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January-March 2017
Volume 10 | Issue 1
Page Nos. 1-297

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REVIEW ARTICLE  

Perioperative medicine: a new concept for anesthetic care Highly accessed article p. 1
Kerolos E Moris, Amr M Hilal
DOI:10.4103/1687-7934.238445  
Perioperative medicine is the future of our specialty, and it is defined as patient-centered multidisciplinary superior medical care from the time of taking the decision of surgery till the patient’s full recovery and discharge. Formerly most of the anesthetic practice focused on the index of the operation and the disease being treated by this procedure; however the appearance of postoperative related outcomes modulated by the type and quality of surgery had encouraged the development of that new concept.
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ORIGINAL ARTICLES Top

Effectiveness of minimal acute normovolemic hemodilution to minimize allogenic blood transfusion and re-exploration in elective adult coronary artery bypass graft surgery using colloid as a replacement solution Highly accessed article p. 3
Mohammed S Shorbagy, Dina Salah
DOI:10.4103/1687-7934.238460  
Background and aim Various studies have questioned the efficacy of intraoperative acute normovolemic hemodilution (ANH) in reducing bleeding, the need for allogenic transfusion, and the incidence of re-exploration in cardiac surgery. The aim of the present study was to evaluate the effectiveness of the use of minimal ANH for blood transfusion requirements and re-opening in elective adult coronary artery bypass graft surgery using cardiopulmonary bypass. Patients and methods This prospective, randomized controlled study was conducted on 100 consecutive adult patients who underwent elective coronary artery bypass graft. Patients were randomly divided into two equal groups: the ANH group (n=50) and the control group (n=50). In the ANH group, 5–8 ml/kg of autologous blood was withdrawn after administering anesthesia and before systemic heparinization. Simultaneously, colloid solution (6% hydroxyethyl starch 130/0.4; Voluven) was infused in a ratio of 1:1, and then the blood was re-infused after bypass. Hemodilation was not carried out for the control group. Total amount of allogenic-packed red blood cell, fresh frozen plasma, platelet concentrate transfusion, and the number of patients undergoing re-opening because of excessive bleeding were calculated for the two groups. Results A significant decrease was observed in the number of red blood cell units and fresh frozen plasma transfusion per patient in the ANH group compared with the control group. Conversely, chest tube output, representing postoperative bleeding and platelet count, did not differ between the two groups. Conclusion In this study, the use of the minimal ANH technique reduced the consumption of allogenic red blood cells and fresh frozen plasma in adult cardiac surgery patients. However, this technique had no effect on postoperative bleeding, incidence of re-exploration, and platelet count.
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The effect of perioperative use of dexmedetomidine on pediatric patients with pulmonary hypertension undergoing congenital cardiac surgery Highly accessed article p. 10
Hadil M Abdel-Hamid, Mai M Abdel-Azziz, Ahmed H Aly Omar
DOI:10.4103/1687-7934.238483  
Background Anesthetic management of a pediatric patient with pulmonary arterial hypertension (PAH) poses an enormous challenge. The objective of this study was to evaluate the ability of dexmedetomidine to reduce the pulmonary artery pressure in pediatric patients with PAH undergoing cardiac surgery. Patients and method Seventy patients diagnosed with PAH were enrolled in this study. The patients were randomized into two groups: group D received dexmedetomidine infusion of 1 μg/kg/h for one hour, which was reduced to 0.5 μg/kg/h throughout the surgery until extubation in the post anesthesia care unit (PACU), and group C received 0.9% normal saline in the same volume. Pulmonary artery systolic pressure (PASP) and systemic systolic blood pressure (SSBP) were recorded throughout surgery and postoperatively in the PACU. The need for vasodilator and sedative drugs and the time of extubation and ICU stay were recorded for all patients. Results The patients in the dexmedetomidine group showed a significant decrease in PASP and PASP/SSBP ratio during surgery and throughout the first 24 h in the PACU (P<0.001). The dexmedetomidine group required a significantly lower amount of vasodilator drugs than the control group (P<0.001), as well as a lower amount of sedatives (P<0.001). Conclusion We concluded that perioperative use of dexmedetomidine in pediatric patients with pulmonary hypertension reduces the PASP throughout the operative and postoperative period.
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Postoperative analgesic effect of dexmedetomidine in patients undergoing cardiac surgery Highly accessed article p. 15
Assem A Moharram, Ashraf A.H El Midany
DOI:10.4103/1687-7934.238449  
Aim Open heart surgeries are painful procedures that require a large dose of analgesics. The aim of this study was to investigate the effect of postoperative dexmedetomidine (DEX) on the analgesic requirements in postcardiac surgery patients. Settings and design This prospective, randomized, double-blind study was conducted on 60 patients scheduled for elective coronary artery bypass graft surgery at the Cardiothoracic Surgery Unit, Ain Shams University Hospital. Patients and methods this study, group D (n=30) received DEX diluted to 4 μg/ml and infused at a rate of 0.1–0.2 μg/kg/h, whereas group C (n=30) received an equal volume of saline at an infusion rate of 0.1–0.2 μg/kg/h immediately from the end of surgery and postoperatively in the ICU thereafter. Postoperative analgesia was assessed using the Numeric Pain Intensity Scale, and sedation was assessed using the Modified Ramsay Score at T1, T2, T3, T4, T5, and T6 for the first 24 h, as well as postoperative rescue morphine analgesic requirements. Statistical analysis Analysis of data was performed using the Student t-test for independent samples for parametric data and using the χ2-tests for categorical data. Results There was a significant decrease in the pain scores in group D compared with group C (P<0.001). Morphine rescue analgesia was needed in 10% of patients in group D and in 95% of patients in group C, with a significant reduction in time to extubation and ICU length of stay in group D. The incidence of postoperative nausea and vomiting was lower in group D compared with group C but did not reach statistical significance. Conclusion Adding DEX after coronary artery bypass graft decreased both postoperative analgesic requirement and pain score without hemodynamic effects.
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Efficacy and safety of single versus repeated stepwise cycling recruitment maneuver during one-lung ventilation in patients with normal pulmonary function undergoing video-assisted thoracoscopic lung surgery: a randomized, controlled trial Highly accessed article p. 20
Elokda A Sherif, Arafa A Rasha, Gamil Khaled
DOI:10.4103/1687-7934.238456  
Background One-lung ventilation (OLV)-associated hypoxemia is a major concern and a challenge for the anesthesiologist. Lung recruitment maneuvers (RMs) are ventilator strategies in which the main goal is to restore the functional residual capacity and improve arterial oxygenation. Hemodynamic side effects are mainly associated with ‘fast’ RM not with ‘slow’ cycling RM and their effects are self-limited; therefore, they must be performed repetitively. Aim The aim of this study was to evaluate the efficacy and safety of single versus repeated stepwise cycling RMs during OLV in patients with normal lung function. Settings and design The study design is a randomized, double-blinded, controlled one. Patients and methods Sixty adult patients of ASA I–II who were scheduled for elective thoracoscopic lung surgery were randomized into groups C, single recruitment maneuver (SRM), and repeated recruitment maneuver (RRM) comprising 20 patients each. Group C patients received standard ventilation protocol: volume-controlled ventilation mode, VT 6 ml/kg, I : E ratio 1 : 2, positive end expiratory pressure (PEEP) 5 cmH2O, and respiratory rate 10–12 breaths/min. SRM patients received standard ventilation protocol with one alveolar RM 10 min after initiation of OLV with a PEEP of 10 cmH2O until end of surgery. RRM patients received standard ventilation protocol with first RM 10 min after initiation of OLV and then repeated every 30 min during OLV and a PEEP of 10 cmH2O until end of surgery. The following were assessed: hemodynamic parameters – heart rate, mean arterial blood pressure, and central venous pressure; respiratory mechanical parameters – peak airway pressure (Paw-peak), plateau pressure (Paw-plat), and static lung compliance; and oxygenation parameters – partial arterial oxygen tension (PaO2), PaO2/FiO2, and oxygen saturation (SpO2). Results PaO2 and PaO2/FiO2 ratio increased in the SRM and RRM groups after RM from T2 (10 min after first RM) to T4 (45 min from first RM), with a significant difference compared with group C (P<0.05). Peak and plateau airway pressures declined in the SRM and RRM groups after RM from T2 to T4, with a significant difference when compared with group C (P<0.05). Static lung compliance increased in the SRM and RRM groups after RM, with a significant difference among the groups (P<0.05). Conclusion Single or repeated cycling RM was considered effective with high safety profile in patients with normal pulmonary function undergoing thoracoscopic lung surgery using OLV.
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Perioperative magnesium sulfate: an adjuvant to patients undergoing video-assisted thoracoscopic surgery p. 28
Assem A Moharram, Aktham A Shoukry, Nirvana A Elshalakany, Ahmed M Mostafa
DOI:10.4103/1687-7934.238467  
Background This randomized, prospective, double-blind, placebo-controlled study was designed to assess perioperative magnesium sulfate, an N-methyl-d-aspartate receptor blocker, as an anesthetic adjuvant reducing intraoperative anesthetic requirement, with a decrease in postoperative analgesic requirement and less adverse events. Patients and methods A total of 24 patients undergoing video-assisted thoracoscopic surgery were included in two parallel groups − the magnesium group (group M, n=12) received magnesium sulfate 40 mg/kg intravenously before induction of anesthesia followed by 15 mg/kg/h continuous intravenous infusion during the operation. The same volume of isotonic solution was administered to the control group (group C, n=12). Primary outcome measures were postoperative analgesic requirement (doses of morphine and ketorolac). Secondary outcomes included intraoperative anesthetic requirements (fentanyl, sevoflurane, and vecuronium), postoperative visual analog score, Ramsay sedation score, and postoperative adverse events. Results In the magnesium group, there was a reduction in intraoperative fentanyl (P=0.01), sevoflurane (P=0.02), and vecuronium (P=0.008), with a significant reduction in the postoperative dose of morphine (P=0.02), the need for rescue ketorolac (P=0.02), and a significant reduction in visual analog score and Ramsay sedation score compared with group C at 2, 3, 4, 6, and 8 h. There was a significant reduction in the number of patients who suffered an episode of tachyarrhythmia (P=0.03) with a decrease in nausea (P=0.06), vomiting (P=0.06), and pruritus (P=0.3), but did not reach statistical significance in group M compared with group C. Conclusion Magnesium sulfate as an anesthetic adjuvant decreased postoperative analgesic requirement with a decrease in intraoperative anesthetic doses, with less adverse events.
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Propofol, remifentanil, and low-dose atracurium besylate versus sevoflurane and fentanyl for bronchoscopy in children: a randomized-controlled trial p. 34
Amr Ahmed Kasem, Fekry Elbokl, Hany Elzahaby, Hisham Elazzazy, Ahmed Elsayed, Amr Ahmed Kasem
DOI:10.4103/1687-7934.238452  
Objective The aim of this study was to compare the use of remifentanil and propofol infusion plus low-dose atracurium besylate technique with the commonly used inhalational technique using sevoflurane with fentanyl for children undergoing bronchoscopy for foreign body (FB) removal. Patients and methods This prospective randomized-controlled trial was conducted at Ain Shams University Hospitals. Sixty children aged 1–5 years planned for elective or emergency FB removal by bronchoscopy were included in the current study. The recruited children were assigned randomly into two groups: group I: total intravenous anesthesia (TIVA group) (remifentanil, propofol, and low-dose atracurium besylate); group II: volatile induction and maintenance of anesthesia (VIMA) (sevoflurane and fentanyl). Intraoperative and postoperative measurements and complications were recorded. Results There was no statistically significant difference between both groups in induction time, bronchoscopy time, time for discharge from the recovery room, and emergence time between both groups. The number of bronchoscopy attempts, interruptions of bronchoscopy, and body movements were significantly higher in the VIMA group than the TIVA group; satisfaction with surgery was greater in the TIVA group than the VIMA group. There was no difference between groups in the incidence of complications, except for postoperative agitation, with a higher incidence in the VIMA group compared with the TIVA group. Conclusion The use of 0.1 µg/kg/min remifentanil-propofol TIVA, plus a small dose (0.25 mg/kg) of atracurium besylate at induction, provided stable hemodynamics, better surgeon satisfaction, and less postoperative agitation compared with sevoflurane 2% in 100% oxygen plus fentanyl 1 µg/kg in children undergoing tracheobronchial FB removal during rigid bronchoscopy.
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Evaluation of the value of hypertonic saline as adjuvant treatment of severe ovarian hyperstimulation syndrome p. 41
Amr Sobhy, Hany V Zaki, Doaa M Kamal Eldin, Walid E Mohammed
DOI:10.4103/asja.asja_3_17  
Background At present, ovarian hyperstimulation syndrome (OHSS) is an uncommon and potentially life-threatening complication of ovarian stimulation. The ideal colloid solution for the treatment of patients with severe OHSS is still unknown. Human albumin, however, is considered the most ‘physiologic’ solution for this purpose and commonly used. However, severe life-threatening anaphylaxis has been reported with albumin infusion. The purpose of this study was to compare the efficacy and safety of hypertonic saline 3% for the treatment of severe OHSS rather than albumin. Patients and methods Over a period of 2 years, this randomized prospective study was conducted on 60 patients diagnosed with severe or critical OHSS admitted to Obstetric ICU of Ain-Shams University Hospitals. Patients were randomly allocated into two groups, each containing 30 patients. Group A (n=30) received 100 ml of albumin 20% over 4 h every 12 h plus conventional treatment according to the Ain Shams obstetric ICU protocol. Group N (n=30) received 500 ml of hypertonic saline 3% over 24 h (20 ml/h) plus conventional treatment. The efficacy of the study medications was compared in this study between the two groups in terms of daily urine output, serum creatinitine, percentage of occurrence established renal impairment, need of paracentesis, occurrence of established acute respiratory distress syndrome, and ICU length of stay. Results Significant difference was found regarding daily urine output among the study groups, with a significantly higher value (3350±142.6) in group N compared with group A (2150±133.4) associated with significant reduction in occurrence of established renal impairment in three cases in group A rather than 1 in group N. This is reflected by significant reduction in the length of ICU stay (3.1±1.1) in group N rather than group A (3.7±1.2). Conclusion The use of hypertonic saline 3% as a small-volume resuscitation is comparable to and effective and superior to albumin for the treatment of severe OHSS with regard to urine output, and may have a protective effect against occurrence of acute respiratory distress syndrome in such patients, but further studies are needed to prove that.
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Evaluation of the value of early use of norepinephrine infusion in the improvement of renal function in patients with severe sepsis with early renal impairment using cystatin C, a sensitive renal marker p. 46
Amr Sobhy, Ayman I. Tharwat, Ahmad Nabil, Akthm Adel
DOI:10.4103/1687-7934.238464  
Introduction Acute renal failure occurs in ∼23% of patients with severe sepsis. The combination of acute renal failure and severe sepsis may carry a mortality of up to 70%. Several studies have demonstrated that serum cystatin C level is a better marker of glomerular filtration rate (GFR) compared with serum creatinine, particularly for individuals with small-to-moderate decreases in GFR. To maintain organ perfusion in sepsis, a mean arterial pressure of 65 mmHg should be maintained with fluid therapy and vasopressors. Marked delays in initiation are associated with increase in mortality risk in patients with septic shock. Patients and methods Sixty patients enrolled in the study proved to have severe sepsis with early renal impairment. Patients were randomly allocated into one of two groups (30 patients each): the norepinephrine infusion group (the N group) and the control group (the C group). The N group received norepinephrine infusion + conventional treatment for severe sepsis, whereas the C group was treated with conventional treatment for severe sepsis according to the latest Surviving Sepsis Campaign. For each patient, the following data were collected: age, body weight, hemodynamic changes, urine output, renal function as detected from levels of the sensitive renal marker cystatin C and from serum creatinine levels, blood urea nitrogen, and estimated GFR (eGFR). Results There was a statistically significant increase in blood pressure and urine output in the N group at 10 min and 2 h, respectively, after norepinephrine infusion and on comparing subsequent measures with baseline values (T0) and also when compared with corresponding values in the C group. In addition, patients in the N group showed a statistically signifi cant decrease in serum cystatin C levels and an increase in eGFR based on cystatin C levels after 2 h of norepinephrine infusion, compared with baseline values and values in the C group, denoting marked improvement in GFR. Serum creatinine levels, blood urea nitrogen levels, and eGFR based on serum creatinine levels showed no significant difference in either group whether compared with baseline of the same group or when comparing both groups together. Conclusion The results this study demonstrate that early continuous infusion of norepinephrine at 0.5–1 μg/ kg/min may have a renoprotective role in septic patients with early renal impairment detected by levels of the sensitive renal marker cystatin C.
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Local application of tranexamic acid to reduce upper gastrointestinal bleeding in patients with liver cirrhosis p. 54
Rasha S Bondok, Dina Salah, Wael Sayed
DOI:10.4103/1687-7934.238465  
Background There has been a growing interest in the topical use of tranexamic acid (TXA) for the prevention of bleeding during different surgeries. Patients with liver cirrhosis may develop upper gastrointestinal (UGI) bleeding, which arises because of portal hypertension, which includes gastroesophageal varices and portal hypertensive gastropathy. The aim of this study was to evaluate the efficacy of the local application of TXA in reducing blood loss, transfusion requirements, and shortening the time for emergency endoscopy in cirrhotic patients presenting with UGI bleeding. Patients and methods A total of 100 patients with end-stage chronic liver disease presenting with UGI bleeding were randomly assigned to two groups to receive a standard protocol for UGI bleeding management, in addition to nasogastric lavage with either normal saline only (group S) or normal saline with TXA (group S+TXA). The lavage was repeated till its measured hematocrit (Hct) was less than 1%. The duration to reach this Hct was recorded. The volume of washes and transfusion requirements for each group were also recorded. Results Hemodynamic stability was observed in group S+TXA with less bleeding. The volumes of washes were significantly lower in group S+TXA. Time to reach Hct less than 1% in washed fluid was significantly shorter in group S+TXA (81.5±20.7 min) compared with group S (230.1±29.9 min). Transfusion requirements were significantly low in group S+TXA (765±184 ml) compared with group S (1345±278 ml). Duration to perform emergency upper endoscopy was shorter in group S+TXA (667±198 min) compared with group S (1094±163 min). Conclusion Local application of TXA during nasogastric lavage was efficient in reducing blood loss and transfusion requirements and in shortening the time for emergency endoscopy in cirrhotic patients presenting with UGI bleeding.
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Intravenous glutamine supplementation improves gut mucosal function in burn patients: a randomized controlled trial p. 60
Yasser A Salem, Heba A Labib, Mohammad A.S Algendy
DOI:10.4103/1687-7934.238453  
Background Glutamine supplementation in burned adults was found to improve the overall immune functions and gut integrity, and shortens overall hospital stay after burn injury with better clinical outcome. Glutamine depletion jeopardizes the functional integrity of the gut and leads to immunosuppression. Enteral intolerance is a clinical sign of defective gut mucosal integrity and is considered as a major complication along the course of treatment of burned patients. It is associated with the development of sepsis and increased mortality. We aimed in this study to find out whether intravenous glutamine supplementation will improve tolerance to enteral feeding and eventually clinical outcome of burn patients. Patients and methods Sixty critically ill burn patients were included in this study. They were randomly allocated into two groups. Group A received intravenous glutamine, and group B received placebo. Both groups were assessed as regards inflammatory and nutritional markers. Tolerance to enteral nutrition was observed and compared between the two groups, in addition to development of bacteremia. Results Group A patients were found to be more tolerant to enteral feeding compared with group B patients, with a statistically significant drop in enteral feeding intolerance rate in group A (P=0.048). As regards nutritional markers, a drop in serum transferrin and serum prealbumin with statistical significance was noticed among group B patients compared with group A patients after day 7, whereas no difference of statistical significance was noticed in serum albumin values. Positivity of blood culture for gram-negative organisms was less frequent among patients in group A, with high statistical significance. Conclusion Early use of intravenous glutamine in severely burned patients might provide a gut mucosal protective value reflected on its function. This was evident with improvement in enteral feeding intolerance, in addition to improvement in the barrier function of the gut mucosa that limits bacterial translocation.
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Comparative study between enteral and intradialytic parenteral nutrition in hemodialysis patients p. 68
Ahmed M El demerdash, Sherif G Anis, Heba Abd Elazim Labib, Sherif Farouk Ibrahim, Alaa El-din Abd Elwahab Koraa
DOI:10.4103/1687-7934.238455  
Background Protein–energy malnutrition is very common among patients with end-stage renal disease undergoing maintenance hemodialysis therapy. Aim The aim of this prospective randomized study was to compare the effect of enteral nutrition (EN) and intradialytic parenteral nutrition (IDPN) on malnourished hemodialysis patients receiving nutritional support admitted in the intensive care unit. Patients and methods A total of 135 patients between 18 and 60 years of age admitted in Ain shams University Hospitals’ intensive care units and on regular hemodialysis were randomly allocated to three groups of 45 each. Group A received enteral and IDPN (250 ml dextrose 25%, 250 ml intralipid 10%, 250 nephrosteril 7%, and trace elements and vitamins). Group B received enteral and IDPN (250 ml dextrose 25%, 250 ml intralipid 10%, 250 aminosteril N-Hepa 8%, and trace elements and vitamins). Group C received only EN. The following evaluations were carried out: biochemical evaluation, which included serum albumin, prealbumin, transferrin, and urinary urea nitrogen evaluation every 20, 4, 8, and 0 days, respectively, and after 6 weeks at the end of the study, and anthropometric parameter measurement, which included BMI, mid-arm circumference, and dialysis malnutrition score (DMS). Results Serum albumin, prealbumin, BMI, and DMS significantly increased (P≤0.001) at the end in all groups. Serum transferrin increased only in groups A and B (P≤0.001), and there was a nonsignificant increase in group C (P≤0.05). No significant difference was found at the end between group A and group B as regards serum albumin (P=0.056), serum prealbumin (0.062), serum transferrin (0.0942), BMI (0.455), and DMS (P=0.840). Serum albumin, prealbumin, transferrin, and BMI showed a significant difference (P≤0.001) in group C at the end of the study in comparison with groups A and B with lower SD. Conclusion IDPN, either aromatic or branched amino acid, in addition to EN showed the same and greater improvement compared with patients who received only EN.
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Hypotensive anesthesia for the correction of scoliosis under total intravenous anesthesia: comparison between dexmedetomidine and magnesium sulfate p. 76
Ibrahim A Nasr, Khaled M Elnaghy, Hesham F Soliman
DOI:10.4103/1687-7934.238468  
Context This study was designed to compare dexmedetomidine with magnesium sulfate as an adjunctive to total intravenous anesthesia (TIVA) as regards the efficacy and safety as hypotensive agents in scoliosis correction surgery. Patients and methods This prospective randomized double-blinded study included 40 patients of American Society of Anesthesiology II who were scheduled for the correction of scoliosis under TIVA and divided into two groups of 20 patients each. The first group was the Dex group, which was administered dexmedetomidine infusion at a rate of 0.5 μg/kg/h, and the second group was the Mg group, which was administered magnesium sulfate infusion at a rate of 15 mg/kg/h. The target mean arterial pressure (MAP) was 60–70 mmHg. The two groups were compared as regards MAP, heart rate (HR), intraoperative blood loss, blood transfusion, quality of surgical field, need for vasodilators and analgesics, time to extubation, time to recover the hypotension, time to recover the full conscious level, and perioperative serum levels of calcium and magnesium. Results Both groups could achieve the target MAP before skin incision. The Dex group showed more HR stability, less intraoperative blood loss, and less intraoperative blood transfusion with better surgical field quality. Moreover, the need for vasodilators was lesser in this group. However, the Mg group showed faster extubation time, faster reversibility of hypotension, and faster recovery of full conscious level. Need for intraoperative analgesia was comparable between the two groups. Intraoperative and postoperative serum magnesium were higher in the Mg group and intraoperative and postoperative serum calcium levels showed gradual drop in the Mg group compared with the Dex group and the preoperative level in the Mg group. Both electrolytes showed recovery to normal preoperative level 24 h postoperatively without interference. Conclusion TIVA with both dexmedetomidine and magnesium sulfate could achieve the target MAP for hypotensive anesthesia. Dexmedetomidine can control MAP with lesser need for vasodilators and with better control of HR. It provided lesser blood loss and better quality of surgical field. Magnesium sulfate showed faster extubation and recovery of conscious level with faster reversibility of hypotensive state but with the risk for perioperative hypocalcemia.
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Management of early postoperative hypoxemia: a comparative performance of Hudson face mask with nasal prongs p. 84
Suleiman A Adetunji, Oyebola O Adekola, Ibironke Desalu, Olushola T Kushimo
DOI:10.4103/1687-7934.238469  
Introduction Early postoperative hypoxemia may occur when patients breathe room air during their initial recovery period. Prolonged hypoxemia can result in delirium, dysrhythmia, and cardiac arrest. Aim The aim of the present study was to compare the performance of face mask compared with that of the nasal prong in the management of early postoperative hypoxemia. Patients and methods All procedures were performed using standard anesthetic and surgical techniques modified to the specific procedures. All patients had peripheral oxygen saturation (SpO2) at least 97% before being transferred to the recovery room. On arrival to the recovery room, 120 patients whose SpO2 decreased up to 94% were randomly allocated to either the face mask or nasal prong groups. They were commenced on oxygen therapy at 4 l/min through either device. A modified visual analogues scale was used to evaluate the level of comfort during oxygen therapy. Results Early postoperative hypoxia occurred in 18.1%. The increase in oxygen saturation after commencement of oxygen therapy was significantly faster with nasal prongs (0.63±1.42 min) than with face mask (1.78±1.10 min) (P=0.001). The maximum SpO2 obtained was significantly higher with nasal prongs (98.77±1.29%) than with face mask (97.63±1.89%) (P<0.001). There was no significant association found between early postoperative hypoxemia and site or duration of surgery, as well as the volume of intravenous fluid (crystalloids) administered intraoperatively (P>0.05). Nasal prongs (91.7%) were significantly more comfortable compared with face mask (61.7%) (P=0.001). We have demonstrated that the use of nasal prongs was more efficient and comfortable compared with face mask in the management of early postoperative hypoxemia.
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Controlled hypotension for functional endoscopic sinus surgery: a Comparative study between magnesium sulfate and nitroglycerin p. 91
Randa Ali Shoukry, Ahmed El-Sayed Mahmoud
DOI:10.4103/asja.asja_46_16  
Background Intraoperative bleeding during functional endoscopic sinus surgery (FESS) leads to poor visibility of the surgical field, and is of major concern. Controlled hypotension, using a variety of pharmacological agents, during general anesthesia reduces blood loss and helps clear visibility of the surgical field during FESS. The aim of this study was to compare the surgical conditions for FESS during controlled hypotension provided by nitroglycerin (NTG) versus magnesium sulfate (MGS) under general anesthesia. Patients and methods Fifty adult patients of both sexes requiring FESS under general anesthesia were randomly divided to receive either NTG infusion of 3–5 µg/kg/min (group NTG, n=25) or MGS (group MGS, n=25) 30 mg/kg, administered as a slow intravenous bolus and 10 mg/kg/h by continuous infusion during the operation, to provide controlled hypotension. In both the groups, the mean arterial blood pressure was reduced until the targeted mean arterial blood pressure (55–65 mmHg) was achieved. Results Both drugs produced the desired hypotension, in the magnesium group there were better operative conditions, reduction in the duration of surgery (85.3±13.1 vs. 92.9±10.3 min) and reduced anesthetic requirements [average end-tidal sevoflurane concentration (vol %) and fentanyl consumption (μg); P<0.0001]. However, there was longer extubation time (10.0±2.9 vs. 5.5±2.3 min) and recovery time (16.7±4.4 vs. 9.8±2.3 min) in comparison with the NTG group. Heart rate values were significantly higher in the NTG group compared with the magnesium group (P<0.0004). Conclusion Both NTG and MGS can be used safely to provide controlled hypotension during FESS. However, MGS was better as it provided optimum surgical condition and less tachycardia. In addition, it led to decreased anesthetic requirements.
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Postoperative outcome in major abdominal trauma: is the treatment of hypoalbuminemia beneficial? p. 97
Farahat Ibrahim, Essam F Abdelgalel
DOI:10.4103/1687-7934.238472  
Background It had been suggested that the use of fluids containing albumin in critically ill patients may increase the absolute risk for death when compared with crystalloids. Objective The aim of this study was to compare the effect of albumin infusion versus conservative therapy on both serum albumin concentration (SAC) and patient outcome in case of postoperative hypoalbuminemia after exploration laparotomy for major abdominal trauma. Patients and methods Sixty-four patients with major abdominal trauma who had undergone exploration laparotomy were studied. In addition to patient’s demographic data, serial postoperative SAC and intra-abdominal pressure up to the seventh day were measured. Moreover, clinical, laboratory, and radiological follow-up was conducted to evaluate the morbidity until patient discharge from the hospital. The mortality rate was also recorded. Results There were no significant differences between patients who received albumin (group A) for the treatment of hypoalbuminemia and those who did not receive albumin (group B) as regards length of ICU stay (P=0.33), first postoperative day SAC (P=0.99), total complications (P=1), and individual postoperative complications [hemodynamic instability with vasopressor requirement (P=0.74), abdominal compartment syndrome (P=1), multiple organ dysfunction syndrome (P=1), and anastomotic leak (P=1), acute respiratory distress (P<0.6), and mortality (P=1)]. However, SAC was significantly higher on the third, fifth, and seventh day postoperatively in group A than in group B (P<0.001). Conclusion Postoperative treatment of hypoalbuminemia in major abdominal trauma had no benefit as regards morbidity and mortality.
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Efficacy of adding fixed dose dexmedetomidine to nitroglycerin for controlled hypotension in functional endoscopic sinus surgery p. 103
Eslam N Nada
DOI:10.4103/asja.asja_49_16  
Background Functional endoscopic sinus surgery (FESS) is a surgical procedure during which all possible measures to minimize bleeding should be considered, as even small amount of blood may obstruct vision. Controlled hypotension is one of these measures used to limit intraoperative blood loss to provide the best possible surgical field. The aim of this study was to compare the effect of a fixed dose of dexmedetomidine (DEX) and nitroglycerin (NTG) with NTG alone on hemodynamic parameters, NTG dose, surgeon satisfaction, and blood loss during controlled hypotensive anesthesia in FESS. Patients and methods Fifty patients of both sexes, classified as American Society of Anesthesia physical status I and II, aged between 20 and 50 years, and candidates for FESS were randomly allocated into two groups by using the sealed envelope method. Group I (n=25) received hypotensive anesthesia with NTG and group II (n=25) received hypotensive anesthesia with NTG and DEX. DEX 1 μg/kg over 10 min was given, and then infused by a syringe pump at a fixed rate of 0.5 μg/kg/h before induction of anesthesia in group II only. After induction and intubation NTG was infused in both groups and titrated to obtain a target mean arterial blood pressure (MAP) of 55–65 mmHg. The MAP and heart rate (HR) were measured at baseline, and then periodically. The following parameters were also recorded: duration of surgical interference (time from the beginning to the end of surgical intervention), blood loss volume, surgeon satisfaction, time to achievement of the target MAP, time to reversibility of MAP to baseline, and the highest dose of NTG needed to reach target MAP. Results There was no significant difference between two groups regarding demographic data, basal hemodynamics, duration of surgical intervention, American Society of Anesthesia physical status, surgeon satisfaction, and all measurements of MAP except time of intubation, which was significantly less in group II. On the other hand, there was a significant difference between both groups regarding HR, time to achievement and reversibility of MAP, blood loss volume, and the highest dose of NTG needed to reach the target MAP, as all of these measurements were significantly lower in group II. Conclusion DEX (1 μg/kg bolus, followed by 0.5 μg/kg/h infusion) and NTG is superior to NTG alone in rapid achievement of target MAP with lower HR and lower NTG doses and in reducing blood loss volume during FESS.
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Nasopharyngeal airway for oxygenation and sevoflurane inhalation during endoscopic retrograde cholangiopancreatography in patients with obstructive sleep apnea p. 109
Alfred M Said, Heba B El-Serwi
DOI:10.4103/1687-7934.238484  
Objectives The aim of this study was to evaluate applicability of nasopharyngeal airway (NPA) for the maintenance of patients’ oxygenation during sevoflurane inhalational anesthesia through NPA against propofol infusion and traditional endotracheal intubation (ETT). Patients and methods The study included 111 patients with obstructive sleep apnea (OSA). Risk of OSA was evaluated preoperatively using the STOP-BANG Questionnaire. Patients were randomly allocated into three groups: group E received propofol infusion (50–150 μg/kg/min) with atracurium (0.3 mg/kg), group S received sevoflurane inhalation (1 MAC) through NPA, and group P was maintained on propofol infusion (50–150 μg/kg/min). The frequency and severity of hypoxemic attacks and the requirement for ETT in groups S and P were compared. Results Sixty-four patients (57.7%) had mild, whereas and 47 patients (42.3%) had an iintermediate OSA grade on STOP-BANG score. At the end of endoscopic retrograde cholangiopancreatography, heart rate, mean arterial pressure, and mean PSaO2 measures were found significantly lower in all patients compared with baseline estimates. Concentration of PSaO2 was significantly lower in group P compared with groups E and S. The frequency of hypoxemic attacks was nonsignificantly higher with NPA compared with ETT and only five patients required ETT. The frequency of procedural sedation-related adverse events was nonsignificantly lower with NPA compared with ETT (27 vs. 32.4%). The frequency till full recovery was significantly longer in group E compared with groups S and P, with a significant difference in favor of group S. Patients’ satisfaction scorings were significantly higher in groups S and P compared with group E. Endoscopist satisfaction scorings were significantly higher in groups S and E compared with group P. Conclusion NPA could be applied for the oxygenation of patients undergoing endoscopic retrograde cholangiopancreatography, even on those having OSA with an acceptable frequency of hypoxic attacks and conversion rate to ETT. Sevoflurane sedation was an advantageous alternative to propofol sedation for an early, easy recovery with less adverse events.
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Comparative study between Macintosh versus C-MAC laryngoscopic performance in airway management with dexmedetomidine as stress response attenuator in obese patients p. 117
Abdelazim A.T Hegazy, Ahmed F Abd El-Aziz
DOI:10.4103/asja.asja_89_16  
Introduction Laryngoscopy as well as tracheal intubation causes changes in the hemodynamics of the patient owing to stress response. C-MAC videolaryngoscope (VL) is a relatively recent development that improves the success of tracheal intubation. Aim The aim of this study was to compare and evaluate the effects of dexmedetomidine for attenuation of hemodynamic responses during laryngoscopy using Macintosh laryngoscope versus C-MAC laryngoscope. Patients and methods A total of 60 patients, ASA II, 18–60 years old, scheduled for different surgeries under general anesthesia with BMI up to 40 kg/m2 were included in the study. Patients were divided into two groups (30 patients each) and were appropriately positioned, and intubation was done. Hemodynamic stress response to intubation was recorded, and plasma epinephrine level was estimated at baseline and at 1 and 5 min after intubation. Success rate, duration, attempts of intubation, and SpO2% were assessed. Results Plasma epinephrine level (ng/ml) at baseline and at 1 and 5 min after intubation showed no statistically significant difference in both groups, but there were highly significant differences at 1 and 5 min after intubation compared with baseline values (P<0.0001 and <0.0007, respectively) in each group. Intubation time was longer in ML (17±4.47 s) compared within VL (12±3.4 s). There were no significant differences between both groups after intubation regarding hemodynamic changes, SpO2, or EtCO2. Conclusion The stress response in both laryngoscopic techniques appears to be the same as detected by the nonsignificant difference in plasma epinephrine levels and hemodynamic changes in both groups, so 1 μg/kg dexmedetomidine is not enough to obtund the stress response completely. C-MAC VL is an efficient and suitable intubating device and provides excellent visualization of laryngeal structures in shorter time with less intubation attempts than Macintosh (Techron Surgical, Sialkot, P, Pakistan) laryngoscopy.
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Hypotensive anesthesia during functional endoscopic sinus surgery: a comparative study of remifentanil versus magnesium sulfate infusion p. 124
Michel B. Zaky, Amir K.E. Saleh
DOI:10.4103/1687-7934.238486  
Objective The aim of this study was to compare the adequacy and outcome of controlled hypotensive anesthesia using remifentanil or magnesium sulfate during functional endoscopic sinus surgery (FESS). Patients and methods The study included 104 patients with chronic rhinosinusitis assigned for FESS. They were randomly divided into two equal groups: group R received remifentanil loading dose of 1 μg/kg over 60 s, followed by 0.15 μg/kg/min infusion, and group M received magnesium sulfate loading dose of 40 mg/kg over 10 min, followed by 15 mg/kg/h infusion. Hemodynamic variables were noninvasively monitored and expressed every 15 min. Operative field bleeding and subsequently its visibility were graded using a six-point scale. Recovery time was estimated as the time until the patient achieves a modified Aldrete scoring of 11 or more. The degree of sedation was assessed using the Brussels Sedation Scale. Results The mean collective heart rate and mean arterial pressure measures were signifi cantly low in group R compared with group M. The mean amount of collected blood loss and total field visibility scale score were significantly lower with remifentanil than with magnesium sulfate. The frequency of patients who achieved early recovery was significantly higher with remifentanil with significantly shorter time to achieve modified Aldrete scoring of 11 or more compared with magnesium sulfate. Conclusion Controlled hypotensive anesthesia minimized bleeding and provided excellent fi eld visibility during FESS. Remifentanil provided superior outcome manifested as signifi cant reduction in operative field bleeding, better field visibility, and shorter operative time compared with magnesium sulfate. In addition, remifentanil provided early recovery without postoperative sedation and thus allowed FESS to be conducted as a day-case surgery.
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Efficacy of preoperative autologous blood donation and tranexamic acid in revision total hip arthroplasty: a randomized controlled trial p. 131
Dina Y Kassim, Ibrahim M Esmat, Mohammed A Elgendy
DOI:10.4103/asja.asja_107_16  
Background Revision total hip arthroplasty (RTHA) is known to entail some risk of hemorrhage during the intraoperative period. Preoperative autologous blood donation (PAD) is one of the most popular alternatives to allogeneic blood transfusion (ABT) in elderly patients undergoing major orthopedic procedures in which a substantial blood loss is expected. The aim of this study was to evaluate the effectiveness of a combination of PAD and intravenous tranexamic acid (TXA) in reducing the need for ABT following RTHA. Patients and methods A total of 60 patients were included in this randomized study that were divided into a study group of 30 patients, who had been transfused autologous blood and a control group of 30 patients who had been transfused only allogeneic blood. Parenteral iron preparation was given to all patients of the study group after each donation. Intraoperatively all patients of the study group received 2 g of intravenous TXA. This study was conducted through laboratory analysis of hemoglobin and hematocrit values during blood donation and for both groups in the preoperative and the postoperative period and the assessment of the amount of transfused blood units in both groups. Results The average values of hemoglobin and hematocrit in the first and the second donation were 11.9±1.2 g/dl, 36.1±3.8%, and 11.9±1.0 g/dl, 35.6±3.5%, respectively. During operative and postoperative periods, the statistical data processing showed that there was a nonsignificant difference between the study and control groups regarding the number of transfused blood units (both autologous and allogeneic) (P=0.578 and 0.089), respectively, and only 10% of patients in the study group needed allogeneic blood. Conclusion PAD combined with intraoperative intravenous TXA administration reduced the number of ABTs in patients who underwent RTHA.
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Comparative study between sevoflurane and isoflurane on the perioperative and postoperative bleeding of adenotonsillectomy patients p. 140
Sanaa el Fawal, Wail Ahmed Abdelaal, Walid Hamed Nofal
DOI:10.4103/asja.asja_109_16  
Objective The aim of this study was to compare the effects of volatile anesthetics isoflurane and sevoflurane on intraoperative and postoperative bleeding in patients who underwent tonsillectomy and adenoidectomy. Patients and methods A total of 64 children classified as American Society of Anesthesiologists class I or II, aged between 2 and 16 years, who were scheduled for tonsillectomy and adenoidectomy were included in this prospective randomized double-blind study. The patients were randomized into two groups, isoflurane group and sevoflurane group, with each including 32 patients. They received balanced general anesthesia with isoflurane concentration 1.2% or sevoflurane concentration 2%. In all patients, the amount of intraoperative blood loss in milliliters was measured by the suction bottle, as well as by weighing the used sponges for each patient. The duration of operation and recovery time were recorded. Results Isoflurane caused significantly lower amount of perioperative bleeding compared with sevoflurane (P=0.03). No significant difference was observed between the two groups in terms of age, BMI, and operation duration, Conclusion Anesthesia with isoflurane can lead to a lower amount of intraoperative bleeding compared with sevoflurane. Therefore, isoflurane may be preferred as an inhalational agent for maintenance of general anesthesia during tonsillectomy and adenoidectomy operations.
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Aprepitant for attenuation of postoperative nausea and vomiting with a decrease in postoperative analgesic needs after laparoscopic surgery p. 144
Mostafa M Hussein, Raham H Mostafa
DOI:10.4103/asja.asja_110_16  
Background Postoperative nausea and vomiting (PONV) is one of the most common postsurgical complications. Multiple drugs have been used to prevent its occurrence. Ondansetron and aprepitant block the emetic effect of serotonin and neurokinin, respectively. Corticosteroids are well known for their anti-inflammatory effects, but the basis behind their use as antiemetics is not well understood. Objective The aim was to investigate the effect of combining aprepitant with ondansetron and dexamethasone compared with ondansetron and dexamethasone alone on PONV in patients undergoing laparoscopic cholecystectomy. Patients and methods A total of 60 patients with American Society of Anesthesiologists physical status I/II undergoing laparoscopic cholecystectomy (with preoperative two or more Apfel four-point risk factors) were recruited into the study and were randomly divided into two equal groups. In both groups, dexamethasone was administered intravenously at the beginning of surgery, and ondansetron was administered intravenously at the end of surgery. In the aprepitant group, oral aprepitant was given 2 h before anesthesia with a sip of water. The primary outcome measure was complete response (no PONV and no rescue antiemetics) up to 24 h postoperatively. The secondary outcome measure was the amount of rescue postoperative analgesics given during the first 24 h postoperatively. Results There was a statistical significant difference between the two groups in complete response at the sixth hour after surgery. In the aprepitant group, none of the patient experienced a verbal numeric rating scale score greater than 3. Moreover, none of the patients of the aprepitant group had received rescue antiemetics during the first 24 h after surgery compared with the control group. In addition, no difference existed regarding postoperative pain score, although the score was slightly lower in the aprepitant group. Conclusion Oral aprepitant when combined with intravenous ondansetron and dexamethasone is effective in suppressing early PONV up to 24 h postoperatively.
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Comparison of the performance of the self-pressurized air-Q intubating laryngeal airway with the LMA–ProSeal in pediatric patients under general anesthesia: a randomized controlled trial p. 149
Amani A Aly, Mohamed T Ghanem
DOI:10.4103/asja.asja_111_16  
Background Self-pressurized air-Q intubating laryngeal airway (air-Q SP) is a supraglottic airway device with a noninflatable cuff that does not need continuous monitoring of the cuff pressure. As the ProSeal laryngeal mask airway (PLMA) is considered the ‘state-of-the-art’ supraglottic device, we conducted this randomized trial to evaluate the safety and efficacy of air-Q SP compared with that of PLMA in pediatric patients. Patients and methods The study included 70 pediatric patients aged from 4 to 15 years undergoing elective surgery under general anesthesia who were randomized to either the air-Q SP group or the PLMA group. The primary outcome parameter in this study was the oropharyngeal leak pressure, and the secondary outcome parameters were ease of insertion, time of insertion, first attempt insertion success rate, number of gastric insufflations, fiberoptic glottic view, and complications related to the supraglottic airway device use. Results There was no significant difference between air-Q SP and PLMA regarding first insertion success rate, ease of insertion, oropharyngeal leak pressure, number of gastric insufflations, number of manipulations required to adjust the airway, and complications. Time to insert the air-Q SP was significantly shorter than that of PLMA (13.2±4.2 vs. 17.5±4.8 s, P=0.03). The fiberoptic view was significantly better with air-Q SP than with PLMA (P=0.018). Conclusion The performance of air-Q SP is comparable to that of PLMA as a primary airway device during general anesthesia in pediatric patients, with a shorter insertion time and better fiberoptic view for air-Q SP.
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Comparative study between dexamethasone and dexmedetomidine as an adjuvant to ondansetron for the prevention of postoperative nausea and vomiting following functional endoscopic sinus surgery operation p. 156
Sameh H Seyam
DOI:10.4103/asja.asja_117_16  
Background Postoperative nausea and vomiting (PONV) are the most common annoying events and complications following general anesthesia and surgery. Emetic incidents can lead to aspiration of gastric contents, wound unsealing, psychological distress, and delayed recovery from anesthesia and discharge times. Aim This study was designed to compare the effects of a single dose of dexmedetomidine or dexamethasone as an adjuvant to ondansetron for reducing PONV after functional endoscopic sinus surgery operation and to assess if there is any advantage of one drug over the other. Patients and methods This study is a prospective randomized single-blind study. The study involved 60 patients with American Society of Anesthesiologists physical status I and II, of both sexes, between 18 and 50 years of age, undergoing elective functional endoscopic sinus surgery operation. At the end of surgery, patients were randomly allocated to receive an intravenous single dose of either 0.1 mg/kg of ondansetron as a control group, or 8 mg of dexamethasone following 0.1 mg/kg of ondansetron, or dexmedetomidine 0.1 μ/kg following 0.1 mg/kg ondansetron. Postoperatively, all the incidents of nausea, retching and/or vomiting were recorded and patients were asked if vomiting had occurred or if the patients felt nauseated with only two possible answers (yes or no). Results There was no significant differences among the three groups regarding the incidence of PONV during the first 24 h postoperatively, with a slight difference in the ondansetron–dexmedetomidine (ondan–dexmed) group, which was less in frequency in relation to the other groups (P<0.211). Regarding the PONV incidence in relation to intraoperative and postoperative medications, there was a highly significant difference among the three groups regarding the severity of PONV. The PONV severity was lower in the ondan–dexmed group in relation to the other groups (P<0.001). The metoclopramide dose during the following 24 h was significantly low in ondan–dexmed group in relation to the other groups (P<0.001). The tramadol dose during the following 24 h was significantly low in ondan–dexmed group in relation to the other groups (P<0.001). The intraoperative fentanyl requirements was significantly lower in ondan–dexmed group in relation to the other groups (P<0.001). Regarding the first analgesic request, it was significantly delayed in ondan–dexmed group in relation to the other groups (P<0.021). Conclusion A single dose of dexmedetomidine combined with ondansetron is superior to ondansetron alone or ondansetron combined with dexamethazone for preventing PONV in patients undergoing functional endoscopic sinus surgery under general anesthesia.
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Feasibility and outcome of GlideScope videolaryngoscope versus C-MAC videolaryngoscope in the management of obese patients with potentially difficult intubation p. 164
Abd-Elfattah M Daboun, Ezz El-Din F Ismail, Hassanain A Hamzawy, Ayman S Emara
DOI:10.4103/1687-7934.238446  
Background Difficult and failed tracheal intubation remains a leading cause of morbidity and mortality related to anesthesia practice. Videolaryngoscopes were introduced into practice to increase the success rate of intubation in obese patients with difficult airway. Aim The aim of this study was to compare GlideScope and C-MAC videolaryngoscopes in obese patients with anticipated difficult intubation as regards feasibility and outcome. Patients and methods The study was designed as a prospective comparative single-blind study, which was conducted at King Abdullah Hospital, Bisha, KSA, during the period from January 2013 to January 2015. It included 60 obese patients with anticipated difficult intubation. They were randomly divided into two equal groups: the GlideScope group and the C-MAC group. All patients were assessed for demographic characteristics, intubation parameters, and outcome. Results There were no significant differences between the two groups as regards general characteristics and hemodynamics. However, there was a significantly better glottic view in the GlideScope group compared with the C-MAC group. There was a significantly shorter total intubation time and first attempt intubation time in the GlideScope group compared with the C-MAC group (32.43±2.40 and 28.70±2.15 s vs. 40.40±5.07 and 34.80±2.92 s, respectively). The incidence of failure of the first intubation attempt was significantly higher in the C-MAC group compared with the GlideScope group (33.3 vs. 10.0%, respectively). Overall satisfaction was significantly better in the GlideScope group compared with the C-MAC group. Conclusion GlideScope had better glottic view, shorter total intubation and first attempt intubation times, and higher success rate of first intubation attempt compared with C-MAC. These results advocate the use of GlideScope in obese patients with potentially difficult intubation.
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Perioperative terlipressin infusion in living donor liver transplantation: effects on sodium and water balance p. 173
Tarek S Shabana, Sherif G Anis, Fady A Abdelmalek
DOI:10.4103/1687-7934.238450  
Background Although terlipressin is being used perioperatively in recipients of liver transplantation to improve splanchnic hemodynamics and postoperative renal functions, its associated antidiuretic effect has not been specifically investigated in this group of patients. The aim of this study is to assess the effect of terlipressin infusion started intraoperatively and continued for 48 h postoperatively in recipients of living donor liver transplantation on serum sodium and water/sodium excretion. Materials and methods Thirty patients with end-stage liver disease and portal hypertension scheduled for living donor liver transplantation were randomized into two groups including 15 patients each. Group 1 (control): patients did not receive terlipressin. Group 2: terlipressin was administered as an infusion at a rate of 2 µg/kg/h continued for 48 h after postoperative ICU admission. Comparisons were performed between both groups in terms of serum sodium, urine sodium, urine osmolarity, and the urine : sodium osmolarity ratio. Results There were no significant changes between the control group and the terlipressin group in serum sodium, urine sodium, urine osmolarity, and the urine : sodium osmolarity ratio. Conclusion Terlipressin infusion started intraoperatively at a rate of 2 µg/kg/h and continued for 48 h postoperatively in recipients of living donor liver transplantation did not result in significant changes in serum sodium and sodium/water excretion.
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Awake orotracheal intubation using fiberoptic bronchoscope versus Airtraq laryngoscope in morbidly obese patients p. 177
Ashraf E Alzeftawy, Ahmad A El-Daba
DOI:10.4103/1687-7934.238451  
Background Awake endotracheal intubation using the fiberoptic bronchoscope is the gold standard in morbidly obese patients. It needs special skills and high training. The disposable Airtraq laryngoscope had been used for difficult intubation. It can have some advantages compared with the fiberoptic bronchoscope during awake orotracheal intubation. Patients and methods In this study, 60 morbidly obese patients were randomly assigned to be intubated awake with either the fiberoptic bronchoscope (30 patients) or the Airtraq laryngoscope (30 patients). Time needed for intubation, the number of intubation attempts, success rate, and complications were assessed in the two groups. Results The time needed for intubation was significantly shorter in the Airtraq group compared with the bronchoscope group. As regards the number of attempts, there was a nonsignificant difference between the two groups. All patients were intubated successfully with a nonsignificant incidence of complications between the two groups. Conclusion The Airtraq laryngoscope can be used safely as the fiberoptic bronchoscope for awake orotracheal intubation in morbidly obese patients.
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Intravenous ephedrine, phenylephrine, and ketamine for attenuation of hypotension associated with induction of general anesthesia with propofol p. 182
Mostafa Mansour Hussein, Raham Hasan Mostafa, Ibrahim Mohamed Ibrahim
DOI:10.4103/1687-7934.238454  
Background and objective Hypotension and bradycardia remain the major adverse effects of propofol during induction of general anesthesia. Several drugs were studied to prevent these adverse effects. In our study, we compare the effect of mixing ephedrine, phenylephrine, or ketamine with propofol to attenuate its hypotensive effect during induction of general anesthesia. Materials and methods A total of 120 patients of both sexes between 20 and 50 years of age and ASA I–II physical status undergoing elective ambulatory surgeries under general anesthesia were included in our study. Patients were randomly allocated into four groups (30 patients each): group C (the control group), which received plain propofol; group E (the ephedrine group), which received 15 mg of ephedrine premixed with propofol; group Ph (the phenylephrine group), which received 100 μg of phenylephrine premixed with propofol; and group K (the ketamine group), which received 30 mg of ketamine premixed with propofol. In all groups, mean arterial blood pressure (MABP) and heart rate (HR) were recorded at baseline (before induction) and then every 1 min until 6 min after induction. Results Addition of ephedrine, phenylephrine, or ketamine to propofol during general anesthesia induction can significantly attenuate hypotension and bradycardia. In the control group, the MABP dropped from 91.96±3 mmHg just before induction to 75.6±8.7 mmHg at 6 min after induction. HR in the control group dropped from 83.76±7.29/min just before induction to 75.3±12/min at 6 min after induction. The drop in MABP and HR were nonsignificant in the other three groups. Conclusion Mixing propofol with ketamine, ephedrine, or phenylephrine before induction can attenuate its hypotensive and bradycardic effects.
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Effect of dexmedetomidine infusion on desflurane requirement and perioperative hemodynamic changes during laparoscopic gastric sleeve operations: a study based on entropy p. 188
Khaled M Elnaghy, Ibrahim Abd-Elsalam Nasr
DOI:10.4103/1687-7934.238444  
Context Obese patients undergoing laparoscopic gastric sleeve operations are sensitive to the respiratory depressant effect of opioid analgesics. Alternative methods for analgesia may be beneficial for intraoperative management of those patients. Dexmedetomidine is a highly selective α2 agonist with anesthetic and analgesic sparing properties that makes it an adjuvant in general anesthesia. Aim The aim of this study was to assess the effect of intravenous administration of dexmedetomidine during laparoscopic gastric sleeve operations on desflurane requirements, perioperative hemodynamic changes, and also postoperative recovery. This study was based on entropy to monitor the depth of anesthesia. Patients and methods Eighty patients of American Society of Anesthesiologists II and III who were scheduled for laparoscopic gastric sleeve operations were randomly allocated to two groups of 40 patients each. Dexmedetomidine at a loading dose of 1 μg/kg was given over 10 min before anesthesia induction, followed by 0.5 μg/kg/h maintenance throughout the operation in group II, and saline (placebo) was given in group I at the same volume and rate. Routine induction with propofol, fentanyl, and cisatracurium was carried out. Anesthesia was maintained with desflurane that was adjusted to maintain adequate depth of general anesthesia with response entropy between 40 and 60 and a difference of less than 10 with the state entropy. Desflurane inspired fraction and desflurane expired fraction were monitored. Results End-tidal concentration of desflurane was significantly low at 15, 30, 45, and 60 min of operation. End-tidal concentration of desflurane decreased by 13.2–21.8% with the use of dexmedetomidine in comparison with group I. Systolic blood pressure, diastolic blood pressure, and heart rate were significantly decreased with the use of dexmedetomidine at different time intervals throughout the operation in comparison with group I and in comparison with the baseline in group II. Perioperative fentanyl consumption was significantly low with the use of dexmedetomidine in group II in comparison with group I. It was 325±55 μg in group II in comparison with 178±45 μg in group I. There was no significant difference between the two study groups as regards the extubation time. Pain score was significantly higher in group I in comparison with group II on admission to the postoperative acute care unit, and at 1 and 2 hlater. Conclusion In conclusion, the use of dexmedetomidine as preanesthetic medication followed by infusion during laparoscopic sleeve gastrectomy reduces desflurane requirement, maintains hemodynamic stability due to attenuation of stress response, and reduces the fentanyl requirement during intraoperative and early postoperative period, with decreased risk for respiratory depression in the postoperative acute care unit for morbidly obese patients who are at great risk for obstructive sleep apnea and oxygen desaturation.
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Effect of preoperative pregabalin versus gabapentin on postoperative pain control after laparoscopic gastric bypass surgery p. 195
Khalid G Abd El-Maksoud, Mokhtar M Younes, Sherif A Elokda
DOI:10.4103/asja.asja_21_16  
Background Perioperative gabapentin helps produce a significant opioid-sparing effect and probably also improves postoperative pain scores. Pregabalin is a novel drug with a heightened research interest in the analgesic, sedative, anxiolytic, and opioid-sparing effects, in various pain settings, including postoperative pain. We investigated pregabalin analgesic efficacy in morbid obese patients experiencing acute pain after laparoscopic gastric bypass surgery and compared it with gabapentin and placebo. Patients and methods A randomized, placebo-controlled study was conducted on 90 morbidly obese patients undergoing laparoscopic gastric bypass surgery. Patients were allocated into one of the three groups; the pregabalin group in which the patients received 300 mg pregabalin, the gabapentin group in which the patients received 1200 mg gabapentin, or the control group in which the patients received placebo 2 h prior to surgery. Postoperative pain was controlled with intravenous fentanyl via patient controlled analgesia (PCA). Fentanyl consumption over 24 h and pain intensity measured by visual analogue score at rest (static) and during cough (dynamic) at recovery time, 1, 2, 6, 12, and 24 h were recorded. Also sedation status, somnolence, dizziness, headache, nausea, and vomiting were monitored. Results Postoperative 24 h fentanyl consumption was significantly higher in the control group compared with both pregabalin and gabapentin groups (P<0.001). Pain intensity on visual analogue score (static and dynamic) was significantly higher in the control group compared with both pregabalin and gabapentin groups at time of recovery, 1, 2, 6, 12, and 24 h postoperatively. Numeric sedation score was significantly lower in the control group compared with pregabalin and gabapentin groups at time of recovery, 1, 2, and 6 h postoperatively. No significant differences were found among the three groups as regards somnolence, dizziness, headache, nausea, and vomiting. Conclusion A single dose of 300 mg pregabalin or 1200 mg gabapentin given 2 h before surgery is better than placebo for postoperative pain control for laparoscopic gastric bypass surgery without significant side effects.
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Tramadol versus hyoscine-N-butylbromide as intrapartum analgesics during the first stage of labor p. 201
Ashraf A AbouSlemah
DOI:10.4103/asja.asja_53_16  
Objective The aim was to evaluate and compare the analgesic efficacy of tramadol versus hyoscine-N-butylbromide intramuscularly given during the active phase of the first stage of labor. Materials and methods This prospective study included 140, American Society of Anesthesiologists I, laboring primigravidae, who were divided into two equal groups: group I (group B) received hyoscine-N-butylbromide (Buscopan) 40 mg intramuscular and group II (group T) received tramadol 100 mg intramuscular. Labor pain was assessed by visual analog scale before and at 30 min, 1 h, 2 h, and 3 h after drug administration. Maternal and neonatal adverse effects, drug-delivery interval, mode of delivery, need for additional analgesia, and postpartum maternal satisfaction were assessed too. Results Baseline visual analog scale scores were comparable between the groups (P>0.05). Pain scores at 30 min, 1 h, 2 h, and 3 h were significantly higher (P<0.001) in group B. Overall, 30 (42.8%) women in group B required additional analgesia versus only seven (10%) women in group T (P<0.001). Drug-delivery interval was significantly (P<0.05) shorter in group B at 175 versus 220 min in group T. Apgar score at 1 min was significantly higher (P<0.05) in group B, whereas the scores at 5 min were comparable (P>0.05). A total of 56 (80%) women in group B had adverse effects versus 54 (77.1%) women in group T (P>0.05). Adverse effects were generally mild (well tolerated). Cesarean delivery percentages were comparable between the groups (P>0.05). Postpartum maternal satisfaction was significantly higher (P<0.001) in group T. Conclusion Although Buscopan is cheap and safe, it is a less effective intrapartum analgesic than tramadol. It offers shorter duration of labor, so it is better recommended for primiparous women.
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Dexmedetomidine infusion versus placebo for analgesia and prevention of emergence agitation in morbidly obese patients undergoing laparoscopic sleeve gastrectomy p. 207
Mostafa M Hussein, Raham H Mostafa
DOI:10.4103/asja.asja_59_16  
Background Emergence agitation (EA) can occur following recovery from general anesthesia. The patient may exhibit aggressive behavior, disorientation, agitation, and restlessness. If untreated, this complication may result in significant morbidity. EA has been poorly investigated in patients undergoing laparoscopic sleeve gastrectomy. Aim The aim was to assess the efficacy of perioperative dexmedetomidine infusion on EA and quality of recovery after elective laparoscopic sleeve gastrectomy in morbidly obese adult patients. Materials and methods A total of 60 patients undergoing laparoscopic sleeve gastrectomy were randomized into two groups (30 patients each). The dexmedetomidine group (group D, N=30) received dexmedetomidine infusion, whereas the control group (group C, N=30) received normal saline in the same volume and rate as placebo. Propofol, fentanyl, and atracurium were used for induction of anesthesia, and isoflurane was used for maintenance of anesthesia. Postoperative hemodynamic variables, postoperative pain, the need for ‘rescue’ analgesics and antiemetics, and the incidence of agitation were recorded up to 2 h postoperatively. Pain was evaluated using the visual analog scale score in the postanesthesia care unit on arrival, at 5 min, and then every 15 min for 120 min. EA was evaluated at the same time intervals by Richmond agitation-sedation scale (RASS). Pethidine 50 mg intravenously was given for pain (if pain score >4) or severe agitation (RASS score >+1). Results No patients in group D experienced postoperative EA during the second hour postoperatively (RASS ˂1). On the contrary, RASS scores of patients in group C were 2 (2–3) on arrival to postanesthesia care unit and greater than +1 during the remaining time up to 2 h postoperatively, indicating postoperative EA. In group C, 25 (92.5%) patients required rescue analgesia compared with only five (18.5%) patients in group D. Hemodynamic parameters were stable in group D. Conclusion Dexmedetomidine infusion during laparoscopic sleeve gastrectomy for morbidly obese patients is beneficial and effective in preventing postoperative pain and postoperative EA.
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Effect of addition of hyaluronidase as an adjuvant to local anesthetics in ultrasound-guided supraclavicular brachial plexus block p. 213
Karim Y kamal Hakim, Mohamed Awad Al Saeid Ahmed
DOI:10.4103/1687-7934.238458  
Background This study was carried out to evaluate the efficacy of hyaluronidase as an adjuvant to the mixture of local anesthetics in ultrasound-guided supraclavicular brachial plexus block. Patients and methods Ninety patients received ultrasound-guided brachial plexus block through supraclavicular approach. They were then randomly divided into three groups: group C, group H1, and group H2. Group C patients received 2% (15 ml) lignocaine and 0.5% (15 ml) bupivacaine, making a total volume of 30 ml, by triple-injection technique. Group H1 patients received 2% (10 ml) lignocaine and 0.5% (10 ml) bupivacaine plus 0.9% (10 ml) normal saline containing 900 IU (90 IU/ml) hyaluronidase, making a total volume of 30 ml, by triple-injection technique. Group H2 patients received 2% (10 ml) lignocaine and 0.5% (10 ml) bupivacaine plus 0.9% (10 ml) normal saline containing 900 IU (90 IU/ml) hyaluronidase, making a total volume of 30 ml, by single-injection technique. Parameters such as needling time, onset of sensory block, onset of motor block, total dose of intraoperative rescue analgesics, rate of success of the block, duration of sensory block, duration of motor block, and possible side effects were measured. Results Time needed to perform the block was significantly shorter in the H2 group compared with the C and H1 groups. Onset of sensory block was statistically significantly lower in the two groups in which hyaluronidase was used compared with that in group C. Onset of motor block was statistically significantly lower in H1 and H2 groups compared with that in group C. The mean total intraoperative fentanyl administration was found to be nonsignificantly higher in group C compared with groups H1 and H2. The success of the ultrasound-guided block was 90% in group C versus 96.6% in groups H1 and H2. As regards the duration of sensory and motor block there were no statistically significant differences between the three studied groups. Comparison between the three groups revealed nonsignificant differences as regards the time of first analgesic dose. The total dose of morphine given during the first 24 h postoperatively was significantly lower in the control group compared with that in groups H1 and H2. Conclusion The use of hyaluronidase as an adjuvant to the local anesthetic reduces the time to reach complete sensory block of ultrasound-guided supraclavicular brachial plexus blocks and therefore shortens the total anesthetic time before operation. Although it also reduces the block duration, hyaluronidase had only a little effect on the total analgesic duration and on the consumption of postoperative analgesics. Also single-injection technique is sufficient for performing a successful block.
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The efficacy of rectus sheath block for pain management following laparoscopic orchiopexy surgery p. 219
Hoda Shokri
DOI:10.4103/1687-7934.238459  
Background Ultrasound (U/S)-guided rectus sheath block is an effective analgesic technique in elective pediatric laparoscopic surgical procedures. The aim of the study was to evaluate the efficacy of rectus sheath block for pain management following laparoscopic orchiopexy surgery. Patients and methods A total of 50 patients undergoing elective laparoscopic orchiopexy were allocated randomly into two groups: the U/S-guided rectus sheath block group (the REC group) and the general anesthesia-only group (the GA group), in which no rectus sheath block was performed. All patients received the same general anesthetic technique. In the REC group, patients received bilateral U/S-guided rectus sheath block, using 0.4 ml/kg of 0.25% bupivacaine, and morphine (0.1 mg/kg) was administered for rescue analgesia postoperatively and its total dose was recorded. Pain was measured by means of Children’s Hospital of Eastern Ontario Pain Scale score. Hospital stay and the incidence of respiratory depression or vomiting were recorded. Results In all, 50 patients completed the study. The total dose of morphine used over 24 h was significantly lower in the REC group. Children’s Hospital of Eastern Ontario Pain Scale scores were significantly lower in the REC group during the first 3 h postoperatively, and the incidence of vomiting, respiratory depression, and oxygen saturation in the postanesthesia care unit showed no significant difference between the study groups. Hospital stay was significantly shorter in the REC group compared with the GA group. Conclusion U/S-guided rectus sheath block is an effective analgesic technique with morphine-sparing effect after laparoscopic orchiopexy surgery.
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Comparative study between a combination of lidocaine and levobupivacaine and that of lidocaine, levobupivacaine, and dexmedetomidine during peribulbar anesthesia for phacoemulsifi cation cataract surgery p. 224
Joseph Makram Botros, Maged Labib boulos
DOI:10.4103/1687-7934.238462  
Background and objective Eye surgeries are very common nowadays. Most surgeries, including cataract surgeries, can be safely performed in an outpatient setting using local anesthesia. Levobupivacaine, a levorotatory isomer of the racemic mixture of bupivacaine, has been used at regional blocks, including local eye blockades. Dexmedetomidine, a potent, highly selective and specific α2-adrenoreceptor agonist, with both sedative and analgesic effects and no respiratory depression, is used as an adjuvant to local eye anesthesia to prolong the analgesic duration of the local anesthetic used. We expected that the addition of dexmedetomidine to levobupivacaine would increase both sensory and motor block durations compared with levobupivacaine alone. Patients and methods In our study, a total of 80 patients of both sexes, aged 50–70 years, belonging to the American Society of Anesthesiologists (ASA) grade I and II, and scheduled for phacoemulsification cataract surgery were randomly allocated into one of two study groups: the levobupivacaine group (group L), in which 40 patients received 3 ml of 2% lidocaine with 10 IU/ml of hyaluronidase + 3 ml of 0.5% levobupivacaine+1 ml of normal saline; and the levobupivacaine dexmedetomidine group (group LD), in which 40 patients received 3 ml of 2% lidocaine with 10 IU/ml of hyaluronidase+3 ml of 0.5% levobupivacaine+1 ml of dexmedetomidine (100 μg). Results There was no significant difference between the two groups regarding the onset times of lid akinesia, globe anesthesia, and globe akinesia (P > 0.05). The duration of globe anesthesia, lid akinesia, and globe akinesia in the dexmedetomidine group was significantly longer than in the levobupivacaine group (P < 0.001). In group LD, the first analgesic requirement was significantly delayed and the total analgesic consumption in the first 24 h was significantly lower compared with group L (P < 0.0001 for both). Conclusion The addition of 100 μg dexmedetomidine as an adjuvant to 2% lidocaine with 10 IU/ml of hyaluronidase and 0.5% levobupivacaine in peribulbar anesthesia for cataract surgery significantly increases the duration of peribulbar block and improves the analgesic duration, without significant side effects, and significantly decreases the intraocular pressure.
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Intrathecal hyperbaric bupivacaine with fentanyl for labor pain control: a comparative study with continuous epidural analgesia with bupivacaine p. 230
Mokhtar Younes, Khaled Gamil, Ahmed M. Elgarhy
DOI:10.4103/1687-7934.238463  
Objective The aim of the study was to assess single-dose intrathecal bupivacaine in combination with fentanyl as a safe and effective alternative to epidural for labor analgesia. Patients and methods Sixty women aged 20–30 years, of American Society of Anesthesiology I–II, and with a single uncomplicated pregnancy were included in this study. Patients were randomly allocated to two equal groups: the spinal group received hyperbaric bupivacaine 0.5% at a dose of 1 ml plus 25 μg fentanyl (0.5 ml), whereas the epidural group received bupivacaine 0.25% at a 14 ml bolus dose with a background epidural infusion of bupivacaine 0.125% at 10 ml/h. Pain intensity was recorded on a visual analogue scale. The quality of pain relief was also related to patient satisfaction after delivery. Side effects such as hypotension, motor block, pruritus, sedation, and nausea were noted. Obstetric parameters and Apgar score were noted, and all results were compared. Results Onset of sensory block was earlier (5.6 ± 1.27 vs. 8.8 ± 1.62 min, P < 0.001) and visual analogue scale at 5, 60, 90, 120, and 150 min was lower in the spinal group compared with the epidural group. All these results were statistically signifi cant. Ninety percent of the parturients in the spinal group versus 62% in the epidural group scored the analgesic quality as excellent. No significant hemodynamic changes were recorded in either group. There were no significant differences between the two groups in motor block, sedation, and nausea. No cesarean section or instrumental delivery was performed. Oxytocin augmentation was needed in 33.3 versus 50% of the parturients in the spinal and epidural groups, respectively. Fetal heart rate disturbances were seen in 10% in the epidural group versus 6.6% in the spinal group. Apgar scores were high and no neonate had Apgar score less than 7 in either group. The overall cost was lower in the spinal group compared with the epidural group. Conclusion Single-dose intrathecal local anesthetic with narcotics is shown to relieve pain safely in most laboring women, with rapid onset and prolonged duration of labor analgesia comparable to that of epidural analgesia while being more easily performed, less time-consuming, and less expensive, and providing similarly excellent analgesia.
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Subarachnoid anesthesia (with and without sedation) versus general anesthesia for ex-preterm neonates undergoing elective infraumbilical operations p. 237
Mostafa M Hussein, Raham H Mostafa
DOI:10.4103/asja.asja_50_16  
Background Postoperative respiratory problems, especially apnea, is a common postoperative complication in ex-preterm neonates undergoing infraumbilical operations. So, most of these neonates require close postoperative monitoring for at least 12 h to avoid this hazard. Postoperative apnea is related more to the use of respiratory depressant drugs used during general anesthesia. Aim The aim was to evaluate safety and effectiveness of spinal anesthesia in ex-preterm infants undergoing infraumbilical operations and evaluate its role in elimination of routine postoperative hospital stay for apnea monitoring. Settings and design A prospective single-blinded randomized study was conducted. Materials and methods From March 2015 to March 2016, 105 ex-preterm neonates (gestational age <37 weeks), with postconceptual age at surgery less than 60 weeks, undergoing elective infraumbilical operations were studied prospectively. Patients were divided randomly into three groups (35 patients each). Group I received spinal anesthesia without sedation (only sugared pacifier), group II received spinal anesthesia with sedation in the form of ketamine/midazolam, and group III received general anesthesia with caudal analgesia. Postoperative apnea, bradycardia, and oxygen saturation were observed and compared for 12 h after operation. The primary outcome measures were postoperative apnea, postoperative bradycardia, and SpO2. The secondary outcome measures were postoperative complications (e.g. hypotension) and the need for postoperative respiratory support. Results No patients in group I developed any attacks of postoperative apnea, postoperative bradycardia, or hypoxia. On the contrary, 11 patients in group II and 16 patients in group III developed attacks of postoperative apnea and hypoxia and required postoperative respiratory support. Conclusion Spinal anesthesia without sedation is safe and effective for infraumbilical operations in ex-preterm neonates with short hospitalization.
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Comparison of butorphanol and tramadol as an adjuvant to local anesthetic drug in axillary brachial plexus block p. 242
Upasna Bhatia, Gauri Panjabi, Atisha Patel
DOI:10.4103/asja.asja_51_16  
Background With the advent of opioid receptors, a variety of opioid agents are added to local anesthetic mixtures used in peripheral blocks to improve the quality and duration of block. In this study, we compared the effect of butorphanol and tramadol as adjuvant agents for orthopedic upper extremity surgery. Patients and methods This study was carried out on 50 patients aged between 18 and 60 years, of American Society of Anesthesiologists grades I and II, of either sexes in each group, undergoing orthopedic upper limb surgeries through axillary brachial plexus block. An injection of butorphanol 2 mg (group B) and that of tramadol 100 mg (group T) were added to local anesthetic mixture. Onset of sensory and motor blockade, extent of blockade, and occurrence of any complications were studied in both groups. All patients were observed for analgesia postoperatively by visual analog scale pain score. Results In our study, the onset time (minutes) of sensory and motor blockade was delayed in group B (8.76±1.0 and 5.86±0.71, respectively) as compared with group T (7.54±0.88 and 4.6±0.73, respectively). In group B, the duration of sensory block (291.24±48.51 min) was longer than group T (160.42±12.66 min). Duration of analgesia postoperatively (first rescue analgesic) was 619.96±26.96 min in group B, whereas it was 290.2±20.38 min in group T. Conclusion Butorphanol is more potent and produces longer duration of postoperative analgesia than tramadol, with an extra advantage of sedation and calmness.
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Systemic granisetron can minimize hypotension and bradycardia during spinal anesthesia in patients undergoing elective lower-abdominal surgeries: a prospective, double-blind randomized controlled study p. 247
Waleed Abdalla, Mona A Ammar
DOI:10.4103/1687-7934.238477  
Introduction Although it is considered safe, spinal anesthesia has many side effects, including hypotension, and bradycardia. Increased activity of chemoreceptors (Bezold–Jarisch reflex) may play a role in this. The release of serotonin has been suggested as a possible trigger for Bezold–Jarisch reflex. Granisetron, a selective 5-HT3 receptor antagonist, may play a role in preventing hypotension and bradycardia. Aim The aim of this study was to assess the effects of granisetron on hypotension, bradycardia, shivering, nausea, and vomiting after spinal anesthesia in patients undergoing elective lower-abdominal surgeries. Patients and methods This study was designed as a randomized, double-blind, placebo-controlled trial. Fifty-four American Society of Anesthesiologists I–III patients, ages 25–55 years, scheduled for elective lower-abdominal surgeries under spinal anesthesia were included in this prospective study and were divided into two equal groups. Group G received 1 mg intravenous granisetron diluted in 0.9% normal saline to a total volume of 5 ml, and group C received 5 ml normal saline 5 min before undergoing spinal anesthesia. The mean arterial blood pressure, the heart rate, nausea, vomiting, and shivering were assessed. Results The reduction in mean arterial blood pressure and heart rate was significantly lower in group G compared with group C. Regarding the incidence of complications, hypotension, bradycardia, nausea, and shivering were significantly lower in group G compared with group C. No significant difference was observed with regard to the incidence of vomiting. Conclusion In lower-abdominal surgery, intravenously 1 mg granisetron before subarachnoid block decreased the incidence of hypotension and bradycardia significantly, besides being effective for the prevention of nausea, vomiting, and shivering.
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The effects of adding dexamethasone to intra-articular morphine injection on postoperative pain after knee arthroscopy p. 253
Abd-Elazeem A El Bakry, Wesam-Eldin A Sultan
DOI:10.4103/asja.asja_60_16  
Background Postoperative analgesia after knee arthroscopy is mandatory for recovery and early rehabilitation. Medications were used intra-articularly to prolong postoperative analgesia and improve the quality of pain. The present study was scheduled to study the effects of dexamethasone addition to intra-articular morphine on postoperative pain after knee arthroscopy. Patients and methods This randomized double-blinded controlled study was carried out on 90 patients undergoing knee arthroscopy. The patients were randomly allocated into three equal groups. All medications were injected intra-articularly at the end of surgery. In the control group, the patients were administered 0.5% bupivacaine in normal saline. In M group, the patients were administered 5 mg morphine added to bupivacaine 0.5%. In MD group, the patients were administered 5 mg morphine and 8 mg dexamethasone added to bupivacaine 0.5%. Vital signs, visual analog score for pain at rest and movement, duration of analgesia, total analgesic consumption and adverse effects were recorded. Results MD Group showed lower visual analog score at rest and movement, prolonged postoperative analgesia, and decreased total analgesic consumption compared with the other groups (P<0.05). Conclusion The addition of dexamethasone to intra-articular morphine after knee arthroscopy prolongs the duration of analgesia, lowers pain scores, and decreases total analgesic consumption with minimal adverse effects.
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Efficacy of the transversus abdominis plane block using 30 ml bupivacaine 0.25% in reducing postoperative fentanyl requirements in renal transplant recepients p. 258
Tamer H Ibrahim, Mostaf K Abdellatif, Fatma M Osama
DOI:10.4103/1687-7934.238480  
Context Postoperative pain management for renal transplant recipients is limited by considerations related mainly to the impaired renal functions. Patient-controlled analgesia (PCA) by fentanyl has been used and provides good pain control. The transversus abdominis plane (TAP) block provides good postoperative analgesia for abdominal surgeries Aims The aim of the present study was to examine the efficacy of the TAP block using 30 ml bupivacaine 0.25% in reducing the postoperative fentanyl requirements in renal transplant recipients Patients and materials This double-blinded, prospective, randomized, controlled study included 50 patients divided into two equal groups: group A, the control group, which included patients who received the TAP injection with only normal saline and kept on PCA fentanyl; and group B, the TAP block group, which included patients who received the TAP block using 30 ml of bupivacaine 0.25% in addition to PCA fentanyl. The primary outcome was the postoperative 24 h fentanyl consumption, whereas other outcomes included pain scores, heart rate, mean arterial blood pressure, and incidence of nausea, vomiting, excessive sedation, and respiratory depression. Results Postoperative 24 h PCA fentanyl consumption was significantly lower in the TAP block group (330.9±36.8) compared with the control group (636.9±40) (P<0.01). The pain scores recorded in the TAP group were significantly lower (P<0.01). Mean arterial blood pressure was also significantly lower in the TAP group; however, differences between the recorded heart rates were nonsignificant (P=<0.01 and 0.6, respectively). None of the patients developed excessive sedation or respiratory depression. Conclusion A TAP block with 30 ml bupivacaine 0.25% provides excellent postoperative analgesia for renal transplant recipients and significantly reduced the 24 h postoperative PCA fentanyl requirements and the pain scores.
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Dexmedetomidine as adjuvant to hyperbaric bupivacaine in spinal anesthesia for inguinoscrotal surgery p. 264
Nirvana A Elshalakany, Ahmed N El-Shaer, Amal H Rabie, Assem A Moharram, Amr M.M Elsofy
DOI:10.4103/asja.asja_65_16  
Background and aim The purpose of this study was to evaluate the anesthetic and analgesic effects of dexmedetomidine as adjuvant in spinal anesthesia for patients undergoing inguinoscrotal surgery. Patients and methods A total of 70 adult male patients (American Society of Anesthesiologists I or II) scheduled for inguinoscrotal surgery were randomized into two equal groups using a computer-generated randomization table and received 3 ml plain hyperbaric bupivacaine 0.5% diluted in 0.5 ml normal saline in group C or plus dexmedetomidine (5 µg) in group D. Anesthesia, analgesia, and sedation qualities; hemodynamic changes; and adverse effects were recorded. Results The studied groups showed no significant difference regarding demographic data. The highest sensory level (T8) was the same in both groups, but there were statistically significant differences between the two groups (P<0.05) regarding quality of anesthesia, times of onset, and duration and regressions of sensory and motor blocks (rapid onset and delayed offset of sensory and motor blocks in group D). Postoperative pain score (visual analog scale) and rescue analgesic requirements were lower in group D compared with group C, and excellent analgesic quality was higher in group D. Sedation score intraoperatively and up to 60 min postoperatively was significantly higher in group D compared with group C. Regarding hemodynamics, mean arterial blood pressure and heart rate showed a statistically significant difference intraoperatively and till discharge to ward (P<0.05). Regarding adverse effects, two patients in group C compared with three patients in group D had incidence of hypotension (mean arterial blood pressure˂55 mmHg). Conclusion Dexmedetomidine as an adjuvant to hyperbaric bupivacaine in spinal anesthesia seems to be a profound intrathecal anesthetic, analgesic, and sedative agent, with preservation of hemodynamic stability and minimal adverse effects.
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Comparative study between ultrasound-guided thoracic paravertebral nerve block and intraperitoneal instillation of local anesthetic as pre-emptive analgesia in laparoscopic cholecystectomy surgery p. 272
Asmaa S Abdellah, Fatma H Ashour, Enas M.A Elshanawany
DOI:10.4103/asja.asja_126_16  
Background Thoracic paravertebral block (TPVB) is an effective technique in controlling pain after lower thoracic and upper abdominal surgery, and ultrasound guidance is a recent technique that may offer several advantages. Intraperitoneal injections of local anesthetics have been proposed to minimize postoperative pain after laparoscopic surgery. Patients and methods A total of 60 patients with American Society of Anesthesiologists status I and II aged 30–50 years undergoing elective laparoscopic cholecystectomy were divided into three equal groups (20 patients each): ultrasound-guided thoracic paravertebral block (UG-TPVB group) with 20 ml 0.25% bupivacaine bilaterally, intraperitoneal instillation of local anesthetics with 50 ml 0.25% bupivacaine after inflation of the abdomen with gas (IP group), and general anesthesia alone without any local anesthetics (GA group) (control group). General anesthesia was induced for all patients. Intraoperative and postoperative hemodynamic data (mean arterial blood pressure and heart rate) were recorded. Intraoperative anesthetic and analgesic consumption, pain intensity using visual analog scale, pethidine consumption, serum cortisol, blood glucose level, and complications were estimated. Results Hemodynamic data were significantly lower in IP and UG-TPVB groups compared with GA group (P<0.05), and on comparing UG-TPVB group with IP group, with no significant difference was seen regarding postanaesthesia care unit admission and discharge (P1>0.05). End-tidal sevoflurane % (UG-TPVB: 1.1±0.21, IP: 1.8±0.22, GA: 2±0.23) and volume of consumption (UG-TPVB: 12.0±0.9, IP: 15.1±0.7, GA: 18.2±2) showed significant decrease when comparing UG-TPVB and IP groups with GA group (P<0.05). The mean dose of intraoperative fentanyl, mean dose of postoperative pethidine consumption, and the number of patients who received pethidine were significantly lower in IP and UG-TPVB groups compared with GA group (P<0.05). Postoperative serum cortisol and blood glucose level showed significant decrease in UG-TPVB and IP groups compared with GA group at 6 and 24 h postoperative (P<0.05). Pain score using visual analog scale and number of patients who experienced postoperative nausea and vomiting were significantly decreased in both groups in comparison with GA group. Conclusion UG-TPVB and IP bupivacaine instillation as pre-emptive analgesia in laparoscopic cholecystectomy provided good intraoperative and postoperative analgesia and decreased the dose of anesthetics used with great safety, and the incidence of complications was less.
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Clinical evaluation of intravenous dexmedetomidine and intravenous midazolam for hysterectomy under subarachnoid blockade with 0.5% hyperbaric bupivacaine p. 279
Kumkum Gupta, Bhawana Rastogi, Prashant K Gupta, Ivesh Singh, Manoranjan Bansal, Vasundhera Tyagi
DOI:10.4103/1687-7934.238448  
Background The excellence of subarachnoid blockade (SAB) can be improved with a variety of adjuvants, used either intrathecally or intravenously. Objective The present study aimed to compare the clinical efficacy of intravenous dexmedetomidine with midazolam for hysterectomy under SAB with 0.5% hyperbaric bupivacaine. Materials and methods After approval, 90 adult consenting middle-aged female patients of American Society of Anesthesiologists (ASA) physical status I and II scheduled for hysterectomy under SAB were blindly randomized into three groups of 30 patients each, to receive either intravenous dexmedetomidine 0.5 μg/kg (group I) or intravenous midazolam 0.05 mg/kg (group II) or normal saline (group III), 20 min after the SAB. Patients were assessed for the onset and duration of sensory and motor blockade, maximum cephalic spread, and intraoperative hemodynamic changes as primary endpoints. The study also evaluated the sedation level and visual analogue scale score for postoperative pain as secondary outcome. Results Patients in the dexmedetomidine group showed a higher cephalic level of sensory blockade. Time for two dermatomes’ sensory regression (144.33±19.2 min) and duration of sensory analgesia (270.10±16.6 min) in the dexmedetomidine group was extended, with a statistically highly significant difference among the groups and no hemodynamic variability. Ramsay sedation score was higher in the dexmedetomidine and midazolam groups than in the saline group. Respiratory depression was not observed in any patient. The incidence of postspinal shivering was low in patients of the dexmedetomidine group. Conclusion Midazolam provided only sedation, whereas dexmedetomidine extended the duration of sensory analgesia of SAB, maintained hemodynamic stability, and also provided arousable sedation without respiratory depression.
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Ketamine versus pregabalin as an adjuvant to epidural analgesia for acute post-thoracotomy pain p. 287
Ahmed H Bakeer, Nasr M Abdallah
DOI:10.4103/asja.asja_37_16  
Objective The aim was to compare analgesic effect of ketamine versus pregabalin as adjuvant to post-thoracotomy epidural analgesia in the National Cancer Institute. Patients and methods This randomized controlled trial involved 60 adults planned for thoracotomy under general anesthesia for management of lung cancer. They were randomly assigned into one of two groups. Group K (n=30) received three doses of ketamine 0.5 mg/kg intravenously, that is, after induction of anesthesia and at 6 and 30 h postoperatively. Group P (n=30) received oral pregabalin 150 mg 2 h before surgery and at 6 and 30 h postoperatively. The endpoints were pain reduction using visual analog score (VAS) score, frequency of rescue morphine doses, hemodynamic parameters, and adverse effects in the first 48 h. Results VAS score was significantly lower in ketamine group than that in the pregabalin group from 8 up to 48 h postoperatively. In group P, VAS score decreased after 16 h (P<0.001) and continued to decrease up to 48 h. Rescue analgesia was required after 2 h by 11 (36.7%) patients in group K and 15 (50%) patients in group P (P=0.297). The two drugs were accompanied by hemodynamic stability. Patients in group P were more sedated 2 h after surgery compared with those in group K (P=0.006). No cases of nausea and vomiting or psychological adverse effects related to ketamine use were recorded. Conclusion Ketamine and pregabalin are good alternatives for augmentation of the efficacy of thoracic epidural analgesia following thoracotomy in patients with lung cancer. Ketamine has the advantage of more rapid action and higher efficacy in addition to less sedation in early postoperative period.
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Optimum target in percutaneous upper thoracic thermocoagulation in primary hyperhidrosis p. 293
Osama Yehia A Khalifa, Ahmed Sobhi M.E Hegab
DOI:10.4103/asja.asja_73_16  
Introduction Primary palmar hyperhidrosis is a disabling problem that affects young age groups and usually continues for years without an effective treatment. It is usually accompanied by plantar hyperhidrosis and to a lesser extent by axillary affection. We have tried to improve the efficacy of percutaneous radiofrequency ablation of upper thoracic sympathetic ganglia via imitating what thoracoscopic surgeons do in endoscopic thoracic sympathectomy. Patients and methods A total of 40 patients with primary hyperhidrosis were randomly classified into two groups. Group Tb (n=20) underwent thermocoagulation of sympathetic chain on vertebral body. Group Th (n=20) underwent thermocoagulation of sympathetic chain on the head and neck of ribs. Hand temperature and dryness were followed up during the procedure and on the following intervals: 1 week, 1 month, 3 months, 6 months, 9 months, and 12 months after the procedure. Results During the procedure, the hands of 50% of patients became warm and dry in group Tb and only 40% remained so till 12 months, whereas in group Th, the hands of 100% of the patients became warm and dry during the procedure till 12 months. Conclusion Thermocoagulation of upper thoracic sympathetic chain on the head and neck of the second and third ribs is more effective than attacking the chain on vertebral bodies in patients with primary hyperhidrosis with no recorded complications.
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LETTER TO THE EDITOR Top

Intrathecal ketamine as an adjuvant in day-case surgeries: a reply for the comments on a previously published article p. 297
Manal Kamal, Dalia El-Fawy
DOI:10.4103/1687-7934.238470  
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