Mohamed S. Abbas* and Hany Maher
Background: We conducted this study to reach up to a safer and effective spinal anesthetic drug for use in high risk geriatric patients undergoing major lower limb surgery by comparing intrathecal isobaric ropivacaine with the commonly used intrathecal hyperbaric bupivacaine in such group of patients.
Methods: Fifty two geriatric patients ASA grade II–III undergoing elective total knee arthroplasty (TKA) surgery under spinal anesthesia were randomized into two groups. Group I including patients who received 12.5 mg (2.5 ml) of hyperbaric bupivacaine 0.5% and group II including patients who received 15 mg (3ml) of isobaric ropivacaine 0.5%. The extent and duration of sensory and motor block and hemodynamics including heart rate (HR), non invasive mean arterial blood pressure (MAP) and respiratory depression were recorded.
Results: Successful block has been attained in all patients in both groups. There were significant statistical difference between the two groups as regards onset time to T10 (group I 7 ± 1.85 min ; group II 10.3 ± 1.34 min; P < 0.001), time to maximal sensory level (group I 21.27 ± 9.37 min; group II 26.5 ± 7.21 min; P < 0.028) , median maximum sensory extent (group I T6 ; group II T8; P < 0.031), duration of T10 anesthesia (group I 93 ± 10.37 min ; group II 60 ± 10.92 min; P < 0.001) and onset time to maximal motor block (group I 8.5 ± 1.2 min; group II 12.8 ± 1.6 min; P < 0.001). The total duration of both sensory block (group I 180 ± 20 min vs. group II 150 ± 25 min; P < 0.001) and motor block (group I 160 ± 10.92 min vs. group II 130 ± 13.61 min; P < 0.001) were shorter in the ropivacaine group significantly but sufficient for surgery. In addition, ropivacaine caused less hemodynamic complications such as hypotension, bradycardia and respiratory depression than did bupivacaine.
Conclusion: Isobaric ropivacaine 15 mg can be used to provide a reliable spinal anesthesia for geriatric patients undergoing total knee replacement surgery that is comparable to that of the commonly used hyperbaric bupivacaine 12.5 mg as regards the efficacy of the block with a shorter recovery profile and less hemodynamic derangement.
The study was registered on www.clinicaltrials.gov, Registration ID: NCT02764723, Registered June 6, 2016.
Antonio Weingartshofer, Heather Mingo, Blaine Kent, Jean-Francois Legare, Karen Buth, and Myron M. Kwapisz*
Purpose: A retrospective chart review was performed to evaluate the effectiveness and safety of fibrinogen concentrate as an additional treatment option for excessive bleeding in cardiac surgery.
Methods: Data from patients receiving fibrinogen concentrate between January 2010 and June 2013 was retrospectively collected from the Maritime Heart Centre database for Cardiac Surgery and from patients’ electronic charts at the Queen Elizabeth II Health Sciences Centre.
Results: In total, data for 50 patients receiving fibrinogen concentrate were collected. On average, patients were 60.7 years of age and 68% were male. Baseline laboratory characteristics were slightly lower than reference ranges, possibly due to the high number of urgent or emergency procedures (36%). Patients received fibrinogen concentrate as an additional line of treatment for bleeding and also received, on average, a total of 8.8 units of blood products: 4.3 units of packed red blood cells, 2.5 units of fresh frozen plasma, 1.5 units of platelets and 0.5 units of cryoprecipitate. The overall transfusion rate was 94%. Two patients (4%) suffered from in-hospital stroke and the overall mortality rate was 18%.
Conclusion: Patients received a relatively high number of blood components despite receiving fibrinogen concentrate as an additional line of treatment for blood loss. As the study was retrospective in nature, it has significant limitations and demonstrates the importance of considering confounding variables, including different transfusion triggers among anesthetists. However, the study does demonstrate the need for a larger-scale randomized prospective study to fully understand the effects of fibrinogen concentrate.
Manoj Kumar* and Deepshikha C. Tripathi
Background: Hemodynamic stress response to laryngoscopy and intubation produces a significant hemodynamic alteration that may adversely affect patients with cardiac and neurological diseases. Fentanyl before induction attenuates hemodynamic stress response. We compared three different doses of fentanyl so as to find the most appropriate dose which prevents the response without adverse consequences.
Methods: In this prospective double blind clinical study, 90 patients aged 18 to 40 years of American Society of Anaesthesiologist (ASA) physical status I and II, scheduled for elective surgery under general anaesthesia requiring endo tracheal intubation. Patients were randomised to three groups of 30 patients each, which received 2, 3 or 4 µg/kg of fentanyl intravenously 5 minutes before induction of anaesthesia in group I, II and III respectively. All groups were assessed for pre-operative sedation, hemodynamic changes after premedication, during laryngoscopy and intubation, after intubation at specific timing up to 20 minutes and post-operative side effects.
Results: Fentanyl in doses of 3 and 4µg/kg was effective in complete prevention of hemodynamic stress response during laryngoscopy and intubation. However, 4 µg/kg of fentanyl produced a 20-25% decrease in hemodynamic variables from baseline compared to 15-20% with 3 µg/kg of fentanyl. Sedation score at exudation was higher with higher doses of fentanyl. Three patients receiving 4µg/kg of fentanyl required O2 supplementation in immediate post operative period.
Conclusion: Fentanyl in dose of 3µg/kg, five minute before induction is the most appropriate dose in terms of efficacy and safety for preventing hemodynamic stress response during laryngoscopy and intubation.
Purpose: This study evaluated the adverse events [AEs] rates of sedation with midazolam and fentanyl in ambulatory patients undergoing oral surgery.
Methods: 844 consecutive patients aged 8-95 years, ASA class 1-4, undergoing oral surgery [multiple surgical extractions, wisdom teeths extractions, difficult conservative care, sinus lift, bone grafts] were sedated with small dosages of midazolam and fentanyl under full monitoring (ECG, NIBP [non invasive blood pressure], SaO2, et CO2] with the aim to maintain conscious sedation (CS) [Ramsay scale score 3-4]. AEs included episodes [number and/or duration] of hypertension, hypotension, tachycardia, bradycardia, hypercapnia, desaturation, sleepiness. AEs were correlated to demographic and study variables with a multivariate analysis .
Results: Patients were premedicated with various drugs before the induction of CS. Surgery lasted a mean of 118 +/- 55 min:mean midazolam and fentanyl dosage were 0.048 +/- 0.029 mg/kg and 0.79 +/- 0.60 microgr/kg respectively. Per cent of cases [%] occurrence of AEs was : desaturation [SaO2<90] 17.7% ,duration 2.5 +/- 8 min: hypertension [diastolic BP > 95 mmHg or BP >25% basal ] 17.9, hypotension[ systolic or diastolic <25% of basal ] 3.7, bradycardia 4 [ hr<50 or <25% of basal], tachycardia 0.6 [>25% of basal], hypercapnia 38.4 [etCO2 >40 mmHg], sleepiness 21 [Ramsay 5][duration 4.3 +/- 11 min]. All surgeries were completed and patients sent home with a responsible adult within 2 hours.
Hypertension hypotension, tachycardia occurrences were associated with ASA, age, dosages of midazolam .Bradycardia was associated with age. Desaturation cases,duration and episodes were linked to the drugs used [midazolam and fentanyl]. Sleepiness was accompanied by desaturation and hypotension and little influenced by drugs dosages.
Discussion: Aes were frequent but of relatively minor intensity and all responded to the approriate therapy. Titration of sedatives and analgesics was kept to a minimun compatible with the condition of the patient and the extent of surgery.
Safety in the dentist office can be maintained with the careful monitoring of the vital signs under this drug regimen [midazolam and fentanyl] assuring the maintenance of conscious sedation.Any derangement from the normal physiology must be timely and properly treated.