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   Table of Contents - Current issue
July-September 2017
Volume 4 | Issue 3
Page Nos. 99-176

Online since Wednesday, July 5, 2017

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Serial heparin-binding protein compared with sequential organ failure assessment, acute physiological and chronic health evaluation ii, multiple organ dysfunction and charlson scores as predictors of mortality in critically ill septic patients Highly accessed article p. 99
Gamal Hamid Ibrahim, Dalia Mohamed Ragab, Amal Foad Rizk, Nora Ismail Abbas, Talal Ibrahim Hagag
Introduction Early detection and management of severe sepsis is crucial for successful outcome. We hypothesized that the progression of sepsis to severe sepsis is preceded by vascular leakage, which is caused by neutrophil-derived mediators, as heparin-binding protein (HBP). Aim The aim of the study was to identify the role of serial HBP measurement as a predictor of morbidity and mortality in critically ill septic patients in comparison with sequential organ failure assessment (SOFA), acute physiological and chronic health evaluation II (APACHE II) score, multiple organ dysfunction (MODS) scores, and Charlson scores. Settings and design This was an observational prospective controlled study. Materials and methods Patients were classified into two groups: group I, which included 40 patients with evident sepsis; and group II (control group), which included 10 critically ill nonseptic patients. Results Statistically significant difference was detected between survivors and nonsurvivors in max SOFA score, APACHE II, MODS, white blood cells, and serial HBP. Receiver-operating characteristic curve using admission HBP for prediction of severe sepsis showed a sensitivity of 94.7% and specificity of 100% at cut-off level more than 1.9 ng/ml, and for prediction of mortality the sensitivity was 91.6% and specificity 100% at cut-off level more than 1.9 ng/ml. Conclusion Serial plasma HBP levels can predict severe sepsis and mortality in ICU septic patients without statistically significant difference compared with SOFA, APACHE, and MODS scores.
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Experience at a Critical Care Department with trauma patients: a 5-year registry study p. 108
Amr A.E.E Amin Abd Allah, Nashwa A Alamir, Abdou M Alazab, Lamiaa H Mohammed
Background and objective Trauma is the sixth leading cause of death worldwide, resulting in five million or 10% of all deaths annually. Mortality can be grouped into immediate, early, and late deaths. Recognition of these patterns has led to the development of Advanced Trauma Life Support, which is the standard of care for trauma patients, and it is built around a consistent approach to patient evaluation. The aim of our study was to assess and find a way to predict outcomes in trauma patients admitted to the Critical Care Department using admission data (clinical and laboratory) and scoring systems. Patients and methods This was a prospective–retrospective study carried out between January 2010 and December 2014 on 67 trauma patients. Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were obtained. Revised Trauma Score (RTS) was calculated using data collected within the first 24 h of admission. Results Nonsurvivors were relatively younger than survivors (29.16±12.83 vs. 39.69±19.83, P=0.036), and they had more dangerous penetrating injuries compared with survivors. Road traffic accidents were more common among nonsurvivors compared with survivors (penetrating injuries: 16% in survivors vs. 56.2% in nonsurvivors; road traffic accidents: 68% in survivors vs. 37% in nonsurvivors, P=0.025). pH, PaCO2, random blood sugar, and serum sodium were significantly higher in nonsurvivors compared with survivors. Nonsurvivors had a significantly lower Glasgow Coma Score, lower RTS, and higher APACHE II scores than survivors. A receiver operating characteristic curve analysis was carried out, and an APACHE II score of 20 was significant in predicting mortality with an area under the curve of 91.6%, sensitivity of 81.3%, and specificity of 87.2%. In addition, an RTS cutoff score of 6 had an area under the curve of 91.4%, sensitivity of 74.4%, and specificity of 87.5% for predicting mortality. Conclusion Both APACHE II and RTS are better predictors of mortality in trauma patients admitted to ICUs.
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Does combined general–epidural anesthesia reduce the risk for surgical site infections in radical cystectomy? p. 117
Hoda Shokri
Background Radical cystectomy is an aggressive surgical procedure associated with the highest morbidity and mortality of all commonly performed urological procedures. It has been assumed that regional anesthesia may reduce infectious complications. Objective This aim of this study was to compare whether general anesthesia (GA) combined with epidural anesthesia reduces the incidence of superficial and deep surgical site infections, chest infection, mortality rate, and length of hospital stay. Patients and methods In this prospective randomized parallel group study, 150 patients between 50 and 65 years of age who were scheduled for elective radical cystectomy were randomly divided into two groups: the GA-only group (n=75), which received GA-alone, and the Epi–GA group (n=75), which received both GA and epidural anesthesia. Demographic and clinical data, such as age, sex, and BMI, and surgical data, such as duration of surgical procedure and number of whole blood units given, were recorded. Postoperative data such as superficial and deep surgical site infections, chest infection diagnosed by the consultant over 10 days’ duration, mortality rate, and duration of hospital stay were recorded. Results Demographic, clinical, and surgical data were similar among the study groups. There was no significant difference between the study groups as regards the incidence of superficial and deep surgical site infections, chest infection, and mortality rate. The duration of hospital stay was significantly shorter in the Epi–GA group compared with the GA-only group. Conclusion Our study showed that combined GA and epidural anesthesia offers no advantage over GA alone with regard to the incidence of infectious complications within 10 days postoperatively, but it significantly reduced the length of hospital stay.
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Traumatic brain injury predictive value of common intensive care severity scores p. 124
Ahmed Kandil, Mahmoud Kenawi, Ahmed Samir, Khaled Hussein
Background Traumatic Brain Injury (TBI) causes a severe toll on society as a leading cause of mortality worldwide and the major cause of disability among young adults. The prognosis after TBI had been particularly challenging to predict, with limited availability of robust prognostic models. Aim To evaluate the usefulness of the acute physiology and chronic health evaluation II (APACHE II), simplified acute physiology score II (SAPS II) and sequential organ failure assessment (SOFA) scores compared to simpler models based on age and Glasgow coma scale (GCS) in predicting a six-month mortality of patients with moderate to severe traumatic brain injury (TBI) in the intensive care unit (ICU). Methods A prospective cohort study conducted on acute TBI patients admitted to ICU at EL-HELAL trauma Centre and KASR AL AINI university hospital, Egypt during the period from August 2014 to April 2015. All patients were followed-up for 6 months from the day of admission. Patients were divided into two groups (survivors and non-survivors). Results A total of 104 patients were enrolled. Mean age was 37±17.16 years. The overall six-month mortality was 25 patients (24.4%). The univariate analysis showed that APACHE II, SAPS II, SOFA, GCS, and age had a significant statistical difference regarding mortality between both groups (P-value < 0.05) and the optimal cut-off point as mortality indicator was 14, 26, 4, 9 and 49, respectively with area under the curve (AUC) 0.88, 0.87, 0.83, 0.80 and 0.79, respectively. Multivariate analysis using logistic regression found that only age and GCS had a statistically significant impact on outcome (P-value; 0.001, 0.022, respectively). Conclusions A simple prognostic model based only on GCS and age displayed good predictor for six-month mortality of ICU treated patients with TBI. The use of the more complex scoring systems (APACHE II, SAPS II and SOFA) added little to the prognostic performance.
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Shorter postanesthesia care unit stay with dexmedetomidine infusion during laparoscopic bariatric surgery: a randomized controlled trial p. 129
Mohamed El Sayed, Akmal Abdelsamad, Ayat Amer
Introduction Lesser narcotics use during laparoscopic bariatric surgery is needed to decrease the impact on respiratory parameters and reduce analgesic requirements after surgery. Using dexmedetomidine has a role in perioperative pain control in obese patients’ recovery in postanesthetic care unit (PACU) and hospital stay. In this study, we hypothesized that dexmedetomidine would delay and decrease opioid requirements during surgery, promoting less time in the PACU and faster, safer recovery. Patients and methods After obtaining ethics committee approval, informed consent to participate in this study was obtained from 56 patients who were scheduled for planned laparoscopic bariatric surgery. Patients were randomly divided into two groups − group D (n=28) received dexmedetomidine 1 µg/kg loading for 10 min and 0.4 µg/kg/h maintenance until extubation, and group N (n=28) received normal saline (placebo) at the same volume and rate. PACU stay time, the total amount of intraoperative fentanyl used, recovery profile, pain score, and the total amount of pethidine used postoperatively were measured. Results The dexmedetomidine group showed significant decrease in intraoperative and postoperative hemodynamics, shorter recovery time, and shorter stay in PACU. Perioperative narcotic use, intraoperative fentanyl use, visual analog scale scores, PACU pethidine dose in the first hour, and total pethidine dose on the first day were significantly less in the dexmedetomidine group. Patient satisfaction at discharge regarding pain management was less in the control group. Conclusion Intraoperative dexmedetomidine infusion with its opioid-sparing effect enhanced recovery in this study population of morbidly obese patients undergoing laparoscopic bariatric surgery with minimal side-effects.
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Bronchoscopic instillation of amikacin in patients with ventilator-associated pneumonia p. 134
Mohamed E Fathy, Tamer A Helmy, Ehab M Elreweny, Mahmoud I Mahmoud
Introduction In the era of the emergence of multidrug resistant organisms, it appears that bacteria are beating the battle against the poor development of new effective antibiotics. Aminoglycosides are effective against many Gram-negative bacteria especially when given in large doses, but unfortunately it may be potentially toxic; therefore, there was an inclination toward administration of these antibiotics directly to the airway to get a high concentration of the drug at the site of infection with minimal systemic adverse effects. Patients and methods A total of 130 patients with ventilator-associated pneumonia were randomized to amikacin instillation (amikacin-instillation group) (AIG) and intravenous control group (ICG). Bronchial amikacin and serum trough amikacin levels were measured. Enrolled patients were followed up, and clinical cure, microbiological cure, mortality, and length of stay in the ICU stay were monitored. Results In AIG, bronchial level of amikacin reached a concentration of 18 700 mcg/l (mean=13 156 mcg/l), associated with nonsignificant increase in the trough levels of amikacin. There was a significant expedition of the clearance of infection and decrease in the ventilator-free days in the AIG. However, there were no significant differences between the two groups regarding mortality and ICU stay. Conclusion Bronchoscopic instillation of amikacin is a feasible, effective, and safe mode of direct antibiotic delivery in patients with ventilator-associated pneumonia.
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Efficacy of sugammadex compared with neostigmine for reversal of rocuronium-induced neuromuscular blockade and deep extubation in outpatient surgeries for asthmatic pediatric patients p. 143
Eslam N Nada
Background Bronchial asthma in children is considered a challenge for the anesthesiologist because of the perioperative adverse effects, especially the risk for bronchospasm either during induction or more commonly during recovery and extubation. Therefore, the goal should be to minimize this risk by avoiding any triggering stimulus and deep extubation with adequate recovery from the neuromuscular blocker to have full control of pharyngeal and respiratory muscles. The aim of this study was to compare the efficacy of sugammadex with neostigmine on reversing rocuronium-induced neuromuscular blockade (NMB) in asthmatic pediatric patients undergoing outpatient surgical procedures. Patients and methods This prospective randomized study was conducted on 60 patients, aged 3–12 years, with history of bronchial asthma, and scheduled for outpatient lower abdominal or urogenital surgeries. NMB was achieved by administration of rocuronium 0.6 mg/kg and monitorized subjectively with train-of-four mode of peripheral nerve stimulator. Patients were randomly allocated into two groups by using the sealed-envelope method: group N (n=30), which received 0.04 mg/kg neostigmine, and group S (n=30), which received 2 mg/kg sugammadex for reversal of rocuronium-induced NMB. Duration of surgery, time from injection of the reversal agent to the time of extubation (time to extubation), total doses of rocuronium, and time from extubation to recovery were recorded. Any complications such as hemodynamic abnormalities, retching, vomiting, bucking, bronchospasm, laryngospasm, coughing, need for reintubation, or any other complications were recorded. Results There was no significant difference between the two groups as regards age, sex, weight, duration of surgery, and total doses of rocuronium. On the other hand, there was statistically significant difference between the two groups regarding time of NMB reversal to time of extubation: 13.43±4.92 min in the neostigmine group versus 1.84±0.66 min in the sugammadex group (P<0.0001). Moreover, there was statistically significant difference between the two groups regarding time from extubation till time of recovery: 21±5.72 min in group N versus 25.57±5.72 min in group S (P=0.019). Regarding complications, need for succinylcholine, and need for reintubation, although their incidence was higher in the neostigmine group, there was no statistically significant difference between the two groups. Conclusion It was concluded that reversal of rocuronium-induced NMB by using sugammadex was more rapid and safer when compared with neostigmine in asthmatic pediatric patients undergoing outpatient lower abdominal or urogenital surgeries.
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Intraperitoneal ketamine attenuates the inflammatory reactivity associated with pneumoperitoneum p. 149
Soad Sayed El-Gaby, Sawsan Soliman Mohamed
Background Laparoscopic surgery is a common procedure that has replaced many types of open surgeries. Ketamine is an anesthetic drug that has immunomodulatory and anti-inflammatory effects. It results in ‘homeostatic regulation’ of the acute inflammatory reaction. Aim The primary outcome was to evaluate the anti-inflammatory effect of intraperitoneal instillation of low-dose ketamine (0.5 mg/kg) in laparoscopic pneumoperitoneum. The secondary outcome was to evaluate its analgesic effect. Patients and methods This study was carried out on 46 patients aged 26–46 years of ASA grade I–II. All patients were scheduled for laparoscopic cholecystectomy. The patients’ history, clinical examination, and laboratory investigations were carried out on the preoperative day. Patients were randomly allocated to one of two groups: the ketamine intraperitoneal (KIP) group (n=23 patients), in which 0.5 mg/kg ketamine diluted in 30 ml normal saline was instilled intraperitoneally; and the saline intraperitoneal (SIP) group (n=23 patients), in which 30 ml of normal saline was instilled intraperitoneally. The following parameters were recorded: time to extubation, time to first request for analgesia, numerical rating scale for pain, the total dose of pethidine postoperatively, and biochemical assay for interleukin 6 (IL-6). Results No patients complained of pain in the KIP group compared with the SIP group. The time to first analgesic request postoperatively was significant longer in the KIP group than in the SIP group (P<0.013). Patients in the KIP group required a lower dose of pethidine in the first 24 h postoperatively compared with patients in the SIP group (P<0.001). The postoperative serum IL-6 levels were significantly lower in the KIP group compared with the levels in the SIP group (P<0.001). Conclusion This study suggests that low-dose ketamine (0.5 mg/kg) attenuates the increase of IL-6, which is a biomarker of inflammatory activation associated with pneumoperitoneum.
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Prospective randomized study of interscalene brachial plexus block using 0.5% bupivacaine HCl with or without dexamethasone in shoulder surgery p. 156
Rabab S Mahrous, Rehab A Abd El-aziz
Background Interscalene brachial plexus block is one of the commonly performed techniques for regional anesthesia of the upper extremity. The aim of this study was to compare the analgesic efficacy and duration of 5 ml versus 10 ml of 0.5% bupivacaine HCl with and without 1 ml of dexamethasone in patients undergoing shoulder surgery. Materials and methods This prospective randomized blinded study was carried on 75 American Society of Anesthesiology I and II patients. Patients were assigned randomly to one of the three groups: group A received 10 ml of bupivacaine HCl 0.5%; group B received 5 ml of bupivacaine HCl 0.5%; and group C received 4 ml of bupivacaine HCl 0.5%+1 ml of dexamethasone. Results There was no significant difference between the three groups in the total dose of intraoperative fentanyl dose. A statistically significantly high visual analog scale value was found in group B in comparison with groups A and C at 12 h postoperatively, and a statistically significant low visual analog scale was found in group C after 36 h. There was statistically significant earlier timing of first rescue analgesia requisite in group B and there was a significant difference between group C and the other two groups studied in the total amount of nalbuphine consumed. The incidence of block-related complications was significantly higher in group A compared with the other groups. Conclusion High volume of bupivacaine HCl 0.5% provides perioperative analgesia comparable to low volume, but low volume is safer in terms of the incidence of complications. Addition of dexamethasone to bupivacaine led to prolonged analgesic duration and was accompanied by a lower consumption of postoperative opioids.
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Diagnostic value of serum procalcitonin compared with c-reactive protein for postoperative wound infection of surgically treated trochanteric fracture p. 164
Rabab S Saleh, Amin A Youssef, Hala M Demerdash
Introduction Because of the high prevalence of postoperative infection and its impact on mortality and morbidity in patients undergoing orthopedic and nonorthopedic procedures, a reliable marker for the diagnosis of infection would be of great importance. There has been an increasing use of procalcitonin (PCT) measurements in identifying systemic bacterial infections. This study was carried out to investigate the value of serum PCT level versus the C-reactive protein (CRP) in the diagnosis of postoperative inflammatory response with or without sepsis after trochanteric fracture surgery in the elderly. Patients and methods The study was carried out in El-Hadara University Hospital on 60 American Society of Anesthesiologists physical status I and II patients aged above 50 years scheduled for peritrochanteric hip fracture surgery [dynamic hip screw (DHS), dynamic condylar screw, gamma nail, cemented bipolar, cemented Thompson, and Austin Moore]. Blood samples for PCT, CRP, and white blood cells (WBCs) were drawn on day 0 (preoperatively) and days 1, 3, 5, and 7 postoperatively. The samples were collected at the same hour in the morning for each patient. Results The age ranged from 65.0 to 90.0 years with a mean of 77.0±8.66 years. There were 15 (25.0%) male and 45 (75.0%) female patients. Ten (16.7%) patients underwent cemented bipolar operation, 28 (46.7%) patients were treated with DHS, and four (6.7%) were treated with cemented Thompson, and 18 (30.0%) were treated with gamma nail. In the studied group, 15 (25%) patients had proven local wound sepsis on culture and sensitivity performed on day 3, and 45 (75%) patients were not infected. There was a significantly higher difference in the infected ones than in the noninfected ones as regards WBCs, PCT, and CRP changes. In the infected group seven (46.7%) patients were treated with DHS, four (26.7%) with cemented bipolar, two (13.3%) with cemented Thompson, and two (13.3%) were treated with gamma nail. Conclusion We could conclude that PCT is an earlier and more specific marker of wound infections compared with CRP or WBC count after trochanteric fractures in the elderly.
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Hereditary thrombophilia (rare multiple genetic defects combination) caused portal vein thrombosis complicated by hypersplenism and pancytopenia p. 173
Sally S Eldin, Nora I Abbas, Noha K Mohamed, Aml S Nasr
Venous thrombosis is the third-ranking cardiovascular disease following only coronary heart disease and stroke [1]. Venous thrombosis has an overall yearly incidence of less than 1 in 1000 [2]. A middle-aged female patient without relevant medical history was admitted with syncope and pancytopenia to the critical care unit of Cairo University hospitals. Viral profile and renal and hepatic functions were normal, as well as bone marrow aspirate. Abdominal ultrasound followed by computed tomography of the abdomen showed moderate splenomegaly with no focal splenic lesions for clinical laboratory correlation and portal hypertension with portal vein cavernoma (mostly an organized old thrombosis during pregnancy) for color Doppler evaluation, which confirmed the diagnosis. Thrombophilia screening showed rare multiple thrombophilic genetic defects.
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