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  Citation statistics : Table of Contents
   2016| January-March  | Volume 9 | Issue 1  
    Online since March 17, 2016

 
 
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ORIGINAL ARTICLES
Does nebulized dexamethasone decrease the incidence of postextubation sore throat?: a randomized controlled study
Atef K Salama, Ahmed M El-badawy
January-March 2016, 9(1):104-107
DOI:10.4103/1687-7934.178888  
Objective and aim of study Postoperative sore throat (POST) is a common complaint in about 21-65% of patients undergoing general anesthesia with endotracheal intubation. The aim of this randomized controlled study was to evaluate the efficacy of preoperative nebulized dexamethasone in decreasing the incidence of postextubation sore throat. Patients and methods A total of 120 American Society of Anesthesiologists (ASA) physical status I-II patients of both sexes aged 25-60 years sexes were included in this study. Patients were randomly assigned into one of the two groups of 60 patients each: group D received dexamethasone 8 mg in 5 ml nebulization and group S (the control group) received normal saline in 5 ml nebulization 15 min before general anesthesia and endotracheal intubation. The intensity of sore throat and hemodynamic variables were monitored before nebulization, on arrival to the postanesthesia care unit (0 h), and at 2, 4, 8, 12, and 24 h postoperatively. Results The incidence and severity of POST were significantly reduced in the dexamethasone group than in the saline group at the following time intervals: 2 h after extubation (P = 0.009), 4 h after extubation (P = 0.000), 8 h after extubation (P = 0.000), and 12 h after extubation (P = 0.002). There was no complication associated with dexamethasone nebulization. Conclusion Preoperative nebulization with dexamethasone 8 mg reduces the incidence and severity of POST in patients receiving general anesthesia with endotracheal intubation.
  4 7,014 458
A comparative study on combined general anesthesia with either continuous fascia iliaca block or epidural anesthesia in patients undergoing lower limb orthopedic surgeries
Nihal G.E. Nooh, Ahmed M.S. Hamed, Aasem A Moharam, Ahmed M Rashad
January-March 2016, 9(1):76-82
DOI:10.4103/1687-7934.178884  
Introduction The purpose of this study was to compare between epidural anesthesia and continuous fascia iliaca block in adults patients undergoing fixation of neck femur or knee arthroplasty including comparison of analgesic efficacy, side effects, and complications. Patients and methods The study was performed upon 60 patients, aged 20-60 years, and randomly distributed among two groups. Group A included 30 patients who received lumber epidural anesthesia, using Tuohy needle 18 G and epidural catheter 20 G, injected initially with 15 ml bupivacaine HCl 0.25% then 6-8 ml/h bupivacaine HCl 0.125% as continuous epidural infusion for 12 h postoperatively. Group B included 30 patients who received fascia iliaca block using Tuohy needle 18 G, injected initially with 20 ml bupivacaine HCl 0.25%, then an epidural catheter 20 G was threaded through the needle and another 20 ml of local anesthetic was injected, followed by 8-10 ml/h bupivacaine HCl 0.125% injected as continuous epidural infusion into the plane for 12 h postoperatively. Results Regarding the technique time, the fascia iliaca group B was significantly faster than the epidural group A. The results showed that performing continuous fascia iliaca block was a significantly faster technique, providing fewer complications such as hypotension, postoperative vomiting, and urinary retention and more patient satisfaction in comparison with epidural anesthesia. Conclusion Continuous fascia iliaca block provided effective unilateral analgesia in patients undergoing fixation of fractured femur neck or shaft or knee arthroplasty with a high patient satisfaction rate, low incidence of hemodynamic instability, and low incidence rate of complications when compared with epidural analgesia.
  2 1,912 176
Dexmedetomidine premedication with three different dosages to attenuate the adverse hemodynamic responses of direct laryngoscopy and intubation: a comparative evaluation
Kumkum Gupta, Manoranjan Bansal, Prashant K Gupta, Meetu Singh, Shikha Agarwal, Vaibhav Tiwari
January-March 2016, 9(1):66-71
DOI:10.4103/1687-7934.178882  
Background Direct laryngoscopy and tracheal intubation predictably lead to transient and variable hemodynamic responses, which can be attenuated by α2-receptor agonists. The present study aimed to evaluate comparatively the three different dosages of dexmedetomidine (0.5, 0.8, and 1 μg/kg) as premedication for the attenuation of these hemodynamic responses of direct laryngoscopy and intubation. Participants and methods Ninety adult consented patients of ASA grades I and II of either sex were randomized into three equal groups of 30 patients each in a double-blind manner. Dexmedetomidine in dosages of 0.5 μg/kg (group I), 0.8 μg/kg (group II), and 1 μg/kg (group III) was infused over 10 min as premedication before propofol induction. The hemodynamic changes during infusion, after induction, and after laryngoscopy and intubation were recorded for statistical analysis. Results Patients with a comparable demographic profile showed a decrease in heart rate and blood pressure after dexmedetomidine infusion in a dose-dependent manner. Further decrease in heart rate and blood pressure after propofol induction showed a statistically significant (P < 0.05) difference among groups. After laryngoscopy and intubation, the increase in heart rate and blood pressure was more evident in patients in whom low dosages of dexmedetomidine was infused with a statistically significant (P < 0.05) difference among the groups. Conclusion Premedication with dexmedetomidine at a dosage of 1 μg/kg attenuated the adverse hemodynamic responses of laryngoscopy and intubation adequately.
  2 2,400 214
Fluid preloading versus ephedrine in the management of spinal anesthesia-induced hypotension in parturients undergoing cesarean delivery: a comparative study
Atef K Salama, Hala M Goma, Bassant M Abdel Hamid
January-March 2016, 9(1):72-75
DOI:10.4103/1687-7934.178883  
Introduction and objectives Spinal anesthesia-induced hypotension in parturients undergoing cesarean delivery is a very common complication that has detrimental effects on both the mother and the fetus. The objective of our study was to compare the two therapeutic modalities, fluid preloading and ephedrine, in the management of spinal anesthesia-induced hypotension in parturients undergoing elective cesarean delivery. Patients and methods A total of 50 ASA I-II parturient women who presented for cesarean section under spinal anesthesia were enrolled in this study. They were randomly assigned into two groups: the F group (n = 25) (the fluid preloading group), which received 15 ml/kg of lactated Ringer's solution 10 min before spinal anesthesia, and the E group (n = 25) (the ephedrine group), which received prophylactic 5 mg ephedrine first and second minute and 1 mg every minute until 15 min after the block. Hemodynamic variables and any postoperative complication were recorded. Results Demographic data and duration of procedures were comparable. Systolic blood pressure was generally higher in the E group than in the F group. However, the result was not statistically significant, except at 4 and 22 min after spinal anesthesia. Heart rate was higher in the E group than in the F group; however, it was not statistically significant. The incidence of hypotension and rescue boluses of ephedrine was significantly higher in the fluid group. Conclusion The use of ephedrine is superior to that of fluid preloading in maintaining blood pressure after spinal anesthesia in cesarean section.
  1 3,079 318
Induction of anesthesia and endotracheal intubation in children without muscle relaxant: a comparative study on addition of fentanyl or propofol to sevoflurane
Hazem M Fawzi, Ghada M Samir
January-March 2016, 9(1):39-44
DOI:10.4103/1687-7934.178878  
Background Intubation without the need of muscle relaxant is a common practice in pediatric patients. Many drugs are used with inhalational induction to improve the intubation score and to decrease the induction time; of these drugs are propofol and narcotics. The aim of this study was to compare the effect of adding propofol or fentanyl to sevoflurane on the intubating conditions in pediatric patients undergoing adenotonsillectomy. Patients and methods A randomized controlled study was conducted on 90 patients aged 4-8 years and with ASA physical status I and II scheduled for elective adenotonsillectomy. Patients were divided by opening a sealed envelope into three equal groups, each consisting of 30 patients. Group S patients received inhalational induction alone using sevoflurane. Group SF received 3 mcg/kg fentanyl intravenously followed by inhalational induction using sevoflurane. Group SP received 3 mg/kg propofol intravenously followed by inhalational induction using sevoflurane. The intubation conditions, hemodynamic parameters (heart rate and systolic blood pressure), oxygen saturation, operative time, induction time, and recovery time, were all recorded and statistically analyzed. Results With respect to the intubating condition, no patient in any of the three groups needed rescue muscle relaxant for intubation. Group SP showed more acceptable and excellent intubating conditions compared with the other two groups (90 and 83.3%, respectively). After 6 min, the heart rate was slower, 106.5 (100-110.5) beats/min, and the systolic blood pressure was lower, 110 (110-115) mmHg, in group SF than in the other two groups. Induction time was faster, 107 (99.8-117) min, in group SP than in the other two groups. The recovery time was shorter in group S than in group SF and slightly longer in group SP, with median and interquartile range of 265 (249.5-280) s, 337 (320-360) s, and 500 (496.8-510) s, respectively. Conclusion Endotracheal intubation without neuromuscular blocking agents in pediatric patients undergoing adenotonsillectomy can be achieved with no serious respiratory or hemodynamic adverse events by adding propofol (3 mg/kg) or fentanyl (3 mcg/kg) to sevoflurane. Propofol is suitable for rapid induction as it offers the shortest induction time with 83.3% excellent intubating conditions, whereas fentanyl blunts the stress response to intubation with 46.7% excellent intubating conditions.
  1 3,240 274
Controlled hypotensive anesthesia for functional endoscopic sinus surgery: a new protocol for dexmedetomidine administration
Ayman A Rayan
January-March 2016, 9(1):57-65
DOI:10.4103/1687-7934.178881  
Objective The aim of the study was to conduct a comparative investigation to evaluate the efficacy of dexmedetomidine as a hypotensive agent by presenting a new protocol for administration versus the conventional protocol in functional endoscopic sinus surgery (FESS). Materials and methods Forty patients of ASA grade I-II scheduled for FESS were equally randomly assigned to two groups: the DEX group and the DEXnew group. The DEX group received dexmedetomidine at 1 μg/kg diluted in 10 ml normal saline 10 min before surgical incision (SI), followed by intravenous infusion of dexmedetomidine at 0.2-0.7 μg/kg/h according to the hemodynamic status and BIS. The DEXnew group received dexmedetomidine at 1 μg/kg diluted in 10 ml normal saline 10 min before SI, followed by intravenous top-up doses of 1/4 of the loading dose over 2 min in the form of intravenous shots to maintain MAP between 65 and 70 mmHg. Mean arterial blood pressure (MAP), heart rate (HR), cortisol level, fentanyl consumption, emergence time, and recovery from anesthesia (modified Aldrete score) were recorded. The sedation score and time to first analgesic request were recorded. Results In the DEX group there was a statistically significant decrease in MAP at 30, 45, 60, and 90 min after SI in comparison with preoperative MAP. In the DEXnew group also there was a statistically significant decrease in MAP at 30, 45, 60, and 90 min after SI in comparison with preoperative MAP. There was a nonsignificant difference as regards intraoperative fentanyl and postoperative pethidine consumption between the two groups. There was a significant decrease in the total amount of consumed dexmedetomidine in the DEXnew group (118 ± 14.6 μg) compared with the DEX group (189.4 ± 22.7 μg). Emergence time was significantly shorter in the DEXnew group (5.34±1.83 min) compared with the DEX group (9.45 ± 2.02 min). Conclusion This modified protocol of dexmedetomidine administration is safe and effective for controlled hypotension, providing an ideal surgical field during FESS. Compared with the conventional protocol of dexmedetomidine administration, the modified protocol offers fewer side effects; significant decrease in dexmedetomidine consumption, faster emergence time, and better modified Aldrete scores.
  1 5,935 538
Outcome of sedation therapy using midazolam or propofol continuous infusion in patients with severe traumatic brain injury
Mohamed Amr Shabana
January-March 2016, 9(1):108-115
DOI:10.4103/1687-7934.178889  
Objectives The aim of this study was to compare the sedative effect of midazolam and propofol alone or in combination on hemodynamic stability and subsequent intracranial pressure (ICP) changes in adults with severe traumatic brain injury. Patients and methods All patients received fentanyl continuous infusion and were randomly divided into three groups: group I received midazolam continuous infusion, group II received propofol continuous infusion, and group III received midazolam and propofol combination at half the dose used for groups I and II. Doses were titrated with gradual increments until the patients were well-sedated irrespective of the upper-dose limit as long as hemodynamic stability was maintained. Intraventicular ICP sensor was inserted at the end of the surgery for patients who underwent surgical interference or through Kocher's pathway at the right frontal lobe for patients did not undergo surgical interference. Patients were monitored to maintain mean arterial pressure at 80 mmHg or greater and cerebral perfusion pressure and ICP in the range of 50-70 and 18-21 mmHg, respectively. Sedation was judged according to the behavioral pain scale and Bispectral Index. Results Intraoperative catheter was applied in 72 patients and through Kocher's pathway in 48 patients. The catheter was removed without complications in 104 patients (86.7%). The applied therapeutic strategies provided a significant reduction in ICP compared with baseline measures, but with significantly lower ICP in group III compared with other groups. The number of patients who had an ICP less than 21 mmHg was significantly higher in group III compared with other groups. Nineteen patients required mannitol therapy and 20 patients required muscle relaxant infusion, with a significant difference in favor of group III. The mean total Glasgow Coma Scale of patients in group III was significantly higher compared with groups I and II, with a significantly higher difference in favor of group II. Conclusion Midazolam-propofol combination in the used dosage allowed proper control of hemodynamic changes and improved cerebral perfusion pressure with reduction in ICP and minimizing the need for additional therapy.
  1 3,251 235
Prevention of reperfusion tachyarrhythmia after CABG: magnesium versus lidocaine
Magdy M Atallah
January-March 2016, 9(1):18-22
DOI:10.4103/1687-7934.178874  
Background Reperfusion tachyarrhythmia after aortic cross-clamp (ACC) release is one of the most commonly encountered complications after coronary artery bypass grafting (CABG) surgery, and its control may save these patients. Materials and methods Ninety patients who had undergone CABG surgery were enrolled in this study. Patients were assigned randomly to three groups (30 patients each). The lidocaine group (LIDO) group received lidocaine (2 mg/kg) in 100 ml isotonic saline, the magnesium group (MAGN) group received magnesium (30 mg/kg) diluted in 100 ml of an isotonic saline 0.9% solution, and the control group received 100 ml normal saline by a pump circuit 3-5 min before ACC release. Anesthetic management, weaning protocol from cardiopulmonary bypass, was standardized. All the patients were monitored after the release of ACC and electrical rhythms (including ventricular fibrillation and supraventricular tachyarrhythmia) were recorded. Results Incidences of postrelease of ACC and ventricular fibrillation were lower in the lidocaine and magnesium groups compared with the control group [7 (23%), 4 (13%) vs. 11 (36%)] (P = 0.042). Also, the incidence of an atrioventricular block postrelease ACC was higher in the lidocaine group compared with the magnesium and control groups [7 (23%) vs. 2 (6%) and 3 (10%), respectively] (P = 0.039). The need for a temporary pace maker was higher in the lidocaine group compared with the magnesium and control groups [7 (23%) vs. 2 (6%) and 1 (3%), respectively] (P = 0.044). Also, the total duration of ICU stay was shorter in the magnesium group compared with the lidocaine and control groups. Conclusion The administration of lidocaine and magnesium sulfate before the release of ACC reduced the incidence of ventricular fibrillation. The administration of magnesium shortened the ICU stay in adult patients undergoing CABG surgery by cardiopulmonary bypass. However, the administration of Lidocaine was associated with more transient atrioventricular block.
  1 2,201 240
Effect of lidocaine instillation into endotracheal tube on intraocular pressure during extubation
Ahmed Hassanein, Josef Zekry, Hosam Moharram
January-March 2016, 9(1):23-26
DOI:10.4103/1687-7934.178875  
Objectives The aim of this study was to investigate the effect of lidocaine instillation into the endotracheal tube before extubation on intraocular pressure (IOP) and hemodynamics. Patients and methods A total of 60 patients of ASA physical status I and II between 18 and 40 years of age who were scheduled for elective unilateral ocular surgery (cataract, squint, or ptosis) were included in the study. Patients were randomly classified into two groups of 30 patients each: the lidocaine group, which received 1 mg/kg of lidocaine into the endotracheal tube before extubation, and the control group, which received saline into the endotracheal tube. IOP, systolic blood pressure, diastolic blood pressure, and heart rate were all measured before and after extubation. Results There was a significant increase in IOP in the control group at 2, 5, and 10 min after extubation (P < 0.01) compared with baseline value (2 min before extubation). The elevation in IOP in the lidocaine group at 2 min was significantly lower than that in the control group (P < 0.05). The readings of IOP at 5 and 10 min were lower in the lignocaine group compared with the control group. Both groups showed a significant increase in systolic blood pressure and diastolic blood pressure after extubation compared with baseline (2 min before extubation), and the elevation in the lidocaine group was significantly lower than that in the control group (P = 0.0001). Conclusion Instillation of lidocaine into the endotracheal tube before extubation attenuates IOP after extubation.
  1 1,858 175
CASE REPORTS
Unique cardiac injury after high-voltage electrical burn
Yasser A Salem, Rania Hassan
January-March 2016, 9(1):122-125
DOI:10.4103/1687-7934.178891  
Patients of high-voltage injury commonly present with devastating burns requiring prolonged hospitalization with multiple complications. Crossing of sufficient current flow through cardiac tissue can cause lethal arrhythmia. This may lead to immediate cardiac arrest. In the following case report we described a condition of probable anatomic disfigurement of the endocardium and intracardiac structures secondary to high-voltage electrical burn.
  - 2,144 140
Dexmedetomidine for heart rate control and renal protection in patients undergoing mitral valve replacement for tight mitral stenosis
Salah M Asida, Hatem S Mohamed
January-March 2016, 9(1):126-133
DOI:10.4103/1687-7934.178892  
Background Dexmedetomidine (DXM) is an α2 adrenoceptor agonist that reduces the sympathetic outflow from the central nervous system resulting in bradycardia and hypotension. We used this drug in this randomized controlled double-blind study to test its efficacy in controlling the heart rate and its safety regarding renal function in patients undergoing mitral valve replacement surgery. Patients and methods A total of 70 patients scheduled for mitral valve replacement were randomly allocated into two groups: in group D, 35 patients received DXM 1 μg/kg bolus dose over 10 min followed by an infusion of 0.5 μg/kg/h. In group C, 35 patients received saline bolus and infusion by the same method instead of DXM. The heart rate was measured at induction of anesthesia, after the end of bolus infusion, at skin incision, and every 10 min till the start of the cardiopulmonary bypass. We also measured the urine interleukin-18 level during the first 12 h of surgery and serum creatinine and blood urea for 3 days postoperatively. Results The mean heart rate was significantly lower after bolus infusion, at skin incision, at 10 and 30 min, and just before bypass in the DXM group. Also, the urine output was higher in the DXM group during surgery and on the first postoperative day of surgery. No significant difference was found regarding other parameters of renal functions. Conclusion DXM can be used effectively in reducing the heart rate in patients undergoing mitral valve replacement surgery and was associated with an increase in the urinary output, and it did not alter the renal function in this cohort of patients.
  - 2,178 151
An unusual perioperative event in a complex pediatric surgery
Gaurav Chopra, Gulam M Parihar
January-March 2016, 9(1):134-135
DOI:10.4103/1687-7934.178893  
Sacrococcygeal teratomas are tumors that arise in the sacrococcygeal area containing tissue from all three germ layers. Sacrococcygeal teratoma has an incidence of ~one in 27 000 live births, with malignant transformation with increasing age. We report a unique case of a 6-year-old child with a large sacrococcygeal mass with rudimentary genitals with an intraoperative intraoral misplacement of the endotracheal tube during positioning.
  - 1,539 102
Anesthetic management of ischemic heart disease with ejection fraction of 35% in a patient of fracture neck femur
S Jawe Nilesh, Naik Sanyogita, Jadhav Rahul, Kurhekar Vikas
January-March 2016, 9(1):136-138
DOI:10.4103/1687-7934.178894  
Anesthetic management of cardiac patients coming for noncardiac surgery has always been challenging. Goal of anesthesia management is to keep myocardial oxygen supply greater than demand to avoid ischemia. In this case report, anesthetic implications included assessment of cardiovascular status of the patient preoperatively with selection of epidural anesthesia (EA) and analgesia technique. Incremental doses of local anesthetic were given to maintain myocardial oxygen demand. To the best of our knowledge, there have been only few case reports on EA for ischemic heart disease patient coming for noncardiac surgery. Hence, we report a successful anesthetic management of a patient with ischemic heart disease posted for fracture neck of femur under EA and analgesia.
  - 12,748 851
Venous oxygen embolism after inadvertent subcutaneous injection of hydrogen peroxide
Kundan S Gosavi, Surbhi D Mundada, Senthil K Praveen Kumar
January-March 2016, 9(1):139-141
DOI:10.4103/1687-7934.178895  
The hazards of hydrogen peroxide have been known for long time, but it is still widely used in our country for irrigation of wounds. We report a case of oxygen embolism when hydrogen peroxide was accidently infiltrated subcutaneously along with local anesthetic during spine surgery and was successfully managed. We discuss the possible mechanism for embolism and its management. We also want to emphasize on the importance of being vigilant and avoiding such mistakes.
  - 2,510 114
Anesthetic management for elective lower segment cesarean section in a patient with systemic lupus erythematosus and thrombocytopenia
B Patel Kiran, Shah Tapan, S Sharma Ananyaruchi
January-March 2016, 9(1):142-145
DOI:10.4103/1687-7934.178896  
Systemic lupus erythematosus is a multisystem, chronic inflammatory disease characterized by autoantibodies directed against nuclear antigens. The disease is most frequently found in women of child-bearing age and therefore may coexist with pregnancy. The clinical symptoms are variable and depend on the severity of damage to organ systems such as the musculoskeletal, renal, hematological, neurological, cardiac, and respiratory systems. The pregnant patient may experience exacerbations of disease, neonatal loss, and obstetric complications such as pre-eclampsia.The anesthetic management will depend on the patient's clinical status and the well-being of the fetus. The patient should be thoroughly examined for the extent of end-organ damage, current medications, and the health of the fetus. Laboratory investigations, such as coagulation profiles and testing for renal functions, should be performed and enough amount of blood substitutes should be kept ready before anesthetic intervention if time permits. A multidisciplinary approach by the obstetrician, the anesthesiologist and the hematologist for regular antenatal checkups, proper preoperative evaluation, and rational preparation of blood substitutes, with the availability of enough resources to manage complications during the entire course of the peripartum period, is essential to optimize the outcome for both the mother and the newborn.
  - 2,452 225
LETTERS TO EDITOR
Successful recovery from disseminated intravascular coagulation in a patient with abruptio placentae who presented for emergency lower-segment cesarean section
B Patel Kiran, Borah Bidyut, S Sharma Ananyaruchi
January-March 2016, 9(1):146-148
DOI:10.4103/1687-7934.178897  
Healthy pregnancy is accompanied by changes in the hemostatic system that convert it into a hypercoagulable state vulnerable to a spectrum of disorders ranging from venous thromboembolism to disseminated intravascular coagulation (DIC). DIC is always a secondary phenomenon triggered by specific disorders such as abruption placentae and amniotic fluid embolism due to intravascular release of thromboplastin or endothelial damage resulting from pre-eclampsia and sepsis. Delivery of the fetus and placenta in the early stage of accelerated disease progression is the definitive therapy. Uncompensated DIC, associated with pre-eclampsia, is monitored with serial hematological investigation of platelet count, fibrin degradation products, and serum fibrinogen level. Removal of triggering mechanisms with supportive measures associated with or without mechanical ventilator support is key to successful management. Outcome depends on our ability to deal with the triggers primarily and not only on correcting coagulation and providing mechanical ventilatory therapy.
  - 3,328 160
New technique for caudal epidural block in pediatric patients
Abdelaziz A Abdelaziz
January-March 2016, 9(1):149-151
DOI:10.4103/1687-7934.178898  
Caudal block is one of the most popular and effective techniques of regional anesthesia in pediatric surgery. Good anatomic knowledge and accurate adherence to guidelines pertaining to the technique and to drug administration is necessary to perform this block safely. The usual approach is well-known and has been extensively described, but failure is seen in some cases. Another approach is the 'no turn' technique, which is a new method developed in the Ain-Shams University, Pediatric Surgical Unit by the author. It has a high success rate and can be easily learned and implemented even by junior staff.
  - 6,683 437
ORIGINAL ARTICLES
Airway management for morbidly obese patients: a comparative study between fiberoptic bronchoscopes and intubating laryngeal masks
Hala M.S. Eldeen, Aboelnour Elmorsy Badran, Mona A Hashish, Doaa G Diab
January-March 2016, 9(1):27-33
DOI:10.4103/1687-7934.178876  
Background Obesity is an epidemic disease that continues to increase in most countries. It is estimated that more than 30% of the adult population is obese. Airway management in morbidly obese adults may be a challenge to anesthesiologists due to anatomical and physiological changes that affect obese patients. The intubating laryngeal mask airway (ILMA) is a new device specifically designed to be an effective ventilator device and blind intubation guide in patients with normal and abnormal airways. The aim of this study was to compare the effectiveness and the safety of the ILMA technique with fiberoptic intubation (FOI) in obese patients with an anticipated difficult intubation. Patients and methods Eighty morbidly obese adult patients of either sex, aged 18-60 years, with BMI more than 40 kg/m 2 , with anticipated difficult intubation, and ASA physical status I-III, were scheduled for elective bariatric abdominal surgery, which required tracheal intubation and general anesthesia, in Mansoura University Hospital. Patients were randomly allocated into two groups: the FOI and the ILMA group. Randomization of the groups was performed by a computerized method, with 40 patients in each group. Anesthesia was induced with intravenous propofol 2-3 mg/kg of ideal body weight and fentanyl (2 mg/kg). Anesthesia was maintained with a propofol infusion (10 mg/kg/h). Patient characteristics such as age, sex, BMI, and the ASA class, heart rate and noninvasive blood pressure (NIBP), oxygen saturation, the success or failure rate, the number of attempts, and the duration of the successful attempt were all recorded. Results Patients in the ILMA and the FOI groups were comparable to each other regarding the duration of intubation and the success rate. However, complications were significantly lower in the ILMA group than in the FOI group. Conclusion ILMA may be a good alternative device for FOI for tracheal intubation in morbidly obese patients.
  - 3,461 307
Comparison of hemodynamic response to tracheal intubation with laryngoscope versus intubating laryngeal mask airway in elderly hypertensive patients
Mohamed M Abdel Fattah
January-March 2016, 9(1):34-38
DOI:10.4103/1687-7934.178877  
Background Management of airways during intubation is a very stressful process that affects the hemodynamics, especially in elderly hypertensive patients. We aimed in this study to compare the hemodynamic response to tracheal intubation in elderly hypertensive patients using ILMA and Direct laryngoscopy. We aim in this study to prove that hemodynamic consequences with intubation using ILMA is that intubation with an ILMA has less hemodynamic consequences that last for a shorter period compared with DL in elderly hypertensive. Patients and methods A total of 70 patients of both sexes, ASA physical status II, above 60 years of age, undergoing elective abdominal surgery lasting less than 2 h were divided randomly using a regular sample method into two equal groups. Intubation was performed using a Macintosh laryngoscope in group (direct laryngoscopy), and in the second group [intubating laryngeal mask airway (ILMA)] intubation was performed with laryngeal mask airway. Hemodynamic data and oxygen saturation were recorded. Intraoperative adverse effects and postoperative complications such as sore throat, hoarseness of voice (during the first 24 h after surgery), and laryngospasm were recorded. Results There was a significant increase in heart rate and mean arterial blood pressure immediately after laryngoscopy and tracheal intubation until 3 min when compared with ILMA. Moreover, there was significant increase in heart rate, mean arterial blood pressure, and rate pressure product after tracheal extubation for 3 min, whereas it was for 1 min in the ILMA group. No significant difference was seen between the number of patients with or without symptoms after extubation in both groups. Conclusion Intubation with ILMA has less hemodynamic consequences for a shorter time compared with direct laryngoscopy in elderly hypertensive patients.
  - 2,578 261
Pregabalin versus bromazepam as a sedative in embryo transfer during in-vitro fertilization
Eman M Kamal Aboseif, Dalia M Elfawy, Niven Gerges
January-March 2016, 9(1):116-121
DOI:10.4103/1687-7934.178890  
Background The majority of infertile women are young and healthy but exhibit stress, anxiety, and other psychological disorders associated with infertility. This anxiety should be attenuated with appropriate drugs during premedication. Moreover, after the procedure, patients report visceral pain resulting from cervical manipulation, which should be relieved with appropriate analgesia. Objectives The aim of this study was to evaluate and compare the clinical efficacy of oral premedication with pregabalin and bromazepam for sedation in terms of effectiveness and postoperative analgesia in patients undergoing embryo transfer during in-vitro fertilization (IVF). Patients and methods A total of 60 healthy infertile consented female patients younger than 39 years with ASA physical status I or II who were scheduled for embryo transfer during IVF were randomized to receive either pregabalin (300 mg) (group A), bromazepam (3 mg) (group B), or placebo (folic acid 0.5 mg) (group C) 90 min before surgery as oral premedication. The Ramsay sedation scale was used to evaluate preoperative sedation. Hemodynamic data were recorded before premedication, just after induction, after recovery, and 2 and 4 h postoperatively. Severity of postoperative pain was assessed using a visual analogue scale (VAS). Results Perioperative sedation levels were lighter in the pregabalin group than in the bromazepam group, as there were statistically significant differences in terms of attenuation in mean arterial blood pressure and heart rate. Moreover, VAS score was significantly lower in the pregabalin group at induction, recovery, and 2 and 4 h after surgery. Conclusion This study showed that the use of pregabalin 300 mg or bromazepam 3 mg causes good preoperative sedation with hemodynamic stability intraoperatively together with decreasing postoperative pain in embryo transfer during IVF procedure.
  - 2,797 139
Comparative study between the effect of sevoflurane and ketamine-midazolam on the cardiac troponin I level and hemodynamic variables in pediatric therapeutic cardiac catheterization for pulmonic stenosis
Hala M.S. Eldeen, Medhat M Messeha
January-March 2016, 9(1):12-17
DOI:10.4103/1687-7934.178873  
Introduction Congenital pulmonary stenosis is considered one of the most common cardiac anomalies in pediatrics. Percutaneous balloon dilatation is one method for its treatment, but it is usually associated with an increase in the cardiac troponin level. Aims and objectives The study was carried out to compare between the effect of sevoflurane and ketamine-midazolam on the level of cardiac troponin I as a specific marker for myocardial injury in children before and after therapeutic cardiac catheterization for pulmonic stenosis. Patients and methods Forty patients, up to 13 years old, undergoing cardiac catheterization were divided randomly into two groups: sevoflurane group (Gs) and ketamin-midazolam group (Gk-m). The standardized protocol for cardiac catheterization was maintained for all the patients. Serum samples were withdrawn at the start of - and 6 h subsequent to - the procedure for analysis of cardiac troponin I. Hemodynamic and oxygenation parameters were recorded at induction, T10, T20, and T30 minutes after induction. After recovery, sedation was assessed using the Ramsay Sedation Score. Results Hemodynamic parameters, mean arterial blood pressure, heart rate, and cardiac index were significantly increased in Gk-m as compared with its basal values and with Gs. The serum cardiac troponin I was significantly increased after the procedure in both groups as compared with its basal value before the procedure. The increase in the cardiac troponin I was significantly higher in Gk-m than Gs (P < 0.001). The Ramsay Sedation Score showed a significant increase in Gk-m than Gs at all times postoperatively. Conclusion The use of sevoflurane as an anesthetic regimen for pediatric therapeutic cardiac catheterization for pulmonic stenosis is superior to the ketamine-midazolam combination as it is associated with a lower troponin I level, less myocardial injury, and greater hemodynamic stability.
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Isoflurane versus desflurane: hemodynamic parameters and recovery characteristics: a comparative study
Aktham A Shoukry, Ayman Abd Laltif, Amr Abd Fattah, Ibrahim Abd Ghani, Mohamed Serag
January-March 2016, 9(1):45-51
DOI:10.4103/1687-7934.178879  
Introduction Inhaled volatile anesthetics remain the most widely used drugs for maintenance of general anesthesia because of their ease of administration and predictable intraoperative and recovery characteristics. Management of hemodynamic stability and early recovery is the most important part of a standardized balanced technique. Given the low blood-gas partition coefficients of isoflurane (1.4) and desflurane (0.42), a more rapid emergence from anesthesia is expected compared with traditional inhalation anesthetics, The aim of this study was to compare the hemodynamic, emergence, and recovery characteristics of isoflurane with those of desflurane in general anesthesia for patients undergoing pelviabdominal operations. Patients and methods Ninety ASA I patients aged 15-50 years scheduled for elective abdominal or pelvic surgeries were enrolled in the study. Patients were allocated randomly into one of two groups (45 patients each): group I and group D. Group I patients received isoflurane (Forane) for maintenance of general anesthesia after a standardized induction sequence. Group D patients received desflurane (Suprane) for maintenance of general anesthesia after a standardized induction sequence. Results In the hemodynamic parameters, there were no statistically significant differences between the two groups in heart rate (after induction, after intubation, before skin incision, after skin incision, 5 min later, 10, 15, and 20 min later) (P > 0.05), but there was a significant increase in group D at 25, 30, 35, and 40 min later, just before extubation, and just after extubation (P < 0.05). On comparing the systolic blood pressure and the diastolic blood pressure, there were no significant differences between the two groups before induction, after induction, 5, 10, 15, 25, and 30 min later, just before extubation, and just after extubation (P > 0.05), but there was a significant increase in group D after intubation, after skin incision, and 20, 35, and 40 min later (P < 0.05). In terms of postoperative complications and depth of anesthesia by the bispectral index, there were no significant differences between the study groups, but in terms of recovery characteristics, desflurane was more rapid. Conclusion The results of the study indicate that desflurane has better hemodynamic parameters and recovery characteristics in comparison with isoflurane in patients undergoing elective pelviabdominal operations.
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Correlation between central venous and peripheral venous pressures in surgical patients
Rajan Sunil, Nadarajan Vishnu, Kumar Lakshmi
January-March 2016, 9(1):52-56
DOI:10.4103/1687-7934.178880  
Introduction The central venous pressure (CVP) measurement is important in assessing right ventricular function and systemic fluid status, and the venous pressures measured from peripheral venous catheters closely correlate with CVP and/or CVP trends. The correlation between CVP and peripheral venous pressure (PVP) in patients undergoing major surgical procedures under mechanical ventilation during normotension, hypotension, in the presence of inotropes, and postoperatively during spontaneous respiration was studied in this study. Materials and methods In this prospective, observational study, 40 adult patients undergoing surgical procedures lasting for more than 5 h, where a major blood loss was expected, were studied. The CVP and PVP were recorded simultaneously at a 15 min interval until 4 h intraoperatively, followed by hourly during the postoperative period for 4 h. Statistical analysis used Student's t-test to analyze statistical significance of difference in mean, Pearson's product moment correlation coefficient to assess correlation, and paired t-test to assess changes in mean arterial pressure. Results Throughout the study period, PVP persistently showed a positive trend with a significantly higher value than CVP (P < 0.001), but a statistically significant correlation could not be demonstrated persistently. Conclusion Hence, it is concluded that measurement of PVP can be considered as an alternative to CVP monitoring, when conditions are impractical for central venous catheterization.
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Efficacy of intravenous regional anesthesia with dexmedetomidine: local addition versus systemic infusion
Ayman A Rayan, Ayman A El Sayed
January-March 2016, 9(1):83-91
DOI:10.4103/1687-7934.178885  
Background Intravenous regional anesthesia (IVRA) is a type of regional anesthesia that is administered using a pneumatic tourniquet isolating the limb from the systemic circulation. IVRA has been limited by tourniquet pain and the inability to provide postoperative analgesia. Thus, to improve the quality of IVRA and avoid these problems, additives are added to local anesthetics. We designed this study to evaluate the efficacy of IVRA by using dexmedetomidine locally versus an intravenous systemic infusion. Materials and methods Overall, 60 ASA I-II patients of either sex, 18-65 years old, scheduled for hand or distal forearm surgeries were studied. Patients were divided randomly into three groups (20 patients each): group L received 3 mg/kg lignocaine completed to 40 ml normal saline (NS), group LD1 received 0.5 μg/kg dexmedetomidine added to 3 mg/kg lignocaine completed to 40 ml NS, and group LD2 received 3 mg/kg lignocaine completed to 40 ml NS plus an intravenous infusion of 1 μg/kg dexmedetomidine over 10 min 15 min before IVRA, followed by maintenance of dexmedetomidine infusion at the rate of 0.02-0.06 μg/kg/min. Onset and recovery times of sensory and motor blocks, tourniquet pain, rescue analgesia, and visual analogue scale postoperatively were monitored. Results Onset and recovery times of sensory and motor blocks were shorter in group LD1 compared with the other two groups. Time of tourniquet pain was found to be prolonged in groups LD1 and LD2 compared with group L. The use of rescue fentanyl and tramadol in the first 24 h was increased in group L versus both the other two groups. Conclusion Local addition of dexmedetomidine to IVRA produced shorter onset and slower recovery of sensory and motor blocks compared with systemic infusion of dexmedetomidine. The durations of postoperative analgesia and rescue analgesia were comparable between both groups using dexmedetomidine either locally or systemically.
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Dexmedetomidine versus ketorolac as adjuvants for intravenous regional anesthesia
Ahmed Hassanein
January-March 2016, 9(1):92-98
DOI:10.4103/1687-7934.178886  
Background Multiple adjuvants have been added to improve the quality of intravenous regional anesthesia (IVRA). The aim of this study was to compare the effect of dexmedetomidine with that of ketorolac as an adjuvant for lidocaine IVRA as regards the onset and duration of sensory and motor blocks, intraoperative-postoperative pain, and intraoperative and postoperative analgesic requirement. Patients and methods This study was a prospective, randomized, double-blinded trial. Sixty patients scheduled for hand or forearm surgery were randomly divided into three equal groups (n = 20): group I was given 3 mg/kg of lidocaine 2% (maximum: 200 mg) + 0.5 μg/kg of dexmedetomidine; group II was given 3 mg/kg of lidocaine 2% (maximum: 200 mg) + 30 mg ketorolac; and group III was given 3 mg/kg of lidocaine 2% (maximum: 200 mg). In the three groups, 0.9% normal saline was added for a total volume of 40 ml. Sensory and motor block onset, recovery times, intraoperative and postoperative analgesic requirement, and hemodynamic variables were recorded and compared between the three groups. Results There was a significant reduction in sensory and motor onset, and prolonged sensory and motor duration in the dexmedetomidine group than in the ketorolac and the control group, and in the ketorolac group than in the control group (P < 0.001). There was improved tolerance to tourniquet and postoperative pain, with low levels of intraoperative and postoperative analgesic requirement in the dexmedetomidine group than in the ketorolac group followed by the control group. Conclusion We concluded that dexmedetomidine seems to be superior to ketorolac as an adjuvant to lidocaine in IVRA in terms of tourniquet pain and intraoperative and postoperative analgesic requirements.
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Effect of nitrous oxide inhalation on induction dose of propofol, induction time, oxygen saturation, and hemodynamic responses to laryngoscopy and intubation
Rajan Sunil, Sarath Vijayakrishna Pillai, Kumar Lakshmi
January-March 2016, 9(1):99-103
DOI:10.4103/1687-7934.178887  
Context Nitrous oxide enhances the anesthetic potential of other agents and thereby reduces their requirement. Aims This study aimed to determine the effect of nitrous oxide inhalation on the induction dose of propofol, induction time, oxygen saturation, and hemodynamic responses to laryngoscopy and intubation. Settings and design This was a randomized, prospective clinical trial. Participants and methods A total of 150 surgical patients ASA status I and II were included in the study. Patients in group A inhaled 66% nitrous oxide in oxygen for 3 min, whereas in group B, 100% oxygen was used. In both the groups, patients were administered a propofol bolus 20 mg every minute intravenously after 3 min of gas inhalation until induction was achieved. Loss of response to verbal command and no response to jaw thrust were considered the endpoint of induction. Patients were then intubated after administration of suxamethonium 2 mg/kg. Results The mean dose of propofol required for induction was significantly lower in group A compared with group B (30.4 ± 26.17 vs. 101.87 ± 26.19), as was the induction time (1.52 ± 1.31 vs. 5.09 ± 1.33). Heart rate was comparable throughout the study period. At induction, group A had a significantly higher mean arterial pressure (MAP) (94.51 ± 16.21 vs. 86.57 ± 15.47). At 5 and 10 min, MAP was significantly high in group B and significantly high oxygen saturation was observed at induction (99.81 ± 0.46 vs. 99.96 ± 0.26). No patient developed desaturation (SpO 2 <90%) during the study. Conclusion Inhalation of 66% nitrous oxide for 3 min significantly reduced the induction time and the dose of propofol, prevented a precipitous decrease in MAP at induction, and effectively attenuated stress response to laryngoscopy and intubation without desaturation.
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REVIEW ARTICLES
Consent for anesthesia
Kaur Gagandeep, Bala Neeru, Attri Joginder Pal, Sandhu Kulwinder Singh, Kataria Amar Parkash
January-March 2016, 9(1):6-11
DOI:10.4103/1687-7934.178872  
Modern anesthesia practice has become technically more challenging. Today's anesthesiologist is more often involved in administering anesthesia to elderly and sick patients who are having other comorbidities, with their inherent risks. This leads to increased morbidity and mortality. Anesthesiologists are not able to carry out detailed discussions about the proposed procedure with their patients because of work load and time restraints. Hence, they are not able to build up healthy relationship with their patients. Hence, whenever some eventuality takes place, patients and relatives react in a hostile manner. In this situation, if a negligence case goes to the court, then a well-informed anesthesia-specific consent can help an anesthesiologist to prove his or her side during legal proceedings. In this article, consent for anesthesia is reviewed with respect to its three major components - that is, information, decision-making capacity, and autonomy of the patient.
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Use of growth hormone in the treatment of pediatric burns
Yasser A Salem
January-March 2016, 9(1):1-5
DOI:10.4103/1687-7934.178871  
Hypermetabolic response is characterized by a hyperdynamic circulatory response, with increased body temperature; increased oxygen and glucose consumption; increased carbon dioxide production; hyperglycemia (raised blood sugar levels); peripheral insulin resistance; glycogenolysis, proteolysis, and lipolysis (i.e. the breakdown of glycogen, protein, and lipids, respectively); the loss of lean body mass; and muscle and bone wasting. These symptoms can last for 1-2 years after the burn injury. Failure to satisfy overwhelming energy and protein requirements results in multiorgan dysfunction and an increased susceptibility for infection and death. Immunocompromization and delayed wound healing usually result in severe sepsis, which is the most common direct cause of death in these patients. Nevertheless, providing adequate caloric and protein requirements alone was found to be insufficient to attenuate the hypermetabolic response efficiently. Thereby, various pharmacologic modalities to modulate metabolic response have become a corner stone in the management of severely burned patients. Recombinant growth hormone is the most frequently prescribed agent in pediatrics. This review will focus on the metabolic and immune responses to the use of recombinant growth hormone in pediatric burn patients. It will explore what is beyond growth hormone and the role of insulin-like growth factor-1 in modulation of immunity and apoptosis.
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