An observational study is a type of epidemiological study design, which can take the form of a cohort, a case–control, or a cross-sectional study. When presenting observational studies in manuscripts, an author needs to ascertain a clear presentation of the work and provide the reader with appropriate information to enable critical appraisal of the research. The Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines were created to aid the author in ensuring high-quality presentation of the conducted observational study. The original articles publishing the STROBE guidelines together with their bibliographies were identified and thoroughly reviewed. These guidelines consist of 22 checklist items that the author needs to fulfil before submitting the manuscript to a journal. The STROBE guidelines were created to aid the authors in presenting their work and not to act as a validation tool for the conducted study or as a framework to conduct an observational study on. The authors complying with these guidelines are more likely to succeed in publishing their observational study work in a journal.

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The task of developing a new questionnaire or translating an existing questionnaire into a different language might be overwhelming. The greatest challenge perhaps is to come up with a questionnaire that is psychometrically sound, and is efficient and effective for use in research and clinical settings. This article provides guidelines for the development and translation of questionnaires for application in medical fields, with a special emphasis on perioperative and pain medicine. We provide a framework to guide researchers through the various stages of questionnaire development and translation. To ensure that the questionnaires are psychometrically sound, we present a number of statistical methods to assess the reliability and validity of the questionnaires.

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Context: Little is known about the relationship between sedative drugs used preoperatively and postoperative delirium. Melatonin is a drug used to sedate patients preoperatively and is hypothesized by recent works to have a curative effect on postoperative delirium. Aims: The incidence of postoperative delirium will be tested if affected by three different sedative drugs including melatonin. Settings and Design: Controlled randomized double-blind study. Patients and Methods: Three-hundred patients aged>65 years scheduled for hip arthroplasty under spinal anesthesia were randomly distributed to one of the four groups. Group 1 (control) received nothing for sedation. Group 2 (melatonin) received 5 mg melatonin. Group 3 (midazolam) received 7.5 mg midazolam. Group 4 (clonidine) received 100 μg clonidine. These medications were given orally at sleep time at night of operation and another dose 90 min before operative time. Patients who developed postoperative delirium received 5 mg of melatonin 9 pm for three successive days in a trial to treat delirium. Statistical Analysis Used: Statistical analysis was done using the SPSS Software (version 13). Results: Total of 222 patients completed the study. Percentage of postoperative delirium in the control group was 32.65% (16/49 patients). The melatonin group showed a statistically significant decrease in the percentage of postoperative delirium to 9.43% (5/53 patients). Melatonin was successful in treating 58.06% of patients suffered postoperative delirium (36/62 patients) with no difference between different groups. Conclusions: Postoperative delirium is affected with the drug used for preoperative sedation. Melatonin was successful in decreasing postoperative delirium when used preoperatively and in treating more than half of patients developed postoperative delirium when used for three postoperative nights.

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Given the continued increase in the complexity of invasive and noninvasive procedures, healthcare practitioners are faced with a larger number of patients requiring procedural sedation. Effective sedation and analgesia during procedures not only provides relief of suffering, but also frequently facilitates the successful and timely completion of the procedure. However, any of the agents used for sedation and/or analgesia may result in adverse effects. These adverse effects most often affect upper airway patency, ventilatory function or the cardiovascular system. This manuscript reviews the pharmacology of the most commonly used agents for sedation and outlines their primary effects on respiratory and cardiovascular function. Suggested guidelines for the avoidance of adverse effects through appropriate pre-sedation evaluation, early identification of changes in respiratory and cardiovascular function, and their treatment are outlined.

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Introduction: The Hospital Anxiety and Depression Scale (HADS) is widely used to predict and diagnose hospital anxiety and depression. It has been translated and validated in many languages, but the existing Arabic version was not validated in hospitalized patients. The aim was to translate, culturally adapt, and validate the HADS Questionnaire into Arabic language for in-patient use, especially for surgical wards. Methods: A systematic translation process was used to translate the original English HADS into Arabic. After the pilot study, we validated our version in surgical patients at two tertiary care centers. We tested the reliability of our version using internal consistency. We examined the validity by assessing construct validity, concurrent validity (by testing the associations between HADS, Generalized Anxiety Disorder 7-item scale [GAD-7], and Major Depression Inventory [MDI]), and face validity. The questionnaire was administered before and after surgery to examine responsiveness. Results: A total of 110 patients (22 men, 88 women) were included in the study. Cronbach's αs for the HADS anxiety subscale were 0.83 (95% confidence interval: 0.79– 0.88) and for the HADS depression subscale were 0.77 (0.7–0.83). Nearly 36% of the patients reported symptoms indicative of borderline or case anxiety before surgery, which decreased to 25% 1 week after surgery. HADS anxiety score was strongly correlated with GAD-7, and HADS depression score was strongly associated with MDI. Patients with higher American Society of Anesthesiologists Physical Status and those who remained hospitalized for more than 5 days were more likely to report depression symptoms. Most patients found the HADS questions to be clear and easy to understand, and thought the questionnaire items covered all their problem areas regarding their hospital anxiety and depression. Conclusions: Our Arabic version of HADS is a reliable and valid tool to assess the mood states in hospitalized patients.

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Background and Aims: Opioids as epidural adjunct to local anesthetics (LA) have been in use since long and α-2 agonists are being increasingly used for similar purpose. The present study aims at comparing the hemodynamic, sedative, and analgesia potentiating effects of epidurally administered fentanyl and dexmedetomidine when combined with ropivacaine. Methods: A total of one hundred patients of both gender aged 21-56 years, American Society of Anaesthesiologist (ASA) physical status I and II who underwent lower limb orthopedic surgery were enrolled into the present study. Patients were randomly divided into two groups: Ropivacaine + Dexmedetomidine (RD) and Ropivacaine + Fentanyl (RF), comprising 50 patie nts each. Inj. Ropivacaine, 15 ml of 0.75%, was administered epidurally in both the groups with addition of 1 μg/kg of dexmedetomidine in RD group and 1 μg/kg of fentanyl in RF group. Besides cardio-respiratory parameters and sedation scores, various block characteristics were also observed which included time to onset of analgesia at T10, maximum sensory analgesic level, time to complete motor blockade, time to two segmental dermatomal regressions, and time to first rescue analgesic. At the end of study, data was compiled systematically and analyzed using ANOVA with post-hoc significance, Chi-square test and Fisher's exact test. Value of P<0.05 is considered significant and P<0.001 as highly significant. Results: The demographic profile of patients was comparable in both the groups. Onset of sensory analgesia at T10 (7.12±2.44 vs 9.14±2.94) and establishment of complete motor blockade (18.16±4.52 vs 22.98±4.78) was significantly earlier in the RD group. Postoperative analgesia was prolonged significantly in the RD group (366.62±24.42) and consequently low dose consumption of local anaesthetic LA (76.82±14.28 vs 104.35±18.96) during epidural top-ups postoperatively. Sedation scores were much better in the RD group and highly significant on statistical comparison (P<0.001). Incidence of nausea and vomiting was significantly high in the RF group (26% and 12%), while incidence of dry mouth was significantly higher in the RD group (14%) (P<0.05). Conclusions: Dexmedetomidine seems to be a better alternative to fentanyl as an epidural adjuvant as it provides comparable stable hemodynamics, early onset, and establishment of sensory anesthesia, prolonged post-op analgesia, lower consumption of post-op LA for epidural analgesia, and much better sedation levels.

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Randomized control trials (RCT's) are the gold standard in evaluating and efficiently translating research data into clinical practice. The CONSORT statement was conceptualized in order to help ascertain standardization and reproducibility of RCT's. The articles publishing the CONSORT 2010 statement along with their bibliographies were identified and thoroughly reviewed. The CONSORT statement is made up of a 25-item checklist that provides the author with a solid backbone around which to construct and present an RCT. It sets standards on the trial's design, analysis, and interpretation of the results.

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Quality of clinical trials has improved steadily over last two decades, but certain areas in trial methodology still require special attention like in sample size calculation. The sample size is one of the basic steps in planning any clinical trial and any negligence in its calculation may lead to rejection of true findings and false results may get approval. Although statisticians play a major role in sample size estimation basic knowledge regarding sample size calculation is very sparse among most of the anesthesiologists related to research including under trainee doctors. In this review, we will discuss how important sample size calculation is for research studies and the effects of underestimation or overestimation of sample size on project's results. We have highlighted the basic concepts regarding various parameters needed to calculate the sample size along with examples.

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Background: Postoperative nausea and vomiting (PONV) is one of the complications which hamper the successful implementation of day care surgical procedure in spite of the availability of so many antiemetic drugs and regimens for its prevention. The aim was to compare the prophylactic effects of intravenously (IV) administered ondansetron and palonosetron on PONV prevention in patients undergoing laparoscopic gynecological surgery under general anesthesia. Methods: A prospective double-blind study comprised of 60 ASAI/II female patients between the age group of 25 and 40 years was carried out in the Departments of Anesthesiology and Obstetrics and Gynecology of our institute. Patients were randomly divided into two groups of 30 patients each in a double-blind manner. Group I received 8 mg of inj. ondansetron IV while group II received inj. palonosetron 0.075 mg IV 5 minutes before the induction of anesthesia. The need for rescue antiemetics, episodes of PONV and other side effects were observed for 6 hours in the postanesthesia care unit and thereafter complaints were received on phone after the discharge. At the end of study, results were compiled and statistical data was subjected to statistical analysis using Student two-tailed 't' and c² test and value of P<0.05 was considered significant. Results: The demographical profile of the patients was comparable. Twenty and 13.33% of the patients in group I had nausea and vomiting episodes postoperatively as compared to 6.67% and 3.33%, respectively, in group II which was statistically significant (P<0.05). Twenty percent of the patients in group I experienced significant post-op headache as compared to 6.67% in group II. The mean rescue dose of antiemetic was significantly higher (10.6 mg) in the group I as compared to group II (6.4 mg) (P=0.036). The rest of parameters were comparable and statistically nonsignificant. Conclusions: Palonosetron is a comparatively better drug to prevent the PONV in patients undergoing day care surgical procedures as compared to ondansetron as it has got a prolonged duration of action and favorable side-effects profile.

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Background: Dexmedetomidine, is a selective α2-adrenoceptor agonist that is used as an adjuvant mixed with local anesthetics during regional anesthesia. This study was designed to test the efficacy of adding dexmedetomidine to bupivacaine during placement of infraclavicular brachial plexus blockade (ICB). Methods: Sixty adult patients were divided into 2 equal groups of 30 subjects each. Patients in Group I received an ICB using 30 mL of 0.33% bupivacaine and Group II patients received 30 mL of 0.33% bupivacaine mixed with 0.75 μg/kg of dexmedetomidine. The following brachial plexus nerve block parameters were assessed: block success rate, sensory onset time and duration, motor block onset time and duration, analgesic pain scores using the verbal rating scale (VRS) for pain, duration of analgesia, and amount of supplemental intravenous (IV) morphine required. Results: There was a statistically significant shorter time to onset of sensory blockade (13.2 vs 19.4 min, P=0.003), longer duration of sensory block (179.4 vs 122.7 min, P=0.002), shorter onset time to achieve motor block (15.3 vs 22.2 min, P=0.003), longer duration of motor block (155.5 vs 105.7 min, P=0.002), lower VRS pain scores, prolonged analgesia (403 vs 233 min, P=0.002), and lower morphine rescue requirements for 48 h after surgery (4.9 (0-8.0) vs 13.6 mg (4.0-16.0) mg, P=0.005). All patients recovered without evidence of sensory or motor deficit. Conclusion: Adding dexmedetomidine to bupivacaine during the placement of an ICB provides: (1) enhancement of onset of sensory and motor blockade, (2) prolonged duration of analgesia, (3) increases duration of sensory and motor block, (4) yields lower VRS pain scores, and (5) reduces supplemental opioid requirements.

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Background: Emergence agitation (EA) in children is increased after sevoflurane anesthesia. Propofol and dexmedetomidine have been used for prophylactic treatment with controversial results. The aim of the present study was to compare the effect of a single dose of propofol or dexmedetomidine prior to termination of sevoflurane-based anesthesia on the incidence and severity of EA in children. Methods: One hundred and twenty children, American Society of Anesthesiologists I-II, 2-6 years old undergoing adenotonsillectomy under sevoflurane based anesthesia were enrolled in the study. Children were randomly allocated to one of the three equal groups: (Group C) received 10 ml saline 0.9%, (Group P) received propofol 1 mg/kg or (group D) received dexmedetomidine 0.3 ug/kg ^-1 . The study drugs were administered 5 min before the end of surgery. In post anesthesia care unit (PACU), the incidence of EA was assessed with Aonos four point scale and the severity of EA was assessed with pediatric anesthesia emergence delirium scale upon admission (T0), after 5 min (T5), 15 min (T15) and 30 min (T30). Extubation time, emergence time, duration of PACU stay and pain were assessed. Results: The incidence and severity of EA were lower in group P and group D compared to group C at T0, T5 and T15. The incidence and severity of EA in group P were significantly higher than group D at the same times. The incidence and severity of EA decreased significantly over time in all groups. The modified Children's Hospital of Eastern Ontario Pain Scale was significantly lower in group D compared to group C and group P. Conclusions: Dexmedetomidine 0.3 ug/kg ¹ was more effective than propofol 1 mg/kg in decreasing the incidence and severity of EA, when administered 5 min before the end of surgery in children undergoing adenotonsillectomy under sevoflurane anesthesia.

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Background: Relieving preoperative anxiety is an important concern for the pediatric anesthesiologist. Midazolam has become the most frequently used premedication in children. However, new drugs such as the α₂ -agonists have emerged as alternatives for premedication in pediatric anesthesia. Methods: One hundred and twenty children scheduled for adenotonsillectomy were enrolled in this prospective, double-blind, randomized study. The children were divided into two equal groups to receive either intranasal dexmedetomidine 1 μg/kg (group D), or oral midazolam 0.5 mg/kg (group M) at approximately 60 and 30 mins, respectively, before induction of anesthesia. Preoperative sedative effects, anxiety level changes, and the ease of child-parent separation were assessed. Also, the recovery profile and postoperative analgesic properties were assessed. Results: Children premedicated with intranasal dexmedetomidine achieved significantly lower sedation levels (P=0.042), lower anxiety levels (P=0.036), and easier child-parent separation (P=0.029) than children who received oral midazolam at the time of transferring the patients to the operating room. Postoperatively, the time to achieve an Aldrete score of 10 was similar in both the groups (P=0.067). Also, the number of children who required fentanyl as rescue analgesia medication was significantly less (P=0.027) in the dexmedetomidine group. Conclusion: Intranasal dexmedetomidine appears to be a better choice for preanesthetic medication than oral midazolam in our study. Dexmedetomidine was associated with lower sedation levels, lower anxiety levels, and easier child-parent separation at the time of transferring patients to the operating room than children who received oral midazolam. Moreover, intranasal dexmedetomidine has better analgesic property than oral midazolam with discharge time from postanesthetic care unit similar to oral midazolam.

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Purpose: Different adjuvants have been used to improve the quality and increase the duration of local anesthetics during various nerve block techniques. The current study was aimed to evaluate the effect of adding dexamethasone to bupivacaine on the quality and duration of transversus abdominis plane (TAP) block. Methods: Sixty adult patients undergoing elective open abdominal hysterectomy were randomly allocated to receive TAP block using 20 mL of bupivacaine hydrochloride 0.25% + 2 mL saline 0.9% (control group, n=30) or 20 mL of bupivacaine hydrochloride 0.25% + 2 mL dexamethasone "8 mg" (dexamethasone group, n=30). The primary outcome was postoperative pain, as evaluated by visual analog scale (VAS) for pain scoring at 1, 2, 4, 12, 24 and 48 h postoperatively, whereas the secondary outcomes were time to first analgesia (TFA), morphine consumption and the occurrence of nausea, vomiting or somnolence. Results: The pain VAS score was significantly lower at the postoperative 2 h (4.9 vs. 28.1, P=0.01), 4 h (12.2 vs. 31.1, P=0.01) and 12 h (15.7 vs. 25.4, P=0.02). Furthermore, TFA was significantly longer in the dexamethasone group (459.8 vs. 325.4 min, P=0.002), with lesser morphine requirements in the postoperative 48 h (4.9 vs. 21.2 mg, P=0.003) and lower incidence of nausea and vomiting (6 vs. 14, P=0.03). No complications attributed to the block were recorded. Conclusion: Addition of dexamethasone to bupivacaine in TAP block prolonged the duration of the block and decreased the incidence of nausea and vomiting.

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Background: Pregabalin is a potent ligand for alpha-2-delta subunit of voltage-gated calcium channels in the central nervous system, which exhibits potent anticonvulsant, analgesic and anxiolytic activity. The pharmacological activity of pregabalin is similar to that of gabapentin and shows possible advantages. Although it shows analgesic efficacy against neuropathic pain, very limited evidence supports its postoperative analgesic efficacy. We investigated its analgesic efficacy in patients experiencing acute pain after abdominal hysterectomy and compared it with gabapentin and placebo. Methods: A randomized, double-blind, placebo-controlled study was conducted in 90 women undergoing abdominal hysterectomy who were anaesthetized in a standardized fashion. Patients received 300 mg pregabalin, 900 mg gabapentin or placebo, 1-2 hours prior to surgery. Postoperative analgesia was administered at visual analogue scale (VAS) ≥3. The primary outcome was analgesic consumption over 24 hours and patients were followed for pain scores, time to rescue analgesia and side effects as secondary outcomes. Results: The diclofenac consumption was statistically significant between pregabalin and control groups, and gabapentin and control groups; however, pregabalin and gabapentin groups were comparable. Moreover, the consumption of tramadol was statistically significant among all the groups. Patients in pregabalin and gabapentin groups had lower pain scores in the initial hour of recovery. However, pain scores were subsequently similar in all the groups. Time to first request for analgesia was longer in pregabalin group followed by gabapentin and control groups. Conclusion: A single dose of 300 mg pregabalin given 1-2 hours prior to surgery is superior to 900 mg gabapentin and placebo after abdominal hysterectomy. Both the drugs are better than placebo.

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Background: Postpartum hemorrhage (PPH) and anemia thereafter can be a life threatening condition in parturients undergoing lower segment cesarean section (LSCS), especially when anemia is present. Aim: The objective of this study was to assess two doses of Tranexamic acid (TXA) in reducing intra operative blood loss and incidence of PPH, in terms of both efficacy and safety profiles, when used prophylactically. Methods: A monocenter prospective case control double blind randomized study was carried out on a consecutive series of 90 anemic patients undergoing LSCS, with hemoglobin between 7-10 g percent. Three random groups were formed. Group T1 (n=30) received 10mg/kg TXA in 20 ml of 5% dextrose intravenously, while T2 group (n=30) received 15mg/kg. Group C (n=30) received a placebo. Drug was administered prophylactically 20 min before skin incision. Blood loss was measured from placental delivery up to 24 hours by method of weight and volume. Staistical Analysis: To compare quantitative data between two groups, t-test, and for more than two groups ANOVA was used. To compare the mean for non- parametric data between two groups Mann - Whitney test was used, while in case of more than two groups Kruskal - Wallis test was employed. Probability (p) value was considered significant when it was 0.05 or less. Results: TXA significantly reduced blood loss in both the study groups. Mean total blood loss was 527.17±88.666 ml, 376.83±31.961ml and 261.17±56.777 ml in group C, T1, and T2 respectively. While reduction of blood loss in T1 group compared to control group was 146.34±56.32ml, it was 262±31.51ml in T2 group. Difference between T1 and T2 was 115.66±24.81ml, which was statistically significant (P<0.05). Postoperative blood loss was insignificant in all three groups. Pre- and post-operative hemoglobin levels differed significantly when compared to control group. Blood transfusion was needed in two patients in the control group, whereas no patient in groups T1 and T2 needed transfusion (P=0.02). No significant adverse effect was seen in all the three groups. Conclusion: Hence, TXA was found to be effective in reducing blood loss and transfusion in anemic parturients undergoing LSCS. 15mg/kg dose of TXA was more efficacious than the 10mg/kg dose and without any undue increase in adverse events. Postpartum anemia is a public health problem worldwide and TXA could prove to be a very useful drug to prevent blood loss and transfusions in patients undergoing LSCS, especially in the anemic subgroup.

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Context: Dexmedetomidine as an adjuvant to local anesthetics in peripheral nerve blocks has been used in only a few studies. Aims: We aimed at assessing the effect of dexmedetomidine as an adjuvant to ropivacaine in supraclavicular brachial plexus block. Settings and Design: Random, controlled, and triple blind. Materials and Methods: Sixty American Society of Anesthesiologist grade I and II patients of either sex scheduled for elective upper limb surgery under supraclavicular brachial plexus block were divided into three equal groups in a prospective randomized double-blind controlled manner. For block patients in Group C received 0.5% ropivacaine (30cc), 0.5% ropivacaine with 50 μg dexmedetomidine (30cc) in Group D and 0.5% ropivacaine (30cc) in Group D-IV along with intravenous infusion of 50 μg dexmedetomidine in normal saline. Statistical Analysis Used: IBM-SPSS software version 17, Chi-square test, Mann-Whitney U-test. Results: Demographic profile and surgical characteristics were similar in all the three groups. Sensory block and motor block onset was earlier in group D than in group D-IV and group C. The sensory block and motor block duration was also prolonged in group D when compared with group D-IV and group C. The duration of analgesia was significantly longer in group D and D-IV when compared to group C. Conclusions: Dexmedetomidine as an adjuvant to 0.5%ropivacaine in ultrasound guided brachial plexus block shortens the sensory as well as motor block onset time, prolongs sensory and motor block duration and also increases the duration of analgesia. The action of dexmedetomidine most probably is local rather than centrally mediated.

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Background: Pain control is a vitally important goal because untreated pain has detrimental impacts on the patients as hopelessness, impede their response to treatment, and negatively affect their quality of life. Limited knowledge and negative attitudes toward pain management were reported as one of the major obstacles to implement an effective pain management among nurses. The main purpose for this study was to explore Saudi nurses' knowledge and attitudes toward pain management. Methods: Cross-sectional survey was used. Three hundred knowledge and attitudes survey regarding pain were submitted to nurses who participated in this study. Data were analyzed with the Statistical Package for the Social Sciences software (SPSS; version 17). Results: Two hundred and forty-seven questionnaires were returned response rate 82%. Half of the nurses reported no previous pain education in the last 5 years. The mean of the total correct answers was 18.5 standard deviation (SD 4.7) out of 40 (total score if all items answered correctly) with range of 3–37. A significant difference in the mean was observed in regard to gender (t = 2.55, P = 0.011) females had higher mean score (18.7, SD 5.4) than males (15.8, SD 4.4), but, no significant differences were identified for the exposure to previous pain education (P > 0.05). Conclusions: Saudi nurses showed a lower level of pain knowledge compared with nurses from other regional and worldwide nurses. It is recommended to considered pain management in continuous education and nursing undergraduate curricula.

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Objective: A comparative study to evaluate the efficacy of dexmedetomidine as a hypotensive agent in comparison to esmolol in Functional Endoscopic Sinus Surgery (FESS). Methods: Forty patients ASA I or II scheduled for FESS were equally randomly assigned to receive either dexmedetomidine 1 μg/Kg over 10 min before induction of anesthesia followed by 0.4-0.8 μg/Kg/h infusion during maintenance (DEX group), or esmolol, loading dose 1mg/kg was infused over one min followed by 0.4-0.8 mg/kg/h infusion during maintenance (E group) to maintain mean arterial blood pressure (MAP) between (55-65 mmHg). General anesthesia was maintained with sevoflurane 2%-4%. The surgical field was assessed using Average Category Scale and average blood loss was calculated. Hemodynamic variables (MAP and HR); arterial blood gas analysis; plasma cortisol level; intraoperative fentanyl consumption; Emergence time and total recovery from anesthesia (Aldrete score ≥9) were recorded. Sedation score was determined at 15, 30, 60 min after tracheal extubation and time to first analgesic request was recorded. Result: Both DEX group and E group reached the desired MAP (55-65 mmHg) with no intergroup differences in MAP or HR. The for the quality of the surgical filed in the range of MAP (55-65 mmHg) were <=2 with no significant differences between group scores during hypotensive period. Mean intraoperative fentanyl consumption was significantly lower in DEX group than E group. Cortisol level showed no significant changes between or within groups. No significant changes were observed in arterial blood gases. Emergence time and time to achieve Aldrete score ≥9 were significantly lower in E group compared with DEX group. The sedation score were significantly lower in E group compared with DEX group at 15 and 30 minutes postoperatively. Time to first analgesic request was significantly longer in DEX group. Conclusion: Both dexmedetomidine or esmolol with sevoflurane are safe agents for controlled hypotension and are effective in providing ideal surgical field during FESS. Compared with esmolol, dexmedetomidine offers the advantage of inherent analgesic, sedative and anesthetic sparing effect.

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Context: Pharmacological agents are used to reduce postoperative blood loss. Aims: To assess the effects of tranexamic acid on prevention of bleeding and requirement of blood transfusion after major hip and femoral surgeries. Settings and Design: A prospective, randomized, double blinded study was conducted in the tertiary care teaching hospital. Methods: Ninety ASA grade I-II patients undergoing hip fracture surgery were included in this prospective study. Forty-five patients received tranexamic acid (TA) given in a bolus dose of 500 mg 15 min before surgical incision followed by continuous infusion. The remaining, 45 patients were allocated as a control group. Postoperative bleeding (volume of blood in the drain), percentage fall of hemoglobin, transfusions and complications were recorded. Results: Mean volume of blood in the drain was 39.33±10.09 ml (mean±SD) as compared to 91.11±17.61 ml in placebo group showing a P>0.001. Mean percentage fall in Hb at day 0 was 2.99±3.45 in the study group as compared to 7.70±6.05 in the placebo group (P>0.001), and fall at day 2 in the study group was 0.35±0.74, compared to 2.72±2.70 in the placebo group (P<0.001). The number of patients required blood transfusions were lower in the study group than in the placebo group (P=0.01). Conclusions: We conclude that tranexamic acid significantly reduces postoperative blood loss and transfusion requirements during major hip and femoral surgeries.

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In recent anesthetic practice, peripheral nerve blocks (PNBs) are used extensively for surgical anesthesia and nonsurgical analgesia. PNBs offer many benefits over other anesthetic techniques in a certain population of patients, and in some specific clinical setting, that may contribute to faster and safer pain relief, increased patient satisfaction, reduced hospital stay, and decreased overall healthcare cost. The technique involves the injection of the anesthetic in the vicinity of a specific nerve or bundle of nerves to block the sensation of pain transmitting to a specific portion of the body. However, the length of analgesia when a single anesthetic is used for PNB may not last long. Therefore, the practice of adding an additional agent called adjuvant has been evolved to prolong the analgesic effect. There are many such adjuvants available that are clinically being used for this purpose imparting great efficacy and safety to the anesthetic process. The adjuvants molecules are generally classified as opioids, alpha-2 agonist, steroids, etc. Most of them are safe to use and show little or no adverse event related to neurotoxicity and tissue damage. Although there is extensive use of such adjuvants in the clinical field, none of the molecules is approved by the FDA and is used as an off-label drug. The risk to benefit ratio must be assessed while using such an agent. This review will try to delineate the basic need of adjuvant in peripheral nerve block and will discuss the advantages and limitations of using different adjuvants and will discuss the future prospect of such application.

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Negative pressure pulmonary edema (NPPE) is a dangerous and potentially fatal condition with a multifactorial pathogenesis. Frequently, NPPE is a manifestation of upper airway obstruction, the large negative intrathoracic pressure generated by forced inspiration against an obstructed airway is thought to be the principal mechanism involved. This negative pressure leads to an increase in pulmonary vascular volume and pulmonary capillary transmural pressure, creating a risk of disruption of the alveolar-capillary membrane. The early detection of the signs of this syndrome is vital to the treatment and to patient outcome. The purpose of this review is to highlight the available literature on NPPE, while probing the pathophysiological mechanisms relevant in both the development of this condition and that involved in its resolution.

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Background: Dexmedetomidine is an alpha 2 adrenergic agonist, prolongs analgesia when used in neuraxial and peripheral nerve blocks. We studied the effect of addition of dexmedetomidine to bupivacaine to perform transversus abdominis plane (TAP) block. Materials and Methods: A total of 50 patients scheduled for abdominal hysterectomy were divided into two equal groups in a randomized double-blinded way. Group B patients (n = 25) received TAP block with 20 ml of 0.25% bupivacaine and 2 ml of normal saline while Group BD (n = 25) received 0.5 mcg/kg (2 ml) of dexmedetomidine and 20 ml of 0.25% bupivacaine bilaterally. Time for first analgesic administration, totally used doses of morphine, pain scores, hemodynamic data and side-effects were recorded. Results: Demographic and operative characteristics were comparable between the two groups. The time for the first analgesic dose was longer in Group BD than Group B (470 vs. 280 min, P < 0.001) and the total doses of used morphine were less among Group BD patients in comparison to those in Group B (19 vs. 29 mg/24 h, P < 0.001). Visual analog scores were significantly lower in Group BD in the first 8 h post-operatively when compared with Group B, both at rest and on coughing (P < 0.001). In Group BD, lower heart rate was noticed 60 min from the induction time and continued for the first 4 h post-operatively (P < 0.001). Conclusions: The addition of dexmedetomidine to bupivacaine in TAP block achieves better local anesthesia and provides better pain control post-operatively without any major side-effects.

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Background: Considering the important role of pituitary gland in regulating various endocrine axes and its unique anatomical location, various postoperative complications can be anticipated resulting from surgery on pituitary tumors. We examined and categorized the immediate postoperative complications according to various tumor pathologies. Materials and Methods: We carried out a prospective study in 152 consecutive patients and noted various postoperative complications during neurosurgical intensive care unit stay (within 48 hrs of hospital stay) in patients undergoing transsphenoidal removal of pituitary tumors. Results: In our series, various groups showed different postoperative complications out of which, cerebrospinal fluid leak was the commonest followed by diabetes insipidus, postoperative nausea and vomiting, and hematoma at operation site. Conclusion: Various immediate postoperative complications can be anticipated in transsphenoidal pituitary surgery even though, it is considered to be relatively safe.

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Background: The objective of this study was to evaluate the reliability of the postoperative pain control using adductor canal block (ACB) compared that using the femoral nerve block (FNB) in patients with anterior cruciate ligament reconstructions (ACLR). Materials and methods: One hundred and twenty-eight patients who had been scheduled to patellar graft ACLR were included in this double blind study, and were randomly allocated into two groups; group ACB and group FNB (64 patients each). All patients received general anesthesia. At the end of the surgery, patients in group FNB received a FNB and those in group ACB received an ACB. The postoperative pain (visual analog scale [VAS]) and muscle weakness were assessed in the postoperative care unit and every 6 h thereafter for 24 h. The total morphine requirements were also recorded. Results: Patients in group ACB had significantly higher VAS (at 18 h and 24 h), higher morphine consumption, but significantly less quadriceps weakness than those in group FNB. Conclusion: In patients with patellar graft ACLR, the ACB can maintain a higher quadriceps power, but with lesser analgesia compared with the FNB.

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Background: Tranexamic acid has been used to reduce bleeding and the subsequent need for blood transfusion in many surgeries. Because orthognathic surgery can be associated with significant bleeding, this study evaluated the efficacy of prophylactic intravenous (IV) tranexamic acid on blood loss during bimaxillary osteotomy. Methods: Thirty-two consecutive patients, scheduled for elective bimaxillary osteotomy, were included in the study and 16 were randomly assigned to each group. They received tranexamic acid (20 mg/kg) or equal volume of placebo (normal saline) intravenously just before induction of anesthesia. Intraoperative blood loss, pre and post operative hemoglobin (Hb) and hematocrit (Hct) concentration, duration of surgery, hospital stay time, and rate of blood transfusion were recorded for each patient. Results: Intraoperative blood loss in the tranexamic group and control group were 585.9 and 790 mL respectively (P=0.008). Postoperative Hb concentration at the 6 ^th hour was greater in the tranexamic group (P=0.008). There was no significant difference in the Hct concentration between the study groups. There was no significant difference in blood transfusion rate, hospital stay time and duration of surgery between the study groups. Conclusion: Preoperative IV administration of tranexamic acid reduces the amount of blood loss during bimaxillary osteotomy.

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