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   Table of Contents - Current issue
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January-March 2018
Volume 5 | Issue 1
Page Nos. 1-71

Online since Wednesday, January 24, 2018

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ORIGINAL ARTICLES  

Atherosclerotic plaque composition and significance of nonculprit intermediate coronary lesions. Intravascular ultrasound and quantitative coronary angiography study in acute coronary syndrome Highly accessed article p. 1
Helmy H El Ghawaby, Mohamed A Shawki, Ahmed H Mowafi, Akram M Abd Elbary, Farouk M Faris
DOI:10.4103/roaic.roaic_14_17  
Background Detection of potentially vulnerable plaques inducing acute coronary syndrome (ACS) improves prevention of cardiovascular events. We aimed at using intravascular ultrasound (IVUS) for morphological assessment, anatomical significance of atherosclerotic plaques of nonculprit intermediate coronary lesions and correlation with quantitative coronary angiography (QCA) in ACS. Patients and methods 2IVUS was performed on 61 nonculprit intermediate coronary lesions in 28 patients diagnosed with non-ST-elevation ACSs. Percent area stenosis more than 70% was the cutoff value for intervention. Results The mean age was 53.2±9.1 years, men=20 (71.4%). Culprit vessels represent 42% of affected vessels. Higher lipid content was found in lesions of culprit vessels (P<0.001). Six lesions were revascularized based on IVUS measures (QCA accuracy=90.1%, sensitivity=77.8%, and negative predictive value=85%). Minimal lumen area (MLA) and plaque burden are the main predictors for lesion anatomical significance with [P<0.001, odds ratio=0.25, 95% confidence interval (CI)=0.12–0.55] and (P=0.011, odds ratio=2.0, 95%CI=1.2–3.3), respectively. There was a positive strong correlation between QCA minimal lumen diameter and MLA (P<0.001, r=0.695). An inverse moderate correlation was seen between QCA minimal lumen diameter and percent area stenosis (P<0.001, r=−0.449). There was a significant concordance between QCA and IVUS regarding percent stenosis (P=0.01, intraclass correlation coefficient=0.451, 95%CI=0.084–0.67), while there was disconcordance in measurement of the lesion length (P=0.2, intraclass correlation coefficient=0.22, 95%CI=−0.3–0.53). Conclusion IVUS might be valuable for the assessment of nonculprit lesions in ACS. There is high vulnerability for plaque rupture in intermediate lesions of culprit vessels. MLA and plaque burden are the main predictors for lesion anatomical significance. QCA is a reliable tool for detecting severity of coronary artery disease.
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Urinary soluble triggering receptor expressed on myeloid cells-1 is an early predictor for sepsis outcome and sepsis-induced acute kidney injury p. 8
Ahmed Farghal, Hossam M Sherif, Adel Al Sisi, Sameh Al-Maraghy
DOI:10.4103/roaic.roaic_9_17  
Background Recent reports had indicated the usefulness of urinary soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) as a prognostic marker for sepsis and sepsis-induced acute kidney injury (AKI). Objective This study aimed to detect the prognostic value of urinary sTREM-1 in sepsis in terms of the clinical course, development of AKI, and the survival rate. Patients and methods Thirty critically ill patients with sepsis were included (57.6±7.5 years, 18 men), in addition to a group of 10 controls (45.6±3.5 years, six men). Urinary sTREM-1 and C-reactive protein serum levels were estimated on admission, and days 3 and 7. The sepsis-related organ failure assessment scoring system was calculated at baseline and daily until discharge, mortality, or up to 28 days. Length of stay in ICU, need for vasopressors, mechanical ventilation or hemodialysis, and development of AKI and the outcomes were recorded. Results Compared with stable patients, patients who required vasopressors (23 patients) or hemodialysis (patient 4) showed significantly higher sTREM-1 values (4.06±1.22 vs. 2.86±0.51 ng/ml, P<0.001, and 5.27±1.2 vs. 3.55±1.05 ng/ml, P<0.05). Fair correlation could be detected between the sepsis-related organ failure assessment scoring system and sTREM-1 on day 1 and 7 (r=0.45, P<0.05 and r=0.47, P<0.05). In patients who developed AKI (12 patients), sTREM-1 showed significantly higher values than those who did not develop AKI (4.37±1.34 vs. 3.39±0.95 ng/ml, P<0.05). Compared with the survivors, the nonsurvivors (14 patients) showed significantly higher sTREM-1 values (4.6±1.14 vs. 2.96±0.52 ng/ml, P<0.001). The area under the curve for sTREM-1 to predict AKI on day 1 was 0.73 (95% confidence interval: 0.53–0.92), with the best cut-off value at 4.02 ng/ml (sensitivity 66.7% and specificity 83.3%). The area under the curve for sTREM-1 to predict the ICU mortality on day 1 was 0.91 (95% confidence interval: 0.81–1.01), with the best cut-off value at 4.02 ng/ml (sensitivity 73.3% and specificity 100%). Conclusion Urinary sTREM-1 can be used as a clinical outcome predictor for the development of AKI and ICU mortality in patients with sepsis.
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Role of early propranolol in weaning from mechanical ventilator in severe traumatic brain injury patients p. 15
Tamer Habib, Ahmed Sabry, Ahmed El-Beheiry, Islam Ahmed
DOI:10.4103/roaic.roaic_58_17  
Background Traumatic brain injury (TBI) is responsible for up to 30% of all injury-related deaths. The majority of patients with severe TBI require mechanical ventilation (MV). To date, no pharmacologic agent has been developed to improve outcomes in TBI. The primary aim of this prospective study was to investigate whether early use of low-dose propranolol within 24 h in patients with severe TBI can affect their weaning from MV or not. Patients and methods This study was carried out on 340 adult patients with severe TBI randomly assigned to two groups. The early propranolol after traumatic brain injury (EPAT) group (102) received propranolol 40 mg twice daily within 24 h from admission. The non-EPAT group (238) did not receive any β blockers. Results EPAT patients showed lower duration of MV (7.74 vs. 11.14 days, P=0.0013). The length of stay in ICU was lower in the EPAT group (10.62 vs. 14.13 days, P=0.003), but there was no statistically significant difference in mortality between the two groups studied (P=0.392). Conclusion Early use of propranolol does not increase episodes of bradycardia or hypotension. Early propranolol after TBI can be used safely and may be associated with decreased days on MV and ICU length of stay.
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Postoperative analgesia by a surgically inserted transversus abdominis plane catheter versus a thoracic epidural catheter after flank incision: randomized-controlled trial p. 21
Fathi M Heba, Elgalaly Hazem, Eliwa M Ahmed, Abdelwahab Khalid
DOI:10.4103/roaic.roaic_46_16  
Introduction Transversus abdominis plane (TAP) block has been reported to be an effective method of analgesia after abdominal surgery. This prospective randomized study compared the analgesic effect by a surgically inserted TAP catheter versus a thoracic epidural catheter in the postoperative period after a flank incision. Patients and methods Sixty-four American Society of Anesthesiologists physical status I and II patients, 18–59 years of age scheduled for renal surgery for a nonmalignant lesion with a flank incision, were allocated randomly to two equal groups. The group E (n=29; three excluded) received 0.125% bupivacaine with fentanyl 2 µg/ml at the rate of 5–8 ml/h, whereas the group T (n=30; two excluded) received 1 mg/kg bupivacaine 0.375%/8 h. Rescue analgesia of 5 mg morphine bolus doses was administered upon patients’ requests with a maximum dose of 10 mg/4 h. Visual analog scale, morphine consumption in 48 h, and incidence of postoperative complications were assessed. Results Visual analog scale and morphine consumption were comparable in the two groups. No significant complications were found in the TAP group, whereas the incidences of hypotension and motor block were higher in the epidural group. Conclusion A surgically assisted-TAP catheter is an easy, safe and effective method for analgesia after a flank incision and can be a good alternative to epidural analgesia, especially when the latter is contraindicated.
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Plasminogen activator inhibitor-1 as a predictor after cardiopulmonary bypass for postoperative atrial fibrillation p. 27
Suzy Fawzy, Mohamed F Abdel Aleem, Mohamed A El Badawy, Islam H Mohamed
DOI:10.4103/roaic.roaic_37_17  
Background Following cardiac surgery, atrial fibrillation may be a common event. While postoperative atrial fibrillation (POAF) can be transient, it may lead to serious consequences, such as stroke, hemodynamic instability, and death. Plasminogen activator inhibitor-1 (PAI-1) serves as the primary inhibitor of tissue-type plasminogen activator, but also is mainly an acute-phase reactant. Increased PAI-1 promotes fibrosis and reduces extracellular matrix turnover, which modify the atrial substrate and potentially lead to POAF trigged by cardiac surgery. Aim The aim the study was to assess the efficacy of PAI-1 as a predictor of POAF after cardiopulmonary bypass (CPB). Patients and methods In this study, we enrolled 100 patients undergoing cardiac surgery requiring CPB and were in sinus rhythm at surgery time. Blood samples were obtained for the measurement of PAI-1 in the morning of the operation and immediately after separation from CPB and administration of protamine. Pearson’s χ2-test, Fisher’s exact test, area under the receiver operating characteristic curves, P-value less than 0.05, multivariable binary logistic regression were used. Results This study has shown that the serum level of preoperative PAI-1 more than 15 ng/ml and post-CPB level of PAI-1 more than 23 ng/ml are associated with high incidence of POAF (P<0.01 and 0.01, respectively). Left atrial diameter more than 4 cm (P<0.01), advanced age (>60 years) (P=0.04), hypertension history (P=0.035), number of grafts (P=0.01), Right Coronary Artery (RCA) graft (P<0.01), prolonged time of CPB (P=0.03), postoperative administration of epinephrine and dobutamine (P=0.005), and postoperative reduced ejection fraction less than 35% (P=0.028) are other risk factors for POAF development. Conclusion PAI-1 could be considered as a predictor of POAF whether measured preoperatively or postoperatively immediately after separation from CPB.
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Postdural puncture headache and maternal hemodynamics after single-shot and continuous spinal anesthesia using epidural kit for cesarean section p. 35
Essam F Abdelgalel, Osama A Nofal, Mona A Shahin
DOI:10.4103/roaic.roaic_41_17  
Background The aim of this study was to compare the incidence of postdural puncture headache and maternal hemodynamics after single-dose spinal anesthesia and continuous spinal anesthesia using epidural kit with prophylactic intrathecal saline injection for a cesarean section. Patients and methods Ninety patients scheduled for elective cesarean section were randomly allocated to one of the three groups. Group A (30 patients) received single-dose spinal anesthesia using a 25-G Quincke type point spinal needle. Groups B and C (30 patients each) received continuous spinal anesthesia using 18-G epidural needles and intrathecal 20-G epidural catheters. In group C, the patients received 5 ml normal saline intrathecally before local anesthetic injection and 10 ml just before catheter removal 24 h after insertion. Incidence and severity of postdural puncture headache, block characteristics, patient satisfaction, hemodynamic parameters, and incidence of complications were recorded. Results Significantly longer sensory and motor regression times with higher total bupivacaine dose in group A compared with groups B and C. The hypotension and ephedrine dose needed were significantly more in group A compared with the other two groups. Nausea and vomiting were significantly more in group A compared with the other two groups. Incidence of postdural puncture headache was 16.7% in group B and 10% in both groups A and C. Patient satisfaction was significantly more in group C compared with the other two groups. Mean arterial pressure and heart rate were significantly lower in group A compared with the other two groups at 10, 15, 20, and 25 min Conclusion Incidence of postdural puncture headache with continuous spinal anesthesia with keeping of the intrathecal catheter for 24 h and prophylactic intrathecal saline is comparable to single-dose spinal anesthesia for a cesarean section. It allows using lower doses of local anesthetic with better hemodynamic stability, fewer complications, and better patient satisfaction.
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Heart-type fatty-acid-binding protein is a prognostic biomarker for sepsis outcome and sepsis-related left-ventricular dysfunction: a comparison with troponin I p. 42
Mohamed Abul Wafa, Hossam M Sherif, Ayman Gaber, Wael Sami
DOI:10.4103/roaic.roaic_8_17  
Background Using heart-type fatty-acid-binding protein (H-FABP) in critically ill patients provides a superior results than the conventional cardiac biomarkers. Objective The aim of the study was to estimate the prognostic significance of H-FABP in patients with septic shock and the prevalence of sepsis-related myocardial dysfunction in comparison to troponin I. Patients and methods Fifty ICU patients with sepsis were enrolled in this study. All patients were evaluated using Acute Physiology and Chronic Health Evaluation II score on admission and every 24 h during ICU stay. Serum levels of both H-FABP and troponin I were investigated during the first 24 h after admission. Using modified Simpson’s method, echocardiographic left-ventricular end-diastolic volume (LVEDV), left-ventricular end-systolic volume (LVESV), and left-ventricular ejection fraction (LV%EF) were calculated on admission and after 24 h. Results The patients were divided into two groups: group 1, which included 12 patients (mean age: 50.2±21 years) suffering from sepsis; and group 2, which included 38 patients (mean age: 58.4±19.2 years) with septic shock. Compared with group 1, H-FABP of group 2 showed significant higher values (76.3 vs. 33.3% of patients, P<0.05). In both groups, compared with patients with negative H-FABP, patients with positive H-FABP showed significantly increased values (66 vs. 34%, P<0.05). The positive H-FABP patients showed significantly increased left ventricular volumes (LVEDV=105 vs. 77 ml, P<0.05; and LVESV=49 vs. 33 ml, P<0.05). The mortality rate was significantly higher in group 2 compared with group 1 (78.9 vs. 41.7%, P<0.05). H-FABP was a better prognostic marker than troponin I; it showed an increased prevalence of mortality (88 vs. 35%, P<0.001) with good correlation (r=0.54, P<0.05). Conclusion In septic shock, H-FABP can be used as a prognostic marker for mortality rathar than troponin I. The positive H-FABP patients showed a significant relation with sepsis-related left-ventricular systolic myocardial dysfunction.
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Comparison between sugammadex and neostigmine–atropine in morbidly obese patients during anesthesia in ophthalmic surgery p. 52
Heba M Fathi, Gehan F Ezz
DOI:10.4103/roaic.roaic_26_17  
Background Sugammadex provides fast and complete recovery from rocuronium-induced neuromuscular blockade. The objective of this study was to compare between the effect of sugammadex and neostigmine on intraocular pressure (IOP), hemodynamics, and postoperative complications in morbidly obese patients. Patients and methods A prospective randomized study was done to study the effect of sugammadex and neostigmine on IOP in morbidly obese patients during elective eye surgery. A total of 60 morbidly obese patients (BMI >35 kg/m2) American Society of Anesthesiologists I–II, aged between 35 and 55 years, requiring general anesthesia and who received rocuronium for muscle relaxation were randomly assigned into two groups: group I (n=30) (Sug) received sugammadex 2 mg/kg and group II (n=30) (Neo) received neostigmine of 0.05 mg/kg at the end of surgery when response of train-of-four reached T2 by using peripheral nerve stimulator. The neuromuscular function was recorded and time to achieve 90% of train-of-four (safe extubation) was measured. After extubation was done, the IOP was measured 1, 2, 5, 10, and 20 min for all patients (those with baseline IOP of >30 mmHg were excluded). Tono-Pen XL applanation tonometer was used to measure IOP. Heart rate and blood pressure were measured and compared in both groups. Patients were examined directly after arrival to the recovery room for observation of complications. Results Sugammadex give safe, fast, and complete recovery in morbidly obese patients, lower values of IOP and minimal effect on hemodynamics during ophthalmic operations. Conclusion Sugammadex provided a more rapid reversal of neuromuscular functions in morbidly obese patients, lower IOP and hemodynamic stability during ophthalmic operations.
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Effects of intrathecal midazolam in potentiating the analgesic effect of intrathecal dexmedetomidine in elderly patient undergoing hip repair surgeries p. 58
Haidy S Mansour, Ahmed H Mohamad
DOI:10.4103/roaic.roaic_33_17  
Objective This study was designed to assess the effect of intrathecal midazolam on dexmedetomidine with a low-dose bupivacaine in elderly patients undergoing hip repair surgery. Materials and methods This is a double-blind study involving 75 patients with American Society of Anesthesiologists physical status II and III aged over 60 years scheduled for elective hip repair surgery under intrathecal anesthesia. They were randomly divided into three groups: control (C group) received 7.5 mg of 0.5% hyperbaric bupivacaine, dexmedetomidine group (D group) received 7.5 mg of 0.5% hyperbaric bupivacaine+5 μg of dexmedetomidine, and dexmedetomidine+midazolam group (DM) received 7.5 mg of 0.5% hyperbaric bupivacaine+5 μg of dexmedetomidine+1 mg of midazolam. The onset and duration of sensory and motor blockade, intraoperative hemodynamic change, and postoperative analgesia were recorded. Results Compared with group C, the groups D and DM had significantly faster onset of sensory block (P=0.032 and 0.0001, respectively), faster onset of motor block (P=0.024 and 0.006, respectively), prolonged duration of sensory block (P=0.003 and 0.0001, respectively), prolonged duration of motor block (P=0.015 and 0.002, respectively), prolonged duration of postoperative analgesia (P=0.0001), and significantly decreased postoperative visual analog scale sedation score for 12 h. Compared with group D, group DM had a significantly longer duration of sensory block (P=0.012), longer duration of postoperative analgesia (P=0.042), and postoperative visual analog scale significantly decreased for 12 h postoperatively. Conclusion Intrathecal addition of 1 mg midazolam to 5 µg dexmedetomidine and 7.5 mg 0.5% hyperbaric bupivacaine provided intraoperative hemodynamic stability, prolonged motor, and sensory block as well as potentiating the postoperative analgesic.
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The revised-Face, Leg, Activity, Cry, and Consolability scale: an Egyptian version p. 67
Tarek Shabana, Ahmed N Ibrahim
DOI:10.4103/roaic.roaic_36_17  
Background Children with cerebral palsy lack the luxury of self-reporting their pain postoperatively. The revised FLACC (Face, Leg, Activity, Cry, and Consolability) pain scale is a behavioral pain assessment tool that is universally accepted for use in children with cognitive dysfunction. Objective The aim of this study was to cross-culturally adapt and evaluate the validity and reliability of the Egyptian version of the revised FLACC (r-FLACC) scale for use in postoperative pain assessment in children with cerebral palsy. Patients and methods The study was carried out in Ain Shams University Pediatric Hospital on 30 children with cerebral palsy aged 3–12 years scheduled for open Nissen fundoplication. Pain was assessed at baseline, on arrival to postanesthesia care unit, and 30 min after administration of analgesia using the r-FLACC scale (by two independent caregivers) and the visual analog scale (by the child’s parent). Results The r-FLACC scores increased postoperatively and decreased after administration of analgesia (P<0.001) supporting good construct validity. Criterion validity was acceptable in view of the positive correlations between r-FLACC scores and visual analog scale scores provided by the parents (P<0.001). Moderate to significant correlations between observers for total r-FLACC scores (P<0.001), and good agreements for each of the five categories of the r-FLACC scores at baseline (k=0.422–0.627), in postanesthesia care unit (k=0.531–0.737), and after administration of analgesia (k=0.683–0.783) reflected strong inter-rater reliability. Conclusion The Egyptian version of the r-FLACC scale is a valid and reliable tool for postoperative pain assessment in Egyptian children with cerebral palsy.
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