Nurse Anesthesia

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    Dose Response Study of Intrathecal Fentanyl Added to Bupivacaine in Patients Undergoing Elective Caesarean Section in Spinal Anesthesia
    (An-Najah National University, 2020-01-16) Yahya, Ahed
    Background Applying spinal anesthesia for caesarean sections associated with a certain side effect such as hypotension caused by the dose of hyperbaric bupivacaine, additives of potent opioid such as fentanyl may reduce the dose of toxic local anesthesia which will be more hemodynamic stability and also enhance of adequate analgesia. Aims This study conducted in order to evaluate the side effects of four spinal solutions in purpose of finding best possible combinations of fentanyl and bupivacaine, comparing the efficiency and safety of this combinations by using different doses of fentanyl in spinal anesthesia in cesarean section, and assessing the side effects, duration of analgesia, hemodynamic parameters and neonatal outcomes by using an Apgar score. Methods One hundred sixty Patients randomized into four groups 40 of each : Group-I (F10): received 1.5ml (7.5mg) of 0.5% Bupivacaine heavy & 10μg Fentanyl .Group-II (F15): received 1.5ml (7.5mg) of 0.5% Bupivacaine heavy & 15μg Fentanyl .Group-III (F25): received 1.5ml (7.5mg) of 0.5% Bupivacaine heavy & 25μg Fentanyl and (control group ). Group-IV (B10): received 2 ml (10mg) of 0.5% Bupivacaine heavy and saline containing no fentanyl. Side effects such as: nausea, vomiting, bradycardia, hypotension episodes, headache, pruritis, shivering, drowsiness, restlessness, dizziness, sedation, patients’ satisfaction, analgesic requirements and duration of effective analgesia were evaluated. Moreover, onset and duration of sensory and motor block were measured. Results Similar distribution of age, height, weight and duration of surgery as evidenced by statistical analysis, The results show that there was significant differences at the level (p ≤ 0.05) in comparison between B10 only and Fentanyl 10mcg, Fentanyl 15mcg and Fentanyl 25mcg related to the onset of sensory blockade to T10 and T6 and indicate fentanyl 25 mcg more fast onset of sensory block. Onset of motor block was earlier in bupivacaine 10 mg group in comparison with other three groups, which is statistically significant difference. According to bradycardia, there were no significant differences between groups. Hypotension episodes in bupivacaine 10mg more common mean (3.12), which is statistically significant difference when compared to other three groups. Incidence of headache was decreased in fentanyl groups in comparison with B10 group but there were no significant differences between the groups. There were significant differences regarding the incidence of pruritis in fentanyl 25 mcg (9/40) and fentanyl 15 mcg (6/40) groups when compared to B10. Nausea and vomiting were observed in B10 group while decreased significantly in other three groups. According to Restlessness, sedation and respiratory depression, there were no significant differences between all groups. There were no significant differences in Apgar scores at 1 and 5 min. The duration of sensory block was prolonged significantly in fentanyl groups. Duration of motor blocked was decreased significantly with decrease Bupivacaine dose and early motor recovery was observed significantly in fentanyl groups compared to B10 group. Duration of effective analgesia increased as increased fentanyl dose which was statistically significant difference in all fentanyl groups compared to B10 group. Regarding to postoperative analgesic needed, significant differences were found in all fentanyl groups in comparison to control group, fentanyl 25 mcg more significant and less rescue analgesic requirements in post-operative period by mean (1.85 ) followed by fentanyl 15 ( 2.3) mcg then B10 (2.37) and fourthly fentanyl 10 mcg (2.42 ) . Conclusion Addition of Fentanyl was effective with minimal side effects; also it improves the quality of anesthesia, prolongs the duration of sensory block, faster onset of sensory block and significantly reduces post-operative rescue analgesic needed, also better hemodynamic stability. Where 0.5% bupivacaine 10 mg alone faster of onset of motor blocked and prolonged of duration of motor blocked. Finally we conclude and recommend of best combination in spinal anesthesia for elective cesarean section is fentanyl 25 mcg with 0.5% bupivacaine 7.5 mg because it was superior in duration of effective analgesia and less post-operative rescue analgesic needed also more patients’ satisfaction, however may have less side effect in fentanyl 10 mcg and 15 mcg groups. In conclusion fentanyl 25 mcg with 0.5% bupivacaine 7.5 mg is more favorable.
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    The effect of alkalized lidocaine, dexamethasone, and their combination versus air in the endotracheal tube cuff to evaluate post-extubation morbidity in smoker patients undergoing laparoscopic surgery. A double blind randomized control study
    (ِAn-Najah National University, 2019-01-10) Zagharneh, Islam
    المزيج بين الليدوكائيين القلوي والديكساميثازون داخل كفة الأنبوب الرغامي لديه الافضليه والفائدة في تقليل حدوث السعال في مرحلة الافاقه. الليدوكايين القلوي والخليط بين الليدوكائيين القلوي والديكساميثازون متساويين في تقليل حدوث السعال وتقرح الحلق وبحة الصوت في جميع المراحل ابتداء من ساعتين بعد وحدة ما بعد التخدير وحتى 24 ساعة . الديكساميثازون ليس ذو فائدة في تقليل حدوث تقرح الحلق عند الساعتين و8 ساعات بعد وحدة ما بعد التخدير وكذلك ليس ذو فائدة في تقليل بحة الصوت عند الثمان ساعات. ولكنه يمتلك نفس التأثير لتقليل حدوث السعال تماما مثل الليدوكائيين القلوي والخليط بين الليدوكائيين القلوي والديكساميثازون. بالنسبة لشدة حدوث الأعراض /السعال/ وتقرح الحلق/ وبحة الصوت. فان المجموعات الثلاث /الليدوكائيين القلوي/ والديكساميثازون/ والخليط بين الليدوكائيين القلوي والديكساميثازون أفضل من الهواء لتقليل شدة الأعراض عند وقت الساعتين بعد وحدة ما بعد التخدير. بالنسبة لشدة حدوث بحة الصوت فان الليدوكائيين القلوي هو الأفضل لتقليله. الليدوكائيين القلوي والخليط بين الليدوكائيين القلوي والديكساميثزون يعمل على تحسين انسجام القصبة الهوائية للأنبوب الرغامي ويجعل عملية نزع الأنبوب أكثر سهوله. وبشكل عام نستطيع القول أن الليدو كائيين القلوي والخليط بين الليدوكائيين القلوي والديكساميثازون داخل كفة الأنبوب الرغامي أفضل من الديكساميثازون والهواء. ولا يوجد فرق بين الليدوكائيين القلوي والخليط بين الليدوكائيين القلوي والديكساميثازون. تطبيقات تمريض التخدير: المزيج بين الليدوكايين القلوي والديكساميثازون أو الليدوكايين القلوي لوحده داخل كفة الأنبوب الرغامي يؤدي إلى تأثيرات جيده لمنع حدوث اعتلالات القصبة الهوائية )السعال وتقرح الحلق وبحة الصوت( بعد نزع الأنبوب. بالإضافة إلى جعل عملية نزع الأنبوب أكثر سهوله واقل خطورة. الكلمات المفتاحية: التدخين. الليدوكائين. الديكساميثازون. السعال. بحة الصوت. تقرح الحلق.
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    Role of Intravenous Dextrose on Reducing PONV in Children Undergoing Tonsillectomy and /or Adenoidectomy
    (An-Najah National University, 2019-05-19) Nassar, Ahmad
    Background. Post-operative nausea and vomiting (PONV) is the most frequent complication of Tonsillectomy and /or Adenoidectomy surgeries and is the major cause for readmissions and increase the length of stay in hospital. Aims. The aims of the study are to evaluate the effect of postoperative administration of IV 5% dextrose on the incidence and severity of nausea, and incidence of vomiting in patients undergoing tonsillectomy/adenoidectomy and its effect on the incidence of another postoperative symptoms that are (pain, headache, drowsiness, fatigue, thirst, hunger and bleeding) and consumption of rescue antiemetic and rescue analgesia medications. Methods. A prospective, randomized, controlled double-blind clinical trial in 90 Pediatric patients, aged 4-12 years, American Society of Anesthesiologist (ASA) physical status I and II. Patients undergoing adeno/tonsillectomy surgery under general anesthesia, were randomly assigned into two groups (n = 45 each). Group one, dextrose water (DW) group, and group two, ringer lactate (RL) group. The incidence of postoperative symptoms focusing on the incidence and severity of nausea, and frequency of vomiting and the need for “rescue” medications are assessed at specific time intervals from 30 mints post operation until discharge. Results. Intravenous dextrose water given postoperatively had a significant effect on decreasing the incidence of post-operative nausea at 30 mints (P-value 0.000), 1st hr after operation ( P= 0.001) and the overall incidence of nausea (0-5 hr) was significantly lower in DW group 23(48.9%) compared to the RL group 35(77.8%), p= 0.004. Moreover, The results indicated that 5% DW administered postoperatively reduces the intensity of nausea at 30 min, one hour, and on discharge from the hospital M±S.D of VAS-N scale in the DW group (0.04±0.3) is significantly lower than the RL group (0.4+0.91), p=0.015. Although there is a significant difference in the incidence of complete response in the dextrose group 23(51.1%) compared to RL group 10(22.2%), P=0.004 at 0-5 hrs. There is a significant difference for use of rescue antiemetic drug of Ondansetron on the whole entire period of the study (0-5 hrs.) between the dextrose group 7(15.6%) compared to Ringer lactate group 17(37.8%), p=0.017. The incidence of headache in overall period (0-5 hr.) in the DW group (0%(0)) is significantly lower compared to RL group 6(13.3%), p= 0.011. Also, the incidence of headache at 2hrs in the DW group (0%(0)) versus RL group 5(11.1%), P= 0.0. In the overall period (0-5 hrS.),the number of patients with drowsiness in the RL group 36(80%) is significantly higher than the DW group 8(17.8%), p= 0.000, at 30 mints after operation in the DW group 5(11.1%)versus RL group 16(35.6%), p= 0.006, at 1hrs. After operation in the DW 3(6.7%) is significantly lower than the RL group 19(42.2%), P= 0.000. Like some drowsiness at 2 hrs. after operation in the Dw 0(0%) is significantly lower than RL group 8(17.8%), p=- 0.003. The incidence of fatigue in the DW group is significantly lower than in the RL group at 30 minDW group 3(6.7%) versus the RL group 10(22.2%), p=0.036, one hour DW group 0(0%) versus the RL group 4(8.9%), p=0.041 and 4 hours postoperatively DW group 0(0%) versus RL group 4(8.9%), p=0.041. Thirst at 3 hrs. after operation in the DW group 4(8.9%) is significantly lower than the RL group 11(24.4%, ) p= 0.048, and at 4 hrs., the DW group 4(8.9%) versus the Ringer lactate group 11(24.4%), p=0.000, like some, number of patients with thirst at discharge in the DW group 1(2.2%) is significantly lower than the RL group 7(15.6%), p=0.026, also the overall period, the number of patients who were thirsty in the RL group 38(84.4) is significantly higher than the number of patients who were thirsty in the DW group 13(28.9%), p= 0.000. Hunger at 3 hrs. after the operation in the DW group 2(4.4%) is significantly lower than the RL group 18(40%), p= 0.000, and hunger in 4 hr DW group 9(20%) versus the RL group 23(51.1%), p= 0.002. In the overall period (0-5 hr.), the number of patients who were hungry in the RL group39 (86.7%) is significantly higher than the number of patients who were hungry in the DW group19 (42.2%), p= 0.000. Conclusion. The administration of intravenous dextrose postoperatively for pediatric patients undergoing adeno/tonsillectomy reduces the incidence and the Intensity of nausea, the consumption of rescue medication, incidence of headache, fatigue, thirst, hunger and had no significant effect on the incidence of vomiting, and the incidence and intensity of pain.
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    The Effect of Femoral Nerve Block on Opioid Consumption among Patient’s who Underwent Total Knee Replacement under Spinal Anesthesia
    (An-Najah National University, 2019-02-14) Kulaib, Sameh
    Background Total knee replacement (TKR) is a common surgical procedure which has become the treatment of choice for people with intractable joint pain and disability. It’s a clinically efficacious and cost-effective intervention, with high rates of success in terms of alleviating pain and improving function in patients with advanced arthritis of the knee. The post-operative complications may delay the mobility and discharge. There are many complications such as traumatic to nerves or blood vessels in the leg, dislocation of the prosthesis, allergic to the cement material and pain post operation. Pain management is an important part of recovery. The multi module post-operative pain management continuous epidural, lumbar plexus, and femoral or sciatic nerve blocks improve postoperative pain management and reduce opioid consumption. Femoral nerve block (FNB) is one of the methods used to decreased opioid consumption. A femoral nerve block can be used to provide anesthesia for the anterior thigh, knee, and a small part of the medial foot. It is typically used in conjunction with other lower extremity blocks. It may also be used for postoperative pain relief following knee surgery. Aims To assess the efficacy of FNB in reducing pain among spinal anesthesia total knee replacement, the efficacy of FNB in reducing post-operative nausea and vomiting (PONV) among spinal anesthesia total knee replacement, and to assess the efficacy of femoral nerve block in reducing opioid consumption post-operative spinal anesthesia total knee replacement. Methods A randomized controlled trial (RCT) conducted at Rafidia hospital. The patients participating in the trial were randomly assigned to either group received the femoral nerve block under investigation (intervention group) or to a group did not receive treatment (control group). The sample size based on α 0.05 and affect referred size and power 0.80. The estimated sample size is (100 participants). Results Of the 100 subjects who underwent unilateral total knee arthroplasty (TKA) included in this study, 44% (n = 44) of subjects had received a femoral nerve block (FNB) prior to total knee arthroplasty (TKA), while 56% (n = 56) did not receive a femoral nerve block prior to surgery. The two groups, femoral nerve block vs. non-femoral nerve block, showed differences in the percentage of reported postoperative surgery outcome parameters variables including nausea, vomiting, and drowsiness. Non-femoral nerve block group reported higher percentage of post-operative surgery nausea than femoral nerve block group at all post-operative surgery measured time intervals except at the 4th post-operative hour. The percentage of vomiting by non-femoral nerve block group at the 4th and 24th post-operative hours was lower (26.8% & 3.6%) than the reported percentage of vomiting by femoral nerve block group (27.3% & 4.5%). The two groups, femoral nerve block vs. non-femoral nerve block, showed no statistically differences in the mean of systolic blood pressure or diastolic blood pressure at pre and all post-operative surgery measured time intervals except at the 12th post-operative hour for systolic and diastolic blood pressure (p value < 0.05) and pre-operative heart rate (p value < 0.05). The mean of systolic blood pressure and diastolic blood pressure at 12th hour post-operative were 120.5 ± 12.9 mmHg and 70.0 ± 7.1 mmHg for non-femoral nerve block group and were 128.1±9.3 mmHg and 72.7±4.0 mmHg for femoral nerve block group The two groups, femoral nerve block vs. non-femoral nerve block, showed no statistically differences in the mean of heart rate at all post-operative surgery measured time intervals except at the pre-operative heart rate (p value < 0.05). The two groups, femoral nerve block vs. non-femoral nerve block, showed no statistically differences in the mean of O2 saturation at pre and all post-operative surgery measured time intervals (p value > 0.05). The overall pain relief among patients’ femoral nerve block group following TKR surgery was higher comparing with pain relief among non-femoral nerve block group after the surgery. There is a significant difference in post-operative surgery analgesia consumption between femoral nerve block and non-femoral nerve block. A Mann-Whitney test indicated that post-operative surgery analgesia consumption was greater for non-femoral nerve block group than femoral nerve block group (U = 66, Z score= -7.85, p = .001). The overall satisfaction of patients’ femoral nerve block group following TKR surgery was higher comparing with overall satisfaction of non-femoral nerve block group. Conclusion This study compared post-operative nausea vomiting and drowsiness pain scores, opioid consumption, and patient satisfaction between subjects who received femoral nerve block with non-femoral nerve block in total knee replacement. This study found the overall satisfaction with the function of their operation knee among patients’ femoral nerve block group following total knee replacement surgery was higher comparing with overall satisfaction with the function of their operation knee among non-femoral nerve block group after the surgery. And pain relief among patients’ femoral nerve block group following total knee replacement surgery was higher comparing with pain relief among non-femoral nerve block group after the surgery some trends in the data, do suggest efficacy in the use of a femoral nerve block for total knee replacement
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    Clinical Comparison Between Isoflurane and Sevoflurane In Patients with Open-Heart Surgery: A Prospective, Observational Study from Palestine
    (Mohammad Masoud Jaber, 2018-04-05) Jaber, Mohammad
    Background: volatile anesthetic agents sevoflurane and isoflurane gases can effects on hemodynamic intra- and post-operative course on-pump coronary artery bypass surgery in patients. Anesthesia type affects adequate depth of anesthesia, reduction in need of analgesic dosage, early extubation and transfer from the Intensive Care Unit (ICU). Objectives: Study objectives were to compare the induction and recovery criteria following anesthesia with sevoflurane and isoflurane in open heart surgery, intra and post operation. Methods: This study was an observational, cohort prospective study, it was performed at the Arab Specialized Hospital in Nablus, Heart Center in the West Bank/Palestine between May – August 2016 on all patients who were between 30-70 years and admitted to open heart surgery. All information was collected from files and observational and data collection. The statistical package of social science (SPSS) was used for data entry in statistical analysis. Results: During the study period, 63 patients were included, among them, 32 patients were given isoflurane, and 31 patients were given sevoflurane during open heart surgery. Systolic blood pressure (SBP) value was significantly lower in the isoflurane group compared to the sevoflurane group at the time of induction, once the sternum was opened, and once the sternum was closed (P< 0.05). Furthermore, diastolic blood pressure values were significantly lower in the isoflurane group compared to the sevoflurane group at the time of induction, once the sternum was opened (P = 0.004), and once the sternum was closed (P = 0.009). The median heart rate (HR) between the two groups revealed higher values in the isoflurane group, which were statistically significant when compared to the sevoflurane group at time of induction (P < 0.001 ), once the sternum was open (P = 0.001), and once the sternum was closed (P = 0.010). However, the HR values between the two groups did not reveal a statistically significant difference before induction, after Cardiac Care Unit (CCU) admission, and at extubation time (P > 0.05). The median respiratory rate in the isoflurane group was statistically significantly higher when compared to the sevoflurane group at extubation time (P < 0.001).Patients in the isoflurane group had a higher total intubation time compared to patients in the sevoflurane group (P = 0.009). In addition, the median (interquartile range) of the recovery time among patients in the sevoflurane group was significantly shorter than that among patients in the isoflurane group (120 (90-150) min versus 150 (120-180) min, respectively (P-value< 0.001)). Furthermore, regarding the duration of hospital stay, patients who received isoflurane had significantly longer hospital stays (7 [7-8] days) than patients who received sevoflurane (7 [6-7] days), (P = 0.012). Patients in the sevoflurane group were extubated earlier than those in the isoflurane group. Regarding complications that occurred post open heart surgery in patients, there was no significant difference regarding the prevalence of arrhythmias through or post open heart surgery among the two groups. Atrial fibrillation (AF) was seen in the isoflurane group in five (7.9%) patients, and in two patients (3.2%) in sevoflurane group (P = 0.226). Furthermore, no significant differences were noted in the type and incidence of complications regarding bleeding or cerebral vascular attack (CVA). Bleeding post open heart surgery was seen in five (7.9%) patients who were on isoflurane, and in three patients (4.8%) who were receiving sevoflurane (P = 0.372). CVA was reported in two patients (3.2%) in the isoflurane group and in none of the patients in the sevoflurane group (P = 0.254). On the other hand, nausea and vomiting occurred in nine (14.3%) patients who were administered isoflurane, but in only two (3.2%) patients who were administered sevoflurane (P = 0.026). Conclusions: The results reflect that sevoflurane has a better impact on hemodynamic stability than isoflurane. Sevoflurane produces better results in regards to systolic and diastolic pressure, HR, recovery time, ICU stay, analgesia dosage and muscle relaxant dosage. Sevoflurane usage results in less complications than isoflurane, but not significantly.