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   2014| January-April  | Volume 7 | Issue 1  
    Online since May 31, 2014

 
 
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ORIGINAL ARTICLES
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.
  4,404 468 3
Difficult weaning from mechanical ventilation in the pediatric ICU
Mohamed Abdo, Mohamed A Talat, Samir M Zamzam
January-April 2014, 7(1):76-79
DOI:10.4103/1687-7934.128423  
Background Respiratory disorders are the main cause of respiratory failure in children. Insufficient alveolar ventilation results in hypoxemia and hypercapnia, which contribute to further depression of ventilation, resulting in respiratory failure. Although most patients wean from mechanical ventilation with little difficulty, some patients are unable to maintain sustained efforts of breathing for long periods and develop signs of fatigue. A failed weaning is defined as either the failure of spontaneous breathing trial or the need for reintubation within 48 h after extubation. Objective This study was undertaken to identify the causes of difficult weaning from mechanical ventilation and predict the variables responsible for this difficulty. Participants and methods A prospective study was performed on 100 children, comprising 59 boys and 41 girls. Their ages ranged between 2 months and 10 years. All the children were subjected to a detailed medical history taking, clinical examination, and laboratory investigations (complete blood count, serum electrolytes, and arterial blood gas). Patients were selected to participate in this study on the basis of the inclusion and exclusion criteria. Statistical analysis The Mann-Whitney U-test and the χ2 -test were used for statistical analysis. Results Among the 100 studied patients, 86 (86%) succeeded in being weaned from mechanical ventilation, whereas the remaining 14 patients (14%) failed to wean. This group included nine children who experienced difficulty in weaning and five children with prolonged weaning. Patients who were successfully weaned spent statistically less time on mechanical ventilation, had lower PaCO 2 , and lower bicarbonate level compared with patients who failed to wean (P = 0.002, 0.001, 0.04, respectively). There was no association between clinical diagnosis, hematological parameters, serum electrolytes, and weaning success. Conclusion We conclude that patients who were successfully weaned were statistically older, spent less time on mechanical ventilation, had lower PaCO 2 and FiO 2 , and lower bicarbonate level compared with those who failed to be weaned. We did not find a significant relation between the clinical diagnosis, hematological parameters, serum electrolytes, and weaning success.
  4,367 389 2
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.
  3,860 381 4
REVIEW ARTICLES
Preoperative evaluation: impact on anesthetic management
Mohamed Saleh, Yasser A Salem, Marwa A Khairy
January-April 2014, 7(1):5-6
DOI:10.4103/1687-7934.128389  
Preoperative evaluation has a major impact on anesthetic management. Through a systematic approach of preoperative evaluation, involving history taking, physical examination, and preoperative investigation, the anesthetist could optimize patient's medical condition, determine a proper perioperative risk, develop an appropriate perioperative anesthetic plan, and improve quality for perioperative care.
  3,628 363 -
ORIGINAL ARTICLES
Management of postdural puncture headache: greater occipital nerve block technique
Saher M Kamal, Ghada A Hassan, Sherif S Wahba
January-April 2014, 7(1):25-31
DOI:10.4103/1687-7934.128394  
Background Although epidural blood patch remains the gold standard for the treatment of postdural puncture headache (PDPH), it may not be successful in severe and persistent cases. Greater occipital nerve block (GONB) is a novel and easy technique that can be performed in an anesthesia clinic. The present study was carried out to evaluate ultrasound-guided GONB as a line of management for patients with PDPH. Materials and Methods We examined 30 patients age range 18-60 years, of both sexes American Society of Anesthesiologists I-II who developed PDPH either after a cesarian section or any operation under spinal anesthesia. Patients were randomized into two groups: the GONB group, which received ultrasound-guided GONB, and the control group, which received medications. Patients were examined for development of PDPH either during hospitalization or within 2 weeks of operation. If headache was not relieved within both groups, epidural blood patch was performed 24-48 h from the start of medical treatment in the control group but from the time of GONB in the study group. We recorded time of improvement or disappearance of headache, amount of analgesic consumption, and any side effects. Results Patients in the GONB group showed a statistically significant lower numerical rating score and greater improvement than the control group (P < 0.0001) during the second 12 h. The headache was completely relieved in the GONB group within a significantly shorter time than in the control group: 29.20 ± 14.67 and 73.60 ± 43.47 h, respectively (P = 0.00). Tramadol and pregabalin were consumed significantly less by the participants in the GONB group compared with those in the control group (P < 0.001). Conclusion GONB is a potentially useful alternative technique for the management of PDPH.
  3,069 273 -
The equisedative effect of dexmedetomidine versus propofol on supraclavicular brachial plexus block and recovery profile in patients with ischemic heart disease
Rasha S Bondok, Nirvana A El-Shalakany
January-April 2014, 7(1):32-39
DOI:10.4103/1687-7934.128398  
Background The study investigated the effect of intraoperative equisedative doses of dexmedetomidine and propofol on supraclavicular nerve block in patients with ischemic heart disease. Patients and methods Patients with ischemic heart disease, American Society of Anesthesia (ASA) II-III, scheduled for upper-limb orthopedic surgery after an effective ultrasound-guided supraclavicular nerve block were included in this study. Patients were randomly allocated to receive dexmedetomidine 0.5 μg/kg or propofol 0.5 mg/kg as an initial loading dose for 10 min followed by a maintenance dose adjusted intraoperatively to a bispectral index of 70-80. In the postanesthesia care unit, the sedation score was recorded every 10 min until discharge. The degree of pain was evaluated hourly for the first 12 h and at 18 and 24 h postoperatively. Duration of analgesia and need of rescue analgesia were calculated. Results During recovery, hemodynamic variables were significantly high in group P compared with group D (P < 0.001). The duration of analgesia was significantly longer in group D compared with group P (11.81 ± 3.54 vs. 7.18 ± 3.21 h, P < 0.001) and requirement for rescue analgesia was significantly lower in group D (27% compared with 81% in group P, P < 0.001). Conclusion Dexmedetomidine may prove a valuable adjuvant for sedation and analgesia in ischemic heart patients undergoing surgery under regional block.
  3,000 180 -
Anesthesia-related morbidity and mortality: where are we? A descriptive study
Bahaa Ewees, Yasser A Salem, Mohamed Saleh, Marwa A Khairy
January-April 2014, 7(1):7-11
DOI:10.4103/1687-7934.128390  
Background Safe anesthesia practice is by default the ultimate target for every anesthesiologist. Mortality and morbidity discussions constitute the most important method to address this issue, although a well-designed productive mortality and morbidity discussion is rare. In this study we tried to initiate a project of a systematic mortality and morbidity analysis that could easily gather data about the incident. These data were statistically analyzable and could finally address the problem. Materials and Methods A total of 56 mortality and morbidity reports from July 2009 to August 2012 were reviewed. These were analyzed using a self-constructed chart. This chart was designed to achieve the goal of addressing the problem. This chart also assessed the degree of attribution of the incident to anesthesia, anticipation of the incidents, and the contributing factors that led to this incident. Results Equal distribution of the three main categories of contributing factors (preoperative, intraoperative, and postoperative) was noticed, although 62% of the incidents could be easily gathered under a specific scenario of inappropriate preoperative management (20%) that led to improper choice of anesthesia (22%). Logically, this will lead to poor anticipation of intraoperative complications, followed by poor crisis management (14%) and finally insufficient postoperative management (6%). Hence, poor planning was responsible for 62% of the incidents. This result was supported by an almost similar percentage (65%) of unanticipated incidents. Moreover, 8% of the errors analyzed comprised system errors, which is a relatively high percentage. Conclusion Poor planning and nonanticipation of complications are the major problems that should be overcome by improving anesthesia planning. Also a stronger system is needed to minimize system errors.
  2,842 278 -
Pregabalin/celecoxib versus midazolam/celecoxib as pre-emptive analgesia for minor day-case surgery
Sameh Mohamed Osman Abdelghany, Sherif Samir Wahba
January-April 2014, 7(1):45-50
DOI:10.4103/1687-7934.128406  
Background Surgical stress is one of the most common causes of perioperative anxiety and postoperative pain. Pregabalin and celecoxib (P/C) have different mechanisms of analgesia demonstrated after a variety of surgical procedures. This study was designed to evaluate the efficacy, sedation, and postoperative pain control using combination of P/C as against midazolam and celecoxib (M/C) as a premedication. Patients and methods Sixty adult patients (20-60 years of age), ASA physical status I and II, of either sex scheduled to undergo elective minor day-case surgeries were randomly allocated into two groups of 30 patients each in this prospective study. Group I (P/C) received oral pregabalin (150 mg) and celecoxib (200 mg) 1 h before surgery, whereas group II (M/C) received oral midazolam (7.5 mg) and celecoxib (200 mg) 1 h before surgery. Preoperative sedation level was assessed using the Ramsay sedation scale. Intraoperative and postoperative analgesic consumption, the time to first analgesic requirement, and postoperative pain were recorded using visual analog scale. Adverse events were also recorded. Results Preoperative sedation level and intraoperative hemodynamic parameters were significantly higher in the M/C group compared with the P/C group. Intraoperative and postoperative analgesic consumption were significantly higher in the M/C group, whereas the time for first analgesic requirement was significantly higher in the P/C group compared with the M/C group. Conclusion Premedication using combination of P/C in day-case surgery decreased analgesic consumption and had a good sedative level with limited adverse effects.
  2,636 214 -
Ultrasound-guided ipsilateral transverse abdominis plane and ilioinguinal-iliohypogastric nerve block for inguinal hernia repair in patients with liver cirrhosis
Rasha S Bondok, Rania M Ali
January-April 2014, 7(1):51-58
DOI:10.4103/1687-7934.128409  
Background Patients with liver cirrhosis have a limited hepatic reserve and are vulnerable to surgical and anesthetic stress. The purpose of the present study was to observe the effect of combining ultrasound-guided ipsilateral transverse abdominis plane block with ilioinguinal-iliohypogastric block as a sole anesthetic technique for inguinal hernial repair in a series of chronic liver patients with cirrhosis. Materials and methods Twenty-nine male patients having chronic liver disease with cirrhosis underwent elective inguinal hernia repair, with inclusion criteria of American Society of Anesthesiologists physical status classification groups II or III and age between 40-75 years. All patients were with chronic liver disease and liver cirrhosis, having a Child-Pugh class B or Moemen modified classification of liver disease class B and an international normalized ratio not exceeding 1.5. Results No patients necessitated the conversion to general anesthesia and only three patients (10%) needed local anesthetic infiltration. Cardiorespiratory parameters were stable throughout the study period. Patients had a significantly low visual analog scale for pain in the first 6 h postoperatively (P<0.001). Mean duration of postoperative analgesia was 13.16 ± 4.5 h. No patients (0%) required rescue analgesia in the first 6 h postoperatively, whereas 16 patients (55.17%) required rescue analgesia in the following next 6 h postoperatively and 11 patients (37.9%) required rescue analgesia between 18 and 24 h postoperatively. Patients reported a high median satisfaction score of 6 (5-7). Conclusion This study showed the feasibility of combined ultrasound-guided transverse abdominis plane and ilioinguinal-iliohypogastric nerve block as a sole anesthetic technique for inguinal hernia repair in patients with liver cirrhosis as well as for providing postoperative analgesia and early ambulation.
  2,537 257 1
REVIEW ARTICLES
Risk management and anesthesia
Marwa A Khairy, Yasser A Salem, Mohamed Saleh
January-April 2014, 7(1):1-4
DOI:10.4103/1687-7934.128386  
Risk management in Anesthesia is a crucial part of patient safety. Because anesthesia care is usually considered as facilitative rather than therapeutic, the outcome of anesthesia care has traditionally been measured in terms of the absence of 'complications'. Consequently, anesthetists have been at the forefront of clinical risk management. It can be described in five stages as follows: risk awareness, risk identification, risk assessment, risk management, and re-evaluation. By identifying the strong points and the weakest points in concurrent health systems; policies and procedures can be implanted in order to ensure effective risk control. If applied correctly and not limited to compelling statistics, risk management can be a powerful, highly beneficial aid to our practice.
  2,377 278 2
ORIGINAL ARTICLES
Intravenous regional anesthesia: effect of magnesium using two different routes of administration
Sherif S Wahba, Tarek F Tammam
January-April 2014, 7(1):65-69
DOI:10.4103/1687-7934.128419  
Background Magnesium has been reported as an adjuvant to local anesthetics to improve the quality of intravenous regional anesthesia (IVRA); however, different routes of administration have not been compared before. The aim of this study was to compare between the effect of intravenous infusion of magnesium and the effect when it is added to a local anesthetic on the quality of analgesia and opioid consumption during IVRA in patients undergoing hand surgery. Patients and methods Fifty-nine patients undergoing elective hand surgery were randomly allocated to one of three groups: the R group (n = 20 patients), which received IVRA using ropivacaine 0.2%; the RM group (n = 20 patients), which received IVRA using ropivacaine 0.2% and magnesium sulfate 10 mg/kg; and the RMV group (n = 19 patients), which received IVR using ropivacaine 0.2% and a systemic intravenous single dose of magnesium sulfate 30 mg/kg. The primary outcome measure included morphine consumption in the first 24 h andthe secondary outcome measure included onset of both sensory and motor blockade, tourniquet pain, intraoperative fentanyl consumption, and postoperative pain using the Verbal Rating Scale (VRS). Results Onset times of sensory and motor blockades were shorter in the RM group (10.5 ± 4 and 14 ± 5 min) than in the R group (16.5 ± 6 and 21 ± 6 min) and RMV group (16 ± 5.5 and 20.5 ± 5.3 min). Time to first analgesic requirement was significantly longer in the RMV group (98 ± 12 min) than in the R group (70 ± 11 min) and RM group (75 ± 13 min), whereas the 24 h morphine consumption in the RMV group (14.5 ± 8.7 mg) was significantly lower than that in the RM group (25 ± 10 mg)and Rgroup (27 ± 15 mg). Tourniquet discomfort was significantly lower in the RM group [1 (0-2)] than in the R group [2 (1-4)] and RMV group [3 (1-4)]. Intraoperative fentanyl consumption was lower in the RM group (20.5 ± 9) than in the Rgroup (43.8 ± 9) and RMV group (38 ± 15),whereas VRS was significantly lower in the RM Vgroup at 1, 3, 6, and 12 h (P < 0.05) in comparison with the other groups. Conclusion The addition of magnesium to ropivacine in the IVRA improved the quality of block and reduced the tourniquet discomfort,and the systemic magnesium administration reduced the postoperative pain and morphine consumption.
  1,967 218 2
Caudal levobupivacaine-fentanyl achieves stress response attenuation and early extubation in pediatric cardiac surgery
Waleed A.M. Al-Taher, Rasha S Bondok
January-April 2014, 7(1):12-18
DOI:10.4103/1687-7934.128391  
Background Adequate postoperative analgesia coupled with stress response attenuation in children are vital parts of perioperative care. The present study was carried out to evaluate the efficacy of caudal levobupivacaine and fentanyl combination on stress response, postoperative analgesia, and extubation in pediatric cardiac surgery. Patients and methods Fifty patients, ASA II-III, 2-8 years old, undergoing elective cardiac surgical repair were allocated randomly to two groups: group L received 0.125% levobupivacaine at a volume of 1.8 ml/kg; whereas group LF received 0.125% levobupivacaine plus fentanyl 1 μg/kg up to a volume of 1.8 ml/kg. Results Intraoperative fentanyl consumption was significantly low in group LF compared with group L [1.56 ± 0.64 vs. 2.76 ± 0.52 μg/kg in group LF and group L, respectively, 95% confident interval (CI) 0.862-1.538; P < 0.001]. Extubation time was significantly shorter in group LF 2.24 ± 0.87 h compared with group L (5.84 ± 1.07 h, 95% CI 2.94 − 4.25; P < 0.001). The duration of postoperative analgesia following extubation was significantly longer in group LF 4.56 ± 0.96 h compared with group L (2.21 ± 0.73 h, 95% CI 2.99 − 1.89; P < 0.001). The serum cortisol levels were significantly higher in group L than group LF at T2, after sternotomy (21.92 ± 8.39 vs. 13.40 ± 5.48 μg/dl; P < 0.001); T3, after termination of cardiopulmonary bypass (32.32 ± 6.82 vs. 20.82 ± 5.85 μg/dl; P < 0.001); and T5, at extubation (36.64 ± 9.97 vs. 25.84 ± 9.16 μg/dl; P < 0.01). Blood glucose levels increased significantly relative to baseline in both groups, but the increase was significantly lower in group LF compared with group L. Conclusion Caudal levobupivacaine-fentanyl is effective in pediatric cardiac surgery; it attenuates the stress response with concomitant stabilization of hemodynamics. In addition, it provides adequate postoperative analgesia and early extubation.
  1,971 207 -
Validity of right ventricular end-diastolic volume as a guide for fluid resuscitation compared with central venous pressure in living donor liver transplantation recipients: a randomized controlled trial
Amr M Yassen, Waleed R Elsarraf, Mohamed Elmorshidy, Mohamed Elsadany, Tarek Salah, Ahmed M Sultan
January-April 2014, 7(1):19-24
DOI:10.4103/1687-7934.128392  
Background Fluid transfusion inflects major impact on graft and renal functions in living donor liver transplantation. Major hemodynamic swinging renders intraoperative preload assessment crucial yet difficult task. In this prospective randomized double-blind controlled trial, we examined the validity of right ventricular end-diastolic volume (RVEDV) as a preload indicator compared with central venous pressure (CVP) in recipients of living donor liver grafts. Patients and methods A total of 21 patients included in the study were randomly allocated into either the RVEDV group (n = 11) or the CVP group (n = 10) on the basis of the trigger for operative fluid resuscitation. Basal value for both right ventricular end-diastolic volume index (RVEDVI) and CVP was recorded after laparotomy. Fluids (albumin 4% or Voluven) were given in boluses of 250 ml when the triggering parameter decreased by 20% of its basal value. Hemodynamic data were recorded after laparotomy (basal), at the end of hepatectomy, before portal unclamping, 15 min after portal unclamping, and at skin closure. Total fluids infused, blood loss, early graft, and patient's outcomes were also recorded. Results Both groups were similar with respect to demographic and operative data. Fluids infused were significantly higher in the RVEDVI group compared with the CVP group. Cardiac output and stroke volume were significantly higher in the RVEDVI than in the CVP group starting at end of hepatectomy and thereafter. Urine output was significantly less in the CVP group compared with the RVEDVI group. Hypotensive episodes were greater in the CVP group compared with the RVEDVI group. RVEDVI and CVP did not correlate at any time point. No intergroup differences were observed with respect to early graft functions, serum creatinine, blood urea, ICU stay, 28th day graft, and patient survival. Conclusion RVEDV appears to be a more sensitive preload indicator and a trigger for fluid resuscitation compared with CVP; however, patient monitoring with either parameter did not significantly affect the patient outcome.
  1,938 171 -
Temporary application of an additional forearm tourniquet reduces the dose of lidocaine for intravenous regional anesthesia
Waleed M Abdelmageed, Waleed M Al Taher
January-April 2014, 7(1):70-75
DOI:10.4103/1687-7934.128420  
Background Local anesthetic toxicity is a serious complication of intravenous regional anesthesia (IVRA). We investigated whether temporary application of an additional forearm tourniquet would permit the reduction of lidocaine dosage for IVRA without affecting the quality of the block. Patients and methods One hundred patients undergoing hand surgery under IVRA were randomized to receive ketorolac 10 mg with 40 ml of either 0.5% lidocaine (conventional group, N = 50) or 0.25% lidocaine and an additional simple forearm tourniquet applied for 5 min during and after administration of the local anesthetic (forearm group, N = 50). Results Surgical anesthesia occurred more rapidly in the forearm group (6.3 ± 1.4 vs. 8.4 ± 1.8 min in the conventional group, respectively; P < 0.001). There were no statistically significant differences in motor block onset and recovery times, intraoperative sedation requirement and operative conditions assessed by the surgeon between both groups. The mean ± SD verbal numerical scale values of quality of anesthesia were similar in both groups (3.2 ± 1.2 vs. 3.4 ± 1.1, P = 0.387). Time to the first analgesic requirement and the total postoperative analgesic consumption were similar in the studied groups. Significantly more patients in the conventional group experienced postoperative central nervous system manifestations than those in the forearm group (15 vs. three, respectively; P = 0.004). These manifestations were shorter lived in the forearm group (5 ± 2 vs. 16 ± 6 min, in conventional group; P < 0.0001). Conclusion Temporary application of an additional forearm tourniquet speeds the onset of IVRA and permits the use of half the dose of lidocaine, hence increasing the safety profile of the block.
  1,906 168 -
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