Great cardiac vein injury after circumflex artery intervention: a case report

Background

Injury of the great cardiac vein (GCV) during circumflex coronary artery intervention is not discussed enough in the literature. In addition, relationship between the GCV and circumflex artery is highly variable and practically unpredictable in 30% of cases. This report describes a rare case of GCV injury during circumflex artery intervention.

Case summary

An 80-year-old man with known ischaemic heart disease was admitted with unstable anginal pain for urgent coronary angiography. Circumflex (Cx) percutaneous coronary intervention (PCI) of proximal-to-medial high-grade calcified stenosis was performed. Two hours later, the patient developed pericardial tamponade. Pericardiocentesis revealed a venous bloody effusion. Due to continuous bleeding, an urgent exploratory thoracotomy was performed. Intraoperatively, a large pericardial haematoma in the Cx region was evacuated. The perforation site was sought and identified as a tear at the GCV. Further hospitalization was uneventful, and the patient was discharged after one week. Clinical and echocardiographic outcomes were favourable at the 3-month follow-up.

Discussion

A GCV injury during PCI is a diagnosis of exclusion if there is a venous pericardial effusion directly after PCI and no injury of the right ventricle or surrounding structures, and thoracic computed tomography demonstrates a pericardial haematoma in the PCI region, especially the Cx region. A haematoma can deteriorate the haemodynamic status without effusion 'dry tamponade'. Treatment should be addressed according to haemodynamics. A conservative therapy, pericardiocentesis, catheter-based bailout intervention or even an explorative pericardiotomy could be imperative to evacuate the haematoma and seal the injured vein.

Using a Fibrinolysis Delivery Catheter in Pulmonary Embolism Treatment for Measurement of Pulmonary Artery Hemodynamics

Background: Ultrasound-facilitated and catheter-directed low-dose fibrinolysis (EKOS) has shown favorable hemodynamic and safety outcomes in intermediate- to high-risk pulmonary embolism (PE) cases. Objectives: This prospective single-arm monocentric study assessed the effects of using a delivery catheter for fibrinolysis as a novel approach for acute intermediate- to high-risk patients on pulmonary artery hemodynamics PE. Methods: Forty-five patients (41 intermediate−high and 4 high risk) with computer tomography (CT)-confirmed PE underwent EKOS therapy. By protocol, a total of 6 mg of tissue-plasminogen activator (t-PA) was administered over 6 h in the pulmonary artery (unilateral 6 mg or bilateral 12 mg). Unfractionated heparin was provided periprocedurally. The primary safety outcome was death, as well as major and minor bleeding within 48 of procedure initiation and at 90 days. The primary effectiveness outcomes were: 1. to assess the difference in pulmonary artery pressure from baseline to 6 h post-treatment as a primary precise surrogate marker, and 2. to determine the echocardiographic RV/LV ratio from baseline to 48 h and at 90 days post-delivery. Results: Pulmonary artery pressure decreased by 15/6/10 mmHg (p < 0.001). The mean RV/LV ratio decreased from 1.2 ± 0.85 at baseline to 0.85 ± 0.12 at 48 and to 0.76 ± 0.13 at 90 days (p < 0.001). Five patients (11%) died within 90 days of therapy. Conclusions and Highlights: Pulmonary artery hemodynamics were assessed using a delivery catheter for fibrinolysis, which is reproducible for identifying PE at risk of adverse outcomes. The results matched the right heart catheter results in EKOS and Heparin arm of Ultima trial, thereby confirming the validity of this potential diagnostic tool to assess therapy effectiveness and thereby reduce additional procedure-related complications, hospital residency, and economics. These results stress the importance of having an interdisciplinary team involved in the management of PE to evaluate the quality of life of these patients and this protocol shortens ICU admission to 6 h.

Epidemiology of the first and second waves of COVID-19 pandemic in Djibouti and the vaccination strategy developed for the response

Since the first case of COVID-19 in Djibouti in March 2020 up to the end of May 2021, the country experienced two major epidemic waves of confirmed cases and deaths. The first wave in 2020 progressed more slowly in Djibouti compared with other countries in the Eastern Mediterranean Region. The second wave in 2021 appeared to be more aggressive in terms of the number and severity of cases, as well as the overall fatality rate. This study describes and analyses the epidemiology of these two waves of the COVID-19 pandemic in Djibouti and highlights lessons learnt from the National Plan for Introduction and Deployment of COVID-19 vaccines developed and implemented by the Ministry of Health of Djibouti.From 17 March 2020 up to 31 May 2021, Djibouti officially reported 11 533 confirmed cases of COVID-19 with 154 related deaths (case fatality rate, CFR: 1.3%), with an attack rate of 1.2%. The first epidemic wave began in epidemiological week 16/2020 (12-18 April) and ended in epidemiological week 25/2020 (14-20 June) with 4274 reported cases and 46 deaths (CFR: 1.1%). The second wave began in epidemiological week 11/2021 (14-20 March) and ended in epidemiological week 18/2021 (2-8 May) with 5082 reported cases and 86 deaths (CFR: 1.7%).A vaccination campaign was launched by the President of the Republic in March 2021; approximately 1.6% of the population were vaccinated in only two months' time. Early Preparedness, multisectoral and multicoordinated response, and collaboration with WHO are among the major lessons learnt during the pandemic in Djibouti.

US Survey of Incidence of and Reasons for Nurse Anesthetists Leaving or Having Considered Leaving Their Jobs

Many nurse anesthetists changing positions or considering leaving their positions can give the impression that suboptimal quality of anesthesia department leadership exists. To provide nationally accurate benchmark data on annual turnovers of nurse anesthetists to assist chief nurse anesthetists who may be scrutinized for the resignation rate of nurse anesthetists at their hospital, we used the 2018 US National Sample Survey of Registered Nurses. Analyses show that, during 2017, approximately 13.6% (99% CI, 6.6%-25.8%) of survey respondents left the positions that they held as of December 31, 2016. Approximately 37.6% considered leaving but did not resign as of December 31, 2017 (CI, 26.2%-50.6%). Estimates for nurse anesthetists were comparable to those for registered nurses (ie, not unique to nurse anesthetists). With both estimates combined, approximately 53% of nurse anesthetists changed or considered leaving their primary position (CI, 37.3%-68.0%, P=.62 compared with half). The most commonly reported reason was "better pay/benefits" (P≤.0064 vs all other reasons, including burnout). Applying the results, in a department with 37 nurse anesthetists, the national incidence of 13.6% would represent a turnover of 5.0 per year. The 13.6% incidence could also result in 1 of 5 years having as many as 11 nurse anesthetists (30%) leaving.

COVID-19 pandemic in Djibouti: Epidemiology and the response strategy followed to contain the virus during the first two months, 17 March to 16 May 2020

First cases of COVID-19 were reported from Wuhan, China, in December 2019, and it progressed rapidly. On 30 January, WHO declared the new disease as a PHEIC, then as a Pandemic on 11 March. By mid-March, the virus spread widely; Djibouti was not spared and was hit by the pandemic with the first case detected on 17 March. Djibouti worked with WHO and other partners to develop a preparedness and response plan, and implemented a series of intervention measures. MoH together with its civilian and military partners, closely followed WHO recommended strategy based on four pillars: testing, isolating, early case management, and contact tracing. From 17 March to 16 May, Djibouti performed the highest per capita tests in Africa and isolated, treated and traced the contacts of each positive case, which allowed for a rapid control of the epidemic. COVID-19 data included in this study was collected through MoH Djibouti during the period from 17 March to 16 May 2020. A total of 1,401 confirmed cases of COVID-19 were included in the study with 4 related deaths (CFR: 0.3%) and an attack rate of 0.15%. Males represented (68.4%) of the cases, with the age group 31-45 years old (34.2%) as the most affected. Djibouti conducted 17,532 tests, and was considered as a champion for COVID-19 testing in Africa with 18.2 tests per 1000 habitant. All positive cases were isolated, treated and had their contacts traced, which led to early and proactive diagnosis of cases and in turn yielded up to 95-98% asymptomatic cases. Recoveries reached 69% of the infected cases with R0 (0.91). The virus was detected in 4 regions in the country, with the highest percentage in the capital (83%). Djibouti responded to COVID-19 pandemic following an efficient and effective strategy, using a strong collaboration between civilian and military health assets that increased the response capacities of the country. Partnership, coordination, solidarity, proactivity and commitment were the pillars to confront COVID-19 pandemic.

Health consequences of drought in the WHO Eastern Mediterranean Region: hotspot areas and needed actions

BACKGROUND

Over the past four decades, drought episodes in the Eastern Mediterranean Region (EMR) of the of the World Health Organization (WHO) have gradually become more widespread, prolonged and frequent. We aimed to map hotspot countries and identified key strategic actions for health consequences.

METHODS

We reviewed scientific literature and WHO EMR documentation on trends and patterns of the drought health consequences from 1990 through 2019. Extensive communication was also carried out with EMR WHO country offices to retrieve information on ongoing initiatives to face health consequences due to drought. An index score was developed to categorize countries according vulnerability factors towards drought.

RESULTS

A series of complex health consequences are due to drought in EMR, including malnutrition, vector-borne diseases, and water-borne diseases. The index score indicated how Afghanistan, Yemen and Somalia are "hotspots" due to poor population health status and access to basic sanitation as well as other elements such as food insecurity, displacement and conflicts/political instability. WHO country offices effort is towards enhancing access to water and sanitation and essential healthcare services including immunization and psychological support, strengthening disease surveillance and response, and risk communication.

CONCLUSIONS

Drought-related health effects in the WHO EMR represent a public health emergency. Strengthening mitigation activities and additional tailored efforts are urgently needed to overcome context-specific gaps and weaknesses, with specific focus on financing, accountability and enhanced data availability.

Strategies for daily operating room management of ambulatory surgery centers following resolution of the acute phase of the COVID-19 pandemic

We performed a narrative review to explore the economics of daily operating room management decisions for ambulatory surgery centers following resolution of the acute phase of the Coronavirus Disease 2019 (COVID-19) pandemic. It is anticipated that there will be a substantive fraction of patients who will be contagious, but asymptomatic at the time of surgery. Use multimodal perioperative infection control practices (e.g., including patient decontamination) and monitor performance (e.g., S. aureus transmission from patient to the environment). The consequence of COVID-19 is that such processes are more important than ever to follow because infection affects not only patients but the surgery center staff and surgeons. Dedicate most operating rooms to procedures that are not airway aerosol producing and can be performed without general anesthesia. Increase throughput by performing nerve blocks before patients enter the operating rooms. Bypass the phase I post-anesthesia care unit whenever possible by appropriate choices of anesthetic approach and drugs. Plan long-duration workdays (e.g., 12-h). For cases where the surgical procedure does not cause aerosol production, but general anesthesia will be used, have initial (phase I) post-anesthesia recovery in the operating room where the surgery was done. Use anesthetic practices that achieve fast initial recovery of the brief ambulatory cases. When the surgical procedure causes aerosol production (e.g., bronchoscopy), conduct phase I recovery in the operating room and use multimodal environmental decontamination after each case. Use statistical methods to plan for the resulting long turnover times. Whenever possible, have the anesthesia and nursing teams stagger cases in more than one room so that they are doing one surgical case while the other room is being cleaned. In conclusion, this review shows that while COVID-19 is prevalent, it will markedly affect daily ambulatory workflow for patients undergoing general anesthesia, with potentially substantial economic impact for some surgical specialties.

Epidemiology of severe cases of influenza and other acute respiratory infections in the Eastern Mediterranean Region, July 2016 to June 2018

BACKGROUND

Influenza surveillance systems in the Eastern Mediterranean Region have been strengthened in the past few years and 16 of the 19 countries in the Region with functional influenza surveillance systems report their influenza data to the EMFLU Network. This study aimed to investigate the epidemiology of circulating influenza viruses, causing SARI, and reported to the EMFLU during July 2016 to June 2018.

METHODS

Data included in this study were collected by 15 countries of the Region from 110 SARI sentinel surveillance sites over two influenza seasons.

RESULTS

A total of 40,917 cases of SARI were included in the study. Most cases [20,551 (50.2%)] were less than 5years of age. Influenza virus was detected in 3995 patients, 2849 (11.8%) were influenza A and 1146 (4.8%) were influenza B. Influenza A(H1N1)pdm09 was the predominant circulating subtype with 1666 cases (58.5%). Other than influenza, respiratory syncytial virus was the most common respiratory infection circulating, with 277 cases (35.9%).

CONCLUSION

Influenza viruses cause a high number of severe respiratory infections in EMR. It is crucial for the countries to continue improving their influenza surveillance capacity in order detect any unusual influenza activity or new strain that may cause a pandemic.

MERS-CoV infection among healthcare workers and risk factors for death: Retrospective analysis of all laboratory-confirmed cases reported to WHO from 2012 to 2 June 2018

Background

Approximately half of the reported laboratory-confirmed infections of Middle East respiratory syndrome coronavirus (MERS-CoV) have occurred in healthcare settings, and healthcare workers constitute over one third of all secondary infections. This study aimed to describe secondary cases of MERS-CoV infection among healthcare workers and to identify risk factors for death.

Methods

A retrospective analysis was conducted on epidemiological data of laboratory-confirmed MERS-CoV cases reported to the World Health Organization from September 2012 to 2 June 2018. We compared all secondary cases among healthcare workers with secondary cases among non-healthcare workers. Multivariable logistic regression identified risk factors for death.

Results

Of the 2223 laboratory-confirmed MERS-CoV cases reported to WHO, 415 were healthcare workers and 1783 were non-healthcare workers. Compared with non-healthcare workers cases, healthcare workers cases were younger (P < 0.001), more likely to be female (P < 0.001), non-nationals (P < 0.001) and asymptomatic (P < 0.001), and have fewer comorbidities (P < 0.001) and higher rates of survival (P < 0.001). Year of infection (2013–2018) and having no comorbidities were independent protective factors against death among secondary healthcare workers cases.

Conclusion

Being able to protect healthcare workers from high threat respiratory pathogens, such as MERS-CoV is important for being able to reduce secondary transmission of MERS-CoV in healthcare-associated outbreaks. By extension, reducing infection in healthcare workers improves continuity of care for all patients within healthcare facilities.

Pandemic influenza preparedness (PIP) framework: Progress challenges in improving influenza preparedness response capacities in the Eastern Mediterranean Region, 2014-2017

Influenza viruses with pandemic potential have been detected in humans in the Eastern Mediterranean Region. The Pandemic Influenza Preparedness (PIP) Framework aims to improve the sharing of influenza viruses with pandemic potential and increase access of developing countries to vaccines and other life-saving products during a pandemic. Under the Framework, countries have been supported to enhance their capacities to detect, prepare for and respond to pandemic influenza. In the Eastern Mediterranean Region, seven countries are priority countries for Laboratory and Surveillance (L&S) support: Afghanistan, Djibouti, Egypt, Jordan, Lebanon, Morocco and Yemen. During 2014–2017, US$ 2.7 million was invested in regional capacity-building and US$ 4.6 million directly in the priority countries. Countries were supported to strengthen influenza diagnostic capacities to improve detection, enhance influenza surveillance systems including sentinel surveillance for severe acute respiratory infection and influenza-like illness, and increase global sharing of surveillance data and influenza viruses. This paper highlights the progress made in improving influenza preparedness and response capacities in the Region from 2014 to 2017, and the challenges faced. By 2017, 18 of the 22 countries of the Region had laboratory-testing capacity, 19 had functioning sentinel influenza surveillance systems and 22 had trained national rapid response teams. The number of countries correctly identifying all influenza viruses in the WHO external quality assurance panel increased from 9 countries scoring 100% in 2014 to 15 countries in 2017, and the number sharing influenza viruses with WHO collaborating centres increased by 75% (from eight to 14 countries); more than half now share influenza data with regional or global surveillance platforms. Seven countries have estimated influenza disease burden and seven have introduced influenza vaccination for high-risk groups. Challenges included: protracted complex emergencies faced by nine countries which hindered implementation of influenza surveillance in areas with the most needs, high staff turnover, achieving timely virus sharing and limited utilization of influenza data where they are available to inform vaccine policies or establish threshold values to measure the start and severity of influenza seasons.

Reported Direct and Indirect Contact with Dromedary Camels among Laboratory-Confirmed MERS-CoV Cases

Dromedary camels (Camelus dromedarius) are now known to be the vertebrate animal reservoir that intermittently transmits the Middle East respiratory syndrome coronavirus (MERS-CoV) to humans. Yet, details as to the specific mechanism(s) of zoonotic transmission from dromedaries to humans remain unclear. The aim of this study was to describe direct and indirect contact with dromedaries among all cases, and then separately for primary, non-primary, and unclassified cases of laboratory-confirmed MERS-CoV reported to the World Health Organization (WHO) between 1 January 2015 and 13 April 2018. We present any reported dromedary contact: direct, indirect, and type of indirect contact. Of all 1125 laboratory-confirmed MERS-CoV cases reported to WHO during the time period, there were 348 (30.9%) primary cases, 455 (40.4%) non-primary cases, and 322 (28.6%) unclassified cases. Among primary cases, 191 (54.9%) reported contact with dromedaries: 164 (47.1%) reported direct contact, 155 (44.5%) reported indirect contact. Five (1.1%) non-primary cases also reported contact with dromedaries. Overall, unpasteurized milk was the most frequent type of dromedary product consumed. Among cases for whom exposure was systematically collected and reported to WHO, contact with dromedaries or dromedary products has played an important role in zoonotic transmission.

Emerging and Reemerging Diseases in the World Health Organization (WHO) Eastern Mediterranean Region-Progress, Challenges, and WHO Initiatives

The Eastern Mediterranean Region (EMR) of the World Health Organization (WHO) continues to be a hotspot for emerging and reemerging infectious diseases and the need to prevent, detect, and respond to any infectious diseases that pose a threat to global health security remains a priority. Many risk factors contribute in the emergence and rapid spread of epidemic diseases in the Region including acute and protracted humanitarian emergencies, resulting in fragile health systems, increased population mobility, rapid urbanization, climate change, weak surveillance and limited laboratory diagnostic capacity, and increased human–animal interaction. In EMR, several infectious disease outbreaks were detected, investigated, and rapidly contained over the past 5 years including: yellow fever in Sudan, Middle East respiratory syndrome in Bahrain, Oman, Qatar, Saudi Arabia, United Arab Emirates, and Yemen, cholera in Iraq, avian influenza A (H5N1) infection in Egypt, and dengue fever in Yemen, Sudan, and Pakistan. Dengue fever remains an important public health concern, with at least eight countries in the region being endemic for the disease. The emergence of MERS-CoV in the region in 2012 and its continued transmission currently poses one of the greatest threats. In response to the growing frequency, duration, and scale of disease outbreaks, WHO has worked closely with member states in the areas of improving public health preparedness, surveillance systems, outbreak response, and addressing critical knowledge gaps. A Regional network for experts and technical institutions has been established to facilitate support for international outbreak response. Major challenges are faced as a result of protracted humanitarian crises in the region. Funding gaps, lack of integrated approaches, weak surveillance systems, and absence of comprehensive response plans are other areas of concern. Accelerated efforts are needed by Regional countries, with the continuous support of WHO, to build and maintain a resilient public health system for detection and response to all acute public health events.

Novel coronavirus infection in the eastern mediterranean region: time to act

The Eastern Mediterranean Region of World Health Organization has been an emerging focus for global health after the discovery of a novel coronavirus infection in some countries in the Region. The Region has already witnessed a number of emerging zoonoses with epidemic potential. In view of this new virus, there is now an urgent need for strong public health vigilance and monitoring of the evolution of the virus in the Region. The situation will challenge and test the national health authorities' resilience and ability to respond in a timely manner. This review summarizes the evidence related to the emergence in the Region of new epidemic diseases of predominantly zoonotic origin and the challenges posed by the discovery of the novel coronavirus infection, and outlines recommendations for the countries for early detection, prevention threats from this novel coronavirus infection. and control of public health

Effect of epidural dexmedetomidine on intraoperative awareness and post-operative pain after one-lung ventilation

BACKGROUND

During combined general and regional anaesthesia, it is difficult to use autonomic signs to assess whether wakefulness is suppressed adequately. We compared the effects of a dexmedetomidine-bupivacaine mixture with plain bupivacaine for thoracic epidural anaesthesia on intraoperative awareness and analgesic benefits, when combined with superficial isoflurane anaesthesia (<0.05 maximum alveolar concentration) in patients undergoing thoracic surgery with one-lung ventilation (OLV).

METHODS

Fifty adult male patients were randomly assigned to receive either epidural dexmedetomidine 1 microg/kg with bupivacaine 0.5% (group D) or bupivacaine 0.5% alone (group B) after induction of general anaesthesia. Gasometric, haemodynamic and bispectral index values were recorded. Post-operative verbal rating score for pain and observer's assessment of alertness/sedation scale were determined by a blinded observer.

RESULTS

Dexmedetomidine reduced the use of supplementary fentanyl during surgery. Patients in group B consumed more analgesics and had higher pain scores after operation than patients of group D. The level of sedation was similar between the two groups in the ICU. Two patients (8%) in group B reported possible intraoperative awareness. There was a limited decrease in PaO2 at OLV in group D compared with group B (P<0.05).

CONCLUSION

In thoracic surgery with OLV, the use of epidural dexmedetomidine decreases the anaesthetic requirements significantly, prevents awareness during anaesthesia and improves intraoperative oxygenation and post-operative analgesia.

Analgesic and antacid properties of i.m. tramadol given before Caesarean section under general anaesthesia

BACKGROUND

Intramuscular (i.m.) tramadol increases gastric pH during anaesthesia similar to famotidine. We investigated the antacid analgesic value of a single dose of i.m. tramadol given 1 h before elective Caesarean section performed under general anaesthesia.

METHODS

Sixty ASA I parturients undergoing elective Caesarean section were included in a randomized double-blind study. The patients were randomly allocated to receive i.m. tramadol 100 mg (n=30) or famotidine 20 mg (n=30) 1 h before general anaesthesia.

RESULTS

At the beginning and the end of anaesthesia, patients receiving tramadol had a median gastric fluid pH of 6.4, which was not significantly different from those treated with famotidine (median 6.3). The infant well-being, as judged by Apgar score, cord blood gas analysis, and neurobehavioural assessment showed no significant difference between the two groups. Nalbuphine consumption in the first 24 h after operation was reduced by 35% in the tramadol group. Pain intensity score on sitting and sedation were significantly greater in famotidine group up to 24 h after surgery. There was no significant difference in incidence and severity of nausea and vomiting between the two groups.

CONCLUSION

A single i.m. dose of tramadol is useful pre-treatment to minimize the risk of acid aspiration during operation, and in improving pain relief during 24 h after surgery.

Ketamine reduces swallowing-evoked pain after paediatric tonsillectomy

BACKGROUND

Ketamine efficacy as an analgesic adjuvant has been studied in several clinical settings with conflicting results. The aim of this study was to investigate the effect of ketamine on spontaneous and swallowing-evoked pain after tonsillectomy.

METHODS

Fifty children were randomized to receive premedication with either ketamine 0.1 mg kg(-1) i.m. or placebo given 20 min before induction of a standard general anaesthesia. All children received rectal diclofenac 2 mg kg(-1) and fentanyl 1 micro g kg(-1) i.v. before surgery.

RESULTS

The ketamine group showed significantly lower pain scores both at rest and on swallowing, with less total paracetamol consumption (P < 0.05) during the 24 h after surgery. Significantly more patients required postoperative morphine titration in the control group (P < 0.05). The time to the first oral intake, and duration of i.v. hydration, were significantly shorter and the quality of oral intake was significantly better in the ketamine group (P < 0.05). There were no differences in the incidence of vomiting or dreaming between the groups.

CONCLUSION

Premedication with a small dose of ketamine reduces swallowing-evoked pain after tonsillectomy in children who received an analgesic regimen combining an opioid and a NSAID.

Effects of intraperitoneal lidocaine combined with intravenous or intraperitoneal tenoxicam on pain relief and bowel recovery after laparoscopic cholecystectomy

BACKGROUND

Previous work has demonstrated that intraperitoneal (i.p.) lidocaine may provide analgesia after laparoscopic cholecystectomy. The aim of this prospective, randomized, double-blind study was to compare pain relief, recovery variables, and side effects after i.p. instillation of lidocaine plus tenoxicam given either i.v. or i.p. after laparoscopic cholecystectomy.

METHODS

Ninety patients were randomly allocated to one of three groups to receive either 200 ml normal saline i.p. and 2 ml of normal saline i.v. (saline group), 200 ml lidocaine 0.1% i.p. and 2 ml tenoxicam 20 mg i.v. (tenoxicam i.v. group), or 200 ml lidocaine 0.1% with 20 mg tenoxicam i.p. and 2 ml of normal saline i.v. (tenoxicam i.p. group). The i.p. instillation was made under the right diaphragm and on the gall bladder bed. VAS pain scores at rest, on movement and during coughing, were measured 2, 4, 6, 12, and 24 h after operation. The time to first demand of analgesia, total analgesic requirement, recovery variables, and side effects were investigated.

RESULTS

In the tenoxicam i.p. group, pain scores were significantly lower both at rest and on movement and analgesic consumption was reduced compared with the saline group (P<0.05). In the tenoxicam i.v. group, pain scores at rest were significantly lower compared with the saline group. Although recovery of bowel function was significantly faster in the tenoxicam i.p. group (P<0.05), there were no differences in any other recovery characteristics or incidence of nausea between the groups.

CONCLUSION

Combination of intraperitoneal lidocaine and tenoxicam provided better analgesia on movement, and faster return of bowel function compared with i.p. lidocaine and i.v. tenoxicam during the 24 h period after surgery.

Topical tenoxicam from pharyngeal pack reduces postoperative sore throat

BACKGROUND

One puff of beclomethasone inhaler has been shown to reduce the incidence of sore throat following endotracheal intubation. The aim of this study was to determine the effect of a pharyngeal pack on the incidence of sore throat and whether tenoxicam-impregnated gauze pack significantly influenced the frequency of sore throat.

METHODS

Eighty patients undergoing general anaesthesia for elective surgery of the nasal septum were evaluated. The anaesthetist sprayed the upper airway towards the trachea with one puff of beclomethasone inhaler (50 microg) before orotracheal intubation. Patients were randomly assigned to have either a 0.2% tenoxicam- or a 0.9% saline-impregnated gauze pack in the oropharynx during operation. They were evaluated for occurrence and severity of postoperative sore throat by direct questions 12-24 h after surgery.

RESULTS

Four patients who experienced any symptoms in the tenoxicam group scored mild sore throat compared to 16 patients in the control group scoring mild, gradually developing moderate or severe sore throat (P<0.01). No drug-related side effects were observed.

CONCLUSION

The intraoperative use of a tenoxicam-impregnated gauze pack is effective in reducing moderate or severe postoperative sore throat following the use of throat pack.

Effect of i.v. tenoxicam during caesarean delivery on platelet activity

BACKGROUND

Non-steroidal anti-inflammatory drugs inhibit platelet aggregation and prolong bleeding time in healthy subjects. We have studied the effect of i.v. tenoxicam during caesarean delivery on skin bleeding time, operative, and postoperative blood loss, and beta-thromboglobulin and platelet factor 4 as specific molecular markers for platelet activity.

METHODS

Fifty women were studied. Twenty-five were given tenoxicam 20 mg i.v. 10 min before induction of general anaesthesia, and 25 formed a control group. Skin bleeding time and platelet markers were determined the day before and 1 h after induction of anaesthesia.

RESULTS

In the tenoxicam group, there was an slight increase in skin bleeding time with no statistically significant changes in platelet marker levels. In the control group, platelet markers increased 1 h after surgery. The surgeon's assessment of uterine relaxation, using a visual analogue score, operating theatre blood loss, and the frequency of bleeding over 24 h after operation, showed no significant difference between the two groups.

CONCLUSION

During caesarean delivery i.v. tenoxicam causes a slight increase in bleeding time with no significant changes in platelet marker levels.

Intraperitoneal lidocaine for postoperative pain after laparoscopy

BACKGROUND

A controversy exists over the effectiveness and clinical value of intraperitoneal local anaesthetics for treating pain after laparoscopic cholecystectomy. The use of intraperitoneal lidocaine was evaluated in this study.

METHODS

At the end of surgery, 200 ml saline containing 200 mg lidocaine, or the same volume of saline, were randomly splashed under the right diaphragmatic surface in 50 patients in a double-blind manner. Postoperative shoulder and abdominal pain intensity were recorded on a numeric grading scale and a visual analogue scale, respectively. Analgesic consumption was also recorded. Respiratory function tests were compared before and after surgery. Side effects and recovery variables were assessed by the nurses at 2-h intervals.

RESULTS

The incidence, severity and duration of shoulder pain were reduced from 40% of patients scoring 3.9+/-0.2 for duration of 17.9+/-0.2 h in the control group to 12% scoring 2.5+/-0.5 for duration of 1.6+/-0.01 h in the lidocaine group. Lidocaine treated patients had significantly less abdominal postoperative pain immediately on return to the ward and during the first postoperative day (P<0.05). "No pain on deep inspiration" was reported by 72% of patients in the lidocaine group immediately on return to the ward compared to 8% of those in the control group. Analgesic consumption for 24 h after surgery was significantly less in the lidocaine group (P<0.05). There were no significant differences in respiratory function tests, recovery variables or incidence of side effects between the two groups.

CONCLUSION

Intraperitoneal lidocaine is simple to use and results in a long-lasting reduction of pain after a single administration.

Combination of intra-articular tenoxicam, lidocaine, and pethidine for outpatient knee arthroscopy

BACKGROUND

Studies of intra-articular non-steroidal anti-inflammatory drugs have revealed an analgesic effect equivalent to that of intra-articular local anaesthetic agents and morphine. The aim of this study was to evaluate the analgesic effect of intra-articular lidocaine, pethidine and tenoxicam compared with that of lidocaine and pethidine on postoperative pain after arthroscopy.

METHODS

After day-case knee arthroscopy, 60 patients were randomly allocated to one of three groups to receive 20 ml of a solution containing 0.9% saline (group S), 2% lidocaine and 10 mg preservative-free pethidine (group LP) and 2% lidocaine, 10 mg preservative-free pethidine and 20 mg tenoxicam (group LPT). Postoperative pain was assessed using a visual analogue scale and measuring analgesic requirements.

RESULTS

Pain scores were significantly lower in the LP group than in the S group at 1 and 2 h after surgery. From 4 h until the end of the first postoperative day, pain scores were significantly lower in the LPT group of patients at rest and on knee flexion than in the other two groups; these patients also used less oral analgesics (P<0.05).

CONCLUSION

The combination of 20 ml lidocaine 2%, 10 mg pethidine and 20 mg tenoxicam given intra-articularly provided superior analgesia and reduced oral analgesic requirement during the first day after arthroscopy compared with lidocaine and pethidine alone.

Intravenous fluid and postoperative nausea and vomiting after day-case termination of pregnancy

BACKGROUND

Deprivation of oral fluid before minor surgery has been alleged to cause postoperative nausea. We examined the effect of intraoperative fluid load on postoperative nausea and vomiting over 3 d after day-case termination of pregnancy.

METHODS

In a randomized study, 100 patients were allocated into one of two groups; receiving 1000 ml of compound sodium lactate solution during surgery or no intraoperative fluid. Propofol and alfentanil was used to induce and maintain anaesthesia with nitrous oxide (67%) and oxygen (33%). Visual analogue scores for nausea and pain, the time and frequency of emetic episodes, analgesic and antiemetic consumption were recorded for 3 d postoperatively.

RESULTS

The scores of nausea were significantly lower in the fluid group (P < 0.05) compared with the control group at 1, 2, 4 h and during 24-48 h following surgery. The incidence of emesis was lower (P < 0.01) after discharge, and the time to first oral fluid was shorter (P < 0.05) in the fluid group. There was no difference in pain score or analgesic consumption between the groups. Five patients (10%) in the control group requested antiemetic medication compared with none in the fluid group.

CONCLUSION

Intraoperative fluid administration may offer some benefit in decreasing the incidence of postoperative nausea and vomiting following day-case surgery.

Inclusion of pethidine in lidocaine for infiltration improves analgesia following tonsillectomy in children

BACKGROUND

Previous work has demonstrated that pethidine exerts local anaesthetic effects on peripheral nerves in vivo. We examined the effects of infiltration anaesthesia by a combination of pethidine and lidocaine on post-tonsillectomy pain and restlessness in children.

METHODS

Eighty children were randomly allocated to receive peritonsillar infiltration postoperatively with 3 ml of lidocaine 2% (1.5 ml on each side) combined with either 0.1 ml pethidine, 10 mg.ml-1, (pethidine group) or 0.1 ml normal saline (control group). Pain and behaviour were assessed at 1, 3, 6 and 12 h postoperatively and on the following morning by the patients and by a nurse blinded to previous treatment.

RESULTS

Patients in the pethidine group had lower pain scores than those in the control group at rest as well as swallowing during the whole observation period (P < 0.05). Paracetamol was given to 34/40 children in the control group and to 6/40 children in the pethidine group. The corresponding figures for pethidine administration were 6/40 and 0/40, respectively. Patients in the pethidine group displayed a more rapid return to calm wakefulness than those in the control group (P < 0.01).

CONCLUSION

Inclusion of a low dose of pethidine in lidocaine for tonsillar infiltration improves pain relief after tonsillectomy in children.

Intra-articular tenoxicam relieves post-arthroscopy pain

BACKGROUND

Nonsteroidal anti-inflammatory drugs have been documented to be effective in the treatment of postoperative pain. The aim of this study was to evaluate the analgesic effect of local intra-articular injection of tenoxicam compared with intravenous injection on postoperative pain after arthroscopy.

METHODS

After day-case arthroscopy, 60 patients were randomized to receive either tenoxicam 20 mg in 20 ml of normal saline intra-articularly and 2 ml of normal saline i.v., or 20 ml of normal saline intra-articularly and 2 ml tenoxicam 20 mg i.v. Postoperative pain was assessed using a visual analogue scale and measuring analgesic requirements.

RESULTS

Pain scores were significantly lower in the intra-articular group at rest and during active flexion of the knee at 1, 2 and 4 hours postoperatively and during walking at 6 hours postoperatively (P < 0.05). Significantly more patients in the intravenous group required supplemental opioid analgesia within the first 4 hours postoperatively (P < 0.05).

CONCLUSION

Intra-articular tenoxicam 20 mg provided better analgesia and decreased the requirements for postoperative analgesic compared with i.v. tenoxicam 20 mg.

Comparison of preoperative with postoperative topical lidocaine spray on pain after tonsillectomy

Seventy-five children aged 4-6 years scheduled for tonsillectomy were randomly allocated to receive either topical tonsillar spray with 10% lidocaine 4 mg kg-1 3 minutes before surgical incision; identical tonsillar spray after both tonsils had been removed; or no topical spray (control group). There were significant differences in postoperative pain between the lidocaine groups and the control group at 0.5 and one hour after awaking (P < 0.05). Also in the lidocaine groups, consumption of paracetamol on the day of operation was less, and additional postoperative pethidine was not required. There were no significant differences between pre- and postoperative lidocaine groups in pain scores during the observation period but the use of pre-operative lidocaine tended to be associated with a more rapid return to calm wakefulness. Topical lidocaine seemed to have short-acting analgesic activity. The results of this study do not support the theory of pre-emptive analgesia.

I.v. tenoxicam for analgesia during caesarean section

We have studied the analgesic efficacy of a single i.v. dose of tenoxicam 20 mg, given 10 min before induction of anaesthesia in 25 patients undergoing elective Caesarean section. Another group of 25 similar patients served as controls. Nalbuphine consumption in the first 24 h after operation was reduced by 50% when tenoxicam was given. The median time to first request for analgesia was increased from 25 to 110 min in the tenoxicam group. Subjective experiences of pain and sedation were significantly greater in the control group up to 24 h after operation. The haemodynamic variability after intubation was of shorter duration in the tenoxicam group. There was no significant difference in incidence and severity of postoperative nausea and vomiting between the two groups. The surgeon's assessment of uterine relaxation and bleeding, using a visual analogue score, and infant well-being, as judged by Apgar score and cord blood-gas analysis, showed no significant difference between the two groups. There was no evidence of premature closure of the ductus arteriosus or pulmonary hypertension. We conclude that a single i.v. dose of tenoxicam is a useful pretreatment to minimize the haemodynamic variability of light general anaesthesia at induction-delivery and in reducing 24 h postoperative opioid consumption.

Addition of atracurium to lidocaine for intravenous regional anaesthesia

This study was undertaken to examine the possible clinical advantages of using muscle relaxant with intravenous regional anaesthesia, (IVRA). Forty unpremedicated adult patients undergoing hand surgery were randomly allocated to receive either 40 ml 0.5% lidocaine or 40 ml 0.5% lidocaine with 2 mg of atracurium. The atracurium group of patients had a significantly greater degree of muscle relaxation, easier reduction of fractures, and better operative conditions (P < 0.01). Less pain was also reported during surgery (P < 0.025), and 5 and 15 min after release of the tourniquet (P < 0.01). Clinically, there was no difference in the speed of onset of block between the two groups. It is concluded that the addition of atracurium to lidocaine improves the operating condition during IVRA with less pain during and after surgery.

Painless dental extraction in children

A controlled investigation was undertaken to compare topical lignocaine and rectal paracetamol in the prevention of pain after day case dental extraction in children under general anaesthesia. Sixty patients were allocated randomly to receive intraoperatively either topical lignocaine 4 mg/kg (group A), rectal paracetamol 10 mg/kg (group B) or no analgesia (group C) immediately after completion of surgery. Pain, appearance and side-effects were assessed 15, 30 and 60 minutes postoperatively. The patients who received topical lignocaine (group A) had significantly lower pain scores at 15 minutes (p < 0.001) and 30 minutes (p < 0.01) with no need for postoperative analgesia. The use of topical lignocaine was associated with a significantly (p < 0.01) more rapid return to a calm awake appearance at 15 and 30 minutes postoperatively. Patients in group C who received no analgesia at the end of the operation received 10 mg/kg acetyl salicylic acid intramuscularly after their return to the ward. No significant differences in the incidence of nausea, vomiting, or any other toxic reaction were found between the three groups. The improved analgesia and shorter recovery period topical lignocaine render it more satisfactory for the prevention of pain after day dental extraction in children than the more commonly used rectal paracetamol.

A comparison of intravenous ketoprofen with pethidine for postoperative pain relief following nasal surgery

A controlled investigation was conducted to compare the efficacy of ketoprofen and pethidine in relief of postoperative pain after nasal surgery. Sixty patients were randomly allocated to receive intravenous ketoprofen 1.5 mg.ml-1 or pethidine 1 mg.kg-1 during induction of anaesthesia. Appearance, pain and headache were assessed 1, 2, and 4 h postoperatively, and the following morning. The use of ketoprofen was associated with a significantly faster recovery from anaesthesia (P less than 0.001), and a more rapid return to calm awakening (P less than 0.05). Patients who received ketoprofen had significantly lower pain and headache scores (P less than 0.01 and P less than 0.001, respectively), and required significantly (P less than 0.05) less postoperative analgesia. No significant difference in incidence and severity of postoperative nausea or vomiting was found between the two groups at any time. A single intravenous dose of ketoprofen during anaesthesia may offer an advantage compared to pethidine in reducing postoperative pain following nasal surgery.