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   2015| April-June  | Volume 8 | Issue 2  
    Online since May 8, 2015

 
 
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ORIGINAL ARTICLES
The minimal effective dose of spinal hyperbaric bupivacaine for successful reliable saddle block for minor perianal surgeries
Roshdi R Al-Metwalli
April-June 2015, 8(2):265-268
DOI:10.4103/1687-7934.156714  
Objective The aim of this study was to determine the minimal effective dose of spinal hyperbaric bupivacaine required to induce a reliable and satisfactory saddle block for perianal surgeries (using a modified Dixon's up-and-down method). Materials and methods A total of 24 adult patients scheduled for perianal surgeries were enrolled in this study. Dural puncture was performed using a standard midline approach in the sitting position at the L3-L4 intervertebral space, using a 25 G Whitacre needle with its orifice directed caudal. A small quantity (1.5 mg) of hyperbaric bupivacaine was injected. All patients remained in the sitting position for 10 min immediately before and after surgery; the block was tested using a long surgical toothless clamp and modified Bromage scale. A successful block was defined as one that was sufficient to proceed with the surgery without any supplementation. The dose of bupivacaine given to the next patient was guided by modified Dixon's up-and-down method using 0.5 mg as a step size. Patients' ability to position themselves, ambulation time, time of hospital discharge, patient and surgeon satisfaction, and any intraoperative or postoperative complication were recorded. The minimal effective dose of hyperbaric bupivacaine for successful saddle block for 50% (ED 50 ) of patients was determined by calculating the midpoint dose of all independent pairs of patients after at least seven crossover points. Results The ED 50 of hyperbaric bupivacaine for successful saddle block for perianal surgeries was 1.9 mg (95% confidence interval = 1.7-2.1 mg). There were zero motor blockade, early ambulation, short time to void, and early hospital discharge, as well as no complications and excellent patient and surgeon satisfaction. Conclusion The ED 50 of spinal hyperbaric bupivacaine for saddle block for perianal surgery is 1.9 mg (95% confidence interval = 1.7-2.1 mg). This block is reliable and has short duration, no complication, and excellent patient and surgeon satisfaction.
  20,027 762 2
A comparative study of prophylactic intravenous granisetron, ondansetron, and ephedrine in attenuating hypotension and its effect on motor and sensory block in elective cesarean section under spinal anesthesia
Omyma Sh M Khalifa
April-June 2015, 8(2):166-172
DOI:10.4103/1687-7934.156667  
Context Although spinal anesthesia avoids the risks involved in managing the airway of the parturient, an undesired side effect often seen is hypotension. Prophylactic intravenous (i.v.) administration of vasopressors such as ephedrine or of serotonin receptor antagonists such as granisetron and ondansetron has been used to overcome this problem. Aims The aim of the study was to compare granisetron and ondansetron with the traditionally used vasopressor 'ephedrine' in reducing hypotension following spinal anesthesia and their effect on sensory and motor blockade in parturients undergoing cesarean section. Settings and design This study was designed as a randomized, prospective, double-blind, placebo-controlled trial. Materials and methods Eighty parturients of ASA I or II grade, aged 2040 years, scheduled for elective cesarean section were randomly allocated into four equal groups (G, O, E, and C). 'Group G' received 1 mg i.v. granisetron, 'group O' received 4 mg i.v. ondansetron, 'group E' received 10 mg i.v. ephedrine, and 'group C' received 10 ml normal saline. All of the studied drugs were diluted in 10 ml normal saline and administered over a period of 1-5 min before induction of spinal anesthesia. Mean arterial blood pressure, heart rate, sensory and motor blockade, nausea, shivering, bradycardia and vasopressor need were assessed. Results The reduction in mean arterial pressure was significantly lower in the therapeutic groups, with the best results recorded in the O group and nearly comparable results in G and E groups. Heart rate was statistically different only at 10 and 15 min. No significant difference was seen in motor block or in the incidence of bradycardia. Significantly faster recovery of sensation was detected in the G group. Groups G, O, and E had significantly less vasopressor need and lower incidence of nausea. Conclusion In the cesarean section, prophylactic use of i.v. granisetron, ondansetron, or ephedrine reduced the severity of spinal-induced hypotension, nausea, and vasopressor need, but faster recovery of sensory block was noticed with granisetron.
  5,511 644 5
Comparison of dexmedetomidine and fentanyl for attenuation of the hemodynamic response to laryngoscopy and tracheal intubation
Vaibhav Jain, Aruna Chandak, Alok Ghosh, Mayuri Golhar
April-June 2015, 8(2):236-243
DOI:10.4103/1687-7934.156699  
Background The pressor response, which is part of a huge spectrum of stress responses, results from the increase in sympathetic and sympathoadrenal activity. This study was conducted to compare the efficacy of dexmedetomidine and fentanyl for attenuation of largyngoscopic pressor response. Patients and methods Sixty patients of ASA I and II were randomly divided into two groups. Group D patients received an injection of dexmedetomidine at a dose of 1 μg/kg, whereas group F patients received an injection of fentanyl at a dose of 2 μg/kg preoperatively over 10 min before induction of anesthesia with an injection of thiopentone and vecuronium. After laryngoscopy, anesthesia was maintained with isoflurane (0.6% v/v)+N 2 O (50%)+O 2 (50%). Intraoperatively, heart rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure (MBP), SpO 2 , and ECG were recorded at the following intervals: at baseline, after drug administration (at 2, 5, and 8 min), before induction, after induction, and after laryngoscopy. Results Dexmedetomidine significantly attenuated the sympathetic response to laryngoscopy and intubation in terms of heart rate, systolic blood pressure, and diastolic blood pressure compared with fentanyl. The total dose of thiopentone for induction of general anesthesia was significantly less in the dexmedetomidine group as compared with the fentanyl group. Incidence of bradycardia and hypotension was higher in patients of the dexmedetomidine group when compared with the fentanyl group. Conclusion An intravenous infusion of dexmedetomidine at 1 μg/kg administered 10 min before laryngoscopy and endotracheal intubation can be recommended over fentanyl at 2 μg/kg to attenuate the sympathetic response to laryngoscopy and endotracheal intubation with minimal side effects.
  3,548 494 2
Midazolam, ketamine, or fentanyl added to propofol as total intravenous anesthesia in skin grafting after burn in pediatrics: a comparative study
M Elham, El Feky, Hala M Koptan
April-June 2015, 8(2):160-165
DOI:10.4103/1687-7934.156664  
Background Total intravenous anesthesia is an alternative to inhalational anesthesia. The combination of two drugs to achieve hypnosis and analgesia is the most common regimen. The combination of propofol and other drugs (midazolam, ketamine, and fentanyl) can be used for induction and maintenance of anesthesia. Aim of the study This study aimed to compare the effects of propofol - midazolam, propofol - ketamine, and propofol - fentanyl on intraoperative hemodynamics, recovery, postoperative pain and sedation, and postoperative complications in skin grafting after burn in pediatrics. Patients and methods Ninety pediatric patients (4-11 years' old) scheduled for skin graft after burn (10-20%) were divided into three groups. In group I (the propofol - midazolam group), anesthesia was maintained by an infusion of propofol at a dose of 5 mg/kg/h plus midazolam infusion at a dose of 0.05 mg/kg/h. In group II (propofol - ketamine group), anesthesia was maintained by an infusion of propofol at a dose of 5 mg/kg/h plus ketamine infusion at a dose of 1.5 mg/kg/h. In group III (propofol - fentanyl group), anesthesia was maintained by an infusion of propofol at a dose of 5 mg/kg/h plus fentanyl infusion at a dose of 1 μg/kg/h. Results Propofol - ketamine was superior in intraoperative hemodynamic stability. The three groups were comparable in terms of recovery, orientation time, and postoperative complications. Pain and sedation scores were comparable between the three groups in the first postoperative hour, but in the second hour, the propofol - ketamine and the propofol - fentanyl groups showed a significant decrease compared with the propofol - midazolam group. Conclusion Propofol - ketamine showed more hemodynamic stability than the other two groups. The propofol - ketamine and propofol - fentanyl combinations prolonged analgesia and sedation more than propofol - midazolam.
  3,527 304 -
Different local anesthetic technique for postoperative analgesia in open cholecystectomy
Ahmed Eldaba, Mohamed Lofty
April-June 2015, 8(2):252-258
DOI:10.4103/1687-7934.156704  
Background Paravertebral block is the technique of injecting a local anesthetic (LA) solution alongside the vertebral column close to the emergence of the spinal nerves. Infiltration of LAs into the surgical wound is a simple, safe, and low-cost technique for postoperative analgesia. Patients and methods Patients with physical status ASA I-II aged 20-45 years of both sexes and scheduled for an elective open cholecystectomy with subcostal incision were included in this study. Patients were classified randomly using sealed envelopes into three equal groups of 60 patients each. At the end of the surgical procedures, for all the patients of the study, a continuous wound catheter (CWC) and a continuous paravertebral catheter were inserted: group I (CWC), group II (continuous paravertebral catheter), and group III (control group). Anesthesia was induced with an intravenous fentanyl injection (1.5 µg/kg), propofol (1.5 mg/kg), followed by cis-atracurium (0.15 mg/kg), and then the patient was intubated after 3 min. Maintenance of anesthesia was by isoflurane with minimal alveolar concentration (1.5) with additional doses of cis-atracurium (0.04 mg/kg) when needed. Results A total of 120 patients were included in the study, with 40 patients randomized to each group. There were no significant differences in demographic data. For mean arterial blood pressure, heart rate, and respiratory rate, there were no significant differences between the groups, except 30 min after extubation, when there was a significant increase in group III compared with the other two groups. For SpO 2 , there was no significant difference between the three groups. In terms of pain assessment using visual analogue scale, there was a significant decrease at all time points in the values of group II compared with the other two groups and in group I compared with group III. Conclusion We conclude that paravertebral block with a continuous infusion is more effective than a CWC infusion in postoperative pain management after surgeries with subcostal incisions, although both techniques showed a significant improvement compared with the control group.
  3,317 221 1
Effect of intraperitoneal magnesium sulfate on hemodynamic changes and its analgesic and antiemetic effect in laparoscopic cholecystectomy
Rania M Ali, Amal H Rabie, Nirvana A Elshalakany, Tarek M El Gindy
April-June 2015, 8(2):153-159
DOI:10.4103/1687-7934.156661  
Background Laparoscopic cholecystectomy is now a routinely performed procedure that has replaced conventional open cholecystectomy. Magnesium sulfate (MgSO 4 ) has been used in the management of postoperative pain through different routes. This prospective randomized, double-blind study aimed to assess the effect of MgSO 4 on hemodynamic response and its analgesic and antiemetic effects in patients undergoing laparoscopic cholecystectomy. Patients and methods Sixty adult patients scheduled for elective cholecystectomy under general anesthesia were randomly allocated into two groups: group M and group C. Patients in group M received 20 ml of MgSO4 10% instilled intraperitoneally after pneumoperitoneum was created before any dissection, whereas group C patients received the same volume of 0.9% sodium chloride. Results Hemodynamic parameters were significantly higher in group C compared with group M at 10, 20, and 30 min after pneumoperitoneum, and at the time of extubation. Recovery characteristics in terms of extubation time (9.70 ± 1.12 vs. 6.77 ± 0.73), emergence time (19.83 ± 1.44 vs. 15.93 ± 1.60), and time to reach full Aldrete score (43.03 ± 8 vs. 21.4 ± 4.7) were significantly longer in group M compared with group C. Mean pain scores (visual analog scale) were significantly lower in group M compared with group C during the first 6 postoperative hours, and the time to first analgesic requirement was longer in group M (9.2 ± 3 h) compared with group C (2.4 ± 1.3 h). Postoperative nausea was significantly higher in group C (63.3%) compared with group M (36.6%). There was no incidence of vomiting in group M compared with 13.3% in group C. Conclusion Intraperitoneal instillation of MgSO 4 attenuated the hemodynamic stress response to pneumoperitoneum, as well as reduced postoperative pain, nausea, and vomiting in patients undergoing laparoscopic cholecystectomy.
  3,111 393 1
CASE REPORTS
Central cord syndrome
Bahaa Ewees, Hadil Magdy, Mohamed Saleh, Ahmed Morsy, Mohamed Hany Ashour
April-June 2015, 8(2):276-278
DOI:10.4103/1687-7934.156721  
Spinal cord injuries (SCIs) are classified as complete or incomplete injuries. Central cord syndrome (CCS) is the most common type of incomplete SCI. The syndrome mostly occurs in older individuals with underlying cervical spondylosis caused by a hyperextension injury. The neurological impairment is characterized by a disproportionate weakness of the upper extremities more than the lower extremities and may also include bladder dysfunction and varying degrees of sensory loss. The natural history of the syndrome varies, with some patients experiencing complete spontaneous recovery and others having persistent neurological deficits. The role of surgical intervention remains controversial. We present a case of an elderly patient with cervical spondylosis who underwent thoracolumbar spine fixation and was complicated by CCS mostly due to hyperextension injury during surgery.
  2,871 241 -
ORIGINAL ARTICLES
Intraperitoneal instillation of l-bupivacaine in laparoscopic pediatric procedures: a randomized-controlled study
Saad El Basha, Maha G Hanna, Sherif M Soaida, Hagar H Refaee
April-June 2015, 8(2):247-251
DOI:10.4103/1687-7934.156702  
Background and aim Pain following laparoscopy is mostly because of irritation of the diaphragm and stretching of the peritoneum associated with carbon dioxide insufflation. In this study, we evaluate the effectiveness of periportal xylocaine infiltration and intraperitoneal instillation of l-bupivacaine at the beginning of laparoscopy in pediatrics in reducing postoperative pain, delaying the onset and reducing the total dose of rescue analgesia, and improving perioperative hemodynamics. Patients and methods After receiving ethical committee approval in Kasr Al Ainy University Hospital and parents' consent, 40 ASA I and II children were allocated randomly to two groups. In group I, l-bupivacaine 0.5% instilled into the peritoneal cavity immediately after gas insufflation at a dose 2 mg/kg. In group II, normal saline was instilled instead of l-bupivacaine. All patients were subjected to preincisional periportal lidocaine 1% infiltration. Heart rate (HR) and blood pressure were recorded at 5 min intervals starting from the preoperative period until 6 h postoperatively. The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) score was used, and the onset and dose of pethidine were recorded. Results HR was lower in group I and HR4 was significantly lower (P < 0.001). The mean arterial blood pressure (MAP) was also lower in group I. It was significantly lower in MAP3 and MAP4 (P = 0.049 and 0.004, respectively). The median pain score was significantly lower in group I (P = 0.001). Onset of rescue analgesia demand was longer in group I and the total dose of pethidine was significantly lower in group I (P < 0.001). Conclusion Periportal lidocaine infiltration and intraperitoneal l-bupivacaine instillation in pediatric laparoscopy, after pneumoperitoneum, reduced postoperative pain and improved perioperative hemodynamics.
  2,876 200 1
A comparison of I-gel with the LMA-classic in spontaneously breathing patients
Priyamvada Gupta, Alok Kumar, Dharam Das Jethava, Sameer Kapoor, Durga Jethava
April-June 2015, 8(2):179-182
DOI:10.4103/1687-7934.156672  
Introduction Laryngeal mask airway (LMA) is a supraglottic airway device (SAD), which was primarily designed to facilitate airway maintenance. Thereafter, many modifications have been made in the SADs, and I-gel is a recent one, which has a unique characteristic of a self-inflatable cuff. It is claimed to be better in terms of ease and success of insertion, risk of complications, etc. Aims and objectives The aim of this study was to investigate and compare the insertion characteristics and complication rate of classic LMA with I-gel. Materials and methods Eighty patients of American Society of Anaesthesiologists I/II, between 16 and 60 years of age, of either sex were randomly divided into two groups of 40 patients each. In respective groups, classic LMA or I-gel were introduced under spontaneous ventilation. Insertion characteristics such as number of attempts at insertion, ease of insertion, better seal, etc. were studied. Proper positioning was confirmed as per fiberoptic view of the glottis. Patients were continuously monitored and hemodynamic variables were studied at frequent intervals. We also recorded the complications at the time of extubation, if any. Data were statistically analyzed using t-test and the χ2 -test. A P value less than 0.05 was considered statistically significant. Results I-gel required less time to insertion (29.32 ± 6.88) compared with cLMA (36.72 ± 7.33 s) (P < 0.05). Airway leak pressure was significantly higher among patients of the I-gel group (26.12 ± 7.41 cm H 2 O) compared with the LMA group (20.77 ± 8.20 cm H 2 O) (P = 0.003). Statistically significant difference was found between the two groups as regards the assessment of patients after removal of the SAD. Fiberoptic view of vocal cords was better in the I-gel group. Conclusion Insertion of I-gel was easier and quicker and proper positioning was achieved in more number of patients as compared with classic LMA. Moreover, there were fewer complications noted at the time of removal of the device.
  2,786 279 2
Ultrasound-guided single injection transversus abdominis plane block of isobaric bupivacaine with or without dexamethasone for bariatric patients undergoing laparoscopic vertical banded gastroplasty: a comparative study of different doses
Noha M El Sharnouby, Hanaa A A El Gendy
April-June 2015, 8(2):194-199
DOI:10.4103/1687-7934.156683  
Background Dexamethasone has anti-inflammatory properties that can prolong postoperative analgesia when added to isobaric bupivacaine transversus abdominis plane (TAP) block for bariatric patients undergoing laparoscopic vertical banded gastroplasty. Patients and methods A total of 111 bariatric patients, scheduled for laparoscopic vertical banded gastroplasty under ultrasound-guided TAP block, were randomized blindly into three parallel groups: Group BC that received TAP block using 20 ml of isobaric bupivacaine hydrochloride 0.25%+2 ml saline 0.9%; low-dose dexamethasone group (Group DB4) that received TAP block using 20 ml of isobaric bupivacaine hydrochloride 0.25%+4 mg dexamethasone; and high-dose dexamethasone group (Group DB8) that received TAP block using 20 ml of isobaric bupivacaine hydrochloride 0.25%+8 mg dexamethasone. Results Postoperatively, pain scores were significantly lower in Group BD4 and Group BD8 compared with Group BC at rest and on movement at 6, 8, 12, and 24 h. There was a significant difference with respect to the duration of analgesia (P = 0.0001), 24 h consumption of paracetamol (P = 0.0001), 24 h consumption of meperidine hydrochloride (P = 0.001), the number of patients who needed meperidine hydrochloride rescue analgesic (P = 0.008), time to ambulation (P = 0.0001), and incidence of postoperative nausea and/or vomiting (P = 0.03) among groups. Conclusion Adding dexamethasone (4 or 8 mg) to isobaric bupivacaine TAP block reduces postoperative pain, reduces analgesic requirement, and promotes early ambulation in bariatric patients undergoing laparoscopic vertical banded gastroplasty in comparison with isobaric bupivacaine TAP block alone.
  2,465 280 3
Addition of magnesium sulfate to caudal block for preventing emergence agitation in sevoflurane-based anesthesia in children
Ashraf E El-Agamy, Alaa S El-Kateb, Mostafa G Mahran
April-June 2015, 8(2):217-222
DOI:10.4103/1687-7934.156691  
Background Postoperative emergence agitation (EA) is still a problem in sevoflurane-based anesthesia in children. Among the solutions of this problem is giving caudal anesthesia during operations in the lower half of the body. The aim of this study was to evaluate the addition of magnesium sulfate to bupivacaine in caudal block for the prevention of EA. Materials and methods In this prospective, randomized, double-blind study, 80 children aged 1-6 years, ASA I, undergoing unilateral hernia repair/orchiopexy with sevoflurane-based anesthesia were allocated into one of two groups: either bupivacaine 1 ml/kg 0.25% plus magnesium 50 mg (BM group) or bupivacaine 1 ml/kg 0.25% (B group) received in caudal block. EA was evaluated in both groups using the Pediatric Anesthesia Emergence Delirium scale and Aono's scale. The sedation score, the recovery time, and the occurrence of complications were assessed during the stay in the postanesthesia care unit. Results Only 72 children completed the study (36 in each group). There was a statistically significant difference in the Pediatric Anesthesia Emergence Delirium scale, the value being lower in the BM group than in the B group at 5 min [6 (5-17) compared with 8 (5-18)] (P < 0.001) and at 10 min [5 (4-16) compared with 6 (4-13)] (P < 0.001) postoperatively. Aono's scale showed that the incidence of EA was significantly lower in the BM group than in the B group (P = 0.003). The sedation score was significantly higher in the BM group than in the B group at 15 min (P = 0.001). In contrast, the duration of motor block after operation was similar in both groups. Conclusion The use of caudal magnesium sulfate (50 mg) combined with bupivacaine 0.25% was effective in reducing postoperative EA in preschool children undergoing hernia repair/orchiopexy procedures.
  2,489 221 2
Comparison of intrathecal magnesium, dexmedetomidine, or placebo combined with bupivacaine 0.5% for patients with mild pre-eclampsia undergoing cesarean section
Tamer Y Elie Hamawy, Mahmoud Hassan Mohamed
April-June 2015, 8(2):230-235
DOI:10.4103/1687-7934.156696  
Background Neuraxial anesthesia for pre-eclamptic patients undergoing cesarean section is a well-established safe and effective anesthetic technique. Several agents had been studied as adjuvants to commonly used intrathecal drugs. Aim The aim of this prospective, randomized, double-blinded placebo-controlled study is to compare intrathecal magnesium versus dexmedetomidine (DXM) combined with bupivacaine 0.5% for parturients with mild pre-eclampsia undergoing cesarean section in terms of duration of spinal block as a primary outcome and postoperative analgesia and incidence of intraoperative side effects as secondary outcomes. Patients and methods Ninety pregnant women with singleton pregnancies, scheduled for elective cesarean section and diagnosed with mild pre-eclampsia, were enrolled in this prospective, randomized-controlled double-blind study. Lumbar puncture was performed and then patients were allocated to three groups: group D [0.5% hyperbaric bupivacaine 2.5 ml and 0.1 ml (10 μg) preservative-free DXM]; group M [0.5% hyperbaric bupivacaine 2.5 ml and 0.1 ml preservative-free 10% magnesium sulfate (10 mg)]; and group C (0.5% hyperbaric bupivacaine 2.5 ml and preservative-free saline 0.1 ml as a control). Duration of sensory block, motor block, maximal level of sensory block, and duration of spinal anesthesia were recorded. The incidences of hypotension, sedation, nausea, and vomiting were noted every 15 min during surgery. Pain was assessed using a verbal numeric scale from 0 to 10 at 2, 4, 8, 12, 18, and 24 h postoperatively. Intramuscular diclofenac 75 mg was administered for rescue analgesia whenever the pain score was greater than 3. Overall patient satisfaction with anesthesia and analgesia was recorded at 24 h as 1 = excellent; 2 = good; and 3 = poor. Results The three groups were comparable with respect to patients' demographics, gestational age, and duration of surgery. The duration of sensory block, motor block, and spinal anesthesia were prolonged in group M (175.2 ± 19.4, 216.3 ± 12.6, and 200.3 ± 6.4 min) compared with group D (153 ± 4.78, 181.7 ± 7.8, and 160.4 ± 7 min) and group C (150.37 ± 8.8, 171 ± 8.1, and 165 ± 5.83 min), P < 0.001. There was less ephedrine consumption in group M (7.87 ± 0.98 mg) compared with group D (12.4 ± 1.1 mg) and group C (12.3 ± 1.3 mg), P < 0.001. The cumulative requirement of diclofenac over 24 h was significantly less in group M (135.8 ± 27.7 mg) than in group D (183.3 ± 26.7 mg) and group C (187 ± 22.6 mg), P < 0.001. Verbal numeric scale scores in the first 24 h were significantly higher in the control group (group C) than the other two groups. Conclusion The addition of intrathecal magnesium sulfate (10 mg) to bupivacaine in patients with mild pre-eclampsia undergoing cesarean section prolongs the duration of analgesia and reduces postoperative analgesic requirements without additional side effects compared with intrathecal DXM (10 μg).
  2,033 255 -
CASE REPORTS
Acquired bronchoesophageal fistula: an anesthetic challenge
Kalyani N Patil, Sharvari D Deshpande, Saroj B Bande
April-June 2015, 8(2):279-282
DOI:10.4103/1687-7934.156729  
We report a rare case of acquired esophageal traction diverticulum, associated with tuberculous lymphadenitis leading to benign bronchoesophageal fistula of the right lower lobe bronchus. A 30-year-old male patient was admitted to our hospital with history of pulmonary tuberculosis 2 years back and complaints of cough and choking sensation after swallowing for 1 year. The diagnosis of bronchoesophageal fistula was made by contrast esophagogram and confirmed on computed tomographic scan. He was posted for thoracoscopic ligation of the fistula. Anesthetic management included thoracic epidural and general anesthesia with one-lung ventilation. Preoperative optimization, management of one-lung ventilation, optimum fluid management guided by central venous pressures, excellent analgesia with thoracic epidural, postoperative ICU care, and team efforts were important to make us succeed in this rare case of acquired benign bronchoesophageal fistula.
  2,032 202 -
ORIGINAL ARTICLES
The hemodynamic and analgesic profile of dexmedetomidine against fentanyl in preeclamptic parturients undergoing Cesarean section under general anesthesia
Nadia Helmy, Jehan Helmy, Ahmed El-Sakka, Heba Rafaat
April-June 2015, 8(2):183-188
Objective The aim of the study was to evaluate the effect of dexmedetomidine against fentanyl infusions on stabilizing intraoperative and postoperative hemodynamic parameters; the study also aimed to detect the effect of dexmedetomidine on postoperative pain and analgesic requirements and the neonatal outcome in preeclamptic parturients undergoing Cesarean section under general anesthesia. Patients and methods The study was conducted on 100 female preeclamptic parturients scheduled for elective Cesarean section under general anesthesia in the Kasr Elainy school of medicine. Patients were allocated randomly into two groups: group F, fentanyl group (n = 50); group D, dexmedetomidine group (n = 50). During surgery, the blood pressure and the heart rate were traced, and the ventilation time, the extubation time, the postoperative visual analogue score, the time for the first analgesic, the total analgesic requirements, postoperative nausea and vomiting, maternal satisfaction, and the neonatal outcome for each group were observed and recorded. Results Regarding hemodynamic parameters, the mean arterial blood pressure and the heart rate were significantly lower in group D in comparison with group F. There was a significant difference between the two study groups in the neurologic adaptive capacity score in favor of group D. Group D showed significantly longer spontaneous ventilation and extubation times compared with group F. The visual analogue score was significantly lower in group D than in group F at all times. Maternal satisfaction was higher in group D than in group F. Both study groups were comparable with regard to the quality of extubation and maternal complications. Conclusion The present study demonstrates the benefits of dexmedetomidine in augmenting the hemodynamic stability and the analgesic quality in preeclamptic patients undergoing Cesarean section under general anesthesia without any apparent deleterious maternal or fetal effects. This favors the use of dexmedetomidine as an adjuvant to general anesthesia in preeclamptic parturients in the future.
  1,967 251 -
Addition of dexmedetomidine to bupivacaine in the lumbar plexus block potentiates postoperative analgesia among hip arthroplasty patients: a prospective randomized controlled trial
Hesham F Soliman
April-June 2015, 8(2):269-275
DOI:10.4103/1687-7934.156716  
Background Dexmedetomidine is an α2-adrenergic agonist, which prolongs analgesia when administered in neuroaxial and peripheral nerve blocks. The aim of this study was to evaluate the effect of adding dexmedetomidine to bupivacaine in the lumbar plexus block (LPB) as regards analgesic characteristics and opioid consumption. Materials and methods Fifty patients scheduled for total hip arthroplasty were divided into two groups: group B patients (N = 25) received LPB with 30 ml of 0.25% bupivacaine and 2 ml of normal saline, while group BD patients (N = 25) received LPB with 30 ml of 0.25% bupivacaine and dexmedetomidine 1 μg/kg diluted in 2 ml of normal saline. Time for first analgesic administration, totally used doses of morphine, pain scores, hemodynamic data, and side effects were recorded. Results Demographic and operative characteristics were comparable between the two groups. The time for first analgesic request was longer in group BD than group B [502 vs. 243 min (P < 0.001) and the total morphine consumption in 24 h was less among group BD patients compared with those in group B (19 vs. 32 mg, P < 0.001)]. The visual analogue score was significantly lower in group BD in the first 8 h postoperatively compared with group B (P < 0.001). In group BD a lower heart rate was noticed 120 min postinduction that continued for the first 4 h postoperatively (P < 0.001). Conclusion The addition of dexmedetomidine to bupivacaine in LPB prolongs the time for first analgesic requirement and reduces the total postoperative opioid consumption without major side effects.
  1,964 196 -
Neostigmine versus Fentanyl administration with Ropivacaine by patient-controlled epidural analgesia for the management of labor pain
Ahmed A Khalaf
April-June 2015, 8(2):211-216
DOI:10.4103/1687-7934.156689  
Aim The aim of this study was to evaluate the use of epidural Neostigmine (4 mcg/ml) in patient-controlled epidural anesthesia (PCEA) in the management of labor pain. Patients and methods This randomized double-blind controlled prospective study was designed to compare PCEA Ropivacaine 0.15%+Fentanyl 2 mcg/ml (F group) with PCEA Ropivacaine 0.15%+Neostigmine 4 mcg/ml (N group). The study included 60 ASA I-II laboring mothers. Pain, sedation, nausea, maternal vital signs, motor power, and fetal heart rate were evaluated every 5 min after epidural bolus for the first 30 min, and then every 2 h until delivery. The incidence of shivering was documented. Apgar scores at 1 and 5 min were documented. Results There were no differences in maternal and labor characteristics between groups. Progress of labor and modes of delivery were the same (P = 0.47). Pain scores were significantly reduced 20 min after initiation of analgesia compared with baseline in both groups (P < 0.001) and did not differ between groups at any time during the study (P = 0.21-0.43). Addition of Neostigmine reduced the mean hourly epidural dose of Ropivacaine by 11% compared with the Fentanyl group (P = 0.003). There were no differences in maternal vital signs between groups. The sedation score increased compared with baseline through the first 20 min after initiation of analgesia in both groups (Fentanyl P = 0.043 - Neostigmine P = 0.04). There was no significant difference in sedation scores between groups at any time or compared with baseline (P = 0.23-0.46). The incidence of nausea, shivering, pruritus, and motor block was similar in both groups. Conclusion Neostigmine 4 mcg/ml can be used as a safe adjuvant with Ropivacaine 0.15% by PCEA for the management of labor pain. Its analgesic properties are comparable to that of epidural Fentanyl. It causes temporary sedation within the first 20 min. This sedation is comparable to that of Fentanyl. Epidural low-dose Neostigmine infusion did not increase the risk for nausea during labor.
  1,973 173 -
Oral propranolol premedication and hypotensive anesthesia in shoulder arthroscopic surgery: a randomized controlled double-blind study
Sahar M Talaat, Hanaa A El Gendy
April-June 2015, 8(2):189-193
DOI:10.4103/1687-7934.156677  
Objective The current study tested whether premedication with oral propranolol (10 mg) before hypotensive anesthesia in shoulder arthroscopic surgery could diminish reflex tachycardia following endotracheal intubation and nitroglycerine (NTG) infusion, the amount of NTG used, and the minimum alveolar concentration (MAC) values of inhalational anesthetic used during hypotensive anesthesia for shoulder arthroscopic surgery. Patients and methods A total of 60 American Society of Anesthesiologists (ASA) I patients scheduled for shoulder arthroscopic surgery were included in this randomized controlled double-blinded study on oral propranolol (10 mg) or placebo as a premedication 1 h before the induction of anesthesia. Hemodynamic variables, the amount of NTG, and the MAC values of inhalational anesthetic used were recorded. Visual field visibility by the surgeon using visual analogue score was assessed. Results The heart rate, amount of NTG, and the MAC values of sevoflurane used were highly significantly lower (P < 0.01) in the propranolol group; however, no significant difference (P > 0.05) was found in the visual analogue score of the surgeon between the two groups. No statistically significant complications were observed in either group. Conclusion Premedication with 10 mg of oral propranolol before shoulder arthroscopic surgery was effective in achieving hypotensive anesthesia. It reduced reflex tachycardia, decreased NTG, and sevoflurane consumption without recorded complications.
  1,948 161 -
Comparative study between a sensascope and a flexible fiberoptic in head and neck cancer surgeries with difficult airways
Emad G Saleh, Ekramy M Abdelghafar
April-June 2015, 8(2):173-178
DOI:10.4103/1687-7934.156671  
Background Many devices have been become widely available for managing difficult airways, including rigid fiberscopes and flexible fiberoptic bronchoscopes. The sensascope is different from the flexible fiberoptic in that it can be used with one hand (preferably the right hand) while the left hand is used to insert the laryngoscope as recommended by experienced users. The objective of this study was to evaluate the efficacy of a sensascope in the management of difficult airways in patients scheduled for head and neck cancer surgeries. Patients and methods This study was conducted at the National Cancer Institute on 60 patients. The patients were divided into two equal groups, group F (FOB) and group S (sensascopes), each comprising 30 patients. The following parameters were measured: patient characteristics including age, sex, weight, and ASA classification, airway assessment, hemodynamic changes, number of failures of intubation, duration of intubation, number of attempts, and complications that may occur during manipulation of the airway. Results The success rate of intubation and the number of failures were statistically comparable between the two groups. The mean time taken to complete successful intubation was significantly shorter in group F compared with group S. The number of patients successfully intubated at first attempt was significantly higher in group F than in group S. The number of patients successfully intubated at second attempt was significantly higher in group S than in group F. The number of patients who needed three attempts to be successfully intubated was statistically comparable between the two groups. There was statistically significant increase in pulse rate and mean arterial blood pressure immediately after successful intubation in group S compared with baseline and with group F. There was a significantly higher incidence of staining of the fiberscope blade with blood and transient change in voice in group S compared with group F. Conclusion The sensascope can be a valuable aid in the management of difficult intubation in a spontaneously breathing anesthetized patient, and should be added to backup devices in the event of difficult intubation.
  1,914 186 -
Percutaneous endoscopic gastrostomy under conscious sedation
Mohamed A Lotfy, Mohamad G Ayaad, Rehab S El-Kalla
April-June 2015, 8(2):223-229
DOI:10.4103/1687-7934.156693  
Background Dexmedetomidine may be appropriate for painful procedures as a conscious sedation because of its sedative and analgesic properties. Percutaneous endoscopic gastrostomy (PEG) is mildly painful and thus may need conscious sedation. Hence, in this trial we aimed to evaluate the efficacy of propofol in comparison with dexmedetomidine for conscious sedation during PEG. Patients and methods Forty-four patients between 40 and 60 years old were included in the study. Patients undergoing elective PEG were randomly assigned to either the dexmedetomidine group or the propofol group. All patients received fentanyl 1 μg/kg, intravenous, 10 min before the procedure. An initial loading dose of 1 μg/kg dexmedetomidine was administered intravenously over 10 min to patients in group I (n = 22) before the procedure and as a continuous infusion dose of 0.2 μg/kg/h just before the procedure started. In group II (n = 22) propofol was infused at 4 mg/kg/h for 10 min, followed by infusion of 2 mg/kg/h. The visual analog scale was used to evaluate pain intensity at 5-min intervals during PEG (15-30 min). The Observer's Assessment of Alertness/Sedation was used to evaluate the sedation degree. Hemodynamic and respiratory variables and the Observer's Assessment of Alertness/Sedation scores were regularly recorded during PEG at 5-min intervals (35 min) and to 90 min after. Results Forty-four patients were evaluated. In the dexmedetomidine group, visual analog scale values were significantly lower than those in the propofol group at the 20-35 min assessments (P < 0.05). During sedation, the respiratory rate was significantly lower in the dexmedetomidine group; however, SpO 2 was significantly higher than that in the propofol group (P < 0.05). Conclusion Dexmedetomidine provides more efficient hemodynamic stability, higher Observer's Assessment of Alertness/Sedation, higher satisfaction scores, and lower visual analog scale scores. According to our results we believe that dexmedetomidine can be safely used as a sedoanalgesic agent in PEG.
  1,922 151 -
Continuous femoral nerve against psoas compartment block for analgesia in total knee arthroplasty
Amr M.A. Sayed, Kareem Yousef
April-June 2015, 8(2):200-205
DOI:10.4103/1687-7934.156684  
Background Total knee arthroplasty (TKA) is a surgical procedure that often demands potent analgesia. Anesthetists commonly rely on continuous epidural analgesia or psoas compartment block. After the American Society of Regional Anesthesia (ASRA) recent recommendation against the implication of deep regional blocks in the setting of perioperative anticoagulation, femoral nerve block might be a suitable alternative technique. Its effectiveness in TKA is a questionable issue. Our study is hypothesizing that continuous femoral block could provide an analgesic profile similar to continuous psoas compartment block. Patients and method Sixty patients undergoing TKA were randomly assigned into two groups to receive continuous femoral block or continuous psoas compartment block using ultrasound and nerve stimulation guidance. A bolus of 20 ml 0.25% levobupivacaine was injected through a perineural catheter in each group before surgery followed by a 5 ml bolus of 0.125%, and then 5 ml/h infusion at completion of surgery. A bolus of 5 ml 0.125% levobupivacaine was injected when numerical rating scale (NRS) was at least 5. In the first 24 h postoperatively, the median value and the interquartile range of the NRS at 1, 6, 12, and 24 h and after the first physiotherapy session were recorded as the primary end point. The total levobupivacaine and morphine consumption during the same 24-h period were the secondary end points, apart from patient's satisfaction with analgesia during hospitalization. Results The median and interquartile range of the NRS were 4.00 and 2.00 in the first hour, 4.00 and 1.5 in the sixth hour, 4.00 and 1.5 in the 12 th hour, 4.00 and 2.00 in the 24 th hour, and 4.00 and 2.00 after the first physiotherapy session, respectively, in the Fm group, and 3.00 and 3.00 in the first hour, 4.00 and 2.00 in the sixth hour, 4.00 and 1.5 in the 12 th hour, 3.00 and 2.5 in the 24 th hour, and 3.00 and 2.00 after the first physiotherapy session, respectively, in the Ps group. The total mean levobupivacaine and morphine consumption in the Fm and the Ps groups were 218. ± 7.89 vs. 216.6 ± 8.42 and 15.5 ± 4.01 vs. 13.50 ± 4.38, respectively, with no statistically significant difference between both the groups. The catheter insertion time was significantly shorter in the Fm group (8.53 ± 3.1 min) compared with (10.5 ± 3.2 min) the Ps group (P = 0.021). Conclusion Continuous femoral nerve block provides a suitable alternative analgesic technique in patients undergoing TKA when psoas compartment block is unwarranted in the setting of perioperative anticoagulation as recommended by ASRA.
  1,882 149 -
Post-thoracotomy pain: three different analgesic modalities
Ola T Abd el-Dayem, Magdy M Atallah, Mohamed M Abdel Fattah
April-June 2015, 8(2):259-264
DOI:10.4103/1687-7934.156712  
Background Pain following chest surgery is often underestimated and under treated which may lead to pulmonary dysfunction, prolonged stay, higher cost, potential development of chronic pain, and decreased patient satisfaction. Purpose The aim of this article is to compare thoracic paravertebral versus epidural thoracic block in the control of post-thoracotomy pain. Patients and methods Ninety patients subjected to thoracic surgery were enrolled in this study. They were randomly divided into three equal groups (30 patients each). In the control group (C group) we used intravenous analgesia (fentanyl). In both the thoracic epidural group (TEP group) and the thoracic paravertebral group (TPV group), bupivacaine (0.25%) in a dose of 0.5 mg/kg supplemented with fentanyl 1 μg/kg was used for perioperative analgesia. Assessment included the visual analogue scale for pain, number of patients who needed postoperative analgesia, and the total analgesic dose. Also pulmonary functions represented by forced vital capacity and forced expiratory volume in 1 s were recorded as baseline and at 24 and 48 h postoperatively. Results Visual analogue scale for pain was significantly lower in the TPV group compared with the other two groups, and at the same time it was lower in the TEP group compared with the control group. TEP analgesia was associated with significant hypotension compared with the other two groups. The number of patients who needed postoperative analgesia was lower in the TPV group than the other groups. Respiratory functions represented by forced vital capacity and forced expiratory volume in 1 s were better in TEP and TPV groups in comparison with the control group. Conclusion Thoracic paravertebral block (TPV) provides a higher quality control of postoperative pain than thoracic epidural (TEP) and systemic opioids.
  1,774 177 -
Effects of adding low-dose clonidine to a small intrathecal dose of either bupivacaine or ropivacaine on the characteristics of spinal block in elderly patients undergoing primary hip arthroplasty
Amira F Hefni
April-June 2015, 8(2):206-210
DOI:10.4103/1687-7934.156687  
Background The use of an adjuvant with small doses of local anesthetics is a preferred technique for spinal anesthesia in elderly patients. In our study, we compared the characteristics of spinal block after adding 15 µg clonidine to either 8 mg bupivacaine or 12 mg ropivacaine with regard to the anesthetic efficacy and the incidence of side effects in geriatric patients undergoing lower limb orthopedic surgery. Patients and methods In a prospective, double-blind randomized study, 60 patients of at least 60 years old undergoing primary hip arthroplasty under spinal anesthesia were randomly allocated into one of the two groups. Group BC received 8 mg bupivacaine with 15 µg of clonidine and Group RC received 12 mg of ropivacaine with 15 µg of clonidine. Onset times to reach the peak sensory and motor levels and the duration of sensory and motor blocks were recorded. Hemodynamic changes and side effects including the level of sedation were also recorded. Results The highest levels of sensory blocks were similar (T5) in both groups, but the onset time of sensory block was significantly shorter in Group BC (2.54 ± 0.66 min) than in Group RC (3.19 ± 0.70) (P < 0.01).The onset time of motor block (4.80 ± 1.46 min in the BC Group and 4.95 ± 1.04 min in the RC Group), the time to the maximum motor block (11 ± 2.1 min in the BC Group and 11.5 ± 3.2 min in the RC Group),the mean durations of both the sensory block (149 ± 20 min in the BC Group and 148 ± 15 min in the RC Group) and the motor block (165 ± 25 min in the BC Group 164 and ± 20 min in the RC Group) were all comparable between both groups. Differences in the hemodynamic parameters between both groups were insignificant. Conclusion Adding low-dose clonidine (15 µg) to an intrathecal small dose of either bupivacaine (8 mg) or ropivacaine (12 mg) made the difference between both local anesthetics with regard to the motor block and hemodynamic changes insignificant, but did not change the significant difference between them in the onset of sensory block. Either the bupivacaine-clonidine or the ropivacaine-clonidine combination provides sufficient motor and sensory block in elderly patients undergoing major orthopedic surgery without inducing hemodynamic instability.
  1,666 147 -
Does the self-pressurizing Air Q produce less postoperative sore throat compared with the classic laryngeal mask airway? A randomized controlled double-blind study
Mohamed I.S. El-Ahl
April-June 2015, 8(2):244-246
DOI:10.4103/1687-7934.156700  
Background The aim of the study was to evaluate the risk for postoperative sore throat (POST) using the self-pressurizing Air Q compared with that using classic laryngeal mask airway (LMA). Patients and methods A total of 150 patients were included in this double-blind prospective study. After induction of general anesthesia, the airway was maintained with an Air Q device (in group Q, 75 patients) and with a classic LMA (in group C, 75 patients). The POST was evaluated and graded (on the basis of its severity) within 20 min in the recovery room and 24 h after surgery. Results The incidence of POST and its severity were comparable in both groups. Conclusion Despite the self-pressurizing cuff of Air Q, there was no reduction in the POST incidence or severity compared with that using classic LMA.
  1,641 121 -
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