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Cardiovascular effects of prolonged milrinone inhalation in patients with pulmonary hypertension undergoing mitral valve replacement
Sherif S Sultan, Khaled M.A. Abdelsalam
October-December 2015, 8(4):474-478
Context Inhaled milrinone has short-acting selective pulmonary vasodilator effect. Aims The aim of the study was to investigate the cardiovascular effects of prolonged inhalation of nebulized milrinone on patients with pulmonary hypertension undergoing mitral valve replacement. Settings and design This is a controlled, randomized, double-blinded study. Patients and methods Forty patients were divided into two groups: the milrinone group and the control group. The milrinone group received milrinone nebulization before cardiopulmonary bypass (CPB) as the loading dose at 50 mg/kg, followed by a maintenance dose of 0.5 mg/kg/min, which was continued for 2 h after tracheal extubation. The control group received an equivalent volume of 0.9% sodium chloride. The measured and calculated variables included heart rate, mean arterial blood pressure, central venous pressure, mean pulmonary artery pressure (mPAP), pulmonary capillary wedge pressure, cardiac index (CI), pulmonary vascular resistance (PVR), and systemic vascular resistance. The time points of measurements and calculations were as follows: at T 0 - after anesthesia induction and before sternotomy; at T 1 - 20 min after CPB cessation; at T 2 - 1 h after CPB cessation; at T 3 - 3 h after CPB cessation; at T 4 - 1 h after tracheal extubation; and at T 5 - 1 h after milrinone discontinuation. The duration of CPB and time of tracheal extubation were recorded. Results The milrinone group showed significant reduction in mPAP (T 2 to T 4 readings), pulmonary capillary wedge pressure (T 3 reading), and PVR (T 2 to T 4 readings), increase in CI (T 3 and T 4 readings), and shorter CPB duration and tracheal extubation time. Conclusion Prolonged inhalation of nebulized milrinone proved to be feasible in patients with pulmonary hypertension (PAH) undergoing mitral valve replacement. It decreased PVR and mPAP while increasing CI. This helped shorter CPB duration and earlier tracheal extubation.
  25,527 1,394 2
The minimal effective dose of spinal hyperbaric bupivacaine for successful reliable saddle block for minor perianal surgeries
Roshdi R Al-Metwalli
April-June 2015, 8(2):265-268
Objective The aim of this study was to determine the minimal effective dose of spinal hyperbaric bupivacaine required to induce a reliable and satisfactory saddle block for perianal surgeries (using a modified Dixon's up-and-down method). Materials and methods A total of 24 adult patients scheduled for perianal surgeries were enrolled in this study. Dural puncture was performed using a standard midline approach in the sitting position at the L3-L4 intervertebral space, using a 25 G Whitacre needle with its orifice directed caudal. A small quantity (1.5 mg) of hyperbaric bupivacaine was injected. All patients remained in the sitting position for 10 min immediately before and after surgery; the block was tested using a long surgical toothless clamp and modified Bromage scale. A successful block was defined as one that was sufficient to proceed with the surgery without any supplementation. The dose of bupivacaine given to the next patient was guided by modified Dixon's up-and-down method using 0.5 mg as a step size. Patients' ability to position themselves, ambulation time, time of hospital discharge, patient and surgeon satisfaction, and any intraoperative or postoperative complication were recorded. The minimal effective dose of hyperbaric bupivacaine for successful saddle block for 50% (ED 50 ) of patients was determined by calculating the midpoint dose of all independent pairs of patients after at least seven crossover points. Results The ED 50 of hyperbaric bupivacaine for successful saddle block for perianal surgeries was 1.9 mg (95% confidence interval = 1.7-2.1 mg). There were zero motor blockade, early ambulation, short time to void, and early hospital discharge, as well as no complications and excellent patient and surgeon satisfaction. Conclusion The ED 50 of spinal hyperbaric bupivacaine for saddle block for perianal surgery is 1.9 mg (95% confidence interval = 1.7-2.1 mg). This block is reliable and has short duration, no complication, and excellent patient and surgeon satisfaction.
  24,796 903 3
Utilizing heart rate variability: Midazolam prevents the sympathovagal imbalance caused by fentanyl/propofol induction
Sherif S Sultan, Nasr A Hegazy
January-March 2015, 8(1):31-35
Context Heart rate variability (HRV) can monitor cardiac autonomic control. Sympathovagal imbalance is expected after fentanyl/propofol induction. Aim The aim of the study was to investigate the effects of intravenous midazolam on HRV and whether it prevents the sympathovagal imbalance caused by fentanyl/propofol induction. Settings and design This is a controlled, randomized, double-blinded study. Patients and methods The study included 50 patients undergoing knee arthroscopies under general anesthesia. Powers of low-frequency (LF: 0.04-0.15 Hz) and high-frequency (HF: 0.15-0.4 Hz) components of HRV, total power (TP), and LF/HF ratio were recorded using MemCalc software. Patients received midazolam 0.05 mg/kg (midazolam group) or an equivalent volume of normal saline (control group), followed by fentanyl 1 mcg/kg and then propofol 2 mg/kg intravenously. Statistical analysis The Mann-Whitney U-test and two-way repeated analysis of variance, followed by Bonferroni correction as a post-hoc test, were used to analyze the data. Results Midazolam induced significant decrease in TP and HF powers, with unchanged LF power and LF/HF ratio. Fentanyl induced significant decrease in TP and LF powers with unchanged HF power and LF/HF ratio in both groups. Propofol induced a significant decrease in TP, HF, and LF powers in both groups. Propofol decreased the LF/HF ratio significantly in the control group but not in the midazolam group. Conclusion Midazolam premedication induced significant decrease in TP and HF powers without changes in LF power or LF/HF ratio. When fentanyl and propofol were given, midazolam was capable of modulating the net effects of both drugs on the HRV by minimizing the decrease in LF power to keep the LF/HF ratio unchanged. This modulatory effect of midazolam works in favor of maintaining the sympathovagal balance.
  23,490 1,268 2
Anaesthetic concerns with intramyometrial vasopressin during myomectomy
Geetanjali Chilkoti, Medha Mohta, Shivika Nath, Ashok Kumar Saxena, Priyanka Khurana
July-September 2016, 9(3):452-454
Vasopressin, a potent vasoconstrictor, has often been used intramyometrially to prevent blood loss during surgical management of uterine myomas. Various lethal complications reported with its use include bradycardia, unmeasurable blood pressure, loss of palpable peripheral pulse, marked pallor, arrhythmia, pulmonary oedema and cardiac arrest. We herein report a case of uterine myomas in which intramyometrial vasopressin-induced complications such as bradycardia, absent pulse and marked pallor were observed with very low dose and concentration (i.e. 1.5 U and 0.1 U/ml). This could be attributed to the coexistence of hypertension in our patient. Here, we discuss the anaesthetic concerns with the use of intramyometrial vasopressin and reinforce the need for dogmatic guidelines envisaging the recommended safe dose and concentrations of intramyometrial vasopressin and proper patient selection.
  19,422 1,031 3
Anesthetic management of ischemic heart disease with ejection fraction of 35% in a patient of fracture neck femur
S Jawe Nilesh, Naik Sanyogita, Jadhav Rahul, Kurhekar Vikas
January-March 2016, 9(1):136-138
Anesthetic management of cardiac patients coming for noncardiac surgery has always been challenging. Goal of anesthesia management is to keep myocardial oxygen supply greater than demand to avoid ischemia. In this case report, anesthetic implications included assessment of cardiovascular status of the patient preoperatively with selection of epidural anesthesia (EA) and analgesia technique. Incremental doses of local anesthetic were given to maintain myocardial oxygen demand. To the best of our knowledge, there have been only few case reports on EA for ischemic heart disease patient coming for noncardiac surgery. Hence, we report a successful anesthetic management of a patient with ischemic heart disease posted for fracture neck of femur under EA and analgesia.
  15,790 1,009 -
Addition of dexamethasone–chlorpheniramine mixture reduces the incidence of vomiting associated with oral ketamine premedication after pediatric dental procedures
Ayman A Abdellatif, Manal M Kamal, Rania A.H. Ishak
October-December 2016, 9(4):478-484
Background Oral ketamine has been shown to induce safe and effective sedation in children, but with a high incidence of postoperative vomiting. Vendexine (dexamethasone–chlorpheniramine mixture) is a commercially available syrup used primarily to treat allergic conditions. Each of its components has antiemetic effects. In the present study, we aimed to determine whether the addition of vendexine to oral ketamine premedication affects the incidence of postoperative vomiting. Patients and methods Sixty-four children scheduled for elective dental procedures under general anesthesia were enrolled in this prospective, randomized, double-blind study. They received an oral premedication mixture (total volume of 0.42 ml/kg) of either ketamine 6 mg/kg (0.12 ml/kg) mixed with dextrose 50% and apple juice (the K group), or ketamine 6 mg/kg (0.12 ml/kg) mixed with dextrose 50% and vendexine syrup (0.25 ml/kg) (the VK group). Sedation onset was noted. Scores for drug acceptance, sedation, emotional status, and behavior during parents’ separation, on venipuncture, and face mask application were rated. Incidence of postoperative vomiting, emergence agitation score, fentanyl consumption, and recovery time were also recorded. Results The two groups were comparable as regards sedation onset, scores for drug acceptance, sedation, emotional status, and behavior during parents’ separation, on venipuncture, and face mask application. However, a significant reduction of postoperative vomiting in the VK group was noticed compared with the K group (9.3 vs. 37.5%). In addition, emergence agitation and fentanyl consumption were significantly reduced in the VK group. Conclusion Vendexine added to oral ketamine reduces the incidence of postoperative vomiting associated with ketamine premedication in children.
  14,865 539 1
Comparison between effects of adductor canal block and femoral nerve block on early postoperative course in total knee arthroplasty: A prospective double-blind, randomized controlled study
Nasr A Hegazy, Sherif S Sultan
January-March 2015, 8(1):124-128
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.
  13,979 1,357 7
Effects of esmolol infusion on recovery profile and discharge from postanesthesia care unit after ambulatory gynecologic laparoscopic surgeries
Sherif S Sultan
October-December 2015, 8(4):555-559
Context Ambulatory surgery has a target of rapid recovery and discharge. Esmolol has sparing effects on inhalational anesthetics and opioids. Aim The aim of the study was to demonstrate effects of esmolol infusion on recovery profile and discharge from postanesthesia care unit (PACU). Settings and design This study was a randomized, double-blind, and controlled study. Patients and methods Sixty female patients scheduled for elective gynecologic laparoscopic surgery under general anesthesia were divided into two groups. Patients were given either esmolol loading and maintenance doses (the esmolol group) or equivalent volume of normal saline (the control group). Esmolol was given as a loading dose of 1 mg/kg just before induction of anesthesia followed by an infusion of 30 mg/kg/min. Depth of anesthesia was controlled by bispectral index monitoring and variable dose propofol infusion, whereas fentanyl and sevoflurane doses were fixed throughout the procedure. Times denoting recovery from anesthesia were recorded. Patients who reached White-Song score of 12 plus pain numerical rating scale below 4 were discharged from PACU. Time needed for PACU discharge was recorded. Results Compared with the control group, the esmolol group had following statistically significant results: lower blood pressure and heart rate, less fluctuant bispectral index values, lower amount of propofol infusion used, shorter times for immediate postoperative eye opening, extubation, tongue protrusion, and ability of the patient to mention her name, lower pain scores, fewer patients needed analgesics and earlier discharge from PACU. Conclusion Intraoperative esmolol infusion is associated with hemodynamic stability and antinociceptive properties. Recovery profile was excellent and helped early discharge from PACU.
  13,265 1,168 2
Role of anesthesiologists in the management of trauma patients: Updates
Eman M.K. Aboseif
April-June 2016, 9(2):153-158
Trauma is the leading cause of death for individuals up to the age of 45 years and the third leading cause of death overall for every age groups. In the United States, trauma accounts for more than 180.000 deaths per year and about 2.8 million hospital admissions, Trauma anesthesiologists are prepared to immediate care of patients with any form and severity of injury, who may require any kind of operations regardless of the day time of night. Therefore trauma anesthesiologists offer a unique expertise and skill set that are significantly different from those offered by other medical specialists and being a part of the hospital trauma team.
  12,464 1,914 2
A case report of asystole after a test dose of ceftriaxone in an adult man
Sawsan Aboul-Fotouh, Yosra M Magdy, Rania M Ali
October-December 2016, 9(4):617-619
Ceftriaxone is a commonly used antibiotic for various infections such as respiratory tract infection, urinary tract infection, and enteric fever, as well as in surgical prophylaxis. Hypersensitivity reactions after ceftriaxone therapy are uncommon but are potentially life-threatening, and they may lead to cardiac arrest. Here we report a 44-year-old man who presented with bradycardia, bronchospasm, hypotension, and cardiac arrest (asystole) after a single injected dose of ceftriaxone introduced for surgical prophylaxis. Epinephrine was given intravenously, and cardiopulmonary resuscitation was performed successfully. The patient regained his conscious level 2 h later and became hemodynamically stable within 4 h; next, he was extubated and closely observed for 24 h and then discharged. Physicians should be aware of the risk of anaphylaxis and asystole that may occur after the first dose of ceftriaxone and be ready for managing it properly.
  12,638 348 2
Effectiveness of ultrasound-guided transversus abdominis plane block for intraoperative and postoperative analgesia in kidney transplantation
Khaled M.A Abdelsalam, Sherif S Sultan
January-March 2015, 8(1):140-143
Background The transversus abdominis plane (TAP) exists between the internal oblique and transversus abdominis muscles, and encompasses an intersected plexus of nerves. The TAP block has been the subject of multiple clinical trials to determine its analgesic efficacy. Patients and methods A total of 60 patients were randomized into one of two groups: TAP block group (group 1) or no-TAP block group (group 2). All patients underwent a standardized anesthetic technique. The TAP block group received preincisional ultrasound-guided TAP block on the side of surgery with a 20-ml volume of 0.5% of bupivacaine, and the no-TAP group received equivalent amounts of saline. A standardized postoperative analgesic regimen composed of intravenous paracetamol and a morphine patient-controlled analgesia (PCA). The amounts of intraoperative fentanyl and post-anesthesia care unit (PACU) morphine and PCA-administered morphine, pain scores, as well as number of patients experienced postoperative nausea and vomiting in the ward at 6 and 24 h were recorded. Results TAP block group patients received a significantly lower cumulative intraoperative fentanyl, significantly less boluses of morphine in postanesthesia care unit, and significantly lower cumulative 24-h postoperative morphine dosage than the no-TAP block patients. Pain visual analog scale scores were significantly lower at both 6 and 24 h postoperatively in the TAP group when compared with the no-TAP group. There were no complications related to the TAP block procedures. No signs or symptoms of local anesthetic systemic toxicity were detected. Conclusion On the basis of our current results, preincisional ultrasound-guided TAP blocks confer analgesic benefit when added to the multimodel analgesia regimen during and after kidney transplantation.
  11,448 1,206 4
Root cause analysis of ventilator-associated pneumonia and the effect of analysis of expanded ventilator bundle of care
Hossam Ibrahim Eldesuky Ali, Ayman Ali Rayan, Tamer Hussein Ibrahim
April-June 2016, 9(2):170-177
Objectives The study had the following aims: (i) assess the risk factors and causes of ventilator-associated pneumonia (VAP) by means of the root cause analysis (RCA) module; (ii) compare the compliance with expanded ventilator bundle (EVB) and the effect of EVB on VAP rate, length of ICU stay (LOS), and mortality rate before and after bundle implementation; and (iii) suggest an action plan to reduce VAP. Patients and methods An 18-month study was conducted on all ventilated patients in our ICU. The preinterventional period was 9 months before implementing the bundle. We analyzed the causes and risk factors of VAP by using the RCA module. The postinterventional period was 9 months after implementing the bundle. Compliance with EVB was compared before and after implementing the bundle on a quarterly basis. We analyzed the effect of the bundle on VAP rate, LOS, and mortality rate. We suggested an action plan to reduce the VAP rate. Results There was lower compliance with the bundle in the preinterventional period than in the postinterventional period (P < 0.001). There were highly statistically significant reductions in VAP rate, LOS, and mortality rate after implementation of EVB (P < 0.001). Conclusion EVB was associated with effective and significant reductions in VAP rate, LOS, and mortality rate. Implementation of the RCA module was helpful in suggesting a new action plan that would improve bundle of care and its compliance.
  11,995 596 1
Psoriasis: is a central neuraxial block safe?
Nita Hazarika, Rahul Kumar, Rajesh Sood
September-December 2014, 7(3):253-254
  11,558 646 -
Perioperative medicine: a new concept for anesthetic care
Kerolos E Moris, Amr M Hilal
January-March 2017, 10(1):1-2
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.
  8,102 3,609 -
Does nebulized dexamethasone decrease the incidence of postextubation sore throat?: a randomized controlled study
Atef K Salama, Ahmed M El-badawy
January-March 2016, 9(1):104-107
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.
  10,472 602 4
The effect of nitroglycerin infusion versus hydralazine infusion as antihypertensive therapy in acute management of patients with severe pre-eclampsia
Rania M Ali, Dina Salah, Dina Y Mansour
October-December 2015, 8(4):499-504
Background Severe pre-eclampsia (PE) is a potentially life-threatening multisystem disease that requires urgent management. Delivery of the fetus is the definitive treatment for PE. However, effective and safe control of severe hypertension is the most important aspect of critical care management. This study aimed to compare the effectiveness and safety profile of hydralazine infusion versus nitroglycerin infusion as antihypertensive therapy in the acute management of patients with severe PE. Patients and methods A total of 180 patients with severe PE admitted to Ain Shams Obstetric ICU to stabilize blood pressure before delivery were randomly assigned to one of two equal groups: group H and group N. Group H received hydralazine infusion (1 mg/ml) and group N received nitroglycerin infusion (1 mg/ml). The infusion rate (5 ml/h) was adjusted to maintain systolic blood pressure at 130-140 mmHg and diastolic blood pressure at 80-100 mmHg. Results As regards hemodynamic parameters, the time to achieve blood pressure control was significantly shorter in the N group compared with the H group. However, the number of cases of severe persistent hypertension and the number of attacks of hypotension were comparable between the two groups. Maternal side effects and fetal and neonatal complications were comparable between the two groups, except for maternal headache and tachycardia, which were significantly higher in the H group compared with the N group. Concerning the mode of delivery, the rate of cesarean section delivery was significantly higher than the rate of vaginal delivery in both groups. Meanwhile, the rate of cesarean section after induction of labor was significantly higher in the N group compared with the H group. Conclusion Nitroglycerin could be a good alternative option for the acute management of patients with severe PE. It is an effective antihypertensive with minimal side effects.
  9,569 501 3
Rocuronium continuous infusion versus intermittent bolus for maintaining suitable muscle relaxation and recovery status without using a peripheral nerve stimulator during anesthesia
K Taye Mrinal, K Saloi Dilip, Kaur Sulakshana, Baruah Panchami
October-December 2015, 8(4):567-572
Introduction The objective of anesthesia has always been to enable correction of surgical pathology with the best technique and minimum risk to the patient. The aim of the present study was to determine clinically, without using a peripheral nerve stimulator, whether continuous infusion or intermittent bolus dosing of rocuronium bromide yielded a better clinical condition during general anesthesia. Patients and methods The study was carried out on 60 adult patients. A common technique of general anesthesia was used in all patients. Patients were randomized to receive either a continuous infusion (group I, n = 30) or intermittent bolus dosing (group II, n = 30) of rocuronium bromide. Intraoperatively (a), hemodynamic parameters (heart rate and arterial pressure), (b) clinical relaxation by a grading technique, (c) total drug requirement, (d) recovery status by modified Steward score were assessed and were compared between the two groups. Results The mean heart rate and mean arterial pressure at different time intervals after intubation with rocuronium were not significantly different between the two groups. The total drug requirement was significantly greater in patients who received an intermittent bolus dose of rocuronium than those who received a continuous infusion. Clinical relaxation and recovery status in patients receiving rocuronium infusion were significantly better. Conclusion Rocuronium infusion offers a better and stable degree of relaxation compared with intermittent bolus dosing for intermediate duration of operation, which can be assessed using the clinical relaxation grading system. Rocuronium is a rapidly acting and hemodynamically stable nondepolarizing muscle relaxant with fewer drug requirements and provides better quality of recovery status during a continuous infusion.
  9,567 500 1
New technique for caudal epidural block in pediatric patients
Abdelaziz A Abdelaziz
January-March 2016, 9(1):149-151
Caudal block is one of the most popular and effective techniques of regional anesthesia in pediatric surgery. Good anatomic knowledge and accurate adherence to guidelines pertaining to the technique and to drug administration is necessary to perform this block safely. The usual approach is well-known and has been extensively described, but failure is seen in some cases. Another approach is the 'no turn' technique, which is a new method developed in the Ain-Shams University, Pediatric Surgical Unit by the author. It has a high success rate and can be easily learned and implemented even by junior staff.
  9,437 552 -
Anesthetic management of a patient with β-thalassemia and superimposed pneumonia
Anuka Singh, Veena Kachwah, Sheetal Songir, Hemendra Modi
October-December 2014, 7(4):554-556
Beta-thalassemia is an autosomal hematological disorder that is the result of genetically deficient synthesis of beta-globin chains of hemoglobin. Beta-thalassemia is one of the most common single-gene disorders with >400,000 new borns affected per year worldwide. Patients present with severe microcytic hypochromic anemia, massive hepatosplenomegaly, and bony deformities. Infection is a major complication and the leading cause of death in thalassemia out of which Pulmonary disease was the most common cause of mortality. In this report we aimed to discuss our experience with a case of beta-thalassemia major with massive splenomegaly & superimposed pneumonia in a child presenting for splenectomy.
  9,299 585 -
Perioperative nutrition to enhance recovery after surgery
Dina Salah
October-December 2016, 9(4):469-477
Preoperative malnutrition is a major risk factor for increased postoperative morbidity and mortality. Patients at risk for malnutrition should be identified early. The Nutritional Risk Score is a validated tool to identify patients who should benefit from nutritional support. The adoption of total parenteral nutrition followed by the extraordinary progress in parenteral and enteral feedings, in addition to the increased knowledge of cellular biology and biochemistry, has allowed clinicians to treat malnutrition and improve surgical patient’s outcomes. Periods of prolonged fasting should be minimized and nutrition should be commenced as early as possible after surgery, preferably through the enteral route. The surgical patient with established malnutrition should begin aggressive nutrition at least 7–10 days before surgery. Those patients in whom eating is not anticipated beyond the first 5 days following surgery should receive the benefits of early enteral or parenteral feeding depending on whether the gut can be used. Many patients may benefit from newer enteral formulations, such as those designed to enhance immune function (immunonutrition).
  8,335 990 3
Methylene blue: Role in early management of septic shock patients?
Amr E Abd-Alhameed, Ahmed MS Hamed, Ahmed S Omran
September-December 2014, 7(3):327-335
Background The incidence of sepsis has increased steadily over the last three decades. Aggressive fluid challenge and administration of catecholamines still play a vital role in the current treatment regimen of patients with septic shock. However, new methods and drugs are needed for better management. Objective The aim of the study was to evaluate the role of early intervention with continuous infusion of methylene blue in management of septic shock patients regarding hemodynamics, duration of septic shock, and vasopressor support. Patients and methods Forty patients fulfilling the criteria of septic shock were randomized into two groups: group 1 that received methylene blue bolus at a dose of 1 mg/kg followed after 2 h by infusion at 0.5 mg/kg/h for 4 h and group 2 that received normal saline. Results The results were favorable in the study group, which showed higher and better mean arterial blood pressure, systemic vascular resistance, and cardiac output and less need for inotropes reflected by the lower length of ICU stay. Conclusion It can be concluded that the early application of methylene blue (defined by the need for norepinephrine at a dose of at least 0.2 μg/kg/min required to maintain mean arterial blood pressure between 70 and 90 mmHg) at a dose of 1 mg/kg bolus followed by 0.5 mg/kg/h for 4 h showed favorable effects on hemodynamics of cardiac output, decreasing the length of hospital stay.
  7,973 917 1
Components of respiratory function tests
Bahaa El-Din Ewees Hassan, Mai M Abdel-Aziz
September-December 2014, 7(3):255-258
The respiratory system is composed of the lungs, the conducting airways, the parts of the central nervous system concerned with the control of the muscles of respiration, and the chest wall [1]. The main functions of the respiratory system are to obtain oxygen from the external environment and supply it to the cells and to remove from the body the carbon dioxide produced by cellular metabolism [2]. Pulmonary function tests provide valuable clinical information. They are designed to identify and quantify defects in the respiratory system [3].
  8,194 570 -
Pin index safety system and color coding: is it enough?
Udita Naithani, Sneha Arun Betkekar, Devendra Verma, Ravindra K Gehlot, Rajkumar Sundararaj
October-December 2016, 9(4):626-628
Despite a number of preventive mechanisms, inadvertent administration of nitrous oxide in place of oxygen can lead to fatal hypoxemia. Here we report two cases of hypoxia that occurred when we switched to the emergency cylinder for oxygen supply after exhaustion of the main oxygen cylinder. The urgency shown by the anesthetist and operating room staff to restore the main oxygen supply prevented any fatalities from occurring in our case. We found that there was incorrect painting of the nitrous oxide cylinder with the color code of oxygen. Further, damaged pins on the yoke assembly allowed the attachment of the faulty E cylinder to the machine. Even though such errors are made by the supplier we suggest that all equipment including the cylinder be thoroughly checked by the anesthetist. This also highlights the role of respiratory gas monitoring in the prevention of such mishaps.
  8,460 266 -
Emergent management of Guillain-Barré syndrome
Amr Mohamed EL-Said
April-June 2014, 7(2):88-95
Guillain-Barré syndrome (GBS) is an acute inflammatory demyelinating polyneuropathy usually triggered by an infection. Ascending paralysis, weakness beginning in the feet and hands and migrating toward the trunk, is the most typical symptom, and some subtypes cause change in sensation or pain as well as dysfunction of the autonomic nervous system. This review aimed to revise knowledge and updates about this disease.
  7,874 749 -
Controlled hypotensive anesthesia for functional endoscopic sinus surgery: a new protocol for dexmedetomidine administration
Ayman A Rayan
January-March 2016, 9(1):57-65
Objective The aim of the study was to conduct a comparative investigation to evaluate the efficacy of dexmedetomidine as a hypotensive agent by presenting a new protocol for administration versus the conventional protocol in functional endoscopic sinus surgery (FESS). Materials and methods Forty patients of ASA grade I-II scheduled for FESS were equally randomly assigned to two groups: the DEX group and the DEXnew group. The DEX group received dexmedetomidine at 1 μg/kg diluted in 10 ml normal saline 10 min before surgical incision (SI), followed by intravenous infusion of dexmedetomidine at 0.2-0.7 μg/kg/h according to the hemodynamic status and BIS. The DEXnew group received dexmedetomidine at 1 μg/kg diluted in 10 ml normal saline 10 min before SI, followed by intravenous top-up doses of 1/4 of the loading dose over 2 min in the form of intravenous shots to maintain MAP between 65 and 70 mmHg. Mean arterial blood pressure (MAP), heart rate (HR), cortisol level, fentanyl consumption, emergence time, and recovery from anesthesia (modified Aldrete score) were recorded. The sedation score and time to first analgesic request were recorded. Results In the DEX group there was a statistically significant decrease in MAP at 30, 45, 60, and 90 min after SI in comparison with preoperative MAP. In the DEXnew group also there was a statistically significant decrease in MAP at 30, 45, 60, and 90 min after SI in comparison with preoperative MAP. There was a nonsignificant difference as regards intraoperative fentanyl and postoperative pethidine consumption between the two groups. There was a significant decrease in the total amount of consumed dexmedetomidine in the DEXnew group (118 ± 14.6 μg) compared with the DEX group (189.4 ± 22.7 μg). Emergence time was significantly shorter in the DEXnew group (5.34±1.83 min) compared with the DEX group (9.45 ± 2.02 min). Conclusion This modified protocol of dexmedetomidine administration is safe and effective for controlled hypotension, providing an ideal surgical field during FESS. Compared with the conventional protocol of dexmedetomidine administration, the modified protocol offers fewer side effects; significant decrease in dexmedetomidine consumption, faster emergence time, and better modified Aldrete scores.
  7,853 666 1