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   2016| April-June  | Volume 9 | Issue 2  
    Online since May 11, 2016

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Efficacy of dexmedetomidine as an anesthetic adjuvant for functional endoscopic sinus surgery under general anesthesia: A randomized-controlled study
Kumkum Gupta, Prashant K Gupta, Kanwaljit Singh Bhatia, Bhawana Rastogi, Mahesh Narayan Pandey, Shikha Agarwal
April-June 2016, 9(2):207-211
Background Functional endoscopic sinus surgery (FESS) requires effective control of bleeding for better visibility of the operating field and reduced risk of injury to the optic nerve or the internal carotid artery. Dexmedetomidine can provide controlled hypotension, analgesia, and sedation. The present study aimed to evaluate the clinical efficacy, safety, and advantages of dexmedetomidine as an anesthetic adjuvant for FESS. Patients and methods Fifty adult consented patients of comparable demographic profile, scheduled for FESS, were assigned randomly to two groups. Patients of group D received a loading dose of dexmedetomidine 1 mg/kg over 10 min, followed by an infusion at 0.4-0.7 mg/kg/h and patients of group C were administered an identical amount of saline solution. During the procedure, hemodynamic changes, intraoperative surgical grade of bleeding (on the basis of the Fromme-Boezaart scale), intraoperative fentanyl consumption, emergence time, and total recovery from anesthesia (Aldrete's score ≥9) were recorded. Results Patients of group D comparatively had a lower intraoperative heart rate and mean arterial blood pressure, along with a significantly lower bleeding score (P < 0.001). The mean intraoperative fentanyl consumption was significantly lower in patients of group D. Emergence time and time to achieve an Aldrete's score 9 or more were significantly lower in group C at 15 and 30 min postoperatively. Conclusion Dexmedetomidine has effectively provided the ideal oligemic surgical field during FESS and offers the inherent advantages of analgesia, sedation, and anesthetic-sparing effects.
  4 2,413 302
Ultrasound-guided transversus abdominis plane block versus caudal block for postoperative analgesia in children undergoing unilateral open inguinal herniotomy: A comparative study
Ashraf A Ahmed, Ayman A Rayan
April-June 2016, 9(2):284-289
Background Ultrasound (US)-guided transversus abdominis plane (TAP) block is an effective technique in providing analgesia for abdominal surgery. This study was designed to evaluate the efficacy of a US-guided TAP block and to compare it with a caudal block in unilateral day-case open inguinal hernia repair in children. Patients and Methods Forty ASA I-II, 1-5-year-old children scheduled for elective unilateral open inguinal herniotomy were studied. All patients received general anesthesia; sevoflurane was used for induction and maintenance of anesthesia and laryngeal mask airway (LMA) was used to secure the airway. After securing an intravenous cannula, patients were randomized to a US-guided TAP block (n = 20) (group T) using 0.5 ml/kg 0.25% bupivacaine, injected on the same side of surgery, and group C received a caudal block using 1 ml/kg 0.2% bupivacaine (n = 20). Surgery was allowed 15 min after administration the block. Block failure was considered in case of gross movement or more than 20% change in heart rate and/or ABP persisting more than 1 min after skin incision. Any adverse events were recorded. After surgery, patients remained for 4 h in the recovery room. Postoperative analgesia was evaluated using Children and Infants Postoperative Pain Scale (CHIPPS). An anesthesiologist, who was not part of the study team, evaluated the need for rescue analgesia in the intraoperative and postoperative period and a recovery nurse collected the data. If the CHIPPS score was greater than 4, a rescue analgesia of 20 mg/kg acetaminophen was administered. Results No difference was found in hemodynamics in both groups. Also, intraoperative fentanyl consumption was not different and no rescue analgesia was required in the postanesthesia care unit. Conclusion A US-guided TAP block is as effective as a caudal block in providing immediate postoperative analgesia in inguinal hernia repair.
  4 2,488 268
Exacerbation of phantom limb pain following spinal anaesthesia: A case report and review of the literatures
Gentle S Shrestha, Sabin Koirala
April-June 2016, 9(2):309-310
Phantom limb pain has been reported in patients with lower limb amputation during subsequent spinal anaesthesia. No therapy has been proven to be uniformly effective. Here, we report a case managed successfully with ketamine and magnesium sulphate.
  2 1,782 153
Deliberate hypotensive anesthesia during maxillofacial surgery: A comparative study between dexmedetomidine and sodium nitroprusside
Rehab S El-Kalla, Mona B El Mourad
April-June 2016, 9(2):201-206
Background The aim of the present study was to evaluate the anesthetic properties such as the onset of required hypotension, the quality of the surgical field, the percentage of inhaled anesthesia, intraoperative consumption of fentanyl, time to recovery, and adverse events of dexmedetomidine (DEX) as a hypotensive agent in comparison with sodium nitroprusside (SNP) in maxillofacial surgery. Patients and methods A total of 70 ASA I or II patients, aged 20-60 years, scheduled for maxillofacial surgery were randomly assigned to receive either DEX 1 mg/kg before induction of anesthesia for over 10 min followed by 0.2-0.5 mg/kg/h infusion during maintenance (DEX group; n = 35 patients) or SNP 0.25 mg/kg/min infusion after induction of anesthesia (SNP group; n = 35 patients) to maintain mean arterial blood pressure (MAP) between 50 and 65 mmHg. Hemodynamic variables and end-tidal isoflurane concentration were recorded, quality of surgical field was assessed by the same surgeon who was blinded of the selected hypotensive agent, and intraoperative fentanyl consumption and recovery time were recorded. Results Heart rate was significantly lower (P < 0.05) in DEX group. Both drugs were effective in achieving the desired level of hypotension (MAP: 50-65 mmHg). However, the time needed to reach the target MAP was significantly shorter in the SNP group than in the DEX group. End-tidal isoflurane concentration and intraoperative fentanyl consumption were significantly lower in the DEX group than in the SNP group, and the quality of the surgical field was better in the DEX group compared with the SNP group, but the time for recovery was significantly longer in the DEX group than in the SNP group. Conclusion We concluded that DEX is an effective and safe agent with anesthetic benefits for controlled hypotension, and that compared with SNP DEX offers the advantage of better quality of the surgical field and decreased anesthetic and fentanyl requirements intraoperatively. However, DEX was associated with significantly longer time to reach the target MAP and delayed recovery from anesthesia compared with SNP.
  2 2,273 251
A comparison of the postoperative analgesic effects of intravenous dexmedetomidine with a combination of dexmedetomidine and bupivacaine wound infiltration for lower segment cesarean section: A prospective, randomized study
Ahmed M Abd El-Hamid, Mohamed I.A. Alrabiey, Mohamed H Abd El-Fattah
April-June 2016, 9(2):235-239
Background and aim This study was designed to compare the postoperative analgesic effect of dexmedetomidine administered intravenously or in wound infiltration with bupivacaine in patients undergoing cesarean section. Patients and methods Ninety female patients scheduled for cesarean section were randomly allocated into three equal groups: group I received 100 ml normal saline infusion over 10 min before closure plus wound infiltration with 25 ml of 0.25% bupivacaine at the end of surgery; group II received 1 mg/kg of dexmedetomidine in 100 ml normal saline infusion over 10 min before closure plus wound infiltration with 25 ml of 0.25% bupivacaine at the end of surgery; and group III received 100 ml normal saline infusion over 10 min before closure plus wound infiltration with 1 mg/kg of dexmedetomidine added to 25 ml of 0.25% bupivacaine at the end of surgery. The number of patients requiring rescue analgesia, total morphine consumption during the first 24 h after the operation, and the level of sedation were recorded. Results Morphine consumption was significantly less in patients receiving dexmedetomidine by either route. All patients in group I required supplemental morphine, whereas 14 patients in group II and 16 patients in the wound infiltration group required supplemental morphine. Patients in group II had more hypotension and sedation compared with other groups. Conclusion Dexmedetomidine provided effective postoperative analgesia and reduced morphine consumption when administered intravenously or in wound infiltration with bupivacaine. The incidence of complications was less with wound infiltration.
  2 1,992 208
Role of anesthesiologists in the management of trauma patients: Updates
Eman M.K. Aboseif
April-June 2016, 9(2):153-158
Trauma is the leading cause of death for individuals up to the age of 45 years and the third leading cause of death overall for every age groups. In the United States, trauma accounts for more than 180.000 deaths per year and about 2.8 million hospital admissions, Trauma anesthesiologists are prepared to immediate care of patients with any form and severity of injury, who may require any kind of operations regardless of the day time of night. Therefore trauma anesthesiologists offer a unique expertise and skill set that are significantly different from those offered by other medical specialists and being a part of the hospital trauma team.
  2 8,516 1,600
Studying the sedative effect of dexmedetomidine administered by two different routes, a randomized comparative trial
Wael Sayed, Dina Salah, Fady Adib
April-June 2016, 9(2):240-244
Background Efforts to find a better adjuvant in spinal anesthesia have been underway for a long time to achieve both effective analgesia and targeted sedation. We evaluated whether we can use dexmedetomidine in spinal anesthesia through its multiple modes of action and reduced adverse events in comparison with its intravenous use to achieve desirable patient comfort and sedation. Patients and methods A total of 100 patients classified as American Society of Anesthesiologists class I and II scheduled for inguinal hernia repair were studied. Patients were allocated randomly to receive either 15 mg of 0.5% hyperbaric bupivacaine plus 0.5 ml normal saline intrathecally and an intravenous infusion of dexmedetomidine 1 mg/kg over 10 min (group V, n = 50) or 15 mg of 0.5% hyperbaric bupivacaine plus 5 mg of dexmedetomidine diluted in 0.5 ml normal saline intrathecally and an intravenous infusion of same volume normal saline over 10 min (group S, n = 50). Results Patients in both groups were comparable in the characteristics of the spinal block and sedation score. Conclusion Intrathecal dexmedetomidine can act both as an adjuvant to bupivacaine and as a sedative without the need for other intravenous sedation drugs.
  1 1,508 154
Dexmedetomidine versus midazolam for sedation of critically ill patients on noninvasive mechanical ventilation
Mohamed G.I.M. Allam
April-June 2016, 9(2):178-185
Introduction Dexmedetomidine is a highly selective a-2 adrenoceptor agonist and eight times more specific than clonidine. It exerts its major sedative and analgesic effect through stimulation of the a-2 adrenoceptor and the locus coeruleus. Its analgesic effect is also produced by direct stimulation of the a-2 adrenoceptor in the spinal cord. The unique sedative effect of dexmedetomidine that mimics natural sleep makes the postsedative delirium after stopping dexmedetomidine very rare. Moreover, even on the sedative score Richmond Agitation-Sedation Scale (RASS)-1-2, patients can respond easily to verbal command and go back to sleep. The most commonly reported adverse effects are bradycardia and hypotension. Aim of the work This was a comparative prospective double-blind study comparing dexmedetomidine versus midazolam as a sedative agent used in noninvasive ventilation (NIV) and short-term intubation and mechanical ventilation (5 days). Patients and methods In all, 200 patients admitted to King Abd el Aziz Specialist Hospital, Taif, in the ICU with acute hypoxemia with SpO 2 less than 80% were allocated randomly to two groups. All patients in both groups were subjected to NIV for 3 days and if this failed (persistent hypoxemia, became hemodynamically unstable, or showed marked tracheal secretion), intubation and mechanical ventilation was considered for 5 days. Group A included 100 patients who received midazolam as a sedative agent, whereas group B included 100 patients who received dexmedetomidine as a sedative agent. The number of patients who responded to NIV in both groups was recorded and the number of patients who were extubated and weaned from mechanical ventilation in 5 days in both groups was also recorded together with the complications from sedation. Results There was a significant increase in the number of patients who responded to NIV in group B compared with group A. Moreover, there was a significant increase in the number of patients extubated and weaned from mechanical ventilation in the 5-day period in group B compared with group A. Conclusion Dexmedetomidine is a safer agent for sedation of critically ill patients with fewer incidences of delirium, and less morbidity and mortality compared with midazolam with the same efficacy.
  1 2,442 299
Percutaneous vertebroplasty under epidural anesthesia: comparative study versus local anesthesia
Alfred M Said, Heba B El-Serwi, Fady M Fahmy
April-June 2016, 9(2):267-273
Objectives This study aimed to evaluate percutaneous vertebroplasty (PVP) under epidural (EPI) anesthesia and its effect on patients' and surgeons' satisfaction. Patients and methods Sixty-three patients undergoing thoracolumbar PVP were divided randomly as follows: the LA group received local anesthesia (LA) and the EPI group received EPI anesthesia as one pre-emptive shot of 8-10 ml plain levobupivacaine 0.25% (2.5 mg/ml). PVP involved an injection of 4-8 ml polymethlymethacrylate into each treated vertebra. Anesthetic outcome was defined as assessment of injection pain using a 10-point numeric rating scale, hemodynamic stability; efficacy of postoperative (PO) analgesia and patients' satisfaction were rated using the Iowa Satisfaction with Anesthesia Scale for monitored anesthesia care and surgeons' satisfaction was evaluated using a seven-point Likert scale. Surgical outcome was defined as patients' disease-related pain levels assessed before and 24-h PO using numeric rating scale. Results EPI anesthesia provided multiple advantages over LA; injection pain and anxiety-induced tachycardia and hypertension were significantly lower. EPI anesthesia allowed multiple-level PVP in the same setting with a single anesthetic injection; this was reflected as significantly higher surgeon and patient satisfaction. PO pain was significantly lower with EPI versus LA, with less need for PO analgesia. Both groups showed PO improvement in their disease-related pain. Conclusion EPI anesthesia is a safe and effective alternative for LA during PVP. It allowed multiple-level corrections in the same setting, adequate hemodynamic stability and PO analgesia, and resulted in significantly higher surgeon and patient satisfaction, especially those who had one-setting multiple-level corrections.
  1 1,965 150
Transversus abdominis plane block versus local anesthetic wound infiltration in patients undergoing open inguinal hernia repair surgery
Ahmed M Abd El-Hamid, Ehab E Afifi
April-June 2016, 9(2):280-283
Objectives This study aimed to compare the analgesic effect of ultrasound-guided transversus abdominis plane (TAP) block versus wound infiltration in patients undergoing open inguinal hernia repair. Patients and methods A total of 60 male patients scheduled for open unilateral inguinal hernia repair under general anesthesia were randomly allocated into two equal groups: group W received wound infiltration with 0.2 ml/kg of 0.25% levobupivacaine at the site of incision, and group T received ultrasound-guided TAP block with 0.5 ml/kg of 0.25% levobupivacaine. Time to first analgesic request, total morphine requirement over 24 h, and visual analogue pain score at rest and during cough were assessed over the course of 24 h. Results Total morphine requirement during the first 24 h was significantly less in group T. A total of 21 patients in group W required supplemental morphine compared with 13 patients in group T. Time to first analgesic request was significantly longer in group T. Patients receiving TAP block had significantly lower pain scores at rest for 12 h and on cough for 6 h after operation when compared with patients who received wound infiltration. Conclusion TAP block provided more reliable and effective analgesia and less total 24-h postoperative morphine consumption compared with wound infiltration with the local anesthetic.
  1 2,108 244
Shoulder block versus interscalene block for postoperative pain relief after shoulder arthroscopy
Hala E Zanfaly, Amani A Aly
April-June 2016, 9(2):296-303
Background Adequate pain control allows early rehabilitation and improves outcome after shoulder arthroscopic procedures. Objective The aim of this study was to compare the interscalene nerve block (ISB) with shoulder block (ShB) (suprascapular and axillary nerve blocks) for postoperative pain relief after arthroscopic shoulder surgery. Design This was a prospective, randomized, comparative study. Patients and methods A total of 75 patients of ASA grade I or II scheduled for shoulder arthroscopic surgery were equally divided into three groups (25 patients each): the general anesthesia (GA)-only group; the GA with ISB group; and the GA with ShB group. The nerve block was guided by both ultrasound and nerve stimulator. Visual analogue scale score was evaluated at the recovery room and 2, 4, 8, 16, and 24 h postoperatively. The time to first call for analgesia, total analgesic requirement for 24 h postoperatively, patient satisfaction, and any complications were recorded. Results The visual analogue scale score was significantly less in the GA + ISB and GA + ShB groups compared with the GA-only group (P < 0.001). The time to first analgesic request was significantly longer in the GA + ISB group [10 (9-10 h)] and GA + ShB group [9 (9-10 h)] compared with the GA-only group [1 (1 h)] (P < 0.001). The total dose of morphine consumption was significantly higher in the GA-only group [10 (9-10 mg)] compared with the GA + ISB group [6 (5-6 mg)] and the GA + ShB group [6 (6-7 mg)] (P < 0.001). Patient satisfaction was significantly higher in the GA + ISB group [9 (9-10)] and in the GA + ShB group [8 (8-9)] compared with the GA-only group [1 (1-2)] (P < 0.001). The incidence of complications was significantly higher in the GA + ISB group compared with the other two groups (P < 0.001). Conclusion ShB was as effective as ISB for postoperative pain relief but with fewer complications. Thus, ShB is a good alternative for patients at high risk for adverse events with ISB.
  1 3,396 382
Four kidneys and a tumor: Laparoscopic radical nephrectomy in a renal transplant recipient
Binod K Naithani, Uma Hariharan, Shagun B Shah
April-June 2016, 9(2):311-313
Ever since the advent of organ transplantation, the survival rate and future encounter of recipients with anesthesiologists has increased. There have been several case reports and reviews on anesthesia for renal transplant recipients. We present a unique case of a patient who had previously undergone double renal transplantation, presenting to the anesthesiologist with four kidneys for laparoscopic radical nephrectomy for renal cell carcinoma. To the best of our knowledge, there has been no reported case of a postrenal transplant patient with four kidneys presenting for minimally invasive radical nephrectomy. Hemodynamic stability, preservation of renal function, careful choice of anesthetic agents, protection of fistula sites, complete asepsis, institution of extensive monitoring, cautious positioning, and use of ultrasound-guided regional block for pain management are some of the clinical pearls gained from this unique and rare case.
  - 1,310 103
Intrathecal ketamine as an adjuvant in day-case surgeries: Comments
Mohd Saif Khan
April-June 2016, 9(2):314-315
  - 1,269 133
Magill's forceps-shaped stylet: An aid to difficult intubation
Ravindra R Bhat, Gayatri Mishra, Sandeep K Mishra, Satyen Parida
April-June 2016, 9(2):316-316
  - 2,025 132
Efficacy of forearm intravenous regional anesthesia through comparison of concentration and volume of lidocaine at a dose of 2 mg/kg for hand and wrist surgeries
Ayman A Rayan, Hossam I Eldesuky
April-June 2016, 9(2):290-295
Aim This study aimed to evaluate the efficacy of intravenous regional anesthesia (IVRA) as regards volume versus concentration of lidocaine in surgeries. Patients and methods The study enrolled 46 patients of ASA physical status I and II, aged 18-65 years, undergoing IVRA using lidocaine 2% at a dose of 2 mg/kg plus fentanyl 1 mg/kg diluted with a volume of 25 ml normal saline [the concentration group (group C, n = 23)], or 2 mg/kg lidocaine 2% plus fentanyl 1 mg/kg diluted with a volume of 40 ml normal saline [the volume group (group V, n = 23)]. The total supplemental systemic fentanyl intraoperatively and rescue pethidine consumption during the first 4 h postoperatively were recorded. The success rate of the IVRA block was also recorded. First and second tourniquet pain times, as well as times of onset and recovery of sensory and motor block, were calculated. Visual analogue scale score for evaluation of the pain resulted from the surgical stimulation was recorded. The side effects of the drugs and complications of the technique were also recorded. Results Intraoperative supplemental fentanyl dose was significantly higher in group V compared with group C. The total pethidine consumption during the first 4 postoperative hours showed nonsignificant difference between patients of the two groups, with a mean of 48.27 ± 9.75 mg in group C versus 52.42 ± 13.83 mg in group V. Hemodynamic parameters such as heart rate and mean arterial pressure were comparable in the two groups. The time to first call of analgesia was significantly prolonged (P < 0.05) in group C. Block characteristics were significantly better in group C. We did not encounter any serious side effect of any of the drugs used. Conclusion IVRA with lidocaine at a dose of 2 mg/kg in 25 ml volume of normal saline represented an effective block and reduced the second tourniquet pain, increased the second tourniquet tolerance, and significantly decreased intraoperative supplemental fentanyl in comparison with the same dose in 40 ml volume of normal saline.
  - 1,747 171
Articaine versus bupivacaine/lidocaine mixture in episcleral peribulbar anesthesia for cataract surgery: A prospective randomized-controlled study
Mostafa M Houssein Khalil, Ibrahim M Ibrahim Mohamed
April-June 2016, 9(2):304-308
Background Medial episcleral peribulbar anesthesia has been shown to be a valid alternative for ocular regional anesthesia because of the infrequent complications observed. Articaine is a new local anesthetic drug used in eye surgery with dense motor block and fewer complications. Aim The aim of this study was to compare the efficacy and safety of an episcleral peribulbar block using articaine 2% versus bupivacaine 0.5%/lidocaine 2% mixture in patients undergoing cataract surgery. Patients and methods This study was carried out in Ain Shams University Hospital on 60 patients who underwent elective cataract surgery with peribulbar episcleral anesthesia. Patients were allocated randomly to two groups of 30 patients each. Group A included patients who received peribulbar episcleral anesthesia using 2% articaine as a local anesthetic agent. Group B included patients who received peribulbar episcleral anesthesia using a mixture of 0.5% bupivacaine and 2% lidocaine as a local anesthetic agent. The primary outcome measures were the onset of eye globe akinesia and the ocular mobility score. The secondary outcome measures were the need for a supplementary injection and the occurrence of complications. Results In terms of eye globe akinesia, there were statistically significant differences between the two groups in the onset of satisfactory globe akinesia. Group A showed rapid onset, whereas group B had delayed onset of action. The onset of satisfactory globe akinesia with an ocular mobility score less than 4 was achieved in 4.44 ± 0.76 min in group A (articaine group) compared with 8 ± 0.85 min in group B (bupivacaine/lidocaine mixture group). Conclusion The current study showed that the episcleral peribulbar technique with 2% articaine and epinephrine 5 mg/ml was effective and provided a superior option to a mixture of 0.5% bupivacaine/2% lidocaine.
  - 1,562 134
Enhancement of bupivacaine caudal analgesia by using dexamethasone or clonidine in children undergoing subumbilical surgery
M Solanki Nilesh, R Engineer Smita, B Patel Rahul, K Vecham Pavan
April-June 2016, 9(2):274-279
Background and aims Caudal analgesia produces profound intraoperative, as well as postoperative analgesia, with minimal psychological alteration in children. Because of its short duration, various additives have been used to prolong the duration of analgesia. The present study aimed to evaluate the effect of adding dexamethasone and clonidine to bupivacaine in caudal analgesia for children undergoing subumbilical surgeries. Patients and methods We conducted a prospective, randomized, single-blinded study on 100 patients of either sex belonging to the American Society of Anesthesiologists' physical status I, II in the age group 1-12 years, and undergoing subumbilical surgery under general anesthesia, were enrolled. Written informed consent was obtained from their parents. Patients were randomly divided into two groups (group D and C). Group D received 1 ml/kg of 0.25% bupivacaine with 0.2 mg/kg of dexamethasone in normal saline and group C received 1 ml/kg of 0.25% bupivacaine with 1 mg/kg of clonidine in normal saline, with maximum volume of 12 ml in both the groups. All patients were assessed intraoperatively for hemodynamic changes and requirement of sevoflurane concentration and postoperatively for pain by using FLACC pain score and for sedation by using four-point sedation score. Results The mean duration of analgesia was 18-24 h in group D, whereas in group C it was 12-15 h. Group C had a higher sedation score up to 2 in immediate postoperative period for 1 h compared with below 1 h in group D. Conclusion Postoperative analgesia is longer with dexamethasone compared with clonidine without any side effects.
  - 1,892 160
Terlipressin versus adrenaline in refractory septic shock
Heba A Labib, Niven G Fahmy, Tamer Y Elie Hamawy
April-June 2016, 9(2):186-193
Objective The aim of this study was to compare terlipressin versus adrenaline in refractory septic shock. Patients and methods In this interventional prospective randomized study, 80 patients between 18 and 60 years of age who presented with refractory septic shock were enrolled. The patients were divided randomly into two groups of 40 patients each. Group A patients were treated with adrenaline and group T patients were treated with terlipressin. The goals of the therapy were to achieve and maintain for 6 h all of the following: (i) mean blood pressure greater than 65 mmHg; (ii) systemic vascular resistance index greater than 1300 dynes s/cm 5 /m 2 ; (iii) cardiac index (CI) greater than 4.0 l/min/m 2 ; and (iv) oxygen delivery index greater than 550 ml/min/m 2 . The patients were classified into responders and nonresponders to the drugs used. Results The number of responders was significantly higher in the terlipressin group. There were 23 (58.97%) responders in the T group and 13 (35.13%) responders in the A group. The terlipressin group showed a significant increase in mean blood pressure from 49.9 ± 14.82 to 77.79 ± 20 mmHg and a significant increase in systemic vascular resistance index from 898 ± 292 to 1420 ± 537 dynes s/cm 5 /m 2 ; urine output and creatinine clearance also showed an increase. Group T patients showed a significant decrease in heart rate and norepinephrine infusion. As regards cardiac index and oxygen delivery index, they showed minimal decrease at the end of the study, but their levels were still above our target levels. Conclusion Terlipressin therapy is better than adrenaline in improving the hemodynamic variables and kidney functions in refractory septic-shock patients.
  - 3,201 403
Effect of recombinant growth hormone on immune response in pediatric burn patients
Yasser A Salem, Rania Hassan, Dalia M Elfawy, Neveen Girgis
April-June 2016, 9(2):194-200
Background Management of severely burnt children is one of the most challenging situations in the ICU. Control of the hypercatabolic state is the most limiting step that determines patient survival. Immunocompromisation and delayed wound healing usually result in severe sepsis, which is the most common direct cause of death in these patients. There is debate about the efficacy and safety of recombinant human growth hormone (rGH), although it has been used to improve healing of burnt patients. Role of growth hormone in immunomodulation has been proposed theoretically and serologically, but it has not been tested clinically. We reported in this study how far the use of rGH in the management of burnt patients can improve their immune status and increase survival. Patients and methods Forty pediatric patients were enrolled in this study, randomly assigned into two groups. Group A received rGH and was compared with group B, which did not receive rGH. Those two groups were compared with respect to overall mortality rate, hospital and ICU stay, serum transferrin, C-reactive protein, and positivity of blood culture. Results The overall mortality rate was slightly lower in group A (20%) compared with B group (25%). No significant decrease in hospital stay was noticed between the two groups. There was significant improvement in serum transferrin especially by day 14 in addition to a significant drop in C-reactive protein in group A. Group A was found to be more protected from bacteremia. Conclusion The use of rGH in pediatric burnt patients improves overall mortality and optimizes immune status, in addition to improvement of wound healing and donor site healing. This eventually reduces the length of hospital stay.
  - 1,605 145
Ketamine-propofol sedation versus propofol-pethidine sedation for minor plastic surgery procedures
Hoda Shokri
April-June 2016, 9(2):245-249
Objective The aim of the study was to compare the efficacy of ketamine-propofol (KP) sedation versus propofol-pethidine (PP) sedation for minor plastic surgery procedures. Patients and methods This prospective study was conducted by randomization of 60 patients undergoing minor plastic surgery procedures. Patients were randomly divided into two groups by means of the sealed envelope technique: the KP group (n = 30) and the PP group (n = 30). In the former group, patients received induction with a bolus dose of ketamine 1 mg/kg dissolved in 10 ml saline, and in the latter group patients received induction with a bolus dose of 1 mg/kg pethidine dissolved in 10 ml saline intravenously. In both groups propofol was given as 1 mg/kg propofol, intravenous, bolus dose, additional doses of propofol 30 mg IV were given if sedation score was less than 4 in both groups followed by 5 mg/kg/h intravenous infusion. Sedation score, pain score, mean arterial blood pressure, total dose of propofol, conversion to general anesthesia, postoperative patient satisfaction score, and incidence of postoperative complications such as hypotension, oxygen desaturation, and vomiting were all recorded. Results Intraoperative pain scores, mean arterial blood pressure, and postoperative patient satisfaction scores were significantly higher in the PP group compared with the KP group. The sedation score was significantly higher in the KP group than in the PP group. Total dose of propofol was significantly lower in the KP group than in the PP group. There was no significant difference between the study groups regarding conversion to general anesthesia. Recovery time was significantly longer in the KP group compared with the PP group. There were significant differences in the incidence of complications such as oxygen desaturation and postoperative vomiting among the study groups. Conclusion The KP combination provides an attractive combination for procedural sedation compared with PP combination in terms of better sedation, hemodynamic stability, and lower incidence of complications.
  - 1,570 144
Comparison between colloid preload, coload, and no load in the prevention of spinal anesthesia-induced hypotension in patients undergoing inguinal hernia repair
Gamal M Elewa, Heba A Labib, Ghada M Samir
April-June 2016, 9(2):250-255
Background and objective The aim of this study was to know whether colloid fluid administration (either preloading or coloading) can decrease the incidence of hypotension secondary to spinal anesthesia in an elderly population undergoing inguinal hernia repair without mesh. Patients and methods After obtaining institutional ethical committee's approval and patients' informed consent, 84 patients (aged 61-89 years) scheduled for elective inguinal hernia repair were enrolled in this prospective, randomized study. We compared the incidence of hypotension and ephedrine requirement after spinal anesthesia between three groups: group P (n = 28), in which patients were preloaded with 500 ml of 6% hydroxyethyl starch solution (130/0.4), group C (n = 28), in which patients were coloaded with 6% hydroxyethyl starch solution during spinal anesthesia, and group N (n = 28), in which patients were not given any fluid. Results The incidence of hypotension and the mean dose of ephedrine were not significantly different between the three groups. Conclusion We concluded that, in elderly patients undergoing inguinal hernia repair, withholding fluid loading (whether preloading or coloading) did not increase the incidence of spinal anesthesia-induced hypotension and did not affect the dose of ephedrine required to correct hypotension, if occurred.
  - 1,922 212
Dexmedetomidine and sodium bicarbonate as adjuvants to epidural lidocaine: A comparative study
Srivishnu V Yallapragada, Gopi K Vutukuri, Nagendra N Vemuri, Mastan S Shaik
April-June 2016, 9(2):256-259
Context Efforts to find a better adjuvant in regional anesthesia have been underway since long. Dexmedetomidine and sodium bicarbonate have been proven to be effective in providing the same pharmacological benefit through two different mechanisms of action. In this study, we sought to investigate which is superior between the two. Aims The aim of the study was to compare the efficacy of dexmedetomidine and sodium bicarbonate as adjuvants to lidocaine in epidural anesthesia. Settings and design This was a prospective, randomized, double-blind study. Materials and methods Sixty patients scheduled for lower-limb trauma orthopedic surgeries under epidural anesthesia were divided into two groups group D and group S, with 30 patients in each. Patients in group D received 12.5 ml of 2% lidocaine+dexmedetomidine 0.5 mg/kg in 1.5 ml solution, making a total volume of 14 ml. Patients in group S received 12.5 ml of 2% lidocaine+1.5 ml of 7.5% sodium bicarbonate, making a total volume of 14 ml. Onset, time for peak sensory level, time for two-segment regression, and the total mephentermine consumed to maintain the hemodynamics were recorded, tabulated, and statistically analyzed. Results The onset of sensory block was quicker in group D. The time for attaining peak sensory level and the mephentermine consumption was nearly the same in both groups. The time for two-segment regression was more in group D than in group S. Conclusion Dexmedetomidine is more effective than sodium bicarbonate in hastening the onset and prolonging the duration of blockade when used as an adjuvant to epidural lidocaine.
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Efficacy of sacral epidural blockade with bupivacaine versus morphine as pre-emptive analgesia for lumbar laminectomy surgeries
Eid Mansy Mohammed Hussien, Gihan Seif El Nasr Mohammed, Ahmed Nagah Elhassanin El Shaer, Abdelaziz Abdallah Abdelaziz, Assem Adel Moharram
April-June 2016, 9(2):260-266
Objectives Patients undergoing lumbar laminectomy experience severe pain in the postoperative period, which may increase the incidence of postoperative morbidity and complications. Adequate pain relief hastens rehabilitation and decreases the incidence of chronic pain. This study was designed to compare the efficacy of pre-emptive image-guided caudal epidural blockade with bupivacaine at low concentrations versus morphine administration on the attenuation of the stress response during and after lumbar laminectomy surgeries. Patients and methods Ninety adult American Society of Anaesthesiologists' physical status I and II patients were scheduled to undergo a single-level lumbar laminectomy and were administered a pre-emptive caudal injection of either 30 ml of bupivacaine 0.125% (group A) or 50 mg/kg preservative-free morphine added to a total dose of 30 ml saline (group B) or 30 ml saline (group C). Intraoperative vital data (heart rate, systolic, and diastolic blood pressure) were collected. The postoperative verbal rating scale score, the time of the first rescue analgesia, the total dose of rescue analgesia, and adverse effects were recorded for all patients in the first 24 h after surgery. Results The total verbal rating scale score and the need for rescue analgesia were significantly less in group A and group B than in group C, indicating better analgesia. There was no significant difference between the three groups in itching or the sedation score. Group C had a higher incidence of vomiting than groups A and B, whereas there was delayed ambulation in group A in comparison with the other groups. Conclusion A single caudal epidural injection of morphine is a safe, simple, and effective technique that provides prolonged postoperative duration of analgesia with fewer analgesic requirements postoperatively with earlier patients' ambulation without occurrence of any hemodynamic changes or increased incidence of adverse effects in lumber laminectomy surgeries.
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The effects of dexmedetomidine added to bupivacaine for parasternal intercostal block in pediatric open heart surgery
Hani I Taman, Ibrahim I Abd El Baser, Mohamed A.F. El Gamal
April-June 2016, 9(2):159-164
Background Regional analgesia is used for pain relief after pediatric open heart surgery. This study was designed to compare the analgesic effect of dexmedetomidine added to bupivacaine in performing parasternal block after sternotomy. Patients and methods Sixty American Society of Anesthesiologists (ASA) III-IV patients who were submitted to corrective open cardiac surgery were enrolled in this study and randomly allocated either into the dexmedetomidine group in which patients were given a mixture of 0.25% bupivacaine, 0.6 ml/kg and dexmedetomidine 1 mg/kg (dexmedetomidine group, n = 30) or into the control group in which patients were given 0.25% bupivacaine and 0.6 ml/kg (control group, n = 30). Postoperative pain (FLACC) scores, hemodynamics, opioid consumption, and hospital length of stay were evaluated in all patients. Results Heart rate, mean arterial pressure, and FLACC score were significantly lower in the dexmedetomidine group compared with the control group after 4 and 8 h in ICU. Duration of intubation and ICU stay were significantly shorter in the dexmedetomidine group compared with the control group. Ramsay sedation score was lower in the dexmedetomidine group compared with the control group at 4 h in ICU. Bradycardia and hypotension incidence were higher in the dexmedetomidine group compared with that in the control group. Conclusion Adding dexmedetomidine to bupivacaine for parasternal block in pediatric patients submitted to open heart surgery leads to good pain control, less analgesic consumption, early extubation, and short ICU length of stay.
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Use of dexmedetomidine for fast-track anesthesia in noncomplex pediatric cardiac surgery
Eman Mohamed Kamel, Heba Fouad Abdelaziz, Iman Kamal Abo Seif
April-June 2016, 9(2):165-169
Introduction Fast-track anesthesia technique is now an important aspect for reducing or eliminating the adverse effects of prolonged postoperative ventilation together with reducing ICU and hospital length of stay. This study was conducted to evaluate the effect of using dexmedetomidine as an adjuvant drug for fast-track technique in pediatric cardiac surgery. Patients and methods Sixty patients of both sexes with ages ranging from 1 to 12 years indicated for correction of noncomplex congenital heart diseases with cardiopulmonary bypass (CPB) were included in this study. After standard inhalational induction using sevoflurane for all patients, they were randomly classified into two groups of 30 each. In the dexmedetomidine group (group D), the patients received an initial bolus dose of dexmedetomidine (0.4 mg/kg) over 10 min, followed by continuous infusion of 0.5 mg/kg/h until the end of CPB. In the propofol group (group P) the patients received an initial bolus dose of propofol (2 mg/kg) over 30 s, followed by infusion at rate of 0.5 mg/kg/min until the end of CPB. Results There were significant differences between the two groups (P < 0.05). As regards hemodynamics, heart rate was higher in the propofol group, whereas mean arterial pressure was higher in the dexmedetomidine group. Moreover, total dose of fentanyl, time of extubation in ICU, postoperative pain score, and need for postoperative analgesia were significantly higher in the propofol group. Conclusion Dexmedetomidine helps in fast-track anesthesia in pediatric cardiac surgery and has many desirable effects that encourage its use in the perioperative period.
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Root cause analysis of ventilator-associated pneumonia and the effect of analysis of expanded ventilator bundle of care
Hossam Ibrahim Eldesuky Ali, Ayman Ali Rayan, Tamer Hussein Ibrahim
April-June 2016, 9(2):170-177
Objectives The study had the following aims: (i) assess the risk factors and causes of ventilator-associated pneumonia (VAP) by means of the root cause analysis (RCA) module; (ii) compare the compliance with expanded ventilator bundle (EVB) and the effect of EVB on VAP rate, length of ICU stay (LOS), and mortality rate before and after bundle implementation; and (iii) suggest an action plan to reduce VAP. Patients and methods An 18-month study was conducted on all ventilated patients in our ICU. The preinterventional period was 9 months before implementing the bundle. We analyzed the causes and risk factors of VAP by using the RCA module. The postinterventional period was 9 months after implementing the bundle. Compliance with EVB was compared before and after implementing the bundle on a quarterly basis. We analyzed the effect of the bundle on VAP rate, LOS, and mortality rate. We suggested an action plan to reduce the VAP rate. Results There was lower compliance with the bundle in the preinterventional period than in the postinterventional period (P < 0.001). There were highly statistically significant reductions in VAP rate, LOS, and mortality rate after implementation of EVB (P < 0.001). Conclusion EVB was associated with effective and significant reductions in VAP rate, LOS, and mortality rate. Implementation of the RCA module was helpful in suggesting a new action plan that would improve bundle of care and its compliance.
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Insertion characteristics of three supraglottic airway devices: A randomized comparative trial
Hesham F Soliman
April-June 2016, 9(2):212-218
Background I-gel is a new single-use supraglottic airway device without an inflatable cuff. The aim of this study was to compare I-gel, a Proseal laryngeal mask airway (PLMA), and a laryngeal tube (LT) for ease of insertion, hemodynamic effects of insertion, and associated airway morbidity. Patients and methods Seventy-five adult patients, both sexes, were assigned randomly to I-gel (I), PLMA (P), and LT (L) groups according to the supraglottic device applied. Insertion time, airway sealing pressure, insertion success rate, insertion-associated hemodynamic effects, ease of gastric tube insertion, and associated airway morbidities were assessed. Results Demographic data and duration of both surgery and anesthesia in the three groups were comparable. Insertion time (s) was significantly shorter in group I (18.9 ± 0.9) compared with group P (26.2 ± 1.1) and group L (26.2 ± 1.0). Airway sealing pressure (cm H 2 O) was higher in group P (29.6 ± 1.2) compared with group I (26.0 ± 1.0) and group L (22.9 ± 0.9). The success rate at the first insertion attempt was higher in group I (96.0%) compared with group P (84.0%) and group L (88%). Blood-stained devices and occurrence of postoperative sore throat were lower in group I than the P and L group, with no significant differences. Heart rate, mean arterial pressure, and cardiac index were significantly increased in the postinsertion period in the P and L group compared with group I. Conclusion In the I-gel group, higher insertion success rate, and lower both hemodynamic changes and airway morbidities were noted compared with PLMA and LT. However, airway sealing ability was better with PLMA.
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Effect of alpha-lipoic acid on acute lung injury and acute kidney injury in major postpartum hemorrhage
Rania M Ali, Marwa A Khairy, Dina Y Mansour
April-June 2016, 9(2):219-224
Introduction Postpartum hemorrhage (PPH) is a major cause of maternal morbidity and mortality. Resuscitated hemorrhagic shock patients are susceptible to the development of a systemic inflammatory response and organ dysfunction. This study aimed to investigate the effects of alpha-lipoic acid (ALA) as an adjunctive therapy that protects against the occurrence of acute lung injury (ALI) and acute kidney injury (AKI) in patients with major PPH. Patients and methods Forty patients admitted to Ain Shams Obstetric ICU with major PPH were randomly allocated into two equal groups: the ALA group received intravenous 1200 mg ALA once daily for 3 days and the placebo group received 500 ml of 0.9% isotone saline solution over 60 min once daily for 3 days. The primary study outcome was the serum levels of thiobarbituric acid reactive species as a marker of oxidative damage and interleukin-6 as a marker of inflammatory response. The secondary outcomes were the incidence of ALI and AKI. Results ALA attenuated the oxidative damage and the inflammatory response as evidenced by the reduction in both thiobarbituric acid reactive species and interleukin-6 levels, respectively (P < 0.001). AKI developed in 5% of patients in the ALA group versus 25% of patients in the placebo group 48 h after ICU admission. The oxygenation index (PaO 2 /FiO 2 ) reached less than 300 in 10% of patients in the ALA group and in 30% of patients in the placebo group. Conclusion ALA decreases markers of oxidative stress and inflammatory response and also has a preventive effect on the progression of ALI and AKI in patients with major PPH.
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Comparative study between magnesium sulfate and phenytoin for prevention of eclampsia in severely pre-eclamptic patients with acute kidney injury
Aktham A shoukry, Ahmed Al Hennawy, Mohsen Bassiony, Mohamed Sallam, Ramy A Mahrous
April-June 2016, 9(2):225-228
Introduction Pre-eclampsia is a pregnancy-specific, multisystem disorder that is characterized by the development of hypertension and proteinuria after 20 weeks of gestation. Acute kidney failure occurs in about 20% of patients with severe pre-eclampsia. Magnesium sulfate is the medication of choice for the prevention of eclamptic seizures in women with severe pre-eclampsia and for the treatment of women with eclamptic seizures. This medication is renally excreted and hence significant renal impairment can result in exaggerated toxicity. Phenytoin was specifically developed as an anticonvulsant and is the most widely prescribed drug for epilepsy worldwide. The aim of this study is to compare magnesium sulfate with phenytoin for prevention of eclampsia in severely pre-eclamptic patients with acute kidney injury. Patients and methods Forty pregnant women were enrolled in the study; all patients had American Society of Anesthesiologists (ASA) physical status of II or III and were proved to have severe pre-eclampsia with acute kidney injury. Patients were allocated randomly into one of two groups (20 patients each). Group A (magnesium sulfate group) included 20 patients who received magnesium sulfate for prophylaxis against eclampsia. Group B (phenytoin group) included 20 patients who received phenytoin for prophylaxis against eclampsia. For each patient, the following data were collected: age, gestational age, body weight, height, occurrence of magnesium or phenytoin toxicity, occurrence of fits, and fetal outcome. Results In terms of the occurrence of fits, we found a statistically significant difference between the magnesium group and the phenytoin group as five patients in the phenytoin group developed fits, whereas none of the patients in the magnesium group developed fits. In this study, we did not find a statistically significant difference between the magnesium group and the phenytoin group in the incidence of magnesium or phenytoin toxicity and fetal outcome. Conclusion The results of this study showed that prophylaxis against eclampsia in severely pre-eclamptic patients with acute kidney injury using magnesium sulfate (adjusted dose) resulted in no toxicity and no fetal effects besides fewer incidences of fits compared with phenytoin.
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The effect of pentoxifylline on the glomerular function in patients with severe pre-eclampsia
Rania M Ali, Rasha S Bondok, Amal H Rabie, Menat Allah A Shaaban, Noha H Rabie
April-June 2016, 9(2):229-234
Introduction Pentoxifylline (PTX) is a phosphodiesterase inhibitor that directly upregulates the expression of vascular endothelial growth factor mRNA. Pre-eclampsia (PE) is a pregnancy-specific vascular endothelial disorder with a characteristic glomerular lesion, glomerular endotheliosis, that is due to vascular endothelial growth factor deprivation. This study aimed to investigate the effect of PTX on the functional manifestations of the glomerular endothelial injury in patients with severe PE. Patients and methods Forty patients with severe PE admitted to the Ain Shams Obstetric ICU were assigned randomly in the immediate postpartum period to one of two groups (20 in each group): the PTX group received a continuous intravenous infusion of PTX 400 mg every 8 h daily for 3 days; the control group received normal saline solution as placebo every 8 h daily for 3 days. The primary endpoint was the improvement of renal assessment data in the form of the serum creatinine level, the urine protein/creatinine (P/C) ratio, and urine nephrin levels. Results PTX administration in patients with severe PE was associated with significant reduction of urinary nephrin compared with baseline values (day 1) as well as with the values on day 3 in the control group (P = 0.007 and P < 0.001, respectively). Further, administrating PTX showed significant reduction of the urine P/C ratio and serum creatinine levels. Acute kidney injury developed overall in 10 and 40% of the patients in the PTX group and the control group, respectively. Conclusion The current study demonstrates that PTX administration to patients with severe PE, as an additional treatment to standard therapy on admission to the ICU, exhibits a renoprotective effect.
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