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  Citation statistics : Table of Contents
   2014| September-December  | Volume 7 | Issue 3  
    Online since August 27, 2014

 
 
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ORIGINAL ARTICLES
Comparative study of the effect of adding two different doses of dexmedetomidine to levobupivacaine/hyaluronidase mixture on the peribulbar block in vitreoretinal surgery
Hala S El-Ozairy, Ayman I Tharwat
September-December 2014, 7(3):393-399
DOI:10.4103/1687-7934.139576  
Background Many additives have been added to local anesthetics in PBA to decrease the time of onset and increase the duration of analgesia to suit the relatively long vitreoretinal surgery with limited success. Dexmedetomidine has been added to local anesthetics for such purpose. Patients and methods Sixty consented ASA I-II adult patients undergoing vitreoretinal surgery were enrolled in this randomized, double blind, controlled study. Patients were randomly and evenly assigned to three groups to receive one of three anesthetic solutions for PBA: group C, group D25, and group D50. Patients in group C received 6 ml of 0.5% levobupivacaine with 10 IU/ml hyaluronidase in addition to 1 ml of normal saline. Patients in groups D25 and D50 received the same mixture but with replacement of the normal saline with 25 and 50 mcg dexmedetomidine, respectively. Intraoperative recordings included onset and duration of corneal anesthesia and globe akinesia, hemodynamics, intraocular pressure (IOP), and Ramsay sedation score. Postoperative recordings included time to first rescue analgesia and number of doses required, pain score, and patient and surgeon satisfaction score. Results The onset of corneal anesthesia and globe akinesia was significantly shorter in group D50 than in group C (1.05 ± 0.50 and 6.90 ± 1.94 vs. 1.68 ± 0.78 and 9.10 ± 2.14); in group D25 the onset was insignificantly shorter. Duration of anesthesia was significantly longer in both groups compared with control, as was the time to first rescue analgesia. IOP was also significantly lower in both groups compared with control. Conclusion Addition of two different doses of dexmedetomidine (25 and 50 mcg) to levobupivacaine/hyaluronidase mixture shortened the onset and prolonged the duration of peribulbar block in patients undergoing vitreoretinal surgery. It also lowered the IOP and provided sedation with patient's cooperation, leading to better patient and surgeon satisfaction.
  5 2,315 257
Magnesium sulfate reduces sevoflurane-induced emergence agitation in pediatric patients
Rasha S Bondok, Rania M Ali
September-December 2014, 7(3):282-288
DOI:10.4103/1687-7934.139544  
Background Despite the fact that sevoflurane is widely used in pediatric anesthesia due to its fast and well-tolerated inhaled induction and rapid emergence, sevoflurane-induced emergence agitation (EA) in children is not uncommon. This study aims to test the effect of intraoperative magnesium sulfate on reducing the incidence of EA in children anesthetized with sevoflurane. Materials and methods The study included 50 male children, aged 3-6 years, with ASA status I or II, scheduled for elective inguinal herniorrhaphy under GA through laryngeal mask airway (LMA). The patients were allocated into two groups: group M (25 patients) received intravenous magnesium sulfate 10% (0.2 ml/kg), followed by a continuous infusion of 0.1 ml/kg till the end of surgery; group C (25 patients) received a similar volume of intravenous normal saline (0.2 ml/kg), followed by a continuous infusion of 0.1 ml/kg till the end of surgery. Anesthesia was induced using 6 l/min of O 2 100% with sevoflurane 8 vol%. Anesthesia was maintained with sevoflurane 1.5-2 vol% in an oxygen-air mixture. After LMA removal, the agitation scoring scale was used for assessing the quality of emergence. Agitation parameters were measured using a four-point scale. Agitated children were managed by giving intravenous midazolam (0.1 mg/kg). Results The study was completed by 42 children. Magnesium concentrations in group M were significantly higher [2.95 (0.50) mg/dl] compared with group C [2.01 (0.42) mg/dl; P < 0.001]. The emergence time was significantly longer in group M [19.11 (7.45) min] compared with group C [15.421 (6.54) min; P < 0.001]. Other recovery characteristics in terms of the time to LMA removal and the time to reach full Aldrete score were comparable between both groups. Heart rate and systolic blood pressure variables were significantly higher in group C compared with group M at the time of LMA removal (P < 0.01). At the postanesthesia care unit, there was no incidence of agitation reported in group M as compared with 11 patients in group C (P < 0.001). In group C, the mean duration of agitation was 16.4 (8.2) min and the mean dose of midazolam administered was 0.09 (0-0.2) mg/kg per child. No patients in group M complained of pain compared with group C at 5, 10, and 30 min after emergence from anesthesia (P < 0.001). Conclusion Intravenous magnesium sulfate infusion significantly reduced the incidence of sevoflurane-induced EA.
  4 2,583 279
Single-injection penile block versus caudal block in penile pediatric surgery
Enas M Ashrey, Bosat E Bosat
September-December 2014, 7(3):428-433
DOI:10.4103/1687-7934.139588  
Background Penile block is recommended for analgesia during and after surface operation on the penis, for example circumcision, phimosis, meatal stenosis, and hypospadias repair. Objective To evaluate the effect of penile block versus caudal block using bupivacaine on the quality of analgesia, and the surgeon's and parents' satisfaction after penile pediatric surgery. Patients and methods This study was conducted on 80 healthy boys aged 1-7 years, of American Society of Anesthesiologists (ASA) I and II health classes, scheduled for hypospadias repair, circumcision and meatal stenosis under general anesthesia. The patients were randomly divided into two equal groups: group P (penile block, 0.25% bupivacaine, 0.5 mg/kg; n = 40) and group C (caudal block, 0.25% bupivacaine, 0.5 mg/kg; n = 40). The heart rate (HR), the mean arterial blood pressure (MAP) and oxygen saturation were measured perioperatively. Postoperative pain evaluated by the FLACC pain scale of five categories, (F) Face, (L) Leg, (A) Activity, (C) Cry, (C) Consolability, was assessed on admission to and on discharge from the PACU and 2, 4, 8, 12, 16 and 24 h postoperatively. Also, the time to first rescue analgesic request and doses of analgesic requirements were recorded. The surgeon's and parents' satisfaction were evaluated on the first day of the operation using a five-point verbal score. Results In group P, there was no significant decrease in the HR and the MAP compared with the baseline, but in group C, there was a significant decrease in HR and MAP compared with the baseline. FLACC pain scores were significantly lower in group P compared with group C (P < 0.05). Also, the time to first need for analgesia was significantly (P < 0.05) lower in group P compared with group C. The total analgesic requirement was also significantly lower (P < 0.05) in group P compared with group C. Conclusion Single-injection penile block is superior to caudal epidural block for relief of postoperative pain in children undergoing penile surgery with more satisfaction to the surgeon and the parents, without significant increase in the rate of adverse events.
  4 4,724 357
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.
  3 4,328 517
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.
  3 5,316 557
Neostigmine/rocuronium versus TIVA for tracheal stenting and dilatation
John N Bestarous, Ashraf A Abou Slemah
September-December 2014, 7(3):356-361
DOI:10.4103/1687-7934.139566  
Background Usage of airway stents in cases with tracheobronchial stenoses or obstruction has evolved rapidly. General anaesthesia has become less hazardous, particularly with recent developments in total intravenous anaesthetic agents and nondepolarizing neuromuscular blocking drugs. This study aimed at comparing the effectiveness of neostigmine/rocuronium technique to TIVA technique for tracheal stenting and dilatation. Patients and methods This prospective study was carried out on 80 patients scheduled for tracheal dilatation and stenting. Cases were randomly categorized into two equal groups. Group I (TIVA) received fentanyl and propofol with bilateral superior laryngeal nerve block. Group II (muscle relaxant) received rocuronium and sevoflurane 2% in 100% O 2 . Heart rate, mean arterial pressure and oxygen saturation were assessed, and PaCO 2 readings were taken through arterial blood gases at regular intervals intraoperatively. Recovery profile, perioperative complications and patient and doctor satisfaction were recorded in both groups. Results Both techniques offered haemodynamic stability. PaCO 2 readings were significantly higher (P < 0.001) in group II. Earlier recovery was recorded in group I (P < 0.001). Incidence of complications was generally higher in group II (P > 0.05), except hypotension (higher in group I; P < 0.05). Patient and doctor satisfaction were comparable (P > 0.05). Conclusion Both the TIVA and neostigmine/rocuronium techniques were used successfully. The TIVA technique had the advantages of earlier recovery, less hypercapnia, desaturation, distal total obstruction and stridor on recovery, whereas the muscle relaxant technique offered less hypotension and hemoptysis. Thus, we strongly recommend the TIVA technique for such operations.
  2 2,911 188
Palonosetron versus ondansetron for prevention of postoperative nausea and vomiting during middle ear surgery: a double-blind, randomized, comparative trial
Ahmed M AbdEl-Hamid, Mohamed S.K. Othman, Ehab E Afifi
September-December 2014, 7(3):309-313
DOI:10.4103/1687-7934.139554  
Objective The aim of the study was to assess the efficacy and safety of palonosetron versus ondansetron for postoperative nausea and vomiting during middle ear surgery. Patients and methods This study was conducted on 60 patients, ASA I and II, ages ranging between 23 and 48 years, scheduled for middle ear surgery; they were randomly allocated into two equal groups: group 1 received ondansetron (4 mg) intravenously and group 2 received palonosetron (0.25 mg) intravenously. All medications were given over 30 s immediately before induction of general anesthesia. The duration of surgery, hemodynamic parameters, the severity and frequency of nausea, retching, and vomiting, time to recovery, and time to discharge of all patients were recorded. The patient's requests for rescue antiemetics and details of adverse events throughout the study were recorded. Results A total of 28 patients in group 2 and 22 patients in group 1 had complete response to antiemetic drugs. No patient in group 2 needed rescue antiemetic, whereas four patients in group 1 received ondansetron (4 mg) as rescue. With respect to the severity of nausea, group 2 showed significant decrease in nausea score in comparison with group 1. With respect to the complications, four patients in group 2 and one patient in group 1 developed headache. One patient in group 2 had diarrhea. Conclusion Palonosetron is a good antiemetic alternative during anesthesia with minimal side effects.
  2 2,139 256
CASE REPORTS
Surgical emphysema and pneumothorax following open cholecystectomy under general anesthesia
Prasad G Curpod, Govindswamy Suresh, Thaggikuppe V Giri, Syeda G Azha
September-December 2014, 7(3):465-466
DOI:10.4103/1687-7934.139598  
We present a case of surgical emphysema and bilateral pneumothorax following open cholecystectomy under general anesthesia in a patient previously treated for lower respiratory infection. Pneumothorax following open cholecystectomy under general anesthesia is rare. The incidence is about 0.01-0.4%. Immediate recognition and prompt treatment is essential. A female patient with history of treated lower respiratory tract infection 6 weeks before surgery posted for open cholecystectomy. Induction/maintenance phase was uneventful. At the time of extubation, surgical emphysema was noticed in the chest, neck, and face. Airway pressures and vitals were normal. Chest radiograph confirmed pneumothorax, which was promptly treated. Pneumothorax following general anesthesia is due to injury to the pleura or rupture of intrapulmonary alveoli. The probable precipitating cause in our patient could be because of previous history of lower respiratory tract infection, intermittent positive-pressure ventilation, and nitrous oxide. High index of suspicion is required to diagnose pneumothorax in a patient with surgical emphysema with stable vital data and normal airway pressures.
  1 1,828 160
LETTERS TO THE EDITOR
The curious case of a missing throat pack: our experience and lessons learnt
Uma Hariharan, Punit Sharma, Dhirja Sharma, Namita Sharma
September-December 2014, 7(3):251-252
DOI:10.4103/1687-7934.139527  
  1 2,198 232
ORIGINAL ARTICLES
Impact of sevoflurane versus isoflurane on coagulation profile in living donor liver transplant recipients: a prospective randomized trial
Waleed M.R. Elsarraf, Tarek Salah, Ahmad M Sultan, Mohamed M El Shobari, Mohamed Abdel Wahab
September-December 2014, 7(3):263-268
DOI:10.4103/1687-7934.139539  
Background End-stage liver disease is characterized by severe coagulopathy, and bleeding is common during liver transplantation (Ltx). Previous studies reported a depressant effect of some inhalational anesthetics on platelet function in normal patients. None of them investigated this effect in Ltx recipients with end-stage liver disease. In this study, we evaluated the effects of sevoflurane versus isoflurane on coagulation function, blood loss, and transfusion requirements in living donor liver transplantation recipients. Patients and methods A total of 32 patients of either sex, with MELD score between 12 and 18 scheduled for living donor liver transplantation, were randomly allocated into either the sevoflurane group (N = 18) or the isoflurane group (N = 14), based on the inhalational anesthetics used. Standard hemodynamic monitoring was applied. All operations were performed by the same anesthesia and surgery teams. All patients were administered propofol/fentanyl and rocuronium bromide for induction, followed by continuous infusion of fentanyl for analgesia and rocuronium bromide for muscle relaxation. Samples for INR, prothrombin time, bleeding time, Factor V, Factor VII, serum fibrinogen, complete blood picture, and aPTT were collected before the induction of anesthesia, end hepatectomy, 60 min after reperfusion, and 6, 12, 24 h in the ICU. Amounts of blood loss and blood components transfusion were also recorded at the end of operation and first postoperative day. Results Both the groups had comparable demographics, coagulation profiles, and MELD scores. Bleeding time was significantly longer in the sevoflurane group (P = 0.04), starting at end hepatectomy and persisted till the sixth hour postoperative reading, compared with the isoflurane group. INR, aPTT, PT, Factor V and Factor VII, and Hg were comparable in both groups. Platelet count was also not significantly different between both groups. Blood loss and transfusion requirements were comparable in both groups. No outcome difference was observed between groups. Conclusion In Ltx recipients, sevoflurane induced prolongation of the bleeding time compared with the isoflurane group. Yet, no clinically significant impact was encountered regarding blood loss and transfusion requirements either during intraoperative or the early postoperative period.
  1 2,241 260
Clonidine in lumbar sympathetic block for lower limb complex regional pain syndrome
Karim Y.K. Hakim, Amr M Abd El Fatah
September-December 2014, 7(3):320-326
DOI:10.4103/1687-7934.139557  
Background Complex regional pain syndrome (CRPS) is a condition of continuing (spontaneous and/or evoked) limb pain. The pain is nondermatomal and usually has a distal predominance of abnormal sensory, motor, sudomotor, vasomotor, and/or trophic findings. Sympathetic nerve blockade of the upper and lower extremities using a local anesthetic and corticosteroids is one of the modalities in the treatment of severe, sympathetically mediated pain. This randomized controlled trial studies the effect of adding clonidine to levobupivacaine in repeated lumbar sympathetic blocks for patients suffering from lower limb CRPS type 1. Methods Thirty patients of ASA physical status I and II having CRPS-1 in the lower limb were enrolled. All patients underwent lumbar sympathetic block as treatment. They were assigned to one of two groups comprising 15 patients each. Group A patients were injected with 20 ml of levobupivacaine (0.5%) +8 mg dexamethasone (2 ml)+150 µg (1 ml) clonidine. Group B patients were injected with 20 ml of levobupivacaine (0.5%)+8 mg dexamethasone (2 ml)+saline (1 ml). Patients were seen in the clinic every week for 6 weeks. During each follow-up visit, edema score (grades 0-2) and range of motion at knee and ankle joints (grades 0-2) were assessed. Repeated blocks by the same technique were performed with a maximum of five blocks for each patient over a period of 6 weeks. Repetition of blocks was dependent on exacerbation of pain if visual analogue scale (VAS) score was greater than 50. The number of blocks needed during the 6-week period in each group was recorded. Side effects after each block, such as hypotension, bradycardia, and backache, were recorded. At 6 weeks, all patients were asked to fill out a satisfaction score (grades 0-10). Results Intergroup comparison showed that the VAS score was lower in group A than in group B, but there was no statistically significant difference between them except in the fifth week. Within-group comparison revealed a statistically significant decrease in the two groups in the 6 weeks in the measured VAS score compared with the baseline VAS scores. There was improvement in edema and motion in the two groups throughout the 6 weeks, but there was no statistically significant difference between the two groups. There was a statistically significant difference between the two studied groups as regards the number of blocks, where group A had a fewer blocks compared with group B. Patients in group A were significantly more satisfied after the 6 weeks compared with patients in group B. Conclusion Adding clonidine to levobupivacaine and steroids in repeated lumbar sympathetic blocks for patients suffering from lower limb CRPS type 1 prolongs analgesia and improves edema and tolerability to physical therapy.
  1 2,367 177
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.
  1 6,358 799
Efficacy of transversus abdominis plane block with ketamine for inguinal hernioplasty: A controlled study
Doaa G Diab, Hosam Roshdy
September-December 2014, 7(3):346-349
DOI:10.4103/1687-7934.139564  
Background Addition of ketamine to bupivacaine would improve the duration of analgesia after transversus abdominis plane (TAP) block for inguinal hernioplasty. Materials and Methods After ethical approval, 28 patients scheduled for elective unilateral inguinal hernioplasty under sevoflurane-fentanyl-rocuronium anesthesia were randomly allocated to receive ipsilateral TAP block to the side of surgery with either bupivacaine 0.5% or bupivacaine 0.5% with 0.5 mg/kg ketamine (n = 14 for each). Postoperative 24 h cumulative morphine consumption, first request for morphine, pain scores at rest, sedation, nausea and vomiting scores, and complications were recorded. Results Patients who received TAP bupivacaine-ketamine had comparable postoperative 24 h cumulative morphine consumption, first request for morphine, pain and sedation scores, and postoperative nausea and vomiting. No patient reported postoperative complications related to ketamine. Conclusion The author is able to reject with confidence the hypothesis that the addition of ketamine to bupivacaine for TAP block has any major analgesic effect after inguinal hernioplasty.
  1 2,168 244
Epidural volume extension with saline in combined spinal epidural anesthesia for dynamic hip screw surgeries using low dose of intrathecal hyperbaric bupivacaine
Mahmoud M Okasha, Sahar Kamal, Ahmed Ramzy
September-December 2014, 7(3):350-355
DOI:10.4103/1687-7934.139565  
Background Combined spinal epidural (CSE) anesthesia is the preferred and widely used method for lower limb orthopedic surgeries. The epidural volume extension (EVE) technique is a modification of CSE in which the level of sensory analgesia obtained by subarachnoid block is increased by a small volume of saline administered through the epidural catheter. Patients and methods Fifty patients of both sexes, aged between 50 and 70 years scheduled for dynamic hip screw surgery were enrolled in the study. Patients were divided into two groups: group I (the CSE-EVE group) included 25 patients who were anesthetized using CSE with EVE and group II (the CSE group) included patients who were anesthetized using CSE without EVE, using the same technique and the same dose of intrathecal hyperbaric bupivacaine and fentanyl. Results Regarding all demographic data (age, height, weight, sex, and duration of operation), there were no statistically significant differences between the studied groups (P = 0.248, 0.901, 0.064, 0.564, and 0.967, respectively). Regarding the block profile, there was a statistically significant difference between the two groups regarding the level of maximal sensory block (P < 0.02), as five patients (20%) of group I showed sensory block level extended to T1-T2 and 20 patients (80%) showed sensory block below T2, whereas in group II, the sensory block level in all patients was limited below T2. The time required for reaching the maximal sensory block level was faster in group I, ranging from 8 to 15 min (mean ± SD: 10.7 ± 1.7), whereas in group II the time ranged from 9 to 16 min (mean ± SD: 13.4 ± 2.4; P < 0.001). Two-segment regression was faster in group II, ranging from 60 to 80 min (mean ± SD: 67.9 ± 5.1), whereas in group I it ranged from 70 to 95 min (mean ± SD: 81.0 ± 7.3; P < 0.001). The time required to reach the maximum motor block was faster in group I, ranging from 3 to 5 min (mean ± SD: 3.8 ± 0.5), whereas in group II the time ranged from 4.5 to 7.5 min (mean ± SD: 6.1 ± 0.8; P < 0.001). A volume of 10 ml bupivacaine 0.5% was injected by epidural catheter in 16 patients (64%) in group II, whereas only four patients (16%) in group I required activation of epidural anesthesia (P < 0.001). The systolic blood pressure and heart rate showed no significant changes between the two groups. Conclusion It can be concluded that low dose of intrathecal hyperbaric bupivacaine with EVE (10 ml saline) is associated with early onset of motor and sensory block, high level of sensory block, and shorter time of two-segment regression while maintaining hemodynamic stability.
  1 2,561 302
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.
  1 4,708 314
Jugular bulb oxygen saturation and the pyruvate lactate ratio are good signals for cerebral metabolism and oxygenation during hypothermia with altered target ventilation
R Tarek, Zohry Gomaa, Aamer Mahmod, Farag Ehab
September-December 2014, 7(3):444-450
DOI:10.4103/1687-7934.139594  
Background The effect of deliberate hypothermia and hypocapnia on brain protection during neurosurgical procedures has been studied for many years, but in this study, the combination of deliberate hypothermia and hypocapnia was analyzed to detect their effects on cerebral oxygenation by the assessment of SjvO 2 and cerebral metabolism by the measurement of both jugular bulb lactate and pyruvate. Patients and methods Sixty patients scheduled for excision of supratentorial space-occupying lesions were randomly allocated into two groups. In group I, hypocapnia was induced combined with hypothermia, and in group II, normocapnia was maintained combined with hypothermia. Hypothermia was induced using a water blanket under the patient controlling the tympanic membrane temperature at 35°C. Jugular bulb venous and arterial blood gas analyses were performed before the induction of hypothermia ± hypocapnia (baseline), and then every 20 min till closure of the dura. The arterio-jugular venous oxygen content difference (AJDO 2 ) and the cerebral oxygen extraction ratio (COER) were calculated. Jugular bulb lactate and pyruvate levels were measured before the induction of hypothermia ± hypocapnia (baseline) and then every 30 min till closure of the dura. Results There was a significant increase in pjH and significant decreases in both PjCO 2 and SjvO 2 in the hypocapnic group after the induction of hypocapnia. SjvO 2 reached 80.32 ± 4.59% in the normocapnic group, whereas it reached 75.3 ± 4.02% in the hypocapnic group. AJDO 2 and COER started to decrease after induced hypothermia in both groups compared with readings before induced hypothermia, but the hypocapnic group had a significantly higher AJDO 2 and COER than the normocapnic group during the period of induced hypothermia (AJDO 2 reached 3.98 ± 0.47 ml/dl and COER reached 25.93 ± 4.13% in comparison with the hypocapnic group, where AJDO 2 reached 4.58 ± 0.51 ml/dl and COER reached 31.96 ± 4.01%).Jugular bulb lactate and pyruvate levels were significantly higher during hypocapnia than during normocapnia. Conclusion Cerebral oxygenation and metabolism were better during hypothermia combined with normocapnia as reflected by relative ͽͽSjvO 2 and ͿͿAJDO 2 and COER as well as ͿͿjugular bulb lactate and pyruvate.
  1 2,041 266
The role of intravenous magnesium sulphate in attenuating pressor response to laryngoscopy and intubation in patients undergoing major head and neck surgeries
Rajan Sunil, Shankar Vijay, Paul Jerry
September-December 2014, 7(3):451-455
DOI:10.4103/1687-7934.139595  
Background Elevation in blood pressure and heart rate (HR) following laryngoscopy and tracheal intubation, although brief, may have detrimental effects in high-risk patients. Aim of the study To assess the role of intravenous magnesium sulphate in attenuating pressor response to laryngoscopy and intubation in patients undergoing major head and neck surgeries. Settings and design This was a randomized, observational, pilot study. Materials and methods One hundred patients undergoing major head and neck surgeries were divided into two groups: A and B. Patients in group A received intravenous magnesium sulphate 50 mg/kg body weight 10 min before induction of general anaesthesia and those in group B received intravenous lignocaine 1.5 mg/kg body weight 90 s before intubation. HR, systolic blood pressure, diastolic blood pressure and mean arterial pressures were recorded immediately after starting the intravenous line (baseline), just before induction, 1, 3, 5, 10, 15 and 30 min after intubation. Statistical analysis Normal test for means and normal test for significant difference between two proportions were used. Results In group A, there was a statistically significant decrease in HR from the preinduction values at 1, 3, 5, 10 and 15 min following intubation. Although there was a decrease in systolic blood pressure, diastolic blood pressure and mean arterial pressures from induction values in both groups, there was no significant difference between the groups. Conclusion Intravenous magnesium sulphate effectively attenuated both HR and arterial blood pressure responses to laryngoscopy and intubation compared with intravenous lignocaine.
  1 2,782 380
A survey on public awareness about the role of anesthesiologists
Curpod Girivas Srinivas Prasad, Govindswamy Suresh
September-December 2014, 7(3):456-459
DOI:10.4103/1687-7934.139596  
Introduction Anesthesiologist plays a crucial role in perioperative, intensive care, and pain clinic, but the public awareness about the speciality is limited. Aim The present study was conducted to assess the public knowledge about the role of anesthesiologist and to educate the public. Settings and design The study was designed as a cross-sectional observational study. Patients and methods The study was conducted by Department of Anesthesia at the Health Mela organized by ESIC PGIMSR (Employers State Insurance Co-operation Medical College and Post Graduate Institute Of Medical Science and Research) at Kassia Bhavan, Vijayanagar, Bangalore. A questionnaire containing 10 questions was distributed among the public in both English and Kannada. A total of 200 individuals responded for the questionnaire; 65% responded in English and 35% in Kannada. Their responses were recorded as Yes/No. The results are expressed as percentage. Results In all, 82% knew about anesthesia; 75% knew that anesthesiologists are doctors; 74% knew that anesthesia is safe; 73% knew that different anesthesias are required for different surgeries; 77% knew that informed consent is required for surgery; 69% knew that all types of pain are managed by anesthesiologist; 72.5% knew that labor can be painless with labor analgesia; 73% preferred labor analgesia; 81% knew that preoperatively they need to follow anesthesiologist orders; and 92% were benefited from visiting the anesthesia stall. Conclusion Majority of the public who attended the mela knew the role of anesthesiologists, but still further education is required to create awareness on anesthesia speciality. This can be achieved by conducting health melas, camps, and also through audiovisual and print media.
  1 2,772 311
Efficacy of lignocaine versus midazolam in controlling etomidate-induced myoclonus: a randomized placebo-controlled study
Kahlon A Singh, Gupta Ruchi, Aujla K Singh, Bindra T Kaur
September-December 2014, 7(3):460-464
DOI:10.4103/1687-7934.139597  
Background Etomidate has many desirable properties like rapid onset of profound hypnosis, short duration, hemodynamic stability, and minimal respiratory depression. Few side effects such as myoclonus, reduced cortisol secretion, and pain on injection abate its regular use. Aim The aim of this study was to evaluate the effect of pretreatment with lignocaine and midazolam on the incidence and severity of myoclonus due to etomidate. Materials and methods A prospective, randomized, double-blind, placebo-controlled study was conducted on 75 patients with American Society of Anesthesiology physical status I or II, undergoing general anesthesia for various elective surgical procedures. Patients were divided into three groups each comprising 25 patients: group I received 1 ml of normal saline, group II received 1 ml of 2% lignocaine and group III received 1 ml of midazolam (1 mg) as premedication 2 min before induction with 0.3 mg/kg etomidate. Myoclonus was assessed and graded on a four-point scale. Statistical data analysis Results were compiled and statistically analyzed using the χ2 -test for nonparametric data and analysis of variance test for parametric data. For all statistical analysis, P less than 0.05 was considered statistically significant. Results The incidence of myoclonus in control group was 76%, whereas patients premedicated with midazolam or lignocaine showed 28 and 44% incidence, respectively. The severity of myoclonus was also decreased in both midazolam and lignocaine groups. The incidence of other side effects among the groups was similar (P > 0.05). Conclusion Premedication with both lignocaine and midazolam was effective in reducing the incidence and severity of myoclonus.
  1 1,845 228
CASE REPORTS
An atypical presentation of posterior reversible encephalopathy syndrome: diagnostic and therapeutic dilemmas
Smriti Anand, Sukhminder J.S. Bajwa, Jasleen Kaur, Sukhwinder K Bajwa
September-December 2014, 7(3):467-469
DOI:10.4103/1687-7934.139599  
Anesthetic management in patients with altered sensorium presenting for emergency surgical procedures has always been a challenging task for the attending anesthesiologist. We report a 21-year-old primigravida who presented to us at term pregnancy with seizures, altered sensorium, and hypertension. A provisional diagnosis of eclampsia was made clinically, and the patient was taken up for emergency cesarean section under general anesthesia. She underwent uneventful operative delivery and was successfully extubated. However, during the postoperative period, she developed high-grade fever and gradually progressive respiratory and cardiovascular depression. She was shifted immediately to ICU after securing the airway and primary resuscitation. A possible suggestive differential diagnosis of posterior reversible encephalopathy syndrome was arrived, as postoperative computed tomography of the brain revealed bilateral hypodense cerebral hemispheres involving predominantly parieto-occipital lobes. Patient improved clinically with aggressive supportive treatment over the next 2 days and was successfully extubated. Diagnosis of posterior reversible encephalopathy syndrome is often delayed clinically in such circumstances and may lead to permanent neurological damage. An atypical presentation as in the present case may further add to the diagnostic dilemma and can possibly lead to institution of inappropriate therapeutic interventions. The present case emphasizes the importance of early recognition of the atypical cases and their timely management by the obstetricians, anesthesiologists, and the intensivists.
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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  
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ORIGINAL ARTICLES
The effect of cholinesterase inhibition on liver dysfunction in experimental acute liver failure: a randomized controlled study
Rasha S Bondok, Mona A Ahmed, Nevine Bahaa E Soliman, Mona H El-Shokry, Rania M Ali, Hala F Fahmy, Mohamed S Eldin
September-December 2014, 7(3):289-296
DOI:10.4103/1687-7934.139546  
Introduction Acute liver failure (ALF), similar to sepsis, is associated with an overwhelming activation of the immune response in which hepatic and circulating inflammatory cytokines play a pivotal role. The cholinesterase inhibitor neostigmine has been shown to have anti-inflammatory properties in experimental sepsis. We investigated the role of neostigmine in attenuating d-galactosamine (d-GalN)-induced ALF. Materials and methods Thirty-six female Wistar rats were randomly allocated to three groups: the control group, the d-GalN group receiving a single intraperitoneal injection of d-GalN (400 mg/kg body weight), and the neostigmine-treated d-GalN group receiving a single intraperitoneal injection of d-GalN followed 24 h later by intraperitoneal injection of neostigmine methylsulfate 0.25% (80 μg/kg body weight) three times daily for 3 successive days. Rats were killed 24 h after the last injection. Plasma levels of alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, total proteins, albumin, prothrombin, total bilirubin, and hepatic levels of superoxide dismutase and malondialdehyde were measured. Liver expression of cytokines (HMGB-1, TNF-α, and IL-10) and histopathology were evaluated. Results Neostigmine attenuated liver dysfunction and improved liver synthetic and excretory functions. It reduced proinflammatory cytokine HMGB-1 [95% confidence interval (CI) 0.33-1.09] and TNF-α (95% CI 1.26-2.06) expression compared with the d-GalN group (95% CI 2.67-4.73 and 7.33-14.53, respectively, P < 0.001) and increased expression of the anti-inflammatory cytokine IL-10 in the liver tissue (95% CI 2.49-4.17 vs. 0.04-0.21 in the d-GalN group, P < 0.001). Neostigmine also significantly increased antioxidant level and decreased oxidative burden caused by d-GalN. Conclusion Neostigmine improved liver function in a rat ALF model through an anti-inflammatory activity.
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Evaluation of the value of dexmedetomidine infusion in the improvement of renal function in preeclamptic patient with early renal impairment using cystatin C, a sensitive renal marker
Hatem Saied, Amr Sobhy, Aassem Mohram
September-December 2014, 7(3):297-303
DOI:10.4103/1687-7934.139550  
Background Preeclampsia is characterized by the development of hypertension and proteinuria after 20 weeks of gestation. Altered renal function is an essential component of its pathophysiology. Serum cystatin C level is a better marker of glomerular filtration rate (GFR) than serum creatinine particularly for individuals with small to moderate decreases in GFR. Dexmedetomidine has great α2 selectivity and low placental transfer with anxiolytic, anesthetic, hypnotic, and analgesic properties. α2-Adrenoceptor activation produces renal-protective effects including inhibition of renin release, increased GFR, and increased secretion of sodium and water. Patients and methods The study included 60 American Society of Anesthesiology II-III patients, 19-40 years of age, proved to have mild preeclampsia with early renal impairment. They were randomly divided into two groups. The dexmedetomidine infusion group (Dexa group) that included 30 patients who received dexmedetomidine infusion (n = 30), whereas the control group (Cont group) (n = 30) were treated by conventional treatment according to the Obstetric ICU Protocol of Ain-Shams University Hospitals. For each patient, the following data were collected: age, gestational age, body weight, height, hemodynamic changes, fetal heart rate, urine output, and renal function as detected by sensitive renal marker cystatin C and also by serum creatinine, blood urea nitrogen (BUN), and then estimation of GFR. Results There was statistically significant decrease in blood pressures (systolic blood pressure, diastolic blood pressure, and mean arterial blood pressure) in the Dexa group 10 min after dexmedetomidine infusion and after comparing subsequent measures to baseline value (T0 ) and also when compared with corresponding values in the Cont group. In addition, the Dexa group showed statistically significant increase in urine output 2 h after dexmedetomidine infusion in comparison with the baseline values and with the Cont group, denoting improvement in urine output. Patients in the Dexa group showed a statistically significant decrease in serum cystatin C and increase in estimated glomerular filtration rate (eGFR) based on cystatin C after 2 h of sympathetic block by epidural activation in comparison with baseline value and when compared with the Cont group, denoting marked improvement in GFR. Measurement of urine protein/creatinine ratio, serum creatinine, BUN, and eGFR based on serum creatinine showed no significant difference in both groups whether comparing to baseline of the same group or comparing both groups together. Conclusion Continuous infusion of dexmedetomidine 0.4 mcg/kg/h showed marked benefit improving renal function and better control of blood pressure in preeclamptic patients with early renal impairment detected by sensitive renal marker cystatin C.
  - 1,690 184
Arterial versus venous blood samples for monitoring of activated clotting time during open heart surgery and its correlation with postoperative bleeding and reopening
Sanaa S Eldeen, Ehab E Afifi, Ahmed M Abd El-Hamid, Khaled A Amer
September-December 2014, 7(3):304-308
DOI:10.4103/1687-7934.139552  
Objective The aim of this study was to compare between arterial and venous sampling for activated clotting time (ACT) monitoring during cardiac surgery, and to record incidence of postoperative bleeding and reopening in both the situations. Patients and methods This prospective, comparative, double-blind study was conducted on 100 patients with heart disease undergoing open heart surgery, using systemic heparinization, cardiopulmonary bypass, and protamine reversal. Patients were randomly allocated into two equal groups. In group I, arterial ACT was used as a guide for heparinization and heparin reversal. In group II, venous ACT was used as a guide for heparinization and heparin reversal. Each patient in both groups had simultaneous arterial and venous ACT carried out at the following time points: baseline, after heparinization, 10 min after heparinization, and after protamine administration. All patients were monitored for the amount of bleeding from the chest tube during the first 3 h postoperatively and the incidence of reopening after surgery for the first 24 h postoperatively. Results Baseline venous ACT was significantly higher than arterial ACT, whereas after heparinization and after blood collection, venous ACT became significantly lower. After administration of protamine, venous ACT was nonsignificantly lower than arterial ACT. Blood loss was significantly increased in the venous group than in the arterial group. With regard to the incidence of reopening, there was an increase in the rate of reopening in the venous group than in the arterial group. Conclusion There is great individual variability between the venous and arterial ACT measures. The use of arterial samples for ACT measurement had lesser rates of postoperative bleeding and reopening.
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Comparison between different atropine doses as an antisialagogue for patients receiving ketamine-midazolam undergoing gamma knife radiosurgery
Hesham M Elazzazi, Adham A Saleh
September-December 2014, 7(3):336-339
DOI:10.4103/1687-7934.139560  
Objectives Comparing different atropine doses to detect the least effective dose as an antisialagogue, in patients receiving ketamine-midazolam sedation for gamma knife radiosurgery. Patients and methods The study included 120 American Society of Anesthesiologists Physical Status I, II patients (age range 1860 years) undergoing gamma knife radiosurgery. The patients were randomly divided into three equal groups. Patients in group A received atropine 0.5 mg intravenously, atropine 0.3 mg intravenously in group B, whereas patients in group C received 0.1 mg atropine intravenously. All patients received intravenous ketamine 0.5 mg/kg, plus intravenous midazolam 1 mg. Baseline heart rate and blood pressure, change in heart rate, and occurrence of increased secretions were recorded. Results A total of 120 patients undergoing gamma knife radiosurgery were included in the study. Only one patient in group A and two patients in group B showed increased secretions (2.5 and 5%, respectively), whereas in group C 15 patients experienced increased secretions (37.5%). None of the patients who experienced increased secretions required suctioning of secretions. With regard to the change in heart rate, group A patients had significant increase in heart rate, whereas the changes in heart rate in group B and C were not significant. Conclusion The dose of 0.3 mg atropine used in group B showed the same efficacy as an antisialagogue as the dose of 0.5 mg atropine that was used in group A, and was significantly more efficient than the dose of 0.1 mg atropine used in group C patients, who experienced significant increase of secretions. In addition, group B patients did not experience the significant increase in heart rate that was experienced by group A patients.
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Premedication with dexmedetomidine decreases emergence agitation after sevoflurane anesthesia in children
Nermin S Boules, Hossam Z Hanna
September-December 2014, 7(3):340-345
DOI:10.4103/1687-7934.139562  
Background Diagnostic procedures such as bone marrow aspiration and biopsy have increased in recent years. The pain during such procedures is too much for most children to tolerate, and therefore general anesthesia with sevoflurane is the only choice. Emergence agitation (EA) is described as a mental disturbance during the recovery from general anesthesia. The aim of this study is to test the hypothesis that, because of its sedative effects, the use of dexmedetomidine decreases EA and improves parents and nurses' satisfaction after sevoflurane-based anesthesia in children. Patients and methods A total of 200 children aged 2-6 years, scheduled for bone marrow aspirations and biopsies, in a hospital procedure room, were enrolled. Patients were randomized into two groups: group D, receiving dexmedetomidine (2 μg/kg) in 10 ml saline over 2 min; and group S, receiving 10 ml saline over 2 min. Procedure duration, recovery time, and discharge time were recorded. Agitation score and parents and nurses' satisfaction scores were assessed. Results There were no significant differences between groups in the duration of the procedure or the time of discharge. The recovery time was longer in group D. Both parents and nurses' satisfaction scores were significantly lower in group D. Both agitation score and percent of patients who had agitation were significantly lower in group D. The mean arterial blood pressure and heart rate were significantly lower in group D. Conclusion Dexmedetomidine is an effective drug to reduce EA in pediatric patients after sevoflurane anesthesia without prolongation in the time of discharge, and provide better parents and nurses' satisfaction scores, which may allow better performance of the nurses.
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Euglycemic control: does it affect the incidence of chest infection in ICU patients?
Hesham M Elazzazi, Mahmoud M Okasha
September-December 2014, 7(3):269-273
DOI:10.4103/1687-7934.139541  
Background Acute hyperglycemia in ICU patients is associated with increased risk for nosocomial infections by raising plasma levels of proinflammatory cytokines, stimulating muscle-protein degradation, and inhibiting protein synthesis, which could contribute to muscle wasting. Euglycemic control with insulin reduced septicemia and the need for prolonged antibiotic therapy, prevented nosocomial infection, accelerated resolution of inflammation, and reduced muscle catabolism . Patients and methods A total of 200 patients of both sex, diabetic or nondiabetic, aged 20-70 years admitted to ICU of Ain Shams University Hospitals for more than 2 days who gave written and informed consent were enrolled in the study. Age, sex, clinical assessment for chest infection, C-reactive protein, chest radiograph, random blood sugar, HbA1C, and serum potassium were recorded at the time of ICU admission. Patients were divided into two groups. Group I was the euglycemic control group (n = 100 patients) in which blood sugar was kept between 100 and 120 mg/dl using regular insulin infusion and group II (n = 100 patients) received the standard care using an intravenous insulin infusion titrated to maintain blood glucose between 120 and 180 mg/dl. Blood sugar was measured every 1 h in both groups; indicator of chest infection (clinical signs, C-reactive protein, and chest radiography) was performed daily. Results Regarding all demographic data (age and sex), there were no statistically significant differences between the studied groups (P = 0.744 and 0.730, respectively). Regarding duration of ICU stay, there was a significantly higher rate of ICU stay for more than 7 days among patients of group II (P < 0.001). Comparing the incidence of chest infection in group I and group II, there was low incidence of chest infection in four patients (4%) of group I , whereas 18 patients (18%) of group II (22 of 200 patients) showed chest infection (P 0.003). Conclusion Euglycemic control reduces the incidence of chest infection in ICU patients.
  - 1,485 163
Neuroendocrine stress response and hyperglycemia in children undergoing laparoscopic surgery: a comparative study between remifentanil infusion and fentanyl boluses during sevoflurane-based anesthesia
Hany A Shehab, Samar A Abdou, Abdulrhman A Alwassef, Yasser Shaban
September-December 2014, 7(3):274-281
DOI:10.4103/1687-7934.139542  
Objective The aim of the study was to determine the effect of remifentanil (REM) infusion versus fentanyl (FEN) boluses during sevoflurane-based anesthesia on the frequency and the severity of stress hyperglycemia in children undergoing laparoscopic surgery. Patients and methods The study included 64 children randomly allocated into the REM group, receiving REM infusion (0.05-0.5 μg/kg/min), and the FEN group, receiving FEN boluses of 1-2 μg/kg. All patients were maintained by sevoflurane (1-2%) inhalation. Six blood samples were taken for the estimation of random blood glucose (RBG), serum glucagon and insulin, and plasma adrenaline. Hyperglycemia was considered if RBG was more than 140 mg/dl, and was treated with insulin if RBG was more than 200 mg/dl. The frequency and the extent of hyperglycemia were determined in both groups. Results In the FEN group, RBG levels were elevated from the start of surgery till second postoperative day with a significant difference compared with baseline levels. Eight patients had RBG less than 140 mg/dl, and 13 patients had temporary and 11 had persistent hyperglycemia, and four of them required insulin therapy. There were significant elevations in the serum glucagon and plasma adrenaline with a significant decrease in the serum insulin. In the REM group, mean RBG levels were significantly elevated from the time of maximal surgical stress till second postoperative day in comparison with baseline levels, but were significantly lower compared with the FEN group. Fourteen patients had RBG less than 140 mg/dl, 12 patients had temporary and six had persistent hyperglycemia, and three of them required insulin therapy with a significantly lower frequency of both temporary and persistent hyperglycemia and a nonsignificantly lower number of patients received insulin therapy in the REM group compared with the FEN group. There were significantly lower plasma adrenaline and glucagon levels, with a nonsignificantly lower serum insulin level in the REM group compared with the FEN group. Conclusion REM/sevoflurane anesthesia attenuated the neuroendocrine stress response during laparoscopic surgery and reduced the frequency and the extent of intraoperative and postoperative hyperglycemia, with sparing need for insulin therapy.
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Comparative study between lidocaine/epinephrine, lidocaine/ketamine/epinephrine, and lidocaine/dexamethasone/epinephrine mixtures in rhinoplasty surgery
Hesham M El-Azzazi, Sahar M Talaat
September-December 2014, 7(3):314-319
DOI:10.4103/1687-7934.139556  
Aim The aim of this study was to evaluate the prolongation of lidocaine epinephrine for local anesthesia (LA) of the nose for rhinoplasty by adding dexamethasone 8 mg or ketamine 100 mg. Patients and methods Fifty-nine ASA I female patients aged 20-45 years scheduled for rhinoplasty surgery under LA were included in this randomized prospective study. Patients were randomly assigned to have LA for the nose by injecting a volume of 32 ml of either lidocaine 1%+epinephrine (1 : 200 000) (group lidocaine, n = 20), lidocaine 1%+epinephrine (1 : 200 000) and 8 mg dexamethasone (group lidocaine dexamethasone, n = 20), or lidocaine 1%+epinephrine (1 : 200 000) and 100 mg ketamine (group lidocaine ketamine, n = 19). Heart rate and NIBP were measured and recorded before injection of the LA and every 5 min after that until the end of surgery. Any extra LA injection required by the patient was recorded. The duration of sensory block was recorded. Postoperative pain was measured by visual analog score and pain scores were obtained on arrival in the postanesthesia care unit (PACU) and 1 and 2 h postoperatively. Results The duration of sensory block was significantly longer in the lidocaine ketamine group compared with the lidocaine group and the lidocaine dexamethasone group, and the duration was significantly longer in the lidocaine dexamethasone group than the lidocaine group. Only one (5.26%) patients in the lidocaine ketamine group required extra LA injection, whereas five (25%) patients in the lidocaine dexamethasone group and eight (40%) in lidocaine group required extra LA injection; thus, the need for extra LA injection was significantly lower in the lidocaine ketamine group. Visual analog score in PACU and 1, and 2 h postoperatively showed significant decrease in the lidocaine ketamine group in comparison with the lidocaine and lidocaine dexamethasone groups. Heart rate, systolic blood pressure, and diastolic blood pressure showed no significant difference among the three groups throughout the procedure. Conclusion Addition of ketamine to lidocaine epinephrine mixture significantly prolonged the duration of sensory block for rhinoplasty and significantly decreased pain in PACU and 1 and 2 h postoperatively compared with lidocaine epinephrine mixture and lidocaine epinephrine dexamethasone mixture. Thus, the addition of ketamine 100 mg to lidocaine epinephrine mixture is a useful adjuvant to lidocaine epinephrine admixture.
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Ultrasound-guided bilateral transversus abdominis plane block versus conventional systemic analgesia after cesarean section
Yahia A Hemimi, Ayman M Kamaly, Sahar M Talaat, Mohamed A Nosseir
September-December 2014, 7(3):400-405
DOI:10.4103/1687-7934.139579  
Goal The aim of this study was to test whether the ultrasound (US)-guided continuous transversus abdominis plane (TAP) block, as a part of a multimodal analgesic regimen, would result in decreasing systemic analgesic consumption and improving analgesia in the first 24 h after cesarean section in comparison with conventional systemic analgesia. Patients and methods Sixty-two healthy parturients scheduled for elective cesarean delivery under general anesthesia were included in this double-blinded randomized prospective study. Participants were randomly assigned into one of two groups. In the TAP group (n = 31), TAP catheter was inserted bilaterally immediately after completing the surgery and before recovery from general anesthesia under US guidance. Bupivacaine (0.25%) 15 ml was then injected on each side and then every 6 h for the first 24 h. In the systemic analgesia group (Sys group; n = 31), patients received intravenous ketolac (20 mg) before recovery to be repeated every 8 h. The assessment of both groups was performed at 1, 2, 4, 6, 12, and 24 h postoperatively. The assessment included heart rate and blood pressure, visual analog score at rest and during movement, frequency of giving paracetamol to patients, and total morphine requirement throughout the 24 h. Salivary α-amylase was measured 4 h postoperatively. Complications were also recorded. Results The TAP group showed significantly lower visual analog score at rest and during movement. A significantly higher percentage of patients among the systemic analgesia group required more rescue paracetamol analgesia than those in the TAP group. The total morphine consumption in 24 h was highly significantly greater in the systemic analgesia group. Salivary α-amylase showed significant increase in the systemic analgesia group in comparison with the TAP group. Conclusion US-guided continuous TAP block decreased systemic analgesic consumption and improved analgesia in the first 24 h after cesarean section. US-guided continuous TAP block is recommended to be incorporated to the multimodal analgesia protocol.
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Influence of choice of analgesic agent on the course and outcome of sickle cell patients presented to ICU with acute chest syndrome
Hatem Said Abdel Hamid, Amr Sobhi
September-December 2014, 7(3):406-411
DOI:10.4103/1687-7934.139581  
Background Sickle cell anemia is an inherited disease in which red blood cells become crescent shaped, resulting in abnormal function causing small blood clots that give rise to recurrent painful episodes called sickle cell pain crises. Acute chest syndrome (ACS) is the leading cause of death among patients with sickle cell disease. The purpose of the study was to compare tramadol versus dexmedetomidine as a painkiller and a morphine-sparing drug, besides its role in improvement of the respiratory parameters and improving prognosis in patients with ACS. Patients and methods Over a period of 1 year, this prospective study was conducted on 60 sickle cell disease patients admitted to the ICU with ACS. Patients were randomly allocated into two groups, each containing 30 patients. Group A (n = 30) received morphine (10-20 mcg/kg/h) + tramadol (0.2 mg/kg/h) intravenous infusion. Group B (n = 30) received morphine (10-20 mcg/kg/h) + dexmedetomidine (0.5 mcg/kg/h) intravenous infusion. The efficacy of the study medications were compared in this study between the two groups in terms of pain relief assessment using a visual analogue scale. At the same time, the degree of sedation was monitored according to a four-point scale and bispectral index. Lung performance was assessed between the two groups through arterial blood gases, oxygenation index, and rapid shallow breathing index monitoring; hemodynamic parameters were also measured. All these variables were monitored for the first 4 days of admission to the ICU. The outcome prognosis was also compared between the two groups in terms of the average length of ICU stay, and survival or death was assessed during a follow-up of as long as 20 days. Results Significant difference was found with regard to pain relief among the study groups, with significantly lower (visual analogue scale) parameters in group A (n = 30) (morphine/tramadol) compared with group B (n = 30) (morphine/dexmedetomidine). No significant difference was discovered regarding degree of awareness, lung performance, and hemodynamic parameters among the two study groups. With regard to outcome prognosis, in terms of average length of ICU stay and mortality, comparable results were obtained in the two groups. Conclusion Adequate pain control is one of the cornerstones in the management of ACS; yet no influence on the outcome prognosis was detected in the choice of study medications.
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The effect of addition of neostigmine to epidural levobupivacaine/fentanyl mixture on return of intestinal motility in postoperative ICU
Heba I.A. Nagy, Nashwa Sami El Zayyat, Hesham Abo El Dahab
September-December 2014, 7(3):412-416
DOI:10.4103/1687-7934.139582  
Background Postoperative ileus is a major cause of morbidity and mortality. It has a direct correlation with pain and the use of narcotic analgesics. Neostigmine is an anticholine esterase. It acts as an adjuvant analgesic in the epidural space. This study aimed to demonstrate the effect of epidural neostigmine addition to levobupivacaine/fentanyl mixture on postoperative analgesia following abdominal hysterectomy. Materials and methods A total of 40 patients were divided into group N (the neostigmine group) and group C (the control group). In group N, neostigmine 1 μg/kg was added to the epidural infusion of levobupivacaine and fentanyl. Results Both groups were comparable in demographic data, surgical time, and hemodynamic data. Group N had significantly lower visual analogue scale (P < 0.05). In addition, time to first analgesic request was significantly longer in group N (9.5+ or −1.3 vs. 8.1+ or −0.9 in group C). The number of patients requiring analgesia in group N was two (10%), whereas in group C the number was nine (45%), which was statistically significant. Total narcotic consumption was significantly less in group N (104 ± 21.6 vs. 218 ± 35.2 mg in group C) and return of intestinal sounds was significantly faster in group N (8.1 ± 0.7 vs. 10.5 ± 1.8 h in group C). Group N had less nausea and vomiting. However, the difference was nonsignificant. Conclusion Neostigmine addition to levobupivacaine and fentanyl in lumbar epidural analgesia reduces pain scores and helps early return of intestinal motility during the postoperative period following abdominal hysterectomy.
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Comparison of a single injection of morphine versus ketamine or neostigmine into the epidural space on postoperative analgesia and hormonal stress response after spinal anesthesia
Galal A El-Kady, Mohamed A El-Shafaey, Ahmed M El-Sayed
September-December 2014, 7(3):417-422
DOI:10.4103/1687-7934.139584  
Background In patients undergoing lower extremity orthopedic procedures who receive spinal anesthesia, an epidural injection of morphine, ketamine, or neostigmine has an effect on postoperative analgesia duration and hormonal stress response. Patients and methods We carried out a prospective, randomized study comparing the effects of addition of 0.6 mg morphine versus 50 mg ketamine versus 60 μg neostigmine into the epidural space in patients who received spinal anesthesia in terms of postoperative analgesia duration and hormonal stress response. Results There was marked prolongation in the postoperative analgesia (428 ± 257) and attenuation of the hormonal stress response in the morphine group compared with the other groups. Also, neostigmine led to prolongation of postoperative analgesia and attenuation of stress response but less than morphine (363 ± 119). Conclusion The preemptive morphine injection into the epidural space could attenuate hormonal stress response and led to prolongation in the postoperative analgesia period.
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Conscious sedation during diagnostic cerebral angiography: A comparative study between dexmedetomidine and midazolam
Ahmed Mostafa Abd El-Hamid, Mohamed Ahmed I Elrabiey, Osama Ramzy Youssef
September-December 2014, 7(3):423-427
DOI:10.4103/1687-7934.139586  
Objective To compare the efficacy and safety of dexmedetomidine versus midazolam in conscious sedation during diagnostic cerebral angiography. Patients and methods This prospective randomized, double-blind, comparative study was conducted on 66 patients scheduled for diagnostic cerebral angiography, who were randomly allocated into two equal groups: group I (dexmedetomidine group), in which patients received infusion of dexmedetomidine 1 mcg/kg administered over 10 min followed by continuous infusion of 0.2-0.7 mcg/kg/h; and group II (midazolam group), in which patients received midazolam 0.05-0.15 mg/kg administered over 10 min followed by infusion of 0.02-0.1 mg/kg/h. Intraoperative sedation levels were titrated to achieve a bispectral index score between 70-80 and Ramsay sedation score between 3-4. Hemodynamic variables (heart rate, mean arterial pressure) and ventilation (respiratory rate, peripheral oxygen saturation) were recorded at 15 min before drugs were administered, 5 min after the infusion of the bolus dose, and then every 10 min until 1 h after the end of the procedure. The onset of sedation and the recovery time were also recorded. Results Group I showed significant decrease in heart rate, but this decrease did not require treatment. No other significant differences between groups were found with regard to main blood pressure, ventilation parameters, and the onset of sedation. Group I showed significant decrease in recovery time in comparison with group II. Conclusion Dexmedetomidine is a good alternative to midazolam for intravenous sedation during diagnostic cerebral angiography, because it seems to be reliable and safe, providing a satisfactory sedation level without any serious side effects.
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Efficacy and safety of ankle block versus sciatic-saphenous nerve block for hallux valgus surgery
Ayman I Tharwat, Ossama El Shazly
September-December 2014, 7(3):376-380
DOI:10.4103/1687-7934.139571  
Background Various nerve block techniques had been used in foot surgery. Objectives The aim of this study was to compare the efficacy of ankle block versus sciatic-saphenous nerve bock for elective hallux valgus surgery. Materials and methods A total of 42 patients who underwent elective hallux valgus surgery under regional anaesthesia were randomized to undergo either ankle block (group I) or combined sciatic-saphenous nerve block (group II). Both blocks were performed using 0.5% bupivacaine mixed with 2% lignocaine. Results Hemodynamic analysis had shown statistically nonsignificant difference between groups I and II. With regard to the duration of postoperative analgesia, there was a statistically nonsignificant difference in the time elapsed before the first analgesic dose between group I (105 min) and group II (88.7 min). However, there was a statistically significant difference in total fentanyl consumption and the need for pethidine injection between group I and group II (P < 0.005). Regarding the visual analogue score, there was a statistically significant difference in the visual analogue score between group I (5.5 ± 4.5) and group II (3.5 ± 3.2) in the 12-h postoperative period (P < 0.005). Conclusion Combined sciatic-distal saphenous nerve block is as efficient as ankle block with anaesthesia, with no difference in hemodynamics. However, sciatic-saphenous block provides longer postoperative analgesia than ankle block alone and allows the use of thigh tourniquet, thus reducing bleeding and operative time.
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The effects of magnesium sulfate pretreatment on reperfusion injury after coronary artery bypass graft surgery
Mostafa K Abdellatif, Marwa A Khairy, Hani A Mabood
September-December 2014, 7(3):362-366
DOI:10.4103/1687-7934.139567  
Background Myocardial ischemia/reperfusion (IR) injury is a complex phenomenon that leads to organ dysfunction and failure after coronary artery bypass graft surgery (CABG). Data from numerous animal experiments and clinical trials suggest that magnesium, a physiological calcium blocker, may be efficacious for the reduction in reperfusion injury. We investigated whether an intravenous administration of magnesium before reperfusion can decrease IR injury after CABG with cardiopulmonary bypass. Patients and methods A total of 40 patients undergoing CABG were randomly assigned to a MG group (n = 20) or an NS group (n = 20). The patients in the MG group were administered 25 mg/kg of MgSO 4 mixed in 100 ml normal saline intravenously before reperfusion, and patients in the NS group were administered an equal volume of normal saline. The levels of lactate and pH were measured to assess reperfusion injury at three specific times, which were before induction and after declamping by 10 min and 30 min. To evaluate postoperative other organ dysfunction, alanine aminotransferase and creatinine levels were measured at postoperative day 0. Results The blood lactate levels were significantly lower at 10 and 30 min after reperfusion in the MG group compared with the NS group. In addition, postoperative alanine aminotransferase was significantly higher in the NS group than in the MG group. Conclusion Magnesium administration before reperfusion of the heart in CABG with cardiopulmonary bypass significantly reduces blood lactate levels. These findings suggest that magnesium treatment may have protective effects on IR injury.
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The effect of the cytoreductive surgery and hyperthermic intraperitoneal chemotherapy procedure on endotracheal tube cuff pressure
Essam Mahran, Mohamed Elsaid
September-December 2014, 7(3):367-369
DOI:10.4103/1687-7934.139568  
Objective The cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) procedure is a relatively new modality in treatment that can benefit many abdominal cancer patients. This lengthy procedure has many steps with many anesthesia challenges. One of the challenges that we studied is the effect of this procedure on endotracheal tube (ETT) cuff pressure. Patients and methods After obtaining ethical approval, 25 patients of both sexes, ASA I and II, Mallampati I and II, who had undergone this surgery in our institute from 1 June 2013 to 1 October 2013 were enrolled in this study. In each patient, we measured the ETT cuff pressure five times, at the following time points: (a) immediately after intubation; (b) at the end of cytoreduction before the start of HIPEC; (c) at the end of HIPEC; (d) immediately before transfer to ICU; and (e) in the ICU immediately before extubation. Everytime, we reduced the cuff pressure (if higher) to 35 cmH 2 O using a Portex manometer. Statistical analyses were performed using SPSS version 17. Continuous variables were analyzed as mean ± SD or median (range) as appropriate. Rates and proportions were calculated for categorical data. Differences among the pressure of the ETT cuff over time were analyzed by analysis of variance test using the generalized linear model methodology, whereas a pairwise comparison was performed by the Bonferroni post-hoc test adjusted for multiplicity. P values less than or equal to 0.05 were considered significant. Results Pairwise comparisons between the ETT cuff pressure performed by the Bonferroni post-hoc test showed a significant difference between the ETT cuff pressure at all measured time points (P < 0.005). Conclusion The cytoreductive surgery and HIPEC procedure has a significant effect on the ETT cuff pressure. We recommend close and frequent monitoring of the ETT cuff pressure during the steps of this major procedure.
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Total intravenous propofol and remifentanil versus balanced anesthesia with sevoflurane and remifentanil for pediatric lower abdominal surgery
Omar M.T. Elsafti, Ahmed M.S. Hamed, Sahar M Talaat, Simon H Armanious
September-December 2014, 7(3):434-440
DOI:10.4103/1687-7934.139589  
Background This study aimed to evaluate and compare the induction, the maintenance, hemodynamic responses and the recovery profile of propofol-remifentanil combination (total intravenous anesthesia) and sevoflurane-remifentanil under the Bispectral index for pediatric patients undergoing short lower abdominal surgery. Materials and methods Sixty ASA physical status I and II patients aged 3-10 years scheduled for elective lower abdominal procedure were assigned to receive either the propofol and remifentanil combination (group P/R = 30 patients) or sevoflurane and remifentanil (group S/R = 30 patients) under Bispectral index monitoring. In both groups, anesthesia was started with remifentanil infusion (0.5 μg/kg/min) for 2 min. In the P/R group, a bolus dose of propofol 2 mg/kg was given, and then the infusion was started (7.5 mg/kg/h) and reduced gradually to 3 mg/kg/h. In the S/R group, sevoflurane 2 vol% in 100% O 2 was added and increased gradually to 8 vol%, and then reduced to 4, 3, 2 vol%. Results Induction of anesthesia was rapid in the P/R group (2.3 ± 0.7 min) compared with the S/R group (2.6 ± 1.3 min). Hypotension occurred after induction 10% in the P/R group versus 30% in the S/R group. Bradycardia was a defining feature in the P/R group only. Group P/R achieved rapid extubation in 12 min and was transferred to the postanesthesia care unit, in 17 min compared with 15 and 20 min, respectively, in the S/R group. Conclusion This study indicates that the propofol-remifentanil combination is superior to the sevoflurane-remifentanil combination, with faster induction and recovery, although both techniques are considered to be safe and effective for providing anesthesia to pediatric patients.
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Does selective sympathetic block in live donor affect renal resistivity index and urine output in recipient kidney?
Z Gomaa, Hazem Aboftooh, T Haytham
September-December 2014, 7(3):441-443
DOI:10.4103/1687-7934.139591  
Rationale The intrarenal resistive index (RI) is routinely measured in many renal transplantation centers for assessment of postoperative renal function. The present study dealt with the effect of chemical sympatholytics by blocking the sympathetic supply to the kidney on urine output and renal RI. Patients and methods A total of 50 patients were enrolled in this prospective, randomized study. The donors were divided into two groups: group P in which Papavarine was infiltrated by surgeon under complete aseptic technique around the renal artery and the other group (group B) in which bupivacaine was infiltrated by surgeon under complete aseptic technique around the renal vessels. Urine output was monitored and calculated over 6 h from renal transplantation. Renal RI was recorded over 6 h after transplantation of live donor kidney. Results There was significant increase in the urine output collected over 6 h postoperative in the Bupivacaine group (1115.2 ml) (P = 0.0001) in comparison with the Papavarine group (823.6 ml). There was a significant decrease in renal arterial RI of the Papaverine group (0.66) (P < 0.0001) compared with the Bupivacaine group (0.79). Conclusion Bupivacaine injection around the renal vessels in donor might be of benefit for recipient transplanted kidney to improve urine output.
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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].
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Perioperative pulmonary function assessment
Bahaa El-Din Ewees Hassan, Mai M Abdel-Aziz
September-December 2014, 7(3):259-262
DOI:10.4103/1687-7934.139536  
The purpose of perioperative pulmonary assessment is to predict which patients are at increased risk for pulmonary complications. The postoperative pulmonary complications contribute significantly to overall morbidity and mortality rates. Atelectasis, hypoxemia, pneumonia, and respiratory failure are pulmonary complications that can follow surgical procedures.
  - 3,253 436
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