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   2015| July-September  | Volume 8 | Issue 3  
    Online since July 29, 2015

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A comparative study of dexmedetomidine, magnesium sulphate, or glyceryl trinitrate in deliberate hypotension during functional endoscopic sinus surgery
Omyma S M Khalifa, Osama G Awad
July-September 2015, 8(3):320-326
Context Induced hypotension to minimize bleeding during functional endoscopic sinus surgery (FESS) is of vital importance to the surgeon and anesthetist to decrease the risk of complications as well as procedural failure. Aim This study was designed to compare the efficacy of dexmedetomidine, magnesium sulfate, or glyceryl trinitrate in inducing deliberate hypotension during FESS and their effect on postoperative recovery, discharge, and postoperative analgesic requirement. Settings and design This was a randomized prospective single-blind study. Patients and methods Sixty patients of ASA physical status I or II scheduled for FESS were equally randomly assigned into three groups. The glyceryl trinitrate group (the G group) received glyceryl trinitrate infusion of 2-10 μg/kg/min. The dexmedetomidine group (the DEX group) received dexmedetomidine bolus of 1 μg/kg, followed by 0.2-0.7 μg/kg/h infusion for maintenance, and the magnesium sulfate group (the M group) received a bolus of 50 mg/kg magnesium sulfate, followed by infusion of 15 mg/kg/h for maintenance. The target mean arterial pressure was 55-65 mmHg. Hemodynamic parameters, blood lose, surgical field quality, intraoperative atropine, ephedrine or fentanyl use, emergence time, time to achieve an Aldrete score of 9 or greater, sedation score, time of discharge from postanesthesia care unit, and time to first analgesic request were recorded. Results The studied drugs achieved the target mean arterial pressure (55-65 mmHg) with superior hemodynamic stability in the DEX group. Intraoperative blood lose and quality of the surgical field were comparable. Both dexmedetomidine and magnesium sulfate offered the advantage of inherent analgesic and sedative effect, but at the expense of longer recovery of anesthesia and discharge from postanesthesia care unit. Conclusion Dexmedetomidine, magnesium sulfate, or glyceryl trinitrate induced deliberate hypotension, with superior hemodynamic stability in dexmedetomidine. Analgesic and sedative effects were obtained with dexmedetomidine and magnesium sulfate, but with longer recovery and discharge times.
  4 3,214 362
Safety and efficacy of intrathecal adjuvants for cesarean section: bupivacaine, sufentanil, or dexmedetomidine
Ibrahim A Nasr, Sherif A Elokda
July-September 2015, 8(3):388-395
Context Coadministration of adjuvants with bupivacaine for spinal anesthesia is advocated to reduce its dose and improve the quality of intraoperative and postoperative analgesia with the least number of side effects. Aim The aim of the study was to compare the efficacy and safety of three intrathecal regimens for cesarean section. Patients and methods Ninety patients of ASA grade I or II who were scheduled for cesarean section under spinal anesthesia were randomly allocated into three groups of 30 patients each. Group B was injected with 15 mg of 0.5% hyperbaric bupivacaine, group F was injected with 10 mg of 0.5% hyperbaric bupivacaine +10 mg of sufentanil, and group D was injected with 10 mg of hyperbaric bupivacaine +10 mg of dexmedetomidine. Study parameters were as follows: mean arterial blood pressure, heart rate, respiratory rate, oxygen saturation (SpO 2 ), sedation scores, side effects (such as hypotension, bradycardia, nausea/vomiting, shivering, pruritus, respiratory depression), neonatal outcome, onset and duration of sensory and motor block, intraoperative and postoperative analgesic requirements, and duration of complete and effective analgesia. Results There were no significant differences regarding mean arterial blood pressure, heart rate, respiratory rate, SpO 2 , and neonatal outcome among the study groups. Sedation scores were higher in group D compared with groups B and S. Onset of motor block was comparable among the three groups, whereas onset of sensory block, time to two-segment regression and regression time to sensory S1, and motor recovery time were longer in groups D and S compared with group B. Intraoperative analgesic requirements showed no significance among the three groups, whereas duration of complete and effective analgesia was longer in groups S and D compared with group B. Further, postoperative 24 h analgesic requirements were higher in group B compared with groups S and D. Side effects such as hypotension, bradycardia, shivering, and respiratory depression were comparable among the study groups, whereas nausea/vomiting and pruritus were higher in group S compared with groups B and D. Conclusion Addition of sufentanil or dexmedetomidine to hyperbaric bupivacaine for intrathecal block prolongs the duration of sensory and motor block and reduces postoperative analgesic requirements. Sufentanil has a higher incidence of nausea/vomiting and pruritus, whereas dexmedetomidine has better analgesic effects and sedation without respiratory depression.
  4 3,538 382
Tracheal intubation with the aid of fiberoptic bronchoscopy with or without the C-MAC device in patients with a suspected difficult airway undergoing elective uvulopalatopharyngoplasty
Khaled M Maghawry, Ayman A Rayan
July-September 2015, 8(3):308-315
Background Endotracheal intubation is considered as the definitive method of airway management. Difficulty encountered during direct laryngoscopy for the intubation process is one aspect of the overall problems in airway management. Fiberoptic bronchoscopy (FOB) represents a significant advancement in the management of patients with a difficult airway. C-MAC videolaryngoscopes present a new approach for the management of difficult laryngoscopy. Patients and methods Sixty patients, of both sexes, aged 20-50 years, ASA I-II, undergoing an elective uvulopalatopharyngoplasty surgery were included. Patients were allocated randomly to be intubated using FOB (F group) or FOB plus C-MAC videolaryngoscopy (F-CMAC group). Collected data included grades of the Cormack-Lehane laryngeal view, success or failure of the technique, the number of attempts, the duration of the successful attempt, and hemodynamic measurements throughout the intubation procedure. Complications (such as oxygen desaturation, patient distress, soft tissue damage, gagging/vomiting, bradycardia and hypotension, laryngospasm, and bronchospasm) were recorded. Results There was a significant decrease in the duration of the successful attempt, the number of intubation trials, and Cormack-Lehane grades regarding the laryngeal view as well as a decrease in the number of patients who needed facilitating techniques in group F-CMAC compared with group F. No significant difference was found on comparing the heart rate, the mean arterial pressure, and the incidence of complications during intubation between the two groups. Conclusion The C-MAC videolaryngoscope with fiberoptic bronchoscopy allows a significantly faster intubation time, with a decrease in the duration of the successful attempt, fewer intubation trials, and a better grade of laryngeal views assessed by Cormack-Lehane grades, with a decrease in the number of patients who needed facilitating techniques and a comparable incidence of complications during intubation compared with fiberoptic alone for tracheal intubation in patients with a suspected difficult airway undergoing elective uvulopalatopharyngoplasty.
  3 2,870 261
Bilateral single bupivacaine injection ultrasound-guided paravertebral block facilitates early extubation and reduces perioperative opioids requirements in on-pump pediatric cardiac surgery
Hanaa M El Bendary, Ibrahim I Abd El Baser
July-September 2015, 8(3):287-293
Background Paravertebral block (PVB) is a simple and easy technique with low incidence of complications and contraindications. The aim of the current study is to test the hypothesis that bilateral single-dose PVB may facilitate early extubation and reduce perioperative opioid requirements in pediatric patients submitted for open heart surgery by median sternotomy. Patients and methods A total of 70 pediatric patients submitted for open heart surgery by median sternotomy were randomized into two groups. The control group (n = 35) received 0.4 ml/kg normal saline with fentanyl 2 mg/ml, whereas for the bupivacaine group (n = 35) 0.4 ml/kg bupivacaine 0.25% with fentanyl 2 mg/ml was injected down each side of the paravertebral space. Heart rate, mean arterial blood pressure, perioperative opioid requirements, operating room extubation, time to extubation, postextubation PaO 2 , PaCO 2 , postoperative objective pain discomfort score, ICU length of stay, and postoperative complications were recorded. Results Heart rate and invasive mean arterial blood pressure were significantly lower in the bupivacaine group compared with the control group, after skin incision, after sternotomy, 15 min after cardiopulmonary bypass, and after the closure of sternum. Perioperative opioid requirements were significantly lower in the bupivacaine group than in the control group. The number of extubations in operating room was significantly higher, and time to extubation was significantly lower in the bupivacaine group compared with the control group. Postoperative pain score was significantly lower at 1, 2, and 6 h, and ICU length of stay was significantly shorter in the bupivacaine group than in the control group. Conclusion Bilateral single bupivacaine dose PVB is a safe and effective technique that facilitates early extubation and provides good intraoperative and postoperative analgesia that results in reduced perioperative opioid requirements in pediatric patients submitted for open heart surgery by median sternotomy.
  2 2,684 313
Evaluation and comparison of the three scoring systems at 24 and 48 h of admission for prediction of mortality in an Indian ICU: a prospective cohort study
Mohd Saif Khan, Pandey Maitree, Agarwala Radhika
July-September 2015, 8(3):294-300
Introduction Predictive accuracy of severity scoring systems in Indian ICUs does not fit well owing to differences in case mix from the west. We hypothesized that 24 h is too early to predict the outcome and that the predictive accuracy of these scores might be better at 48 h of ICU admission. Objective The aim of this study was to evaluate and compare Acute Physiology and Chronic Health Evaluation (APACHE) II, Simplified Acute Physiology (SAPS) II, and Sequential Organ Failure Assessment (SOFA) as a predictor of outcome in critically ill patients at 24 and at 48 h in a tertiary care hospital ICU. Patients and methods A prospective cohort study was conducted on 169 patients over 2 years at a single medical surgical ICU. Eighty-five critically ill patients were included. For each patient, APACHE II, SAPS II, and SOFA scores were calculated at two time frames (first at 24 and then at 48 h) after ICU admission. The accuracies and comparisons of outcome prediction by the three scores were assessed with standardized mortality ratio and area under the receiver operating characteristic (AUROC) curves. Results All scoring systems (except SOFA) underestimated the deaths (standardized mortality ratio>1). All scoring systems displayed larger AUROC curves at 48 h than those at 24 h. APACHE II 48 showed the largest AUROC of 0.933. Conclusion All scores performed better when calculated at 48 h rather than at 24 h. Overall, APACHE II 48 is the best predictor of 28-day mortality in critically ill patients. A worsening APACHE II score at 48 h after ICU admission may identify the patients at high risk of mortality.
  2 3,629 365
Intravenous esmolol versus ropivacaine abdominal wound infiltration for postoperative analgesia after inguinal herniotomy: a randomized controlled trial
Manal M Kamal, Mahmoud Hassan
July-September 2015, 8(3):360-363
Objectives This study was designed as a randomized comparison of postoperative pain after inguinal herniotomy in patients treated with intravenous esmolol and others treated with ropivacaine abdominal wound infiltration. Patients and methods Sixty American Society of Anesthesiologists physical status I-II patients undergoing herniotomy and anesthetized with isoflurane were randomized into one of two groups. Group R received 20 ml of ropivacaine 0.75% in 20 ml of saline 0.9% preincisional wound infiltration and group E patients received a bolus of esmolol 0.5 mg/kg intravenous at induction followed by an infusion of 5-15 mg/kg/min. After surgery, a bolus of pethidine was given according to visual analogue scale for pain intensity. Results Patients in group E had lower pain scores than patients in group R. Median consumption of pethidine was higher in group R than in group E. Conclusion Intravenous esmolol reduces pethidine consumption and provides more analgesia compared with preincisional ropivacaine infiltration in patients undergoing herniotomy.
  2 1,849 217
Norepinephrine versus ephedrine for the prevention of spinal anesthesia-induced hypotension in coronary artery disease patients undergoing knee arthroscopy
Mohamed M El Shafei, Hanaa A El Gendy, Dalia M El Fawy
July-September 2015, 8(3):424-428
Background Spinal anesthesia, a popular technique used for lower limb surgery in coronary artery disease patients, could be associated with hypotension, which could be managed with colloids, vasopressor, ephedrine, or norepinephrine (NE). Aim The aim of this study was to assess the efficacy and safety of bolus administration of NE versus ephedrine for the maintenance of systolic blood pressure during spinal anesthesia in coronary artery disease patients undergoing knee arthroscopy. Patients and methods A randomized, controlled, double-blinded study was carried out on 100 ASA II or III coronary artery disease patients undergoing knee arthroscopy. The patients were divided into two groups of 50 patients each: the ephedrine group (group EPH) and the norepinephrine group (group NE). When hypotension occurred, group EPH received 5 mg of ephedrine and group NE received 5 μg of NE. Systolic blood pressure and heart rate were recorded at 0, 5, 10, 15, 30, and 60 min, and side effects of both drugs were also recorded. Results Efficacy was found in 20 (40%) patients of group EPH and in 40 (80%) patients of group NE. The results were highly significant (P < 0.0001). Tachycardia was significantly higher (P < 0.0001) in group EPH. The incidence of hypotension, hypertension, and bradycardia was not significantly different between the two groups. Conclusion NE is more effective compared with ephedrine in the maintenance of systolic blood pressure with reduction in heart rate, which is useful in coronary artery disease patients undergoing knee arthroscopy under spinal anesthesia in whom tachycardia is undesirable.
  2 4,267 479
Anesthesia for herniotomy in Schwartz-Jampel syndrome
Bahaa El-din Ewees, Dalia M El Fawy
July-September 2015, 8(3):455-457
Patients with neuromuscular disorders may develop specific anaesthetic complications; these include pulmonary insufficiency, cardiac arrhythmias, thermoregulatory instability and technical difficulties with tracheal intubation. We describe the anaesthetic management of a child with a rare autosomal recessive disorder, Schwartz-Jampel syndrome, characterised by various musculoskeletal disorders and a potential for thermoregulatory dysfunction.
  1 2,033 178
Paravertebral block against intercostal nerve block for postoperative pain relief in open renal surgery: a randomized controlled trial
Hazem El Sayed Moawad, Diaa-Eldin Taha
July-September 2015, 8(3):413-419
Background Renal surgeries are usually associated with significant postoperative pain. Ineffective postoperative pain management may result in clinical and psychological changes that increase morbidity and mortality. In the current study, intercostal nerve block (ICB) and paravertebral block (PVB) were compared with regard to their analgesic efficacy, hemodynamic stability, blood gasometric profile, and postoperative complication. Patients and methods After local Ethics Committee approval, 100 patients, aged between 20 and 60 years, American Society of Anesthesiologists (ASA) physical status I or II, scheduled for elective open renal surgery were enrolled in this study. Patients were randomized into two groups to receive either ICB (ICB group) with bupivacaine (0.5%; n = 50) or PVB (PVB group) with bupivacaine (0.5%; n = 50). The postoperative visual analogue scale score for pain, patients' satisfaction score, and the need for analgesia were evaluated. Results The mean postoperative visual analogue scale scores demonstrated significant decrease in the PVB group compared with the ICB group during quite and motion states (P < 0.05). Patient satisfaction was greater in the PVB group than in the ICB group (P < 0.0001). The mean time elapsed before the first request for analgesia in the PVB group was 17.37 ΁ 2.70 h, whereas patients in the ICB group started to request for analgesia after 8.96 ΁ 1.88 h (P < 0.0001). The total analgesic consumption (meperidine) at 24 h postoperatively showed a significant decrease in the PVB group compared with the ICB group (P < 0.05). Conclusion PVB and ICB are safe analgesic techniques, and they decrease the postoperative pain score and analgesic requirements after open renal surgery. PVB provides more patient satisfaction and a longer duration of analgesia postoperatively.
  1 3,825 280
A comparative study between the addition of MgSO 4 against dexamethasone to bupivacaine in the prolongation of ultrasound-guided interscalene nerve block for shoulder arthroscopy
Niven G Fahmy, Dalia M Ahmed, Ghada M Sameer
July-September 2015, 8(3):402-406
Background Local anesthetic adjuvants have been studied previously to prolong the duration of analgesia after peripheral nerve block and thus reduce postoperative adverse reactions associated with excessive systemic analgesic intake. The aim of this study was to compare the addition of MgSO 4 against dexamethasone to bupivacaine in the prolongation of ultrasound-guided interscalene brachial plexus block (ISPB) for shoulder arthroscopy. Patients and methods A total of 63 patients, ASA I and II grades, undergoing arthroscopic rotator cuff repair were enrolled in this study. The ISPB was performed with 0.5% bupivacaine 20 ml plus either 5 ml of 10% MgSO 4 (group M) or 5 ml of normal saline containing dexamethasone 8 mg (group D) or 5 ml of 0.9% NaCl (group C). The following data were collected: the onset of sensory block, the analgesic duration (time of the first call for analgesics), the occurrence of satisfactory motor block, the motor block duration, and postoperative analgesic consumption. Results The magnesium sulfate group and the dexamethasone group patients showed significantly higher analgesic duration values and significantly lower total meperidine consumption values than control group patients. Conclusion The addition of either magnesium sulfate or dexamethasone to bupivacaine in ISPB prolongs the analgesic duration significantly and also decreases the postoperative analgesic consumption.
  1 2,511 326
Nebulized versus intravenous fentanyl for postoperative analgesia after unilateral arthroscopic anterior cruciate ligament reconstruction surgery: a prospective, randomized, comparative trial
Ahmed M Abd El-Hamid, Mohamed AI Elrabeie, Ehab E Afifi
July-September 2015, 8(3):316-319
Objectives This study aimed to compare the effect of nebulized fentanyl with intravenous fentanyl for postoperative analgesia after unilateral arthroscopic anterior cruciate ligament reconstruction surgery. Patients and methods A total of 87 patients scheduled for unilateral arthroscopic anterior cruciate ligament reconstruction surgery under regional anesthesia were enrolled in the study and were randomly allocated into two groups. Group IV included 42 patients who received 2 μg/kg of fentanyl intravenously, and Group N included 45 patients who received 4 μg/kg of fentanyl nebulization using a standard ventimask. Both groups received the analgesic drug through either intravenously or nebulization route whenever the patient reported pain for the first time in the postanesthesia care unit that was of a score greater than 4 on the visual analog scale. Observations were made for the onset and duration of analgesia, number of patients who were not relieved of pain even 15 min after analgesia administration, level of sedation using the Ramsay sedation scale, and side effects. Results Both groups were similar in terms of demographic characteristics and duration of surgery. The onset of analgesia was significantly delayed in group N in comparison with group IV, whereas the duration of analgesia was significantly longer in group N in comparison with group IV. In group IV, the Ramsay sedation score was the maximum at 5 min. In group N, there was a slow rise in the sedation score, but it was always less than that in group IV. Side effects in group N were less compared with group IV, and the number of patients who developed bradycardia was significantly higher in group IV. Conclusion This study showed that nebulization with fentanyl is a good alternative to intravenous fentanyl for adequate postoperative pain relief with fewer side effects.
  1 2,127 221
The emergence profile of propofol sedation compared with dexmedetomidine injection during ultrasound-guided oocyte pickup for in-vitro fertilization
Mayar H Elsersi, Wessam M Abuelghar, Ahmed K Makled
July-September 2015, 8(3):327-333
Background The purpose of this study was to assess the quality, the recovery, and side effects of propofol sedation compared with dexmedetomidine in a very short minimally invasive procedure such as ultrasound-guided oocyte pickup for in-vitro fertilization. Patients and methods Sixty-two female patients undergoing 'ultrasound-guided oocyte pickup' were randomly enrolled in the study, conducted in a specialized center (Elite Fertility Center, Cairo, Egypt). The emergence profile of sedation with propofol+fentanyl versus dexmedetomidine +fentanyl was compared. The sedation level was assessed and titrated to an Observer's Assessment of Alertness/Sedation (OAAS) score of 1-2 (responds only after mild prodding or no response to prodding or shaking). Recovery was assessed objectively by OAAS and subjectively by visual analog scale (VAS). Results There is no significant difference in intraoperative parameters regarding the heart rate, the mean arterial blood pressure, the respiratory rate, and SpaO 2 between group D (dexmedetomidine) and group P (propofol). Yet the induction time to the desired level of sedation was significantly shorter in group P compared with group D. Most of the group D patients returned postoperatively to an OAAS score of 5 earlier than group P patients. Group D showed a significantly lower VAS as compared with group P at 1 and 2 h postoperatively, whereas there was no significant difference in the VAS between the two groups at 3 h postoperatively. Conclusion Both propofol and dexmedetomidine are useful and safe for short-period procedural sedation; yet dexmedetomidine has a more rapid induction time of sedation than propofol, better analgesic effect with similar hemodynamic effects, better preservation of respiratory function, and rapid recovery. Thus, dexmedetomidine is a good alternative for short-period procedural sedation such as in ultrasound-guided oocyte pickup.
  1 2,035 163
Efficacy of systemic lidocaine infusion compared with systemic ketorolac infusion in improvement of recovery after laparoscopic bariatric surgery
Hesham F Soliman, Ahmed R Gharbiya
July-September 2015, 8(3):334-340
Background Obese patients are at a high risk for both aspiration and acute airway obstruction after tracheal extubation. Thus, rapid recovery is desirable to ensure early efficient coughing and to decrease the rate of postoperative respiratory complications. Patients and methods Sixty patients who were assigned for elective laparoscopic bariatric surgery were divided into three equal groups. Lidocaine group, in which the patients received intravenous (i.v.) lidocaine (1.5 mg/kg bolus, followed by a 2 mg/kg/h infusion until the end of surgery); ketorolac group, in which the patients received i.v. ketorolac (30 mg i.v. as a bolus over 15-30 s, followed by a continuous i.v. infusion of ketorolac 0.5 mg/kg/h until the end of surgery); and the control group, in which participants received an i.v. infusion (normal saline) of the same volume as the drug groups. Immediate recovery from anesthesia was assessed on the basis of the time to eye opening, extubation, and orientation from the time of discontinuation of inhalation agents and reversal of neuromuscular block. Postoperative pain was assessed using a pain numeric scale, and postoperative nausea and vomiting were documented. Results No significant difference was found between the groups studied in terms of patient characteristics, type, and duration surgery, but there was a significant decrease in the intraoperative bispectral index value of the control group compared with the lidocaine and ketorolac groups (61.35 ± 4.54 vs. 63.35 ± 4.0 and 66.60 ± 7.19, respectively). The lidocaine group had a better postoperative mobility score, less nausea and vomiting, good incentive spirometry, greater patient satisfaction, low total fentanyl dose, and low postoperative pain at all the time points studied. The difference was statistically significant. Conclusion Lidocaine i.v. infusion was found to be an effective and safe adjuvant for the rapid recovery of obese patients following bariatric surgery. Ketorolac led to better outcome than that in the control group, but was less effective compared with lidocaine.
  1 2,507 227
Bispectral index-guided induction of anesthesia by ketofol infusion provides the same cardiovascular stability like that of etomidate infusion
Hesham F Soliman
July-September 2015, 8(3):341-348
Introduction Various techniques have been tried to maintain cardiovascular stability with anesthesia induction. This study compares the cardiovascular effects of propofol-ketamine mixture versus etomidate during the induction of anesthesia. Materials and methods A total of 50 patients undergoing elective surgeries were randomly assigned according to the induction agents into two groups: group K (n = 25) received propofol-ketamine mixture (ketofol), and group E (n = 25) received etomidate, both by bispectral index (BIS) guidance. Mean arterial pressure (MAP), cardiac output (CO), heart rate, and systemic vascular resistance (SVR) were measured 6 min preintubation and up to 16 min postintubation. P-value less than 0.05 was considered statistically significant. Results MAP and SVR were significantly increased (P < 0.001) in both groups immediately and up to 4 min postintubation compared with baseline, whereas CO and stroke volume (SV) remain unchanged. Meanwhile, there was no significant difference between both groups with regard to CO, MAP, SVR, heart rate, and BIS at each time intervals. Conclusion BIS-guided/induction by propofol-ketamine mixture is effective as etomidate in maintaining cardiac stability; however, both techniques did not prevent any hemodynamic changes as hypotension and hypertension preintubation and postintubation, respectively.
  1 2,890 271
Anticipated difficult intubation due to intraoral lipomatous polyp
Neeraj Kumar, Gautam Bhardwaj, Rakesh K Singh
July-September 2015, 8(3):450-452
Anticipated difficult intubation if not planned meticulously can be challenging to a anesthesiologist. We describe a successful management of a case of anticipated difficult intubation due to a rare intra oral lipomatous polyp arising from the posterior pharyngeal wall. We use levering McCoy laryngoscope for intuabting trachea because we failed to intubate with conventional MacIntosh laryngoscope in first attempt and for fear of complete airway obstruction dexmedetomidine infusion was used for sedation. In our case we relied on radiological imaging for assessment of difficult airways. So managing each case is highly unique, individualized and no technique is obsolete in managing difficult airways even with a unavailability of modern aids.
  - 2,047 162
Acute airway obstructions after heparin-free hemodialysis: management outside comfort zone
Tushar Kumar
July-September 2015, 8(3):453-454
Acute airway obstruction can be caused by many conditions. Here is a case of severe spasm of upper airway leading to acute airway obstruction and its anaesthetic management in the emergency setting.
  - 1,871 133
Postoperative complete amaurosis fugax in severe pre-eclampsia: a case report
Mohit Somani, Prateek Sharma, Vijay Mathur, Durga Jethava, Sudhir Sachdev
July-September 2015, 8(3):458-460
Introduction One of the complications of severe preeclampsia is cortical blindness which could be reversible or permanent. It is the most disturbing symptom of reversible post encephalopathy syndrome in preeclampsia and eclampsia. Case Discription An 18-year-old primigravida was admitted with term pregnancy in the obstetrics department, having high arterial blood pressure with pitting edema with proteinuria, hematuria, impaired renal functions, and elevated serum transaminases. She was treated with 250 mg of methyldopa three times a day, but as hypertension persisted, the patient was admitted to ICU and was given labetolol 200 mg three times a day orally, along with oxygen by mask. Sonographic examination showed cord around the neck with an arterial blood pressure of 160/110 mmHg. Cesarean section was planned. The patient was given 500 mg of methyldopa and labetalol 200 mg orally in the morning, few hours before being taken to the operating room. Segmental epidural block with 12 ml of 0.5% ropivacaine was performed, with epidural catheter left in situ in the L2-3 space and top up dose of same 6ml drug is given later on. Lower segment cesarean section was performed and the baby was delivered with an APGAR score of 8. On the second postoperative day, she developed headache, giddiness, and blurred vision, which became progressive. Computed tomography and MRI reports confirmed posterior reversible encephalopathy syndrome. She was treated accordingly and early management helped her recover completely. Conclusion This case report emphasizes the need for early diagnosis and prompt treatment of PRES to avert short-term and long-term neurological sequelae. Early treatment usually results in complete reversal of deficits over few days to few weeks.
  - 1,859 128
Significance of preoperative endotracheal tube check
Ramaiah M Mohan Kumar, Nataraj M Srinivasan
July-September 2015, 8(3):461-462
  - 1,386 117
A comparison of different doses of spinal levobupivacaine combined with S-ketamine and clonidine for elective cesarean section: a prospective, randomized, and double-blind study
Ahmed M Abd El-Hamid, Mohamed A.I. Elrabeie, Ehab E Afifi, Mohamed H Abdel Fattah
July-September 2015, 8(3):420-423
Objectives This study aimed to investigate the block characteristics and adverse effects of using different doses of spinal plain levobupivacaine combined with S-ketamine and clonidine during cesarean section. Patients and methods This prospective, randomized, controlled, double-blind clinical trial was conducted on 120 female patients scheduled for elective cesarean section. Patients were randomly assigned into three equal groups: group I received 10 mg of levobupivacaine 0.5% along with 12.5 mg of S-ketamine and 25 μg of clonidine intrathecally; group II received 7.5 mg of levobupivacaine 0.5% along with 12.5 mg of S-ketamine and 25 μg of clonidine intrathecally; and group III received 5 mg of levobupivacaine 0.5% intrathecally along with 12.5 mg S-ketamine and 25 μg clonidine. Hemodynamic parameters, the onset of the sensory block, the level of the sensory blockade, duration of the sensory block, the motor blockade and duration of the motor blockade, the quality of intraoperative analgesia, and the occurrence of side effects were recorded. Results Comparison of onset and duration of sensory block did not reveal any significant differences among the groups. Duration of motor blockade and the time to first analgesic request was significantly longer in group I than in groups II and III, and it was significantly longer in group II than in group III. The incidence of intraoperative nausea, vomiting, pruritus, and shivering was comparable in all groups. As regards hypotension, there was a significant reduction in its incidence in group III compared with groups I and II. As regards bradycardia, there was a significant reduction in its incidence with decreasing dose of levobupivacaine (group III showed the least incidence). Conclusion Spinal anesthesia using small doses of levobupivacaine with a combination of S-ketamine and clonidine was effective in cesarean section both intraoperatively and postoperatively with less adverse effects.
  - 1,875 147
Perioperative acupuncture in asthma patients under general anesthesia
Maha M.I. Youssef, Amani Abou Zeid, Laila Ahmed Abou Ismail
July-September 2015, 8(3):429-436
Background and objective The incidence of asthma has increased in the last few years. Acupuncture was found to have a bronchodilating effect in asthmatic patients. The aim of this study was to evaluate the perioperative bronchodilator effect of acupuncture in comparison with regular inhalation asthma treatment. Patients and methods The study was conducted at Kasr AL Ainy Teaching Hospital. Forty patients of both sexes, aged 20-40 years, classified as ASA 2, with mild partially controlled asthma [determined from forced expiratory volume in the first second (FEV 1 ), forced expiratory volume/forced vital capacity (FEV 1 /FVC), peak expiratory flow rate (PEFR) ranging from 70 to 79%] were allocated to two groups. Group A (n = 20) received preoperative acupuncture for 30 min, and if there was clinical improvement on the basis of spirometer tests patients were allowed to proceed with their operation, followed by intraoperative acupuncture until fully awake. Group B (n = 20) received a 30 min preoperative treatment with 10 drops of nebulized salbutamol (1 mg, 1 ml) and 500 mg ipratropium bromide diluted in 2 ml normal saline inhaled through a nebulizer. FEV 1 , FEV 1 /FVC, PEFR, SPO 2 , and hemodynamic data were collected before treatment T(0) and 30 min after the end of treatment T(30). The onset of bronchodilation as marked by the disappearance of wheezing and improvement in patient symptomatology, the success rate of treatment (improved pulmonary function tests >12%, disappearance of wheezing) recorded at T(30), intraoperative hemodynamic changes, peripheral oxygen saturation, end tidal CO 2 levels, peak airway pressure, and any complications related to the different treatments used were also recorded. Results Wheezing disappeared after 9.5 ± 1.67 min, recorded from T(0), in group A compared with 14.4 ± 2.80 min in group B. At T(30), pulmonary function tests improved by more than 12% and wheezing disappeared in 16 (80%) patients in group A and in 18 (90%) patients in group B. This was statistically significant (P < 0.001). There was a statistically significant increase in FEV 1 , FEV 1 /FVC, and PEFR peripheral oxygen saturation (SpO 2 ) within each group compared with T(0). Intraoperatively, the peak airway pressure was clinically comparable in both groups, although it was statistically significant (P = 0.04). In group A there were no complications related to the use of acupuncture. Two (10%) patients in group A and 14 (70%) patients in group B experienced an increase in heart rate by more than 10%. Conclusion Perioperative acupuncture seemed to improve respiratory functions without serious side effects.
  - 2,473 146
A comparative study between a small dose of ketamine, lidocaine 1%, and acetominophen infusion to decrease propofol injection pain
Ayman A Elsayed, Ayman A Rayan
July-September 2015, 8(3):437-442
Background and objectives Pain during the injection of propofol is one of its drawbacks. The aim of this prospective, randomized and double-blinded study was to compare ketamine (K), lidocaine (L) 1%, and paracetamol (P) infusion as pretreatment before propofol injection regarding pain during injection. Patients and methods A total of 200 patients aged between 20 and 60 years, ASA I or II physical status, were randomly assigned into four equal groups. All patients received pretreatment solutions made up in 20-ml syringes with isotonic saline 0.9%. All the patients were pretreated over a period of 20 s. In group K, patients received ketamine 0.5 mg/kg. In group L, patients received lidocaine 0.5 mg/kg. In group P, patients received paracetamol (perfagan 10 mg/ml) 2 mg/kg. In group C (which served as a control group), patients received isotonic saline. We placed a rubber tourniquet on the forearm for 50 s to occlude the venous blood before giving the study drug. A blinded researcher assessed the patient's pain on propofol injection using a four-point scale, hemodynamics, the incidence of complications, and the dose of propofol used to induce anesthesia. Results There was a significant increase in the pain in group L compared with group K and group P. Also, there was a significant increase in the pain in group C compared with all other groups. After propofol injection, there was a significant decrease in the mean arterial pressure in P, L, and C groups in comparison with the baseline values. There was a significant decrease in the propofol dose for the induction of anesthesia in the ketamine group in comparison with the other groups. Conclusion Pretreatment with paracetamol 2 mg/kg, ketamine 0.5 mg/kg, and lidocaine 0.5 mg/kg were significantly effective in attenuating the pain of propofol. However, pretreatment with lidocaine 0.5 mg/kg was the least effective and pretreatment with paracetamol 2 mg/kg was the most effective in attenuating propofol pain. The incidence of complications was not significant in all groups.
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Cerebral oxygen saturation monitoring: a comparative study between bolus doses of ephedrine and phenylephrine in elective cesarean section
Khaled M Maghwry, Ashraf E Elagamy, Wael I Tahir
July-September 2015, 8(3):443-449
Background Maternal hypotension is suspected to occur during cesarean section, especially under spinal anesthesia. Ephedrine and phenylephrine are the most common drugs used to treat this phenomenon. Phenylephrine has been claimed to decrease cerebral oxygen saturation (ScO 2 ) under general anesthesia but it is unclear whether it has the same effect in spinal anesthesia. Patients and methods A randomized double-blinded study was conducted that included 42 pregnant women for elective cesarean section under spinal anesthesia. A bolus dose of ephedrine (10 mg) or phenylephrine (0.1 mg) was given for treatment of hypotension. Frontal lobe oxygenation (ScO 2 ), mean arterial blood pressure (MAP), and heart rate (HR) were recorded, besides standard monitoring of other vitals. Results There was a significant decrease in left ScO 2 in the phenylephrine group after bolus treatment in response to hypotension when compared with the ephedrine group (rate of change -6 ± 2 vs. +2 ± 1; P < 0.001), as well as in right ScO 2 (-8.65 ± 0.81 vs. +2.38 ± 0.9; P < 0.001). HR was significantly lower in the phenylephrine group than in the ephedrine group after the bolus dose (60 ± 7.3 vs. 71.1 ± 4.8; P < 0.001). There was no significant difference between the two groups as regards fetal outcome. Conclusion Bolus dose of phenylephrine for treatment of spinal anesthesia-induced hypotension in elective cesarean section causes more decrease in ScO 2 and maternal HR in comparison with a bolus dose of ephedrine, but both are effective in maintaining mean arterial blood pressure, with satisfactory fetal outcome.
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The effect of 6% hydroxyethyl starch 130/0.4 on hemodynamic efficacy and hemostasis in major orthopedic surgery: a comparison with 6% hydroxyethyl starch 200/0.5
Hannaa F.M. Salama, Mohamad A Ameen, Mostafa A Aziz
July-September 2015, 8(3):349-354
Background Clinical trial on patients undergoing major orthopedic surgeries to assess the safety and efficacy of 6% hydroxyethyl starch (HES) 130/0.4 (voluven) in comparison with 6% HES (200/0.5). Patients and methods A total of 40 patients scheduled for major orthopedic surgery were randomized to receive either 6% HES 130/0.4 (voluven group) or 6% HES 200/0.5 (haesteril group) during the intraoperative period. Amount of given colloids and crystalloids, blood loss, and the number of patients who needed blood transfusion were recorded. Mean blood pressure and heart rate were recorded at four time points during the operation. Laboratory measurements included hemoglobin, platelet count, prothrombin time, activated partial thromboplastin time, fibrinogen, and factor VIII concentrations. They were recorded before the surgery (baseline) and at 6 and 24 h after the surgery. Results Mean blood pressure and heart rate were comparable between both groups. There was equivalence of mean infused volumes of voluven and haesteril during the study period (P = 0.086). The intraoperative blood loss was significantly lower in the voluven group than in the haesteril group (P = 0.001), and a smaller number of patients in the voluven group required blood transfusion compared with the haesteril group (P = 0.023). Hemoglobin and platelets decreased significantly at 6 and 24 h after surgery compared with the baseline values, with insignificant difference between both groups. Prothrombin time increased significantly at 6 and 24 h after surgery in both the groups. The increase was significantly more in the haesteril group. Activated partial thromboplastin time increased significantly in the haesteril group at 6 and 24 h after surgery, whereas there was a nonsignificant change in the voluven group. Factor VIII concentration showed a significantly larger increase at 6 and 24 h after surgery in the voluven group than in the haesteril group. Conclusion In surgeries with major blood loss, voluven has a comparable efficacy to haesteril and may reduce coagulation impairment, possibly leading to less requirements of allogenic blood transfusion.
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Bupivacaine in transverses abdominis plane block for postcesarean section either blindly or ultrasound guided
Mayar H El Sersi, Ahmed K Makled
July-September 2015, 8(3):355-359
Study objective To compare the effectiveness of blind transverses abdominis plane (TAP) block versus ultrasound-guided TAP block for pain relief after a cesarean section. Background For decades, postoperative analgesia for cesarean deliveries was either systemic drugs, with their adverse effects such as nausea, or epidural analgesia, which would hinder ambulation. The TAP block was introduced by Rafi. It is a novel technique in which blockade of the sensory nerves to the anterior abdominal wall is performed by a regional anesthetic. This is a regional analgesic technique that blocks T6-L1 nerve branches and is increasingly playing a role in postoperative analgesia for lower abdominal surgeries. Patients and methods Sixty American Society of Anesthesiology I and II multiparous pregnant women aged 25 and 30 years old with BMI between 20 and 25 kg/m 2 planned for elective cesarean section (CS) at 38 weeks were allocated randomly to two groups of 30 patients each. Group B received bupivacaine 2 mg/kg of 0.375% solution per side to a maximum dose of 150 mg landmark guided. Group U received bupivacaine 2 mg/kg of 0.375% solution per side to a maximum dose of 150 mg ultrasound guided. Postoperatively, women were asked to document the degree of pain they experienced at 30 min, 1-, 4-, 6-, and 12-h periods. Printed copies of the visual analogue scale (VAS) between 'no pain' (0) and 'very severe pain' (100 mm) were given to patients and they were taught how to fill them. We assessed the patient clinically for pain and prescribed pethidine 100 mg intramuscularly if the patient complained of severe pain (VAS<60 mm). The time of analgesia was documented in the patient's form. Any local complications of the TAP block were also recorded.
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Progesterone versus combination therapy of progesterone, ω3 fatty acids, glutamine and vitamin D 3 in improving clinical outcome in patients with traumatic brain injuries
Nagy S Ali, Omyma S Mohamed, Medhat S Aead
July-September 2015, 8(3):301-307
Introduction Traumatic brain injury (TBI) is a major health problem. No single agent that can halt the progression of secondary injury exists. Progesterone, glutamine, ω3 fatty acids, and vitamin D 3 are all immune modulators, which can prevent secondary brain insult. Aim The aim of this study was to evaluate and compare the efficacy of progesterone alone with a half dose of progesterone plus vitamin D 3 , ω3 fatty acids, and glutamine (combination therapy) on the outcome of patients with acute TBI. Settings and design This was a randomized, prospective, controlled study. Patients and methods Sixty adult patients of both sexes, with moderate or severe TBI [Glasgow coma score (GCS) 4-12)] within 8 h of trauma, were equally randomly assigned to three groups: the control (C) group, which received the standard care and medications according to the guidelines of head trauma protocol; the progesterone (P) group, which received progesterone; and the combination therapy (T) group, which received a half dose of progesterone combined with vitamin D 3 , ω3 fatty acids, and glutamine. The GCS, ICU and hospital stay, computed tomography findings, mortality rate, and the Glasgow outcome scale (GOS) at 3 months after trauma were recorded and analyzed. Results Significant improvement in GCS and computed tomography findings, significantly shorter ICU and hospital stay, lower mortality rate, and more favorable GOS after 3 months were recorded among the therapeutic groups compared with the control group. Only ICU stay was significantly shorter on comparing the progesterone group with the T group. Conclusion Both progesterone and the combination therapy improved outcome in acute TBI, although progesterone dose was halved in the latter.
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Role of oral clonidine in preventing postsubarachnoid block shivering in patients undergoing elective urological surgeries: an experience
Israr-UL-Haq Lone, Yasir Bashir, Ansar-UL-Haq-Lone , Nusrat Bashir, Sadat S Ali, Zahoor A Shah, Nadeem A Khan, Mohd A Shah, Abdul Q Lone
July-September 2015, 8(3):407-412
Purpose The aim of this study was to investigate the effectiveness of oral clonidine in preventing postsubarachnoid block shivering in urological surgeries. Patients and methods It was a prospective double-blind study carried out on 120 elective patients after ethical clearance and after written informed consent was obtained from the patients who underwent urological surgeries. Patients were divided into two groups of 60 each: the study group and the placebo group. Patients in the study group received an oral clonidine tablet of 150 mg 90 min before block. The severity of shivering and other hemodynamic parameters were noted and compared between the two groups. Results We found a statistically significant decrease in postblock shivering incidence as well as severity in the clonidine-treated group, with no significant changes in hemodynamic and other parameters between the two groups and thus recommend its use. Conclusion As a prophylaxis, clonidine given orally at a dose of 150 mg seems to be a cheap, effective, and easily available drug for preventing postsubarachnoid block shivering in patients undergoing elective urological surgeries.
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Caudal bupivacaine plus ketamine compared with bupivacaine plus tramadol for postoperative analgesia in children
Reda S Abdelrahman, Ahmad A Eldaba
July-September 2015, 8(3):396-401
Background Caudal epidural block has been used commonly in pediatric postoperative pain management. However, the analgesic effect of caudal of bupivacaine lasts for 4-12 h. Aim The aim of this study was to compare the analgesic efficacy of the coadministration of tramadol (2 mg/kg) and ketamine (0.25 mg/kg) on the duration of caudal block produced by 0.25% bupivacaine 0.75 ml/kg on postoperative pain after an elective subumbilical surgery in children. Settings and design This is a controlled, randomized, single-blinded study. Patients and methods This study was carried out on 40 children between 2 and 12 years of age, ASA grade 1, of both sexes in Tanta University after obtaining the approval of the local hospital organization and parents' consent. The patients were divided into two equal groups. The patients in the bupivacaine plus ketamine group (group 1) received caudal bupivacaine 0.25%, 0.75 ml/kg mixed with ketamine 0.25 mg/kg, diluted in a 0.9% NaCl solution to a total volume of 1 ml/kg. The patients in the bupivacaine plus tramadol group (group 2) were administered caudal bupivacaine 0.25%, 0.75 ml/kg mixed with tramadol 2 mg/kg, diluted in a 0.9% NaCl solution to a total volume of 1 ml/kg. Statistical analysis Mean and SD were calculated as numerical data. Continuous variables were compared using the unpaired Student's t-test. Nominal nonparametric data were analyzed using the χ2 -test. Results Patients were monitored over the first 24 h postoperatively to assess analgesia using the All India Institute of Medical Science (AIIMS) objective pain discomfort scale and associated hemodynamic and respiratory changes. Our results showed that the addition of tramadol in group 2 significantly prolonged the analgesic effect of bupivacaine; also, there was hemodynamic stability and pain scores indicated minimal pain. Conclusion Caudal epidural tramadol has been proven to be safe at the concentration used and to prolong bupivacaine's analgesic duration postoperatively in children.
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Epidural injection of methylprednisolone with levobupivacaine under CT guidance improve radicular pain in herniated disc versus spinal stenosis
Enas M Ashrey, Ashraf M Enite, Samy M Abdelraouf
July-September 2015, 8(3):364-369
Introduction Epidural injections are commonly used for the treatment of low back pain in patients in whom conservative management has failed and who may wish to avoid surgery. Computed tomography guidance allows lumbar epidural injection to be performed rapidly, while allowing precise needle placement and proper placement of steroids near the pathologically inflamed nerve roots. Patients and Methods A total of 40 patients with chronic persistent lumbar radicular pain were allocated into two groups (20 patients each). The disc herniation (DH) group and the spinal stenosis (SS) group, each received a mixture of 40 mg of methylprednisolone plus 25 mg of 0.5% levobupivacaine+4 ml of saline 0.9% (both in a 10 ml syringe) through a paramedian interlaminar lumbar epidural injection. The visual analogue scale (VAS) was used, where 0 = no pain and 10 = the worst pain imaginable. The patient satisfaction scale (excellent, good, poor, bad) was assessed before injection, after 24 h, and 2 weeks, 3, and 6 months from injection; the need for repeated injection at less than 3 months and adverse events were also recorded. Results There was a significant reduction in the VAS score at 24 h (group DH 4.3 ± 1.5 VS. group SS 5.8 ± 2.4) (P < 0.05) and 2 weeks after injection; patients in group DH had a significantly lower VAS score (3.2 ± 1.6) in relation to group SS (5.2 ± 1.5) (P<0.05), but there was highly significant reduction in VAS at 3 and 6 months in the DH group (2.4 ± 1.4, 1.6 ± 1.2) compared with the SS group (4.6 ± 1.5, 4.9 ± 2.4) (P <0.01). Repeated injections at less than 3 months were lesser in the DH group (20%) than in the SS group (55%) (P < 0.01). The patient satisfaction scale was significantly increased in group DH compared with group SS (P < 0.001), with no major adverse events in the DH group compared with the SS group (P < 0.01). Conclusion An interlaminar lumbar epidural injection of methylprednisiolone with levobupivacaine under computed tomography guidance provided effective pain relief in the herniated disc group compared with the SS group, because it was safe, simple, and more accurate.
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Epidural dexmedetomidine, tramadol, or neostigmine for postoperative pain after major breast surgeries
Mohamed Amr Abusabaa, Mohamad H Hamada, Mostafa A Abo El Enin, Salah M Kamal
July-September 2015, 8(3):370-376
Background It is postulated that the beneficial effects of epidural analgesia result from attenuation of stress response and provision of good postoperative analgesia. We added dexmedetomidine, tramadol, or neostigmine to bupivacaine in thoracic epidural anesthesia to evaluate their effect on perioperative cortisol level, postoperative analgesia, time to ambulation, and complications. Patients and methods Eighty female patients scheduled for major breast surgery were divided into four equal groups (20 patients each) in a randomized double-blinded manner. Thoracic epidural anesthesia was induced. In group C 15 ml of 0.5% bupivacaine (control group), in group D 15 ml of 0.5% bupivacaine +75 μg of dexmedetomidine, in group T 15 ml of 0.5% bupivacaine +75 mg of tramadol, and in group N 15 ml of 0.5% bupivacaine +75 μg of neostigmine were given. Perioperative cortisol level, postoperative analgesia, time to ambulation, and complications were assessed. Results Demographic data and surgical characteristics were similar in all groups. Patients in groups D and T had lower pain scores compared with patients in groups C and N at all time points in the following 24 h postoperatively. Hence, patients in groups D and T consumed a lower dose of bupivacaine in the postoperative period compared with patients in groups C and N. There was a highly significant reduction in the mean time to postoperative ambulation in groups D, T, and N compared with group C. Conclusion Dexmedetomidine is superior to tramadol and neostigmine in providing hemodynamic stability, excellent attenuation of stress response, prolonged postoperative analgesia, and early mobilization with minimal undesirable side effects.
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Epidural fentanyl for the prevention of autonomic dysreflexia in chronic spinal cord injury patients undergoing urological procedures
Dalia A Nasr, Tarek Osman Elsayed
July-September 2015, 8(3):377-381
Background Spinal cord injury (SCI) patients with lesions above T6 are susceptible to develop autonomic dysreflexia (AD) during surgery. The aim of this study was to investigate the efficacy of epidural fentanyl for the prevention of AD in chronic SCI patients undergoing urological procedures. Patients and methods Thirty chronic SCI patients scheduled for cystoscopy were randomized to receive epidural anesthesia using 5 ml bupivacaine 0.25% with fentanyl 50 µg in 10 ml saline (group F) or 5 ml bupivacaine 0.25% in 10 ml saline (group C). Results There was a significant decrease in the blood pressure and the heart rate 20 min after epidural anesthesia in both groups, with significantly lower systolic and diastolic blood pressures in group F compared with group C; however, the systolic and diastolic blood pressure showed a significant increase, with a decrease in the heart rate, in group C compared with group F during bladder manipulation (25 min). Six patients in group C showed manifestations of autonomic dysreflexia, with an increase in the systolic blood pressure more than 160 mmHg and diastolic blood pressure more than 100 mmHg in three of them. Conclusion The addition of fentanyl to epidural bupivacaine succeeded in preventing AD manifestations in chronic SCI patients undergoing cystoscopy.
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Preemptive analgesia of ultrasound-guided transversus abdominis plane block compared with deep wound infiltration in patients undergoing urological surgery
Hoda Shokri, Karim O Elsaeed
July-September 2015, 8(3):382-387
Background Transversus abdominis plane (TAP) block is suitable for unilateral urologic surgeries. Blind TAP block has many complications and uncertainty regarding its effects. Use of ultrasonography increases the safety and efficacy. This study was conducted to evaluate the analgesic efficacy of ultrasound-guided TAP block compared with wound infiltration with bupivacaine (0.25%) in patients undergoing urologic surgeries. Patients and methods In a prospective study, 30 patients undergoing elective unilateral urological surgeries such as nephrolithotomy were allocated into two groups: the TAP group and the infiltration group. The TAP group (n = 15) received TAP block with 0.25% bupivacaine (50 ml), and in the infiltration group (n = 15) the skin and subcutaneous tissues of the surgical incision and deep muscle layers were infiltrated with 0.25% bupivacaine (50 ml). Pethidine 1 mg/kg was given as rescue analgesic at visual analog scale (VAS) more than 3 at rest and on movement. The total dose of pethidine, VAS at rest and on movement, and sedation scores were recorded. Results Patients of the TAP group had significantly lower VAS score and lower pethidine consumption, and there was a nonsignificant difference between study groups as regards sedation score. Conclusion The ultrasound-guided TAP block is easy to perform and more effective as a postoperative analgesic regimen in urologic surgeries with opioid-sparing effects.
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Beyond the fire: smoke inhalational injury as a respiratory concern
Ayman M Kamaly
July-September 2015, 8(3):283-286
In fire events, smoke inhalation is the leading cause of death in survivors of the primary fire mortality. Direct upper airway thermal injury is only one of the contributing mechanisms. Others may be related to the nature of the combusted (or incomplete combusted) materials in the scene; eg.; aldehydes, sulphur oxides and nitrogen as a cotton combustion products, while burning polyvinylchloride (PVC's) releases carbon monoxide (CO) and hydrochloric acid, among more than 75 potentially toxic compounds including cyanide. Hot carbonated gaseous materials and soot may lead to supraglottic, glottic, or infraglottic airway obstruction however; significant hypoxemia is not the typical sign in acute cases without aspiration or parenchymal lung injuries. Injury may not manifest until after 48 hours.
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