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   Table of Contents - Current issue
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April-June 2018
Volume 5 | Issue 2
Page Nos. 73-145

Online since Thursday, June 28, 2018

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ORIGINAL ARTICLES  

Cervical spine motion during intubation: a fluoroscopic comparison between three intubation techniques p. 73
Moutaz A Ghandour, Nader A Elgamal, Ramadan A Ammar, Abdel Aziz M Elnekiedy
DOI:10.4103/roaic.roaic_13_17  
Background Anaesthetists are responsible for the management of the airway in patients with unstable cervical spine (C spine). The optimal tracheal intubation technique for patients with potential C spine injury remains controversial. Videolaryngoscopes are used in an attempt to balance the need to limit cervical motion and overcome the difficulty of obtaining laryngeal views especially with manual in-line stabilization or cervical collar. Aim The current study aimed to compare the degree of C spine movement during intubation using different devices, Macintosh direct laryngoscope, C-MAC D-Blade videolaryngoscope and flexible intubation video endoscope (FIVE), in anaesthetized patients with normal airway and simulated C spine immobilization. Patients and methods This study was carried out on 45 adult patients scheduled for radiographic procedures under general anaesthesia with endotracheal intubation (ETT). Patients were randomly divided into three equal groups (15 patients each) using the sealed envelope technique: group M (Macintosh direct laryngoscope), group D (C-MAC D-Blade) and group F (FIVE). C spine movement was recorded with continuous fluoroscopy at 3–8 frames/s using a digital videofluoroscopy unit during both laryngoscopy and intubation to capture the maximal extent of C spine movement. The following parameters were evaluated: age, BMI, airway score, haemodynamic parameters, glottic view grade (Cormack and Lehane), time to successful ETT insertion and maximum segmental spine motion. Results The three studied groups were matching as regards age, BMI and airway score. Heart rate and mean arterial blood pressure observed after insertion of the ETT were statistically higher in group M compared with groups D and F. However, there were no significant differences in mean observed HR and mean arterial blood pressure between groups D and F at all time intervals. The Macintosh (group M) had significantly higher C and L grades than the two other devices in groups D and F. There was no significant difference in C and L grades attainted by the D-Blade in group D and the FIVE in group F. D-Blade had significantly shorter intubation time compared with Macintosh and FIVE. Macintosh direct laryngoscope resulted in significantly greater cervical movement at all measured motion segments compared with D-Blade and FIVE. Meanwhile, FIVE caused significantly less motion compared with D-Blade. Conclusion In patients with potential C spine injury and cervical immobilization, D-Blade results in less cervical motion, better glottic views and shorter intubation time compared with Macintosh laryngoscope. Flexible intubation scope causes the least cervical motion but with the longest intubation time.
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Sacroiliac joint denervation, the joint and ligaments: aretrospective study and algorithm p. 80
Mohammad-Hazem Ahmad-Sabry, Gholamreza Shareghi
DOI:10.4103/roaic.roaic_44_17  
Introduction We included patients who had sacroiliac joint complex pain (SIJCP) and failing all conservative approaches to alleviate SIJCP, all had SI joint procedure with fluoroscopic guidance. Some had more than 3 months of better than 50% with SI steroid injection (62/144 patients), others became candidates for sacroiliac joint complex sensory radiofrequency (RF) denervation for long-term pain relief (24 patients), with facet denervation (22 patients) or with piriformis injection (19 patients). Materials and methods In all, 170 patient charts were reviewed, and 17 were excluded for unclear block results and 26 for discogenic pathology. Fluoroscopy and 10 or 15-mm active tip RF cannula was used. An imaginary stripline was drawn about 3–5 cm medial and parallel to the joint line. Posterior primary sensory denervation was then carried out through 10–15 mm segments in series. Denervation was repeated 9–12 months later if greater than 50% of original pain had returned (first repeat and second repeat). The denervation process was then expanded to other sets of patients having (II) SIJCP plus ipsilateral lumbar facet pain and (III) SIJCP plus ipsilateral piriformis syndrome exclusively. Results All groups showed an increase in activities of daily living (through Oswestry Scores), better pain score, and at least 45 weeks improvement of pain score after RF denervation. Conclusion SIJCP can be effectively (50% or better) reduced for 4.5 months with steroid injection, or 10–12 months with denervation. The procedures were repeated once or twice with the same effectiveness. The method of pain management through our approach is effective, safe, simple, and reproducible.
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Superficial cervical plexus block in thyroid surgery and the effect of adding dexamethasone: a randomized, double-blinded study p. 98
Khaled Elbahrawy, Alaa El-Deeb
DOI:10.4103/roaic.roaic_45_17  
Background Thyroid surgeries are widely performed nowadays as an ambulatory procedure; so, the use of regional block for postoperative analgesia has gained popularity. Bilateral superficial cervical plexus blocks (BSCPB) alone or in combination with deep cervical plexus block are good examples. The duration of analgesia following these nerve blocks last for only a few hours. Patients and methods We randomly allocated 90 patients who are American Society of Anesthesiologists I or II scheduled for thyroid surgeries into three groups according to the contents of cervical block in addition to general anesthesia. Group C, which is the control group, received BSCPB with ropivacaine 0.2%. Group DB received BSCPB with ropivacaine 0.2% plus 8 mg dexamethazone. BSCPB with ropivacaine 0.2% plus 8 mg dexamethazone intravenously was given in group DI. Time to the first administration of supplemental analgesic postoperatively is our primary concern. Secondary outcomes include discharge time, rescue analgesic, rescue antiemetic, postoperative nausea or vomiting, pain score, and side effects of either block or drugs. Results Patients in group DB and DI need less postoperative rescue analgesic requirement than in the control group. Pain scores was statistically significantly less in group DB and in the DI group than in control groups at 6 and 8 h postoperatively. The occurrence of nausea and/or vomiting is statistically significantly less frequent in groups DB and DI when compared with the control group postoperatively. Conclusion The addition of dexamethasone to BSCPB resulted in decrease in time that elapsed until the first administration of supplemental analgesic, improved pain control, and reduced analgesic requirements postoperatively. This finding does not differ if dexamethazone is given either with block or intravenously.
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Renal dysfunction after coronary artery bypass surgery p. 103
Akram R Allam, Magdy A Sorour, Mohamed M Agha, Wael M Hassanein, Eisa A.A Aly
DOI:10.4103/roaic.roaic_46_17  
Background Renal dysfunction or acute renal failure in patients undergoing coronary artery bypass grafting (CABG) is one of the most important causes of morbidity and mortality. The great effect of acute renal dysfunction in the outcomes of CABG surgery demands its study in our population, encouraging to the elaboration of this study, which aimed to identify the incidence and risk factors of renal dysfunction after CABG. Patients and methods Since January 2013 to December 2014, 290 patients were studied who underwent CABG with preoperative normal renal function. In this cross-sectional study, patients were divided into two groups based on the occurrence of renal dysfunction after CABG, and measured variables were compared between the two groups and statistically analyzed. P value less than 0.05 was set as a significant level. Results Renal dysfunction was seen in ∼21.37% of patients after CABG. The mean age of renal dysfunction group was higher than that in the other group, and the difference was significant between the two groups. Moreover, reduced ejection fraction was significantly different between the two groups. Cardiopulmonary bypass time was also statistically significant. Postoperative hemodynamic instability and postoperative bleeding were also statistically significant. Conclusion Our study showed older patients were more prone to acute renal failure. Conditions that affect renal perfusion as reduced ejection fraction, hemodynamic instability, and postoperative bleeding are associated with increased risk of renal dysfunction.
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Lung ultrasound in intensive care unit: a prospective comparative study with bedside chest radiography using computed tomography of chest as a gold standard p. 110
Ali Mohsen, Wael Samy, Hatem El-Azizy, Mohammed A Shehata
DOI:10.4103/roaic.roaic_52_17  
Background Bedside chest radiography (CXR) is routinely performed on a daily basis to assess lung status for the critically ill patients. However, the technical difficulties during the procedure have led to the incorrect assessment of most common lung pathologies diagnosed in the ICUs, like pneumothorax (PTX), pleural effusion, lung consolidation, and acute interstitial syndrome (AIS). Recently, lung ultrasound (LUS) has become a new reliable, accurate, and attractive tool for diagnosing most of these lung pathologies. Objective Our study was designed to find out if LUS could be a more reliable, accurate, and sensitive bedside tool in diagnosing most of the common chest diseases encountered in the ICUs, in comparison with bedside CXR, using thoracic computed tomography (CT) as a gold standard. Patients and methods Forty critically ill patients scheduled for CT chest were prospectively studied with a standard LUS protocol. Four pathologic entities were evaluated: consolidation, AIS, PTX, and pleural effusion. Each hemithorax was evaluated for the presence or absence of each abnormality. Eighty hemithoracies were evaluated by the three imaging techniques. Results In comparing bedside CXR with CT chest, bedside CXR detected three cases of PTX of 12 by CT (P=0.02), 11 cases of pulmonary consolidation of 21 by CT (P=0.04), 12 cases of pleural effusion of 19 by CT (P=0.03), and 27 cases of AIS of 36 by CT (P=0.11). On the contrary, comparing LUS with CT chest, LUS detected 11 cases of PTX of 12 by CT (P=0.12), 21 cases of pulmonary consolidation of 21 by CT (P=1.0), 17 cases of pleural effusion of 19 by CT (P=0.32), and 32 cases of AIS of 36 by CT (P=0.02). The sensitivity, specificity, and diagnostic accuracy of CXR were found to be 62, 89, and 73%, respectively, for consolidation; 50, 73.6, and 60%, respectively, for AIS; 25, 100, and 78%, respectively, for PTX; and 46, 90, and 78%, respectively, for pleural effusion. The corresponding values for LUS were 100, 81.4, and 93% for consolidation; 100, 58, and 78% for AIS; 100, 86, and 90% for PTX; and 100, 97, and 98% for pleural effusion. Conclusion In our general ICU population, LUS has shown a considerably better diagnostic performance and is more reliable than CXR for the diagnosis of common pathologic conditions and may be used as an alternative to chest CT.
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Early hydrocortisone for multiple trauma patients may lower the incidence of nosocomial pneumonia p. 115
Mohamed Megahed, Tamer Habib, Islam Ahmed, Mostafa Hefnawy
DOI:10.4103/roaic.roaic_59_17  
Background Early post-traumatic pneumonia increases the duration of mechanical ventilation (MV), hospitalization, and risk of death. In this study, the efficacy of hydrocortisone therapy in the prevention of nosocomial pneumonia in multiple trauma patients has been assessed. Patients and methods Six hundred patients who were admitted with multiple trauma were randomly assigned into two groups. The early hydrocortisone (EH) group consisted of 300 patients who received intravenous hydrocortisone 200 mg/day within 24 h from admission or trauma for 5 days and 100 mg, 50 mg on the following 2 days, respectively. The no early hydrocortisone group consisted of 300 patients who received placebo. All patients were followed up for the incidence of noscomial pneumonia. The days of ICU stay, MV, and mortality rates were calculated in both groups as secondary outcomes. Results The incidence of nosocomial pneumonia in the EH group was significantly lower than the no early hydrocortisone group [120 (40%) vs. 240 (80%), P<0.0001].The EH group showed shorter durations of ICU stay (9.89 vs. 13.6 days, P=0.0027) and MV (7.98±2.31 vs. 10.98±3.98, P=0.0031), respectively. Conclusion The use of early intravenous stress dose of hydrocortisone in patients with multiple trauma may be associated with lower incidence of nosocomial pneumonia but with no difference in mortality.
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Validity of ultrasonography in detection of central venous catheter position and pneumothorax compared with portable chest radiography p. 120
Mohamed Megahed, Tamer Habib, Mohamed Abdelhady, Haitham Zaki, Islam Ahmed
DOI:10.4103/roaic.roaic_60_17  
Background Ultrasonographic guidance for insertion of central venous catheters (CVC) is now almost a standard of care, leading to fewer failed attempts and complications. We evaluated the use of ultrasound examination to detect the position of the CVC and pneumothorax (PTX) occurrence after CVC insertion as an alternative to chest radiography (CXR). Patients and methods This study was carried out on 100 catheter insertions for patients who were admitted to Critical Care Department in Alexandria Main University Hospital. Confirmation of endovenous placement of the catheter was done by ultrasonography using ‘Bubble test’ along with the examination of internal jugular veins and subclavian veins of both sides. Then, lung ultrasound was used to detect PTX occurrence. After that, a portable CXR and computed tomography (CT) of the chest were done for all patients. Results In detection of the catheter position, the ultrasound showed sensitivity and specificity of 82.7 and 96.8%, respectively, versus 93.8 and 95.8%, respectively, for portable radiography. Furthermore, in detection of postinsertion PTX, the ultrasound showed sensitivity and specificity of 90 and 96.3%, respectively, versus 45 and 96.3%, respectively, for portable CXR. Conclusion Ultrasound may be used to detect the position of catheter tip and PTX as a better alternative to routine portable CXR with higher accuracy.
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Inflammatory markers and cerebral vasospasm after aneurysmal subarachnoid hemorrhage p. 127
Sherif Al-Kholy, Mahmoud M Kenawi, Ahmed Battah, Mohamed Al-Desouky
DOI:10.4103/roaic.roaic_35_17  
Background Aneurysmal subarachnoid hemorrhage (aSAH) is considered a major cause of morbidity and mortality. It accounts for about 85% of spontaneous SAH. Cerebral vasospasm is a devastating complication of aSAH. Aim The aim of this study was to evaluate the probable etiological determinant, the outcome of aSAH, and the role of inflammatory markers in predicting cerebral vasospasm post-SAH. Patients and methods A prospective cohort study was conducted on aSAH patients who attended the Emergency Unit, Outpatient Clinics of Neurosurgery Department, and the ICU in Nasser Institute of Research and Treatment during the period between July 2014 and September 2016. Inflammatory marker samples were collected on days 0, 1, 3, 7, and 9. Patients were divided into two groups: (i) group A, which included patients with cerebral vasospasm (n=35) and (ii) group B, which included patients without cerebral vasospasm (n=25). Results A total of 60 patients were enrolled. The mean age was highly significant between both groups (51.31±10.46 years in group A vs. 43.12±8.77 years in group B, P=0.002). The overall mortality was 18 patients, all of which in group A (P<0.001). The univariate analysis showed that C-reactive protein, total leukocytic count, and interleukin-6 had a significant statistical difference between both groups throughout the follow-up period (P<0.05). The optimal cutoff points as cerebral vasospasm indicator in days 0, 1, 3, 7, 9 were (i) 2.7, 4.6, 6.35, 7.45, and 3.8 mg/l for C-reactive protein; (ii) 9.79×109/l, 13.45×109/l, 9.75×109/l, 11.09×109/l, and 12.65×109/l for total leukocytic count; and (iii) 3.15, 3.95, 3.75, 5.1, and 5 pg/ml for interleukin-6, respectively. Conclusion A strong correlation exists between inflammation, cerebral vasospasm, and poor survival outcomes among patients presenting with aSAH. Inflammation and inflammatory markers are dependent risk factors for mortality after cerebral vasospasm.
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Comparison between fiberoptic bronchoscope versus C-MAC video-laryngoscope for awake intubation in obese patients with predicted difficult airway p. 134
Abdelazim A.T Hegazy, Helmy Al-Kawally, Ezz F Ismail, Mofeed A Abedlmabood, Usama A Mandour
DOI:10.4103/roaic.roaic_28_17  
Background Airway care providers are familiar with video-laryngoscopes (VL) that have blades like that of traditional laryngoscope (Macintosh and Miller). Moreover, most of these providers have limited experience with fiberoptic bronchoscope (FOB). C-MAC VL is one of such VLs, and its D-blade was designed for anticipated difficult airway and airway management of obese patients. Aim The aim of this study was to assess the time required for awake intubation using C-MAC VL versus flexible FOB in morbidly obese patients with anticipated difficult airway assessed by El-Ganzouri simplified risk index. Patients and methods Sixty adult patients of both sexes were divided into two equal groups (30 patients each). In group FOB, awake patients were intubated using the flexible FOB. In group VL, awake patients were intubated using the C-MAC VL. Intubating time, laryngeal view, intubating attempts, heart rate, mean arterial pressure, oxygen saturation, and sore throat were recorded. Results Intubation time was significantly longer in FOB group compared with VL group. In VL group, 26 patients were intubated successfully on the first attempt, two patients on the second attempt, and two patients on the third attempt, whereas in FOB group, 22 patients were intubated successfully on the first attempt, six patients on the second attempt, and two patients on the third attempt. In FOB group, all patients had 100% percentage of glottic opening score. In VL group, 24 patients had 100% percentage of glottic opening score, four patients had 50–100% score, and two patients had less than 50%. The intubation success rate was 100% in both groups. There were no significant differences between both the groups at baseline and at first and fifth minute after intubation in hemodynamic parameters, CO2, and O2 saturation. Conclusion This study concluded that intubation time was shorter using C-MAC VL compared with flexible FOB for awake intubation of morbidly obese patients with anticipated difficult airway. However, flexible FOB provides excellent visualization of the glottic opening.
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Acoustic puncture assist device versus ultrasound imaging technique for thoracic epidural space identification in obese patients p. 141
Yasser M.M Osman, Nader El-Gamal
DOI:10.4103/roaic.roaic_49_17  
Introduction Newer techniques have been used lately such as the ultrasonography (US) and the acoustic puncture assist device (APAD) to identify the epidural space (EDS). The difference between using these techniques in obese patients has not been studied enough yet. The primary aim of this study is to evaluate the ease of placement of thoracic epidural catheter in obese patients using either APAD versus US imaging assisted technique. The secondary aim is to compare the incidence of complications between both techniques. Patients and methods The institutional review board at the University of Alexandria approved the study protocol. One hundred obese patients (BMI >30 kg/m2) were randomly enrolled into one of the two study groups. The placement of thoracic epidural catheter was done using an US-assisted technique in cases of group I, while epidural catheter was inserted into the thoracic EDS using APAD in group II patients. Results First attempt success rate for EDS localization was higher in group II (APAD) as compared with group I (US group) (83 vs. 79%), but there was no significant statistical difference between both groups (P=0.461). Mean time for EDS localization was statistically significantly longer in group I (US-guided group) than in group II (APAD) (78.44±23.6 vs. 58.78±22.2 s; P<0.00001). Patients of group II were statistically more comfortable during the procedure (P=0.001). The mean visual analogue scale score for discomfort postprocedure was 2.5±1.18 in cases of group I versus 1.74±0.85 in patients of group II. There was no statistical difference as regards the complication in both groups. Conclusion The previous findings of the shorter time of EDS localization and more patient comfort in APAD-guided epidural analgesia than those of US-guided technique has ended in the conclusion that the use of APAD for thoracic epidural anesthesia in obese patients is a better choice than using US.
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