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   Table of Contents - Current issue
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April-June 2020
Volume 7 | Issue 2
Page Nos. 135-251

Online since Saturday, June 27, 2020

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ORIGINAL ARTICLES  

Analgesic efficacy of intramuscular ketamine/ketorolac versus fentanyl/ketorolac for children undergoing bone marrow biopsy and aspiration p. 135
Enas A. Abd El Motlb
DOI:10.4103/roaic.roaic_37_19  
Background Bone marrow aspiration and/or biopsy (BMAB) in children with hematological disorders is a painful procedure, is required to be repeated at regular intervals, and is under researched. Objective To compare intramuscular administration of fentanyl/ketorolac (F) versus ketamine/ketorolac (K) as an analgesic regimen in pediatric population undergoing BMAB under general anesthesia. A total of 80 children underwent BMAB under general anesthesia, who were randomized into two equal groups: group K received ketamine 0.5 mg/kg/ketorolac 1 mg/kg and group F received fentanyl 1.5 μg/kg/ketorolac 1 mg/kg. The study drugs are injected intramuscularly after induction of general anesthesia. Result No statistically significant difference was found between groups regarding patient characteristics, duration of procedure or duration of anesthesia, pain score, time to first analgesic request, emergence-agitation score, or incidence of vomiting. There was a significant decrease in heart rate, systolic blood pressure, and respiratory rate in both groups at 15 and 20 min compared with basal values. Conclusion Ketamine 0.5 mg/kg+ketorolac 1 mg/kg and fentanyl 1.5 μg/kg+ketorolac 1 mg/kg administered intramuscular are similarly effective analgesic regimens in pediatric population undergoing BMAB under general anesthesia without adverse effects.
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Distal versus proximal pulsed radiofrequency for treating trigeminal neuralgia p. 142
Ahmed Sobhi M.E Hegab, Osama M Baha’a Khidr
DOI:10.4103/roaic.roaic_43_19  
Aims The aim of this study was to evaluate and compare percutaneous distal pulsed radiofrequency (DPRF) and proximal pulsed radiofrequency (PPRF) for the trigeminal nerve in the management of trigeminal neuralgia (TN). Patients and methods We conducted a prospective clinical trial including 20 patients with recent TN (3–6 months). The patients were randomized into two groups: DPRF (n=10) and PPRF (n=10). Patients were clinically followed up for 1 year and pain intensity was assessed at 3, 6, 9, and 12 months after the procedure using the visual analog scale (VAS). Results The percentages of patients with satisfactory pain relief (50–80% pain relief) were 30% at 3 months, 40% at 6 months, and 40% at 12 months in DPRF group. However, in PPRF group, the percentages of patients who showed excellent pain relief (≥80% pain relief) at 3, 6, and 12 months were 50, 50, and 40%, respectively, whereas the percentages of patients with satisfactory pain relief (50–80% pain relief) at 3, 6, and 12 months were 40, 30, and 60%, respectively. Comparing the VAS score at 1, 3, 6, and 12 months did not show any significant difference between the two groups. In both groups, there was a significant decrease in VAS score after 1, 3, 6, 9, and 12 months compared with the preprocedure score (P<0.001). Conclusion PRF treatment is a safe, effective, well-controlled procedure for the treatment of TN. There was no significant difference between DPRF and PPRF procedures. DPRF is a simple, safe, and effective procedure before the attempt to do the intracranial procedure.
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Intranasal premedication with dexmedetomidine versus midazolam for pediatric patients in ophthalmic surgery: a randomized controlled study p. 149
Ghada F Amer
DOI:10.4103/roaic.roaic_54_19  
Background Excessive anxiety has a bad implication on anesthetic practice in pediatric anesthesia; therefore, decreasing anxiety by premedication is an important issue. Intranasal administration of various drugs is an easy route with rapid onset of action allowing administration of variable drugs such as midazolam and dexmedetomidine used in pediatric preoperative sedation. Patients and methods A total of 64 pediatric patients who were subjected to elective ophthalmic surgeries received either 0.5 mg/kg midazolam or 1 μg/kg dexmedetomidine intranasally. Basal heart and respiratory rate, blood pressure, sedation score, and oxygen saturation were recorded initially and every 5 min till the transfer to the operating room. Sedation score was also assessed at 30 min after drug administration. Postoperative monitoring was continued, and any postoperative complications were recorded. Results Oxygen saturation, heart rate, systolic blood pressure, and respiratory rate values showed insignificant differences when both groups were compared together but showed significance differences when compared with the basal value in each group separately after 30 min. Sedation score was faster and child–parents separation score was higher in dexmedetomidine group when compared with midazolam group, and also both groups showed significant sedation score less than 3 when compared with the basal value at 15, 20, 25, and 30 min. Conclusion Midazolam and dexmedetomidine were nearly equally effective as intranasal premedication for pediatric patients subjected to elective ophthalmic surgery with minimal adverse effects, and we recommend the use of midazolam owing to its safety, effectiveness, and lower cost.
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Quality of health care service in pain clinics in Mansoura, Egypt: a cross-sectional comparative study p. 157
Nevert A Abdel Ghaffar, Mahmoud A Abdel Ghaffar, Adel A El Ghaffar
DOI:10.4103/roaic.roaic_63_19  
Background Patient satisfaction is an essential parameter for health care service evaluation. The authors evaluated the quality of the health care services and treatment satisfaction among patients with cancer with chronic pain. Materials and methods The authors conducted our study in Oncology Center Mansoura and Mansoura University Hospitals from April 2019 till September 2019. The authors enrolled 259 patients who were subjected to Patient Satisfaction Questionnaire Short Form, pain treatment satisfaction scale, and numerical rating scale. Results Regarding Patient Satisfaction Questionnaire, patients were generally satisfied in the Oncology Center (P<0.001). Moreover, technical quality, accessibility, and convenience were better in the Oncology Center (P<0.001). Patients were more satisfied with the financial aspects in Mansoura University Hospital (P<0.001). Regarding pain treatment satisfaction scale, patients were more satisfied about medication characteristics in the Oncology Center (P<0.001). Conclusion General satisfaction, technical quality, accessibility, convenience, and medication characteristics were better in the Oncology Center. Patients were more satisfied with the financial aspects in Mansoura University Hospital.
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Pregabalin effects on hypotensive anesthesia during spine surgery p. 161
Alaa Mazy, Maha A Abo-Zeid
DOI:10.4103/roaic.roaic_64_19  
Background Elective lumbar spine surgeries are commonly performed under controlled hypotensive general anesthesia to ameliorate intraoperative blood loss and improve the surgical field. Purpose To demonstrate the effect of preoperative 150 mg oral pregabalin on facilitation of induced hypotension during spine surgery evaluated by the total intraoperative consumption of nitroglycerin required to maintain the targeted mean arterial blood pressure. Patients and methods This prospective, randomized, controlled, double-blinded study included two groups of adult patients, who had undergone elective spinal surgery: the pregabalin group (n=53): received oral pregabalin capsule 150 mg 1 h before general anesthesia and the control group (n=53): received oral placebo capsule. The intraoperative invasive mean arterial blood pressure was maintained at the targeted range of 55–65 mmHg by nitroglycerin infusion titration. The intraoperative hemodynamics, blood loss and postoperative sedation, pain scores, and morphine consumption were recorded. Results There was a statistically significant decrease in the consumption of both intraoperative nitroglycerin and postoperative morphine in the pregabalin group compared with the control group, but there was no concomitant decrease in intraoperative blood loss. Also, there was a statistically significant suppression of stress response to intubation in the pregabalin group. Conclusion Premedication with oral 150 mg pregabalin before elective spinal surgery facilitated induced hypotension. Furthermore, it attenuated the stress response to tracheal intubation and enhanced postoperative analgesia.
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Ultrasound-guided quadratus lumborum block versus transversus abdominis plane block in children undergoing laparoscopic appendectomy: a randomized controlled study p. 167
Shereen E Abd Ellatif, Fatma M Ahmed
DOI:10.4103/roaic.roaic_72_19  
Context Ultrasound (US)-guided quadratus lumborum block (QLB) is a new abdominal truncal block used for perioperative pain management of both upper and lower abdominal surgeries. Aims To compare the analgesic efficacy of US-guided QLB with transversus abdominis plane (TAP) block. Settings Approval of Zagazig Institutional Review Board (IRB) was obtained (ZU-IRB # 5504/16-9-2018) before the study, and patient’s informed written consent was also obtained. Our clinical study was registered with ClinicalTrials.gov (NCT04031196). A total of 34 pediatric patients scheduled for elective laparoscopic appendectomy were randomly allocated in two equal groups: QLB and TAP block groups. Patients and methods All patients received general anesthesia using intravenous 2 mg/kg propofol, 1 µg/kg fentanyl, and atracurium 0.5 mg/kg. After induction of anesthesia, QLB group received bilateral US-guided QLB type 2, using 0.5 ml/kg of 0.25% levobupivacaine, whereas TAP block group received bilateral US-guided TAP block using 0.5 ml/kg of 0.25% levobupivacaine. The primary outcomes were changes of intraoperative hemodynamics and postoperative pain assessment. Secondary outcomes were total intraoperative fentanyl consumption, the first time of rescue analgesics, total rescue analgesic consumption in the first postoperative 24 h, and degree of parent satisfaction. Results QLB group had statistically significant lower hemodynamic changes 15 min after performing the block to the end of surgery (P<0.05), highly significant lower visual analog scale score in the first postoperative 4 h (P<0.001), highly significant lower intraoperative fentanyl dose (P<0.001), significant longer time for the first rescue analgesic, lower analgesic doses given in the first 24 h postoperatively (P<0.001), and higher parent satisfaction compared with TAP block group. Conclusion This study revealed that QLB provides longer and more effective postoperative analgesia compared with TAP block in pediatric patients undergoing laparoscopic appendectomy.
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Efficacy of adding magnesium sulfate to bupivacaine for ilioinguinal and iliohypogastric nerve block in acute postherniorrhaphy pain p. 176
Maha A Abo-Zeid, Mahmoud S.F El Mansy
DOI:10.4103/roaic.roaic_88_19  
Background Regional block of ilioinguinal and iliohypogastric (IIIH) nerves has been applied to provide postoperative analgesia after inguinal hernia repair. Magnesium sulfate (MgSo4) blocks N-methyl-d-aspartate receptors, and that is why, it was used as an adjuvant to the local anesthetic (LA) in different anesthetic approaches. Although the prolongation in postoperative duration resulting from the addition of MgSO4 to LA was significant in some literature studies, it was insignificant in others. Objective This study was designed to investigate the adjunctive effect of MgSo4 when added to bupivacaine for IIIH blockade on the postoperative analgesic duration as a primary outcome and on the verbal rating scale (VRS) scores, analgesic consumption, and hemodynamics as secondary outcomes. Patients and methods Patients were divided into two groups of 45 patients each by means of coded envelopes according to the LA used for IIIH blockade. In the first group (control group), patients received 10 ml 0.5% isobaric bupivacaine plus 1 ml normal saline for IIIH blockade, whereas in the second group (MgSo4 group), 10 ml 0.5% isobaric bupivacaine and 1 ml of MgSo4 10% were prepared. All the patients received intrathecal 3 ml 0.5% hyperbaric bupivacaine, and then, IIIH blockade was performed under ultrasound guidance according to the group. Postoperatively, VRS scores, analgesic duration, and any complication were recorded. Results There was a significantly prolonged analgesic duration in MgSo4 group when compared with the control group. However, the consumed analgesic in the first postoperative day and the pain score were insignificantly lower in MgSo4 group. Conclusion The addition of MgSO4 to bupivacaine for IIIH nerve block prolonged the postoperative analgesic duration after inguinal hernia repair without significant effect on the analgesic consumption or VRS scores.
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Sedation of mechanically ventilated patients in intensive care units: Dexemedetomidine versus ketofol p. 182
Ghada F Amer
DOI:10.4103/roaic.roaic_101_19  
Background Patients in the ICUs are usually provided with sedation and analgesia to avoid pain and anxiety, facilitate invasive maneuvers, decrease stress and oxygen utilization, and facilitate mechanical ventilation. The Association of Critical Care Medicine recommends the use of nonbenzodiazepine drugs such as propofol and dexmedetomidine in sedating the intensive care patients to improve outcomes. Usual sedation protocols should be changed by incorporating propofol, dexmedetomidine, or drug combinations to reach arousal targets and decreasing benzodiazepine use. Objectives The study was conducted to compare between the sedative effect of dexmedetomidine versus ketamine–propofol combination (ketofol) in ICU patients on mechanical ventilation. Patients and methods A total of 90 patients who needed sedation for postoperative mechanical ventilation and monitoring in ICUs were randomly allocated into two groups: ketofol group, where sedation of the patients was done with ketofol at a loading dose of 500 μg/kg of ketamine and propofol mixture 1 : 1 (ketamine 8 mg/ml and propofol 8 mg/ml), followed by continuous infusion at 8–10 μg/kg/min, and dexmedetomidine group, where patients were sedated with an initial bolus dose of dexmedetomidine of 2 µg/kg intravenous infused over 10 min followed by infusion rate of 0.3–0.5 µg/kg/h. Patients’ hemodynamics, Ramsay sedation scale, and total analgesic requirement were recorded. Results Mean blood pressure and heart rate were statistically significantly lower in dexmedetomidine group than in ketofol group. Ramsay sedation score was clinically efficient in both groups but statistically higher in dexmedetomidine group than ketofol group. Dexmedetomidine group showed faster recovery time and less analgesic requirement than ketofol group. Conclusion Dexmedetomidine is an effective sedative drug for ICU patients, with more hemodynamic stability, less analgesic requirement, and rapid recovery time than ketofol.
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Efficacy of adding ketamine, dexamethasone, and epinephrine with bupivacaine in ultrasound-guided supraclavicular brachial plexus block p. 188
Maha Y Youssef, Sherif F.H Elsayed, Enas A Abd El-Mottalb, Gehan A Tarabai
DOI:10.4103/roaic.roaic_60_19  
Background Supraclavicular brachial plexus block is an effective anesthesia for upper limb surgery as it provides anesthesia and postoperative analgesia. Various adjuvants were added to local anesthetics to achieve dense and prolonged blocks. Objective The aim of this study is to compare the effect of adding ketamine, dexamethasone, or epinephrine to bupivacaine on onset time, duration of sensory and motor block, intraoperative and postoperative hemodynamic stability, patient satisfaction, and any adverse effects. Patients and methods This study was carried out on four groups of patients. Patients were anaesthetized by ultrasound-guided supraclavicular brachial plexus block; group B was anaesthetized by an injection of 20 ml bupivacaine (0.5%) plus 2 ml of saline; group K received 20 ml bupivacaine (0.5%) and ketamine 1.5 mg/kg; group D received 20 ml bupivacaine (0.5%) and dexamethasone 8 mg; and group E received 20 ml bupivacaine and epinephrine (5 μg/ml). Patients were assessed for the onset and duration of sensory and motor block. Intraoperative and postoperative analgesia were assessed by visual analog scale, and intraoperative and postoperative sedation was assessed according to Culebras scale. Results Group D showed a shorter onset of sensory and motor blocks compared with the other groups. Group D showed statistically significant longer duration of analgesia compared with the other groups. There was significant decrease in postoperative analgesic requirement in group D during the first 24 h postoperatively compared with the other groups. Conclusion Dexamethasone with bupivacaine in supraclavicular brachial plexus block has a longer duration of sensory and motor blocks and less requirement of rescue analgesia in the first 24 h postoperatively.
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Oxygen exposure as quantified by time-weighted area under curve for arterial oxygen content is associated with mortality in mechanically ventilated critically ill patients Highly accessed article p. 197
James P Harvey, Dayal G Jayawardena, Mahesh Ramanan
DOI:10.4103/roaic.roaic_84_19  
Background Oxygen is frequently administered to intensive care patients, for both treatment and prophylaxis. Arterial oxygen content (CaO2) represents the total amount of oxygen in arterial blood, both bound to hemoglobin and dissolved. CaO2 could be a useful marker of tissue oxygen levels and oxygen exposure. Aims We undertook this study to determine the relationship between CaO2 and mortality in mechanically ventilated critically ill patients. Settings and design A retrospective cohort study of all mechanically ventilated adult patients in the Multiparameter Intelligent Monitoring in Intensive Care III database was conducted. Patients with less than three arterial blood gases were excluded. The primary exposure variable was time-weighted CaO2 (TWCaO2) over the course of the entire ICU admission. The primary outcome was 6-month mortality. Multivariate logistic regression analysis was used to assess the relationship between CaO2 and mortality. Results A total of 7452 patients were identified who satisfied all inclusion and exclusion criteria. In the multivariate analysis, higher CaO2 was significantly associated with increased mortality. After adjustment for age, sex, transfusion, admission type, Elixhauser Comorbidity Index, Simplified Acute Physiology Score II, and time-weighted fraction of inspired oxygen, the highest quartile had an odds ratio (mortality) of 1.22 (95% confidence interval, 1.03–1.46; P=0.02). The second (TWCaO2, 12.2–13.3 ml/100 ml) and third (TWCaO2, 13.4–14.4 ml/100 ml) quartiles had odds ratio (mortality) of 1.19. Postestimation analysis revealed good model discrimination with a c-statistic of 0.80 for the final model. Conclusion In mechanically ventilated patients, after adjusting for disease severity and comorbidities, higher oxygen exposure as indicated by TWCaO2 over the entire ICU admission was associated with increased mortality.
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The effect of local wound infiltration vs caudal block on wound infection and healing after inguinal herniotomy in pediatrics − a double-blinded randomized study p. 205
Mohammad H.I Ahmad Sabry, Ramadan A Ammar, Rana Bakr
DOI:10.4103/roaic.roaic_48_19  
Purpose The aim was to compare the use of local wound infiltration (LWI) vs caudal block (CB) on wound infection and healing after inguinal herniotomy in pediatrics. Patients and methods A total of 50 patients were assigned randomly into two groups (n=25/group) that received LWI using up to 1 mg/kg bupivacaine 0.25% or CB in group C using 1 mg/kg bupivacaine 0.25%. The authors measured wound infection and healing (primary outcome) using Southampton scoring system and postoperative analgesia (secondary outcome) using Faces Legs Activity Cry Consolability tool scale. Results There was a statistically significant difference regarding Southampton scoring system between the two studied groups, with higher number of patients with higher scores in group L (P=0.008). Comparison between the two groups according to preoperative and postoperative white blood cell count shows statistically significant increase in group C on day 7 postoperatively (P=0.015). There was a statistically significant decrease in pain score scale in group C compared with group L at 15 min (P=0.035), 60 min (P=0.007), and 3 h postoperatively (P=0.049). Analgesic requirement shows a statistically significant increase in group L at 15 and 60 min postoperatively (P=0.022). Postoperative complication was not statistically significant (P=1.000). Conclusion LWI is a safe and satisfactory analgesia option for surgery, and compared with CB, it is not overwhelming. CB provides better and longer analgesia; however, complications are more common. Wound healing was found to be better with CB, but it was clinically insignificant, as all patients healed normally. LWI did not cause wound infection in any of the patients included in the study and showed decrease in white blood cells in group L on day 7 postoperatively.
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Application of lung ultrasound for predicting outcome of weaning from mechanical ventilation p. 211
Mona R Hosny, Randa A Shoukry
DOI:10.4103/roaic.roaic_16_19  
Background Weaning failure is an important issue among critically ill patients. Currently, lung ultrasound (US) is a useful tool to early predict this problem. This study was conducted to assess the efficacy of lung ultrasound to predict early weaning failure in critically ill patients. Patients and methods A total of 50 patients requiring mechanical ventilation (MV) were included in this prospective observational study. Patients were divided into two groups after 48 h: group NS included patients who were unsuccessfully weaned, either failed 30 min of spontaneous breathing trial (SBT) or reintubated within 24 h after being extubated, and group S included patients who were successfully weaned (extubated). Lung US was completed for all patients, 1 h before SBT while patients were mechanically ventilated, 30 min after SBT, and 6 h after extubation. Patients were prospectively followed up for the need for reintubation and mechanical ventilation or the need for non-invasive positive pressure ventilation (NIPPV) after successful extubation (primary endpoints). The length of Intensive care Unit (ICU) stay, duration of mechanical ventilation (MV) and ICU mortality (secondary end points). Results Lung US done for all patients in the anterior, lateral, and posterior regions of the lung showed significantly high lung US score in group NS than group S (P<0.001). The number of patients who failed SBT, needed reintubation and MV or noninvasive positive pressure ventilation, after being successfully extubated were significantly high in group NS than group S (P<0.001). During the study period, there were a significant decrease in ICU stay, ventilator days, and patient mortality in Group S than Group NS (P<0.001). Conclusions Lung US can accurately detect lung aeration changes and predict weaning outcome through estimating the lung US scoring system for lung aeration changes where high scores are associated with weaning failure.
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Relation between central venous pressure values and outcome in critically ill patients p. 220
Amr Abdalla, Amr H Dahroug, Ahmed Rashad
DOI:10.4103/roaic.roaic_30_19  
Background Central venous pressure (CVP) was the most commonly used parameter to guide fluid responsiveness. However, recent studies showed that there is no correlation between CVP and circulating blood volume, and CVP more than 8 mmHg is independently associated with a higher mortality and increased risk of acute kidney injury in patients with sepsis and heart failure. Objective The aim of this study was to assess the effect of CVP over 7 days after ICU admission on clinical prognosis and mortality. Patients and methods The study was conducted on 218 patients in whom hemodynamic monitoring was required, and CVP was measured from the first day of ICU admission. Three values of CVP were selected to be measured (the values once inserted, the peak values, and the mean values of CVP) throughout the monitoring process over 7 days of ICU admission. Acute Physiology and Chronic Health Evaluation II score was calculated on admission, and Sequential Organ Failure Assessment (SOFA) score was calculated every other day. Length of ICU stay, mechanical ventilation days, and mortality at days 7 and 28 were recorded. Results Although the initial CVP values were only correlated with mean of SOFA scores, mean and peak CVP values were correlated with Acute Physiology and Chronic Health Evaluation II score, mean SOFA score, mechanical ventilation days, and mortality. Only peak CVP showed correlation with mean creatinine, and only mean CVP values were correlated with length of ICU stay. According to mean CVP values, patients were classified as low CVP (<8 mmHg), intermediate CVP (8–12 mmHg), and elevated CVP (>12 mmHg). The elevated mean CVP group was associated with increased 28-day mortality, and regarding further investigations such as renal function, duration of mechanical ventilation, and laboratory results related to organ dysfunction, it also demonstrated that higher mean CVP group was associated with poor ICU outcome for patients in ICU settings. Conclusion The study showed that for patients in ICU settings, elevated mean CVP load was associated with poor clinical outcome and prolonged treatment in ICU. Level and duration of elevated mean CVP should be evaluated, and more effort should be made to establish the cause and appropriate treatment for elevated mean CVP.
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Transversus abdominis plane block versus simple instillation of local anesthetics in the peritoneal cavity for postoperative analgesia in laparoscopic prostatectomy p. 230
Tarek I Ismail
DOI:10.4103/roaic.roaic_14_19  
Background Laparoscopic radical prostatectomy is minimally invasive technique used to treat cancer prostate. Controlling post-operative pain is one of the main concerns for better post-operative recovery. This study compared the efficacy of ultrasound guided transversus abdominis plane (TAP) block with intraperitoneal instillation of local anesthetics for reduction of postoperative pain after laparoscopic radical prostatectomy. Methods Forty adult patients scheduled for laparoscopic radical prostatectomy were randomized to receive TAP block (group I) or simple instillation of local anesthetics in the peritoneal cavity (group II). The primary outcome was assessing Visual Analogue scale (VAS) during rest and during mobilization. Secondary outcome was measuring total amounts of supplementary morphine consumption. Results There were significant lower pain scores in group II when compared to group I at rest and on movement till the end of the first 24 hours post-operatively. patients undergoing peritoneal block had reduced total amount of 24 h morphine consumption (8±1.9) in comparison to TAB block group (5.8±1). Conclusion Peritoneal block with local anesthetics provides better post-operative analgesia and reduced morphine consumption up to 24 hours after laparoscopic surgery when compared to TAP block.
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Plasma epinephrine as a prognostic marker in traumatic brain injury p. 235
Ahmed E Elshewy, Ahmed M Nabil, Ehab M El-Reweny
DOI:10.4103/roaic.roaic_82_19  
Background Traumatic brain injury is an international health problem with high morbidity and mortality. It is associated with catecholamine release (catecholamine surge). Objective The purpose of the work was to study plasma epinephrine as a prognostic marker in traumatic brain injury. Patients and methods The authors enrolled 60 adult persons of both sexes [30 patients with diagnosis of isolated traumatic brain injury with Glasgow coma score (GCS) ≤11 and 30 volunteers as a control group]. Plasma epinephrine levels were measured on admission and after 24 h. Then the patients were classified into two groups at the end of the study (3 months) according to the GOS: group I (favorable outcome; GOS IV, V) which included 11 (36.6%) patients and group II (unfavorable outcome; GOS I, II, III) which included 19 (63.3%) patients. Results Receiver operating characteristic curves were used to describe the prognostic value of plasma epinephrine on admission and after 24 h to predict unfavorable outcome and mortality. Higher levels of epinephrine on admission were associated with a higher rate of unfavorable outcome [areas under the curve (AUC)=0.921, confidence interval (CI): 0.828–1.014, P<0.001] and mortality (AUC=0.855, CI: 0.707–1.003, P=0.003). Also, higher levels of epinephrine after 24 h were associated with a higher rate of unfavorable outcome (AUC=0.971, CI: 0.912–1.030, P<0.001) and mortality (AUC=0.884, CI: 0.752–1.02, P=0.002). Conclusion Plasma epinephrine could be used as a prognostic marker in traumatic brain injury.
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CASE REPORTS Top

Nemaline myopathy: a chance diagnosis and management dilemma p. 240
Aseem Gargava, Jaspal S Dali, Mona Arya
DOI:10.4103/roaic.roaic_67_19  
Nemaline myopathy is one of the most rare muscle disorders and its diagnosis is based on both clinical and histopathological findings in muscle biopsy. Chances of missing the diagnosis are high considering the rarity of the disease. Here, the authors discuss a case of nemaline myopathy which was in fact a chance diagnosis that led to intraoperative changes in the plan of anaesthesia, successfully abetting the complications related to it. Although general anaesthesia has been used in a similar patient population in the past, the authors advocate the use of epidural anaesthesia considering the benefits of the same over the added risks of general anaesthesia.
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Subarachnoid block in transurethral surgery for bladder tumor in Eisenmenger’s syndrome p. 244
Sankar NK, Kumar Lakshmi, Vasu BK, Rajan S
DOI:10.4103/roaic.roaic_44_19  
Uncorrected left to right intracardiac shunts can progress to a reversal of shunting in the fourth or fifth decade of life due to severe pulmonary artery hypertension. As the changes in the pulmonary vasculature are irreversible at this stage the condition can only be palliated by medication. Regional anaesthesia decreases the systemic vascular resistance and increases the right to left shunt but in optimal doses can minimize this shunting while protecting from other adverse effects of general anaesthesia. We highlight the anaesthetic management of a 53 year old male with Eisenmenger’s syndrome with atrial septal defect on anti failure medications successfully managed with a low dose subarachnoid blockade for transurethral surgery. We believe that this simplified management while providing a safe protocol for use.
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LETTERS TO THE EDITOR Top

Accidental extubation owing to internal displacement of an armored endotracheal tube during craniosynostosis surgery in a pediatric patient p. 247
Mridul Dhar, G Hari Haran, Praveen Talawar
DOI:10.4103/roaic.roaic_6_19  
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Check at every point: failed epidural catheter owing to stretching p. 250
Ravneet K Gill, Uma Rathi, Richa Saroa, Ashwani Mudgal
DOI:10.4103/roaic.roaic_41_19  
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