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   Table of Contents - Current issue
July-September 2020
Volume 7 | Issue 3
Page Nos. 253-321

Online since Tuesday, September 29, 2020

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Effect of ultra-low-dose naloxone during supraclavicular brachial plexus block on the antinociceptive criteria of postoperative opioid in orthopedic upper limb surgeries p. 253
Doaa G Diab, Eiad A Ramzy, Heba Allah M Zaghloul, Mona A Hasheesh
Background Brachial plexus block is a popular and widely used regional nerve block technique for perioperative anesthesia and analgesia for upper extremity surgeries. Many drugs such as morphine and midazolam have been used as an adjuvant with local anesthetics to achieve quick, dense, and prolonged block. Drugs with minimal side effects are always looked for. Naloxone as opioid antagonists could selectively block excitatory effects of opioids, stimulate release and displace endorphins from receptor sites, and reduce the side effects of opioids. An ultra-low-dose naloxone, added as an adjuvant to local anesthetic, may prolong sensory and motor blockades with enhanced opioid effect or direct antagonism of its excitatory receptors. Patients and methods After approval by Institutional Research Board, clinical trial registration, and obtaining informed consents, 64 patients scheduled for orthopedic upper limb surgeries under supraclavicular brachial plexus block were enrolled into two equal groups: group B (bupivacaine 0.5%) and group BN (bupivacaine 0.5% plus 100 ng naloxone). Results There was significant decrease in fentanyl consumption in GBN (216.6±76.10) versus group B (507.5±117.50). Also, the number of fentanyl requests was lesser in group BN (3.0±1.11) than in group B (7.3±1.73). The onset time for sensory and motor blocks showed no significant difference among groups; the duration of sensory and motor blocks was prolonged in GBN (17.2±2.96–7.7±1.93 h) versus GB (7.3±1.22–4.7±.79 h). The time to first rescue fentanyl was prolonged in GBN (18.3±3.21 h) than in GB (8.0±1.41 h). There was significant reduction in visual analog scale score at 8, 12, and 18 h postoperatively in GBN versus GB. There were no significant changes in Ramsay sedation scale or complications within 48 h postoperatively. Conclusion Ultra-low dose of naloxone (100 ng) added to 20 ml bupivacaine 0.5% for supraclavicular brachial plexus block enhanced the postoperative opioid analgesia by reducing the total postoperative opioid consumption, prolonging the interval between opioid doses and the duration of sensory and motor block.
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Forced air-warming blanket versus pethidine for the prevention of shivering during and after caesarean section p. 260
Mohamed H Agamia, Ahmed R Morsy, Mervat M Abd Al-Maksod, Rehab A Abd El Aziz
Background Spinal anaesthesia significantly impairs thermoregulation by inhibiting vasomotor and shivering responses and by redistributing heat from the core of body to peripheral tissues. Core hypothermia may be associated with a number of adverse outcomes in pregnant women, including shivering, wound infection, coagulopathy, increased blood loss and transfusion requirements. Several pharmacological and mechanical methods have been used in an attempt to maintain normothermia and prevent intra-anaesthetic and postanaesthetic shivering. Therefore, the aim of the present study was to compare the efficacy of prophylactic use of forced air-warming blanket with pethidine for the prevention of shivering during and after spinal anaesthesia in elective caesarean section. Patients and methods The present study included 96 pregnant women with ASA I and II, admitted to Al Shatby Maternity Hospital. Patients were randomly assigned into three equal groups of 32 patients each. Group I patients were covered with forced air-warming blanket over the upper limbs and chest, group II patients received a single bolus of 0.5 mg/kg pethidine intravenously and group III patients did not receive anything, and they were regarded as control. Results Heart rate and mean arterial blood pressure decreased significantly in all the three studied groups after spinal anaesthesia. The decrease in the mean arterial blood pressure required ephedrine boluses, which ranged between 0 and 4 boluses, with no significance between the three studied groups. The core body temperature decreased significantly 15 min after spinal anaesthesia and thereafter in all patients of the three studied groups. However, the decrease in core temperature was significantly more in groups II and III. The shivering score increased significantly 10 min after spinal anaesthesia and thereafter intraoperatively. The shivering scores were significantly lower in groups I and II when compared with group III. There was a negative correlation between core body temperature and shivering scores in all the three studied groups. The mean core body temperature for shivering patients was significantly less in group II patients compared with groups I and III patients. The three groups were matched as regard to APGAR score at 1 and 5 min. No significant changes were observed as regard to hypotension, nausea, vomiting and feeling cold extremities. Conclusion Forced air-warming blanket decreased the shivering incidence by preserving core body temperature, whereas pethidine can prevent and treat shivering.
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Tramadol as an adjuvant to peribulbar anesthesia p. 267
Wail Abdelaal, Dalia Fahmy, Rafik Atalla
Background A large number of additives have been used as an adjuvant to local anesthetic (LA) mixture in peribulbar block to fasten the onset, enhance the potency, and prolong the duration of the block to cover the long duration of vitreoretinal surgeries and provide better postoperative analgesia. The authors designed a prospective, randomized, double-blind, controlled clinical trial to assess the effect of adding tramadol 20 mg to standard LA mixture concerning the onset of lid and globe akinesia, time for satisfactory block, and duration of postoperative akinesia and analgesia. Patients and methods A double-blind randomized study was done on 80 American Society of Anesthesiologists I and II patients scheduled for elective vitreoretinal surgery. Patients were chosen randomly into two groups, with 40 patients in each group. Group I (control group) received a mixture of bupivacaine 0.5% (4 ml)+lidocaine 2% (4 ml)+hyaluronidase 150 IU (1 ml) with 1 ml normal saline to a total volume of 10 ml. Group II (tramadol group) received a mixture of bupivacaine 0.5% (4 ml)+lidocaine 2% (4 ml)+hyaluronidase 150 IU (1 ml) supplemented with 20 mg tramadol in 1 ml normal saline to a total volume of 10 ml. The onset and duration of lid and globe akinesia and optimum time to begin surgery were recorded, in addition to postoperative visual analog score, duration of analgesia, and time to first rescue analgesic request. Results The results show statistically significant differences between the two groups, as tramadol group had faster onset of akinesia, better akinesia score, and shorter time needed to start surgery. In addition, tramadol group also showed significantly prolonged postoperative analgesia and akinesia with lower median pain score and less postoperative analgesic requirements. Conclusion The present study concluded that tramadol is a safe adjuvant to LA in peribulbar block that fastens the onset and prolongs the duration of lid and globe akinesia and improves the quality of analgesia without any obvious adverse effects.
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Transcranial Doppler to detect early abnormalities in cerebral hemodynamics following traumatic brain injury in adult patients p. 274
Amani A Aly, Manal S Farmawy
Background Transcranial Doppler (TCD) can be a valuable tool in detecting early changes in cerebral blood flow (CBF) velocities following traumatic brain injury (TBI). We designed this prospective observational study to screen for early abnormalities in CBF following TBI using TCD and to evaluate its ability to predict the patients’ outcome. Patients and methods The study was carried out on 66 adult patients admitted to the ICU with TBI. TCD was performed on admission by insonating the middle cerebral arteries and extracranial internal carotid arteries, and flow velocities were recorded, and pulsatility index (PI) and Lindegaard ratio were calculated. End-diastolic velocity (EDV) less than 25 cm/s and PI more than 1.3 were considered abnormal. The patient outcome was evaluated at discharge from the hospital using the Glasgow Outcome Scale. Results Admission TCD revealed that EDV less than 25 cm/s was present in 11.1% of the patients with mild-to-moderate TBI [Glasgow Coma Score (GCS)>8] and in 46.7% of the patients with severe TBI (GCS≤8). PI more than 1.3 was present in 16.7% of the patients with GCS more than 8 and in 46.7% of the patients with GCS less than or equal to 8. The incidence of vasospasm was highest on the fifth day after trauma as it was detected in 16.7% of the patients with GCS more than 8 and in 40% of the patients with GCS less than or equal to 8. The logistic regression analysis of outcome predictors showed that the initial PI more than 1.3 had 91% sensitivity and 89% specificity and EDV less than 25 cm/s had 88% specificity and sensitivity 85% in predicting poor outcome; meanwhile, cerebral vasospasm had 84% sensitivity and 75% specificity in poor outcome prediction. Conclusion Early abnormal CBF velocity detected by TCD following TBI can predict poor outcome at discharge from the hospital.
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Renal protective effects of dexmedetomidine in patients undergoing radical nephrectomy p. 282
Rania AA Sabra, Mohamed M Abdelhady, Mounir K Afify, Sherief Y Omar
Background Acute kidney injury (AKI) after radical nephrectomy is a serious complication that increases morbidity and mortality rates. Early detection and prevention of this complication are very important. A novel biomarker named neutrophil gelatinase-associated lipocalin (NGAL) can play an important role in early diagnosis of AKI. Recent studies have been published on the favorable effects of dexmedetomidine on renal functions. Objective The aim was to evaluate the possible renal protective effects of dexmedetomidine regarding urine output, creatinine clearance, serum cystatine C, NGAL in patients undergoing radical nephrectomy. Patients and methods A randomized double-blind, placebo-controlled study was conducted on 30 adult patients scheduled for radical nephrectomy. The patients were randomly allocated into two equal groups. Dexmedetomidine group (D group) received dexmedetomidine 0.8 µg/kg intravenously over 10 min as a loading dose, and then it was infused at a rate of 0.4 µg/kg/h. Placebo group (P group) received normal saline instead of dexmedetomidine in the same volume (ml) and rate (ml/h). In both groups, fentanyl (0.5 µg/kg) boluses were given if blood pressure or heart rate (HR) showed 20% increase from the baseline reading to control the hemodynamics. Vital signs [HR and mean arterial blood pressure (MABP)] were recorded before induction, after induction, after intubation, intraoperatively every 10 min till the end of surgery, and postoperatively every 2 h during the first 24 h. Urine output was assessed intraoperatively every 1 h and postoperatively every 4 h in the first 48 h. Serum creatinine, urinary creatinine, and creatinine clearance were assessed 24 h before surgery, 24 h after urinary catheter insertion after induction of anesthesia, and 24–48 h postoperatively. Cystatine C and NGAL were assessed after induction of anesthesia and after 24 h and 48 h postoperatively. Sedation was assessed during the first 5, 15, 30, and 60 min in the recovery room by the investigator using a five-point sedation scale. Postoperative pain was assessed using the visual analog scale, based on 0–10 points, every hour in the first 4 h postoperatively and then every 4 h in the first postoperative day. Results There was a significant decrease in HR and MABP in the dexmedetomidine group compared with placebo group. Urine output showed significant difference between the two groups in all studied periods except for the first hour. Urine output was higher in dexmedetomidine group, and seven patients in the placebo group needed lasix. Serum creatinine values, creatinine clearance, and cystatine C showed no statistically significant difference between the two groups in the three studied periods. NGAL values were similar after induction but were significantly different between the two groups after 24 and 48 h, with values higher in the placebo group. Sedation was different between the two groups in all studied periods except after 5 min. Patients in dexmedetomidine group were more sedated compared with the placebo group. Dexmedetomidine had postoperative analgesic effect represented by low visual analog scale score. Conclusion Dexmedetomidine proved to be effective in the prophylaxis of postoperative AKI after radical nephrectomy in terms of NGAL values but did not affect renal functions in terms of serum creatinine, creatinine clearance, and cystatine C. Dexmedetomidine in the used dose did not have adverse effects on MABP and HR. In addition to renal protection, dexmedetomidine proved to have sedative and analgesic properties.
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Ultrasound-guided T2 and T3 paravertebral block versus ultrasound-guided stellate ganglion block in acute upper limb ischemia p. 291
Ahmed S Hegab, Gehan F Ezz
Background Accidental intra-arterial injection can cause severe limb ischemia, often resulting in amputation. We reported a number of cases of acute upper limb ischemia with severe pain and ischemia in vascular surgery department for urgent relief of the pain and ischemia. Either ultrasound-guided stellate ganglion block or thoracic paravertebral block was done to protect upper limb from gangrene and amputation. Purpose The aim of the present study is to compare the effect of ultrasound-guided stellate ganglion block with ultrasound-guided thoracic T2 and T3 paravertebral block in relief of pain and ischemia and also to compare the result of the block and complications. Patients and methods Forty American Society of Anaesthesiologists status I–II adult patients 16–60 years of age with acute upper limb ischemia and severe pain were admitted to Vascular Surgery Department of Zagazig University Hospital. They were randomly divided into two groups: group S (n=20) where ultrasound-guided stellate ganglion block was done, and group TPV (n=20), where ultrasound-guided thoracic paravertebral block was done. Both groups received 10 ml bupivacaine (0.25%)+16 mg dexamethasone for relief of the pain and ischemia, and the complications that resulted from the procedure were followed and recorded. Results There was significant decrease in visual analog scale in both groups after the stellate ganglion block and thoracic paravertebral block, with minimal complications with thoracic paravertebral block and relief of pain and ischemia in both groups. Conclusion Thoracic paravertebral block is a good choice in acute upper limb ischemia with rapid relief of the pain and restoration of peripheral perfusion with minimal complications.
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Effect of clustered nursing interventions on physiological responses in critically ill patients p. 299
Nadia T Mohamed, Amr H Dahroug, Intessar M Ahmed, Samar A Younes
Background Caring of the critically ill patients is a fundamental component of a nurse’s clinical practice in ICUs. Clustered nursing interventions are defined as a group of interventions of more than six for each patient in one nursing interaction. Physiological responses may be an immediate response or long-term effects of one or more of the body systems related to physiological condition and therapeutic interventions. Critical care nurses monitor physiologic patient parameters on a regular basis to ensure patient’s stability. Objective The aim was to determine physiological responses related to clustered nursing interventions among critically ill patients. Participants and methods The study was conducted on 80 mechanically ventilated adult patients admitted to ICUs of Alexandria Main University Hospital and Damanhour Medical National Institute. The most common procedures provided by nurses in direct care for those patients based on a pilot study of 10 patients were vital signs measurements, central venous pressure measurement, suctioning, feeding, laboratory sampling, general care, repositioning, and administration of medications. Physiological parameters measured were end-tidal carbon dioxide using capnography, vital signs using bed side monitor, and oxygen saturation using pulse oximeter. They were measured before, at 5 min and 10 min during clustered nursing interventions, immediately after, and 15 min after clustered nursing intervention performance. Results Respiratory rate, systolic blood pressure, and oxygen saturation were significantly changed in relation to clustered nursing interventions. Conclusion Clustered nursing interventions may worsen some physiological parameters in critically ill patients, and therefore, nonclustered interventions should be applied instead. Moreover, continuous monitoring of physiological responses during nursing care is crucial.
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Ultrasound-guided arterial catheterization in critical patients with nonpulsatile continuous circulation conditions on ventricular assist devices or veno-arterial extracorporeal membrane oxygenation support p. 308
Mohamed Laimoud, Mosleh Alanazi
Background Arterial catheterizations, especially of radial and femoral arteries, are very common procedures performed by physicians dealing with critical patients for invasive hemodynamic monitoring and frequent arterial blood sampling. Traditionally, the technique of locating surface landmarks and palpation was used in catheterization. Getting arterial access can be challenging in critical patients with hemodynamic instability, impalpable pulses, and coagulopathy. Our objective was to study the effectiveness of vascular ultrasound in arterial catheterization in critical patients with nonpulsatile circulation admitted at cardiac critical care units in comparison with the landmark technique. Patients, methods, and results This retrospective study was conducted in a tertiary care hospital and included patients from January 2015 to November 2018 who were admitted to adult cardiac critical care unit with veno-arterial extracorporeal membrane oxygenation or left ventricular assist device and required arterial vascular access for invasive hemodynamic monitoring. A total of 124 vascular catheters were inserted in 109 critical patients. Overall, 87 (79.8%) patients were hemodynamically unstable and supported with vasopressors infusions. Heparin infusion was maintained in 91 (83.4%) patients, while 18 (16.51%) patients were anticoagulated with oral warfarin therapy during arterial catheterization. The first-attempt success was achieved in 78.9 versus 5.6% (P=0.001) and the procedural success rate was 100 versus 62.1% (P=0.001) in the ultrasound and landmark groups, respectively. The number of attempts was 1.2±0.4 versus 2.1±0.5 (P=0.001), and the hematoma occurred in 2.8 versus 11.1% (P=0.001) in the ultrasound and landmark groups, respectively. Conclusion Ultrasound-guided arterial catheterization in critical patients with unstable hemodynamics and nonpulsatile continuous circulation was associated with higher first-attempt and procedural success and less complications compared with the landmark technique.
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Acute coronary disruption after Bentall’s procedure: outcome and the role of emergency coronary angiography p. 313
Mohamed Laimoud
Coronary ostial stenosis is a rare but fatal consequence of aortic root surgery. Clinical presentations can include ventricular arrhythmias, acute coronary syndromes, congestive heart failure, or sudden death. Three interesting cases of acute coronary disruption after Bentall’s procedure were presented, with each case having a different outcome. The first case was a 56-year-old male patient admitted for elective Bentall’s procedure and developed inferoposterior STEMI complicated with ventricular fibrillation. After resuscitation, emergency percutaneous coronary intervention (PCI) and stenting of right coronary artery were performed successfully. The second case was a 39-year-old female patient admitted for Bentall’s procedure and was complicated with ventricular tachycardia with hemodynamic collapse necessitating venoarterial extracorporeal membrane oxygenation and emergency PCI to the left main coronary artery. The third case was a 41-year-old woman admitted for Bentall’s procedure and was complicated with fatal ventricular arrhythmias. After venoarterial extracorporeal membrane oxygenation and coronary angiography, emergency coronary artery bypass graft was done. Conclusion: Acute coronary ostial stenosis may occur after aortic root surgery and this complication may be life threatening and may lead to myocardial infarction or fatal ventricular arrhythmia. PCI with stenting is safe and effective after aortic root surgery and is an efficient alternative to coronary artery bypass graft.
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Maggots: bronchoscopic removal of a rare live foreign body p. 318
Pulak Tosh, Sunil Rajan, Jerry Paul, Lakshmi Kumar
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Stress in anesthesia practice: a deterrent or a driving force? p. 320
Vishal K Pai, Mridul Dhar, Ajit Kumar
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