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   Table of Contents - Current issue
October-December 2017
Volume 4 | Issue 4
Page Nos. 177-254

Online since Wednesday, October 11, 2017

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Relation of left ventricular function and serum interleukin level to mortality in septic patients Highly accessed article p. 177
Mohamed Soliman, Abdou M Azab, Rania M El Hossainy, Mahesh Nirmalan, Hasan Khaled Nagi
Introduction Left ventricular systolic dysfunction and elevated serum interleukins (ILs) are common in septic patients. However, whether left ventricular diastolic dysfunction is related to mortality in septic patients is a matter of debate. Aim The aim of the study was to assess the effect of myocardial systolic and diastolic functions on mortality in cases of sepsis and to predict an inflammatory marker that could be clearly linked to mortality in sepsis. Patients and methods Twenty patients were prospectively studied, with measurement of the following on admission and on day 7: left ventricular end-diastolic volume, left ventricular end-systolic volume, left ventricular ejection fraction% (echocardiography), mitral annulus S-velocity, Ed/t, and serum levels of ILs (IL-1α, IL-1β, IL-6, and IL-10). Mortality on day 28 was the study endpoint. Results Twenty patients with sepsis and septic shock were studied (45% were male and 55% were female; mean age 52±17 years). The patients were divided into group I (survivors, 55%) and group II (nonsurvivors, 45%). Regarding echocardiography there was no significant difference between the two groups in end-diastolic volume, end-systolic volume, or ejection fraction% (112.3±51 vs. 94.5±30, 43.8±30 vs. 29.4±22, and 61.5±12 vs.71.2±11; P=0.4, 0.1, and 0.08, respectively) on admission or on day 7 (114.6±21 vs. 99.8±65, 43.8±30 vs. 29.4±22, 61.7±12 vs. 59.6±17; P=0.1, 0.2, and 0.7, respectively), whereas Ed/t data on admission showed statistically significant short Ed/t in group II (103.5±28) compared with group I (127.2±25) (P=0.04). However, on day 7 the difference was not significant (115.3±41 vs. 119±48, P=0.8). The mitral annulus S-velocity did not show significant difference either on admission (10.7±5 vs. 9.9±2, P=0.9) or on day 7 (8.6±4 vs. 10.7±4, P=0.1). Regarding the levels of ILs, there was no difference between group I and group II in terms of admission IL-1α (33.7±48 vs. 27.1±21, P=0.7), IL-1β (74±55 vs. 54.5±32, P=0.7), IL-6 (235.1±357 vs. 234.2±355, P=0.9), or IL-10 (110.7±121 vs. 135.3±241, P=0.9) or in terms of day 7 IL-1α (41.6±76 vs. 208.2±410, P=0.8), IL-1β (154.1±255 vs. 39.3±15, P=0.06), or IL-10 (87.2±230 vs. 189.6±335, P=0.9). However, on day 7 IL-6 showed a significantly high level in group II (294.8±385) versus group I (68.9±110) (P=0.05). Conclusion Systolic function did not predict prognosis. However, diastolic dysfunction in the form of Ed/t predicted poor prognosis. The higher IL-6 level on day 7 was a good predictor of mortality.
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Steroids versus pulsed radiofrequency in treatment of radicular pain due to lumbar disc prolapse: a randomized clinical trial p. 184
Osama Y.A. Khalifa, Ayman E.T. Saadalla
Background Both lumbar transforaminal epidural steroids (TESs) and dorsal root ganglion pulsed radiofrequency (PRF) are used in the treatment of radiculopathy after lumbar disc prolapse. We try to detect which is more effective. Patients and methods A total of 90 patients were randomly allocated into two groups: the TESs group, which comprised 45 patients, and the PRF group, also comprising 45 patients. In the first group, transforaminal epidural methylprednisolone was injected on the affected roots at a dose of 24 mg/root and in group PRF for 4 min was done and only 8 mg of methylprednisolone was injected after radiofrequency. Visual analog scale (VAS) was assessed by a blinded pain physician before intervention and 1 week, 4 weeks, 2 months, and 3 months after intervention through telephone calls. Results At 1 week the VAS was significantly reduced in both groups, and there was a nonsignificant difference between the two groups. At 4 weeks the VAS reduction was still significant in both groups but the reduction in group PRF was significant in comparison with the TES group. At 2 months there was a nonsignificant difference between VAS and preintervention value in group TES, whereas it was significant in group PRF either in comparison with preinterventional value or with the TES group. At 3 months, the VAS reduction was significant in group PRF in comparison with group TES. Conclusion PRF of lumbar dorsal root ganglia is more effective than lumbar TES injection up to 3 months of follow-up in patients with radiculopathy due to lumbar disc prolapse.
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Local anesthesia with sedation versus local anesthesia after general anesthesia for sinus surgery: a randomized trial p. 188
Mohamed T Ghanem, Ashraf Elmalt
Background Satisfaction for patients and surgeons during the perioperative functional endoscopic sinus surgery (FESS) remains an anesthetic challenge. We compared FESS under local anesthesia (LA) with monitored anesthesia care (MAC) and LA after induction of general anesthesia. Patients and methods One hundred patients scheduled for FESS were randomly recruited in this randomized controlled study. Fifty of them received LA after induction of general anesthesia (G group), while the rest of the patients received LA with MAC (M group). The outcome measures included satisfaction for the patient and surgeon, cost, surgical, and postoperative profiles. Results Surgeon’s satisfaction was comparable in both groups, while patient’s satisfaction was significantly higher in the M group (P<0.001). Total operative time and time to postanesthetic care unit discharge were significantly shorter in the M group (70.65±4.3 and 13.3±2 vs. 95.8±4.4 and 47.3±5.8 min in the G group, respectively; P<0.001). Time to home discharge was also shorter in the M group (66.0±23.78 vs. 262.20±11.8 min in the G group; P<0.001). The overall costs were significantly lesser in the M group (234.0±5.3 vs. 836.15±41.25 Egyptian pounds in the G group; P<0.001). Conclusion In FESS, LA with MAC provided excellent patient’s experience with optimum surgical and postoperative profiles and lower cost.
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Pulse index continuous cardiac output versus central venous pressure-based early goal-directed therapy for septic shock patients: a randomized trial p. 195
Mohamed T Ghanem, Amani A Aly
Background Central venous pressure-based early goal-directed therapy (EGDT) is considered the gold standard in the management of septic shock. We compared this approach with pulse index continuous cardiac output (PiCCO)-based EGDT in a randomized controlled study. Patients and methods Eighty septic shock patients were randomly divided into the conventional survival sepsis bundle group using central venous and arterial catheters (group C, n=40), and the modified survival sepsis bundle group using central venous and PiCCO arterial thermistor catheters (group P, n=40). Primary outcome included mortality at 28 days after diagnosis of shock. Secondary outcomes included ICU stay, days on mechanical ventilation, and renal replacement therapy (RRT). Results In comparison with group C, group P showed a lower mortality with no statistical differences at 28 days after diagnosis of shock [15 (37.5%) patients in the P group vs. 21 (52.5%) patients in the C group; P=0.11]. The population in the C group showed longer duration on ventilation, which was statistically significant [6 (5.0–7.0) in the C group vs. 3 (2.0–3.0) in the P group; P<0.001]. Days on RRT and ICU stay were also statistically shorter in the P group [1 (0.0–2.0) in the P group vs. 4 (1.0–5.0) in the C control group; P<0.001 for duration on RRT and 5 (4.0–6.0) in the P group vs. 10 (6.0–16.0) in the C group; P<0.001 for ICU stay]. Conclusion PiCCO-based EGDT produced lower ICU stay, and shorter duration of ventilation and RRT; however, it did not reduce mortality in septic shock patients when compared with the conventional central venous pressure-based approach.
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Comparison between sedation and general anesthesia for endoscopic ear surgery p. 203
Yasser Osman
Introduction There are few published articles discussing anesthesia in patients undergoing endoscopic transcanal stapes surgery. In addition, general anesthesia carries a greater cost to the hospital and the patient’s recovery in the immediate postoperative period is more symptomatic. Aim This study aims to compare the effectiveness of performing endoscopic ear surgery under sedation using dexmedetomidine and under general anesthesia. The secondary aim is to identify any side effect to the sedation with dexmedetomidine. Patients and methods This is a prospective randomized study comparing two groups of 20 adult patients scheduled for endoscopic transcanal stapes surgery; the surgery in the first group (group I) was performed under sedation with dexmedetomidine and in the second group (group II), surgery was performed under general anesthesia. Both groups received local anesthesia to decrease postoperative pain and to minimize the bleeding. Results There were no operative time differences between both groups, but time in the recovery room was significantly shorter in group I (19.7±5.4 min) in comparison with group II (30.8±7.6 min). There were no significant differences in the postoperative complaints between both groups, except for postoperative intubation sore throat, which was not found in the patients with sedation, and postoperative nausea and vomiting, which was statistically significant higher in the patients using general anesthesia 25%. Conclusion We conclude that endoscopic ear surgery may be performed with local anesthesia and sedation using dexmedetomidine in adult patients, with some advantages over general anesthesia (especially in the postoperative period faster recovery and lower incidence of nausea and vomiting), being an option at the time of surgical decision.
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Role of transcranial Doppler and FOUR score in assessment of sepsis-associated encephalopathy p. 209
Dina H Zidan, Tamer A Helmy, Ahmed Taha
Background Monitoring of the septic complications on the brain is useful in management and in attenuating the effect of sepsis-related cerebral complications on outcome. Patients and methods A transcranial Doppler probe was applied through the temporal bone window at both sides of the skull within the first day of diagnosing sepsis for 10 s. The values of the brain side with the highest peak systolic velocity (PSV) and end diastolic velocity (EDV) were registered. We calculated the pulsatility index (PI) as follows: PI=(PSV−EDV)/mean velocity; the neurological status was evaluated 6 h after sedation cessation, using Glasgow Coma Scale and Full Outline of UnResponsiveness score. Results There was a significant difference in the PI between conscious patients and patients suffering from sepsis-associated encephalopathy. Conclusion PI is a predictor of sepsis-associated encephalopathy in septic patients.
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Risk factors in adult patients with chronic hepatitis C virus undergoing cardiac surgery with cardiopulmonary bypass: a prospective study p. 213
Amal M Sabry, Hisham A Fouad, Amr Hashem, Ayman F Khalifa
Background Variable outcomes of cardiac operations have been reported in patients with liver disease, but no definitive predictive prognostic factors have been established. This prospective study assessed operative results to identify risk factors associated with morbidity after cardiovascular operations in patients with chronic viral hepatitis. Patients and methods The study group consisted of 90 patients with documented chronic viral hepatitis who were subject to elective cardiac surgery with cardiopulmonary bypass (CPB). Potential preoperative predictors of outcome, as well as preoperative model for end-stage liver disease (MELD) score and European system for cardiac operative risk evaluation (EuroSCORE), were calculated. The primary study end points were hospital morbidity (according to sequential organ failure assessment score and other additional morbidities not captured by sequential organ failure assessment score) or mortality (as defined by EuroSCORE II). Results The average EuroSCORE II was 1.12±0.56. The average MELD score was 10.12±2.7, which corresponds to a mild to moderate liver dysfunction. Despite the low EuroSCORE II values, 39 patients developed postoperative significant morbidity including seven patients who died in hospital. There were four patients with gastrointestinal complications (two cases with prolonged ileus and two cases with gastrointestinal bleeding bleeding); eight cases with occurrence of infection (six cases with sternal wound infection and two cases with sepsis); five reopen cases; and five cases that needed intra-aortic balloon pump. Analysis showed significant differences in age, MELD score, preoperative platelet count, preoperative creatinine, and preoperative total bilirubin when patients with postoperative morbidity and mortality (group M) were compared with patients without significant morbidity (group N). CPB time, cross-clamp time, postoperative mechanical ventilation, and duration of ICU stay were significantly higher in the group M. In addition, blood products transfused and total chest tubes drainage were significantly higher in the group M. Central venous pressure was significantly higher in the group M after weaning of CPB and thereafter. Arrhythmias were seen postoperatively in 16.6% of cases, the most common being atrial fibrillation, and was significantly higher in the group M. Receiver operating characteristic curve analysis showed that age of 58 years and MELD score of 12 were cutoff values for hospital morbidity, whereas the optimal cutoff values for preoperative platelet count, creatinine, and total bilirubin were 146×103/μl, 1.27 mg/dl, and 1.21 mg/dl, respectively. Conclusion Careful consideration of operative indications and methods are necessary in chronic viral hepatitis patients with old age, high MELD scores, low platelet counts, and high serum creatinine and bilirubin. It is vital that liver dysfunction is added to the risk models, which are currently used to predict the postoperative morbidity of cardiac surgery patients.
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Comparison between prophylactic infusion of ephedrine and lower extremity compression in the prevention of postspinal hypotension during elective cesarean delivery p. 226
Haidy S Mansour, Ahmed Zein Elabdein Mohamed
Background Hypotension during spinal block for cesarean section is secondary to the aortocaval compression by the uterus and sympathetic blockade and it can be deleterious to both the fetus and the mother. In this study, we compared the effect of leg wrapping, low-dose ephedrine infusion, and placebo on systolic blood pressure (SBP) during spinal block for cesarean section. Patients and methods In this randomized, double-blinded, placebo-controlled study, 90 American Society of Anesthesiology I and II women scheduled for elective cesarean section received either ephedrine (group E; n=29; initial bolus of 5 mg and infusion of 1.5 mg/min), leg wrapping (group L; n=30), or no treatment (group C; n=29). SBP and maximal decrease in SBP were the primary outcomes, and heart rate, neonatal acid–base status, Apgar score, and side effect as bradycardia, neausea, and vomiting were secondary outcome variables during the first 20 min after induction of spinal anesthesia. Results Fall in blood pressure in group C was more significant as compared with groups E and L (P<0.05). The incidence of hypotension was significantly lower in group C than in groups E and L (P=0.004 and 0.02, respectively). The incidence of bradycardia showed a significant difference between group E and both group L and group C (P=0.04 and 0.001, respectively). Nausea, vomiting, the umbilical blood gases, and Apgar scores in the first and fifth minute did not show significant differences between the three groups (P>0.05). Conclusion An initial bolus of ephedrine followed by a low-dose ephedrine infusion was superior to leg wrapping and no intervention for the prevention of hypotension during spinal anesthesia for cesarean delivery. Leg wrapping prevented hypotension compared with no intervention by limiting modest early spinal anesthesia-mediated venodilation.
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Sedation with intrathecal clonidine versus fentanyl with bupivacaine in elective cesarean section in a sample of Egyptian parturients p. 235
Mohammad Hazem I Ahmad Sabry, Mohamed A Aboghanima, Amal M Sabry
Background and objective Regional analgesia has become the preferred technique in obstetrics. Spinal analgesia has many advantages, including being a single injection, being easier to administer, and being faster to take effect. Patients and methods This study was carried out on 40 parturients scheduled for cesarean sections with spinal analgesia who were categorized as follows: the fentanyl group − 20 parturients received 2 ml of 0.5% hyperbaric bupivacaine and 25 μg fentanyl; and the clonidine group − 20 parturients received 2 ml of 0.5% hyperbaric bupivacaine and 75 μg clonidine. Hemodynamic measurements, sensory blockade, pain intensity using visual analog scale (VAS) and time to first request for analgesia, motor blockade, perioperative side effects or complications, fetal well-being using Apgar score, and both parturient and surgeon satisfaction were recorded and statistically analyzed. Results The parturients who received intrathecal clonidine had a higher level and faster onset of sensory blockade and delayed regression of sensory level compared with those who received intrathecal fentanyl. Regarding the changes in pain intensity measured by VAS, the clonidine group revealed low VAS compared with the fentanyl group immediately after spinal anesthesia and up to 3 h postoperatively with earlier and multiple requests for analgesics in the fentanyl group. On comparing both groups regarding onset of motor block and its regression using the modified Bromage score, we noticed slower onset and regression of motor block in the fentanyl group with longer duration of motor block compared with the clonidine group. Sedation was significantly higher in the clonidine group (25%) than in the fentanyl group. The incidence of nausea and vomiting was significantly higher in parturients who received intrathecal fentanyl (30%) than in those who received intrathecal clonidine (5%) (P<0.05). Conclusion Use of intrathecal clonidine for cesarean section results in better sensory blockade and early recovery of motor blockade as compared with the use of intrathecal fentanyl. Intraoperative sedation is significantly better in the clonidine group.
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Magnesium sulfate versus tramadol as adjuvants to local anesthetics in sciatic nerve block for lower extremities surgeries p. 239
Ibrahim A Youssef, Ahmaed Q Mouhamed, Haidy S Mansour, Nehal F Ramadan
Background The aim of this study was to compare the effect of addition of tramadol and magnesium sulfate as adjuvants to local anesthetics lidocaine 2% and bupivacaine 0.5% in sciatic nerve block classic posterior approach. Patients and methods A total of 90 ASA I or II patients, aged 17–50 years, scheduled for lower extremities surgeries under sciatic nerve block classic posterior approach were randomized into three equal groups. All groups received 20 ml of local anesthetics, which consisted of 10 ml bupivacaine 0.5% and 8 ml lidocaine 2% mixed with 2 ml saline in the control (C) group, 2 ml of 150 mg magnesium sulfate made in saline in the magnesium (M) group, and 2 ml of 100 mg tramadol in the tramadol (T) group. The onset and duration of both sensory and motor blocks, the intraoperative pain assessment by visual analogue scale, intraoperative analgesic requirements, postoperative pain by visual analogue scale, time to first analgesic request after surgery, postoperative diclofinac consumption, and adverse effects were assessed. Results The onsets of sensory and motor blocks were rapid in the M group, then C group, and lastly, T group. Much more time was needed for group T until sensory and motor blocks faded away followed by group M and then group C. There was a significant delay in the time of first analgesic request in groups M and T when compared with group C. There was a significant decrease in the total dose of diclofinac consumption in groups T and M in comparison with group C, where the patients consumed more analgesia. Conclusion Magnesium sulfate and tramadol as adjuncts to local anesthetics increase the duration of sensory and motor sciatic nerve block. The time for first rescue analgesia was longer in groups M and T, and they both showed decreased postoperative analgesic consumption.
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Intubation through air-Q and LMA-Excel using Shikani optical stylet in normal versus simulated difficult airway p. 247
Salwa S Sharawy, Sami M El-Shafie, Shahira Y El-miteny, Aly M.M. Ahmed
Background Unanticipated difficult mask ventilation and difficult intubation may cause serious complications, and airway management in such cases is challenging. Shikani seeing optical stylet (SOS) is a semirigid fiber-optic stylet used to manage difficult airway. Aims The current study aimed to assess and compare the intubation procedure through different intubating supraglottic devices (AIR-Q and LMA-Excel) while using the SOS in anesthetized patients with normal or simulated difficult airway scenario. Patients and methods This study was carried out on 120 adult female patients scheduled for elective abdominal hysterectomy under general anesthesia. All patients were intubated using the SOS through the supraglottic airways: 30 patients through Air-Q (group A-N), 30 patients through Air-Q while applying a neck collar (group A-D), 30 patients through LMA-Excel (group L-N), and 30 patients through LMA-Excel while applying a neck collar (group L-D). Evaluation parameters were as follows: airway score, hemodynamic parameters, leak pressure, laryngeal view grade, time to successful endotracheal tube insertion and number of attempts, and complications. Results The laryngeal view grade of the A-D group was significantly higher than that of the A-N group (P1) and L-D group (P4), and there was no significant difference when comparing group L-N with L-D (P2) and group A-N with L-N (P3). The mean successful time for intubation of group A-D (100.50±42.63 s) was significantly longer than that of group A-N (62±21.20 s) and group L-D (72±31.39 s), with a P value of 0.001. The number of intubation attempts ranged from 1 to 2 in groups A-N, L-N, and L-D, whereas 1 to 3 in group A-D. Conclusion The intubation through supraglottic airways (Air-Q and LMA-Excel) using the SOS is a feasible technique. The SOS can be used as an alternative apparatus for intubation through device when the flexible fiber-optic bronchoscope is not available. Laryngeal view grade is better with LMA-Excel when using the SOS. Intubation through LMA-Excel is easier than through Air-Q when using the SOS.
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