of muscle fibers, which increases the potency of a neuromuscular blockade by nondepolarizing neuromuscular blockers. This activity may lessen the need for primary muscle relaxants. Moreover, its capacity to potentially reduce the total amount of main aesthetic agents needed emphasizes its function in maximizing anesthesia dosage, ensuring sufficient depth while perhaps potentially reducing adverse effects linked with increased dosages. MgSO4's adaptable qualities present a viable path for improving anesthetic outcomes, possibly improving patient safety and improving surgical results.
Collapse
Affiliation(s)
- Janhavi S Dahake
- Anesthesia, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Neeta Verma
- Anesthesia, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Dushyant Bawiskar
- Sports Physiotherapy, Abhinav Bindra Targeting Performance, Bengaluru, IND
| |
Collapse
|
8
|
Sawant U, Sen J. A Comprehensive Review of Magnesium Sulfate Infusion: Unveiling the Impact on Hemodynamic Stability During Laryngoscopy and Tracheal Intubation in Ear, Nose, and Throat Surgeries. Cureus 2024; 16:e57002. [PMID: 38681416 PMCID: PMC11046371 DOI: 10.7759/cureus.57002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 03/26/2024] [Indexed: 05/01/2024] Open
Abstract
This comprehensive review explores the potential of magnesium sulfate infusion in mitigating hemodynamic instability during laryngoscopy and tracheal intubation in ear, nose, and throat (ENT) surgeries. Hemodynamic fluctuations during these procedures pose challenges, and magnesium sulfate, with its vasodilatory, antiarrhythmic, and neuroprotective properties, emerges as a promising intervention. The review critically examines existing literature, emphasizing patient selection criteria, dosage protocols, and a comparative analysis with other hemodynamic stabilizers. Safety considerations, including known adverse effects and risk-benefit assessments, and monitoring and management strategies are elucidated. The implications for ENT surgery are discussed, highlighting the potential for enhanced hemodynamic management and individualized approaches. The review concludes with a call for continued research, emphasizing the ongoing evolution of understanding and practice incorporating magnesium sulfate into perioperative care. The insights offered aim to guide clinicians in navigating this dynamic landscape for improved patient outcomes in ENT surgeries.
Collapse
Affiliation(s)
- Urvi Sawant
- Anaesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Jayashree Sen
- Anaesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| |
Collapse
|
9
|
Kilic K, Sakat MS, Sahin A, Ahiskalioglu EO, Altunok H. Efficacy of intravenous magnesium sulfate infusion on postoperative pain and quality of recovery for septorhinoplasty: a randomized controlled study. Acta Otolaryngol 2023; 143:979-983. [PMID: 38108626 DOI: 10.1080/00016489.2023.2289584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 11/23/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND The pain that occurs after septorhinoplasty is an important factor affecting the comfort of the patient. OBJECTIVES To investigate the effect of perioperative intravenous magnesium sulfate infusion on postoperative pain and quality of recovery in patients underwent septorhinoplasty surgery. MATERIAL AND METHODS One hundred twenty patients who underwent septorhinoplasty were randomly divided into two groups. Magnesium group received intravenous magnesium after induction of anesthesia (30 mg/kg), then infused until the end of the surgical procedure (9 mg/kg). The placebo group received the same volume of saline infusion. The VAS score was used for postoperative pain assessment, and the Quality of Recovery-40 (QoR-40) score was used for the assessment of recovery status. RESULTS The postoperative 30 min, 1st, 2nd, 4th (p < .001) and 24th hour (p < .05) VAS scores of the patients in the magnesium infusion group were significantly lower compared to the placebo group. Also; in terms of physical comfort (p < .001), emotional state (p < .05), psychological support, pain and total score values (p < .001), patients in magnesium group had significantly higher QoR-40 scores than those in placebo group. CONCLUSION Intraoperative magnesium infusion, which is widely used in many surgeries to provide controlled hypotension, also contributes significantly to patient comfort with its positive effect on postoperative pain and recovery scores.
Collapse
Affiliation(s)
- Korhan Kilic
- Department of Otorhinolaryngology, Ataturk University Faculty of Medicine, Erzurum, Turkey
| | - Muhammed Sedat Sakat
- Department of Otorhinolaryngology, Ataturk University Faculty of Medicine, Erzurum, Turkey
| | - Abdulkadir Sahin
- Department of Otorhinolaryngology, Ataturk University Faculty of Medicine, Erzurum, Turkey
| | | | - Hazal Altunok
- Department of Otorhinolaryngology, Ataturk University Faculty of Medicine, Erzurum, Turkey
| |
Collapse
|
10
|
Preethi A, Venkatraman R, Karthika U, Rangapriya A. Evaluation of the Efficacy of Magnesium Sulfate in Reducing Blood Loss in Functional Endoscopic Sinus Surgery: A Randomized Double-Blinded Controlled Trial. Cureus 2023; 15:e38636. [PMID: 37284355 PMCID: PMC10241315 DOI: 10.7759/cureus.38636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2023] [Indexed: 06/08/2023] Open
Abstract
Objectives The primary concern in functional endoscopic sinus surgery (FESS) is maintaining a clear and unobstructed surgical field. Achieving this objective necessitates controlled hypotension, which can aid in the surgical dissection process and reduce the overall duration of the operation. This study aims to evaluate the efficacy of a sole bolus injection of intravenous magnesium sulfate in FESS. The outcomes measured include blood loss, surgical field grading, the additional intraoperative requirement of fentanyl, stress attenuation during laryngoscopy and endotracheal intubation, and extubation time. Methods In this prospective, double-blinded, randomized control trial (CTRI/2021/04/033052), 50 patients scheduled for FESS were randomly divided into two groups: Group M received 50 mg/kg MgSO4 in 100 ml normal saline, and Group N received 100 ml plain normal saline 15 min before induction. The study assessed total blood loss, measured by blood collected from the surgical field and weighing gauze. The surgical field grading was assessed by a six-point Fromme and Boezaart scale. We also observed stress attenuation during laryngoscopy and endotracheal intubation, additional intraoperative fentanyl requirements, and time taken for extubation. The sample size was estimated using the G power calculator 3.1.9.2 (http://www.gpower.hhu.de/). Data were entered in Microsoft Excel (Microsoft Corporation, Redmond, WA) and analyzed using Statistical Package for Social Sciences version 20.0 (IBM Corp., Armonk, NY). Results The demographic data and duration of the surgery were comparable in both groups. The total blood loss in Group M was 100.40 ml ±60.71 ml, which is lower than Group N (133.80 ml ±59.7 ml) with a p-value of 0.016. In addition, the surgical field grading was also better in Group M. The total vecuronium consumption was significantly lower in Group M, which was (7.23±0.84 mg); in Group N, it was (10.64±1.74 mg) with a p-value of 0.0001, respectively. The dosage of additional fentanyl in Group N was 38.46 mcg ± 8.99 mcg, more than in Group M (33.64 mcg ± 11.20 mcg). The time required for extubation was similar in both groups. The duration of the surgery was significantly more significant in Group M (150.0 ±31.36) than in Group N (205.0 ±32.79), with a p-value of 0.0001, respectively. Furthermore, the mean arterial pressure after induction, at 2 min and 4 min after laryngoscopy, was less in Group M, with p=0.001, p=0.003, and p<0.0001, respectively, when compared with Group N. The heart rate after induction, at 2 min and 4 min after laryngoscopy, was also less in Group M, with p=0.016, p=0.003, and p=0.003, respectively, when compared with Group N. The Ramsay Sedation Score was higher in Group M than in Group N's fourth, eighth, and sixteenth hour, with p=0.001, p=0.021, and p=0.001, respectively, in the postoperative period. The sedation score was statistically insignificant after that. No complications were encountered during the study. Conclusion We conclude that a single bolus dose of MgSO4 reduced surgical blood loss more effectively than in the control group. The surgical field grading was also better in Group M, as was the stress attenuation during laryngoscopy and endotracheal intubation. The intraoperative fentanyl requirement was not statistically significant. The time for extubation was similar between the groups. No other adverse effects were encountered during the study.
Collapse
|
11
|
Enayati A, Gin JH, Sajeev JK, Cooke JC, Carey P, MacPherson M, Roberts L, Buntine P, Teh AW, Nogic J. Efficacy of intravenous magnesium for the management of non-post operative atrial fibrillation with rapid ventricular response: A systematic review and meta-analysis. J Cardiovasc Electrophysiol 2023; 34:1286-1295. [PMID: 37186322 DOI: 10.1111/jce.15911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/05/2023] [Accepted: 04/09/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Intravenous magnesium (IV Mg), a commonly utilized therapeutic agent in the management of atrial fibrillation (AF) with rapid ventricular response, is thought to exert its influence via its effect on cellular automaticity and prolongation of atrial and atrioventricular nodal refractoriness thus reducing ventricular rate. We sought to undertake a systematic review and meta-analysis of the effectiveness of IV Mg versus placebo in addition to standard pharmacotherapy in the rate and rhythm control of AF in the nonpostoperative patient cohort given that randomized control trials (RCTs) have shown conflicting results. METHODS Randomized controlled trials comparing IV Mg versus placebo in addition to standard of care were identified via electronic database searches. Nine RCTs were returned with a total of 1048 patients. Primary efficacy endpoints were study-defined rate control and rhythm control/reversion to sinus rhythm. The secondary endpoint was patient experienced side effects. RESULTS Our analysis found IV Mg in addition to standard care was successful in achieving rate control (odd ratio [OR] 1.87, 95% confidence interval [CI] 1.13-3.11, p = .02) and rhythm control (OR 1.45, 95% CI 1.04-2.03, p = .03). Although not well reported among studies, there was no significant difference between groups regarding the likelihood of experiencing side effects. CONCLUSIONS IV Mg, in addition to standard-of-care pharmacotherapy, increases the rates of successful rate and rhythm control in nonpostoperative patients with AF with rapid ventricular response and is well tolerated.
Collapse
Affiliation(s)
- Anees Enayati
- Department of Cardiology, Austin Hospital, Melbourne, Victoria, Australia
| | - Julian H Gin
- Department of Cardiology, Austin Hospital, Melbourne, Victoria, Australia
| | - Jithin K Sajeev
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Jennifer C Cooke
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Patrick Carey
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
| | - Michael MacPherson
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
| | - Louise Roberts
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Paul Buntine
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
- Emergency Medicine Program, Eastern Health, Melbourne, Victoria, Australia
| | - Andrew W Teh
- Department of Cardiology, Austin Hospital, Melbourne, Victoria, Australia
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
- Austin Health Clinical School, University of Melbourne, Melbourne, Victoria, Australia
| | - Jason Nogic
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
12
|
Muacevic A, Adler JR. Controlled Hypotension for Functional Endoscopic Sinus Surgery With Two Different Doses of Fentanyl. Cureus 2023; 15:e33859. [PMID: 36819423 PMCID: PMC9932825 DOI: 10.7759/cureus.33859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2023] [Indexed: 01/19/2023] Open
Abstract
Background and Objectives Functional endoscopic sinus surgery (FESS) is a type of minimally invasive surgery done for acute and chronic sinus diseases or paranasal illnesses. The idea of FESS is to preserve the normal anatomy, which is non-obstructing and mucous membrane while removing tissue obstructing OMC (osteo metal complex) and facilitating drainage. The critical structures, including the brain, orbit, and carotid veins, the lack of adequate operating room, and bleeding that obscures endoscopic vision throughout the procedure may increase the likelihood of unfavorable surgical results. This study seeks to examine the hemodynamic effects of intubation and extubation as well as the impact of fentanyl infusion on lowering blood pressure during FESS procedures. Materials and Methods Sixty-eight patients from the American Society of Anesthesiologists classes 1 and 2 who were planned for functional endoscopic sinus operations were randomly split into two groups for this randomized prospective trial. Group 1 patient belonging to the fentanyl 2 mcg per kg bolus 30 minutes before induction followed by 2 mcg per kg per hr infusion for 90 minutes of surgery, and Group 2 patient belonging to fentanyl 1 mcg per kg bolus 30 minutes before induction followed by 1 mcg per kg per hr infusion for 90 minutes of surgery. The significance of the difference in quantitative measures was measured using the student-t test, and the Chi-square test was used to measure up the difference in proportion. Statistically significant was set at P<0.05. Results Mean systolic blood pressure was higher in members of Group 2 than in Group 1. In contrast to Group 2, Group 1 had considerably better surgical field conditions, surgeon satisfaction on the AONO'S scale, post-operative nausea and vomiting, and a post-operative VAS Score during the first 24 hours. Conclusion Pre-induction Fentanyl with infusion can effectively control hypotension during functional endoscopic sinus surgery.
Collapse
|
13
|
Abu Sabaa MA, Elbadry AA, Hegazy S, El Malla DA. Intravenous Versus Wetting Solution Magnesium Sulphate to Counteract Epinephrine Cardiac Adverse Events in Abdominal Liposuction: A Randomized Controlled Trial. Anesth Pain Med 2022; 12:e129807. [PMID: 36937176 PMCID: PMC10016130 DOI: 10.5812/aapm-129807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 11/02/2022] [Indexed: 11/21/2022] Open
Abstract
Background The increased frequency of liposuction has resulted in more complications being reported. Adding epinephrine to the wetting solution could induce some cardiac adverse effects, some of which may be fatal. For instance, magnesium sulfate (MgSO4) is known for its cardioprotective effects. Objectives This study aimed to evaluate the efficacy of intravenous (IV) versus wetting solution containing MgSO4 in decreasing such cardiac adverse events during abdominal liposuction. Methods This randomized controlled study included 129 adult cases undergoing abdominal liposuction under general anesthesia. The participants were divided into 3 groups: Group I (control group) was only subjected to the injection of the wetting fluid (1 mL 1/1000 epinephrine added to every 1000 mL of normal saline), group II was subjected to IV MgSO4 (40 mg/kg over 1 minute) at the same time of installing the wetting solution, and group III was subjected to MgSO4 (40 mg/kg) added to the wetting solution. Results Intraoperative isoflurane consumption, intraoperative heart rate (HR), mean arterial pressure (MAP), and postoperative pain scores were significantly lower in the MgSO4 groups (groups II and III) than group I. Cardiac adverse events (sinus tachycardia and premature ventricular contractions (PVCs)) were also significantly less frequent in groups II and III compared to group I. Conclusions Adding MgSO4, either through IV or subcutaneous routes, is associated with lower intraoperative HR, MAP, and postoperative pain scores and a remarkable decrease in epinephrine-induced cardiac adverse events during liposuction.
Collapse
Affiliation(s)
- Motaz Amr Abu Sabaa
- Surgical Intensive Care and Pain Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt
- Corresponding Author: Lecturer of Anesthesiology, Surgical Intensive Care and Pain Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt.
| | - Amr Arafa Elbadry
- Surgical Intensive Care and Pain Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Safwat Hegazy
- Faculty of Medicine, Kafr Elsheikh University, Kafr Elsheikh, Egypt
| | - Dina Ahmed El Malla
- Surgical Intensive Care and Pain Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt
| |
Collapse
|
14
|
Jitsinthunun T, Raksakietisak M, Pantubtim C, Mahatnirunkul P. Effects of Magnesium Sulfate on Intraoperative Blood Loss and Anesthetic Requirement in Meningioma Patients Undergoing Craniotomy with Tumor Removal: A Prospective Randomized Study. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2022. [DOI: 10.1055/s-0042-1750692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
Abstract
Background Meningioma brain tumor is associated with significant blood loss. Magnesium (Mg), a calcium blocker, can facilitate blood pressure control during surgery. This study aimed to evaluate effects of magnesium on blood loss, anesthetic requirement, and its neuroprotective effect in meningioma patients undergoing craniotomy.
Methods Eighty patients aged between 18 and 70, American Society of Anesthesiologists physical status I and II, diagnosed with meningioma and scheduled for craniotomy tumor removal were randomized into two groups. Group M (Mg) received intravenous magnesium sulfate 40 mg/kg over 30 minutes initiated at skin incision and followed by continuous infusion of 10 mg/kg/h until dura closure. Group N (NSS) received 0.9% NaCl as placebo. Anesthesiologists in charge, surgeons, and patients were all blinded. The assessed outcomes were perioperative blood loss, anesthetic requirement, and pre- and postoperative neurocognitive functions assessed by Montreal Cognitive Assessment (MoCA).
Results Thirty-eight patients in each group were analyzed. In group M, the intraoperative blood losses were 500 (70, 2300) mL, and 510 (100, 1600) mL in group N (p = 0.315). Patients who received blood within 24 hours were 39.5% in group M and 47.4% in group N (p = 0.644). No differences were observed in anesthetic requirement, intraoperative mean arterial pressure, hypotensive episodes, and vasopressor usages. There were no significant differences in postoperative MoCA score. Magnesium levels did not exceed acceptable levels.
Conclusions Magnesium administration in meningioma patients had no significant effects on blood loss, anesthetic requirement, and postoperative cognitive function.
Collapse
Affiliation(s)
- Thanawut Jitsinthunun
- Department of Anaesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Manee Raksakietisak
- Department of Anaesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chanitda Pantubtim
- Department of Anaesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Porntip Mahatnirunkul
- Department of Anaesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| |
Collapse
|
15
|
Mohamed Ali HS, Gad GS, Fayed HM. A comparative study of clonidine and magnesium sulfate premedication on perioperative hormonal stress responses, hemodynamic stability and postoperative analgesia in patients with gallbladder diseases undergoing laparoscopic cholecystectomy. A randomized, double-blind, controlled study. EGYPTIAN JOURNAL OF ANAESTHESIA 2022. [DOI: 10.1080/11101849.2022.2031546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Hatem Saber Mohamed Ali
- Assistant Professor of Anesthesia, Qena Faculty of Medicine, South, Valley University, Qena, Egypt
| | - Gad Sayed Gad
- Assistant Professor of Anesthesia, Qena Faculty of Medicine, South Valley University, Qina, Egypt
| | - Hanan Mahmoud Fayed
- Assistant Professor of Clinical pathology,Qena Faculty of Medicine,South Valley University, Qina, Egypt
| |
Collapse
|
16
|
Local anaesthetic techniques in endoscopic sinonasal surgery: a contemporaneous review. The Journal of Laryngology & Otology 2021; 136:683-691. [PMID: 34814956 DOI: 10.1017/s0022215121003583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
|
17
|
Preoperative effects of magnesium sulfate on hemodynamics and muscle relaxation. JOURNAL OF SURGERY AND MEDICINE 2021. [DOI: 10.28982/josam.954330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
18
|
Almeida CEDD, Carvalho LRD, Andrade CVC, Nascimento PD, Barros GAMD, Modolo NSP. Effects of magnesium sulphate on the onset time of rocuronium at different doses: a randomized clinical trial. Braz J Anesthesiol 2021; 71:482-488. [PMID: 34403648 PMCID: PMC9373264 DOI: 10.1016/j.bjane.2021.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 07/29/2021] [Accepted: 07/31/2021] [Indexed: 11/11/2022] Open
Abstract
Background and aims Rocuronium may provide excellent onset time, but high doses are required for effective action. Several strategies have managed to shorten rocuronium onset time, including the use of Magnesium Sulphate (MgSO4). Methods One hundred and eighty patients were randomized into six groups according to rocuronium dose received (0.3, 0.6 or 1.2 mg.kg-1) and the administration of saline or MgSO4 (60 mg.kg-1). Correlations between tissue perfusion and rocuronium onset time was determined by variations in perfusion index. Results Median (quartiles) rocuronium onset times were 85.5 (74.0–92.0); 76.0 (52.0–87.0) and 50.0 (41.0–59.5) seconds for 0.3, 0.6 mg.kg-1 and 1.2 mg.kg-1 doses, respectively. MgSO4 decreased rocuronium onset at doses of 0.3 mg.kg-1 (60.0 [48.0–74.3] seconds) and 0.6 mg.kg-1 (44.0 [39.0–49.0] seconds) but not at 1.2 mg.kg-1 (38.0 [33.5–56.3] seconds) (p < 0.001). Perfusion index variations in groups that received MgSO4 were greater than in controls. A negative correlation between shorten onset and increased perfusion index was observed in rocuronium doses of 0.3 mg.kg-1 (r = -0.50; p < 0.001) and 0.6 mg.kg-1 (r = -0.424; p < 0.001), but not for 1.2 mg.kg-1 dose (r = -0.25; p = 0.07). Conclusion MgSO4 reduces rocuronium onset time at doses of 0.3 mg.kg-1 and 0.6 mg.kg-1 being that the latter has a similar effect when compared to the dose of 1.2 mg.kg-1, with or without the use of MgSO4. Trial registry at http://www.ensaiosclinicos.gov.br/ Registry Number RBR-96CY3K
Collapse
Affiliation(s)
- Carlos Eduardo David de Almeida
- Universidade Estadual Paulista (Unesp), Faculdade de Medicina, Programa de Pós-Graduação em Anestesiologia, Botucatu, SP, Brazil
| | | | - Carla Vasconcelos Caspar Andrade
- Universidade Estadual Paulista (Unesp), Faculdade de Medicina, Programa de Pós-Graduação em Anestesiologia, Botucatu, SP, Brazil
| | - Paulo do Nascimento
- Universidade Estadual Paulista (Unesp), Faculdade de Medicina, Divisão de Anestesiologia, Botucatu, SP, Brazil
| | | | - Norma Sueli Pinheiro Modolo
- Universidade Estadual Paulista (Unesp), Faculdade de Medicina, Divisão de Anestesiologia, Botucatu, SP, Brazil
| |
Collapse
|
19
|
Reducing the dose of neuromuscular blocking agents with adjuncts: a systematic review and meta-analysis. Br J Anaesth 2020; 126:608-621. [PMID: 33218672 DOI: 10.1016/j.bja.2020.09.048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 09/14/2020] [Accepted: 09/14/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Acute global shortages of neuromuscular blocking agents (NMBA) threaten to impact adversely on perioperative and critical care. The use of pharmacological adjuncts may reduce NMBA dose. However, the magnitude of any putative effects remains unclear. METHODS We conducted a systematic review and meta-analysis of RCTs. We searched Medline, Embase, Web of Science, and Cochrane Database (1970-2020) for RCTs comparing use of pharmacological adjuncts for NMBAs. We excluded RCTs not reporting perioperative NMBA dose. The primary outcome was total NMBA dose used to achieve a clinically acceptable depth of neuromuscular block. We assessed the quality of evidence using the GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) criteria. Data are presented as the standardised mean difference (SMD); I2 indicates percentage of variance attributable to heterogeneity. RESULTS From 3082 records, the full texts of 159 trials were retrieved. Thirty-one perioperative RCTs met the inclusion criteria for meta-analysis (n=1962). No studies were conducted in critically ill patients. Reduction in NMBA dose was associated with use of magnesium (SMD: -1.10 [-1.44 to -0.76], P<0.001; I2=85%; GRADE=moderate), dexmedetomidine (SMD: -0.89 [-1.55 to -0.22]; P=0.009; I2=87%; GRADE=low), and clonidine (SMD: -0.67 [-1.13 to -0.22]; P=0.004; I2=0%; GRADE=low) but not lidocaine (SMD: -0.46 [-1.01 to -0.09]; P=0.10; I2=68%; GRADE=moderate). Meta-analyses for nicardipine, diltiazem, and dexamethasone were not possible owing to the low numbers of studies. We estimated that 30-50 mg kg-1 magnesium preoperatively (8-15 mg kg h-1 intraoperatively) reduces rocuronium dose by 25.5% (inter-quartile range, 14.7-31). CONCLUSIONS Magnesium, dexmedetomidine, and clonidine may confer a clinically relevant sparing effect on the required dose of neuromuscular block ing drugs in the perioperative setting. SYSTEMATIC REVIEW REGISTRATION PROSPERO: CRD42020183969.
Collapse
|
20
|
Kosucu M, Tugcugil E, Arslan E, Omur S, Livaoglu M. Effects of perioperative magnesium sulfate with controlled hypotension on intraoperative bleeding and postoperative ecchymosis and edema in open rhinoplasty. Am J Otolaryngol 2020; 41:102722. [PMID: 32950829 DOI: 10.1016/j.amjoto.2020.102722] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 09/07/2020] [Indexed: 12/01/2022]
Abstract
PURPOSE This randomized, double-blind study was planned to evaluate the effect of perioperative magnesium sulfate with controlled hypotension on intraoperative bleeding, postoperative ecchymosis and edema, and side-effects. MATERIALS AND METHOD Forty-nine patients undergoing open rhinoplasty were divided into two groups - magnesium sulfate and control. The magnesium sulfate group received 30-50 mg·kg-1 intravenously as a bolus before induction of anesthesia, followed by 10-20 mg·kg-1 h-1 by continuous intravenous infusion during surgery. Anesthesia was induced with propofol 3 mg·kg-1, fentanyl 15 μg·kg-1 and cisatracurium 0.6 mg·kg-1. Mean arterial pressure was maintained at 50 to 60 mmHg under controlled hypotensive anesthesia with magnesium sulfate titration. Hemodynamic variables, operational bleeding, early postoperative side-effects and postoperative first-, third- and seventh-day ecchymosis and edema were compared between the groups. Ecchymosis and edema were evaluated using a graded scale from 0 to 4. RESULTS In the magnesium sulfate group, mean arterial pressure decreased during most of the perioperative period. Intraoperative bleeding also decreased. A distinct reduction in ecchymosis and edema was observed in both the upper and lower eyelids on the first, third and seventh days. Patients in the magnesium sulfate group also had a more peaceful postoperative course with less postoperative nausea vomiting, and shivering. CONCLUSION Magnesium sulfate with controlled hypotension can lower ecchymosis and edema of the upper and lower eyelids in rhinoplasty surgery by reducing bleeding.
Collapse
Affiliation(s)
- Muge Kosucu
- Medical School of Karadeniz Technical University, Department of Anesthesiology, 61080 Trabzon, Turkey.
| | - Ersagun Tugcugil
- Medical School of Karadeniz Technical University, Department of Anesthesiology, 61080 Trabzon, Turkey
| | - Erhan Arslan
- Medical School of Karadeniz Technical University, Department of Neurosurgery, 61080 Trabzon, Turkey
| | - Sahin Omur
- Medical School of Karadeniz Technical University, Department of Anesthesiology, 61080 Trabzon, Turkey
| | - Murat Livaoglu
- Medical School of Karadeniz Technical University, Department of Plastic and Reconstructive Surgery, 61080 Trabzon, Turkey
| |
Collapse
|
21
|
Dehkordy ME, Tavanaei R, Younesi E, Khorasanizade S, Farsani HA, Oraee-Yazdani S. Effects of perioperative magnesium sulfate infusion on intraoperative blood loss and postoperative analgesia in patients undergoing posterior lumbar spinal fusion surgery: A randomized controlled trial. Clin Neurol Neurosurg 2020; 196:105983. [PMID: 32521394 DOI: 10.1016/j.clineuro.2020.105983] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 05/27/2020] [Accepted: 05/31/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Many studies have suggested the anti-nociceptive role for magnesium either as an adjunct for postoperative pain. Although several studies have been carried out to evaluate the anti-nociceptive effect of magnesium, there is still considerable uncertainty. PATIENTS AND METHODS Eighty patients who underwent posterior spinal fusion were randomly divided into two groups (magnesium and saline). Changes in cell count, magnesium concentration and coagulation status were assessed one hour after operation at both group and compared to baseline. At recovery room, their pain score was assessed according to 10 points visual analogue scale (VAS). Morphine consumption was evaluated at regular times after the surgery by patient controlled analgesia (PCA) device. RESULTS VAS scores were significantly lower in the magnesium group. Cumulative PCA morphine consumption after the surgery was significantly lower in the magnesium group. Pre and postoperative values for haemoglobin, platelet count, Prothrombin Time (PT), fibrinogen were not significantly different. There was a significant increase in activated Partial Thromboplastin Time (aPTT), International Normalized Ratio (INR), and bleeding time (BT), one hour after the operation in the magnesium group but intraoperative blood loss was similar in both groups. CONCLUSIONS Perioperative magnesium sulfate infusion improves the postoperative analgesia, decreases the amount of morphine consumption after the operation and does not change the intraoperative bleeding in patients undergoing posterior spinal fusion surgery.
Collapse
Affiliation(s)
- Masih Ebrahimy Dehkordy
- Department of Anesthesiology, Shohada Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Roozbeh Tavanaei
- Shohada Tajrish Neurosurgical Center of Excellence, Functional Neurosurgery Research Center, Shohada Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Elahe Younesi
- Department of Anesthesiology, Shohada Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shayesteh Khorasanizade
- Department of Anesthesiology, Shohada Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamidreza Azizi Farsani
- Department of Anesthesiology, Shohada Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Saeed Oraee-Yazdani
- Shohada Tajrish Neurosurgical Center of Excellence, Functional Neurosurgery Research Center, Shohada Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| |
Collapse
|
22
|
Sadek AA, Mostafa M, Abdel-Monem T. Metoprolol Significantly Improves Visual Clarity and Hemodynamic Parameters during Functional Endoscopic Sinus Surgery. Biomed Hub 2020; 4:1-8. [PMID: 31993421 PMCID: PMC6985881 DOI: 10.1159/000497045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 01/14/2019] [Indexed: 11/19/2022] Open
Abstract
Background and Objectives The success of functional endoscopic sinus surgery (FESS) depends on the visual clarity of the surgical field, which is understudied. Controlled hypotension has many advantages for FESS including reduction in blood loss and improved quality of the surgical field. This study determined whether the use of β-blockers as a premedication could improve the operative field in FESS. Methods : Sixty patients aged from 18 to 50 years, undergoing septoplasty and FESS were included in this prospective, randomized, double-blind, placebo-controlled study. Patients were randomly assigned to receive either metoprolol (100 mg, group 1) or a placebo (a vitamin tablet, group 2) 60 min before surgery. Results The average blood loss and surgery duration were not significantly higher in the placebo group. The surgical field was graded using the Fromme-Boezaart scale, and it was significantly clearer (p < 0.001) in metoprolol group. The mean arterial blood pressure was significantly lower in the metoprolol group after 30 min of induction until the end of surgery (p < 0.001). The heart rate was also significantly lower (p < 0.001) in those who received metoprolol from before induction of anesthesia up to the end of surgery. Conclusion : Metoprolol significantly improves visual clarity and hemodynamics during FESS. We would recommend the use of metoprolol in FESS and septoplasty.
Collapse
Affiliation(s)
- Ahmed A Sadek
- Otorhinolaryngology Department, Faculty of Medicine, Minia University, Minia, Egypt
| | - Mokhtar Mostafa
- Anesthesiology and Intensive Care Department, Faculty of Medicine, Minia University, Minia, Egypt
| | - Tarek Abdel-Monem
- Anesthesiology and Intensive Care Department, Faculty of Medicine, Minia University, Minia, Egypt
| |
Collapse
|
23
|
Lang B, Zhang L, Lin Y, Zhang W, Li FS, Chen S. Comparison of effects and safety in providing controlled hypotension during surgery between dexmedetomidine and magnesium sulphate: A meta-analysis of randomized controlled trials. PLoS One 2020; 15:e0227410. [PMID: 31914454 PMCID: PMC6949117 DOI: 10.1371/journal.pone.0227410] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 12/18/2019] [Indexed: 02/05/2023] Open
Abstract
Background Effectiveness of controlled hypotension has been proven in alleviating intraoperative bleeding. Many recent studies emphasized the efficacy of dexmedetomidine and magnesium in providing controlled hypotension during various surgeries. The present meta-analysis of randomized controlled trials (RCTs) was performed to evaluate comprehensively the effects and safety of these two medications. Methods Literature search was performed in four databases from inception to April 2019. All RCTs that used dexmedetomidine and magnesium as hypotensive agents were enrolled. The outcomes contained bleeding condition of surgical site, hemodynamic parameters, duration of surgeries, number of patients requiring opioid/analgesia administration, recovery period, and adverse events emerged during surgeries. Results Ten studies with 663 patients met with our inclusion criteria. The results indicated that both bleeding score and values of mean arterial pressure (MAP) and heart rate (HR) were significantly lower in patients receiving dexmedetomidine (SMD 1.65 with 95% CI [0.90,2.41], P<0.00001) compared to the patients receiving magnesium. The effect in decreasing the necessity of using opioid/analgesia was affirmative in dexmedetomidine group (29.13% with magnesium vs 10.78% with dexmedetomidine), and the condition was more favorable in magnesium group in reducing recovery period (SMD -1.98 with 95% CI [-4.27,0.30], P = 0.09). Compared with magnesium, using of dexmedetomidine was associated with higher incidence of bradycardia but lower incidence of nausea and vomiting. Conclusion Compared with magnesium, dexmedetomidine is more effective to provide promising surgical field condition, favorable controlled hypotension, and less necessity of opioid or analgesia administration. But long recovery period and high-probability bradycardia should be deliberated.
Collapse
Affiliation(s)
- Bingchen Lang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Lingli Zhang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, People’s Republic of China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, People’s Republic of China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, People’s Republic of China
- * E-mail:
| | - Yunzhu Lin
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Wensheng Zhang
- Department of Anesthesiology, Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Feng-shan Li
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Shouming Chen
- Department of Anesthesiology, West China Second University Hospital, Sichuan University, Chengdu, People’s Republic of China
| |
Collapse
|
24
|
Escamilla Y, Cardesín A, Samara L, López S, Izquierdo A, Fradera M, Vives R, Bernal-Sprekelsen M, Pontes C. Randomized clinical trial to compare the efficacy to improve the quality of surgical field of hypotensive anesthesia with clonidine or dexmedetomidine during functional endoscopic sinus surgery. Eur Arch Otorhinolaryngol 2019; 276:3095-3104. [DOI: 10.1007/s00405-019-05575-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 07/16/2019] [Indexed: 12/18/2022]
|
25
|
Liu W, Jiang H, Pu H, Hu D, Zhang Y. The effect of magnesium sulfate on surgical field during endoscopic sinus surgery: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2019; 98:e16115. [PMID: 31305395 PMCID: PMC6641709 DOI: 10.1097/md.0000000000016115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION The benefits of magnesium sulfate for surgical field during endoscopic sinus surgery remain controversial. We conduct a systematic review and meta-analysis to explore the influence of magnesium sulfate versus placebo on surgical field during endoscopic sinus surgery. METHODS We search PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through November 2018 for randomized controlled trials (RCTs) assessing the effect of magnesium sulfate versus placebo on surgical field during endoscopic sinus surgery. This meta-analysis is performed using the random-effect model. RESULTS Four RCTs and 404 patients are included in the meta-analysis. Overall, compared with control group endoscopic sinus surgery, magnesium sulfate has remarkably positive impact on surgical field scores (MD = -1.76; 95% CI = -2.33 to -1.18; P < .00001), and intraoperative blood loss (MD = -89.09; 95% CI = -163.20 to -14.97; P = .02), but shows no markedly effect on surgery duration (MD = -7.08; 95% CI = -21.38 to 7.22; P = .33), fentanyl (MD = -0.64; 95% CI = -1.97 to 0.70; P = .35), and vecuronium (MD = -3.64; 95% CI = -10.99 to 3.70; P = .33). CONCLUSIONS Magnesium sulfate exerts positive impact on surgical field and blood loss reduction for endoscopic sinus surgery.
Collapse
|
26
|
Can systemic lidocaine be used in controlled hypotension? A double-blinded randomized controlled study in patients undergoing functional endoscopic sinus surgery. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2013.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
|
27
|
ELShamaa HA, Ibrahim M, Eldesuky HL. Magnesium sulfate in femoral nerve block, does postoperative analgesia differ? A comparative study. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2013.10.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
| | - Mohamed Ibrahim
- Anesthesia Department, Faculty of Medicine , Zagazig University , Egypt
| | | |
Collapse
|
28
|
Aboushanab OH, El-Shaarawy AM, Omar AM, Abdelwahab HH. A comparative study between magnesium sulphate and dexmedetomidine for deliberate hypotension during middle ear surgery. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2011.07.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
| | | | - Ahmed M. Omar
- King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | | |
Collapse
|
29
|
Evaluation of effect of intravenous Magnesium Sulfate infusion on tourniquet induced hypertension and pain in arthroscopic knee surgery patients under epidural anesthesia. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2016.08.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
|
30
|
Oral nifedipine as a premedication for induced hypotension in functional endoscopic sinus surgery (FESS). EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2015.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
|
31
|
Samir EM, Badawy SS, Hassan AR. Intrathecal vs intravenous magnesium as an adjuvant to bupivacaine spinal anesthesia for total hip arthroplasty. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2013.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Affiliation(s)
- Enas M. Samir
- Kasr Al Aini Hospital, Department of Anesthesia and Intensive Care, Faculty of Medicine, Cairo University, Egypt
| | - Sahar S. Badawy
- Kasr Al Aini Hospital, Department of Anesthesia and Intensive Care, Faculty of Medicine, Cairo University, Egypt
| | - Amira Refaie Hassan
- Kasr Al Aini Hospital, Department of Anesthesia and Intensive Care, Faculty of Medicine, Cairo University, Egypt
| |
Collapse
|
32
|
Prophylactic vs. therapeutic magnesium sulfate for shivering during spinal anesthesia. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2013.07.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
33
|
Bharathwaj DK, Kamath SS. Comparison of dexmedetomidine versus propofol-based anaesthesia for controlled hypotension in functional endoscopic sinus surgery. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2019. [DOI: 10.36303/sajaa.2019.25.2.2051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Background: Increased intraoperative bleeding during functional endoscopic sinus surgery (FESS) affects operative field visibility, which increases both duration of surgery and frequency of complications. Controlled hypotension is an anaesthetic technique in which there is deliberate reduction of systemic blood pressure during anaesthesia. The aim of the study was to compare the efficacy of dexmedetomidine against propofol infusion when used for controlled hypotension during FESS.
Methods: A randomised, prospective, and single-blinded study was carried out, which included 80 patients of either sex of ASA grade І & ІІ who underwent elective FESS. Patients were randomly assigned to two groups: Group A (dexmedetomidine), Group B (propofol). Intraoperative mean arterial pressure (MAP), heart rate (HR), surgical grade of bleeding (based on the Fromme– Boezzart scale), and amount of bleeding were recorded.
Results: Groups were well matched for their demographic data. There was a statistically significant difference (p < 0.05) between Group A and Group B in heart rate, mean arterial pressure (MAP) and mean total blood loss, with Group A being effectively in controlled on all three parameters during FESS. However, there was no significant difference (p > 0.05) in terms of surgical grade of bleeding between Group A and Group B.
Conclusions: Both dexmedetomidine and propofol infusion are efficacious to facilitate controlled hypotension and haemodynamic stability intraoperatively.
Collapse
|
34
|
Alsaleh S, Manji J, Javer A. Optimization of the Surgical Field in Endoscopic Sinus Surgery: an Evidence-Based Approach. Curr Allergy Asthma Rep 2019; 19:8. [PMID: 30712131 DOI: 10.1007/s11882-019-0847-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The advent of endoscopic sinus surgery (ESS) has enabled the development of minimally invasive surgical procedures in Rhinology. However, proficiency with ESS techniques can still be hampered by poorly controlled bleeding limiting visibility of the surgical field (VSF). This can lead to increased operating time and, more importantly, increased risk of major and minor complications. To optimize the VSF and mitigate the risk of complications, many strategies have been explored. RECENT FINDINGS This is a narrative review of the relative risks and benefits of pre- and intra-operative interventions aimed at optimizing intraoperative conditions during ESS. The value of these interventions is determined based on their impact on intraoperative blood loss, time of surgery, and the VSF, and weighed against their adverse event profile. This review provides a comprehensive overview of the evidence relating to the safety and efficacy of interventions used to improve intraoperative conditions during ESS.
Collapse
Affiliation(s)
- Saad Alsaleh
- Otolaryngology - Head and Neck Surgery Department, College of Medicine, King Saud University Medical City, PO Box 245, Riyadh, 11411, Saudi Arabia.
- St. Paul's Sinus Centre, Vancouver, BC, Canada.
| | - Jamil Manji
- St. Paul's Sinus Centre, Vancouver, BC, Canada
| | - Amin Javer
- St. Paul's Sinus Centre, Vancouver, BC, Canada
| |
Collapse
|
35
|
Hamed MA. Comparative Study between Magnesium Sulfate and Lidocaine for Controlled Hypotension during Functional Endoscopic Sinus Surgery: A Randomized Controlled Study. Anesth Essays Res 2018; 12:715-718. [PMID: 30283182 PMCID: PMC6157236 DOI: 10.4103/aer.aer_103_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background: Intraoperative bleeding impairs surgical field visibility during functional endoscopic sinus surgery (FESS); several methods have been used to decrease blood loss and improve surgical field, one of them is usage of hypotensive anesthetic agents. Aim: We intended to compare magnesium sulfate with lidocaine, regarding their efficiency in inducing controlled hypotension and providing a better surgical field exposure during FESS and the influence of their usage on extubation time. Settings and Design: This study design was a prospective randomized controlled double-blinded clinical study. Patients and Methods: Eighty adult patients with patients' physical status ASA Classes I and II, aged 20–50 years scheduled for FESS were randomly divided into two study groups; each group contains 40 patients: Group L received lidocaine 2 mg/kg/h with maximum of 200 mg/h starting at induction of anesthesia and continuing until the end of surgery and Group M received an iv bolus of magnesium sulfate 50mg/kg in a total of 100ml saline over 10 min followed by infusion of 15mg/kg/h until the end of surgery; patients were observed for the quality of the surgical field, blood loss, and extubation time. Statistical Analysis Used: Student's t-test or Mann–Whitney's U, Chi-square, or Fisher's exact tests were used. Results: Group L showed a significant decrease in blood loss (P = 0.01), better surgical field clarity (P = 0.002), and shorter extubation time (P = 0.001) than Group M, but there was no statistically significant difference between the two study groups as regards hemodynamics. Conclusion: We concluded that both magnesium sulfate and lidocaine successfully induced controlled hypotension in patients undergoing FEES, but lidocaine provided better surgical field clarity and shorter extubation time.
Collapse
Affiliation(s)
- Mohamed Ahmed Hamed
- Department of Anesthesiology, Faculty of Medicine, Fayoum University, Faiyum, Egypt
| |
Collapse
|
36
|
Bharathwaj DK, Kamath SS. Comparison of dexmedetomidine versus propofol-based anaesthesia for controlled hypotension in functional endoscopic sinus surgery. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2018. [DOI: 10.1080/22201181.2018.1517484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- DK Bharathwaj
- Department of Anaesthesiology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - SS Kamath
- Department of Anaesthesiology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India
| |
Collapse
|
37
|
Analgesic effects of methadone and magnesium following posterior spinal fusion for idiopathic scoliosis in adolescents: a randomized controlled trial. J Anesth 2018; 32:702-708. [DOI: 10.1007/s00540-018-2541-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 07/30/2018] [Indexed: 10/28/2022]
|
38
|
Garg BD. Antenatal magnesium sulfate is beneficial or harmful in very preterm and extremely preterm neonates: a new insight. J Matern Fetal Neonatal Med 2018; 32:2084-2090. [PMID: 29301419 DOI: 10.1080/14767058.2018.1424823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AIMS To evaluate whether antenatal MgSO4 is beneficial or harmful in very preterm and extremely preterm neonates. MATERIALS AND METHODS We retrieved published literature through searches of PubMed or Medline, CINAHL, and the Cochrane Library. Results were restricted to systematic reviews, meta-analysis, randomized controlled trials (RCTs), and relevant observational studies. RESULTS Evidence revealed that antenatal MgSO4 has neuroprotective role in preterm neonates and it decreased the risk of cerebral palsy and gross motor dysfunction. Evidences regarding association of antenatal MgSO4 with feed intolerance, NEC and SIP were from cohort studies and controversial. CONCLUSIONS We should continue use antenatal MgSO4 to all eligible patients according to protocol till the more robust evidence will suggest association with gastrointestinal complications. In the meantime, we should have a high index of suspicion of gastrointestinal complications in extremely preterms particularly <26 weeks of gestation.
Collapse
Affiliation(s)
- Bhawan Deep Garg
- a Surya Mother and Child Care Super Speciality Hospital , Mumbai , India
| |
Collapse
|
39
|
Rokhtabnak F, Djalali Motlagh S, Ghodraty M, Pournajafian A, Maleki Delarestaghi M, Tehrani Banihashemi A, Araghi Z. Controlled Hypotension During Rhinoplasty: A Comparison of Dexmedetomidine with Magnesium Sulfate. Anesth Pain Med 2017; 7:e64032. [PMID: 29696129 PMCID: PMC5903392 DOI: 10.5812/aapm.64032] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 11/27/2017] [Accepted: 12/22/2017] [Indexed: 12/21/2022] Open
Abstract
Objective The current study aimed at comparing the efficacy of dexmedetomidine and magnesium sulfate to control blood pressure (BP) during rhinoplasty and the resultant effects on the quality of surgical field in terms of bleeding and visibility. Methods The current randomized, prospective, double-blind study was conducted on 60 patients aged 18 to 50 years classified as ASA (American Society of Anesthesiologists) physical status I who were candidates for rhinoplasty. Patients were randomly divided into 2 groups: (1) group Dex, received 1 µg/kg dexmedetomidine in 10 minutes before induction of anesthesia, followed by 0.4 - 0.6 µg/kg/hour during the maintenance of anesthesia, and (2) group Mg, received 40 mg/kg in 10 minutes before anesthesia induction followed by 10 - 15 mg/kg/hour during anesthesia maintenance. In both groups, the goal was to achieve a mean arterial pressure (MAP) of 60 - 70 mmHg. Hemodynamic variables, anesthetic, opioid, muscle relaxant requirements, and surgical field condition were recorded. Sedation score, time to reach modified Aldrete score ≥ 9, and adverse effects including nausea and vomiting (N&V) and shivering were recorded. Results Controlled hypotension was achieved in both groups. There was no significant difference in MAP between the groups, but heart rate (HR) was significantly lower in the Dex group (P < 0.001), compared with that of the Mg group. Bleeding score was lower (P < 0.001) and surgeon's satisfaction score was higher (P < 0.001) in the Dex group. More patients required fentanyl (P < 0.001) or nitroglycerin (P < 0.001) and the mean fentanyl (P = 0.005) or nitroglycerin (P < 0.001) required doses were higher in the Mg group. Patients in the Dex group required more frequent administration of cisatracurium (P = 0.004). Five patients in the Dex group versus no patients in the Mg group received atropine (P = 0.023). Ramsay sedation score and time to reach modified Aldrete score ≥ 9 were significantly higher in the Dex group (P < 0.001 and P < 0.001, respectively). The incidence rate of N&V and shivering were similar in both groups. Conclusion Dexmedetomidine was more effective than magnesium to achieve controlled hypotension, and provide a favorable surgical field condition. However, dexmedetomidine also heightened the risk of induced bradycardia and prolonged sedation. These are 2 important points to consider when applying this drug as a hypotensive agent during operation.
Collapse
Affiliation(s)
- Faranak Rokhtabnak
- Department of Anesthesia, Iran University of Medical Sciences, Tehran, Iran
| | - Soudabeh Djalali Motlagh
- Department of Anesthesia, Iran University of Medical Sciences, Tehran, Iran
- Corresponding auther: Soudabeh Djalali Motlagh, Department of Anesthesia, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran. Tel: +98-9123093144, Fax: +98-2188660660, E-mail:
| | | | | | | | - Arash Tehrani Banihashemi
- Preventive Medicine and Public Health Research Center, Community Medicine Department, Iran University of Medical Sciences, Tehran, Iran
| | - Zeinab Araghi
- Department of Anesthesia, Iran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
40
|
Forget P, Cata J. Stable anesthesia with alternative to opioids: Are ketamine and magnesium helpful in stabilizing hemodynamics during surgery? A systematic review and meta-analyses of randomized controlled trials. Best Pract Res Clin Anaesthesiol 2017; 31:523-531. [DOI: 10.1016/j.bpa.2017.07.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 05/18/2017] [Accepted: 07/03/2017] [Indexed: 11/29/2022]
|
41
|
Rodríguez-Rubio L, Nava E, del Pozo JSG, Jordán J. Influence of the perioperative administration of magnesium sulfate on the total dose of anesthetics during general anesthesia. A systematic review and meta-analysis. J Clin Anesth 2017; 39:129-138. [DOI: 10.1016/j.jclinane.2017.03.038] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 03/08/2017] [Accepted: 03/19/2017] [Indexed: 10/19/2022]
|
42
|
Abstract
Endoscopic sinus approach has become one of the most common surgical techniques for endoscopic sinus and skull base surgery. Anesthetic management has an important impact on the overall patient management, from the preoperative assessment and management to the quality of the surgical field and the postoperative recovery. Hemostasis is critical for adequate anatomical endoscopic visualization. Mild controlled hypotension seems to improve the visibility of the surgical field. Reduction of intraoperative bleeding should be considered during the treatment planning. Preoperative preparations include the optimization of comorbidities and cessation of drugs that may inhibit coagulation.
Collapse
Affiliation(s)
- Martha Cordoba Amorocho
- Department of Anesthesiology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243 Charles Street, Boston, MA 02114, USA; Department of Anesthesiology and Critical Care, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
| | - Iuliu Fat
- Department of Anesthesiology, Harbor Hospital, 3001 South Hanover Street, Baltimore, MD 21225, USA
| |
Collapse
|
43
|
Lin S, McKenna SJ, Yao CF, Chen YR, Chen C. Effects of Hypotensive Anesthesia on Reducing Intraoperative Blood Loss, Duration of Operation, and Quality of Surgical Field During Orthognathic Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Oral Maxillofac Surg 2017; 75:73-86. [DOI: 10.1016/j.joms.2016.07.012] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 07/15/2016] [Accepted: 07/18/2016] [Indexed: 10/21/2022]
|
44
|
Soliman R, Fouad E. The effects of dexmedetomidine and magnesium sulphate in adult patients undergoing endoscopic transnasal transsphenoidal resection of pituitary adenoma: A double-blind randomised study. Indian J Anaesth 2017; 61:410-417. [PMID: 28584351 PMCID: PMC5444220 DOI: 10.4103/ija.ija_581_16] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background and Aim: Transnasal transsphenoidal resection of pituitary tumours is associated with blood loss and wide fluctuations in haemodynamic parameters. The aim of the present study was to compare the effect of dexmedetomidine and magnesium sulphate during the transsphenoidal resection of pituitary tumours. Methods: The study was a double-blind, randomised study and included 152 patients classified randomly into two groups: Group D: Dexmedetomidine was given as a loading dose 1 μg/kg over 10 min before induction followed by an infusion at 0.5 μg/kg/h during the surgery. Group M: Magnesium sulphate was given as loading dose of 50 mg/kg over 10 min followed by an infusion at 15 mg/kg/h during the surgery. The systolic, diastolic and mean arterial blood pressures, in addition to the amount of blood loss were measured at specific timepoints. Data were described in terms of mean ± standard deviation, median, frequencies, 95% confidence of interval of mean and percentages. Results: Mean bleeding score was lower in Group D than Group M (1.36 ± 0.48 vs. 3.05 ± 0.65, respectively; P = 0.002). Mean blood loss was lower in Group D (157.43 ± 48.79 ml vs.299.47 ± 77.28 ml in Group M; P < 0.001)Heart rate, mean arterial pressure, fentanyl requirements, end-tidal sevoflurane concentration, and extubation and emergence times were lower, while incidence of bradycardia and hypotension were higher in Group D. Conclusions: During transsphenoidal pituitary resection, dexmedetomidine, compared to magnesium, is associated with lower blood loss and better operating conditions but with more hypotension and bradycardia
Collapse
Affiliation(s)
- Rabie Soliman
- Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Eman Fouad
- Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt
| |
Collapse
|
45
|
Magnesium in obstetric anesthesia and intensive care. J Anesth 2016; 31:127-139. [PMID: 27803982 DOI: 10.1007/s00540-016-2257-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Accepted: 09/24/2016] [Indexed: 12/14/2022]
Abstract
Magnesium, one of the essential elements in the human body, has numerous favorable effects that offer a variety of possibilities for its use in obstetric anesthesia and intensive care. Administered as a single intravenous bolus dose or a bolus followed by continuous infusion during surgery, magnesium attenuates stress response to endotracheal intubation, and reduces intraoperative anesthetic and postoperative analgesic requirements, while at the same time preserving favorable hemodynamics. Applied as part of an intrathecal or epidural anesthetic mixture, magnesium prolongs the duration of anesthesia and diminishes total postoperative analgesic consumption with no adverse maternal or neonatal effects. In obstetric intensive care, magnesium represents a first-choice medication in the treatment and prevention of eclamptic seizures. If used in recommended doses with close monitoring, magnesium is a safe and effective medication.
Collapse
|
46
|
Boonmak P, Boonmak S, Laopaiboon M. Deliberate hypotension with propofol under anaesthesia for functional endoscopic sinus surgery (FESS). Cochrane Database Syst Rev 2016; 10:CD006623. [PMID: 27731501 PMCID: PMC6457960 DOI: 10.1002/14651858.cd006623.pub3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Functional endoscopic sinus surgery (FESS) is a minimally invasive technique that is used to treat chronic sinusitis. Small bleeding areas can reduce operative visibility and result in destruction of surrounding structures. Deliberate hypotension (lowering the mean arterial blood pressure to between 50 and 65 mm Hg in normotensive patients) using a range of pharmacological agents during general anaesthesia reduces blood loss in many operations. This review was originally published in 2013 and updated in February 2016. OBJECTIVES We aimed to compare the use of propofol versus other techniques for achieving deliberate intraoperative hypotension during FESS procedures with regard to blood loss and operative conditions. SEARCH METHODS We searched the following databases in the updated review: the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 2), MEDLINE (1950 to February 2016), Embase (1980 to February 2016), LILACS (1982 to February 2016), and ISI Web of Science (1946 to February 2016). We also searched the reference lists of relevant articles and conference proceedings and contacted the authors of included trials. SELECTION CRITERIA We sought all randomized controlled trials comparing propofol with other techniques for deliberate hypotension during FESS with regard to blood loss and operative conditions in both adults and children. Our primary outcome was total blood loss (TBL). Other outcomes included surgical field quality, operation time, mortality within 24 hours, complications, and failure to reach target blood pressure. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Two review authors independently extracted details of trial methodology and outcome data from the reports of all trials considered eligible for inclusion. We made all analyses on an intention-to-treat basis where possible. When I2 was less than 40% and the P value from the Chi2 test was higher than 0.10, we pooled data using the fixed-effect model. Otherwise, we pooled data using the random-effects model. MAIN RESULTS We found no new studies. This updated review therefore includes four studies with 278 participants. Most analyses were based on data from few participants and low-quality evidence, so our results should be interpreted with caution. Deliberate hypotension with propofol did not decrease TBL (millilitres) when compared with inhalation anaesthetics in either children (1 study; 70 participants; very low-quality evidence), or adults (1 study; 88 participants; moderate-quality evidence). Propofol improved the quality of the surgical field by less than one category on a scale from 0 (no bleeding) to 5 (severe bleeding) (mean difference -0.64, 95% CI -0.91 to -0.37; 4 studies; 277 participants; low-quality evidence), but no difference in operation time was reported (3 studies; 214 participants; low-quality evidence). Failure to lower blood pressure to target was less common in the propofol group (risk ratio of failure with propofol 0.24, 95% CI 0.09 to 0.66; 1 study; 88 participants; moderate-quality evidence). AUTHORS' CONCLUSIONS Using propofol to achieve deliberate hypotension probably improves the surgical field, but the effect is small. Deliberate hypotension with propofol did not decrease TBL and the operation time. However, due to the very low quality of the evidence, this conclusion is not definitive. Randomized controlled trials with good-quality methodology and large sample size are required to investigate the effectiveness of deliberate hypotension with propofol for FESS.
Collapse
Affiliation(s)
- Polpun Boonmak
- Khon Kaen UniversityDepartment of Anaesthesiology, Faculty of MedicineFaculty of MedicineKhon KaenThailand40002
| | - Suhattaya Boonmak
- Khon Kaen UniversityDepartment of Anaesthesiology, Faculty of MedicineFaculty of MedicineKhon KaenThailand40002
| | - Malinee Laopaiboon
- Khon Kaen UniversityDepartment of Epidemiology and Biostatistics, Faculty of Public Health123 Mitraparb RoadAmphur MuangKhon KaenThailand40002
| | | |
Collapse
|
47
|
Jangra K, Malhotra SK, Gupta A, Arora S. Comparison of quality of the surgical field after controlled hypotension using esmolol and magnesium sulfate during endoscopic sinus surgery. J Anaesthesiol Clin Pharmacol 2016; 32:325-8. [PMID: 27625479 PMCID: PMC5009837 DOI: 10.4103/0970-9185.173400] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background and Aims: Most vital aspect of Endoscopic Sinus Surgery (ESS) is an optimal visibility in the surgical field. This invariably requires controlled hypotension to facilitate surgical dissection and to decrease operative time. We used esmolol and magnesium sulfate to achieve controlled hypotension and assessed the quality of the surgical field in ESS. Material and Methods: A total of 30 patients undergoing ESS, were enrolled in three parallel groups of 10 patients each in a prospective randomized double-blind study. “Magnesium Sulfate group” received magnesium sulfate 40 mg/kg intravenously (i.v.) as a bolus over 10 min before induction of anesthesia, followed by 15-30 mg/kg/h through infusion. “Esmolol group” received 0.5 mg/kg i.v. bolus over 10 min after induction followed by 150-300 μg/kg/min infusion and “control group” received normal saline in same volume schedule. The primary aim was to assess the quality of surgical field, using Fromme scale. Category Scale values of all the three groups were compared using Kruskal-Wallis analysis of variance (ANOVA) test. Hemodynamic data was compared using ANOVA test. Results: Quality of the surgical field was better in both magnesium sulfate and esmolol groups as compared to the control group. Durations of anesthesia and surgery were significantly lower in esmolol group as compared to the control group. Blood loss was comparable in all the three groups. Conclusion: Quality of the surgical field was better in esmolol and magnesium sulfate groups as compared to control group. Duration of surgery was significantly less in esmolol group as compared to other two groups.
Collapse
Affiliation(s)
- Kiran Jangra
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Surender Kumar Malhotra
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashok Gupta
- Department of Otorhinolaryngology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Suman Arora
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
48
|
MAGNESIUM SULPHATE INFUSION PREVENTS SHIVERING DURING SPINAL ANAESTHESIA: A RANDOMISED DOUBLE BLINDED CONTROLLED STUDY. ACTA ACUST UNITED AC 2016. [DOI: 10.14260/jemds/2016/1052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
|
49
|
Liu L, Han X, Huang Q, Zhu X, Yang J, Liu H. Increased neuronal seizure activity correlates with excessive systemic inflammation in a rat model of severe preeclampsia. Hypertens Res 2016; 39:701-708. [DOI: 10.1038/hr.2016.53] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Revised: 03/22/2016] [Accepted: 03/29/2016] [Indexed: 12/15/2022]
|
50
|
Aravindan A, Subramanium R, Chhabra A, Datta PK, Rewari V, Sharma SC, Kumar R. Magnesium sulfate or diltiazem as adjuvants to total intravenous anesthesia to reduce blood loss in functional endoscopic sinus surgery. J Clin Anesth 2016; 34:179-85. [PMID: 27687369 DOI: 10.1016/j.jclinane.2016.03.068] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 03/16/2016] [Accepted: 03/17/2016] [Indexed: 01/23/2023]
Abstract
STUDY OBJECTIVE This study was designed to know whether addition of magnesium sulfate (MgSO4) or diltiazem to total intravenous anesthesia (TIVA) (propofol) aided reduction in blood loss during functional endoscopic sinus surgery (FESS). The secondary outcomes measured were surgeon's assessment of the surgical field and hemodynamics. DESIGN Randomized, double-blinded, placebo-controlled trial. SETTING Operating room. PATIENTS Forty-five American Society of Anesthesiologists I and II adult patients (18-60years) undergoing FESS. INTERVENTIONS All groups received propofol-fentanyl TIVA. Patients were randomly allocated to 1 of the 3 groups (MgSO4 group, n=15; diltiazem group, n=15; saline group, n=15). MEASUREMENTS Intraoperative bleeding was quantified, and quality of surgical field was graded. Hemodynamic parameters were recorded. MAIN RESULTS Addition of both MgSO4 and diltiazem significantly reduced blood loss (240 and 350mL) in comparison to control group (415mL) (P=.003). The surgical field was significantly better in the MgSO4 group compared with the diltiazem (P=.028) and saline groups (P=.0001). CONCLUSION It was concluded that the addition of both MgSO4 and diltiazem to TIVA propofol results in significant reduction in blood loss and significant improvement in the quality of surgical field during FESS without causing any adverse effects on the hemodynamics or on the recovery from anesthesia. The surgical field in the MgSO4 group was significantly better than that in the diltiazem group (P=.04).
Collapse
|