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   Table of Contents - Current issue
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January-March 2019
Volume 6 | Issue 1
Page Nos. 1-139

Online since Wednesday, February 27, 2019

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ORIGINAL ARTICLES  

Neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, and c-reactive protein as markers for severity of pre-eclampsia Highly accessed article p. 1
Aly Kholief, Rania Swilam, Ahmed Elhabashy, Rana Elsherief
DOI:10.4103/roaic.roaic_101_17  
Objective In this study , we aimed to compare and correlate neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), and C-reactive protein (CRP) levels in patients with different degrees of pre-eclampsia (PE). Patients and methods We recruited 105 Egyptian pregnant women with gestational age more than or equal to 34 weeks. They were divided into 35 normotensive pregnant women and 70 pre-eclamptic women and were further subdivided into 35 mild and 35 severe PE cases according to the American College of Obstetricians and Gynecologists criteria. Results There was no statistically significant difference between patients with PE and healthy pregnant women regarding NLR. PLR showed a statistically significant difference between the control and severe PE cases and between mild and severe PE cases. CRP levels showed statistically significant difference between the control and mild PE cases and between the control and severe PE cases. Conclusion CRP was more sensitive and specific than PLR to predict PE in pregnant women, so it can be used in prediction of PE. PLR was more sensitive but less specific than CRP to predict severity of PE in pregnant women, so PLR can be used for early prediction of severity. NLR cannot be used as a marker for prediction of PE or its severity.
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Rocuronium versus cisatracurium as adjuvants to local anesthetic in peribulbar-induced akinesia p. 9
Heba B El-Serwi, Ramy Mahrose
DOI:10.4103/roaic.roaic_99_17  
Background and objectives Peribulbar anesthesia is widely used in cataract surgery, but the beginning of akinesia is much slower and slower compared with retrobulbar technique. The effect of using adjuvant to the peribulbar block for the development of improved conditions in the absence of any adverse effects and in fastening the onset of akinesia has been implicated. We investigate the effect of the use of rocuronium, cisatracurium, and hyaluronidase as adjuvants for the local anesthetic on peribulbar-induced akinesia in relation to the grade of akinesia. Patients and methods A total of 135 women were assigned for cataract surgery to three groups (45 patients in each group), who received local eye anesthesia of a mixture (8 ml) containing equal amounts of Marcaine 0.5% and lidocaine 2%, containing hyaluronidase 15 IU/ml plus 0.5 ml saline 0.9% (group C); a mixture (8 ml) containing equal parts of 0.5% Marcaine and 2% lidocaine plus 0.5 ml cisatracurium (1 mg) (group A); and a mixture (8 ml) containing equal parts of 0.5% Marcaine, 2% lidocaine plus 0.5 ml rocuronium (5 mg) (group R). Lid akinesia, globe akinesia, hemodynamics, and adverse effects were evaluated among groups. Results After 1 min of injection, the number of patients reaching total akinesia was 15 (33%) with rocuronium, nine (20%) with cisatracurium, and zero (0%) in the control group. After 3 min of injection, the total number of individuals achieving total immobility was 21 (46%) with rocuronium, 15 (33%) with cisatracurium, and six (13%) in the control group. After 5 min of injection, the number of patients reaching total akinesia was 33 (73%) with rocuronium, 27 (60%) with cisatracurium, and 21 (46%) with the control group. At the 10th minute after injection, the number of individuals reaching total akinesia was 39 (86%) with rocuronium, 33 (73%) with cisatracurium, and 30 (66%) with control. In groups of rocuronium and cisatracurium, the total akinesia is relatively more frequent than in the control group. The number of patients with complete akinesia was higher in the rocuronium group after 10 min than in the cisatracurium and control groups, but there was no statistically significant difference among the three groups regarding lid akinesia. We did not notice any adverse effects related to the peribulbar block or the drugs used during the study. Conclusion This study demonstrated that addition of low-dose cisatracurium and rocuronium to the anesthetic drug is recommended to improve the quality of akinesia especially when hyaluronidase is not added.
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Postintubation vocal cord palsy: possible role of pre-existing laryngeal deformity? p. 17
Mridul Dhar, Deepak K Sreevastava, Satish Nair
DOI:10.4103/roaic.roaic_80_17  
Background Unilateral or bilateral vocal cord (VC) paralysis following atraumatic intubation is extremely rare and has been reported even in the absence of any predisposing factors. Occurrence of such a complication is disconcerting to the clinician as well as the patient alike. Case A 42-year-old man suffering from cryptogenic cirrhosis of the liver, who underwent a deceased donor liver transplant, developed left-sided VC palsy postoperatively. No apparent cause was found and his symptoms recovered after conservative management. It was concluded that the patient possibly had recurrent laryngeal nerve neuropraxia due to compression by the endotracheal tube cuff. Conclusion We would like to briefly describe the case, possible mechanisms for VC palsy following intubation, its benign course and the possible role of pre-existing laryngeal deformity, with the aim of enhancing the awareness among anaesthesiologists about this rare complication. Although not unique to liver transplant surgeries, the relatively longer perioperative period of ventilation in such surgeries may accentuate any pressure effects.
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Sugammadex based on ideal, actual, or adjusted body weights for the reversal of neuromuscular blockade in patients undergoing laparoscopic bariatric surgery p. 20
Dalia M Elfawy, Mohamed Saleh, Walid H Nofal
DOI:10.4103/roaic.roaic_12_18  
Background and objectives Sugammadex is a novel neuromuscular reversal drug. The recommended dose for sugammadex is 2 mg/kg. For morbidly obese patients, the calculation of an appropriate sugammadex dose is problematic. The aim of this study was to compare the reversal of rocuronium-induced neuromuscular blockade in morbidly obese patients using three doses of sugammadex; based on ideal body weight (IBW), adjusted body weight, and actual body weight. Patients and methods Sixty patients scheduled for laparoscopic bariatric surgery in Ain Shams University Hospital were enrolled into this prospective randomized study. At the end of the surgery, patients received sugammadex only when train of four response reached second twitch. According to their randomization, group A received sugammadex at a dose of 2 mg/kg for an IBW. Group B received sugammadex at a dose of 2 mg/kg for adjusted body weight, and group C received sugammadex, at a dose of 2 mg/kg for actual body weight. Time from administration of sugammadex to train of four ratio more than or equal to 0.9 was measured. Results Mean reversal time was 176.30±5.44 s in group A and decreased to 141.85±5.184 s in group B, and decreased again to 137.9±3.307 in group C. Pairwise comparisons between each of the two groups revealed that the decrease in reversal time from group A to group B, and from group A to group C were statistically significant. However, the decrease in reversal time from group B to group C was not statistically significant. Conclusion This study demonstrated that there was a statistically significant difference with respect to reversal time for sugammadex in morbidly obese patients, when given based on IBW versus adjusted body weight, and when given based on IBW versus actual body weight. However, there was no statistically significant difference with respect to reversal time for sugammadex, when given based on adjusted body weight versus actual body weight.
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The effects of dexmedetomidine on the bispectral index during cesarean section under general anesthesia with low-isoflurane anesthesia p. 27
Hadil M Abd El-Hamid, Mai M Abd El-Azziz, Ahmed Hamedy
DOI:10.4103/roaic.roaic_86_17  
Background Intraoperative awareness is a disturbing experience for all women undergoing general anesthesia for cesarean section; this may lead to posttraumatic stress which can last for many years. The bispectral index (BIS) is now widely used to evaluate the sedative hypnotic effect of anesthetic drugs. The effects of dexmedetomidine used with low concentration isoflurane on the BIS are investigated. Patients and methods After ethical approval, 40 parturients undergoing cesarean section received either normal saline, as a control group (n=20), or 0.3 μg/kg/h intravenous dexmedetomidine 20 min before induction (n=20) with anesthesia maintained using isoflurane 0.5 minimum alveolar concentration in 100% O2, fentanyl 1 μg/kg is given after fetal expulsion. Change in BIS, hemodynamic, uterine tone, Apgar score, sedative score, and pain score were recorded for all patients. Results Patients who received dexmedetomidine showed lower BIS values (P<0.001) with BIS maintained between 40 and 60 throughout the surgery. Much more patients in the control group required increment of propofol to maintain the BIS below 60 (12 in the control group vs. 1 in the dexmedetomidine group, P<0.001). Patients on dexmedetomidine showed much more hemodynamic stability (lower heart rate and blood pressure after 10 min from starting infusion and throughout the surgery, P<0.001), adequate uterine tone is reached faster with a lower dose of ecbolics [median 10 (5–25) vs. median 25 (5–25) in the control group, P<0.001], higher sedation score at postoperative anesthesia care unit (PACU) [median 3 (3–4) vs. median 2 (1–3) in the control group, P<0.001], and lower postoperative pethidine is required (P<0.001) than the control group. Apgar scores were similar for both groups. Conclusion The administration of dexmedetomidine 0.3 μg/kg/h is effective in maintaining a lower BIS with low-isoflurane anesthesia without adverse maternal or neonatal effects.
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Comparison of postoperative analgesic efficacy of transdermal and epidural buprenorphine following major abdominal surgeries: a prospective randomized study p. 33
Sunil Rajan, Dilesh Kadapamannil, Kaushik Barua, Lakshmi Kumar
DOI:10.4103/roaic.roaic_6_18  
Introduction A transdermal delivery system provides steady and continuous drug delivery as compared with epidural route. The aim of the present study was to compare the efficacy of transdermal and epidurally administered buprenorphine in providing adequate postoperative analgesia in patients undergoing major abdominal surgeries. Patients and methods The present study was a prospective, randomized, open-label study conducted in 30 patients aged between 18 and 70 years undergoing major abdominal surgeries. Patients were randomized equally into two groups. T group received a transdermal buprenorphine 10-mg patch, with a delivery rate of 10 μg/h, which was applied ∼20–24 h before surgery. On day of the surgery for patients belonging to E group, an epidural catheter was placed at the start of the surgery and buprenorphine 150 μg in 10-ml saline was given epidurally. All patients received general anesthesia following standardized anesthesia protocol. In the postoperative period, pain relief was checked using numerical rating scale. Results Mann–Whitney U test and independent t test were used as applicable. Numerical rating score was significantly higher in group T at 0, 6, 12, 18, 24, and 30 h as compared with group E. It became comparable at 36, 42, and 48 h. The need for rescue analgesia was significantly higher in group T as compared with group E. Conclusion Epidurally administered buprenorphine is superior in providing adequate analgesia in the early postoperative period in patients undergoing major abdominal surgeries as compared with the transdermal route.
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Efficacy of platelet-rich plasma injection with lumbar epidural analgesia after total knee arthroplasty p. 39
Gehan F Ezz, Mohamed El-Attar
DOI:10.4103/roaic.roaic_43_18  
Introduction Lumbar epidural analgesia, one of the most effective methods for postoperative pain relief, was used with autologous platelet-rich plasma (PRP) derived from the patient’s own blood. The effects of application of PRP on pain control, wound healing and occurrence of wound complications were followed. Patients and methods A sum of one hundred sixty patients were allocated into two equal groups. Postoperative analgesia was maintained with patient-controlled epidural analgesia with bupivacaine and fentanyl solution in both groups. Group platelet rich plasma (PRP) received epidural analgesia with analgesic solution of 0.0125% bupivacaine+fentanyl 2 mic/kg of basal infusion rate 4 ml/h with application of PRP, control group received epidural analgesia with analgesic solution of 0.0125% bupivacaine+fentanyl 2 mic/kg of basal infusion rate 4 ml/h by ordinary manner without application of platelet rich plasma. Pain was evaluated at 4, 8, 12, 24 and 48 hours. Both groups received 5ml solution as rescue analgesia whenever visual analog scale score was 5 and above. Heart rate, mean arterial pressure (MAP), sedation scores, and physiotherapy cooperation were also assessed. Results PRP group was associated with good pain control, reduced postoperative infection rates, and good wound healing as compared with the control group. Conclusion Postoperative lumber epidural analgesia with PRP is an appropriate method in post-total knee arthroplasty pain control with possible benefits concerning wound healing and prevention of infection.
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Renal protective effects of dexmedetomidine in patients undergoing cardiac surgery using cardiopulmonary bypass p. 46
Moustafa N Abou Shamaa, Doaa M Abou Alia, Reham A Abo Elwafa, Kareem M Ateba
DOI:10.4103/roaic.roaic_89_17  
Background Cardiac surgery-associated acute kidney injury (CSA-AKI) is a serious complication that increases morbidity and mortality rates. Early detection and prevention of this complication is very important. A novel biomarker, neutrophil gelatinase-associated lipocalin (NGAL), can play an important role in the early diagnosis of acute kidney injury (AKI). Recent studies on the favourable effects of dexmedetomidine (DEX) on renal functions have been published. Objective To evaluate the potential protective effects of DEX against the occurrence of AKI, in patients undergoing cardiac surgeries using cardiopulmonary bypass (CPB), whether coronary artery bypass grafting or valvular surgery, regarding urine output (UOP), serum creatinine, creatinine clearance, and urinary NGAL. Patients and methods A prospective randomized double-blind study was conducted, in which 60 adult patients of both sexes, with Cleveland Clinic Score of 0–5, scheduled for elective cardiac surgeries were included. Patients were randomly allocated into two groups: DEX group, where patients received 0.4 µg/kg/h infusion after weaning from CPB, and placebo group (non-DEX) group, where patients received normal saline in the same volume (ml) and rate (ml/h). The primary end point was the incidence of AKI defined by the AKIN criteria of serum creatinine. Urinary NGAL was assessed immediately after anaesthetic induction, and 4 and 24 h postoperatively. Blood urea, serum creatinine, and creatinine clearance were measured just before anaesthetic induction, and every 12 h for 3 days postoperatively. Moreover, UOP was measured intraoperatively and every 4 h for 72 h after surgery. Postoperative pain was assessed using the visual analogue scale every 4 h for the first postoperative day. Results The severity of AKI in DEX group was confined to stage ‘1’, except for one patient, whereas in non-DEX group, five patients developed stage ‘2’, with a significant higher incidence than in DEX group. Urinary NGAL was significantly lower in DEX group, in addition to the significantly higher values in UOP during the postoperative period. Other conventional renal function tests showed comparable results between both groups. A shorter time to extubation and a lower visual analogue scale pain score were accompanying the use of DEX. Conclusion DEX proved to be effective in the prophylaxis against AKI in this cohort of relatively low-risk elective cardiac patients in terms of NGAL values, but did not affect conventional renal functions in terms of serum creatinine, and creatinine clearance, and it was associated with an increase in urinary output. DEX also helped in earlier extubation, and shorter duration of mechanical ventilation. In addition, DEX proved to have potent analgesic properties.
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Ultrasound-guided thin-wall needle technique versus cannula-over-needle technique in internal jugular vein catheterization in infants p. 56
Saleh Abdelaziz Hamouda, Amr Elsayed Hashem, Mohamed Ahmed Adel Okasha
DOI:10.4103/roaic.roaic_102_17  
Background Internal jugular vein (IJV) is the most common site for central venous catheter (CVC) insertion in pediatric cardiac surgery, with a lower success rate than adults. Two techniques are used, the thin-wall introducer needle (TWN) technique (Seldinger) or cannula-over-needle (CON) technique (modified Seldinger). Purpose To compare between TWN and CON techniques for the insertion of IJV CVC in infants in terms of success, number of attempts, catheter insertion time, and complications. Patients and methods One hundred and twenty infants admitted for elective cardiac surgery randomly assigned into either TWN group or CON group (60 patients each). CVC insertion was performed on the right IJV under ultrasound (US) guidance. Demographic data were recorded and infants subcategorized according to their age to less than 30 days, 2–6 months, and 7–12 months. The success rate, first attempt success, number of attempts, duration of each attempt, access time, cannulation time, and complications as assessed by US were recorded and subjected to statistical analysis. Results There were significantly higher first trial success in CON than TWN in age subgroups of less than 30 days (75 vs. 22.2%) and 2–6 months (76.5% vs. 40%) and significantly higher overall success rate in CON in the age subgroup of less than 30 days (91.7 vs. 44.4%). Significantly lower number of attempts in CON in age subgroups of less than 30 days (mean, 1.75 vs. 4.77) and 2–6 months (mean, 1.24 vs. 1.73) with significant reduction in venous hematoma were detected by US. No significant difference in cannulation time between the two techniques in any of the subgroups. Conclusion In the age group of less than 30 days, CON had higher first trial success, overall success, lower number of attempts, and lower complication rate than TWN. In the age group of 2–6 months, CON had higher first trial success, lower number of attempts, and lower complication rate than TWN. In age the group of 7–12 months, TWN offered an advantage over CON with shorter access time and duration of attempt with no other significant difference.
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Reversal of rocuronium neuromuscular blockade in elderly patients undergoing elective open abdominal surgery: comparative study of sugammadex versus neostigmine p. 64
Abd-El Fattah Mohammed Abd-Elfattah
DOI:10.4103/roaic.roaic_80_18  
Objectives To evaluate neuromuscular recovery in elderly patients assigned for open abdominal surgery using sugammadex (Sx) versus neostigmine–atropine (NA) combination. Patients and methods A total of 142 male patients were randomly allocated into two equal groups: group NA received neostigmine (50 μg/kg) and group Sx received Sx (2 mg/kg). Neuromuscular function was monitored according to changes of the train-of-four (TOF) using the TOF-Watch-SX; at TOF0, rocuronium (0.5 mg/kg) was given and trachea was intubated. During surgery, at TOF25, a dose of one-quarter of the initial dose of rocuronium was given. At the end of surgery, when TOF25 was reached, the assigned reversal drug was administered, and patients were extubated at TOF90. The study outcomes included TOF25–90 interval (time since injection of the reversal drug till recovery to TOF ratio of 0.9), the recovery period (time since anesthetic gases were stopped till modified Aldrete Recovery Score was ≥9), and the development of critical respiratory events (CREs). Results The percentage of patients whose had short TOF25–90 interval was significantly higher with Sx than neostigmine. TOF25–90 interval with Sx (3.3±1.6 min) was significantly shorter compared with neostigmine (9.9±2 min). Patients who received Sx reached modified Aldrete Recovery Score more than or equal to 9 significantly earlier than those who received neostigmine. Thirteen (9.2%) patients developed postoperativeCRE, 10 (14.1%) in group NA versus three (4.2%) patients in group Sx, with significantly lower percentages in Sx than neostigmine groups. Only two patients in NA group required re-intubation for residual neuromuscular blockade (NMB) and were maintained on oxygen but failed to reach TOF90, both patients responded well to Sx (2 mg/kg) injection and reached to TOF90 after 2 and 3 min, respectively. Conclusion Reversal of NMB using Sx is an effective, satisfactory, and safe modality versus neostigmine with significantly short TOF25–90 interval and lower frequency of CRE. Sx effectively resolved residual NMB after failure or delayed recovery after neostigmine injection in elderly patients who underwent open abdominal surgery.
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Randomized comparison of continuous spinal anesthesia versus continuous epidural anesthesia in high-risk elderly patients undergoing major orthopedic lower limb surgeries Highly accessed article p. 72
Mohamad A Elfeky, Al Sayed M Stohy, Mostafa M Sabra, Ali A Mahareak, Ali A Alkumity
DOI:10.4103/roaic.roaic_75_18  
Background Continuous spinal anesthesia (CSA) is a reliable method for providing effective anesthesia and offers considerable advantages over ‘single-shot’ spinal or epidural anesthesia, as it provides the performance of well-controlled anesthesia using small doses of local anesthetics and a definite end point with less failure rate. Materials and methods A total of 100 patients of American Society of Anesthesiology grades III–IV were scheduled for elective major orthopedic lower limb surgeries. They were divided into two groups: one received CSA using spinocath set, and the other group received continuous epidural anesthesia (CEA). The doses of local anesthetic used, hemodynamic variables, a degree of technical difficulties, and the incidence of complications were recorded. Results The performance time was significantly shorter in the CEA group. The total dose of bupivacaine and number of top-up doses were significantly smaller in the CSA group than in the CEA group. The onset of sensory blockade level and motor blockade was significantly longer with CEA. Regarding the mean arterial pressure, there was a statistically significant difference between the two groups. The number of patients treated for hypotension and total dose of ephedrine was more in CEA group, but there was no statistical difference between the two groups. No major complications were observed in any patient in both groups. Conclusion We conclude that CSA is an effective and safe choice with hemodynamic stability and negligible failure rate, for prolonged procedures in elderly high-risk patients and in those with possible difficulties in administration of general anesthesia.
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Comparative study between pre-emptive transcutaneous versus transoral ultrasound-guided peritonsillar space infiltration with bupivacaine during elective tonsillectomy p. 80
Warda D.K Ali, Tawfik Abd El Atey El Kholy, Tamer A Abo El Ezz, Hala M.M Sherief
DOI:10.4103/roaic.roaic_61_18  
Background Ultrasound (US) as a technique is safe, readily available, quick, and portable allowing more accuracy of different regional blocks and local infiltration. It allows imaging of the mouth, oropharynx, infrahyoid structures, larynx, vocal cords, and the trachea. Recently, point-of-care US has been shown to improve accuracy in US-guided block with local anesthetic infiltration. Objective The objective of the study was to compare the effect of pre-emptive transoral US-guided peritonsillar infiltration versus transcutaneous US-guided peritonsillar infiltration with bupivacaine for post-tonsillectomy analgesia on surgical field, and surgeon satisfaction (intraoperative reactionary bleeding). Study design A clinical, prospective study. Patients and methods Sixty patients (25 men, 35 women) were admitted for tonsillectomy at the ENT Department of the Al-Azhar and Ain Shams University Hospitals. The age of the patients ranged from 3 to 15 years. The patients were divided into cutaneous group consisting of 30 patients who were submitted to transcutaneous US-guided peritonsillar infiltration with bupivacaine and the oral group consisting of 30 patients who were submitted to transoral US-guided peritonsillar infiltration with bupivacaine. Results The study showed no statistically significant difference between the two studied groups regarding age, sex, and weight with P values of 0.602, 0.190, and 0.164, respectively. The oral group was significantly shorter as regards the time needed to detect peritonsillar space and the time needed to perform peritonsillar infiltration with a P value of 0.000. The cutaneous group gave significantly better results as regards direct surgeon satisfaction questionnaire about bleeding and surgical field, weighing amount of soaked gauze with blood per tonsil, dissection time, and the amount of blood suctioned with P value 0.118, 0.318, 0.851, and 0.112, respectively. Conclusion Peritonsillar space can be infiltrated equally and safely using transcutaneous US or transoral US and may be considered as an alternative technique to traditional blind technique when performed by an experienced team.
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Shivering prevention during cesarean section by intrathecal injection of magnesium sulfate: randomized double-blind controlled study p. 89
Mohamed F Mostafa, Zein El-Abden Z Hassan, Samia Moustafa Hassan
DOI:10.4103/roaic.roaic_43_17  
Background Shivering was found to be a common side effect with spinal anesthesia. It was observed in about 55% of patients with neuraxial anesthesia. It results in increased oxygen consumption and pain which usually interfere with patient’s monitoring. Objectives This study was designed to show the effect of intrathecal injection of magnesium sulfate to control shivering during spinal anesthesia for cesarean section. Study Design This study was a prospective randomized controlled double-blind study using a computer-generated randomization scheme. Methods 84 Women were randomly allocated into 2 groups: Magnesium sulfate group (M); patients received intrathecal 2 ml of 0.5% heavy bupivacaine (10 mg) plus 25 mg MgSO4. Placebo group (P); patients received intrathecal 2 ml of 0.5% heavy bupivicaine (10 mg) plus 0.5 ml normal saline. Vital signs, temperature, shiverig score, sensory level, motor block, and any complications were recorded. Results Shivering score revealed a statistically significant difference between both study groups throughout the whole intraoperative and postoperative periods with lower shivering incidence in the M group. There was a statistically significant difference between both groups regarding temperature readings during the first 30 minutes postoperatively. Intraoperative sensory level block was statistically significant different only 30 minutes after drugs injection. No serious complications were recorded in both groups. Conclusion We concluded that intrathecal Magnesium sulfate is safe and can decrease the incidence and intensity of shivering during cesarean section under spinal anesthesia, without having any serious side effects.
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Incidence and risk factors of acute kidney injury in trauma patients in Zagazig University Hospital p. 95
Ahmed Mohamed Ali Zyada, Hala Abdel Kader Mohammed, Amal Abd El-Azeem Salah, Mona Abd El-hamid Elharrisi, Samar Mahmoud Abdel Halim
DOI:10.4103/roaic.roaic_51_17  
Background Acute kidney injury (AKI) is common in the ICU population with an incidence of 1–25%, depending on the criteria used for definition, and is associated with mortality rates of 50–70%. Few studies have evaluated the epidemiology of AKI in a population of trauma patients. The critically ill trauma patient sustains multiple insults to the kidney which include hypovolemic shock, hypothermia, direct urological organ injury, rhabdomyolysis, abdominal compartment syndrome, sepsis, and exposure to nephrotoxins such as contrast material and antimicrobials. AKI in trauma patients affect outcome that increases both morbidity and mortality. Patients and methods This study was conducted on 105 adult polytrauma patients in the emergency ICU at Zagazig University Hospital, who were polytrauma patients with exclusion of patients with history of chronic kidney disease, patients with history of diabetes and hypertension. The following data were recorded: demographic data (name, age, sex), data related to trauma (time between onset of trauma and hospital admission, time between onset of trauma and ICU admission, Glasgow Coma Scale, Injury Severity Score, type of trauma), data to detect AKI using RIFLE criteria (serum creatinine basal, peak and discharge and urine output estimation level). Serum neutrophil gelatinase-associated lipocalin level was detected in the first 24 h of trauma, data to detect risk factors (hemodynamics, nephrotoxic drugs, fluids used in resuscitation, coagulation profile, creatine kinase, complete blood count, intubation and mechanical ventilation, and data collected to detect the outcome (length of ICU stay, renal replacement therapy, and mortality). Results There were 53 (50.5%) patients developed AKI by RIFLE criteria. Within this population, patients were classified as 16 (15.2%) patients in the Risk stage; 25 (23.8%) patients in Injury stage, and 12 (11.4%) patients in Failure stage; however, no patients enter in loss of function or end-stage renal disease The risk factors of AKI were: rhabdomyolysis (CK>1000 IU/l) was found in 31 (58.5%) patients, sepsis in 23 (43.4%) cases, coagulopathy in 11 (20.8%) cases, and abdominal trauma in two (3.8%) cases and so there were statistically significant differences between AKI and no-AKI as regards rhabdomyolysis, coagulopathy, and sepsis as risk factors of developing AKI in trauma patients (P=0.000, 0.0001, and 0.001, respectively); however, among patients with AKI, only one patient takes contrast dye and develops AKI (P=0.32). There were statistically significant differences between AKI and no-AKI as regards need for blood transfusion, HCO3 resuscitation, diuretic intake, inotropic support, and crystalloid resuscitation (P=0.002, 0.001, 0.023, 0.000, 0.037, respectively) as risk factors of developing AKI in trauma patients. As regards outcome there were statistically significant increase in mortality in patients who develop AKI (P=0.03) increased mortality with increased severity of RIFLE class. Conclusion The incidence of AKI among trauma patients in emergency ICU in Zagzig University Hospital was 50.5%. AKI is a frequent and fatal complication after major trauma. Development of AKI is associated with increased mortality. The causes of AKI in trauma patients are multifactorial. Early detection of AKI and management of risk factors of AKI can improve the outcome.
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Comparison of efficacy of different physical methods in preventing severe hypotension in cesarean deliveries in supine hypotension syndrome p. 108
Osama Y.A Khalifa
DOI:10.4103/roaic.roaic_85_18  
Background Supine hypotension syndrome is a serious condition that can affect maternal and fetal morbidity during a cesarean delivery. We try to detect the effect of manual left uterine tilt on reducing the impacts of such syndrome. Patients and methods Ninety patients were randomly divided into three groups: manual displacement group (N=30), wedge group (N=30), and 15° table-tilt group. All parturients suffered from supine hypotension syndrome and were scheduled for cesarean section under subarachnoid anesthesia. The amount of fall in blood pressure, ephedrine consumption, induction delivery time, patient and surgeon satisfaction were all recorded. Results In the manual displacement group, the maximum drop in blood pressure and total ephedrine consumption were significantly lower than the wedge group and table-tilt group [20 (8.5), 27.8 (9.6), and 28.6 (8.5) mmHg, respectively, and 5 (1.5), 15.8 (3.6), and 16.4 (4.7) mg, respectively]. Also, patient and surgeon satisfaction was higher in the manual displacement group than the other two groups. Conclusion Manual uterine displacement is more effective than modified Crawford edge and 15° left table tilt in preventing severe hypotension in parturients with supine hypotension syndrome during a cesarean delivery with subarachnoid anesthesia with more patient and surgeon satisfaction.
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Intrathecal nalbuphine versus fentanyl as an adjuvant to bupivacaine in spinal anesthesia for elective cesarean section: a randomized double-blind study p. 112
Farahat I Ahmed
DOI:10.4103/roaic.roaic_109_17  
Background Opioids have been used as an adjunct to bupivacaine in spinal blockade to enhance the onset of action, to improve the quality of intraoperative and postoperative analgesia, and to increase the duration of block. Fentanyl is a synthetic opioid agonist and nalbuphine is a synthetic opioid agonist-antagonist. The present study aimed to compare the effects of adding nalbuphine or fentanyl as an adjunct to bupivacaine on the characteristics of spinal blockade, quality of postoperative analgesia, and on fetomaternal outcome after elective cesarean section. Participants and methods A total of 80 full-term parturients scheduled for elective cesarean section were randomly allocated into two groups. Nalbuphine group (BN group) included parturients who received 12.5 mg of 0.5% hyperbaric bupivacaine with 800 μg nalbuphine intrathecally. Fentanyl group (BF group) included parturients who received the same dose of hyperbaric bupivacaine with 25 μg fentanyl intrathecally. Subarachnoid blockade characteristics, duration of postoperative analgesia, the amount of postoperative analgesic requirements, maternal adverse effects, and neonatal outcome were compared. Results Onset of sensory and complete motor block, maximum height of sensory block, and time to two-segment sensory regression were significantly faster in BF group than in BN group. Maximum dermatomal block level was significantly higher in BF group than in BN group. The duration of motor block and the quality of anesthesia of both groups were comparable. Durations of postoperative complete and effective analgesia were highly significantly longer in BN group than the corresponding durations in BF group (P<0.001 and 0.002, respectively). The postoperative 24-h analgesic doses of ketorolac and pethidine were less in BN group than in BF group (P=0.03, 0.005, respectively). There was no pruritus in BN group (0%), but it occurred in five (12.5%) parturient in BF group, which was mild. The incidence of shivering was significantly lower in BN group (7.5%) than in BF group (27.5%) (P=0.01). Neonatal APGAR (Airway, Pulse, Grimace, Activity, Respiration) score and neurologic and adaptive capacity score were comparable between the two groups. Conclusion As an adjunct to hyperbaric bupivacaine in spinal block, fentanyl was superior to nalbuphine in enhancing the onset of both sensory and motor block. Nalbuphine is superior to fentanyl in increasing the duration of postoperative complete and effective analgesia and in decreasing incidences of pruritus and shivering, and both drugs have similar effects on neonatal APGAR score and neurologic and adaptive capacity score.
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General versus spinal anesthesia during elective cesarean section in term low-risk pregnancy as regards maternal and neonatal outcomes: a prospective, controlled clinical trial p. 119
Nadia M Madkour, Safaa A Ibrahim, Gehan F Ezz
DOI:10.4103/roaic.roaic_104_17  
Objective The objective of this study was to compare general and spinal anesthesia as regards its maternal and neonatal outcomes in low-risk pregnancies undergoing elective cesarean section (C-section) at term. Patients and methods In a prospective, controlled clinical trial, 64 low-risk pregnant women underwent elective C-section for the first time for variant indications. The included women were randomly divided into two groups; group I (n=32) received spinal anesthesia and group II (n=32) received general anesthesia. The distinction between preoperative and postoperative maternal hematological indices, intraoperative and postoperative maternal hemodynamic parameters, the maternal requirement for analgesia, return of bowel function, and neonatal outcomes were compared between the two groups. Results The mean time for bowel to be open (9.7±1.3 vs. 6.8±1.6 h, P=0.001), and the first analgesia requirement was significantly (5.33±4 vs. 2.91±2.16 h, P=0.004) longer, and the hemoglobin and hematocrit difference values at 24 h postoperative were significantly (P=0.03, and 0.02, respectively) larger in group II. Urine output at the first postoperative hour was more (P=0.002) in the spinal group. The median Apgar scores at the first minute and at fifth minute were significantly higher (P=0.001, and 0.005, respectively) in the spinal group. Conclusion As long as it is not contraindicated, spinal anesthesia during elective C-section was safer for both neonates (higher Apgar scores), and mother (less bleeding, less postoperative pain) than general anesthesia and can be the ideal anesthesia and method of choice during elective C-section.
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Impact of morbidity and mortality conferences on patient outcome p. 125
Ahmed M Elmenshawy
DOI:10.4103/roaic.roaic_94_17  
Introduction Despite decades of morbidity and mortality conference (MMC) research studies, there is still limited evaluation of their effect on healthcare outcome, especially in ICUs. Aim The aim of this study was to explore the effectiveness of goal-directed multidisciplinary MMCs on mortality and adverse event rates. Patients and methods A 4-year retrospective study was conducting in two ICUs for evaluating a systematized MMCs with a clear goal of improving local care through case discussion, analysis, brainstorming, and clear recommendations or action plans in a multidisciplinary meeting involving all related caregivers in a blame-free environment. This study included four phases: preintervention (January 2012–April 2013), intervention (May–June 2013), postintervention (July 2013–October 2014), and washout period (November 2014–December 2015, after MMC stoppage). A period prevalence study of ICU-acquired adverse events was done in March 2013, December 2013, and March 2015, in addition to monthly ventilator-associated pneumonia, catheter-associated blood stream), and catheter-associated urinary tract infection rates. Results A total of 5308 patients were included in this study, of which 1396 (26.3%) died. During the intervention and postintervention phases, 18 MMCs were held, which discussed 49 cases (38; 77.6% from ICU3 and 11; 22.4% from ICU1), reviewed other causes of death and unit performance indicators, and made 96 recommendations (85% accomplished in ICU3 vs. 55% in ICU1). All-cause combined and ICU3 mortality rates decreased after MMC implementation and then increased after MMC stoppage, with nonsignificant differences between the three groups regarding age, Acute Physiological and Chronic Health Evaluation II score, or primary diagnosis. Unexpected cardiac arrest (ICU3) and unplanned extubation (ICU1) decreased significantly with MMC and then increased significantly after MMC, whereas ICU-acquired gastrointestinal bleeding, deep vein thrombosis, and pneumothorax did not differ significantly across the three phases. Ventilator-associated pneumonia (ICU3), blood stream infection (ICU1), and urinary tract infection decreased significantly with MMC without significant change after MMC stoppage. Conclusion Goal-oriented multidisciplinary MMC reduced adverse events and probably mortality rate in medical/surgical ICU. Discrepancies between both units emphasized the need for continuous monitoring and tailoring of MMC system in case selection and recommendation implementation.
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Scalp block versus subcutaneous infiltration for stereotactic brain biopsy: a randomized controlled trial p. 134
Amr A Kassem, Azza Youssef, Nevine Ahmed, Manal Mohammed, Amira Gamal
DOI:10.4103/roaic.roaic_24_18  
Objective The aim of the current study was to compare scalp block and subcutaneous infiltration anesthesia in adult patient during the placement of a stereotactic head frame and taking brain biopsy. Patients and methods The current randomized controlled trial was conducted at the Neurosurgery Department in Ain Shams University Hospitals on patients who were scheduled for stereotactic brain biopsy. The recruited patients were randomly allocated into one of two groups: group A had 40 patients who received subcutaneous infiltration anesthesia and group B included 40 patients who received scalp nerve block. Both groups were compared regarding analgesic efficacy, hemodynamic changes, duration of local anesthetic, need of supplementary subcutaneous injections, need for postoperative analgesia, and postoperative complications. Results A total of 80 patients were recruited in the current trial. The mean values of the 10-cm visual analogue scale for assessment of pain was significantly lower in patients of group B when compared with patients of group A. Conclusion Scalp block with 0.5% bupivacaine reduced pain, heart rate, and mean arterial pressure response during the fixation of stereotaxy frame, the skin incision, and biopsy intake, and it also decreased the need for more local infiltration in comparison with the use of local subcutaneous infiltration. Moreover, the pain intensity was lower after scalp block in the early postoperative period with less incidence of headache in postoperative period.
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