Plasma neutrophil gelatinase-associated lipocalin and Interleukin-18 as predictors of acute kidney injury in renal transplant recipients: A pilot study

Urine neutrophil gelatinase-associated lipocalin (NGAL) and interleukin-18 (IL- 18) have shown promise for predicting renal graft recovery. However, urinary flow rate variations may cause variable biomarker dilution. Plasma NGAL and IL-18 may form a biomarker panel that may help predict delayed graft function and slow graft function (SGF) in renal transplant recipients within the first two postoperative days earlier than serum creatinine. There are only a few studies in the literature using plasma NGAL for predicting renal graft recovery. Hence, we planned this study. This observational single-center, prospective cohort study was conducted in renal transplant recipients above 18 years of age. In 22 consecutive renal transplant recipients, we collected ethylenediaminetetraacetic acid-plasma samples 1 h before surgery and subsequently at 6 h, 24 h, and 48 h after surgery for NGAL and IL-18 by sandwich enzyme-linked immuno-sorbent assay technique. Serum creatinine was measured as a part of routine transplant protocol. In renal transplant recipients, neither serum levels of NGAL and IL-18 nor their trends could reliably predict SGF. The only significant correlation existed between serum creatinine at day 2 and IL-18 at day 2 with P = 0.023. Serum NGAL did not correlate with serum creatinine in this setting of renal transplantation. Patients with immediate graft function had a greater percentage decrease of creatinine at day 1 and day 2 (P = 0.002 and 0.001) The percentage change in IL-18 at 24 h and 48 h after transplant from baseline could predict the occurrence of early graft loss (EGL) (P = 0.05, 0.04). The cutoffs were -4.12% at day 1 and +3.39% at day 2 with area under receiver operator characteristics of 0.82 and 0.83, respectively. The percentage change in IL-18 may be a useful marker of EGL in renal transplant recipients. Serum NGAL and creatinine were not able to predict EGL.

Effect of Gelfoam Soaked Epidural Dexmedetomidine or Bupivacaine for Postoperative Analgesia in Lumbar Laminectomy: A Prospective Randomized Clinical Study

Background and Aims:

Postoperative pain is spine surgery can last for an average of two to three days. Epidural catheter management are difficult in spine surgery for postoperative pain. Still, there have been not much studies on epidural administered gelfoam soaked dexmedetomidine or bupivacaine, to enhance postoperative analgesia.

Methods:

Ninety six adult patients were randomized into three groups. Gelfoam soaked in 0.1 mg dexmedetomidine (0.02 mg. mL-1) in group D, 0.25% isobaric bupivacaine (5 mL) in group B and gelfoam soaked in 0.9% normal saline (5 mL) in group C. The Primary outcome was to compare the total amount of rescue analgesic consumption till 48 hours. The Secondary outcome was to compare time to first dose of rescue analgesia (duration of analgesia), the visual analogue scale and side effects up to 48 hours. Chi-square test, independent t test and analysis of variance test were used, and P < 0.05 was considered significant.

Results:

Ninety patients completed the study. Total dose of rescue analgesic consumed in 48 hours was significantly higher in control group (paracetamol 4.17 ± 0.75 gm with tramadol 205 ± 37.94 mg). Bupivacaine soaked gelfoam group (paracetamol 3.04±0.71 gm with tramadol 151.85 ± 35.31 mg) had more rescue analgesic consumption than dexmedetomidine soaked gelfoam group (paracetamol 1.72 ± 0.57 gm with tramadol 86.11 ± 28.73 mg). Time for first rescue analgesic requirement with dexmedetomidine soaked gelfoam group was significantly longer (14.67 ± 7.76 hours) than in bupivacaine soaked gelfoam group (11.33 ± 6.08 hours) and control group (6.40 ± 2.77 hours). Postoperative mean VAS scores were lower in group D and group B compared with group C along with no significant adverse effects.

Conclusion:

Patients undergoing lumbar laminectomy with gelfoam soaked epidural dexmedetomidine or bupivacaine decreases rescue analgesic consumption, prolongs the duration of analgesia and decreases mean VAS score postoperatively.

Tongue thickness in health vs cirrhosis of the liver: Prospective observational study

BACKGROUND

Malnutrition affects 40%-90% of patients with cirrhosis of the liver. L3 skeletal muscle index (L3SMI) is presently accepted as the most objective and quantitative measure available for sarcopenia, a surrogate marker of malnutrition. L3SMI application is, however, limited by non-availability of computed tomography scanning in remote areas, cost, need for extensive training, and the risk of exposure to radiation. Therefore, an alternative dependable measure with wider availability is needed. Malnutrition causes sarcopenia not only in skeletal muscles but also in other muscular structures such as the psoas muscle, diaphragm and tongue. We therefore hypothesised that the tongue, being easily accessible for inspection and for measurement of thickness using ultrasonography, may be used to document sarcopenia.

AIM

To measure and compare tongue thickness in healthy individuals and in patients with cirrhosis of the liver and to study its correlation with conventional prognostic scores for patients with cirrhosis of the liver.

METHODS

Tongue thickness was measured using ultrasonography. One hundred twenty subjects of either gender aged 18 to 65 years were studied, with 30 subjects in each group. The tongue thickness was compared between groups based on “Child Turcotte Pugh” (CTP) scores. The correlations between measured tongue thickness and “Model for end stage liver disease” (MELD) score and between age and measured tongue thickness were also assessed.

RESULTS

Mean tongue thickness (mean ± SD) in patients with CTP class A, B and C was 4.39 ± 0.39 cm, 4.19 ± 0.53 cm, and 3.87 ± 0.42, respectively, and was 4.33 ± 0.49 cm in normal healthy individuals. Significant differences were seen in tongue thickness between patients with CTP class C and those with CTP class A and B (P < 0.05). Patients with CTP class C also had a significantly reduced tongue thickness than normal individuals (P < 0.05). However, no significant difference was seen in tongue thickness between patients with CTP class A and B and normal individuals. A statistically significant, negative correlation was found between MELD score and tongue thickness (r = -0.331) (P < 0.001). No correlation was observed between L3SMI and MELD score (r = 0.074, P = 0.424). L3SMI (mean ± SD) in healthy subjects was 39.66 ± 6.8 and was 38.26 ± 8.88 in patients with CTP class C, and the difference was not significant. No significant correlation was found between age of the patients and tongue thickness. Intra-class correlation coefficient was used to determine the reliability of the tongue thickness measurements. The intra-class correlation coefficient was 0.984 (95%CI: 0.979-0.989) and was indicative of good reliability.

CONCLUSION

Tongue thickness measured by ultrasonography, correlates significantly with the severity of liver disease, as assessed by CTP and MELD scores. The patients with a CTP score ≥ 10 have significantly reduced tongue thickness as compared to normal individuals and those with less severe liver disease and CTP scores of 5-9. No significant difference in tongue thickness was found between healthy individuals and CTP class A and B patients.

Preoperative Glycated Haemoglobin Level and Postoperative Morbidity and Mortality in Patients Scheduled for Liver Transplant

BACKGROUND

There is high prevalence of diabetes mellitus in patients of end stage liver disease and it has been implicated for complications in post-transplant patients. Glycated hemoglobin is now targeted as a modifiable preoperative risk factors for postoperative complications. Data describing the course and severity of postoperative liver transplant complication and their relation with pre-operative glycated hemoglobin level is sparse. In this study, we looked for co-relation between the preoperative HbA1c level and post-operative mortality and morbidity in patients scheduled for liver transplant.

MATERIALS AND METHODS

Retrospective data in 400 adult patients operated for liver transplant were retrieved. After exclusion, data were analyzed for 224 patients. Patients were divided into two groups on the basis of glycated hemoglobin levels (Group 1 (HbA1C ≥6.5) and Group 2 (HbA1C <6.5)).

RESULTS

Glycated hemoglobin levels were not associated with postoperative death during stay in intensive care unit, incidence of postoperative cardiovascular, renal, and central nervous complications. No difference was seen between 2 groups for need for renal replacement therapy, incidence of infections, rejection, need for re-exploration surgery and duration of intensive care unit and hospital stay. Glycated hemoglobin cannot predict 30 day survival (Area under curve {AUC} = 0.629, P value 0.05).

CONCLUSION

Preoperative glycated hemoglobin level is not associated with postoperative morbidity and mortality in patients scheduled for liver transplant.

TRIAL REGISTRATION NUMBER

CTRI/2018/04/012966.

Living Donor Liver Transplantation for Acute Liver Failure: Donor Safety and Recipient Outcome

In countries where deceased organ donation is sparse, emergency living donor liver transplantation (LDLT) is the only lifesaving option in select patients with acute liver failure (ALF). The aim of the current study is living liver donor safety and recipient outcomes following LDLT for ALF. A total of 410 patients underwent LDLT between March 2011 and February 2018, out of which 61 (14.9%) were for ALF. All satisfied the King's College criteria (KCC). Median admission to transplant time was 48 hours (range, 24-80.5 hours), and median living donor evaluation time was 18 hours (14-20 hours). Median Model for End-Stage Liver Disease score was 37 (32-40) with more than two-thirds having grade 3 or 4 encephalopathy and 70% being on mechanical ventilation. The most common etiology was viral (37%). Median jaundice-to-encephalopathy time was 15 (9-29) days. Preoperative culture was positive in 47.5%. There was no difference in the complication rate among emergency and elective living liver donors (13.1% versus 21.2%; P = 0.19). There was no donor mortality. For patients who met the KCC but did not undergo LT, survival was 22.8% (29/127). The 5-year post-LT actuarial survival was 65.57% with a median follow-up of 35 months. On multivariate analysis, postoperative worsening of cerebral edema (CE; hazard ratio [HR], 2.53; 95% confidence interval [CI], 1.01-6.31), systemic inflammatory response syndrome (SIRS; HR, 16.7; 95% CI, 2.05-136.7), preoperative culture positivity (HR, 6.54; 95% CI, 2.24-19.07), and a longer anhepatic phase duration (HR, 1.01; 95% CI, 1.00-1.02) predicted poor outcomes. In conclusion, emergency LDLT is lifesaving in selected patients with ALF. Outcomes of emergency living liver donation were comparable to that of elective donors. Postoperative worsening of CE, preoperative SIRS, and sepsis predicted outcome after LDLT for ALF.

Detection of Coagulopathy in Chronic Renal Disease using Thromboelastography and its comparison with Conventional Tests

PURPOSE OF THE STUDY

Thromboelastography provides a holistic picture of blood coagulation including fibrin formation, cross, linking and fibrinolysis. Coagulaopathy in end stage renal disease (ESRD) is multifactorial. The present evaluated the thromboelastographic profile of ESRD patients and compared it to conventional tests of coagulation.

STUDY DESIGN

In this observational case control study, fifty ESRD patients and 50 controls were recruited. Venous samples were withdrawn and platelet count, International Normalization Ratio and fibrinogen levels were measure. Simultaneously a thromboelastography (TEG) was performed. All samples were drawn prior to initiation of dialysis.

RESULTS

The fibrinogen concentration was higher in the ESRD group compared to control (455.51±83.39 vs. 233.84±71.71 mg/dl, P<0.05). The maximum amplitude in ESRD group was 76.94 ± 15.11 mm, which was significantly higher than control group 65.10±10.31 mm (P<0.05).Out of 50 ESRD patients,39 had maximum amplitude (MA) >73mm, 3 had MA <55 mm while 8 patients had normal MA. Further, it was seen that in four out if the five patients whose INR was greater than 1.5. TEG was hypercoaguable. Also, three patients whose platelet count was less than x105/dl had normal thromboelastographs. Two patients with normal platelet count, fibrinogen and INR had hypercoaguable thromboelastographs. Thromboelastography could detect fibrinolysis in 5 patients of end stage renal disease.

CONCLUSION

The present study demonstrated that INR, platelet count and fibrinogen levels do not reflect the actual coagulation status in patients of ESRD. Thromboelastography is a better tool to detect coagulopathy in this group of patients.

Patients with Cirrhosis of Liver Operated for Non-transplant Surgery: A Retrospective Analysis

Background and Aims: Patients with cirrhosis of the liver have high mortality after surgery. We investigated the mortality in patients with cirrhosis of the liver who underwent surgery other than liver transplant and applied the Mayo clinic model to predict mortality and compare with the observed mortality. We also studied the association of the observed mortality with the Child-Turcotte-Pugh (CTP) class and the model for end-stage liver disease (MELD) and model for end-stage liver disease-sodium (MELD-Na) scores. Methods: The electronic records database of our hospital was accessed to analyze the data of 133 cirrhotic patients who underwent various surgeries under general anesthesia from October 2009 to June 2017. The Mayo risk score was applied to each and used to calculate predicted mortality; the MELD and MELD-Na scores were also calculated. Telephonic interview was performed with the patients and or their relative to ascertain survival or time of death after surgery, when the information was not available from the hospital records. Results: The all-cause observed mortality rates at postoperative days 30 and 90 and at 1 year were 12%, 20.3% and 26.3% respectively. The area under the receiver operating characteristic curve values for the Mayo model as a predictor of 30-day, 90-day and 1-year mortality were 0.836, 0.828 and 0.744 respectively. Good correlation was seen for observed mortality with CTP class and with MELD and MELD-Na scores. Conclusions: The Mayo model for predicting postoperative mortality in patients with cirrhosis of the liver demonstrated good correlation in this study. The strength of prediction of mortality by Mayo risk score calculation was similar at postoperative days 30 and 90 but decreased at 1-year after the surgery. Good correlation was seen for the observed mortality with MELD, MELD-Na and CTP scores.

Multimodal temperature management during donor hepatectomy under combined general anaesthesia and neuraxial analgesia: Retrospective analysis

Background and Aims:

Unintended hypothermia (UIH) during surgery under general anaesthesia has adverse implications. A retrospective analysis of the perioperative temperature records of healthy voluntary liver donors was done to evaluate the efficacy of a multimodal protocol for temperature management.

Methods:

Records of 50 American Society of Anesthesiologists physical status Class 1 patients operated for Donor Hepatectomy lasting >2 h under combined general and epidural anaesthesia were analysed. Ambient temperature was maintained 24°C–27°C before induction of GA and during insertion of epidural catheter. Active warming was done using warming mattress set to temperature 38°C, hot air blanket with temperature set to 38°C and fluid warming device (Hotline™) with preset temperature of 41°C. Nasopharyngeal temperature was continuously monitored. After induction of GA and draping of the patient, ambient temperature was decreased and maintained at 21°C–24°C and was again increased to 24°C–27°C at the conclusion of surgery. During surgery, for every 0.1°C above 37°C, one heating device was switched off such that at 37.3°C all the 3 devices were switched off. Irrigation fluid was pre-warmed to 39°C.

Results:

Baseline temperature was 35.9°C ± 0.4°C. Minimum temperature recorded was 35.7°C ± 0.4°C. Mean decrease in temperature below the baseline temperature was 0.2°C ± 0.2°C. Temperature at the end of surgery was 37.4°C ± 0.5°C.

Conclusion:

Protocol-based temperature management with simultaneous use of resistive heating mattress, forced-air warming blanket, and fluid warmer along with ambient temperature management is an effective method to prevent unintended perioperative variation in body temperature.

Use of ultrasound-guided preoperative diaphragmatic thickness as a predictor of postoperative weaning failure in recipients and donors scheduled for living donor liver transplant surgery

Background and Objectives:

The present study was designed to explore the utility of ultrasound-guided diaphragmatic thickness in the preoperative period in healthy controls scheduled for live-related donor hepatectomy and patients suffering from chronic liver disease scheduled for liver transplantation (LT) and its use as a predictor of postoperative weaning failure.

Materials and Methods:

This prospective observational study was conducted in a tertiary health care center and 65 adult (18–70 years) participants (30 healthy liver donors and 35 liver transplant recipients) were enrolled for this study. Right diaphragmatic thickness of both donors and recipients was measured by B-mode ultrasound using a 10 MHz linear array transducer in the supine position in the operation theater just before induction of anesthesia. For subgroup analysis of the recipients, we further divided them into two groups – Group 1 (diaphragmatic thickness < 2 mm) and Group 2 (diaphragmatic thickness > 2 mm), and comparison was done for duration of mechanical ventilation. Intergroup comparison was made for duration of mechanical ventilation and various other parameters.

Results:

The sonographic measurement of diaphragm revealed that its thickness is decreased in patients with chronic liver disease patients (2.12 ± 0.54 mm) as compared to healthy donors (3.70 ± 0. 58 mm). On multiple logistic regression, higher duration of mechanical ventilation was associated with diaphragmatic thickness < 2 mm (Group 1 of recipients) (adjusted odds ratio 0.86; 95% confidence interval: 0.75–0.99; P = 0.013) after adjusting for age, gender, and body mass index.

Conclusions:

Diaphragmatic thickness is decreased in patients with chronic liver disease as compared to healthy liver donors. Preoperative measurement of ultrasound-guided right hemidiaphragm thickness can be used to predict weaning failure in patients undergoing LT. Other studies are needed to confirm these finding on different group of patients.

Deceased donor liver transplant: Experience from a public sector hospital in India

BACKGROUND

Deceased donor liver transplant (DDLT) is an uncommon procedure in India. We present our experience of DDLT from a public sector teaching hospital.

METHODS

A retrospective analysis of all DDLT was performed from April 2012 till September 2016. Demographics, intraoperative, donor factors, morbidity, and outcome were analyzed.

RESULTS

During the study period, 305 liver transplants were performed, of which 36 were DDLT (adult 32, pediatric 4; 35 grafts; 1 split). The median age was 42.5 (1-62) years; 78% were men. The median donor age was 28 (1-77) years; 72.2% were men. About 45% of organs were procured from outside of Delhi and 67% of all grafts used were marginal. Three of 38 liver grafts (7.8%) were rejected due to gross steatosis. Commonest indication was cryptogenic cirrhosis (19.4%). The median model for end-stage liver disease sodium and pediatric end-stage liver disease scores were 23.5 (9-40) and 14.5 (9-22), respectively. Median warm and cold ischemia times were 40 (23-56) and 396 (111-750) min, respectively. Major morbidity of grade III and above occurred in 63.8%. In hospital (90 days), mortality was 16.7% and there were two late deaths because of chronic rejection and biliary sepsis. The overall survival was 77.8% at median follow up of 8.6 (1-54) months.

CONCLUSIONS

DDLT can be performed with increasing frequency and safety in a public sector hospital. The perioperative and long-term outcomes are acceptable despite the fact that most organs were extended criteria grafts.

Diagnostic and therapeutic challenge of heart failure after liver transplant: Case series

Heart failure (HF) following liver transplant (LT) surgery is a distinct clinical entity with high mortality. It is known to occur in absence of obvious risk factors. No preoperative workup including electrocardiogram, echocardiography at rest and on stress, reasonably prognosticates the risk. In patients of chronic liver disease, cirrhotic cardiomyopathy, alcoholic cardiomyopathy, and stress induced cardiomyopathy have each been implicated as a cause for HF after LT. However distinguishing one etiology from another not only is difficult, several etiologies may possibly coexist in a given patient. Diagnostic dilemma is further compounded by the fact that presentation and management of HF irrespective of the possible underlying cause, remains the same. In this case series, 6 cases are presented and in the light of existing literature modification in the preoperative workup are suggested.

Living Donor Liver Transplantation for Acute Liver Failure With Fixed Pupils: Are We Fixed?

Living donor liver transplantation (LDLT) is fraught with the social and ethical dilemma of excising a part of the liver from a healthy first-degree relative. When LDLT is to be done for an acute liver failure (ALF), identification of a suitable donor is a race against time. Herein, we describe a unique challenge faced by the transplant team of whether to proceed with donor hepatectomy from a son, when the recipient (HBV-related ALF) developed non-reactive fully dilated pupils on the table, prior to beginning the surgery. The patient ultimately underwent a LDLT despite fixed dilated pupils by virtue of further workup, which suggested that cerebral blood flow was maintained despite clinical evidence of brainstem herniation.

Post-operative hypertension, a surrogate marker of the graft function and predictor of survival in living donor liver transplant recipients: A retrospective study

BACKGROUND AND AIMS

De novo hypertension (HTN) in liver transplantation recipients is a known entity. We investigated haemodynamic behaviour after a liver transplant to see if it can predict survival to discharge from the hospital.

METHODS

electronic records of Haemodynamic parameters and laboratory investigations of 95 patients of living donor liver transplant (LDLT) were retrospectively analysed.

RESULTS

Twenty-three patients were operated for acute liver failure (ALF) and 72 patients for chronic liver disease (CLD). Eight patients of CLD and four of ALF did not survive. CLD patients had statistically significant rise in systolic blood pressure from the post-operative day (POD) 1 to POD 4 and diastolic blood pressure (DBP) from POD 3 to POD 6. Heart rate (HR) significantly decreased from POD 3 to POD 5. Haemodynamic parameters returned to baseline values within 20 days. Diastolic HTN had a positive predictive value of 100% for survival with 100% sensitivity and specificity. Systolic HTN had a positive predictive value of 100% for survival (sensitivity-89%, specificity-100%). ALF patients had a significant decrease in HR from POD 2 to POD 10. Bradycardia (HR ≤60/min) had a positive predictive value of 100% for survival with a sensitivity of 45% and 58% in CLD and ALF, respectively, with a specificity of 100% in both the groups. Non-survivors had no significant change in haemodynamics. In CLD group, International Normalised Ratio had statistically significant, strong negative correlation with DBP.

CONCLUSION

Haemodynamic pattern of recovery may be used for predicting survival to discharge after LDLT.

Preoperative cardiovascular investigations in liver transplant candidate: An update

Cardiovascular complications are a major cause of morbidity and mortality in patients with end-stage liver disease (ESLD) undergoing liver transplantation. Identifying candidates at the highest risk of postoperative cardiovascular complications is the cornerstone for optimizing the outcome. Ischaemic heart disease contributes to major portion of cardiovascular complications and therefore warrants evaluation in the preoperative period. Patients of ESLD usually demonstrate increased cardiac output, compromised ventricular response to stress, low systemic vascular resistance and occasionally bradycardia. Despite various recommendations for preoperative evaluation of cardiovascular disease in liver transplant candidates, a considerable controversy on screening methodology persists. This review critically focuses on the rapidly expanding body of evidence for diagnosis and risk stratification of cardiovascular disorder in liver transplant candidates.

Validation of a New "Objective Pain Score" Vs. "Numeric Rating Scale" For the Evaluation of Acute Pain: A Comparative Study

Background:

Pain scores are used for acute pain management. The assessment of pain by the patient as well as the caregiver can be influenced by a variety of factors. The numeric rating scale (NRS) is widely used due to its easy application. The NRS requires abstract thinking by a patient to assign a score to correctly reflect analgesic needs, and its interpretation is subject to bias.

Objectives:

The study was done to validate a 4-point objective pain score (OPS) for the evaluation of acute postoperative pain and its comparison with the NRS.

Patient and Methods:

A total of 1021 paired readings of the OPS and NRS of 93 patients who underwent laparotomy and used patient-controlled analgesia were evaluated. Acute pain service (APS) personnel recorded the OPS and NRS. Rescue analgesia was divided into two incremental levels (level 1-paracetamol 1 g for NRS 2 - 5 and OPS 3, Level 2-Fentanyl 25 mcg for NRS ≥ 6 and OPS 1 and 2). In cases of disagreement between the two scores, an independent consultant decided the rescue analgesia.

Results:

The NRS and OPS agreed across the range of pain. There were 25 disagreements in 8 patients. On 24 occasions, rescue analgesia was increased from level 1 to 2, and one occasion it was decreased from level 2 to 1. On all 25 occasions, the decision to supplement analgesia went in favor of the OPS over the NRS. Besides these 25 disagreements, there were 17 occasions in which observer bias was possible for level 2 rescue analgesia.

Conclusions:

The OPS is a good stand-alone pain score and is better than the NRS for defining mild and moderate pain. It may even be used to supplement NRS when it is indicative of mild or moderate pain.

Postoperative coagulopathy after live related donor hepatectomy: Incidence, predictors and implications for safety of thoracic epidural catheter

Background:

Coagulopathy after living donor hepatectomy (LDH) may endanger donor safety during removal of thoracic epidural catheter (TEC). The present study was conducted to evaluate the extent and duration of immediate postoperative coagulopathy after LDH.

Materials and Methods:

A retrospective analysis of perioperative record of LDH over three years was conducted after IRB approval. Variables such as age, gender, BMI, ASA classification, liver volume on CT scan, preoperative and postoperative INR, platelet count (PC) and ALT of each donor for five days was noted. In addition, duration of surgery, remnant as percentage total liver volume (Remnant%), blood loss, day of peak in PC and INR were also noted. Coagulopathy was defined as being present if INR exceeded 1.5 or platelet count fell below 1 × 10⁵/mm³ on any day. Data was analyzed using SPSS 20 for Windows. Between group comparison was made using the Student ‘t’ test for continuous variables and chi square test for categorical variables. Univariate analysis was done. Multiple logistic regression analysis was used to find independent factor associated with coagulopathy.

Results:

Eighty four (84) donors had coagulopathy on second day (mean INR 1.9 ± 0.42). Low BMI, % of remnant liver and duration of surgery were independent predictors of coagulopathy. Right lobe hepatectomy had more coagulopathy than left lobe and low BMI was the only independent predictor. There was no correlation of coagulopathy with age, gender, blood loss, presence of epidural catheter, postoperative ALT or duration of hospital stay. High INR was the main contributor for coagulopathy.

Conclusions:

Coagulopathy is seen after donor hepatectomy. We recommend removal of the epidural catheter after the fifth postoperative day when INR falls below 1.5.

Intraoperative blood loss in orthotopic liver transplantation: The predictive factors

Liver transplantation has been associated with massive blood loss and considerable transfusion requirements. Bleeding in orthotopic liver transplantation is multifactorial. Technical difficulties inherent to this complex surgical procedure and pre operative derangements of the primary and secondary coagulation system are thought to be the principal causes of perioperative hemorrhage. Intraoperative practices such as massive fluid resuscitation and resulting hypothermia and hypocalcemia secondary to citrate toxicity further aggravate the preexisting coagulopathy and worsen the perioperative bleeding. Excessive blood loss and transfusion during orthotopic liver transplant are correlated with diminished graft survival and increased septic episodes and prolonged ICU stay. With improvements in surgical skills, anesthetic technique, graft preservation, use of intraoperative cell savers and overall perioperative management, orthotopic liver transplant is now associated with decreased intra operative blood losses. The purpose of this review is to discuss the risk factors predictive of increased intra operative bleeding in patients undergoing orthotopic liver transplant.

Dyskeratosis congenita induced cirrhosis for liver transplantation-perioperative management

Dyskeratosis congenita (DC) is an inherited disorder with progressive multisystem involvement. End stage liver disease (ESLD) in patients with DC is rare. We describe the perioperative management of a patient with DC induced ESLD and severe hepatopulmonary syndrome for living donor liver transplantation.

Acute liver failure in pregnancy: Challenges and management

Acute liver failure (ALF) in pregnancy negatively affects both maternal and foetal outcome. The spectrum of liver disease in pregnancy may range from mild asymptomatic transaminitis to fatal and irreversible deterioration in liver functions leading to significant morbidity and even mortality. In this comprehensive review, we searched articles published as review articles, clinical trials, and case series in the Medline from 1970 to 2012. The overall outcome of ALF in pregnancy depends on the aetiology, timely diagnosis, prompt management, and early referral to a centre equipped in managing medical or obstetric complication. The foetal outcome is affected by the stage of pregnancy in which the mother has a deterioration of the liver function, with a worst prognosis associated with first or second-trimester liver failure. When ALF complicates pregnancy, liver transplantation is the one of the viable options. Management protocols need to be individualised for each case keeping in mind the risk versus benefit to both the mother and the foetus.

Addition of sub-anaesthetic dose of ketamine reduces gag reflex during propofol based sedation for upper gastrointestinal endoscopy: A prospective randomised double-blind study

Background and Aims:

Gag reflex is unwanted during upper gastrointestinal endoscopy (UGIE). Experimental studies have demonstrated that N-methyl-D-aspartate receptor antagonism prevents gag reflex. We conducted a study to determine if sub-anaesthetic doses of ketamine, added to propofol, reduce the incidence of gag reflex.

Methods:

This prospective, randomised, double-blind and placebo-controlled study was done in a tertiary care hospital. A total of 270 patients undergoing UGIE, were randomised to propofol (P) group (n = 135) or propofol plus ketamine (PK) group (n = 135). All patients received propofol boluses titrated to Ramsay sedation score of not <4. Patients in PK group in addition received ketamine, 0.15 mg/kg immediately before the first-propofol dose. Top-up doses of propofol were given as required. Stata 11 software (StataCorp.) was used to calculate the proportion of patients with gag reflex and the corresponding relative risk. Propofol consumed and time to recovery in the two groups was compared using Student's t-test and Cox proportional hazards regression respectively.

Results:

Significantly, fewer patients in the PK group had gag reflex compared to the P group (3 vs. 23, risk ratio = 0.214, 95% confidence interval [CI], 0.07-0.62; P = 0.005). The incidence of hypotension (6 vs. 16, risk ratio = 0.519, 95% CI = 0.25-1.038; P = 0.06), number of required airway manoeuvres (4 vs. 19, risk ratio = 0.32, 95% CI = 0.13-0.74; P = 0.014), median time to recovery (4 min vs. 5 min, hazard ratio = 1.311, 95% CI = 1.029-1.671; P = 0.028) and propofol dose administered (152 mg vs. 167 mg, 95% CI = 4.74-24.55; P = 0.004) was also less in the PK group compared to the P group.

Conclusion:

Ketamine in sub-anaesthetic dose decreases gag reflex during UGIE.

Brachial plexus injury in live related donor hepatectomy: a chart review

Retrieval of the partial liver graft is a complicated and time-consuming procedure and reported to be associated with brachial plexus injury. We present a case series of brachial plexus injury in live related donor hepatectomy of 95 donors analyzed retrospectively. Seven donors suffered from brachial plexus injuries of varying severity and duration. Out of these, one donor had residual paresis. The reasons could be application of retractors, which may have led to traction and compression above the nerve roots.

Hepatorenal syndrome: a decade later

Hepatorenal syndrome is a unique form of acute kidney injury seen in patients with acute liver failure or chronic liver disease in absence of any other identifiable cause of renal failure. It is primarily a diagnosis of exclusion. Despite of good pathophysiological understanding and better available therapeutic options for management of hepatorenal syndrome, it is still associated with significant morbidity and mortality. Liver transplantation forms the cornerstone for its management. In this review article, we have attempted to assimilate and summarise the advances made in the previous decade with regards to pathophysiology, classification and management of this entity.

Perioperative ischaemia-induced liver injury and protection strategies: An expanding horizon for anaesthesiologists

Liver resection is an effective modality of treatment in patients with primary liver tumour, metastases from colorectal cancers and selected benign hepatic diseases. Its aim is to resect the grossly visible tumour with clear margins and to ensure that the remnant liver mass has sufficient function which is adequate for survival. With the advent of better preoperative imaging, surgical techniques and perioperative management, there is an improvement in the outcome with decreased mortality. This decline in postoperative mortality after hepatic resection has encouraged surgeons for more radical liver resections, leaving behind smaller liver remnants in a bid to achieve curative surgeries. But despite advances in diagnostic, imaging and surgical techniques, postoperative liver dysfunction of varied severity including death due to liver failure is still a serious problem in such patients. Different surgical and non-surgical techniques like reducing perioperative blood loss and consequent decreased transfusions, vascular occlusion techniques (intermittent portal triad clamping and ischaemic preconditioning), administration of pharmacological agents (dextrose, intraoperative use of methylprednisolone, trimetazidine, ulinastatin and lignocaine) and inhaled anaesthetic agents (sevoflurane) and opioids (remifentanil) have demonstrated the potential benefit and minimised the adverse effects of surgery. In this article, the authors reviewed the surgical and non-surgical measures that could be adopted to minimise the risk of postoperative liver failure following liver surgeries with special emphasis on ischaemic and pharmacological preconditioning which can be easily adapted clinically.

Perioperative risk factors in patients with liver disease undergoing non-hepatic surgery

The patients with liver disease present for various surgical interventions. Surgery may lead to complications in a significant proportion of these patients. These complications may result in considerable morbidity and mortality. Preoperative assessment can predict survival to some extent in patients with liver disease undergoing surgical procedures. A review of literature suggests nature and the type of surgery in these patients determines the peri-operative morbidity and mortality. Optimization of premorbid factors may help to reduce perioperative mortality and morbidity. The purpose of this review is to discuss the effect of liver disease on perioperative outcome; to understand various risk scoring systems and their prognostic significance; to delineate different preoperative variables implicated in postoperative complications and morbidity; to establish the effect of nature and type of surgery on postoperative outcome in patients with liver disease and to discuss optimal anaesthesia strategy in patients with liver disease.

Gabapentin for refractory idiopathic trigeminal neuralgia

Trigeminal neuralgia is sudden, usually unilateral, severe, stabbing, brief recurrent pain in the distribution area of one or more of the branches of trigeminal nerve. Various pharmacological agents including carbamazepine, oxcarbazepine, phenytoin, lamotrigine, baclofen and clonazepam have been tried with variable success rate. Here a case of idiopathic trigeminal neuralgia is presented. The patient presented in the emergency room with severe pain in the distribution area of maxillary branch of trigeminal nerve, resistant to conventional pharmacotherapy, managed successfully with gabapentin without untoward side-effects.

Prophylactic gabapentin for prevention of postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy: a randomized, double-blind, placebo-controlled study

BACKGROUND

Gabapentin is an antiepileptic drug. Its antiemetic effect is demonstrated in chemotherapy-induced acute and delayed onset of nausea and vomiting in breast cancer patients.

AIM

To evaluate the antiemetic effect of gabapentin on incidence and severity of postoperative nausea and vomiting in laparoscopic cholecystectomy.

SETTINGS AND DESIGN

Double-blind, randomized, placebo-controlled study.

MATERIALS AND METHODS

Two hundred and fifty patients of ASA physical status I and II, scheduled for laparoscopic cholecystectomy were randomly assigned into two equal groups to receive 600 mg gabapentin or matching placebo two hours before surgery. Standard anaesthesia technique was used. Fentanyl was used as rescue postoperative analgesic. Ondansetron 4 mg was used intravenously as rescue medication for emesis. The total number of patients who had nausea or vomiting, and its severity and total fentanyl consumption in the first 24 hours were recorded.

STATISTICAL ANALYSIS

"Z test" was used to test the significance of severity of post-operative nausea and vomiting between groups. Fentanyl consumed in each group (Mean+/-SD) within 24 hrs was compared using student t test. P value < 0.05 was considered significant.

RESULTS

There were no demographic difference between the two groups. Incidence of post-operative nausea and vomiting within 24 hrs after laparoscopic cholecystectomy was significantly lower in gabapentin group (46/125) than in the placebo group (75/125) (37.8% vs 60%; P =0.04). There was a significantly decreased fentanyl consumption in gabapentin group (221.2+/-92.4 microg) as compared to placebo group (505.9+/-82.0 microg; P =0.01).

CONCLUSION

Gabapentin effectively suppresses nausea and vomiting in laparoscopic cholecystectomy and post-operative rescue analgesic requirement.

Gabapentin provides effective postoperative analgesia whether administered pre-emptively or post-incision

PURPOSE

We investigated the effects of pre-incision and post-incision administration of gabapentin on postoperative pain and fentanyl consumption associated with open donor nephrectomy.

METHODS

Sixty ASA I subjects were randomly allocated into three groups to receive gabapentin 600 mg two hours before surgery and placebo after surgical incision (pre-incision group), placebo two hours before surgery and gabapentin 600 mg after surgical incision (post-incision group), or placebo two hours before surgery and after surgical incision (placebo group). After surgery, pain was assessed using a visual analogue scale (VAS), (1-10 cm) at time points 0, 6, 12, 18, and 24 hr. Subjects received patient-controlled-analgesia (fentanyl 1.0 microg x kg(-1) subject activated dose). Total fentanyl consumption in each group was recorded.

RESULTS

Subjects of pre-incision and post-incision groups had lower VAS scores at all time points (3.1 +/- 1.8, 2.9 +/- 1.3, 2.8 +/- 1.3, 2.5 +/- 0.9, 2.5 +/- 1.5 and 3.6 +/- 1.1, 3.0 +/- 1.2, 3.2 +/- 1.1, 2.9 +/- 1.0, 2.6 +/- 2.2) compared to placebo group (6.6 +/- 1.3, 5.0 +/- 1.0, 4.4 +/- 0.7, 4.2 +/- 0.8, 3.9 +/- 1.0). They also used less fentanyl (563.3 microg +/- 252.8 and 624.0 microg +/- 210.5 respectively) compared to placebo (924.7 microg +/- 417.5), (P < 0.05). No difference in total fentanyl consumption and pain scores at any time points were observed between pre- and post-incision groups.

CONCLUSION

Pre-incision administration of 600 mg gabapentin has no added benefit over post-incision administration in terms of pain scores and fentanyl consumption in subjects undergoing open donor nephrectomy.

The efficacy of tolterodine for prevention of catheter-related bladder discomfort: a prospective, randomized, placebo-controlled, double-blind study

Bladder discomfort secondary to an indwelling urinary catheter is distressing, particularly for patients awakening from anesthesia. We sought to discover the incidence and severity of bladder discomfort in patients who were catheterized intraoperatively and to evaluate the efficacy of tolterodine, a pure muscarinic receptor antagonist, in preventing this. Two-hundred-fifteen consecutive adult patients, ASA physical status I and II, either sex, undergoing urologic surgery requiring bladder catheterization were enrolled. Group C (control, n = 165) received placebo and group T (tolterodine, n = 50) received tolterodine 2 mg. Drugs were administered orally 1 h before surgery. After induction of anesthesia, patients were catheterized with a 16F Foley catheter and the balloon was inflated with 10 mL of normal saline. In the postanesthesia care unit, bladder discomfort was assessed on arrival (0), 1, 2 and 6 h. Severity of bladder discomfort was graded as mild, moderate, and severe. Bladder discomfort observed in group C was 55% (91 of 165). Tolterodine reduced both the incidence 36% (18 of 50) and severity of bladder discomfort (P < 0.05).

IMPLICATIONS

Bladder discomfort secondary to an indwelling urinary catheter is distressing to patients. In the present study, we observed that tolterodine (2 mg), a competitive muscarinic receptor antagonist administered 1 h before surgery, reduced both the incidence and severity of bladder discomfort secondary to bladder catheterization.

The comparative evaluation of gabapentin and carbamazepine for pain management in Guillain-Barré syndrome patients in the intensive care unit

We evaluated the effects of gabapentin and carbamazepine for pain relief in 36 Guillain-Barré syndrome patients. Patients were randomly assigned to receive gabapentin 300 mg, carbamazepine 100 mg, or matching placebo 3 times a day for 7 days. Fentanyl 2 microg/kg was used as a supplementary analgesic on patient demand. The pain score was recorded by using a numeric pain rating scale of 0-10, and sedation was recorded with a Ramsay sedation scale of 1-6 before medications were given and then at 6-h intervals throughout the study period. Total daily fentanyl consumption was recorded each day for each patient. The results of the study demonstrated that patients in the gabapentin group had significantly lower (P < 0.05) median numeric pain rating scale scores (3.5, 2.5, 2.0, 2.0, 2.0, 2.0, and 2.0) compared with patients in the placebo group (6.0, 6.0, 6.0, 6.0, 6.0, 6.0, and 6.0) and the carbamazepine group (6.0, 6.0, 5.0, 4.0, 4.0, 3.5, and 3.0). There was no significant difference in fentanyl consumption between the gabapentin and carbamazepine groups on Day 1 (340.1 +/- 34.3 microg and 347.5 +/- 38.0 microg, respectively), but consumption was significantly less in these 2 groups compared with the placebo group (590.4 +/- 35.0 microg) (P < 0.05). For the rest of the study period, there was a significant difference in fentanyl consumption among all treatment groups, and it was minimal in the gabapentin group (P < 0.05). We conclude that gabapentin is more effective than carbamazepine for decreasing pain and fentanyl consumption.

Clinical evaluation of the ‘T-Dagger™’: a new bedside percutaneous dilational tracheostomy device

A number of percutaneous dilational tracheostomy devices are now available for clinical use. Recently, a new percutaneous dilational tracheostomy device, the "T-Dagger" (Criticure Invasives, India), has been introduced for rapid bedside percutaneous tracheostomy. In a prospective preliminary study, we have performed percutaneous dilational tracheostomy (PDT) using the T-Dagger in 20 adult ventilated patients in order to evaluate the safety and efficacy of the new device. The T-Dagger facilitated bedside PDT in about 3 min with no untoward incidents. There was no significant bleeding, pneumothorax, pneumomediastinum, tracheal wall injuries or difficulty in ventilation in any of the patients. We conclude that the T-Dagger shows early promise in bedside percutaneous dilational tracheostomy. However, controlled studies are required in a larger patient population before it can be recommended for routine use.

Preemptive gabapentin decreases postoperative pain after lumbar discoidectomy

PURPOSE

We investigated whether the preemptive use of gabapentin, a structural analogue of gamma amino butyric acid could reduce postoperative pain and fentanyl consumption in patients after single-level lumbar discoidectomy.

METHODS

Fifty-six ASA I and II patients were randomly allocated into two equal groups to receive either gabapentin 300 mg or placebo two hours before surgery. After surgery, the pain was assessed on a visual analogue scale (VAS) at intervals of 0-6, 6-12, 12-18, and 18-24 hr at rest. Total fentanyl consumption in the first 24 hr after surgery was also recorded. Fentanyl 2 mug.kg(-1) intravenously was used to treat postoperative pain on patients' demand.

RESULTS

Patients in the gabapentin group had significantly lower VAS scores at all time intervals of 0-6, 6-12, 12-18, and 18-24 hr than those in the placebo group (3.5 +/- 2.3, 3.2 +/- 2.1, 1.8 +/- 1.7, 1.2 +/- 1.3 vs 6.1 +/- 1.7, 4.4 +/- 1.2, 3.3 +/- 1.1, 2.1 +/- 1.2; P < 0.05). The total fentanyl consumed after surgery in the first 24 hr in the gabapentin group (233.5 +/- 141.9, mean + SD) was significantly less than in the placebo group (359.6 +/- 104.1; P < 0.05).

CONCLUSION

Preemptive gabapentin 300 mg po significantly decreases the severity of pain postoperatively in patients who undergo single-level lumbar discoidectomy.

Intravenous lidocaine 0.5 mg.kg-1 effectively suppresses fentanyl-induced cough

PURPOSE

To evaluate the minimal dose of lidocaine required for suppression of fentanyl-induced cough.

METHODS

320 ASA I and II patients, non-smokers of both sexes scheduled for elective surgery between the ages of 18 to 60 yr were randomly allocated into four equal groups. The patients were assigned to receive lidocaine 0.5 mg.kg(-1) (Group I), 1.0 mg.kg(-1)(Group II), 1.5 mg.kg(-1) (Group III) or placebo (Group IV) over five seconds, one minute prior to the administration of fentanyl 3 microg.kg(-1) in a randomized and double-blind fashion. Any episode of cough was classified as coughing and graded as mild (1-2) moderate (3-4) or severe (5 or more). The data were analyzed by test of proportion.

RESULTS

Eleven, 12, 11 and 28 patients (13.75%, 15%, 13.75% and 35%) had cough in Groups I, II, III and IV respectively (P < 0.05 Groups I, II, III vs IV). There was no significant difference in the incidence and severity of cough among the lidocaine pretreated groups (P > 0.05).

CONCLUSION

The results of our study suggest that iv lidocaine 0.5 mg.kg(-1) is the minimal dose required to suppress fentanyl-induced cough when administered one minute prior to fentanyl. Any further increase in the lidocaine dose does not reduce the incidence or severity of fentanyl-induced cough.

Evaluation of the Optimal Preemptive Dose of Gabapentin for Postoperative Pain Relief After Lumbar Diskectomy

We evaluated the optimal preemptive dose of gabapentin for postoperative pain relief after single-level lumbar diskectomy and its effect on fentanyl consumption during the initial 24 hours in a randomized, double-blinded, placebo-controlled study in 100 patients with American Society of Anesthesiologists physical status I and II. Patients were divided into five groups to receive placebo or gabapentin 300, 600, 900, or 1200 mg 2 hours before surgery. After surgery, patients were transferred to the postanesthesia care unit (PACU). A blinded anesthesiologist recorded the pain scores at time points of 6, 12, 18, and 24 hours in the PACU on a Visual Analog Scale (VAS; 0-10 cm) at rest. Patients received patient-controlled analgesia (fentanyl 1.0 mug/kg on each demand with lockout interval of 10 minutes); total fentanyl consumption during initial 24 hours was recorded. Data were entered into the statistical software package SPSS 9.0 for analysis (one-way analysis of variance and Student-Newman-Keuls test). Patients who received gabapentin 300 mg had significantly lower VAS score at all time points. They consumed less fentanyl (patients who received placebo processed 1217.5 +/- 182.0 versus 987.5 +/- 129.6 mug; P < 0.05). Patients who received gabapentin 600, 900, and 1200 mg had lower VAS scores at all time points than patients who received gabapentin 300 mg (P < 0.05). Increasing the dose of gabapentin from 600 to 1200 mg did not decrease the VAS score, nor did the increasing dose of gabapentin significantly decrease fentanyl consumption (702.5, 635, and 626.5 microg). Thus, gabapentin 600 mg is the optimal dose for postoperative pain relief following lumbar diskectomy.

Effect of preoperative dexamethasone on edema of oral and extra-oral structures following trans-oral decompression and posterior fusion

We investigated the anti-edema effect of intravenous dexamethasone in a randomized, double-blinded, placebo-controlled study in 40 ASA physical status I and II patients scheduled for trans-oral decompression and posterior fusion. Patients were divided into two groups to receive either placebo or 10 mg dexamethasone one hour prior to induction of anesthesia. After anesthesia induction, oral structures were graded as swelling grade 0 at direct laryngoscopy. Duration of trans-oral surgery, duration of posterior fusion, and total duration of surgery were recorded. After completion of surgery, direct laryngoscopy was repeated, and swelling was graded from 1 to 4. Patients who had a swelling grade of 1 or 2 were extubated while grades of 3 and 4 were transferred to a neurosurgical intensive care unit, and re-assessments were performed 12 hours apart. Patients with swelling grades of 1 and 2 were extubated on each assessment. On statistical analysis of the results, the study found that in comparison to placebo, patients in the dexamethasone group were extubated earlier (P < 0.006, Chi Square for trend). Total duration of surgery and duration of posterior fusion were significantly greater (P < 0.05) in patients who had swelling grade >2 than in patients who had swelling grade < or =2 at completion of surgery (192.50 +/- 16.26, 356.07 +/- 17.06 minutes versus. 158.27 +/- 9.07, 311.41 +/- 14.06 minutes).

Vein pretreatment with magnesium sulfate to prevent pain on injection of propofol is not justified

PURPOSE

Propofol produces anesthesia with rapid recovery. However, it causes pain or discomfort on injection. A number of techniques have been tried for minimizing propofol-induced pain with variable results. We have compared the efficacy of magnesium and lidocaine for the prevention of propofol induced pain.

METHODS

Three hundred ASA I and II adults undergoing elective surgery were randomly assigned into three groups of 100 each. Group I received magnesium sulfate 1 g, Group II received lidocaine 2% (40 mg) and Group III received normal saline, all in a volume of 2 mL and accompanied by venous occlusion for one minute. Induction with propofol 2.5 mg.kg(-1) was accomplished following the release of venous occlusion. Pain was assessed on a four-point scale: 0 = no pain, 1 = mild pain, 2 = moderate pain, and 3 = severe pain at the time of pretreatment and propofol injection. Results were analyzed by 'Z' test. A P value of < 0.05 was considered as significant.

RESULTS

Pain during i.v. pretreatment with magnesium was 31% as compared to 2% for both the lidocaine and control groups (P < 0.05). Seventy-six percent of patients in the control group had pain during i.v. propofol as compared to 32% and 42% in the magnesium and the lidocaine groups respectively (P < 0.05). Lidocaine and magnesium pretreatment were equally effective in attenuating pain during the propofol injection (P > 0.05).

CONCLUSIONS

Intravenous magnesium and lidocaine pretreatment are equally effective in attenuating propofol-induced pain. However, magnesium pretreatment itself causes pain. Therefore, there is no justification in the use of magnesium pretreatment for attenuating pain associated with i.v. propofol.

Pain During Injection of Propofol: The Effect of Prior Administration of Butorphanol

Propofol causes pain or discomfort on injection in 28%-90% of patients. A number of techniques have been tried for minimizing propofol-induced pain with variable results. We compared the efficacy of butorphanol and lidocaine for prevention of propofol-induced pain. One-hundred-fifty ASA I-II adults, undergoing elective surgery were randomly assigned into 3 groups of 50 each. Group I (NS) received normal saline, Group II (L) received lidocaine 2% (40 mg), and Group III (B) received butorphanol 2 mg. All patients received pretreatment solutions made in 2 mL with normal saline administered over 5 s. One min after pretreatment patients received one-fourth of the total calculated dose of propofol (2.5 mg/kg) over 5 s. Assessment of pain with IV propofol was done by using a four-point scale: 0 = no pain, 1 = mild pain, 2 = moderate pain and 3 = severe pain at the time of propofol injection. In the control Group 39 (78%) patients had pain during propofol injection as compared to 21 (42%) and 10 (20%) in the lidocaine and butorphanol groups, respectively (P < 0.05). Butorphanol was the most effective. We therefore suggest the IV pretreatment with butorphanol 2 mg for attenuation of pain associated with propofol injection.

Rapid preparation of severe uncontrolled thyrotoxicosis due to Graves' disease with Iopanoic acid--a case report

PURPOSE

To report the rapid preoperative preparation of a case of thyrotoxicosis due to Graves' disease resistant to medical treatment.

CLINICAL FEATURES

A 14-yr-old boy presented with a history of progressive swelling in the neck. Signs and symptoms were compatible with hyperthyroidism. Thyroid function tests revealed: serum T4 296.5 nmol.L(-1), serum T3 6.06 nmol.L(-1) and serum thyroid-stimulating hormone < 0.15 mIU.L(-1). The diagnosis of thyrotoxicosis due to Graves' disease was made. Therapy was instituted with carbimazole 30 mg.day(-1) and propranolol 80 mg.day(-1), which were gradually increased to carbimazole 80 mg.day(-1) and propranolol 120 mg.day(-1), without response. Preparation was attempted by adding Iopanoic acid 500 mg four times a day and dexamethasone 0.5 mg four times a day in addition to the above drugs for five days. T3 levels declined to 1.8 nmol.L(-1), but the serum T4 remained elevated. Symptoms of hyperthyroidism persisted but with decreased intensity. As the patient could not be made euthyroid, surgery was planned to relieve the symptoms. Anesthesia was uneventful except for intraoperative and postoperative tachycardia, which was managed successfully with esmolol.

CONCLUSION

In life threatening thyrotoxicosis refractory to medical treatment, Iopanoic acid may be used as an adjuvant to antithyroid drugs for rapid preparation of the patient prior to surgery.

Preemptive use of gabapentin significantly decreases postoperative pain and rescue analgesic requirements in laparoscopic cholecystectomy

PURPOSE

To evaluate the comparative preemptive effects of gabapentin and tramadol on postoperative pain and fentanyl requirement in laparoscopic cholecystectomy.

METHODS

Four hundred fifty-nine ASA I and II patients were randomly assigned to receive 300 mg gabapentin, 100 mg tramadol or placebo in a double-blind manner two hours before laparoscopic cholecystectomy under general anesthesia. Postoperatively, patients' pain scores were recorded on a visual analogue scale every two hours for the initial 12 hr and thereafter every three hours for the next 12 hr. Patients received fentanyl 2 micro g*kg(-1) intravenously on demand. The total fentanyl consumption for each patient was recorded.

RESULTS

Patients in the gabapentin group had significantly lower pain scores at all time intervals (2.65 +/- 3.00, 1.99 +/- 1.48, 1.40 +/- 0.95, 0.65 +/- 0.61) in comparison to tramadol (2.97 +/- 2.35, 2.37 +/- 1.45, 1.89 +/- 1.16, 0.87 +/- 0.50) and placebo (5.53 +/- 2.22, 3.33 +/- 1.37, 2.41 +/- 1.19, 1.19 +/- 0.56). Significantly less fentanyl was consumed in the gabapentin group (221.16 +/- 52.39 micro g) than in the tramadol (269.60 +/- 44.17 micro g) and placebo groups (355.86 +/- 42.04 micro g; P < 0.05). Sedation (33.98%), nausea/retching/vomiting (24.8%) were the commonest side effects in the gabapentin group whereas respiratory depression (3.9%) was the commonest in the tramadol group and vertigo (7.8%) in the placebo group.

CONCLUSION

Preemptive use of gabapentin significantly decreases postoperative pain and rescue analgesic requirement in laparoscopic cholecystectomy.