The combinatorial use of propofol-fentanyl-ketamine for sedoanalgesia in patients undergoing urological procedures

Objectives:

To compare sedoanalgesia achieved using propofol-fentanyl-ketamine (PFK) combination with general anesthesia (GA) in terms of safety, hemodynamic stability, and perioperative complications.

Methods:

Patients in the GA group were anesthetized using fentanyl (2 μg kg-1) and propofol (2 mg kg-1). The PFK group was anesthetized using a mixture of which each one ml contains 0.005 mg of fentanyl, 5 mg of propofol, 5 mg of ketamine, and 2 mg of lidocaine. Patients received an initial dose of 0.05 ml kg-1, followed by 0.05 mg kg-1 60 seconds later. Maintenance boluses of 0.025 ml kg-1 were administered every 3-5 minutes. Respiration occurred spontaneously through a simple face mask with 3 L min-1 O₂.

Results:

The GA group had 37 (37%) patients develop hypotensive episodes, compared to one (1%) episode in the PFK group (p<0.001). Five (5%) patients in the PFK group had an episode of transient O₂ desaturation, compared to one (1%) patient in the GA group (p=0.212). The duration of induction and termination of anesthesia were significantly shorter in the PFK group (p<0.001).

Conclusion:

The PFK combination herein described is safe, effective, and provides intraoperative hemodynamic stability in patients with multiple comorbidities undergoing urological procedures.

Clinical characteristics and predictors of the duration of hospital stay in COVID-19 patients in Jordan

Background: On March 11th, 2020, the World Health Organization (WHO) declared coronavirus disease 2019 (COVID-19) as a global pandemic. Healthcare systems in low- and middle-income countries may face serious limitations during a pandemic, for which understanding the predictors of prolonged hospital stay are crucial in decreasing the mortality rate. The aim of this study was to investigate the predictors of increased length of hospitalization among COVID-19 patients. Methods: In this prospective study, we investigated the effect of presenting symptoms and laboratory investigations on the duration of hospitalization of 131 COVID-19 patients at a tertiary hospital in Jordan from March 17th to April 9th, 2020. Results: Patients median age was 24 years [interquartile range (IQR): 8-39], of which 67 (51.15%) were males and 64 (48.85%) were females. Smokers had shorter in-hospital stay (OR: -3.52; 95% CI: -6.73 to -0.32; P=0.03). Taste loss (OR: 5.1; 95% CI: 1.95 to 8.25; P<0.01) and chills or rigors (OR: 4.08; 95% CI: 0.73 to 7.43; P=0.02) were the symptoms significantly associated with increased in-hospital stay, while those who had malaise (OR: -4.98; 95% CI: -8.42 to -1.59; P<0.01) and high white blood cell (WBC) count (OR: -0.74; 95% CI: -1.31 to -0.17; P=0.01) had faster recovery. Conclusions: Our study found that the most common presenting symptoms of COVID-19 are cough, malaise, and headache. Smoking, presenting with malaise or elevated WBCs were associated with shorter hospital stay, while loss of taste and chills or rigors at presentation were associated with a longer in-hospital stay.

Remifentanil consumption in septoplasty surgery under general anesthesia. Association with humane mu-opioid receptor gene variants

Objectives:

To evaluate the influence of the ORM1 variants in codon 118 on the intra-operative remifentanil consumption under general anesthesia.

Methods:

A prospective gene association study, performed at the Jordan University Jordan, Amman, Jordan from September 2013 to August 2014. It includes patients who underwent septoplasty surgery under general anesthesia. All patients received standard intravenous anesthesia. Anesthesia maintained with fixed dose of Sevoflurane and variable dose of Remifentanil to keep the systolic blood pressure between 90-100 mm Hg. The Remifentanil dose was calculated and correlated with ORM1 genotype variance.

Results:

Genotype and clinical data were available for 123 cases. The A118A genotype was seen in 96 patients (78%), the A118G genotype was seen in 25 patients (20.3%), and only 2 patients had genotype G118G (1.6%). The G118G variant was removed from the statistical analysis due to small sample size. There was a significant effect of ORM1 genotype variant and the amount of remifentanil consumed. The A118A genotype received 0.173 ± 0.063 µg kg^-1 min^-1 and the A118G genotype received 0.316 ± 0.100 µg kg^-1 min^-1 (p<0.0001).

Conclusion:

The ORM1 gene has a role in intra-operative remifentanil consumption in patients who underwent septoplasty surgery under general anesthesia. The A118G gene required higher dose of remifentanil compared with the A118A genotype.

Comparison of caudal bupivacaine alone with bupivacaine plus two doses of dexmedetomidine for postoperative analgesia in pediatric patients undergoing infra-umbilical surgery: a randomized controlled double-blinded study

BACKGROUND

Data are still insufficient about the effects of different concentrations of caudal dexmedetomidine when used to prolong postoperative analgesia in children. The aim of this study was to assess the analgesic efficacy and side effects of two doses of caudal dexmedetomidine (1 and 2 μg·kg(-1)) co-administered with bupivacaine in terms of postoperative pain scores and requirement of postoperative analgesia over 24 h in children undergoing infra-umbilical surgery.

METHODS

Ninety-one children, aged 1-6 years, undergoing infra-umbilical surgery were included and randomly allocated into three groups of caudal block. Group B received 0.25% bupivacaine 2 mg·kg(-1) (0.8 ml·kg(-1)). Groups BD1 and BD2 received dexmedetomidine 1 and 2 μg·kg(-1), respectively along with bupivacaine 2 mg·kg(-1) in a total volume of 0.8 ml·kg(-1). Anesthesia was induced and maintained with sevoflurane in 100% oxygen. Hemodynamic and other routine intraoperative monitoring was carried out in addition to endtidal sevoflurane concentration. Time to spontaneous eye opening and postoperative pain and sedation scores were recorded in addition to time to first analgesia, paracetamol analgesic requirements, and any side effects during the first 24 postoperative hours.

RESULTS

Time to first analgesia requirement was significantly longer in BD1 and BD2 groups compared to B group with mean values (95% CI) of 809 min (652-965), 880 (733-1026), and 396 (343-448), respectively, P < 0.001. Postoperative paracetamol analgesic requirements over 24 h were higher in group B compared to BD1 and BD2 groups (Mean (95% CI): 3.2 (2.9-3.5) doses, 1.9 (1.5-2.3), and 1.6 (1.3-1.9), respectively), P < 0.001. The dexmedetomidine groups had significantly higher postoperative sedation scores compared to plain bupivacaine group that were dose dependent and for longer time in BD2 group. Two patients in BD2 group developed bradycardia and hypotension, and one developed urine retention compared to none in other groups.

CONCLUSION

A 1 μg·kg(-1) dose of caudal dexmedetomidine achieved comparable prolongation of postoperative analgesia to 2 μg·kg(-1) dose, with shorter duration of postoperative sedation and lower incidence of other side effects.

Comparison of ilioinguinal/iliohypogastric nerve blocks and intravenous morphine for control of post-orchidopexy pain in pediatric ambulatory surgery

BACKGROUND

The present study is a prospective randomized double-blinded study that designed to evaluate and compare the effectiveness of postoperative pain control and incidence of complications between ilioinguinal/iliohypogastric nerve block and intravenous morphine in paediatric patients undergoing unilateral orchidopexy in day surgery unit.

METHODS

Seventy patients aged 2-12 years were randomly allocated to two groups of thirty five. One group received intravenous morphine 100 microgram/kg before skin incision and the other group had ilioinguinal/iliohypogastric nerve block with 0.25 ml/kg bupivacaine 0.5% also before skin incision. All patients have received standardized anaesthesia. Postoperative pain was assessed using 0 - 10 scale at 0, 1, 2, 3 and 4 postoperative hours, also the intraoperative fentanyl requirements, time to first postoperative analgesia, the total number of paracetamol doses and any extra analgesic requirements were recorded, side effects like respiratory depression, vomiting, itching, inguinal hematoma and lower limb weakness were assessed during the first 24 hours.

RESULTS

Pain scores were significantly lower in the morphine group compared to the block group on admission and one hour after admission to the postanaesthesia care unit, no significant difference in pain score on 2nd, 3rd and 4th postoperative hours. The total number of intraoperative fentanyl doses was significantly higher in the block group compared to morphine group, there was no significant difference in the duration of analgesia, number of total paracetamol doses, need for extra analgesics in both groups over the 24 postoperative hours. None of the seventy patients experienced postoperative respiratory depression, inguinal hematoma or lower limb weakness, but significantly more patients in morphine group experienced vomiting and itching compared to the block group.

CONCLUSION

Ilioinguinal/iliohypogastric nerve block and intravenous morphine administered following general anaesthesia for unilateral orchidopexy in day surgery unit are safe and effective in controlling postoperative pain, morphine analgesia had a higher incidence of postoperative vomiting and itching.

Comparison of three methods of preventing rocuronium induced pain on injection using venous occlusion technique: a randomized prospective double blind controlled study

BACKGROUND

Intravenous administration of rocuronium bromide causes pain at the site of injection in most patients. The mechanism that leads to this side effect is still unknown and multiple drugs' pretreatments were used to prevent its occurrence with varying success rates.

PURPOSE

The study aimed to evaluate the effects of the pretreatment with lidocaine, fentanyl, and remifentanil using a venous occlusion technique in preventing pain caused by intravenous injection of rocuronium during induction of general anesthesia.

METHOD

Two hundred patients, ASA I-II, requiring various types of surgical procedures under general anesthesia with muscle relaxation and mechanical ventilation, were enrolled. Patients were pre-educated to report pain severity on rocuronium injection on a 4-point severity scale. Patients were allocated randomly using sealed envelopes method into one of four pretreatment groups: (Xylocaine group, 50), Remifentanyl group 50), (Fentanyl group, 50), and (Normal saline group, 50). After venous occlusion, study drugs were injected and the venous occlusion was maintained for one minute. Rocuronium was then administered and patients were asked to report their pain

RESULTS

Compared to control group, all pretreatment drugs were effective in reducing pain on rocuronium injection. Xylocaine was the most effective (Mean difference-1.42, P <0.001), followed by Remifentanil (Mean difference-1.32, P <0.001) and Fentanyl (Mean difference-0.50, P <0.001) in reducing pain on rocuronium injection. Remifentanil was statistically comparable to Xylocaine (P = 0.820) and both drugs were superior to Fentanyl in reducing pain on rocuronium injection.

CONCLUSION

Remifentanyl is a better choice of opioid in preventing pain on rocuronium injection using venous occlusion technique than fentanyl, with efficacy comparable to Xylocaine.

The impact of long-lasting preemptive epidural analgesia before total hip replacement on the hormonal stress response. A prospective, randomized, double-blind study

Recent studies suggest that preemptive analgesia may be effective in reducing postoperative pain. One physiologic explanation may be interference with the endogenous opioid response. We investigated whether long-lasting preoperative preemptive analgesia may have an effect on the hormonal stress response after total hip replacement.

METHODS

42 patients scheduled for elective hip replacement for coxarthrosis were randomized to receive, on the day before the operation, either 5 ml*h(-1) ropivacaine 0.2% (study group, n = 21) or 5 ml*h(-1) saline (control group, n = 21). Postoperative analgesia was achieved in both groups by patient-controlled epidural analgesia (PCEA) with ropivacaine 0.2%. The main outcome measure was the concentration of authentic beta-endorphin [1-31] in plasma up to 4 days after surgery. Additional parameters included concentrations of adrenocorticotrope hormone and cortisol.

RESULTS

Both groups were comparable concerning preoperative parameters and pain scores. Epidural blocks were sufficient in all patients for operative analgesia. Preemptive analgesia was performed for 11-20 hours in both groups and led to significantly decreased pain scores before surgery. Preemptive analgesia with epidural ropivacaine did not lead to decreased concentrations of beta-endorphin [1-31] before the start of surgery or in the postoperative period. Furthermore, no differences could be detected in the time course of beta-endorphin and adrenocorticotrope hormone after surgery. However, cortisol concentrations differed significantly between groups before the operation, but showed a comparable rise after surgery.

CONCLUSION

Differences in postoperative pain after preemptive analgesia do not seem to be due to an altered endogenous opioid response.

Effect of dexmedetomidine added to spinal bupivacaine for urological procedures

OBJECTIVES

To determine the effect of adding dexmedetomidine to bupivacaine for neuraxial anesthesia.

METHODS

Sixty-six patients were studied between April and May 2008 in the University of Jordan, Amman Jordan. They were randomly assigned into 3 groups, each receiving spinal bupivacaine 12.5mg combined with normal saline (group N) Dexmedetomidine 5 microg (group D5), or dexmedetomidine 10 microg (group D10). The onset times to reach T10 sensory and Bromage 3 motor block, and the regression times to reach S1 sensory level and Bromage 0 motor scale, were recorded.

RESULTS

The mean time of sensory block to reach the T10 dermatome was 4.7 +/- 2.0 minutes in D10 group, 6.3 +/- 2.7 minutes in D5, and 9.5 +/- 3.0 minutes in group N. The mean time to reach Bromage 3 scale was 10.4 +/- 3.4 minutes in group D10, 13.0+/-3.4 minutes in D5, and 18.0 +/- 3.3 minutes in group N. The regression time to reach S1 dermatome was 338.9 +/- 44.8 minutes in group D10, 277.1 +/- 23.2 minutes in D5, and 165.5 +/- 32.9 minutes in group N. The regression to Bromage 0 was 302.9 +/- 36.7 minutes in D10, 246.4 +/- 25.7 minutes in D5, and 140.1 +/- 32.3 minutes in group N. Onset and regression of sensory and motor block were highly significant (N vesus D5, N versus D10, and D5 versus D10, p<0.001).

CONCLUSION

Dexmedetomidine has a dose dependant effect on the onset and regression of sensory and motor block when used as an adjuvant to bupivacaine in spinal anesthesia.

Rapid sequence induction and intubation with 1 mg/kg rocuronium bromide in cesarean section, comparison with suxamethonium

OBJECTIVE

To demonstrate that Rocuronium Bromide can be used for rapid sequence induction in emergency conditions.

METHODS

Our study was performed between December 2005 and May 2006 in Jordan University Hospital, Jordan. We studied the efficacy and intubating conditions after administrating of Rocuronium Bromide 1 mg/kg at 60 second in group of 60 pregnant women undergoing elective or emergency cesarean section and compared the results with those obtained after giving Suxamethonium 1 mg/kg at 60 seconds in a group of patients similar to the Rocuronium group.

RESULTS

Intubating conditions after 1 mg /kg of Rocuronium Bromide were found to be acceptable (good and excellent) in 95% of patients and were similar to the Suxamethonium group (97%). The endotracheal tube could be passed through the vocal cards of all patients enrolled in the study.

CONCLUSION

Rocuronium Bromide 1 mg/kg can be safely used for rapid sequence induction in cesarean section and the intubating conditions are similar to those of Suxamethonium.

Bupivacaine with meperidine versus bupivacaine with fentanyl for continuous epidural labor analgesia

OBJECTIVE

To compare the efficacy of bupivacaine-meperidine and bupivacaine-fentanyl mixtures when continuously infused epidurally to relief the labor pain.

METHODS

We performed this prospective double-blinded study at Jordan University Hospital, Amman, Jordan between October 2005 and April 2006. Sixty-seven American Society of Anesthesia physical status I parturients were randomly divided into 2 groups, Group M (n=34) received a continuous infusion of 1 mg/ml of bupivacaine mixed with 1 mg/ml meperidine, and Group F (n=33) received a continuous infusion of 1 mg/ml bupivacaine mixed with 2 micrometer/ml fentanyl. Efficacy of analgesia, degree of motor block, hemodynamic variability, incidence of nausea and vomiting, pruritus, sedation, and the neonatal outcome were all compared between the 2 groups. A p value <0.05 was considered to be significant.

RESULTS

Highly effective analgesia was achieved in both groups with a similar incidence of motor block, sedation, pruritus, and neonatal outcome. The only significant difference was in the incidence of nausea and vomiting. Group M had 8 parturients with nausea, compared with only 2 parturients in Group F (p=0.003).

CONCLUSION

Bupivacaine-meperidine in a continuous epidural infusion is as efficient as bupivacaine-fentanyl for pain relief during labor, but associated with a higher incidence of nausea and vomiting.

Venous occlusion with lidocaine for preventing propofol induced pain. A prospective double-blind randomized study

OBJECTIVE

Pain is a well-known complication of intravenous administration of propofol, and to find out the optimal method to decrease this pain, we studied 4 methods of delivering propofol.

METHODS

The study took place at Jordan University Hospital, Amman, Jordan between November 2004 and March 2005 on 200 patients. The patients were divided into 4 groups, group I (n=50), the control group, propofol 1% was given alone. Group II (n=50), patients received propofol 1% premixed with 40 mg of lidocaine. Group III (n=50), patients received propofol 1% 60 seconds after giving 40 mg of lidocaine. Group IV (n=50), patients had venous occlusion for 60 seconds with the use of lidocaine 1% (40 mg), followed by release of the occlusion and administration of the propofol. Pain was assessed during injection and categorized into: no pain, pain, and pain with behavioral changes.

RESULTS

In group I (control), 35 patient complained of pain, compared to 26 in group II, 23 in group III, and 7 patients in group IV, with a significant reduction in the incidence and intensity of pain in group II, III, and IV compared with the control (p<0.005). The best reduction of intensity and incidence was achieved in group VI, when compared with groups I, II and III (p<0.005), with no statistical difference between group II and III when compared with each other.

CONCLUSION

Of the 4 methods studied, the optimal method to decrease the incidence and intensity of pain resulting from propofol injection is to inject lidocaine while applying venous occlusion for 60 seconds prior to administering propofol.