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   Table of Contents - Current issue
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July-September 2018
Volume 5 | Issue 3
Page Nos. 147-259

Online since Friday, August 31, 2018

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ORIGINAL ARTICLES  

Weaning of chronic obstructive pulmonary disease patients after coronary artery bypass graft surgery p. 147
Heba M Fathi, Dina M Osman
DOI:10.4103/roaic.roaic_55_17  
Background Cardiac surgery has become more common in chronic obstructive pulmonary disease (COPD) patients, but this category is still at a high risk of postoperative prolonged ventilation. Finding of the appropriate mode for faster weaning is important to improve a patient’s outcome. Objective This study aimed to evaluate the effect of adaptive support ventilation (ASV) as a weaning mode in comparison with the pressure support mode in COPD patients in the postoperative period after a coronary artery bypass grafting (CABG) surgery. Patients and methods A randomized-controlled trial was conducted on 90 COPD (stage I and II) patients between 40 and 65 years old in the postoperative cardiothoracic ICU after CABG surgeries. Patients were initially ventilated with synchronized intermittent mandatory ventilation and were then allocated randomly to two equal groups to wean either by ASV group or pressure support ventilation group. The primary outcome was the number of patients weaned successfully from the first trial. The secondary outcomes were duration of mechanical ventilation, duration of weaning, number of arterial blood gas samples before extubation, length of ICU stay, cardiac and respiratory parameters at extubation, and mortality. Result In the ASV group, significantly higher numbers of patients were weaned from first trial, there was a shorter duration of weaning and mechanical ventilation and ICU stay, with fewer times of manual ventilator adjustments and arterial blood gas samples drawing during weaning. At extubation, this group showed a significantly lower respiratory rate, higher tidal volume, and lower peak airway pressure, with less tachycardia and lower systolic blood pressure compared with the pressure support ventilation group. Conclusion The ASV mode improves the quality of weaning and shortens ICU stay in COPD patients after CABG surgery.
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Urinary liver-type fatty acid binding protein predicts renal angina in patients undergoing cardiac angiography: comparison with intrarenal arterial duplex p. 154
Azza Al Mandouh, Hossam Sherif, Mahmoud Al Badry, Amaal Rizk, Ahmed Al Sherif
DOI:10.4103/roaic.roaic_32_17  
Background Patients undergoing cardiac angiography may suffer from acute kidney injury (AKI) due to the effect of the contrast medium. Different biomarkers described the clinical condition and had led to concepts like subclinical AKI or renal angina (RA). Objective Detection of the usefulness of the biomarker urinary liver-type fatty acid binding protein (L-FABP) which increases along with renal tubular hypoxia, in early prediction of RA in patients subjected to coronary angiography (CA). Patients and methods Forty patients (54.10±9.13 years, 34 males) routinely scheduled for CA were included. The risk for AKI was evaluated, and the renal function was assessed using RIFLE (risk, injury, failure, loss, and end stage kidney) criteria. L-FABP was detected on admission and 4 h after CA. The intrarenal duplex was performed on admission and after CA, and resistivity index (RI) and pulsatility index were estimated. Results Compared to serum creatinine before CA, its values increased significantly but within the normal range 4 h after CA (0.86±0.23 vs 1.08±0.52 mg/dl, P<0.05), and compared to the estimated creatinine clearance rate before CA, its values reduced significantly but within the normal range 4 h after CA (110.33±34.19 vs 92.98±25.41 ml/min, P<0.001). Compared to L-FABP before CA, it values increased significantly 4 h after CA (5.19±1.95 vs 39.28±13.06 μg/ml, P<0.001), and compared to RI before CA, the index increased significantly 4 h after CA (0.62±0.1 vs 0.67±0.12, P<0.001). L-FABP could predict RA, with area under the curve at 0.55 (sensitivity 41%, specificity 76%) and cutoff value at 39.1 μg/ml. RI could also predict RA, with area under the curve at 0.65 (sensitivity 69%, specificity 48%) and cutoff value at 0.56. Conclusion This study highlighted the importance of L-FABP and RI in early prediction of RA 4 h after contrast media injection and earlier than either serum creatinine or its clearance rate. Although L-FABP is more specific, but RI showed more sensitivity to RA.
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Ultrasound-guided pectoral nerve blocks versus serratus intercostal plane block in breast surgeries p. 162
Assem Abdel Razek, Magda Mohamed AbouAllo, Sherif Ahmed Abd El Hamid, Mariam Deifallah Margany Osman
DOI:10.4103/roaic.roaic_19_17  
Introduction Analgesia in breast surgeries can be delivered orally, intravenously, intramuscularly, neuroaxially, or using regional nerve blocks. Pectoral nerve block (Pecs) and serratus intercostal plane block (SIPB) are a recently introduced ultrasound-guided technique for providing intraoperative and postoperative analgesia. Aim The aim of the present study was to compare intraoperative and postoperative analgesic effect of Pecs versus SIPB in breast surgeries. Patients and methods The current study was carried out on 60 female patients of American Society of Anaesthesiologists class I or II. The patients were undergoing nonreconstructive breast surgery. The patients were randomly divided into two equal groups. The Pecs group included 30 patients who received ultrasound-guided Pecs with 40 ml of levobupivacaine with adrenaline 1 : 200 000. The SIPB group included 30 patients who received ultrasound-guided SIPB with 40 ml of levobupivacaine with adrenaline 1 : 200 000. After assessing the efficacy of the block using sensory block scale, standard general anesthesia was induced in both groups using intravenous fentanyl (1 µg/kg), propofol (2.5 mg/kg) and cisatracurium (0.15 mg/kg). Results The completion of block was significant shorter in SIPB group than Pecs group. The duration of paresthesia in the SIPB group extended to 8 h postoperatively, whereas in the Pecs group the duration extended to 3 h postoperatively. Visual analog scale at rest and in movement was significantly higher in the Pecs group compared with the SIPB group. The number of patients who received postoperative fentanyl was significantly increased in the Pecs group than in the SIPB group. The first request for postoperative fentanyl was significantly delayed in the SIPB group than in the Pecs group. There was no significant difference in the total dose of fentanyl consumption during 24 h postoperatively between the two groups. Conclusion The present study found that SIPB provided superior postoperative analgesia compared with Pecs in patients undergoing nonreconstructive breast surgeries.
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Comparison between the effects of two enteral nutrition support algorithms on nutrition care outcome in critically ill adult patients p. 170
Ahmed M Mohamed, Samia A El- Wakel, Amani A Aly, Nahla M Amin
DOI:10.4103/roaic.roaic_71_16  
Background The use of enteral nutrition (EN) algorithm optimizes nutrition by increasing the intake of calories in critically ill patients, but it does not compensate for loss of feeding time due to frequent interruptions as during fasting for operation or investigation.Aims were to compare implementation of enteral feeding support algorithm based on the SCCM/A.S.P.E.N guidelines and modifications to this algorithm (using a protocol that shifted from an hourly rate target goal to a twenty four hour volume goal). Settings and Design Case control study in the surgical ICU of zagazig university hospital. Methods and Material Patients of group1 were given caloric requirements as five bolus meals, patients of group 2 were given Fresubin by continuous infusion with hourly rate target goal and in Group 3 there was a Shift from hourly rate target goal to 24 hour volume goal and metoclopramide 10 mg I.V. q. 6 hours with the start of EN. Results There were statistically significant differences between groups regarding adequacy of caloric intake in 2nd, 3rd days and the overall adequacy of calories in all four days, where Group 2 provided more EN adequacy than Group 1 (P=0.02, 0.001, 0.01) respectively, and Group 3 provided more calories adequacy than Group1in 3rd day and overall adequacy (P=0.008 and 0.007) respectively. Also Patients in Group 2and 3 started accommodating EN earlier and had less episodes of vomiting than patients in group 1, (P value=0.043 and0.003 respectively). Conclusion The use of EN protocol provides more adequacy of calories and proteins from EN in comparison to bolus meals.
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Left-ventricular global longitudinal systolic strain and strain rate can predict sepsis outcome: comparison between speckle-tracking echocardiography and tissue-Doppler imaging p. 178
Hany Hassanin, Hossam M Sherif, Rania Al Hossainy, Wael Sami
DOI:10.4103/roaic.roaic_20_17  
Background Strain imaging, by either tissue-Doppler imaging (TDI) velocity converted to strain or strain rate or by two-dimensional speckle-tracking echocardiography (STE) analysis, is used to evaluate abnormal left-ventricular (LV) mechanical activation patterns in sepsis. Objective The aim of this study was to predict sepsis outcomes using LV strain and strain-rate measurements as well as to establish a comparison between STE and TDI. Patients and methods This study included 32 patients (43.7±13.7 years, 21 males) [13 patients with sepsis (group 1) and 19 patients with severe sepsis/septic shock (group 2)] and a subset of 10 controls (36.5±8.7 years, eight males). In the first 24 h, color-TDI was performed for LV 16 segments, and Doppler flow profiles were reanalyzed using STE to retrieve LV peak global longitudinal systolic strain (GLSS) and global longitudinal systolic strain rate (GLSSR), which were averaged for the whole segment. Results Compared with the controls, ejection fraction (%EF) of both groups were comparable, but GLSS showed increased values (−17.5±2.9 vs. −20.2±1.6%, P<0.05 by STE; and −14.9±2.6 vs. −19.7±1.8%, P<0.001 by TDI) and for GLSSR values (−1.3±0.2 vs. −1.6±0.1 s−1, P<0.001 by STE, and −1.1±0.4 vs. −1.6±0.1 s−1, P<0.001 by TDI). Compared with group 1, GLSS of group 2 showed increased values (−15.4±1.5 vs. −20.2±2.4%, P<0.05 by STE; and −12.7±6.8 vs. −18.1±2.4%, P<0.05 by TDI). A good correlation was detected between Acute Physiology and Chronic Health Evaluation II score and either GLSS-STE or GLSSR-STE (r=0.88, P<0.001; and r=0.54, P<0.05) and a moderate correlation was detected between %EF and either GLSS-STE or GLSSR-STE (r=0.47, P<0.05; and r=0.45, P<0.05). The area under the curve of GLSS-STE to predict mortality was 0.9 (95% confidence interval: 0.32–0.48), with best cutoff value at −16.8% (sensitivity: 100%, specificity: 86%), and the area under the curve for GLSS-TDI was 0.76% (95% confidence interval: 0.1–0.44), with best cutoff value at −14.9 (sensitivity: 100%, specificity: 82%). Conclusion LV GLSS and GLSSR obtained using STE were more specific and showed a better correlation with both Acute Physiology and Chronic Health Evaluation II and %EF rather than TDI in predicting mortality.
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Assessment of the effect of two doses of prophylactic onandsetron on maternal hemodynamics, neonatal outcome and spinal blockade specifications, in parturients scheduled for cesarean delivery p. 187
Ahmed Zein Elabdein Mohamed, Haidy Salah Mansour
DOI:10.4103/roaic.roaic_22_16  
Objective To compare between two doses of ondansetron (2 mg, 4 mg) and ephedrine in prevention of maternal hypotension and bradycardia induced by spinal anesthesia, their effects on specifications of spinal blockade, neonatal outcome, and their side effects. Patients and methods One hundred twenty parturients ASA І or ІІ aged between 18 and 40 years, scheduled for elective cesarean section under spinal anesthesia. They were randomly divided into four equal groups. First group received intravenous I.V. 2 mg ondansetron, second group received I.V. 4 mg ondansetron, third group received 10 mg ephedrine, and the fourth group received normal saline. All the test drugs were administered as bolus dose five minutes before intrathecal injection. Mean blood pressure, heart rate, vasopressor use, spinal anesthesia specifications, neonatal outcome, and side effects were assessed. Results The fall in mean blood pressure after spinal anesthesia in ondansetron 4 mg group was the least and the greatest was in the control group. There was dropping in heart rate values after spinal anesthesia started from 5 minutes value with significance to the control group only. No significant difference between the four groups in the spinal anesthesia characters. Slight acidosis was noticed in the ephedrine group which doesn’t affect the clinical neonatal outcome. Conclusion Prophylactic bolus intravenous ondansetron 4 mg and to less extent 2 mg could decrease the fall in mean blood pressure of parturients following spinal anesthesia as well as intravenous ephedrine 10 mg with added advantage that it could decrease neonatal acidosis associated with ephedrine use.
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CASE REPORT Top

Peripheral arterial disease for aortobifemoral bypass grafting with severe postoperative complications: a case report p. 195
Ameta Nihar, Jacob Mathews, Pathak Sharmishtha, Arun Prakash
DOI:10.4103/roaic.roaic_6_17  
Peripheral arterial disease (PAD) is caused by atherosclerosis in the major extremity vessels. Incidence of PAD ranges from 3 to up to 20%. The most common symptom of the disease is intermittent claudication, mainly affecting the calf muscles. These patients usually present for surgeries extending from bypassing the blocked vascular segment to amputations. Successful outcome of these surgeries require a well-planned preoperative testing, controlled intraoperative environment and adequate postoperative management. We present an interesting case of a PAD patient who underwent a re-do surgery complicated by graft thrombosis, electrolyte disturbances and renal dysfunction, which, managed appropriately, resulted in best surgical outcomes.
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RESEARCH PAPER Top

Ketamine–propofol versus ketamine–midazolam for procedural sedation and analgesia in children with hematological malignancies: a randomized, open-labeled, cross-over trial p. 198
Oyebola O Adekola, Edamisan O Temiye, Gabriel K Asiyanbi, Nurudeen O Akanmu, Ibironke Desalu
DOI:10.4103/roaic.roaic_54_17  
Background The use of procedural sedation and analgesia for painful procedures in children with hematological malignancies has become a standard practice in recent time. We compared the occurrence of hypoxia, apnea, and pain between ketamine–propofol and ketamine–midazolam combination. Patients and methods This randomized, open-labeled cross-over study was conducted in 60 children aged 1–15 years scheduled for bone marrow aspiration and, or intrathecal chemotherapy. They were divided into two groups of 30 to receive either ketamine–propofol or ketamine–midazolam. Sedation was performed by trained anesthetists according to the study protocol. Data were analyzed with independent t-test, χ2-test and Fisher’s exact test. P value 0.05 or less was considered significant. Results A total of 120 procedures were performed. One (1.7%) patient in each group had hypoxia, (P=0.8). The oxygen saturation decreased to 83 and 88% in ketamine–propofol and ketamine–midazolam groups, respectively. This was accompanied by bradycardia with a heart rate of 56 and 58 beats/min, respectively. Both events responded to oxygen therapy. There was no episode of apnea, and all maintained spontaneous respiration. The number of patients with a pain score of at least 5 during the procedure was comparable; ketamine–propofol group [6 (10%)] versus ketamine–midazolam group [4 (6.7%)] (P=0.4). Hallucinations were more common in the ketamine–propofol group [4(6.7%)] than the ketamine–midazolam group [0 (0%)] (P=0.05). Conclusion The occurrence of hypoxia, apnea, and pain was comparable following the administration of ketamine–propofol and ketamine–midazolam combination.
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ORIGINAL ARTICLES Top

Adding dexmedetomidine to bupivacaine–fentanyl mixture in high-risk elderly patients undergoing orthopedic surgery: a randomized, double-blind, controlled study p. 205
Sohair A Megalla
DOI:10.4103/roaic.roaic_39_17  
Objectives The increased demand for spinal anesthesia in high risk elderly patients with comorbidity dictates the continual search for drug combinations to improve perioperative analgesia while limiting side effects. This study was designed to compare block characteristics, postoperative analgesia and hemodynamic effects associated with intrathecal dexmedetomidine when added to bupivacaine–fentanyl mixture in high risk elderly patients undergoing orthopedic surgery. Methods This prospective, double blind, randomized controlled study included fifty patients ≥60 years old, of either sex, ASA III and IV undergoing elective orthopedic hip surgery in one lower limb under unilateral spinal anesthesia. The patients were randomized in two groups to receive; Group F: 12.5 mg of 0.5% hyperbaric bupivacaine + 20 μg fentanyl. Group FD: 12.5 mg of 0.5% hyperbaric bupivacaine + 20 μg of fentanyl + 6 μg dexmedetomidine. Block characteristics, hemodynamic changes, postoperative analgesia and adverse effects were studied. Results The addition of dexmedetomidine (DEX) had no significant impact on the onset or highest level of sensory or motor blockade. DEX, however, significantly increased the duration of sensory and motor block and postoperative analgesia. Average times to first request for analgesia were longer in FD group (522.79±59.0 min) compared to (207.37±20.19 min) in F group (P=0.000). Blood pressure and heart rate changes were not significantly different among both groups. Pruritis was observed in 12% in F Group, whereas sedation was significantly more frequent in Group FD. Conclusion Addition of 6 μg dexmedetomidine to 12.5 mg bupivacaine + 20 µg fentanyl intrathecally greatly enhanced the duration of postoperative analgesia and was not associated with hemodynamic instability or other complications in high risk elderly patients undergoing orthopedic surgery under unilateral spinal anesthesia.
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Caudal, ultrasound-guided inguinal field block, ultrasound-guided transversus abdominis plane block as an adjuvant to general anesthesia in unilateral inguinal hernia repair in pediatrics: a comparative study p. 213
Elham M El-Feky, Ahmed A Abd El Aziz
DOI:10.4103/roaic.roaic_57_17  
Background Caudal analgesia is the most common method used in the subumbilical region in pediatrics. The inguinal field block and the ultrasound-guided transversus abdominis plane block are other modalities to control postoperative pain in inguinal hernial repair in pediatrics. The aim of this study is to compare the combination of general anesthesia and these techniques on postoperative pain score, first time to rescue analgesia, intraoperative hemodynamics, and postoperative sedation. Methods In all, 120 pediatric patients (3–10 years old) scheduled for inguinal hernia repair under general anesthesia were allocated into three groups: Group I [caudal block (CB)]: in this group, the patients received 0.5 ml/kg of bupivacaine 0.25% caudally. Group II [inguinal field block (IFB)]: received 0.5 ml/kg of bupivacaine 0.25% under ultrasound guidance. Group III [transversus abdominis plane block (TAP)]: received 0.5 ml/kg of bupivacaine 0.25% under ultrasound guidance. The measurement: intraoperative (heart rate and mean arterial blood pressure), modified objective pain score, first time to rescue analgesia, Ramsay sedation score, and postoperative adverse effects. Results The time to first rescue analgesia and the modified objective pain was less with more sedation in IFB and TAP groups compared with the CB group from after 6 till 18 h. Also, the IFB is superior to TAP in pain control at 24 h and in prolongation of the time of analgesia. Conclusion The three techniques are safe and provide good intraoperative hemodynamic stability. Both IFB and TAP provide less pain score and prolonged postoperative analgesia and also more sedation than CB after 6 till 18 h.
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Potential analgesia of lumbar intrathecal fentanyl in breast cancer surgery p. 220
Alaa El-Din Mazy Abdou Mazy, Hossam I El-Said Saber
DOI:10.4103/roaic.roaic_66_17  
Background Various regional anesthetic techniques are used during mastectomy for reduction of pain and side effects. The intrathecal (IT) route for drug administration is interesting despite the poorly understood and complex nature of cerebrospinal fluid kinetics and IT drug pharmacokinetics. Lumbar IT opioids are used for analgesia during thoracic and cardiac surgeries, but not for breast surgeries. IT fentanyl (F) is evaluated in this study for mastectomy analgesia. Patients and methods Forty-four patients were divided into two equal groups: one group was given general anesthesia only and the other group given lumbar IT 20 mg bupivacaine plus F 25 microgram (mcg) in lateral position followed by general anesthesia. Results In the IT group, analgesia manifested as delayed request for postoperative analgesia 5 h postinjection; 50% reduction in intraoperative and 24 h postoperative analgesic requirements; low visual analog pain scale, and high range of arm movement in the first 3 h postoperatively. But there was associated intraoperative hypotension and postoperative pruritus. Conclusion Lumbar IT F potentiates analgesia in mastectomy surgery.
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Intravenous ondansetron versus lidocaine as pretreatment drugs to prevent pain on propofol injection p. 226
Ashraf A AbouSlemah
DOI:10.4103/roaic.roaic_105_17  
Background Propofol is one of the most popular intravenous anesthetics used for induction and maintenance of anesthesia and sedation in and outside of the operating room. Its role is valuable especially for day-case surgeries, and with laryngeal mask airways. Pain on propofol injection still remains a common anesthetic problem. This study aimed at comparing the effectiveness of pretreatment with ondansetron, a common antiemetic agent, with lidocaine, the commonest drug/method for prevention of this pain. Materials and methods This study included 100 women, American Society of Anaesthesiologists physical status classification I–II, scheduled for gynecological surgery under general anesthesia and randomly categorized into two equal groups. Group I (group O) received 4-mg (2 ml) ondansetron, whereas group II (group L) received 40-mg (2 ml) lidocaine 2%, accompanied by manual venous occlusion for 1 min, and then 25% of the total induction dose of propofol (2.5 mg/kg) was initially injected through the same cannula, and patients were asked for pain rating using a four-point verbal rating scale. Results The incidence of pain was higher in group L than group O, with 17 (34%) patients versus 13 (26%) patients, respectively; however, both groups were still comparable (P>0.05). Three (6%) patients in group O versus four (8%) patients in group L complained of severe pain (P>0.05). Three (6%) patients in each group had moderate pain (P>0.05). Seven (14%) patients in group O versus 10 (20%) patients in group L experienced mild pain (P>0.05). Conclusion Both ondansetron and lidocaine were similarly effective pretreatment drugs for prevention of propofol-induced pain.
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Optimizing heavy marcaine dose for spinal anesthesia in short stature pregnant female individuals undergoing cesarean section p. 231
Wael Elgharabawy, Ramy Mahrose
DOI:10.4103/roaic.roaic_98_17  
Background and objectives Hypotension after spinal anesthesia is still widespread in cesarean delivery, especially in pregnant women with short stature. The use of a reduced dose of local anesthesia allows adequate spinal anesthesia with minimal hypotension. We investigate the lowest dose of heavy bupivacaine that can be used to reduce the frequency of hypotension associated with adequate spinal anesthesia in short stature pregnant female individuals undergoing cesarean section. Patients and methods Sixty women scheduled for cesarean section were divided into three groups of patients (20 in each group) receiving spinal injections of 0.04 mg heavy bupivacaine/cm height (group A), 0.05 mg heavy bupivacaine/cm height (group B), and 0.06 mg heavy bupivacaine/cm height (group C). A decrease in systolic pressure greater than 20% of the baseline was considered low blood pressure and was treated with a bolus of 5–10 mg intravenous ephedrine. The quality of surgical anesthesia was assessed among groups. Results Groups B and C were assigned a higher sensory level block than group A after spinal anesthesia, and the difference was statistically significant (P<0.05). In group C, 18 (90%) patients developed a complete motor block, while in group B, 16 (80%) patients developed a complete motor block, compared with patients of group A in which only four (20%) patients developed complete motor block, and the difference between groups was statistically significant (P<0.05). The spinal block resulted in excellent surgical anesthesia in groups B and C compared with group A. Patients in group C were more likely to develop hypotension than patients in groups B and A. There was no significant statistical difference between the groups as regards neonatal outcome. Conclusions This study showed that the use of spinal anesthesia in pregnant women of short stature using heavy bupivacaine at a concentration of 0.05 mg/cm body weight showed a clear benefit in terms of adequate anesthesia and stable hemodynamics.
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The role of brain natriuretic peptide in correlation to mitral annular plane systolic excursion in predicting sepsis-induced myocardial dysfunction p. 240
Selim Hashem, Walid Farouk, Aymen Gaber, Mohamed A Shehata
DOI:10.4103/roaic.roaic_97_17  
Introduction Sepsis is one of the leading causes of mortality and morbidity around the world. Myocardial dysfunction is one of the important factors in the hemodynamic compromise seen in sepsis. B-type natriuretic peptide (BNP) and mitral annular plane systolic excursion (MAPSE) are proposed to be useful markers in predicting sepsis-induced myocardial dysfunction (SIMD). Objective To signify the role of BNP, MAPSE, and their correlation in the prediction of SIMD. Patients and methods Forty patients diagnosed with sepsis or septic shock, in addition to 10 healthy volunteers were included in the study in the period from March 2016 to March 2017 in the Critical Care Department of Cairo University and Alexandria University. All patients were subjected to BNP measurement and echocardiography measuring MAPSE on admission and after 48 h with correlation of these measurements to sepsis-induced cardiomyopathy. Results The studied patients were divided into two groups. Group I: patients who did not develop myocardial dysfunction (n=16) and group II patients who developed myocardial dysfunction (n=24).There was statistically significant difference between both groups as regards BNP level and MAPSE both on admission and after 48 h with a P value of less than 0.001, with patients who developed sepsis-induced cardiomyopathy exhibiting higher levels of BNP and lower MAPSE. In addition, the current study demonstrated a strong negative correlation between MAPSE and BNP level on admission (P=0.004 and r=−0.572) and after 48 h (P=0.0030 and r=−0.444) in patients who developed myocardial dysfunction due to sepsis (group II). Conclusion Both BNP level and MAPSE could significantly predict sepsis-induced cardiomyopathy with a strong negative correlation found between BNP level and MAPSE both on admission and after 48 h in the prediction of SIMD.
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Comparison of the ultrasonography-guided technique and conventional anatomical landmark technique for localization of epidural space during epidural block p. 246
Dinesh K Sahu, Jitendra H Ramteke, Atul Sharma, Reena Parampill, Chandrakant Patel
DOI:10.4103/roaic.roaic_111_17  
Background and aims Anatomical landmarks-based level confirmation and loss of resistance-based space confirmation is a standard method for epidural block but is a blind procedure. Recently, the use of ultrasonography (USG) guidance during central neuraxial blocks to preview the anatomy before needle puncture has started. We carried out a study to find whether USG-guided technique is superior than landmark guided for epidural space localization. Patients and methods This randomized prospective, open-label study included 76 patients aged 40 to 65 years, American Society of Anesthesiologist physical status I–III undergoing infraumbilical surgeries, divided in two groups. In group 1, anatomical landmark-guided technique and in group 2, preprocedural USG scan was used for puncture site determination. We evaluated the time taken to insert an epidural needle; number of attempts, number of times the cortexes of bone touched by needle, ultrasound visibility score, distance between skin to ligamentum flavum, correlation between actual needle depth and ultrasound-measured depth. Results Mean time taken for insertion of epidural needle in group 1 was 72.21±45 s and in group 2 was 54.82±40.87 s (P=0.027). Epidural space was located in the first attempt in 71.15% individuals of group 1 and 92.1% individuals of group 2. The Pearson’s correlation coefficient between the USG-measured distance between skin to ligamentum flavum and the actual depth of needle mark was significant. Conclusion The USG-guided epidural space localization reduces time to insert epidural needle and number of attempts for localization of epidural space. There is a strong correlation between the USG-measured depth and the actual needle depth.
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Easy pediatric nasal intubation p. 252
Ramy Mahrose
DOI:10.4103/roaic.roaic_82_17  
Background Pediatric anesthesiologists during nasal intubation use Magill forceps frequently, but it is often difficult to push the tube into the trachea. Differences in the airway structure of children compared with adults may be the cause of the problem. Modified pediatric Magill forceps (modified by Farouk and his colleagues) added anteroposterior firm grasping of the nasotracheal tube which enables us for elevation and downward rotation of the nasotracheal tube, which makes the tube in line with the axis of the trachea facilitating its passage into the trachea. Objectives The aim of this study was evaluation of the value of modified pediatric Magill forceps in facilitating nasal intubation. Patients and methods The study included 100 American Society of Anesthesiologists physical status I–II patients (age range: 2–6 years) who were scheduled for tonsillectomy operation. The patients were divided randomly into two equal groups. Group A in which modified pediatric Magill forceps was used to assist nasotracheal intubation, while group B in which Magill forceps was used to assist nasotracheal intubation. For each patient, the following data were collected: age, body weight, intubation time, number of intubation attempts, hypoxia, pharyngeal trauma, and need for tube corkscrewing. Results The results showed that there was a statistically significant decrease in intubation time in group A when compared with the corresponding values in group B. Also, group A showed a statistically significant decrease in the number of intubation attempts in comparison to group B denoting easier nasal intubation attempts in group A. Patients in group A showed a decrease in the number of patients who developed hypoxia during intubation attempts in comparison to group B. There were no statistically significant differences between both groups regarding pharyngeal trauma. Group A showed a decrease of numbers of the need to do corkscrewing in comparison to group B, and the difference between the two groups was significant statistically. Conclusion The results of this study demonstrated that performing nasal intubation using the modified pediatric Magill forceps showed greater ease of nasotracheal intubation than the usage of conventional Magill forceps.
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LETTER TO THE EDITOR Top

Perioperative care and hypothyroidism p. 259
Khichar P Shubhakaran, Rekha J Khichar
DOI:10.4103/roaic.roaic_80_16  
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