Asmaa Moatasem has completed her Master’s Degree from Assiut University, Egypt. She has a Fellowship in Pain Management at the University of Würzburg, Germany. She completed the European Diploma in Anaesthesiology and Intensive Care in 2015, and her PhD from Assiut University, Egypt. She is a Consultant of Anesthesia, Intensive Care and Pain Management at Assiut University, Egypt.

Introduction: Postoperative pain following open abdominal surgeries could cause a restrictive respiratory dysfunction, which is associated with poor postoperative outcomes. Thoracic epidural analgesia provides solid pain control; however, it can lead to complications, has some contraindications, and occasionally fails. Intravenous lidocaine infusion has been suggested as an alternative due to its anti-nociceptive and anti-inflammatory properties. This trial aimed at comparing perioperative intravenous lidocaine infusion with thoracic epidural analgesia for open abdominal surgery with regard to postoperative pain, opioid consumption and respiratory function. Methods: scheduled for upper abdominal surgery were randomly allocated into two groups. Intravenous lidocaine groups received 1.5 mg/kg IV bolus before induction, then intraoperative IV infusion of 2–3 mg/min and then reduced postoperatively to 0.5–1 mg/min. The thoracic epidural group received bupivacaine 0.125% epidural infusion of 5–8 ml/hour intraoperatively, and then reduced postoperatively to 4–5 ml/hour. The infusions in both groups continued for 24 hours postoperatively. Results: Sixty-nine patients (35 in the lidocaine group and 34 in the epidural group) were analyzed. There was not a statistically significant difference between the two groups with respect to the verbal numeric rating scale measured at rest at the 4th, 8th. 12th or 24th hours postoperatively, with ambulation (P=0.163) or coughing (P=0.079). Opioid consumption in the first postoperative day showed no statistically significant difference (P=0.356). Postoperative lung function (FVC–forced vital capacity, FEV1– forced expiratory volume in one second, and PEF–peak expiratory flow) showed slightly lower values than the preoperative ones in both groups. However, there was no statistically significant difference between the two groups as regard to postoperative FVC (P=0.560), FEV1 (P=0.657) or PEF (P=0.167). Conclusions: Intravenous lidocaine infusion provides postoperative analgesia comparable to that of thoracic epidural analgesia for upper abdominal surgery with opioid sparing properties.

Ah-Young Oh is an Anesthesiologist, specializing in Pediatric Anesthesia and Anesthesia Pharmacology. She has published articles in international journals regarding pediatric anesthesia, the safety and efficiency of muscle relaxants and inhalational anesthetics, monitoring the level of consciousness during general anesthesia, and postoperative pain management. She graduated from and had a Doctorship at the Seoul National University, College of Medicine.

Background: Changes in acute reactive substances of cytokines after surgery are related to the degree of tissue damage and are related to the occurrence of side effects. We evaluated the effect of deep neuromuscular blockade on the responses of inflammatory cytokines following laparoscopic gastrectomy. Method: Patients undergoing elective laparoscopic gastrectomy were randomized to either moderate (train-of-four count of 1 or 2) or deep group (post-tetanic count of 1 or 2). Neuromuscular blockade was induced and maintained with rocuronium that was reversed with sugammadex in the deep group and with neostigmine in the moderate group. Plasma TNF-α, IL-1β, IL-6, IL-8, and CRP were measured before operation and post- incision of 3, 4 and 48 hours. Results: Intraoperative spontaneous breathing (26.7% vs. 4.7%, P=0.005), and request for neuromuscular blockade (75% vs. 47.6%, P=0.015) were more frequent in the moderate group compared to the deep group. There were no statistically significant differences in post-incisional plasma TNF-α, IL-1β, IL-6, IL-8, and CRP between the two groups. Conclusion: In patients undergoing elective laparoscopic gastrectomy, intraoperative conditions were favorable during a deep neuromuscular blockade compared to a moderate neuromuscular blockade. However, the depth of neuromuscular blockade did not affect the release of inflammatory cytokines during laparoscopic gastrectomy.

Ruijuan Guo Attending doctor in Department of Anesthesiology, Beijing Friendship Hospital, Capital, Medical University, Beijing, China. Ph.D. at Capital Medical University, Beijing, China. Master of Medicine in Anesthesiology at Capital Medical University, Beijing, China. Bachelor of Medicine at Chengde Medical College, Hebei, China.

Statement of the Problem: Neuroligin1 is an important synaptic cell adhesion molecule that modulates the function of synapses through protein-protein interactions. Yet, it remains unclear whether the regulation of synaptic transmission in the spinal cord by neruoligin1 contributes to the development of postoperative pain. Methodology: In a rat model of postoperative pain induced by plantar incision, we conducted Western blot study to examine changes in the expression of postsynaptic membrane of neuroligin1, postsynaptic density (PSD)-95, and α-amino-3-hydroxy-5-methyl-4-isoxazole propionate (AMPA) receptor GluR1 and GluA2 subunits in the spinal cord dorsal horn after injury. The interaction between neuroligin1 and PSD-95 was further determined by using co-immunoprecipitation. Findings: Protein levels of neuroligin1 and GluR1, but not GluA2 and PSD-95, were significantly increased in the postsynaptic membrane of the ipsilateral dorsal horn at 3 h and one day after incision, as compared to that in control group (naïve). A greater amount of PSD-95 was co-immunoprecipitated with neuroligin1 at 3 h after incision than that in the control group. Intrathecal administration of small interfering RNAs (siRNAs) targeting neuroligin1 suppressed the expression of neuroligin1 in the spinal cord. Importantly, pretreatment with intrathecal neuroligin1 siRNA2497, but not scrambled siRNA or vehicle, prevented the upregulation of GluR1 expression at 3 h after incision, inhibited the enhanced neuroligin1/PSD-95 interaction, and attenuated postoperative pain. Conclusion & Significance: Current findings suggest that downregulation of spinal neuroligin1 expression may ameliorate postoperative pain through inhibiting neuroligin1/PSD-95 interaction and synaptic targeting of GluR1 subunit. Accordingly, spinal neuroligin1 may be a potential new target for postoperative pain treatment.

Jinghui Chen is a Senior Resident in Anaesthesia in his penultimate year of training. His interests include intensive care medicine, and clinical ultrasound in critical care.

A 50 year old female, ASA 1 with normal airway examination underwent general anesthesia for total knee arthroplasty. After induction with propofol 150 mg and fentanyl 75 mcg, bag mask ventilation was attempted and found to be difficult. An Ambu® Auragain supra-glottic airway, size 3 was inserted without any difficulties. Airway pressure was noted to be persistently high despite further boluses of propofol and administration of atracurium. A ProSeal™ LMA of size 4 was changed; however, airway pressure remained high without any improvement in tidal volumes delivered. Bronchospasm was excluded with auscultation. Decision was made for endotracheal intubation and she was intubated with a Portex® ETT, size 7.5. Direct laryngoscopy revealed edematous large epiglottis without any evidence of trauma. Post intubation airway pressures were normal without any leak, suggesting that the ventilation problem was likely supraglottic. A video laryngoscopy was performed to further examine the laryngeal structures, revealed an edematous posterior arytenoid and large swollen epiglottis. (See image). An ENT surgeon was consulted prior to extubation and our patient was extubated, with the availability of necessary backup airway equipment for reintubation if required. A nasoendoscopy was performed, showing a small larynx, a patent airway with mild posterior arytenoid oedema with granulomatous appearance suggesting chronic inflammation. Vocal cord abduction and adduction were normal. A diagnosis of laryngo-oesophageal reflux was made and our patient was started on oral pantoprazole. Further interrogation revealed that the patient had features of gastro-oesophageal reflux disease (GERD) symptoms and hoarseness of voice over the last couple of months. GERD can lead to laryngo pharyngeal inflammatory changes. This rare case highlights how an undiagnosed GERD may impact on anesthesia management and educate the anesthetist to be more vigilant to routinely look for GERD symptoms and evidence of reflux laryngitis in patients with GERD.

Ahmad Nadeem Qamar is a British doctor of Pakistani origin, currently working as a consultant anaesthetist in Prince Sultan Military Medical City, Riyadh, Kingdom of Saudi Arabia. He did bachelor of medicine and bachelor of surgery from Punjab Medical College, Faisalabad, Pakistan in 1986. After initial anaesthetic training, he cleared the membership examination of College of Physicians and Surgeons in 1992. After coming to England for further training, he did Senior House Officer rotation in London Deanery and Specialist Registrar rotation in Cambridge Deanery and passed the Fellowship of Royal College of Anaesthetists in 2001. He worked as locum consultant in England and then in 2006 I came to Saudi Arabia to continue my professional career. His research interest includes Fluid therapy, Sedation and Regional anaesthesia.

Sedation techniques have the potential to relieve anxiety, reduce pain and provide amnesia to make uncomfortable diagnostic and therapeutic procedures easy and possible. However the ethical imperative, ‘first do no harm’ includes safety of both anesthesia and sedation. Safety is challenged because even with the highest level of training, moderate sedation can proceed to deep sedation and even to general anesthesia which will compromise cardio- respiratory function that may lead to serious morbidity and mortality. The wide variability in drug dose-response relationship, as well as inter-patient difference in pharmacodynamics and pharmacokinetics limits the ability to predict the response across the patients. Managing adverse events in remote areas, outside operating room settings as gastrointestinal endoscopy and dental clinic is problematic as most places and personnel do not have the same level of training of an inpatient code team to resuscitate a patient who has cardio-respiratory arrest. It is time to make evidence-based sedation practice apply ultimate criteria for patient safety. We practiced and established run reversible principal (RRP) which recognizes and uses the pharmacological property of aminophylline to antagonize the depressant effect of benzodiazepines, barbiturates, morphine, and propofol on the conscious level as well as the cardio-respiratory functions. Doxapram which is also a respiratory and central nervous system stimulant hastens recovery from dexmedetomidine, propofol and remifentanil. Ephedrine is an indirect sympathomimetic drug increases the bispectral index (BIS) during propofol anesthesia. Thus we add aminophylline, doxapram and ephedrine to our back-up reversible plan in case of cardio-respiratory depression. We will describe our experience with other medications as dexmedetomidine and lidocaine infusion both have the ability to decrease BIS, and narcotic sparing effect without inducing respiratory depression which will make a perfect combination with remifentanil, which is an ultra-short acting narcotic medication that can even be reversed by naloxone. Safe sedation may involve increased cost in medications, training, monitoring, and staffing, which will need to be recognized in the business plans of non-anesthetic departments.