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ORIGINAL ARTICLES
Pre-emptive analgesia of ultrasound-guided pectoral nerve block II with dexmedetomidine–bupivacaine for controlling chronic pain after modified radical mastectomy
Ali M Ali Hassn, Hala E Zanfaly, Taha A Biomy
January-March 2016, 3(1):6-13
DOI:10.4103/2356-9115.184078  
Background The term chronic pain refers to pain in and around the area of surgery lasting beyond 3 months after surgery when all other causes of pain, such as recurrence, have been ruled out. Persistent pain after treatment has a considerable negative influence on quality of life in breast cancer survivors. Patients and methods Sixty female patients were enrolled for ultrasound-guided modified pectoral block. They were randomly assigned into two groups of 30 patients each: group C was administered 30 ml saline, and group BD was administered 30 ml 0.5% bupivacaine with dexmedetomidine 1 μg/kg. Pectoral block II was performed with ultrasound preoperatively and general anesthesia was induced after 15 min of assessment of the block in both groups. Patients were assessed for acute pain, chronic pain, and patient satisfaction. Results A total of 60 female patients were randomized into two groups: group C (the control group) and group BD (the bupivacaine–dexmedetomidine group). Group BD showed highly significant reduction in intubation heart rate, intubation mean arterial blood pressure, intraoperative heart rate, intraoperative mean arterial blood pressure, and total fentanyl dose (μg) (76.1 ± 5.3 vs. 82.9 ± 4.6, P = 0.00007**; 75.2 ± 2.8 vs.77.5 ± 3.9, P = 0.01*; 76.2 ± 5.3 vs. 88.9 ± 6.3, P = 0.00**; 71.6 ± 8.06 vs.78.2 ± 7.03, P = 0.001**; and 107.76 ± 11.77 vs. 150.83 ± 26.6, P = 0.00**, respectively). Follow-up of patients for 6 months regularly for chronic pain, satisfaction, and need for analgesics revealed significant differences at 1 month, 3 months, and 6 months in group C in relation to group BD [1 month, 7 (23.3%) vs. 3 (10%) with P = 0.02*; 3 months, 11 (36.6%) vs. 6 (20%) with P = 0.03*; and 6 months, 16 (53.3%) vs. 8 (26.6%) with P = 0.002*]. Conclusion Reduced visual analogue scale was seen at the first 24 h postoperatively, with significant reduction in total postoperative analgesia and delayed rescue analgesia in the bupivacaine dexmedetomidine group (the BD group) in relation to the control group. This marked reduction in the severity of postoperative pain correlates with reduced chronic pain on follow-up of our patients with patient satisfaction, good sleep, and reduced analgesic need, which improves quality of life.
  5 2,437 377
Post-thoracotomy pain relief in pediatric patients epidural versus inter-pleural analgesia
Muhammad A Abd El-Aziz, Abeer M Elnakera, Amal A Salah
October-December 2015, 2(4):132-139
DOI:10.4103/2356-9115.178900  
Background For controlling post-thoracotomy pain, thoracic epidural (TE) analgesia is considered a gold standard technique. However, it may be associated with serious complications. Interpleural (IP) analgesia is thought to be a simpler technique. Therefore, the current study aimed to compare the efficacy of simple IP with TE bupivacaine in controlling post-thoracotomy pain in pediatrics. Patients and methods A total of 80 pediatric patients undergoing elective thoracotomy were randomly assigned to either the TE or the IP group. In the TE group, epidural catheter was threaded through the caudal space and the tip was placed at the fourth intercostal space. In the IP group, the surgeon inserted the IP catheter through the IP space under direct vision and directed its tip towards the fourth intercostal space on the paravertebral line. Bupivacaine 1.5 mg/kg in 25% concentration was administered through either TE or IP catheters as intermittent boluses every 6 h, starting from the beginning of skin closure, for 24 h postoperatively. Fentanyl 1 mg/kg intravenous bolus was administered as rescue analgesia to keep the pain score less than 0.4. Hemodynamic parameters and pain scores were recorded at 1, 6, 12, 18, and 24 h. In addition, interleukin-6 was measured at 1, 6, and 24 h beginning from the first injected local anesthetic dose. Total postoperative 24 h fentanyl requirements and time to first postoperative rescue analgesia were recorded. Results CRIES pain score showed no significant difference between the studied groups. Time to first rescue analgesia was significantly shorter in the IP group (2.75 ± 0.93) compared with the TE group (4.17 ± 1.07). Patients of the IP group required higher doses of intravenous fentanyl than did those in the TE group (12.83 ± 3.83 vs. 8.16 ± 3.4μg) (P<0.05). Conclusion For post-thoracotomy pain in pediatrics, equipotent analgesia can be achieved through TE blockade and the simpler IP technique, but with higher postoperative intravenous fentanyl supplementation to the latter technique.
  3 1,304 149
Urine albumin/creatinine ratio as an early predictor of outcome in critically ill patients with sepsis
Mohammed A.M Saeed, Reem E Mahdy, Sara A Mohammed
October-December 2018, 5(4):267-278
DOI:10.4103/roaic.roaic_14_18  
Background Many scoring systems have been developed for the prognosis and outcome prediction in sepsis, so trying to find a prognostic marker confirming the scoring systems results and predicting outcome is very important to improve patient’s outcome. Objective This study aimed to evaluate the urinary albumin/creatinine ratio (ACR) as a prognostic marker in sepsis. Patients and methods Forty adult patients with sepsis were included in a prospective observational study. Patients with pre-existing chronic kidney disease or Diabetes mellitus were excluded. Clinical evaluation was done first and then urine spot samples were collected on admission and 24 hrs later for ACR1 and ACR2 estimation. Acute physiology and chronic Health Evaluation (APACHE) IV score done on admission and sepsis related organ failure Assessment score, with the highest recorded score of their daily estimation, were considered. The need for mechanical ventilation, inotropic and for vasoactive support, renal replacement therapy and in hospital mortality were also evaluated in our study. Results The mean age of the patients was 63 (55–71) years and 29 (72.5%) were male. We found that the ACR2 is correlated with the sepsis related organ Failure assessment [14 (4.8–16.8) vs 5 (3–8), P=0.01] of the ACR measures, none of them were correlated with APACHE IV Score. In patients who needed mechanical ventilation and inotropic and/or vasoactive support, ACR2 was higher [140 (125–207) and 151 (127–218) mg/gm, respectively] compared with those who did not need [65 (47–174) and 74 (54–162/mg/g], P=0.01 and 0.009. All of the measured parameters were not related to the need of renal replacement therapy. Predictors of mortality were ACR1, ACR2, APACHE IV and increasing ACR. Area under the curve for mortality prediction was largest for APACHE IV (0.90) and the ACR2 (0.88). ACR2 of 110.5 mg/g was 100%. Sensitive and 86% specific to predict mortality. Conclusion Urinary ACR can be used as a simple test for prognosis and mortality prediction in sepsis cases.
  2 1,240 88
Intubating laryngeal mask airway and air-Q for blind tracheal intubation
Moustafa Abo Shamaa, Doaa Abo Alia, Mohamed El-Sayed
October-December 2015, 2(4):101-110
DOI:10.4103/2356-9115.178901  
Background Airway management remains an important problem in the practice of anesthesia. The present study was carried out to compare intubating laryngeal mask airway (ILMA) and air-Q for blind tracheal intubation during surgical procedures under general anesthesia. Materials and methods This study was carried out on 70 adult patients scheduled for elective surgical procedures under general anesthesia with controlled ventilation such as gynecological, orthopedic, ophthalmic, or general surgery lasting up to 2 h. Data were collected on airway assessment, hemodynamic changes, insertion time of the device and the endotracheal tube, number of attempts of blind tracheal intubation, ease of insertion, and complications. Results Airway assessment parameters were similar in patients of both groups. The incidence of hemodynamic changes was significantly higher in the air-Q group than the fastrack group and the insertion time of the endotracheal tube as well as the percentage of ease of insertion in group I (fastrack) showed a statistically significantly higher value than group II (air-Q). However, there was no statistically significant difference between the two groups in the number of insertion attempts (a success rate of 88.57% for the fastrack vs. a success rate of 82.86% for the air-Q) and the complications. Conclusion Both the fastrack and the air-Q are suitable devices for blind tracheal intubation. The fastrack has a higher success rate in terms of blind tracheal intubation than the air-Q.
  2 1,892 238
CASE REPORT
Endobronchial blocker for one-lung ventilation through a fresh tracheostomy
Falguni R Shah, Vaibhavi V Baxi
October-December 2015, 2(4):140-142
DOI:10.4103/2356-9115.178910  
Different methods have been described for lung isolation in patients for thoracic surgery with tracheotomies. It is important to consider whether it is a fresh stoma or a chronic tracheostomy. We would like to describe the use of endobronchial blocker directed fibreoptically in a fresh tracheostomy as a simple and safe technique for one-lung ventilation without causing any trauma to the fresh stoma site.
  1 1,826 142
ORIGINAL ARTICLES
Comparison between effects of two anesthetic techniques on acute stress proteins and d-dimer in patients undergoing lower limb orthopedic surgery
Emad A Areda, Wafaa M Shafshak, Ola M Zanaty, Abeer S Hadidi, Atef G Omar
January-March 2016, 3(1):14-19
DOI:10.4103/2356-9115.184079  
Background Anesthetic techniques may modulate the extent of endocrine–metabolic response to surgery. Attenuation of the endocrine–metabolic response may reduce the frequency of postoperative complications. The aim of this study was to compare the effect of two different anesthetic techniques (combined general anesthesia with epidural blockade vs. combined spinal–epidural blockade) on acute stress proteins including serum albumin, C-reactive protein, leptin, cortisol, and d-dimer in patients undergoing lower limb orthopedic surgery. Materials and methods After approval of the ethics committee of Alexandria Faculty of Medicine and having an informed consent from every patient, the present study was carried out on 40 patients ASA I or II physical status. Group I; 20 patients received combined general anesthesia with epidural blockade and group II; 20 patients received combined spinal–epidural blockade. Epidural analgesia was activated just before wound closure. Results The blood loss was statistically significantly low in group II. The mean values of serum albumin were significantly lower in the group II at 3 and 24 h postoperatively. There were no significant differences between preoperative and 24 h postoperative serum cortisol. Serum cortisol levels were significantly lower in the group II at 3 h postoperatively. There were no significant differences in serum leptin concentrations and preoperative plasma d-dimer. Plasma d-dimer concentrations were significantly higher in the group I at 3 h postoperatively and at 24 h postoperatively. Conclusion Subarachnoid block decreases postoperative pain score and reduces blood loss in comparison with general anesthesia. It reduces the acute stress response and acute stress proteins (albumin, cortisol). It did not reduce C-reactive protein. It reduces plasma d-dimer level after lower-limb orthopedic surgery in comparison with general anesthesia.
  1 1,154 125
Study on the effect of dexmedetomidine in reducing hemodynamic responses to general anesthesia for elective cesarean section in patients with pre-eclampsia
Rabab S Mahrous
January-March 2016, 3(1):25-29
DOI:10.4103/2356-9115.184081  
Background Because of the effect of dexmedetomidine (DEX) in hemodynamic stability, it was started as a sedative before and during surgical and other procedures in nonintubated adult and pediatric patients. Since 2009 DEX has been successfully used in laboring parturients. It provides maternal hemodynamic stability, anxiolysis, and stimulation of uterine contractions. Studies have shown that DEX has high placental retention and does not cross the placenta, and there is lower incidence of fetal bradycardia. We hypothesized that dexmedetomidine would be effective in reducing the maternal hemodynamic responses to elective cesarean section in pre-eclamptic patients without adverse neonatal effects. Patients and methods The present study included 40 parturients with pre-eclampsia who were planned for elective cesarean delivery for different indications under general anesthesia. The patients were divided in two groups and they were selected randomly to receive either fentanyl (control group) or 0.4 μg/kg/h intravenous DEX 10 min before induction (n = 20 per group). Changes in maternal heart rate, mean blood pressure, time from induction to delivery, the full anesthesia time, uterine contraction after placental delivery, umbilical blood gas parameters, and sedation scores were recorded. Results The heart rate in the DEX group was lower than that in the fentanyl group. Patients in the dexmedetomidine group had statistically significantly lower change in mean arterial blood pressure, whereas patients taking fentanyl showed much higher mean arterial blood pressure from induction until 5 min after extubation. Further, the dexmedetomidine group showed greater uterine contraction, but there was no difference between the two groups in terms of Apgar score at 1 and 5 min, NACS below 35, and umbilical blood gas analysis. Conclusion It can be concluded that DEX is effective in pre-eclamptic patients undergoing elective cesarean as it stabilizes the maternal hemodynamic parameters with negligible effect on the fetus.
  1 1,173 136
Evaluation of the analgesic effect of caudal dexamethasone combined with bupivacaine in hypospadias repair surgery
Ahmed Z Mohamed
January-March 2016, 3(1):42-47
DOI:10.4103/2356-9115.184077  
Background Caudal analgesia is the most popular regional technique in infants and children for the infraumbilical surgeries. Its main disadvantage though is its short duration. The aim of this prospective, randomized, double-blind study was to examine the effect of dexamethasone (when added to the caudal bupivacaine) on the duration of postoperative analgesia and the intensity of postoperative pain during hypospadias repair surgeries. Patients and methods A total of 70 patients aged 2–5 years with American Society of Anesthesiologists (ASA) physical status classification I or II were randomly divided into two equal groups in a double-blinded manner. The first group (group B) (n = 35) received caudal analgesia with 0.25% bupivacaine 1 ml/kg, whereas the second group (group D) (n = 35) received caudal analgesia with bupivacaine 0.25% 1 ml/kg plus 0.1 mg/kg dexamethasone. After inhalational induction with sevoflurane and tracheal intubation, patients were turned to lateral position and were given the caudal analgesia. After the end of surgery, postoperative pain score was measured by using Children's and Infants' Postoperative Pain Score (CHIPPS). The primary outcome of this study was the duration of the postoperative caudal analgesia. Severity of postoperative pain, number of rescue analgesic doses, residual motor block, and side effects like nausea and vomiting (secondary outcomes) were monitored. Results The second group (group D) showed significantly longer duration of postoperative analgesia when compared with the first (group B) group. CHIPPS was less in group D compared with group B at 3, 6, 12, and 24 h. Number of rescue analgesic doses of was less in group B than in group D. Modified Bromage scale score were comparable in both groups. Conclusion Adding dexamethasone 0.1 mg/kg to the caudal bupivacaine significantly prolonged the duration of postoperative caudal analgesia and decreased the intensity of postoperative pain during hypospadias repair surgery.
  1 1,368 173
Comparison of dexmedetomidine, lidocaine, and their combination in attenuation of cardiovascular and catecholamine responses to tracheal extubation and anesthesia emergence in hypertensive patients
Ashraf MA Moustafa, Hatem Atalla, Hala M Koptan
April-June 2015, 2(2):1-6
DOI:10.4103/2356-9115.161307  
Introduction This study was carried out to compare the effi cacy of the dexmedetomidine– lidocaine combination with each drug alone in suppressing the hemodynamic and catecholamine stress responses during tracheal extubation and emergence from general anesthesia. Patients and methods Sixty hypertensive patients (ASA II– III), defi ned as systolic blood pressure more than 160 mmHg and/or diastolic blood pressure more than 95 mmHg, undergoing elective surgery were assigned to a randomized, double-blind approach and were divided into three equal groups: group D received 0.25 mg/kg dexmedetomidine intravenously, group L received 1.0 mg/kg lidocaine intravenously, and group DL received dexmedetomidine plus lidocaine at the same doses intravenously 2 min before tracheal extubation. Changes in heart rate, mean arterial pressure, rate– pressure product, and plasma catecholamine levels were measured before and after tracheal extubation. Results It was found that heart rate, mean arterial pressure, and rate– pressure product following tracheal extubation were lower in patients receiving the dexmedetomidine– lidocaine combination than in those receiving dexmedetomidine or lidocaine as a sole drug. In addition, catecholamine concentrations increased significantly after extubation (P < 0.05) in the three groups, with no signifi cant difference between them. Also, the tracheal extubation score was lower in groups L and DL compared with group D. Conclusion Although dexmedetomidine, lidocaine, or their combination failed to suppress the catecholamine responses to tracheal extubation and emergence from anesthesia, the dexmedetomidine– lidocaine combination was superior to each drug alone in attenuating the cardiovascular changes in hypertensive patients.
  1 1,881 294
Effects of dexmedetomidine versus morphine on surgical stress response and analgesia in postoperative open cardiac surgery
Said M Al-Medani, Fawzi A Neemat-Allah, Mohamed M El-Sawy, Ragab S Beltagi, Mohamed H Osman
April-June 2015, 2(2):16-23
DOI:10.4103/2356-9115.161316  
Background The aim of this study was to compare between dexmedetomidine and morphine for use as sedative/analgesics and to evaluate their effects on surgical stress response during the first 24 h following open cardiac surgery in the Cardiac Intensive Care Unit (CICU). Patients and methods The present double-blind study was carried out on 30 adult patients 60 years of age or older admitted to the Cardiothoracic Surgery Department of the Alexandria Main University Hospital of ASA physical status grade II and III, scheduled for elective coronary artery bypass grafting surgery under general anesthesia. Immediately after sternal closure at the end of surgery, patients were classified randomly using the closed-envelope technique into two equal groups, started immediately on a continuous intravenous infusion (without a loading dose) of either dexmedetomidine or morphine and continued for 24 h postoperatively. Dexmedetomidine group (group D): dexmedetomidine was prepared at a concentration of 0.1 μg/kg/ml and was infused at a dose of 0.1-0.7 μg/kg/h (equivalent to an infusion rate of 1-7 ml/h). Morphine group (group M): morphine was prepared at a concentration of 10 μg/kg/ml and was infused at a dose of 10-70 μg/kg/h (equivalent to an infusion rate of 1-7 ml/h). Patients were followed up in the CICU for the first 24 h following open cardiac surgery on the basis of hemodynamic changes, plasma interleukin (IL)-6 and cortisol levels, time to successful tracheal extubation, postoperative pain, incidence of delirium, and postoperative nausea and vomiting. Results The mean heart rate values were significantly lower in group D compared with group M during most of the postoperative period. The mean values of systolic blood pressure, diastolic blood pressure, and mean arterial pressure, on comparing the two groups, had showed no statistically significant difference during the entire postoperative period. The mean values of IL-6, cortisol, and glucose were increased significantly in group M relative to group D at 6 and 24 h postoperatively. Time to successful tracheal extubation was significantly shorter in patients of group D than in patients of group M. Visual analogue scale for pain score and Motor Activity Assessment Scale for sedation score showed no significant difference when both groups were compared during the entire postoperative period. The total number of patients with delirium was significantly fewer in group D than group M. The incidences of nausea and vomiting events were insignificantly lower in group D than group M. Conclusion The administration of dexmedetomidine exerted a potent negative chronotropic effect with decreased heart rate. Both dexmedetomidine and morphine equivalently decreased the blood pressure (systolic blood pressure, diastolic blood pressure, and mean arterial pressure) in a range of 15-20% in relation to the preoperative readings. Dexmedetomidine significantly attenuated the surgical stress response and the neuroendocrine response in comparison with morphine through the suppression of the postoperative increase of IL-6 and cortisol, respectively. Dexmedetomidine had promoted earlier recovery and tracheal extubation than morphine, with no accompanying respiratory depression. Both dexmedetomidine and morphine were efficient sedative/analgesics for postoperative cardiac surgery. Dexmedetomidine significantly reduced the incidence and duration of delirium after cardiac surgery.
  1 1,748 212
The relation between interleukin-6 and different categories of acute coronary syndrome
Tarek Hussein Elbadawy, Atef Abdel Aziz Mahrous, Haitham Hosney El Samnody
April-June 2015, 2(2):7-15
DOI:10.4103/2356-9115.161311  
Background Inflammation is now recognized to play a key role in the pathogenesis of atherosclerotic cardiovascular disease. Two circulating markers of inflammation, C-reactive protein (CRP) and interleukin (IL)-6, have emerged as predictors of future cardiovascular pathology and mortality in epidemiologic studies of (middle aged women) midlife healthy men and women, postmenopausal women, and older adults. The aim of the present study was to study the changes in IL-6 in acute coronary syndrome (ACS) and to clarify whether IL-6 release is a factor initiating the inflammatory process in ACS or whether it is predominantly a response to this clinical condition, and to assess its correlation with CRP, cardiac biomarkers troponin I, and CK-MB for risk prediction in ACS. Patients and methods The study included 60 patients admitted by ACS who were categorized randomly into three groups: group I included 20 patients admitted for unstable angina, group II included 20 patients admitted for ST-segment elevation myocardial infarction with successful thrombolytic therapy, and group III included 20 patients admitted for ST-segment elevation myocardial infarction with failed thrombolytic therapy. The study also included 12 healthy control patients matched for age and sex (group IV). Blood levels of IL-6, CRP, and cardiac troponin I were measured; all samples of groups II and III were obtained after thrombolytic therapy whereas samples of group I were obtained on admission. Results IL-6 was significantly higher in group II, with a mean of 87.10, and ranged from 3.0 to 550.0; on exclusion of two patients who had an IL-6 level of 220 and 550 we obtained a mean of 54. In group III, the mean level was 52.36, ranging from 5.0 to 120.0, compared with control group IV, in which it ranged from 3.0 to 5.0, mean 3.67 (P < 0.001*). There was a positive correlation between IL-6 and CRP levels in group I (r = 0.385, P = 0.094) and group II (r = 0.166, P = 0.483), but this was statistically nonsignificant, and in group III, there was a statistically significant correlation (r = 0.638, P = 0.0002). IL-6 serum levels did not correlate with cardiac troponin levels in any of the patient groups I (r = 0.049, P = 0.836), in group II (r = 0.151, P = 0.524), and in group III (r = 0.079, P = 0.741). IL-6 did not correlate with any of the risk factors such as history of IHD, HTN, DM, and smoking. There was no statistically significant correlation between IL-6 and complications, except for the development of shock. The CRP level was significantly increased in ACS in comparison with the control group. CRP showed a significant increase in group III, ranging from 10.70 to 181, mean 84.25, and ranging from 2.47 to 155, mean 54.37 in group II compared with a mean level of 50.44 in group I and a mean of 1.96 in the control group, group IV (P = 0.0001*). Conclusion Atherosclerosis is currently considered a systemic inflammatory disease and IL-6 is an inflammatory cytokine. The IL-6 serum level was significantly increased in patients with ACS and in patients with successful thrombolytic therapy. There was a statistically significant positive correlation between IL-6 and CRP in ACS patients with failed thrombolytic therapy; IL-6 serum levels did not correlate with cardiac troponin levels in any of the ACS patient groups.
  1 1,205 179
Pulse co-oximetry perfusion index as a tool for acute postoperative pain assessment and its correlation to visual analogue pain score
Sabah Abdel Raouf Mohamed, Nashwa Nabil Mohamed, Doaa Rashwan
July-September 2015, 2(3):62-67
DOI:10.4103/2356-9115.172783  
Background A painful stimulus can produce vasoconstriction and a decrease in perfusion index (PI). The visual analogue scale (VAS) is the most common pain assessment scale. However, it is affected by psychometric instability. This study was designed to evaluate the correlation between VAS as a subjective indicator of pain and PI as an objective indicator of pain. Patients and methods At postanesthesia care unit, a Masimo pulse co-oximetry perfusion index was attached to 70 adult patients of ASA I who underwent lumbar spine discectomy. At the time of the first request for analgesia (T1) VAS was recorded together with the PI, heart rate (HR), mean arterial blood pressure (MAP), peripheral oxygen saturation, and axillary temperature, following which analgesia was given. Thirty minutes thereafter (T2) second measurements for the mentioned parameters were taken. Results The PI was significantly higher at T2 than at T1 (mean increase% = 94.3 ΁ 82.7%). This increase was associated with a statistically significant decrease in VAS, HR, and MAP. The mean decrease% was 70.5 ΁ 19.88%, 11.1 ΁ 7.2%, and 3.96 ΁ 5.01% in VAS, HR, and MAP, respectively. This means that the PI increases with adequate relief from pain, as indicated by a decrease in VAS, HR, and MAP. A decrease in VAS was associated with an increase in PI, but the correlation was not statistically significant as the degree of the increase in PI in relation to the decrease in VAS was variable among patients. Conclusion PI can be added to other indicators of pain assessment in the postanesthesia care unit.
  1 2,445 346
Evaluation of the efficacy of dexmedetomidine infusion on the quality of balanced anesthesia and postmastectomy pain
Ashraf E Alzeftawy, Nabil A Elsheikh
July-September 2015, 2(3):73-78
DOI:10.4103/2356-9115.172793  
Background The authors studied the effect of intraoperative infusion of dexmedetomidine on the quality of anesthesia, anesthetic requirements in patients undergoing radical mastectomy, and its effect on acute and chronic postmastectomy pain. Patients and methods A total of 76 female patients undergoing radical mastectomy were randomly classified into two groups: group I received intraoperative dexmedetomidine infusion and group II, the control group, received an infusion of normal saline. Heart rate, mean arterial blood pressure, end tidal isoflurane concentration, amount of fentanyl and muscle relaxant increments, recovery characteristics, quality of postoperative analgesia for 3 days, and incidence of side effects were recorded. Incidence of chronic pain was reported after 6 months. Results There was a significant decrease in mean arterial blood pressure and heart rate in group I from 1 min after skin incision and onwards. Extubation time and response to verbal command were significantly shorter in the dexmedetomidine group than in the control group (P = 0.003 and P < 0.0001, respectively), and end tidal concentration of isoflurane was significantly lower in group I (P < 0.0001). There was a significant decrease in fentanyl requirement in the operating room in group I (P < 0.0001). Time to first analgesia was significantly longer in group I (P < 0.0001). There was a significant decrease in postoperative analgesic requirement and a better quality of analgesia in the dexmedetomidine group (P < 0.0001). Pain scores at 6 months were comparable in both groups. Conclusion This study showed that the use of intravenous dexmedetomidine had a sparing effect on anesthetic and analgesic requirements with hemodynamic stability effect and no protective effect from the development of chronic pain.
  1 1,169 129
Comparison between fluoroscopic posterior versus ultrasound-guided anterior approach for superior hypogastric plexus neurolysis: a prospective, randomized, comparative study
Mahmoud A Kamel, Ahmed Shaker R Ahmed, Mohamed H Shaaban, Rania Hamdy Hashem
October-December 2016, 3(4):151-156
DOI:10.4103/2356-9115.195882  
Background Pain due to advanced pelvic cancer is a common and disabling complain. This study compared the safety and efficacy of the ultrasound (US)-guided anterior approach of superior hypogastric plexus (SHP) neurolysis with the fluoroscopy-guided posterior approach in the management of patients with intractable pelvic cancer pain. Patients and methods A total of 30 patients with advanced-stage pelvic cancer were enrolled and divided into two equal groups. The first group was named group F, which included 15 patients in whom SHP block was performed with the fluoroscopy-guided posterior oblique technique. The second group was named group U, which included 15 patients in whom the SHP block was performed with the US-guided anterior approach. Visual analogue scale score, patient satisfaction score, and daily morphine consumption were assessed at the following time points: before the procedure and on day 1, 1 month, and 3 months after procedure. Any adverse effects of the procedure were also recorded. Results For both groups, visual analogue scale score and daily morphine consumption were significantly decreased at day 1, 1 month, and 3 months after procedure compared with before the procedure. Patient satisfaction score significantly improved at day 1, 1 month, and 3 months after procedure compared with before the procedure. Conclusion The present study demonstrated a comparable efficacy of the US anterior approach for SHP neurolysis in patients with advanced pelvic cancer pain with the standard, classic, fluoroscopic posterior technique.
  1 2,157 1,073
Evaluation of the efficacy of bilateral sphenopalatine ganglion block in endoscopic sinus surgery under general anesthesia: a randomized prospective controlled trial
Susmita Bhattacharyya, Mandeep K Tewari, Sarmila Ghosh, Jayanta Chakroborty, Writuparna Das, Utpal Barman
October-December 2016, 3(4):173-178
DOI:10.4103/2356-9115.195878  
Background The major problem of functional endoscopic sinus surgery is impaired visibility of the surgical field due to excessive bleeding. Although controlled hypotension has been used to minimize intraoperative blood loss, it may invite several problems. To avoid these complications, this randomized controlled study was designed to evaluate the efficacy of bilateral sphenopalatine ganglion block (SPGB) under general anaesthesia, which could provide better hemodynamic parameters, good surgical condition, decreased blood loss, rapid recovery, better postoperative pain control and fewer complications during functional endoscopic sinus surgery. Patients and methods Sixty adult patients of both sexes between 15 and 55 years of age of American Society of Anaesthesiologists Physical Status I–II were randomly allocated into two equal groups. Group A patients received bilateral SPGB with 2.5 ml of 0.25% levobupivacaine on each side after induction of general anaesthesia. Group B patients received only general anaesthesia. Baseline and intraoperative heart rate, mean arterial blood pressure, oxygen saturation, end tidal carbon dioxide, temperature and blood loss were recorded. Surgical field, recovery score and postoperative pain were assessed using the average category scale, Aldrete recovery score and the visual analogue scale, respectively. The time to first rescue analgesic was noted. Results Intraoperative mean arterial blood pressure, heart rate, blood loss, average category scale and postoperative visual analogue scale were significantly lower in the block group compared with the control group. Aldrete recovery score was significantly higher in the block group compared with the control group. First rescue analgesic requirement was delayed in the block group compared with the control group. Conclusion SPGB is effective for providing better haemodynamic control, good surgical field, lesser blood loss, early recovery and prolonged postoperative analgesia in this surgery.
  1 1,210 215
Endotracheal intubation using direct laryngoscopy with Macintosh blade versus C-MAC videolaryngoscopy (Macintosh blade and D-blade)
Hossam Eldin Fouad Rida, Nagwa Mahmoud Elkobbia, Moustafa Abdel Aziz Moustafa, Hend Abdel Nasser Aboshanab
January-March 2017, 4(1):1-6
DOI:10.4103/2356-9115.202697  
Background Direct laryngoscopes have been developed to many optical fiberscopes to provide better view of the glottis without alignment of the oral, pharyngeal and tracheal axes. Recently, videolaryngoscopes have become increasingly important devices in difficult airway management. Purpose The aim of the present study was to compare the efficacy of direct laryngoscopy using a conventional Macintosh blade with C-MAC videolaryngoscopy (with a Macintosh blade or D-blade), and to select the device of choice for the best first attempt for laryngoscopy and endotracheal intubation. Patients and methods A total of 90 adult patients were randomly categorized into three equal groups (30 patients each): group I, in which patients were subjected to general anaesthesia with endotracheal intubation using direct laryngoscopy with conventional Macintosh blade; group II, in which patients were subjected to general anaesthesia with endotracheal intubation using C-MAC videolaryngoscopy with conventional Macintosh blade; and group III, in which patients were subjected to general anaesthesia with endotracheal intubation using C-MAC videolaryngoscopy with the D-blade. Then, the assessment of the laryngoscopic view and the whole procedure of laryngoscopy and intubation was carried out. Conclusion This study validated the efficacy of C-MAC Macintosh blade and D-blade when compared with a direct laryngoscope. D-Blade has been found to be more effective in reducing haemodynamic responses to laryngoscopy and intubation. Its use improves the laryngoscopic view with a high success rate, makes the procedure of laryngoscopy and intubation easier from the first attempt and involves the least usage of assisting manoeuvres while achieving the shortest ETT insertion time without any complications.
  1 1,135 155
Impact of progesterone administration on outcome in patients with severe traumatic brain injury
Hassan A Aboukhabar, Amr Abouelela, Sherif M Shaban
April-June 2017, 4(2):84-89
DOI:10.4103/roaic.roaic_106_16  
Background No medication exists to halt the progression of secondary injuries in severe traumatic brain injury (TBI), but the variety of pathological events presents opportunities to find treatments that interfere with the damage processes. The effects of progesterone on the reproductive and endocrine systems are well known, but a growing body of evidence indicates that the hormone also exerts neuroprotective effects on the central nervous system by decreasing overall cerebral edema, protecting and rebuilding the blood–brain barrier, downregulating the inflammatory cascade, and limiting cellular necrosis and apoptosis. Aim The aim of this study was to evaluate the effect of progesterone administration on improvement in outcomes of patients with TBI as measured by the Glasgow Outcome Scale. Patients and methods The present study was a prospective, randomized trial. A total of 100 patients with severe TBI were enrolled for the present study. The selected patients were categorized at random into two equal groups − the control group and the progesterone group. In the control group, patients were given conventional therapy. The progesterone group was given 1 mg/kg progesterone by intramuscular injection within 8 h of admission and then every 12 h for 5 consecutive days in addition to the conventional therapy. The neurological outcome after 30 days was evaluated using the Glasgow Outcome Scale score as well as duration of ICU stay. Results In the progesterone group, 33/50 (66%) patients had favorable outcomes and 17/50 (34%) had unfavorable outcomes, whereas in the control group 23/50 (46%) patients had favorable outcomes and 27/50 (54%) had unfavorable outcomes (P=0.072). Length of ICU stay had a mean value of 10.88±7.98 days in the progesterone group versus 19.96±10.36 days in the control group (P<0.001). Conclusion No significant difference in outcome between the two groups was observed, but there was a significant decrease in ICU length of stay in the progesterone group.
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Traumatic brain injury predictive value of common intensive care severity scores
Ahmed Kandil, Mahmoud Kenawi, Ahmed Samir, Khaled Hussein
July-September 2017, 4(3):124-128
DOI:10.4103/roaic.roaic_90_16  
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.
  1 1,082 130
Bronchoscopic instillation of amikacin in patients with ventilator-associated pneumonia
Mohamed E Fathy, Tamer A Helmy, Ehab M Elreweny, Mahmoud I Mahmoud
July-September 2017, 4(3):134-142
DOI:10.4103/roaic.roaic_102_16  
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.
  1 1,152 156
Intraperitoneal ketamine attenuates the inflammatory reactivity associated with pneumoperitoneum
Soad Sayed El-Gaby, Sawsan Soliman Mohamed
July-September 2017, 4(3):149-155
DOI:10.4103/roaic.roaic_121_16  
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.
  1 1,002 124
Role of transcranial Doppler and FOUR score in assessment of sepsis-associated encephalopathy
Dina H Zidan, Tamer A Helmy, Ahmed Taha
October-December 2017, 4(4):209-212
DOI:10.4103/roaic.roaic_109_16  
Background Monitoring of the septic complications on the brain is useful in management and in attenuating the effect of sepsis-related cerebral complications on outcome. Patients and methods A transcranial Doppler probe was applied through the temporal bone window at both sides of the skull within the first day of diagnosing sepsis for 10 s. The values of the brain side with the highest peak systolic velocity (PSV) and end diastolic velocity (EDV) were registered. We calculated the pulsatility index (PI) as follows: PI=(PSV−EDV)/mean velocity; the neurological status was evaluated 6 h after sedation cessation, using Glasgow Coma Scale and Full Outline of UnResponsiveness score. Results There was a significant difference in the PI between conscious patients and patients suffering from sepsis-associated encephalopathy. Conclusion PI is a predictor of sepsis-associated encephalopathy in septic patients.
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Plasminogen activator inhibitor-1 as a predictor after cardiopulmonary bypass for postoperative atrial fibrillation
Suzy Fawzy, Mohamed F Abdel Aleem, Mohamed A El Badawy, Islam H Mohamed
January-March 2018, 5(1):27-34
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.
  1 1,048 121
Lung ultrasound in intensive care unit: a prospective comparative study with bedside chest radiography using computed tomography of chest as a gold standard
Ali Mohsen, Wael Samy, Hatem El-Azizy, Mohammed A Shehata
April-June 2018, 5(2):110-114
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.
  1 1,495 199
Adding dexmedetomidine to bupivacaine–fentanyl mixture in high-risk elderly patients undergoing orthopedic surgery: a randomized, double-blind, controlled study
Sohair A Megalla
July-September 2018, 5(3):205-212
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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Shivering prevention during cesarean section by intrathecal injection of magnesium sulfate: randomized double-blind controlled study
Mohamed F Mostafa, Zein El-Abden Z Hassan, Samia Moustafa Hassan
January-March 2019, 6(1):89-94
DOI:10.4103/roaic.roaic_43_17  
Background Shivering was found to be a common side effect with spinal anesthesia. It was observed in about 55% of patients with neuraxial anesthesia. It results in increased oxygen consumption and pain which usually interfere with patient’s monitoring. Objectives This study was designed to show the effect of intrathecal injection of magnesium sulfate to control shivering during spinal anesthesia for cesarean section. Study Design This study was a prospective randomized controlled double-blind study using a computer-generated randomization scheme. Methods 84 Women were randomly allocated into 2 groups: Magnesium sulfate group (M); patients received intrathecal 2 ml of 0.5% heavy bupivacaine (10 mg) plus 25 mg MgSO4. Placebo group (P); patients received intrathecal 2 ml of 0.5% heavy bupivicaine (10 mg) plus 0.5 ml normal saline. Vital signs, temperature, shiverig score, sensory level, motor block, and any complications were recorded. Results Shivering score revealed a statistically significant difference between both study groups throughout the whole intraoperative and postoperative periods with lower shivering incidence in the M group. There was a statistically significant difference between both groups regarding temperature readings during the first 30 minutes postoperatively. Intraoperative sensory level block was statistically significant different only 30 minutes after drugs injection. No serious complications were recorded in both groups. Conclusion We concluded that intrathecal Magnesium sulfate is safe and can decrease the incidence and intensity of shivering during cesarean section under spinal anesthesia, without having any serious side effects.
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* Source: CrossRef