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   2016| October-December  | Volume 9 | Issue 4  
    Online since January 12, 2017

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Addition of dexamethasone–chlorpheniramine mixture reduces the incidence of vomiting associated with oral ketamine premedication after pediatric dental procedures
Ayman A Abdellatif, Manal M Kamal, Rania A.H. Ishak
October-December 2016, 9(4):478-484
Background Oral ketamine has been shown to induce safe and effective sedation in children, but with a high incidence of postoperative vomiting. Vendexine (dexamethasone–chlorpheniramine mixture) is a commercially available syrup used primarily to treat allergic conditions. Each of its components has antiemetic effects. In the present study, we aimed to determine whether the addition of vendexine to oral ketamine premedication affects the incidence of postoperative vomiting. Patients and methods Sixty-four children scheduled for elective dental procedures under general anesthesia were enrolled in this prospective, randomized, double-blind study. They received an oral premedication mixture (total volume of 0.42 ml/kg) of either ketamine 6 mg/kg (0.12 ml/kg) mixed with dextrose 50% and apple juice (the K group), or ketamine 6 mg/kg (0.12 ml/kg) mixed with dextrose 50% and vendexine syrup (0.25 ml/kg) (the VK group). Sedation onset was noted. Scores for drug acceptance, sedation, emotional status, and behavior during parents’ separation, on venipuncture, and face mask application were rated. Incidence of postoperative vomiting, emergence agitation score, fentanyl consumption, and recovery time were also recorded. Results The two groups were comparable as regards sedation onset, scores for drug acceptance, sedation, emotional status, and behavior during parents’ separation, on venipuncture, and face mask application. However, a significant reduction of postoperative vomiting in the VK group was noticed compared with the K group (9.3 vs. 37.5%). In addition, emergence agitation and fentanyl consumption were significantly reduced in the VK group. Conclusion Vendexine added to oral ketamine reduces the incidence of postoperative vomiting associated with ketamine premedication in children.
  9,359 427 -
A case report of asystole after a test dose of ceftriaxone in an adult man
Sawsan Aboul-Fotouh, Yosra M Magdy, Rania M Ali
October-December 2016, 9(4):617-619
Ceftriaxone is a commonly used antibiotic for various infections such as respiratory tract infection, urinary tract infection, and enteric fever, as well as in surgical prophylaxis. Hypersensitivity reactions after ceftriaxone therapy are uncommon but are potentially life-threatening, and they may lead to cardiac arrest. Here we report a 44-year-old man who presented with bradycardia, bronchospasm, hypotension, and cardiac arrest (asystole) after a single injected dose of ceftriaxone introduced for surgical prophylaxis. Epinephrine was given intravenously, and cardiopulmonary resuscitation was performed successfully. The patient regained his conscious level 2 h later and became hemodynamically stable within 4 h; next, he was extubated and closely observed for 24 h and then discharged. Physicians should be aware of the risk of anaphylaxis and asystole that may occur after the first dose of ceftriaxone and be ready for managing it properly.
  7,482 222 1
Perioperative nutrition to enhance recovery after surgery
Dina Salah
October-December 2016, 9(4):469-477
Preoperative malnutrition is a major risk factor for increased postoperative morbidity and mortality. Patients at risk for malnutrition should be identified early. The Nutritional Risk Score is a validated tool to identify patients who should benefit from nutritional support. The adoption of total parenteral nutrition followed by the extraordinary progress in parenteral and enteral feedings, in addition to the increased knowledge of cellular biology and biochemistry, has allowed clinicians to treat malnutrition and improve surgical patient’s outcomes. Periods of prolonged fasting should be minimized and nutrition should be commenced as early as possible after surgery, preferably through the enteral route. The surgical patient with established malnutrition should begin aggressive nutrition at least 7–10 days before surgery. Those patients in whom eating is not anticipated beyond the first 5 days following surgery should receive the benefits of early enteral or parenteral feeding depending on whether the gut can be used. Many patients may benefit from newer enteral formulations, such as those designed to enhance immune function (immunonutrition).
  6,328 838 2
Pin index safety system and color coding: is it enough?
Udita Naithani, Sneha Arun Betkekar, Devendra Verma, Ravindra K Gehlot, Rajkumar Sundararaj
October-December 2016, 9(4):626-628
Despite a number of preventive mechanisms, inadvertent administration of nitrous oxide in place of oxygen can lead to fatal hypoxemia. Here we report two cases of hypoxia that occurred when we switched to the emergency cylinder for oxygen supply after exhaustion of the main oxygen cylinder. The urgency shown by the anesthetist and operating room staff to restore the main oxygen supply prevented any fatalities from occurring in our case. We found that there was incorrect painting of the nitrous oxide cylinder with the color code of oxygen. Further, damaged pins on the yoke assembly allowed the attachment of the faulty E cylinder to the machine. Even though such errors are made by the supplier we suggest that all equipment including the cylinder be thoroughly checked by the anesthetist. This also highlights the role of respiratory gas monitoring in the prevention of such mishaps.
  5,515 163 -
Lidocaine versus dexmedetomidine infusion in diagnostic laparoscopic gynecologic surgery: a comparative study
Sherif G Anis, Ghada M Samir, Heba B ElSerwi
October-December 2016, 9(4):508-516
Background The aim of this study was to assess the effectiveness of intraoperative lidocaine versus dexmedetomidine infusion on hemodynamic stability during pneumoperitoneum, as well as the recovery profile of diagnostic laparoscopic gynecologic surgeries. Patients and methods A total of 60 female patients of American Society of Anesthesiologist (ASA) physical status I were included in the study and divided into two groups: group L and group D. Group L received lidocaine hydrochloride 2%, and group D received dexmedetomidine hydrochloride. The hemodynamic changes during pneumoperitoneum as well as the recovery profile (postoperative sedation, pain scores, and analgesic requirements) were recorded. Results During pneumoperitoneum, group D patients showed a statistically significant decrease in mean heart rate compared with group L patients. However, the mean systolic blood pressure, diastolic blood pressure, and mean blood pressure in group L patients showed statistically and clinically nonsignificant changes compared with those of group D patients. As regards the recovery profile, group D patients recorded a significantly higher median sedation score compared with group L patients, and the postoperative pain scores were significantly better in group L than in group D patients after 30 min, 1 h from arrival at the postanesthesia care unit, and at 2 h in the ward. However, this resulted in a statistically nonsignificant number of patients requiring pethidine in the postanesthesia care unit, as well as statistically nonsignificant total pethidine requirements of less than 50 mg. Conclusion Lidocaine offers hemodynamic stability during pneumoperitoneum, as well as a decrease in the intensity of postoperative pain with opioid sparing, offering a less sedated patient than dexmedetomidine during day-case diagnostic laparoscopic gynecologic surgery.
  3,506 360 1
The effects of adding lidocaine hydrochloride nasal spray (10%) to xylometazoline nasal drops (0.1%) in functional endoscopic sinus surgery: a comparative study
Ghada M Samir, Niven Gerges-Fahmy, Heba A Labib
October-December 2016, 9(4):598-605
Background The aim of this study was to assess the effectiveness of adding lidocaine hydrochloride nasal spray (10%) to xylometazoline nasal drops (0.1%) as an anesthetic approach in patients undergoing functional endoscopic sinus surgery. Patients and methods A total of 52 patients of American Society of Anesthesiologist physical status I were included in the study and divided into two groups: the first group (group X) received xylometazoline hydrochloride nasal drops (0.1%) and lidocaine hydrochloride nasal spray (10%), whereas the second group (group S) received xylometazoline hydrochloride nasal drops (0.1%) only. The total blood loss (TBL) during surgery, the hemodynamic changes up to 30 min following incision of the nasal mucous membrane (m.m.) and in the immediate postoperative period, the need to add propranolol and the dose of propranolol given, as well as the duration of surgery and the quality of the surgical field were recorded. Results TBL and the duration of surgery were statistically significantly lower in group X than in group S. On comparing the grades given by the surgeon for the surgical field assessment, we found the results to be statistically highly significant for each group in favor of a better surgical field in group X than in group S. As for the hemodynamic parameters, the systolic blood pressure, diastolic blood pressure, mean blood pressure, and heart rate in group S were higher than the values at baseline after induction of anesthesia, after incision of the nasal m.m., and during the 30 min after incision of the nasal m.m., and were also higher than those recorded in group X at the same time periods and this was statistically and clinically significant as propranolol was given to patients in group S after induction of anesthesia. Conclusion Better intraoperative hemodynamic control ensuring patient safety with decreased intraoperative TBL and duration of surgery, with better grades for the quality of the surgical field during functional endoscopic sinus surgery, can be achieved with the use of lidocaine hydrochloride nasal spray (10%) with xylometazoline nasal drops (0.1%).
  3,433 200 -
Patient-controlled analgesia versus patient-controlled analgesia by proxy for the management of postoperative pain in major pediatric cancer surgery
Essam Mahran, Ahmed H Abou El-Soud, Ahmed S Ragab, Fatma H Elshamy
October-December 2016, 9(4):501-507
Background Children suffer postoperative pain in the same way as adults. Pediatric pain management is a challenge. Patient-controlled analgesia (PCA) is a flexible, reliable, and individualized method in postoperative pain therapy. However, young children are not able to use PCA themselves, and hence they need to receive PCA by proxy (parent or nurse). The guidelines for PCA by proxy in pediatrics are still insufficient. Aim The aim of this study was to determine the safety and efficacy of PCA by proxy after major pediatric cancer surgery. Patients and methods We studied 330 pediatric cancer patients between 1 and 10 years of age scheduled for major surgery. They were divided into three equal groups: group C (child PCA), group P (parent proxy), and group N (nurse proxy). In each group we measured vital signs, pain intensity, total morphine consumption, side effects, and specific PCA monitoring for the first 72 h postoperatively. Results We found that pain scores were higher in the nurse group compared with the other two groups on days 2 and 3 (P < 0.001); morphine consumption was higher in the child group (older age). Vital signs were comparable between groups. There were no significant differences in sedation scale, and there were limited complications with no difference between groups. Conclusion Parent-controlled PCA is a safe and effective method of analgesia for children between 1 and 6 years of age. Nurse-controlled proxy is safe but not effective in controlling child pain. Child-controlled analgesia is safe and effective in children above 6 years of age.
  3,249 313 1
Dexmedetomidine infusion versus fentanyl for analgesia and prevention of emergence agitation and delirium in children undergoing adenotonsillectomy
Sanaa M Elfawal, Abeer M Eldeek, Manal M Kamal
October-December 2016, 9(4):485-492
Background This randomized controlled study aimed to evaluate whether an intraoperative infusion of dexmedetomidine would be a safe and effective substitute to fentanyl intraoperatively, and whether it would be effective in reducing the incidence and severity of emergence agitation and delirium in children undergoing adenotonsillectomy. Patients and methods This study was conducted on 70 pediatric patients, aged 3–7 years, of both sexes, of ASA I and II, who were scheduled for elective adenotonsillectomy. The patients were randomly assigned to two groups: group D (dexmedetomidine infusion group; 35 patients) received intravenous dexmedetomidine (2 μg/kg) over 10 min, followed by 0.7 μg/kg/h until 5 min before the end of the surgery, and group F (intravenous fentanyl group; 35 patients) received intravenous fentanyl 1 μg/kg as a bolus. No premedication was given to any of the patients. The number of patients in each group who needed intraoperative fentanyl, the fentanyl dose, time of administration of fentanyl, duration of surgery and anesthesia, and the time to awakening were recorded. Pain was evaluated using the objective pain scale score in the postanesthesia care unit (PACU), which was managed with rescue intravenous pethidine. Emergence agitation was evaluated in the PACU using two scales: the Pediatric Anesthesia Emergence Delirium scale and the five-point agitation scale described by Cole. Results The time to awakening in group D was significantly shorter compared with that in group F (P<0.05). Group D showed a statistically significantly lower maximum objective pain scale score, lower Pediatric Anesthesia Emergence Delirium score, and lower emergence agitation score compared with group F at arrival at the PACU. There was no statistically significant difference between the two groups as regards preoperative heart rate, but there was significantly lower heart rate in group D than in group F after induction (P<0.05). No side effects were observed during the first 24 h postoperatively in the two groups. Conclusion Dexmedetomidine is a safe and effective analgesic substitute to fentanyl intraoperatively and reduces analgesic requirements postoperatively. It is also effective in reducing the incidence and severity of emergence agitation and delirium in children undergoing adenotonsillectomy.
  3,186 352 -
Comparison of caudal epidural clonidine with fentanyl as an adjuvant to ropivacaine 0.25% for postoperative analgesia in children undergoing various infraumbilical surgeries: A prospective randomized study
Sudheendra Saini, Veena Patodi, Surendra K Sethi, Neena Jain, Pooja Mathur, Beena Thada
October-December 2016, 9(4):493-500
Background Caudal epidural block is commonly used as a safe, reliable, easy-to-administer technique for abdominal and lower limb surgeries in pediatric patients and allows rapid recovery from anesthesia with effective postoperative analgesia. The aim of our study was to compare the efficacy of clonidine versus fentanyl when used as an additive to ropivacaine during single-shot caudal epidural analgesia in pediatric patients for postoperative pain relief. Patients and methods This randomized prospective double-blind study was conducted on 60 children of American Society of Anesthesiologists grades I and II aged 1–7 years scheduled for various infraumbilical surgical procedures who were randomly allocated into two groups to receive either ropivacaine (0.25%, 1 ml/kg) and clonidine (2 μg/kg) (group RC) or ropivacaine (0.25%, 1 ml/kg) and fentanyl (1 μg/kg) (group RF). Caudal epidural block was performed after induction of general anesthesia. Postoperatively, patients were observed for duration of analgesia, sedation score, recovery time, hemodynamics, and side effects or complications. Results Both groups were similar with respect to patient’s demographic profile, baseline hemodynamic parameters, and duration of surgery. The analgesic properties and hemodynamics were also comparable in both groups (P>0.05). The mean recovery time and sedation score were significantly lower in group RC as compared with group RF (P<0.05). Side effects such as nausea, vomiting, and respiratory depression were seen only in group RF. Conclusion From our study we concluded that both clonidine (2 μg/kg) and fentanyl (1 μg/kg) can be used as an adjuvant to single-shot caudal epidural anesthesia using 0.25% ropivacaine for effective postoperative analgesia in children. Because of its more favorable side-effect profile, with less respiratory depression, nausea, vomiting, and more patient comfort, clonidine is a better choice for use as an adjuvant to caudal epidural anesthesia in children.
  3,060 383 2
Ultrasound-guided caudal analgesia using fentanyl versus dexmedetomidine as an adjuvant for levobupivacaine in infraumbilical pediatric surgeries
Mai Mohsen Abdel Aziz, Amr Mohamed Abdelfatah, Hadil Magdy Abdel Hamid
October-December 2016, 9(4):542-548
Introduction Single-shot caudal analgesia is a useful technique in controlling postoperative pain in infraumbilical pediatric surgeries, although of a limited duration. The aim of this study was to evaluate the analgesic efficacy and rate of success when incorporating dexmedetomidine or fentanyl to levobupivacaine in ultrasound (U/S)-guided caudal block for infraumbilical surgeries. Patients and methods This prospective, randomized, double-blinded study was conducted on 63 pediatric patients undergoing infraumbilical surgeries, allocated into three groups to receive inhalational anesthesia with an appropriately sized laryngeal mask airway, followed by U/S-guided caudal epidural block using either only 0.25% levobupivacaine (L), or incorporating it with 1 μg/kg fentanyl (LF) or 1 μg/kg dexmedetomidine (LD) in a total volume of 0.7 ml/kg. Pain assessment using Children’s and Infants’ Postoperative Pain Scale (CHIPPS) score, time to first analgesic, and total analgesia required in the three groups and Ramsay sedation score were recorded. Hemodynamics and any adverse effects were also documented. Results None of the patients required intraoperative additional analgesia. A statistically significantly lower postoperative CHIPPS values with prolonged analgesic duration and time to rescue analgesia was observed in the levobupivacaine–fentanyl and levobupivacaine–dexmedetomidine groups (275±20.62 and 304.75±25.2, respectively) as opposed to the levobupivacaine only group (203.1±18), with an evident reduction in the total paracetamol dose required postoperatively (P<0.001). Arousable sedation time was significantly prolonged in the levobupivacaine–fentanyl and levobupivacaine–dexmedetomidine groups. Apart from pruritus and urine retention in the levobupivacaine–fentanyl group, no adverse events were recorded in all groups. Conclusion Caudal levobupivacaine combined with dexmedetomidine 1 μg/kg in pediatric patients undergoing infraumbilical surgeries provides prolonged postoperative analgesia comparable to levobupivacaine–fentanyl and superior to levobupivacaine alone, with reduced postoperative analgesic requirements and extended arousable sedation time. The use of U/S raises the safety and ensures the success of caudal block.
  2,555 205 3
Systemic versus perineural dexamethasone as an adjuvant to bupivacaine in combined femoral and sciatic nerve blocks in lower-limb vascular surgeries: a prospective randomized study
Hala E Abdel Naim, Khaled A Elshafaie, Sherif M Soaida, Mohammed M Abdel-Haq, Kareem M Nawar
October-December 2016, 9(4):569-575
Background and aim Various peripheral nerve block techniques have been described to deliver anesthesia and analgesia that allow better functional recovery and shortened hospital stay following major lower-limb surgeries. We aimed to compare the possible effect of perineural dexamethasone versus systemic dexamethasone after nerve stimulator-guided combined femoral and sciatic nerve blocks in lower-limb vascular surgeries. Patients and methods After obtaining approval from the ethical committee of Kasr Al-Ainy University Hospital and obtaining written informed consent, 63 patients aged 18–70 years were randomly allocated into three equal groups. Group P received perineural dexamethasone plus bupivacaine 0.5%, group I received intravenous dexamethasone plus perineural bupivacaine 0.5%, and group B received perineural bupivacaine 0.5% alone. We compared the onset and duration of sensory and motor blockade, duration of analgesia, and hemodynamic changes. Results Sensory and motor block onset showed nonsignificant difference between the three groups. Sensory block duration was significantly longer in group P than in groups I and B. Motor block duration was significantly prolonged in groups P and I when compared with group B. Motor block duration was longer in group P than in group I; however, the difference was statistically nonsignificant (p-value 0.34). The duration of analgesia was significantly longer in group P than in the other groups, and significantly longer in group I compared with group B. Conclusion The use of equal doses of perineural or intravenous dexamethasone as an adjuvant in single injection combined femoral and sciatic nerve blocks is associated with extended duration of sensory and motor blocks, extension of postoperative analgesia duration, and reduced postoperative analgesic requirements.
  2,504 251 1
Severe pre-eclampsia masquerading as peripartum cardiomyopathy in an emergency cesarean section: a challenge to the perioperative physician
Vishal K Pai, Mridul Dhar, Anil P Singh, Atchya A Kumar
October-December 2016, 9(4):623-625
Peripartum cardiomyopathy (PPCM) is a rare and unusual form of cardiac failure of unknown etiology that is observed in late pregnancy or early postpartum. Although the complete pathogenesis of PPCM is not completely understood, the signs and symptoms are similar to those of left-ventricular heart failure. PPCM is diagnosed in a parturient woman only after other causes of cardiac failure have been ruled out. Its management is similar to that of congestive heart failure. This report describes the role of an anesthesiologist in the postoperative management of a parturient woman who was admitted with severe preeclampsia and developed pulmonary edema and heart failure in the postoperative period necessitating management in the ICU. Subsequently, PPCM was diagnosed and managed successfully. The diagnosis of PPCM is challenging and requires a high index of suspicion by the perioperative physician. Routine medical management in the form of digoxin, diuretics, vasodilators, β-blockers, and anticoagulants should be the first step but may also require vasoactive drugs and circulatory support. Future pregnancies are generally avoided in such patients.
  2,507 185 -
Intravenous low-dose ketamine injection versus dexmedetomidine infusion for prevention of intraoperative shivering during spinal anesthesia
Mostafa Mansour Houssein, Ibrahim Mohamed Ibrahim
October-December 2016, 9(4):524-530
Background Shivering is considered one of the most common adverse effects that occur during spinal anesthesia. Besides causing patient discomfort, shivering also interferes with patient monitoring and increases tissue oxygen demand. The present study was carried out to compare the effectiveness of intravenous low-dose ketamine (0.25 mg/kg) and dexmedetomidine intravenous infusion in prevention of shivering during spinal anesthesia. Materials and methods Sixty patients of both sexes were included in this prospective randomized-controlled study. Patients were divided randomly into two groups of 30 patients each. Group K (30 patients) received low-dose ketamine (0.25 mg/kg) and group D (30 patients) received dexmedetomidine infusion. The primary outcome measure of this study was intraoperative shivering. The secondary outcome measures were hemodynamic changes, sedation scores, and postoperative side effects. Results Patients in group D had a lower incidence of postspinal anesthesia shivering compared with patients in group K. In all, 13.33% of group K patients had grade 3 shivering in comparison with only 3.33% of patients in group D 10 min after the onset of spinal anesthesia (P=0.031). Deeper sedation was observed in group D patients as 36.67% of group D patients had grade 4 sedation compared with 23.33% of patients in group K after 10 min (P=0.048). Conclusion Dexmedetomidine infusion is more effective as an antishivering and sedating agent than low-dose ketamine injection in patients receiving spinal anesthesia.
  2,430 220 -
Postoperative analgesia for arthroscopic shoulder surgery: comparison between ultrasound-guided interscalene block and combined suprascapular and axillary nerve blocks
Abdalla Waleed
October-December 2016, 9(4):536-541
Background Arthroscopic shoulder surgery is often associated with severe postoperative pain that is often significant enough to interfere with initial recovery and rehabilitation − the pain that can be difficult to manage without large-dose opioids. Opioids can cause nausea, vomiting, sedation, and/or failure to control pain. Supplementing general anesthesia with a regional nerve block might improve the quality of postoperative pain relief. The use of interscalene blockade (ISB) is gaining popularity, but it is associated with infrequent but potentially serious complications. Combined suprascapular nerve block and axillary nerve block (SSNB+ANB) can offer a safe alternative to ISB. Objective This study was designed to compare between ISB and SSNB+ANB in arthroscopic shoulder surgery as regards postoperative analgesia Patients and methods Sixty American Society of Anesthesiologist physical status I and II patients, aged between 18 and 40 years, scheduled for arthroscopic shoulder surgery were randomized to receive ISB or SSNB+ANB. After performing the blocks, general anesthesia was standardized in all groups. All the patients in the two groups were compared as regards postoperative pain assessed by the visual analog scale score at postanesthesia care unit, 4, 6, 12, and 24 h, occurrence of complications, and patient’s satisfaction. Results In the postoperative period, there were no statistically significant differences between the two groups as regards visual analog scale and analgesic requirements. Complications such as Horner’s syndrome, hoarseness of voice, major weakness of the upper arm, and dyspnea were recorded in the ISB group. Conclusion For certain procedures of shoulder arthroscopic surgery, SSNB+ANB is a safe and effective alternative to ISB as postoperative analgesia.
  2,388 256 3
A comparative study of propofol and isoflurane for the maintenance of anesthesia in spine surgery using the bispectral index monitor: a randomized control study
Manisha , Babita , Tarun Lall, Bhupendra Singh, Kanchan Sharma, Rajat Dadhich
October-December 2016, 9(4):584-592
Background Early awakening is required in spine surgery to perform neurological examination in the early postoperative period. Bispectral index (BIS) monitoring allows reduction in the total amount of anesthetic drugs and decreases the time for emergence and recovery. Thus, BIS monitor helps in reducing the incidence of awareness. Kinetics of propofol allows both induction and continuous intravenous maintenance of anesthesia with rapid recovery of consciousness that aids in performing neurological examination in the early postoperative period. This study was conducted to compare propofol and isoflurane in the maintenance of anesthesia during spine surgery using the BIS monitor. Patients and methods A total of 50 patients (American Society of Anesthesiologists grades I and II) scheduled for spine surgeries were divided into two groups (25 each). Group A received an infusion of propofol 5 mg/kg/h and group B received isoflurane 1% vol. for maintenance to keep the BIS value between 40 and 60. The groups were compared as regards pulse rate, systolic blood pressure, diastolic blood pressure, mean arterial blood pressure, surgeons’ satisfaction, time to recovery, extubation time, and side effects. Results Both groups were well matched for their demographic data and preoperative vital data. There was no significant difference in hemodynamic parameter between the two groups. The mean recovery time was significantly different (P<0.001) between groups, with earlier recovery in the propofol group (8.14±0.805 min) compared with the isoflurane group (9.06±0.766 min). Values for BIS were similar between the two groups during surgery (P>0.05). Incidence of postoperative nausea and vomiting was 35% lower in group A compared with group B. The quality of surgical field was acceptable in both groups but slightly better in the propofol group. No other major complications were noted in our study. Conclusion Propofol-based anesthesia provides early and better recovery with clear headedness for early neurological assessment for spine surgery.
  2,404 184 -
Control of autonomic dysreflexia in patients with high level of chronic spinal cord injury during cystoscopy
Ibrahim A Nasr, Khaled M Elnaghy
October-December 2016, 9(4):606-611
Background Autonomic dysreflexia (AD) is a clinical emergency that frequently occurs in patients with spinal cord injury (SCI) during cystoscopy. It should be treated by removing the stimulus and by medications. We aimed in this study to evaluate the effect of adding magnesium sulfate to dexmedetomidine infusion to control AD in high-level chronic SCI patients during cystoscopy. Patients and methods Forty patients with chronic SCI at the level of T6 or above scheduled for cystoscopy were randomly divided into two groups: the dex group, in which the patients received dexmedetomidine infusion 1 µg/kg for 10 min, followed by 0.5 µg/kg/min; and the Mg group, in which patients received a single i.v. dose of magnesium sulfate 50 mg/kg in addition to the same infusion of dexmedetomidine. Blood pressure (BP) and heart rate (HR) were recorded for each patient, and serum magnesium, epinephrine, and norepinephrine levels were estimated preoperatively, intraoperatively, and postoperatively. Results Results showed a significant elevation in intraoperative BP in the Dex group 10 min after cystoscopy and persisted for 20 min compared with the presedation level in the same group and with the same readings in the Mg group. HR dropped down in the Dex group 15 min after cystoscopy and persisted for 15 min compared with the presedation reading in the same group and with the same readings in the Mg group. Serum magnesium was significantly higher intraoperatively and postoperatively in the Mg group, whereas serum epinephrine and serum norepinephrine were significantly higher intraoperatively and postoperatively in the Dex group compared with the presedation level in the same group and with the same readings in the Mg group. Seven patients (35%) in the Dex group experienced a dysreflexic episode [increase in systolic blood pressure (SBP) 30 mmHg or more compared with the presedation reading]; two of them showed elevation of SBP more than 160 mmHg and needed to be treated. On the other hand, only one patient in the Mg group (5%) experienced a dysreflexic episode (SBP 135 mmHg) with no need for medication. Conclusion Addition of a single i.v. dose of magnesium sulfate to dexmedetomidine infusion provides a better control of BP and HR, and reduces the incidence of AD during cystoscopy in patients with high level of chronic SCI.
  2,347 169 -
Preoperative external nasal compression: does it decrease emergence agitation after nasal surgery?
Ayman Kasem, Ashraf Abdelkader
October-December 2016, 9(4):593-597
Background Emergence agitation after nasal surgeries in adults is common. Acute postoperative nasal obstruction with nasal packing is an important factor in developing agitation after nasal surgeries. Aim The aim of this study was to evaluate the effectiveness of preoperative nasal obstruction by means of external nasal compression on the incidence of emergence agitation after nasal surgeries. Methods Sixty patients of American Society of Anesthesiologists I or II between 20 and 45 years of age who were scheduled for nasal surgery were randomly assigned into three equal groups: the control (C) group, the T10 group, in which nasal compression was carried out for 10 min, and the T30 group, in which nasal compression was carried out for 30 min preoperatively. All patients received the same anesthetic technique. The incidence of agitation, and recovery characteristics were evaluated during emergence. Patient satisfaction was evaluated 24 h after surgery. Results There was a significantly lower incidence of emergence agitation and fentanyl consumption during the emergence period in the T30 group. Moreover, patient satisfaction with recovery was significantly higher in the T30 group. Conclusion Elective preoperative external nasal obstruction may decrease the incidence of emergence agitation and improve patient satisfaction with recovery after nasal surgery.
  2,117 296 2
Ultrasound-guided transversus abdominis plane block for control of postoperative pain after laparoscopy-assisted robotic abdominal cancer surgery
Essam Mahran, Mohamed E Hassan
October-December 2016, 9(4):558-562
Background and objective Transversus abdominis plane (TAP) block is a recently developed method for analgesia that is now widely used in a variety of abdominal surgeries. Robotic laparoscopy is being increasingly adopted for surgical resection of abdominal cancers. We studied the efficacy and safety of TAP block to control pain after robot-assisted laparoscopic abdominal cancer surgery. Methods Totally, 30 patients scheduled for robot-assisted laparoscopic abdominal cancer surgery (hysterectomy, colorectal cancer resection, or cystectomy) received general anesthesia. Before extubation the patients were randomized into two equal groups: group T, in which TAP block was performed by means of an ultrasound-guided subcostal approach, and group C (control group), in which no TAP block was performed or other regional anesthesia was induced. We measured visual analog scale (VAS) both at rest and during episodes of coughing at 1, 2, 6, 12, and 24 h postoperatively. We measured total 24 h morphine consumption, in addition to complications and postoperative nausea and vomiting. Results VAS both at rest and during coughing was lower in the T group at all time intervals until 12 h (P<0.001). At 24 h there was no significant difference in VAS but there was marked difference in the total morphine consumption between the T group (26.0±1.8) and the C group (64.3±4.3). Except for two cases of postoperative nausea and vomiting in each group there were no complications detected. Conclusion Ultrasound-guided TAP block by subcostal approach is an effective and safe method for providing analgesia that markedly reduces morphine consumption after robot-assisted laparoscopic abdominal cancer surgery
  2,219 189 -
Comparison between dexmedetomidine and verapamil as an adjuvant to local anesthesia in intravenous regional anesthesia in upper limb orthopedic surgery: a randomized double-blind prospective study
Medhat M Messseha Gerges
October-December 2016, 9(4):576-583
Background The use of intravenous regional anesthesia has increased significantly in recent years. Adjuvants are frequently added to local anesthetics to prolong analgesia following peripheral nerve blockade. Objective This randomized double-blind prospective study was designed to compare the effectiveness of adding dexmedetomidine (α2 adrenoceptor agonist) or verapamil (calcium channel antagonist) as an adjunct to lidocaine in upper limb orthopedic surgery. Patients and methods Sixty adult patients scheduled for elective upper limb orthopedic surgery were divided into three groups: the lidocaine group, in which patients received 3 mg/kg of lidocaine 2% diluted with saline to a total volume of 40 ml; the lidocaine dexmedetomidine group, in which patients received 0.5 µg/kg of dexmedetomidine plus 3 mg/kg of lidocaine 2%; and the lidocaine verapamil group, in which patients received 2.5 mg of verapamil plus 3 mg/kg of lidocaine 2%. The onset and duration of sensory and motor block were recorded. Postoperative Visual Analog Score, onset of tourniquet pain, duration of analgesia, and total analgesic requirements at the 12th postoperative hour were monitored. Results Adding dexmedetomidine or verapamil to lidocaine causes faster onset and prolonged recovery of sensory and motor block and improvement of postoperative analgesia, without causing side effects compared with lidocaine alone. Conclusion The use of either verapamil or dexmedetomidine as an adjuvant to lidocaine solution causes equal improvement of the quality of anesthesia in intravenous regional anesthesia of upper limb orthopedic surgeries.
  2,192 194 1
Dexmedetomidine versus granisetron for the management of postspinal shivering
Usama I Abotaleb, Abdalla M Abdalla, Ahmad S Abdelrahman, Gad S Gad, Abdalla M Elsayed
October-December 2016, 9(4):517-523
Background Shivering is one of the most stressful complications for patients and surgeons during spinal anesthesia. In this prospective, randomized, double-blinded study, we compared the efficacy of dexmedetomidine versus granisetron for control of postspinal shivering. Methods This study was conducted on 120 patients, ASA I–III, of either sex, aged 18–60 years, who were scheduled for elective lower limb and lower abdominal surgeries under spinal anesthesia. The response rate, time taken to control shivering, recurrence rate, and adverse effects were recorded. Results Incidence of shivering in 1127 patients was 52.7% (594 patients): we studied 120 patients; 28 patients (2.5%) developed grade 4 and 92 patients (8.2%) developed grade 3 shivering. There were no statistically significant differences regarding the time for onset of shivering, severity, response rate, need for a second dose, or pethidine between the two groups. However, time to control shivering was shorter in the dexmedetomidine group, with a higher recurrence rate. Incidences of hypotension, bradycardia, and sedation were higher in the dexmedetomidine group. However, there was no incidence of severe bradycardia or respiratory depression in our study. Conclusion Both dexmedetomidine and granisetron effectively reduce postspinal shivering without any major adverse effects. However, dexmedetomidine has rapid onset and short duration, whereas granisetron has less hemodynamic alterations.
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Endobronchial tumor laser resection: handling anesthetic challenges through a modified technique
Malik Sunny, Puri Arun, Bhandari Hricha, Malik Shraddha
October-December 2016, 9(4):612-616
Reported is a case of left mainstem bronchus carcinoid that was managed by means of a modified technique using a microlaryngeal tube for right lung ventilation and laser resection using an AMBU Ascope. The upper lobe of the left lung showed dramatic improvement on postoperative chest radiograph and computed tomography scan. Precautions for laser surgery and sharing of the airway by the surgeon and the anesthetist were taken care of during ventilation of the right lung. Soiling and tumor migration of the opposite lung were prevented intraoperatively and postoperatively.
  2,190 151 -
Monitored anesthesia care with propofol or dexmedetomidine for patients undergoing upper limb surgeries under brachial plexus blockade: a comparative study
Kumkum Gupta, Vasundhra Tyagi, Prashant K Gupta, Bhawana Rastogi, Manish Jain, Manoranjan Bansal
October-December 2016, 9(4):563-568
Background Brachial plexus block is widely used for upper limb surgeries but intraoperatively patients remain aware. The present study aimed to compare the sedative efficacy and safety of propofol infusion versus dexmedetomidine infusion for monitored anesthesia care during upper limb surgeries under ultrasound (US)-guided brachial plexus blockade. Patients and methods Sixty adult consented patients of American Society of Anesthesiologists physical status I–III of both sexes were given 20 ml of 0.75% ropivacaine (150 mg) for brachial plexus blockade under US guidance. The patients were randomized into two groups of 30 patients each, to receive either propofol infusion [group I (P)] or dexmedetomidine infusion [group II (D)] during the intraoperative period. The primary goals were to achieve a sedation score of 2–3 on the Ramsay sedation scale and to compare the duration of postoperative analgesia assessed using the visual analog scale. The hemodynamic stability, respiratory depression, or any complication due to technique or medications was also recorded as secondary outcomes. Results US guidance helped visualization of the nerves, the needle, and the spread of local anesthetic at the brachial plexus block site. Desired sedation score of 2–3 was effectively achieved with intraoperative infusions of dexmedetomidine and propofol. Hypotension occurred in 11 patients of the propofol group, whereas no episode of hypotension was noted in the dexmedetomidine group. Bradycardia was evident in five patients of the dexmedetomidine group. The duration of postoperative analgesia with dexmedetomidine infusion was significantly prolonged when compared with propofol infusion as assessed using visual analog scale. Respiratory depression did not occur in any patient. No adverse events inherent to sedative medication or technique were observed in any patient. Conclusion The clinical efficacy and safety of dexmedetomidine was better than propofol due to prolonged postoperative analgesia and intraoperative hemodynamic stability without respiratory depression.
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Intraperitoneal bupivacaine plus fentanyl after laparoscopic pyeloplasty
Hoda Shokri
October-December 2016, 9(4):531-535
Objective Laparoscopic surgery has decreased the severity of postoperative pain. However, patients often experience abdominal and shoulder pain, requiring significant amounts of opioids and potentially prolonging their hospitalization. This study was conducted to assess the effectiveness of intraperitoneal bupivacaine plus fentanyl in reducing postoperative pain without incidence of postoperative complications in patients undergoing laparoscopic pyeloplasty. Patients and methods After hospital ethics committee approval and obtaining written informed consent, 50 consecutive patients undergoing unilateral laparoscopic pyeloplasty were enrolled in this prospective randomized trial. Patients were randomly divided into two groups using the sealed envelope technique: the BF group (25 patients) received induction with 30 ml of bupivacaine (0.25%) plus fentanyl (20 μg) intraperitoneally just before trocar removal, and the saline group (25 patients) received induction with saline (30 ml). Pain scores, time to first analgesic requirement, postoperative opioid requirements, and occurrence of adverse effects were all recorded. Results There was a significant reduction in 24 h of postoperative opioid utilization and visual analog scale scores in the BF group compared with the saline group at all time points. The time to first opioid consumption was significantly longer in the BF group compared with the saline group. The incidence of complications was not significantly different between the study groups. Systolic and diastolic blood pressures were significantly lower in the BF group compared with the saline group. Conclusion The administration of intraperitoneal bupivacaine plus fentanyl just before trocar removal appears to be a simple, effective, and low-cost method to reduce postoperative pain in adults undergoing laparoscopic pyeloplasty.
  1,998 166 -
Midazolam as an adjunct to lignocaine at two different doses in ultrasound-guided supraclavicular brachial plexus block: a randomized controlled trial
Jai Singh, Versha Verma, Priyanka Sood, Aman Thakur, Shelly Rana, Lokesh Thakur
October-December 2016, 9(4):549-557
Background and aims The present study was carried out to investigate the efficacy of midazolam at two different doses as an adjunct to lignocaine with adrenaline in ultrasound-guided supraclavicular brachial plexus block. Materials and methods In this prospective controlled study, 95 consenting patients scheduled for forearm fracture surgeries were randomized into three groups. Five patients were excluded from the study for not meeting the inclusion criteria. Group L (n=30) received 20 ml of 1.5% lignocaine with adrenaline (1 : 200 000)+5 ml of normal saline (total volume=25 ml). Group M30 (n=30) received 20 ml of 1.5% lignocaine with adrenaline (1 : 200 000)+30 μg/kg midazolam+normal saline (total volume =25 ml). Group M50 (n=30) received 20 ml of 1.5% lignocaine with adrenaline (1 : 200 000)+50 μg/kg midazolam+normal saline (total volume =25 ml). Results The onset of sensory and motor block was found to be earliest in group M50, followed by group M30 and group L, and the difference was statistically significant (P<0.05). The mean duration of motor block and sensory block was longest in group M50 followed by groupM30 and shortest in group L, which was also statistically significant (P<0.05). The mean duration of analgesia was longest in group M50 (254.53±34.77 min) followed by group M30 (211.03±52.69 min) and shortest in group L (181.47±20.63 min). The differences were statistically significant (P<0.05). Group L received the highest doses of rescue analgesics (2.80±0.407 doses) followed by group M30 (1.97±0.615 doses) and group M50 (1.47±0.819 doses). The difference was statistically significant (P<0.05). Conclusion Midazolam increases the duration of sensory and motor blockade and delays need for rescue analgesic. In addition, midazolam at a dose of 50 μg/kg had superior therapeutic profile compared with 30 μg/kg, and hence may be the recommended dose.
  1,972 171 -
Case report and review of the literature. Novel anesthetic technique in laparoscopic myomectomy
Megahed M El Fattah, Samia A Gamie
October-December 2016, 9(4):620-622
Thoracic epidural anesthesia for elective laparoscopic myomectomy is a good alternative to general anesthesia and seems to be an effective technique, with minimal hemodynamic consequences and excellent patient satisfaction and no postoperative complications (provided the patient cooperated), minimal inflation pressure, and mild table tilt. We present here one case of laparoscopic myomectomy under thoracic epidural anesthesia in a patient with relative contraindication to general anesthesia.
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