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   2015| January-March  | Volume 8 | Issue 1  
    Online since March 25, 2015

 
 
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ORIGINAL ARTICLES
Utilizing heart rate variability: Midazolam prevents the sympathovagal imbalance caused by fentanyl/propofol induction
Sherif S Sultan, Nasr A Hegazy
January-March 2015, 8(1):31-35
DOI:10.4103/1687-7934.153935  
Context Heart rate variability (HRV) can monitor cardiac autonomic control. Sympathovagal imbalance is expected after fentanyl/propofol induction. Aim The aim of the study was to investigate the effects of intravenous midazolam on HRV and whether it prevents the sympathovagal imbalance caused by fentanyl/propofol induction. Settings and design This is a controlled, randomized, double-blinded study. Patients and methods The study included 50 patients undergoing knee arthroscopies under general anesthesia. Powers of low-frequency (LF: 0.04-0.15 Hz) and high-frequency (HF: 0.15-0.4 Hz) components of HRV, total power (TP), and LF/HF ratio were recorded using MemCalc software. Patients received midazolam 0.05 mg/kg (midazolam group) or an equivalent volume of normal saline (control group), followed by fentanyl 1 mcg/kg and then propofol 2 mg/kg intravenously. Statistical analysis The Mann-Whitney U-test and two-way repeated analysis of variance, followed by Bonferroni correction as a post-hoc test, were used to analyze the data. Results Midazolam induced significant decrease in TP and HF powers, with unchanged LF power and LF/HF ratio. Fentanyl induced significant decrease in TP and LF powers with unchanged HF power and LF/HF ratio in both groups. Propofol induced a significant decrease in TP, HF, and LF powers in both groups. Propofol decreased the LF/HF ratio significantly in the control group but not in the midazolam group. Conclusion Midazolam premedication induced significant decrease in TP and HF powers without changes in LF power or LF/HF ratio. When fentanyl and propofol were given, midazolam was capable of modulating the net effects of both drugs on the HRV by minimizing the decrease in LF power to keep the LF/HF ratio unchanged. This modulatory effect of midazolam works in favor of maintaining the sympathovagal balance.
  18,440 911 -
Comparison between effects of adductor canal block and femoral nerve block on early postoperative course in total knee arthroplasty: A prospective double-blind, randomized controlled study
Nasr A Hegazy, Sherif S Sultan
January-March 2015, 8(1):124-128
DOI:10.4103/1687-7934.153953  
Context Femoral nerve block (FNB) provides effective analgesia after total knee arthroplasty (TKA) but has been associated with delayed ambulation due to quadriceps muscle weakness. Adductor canal block (ACB) may be a promising alternative, with less effect on the quadriceps muscle and comparable analgesic efficacy. Aim The aim of the study was to compare ACB with FNB regarding the quadriceps muscle strength and its analgesic efficacy in patients following TKA. Settings and design This was a prospective, randomized, controlled, double-blinded study. Patients and methods The patients were randomized to receive either ACB or FNB. The primary outcome was the effect on quadriceps muscle and early ambulation as determined by the timed up and go test and 10-min walk test. The secondary outcome was to compare the analgesic efficacy as determined by numeric rating scale, opioid consumption, and hospital length of stay. Results We enrolled 110 patients, of whom 107 were analyzed. The timed up and go test and the 10-m walk test were significantly shorter in the ACB group than in the FNB group on the postoperative day 1 with P-value of 0.002 and 0.005, respectively, whereas the difference between both study groups was statistically nonsignificant on the postoperative day 2. There was no significant difference between the study groups regarding the numeric rating scale, morphine consumption, or length of stay. Conclusion ACB may promote early ambulation after TKA without a reduction in analgesia when compared with FNB.
  9,428 940 4
Effectiveness of ultrasound-guided transversus abdominis plane block for intraoperative and postoperative analgesia in kidney transplantation
Khaled M.A Abdelsalam, Sherif S Sultan
January-March 2015, 8(1):140-143
DOI:10.4103/1687-7934.153956  
Background The transversus abdominis plane (TAP) exists between the internal oblique and transversus abdominis muscles, and encompasses an intersected plexus of nerves. The TAP block has been the subject of multiple clinical trials to determine its analgesic efficacy. Patients and methods A total of 60 patients were randomized into one of two groups: TAP block group (group 1) or no-TAP block group (group 2). All patients underwent a standardized anesthetic technique. The TAP block group received preincisional ultrasound-guided TAP block on the side of surgery with a 20-ml volume of 0.5% of bupivacaine, and the no-TAP group received equivalent amounts of saline. A standardized postoperative analgesic regimen composed of intravenous paracetamol and a morphine patient-controlled analgesia (PCA). The amounts of intraoperative fentanyl and post-anesthesia care unit (PACU) morphine and PCA-administered morphine, pain scores, as well as number of patients experienced postoperative nausea and vomiting in the ward at 6 and 24 h were recorded. Results TAP block group patients received a significantly lower cumulative intraoperative fentanyl, significantly less boluses of morphine in postanesthesia care unit, and significantly lower cumulative 24-h postoperative morphine dosage than the no-TAP block patients. Pain visual analog scale scores were significantly lower at both 6 and 24 h postoperatively in the TAP group when compared with the no-TAP group. There were no complications related to the TAP block procedures. No signs or symptoms of local anesthetic systemic toxicity were detected. Conclusion On the basis of our current results, preincisional ultrasound-guided TAP blocks confer analgesic benefit when added to the multimodel analgesia regimen during and after kidney transplantation.
  7,378 810 2
Does magnesium sulfate affect the oxytocin bolus requirement in pre-eclamptic patients undergoing cesarean section?
Riham Hasanein, Sahar El-Shal
January-March 2015, 8(1):50-55
DOI:10.4103/1687-7934.153938  
Objective The aim of this study was to determine whether the magnesium sulfate (MgSO 4 ) used for pre-eclamptic patients affects the oxytocin bolus dose requirement to maintain adequate uterine tone during cesarean section under spinal anesthesia. Materials and methods A total of 80 patients with mild pre-eclampsia were randomized to receive either intravenous MgSO 4 (group M, n = 40) or matched normal saline (group S, n = 40). After delivery of the baby, oxytocin was injected as an intravenous bolus of 3 IU. The uterine tone was assessed by the obstetrician to be either satisfactory or unsatisfactory at 2, 4, 6, 8, and 10 min. If the tone was assessed as unsatisfactory at any time less than 3 IU of oxytocin were injected as a 'rescue' bolus dose. A maximum of two 'rescue' doses of oxytocin were allowed at two separate recordings of inadequate uterine tone. If the uterine tone was still unsatisfactory after two rescue doses of oxytocin, then other uterotonic drugs were given. The primary endpoint was the number of patients who received rescue doses of oxytocin or other uterotonic medications. Secondary endpoints, including the change in the hematocrit value before surgery and within 30 min after cesarean section, the estimated amount of intraoperative blood loss, and any side effects associated with oxytocin, were recorded. Results The number of patients who required one rescue dose of oxytocin during the study was significantly higher in group M in comparison with group S (P = 0.029). The total number of patients who received both additional oxytocin boluses and other uterotonic agents to achieve a satisfactory uterine tone was also statistically significant between both groups (P = 0.034). Conclusion The use of MgSO 4 in mild pre-eclamptic patients leads to increased oxytocin requirements in order to maintain a satisfactory uterine tone during cesarean section under spinal anesthesia.
  3,814 170 1
A comparative study between midazolam, promethazine, and chloral hydrate as oral premedication in pediatric patients
Osama A El Hay, Mostafa A Abo El Enin, Mohamad H Hamada, Abdallah M Ahmed
January-March 2015, 8(1):56-63
DOI:10.4103/1687-7934.153939  
Background Ensuring adequate preoperative sedation and anxiolysis is essential, especially in pediatric surgery. Various drugs and routes of administration have been evaluated to determine the optimal method of sedation. Aim The aim of the study was to compare the clinical effects of orally administered midazolam, promethazine, and chloral hydrate as premedication in pediatric patients. Patients and methods Ninety children of both sexes, of ASA grade I-II, aged 3-6 years, scheduled to undergo pediatric surgery were allocated randomly into three groups of 30 patients each. Group M (midazolam) patients were premedicated with a dose of 0.5 mg/kg of injectable midazolam mixed in sugar-free apple juice. Group P (promethazine) patients were premedicated with 1 mg/kg of the commercially available syrup. Group CH (chloral hydrate) patients were premedicated with 50 mg/kg of the commercially available syrup. In the presence of their parents, oral sedative premedication in the form of syrup was given 45 min before induction of general anesthesia. On arrival at the operating room, the sedation score, the easy separation score, and behavior at the time of venipuncture were assessed. At the end of the operation, recovery was assessed using the 'Vancouver sedative recovery scale for children'. The incidence of adverse effects was recorded and amnesia was assessed after 24 h. Results Sedation and ease of separation scores were higher in the M group than in the P and CH groups. As regards behavior at the time of venipuncture the proportion of children with no reaction was higher in the M group than in the P group; no cases were recorded in the CH group. The recovery time from anesthesia was shorter in group M (15.3 ± 5.2 min), longer in group CH (24.2 ± 3.7 min), and midway in group P (20.8 ± 3.5 min) (P < 0.001). Anterograde amnesia was more pronounced in group M in comparison with groups P and CH (P < 0.001). Conclusion Oral midazolam at a dose of 0.5 mg/kg of body weight is a suitable premedication for children. It may be preferred over promethazine and chloral hydrate because of its better sedative effect, good easy separation score, good behavior scores of children at the time of venipuncture, and better recovery from anesthesia with postoperative amnesia.
  3,350 344 -
Ultrasound-guided rectus sheath block versus local infiltration in management of pain after single-incision laparoscopic cholecystectomy
Ayman A Kasem, Ashraf A AbdelKader
January-March 2015, 8(1):100-106
DOI:10.4103/1687-7934.153950  
Background Single-incision laparoscopic cholecystectomy (SILC) allows decreasing the number of incisions and tissue trauma. Efforts have been made to decrease port incision pain, as it constitutes up to 70% of postoperative pain. Rectus sheath block provides effective analgesia to the midline. Aim The aim of the study was to evaluate the efficacy of ultrasound (U/S)-guided rectus sheath block for pain management following SILC surgery. Patients and methods A total of 50 patients undergoing elective SILC were allocated randomly into two groups: U/S-guided rectus sheath block, the R group, or local infiltration, the L group. All patients received the same general anesthetic technique. In the L group, port-site infiltration was made by the surgeon using 0.5% bupivacaine. In the R group, bilateral U/S-guided rectus sheath block was performed using 10 ml of 0.5% bupivacaine. Total fentanyl amount received intraoperatively was recorded. Patient Controlled Analgesia (PCA) morphine was used for postoperative analgesia and the morphine consumption was recorded. Lornoxicam was given as rescue analgesia and its time was recorded. Pain was measured by visual analogue score. Sedation score (from 0 awake to 5 unarousable) was used. Any adverse events were recorded. Results In all, 45 patients completed the study. Total amount of fentanyl was not different and no adverse events were reported. The number of patients who received rescue analgesia was not different. In addition, neither PCA start time nor PCA morphine consumption was different, whereas the total PCA morphine use in 24 h was lower in the R group. Conclusion U/S-guided rectus sheath block is an effective analgesic technique with morphine-sparing effect after SILC surgeries.
  3,206 301 -
Comparative evaluation of bupivacaine alone versus bupivacaine and dexmedetomidine for spinal anesthesia in infraumbilical surgeries
Veena Chatrath, Joginder P Attri, Gagandeep Kaur, Ranjana Khetarpal, Priyanka Bansal
January-March 2015, 8(1):83-88
DOI:10.4103/1687-7934.153946  
Introduction The efficacy of local anesthetics in spinal anesthesia can be enhanced by using adjuvants like opioids and α2 -agonists. Aim The present study was designed to determine the analgesic efficacy and side effects of adding dexmedetomidine to bupivacaine in spinal anesthesia for infraumbilical surgeries. Patients and methods In a prospective, randomized, double-blind study, 100 patients were randomly divided into two groups of 50 each, after taking their informed consent. Spinal anesthesia was achieved with 12.5 mg of 0.5% hyperbaric bupivacaine in group B (n = 50) and with 12.5 mg of 0.5% hyperbaric bupivacaine plus 10 μg of dexmedetomidine in group D (n = 50). The two groups were compared with respect to hemodynamic parameters, onset of sensory block to T10 and regression to S1, time to achieve Bromage 3 and regression to Bromage 0, duration of analgesia, number of doses of rescue analgesia required, and complications occurring in 24 h. Results Significant difference was observed in relation to onset of sensory block [12.7 ± 1.015 min in group B and 6.84 ± 0.792 min in group D (P < 0.001)], total duration of sensory block [177.74 ± 28.573 min in group B and 353.36 ± 12.138 min in group D (P < 0.001)], total duration of motor block [146.94 ± 9.173 min in group B and 318.36 ± 9.374 min in group D (P < 0.001)], duration of analgesia [283.96 ± 11.165 min in group D and 126.34 ± 7.684 min in group B (P < 0.001)], and total number of doses of rescue analgesia required in 24 h [1.44 ± 0.501 in group D and 2.56 ± 0.675 in group B (P < 0.001)]. Conclusion Addition of dexmedetomidine to bupivacaine leads to early onset of sensory and motor block with prolonged duration, and patients remained pain free for a longer period with decreased demand for rescue analgesia in the postoperative period as compared with plain bupivacaine.
  2,901 303 2
Comparison of intrathecal hyperbaric bupivacaine and levobupivacaine for Cesarean section
Feroz A Dar, Ishrat H Mir, Hilal A Bhat
January-March 2015, 8(1):89-92
DOI:10.4103/1687-7934.153948  
Background Levobupivacaine is a relatively new amide local anesthetic, and it has been already investigated in epidural and locoregional techniques, but more has to be known regarding its characteristics in spinal anesthesia. Aims The aim of our study was to compare clinical and anesthetic features of levobupivacaine and racemic bupivacaine when intrathecally administered in patients undergoing elective Cesarean section. Patients and methods Hundred patients of ASA I and II were randomized to receive an intrathecal injection of one of two local anesthetic solutions. Each patient in group L (n = 50) received 2 ml of isobaric levobupivacaine 5 mg/ml (10 mg) with 15 μg of fentanyl, whereas each patient in group B (n = 50) received 2 ml of hyperbaric bupivacaine (10 mg) with 15 μg of fentanyl. The parameters studied were onset and total duration of sensory block, onset and total duration of motor block, the quality of intraoperative anesthesia, hemodynamic alterations, and any intraoperative and postoperative complications. Results There were no significant differences in demographic or surgical variables between the two groups. There was no significant difference in the quality of anesthesia and intraoperative side effects in the two groups. Time to complete regression of motor blockade was statistically lower in group L (135 ± 15.6 vs. 145 ± 20.5 min; P < 0.005) compared with group B. There were no significant differences in onset of sensory and motor block in the two groups. The total duration of sensory at T 12 level in group L (168.3 ± 15.6 vs. 172.2 ± 20.5 min; P > 0.005) was nonsignificant when compared with group B. Conclusion Levobupivacaine, the pure S (-) enantiomer of racemic bupivacaine, is an equally effective local anesthetic for spinal anesthesia for Cesarean section, compared with racemic bupivacaine.
  2,711 360 -
The effect of intrathecal compared with intravenous dexmedetomidine as an adjuvant to spinal bupivacaine anesthesia for cesarean section
Hadil Magdy, Mai Mohsen, Mohamed Saleh
January-March 2015, 8(1):93-99
DOI:10.4103/1687-7934.153949  
Introduction The aim of this study was to evaluate the effect of intrathecal compared with intravenous dexmedetomidine as an adjuvant to spinal bupivacaine anesthesia for pregnant women undergoing cesarean section on intraoperative and postoperative analgesia with special emphasis on their sedative properties and on the neonatal outcome. Patients and methods A total of 105 women of ASA physical status I or II at term pregnancy were enrolled randomly into three groups. Patients in group I received spinal anesthesia with hyperbaric bupivacaine. In group II, 5 μg dexmedetomidine was added to bupivacaine. In group III, after administration of spinal anesthesia with bupivacaine and an intravenous infusion of 0.5 μg/kg/h dexmedetomidine throughout the surgery, the incidence of hypotension, bradycardia, the onset, and the duration of sensory and motor block and the postoperative pain score were assessed. Results No differences were observed in the rate of occurrence of hypotension and bradycardia between the three groups. The time to reach the peak sensory level was shorter in group II and group III with a longer duration compared with group I. The duration of motor block was shorter in group I compared with the two other groups with no significant difference between the three groups in the onset of motor block. The onset of postoperative pain was significantly earlier in group I, and more patients in group I needed supplementary analgesia. No significant difference was noted between the three groups regarding the Apgar score and the incidence of maternal side effects such as nausea, vomiting, and dryness of the mouth. Conclusion The use of intrathecal dexmedetomidine or intravenous dexmedetomidine as an adjuvant to spinal bupivacaine in women undergoing elective cesarean section improved the intraoperative condition and the quality of postoperative analgesia without neonatal or maternal side effects.
  2,506 337 7
Role of perioperative oxygen supplementation in relation to surgical site infection in urological surgery under neuraxial anesthesia
Md R Karim Habib, Md Yunus , L Sailo Stephen, Bhattacharyya Prithwis, K Mitra Jayanta, M Lyngdoh Nari
January-March 2015, 8(1):76-82
DOI:10.4103/1687-7934.153945  
Background Hyperoxia exerts variable effects on multiple cellular and immunologic parameters and offers potential benefits from use of supplemental oxygen. Supplementation with high concentration of O 2 has been shown to reduce colorectal anastomotic leakage by 50% and subsequently its use has been recommended to reduce surgical site infection (SSI) by surgical associations of America and Canada. We designed this randomized controlled trial to determine the impact of O 2 supplementation on the incidence of SSI in urological surgeries performed under neuraxial anaesthesia. Aim The aim of the study was to evaluate whether use of supplemental high-concentration perioperative oxygen decreases the risk of post-uro-SSI as it did after colorectal surgery in previous studies. Settings The study was conducted in the Department of Anaesthesiology and Critical Care in collaboration with the Department of Urology at our institute after obtaining clearance from the Institute of Ethical Committee and written informed consent from patients enrolled in this study. Patients and methods Eighty ASA grade I and II patients, aged between 15 and 60 years, undergoing selected urological surgeries were randomly assigned to two equal groups after they had fulfilled inclusion and exclusion criteria. One group received 8-10 l O 2 /min through a non-rebreathing face mask during the intraoperative period, which was continued in the postoperative period for about 6 h, whereas the other group continued breathing room air. Data were collected by physicians from the Department of Urology who were blinded to the intervention and were analysed using INSTAT software with appropriate statistical tools. Results Demographic, physical, preoperative, intraoperative and postoperative haemodynamic parameters in both groups were comparable (P > 0.05). Although our study showed a tendency towards reduction in SSI (17.5 vs. 12.5%), compared with the control group, the difference was not statistically significant (P > 0.05). Conclusion Perioperative high-concentration oxygen supplementation does not reduce SSI in clean contaminated types of wounds in urological surgeries.
  2,662 178 2
Pre-emptive intravenous ketorolac analgesia does not alter the risk of bleeding after tonsillectomy in children
Waleed M Abdelmageed, Hesham F Soliman, Mohamed A Fatthallah
January-March 2015, 8(1):43-49
DOI:10.4103/1687-7934.153937  
Background NSAIDs inhibit platelet aggregation and prolong bleeding time, which may augment the risk of postoperative bleeding. We investigated the effects of pre-emptive analgesia with intravenous ketorolac on intraoperative and postoperative hemorrhage with pediatric tonsillectomy. Patients and Methods A total of 147 children, aged 2-7 years, scheduled for tonsillectomy with or without adenoidectomy were randomized to receive a slow intravenous infusion of either ketorolac 1 mg/kg (ketorolac group, n = 74) or paracetamol 15 mg/kg (paracetamol group, n = 73) after induction of anesthesia. Noninvasive hemoglobin was assessed preoperatively and several times after surgery. Bleeding times were measured before and after surgery. Intraoperative blood loss was estimated. Intensity of postoperative pain was measured using an objective pain score. The incidence and severity of post-tonsillectomy bleeding were recorded until the seventh postoperative day. Results There was no statistically significant difference in the estimated intraoperative blood loss between ketorolac and paracetamol groups (2.4 ± 1.1 vs. 2.1 ± 0.8 ml/kg, respectively; P = 0.061). Bleeding time increased between preoperative and postoperative assessments in both groups, with significant postoperative elevation in the ketorolac group (P = 0.001). Both groups were comparable regarding the perioperative noninvasive hemoglobin measurements. The overall incidence of post-tonsillectomy bleeding was 5.4%, with no statistically significant difference between ketorolac and paracetamol groups [5 (6.75%) vs. 3 (4.1%) patients, respectively; P = 0.705]. Postoperative objective pain score were significantly lower in the ketorolac group on postanesthesia care unit admission and at 1, 2, and 6 postoperative hours (P < 0.05). Conclusion Pre-emptive ketorolac infusion during pediatric tonsillectomy provides superior postoperative analgesia with no effect on intraoperative or postoperative clinical bleeding.
  2,635 202 1
Does tramadol or bupivacaine intraincisional infiltration with inguinal canal block during hernioplasty change the postoperative pain profile?
Gamal Musstafa, Ahmed A Badawy, Ahmed El-sakka, Amr Wahdan
January-March 2015, 8(1):107-113
DOI:10.4103/1687-7934.153951  
Objective The study aimed to evaluate the effect of inguinal canal block together with intraincisional injection of tramadol against bupivacaine 0.25% on both intraoperative and postoperative pain relief in patients undergoing inguinal hernioplasty under general anesthesia. Patients and methods The study was conducted on 60 male patients scheduled for elective inguinal hernioplasty under general anesthesia in the Kasr Al-Ainy School of Medicine. Patients were randomly allocated into three groups: group C [control group (n = 20)], group B [bupivacaine 0.25% group (n = 20)], and group T [tramadol group (n = 20)]. During the surgery, the mean arterial blood pressure and the heart rate were traced every 5 min. The total intraoperative fentanyl requirement, postoperative visual analogue score and sedation scores, and nausea and vomiting were recorded; patient and surgeon satisfaction were assessed. Results The intraoperative mean arterial blood pressure, heart rate, and fentanyl requirement were statistically lower in both the bupivacaine and the tramadol groups compared with the control group. The postoperative visual analogue score was statistically lower in both the bupivacaine and the tramadol groups compared with the control group. Postoperative nausea and vomiting were statistically higher in the tramadol group compared with the control group and the bupivacaine groups. The scoring of postoperative patient satisfaction was statistically higher in the tramadol group compared with the bupivacaine and the control groups. Conclusion The study offered a new technique using tramadol as a locally infiltrated drug during inguinal hernioplasty aiming to decrease intraoperative and postoperative pain together with reducing analgesic needs to minimum during and after the operation with the consequent beneficial reduction of narcotic side effects.
  2,586 218 -
REVIEW ARTICLES
Rapid reversal of anticoagulants in trauma patients
Dalia M El-Fawy
January-March 2015, 8(1):5-9
DOI:10.4103/1687-7934.153930  
Anticoagulation therapies are one of the most commonly encountered therapies by healthcare professionals each day. One of the most important adverse effects of anticoagulation therapy is life-threatening hemorrhage, and it may result in visits to the emergency department. Some of the common reversal agents include vitamin K, protamine sulfate, desmopressin, recombinant factor VIIa, and prothrombin complex concentrates. Each of these agents has the potential to reverse specific anticoagulation therapies, but each agent has a unique administration procedure and monitoring parameters. However, these agents are not without a risk of adverse effects.
  2,403 295 -
ORIGINAL ARTICLES
Does scalp block with general anesthesia in craniotomy affect the intraoperative course and outcome in geriatric patients?
Omar W Abbass, Gomaa Z Hussien, Hesham A Aboeldahab, Safenas Othman, Mohamed Fareed
January-March 2015, 8(1):25-30
DOI:10.4103/1687-7934.153934  
Background The noxious stimuli during supratentorial brain tumor resection in geriatric patients result in a vigorous hemodynamic response and stress response, which represents a challenge during anesthesia. Patients and methods A total of 80 patients were enrolled in the study. There were 43 male and 37 female patients undergoing elective supratentorial craniotomy. Patients were randomly assigned into two equal groups: group B patients had scalp block using bupivacaine (0.5%) and epinephrine (1 : 400 000) and group F patients received fentanyl 2 μg/kg (during maintenance of general anesthesia (GA)). Heart rate (HR), mean arterial pressure (MAP), plasma cortisol level, and intracranial pressure (ICP) were recorded at baseline (before induction of anesthesia), 1 min after intubation, 1 min after skin incision, 1 min after dural incision, 1 min after dural closure, 1 min after skin closure, and 1 min after extubation. ICP measurement ceased at dural incision. Time to recovery from anesthesia was also recorded. Results MAP, HR, and plasma cortisol level showed significant differences between groups, wherein group F had higher MAP, HR, and plasma cortisol level than group B. Group B had rapid recovery period. Conclusion Scalp block with 0.5% bupivacaine with adrenaline 1 : 400 000 can be used as an alternative to general anesthesia with fentanyl in preventing the increase in arterial blood pressure (ABP), HR, ICP, cerebral perfusion pressure (CPP), and cortisol level, and also it allows early extubation and assessment of conscious level.
  2,253 278 -
REVIEW ARTICLES
Management of uncontrolled hemorrhagic trauma: State of the art
Mohamed Saleh
January-March 2015, 8(1):10-13
DOI:10.4103/1687-7934.153931  
Uncontrolled hemorrhagic trauma represents a challenge to the intensivist as it is a leading cause of potentially preventable death in trauma patients. Recently, damage control resuscitation and hemostatic resuscitation has become the standard of care for the management of these patients. The aim of this review is to highlight the pathophysiology of acute traumatic coagulopathy and the management of these challenging patients.
  2,271 251 -
ORIGINAL ARTICLES
Topical lidocaine against deep sedation for intragastric balloon insertion
Ayman A Kasem, Ashraf A AbdelKader
January-March 2015, 8(1):64-69
DOI:10.4103/1687-7934.153940  
Background Intragastric balloon (IGB) insertion is a known method for the treatment of the special group of morbidly obese patients. The procedure can be performed under general anesthesia or deep sedation; however, it is associated with many complications, particularly respiratory complications, in this risky group of patients, which makes topical anesthesia an acceptable alternative option. Aim The aim of this study was to demonstrate the efficacy of topical anesthesia for IGB insertion in comparison with the deep-sedation technique. Patients and methods A total of 100 patients were enrolled in the study, and were divided into two groups. The T group received topical anesthesia in the form of lidocaine gel ± lidocaine spray. If the patient did not tolerate the endoscope advancement, either midazolam or alfentanil was given, whereas S group patients received deep sedation in the form of alfentanil, propofol, and midazolam. Results Endoscopy was performed in all patients successfully. The topical group had more hemodynamic stability, less respiratory adverse events, a shorter time to return to baseline condition, and higher patient satisfaction compared with the other group. Conclusion The use of topical anesthesia is an effective technique for IGB insertion as it provides a good operative condition and a safer procedure for high-risk morbidly obese patients, with high patient satisfaction.
  2,231 172 -
Comparison between dexmedetomidine and magnesium sulfate as adjuvants for intravenous regional anesthesia
Mohamed El-Tahawy, Ahmad Ramzy Shaaban, Ayman Ahmad
January-March 2015, 8(1):129-133
DOI:10.4103/1687-7934.153954  
Background Many adjuvants have been used to improve the quality of intravenous regional anesthesia (IVRA). The aim of this study was to compare the use of dexmedetomidine with that of magnesium sulfate as an adjuvant for IVRA as regards onset and duration of sensory and motor blocks, quality of anesthesia, intraoperative-postoperative hemodynamic variables, and intraoperative and postoperative pain. Patients and Methods This study was a prospective, randomized, double-blinded trial. Sixty patients scheduled for upper hand or forearm surgery were randomly divided into two groups, comprising 30 patients each. Group D received dexmedetomidine at 0.5 μg/kg diluted with saline to 20 ml in addition to 20 ml of 1% lidocaine to reach a total volume of 40 ml, whereas group M received 5 ml of 20% magnesium sulfate and 15 ml saline added to 20 ml of 1% lidocaine to reach a total volume of 40 ml. Sensory and motor block onset, recovery times, anesthesia quality, and hemodynamic variables were recorded and compared between the two groups. Results No statistically significant difference was observed between dexmedetomidine and magnesium sulfate as regards sensory block onset time and motor block onset time (P = 0.102 and 0.206, respectively) as well as intraoperative analgesic requirements (P = 0.76). However, dexmedetomidine showed more favorable hemodynamic variables and less tourniquet pain. Conclusion We concluded that dexmedetomidine seems to be superior to magnesium sulfate as an adjuvant to lidocaine in IVRA regarding tourniquet pain and intraoperative and postoperative hemodynamic stability.
  1,987 263 1
Comparative study between the effect of intrathecal midazolam versus intrathecal midazolam plus magnesium sulfate on the efficacy and duration of analgesia in patients undergoing cesarean section
Maged L Boules, Josepph M Botros
January-March 2015, 8(1):70-75
DOI:10.4103/1687-7934.153941  
Background Regional techniques using either epidural or intrathecal routes are currently the most popular methods of pain relief during labor and delivery. Aim The aim of the study was to compare efficacy and duration of analgesia produced by adding magnesium sulfate to intrathecal bupivacaine (10 mg) plus midazolam (1 mg) in patients undergoing cesarean section. Patients and methods In our study, 60 patients aged 18-35 years of American Society of Anesthesiologists (ASA) class I and II were scheduled for a cesarian section under an intrathecal block and divided randomly into two groups: midazolam group (group M): A total of 30 patients received 10 mg/2 ml intrathecal 0.5% hyperbaric bupivacaine, midazolam (1 mg/0.2 ml), and 0.8 ml normal saline and magnesium midazolam group (group MM): A total of 30 patients received 10 mg/2 ml intrathecal 0.5% hyperbaric bupivacaine, midazolam (1 mg/0.2 ml), magnesium sulfate (50 mg/0.5 ml), and 0.3 ml normal saline. The onset and duration of both sensory and motor block, the total dose of analgesia, and adverse effects were recorded. Results The onset of sensory block was significantly delayed in the MM group compared with the M group (6.05 ± 1.1 vs. 3.5 ± 0.45 min, P = 0.024); the duration of sensory block was longer in the MM group compared with the M group (132.4 ± 7.8 vs. 115.3 ± 6.60 min, P = 0.018). In addition, the onset of motor block was delayed in the MM group (7.05 ± 1.3 min) compared with the M group (5 ± 0.65 min, P = 0.028) as well as its duration (149.9 ± 8.67 vs. 126.3 ± 5.35 min, P = 0.005). Conclusion The addition of magnesium sulfate to intrathecal bupivacaine plus midazolam led to a significant delay in the onset of both sensory and motor blockade, and also prolonged their duration without side effects.
  1,794 213 1
Comparison between the level of interleukin-6 and B-type natriuretic peptide as predictors of the outcome after coronary artery bypass graft surgery
Ahmad Ramzy Shaaban, Mohamed El Tahawy
January-March 2015, 8(1):14-20
DOI:10.4103/1687-7934.153932  
Introduction The B-type natriuretic peptide (BNP) and interleukin-6 (IL-6) are increasingly being used as biomarkers for the diagnosis, management, and prognosis of complications after cardiac surgery with cardiopulmonary bypass (CPB). The aim of this study was to assess preoperative and postoperative levels of BNP and IL-6 in patients undergoing coronary artery graft surgery (CABG) with CPB and investigate their variation and ability to correlate with immediate postoperative outcome. Patients and Methods Patients scheduled for elective CABG with CPB were enrolled in this study. Plasma levels of BNP and IL-6 were measured preoperatively, 6, 12, and 24 h after CPB. The main endpoints were the correlation between the level of BNP and IL-6 and the requirements for an intra-aortic balloon pump, artificial ventilation for more than 24 h, intensive care unit (ICU) stay longer than 5 days, requirement for inotropic support, hospital stay, and clinical complications (infection, myocardial infarction, ventricular arrhythmias, stroke, or renal failure). Results Sixty-eight patients (eight women and 60 men), median age 63.3 ± 6.9 years, were included in the study. Preoperative BNP levels correlated with longer ICU stay (P = 0.003), longer mechanical ventilation (P = 0.016), and longer epinephrine and milrinone use (P < 0.001), whereas BNP at 24 h after CABG correlated only with longer epinephrine and milrinone use (r = 0.418, P = 0.003). Preoperatively and 6 h postoperatively, IL-6 correlated with longer epinephrine and milrinone use (P = 0.018) and longer ICU stay, and was significantly increased in patients with infection at all time points of measurement. Conclusion BNP correlates with clinical endpoints more than IL-6 and both can be used together as predictors of early outcome after coronary artery bypass grafting surgery.
  1,780 161 -
Ultrasound-guided transversus abdominis plane block versus dexmedetomidine infusion in open ovarian cystectomy: Analgesic efficacy and effect on stress response
Khaled M Maghawry, Ayman A Rayan, Alaa S El-Kateb
January-March 2015, 8(1):114-123
DOI:10.4103/1687-7934.153952  
Background Ultrasound (US)-guided transversus abdominis plane (TAP) block has been proven to be an effective method of providing postoperative analgesia in laparotomy. Dexmedetomidine has sedative, analgesic, sympatholytic, and amnestic properties. In the present study, we evaluated the analgesic efficacy and the attenuation of stress surgical response of US-guided TAP block in comparison with dexmedetomidine infusion in patients undergoing open ovarian cystectomy in a randomized, double-blinded clinical study. Patients and methods A total of 60 patients were randomly assigned into two groups (30 in each) to be administered, before skin incision, either a combination of general anesthesia with a US-guided TAP block (TAP group), or an intraoperative intravenous infusion of dexmedetomidine (DEX group). In the DEX group, loading dose of 1 μg/kg of dexmedetomidine was infused over 10 min, followed by infusion of 0.2-0.6 μg/kg/h. Measurements included hemodynamics, stress hormones, pain score, time of first analgesia, and amount of pethidine during the first 24 h postoperative. Results In the DEX group, there was a significant decrease in heart rate (HR) at 45, 60, and 90 min after surgical incision in comparison with preoperative HR. In the TAP group, there was a significant decrease in HR at 60 and 90 min after surgical incision in comparison with preoperative HR. In the DEX group, there was a significant decrease in mean arterial pressure at 30, 45, 60, and 90 min after surgical incision in comparison with preoperative mean arterial pressure. The DEX group had shown a statistically significant increase with regard to change in the blood level of stress hormones 12 and 24 h postoperative in comparison with the preoperative values. There was a highly significant increase in postoperative pethidine supplementation in the DEX group than in the TAP group. There was a significant difference with regard to time of the first postoperative request of analgesia in the DEX group than in the TAP group. Conclusion In open ovarian cystectomy, US-guided TAP block was comparable to dexmedetomidine infusion with regard to intraoperative hemodynamic stability and opioid requirement without change in stress response hormones. However, TAP block provided superior analgesia when compared with dexmedetomidine infusion up to 24 h postoperatively.
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Preemptive parenteral paracetamol analgesia in off-pump coronary artery bypass
Khaled M.A Abdelsalam
January-March 2015, 8(1):21-24
DOI:10.4103/1687-7934.153933  
Background NSAIDs are routinely used for pain control in cardiac surgery; however, these drugs are burdened by side effects. Paracetamol is believed to be lacking in such side effects. The aim of this study was to examine the efficacy of preemptive intravenous paracetamol analgesia on opioid sparing in off-pump coronary artery bypass (OPCAB). Materials and Methods This was a prospective randomized controlled double-blinded study. A total of 80 patients scheduled for elective OPCAB were randomly allocated into two groups: in group I (the control group) 40 patients received intravenous infusion of 100 ml of normal saline solution, whereas in group II (the paracetamol study group) 40 patients received intravenous infusion of 1 g of the study drug in 100 ml solution bag. Solution bags were prepared by the pharmacy department, and treating teams were blinded to the infused solution until end of study. Hemodynamic variables and sufentanil usage were recorded and compared between the two groups. Results The two groups were comparable regarding their demographic and operative data. Hemodynamic variables showed nonsignificant differences between the two studied groups. Total intraoperative consumption of sufentanil was comparable between the two groups with insignificant difference. Postoperatively, extubation time and length of ICU stay were statistically nonsignificant. Conclusion Preemptive administration of parenteral paracetamol had a limited opioid-sparing effect during intraoperative management of cardiac cases undergoing OPCAB.
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The effect of adding ketamine to bupivacaine in greater palatine nerve block in platoplasty
Dalia M El Fawy, Niven Gerges, Yasser A Salem
January-March 2015, 8(1):134-139
DOI:10.4103/1687-7934.153955  
Background Greater palatine nerve block anesthetizes the posterior part of the hard palate and its overlying soft tissue. It is performed for pain relief in children undergoing cleft palate surgery. This study was conducted to compare the efficacy and the duration of this block using the local anesthetic bupivacaine 0.25% alone with that of ketamine 0.5 mg/kg plus bupivacaine 0.25%. Patients and methods After institutional ethical committee approval and parental consent were obtained, 40 ASA I, II children aged 1-6 years undergoing palatoplasty were enrolled in this prospective randomized double-blind study. A standardized technique of general anesthesia was used, and then patients were classified into two groups: in group B (n = 20), the greater palatine nerve block was performed using 0.5 ml bupivacaine 0.25% alone; and in group K (n = 20), the block was performed using ketamine 0.5 mg/kg added to bupivacaine 0.25%. The heart rate, the systolic blood pressure, the pain score, the time to rescue analgesics, and the total amount of analgesics used in 24 h were assessed. Results Group KB had a significantly longer time to first rescue analgesia (8.62 ± 0.5 vs. 4.25 ± 1.1 h) and significantly lower doses of rectal diclofenac (0, 0, 0 vs. 0, 0, 12.5 mg) than group B. The Children's Hospital Eastern Ontario Pain Scale pain scale was significantly lower in group BK than in group B (P < 0.05) at 4, 8, 12, 18, and 24 h postoperatively. There was a significant difference between the groups in dysphagia to solid and sleep disturbance at 6 and 12 h. Conclusion Addition of ketamine to bupivacaine in greater palatine nerve block increased the quality and the duration of analgesia, and also decreased the total dose of postoperative analgesic requirement in children undergoing cleft palate repair surgery.
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CASE REPORTS
Anesthetic management of carcinoma of thyroid involving trachea in a patient with hypertrophic obstructive cardiomyopathy
Sapna A Nikhar, Monu Yadav, Ramachandran Gopinath, Mohammad Azharuddin
January-March 2015, 8(1):144-147
DOI:10.4103/1687-7934.153958  
Airway management still remains a challenge for anesthesiologists. We discuss a case of carcinoma of thyroid infiltrating trachea, causing respiratory distress in a patient with hypertrophic obstructive cardiomyopathy. This presentation is itself a challenge to the anesthesiologists in view of difficult airway. Hypertrophic obstructive cardiomyopathy can worsen the condition. To avoid and manage any complications, we need to anticipate the course of surgery and design a successful anesthetic plan.
  1,588 184 -
ORIGINAL ARTICLES
Can topical administration of tranexamic acid be a good adjuvant to the intravenous route for decreasing postoperative seizure incidence? A double blinded randomized study
Hani I Taman, Ghada F Amer, Sameh A Amer
January-March 2015, 8(1):36-42
DOI:10.4103/1687-7934.153936  
Background Antifibrinolytic therapy has become a mainstay in complex cardiac surgical procedures for decreasing bleeding and minimizing transfusion requirements. Tranexamic acid (TA) is an antifibrinolytic agent that can be used both systemically and topically. Current studies and case series reports mention an increased incidence of seizures after administration of high doses of TA (60-260 mg/kg body weight). Thus, we hypothesize that adding a topical dose of TA to a small dose intravenously could reduce postoperative bleeding in patients who have undergone cardiac surgery with subsequent decrease in the overall complications associated with this drug, mainly seizures. Materials and methods A total of 120 patients were randomly allocated to two groups, the intravenous TA group (group I) and the topical and intravenous TA group (group II), with 60 patients in each. Every patient in group I received an initial bolus dose of TA consisting of a bolus of 50 mg/kg body weight at the beginning and at the end of cardiopulmonary bypass (CPB), and 100 mg/100 ml priming volume was added to the priming fluid of the CPB system. In group II every patient received an initial bolus dose of TA at 30 mg/kg infused over 15 min followed by a 16 mg/kg/h infusion until chest closure with a 2 mg/kg load within the pump prime; in addition, before sternotomy closure, patients received another 2 g of TA diluted in 500 ml of warm saline (37°C), which was poured into the pericardial cavity. Results Hemoglobin concentration, hematocrit value, platelet count, international normalized ratio, bleeding time, activated partial thromboplastin time, total volume of blood loss, and total volume of blood transfused into the patients showed no significant differences between the two groups throughout the study. In contrast, prothrombin time and activated clotting time were significantly higher in group II when compared with group I at 2 h postoperatively. Seizure incidence was significantly lower in group II when compared with group I. However, the number of re-explored cases was insignificant when the two groups were compared. Conclusion Topical application of TA in addition to a small intravenous dose in patients undergoing open cardiac surgery using CPB reduces perioperative blood loss and transfusion in those patients to the same extent as sole large intravenous dose with less incidence of seizures.
  1,494 155 1
LETTERS TO THE EDITOR
An indigenous multipurpose low-cost bite-block: A novel method for use with laryngeal mask airway
Uma Hariharan
January-March 2015, 8(1):1-2
DOI:10.4103/1687-7934.153925  
  1,492 151 -
CASE REPORTS
Bronchial lavage and chest percussions relieved complete airway obstruction due to crushed foreign body: A case report
Roshdi R Al-Metwalli
January-March 2015, 8(1):148-150
DOI:10.4103/1687-7934.153960  
Tracheobronchial foreign body (FB) is always a clinical challenge. Dropping the FB during retrieval is a potentially life-threatening complication, which, if not promptly diagnosed and treated, can prove fatal. We present a case of complete airway obstruction due to crushed and slipped FB during its retrieval from the upper airway. Its tiny fragments dropped down and obstructed the lower bronchial trees. This is a very rare potentially lethal event, which was successfully managed with concomitant bronchial lavage and chest percussion.
  1,363 151 -
LETTERS TO THE EDITOR
Malfunctioning of central venous catheter in obese patients
Ankur Sharma, Hamsenandinie , Girija P Rath
January-March 2015, 8(1):3-4
DOI:10.4103/1687-7934.153927  
  1,222 147 -
RETRACTION
The effect of cholinesterase inhibition on liver dysfunction in experimental acute liver failure: Retraction

January-March 2015, 8(1):151-151
DOI:10.4103/1687-7934.153961  
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