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ORIGINAL ARTICLES
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
DOI:10.4103/1687-7934.172666  
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.
  4,275 385 -
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
DOI:10.4103/1687-7934.156714  
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.
  3,539 263 -
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
DOI:10.4103/1687-7934.153935  
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.
  3,305 456 -
Tracheal intubation in paediatric surgeries without muscle relaxation using magnesium sulphate as an adjuvant
Dina Salah, Mohammed S Shorbagy, Mohammed Saleh
September-December 2014, 7(3):370-375
DOI:10.4103/1687-7934.139569  
Background Tracheal intubation under deep inhalational anaesthesia is a common practice in paediatrics; however, since the introduction of short-acting opioids, intubation has become more successful when these drugs are used in combination with propofol, avoiding the use of neuromuscular blocking agents with their unwanted side effects. Several techniques and adjuvants have been used to improve intubating conditions. We studied the interaction between magnesium sulphate and the anaesthetic agent's propofol and fentanyl to facilitate intubation in paediatrics. Patients and methods A total of 40 preschool and school-aged patients scheduled for short urogenital procedures were randomly assigned in a double-blind study to be administered either a 5-min infusion of magnesium sulphate (30 mg/kg) in 0.9% saline 5 ml/kg (magnesium group, n = 20), or the same volume of saline (control group, n = 20). Anaesthesia was induced (1 μg/kg) fentanyl followed by propofol (2.5 mg/kg). Intubating conditions were assessed by Copenhagen score. Blood pressure, heart rate, respiratory rate and EtCO 2 were recorded. Serum magnesium was measured, and Aldrete recovery score was assessed. Results The two groups were comparable regarding demographic data. Intubating conditions were better in the magnesium group than in the control group (0 vs. 60%). There were no differences between both groups regarding haemodynamic variables. The duration of intubation was insignificantly shorter in the magnesium group. Aldrete recovery score showed no difference between both groups. Serum magnesium increased from 1.92 to 3.18 mg/dl in the magnesium group, but with no signs of hypermagnesemia. Conclusion Adding magnesium sulphate to propofol and fentanyl improves intubating conditions without the use of muscle relaxants during the start of procedures in paediatrics.
  3,065 194 1
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
DOI:10.4103/1687-7934.172740  
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.
  2,611 301 -
REVIEW ARTICLES
Emergent management of Guillain-Barré syndrome
Amr Mohamed EL-Said
April-June 2014, 7(2):88-95
DOI:10.4103/1687-7934.133302  
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.
  2,435 394 -
ORIGINAL ARTICLES
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
DOI:10.4103/1687-7934.139558  
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.
  2,398 423 -
REVIEW ARTICLES
Components of respiratory function tests
Bahaa El-Din Ewees Hassan, Mai M Abdel-Aziz
September-December 2014, 7(3):255-258
DOI:10.4103/1687-7934.139533  
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].
  2,205 305 -
LETTERS TO THE EDITOR
Psoriasis: is a central neuraxial block safe?
Nita Hazarika, Rahul Kumar, Rajesh Sood
September-December 2014, 7(3):253-254
DOI:10.4103/1687-7934.139530  
  2,153 234 -
ORIGINAL ARTICLES
Effect of intravenous versus intrathecal low-dose dexmedetomidine on spinal block in lower limb orthopedic surgery
Ahmed M.S. Hamed, Sahar M. Talaat
April-June 2014, 7(2):205-210
DOI:10.4103/1687-7934.133442  
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.
  2,020 339 -
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
DOI:10.4103/1687-7934.153953  
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.
  1,914 402 1
The effect of adding dexamethasone to bupivacaine on the duration of postoperative analgesia after caudal anesthesia in children
Karim Girgis
September-December 2014, 7(3):381-387
DOI:10.4103/1687-7934.139573  
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.
  1,987 328 1
Does pressure-controlled ventilation-volume guaranteed differ from pressure-controlled ventilation in anesthetized patients
Nermin S. Boules, Mohamed A El Ramely
April-June 2014, 7(2):96-100
DOI:10.4103/1687-7934.133303  
Background General anesthesia causes depression of both respiratory centers and respiratory muscles. Hence, patients under general anesthesia require ventilatory support to maintain arterial oxygenation and eliminate carbon dioxide. Mechanical ventilation can improve patients outcome. The purpose of this study was to determine whether pressure-controlled ventilation-volume guaranteed (PCV-VG) provide better oxygenation than pressure-controlled ventilation (PCV) in anesthetized patients. Patients and methods A total of 30 patients scheduled for abdominal cancer surgery under general anesthesia were enrolled in the study. Mechanical ventilation was started with PCV for 60 min then PCV-VG was applied to all patients with the same parameters, targeting the obtained tidal volume (Vt). Arterial blood pressures, heart rate, ETCO 2 , SpO 2 , pH, PaCO 2 , and PaO 2 were measured after 60 min of intubation during PCV and after 60 min of initiation of PCV-VG. Vt, mean airway pressure, and peak airway pressure (during PCV-VG) were recorded. Oxygenation index calculation was performed at the preset times. Results All parameters were comparable with no significant difference between both modes of ventilation in anesthetized patients ( P ≥ 0.05). Conclusion While maintaining constant Vt and I/E ratio, there were no significant differences in respiratory and ventilatory parameters, and also the oxygenation index was comparable between both PCV and PCV-VG modes of ventilation.
  2,066 240 -
Comparing the effect of adding dexmedetomidine versus dexamethasone on prolonging the duration of intrathecal bupivacaine in lower abdominal operations
Nashwa Sami Elzayyat, Heba Ismail Ahmed Nagy, Karim Girgis
September-December 2014, 7(3):388-392
DOI:10.4103/1687-7934.139574  
Objective The aim of this study was to evaluate the efficacy of adding dexmedetomidine compared with dexamethasone to bupivacaine to prolong the duration of spinal anesthesia and analgesia in lower abdominal operations. Patients and methods This randomized double-blind study included 60 ASA I or II patients, aged between 25 and 55 years old, scheduled for lower abdominal operations. They were administered 0.5% intrathecal bupivacaine injection and randomly divided into one of three groups: control group (GC), in which patients were administered additional 1 ml of saline; GDX group, in which patients were administered 4 mg dexamethasone; and GDM group, in which patients were administered 10 μg dexmedetomidine. The patients were monitored for heart rate, mean arterial pressure, oxygen saturation, onset and duration of sensory and motor block, intraoperative and postoperative sedation and pain, and adverse events. Results Compared with GC, GDM had significantly faster onset of sensory block (P = 0.006), longer duration of sensory block (P < 0.001), longer duration of motor block (P = 0.013), longer duration of postoperative analgesia (P < 0.001), and significantly higher sedation score (P < 0.001). Compared with GDX, GDM had significantly longer duration of sensory block (P = 0.025) and longer duration of postoperative analgesia (P < 0.001). Compared with GC, GDX had significantly longer duration of sensory block (P < 0.001) and longer duration of postoperative analgesia (P < 0.001). The three groups were comparable in terms of the onset of motor block (P = 0.637) and frequency of adverse events. Conclusion Intrathecal dexmedetomidine and dexamethasone are safe and effective adjuncts to intrathecal bupivacaine anesthesia in lower abdominal surgery. Dexmedetomidine showed to provide more rapid onset and longer duration of sensory block, longer duration of motor block, and longer postoperative analgesia.
  1,954 317 -
A comparative study of prophylactic intravenous granisetron, ondansetron, and ephedrine in attenuating hypotension and its effect on motor and sensory block in elective cesarean section under spinal anesthesia
Omyma Sh M Khalifa
April-June 2015, 8(2):166-172
DOI:10.4103/1687-7934.156667  
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.
  1,897 308 1
Effects of epidural dexmedetomidine and low-volume bupivacaine on postoperative analgesia after total knee replacement
Ashraf M. Eskandar, Ayman M. Ebeid
April-June 2014, 7(2):193-197
DOI:10.4103/1687-7934.133440  
Background Postoperative pain after total knee arthroplasty is a major interest. Epidural analgesia is considered the preferable method of postoperative analgesia for total knee arthroplasty in many countries. Dexmedetomidine is an α-2 agonist, which has many beneficial effects when administered epidurally. Purpose The aim of the study was to provide effective postoperative analgesia with hemodynamic stability through reduction in the amount of local anesthetic administered epidurally using dexmedetomidine as an adjuvant to epidural bupivacaine. Patients and methods A total of 50 patients who were 40-60 years of age, had ASA physical status I-III, and who were undergoing elective total knee arthroplasty were randomly divided into two equal groups: group D received 2.5 ml of a mixture of bupivacaine 0.125% and dexmedetomidine 0.2 μg/kg/h and group B received only 0.125% bupivacaine 5 ml/h for postoperative analgesia. Postoperative pain was scored by visual analogue scale; sedation score and cardiorespiratory parameters were recorded every 6 h for 48 h postoperatively. Data were recorded and statistically analyzed. Results The demographic data were comparable in both groups. Visual analogue scale of pain showed a significant reduction between the two groups at both rest and movement, and the total dose of nalbuphine consumption during the study period was significantly reduced (P < 0.002) in group D (5 ± 5.15) than in group B (11 ± 7.63). Sedation scores were significantly higher in group D compared with group B. Heart rate was significantly reduced in group D from 18 h postoperative until the end of the study, and the mean arterial blood pressure was significantly reduced in group B than in group D throughout the study period. Conclusion Dexmedetomidine is an ideal adjuvant to epidural bupivacaine for postoperative analgesia in patients undergoing total knee arthroplasty.
  1,692 266 -
CASE REPORTS
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
DOI:10.4103/1687-7934.145725  
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.
  1,724 192 -
ORIGINAL ARTICLES
Methylene blue versus vasopressin in sepsis-induced vasoplegia
Mostafa ElAdawy, Ahmed S Omran
July-September 2016, 9(3):319-324
DOI:10.4103/1687-7934.189091  
Background Septic shock is one of the biggest causes of mortality in intensive care settings, and, despite all the recent advances in pharmacological and mechanical support therapies, is the second leading cause of death among ICU patients. Although vasopressors have been widely used in these situations, where keeping the hemodynamic stability is of utmost importance, a detailed study of their effects is undoubtedly needed. Objective Our study compared the effect of methylene blue (MB) in the vasoplegic situation associated with sepsis with that of vasopressin. Patients and methods We randomized 40 patients into two groups (20 patients each); patients in the first group received MB, whereas patients in the second group received vasopressin as a hemodynamic support. Results In the present study, mean arterial blood pressure was found to be significantly higher in the MB group compared with the vasopressin group, whereas within the MB group, it was significantly higher after 6 h compared with the baseline level. The systemic vascular resistance showed no difference between the two groups at the start but a marked difference only after 2 h, being higher for the MB group — that is, there was a significant decrease in the vasopressors and inotropes needed in the MB group. There was no significant difference between the two groups regarding the ICU length of stay, the central venous pressure, pulmonary artery pressure, and oxygen extraction ratio. Conclusion The use of MB in sepsis-induced refractory vasoplegic situations remains one of the salvage management strategies; however, the practice of its routine use is yet to be established and needs further investigation.
  1,517 336 -
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
DOI:10.4103/1687-7934.153956  
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.
  1,521 321 -
REVIEW ARTICLES
Intensive care unit-acquired weakness
Amr M El-Said
April-June 2014, 7(2):81-87
DOI:10.4103/1687-7934.133301  
ICU-acquired weakness (ICU-AW) represents a severe and frequent complication of critical illness. It is believed that ICU-AW can affect more than half of all ICU patients. This major neuromuscular complication of critical illness is associated with increased rates of morbidity and mortality, markedly affecting both short-term and long-term clinical outcomes in critically ill patients. This article aimed to review all available data about this common problem.
  1,550 247 -
ORIGINAL ARTICLES
Lidocaine-nalbuphine versus lidocaine-tramadol for intravenous regional anesthesia
Maha M.I. Youssef, Nashwa S. ElZayyat
April-June 2014, 7(2):198-204
DOI:10.4103/1687-7934.133441  
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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The effect of adding magnesium sulfate to lidocaine in an interscalene plexus block for shoulder arthroscopic acromioplasty
Amr M Abdelfatah, Ahmed N Elshaer
January-April 2014, 7(1):59-64
DOI:10.4103/1687-7934.128416  
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.
  1,513 221 2
Postoperative pain relief after laparoscopic cholecystectomy: intraperitoneal lidocaine versus nalbuphine
Khaled Mohamad Morsy, Esam Eldin Mohamad Abdalla
January-April 2014, 7(1):40-44
DOI:10.4103/1687-7934.128402  
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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Ultrasound-guided transversus abdominis plane block versus caudal block for postoperative pain relief in infants and children undergoing surgical pyeloplasty
Dalia M El Fawy, Hanaa A El Gendy
April-June 2014, 7(2):177-181
DOI:10.4103/1687-7934.133430  
Background Caudal block is the most frequently used regional anesthetic technique for pediatric analgesia, with the disadvantage of limited duration of action. Transversus abdominis plane (TAP) block has been reported to provide effective analgesia after lower abdominal surgery, but there are few data comparing caudal block with ultrasound-guided TAP block in pediatric patients undergoing surgical pyeloplasty. Patients and methods Thirty-nine patients (6 months to 6 years) scheduled for elective surgical pyeloplasty were divided into two groups in a double-blinded randomized manner. After sevoflurane in oxygen anesthesia, patients were assigned to one of the two groups: group A (caudal; n = 19 patients) received a single caudal dose of isobaric bupivacaine 0.25% (1.25 ml/kg) and group B (TAP block; n = 20 patients) received isobaric bupivacaine 0.25% (0.3 ml/kg). The primary outcomes were the time to first analgesia in minutes and the analgesic doses (oral acetaminophen and rectal diclofenac) required during the first 24 h postoperatively. The secondary outcome measures included FLACC pain scale score and intraoperative hemodynamic variables. Results Group B had a significantly longer time to first analgesia (602, 705, 748 vs. 250, 280, 365 min) and required significantly lower doses of acetaminophen (301.9 ± 161.26 vs. 635.05 ± 205.42) and rectal diclofenac (0, 0, 0 vs. 0, 0, 12.5 mg) than group A. FLACC pain scale score was significantly lower in group B than in group A (P < 0.05) at 2, 4, 6, 8, 10, 12, 16, 18, 20, and 24 h postoperatively. There was no significant difference between both groups with respect to intraoperative hemodynamic variables. Conclusion Unilateral TAP block provided superior analgesia compared with single caudal block injection in the first 24 postoperative hours after surgical pyeloplasty in infants and children aged 6 months to 6 years.
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Ultrasound-guided transversus abdominis plane block for radical cystectomy with and without dexamethasone: a prospective, double-blinded controlled trial
Waleed Abdalla
October-December 2014, 7(4):539-544
DOI:10.4103/1687-7934.145709  
Introduction Poor control of pain after major abdominal surgeries is associated with a variety of unwanted consequences. The transversus abdominis plane (TAP) block provides analgesia to the parietal peritoneum and to the skin and muscles of the anterior abdominal wall. Different adjuvants including dexamethasone have been used to intensify the quality and increase the duration of local anesthetics. The aim of the study was to assess the efficacy of TAP block and to measure the effect of adding dexamethasone to bupivacaine on the quality of TAP block. Patients and methods Ninety ASA I-III patients, scheduled for radical cystectomy under general anesthesia, were enrolled in the study and were divided into three groups: group I was given TAP block with 20 ml 0.25% bupivacaine + 2 ml dexamethasone (8 mg)/side (n = 30); group II was given TAP block with 20 ml of 0.25% bupivacaine + 2 ml saline 0.9%/side (n = 30); and group III was given general anesthesia without TAP block (n = 30). The primary outcome was postoperative pain evaluated using the visual analogue scale (VAS) score for pain at 2, 4, 6, 12, and 24 h postoperatively, whereas the secondary outcome was the time to first analgesia (TFA), morphine consumption, and incidence of nausea or sedation. Results Adding dexamethasone to bupivacaine compared with bupivacaine alone resulted in a reduction in the postoperative VAS for pain score, a longer TFA (220.5 ± 25.02 vs. 140.54 ± 15.12 min, P < 0.001), and lesser 24-h morphine consumption (5.11 ± 3.01 vs. 17.20 ± 7.75 mg, P < 0.001). The bupivacaine TAP group compared with the control group showed a significant reduction of the VAS pain score, a longer TFA (140.54 ± 15.12 vs. 35.055 ± 4.15 min, P = 0.01), and lesser 24-h morphine requirement (17.20 ± 7.75 vs. 27.58 ± 8.41 mg, P < 0.001). Both TAP block groups compared with the control group showed a significant reduction of nausea and a lower incidence of sedation. Conclusion TAP block with bupivacaine provided better analgesia with fewer side effects compared with conventional systemic analgesia. Adding dexamethasone to bupivacaine in TAP block added better analgesic effect.
  1,055 576 -
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