Introduction The aim of this study was to evaluate the effect of intrathecal compared with intravenous dexmedetomidine as an adjuvant to spinal bupivacaine anesthesia for pregnant women undergoing cesarean section on intraoperative and postoperative analgesia with special emphasis on their sedative properties and on the neonatal outcome. Patients and methods A total of 105 women of ASA physical status I or II at term pregnancy were enrolled randomly into three groups. Patients in group I received spinal anesthesia with hyperbaric bupivacaine. In group II, 5 μg dexmedetomidine was added to bupivacaine. In group III, after administration of spinal anesthesia with bupivacaine and an intravenous infusion of 0.5 μg/kg/h dexmedetomidine throughout the surgery, the incidence of hypotension, bradycardia, the onset, and the duration of sensory and motor block and the postoperative pain score were assessed. Results No differences were observed in the rate of occurrence of hypotension and bradycardia between the three groups. The time to reach the peak sensory level was shorter in group II and group III with a longer duration compared with group I. The duration of motor block was shorter in group I compared with the two other groups with no significant difference between the three groups in the onset of motor block. The onset of postoperative pain was significantly earlier in group I, and more patients in group I needed supplementary analgesia. No significant difference was noted between the three groups regarding the Apgar score and the incidence of maternal side effects such as nausea, vomiting, and dryness of the mouth. Conclusion The use of intrathecal dexmedetomidine or intravenous dexmedetomidine as an adjuvant to spinal bupivacaine in women undergoing elective cesarean section improved the intraoperative condition and the quality of postoperative analgesia without neonatal or maternal side effects.

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Background Regional anesthesia has been widely practiced with minimal risk of complications. The aim of this study was to compare the efficacy of nalbuphine and tramadol as separate adjuvants to lidocaine in intravenous regional anesthesia (IVRA) (Bier's block). Materials and methods This randomized double-blind controlled study was conducted in the Department of Anesthesia, Kasr Al Ainy Teaching Hospital, Cairo University, Egypt. Sixty patients, aged 20-60 years, ASA I-II, both sexes, scheduled for minor hand surgeries under IVRA were enrolled in the study. The patients were randomly allocated into three equal groups: group L (n = 20) received lidocaine in IVRA, group LT (n = 20) received lidocaine and tramadol mixture, and group LN (n = 20) received lidocaine and nalbuphine mixture. The onset, duration of both sensory and motor blocks, time to first analgesic request postoperatively, and complications related to the drugs or technique were recorded. Results There was a statistically significant acceleration in the mean onsets with significant prolongation of the mean duration of sensory and motor blocks in group LT and group LN compared with group L (P < 0.05). The results observed in both groups were comparable. In addition, there was an increase in the mean time to first analgesic request in group LT and group LN compared with group L (P < 0.001). Group LN had the longest duration time of postoperative analgesia and this was statistically significant compared with group LT (P < 0.001). Complications were minimal and nonsignificant. Conclusion The use of nalbuphine and tramadol as adjuvants to lidocaine in IVRA resulted in significant acceleration of the onset and prolongation of the duration of both sensory and motor blocks, with minimal insignificant complications. Both tramadol and nalbuphine effects were comparable.

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Objectives The aim of this study was to investigate the effect of dexmedetomidine administered intravenously or intrathecally in prolonging spinal anesthesia using bupivacaine in patients undergoing lower limb orthopedic surgery. Patients and methods Sixty adult patients classified as ASA I or II and scheduled for lower limb orthopedic surgery under spinal anesthesia were enrolled in this study. Patients were randomly assigned into one of the three groups. Group B (n = 20) was injected with 10 ml isotonic saline intravenously over 5 min immediately after patient has received intrathecal hyperbaric bupivacaine 12.5 mg; group IV (n = 20) was injected with dexmedetomidine 0.5 μg/kg intravenously diluted in 10 ml isotonic saline over 5 min immediately after patient has received intrathecal hyperbaric bupivacaine 12.5 mg; and group IT (n = 20) was injected with 10 ml isotonic saline over 5 min immediately after patient has received intrathecal hyperbaric bupivacaine 12.5 mg and dexmedetomidine 3 μg. The onset time, maximum block level, time to maximum sensory and Bromage 3 motor block, duration of sensory and motor anesthesia, time to first analgesic request, and total analgesic consumption in the first 24 h were recorded. Hemodynamics, side effects, and sedation scores were assessed. Results Patients in groups IV and IT had a highly significantly longer sensory and motor block duration than patients in group B. Both durations were significantly longer in the IT group than in the IV group. The time to reach Bromage 3 motor block was significantly shorter in the IV and IT groups than in the B group, with no statistically significant difference between each other. The systolic and diastolic blood pressures were comparable in the three groups intraoperatively and postoperatively. Mean heart rate values were significantly decreased at 20-60 min in the IV group in comparison with the other two groups. The time to first analgesic needed was significantly prolonged in groups IV and IT in comparison with group B. The mean total consumption of intravenous tramadol postoperatively in the first 24 h was significantly decreased in groups IV and IT in comparison with group B. Conclusion In bupivacaine spinal block, dexmedetomidine whether administered intravenously at a dose of 0.5 μg/kg or intrathecally in addition to bupivacaine at a dose of 3 μg produced a significant prolongation in the durations of the motor and sensory block, but that administered intrathecally produced more significant prolongation of effect than that administered intravenously, with preserved hemodynamic stability and lack of sedation.

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Background Incorporation of adjuvants into local anesthetics could potentially aid in producing satisfactory prolonged postoperative analgesic duration and reducing postoperative adverse reactions associated with excessive systemic analgesic intake. The aim of this trial was to study the effect of incorporating magnesium sulfate as an adjuvant into lidocaine in an interscalene plexus block (ISPB) for arthroscopic acromioplasty. Materials and methods Sixty ASA I and II grade patients scheduled for elective arthroscopic acromioplasty under ultrasound guidance and peripheral nerve stimulation technique were allocated randomly to two groups: group L, which included patients who received 20 ml of lidocaine 2% with epinephrine 1 : 200 000 plus 5 ml 0.9% NaCl, and group LM, which included patients who received 20 ml of lidocaine 2% with epinephrine 1 : 200 000 plus 5 ml of 10% MgSO ₄ (500 mg MgSO ₄ ). The following data were collected: the onset of sensory block, the occurrence of satisfactory motor block, sensory block duration, Numeric Rating Scale (NRS) at the first analgesic dose, motor block duration, total morphine consumption in the first 24 h, and the presence of any adverse reactions. Results Patients in the magnesium sulfate group showed a prolonged postoperative analgesic duration, the NRS records decreased significantly on the first analgesic dose, and morphine consumption was reduced, and no adverse events related to its use in ISPB were recorded. Conclusion The addition of magnesium sulfate to lidocaine in ISPB significantly prolongs the analgesic duration and reduces the NRS score and postoperative opioid requirements in shoulder arthroscopic acromioplasty without side effects.

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Objectives Acute postoperative pain following radical mastectomy has been shown to increase the risk for chronic postmastectomy pain, a type of neuropathic pain. Preemptive analgesia has been shown to be effective in reducing the incidence of some types of neuropathic pain. We investigated the analgesic efficacy of duloxetine on acute and chronic pain in patients undergoing breast surgery. Materials and methods Fifty patients scheduled for radical mastectomy with axillary dissection were randomized in a double-blinded manner to receive either duloxetine 60 mg (group D) starting 2 days before operation for 2 weeks followed by 30 mg until the end of study or placebo capsules (group P) for the same course. Total morphine consumption over the first 48 h, time to first rescue analgesic, and pain scores were recorded [visual analog scale (VAS)] at 2, 4, 12, and 24 h postoperatively, daily until the fourth day, then 3 and 6 months later. Results In the duloxetine group compared with the placebo group, total morphine consumption was less (at 24 h, 14 ± 2.3 vs. 24 ± 1.7 and at 48 h, 11.5 ± 2.5 vs. 20 ± 1.4, P < 0.001, respectively), time to first rescue analgesic was longer (4.6 ± 0.7 h vs. 2.5 ± 0.5 h, P < 0.001, respectively), with significant decrease in VAS scores of pain at all time points (P < 0.001), and the incidence of pain was less at 3- and 6-month follow-up. Conclusion Duloxetine significantly reduced postoperative analgesic requirements, VAS, and incidence of chronic pain at 3- and 6-month follow-up in women undergoing breast surgery.

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Background Many additives have been added to local anesthetics in PBA to decrease the time of onset and increase the duration of analgesia to suit the relatively long vitreoretinal surgery with limited success. Dexmedetomidine has been added to local anesthetics for such purpose. Patients and methods Sixty consented ASA I-II adult patients undergoing vitreoretinal surgery were enrolled in this randomized, double blind, controlled study. Patients were randomly and evenly assigned to three groups to receive one of three anesthetic solutions for PBA: group C, group D25, and group D50. Patients in group C received 6 ml of 0.5% levobupivacaine with 10 IU/ml hyaluronidase in addition to 1 ml of normal saline. Patients in groups D25 and D50 received the same mixture but with replacement of the normal saline with 25 and 50 mcg dexmedetomidine, respectively. Intraoperative recordings included onset and duration of corneal anesthesia and globe akinesia, hemodynamics, intraocular pressure (IOP), and Ramsay sedation score. Postoperative recordings included time to first rescue analgesia and number of doses required, pain score, and patient and surgeon satisfaction score. Results The onset of corneal anesthesia and globe akinesia was significantly shorter in group D50 than in group C (1.05 ± 0.50 and 6.90 ± 1.94 vs. 1.68 ± 0.78 and 9.10 ± 2.14); in group D25 the onset was insignificantly shorter. Duration of anesthesia was significantly longer in both groups compared with control, as was the time to first rescue analgesia. IOP was also significantly lower in both groups compared with control. Conclusion Addition of two different doses of dexmedetomidine (25 and 50 mcg) to levobupivacaine/hyaluronidase mixture shortened the onset and prolonged the duration of peribulbar block in patients undergoing vitreoretinal surgery. It also lowered the IOP and provided sedation with patient's cooperation, leading to better patient and surgeon satisfaction.

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Background Penile block is recommended for analgesia during and after surface operation on the penis, for example circumcision, phimosis, meatal stenosis, and hypospadias repair. Objective To evaluate the effect of penile block versus caudal block using bupivacaine on the quality of analgesia, and the surgeon's and parents' satisfaction after penile pediatric surgery. Patients and methods This study was conducted on 80 healthy boys aged 1-7 years, of American Society of Anesthesiologists (ASA) I and II health classes, scheduled for hypospadias repair, circumcision and meatal stenosis under general anesthesia. The patients were randomly divided into two equal groups: group P (penile block, 0.25% bupivacaine, 0.5 mg/kg; n = 40) and group C (caudal block, 0.25% bupivacaine, 0.5 mg/kg; n = 40). The heart rate (HR), the mean arterial blood pressure (MAP) and oxygen saturation were measured perioperatively. Postoperative pain evaluated by the FLACC pain scale of five categories, (F) Face, (L) Leg, (A) Activity, (C) Cry, (C) Consolability, was assessed on admission to and on discharge from the PACU and 2, 4, 8, 12, 16 and 24 h postoperatively. Also, the time to first rescue analgesic request and doses of analgesic requirements were recorded. The surgeon's and parents' satisfaction were evaluated on the first day of the operation using a five-point verbal score. Results In group P, there was no significant decrease in the HR and the MAP compared with the baseline, but in group C, there was a significant decrease in HR and MAP compared with the baseline. FLACC pain scores were significantly lower in group P compared with group C (P < 0.05). Also, the time to first need for analgesia was significantly (P < 0.05) lower in group P compared with group C. The total analgesic requirement was also significantly lower (P < 0.05) in group P compared with group C. Conclusion Single-injection penile block is superior to caudal epidural block for relief of postoperative pain in children undergoing penile surgery with more satisfaction to the surgeon and the parents, without significant increase in the rate of adverse events.

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Context Coadministration of adjuvants with bupivacaine for spinal anesthesia is advocated to reduce its dose and improve the quality of intraoperative and postoperative analgesia with the least number of side effects. Aim The aim of the study was to compare the efficacy and safety of three intrathecal regimens for cesarean section. Patients and methods Ninety patients of ASA grade I or II who were scheduled for cesarean section under spinal anesthesia were randomly allocated into three groups of 30 patients each. Group B was injected with 15 mg of 0.5% hyperbaric bupivacaine, group F was injected with 10 mg of 0.5% hyperbaric bupivacaine +10 mg of sufentanil, and group D was injected with 10 mg of hyperbaric bupivacaine +10 mg of dexmedetomidine. Study parameters were as follows: mean arterial blood pressure, heart rate, respiratory rate, oxygen saturation (SpO ₂ ), sedation scores, side effects (such as hypotension, bradycardia, nausea/vomiting, shivering, pruritus, respiratory depression), neonatal outcome, onset and duration of sensory and motor block, intraoperative and postoperative analgesic requirements, and duration of complete and effective analgesia. Results There were no significant differences regarding mean arterial blood pressure, heart rate, respiratory rate, SpO ₂ , and neonatal outcome among the study groups. Sedation scores were higher in group D compared with groups B and S. Onset of motor block was comparable among the three groups, whereas onset of sensory block, time to two-segment regression and regression time to sensory S1, and motor recovery time were longer in groups D and S compared with group B. Intraoperative analgesic requirements showed no significance among the three groups, whereas duration of complete and effective analgesia was longer in groups S and D compared with group B. Further, postoperative 24 h analgesic requirements were higher in group B compared with groups S and D. Side effects such as hypotension, bradycardia, shivering, and respiratory depression were comparable among the study groups, whereas nausea/vomiting and pruritus were higher in group S compared with groups B and D. Conclusion Addition of sufentanil or dexmedetomidine to hyperbaric bupivacaine for intrathecal block prolongs the duration of sensory and motor block and reduces postoperative analgesic requirements. Sufentanil has a higher incidence of nausea/vomiting and pruritus, whereas dexmedetomidine has better analgesic effects and sedation without respiratory depression.

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Background Providing efficient postoperative analgesia for pediatric herinorrraphy is essential for surgical success. Different ultrasound (US)-guided techniques have been developed for pediatric nerve blocks. Aim This study aimed to compare US-guided ilioinguinal/iliohypogastric (II/IH) nerve block and US-guided transversus abdominis plane (TAP) block for pediatric unilateral inguinal herniorraphy with respect to postoperative analgesic efficacy by considering the time to first rescue analgesic as the primary outcome. Secondary outcomes included average pain scores, assessment of analgesic drug requirement, and incidence of postoperative vomiting. Patient and methods Fifty children scheduled to undergo unilateral herniorraphy were included in the study. After induction of general anesthesia patients were randomly allocated to one of two groups: group A or group B. Group A received US-guided II/IH nerve block with 0.2 ml/kg of 0.25% levobupivacaine and group B received US-guided TAP block with 0.2 ml/kg of 0.25% levobupivacaine. Fentanyl was given intravenously in case of failed block; failure was seen in one child (4%) in group A and in two children (8%) in group B and their postoperative data were not included in the statistical analysis. Time to first rescue analgesic, pain scores (FLACC score), the number of children who required postoperative analgesics, and incidence of vomiting were recorded. Results Time to first rescue analgesic was longer and the duration of analgesia was more stable in group A (273 ± 41.7 min) as compared with group B (209.6 ± 98.4 min) (P < 0.001). The average FLACC pain score for group A was 2 (1-2) compared with 3 (2.25-3.5) in group B, with statistically significant difference between the two groups (P < 0.001). The total number of patients who required paracetamol as a rescue analgesic in group A was 8 (33.3%) compared with 14 (60.9%) in group B (P < 0.001). Two patients in group B required morphine and both suffered from vomiting. Conclusion US-guided II/IH nerve block provides longer and more efficient postoperative analgesia compared with TAP block for pediatric inguinal herniorraphy.

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Background Functional endoscopic sinus surgery (FESS) requires effective control of bleeding for better visibility of the operating field and reduced risk of injury to the optic nerve or the internal carotid artery. Dexmedetomidine can provide controlled hypotension, analgesia, and sedation. The present study aimed to evaluate the clinical efficacy, safety, and advantages of dexmedetomidine as an anesthetic adjuvant for FESS. Patients and methods Fifty adult consented patients of comparable demographic profile, scheduled for FESS, were assigned randomly to two groups. Patients of group D received a loading dose of dexmedetomidine 1 mg/kg over 10 min, followed by an infusion at 0.4-0.7 mg/kg/h and patients of group C were administered an identical amount of saline solution. During the procedure, hemodynamic changes, intraoperative surgical grade of bleeding (on the basis of the Fromme-Boezaart scale), intraoperative fentanyl consumption, emergence time, and total recovery from anesthesia (Aldrete's score ≥9) were recorded. Results Patients of group D comparatively had a lower intraoperative heart rate and mean arterial blood pressure, along with a significantly lower bleeding score (P < 0.001). The mean intraoperative fentanyl consumption was significantly lower in patients of group D. Emergence time and time to achieve an Aldrete's score 9 or more were significantly lower in group C at 15 and 30 min postoperatively. Conclusion Dexmedetomidine has effectively provided the ideal oligemic surgical field during FESS and offers the inherent advantages of analgesia, sedation, and anesthetic-sparing effects.

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Background Ultrasound (US)-guided transversus abdominis plane (TAP) block is an effective technique in providing analgesia for abdominal surgery. This study was designed to evaluate the efficacy of a US-guided TAP block and to compare it with a caudal block in unilateral day-case open inguinal hernia repair in children. Patients and Methods Forty ASA I-II, 1-5-year-old children scheduled for elective unilateral open inguinal herniotomy were studied. All patients received general anesthesia; sevoflurane was used for induction and maintenance of anesthesia and laryngeal mask airway (LMA) was used to secure the airway. After securing an intravenous cannula, patients were randomized to a US-guided TAP block (n = 20) (group T) using 0.5 ml/kg 0.25% bupivacaine, injected on the same side of surgery, and group C received a caudal block using 1 ml/kg 0.2% bupivacaine (n = 20). Surgery was allowed 15 min after administration the block. Block failure was considered in case of gross movement or more than 20% change in heart rate and/or ABP persisting more than 1 min after skin incision. Any adverse events were recorded. After surgery, patients remained for 4 h in the recovery room. Postoperative analgesia was evaluated using Children and Infants Postoperative Pain Scale (CHIPPS). An anesthesiologist, who was not part of the study team, evaluated the need for rescue analgesia in the intraoperative and postoperative period and a recovery nurse collected the data. If the CHIPPS score was greater than 4, a rescue analgesia of 20 mg/kg acetaminophen was administered. Results No difference was found in hemodynamics in both groups. Also, intraoperative fentanyl consumption was not different and no rescue analgesia was required in the postanesthesia care unit. Conclusion A US-guided TAP block is as effective as a caudal block in providing immediate postoperative analgesia in inguinal hernia repair.

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Context Femoral nerve block (FNB) provides effective analgesia after total knee arthroplasty (TKA) but has been associated with delayed ambulation due to quadriceps muscle weakness. Adductor canal block (ACB) may be a promising alternative, with less effect on the quadriceps muscle and comparable analgesic efficacy. Aim The aim of the study was to compare ACB with FNB regarding the quadriceps muscle strength and its analgesic efficacy in patients following TKA. Settings and design This was a prospective, randomized, controlled, double-blinded study. Patients and methods The patients were randomized to receive either ACB or FNB. The primary outcome was the effect on quadriceps muscle and early ambulation as determined by the timed up and go test and 10-min walk test. The secondary outcome was to compare the analgesic efficacy as determined by numeric rating scale, opioid consumption, and hospital length of stay. Results We enrolled 110 patients, of whom 107 were analyzed. The timed up and go test and the 10-m walk test were significantly shorter in the ACB group than in the FNB group on the postoperative day 1 with P-value of 0.002 and 0.005, respectively, whereas the difference between both study groups was statistically nonsignificant on the postoperative day 2. There was no significant difference between the study groups regarding the numeric rating scale, morphine consumption, or length of stay. Conclusion ACB may promote early ambulation after TKA without a reduction in analgesia when compared with FNB.

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Objective and aim of study Postoperative sore throat (POST) is a common complaint in about 21-65% of patients undergoing general anesthesia with endotracheal intubation. The aim of this randomized controlled study was to evaluate the efficacy of preoperative nebulized dexamethasone in decreasing the incidence of postextubation sore throat. Patients and methods A total of 120 American Society of Anesthesiologists (ASA) physical status I-II patients of both sexes aged 25-60 years sexes were included in this study. Patients were randomly assigned into one of the two groups of 60 patients each: group D received dexamethasone 8 mg in 5 ml nebulization and group S (the control group) received normal saline in 5 ml nebulization 15 min before general anesthesia and endotracheal intubation. The intensity of sore throat and hemodynamic variables were monitored before nebulization, on arrival to the postanesthesia care unit (0 h), and at 2, 4, 8, 12, and 24 h postoperatively. Results The incidence and severity of POST were significantly reduced in the dexamethasone group than in the saline group at the following time intervals: 2 h after extubation (P = 0.009), 4 h after extubation (P = 0.000), 8 h after extubation (P = 0.000), and 12 h after extubation (P = 0.002). There was no complication associated with dexamethasone nebulization. Conclusion Preoperative nebulization with dexamethasone 8 mg reduces the incidence and severity of POST in patients receiving general anesthesia with endotracheal intubation.

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Background Despite its strategic role in health-care delivery, anesthesia does not attract medical manpower in developing countries, more so among medical trainees. This has resulted in an alarming lack of physician anesthetists. This study aims to determine the rate of selection of anesthesia as a specialty choice and factors that influence medical students when choosing specialties. Patients and methods A cross-sectional study was conducted on final-year medical students in the University of Calabar. A semistructured self-administered questionnaire was distributed to a total of 105 final-year students who had undergone their posting in anesthesia. Summarization of data was done using frequencies/proportions and graphs, and significance level was set at P-value less than 0.05. Results The mean age of respondents was 27.2 ± 4.15 years. Of the students, 72 (69%) were male, whereas 33 (31%) were female. Of them, 96 (91%) indicated interest in specializing, 34 (32%) preferred obstetrics and gynecology, 20 (19%) wanted pediatrics, 13 (12%) preferred family medicine and three (3%) preferred anesthesia. Factors that influenced choice of specialty among the graduating students included: personal interests in 85 students (81%), future job opportunities in the field in 66 students (63%) and requirement of specialized skill in 65 students (62%). In all, 46 respondents (44%) reported that their anesthesia posting experience was interesting, whereas 27 respondents (28%) reported it as very educative. The duration of the posting was rated very short by 25 students (24%). Conclusion With less than 5% of the graduating medical students indicating interest in anesthesia specialization, improvement in training facilities and provision of incentives to intending trainees are strongly recommended.

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Introduction Care of the critically ill patients is resource-intensive, and 15-20% of hospital budgets are spent in the ICUs. Objectives This study aimed to analyze the epidemiologic patterns of pediatric critically ill patients presenting to the pediatric intensive care unit (PICU) and the etiologies of PICU admission of different age groups. Materials and methods This descriptive study of all children aged less than 14 years presenting with critical illnesses to the PICU was conducted in a tertiary medical Hospital, in Cairo, from 2011 to 2012. All patients transferred to the PICU were included without distinction. Demographic data of critically ill children admitted to the PICU were analyzed. Etiologies of the PICU admissions were analyzed by various age groups. Results There were 532 critically ill children admitted to the PICU. Respiratory system diseases, foreign body inhalation removal, and encephalopathy were the predominant etiologies of admission 49.6, 11.9, and 11.5%, respectively. Mortality rate was the highest in infants below 1 year of age (43.9%). Predominant length of ICU stay was around 7 days. Conclusion The present study shows the etiologies of pediatric patients admitted to ICUs. The epidemiologic analysis of patients admitted to PICU can serve as basis for developing dedicated protocols for critical care and redistributing the ICUs' resources.

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Objective This study aimed to evaluate the postoperative analgesic efficacy of either preincisional peritonsillar infiltration of ketamine in combination with bupivacaine, or intravenous ketamine combined with infiltration of bupivacaine. Patients and methods A total of 60 patients were randomized into three groups: intravenous group, in which patients received intravenous ketamine (0.5 mg/kg) in 10 ml plus peritonsillar infiltration of bupivacaine 2 ml (5 mg/ml); infiltration group, in which patients received peritonsillar infiltration of ketamine (0.5 mg/kg) in 2 ml plus bupivacaine 2 ml and intravenous 10 ml saline; and placebo group, in which patients received 10 ml intravenous saline and peritonsillar infiltration of 2 ml saline plus 2 ml bupivacaine 2 ml/tonsil. The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and Wilson scale were used to evaluate pain and sedation, respectively. Time to first analgesic request and total analgesic request, total analgesic consumption during 24 h postoperatively, intraoperative blood loss, and adverse effects were evaluated. Results Time to analgesic request was significantly prolonged in the intravenous and infiltration groups (4.3 ± 2.1 and 11.6 ± 3.6 h, respectively) compared with the placebo group (1.2 ± 1.2 h), with significant prolonged time in the infiltration group compared with the intravenous group. Significant lower (CHEOPS) scores and significant lower analgesic consumption were observed in the intravenous and infiltration groups (69 ± 4.1 and 45.1 ± 2.1 mg), respectively, compared with the placebo group (90.6 ± 5.3 mg). Both the intravenous and infiltration groups had comparable pain scores, with statistical significance at 4, 6, and 8 h postoperatively. Dysphagia was significantly higher in the placebo group compared with the intravenous and infiltration groups. No serious complication was reported in the three groups. Conclusion Intravenous or peritonsillar infiltration of ketamine with bupivacaine enhanced post-tonsillectomy analgesia in children. In comparison, the analgesic efficacy of infiltration of ketamine was superior to intravenous administration, without significant side effects.

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Context Although spinal anesthesia avoids the risks involved in managing the airway of the parturient, an undesired side effect often seen is hypotension. Prophylactic intravenous (i.v.) administration of vasopressors such as ephedrine or of serotonin receptor antagonists such as granisetron and ondansetron has been used to overcome this problem. Aims The aim of the study was to compare granisetron and ondansetron with the traditionally used vasopressor 'ephedrine' in reducing hypotension following spinal anesthesia and their effect on sensory and motor blockade in parturients undergoing cesarean section. Settings and design This study was designed as a randomized, prospective, double-blind, placebo-controlled trial. Materials and methods Eighty parturients of ASA I or II grade, aged 2040 years, scheduled for elective cesarean section were randomly allocated into four equal groups (G, O, E, and C). 'Group G' received 1 mg i.v. granisetron, 'group O' received 4 mg i.v. ondansetron, 'group E' received 10 mg i.v. ephedrine, and 'group C' received 10 ml normal saline. All of the studied drugs were diluted in 10 ml normal saline and administered over a period of 1-5 min before induction of spinal anesthesia. Mean arterial blood pressure, heart rate, sensory and motor blockade, nausea, shivering, bradycardia and vasopressor need were assessed. Results The reduction in mean arterial pressure was significantly lower in the therapeutic groups, with the best results recorded in the O group and nearly comparable results in G and E groups. Heart rate was statistically different only at 10 and 15 min. No significant difference was seen in motor block or in the incidence of bradycardia. Significantly faster recovery of sensation was detected in the G group. Groups G, O, and E had significantly less vasopressor need and lower incidence of nausea. Conclusion In the cesarean section, prophylactic use of i.v. granisetron, ondansetron, or ephedrine reduced the severity of spinal-induced hypotension, nausea, and vasopressor need, but faster recovery of sensory block was noticed with granisetron.

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Background Dexamethasone has anti-inflammatory properties that can prolong postoperative analgesia when added to isobaric bupivacaine transversus abdominis plane (TAP) block for bariatric patients undergoing laparoscopic vertical banded gastroplasty. Patients and methods A total of 111 bariatric patients, scheduled for laparoscopic vertical banded gastroplasty under ultrasound-guided TAP block, were randomized blindly into three parallel groups: Group BC that received TAP block using 20 ml of isobaric bupivacaine hydrochloride 0.25%+2 ml saline 0.9%; low-dose dexamethasone group (Group DB4) that received TAP block using 20 ml of isobaric bupivacaine hydrochloride 0.25%+4 mg dexamethasone; and high-dose dexamethasone group (Group DB8) that received TAP block using 20 ml of isobaric bupivacaine hydrochloride 0.25%+8 mg dexamethasone. Results Postoperatively, pain scores were significantly lower in Group BD4 and Group BD8 compared with Group BC at rest and on movement at 6, 8, 12, and 24 h. There was a significant difference with respect to the duration of analgesia (P = 0.0001), 24 h consumption of paracetamol (P = 0.0001), 24 h consumption of meperidine hydrochloride (P = 0.001), the number of patients who needed meperidine hydrochloride rescue analgesic (P = 0.008), time to ambulation (P = 0.0001), and incidence of postoperative nausea and/or vomiting (P = 0.03) among groups. Conclusion Adding dexamethasone (4 or 8 mg) to isobaric bupivacaine TAP block reduces postoperative pain, reduces analgesic requirement, and promotes early ambulation in bariatric patients undergoing laparoscopic vertical banded gastroplasty in comparison with isobaric bupivacaine TAP block alone.

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Background Endotracheal intubation is considered as the definitive method of airway management. Difficulty encountered during direct laryngoscopy for the intubation process is one aspect of the overall problems in airway management. Fiberoptic bronchoscopy (FOB) represents a significant advancement in the management of patients with a difficult airway. C-MAC videolaryngoscopes present a new approach for the management of difficult laryngoscopy. Patients and methods Sixty patients, of both sexes, aged 20-50 years, ASA I-II, undergoing an elective uvulopalatopharyngoplasty surgery were included. Patients were allocated randomly to be intubated using FOB (F group) or FOB plus C-MAC videolaryngoscopy (F-CMAC group). Collected data included grades of the Cormack-Lehane laryngeal view, success or failure of the technique, the number of attempts, the duration of the successful attempt, and hemodynamic measurements throughout the intubation procedure. Complications (such as oxygen desaturation, patient distress, soft tissue damage, gagging/vomiting, bradycardia and hypotension, laryngospasm, and bronchospasm) were recorded. Results There was a significant decrease in the duration of the successful attempt, the number of intubation trials, and Cormack-Lehane grades regarding the laryngeal view as well as a decrease in the number of patients who needed facilitating techniques in group F-CMAC compared with group F. No significant difference was found on comparing the heart rate, the mean arterial pressure, and the incidence of complications during intubation between the two groups. Conclusion The C-MAC videolaryngoscope with fiberoptic bronchoscopy allows a significantly faster intubation time, with a decrease in the duration of the successful attempt, fewer intubation trials, and a better grade of laryngeal views assessed by Cormack-Lehane grades, with a decrease in the number of patients who needed facilitating techniques and a comparable incidence of complications during intubation compared with fiberoptic alone for tracheal intubation in patients with a suspected difficult airway undergoing elective uvulopalatopharyngoplasty.

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Context Induced hypotension to minimize bleeding during functional endoscopic sinus surgery (FESS) is of vital importance to the surgeon and anesthetist to decrease the risk of complications as well as procedural failure. Aim This study was designed to compare the efficacy of dexmedetomidine, magnesium sulfate, or glyceryl trinitrate in inducing deliberate hypotension during FESS and their effect on postoperative recovery, discharge, and postoperative analgesic requirement. Settings and design This was a randomized prospective single-blind study. Patients and methods Sixty patients of ASA physical status I or II scheduled for FESS were equally randomly assigned into three groups. The glyceryl trinitrate group (the G group) received glyceryl trinitrate infusion of 2-10 μg/kg/min. The dexmedetomidine group (the DEX group) received dexmedetomidine bolus of 1 μg/kg, followed by 0.2-0.7 μg/kg/h infusion for maintenance, and the magnesium sulfate group (the M group) received a bolus of 50 mg/kg magnesium sulfate, followed by infusion of 15 mg/kg/h for maintenance. The target mean arterial pressure was 55-65 mmHg. Hemodynamic parameters, blood lose, surgical field quality, intraoperative atropine, ephedrine or fentanyl use, emergence time, time to achieve an Aldrete score of 9 or greater, sedation score, time of discharge from postanesthesia care unit, and time to first analgesic request were recorded. Results The studied drugs achieved the target mean arterial pressure (55-65 mmHg) with superior hemodynamic stability in the DEX group. Intraoperative blood lose and quality of the surgical field were comparable. Both dexmedetomidine and magnesium sulfate offered the advantage of inherent analgesic and sedative effect, but at the expense of longer recovery of anesthesia and discharge from postanesthesia care unit. Conclusion Dexmedetomidine, magnesium sulfate, or glyceryl trinitrate induced deliberate hypotension, with superior hemodynamic stability in dexmedetomidine. Analgesic and sedative effects were obtained with dexmedetomidine and magnesium sulfate, but with longer recovery and discharge times.

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Background This randomized double-blind study was started with an objective of comparing two commonly used vasopressors (phenylephrine and ephedrine) as intravenous bolus injection to reduce hypotension in elective cesarean section in mothers with pre-eclampsia and estimating their impact on fetal outcome. Place of the study The study was conducted in Woman Health Hospital, Assiut University, Egypt. Patients and methods We studied 40 pre-eclamptic patients undergoing elective cesarean section under spinal anesthesia who developed hypotension after subarachnoid block. They were randomly allocated to one of the two groups to receive an intravenous bolus of the following drugs: group P, phenylephrine (75 μg, n = 20) or group E, ephedrine (6 mg, n = 20). Hypotension was defined as a decrease in systolic pressure to more than 25% of baseline values or systolic blood pressure of less than 90 mmHg. Results There were significant differences in systolic and diastolic blood pressure and pulse rate for the two studied drugs, which were less affected in the ephedrine group as compared with the phenylephrine group. Neonatal Apgar scores were within normal range in both groups. With respect to arterial and venous blood gases, there was significant difference in base excess and nonsignificant difference in pH and PO ₂ between the two groups. Conclusion Both vasopressors phenylephrine (75 μg) and ephedrine (6 mg) were given as a bolus dose to pre-eclamptic candidates receiving spinal anesthesia, causing hemodynamic stability to mothers. However, the usage of phenylephrine was safer for fetal outcome than epinephrine in high-risk cesarean sections (pre-eclampsia) under spinal anesthesia.

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Background Despite the fact that sevoflurane is widely used in pediatric anesthesia due to its fast and well-tolerated inhaled induction and rapid emergence, sevoflurane-induced emergence agitation (EA) in children is not uncommon. This study aims to test the effect of intraoperative magnesium sulfate on reducing the incidence of EA in children anesthetized with sevoflurane. Materials and methods The study included 50 male children, aged 3-6 years, with ASA status I or II, scheduled for elective inguinal herniorrhaphy under GA through laryngeal mask airway (LMA). The patients were allocated into two groups: group M (25 patients) received intravenous magnesium sulfate 10% (0.2 ml/kg), followed by a continuous infusion of 0.1 ml/kg till the end of surgery; group C (25 patients) received a similar volume of intravenous normal saline (0.2 ml/kg), followed by a continuous infusion of 0.1 ml/kg till the end of surgery. Anesthesia was induced using 6 l/min of O ₂ 100% with sevoflurane 8 vol%. Anesthesia was maintained with sevoflurane 1.5-2 vol% in an oxygen-air mixture. After LMA removal, the agitation scoring scale was used for assessing the quality of emergence. Agitation parameters were measured using a four-point scale. Agitated children were managed by giving intravenous midazolam (0.1 mg/kg). Results The study was completed by 42 children. Magnesium concentrations in group M were significantly higher [2.95 (0.50) mg/dl] compared with group C [2.01 (0.42) mg/dl; P < 0.001]. The emergence time was significantly longer in group M [19.11 (7.45) min] compared with group C [15.421 (6.54) min; P < 0.001]. Other recovery characteristics in terms of the time to LMA removal and the time to reach full Aldrete score were comparable between both groups. Heart rate and systolic blood pressure variables were significantly higher in group C compared with group M at the time of LMA removal (P < 0.01). At the postanesthesia care unit, there was no incidence of agitation reported in group M as compared with 11 patients in group C (P < 0.001). In group C, the mean duration of agitation was 16.4 (8.2) min and the mean dose of midazolam administered was 0.09 (0-0.2) mg/kg per child. No patients in group M complained of pain compared with group C at 5, 10, and 30 min after emergence from anesthesia (P < 0.001). Conclusion Intravenous magnesium sulfate infusion significantly reduced the incidence of sevoflurane-induced EA.

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Background Different additives have been reported to prolong the duration of caudal anesthesia in pediatrics. Although these drugs successfully increased the duration of the block, many of them were associated with undesirable adverse effects. Dexamethasone has been found to effectively increase the duration of an epidural block in adults, with no resulting side effects. Objective The aim of this study was to assess the effect of adding dexamethasone to bupivacaine on the duration of a caudal block in pediatric patients. Patients and methods This was a prospective randomized-controlled study that included 80 children, aged 1-6 years, American Society of Anesthesiologists physical status I, undergoing elective unilateral inguinal herniotomy. Patients were randomized to receive 1 ml/kg bupivacaine 0.25% (group B) or a mixture of dexamethasone 0.2 mg/kg added to 1 ml/kg bupivacaine 0.25% (group BD). In the postoperative period, pain was assessed using a modified Objective Pain Scale (mOPS) score until 24 h after surgery and rescue analgesia (oral paracetamol 15 mg/kg) was administered when mOPS score 4 or more was recorded. The primary outcome measure was the time to first analgesic requirement. The number of analgesic doses required in the first 24 h after surgery, residual motor block, sedation scores, intraoperative and postoperative hemodynamic variables, postoperative nausea and vomiting (PONV), and other adverse effects were recorded. Results Group BD showed a significantly longer time to first analgesic requirement than group B. The number of oral paracetamol doses required in the first 24 h was significantly less in group BD. Group BD showed lower mOPS scores than group B. Modified Bromage scale scores, sedation scores, as well as intraoperative and postoperative hemodynamic variables were comparable in the two groups. Group BD showed significantly fewer incidences of PONV compared with group B. Conclusion Adding dexamethasone to bupivacaine prolongs the duration of postoperative analgesia and decreases the incidence of PONV after a caudal block in pediatric patients.

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Background Patients undergoing laparoscopic procedures do experience postoperative pain, especially in the abdomen, back, and shoulder region. Intraperitoneal injections of a local anesthetic have been proposed to minimize postoperative pain after laparoscopic surgery. Therefore, this prospective, randomized, controlled, placebo study was conducted to compare the effectiveness of intraperitoneal lidocaine with that of intraperitoneal nalbuphine for postoperative analgesia after laparoscopic cholecystectomy (LC) surgery. Setting Assiut University Hospitals, postoperative surgical world, Egypt. Patients and methods Eighty-one patients with ASA I or II undergoing LC were included in the study. They were classified randomly into three groups: group C, which comprised 27 patients who were given 50 ml normal saline intraperitoneally; group L, which included 27 patients who were given 200 mg lidocaine intraperitoneally in 50 ml normal saline; and group N, which included 27 patients given 10 mg nalbuphine intraperitoneally in 50 ml normal saline. Postoperative pain was recorded using the visual analogue scale for 24 h after LC. Postoperative analgesic consumption was also recorded. Results The mean visual analogue scale was significantly lower in both lidocaine and nalbuphine groups than in the control group within 24 h after surgery. The incidence of shoulder pain was 29.6% in the control group, 22.2% in the nalbuphine group, and 14.8% in the lidocaine group. The mean value of total analgesic consumption in the form of intravenous paracetamol was significantly lower in the lidocaine group (2.3 g ± 0.60) and nalbuphine group (2.5 g ± 0.63) when compared with control group C. There were no significant differences between the three groups as regards hemodynamics. Conclusion Although both lidocaine and nalbuphine when used intraperitoneally produce postoperative analgesia, intraperitoneal lidocaine gives a better analgesic profile with fewer unwanted effects.

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Background Respiratory disorders are the main cause of respiratory failure in children. Insufficient alveolar ventilation results in hypoxemia and hypercapnia, which contribute to further depression of ventilation, resulting in respiratory failure. Although most patients wean from mechanical ventilation with little difficulty, some patients are unable to maintain sustained efforts of breathing for long periods and develop signs of fatigue. A failed weaning is defined as either the failure of spontaneous breathing trial or the need for reintubation within 48 h after extubation. Objective This study was undertaken to identify the causes of difficult weaning from mechanical ventilation and predict the variables responsible for this difficulty. Participants and methods A prospective study was performed on 100 children, comprising 59 boys and 41 girls. Their ages ranged between 2 months and 10 years. All the children were subjected to a detailed medical history taking, clinical examination, and laboratory investigations (complete blood count, serum electrolytes, and arterial blood gas). Patients were selected to participate in this study on the basis of the inclusion and exclusion criteria. Statistical analysis The Mann-Whitney U-test and the χ² -test were used for statistical analysis. Results Among the 100 studied patients, 86 (86%) succeeded in being weaned from mechanical ventilation, whereas the remaining 14 patients (14%) failed to wean. This group included nine children who experienced difficulty in weaning and five children with prolonged weaning. Patients who were successfully weaned spent statistically less time on mechanical ventilation, had lower PaCO ₂ , and lower bicarbonate level compared with patients who failed to wean (P = 0.002, 0.001, 0.04, respectively). There was no association between clinical diagnosis, hematological parameters, serum electrolytes, and weaning success. Conclusion We conclude that patients who were successfully weaned were statistically older, spent less time on mechanical ventilation, had lower PaCO ₂ and FiO ₂ , and lower bicarbonate level compared with those who failed to be weaned. We did not find a significant relation between the clinical diagnosis, hematological parameters, serum electrolytes, and weaning success.

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