Document 1560904

MIDDLE EAST JOURNAL OF ANESTHESIOLOGY
Department of Anesthesiology
American University of Beirut Medical Center
P.O. Box 11-0236. Beirut 1107-2020, Lebanon
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Ghassan Kanazi
Assem Abdel-Razik
(Egypt)
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Bassam Barzangi
(Iraq)
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Marie Aouad
Sahar Siddik-Sayyid
Izdiyad Bedran
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Mohammad Seraj
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Abdul-Hamid Samarkandi
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Bernard Brandstater
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Middle East Journal of Anesthesiology
Vol. 21, No. 4, February 2012
CONTENTS
editorial
One-Lung Ventilation In Children Using The Single-Lumen Tracheal Tube
Baraka
455
�������������������������������������������������������������������������������������������������������������������������������������Tong SaaChai, Jun Lin
457
������������������������������������������������������������������������������������������������������������������������������������������������������� Anis
review articles
Anesthetic Aspect Of Malaria Disease: A Brief Review
Low Back Pain as Perceived by the Pain Specialist
������������������������������������������������������������Marwan Rizk, Elie Abi Nader, Cynthia Karam, Chakib Ayoub
463
Anesthetic Considerations for the Patient with Systemic Lupus Erythematosus
����������������������������������������������������������������������� Sharon Carrillo, Emily Gantz, Amir Baluch, Alan Kaye
483
scientific articles
Ultrasound Assessment Of Vocal Fold Paresis: A Correlation Case Series With Flexible
Fiberoptic Laryngoscopy And Adding The Third Dimension (3-D) To Vocal Fold
Mobility Assessment
��������������������������������������������������������������������������������������� Randall Amis, Deepak Gupta, Jayme Dowdall,
493
Arvind Srirajakalindini, Adam Folbe
A Randomized Evaluation Of Intravenous Dexamethasone Versus Oral Acetaminophen
Codeine In Pediatric Adenotonsillectomy: Emergence Agitation And Analgesia
������������������������������������������������������������������������������������� Gholamreza Khalili, Parvin Sajedi, Amir Shafa,
499
Behnam Hosseini, Houman Seyyedyousefi
A Retrospective Study Of Risk Factors For Cardiopulmonary Events During PropofolMediated Gastrointestinal Endoscopy In Patients Aged Over 70 Years
�������������������������������������������������������������������������������� Ying Guo, Hong Zhang, Xuexin Feng, Aiguo Wang
Comparison Between Betamethasone
gel applied over endotracheal tube and
505
Ketamine
gargle for attenuating postoperative sore throat, cough, and hoarseness of voice
��������������������������������������������������������������������������������������������������������������������� Ahmad Shaaban, Sahar Kamal
513
Attitudes Of Anesthesiology Residents And Faculty Members Towards Pain Management
������������������������������������������������������������������������������ Mahdi khahi, Mohammad Khajavi, Atabak Nadjafi,
521
Reza Moharari, Farsad Imani, Iman Rahimi
Burnout and Coping amongst Anesthesiologists In a US Metropolitan Area: A Pilot Study
������������������������������������������������������������������������� Rebecca Downey, Tammam Farhat, Roman Schumann
529
The Incidence Of Residual Neuromuscular Blockade Associated With Single Dose Of
Intermediate-Acting Neuromuscular Blocking Drugs
�������������������������������������������������������������������������� Nil Kaan, Ozlem Kocaturk, Ibrahim Kurt, Halil Cicek
451
535
M.E.J. ANESTH 21 (4), 2012
Efficacy Of Three IV Non-Opioid-Analgesics On Opioid Consumption For Postoperative
Pain Relief After Total Thyroidectomy: A Randomised, Double-Blind Trial
��������������������������������������������������������� Susanne Abdulla, Regina Eckhardt, Ute Netter, Walied Abdulla
543
Hemodynamic Effects Of Dexmedetomidine--Fentanyl Vs. Nalbuphine--Propofol In Plastic
Surgery
������������������������������������ Juan De la Mora-González, José Robles-Cervantes, José Mora-Martínez,
Francisco Barba-Alvarez, Emigdio de la Cruz Llontop-Pisfil,
Manuel González-Ortiz, Esperanza Martínez-Abundis,
Juan Llamas-Moreno, Maria Claudia Espinel Bermudez
553
Identifying Resource Needs For Sepsis Care And Guideline Implementation In The
Democratic Republic Of The Congo: A Cluster Survey Of 66 Hospitals In Four
Eastern Provinces
������������������������������������������������������������������������Inipavudu Baelani, Stefan Jochberger, Thomas Laimer,
Christopher Rex, Tim Baker, Iain Wilson,
Wilhelm Grander, Martin Dünser
559
Comparison Of The Anesthetic Effects Of Intrathecal Levobupivacaine + Fentanyl And
Bupivacaine + Fentanyl During Caesarean Section
����������������������������������������������������������� Aygen Turkmen, Dondu Genc Moralar, Ahmet Ali, Aysel Altan
577
Comparative Study Between I-Gel, A New Supraglottic Airway Device, And Classical
Laryngeal Mask Airway In Anesthetized Spontaneously Ventilated Patients
������������������������������������������������� Hossam Atef, Amr Helmy, Ezzat El-Taher, Ahmed Mosaad Henidak
583
Optimal Dose Of Hyperbaric Bupivacaine 0.5% For Unilateral Spinal Anesthesia During
Diagnostic Knee Arthroscopy
���������������������������������������������������������������������������������������������������������Hossam Atef, Alaa El-Din El-Kasaby,
Magdy Omera, Mohamed Badr
Comparison
between
Prostaglandin E1, and Esmolol infusions
591
in controlled hypotension
during scoliosis correction surgery a clinical trial
���������������������������������������������������������������������������������������������������������������������������������������������������������� Hala Goma
599
Dexmedetomidine Use in Direct Laryngoscopic Biopsy under TIVA
����������������������������������������������������������������������������������������Ayse Mizrak, Maruf Sanli, Semsettin Bozgeyik,
Rauf Gul, Suleyman Ganidagli, Elif Baysal, Unsal Oner
605
The Effect Of Dexmedetomidine On Bispectral Index Monitoring In Children
����������������������������������������������������������������������������������������������������������������� Dilek Özcengiz, Hakkı Ünlügenç,
case reports
613
Yasemin Güneş, Feride Karacaer
General Anesthesia Complicated by Perioperative Iatrogenic Splenic Rupture
����������������������������������������������������������������������������������������������������������������������� Jeremy Asnis, Steven Neustein
619
Continuous Spinal Anaesthesia For A Total Hip Arthroplasty In A Patient With An Atrial
Septal Defect
��������������������������������������������������������������������������������� Laurent Lonjaret, Olivier Lairez, Vincent Minville
623
Percutaneous Balloon Mitral Valvuloplasty In A Pregnant Patient Under Minimally
Invasive Intravenous Anesthesia
������������������������������������������������������������� Leigh Apple, Deepak Gupta, Michael Okumura, Hong Wang
452
627
Airway Evaluation For Magnetic Resonance Imaging Sedation In Pediatric Patients With
Plexiform Neurofibroma
������������������������������������������������������������������������������������������������������������������������������������������������ Claude Abdallah
631
Spontaneous Intracranial Hypotension In A Patient With Marfan’s Syndrome Treated
With Epidural Blood Patch – A Case Report
�������������������������������������������������������������������������������������������������������� Khalid Samad, Gurmukh Das Punshi,
635
Mohammad Hamid, Hameed Ullah
The Laryngeal Mask Airway for Difficult Airway in Temporomandibular Joint Ankylosis
- A Case Report
���������������������������������������������������������������������������������������� Behzad Ahsan, Ghazal Kamali, Karim Nasseri
639
Skin Rash as Early Presentation of Guillain–Barré syndrome
������������������������������������������������������������������������������������ Daher Rabadi, Ahmad Abu Baker, Ayman Greize
643
Airway Management In Submandibular Abscess Patient With Awake Fibreoptic Intubation
- A Case Report ���������������������������������������������������������������������������������������������������������������������������� Chetan Raval, Mohd. Khan
647
Angiofibroma of the Nasal Septum
����������������������������������������������������������������������������������������������������Abdul-Latif Hamdan, Roger Moukarbel,
653
Mireille Kattan, Mohamad Natout
letter to the editor
Use Of Deep Cervical Halo In The Preservation Of Tracheostimised Airway In Prone
Position
��������������������������������������������������������������������������������������������������Haider Abbas, Zia Arshad, Jaishri Bogra
Erratum
453
657
659
M.E.J. ANESTH 21 (4), 2012
EDITORIAL
ONE-LUNG VENTILATION IN CHILDREN
USING THE SINGLE-LUMEN
TRACHEAL TUBE
In adult patients, one-lung ventilation (OLV) is usually achieved by the double-lumen tubes,
the Univent tubes, or by using bronchial blocker combined with a single-lumen tracheal tube.
Fiberoptic bronchoscopy is usually used to confirm the proper positioning of the tube or the blocker.
In infants and young children, the available sizes of the double lumen tubes or the Univent
tubes do not match the anatomy of this age group. A bronchial blocker combined with a singlelumen tracheal tube may be used. Fiberoptic bronchoscopy is needed to confirm the proper position
of the blocker.
In children, it has been shown that the angles of the tracheobronchial bifurcation total
approximately 80 degrees; the overall mean of the right bronchial angle is about 30º, while the
left bronchial angle is about 50º. This tracheobronchial relationship may explain why the tracheal
tube is more likely to enter the more vertical and wider right main stem bronchus than the
more obliquely placed and narrower left main stem bronchus1. However, Block challenged this
conclusion, suggesting that the tracheal tube invariably enters the right bronchus because the bevel
of the tube faces the left following insertion, and its tip, therefore, lies to the right of the midline of
the trachea2. This postulation has been confirmed by Baraka et al in children, who showed that the
available left-bevelled tube enters the right main bronchus, while a right-bevelled tube whose tip
lies to the left of the midline of the trachea enters the left main stem bronchus. Each child served as
his own control, suggesting that the bevel of the tracheal tube, and not the tracheobronchial angle
is the principal factor determining the side of bronchial intubation3.
The simplest technique for one-lung ventilation in infants and young children is to intubate
the main stem bronchus of the non-operated lung by the conventional single-lumen tracheal tube.
The main stem right bronchus can be readily intubated by the available left beveled tracheal tube.
However, it will be difficult to achieve left bronchial intubation without the help of fiberoptic
bronchoscopy(deleted). In order to achieve blind left bronchial intubation, many techniques have
been suggested such as using a metal stylet to curve the distal end of the tracheal tube to the left4,
or by using a distally curved rubber bougie which is directed blindly to the left bronchus, followed
by railroading the tube over the bougie5.
Other simple techniques have been suggested to align the trachea with the left main stem
bronchus. The first suggested technique is to position the child with his left side up, and his head
turned to the right6, so that the mediastinum and gravity may push the left bronchus down to align
with the trachea.
A second technique is to rotate the bevel of the tube 180º and the head turn to the right so
that the bevel of the tube will shift to the right, while its tip will be on the left of the midline which
favors left bronchial intubation7. A third simpler technique is to rotate the tube within the trachea
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M.E.J. ANESTH 21 (4), 2012
456
90 degrees counter clock wise so that the curvature of
the tube becomes concave to the left side towards the
left main stem bronchus8.
A fourth technique is to manufacture special
right-bevelled tubes for left bronchial intubation; the
tip of the tube will lie to the left of the midline of the
trachea which favors left bronchial intubation3,9.
In all these techniques, the head and neck of
the child are turned to the right which optimizes
the alignment of the trachea with the left main
stem bronchus. The endotracheal tube is blindly
ANIS BARAKA
advanced into the bronchus until the breath sounds
on the operative side disappear confirming main stem
bronchial intubation of the left lung.
Baraka, MD, FRCA (Hon)
Emeritus Professor
Department of Anesthesiology
American University of Beirut Medical
Center
Beirut - Lebanon
References
1. Kubota Y, Toyoda Y, Nagafa N, et al: Tracheo-bronchial angles in
infants and children. Anesthesiology; 1986, 64:374-376.
2. Block EC: Tracheobronchial angles in infants and children.
Anesthesiology; 1986, 65:236.
3. Baraka A, Akel S, Haroun S, et al: Bronchial intubation in children:
does the tube bevel determine the side of intubation. Anesthesiology;
1987, 67:869-870.
4. Baraka A, Slim M, Dajani A, et al: One-lung ventilation of children
during surgical excision of hydatid cysts of the lung. Br J Anaesth;
1982, 54:523-528.
5. Baraka A, Dajani A, Maktabi M: Selective contralateral bronchial
intubation in children with pneumothorax or bronchopleural fistula.
Br J Anaesth; 1983, 55:901-904.
6. Brooks JG, Bustamante SA, Koops BL, et al: Selective bronchial
intubation for treatment of severe localized pulmonary interstitial
emphysema in newborn infants. J Pediatrics; 1977, 91: 648.
7. Kubota A, Kubota Y, Tachira T, et al: Selective blind endbronchial
intubation in children and aduls. Anesthesiology; 1987, 67:587-589.
8. Baraka A: A simple tube for contralateral left bronchial intubation
in children undergoing right thoracotomy or thoracoscopy. Journal
of Cardiothoracic and Vascular Anesthesia; 1997, Vol. 11; 5:684685.
9. Baraka A: Right beveled tube for selective left bronchial intubation
in a child undergoing right thoracotomy. Paediatric Anaesthesia;
1966, 6:487-489.
Anesthetic Aspect Of Malaria Disease:
A Brief Review
Tong SaaChai, Jun Lin*
Abstract
Background: Malaria has caused an estimated 190-311 million cases in year 2008 alone
and around 1500 patients are diagnosed with the disease annually in the United States. Out of
these numbers, few of them have presented for surgery. Malaria disease is a multi-organ systemic
disease that may affect significantly patient’s outcome after surgery. It is therefore prudent for
the anesthesiologists, from both the endemic and non-endemic area, to understand the
implication of the disease during the preoperative, intraoperative and postoperative
course.
Methods: Google scholar, Medline and Cochrane data base search are performed using
keywords malaria, anesthesia, quinine, dapsone, clindamycin, mefloquine, surgery, wound healing,
cardiopulmonary bypass and obstetric. Bibliographies are systemically analyzed and grouped base
on clinical presentation and potential anesthetic implication.
Key words: Malaria, Anesthesia, quinine, dapsone, clindamycin, mefloquine, surgery,
cardiopulmonary bypass, wound healing, obstetric.
Introduction
Malaria is a multi-organ systemic disease caused by the genus plasmodium. According to
the World Health Organization World Malaria Report in 2009, malaria has caused an estimated
190-311 million clinical episodes in year 2008 alone. Out of these numbers, an estimated 708,000
to 1,003,000 patients have died1. Malaria is a disease transmitted by mosquito species Anopheles.
Four malarial species are closely linked to the disease: plasmodium falciparum, plasmodium vivax,
plasmodium malariae and plasmodium ovale. P. falciparum infection is the most common disease
out of all. Geographically, malaria disease is most prevalent in countries in the sub-Saharan region.
In the U.S only approximately 1500 cases of malaria were reported yearly1 From year 1963 to
2001, 123 deaths involving U.S travelers have been reported to the Center for Disease Control
(CDC)2.
Patients with malaria may present for surgery for both traumaticor non-traumatic reasons.
To date, few literature exists to describe the anesthetic implication of the disease. In the endemic
area, the implication of the disease is significant as anesthesiologists are constantly involved in the
management of patients from both the operative and the postoperative course.
One of the most common surgical conditions that bring patient with malarial disease for
surgery is tropical splenomegaly3. Splenic rupture is encountered occasionally with
*
Department of Anesthesiology, State University of New York-Downstate Medical Center, 450 Clarkson Avenue Box 6,
Brooklyn, NY 11203; Correspondence: Dr. Tong Saa Chai @ [email protected], or Dr. Jun Lin @ Jun.Lin@downstate.
edu
457
M.E.J. ANESTH 21 (4), 2012
458
trauma and may present as an emergent case4. Other
less common surgical conditions include creation of
arterial- venous fistula for renal failure, liver transplant,
renal transplant and cardiac transplant. Occasionally,
pregnant women with malarial disease may present for
an emergent caesarean section or epidural5.
Life Cycle
Fig. 1
Life cycle of malaria parasite (Courtesy: National Institute Of
Allergy And Infectious Disease)
T. SaaChai & J. Lin
Clinical Manifestation
The severity of malarial disease is classified
loosely based on the parasite load and the clinical
presentation into two broad categories: uncomplicated
malaria and complicated malaria. Uncomplicated
malaria involves spectrum of illness which is less severe
in origin. It may include non-specific symptom such as
nausea, vomiting, headache, cough, myalgia, diarrhea
and athralgias. Complicated malaria involves high
parasite load with more severe clinical presentations,
with involvement of any of the following: metabolic
acidosis, acute respiratory distress syndrome, hepatic
failure, liver failure and severe anemia.
Anesthetic Concern
Central Nervous System
The knowledge of malarial disease may not
be complete without a full understanding of the life
cycle. In general, there are two major hosts for malaria
parasites: (1.) primary host, which only involves the
female species of the Anopheles mosquitoe and (2.)
secondary host, which involves either human being
or other vertebrae. The typical life cycle of malaria
parasite in human body begins with the deposition
of sporozoite into bloodstream by the Anopheles
mosquitoe. The sporozoite replicated within the liver
cells to form a new stage, schizonts which contains
replica of merozoites. This is followed by the death of
hepatocytes, with rupture of hepatocyte cell membrane
and release of meroziotes into the bloodstream. This
commences a cascade of invasion of red blood cells by
the meroziotes, where the species multiples asexually
within the red blood cells, which are followed by
hemolysis of the red cell secondary to heavy parasitic
load. The newly released merozoites then infect fresh
red cell, causing a cascade of red cell infections.
Merozoites may travel to the cerebral and splenic
circulation, causing splenomegaly and cerebral malaria.
With uncomplicated malaria, neurological
symptoms may be limited to headache, nausea and
vomiting. However, complicated malaria may cause
raised intracranial pressure and change in mental status.
Airway protection is therefore mandatory for patient
who losses airway control. Increased intracranial
pressure is largely the result of cerebral edema caused
by vasocapillary obstruction with parasitized red
cells6. The constellation of finding involving increased
intracranial pressure, cerebral edema and change in
mental status is known as ‘cerebral malaria’.
Volatile agents should be used prudently to inn
the patient with increased intracranial pressure, , since
it may worsen cerebral edema by increase in cerebral
blood flow caused by volatile anesthetics. However,
no study involving patients with cerebral malaria
receiving volatile anesthetics has been performed.
Thiopental and propofol have theoretical advantage
over volatile anesthetics by decreasing intracranial
pressure in patients with cerebral malaria, which is
supported by their therapeutic effects in patient with
vasogenic edema secondary to trauma. However, lack
of systemic trial again precludes the conclusion that the
agent has any significant effect in this patient category.
Diazepam has been demonstrated to be effective
as antiepileptic in children with cerebral malaria7.
Benzodiazepine has high therapeutic index and can
be a safe anxiolytic in patients with malarial disease,
Anesthetic Aspect Of Malaria Disease: A Brief Review
though proper monitoring would be prudent. No study
was performed to date involving lorazepam or shorter
acting benzodiazepine midazolam.
Hematological System
Hematological aspect of malaria includes
splenomegaly, anemia and thrombocytopenia. A
decrease in leukocyte count may occasionally be
observed.
Splenomegaly in patients with chronic malaria
is caused by the sequestration of hemolyzed red
cells within sinusoids. Clinically, splenomegaly may
lead to consumptive thrombocytopenia. Tropical
splenomegaly syndrome is a poorly understood
condition where patient presents with an elevated
malarial antigen, hypersplenism but with very minimal
parasite load3.
Severe anemia in patients with malaria disease
can be either caused by hemolysis or red cell dysplasia.
Expert opinion for transfusion in malarial disease
is such that adults with hematocrit level below 20%
of normal and children with hematocrit below 15%
should be transfused7. For patients with life threatening
anemia, exchange transfusion should be considered.
Splenectomy is reserved after medical therapy has
failed³. The concern of splenectomy is its high surgical
mortality and also risk of pneumococcal, Haemophilus
influenza and Neisseria meningiditis infection.
Transfusion transmitted malaria has rarely been
an issue in the United States with malarial ELISA
detection technique. So far, only 14 cases of transfusion
transmitted malaria are reported from year 1990 to
19999.
Cardiopulmonary bypass in patients with malaria
for open heart surgery may worsen the underlying
hemolysis10. This possibility has brought suggestion
that open heart surgery in this patient population should
be done with off-pump technique. Chemo-prophylaxis
with antimalarial agents is virtually indicated in every
patient undergoing surgery to decrease malarial load.
Cardiovascular System
Congestive heart failure in patients with malarial
disease is multifactorial. Severe anemia may cause
high output cardiac failure. Quinine toxicity related
459
to malarial treatment can lead to heart failure also.
Anesthetic monitoring will therefore include close
monitoring with arterial line and central venous
catheter or Swan-ganz catheter when indicated.
Splenomegaly may cause profound hemodynamic
changes. This observation is most prominent with
aorto-caval compression. Supine positioning may
exacerbates hemodynamic instability secondary to
aortocaval compression.
In patients with severe malaria, pulmonary artery
catheter may show two possible changes: elevated
pulmonary artery wedge pressure with severe heart
failure and a normal pulmonary wedge pressure with
no cardiac involvement11.
Pulmonary System
In general, there are three lung conditions related
to malaria that may pose an issue to the anesthesiologist,
including noncardiogenic pulmonary edema, fluid
overload and pneumonia11.
The
mechanism
behind
noncardiogenic
pulmonary edema in patients with malaria is largely
unknown and is believed to be caused by the
breakdown of alveolar-capillary interface induced by
malaria. Fluid overload is commonly observed in this
population because of prevalence of renal failure and
fluid shift caused by hormonal imbalances11.
Anesthetic consideration in this group of
patient therefore involves one of several aspects. In
patients with impending pulmonary edema, judicious
fluid management to keep the patient ‘dry’ may be
indicated. The goal of ventilation is to maximize tissue
oxygenation and this can be done accomplished by
maintaining hemoglobin level above 12mg/dL, and or
optimal ventilation setting with PEEP or CPAP.
Renal System
Acute renal failure is the most common renal
manifestation and around 50-80% of patients require
hemodialysis. Creatinine clearance level should
therefore be determined before surgery. The etiology
of renal failure may involve in mechanical obstruction
by erythrocytes in the glomerular capillaries, or
immune mediated12. As mentioned above, judicious
fluid management is indicated as fluid overload in
M.E.J. ANESTH 21 (4), 2012
460
patients with renal failure may implicate pulmonary
edema. Dosing of non-depolarizing muscle relaxants,
benzodiazepine and narcotics should be done base on
underlying renal function.
Electrolyte abnormalities are commonly found
with malarial acute renal failure. The most common
abnormalities observed are hyperkalemia and
hyponatremia13. Dilutional hyponatremia is the most
common etiology for hyponatremia and is caused by
fluid overload, although excess serum ADH levels
are involved in the pathophysiology. In term of
hyperkalemia, it is usually accompanied by metabolic
acidosis and hemolysis and is seen in patients with
complicated malaria. Profound hyperkalemia caused
by hemolysis can be fatal.
Endocrine System
Hypoglycemia is commonly observed in severe
malaria. The incidence of hypoglycemia is increased
with the severity of malarial disease. The etiology
is multifactorial and probably related to starvation,
utilization of blood glucose by the malarial parasite
and quinine therapy. Intraoperative serum glucose
monitoring is therefore mandatory with clinical
suspicion.
Dermatological System
Dermatological manifestation caused by malarial
disease is rarely encountered. It may include symptoms
like urticarial, purpura or angioedema14.
Post-injury malaria is associated with a higher
incidence of wound infection in trauma patients15. The
cause for this temporal relationship remains unknown.
It may be related to post-trauma immune-suppression
or directly related to malaria parasites. Whether the
same relationship exists in other surgical populations
is not known as no investigation has been performed.
Malaria Treatment Guideline
Most patients who presented for surgery are on
one or more chemo-prophylactic agent for malaria
disease. Traditionally, the antibiotic treatment for
malaria disease are broadly divided into two groups:
(1) Chloroquine susceptible and (2) Chloroquine
resistant group. Base on the current guideline in
T. SaaChai & J. Lin
U.S1, three antibiotic regimens are employed for
chloroquine resistant group (1) oral quinine plus
either tetracycline, doxycycline or clindamycin, (2)
atovaquone- proguanil and (3) mefloquine. Of all
antibiotics, tetracycline, doxycycline, clindamycin,
quinine and have been demonstrated to interact with
the neuromuscular blocker. Mefloquine may interact
with anticholinesterase agent.
Pharmacologic Interaction
Quinine
Quinine has been long known to possess
neuromuscular blockade property16-17. The mechanism
of neuromuscular blockade is secondary to inhibition
of the phosphodiesterase activity in the skeletal muscle
cytosol18. Quinidine, a close relative to quinine, has
also been reported to interact with both depolarizing
and non-depolarizing muscle relaxants to produce
prolonged neuromuscular blockade19-20.
Clindamycin
Clindamycin has been known to prolong
neuromuscular blockade with non-depolarizing muscle
relaxant, such as pancuronium and rocuronium. The
prolonged effect is poorly responsive to calcium and
reversal agent such as neostigmine21.
Mefloquine
Mefloquine may interact with a number of
anticholinesterase agents (e.g. physostigmine) to
produce central anticholinergic syndrome22. If used
independently, mefloquine may cause a number
of neuropsychiatric symptoms such as anxiety,
hallucination and depression.
Dapsone
Dapsone is a sulfonamide derivative used
uncommonly in the treatment of malaria. It is typically
used with pyrimethamine as chemoprophyaxis for
malaria disease. It inhibits the synthesis of dihydrofolic
acid by competing with para-aminobenzoate for
the enzyme dihydropteroate synthetase. Clinically,
dapsone causes methemoglobenemia. Reports
involving intraoperative methemoglobinemia have
Anesthetic Aspect Of Malaria Disease: A Brief Review
been made in patient who received dapsone for bullous
lupus23. Pulse oximetry is typically inaccurate for the
diagnosis of methemoglobinemia and co-oximetry is
necessary in suspected cases intraopertatively.
Malaria in Transplant Surgery
Post-transplant diagnoses of malaria have been
variously described in different literatures in cases
involving liver, bone marrow and renal transplant24.
In general, two mechanisms are responsible for
transmission of malaria during organ transplantation:
(1) blood product related (2) transmission of malarial
parasites embedded in donor cells.
Therefore, chemoprophylaxis
indicated in patients at endemic area.
is
routinely
Chemoprophylaxis in patients who receive
cyclosporine should be done with caution. This is
because quinine suppresses plasma cyclosporine
level25 while chloroquine may induce cyclosporine
toxicity26.
Malaria in Obstetric Patient
Malaria disease has been a usual cause of
maternal death, miscarriage and preterm labor in the
developing countries. However, little literature exists
describing the implication of the disease in obstetric
anesthesia.
Malaria disease in pregnancy is typically
associated with heightened state of anemia, pulmonary
complication and hypoglycemia27. This suggests that
malaria during pregnancy may cause a higher mortality
to both the mother and the fetus, and potentially
aggravate anesthetic care.
Thrombocytopenia is commonly observed in
this patient population. Therefore, performance of
neuroaxial anesthesia should be accompanied by
461
careful check of platelet count prior to the procedure.
Theoretically spinal anesthesia may introduce malarial
parasites from the blood stream into the spinal
cerebrospinal fluid, causing cerebral malaria. However,
this has not been proven clinically. Nonetheless, general
anesthesia may be indicated in the situations of severe
anemia, severe thrombocytopenia, fetal compromise
and hemodynamic perturbation in the mother5.
Chronic Pain in Malarial Patients
Chronic pain is relatively common in patients
with malaria disease. Chronic headache is especially
prevalent and as many as 80% of malaria infected
patients present with headache28. It may be related to
(1) cerebral malaria, (2) side effects of antimalarial
drugs and (3) postmalaria neurologic syndrome.
Cerebral malaria should be ruled out prior to
prescription of pain medication. Neurologic referral
may be critical if cerebral malaria is suspected. Quinine
toxicity or more commonly referred to ‘cinchonism’
may also cause headache. If necessary, referral for
management of toxicity may be indicated.
Postmalaria neurologic syndrome is a poorly
understood disease in patients recovered from malarial
disease. Headache could present as one of the many
symptoms. Steroids may be indicated in patients with
severe, relapsing disease29.
Conclusion
Malaria disease is still a significant disease in the
beginning of the 21th century and it poses a significant
healthcare burden to both the anesthetic team and nonanesthetic team alike. Understanding of the disease
is therefore crucial for anesthetic management of
patients with malaria. Further research is needed to
fully disclose the anesthetic implication of the disease.
M.E.J. ANESTH 21 (4), 2012
462
T. SaaChai & J. Lin
References
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the United States: a systematic review. JAMA; 2007, 297:2264-77.
2. Newman RD, Parise ME, Barber AM, Steketee RW: Malariarelated deaths among U.S. travelers, 1963-2001. Ann Intern Med;
2004, 141:547-55.
3. Gibney EJ: Surgical aspects of malaria. Br J Surg; 1990, 77:964-7.
4. Gupta N, Lal P, Vindal A, Hadke Ns, Khurana N: Spontaneous
rupture of malarial spleen presenting as hemoperitoneum: a case
report. J Vector Borne Dis; 2010, 47:119-20.
5. Mathew DC, Loveridge R, Solomon AW: Anaesthetic management
of caesarean delivery in a parturient with malaria. Int J Obstet
Anesth; 2011, 20:341-4.
6. Idro R, Marsh K, John CC, Newton CR: Cerebral malaria:
mechanisms of brain injury and strategies for improved
neurocognitive outcome. Pediatr Res; 2010, 68:267-74.
7.World Health Organization. Severe falciparum malaria. World
Health Organization, Communicable Diseases Cluster. Trans R Soc
Trop Med Hyg; 2000, 94:S1-S90.
8. Ikumi ML, Muchohi SN, Ohuma EO, Kokwaro GO, Newton CR:
Response to diazepam in children with malaria-induced seizures.
Epilepsy Res; 2008, 82:215-8.
9. MUNGAI M, TEGTMEIER G, CHAMBERLAND M, PARISE
M: Transfusion transmitted malaria in the United States from 1963
through 1999. N Engl J Med; 2001, 344:1973–1978.
10.Purohit M: Malaria and open heart surgery. Asian Cardiovasc
Thorac Ann; 2003, 11:277-8.
11.Taylor WR, White NJ: Malaria and the lung. Clin Chest Med; 2002,
23:457-68.
12.Das BS: Renal failure in malaria. J Vector Borne Dis; 2008, 45:8397.
13.Barsoum RS: Malarial acute renal failure. J Am Soc Nephrol; 2000,
11:2147-54.
14.Vaishnani JB: Cutaneous findings in five cases of malaria. Indian J
Dermatol Venereol Leprol; 2011, 77:110.
15.Sundet M, Heger T, Husum H: Post-injury malaria: a risk factor
for wound infection and protracted recovery. Trop Med Int Health;
2004, 9:238-42.
16.Moller KO: Action of quinine methochloride (methoquin) on
neuromuscular transmission and its respiratory and cardiovascular
actions. Acta Pharmacol Toxicol (Copenh); 1946, 2:383-402.
17.Sieb JP, Milone M, Engel AG: Effects of the quinoline derivatives
quinine, quinidine, and chloroquine on neuromuscular transmission.
Brain Res; 1996, 712:179-89.
18.Shute JK, Smith ME: Inhibition of phosphatidylinositol
phosphodiesterase activity in skeletal muscle by metal ions and drugs
which block neuromuscular transmission. Biochem Pharmacol;
1985, 34:2471-5.
19.Kambam JR, Franks JJ, Naukam R, Sastry BV: Effect of quinidine
on plasma cholinesterase activity and succinylcholine neuromuscular
blockade. Anesthesiology; 1987, 67:858-60.
20.Schmidt JL, Vick NA, Sadove MS: The effect of quinidine on the
action of muscle relaxants. JAMA; 1963, 183:669-71.
21.Al Ahdal O, Bevan DR: Clindamycin-induced neuromuscular
blockade. Can J Anaesth; 1995, 42:614-7.
22.Speich R, Haller A: Central anticholinergic syndrome with the
antimalarial drug mefloquine. N Engl J Med; 1994, 331:57-8.
23.Szeremeta W, Dohar JE: Dapsone-induced methemoglobinemia: an
anesthetic risk. Int J Pediatr Otorhinolaryngol; 1995, 33:75-80.
24.Barsoum RS: Parasitic infections in transplant recipients. Nat Clin
Pract Nephrol; 2006, 2:490-503.
25.Tan Hw, Ch’ng SL: Drug interaction between cyclosporine A and
quinine in a renal transplant patient with malaria. Singapore Med J;
1991, 32:189-190.
26.Nampoory MR, Nessim J, Gupta RK, Johny KV: Drug interaction of
chloroquine with ciclosporin. Nephron; 1992, 62:108-109.
27.Warrell DA, Molyneuz ME, Beales PF: Severe and complicated
malaria. Trans R Soc Trop Med Hyg; 1990, 84:1.
28.Suyapuhn A, Wiwanitkit V, Suwansaksri J, Nithiuthai S,
Sritar S, Suksirisampant W, Fongsungnern A: Malaria among
hilltribe communities in northern Thailand: a review of clinical
manifestations. Southeast Asian J Trop Med Public Health; 2002,
33:14-5.
29.Hsieh CF, Shih PY, Lin RT: Postmalaria neurologic syndrome: a case
report. Kaohsiung J Med Sci; 2006, 22:630-5.
Low Back Pain as Perceived
by the Pain Specialist
M arwan Rizk*, Elie Abi N ader**, Cynthia K aram ***
and C hakib Ayoub ****
Low back pain is considered to be chronic if it has been present for longer than three months.
Chronic low back pain may originate from an injury, disease or stresses on different structures of
the body. The type of pain may vary greatly and may be felt as bone pain, nerve pain or muscle
pain. The sensation of pain may also vary. For instance, pain may be aching, burning, stabbing or
tingling, sharp or dull, and well-defined or vague. The intensity may range from mild to severe. Many
different theories try to explain chronic pain. The exact mechanism is not completely understood.
The specialty of interventional pain management continues to emerge. There is a wide degree
of variance in the definition and practice of interventional pain management and interventional
techniques. Application of interventional techniques by multiple specialties is highly variable for
even the most commonly performed procedures and treated conditions1-12.
Diagnostic Approach to Low Back Pain
Appropriate history, physical examination, and medical decision-making are essential to
provide appropriate documentation and patient care. The socioeconomic issues and psychosocial
factors are important in the clinical decision-making process.
Kuslich et al identified intervertebral discs, facet joints, ligaments, fascia, muscles, and nerve
root dura as tissues capable of transmitting pain in the low back13. Facet joint pain, discogenic
pain, nerve root pain, and sacroiliac joint pain have been proven to be common causes of pain with
proven diagnostic techniques14-23. In a prospective evaluation24, the relative contributions of various
structures in patients with chronic low back pain who failed to respond to conservative modalities
of treatments, with lack of radiological evidence to indicate disc protrusion or radiculopathy, were
evaluated utilizing controlled, comparative, diagnostic blocks. In this study, 40% of the patients
were shown to have facet joint pain, 26% discogenic pain, 2% sacroiliac joint pain, and possibly,
13% segmental dural nerve root irritation. No cause was identified in 19% of the patients. If there
is evidence of radiculitis, spinal stenosis, or other demonstrable causes resulting in radiculitis,
one may proceed with diagnostic transforaminal or therapeutic epidural injections23. Otherwise,
the approach should include the diagnostic interventions with facet joint blocks, sacroiliac joint
injections, followed by discography.
Lumbar discography at the present time suffers from significant controversy with Level
II-2 evidence14. In contrast, facet joint nerve blocks in the diagnosis of lumbar facet joint pain
*
**
Instructor, Department of Anesthesiology, American University of Beirut Medical Center, Beirut 1107-2020 Lebanon.
Assistant Professor, Cairman of the Department of Anesthesiology, University Medical Center Rizk Hospital, Beirut,
Lebanon.
*** Resident, Department of Anesthesiology, American University of Beirut Medical Center, Beirut 1107-2020 Lebanon.
**** Professor, Department of Anesthesiology, American University of Beirut Medical Center, Beirut 1107-2020 Lebanon.
Corresponding author: Dr. Marwan Rizk, Department of Anesthesiology, American University of Beirut Medical Center,
Beirut 1107-2020 Lebanon. E-mail: [email protected].
463
M.E.J. ANESTH 21 (4), 2012
464
provide higher evidence with Level I or Level II-115.
However, sacroiliac joint injections provide Level II-2
evidence16.
The investigation of chronic low back pain without
disc herniation commences with clinical questions,
physical findings, and findings of radiological
investigations. Radiological investigations should be
obtained if the history and physical exam findings
indicate their need. Controlled studies have illustrated a
prevalence of lumbar facet joint pain in 21% to 41% of
patients with chronic low back pain15,17-20,24-29 and 16%
in post laminectomy syndrome30. Thus, facet joints
are entertained first because of their commonality as a
source of chronic low back pain, available treatment,
and ease of performance of the blocks. Further, among
all the diagnostic approaches in the lumbosacral spine,
medial branch blocks have the best evidence (Level I)
with the ability to rule out false-positives (27% to 47%)
and demonstrated validity with multiple confounding
factors, including psychological factors31,32, exposure
to opioids33, and sedation34-36. In this approach,
investigation of facet joint pain is considered as a prime
investigation, ahead of disc provocation and sacroiliac
joint blocks. Multiple studies have indicated that facet
joint pain may be bilateral in 60% to 79% of cases,
involving at least 2 joints and involving 3 joints in 21%
to 37% of patients26-28. Due to the innocuous nature of
lumbar facet joint nerve blocks, it is recommended
that all blocks be performed in one setting. However,
based on the clinical examination, only 2 blocks are
performed provided the first block was positive, thus
avoiding a screening block and repeat blocks for
separate joints37. If a patient experiences at least 80%
relief with the ability to perform previously painful
movements within a time frame that is appropriate
for the duration of the local anesthetic used and the
duration of relief with the second block relative to the
first block is commensurate with the respective local
anesthetic employed in each block, then a positive
diagnosis is made.
The sacroiliac joint as the pain generator, pain
must be caudal to L5 and must be positive with flexion
and abduction of the hip, along with tenderness over
the sacroiliac joint on palpation16,38,39. Sacroiliac joint
blocks have a Level II-2 evidence in the diagnosis of
sacroiliac joint pain utilizing comparative controlled
M. Rizk et al.
local anesthetic blocks. The prevalence of sacroiliac
joint pain is estimated to range between 2% and
38% using a double block paradigm in specific study
populations16,21,22,24,39-44. The false-positive rates of
single, uncontrolled, sacroiliac joint injections have
been shown to be 20% to 54%16. However, there has
been a paucity of the evidence in the evaluation of the
effectiveness of sacroiliac joint blocks in the diagnosis
of sacroiliac joint pain16,21,22. The relief obtained should
be 80% with the ability to perform previously painful
movements and also should be concordant based on
the local anesthetic injection16,38.
If pain is not suggestive of facet joint or sacroiliac
joint origin, then an epidural is to be considered. Caudal
and lumbar interlaminar epidurals are non-specific as
far as identifying the source of pain. If a patient fails to
respond to epidural injections, the discogenic approach
may be undertaken.
Provocation lumbar discography is performed
as the first test in only specific settings of suspected
discogenic pain and availability of a definitive
treatment is offered solely for diagnostic purposes
prior to fusion. Otherwise, once facet joint pain, and
if applicable sacroiliac joint pain, is ruled out and the
patient fails to respond to at least 2 fluoroscopically
directed epidural injections, discography may be
pursued if determination of the disc as the source
of pain is crucial. Moreover, lumbar provocation
discography is the last step in the diagnostic algorithm
and is utilized only when appropriate treatment can
be performed if disc abnormality is noted. Magnetic
resonance imaging (MRI) will assist in ruling out any
red flags and disc herniation, but will not determine if
the disc is the cause of the pain. Lumbar provocation
discography has been shown to reveal abnormalities
in asymptomatic patients with normal MRI scans45,46.
Thus, when performed appropriately, discography
can enhance sensitivity and specificity compared to
non-provocational imaging. Discography continues
to be the only diagnostic tool capable of establishing
whether or not a particular disc is painful, irrespective
of the presence or absence of degenerative pathology
observed on other imaging modalities. Provocation
discography continues to be controversial with
respect to diagnostic accuracy14, 47-49, utilization4-11,50,
and its impact on surgical volume51,52. However,
Low Back Pain as Perceived by the Pain Specialist
lumbar discography has been refined substantially
since its inception and its diagnostic accuracy has
been established as Level II-214,53,38,49. In order to be
valid, the provocation discography must be performed
utilizing strict criteria of having concordant pain in
one disc with at least 2 negative discs, one above and
one below except when the L5/S1 is involved. Studies
have shown the effectiveness of epidural injections in
discogenic pain, with or without the use of steroids,
after facet joint pain and other sources of low back
pain have been eliminated54-56. In addition, the relief
derived from discogenic pain with caudal epidural
injections, with or without steroids, was equivalent to
relief in managing disc herniation and superior to the
relief obtained by patients with either spinal stenosis or
post lumbar laminectomy syndrome54-59.
Given the realities of health care in the United
States and the available evidence from the literature,
it appears that lumbar facet joints account for 30% of
cases of chronic low back pain, sacroiliac joint pain
accounts for less than 10% of cases, and discogenic
pain accounts for 25% of cases.
Approximately 70% of low back pain patients
would undergo investigations of their facet joints, with
approximately 30% proving positive and requiring
no other investigations. Of the 70% remaining,
approximately 10% will require sacroiliac joint
blocks and perhaps 30% will prove to be positive.
The remaining 60% of 70% and original 30% not
undergoing facet injections - overall 60% to 70%
- will probably undergo epidural injections and
approximately 65% will respond to epidural injections
and the remaining 20% of 35% will be candidates
for provocation discography if a treatment can be
provided1,60-63,54-59.
Treatment of Somatic Pain
The patients testing positive for facet joint pain
may undergo either therapeutic facet joint nerve
blocks or radiofrequency neurotomy based on the
patients’ preferences, values, and physician expertise.
However, there is no evidence for lumbar intraarticular
facet joint injections15. In contrast, based on the review
of included therapeutic studies64-66, Level II-1 to II-2
evidence is presented for lumbar facet joint nerve
blocks with an indicated level of evidence of II-2 to
465
II-3 for lumbar radiofrequency neurotomy15, 64-68.
The next modality of treatment is epidural
injections. Epidural injections have been shown to
present with variable evidence. A recent systematic
review of caudal epidural injections in the management
of chronic low back pain54 showed Level I evidence for
relief of chronic pain secondary to disc herniation or
radiculitis and discogenic pain without disc herniation
or radiculitis55-57. Further, the indicated evidence
was Level II-1 or II-2 for caudal epidural injections
in managing chronic pain of post lumbar surgery
syndrome and spinal stenosis54,58,59.
The indicated evidence for therapeutic sacroiliac
joint interventions16,21,22 is Level II-2 with no evidence
for sacroiliac joint neurotomy.
Treatment of Radicular Pain
While disc protrusion, herniation, or prolapsed
resulting in sciatica are seen in less than 5% of
the patients with low back pain69,70, approximately
30% of the patients presenting to interventional
pain management clinics will require either caudal,
interlaminar, or transforaminal epidural injections
as an initial treatment. Many patients with postsurgery syndrome, spinal stenosis, and radiculitis
without disc protrusion may respond to epidural
injections54,60,61,63,71-74. Patients non-responsive to
epidural injections will require either mechanical disc
decompression75-78, percutaneous adhesiolysis79,71,73,
spinal endoscopic adhesiolysis71,73,80, implantation
of spinal cord stimulation81, or intrathecal infusion
systems82 depending on the clinical presentation,
pathology, and other biopsychosocial factors.
Transforaminal epidural injections may be performed
for diagnostic purposes; however, these also lead to
therapeutic improvement. Buenaventura et al63 in a
systematic review of therapeutic lumbar transforaminal
epidural steroid injections showed the indicated level
of evidence as II-1 for short-term relief of 6 months or
less and Level II-2 for long-term relief of longer than
6 months in managing chronic low back and lower
extremity pain. Conn et al54 in a systematic review of
caudal epidural injections in the management of chronic
low back pain showed variable evidence for various
conditions causing low back and lower extremity pain.
The evidence level shown is Level I for short- and longM.E.J. ANESTH 21 (4), 2012
466
term relief in managing chronic low back and lower
extremity pain secondary to lumbar disc herniation and
radiculitis and discogenic pain without disc herniation
or radiculitis. The indicated level of evidence is Level
II-1 or II-2 for caudal epidural injections in managing
low back pain of post-lumbar laminectomy syndrome
and spinal stenosis.
In contrast to lumbar transforaminal epidural and
caudal epidural injections, the evidence for lumbar
interlaminar epidural injections in managing chronic
low back and lower extremity pain is limited due to
the lack of availability of studies utilizing fluoroscopy.
The evidence is delivered from blind interlaminar
epidural injections. Based on Parr et al’s60 systematic
review, the indicated evidence is Level II-2 for shortterm relief of pain of disc herniation or radiculitis
utilizing blind interlaminar epidural steroid injections
with a lack of evidence with Level III for long-term
relief of disc herniation and radiculitis. Furthermore,
the evidence at present is lacking for short- and longterm relief of spinal stenosis and discogenic pain
without radiculitis or disc herniation utilizing blind
epidural injections.
If a patient presents with unilateral, single,
or 2 level involvement, one may proceed with
transforaminal epidural injections (diagnostic and
therapeutic). Bilateral or extensive involvement of
multiple segments will lead to either interlaminar
or caudal based on the upper or lower levels being
involved, extensive stenosis (central or foraminal) and
lack of response to caudal or interlaminar approaches.
Except in specific documented circumstances with
spinal stenosis, the approach also is based on the same
philosophy as described above for transforaminal
epidurals. For postsurgery syndrome, a caudal epidural
is preferred and one may consider a transforaminal
epidural if essential in patients without obstructing
hardware.
The evidence for intradiscal procedures with
thermal annular technology is also limited. The
systematic review of the effectiveness of thermal
annular procedures in treating discogenic low back
pain62 showed an indicated level of evidence of II-2
for IDET, Level II-3 for radiofrequency annuloplasty,
and limited or lack of evidence for intradiscal
biacuplasty.
M. Rizk et al.
Treatment of Chronic Pain non responsive to
conventional management
Patients non-responsive to epidural injections
may be considered for mechanical disc decompression,
percutaneous adhesiolysis, spinal endoscopic
adhesiolysis, spinal cord stimulation, or implantation
of intrathecal infusion systems.
Percutaneous mechanical disc decompression
lacks evidence. There are 4 modalities, namely
automated
percutaneous
lumbar
discectomy,
percutaneous laser discectomy, a high RPM device
utilizing Dekompressor, and coblation nucleoplasty or
plasma decompression. Recent systematic reviews75-78
showed the evidence to be Level II-2 for short- and
long-term (> 1 year) improvement for percutaneous
automated lumbar discectomy and laser discectomy.
The evidence for coblation nucleoplasty (Level II-3)
and Dekompressor (Level III) is only emerging.
In patients with post-lumbar surgery syndrome
after failure to respond to fluoroscopically directed
epidural injections, percutaneous adhesiolysis is
considered79. Despite a paucity of efficacy and
pragmatic trials, the systematic review by Epter et
al79 indicated the evidence as Level I or II-1 with
short term relief being considered as 6 months or less
and long-term longer than 6 months83-89, in managing
post-lumbar laminectomy syndrome. Another type of
adhesiolysis is spinal endoscopic adhesiolysis, which
is considered to be an experimental procedure. It also
showed the indicated level of evidence of II-1 for shortterm and Level III for long-term relief (≤ 6 months or
> 6 months)80.
The next step in the radicular pain is implantable
therapy. Frey et al81 in a systematic review of spinal
cord stimulation for patients with failed back surgery
syndrome (FBSS) indicated the level of evidence as
II-1 or II-2 for long-term relief (> 1 year) in managing
patients with FBSS. In this systematic review81, 2
randomized trials90,91 and 8 observational studies were
included92-99. Despite early increased expense, costeffectiveness has been demonstrated for spinal cord
stimulation100-104.
Finally, long-term management of chronic
noncancer pain may be achieved with intrathecal
infusion systems82. Intrathecal infusion systems are also
Low Back Pain as Perceived by the Pain Specialist
utilized for non-cancer pain in FBSS as an advanced
stage intervention. While there is a lack of conclusive
evidence due to the paucity of quality literature, Patel
et al concluded that the level of evidence for intrathecal
infusion systems was indicated as Level II-3 or Level
III with longer than one-year improvement considered
as long-term response82.
Interventional Pain Management
There is no consensus among interventional
pain management specialists with regards to type,
dosage, frequency, total number of injections, or other
interventions. The literature provides some guidance
even though not conclusive. The recent literature
shows no significant difference in the outcomes with
or without steroids with medial branch blocks15,64,105,106
and epidural injections60,61,63,54,55,57-59. Many of the
techniques including radiofrequency neurolysis and
disc decompressions do not require any steroids.
The most commonly used formulations of long
acting steroids include methylprednisolone (DepoMedrol), triamcinolone acetonide (Aristocort or
Kenalog), and betamethasone acetate107-132.
Soon after the historic introduction of cortisone
in 1949, steroids were used for various other
purposes including placement in the epidural space,
facet joints, sacro-iliac joints, and for infiltration of
other nerves127,133-135. The first published report of
the injection of steroids into an arthritic joint was in
1951133, followed by the application of transforaminal
epidural steroid injections in 1952 and 1953. Since
then, the use of spinal steroids has been reported with
various approaches127,136-140. Simultaneous with the
introduction of neuraxial steroids in interventional
pain management, various complications related
to steroid therapy, including systematic effects
of particulate steroids, have been described with
increasing frequency, cautioning against use of spinal
steroids in interventional pain management1,72,74,127-138.
The rationale for the use of epidural steroids into
various joints and epidural space has been based on the
strong anti-inflammatory effects of corticosteroids138.
However, while inflammation is an issue with
discogenic pain and radiculitis, no inflammation has
been proven to be present in other cases. It is postulated
that corticosteroids reduce inflammation either by
467
inhibiting the synthesis of or release of a number of
pro-inflammatory substances or by causing irreversible
local anesthetic effect on C-fibers141-156. The role of
epidural steroids has been evaluated in experimental
models with betamethasone reducing the nerve root
injury produced by epidural application146,149, with
suppression of disc resorption by high dose steroids153,
the depression of heat hyperalgesia and mechanoallodynia155, prevention of neuropathic edema and
blockade of neurogenic extravasation154, inhibition of
phospholipase A2 activity150, protection of C-fibers
from damage151, prevention of endoneural vascular
permeability induced by nucleus pulposus152, and
decrease of the extent of intramedullary spinal cord
injury secondary to spinal cord hemorrhage156. The
chemistry of neuraxial steroids has taken center stage
in recent years due to devastating complications
following
epidural
injections,
specifically
transforaminals128-131,157-168,169.
Steroid
particle
embolization into small radicular arteries is believed
to be an important causative factor131,163. Tiso et al128
and Benzon et al129 extensively evaluated chemical
properties and their relationship to interventional pain
management. Data from Tiso et al and Benzon et al
regarding particle sizes were in general agreement
with regards to methylprednisolone, triamcinolone,
and commercial betamethasone. However, there were
some differences pertaining to dexamethasone and
betamethasone sodium phosphate. Nonetheless, based
on the available literature and scientific applications,
all the formulations of steroids may be considered
clinically safe; however important physiochemical
characteristics distinguish one compound from the
others (Table 1). Though all formulations of steroids
may be considered safe, formulations of betamethasone
appear to be safer with no significant difference
in the effectiveness127. Formulations of commonly
used epidural steroids are shown in Table 1 and the
pharmacologic profile of commonly used epidural
steroids is shown in Table 1.
Steroids lead to suppression of the hypothalamic
pituitary axis with decreased plasma cortisol, decreased
plasma adrenocorticotropic hormone (ACTH), and
adrenal atrophy127,170,171. Other side effects may
be specific to the site of injection which includes
arachnoiditis, intrathecal injection, and particulate
embolism. Numerous arguments of steroid toxicity to
M.E.J. ANESTH 21 (4), 2012
468
M. Rizk et al.
the nervous system stem from the potential toxicity of
multiple chemical entities used mostly as preservatives
in the formulations of epidural steroids. Nelson132
spearheaded the crusade against intraspinal therapy
using steroids and argued that methylprednisolone
acetate was neurotoxic. Betamethasone does not
contain either polyethylene glycol or benzyl alcohol.
Similarly, single dose vials of methylprednisolone
(DepoMedrol) are available without alcohol. Latham
et al119 reported that when injected deliberately into the
subarachnoid space in sheep, betamethasone caused no
reaction in the meninges or neural structures when small
doses of 1 mL were used, even on repeated occasions.
Other central nervous system (CNS) events described
are worrisome. These are based on the particle size of
epidural steroids and the risk of vascular obstruction
and ischemic CNS injury as a result of embolization.
There have been several reported cases of CNS injuries
after transforaminal epidural injections172,173,128,129,160-167.
One of the postulated mechanisms of these events is
occlusion of the segmental artery accompanying the
nerve root by the particulate steroid or embolization
of the particulate steroid through the vertebral
artery128,129,165,168,171. Consistent with the present
literature of the pharmacology of steroids, it appears
that non-particulate steroids may be the agents of
choice for transforaminal epidural injections, though
no trials have compared particulate to non-particulate
steroids. However, particulate steroids may be safely
utilized for interlaminar or caudal epidural injections.
Caution must be exercised in the use of particulate
steroids in transforaminal epidural injections and
specifically for cervical transforaminal epidural
injections, particularly if sharp needles are used.
The frequency and total number of injections
have been considered important issues, even though
controversial and poorly addressed. These are based
on flawed assumptions from non-existing evidence.
Over the years, some authors have recommended one
injection for diagnostic as well as therapeutic purposes.
Some have preached 3 injections in a series, irrespective
of a patient’s progress or lack thereof, whereas others
suggest 3 injections followed by a repeat course of 3
injections after 3-, 6-, or 12-month intervals. There are
also proponents of an unlimited number of injections
with no established goals or parameters. A limitation
of 3 mg per kilogram of body weight of steroid or 210
mg per year in an average person and a lifetime dose of
420 mg of steroid also have been advocated, however,
with no scientific basis. The review of the literature
and of all the systematic reviews has not shown
any basis for the above reported assumptions and
limitations. The administration must be based solely
on the patients’ responses, safety profile of the drug,
experience of the physician, and pharmacological and
chemical properties such as duration of action and
suppression of adrenals.
Indication and frequency of interventional
pain management techniques
Some criteria should be considered carefully
before performing any interventional technique.
The physician has to complete an initial evaluation,
Table 1
Epidural Steroids
Drug
Equivalent
Dose
Epidural
Dose
AntiInflammatory
Potency
Sodium
Retention
Capacity
Hydrocortisone
20 mg
N/A
1
Depo-Methylprednisolone
(Depo-Medrol)
4 mg
40–80 mg
Triamcinolone acetonide
(Kenalog)
4 mg
0.75 mg
Dexamethasone
(Decadron)
Duration of adrenal Suppyression
IM
Single
Epidural
Three
Epidurals
1
N/A
N/A
N/A
5
0.5
1–6 weeks
1–3 weeks
N/A
40–80 mg
5
0
2–6 weeks
N/A
2–3 months
8–16 mg
27
1
N/A
N/A
N/A
N/A = Not available
Data adapted and modified from McEvoy et al (109), Jacobs et al (161) Kay et al (158), Hsu et al (159), Manchikanti et al (105,106),
Schimmer and Parker (108), and Benzon et al (129).
Low Back Pain as Perceived by the Pain Specialist
including history and physical examination, with
a psychosocial and functional assessment. The
indications are a suspected organic problem,
nonresponsiveness to less invasive modalities of
treatments except in acute situations such as acute
disc herniation, herpes zoster, complex regional pain
syndrome (CRPS), and intractable cancer-related
pain. These techniques are applied when the pain and
disability are of moderate-to-severe degree and when
there is no contraindication such as severe spinal
stenosis resulting in intraspinal obstruction, infection,
impaired coagulation, or predominantly psychogenic
pain. The responsiveness to prior interventions with
improvement in physical and functional status is a
must to justify repeat blocks or other interventions. The
interventions are repeated only upon return of pain and
deterioration in functional status with a documented
decreased pain and increased function after the initial
intervention. The indications are variable for various
types of interventional techniques.
Facet Joint interventional procedures
Lumbar facet joints are a well-recognized source
of low back and referred pain in the lower extremity in
patients with chronic low back pain. Facet joints are
well innervated by the medial branches of the dorsal
rami174,175. Kalichman et al176 evaluated facet joint
osteoarthritis and low back pain in the communitybased Framingham Heart Study. They concluded that
there is a high prevalence of facet joint osteoarthritis in
the community-based population with a prevalence of
59.6% in males and 66.7% in females. The prevalence
of facet joint osteoarthritis increased with age and
reached 89.2% in individuals 60 to 69 years old
with highest prevalence of facet joint osteoarthritis
found at the L4/5 spinal level. Facet joint pain may
be managed by intraarticular injections, facet joint
nerve blocks, and neurolysis of facet joint nerves.
Facet arthrosis has been suggested as a cause of low
back pain for decades. However, the exact source of
pain in the facet joints is ambiguous. Theories on the
generation of pain range from mechanical alterations to
vascular changes and molecular signaling. While disc
degeneration can clearly cause low back pain, some
patients may not experience pain until degenerative
changes in the facet joints alter mechanical alignment
469
sufficiently to produce “articular” low back pain177.
Most publications agree that 2 diagnostic blocks must
be performed before radiofrequency denervation and
many payors are requiring 80% or more pain relief.
Consequently, a single block will definitely increase
costs of care as the single diagnostic block will lead to
an increase in number of radiofrequency denervations,
which are more expensive and time consuming. The
most common and worrisome complications of facet
joint interventions are related to needle placement
and drug administration. Potential complications
include dural puncture, spinal cord trauma, infection,
intraarterial or intravenous injection, spinal anesthesia,
chemical meningitis, neural trauma, pneumothorax,
radiation exposure, facet capsule rupture, hematoma
formation, and steroid side effects178-179. Potential
side effects with radiofrequency denervation include
painful cutaneous dysesthesias, increased pain due
to neuritis or neurogenic inflammation, anesthesia
dolorosa, cutaneous hyperesthesia, pneumothorax, and
deafferentation pain. Unintentional damage to a spinal
nerve during medial branch radiofrequency, causing
a motor deficit, is also a complication of a neurolytic
procedure180.
Common indications for diagnostic facet joint
interventions are somatic or nonradicular low back,
midback, or upper back and/or lower extremity pain.
This pain should be intermittent or continuous in
nature, causing functional disability and is present at
least for the past 3 months. Those blocks are performed
after eliminating a disc herniation or evidence of
radiculitis and when more conservative management,
including physical therapy modalities with exercises,
chiropractic management, and nonsteroidal antiinflammatory agents fails.
In the diagnostic phase, a patient may receive
two procedures at intervals of no sooner than one
week or preferably two weeks, with careful judgment
of response. A positive response to controlled local
anesthetic blocks (<1 mL) is associated with 80%
pain relief and the ability to perform prior painful
movements without any significant pain. In the
therapeutic phase (after the diagnostic phase is
completed), the suggested frequency would be two to
three months or longer between injections, provided
that ≥ 50% relief is obtained for 6–8 weeks. If the
M.E.J. ANESTH 21 (4), 2012
470
interventional procedures are applied for different
regions, they may be performed at intervals of no
sooner than one week or preferably two weeks for most
types of procedures. It is suggested that therapeutic
frequency remain at least a minimum of 2 months for
each region; it is further suggested that all the regions
be treated at the same time provided that all procedures
can be performed safely. In the treatment or therapeutic
phase, facet joint interventions should be repeated
only as necessary according to the medical necessity
criteria, and it is suggested that these be limited to
a maximum of 4 to 6 times for local anesthetic and
steroid blocks over a period of one year, per region.
Under unusual circumstances with a recurrent injury,
procedures may be repeated at intervals of 6 weeks
after stabilization in the treatment phase. For medial
branch neurotomy, the suggested frequency would be
3 months or longer (maximum of 3 times per year)
between each procedure, provided that 50% or greater
relief is obtained for 10 to 12 weeks. The therapeutic
frequency for medial branch neurotomy should remain
at intervals of at least 3 months per each region with
multiple regions involved. It is further suggested that
all regions be treated at the same time, provided all
procedures are performed safely.
Epidural Infiltrations
Epidural injections in the lumbar spine
are provided by caudal, lumbar interlaminar, or
transforaminal routes. While interlaminar entry is
considered to deliver the medication closely to the
assumed site of pathology, the transforaminal approach
is considered as target-specific requiring the smallest
volume to reach the primary site of pathology. Caudal
epidurals are considered as the safest and easiest,
with minimal risk of inadvertent dural puncture, even
though re quiring relatively high volumes. They have
also been shown to be significantly effective compared
to interlaminar epidural injections181,182. Even then,
controversy continues with regards to the medical
necessity and indications of lumbar epidural injections.
These guidelines apply to all epidural injections
including caudal, interlaminar, and transforaminal.
Complications and side effects include
infection, intravascular injection, extra epidural
placement, hematoma formation, abscess formation,
M. Rizk et al.
subdural injection, intracranial air injection, epidural
lipomatosis, dural puncture, nerve damage, headache,
increased intracranial pressure, vascular injury,
cerebral vascular or pulmonary embolus and effects of
steroids.
Caudal
The caudal approach to the epidural space
via the sacral hiatus is often the preferred injection
method in the treatment of low back pain caused by
lumbosacral root compression. Many nonanesthetists
prefer this injection method because it carries a lower
risk of inadvertent thecal sac puncture and intrathecal
injection. Successful caudal epidural injection relies
on the proper placement of the needle in the epidural
space. The most common method used to identify the
caudal epidural space is by detecting the characteristic
“give” or “pop” when the sacrococcygeal ligament
is penetrated. In the event of unaided or blind needle
insertion, incorrect needle placement has been reported
to occur in 25% to 38% of cases, even in the hands
of experienced physicians. Furthermore, even when
physicians are confident with their injection technique,
incorrect needle placement has been observed in about
1 of 7 caudal injection procedures. An incorrect needle
position would most likely result in deep subcutaneous
injections. In clinical practice, the “whoosh” test,
nerve stimulation, and fluoroscopy are the 3 methods
that can be used to identify the caudal space before
the injection of medications. Approximately 3% of
the studied population has closed sacral canals, thus
making caudal epidural injections impossible for these
subjects.
The common indications are chronic low back
and/or lower extremity pain which has failed to
respond or poorly responded to noninterventional
and nonsurgical conservative management resulting
from disc herniation, lumbar radiculitis, lumbar spinal
stenosis, post lumbar surgery syndrome, epidural
fibrosis, degenerative disc disease and discogenic low
back pain. The facet joint pain should be eliminated by
controlled local anesthetic blocks.
Lumbar Interlaminar
In a randomized, double-blind, controlled trial
of lumbar interlaminar epidural injections in chronic
Low Back Pain as Perceived by the Pain Specialist
function-limiting low back pain without facet joint
pain, disc herniation, and/or radiculitis, Manchikanti et
al demonstrated an effectiveness in 74% of the patients
receiving local anesthetic only and 63% of patients
receiving local anesthetic and steroids with an average
of 4 procedures per year.
The indications are the same as for caudal
epidural injections, except for post-surgery syndrome
where caudal epidural is the modality of choice183.
Lumbar Transforaminal
Lumbar transforaminal epidurals are provided
for diagnostic and therapeutic purposes. The aim of
the diagnostic procedure is to identify an inflamed
nerve root in a patient with a history of radicular
pain when results of visual anatomic studies and
neurophysiologic studies are not collaborative. It also
helps to identify the pain generator when patients have
multiple abnormalities on visual anatomic studies and
to determine a primary pain generator in the spinehip syndrome, the symptomatic level in multilevel
disc herniation or stenosis and the irritated root in
patients with documented postoperative fibrosis or
spondylolisthesis.
The therapeutic indications are an intermittent or
continuous pain causing functional disability. A chronic
low back and/or lower extremity pain which has failed
to respond or poorly responded to non-interventional
and non-surgical conservative management, resulting
from disc herniation, failed back syndrome without
extensive scar tissue and hardware, spinal stenosis
with radiculitis and discogenic pain with radiculitis.
The guidelines of frequency of interventions
apply to epidural injections caudal, interlaminar, and
transforaminal. In the diagnostic phase, a patient may
receive two procedures at intervals of no sooner than
one week or preferably two weeks except in cancerrelated pain or when a continuous administration of
local anesthetic is employed for CRPS.
In the therapeutic phase (after the diagnostic
phase is completed), the suggested frequency of
interventional techniques should be two months or
longer between each injection, provided that > 50%
relief is obtained for six to eight weeks. If the neural
blockade is applied for different regions, they may be
471
performed at intervals of no sooner than one week and
preferably two weeks for most types of procedures.
The therapeutic frequency may remain at intervals
of at least two months for each region. It is further
suggested that all regions be treated at the same time,
provided all procedures can be performed safely. In the
treatment or therapeutic phase, the epidural injections
should be repeated only as necessary according to
medical necessity criteria, and it is suggested that these
be limited to a maximum of 4–6 times per year. Under
unusual circumstances with a recurrent injury, cancerrelated pain, or CRPS, blocks may be repeated at
intervals of 6 weeks or less after diagnosis/stabilization
in the treatment phase.
Percutaneous Adhesiolysis
Adhesiolysis of epidural scar tissue, followed by
the injection of hypertonic saline, has been described
by Racz and coworkers in multiple publications.
The technique described by Racz and colleagues
involved epidurography, adhesiolysis, and injection of
hyaluronidase, bupivacaine, triamcinolone diacetate,
and 10% sodium chloride solution on day one,
followed by injections of bupivacaine and hypertonic
sodium chloride solution on days 2 and 3. Manchikanti
and colleagues modified the Racz protocol from a
3-day procedure to a one-day procedure. The goal
of percutaneous lysis of epidural adhesions is to
assure delivery of high concentrations of injected
drugs to the target areas. Thus, percutaneous epidural
lysis of adhesions is the first and most commonly
used treatment to incorporate multiple therapeutic
goals184,185. Inflammation, edema, fibrosis, and
venous congestion; mechanical pressure on posterior
longitudinal ligaments, annulus fibrosus, and spinal
nerve; reduced or absent nutrient delivery to the
spinal nerve or nerve root; and central sensitization
may be present in patients with radiculitis with disc
herniation, stenosis, and epidural fibrosis. Hence, it has
been postulated as reasonable to treat back pain with or
without radiculopathy with the local application of antiinflammatory medication agents (e.g., corticosteroids)
aimed at reducing edema (e.g., hypertonic sodium
chloride solution, corticosteroids), local anesthetics,
and hyaluronidase to promote lysis185,186. Thus,
percutaneous lysis of adhesions is indicated in patients
with appropriate diagnostic evaluation and after the
M.E.J. ANESTH 21 (4), 2012
472
failure or ineffectiveness of conservative modalities of
treatment have been proven.
The most common and worrisome complications
of adhesiolysis in the lumbar spine are related to
dural puncture, spinal cord compression, catheter
shearing, infection, steroids, hypertonic saline, and
hyaluronidase187, 188-191. Spinal cord compression
following rapid injections into the epidural space,
which may cause large increases in intraspinal pressure
with a risk of cerebral hemorrhage, visual disturbance,
headache, and compromise of spinal cord blood flow,
has been mentioned.
The indications for an epidural adhesiolysis
are chronic low back and/or lower extremity pain
resulting from a failed back surgery syndrome or
epidural fibrosis, spinal stenosis, disc herniation with
radiculitis and failure to respond or poor response
to noninterventional and non-surgical conservative
management and fluoroscopically-directed epidural
injections. Adhesiolysis can be performed after
eliminating a facet joint pain by controlled local
anesthetic blocks. The number of procedures is
preferably limited to two interventions per year.
Spinal Endoscopic Adhesiolysis
There is insufficient evidence to conclude that
epiduroscopy can improve patient management or
disease outcomes. The available studies primarily
evaluated the feasibility of the procedure and the
ability to visualize normal and pathological structures
with an epiduroscope. Some studies concluded that
epiduroscopy could identify the cause of pain and
other neurological signs in some patients who had
been either undiagnosed or incorrectly diagnosed by
radiography or magnetic resonance imaging (MRI).
Geurts et al. reported that epiduroscopy outperformed
MRI in 8 out of 20 patients with chronic sciatica with
or without failed back syndrome (Geurts, 2002). In
this study, MRI findings agreed with epiduroscopy
observations in 11 patients, while epiduroscopy
identified an adhesion on the nerve root in 8 patients
in whom MRI detected no abnormalities of the spinal
structures. There is insufficient evidence to conclude
that epidural lysis of adhesions can provide sustained
reduction in chronic back pain in patients with a
presumptive diagnosis of epidural adhesions. The
M. Rizk et al.
common indications of this procedure are chronic
low back and lower extremity pain nonresponsive or
poorly responsive to conservative treatment, including
fluoroscopically directed epidural injections and
percutaneous adhesiolysis with hypertonic saline
neurolysis. The procedures are preferably limited to a
maximum of two per year provided the relief was >
50% for > 4 months.
Intradiscal Procedures
The lumbar intervertebral discs have been
shown to be sources of chronic back pain without
disc herniation in 26% to 39%. Lumbar provocation
discography, which includes disc stimulation and
morphological evaluation, is often used to distinguish
a painful disc from other potential sources of
pain. Conversely, there is evidence that subtle but
painful lesions may be present in discs that appear
morphologically normal on MRI. Discography has
been shown to reveal abnormalities in symptomatic
patients with normal MRI scans192,193. Lei et al194
concluded that MRI should continue to supplement
discography rather than replace it. In a meta-analysis
by Wolfer et al195, the authors concluded that the
false-positive rate was acceptably low and indicated
the level of evidence for discography was Level II-2.
In a therapeutic attempt, a steroid might be injected
to decrease inflammation and swelling that may be
present within a disc. The steroid usually starts to work
in 2-3 days, but the optimal effects are not known until
1-2 weeks after the injection. The duration and extent
of pain relief from therapeutic intradiscal injection is
associated with variable results. The indications are
axial low back pain of at least 6 months duration with
failure to respond to conservative treatment, abnormal
nucleus signal on T2-weighed MRI images with >
60% residual disc height and no evidence of root
compression, tumor, or infection. Finally, even though
lumbar provocation discography with a double needle
technique is considered safe196, discitis is a serious
problem. Further, needle puncture injury was shown
to affect intervertebral disc mechanics and biology in
an organ culture model197. In addition, incidence of
intravascular uptake during fluoroscopically guided
lumbar disc injections also has been demonstrated198.
Low Back Pain as Perceived by the Pain Specialist
Mechanical Disc Decompression
Lumbar disc prolapse, protrusion, or extrusion
account for less than 5% of all low back problems,
but are the most common causes of nerve root pain
and surgical interventions. The primary rationale for
any form of surgery for disc prolapse is to relieve
nerve root irritation or compression due to herniated
disc material. The primary modality of treatment
continues to be either open or microdiscectomy, but
several alternative techniques including nucleoplasty,
automated percutaneous discectomy, and laser
discectomy have been described199. Disc herniations
consist of both contained and non-contained types.
While for non-contained disc herniations, open
discectomy is the approach of choice200, partial
removal of the nucleus pulposus in contained discs
has been shown to decompress herniated discs and
relieve pressure on nerve roots in a much less invasive
manner201,202.
Nucleoplasty, a minimally invasive procedure,
uses radiofrequency energy to remove nucleur material
and create small channels within the disc. Nucleoplasty
utilizing Coblation technology dissolves the nuclear
material through molecular dissociation, and is thought
to lower nuclear pressure, thereby reducing the nerve
root tension and allowing a protrusion to implode
inward. However, epidural fibrosis may develop with
nucleoplasty203. At present, the common indication
is unilateral leg pain with radicular symptoms in a
specific dermatomal distribution that correlates with
MRI findings. Imaging studies (CT, MRI, discography)
should indicate a subligamentous contained disc
herniation with a well maintained disc height of
60%. Nucleoplasty may be considered prior to open
discectomy, however, automated percutaneous lumbar
discectomy and laser discectomy have been shown to
have better evidence with extensive experience201.
Sacroiliac Joint Injections
The sacroiliac joint is a diarthrodial joint,
receiving innervation from the lumbosacral nerve
roots204. Controlled local anesthetic blocks continue
to be the best available tool to identify either the
intervertebral discs, facet, or sacroiliac joints as
the source of low back pain205,206. Sacroiliac joint
pain may be managed by intraarticular injections or
473
neurolysis of the nerve supply. A retrospective review
by Borowsky and Fagen207 conducted in 120 patients
found the combination of intra- and peri-articular
injectate deposition provided superior analgesia than
intraarticular injection alone.
The common indications are somatic or
nonradicular low back and lower extremity pain below
the level of L5 vertebra which failed to respond to more
conservative management, including physical therapy
modalities with exercises, chiropractic management,
and non-steroidal anti-inflammatory agents. For
therapeutic sacroiliac joint interventions with
intraarticular injections or radiofrequency neurotomy,
the joint should have been positive utilizing controlled
diagnostic blocks.
In the diagnostic phase, a patient may receive two
SI joint injections at intervals of no sooner than one
week or preferably two weeks. In the therapeutic phase
(after the diagnostic phase is completed), the suggested
frequency would be two months or longer between
injections, provided that >50% relief is obtained for six
weeks. If the procedures are done for different joints,
they should be performed at intervals of no sooner
than one week or preferably two weeks. It is suggested
that therapeutic frequency remain at two months for
each joint. It is further suggested that both joints be
treated at the same time, provided the injections can
be performed safely. In the therapeutic phase, the
interventional procedures should be repeated only as
necessary according to the medical necessity criteria,
and it is suggested that they be limited to a maximum
of 4 – 6 times for local anesthetic and steroid blocks
over a period of one year, per region. Under unusual
circumstances with a recurrent injury, procedures
may be repeated at intervals of six weeks after
stabilization in the treatment phase. For sacroiliac joint
radiofrequency neurotomy the suggested frequency
is three months or longer between each procedure
(maximum of 3 times per year), provided that >50%
relief is obtained for 10 to 12 weeks.
Trigger-Point and Ligamental Injections
Limited evidence was found suggesting that a
combination of corticosteroid injections and local
anaesthetic injections in trigger points and phenolinjections in lumbar ligaments were effective in
M.E.J. ANESTH 21 (4), 2012
474
M. Rizk et al.
chronic low back pain. 15 One RCT (n=57) compared
‘trigger-point’ injections with methyl-prednisolone
plus lidocaine versus triamcinolone plus lidocaine
versus lidocaine alone. 60-80% of patients with a
combination of lidocaine and corticosteroid had
complete relief of pain after three months compared
to 20% in the lidocaine group. The other RCT (n=81)
compared
ligamental
dextrose-glycerine-phenol
injections with saline. The decrease in pain and
improvement in functional status was larger with
phenol than with saline at one, three and six months.
Currently, the common indications for a spinal cord
stimulator implantation are a documented lumbosacral
arachnoiditis that has not responded to medical
management. The best candidates are those with
intractable pain caused by nerve root injuries, including
the postlaminectomy syndrome, this umbrella term
overlies a constellation of different symptoms and
etiologies, predominantly neuropathic extremity
pain209. Demonstration of pain relief stipulates a
screening period using temporary percutaneous
placement of leads and an external generator210.
Spinal Cord Stimulator
Intrathecal Pump Insertion
Patients may have persistent disabling low
back pain despite use of several standard therapies
or following back surgery (i.e, failed back surgery
syndrome). Chronic opioids may be used in such
patients to manage pain, but responses are incomplete,
long-term outcome unknown, and side effects can be
serious. Opioids should only be used after adequate
risk assessment and with appropriate monitoring
and supervision. Spinal cord stimulation involves
the placement of electrodes in the epidural space
adjacent to the spinal area presumed to be the source
of pain. An electric current is then applied to achieve
sympatholytic and other neuromodulatory effects.
The resulting impulses in the fibers may inhibit the
conduction of pain signals to the brain according to
the pain gate theory. Moreover, the number and type
of leads (unipolar, bipolar, or multipolar) and the
parameters of stimulation (amplitude pulse wide
electrode sensation) may vary depending on the nerve
roots involved and the intensity of the pain being
experienced by the patient. Further, the electrodes
may be implanted percutaneously or by laminectomy,
and power for the spinal cord stimulator is supplied
by an implanted battery or transcutaneously through
an external radiofrequency transmitter. The implanted
source of power is equipped with a computerized
telemetry system that allows transcutaneous
programming of the specific pattern of stimulation208.
In the randomized trials, 26 to 32 percent of patients
experienced a complication following spinal
cord stimulator implantation, including electrode
migration, infection or wound breakdown, generator
pocket-related complications, and lead problem.
Intrathecal drug delivery systems are implanted for
chronic pain when conservative therapies have failed,
surgery is ruled out, no active or untreated addiction
exists, psychological testing indicates appropriateness
for implantable therapy, medical contraindications
have been eliminated (coagulopathies, infections), and
a successful intrathecal drug trial has been completed211.
Intrathecal pumps deliver small doses of medication
directly to the spinal fluid. It consists of a small batterypowered, programmable pump that is implanted under
the subcutaneous tissue of the abdomen and connected
to a small catheter tunneled to the site of spinal entry.
Sophisticated drug dose regimens can be instituted.
Implanted pumps need to be refilled every 1 to 3
months. There is no evidence showing whether it is
more clinically effective to use bolus or continuous
dosing. No intrathecal device should be implanted for
pain management of chronic low back pain without
first performing a trial. This phase determines whether
a patient will benefit from an implant212. The first line of
treatment includes morphine and hydromorphone. The
second protocol may actually be chosen as first line in
cases where an individual has prominently neuropathic
symptoms. This consists of either hydromorphone
or morphine with the addition of bupivacaine or
clonidine. After failure of first and second line drug
combination treatments, either due to intolerable side
effects or inadequate analgesia, the physician might
consider using lipophilic opioid agents such as fentanyl
and gamma-aminobutyric acid (GABA) agonists such
as baclofen and midolazam. Bleeding, neurological
injury, infection, cerebral spinal leaks, shredded
catheters, and malpositioned subcutaneous pockets
Low Back Pain as Perceived by the Pain Specialist
are the surgical complications during the insertion
of an intrathecal pump. Drug refills must be done by
trained individuals who are able to accurately assess
pain and subtle changes in the patient condition. Drug
tolerance is caused by psychological, pharmacological
or physiological aspects and can best be described
as the need for dose escalation for equivalent effect.
A Canadian study in 2002 showed that patients who
responded to intrathecal drug treatment for failed
low back syndrome is cost-effective in the long term,
despite high initial costs of the implantable devices213.
475
Conclusion
In this chapter, we described the most common
modalities of management. However, there is no
single approach that covers every patient. Further,
typical patients present with multiple problems. Thus,
this should not be construed as the entire evaluation.
Only relevant descriptions are provided. Abuse and
overuse of multiple procedures is a major concern.
These guidelines must not be used to justify multiple
procedures, without documentation of medical
necessity.
Biography
Dr. Marwan Rizk is an instructor of clinical
anesthesiology at the Department of Anesthesiology at
AUB-MC.
Dr. Rizk is Arab board certified in anesthesiology
and critical care medicine. He has more than 15
publications in international journals.
Dr. Rizk received his MD from St. Joseph
University of Beirut in 1997. Following graduation,
he completed four years of residency training in
anesthesiology at the FM/AUBMC from 1998-2002.
He subsequently completed a year of advanced training
in pain management and regional anesthesia at Wayne
State University School of Medicine. He also attained
a DISS and Masters degree in Hospital Management
from Denis Diderot University, Paris in 2007.
Dr. Rizk added clinical expertise is mostly in the
area of pain and regional anesthesia. He was employed
as an attending physician in anesthesiology and director
of Pain Clinic at St. Joseph Hospital, Beirut, where he
also served as vice Medical Director and director of
the Quality Management Program and Patient Safety
Committee and a member in the Governing and
Strategic Committee, 2003-10.
M.E.J. ANESTH 21 (4), 2012
476
M. Rizk et al.
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Anesthetic Considerations for the Patient
with Systemic Lupus Erythematosus
S haron T. Carrillo*, Emily G antz**, A mir R. Baluch***
Rachel J. Kaye****, and A lan D. K aye *****
Systemic lupus erythematosus (SLE) is a complex disorder characterized by dysregulation of
pathogenic autoantibodies and immune complexes that leads to multisystem chronic inflammatory
processes1. SLE is not a rare condition; the estimated prevalence is 100 physician-diagnosed
patients per 100,000 people. The disease may present at any age, although it primarily affects
women of reproductive ages. The ratio of female to male patients is 9:1.
The prevalence of SLE is described as having an ethnic component, with black women
affected 3 times more than whites2; in addition, blacks and Hispanics are reported to have higher
rates of morbidity3. Although a classical presentation of SLE has been described, clinically there
are many variations of the disease. For example, elderly patients tend to have a less-severe form
involving fewer organ systems overall; men usually experience less photosensitivity but have a
higher rate of mortality4,5.
SLE was first documented in the Middle Ages when it was termed lupus (“wolf” in Latin) to
describe the appearance of the classical facial (malar) rash. It was suggested that the rash resembled
the fur on the forehead and muzzle of the wolf. Others have suggested that the disease may have
been named after a veil (loup) used by women in France to cover facial blemishes. It was not until
1872 that Móric Kaposi, a Hungarian dermatologist, began to recognize and describe the systemic
manifestations of the disease6.
A groundbreaking advance in the study of lupus was made when Malcolm Hargraves, a
hematologist at Mayo Clinic in 1948, described the lupus erythematosus or LE cell found in the
bone marrow of patients. Ten years later, George Friou, MD, developed a test using fluorescent
antihuman globulin demonstrating the antigen–antibody reaction, thus advancing the immunologic
study of the disease7. Although SLE is largely attributed to autoimmune processes, its pathogenesis
can be induced by drugs. This feature of SLE was discovered at the Cleveland Clinic in 1954,
when a patient who was treated with hydralazine for hypertension subsequently developed SLE8.
Clinical Manifestations
Considerable variation exists in the clinical presentation of SLE, ranging from acute
features with the classical malar, erythematous “butterfly rash” to a progressive fatal illness most
commonly caused by complications of renal, cardiovascular, pulmonary, and central nervous
*
Resident, Ochsner Clinic Foundation, in New Orleans, Louisiana.
**
Medical Student, Texas College of Osteopathic Medical School, Fort Worth, Texas.
*** Attending, Anesthesiologist, Metropolitan Anesthesia Consultants, Dallas, Texas.
***** Research Associate, Department of Anesthesiology, Louisiana State University School of Medicine, New Orleans,
Louisiana.
***** Professor and chairman, Department of Anesthesiology, Louisiana State University School of Medicine, New Orleans,
Louisiana.
Corresponding author: Alan David Kaye, Email: [email protected]
483
M.E.J. ANESTH 21 (4), 2012
484
system (CNS) pathologies9. Across all age groups,
SLE is characterized by chronic, inflammatory,
multiorgan symptoms caused by immune complexes
and antibodies against cell surface molecules or serum
constituents10. The level of involvement of each organ
system varies (Figure).
Mucocutaneous involvement is the most
commonly reported clinical feature. It can appear as
a rash (acute to chronic), alopecia, photosensitivity,
and pathology of mucous membranes4. SLE patients
commonly have manifestations found in other
autoimmune diseases, such as Raynaud’s phenomenon,
sclerodactyly, rheumatoid nodules, and erythema
multiforme11. These manifestations are secondary
to activation of the membrane attack complex and
immune complex deposition12.
Musculoskeletal symptoms play a major role
in the pathogenesis of SLE, affecting 53% to 95% of
cases4. These include arthritic, arthropathic, myositic,
and necrotic processes. Some complications arise from
immunoglobulin deposition; others may be a result of
corticosteroid treatment or hematologic pathogenesis.
Hematologic involvement is a common
characteristic of SLE. It is defined variously
as anemia, leukopenia, thrombocytopenia, and
antiphospholipid syndrome. Most patients with SLE
have anemia secondary to many causes, including
immune-mediated hemolysis, chronic disease, renal
insufficiency, aplastic anemia, hypersplenism, blood
loss, myelodysplasia, myelofibrosis, and medication
use. Thrombocytopenia in these patients can result
from platelet destruction, microangiopathic hemolytic
anemia, hypersplenism, bone marrow suppression,
and thrombopoietin antibodies. SLE is commonly
complicated by leukopenia-either neutropenia or
lymphocytopenia. Antiphospholipid syndrome may
coexist with SLE, causing thrombosis and vascular
disease4.
Renal symptoms affect 40% to 70% of patients4.
Mild, asymptomatic disorders of the urinary system
affect many patients. A small percentage of cases
progress to chronic renal insufficiency, a renal vasculitis
syndrome, or severe lupus glomerulonephritis13.
Perhaps the most debilitating complications
seen in SLE are those affecting the peripheral
nervous system and CNS. The American College of
S. T. Carrillo et al.
Rheumatology (ACR) classifies these manifestations
as neuropsychiatric systemic lupus erythematosus
syndromes (NPSLE)14. The ACR has designated 19
syndromes within the NPSLE group. CNS syndromes
include cerebrovascular disease, demyelinating
syndrome, myelopathy, seizure disorder, psychosis,
and aseptic meningitis. Peripheral nervous system
syndromes include Guillain-Barré syndrome,
mononeuropathy, myasthenia gravis, and cranial
neuropathy4.
Cardiovascular involvement is variable.
Chronic inflammation and autoantibodies accelerate
atherosclerosis by injuring endothelial cells and
altering lipoproteins15. The correlation between early,
severe atherosclerosis and SLE, leads to an increased
prevalence of coronary artery disease, myocardial
infarction, and stroke in these patients16. Approximately
25% of patients with SLE develop pericarditis,
whereas myocardial pathology is reported in less than
5% of patients4. Additionally, SLE increases the risk
for valvular heart disease defined as aortic and mitral
valve thickening, vegetations, regurgitation, and
stenosis17.
Pulmonary involvement includes pleural,
parenchymal, vascular, and muscular manifestations.
The most common respiratory finding is pleuritic pain.
Pleuritis is reported in more than 50% of patients with
SLE. Clinically insignificant pleural effusions often are
diagnosed. A more debilitating complication, although
rare, is interstitial lung disease; its severity ranges
from mild inflammation to extensive fibrosis18. Reports
of other types of parenchymal involvement include
acute pneumonitis secondary to alveolar wall necrosis,
bronchiolitis obliterans, pulmonary hypertension, and
infection due to immunosuppression19. Perhaps most
worrisome is pulmonary hemorrhage secondary to
inflamed capillaries, a relatively rare complication that
has a mortality rate as high as 90%20. A late pulmonary
consequence of SLE is diaphragmatic pathology. This
complication, known as “shrinking lung syndrome”,
causes decreased total lung capacity and volume21.
Infections play an important role in the morbidity
and mortality in SLE. Disruption of normal immunity,
chronic inflammation, and immunosuppressive
therapy make these patients particularly susceptible.
Complement deficiencies occur in SLE due to immune
Anesthetic Considerations for the Patient with Systemic Lupus Erythematosus
complexes activating the classical pathway. These
deficiencies increase vulnerability to encapsulated
bacteria and disseminated Neisseria infections22.
Tuberculosis and Herpes Simplex Virus infections are
also more prevalent among SLE patients. However,
most often the respiratory and urinary tracts are
involved by gram-negative and gram-positive
bacteria23,24.
As supported by recent evidence, patients with
SLE have an increased risk for cancer, including nonHodgkin’s lymphoma and lung, breast, and cervical
malignancies. Although there is an association between
malignancy and SLE, the pathogenic mechanisms
are unknown. It has been suggested that genetic and
environmental factors play a role25.
Pathogenesis
The pathogenesis of SLE is complex. Main
factors include genetic patterns, gender, and
environmental risks. Despite the different presentations
of SLE, each patient shares a common dysregulation
of autoantibody activity and an increased amount
of immune complexes. Functionality at every level
of the immune system is affected. Abnormalities in
B cells, T cells, and immunoregulatory pathways
have been described. [The unchecked production of
these self-destructing molecules causes widespread
inflammatory processes leading to a common theme
of damaged organ systems]. The unchecked activation
of inflammatory processes and resultant production of
cytokines, most notably INF-α, are responsible for the
systemic damage of organs26,27.
In SLE, many autoantibodies have a pathogenic
role, targeting DNA, RNA, cell membrane structures,
the cellular surface, and intracellular molecules1.
The most prevalent self-destructing molecules are
within the antinuclear antibody (ANA) group. The
hypothesis supported by increasing evidence is that
these antibodies originate from antinucleosomal
antibodies28. A main concern is the effect of the antiDNA antibodies on renal parenchyma. The antibodies
directly bind to or form complexes with various renal
components, such as heparin sulfate proteoglycan,
laminin, α-actinin, histone proteins, and glomerular
basement membrane collagen29,30. In SLE, anti-DNA
molecules also attack the CNS. These antibodies target
485
neurons and cause apoptosis, leading to cognitive
impairment, altered mental status, and deterioration
in mood31. Anti-phospholipid antibodies also contribute
to neurologic dysfunction and are associated with an
increased risk of strokes, seizures, and migraines32.
Other autoantibodies specific to cellular types
cause complications in patients. A common selfdestructing molecule with up to 25% prevalence is the
anti-Smith autoantibody, another ANA subtype. Highly
specific for SLE, this autoantibody acts as an accelerator
of disease1. Similarly, anti-Ro autoantibody has a
particularly important part in the pathogenesis of SLE
and is associated with nephritis, dermatitis, vasculitis,
neonatal lupus, and Sjögren’s syndrome1.
With a variable severity of disease, some
autoantibodies cause hematologic pathology;
antibodies against platelets cause thrombocytopenia.
More specifically, these antibodies are targeted
against platelet cytoplasmic and surface components,
including phospholipids and glycoproteins II and III33.
The immunoglobulin G non-Rhesus antibody against
an erythrocyte surface molecule contributes to SLE
by causing hemolysis and anemia34. Additionally,
Table 1
Environmental Factors Associated With Pathogenesis of SLE
Ultraviolet B light
Epstein-Barr virus
Estrogen and prolactin:
Predilection for females (9:1 ratio, female: male)
Lupus-inducing medications
Hydralazine
Procainamide
Isoniazid
Hydantoins
Chlorpromazine
Methyldopa
Penicillamine
Minocycline
Tumor necrosis factor-α inhibitors
Interferon-α
Dietary factors:
Alfalfa sprouts and related sprouted foods containing
canavanine, pristane
Infectious agents other than Epstein-Barr virus
Bacterial DNA
Human retroviruses
Endotoxins, bacterial lipopolysaccharides
SLE, systemic lupus erythematosus
Adapted from reference 1.
M.E.J. ANESTH 21 (4), 2012
486
S. T. Carrillo et al.
Table 2
ACR Classification Criteria for SLE
Criteria
Description
ANA
Abnormal titer of ANA by immunofluorescence or equivalent assay at any time and in the absence of
drugs known to be associated with drug-induced lupus syndrome
Arthritis
Non-erosive arthritis involving 2 or more peripheral joints and characterized by tenderness, swelling,
or effusion
Discoid rash
Erythematous, raised patches with adherent keratotic scaling and follicular plugging; atrophic
scarring occurs in older lesions
Hematologic disorder
Hemolytic anemia with reticulocytosis, or
Leukopenia: <4,000/mm3, or
Lymphopenia: <1,500/mm3, or
Thrombocytopenia: <100,000/mm3 in the absence of contributing medications
Immunologic disorder
Anti-DNA: antibody to native DNA in abnormal titer, or
Anti-Smith: presence of antibody to Smith nuclear antigen, or
Positive finding of antiphospholipid antibodies based on: 1) abnormal serum concentration of IgG or
IgM anticardiolipin antibodies; 2) positive test result for lupus anticoagulant using a standard method;
or 3) false-positive serologic test for syphilis known to be positive for at least 6 months and confirmed
by Treponema pallidum immobilization or fluorescent treponemal antibody absorption test
Malar rash
Fixed erythema, flat or raised, over the malar eminences, tending to spare the nasolabial folds
Neurologic disorder
Seizures in the absence of contributing medication or known metabolic derangements (eg, uremia,
acidosis, or electrolyte imbalance)
Psychosis in the absence of contributing medication or known metabolic derangements (eg, uremia,
acidosis, or electrolyte imbalance)
Oral ulcers
Oral or nasopharyngeal ulceration, usually painless, observed by a physician
Photosensitivity
Skin rash as a result of unusual reaction to sunlight, by patient history or physician observation
Renal disorder
Persistent proteinuria, >0.5 g per day, >3+ if quantitation is not performed, or
Cellular casts: may be red blood cell, hemoglobin, granular tubular, or mixed
Serositis
Pleuritis: convincing history of pleuritic pain or rub heard by physician or evidence of pleural effusion,
or
Pericarditis documented by ECG or rub or evidence of pericardial effusion
ACR, American College of Rheumatology; ANA, antinuclear antibody; ECG, electrocardiography; Ig, Immunoglobulin; SLE,
systemic lupus erythematosus.
Adapted from reference 29.
anticardiolipin antibody and lupus anticoagulant target
phospholipids, inducing vascular thrombosis1.
Numerous genetic factors affect pathogenesis of
SLE. Monozygotic twins appear to have an increased
prevalence of SLE35. First-degree relatives have a
reported 29-fold relative risk36. A predisposition
to develop SLE is thought to involve expression
of multiple genes and gene regions, including
autoantibody production, several human leukocyte
antigens, and non-leukocyte antigens1.
The clinical picture of each patient differs
according to unique and multiple stimuli, and the
pathogenesis of the disease may be influenced by
a number of environmental factors1. These include
exposure to viruses (most notably Epstein-Barr),
ultraviolet light, certain medications (including
procainamide, hydralazine, isoniazid, hydantoins, chlorpromazine, methyldopa, penicillamine, minocycline,
tumor necrosis factor blockers, and interferon-α), and
certain dietary components (Table 1).
Diagnosis
The ACR has established clinical criteria
for the diagnosis of SLE (Table 2). A patient must
exhibit at least 4 of the following 11 features:
serositis, manifested as pleuritis or pericarditis; oral
ulcers, including nasopharyngeal lesions; arthritis;
photosensitivity; hematologic abnormalities, including
hemolytic anemia or any blood component deficiency;
renal pathology, such as proteinuria or cellular casts;
Anesthetic Considerations for the Patient with Systemic Lupus Erythematosus
487
presence of immunologic disorders such as anti-Smith,
anti-double-stranded DNA (anti-dsDNA), anti-histone,
anti-U1RNP, anti-Ro/SSA, or anti-La/SSB; positive
antinuclear antibodies; neurologic disorders; malar
rash; and discoid rash. These standard criteria confer
95% specificity and 85% sensitivity for SLE diagnosis37.
Positive ANA is the most sensitive and optimal test for
SLE screening. However, ANA is commonly seen in
other autoimmune disorders, while anti-dsDNA and
anti-Smith antibodies are more specific to SLE38.
Table 3
Clinical Manifestations and Associated Autoantibodies in SLE
Diagnosing SLE may be a tedious process;
however, many laboratory studies, imaging studies,
and histologic tests are available. A Coombs’ test
measures erythrocyte-specific antibodies in patients
with anemia. Anti-histone screening may confirm druginduced lupus in a patient whose prescription history
is pertinent1. Other tests are used to determine levels
of certain biological markers to support the diagnosis.
For example, an increased level of creatine kinase
supports myositis; an elevated C-reactive protein
level or erythrocyte sedimentation rate indicates
an inflammatory state; and depressed levels of the
complement proteins C3 and C4 suggest immune
complex activity.
Hematologic
Lymphopenia
Hemolysis
Thrombocytopenia
Clotting
Antilymphocyte
Antierythrocyte
Antiplatelet
Antiphospholipid
Fetal loss
Antiphospholipid
Sjögren’s syndrome
Anti-Ro
Neonatal lupus
Anti-Ro
Lupus band test (LBT) is a useful diagnostic
test that detects the deposition of immunoglobulins
and complement in the dermal-epidermal junction
by direct immunofluorescence. Specificity of LBT is
very high, making it useful in the differentiation of
SLE from other skin lesions, as well as, from other
ANA positive diseases. A positive LBT in a patient
without dermal involvement can aid in making the
early diagnosis of SLE and can predict a decreased
prognosis if involvement is seen in areas not exposed
to UV-light39.
The use of various molecular biology techniques
to test for antibodies coupled with the clinical
picture may distinguish SLE from other connective
tissue disorders or determine coexisting disease. For
example, the presence of anti-Ro/SSA or anti-La/
SSB indicates Sjögren’s syndrome and is associated
with neonatal lupus. Anti-RNP antibodies suggest
scleroderma, whereas anti-cardiolipin antibodies have
been described in the pathogenesis of antiphospholipid
antibody syndrome1 (Table 3).
Manifestation
Autoantibody
Nephritis
Anti-dsDNA
Anti-Ro
Anti-C1q
Dermatitis
Anti-Ro
Anti-dsDNA
Vasculitis
Anti-Ro
CNS
Anti-ribosomal P
Antineuronal
Anti-NR2
CNS, central nervous system; dsDNA, double-stranded DNA;
SLE, systemic lupus erythematosus
Adapted from reference 1.
Prognosis and Treatment
Prior to advancements in screening tests,
diagnostic laboratory studies, and treatment options, the
prognosis was dismal for patients with SLE. Currently,
the survival rate exceeds 90% in patients diagnosed 10
years previously40. Although the pathogenesis of SLE
is different for each patient, there is an established
correlation of increased mortality with infection,
accelerated atherosclerosis, CNS involvement, and
renal disease. For the younger patient, infection seems
to be a main cause of death, whereas complications
related to atherosclerosis decrease survival in older
patients4. Etiologic factors that increase mortality
include age greater than 50 years, male gender, and
low socioeconomic status41.
Current therapeutic options for SLE are
treatments directed at systemic inflammation, immunecell targets, signaling pathways, and cytokines.
Antimalarial drugs, corticosteroids, cyclophosphamide,
MMF, Methotrexate, and Aziothioprine are effective
in suppressing inflammation. Agents that target B
lymphocytes to prevent production of autoantibodies
include rituximab (anti-CD20), epratuzumab (antiCD22), belimumab (anti–B-cell lymphocyte-activating
factor [BAFF]), and atacicept (anti-BAFF and a
M.E.J. ANESTH 21 (4), 2012
488
proliferation-inducing ligand [APRIL]). Anti-cytokines,
such as anti-TNF, anti-interleukins, and anti-INFα,
interfere with immune cell signaling and activity42.
The treatment and management of patients with
SLE varies. Disease severity and organ involvement
determine a suitable treatment regimen. Treatment
is induced during relapses in an effort to prevent
exacerbations. Patients with mild SLE, defined by
musculoskeletal and cutaneous involvement, generally
are treated with antimalarials, glucocorticoids, and
nonsteroidal anti-inflammatory agents. Patients in
whom there is major organ involvement, including
renal, hematologic, pulmonary, cardiac, and nervous
systems, are considered to have moderate to severe
SLE. These patients benefit from more intense
treatment with immunosuppressive, cytotoxic, and
biologic agents.4 Clinical guidelines set forth by the
ACR recommend drug therapy with azathioprine,
mycophenolate
mofetil,
cyclophosphamide,
methotrexate, and cyclosporine, with appropriate
monitoring for toxicity4. In addition, a new drug
belimumab, a monoclonal antibody that inhibits B
lymphocyte differentiation and autoreactivity, shows
promising results in patients with active disease43.
Anesthetic Considerations
Preoperative Assessment
Because of extensive, multiple organ dysfunction
that can develop in SLE, the preoperative assessment
of a patient with this disease may be extensive. Patient
history, thorough physical examination, laboratory
testing, and imaging are indicated. Cardiovascular
function should be assessed with chest radiography,
echocardiography, and electrocardiography to determine
the presence of pericarditis, endocarditis, myocarditis,
congestive heart failure, and conduction blocks.
In addition to cardiovascular evaluation,
pulmonary function and arterial blood gas tests should
be conducted if respiratory symptoms are present.
Other complications such as lupoid hepatitis can be
uncovered by liver function tests, a gastrointestinal
series, and determination of albumin/globulin ratios
and bilirubin levels. Anemia, thrombocytopenia, and
leukopenia can be assessed by hematologic studies,
including complete blood count, platelet count,
prothrombin time, and partial thromboplastin time.
S. T. Carrillo et al.
For CNS involvement, electroencephalography
and a computed tomography scan may be necessary.
Renal involvement can be evaluated by urinalysis,
renal ultrasound and scan, blood urea nitrogen level,
and creatinine, albumin, and total serum protein
levels44. Identifying specific organ dysfunctions and
the clinical picture will determine the appropriate
anesthetic plan (Table 4).
Intraoperative Assessment
There are many perioperative issues to consider in
the patient with SLE-from organ pathology to anatomic
change. As mentioned, multiple manifestations of
the disease may alter anesthetic management of the
patient. Renal or hepatic involvement may affect the
metabolism and efficacy of common drugs, including
IV and inhaled anesthetics, analgesics, neuromuscular
inhibitors, cholinesterase inhibitors, and muscarinic
antagonists. Patients treated with cyclophosphamide
may require a longer period of anesthesia induction
because of an inhibitory effect on cholinesterase
that may lengthen the response to succinylcholine45.
Intubation, extubation, and maintaining an airway may
be difficult in some patients because of SLE-induced
upper airway obstruction and laryngeal involvement10.
Airway Maintenance
Airway protection is a major concern in all patients
undergoing anesthesia. Patients with SLE may have
mucosal ulceration, cricoarytenoid arthritis, laryngeal
pathology including recurrent laryngeal nerve palsy,
or temporomandibular joint dysfunction that results
in a difficult intubation10. Avoiding intubation when
possible or using fiber-optic techniques are alternative
approaches44.
Pulmonary
In patients with SLE, respiratory involvement
may include acute pneumonitis, chronic alveolar
infiltrates, and recurrent infectious pneumonia4.
Perioperatively, pulmonary function and oxygenation
should be carefully assessed. Avoidance of hypoxia,
hypercapnia, and catecholamine release maintains
pulmonary blood flow and reduces pulmonary vascular
resistance. Arterial cannulation for blood gas analyses,
and placement of a pulmonary artery catheter to assess
Anesthetic Considerations for the Patient with Systemic Lupus Erythematosus
489
Table 4
Preoperative Assessment of the Patient With SLE
System
Effects
Assessment by
History
Physical Examination
Tests
Cardiovascular
Pericarditis
Endocarditis
Myocarditis
CHF
Conduction blocks
Chest pain
Palpitations
Murmur
Effusion
Diastolic noncompliance
Pericardial friction rub
ECG
CXR
Echocardiography
Respiratory
Infiltrates
Restrictive PFTs
h a-a gradient
Atelectasis
Pleuritic pain
Dyspnea
Cough
Hemoptysis
Friction rub
Effusion
Cyanosis
Normal peak flow
CXR
PFTs
ABGs
Gastrointestinal
Perforated viscus
Pseudo-obstruction
Liver congestion
Lupoid hepatitis
Nausea/vomiting
Peritonitis
Pancreatitis
Abdominal pain
Ileus
Dilated loops of bowel
Peritoneal free air
Hepatomegaly
Jaundice
Gastrointestinal series
LFTs
Bilirubin level
A/G ratio
Hematologic
Hemorrhage
Thromboembolism
Anemia
Bruising
Thrombosis
Lymphadenopathy
Splenomegaly
Anemia
CBC
Platelet count
PT, PTT
Renal
Glomerulitis
Nephrotic
syndrome
Renal insufficiency
Renal failure
Polyuria
Oliguria
Hematuria
Fever
Costophrenic tenderness
Edema
Urinalysis
Renal US
Renal scan
BUN, Cr, TP, albumin
CNS
Confusion
Hallucinations
Psychoses
Seizures
Paranoid states
Hyperirritability
Numbness
Hemiparesis
Psychosis
Nystagmus, ptosis, diplopia
Aphasia
Peripheral neuropathy
EEG
CT scan
Neurologic, psychiatric
evaluations
Photosensitivity
Atrophic/scarred
lesions
Ecchymosis
Purpura
Joint pain
Immobility
Malar or butterfly rash
Perioral ulcerations
Reduced range of motion
Hip pain
Hip x-rays
Antinuclear antibody
Musculoskeletal and Vasculitis
dermatologic
Symmetric arthritis
Joint immobility
Aseptic necrosis
a-a,
alveolar-arterial; ABG, arterial blood gas; A/G, albumin/globulin; BUN, blood urea nitrogen; CBC, complete blood count;
CHF, congestive heart failure; CNS, central nervous system; Cr, creatinine; CT, computed tomography; CXR, chest x-ray; ECG,
electrocardiography; EEG, electroencephalography; LFT, liver function test; PFT, pulmonary function test; PT, prothrombin time;
PTT, partial thromboplastin time; SLE, systemic lupus erythematosus; TP, total protein; US, ultrasound
Adapted from Robinson DM. Systemic lupus erythematosus. In: Roizen MF, Fleisher LA, eds. Essence of Anesthesia Practice.
2nd ed. Philadelphia, PA: WB Saunders; 2002.
pulmonary hypertension, may be indicated44. A rare
complication in these patients is alveolar hemorrhage,
in which case pulmonary capillary exchange,
oxygenation, and airway pressure must be monitored;
suction should be readily available.
Renal
Glomerulitis,
nephrotic
syndrome,
renal
insufficiency, and renal failure may develop. Renal
involvement poses a significant challenge in patients
with SLE and may alter standard administration of
anesthetics44. Drugs requiring renal excretion, including
some opioids, benzodiazepines, and neuromuscular
blocking agents, may accumulate. The lingering, toxic
metabolites lead to prolonged sedation, paralysis, and
an increased recovery period. Additionally, the kidneys
M.E.J. ANESTH 21 (4), 2012
490
S. T. Carrillo et al.
or other organ systems may be further damaged.
In cases of extreme end-organ damage, the use of
remifentanil and cisatracurium-both metabolized via
processes that are end organ-independent-is indicated.
Cardiovascular
Premature and accelerated atherosclerosis
increases the risk for cardiovascular disease46. Patients
are predisposed to potentially catastrophic events such
as intraoperative myocardial infarction. Every effort
should be made to maintain hemodynamic stability.
Management of the Case Presented
A detailed medical history of the patient was
obtained, and a physical examination completed. Her
airway was characterized as Mallampati class II with
good cervical range of motion. Her lungs were clear
to auscultation; heart sounds were regular without
murmurs. Other findings of the physical examination
were within normal limits, except for alopecia, which
was moderate.
After a discussion with the patient about the risks
and benefits of general anesthesia, regional anesthesia,
and supplemented local anesthesia, the latter was chosen.
After IV administration of 2 mg of midazolam and 50
mcg of fentanyl, the surgeon locally injected a mixture
of bupivacaine and lidocaine. A propofol infusion of
40 mcg/kg per minute was started. The patient also
received 4 mg of ondansetron. The procedure lasted
45 minutes. The patient was discharged to undergo
dialysis, and later to home.
Conclusion
SLE is a complicated autoimmune disease with
variable systemic manifestations. Because of the
complexity and potentially wide-ranging clinical
presentations of SLE, anesthetic management of
patients is challenging. The inherent heterogeneity of
SLE necessitates extensive preoperative assessments
of patients, in addition to obtaining detailed histories
and physical examinations. Careful anesthetic
planning and intraoperative monitoring of all affected
organ systems-particularly renal, pulmonary, and
cardiovascular function-are required.
Anesthetic Considerations for the Patient with Systemic Lupus Erythematosus
491
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Ultrasound assessment of Vocal
Fold Paresis: A Correlation Case
Series with Flexible Fiberoptic
Laryngoscopy and Adding the
Third Dimension (3-D) to Vocal
Fold Mobility Assessment
Randall J. Amis*, Deepak Gupta*, Jayme R. Dowdall**,
Arvind Srirajakalindini* and Adam Folbe**
Abstract
Background: Perioperative examination of the vocal folds with flexible fiberoptic laryngoscopy
is not always feasible. Prior studies suggest vocal fold ultrasound may provide a useful screening
tool, however, correlation to laryngoscopic findings is necessary. The purpose of the case series
was to validate vocal fold ultrasound in the adult population and to correlate the ultrasound findings
to the assessment provided by flexible fiberoptic laryngoscopy.
Materials and Methods: This IRB approved study accrued sixteen patients. Vocal fold
ultrasound performed by the anesthesiologist was correlated with the laryngoscopy performed by
the otolaryngologist.
Results: Assessment of vocal fold motion was congruent in thirteen patients with normal
vocal fold mobility; however, there was discordance between the findings in three patients.
Conclusion: Vocal fold ultrasound may be useful to screen for vocal fold motion abnormalities
in the adult population. Abnormal findings on vocal fold ultrasound should be confirmed with
subsequent laryngoscopy.
Introduction
Studies trying to ultrasonically assess the vocal folds has been published in the past1-2. Per
earlier results, ultrasound supplemented the diagnostic modality of flexible fiberoptic laryngoscopy
in assessing pediatric benign vocal fold pathologies3-4. Additionally, the ultrasound was deemed
highly accurate, reliable, radiation-free and improved patient tolerance for vocal fold mobility
assessment5. Despite the ossified thyroid cartilage interfering vocal folds assessment in 16% cases,
ultrasound depiction of laryngeal anatomy is still adequate6. Vats et al7 reported 81% concordance
between ultrasonic and endoscopic findings in vocal folds of young patients. The rates were
higher in infants. However, there has been some conflicting report in animal studies recently
*
**
Department of Anesthesiology, Wayne State University, UHC 4J, Room 30, 4201 St. Antoine, Detroit, MI 48201.
Department of Otolaryngology-Head and Neck Surgery, Wayne State University, 5E UHC, 4201 St. Antoine, Detroit, MI
48201.
Corresponding author: Randall J. Amis, Staff Anesthesiologist, Box No. 162, 3990 John R, Detroit, Michigan 48201,
United States, Ph: 1-313-745-7233, Fax: 1-313-993-3889. E-mail: [email protected]
493
M.E.J. ANESTH 21 (4), 2012
494
R. J . Amis et al.
that ultrasound may not be as effective as the direct
laryngeal visualization8.
The purpose of the study was to correlate the
ultrasound assessment and the laryngoscopy view to
assess vocal fold motion in adults.
Methods
After institutional review board approval for the
study protocol, the patients were enrolled in the study
after obtaining the written informed consent. Adults
aged 18-80 years of age with known vocal fold motion
abnormalities or perioperative patients undergoing
surgery presenting risk to the recurrent laryngeal
nerve were recruited for this prospective, doubleblind correlational study. Patients with head and neck
anatomical pathologies that may have unpredictable
effect on the ultrasound assessment of the vocal folds
were excluded.
Ultrasound: The ultrasonic view of the airway
was assessed with high frequency linear probe by the
anesthesiologist. The patients were asked to engage
in active maximal head tilt-chin lift position. The
probe was placed in the midline of the submandibular
region. Without changing the position of the probe,
the linear array of the ultrasound probe was rotated
in the transverse planes from cephalad to caudal or
plane “A” (a coronal plane to see the mouth opening)
to plane “G” (an oblique transverse plane that bisects
the epiglottis and posterior most part of vocal folds
with arytenoids in one 2-dimensional view) (Fig. 1).
The further rotation of the ultrasound array was ceased
at the first simultaneous visualization (in the same
ultrasonic frame) of the epiglottis and posterior most
part of vocal folds with arytenoids (Fig. 2). The patient
was then asked to phonate to assess vocal fold motion
in two directions: latero-medial and supero-inferior.
Following data was assessed from the ultrasonic
image:
1. The alignment of non-phonating folds in
relation to the midpoint between them to assess any
supero-inferior pre-existing misalignment
2. The latero-medial and/or supero-inferior
movements of the vocal folds during phonation in
relation to the midpoint between them to appreciate
the discordance in the vocal fold mobility secondary
to impending paresis and/or established paresis. If
we noted a supero-medial pull on the vocal folds,
we described it as “tenting” to describe that the
examination is abnormal as it was difficult to use
familiar descriptors due to the unfamiliar angle.
Laryngoscopy: Flexible fiberoptic laryngoscopy
was performed. Patients were assessed for vocal fold
motion.
Results
On comparing the ultrasound and fiberoptic
laryngoscopy assessment of vocal fold motion,
congruent findings were obtained in thirteen of the
sixteen study patients.
In three patients there was discordance between
the findings (Table 1). Overall the sensitivity of the
Fig. 1
Ultrasonic Planes (Planes A-G) for the Ultrasound Assessment of the Vocal Folds
Ultrasound assessment of Vocal Fold Paresis: A Correlation Case Series with Flexible Fiberoptic
Laryngoscopy and Adding the Third Dimension (3-D) to Vocal Fold Mobility Assessment
Fig. 2
Ultrasonic View in the Plane G for assessment of the Vocal
Folds Mobility
495
motion was 89% (Table 2). The positive predictive
value of the ultrasound assessment of the vocal folds
was 83% and the negative predictive value was 80%.
Discussion
ultrasound assessment to detect vocal fold motion
abnormality was 71%; however the specificity of the
ultrasound assessment to detect normal vocal fold
Thirteen of sixteen patients had congruent
examinations in the prospective double blind
correlational study. Three patients did not have
congruent examinations: two of these three patients
had undergone thyroidectomy and the third
patient was status-post injection laryngoplasty for
idiopathic paresis (Injection laryngoplasty may have
contributed to unclear results). The anesthesiologist
(ultrasonographer) when noted a supero-medial
difference in vocal fold level described the phenomenon
as “vocal fold tenting”. While the ultrasonographer
was able to describe the vocal fold examination as
abnormal, it was difficult to use familiar descriptors
for this as “vocal fold tenting” due to the unfamiliar
supero-medial angle.
Flexible fiberoptic laryngoscopy is a useful preoperative assessment, especially in patients undergoing
Table 1
Patient Findings of Ultrasound Assessment of Vocal Folds compared with Fiberoptic Laryngoscope Assessment of Vocal Folds
Table 1
Patient Care Setting
Patient 1
Clinic
Patient 2
Clinic
Patient 3
Patient 4
Reason for Laryngoscopy
Odynophagia
Ultrasonographic
Vocal Folds Findings
Equal Mobility
Fiberoptic Laryngoscopic
Vocal Folds Findings
Equal Mobility
s/p Thyroidectomy
Left Cord Paresis
Left Cord Paresis
Floor
s/p Thyroidectomy
Left Cord Tenting
Equal Mobility
Floor
s/p Thyroidectomy
Equal Mobility
Right Cord Paresis
Patient 5
Floor
s/p Thyroidectomy
Equal Mobility
Equal Mobility
Patient 6
Operating Room
s/p Esophagectomy
Equal Mobility
Equal Mobility
Patient 7
Operating Room
s/p Thoracotomy
Equal Mobility
Equal Mobility
Patient 8
Operating Room
s/p Thoracotomy
Equal Mobility
Equal Mobility
Patient 9
Floor
s/p Thyroidectomy
Left Cord Tenting
Left Cord Paresis
Patient 10
Operating Room
s/p Anterior Cervical Dissectomy Cranial Tilting of Left Vocal Cranial Tilting of Left Vocal
and Fusion
Cord
Cord
Patient 11
Floor
s/p Anterior Cervical Dissectomy Left Cord Paresis
and Fusion
Left Cord Paresis
Patient 12
Floor
s/p Thoracotomy
Left Cord Paresis
Left Cord Paresis
Patient 13
Clinic
Vocal Cord Paresis
Equal Mobility
Right Cord Paresis
Patient 14
Clinic
Gastroesophageal Reflux Disease Equal Mobility
Equal Mobility
Patient 15
Clinic
s/p Anterior Cervical Dissectomy Equal Mobility
and Fusion
Equal Mobility
Patient 16
Clinic
s/p Anterior Cervical Dissectomy Equal Mobility
and Fusion
Equal Mobility
M.E.J. ANESTH 21 (4), 2012
496
R. J . Amis et al.
Table 2
Statistical Measures of the Comparative Ultrasound Assessment and Fiberoptic Laryngoscope Assessment of Vocal Folds
Table 2
Ultrasound Assessment:
Impaired Vocal Folds
Mobility
Ultrasound Assessment:
Normal Vocal Folds
Mobility
Total
Fiberoptic Laryngoscopy 5
Assessment: Impaired
Vocal Folds Mobility
2
7
Sensitivity:
5/7*100 = 71%
Fiberoptic Laryngoscopy 1
Assessment: Normal
Vocal Folds Mobility
8
9
Specificity:
8/9*100 = 89%
Total
6
10
16
Positive Predictive Value:
5/6*100 = 83%
Negative Predictive
Value:
8/10*100 = 80%
procedures which may place patients at risk of recurrent
laryngeal nerve injury and subsequent vocal fold
paresis. Common procedures including thyroidectomy,
carotid endarterectomy, anterior approach to cervical
spine surgery and thoracic procedures have been
known to result in vocal fold paralysis. In addition,
intubation trauma and the use of laryngeal mask airway
has also been associated with vocal fold paralysis9. The
gold standard examination for vocal fold assessment
is flexible fiberoptic laryngoscopy. However, it is not
always feasible to examine patients pre-operatively in
the office for an otolaryngology assessment.
The majority of the literature has focused on
the use of ultrasound in children because the prior
researchers found it difficult to see through the calcified
thyroid cartilage in the adults; however with the
ultrasound view that we have found in the oblique G
plane (Fig. 1), we have been able to bypass the thyroid
cartilage altogether from the ultrasound view in the
adult population that we investigated. Additionally
our limited evidence directs to the possible future role
of the ultrasound in oblique G plane as adding the
third dimension (3-D) as Supero-Inferior Dimension
(Cranio-Caudal) to the vocal fold mobility assessment
by the 2-D flexible fiberoptic laryngoscopy (LateroMedial Dimension and Anterio-Posterior Dimension).
This addition of the third dimension by ultrasound was
based on the observation in the peri-operative patients
during our investigation wherein we found that in
immediate post-operative period, the impending vocal
fold paresis was observed by the ultrasonographer as
the supero-medial vocal fold tenting and in delayed
post-operative period, the established vocal fold
paresis was observed by the ultrasonographer as the
infero-medial lax paretic vocal fold.
We acknowledge limitations to the study. The
linear transducers or even convex curved transducers
does not conform to the neck anatomy and this may
contribute to limiting views. The answer to this
technical issues may be resolved by the development
of concave curve high frequency transducer for
adequately maintained contact between the probe and
skin surface; this concave curve ultrasound probe may
be essential to establish the ultrasound assessment of
the airway and airway-related anatomical structures as
standard of care. Additional limitation of the ultrasound
examination is that the air-mucosa interface is noted
as having a hyperechoic linear appearance which is
sometimes difficult to appreciate and differentiate.
Moreover, sensitivity-specificity ranging from 71-89%
may underline the fact that ultrasound assessment for
vocal folds may be a better modality for ruling out the
vocal fold paresis (specificity 89%) than for screening
vocal fold paresis (sensitivity 71%) that will require
confirmation with flexible fiberoptic laryngoscopy.
Finally, the results are preliminary due to the small
sample size of the case series.
Ultrasound assessment of Vocal Fold Paresis: A Correlation Case Series with Flexible Fiberoptic
Laryngoscopy and Adding the Third Dimension (3-D) to Vocal Fold Mobility Assessment
497
Conclusion
Ultrasound imaging is a safe modality wherein
soft tissues can be visualized and identified. The
external technique is non-invasive and minimally
uncomfortable for the patient with no major
sterilization concerns. The major drawback of the
external technique is the difficulty in maintaining good
probe-skin contact over an uneven and curved surface.
However, the images of the larynx can be optimized by
placing the probe under-the-chin on-the-skin (external
suprathyroid ultrasonic view) and gradually tilting
the probe upwards with ultrasound array pointing
caudally. The vocal folds are readily visualized with
this external suprathyroid ultrasonic view (Plane
G) for obtaining ultrasound plane of the posterior
most part of vocal folds with arytenoids. Vocal
fold mobility is readily visualized with appreciable
correlation between ultrasound and flexible fiberoptic
laryngoscopy assessment of vocal folds.
M.E.J. ANESTH 21 (4), 2012
498
R. J . Amis et al.
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ultrasonic diagnosis of the larynx. Laryngol Rhinol Otol (Stuttg);
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2.Grunert D, Stier B, Klingebiel T, Schoning M: Ultrasound
diagnosis of the larynx with the aid of computerized sonography.
Laryngorhinootologie; 1989, 68:236-8.
3.Bisetti MS, Segala F, Zappia F, Albera R, Ottaviani F, Schindler
A: Non-invasive assessment of benign vocal folds lesions in children
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4.Sirikci A, Karatas E, Durucu C, Baglam T, Bayazit Y, Ozkur A,
Sonmezisik S, Kanlikama M: Noninvasive assessment of benign
lesions of vocal folds by means of ultrasonography. Ann Otol Rhinol
Laryngol; 2007, 116:827-31.
5.Friedman EM: Role of ultrasound in the assessment of vocal cord
function in infants and children. Ann Otol Rhinol Laryngol; 1997,
106:199-209.
6.Bozzato A, Zenk J, Gottwald F, Koch M, Iro H: Influence of thyroid
cartilage ossification in laryngeal ultrasound. Laryngorhinootologie;
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7.Vats A, Worley GA, Bruyn R, Porter H, Albert DM, Bailey CM:
Laryngeal ultrasound to assess vocal fold paralysis in children. J
Laryngol Otol; 2004, 118:429-31.
8.Radlinsky MG, Williams J, Frank PM, Cooper TC: Comparison of
three clinical techniques for the diagnosis of laryngeal paralysis in
dogs. Vet Surg; 2009, 38:434-8.
9.Chan TV, Grillone G: Vocal cord paralysis after laryngeal mask
airway ventilation. Laryngoscope; 2005, 115:1436-9.
A randomized evaluation of intravenous
dexamethasone versus oral acetaminophen
codeine in pediatric adenotonsillectomy:
emergence agitation and analgesia
Gholamreza Khalili*, Parvin Sajedi**, Amir Shafa***,
Behnam Hosseini**** and Houman Seyyedyousefi***
Abstract
Background: Adenotonsillectomy is the most frequently performed ambulatory surgical
procedure in children. Post operative agitation and inadequate pain control, for children
undergoing adenotonsillectomy, can be a challenge. The aim of this study was to assess the effect
of intravenous dexamethasone and oral acetaminophen codeine on emergence agitation and pain
after adenotonsillectomy in children.
Methods: One hundred and five pediatric patients (3-7 years old), scheduled to undergo
adenotonsillectomy under general anesthesia, were enrolled in the study. Thirty minutes before
induction, patients were randomized to three groups. Group 1 received 0.2 mg/kg of intravenous
dexamethasone and 0.25 ml/kg of oral placebo syrup. Group 2 received 20 mg/kg of oral
acetaminophen codeine syrup and 0.05 ml/kg of intravenous saline. Group 3 received 0.25 ml/kg
of oral placebo syrup and 0.05 ml/kg of intravenous saline. Emergence agitation and postoperative
pain were assessed, recorded and compared.
Result: Agitation was less frequent in dexamethasone and acetaminophen codeine groups in
comparison with placebo group, but there were not significant differences between the two groups.
The pain frequencies in the three groups were not significantly different.
Conclusion: The results of this study suggest that the administration of intravenous
dexamethasone (0.2 mg/kg) and oral acetaminophen codeine (20 mg/kg) thirty minutes before
anesthesia can significantly decrease the incidence and severity of agitation but does not have an
effect on postoperative pain.
Financial support: Isfahan University of Medical Sciences, Faculty of Medicine, Deputy of
Research
Introduction
Adenotonsillectomy is the most frequently performed ambulatory surgical procedure
in children1,2. Post operative agitation and inadequate pain control for children undergoing
*
Associate professor of anesthesiology, Isfahan University of Medical Sciences.
**
Professor of anesthesiology, Isfahan University of Medical Sciences.
*** Anesthesiologist, Isfahan University of Medical Sciences, Alzahra Hospital.
****Anesthesiologist, fellow of pain, Shahid Beheshti University.
Corresponding author: Amir Shafa, MD. Anesthesiologist, Isfahan University of Medical Sciences, Al-Zahra hospital,
Department of Anesthesiology, Sofeh St, Isfahan, Iran. E-mail: [email protected], Tel: +989133180281, Fax:
+983117735517.
499
M.E.J. ANESTH 21 (4), 2012
500
adenotonsillectomy can be a challenge. The underlying
mechanisms for this agitation have not been
identified3,4. Possible etiologic factors include a rapid
recovery from sevoflurane, psychological immaturity,
genetic predisposition, type of procedure, duration of
anesthesia and concurrent medications5,6,7. Opioids8,
midazolam9 and clonidine10 have been administered for
both prophylaxis and treatment of emergence agitation
in children with different levels of goal achievement.
Although opiates are excellent analgesics in
these patients, they are often contraindicated because
of their potentially adverse effects on respiration and
the central nervous system11. Acetaminophen and
NSAIDs do not have these effects. Dexamethasone has
been used as an antiemetic drug in patient undergoing
chemotherapy with limited side effects5. It has been
found to have a prophylactic effect on postoperative
vomiting in children undergoing tonsillectomy5.
Dexamethasone has combined antiemetic and antiinflammatory effects that may decrease postoperative
tissue injury, edema and pain after tonsillectomy.
Acetaminophen codeine is widely used for
musculoskeletal pain, but few studies have evaluated
it for tonsillectomy.
The aim of this study was to assess the effect of
intravenous dexamethasone and oral acetaminophen
codeine on emergence agitation and pain after
adenotonsillectomy in children.
Methods
The study was approved by the local ethics
committee and written informed consents were
obtained from all parents. We conducted a randomized,
prospective, blinded clinical trial from March 2009 to
March 2010, in Alzahra Hospital, Isfahan, Iran.
We investigated 105 pediatric patients aged 3-7
years with ASA status I and II scheduled to undergo
adenotonsillectomy with general anesthesia. Children
with active lower and upper respiratory infection,
history of asthma, allergy, and those who received
antiemetics, steroids, antihistaminic or psychoactive
drugs during the week before the surgery were
excluded from the study
An anesthesiologist who contributed in our
team used a random-number table to allocate the
G. Khalili et al.
patients into three groups. Thirty minute before the
anesthesia, the first group received 0.2 mg/kg of
intravenous dexamethasone and 0.25 ml/kg of oral
placebo syrup. The second group received 20 mg/kg of
oral acetaminophen codeine syrup and 0.05 ml/kg of
intravenous saline. The third group received 0.25 ml/
kg of oral placebo syrup and 0.05 ml/kg of intravenous
saline.
All drugs and data sheets were labeled with the
randomization number of the patient. Patients, and
the anesthesiologist who gave the scores, and the staff
were unaware of the patient group assignment.
All operations were performed by one surgeon
using a standard surgical technique. No premedication
was administered. All patients received an identical
anesthetic technique, consisting of atropine (0.02 mg/
kg), fentanyl (2 µg/kg), sodium thiopental (5 mg/kg),
and atracurium (0.5 mg/kg).
After intubation with appropriate tracheal tube
anesthesia was maintained with N2O and O2 in a 50/50
ratio and isoflurane with %1.25 MAC. At the end of
the surgery, reversal of neuromuscular blockage was
performed through intravenous administration of 0.02
mg/kg of atropine and 0.04 mg/kg of neostigmine. In
the recovery room, the patients were placed in slight
head-down tonsil position. Extubation was performed
when the patient responded to commands.
Patients were constantly supervised during their
stay in the recovery room, and agitation and pain
scores were assessed by an anesthesiologist, blinded
to patient group assignment, during the first hour
following the operation. Agitation was assessed using
a 5 point scale7 (1 = sleeping; 2 = awake, calm; 3 =
irritable, crying; 4 = inconsolable crying; 5 = severe
restlessness, disorientation, thrashing around) and
pain assessments were made using a 5 point rating
scale (1 = the child had no pain or was asleep; 2 = the
child complained of mild pain but was not distressed
by it; 3 = the child stated that his or her throat was
very painful but was not distressed or the child was
moderately tearful but consolable; 4 = the child was in
considerable distress; 5 = the child was screaming and
struggling violently).
Throughout the procedure and in the recovery
room, heart rate, peripheral oxygen saturation and
blood pressure were monitored.
A randomized evaluation of intravenous dexamethasone versus oral acetaminophen
odeine in pediatric adenotonsillectomy: emergence agitation and analgesia
501
The anesthesiologist was blinded to drugs,
tracheal extubation time (time from the discontinuation
of anesthetic gas to tracheal extubation), anesthesia
time (the time from induction of anesthesia to
discontinuation of anesthetic gas), recovery time (time
span between entrance to recovery room and discharge
from the recovery room) and duration of surgery.
Agitation and pain scores were recorded. If agitated
patients could not be calmed, the second investigator
was allowed to administer midazolam; furthermore, if
patients had uncontrolled pain, additional opioid was
administrated.
extubation time, anesthesia time and recovery time
(duration of stay in PACU) in the three groups (Table
2). Agitation was less frequent in dexamethasone and
acetaminophen codeine groups in comparison with
the placebo group (p = 0.016, p = 0.042, respectively)
(Table 3); but there were not significant differences
between acetaminophen-codeine and dexamethasone
groups.
Statistical analysis was performed through
Mann Whitney, U-test for agitation and pain scores.
Nominal and numerical data were analyzed through
chi square, Fisher's exact test and unpaired student's
T-test. Statistical significance was accepted for p<0.05,
using SPSS 17.
No adverse events such as laryngospasm,
bronchospasm,
hypotension,
bradycardia,
postoperative respiratory depression and hypoxia were
noted in the three groups. Heart rate, blood pressure
and spO2 values before the surgery, by the time of
admission to recovery unit and by recovery discharge
were compared but showed no significant differences.
The pain frequencies in the three groups were
not significantly different (p = 1, p = 0.142, p = 0.142)
(Table 3). Agitation and pain score means are shown
in Table 4.
Results
A total of 105 pediatric patients were studied; 35
patients were allocated randomly to each group.
There were no significant differences between
the groups with respect to age, weight, height, gender
and duration of surgery (p<0.05) (Table 1). There were
no significant differences between the mean values of
Discussion
Emergence agitation (EA) is one of the most
common complications after adenotonsillectomy in
pediatric patients. In epidemiologic study incidence of
agitation after surgery were 5.3% in all age and 1213% in children4. EA is a self-limiting phenomenon;
Table 1
Demographic and surgical data
Mean age ±
SD (year)
Mean weight ±
SD (kg)
Mean Height ±
SD (cm)
Gender (m; f) (N)
Mean Duration of
surgery ± SD (min)
Placebo
4.66 ± 1.16
22.32 ± 8.51
108.36 ± 19.59
16; 19
39.12 ± 11.3
Dexamethasone
4.71 ± 1.33
23.56 ± 9.13
109.9 ± 19.3
17; 18
39.86 ± 11.5
Acetaminophen codeine
4.8 ± 1.41
23.84 ± 9.35
111.2 ± 18.3
15; 20
38.67 ± 11.2
0.271
0.332
0.315
0.186
0.87
Group
P value
Table 2
Mean values of anesthesia, extubation and recovery times
Group
Placebo
Mean
Anesthesia time
± SD (min)
P
value
42 ± 11
Dexamethasone
42.29 ± 11.3
Acetaminophen codeine
41.57 ± 11.1
Mean Extubation
time ± SD (min)
P value
36.57 ± 7
0.87
34.29 ± 7
34.86 ± 7.2
Mean
Recovery time
± SD (min)
P value
57.49 ± 9.1
0.31
54.71 ± 9.4
0.33
55.14 ± 9.1
M.E.J. ANESTH 21 (4), 2012
502
G. Khalili et al.
Table 3
comparison of agitation and pain frequencies between the groups. (* = p value <0.05)
Group
Agitation
(Number of patients)
-
0.016*
32
32
3
3
1.0
5
12
0.042*
32
28
3
7
0.142
14
12
0.752
32
28
3
7
0.142
-
Placebo
Dexamethasone
30
21
5
14
Placebo
Acetaminophen codeine
30
23
Dexamethasone
Acetaminophen codeine
21
23
The results of this study indicate that
administration of dexamethasone (intravenous) and
acetaminophen codeine (oral) 30 minute before
anesthesia, reduces agitation frequency. According
to tables we did not observe any significant changes
in extubation, recovery and anesthesia time and pain
frequency between the three groups.
Although the causes of postoperative agitation
following general anesthesia are not exactly known,
risk factors such as preschool age, otolaryngologic
procedures and using sevoflurane of desflurae, which
provoke this phenomenon, are suggested4,5,6. Thus, we
decided to investigate the efficacy of dexamethasone
and acetaminophen codeine in adenotonsillectomy
procedures and in preschool age children and in
whom that the incidence of postoperative agitation
is high. Although the reason for this high incidence
is unknown, two articles suggested that a sense of
suffocation during procedures on airway tract can
P value
+
+
however, it can occasionally lead to harmful effects14.
In rare cases, EA has lasted for longer than two days15.
Pain
(Number of
patients)
P value
result in remarkable frequency of agitation16,17. The
incidence of postoperative agitation in children
who received midazolam premedication increased
according to lapin et al9 and decreased according to
coke et al7. Regarding the diversity of previous results,
the present study focuses on the use of midazolam
premedication.
Opioids remarkably decrease the incidence
postoperative agitation8. However pain is not a
cause of agitation by itself18,19, it can be one of the
most important factors resulting in the severity and
frequency of agitation14,20.
Effective analgesia following adenotonsillectomy
is not easy to achieve and this might influence the
high incidence of agitation in these patients. Although
opioids are effective analgesic, they may increase
the airway problem and nausea and vomiting8.
Acetaminophen codeine and dexamethasone did
not provide the expected level of analgesia in our
study; 37% of the patients in dexamethasone and
acetaminophen codeine groups and 42% of the patients
Table 4
Mean agitation and pain scores (* = p value <0.05)
Group
Mean agitation
score ± SD
P value
Mean pain score
± SD
P value
Placebo
2.09 ± 1.2
0.011*
2.46 ± 1.0
0.193
Dexamethasone
1.34 ± 0.8
2.57 ± 1.0
Acetaminophen
codeine
1.49 ± 0.7
2 ± 1.2
A randomized evaluation of intravenous dexamethasone versus oral acetaminophen
odeine in pediatric adenotonsillectomy: emergence agitation and analgesia
in control group required additional analgesia doses.
Acetaminophen codeine produced
analgesia postoperatively as dexamethasone.
similar
This investigation shows a decrease in the
incidence of postoperative agitation in dexamethasone
and acetaminophen codeine groups (p<0.016,
p<0.042). Research has shown that the principle
cause of agitation may be edema in airway tract, and
dexamethasone and acetaminophen codeine reduce
edema and agitation.
In conclusion, the administration of intravenous
dexamethasone (0.2 mg/kg) and oral acetaminophen
503
codeine (20 mg/kg) can significantly decrease the
incidence and severity of agitation but does not have
an effect on postoperative pain. This study may suggest
that the control of edema with corticosteroids or other
drugs can reduce postoperative agitation, and that pain
cannot be the only reason for agitation.
Funding
This study has been supported financially by
Isfahan University of medical sciences, faculty of
medicine, deputy of research, registration number 87223-2.
M.E.J. ANESTH 21 (4), 2012
504
G. Khalili et al.
References
1. Pappas AL, Sukhani R, Hotaling Aj: The effect of preoperative
dexamethasone on the immediate and delayed postoperative
morbidity in children undergoing adenotonsillectomy. Anesth
Analg; 1998, 87:57-61.
2. Schoem SR, Watkins GL, Kuhn JJ: Control of early post operative
pain with bupivacaine in pediatric tonsillectomy. Ear Nose Throat J;
1993, 72:560-563.
3. Wells LT, Rasch DK: Emergence delirium after sevoflurane
anesthesia: a paranoid delusion? Anesth Analg; 1999, 88:1308-1310.
4. Voepel-Lewis T, Malviya S, Prochaska G, Tait AR: Prospective
cohort study of emergence agitation in the pediatric post anesthesia
care unit. Anesth. Analg; 2003, 96:1625-1630.
5. Aono J, Ueda W, Mamiya K: Greater incidence of delirium during
recovery from sevoflurane anesthesia in preschool boys. Anesthesiol;
1997, 87:1928-1930.
6. Welborn LG, Hannallah RS, Norden JM: Comparison of
emergence and recovery characteristics of sevoflurane, desflurane
and halothane in pediatric ambulatory patients. Anesth Analg; 1996,
83:917-920.
7. Cole JW, Murray DJ, Mcallister JD: Emergence behavior
in children: defining the incidence of excitement and agitation
following anesthesia. Pediatric Anesth; 2002, 12:442-447.
8. Cohen IT, Finkel JC, Hannallah RS: The effect of fentanyl on the
emergence characteristics after desflurane or sevoflurane anesthesia
in children. Anesth Analg; 2002, 94:1178-1181.
9. Lapin SL, Auden SM, Goldsmith LJ: Effects of sevoflurane
anesthesia on recovery in children: a comparison with halothane.
Pediat Anesth; 1999, 9:299-304.
10.Kulka PJ, Bressem M, Tryba M: Clonidine prevents sevoflurane
induced agitation in children. Anesth Analg; 2001, 93:335-338.
11.Fazil EC, Rose JB: A comparison of oral clonidine and oral midazolam
as pre anesthetic medication in the pediatric tonsillectomy patients.
Anesth Analg; 2001, 92(1):56-61.
12.Finkel JC, Cohen IT, Hannallah RS: The effects of intranasal
fentanyl on emergeace characteristics after sevoflurane anesthesia
in children undergoing surgery for bilateral myringotomy tube
placement. Anesth Analg; 2001, 92:1164-1168.
13.Sturt JC, Macgregor FB, Carins CS: Peritonsillar infiltration with
bupivacaine for pediatric tonsillectomy. Anaesth Intensive Care;
1994, 22:679-682.
14.Galinkin JL, Fazi LM, Cuy RM: Use of intranasal fentanyl in
children undergoing myringotomy tube placement. Anesthesiol;
2000, 93(6):1378-1383.
15.Holzki J, Kretz FJ: Changing aspect of sevoflurane in pediatric
anesthesia. Pediat Anesth; 1999, 9:283-286.
16.Eckenhoff JE, Kneale DH, Dripps RD: The incidence and etiology
of postanesthetic exitment. Anesthesiol; 1961, 22:667-673.
17.Bastron RD, Moyers J: Emergence delirium. JAMA; 1967, 200:883.
18.Cravero JP, Beach M, Thyr B: The effect of small dose fentanyl on
the emergence characteristics of pediatric patients after sevoflurane
anesthesia without surgery. Anesth Analg; 2003, 97:364-367.
19.Weldon BC, Bell M, Craddock T: The effect of caudal analgesia on
emergence agitation in children after sevoflurane versus halothane
anesthesia. Anesth Analg; 2004, 98:321-326.
20.Watcha MF, Ramirez-Ruiz M, White PF: Perioperative effects of
oral ketorolac and acetaminophen in children undergoing bilateral
myringotomy. Can J Anesth; 1992, 39:649-654.
A Retrospective Study of Risk Factors for
Cardiopulmonary Events During PropofolMediated Gastrointestinal Endoscopy In
Patients Aged Over 70 Years
Ying Guo*, Hong Zhang*, Xuexin Feng**
and A iguo Wang
Abstract
Background: Because of its rapid onset and recovery profile, propofol-mediated sedation is
predominantly used during endoscopy.
Objective: To examine procedure-specific occurrence and risk factors for cardiopulmonary
events during propofol-mediated gastrointestinal endoscopy in patients aged over 70 years.
Methods: Retrospective study with the anesthesia recorder system was performed to
determine the occurrence and frequency of cardiopulmonary events. We enrolled 660 elderly
outpatients who had undergone gastrointestinal endoscopies in our hospital between May 2006 and
May 2007. Multivariate logistic regression analysis was performed using variables, including age,
body mass, American Society of Anesthesiologists (ASA) classification, anddifferent anesthetic
method either by monitored anesthesia care or intravenously administered propofol, to determine
the risks of cardiopulmonary events.
Results: Slight adverse effects occurred in 88 patients during gastro-intestinal endoscopy,
and no severe cardiopulmonary events occurred. There was no significant correlation between the
adverse effects and sex or anesthetic methods (p = 0.95 and p = 0.053, respectively). There was a
significant correlation between the occurrence of cardiopulmonary events and both age and body
mass (p = 0.022 and p = 0.009, respectively).
Conclusion: The procedure-specific risk factors for cardiopulmonary events during propofolmediated gastrointestinal endoscopy in patients aged over 70 years include age and body mass.
These factors should be taken into account during future comparative trials.
Key words: Cardiopulmonary events (CP), Propofol-mediated gastro-intestinal endoscopy,
Digestive System, Hypotics and sedatives Administration & dosage/adverse effects.
*
**
Doctor of medicine, Anesthesia Surgery Center of PLA General Hospital, Beijing 100853, China.
Master of medicine, Anesthesia Surgery Center of PLA General Hospital, Beijing 100853, China.
Corresponding author: Hong Zhang, Anesthesia Surgery Center of PLA General Hospital, Beijing 100853, China. Tel:
+86-10-66938051, Fax: +86-10-66938051. E-mail: [email protected]
505
M.E.J. ANESTH 21 (4), 2012
506
Introduction
Intravenous sedation with benzodiazepines
is a standard practice in interventional endoscopic
procedures
including
therapeutic
esophagogastro-duodenoscopy or endoscopic retrograde
cholangiopancreatography. Midazolam is frequently
selected because it has powerful amnesic properties,
some anxiolytic effects, and a short elimination
half-life. However, the sedative and amnesic effects
of benzodiazepines sometimes do not provide
adequate patient comfort during more sophisticated
interventional
procedures.
Propofol
(2,6-diisopropylphenol) is classified as an ultra-short acting
sedative-hypnotic agent with a short duration of
action (t1/2 distribution, 2–4 min). Consequently,
propofol has a more rapid recovery time for the
patient (10–20 min) compared with the available
benzodiazepines, which provide amnesia, but affords
minimal levels of analgesia1-2. Currently, propofol is
used for sedation during gastrointestinal endoscopy.
Proponents of propofol indicate its superior recovery
and patient satisfaction parameters when compared
with the standard combination of a narcotic agent and
benzodiazepine3-4. However, propofol is relatively
expensive and may lead to respiratory arrest when
used in higher doses. The successful performance of
endoscopic procedures can be achieved with patients
in either moderate or deep sedation or under general
anesthesia. The use of sedation or anesthesia can relieve
the patients’ anxiety and discomfort and improve the
outcome of examination. Elderly patients with chronic
diseases who are more vulnerable to complications are
an exception. The most important issue is to guarantee
the patients’ safety and ensure vital signs stability
during the examination.
In a previous study, more than 140,000 cases
of gastroenterologist or nurse-administered propofol
sedation (NAPS) for endoscopic procedures were
reported with no instances of significant adverse
events (SAEs) such as endotracheal intubation or
death5. Despite the size of the study, the comparative
safety of propofol is still unknown. The objective
of this retrospective study was to compare the
morbidity of cardiopulmonary events with or without
propofol among septuagenarians, octogenarians, and
nonagenarians, and determine the risk factors for
Ying Guo et al.
cardiopulmonary events of propofol-mediated gastrointestinal endoscopy.
Materials and Methods
Study design
This study was approved by the People’s
Liberation Army General Hospital Ethics Committee,
and got all of the subjects’ written consent 660 ASA
physiological status □~□ cases that had scheduled
gastrointestinal endoscopy between May 2006 and
May 2007 were included in our study. Inclusion criteria:
Healthy, aged over 70 years, and no prior endoscopic
examinations. Exclusion criteria: Prior gastrectomy,
psychiatric diseases or long-term psychiatric drug
addiction, presence of neoplastic or other serious
concomitant diseases, history of intolerance to
propofol, obesity (body mass index >30), and severe
cardiopulmonary disease. Patient demographics
were as follows male/female ratio was389/271, 592
patients aged 70–79 years, 61 patients aged 80–89
years, and 7 patients aged more than 90 years. 293
patients underwent gastroduodenoscopy, 277 patients
underwent colonoscopy, and 90 cases underwent
gastro-intestinoscopy. The patients were divided into
two groups according to propofol used or not: Group
A (control group, propofol not used) and Group B
(propofol used).
No premedication or intravenous solution was
given before examination. An intravenous cannula
was placed in the right antecubital vein for the infusion
of anesthetics and analgesics. Cardiopulmonary (CP)
events included: (1) chest pain, (2) transient hypoxaemia,
(3) prolonged hypoxaemia, (4) bradycardia, (5)
wheezing, (6) dysrhythmia, (7) tachycardia, (8) tracheal
compression, (9) hypertension, (10) hypotension, (11)
respiratory distress, and (12) pulmonary edema and
vasovagal reaction. The majority of quantitative CP
events were not given threshold values, which includes
transient and prolonged hypoxaemia, dysrhythmia,
hypertension and hypotension. Noninvasive blood
pressure, heart rate and pulse oxygen saturation were
recorded routinely. Supplemental oxygen was given by
endoscopy mask with O2 at 2 L/min. Patients with three
minutes of persistent oxygen saturation nadir <90%
were defined as having respiratory depression and
A Retrospective Study of Risk Factors for Cardiopulmonary Events During PropofolMediated Gastrointestinal Endoscopy In Patients Aged Over 70 Years
needed respiratory assistance or controlled breathing.
If hypotension (<90 mmHg systolic arterial pressure)
or bradycardia (<45 beats/min) persisted for more than
5 minutes, this was defined as circulatory depression,
and was restored by a combination of intravenously
administered fluid, ephedrine, and atropine.
Anesthetic method
Neuroleptanalgesia (NLA) with midazolam
(1.0–2.0 mg) and fentanyl (50–150 μg) was given
intravenously in the group A that we called monitored
anesthesia care (MAC). Propofol (1–1.5 mg/kg;
30–40s) was given slowly after the administration
of midazolam (1.0 mg) and fentanyl (50 μg) in the
Group B. The endoscope was inserted when the
patients lost consciousness and exhibited no eyelash
reflex. Propofol at 10–20 mg was added intermittently
according to the patient’s reaction and the duration of
examination.
Statistical analysis
The data analysis was performed using SPSS
11.0 for Windows (SPSS China Inc, Beijing). Logistic
regression analyses were performed to determine
cardiopulmonary (CP) events during gastro-intestinal
endoscopy. Predictors from univariate analyses with P
values less than 0.5 were included in the multivariate
models. Stepwise elimination of predictors was used
to arrive at a parsimonious model and interaction
testing (NLA versus plus propofol) was conducted
on an intention-to-treat basis. A p value <0.05 was
considered to be statistically significant.
Results
A total of 660 gastro-intestinal endoscopies were
performed. In 455 of these, propofol was utilized
while the remainder received MAC (Table 1). The
most common CP event for both groups was transient
hypoxaemia. When comparing MAC to propofol
usage during colonoscopy, no significant statistical
differences were seen between the two groups for age
distribution, gender, dichotomized ASA classification,
and the setting in which the colonoscopy was performed
(Table 1). There was no significant difference between
the demographics of two groups (Table 1).
507
Table 1
Demographic data of the study
Group A
Group B
Age(years) (mean ± sd)
78.95±6.71
77.98±6.15
Body weight(kg)(mean ± sd)
65.16±8.07
66.35±9.46
Gender(male/female)
122/83
267/188
ASA
□~□(n(%))
□(n(%))
180(87.9)
25(12.1)
414(90.9)
41(9.1)
97
73
35
196
204
55
26.87±9.07
29.48±8.49
Procedure(n)
Gastroscopy
Colonoscopy
Gastro-intestinal scopy
Duration of examination(min)
(mean ± sd)
The patients were divided into 3 different groups
according to their age: 70–79 years old, 80–89 years
old, and over 90 years old. We observed respiratory
events in 9.83% of patients in the 80–89 years old
group and circulatory events were also observed in
9.83% of the 80–89 year olds. The 80–89 years old
group had significantly higher rates of respiratory and
circulatory events than the 70–79 years old group,
which had respiratory events in 6.93% of patients
and circulatory events in 5.74% of these patients (p =
0.024). However, there was no significant difference
between the two groups using different anesthetic
methods (Table 2).
Table 2
Occurrence of cardiopulmonary events in patients over 70
years old
Group A
Group B
Respiratory
events(n(%))
70–79 yrs
80–89 yrs
≥90 yrs
13(6.34)
34(5.74)
Circulatory
events(n(%))
70–79 yrs
80–89 yrs
≥90 yrs
Body mass(kg)
(mean ± sd)
Gender (male/
female)
* P<0.05
9(4.29)
Total
41(6.93)
6(9.83)*
-
31(6.81)
64.15±10.24
65.25±11.01
53/35
343/229
34(5.74)
6(9.83)*
-
M.E.J. ANESTH 21 (4), 2012
508
Ying Guo et al.
Table 3
Results of univariate logistic analysis of risk factors for CP events
Characteristic
Sig (B)
Exp (B)
95% CI for Exp(B)
Lower
Upper
ASA□
Procedure
Anesthetic method
0.721
0.882
0.196
1.881
1.682
1.404
0.783
0.864
0.841
1.164
1.232
2.306
Body weight
0.416
0.914
0.725
1.136
Gender
0.953
0.986
0.624
1.560
Age
Duration of examination
0.330
0.820
1.332
0.958
0.748
0.596
2.337
1.062
A univariate logistic analysis of risk factors
for CP events was performed while controlling for
potential confounders, and the characteristics include
ASA III, procedure, anesthetic methods, body weight,
gender age, and duration of examination (Table 3). The
different anesthetic method was one of the most critical
factors, and exp (B) is 1.404. Then a multivariate
logistic regression model was set up for gastrointestinal endoscopy to estimate the ARR of CP events
when controlling for potential confounders (Table 4).
However, no significant difference was found among
different anesthetic methods. Age and body weight in
different groups are two critical factors that affect CP
events, as both showed significant difference for CP
events (p <0.05).
of sedation, and marked cardiorespiratory depressant
effects6. Despite these effects, several empirical
statements and reports have favored the use of propofol
for sedation during gastrointestinal endoscopy-one of
the most widely performed procedures throughout
the world. Endoscopy has proved to be safe; although
bloating and mild throat discomfort can occur after the
procedure, severe complications are rare. Endoscopy
gives a high diagnostic yield in elderly people7-8. Jia et
al9 reported the incidence of digestive tract carcinoma
in the elderly Chinese population (aged more than
80 years) as 46.6%, and that of pre-carcinoma as
63.6%. These rates are much higher than reported
previously10-12. Therefore, age is one of the most
critical risk factors.
Table 4
Results of multivariate logistic analysis of risk factors for CP
events
Although sedation is intended to facilitate
endoscopy, it may cause slight adverse effect, even
severe adverse cardiopulmonary events, especially in
elderly patients. There is a paradox in using NLA in
the elderly population, as small doses of midazolam
and fentanyl can cause purposeful movement of
body and complicate the examination. Furthermore,
Padmanabhan et al13 reported the administration
of >2 mg of midazolam as a predictor of impaired
cognitive function at discharge after colonoscopy. In
patients undergoing routine endoscopy procedures, the
rapid action and short half-life of propofol offers an
excellent sedative state and early recovery5,14-16. Gangi
et al. reported, in an analysis of 31,039 endoscopic
procedures utilizing either standard sedation or
propofol, cardiovascular complications rate was of
3.08%17. In this study, CP events were mainly cardiac
in nature, including dysrhythmia, chest pain, angina,
hypotension, and myocardial infarction. Risk factors
Characteristic
Sig.
Age
70–79 yrs
≥80 yrs
0.022*
0.99
0.99
Anesthetic method
0.053
Body weight
<50 kg
50–59 kg
60–69 kg
≥70 kg
0.009*
0.544
0.189
0.696
0.894
Exp(B)
95% CI for Exp(B)
Lower Upper
0.000
0.000
…
..
0.577
0.331
1.006
1.897
3.979
1.552
0.858
0.239
0.506
0.171
0.90
15.035
31.274
14.084
8.178
* p< 0.05
Discussion
Propofol is a potent hypnotic agent with an
unclear mechanism of action, a rapid onset and offset
A Retrospective Study of Risk Factors for Cardiopulmonary Events During PropofolMediated Gastrointestinal Endoscopy In Patients Aged Over 70 Years
for these cardiopulmonary events include male sex,
modified Goldman score, and the use of propofol. In
our study, the rates of cardiocirculatory and pulmonary
events were 6.06% and 7.12%, respectively, which
are significantly different from the reported morbidity
rates. This difference between the 2 studies may be
due to the difference in study population of ours and
Gangi’s; in their study, the subjects were middle-aged
adults, and theoretically they may have an increased
tolerance for the sedation drug.
In randomized controlled trials, it is difficult to
comment on safety, as the sample sizes were powered
to detect differences in recovery profiles and patient
or endoscopist satisfaction. Rex et al18 reported a
large multicenter case series of 36,473 endoscopic
procedures employing nurse/endoscopy teamadministered propofol. In our study, propofol was not
the independent predictor for the cardiopulmonary
events (p = 0.053). However, in clinical practice, the
elderly people exhibit greater sensitivity to propofol
than other adults. We considered the possibility that this
difference might be due to the small number of patients
in our study. If additional patients were included, our
results would have been consistent with the previous
report. Further, different propofol concentrations
that are safe for gastrointestinal endoscopy are also
crucial19,20. Patterson et al21 reported the plasma
propofol concentration for different age groups in
which 50% of patients do not respond to gastrointestinal
endoscopy stimuli and do not have hemodynamic
disordance. The results demonstrated that the propofol
concentration necessary for gastroscopy decreased
with increasing age (Cp50 endo at 2.87 mg/ml, 2.34
mg/ml, and 1.64 mg/ml in ages 17–49 years, 50–69
years, and 70–89 years, respectively), and systolic
blood pressure decreased significantly with increasing
propofol concentrations. In the present study, heart rate
response to endoscopy was minimal when compared
with systolic blood pressure response. In previous
reports, propofol was associated with a significantly
slower heart rate than midazolam. In addition, a recent
study by Padmanabhan et al13 concluded that significant
cognitive impairment was common at discharge from
elective outpatient colonoscopy. However, the addition
of midazolam and/or fentanyl to propofol sedation did
not result in increased cognitive impairment when
compared to the use of propofol alone. Furthermore,
509
the use of adjuvants improved the ease of colonoscopy
without increasing the rate of complications or
prolonging early recovery time. Post-procedure patient
satisfaction ratings with sedation were excellent in
86%, good in 12% and fair in 2%. The results indicate
that the very low dose of benzodiazepine allows
successful titration of propofol to moderate levels of
sedation. The percentage of sedation level assessments
at the deep sedation level compares quite favorably
with the study on the percentage of deep sedation
assessments using only midazolam22.
The risk of arrhythmias may be increased during
periods of arterial desaturation23-25. According to
the results of Lieberman26, if sedation is necessary
for elderly patients with marginal arterial oxygen
saturation, supplemental oxygen should be used.
Therefore, in our study, all the patients breathed
oxygen using an endoscopy mask with O2 at 2L/min.
In our retrospective study, a higher ASA
physiologic classification was associated with an
increased ARR of a CP event. MAC was associated
with a lower ARR of CP events when compared with
Group B. During gastro-intestinal endoscopy, ASA
class I and II patients receiving MAC exhibited a
significantly lower ARR for CP events when compared
with Group B. In addition, age and body mass were
also independent risk factors for CP events during
gastrointestinal endoscopy. It has been well recognized
that with the increasing age, the incidence rate of
systemic complications increases sharply whether
the patients received diagnostic checking or surgical
procedures. That coincides with Xu’s study27, in
which to maintain the target plasma concentration of
propofol, the infusion rate decreased with decreasing
body weight and increasing age. The reason for this
may be that healthier patients require deeper sedation
with propofol due to the absence of an analgesic effect,
predisposing the patient to central and/or obstructive
apnea. There also may be a preconceived, albeit
unfounded, notion that younger patients are healthier
and therefore, can be taken to deeper levels of sedation
without difficulty. However, the true relationship
between body mass and cardiopulmonary events still
need preceding prospective, random, and control study
in the future.
Our study showed an association between ASA
M.E.J. ANESTH 21 (4), 2012
510
classification and CP events for gastro-intestinal
endoscopy. Additionally, the ARR for CP events was
significantly less for MAC when compared to propofol
administration. However, there are several limitations
of this study that are inherent to its design. Since this
is a cohort study, there are no randomization and
inclusion/exclusion criteria for propofol-mediated
endoscopy that may have been center- and operatorspecific. In a recent study, a randomized, controlled,
double blind trial of patient-controlled sedation with
propofol/Remifentanil versus midazolam/fentanyl
for colonoscopy demonstrated that patient-controlled
sedation with propofol/Remifentanil yields superior
facility throughout compared to midazolam/fentanyl
when used in an appropriate care setting28. However,
we hypothesized that higher risk patients would
be more likely to have MAC. Therefore, this bias
may increase the likelihood of adverse events in the
propofol administration group. It is unlikely that a
truly independent and unbiased observer was recording
the physiological outcomes. The definition of the CP
event contains elements such as tracheal compression
that may be open to variable interpretation. Tinker et
Ying Guo et al.
al29 performed a closed claim analysis of anesthetic
mishaps and utilized subjective findings, such as
cyanosis and hypotension as a quantifiable variable
without specific threshold value.
Conclusion
In conclusion, a spectrum of adverse side effects
occurs during gastrointestinal endoscopy via MAC
or propofol administration. In the elderly people, the
risk factors for adverse events are related to age and
body mass. Although the majority of adverse events
are most likely a minor clinical consequence, we
hypothesize that they may potentially lead to serious
events, such as respiratory and cardiac arrest, even
death. The risk factors for the CP events are procedurespecific, and they need to be critically appraised in any
future comparative sedation trial. However, this study
was a retrospective investigation, and we await further
randomized-controlled studies that may give us a clear
glimpse of the risk factors for complications in the
elderly people using meta-analytic or meta-regressive
modeling.
A Retrospective Study of Risk Factors for Cardiopulmonary Events During PropofolMediated Gastrointestinal Endoscopy In Patients Aged Over 70 Years
511
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M.E.J. ANESTH 21 (4), 2012
Comparison Between Betamethasone
Gel Applied Over Endotracheal Tube
And Ketamine Gargle For Attenuating
Postoperative Sore Throat, Cough And
Hoarseness Of Voice
Ahmad R. Shaaban* and Sahar M. Kamal*
Abstract
Background: Tracheal intubation for general anesthesia often leads to trauma of the
airway mucosa resulting in postoperative sore throat, hoarseness of voice and cough. The aim
of this study was to evaluate two different methods as regard their efficacy for controlling the
postoperative pharyngo-laryngo-tracheal sequelae (sore throat, cough, hoarseness of voice) after
general anesthesia with laryngoscopy and tracheal intubation. We compared between the effects
of betamethasone gel applied over the endotracheal tube and gargling with ketamine solution
in reducing these complications during the first 24 postoperative hours after elective surgical
procedures in a prospective randomized controlled single blind clinical trial.
Methods: Seventy five patients ASA physical status I and II, undergoing elective surgery under
general anesthesia using endotracheal intubation were enrolled in this prospective, randomized,
single-blind study. Patients were randomly divided into 3 groups of 25 patients each: Group (K):
(n: 25) Patients in this group were asked to gargle with ketamine 40 mg in 30 ml saline for 60
seconds as repeated smaller attempts, 5 minutes before induction of anesthesia. Group (B) (n: 25):
Endotracheal tubes were lubricated with 0.05% betamethasone gel. Group(C) (n: 25): Control
group: patients did not receive ketamine gargle nor betamethasone gel. The incidence and the
severity of Postoperative sore throat, cough, and hoarseness of voice were graded at 0, 2, 4, and 24
h after operation by a blinded investigator.
Results: The incidence and severity of sore throat were significantly lower in group (K) and
group (B) than group (C) (p <0.05) at all time intervals. While there was no significant difference
between group (K) and group (B) (p >0.05). The incidence and severity of cough and hoarseness
of voice were significantly lower in group (B) than group (C) and group (k) (p <0.05) at all time
intervals.
Conclusion: Gargling with ketamine before induction of anesthesia is comparable with
application of 0.05% betamethasone gel over the Endotracheal tubes in decreasing postoperative
sore throat. In addition, Betmethasone application decreased the incidence and severity of
postoperative cough and hoarsness of voice.
*
Department of anesthesia and intensive care,Faculty of medecine, Ain Shams university, Cairo, Egypt.
Corresponding author: Ahmad Ramzy Shaaban, Department of Anesthesia, Ain shams University Cairo, Egypt,
Telephone 002022730365.
E-mail: [email protected]
513
M.E.J. ANESTH 21 (4), 2012
514
A. R. Shaaban & S. M. Kamal
Introduction
Patients and Methods
Postoperative sore throat, cough, and hoarseness
of voice are common, uncomfortable, sequelae after
tracheal intubation. Even though they are minor
complications, But still contribute to postoperative
morbidity and patient dissatisfaction and may decrease
patient satisfaction with their anesthetic and surgical
experience1-3. Theses effects are likely to be due to
irritation and inflammation of the airway as a result
from the trauma occurs to the airway mucosa4,5.
After approval from the hospital Ethics
Committee and written informed consent, 75 patients
were enrolled in this prospective randomized single
blind controlled clinical study. Patients were of either
sex, aged between 20 and 50 year, belonging to ASA
physical status class I or II, scheduled for elective
surgery (likely to last between half an hour and four
hours) under general anesthesia with orotracheal
intubation. Operations included gynecological, lower
abdominal, and orthopedic surgeries in the supine
position with expected extubation immediately after
the operation.
Numerous
non
pharmacological
and
pharmacological measures have been used for
attenuating Postoperative sore throat, cough, and
hoarseness of voice with variable success. Among
the non pharmacological methods, smaller sized
endotracheal tubes, lubricating the endotracheal
tube with water soluble jelly, careful airway
instrumentation, intubation after full relaxation,
minimizing intracuff pressure, gentle oropharyngeal
suctioning, and extubation when the tracheal tube cuff
is fully deflated6,7. Numerous pharmacological methods
have been tried like, Aspirin gargles, gargling with
azulene sulphonate, and beclomethasone inhalation8,9.
It was postulated that postoperative airway
complications are most likely due to local irritation
and inflammation of the airway6.
Betamethasone gel applied over the endotracheal
tube might reduce the incidence of postoperative sore
throat, cough, and hoarseness of voice due to its antiinflammatory effect14.
As regard the role of gargling with ketamine,
there is an increasing amount of experimental data
showing that NMDA receptors are not found only in
the central nervous system but also in the peripheral
nerves. Moreover, experimental studies point out
that peripherally administered NMDA receptor
antagonists are involved with antinociception and antiinflammatory cascade10. Therefore ketamine gargle
was evaluated in this study.
The purpose of this study is to compare the role
of extensive application of betamethasone gel on the
tracheal tube and cuff with another method which is
gargling with ketamine for reducing the incidence of
post operative sore throat, cough, and hoarseness of
voice.
Calculation of sample size was based on the
presumption that theses studied drugs would reduce
the incidence of post operative sore throat by 50%,
For the results to be of clinical significance with power
analysis (α = 0.5, β = 0.5), one needed to recruit 19
patients in each group.
Patients were excluded who were smokers
or with a history of preoperative sore throat, upper
respiratory tract infection, common cold or asthma,
known allergies to the study drugs, Patients undergoing
surgeries of the oral, nasal cavity or pharynx, use of
nasogastric tube, oesopgageal temperature probe or
throat packs, patients with anticipated difficult airway
(Mallampati grade >2), and more than two attempts at
intubation.
After exclusion, Patients were randomly allocated
to one of three groups using a computer-generated
randomization list (n = 25 for each group).
= Group(K) (n = 25): Patients were asked to
gargle with a mixture of ketamine 40 mg in 30 ml
saline for 60 seconds as repeated smaller attempts, 5
min before induction of anaesthesia.
= Group (B) (n = 25): The external surface
of tracheal tubes were lubricated with 2.5 ml of
betamethasone gel 0.05% from the distal end of the
cuff to a distance of 15 cm from the tip with sterile
precautions
= Group (C) (n = 25): Control group. No
ketamine gargle. nor betamethasone gel applied.
The patients and the staff providing postoperative
scoring were blinded to the group. After the patients
arrival in the operating room, standard monitoring
Comparison Between Betamethasone Gel Applied Over Endotracheal Tube And Ketamine
Gargle For Attenuating Postoperative Sore Throat, Cough And Hoarseness Of Voice
(electrocardiogram, noninvasive arterial blood
pressure, end tidal co2, and arterial oxygen saturation)
was initiated.
Anesthesia was induced with intravenous
fentanyl 2 µg/kg and propofol 2.5 mg/kg IV over 1520 s. Rocuronium, 0.6 mg/kg IV, to facilitate tracheal
intubation. Tracheal intubation was performed by an
experienced anaesthesiologist after ensuring maximum
neuromuscular blocking effect as assessed by TOF
guard. Direct laryngoscopy was done with the use of
a Macintosh laryngoscope blade by applying minimal
pressure, The endotracheal tubes used were Single use
PVC tracheal tubes (Portex ® Profile tracheal tube),
having low-pressure-high-volume cuffs, of size 8.0
mm and 7.0 mm internal diameter were used for male
and female patients, respectively.
The tracheal tube cuff was inflated with just
enough room air to prevent an audible leak. With a
peak airway pressure at 20 cm H2O, and cuff pressure
was maintained between 18 and 22 cm H2O using
handheld pressure gauge in which the transducer was
connected to the pilot balloon of the endotracheal tube
to provide digital display of the intra-cuff pressure on
the screen of the monitor (Endotest; Rüsch, Kernen,
Germany). Anaesthesia was maintained with oxygen
33% in air, supplemented with sevoflurane and bolus
doses of rocuronium guided by TOF (maintain one
to two twitches on train-of-four stimulation of ulnar
nerve). A heat and moist exchanger was used to provide
humidification of the anesthetic gases.
At the end of the surgery, oxygen 100% was
administered and residual neuromuscular block was
antagonized with by a combination of neostigmine
0.05 mg/kg and glycopyrolate 0.01 mg/kg. Oral
suctioning by a 12 F suction catheter was done gently
just before extubation only under direct vision to avoid
trauma to the tissues and to confirm that the clearance
of secretions was complete. The trachea was extubated
after deflating the cuff when the TOF ratio was at least
70% and patient fully awake. All patients received
oxygen by a facemask after operation.
Assessment of patients for the incidence and
the severity of postoperative sore throat, cough, and
hoarseness of voice, and any side effect was done on
arrival in the post-anesthesia care unit (o h) and at 2,
4, and 24 h after operation by the anesthetist in charge
515
of the post-anesthesia care unit, blinded to the group
allocation, using the questionnaire shown in Table
(1). (By providing direct questions, as suggested by
Harding and McVey7.
Table 1
Scoring System for Sore Throat, Cough, and Hoarseness7
Please grade any sore throat you may have according to
the following scale:
0: No sore throat at any time since your operation (until now).
1: Minimal sore throat, less severe than with a cold, occurring
at any time since your operation.
2: Moderate sore throat, similar to that noted with a cold,
occurring at any time since your operation.
3: Severe sore throat, more severe than noted with a cold,
occurring at any time since your operation.
Please grade any cough that you may have according to
the following scale:
0: No cough or scratchy throat occurring at any time since
your operation.
1: Minimal scratchy throat or cough, less than noted with a
cold, occurring at any time since your operation.
2: Moderate cough, as would be noted with a cold, occurring
at any time since your operation.
3: Severe cough, greater than would be noted with a cold,
occurring at any time since your operation.
Please grade any hoarseness that you have according to
the following scale:
0: No evidence of hoarseness occurring at any time since
your operation.
1: No evidence of hoarseness at the time of interview, but
hoarseness was present previously
2: Hoarseness at the time of interview that is noted by the
patient only.
3: Hoarseness that is easily noted at the time of interview
The method of analysis was decided
prospectively. Demographic data were analyzed with
one way analysis of variance (ANOVA) for continuous
test for categorical variables. The
variables and
incidence of postoperative symptos was analyzed by
Chi-square test and Fisher's exact test, whereas the
severity of symptoms was analyzed by the KruskalWallis and Mann-Whitney U tests. The incidence of
side effects if present was analyzed with Fisher’s exact
test. All statistical analysis were perfermored with
SPSS 14.0 (SPSS, Chicago, IL). Probability values (P)
<0.05 was considered significant.
M.E.J. ANESTH 21 (4), 2012
516
A. R. Shaaban & S. M. Kamal
Results
Fig. 1
Incidence of postoperative sore throat, Data presented as
percentage of patients. P <0.05 during intergroup comparison
between control (C) versus ketamine (k) and P <0.05 between
control (C) versus betamethasone (B)
Eighty one patients were evaluated in this study,
of which four patients were excluded from the study
because of a history of preoperative common cold and
anticipated difficult intubation. Two other patients were
excluded from the ketamine group as they could not
gargle properly. There were no significant differences
between the groups in terms of age, body weight,
gender distribution, or duration of surgery, (Table 2).
Table 2
Patients characteristics and and duration of surgery. Data
Presented Either as Mean ± SD or Absolute Numbers. No
significant differences between the groups by one way analysis
of variance (ANOVA) for continuous variables and
test for categorical variables
variable
Group
Ketamine
(n = 25)
Betamethasone
(n = 25)
Control
(n =
25)
35.2 ± 11.6
31.9 ± 12.2
32.7 ±
11.9
12/13
13/12
12/13
Weight (kg)
59.2 ± 7.2
57 ± 6.2
58.3 ±
7.7
Duration of
surgery (min)
71 ± 22.2
89 ± 36.6
79 ±
30.9
Age (years)
Sex
(male\
female)
with the other 2 groups (p <0.05). Four patients from the
control group suffered from severe postoperative sore
throat. The severity of postoperative sore throat was
similar between the ketamine and the betamethasone
group (p >0.05) (Table 3).
The incidence of hoarseness and cough were
significally high in the control group in comparison
with the ketamine and the betamethasone group (p
<0.05) while it was comparable between the ketamine
and the betamethone group. None of the patients
suffered from sever cough or sever hoarsness of voice
in any group. (Fig. 2, 3). There were no complications
related to administration of betamethasone gel or
ketamine gargle.
The incidence of sore throat was significantly
higher in the control group in all time points in
comparison with the other two groups (p <0.05).
While there was no significant difference between the
ketamine group and the betamethason group (p >0.05)
(Fig. 1).
Discussion
This study confirms the relatively high incidence
of pharyngo-laryngotracheal sequelae (sore throat,
cough, hoarseness of voice) after general anesthesia
with laryngoscopy and tracheal intubation.which
ranges from 44.2 to 50.9%.and these results consistent
The severity of postoperative sore throat was
significantly high in the control group when compared
Table 3
grades of sore throat in the three groups (Data ae presented as number of patients and percentage)
Number of patients
Group
Score o
Score 1
Score 2
Score 3
ketamine
12 (48%)
10 (40%)
3 (12%)
0 (0%)
Betamethasone
13 (52%)
9 (36%)
3 (12%)
0 (0%)
2 (8%)
11 (44%)
8 (32%)
4 (16%)
control
Comparison Between Betamethasone Gel Applied Over Endotracheal Tube And Ketamine
Gargle For Attenuating Postoperative Sore Throat, Cough And Hoarseness Of Voice
Fig. 2
incidence of postoperative
cough, data presented as
percentage of patients. P <0.05
during intergroup comparison
between control (C) versus
ketamine (k) and P <0.05
between control (C) versus
betamethasone (B)
100%
90%
80%
70%
60%
ketamine
50%
40%
30%
betamethasone
20%
10%
control
0%
Fig. 3
incidence of postoperative
hoarseness of voice, data
presented as percentage of
patients. P <0.05 during
intergroup comparison between
control (C) versus ketamine (k)
and P <0.05 between control (C)
versus betamethasone (B)
517
0
2h
4h
24 h
100%
90%
80%
70%
60%
50%
ketamine
40%
betamethasone
30%
control
20%
10%
0%
0
with other studies1,3,6.
Several factors have been described to influence
the incidence of this sequels like the diameter of
the endotracheal tube used, the intra-cuff pressure,
coughing on the tube, and excessive pharyngeal
suction12.
We found that the incidence and severity of sore
throat, was significantly reduced after preoperative
gargling with ketamine and also in the group when
betamethasone gel was widely applied over the
tracheal tube with no significant inter group difference
compared with the control group .But the incidence
of postoperative cough, and hoarseness of voice was
less when betamethasone gel was widely applied over
the tracheal tube compared with the ketamine gargle
group. While it was significantly high in the control
group.
The potential role of aseptic inflammation in
these postoperative airway sequelae due to localized
trauma of the tracheopharyngeal mucosa have
2h
4h
24 h
been recognized12,16. So many agents acting on the
inflammatory cascade have been tried to allocate
theses sequlea12,13.14,16.
Locally administered steroids have been tried;
Topical application of 1% hydrocortisone near the
endotracheal tube cuff was not beneficial13. Whereas
one puff of a beclomethasone inhaler (50 pg) effectively
reduced the incidence of sore throat from 55% to
10%8. In our study, the widespread application of
betamethasone gel to cover the major points of contact
with the pharynx, larynx, and trachea may account
for the greater benefit compared with those achieved
by Stride when he applied topical hydrocortisone
1% from the distal tip of the endotracheal tube to 5
cm above the cuff. Our study confirms the findings
of studies by Sumathi and colleagues15 and the study
done by George Allen16 proving that widespread
application of betamethasone gel significantly reduces
the incidence of postoperative sore throat, cough,
and hoarseness of voice. However, both Sumathi
M.E.J. ANESTH 21 (4), 2012
518
and colleagues15 and George Allen16, compared the
betamethasone gel group versus lidocaine gelly group.
We included another method which is gargling with
ketamine, 5 minutes prior to the operation.
In recent years, studies have shown that ketamine
has its anti-inflammatory properties and it plays
a protective role against lung injury15 In addition,
ketamine has been shown to attenuate symptoms
of endo-toxemia in a lipopolysaccharide (LPS)induced rat model of sepsis, by reducing NF-kappa B
activity and TNF-alpha production and decreasing the
expression of inducible nitric oxide synthase which has
been implicated in endotoxin-induced tissue injury16.
Taken together, these results suggest that ketamine
has anti-inflammatory and anti-hyperresponsiveness
effects. The effect of nebulized ketamine inhalation on
allergen-induced rats have been examined in the study
done by Zhu et al. and they concluded that Ketamine
administration by local route appears to inhibit the
inflammatory cascade response as there is a growing
amount of experimental data presenting that NMDA
receptors are present in the CNS and in the peripheral
nerves19.
Besides, experimental studies point out that
peripherally administered NMDA receptor antagonists
are implicated with antinociception20,21. Our results for
the effect of gargling with ketamine in reducing the
postoperative sore throat confines with study done by
O. Canbay and his colleagues21,Who studied the effect
of ketamine gargle for attenuating postoperative sore
A. R. Shaaban & S. M. Kamal
throat, but unlike our study, they did not study its effect
on postoperative cough or hoarseness of voice.
The dose of betamethasone gel used in our
study was equivalent to 4 mg of prednisone and that
of ketamine was 40 mg, which is in the safe clinical
range for both drugs. Although flaring up of local
subtle infection is a possibility with topical steroid
application, there are no reports of adverse effects
secondary to betamethasone gel application over
the tracheal tube. Also Comparing with the previous
reports with topical ketamine with higher doses22, our
doses were relatively low and we did not observe any
CNS side-effects.
The drawbacks of this study are that it could not
evaluate the effect on prolonged intubation period.
And it did not measure the plasma level of ketamine
or betamethasone, so it did not rule out the effect of
possible systemic absorption.
In conclusion, We found that gargling with
ketamine prior to intubation is comparable with
betamethasone gel when applied over the endotracheal
tube in reducing postoperative sore throat. In addition,
using betamethasone gel decreased the incidence and
the severity of postoperative cough and hoarseness
of voice more than gargling with ketamine. Also,
this study suggests that airway inflammation is an
important causative factor in eliciting the postoperative
larngopharyngeal sequelae in adult patients undergoing
laryngoscopy and tracheal intubation under general
anesthesia.
Comparison Between Betamethasone Gel Applied Over Endotracheal Tube And Ketamine
Gargle For Attenuating Postoperative Sore Throat, Cough And Hoarseness Of Voice
519
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M.E.J. ANESTH 21 (4), 2012
Attitudes Of Anesthesiology Residents
And Faculty Members Towards
Pain Management
M ahdi Panah
khahi *
,
M ohammad Reza K hajavi **, Atabak N adjafi **
R eza S hariat M oharari**, Farsad I mani * and I man
Rahimi***
Abstract
Introduction: There is a large armamentarium of pain-reducing interventions and analgesic
choices available to anesthesiologists, but oligoanalgesia continues to be a large problem. We
studied the attitudes of residents and faculty members of anesthesiology towards different domains
of pain medicine. Methods: anonymous questionnaires were mailed to 68 professionals containing
demographic and personal data plus 40 items in 10 domains: control, emotion, disability, solicitude,
cure, opioids, harm, practice settings, training, and barriers. Internal consistency was 0.70 and the
test-retest reliability was 0.80. Results: With 81% response rate, we observed desirable beliefs
towards all domains except moderately undesirable beliefs towards the domain solicitude. Scores
of residents and faculties were not significantly different. Conclusion: Continuing education
programs on both the international guidelines, routine professional education, are needed to
improve attitudes towards pain control.
Introduction
As the treating physicians for a large number of severely painful diagnoses, anesthesiologists
have the opportunity to embrace a wealth of principles and interventions used in pain medicine.
However, it is surprising that residents of anesthesiology have not established themselves as
champions in the optimal management of pain. Oligoanalgesia continues to be a large problem and
postoperative pain management in Iran is contextually complex, and may be controversial1.
Effective pain management requires accurate knowledge, attitudes, and assessment skills.
Besides the factors that hinder our effective pain management, including organizational policies,
time constraints, and limited communication, the enlightened attitude of practicing physicians may
play a central role for facilitation of acute pain service in our country.
In this survey we targeted a sample of Iranian residents and attending staff of anesthesiology
to assess their attitudes and beliefs towards different aspects of acute and chronic pain management
and their views on their current practice settings, academic training, and barriers to an effective
pain management.
*
**
***
Assistant Professor of Anesthesiology, Tehran University of Medical Sciences – Pain Management Center, Sina Hospital,
Imam ave., Tehran, Iran.
Associated Professor of Anesthesiology, Tehran University of Medical Sciences – Pain Management Center, Sina
Hospital, Imam ave., Tehran, Iran.
Anesthesiologist, Tehran University of Medical Sciences – Pain Management Center, Sina Hospital, Imam ave., Tehran,
Iran.
Corresponding author: Mahdi Panah Khahi, MD, FIPP, Tehran University of Medical Sciences, Pain
Management Center, Sina Hospital, Imam ave., Tehran, 1136746911, Iran. E-mail: [email protected]
521
M.E.J. ANESTH 21 (4), 2012
522
Methods
Sample and setting
This cross-sectional study was approved by the
Research and Ethics Committees of the anesthesiology
group in Tehran University of Medical Sciences.
The participants included the faculty members and
residents of anesthesiology at the training hospitals of
the university.
A questionnaire was enveloped for every qualified
individual, labeled by his/her name, and posted to their
working hospital. To increase the reliability of answers,
the questionnaires were anonymous and confidential.
Those who agreed to complete the questionnaire were
invited to put their answer sheets into a collecting
box at the central seminar room, in which all the
anesthesiology faculty members and residents gather
up weekly, between January and March 2007.
Questionnaire
A questionnaire was developed in two sections:
The section one included a Personal Data Record (age,
sex, profession, time since graduation, highest degree
earned, number of years of experience as resident or
faculty member, self-assessment of knowledge and
experience in the treatment of patients with acute or
chronic pain).
The section two contained 40 items (Table 1).
Content of this section was established from a brief
version of the Survey of Pain Attitudes2 and other
regional and relevant resources1;3;4. It was a self applied
inventory where the respondents indicated their
agreement with each of the statements, on a 5-point
Likert scale, ranging from 0 to 4 (0=completely false,
1=almost false, 2=neither true nor false, 3=almost true,
4=completely true).
The items in the section two can be categorized
into 10 domains: The domain control (items 1, 8, 11
and 13) refers to how much the respondent believes
that pain can be controlled by the patient (personal
control over pain). The domain emotion (items 3, 6,
9 and 16) refers to how much the health professional
believes emotions influence pain (relationship between
emotion and pain intensity). The domain disability
(items 14 and 17) refers to how much the professional
M. P. khahi et al.
Table 1
Section two of the questionnaire
1. Oftentimes the patient can influence the intensity of pain.
2. Whenever someone experiences pain family members should
treat him better.
3. Anxiety increases pain.
4. Whenever someone experiences pain people should treat that
person with care and concern.
5. It is the responsibility of those who love the person with pain
to help him when he experiences pain.
6. Stress increases pain.
7. Exercise and movement are good for people with pain.
8. Pain can be reduced through concentration or relaxation.
9. Depression increases pain.
10. Exercise can worsen pain.
11. Pain can be controlled by altering thoughts.
12. Oftentimes, when someone is in pain, that person does not
get enough attention.
13. One can certainly learn to deal with pain.
14. Pain does not keep one from leading a physically active life.
15. Physical pain will never be cured.
16. There is a strong link between emotions and the inten­sity
of pain.
17. A person with pain can do almost everything he did be­fore
the pain.
18. If a person with pain does not exercise regularly, the pain
will continue to worsen.
19. Exercise can reduce the intensity of pain.
20. There is no medical procedure to alleviate pain.
21. Management of pain has a low priority for chronic pain
patients.
22. Acute pain is adequately managed in our daily practice.
23. Training for pain management in medical school and in
residency is not satisfactory.
24. Pain has to have a diagnosed physical component to be
treated.
25. Inability to access professionals who practice specialized
methods in this field is a barrier to good pain management.
26. Inadequate staff knowledge of pain management is a barrier
to good pain management.
27. Opioids are adequately utilized in the treatment of acute
pain.
28. International guidelines should be disseminated during
active continuing education programs.
29. The primary goal of treatment is improvement in symptoms
with less importance of functional improvement.
30. Regulatory pressure has not significant impact on use of
opioids in treatment of chronic pain.
31. Prescribing opioids should be discouraged due to risk of
abuse.
32. Department of anesthesiology is the only responsible for
acute pain service.
33. Routine professional education helps improvement in pain
control.
34. Postoperative pain management needs not to be shared
between surgeons and anesthesiologists.
35. Acute pain service is not a specialized and expert teamwork.
36. Tolerance and dependence do not limit usage of opioids.
37. Opioids should only be prescribed in chronic pain.
38. Expert pain specialists have got most of their expertise by
their own.
39. Patients with chronic pain usually receive satisfactory care.
40. Special educational courses in pain management are
mandatory for anesthesiology residents.
Attitudes Of Anesthesiology Residents And Faculty Members Towards Pain Management
believes that disability is due to pain (pain as a factor
of disability). The domain solicitude (items 2, 4, 5 and
12) refers to how much the professional believes that
others, especially family members, should be more
attentive toward the person who experiences pain
(attentiveness of others toward the person with pain).
The domain cure (items 15, 20, 21 and 24) refers to
how much the health professional believes in a medical
cure for chronic pain (cure through medical means).
The domain opioids (items 27, 29, 31, 36 and 37)
refers to how much the respondent stays away from
prescription of opioids for acute and chronic pain. The
domain harm (items 7, 10, 18 and 19) refers to how
much the professional believes that pain means injury
and that physical exercise should be avoided. The
domain practice settings (items 22, 30, 32, 34, 35, and
39) refers to how much the professional believes in the
necessity of acute pain service and shortages of pain
management at their hospital. The domain training
(items 23, 28, 33, 38, and 40) refers to how much the
health professional believes in the need for enhanced
education in pain medicine. The domain barriers
(items 25 and 26) refers to what the health professional
believes as barriers to good pain management.
Analysis of the inventory was performed for each
domain. The score for each domain was calculated by
adding together the points from the responses to each
item, and dividing this number by the total number
of items answered. The final average score from each
scale varied from 0 to 4. There are no cutoff points,
right or wrong answers and the scores from the
domains are not added together. The responses deemed
more “desirable” were labeled as such because they
are considered to be hypothetically more adaptive
by the authors. The desirable scores for each domain
are: control=4, emotion=4, disability=0, harm=0,
solicitude=0, cure=0, opioids=0, practice settings=0,
training=4, barriers=4, and 2 are neutral points2.
The scores were classified according to following
the cutoff points.
highly desirable
moderately desirable
moderately undesirable
highly undesirable
Score range
4
0
>3
≤1
>2 - 3
>1 – 2
>1 - 2
>2 – 3
≤1
>3
523
Content validity was established by comparing
the scores of five residents and five faculty members of
anesthesiology at various levels of pain management
expertise at another university of medicine in Tehran.
Internal consistency was reported at 0.70 and the testretest reliability as 0.80.
Data analysis
We started with the hypothesis that the
characteristics of health professionals can influence
their beliefs. The data were analyzed using SPSS 15.0.
A significance level of P = .05 was used. This was done
to reduce the probability of identifying differences
erroneously.
Results
A total of 37 residents and 18 academic staffs
filled out 55 questionnaires out of the 68 mailed
surveys (81% response rate). The characterization of
the sample is shown in Table 2 and the descriptive
statistics of the respondents’ beliefs are shown in Table
Table 2
Characterization of sample (n=52)
Characteristics
Sex, n (%)
Female
Male
Age
mean (SD)
median (range)
Time since graduation
mean (SD)
median (range)
Self-evaluation
of
experience with chronic
pain, n (%)
Little experience
A v e r a g e
experience
E x t e n s i v e
experience
Number of pain patients
seen per month, n (%)
From 1 to 5
patients
From 6 to 10
From 11 to 20
21 or more
Residents
F a c u l t y
members
6 (11)
28 (54)
5 (10)
13 (25)
33 (2.3)
31 (28-42)
46 (6)
42 (38-66)
5 (1.5)
4 (1-12)
14 (6)
10 (1-36)
23 (44)
11 (21)
2 (4)
12 (23)
0 (0)
4 (8)
8 (15)
1 (2)
6 (12)
12 (23)
8 (15)
6 (12)
4 (8)
7 (13)
M.E.J. ANESTH 21 (4), 2012
524
M. P. khahi et al.
Table 3
Descriptive statistics of the respondents’ beliefs (n=55)
Domain
Desirable
score
Mean
Median
Standard
deviation
Minimum
Maximum
Control
4
3.1
3.1
0.24
1.0
4.0
Emotion
4
3.7
3.7
0.09
1.75
4.0
Disability
0
1.6
1.6
0.89
0
4.0
Solicitude
0
2.4
2.5
0.26
0.5
4.0
Cure
0
0.5
0.5
0.37
0
3.25
Opioids
0
0.8
0.5
0.74
0
3.5
Harm
0
1.1
1.1
0.53
0
4.0
Practice settings
0
0.9
0.7
0.68
0
3.75
Training
4
3.7
3.9
0.46
1.0
4.0
Barriers
4
3.6
3.6
0.46
1.25
4.0
3. The professionals presented “highly desirable”
attitudes for the domains control, emotion, cure,
opioids, practice settings, training, and barriers.
Meanwhile they revealed "moderately desirable"
beliefs towards the domains disability and harm, and
"moderately undesirable" beliefs towards the domain
solicitude, as shown in Table 3. The response frequency
for the 40 items of the 10 domains in the questionnaire
is presented in Table 4. There were no instances of
significant difference between residents and faculty
members in their scores for the ten domains of the
section two.
Discussion
All the professionals evaluated (n=55)
have academic education; 18 (35%) of them are
anesthesiologist with varying years of experience as
attending staff; and 37 (65%) of them are being trained
as residents of the first to the fourth year after they
had already spent 5.5 years of education in medicine,
1.5 years of internship at educational hospitals, and at
least two years of practice thereafter before beginning
residency. One would suppose that their beliefs on
pain would be entirely appropriate and that the most
qualified and experienced would present the most
desirable beliefs, but this was not always the case.
Most of the respondents demonstrated desirable
beliefs on the influence of emotion on pain, on the
possibility of personal control over pain and that
worsening pain is not always related to a worsening
injury; and a great number believed that pain and
disability are not related. However, 55% believed
that solicitude is desirable and a significant portion
believed that exercise can worsen pain. Besides a
general agreement that opioids are underutilized in
the treatment of acute pain, 38% undesirably declared
that prescription of opioids should be discouraged due
to risk of abuse. Almost all of these anesthesiologists
believe that postoperative pain management should be
shared with surgeons; while 37% voted for delegation
of the responsibility of acute pain service only to the
department of anesthesiology which is undesirable
(Tables 3 and 4). Desirable and undesirable mean
these beliefs are more or less functional/adaptive,
aiding or not in recovery and not “right” or “wrong”
as such. Less functional/adaptive beliefs contribute to
disability and unrealistic expectations4. Undesirable
beliefs and clinician’s biases may ultimately impact
accurate assessment and optimal management of pain5.
In the domain control, 78% of the responses were
in the desirable range (personal control over pain is
possible), which shows that a portion (22%) of those
interviewed still has doubts about this belief. Pain is
made up of both sensation and emotion, and modulated
by the interaction between the harmful stimulus,
cognitive and emotional factors such as mood,
beliefs, expectations, previous experience, attitudes,
knowledge and the symbolic meaning attributed to the
complaint6. Not believing that the patient is capable
Attitudes Of Anesthesiology Residents And Faculty Members Towards Pain Management
525
Table 4
Response frequency by item and domain
Completely
false (%)
Item
Domain/statement
1
8
11
13
3
6
9
16
Control
Oftentimes the patient can influence the intensity of pain
Pain can be reduced through concentration or relaxation
Pain can be controlled by altering thoughts
One can certainly learn to deal with pain
Emotion
Anxiety increases pain
Stress increases pain
Depression increases pain
There is a strong link between emotions and the intensity of pain
Almost
false (%)
Neither true nor Almost true
false (%)
(%)
Completely
true (%)
0
0
0
7
7
2
7
9
9
9
20
17
38
40
35
29
46
49
38
38
2
0
0
2
0
0
2
0
0
5
7
9
14
15
18
14
84
80
73
75
44
18
31
13
11
16
11
31
3
22
13
18
25
33
11
9
9
22
38
22
9
11
14
31
35
13
11
23
31
22
53
76
89
46
31
15
9
25
13
7
2
20
3
2
0
5
0
0
0
4
78
15
5
2
0
49
20
11
9
11
13
82
75
27
14
14
22
4
2
25
0
4
13
0
5
63
18
31
47
24
27
31
29
9
22
24
9
2
22
14
11
2
11
0
4
91
5
4
0
0
54
22
18
4
2
24
24
15
24
13
67
27
6
0
0
58
22
29
34
7
13
4
22
2
9
0
2
3
33
62
0
0
0
2
98
0
11
0
11
2
7
7
18
91
53
0
0
0
0
100
4
7
5
26
58
0
0
2
4
94
Disability
14
17
2
4
5
12
15
20
21
24
27
29
31
36
37
7
10
18
19
22
30
32
34
35
39
23
28
33
38
40
25
26
Pain does not keep one from leading a physically active life
A person with pain can do almost everything he did before the pain
Solicitude
Whenever someone experiences pain, family members should treat him better
Whenever someone experiences pain, people should treat that person with care
and concern
It is the responsibility of those who love the person with pain, to help him when
he experiences pain
Oftentimes, when someone is in pain, that person needs to receive more attention
Cure
Physical pain will never be cured
There is no medical procedure to alleviate pain
Management of pain has a low priority for chronic pain patients
Pain has to have a diagnosed physical component to be treated
Opioids
Opioids are adequately utilized in the treatment of acute pain
The primary goal of treatment is improvement in symptoms with less importance
of functional improvement
Prescribing opioids should be discouraged due to risk of abuse
Tolerance and dependence do not limit usage of opioids
Opioids should only be prescribed in chronic pain
Harm
Exercise and movement are good for those with pain
Exercise can worsen pain
If a person with pain does not exercise regularly, the pain will continue to worsen
Exercise can reduce the intensity of pain
Practice settings
Acute pain is adequately managed in our daily practice
Regulatory pressure has not significant impact on use of opioids in treatment of
chronic pain
Department of anesthesiology is the only responsible for acute pain service
Postoperative pain management needs not to be shared between surgeons and
anesthesiologists
Acute pain service is not a specialized and expert teamwork
Patients with chronic pain usually receive satisfactory care
Training
Training for pain management in medical school and in residency is not
satisfactory
International guidelines should be disseminated during active continuing
education programs
Routine professional education helps improvement in pain control
Expert pain specialists have got most of their expertise by their own practice
Special educational courses in pain management are mandatory for
anesthesiology residents
Barriers
Inability to access professionals who practice specialized methods in this field is
a barrier to good pain management
Inadequate staff knowledge of pain management is a barrier to good pain
management
M.E.J. ANESTH 21 (4), 2012
526
of controlling/influencing his own pain may dissuade
professionals from teaching self-care strategies thus
increasing the feeling of helplessness and disability7.
In the domain emotion, 91% of the responses were
“almost true” or “completely true” for emotions
influence pain, which is desirable.
Considering that emotion and perception of
control are cognitive processes, it was expected that the
mean scores for these beliefs would be similar. Greater
acceptance of pain and emotion is perhaps related
to greater verbalization by the patient of this fact or
a way of blaming the patient for therapeutic failures.
It is common for professionals to state, in an almost
condescending manner, that “emotional problems” are
responsible for exacerbating pain, ignoring the fact
that fear, depression, anxiety, stress, interfere in the
mechanism for perceiving painful phenomena7.
In the domain disability, 33% of the responses
showed that pain, on various levels, is not the cause
of disability. This belief may be related to excessive
dismissal from work, family dependence and
withdrawal of the patient. Complaints of disability
vary greatly between individuals and appear to be a
culturally learned attitude and behavior. Disability can
be inadvertently reinforced by friends, family members,
colleagues from work8;9 and health professionals10.
When the health professional has appropriate beliefs and
knowledge on the control of pain and not necessarily a
cure, on dysfunction and not necessarily injury, on pain
and not necessarily disability, he can advise patients
to enroll in educational and rehabilitation programs.
Rehabilitation programs are costly and require
time, both for the patient and healthcare provider.
Sometimes it is more “advantageous” for both to opt
for invasive treatment. These treatments, however, can
add to frustration, worsen disability, lead to seeking
out professionals that promise “magic” treatments and
expose the patient to increasingly difficult situations.
With regard to the domain harm, 67.5% of the
responses show an understanding that pain is not related
to a “physical injury”. The traditional biomedical
model that focuses the treatment of chronic pain on
the existence of physical injury is still the most widely
understood and accepted by health professionals11. The
treatment of chronic pain requires an understanding of
how physical, psychological and social factors affect
M. P. khahi et al.
the neurophysiology of nociception, of the perception
of pain, of the modulation of pain, of suffering and the
behavior of pain6;7;11.
With regard to the domain solicitude, most of
the responses indicated a belief that solicitude is
desirable, which is not always true. Attention and
encouragement are almost universally accepted as
having positive effects on suffering and adaptation to
disability by chronic patients. However, if excessive, it
can reinforce and encourage an increased occurrence
of pain behavior, greater disability and difficulty in
adjusting. Solicitude is acceptable for acute pain,
because of its short duration, the need for rest and
immobilization due to the presence of injury, but this
is not the case for chronic pain. Health professionals
that believe that solicitude is highly desirable may be
encouraging dependence and disability4.
Our respondents’ attitude towards opioids in
the treatment of chronic pain resemble the American
Pain Society (APS) survey on its member pain
specialists in 199212. First, most surveyed stated that
they did treat at least some patients with chronic pain
with opioids, but there were reservations expressed
about this practice. Second, there was consensus that
opioids are underutilized, and that fear of addiction
is overemphasized, but there was concern expressed
about dependence and tolerance. Third, there was
strong agreement that the primary goal of therapy
should be functional improvement.
The majority (98%) of physicians recognized
the importance of pain management priority and
76% of the physicians acknowledged the problem of
inadequate pain management in their settings. Most
cited inability to access professionals who practice
specialized methods in this field, and inadequate staff
knowledge of pain management as barriers to good
pain management. A large majority of them expressed
dissatisfaction with their training for pain management
in medical school and in residency.
It seems that a culture of suspicion, limited
research, diverse and often difficult patient populations,
and challenging clinical environments have plagued
our physicians before special training in their approach
to pain management. Pain management is deficiently
dealt with in our medical school curricula, and the
treatment of pain is almost never given a format for
Attitudes Of Anesthesiology Residents And Faculty Members Towards Pain Management
formal teaching to medical students. This lack of
education was demonstrated in a survey of medical
students as freshmen and then repeated as seniors.
Weinstein et al13 found that prejudice toward the use
of opioid analgesics had increased during the 4 years
of medical school training. Opiophobia (prejudice
against the use of opioid analgesics) is used to describe
a barrier to the use and prescription of narcotic
analgesics. Regulatory and licensing concerns,
suspicion of ‘‘drug-seeking’’ behavior, concern for
addiction or dependence, and lack of follow-up or
continuity of care produce a culture in which adequate
treatment of pain is difficult to achieve14. Weinstein
and colleagues15 found that working physicians have
significant opiophobia, display lack of knowledge
about pain and its treatment, and have negative views
about patients who have chronic pain.
Opportunities to affect change in attitude and
improve treatment of pain should focus on medical
students and residency training programs. On a positive
note, residents' beliefs and concerns about using opioids
for chronic noncancer pain changed after participating
in a 4-hour interactive workshop16. This traininginduced change in attitude has already been revealed
in another way within the National Physician Survey
by Turk et al in 1994. They showed that specialists
have different attitudes towards prescribing opioids
for chronic pain based on their specialty training;
surgeons were most concerned and rheumatologists
were least concerned17. Different cultural ethnicity,
years in training, and previous self-experience of
pain also affect individual’s pain beliefs18. Our survey
resembles much to a similar study by Garcia and
colleagues4 in the methods, although we had dealt
more with acute pain service and we had extended
domains on training, opioid prescription, practice
settings, and barriers to effective pain management.
However, we observed more desirable responses
overall, which may be justified by our specialist and
527
academic sample with more clinical pain practice.
This is another instance in which appropriate training
has led to inline improvement in beliefs and attitudes.
Interestingly, we observed no significant difference
between the attitudes of residents and their attending
staff towards the ten domains in our survey. This is
consistent with the evidence that doctors' specialty,
but not demographic factors and level of education,
impacts their attitudes and beliefs19.
Changing the practice patterns of established
physicians remains extremely difficult. Nationwide
distribution and publication of practice guidelines for
the treatment of back pain have shown poor results
in changing behavior among working physicians20.
As an example, Werner and colleagues showed that
a low back pain (LBP) mass media campaign with
educational initiatives aimed at healthcare providers
did not result in important improvement in LBP beliefs
of providers exposed to the campaign21. On the contrary,
systematic educational intervention strategies may
change behavior of practicing physicians as described
by Ammendolia and colleagues22. They showed a
significant reduction in ordering radiography for LBP
by chiropractors after an evidence-based educational
intervention. Unfortunately, effective training tools to
change attitudes about pain and pain control among
practicing physicians have yet to be described14.
Summary
Changing the attitudes of anesthesiologists about
pain assessment and management will require attention
in several areas of research, education and training. A
combination of active continuing education programs
and dissemination of international guidelines and
routine professional education are needed to bring
about significant improvement in attitudes towards
pain medicine.
M.E.J. ANESTH 21 (4), 2012
528
M. P. khahi et al.
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BK, O'sullivan P. A Cross-cultural Study of the Back Pain Beliefs
of Female Undergraduate Healthcare Students. Clin J Pain; 2009
Jan, 25(1):20-8.
19.Fullen BM, Baxter GD, O'Donovan BG, Doody C, Daly L, Hurley
DA: Doctors' attitudes and beliefs regarding acute low back pain
management: A systematic review. Pain; 2008 Jun, 136(3):388-96.
20 Di Iorio D, Henley E, Doughty A: A survey of primary care
physician practice patterns and adherence to acute low back problem
guidelines. Arch Fam Med; 2000, 9(10):1015-21.
21.Werner EL, Gross DP, Lie SA, Ihlebaek C: Healthcare provider
back pain beliefs unaffected by a media campaign. Scand J Prim
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Manipulative Physiol Ther; 2004 Mar, 27(3):170-9.
Burnout and Coping Amongst
Anesthesiologists In a US Metropolitan
Area: A Pilot Study
Rebecca L. Downey*, Tammam Farhat
and R oman S chumann
Abstract
Background: Anesthesiology is technically complex, caring for sicker patients with growing
production pressure on clinicians. Wellbeing and a balanced lifestyle to prevent clinician burnout
and improve patient safety have been increasingly recognized. This study assesses burnout and
coping strategies in anesthesiologists in a metropolitan area of the Northeastern US.
Methods: An anonymous online questionnaire including the Maslach Burnout Inventory
and assessment of coping strategies was distributed via email to Boston area anesthesiologists.
Correlations between burnout, demographic variables, and coping strategies were examined.
Results: Of 57 respondents to the survey, moderate to high degrees of burnout were found
(61.4% emotional exhaustion, 31.6% depersonalization, 64.9% low personal achievement) and
associated with avoidant and emotion-focused coping behaviors. Significant relationships existed
between burnout and demographics including age, number of years in practice, perceived workload,
and academic versus private practice.
Conclusions: Burnout by anesthesiologists in this study is mainly characterized by emotional
exhaustion and low personal achievement. An association with severe workload, young age, and
moderate number of years in practice (5-15 years) was found. Positive coping strategies which
involved planning and reassessment of stressors as a source of personal growth were utilized by
older, more experienced and less burned out anesthesiologists.
Keywords: burnout, professional; stress, psychological; anesthesiologist; coping
Introduction
Burnout, described as emotional exhaustion, depersonalization and lack of personal
accomplishment in response to chronic occupational stress, occurs in many professions including
health care1, where it is associated with adverse patient outcomes and an increase in medical errors2,3.
Multiple studies have identified greater work load, longer work hours and/or increased number of
monthly calls as contributing to work stress4-13. However, burnout in and of itself increases error
rate3, though for anesthesiology specifically this has not been well studied14. Burnout may be an
independent performance risk factor that can be targeted to improve clinician wellbeing, patient
safety and work place quality. We conducted a pilot study to evaluate the extent of burnout and its
potential sources in private and academic medical centers in a metropolitan area in the Northeastern
United States (Boston). We evaluated correlations between burnout and demographic data including
*
Department of Anesthesiology, Tufts Medical Center, Boston, MA.
Corresponding author: Rebecca Downey, Department of Anesthesiology, Tufts Medical Center, 800 Washington Street,
Box # 298, Boston, MA 02111. E-mail: [email protected]
529
M.E.J. ANESTH 21 (4), 2012
530
age, gender, marital status, number of years in practice,
perceived workload and prior work experience. The
role of personal burnout coping strategies on the work
related stress experience was investigated. Our results
are discussed in the context of the current literature
and may contribute to design interventions to reduce
burnout and improve patient safety.
Methods
Study Design and Participants
Following IRB approval, chairpersons at Boston
area private and academic anesthesiology departments
were contacted with an explanatory e-mail and
asked to forward a survey link to their staff for study
participation. Anesthesiologists, residents and fellows
were invited to complete an anonymous questionnaire
with demographic questions, the validated Maslach
Burnout Inventory-Human Services Survey (MBIHSS) and coping strategy questions.
Assessment Tools
The MBI-HSS (Consulting Psychologists Press,
Inc., Mountain View, CA), examines three subscales
of burnout. The emotional exhaustion scale measures
emotional fatigue and overextension generated by
work place stressors. The depersonalization scale
assesses dehumanization of and impersonal feelings
towards the patient. The personal achievement scale
explores confidence and accomplishment in the
workplace and specifically in working with patients.
The MBI is an instrument originally developed and
validated for assessing the burnout syndrome in health
care workers. We computed the Chronbach alpha,
which measures the reliability of the assessment tool,
for each scale to both confirm it as a reasonable tool for
anesthesiologists and to explore certain questions that
may behave differently in this responder group.
Nine coping questions were modeled on the
Ways of Coping Scale by Lazarus and Folkman15
using a 7-point Likert scale and divided into two
categories to identify active, problem-oriented versus
passive, emotion-focused or avoidant coping patterns.
Active patterns included planning, feelings of personal
growth, and exercise. Passive or avoidant patterns
included wishful thinking, detachment, seeking of
R. L. Downey et al.
emotional support, negative self talk, avoidance, and
tension reduction with destructive behaviors.
Statistical Analyses
Data for each survey question were summarized
and distributions examined to assess data quality and
missing values. The MBI-HSS scales were calculated
and categorized as high, moderate, and low burnout
using the MBI Scoring key2. In cases of the missing
scale items, values were imputed as the mean of nonmissing items before total score summing as long
as at least half of the scale items were non-missing.
Distributions of anesthesiologists demographics and
responses were compared between the high, mid, and
low burnout groupings within the MBI-HSS subscales
to examine unadjusted relationships using chi-square
tests for categorical variables, Kruskal-Wallis tests for
scales and ordinal variables, and Analysis of Variance
for continuous variables. Pearson correlations
were used for associations with the MBI-HSS in its
continuous form.
To further explore factors associated with
burnout, as quantified by the MBI-HSS subscales in
their continuous form, multivariable linear regression
models were constructed using a combination of
stepwise regression and best subsets regression.
Variables with p-values for the unadjusted associations
with the outcomes of ≤0.25 were considered as
candidates for initial stages of the model building
process. The fit and stability of the final model for each
of the three MBI-HSS burnout items was examined by
looking at the residuals and sequentially removing
influential points and possible outliers to check the
impact on the model parameters (SAS version 9.2,
2002-2008, Windows, SAS Institute Inc., Cary,
NC). A p-value of <0.05 was considered statistically
significant.
Results
Demographics
Sixty-one surveys were accessed and 57 were
completed. Table 1 summarizes demographics and
perceived workload of participants. Demographics of
our study compared to prior anesthesia burnout studies
are shown in Table 2.
Burnout and Coping Amongst Anesthesiologists In a US Metropolitan Area: A Pilot Study
Table 1
Demographics of Work Stress Survey Responders (N = 57)
Age
45.6 ± 12.0 (54)
Male
66.7% (38/57)
Type of institution
Academic
Both
Private
N = 57
57.9% (33)
33.3% (19)
8.8% (5)
Position
Attending
Junior Resident
Senior Resident
N = 56
80.4% (45)
7.1% (4)
12.5% (7)
Years of practice
Current resident/fellow
1-5
6-10
11-15
15-20
>20
N = 57
14.0% (8)
28.1% (16)
14.0% (8)
3.5% (2)
12.3% (7)
28.1% (16)
Marital status
Married/partnership
Single
N = 56
82.1% (46)
17.9% (10)
Race
Asian/Pacific Islander
Black (not Hispanic)
Hispanic
Other
White (not Hispanic)
N = 56
10.7% (6)
1.8% (1)
7.1% (4)
7.1% (4)
73.2% (41)
Have children, % yes
70.9% (39/55)
Live alone, % yes
12.7% (7/55)
Full time (vs. part time), %
94.5% (52/55)
Workload
Light-moderate
Moderate
Moderate-severe
Severe
N: number of participants
N = 56
3.6% (2)
32.1% (18)
50.0% (28)
14.3% (8)
Table 2
Comparison demographics to prior studies (Anesthesiology)
Morais
Kinzl
Nyssen
et al.
et al.
et al.
(2006)21 (2007)23 (2003)17
Kluger
et al.
(2003)11
Sample Size
236
86
151
422
Age (average or
most frequent)
46.7
31-40
32
41-50
84:179
53:33
98:53
349:73
M:F
Single:partnership
56:207
20:69
-
-
Children (yes:no)
215:48
38:51
-
-
Staff vs. resident
-
38:51
139:32
-
531
Burnout
Burnout scores demonstrated moderate to high
degree of emotional exhaustion in anesthesiologists
(Table 3, 4). A high degree of depersonalization
towards patients was infrequent, but less than 40% of
responders had a moderate or high sense of personal
work related accomplishment. Significant relationships
existed for demographics, coping questions, and
specific subsets of the MBI-HSS.
Table 3
Mean burnout scores in anesthesiologists in the greater
Boston area compared to average North American
values. (mean, SD, range)
MBI-HSS Subscale
(range)
Greater
Boston Area
(n = 57)
North America
(n = 1104)
Emotional Exhaustion
(0-54)
21.3 (10.8)
(3-45)
22.2 (9.5)
Depersonalization (0-30)
5.7 (5.3)
(0-22)
7.1 (5.2)
Personal Accomplishment
(0-48)
SD: standard deviation
40.0 (5.4)
(25-48)
36.5 (7.3)
Table 4
Burnout Scores by Subscale
Emotional Exhaustion
N = 57
1.HIGH: 27+
29.8% (17)
2.MOD: 17-26
31.6% (18)
3.LOW: 0-16
38.6% (22)
Depersonalization
N = 57
1.HIGH:13+
10.5% (6)
2.MOD: 7-12
21.1% (12)
3.LOW: 0-6
68.4% (39)
Sense of Personal Accomplishment
N = 57
1.HIGH: 0-31
7.0% (4)
2.MOD: 32-38
28.1% (16)
1.LOW: 39+
N: number of participants
64.9% (37)
Coping
Anesthesiologists engaged predominantly in
active coping patterns rather passive ones (Table 5).
The most common strategies were active resolution
of stressful situations and professional growth from
overcoming the stressor. Least common strategies
M.E.J. ANESTH 21 (4), 2012
532
R. L. Downey et al.
involved isolation and activities perceived as negative
or destructive.
Table 5
Mean responses to coping questions
Question
Mean (SD)
N
I make a plan and follow it.
4.92 ± 1.48
52
I wish the situation or problem would go
2.81 ± 1.89
away and would not happen.
52
I try to forget the situation.
2.10 ± 1.95
51
I talk to someone about how I feel.
3.74 ± 1.79
54
I am growing as a professional and as a
4.83 ± 1.49
person.
52
I criticize and lecture myself.
3.51 ± 1.70
51
I avoid people and avoid talking about it. 1.29 ± 1.52
52
I exercise.
52
4.11 ± 1.76
I make myself feel better by engaging in
0.47 ± 0.88 51
activities that I later regret.
Response options: 0 = never, 1 = a few times a year, 2 = once a
month or less,
3 = a few times a month, 4 = once a week, 5 = a few times a
week, 6 = every day
SD: standard deviation, N: number of participants
Emotional Exhaustion Subscale
Moderate and high emotional exhaustion
was strongly associated with perceived severe
and moderate-severe workload (P = 0.0001). Less
emotionally exhausted anesthesiologists reported
fewer incidences of trying to forget the situation
(detachment) (P = 0.005), and of avoiding people or
avoiding discussion of the situation (avoidance) (P
= 0.02), but rather were growing professionally and
personally (P = 0.04). Highly emotionally exhausted
participants were more likely to feel detached (P =
0.04) and depersonalized (P = 0.003). Older age was
associated with less emotional exhaustion (P = 0.002).
Depersonalization Subscale
Anesthesiologists just starting practice (1-5
years) or with long-term experience (>20) had a
low level of depersonalization (P = 0.0009). High
depersonalization scores were significantly related
to high emotional exhaustion scores (P = 0.003).
Participants demonstrating low depersonalization were
less likely to engage in detachment (P = 0.02) and more
likely to cope by planning (P = 0.02). All participants
with high depersonalization scores engaged in a
significant degree of negative self talk (self criticism/
lecturing), P = 0.02).
Sense of Personal Accomplishment Subscale
Academic practice resulted in a decreased sense of
personal accomplishment compared to private settings
(P = 0.009). Anesthesiologists with a high sense of
personal accomplishment were more likely to plan (P =
0.03) and experience personal and professional growth
(P = 0.0007).
The multivariable linear regression of burnout
confirmed univariate analyses results. Avoidance was
strongly associated with greater emotional exhaustion
and higher workload. Older age was predictive of
less emotional exhaustion. Coping strategies that
involved detachment and avoidance were associated
with higher depersonalization scores whereas planning
was associated with less depersonalization. The
perception of growing as a professional was predictive
of a stronger sense of personal accomplishment. An
academic career was associated with a decreased sense
of personal accomplishment.
Discussion
Since Maslach described the relationship of
workplace environmental factors and the subjective
experience of burnout and fatigue in health
professionals1, research in this area has evolved.
The acuity and intensity of challenges in a work
environment such as anesthesiology, which is
stressful at baseline, may lead to a high degree of
burnout16. Despite this conclusion, burnout levels
in anesthesiologists compared with those of other
specialties did not indicate a disproportionately
high anesthesiology burnout rate17. Indeed, a Dutch
study of residents revealed higher burnout rates in
psychiatry than in any other medical specialty in the
study 18, and a Spanish investigation of anesthesia
clinicians determined their burnout levels to be lower
than in other medical specialties, but comparable to
anesthesiologists in other nations19.
In the greater Boston area, our study identified
a moderate degree of burnout in anesthesiologists and
anesthesiology residents which was characterized by
Burnout and Coping Amongst Anesthesiologists In a US Metropolitan Area: A Pilot Study
lack of personal accomplishment (67%) and emotional
exhaustion (61%) more than by depersonalization
(31%). Boston anesthesiologists reported a greater
sense of personal accomplishment than North
American averages but were equivalent in other
domains of burnout11 and, compared to an Australian
study11, experienced greater emotional exhaustion
but also a greater sense of personal accomplishment.
Lack of recognition11 and having patients question the
physician’s abilities8 were predictors of burnout and
emotional exhaustion 8,11. Of the factors identified in
our study, the most significant one linked to emotional
exhaustion was workload though coping styles
involving detachment and depersonalization also
contributed. Older anesthesiologists displayed less
emotional exhaustion, but the reason for this finding is
unclear. Peak burnout during mid-career in emergency
physicians, for example, indicated either a “survivor”
effect due to early retirement of those burned out or
the development of effective coping skills in those
continuing in their profession20. A similar interpretation
may explain our result. Similarly, the number of
years in practice (more than 5 but less than 15 years)
rather than age was more significantly related to the
domain of depersonalization burnout. Negative coping
strategies (avoidance, detachment, negative self-talk,
and tension reduction with destructive behaviors), but
not workload, also contributed to depersonalization.
We found a greater sense of accomplishment
in anesthesiologists who are single and without
children which supports earlier research suggesting
that clinicians with families or partners experience
more stress and burnout than singles4,8,10,21. In addition,
women reportedly experience higher burnout rates than
men5,6,11,21,22,23 particularly if they had more children21.
Only one study suggested fewer or comparable burnout
symptoms in women with versus those without
children, but this was attributed to more perceived
control over their work place24, as a lack thereof
of control8,17,23,24,25,26 and a lack of administrative,
technical and emotional support27,28,29 correlate with
higher burnout rates. A trend of increased feelings
of personal accomplishment in private practice
versus academic centers in our study was surprising,
considering physicians’ greater work stress experience
in smaller community hospitals6,21 and its association
with production pressures and perceived health care
533
commercialization that could fuel burnout16. If part
time work, which was reported more frequently by our
private practice responders, provides a sense of greater
work environment control, this could explain the result
in our study sample.
Positive coping strategies including planning
and perception of stress as an opportunity for personal
growth, were more often employed by participants
that had a high sense of personal accomplishment in
our study. Perception of an adverse event or critical
development as a challenge that can be mastered rather
than a stressor to which the clinician is subjected
reduces work stress30. Emotion-focused coping27,
disengagement12, passivity, isolation, avoidance or
underestimation of the stressor31,32, reduced exercise
and increased alcohol consumption20 have been
associated with burnout. Personality characteristics
such as introversion, conscientiousness, and negative
affect are specific risk factors for burnout12,33, as well
as a decreased sense of self efficacy10 and decreased
perceived capability23. Thus, Bandura’s concept of self
efficacy, i.e. the perception that one can effectively
carry out a task, is vital burout protection34. Additional
protection from burnout or its resolution can be
expected from leadership and involvement in work
environment modification, both of which have been
shown to reduce stress levels21. Clearly, problemoriented coping mechanisms are more effective for
long-term stress relief than more passive, emotionfocused and disengaged/avoidant strategies35.
Our study is limited to a small number of
respondents, and a separate assessment of residents
versus attendings would be desirable. However, our
results indicate a continued need to systematically
address burnout prevention and resolution strategies
for anesthesiologists. A link between anesthesiologist
burnout and patient outcomes should be studied on a
national level. Additionally, departmental, institutional
and organizational research and development is
needed to facilitate identification, effective treatment
and future prevention of health clinician burnout, as
well as recognition of contributing system factors that
could be modified.
Acknowledgements: We thank Robin Ruthazer,
MPH, of the Tufts Clinical and Translational Science
Institute for her assistance with the statistical analyses.
M.E.J. ANESTH 21 (4), 2012
534
R. L. Downey et al.
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THE INCIDENCE OF RESIDUAL NEUROMUSCULAR
BLOCKADE ASSOCIATED WITH SINGLE
DOSE OF INTERMEDIATE-ACTING
NEUROMUSCULAR BLOCKING DRUGS
NIL KAAN*, OZLEM KOCATURK**, IBRAHIM KURT*
and HALIL CICEK ***
Abstract
Background: The goal of this study is to investigate the incidence and risk factors of
residual paralysis associated with single-dose intermediate-acting muscle relaxants (atracurium,
vecuronium, rocuronium) during early postoperative period.
Methods: Adult patients (ASA I and II) who received a single dose of vecuronium, atracurium
or rocuronium during general anesthesia for elective surgical procedure were included in the study.
Train-of-four (TOF) ratios under 0.9 were recorded as “postoperative residual neuromuscular block
(PRNB)”. Age, weight, gender, reversal, anesthesia duration, time for transfer to the recovery room
after extubation were studied regarding with PRNB.
Results: 84 patients were included in this study. 29 patients were received vecuronium, 28
patients were received atracurium and 27 patients were received rocuronium. Neostigmine was
used for reversal in 49 patients (58.3%) at the end of the surgery. PRNB incidence (TOF<0.9) was
13.1%. Based on the regression analysis, the only risk factor affecting PRNB was found as gender.
PRNB risk was increased in women (OR: 7.250, 95%, CI: 1.019-51.593).
Conclusion: In patients who have general anesthesia longer than one hour, “gender” may
affect residual paralysis incidence associated with single-dose intermediate-acting muscle relaxants
use.
Key words: neuromuscular blockade, residual paralysis, neuromuscular monitoring,
atracurium, vecuronium, rocuronium.
Introduction
Neuromuscular blocking drugs (NMBDs) are widely used to facilitate endotracheal intubation
during anesthesia induction and provide muscle relaxation during surgery. Postoperative residual
neuromuscular block (PRNB), postoperative residual paralysis or residual curarization are defined
as; “the presence of postoperative muscle weakness signs or symptoms after the administration
of an intraoperative non-depolarizing NMBDs”1. While, in practice, the sufficiency of recovery
in neuromuscular functions and reversal treatment (acetycholinesterase inhibitor) are evaluated
based on clinical signs, neuromuscular transmission monitoring is considered not only possible
*
**
***
MD, Associate Professor, Adnan Menderes University Hospital, Department of Anesthesiology, Aydin, Turkey.
MD, Bartin Hospital, Department of Anesthesiology, Bartin, Turkey.
MD, Korkuteli Hospital, Department of Anesthesiology, Antalya, Turkey.
Corresponding author: Nil Kaan, Associate Professor, Adnan Menderes University Hospital, Department of
Anesthesiology, Aydin, 09010, Turkey. Tel: +90 256 4441256, Fax: +90 256 214 40 86. E-mail: [email protected]
535
M.E.J. ANESTH 21 (4), 2012
536
N. KAAN et al.
but also a requirement for objective and quantitative
assessments2. Acceleromyography is frequently used
in PRNB research as a useful and objective monitoring
method3. In the past years, the threshold value for
train-of-four (TOF) ratio was 0.7, and values less than
this threshold were considered as PRNB. Because of
studies showed that upper airway protective reflexes
are not completely recovered and aspiration risk is
high at this level; 0.9 was accepted as the threshold
value for TOF ratio4-7.
According to clinical findings, objective data
obtained through neuromuscular monitoring showed
that intermediate-acting NMBDs associated PRNB
incidence was quite high1,8. Naguip et al8 report the
incidence to be 41%.
In this study, we investigated the incidence and
affecting factors of PRNB associated with singledose intermediate-acting non-depolarizing NMBDs,
(vecuronium, atracurium, rocuronium) in patients
during the early postoperative period.
Patients and Methods
Patients
This prospective and observational study was
conducted after obtaining informed consent forms from
the patients after getting permission of the local ethics
committee. The American Society of Anesthesiologists
(ASA) I and II adult patients who underwent elective
surgical operation under general anesthesia were
included in this study. And they received single-dose
intermediate-acting NMBDs (vecuronium, atracurium
or rocuronium) in order to facilitate endotracheal
intubation.
Patients who had renal, hepatic, neuromuscular
and metabolic diseases, craniotomy, cardiac, thoracic,
major vascular surgeries, emergency surgeries,
anesthesia duration longer than 120 minutes, surgical
procedures requiring excessive amount of blood and
liquid replacement, body mass index (BMI) over 30%,
pregnant and who did not want to participate in the
study, were excluded from the study.
Study Design
The decisions about the anesthetic agents,
muscle relaxants, reversal with neostigmine after the
completion of the surgery, extubation and transfer to
the recovery room were made by the anesthesiologist.
Patients were brought into the recovery room by
the anesthesiologist after the operation and, they were
quickly checked whether they meet the criteria to be
included in this study or not by using the anesthesia
recording chart. The patients received neuromuscular
transmission monitoring using acceleromyography
(TOF-Watch SX Monitor®, Organon Ltd, Dublin,
Ireland), in addition to routine hemodynamic
monitoring. The ulnar nerve was stimulated with TOF
stimulation (4 pulses 0.2 ms in duration, at a frequency
of 2 Hz). A supra-maximal stimulation of 50 mA was
applied. Three consecutive TOF stimulations were
applied and recorded at 15-second intervals. The
evoked responses at the thumb were calculated and
two thresholds of the TOF ratio (0.9) were used to
assess the presence of a PRNB.
Based on anesthesia charts of patients, age,
weight, gender, intravenous and inhalation agents used
in anesthesia induction and maintenance, anesthesia
duration, duration between extubation and transfer to
the recovery room and whether they had reversal with
neostigmine or not were recorded.
During the follow-up in the recovery room
patients, whose peripheral oxygen saturation decreased
below 93%, were applied 2-3 lt/min oxygen using a
face mask. Patients who were clinically thought to
have residual effects of muscle relaxants received a
second dose of reversal medications (0.5 mg atrophine
with 0.03 mg/kg neostigmine). These interventions
were recorded.
Statistical analysis
SPSS 10.0 (Statistical Package for Social
Sciences-SPSS Inc. Chicago, IL) program was used in
the statistical analysis of data. Kolmogorov-Smirnov
test showed that; age, weight, anesthesia duration,
duration between extubation and transfer to recovery
room had normal distribution. Since the age variable
showed normal distribution, descriptive statistics
are summarized as mean±standard deviation, and
for comparison based on groups, with independent
t-test was used. Due to other variables not showing
normal distribution, descriptive statistics are shown
THE INCIDENCE OF RESIDUAL NEUROMUSCULAR BLOCKADE ASSOCIATED WITH SINGLE DOSE OF
INTERMEDIATE-ACTING NEUROMUSCULAR BLOCKING DRUGS
537
(41.7%). Median anesthesia duration was 80 minutes.
Patients were taken to the recovery room from the
operating room in 9 minutes (5-10 minutes, 25th-75th
percentiles) as median time (Table 1).
as median (25th-75th percentiles) and Mann-Whitney
U test was used for comparisons according to groups.
In order to investigate risk factors that may affect
residual curarization, Stepwise Logistic Regression
analysis was conducted. Chi-square test was used for
comparing frequencies. Any p value of <0.05 was
considered statistically significant.
Table 1
Demographic characteristics of patients
Gender (Female / Male) (n)
37 / 47
Results
Age (mean ± standard deviation) (year)
40.0 ± 15.2
84 patients were included in this study. The
distribution of patients according to their demographic
characteristics and operation types is shown in Table
1. Propofol (2-3 mg/kg), fentanyl (1-2 µg/kg) and
lidocaine (1 mg/kg) were used for anesthesia induction
in all patients. In order to facilitate endotracheal
intubation, vecuronium (0.1 mg/kg) was administered
to 29 patients, 28 patients received atracurium (0.6
mg/kg), and 27 patients received rocuronium (0.5 mg/
kg). For the maintenance of anesthesia, isoflurane
was administered to 52 patients and sevoflurane was
administered to 32 patients. After the operation, 0.03
mg/kg neostigmine and 0.5 mg of atrophine was
administered to 49 patients, reversal application rate
was 58.3%. Reversal was not applied to 35 patients
Weight [median (25th-75th percentiles)] (kg)
70 (60.277.5)
ASA I / II (n)
70 / 12
Anesthesia duration
percentiles)] (minute)
[median
(25th-75th 80
100)
(60-
Extubation–Time to recovery room
[median (25th-75th percentiles)] (minute)
9 (5-10)
Surgery types
17
14
21
32
Ear-Nose
Orthopedics
Plastic
Laparoscopy
Among 84 patients in 11 patients (13.1%), TOF
ratio measured at the recovery room arrival was less
than 0.9. Gender, reversal use, and type of NMBDs
distribution are summarized in Table 2. Postoperative
Table 2
Comparison of patients who did and did not have postoperative residual neuromuscular block
TOF ≥ 0.9
(n=73)
TOF<0.9 (n=11)
P
40
9
0.090
33
2
25
3
24
3
24
5
29
8
44
3
Age (year) (mean ± SD)
39.7 ± 15.6
41.6 ± 12.7
0.701
Weight (kg) [median (25th-75th percentiles)]
70 (60-77)
67 (62-83)
0.947
Extubation- recovery room duration (minute)
[median (25th-75th percentiles)]
10 (5-10)
5 (5-10)
0.043
80 (60-100)
90 (45-100)
0.858
Reversal drug (n)
NMBDs (n)
Gender (n)
present
absent
atracurium
rocuronium
vecuronium
female
male
Anesthesia duration (minute)
[median (25th-75th percentiles)]
TOF, Train of Four
NMBDs, Neuromuscular blocking drugs
SD, standart deviation
0.715
0.040
M.E.J. ANESTH 21 (4), 2012
538
N. KAAN et al.
residual neuromuscular blockade frequency was found
to be higher in female patients compared to males
(P=0.040) (Table 2). When age, weight, and anesthesia
duration were compared, no difference was determined
between the patients with and without PRNB (Table
2). Time duration from extubation to the recovery
room was found to be shorter in those who had PRNB
compared to those who did not (median time 5 minutes
and 10 minutes, respectively) (P= 0.043).
Based on the logistic regression analysis, gender
was determined to affect PRNB. Female gender is a
factor which increased PRNB (Odds ratio 7.250, 95%
CI: 1.019-51.593). Other risk factors were not found to
have a significant effect on PRNB (Table 3).
In the recovery room, peripheral oxygen
saturation of 10 patients decreased below 93%, and
additional dose of reverse was administered to two of
them.
Discussion
In this study, among patients who had
endotracheal intubation using atracurium, vecuronium
or rocuronium and did not receive additional dose of
intraoperative neuromuscular blocker, 13.1% of them
were determined to have continuing PRNB (TOF
ratio <0.9) when they arrived to the recovery room. In
women, PRNB incidence was higher compared to men,
and female gender was determined to be a factor in
increasing PRNB (Odd’s Ratio 7.250; 95% Confidence
levels of OR: 1,019-51,593). Age, weight, reversal
with neostigmine, anesthesia duration, intermediateacting NMBDs used and time duration from operating
room to recovery room were not determined to have
any effect on PRNB.
Studies show that “effect potential and duration
of neuromuscular nondepolarizing blocking agents
vary based on gender; women are more sensitive than
men and these drugs have longer effects in women9-16.
Semple et al11 reported that women are more sensitive to
vecuronium than men and in order to achieve the same
level of neuromuscular block, they require 22% less
drugs. Xue et al12 showed that during TOF monitoring
following vecuronium administration, average T1
depression was 43% greater, dose-response curve of
vecuronium shifted to the left and it has prolonged
efficacy in women, compared to men. In another
study13, the same authors reported that compared
to women, plasma vecuronium concentration was
found to be low in men due to a higher vecuronium
distribution volume.
In two studies conducted by Adamus et al14 and
Xu et al15 it was published that, women were more
sensitive to rocuronium, onset time of rocuronium
was shorter and had prolonged effective period. Based
on this research, both authors stated that the dose
of rocuronium routinely used in women could be
reduced14,15.
In another study, atracurium clearance was
reported to be greater in men than women and
elimination half-life to be shorter, however, distribution
volume was not affected by gender16. On the other
Table 3
Logistic regression analysis for postoperative residual neuromuscular blockade
Odd’s Ratio (OR)
(%95 Confidence levels of OR)
Beta
P
Age
1.016 (0.958-.076)
0.015
0.602
Gender (#female/male)
7.250 (1.019-51.593)
1.981
0.048
Anesthesia duration
0.977 (0.942-1.014)
-0.023
0.215
Reverse (#absent/present)
0.144 (0.019-1.082)
-1.938
0.060
Weight
1.066 (0.985-1.153)
0.064
0.111
Extubation- recovery room duration
0.816 (0.625-1.065)
-0.204
0.134
Neuromuscular blocker
1.303 (0.191-8.904
0.265
0.577
# Baseline
THE INCIDENCE OF RESIDUAL NEUROMUSCULAR BLOCKADE ASSOCIATED WITH SINGLE DOSE OF
INTERMEDIATE-ACTING NEUROMUSCULAR BLOCKING DRUGS
hand, Xue et al18 show that atracurium action duration
and dose response curve vary between genders, the
effective dose was greater and action duration was
approximately 25% shorter in men compared to
women17.
Studies showing the effect of gender on PRNB
are few. Alkhazrajy et al18 evaluated residual muscle;
in the group that received muscle relaxants, muscle
weakness levels were shown to be different between
genders at one hour after the operation. The hand
shaking power of women who received vecuronium or
rocuronium was determined to be significantly lower
than men (32% and 34% in women, 14% and 19% in
men, respectively)18. Based on these findings, female
patients who received muscle relaxants during general
anesthesia were reported to possibly have a greater
predisposition for PRNB and postoperative pulmonory
complications associated with it19. The variability
of sensitivity and action duration of neuromuscular
blockers, between men and women, is thought to
be associated with physiological difference in body
structures. It has been reported that, women having
a greater amount of fat tissue, and less muscle mass
may lead to a decrease of distribution volume and an
increase of plasma concentrations of muscle relaxant
drug12,13,15. Due to lower levels of total protein and
albumin in the plasma of women, drugs that attach to
albumin at a 30% rate such as vecuronium, may increase
in the plasma12-14. In addition, due to gender related
differences in liver microsomal enzyme activity, drugs
that are metabolized in the liver were published to be
broken down faster in men15. Also, in this study, PRNB
incidence was determined to be higher in women,
compared to men, possibly associated with prolonged
action duration of neuromuscular blockers.
Studies that quantitatively evaluate neuromuscular
transmission using objective monitoring methods
such as acceleromyography and mechanomyography
have shown the PRNB incidence associated with
nondepolarizing neuromuscular blockers to be quite
high. In these studies, PRNB incidence vary between
2% and 64%, many factors associated with perioperative
approach may influence the results1. In their study
where vecuronium, atracurium and rocuronium were
used for only intubation, intraoperative neuromuscular
monitoring was not performed and none of the patients
539
was administered a reversal drug, Debane et al20
determined NMB incidence to be 45%. In the same
study, they reported continued residual block (TOF<
0.9) in 37% of patients whose operation duration
surpassed two hours20. However, Baillard et al21
who performed neuromuscular monitoring on 60%
of patients and used reversal drug in 42% of them,
published vecuronium and atracurium associated
PRNB incidence to be 3.5%. On the other hand,
Murphy et al4 used reversal drug and neuromuscular
monitoring on all patients and determined postoperative
PRNB to be at a rate of 30%. After this, in their study
investigating PRNB incidence, its causes and possible
risk factors, the same researchers1 evaluated in detail
possible reasons for such discrepancy between results.
They reported the following important differences
between the studies: 1. Clinical characteristics
of patients, 2. Operations performed and their
duration, 3. Type of neuromuscular blockers used, 4.
Cumulative dose used for maintenance, 5. Reversal
drug (acetylcholinesterase inhibitor) use and time of its
administration, 6. The method chosen for intraoperative
neuromuscular transmission monitoring1. In our study,
PRNB incidence was 13.1%, which is low compared
to similar studies. We believe that the participation of
healthy, adult patients (ASA I,II) in the study, the lack
of additional nondepolarizing neuromuscular blocker
use, anesthesia duration of 60-100 minutes (27-75
percentiles) and reversal with neostigmine in 58.3%
of patients, were effective in the low PRNB incidence
determined in our study.
There are studies which report that there is no
difference in PRNB incidence among intermediateacting NMBDs24,25. In one of these studies, where
Hayes et al22 studied 150 patients who had vecuronium,
atracurium and rocuronium administered, they
determined the PRNB (TOF <0.8) to be 64%, 52%,
39%, respectively, when they arrived at the recovery
room, and no difference between the three muscle
relaxants was reported. They suggested the high
incidence was associated with the high number of
elderly patients22. However, studies that determined
a statically significant difference are also present25.
In a study which looked at 107 female ASAI-II
patients who had elective breast surgery, Khan et al25
found that rocuronium (37%) had a greater residual
curarization (TOF <0.7) incidence compared with
M.E.J. ANESTH 21 (4), 2012
540
vecuronium (17%). In our study, however, a difference
in postoperative PRNB incidences was not determined
between atracurium, vecuronium and rocuronium.
Although there are studies reporting the use of
acetylcholine esterase inhibitor in order to eliminate
the residual effects of nondepolarizing NMBDs does
not change PRNB incidence23, reversal drug use
have been shown to reduce PRNB risk by numerous
studies26,27. Based on these results, many authors
stressed the necessity of the use of reversal drugs to
decrease PRNB risk, furthermore, they suggested
that in patients who had nondepolarizing NMBDs
administered, reversal drugs should be used routinely,
if neuromuscular function cannot be monitored
quantitatively26-29. Despite the implementation of
reversal with acetylcholinesterase inhibitor drugs,
if TOF ratio is still below 0.9, it is reported that this
might also be associated with insufficient reversal
medication30.
Another reason for the insufficient recovery
of muscle power during early postoperative period,
despite the use of reversal drugs, may be associated
with the maximum effect of neostigmine that has
not begun yet. In patients who were administered
rocuronium, Murphy et al31 discovered that on average,
eight minutes after reversal with neostigmine, 88% of
patients had TOF ratios less than 0.9, after 19 minutes,
they found this ratio to go below 32% and recommended
rocuronium antagonism to be administered 20 minutes
before extubation31.
In our study, we could not find the effect of
reversal drug use on PRNB. The median anesthesia
duration in the study was 80 minutes (27-75 percentiles:
60-100 minutes); we did not have intraoperative
neuromuscular monitoring, however, in a some of the
patients, the effect of neuromuscular drugs may have
terminated during this time. Furthermore, recording
of TOF ratio before neostigmine shows its maximum
effect may have affected our result. Because, the time it
took to be moved to the recovery room after extubation
was shorter in patients who were determined to have
PRNB, compared to those who did not (P=0.043)
(median values: 5 and 10 minutes, respectively).
N. KAAN et al.
It has been published that effects of NMBDs were
prolonged in the elderly, PRNB incidence increased up
to 65%, in older patients, muscle relaxant distribution
and spontaneous recovery associated with change in
eliminations decelerated and antidote use accelerated
recovery22. However, Baillard et al21 reported that the
age factor did not have an effect on PRNB. In our
study, an effect of “age” on PRNB was not found. We
believe that low number of older patients and the lack
of serious systemic diseases among patients included
in the study, may be influential in the result obtained.
While the length of anesthesia duration is one
of the most important factors affecting PRNB, results
from studies on this subject are variable. In studies
where a single-dose intermediate-acting muscle
relaxant is used for intubation, “anesthesia duration” is
a factor that increases PRNB risk32, however, in studies
with moderately long anesthesia duration, this risk
was not determined20. In studies with long anesthesia
duration, it has been stressed that if the frequency of
muscle relaxant use has increased during maintenance,
PRNB risk associated with increased dose escalates32.
In summary, PRNB may be missed with subjective
or qualitative assessments, even in the absence of
clinical symptoms and findings, TOF ratio may be
between 0.4 and 0.91. Even if sufficient ventilation
can be provided for patients with normal tidal volume,
airway and coughing reflexes may be insufficient,
due to pharyngeal dysfunction; aspiration risk may
increase, hypoxia, and chemoreceptor sensitivity may
decrease6,7. The effects of single-dose intermediateacting NMBDs administered to healthy, adult patients;
may continue even after one hour and with 58.3%
patients who had reversal. In patients who do not have
a serious systemic disease, “age” and “weight” may
not have an effect on PRNB, however, compared to
males, in female patients, PRNB may be seen more
frequently, possibly associated with longer action
duration of atracurium, vecuronium or rocuronium.
Based on the results from our study, we believe that
the fact that PRNB associated with intermediate-acting
muscle relaxants may have longer duration in female
patients compared to males, should be taken into
consideration.
THE INCIDENCE OF RESIDUAL NEUROMUSCULAR BLOCKADE ASSOCIATED WITH SINGLE DOSE OF
INTERMEDIATE-ACTING NEUROMUSCULAR BLOCKING DRUGS
541
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M.E.J. ANESTH 21 (4), 2012
Efficacy of three IV non-opioid-analgesics
on opioid consumption for postoperative pain
relief after total thyroidectomy:
*
a randomised, double-blind trial
Susanne Abdulla, Regina Eckhardt,
Ute Netter and Walied Abdulla
Abstract
Objectives: In a randomized, double-blind trial, the synergistic action of intravenous
parecoxib, metamizol or paracetamol on postoperative piritramide consumption was compared in
patients recovering from total thyroidectomy during the first 24h while evaluating pain intensity
and patient satisfaction.
Methods: 120 patients were randomly allocated to four patient groups treated with normal
saline and/or one of non-opioid analgesics (parecoxib 40mg twice daily, metamizol 1g three times
daily, paracetamol 1g three times daily) in addition to piritramide using the PCA pump. Beginning
in the recovery room (PACU), patients were asked every 2h for 6 hours and afterwards once every
6h to quantify their pain experience and patient satisfaction while piritramide consumption was
recorded.
Results: Upon arrival in the PACU piritramide consumption was high and decreased thereafter
significantly in all groups (P<0.05). There were no significant differences between groups in
incremental and cumulative piritramide consumption during the investigation. Also, VAS scores
were high upon arrival in the PACU and dropped in all groups continuously after surgery: At 2h and
4h after surgery they were significantly lower in parecoxib group compared with NaCl (P<0.01).
For overall patient satisfaction, no significant differences were observed. Pain relief scores at 24h
were significantly higher in parecoxib group as compared to metamizol and paracetamol (P<0.01).
Mild PONV was observed frequently in all groups and was treated with metoclopramide.
Conclusion: There is no clear-cut difference between the non-opioid drugs used, even though
parecoxib seems to be superior in regard to VAS scores and piritramide consumption. However, the
clinical significance is debatable.
Key words: piritramide; non-opioid analgesics; postoperative pain management; PCApump; thyroidectomy.
Introduction
Thyroid surgery is a procedure with moderate pain intensity of short duration postoperatively1-2.
A variety of analgesic techniques with controversial results have been used to relieve pain after
*
Department of Anesthesiology and Intensive Care Medicine Klinikum Bernburg, Teaching Hospital, Martin Luther
University Halle-Wittenberg, Germany.
Corresponding author: Prof. Dr. med. habil. Walied Abdulla, Robert-Kirchhoff-Str. 12, D-06406 Bernburg, Germany,
Fax: +49-3212-1175797. E-mail: [email protected]
543
M.E.J. ANESTH 21 (4), 2012
544
S. Abdulla et al.
thyroid surgery2-8. In a study by Gozal et al, the mean
pain level on a visual analog scale (VAS) ranging from
0 to 10 was 6.9 cm and 90% of the patients received
morphine on the first postoperative day9. Other studies
have confirmed the need for opioid analgesia in the
early postoperative period4-6. Because of its ability
to titrate to individual needs, IV patient controlled
analgesia (PCA) is considered as the “gold standard”
for delivery of IV opioids for the management of
postoperative pain10. It is used not only in major surgery,
but also in minor surgery for providing postoperative
analgesia11-12.
Opioids, however, have a range of side effects
such as nausea and vomiting as well as dizziness and
respiratory depression. In addition, thyroid surgery as
cervical procedure carries a high risk of postoperative
nausea and vomiting (PONV), particularly when
performed in women13-14. Therefore, because of their
synergistic action, a combination of opioid and nonopioid analgesics are often used to enhance analgesic
efficacy and reduce side-effects of opioids caused by
intravenous patient-controlled analgesia (PCA)6,15.
Although the majority of PCA studies were
conducted with morphine alone and in combination
with many other drugs to augment analgesic effect or to
reduce the adverse events16-26, piritramide has been used
in parts of Europe and South America as the analgesic
opioid of choice for the management of postoperative
pain27. Its relative analgesic potency compared with
morphine is approximately 0.7. Its duration of action
lasting for 4 to 6 hours is relatively long; hemodynamic
changes are not expected to occur and the incidence of
postoperative nausea and vomiting as happening with
other opioids is less profound28. Only few studies have
evaluated the consumption of piritramide administered
by a PCA in combination with various non-opioid
analgesics after different surgical procedures11,29-31.
Since there is obviously no randomized study
that compares IV administered parecoxib, metamizol
or paracetamol on piritramide consumption in the
early postoperative period of thyroid surgery, the aim
is therefore to perform a prospective, randomized,
double-blind, placebo-controlled study in patients
undergoing total thyroidectomy. The primary objective
is to compare postoperative piritramide consumption
alone or in combination with parecoxib, metamizol or
paracetamol for providing pain relief in adult patients
recovering from thyroid surgery during the first 24
hours. Secondary objectives are to compare the pain
intensity and patient satisfaction.
Methods
The investigative protocol was approved by the
institutional review board at our teaching hospital on
December 9, 2003 and all patients provided written
informed consent before enrolment. The study began
in March 2004 and ended in August 2007. Inclusion
criteria were the following: Patients between the
ages of 18 and 75 years and ASA physical status
I-III. All patients were in a euthyroid state at the
time of surgery. Patients with a history of significant
cardiac, pulmonary, hepatic, or renal disease, morbid
obesity, chronic pain and drug or alcohol abuse, and
contraindications or previous adverse reaction to any
of the drugs used in the study were excluded. Also not
included were patients unable to cooperate.
Patients meeting the inclusion criteria and
scheduled for thyroid surgery under general anesthesia
were instructed the night before surgery about the use
of PCA for postoperative pain relief as well as scales
for the determination of pain intensity and patient
satisfaction. After informed consent, one hundred and
Table 1
Patient groups (30 in each group) and treatment with normal saline (NS) and/or drug
Group
Treatment
15 min prior to
extubation
8h postop.
12h postop.
16h postop.
24h postop.
A
Placebo
NS
NS
NS
NS
NS
B
Parecoxib
40 mg
NS
40 mg
NS
NS
C
Metamizol
1g
1g
NS
1g
NS
D
Paracetamol
1g
1g
NS
1g
NS
Efficacy of three IV non-opioid-analgesics on opioid consumption for postoperative pain
relief after total thyroidectomy: a randomised, double-blind trial
twenty patients were assigned to one of four groups,
based on a computer-generated randomization table
(http://www.randomization.com).
The four study groups were A) placebo, B)
parecoxib 40 mg, C) metamizol 1g, and D) paracetamol
1g (Table 1). The drugs were dissolved in 100 ml
normal saline and given via IV infusion over 15 min.
Patients of the placebo group received only 100 ml of
normal saline. In all groups 10 min before extubation
2 mg piritramide (Dipidolor®, Janssen-Cilag) was
injected. In the postoperative period piritramide was
offered in form of a patient-controlled analgesia by
means of a PCA pump as an electronically steered
syringe pump.
Thyroid surgery was performed by two surgeons
under neuromonitoring, using similar surgical
technique and similar surgical drains. Patients,
surgeons, and anesthesiologists responsible for followup in the postoperative period were blinded to group
allocation; other caretakers were also unaware of the
analgesic drug that would be used for each patient
during the study. The study solutions were clear so that
they could not be recognized by the anesthesiologists
collecting the data and were prepared by one of the
researchers who was not involved in the intraoperative
and postoperative treatment of these patients. The
observation time extended during a period of 24 hours
after surgery. However, to ensure patient safety, a sealed
opaque envelope containing the randomized treatment
assignment was kept with each patient in the operating
room and ward to permit immediate unmasking in case
of an emergency making this step necessary.
For premedication, midazolam 7.5 mg
(Dormicum®, Roche Pharma AG Grenzach-Wyhlen,
Germany) was administered orally 60 min before the
surgical procedure. On arrival in the operating room,
standard monitors were applied. A crystalloid infusion
(Infusionslösung E153®, Serumwerk Bernburg AG,
Bernburg, Germany) was started after placing an
18-gauge catheter in the non-dominant hand for fluid
administration intraoperatively. A second 18-G catheter
in the other hand was used for the administration of
anesthetic drugs; this catheter was removed upon
discharge from the recovery room (postanesthesia care
unit, PACU).
After the administration of oxygen via an
545
anesthetic breathing circuit and facemask for 3 minutes,
1 mg vecuronium bromide (Norcuron®, Organon
GmbH, München, Germany) was given as pre-block
while anesthesia was induced with 2 mg/kg propofol
(Propofol® 1%, Fresenius Kabi Deutschland GmbH
Bad Homburg, Germany) intravenously, followed
by 80 mg suxamethoniumchlorid (Lysthenon® 2%,
Nycomed Deutschland GmbH Konstanz, Germany)
to facilitate endotracheal intubation. After intubation,
mechanical pressure controlled ventilation was
initiated at a flow rate of 1 L/min in a semiclosed
system (Cicero; Dräger, Lübeck, Germany) and nitrous
oxide in oxygen at a ratio 1 : 1 was administered
throughout surgery. The inspired oxygen and end-tidal
concentrations of carbon dioxide (CO2) were measured
continuously at the proximal end of the endotracheal
tube using a calibrated infrared gas analyzer (Dräger
PM 8050, Dräger, Lübeck, Germany). Ventilation was
adjusted to maintain end-tidal CO2 between 34-38
mmHg (4.5-5.0 kPa).
Muscle relaxation was obtained with vecuronium
bromide 0.6 mg/kg and monitored by the train-offour stimulation method using a peripheral nerve
stimulator. Anesthesia was maintained with a
supplemental infusion of 3-6 mg/kg/h propofol and
3-10.5 μg/kg/h remifentanil (Ultiva®, GlaxoSmith
Kline GmbH & Co. KG München, Germany) required
to maintain an adequate depth of anesthesia with mean
arterial pressure and heart rate within 20% range of
preoperative values.
Fifteen minutes before the expected end of
surgery, each patient was treated according to list of
randomization (Table 1). Then, infusion of propofol
and remifentanil were ceased and residual muscle
relaxation was reversed with 0.5 mg atropine and 5
to 10 mg pyridostigmine at the end of the procedure
when necessary. The lungs of each patient were
ventilated with 100% oxygen at a flow rate of 5 L/min.
Spontaneous recovery of neuromuscular function was
confirmed by train-of-four monitoring. The trachea
was extubated when adequate spontaneous ventilation
(tidal volume >5 ml/kg) and response to verbal
commands were established. The pre-programmed
PCA equipment (Master PCA, Fresenius Vial Infusion
Technology, Brezins, France) was provided with a 50ml disposable syringe, and 45 mg piritramide in 45 ml
M.E.J. ANESTH 21 (4), 2012
546
S. Abdulla et al.
saline solution was prepared for each patient. The PCA
administered boluses of 2 ml (= 2 mg piritramide) with
a lockout interval of 10 min and a maximal volume
of 30 ml in 4 h. A bolus of 2 mg piritramide was first
injected 10 min prior to the extubation in the operating
room. Postoperative pain was then treated by selfadministration of IV piritramide using the PCA pump
already mentioned.
was accumulated piritramide consumption. Sample
size was calculated to detect a difference between
groups of 30% (α = less than 0.05 and ß = 0.2; power
= 0.8). The power analysis was based upon a variation
(SD) of piritramide consumption from pilot data.
Based on these assumptions a priori power analysis
suggested a sample size of 30 patients for each group.
For examination of normal distribution, the
Kolmogorov Smirnov test was applied. One-way
analysis of variance (ANOVA) in normal distributed
continuous variables and Kruskal-Wallis-test in nonnormal distributed or ordinal variables between the
groups were used. When significant differences were
determined, pairwise intergroup comparisons using
a post hoc Bonferonni-Test or Mann-Whitney-UTest were followed. Within-group comparisons were
made using repeated-measures analysis of variance
for piritramide consumption. Categorical data were
analyzed using χ2 or Fisher’s exact test as appropriate.
Differences were judged significant at P <0.05.
Thereafter, the patients were directly transferred
to the recovery room, where further clinical
observations were done by an independent, blinded
observer who was unaware of the administered study
drugs. On arrival patients were asked every 2 hours
for the first 6 hours and afterwards once every 6 hours
to quantify their pain experience on a visual analog
scale (VAS) between 0 and 10, with 0 representing no
pain and 10 the worst imaginable pain. Likewise, pain
relief was assessed by the patient on a 0-3 verbal rating
scale (VRS) (0 = no relief, 1 = mild, 2 = moderate,
3 = complete) before the patient was transferred to
the ward and after 24 h. Patient satisfaction with the
effectiveness of pain therapy was inquired at 6 hour
intervals by using a 4 point-scale which shows the
verbal expressed satisfaction of assigned numerical
values: 1 = poor, 2 = moderate, 3 = good, 4 = very
good. The cumulative piritramide consumption within
24 hours postoperatively was recorded after 2, 6, 12
and 24 hours on the display of the PCA pump.
Results
One hundred and twenty patients, scheduled for
elective thyroid surgery under general anesthesia, were
enrolled and randomized in the study with 30 patients
in each group. Because there were no dropouts and
no protocol violations in any of the patients studied, a
complete data set was obtained in all 4 groups. Table 2
contains the demographic and patient-referred data in
each group. The four groups were similar with respect
to sex, age, body mass index (BMI) and ASA physical
status. There was also no significant between-group
Data were first processed in Microsoft® Excel
2000 and then with the statistical program SPSS for
Windows in the version 15.0 (SPSS Inc. Chicago,
Illinois, USA) evaluated. The primary efficacy measure
Table 2
Demographic and patient-referred data of the four groups
Group
Placebo
(n = 30)
Parecoxib
(n = 30)
Metamizol
(n = 30)
Paracetamol
(n = 30)
Sex
Female
Male
27
3
23
7
25
5
25
5
Age (yr)
Mean and SD
47.9 ± 11.8
48.3 ± 14.2
43.8 ± 13.7
44,5 ± 15.1
BMI (kgm-2)
Mean und SD
29.7 ± 5.9
26.9 ± 5.1
28.9 ± 5.4
27.6 ± 6.8
ASA physical status
II/III
19/11
19/11
15/15
19/11
Data are presented as mean ±⋅SD. There were no significant differences among the four groups.
Efficacy of three IV non-opioid-analgesics on opioid consumption for postoperative pain
relief after total thyroidectomy: a randomised, double-blind trial
547
Fig. 1
Piritramide consumption in mg (mean and standard
deviations) in four groups over 24 hours postoperatively.
There is no significant difference between the groups.
Fig. 2
Cumulative PCA-piritramide consumption (mean and standard
deviations) in four groups at different investigation times.
There is no significant difference between the groups.
difference with respect to anesthetic drug usage, total
blood loss, total fluid administration or duration of
anesthesia and surgery.
VAS pain scores are presented in Figure 3. In all
groups, VAS scores were highest upon arrival in the
recovery room. The highest mean value was found
in the NaCl group with 5.3 and the lowest with 4.3
in the metamizol group. Afterwards the VAS scores
dropped in all groups almost continuously after
surgery. A significant between-group difference was
found at 2 and 4h after surgery: Pain scores at 2h after
surgery were significantly lower in the parecoxib and
metamizol group compared with NaCl (P = 0.003;
P = 0.005). Additionally, pain scores at 4h were
significantly lower in parecoxib group compared with
NaCl and paracetamol (P = 0.001; P = 0.01).
Piritramide consumption is presented in Figure 1.
Upon arrival in the PACU piritramide consumption was
similarly high and decreased thereafter significantly
in all the groups receiving non-opioid-analgesics
over 24h with one exception in the paracetamol
group between 12 and 24h. In the placebo group the
significant decrease was only found by comparing the
first two investigation times and 12 with 24h. However
between the four groups, the incremental piritramide
consumptions in the PACU and after 6, 12 and 24
hours showed no significant differences. Likewise, the
frequency of PCA bolus demands did not differ in the
four groups (Table 3). Also with the cumulative PCApiritramide consumption no significant difference
could be found between the groups (Figure 2).
However, the cumulative piritramide consumption
was slightly lower in the parecoxib group at 12 and
24 hours, while the patients of the paracetamol group
had the highest piritramide consumption as compared
to the other groups.
For overall patient satisfaction, assessed on the
4 point-scale, no significant differences among the
four groups were observed at any time. In the PACU,
satisfaction was moderate and improved to good/very
good after 24h (Table 3). In pain relief score, there were
no significant differences among groups at 2h after
surgery; however, at 24h the scores were significantly
higher in patients who received parecoxib as compared
to metamizol (P = 0.008) and paracetamol (P = 0.003)
M.E.J. ANESTH 21 (4), 2012
548
S. Abdulla et al.
Table 3
Number of PCA bolus demands, pain relief score and patient satisfaction in the four groups
(mean values and standard deviations).
Group
Placebo
(n = 30)
Parecoxib
(n = 30)
Metamizol
(n = 30)
Paracetamol
(n = 30)
9.7 ± 4.4
8.4 ± 4.5
10.8 ± 3.9
11.2 ± 5.7
1.6 ± 0.5
1.8 ± 0.6
1.7 ± 0.5
1.7 ± 0.5
2.1 ± 0.3
2.3 ± 0.5
2.0 ± 0.3
2.0 ± 0.0
2h
2.5 ± 0.6
2.7 ± 0.6
2.6 ± 0.7
2.4 ± 0.8
6h
3.1 ± 0.8
3.3 ± 0.7
3.2 ± 0.6
3.0 ± 0.6
12h
3.4 ± 0.7
3.6 ± 0.5
3.4 ± 0.6
3.2 ± 0.6
18h
3.6 ± 0.6
3.6 ±0.6
3.5 ± 0.5
3.4 ± 0.6
No. of PCA bolus demands*
overall demands
Pain relief scores
2h
24h**
Satisfaction scores
*
24h
3.7 ±0.5
3.6 ± 0.6
3.7 ±0.5
3.5 ± 0.5
* no significant differences between groups.
** Pain relief scores were significantly higher in parecoxib group when compared with metamizol and paracetamol after 24h (P =
0.008; P = 0.003).
Fig. 3
Visual analog scale (VAS, mean and standard deviations) in
four groups over 24 hours postoperatively
(0 = no pain; 10 = worst imaginable pain). *P<0.01 NaCl
versus parecoxib and metamizol at 2 h;
*P<0.01 parecoxib versus NaCl and paracetamol at 4h.
(Table 3). No drug reactions, such as dizziness and
respiratory depression occurred in our study. However,
mild postoperative nausea and vomiting (PONV) were
observed frequently in all the groups, which were
treated with 20 mg metoclopramide as an antiemetic
in the PACU and on the ward. In addition, in the
metamizol group there was one patient with a heavy
subcutaneous bleeding at the surgical wound with
upper airway obstruction immediately on arrival in the
PACU.
Discussion
Our results showed that pain was most intense
immediately after recovering from remifentanil
based anesthesia for thyroid surgery and decreased
to low levels in all groups after surgery. Accordingly,
the required piritramide consumption was high in
the PACU and there was no opioid-sparing effect as
demonstrated by the lacking significant differences in
piritramide consumption between the 4 groups.
The early intense pain after thyroidectomy is
complex. Beside the surgical pain itself it may be
caused by cervical hyperextension with postoperative
Efficacy of three IV non-opioid-analgesics on opioid consumption for postoperative pain
relief after total thyroidectomy: a randomised, double-blind trial
muscular pain32 as well as postoperative irritation
and discomfort because of intraoperatively placed
endotracheal tube and wound drains, which are kept in
place for 24 hours. Indeed, patients complain of pain
at the incision site, sore throat, posterior neck pain,
and occipital headache15. Furthermore, remifentanilbased anaesthesia has been shown to be associated
with postoperative periincisional hyperalgesia33-36,
a fact which may have contributed to overall pain
in our patients. The early intense pain in our study
may also partly be explained by a bolus dose of 2
mg piritamide with a lockout time of 10 min which
is routinely prescribed in Germany11. Smaller bolus
doses with a short lockout time have been shown
to reduce piritramide consumption by enabling the
patient to titrate analgesic effect more effectively;
however they obviously do not reduce opioid-related
side effects30. A background infusion of opioid was not
provided due to a possible increased risk of respiratory
depression; furthermore it may induce acute tolerance
with increased pain intensity, thus decreased analgesic
effects and increased frequency of PONV and
dizziness17. However, PCA without a background
infusion may result in the opioid concentration being
in the target range for appropriate pain treatment.
Accordingly, it offers better analgesic efficacy
and results in more patient satisfaction. Numerous
randomized control studies have been published
evaluating efficacy, side effects and patient satisfaction
with PCA19,23-24,26,37. Therefore opioid analgesia with
PCA is justified, at least in the early postoperative
period after thyroidectomy3,5,15,38-40.
Incremental and cumulative PCA-piritramide
consumption showed no significant difference
between the groups. However, the cumulative
piritramide consumption was slightly lower in the
parecoxib group at 12 and 24 hours, while the patients
of the paracetamol group had the highest piritramide
consumption as compared to the other groups. A
reason for the missing clear opioid sparing effect in
paracetamol and metamizol groups may be the doses
of these drugs administered in our study: 40 mg
parecoxib twice a day given is the maximum dosage
recommended by the manufacturer for IV application
in adults. In contrast, we used 1g paracetamol and
1g metamizol three times daily (TID), whereas the
maximum doses recommended by the manufacturers is
549
1g four times daily (QID). In a newly published study,
both parecoxib (80 mg/24h) and paracetamol (5g/24h)
effectively reduced postoperative opioid requirements
after thyroid and parathyroid surgery41. However, a lack
of statistical significance on postoperative cumulative
piritramide consumption was also found in different
surgical procedures when parecoxib was given 40 mg
twice daily and metamizol and paracetamol 4g daily
were administered11,29,31,42-44. May be the results were
also different if we had evaluated the pre-emptive
efficacy of non-opioid-analgesics administered
preoperatively5,44-45.
Apart from the lacking superiority of one of the
investigated drugs in combination with piritramide
given over a PCA, a significant reduction in the
visual analog scales (VAS pain scores) was registered
only at 2h after surgery in parecoxib and metamizol
as compared to the NaCl group while at 4 hour after
surgery VAS scores in parecoxib versus NaCl and
paracetamol were significantly lower. Thereafter,
however, VAS scores were all ≤3. Therefore, it may
be difficult to demonstrate an additional benefit with
an analgesic when baseline pain is low in all groups.
In regard to patient satisfaction there was a continuous
increase over the study period and after 24h almost all
patients in all groups rated their satisfaction with pain
management as good or very good which is consistent
with previous data where most patients were satisfied
with PCA pain management17,46. The pain relief
score after 24 hours showed statistical superiority
of parecoxib versus metamizol and paracetamol.
However, whether this is also of clinical relevance, is
debatable.
In the metamizol group, one patient had a
heavy subcutaneous bleeding at the surgical wound
causing upper airway obstruction which occurred
immediately on arrival in the PACU and made surgical
intervention with ligature of the spurting hemorrhage
necessary. Other drug reactions, such as dizziness
and respiratory depression did not occur in our study.
However, mild postoperative nausea and vomiting
(PONV) were observed frequently in all the groups
and were treated with mild antiemetics in the PACU
and on the ward. Ondansetron and dexamethasone for
effective management of PONV were not used15,47.
PONV is the most common side effect after thyroid
M.E.J. ANESTH 21 (4), 2012
550
surgery15. Patients undergoing thyroid or parathyroid
surgery are at high risk for the development of PONV
with a decreased rate in women by using propofol
for maintenance of anesthesia14,48-49. Use of opioids
might increase the incidence of PONV49. Therefore,
the combined use of opioids with NSAIDs can reduce
PONV in thyroid surgery15,44-45,51.
Non-opioid analgesics including parecoxib,
metamizol (dipyrone) and parecetamol are routinely
used for the IV treatment of postoperative pain. Both
parecoxib and metamizol are considered nonsteroidal
anti-inflammatory drugs (NSAIDs), albeit one
is a selective COX-2 inhibitor while the other is
not selective. Parecoxib is the only parenterally
administered selective COX-2 inhibitor which has
the most supportive data for its beneficial effects as a
part of multimodal analgesia and offer benefits with
regard to its adverse effect profile23,52. Metamizol is
still widespread used in Europe and South America. In
addition to its analgesic properties it has antispasmodic
and antipyretic effects, particularly in patients
with visceral pain. In other countries it is banned
because of an association with life-threatening blood
agranulocytosis although the strength of the association
has been a matter of much debate53-57. However, in the
discussion of metamizol-induced agranulocytosis the
overall risk of NSAIDs with regard to their potentially
life-threatening adverse effects should be considered
in comparison with other non-opiod analgesics which
are not devoid of serious side effects53. Nevertheless,
because of the risk of agranulocytosis after metamizol
patients should probably be monitored for blood
S. Abdulla et al.
dyscrasias and, extremely rarely, broad-spectrum
antibiotics with hematopoietic growth factors be
administered if agranulocytosis occurs29. Paracetamol,
on the other hand, is as para-aminophenol in a different
chemical class and not considered anti-inflammatory.
It can now also be administered intravenously and has
thus gained renewed interest in this setting due to its
minimal adverse effects.
A limitation of this study is that we used drugs
which are not available in all countries. Also, we did
not use the maximal doses recommended from the
manufacturers with metamizol and paracetamol and we
failed to monitor side effects of the drugs adequately.
In addition, the results might have been different if
non-opioid-analgesics had been given prior to surgery
as preemptive analgesics. Furthermore, a comparison
of the combined use of different drug classes (NSAID
and paracetamol) given simultaneously as part of
a multimodal treatment as in other studies might be
worthwhile39,58-59.
Conclusion
Pain is intense in the early postoperative period
after total thyroidectomy and justifies the need for
combined use of opioid and non-opioid analgesics.
There is no difference in piritramide consumption in all
groups at all investigation times and there is no clearcut difference between the non-opioid drugs used,
even though parecoxib seems to be superior in regard
to VAS scores. However, the clinical significance of
this finding can be debated.
Efficacy of three IV non-opioid-analgesics on opioid consumption for postoperative pain
relief after total thyroidectomy: a randomised, double-blind trial
551
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Hemodynamic effects of dexmedetomidine-fentanyl vs. nalbuphine--propofol
in plastic surgery
Juan F. De la Mora-González*, José A. Robles-Cervantes2,4,
José M. Mora-Martínez3, Francisco Barba-Alvarez1,
Emigdio de la Cruz Llontop-Pisfil1, Manuel González-Ortiz4,5,
Esperanza Martínez-Abundis4,5, Juan F. Llamas-Moreno4
and M aría C laudia E spinel B ermúdez 4
Abstract
Dexmedetomidine has demonstrated to be useful in several clinical fields due to its respiratory
safety and cardiovascular stability. We undertook this study to determine its usefulness in plastic
surgery. Sixty patients were divided into two parallel groups. A group received dexmedetomidine-fentanyl and the comparison group received nalbuphine--propofol, both with same dose of
midazolam. Blood pressure, heart rate and oxygen saturation were determined during the
preoperative, intraoperative and recuperation periods. Results. In both groups, hemodynamic
constants decreased intraoperatively. Dexmedetomidine--fentanyl decreased more than in the
nalbuphine--propofol (systolic blood pressure, p = 0.006; diastolic blood pressure, p = 0.01 and
heart rate, p = 0.007). Comparatively, oxygen saturation was greater in the dexmedetomidine-fentanyl group vs. nalbuphine--propofol (p = 0.0001). Recovery time for the nalbuphine--propofol
group was shorter than in the dexmedetomidine--fentanyl group (p = 0.0001). Conclusions.
Dexmedetomidine shows the same cardiovascular stability but with absence of respiratory
depression.
Key words: Dexmedetomidine, Plastic surgery, Respiratory distress, Cardiovascular stability.
Introduction
Analgesic sedation along with local anesthesia has demonstrated efficacy for minimizing
costs, reducing hospital stay and decreasing risks due to general anesthesia in multiple aesthetic
procedures. The aim is to eliminate infiltrative procedures, decrease pain and anxiety and improve
patient mobility by providing a state of reduced consciousness and mild amnesia. Different drugs
with different formulations, routes of administration, dosing and multiple combinations are
available to achieve the desired type and depth of sedation1,2.
* Department of Anesthesiology, Institute of Reconstructive Surgery of Jalisco, Health Secretary, Guadalajara, México.
2
Internal Medicine Service, Institute of Reconstructive Surgery “Dr. José Guerrero Santos”, Guadalajara, México.
3
Department of Anesthesiology, Hospital General Zone 14, Mexican Institute of Social Security, Guadalajara, México.
4
Medical Research Unit in Clinical Epidemiology, West National Medical Center, Mexican Institute of Social Security,
Guadalajara, México.
5
Cardiovascular Research Unit Physiology Department. Health Sciences University Center. University of Guadalajara.
Corresponding author: José Antonio Robles Cervantes, Av. Chapalita 1300. Col. Chapalita, CP 45000, Guadalajara,
Jalisco, México, Phone: +52 33 31212303, Fax: +52 33 31219604. E-mail: [email protected]
553
M.E.J. ANESTH 21 (4), 2012
554
Recently, dexmedetomidine, an α2 agonist with
sedative and analgesic properties, has been tested in
the U.S. for sedation in the intensive care unit (ICU).
Its safety and efficacy has been widely proven in
multiple procedures3.
Dexmedetomidine compared with propofol in
ICU postoperative patients has demonstrated a suitable
pharmacodynamic profile with better psychomotor
recovery. It preserves an appropriate residual analgesic
control and synergism with other analgesic drugs
that decreases the need for complementary opioid
analgesics. Dexmedetomidine also shows ability to
attenuate stress responses during surgery due to its
sympatholytic properties4-6.
Additionally, dexmedetomidine is also useful
as sedation free of adverse events in postoperative
monitored patients in ICU, with lower maintenance
dose6. Trials have been conducted in surgical
procedures with dexmedetomidine7,8.
Dexmedetomidine has not been studied in plastic
surgery. The aim of our study was to compare the
hemodynamic effects of dexmedetomidine--fentanyl
vs. nalbuphine--propofol in these procedures.
Materials and Methods
Approval was obtained from the local ethics
committee and from the participating hospital. Written
informed consent was obtained from all patients.
Sixty patients were selected for plastic surgery. All
patients underwent physical examination and clinical
history, with ASA classification I-. All patients denied
coagulation problems.
The aim was to demonstrate the hemodynamic
effects of dexmedetomidine--fentanyl vs. nalbuphine-propofol in plastic surgery. Sample size consisted of
60 patients distributed in two groups: one group was
administered dexmedetomidine--fentanyl (n = 30) and
another group was administered nalbuphine--propofol
(n = 30), both with the same dose of midazolam. All
patients were >40 years of age and with a Goldman
classification I. Exclusion criteria were patients with
heart failure, coronary disease, renal failure, liver
failure, severe obesity or chronic pulmonary illness.
All patients were admitted to the hospital at
7:00 a.m. after a 10-h overnight fast. On arrival, an
J. F. De la Mora-González et al.
intravenous (IV) line was established to administer
Ringer lactate solution. Subjects were randomized in
open groups to receive dexmedetomidine--fentanyl
or nalbuphine--propofol. Drug dosings for analgesic
sedation were adjusted for each patient according to
body weight.
Before sedation, patients were monitored with
a derivation-II electrocardiogram (ECG), pulse wave
plethysmography, pulse oximetry and blood pressure
with an intermittent pneumatic system. The following
variables were recorded at baseline, every 5 min during
surgery and postoperatively: ECG, oxygen saturation
(O2 sat), systolic blood pressure (SBP), diastolic blood
pressure (DBP) and mean arterial blood pressure
(MAP). Sedation was performed as follows.
Dexmedetomidine--Fentanyl Group
There was an initial loading dose of midazolam
(20 µg/kg), continuing with a dose of fentanyl (1 µg/
kg) in a bolus injection followed by a continuous
maintenance infusion of 0.5 µg/kg/h until surgery was
completed. Finally, a loading dose of dexmedetomidine
was added prior to surgery (1 µg/kg) for 10 to 20 min
observing sedation effect, followed by a maintenance
infusion rate of 0.5 µg/kg/h. Ampoules of 200 µg were
diluted in 98 cc of normal saline.
Nalbuphine--Propofol Group
Initial loading dose of midazolam was 20 µg/kg,
continuing with a single dose of nalbuphine (50 µg/
kg) and, subsequently, propofol in bolus injections (2
mg/kg).
To establish level of sedation, Ramsay sedation
score was measured during the postoperative period9.
All surgical procedures were performed by the
same team of plastic surgeons in the participating
hospital, and in all cases patients were supervised
according to the guidelines for patient safety in crisis
situations10.
Data are presented as mean ± SD. To observe
distribution of the results, Kolmogorov-Smirnov test
was performed, with a normal distribution. Withingroup differences were evaluated with Student’s
t-test for related samples, and for differences between
groups independent Student’s t-test was performed.
Significance was set at p ≤0.05.
Hemodynamic effects of dexmedetomidine-fentanyl vs. nalbuphine-propofol in plastic
surgery
Results
Age and weight for both groups are described
in Table 1. Rhytidoplasty was the most common
procedure performed in both groups (Table 2). There
is no difference between groups in regard to surgical
time (data not shown).
Table 1
Clinical characteristics of both groups
Dexmedetomidine
n = 30
Propofol
n = 30
P
Age (years)
54 ± 8
53 ± 5
0.05
Weight (Kg)
62 ± 10
67 ± 8
NS
Table 2
Types of surgery in study groups
Study group
Type of surgery
Frequency
(%)
Dexmedetomidine
n = 30
Rhytidoplasty
Blepharoplasty
Hair implant
75
20
5
Propofol
n = 30
Rhytidoplasty
Blepharoplasty
85
15
Hemodynamic Function in the
Dexmedetomidine--Fentanyl Group
SBP decreased during surgery (134 ± 18 vs. 103
± 16 mmHg, p = 0.0001) and postoperatively (100 ± 22
mmHg, p = 0.0001). DBP (82 ± 10) decreased to 60 ±
555
10 mmHg (p = 0.0001) and postoperatively preserved
at 60 ± 10 mmHg (p = 0.0001). Transoperative HR
decreased from 74 ± 16 to 63 ± 7 beats per minute
(bpm) (P = 0.0001) and 64 ± 7 bpm postoperatively
(p = 0.001).
In regard to respiratory function, the
dexmedetomidine--fentanyl group increased O2 sat
(96.6 ± 3.1 vs. 97.6 ± 2.7%, p = 0.0001).
Hemodynamic Function in the Nalbuphine-Propofol Group
SBP in the transoperative period decreased from
123 ± 13 to 114 ± 14 mmHg (p = 0.016) and 117 ± 15
(p = 0.083) postoperatively. DBP decreased from 74 ±
12 to 67 ± 11 mmHg transoperatively (P = 0.044) and
postoperatively decreased from 69 ± 11 mmHg (p =
0.083). HR increased transoperatively from 78 ± 13 to
84 ± 13 bpm (p = 0.030) and postoperatively was 85 ±
15 bpm (p = 0.02). O2 sat did not increase significantly
(96 ± 1.7 to 96.5 ± 1%; p = 0.114).
When both groups were compared, in regard to
hemodynamic behavior SBP, DBP and HR decreased
at baseline, transoperatively and postoperatively
(Table 3).
Comparatively, intraoperative O2 sat was
greater in the dexmedetomidine--fentanyl group vs.
Table 3
Hemodynamic behavior in study groups
Systolic blood pressure
(mm Hg)
Dexmedetomidine
n=30
Propofol
n=30
Baseline
134 ± 18
123 ± 13
0.01
Intraoperative
103 ± 16
114 ± 14
0.006
Postoperative
100 ± 22
117 ± 15
0.001
Diastolic blood pressure (mmHg)
p
Dexmedetomidine
Propofol
p
Baseline
82 ± 10
74 ± 12
0.04
Intraoperative
60 ± 10
67 ± 11
0.01
Postoperative
60 ± 10
69 ± 11
0.002
Baseline
74 ± 16
78 ± 13
NS
Intraoperative
63 ± 7
84 ± 13
0.007
Postoperative
64 ± 7
85 ± 15
0.0001
Heart rate (beat/minute)
M.E.J. ANESTH 21 (4), 2012
556
J. F. De la Mora-González et al.
Table 4
Difference between groups in respiratory function and time for recovery from sedative effect
Variable
Dexmedetomidine
n = 30
Propofol
n = 30
P
O2 Sat (%)
Intraoperative
Postoperative
97.5 ± 1.3
97.6 ± 1.4
94.5 ± 2.3
96.5 ± 1.1
0.0001
0.001
Time for recovery (minutes)
23.8 ± 0.5
11.3 ± 4.3
0.004
3 ± 0.4
1.9 ± 0.7
0.0001
Ramsay (score)
O2 sat, oxygen saturation.
nalbuphine--propofol (p = 0.0001). Recovery time in
the nalbuphine--propofol group was shorter than in the
dexmedetomidine--fentanyl group (p = 0.0001) (Table
4).
Discussion
Adverse events are present in 2.3% of all
analgesic sedation procedures. The most frequent
event is respiratory depression that, if untreated, may
lead to serious outcomes11. Our results demonstrate
that dexmedetomidine is an effective, safe and useful
agent for sedation in plastic surgery due to its analgesic
properties and adequate cardiovascular stability,
as well as being devoid of respiratory depressant
effects. Our results are similar to previous trials where
dexmedetomidine has been used for sedation in the
ICU4-6.
In other study, dexmedetomidine was compared
with midazolam in ophthalmic surgeries; nevertheless,
results are contradictory. Alhashemi8 reported that
compared with midazolam, dexmedetomidine group
was accompanied by relative cardiovascular depression
and delayed recovery room discharge in patients
undergoing cataract surgery. Meanwhile, Abdalla et
al.7 assessed efficacy and safety as adjuvant to local
analgesia in ophthalmic surgery; dexmedetomidine
decreased intraocular pressure, provided safe control
of HR and blood pressure during ophthalmic surgery
under local anesthesia.
Results from these clinical trials cannot be
compared with our results because only the sedative
effect is present in the midazolam groups unlike the
hypnotic/analgesic effects that dexmedetomidine
provides, an effect that is required for plastic surgery
procedures7,8,10. Some authors have recently considered
propofol combined with another narcotic drug as the
gold standard for sedative/analgesic procedures1,2,10,12.
In both of our groups, dexmedetomidine and
propofol were considered equal although the propofol
dose was adjusted according to the Ramsay score13.
Our results show that dexmedetomidine is
suitable for plastic surgery according to respiratory
and cardiovascular safety, similar to previous
reports in other types of surgical procedures where
dexmedetomidine was used4-10,14.
One limitation of our study may be that the study
design was based on the Ramsay score rather than an
objective measure such as the bispectral index (BIS),
a parameter that correlates with the sedative/hypnotic
actions of anesthetic drugs15.
In summary, our results show that
dexmedetomidine--fentanyl
was
superior
to
nalbuphine--propofol because it was devoid of
respiratory depressant effects and decreased the
frequency of the use of other anesthetic agents.
Hemodynamic effects of dexmedetomidine-fentanyl vs. nalbuphine-propofol in plastic
surgery
557
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Identifying Resource Needs for
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in Four Eastern Provinces
Inipavudu Baelani*, Stefan Jochberger**, Thomas Laimer***
Christopher Rex****, Tim Baker*****, Iain H. Wilson******,
Wilhelm Grander******* and Martin W. Dünser********
Abstract
The ongoing conflict in the Eastern Republic of the Congo (DRC) has claimed up to 5.4
million lives by 2008. Whereas few deaths were directly due to violence, most victims died from
medical conditions such as infectious diseases. This survey investigates the availability of resources
required to provide adequate sepsis care in Eastern DRC.
The study was conducted as a self-reported, questionnaire-based survey in four Eastern
provinces of the DRC. Questionnaires were sent to a cluster of 80 urban-based hospitals in the
North Kivu, South Kivu, Maniema and Orientale provinces. The questionnaire contained 74
questions on the availability of resources required to adequately treat sepsis patients as suggested
by the latest Surviving Sepsis Campaign (SSC) guidelines.
Sixty-six questionnaires were returned (82.5%) and analyzed. Crystalloid solutions and
intravenous fluid giving sets were the only resources constantly available in all hospitals. None of
the respondents reported to have constant access to piperacillin, carbapenems, fresh frozen plasma,
platelets, dobutamine, activated protein C, echocardiography or equipment to measure lactate
levels, invasive blood pressure, central venous pressure, cardiac output, pulmonary artery pressure
or endtidal carbon dioxide. No respondent stated that a mechanical ventilator, syringe pump, fluid
infuser, peritoneal dialysis or haemodialysis/hemofiltration machine was constantly available at
his/her hospital. Resources required for consistent implementation of the SSC guidelines were not
available in any hospital.
This survey indicates a critical shortage of resources required to provide adequate sepsis
*
Department of Anaesthesiology and Critical Care Medicine, DOCS Hospital, Goma/Democratic Republic of the
Congo.
**
Department of Anaesthesiology and Critical Care Medicine, Innsbruck Medical University, Innsbruck/Austria.
***
Medical University of Vienna, Vienna/Austria.
****
Department of Anaesthesiology and Critical Care Medicine, University Teaching Hospital Reutlingen, Reutlingen/
Germany.
***** Department of Physiology and Pharmacology, Karolinska Institute, Section for Anaesthesia and Intensive Care,
Karolinska University Hospital, Stockholm/Sweden.
****** Royal Devon and Exeter NHS Foundation Trust, Exeter/United Kingdom.
******* Department of Internal Medicine, Community Hospital Hall in Tirol, Hall in Tirol/Austria.
********Department of Anaesthesiology and Critical Care Medicine, Salzburg General Hospital and Paracelsus Private Medical
University, Salzburg/Austria.
Corresponding author: Dr. Stefan Jochberger; Department of Anaesthesiology and Critical Care Medicine, Innsbruck
Medical University, Anichstrasse 35, 6020 Innsbruck, Austria/Europe. E-mail: [email protected]
559
M.E.J. ANESTH 21 (4), 2012
560
care and implement the SSC guidelines in a cluster of
hospitals in the Eastern DRC.
Key words: Sepsis; Resources; Surviving Sepsis
Campaign Guidelines; Democratic Republic of the
Congo; Africa.
Introduction
Over 75% of the global burden of infectious
diseases, as assessed by mortality and disability
adjusted life years lost, occurs in low-income
countries1,2. Infectious diseases make up six of the
ten most frequent causes of death in these parts of the
world3. Except for chronic viral diseases such as HIV/
AIDS, development of sepsis, organ dysfunction and
shock is the common sequence leading to death from
infection, irrespective of its underlying focus4. Case
fatalities of up to 70-100% are observed once infection
has led to organ dysfunction or shock in resource-poor
environments5-11. Accordingly, it must be assumed that
severe sepsis and septic shock substantially contribute
to the overall mortality of infectious diseases in lowincome countries.
The Democratic Republic of the Congo (DRC),
known as Zaire until 1997, is home to ~70 million
people and ranks among the poorest countries in
Sub-Sahara Africa. The DRC’s crude mortality rate
is the highest in the world12. Eastern DRC consists
of five provinces (South and North Kivu, Orientale,
Maniema, Katanga) and, since 1998, has been torn
by an ongoing military conflict characterized by
extreme violence, mass population displacements and
a collapse of public health services12. In a series of
mortality surveys, the International Rescue Committee
estimated that the war and humanitarian crisis had
claimed up to 5.4 million lives by 200813. Whereas
<1% of excess deaths were directly due to violence,
the vast part of conflict-claimed victims died from
preventable and treatable medical conditions with the
majority of deaths caused by infectious diseases14.
Although mortality rates of severe sepsis and septic
shock patients are not available for the Eastern DRC,
critically ill sepsis patients presenting to two hospitals
in neighboring Uganda had mortality rates >50%10. A
retrospective study from Tunisia reported a fatality rate
of 82% for septic shock patients6, and Kalayi11 found
that no burn patient developing septic shock survived
I. Baelani et al.
in a Nigerian university teaching hospital.
Although early recognition and timely treatment
of infection is crucial in preventing progression to
sepsis and organ dysfunction, adequate treatment
of severe sepsis and septic shock may additionally
save a considerable number of lives. For example,
implementation of the Surviving Sepsis Campaign
(SSC) guidelines, which summarize the latest clinical
evidence in sepsis care15, improves sepsis care and
patient outcome16-18. However, implementation of
these guidelines requires specific resources which may
only be inconsistently available or entirely lacking in
Sub-Sahara Africa19-22. Detailed data on the availability
of resources to treat sepsis could help to identify
possibilities to improve sepsis care in the region.
Therefore, this survey investigates the availability
of hospital facilities and resources required to provide
adequate sepsis care, as suggested by the latest SSC
guidelines15, among hospitals in four Eastern provinces
of the DRC. We hypothesized that hospital facilities
and resources needed to implement the SSC guidelines
were only inconsistently available.
Materials and Methods
This study was conducted as a self-reported,
questionnaire-based cluster survey in four Eastern
provinces of the DRC. The study protocol and survey
instrument were reviewed and approved by the Ethical
Committee of the Medical University of Goma/DRC.
In October 2009, 80 questionnaires were sent via
the postal service from Goma, the capital city of the
North Kivu province, to urban-based hospitals in the
provinces of North Kivu (n=35), South Kivu (n=12),
Maniema (n=13) and Orientale (n=20). Hospitals
located in regions with ongoing civil war activities
were inaccessible because of security issues or nonexistent postal services, and had to be excluded from
the sampling frame. Questionnaires were directed
either to the health care provider in charge of the
intensive care unit or the one responsible for the care
of acutely and critically ill patients in the respective
hospital if the hospital did not run an intensive care
unit. All participants were notified that participation
was voluntary and based on the understanding that
results would be published in a scientific journal. No
Identifying Resource Needs for Sepsis Care and Guideline Implementation in the Democratic
Republic of the Congo: A Cluster Survey of 66 Hospitals in Four Eastern Provinces
incentives to complete the questionnaire were offered.
After two months, health care providers who had so far
not responded were contacted and asked to participate.
Returned questionnaires were collected at the DOCS
Hospital in Goma until February 2010 and then taken
to the study centre in Europe for statistical analysis.
The SSC Guidelines
In 2001, 2004 and 2008, international experts
released guidelines for the management of severe
sepsis and septic shock15,23-24. These SSC guidelines are
one of the first international consensus guidelines on
treatment in intensive care medicine and include initial
resuscitation, infection control, hemodynamic support,
adjunctive therapy and other supportive therapies for
severe sepsis and septic shock patients. In its latest
publication (15), the SSC graded their proposals as
recommendations and suggestions. Recommendations
imply that an intervention’s desirable effects clearly
outweigh its risks and should be followed by
physicians in most situations. Suggestions mean that
the relation between desirable and undesirable effects
of an intervention is less clear and physicians may
consider its use. Furthermore, the SSC assessed the
level of clinical evidence for each recommendation
and suggestion. Accordingly, recommendations are
graded as level I evidence subcategorized from A to
D (with A being the highest and D the lowest grade of
evidence). Suggestions are uniformly graded as level
II evidence.
Questionnaire
The questionnaire used as the survey instrument
in this study was designed and based on the latest
SSC guidelines15. The questionnaire contained 74
questions grouped into seven main categories (general
information on the hospital, hospital facilities,
drugs, patient monitoring, laboratory, equipment and
disposables). Responses were classified as ‘yes’, ‘no’,
‘don’t know’ for the category ‘hospital facilities’
and ‘always’, ‘sometimes’, ‘never’, ‘don’t know’ for
the remaining categories. The study questionnaire
was translated into the French. The original study
questionnaire in English (Electronic Supplementary
Material Figure 1) underwent pre-and pilot-testing for
ease of completion and inter-observer variability by
561
anaesthetists in Kenya and Tanzania. It has also been
used in a cross-sectional survey to evaluate resource
availability to implement the SSC guidelines on the
African continent and in Mongolia25.
Outcome Variables
The main outcome variable was availability of
resources necessary to provide adequate sepsis care
and implement the latest SSC guidelines. Prior to
the survey, hospital facilities, equipment, drugs and
disposable materials required to implement single
SSC recommendations and suggestions were defined
by consensus of the study investigators (Electronic
Supplementary Material Table 1). For consistent
implementation of the SSC guidelines, resources had
to be ‘always’ available. Resources ‘sometimes’ or
‘never’ available, as well as those respondents did not
know whether resources were available at their hospital
were considered insufficient to provide adequate sepsis
care and implement the SSC guidelines. Furthermore,
the percentage of implementable recommendations
and suggestions of the SSC guidelines was calculated
for each returned questionnaire.
Table 1
Characteristics of Respondents and Hospitals
n
66
Specialty of Respondent
Non-Physician Anaesthetist
Nurse Anaesthetist
Other
n (%)
Type of Hospital
n (%)
District
Regional/Provincial
University Teaching
Other
31 (47)
31 (47)
4 (6.1)
44 (68.6)
9 (13.6)
2 (3)
11 (16.6)
Size of Hospital
(beds)
Availability of Hospital Facilities
n (%)
84 (43-118)
Emergency Room (n=64)
20 (31.3)
Operation Theatre (n=64)
63 (98.4)
Intensive Care Unit (n=64)
27 (42.2)
Data are given as median values with interquartile ranges, if
not otherwise indicated.
Statistical analysis
Questionnaires were manually entered into
a centralized database. After double checking, the
database was re-checked by calculating minimum and
maximum values of each question to recognize and
M.E.J. ANESTH 21 (4), 2012
562
I. Baelani et al.
Fig. 1
Map of the Democratic Republic of the Congo with the four Eastern provinces surveyed highlighted in grey (A) and the town of
responding hospitals in these provinces marked with black dots (B). Please note that some hospitals were located in the same town
thus rendering a lower number of dots than responding hospitals.
eliminate remaining entry errors. The SPSS software
package (SPSS 13.0.1; SPSS Inc., Chicago, Illinois,
United States) was used for statistical analysis.
Simple frequencies based on the number of completed
questions (some questions were not completed by all
respondents) were calculated for all categorical data.
Continuous variables are presented as median values
with interquartile ranges (IQR).
Results
Of the 80 questionnaires distributed, 66 were
returned (82.5%) and statistically analyzed (Figure
1). Seventeen questionnaires (25.8%) were only
partially completed. The median number of missing
responses in these questionnaires was 3 (IQR, 1-11).
Table 1 summarizes characteristics of the survey
respondents and their hospitals. Tables 2, 3 and 4
display the availability of drugs, equipment and
disposable materials to provide adequate sepsis
care and implement the SSC guidelines. Crystalloid
solutions and intravenous fluid giving sets were the
only resources constantly available in all responding
hospitals. None of the respondents reported to have
constant access to piperacillin, carbapenems, fresh
frozen plasma, platelets, dobutamine, activated protein
C, echocardiography or equipment to measure lactate
levels, invasive blood pressure, central venous pressure,
cardiac output, pulmonary artery pressure or endtidal
carbon dioxide at his/her hospital. No respondent
stated that a mechanical ventilator, syringe pump,
fluid infuser, peritoneal dialysis or haemodialysis/
hemofiltration machine was constantly available at
his/her hospital. Resources required for consistent
implementation of all SSC recommendations/
suggestions were not available in any hospital (Table
5).
Discussion
This cluster survey included 66 hospitals located
in North and South Kivu, Orientale and Maniema
provinces and covered large parts of the Eastern DRC
(Figure 1). Out of an estimated total of 250 hospitals,
a cluster of 80 urban-based hospitals could be studied.
Logistic and security issues prevented us from capturing
the remaining health care facilities which are mostly
located in rural areas. Therefore, our study results can
only reflect the current status on resource availability
for sepsis care in a selected group of urban-based
hospitals. Although these hospitals may be privileged
by their location and enhanced security state compared
Identifying Resource Needs for Sepsis Care and Guideline Implementation in the Democratic
Republic of the Congo: A Cluster Survey of 66 Hospitals in Four Eastern Provinces
Table 2.
563
Availability of Drugs to Provide Adequate Sepsis Care
and Implement the Surviving Sepsis Campaign Guidelines
Alw
ays
Oxygen( n =65)
So
me
tim
es
Ne
ver
26 (39.4)
Do
n't
Kno
w
23 (35.4)
16 (24.2)
0
Ampicillin
65 (98.5)
1 (1.5)
Gentamycin
45 (68.2)
21 (31.8)
12 (18.2)
48 (72.7)
5 (7.6)
1 (1.5)
Antibiotics
3rd /4th
Gen Cephalosporin
0
0
0
0
Piperacillin
0
1 (1.5)
55 (83.3)
10 (15.2)
Carbapenem
0
0
52 (78.8)
14 (21.2)
IV Fluids
Crystalloids
66 (100)
Colloids
14 (21.2)
49 (74.2)
23 (35.4)
0
0
3 (4.5)
0
0
Blood Products
Red Blood Cells (n=65)
Fresh Frozen Plasma (n=63)
Platelets (n=63)
41 (62.1)
1 (1.5)
0
4 (6.3)
54 (85.7)
5 (7.9)
0
0
2 (3.2)
58 (92.1)
3 (4.8)
0
59 (90.8)
1 (1.5)
12 (18.5)
12 (73.8)
1 (1.5)
5 (7.7)
54 (83.1)
6 (9.2)
Cardiovascular Drugs
( n =65)
Noradrenaline
5 (7.7)
Dopamine
4 (6.2)
Dobutamine
Adrenaline
0
36 (55.4)
29 (44.6)
51 (77.3)
15 (22.7)
1 (1.5)
1 (1.5)
52 (80)
14 (21.5)
18 (27.7)
33 (50.8)
2 (3.1)
20 (30.8)
42 (64.6)
10 (15.4)
19 (29.2)
36 (55.4)
0
9 (14.1)
18 (28.1)
37 (57.8)
0
IV opiate/opioid
11 (16.9)
34 (52.3)
20 (30.8)
0
Diazepam
60 (92.3)
4 (6.2)
1 (1.5)
Midazolam
2 (3.1)
19 (29.2)
43 (66.2)
Hydrocortisone (n=66)
Vasopressin
0
0
0
0
11 (16.9)
Anesthetic/Sedative Drugs
( n =65)
Thiopentone
Propofol
Succinylcholine
ND Muscle Relaxant
0
1 (1.5)
0
1 (1.5)
Others
Insulin
25 (37.9)
40 (60.6)
1 (1.5)
0
Heparin or LMWH (n=65)
4 (6.2)
53 (81.5)
8 (12.3)
0
H2-Blockers (n=65)
6 (9.2)
38 (58.5)
17 (26.2)
4 (6.2)
6 (9.2)
34 (52.3)
22 (33.8)
3 (4.6)
52 (80)
13 (20)
Proton Pump Inhibitor (n=65)
Activated Protein C (n=65)
0
0
ND, non-depolarizing; IV, intravenous; LMWH, low molecular weight heparin;
H2, histamine receptor 2.
All data are given as absolute values and percentages.
M.E.J. ANESTH 21 (4), 2012
564
I. Baelani et al.
Table 2.
Availabili ty of Drugs to Provid e Adequate Sepsis Care
and Implement the Surviving Sepsi s Campai gn Gui delines
Al
wa
ys
O xygen (n =65 )
So
met
ime
s
Ne
ver
26 (39.4)
Do
n't
Kn
ow
23 (35.4)
16 (24.2)
0
Ampicillin
65 (98.5)
1 (1.5)
Gentamycin
45 (68.2)
21 (31.8)
0
0
12 (18.2)
48 (72.7)
5 (7.6)
1 (1.5)
Antibi otics
3rd / 4th
Gen Cephal osporin
0
0
Piperacil lin
0
1 (1.5)
55 (83.3)
10 (15 .2
Carbapenem
0
0
52 (78.8)
14 (21 .2
IV Fluids
Crystal loids
66 (100)
Col loids
14 (21.2)
23 (35.4)
0
0
0
49 (74.2)
3 (4.5)
0
41 (62.1)
1 (1.5)
0
0
4 (6.3)
54 (85.7)
5 (7.9)
0
2 (3.2)
58 (92.1)
3 (4.8)
Blood Products
Red Bl ood Cells (n=65)
Fresh Frozen Pla sma (n=63 )
Pl atel ets (n=63 )
Cardiovascular Drugs
( n =65)
Noradrenaline
5 (7.7)
Dopamine
4 (6.2)
Dobutamine
Adrenaline
Hydrocorti sone (n=66)
Vasopressin
0
59 (90.8)
1 (1.5)
12 (18.5)
0
12 (73.8)
1 (1.5)
5 (7.7)
54 (83.1)
6 (9.2)
36 (55.4)
29 (44.6)
0
0
51 (77.3)
15 (22.7)
0
0
1 (1.5)
1 (1.5)
52 (80)
11 (16 .9
14 (21.5)
18 (27.7)
33 (50.8)
0
Anesthetic/Seda tive Drugs
( n =65)
Th iopento ne
Propofol
2 (3.1)
20 (30.8)
42 (64.6)
1 (1.5)
10 (15.4)
19 (29.2)
36 (55.4)
0
9 (14.1)
18 (28.1)
37 (57.8)
0
IV opi ate/op ioid
11 (16.9)
34 (52.3)
20 (30.8)
0
Diazepam
60 (92.3)
4 (6.2)
1 (1.5)
0
Midazolam
2 (3.1)
19 (29.2)
43 (66.2)
1 (1.5)
25 (37.9)
40 (60.6)
1 (1.5)
0
4 (6.2)
53 (81.5)
8 (12.3)
0
6 (9.2)
38 (58.5)
17 (26.2)
4 (6.2)
6 (9.2)
34 (52.3)
22 (33.8)
3 (4.6)
52 (80)
13 (20)
S uccinyl cholin e
N D Muscle Relaxant
Others
Insul in
Heparin or LMWH (n=65)
H2-Blo ckers (n=65)
Proton Pu mp Inhibito r (n= 65)
Activated Protei n C (n=65)
0
0
ND, non-depolarizi ng; IV, intravenous; LM WH, low molecu lar weight hepari n;
H2, h istamine receptor 2.
All data are given as absolute val ues and percentages .
Identifying Resource Needs for Sepsis Care and Guideline Implementation in the Democratic
Republic of the Congo: A Cluster Survey of 66 Hospitals in Four Eastern Provinces
565
Always
Sometimes
Never
Don't Know
Table 3. Availability of Equipment to Provide Adequate Sepsis Care
and Implement the Surviving Sepsis Campaign Guidelines
X-ray
39 (61.9)
1 (1.6)
23 (36.5)
0
Ultrasound
24 (38.1)
6 (9.5)
33 (52.4)
0
0
0
57 (90.5)
6 (9.5)
Gram Stain (n=63)
59 (93.7)
4 (6.3)
0
0
Microbiological Cultures
12 (19.4)
11 (17.7)
38 (61.3)
1 (1.6)
9 (14.5)
11 (17.7)
40 (64.5)
2 (3.2)
32 (51.6)
28 (45.2)
2 (3.2)
0
1 (1.6)
8 (12.9)
53 (85.5)
0
0
5 (8.1)
55 (88.7)
2 (3.2)
4 (6.5)
21 (33.9)
37 (59.7)
0
Creatinine
9 (14.5)
6 (9.7)
47 (75.8)
0
Bilirubin
8 (12.7)
7 (11.3)
47 (75.8)
0
4 (6.5)
0
55 (88.7)
3 (4.8)
16 (25.8)
41 (66.1)
5 (8.1)
0
Body Temperature
62 (95.4)
3 (4.6)
0
0
Non-Invasive Blood Pressure
63 (96.9)
2 (3.1)
0
0
0
1 (1.5)
54 (83.1)
10 (15.4)
9 (13.8)
34 (52.3)
21 (32.3)
1 (1.5)
Central Venous Pressure
0
0
57 (87.7)
8 (12.3)
Cardiac Output
0
0
58 (89.2)
7 (10.8)
Pulmonary Arterial Pressure
0
0
60 (92.3)
5 (7.7)
Endtidal Carbon Dioxide
0
11 (16.9)
48 (73.8)
6 (9.2)
Mechanical Ventilator
0
2 (3.2)
60 (95.2)
1 (1.6)
Syringe Pump
0
3 (4.8)
57 (90.5)
3 (4.8)
Fluid Infuser
0
2 (3.2)
58 (92.1)
3 (4.8)
Peritoneal Dialysis
0
0
56 (88.9)
7 (11.1)
Haemodialysis/Haemofiltration
0
0
56 (88.9)
7 (11.1)
Diagnostic Equipment (n =63)
Echocardiography
Laboratory Investigations (n =62)
Antibiotic Sensitivities
Blood Sugar
Blood Gas Analysis
Lactate
Blood Count
Prothrombin Time/INR
Other Coagulation Tests
Monitoring Equipment (n =65)
Invasive Blood Pressure
Oxygen Saturation
Other Equipment (n =63)
INR, international normalized ratio.
All data are given as absolute values and percentages.
M.E.J. ANESTH 21 (4), 2012
566
I. Baelani et al.
Never
Don't Know
Don't Know
0
0
0
0
0
Urinary
Urinary
Catheter
Catheter 46 (70.8)
46 (70.8)
19 (29.2)
19 (29.2) 0
0
0
0
0
0
Endotracheal
Endotracheal
TubeTube 20 (30.8)
20 (30.8)
18 (27.7)
18 (27.7)
27 (41.5)
27 (41.5) 0
0
Oxygen
Oxygen
FaceFace
MaskMask 19 (29.7)
19 (29.7)
20 (31.3)
20 (31.3)
25 (39.1)
25 (39.1) 0
0
Oxygen
Oxygen
NasalNasal
Cannula
Cannula 17 (26.6)
17 (26.6)
22 (34.4)
22 (34.4)
25 (39.1)
25 (39.1) 0
0
Sometimes
0
Sometimes
0
Always
0
Always
Never
of Disposable
of Disposable
Material
Material
to Provide
to Provide
Adequate
Adequate
Sepsis
Sepsis
Care Care
TableTable
4. Availability
4. Availability
And Implement
And Implement
the Surviving
the Surviving
Sepsis
Sepsis
Campaign
Campaign
Guidelines
Guidelines
(n =65)
(n =65)
Disposable
Disposable
Material
Material
IV Cannula
IV Cannula 63 (96.9)
63 (96.9)2 (3.1)
2 (3.1)
IV Fluid
IV Fluid
Giving
Giving
Set Set 65 (100)
65 (100) 0
0
Nasogastric
Nasogastric
TubeTube 39 (60)
39 (60)
25 (38.5)
25 (38.5)1 (1.5)
1 (1.5)
Central
Central
Venous
Venous
Catheter
Catheter 2 (3.1)
2 (3.1) 3 (4.6)
3 (4.6)58 (89.2)
58 (89.2)2 (3.1)
2 (3.1)
Antithrombotic
Antithrombotic
Stockings
Stockings
(n=60)
(n=60) 8 (13.3)
8 (13.3)
10 (16.7)
10 (16.7)
27 (45)
27 (45)15 (25)
15 (25)
IV, intravenous.
IV, intravenous.
All data
All are
datagiven
are given
as absolute
as absolute
values
values
and percentages.
and percentages.
TableTable
5. Ability
5. Ability
to Implement
to Implement
the Surviving
the Surviving
SepsisSepsis
Campaign
Campaign
Guidelines
Guidelines
n
n
Ability
Ability
to Implement
to Implement
the SSC
the Guidelines
SSC Guidelines
n (%)n (%)
66
66
0
0
Percentage
Percentage
of Implementable
of Implementable
Recommendations/Suggestions
Recommendations/Suggestions
(%) (%) 32 (29-37)
32 (29-37)
Ability
Ability
to Implement
to Implement
All Level
All Level
I Recommendations
I Recommendations
n (%)n (%)
0
0
Percentage
Percentage
of Implementable
of Implementable
LevelLevel
I Recommendations
I Recommendations
(%) (%) 46 (44-54)
46 (44-54)
Ability
Ability
to Implement
to Implement
All Level
All Level
IA and
IAIB
and
Recommendations
IB Recommendations n (%)n (%)
0
0
Percentage
Percentage
of Implementable
of Implementable
LevelLevel
IA and
IAIB
and
Recommendations
IB Recommendations
(%) (%) 50 (46-54)
50 (46-54)
Ability
Ability
to Implement
to Implement
All Level
All Level
IC and
ICID
andRecommendations
ID Recommendations n (%)n (%)
0
0
Percentage
Percentage
of Implementable
of Implementable
LevelLevel
IC and
ICID
and
Recommendations
ID Recommendations
(%) (%) 42 (42-54)
42 (42-54)
Ability
Ability
to Implement
to Implement
All Level
All Level
II Suggestions
II Suggestions
n (%)n (%)
0
0
Percentage
Percentage
of Implementable
of Implementable
LevelLevel
II Suggestions
II Suggestions
(%) (%) 22 (17-22)
22 (17-22)
SSC, SSC,
Surviving
Surviving
SepsisSepsis
Campaign.
Campaign.
Data Data
are given
are given
as median
as median
valuesvalues
with interquartile
with interquartile
ranges,
ranges,
if notifotherwise
not otherwise
indicated.
indicated.
141 141
Identifying Resource Needs for Sepsis Care and Guideline Implementation in the Democratic
Republic of the Congo: A Cluster Survey of 66 Hospitals in Four Eastern Provinces
to those not addressed, our results indicate a striking
shortage of key hospital facilities and resources to
provide adequate care for sepsis patients. On average,
resources were only available to implement one third
of recommendations/suggestions of the life-saving
SSC guidelines. This number is even more alarming
considering that about 25% of SSC recommendations/
suggestions are passive (“do not use”) and do not
require resources15. While relevant shortages of
medical equipment and supplies were reported from
other Sub-Sahara African countries19-22, the situation
appears particularly devastating in Eastern DRC.
Despite of the overall lack of resources, the
shortage of some specific materials is particularly
concerning. For example, only about one third
of respondents stated that oxygen was constantly
available at their hospital. Hypoxaemia and tissue
hypoxia plays a central role in the pathophysiology of
sepsis4. Similarly, not a single respondent claimed to
have consistent access to broad-spectrum antibiotics
such as piperacillin or carbapenems. Less than one
fifth had third/fourth generation cephalosporins
always available. Adequate antibiotic coverage with or
without surgical source control is the mainstay of sepsis
therapy4,26. A high prevalence of microbial resistance
against penicillins and aminoglycosides in Sub-Sahara
Africa27 may render the few constantly available
antibiotics of little benefit for patients suffering from
sepsis. Accordingly, a prospective observational
study of the management and outcome of sepsis in
two Ugandan hospitals observed no survival benefit
of administering empiric antibiotics or administering
any antibiotic within one hour after presentation10.
Epinephrine is an integral drug for the management of
patients with shock or cardiac arrest, but was reported
to be constantly available in only half of the surveyed
hospitals. Finally, diagnostic devices are fundamental
for diagnosing and identifying the infectious source.
The widespread lack of reliable x-ray and sonography
machines in the analyzed hospitals may result in
delayed or failed recognition of the source of infection
in sepsis patients.
Given that the SSC guidelines reflect the current
best practice of sepsis management15, it is clear from
our results that a lack of resources to implement
these guidelines may inevitably result in inadequate
567
sepsis care. Yet, our data cannot prove a cause-effect
relationship between lacking resources to provide
adequate sepsis care and the excess mortality arising
from infectious diseases in the Eastern DRC. It is very
likely that additional factors contribute to high fatality
rates associated with infection and sepsis in this
region. Our survey indicated that key hospital facilities
to treat sepsis patients such as emergency departments
or intensive care units do not exist in the majority of
the analyzed hospitals. Insufficient staffing prevents
consistent implementation of the SSC guidelines into
clinical practice even in high-income countries28. Lack
of health care workers is a well-known and widespread
problem in Sub-Sahara Africa29 and the DRC30. So
far, less than 100 physicians have been trained as
anesthesiologists in the DRC (unpublished data).
Accordingly, the fact that >90% of respondents in this
survey were non-physicians implies that the level of
education of health care providers caring for acutely
and critically ill patients, such as those suffering from
sepsis, may be insufficient.
What could be realistic options to improve the
management of sepsis patients in the Eastern DRC or
other resource poor areas? Based on our survey results,
sepsis guidelines should be adapted to target the few
available resources to be used according to the latest
clinical evidence. This may be particularly relevant
for therapeutic interventions with a high chance of
improving patient survival such as those included
in level IA and IB recommendations of the SSC
guidelines. On average, respondents had resources
constantly available to implement 50% of level IA
and IB recommendations suggesting that guideline
adaption based on locally available resources may
allow implementation of a reasonable number of lifesaving interventions into the care of sepsis patients.
However, given the striking shortage of resources
detected in this survey, adaption of guidelines alone
will most likely not compensate for the lack of essential
resources. Resources such as oxygen, broad-spectrum
antibiotics, epinephrine and diagnostic devices are
indispensable and vital resources which need to be
supplied to health care facilities in order to improve
the care and outcome of septic patients. Availability
of these resources, especially oxygen and epinephrine,
carries a high potential to advance the care of other
acutely and critically ill patients as well. As mentioned
M.E.J. ANESTH 21 (4), 2012
568
above, establishment of emergency and intensive care
departments, adequate staffing and training of health
care providers may be further possibilities to improve
the management of patients suffering from severe
infection in the Eastern DRC.
Some limitations need to be considered
when interpreting our study results. Apart from
the impossibility of evaluation of all hospitals in
the Eastern DRC (for reasons stated above), our
survey investigated the availability of resources in
a binary fashion and might therefore have missed
quantitative shortages in the few constantly available
resources. This could, for example, be relevant for the
availability of fluids. Although all respondents stated
to have crystalloid solutions constantly available at
their hospital, data from the same area showed that
the amount of intraoperatively available fluids was
rationed31. Secondly, although the questionnaire used
in this survey underwent pilot testing and has been
used in another setting before, no assessment of testretest reliability and inter-observer variability was
performed. Together with the lack of clinical sensibility
testing of the survey instrument, this limits the validity
I. Baelani et al.
of our results32. Third, our survey did not assess the
availability of resources necessary to manage children
with sepsis. Since special sized disposable materials
and equipment are required, it is likely that resources
needed to care for critically ill children with sepsis
are even less frequently available in the Eastern DRC.
This may be of particular relevance considering that
children account for nearly 50% of deaths although
they comprise only 19% of the population in this
region13.
In conclusion, our survey indicates a critical
shortage of resources required to provide adequate
sepsis care and implement the SSC guidelines in
a cluster of hospitals in the Eastern DRC. While
adaption of current guidelines may help to target
available resources according to the latest clinical
evidence, this may not be sufficient to compensate
for the shortage of indispensable resources such as
oxygen, broad-spectrum antibiotics, epinephrine and
diagnostic devices. These essential components of
sepsis care need to be provided to improve sepsis care
in the Eastern DRC.
Identifying Resource Needs for Sepsis Care and Guideline Implementation in the Democratic
Republic of the Congo: A Cluster Survey of 66 Hospitals in Four Eastern Provinces
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16.Ferrer R, Artigas A, Levy MM, Blanco J, Gonzalez-Diaz G,
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T, Cohen J, et al: Surviving Sepsis Campaign guidelines for
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2004, 32:858-873.
25.Bataar O, Lundeg G, Tsenddorj G, Jochberger S, Grander W,
Baelani I, et al: Nationwide survey on resource availability for
implementing current sepsis guidelines in Mongolia. Bull World
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26.Kumar A, Ellis P, Arabi Y, Roberts D, Light B, Parrillo JE, et al:
Initiation of inappropriate antimicrobial therapy results in a fivefold
reduction of survival in human septic shock. Chest; 2009, 136:12371248.
27.Vlieghe E, Phoba MF, Tamfun JJ, Jacobs J: Antibiotic resistance
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28.Carlbom DJ, Rubenfeld GD: Barriers to implementing protocolbased sepsis resuscitation in the emergency department-results of a
national survey. Crit Care Med; 2007, 35:2525-2532.
29.Kumar P: Providing the providers – remedying Africa’s shortage of
health care workers. N Engl J Med; 2007, 356:2564-2567.
30.Dünser M, Baelani I, Ganbold L: The specialty of anesthesia
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31.Baelani I, Dünser MW: Back to the future: intraoperative fluid
restriction in gastrointestinal surgery – a new practice to the west,
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M.E.J. ANESTH 21 (4), 2012
570
I. Baelani et al.
ESM Fig. 1
Study Questionnaire in its original version in English language
1. GENERAL INFORMATION
Name of your hospital?
……………………………………………………………………………..
Country where hospital situated?
……………………………………………………………………………..
Type of hospital? ¡District ¡Regional/Provincial ¡University ¡Private ¡Other (please write) ……………..
Number of hospital beds?
…………………………………….
What is your grade?
¡ Physician Anaesthetist
¡ Non-Physician Anaesthetist
¡ Other Physician
¡ Other (please write) ……………………
Always
Sometimes
Never
Don’t know
2. HOSPITAL FACILITIES
Oxygen
¡
¡
¡
¡
Blood Transfusion
¡
¡
¡
¡
Fresh Frozen Plasma
¡
¡
¡
¡
Platelets
¡
¡
¡
¡
Heparin or Low Molecular
Weight Heparin
Ranitidine or other H2
receptor blocker
Omeprazole or other
Proton Pump Inhibitor
IV morphine, pethidine or
other IV opioid
Diazepam
¡
¡
¡
¡
¡
¡
¡
¡
¡
¡
¡
¡
¡
¡
¡
¡
¡
¡
¡
¡
Midazolam
¡
¡
¡
¡
Propofol
¡
¡
¡
¡
Thiopentone
¡
¡
¡
¡
Succinylcholine
¡
¡
¡
¡
Atracurium or other
non-depolarising muscle
relaxant
Noradrenaline
¡
¡
¡
¡
¡
¡
¡
¡
Dopamine
¡
¡
Emergency / resuscitation room
(Room for emergency patient who’s just
arrived to hospital)
¡
¡
Don’t know
No
Yes
Does your hospital have the following?
¡
Intensive care unit
¡
¡
¡
Operating Theatre
¡
¡
¡
(Dedicated unit for critically ill patients)
3. DRUGS
IV Ampicillin
IV Gentamycin
¡
¡
¡
¡
Don’t know
Never
Sometimes
Always
Are the following drugs available in your hospital?
¡
¡
¡
¡
IV Ceftriaxone, Cefotaxime or
¡
¡
¡
¡
IV Piperacillin
¡
¡
¡
¡
IV Meropenem or other
carbapenem
IV Hydrocortisone
¡
¡
¡
¡
¡
¡
¡
¡
¡
¡
Dobutamine
¡
¡
¡
¡
¡
¡
¡
¡
Adrenaline
¡
¡
¡
¡
¡
¡
¡
¡
Vasopressin
¡
¡
¡
¡
¡
¡
Activated Protein C
¡
¡
¡
¡
¡
¡
Ceftazidime
Sodium Chloride, Ringers
Lactate or other crystalloid
Gelatine, Dextran or other
Colloid
Insulin
Identifying Resource Needs for Sepsis Care and Guideline Implementation in the Democratic
Republic of the Congo: A Cluster Survey of 66 Hospitals in Four Eastern Provinces
4. PATIENT MONITORING
6. EQUIPMENT
Non-invasive blood
pressure
Invasive arterial
blood pressure
Oxygen saturation
Don’t know
Never
Always
Sometimes
Is the following equipment available in your
hospital? Don’t know
Never
Always
Sometimes
Can the following variables be monitored in your
hospital?
Temperature
571
X-ray
¡
¡
¡
¡
Ultrasound - Abdomen
¡
¡
¡
¡
Echocardiography
¡
¡
¡
¡
Mechanical Ventilator
¡
¡
¡
¡
¡
Syringe pump
¡
¡
¡
¡
¡
¡
¡
¡
¡
¡
¡
¡
¡
¡
¡
¡
¡
¡
¡
¡
¡
¡
¡
Central venous
pressure
¡
¡
¡
¡
Fluid infuser/Infusion
pump
Cardiac output
¡
¡
¡
¡
Peritoneal Dialysis
¡
¡
¡
¡
Pulmonary arterial
pressure
¡
¡
¡
¡
Hemodialysis/
hemofiltration
¡
¡
¡
¡
End tidal CO2
¡
¡
¡
¡
5. LABORATORY
7. DISPOSABLES
Sometimes
Never
Don’t know
Venous cannula
¡
¡
¡
¡
Don’t know
Never
Are the following items available in your hospital?
Always
Blood slide for malaria
parasites
Direct microscopy & gram
stain
Bacteria culture
Sometimes
Always
Can the following investigations be done in your
hospital?
¡
¡
¡
¡
IV fluid giving set
¡
¡
¡
¡
¡
¡
¡
¡
Urinary catheter
¡
¡
¡
¡
¡
¡
¡
¡
Gastric tube (NG-tube)
¡
¡
¡
¡
Antibiotic sensitivities
¡
¡
¡
¡
Endotracheal tube
¡
¡
¡
¡
Blood glucose
¡
¡
¡
¡
Oxygen masks
¡
¡
¡
¡
Arterial blood gases
¡
¡
¡
¡
Oxygen nasal cannula
¡
¡
¡
¡
Blood lactate
¡
¡
¡
¡
Central venous catheter
¡
¡
¡
¡
Full blood count
¡
¡
¡
¡
Compression stockings
¡
¡
¡
¡
Creatinine
¡
¡
¡
¡
Bilirubin
¡
¡
¡
¡
Prothrombin Time (INR)
¡
¡
¡
¡
Other coagulation test
¡
¡
¡
¡
Thank you very much for participation!
M.E.J. ANESTH 21 (4), 2012
572
ESM Table 1. Hospital facilities, equipment, drugs
and disposable materials required to implement single
recommendations/suggestions of the Surviving Sepsis
Campaign guidelines.
I A - Initial resuscitation (first 6 hrs)
 Begin resuscitation immediately in patients with
hypotension or elevated serum lactate 4
mmol/L; do not delay pending intensive care unit
admission (1C)
Materials required: facility to monitor non-invasive or
invasive arterial blood pressure and measure lactate
levels, intensive care unit
 Resuscitation goals (1C)
Central venous pressure 8–12 mm Hg
Mean arterial pressure 65 mm Hg
Urine output 0.5 mL*kg-1*hr-1
Central venous (superior vena cava) oxygen saturation
70% or mixed venous 65%
Materials required: facility to monitor central venous
pressure, facility to monitor non-invasive or invasive
arterial blood pressure, availability of a urinary
catheter, central venous catheter, and facility to
measure blood gases
o If venous oxygen saturation target is not achieved
(2C)
Consider further fluid
Transfuse packed red blood cells if required to
hematocrit of 30% and/or
Start dobutamine infusion, maximum 20 µg kg-1 min-1
Materials required: central venous catheter, facility
to measure blood gases, availability of IV cannula, IV
fluid giving set, crystalloid or colloid solution, blood
transfusion and dobutamine
I B - Diagnosis
 Obtain appropriate cultures before starting antibiotics
provided this does not significantly
delay antimicrobial administration (1C)
Obtain two or more blood cultures
One or more blood cultures should be percutaneous
One blood culture from each vascular access device in
place 48 hrs
Culture other sites as clinically indicated
Materials required: direct microscopy and gram stain,
bacteria culture
 Perform imaging studies promptly to confirm and
sample any source of infection, if safe to do so (1C)
Materials required: availability of x-ray and ultrasound
I C - Antibiotic therapy
 Begin intravenous antibiotics as early as possible and
always within the first hour of
recognizing severe sepsis (1D) and septic shock (1B)
Materials required: availability of at least one antibiotic
I. Baelani et al.
drug
 Broad-spectrum: one or more agents active against
likely bacterial/fungal pathogens and with good
penetration into presumed source (1B)
Materials required: availability of either ceftriaxone/
cefotaxime/ceftazidime, piperacilline or meropenem/
other carbapenem
 Reassess antimicrobial regimen daily to optimize
efficacy, prevent resistance, avoid toxicity, and minimize
costs (1C)
Materials required: none
o Consider combination therapy in Pseudomonas
infections (2D)
Materials required: bacteria culture and availability
of at least two of the following antibiotic drugs:
ceftriaxone/cefotaxime/ceftazidime, piperacilline,
meropenem/other carbapenem, or gentamycin
o Consider combination empiric therapy in
neutropenic patients (2D)
Materials required: facility to measure full blood count
and at least two antibiotic drugs
o Combination therapy 3–5 days and de-escalation
following susceptibilities (2D)
Materials required: facility to determine antibiotic
sensitivities
 Duration of therapy typically limited to 7–10 days;
longer if response is slow or there are
undrainable foci of infection or immunologic
deficiencies (1D)
Materials required: none
 Stop antimicrobial therapy if cause is found to be
noninfectious (1D)
Materials required: facility to perform bacteria cultures
I D - Source identification and control
 A specific anatomic site of infection should be
established as rapidly as possible (1C) and
within first 6 hrs of presentation (1D)
Materials required: availability of x-ray and ultrasound
 Formally evaluate patient for a focus of infection
amenable to source control measures (e.g.
abscess drainage, tissue debridement) (1C)
Materials required: availability of x-ray and ultrasound
 Implement source control measures as soon as
possible following successful initial
resuscitation (1C) (exception: infected pancreatic
necrosis, where surgical intervention is best
delayed) (2B)
Materials required: operation room
 Choose source control measure with maximum
efficacy and minimal physiologic upset (1D)
Materials required: none
 Remove intravascular access devices if potentially
infected (1C)
Materials required: none
Identifying Resource Needs for Sepsis Care and Guideline Implementation in the Democratic
Republic of the Congo: A Cluster Survey of 66 Hospitals in Four Eastern Provinces
I E - Fluid therapy
 Fluid-resuscitate using crystalloids or colloids (1B)
Materials required: availability of IV cannula, IV fluid
giving set, crystalloid or colloid solution
 Target a central venous pressure of 8 mm Hg (12 mm
Hg if mechanically ventilated) (1C)
Materials required: facility to measure central venous
pressure
 Use a fluid challenge technique while associated with
a hemodynamic improvement (1D)
Materials required: availability of IV cannula, IV fluid
giving set, crystalloid or colloid solution and facility to
monitor non-invasive or invasive arterial blood pressure
 Give fluid challenges of 1000 mL of crystalloids or
300–500 mL of colloids over 30 mins. More rapid and
larger volumes may be required in sepsis-induced tissue
hypoperfusion (1D)
Materials required: availability of IV cannula, IV fluid
giving set, crystalloid or colloid solution
 Rate of fluid administration should be reduced if
cardiac filling pressures increase without
concurrent hemodynamic improvement (1D)
Materials required: availability of IV cannula, IV fluid
giving set, crystalloid or colloid solution, facility to
measure central venous pressure
I F - Vasopressors
 Maintain mean arterial pressure 65 mm Hg (1C)
Materials required: facility to measure non-invasive or
invasive arterial blood pressure
 Norepinephrine and dopamine centrally administered
are the initial vasopressors of choice (1C)
Materials required: availability of a central venous
catheter, norepinephrine or dopamine
o Epinephrine, phenylephrine, or vasopressin should
not be administered as the initial
vasopressor in septic shock (2C). Vasopressin 0.03
units/min may be subsequently added to
norepinephrine with anticipation of an effect equivalent
to norepinephrine alone
Materials required: availability of vasopressin
o Use epinephrine as the first alternative agent in
septic shock when blood pressure is
poorly responsive to norepinephrine or dopamine (2B).
Materials required: facility to monitor non-invasive
or invasive arterial blood pressure, availability of
epinephrine
 Do not use low-dose dopamine for renal protection
(1A)
Materials required: none
 In patients requiring vasopressors, insert an arterial
catheter as soon as practical (1D)
Materials required: facility to monitor invasive arterial
blood pressure
573
I G - Inotropic therapy
 Use dobutamine in patients with myocardial
dysfunction as supported by elevated cardiac
filling pressures and low cardiac output (1C)
Materials required: facility to monitor central venous
pressure or cardiac output, availability of dobutamine
 Do not increase cardiac index to predetermined
supranormal levels (1B)
Materials required: none
I H - Corticosteroids
o Consider intravenous hydrocortisone for adult septic
shock when hypotension responds
poorly to adequate fluid resuscitation and vasopressors
(2C)
Materials required: facility to measure non-invasive
or invasive arterial blood pressure, availability of IV
cannula, IV fluid giving set, availability of crystalloid
or colloid solution, availability of a central venous
catheter, dopamine or norepinephrine, hydrocortisone
o ACTH stimulation test is not recommended to
identify the subset of adults with septic
Shock who should receive hydrocortisone (2B)
Materials required: none
o Hydrocortisone is preferred to dexamethasone (2B)
Materials required: availability of hydrocortisone
o Fludrocortisone (50 g orally once a day) may be
included if an alternative to
hydrocortisone is being used that lacks significant
mineralocorticoid activity. Fludrocortisone is optional if
hydrocortisone is used (2C)
Materials required: none
o Steroid therapy may be weaned once vasopressors
are no longer required (2D)
Materials required: availability of hydrocortisone,
availability of a central venous catheter, dopamine or
norepinephrine
 Hydrocortisone dose should be 300 mg/day (1A)
Materials required: availability of hydrocortisone
 Do not use corticosteroids to treat sepsis in the
absence of shock unless the patient’s
endocrine or corticosteroid history warrants it (1D)
Materials required: none
I I - Recombinant human activated protein C
(rhAPC)
o Consider rhAPC in adult patients with sepsisinduced organ dysfunction with clinical
assessment of high risk of death (typically APACHE II
25 or multiple organ failure) if there
are no contraindications (2B, 2C for postoperative
patients).
Materials required: facility to measure body
temperature, non-invasive or invasive arterial blood
M.E.J. ANESTH 21 (4), 2012
574
pressure, arterial blood gases, creatinine, and full blood
count, availability of recombinant human activated
protein C
 Adult patients with severe sepsis and low risk of
death (typically, APACHE II 20 or one
organ failure) should not receive rhAPC (1A)
Materials required: facility to measure body
temperature, non-invasive or invasive arterial blood
pressure, arterial blood gases, creatinine, and full blood
count
I J - Blood product administration
 Give red blood cells when hemoglobin decreases to
7.0 g/dL (70 g/L) to target a hemoglobin of 7.0–9.0 g/
dL in adults (1B). A higher hemoglobin level may be
required in special circumstances (e.g., myocardial
ischaemia, severe hypoxemia, acute hemorrhage,
cyanotic heart disease, or lactic acidosis)
Materials required: facility to measure full blood count,
availability of IV cannula, IV fluid giving set and blood
transfusion
o Do not use erythropoietin to treat sepsis-related
anemia. Erythropoietin may be used for
other accepted reasons (1B)
Materials required: none
o Do not use fresh frozen plasma to correct laboratory
clotting abnormalities unless there is
bleeding or planned invasive procedures (2D)
Materials required: availability of IV cannula, IV fluid
giving set and fresh frozen plasma
 Do not use antithrombin therapy (1B)
Materials required: none
o Administer platelets when (2D)
Counts are 5000/mm3 (5 x 109/L) regardless of bleeding
Counts are 5000–30,000/mm3 (5–30 x 109/L) and there
is significant bleeding risk
Higher platelet counts (50,000/mm3 [50 x 109/L]) are
required for surgery or invasive procedures
Materials required: availability of IV cannula, IV fluid
giving set and platelets
II A - Mechanical ventilation of sepsis-induced ALI/
ARDS
 Target a tidal volume of 6 mL/kg (predicted) body
weight in patients with ALI/ARDS (1B)
Materials required: facility to measure oxygen
saturation or arterial blood gases, availability of
endotracheal tube and mechanical ventilator
 Target an initial upper limit plateau pressure 30
cmH2O. Consider chest wall compliance when assessing
plateau pressure (1C)
Materials required: availability of endotracheal tube
and mechanical ventilator
 Allow PaCO2 to increase above normal, if needed, to
minimize plateau pressures and tidal volumes (1C)
I. Baelani et al.
Materials required: facility to measure arterial blood
gases or endtidal CO2, availability of endotracheal tube
and mechanical ventilator
 Set PEEP to avoid extensive lung collapse at endexpiration (1C)
Materials required: availability of endotracheal tube
and mechanical ventilator
o Consider using the prone position for ARDS
patients requiring potentially injurious levels
of FIO2 or plateau pressure, provided they are not put at
risk from positional changes (2C)
Materials required: availability of endotracheal tube
and mechanical ventilator
 Maintain mechanically ventilated patients in a
semirecumbent position (head of the bed raised to 45°)
unless contraindicated (1B), between 30° and 45° (2C)
Materials required: none
o Noninvasive ventilation may be considered in the
minority of ALI/ARDS patients with
mild to moderate hypoxemic respiratory failure.
The patients need to be hemodynamically stable,
comfortable, easily arousable, able to protect/clear their
airway, and expected to recover rapidly (2B)
Materials required: facility to monitor oxygen saturation
or arterial blood gases and non-invasive or invasive
arterial blood pressure, availability of mechanical
ventilator
 Use a weaning protocol and an SBT regularly to
evaluate the potential for discontinuing mechanical
ventilation (1A)
Materials required: availability of endotracheal tube
and mechanical ventilator
 Spontaneous breathing trial options include a low
level of pressure support with continuous positive
airway pressure 5 cm H2O or a T piece
Materials required: availability of endotracheal tube
and mechanical ventilator
 Before the spontaneous breathing trial, patients
should
be arousable
be hemodynamically stable without vasopressors
have no new potentially serious conditions
have low ventilatory and end-expiratory pressure
requirement
require FiO2 levels that can be safely delivered with a
face mask or nasal cannula
Materials required: facility to monitor non-invasive
or invasive arterial blood pressure, availability of
endotracheal tube and mechanical ventilator, oxygen,
oxygen mask or nasal cannula
 Do not use a pulmonary artery catheter for the routine
monitoring of patients with ALI/ARDS (1A)
Materials required: none
 Use a conservative fluid strategy for patients with
established ALI who do not have evidence of tissue
Identifying Resource Needs for Sepsis Care and Guideline Implementation in the Democratic
Republic of the Congo: A Cluster Survey of 66 Hospitals in Four Eastern Provinces
hypoperfusion (1C)
Materials required: availability of IV cannula, IV fluid
giving set, crystalloid or colloid solution
II B - Sedation, analgesia, and neuromuscular
blockade in sepsis
 Use sedation protocols with a sedation goal for
critically ill mechanically ventilated patients (1B)
Materials required: none
 Use either intermittent bolus sedation or continuous
infusion sedation to predetermined end points (sedation
scales), with daily interruption/lightening to produce
awakening. Re-titrate if necessary (1B)
Materials required: availability of IV morphine/opioid,
benzodiazepine, propofol or thiopentone
 Avoid neuromuscular blockers where possible.
Monitor depth of block with train-of-four when using
continuous infusions (1B)
Materials required: availability of non-depolarizing
muscle relaxant
II C - Glucose control
 Use intravenous insulin to control hyperglycemia in
patients with severe sepsis following stabilization in the
ICU (1B)
Materials required: facility to measure blood glucose,
availability of insulin
 Aim to keep blood glucose 150 mg/dL (8.3 mmol/L)
using a validated protocol for insulin dose adjustment
(2C)
Materials required: facility to measure blood glucose,
availability of insulin
 Provide a glucose calorie source and monitor blood
glucose values every 1–2 hrs (4 hrs when stable) in
patients receiving intravenous insulin (1C)
Materials required: facility to measure blood glucose,
availability of insulin
 Interpret with caution low glucose levels obtained
with point of care testing, as these techniques may
overestimate arterial blood or plasma glucose values
(1B)
Materials required: facility to measure blood glucose
II D - Renal replacement
o Intermittent hemodialysis and continuous venovenous hemofiltration are considered equivalent
(2B)
Materials required: availability of hemodialysis or
hemofiltration
575
o Continuous veno-venous hemofiltration offers
easier management in hemodynamically unstable
patients (2D)
Materials required: facility to measure non-invasive
or invasive arterial blood pressure, availability of
hemodialysis or hemofiltration
II E - Bicarbonate therapy
 Do not use bicarbonate therapy for the purpose of
improving hemodynamics or reducing vasopressor
requirements when treating hypoperfusion-induced
lactic acidemia with pH 7.15 (1B)
Materials required: none
II F - Deep vein thrombosis prophylaxis
 Use either low-dose unfractionated heparin or low
molecular weight heparin, unless contraindicated (1A)
Materials required: availability of unfractionated or low
molecular weight heparin
 Use a mechanical prophylactic device, such as
compression stockings or an intermittent compression
device, when heparin is contraindicated (1A)
Materials required: availability of compression
stockings
o Use a combination of pharmacologic and
mechanical therapy for patients who are at very
high risk for deep vein thrombosis (2C)
Materials required: availability of unfractionated or low
molecular weight heparin and compression stockings
o In patients at very high risk, low molecular weight
heparin should be used rather than unfractionated
heparin (2C)
Materials required: availability of low molecular weight
heparin
II G - Stress ulcer prophylaxis
 Provide stress ulcer prophylaxis using H2 blocker
(1A) or proton pump inhibitor (1B). Benefits of
prevention of upper gastrointestinal bleed must be
weighed against the potential for development of
ventilator-acquired pneumonia
Materials required: availability of ranitidine/other H2
blocker or omeprazole/other proton pump inhibitor
II I - Consideration for limitation of support
 Discuss advance care planning with patients and
families. Describe likely outcomes and set realistic
expectations (1D)
Materials required: none
M.E.J. ANESTH 21 (4), 2012
Comparison of the Anesthetic Effects
of Intrathecal Levobupivacaine + Fentanyl
and Bupivacaine + Fentanyl during
Caesarean Section
Aygen Turkmen*, Dondu Genc Moralar**,
Ahmet Ali** and Aysel Altan*
Abstract
Background: Regional anesthesia techniques are increasingly preferred for caesarean
section. The aim of the present study was to compare the anesthetic effects of levobupivacaine +
fentanyl and bupivacaine + fentanyl on the mother and newborn during elective caesarean section
under spinal anesthesia.
Methods: In this prospective study, 50 gravidas, who were scheduled for cesarean section
were enrolled after Ethics Committee approval had been obtained. The patients were randomized
into one of the following two groups: bupivacaine + fentanyl group (group B; n = 25), 7.5 mg of
0.5% bupivacaine + 15 µg fentanyl intrathecally; levobupivacaine + fentanyl group (group L; n =
25), 7.5 mg of 0.5% levobupivacaine + 15 µg fentanyl intrathecally. The patients were immediately
placed in supine position with 20-30° head up-tilt. The level of sensory and motor blocks were
evaluated by pin-prick test and Bromage scale, respectively.
Results: The time to sensory block at the T4 dermatome was shorter in group B (group B,
4.8 min; group L, 6.0 min; p <0.05). The time to maximum motor block was also shorter in group
B (group B, 3.4 min; group L, 4.7 min; p <0.05). The duration of analgesia was longer in group L
compared to group B (group B, 102 min; group L, 118 min; p <0.05).
Conclusions: Time to sensory and maximum motor block was shorter in the bupivacaine +
fentanyl group. On the other hand, a longer duration of analgesia was achieved in the levobupivacaine
+ fentanyl group. Although levobupivacaine is a novel drug, it is a good alternative for bupivacaine.
Key words: Caesarean section, levobupivacaine, bupivacaine, fentanyl, hemodynamic
effects.
*
**
Assistant Professor, Okmeydani Training and Research Hospital, Anesthesiology and Reanimation Clinic, Istanbul,
Turkey.
Okmeydani Training and Research Hospital, Anesthesiology and Reanimation Clinic, Istanbul, Turkey.
Corresponding author: U. Aygen Turkmen, Atakoy Konaklari B2-4 Blok No: 2 Bakirkoy/Istanbul-Turkey, Telephone:
+905325175872. E-mail: [email protected]
577
M.E.J. ANESTH 21 (4), 2012
578
A. Turkmen et al.
There are various factors affecting the spread
and duration of block during spinal anesthesia. Factors
affecting the spread of the block include volume and
dose of the injected local anesthetic agent, rate of
injection of the anesthetic solution, position of the
patient during and immediately after the injection, age,
weight and height of the patient, anatomical structure
of the vertebral column, cerebrospinal fluid volume
(CSF), level and velocity of the injection, barbotage,
location and diameter of the tip of the injection needle,
intra-abdominal pressure, pressure of the CSF, and
concentration of the local anesthetic. On the other
hand, type of the local anesthesia, level of anesthesia
and addition of a vasopressor are known to affect the
duration of anesthesia6.
The aim of the present study was to investigate
the effects of low doses of either levobupivacaine or
bupivacaine, with intrathecal fentanyl on maternal
anesthesia, analgesia, hemodynamics, and the
newborn, during elective caesarean section under
spinal anesthesia.
Materials and Methods
Fifty gravidas (age range, 18-40 years; and
Injection of 6 % hydroxyethyl starch (HES 130;
7 mL/kg) was administered pre-operatively to all
patients within 15-30 minutes, and heart rate (HR),
mean arterial pressure (MAP), and peripheral oxygen
saturation (SpO2) values were monitored. Oxygen
therapy was administered to all patients at a rate of 4-6
L/min until delivery.
Fig 1
Heart Rate
HEART RATE
120
100
80
60
40
20
0
*
Group B
Group L
preop.
1
5
10
15
20
25
30
35
40
45
60
90
120
Regional anesthesia techniques are increasingly
preferred for caesarean section. With small amounts
and various combinations of drugs, systemic and
pharmacologic effects are avoided, a deep surgical
anesthesia is obtained, and a safer, beneficial, and
comfortable anesthesia is provided for the mother
and child compared to other techniques. Recently,
levobupivacaine, the pure L (-) enantiomer of
bupivacaine, is preferred during spinal anesthesia due
to its lower cardiovascular side effects and central
nervous system toxicity1-4. The addition of low doses
of opioids to local anesthetics during spinal anesthesia
for caesarean section decreases the incidence of local
anesthetic (LA)-related side effects, reduces the time to
onset of the anesthetic effect, and increases the quality
of intra- and post-operative analgesia by reducing
the administered dose of the LA5. The addition of
intrathecal fentanyl to spinal anesthesia is associated
with an early time to onset of the anesthetic effect and
a low incidence of side effects.
≥37 weeks gestation) who were scheduled for
elective caesarean section under spinal anesthesia
were enrolled in the study after obtaining Ethics
Committee approval and written informed consents
from the patients. All procedures performed were in
accordance with Decleration of Helsinki. All patients
were American Society of Anesthesiologists (ASA)
class I-II. The exclusion criteria included allergy
to the study medications, contraindication to spinal
anesthesia, objection to the use of spinal anesthesia,
and morbid obesity.
beat/min.
Introduction
min.
* p <0.05
* HR at the first minute was lower in group B compared to group L.
The MAP values of the groups were not significantly different.
Following closed-envelope randomization,
patients were divided equally into two groups. The
study drugs were prepared in 1.8 mL volumes as 7.5
mg of 0.5% levobupivacaine + 15 µg fentanyl in
group L (n = 25) and 7.5 mg of 0.5% bupivacaine +
15 µg fentanyl in group B (n = 25). Dura was reached
through the L3-L4 interspace using a 22-gauge
Quincke needle while the patient was in a sitting
position. The study drugs were injected into the
subarachnoid space. The subjects were immediately
placed in supine position with 20-30° head up-tilt.
The MAP, HR, and SpO2 values were monitored and
recorded during the pre-operative period, from the
Comparison of the Anesthetic Effects of Intrathecal Levobupivacaine + Fentanyl and
Bupivacaine + Fentanyl during Caesarean Section
1st to the 45th peri-operative min at 5 min intervals,
and then at 45., 60., 90., and 120. Min. intervals.
The sensory block was evaluated by pin-prick test.
Surgery proceeded when the sensory block at the T4
dermatome was achieved. The time to sensory block
at the T4 dermatome and the time to two segment
regression were recorded. The level of maximum
motor block, the time to maximum motor block, and
the duration of motor block were recorded using the
Bromage scale (Table 1). The side effects (nausea,
vomiting, shivering, headache, sedation, itching, and
the need for sedation) were monitored and recorded.
A decrease of 20% below the baseline level in MAP or
a systolic arterial blood pressure of < 90 mmHg was
considered as hypotension. Under these conditions,
treatment with repeated doses of ephedrine (5 mg iv)
and fluid loading was scheduled to be administered
until the blood pressure returned to normal levels.
Administration of 0.5 mg of atropine was scheduled
when the HR decreased to <50 beats per minute.
Respiratory depression was considered to occur at a
SpO2 <92%. Administration of 0.1 mg of naloxone
was scheduled for the treatment of respiratory
depression. Administration of naloxone (40 µg
iv) was scheduled for long-lasting skin conditions
marked by itching, while metoclopramide (10 mg iv)
was scheduled in the presence of nausea.
Table 1
Bromage Scale
SCORE
Criteria
0
Free movement of legs and feet
1
Just able to flex knees with free movement
of feet
2
Unable to flex knees, but with free
movement of feet
3
Unable to move legs or feet
579
Apgar scores were used to evaluate the health of
newborn infants at 1 and 5 minutes after delivery by a
pediatrician, who was blinded to the study groups.
All statistical analyses were carried out using
SPSS for Windows, version 15.0 (SPSS Inc., Chicago,
IL, USA). Results are expressed as the mean ± SD.
A t-test and Mann-Whitney U test were used for
comparison of quantitative variants. Qualitative
variants were compared using a chi-square test. A p
<0.05 was considered statistically significant.
Results
In the present study, the anesthetic effects of
levobupivacaine + fentanyl and bupivacaine + fentanyl
were compared in patients who were scheduled for
caesarean section under spinal anesthesia. There was
no statistically significant difference between the two
study groups in terms of demographic characteristics
(Table 2).
Hypotension was encountered in 13 patients in
group B and 9 patients in group L. The MAP values of
the groups were not significantly different. HR at the
first minute was lower in group B compared to group
L (Group B: 95.3 ± 14.03; Group L: 104.3 ± 15.1) (p
<0.05) (Fig. 1). The time to sensory block at the T4
dermatome was shorter in group B compared to group
L (4.84 ± 1,62; min and 6.07 ± 1.59 min, respectively;
p <0.05) and the duration of analgesia was longer in
group L compared to group B (118.2 ± 14.9 min and
102,8 ± 18.1 min, respectively; p <0.05) (Table 3). The
time to achieve maximum Bromage score was found
to be shorter in group B compared to group L (3.44 ±
1.32 min and 4.71 ± 1,89 min, respectively; p <0.05)
(Table 4). The number of patients with Bromage grade
3 block was 17 in the levobupivacaine group and 22
in the bupivacaine group. The difference between the
Table 2
Demographic characteristics
Group B
(n = 25)
Group L
(n = 25)
p
Age (years) mean ± SD
26,76 ± 5,6
25,60 ± 5,5
0,408
Weight (kg) mean ± SD
73,32 ± 9,06
74,16 ± 10,5
0,756
Height (cm) mean ± SD
160,9 ± 4,43
158,1 ± 10,1
0,297
There were no statistically significant differences between the two groups.
M.E.J. ANESTH 21 (4), 2012
580
A. Turkmen et al.
Table 3
Sensory block
Grup B
Grup L
p
Time to sensory block at the T4 dermatom (min.)
(mean±SD)
4.84±1,62
6.07±1.59
0,005*
Time to two dermatome regression (min.)
(mean±SD)
59,40± 9,38
63,4±12,80
0,303
Duration of analgesia (min.)
102,80±18.14
118.20±14.92
0,001*
(mean±SD)
* Duration of analgesia and the time to sensory block at the T4 dermatome was shorter in group B compared to group L.
time to two dermatome regression (Group B: 59 min.;
Group L: 63 min.) and the maximum Bromage score
was not statistically significant (Group B: 94.6 min.;
Group L: 89.2 min.) (p >0.05).
In group B, nausea was observed in two patients,
shivering in one patient, headache in one patient,
sedation in three patients, and itching in two patients.
In group L, there was nausea in one patient, shivering
in one patient, headache in two patients, sedation
in two patients, itching in one patient, and the need
for sedation in one patient. No significant difference
existed between the groups with respect to side effects
(p >0.05). The Apgar scores were not significantly
different between the groups (p >0.05).
Discussion
In our study, hypotension was noted in 13 patients
in group B and in 9 patients in group L. No statistically
significant difference was observed between the groups
with respect to MAP.
In the study conducted by Gautier et al.7,
isobaric bupivacaine (8 mg), ropivacaine (12 mg),
and levobupivacaine (8 mg) were administered to the
patients (n = 90) who were scheduled for caesarean
section; however, no significant difference was shown
in the incidence of hypotension7.
Erdil et al.8 conducted a study involving 80
patients divided into two groups who were scheduled
for transurethral resection of the prostate (TURP) and
administered 1.5 mL of 0.5% levobupivacaine and
bupivacaine, in combination with 15 µg fentanyl.
Unlike our study; the MAP that their study was lower
in the bupivacaine group between 10 and 30 min after
injection.
In the current study, the time to sensory block at
the T4 dermatome was shorter in group B. The time to
two dermatome regression was 59 min in group B and
63 min in group L; there was no significant difference
between the groups (p >0.05).
In the study by Seyhan et al.9, the time to
sensory block at T4 was compared between groups
during caesarean section by administration of 9 mg of
hyperbaric bupivacaine in group I, 8 mg of hyperbaric
Table 4
Motor block
Group B
Group L
P
Max. Bromage Score
Mean ± SD
2,88 ± 0,33
2,68 ± 0,47
0,091
Time to achieve
Max. Bromage Score (min.)
Mean ± SD
3.44 ± 1.32
4.71 ± 1,89
0,020*
Duration of motor block time (min.)
94,60 ± 19,89
89,20 ± 12,13
Mean ± SD
* The time to achieve maximum Bromage score was found to be shorter in group B compared to group L.
0,331
Comparison of the Anesthetic Effects of Intrathecal Levobupivacaine + Fentanyl and
Bupivacaine + Fentanyl during Caesarean Section
bupivacaine + 10 μg of fentanyl in group II, and 7 mg
of hyperbaric bupivacaine + 20 μg of fentanyl in group
III. It was demonstrated that the time to sensory block
at T4 was minimum in group II (260 ± 58 sec, 225 ±
56 sec, and 264 ± 76 sec, respectively). The difference
between the groups was statistically significant (p
<0.01). The time to resolution of motor block was
significantly shorter in group III, compared to groups
I and II (p <0.01).
In a study by Bremerich et al.10 involving 60
patients who were scheduled for caesarean section and
were administered 0.5% levobupivacaine (10 mg) and
0.5% bupivacaine (10 mg) in combination with opioid
(10 and 20 μg of fentanyl and 5 μg of sufentanil),
the duration of motor block was found to be shorter
with levobupivacaine compared to bupivacaine.
The number of patients with Bromage score 3 block
was 5 in the levobupivacaine group (n = 30) and 21
in the bupivacaine group (n = 30). In our study, the
number of patients with Bromage score 3 block was
17 in the levobupivacaine group (n = 25) and 22 in the
bupivacaine group (n = 25). Gautier et al.7 demonstrated
that the time to maximum motor block was 9 min in the
bupivacaine group, 14 min in the ropivacaine group,
and 13 min in the levobupivacaine group; the duration
of motor block was 142 min in the bupivacaine group,
116 min in the ropivacaine group, and 121 min in the
levobupivacaine group. In the above-mentioned study,
the duration of analgesia and motor block was longer
and the time to first analgesic request was longer in the
bupivacaine group.
In the current study, the time to maximum motor
block was also shorter in group B (group B, 3.4 min;
group L, 4.7 min). The duration of analgesia was longer
in group L compared to group B (group B, 102 min;
group L, 118 min; p <0.05). In a study conducted by Lee
et al.11 involving 50 patients who were scheduled for
urogenital surgery under spinal anesthesia, the quality
of sensory and motor block and the hemodynamic
581
changes were investigated using levobupivacaine in
24 patients and bupivacaine in 26 patients. Lee et al.11
demonstrated that the time to onset of sensory block
was 10±6 min in the levobupivacaine group and 8±4
min in the bupivacaine group, and found that there
was no statistically significant difference between the
groups. Vanna et al.12 demonstrated that the time to
onset of motor block was approximately 7.5 min in the
levobupivacaine group and 4.9 min in the bupivacaine
group in 70 patients who were scheduled for elective
transurethral endoscopic surgery using 2.5 mL of 0.5%
intrathecal isobaric levobupivacaine and the same
volume of 0.5% hyperbaric bupivacaine. Erdil et al.8
divided 80 patients who were scheduled for TURP
into 2 groups and administered 0.5% levobupivacaine
and bupivacaine in combination with fentanyl (15
µg). They demonstrated that the time to achieve T10,
maximum sensory level, and maximum motor block
level was significantly shorter in the bupivacaine
group, and that the maximum sensory block level was
higher in the bupivacaine group.
Very different onset times of effect and ending
times of effect were found during the studies conducted
with similar doses. When the factors affecting the
onset times of effect are examined characteristics
of the patient as well as the dose of local anesthetic
and the position of the patient immediately after the
technique and injection applied were found important.
During this study, we observed that the onset time of
effect shortened, the level reached increased and drug
dose administered decreased as appropriate techniques
and preferred position were applied in a short time.
In our study; time to sensory and maximum motor
block was shorter in the bupivacaine + fentanyl group.
On the other hand, a longer duration of analgesia was
achieved in the levobupivacaine + fentanyl group.
Although levobupivacaine is a novel drug, it is a good
alternative for bupivacaine.
M.E.J. ANESTH 21 (4), 2012
582
A. Turkmen et al.
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bupivacaine in spinal anesthesia for urological surgery. Anaesth
Intensive Care; 2003, 31:637-41.
12.Vanna O, Chumsang L, Thongmee S: Levobupivacaine and
bupivacaine in spinal anesthesia for transurethral endoscopic
surgery. J Med Assoc Thai; 2006, 89:1133-9.
Comparative study between I-gel,
a new supraglottic airway device,
and classical laryngeal mask
airway in anesthetized spontaneously
ventilated patients
Hossam M. Atef**, Amr M. Helmy*,
Ezzat M. El-Taher* and Ahmed Mosaad Henidak*
Abstract
Objective: To compare two different supraglottic airway devices, the laryngeal mask airway
(LMA) and the I-gel, regarding easiness of insertion of the device, leak pressure, gastric insufflation,
end tidal CO2, oxygen saturation, hemodynamic and postoperative complications in anesthetized,
spontaneously ventilated adult patients performing different non-emergency surgical procedures.
Materials and Methods: The study was carried out as a prospective, randomized, clinical trial
among 80 patients who underwent different surgical procedures under general anesthesia with
spontaneous ventilation in supine position. They were equally randomized into two groups: I-gel
and LMA groups. Both the devices were compared with regard to heart rate, arterial BP, SPO2,
end-tidal CO2, number and duration of insertion attempts, incidence of gastric insufflation, leak
pressure and airway assessment after removal of the device.
Results: No statistically significant difference was reported between both the groups,
regarding heart rate, arterial BP, SPO2 and end-tidal CO2. The mean duration of insertion attempts
was 15.6 ± 4.9 seconds in the I-gel group, while it was 26.2 ± 17.7 seconds in the LMA group.
The difference between both the groups regarding duration of insertion attempts was statistically
significant (P 0.0023*), while the number of insertion attempts was statistically insignificant
between both the study groups (P >0.05). Leak pressure was(25.6 ± 4.9 versus 21.2 ± 7.7 0.016*
cmH2O) significantly higher among studied patients of the I-gel group and incidence of gastric
insufflation was significantly more with LMA 9 (22.5%) versus 2 (5%) 0.016* in I-gel group.
Conclusion: Both LMA and I-gel do not cause any significant alteration in the hemodynamic
status of the patients, end tidal CO2, and SPO2. The postoperative complications were not significantly
different except nusea and vomiting was statistically significant higher in LMAgroup(P 0 .032).
among both LMA and I-gel patients. Insertion of I-gel was significantly easier and more rapid than
insertion of LMA. Leak pressure was significantly higher with I-gel than LMA and thus incidence
of gastric insufflation was significantly lower with I-gel.
Key words: Classical laryngeal mask airway, I-gel, supraglottic airway devices
*
Department of Anesthesia and Intensive Care, Faculty of Medicine, Suez Canal University, Ismailia, Egypt.
Corresponding author: Hosam Atef, Department of Anesthesia and Intensive Care, Faculty of Medicine, Suez Canal
University, Ismailia, Egypt, Email: [email protected]
583
M.E.J. ANESTH 21 (4), 2012
584
Introduction
The major responsibility of the anesthesiologist
is to provide adequate ventilation to the patient. The
most vital element in providing functional respiration
is the airway. Management of the airway has come
a long way since the development of endotracheal
intubation by Macewen in 1880 to the present day
usage of sophisticated devices1. The tracheal intubation
is the gold standard method for maintaining a patent
airway during anesthesia2. However, this maneuver
requires skill and continuous training and practice and
usually requires direct laryngoscopy, which may cause
laryngopharyngeal lesions3.
Laryngoscopy and endotracheal intubation
produce reflex sympathetic stimulation and are
associated with raised levels of plasma catecholamines,
hypertension, tachycardia, myocardial ischemia,
depression of myocardial contractility, ventricular
arrhythmias and intracranial hypertension4. The wide
variety of airway devices available today may broadly
be classified as intraglottic and extraglottic airway
devices, which are employed to protect the airway in
both elective as well as emergency situations5.
The laryngeal mask airway (LMA; Laryngeal
Mask Company, Henley-on-Thames, UK) has been
well established for more than a decade and is often
used when endotracheal intubation is not necessarily
required6. Nevertheless, simple handling of the LMA
is limited by the potential risk of aspiration7 (because
fiberoptic studies have found 6-9% visualization
of the esophagus via the LMA)8,9 or low pulmonary
compliance [(e.g. obesity) requiring peak inspiratory
pressures greater than 20 cm H2O]10.
I-gel is the single use supraglottic airway from
intersurgical, UK (Intersurgical Ltd, Wokingham,
Berkshire, UK) with an anatomically designed mask
made of a gel like thermoplastic elastomer. It has
features designed to separate the gastrointestinal
and respiratory tracts and allow a gastric tube to be
passed into the stomach4. The tensile properties of the
I-gel bowl, along with its shape and the ridge at its
proximal end, contribute to the stability of the device
upon insertion. Upon sliding beneath the pharyngoepiglottic folds, it becomes narrower and longer,
creating an outward force against the tissues. The ridge
at the proximal bowl catches the base of the tongue,
H. M. Atef et al.
also keeping the device from moving upward out of
position (and the tip from moving out of the upper
esophagus)11.
The main aim of this study was to compare the
I-gel with the LMA in terms of the success of insertion
of the device, gas leak pressure, the incidence of
gastric insufflations and postoperative device related
complications.
Materials and Methods
Subjects
This study was carried out as a prospective,
randomized, clinical trial. After getting approval
from our ethics committee, 80 patients aged 21-60
years, of both sexes, who underwent different surgical
procedures under general anesthesia with spontaneous
ventilation in supine position for not more than 2 hours
in routine surgical theaters in Suez Canal University
Hospital in Ismailia city, were enrolled based on
certain inclusion and exclusion criteria. Inclusion
criteria included the following: (i) patients of ASA
I or ASA II and (ii) patients whose body mass index
(BMI) was 20-25 kg/m2. Patients with reported history
of hypersensitivity for one or more of the medications
and latex, patients having any abnormality of the
neck, upper respiratory tract, patients with history of
obstructive sleep apnea or patients who underwent
thoracic, abdominal and neurosurgery operations were
excluded. The patients were equally randomized into
two groups: group 1 (I-gel group) and group 2 (LMA
group).
Methods
Preoperative assessment and medication
Complete medical history and physical
examination were done for all patients, including
assessment of vital signs and airway assessment. After
arrival in the pre-anesthetic area, the patients were given
2 mg midazolam intravenously (IV) as premedication,
and then 10 mg Metoclopramide IV was also given 3
minutes before induction of anesthesia Preoxygenation
for 3minutes, and anesthesia was induced with fentanyl
1mic/kg, and propofol 2mg/kg.
Comparative study between I-gel, a new supraglottic airway device, and classical
laryngeal mask airway in anesthetized spontaneously ventilated patients
585
Device insertion
Parameters measured
After an adequate depth of anesthesia had been
achieved, each device was inserted by the same senior
anesthetist (A H). In group 1, the classical LMA was
inserted according to the manufacturer’s instruction
manual. A size 3 and 4 mask was used in females
and a size 4 and 5 mask in males. The LMA cuff was
inflated with 20ml; 30ml; 40ml of air for size 3; 4; 5
respectively as recommended by the manufacture12.
Monitoring equipments (Datex-Ohmeda™) were
attached to the patient including 3 leads ECG and noninvasive blood pressure pulse oximetry and manometer
was connected to the inspiratory limb of the breathing
system to measure the airway pressure. The following
parameters were measured.
For patients of group 2, the I-gel size #3, 4
or 5 was inserted according to the manufacturer’s
instructions13.
In both the groups, if it was not possible to
ventilate the lungs, the following airway maneuvers
were allowed: chin lift, jaw thrust, head extension, or
flexion on the neck. In the case of I-gel, the position
was also allowed to be adjusted by gently pushing or
pulling the device. After any maneuver, adequacy of
ventilation was re-assessed. This maneuver was used
with one patient in LMA group. If it was not possible
to insert the device or ventilate through it, two more
attempts at insertion were allowed. If placements had
failed after three attempts, the case was abandoned and
the airway maintained through other airway device
as suitable and this case was considered as a failed
attempt.
Maintenance of anesthesia
After securing the device, spontaneous ventilation
in oxygen, air and inhalational agent was started.
Ventilation was judged to be optimal if the following
four tests will be passed: (i) adequate chest movement;
(ii) stable oxygenation not less than 95%; (iii) “square
wave” capnography and (iv) normal range end tidal
CO2.
Removal of the device
At the end of the operation, anesthetic agents
were discontinued, allowing smooth recovery of
consciousness. The device was removed after the
patient regained consciousness spontaneously and
responded to verbal command to open the mouth.
Dysphagia, dysphonia, nausea, vomiting and trauma of
mouth, tooth or pharynx, and sore throat were recorded
and reassessed within 24 hours.
1) Heart rate, non-invasive blood pressure, endtidal CO2 tension and oxygen saturation (SpO2).
2) The leak pressure by closing the expiratory
valve of the circle system at a fixed low gas flow
(3L/min), observing the air-way pressure at which
equilibrium was reached. At this point, gas leakage
was heard at the mouth, at the epigastrium (epigastric
auscultation) or coming out the drainage tube (I-gel
group). manometric stability test is one of the most
reliable test14.
3) Number of insertion attempts and each attempt
duration (time from picking up the device until
attaching it to the breathing system in minutes).
4) Incidence of airway complications caused by
supraglottic devices.
= reporting of post-extubation cough, breath holding
or laryngeal spasm,
= observing presence of blood on the I-gel or LMA,
and
= lip and dental injury.
Each patient was questioned to determine the
following complications (in recovery room and 24
hours postoperatively): sore throat (constant pain,
independent of swallowing), dysphagia (difficulty or
pain with swallowing), sore jaw, dysphonia (difficulty
or pain with speaking), numbness of the tongue or the
oropharynx, blocked or painful ears, reduced hearing,
or neck pain. Primary outcome measures: number
and duration of insertion attempts,sealing pressure
and peak airway pressure. Secondary outcome
measures: postoperative airway complications.
Power analysis was based on Duration of insertion
attempts (sec.) with Standard deviation (s) 15.62 and
Variance (s2) 243.9.considering alpha (zα) error (p =
0.05; therefore, 95% confidence desired (two-tailed
M.E.J. ANESTH 21 (4), 2012
586
H. M. Atef et al.
test); zα = 1.96) and beta (zβ) error (20% beta error,
therefore, 80% power desired (one-tailed test); zβ =
0.84). Difference to be detected (d) 10 sec. Or larger
difference between mean duration of the experimental
group and control group 39 patients were required in
each group.
Statistical Analysis
The Data was collected and entered into the
personal computer. Statistical analysis was done using
Statistical Package for Social Sciences (SPSS/version
17) software. A comparison of the overall abilities of
the two techniques to accurately classify the patients
was performed by a Z test to compare two portions.
Arthematic mean, standard deviation, number and
percent was calculated for each parameter. For
categorized parameters chi-square test was used, Fisher
exact test was used for data less than 5 in each cell,
while for numerical data t-test was used to compare
two groups. The level of significant was 0.0515.
Results
Analysis of the demographic characteristics of
our patients under study has revealed that there was
no statistically significant difference when comparing
the mean age between the two groups (P >0.05). The
same was found regarding the distribution of sex, as
no statistically significant difference was found when
comparing the two groups. Most of the patients in the
groups of the study were found to be males (60 and 70%
in I-gel and LMA groups, respectively). There was no
statistically significant difference found in BMI between
the two groups of the study (P >0.05) (Table 1).
Table 1
Personal characteristics of the patients under study
Characteristic
I-gel group
(n = 40)
LMA group
(n = 40)
Age
38.29 ± 12.4 41.62 ± 13.4
Gender
Male
24 (60%)
28 (70%)
Female
16 (40%)
12 (30%)
BMI (kg/m2)
23.13 ± 2.15 22.91 ± 4.03
Data are presented as mean ± SD or numbers (percentages)
NS: no statistically significant difference (P >0.05)
No statistically significant difference was found
between both groups of the study, regarding each of
systolic BP, diastolic BP, heart rate, SPO2 (%) and endtidal CO2 throughout the whole duration of the surgery.
Table 2 shows that insertion and ventilation was
possible at the first attempt in 90% of patients in the
I-gel group and in 80% in LMA group. In 5% of the
patients in LMA group, intubation and ventilation was
possible after the third attempt. The mean duration of
insertion attempts was 15.62 ± 4.9 seconds in I-gel
group, while it was 26.2 ± 17.7 seconds in LMA group.
The difference between both groups regarding duration
of insertion attempts was statistically significant (P
0.0023), while the number of insertion attempts was
statistically insignificant between both the study
groups (P >0.05). Leak pressure was significantly
higher among patients of the I-gel group (25.62 ± 4.9
Table 2
Comparison between I-gel and LMA groups with respect to different parameters
Parameter
P value
I-gel group (n = 40)
LMA group (n = 40)
One attempt
36 (90%)
32 (80%)
Two attempts
3 (7.5%)
6 (15%)
Three attempts
1 (2.5%)
2 (5%)
Duration of insertion attempts (seconds)
15.62 ± 4.9
26.2 ± 17.7
0.0023*
Leak pressure (cm H2O)
25.62 ± 4.9
21.2 ± 7.7
0.016*
2 (5%)
9 (22.5%)
0.016*
Number of insertion attempts
Incidence of gastric insufflation
Data are presented as mean ± SD or numbers (percentages)
NS: no statistically significant difference (P >0.05)
*Statistically significant difference (P <0.05)
0.45 (NS)
Comparative study between I-gel, a new supraglottic airway device, and classical
laryngeal mask airway in anesthetized spontaneously ventilated patients
587
Table 3
Assessment of patients after device removal among the patients in both groups of the study
I-gel group (n = 40)
LMA group (n = 40)
P value
2 (5%)
4 (10%)
0.46 (NS)
Lip or dental injury
1 (2.5%)
2 (5%)
0.69 (NS)
Post removal cough
2 (5%)
6 (15%)
0.6 (NS)
Laryngeal spasm
4 (10%)
4 (10%)
1 (NS)
12 (32.5%)
10 (25%)
0.34 (NS)
3 (7.5%)
5 (12.5%)
Dysphagia, dysphonia
2 (5%)
2 (5%)
1 (NS)
Postoperative nausea or vomiting
2 (5%)
8 (20%)
0.032*
Arrhythmia
2 (5%)
3 (7.5%)
0.69 (NS)
21 (52.5%)
26 (65%)
0.47 (NS)
Presence of blood on airway device
Sore throat
Mild
Moderate
Pain on swallowing
Mild
Moderate
Ear pain
Hearing change
NS: no statistically significant difference (P > 0.05)
4 (10%)
8 (20%)
3 (7.5%)
5 (12.5%)
0.46 (NS)
1 (2.5%)
2 (5%)
0.69 (NS)
versus 21.2 ± 7.7 cm H2O in LMA group; P <0.016).
The incidence of gastric insufflation was significantly
more with LMA (22.5% versus 5% in I-gel group; P
<0.016).
No statistically significant difference was found
between both I-gel and LMA groups with regard to
the assessment of patients after removal of the airway
device (Table 3).
Success rate of gastric tube insertion was
estimated to be 95%. Failed insertion was reported
only among two patients (5%) (Table 4).
Table 4
Success rate of gastric tube insertion among the patients of
I-gel group
Gastric tube insertion
Total
Number
Percent
Success
38
95
Failure
2
5
40
100
Discussion
The I-gel is a new supraglottic device, without an
inflatable cuff, designed for use during anaesthesia11.
It is a latex free, disposable device, made of a medical
grade thermoplastic elastomer. I-gel is anatomically
preformed to mirror the perilaryngeal structures. The
device contains an epiglottis blocker, which helps to
prevent epiglottis from downfolding or obstructing
laryngeal inlet. The soft non-inflatable cuff seals
anatomically against perilaryngeal structures.
Furthermore, the I-gel has a gastric channel allowing
venting of the air and gastric contents or insertion of
gastric tube16.
It has features designed to separate the
gastrointestinal and respiratory tracts and allow a
gastric tube to be passed into the stomach. Early
reports have postulated its use as a potential airway for
use in resuscitation17. Many studies compared LMA
with I-gel18-20.
Regarding the hemodynamic stability and effect
of each of the supraglottic devices, no statistically
significant difference was reported when comparing
heart rate, systolic and diastolic arterial blood pressure
throughout the surgery. Jindal et al.21 reported
hemodynamic stability with both LMA and I-gel
devices, with no statistically significant difference
between both devices, which is consistent with our
findings.
Richez et al.13 carried out one of the earliest
M.E.J. ANESTH 21 (4), 2012
588
studies to evaluate the I-gel. They found that insertion
success rate was 97%. Insertion was easy and was
performed at the first attempt in every patient. I-gel
is easily and rapidly inserted, providing a reliable
airway in over 90% of cases. Acott22. assessed the
use of I-gel as an airway device during general
anesthesia. In accordance with our results, they
reported that a single insertion attempt was required
in the majority of patients and all the insertion times
recorded were less than 10 seconds. Similar results
were obtained in study done by Gatward et al.23, who
evaluated size 4 I-gel airway in 100 non-paralyzed
patients and found that first insertion attempt was
successful in 86% of patients, the second attempt
in 11% of patients and the third attempt in 3% of
patients.
Levitan and Kinkle11 studied the positioning and
mechanics of this new device in 65 non-embalmed
cadavers with 73 endoscopies (eight had repeat
insertion), 16 neck dissections, and 6 neck radiographs.
A full view of the glottis (percentage of glottic opening
score 100%) occurred in 44/73 insertions, whereas only
3/73 insertions had epiglottis-only views. Including the
eight repeat insertions with a different size, a glottic
opening score of >50% was obtained in all 65 cadavers.
The mean percentage of glottic opening score for the
73 insertions was 82% (95% confidence interval 7589%). In each of the neck dissections and radiographs,
the bowl of the device covered the laryngeal inlet.
They found that the I-gel effectively conformed to the
perilaryngeal anatomy despite the lack of an inflatable
cuff and it consistently achieved proper positioning for
supraglottic ventilation.
The I-gel has potential advantages over other
supraglottic airways for use by non-anesthetists
during cardiopulmonary resuscitation. It has no cuff to
inflate, making it simple to use. Its drain tube allows
access to the gastrointestinal tract and it is designed to
reduce the risk of gastric inflation and regurgitation.
Simple airway maneuvers were required to assist in
the placement but all devices were placed within two
attempts24. These findings are consistent with our
results.
One of the most important parameters to be
compared between both supraglottic devices was
postoperative complications. It was estimated
H. M. Atef et al.
that difference between LMA and I-gel regarding
postoperative complications was not statistically
significant except nausea and vomiting which was
significantly higher in LMA due to high incidence of
gastric insufflation. Consistent with our results, no
major complications associated with I-gel have been
described to date. Protection against aspiration is
probably comparable with LMA family (but certainly
not 100%). Minor complications reported include
sore throat, temporary hoarseness, sore tongue,
hyperesthesia of tongue13.
In the present study, only in two patients of the
I-gel group, blood was on the device after removal.
Acott22, did not report any case of blood on airway
device (I-gel). In accordance with our results, he found
that airway trauma during insertion of the I-gel was
minimal.
Leak pressure was found to be significantly
higher among patients of I-gel group than in LMA
group (25.62 versus 21.2 cm H2O, respectively). This
denotes that I-gel has better sealing pressure and that
it fits well with the anatomy of supraglottic region.
Acott22 reported a leak pressure greater than 20 cm
H2O in all patients.
Assessment of success rate of gastric tube
insertion with I-gel was found to be 95%. This is
consistent with what has been reported by Richez
et al.13, as the gastric tube was inserted in 100% of
cases. This helps in preventing gastric insufflation and
decreasing air leak and thus decreasing postoperative
nausea and vomiting.
A potential risk of the LMA is an incomplete mask
seal, causing gastric insufflation or oropharyngeal air
leakage25. Inconsistent with our findings; Schmidbauer
and colleagues26 concluded that both the ProSeal
LMA and classical LMA provided better seal of the
esophagus than the novel I-gel airway. Consistent with
our results, Weiler et al.6 had reported high incidence
of gastric insufflation with the use of LMA.
There are some limitations of the present study.
Firstly, we studied only low risk patients (ASA I and
II) who had normal airways and were mostly not obese.
Secondly, we did not compare performance with the
likely competitors of the I-gel such as ProSeal LMA
and laryngeal tube.
Comparative study between I-gel, a new supraglottic airway device, and classical
laryngeal mask airway in anesthetized spontaneously ventilated patients
In conclusion, both LMA and I-gel do not
cause any significant alteration in the hemodynamic
status of the patients, end tidal CO2, and SPO2. The
postoperative complications are not significantly
different among both LMA and I-gel patients. Insertion
589
of I-gel is significantly easier and more rapid than
insertion of LMA. Leak pressure is significantly higher
with I-gel than with LMA and thus incidence of gastric
insufflation is significantly lower with I-gel.
M.E.J. ANESTH 21 (4), 2012
590
H. M. Atef et al.
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Optimal dose of hyperbaric bupivacaine 0.5%
for unilateral spinal anesthesia during
diagnostic knee arthroscopy
Hossam Atef**, Alaa El-Din El-Kasaby*,
Magdy Omera* and Mohamed Badr*
Abstract
Objective: To determine the dose of hyperbaric bupivacaine 0.5% required for unilateral
spinal anesthesia during diagnostic knee arthroscopy.
Patients and Methods: This prospective, randomized, clinical study was performed in 80
patients who were assigned to four groups to receive different doses of intrathecal hyperbaric
bupivacaine (5 mg, 7.5 mg, 10 mg and 12.5 mg in Groups 1, 2, 3, and 4 respectively). Onset of
sensory and motor block, hemodynamic changes, regression of motor block, and incidence of
complications were recorded.
Results: Unilateral sensory block was reported in 90% and 85% of patients in Group 1 and
Group 2, respectively, but not in any patient in Group 3 and Group 4. Unilateral motor block
(modified Bromage scale 0) was reported in 95% of patients in Group 1, 90% in Group 2, and only
5% in Group 3, while no patient in Group 4 showed unilateral motor block. The time required for
regression of motor block (Bromage scale 0) was prolonged with higher doses. The incidence of
nausea, vomiting, and urine retention was similar in the study groups.
Conclusion: Unilateral sensory and motor block can be achieved with doses of 5 mg and 7.5
mg hyperbaric bupivacaine 0.5% with a stable hemodynamic state. However, 7.5 mg of hyperbaric
bupivacaine 0.5% was the dose required for adequate unilateral spinal anesthesia.
Key words: hyperbaric bupivacaine 0.5%, unilateral spinal anesthesia, diagnostic knee
arthroscopy
Introduction
Patients undergoing orthopedic surgery are of different ages and sizes. Regional analgesia
and anesthesia are often beneficial for these patients. Knee arthroscopy is a common orthopedic
procedure. This operation includes both diagnostic and operative procedures. The choices of
anesthesia are as varied as the operations done through the scope, and include general blocks,
central neuraxial blocks, peripheral nerve blocks, and intra-articular local anesthetic techniques1.
In the last decade, bupivacaine has been the most frequently used agent for spinal and epidural
anesthesia2,3. In ambulatory surgery, such as diagnostic knee arthroscopy, bupivacaine may delay
the recovery of motor function and cause urinary retention, leading to delayed discharge4,5.
*
Department of Anesthesia and Intensive Care, Faculty of Medicine, Suez Canal University, Ismailia, Egypt.
Corresponding author: Hossam Atef, Email: [email protected]
591
M.E.J. ANESTH 21 (4), 2012
592
Unilateral spinal anesthesia is frequently used
in lower limb surgery6,7. Several advantages are
claimed for this anesthetic technique, including fewer
hemodynamic complications8, selective block on the
operated side, avoidance of unnecessary paralysis on
the nonoperated side, better mobilization during the
recovery period, lower incidence of postoperative
urine retention9, as well as good patient satisfaction10.
To achieve successful unilateral anesthesia, several
factors are required, including needle shape and bevel
direction, site and speed of injection of anesthetic,
volume, baricity, and concentration of the anesthetic
solution, as well as an appropriate degree of operating
table inclination11,12. Moreover, patient posture is
thought to be fundamental in determining the level
of anesthesia spread, particularly when a hyperbaric
anesthetic solution is used13.
Previous studies have failed to determine the ideal
dose of local anesthetic to achieve unilateral spinal
anesthesia. Therefore, our aim was to evaluate the
influence of the dose of hyperbaric bupivacaine on the
success of unilateral spinal anesthesia by assessment
of maximum sensory and motor block on the operative
and nonoperative sides during knee arthroscopy and its
effect on hemodynamics.
Patients and Methods
This study was carried out as a prospective,
randomized, double-blind clinical trial. After approval
of the local ethics committee and informed patient
consent was obtained, 80 male and female patients
undergoing diagnostic knee arthroscopy in routine
surgical theaters at the Suez Canal University Hospital
in Ismailia were enrolled in this study. Inclusion criteria
were American Society of Anesthesiologists (ASA)
score I-II, age 21-50 years, body mass index <30 kg/
m2, and height 160-180 cm. Patients with skin infection
at the site of regional anesthesia, coagulopathy,
taking anticoagulant drugs, having allergy to local
anesthetic drugs, hypovolemia, low fixed cardiac
output, neurologic disorder, or spine deformity were
excluded from the study. The patients were randomly
allocated into four groups (n = 20 each) receiving
different doses of hyperbaric bupivacaine 0.5%. Group
1 received 5 mg, Group 2 received 7.5 mg, Group 3
received 10 mg, and Group 4 received 12.5 mg. All
Hossam Atef et al.
patients were given 2 mg midazolam intravenously
as premedication, as well as an intravenous infusion
of 7 mL/kg of lactated Ringer solution. Standard
monitoring was used, including noninvasive blood
pressure, electrocardiogram, peripheral pulse oximetry,
and respiratory rate measurements.
Procedure for spinal anesthesia
All patients were placed in a lateral position on
the operative side, while the vertebral column was
positioned as horizontally as possible. Under complete
aseptic technique and after back sterilization, dural
puncture was performed using a midline approach at the
L3-L4 interspace with a 25 gauge spinal needle. Using
sealed envelopes prepared according to a computer
generated randomization table, patients were randomly
allocated to one of four groups. Patients in each group
received different doses of bupivacaine (Marcaine
Spinal Heavy, Astra, Sweden), ie, Group 1 received
5 mg bupivacaine 0.5% 1 mL, Group 2 received 7.5
mg bupivacaine 0.5% 1.5 mL, Group 3 received 10
mg bupivacaine 0.5% 2 mL, and Group 4 received
12.5 mg bupivacaine 0.5% 2.5 mL. After observation
of free flow of cerebrospinal fluid, the spinal needle
aperture was turned toward the dependent side and
the selected dose of local anesthetic solution was
injected slowly with an injection speed of 0.5 mL/10
seconds without further aspiration maneuvers. Patients
were maintained in the lateral decubitus position for a
20-minute period, after which patients were turned to
the supine position11,14.
An independent blinded observer evaluated the
evolution of sensory and motor blocks on both sides
immediately after turning the patient supine for 20
minutes after the block, and then after 10 minutes.
Sensory block was assessed as complete loss of
sensation to pinprick (via a 23 gauge hypodermic
needle). Motor block was assessed using a modified
Bromage scale whereby patients were asked to flex
the limb at the hip, knee, and ankle joints, and the
results were recorded as 0 = no motor block, 1= hip
blocked, 2= hip and knee blocked, 3= hip, knee, and
ankle blocked.9 Patients were judged ready for surgery
when complete loss of pinprick sensation was reported
at T12 on the operative limb.
Hemodynamic
parameters
were
recorded.
Optimal dose of hyperbaric bupivacaine 0.5% for unilateral spinal anesthesia during
diagnostic knee arthroscopy
Postoperative analgesia included oral ketorolac (50
mg every eight hours), with the first dose administered
before surgery by the intravenous route.9 Requirement
for rescue analgesia was recorded. Intravenous
tramadol 50 mg was given. Motor and sensory block
was monitored in the postanesthesia care unit at
10-minute intervals until time to complete regression of
spinal block. Occurrence of adverse events, including
nausea, vomiting, pruritus, and urine retention was
also recorded.
593
Fig. 1
Heart rate changes throughout the operation among the
studied patients in the 4 studied groups.
80
78
mean HR (Beat/min)
76
Statistical analysis was performed using the
program SPSS version 15 (SPSS Inc, Chicago, IL).
Demographic data, onset times to anesthetic block,
and surgery times were analyzed by one-way analysis
of variance (ANOVA), whereas changes over time
were analyzed with a two-way ANOVA for repeated
measures. Categoric variables were analyzed using
contingency table analysis and the Chi-square test with
the appropriate corrections. Continuous variables were
presented as means ± standard deviations. Categoric
data were presented as numbers and percentages. A P
value <0.05 was considered statistically significant.
74
72
70
68
66
64
Baseline
15 min
30 min
45 min
60 min
75 min
90 min
Duration of surgery
Group 1
Group 2
Group 3
Group 4
15 minutes and, thereafter returned to near baseline
values, while in Group 4 this drop remained until the
end of the operation (Fig. 2, Table 2).
Sensory block on the nonoperative side was
significantly less than that on the operative side. In
Group 1 and in Group 2, strict unilateral anesthesia
was reported among 90% and 85% of patients,
respectively, in whom the level of sensory block on the
operative side was T10 and T8, respectively. In groups
3 and 4, none of the studied patients showed unilateral
spinal anesthesia and the sensory block in the nonoperative side reached, respectively, while the level of
sensory block in the operative limb reached T6 and T5,
respectively (Tables 3,4, and 5).
Results
There were no significant differences in age,
gender, body mass index, and duration of surgery
between the patients in the four groups (Table 1). No
statistically significant difference was found between
the four groups for heart rate changes during surgery
(Fig. 1). There was a statistically significant decrease
in mean arterial blood pressure in Group 3 and 4
patients who had been injected with 10 mg and 12.5
mg, respectively. In Group 3, this drop lasted for only
Table 1
Personal characteristics of study population.
Characteristic
Age (years, SD)
Group 1
(n = 20)
Group 2
(n = 20)
Group 3
(n = 20)
Group 4
(n = 20)
P value
0.2
36.1 ± 11.5
31.8 ± 10.9
39.1 ± 12.4
35.6 ± 9.4
M
19 (95)
20 (100)
17 (85)
18 (90)
F
1 (5)
0 (0)
3 (15)
2 (10)
1.7 ± 0.5
1.7 ± 0.9
1.7 ± 0.8
1.7 ± 0.6
0.9
24.3 ± 2.6
23.6 ± 3.5
25.1 ± 1.4
24.7 ± 3.1
0.4
Duration of surgery (min, SD)
50.6 ± 18.5
Abbreviatons: SD, standard deviation
54.4 ± 17.9
55.4 ± 19.4
54.5 ± 18.1
0.4
Gender
(n, %)
Height (m, SD)
Body mass index (mean kg/m ,
SD)
2
0.3
M.E.J. ANESTH 21 (4), 2012
594
Hossam Atef et al.
Table 2
Mean arterial blood pressure changes.
Group 2
Group 3
(n = 20)
(n = 20)
Group 1
(n = 20)
Mean arterial blood
pressure (mmHg)
Group 4
(n = 20)
P value
Mean ± SD
Mean ± SD
Mean ± SD
Mean ± SD
Baseline
86.2 ± 5.3
87.5 ± 4.7
89.3 ± 6.2
87.7 ± 3.4
0.9
After 15 minutes
85.3 ± 4.2
86.7 ± 5.2
79.5 ± 5.8**
80.1 ± 5.2**
0.00*
After 30 minutes
84.6 ± 6.1
85.1 ± 3.9
80.3 ± 6.3**
80.6 ± 4.6**
0.001*
After 45 minutes
85.1 ± 5.8
86.4 ± 5.1
85.4 ± 4.9**
80.7 ± 5.5**
0.001*
After 60 minutes
83.7 ± 4.9
85.9 ± 4.8
86.4 ± 5.2
81.3 ± 5.1**
0.001*
After 75 minutes
86.3 ± 5.2
84.8 ± 5.3
87.6 ± 5.7
79.3 ± 5.6**
0.00*
After 90 minutes
84.4 ± 6.9
88.6 ± 4.9
86.5 ± 6.1
81.3 ± 5.9**
0.002*
* Statistically significant difference among all four groups (P value < 0.05);
** Statistically significant difference versus baseline reading of the same group (P value <0.05).
Abbreviation: SD, standard deviation.
Motor block on the operative side was statistically
significant when compared with the nonoperative side
(P <0.05). Motor block on the operative side in Groups
2, 3, and 4 was statistically significant compared with
motor block on operative side in Group 1, while no
Fig. 2
Mean arterial blood pressure changes (mmHg) throughout the
operation among the studied patients in the 4 studied groups.
92
90
mean ABP (mmHg)
88
86
84
statistically significant difference was reported when
comparing pairs of the former three groups. Unilateral
motor block (modified Bromage scale 0) was reported
in 95% of patients in Group 1, 90% in Group 2, and
only 5% in Group 3, while none of the patients in
Group 4 showed unilateral motor block (Table 6).
The time required for regression of motor block
(Bromage scale 0) was more prolonged with higher
doses and the difference was statistically significant.
The regression time was 59.8 (55-100), 98.3 (60120), 123.9 (60-150), and 148.9 (110-180) minutes for
Groups 1, 2, 3, and 4 respectively. The incidence of
nausea, vomiting, and urine retention was similar in
the four study groups (Table 7).
82
Discussion
80
The ideal selective spinal anesthesia for knee
arthroscopy would provide minimal or no motor
blockade at the end of the surgical procedure, such that
the patient can be fast tracked.5 Using a minidose of
lidocaine-fentanyl15 or hyperbaric bupivacaine16, BenDavid et al discharged their knee arthroscopy patients
at 145 minutes and 202 minutes, respectively.
78
76
74
Baseline
15 min
30 min
45 min
60 min
75 min
Duration of surgery
Group 1
Group 2
Group 3
Group 4
90 min
As regards the hemodynamic effects of different
Optimal dose of hyperbaric bupivacaine 0.5% for unilateral spinal anesthesia during
diagnostic knee arthroscopy
595
Group 4
Group 3
Group 2
Group 1
Table 3
Sensory block on operative and nonoperative side after 30 minutes of block.
No level
L5
L4
L3
L2
L1
T12
T11
T10
T9
T8
T7
T6
T5
Op‡†
0
0%
0
0%
0
0%
0
0%
0
0%
0
0%
9
45%
6
30%
5
25%
0
0%
0
0%
0
0%
0
0%
0
0%
Nonop
18
90%
2
10%
0
0%
0
0%
0
0%
0
0%
0
0%
0
0%
0
0%
0
0%
0
0%
0
0%
0
0%
0
0%
Op*†‡
0
0%
0
0%
0
0%
0
0%
0
0%
0
0%
3
15%
5
25%
6
30%
4
20%
2
10%
0
0%
0
0%
0
0%
Nonop
17
85%
2
10%
1
5%
0
0%
0
0%
0
0%
0
0%
0
0%
0
0%
0
0%
0
0%
0
0%
0
0%
0
0%
O†*
0
0%
0
0%
0
0%
0
0%
0
0%
0
0%
0
0%
0
0%
2
10%
5
25%
8
40%
4
20%
1
5%
0
0%
Nonop
0
0%
0
0%
0
0%
4
20%
6
30%
5
25%
5
25%
0
0%
0
0%
0
0%
0
0%
0
0%
0
0%
0
0%
Op*
0
0%
0
0%
0
0%
0
0%
0
0%
0
0%
0
0%
0
0%
0
0%
0
0%
2
10%
5
25%
6
30%
7
35%
Nonop
0
0%
0
0%
0
0%
0
0%
0
0%
0
0%
7
35%
6
30%
4
20%
2
10%
1
5%
0
0%
0
0%
0
0%
* Statistically significant difference between operative and nonoperative side in each group (P < 0.05); †statistically significant difference
versus operative side in Group 4 (P value < 0.05); ‡statistically significant difference versus operative side in Group 3 (P <0.05).
Abbreviations: op, operative side; nonop: nonoperative side.
Table 4
Significance of the difference (P value) between sensory block
on different operative sides.
Group
Group 1 Group 2
Group 4
3
Group 1
Table 5
Significance of the difference (P value) of sensory block on
nonoperative side.
Group 1
Group 2
Group 3
Group 4
Group 1
Group 2
0.06
Group 3
0.0001*
0.004*
Group 4
0.0001*
0.0001*
0.0007*
Group 2
0.8
Group 3
0.0001*
0.0001*
Group 4
0.0001*
0.0001*
0.0002*
* Statistically significant difference.
* Statistically significant difference
Table 6
Motor block in operative and nonoperative side after 30 minutes of block.
No motor block
Hip blocked
Hip and knee blocked
0 (0%)
0 (0%)
Hip, knee and ankle blocked
Group 1
Operative*
10 (50%)
10 (50%)
Nonoperative
19 (95%)
1 (5%)
0 (0%)
0 (0%)
Group 2
Operative *†
0 (0%)
0 (0%)
2 (10%)
18 (90%)
Nonoperative
18 (90%)
2 (10%)
0 (0%)
0 (0%)
Operative *
0 (0%)
0 (0%)
2 (10%)
18 (90%)
Nonoperative
1 (5%)
7 (35%)
9 (45%)
3 (15%)
Operative
0 (0%)
0 (0%)
1 (5%)
19 (95%)
Nonoperative
0 (0%)
0 (0%)
5 (25%)
* Statistically significant difference between operative and nonoperative side in each group (P < 0.05);
† Statistically significant difference versus operative side in Group 1 (P value <0.05)
15 (75%)
Group 3
Group 4
†
†
M.E.J. ANESTH 21 (4), 2012
596
Hossam Atef et al.
Table 7
Time to regression of motor block (Bromage scale 0), incidence of complications, and rescue analgesia requirements
Group 1
(n = 20)
Group 2
(n = 20)
Group 3
(n = 20)
Group 4
(n = 20)
P value
59.8 ± 14.6
98.3 ± 15.8
123.6 ± 9.7
148.9 ± 10.3
0.001*
Nausea/vomiting
0 (0%)
1 (5%)
0 (0%)
2 (10%)
0.3
Urinary retention
0 (0%)
0 (0%)
1 (5%)
1 (5%)
0.6
3 (15%)
1 (5%)
0 (0%)
0 (0%)
0.09
Characteristic
Time for regression of block (minutes)
Number of patients needing rescue
analgesia
* Statistically significant difference
doses of hyperbaric bupivacaine during surgery,
no statistically significant differences were found
between the four study groups with regard to heart
rate changes during surgery. Hemodynamic benefits
have also increased interest in unilateral spinal
anesthesia. Hypotension is a common complication
of spinal anesthesia, occurring in 15%17 to 33%18 of
patients when larger doses of local anesthetic have
been used. Unilateral spinal anesthesia with hypobaric
or hyperbaric bupivacaine was associated with less
hypotension19,20, which is consistent with our results.
In our study, unilateral spinal anesthesia
(regarding sensory block) was reported by 90% and
85% of patients in Group 1 and Group 2, respectively,
while in Group 3 and Group 4 none of the studied
patients showed unilateral anesthesia. For motor
block, unilateral anesthesia was recorded in 95% of
patients in Group 1, 90% in Group 2, and only 5% in
Group 3, while none of the patients in Group 4 showed
unilateral spinal anesthesia.
Valanne et al21 compared the effect of 4 mg and
6 mg of hyperbaric bupivacaine for spinal anesthesia
in 106 ambulatory adult patients undergoing knee
arthroscopy. They found that both doses produced
efficient and adequate sensory and motor block.
However, rapid regaining of motor function was
reported with the lower dose.
In our study, the time to regression of motor block
was found to be significantly increased with increasing
the injected dose of hyperbaric bupivacaine, with mean
times of 59.8, 98.3, 123.6 and 148.9 minutes in Groups
1, 2, 3, and 4, respectively.
In another study, Fanelli et al9 compared unilateral
and conventional bilateral bupivacaine spinal block
in outpatients undergoing knee arthroscopy. In
the unilateral group, they used 8 mg of hyperbaric
bupivacaine 0.5% in 50 patients lateral decubitus
position after spinal injection was maintained in
unilateral group for 15 minutes. They found that, for
the unilateral group, sensory and motor blocks on the
operated limb were T9 (T12-T2) with a Bromage score
0/1/2/3: 0/2/3/45 in the unilateral group. Two segment
regressions of sensory level and home discharge
required 81 ± 25 minutes and 281 ± 83 minutes with
bilateral block, and 99 ± 28 minutes and 264 ± 95
minutes with unilateral block.
Borghi et al22 carried out a prospective,
randomized, blinded study among 90 ASA I and II
outpatients scheduled for elective knee arthroscopy.
After placement of the patients in the lateral decubitus
position, they received spinal block with 4, 6, or 8 mg
of 0.5% hyperbaric bupivacaine on the operative side,
injected slowly with the needle orifice directed toward
the dependent side using a 25-gauge Whitacre needle.
The lateral decubitus position was maintained for 15
minutes. The maximum level of sensory block on the
operative and nonoperative sides was, respectively, T10
(T12-T6) and (<L2) in the 4 mg group, T8 (T12-T6)
and (<L5) in the 6 mg group, and T7 (T12-T5) and
(<T10) in the 8 mg group. Unilateral sensory block
was observed in 27 patients in the 4 mg group (90%),
28 patients in the 6 mg group (93%), and 23 patients
in the 8 mg group (77%, P <0.28). Complete unilateral
motor block was observed in 29 patients in the 4 mg
group (97%), 28 patients in the 6 mg group (93%), and
28 patients in the 8 mg group (93%, P = 0.80). No
failed blocks were reported. Complete regression of
spinal anesthesia required 71 ± 20 minutes in the 4 mg
group (range 40-110 minutes), 82 ± 25 minutes in the 6
Optimal dose of hyperbaric bupivacaine 0.5% for unilateral spinal anesthesia during
diagnostic knee arthroscopy
mg group (range 30-160 minutes), and 97 ± 37 minutes
in the 8 mg group (range 50 to 120 minutes).
Analysis of side effects showed that the injected
dose did not affect the incidence of side effects, such
as nausea, vomiting, urinary retention, or need for
analgesia.
Although our study was different from other
studies regarding dose, position, and patients being
kept on the lateral side for 20 minutes, our results were
found to be consistent with earlier ones because higher
doses of hyperbaric bupivacaine were associated with
higher levels of maximum sensory and motor block
and longer duration to achieve regression of sensory
block.
597
Conclusion
Unilateral sensory and motor block, a faster
recovery profile, and a stable hemodynamic state can be
achieved with doses of 5 mg and 7.5 mg of hyperbaric
bupivacaine 0.5% injected slowly through pencil-point
directional needles in patients who are maintained in
the lateral decubitus position for 20 minutes. However,
7.5 mg of hyperbaric bupivacaine 0.5% was the dose
required for adequate unilateral spinal anesthesia with
adequate sensory and motor block.
Disclosure
The authors report no conflict of interest in this
work.
M.E.J. ANESTH 21 (4), 2012
598
Hossam Atef et al.
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Comparison between Prostaglandin E1, and
Esmolol infusions in controlled hypotension
during scoliosis correction surgery a
clinical trial
Hala Mostafa Goma*
Abstract
Background: scoliosis correction surgery is common in children, and adolescents. Deliberate
hypotension is indicated in scoliosis correction procedures, because bloodless field is needed for
exposure of the nerve roots, and to decrease the need for blood transfusion. Protection of the
kidneys during deliberate hypotension is essential. The ideal hypotensive drug maintains the renal
function and the urine output during the period of hypotension. Aim of this study is to compare
Prostaglandin E1, and Esmolol hypotensive effects, bleeding score, and their effects on the serum
creatnine, and urine output.
Patients and methods: Twenty patients under went hypotensive anesthesia during scoliosis
correction procedure, were enrolled in this clinical trial. In group 1 (n = 10) (Esmolol infusion),
group 2 (n = 10) (prostaglandin E1 infusion), Parameters were measured: Mean arterial blood
pressure, Heart rate, (preoperative, just after induction, 15 minutes, 30 minutes, 60 minutes after
starting the infusions, and 15 minutes after discontinuation of infusions). The bleeding score was
assessed at (15 minutes, 30 minutes, 60 minutes after starting the infusions).
Results: heart rate was significantly higher in prostaglandin E1 group than Esmolol group
at 15, 30, 45, and 60 minutes. There was significant difference in the bleeding score only after
30 minutes, The target mean blood pressure (50 mmHg) was achieved at 30 minutes in group 2
(prostaglandin E1), while it was achieved at 60 minutes in group 1 (Esmolol group). There were
significant differences in Mean blood pressure between both groups at 15, 30, 45, 60 minutes after
starting the infusions. Creatnine level was significantly lower in prostaglandin E1 group, while the
introperative urine output was significantly higher in prostaglandin E1 group.
Conclusions: Prostaglandin E1 hypotensive effects started earlier than Esmolol and its
bleeding score is better than esmolol especially at thirty minutes after initiation of the infusion.
Prostaglandin E1 can maintain renal function and urine output more than Esmolol. This study
recommended using Prostaglandin E1 to induce hypotensive anesthesia in scoliosis correction
surgery.
Key words: Prostaglandin E1, Esmolol, hypotensive anesthesia, Scoliosis.
*
Professor of anesthesia, Anesthesia Department, Cairo University.
Corresponding author: Hala mostafa Goma; Assistant professor of anesthesia; Faculty of medicine; Cairo University.
Phone: 0122819043. E-mail: [email protected]
Meetings at which the work has been presented was at Anesthesia Department Cairo University 10-5-2008.
Financial support for the work was by Cairo University.
My acknowledgement for Professor Hanna Abo elnor for her kind assistance.
599
M.E.J. ANESTH 21 (4), 2012
600
H. M. Goma
Introduction
Deliberate hypotension (Induced hypotension)
is decreasing of blood pressure by 30% or the mean
blood pressure (50-70 mmHg) or systolic blood
pressure (80-90 mmHg) pharmacologically. Deliberate
hypotension is indicated in microsurgical procedures,
when bloodless field is needed such as ear surgery, or to
decrease the need for blood transfusion as in scoliosis
correction procedure (Thomas et al, 1974).
Scoliosis correction is one of the major operations,
the main problem is the blood loss, blood loss in this
operation may be 3-4 units, also the patients are usually
adolescents and young age, and there is increased risk
of blood transfusion complications specially infection.
Another advantage of induced hypotension during
scoliosis correction surgery is exposure of the roots
and nerves (Degoute, 2007).
There are many drugs used to induce hypotension,
may be intravenous drugs, as Na nitroprosside, nitrates,
Ca cannels blockers, beta blockers, Remifentanil,
ACE inhibitors and clonidine, Adenosine, these drugs
have many complications as bradycardia, depression
of myocardial contractility. Volatile anesthetics are
halothane, isoflurane and sevoflurane in which high
dose is needed to produce hypotension; it can be
harmful for the kidney and liver (Longnecke, 1984).
The success of such technique is to keep the
perfusion for vital organs; the major complications of
direct effect on the smooth muscles fibers, it has also
direct bronchodilator, and PGE1 is an agonist at the
PGE2-sensitive receptor (subtype EP2) that activates
adenylate cyclase to increase intracellular cyclic
adenosine. Monophosphate (cAMP), induces smooth
muscle relaxation. Therefore, increased intracellular
cAMP may contribute to the spasmolytic effects
observed, other studies demonstrated that PGE1 can
maintain the renal and hepatic blood flow, doesn’t
disturb their auto regulation. It is usually used in
cardiac patient as patent ductus, coarctation of the
aorta, (Lam, 1990 and Tobias, 2002).
Aim of this study: is to compare Prostaglandin
E1 and Esmolol hypotensive effects, the bleeding
score, and renal function in controlled hypotension for
scoliosis correction surgery.
Patients and Methods
After receiving ethical approval, and Parental
written informed consents, twenty patients under
went hypotensive anesthesia for scoliosis correction
in kasr EL Ani hospital, were enrolled in this clinical
trial. Patients were divided into 2 groups, group 1 (n
= 10), received Esmolol infusion, and group 2 (n =
10) received Prostaglandin E1 infusion as hypotensive
drugs. The patients were ASAI-II; the age ranged
13-18 years old, they were with accepted pulmonary
function tests.
deliberate hypotension are renal, hepatic, and cerebral
Setting
blood flow impairment and alteration of the auto
The study was done in Kasr El Ini Teaching
Hospital Cairo University.
regulation of the organs.
Esmolol is a selective ultra short β1 blocker
lowers blood pressure by decreasing cardiac output
and heart rate. It has rapid onset of action within 1
minute of starting infusion. Many studies investigated
the effects of Esmolol on auto regulation of the liver,
kidney and brain. Many studies demonstrated its effect
on cerebral auto regulation (Masuda R, Takeda S, 2008
and Wiest, 1995).
Prostaglandin E1 (PGE1) is a vasodilator by its
Study design: clinical trial.
The sample size was a convenient sample.
Exclusion criteria: Were Cardiac disease,
Diabetes mellitus, Gross anemia, hemoglobinopathies,
polycythemia,
Hepatic
disease,
Ischemic
cerebrovascular disease, renal disease, Respiratory
insufficiency, severe systemic hypertension.
Each patient received 500 ml of lactated Ringers
solution, 30 minute before induction of anesthesia.
Comparison between Prostaglandin E1, and Esmolol infusions in controlled hypotension
during scoliosis correction surgery a clinical trial
For premedication midazolam 0.1 mg/kg IV was
given 15 minute before induction.
Induction of anesthesia was achieved by 2.5-3
mg/kg propofol injected intravenously on 3-5 minute
to prevent sudden drop of blood pressure, fentanyl 1
µg/kg iv. Tracheal intubation was facilitated with 0.1
mg/kg vecuronium Maintenance of anesthesia:
Anesthesia was maintained with 50% O2 in air
with 1.3 MAC of isoflurane, and then 0.05 mg/kg
vecuronium.
Ventilation was adjusted to maintain end tidal
Co2 between 30-35mmHg
6 ml/kg/hour IV crystalloid solution was given,
and arterial canula was inserted for invasive blood
pressure monitoring.
The patients were placed in prone position.
Monitoring included invasive blood pressure
measurement, SO2 (O2 saturation), end tidal CO2 and
ECG.
Target mean arterial pressure was 50 mmHg.
In group 1 (Esmolol) was initially given by a
bolus of 500 µg/kg, and the infusion of Esmolol was
started at a rate of 100 µg/kg/min, then increased
gradually (300-500 µg/kg/min) every 5 minutes until
the target mean blood pressure was achieved.
In group 2 (PGE1) was started at an infusion
rate of 0.5 µg/kg/min, and increased gradually every 5
minutes (the maximum dose is 2 µg/kg/min) to reach
the target mean blood pressure.
Parameters measured
Mean arterial blood pressure, Heart rate,
(preoperative, just after induction, 15 minutes, 30
minutes, 60 minutes after starting the infusions, and
15 minutes after discontinuation of infusions), surgical
field estimated by using bleeding score (2), the target
was the score 2-3 (15 minutes, 30 minutes, 60 minutes
after starting the infusions), intraoperative urine output
(liters), creatinine mg/dl (preoperative, and just post
operative).
601
Bleeding score
0
No bleeding
1
Slight bleeding no suction is required
2
Slight bleeding occasional suction is required
3
Moderate bleeding, frequent suction is required
4
Moderate bleeding, frequent suction is required,
bleeding threaten surgical field directly after suction
removed.
5
Severe bleeding, constant suction is required,
bleeding appears faster than can be removed
by suction surgical field severely threatened and
surgery is impossible.
Statistical analysis
Sample was convenient sample.
Statistical analysis: Data were presented as
mean and standard deviation (SD). Comparison of
quantitative variables between the study groups using
Mann Whitney U test for independent samples. Within
group comparisons base line and after application
were done using Wilcoxon signed rank test for paired
samples. A probability value (p value) less than 0.05
was considered statistically significant. All statistical
calculation were done using computer programs
Microsoft Excel version 7 (Microsoft Corporation, Ny,
USA) and (statistical Package for the social Science;
SPSS Inc, Chicago, IL, USA) statistical program.
Results
There was no significant difference between both
groups in age, sex and weight (Table 1).
Table 1
Demographic data of both groups mean ± SD
Group 1 (Esmolol)
(n = 10)
Group 2 (PGE1)
(n = 10)
Age (yr)
14.7 ± 1.9
14.6 ± 1.9
Sex (m/f)
2/8
1/9
40.5 ± 11.1
39 ± 10.7
4/6
5/5
Weight (kg)
ASA I/II
Heart rate was significantly higher in Group
M.E.J. ANESTH 21 (4), 2012
602
H. M. Goma
2 (PGE1) than group 1 at 15,30,45,60, but it was
insignificant at 15 minute after discontinuation of the
infusions (Table 2).
Table 2
Heart rate changes during hypotensive anesthesia mean ± SD
Group 1 (Esmolol)
(n = 10)
Group 2 (PGE1)
(n = 10)
Preoperative heart
(HR)
Beat/min
83.6 ± 2.7
83.4 ± 2.3
Just After induction
(HR)
Beat/min
81 ± 2.6
79.7 ± 3.1
15 min (HR) after
starting of infusion.
Beat/min
64.7 ± 1.7
77.5 ± 3.9*
30 min (HR) after
starting of infusion.
Beat/min
63.5 ± 1.7
75.5 ± 3.7*
45 min (HR)
Beat/min
62.2 ± 1.2
73.6 ± 3.0*
60 min (HR)
Beat/min
60.1 ± 1.6
70.9 ± 2.9*
81 ± 2.4
79.9 ± 4
15 min (HR) after
discontinuation of
infusion.
* p ≤0.05
There was significant difference in the bleeding
score only after 30 minutes, p was (0.005), and it was
insignificant at 15, 45, 60 minutes after initiation of
infusions (Table 3). The target mean blood pressure
(50 mmHg) was achieved at 30 minutes in group 2
(prostaglandin E1), while it was achieved at 60 minutes
in group 1 (Esmolol group). There were significant
differences in Mean blood pressure between both
groups at 15, 30, 45, 60 minutes after starting the
infusions (Table 4).
Table 3
Bleeding score of both hypotensive drugs mean ± SD
Timing of bleeding scores
Group 1
assessment.
bleeding score
Group 2
bleeding score.
15 min
2.5 ± 0.5
2.3 ± 0.6
30 min
2.2 ± 0.4
1.7 ± 0.4*
45 min
1.6 ± 0.4
1.5 ± 0,5
60 min
1.3 ± 0.3)
1.2(0.4
* p ≤0.05
Table 4
blood pressure changes of both groups mean ± SD
Group
1(Esmolol)
(n = 10)
Group 2 (PGE1)
(n = 10)
Preoperative mean blood
pressure (MBP) (mmHg)
72.6 ± 3.7
73.8 ± 3.3
15 min (MBP)
mmHg. After initiation of
the infusion
60.8 ± 3.5
55.2 ± 2.6*
30 min (MBP)
mmHg
60.7 ± 1.5
52.9 ± 1.7*
45 min (MBP)
mmHg
59.6 ± 2.3
51.9 ± 1.9*
60 min (MBP)
mmHg
55.4 ± 2.1
50.1 ± 1.1*
15 min after the
discontinuation of
infusion (MBP) mmHg
72.7 ± 3.8
72.7 ± 3.8
* p ≤0.05
Post operative creatnine was significantly higher
in Esmolol group than in prostaglandin E1 group, P
was <0.001. Intraoperative urine out was significantly
higher in prostaglandin E1 than in Esmolol group
(Table 5, 6).
Table 5
preoperative, and postoperative mean ± SD of creatinine (mg/
dl)
creatinine mg/dl
Group 1 (Esmolol)
Group 2 (PGE1)
preoperative
0.4 ± 0.2
0.5 ± 0.3
postoperative
1.8 ± 0.3
0.7 ± 0.1*
* p ≤0.05
Table 6
Mean ± SD of intraoperative urine output.
Intraoperative urine
output (liter)
Group 1
(Esmolol)
Group 2 (PGE1)
800 ± 200)
1200 ± 200*
* p ≤0.05
Discussion
There are many considerations about the drugs
used to induce hypotensive anesthesia in scoliosis
correction surgery, as maintenance of organ blood
flow, organ auto regulation which in turn determines
the organ functions, and the presence of respiratory, or
Comparison between Prostaglandin E1, and Esmolol infusions in controlled hypotension
during scoliosis correction surgery a clinical trial
cardiac lesions (Tobias, 2002).
This study was planned to compare the
hypotensive effects of Esmolol, and Prostaglandin
E1 and their effects on the renal function. This study
found that both drugs could induce hypotension,
and good bleeding score, however Prostaglandin E1
hypotensive effect started earlier than Esmolol and
its bleeding score is better than esmolol especially
at thirty minutes after initiation of the infusion.
Post operative creatinine was significantly lower in
Prostaglandin E1 group than in Esmolol group, and the
urine output was significantly higher in PGE1 group.
The explanation is PGE can maintain renal blood flow
and renal autoregulation more than Esmolol. Some
studies found that PGE1 can maintain the mesenteric
blood flow, so it can maintain hepatic, renal blood
flow, and organs auto regulation. PGE1 is an agonist
at the PGE2-sensitive receptor (subtype EP2) that
activates adenylate cyclase to increase intracellular
cyclic adenosine monophosphate (cAMP) induces
smooth muscle relaxation that maintains blood flow in
the small venules and arterioles of the different organs
(Takeda et al, 2000 and Hoka et al, 1993).
Other studies found that Prostaglandin E1 has
many advantages over Esmolol, as it does not decrease
603
heart rate, depress myocardium, it has antiarrhythmic
effects, and decrease Oxygen consumption. So it can be
used in border line cardiac patients, another benefit of
this drug is its action through the direct smooth muscle
fibers relaxation, it has a bronchodilator effects, so it
can be used in respiratory impairment patients (Kubota
et al, 2004 and Gibson, 2004).
Other studies demonstrated that esmolol when
combined with inhalational anesthesia it will impair
the cerebral auto regulation (Mackenzie et al, 1993).
The mechanism of action of Esmolol depends
on decreasing heart rate, and cardiac output that leads
to decrease the renal blood flow which stimulates the
reninangiotensin system. So the glomerular filtration
rate falls (Andel et al, 2001).
Conclusions: Prostaglandin E1 can induce
hypotensive anesthesia in scoliosis surgery as Esmolol,
Prostaglandin E1 hypotensive effects started earlier
than Esmolol and its bleeding score is better than
esmolol especially at thirty minutes after initiation
of the infusion. Prostaglandin E1 can maintain renal
function and urine output more than Esmolol. This
study recommended using Prostaglandin E1 to induce
hypotensive anesthesia in scoliosis correction surgery.
M.E.J. ANESTH 21 (4), 2012
604
H. M. Goma
References
1.Thomas W, Mcnillironald L, Dewald, Ken N, Kuo: Controlled
Hypotensive Anesthesia in Scoliosis surgery; Journal of bone and
joint, volume, 56-A, No. 6, September 1974, 1169-1172.
2. Degoute CS: Controlled hypotension: a guide to drug choice.
Drugs; 2007, 67(7):1053-76.
3.Longnecker DE: Effects of general anesthetics on the
microcirculation. Microcirc Endothelium Lymphatics; Apr. 1984,
1(2):129-50.
3. Masuda R, Takeda S: Responses of hemodynamic and splanchnic
organ blood flow to esmolol during inhalation of volatile anesthetics
in dogs]. Masui; Jan 2008, 57(1):69-75.
5. Wiest D: Esmolol A review of its therapeutic efficacy and
pharmacokinetic characteristics. Clin Pharmacokinet; Mar 1995,
28(3):190-202.
6. Lam AM: The choice of controlled hypotension during repair of
intracranial aneurysms: techniques and complications. Agressologie;
Jun 1990, 31(6):357-9. in Humans. ANESTH ANALG; 2003,
97:456-60.
7. Tobias JD: Controlled hypotension in children: a critical review of
available agents. Paediatr Drugs; 2002, 4(7):439-53.
8. Takeda S, Tomaru T, Inada Y: Splanchnic organ blood flow during
calcitonin gene-related peptide-induced hypotension with or without
propranolol in dogs. Anesth Analg; Jun. 2000, 90(6):1275-80.
9. Hoka S, Yoshitake J, Dan K, Goto Y, Honda N, Morioka T, Muteki
T, Okuda Y, Shigematsu A, Takasaki M, Totoki T, Yoshimura
N: Intra-operative blood pressure control by prostaglandin E1 in
patients with hypertension and ischemic heart disease. A multicenter study. J Anesth, 1993.
10.Kubota N, Iwasaki K, Ishikawa H, Shiozawa T, Kato J, Ogawa S:
Auto regulation of dynamic cerebral blood flow during hypotensive
anesthesia with prostaglandin E1 or nitroglycerin]. Masui; Apr
2004, 53(4):376-84.
11.Gibson PR: Anaesthesia for correction of scoliosis in children.
Anaesth Intensive Care; Aug 2004, 32(4):548-59.
12.Mackenzie AF, Colvin JR, Kenny GNC, Bisset WIK: Closed loop
control of arterial hypertension following intracranial Surgery using
sodium nitroprusside. A comparison of intraoperative halothane or
isoflurane. Anaesthesia; 1993, 48:202-204.
13.Andel D, Andel H, Hörauf K, Felfernig D, Millesi W, Zimpfer
M: The influence of deliberate hypotension on splanchnic perfusion
balance with use of either isoflurane or esmolol and nitroglycerin.
Anesth Analg; Nov 2001, 93(5):1116-20.
Dexmedetomidine Use in Direct
Laryngoscopic Biopsy under TIVA
Ayse Mizrak*, Maruf Sanli**, Semsettin Bozgeyik*,
Rauf Gul*, Suleyman Ganidagli*,
Elif Baysal*** and Unsal Oner*
Abstract
Background: The purpose of this study is to investigate the suitability of dexmedetomidine
as a helpful sedative agent in direct laryngoscopic biopsy (DLB), under total intravenous anesthesia
(TIVA).
Methods: In this double blind randomised study, patients were allocated to receive
dexmedetomidine 0.5 µg/kg (group D, n = 20) or saline placebo (group P, n = 20) intravenously.
Forty ASA I-III patients were infused propofol and administered rocuronium bromur. They were
intubated and performed biopsy. Aldrete scores, intraoperative propofol and postoperative analgesic
requirements, satisfaction scores, recovery time, Ramsay sedation scale (RSS), haemodynamic
changes and side effects were recorded.
Results: Postoperative analgesic requirement in group D was significantly lower and
satisfaction scores and RSS were significantly higher than in group P. Additionally, MAP (mean
arterial blood pressure) significantly decreased at post-extubation time in group D.
Conclusion: The premedication with a single dose of dexmedetomidine decreases
intraoperative propofol and postoperative analgesic requirements, increases the postoperative
satisfaction and RSS considerably in patients undergoing DLB under TIVA.
Key words: Direct laryngoscopic biopsy (DLB), airway reflexes, dexmedetomidine,
laryngeal tumor, TIVA (Total Intravenous Anesthesia).
Financial Source which supports work: There is no conflict of interest: disclosure of any
financial relationships between authors and commercial interests with a vested interest in the
outcome of the study.
*
**
***
Anesthesiology and Reanimation, Gaziantep University School of Medicine Gaziantep/TURKEY.
Thoracic Surgery, Gaziantep University School of Medicine Gaziantep/TURKEY.
Ear Nose and Throat (ENT), Gaziantep University School of Medicine Gaziantep/TURKEY.
Corresponding author: Dr. Ayse Mizrak, Gaziantep University Medical Faculty, Department of Anesthesiology and
Reanimation, 27310 Sahinbey, Gaziantep, TURKEY, E- mail: [email protected], Fax: 00903423602244, Tel:
00905337181025.
605
M.E.J. ANESTH 21 (4), 2012
606
Introduction
The incidence of laryngeal CA is about 1% of
all cancers. Squamous cell CA’s are the most common
laryngeal tumors in our patient population. Laryngeal
tumors also include papillomas, cysts in the glottic
area1. Before the anesthetic management of these
patients, preoperative examination and evaluation by
the ear, nose, and throat (ENT) surgeons are essential2.
If the patient has difficulty opening the mouth,
mallampati class is higher than grade 2 and airway
categories are higher than grade 2b, generally, the next
procedure is to proceed with fiberoptic intubation or
tracheostomy. There are several advantages of DLB,
along with a number of detrimental effects. Patients
with laryngeal tumors can present a challenge to
guarantee the airway for laryngeal biopsy. During DLB,
there may be acute changes in systemic and pulmonary
haemodynamics, together with blood gas changes
such as increase in heart rate, blood pressure, airway
and circulatory reflexes during surgical procedure3.
Dexmedetomidine, an α-2 agonist, has none to minimal
respiratory depressant effects, which is clearly a great
advantage in handling a critical airway while inducing
sedation. Further, dexmedetomidine has anxiolytic,
antisialagogue4 and moderate analgesic5 effects. It was
demonstrated to be a useful agent for sedation during
awake fiberoptic intubation in difficult airways6.
Furthermore dexmedetomidine was demonstrated to
attenuate the increase in heart rate and arterial blood
pressure during intubation7 and was shown to attenuate
the airway and circulatory reflexes during extubation
in ocular surgery8. Our patients consisted of more
frequently elderly, ASA I-III patients who may have
some latent respiratory and cardiovascular disease.
Jorden et al.9 concluded that, an accidental overdose
in the perioperative setting with the administration
of dexmedetomidine up to 0.5 µg/kg/min produced
excessive sedation but stable haemodynamics.
As, DLB is a rather shortly procedure, it also
needs a short time for general anesthesia. Therefore
the action time of the induction and sedative agents
should be short with minimum respiratory side effects.
Propofol may be the ideal agent with these objectives
for DLB. So far, no drug has been proposed for the
attenuation of cardiovascular and airway responses
during DLB under TIVA. To avoid the detrimental
A. Mizrak ey al.
effects of DLB and benefit from these desirable effects,
we preferred to use dexmedetomidine in the present
study.
Thus, we aimed to investigate the effect of
low dose of dexmedetomidine on airway reflexes,
haemodynamics, patient comfort, sedation, and
intraoperative anesthetic and postoperative analgesic
requirements during and after DLB.
Methods
A. Selection and description of participants:
The study group comprised 40 ASA I-III patients,
aged 32-67 years. All participants were scheduled to
undergo direct laryngoscopy and biopsy under TIVA.
All procedures were performed by the same surgeon.
The work presented was performed in accordance with
the most recent version of the Helsinki Declaration.
Following approval from the institutional review
board, written informed consent was obtained from all
participants.
All patients were in part of grade 1, which includes
patients with fully visible vocal folds, grade 2a, which
includes patients with clearly visible vocal folds with
small or medium size tumors not obstructing the view
of glottis, or grade 2b in which only parts of vocal
folds are partly visible and large tumors involve 1 or
both vocal folds. The evaluation was carried out by the
ear, nose, and throat (ENT) surgeon by means of the
preoperative indirect laryngoscopy. The patients with
difficulty opening the mouth, Mallampati class higher
than 2, airway categories higher than grade 2b (grade 3,
grade 4), or ischemic heart disease, heart blocks, the use
of premedication drugs such as β adrenergic blockers,
and tricyclic antidepressant drugs, and a known or a
family history of reactions to dexmedetomidine HCl
(Precedex®, Abbott, North Chicago, IL, USA) or
propofol (Propofol, 1%, Fresenius Kabi AB, Sweden)
were excluded.
B. Technical information: Patients were
assigned to one of two study groups using a computer
generated random number table. After the patients
had been taken to surgery room, standard monitors
including electrocardiography, non invasive blood
pressure (MAP) measurement and pulse oximetry were
used throughout the procedure (Monitor; Siemens
Dexmedetomidine Use in Direct Laryngoscopic Biopsy under TIVA
SC 7000, Sweden). No patient was premedicated
with another drug. The study medication consisted
of dexmedetomidine (0.5 µg/kg) or normal saline in
a total volume of 20 mL, which was prepared by an
anesthesiologist not involved to measurements and
evaluation, and was infused intravenously in 10 minutes
before induction of anesthesia. After premedication
with the study drugs, fentanyl 1 µg/kg and propofol
were administered slowly (20 mg/10 sec) until the loss
of eyelash reflex or the patient no longer responded to
his name being called loudly. Propofol was continued to
be given at a rate of 6 mg/kg/hour, followed by fentanyl
(Fentanyl citrate, B. Braun Melsungen AG, Berlin,
Germany) 1 µg/kg and rocuronium bromur (Esmeron,
Organon, Oss Holland) 0.6 mg/kg because of the short
duration of the procedure. Tracheal intubation with
Miller blade (2-4 sizes) was attempted to expose the
glottis for intubation using a polyvinyl tracheal tube of
5.5 to 6 mm ID in patients with grade 1, grade 2a and
grade 2b. Ventilation was assisted with 70% oxygen
and 30% air without inhalation anesthetic. At the end
of the procedure, muscle relaxant effects were reversed
using neostigmine and atropine and all patients were
given oxygen after the operations.
When the patients were awake and cooperative,
tracheal extubation was accomplished in the
post anesthesia care unit. Intraoperative propofol
requirement, Aldrete score, and recovery time were
recorded. The recovery time was considered as the
time from the time anesthetics are discontinued until
verbal communication and the eyes being opened. Non
invasive mean arterial blood pressure (MAP), heart rate
(HR), and SPO2 values were recorded at baseline, 0, 5,
10, 15, 30, and 45, minutes. In addition, visual analog
scale (VAS), anesthesia quality, and RSS of the groups
were evaluated at 30 and 60 min in the postoperative
period when the patients were fully awake. At the end
of the operation, the assessment of pain related biopsy
was performed using a 10 cm VAS, with anchors
of 0 = no pain and 10 = worst pain imaginable. The
quality of anesthesia was assessed according to the
following numeric scale: 4 = Excellent (no complaint
from patient); 3 = Good (minor complaint without
any need for supplemental analgesics); 2 = Moderate
(complaint which required supplemental analgesics);
1 = Unsuccessful (requiring general anesthesia). In
addition, sedation was recorded on a numerical scale
607
of Ramsay; 1 = Anxiety and completely awake, 2 =
Completely awake, 3 = Awake but drowsy, 4 = Asleep
but responsive to verbal commands, 5 = Asleep but
responsive to tactile stimulus, and 6 = Asleep and not
responsive to any stimulus. Postoperative analgesic
(Diclomec, Diklofenak Sodyum, 75 mg/3 ml, amp,
Topkapı Istanbul) requirement was ascertained during
postoperative 24-hour-period.
All the evaluations were performed by a blinded
observer who was different from the person who had
performed the premedication. Pre-intra- postoperative
hypertension, hypotension, bradycardia, tachycardia,
nausea, vomiting, coughing, straining, dizziness,
respiratory depression (defined as a respiratory rate
<10 breaths/min), hypoxemia (defined as SPO2
≤90%, tachycardia (HR >100 beat/min), bradycardia
(HR <50 beat/min), hypotension (MAP <60 mmHg),
hypertension (MAP >120 mmHg) were noted if present
at 30 and 60 min in the preoperative and postoperative
period.
C. Statistics: Data are presented as mean ± SD
and median (interquartile ranges) values, and statistical
significance was reported when the p value was <0.05.
Between-groups, differences were evaluated by means
of Mann Whitney-U test. Friedman and Wilcoxon
sign tests were applied to evaluate the differences
between repeated values in the groups. Data were
presented as means ± SD. All data were analyzed
using SPSS (version 14.0) for Windows (SPSS Inc.)
with differences associated with p< 0.05 interpreted as
statistically significant.
After the foremost calculation according to the
t test, the total sample size that we need to detect the
significant difference between the doses of propofol
consumption of the groups was 17 (effect size w: 0.90:
Alpha: 0.05, Power: 0.95, Critical Chi2: 3.84).
Results
Demographic data was similar between the
groups with regard to duration of anesthesia, surgery,
Aldrete score activity >8, and recovery time (p >0.05,
Table 1).
Table 1
Demographic Data, Aldrete Score, Recovery Time,
Intraoperative Propofol and Postoperative Analgesic
M.E.J. ANESTH 21 (4), 2012
608
A. Mizrak ey al.
Requirement (mean ± SD)
Group D
|(n = 20)
Group P
(n = 20)
Age (year)
51 ± 17
49 ± 17
Weight (kg)
71 ± 14
70 ± 11
Gender (M/F)
15/5
17/3
Smoking (%)
95
90
Duration of Anesthesia(min)
16 ± 4
20 ± 4
Duration of surgery (min)
20 ± 5
13 ± 3
Aldrete Score Activity>8 (min)
6±4
8±7
157 ± 15*
171 ± 17
Intraoperative Propofol
Requirement
Recovery time
Postoperative analgesic
(Dicloron amp) requirement
(mg)
5±4
6±5
15 ± 6*
52 ± 12
* p <0.05 when compared with placebo group.
Intraoperative propofol consumption and
postoperative analgesic requirement (Dikloron amp,
intramuscular) were significantly lower in group D
than in group P (p <0.05, Table 1). The number of
patients who experienced coughing, nausea, strain,
tachycardia, hypotension and hypertension in group D
were 4, 6, 3, 3, 2, 1, and in group P were 1, 4, 6, 5,
2, 2 during intraoperative and postoperative periods.
The overall respiratory and haemodynamic side effects
observed in both groups were; hypertension (n = 3),
hypotension (n = 5), bradycardia (n = 1), tachycardia
(n = 7), nausea (n = 10), coughing (n = 8), straining
(n = 9). No patient experienced respiratory depression,
hypoxemia and vomiting. Three patients in group
D and 2 in group P received ephedrine (10 mg) for
Fig. 1
Postoperative Satisfaction Scores
of the groups. The number of
the patients has a postoperative
satisfaction scores reported to be >1
in group D was significantly higher
than in group P (p <0.05)
Table 2
The Number of Perioperative Side Effects
Group D
(n = 20)
Group P
(n = 20)
Hypotension
3
2
Hypertension
1
2
Bradycardia
1
0
Tachycardia
2
5
Nausea
6
4
Vomiting
0
0
Caughing
4
4
Straining
3
6
P >0.05
hypotension, and 1 patient in group D received atropine
(0.5 mg) for bradycardia. Furthermore, 4 patients were
administered atropine (0.5 mg) for decreasing the
saliva in group P. Haemodynamic side effects were
observed during the intubation, surgical procedure
and extubation period but the respiratory side effects
were observed in the preoperative and postoperative
period especially during intubation and extubation
period; however, there was no significant difference
between the groups regarding the respiratory and
haemodynamic side effects (p <0.05, Table 2). The
number of the patients who had a postoperative
satisfaction score of >1 in group D was significantly
higher than in group P (p <0.05, Fig. 1). Moreover,
the number of the patients who had a RSS of >2 in
group D was significantly higher than in group P at
postoperative 30 and 60 minute (p <0.05, Fig. 2). MAP
Dexmedetomidine Use in Direct Laryngoscopic Biopsy under TIVA
609
Fig. 3
Changes in mean arterial
blood pressure between groups
during perioperative period
(Mean ± SD). MAP in group
D was significantly lower than
in group P at 45 minute in the
postoperative period (p <0.05)
in group D was significantly lower than in group P at
45 minute in the postoperative period (p <0.05, Fig. 3),
and HR was similar in group D and group P (p >0.05,
Fig. 4).
Discussion
It has been demonstrated that the low dose of i.v.
dexmedetomidine administration before DLB under
TIVA achieves gratifying patients’ comfort, moderate
sedation, dry airway, reduction of intraoperative
propofol and postoperative analgesic consumption
without serious airway problems and haemodynamic
side effects.
This study includes the patients with larynx
tumor by whom direct laryngoscopy and biopsy under
TIVA are performed. The surgeons can evaluate the
laryngeal tumor and its extent by means of DL10.
During the procedure, the anesthesiologist and the
surgeons are prepared for emergency interventions in
case securing the airway presented a problem.
During
DLB,
some
respiratory
and
haemodynamic side effects might be faced with. For
example, the presence of the endotracheal tube leads
to reflex responses, the most common of which is
coughing11. The incidence of coughing was reported
to be 76% during procedure. Coughing can cause
hypertension, tachycardia, increased intraocular
and intracranial pressure, myocardial ischaemia,
bronchospasm, and surgical bleeding12. Although the
mechanisms responsible for haemodynamic changes
during extubation are not exactly known, possible
factors may be; wound pain, and tracheal irritation8,13.
Endotracheal intubation is associated with
significant increases of MAP, HR, and plasma
Fig. 4
Changes in heart rate
between groups during
perioperative period (Mean
± SD). HR was similar in
group D and P (p >0.05)
M.E.J. ANESTH 21 (4), 2012
610
catecholamine
concentrations.
Additionally,
recovering from anesthesia often results in pain and
elevating catecholamine concentrations. Hence,
α-2 adrenoceptor agonists may be beneficial in the
postoperative period by their sympatholytic and
analgesic effects without respiratory depression14,15. In
addition, airway irritation leads to parasympathetically
mediated reflex bronchoconstriction of airways of 1
mm and larger15,16. Dexmedetomidine may be a useful
premedication agent for such undesirable side effects
during DL and biopsy.
In the patients with laryngeal tumor, mechanical
ventilation and weaning can be further complicated by
airway irritation. It was reported that α-2 adrenergic
receptors inhibit bronchoconstriction in human
airways17,18. Dexmedetomidine is an α-2 adrenoreceptor
agonist with several unique properties that make it an
ideal agent for the management of difficult and critical
airways. Dexmedetomidine causes minimal respiratory
impairment, even when given in large doses19. It
also can relax the airway even in the hyper-reactive
state20. Thus, the efficacy of dexmedetomidine in DLB
procedures for patients under TIVA were decided to
investigate.
In this study, intraoperative propofol requirement
and analgesic consumption during postoperative
24-hour-period were significantly lower in group D than
in group P (Dikloron amp, group D: 15 ± 6 mg; group
P: 52 ± 12 mg). In some cases, supplemental propofol
was discontinued after dexmedetomidine initiation.
Similarly, Venn et al. reported that dexmedetomidine
provides intense analgesia during the postoperative
period. Despite the lower doses of propofol, the higher
satisfaction scores which were observed in group D
may be dependent on the effect of dexmedetomidine.
The need of midazolam for sedation was diminished
by 80%, and postoperative analgesic requirement was
reduced by 50% in cardiac patients21. Some of the
difference in propofol use may be explained by the
difference in case length.
As the mean age of the patients in this study was
51 years, and most of them were chronic smokers, they
may have had latent cardiovascular and respiratory
disorder. Therefore, dexmedetomidine may be useful
for those generally old-patient-population during DLB.
Talke et al.22 reported that because of the decrease in
A. Mizrak ey al.
HR and blood pressure, dexmedetomidine might lead
to fewer ischemic events.
In this study, the course of Aldrete score activity
>8 and recovery time was similar in both groups,
and dexmedetomidine did not prolonge the recovery
time. It activated the postsynaptic α-2 receptors in the
locus coeruleus, which is an important modulator of
wakefulness.
Dexmedetomidine has analgesic, anxiolytic, and
antisialogogue properties7,21. Avitsian et al.23 concluded
that less respiratory depressive effect and facilitation
of post-intubation neurologic examination make
dexmedetomidine a useful alternative for sedation
in awake fiberoptic intubation. Similarly, it is an
advantage during DLB. In group D, the patients who
have a higher satisfaction scores felt comfortable and
acted calmly. Dexmedetomidine provided moderate
levels of sedation without causing respiratory distress.
It was estimated that higher sedation scale and the
analgesic effect of dexmedetomidine provided a better
satisfaction score in the postoperative period.
As the half-life of dexmedetomidine is 4047 min24 and the time to complete all anesthetic and
surgical procedure in our protocol (approximately
20 min) was less than 30 min, a continuous infusion
of dexmedetomidine was not necessary in our study.
The routine postoperative approach in our clinic is to
observe the patients for an hour in the postoperative
care unit, and then send them to their ward. The
dexmedetomidine concentration used in this study
was on the low level of the doses generally used for
sedation in the intensive care unit, where the initial
bolus was 2 µg/kg.
In this study, MAP in group D was significantly
lower than in group P at 45 th. minute during
postoperative period, whereas HR was similar in both
groups. Ephedrine 10 mg was administered to the
patients who experienced hypotension (Group D: n =
3, Group P: n = 2).
It was stated that dexmedetomidine should be
administered over no less than 10 minutes, as because of
sudden exogenous catecholamine release, the loading
dose of up to 1 µg/kg and too rapid administration can
lead to tachycardia, bradycardia, and hypertension25.
With this in mind, dexmedetomidine 0.5 µg/kg was
given over 10 minutes in this study. Furthermore,
Dexmedetomidine Use in Direct Laryngoscopic Biopsy under TIVA
dexmedetomidine has a mid range dose for preventing
haemodynamic side effects.
Hyperdynamic side effects such as hypertension
and tachycardia may have been suppressed by propofol
during surgical procedure in both groups. The decrease
in systemic pressure following an induction dose of
propofol appears to be due to both vasodilation and
myocardial depression, the leading cause of which
may be a reduction in sympathetic activity26. Propofol,
which provides hypnosis and amnesia is antiemetic27
and induces bronchodilation in patients with chronic
obstructive pulmonary disease28.
Three patients in group D and 2 patients in group
P received ephedrine (10 mg), and 1 patient in group
D received atropine (0.5 mg). The possible reasons
may first be the respiratory and haemodynamic effects
of propofol as explained before. Secondly, the use
of low and single dose of dexmedetomidine which
611
may have not suppressed these airway reflexes and
haemodynamic answers sufficiently. Thirdly, patients’
chronic smoking, laryngeal irritation, postoperative
pain because of biopsy and absence of local anesthetics
injection to block the upper airway nerves may trigger
especially respiratory side effects.
Additionally, the cost of dexmedetomidine is
potentially higher than that of conventional anesthetics,
but the advantage of dry airway, high satisfaction,
moderate sedation, reduction of intraoperative
propofol and postoperative analgesic consumption
without serious airway and haemodynamic side effects
may well justify this expense.
In conclusion, the use of low dose
dexmedetomidine before TIVA carried out with
propofol, could provide a safe and advantageous
condition for DLB.
M.E.J. ANESTH 21 (4), 2012
612
A. Mizrak ey al.
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The Effect Of Dexmedetomidine On
Bispectral Index Monitoring
*
In Children
Dilek Özcengiz, Hakkı Ünlügenç,
Yasemin Güneş and Feride Karacaer
Abstract
The primary aim of this study was to test whether dexmedetomidine administration based on
the bispectral index (BIS) monitoring caused a reduction in consumption of sevoflurane.
Following Institutional Ethic Committee approval and written informed consent from all
parents, fifty-four children undergoing sevoflurane anaesthesia randomly allocated to receive
either dexmedetomidine (Group D) or saline (Group S). The anaesthesia was induced with 8%
sevoflurane in nitrous oxide/oxygen in all children.
Following anaesthesia induction, Group D (n=27) children received a loading dose of
dexmedetomidine 1 μgkg–1 IV over ten minutes, followed by a continuous infusion at a rate of 0.5
μgkg–1 hr–1 throughout the surgery. Group S (n=27) children received same volume of saline infusion
due to obtained blindness. Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart
rate (HR), body temperature and peripheral oxygen saturation (SpO2), end-tidal concentrations of
oxygen, carbon dioxide (ETCO2), and sevoflurane (ETsevo) were monitorized. Bispectral index
numbers and ETsevo concentrations were recorded at 2 min before incision, 2 min after incision, at
the end of surgery and before the termination of anaesthesia, and finally immediately after wake-up
from anaesthesia (Final BIS number).
BIS number was found significantly lower in group D at before incision, after incision and at
the end of surgery than in group S (p=0.000, 0.001, 0.007). End tidal sevoflurane concentrations
were significantly higher in group S at before incision, after incision and at the end of surgery than
in group D (p <0.000 to p <0.001). Final BIS number and sevoflurane concentrations were similar
and there were no significant difference between the groups.
It was concluded that intravenous (IV) dexmedetomidine infusion at a rate of 0.5 μgkg–1 hr–1
during sevoflurane anaesthesia significantly reduces end-tidal sevoflurane concentration and BIS
number in children undergoing minor surgical interventions.
*
Çukurova University Faculty of Medicine Department of Anesthesiology Adana/TURKEY.
Corresponding author: Prof.Dr.Dilek Özcengiz, Çukurova University Faculty of Medicine Department of Anesthesiology
Adana/TURKEY, Tel-Fax: 0903223386742. E-mail: [email protected]
613
M.E.J. ANESTH 21 (4), 2012
614
Introduction
Dexmedetomidine is a selective and potent α2adrenoceptor agonist, with hypnotic, analgesic and
sympatholytic properties1. In contrast with many
anaesthetic agents, dexmedetomidine preserves
spontaneous ventilation. This property makes it
a useful adjuvant to general anaesthesia during
procedures requiring spontaneous ventilation, such as
upper airway surgery and manipulation2,3.
In the paediatric population, dexmedetomidine
has been reported to have effective agent for various
clinical scenarios, including the provision of sedation
during mechanical ventilation, prevention of emergence
delirium after general anaesthesia, procedural sedation
during non-invasive radiologic procedures and in the
control of withdrawal after the prolonged use of opioids
and benzodiazepines3-6. In surgical patients, it has been
reported that dexmedetomidine reduces the use of
other anaesthetics, minimizes sympathetic response
to nociceptive stimuli and improves intraoperative
haemodynamic stability1. In a study, dexmedetomidine
given before induction of anaesthesia has shown to
diminish isoflurane requirements during abdominal
surgery in adults7.
This prospective, randomized, double-blind,
controlled study was designed to see if a similar
reduction in sevoflurane requirements can be achieved
by giving intravenous (IV) dexmedetomidine
administration during sevoflurane anaesthesia. Thus,
the primary aim of this study was to test whether
dexmedetomidine administration based on bispectral
index (BIS) monitoring caused a reduction in
consumption of sevoflurane.
Methods
After approval by the Institutional Ethics
Committee, and written informed consent of all
parents, 54 children, between 3 and 10 years old, ASA
class I and II, undergoing minor surgery were enrolled.
Patients were excluded if they had neurological
disability, impaired hearing, epilepsy, chronic renal
or hepatic illness, metabolic disorders were taking
sedative or stimulant medication, or if they had any
contraindication to the planned anaesthesia technique.
No premedication was administered preoperatively.
D. Özcengiz ey al.
Anaesthesia was induced with 8 % sevoflurane
in nitrous oxide/oxygen (70%/30%) and maintained
with sevoflurane in the same N2O/O2 concentrations.
Following sevoflurane induction, intravenous access
was obtained. A dose of fentanyl 1 µgkg-1 was
administered before the initiation of dexmedetomidine
or saline infusions. No neuromuscular blocker has
been used for endotracheal intubation. Trachea was
intubated easily with suitable tracheal tube. After
intubation of trachea, lungs were ventilated with
volume-controlled ventilation to maintain end-tidal
carbondioxide concentration (ETCO2) at 32 to 35
mmHg. (Dräger Primus). Peripheral oxygen saturation
and body temperature were maintained at least 97 %
and in the range of 36.0–36.5oC, respectively.
To estimate the level of consciousness, the skin
was cleaned with alcohol and got dried. The BIS
sensor was placed on the forehead and temple using a
frontal–temporal montage, pressed for 5 seconds, and
skin-sensor connection was established. Sevoflurane
concentrations were set to achieve BIS values between
40 to 60 therefore; we increased or decreased the
sevoflurane vaporizer by 0.2 % step by step to reach
predetermined values of BIS. An anaesthesiologist,
who was unaware of the group, was responsible for
recording the BIS values and adjusting the sevoflurane
concentration. If there were other signs of inadequate
anaesthesia (HR > 20% of baseline, movement or
tears), sevoflurane concentration was increased by 0.5
% step by step to achieve deeper anaesthesia.
Immediately after anaesthesia induction and
IV access, children were allocated randomly to one
of two groups. Randomization was done by opening
a sealed envelope. An anaesthetist, who was not one
of the observers, prepared packages containing either
dexmedetomidine (Abbott lab., N. Chicago, IL60064
USA) or 0.9 % saline. Both solutions were labelled
‘study drug’ and coded to maintain the double-blind
nature of the study. Dexmedetomidine was supplied in
2-ml ampoules at a concentration of 100 µgml-1, and
diluted with 100 ml normal saline to a concentration of
2 µgml-1. The placebo saline solution was prepared in
a similar fashion.
Following anaesthesia induction, Group D (n=27)
children received a loading dose of dexmedetomidine
1 μgkg–1 IV over ten minutes, followed by a continuous
The Effect Of Dexmedetomidine On Bispectral Index Monitoring In Children
infusion at a rate of 0.5 μgkg–1 hr–1 throughout the
surgery. Group S (n=27) received same volume of
saline infusion due to obtained blindness. Scores for
haemodynamic parameters (systolic blood pressure
(SBP ), diastolic blood pressure (DBP), heart rate (HR),
body temperature and peripheral oxygen saturation
(SpO2) were monitored throughout anaesthesia and
recorded by an anaesthetist, who was blinded to the
patient group, at before anaesthesia induction and
every 5 min throughout the study period. End-tidal
concentrations of oxygen, carbondioxide (ETCO2),
and sevoflurane (ETsevo) were also monitorized
continuously. Bispectral index numbers and ETsevo
concentrations were recorded 2 min before incision,
2 min after incision, at the end of surgery and before
the termination of anaesthesia, and finally immediately
after wake-up from anaesthesia (Final BIS number).
The duration of wake-up was defined from discontinued
the anaesthetic drugs to spontaneous eye opening. All
data were recorded by an anaesthetist blind to the
study groups.
It was planned that if the children’ clinical
condition would have necessitated any change during
the infusion of study drugs; the infusion solution would
have been stopped and children would have excluded
from study. If hearth rate (HR) was lower than 80%
of baseline, 20 µgkg-1 of atropine sulphate was
administered intravenously. If bradycardia persists,
then dexmedetomidine infusion was discontinued and
children excluded from study.
A pilot study was performed to asses the number
of children requiring sample size. Eight patients were
accepted for pilot study. The end-tidal sevoflurane
concentration was in group S (0.34±0.12) and in group
D (0.19±0.17). Thus, this study required at two tails,
α=0.05, (1-β) 95%, 54 patients, 27 in each group.
All variables were tested for normal distribution by
Kolmogorov–Smirnov test. Independent sample t-test
was used for comparison of the means of continuous
variables and normally distributed data. Data on side
effects were analyzed with the chi-square test. A p
value <0.05 was considered statistically significant.
Results
The two groups were similar with regard to age,
sex, weight, duration of surgery and wake-up (table 1).
615
BIS number was found significantly lower in group
D at before incision, after incision and at the end of
operation than in group S (p=0.000, 0.001, 0.007.
table 2). End tidal sevoflurane concentrations were
significantly higher in group S at before incision, after
incision and at the end of operation than in group D
(p < 0.000 to p < 0.001, table 3). Final BIS number
and sevoflurane concentrations were similar and there
were no significant difference between the groups.
In group D, ten patients had bradycardia during the
loading dose of dexmedetomidine, and these patients
were treated with 20 μgkg–1 atropine sulphate. Heart
rates, systolic and diastolic blood pressures were also
similar between groups during the study periods.
Table 1
Demographic data of the groups
Group S
(n=27)
Group D
(n=27)
Age (year)
6.1±2.2
5.7±2.1
Weight (kg)
24.9±6.1
24.3±5.9
13/14
12/15
The duration of surgery (min)
58.0±9.5
57.5±8.6
The duration of wake-up (min)
5.1 ± 1.6
6.0 ± 1.2
Sex (girl/boy)
Table 2
BIS number of the groups
BIS number
Group S
(n=27)
Group D
(n=27)
P
Before incision
50.1±8.4
42.5±6.5
,000
After incision
49.8±8.9
41.4±8.1
,001
End of operation
49.7±9.0
43.4±7.6
,007
Final
89.4±4.1
89.0±5.5
,268
Table 3
End tidal sevoflurane concentration of the groups
End Tidal
Sevoflurane
Group S
(n=27)
Group D
(n=27)
P
Before incision
2.14±0.29
0.77±0.25
,000
After incision
2.01±0.25
0.63±0.19
,000
End of operation
1.87±0.20
0.56±0.12
,000
Final
0.29±0.19
0.20±0.18
0.81
M.E.J. ANESTH 21 (4), 2012
616
Discussion
This is the first study evaluating the effect of
dexmedetomidine on sevoflurane requirement and
BIS numbers in children undergoing minor surgical
interventions. The main finding of this study is that,
in children undergoing minor surgical intervention,
intravenous (IV) dexmedetomidine infusion at a rate
of 0.5 μgkg–1 hr–1 during sevoflurane anaesthesia
significantly reduces sevoflurane requirements.
The alpha 2-agonist dexmedetomidine is a new
sedative, analgesic, and anxiolytic agent8. It has been
demonstrated that intraoperative administration of
dexmedetomidine significantly reduces anaesthetic
requirements, speeds postoperative recovery, and
blunts the sympathetic nervous system response
to surgical stimulation9,10. The concomitant
administration of dexmedetomidine has also been
shown to reduce the anaesthetic requirements
for propofol as well as the inhalation anaesthetic
agents1,11,12. We expected that an alpha 2-agonist,
dexmedetomidine, might also reduce the sevoflurane
requirements, which exert an antinociceptive effect via
stimulation of alpha-2 adrenoceptors in sympathetic
nerve endings and the spinal cord. As expected, in
the present study, dexmedetomidine significantly
decreased sevoflurane consumption and BIS numbers
during minor surgery in children. Ngwenyama et al.
reported that dexmedetomidine decreases propofol
requirements by approximately 25–30% during
spine surgery13. A reduction of more than 95% of
minimal alveolar concentration (MAC) of halothane
is observed following intravenous administration of
dexmedetomidine, which shows this drug may induce
anaesthetic state if administered alone14. In our study,
end tidal sevoflurane concentration was lower in
dexmedetomidine group than in saline group during
the study periods.
Recently, Kayusa et al reported that BIS values
were lower with dexmedetomidine than with propofol
at comparable Observer’s Assessment of Alertness
and Sedation (OAA/S) scores15. The authors noted
that BIS values at OAA/S scores of 1, 2, 3, 4, and 5
during dexmedetomidine sedation were 95 (79 –98),
62 (53.5– 68.5), 45.5 (45.3–52), 39.5 (34.3– 41.8),
and 24.5 (22.5–30.5), respectively. It was suggested
that the combination of both BIS and sedative scales
D. Özcengiz ey al.
could provide different and complementary data
to the clinician evaluating the patient’s response to
sedation than would either tool alone, especially when
dexmedetomidine was used. In the present study,
we found that BIS value and end tidal sevoflurane
concentration reduced in a positive correlation. Also,
haemodynamic parameters and other clinical data
suggested the patients in deep anaesthesia. Our findings
showed that dexmedetomidine reduced BIS number.
However, Elias et al reported their experience with
dexmedetomidine during microelectrode recording
(MER) of subthalamic nucleus16. The bispectral index
(BIS) was used to estimate the level of consciousness.
The quality of microelectrode recording was
evaluated as a function of BIS, clinical arousal, and
dexmedetomidine dose. Microelectrode recording
during wakefulness (BIS>80; 0.1 to 0.4 µgkg-1 hr-1
dexmedetomidine) was similar to the unmedicated
state. Subthalamic MER was reduced when the patient
was asleep or unarousable (BIS < 80). In our study,
BIS value was kept between 40 to 60. It is widely
recognized among anaesthesiologists that BIS values
between 40 and 60 generally indicate adequate general
anaesthesia for surgery and improve recovery17.
Hyperpolarization of noradrenergic locus
ceruleus neurons seems to be an important factor
for sedative activity of dexmedetomidine18,19. The
transcriptional activator c-Fos expression pattern is
similar to endogenous non-rapid eye movement sleep
under sedation by dexmedetomidine, which is not
the case when sedation is induced by GABAergic
agonists18-20. Overall, dexmedetomidine enhances the
non-rapid eye movement sleep promoting pathways,
mainly at locus ceruleus.
Adverse cardiovascular effects are limited
and include occasional episodes of bradycardia and
hypotension that are mainly described with rapid
administration of boluses21,22. In our study, ten patients
had bradycardia however it was corrected after atropine
sulphate injection. Possibly, intravenous atropine can
prevent deep bradycardia before dexmedetomidine
injection. Dexmedetomidine has been extensively
used in adults and paediatrics for sedation and as an
adjuvant to anaesthesia, although its use is off-label in
patients under 18 yr of age3,5-7,9,10,12,13,23,24.
Among
paediatric
patients,
an
inverse
The Effect Of Dexmedetomidine On Bispectral Index Monitoring In Children
correlation exists between BIS values and inhaled
anaesthetic agents, and BIS values and age25,26. Kern
et al. reported to confirm the good fit between BIS
and end-tidal concentration of sevoflurane (PEsevo)
concentration using an Emax model even during
spontaneous ventilation in the non-steady state
setting27. Present study confirm the inverse correlation
between sevoflurane concentration an BIS number,
617
as sevoflurane concentration increased, BIS number
decreased.
It was concluded that intravenous (IV)
dexmedetomidine infusion at a rate of 0.5 μgkg–1 hr–1
during sevoflurane anaesthesia significantly reduces
end-tidal sevoflurane concentration and BIS number in
children undergoing minor surgical interventions.
M.E.J. ANESTH 21 (4), 2012
618
D. Özcengiz ey al.
References
1. Tobias JD: Dexmedetomidine: applications in pediatric critical care
and pediatric anesthesiology. Pediatr Crit Care Med; 2007, 8:115131.
2. Ramsay MA: And Luterman DL: Dexmedetomidine as a total
intravenous anaesthetic agent. Anesthesiology; 2004, 101: 787-90.
3. Smania MC, Piva JP, Garcia PC: Dexmedetomidine in anesthesia of
children submitted to videolaparoscopic appendectomy: a doubleblind, randomized and placebo-controlled study. Rev Assoc Med
Bras; 2008, 54:308-13.
4. Munro HM, Tirotta CF, Felix DE, Lagueruela RG, Madril DR,
Zahn EM, Nykanen DG: Initial experience with dexmedetomidine
for diagnostic and interventional cardiac catheterization in children.
Pediatr Anesth; 2007, 17:109-112.
5. Tosun Z, Akin A, Guler G, Esmaoğlu A, Boyaci A:
Dexmedetomidine–ketamine and propofol–ketamine combinations
for anesthesia in spontaneously breathing pediatric patients
undergoing cardiac catheterization. J Cardiothorac Vasc Anesth;
2006, 20:515-19.
6. Barton KP, Munoz R, Morell VO, Chrysostomou C:
Dexmedetomidine as the primary sedative during invasive
procedures in infants and toddlers with congenital heart disease.
Pediatr Crit Care Med; 2008, 9:612-5.
7. Aho M, Lehtinen Am, Erkola O, Kallio A, Korttila K: The effect
of intravenously administered dexmedetomidine on perioperative
hemodynamics and isoflurane requirements in patients undergoing
abdominal hysterectomy. Anesthesiology; 1991, 74:997-1002.
8. Bhana N, Goa KL, MC Clellan KJ.: Dexmedetomidine. Drugs;
2000, 59:263-268.
9. Tobias JD, Berkenbosch JW: Initial experience with
dexmedetomidine in paediatric-aged patients. Pediatr Anaesth;
2002, 12:171-175.
10.Berkenbosch JW, Wankum PC, Tobias JD: Prospective evaluation of
dexmedetomidine for noninvasive procedural sedation in children.
Pediatr Crit Care Med; 2005, 6:435-439.
11.Peden CJ, Cloote AH, Stratford N, Prys Roberts C: The effect
of intravenous dexmedetomidine premedication on the dose
requirement of propofol to induce loss of consciousness in patients
receiving alfentanil. Anaesthesia; 2001, 56:408-413.
12.Thornton C, Lucas MA, Newton DEF, Doré CJ, Jones RM:
Effects of dexmedetomidine on isoflurane requirements in healthy
volunteers. 2: Auditory and somatosensory evoked responses. Br J
Anaesth; 1999, 83:381-386.
13.Ngwenyama NE, Anderson J, Hoernschemeyer DG, Tobias JD.:
Effects of dexmedetomidine on propofol and remifentanil infusion
rates during total intravenous anesthesia for spine surgery in
adolescents. Pediatr Anesth; 2008, 12:1190-1195.
14.Ebert TJ, Hall JE, Barney JA, Uhrih TD, Colinco MD: The effects
of increasing plasma concentrations of dexmedetomidine in humans.
Anesthesiology; 2000, 93:382-394.
15.Kasuya Y, Govinda R, Rauch S, Mascha EJ, Sessler DI, Turan A:
The correlation between bispectral index and observational sedation
scale in volunteers sedated with dexmedetomidine and propofol.
Anesth Analg; 2009, 109:1811-1815.
16.Elias WJ, Durieux ME, Huss D, Frysinger RC: Dexmedetomidine
and arousal affect subthalamic neurons. Mov Disord; 2008, 23:13171320.
17.Recart A, Gasanova I, White PF, Thomas T, Ogunnaike B, Hamza
M, Wang A: The effect of cerebral monitoring on recovery after
general anesthesia: a comparison of the auditory evoked potential
and bispectral index devices with standard clinical practice. Anesth
Analg; 2003, 97:1667-1674.
18.Correa-Sales C, Rabin BC, Maze M: A hypnotic response to
dexmedetomidine, an alpha 2 agonist, is mediated in the locus
coeruleus in rats. Anesthesiology; 1992, 76:948–52.
19.Nacif-Coelho C, Correa-Sales C, Chang LL, Maze M: Perturbation
of ion channel conductance alters the hypnotic response to the alpha
2-adrenergic agonist dexmedetomidine in the locus coeruleus of the
rat. Anesthesiology; 1994, 81:1527-1534.
20.Nelson LE, Lu J, Guo T, Saper CB, Franks NP, Maze M: The
alpha2-adrenoceptor agonist dexmedetomidine converges on an
endogenous sleep-promoting pathway to exert its sedative effects.
Anesthesiology; 2003, 98:428-436.
21.Bloor BC, Ward DS, Belleville JP, Maze M: Effects of intravenous
dexmedetomidine in humans. II. Hemodynamic changes.
Anesthesiology; 1992, 77:1134-1142.
22.Chrysostomou C, Di Filippo S, Manrique Am, Schmitt CG, Orr
RA, Casta A, Suchoza E, Janosky J, Davis PJ, Munoz R: Use of
dexmedetomidine in children after cardiac and thoracic surgery.
Pediatr Crit Care Med; 2006, 7:126-131.
23.Koroglu A, Demirbilek S, Teksan H, Sagir O, But AK, Ersoy MO:
Sedative, haemodynamic and respiratory effects of dexmedetomidine
in children undergoing magnetic resonance imaging examination:
preliminary results. Br J Anaesth; 2005, 94:821-824.
24.Tobias JD, Goble TJ, Bates G, Anderson JT, Hoernschemeyer
DG: Effects of dexmedetomidine on intraoperative motor and
somatosensory evoked potential monitoring during spinal surgery in
adolescents. Paediatr Anaesth; 2008, 18:1082-1088.
25.Kim HS, Oh AY, Kim CS, Kim SD, Seo KS, Kim JH: Correlation of
bispectral index with end-tidal sevoflurane concentration and age in
infants and children. Br J Anaesth; 2005, 95:362-366.
26.Tirel O, Wodey E, Harris R, Bansard JY, Ecoffey C, Senhadji L:
The impact of age on bispectral index values and EEG bispectrum
during anaesthesia with desflurane and halothane in children. Br J
Anaesth; 2006, 96:480-485.
27.Kern D, Fourcade O, Mazoit JX, Minville V, Chassery C,
Chausseray G, Galinier P, Samii K: The relationship between
bispectral index and endtidal concentration of sevoflurane during
anesthesia and recovery in spontaneously ventilating children.
Pediatr Anaesth; 2007, 17:249-254.
General Anesthesia Complicated by
Perioperative Iatrogenic Splenic Rupture
Jeremy Asnis* and Steven M. Neustein**
Abstract
Patients with splenomegaly often present with diverse coexisting medical disease and thus
offer a variety of anesthetic considerations. The challenges that come with splenectomy have also
become increasingly common to the anesthesiologist, given the growing number of indications
for surgical intervention including both benign and malignant disease. Removal of the spleen is
associated with numerous intraoperative and postoperative risks, including massive intraoperative
hemorrhage, perioperative coagulation abnormalities, and post-splenectomy infection1. When
caring for the patient with an enlarged spleen scheduled for splenectomy, the anesthetic plan must
address both patient and procedure specific concerns. We present a medically challenging case of a
28 year old man with splenomegaly secondary to lymphoma, who underwent elective splenectomy,
which was complicated by perioperative splenic rupture and hemorrhage.
Key words: splenomegaly, intraoperative rupture.
Introduction
Patients with splenomegaly often present with diverse coexisting medical disease and thus
offer a variety of anesthetic considerations. The challenges that come with splenectomy have also
become increasingly common to the anesthesiologist, given the growing number of indications
for surgical intervention including both benign and malignant disease. Removal of the spleen is
associated with numerous intraoperative and postoperative risks, including massive intraoperative
hemorrhage, perioperative coagulation abnormalities, and post-splenectomy infection1. When
caring for the patient with an enlarged spleen scheduled for splenectomy, the anesthetic plan must
address both patient and procedure specific concerns. We present a medically challenging case of a
28 year old man with splenomegaly secondary to lymphoma, who underwent elective splenectomy,
which was complicated by perioperative splenic rupture and hemorrhage.
Case Description
A 28 year old man with a medical history significant only for lymphoma presented for elective
splenectomy. Preoperative exam was unremarkable except for a massively enlarged spleen. After
induction and rapid sequence intubation, an arterial line and two large bore intravenous catheters
were placed. Prior to surgical incision, serial abdominal exams were performed by multiple members
of the surgical team in order to appreciate the impressive size of the patient's spleen. Following
incision, massive intraabdominal bleeding was encountered due to pre-incision splenic rupture.
*
**
Resident in Anesthesiology Department, the Mount Sinai School of Medicine, 1 Gustave L. Levy Place, New York, N.Y.
10029.
Professor of Anesthesiology, the Mount Sinai School of Medicine, 1 Gustave L. Levy Place, New York, N.Y. 10029.
Corresponding author: Steven M. Neustein, 1 Gustave L Levy Place, Box 1010, Mount Sinai Hospital, New York, N.Y.
10029, Fax: 212-426-7616. E-mail: [email protected]
619
M.E.J. ANESTH 21 (4), 2012
620
Jeremy Asnis & Steven M. Neustein
Tachycardia and progressive hypotension were treated
with fluid resuscitation and blood product transfusion.
Surgical hemostasis was achieved and the remaining
intraoperative course was uneventful. The massively
enlarged spleen was removed, and weighed 1950 gms
(figure). The estimated blood loss for the procedure
was 3 liters. The patient received 3 units packed red
blood cells (PRBC), and 5 liters Plasmalyte. The
hematocrit at the conclusion of the procedure was 25
per cent.
Fig.
Massively enlarged spleen
There was postoperative bleeding, and the
patient received an additional 10 units PRBC, 4 U
FFP, and 2 units platelets. The patient returned to the
operating room on post op day 1. There was oozing
at the splenic bed, which was surgically controlled.
Intraoperatively the patient received 4 U PRBC, 4 U
FFP, and 2 units platelets. The patient recovered, and
the rest of the hospitalization was unremarkable. The
patient was discharged home 5 days following this
second operation.
Discussion
The patient with splenomegaly represents a
challenge for the anesthesiologist, whether scheduled
for splenectomy or otherwise. Splenic enlargement is
usually secondary to an underlying disease process,
including infectious, hematologic, and congestive
causes1,2. If the patient is scheduled for splenectomy,
the etiology of splenic enlargement is almost certainly
known. If splenomegaly represents an incidental finding
in a patient otherwise scheduled for surgery, however, a
medical workup is necessary to elucidate the causative
and coexisting disease. Specific anesthetic concerns
invariably depend on the underlying disease process,
however, certain themes recur. A large spleen may exert
an abdominal pressure effect, causing early satiety and
possibly requiring rapid sequence intubation. Patient
symptoms and clinical judgment, rather than splenic
dimensions, will ultimately help to guide this decision.
Splenomegaly may also cause anemia, leukopenia, and
thrombocytopenia regardless of etiology, mandating
a complete blood count. Perioperative hematologic
abnormalities may influence intraoperative transfusion
requirements, the feasibility of neuraxial anesthesia
for postoperative pain, and perioperative infectious
prophylaxis. Standard electrolytes, liver tests, and
a focused review of systems are also important in
identifying significant coexisting disease if the cause
of splenomegaly is unknown.
In patients presenting with splenomegaly, the
anesthesiologist must always appreciate the possibility
of splenic rupture regardless of the planned procedure.
Key features to pathologic rupture, which occurs
in the presence of underlying splenic disease, are
splenomegaly, an increase in splenic fragility, and
changes in local circulation and integrity. Pregnancy,
rheumatic diseases, systemic vasculitis, pneumonia,
and any disease state resulting in splenomegaly have
all been implicated in pathologic rupture3. In such
patients at risk for pathologic rupture, especially those
presenting with marked splenomegaly, avoidance
of excessive splenic palpation and manipulation
under anesthesia would appear prudent. Anesthetized
patients cannot provide physical cues to the examiner,
possibly resulting in undue force placed on the already
fragile spleen. In the case we present, rupture was
directly caused by repeated splenic palpation and
pressure. Anesthesiologists must also note positioning
concerns in this patient group, avoiding direct pressure
to the left upper quadrant. It may be advisable to avoid
the left lateral decubitus position, as well as ensure
that retractors or other surgical equipment not press
on the spleen. If splenectomy is planned, large bore
intravenous access and arterial monitoring are essential.
The potential for significant blood loss exists. Blood
products must be immediately available when bleeding
occurs, as it may be very brisk until surgical control is
obtained. If thrombocytopenia or other hematological
General Anesthesia Complicated by Perioperative Iatrogenic Splenic Rupture
derangements are present, platelets or other products
should also be available.
Perioperative complications are common even
for planned splenectomy. The laparoscopic approach
may over advantages compared with the open approach.
A meta-analysis of 51 studies indicated that the
laparoscopic method was associated with a reduction
of postoperative morbidity4. In particular, splenic
weight has been reported to be the most significant
predictor of morbidity5. In that study, massive
splenomegaly, defined as splenic weight greater than
1000 gm, was associated with a 14 times greater
likelihood of developing complications. The incidence
of blood loss greater than 2 liters was 15% in cases
with spleen weight over 1000 gm, compared with 4%
for those with smaller spleen weights. In a subsequent
study, the laparoscopic approach to splenectomy for
massive splenectomy, also defined in that study as a
spleen weighing 1000 gms or greater, was reported
to be associated with a lower postoperative morbidity
and mortality than open splenectomy6. Postoperative
morbidity was 13.3% vs 30.8% respectively, and
postoperative mortality was 0 vs 7.7 %, respectively.
Although massive splenomegaly carries a risk of
rupture, to the best of our knowledge, the current report
is the first reported case of massive bleeding resulting
621
from intraoperative physical examinations while the
patient is under general anesthesia. Particular caution
must be exercised when examining such patients,
especially while anesthetized, and the anesthesiologist
must be prepared for possible hemorrhage. Massive
splenomegaly is associated with a significantly
higher rate of morbidity regardless of technique5.
All splenectomy patients remain at risk for infection
postoperatively, although vaccination and prophylactic
antibiotic regimens have decreased infection-related
morbidity and mortality.
Conclusion
In the patient presenting with splenomegaly,
the anesthesiologist must appreciate the wide variety
of coexisting diseases. Medical workup often reveals
specific anesthetic concerns, although a framework
exists regardless of underlying etiology. Splenic rupture
is always on the differential diagnosis for sudden
decompensation in at risk patients. For splenectomy
patients - particularly those with massive splenomegaly
- appropriate intravenous access, perioperative
monitoring, availability of blood products and overall
preparedness for large-scale resuscitation are critical to
a successful outcome.
M.E.J. ANESTH 21 (4), 2012
622
Jeremy Asnis & Steven M. Neustein
References
1. Katz SC, Pachter HL: Indications for Splenectomy. The American
Surgeon; 2006, 72:565.
2. Pozo AL, Godfrey EM, Bowles KM: Splenomegaly: Investigation,
diagnosis and management. Blood Reviews; 2009, 23:105.
3. Sterlacci W, Heiss S, Augustin F, Tzankov A: Splenic Rupture,
Beyond and Behind: A Histological, Morphometric and Follow-Up
Study of 254 Cases. Pathobiology; 2006, 73:280.
4. Winslow ER, Brunt LM: Perioperative outcomes of laparoscopic
versus open splenectomy: A meta-analysis with an emphasis on
complications. Surgery; 2000, 134:647.
5. Patel AG, Parker JE, Wallwork B, et al: Massive splenomeagaly is
associated with significant morbidity after laparoscopic splenectomy.
Ann Surg; 2003, 238:235.
6. Owera A, Hamade AM, Bani Hani OI, Ammori BJ: Laparoscopic
versus open splenectomy for massive splenomegaly: A comparative
study. Journal of laparoendoscopic and advanced surgical
techniques; 2006, 16:242.
Continuous Spinal Anaesthesia for
A Total Hip Arthroplasty In A Patient
With An Atrial Septal Defect
Laurent Lonjaret*, Olivier Lairez**
and V incent M inville *
Abstract
Atrial septal defect (ASD) is often diagnosed and repaired during childhood. Nevertheless,
it is the most common congenital cardiac defect seen in adults. ASD is characterized by a leftto-right intracardiac shunt and pulmonary hypertension. Pulmonary hypertension increases
perioperative risks of morbidity and mortality. We report the anaesthetic management of a 68-yearold woman with an unrepaired ASD, who underwent a total hip arthroplasty under continuous
spinal anaesthesia.
Key words: atrial septal defect; continuous spinal anesthesia; total hip arthroplasty.
Introduction
Atrial septal defect (ASD) represents the most common congenital cardiac defect seen in
adults¹. Most of them are repaired in childhood. Presenting symptoms in patients with untreated
ASD are usually murmur, fatigue, dyspnea on exertion, palpitations (atrial arrhythmias). Stroke,
caused by paradoxical emboli, are less frequent2. ASD is characterized by chronic pulmonary arterial
hypertension (PAH), which increases the anaesthetic risk³. We report the anaesthetic management
of a 68-year-old woman, with an ASD, who came to hospital for a total hip arthroplasty.
Case Report
A 68-year-old woman, suffering from hip arthritis, came to hospital for a total hip arthroplasty.
She had been diagnosed of an ASD in her young adulthood. She also suffered from atrial fibrillation.
Her daily treatment was composed by furosemide 40mg, digoxin 0.125mg and warfarin. She had
no complain (no dyspnea, no chest pain, no syncope).
The cardiac auscultation revealed an irregularly irregular rhythm with a grade 3 systolic
regurgitation murmur, which was increased during inspiration. Lungs were clear to auscultation.
Signs of right heart failure were present: increase in jugular venous pressure, hepatomegaly (no
peripheral edema was found). The patient’s systemic arterial pressure was 130/75, with an irregular
heart rate of 95 beats/min. Oxygen saturation by pulse oximetry (SpO2) was of 96% in room air.
The chest X-ray showed a cardiomegaly, an enlarged main pulmonary artery and enlarged
hilar vessels. The electrocardiogram found an atrial fibrillation and a right axis deviation suggesting
a right ventricular hypertrophy.
*
**
Department of Anesthesiology, Toulouse University Hospital, Toulouse, France.
Department of Cardiology, Toulouse University Hospital, Toulouse, France.
Corresponding author: Dr. Laurent Lonjaret, Department of Anesthesiology, Purpan University Hospital, Place du Dr.
Baylac, Toulouse, France. Phone: (33) 5 61 77 74 43, Fax: (33) 5 61 77 77 43. E-mail: [email protected]
623
M.E.J. ANESTH 21 (4), 2012
624
The echocardiogram revealed an ostium
secundum ASD at 28mm with a left-to-right shunting.
The cardiac output was estimated at 1.96 L/min/m2.
The left ventricular ejection fraction calculated by the
Simpson’s method was of 45% and the left ventricular
filling was disturbed. The echocardiogram also
showed dilated right areas (right ventricular diameter
= 52mm; right atrium area = 66cm2) and dilated main
pulmonary artery (32mm). The pulmonary artery
pressures revealed PAH (Doppler studies found:
systolic = 75mmHg; mean = 35mmHg; diastolic =
23mmHg).
The patient refused a surgical or transcatheter
closure of her ASD. After a multidisciplinary
evaluation, and a risk-benefits explanation, we decided
to perform the surgery under continuous spinal
anaesthesia (CSA).
Preoperative blood tests were normal
(haemoglobin level at 13.2g/dl). Warfarin was changed
by subcutaneous unfractionned heparin, digoxin was
continued and furosemide was stopped the day of
surgery.
In the operating room, arterial and central venous
pressure (CVP) lines were inserted with the help of local
anaesthesia. The patient received 500 ml of Ringer’s
lactate before the spinal anaesthesia. After antiseptic
preparation of the area and a local anaesthesia,
subarachnoid puncture has been performed with a
19-gauge Tuohy needle at the L4-5 interspace using
a midline approach. Three cm of a 22-gauge catheter
has been introduced cephalad through the needle. An
initial dose of 2.5mg (0.5ml) of isobaric bupivacaine
has been injected through the catheter over 10-15
s. After 20min, a second injection was made. The
dermatome level of sensory blockade was yet T10. A
third injection has been made to have a complete motor
block on modified Bromage scale. Sensory blockade
spread to T8. No modification occurred in mean arterial
pressure (MAP). CVP was maintained at 13-15 mm Hg
throughout the operation (basal level). Diuresis was
80ml/h. The total fluid administration was 750ml of
Ringer’s lactate and 500ml of hydroxyethylamidon for
a surgery time of 50 min. The motor block regressed at
145th min and the sensory block at the 175th min.
There were no postoperative complications.
Intravenous paracetamol and ropivacaine infusion
L. Lonjaret et al.
through ilio-fascial catheter were used for postoperative
analgesia. The patient had no dyspnea, chest pain,
or neurologic complications. Troponin level stayed
normal. She left the hospital on day 7.
Discussion
ASD is often diagnosed and repaired during
childhood. If it is not, the left-to-right cardiac shunt
leads to a right heart ventricular volume overload and
right heart dilatation. Then patients develop PAH, right
ventricular hypertrophy and congestive heart failure⁴.
ASD ultimately leads to Eisenmenger’s syndrome with
right-to-left shunting.
Orthopedic surgery is associated with an
intermediate cardiac risk5. Preoperatively, the patient’s
functional capacity must be evaluated. A complete
physical examination and an electrocardiogram should
be done. These patients should also have special
cardiac investigations to determine perioperative risks.
Echocardiography, a non invasive testing, determines
the anatomic and functional features associated with
the defect: type of ASD, dimension of the defect,
direction of the flow, enlargement of receiving
chambers, importance of the shunt6 (Qp/Qs ratio: ratio
between pulmonary flow and systemic flow). Invasive
assessment by cardiac catheterization is indicated if
there is evidence of PAH7. This technique allows a
direct measurement of pressure in each chambers,
assesses pulmonary vasoreactivity and calculates
Qp/Qs ratio. Catheterization also confirms increased
oxygen saturation in right sided cardiac chambers and
pulmonary artery.
ASD closure is recommended in different
cases: a defect > 10mm, an elevated shunt ratio (Qp/
Qs > 1.5), right ventricular dilatation, pulmonary
hypertension and an episode of paradoxical embolism8.
Before a surgery with a potential risk of bone cement
implantation syndrome, a preventive closure of an
intracardiac shunting appears as a logical strategy9.
The primary anaesthetic goal is to minimize
increases in pulmonary vascular resistance (PVR) and
maintain SVR10 (systemic vascular resistance). In our
case, the main risk was an inversion in the direction
of the shunt (left-to-right to right-to-left shunt),
resulting in major hypoxemia and possible paradoxical
Continuous Spinal Anaesthesia for A Total Hip Arthroplasty In A Patient With An Atrial
Septal Defect
embolization. The shunt direction is related to the
relative pressure gradient across ASD (ratio of SVR
to PVR). A decrease in SVR will favour right-to-left
shunting, whereas increasing SVR will increase leftto-right shunting. PVR increases with sympathetic
stimulation (pain, stress), acidosis, hypoxemia,
hypercarbia, hypothermia, high intrathoracic pressure.
In fact, systemic hypotension (caused by dehydration,
blood loss and anaesthetic drugs) can change the
direction of the shunt. Hypovolemia is also poorly
tolerated in case of ASD, because a high circulating
volume is needed to maintain the shunt volume6.
The choice of anaesthetic technique is central.
In patients with PAH, selected for noncardiac surgery
under general anaesthesia, Ramakrishna and al. found
42% of morbid event and 7% of early death11. General
anaesthesia and mechanical ventilation decrease
SVR and increase PVR, especially with high level of
PEEP (positive end-expiratory pressure). Mechanical
ventilation also causes intraoperative right-to-left
intracardiac shunting12. Spinal anaesthesia provides
a sympathectomy-induced hypotension: spinal block
might induce an acute and dangerous drop in venous
return13. To avoid a rapid decrease of SVR, CSA
is a valuable option. It allows incremental dosing
of local anaesthetic and has the advantage to have
less hemodynamic effects than a single shot spinal
anaesthesia14. Incremental injections produce a
625
gradual, predictable and sufficient block. Nevertheless,
CSA can be associated with infectious complications,
epidural hematoma and post dural puncture headache
(PDPH).
De-air intravenous lines carefully is a specific
management in case of ASD10. Monitoring of the
patient is a main question. SpO2 is an essential tool:
it varies with the Qp/Qs ratio. SpO2 decreases in
case of shunting inversion. Artery line gives data on
SVR, volemia and allows blood gas analysis6. CVP is
not a good marker of circulating volume, because the
shunt biases its value. Nevertheless, CVP monitoring
is interesting to follow the preload: CVP decreases
with hypovolemia. In case of ASD, measurement
of thermodilution cardiac output is inaccurate,
because of early recirculation7. A transesophageal
echocardiography (TEE) is the best monitoring during
surgery5,15, but it is not an acceptable alternative in a
conscious patient.
Conclusion
Our experience shows that CSA is a good
alternative for the management of a total hip
arthroplasty in patient with an ASD and major PAH.
This technique produces a predictable anaesthesia and
maintains SVR.
M.E.J. ANESTH 21 (4), 2012
626
L. Lonjaret et al.
References
1. Brickner ME, Hillis LD, Lange RA: Congenital heart disease in
adults. First of two parts. N Engl J Med; 2000, 342:256-63.
2. Fahmy A, Schiavone W: Unusual clinical presentations of secundum
atrial septal defect. Chest; 1993, 104:1075-8.
3. Rodriguez RM, Pearl RG: Pulmonary hypertension and major
surgery. Anesth Analg 1998, 87:812-5.
4. Campbell M: Natural history of atrial septal defect. Br Heart J;
1970, 32:820-6.
5. Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E,
Fleischmann KE, Freeman WK, Froelich JB, Kasper EK, Kersten
JR, Riegel B, Robb JF, Smith SC, JR, Jacobs AK, Adams CD,
Anderson JL, Antman EM, Buller CE, Creager MA, Ettinger SM,
Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW,
Nishimura R, Ornato JP, Page RL, Riegel B, Tarkington LG, Yancy
CW: ACC/AHA 2007 guidelines on perioperative cardiovascular
evaluation and care for noncardiac surgery: executive summary:
a report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines (Writing Committee
to Revise the 2002 Guidelines on Perioperative Cardiovascular
Evaluation for Noncardiac Surgery). Anesth Analg; 2008, 106:685712.
6. Chassot PG, Bettex DA: Anesthesia and adult congenital heart
disease. J Cardiothorac Vasc Anesth; 2006, 20:414-37.
7. Fox JM, Bjornsen KD, Mahoney LT, Fagan TE, Skorton DJ:
Congenital heart disease in adults: catheterization laboratory
considerations. Catheter Cardiovasc Interv; 2003, 58:219-31.
8. Kim MS, Klein AJ, Carroll JD: Transcatheter closure of intracardiac
defects in adults. J Interv Cardiol; 2007, 20:524-45.
9. Pigot B, Kirkham D, Eyrolles L, Rosencher N, Safran D, Cholley
B: Preventive closure of a patent foramen ovale before total hip
replacement. Br J Anaesth; 2009, 102:888-9.
10.Cannesson M, Earing MG, Collange V, Kersten JR: Anesthesia
for noncardiac surgery in adults with congenital heart disease.
Anesthesiology; 2009, 111:432-40.
11.Ramakrishna G, Sprung J, Ravi BS, Chandrasekaran K, Mcgoon
MD: Impact of pulmonary hypertension on the outcomes of
noncardiac surgery: predictors of perioperative morbidity and
mortality. J Am Coll Cardiol; 2005, 45:1691-9.
12.Jaffe RA, Pinto FJ, Schnittger I, Brock-Utne JG: Intraoperative
ventilator-induced right-to-left intracardiac shunt. Anesthesiology;
1991, 75:153-5.
13.Carpenter RL, Caplan RA, Brown DL, Stephenson C, Wu R:
Incidence and risk factors for side effects of spinal anesthesia.
Anesthesiology; 1992, 76:906-16.
14.Minville V, Fourcade O, Grousset D, Chassery C, Nguyen L,
Asehnoune K, Colombani A, Goulmamine L, Samii K: Spinal
anesthesia using single injection small-dose bupivacaine versus
continuous catheter injection techniques for surgical repair of hip
fracture in elderly patients. Anesth Analg; 2006, 102:1559-63.
15.Marak BA, Wedel DJ, Ammash NM: An unusual presentation of
atrial septal defect in a patient undergoing total hip arthroplasty.
Anesth Analg; 2000, 91:1134-6.
Percutaneous balloon mitral valvuloplasty
in a pregnant patient under minimally
invasive intravenous anesthesia
Leigh Apple*, Deepak Gupta*, Michael Okumura**
and H ong Wang ***
Introduction
The most common rheumatic valvular lesion encountered in pregnant patients is mitral
stenosis. The clinical presentation of mitral stenosis in pregnancy is further complicated by the
physiological increases in cardiac output and blood volume occurring during pregnancy that make
the pregnant patient with this valvular disease more susceptible to decompensation. We report a
case of a 35-year-old woman presenting at 21 weeks gestation with severe mitral valve disease
who underwent percutaneous balloon mitral valvuloplasty under intravenous anesthesia. In the
case described, mitral stenosis during pregnancy and available treatment approaches are being
discussed.
Case Description
A 35-year-old gravida-3-para-2 female at 21.3 weeks gestation presented with symptomatic
rheumatic heart disease. The patient had been unaware of her diagnosis of rheumatic heart disease
until the age of 31 and shortly after successful delivery of her second child. Her presenting symptoms
were shortness of breath at minimal exertion with associated intermittent heart burn sensation.
Vital signs were stable with blood pressure 99/60, heart rate 81 beats per minute, temperature
36.8°C, and an oxygen saturation of 100% on room air. Her weight was 81.5kg. She had additional
past medical history of pulmonary hypertension and class III congestive heart failure. She had no
past surgical history and had 2 previous spontaneous vaginal deliveries 6 and 8 years prior to the
present clinical presentation. Her home medications included metoprolol 150 mg by mouth twice a
day and furosemide 20 mg by mouth daily. She had no known drug allergies and her social history
was negative for tobacco, alcohol, or illicit drug use. Two echocardiographic (ECHO) reports from
an outside institution were reviewed with the following documented findings: mitral valve was
reported as thickened mitral leaflets with thickened chordae and severe stenois; mitral valve area
was reported to be 0.6-1.1 cm2 with peak gradient of 40 mmHg and mean gradient of 30 mmHg;
tricuspid valve was reported as normal; aortic valve was reported as thickened leaflets with mildmoderate aortic insufficiency; pulmonary systolic pressure was 48-75 mmHg; right sided chambers
were normal; left atrium was reported as dilated and left ventricular ejection fraction was 35%.
*
**
***
Resident, Anesthesiology, Detroit Medical Center, Detroit, Michigan, United States.
Staff Anesthesiologist, Detroit Medical Center, Detroit, Michigan, United States.
Professor, Anesthesiology, Detroit Medical Center, Detroit, Michigan, United States.
Corresponding author: Hong Wang MD, PhD, Box No 162, 3990 John R, Detroit, MI 48201, USA, Ph: 313-745-7233.
E-mail: [email protected]
627
M.E.J. ANESTH 21 (4), 2012
628
After review of the patient’s ECHO results, the
cardiology team recommended the patient for right
heartcatheterization and percutaneous balloon mitral
valvuloplasty for severe mitral stenosis. The procedure
was performed with intravenous anesthesia with
consideration of physiological changes in pregnancy
and increased vigilance for aspiration risks. The
patient was taken to the operating room, two 18-gauge
peripheral venous accesses were obtained and standard
ASA monitors were placed. Prior to the start of the
procedure the patient was given metoclopramide 10
mg intravenously and ranitidine 5 mg intravenously.
The patient was essentially awake and able to
communicate throughout the procedure. A propofol
infusion of 25 mcg/kg/min and a total of 150 mcg of
fentanyl were given throughout the procedure in small
multiple doses.
The results of the procedure showed the patient
to have baseline right atrial pressure of 13/12/10
mmHg, right ventricular pressure of 71/3/12 mmHg,
pulmonary artery pressure of 82/37/56 mmHg,
pulmonary capillary wedge pressure of 34/29/33
mmHg, left atrial pressure of 36/28/34 mmHg, left
ventricular pressure of 108/9/15 mmHg, and aortic
pressure of 111/66/55 mmHg. Prior to balloon
valvuloplasty, the mean gradient across the mitral
valve was shown to be 19 mmHg with a calculated
mitral valve area of 0.84 cm2. The procedure yielded
successful balloon valvuloplasty of the mitral valve,
using an Inoue 26 balloon, with reduction in mean
gradient across the mitral valve from 19 mmHg
to 10 mmHg and increase in the mitral valve area
from 0.84 cm2 to 1.17 cm2. Ejection fraction results
from the procedure were 60% with no wall motion
abnormalities. Procedure was completed uneventfully
and patient was discharged home from our institution
on postoperative day 1.
Discussion
Mitral valvular scarring caused by rheumatic
fever leads to morbidity and mortality. Progressive
reduction in valvular cross-sectional area eventually
presents with symptoms of mitral stenosis. However,
the physiological increases in the blood volume and
cardiac output in a pregnant patient with mitral stenosis
precipitate the development of congestive heart failure.
L. Apple et al.
This is secondary to the left atrial pressure elevation,
which is caused by increased transvalvular gradient
across the stenosed mitral valve during the high cardiac
output state of pregnancy1. Further elevations in the
circulating blood volume and heart rate secondary to
auto-transfusion of shunted uterine arterial blood due
to uterine contraction after the delivery of the fetus
may precipitate pulmonary edema in the post-partum
period2. Hence, it seems prudent to consider therapeutic
interventions in pregnant patients with symptomatic
severe mitral stenosis. Valvuloplasty should be a
consideration for pregnant patients who have failed or
responded poorly to medical management. Compared
to percutaneous balloon mitral valvuloplasty, open or
closed surgical commisurotomy have a 5-33% greater
incidence of fetal mortality1.
Administration of anesthesia for percutaneous
balloon mitral valvuloplasty in a pregnant patient is best
obtained in an awake state with minimal dose of opioids
to avoid fetal bradycardia and apnea in the pregnant
patient. Intravenous sedation/anesthesia or regional
anesthesia is preferred over general anesthesia for nonobstetrical procedures in pregnant patients so that the
aspiration risks and difficult airway management with
difficult endotracheal intubation can be avoided. The
avoidance of general anesthesia additionally minimizes
fetal exposure to the potent anesthetic agents. Though
the patient is spontaneously breathing under minimal
sedation or intravenous anesthesia, pregnant patients
are still vigilantly monitored for aspiration risks
secondary to their basal state of being full stomach due
to physiologically decreased gastrointestinal motility
during pregnancy. Additionally, in view of radiation
exposure to fetus, postponing the procedure until after
14-20 weeks gestation is safer. Moreover, complete
abdominal lead shielding with cutting down the
radiation exposure time to minimum further ensures
minimal risk for fetal abnormalities after percutaneous
balloon mitral valvuloplasty3. Ease of the Inoue
balloon for percutaneous balloon mitral valvuloplasty
ensures short procedure time and hence lessens the
total fluoroscopy time2.
Conclusion
In summary, pregnant patients with severe
mitral stenosis requiring percutaneous balloon
Percutaneous balloon mitral valvuloplasty in a pregnant patient under minimally
invasive intravenous anesthesia
mitral valvuloplasty can be safely treated after 14
weeks gestation with minimal sedation/intravenous
629
anesthesia provided optimal abdominal lead shielding
with minimal fluoroscopy exposure time is ensured.
References
1. Nercolini DC, da Rocha Loures Bueno R, Eduardo Guérios E,
Tarastchuk JC, Pacheco AL, Piá de Andrade PM, Pereira da Cunha
CL, Germiniani H: Percutaneous mitral balloon valvuloplasty in
pregnant women with mitral stenosis. Catheter Cardiovasc Interv;
2002, 57:318-22.
2. Ben Farhat M, Gamra H, Betbout F, Maatouk F, Jarrar M, Addad
F, Tiss M, Hammami S, Chahbani I, Thaalbi R: Percutaneous balloon
mitral commissurotomy during pregnancy. Heart; 1997, 77:564-7.
3.Cheng TO: Percutaneous inoue balloon valvuloplasty is the
procedure of choice for symptomatic mitral stenosis in pregnant
women. Catheter Cardiovasc Interv; 2000, 50:418.
M.E.J. ANESTH 21 (4), 2012
Airway Evaluation For Magnetic
Resonance Imaging Sedation In
Pediatric Patients With Plexiform
Neurofibroma
Claude Abdallah**
Introduction
Neurofibromatosis type 1 (NF1) or Von Recklinghausen disease, the most common form
of NF, is an autosomal dominant disease with a variable expressivity and a wide variety of
clinical manifestations. In one half of cases, NF-1 can result from a de novo mutation, with no
previous family history of disease. It affects males and females equally with a disorder frequency
of 1 in 4,0001. The gene affected in NF-1, is located on the long arm of the chromosome 17
(q11.2). Neurofibromatosis modifies neurofibromin, a "tumor suppressor" protein, allowing rapid
growth of cells, especially around the nervous system. This leads to the common symptoms
of neurofibromatosis. The incidence of head and neck involvement in patients with NF varies
between 14% and 37%2. Plexiform neurofibroma of the neck is a cause of morbidity in the affected
individual with possible airway abnormalities. Challenges in the care of these patients include the
evaluation and the determination of airway patency prior to anesthesia/sedation for the MRI exam.
Background
Pediatric patients with NF 1 may present for sedation for MRI exam as outpatients with
a growing large neck mass. Previous MRI exams may suggest involvement of the airway with
the progression of the tumor. Picture 1 shows an example of a neck MRI of a large plexiform
neurofibroma involving predominantly the left side of the neck. The lesion is seen in the left
carotid space, extending through the left lateral neck into the supraclavicular fossa to the brachial
plexus and then into the intercostal space and dorsal paraspinal region. The lesion pushes the
parapharyngeal space forward and seems to compress the airway. Verifying the patency of the
airway prior to proceeding in anesthetizing patients with evolving face/neck masses may require
additional interventions, such as a neck and chest X ray, an otolaryngology consult prior to
sedation, a flexible/rigid fiberoptic laryngoscopy, or a CT scan exam. The pediatric patient offers
a unique challenge in the risk of exposure to radiation and the need of sedation in order to insure
immobilization during different type of examinations.
*
Corresponding author: Claude Abdallah, Assistant Professor of Anesthesiology and Pediatrics, Division of
Anesthesiology, The George Washington University Medical Center, 111 Michigan Avenue, N.W., Washington D.C.
20010-2970, Tel: (202) 476-2025/2407. E-mail: [email protected]
631
M.E.J. ANESTH 21 (4), 2012
632
Picture 1
The long arrow points to the compressed hypopharyngeal
airway, the short arrow points to the superior aspect of the left
pyriform sinus. The right pyriform sinus is not seen.
Discussion
Preoperative assessment of the airway is
focused primarily at the detection and evaluation
of laryngotracheal obstruction and involvement of
adjacent structures. A postero-anterior and lateral neck
andchest radiographs may be sufficient in some patients
to assess the degree of tracheal compression and
deviation; however, more modern imaging techniques
such as a magnetic resonance imaging (MRI) provide
more detailed information about the extent of airway
involvement and the degree of mass extension. MRI
can produce imaging of the airway without incurring a
large dose of radiation to the patient; these images are
susceptible to artifact from movement and therefore
require sedation of the pediatric patient. Sedation may
aggravate airway narrowing secondary to collapse of
the tissues, therefore in the case of suspicion of airway
involvement; a detailed assessment prior to sedation is
requested.
Computerized Tomography (CT) scanning
may offer an alternative way for airway assessment
because of fast imaging but with the risk of exposure
to radiation. There are limitations of axial CT images
for assessing the airways such as limited ability to
detect subtle airway stenosis and craniocaudad extent
of disease; difficulty displaying relationships of the
airway to adjacent mediastinal structures; inadequate
representation of airways oriented obliquely to the
axial plane; and difficulty assessing the interfaces
and surfaces of airways parallel to the axial plane3.
C. Abdallah
Complementary ways of viewing the data from
the original axial CT data set can help to overcome
these limitations. The CT data can be reconstructed
into two-dimensional (2-D) reformations and threedimensional (3-D) images, including internal virtual
endoscopic (VE) renderings that simulate images
from conventional bronchoscopy4. Detection of
lesions in the airway using virtual bronchoscopy
was reported to reach a high sensitivity (>90%) for
lesions that were > 5 mm in diameter. However, there
was limitation by a high false-positive rate due to the
difficulty in differentiating retained secretions from the
airway5,6. External 3-D rendering of the airways, or CT
tracheobronchography, depicts the external surface of
the airway and its relationship to adjacent structures.
Some authors suggested that VE may be considered as
a substitute to direct endoscopic examination sparing
them an extra anesthetic for evaluation7. However,
VE may have some limitations and does not provide
histology, and it cannot identify functional lesions of
the vocal cords8. In the pediatric population sedation/
anesthesia may be needed in order to perform the
CT scan and adequate justification is required so that
the perceived benefits outweigh the risks of using
ionizing radiation. Flexible bronchoscopy and CT
scan are considered complementary techniques in the
evaluation of laryngeal function and during followup while rigid bronchoscopy remains the procedure
of choice in the evaluation of candidates for tracheal
resection and reconstruction for postintubation
stenosis9. Although, the 3-D rendering of CT scanning
in the pediatric population4,10 may be considered
as a useful adjunctive radiological tool in airway
assessment; MRI does not involve ionizing radiation
and is valuable in demonstrating the relation of the
airway to adjacent blood vessels without injection
of intravascular contrast. MRI may be considered
as the preferred modality for assessing paratracheal
abnormalities in children11.
Successful
management
of
plexiform
neurofibromas of the head and neck in patients with
neurofibromatosis type 1 (NF1) requires detailed
preoperative planning. Magnetic resonance imaging
(MRI) is indicated preoperatively to avoid the
associated loss of function and to delineate precisely
the extent of the tumor. Challenges in the care of these
patients include the evaluation and the determination
Airway Evaluation For Magnetic Resonance Imaging Sedation In Pediatric Patients With
Plexiform Neurofibroma
of airway patency prior to sedation for the MRI exam.
Although, computed tomography can yield useful
information, the most definitive technique for upperairway evaluation involves the direct visualization of
the anatomy and dynamics12. Because of the specific
advantages and limitations of each technique, the
combined use of flexible and rigid endoscopes, with a
carefully planned approach to sedation and anesthesia,
yield to the most accurate diagnostic information.
633
Acknowledgments
The author would like to thank Dr. Gilbert Vezina
for providing the picture related to this manuscript.
This work has been presented as a poster presentation
at the Society for Pediatric Anesthesia Meeting, San
Antonio, TX, April 2010.
M.E.J. ANESTH 21 (4), 2012
634
C. Abdallah
References
1. Bissonnette B, Luginbuehl I, Marciniak B, Dalens B: Syndromes;
Rapid recognition and perioperative complications. McGraw-Hill.
First edition, p. 599.
2. Maceri DR, Saxon KG: Neurofibromatosis of the head and neck.
Head Neck Surg; 1984, 6(4):842-50.
3. Boiselle PM, Ernest A: Recent advances in central airway imaging.
Chest; 2002, 121:1651-60.
4. REMY-JARDIN M, REMY J, ARTAUD D, Et Al: Volume rendering
of the tracheobronchial tree: clinical evaluation of bronchographic
images. Radiology; 1998, 208:761–70.
5. Summers RM, Shaw DJ, Shelhamer, JH: CT virtual bronchoscopy of
simulated endobronchial lesions: effect of scanning, reconstruction,
and display settings and potential pitfalls. AJR Am J Roentgenol;
1998, 170:947-950.
6. HOPE H, DINKEL H-P, WALDER B, et al: Grading airway
stenosis down to the segmental level using virtual bronchoscopy.
Chest; 2004, 125:704-11.
7. Taha MS, Mostafa BE, Fahmy M, Ghaffar MK, Ghany EA:
Spiral CT virtual bronchoscopy with multiplanar reformatting in
the evaluation of post-intubation tracheal stenosis: comparison
between endoscopic, radiological and surgical findings. Eur Arch
Otorhinolaryngol; 2009, 266(6):863-6.
8. Walshe P, Hamilton S, Mcshane D, Mcconn Walsh R, Walsh MA,
Timon C: The potential of virtual laryngoscopy in the assessment of
vocal cord lesions. Clin Otolaryngol Allied Sci; 2002, 27(2):98-100.
9. Carretta A, Melloni G, Ciriaco P, Libretti L, Casiraghi M,
Bandiera A, Zannini P: Preoperative assessment in patients with
postintubation tracheal stenosis: Rigid and flexible bronchoscopy
versus spiral CT scan with multiplanar reconstructions. Surg
Endosc; 2006, 20(6):905-8.
10.Heyer CM, Nuesslein TG, Jung D, Peters SA, Lemburg SP, Rieger
CH, Nicolas V: Tracheobronchial anomalies and stenoses: detection
with low-dose multidetector CT with virtual tracheobronchoscopy-comparison with flexible tracheobronchoscopy. Radiology; 2007,
242(2):542-9.
11.Berdon WE: Rings, slings, and other things: vascular compression
of the infant trachea updated from the midcentury to the millennium-the legacy of Robert E. Gross, MD, and Edward B. D. Neuhauser,
MD. Radiology; 2000, 216(3):624-632.
12.Wood RE: Evaluation of the upper airway in children. Curr Opin
Pediatr; 2008, 20(3):266-71.
SPONTANEOUS INTRACRANIAL HYPOTENSION
IN A PATIENT WITH MARFAN’S SYNDROME
TREATED WITH EPIDURAL BLOOD PATCH
- A Case Report -
Samad Khalid*, Punshi Gurmukh Das**,
Hamid Mohammad*** and Ullah Hameed****
Summary
Spontaneous intracranial hypotension (SIH) is a well-defined clinical entity that is frequently
misdiagnosed. We are reporting a case of 38 years old male who presented with severe headache
and an episode of generalized tonic-clonic seizure. He was managed successfully with an epidural
blood patch. Understanding of the characteristics, symptomatology, evaluation, treatment options,
and prognosis is discussed.
Key words: Epidural blood patch, Spontaneous intracranial hypotension, Marfan’s syndrome
Attribution
The manuscript and the work are attributed to the Department of Anaesthesia and Intensive
Care, Aga Khan University, Karachi, Pakistan
Sources of Financial Support
All the resources required for the preparation of the manuscript are provided by the Department
of Anaesthesia and Intensive Care, The Aga Khan University, Karachi, Pakistan
Introduction
Clinical syndrome of spontaneous intracranial hypotension (SIH) characterized by low
cerebrospinal fluid (CSF) pressure with no apparent history of dural puncture or trauma was first
described by Schaltenbrand in 19381. The clinical hallmark of SIH is the presence of orthostatic
headache which may be associated with neck pain, nausea, vomiting, diplopia, blurred vision, and
distorted hearing2.
*
**
Assistant Professor and Consultant, Department of Anaesthesia and Intensive Care, Aga Khan University.
Assistant Anesthesiologist, Anesthesiology Department, King Faisal Specialist Hospital & Research Centre, Kingdom of
Saudi Arabia.
*** Associate Professor and Consultant, Department of Anaesthesia and Intensive Care, Aga Khan University.
**** Associate Professor and Consultant, Department of Anaesthesia and Intensive Care, Aga Khan University.
Corresponding author: Khalid Samad, Assistant Professor and Consultant, Department of Anaesthesia and Intensive
Care, Aga Khan University, P.O. Box 3500, Stadium Road, Karachi-74800, Pakistan, Phone: (92) 21 34864624, Fax: (92)
21 3493-4294, 3493-5095. E-mail: [email protected]
635
M.E.J. ANESTH 21 (4), 2012
636
SIH results from spontaneous leakage of spinal
CSF, presumably due to the weakness in the spinal
meninges but the exact cause remains unknown3. In
some cases there may be history of a trivial traumatic
event. Meningeal diverticula and SIH have been
described in several connective tissue disorders such
as autosomal dominant polycystic kidney disease4,
Marfan’s syndrome5, etc.
We are presenting a case of SIH, relevant
diagnostic and therapeutic interventions are discussed.
Case
A 38-yr-old male, known case of Marfan’s
syndrome, presented in the Emergency Room (ER)
with positional headache since 15 days unresponsive
to oral analgesic, neck stiffness and an episode of
generalized tonic-clonic seizure. His past history
included aortic valve and aortic root replacement (for
which he was on warfarin) and transient ischemic
attack. His examination was unremarkable without any
neurological deficit. Routine laboratory investigations
were also within normal limits except for prolonged
prothrombin time (PT) and International Normalization
Ratio (INR), which was 1.56.
Magnetic Resonance Imaging (MRI) of brain
and spine showed bilateral small subdural hematomas
and cerebral tonsils pointing inferiorly with signs
of patchy meningitis. MRI myelogram of the spine
showed expansion of thecal sac in lumbosacral region
with multiple outpouchings arising at the level of 1st,
2nd and 3rd sacral vertebrae (dural ectasia). Fluid was
seen adjacent to posterior paraspinal muscles in the
lumbosacral region with no definite leaking tract. In
view of the above findings, a diagnosis of spontaneous
dural tear leading to CSF leak with SIH was made.
Acute pain management service (APMS) was consulted
for lumbar epidural blood patch as symptoms were not
improving with conservative management. Lumbar
epidural blood patch was successfully performed
at L4-5 interspace under all aseptic measures using
a 16G Tuohy needle (Portex® Epidural minipack
Smiths Medical International ASD, Inc. Keene, USA.)
with 18ml of autologous blood. Patient remained
hemodynamically stable throughout the procedure.
Pain was moderately relieved immediately after the
procedure and after 48 hours of follow-up there was
S. Khalid et al.
complete pain relief without any neurological deficit.
Discussion
Once considered an exceedingly rare disorder,
recent evidence suggests that SIH should be considered
in the differential diagnosis of new persistent
headaches, particularly among young and middle-aged
individuals. In an emergency department based study
the incidence was found to be five per 100,0006. SIH
usually results from spontaneous leakage of spinal
CSF but the exact cause is unknown. SIH is commonly
associated with spinal meningeal weakness secondary
to an underlying connective tissue disorder and in about
one third of the patients, a history of trivial traumatic
event is also present suggesting a role of mechanical
factor as well7.
The clinical hallmark of intracranial hypotension
is the presence of orthostatic headache which occurs
or worsens in less than 15 minutes after assuming
the upright position, and disappears or improves in
less than 30 minutes after resuming the recumbent
position7. Neck stiffness, tinnitus,
hypoacusis,
photophobia, nausea are the other common symptoms
and suggest meningeal irritation. Schievink described
criteria for the diagnosis of CSF leaks and intracranial
hypotension that rely on both well-established
radiographic and clinical findings8.
MRI of the head has proven to be an extremely
useful investigation that confidently diagnoses SIH.
Characteristic features of SIH include subdural fluid
collection, enhancement of the pachymeninges,
engorgement of venous structures, pituitary hyperemia
and sagging of the brain9.
Computed tomography (CT) scan, although not
as conclusive as MRI, can also be a useful investigation
in emergency setting. It can demonstrate collection of
fluid in the subdural space, herniation of cerebellar
tonsils, collapse of cerebral ventricles and obliteration
of the subarachnoid cisterns10.
It would be ideal to visualize the site of CSF leak
but this is not possible in majority of cases even with
an MRI of spine. It may, however, show signs of SIH
which might include dilatation of veins in epidural
and/or intradural space, enhancement of duramater,
meningeal diverticula and CSF collection in the
SPONTANEOUS INTRACRANIAL HYPOTENSION IN A PATIENT WITH MARFAN’S SYNDROME TREATED WITH
EPIDURAL BLOOD PATCH
extrathecal and retrospinal spaces. In some cases,
MR myelogram, in contrast to conventional MRI may
localize the CSF leak11.
If spinal puncture is performed, the CSF opening
pressure is typically less than 6 cms of H2O (reference
range, 6.5-19.5 cms of H2O) but can be immeasurable
or even negative. However, some patients have
consistently normal CSF opening pressures3.
Most cases of SIH are self-limiting and respond
well to bed rest, aggressive oral hydration, caffeine
and glucocorticoids, or mineralocorticoids9.
The mainstay of treatment for SIH is the injection
of autologous blood into the spinal epidural space, the
so-called epidural blood patch12. This is believed to
seal the leak by temponading the dura and is effective
637
in providing immediate symptomatic relief in about
one third of patients9. In patients where the epidural
blood patch provides temporary or incomplete relief,
a second blood patch can be performed. In cases of
complete failure, fibrin glue or surgical repair is
indicated9.
Symptoms associated with SIH can be
debilitating if timely action is not taken and can lead
to brain herniation. Early diagnosis with appropriate
management is an important aspect of SIH. Clinical
features and radiographic findings can vary, with
diagnosis largely depending on clinical suspicion,
MRI and myelography. Multiple options for the
treatment are available but with limited evidence for
their effectiveness. Much is needed to be learnt about
SIH to provide better care to patients with this disorder.
M.E.J. ANESTH 21 (4), 2012
638
S. Khalid et al.
References
1.Schaltenbrand G: Neure anshaungun zur pathophysiologie der
liquorzirkulation. Zentrabl Neurochir; 1938, 3:290-300.
2. Headache Classification Committee of the International Headache
Society: Classification and diagnostic criteria for headache disorders,
cranial neuralgias and facial pain. Cephalalgia; 1988, 8:1-96.
3.Schievink WI, Meyer FB, Atkinson JLD, Mokri B: Spontaneous
spinal cerebrospinal fluid leaks and intracranial hypotension. J
Neurosurg; 1996, 84:598-605.
4. Schievink Wi, Torres VE: Spinal meningeal diverticula in autosomal
dominant polycystic kidney disease. Lancet; 1997, 349:1223-1224.
5.Davenport RJ, Chataway SJ, Warlow CP: Spontaneous intracranial
hypotension from a CSF leak in a patient with Marfan's syndrome. J
Neurol Neurosurg Psychiatry; 1995, 59:516-519.
6. Schievink WI, Maya MM, Moser F, Tourje J, Torbati J, Torbati S:
Frequency of spontaneous intracranial hypotension in the emergency
department. J Headache Pain; 2007, 8:325-8.
7.Schievink WI: Spontaneous spinal cerebrospinal fluid leaks: a
review. Neurosurg Focus; 2000, 15:9(1):e8.
8. Schievink WI, Maya MM, Louy C, Moser FG, Tourje J: Diagnostic
criteria for spontaneous spinal CSF leaks and intracranial
hypotension. AJNR Am J Neuroradiol; 2008, 29:853-6.
9. Schievink WI: Spontaneous spinal cerebrospinal fluid leaks.
Cephalalgia; 2008, 28:1347-1356.
10.Schievink WI, Maya MM, Tourje J, Moser FG: Pseudo-subarachnoid
hemorrhage: a CT-finding in spontaneous intracranial hypotension.
Neurology; 2005, 65:135-7.
11.Katramados A, Patel SC, Mitsias PD: Non-invasive magnetic
resonance myelography in spontaneous intracranial hypotension.
Cephalalgia; 2006, 26:1160-4.
12.Berroir S, Loisel B, Ducros A, Boukobza M, Tzourio C, Valade D,
Bousser MG: Early epidural blood patch in spontaneous intracranial
hypotension. Neurology; 2004, 63:1950-1951.
The Laryngeal Mask Airway
for Difficult Airway in
Temporomandibular Joint
Ankylosis
- A Case Report-
Behzad Ahsan**, Ghazal Kamali*
and K arim N esseri ***
Abstract
Patients with Temporomandibular Joint Ankylosis are among difficult airways and anesthesia
and airway management of these patients encounter anesthesiologists with challenge. Herein we
report a case of Temporomandibular Joint Ankylosis with difficult ventilation after failed attempts
to intubate with fibroptic broncoscopy a disposable Laryngeal Mask Airway reestablishes the
ventilation. The case suggests that the disposable Laryngeal Mask Airway may be useful in airway
management of patients with a Temporomandibular Joint Ankylosis.
Key Words: Teporomandibular joint ankylosis, airway management, Disposable Laryngeal
Mask
Introduction
Temporomandibular joint (TMJ) ankylosis is a condition that may cause chewing, digestion,
speech, esthetic, hygienic and psychological disorders1,2 in general. Different factors may cause TMJ
ankylosis. Trauma and infection are among the most common etiological factors of TMJ2. Other
less common causes include local and systemic inflammatory conditions (rheumatoid arthritis,
psoriatic arthritis, ankylosing spondylitis)3, neoplasms, measles, pseudoankylosis, and unknown1,4.
Airway management of TMJ ankylosis makes a specific challenge for anesthsiologistes in general
anesthesia. They have limited mouth opening and laryngoscopy and intubations may be difficult
or impossible. Atrophy of jaw muscles specially in geriatric patients add to these problem and may
cause additional ventilation difficulty. We report the successful airway management of a difficult
ventilation and intubation patient due to TMJ ankylosis by insertion of the disposable LMA Solus
without tracheal intubation.
Case Report
A 75-year-old man was admitted by the ophthalmic service because of penetrating eye
trauma. He had a history of trismus for 15 year. Since the patient had no cooperation, and refused
a local anesthesia, the ophtalmologist requested general anesthesia. He was edentulous, and
*
**
***
Department of Anesthesia, faculty of medicine, Kurdistan University of Medical Sciences, sanandaj, Iran.
Department of ophtalemology, faculty of medicine, Kurdistan University of Medical Sciences, sanandaj, Iran.
Department of Anesthesia, faculty of medicine, Kurdistan University of Medical Sciences, sanandaj, Iran.
Corresponding author: Karim Nasseri, Department of anesthesia, Beasat Hospital, Keshavarz St, Sanandaj, Kurdistan
state, Iran., Tel: 00988716660733, Fax: 00988713285890. E-mail: [email protected]
639
M.E.J. ANESTH 21 (4), 2012
640
his exam was notable for a limited mouth opening
(maximum intergum distance in midline 10 mm), and
nasal septum deviation. His Mallampati classification
was impossible to elicit (Fig. 1). Physical findings
included bilateral deformity of ankle and wrest joints,
and restricted cervical motion. The lateral face x ray
showed sclerosis of TMJ. (Fig. 2 and 3) All other
routine investigations were unremarkable. We planned
to insert tracheal tube guided by fibroptic broncoscope.
After the monitoring of ECG, SpO2, and noninvasive
blood pressure, the patient was preoxygenated with
100% O2. He underwent intravenous induction
with 100 μg fentanyl, 3 mg midazolam, and 120 mg
propofol. Naloxone and flumazenil were prepared for
the potential development of cannot ventilate, cannot
intubate. Face mask ventilation with an oral airway
was rather difficult because of the patient’s restricted
neck extension, and toothless condition. Direct
laryngoscopy was avoided. After good oxygenation,
Oral fibreoptic bronchoscopy was attempted with no
visualization of the glottis aperture. While attempting
fibreoptic bronchoscopy, the patient’s SpO2 decreased
to fewer than 40%, face mask ventilation again was
initiated. After unsuccessful attempts to oxygenation
we inserted a size 3 disposable LMA Solus and correct
placement was confirmed by increasing SpO2, and
capnography. It was decided to precede surgery with
the patient breathing spontaneously through the LMA.
Oxygen saturation was maintained 92-96% throughout
the procedure. The procedure and post-operative
recovery was uneventful.
Fig. 1
A 75-year-old men with an intergam distance of 10 mm
B. Ahsan et al.
Discussion
Temporomandibular joint (TMJ) ankylosis
advocate a serious problem for airway management3.
Our patient had TMJ ankylosis because of which he had
restricted mouth opening making direct laryngoscopy
impossible. In difficult situations the options for
securing airway are: fiberoptic bronchoscopy (FOB),
intubating laryngeal mask airway, intubation using
lighted stylet and tracheostomy5. Although FOB is a
gold standard for securing airway in these patients, but
it was unsuccessful because of restricted patient’s head
extension, and limitation to use nasal path. Second
steep was using LMA.
The LMA that was introduced in 1988 is an
alternative to endotracheal intubation for certain
routine anesthetics and is an adjunct in emergency
airway management. Regardless of the shape, size,
and manufacture the LMAs are essentially two large
groups, those with epiglottic bars (ventilating LMA),
and those with open distal end intubating LMA. The
LMA does not necessitate direct laryngoscopy for
Fig. 2
Lift lateral face x ray showed TMJ sclerosis
The Laryngeal Mask Airway for Difficult Airway in Temporomandibular Joint Ankylosis
insertion and, therefore be placed quickly. The LMA
also could restrict the airway trauma occasionally
caused by instrumentation with rigid laryngoscopes6,
supplies adequate ventilation, and can be used as
a channel for tracheal intubation7. The intubating
LMA is a useful apparatus for managing patients with
difficult airways and can be particularly useful where
FOB is impossible8. In the operating room, insertion,
and intubation success rate is close to 100% and 90%
respectively, whether difficult intubation is predicted
or not9.
641
Fig. 3
Right lateral face x ray showed TMJ sclerosis
The two available LMA in our operating room
are classic and Solus. We use the Solus (Intersurgical,
Ltd), which is an potentially intubating LMA. The
Solus LMA has the same sizes and design as the other
LMAs, but it has a harder cuff, and needed more
attempts to be inserted than did the other disposable
LMAs10. We insert this LMA correctly in first attempt
and does not try again for intubation through that,
because the oxygenation of the patient was good and
the duration of the surgery were short.
We used combination of low dose midazolam,
fentanyle, and propofol for induction of anesthesia
without muscle relaxants. These combinations result
in a good condition for ventilation, and prevent
unexpected effects of muscle relaxants11.
In conclusion, the LMA Solus allowed optimal
ventilation in patients with a difficult airway. We
suggest utility of the LMAs in situation that securing
airway by FOB isn't possible.
M.E.J. ANESTH 21 (4), 2012
642
B. Ahsan et al.
References
1.Su-Gwan K: Treatment of temporomandibular joint ankylosis with
temporalis muscle and fascia flap. Int J Oral Maxillofac Surg; 2001,
30(3):189-93.
2.Chidzonga MM: Temporomandibular joint ankylosis: review of
thirty two cases. Br J Oral Maxillofac Surg; 1999, 37(2):123-6.
3.Vas L, Sawant P: A review of anaesthetic technique in 15 paediatric
patients with temporomandibular joint ankylosis. Paediatr Anaesth;
2001, 11(2):237-44.
4.Erdem E, Alkan A: The use of acrylic marbles for interposition
arthroplasty in the treatment of temporomandibular joint ankylosis:
follow up of 47 cases. Int J Oral Maxillofac Surg; 2001, 30(1):32-6.
5. Jain M, Gupta A, Garg M, Rastogi B, Chauhan H: Innovaive
lighted stylet-Succeeds Where Conventional Lighted Stylet Fails.
Middle East J Anesthesiol; 2009, 20(3):447-50.
6.Benumof IL: Larvnneal mask airwav and the ASA difficult airway
algorithm: Alesthesiology; 1996, 84:686-99.
7.Brain AI, Verghese C, Addy EV, Kapila A: The intubating laryngeal
mask. I: development of a new device for intubation of the trachea.
Br J Anaesth; 1997, 79(6):699-703.
8.Joo HS, Kapoor S, Rose DK, Naik VN: The Intubating Laryngeal
Mask Airway After Induction of General Anesthesia Versus Awake
Fiberoptic Intubation in Patients with Difficult Airways. Anesth
Analg; 2001, 92(5):1342-6.
9.Ferson DZ, Rosenblatt WH, Johansen MJ, Osborn I, Ovassapian
A: Use of the intubating LMA-Fastrach in 254 patients with difficult
to manage airways. Anesthesiology; 2001, 95(5):1175-81.
10.M López, Ricard Valero, Paula Bovaira, Montserrat Pons,
Xavier Sala-Blanch, Teresa Anglada: A clinical evaluation of four
disposable laryngeal masks in adult patients. Ana Journal of Clinical
Anesthesia; 2008, 20:514-520.
11.Nasseri K, Tayebi-Arastheh M, Shami S: Pretreatment with
remifentanil is associated with less succinylcholine-induced
fasciculation. MEJ ANESTH; 2010, 20(4):515-19.
Skin Rash as Early Presentation
*
of Guillain–Barré syndrome
Daher Rabadi, Ahmad Abu Baker
and Ayman G reize
Abstract
We report an unusual case of Guillain-Barre syndrome in a 36-year old gentleman, diagnosed
based on clinical presentation, CSF analysis and nerve study tests findings, who presented to our
department for elective cystoscopy and discovered at the day of surgery to have macular skin
rash over the trunk and upper limbs, surgery was postponed. Then and after 12 hours he started to
develop the classical manifestations of Guillain-Barre syndrome. Asymptomatic skin rash should
carefully be investigated as it could be an early presentation of a serious condition.
Key words: Skin Rash, Syndrome, Surgery, Anesthesia, Paralysis.
Introduction
Guillain-Barré syndrome (GBS) is an acute inflammatory demyelinating polyneuropathy
disorderthat affects the peripheral nervous system usually triggered by an acute infection. The
most characteristic symptom is ascending paralysis, weakness beginning in the feet and hands
and migrating towards the trunk. It can cause life-threatening complications, particularly if the
breathing muscles are affected or if there is dysfunction of the autonomic nervous system1.
Skin rash has been reported as possible manifestations during the course of the disease but not
as the first presenting symptoms1,2. We herein reported a rare case of GBS where skin rash was the
earliest clinical presenting symptoms.
Case Report
A 36 year old healthy gentleman admitted to our hospital with left sided colicky loin pain,
dysuria and urinary urgency. His review of symptoms, past medical history and drug history were
within normal except for mild sore throat of 3 day duration. His physical examination was within
normal except for tenderness over the costophrenic angle. Urine analysis showed 2-4 WBC, 2-3
RBC and yellowish discoloration. Other laboratory tests were within normal range except for high
ESR and creatinine. He was scheduled for elective cystoscopy to extract urinary tract stone.
At the day of surgery the patient developed generalized erythematous macuopapula nonscalyl rash over his back, chest andupper arms, Figure 1, numbness in his hands, and minimal upper
extremities weakness. The surgery was cancelled for further evaluation of these symptoms. Twenty
four hours later the patient developed ascending muscle weakness and shortness of breath. He
transferred to the ICU for closed neurological and respiratory monitoring. Lumbar puncture showed:
*
Department of Anesthesiology, Jordan University of Science & Technology, Irbed, Jordan.
Corresponding author: Daher Rabadi, Assistant Professor and anesthesiology consultant, Department of Anesthesiology,
Jordan University of Science & Technology, P.O. Box: 3030, Irbed (22110), Jordan. Tel: 0096 2 79 9051003, Fax: 00962
2 720062. E-mail: [email protected]
643
M.E.J. ANESTH 21 (4), 2012
644
D. Rabadi et al.
albumin-cytological dissociation, elevated protein
level, and increased white blood cell count.Nerve
conduction studies revealed prolongation of the upper
and lower motor action potential latencies, reduced
motor conduction velocities and reduced amplitude.
Median and ulnar nerves sensory action potentials
were absent. The diagnosis of GBS was reached and
he was started on intravenous Immunoglobulin 400
mg/kg, Gababintin 300 mg twice a day and Clexan 40
mg once daily.
Fig. 1
Erythematous maculopapular Rash over the chest
Patient’s level of consciousness and respiratory
status deteriorated on the next day, he was Intubated and
ventilated with mechanical ventilator. Unfortunately
6-days post intubation he died after he developed acute
adult respiratory syndrome secondary to generalized
sepsis.
Discussion
GBS
is
an
acute
immune-mediated
polyneuropathy caused by infection, inflammation,
tumors, medications, vaccines and surgery with
incidence worldwide of 0.6–4/100,000 persons/year.
Up to two thirds of patients report an antecedent
bacterial or viral illness prior to the onset of neurologic
symptoms with Campylobacter jejuni being the most
commonly isolated pathogen3,4.
Gastrointestinal and upper respiratory tract
symptoms can be observed with Campylobacter
jejuni infections. Campylobacter jejuni infections can
also have a subclinical course, resulting in patients with
no reported infectious symptoms prior to development
of GBS. Patients who develop GBS following an
antecedent Campylobacter jejuni infection often
have a more severe course, with rapid progression and
a prolonged, incomplete recovery as we believe in our
case.
A strong clinical association has been noted
between Campylobacter jejuni infections and the
pure motor and axonal forms of GBS. The virulence
of Campylobacter jejuni is thought to result from the
presence of specific antigens in its capsule that are
shared with nerves. Immune responses directed against
capsular lipopolysaccharides produce antibodies that
cross-react with myelin to cause demyelination5.
We didn’t measured patient’s serum autoantibodies
because of the rapid progression of the condition and
the strongly positive laboratory diagnostic tests.
In Summary we presented a patient with acute
fulminant neuropathy which showed characteristic
features of GBS, strongly suggested by the rapid
progression of symptoms over hours and supported
by nerve conduction studies as well as CSF analysis
who had maculopapular skin rash before developing
neurological symptoms. We also stress the importance
of carful and thourghly evaluating patient with skin
rash before general anesthesia which might render
serious medical problems.
Skin Rash as Early Presentation of Guillain–Barré syndrome
645
References
1. Hahn AF: The Guillain-Barré syndrome. Lancet; 1998, 352:635641.
2. Miller RG: Guillain-Barré syndrome. Current methods of diagnosis
and treatment. Postgrad Med; 1985, 77:62-4.
3. Jacobs BC, Rothbarth PH, Van Der Meché FG, Herbrink P, Schmitz
PI, De Klerk MA, et al: The spectrum of antecedent infections in
Guillain-Barré syndrome: a case-control study. Neurology; 1998,
51:1110-5.
4. Van Der Meché FG, Visser LH, Jacobs BC, Endtz HP, Meulstee
J, Van Doorn PA: Guillain-Barré syndrome: multifactorial
mechanisms versus defined subgroups. J Infect Dis; 1997, 176:S99102.
5. Rees JH, Gregson NA, Hughes RA: Anti-ganglioside GM1
antibodies in Guillain-Barré syndrome and their relationship to
Campylobacter jejuni infection. Ann Neurol; 1995, 38:809-16.
M.E.J. ANESTH 21 (4), 2012
Airway management in Submandibular
abscess patient with Awake
Fibreoptic Intubation
- A Case Report -
Chetan B. Raval* and Mohd. Suleiman Khan**
Abstract
Securing the airway is a core skill in anaesthesia, the gold standard of which is tracheal
intubation. Normally this is achieved after induction of anaesthesia. However, some circumstances
demand an awake approach. Skilful airway management is critical in deep neck space infections.
There is currently no universal agreement on the ideal method of airway control for these patients
because this depends on various factors including available local expertise and equipment.
Compromised airway is still a challenge to the anesthesiologist in spite of all modalities available.
Any flaw in airway management may lead to grave morbidity and mortality.
We present a morbidly obese case of submandibular abscess with difficult intubation
underwent incision and drainage. Large facial [jaw] swelling, TRISMUS-limited mouth opening,
edema, protruding teeth and altered airway anatomy makes airway management more difficult.
The case was further complicated by morbid obesity. Chances of rupture of abscess intraorally and
aspiration under GA is a major threat. During GA, there is no change in mouth opening and loss of
airway under muscle relaxation, “difficult to ventilate, difficult to intubate” makes these cases most
challenging. On the basis of our experience case was successfully intubated by awake fibreoptic
intubation.
Key words: Difficult Airway, submandibular abscess, Trismus, Awake fibreoptic intubation
Introduction
Airway management is a critical part of anesthesia practice, especially in patients with deep
neck infections. A cause of death in these patients with difficult intubation is the acute loss of the
airway during interventions to control it1. Deep neck infections are formed from the untreated dental
caries. Infection spreads in the bone and submandibular, sub mental, retropharyngeal or lateral
pharyngeal spaces. Advance cases of abscess formations lead to restricted temporomandibular
joint mobility with Trismus and pharyngeal, laryngeal edema causes narrowing and eventually to
the loss of airway2.
*
**
Specialist, Department of Anesthesia, Al-Nahdha Hospital, P.O. Box: 937, PC: 112, Ruwi, Muscat, Oman.
Junior Specialist, Department of Anesthesia, Al-Nahdha Hospital, P. O. Box: 937, PC: 112, Ruwi, Muscat, Oman.
Corresponding author: Dr. Chetan B. Raval, Department of Anesthesia, SICU, TICU, Hamad Medical Corporation,
P.O. BOX: 3050, DOHA, QATAR.
647
M.E.J. ANESTH 21 (4), 2012
648
C. B. Raval et al.
The American Association of Anesthesiologists
(ASA) developed guidelines for the management of
the difficult airway focus on strategies for intubation as
well as alternative airway techniques that can be used
when a patient with a difficult airway is encountered4,5,
but careful planning and preparation, can reduce the
potential for complications.
Fig. 2
Lateral view
We present a case of Ludwig’s angina with
trismus, limited mouth opening, marked neck swelling
and how the airway was secured for surgery.
Case Report
A 40 year old female patient was referred to AlNahdha hospital which is a tertiary referral hospital
for maxillofacial surgeries, with complaints of fever,
progressive facial swelling with TRISMUS-restricted
mouth opening, redness, severe pain and dysphagia
since 1week. Patient was scheduled for emergency
incision and drainage. Patient’s weight was 112.5
kg and height 150 cms with BMI 49.9. On medical
history, she was known case of hypertension on regular
treatment since 2 years. No other significant cardiac,
surgical or allergic history was noted. On general
examination, fever and high blood pressure once on
admission was noted. Other readings after admission
were under control. Airway examination revealed
mouth opening (inter-incisor Gap-Fig. 1) was less
than one cm with protruding teeth and short neck with
huge breast (Fig. 2). Mento-thyroid distance was less
than six cm. Neck movements were adequate. Nasal
patency was checked and found adequate. Systemic
examination, blood investigations, ECG and Chest
X-ray were within normal limits.
Fig. 1
Front view
Looking at clinical airway examination and
morbid obesity, we planned awake fibreoptic
intubation with sedation with possibility of emergency
tracheostomy and consent was taken. Detailed
information about awake fibreoptic techniques with
methods of local anaesthesia were explained. ENT
surgeon was asked to remain standby in the theatre
for possible need of emergency tracheostomy. Patient
was pre-medicated with IM pethidine 100 mg and
glycopyrrolate 0.2 mg half an hour before surgery.
Topical anesthesia was achieved by nasal packing with
Lignocaine 4% and xylometazoline 0.1%. Pharynx
was sprayed with 4-6 puffs of lidocaine 10% aerosol.
Routine monitoring was used. Difficult intubation cart
was kept ready.
Tracheal mucosa was anaesthetized through cricothyroid injection of 2 ml 2% lignocaine after aspiration
of air. Sedation was supplemented with remifentanil
i.v infusion (titrated dose) in a dose of 0.03 mcg/kg/
min. Topical anesthesia of the larynx and trachea
was supplimented via “Spray as-you-go” technique
through the suction channel of the bronchoscope using
injections of 2 ml of lignocaine 4%. Advancement
of the fiberscope was withheld for 1 minute to allow
for the drug’s anaesthetic effect. Portex endotracheal
tube was railroaded on to the well-lubricated Karl
Storz Fiberscope (Karl Storz, Germany) (Fig. 3, 4,
5). When the scope passed through the larynx, the
endotracheal tube was advanced into the larynx till the
carina was seen. The bronchoscope was removed with
confirmation of ET tube in the trachea by visualization
of the chest movement, auscultation of breath sounds
and ETCO2 monitoring.
Airway management in Submandibular abscess patient with Awake Fibreoptic Intubation
Fig. 3
Procedure
Fig. 4
Procedure
Fig. 5
Intubated patient
After securing airway, general anesthesia was
achieved with propofol 2.5 mg/kg and atracurium 0.5
mg/kg. Anesthesia was maintained with sevolfurane,
N2O in O2. Analgesia was supplemented with
remifentanil titrated infusion. Anesthesia was reversed
at the end of surgery with Neostigmine 50 mcg/kg
and glycopyrrolate 0.4mg administered intravenously.
Extubation was carried out with smooth emergence and
patients in fully awake state, breathing spontaneously,
obeying commands and satisfactory muscle power.
Post operative analgesia provided with Diclofenac
1mg/kg IM 20 min. before extubation. Post-operative
care was given in the high dependency unit.
649
Discussion
Ludwig’s angina originates from an infected or
recently extracted tooth, most commonly the lower
second and third molars. It is rapidly progressive,
potentially fulminant cellulitis involving the sublingual, sub-mental, and sub-mandibular spaces1,2. It
begins as a mild infection and can rapidly progress to
brawny bilateral induration of the upper neck with pain,
trismus, and tongue elevation. Fever and dysphagia are
common. The most serious complication of Ludwig's
angina is asphyxia caused by expanding edema of
soft tissues of the neck3. Medical management with
antibiotics, improved dental care and dexamethasone
in the early stages of the disease has minimized the
need for surgical intervention to control the airway1-3.
But if swelling is too big and spreading fast then
surgical intervention is needed as early as possible.
Airway management of patients with Ludwig’s
angina presenting for surgical drainage is a
challenging task for the anaesthesiologist. There is
no consensus regarding the airway management in
the available literature. The recommendations are
based on the anaesthesiologist’s personal experience
and available resources. The suggested methods
include tracheostomy, conventional laryngoscopy and
intubation (after administration of muscle relaxant),
awake blind nasal intubation and awake fibreoptic
intubation.
Difficult airway management is a dilemma for
any anesthesiologist. Although practice guidelines
and algorithms may help in such situations, the
anesthesiologist's judgment and vigilance remain
the primary means to save lives4,5. Common cause of
death is the acute loss of airway during interventions
to control the condition. Limited access to mouth,
edema, distorted anatomy, tissue immobility makes
oro-tracheal intubation with rigid laryngoscopy very
difficult2,6. In the early stages of the disease, general
anesthesia may overcome trismus and allow the mouth
to be opened for rigid laryngoscopy; it is like the tip
of the iceberg2. Under anesthesia, a potentially lifethreatening condition as rupture of abscess can result
in pulmonary aspiration and in inability to secure the
airway due to blood, pus and secretions. In advanced
cases, induction of general anesthesia is dangerous
because this may precipitate complete airway closure
M.E.J. ANESTH 21 (4), 2012
650
and make mask ventilation and intubation impossible7.
Securing of the airway in the awake state is therefore
the safest option. The surgical airway should always
be kept ready which can be lifesaving in such
circumstances.
Blind Nasal intubation is a simple technique with
two major drawbacks: infrequent success on the first
pass and increased trauma with repeated attempts,
precipitating complete airway obstruction that
necessitates emergent cricothyrotomy1,2,8. Classically,
tracheostomy was considered as the standard of care
for establishment of a definitive airway. Elective awake
tracheostomy has been suggested for all patients with
deep neck infections in order to avoid the dangers of
emergency tracheostomy in a severely compromised
airway9.
Gruen et al10, found that failure to intubate,
secure or protect the airway was the most common
factor related to patient mortality especially in cases
of difficult airway. Single universal technique of
intubation may not be favorable in all circumstances so
timely, decisive and skillful management of the airway
can often make the difference between life and death
or between ability and disability in such situations.
Keeping all above points in mind and as per our
experience, we selected awake fibreoptic intubation
as a method for airway management in our morbidly
obese patient. Although distorted anatomy, edema, and
secretions may contribute to difficulty with fiberoptic
intubation, in skilled and experienced hands. The
success is attributed to a well-organized approach and
expertise in flexible fiberoscopy. Flexible fiberoptic
nasal intubation is the preferred method of airway
management11,12 and has a high rate of success1- 4. Peiris
K at el13, compared awake intubation with attempts
at difficult direct laryngoscopy, awake fibreoptic
intubation provides excellent cardiovascular stability
when performed under good topical anaesthesia and
conscious sedation. Understanding the equipment
used as well as preparing the patient and being
aware of potential pitfalls are important elements to
performing a successful awake intubation. Avoiding
airway irritation and laryngeal spasm by using topical
anesthesia increases the success rate14. F.S. Xue
at el suggested that 2% topical lignocaine provide
acceptable condition, smaller doses and lesser plasma
C. B. Raval et al.
concentration for awake fibreoptic intubation15. In our
case we used 2% lignocaine for topical “spray-as- yougo”. Maximum allowable dose of Lignocaine is 4.5 mg/
kg16. Recently Awake fibrecapnic intubation (AFcI) is
a technique wherein a suction catheter is advanced
through the working channel of the bronchoscope
and via this catheter repeated CO2 measurements are
possible when visibility of pharyngeal and laryngeal
structures is limited, when anatomy is unrecognisable
or in the case of severe airway obstruction17. Opioids
and benzodiazepines increase the risk of respiratory
depression. Therefore, these drugs must be titrated
carefully. Decompression of Ludwig’s angina under
cervical block has also been reported18.
Conclusion
Single universal technique of intubation may not
be favorable in all circumstances so timely, decisive
and skillful management of the airway can often make
the difference between life and death or between
ability and disability in such situations. Sound clinical
judgment is critical for timing and for selecting the
method for airway intervention. The data suggest that
practicing fiberoptic intubation is safe and effective in
patients with difficult airway, but it requires additional
skills and practice. On the basis of our experience,
patient was successfully intubated with visual-guided
fiberoptic intubation and managed without any
complication.
Competing Interests
The authors declare that they have no competing
interests.
Consent
Written informed consent was obtained from
the patient for publication of this case report and
accompanying Figures.
Acknowledgements
We thank the patient for giving us consent for
the publication of the case report. We also thank the
Nurses and surgical team for their help.
Airway management in Submandibular abscess patient with Awake Fibreoptic Intubation
651
References
1. Ovassapian, Meltem Tuncbilek, et al: Airway management in adult
patients with deep Neck infections: a case series and review of the
literature. Anesth Analg; 2005, 100:585-9.
2. Chetan Raval, Mohd Rashiduddin: Nasal Endotracheal Intubation
under Fibreoptic endoscopic control in Difficult Oral Intubation,
two Pediatric Cases of Submandibular abscess. Oman Med J; 2009
January; 24(1):51-53.
3. Anand H Kulkarni, Swarupa D Pai, Basant Bhattarai,
et al: Ludwig's angina and airway considerations: a case report.
Cases Journal; 2008 June; 1:19doi:10.1186/1757-1626-1-19.
4.Berkow LC: Strategies for airway management. Best Pract Res Clin
Anaesthesiol; 2004 Dec; 18(4):531-48.
5. American society of Anesthesiologists Task Force on Management
of the Difficult Airway: Practice guidelines for management of
the difficult airway: an updated report by the American Society
of Anesthesiologists Task Force on Management of the Difficult
Airway. Anesthesiology; 2003; 98:1269-1277.
6.Neff SP, Merry AF, Anderson B: Airway management in Ludwig’s
angina. Anaesth Intensive Care; 1999, 27:659-661.
7.Parhiscar A, Har-EL E: Deep neck abscess. A retrospective
review of 210 cases. Ann Otol Rhinol Laryngol; 2001,
110:1051-54.
8.Saini S, Kshetrapal KK, Ahlawat G, et al: Anaesthetic challenges
in a patient with Ludwig angina: A case report. SAJAA; 2008,
14(5):10-11.
9.Barakate MS, Jensen MJ, Hemli JM, Graham AR: Ludwig's
angina: report of a case and review of management
issues. Ann Otol Rhinol Laryngol; 2001, 110:453-456.
10.Gruen RL, Jurkovich GJ, McIntyre LK, Foy HM, Maier RV:
Patterns of errors contributing to trauma mortality: lessons learned
from 2,594 deaths. Ann Surg; 2006; 244:371-380.
11.Saifeldeen K, Evans R: Ludwig's angina. Emerg Med J;
2004; 21:242-243.
12.Peter J Aquilina and Anthony Lynham: Serious sequelae of
maxillofacial infection. Medical J Australia; 2003, 179(10):551552.
13.Peiris K, Frerk C: Awake intubation. J Perioper Pract; 2008 Mar;
18(3):96-104.
14. ME Walsh, GD Shorten: Preparing to perform an awake fiberoptic
intubation. Yale J Biol Med; 1998 Nov-Dec; 71(6):537-549.
15.FS Xue, HP Liu, N He, YC Xu, QY Yang, X Liao, XZ Xu, XL
Guo and YM Zhang: Spray-As-You-Go Airway Topical
Anesthesia in Patients with a Difficult Airway: A
Randomized, Double-Blind Comparison of 2% and
4% Lidocaine. Anesth. Analg; February 2009, 108(2):536-543.
16.Nibedita P, Shovan R: Regional and topical anaesthesia of upper
airways. Indian J Anaesth; 2009, 53(60):641-648.
17.Huitink JM, Balm AJM, Keizer C, Buitelaar DR: Awake
fibrecapneic intubation in head and neck cancer patient with difficult
airway: new finding and refinement of technique. Anaesthesia;
2007, 62:214-219.
18.Mahrotra M, Mahrotra S: Decompression of Ludwig’s
Angina under cervical block. The Journal of American society of
Anaesthesilogist; 2002, 97(6):1625-6.
M.E.J. ANESTH 21 (4), 2012
Angiofibroma of the
Nasal Septum
Abdul-Latif Hamdan*, Roger V. Moukarbel**,
Mireille Kattan*** and Mohamad Natout****
Abstract
Angiofibromas originate predominantly in the nasopharynx. Extranasopharyngeal sites such
as the paranasal sinuses and nasal cavity are less frequent. Angiofibroma of the nasal septum
is extremely rare and the site of origin is either anterior, at the bony cartilaginous junction or
posterior. Clinically, patients present with recurrent epistaxis and nasal obstruction secondary to
a fleshy or polypoidal nasal mass. Computerized tomography of the nasal cavity and bilateral
carotid angiography are useful in the pre-operative work-up. The main stay of treatment is surgical
resection.
A rare case of nasal septal angiofibroma is hereby presented.
Key Words: Angiofibroma, Nose, Septum, Epistaxis, obstruction.
Introduction
Angiofibromas originate predominantly in the nasopharynx and are confined to males in their
adolescence or early childhood. They carry a significant morbidity in view of their prominent
vascularity and propensity for local growth. Pathologically they are labeled benign, yet their
aggressive destructive behavior carries a potential risk. The lesion is composed of fibrous tissue
interspersed to a variable degree with endothelium lined vascular spaces. The most common site of
origin is the posterolateral wall of the nasopharynx, with an increasing number of cases occurring
extra nasopharyngeal1. Angiofibromas of the nasal cavity are extremely rare, more so of the nasal
septum. A case report of angiofibroma of the nasal septum is presented with a review of the clinical
presentation, diagnosis and modes of treatment.
Case Report
A 19 years old male presented to the Emergency room at the American University of Beirut
Medical Center with history of right nasal obstruction and recurrent epistaxis of few weeks
duration. Patient denied any history of nasal discharge, postnasal drip, facial numbness or pain.
Anterior rhinoscopy revealed a right ulcerative nasal mass, well circumscribed filling the right
nasal cavity (figure 1). An axial and coronal Computerized Tomography of the nose and paranasal
sinuses with contrast showed a 2x1.2 cm enhancing soft tissue density in the anterior aspect of the
right nasal cavity adherent to the nasal mucosa with no evidence of extension into the paranasal
*
Clinical Associate Professor, Department of Otolaryngology – Head & Neck Surgery, American University of Beirut
Medical Center.
**4th Year Resident, Department of Otolaryngology – Head & Neck Surgery, American University of Beirut Medical Center.
*** Associate Professor, Department of Pathology, American University of Beirut Medical Center.
****Lecturer, Department of Otolaryngology – Head & Neck Surgery, American University of Beirut Medical Center.
Corresponding author: Abdul-Latif Hamdan, American University of Beirut, Department of Otolaryngology, P.O.Box:
110236, Tel/Fax: 961-1-746660. E-mail: [email protected]
653
M.E.J. ANESTH 21 (4), 2012
654
sinuses or remodeling of the adjacent bone (figure 2).
The findings were highly suggestive of an angiomatous
polyp. Patient was taken to the operating room where
he underwent resection of this nasal mass through a
lateral rhinotomy incision. After retracting the lateral
nasal wall, the tumor was exposed and found to be
pedunculated with the base originating from the nasal
septum close to the bony cartilaginous junction. It
was totally excised deep to the perichondrium and
the defect was closed using local mucoperichondrial
flaps. Histopathologic examination revealed multiple
vascular spaces lined by endothelium and separated
by fibrous stroma. The pathologic diagnosis was
consistent with angiofibroma.
Fig. 1
A polypoidal ulcerative nasal mass well circumscribed filling
the right nasal cavity
Fig. 2
A 2 x 1, 2 cm enhancing soft tissue density in the anterior
aspect of the right nasal cavity with no evidence of erosion or
remodeling of the adjacent bony structure.
A. Hamdan ET AL.
Fig. 3
Multiple vascular spaces lined by endothelium and separated
by fibrous stroma (H & E x20)
Discussion
The histogenesis of angiofibroma varies from
being developmental to genetic. According to
Tillaux, it is believed that the tumor originates from
the fibrocartilaginous barrier of the basisphenoid or
basiocciput, also termed fascia basalis by Brunner.
This fascia extends over the roof of the nasopharynx
to the vomer, the palatal bone, the posterior ethmoid
and the medial pterygoid process2. The absence of
this fascia in other sites of the nasal cavity such as the
anterior septum and inferior turbinate has suggested
another origin for these tumors mainly the presence
of an ectopic nidus of turbinate like vascular tissue3.
The most common extra nasopharyngeal site for
an angiofibroma is the maxillary sinus followed
by the ethmoid sinuses. Angiofibromas have also
been described in the cheek, infratemporal fossae,
pterygomaxillary fissure, conjunctiva, esophagus,
larynx and trachea. They occur more commonly in
females and appear at a later age.
Angiofibromas of the nasal cavity are extremely
rare and have been reported to occur in the septum,
inferior and middle turbinates, nasal vault and roof. The
nasal septum is an extremely rare site with only five
cases being reported in the english literature4,5. There
has been no major sex or age predilection. The male to
female ratio is 2/1 with the age ranging from 8 to 50
years. The site of origin is either the anterior one third
of the nasal septum, the bony cartilaginous junction,
or the ethmoidal perpundicular plate. The clinical
Angiofibroma of the Nasal Septum
presentation may be earlier than nasopharyngeal
tumors because of the limited space of the nasal vault.
Patients usually complain of recurrent epistaxis and
nasal obstruction. Anterior rhinoscopy and/or nasal
endoscopy reveal a polypoidal or fleshy mass with a
smooth or ulcerative surface filling the anterior nasal
cavity. Computerized tomography helps you delineate
tumor extension whereas bilateral carotid angiography
is more relied upon to determine the nature of the tumor
and its blood supply1,5. The mainstay of treatment
of extranasopharyngeal angiofibroma is surgical
resection. The surgical approach is determined by the
size, location and blood supply of the tumor. Different
innovations have been described for complete excision
ranging from endoscopic approach to alotomy and
lateral rhinotomy for better exposure. The rarity of
septal angiofibromas and the lack of a staging system
make it hard to set a standard guideline for therapeutic
approaches. Recurrence is extremely rare (Table 1).
655
Table 1
Age
8-50 years
Sex
M/F 2/1
Symptoms
Epistaxis, Nasal obstruction
Nasal Findings
A fleshy or polypoidal mass with smooth /
ulcerative surface
Site of Origin
Anterior cartilaginous septum
Junction of bony cartilaginous septum
Ethmoidal perpendicular plate
R a d i o l o g i c CT scan: delineate extent of tumor
Findings
Bilateral carotid angiopathy: Define the
arterial supply
Treatment
Surgical excision: using either of the
following approaches
Endoscopy
Alotomy
Lateral Rhinotomy
References
1. Handa K, Kumar A, Singh M, Chhabra A: Extranasopharyngeal
angiofibroma arising from the nasal septum. Int J Pediatr
Otorhinolaryngol; 2001, 58:163-66.
2. Tillaux P: Traite d’anatomie topographique avec applications a la
chirurgie (ed 2). Paris, P. Asselin, 1978, 348-349.
3. Schiff M: Pathology of juvenile nasopharyngeal angiofibroma – A
lesion of adolescent males. Cancer; 1959, 7:15-28.
4. Sarpa J, Novelly N: Extranasopharyngeal angiofibroma. Otol Head
Neck Surg; 1989, 101(6):693-7.
5. Akbas Y, Anadolu Y: Extranasopharyngeal angiofibroma of the
head and neck in women. Am Jour Otolaryngol; 2003, 24(6):413-6.
M.E.J. ANESTH 21 (4), 2012
Use of deep cervical halo in
the preservation of tracheostimised
airway in prone position
Haidar Abbas*, Zia Arshad**
and J aishri B ogra ***
Dear Sir,
With great Interest we have read the case report, Intraoperative airway obstruction related to
tracheostomy tube malposition in a patient with achondroplasia and Jeune's syndrome1 but I am
of the view that the same airway could have been preserved and author’s decision of abandoning
the case in the first instance and later removing the tracheostomy tube and replacing it with an
armoured tube in the subsequent instances could have been modified, so that repeated manipulation
of airway in such cases could have been avoided and procedures could have been accomplished in
a routine manner.
With reference to this case we want to emphasize that though the authors have nicely described
the case report but the figure b shows that it is not the weight but the curvature/angle of breathing
circuit brushing to the operation theatre table which is causing the tube to block over the inner
surface of trachea. I analyze two points in this favour one that if the tracheostomised tube is sutured
to the neck as it is usually done the weight of the tube in fact will help in the making curvature of
the tube if it is in the deep cervical halo.
Although practice guidelines and algorithms may help in such situations, but the
anesthesiologist's decision and vigilance remain the primary means to manage such situation. Apart
various airway adjuncts the use of tracheostomy as an advance airway management procedure is
also widely described2.
To conclude, the airway management of tracheostomised patients in prone position can be
modified by increasing the depth of cervical halo so that airway management can be simplified and
potential trauma to the airway could be avoided.
*
**
***
Associate Professor, Department of Anesthesia, CSM Medical University, Lucknow-226003, India.
Assistant professor, Department of Anesthesia, CSM Medical University, Lucknow-226003, India.
Professor, Head of the anesthesia department, CSM Medical University, Lucknow-226003, India.
Corresponding author: Haidar Abbas, Department of Anesthesia, CSM Medical University, Lucknow-226003, India,
Tel: 0091-9335037686, Fax: 0091-522-2258866. [email protected]
657
M.E.J. ANESTH 21 (4), 2012
658
References
1.Abola RE, Tan J, Wallach D, Kier C, Seidman PA, Tobias JD:
Intraoperative airway obstruction related to tracheostomy tube
malposition in a patient with achondroplasia and Jeune's syndrome.
Middle East J Anesthesiol; 2010 Jun, 20(5):735-8.
2.Fuhrman TM, Farina RA: Elective tracheostomy for a patient with a
history of difficult intubation. J Clin Anesth; 1995 May, 7(3):250-2.
Erratum
The editorial board of the Middle East Journal of Anesthesiology and based on
the below statement from the corresponding author Dr. Zafer Dogan, is retracting
the manuscript entitled “Effects of Enflurane and Propofol on Seizure Duration
and Recovery Profiles in Electroconvulsive Therapy” that was published in the
February 2011 issue, referenced as follows:
Dogan Z, Orhan F O, Oksuz H, Senoglu N, Yildiz H and Ugur N. Effects of Enflurane
and Propofol on Seizure Durations and Recovery Profiles in Electroconvulsive
Therapy. Middle East J Anesthesiol, 21: 77- 81.
‘The corresponding and the first author (Zafer Dogan) and the journal wish
to retract the February 2011 original article entitled ‘Effects of Enflurane
and Propofol on Seizure Duration and Recovery Profiles in Electroconvulsive
Therapy.’ This decision was based on the information provided by Fatma Özlem
Orhan, one of the senior authors of this manuscript. Based on this information
the list of authors of this manuscript does not represent the actual contribution of
the authors to the preparation of the paper. The corresponding author requests
retraction of the paper in its entirety and apologizes to the reviewers, editors, and
readers of Middle East Journal of Anesthesiology for any adverse consequences
that may have resulted from the paper’s publication.
Zafer Dogan.’
659
M.E.J. ANESTH 21 (4), 2012
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