The success of major surgery depends partly on providing effective post-operative pain relief, which can be commonly achieved by morphine administration via patient- controlled analgesic (PCA) system. Alternatively, tramadol which is a weak opioid analgesic, can be used for post operative pain relief. The purpose of this study was to evaluate the effectiveness of intravenous PCA tramadol in comparison with PCA morphine in term of analgesic properties, sedation and side effects. A randomized, double-blinded study was conducted on 160 ASA I and II patients who underwent major operations. Eighty of them received a loading dose of intravenous morphine 0.1 mg/kg followed by PCA morphine bolus of 1 mg (1 mg/ml) as required, while the other 80 patients received a loading dose of 2.5 mg/kg of intravenous tramadol followed by PCA infusion of 10 mg (10 mg/ml) as required. Patients were monitored for pain, sedation and side effects as well as respiratory rate, nausea, vomiting, pruritus, blood pressure and pulse rate. Patients were evaluated 30 minutes, 4 hours, 24 hours and 48 hours post operation. There were no differences in the demographic data between the two groups (p > 0.05). The overall mean pain score in tramadol group was 0.70 +/- 0.60 as compared to 0.75 +/- 0.67 for morphine group. The mean pain score for tramadol and morphine groups at 30 minutes, 4 hours, 24 hours and 48 hours post operation were 1.32 +/- 0.79, 104 +/- 0.79, 0.35 +/- 0.48, 0.09 +/- 0.33 and 1.35 +/- 0.99, 1.14 +/- 0.81, 0.40 +/- 0.54, 0.10 +/- 0.34 respectively. The overall mean sedation score in tramadol and morphine group was 0.39 +/- 0.44 as compared to 0.35 +/- 0.43 for morphine group. The mean sedation score for tramadol and morphine group at 30 minutes, 4 hours, 24 hours and 48 hours post operation were 0.90 +/- 0.74, 0.56 +/- 0.59, 0.075 +/- 0.27, 0.025 +/- 0.16 and 0.84 +/- 0.70, 0.46 +/- 0.64, 0.08 +/- 0.27, 0.01 +/- 0.11 respectively. There was no significant difference in the overall mean pain and sedation score between the two groups as well as for each duration assessed (p > 0.05). There were also no significant differences between the two groups with regard to the blood pressure and heart rate. The incidence of nausea, vomiting and pruritus were the same in the two groups. This study indicates that PCA tramadol is as equally effective as PCA morphine control following major surgery. The incidences of sedation, nausea or pruritus were the same in the two groups.
A comparative pilot study was conducted to determine the difference in the reduction of total serum bilirubin in a group of infants who had phototherapy at home compared to an in-patient group on hospital phototherapy. Eighteen infants with unconjugated hyperbilirubinaemia who fitted the selection criteria were put under the mobile home unit (Bluelite Portable Light) placed in the home. A control group of 18 infants with the same matching characteristics had intense phototherapy in the hospital using a unit with top and bottom light sources. The infants were matched for race, starting total serum bilirubin level, birth weight (up to 250 grams) and age of baby at initiation of phototherapy (up to one-day difference). It was observed that the mean daily decrease in serum bilirubin concentration was significantly more in the home group as compared to the hospital group (t=2.95, df=17, P<0.05). The mean duration of treatment was significantly less for the home group as compared to the hospital group (t=2.84, df=17, P<0.05). None of the infants who had home phototherapy were re-hospitalized. Phototherapy related complications were mild and comparable in both groups. The result suggests that home phototherapy is safe and effective in bringing down the concentration of serum bilirubin for term babies with uncomplicated hyperbilirubinaemia.
This prospective study was designed to compare the effectiveness of esmolol (either 100 mg or 200 mg) with a placebo in blunting the haemodynamic response to laryngoscopy and intubation. Seventy-five patients of ASA I or II scheduled for routine-surgery were selected and entered into a placebo-controlled study. Patients were randomly allocated to receive placebo, 100 mg or 200 mg of esmolol IV as part of an anaesthetic induction technique. There were no significant differences in the demographic distribution of the patients in the study. There was no statistical difference in the baseline heart rate (HR) and systolic blood pressure (SBP) between the three groups. One minute after the administration of the drug (prior to intubation) the differences in HR between the placebo group and both the 100 mg and 200 mg groups were significant (p < 0.05), and also at 1 min and 2 min following intubation for the 200 mg group (p < 0.05). In the 200 mg group there was a significant decrease, compared with placebo, in SBP at 1 min (p < 0.05) and at 2 min (p < 0.05) after intubation. In this study, adequate haemodynamic control following was obtained with the administration of 200 mg of esmolol.
Background: Psychoeducation has shown promising benefits in managing patients with schizophrenia. In Malaysia, the use of psychoeducation is rather limited and its impact indeterminate.
Aims: To assess the effectiveness of a structured psychoeducation programme for the community in improving caregiver knowledge, decreasing caregivers’ burden, reducing patients’ readmission and defaulter follow up rates.
Method: In a controlled interventional study, 109 caregivers were included, 54 and 55 in the intervention and control groups respectively. Caregivers were assessed at baseline, 3 and 6 months post-intervention for knowledge and burden. Patients were monitored for relapse and defaulting follow up in the clinic.
Results: Caregivers in the intervention group showed significant improvement in knowledge, reduction in burden in assistance in daily living (severity) and a reduced defaulter rate was seen in the patients’ follow up.
Conclusion: The findings shows that structured psychoeducation programme among caregivers has the potential to improve outcome of care for patients with schizophrenia.
Keywords: Schizophrenia; Psychoeducation; Community; Caregiver Questionnaire: Family Burden Interview Schedule–Short Form (FBIS/SF)
A number of psychological approaches to alleviating psychotic symptoms have been reported in the literature. The latest technique among them is cognitive therapy (CT). This paper describes an open trial that makes use of cognitive psychotherapy to treat chronic drug resistant delusions (more than 2 years duration) in 20 patients with schizophrenia. The positive response of all patients with the absence of symptom replacement and maintenance of response at 3 months follow-up, seem to imply that this technique is useful and more effort needs to be invested into this new area of psychotherapy for psychosis. This paper also shows that those patients on risperidone maintenance respond better to CT than those on other neuroleptics.
This paper reports the result of a brief therapy attempt at treating panic in a busy outpatient psychiatric clinic. The patients were cases of panic referred from the various outpatient clinics within the hospital complex. The patients were divided into three groups at random using one of three modalities of treatment, i.e. cognitive behaviour therapy (CBT), CBT and Fluvoxamine (FVX), and FVX alone. The therapy was aimed for a maximum of nine sessions after which the patients were to be discharged. There were 14 patients in each group. The results show that all the groups were similar in the severity and scores pre treatment but after the different types of treatment there was a significant difference among them. The FVX alone group, showed significant improvement from the pretreatment levels but did not show as much improvement as the other groups and the mean score was only 9.07 after nine sessions. The best group was the CBT in combination with FVX. This indicates that the best way to treat panic is to combine drug treatment and psychological treatment. It is also shown from the study that the combination group requires less FVX than the FVX alone group. This finding has implications for the treatment of panic at the family physician clinic.
Study site: Psychiatric clinic, Hospital Universiti Sains Malaysia
A randomised single blinded clinical trial to compare the cost of cataract surgery between extracapsular cataract extraction (ECCE) and phacoemulsification (PEA) was conducted at Hospital Universiti Kebangsaan Malaysia (HUKM) between March and December 2000. A total of 60 patients were included in this study. The cost of a cataract surgery incurred by hospital, patients and households up to two months after discharge were included. The costs of training, loss of patients' income after discharge and intangible costs were excluded. Results showed that the average cost for one ECCE operation is RM1,664.46 (RM1,233.04-RM2,377.64) and for PEA is RM1,978.00 (RM1,557.87-RM3,334.50). During this short period of follow up, it can be concluded that ECCE is significantly cheaper than PEA by an average difference of RM 313.54 per patient (p < 0.001). Cost of equipment and low frequency of PEA technique done in HUKM were the two main reasons for the high unit cost of PEA as compared to ECCE.
Honey dressing has been used to promote wound healing for years but scanty scientific studies did not provide enough evidences to justify it benefits in the treatment of diabetic foot ulcers. We conducted a prospective study to compare the effect of honey dressing for Wagner's grade-II diabetic foot ulcers with controlled dressing group (povidone iodine followed by normal saline). Surgical debridement and appropriate antibiotics were prescribed in all patients. There were 30 patients age between 31 to 65-years-old (mean of 52.1 years). The mean healing time in the standard dressing group was 15.4 days (range 9-36 days) compared to 14.4 days (range 7-26 days) in the honey group (p < 0.005). In conclusion, ulcer healing was not significantly different in both study groups. Honey dressing is a safe alternative dressing for Wagner grade-II diabetic foot ulcers.
We studied the effect of fentanyl pretreatment on alleviating pain during the injection of Propofol-Lipuro. One hundred and seventy patients were randomly allocated to receive either 100 mcg of intravenous fentanyl or normal saline (placebo) followed by intravenous Propofol-Lipuro premixed with 20 mg lignocaine. The incidence of injection pain was 32% and 13% in the placebo and fentanyl groups, respectively. We found a statistically significant reduction in incidence of injection pain in the fentanyl group when compared with the placebo group (p<0.003). The number needed to treat was 6 (3.2< 95% CI <15.1). In conclusion, fentanyl pretreatment is effective in alleviating pain during injection of Propofol-Lipuro.
With the establishment of the inadequate efficiency of atropines and oximes in reducing morbidity and mortality of patients poisoned by organophosphates, more attention is given to using other methods such as Fresh Frozen Plasma (FFP) as a bioscavenger to mop up organophosphate toxins. This randomized clinical trial was conducted on 56 organophosphate poisoned patients who were randomly assigned to the FFP and control groups in order of admission. The routine treatment in both groups included atropine and, in moderate to severe cases of poisoning, pralidoxime. The FFP group received four packs of FFP as stat dose at the beginning of treatment. No significant difference was seen between the two groups on the atropine and pralidoxime dosage, hospitalization length and mortality. The present study showed that using four packs of FFP as stat dose at the onset of treatment had no significant effect on the clinical course of organophosphate poisoned patients.
The use of tissue adhesives has been widely studied since the 1960s. Since then they have found use in specialties like plastic surgery, neurosurgery, ENT surgery and dental surgery. Several papers have reported their safe use, both clinically and experimentally, particularly of the newer homologue n-butyl/2-cyanoacrylate (Histoacryl). In this study 43 patients (46 wounds) whose operations involved a groin incision were randomised into two groups for skin closure either with Dexon subcuticular suture (23 wounds) or Histoacryl glue (23 wounds). We found that both sets of wounds healed well with no wound infections or excessive inflammation when assessed at one week and four weeks. However the glued wounds had consistently better cosmesis scores (mean score 4.71 at four weeks) compared to the subcuticular Dexon wounds (mean score 4.00 at four weeks) and P value of less than 0.05. We feel that there is a place for tissue adhesives in skin closure for some general surgical wounds.
The effectiveness of sodium citrate and sodium citrate/ranitidine were compared in two randomised groups of elective caesarean patients during the various phases of anaesthesia. The mean pH values (3.5, 3.3, 3.6) were lower in the citrate group compared to the citrate/ranitidine group (6.1, 6.3, 5.9). The percentage of patients with pH values less than 2.5 was 40% in the citrate group compared to 7% in the citrate/ranitidine group. Sodium citrate alone is less effective than sodium citrate/ranitidine for acid aspiration prophylaxis.
An open prospective descriptive pilot study was undertaken to assess the effectiveness and experience in the use of ExosurfNeonatal, a synthetic surfactant, on preterm infants with respiratory distress syndrome in the neonatal intensive care unit of the Paediatric Institute. Of 10 infants treated, seven (70%) survived with no major handicap on discharge. The mean duration of ventilation for these survivors was 6.4 days, mean duration of oxygen therapy 9.1 days and mean length of hospital stay 38.3 days. A comparison was made with a retrospective analysis of 15 neonates who were admitted during an eight month period prior to the pilot study. These infants were mechanically ventilated for respiratory distress syndrome but not given surfactant therapy. Of these, nine (60%) survived (P > 0.1 compared to Exosurf treated infants), but two developed post haemorrhagic hydrocephalus requiring shunting. For these nine survivors, the mean duration of ventilator therapy was 12.6 days, the mean duration of oxygen therapy 20.7 days and the mean length of hospital stay 70.8 days. This difference was statistically significant (P < 0.05). Of the three ExosurfNeonatal treated infants who died, two were extremely premature. Both developed grade IV periventricular haemorrhage while the third infant was admitted in shock and hypothermia and died from intraventricular haemorrhage and pulmonary interstitial emphysema. Except for the very sick and extremely premature infants, surfactant therapy is useful in reducing the mortality and morbidity of premature infants with respiratory distress syndrome in our neonatal intensive unit.
Aplastic anemia is a relatively uncommon disease and conventional management options include immunosuppressive drugs and/or haematopoeitic stem cell transplantation. It is now known that the pathogenesis of aplastic anemia is immune mediated. Mycophenolate mofetil is a common immunosuppressive drug now used mainly in prophylaxis of graft rejection in organ transplant and also for prevention/treatment for graft versus host disease in haemtopoeitic stem cell transplantation. It is thought that mycophenolate mofetil may be useful in this group of patients. In this short report, mycophenolate mofetil was tried in 6 patients who had severe aplastic anemia with variable doses for a minimum duration of 9 months. The result has however not been encouraging.
Phenylephrine in concentrations of either 2.5% or 10% is widely used as a mydriatic agent in ophthalmic surgery. Its potential cardiovascular effects are seldom recorded as ophthalmic surgery is not usually monitored by an anaesthetist. A prospective randomised double blind study was carried out in 89 consecutive cases of uncomplicated cataract surgery in the presence of an anaesthesiologist ensuring the continuous monitoring of blood pressure, heart rate, electrocardiography and pulse oximetry. All these patients were given a drop of either normal saline, 2.5% or 10% phenylephrine in addition to mydriacyl prior to surgery. Blood pressure readings were found to be significantly higher in non-hypertensive patients receiving phenylephrine at the start of the operation and at five, 10, 15 and 20 minutes intra-operatively and the first three hours post-operatively. Blood pressure readings in hypertensive patients, on the other hand, were also found to increase after phenylephrine administration, though not statistically significant. 10.3% of the 10% phenylephrine group and 3% of the 2.5% phenylephrine group required intraoperative intravenous hypotensive agent to control the blood pressure. There were no arrhythmias or ischaemic changes observed intraoperatively. None of the patients complained of palpitation, headache or chest discomfort. There was no oxygen desaturation observed. We concluded that significant hypertensive effects can arise after phenylephrine eye drop administration. Hence, it should be used cautiously with intraoperative monitoring of the cardiovascular status during cataract surgery.
A prospective randomized double-blind study was conducted which involved, 60 ASA 1-2, aged 18-65 years patients, who had elective or emergency orthopaedic surgeries of the upper limbs. They were randomly divided into two groups: Group I received 30 mls of 0.5% ropivacaine; and Group II received 0.5% levobupivacaine for infraclavicular brachial plexus block based on the coracoid approach. The onset time required for sensory block of all required dermatomes (C5-T1) and the onset time of motor block were documented. Based on the Visual Analogue Score, pain scores were recorded every 30 minutes during surgery and at the 6th hour. The mean onset time (SD) for sensory block with ropivacaine was 13.5 +/- 2.9 minutes compared to levobupivacaine at 11.1 +/- 2.6 minutes (p = 0.003). The onset time for motor block was 19.0 +/- 2.7 minutes in Group I compared to 17.1 +/- 2.6 minutes (p = 0.013) in Group II. Patients in both groups experienced both mild to moderate pain at the 6th hour. In conclusion, there were statistically significant differences in the onset-time for sensory and motor block. However, there was no statistically significant difference in terms of effectiveness of analgesia at the 6th hour. Although the clinical advantage of levobupivacine is not substantial, its safety profile becomes a major consideration in the choice of local anaesthetic for brachial plexus block where a large volume is required for an effective result.
This prospective, randomized, study was designed to compare the effect of two different preloading volumes of Ringer's lactate for prevention of maternal hypotension induced by spinal anaesthesia for Caesarean section. Eighty ASA I or II obstetric patients were randomized to two groups. Group 1 (n = 40) received 20 ml/kg of Ringer's lactate and Group 2 (n = 40) 10 ml/kg of Ringer's lactate over 20 minutes before spinal anaesthesia. The lowest mean arterial pressure (MAP) for both groups were recorded at 15 minutes after giving spinal anaesthesia, This difference in the drop of MAP from base-line at 15 minutes (mean decrease of 12.5 mmHg from baseline), between preloading with 10 ml/kg and 20 ml/kg of Ringer's was statistically significant. Twelve patients from Group 1 required bolus doses of ephedrine and 15% of these needed additional crystalloid whereas two patients from Group 2 needed ephedrine boluses and 22% of these required additional crystalloid. The difference in frequency of requirement for treatment of hypotension was not statistically significant. There were five patients in Group 1 and six patients in Group 2 who experienced nausea and vomiting, the frequency of occurrence did not show any statistically significant difference between the two groups. In conclusion, for prevention of hypotension during spinal anaesthesia for Caesarean section, infusing 20 ml/kg or 10 ml/kg of Ringer's Lactate gave similar results and we do not recommend the use of a larger volume of crystalloid for preloading before spinal anaesthesia.
This was a prospective randomised, controlled, single-blind study done to determine the effect of intrathecal morphine 0.1 mg as compared with intrathecal fentanyl 25 microg in terms of analgesia and duration for postoperative pain relief after Caesarean section. Sixty ASA I or II parturients were randomised into two groups. Group 1 (n=33) received 1.8 ml of 0.5% hyperbaric bupivacaine combined with 0.1 mg morphine while Group 2 (n=27) received 1.8 ml of 0.5% hyperbaric bupivacaine combined with 25 microg fentanyl for spinal anaesthesia. Postoperatively, all patients were provided with patient controlled analgesia (PCA) morphine. Pain was assessed using visual analogue score (VAS) at 6, 12, 18 and 24 hours. Time to first demand of PCA morphine, cumulative PCA morphine requirement and opioid side effects were documented. The VAS for pain and the cumulative PCA morphine requirement were both significantly lower in Group 1 (p < 0.05) during the 24 hours study period. The time to first demand was also significantly longer in Group 1 (p < 0.05). Overall, there were no significant difference between the two groups in side effects, except for a high incidence of nausea and vomiting requiring treatment in Group B in the first six hours. In conclusion the addition of 0.1 mg morphine for spinal anaesthesia provided superior and longer postoperative analgesia after Caesarean section.