Efficacy of dexmedetomidine as an adjunct to ropivacaine in bilateral dual-transversus abdominis plane blocks in patients with ovarian cancer who underwent cytoreductive surgery

Objective We sought to evaluate the postoperative control of pain and recovery in patients with ovarian cancer who underwent cytoreductive surgery by adding dexmedetomidine to ropivacaine in bilateral dual-transversus abdominis plane (Bd-TAP) blocks. Methods We enrolled 90 patients with an American Society of Anesthesiologists physical status I to III undergoing open abdominal cytoreductive surgery in this study. Patients were randomized and assigned into three groups (TAP-R, TAP-DR, or CON) of 30 participants each. All of the patients received standardized general anesthesia, and postoperative Bd-TAP blocks were performed. The TAP-R, TAP-DR, and CON groups received Bd-TAP blocks with 0.3% ropivacaine, 0.3% ropivacaine and 0.5 μg/kg of dexmedetomidine, and 0.9% normal saline, respectively. All of the patients received patient-controlled analgesia (PCA) (formula, 100 μg of sufentanil and 16 mg of ondansetron diluted with normal saline to 100 mL). Flurbiprofen axetil was used as a rescue drug if the visual analog scale (VAS) score was more than four points. The first request time for PCA bolus; the VAS scores at 0, 6, 12, 24, and 48 h after operation; and the cumulative sufentanil consumption within 24 and 48 h, respectively, were compared. Pulmonary function was evaluated preoperatively and at 24 h after the operation. The use of the rescue drug was recorded. Postoperative functional recovery, including time to stand, time to walk, time to return of bowel function, time to readiness for discharge, and postoperative complications, were recorded. Results Median values of the first request time for PCA of the TAP-R group was significantly prolonged compared to that of the CON group (median [interquartile range], 7.3 [6.5–8.0] hours vs. 3.0 [2.3–3.5] hours) (P < .001), while the TAP-DR group has the longest request time among the three groups (median [interquartile range], 13.5 [12.4–14.5] hours) (P < .001). The VAS scores at rest and upon coughing of the TAP-R group in the first 12 h were significantly lower than those of the CON group (P < 0.05), but showed no significant difference compared to those of the TAP-DR group. The VAS scores at rest and upon coughing were lower in the TAP-DR group at each time point compared to those of the CON group (P < .05). The cumulative sufentanil consumption in the TAP-DR group was significantly lower at 48 h (P = .04) after surgery than in the CON group, while there was no significant difference compared to that in the TAP-R group (P > .05). Less rescue analgesic was required by patients in the TAP-DR group than in the CON group (P < .05). Postoperative mean measured forced expiratory volume in 1 s (FEV1) and FEV1/forced vital capacity values in the TAP-DR group were significantly higher than those of the CON group (P = .009), while there was no significant difference compared to those of the TAP-R group (P = .10). There was no significantly difference in postoperative functional recovery between TAP-DR and CON group (P > 0.05). Conclusion TAP blocks can provide effective pain relief up to 12 h postoperatively without a significant improvement in postoperative pulmonary function. The addition of dexmedetomidine to ropivacaine for Bd-TAP block prolonged the first bolus time of PCA when compared to that in the TAP-R group and decreased sufentanil consumption and the need of rescue analgesia relative to in the CON group at 48 h postoperative. The procedure provided better postoperative analgesia and improved postoperative pulmonary function relative to the CON group. Our results indicate that dexmedetomidine as an adjuvant of Bd-TAP can provide effective pain relief up to 48 h.

A comparative study of dexmedetomidine and propofol infusion during monitored anesthesia care (MAC) in endoscopic retrograde cholangiopancreatography (ERCP): a randomized controlled trial

Background Endoscopic retrograde cholangio-pancreatography (ERCP) is an invasive procedure and hence is distressing for awake patients, requiring adequate level of sedation and analgesia. Recent advancements have encouraged use of monitored anesthesia care (MAC), that allows the patient to tolerate unpleasant procedures while maintaining cardio-respiratory function. The main aim is to compare the effect of dexmedetomidine and propofol on the hemodynamics during ERCP, quality of sedation, recovery profile, and any side effects. A total of 100 patients were randomized by a computer-generated random number table into two groups of 30 patients each. The group P received continuous propofol infusion at a rate of 25-75 mcg/kg/min to achieve a Ramsay sedation scale (RSS) of 3-4 before starting the procedure. Group D received dexmedetomidine at loading dose of 1 μg/kg i.v. over 10 min followed by 0.5 μg/kg/h infusion until RSS reached 3-4. Results The present study shows significant decrease in heart rate in group D (65.27 ± 4. 3 vs.77.27 ± 9.3) with more stable blood pressure values throughout than group P. There were episodes of transient desaturation in few patients in group P while no patient showed any signs of respiratory depression or desaturation in group D. The time to achieve Ramsay sedation score (RSS) 3-4 is significantly more in group D (11.4 ± 1.37 vs. 7.93 ± 1.32) with increased tendency to use rescue drug but shows better and early recovery. Conclusion Dexmedetomidine is a better substitute to propofol for patients undergoing ERCP; however, use of adjunct may be necessary to decrease the need for rescue drug.

hole-Course Application of Dexmedetomidine Combined with Ketorolac in Nonnarcotic Postoperative Analgesia for Patients with Lung Cancer Undergoing Thoracoscopic Surgery: A Randomized Control Trial

BACKGROUND: Opioid-based postoperative analgesia provides adequate analgesia with much adverse effects and immunosuppression. Dexmedetomidine and ketorolac have properties of opioid-sparing, antiinflammation, and immune protection. OBJECTIVES: To investigate the efficacy and safety of whole-course application of dexmedetomidine combined with ketorolac in nonnarcotic postoperative analgesia and its effect on inflammatory response and immune function in thoracoscopic surgery of lung cancer. STUDY DESIGN: Double-blind, randomized control trial. SETTING: The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China. METHODS: Sixty patients scheduled for thoracoscopic surgery were enrolled and randomly divided into 2 groups to receive a combination of intraoperative usage of dexmedetomidine and postoperative patient-controlled intravenous analgesia of dexmedetomidine 0.1 µg/kg/h and ketorolac 3 mg/kg (DEX group) or only postoperative patient-controlled intravenous analgesia of sufentanil 1.5 µg/kg and ketorolac 3 mg/kg (SUF group) for 48 hours. Vital signs, postoperative Visual Analog Scale (VAS) score, Ramsay sedation score, patient-controlled analgesia pressing times, consumption of sufentanil and rescue drug, and complications were compared between the 2 groups. The levels of inflammatory factors and immune function were also compared. RESULTS: A significant reduction in median blood pressures and heart rates within 48 hours after surgery and perioperative consumption of sufentanil were observed in the DEX group compared with the SUF group (P < 0.05). No statistically significant difference was found in VAS scores, patient-controlled analgesia pressing times, and rescue drug consumption between the 2 groups (P > 0.05). The incidence of nausea was significantly lower in the DEX group compared with the SUF group (P < 0.05). A significant decrease of interleukin (IL)-1 beta, IL-6, tumor necrosis factor (TNF)-alpha, and increased CD4+ and CD4+/CD8+ were observed in the DEX group compared with the SUF group at 24 and 48 hours after surgery (P < 0.05). There was no difference in the levels of CD8+ and natural killer cells between the 2 groups (P > 0.05). LIMITATIONS: This study was limited by its sample size. CONCLUSIONS: Whole-course application of dexmedetomidine combined with ketorolac in nonnarcotic postoperative analgesia provided adequate and safe postoperative analgesia, reduced sufentanil consumption, analgesia-related complications, alleviated inflammatory response, and immunosuppression compared with sufentanil-based analgesia in thoracoscopic surgery. KEY WORDS: Dexmedetomidine, ketorolac, sufentanil, thoracoscopic surgery, postoperative analgesic, patient-controlled analgesia, inflammatory response, immune function

Sirolimus: A Rescue Drug to Control Complications of Extensive Venous Malformation

Venous malformations represent a major sector of vascular anomalies. Most cases are asymptomatic or subclinical; however, large extensive lesions can cause severe disability and sometimes mortality. In this report, we present a successful case of sirolimus treatment in managing an extensive venous malformation in the pelvis of a 21-month-old boy who presented with life-threatening complications. With a history dating since the day 2 of life, the patient suffered from chronic bleeding due to scrotal skin ulcerations, in addition to recurrent attacks of severe bleeding per rectum necessitating hospital admission and blood transfusion (three attacks since the age of 7 months). Pelvic magnetic resonance image showed the typical findings of extensive venous malformation involving the pelvis, perineum, scrotum, and extending to the gluteal region. The lesion was seen totally encasing the anorectum with marked thickening of their walls almost occluding their lumen.Oral sirolimus (2 mg/m2) was started with a target blood trough level of 5 to 10 ng/mL. Over a follow-up period of 5 months, there was obvious clinical improvement that included healing of skin lesions (scrotal ulcer) with complete re-epithelialization, absence of bleeding per rectum with improvement of constipation, and rise of hemoglobin level from 7.5 to 11.5 g/dL.

THE EFFECT OF 10 % LIDOCAINE SPRAYED TO NASAL PACKS ON PAIN AFTER ELECTIVE SEPTOPLASTY.

Aim To study analgesic effect of lidocaine10 % sprayed to 10 cm х 10 cm gauze swabs with neomycin and bacitracin ointment nasal packing using visual analog scale (VAS) in postoperative period for patients underwent septoplasty operation. Materials and methods 100 patients aged between 17 and 50 years and divided into two equal groups. Group L lidocaine 10% was sprayed to gauze swabs with neomycin and bacitracin ointment nasal packing and group S control group 0.9% NaCl applied to same nasal packing. Postoperatively, VAS scale, side effects and analgesic requirements were recorded. Results There were no differences between the number of female and male patients. Postoperative pain was less in group L than group S, there was a statistically significant difference between L group and S group (p <0.05). The patient in the S group needs more rescue drug. L group had significantly better pain score versus S group at all intervals (2, 6, 12, 18, and 24) postoperative period. Conclusion Lidocaine 10% sprayed to 10 cm х 10 cm gauze swabs with neomycin and bacitracin ointment nasal pack provide better analgesic effect and reduced needs to analgesic requirement after septoplasty surgery.

Acute care and hydration due to chemotherapy-induced nausea and vomiting (CINV) among patients receiving NEPA prophylaxis for anthracycline + cyclophosphamide (AC).

112 Background: In the US, the CMS OP-35 oncology outcome measure deems 30-day post-chemotherapy acute care involving nausea and emesis (NV) or 8 other toxicities as avoidable, with studies showing 15% of > 2500 patients receiving anthracycline + cyclophosphamide (AC)-based chemotherapy had avoidable acute care, of which 32% involved NV. Our aim was to evaluate resource use (emergency department [ED] visits, inpatient admissions [IP], or hydration) in a prospective trial of women with breast cancer who received combination netupitant/palonosetron (NEPA) + dexamethasone (DEX) for CINV prophylaxis for AC-based chemotherapy. Methods: Women initiating AC received oral or IV NEPA + DEX. Pre-specified endpoints included safety, complete response, acute care (ED/IP), unplanned IV hydrations (as determined by investigator), days of CINV, and ≥3 days of CINV. We defined CINV as emesis or rescue drug use up to 5 days after AC, and defined concomitant ED/IP or hydrations in the same period as CINV-related. We limited our analysis to the first 2 cycles, the median duration in the NEPA study. Results: 402 patients received ≥1 cycle of AC and 391 completed 2 cycles. Nine patients had IP (none CINV-related), and 5 patients had a total of 6 ED visits (1 CINV-related). Three patients had a CINV-related unplanned hydration. Patients had ≥1 day of CINV in 172 of 793 cycles (21.7%); of these, the majority had symptom duration for 1-2 days, while 78 (9.8%) had ≥3 days of CINV in a cycle. Conclusions: In this prospective CINV prophylaxis study in women receiving AC chemotherapy, < 1% of women receiving NEPA + DEX required acute care for CINV and < 1% required unplanned hydrations for CINV. These rates are below previously reported CINV-related acute care rates for AC suggesting NEPA may help avoid CINV-related acute care. Clinical trial information: NCT03403712.

Emergency Salbutomal Inhaler

Asthma is thought by most to be a benign health issue, but the statistics say otherwise. In Canada there are over 146 000 emergency room visits and 500 deaths each year from asthma. An estimated 80% are preventable. These hospital visits cost the Canadian government over $135 million a year. A solution is needed and that solution is the Emergency Salbutomal Inhaler. I have designed a small, easy­to­carry, two­ dose, dry­powder asthma inhaler, with patent pending. The device can easily be attached to a keychain or necklace for carrying ease, and will be quickly accessible in the event of an asthma attack. When an asthmatic has an attack and goes to a hospital, they are given a maximum of 2 doses of the rescue drug Salbutomal. The device carries two doses. Thus, in a sense I have invented a hospital on a keychain for asthmatics. During an asthma attack there is no time to fumble with an inhaler; my easy­to­use design ensures relief will be provided.