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   Table of Contents - Current issue
October-December 2019
Volume 6 | Issue 4
Page Nos. 385-474

Online since Monday, January 6, 2020

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Dexmedetomidine versus midazolam for conscious sedation in children undergoing dental procedures p. 385
Salwa H Waly
Background Pediatric dental sedation aims to have a cooperative child who is required to keep his mouth open during the procedure. Achieving the proper level of sedation might subject the child to circulatory and ventilatory troubles, which draws the attention toward performing researches for the proper sedative to be used in such circumstances. Aim of the work This study compares the effect of two sedatives (dexmedetomidine vs. midazolam) in children undergoing dental procedures. Patients and methods A total of 60 ASA I children aged 6–10 years who were scheduled for lower jaw dental procedure were enrolled in the current study. Children were randomized into two equal groups. In group D (dexmedetomidine group, n=30), 2-µg/kg dexmedetomidine was administered intravenously over 5 min as induction dose, followed by continuous infusion of 0.4 µg/kg/h as a maintenance. In group M (midazolam group, n=30), 0.05 mg/kg midazolam was administered intravenously followed by maintenance dose of 0.06–0.12 mg/kg/h titrated according to patient response. Local infiltration anesthesia was given by the dentist as 0.5 mg/kg mepivacaine 2%. Results In this study, mean arterial blood pressure, heart rate, respiratory rate, and oxygen saturation showed no significant differences between both groups. The time of onset of sedation was comparable between both groups (4.7±1.1 vs. 4.1±1.8 min in group D and group M, respectively). However, recovery time was highly significantly shorter in group D compared with group M (14.3±1.1 vs. 20.2±9.8 min, respectively). The duration of the procedures (24.7±3.1 vs. 22.2±7.5 min in group D and group M, respectively) and discharge times (14.1±2.2 vs. 13.5±5.9 min in group D and group M, respectively) were comparable between both groups. Number of patients requiring supplemental analgesia was significantly lower in group D compared with group M (6 vs. 16, respectively). Dentist satisfaction was equivalent in both groups of the study. Conclusion Dexmedetomidine and midazolam are safe and effective for consciously sedating pediatric patients undergoing dental procedures. Dexmedetomidine shows faster recovery and better postoperative analgesia compared with midazolam.
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Intrathecal atropine versus intravenous metoclopramide for prevention of nausea and vomiting during cesarean section under spinal anesthesia p. 393
Tamer El Metwally Farahat, Mohamed S Abdelhafez
Background One of the most unpleasant sensation is the occurrence of intraoperative episodes of nausea and vomiting in mothers undergoing cesarean section (CS) under spinal anesthesia. Objective The aim of the present study was to compare the use of prophylactic low-dose atropine in comparison with the effect of metoclopramide for prevention of perioperative nausea and vomiting in mothers undergoing CS under spinal anesthesia. Patients and methods The present study was conducted in 60 full-term mothers of American Society of Anesthesiology Grade I and II, with age between 20 and 35 years with uncomplicated pregnancies. Patients were allocated into two equal groups. Atropine group (group A) included 30 patients who received intrathecal study solution which is a mixture of 2.5 ml of 0.5% hyperbaric bupivacaine, 25 μg fentanyl, and 100 μg of a 1 mg/ml of free atropine sulfate. Metoclopramide group (group M) included 30 patients who received intravenous solution of metoclopramide 10 mg in 2 ml in addition to intrathecal study solution (2.5 ml of 0.5 hyperbaric bupivacaine, 25 μg fentanyl and 100 μg of preservative-free saline 0.9% as a placebo) which was given after spinal anesthesia and before the start of surgical incision. The number of episodes of nausea and vomiting were recorded, and also any other adverse effects were recorded. Results The incidence of intraoperative nausea and vomiting (IONV) and late nausea score were significantly decreased in group A compared with group M (P<0.05), and nearly equal incidence in early onset of nausea in both groups. No differences were noted in terms of postoperative pain or hypotensive episodes. Conclusion Intrathecal atropine can be safely used to decrease intraoperative nausea and vomiting for mothers undergoing CS under spinal anesthesia.
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Comparison between three supraglottic airway devices as conduits for fiber-optic tracheal intubation p. 399
Salwa H Waly, Yasser M Nasr, Nahla M Amin
Background Securing the airway is a major task for anesthesiologists. Supraglottic airway devices (SADs) are widely used nowadays. Fiber-optic endotracheal intubation (ETT) plays an important role in difficult-to-manage airways. The general purpose of a conduit is to provide a clear protected pathway for the expensive, sensitive, and fragile fiber-optic cable. Aimof the work To compare between three SADs as conduits for fiber-optic tracheal intubation. Patients and methods A prospective, randomized study involving 81 adult patients (American Society of Anesthesiologists I or II), of both sexes who were allocated into three groups (27 patients each): Air-Q group (group Q), intubating laryngeal mask airway (ILMA) group (group L) or I-Gel group (group G). Fiber-optic ETT through SADs was performed. The number of attempts and duration of insertion of SAD, laryngeal view grading, number of attempts, and duration of insertion of ETT were assessed. Complications were recorded. Results The ease and number of attempts to insert SADs showed no statistically significant differences. The duration of insertion of SADs was statistically favoring the Air-Q intubating laryngeal airway (13±3 s), compared with ILMA (19±4 s) and I-Gel (18±3 s). The fiber-optic grading of laryngeal view through SADs also favored group Q compared with other groups. Number of attempts to insert ETT through SADs showed no statistically significant differences between groups. The duration of insertion of the ETT via fiber-optic bronchoscopic through the SADs showed highly statistically significant difference (P<0.001) in favor of group Q (35±5 s) as compared with group L (45±7 s) and group G (42±6 s). Blood stains on SADs just after removal from patients’ airways and sore throat in the first postoperative hour showed no statistically significant difference between groups. Conclusion Air-Q, ILMA, and I-Gel were useful conduits for fiber-optic ETT. Air-Q intubating laryngeal airway provides better visualization of the glottis and shorter time for insertion of both the device and the ETT than ILMA and I-Gel.
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Pre-emptive nebulized ketamine versus nebulized lidocaine for endoscopic nasal surgeries p. 408
Shereen E Abd Ellatif, Sherif M.S Mowafy
Background Endoscopic nasal surgeries are commonly associated with mild to moderate postoperative pain owing to both nasal packing and surgical trauma itself. Aim To compare the analgesic efficacy of pre-emptive nebulized ketamine versus nebulized lidocaine in patients undergoing these surgeries. This was a randomized controlled clinical trial. Materials and methods A total of 60 adult patients scheduled for elective endoscopic nasal surgeries were randomly allocated in three groups (20 patients each). Patients in each group were nebulized 15 min before the surgery with the respective study drug, that is, ketamine group (group K) patients received ketamine 50 mg; lidocaine group (group L) received lidocaine 2% (40 mg), and control group (group C) received normal saline 0.9%. The outcome measures included hemodynamics, intraoperative opioids, sedation, time of first request for analgesia, the total dose of postoperative rescue analgesia given, and adverse effects. The collected data were coded and analyzed using SPSS version 20. Results Lidocaine group showed the least hemodynamic changes to laryngoscope and intubation at 1, 3, 5, and 10 min after intubation, with no significant differences among the three groups from 15 min after intubation till extubation time. Intraoperative propofol and fentanyl doses were statistically significantly higher in group C compared with groups K and L, with no statistical significant difference between groups L and K themselves. The time to first analgesic request prolonged significantly in groups K and L (255.25±18.45 and 242.50±12.82 min, respectively) when compared with group C (119.75±18.88 min). Diclofenac consumption was significant lower in groups K and L (87.75±9.66 and 91.25±7.23 mg, respectively) compared with C group (150 mg), with no statistically significant difference between both treated groups. Conclusion Nebulization with ketamine or lidocaine before induction of general anesthesia is efficacious, enhances postoperative analgesia, and reduces total doses of rescue analgesics used following endoscopic nasal surgeries.
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Bilateral superficial cervical plexus block for transoral endoscopic thyroidectomy (vestibular approach): a randomized controlled study p. 418
Enas Abd El Motlb, Alaa El-Deeb
Background Transoral endoscopic thyroidectomy is one of the scarless approaches for thyroid surgery. The aim of this study was to assess analgesic efficacy of cervical plexus block after general anesthesia for transoral thyroidectomy. The secondary goals are hospital stay, total analgesic consumption, and adverse effects of either anesthesia or surgery. Patients and methods This study was carried out in Mansoura Oncology Hospital. After informed consent, patients undergoing transoral thyroidectomy were randomized into two groups: the first group received general anesthesia (group G) and the second group received bilateral superficial cervical plexus block with ropivacaine 0.5% after induction of general anesthesia (group GB). Analgesic efficiency was our primary concern. Secondary outcomes included patient satisfaction, hospital stay, rescue analgesic, and adverse effects. Results After applying the exclusion criteria, 40 patients were randomized into two groups in this study. The postanesthesia care unit time, pain score for 8 h postoperatively, postoperative opioid requirement, and hospital stay were statistically significantly less in group GB than in the control group. Patient satisfaction is more observed in group GB. Conclusion Bilateral superficial cervical plexus block provided effective analgesia after transoral endoscopic thyroidectomy. Moreover, it results in more patient satisfaction and less hospital stay.
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Dynamic left intraventricular obstruction in patients with septic shock: pathogenetic role and prognostic implications p. 424
Samir Elhadidy, Moustafa Rafea, Suzy Fawzy, Abdo Elazab
Background Left intraventricular flow obstruction (IVO) has been classically described in asymmetric hypertrophic cardiomyopathy, usually at the level of the left ventricular outflow tract (LVOT) or at midcavitary level, which is due to systolic anterior movement of the anterior leaflet of the mitral valve. This phenomenon has also been previously described in certain clinical situations mainly revolving around hypovolemia and catecholamine exposure and recently as a frequent event in patients with septic shock with an important correlation with fluid responsiveness. Multiple studies have demonstrated that static parameters limited the predictive value for fluid responsiveness, whereas dynamic parameters have shown a greater clinical use, including respiratory changes in aortic blood velocity, superior vena cava collapsibility, inferior vena cava (IVC) collapsibility, and changes in stroke volume and Cardiac Output (CO) owing to passive leg raising. Objective This study aimed to assess (a) the prevalence of dynamic IVO in patients with septic shock; (b) relation among IVO, volume status, and fluid responsiveness; and (c) relation between IVO and in-hospital mortality. Patients and methods A total of 40 patients with septic shock were studied over a period of 1 year for the presence of Doppler signs of dynamic IVO, clinical characteristics, hemodynamic parameters, and APACHE II and SOFA scoring. Echocardiographic data including IVC collapsibility, CO, LVOT mean and peak pressure gradient, LVOT maximum velocity, and midcavitary Doppler pattern were recorded initially and following fluid resuscitation (30 ml/kg). Patients were categorized into two groups: group A included patients with IVO and group B included patients without IVO. There was a statistically nonsignificant difference between both groups regarding the baseline demographic, clinical, and hemodynamic parameters. Results A total of 40 (45% were males and 55% females) patients, with a mean age of 52±20 years, were studied, of whom a total of 13 (32%) had IVO versus 27 patients without IVO. Following fluid infusion, as compared with group B, group A showed significantly greater increase in Cardiac Output (COP) (5.85±1.4 vs. 4.4±1.8, P=0.0203) and IVC collapsibility (54.42±6.8 vs 50.56±13, P=0.42). ICU mortality was significantly higher in patients with IVO [10/13 (76.9%)] versus patients without IVO [7/27 (25.9%), P<0.002]. Conclusion Dynamic left IVO is not uncommon in patients with septic shock in ICU. Response to fluid infusion was significantly higher in patients with IVO compared with patients without IVO, pointing to an additional role of fluid resuscitation in patients with sepsis.
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Serum amyloid A versus C-reactive protein in sepsis: new insights in an Egyptian ICU p. 429
Sohier Yahia, Mohamed M El-Assmy, Waleed Eldars, Marwa Mahmoud, Nevert A Abdel Ghaffar, Yahya Wahba
Background Early diagnosis of sepsis is a challenge. Several biomarkers are available for early diagnosis of sepsis. Serum amyloid A (SAA) and C-reactive protein (CRP) are examples of sepsis biomarkers. Settings and design We conducted a cohort study in a university-affiliated ICU in Mansoura, Egypt during the period from May 2018 to May 2019, including 50 children with sepsis. Patients and methods We subjected all patients to full history taking and clinical examination for age, sex, pediatric risk of mortality (PRISM) III and predicted death rate, symptoms and signs of sepsis, length of ICU stay, and invasive procedures. All patients were subjected to complete blood count, CRP, blood culture, and SAA level assay. Statistical analysis We used Student t-test, χ2, and Mann–Whitney tests. Results Twenty-three (46%) sepsis cases survived, whereas 27 (54%) cases died. SAA was more sensitive and specific than CRP in sepsis detection in children (sensitivity of 74.1 vs. 66.7% and specificity of 69.6 vs. 56.5%, respectively). Higher levels of SAA and CRP were observed in nonsurvivors when compared with survivors (P<0.001and 0.01, respectively). Conclusion SAA is a more sensitive and specific sepsis biochemical marker than CRP among critically ill children. Combined usage of SAA and CRP is helpful in predicting sepsis-related mortality.
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Computed tomography-guided ganglion impar block for management of phantom rectum pain: a randomized controlled trial p. 433
Nevert A Abdel Ghaffar, Mahmoud A Abdel Ghaffar, Adel El-Badrawy
Background Patients who undergo abdominoperineal resection with colostomy may experience phantom rectum pain syndrome. Aim To evaluate combined ganglion impar block and pregabaline for treatment of phantom rectum pain syndrome and improvement of quality of life. Settings and design We conducted a randomized prospective open-label blinded end-point level IV trial in a university-affiliated oncology center in Mansoura, Egypt during the period from June 2018 to May 2019. Patients and methods A total of 40 patients were randomly allocated into two groups: group A (n=20) received pregabaline 150 mg twice daily, and group B (n=20) received pregabaline 150 mg twice daily and ganglion impar block using 5 ml bupivacaine 5% with 14 mg/2 ml betamethasone. We monitored numerical rating scale (NRS), participant satisfaction reporting scale, pain anxiety symptoms scale, postblock complication, and success rate of block. Statistical analysis We used χ2, t-test, and Mann–Whitney tests for statistical analysis. Results NRS improved in each group at 1 week, 1, and 2 months in comparison with basal values (within-group P<0.001). NRS decreased in group B in comparison with group A at 1 week (P<0.001) and 1 month (P=0.01). Participant satisfaction reporting scale Q2 and Q5 were better in group B than group A (P=0.02 and 0.049; respectively). Cognition items, anxiety items, and total pain anxiety symptom scale were better in group B than group A (P=0.003, <0.001, and <0.001; respectively). No complications were detected during or after the procedure, and the success rate of the block was 95%. Conclusion Ganglion impar block with pregabaline improved pain and quality of life in patients with phantom rectum pain syndrome.
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Does pregabalin reduce the sevoflurane requirement during laparoscopic cholecystectomy? p. 439
Eiad A Ramzy, Doaa G Diab, Mohamed El Mahdy
Background Preoperative administration of pregabalin reduces the end-tidal concentrations of sevoflurane (ET-Sevo) during laparoscopic cholecystectomy with the added benefit of improving the quality of postoperative analgesia. Patients and methods After ethical approval, 43 patients scheduled for laparoscopic cholecystectomy were randomly allocated to receive placebo or 150 or 300 mg of pregabalin, 1 h before induction. Anaesthesia was maintained with 0.5–1.5 minimum alveolar concentration of sevoflurane, to maintain bispectral index at 50–60, with supplemental fentanyl and vecuronium. Changes in heart rate, mean blood pressure, ET-Sevo, quality of extubation and postoperative sedation scores, morphine consumptions and pain scores were recorded. Results After induction, compared with placebo and pregabalin 150 mg groups, patients receiving pregabalin 300 mg had smaller increases in heart rate (P<0.01), lower ET-Sevo (−45.5 and −42.9%, respectively) (P<0.001), better quality of extubation (P<0.001), higher sedation scores for first 8 postoperative hours (P<0.001), longer time to the first request of morphine (P<0.001), less morphine consumption (P<0.02) and lower pain scores (P<0.001) for the first 24 h after surgery. Conclusion Preoperative administration of pregabalin 300 mg is effective in reduction of the ET-Sevo during laparoscopic cholecystectomy without noted significant adverse effects.
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A randomized trial comparing three different anesthetic techniques on immune response for patients undergoing abdominal hysterectomy operation p. 446
Amira Abdelfattah Shabaan
Background In the past decade, the published studies indicated that different anesthetic techniques may have different effects on the immune response of patients undergoing the same type of surgery. The aim of the work was to evaluate the effects of three anesthetic techniques [sevoflurane anesthesia, total intravenous anesthesia (TIVA) with propofol, and epidural anesthesia with bupivacaine] on interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and IL-10 in patients undergoing abdominal hysterectomy operation. Patients and methods A total of 60 female patients with an age range of 39–60 years old and American Society of Anesthesiologists status I and II were scheduled for an elective abdominal hysterectomy. They were allocated randomly into three equal groups (n=20): general anesthesia with sevoflurane (group I), TIVA anesthesia (group II), and epidural anesthesia (group III). Vital signs (heart rate and mean arterial blood pressure) were recorded at the baseline and every 10 min. IL-6, IL-10, and TNF-α were also recorded just before the induction of anesthesia and then at 2 and 24 h after the end of the surgery. Results Mean arterial pressure and heart rate showed no statistically significant differences between the three groups. The IL-6 was highly significantly increased at 2 and 24 h after surgery in all groups, but the increase was less in the epidural group in comparison with sevoflurane and TIVA groups. The TNF-α was highly significantly increased at 2 h in all groups in comparison with the preoperative value. This increase was more increased in sevoflurane group in comparison with TIVA and epidural groups. IL-10 increased significantly in epidural group 2 and 24 h after surgery in comparison with sevoflurane group and TIVA group. IL-10 was significantly higher in TIVA group than inhalation group 2 and 24 h after surgery. Conclusion Epidural anesthesia had a better profile in relation to cytokine levels, whereas propofol had little effects on the immune response compared with sevoflurane anesthesia in patients undergoing abdominal hysterectomy operation.
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Ultrasound-guided supraclavicular brachiocephalic vein cannulation versus internal jugular vein cannulation in young children p. 455
Mofeed A Abdelmaboud
Background Ultrasound (US) guided supraclavicular approach of brachiocephalic vein (BCV) cannulation was recently described in children. Aim The primary outcome was to evaluate which is better, US-guided BCV cannulation or internal jugular vein (IJV) cannulation. The secondary outcome was to examine possible complications. Patients and methods According to the site of central line cannulation, 80 children undergoing open cardiac surgery were classified into group I (US-guided supraclavicular BCV cannulation) and group II (US-guided IJV cannulation). The cannulation time (min), first-attempt success rate, overall success rate, number of cannulation attempt, and possible complications (such as artery puncture, difficulty of threading the wire, catheter malposition, multiple puncture, and pneumothorax) were recorded. Results The cannulation time (min) was significantly shorter in group I than group II, and first-attempt success rate was significantly higher in group I than group II. The number of cannulation attempt was significantly higher in group II than group I, and the overall success rate was slightly higher in group I than group II, with no significant difference. There were no significant differences between the two groups regarding complications. Conclusion US-guided supraclavicular BCV cannulation was easier with higher success rate and shorter cannulation time with slightly less complications compared with IJV cannulation.
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Midregional proadrenomedullin in correlation with Sequential Organ Failure Assessment score and Acute Physiology and Chronic Health Evaluation II score in sepsis p. 461
Ashraf Wadie, Sayed Gaber, Amal Rizk, Ziad Safaan
Introduction The early diagnosis of sepsis plays a central role in patient management. Many mediators have been proposed to be the cause of sepsis. In the present study, we investigate the role of plasma proadrenomedullin (proADM) levels in the diagnosis of sepsis, and to estimate its value as a prognostic marker of mortality. Also, the prognostic value of proADM was compared with those of C-reactive protein, serum lactate, Sequential Organ Failure Assessment, and Acute Physiology and Chronic Health Evaluation II scores. Patients and methods This is a prospective cohort study done between March 2015 and January 2016 on 10 healthy individuals and 30 patients admitted with a new diagnosis of sepsis or developed septic shock during their ICU stay in Cairo University Hospitals. All included patients were followed until hospital discharge or death. Our patients were divided into two groups (survivors and nonsurvivors). Results In the analyzed cohort, a total of 30 septic patients were enrolled. The mean age was 57.1±15.9 years; the overall nonsurvivors were 19 (63.3%) patients. ProADM showed the highest area under the curve (0.89) as compared with the rest of the biomarkers (P<0.0001). ProADM levels were directly proportional to Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment score (r=0.547; P=0.002 and r=0.549; P=0.002, respectively). ProADM levels were negatively correlated with mean arterial pressure on admission (r=−0.472; P=0.009) with also a strong association with vasopressor therapy (P<0.0001). ProADM levels at days 3 and 4 in patients required mechanical ventilation (MV) were significantly higher than patients without MV (141.1±32.4 and 154.4±33.5 pmol/l compared with 100.8±18.3 and 94±16.6 pmol/l, respectively) (P<0.0001). Conclusion In patients admitted with sepsis or septic shock plasma proADM is strongly associated with the severity of disease, vasopressor requirement, and short-term mortality. Our prediction model for mortality, based on the best 4 predictors, had high sensitivity (94.7%) for nonsurvivors and high specificity (90.9%) for survivors. The best 4 predictors were proADM levels on day 4, C-reactive protein levels on day 4, MV duration, and type of sepsis (patients with severe sepsis or septic shock).
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Anaesthetic management of a child with tetralogy of Fallot for dental extraction: a modified technique p. 470
Sunil Rajan, Pulak Tosh, Manu Sudevan, Ahlam Abdul Rahman, Lakshmi Kumar
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Langerhans cell histiocytosis: know before you go p. 472
Vijay Adabala, Nishith Govil
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