Ahmed Hasanin

BACKGROUND: Elderly population are at increased risk of spinal anesthesia-induced hypotension increasing their risk for postoperative morbidity and mortality. This study aimed to compare the hemodynamic effects of prophylactic infusion of norepinephrine (NE) versus phenylephrine (PE) in elderly patients undergoing hip fracture surgery under spinal anesthesia.

METHODS: Elderly patients scheduled for hip fracture surgery were randomized to receive either NE infusion (8 µg/min) (NE group, n = 31) or PE infusion (100 µg/min) (PE group, n = 31) after spinal anesthesia. Outcomes included mean heart rate, mean blood pressure, cardiac output, incidence of spinal anesthesia-induced hypotension, incidence of bradycardia, and incidence of hypertension.

RESULTS: Sixty-two patients with a mean age of 71 ± 6 years were included in the final analysis (31 patients in each group). The NE group showed a higher mean heart rate and cardiac output than the PE group. The NE group had a lower incidence of reactive bradycardia (10% vs. 36%, P = 0.031) and hypertension (3% vs. 36%, P = 0.003) than the PE group. No study participant developed hypotension, and the mean blood pressure was comparable between the two groups.

CONCLUSIONS: Both NE and PE infusions effectively prevented spinal anesthesia-induced hypotension in elderly patients undergoing hip fracture surgery. However, NE provided more hemodynamic stability than PE; maintaining the heart rate, higher cardiac output, less reactive bradycardia, and hypertension.

Background: This study aimed to investigate the analgesic efficacy and motor block profile of single-shot transmuscular quadratus lumborum block (QLB) in comparison with those of suprainguinal fascia iliaca block (FIB) in patients undergoing hip arthroplasty.

Methods: This randomized, double-blinded, controlled trial included adult patients undergoing hip arthroplasty under spinal anesthesia. Patients were allocated to one of two groups according to the regional block received: FIB group (n=19) or QLB group (n=17). Both study groups were compared with regard to the duration of analgesia (primary outcome), block performance time, pain during positioning for spinal anesthesia, total morphine consumption in the first postoperative 24-h period, quadriceps muscle power, and static and dynamic visual analog scale.

Results: Thirty-six patients were included in the final analysis. Both study groups had comparable durations of analgesia. Postoperative visual analog scale (static and dynamic) values were comparable between the two groups in most readings. The block performance time was shorter in the FIB group. The number of patients with pain during positioning for the subarachnoid block was lower in the QLB group. The total morphine requirement during the first 24 h was marginally lower in the FIB group, whereas the quadriceps motor grade was higher in the FIB group than in the QLB group at 4 h and 6 h after surgery.

Conclusion: Both single-shot blocks, namely the suprainguinal FIB and transmuscular QLB, provide effective postoperative analgesia after hip arthroplasty. FIB showed slightly lower 24-h morphine consumption, while QLB showed better quadriceps motor power.

Clinical Trial Registration: The study was registered at clinical trials registry system before enrollment of the first participant (NCT04005326; initial release date, 2 July 2019; https://clinicaltrials.gov/ct2/show/NCT04005326).

BACKGROUND: Endotracheal intubation requires optimum position of the head and neck. In obese females, the usual ramped position might not provide adequate intubating conditions. We hypothesized that a new position, termed modified-ramped position, during induction of anesthesia would facilitate endotracheal intubation through bringing the breasts away from the laryngoscope and would also improve the laryngeal visualization.

METHODS: Sixty obese female patients scheduled for general anesthesia were randomly assigned into either ramped or modified-ramped position during induction of anesthesia. In the ramped position (n = 30), the patient head and shoulders were elevated to achieve alignment of the sternal notch and the external auditory meatus; while in the modified-ramped position (n = 30), the patient shoulders were elevated using a special pillow, and the head was extended to the most possible range. Our primary outcome was the incidence of failed laryngoscopic insertion in the oral cavity (the need for patient repositioning). Other outcomes included time till vocal cord visualization, time till successful endotracheal intubation, difficulty of the mask ventilation, and Cormack-Lehane grade for laryngeal view.

RESULTS: Fourteen patients (47%) in ramped group required repositioning to facilitate introduction of the laryngoscope in the oral cavity in comparison to one patient (3%) in the modified-ramped position (p < 0.001). Modified-ramped position showed lower incidence of difficult mask ventilation, shorter time for glottic visualization, and shorter time for endotracheal tube insertion compared to the ramped position. The Cormack-Lehane grade was better in the modified-ramped position.

CONCLUSION: Modified-ramped position provided better intubating conditions, improved the laryngeal view, and eliminated the need for repositioning of obese female patients during insertion of the laryngoscope compared to ramped position.

CLINICAL TRIAL REGISTRATION: Identifier: NCT03640442. Date: August 2018.