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   2012| September  | Volume 5 | Issue 3  
    Online since May 29, 2014

 
 
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ORIGINAL ARTICLES
Role of dexmedetomidine as a perioperative sedative and analgesic for noncyanotic pediatric cardiac patients
Ghada Ali Hassan, Heba Abdel-Azeem Labib, Wesam El-din Ahmed Abdel-Rahman, Ashraf A.H. Elmidany, Mohamed Mohamed Saffwan
September 2012, 5(3):313-320
DOI:10.7123/01.ASJA.0000416589.67264.ea   
Purpose

In this report, we highlight the effectiveness and safety of dexmedetomidine (DEX), a selective α2-agonist, as a perioperative sedative and analgesic for pediatric noncyanotic cardiac patients scheduled for elective open heart surgery.

Patients and methods

Thirty patients aged 6–12 years scheduled for cardiac surgery with a cardiopulmonary bypass were divided randomly into two groups: the DEX group received a DEX infusion at 0.5 μg/kg/h and the midazolam (MDZ) group received a MDZ infusion at 0.2 mg/kg/min before induction of anesthesia to be continued throughout the operation; the dose of the infused drugs was reduced to half by the end of cardiopulmonary bypass and to be discontinued with the last skin suture. Anesthesia was maintained using isoflurane 0.5%.

Results

The heart rate (HR) levels were significantly higher in the MDZ group compared with the DEX group during surgery. The mean arterial pressure was significantly higher in the MDZ group during the induction of anesthesia and at time of sternotomy only. The dose of additional fentanyl required during the operation as well as the pain score during cannulation were significantly higher in the MDZ group. Respiratory rate was significantly higher in the MDZ group during induction of anesthesia. In terms of the variables in ICU, HR was significantly lower in the DEX group at the time of periextubation. Additional fentanyl until the time of extubation and the pain score were significantly lower in the DEX group.

Conclusion

Our data indicate that DEX is a well-tolerated and effective agent that provides an adequate level of perioperative sedation and analgesia in congenital cardiac surgery for noncyanotic pediatric patients.

[ABSTRACT]   Full text not available  [PDF]
  1,156 158 -
Dexamethasone as an adjuvant to thoracic epidural provided more prolonged analgesia for post-thoracotomy pain than clonidine and fentanyl
Ehab Said, Ehab El-Shahat, Mohamed Ahmed Al-Rabiey
September 2012, 5(3):307-312
DOI:10.7123/01.ASJA.0000417545.59332.39   
Objectives

To evaluate the analgesic yield of thoracic epidural (TE) analgesia using bupivacaine in combination with dexamethasone, clonidine versus fentanyl for thoracotomy patients.

Patients and methods

Sixty patients were divided into four equal groups, which received TE analgesia immediately at end of surgery during skin closure using bupivacaine either alone (C group) or in combination with dexamethasone (S1 group), clonidine (S2 group), or fentanyl (S3 group). Postoperative (PO) pain was measured using a visual analogue scale (VAS); rescue analgesia (50 mg mepridine) was given when a patient had a VAS score of 40, and the duration of analgesia and the total mepridine doses consumed were determined during 24-h postoperatively. Verbal rating scores were used for the evaluation of PO sedation and nausea and vomiting (PONV).

Results

The mean duration of analgesia was significantly longer in the study groups compared with group C, with a significantly longer duration in the S1 group compared with the S3 group. The mean 24-h cumulative pain VAS score and the total PO rescue analgesia consumed were significantly lower in the S1 group compared with the other groups and in the S2 group compared with group C. Both S2 and S3 groups showed significantly higher frequency of higher sedation scores compared with the C and S1 groups. The frequency of patients who had a PONV zero score was significantly higher in the S1 group compared with the other groups, with a nonsignificant difference among the other groups.

Conclusion

TE analgesia using bupivacaine with clonidine or dexamethasone is an efficient therapeutic modality for post-thoracotomy pain. Dexamethasone as an adjuvant provided more prolonged PO analgesia, with a reduction of rescue analgesia consumption without PO sedation, and spares the use of antiemetics for PONV that was minimized in frequency and severity.

[ABSTRACT]   Full text not available  [PDF]
  1,134 178 -
Dexmedetomidine versus clonidine as an adjuvant to peribulbar block in vitreoretinal surgery
Reem H El Kabarity, Mohamed Y. Khashaba
September 2012, 5(3):288-294
DOI:10.7123/01.ASJA.0000417547.44085.a4   
Purpose

To assess the efficacy, time to first analgesic request, total analgesic requirement, patients’ satisfaction, intraocular pressure (IOP), and side effects of addition of dexmedetomidine to a local anesthetic mixture for a peribulbar block in vitreoretinal surgery.

Methods

A double-blind prospective study was carried out on 50 ASA I and II patients scheduled for elective vitreoretinal surgery. Patients were divided randomly into two groups, 25 patients in each group. Group C received equal volumes of 9 ml of a 1 : 1 mixture of bupivacaine 0.5% and lidocaine 2% with 1 µg/kg clonidine in 1 ml saline and group D received the same local anesthetic mixture supplemented with 1 µg/kg dexmedetomidine in 1 ml saline (total volume 10 ml). The duration and onset of sensory and motor block, time to first analgesic request, total analgesic requirement, patients’ comfort, IOP, and other side effects of dexmedetomidine were assessed.

Results

Patients who received dexmedetomidine showed significantly prolonged duration of lid, globe akinesia, and globe anesthesia (192.0±34.9, 229.5±58.5, and 130.9±30.5 min, respectively). The measurement of IOP was significantly less in the dexmedetomidine group after 5 and 10 min. The time to first analgesic requirement was statistically higher in the dexmedetomidine group (6.2±2.3 h), whereas the total analgesic requirement was significantly higher in the clonidine group. More than 90% of dexmedetomidine patients were comfortable intraoperatively and postoperatively, with significantly less side effects of dryness of the mouth and dizziness.

Conclusion

The addition of 1 µg/kg dexmedetomidne to the lidocaine–bupivacaine mixture in a peribulbar block for vitreoretinal surgery improves the duration of lid, globe akinesia, and anesthesia, with a significant decrease in the IOP. It prolongs the time to first rescue analgesia and decreases the number of analgesic requirements, with minimal side effects in comparison with clonidine.

[ABSTRACT]   Full text not available  [PDF]
  1,064 221 -
Single-dose dexamethasone administered preoperatively reduces nausea and vomiting following middle ear surgery
Abdelkhalek Aboulseoud, Noha Sayed Hussien
September 2012, 5(3):345-348
DOI:10.7123/01.ASJA.0000417550.89826.75   
Objective

The objective of this study was to evaluate the efficacy of a preoperative single-dose of dexamethasone (8 mg) in ameliorating postoperative nausea and vomiting (PONV) after middle ear surgery.

Patients and methods

Forty patients scheduled for middle ear surgeries were enrolled in this prospective, double-blind, placebo-controlled study. They were randomly divided into two groups. Group A, which was the test group (patients were intravenously administered 2 ml of 8 mg dexamethasone 1 h preoperatively), and group B, which was the placebo group (patients were intravenously administered 2 ml of normal saline 1 h preoperatively). All patients underwent standard GA and tympanoplasty conducted by the same anaesthetic and surgical teams. Number of episodes of PONV were recorded from onset of recovery in the post-operative care unit (PACU) until 24 h postoperatively. Antiemetic requirements and vital data were recorded for 24 h postoperatively.

Results

There were significant statistical differences between the two groups during the early postoperative period in the PACU and at 2 and 4–6 h postoperatively, with the results being in favour of group A. In the PACU no patient in group A experienced nausea or vomiting as compared with two patients (10%) in group B who experienced nausea and one patient (5%) who experienced vomiting (P=0.001 and 0.01, respectively). At 2 h postoperatively, one patient (5%) in group A experienced nausea and no patient suffered from vomiting compared with three patients (15%) in group B who had nausea and two patients (10%) who experienced vomiting (P=0.001). At 4–6 h postoperatively, one patient (5%) in group A suffered from nausea and one patient (5%) experienced vomiting, whereas two patients (10%) in group B had nausea and two patients (10%) experienced vomiting (P=0.01). At 12 h postoperatively, one patient (5%) in both groups experienced nausea and no patient experienced vomiting (P=0.224). At 24 h postoperatively there were no patients suffering from nausea or vomiting in either group. In group A the total number of episodes of nausea and vomiting were three (15%) and one (5%), respectively, as compared with eight incidences (40%) of nausea and five incidences (25%) of vomiting in group B (P=0.001). The mean dose of ondansetron (Zofran) used as an antiemetic supplement was 4.6±1.1 mg in group A and 8.0±3 mg in group B (P=0.01).

Conclusion

Preoperative intravenous administration of single-dose dexamethasone (8 mg) can significantly reduce the incidence of PONV in patients undergoing middle ear surgeries and can therefore be considered a reliable prophylactic antiemetic drug.

[ABSTRACT]   Full text not available  [PDF]
  1,102 177 -
REVIEW ARTICLES
Common statistical errors
Raafat Abd El-Azim Hammad
September 2012, 5(3):264-266
DOI:10.7123/01.ASJA.0000416587.59641.fd   

Statistical errors are frequently met in medical researches. They lead to incorrect conclusions and they are a major cause of failure of scientific papers. Statistical errors can be prevented by understanding how to choose the appropriate descriptive and analytic tests, acquiring knowledge about the common errors, inclusion of a statistician as a co-researcher, reviewing the research protocol by the Ethical Committee before starting the work and improving the ability of the journal reviewers to detect these errors.

[ABSTRACT]   Full text not available  [PDF]
  994 251 -
Choice of statistical tests
Raafat Abd El-Azim Hammad
September 2012, 5(3):257-263
DOI:10.7123/01.ASJA.0000416586.21523.fe   

On reviewing a scientific paper, the most important questions that a reviewer will seek answers for are: Are the statistical procedures appropriate? Are the results convincing and clearly presented? Are the tables and graphs comprehensive and clear? Using statistical software, such as ‘SPSS’ or ‘Statistica for Windows’, does not guarantee appropriate analysis of the research findings and verification of their significance unless the appropriate method has been chosen. The program will not alert you to the fact that you are using a wrong method; it will always give an output for whatever data you enter. Choice of appropriate statistical tests is the cornerstone of successful research projects and of writing scientific papers. Understanding the basics of statistics is a prerequisite for choosing the appropriate test.

[ABSTRACT]   Full text not available  [PDF]
  967 277 -
ORIGINAL ARTICLES
Dexmedetomidine versus magnesium in a modified Bier’s block for diagnostic Knee arthroscopy
Sheirf Anis, Fahmy Saad, Alaa Eid, Ahmed A. Kader, Aliaa Saied
September 2012, 5(3):295-301
DOI:10.7123/01.ASJA.0000417802.90494.6c   
Introduction

Modified Bier’s block, the intercuff technique, has successfully been used recently in the lower limb. The aim of this study is to compare the analgesic efficacy of magnesium and dexmedetomidine when added to lidocaine in a modified Bier’s block in diagnostic knee arthroscopy.

Patients and methods

Sixty adult ASA I and II patients were randomly divided into three groups: group I received docaine 2% at a dose of 3 mg/kg diluted by isotonic saline to a total volume 0.5 ml/kg. Group II received lidocaine 2% at a dose of 3 mg/kg+15 ml magnesium sulfate 10% diluted by isotonic saline to a total volume 0.5 ml/kg. Group III received lidocaine 2% at a dose of 3 mg/kg, 0.5 mg/kg dexmedetomidine diluted by isotonic saline to a total volume 0.5 ml/kg. Onset and recovery of sensory block were detected. Intraoperative analgesic consumption (intravenous fentanyl), and the mean arterial blood pressure, heart rate, respiratory rate, and SpO2 were recorded. Intraoperative side effects (hypotension, bradycardic, nausea and vomiting, skin rash, and local anesthetic toxicity) were observed and managed. Postoperative mean arterial blood pressure, heart rate, Visual Analogue Scale (VAS), and the time to first analgesic requirement were recorded as well as total analgesic (dictofen intramuscularly) consumption within the first 24 postoperative hours.

Results

There was no significant difference between the three groups in terms of intraoperative blood pressure, pulse rate, oxygen saturation, and respiratory rate (P>0.05). There was no significant difference between the three groups in the postoperative average mean blood pressure and pulse rate (P>0.05). In terms of onset time, recovery time, and time to first analgesic dose, there was a highly significant difference between groups I and II (P<0.001) and groups I and III (P<0.001). Patients in group II required less intraoperative fentanyl than those in group I (P<0.037) and patients in group III also required less IV fentanyl in comparison with the patients in group I (P>0.024). Intraoperative VAS was significantly higher in group I compared with groups II and III (P<0.001). VAS was significantly higher in the patients in group III compared with the patients in group II at 30 min after distal above-knee tourniquet infection (P=0.018). There was a significant difference between groups I and II (P=0.0001) and groups I and III (P=0.045) in the postoperative analgesic requirements. Postoperative VAS was significantly high in group I compared with groups II and III in the first 24 h postoperatively (P<0.001). There was so statistical difference in the side effects apart from sedation in group III and pain on injection in group II.

Conclusion

The addition of dexmetetomidine or magnesium to lidocaine in a modified Bier’s block equally shortened the onset time of the block, prolonged the recovery time, and prolonged the time to the first analgesic dose. It also improved the tourniquet pain, decreasing the intraoperative analgesic requirements and improving postoperative VAS and analgesic requirements, with no major side effects.

[ABSTRACT]   Full text not available  [PDF]
  943 189 -
Therapeutic efficacy of a preoperative epidural single shot of dexamethasone/levobupivacaine for postoperative analgesia ( a placebo-controlled comparative study against epidural neostigmine/levobupivacaine)
Hany A. Shehab, Samar A. Salman
September 2012, 5(3):278-283
DOI:10.7123/01.ASJA.0000416592.52017.52   
Objectives

The aim of the present study was to evaluate the postoperative (PO) outcome of epidural dexamethasone (D) or neostigmine (N) compared with epidural placebo at the time of induction of anesthesia in patients assigned for open abdominal hysterectomy.

Patients and methods

The study included 90 women classified under ASA I–II randomly allocated to three equal groups according to administration of an epidural adjuvant as only one preemptive shot of epidural injection: group L received plain levobupivacaine 0.1%; group L/D received a combination of levobupivacaine 0.1% and dexamethasone 8 mg; and group L/N received a combination of levobupivacaine 0.1% and neostigmine 500 μg. The intensity of PO pain was measured using a 100 mm visual analog scale (VAS), and rescue analgesia was given when the patient had a VAS score of 40. The duration of analgesia, postoperative nausea and vomiting (PONV), and its frequency and score were monitored.

Results

Preemptive epidural therapy provided PO analgesia without significant difference until 2 h postoperatively. Until 8 h postoperatively, pain VAS scores were significantly lower in groups L/D and L/N compared with group L; at 10 h postoperatively, pain VAS scores were significantly lower in the L/D group compared with the other groups. The total pain VAS score at the end of 24 h was significantly lower in the L/D group compared with the L/N and L groups, with significantly lower scores in the L/N group compared with group L. The mean duration of PO analgesia was significantly longer in the L/D group compared with groups L/N and L, with significantly longer duration in the L/N group compared with group L. Thirty-nine patients (43.3%) complained of PONV, of whom 19 patients (21.1%) requested for antiemetics with significantly reduced frequency and score in the L/D group compared with the other groups, which showed a nonsignificant difference.

Conclusion

Single-shot epidural dexamethasone and levobupivacaine is a safe and effective PO analgesic modality for patients assigned for open abdominal hysterectomy, with minimization of PONV frequency and severity.

[ABSTRACT]   Full text not available  [PDF]
  927 194 -
Intraoperative magnesium infusion as an adjuvant to a bilateral single-injection thoracic paravertebral block for laparoscopic cholecystectomy
Waleed M. Abdelmageed
September 2012, 5(3):321-326
DOI:10.7123/01.ASJA.0000417543.21214.59   
Background

Magnesium has antinociceptive effects. This prospective randomized, double-blinded, controlled study was designed to examine whether an intraoperative administration of intravenous magnesium with a bilateral thoracic paravertebral block (PVB) enhances postoperative analgesia while reducing opioid consumption and opioid-related side effects.

Methods

Fifty-nine patients undergoing laparoscopic cholecystectomy were administered a bilateral single-injection PVB at the level of T5 with 25 ml bupivacaine 0.5% before induction of general anesthesia. Patients were assigned to two groups. Group M (magnesium group) received a loading dose of magnesium sulphate 30 mg/kg in 100 ml of normal saline over 10 min, followed by an infusion of 10 mg/kg/h till the end of surgery. The control group (group C) received the same volume of normal saline as a loading dose, followed by a continuous infusion. In both groups, postoperative pain was initially controlled by intravenous fentanyl titration and then fentanyl patient-controlled analgesia. Cumulative and patient-controlled analgesia fentanyl consumption, pain intensities, sedation scores, cardiovascular and respiratory variables and opioid-related adverse effects were recorded for 36 h after the operation.

Results

Compared with the control group, patients in the magnesium group required 23.6% less fentanyl during the first 36 h postoperatively, with significantly better visual analogue scale scores, less incidence of pruritis (6 vs. 15 patients, respectively; P=0.0376) and longer time to first analgesic request [413 (56) min vs. 247 (46) min; P<0.001]. Fewer patients in group M experienced nausea and vomiting than those in group C (7 vs. 18 patients, respectively; P=0.0116).

Conclusion

A continuous intravenous magnesium infusion may be a useful adjuvant to PVB for patients undergoing laparoscopic cholecystectomy.

[ABSTRACT]   Full text not available  [PDF]
  949 158 -
Does dexamethasone improve the efficacy of ropivacaine in single-shot femoral nerve block for postoperative analgesia in anterior cruciate ligament reconstruction surgery? A randomized controlled study
Mohamed Sayed-Elahl
September 2012, 5(3):284-287
DOI:10.7123/01.ASJA.0000417544.59332.70   
Background

This study aimed to evaluate the effect of adding dexamethasone to ropivacaine on the duration and quality of single-shot femoral nerve block (FNB) for postoperative analgesia after anterior cruciate ligament reconstruction surgery.

Method

Sixty patients scheduled for elective anterior cruciate ligament reconstruction surgery were enrolled in this prospective, randomized, double-blind study. At the end of the surgery, all patients received combined ultrasound stimulation-guided FNB using either 20 ml of 0.5% ropivacaine (R group, n=30) or 20 ml of 0.5% ropivacaine with 8 mg dexamethasone (RC group, n=30). The duration of sensory block, pain degree, and opioid requirements were recorded.

Results

The duration of sensory block in the RC group was statistically longer than that in the R group (1782±288 vs. 1356±222 min; P<0.001). However, the quality of pain control and analgesic consumption were almost similar in both groups.

Conclusion

Addition of 8 mg dexamethasone to 0.5% ropivacaine prolongs the sensory blockade duration of single-shot femoral nerve block but does not affect the degree of pain control.

[ABSTRACT]   Full text not available  [PDF]
  915 186 -
Comparative study between ultrasound-guided ilioinguinal/iliohypogastric nerve blocks and caudal epidural anaesthesia in lower abdominal surgery in children
Nabil M Abd El Moati, Hany M El Zahaby, Emad El din M Abd El Aziz, Noha E. Hussien, Azza M. Lotfy
September 2012, 5(3):267-271
DOI:10.7123/01.ASJA.0000416585.13899.b4   
Background

The failure rate of the blind technique of ilioinguinal/iliohypogastric nerve blocks is about 20–30%. The use of ultrasound can greatly improve the efficacy of this block by: allowing real-time visualization of both nerves; showing the spread of local anaesthetic injected around the nerve; reducing the dose of local anaesthetics used in children; and decreasing the rate of complications. The current study aimed at comparing ultrasound-guided ilioinguinal/iliohypogastric nerve blocks with the commonly performed caudal epidural block for inguinal operations in children.

Methods

One hundred children (class I–II ASA) aged 1–8 years of both sexes, scheduled for elective inguinal hernial repair, orchidopexy, or hydrocele repair, were included. Patients were divided into two equal groups. Group A received general anaesthesia with a caudal epidural block in the form of 1 ml/kg of bupivacaine 0.25%, and group B received general anaesthesia with an ultrasound-guided ilioinguinal/iliohypogastric nerve block using bupivacaine 0.25%.

Results

The ultrasound group (group B) showed rapid onset of action and longer duration of postoperative analgesia compared with the caudal analgesia group (group A) (P<0.05). The dose of local anaesthetics was lower in group B compared with group A (P<0.05). These doses of local anaesthetics used in group B were not correlated with either age or weight of the patients. There were no recorded complications in the ultrasound group, whereas in the caudal group intravascular puncture occurred in 4%, intrathecal puncture in 2%, and subcutaneous injections occurred in 6% of cases.

Conclusion

The present study showed that an ultrasound-guided ilioinguinal/iliohypogastric nerve block was as effective as a caudal epidural block in children for controlling pain intraoperatively and during the early postoperative period. The use of ultrasound showed the advantage of earlier onset of action, decreased dose of local anaesthetic without affecting the quality of analgesia and increased duration of postoperative analgesia when compared with caudal epidural analgesia.

[ABSTRACT]   Full text not available  [PDF]
  906 168 -
Improving body antioxidant capacity with antioxidant therapies improves pulmonary outcome in COPD patients
Ahmed El-Shaer, Hazem M. Fawzi, Nahla Zakaryia
September 2012, 5(3):339-344
DOI:10.7123/01.ASJA.0000417548.51708.5b   
Background

Chronic obstructive pulmonary disease (COPD) is one of the important causes of morbidity and mortality in the intensive care unit (ICU). Many studies have proven that free radicals cause damage to the pulmonary system. Antioxidants are compounds that can stop free radical-induced oxidative damage. There are two important types of antioxidants with different modes of action: enzymatic and nonenzymatic.

Methods

Our study was carried out on 60 COPD patients admitted to the ICU for respiratory causes. Patients were divided into three groups of 20 each. Group I (control group) received no antioxidant supplementation, group II received nonenzymatic antioxidant in the form of vitamins A, E, and C, group III received in addition to vitamins A, E, and C, enzymatic antioxidants in the form of selenium and zinc. Antioxidant treatment was administered for 30 days from the day of admission to the ICU. Acute physiology and chronic health evaluation II score was measured on the day of admission and after 7 days; total antioxidant capacity (TAC) was also measured on admission and on the seventh day; in addition, incidence and time of mechanical ventilation, time spent in the ICU as well as time until discharge, and, finally, mortality incidence during a 30-day period were all recorded and statistically analyzed.

Results

TAC level increased in both groups of antioxidant supplementation after 7 days of supplementation. In addition, there were decreases in the time spent by the patients on mechanical ventilation as well as the time of ICU stay and hospital stay. There was no statistical change in the incidence of mechanical ventilation, mortality rate, or acute physiology and chronic health evaluation score after 7 days of antioxidant supplementation.

Conclusion

We found from our study that supplementing COPD patients in the ICU with antioxidants, either nonenzymatic (vitamins A, E, and C) or a combination of nonenzymatic and enzymatic (selenium and zinc), led to an increase in the TAC level and an improvement in the clinical condition, evidenced by a decrease in the time spent on mechanical ventilation and in the ICU, with faster discharge from the hospital but with no effect on the incidence of mechanical ventilation or the mortality rate.

[ABSTRACT]   Full text not available  [PDF]
  922 139 -
Comparative study between vasopressin, norepinephrine, or a combination of both in patients with blood disease who developed septic shock
Nour El-Hoda N. Abu-Elnasr, Wafaa G. Ahmed, Salwa Abd El H. Mohamed, Fadia H. Elnekhely
September 2012, 5(3):349-355
DOI:10.7123/01.ASJA.0000417551.97450.76   
Background

The administration of arginine vasopressin (AVP) may be effective for hemodynamic support in septic shock. The aim of the present study is to compare the effect of continuous infusions of AVP, norepinephrine, or a AVP/norepinephrine combination for 48 h, when given as a hemodynamic supportive therapy in patients with blood diseases who developed septic shock and to compare the side effects, especially organ dysfunction.

Patients and methods

The study included 54 patients with different blood diseases who developed septic shock; their mean arterial pressure was less than 60 mmHg or the systolic blood pressure was less than 90 mmHg, although adequate fluids had been administered. Patients were randomly allocated according to the drug infusion into three equal groups, with 18 patients in each group. The first group received AVP at 0.06 IU/min (group 1), the second group received 15 μg/min of norepinephrine (group 2), and AVP was infused at 0.03 IU/min combined with 10 μg/min of norepinephrine in the third group (group 3). For all the groups, norepinephrine could be added to achieve a mean arterial pressure between 65 and 75 mmHg if necessary. The hemodynamic response, laboratory and organ function, AVP level, and norepinephrine requirements as well as adverse events were recorded.

Results

Blood pressure increased significantly in the three study groups throughout the study period (P<0.05), whereas the heart rate was significantly lower in group 1 and group 3 than in group 2 (P<0.05). Central venous pressure was insignificantly decreased in the three treatment groups throughout the study period (P=0.20). Plasma AVP levels were low in all groups at the baseline (P=0.35). These levels did not change in group 2, but increased in group 1 and group 3 at 24 and 48 h after drug infusion (P=0.001 and 0.001, respectively). Serum lactate levels and base deficit decreased significantly (P=0.002 and 0.001, respectively), whereas arterial pH increased significantly in the three study groups (P<0.05). The plasma creatinine concentration increased insignificantly in group 1 and group 2 over the 48-h intervention period as compared with group 3, in which the creatinine level did not change (P=0.45). Patients in group 1 had lower plasma troponin levels than patients in the other two groups (P=0.001). Platelets decreased in group 1 and group 3, but the decrease was only significant in group 1 (P=0.001). It showed a nonsignificant change in group 2 (P>0.05). We did not have to administer norepinephrine to any patient in the three study groups. There was no difference in the rate of serious adverse events between group 1 and group 2 (the rate was 5% in both the groups). One patient in the norepinephrine group had a cardiac arrest, whereas hyponatremia was recorded in group 1; no adverse events were recorded in group 3.

Conclusion

The present study provides evidence that a continuous infusion of low-dose AVP 0.03 IU/min in combination with 10 μg/min of norepinephrine is effective in septic shock, with less complications, especially renal and liver dysfunction and platelet disorder. These findings indicate that this combination is suitable for use in high-risk hematological patients with septic shock.

[ABSTRACT]   Full text not available  [PDF]
  901 141 -
Deliberate hypotension during functional endoscopic sinus surgery ( a comparative study between sodium nitroprusside and dexmedetomidine)
Khaled M. Maghawry, Ashraf E. El-Agamy, Wael I. Tahir
September 2012, 5(3):327-332
DOI:10.7123/01.ASJA.0000417542.13591.c9   
Background

A randomized, double-blind study was designed to evaluate the efficacy of dexmedetomidine (DEX) as a hypotensive agent in comparison with sodium nitroprusside (SNP) in functional endoscopic sinus surgery (FESS).

Patients and methods

Sixty patients ASA I, aged 18–60 years, scheduled for FESS were randomly assigned to receive either DEX 1 µg/kg over 10 min before induction of anesthesia, followed by an infusion of 0.2–0.6 µg/kg/h during maintenance of anesthesia (DEX group) or an SNP 0.5–10 µg/kg/min infusion after induction of anesthesia (SNP group) to maintain the mean arterial pressure (MAP) between 50 and 65 mmHg. MAP, heart rate, reversibility of hypotensive state, intraoperative blood loss, and requirement of postoperative analgesia were compared between the two groups.

Results

The administration of DEX resulted in a significant reduction in MAP and heart rate at preanesthesia (T1), after induction (T2), and 5 min after stopping the hypotensive agent (T4) in comparison with the SNP group. Intraoperative field conditions were significantly better in the DEX group than in the SNP group at 15, 30, and 45 min after the beginning of the surgery. There was a significant reduction in blood loss in the DEX group than the SNP group. Time for first rescue analgesia was significantly longer in the DEX group than the SNP group.

Conclusion

DEX is an effective and safe agent for controlled hypotension in adults undergoing FESS. It may result in reduced blood loss and a kind of postoperative analgesia.

[ABSTRACT]   Full text not available  [PDF]
  881 161 -
Comparison of caudal ropivacaine coadministered with fentanyl and ketamine in pediatric surgery
Ashraf A Abou Slemah
September 2012, 5(3):272-277
DOI:10.7123/01.ASJA.0000416588.59641.19   
Background

Caudal blockade with local anaesthetics is a well-known regional technique for postoperative analgesia in infants and children. It has the disadvantage of a relatively short duration of postoperative analgesia. Many analgesic additives have been suggested to increase the duration and effectiveness of analgesia. The aim of this study was to evaluate and compare the analgesic properties of fentanyl and ketamine as additives to caudal ropivacaine in paediatric surgery.

Methods

Seventy-five children, 1–6 years of age, undergoing surgical procedures below the umbilicus were enrolled in the present double-blind study. The patients were evenly and randomly divided into three groups; each received ropivacaine 0.2%, 1 mg/kg, caudally after sevoflurane induction of anaesthesia. Group I received ropivacaine alone, group II received fentanyl 1 μg/kg with ropivacaine and group III received ketamine 0.5 mg/kg with ropivacaine. Heart rate, mean arterial pressure and arterial oxygen saturation were recorded preoperatively and every 10 min intraoperatively. Postoperatively, the duration of caudal analgesia was determined, the analgesic effect of the caudal block was evaluated using the Hannallah Pain Scale and motor blockade was assessed using a modified Bromage Scale at 1-, 2-, 4-, 6-, 8-, 10- and 12-h time intervals. The incidence of any side effects, for example vomiting, psychomimetic effects, etc., was also determined.

Results

The three groups were comparable in terms of demographic data and duration of anaesthesia. The changes in heart rate and mean arterial pressure were clinically nonsignificant. No patient experienced respiratory depression or oxygen desaturation. The duration of caudal analgesia was highly and significantly longer in group RK (10±0.5 h) than both group RF (4±0.76 h) and group R (4±0.04 h) (P<0.001). In group RF, the duration of analgesia was minimally longer than group R, with a nonsignificant difference (P>0.05). Therefore, group RK had the longest duration and group R had the shortest duration of analgesia. Postoperatively, there were highly significant differences (P<0.001) between the Hannallah Pain Scale scores of both group RK and group RF and group R at 2 h, and a highly significant difference (P<0.001) at 4, 6, 8, 10 and 12 h between the Hannallah Pain Scale scores of group RK and group RF, in favour of the analgesic effect in group RK, with the least pain scores. There were insignificant differences (P>0.05) between all groups in the postoperative motor block scores at 1, 2, 4, 6, 8, 10 and 12 h. The incidence of vomiting was significantly higher in group RF (eight patients) and group RK (six patients) than group R (only one patient) (P<0.05). Only two children developed emergence agitation in group RK, whereas there were no psychomimetic effects in the other two groups.

Conclusion

It was found that the addition of ketamine 0.5 mg/kg to ropivacaine 0.2% prolonged the duration of caudal analgesia highly and significantly, whereas the addition of fentanyl 1 μg/kg to ropivacaine 0.2% led to a nonsignificant increase in the duration of caudal analgesia over ropivacaine 0.2% alone. The best quality of analgesia was in group RK.

[ABSTRACT]   Full text not available  [PDF]
  863 172 -
Impact of clopidogrel antiplatelet therapy on surgical outcome in selected patient populations
Mohamed A. Alrabiey, Ehab Said, Ehab El-Shahat
September 2012, 5(3):333-338
DOI:10.7123/01.ASJA.0000417546.66955.6e   
Objectives

The aim of the study is to evaluate the impact of antiplatelet therapy (APT) on surgical outcome of patients requiring emergency surgery while on APT and on that of patients assigned for elective surgery and had stopped their APT for 1 week before surgery.

Patients and methods

This selective study included 30 patients on aspirin alone (ASP group), 30 patients on clopidogrel alone (CLO group), and 30 patients receiving both (combination group); in addition, 30 patients without any history of APT (control group) and 30 patients on combined APT and assigned to elective major surgeries who discontinued APT for 7 days before surgery were also included.

Results

The study included 150 patients with a mean age of 59.6±7.3 years; range: 43–78 years. Patients who received APT showed significantly greater amounts of blood loss during and at 12 h after surgery, with a concomitantly significantly higher number of blood units consumed compared with the control group. Patients of the CLO group showed the least deviation from the elective group. The combination group showed significantly greater blood loss and a higher need for blood transfusion compared with both the CLO and the elective group. Patients of the ASP group showed significantly higher blood loss and more need for transfusion therapy compared with the elective group.

Conclusion

Elective stoppage of APT for 7 day before surgery, if not hazardous, is advisable. Emergency surgical procedure for patients maintained on chronic APT is not so harmful despite the increased need for transfusions, but the outcome is best in those receiving CLO alone.

[ABSTRACT]   Full text not available  [PDF]
  862 158 -
The efficacy of combined bupivacine/fentanyl continuous wound catheter infusion after lumbar fixation surgery ( a randomized, double-blind, controlled study)
Mohamed Sayed-Elahl, Emad Mansour
September 2012, 5(3):302-306
DOI:10.7123/01.ASJA.0000417549.51708.12   
Background

Lumbar fixation surgery is associated with moderate to severe postoperative pain.

Methods

A total of 68 patients of both sexes admitted for elective posterior stabilization for lumbar instability (ASA status I–II) were randomly allocated to receive either a 0.25% bupivacaine/fentanyl mixture (group BF, n=34) or placebo in the form of normal saline (group P, n=34) by a continuous infusion through a catheter placed subcutaneously at the end of surgery. The catheter was removed after 48 h postoperatively. Pain was assessed every 4 h after surgery using a visual analog scale. Opioid consumption, opioid-related side effects (postoperative nausea and vomiting, respiratory depression, or pruritus), wound-related complications (poor healing or infection), and patient satisfaction scores were compared in both groups.

Results

Bupivacaine/fentanyl wound infusion resulted in better analgesia and a significant decrease in opioid consumption. With respect to opioid-related and wound-related complications, there were no statistically significant differences between the two groups. The overall patient satisfaction was significantly higher in the BF group when compared with group P.

Conclusion

It was concluded that bupivacaine/fentanyl wound instillation improves pain control, decreases opioid requirements, and increases overall patient satisfaction.

[ABSTRACT]   Full text not available  [PDF]
  875 133 -
A case report on a vancomycin-induced hypersensitivity reaction in an elderly woman ( discussion of prevention and management)
Sawsan Aboul-Fotouh, Nihad Abdallah, Lobna A. Saleh, Ahmed El-Shaer, Ahmed M. Abdel-Tawab
September 2012, 5(3):366-367
DOI:10.7123/01.ASJA.0000416593.46179.00   

Vancomycin is widely used against methicillin-resistant Staphylococcus aureus (MRSA) infections. However, it is associated with two types of hypersensitivity reactions – an anaphylactoid reaction known as the ‘red man syndrome’ and anaphylaxis. Vancomycin-induced hypersensitivity occurs much more often at a younger age and is rarely seen in the elderly. Here, we report the case of a 78-year-old woman, who developed a hypersensitivity reaction following vancomycin infusion, which was administered for the treatment of MRSA pneumonia. Vancomycin was stopped and replaced by teicoplanin. The prevention and management of vancomycin-induced hypersensitivity are also discussed.

[ABSTRACT]   Full text not available  [PDF]
  851 145 -
Occult pyriform sinus fistula resulting in intraoperative subcutaneous emphysema ( a case report)
Ayman A. Abdellatif, Abdulaziz Boker, Waleed El-Marakby
September 2012, 5(3):362-365
DOI:10.7123/01.ASJA.0000416594.53803.df   

The occurrence of subcutaneous emphysema in the neck area after endotracheal intubation is an alarming sign for a serious upper airway perforation. This report present a case of a hidden pharyngeal pouch that resulted in subcutaneous emphysema and was diagnosed intraoperatively by pharyngeoscopy.

[ABSTRACT]   Full text not available  [PDF]
  830 107 -
Evaluation of the efficacy and safety of a video-assisted lighted stylet (StyletView) as a modality in the management of a difficult airway
Emad G. Saleh
September 2012, 5(3):356-361
DOI:10.7123/01.ASJA.0000416591.44394.b5   
Background

Many devices have been developed to facilitate intubation in cases of difficult direct laryngoscopy. Visualization of the vocal cords with these devices is achieved using either an optical or a video system. This study was carried out to evaluate the efficacy and safety of a video-assisted lighted stylet (StyletView) in comparison with the classical direct laryngoscopy with a Macintosh blade in the management of patients with grades 3 and 4 difficult airway.

Methods

This study included 80 adult patients who came to National Cancer Institute for elective cancer surgeries under general anesthesia with grade 3 and 4 difficult intubation according to the Cormack and Lehane classification. They were randomized into two equal groups: the Macintosh (M) group and the StyletView (S) group. Both groups were compared according to the rate of success of intubation by each device, the time taken to complete intubation in seconds, the number of patients who required external laryngeal pressure, the degree of intubation difficulty, number of failures, and attempts before successful intubation. The mean pulse rate and the mean arterial blood pressure were determined just before the first attempt of intubation as a baseline reading and just after successful intubation. The adverse effects (hypoxemia during intubation, sore throat, hoarseness of voice, dental and lip trauma, and oropharyngeal bleeding) were recorded.

Results

The rate of success of intubation was significantly higher in the S group (95%) compared with the M group (80%). The mean time taken for complete intubation in seconds was significantly less in the S group (34±8.9) compared with the M group (64.1±10.2). The number of patients who required external laryngeal pressure was significantly less in the S group (four patients) compared with the M group (12 patients). The median degree of intubation difficulty was significantly less in the S group (2) compared with the M group (6). The number of patients intubated successfully at the first attempt was significantly higher in the S group than those in the M group. The number of patients who required three attempts to be intubated was significantly higher in the M group than that in the S group, and four patients in the M group were intubated at the fourth attempt, whereas none of the successfully intubated patients in the S group required this fourth attempt. The mean heart rate and the mean arterial blood pressure immediately after successful intubations were significantly higher in the M group compared with the baseline and compared with those in the S group. The incidence of adverse effects of hypoxemia during intubation, sore throat, hoarseness of voice, and dental and lip trauma was significantly higher in the M group than in the S group.

Conclusion

The StyletView provides a simple and cost-effective solution in various elective surgeries where difficult intubation is anticipated and helps to avoid the need for multiple trials by the Macintosh blade as it allows visualization of the glottic opening and tracheal rings and hence decreases the incidence of complications that may occur in difficult intubation.

[ABSTRACT]   Full text not available  [PDF]
  814 111 -
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