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ORIGINAL ARTICLES
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.
  678 123 -
A comparative study of intrathecal dexmedetomidine and fentanyl as additives to bupivacaine
Ahmed El-Attar, Mohamed Abdel Aleem, Ragab Beltagy, Wafaa Ahmed
April-June 2015, 2(2):43-49
DOI:10.4103/2356-9115.161328  
Background In recent years, the use of intrathecal adjuvants has gained popularity. The quality of spinal anesthesia has been reported to improve with the addition of opioids and other drugs, but until now there is no single drug with no side effects. The aim of this study was to compare the addition of either dexmedetomidine or fentanyl to intrathecal bupivacaine as regards the onset and duration of sensory and motor block, hemodynamic effects, postoperative analgesia, and adverse effects of either drug. Materials and methods Sixty patients classified in American Society of Anesthesiologists as classes I and II scheduled for lower abdominal and lower limb surgeries were studied. Patients were randomly allocated to three groups (20 patients each): group B, group F, and group D. Group B patients received 3 ml (15 mg) of 0.5% hyperbaric bupivacaine plus 0.5 ml of normal saline intrathecally. Group F patients received 3 ml (15 mg) of 0.5% hyperbaric bupivacaine plus 0.5 ml (25 μg) of preservative-free fentanyl intrathecally. Group D patients received 3 ml (15 mg) of 0.5% hyperbaric bupivacaine plus 0.5 ml (5 μg) of diluted, preservative-free dexmedetomidine intrathecally. Results Patients in the dexmedetomidine group (D) had faster sensory and motor onsets compared with those in the fentanyl group (F) and the bupivacaine group (B) (P = 0.000 for both sensory and motor). Patients in group D had significantly longer sensory and motor durations compared with those in groups F and B (P = 0.000). Patients in the dexmedetomidine group (D) did not have significant hemodynamic changes; they had prolonged analgesic effect with less 24 h requirements of analgesics, and they had nonsignificant adverse effects. Conclusion Dexmedetomidine has faster onset compared with fentanyl and bupivacaine when injected intrathecally along with bupivacaine; it prolonged the sensory and motor blocks and was hemodynamically stable, with no significant side effects and with less requirements of postoperative analgesic needs during the first 24h.
  587 132 -
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.
  504 93 1
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.
  490 91 1
Evaluation of red cell distribution width as a septic marker in comparison with clinical scores, C-reactive protein, and procalcitonin levels
Assem Abdel Razek, Atef Abdel Aziz Mahrous, Karim Mohammad Zakaria
April-June 2015, 2(2):24-33
DOI:10.4103/2356-9115.161320  
Introduction Biomarkers, which were introduced in the diagnosis and risk assessment of sepsis, could contribute toward predicting outcome in those patients affected by sepsis, severe sepsis, and septic shock who could benefit from a quick and appropriate therapy. Among different molecules that have been suggested as sepsis biomarkers in the last few years is red cell distribution width, which appears quite promising because of its reported correlation with the septic process. The aim of this study was to compare between red cell distribution width, C-reactive protein (CRP), and procalcitonin as diagnostic and prognostic markers in sepsis. Patients and methods This study was carried out on 45 adult patients of both sexes who had sepsis, severe sepsis, and septic shock; all of them received the same treatment as recommended by the surviving sepsis campaign; 17 of these patients have survived and the other 28 did not survive (group I). There were 45 healthy adult volunteers (group II). The patients in the study group were those who were admitted to the units of the Critical Care Medicine Department in Alexandria Main University Hospital and who fulfilled the diagnostic criteria for severe sepsis or septic shock on arrival to ICU according to the SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Venous blood samples were obtained from group I on admission, day 5, and day 10 to determine red blood cell distribution width (RDW), CRP, and procalcitonin levels on admission, day 5, and day 10; the Sequential Organ Failure Assessment (SOFA) score was also measured on days 1, 5, and 10. The APACHE II score was measured only on admission. Patients were managed according to the surviving sepsis campaign guidelines. Results On comparing the biomarkers studied in both groups, it was found that the values of RDW, CRP, and procalcitonin were significantly different between group I on admission and group II. CRP was less accurate than RDW and procalcitonin in assessing the severity of sepsis at admission. The best diagnostic cut-off for RDW on admission was 15.3%: at that level, sensitivity and specificity were 86.6 and 71.1%, respectively. The best diagnostic cut-off for CRP on admission was 39 mg/dl: at that level, sensitivity and specificity were 66.6 and 80%, respectively, and for procalcitonin, it was 1.4 ng/ml; at that level, sensitivity and specificity were 88.8 and 91.1%, respectively. Higher RDW values were found in patients with higher APACHE II and SOFA scores. RDW, the APACHE II score, and the SOFA score were significantly higher in nonsurvivors in comparison with survivors (P = 0.011, P < 0.001, and P < 0.001, respectively). On comparing the markers studied for their prognostic value, we found that RDW and procalcitonin were significantly higher in nonsurvivors than survivors (P = 0.11 and 0.002, respectively), and CRP concentrations were not statistically different between survivors and nonsurvivors at admission. The best prognostic cut-off for RDW on admission was 16.4%: at that level, sensitivity and specificity were 80 and 67.68%, respectively, and for procalcitonin, it was 5.1 ng/ml; at that level, sensitivity and specificity were 94.12 and 60.7%, respectively. Conclusion RDW is a new promising and readily available cheap biomarker that can aid the diagnosis of sepsis and also aid prediction of outcome comparable with more complex clinical scores (APACHE II and SOFA).
  477 97 -
Adaptive support ventilation versus biphasic positive airway pressure in patients with acute exacerbation of chronic obstructive pulmonary disease
Amr A Elmorsy, Bassem N Beshay, Emad H Mousa
April-June 2015, 2(2):34-42
DOI:10.4103/2356-9115.161325  
Introduction The goal of mechanical ventilation in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is to maintain both adequate oxygenation and ventilation, reduce the work of breathing, and improve the comfort of the patient until the condition has been reversed or alleviated. Unlike conventional pressure-controlled ventilatory modes, biphasic modes [biphasic positive airway pressure (BIPAP)] allow for unrestricted spontaneous breathing. Adaptive support ventilation (ASV) is a new ventilatory mode that uses a closed-loop controlled mode between breaths. It can be used safely during initiation, maintenance, or weaning phases of the mechanical ventilation. Objective The aim of this work was to compare between BIPAP and ASV in the management of patients with AECOPD in terms of ventilatory parameters, lung mechanics, patient ventilator dys-synchrony, days of mechanical ventilation, and mortality. Patients and methods This double-blind randomized trial was conducted on 72 AECOPD adult patients admitted to the units of Critical Care Medicine Department in Alexandria Main University Hospital indicated for invasive mechanical ventilation. Patients were excluded for reasons such as pregnancy, hemodynamic instability, and severe neurological disease. They were categorized randomly as follows: group I included 36 patients who were ventilated using the BIPAP mode and group II included 36 patients who were ventilated using the ASV mode. Informed consent was obtained from patients' first of kin after approval from the Ethical Committee of Alexandria Faculty of Medicine. Ventilatory parameters (respiratory rate, tidal volume, peak airway pressure, and rapid shallow breathing index) and lung mechanics (static compliance and inspiratory resistance) were recorded. Patient ventilator dys-synchrony and asynchrony index were recorded daily. Days of mechanical ventilation, ICU stay, and mortality were calculated. Results In the ASV group, the respiratory rate was significantly lower, tidal volume was higher, and rapid shallow breathing index was lower. Significantly higher compliance and lower resistance were encountered in the ASV group, with better patient-ventilator synchronization. A significant reduction in days of mechanical ventilation in the ASV group was found with less ICU length of stay. Conclusion ASV may be safer in AECOPD patients and may have a better prognosis.
  458 113 -
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.
  522 45 -
Comparative study between succinylcholine, rocuronium and magnesium sulphate with rocuronium in rapid sequence induction
Nagwa M El-Kobbia, Maher M Doghaim, Moustafa Abdelaziz Moustafa, Ahmed M Deifallah
April-June 2015, 2(2):57-61
DOI:10.4103/2356-9115.161335  
Background Rapid sequence induction usually applies when tracheal intubation must be performed in a patient who is suspected of having a full stomach and who is at risk of pulmonary aspiration of gastric contents. Succinylcholine is the traditional depolarizing neuromuscular-blocking agent used in rapid sequence induction. However, it has a number of undesirable side effects. Magnesium may have a role in potentiation of neuromuscular blockade produced by neuromuscular blockers such as rocuronium. Aim The aim of this study was to investigate the effects of magnesium sulphate pretreatment on intubating conditions and cardiovascular responses during rapid sequence tracheal intubation (RSI). Patients and methods A total of 60 adult patients were randomly allocated to three groups: the succinylcholine group, which received 1 mg/kg succinylcholine; the rocuronium group, which received 1.2 mg/kg rocuronium preceded 15 min with 500 ml normal saline; and the magnesium rocuronium group, which received 1.2 mg/kg rocuronium preceded 15 min with 60 mg/kg magnesium sulphate in 500 ml normal saline infusion. Anaesthesia was induced with fentanyl, propofol and a neuromuscular-blocking drug on the basis of the studied group. An anaesthesiologist, blinded to the rocuronium group assignments, performed RSI and assessed the onset time, intubating conditions and clinical duration of neuromuscular block in the different groups. Haemodynamics were recorded before magnesium sulphate or normal saline infusion, after anaesthesia induction and every minute after intubation for 5 min. Results The onset time was shortest in the succinylcholine and magnesium groups. The intubating conditions were significantly better in the magnesium group (P < 0.001) compared with the other two groups. Significant increases in heart rate and blood pressure were observed at 1 min after intubation in the succinylcholine and rocuronium groups relative to stable haemodynamics in the magnesium group (P < 0.05). Conclusion Magnesium sulphate administered before RSI using fentanyl, propofol and rocuronium may shorten the onset time and improve the intubating conditions comparable to those of succinylcholine and suppress the haemodynamic stress response to intubation.
  435 97 -
The effects of adding neostigmine to supraclavicular brachial plexus block for postoperative analgesia in chronic renal failure patients: a prospective randomized double-blinded study
Khaled Elbahrawy, Alaa El-Deeb
January-March 2016, 3(1):36-41
DOI:10.4103/2356-9115.184076  
Background Brachial plexus block is a popular technique for surgery of the upper extremity. Supraclavicular approach is the most consistent method for surgery below the shoulder joint. Neostigmine is often used as an adjuvant for local anesthetics in regional anesthesia. Patients and methods Ninety-three patients of ASA physical status III with chronic renal failure were randomly allocated to three groups according to brachial plexus block solution. The control group received 20 ml of 0.5% bupivacaine added to 10 ml of normal saline solution and the two neostigmine groups received 250 and 500 μg of neostigmine (groups N250and N500, respectively). The block was performed guided by ultrasound. Patients were monitored in the operation theater for ECG, heart rate, respiratory rate, noninvasive blood pressure, and SpO2. Characteristics of the blocks, duration of analgesia, and adverse effects were assessed. If the patient felt pain before or during surgery, the patient was excluded from study and additional lidocaine was used. Postoperative pain was assessed using the visual analogue scale. The postoperative rescue analgesic used was tramadol. Complications of brachial plexus block were reported. Results Patients showed no significant difference with respect to patients' age, sex, weight, and duration of surgery. The onsets of sensory and motor blockade were significantly shorter in patients receiving 500 μg neostigmine. The duration of sensory and motor blockade and hemodynamics were comparable in the three groups. The postoperative rescue analgesic requirement and mean pain score were significantly less in group N500than in the N250and control groups. Complications of the block did not vary among groups. Conclusion Addition of neostigmine to supraclavicular brachial plexus block in chronic renal failure patients has no effect on duration of block. However, 500 μg neostigmine resulted in rapid onset of sensory and motor blockade and enhancement of postoperative analgesia, with no significant side effects.
  468 29 -
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.
  402 87 -
Comparison of the use of laryngeal mask airway Supreme and laryngeal mask airway ProSeal in prone position for pilonidal sinus excision surgery
Adel A.N. Mahgoub
October-December 2015, 2(4):111-115
DOI:10.4103/2356-9115.178902  
Background Surgeries that require the patient to be in the prone position represent a challenge to the anesthesiologist in terms of securing the airway and additional time and personnel required for induction in the supine position and shifting to the prone position. Use of the classic laryngeal mask airway (LMA) in the prone position is a subject of controversy; the ProSeal LMA may be more suitable as it forms a better seal and provides access to the stomach. LMA Supreme is a newly introduced single-use supraglottic device that shares common features of both the LMA ProSeal and the intubating LMA. Aim of this study The aim of the study was to compare the use of LMA ProSeal and LMA Supreme after induction of anesthesia in the prone position. Patients and methods The study included 80 adult male patients for pilonidal sinus excision surgery. They were randomly divided into two equal groups: group P and group S. The ProSeal was used in group P and the Supreme was used in group S. Ease of insertion, ease of ventilation, leakage of inspiratory gases, SpO 2 , EtCO 2 , blood on the airway device after removal, and postoperative incidences of sore throat were recorded. Results There was no statistical difference between the two groups in terms of age, BMI, or duration of surgery. Both devices provided good air seal and good ventilation. Blood-stained saliva and postoperative sore throat were found more with ProSeal use than with Supreme. Conclusion Allowing the patients to take the prone position themselves and then inducing general anesthesia and securing the airway either with ProSeal or with Supreme is a safe practice.
  394 64 -
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.
  340 83 1
Feasibility and perioperative pain-relieving efficacy of ultrasound-guided transversus abdominis plane block in morbidly obese patients undergoing laparoscopic bariatric surgery
Abeer A Sherif, Hala M Koptan, Samer M Soliman
April-June 2015, 2(2):50-56
DOI:10.4103/2356-9115.161334  
Background The implementation of adequate postoperative analgesia is beneficial in morbidly obese patients. Transversus abdominis plane (TAP) block is a new regional anesthetic technique that has been implemented successfully for pain control after laparoscopic surgery in nonobese patients, and is challenging to perform on obese patients. The introduction of ultrasound guidance has enabled greater precision of needle placement in the desired tissue plane in such patients. Patients and methods Hundred patients were included in this study. Patients were assigned randomly to two equal groups: group 1 (TAP, n = 50) and group 2 (control, n = 50). The following parameters were recorded: total volume of morphine consumed, numeric rating scores at rest and on coughing, postoperative nausea and vomiting, time to mobilization, patient, and surgeon satisfaction scores. Results Lower numeric rating scores was reported among patients who received TAP block; cumulative morphine consumption was consistently lower at 24 and 48 h, postoperatively. Patient satisfaction with pain relief was rated as good by 85% of the patients in the TAP block group and 45% of the patients in the control group. Conclusion Ultrasound-guided TAP block is a feasible technique for effective multimodal postoperative analgesia in morbidly obese patients undergoing laparoscopic sleeve gastrectomy.
  338 76 -
Transversus abdominis plane block versus caudal block for postoperative pain control after day-case unilateral lower abdominal surgeries in children: a prospective, randomized study
Khaled Elbahrawy, Alaa El-Deeb
January-March 2016, 3(1):20-24
DOI:10.4103/2356-9115.184080  
Background The transversus abdominis plane (TAP) block is a relatively simple technique that may prove useful in the management of postoperative pain. It decreases the amount of intraoperative and postoperative opioid requirements after surgery. Caudal block is a gold standard technique in pediatric surgeries. Patients and methods Seventy-five children aged 1–7 years with ASA I or II scheduled for day-case unilateral lower abdominal surgeries were randomly allocated to two groups: group C (caudal block) and group T (TAP block). Group C received caudal 0.25% bupivacaine at 1 ml/kg and group T received 0.25% bupivacaine at 1 ml/kg. Time to first analgesic request, total intraoperative fentanyl consumption, postoperative tramadol requirement, sedation level, parent satisfaction scores, pain score, postanesthetic care unit time and day-surgery unit time, and side effects were reported. Results The two groups were comparable in terms of total intraoperative fentanyl consumed, postoperative tramadol requirement, postoperative pain scores, time to first administration of rescue analgesia, and postanesthetic care unit time. Children in the TAP group were discharged home significantly earlier than those in the caudal group (306.8 ± 18 vs. 259 ± 22.4 min with P < 0.001). More children in the caudal group experienced vomiting when compared with the other group. Parent satisfaction score was statistically significantly higher in the TAP group when compared with the caudal group [80 (70–90) vs. 95 (80–95) with P < 0.001]. Conclusion TAP block and caudal block provided adequate relief from postoperative pain after day-case unilateral lower abdominal surgeries in children. However, TAP block resulted in better parent satisfaction and earlier home discharge with fewer side effects when compared with caudal block.
  312 52 -
Role of clinical pulmonary infection score and serum C-reactive protein in detecting the efficacy of therapeutic choices in the management of Enterobacter aerogenes nosocomial pneumonia
Hany Kmale Mickhael, Josef Zekry Attia, Maha Yehia Kamel
January-March 2016, 3(1):1-5
DOI:10.4103/2356-9115.184075  
Introduction and background Nosocomial pneumonia is the second most common nosocomial infection. It is usually bacterial in origin. Nosocomial pneumonia is responsible for 25% of infections in the ICU. Early-onset nosocomial pneumonia tends to carry a better prognosis than does late-onset nosocomial pneumonia. Patients and methods This study was planned to evaluate the role of the clinical pulmonary infection score (CPIS) and C-reactive protein (CRP) in detecting the efficacy of antibiotic therapy chosen for treatment of nosocomial Enterobacter pneumonia. In all, 200 patients admitted to the ICU who had evidence of pneumonia were included in the study. Patients were followed up by evaluating their serum CRP levels and CPIS during the first 8 days of admission. Results Enterobacter aerogenes represented 24% of nosocomial pneumonia cases in the study. An overall 70.8% of patients with E. aerogenes detected in culture and sensitivity were sensitive to both amikacin and levofloxacin. Those patients received only amikacin. Sixteen patients provided good response to amikacin. The remaining 18 patients showed poor response to amikacin therapy (proved by insignificant differences between CPIS and CRP on the first and fourth day of admission). In the case of these patients levofloxacin was added to antibiotic therapy and they were followed up for a further 4 days. The results demonstrated that 16 patients provided good response to amikacin and levofloxacin on the fifth and eighth days. Conclusion This study demonstrated that CPIS and serum CRP can be used as indicators of the efficacy of antibiotics in nosocomial pneumonia.
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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.
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The addition of magnesium sulfate or dexamethasone to levobupivacaine for ultrasound-guided supraclavicular brachial plexus block for upper-limb surgery: a double-blinded comparative study
Adel A.N. Mahgoub
October-December 2015, 2(4):116-120
DOI:10.4103/2356-9115.178904  
Background Levobupivacaine (chirocaine) is a long-acting amide local anesthetic that can be used in different applications like epidural, spinal, peripheral nerve, ocular block, topical application, and local infiltration. Clinical effects are comparable to those of bupivacaine or ropivacaine. Studies are needed on different adjuvants with levobupivacaine, such as dexamethasone and magnesium sulfate. Aim of this study The aim of the study was to compare the effect of adding either magnesium sulfate or dexamethasone to levobupivacaine in supraclavicular brachial plexus block. Materials and methods Sixty adult patients presented for upper-limb surgery under supraclavicular brachial plexus block using ultrasound. The patients were randomly arranged into two equal groups: magnesium sulfate was added to levobupivacaine in one group and dexamethasone was added in the other group. Duration of postoperative analgesia was recorded. Results There was no statistically significant difference in the duration of postoperative analgesia between the two groups. Conclusion There is no preferential difference in postoperative analgesia between dexamethasone and magnesium sulfate when added to levobupivacaine
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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.
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Effect of different baricities of intrathecal bupivacaine on the quality of spinal block in elderly patients undergoing transurethral resection of the prostate
Magdy M Atallah, Ola T Abdel Dayem
October-December 2015, 2(4):121-125
DOI:10.4103/2356-9115.178906  
Background Elderly patients undergoing spinal anesthesia require restricted block with a low dose of a local anesthetic. Considering that the baricity of local anesthetic solutions is the primary determinant of the level of motor and sensory block in nonobstetric patients, the aim of this study was to evaluate the effect of baricity of bupivacaine on the quality of spinal block and on hemodynamics in elderly patients undergoing transurethral resection of the prostate (TURP). Materials and methods Ninety-nine patients undergoing TURP were randomized into three groups. Patients of the first group (33 patients) received intrathecal 10 mg hyperbaric bupivacaine 0.5%. The second group of patients (34 patients) received 5 mg isobaric bupivacaine added to 5 mg hyperbaric bupivacaine, resulting in what was called 'slightly hyperbaric solution'. The third group of patients (32 patients) received 10 mg isobaric bupivacaine 0.5%. All patients were injected below L2 level in the sitting position. Sensory and motor blockade was assessed, as well as the first request for analgesic, rescue analgesics, and the overall incidence of side effects. Results Onset of sensory block was comparable in the three studied groups, but motor block set earlier in the hyperbaric group and the 'slightly hyperbaric' group compared with the isobaric group. Higher sensory block was observed in the isobaric group. Recovery from sensory and motor block was earlier in the hyperbaric group. First need for analgesics was earlier in the hyperbaric group than in the 'slightly hyperbaric' and isobaric groups. Postoperative analgesia and tolerance to urinary catheter were prolonged in the isobaric and 'slightly hyperbaric' group as compared with the hyperbaric group. Conclusion Use of slightly hyperbaric bupivacaine (density = 1.013) than the traditional hyperbaric bupivacaine (density = 1.028) and the isobaric one (density = 1.007) results in good quality spinal block with fewer side effects in patients undergoing TURP.
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Dexmedetomidine versus magnesium sulfate for oligemic field in middle ear surgery
Ahmed Z Mohamed, Usama G Abd-Elnaby
July-September 2015, 2(3):79-84
DOI:10.4103/2356-9115.172795  
Aim of study To compare between the effects of dexmedetomidine and magnesium sulphate on quality of surgical field visualization in middle ear surgery. Patients and Methods 60 patients scheduled for middle ear surgery were included in the study. Patients were randomly divided into two equal groups, the 1st group received dexmedetomidine infusion (D group) while the 2nd received magnesium sulphate infusion (Mg group). Induction of anesthesia was done by propofol 2 mg/kg and atracurium 0.5 mg/kg. Anesthesia was maintained with sevoflurane which titrated to obtain 30% decrease in blood pressure. Infusion of dexmedetomidine 1 μg/kg over 10 minutes followed by 0.5 μg/kg/hr in D group while infusion of 50 mg/kg magnesium sulphate over 10 minutes followed by 15 mg/kg/hr magnesium sulphate in Mg group. Quality of surgical field visualization, Amount of blood loss, blood pressure, heart rate and postoperative side effects were recorded. Results Quality of surgical field visualization was better and amount of blood loss was less in group D than group Mg without serious side effect. Conclusion Dexmedetomidine provided better quality of surgical field vision and less bleeding when compared to magnesium sulphate without any side effects in middle ear surgery.
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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.
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ORIGINAL ARTICLES
Safety of nalbuphine on neural tissues of rats and its efficacy in the treatment of acute herpetic pain in children with acute lymphoblastic leukemia
Josef Z Attia, Maha Y Kamel, Rehab K Yousef
July-September 2015, 2(3):89-95
DOI:10.4103/2356-9115.172801  
Background Acute lymphoblastic leukemia (ALL) has been previously shown to cause severe impairment in immunity, in turn making children more susceptible to viral infections, especially herpes zoster, which manifests with severe pain. Materials and methods The main purpose of this study was to experimentally evaluate the safety of nalbuphine on the neural tissues of rats treated with nalbuphine at doses of 0.5, 1, 2, 4, and 5 mg/kg injected intrathecally every alternate day for 14 days, and to determine the efficacy of caudal injection of nalbuphine with a minimal dose of oral paracetamol as an analgesic in pediatric patients with ALL suffering from acute herpetic pain. Results The results revealed that nalbuphine exerted no pathological changes in either the cerebellum or the spinal cord. However, the protective effect of nalbuphine with the minimal dose of paracetamol was associated with a significant analgesic effect in ALL children. Its analgesic effect was assessed by means of the Facial Pain Scale and the behavioral pain assessment scale, and motor block assessment was made on the basis of the Bromage score. Conclusion Caudal nalbuphine with a minimal dose of paracetamol has adequate analgesic effect on acute herpetic pain in pediatric patients with ALL, without any pathological changes in the cerebellum and spinal cord.
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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.
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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.
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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.
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