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ORIGINAL ARTICLES
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.
  2,280 1,133 1
Local anesthesia with sedation versus local anesthesia after general anesthesia for sinus surgery: a randomized trial
Mohamed T Ghanem, Ashraf Elmalt
October-December 2017, 4(4):188-194
DOI:10.4103/roaic.roaic_111_16  
Background Satisfaction for patients and surgeons during the perioperative functional endoscopic sinus surgery (FESS) remains an anesthetic challenge. We compared FESS under local anesthesia (LA) with monitored anesthesia care (MAC) and LA after induction of general anesthesia. Patients and methods One hundred patients scheduled for FESS were randomly recruited in this randomized controlled study. Fifty of them received LA after induction of general anesthesia (G group), while the rest of the patients received LA with MAC (M group). The outcome measures included satisfaction for the patient and surgeon, cost, surgical, and postoperative profiles. Results Surgeon’s satisfaction was comparable in both groups, while patient’s satisfaction was significantly higher in the M group (P<0.001). Total operative time and time to postanesthetic care unit discharge were significantly shorter in the M group (70.65±4.3 and 13.3±2 vs. 95.8±4.4 and 47.3±5.8 min in the G group, respectively; P<0.001). Time to home discharge was also shorter in the M group (66.0±23.78 vs. 262.20±11.8 min in the G group; P<0.001). The overall costs were significantly lesser in the M group (234.0±5.3 vs. 836.15±41.25 Egyptian pounds in the G group; P<0.001). Conclusion In FESS, LA with MAC provided excellent patient’s experience with optimum surgical and postoperative profiles and lower cost.
  3,107 224 -
Ultrasound-guided pectoral nerve blocks versus serratus intercostal plane block in breast surgeries
Assem Abdel Razek, Magda Mohamed AbouAllo, Sherif Ahmed Abd El Hamid, Mariam Deifallah Margany Osman
July-September 2018, 5(3):162-169
DOI:10.4103/roaic.roaic_19_17  
Introduction Analgesia in breast surgeries can be delivered orally, intravenously, intramuscularly, neuroaxially, or using regional nerve blocks. Pectoral nerve block (Pecs) and serratus intercostal plane block (SIPB) are a recently introduced ultrasound-guided technique for providing intraoperative and postoperative analgesia. Aim The aim of the present study was to compare intraoperative and postoperative analgesic effect of Pecs versus SIPB in breast surgeries. Patients and methods The current study was carried out on 60 female patients of American Society of Anaesthesiologists class I or II. The patients were undergoing nonreconstructive breast surgery. The patients were randomly divided into two equal groups. The Pecs group included 30 patients who received ultrasound-guided Pecs with 40 ml of levobupivacaine with adrenaline 1 : 200 000. The SIPB group included 30 patients who received ultrasound-guided SIPB with 40 ml of levobupivacaine with adrenaline 1 : 200 000. After assessing the efficacy of the block using sensory block scale, standard general anesthesia was induced in both groups using intravenous fentanyl (1 µg/kg), propofol (2.5 mg/kg) and cisatracurium (0.15 mg/kg). Results The completion of block was significant shorter in SIPB group than Pecs group. The duration of paresthesia in the SIPB group extended to 8 h postoperatively, whereas in the Pecs group the duration extended to 3 h postoperatively. Visual analog scale at rest and in movement was significantly higher in the Pecs group compared with the SIPB group. The number of patients who received postoperative fentanyl was significantly increased in the Pecs group than in the SIPB group. The first request for postoperative fentanyl was significantly delayed in the SIPB group than in the Pecs group. There was no significant difference in the total dose of fentanyl consumption during 24 h postoperatively between the two groups. Conclusion The present study found that SIPB provided superior postoperative analgesia compared with Pecs in patients undergoing nonreconstructive breast surgeries.
  2,641 437 -
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.
  2,587 403 7
CASE REPORTS
Anesthetic management of a newborn with a huge tongue teratoma: a case report
Babita , Bhupendra Singh, Monika Gupta, Dilip Garg
October-December 2016, 3(4):188-190
DOI:10.4103/2356-9115.195880  
  2,820 145 -
ORIGINAL ARTICLES
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.
  2,580 356 1
The revised-Face, Leg, Activity, Cry, and Consolability scale: an Egyptian version
Tarek Shabana, Ahmed N Ibrahim
January-March 2018, 5(1):67-71
DOI:10.4103/roaic.roaic_36_17  
Background Children with cerebral palsy lack the luxury of self-reporting their pain postoperatively. The revised FLACC (Face, Leg, Activity, Cry, and Consolability) pain scale is a behavioral pain assessment tool that is universally accepted for use in children with cognitive dysfunction. Objective The aim of this study was to cross-culturally adapt and evaluate the validity and reliability of the Egyptian version of the revised FLACC (r-FLACC) scale for use in postoperative pain assessment in children with cerebral palsy. Patients and methods The study was carried out in Ain Shams University Pediatric Hospital on 30 children with cerebral palsy aged 3–12 years scheduled for open Nissen fundoplication. Pain was assessed at baseline, on arrival to postanesthesia care unit, and 30 min after administration of analgesia using the r-FLACC scale (by two independent caregivers) and the visual analog scale (by the child’s parent). Results The r-FLACC scores increased postoperatively and decreased after administration of analgesia (P<0.001) supporting good construct validity. Criterion validity was acceptable in view of the positive correlations between r-FLACC scores and visual analog scale scores provided by the parents (P<0.001). Moderate to significant correlations between observers for total r-FLACC scores (P<0.001), and good agreements for each of the five categories of the r-FLACC scores at baseline (k=0.422–0.627), in postanesthesia care unit (k=0.531–0.737), and after administration of analgesia (k=0.683–0.783) reflected strong inter-rater reliability. Conclusion The Egyptian version of the r-FLACC scale is a valid and reliable tool for postoperative pain assessment in Egyptian children with cerebral palsy.
  2,654 161 -
Superficial cervical plexus block in thyroid surgery and the effect of adding dexamethasone: a randomized, double-blinded study
Khaled Elbahrawy, Alaa El-Deeb
April-June 2018, 5(2):98-102
DOI:10.4103/roaic.roaic_45_17  
Background Thyroid surgeries are widely performed nowadays as an ambulatory procedure; so, the use of regional block for postoperative analgesia has gained popularity. Bilateral superficial cervical plexus blocks (BSCPB) alone or in combination with deep cervical plexus block are good examples. The duration of analgesia following these nerve blocks last for only a few hours. Patients and methods We randomly allocated 90 patients who are American Society of Anesthesiologists I or II scheduled for thyroid surgeries into three groups according to the contents of cervical block in addition to general anesthesia. Group C, which is the control group, received BSCPB with ropivacaine 0.2%. Group DB received BSCPB with ropivacaine 0.2% plus 8 mg dexamethazone. BSCPB with ropivacaine 0.2% plus 8 mg dexamethazone intravenously was given in group DI. Time to the first administration of supplemental analgesic postoperatively is our primary concern. Secondary outcomes include discharge time, rescue analgesic, rescue antiemetic, postoperative nausea or vomiting, pain score, and side effects of either block or drugs. Results Patients in group DB and DI need less postoperative rescue analgesic requirement than in the control group. Pain scores was statistically significantly less in group DB and in the DI group than in control groups at 6 and 8 h postoperatively. The occurrence of nausea and/or vomiting is statistically significantly less frequent in groups DB and DI when compared with the control group postoperatively. Conclusion The addition of dexamethasone to BSCPB resulted in decrease in time that elapsed until the first administration of supplemental analgesic, improved pain control, and reduced analgesic requirements postoperatively. This finding does not differ if dexamethazone is given either with block or intravenously.
  2,523 228 -
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.
  2,436 175 -
CASE REPORTS
Management of plant cardiac glycoside poisoning
Sonali Tripathi, Uma Hariharan, Jayashree Doval, Pradeep Meshram
April-June 2017, 4(2):90-92
DOI:10.4103/roaic.roaic_13_16  
Oleander poisoning is encountered rarely in clinical practice. The poisonous substances of oleander plant contain cardiac glycosides and their toxicity mimics digoxin overdose. We hereby report a case of intestinal oleander poisoning in an adult male, presenting with vomiting, disorientation, increased tone of muscles (spasticity) in lower limbs, and slow, irregular pulse. He responded to conventional treatment, consisting of intravenous atropine, intravenous phenytoin, intravenous dexamethasone, and correction of electrolytes. This report discusses the cardiotoxic and neurotoxic manifestations of yellow oleander poisoning, its early diagnosis, and prompt treatment. We would like to emphasize the importance of taking an ECG in all cases of poisoning.
  2,410 148 -
ORIGINAL ARTICLES
Ultrasound-guided ilioinguinal, iliohypogastric, and genitofemoral nerve block versus spinal subarachnoid blockade for inguinal hernia repair
Dorreya M Fekry, Nagwa A Megahed, Mohammed H EL-Lakany, Maha Mahmoud Soliman Yakout
January-March 2017, 4(1):29-34
DOI:10.4103/2356-9115.202693  
Introduction All anesthetic methods have been used for inguinal hernia repair surgeries. The use of local anesthesia (LA) techniques such as the ilioinguinal iliohypogastric nerve block (IHNB) may be the most convenient method for patients who are unfit for general anesthesia or spinal anesthesia (SA). The use of ultrasound (US)-guided techniques increases the success rate of the IHNB. The use of intravenous sedation increases the acceptability of LA techniques. Aim The aim of this study was to evaluate the effectiveness, safety, and complications of US-guided IHNB and genital branch of genitofemoral nerve (GF) block in comparison with SA for inguinal hernia repair surgeries. Patients and methods The current study was carried out on 42 patients of American Stroke Association classes I and II. Patients with recurrent, bilateral, irreducible, or large scrotal hernias were excluded. The patients were randomly divided into two equal groups using the closed envelope method, groups 1 and 2. Group 1 included 21 patients who were anesthetized using US-guided IHNB with 25 ml of 0.5% isobaric bupivacaine and genital branch of GF nerve block with 10 ml of 0.5% isobaric bupivacaine. Group 2 included 21 patients who received SA using 3 ml of 0.5% hyperbaric bupivacaine and 25 μg fentanyl. All patients received sedation as continuous propofol infusion. The propofol infusion dose was titrated until the sedation score was 4 using Ramsay Sedation Score. Result Patients receiving IHNB had better hemodynamic stability when compared with the SA group. The total postoperative analgesia was significantly lower and the first dose of postoperative analgesia was significantly delayed in the IHNB group. Postoperative ambulation was significantly early in the IHNB group. Conclusion US-guided IHNB and genital branch of GF nerve block under sedation are good anesthetic techniques for inguinal hernia repair surgeries.
  2,178 305 -
Optimizing heavy marcaine dose for spinal anesthesia in short stature pregnant female individuals undergoing cesarean section
Wael Elgharabawy, Ramy Mahrose
July-September 2018, 5(3):231-239
DOI:10.4103/roaic.roaic_98_17  
Background and objectives Hypotension after spinal anesthesia is still widespread in cesarean delivery, especially in pregnant women with short stature. The use of a reduced dose of local anesthesia allows adequate spinal anesthesia with minimal hypotension. We investigate the lowest dose of heavy bupivacaine that can be used to reduce the frequency of hypotension associated with adequate spinal anesthesia in short stature pregnant female individuals undergoing cesarean section. Patients and methods Sixty women scheduled for cesarean section were divided into three groups of patients (20 in each group) receiving spinal injections of 0.04 mg heavy bupivacaine/cm height (group A), 0.05 mg heavy bupivacaine/cm height (group B), and 0.06 mg heavy bupivacaine/cm height (group C). A decrease in systolic pressure greater than 20% of the baseline was considered low blood pressure and was treated with a bolus of 5–10 mg intravenous ephedrine. The quality of surgical anesthesia was assessed among groups. Results Groups B and C were assigned a higher sensory level block than group A after spinal anesthesia, and the difference was statistically significant (P<0.05). In group C, 18 (90%) patients developed a complete motor block, while in group B, 16 (80%) patients developed a complete motor block, compared with patients of group A in which only four (20%) patients developed complete motor block, and the difference between groups was statistically significant (P<0.05). The spinal block resulted in excellent surgical anesthesia in groups B and C compared with group A. Patients in group C were more likely to develop hypotension than patients in groups B and A. There was no significant statistical difference between the groups as regards neonatal outcome. Conclusions This study showed that the use of spinal anesthesia in pregnant women of short stature using heavy bupivacaine at a concentration of 0.05 mg/cm body weight showed a clear benefit in terms of adequate anesthesia and stable hemodynamics.
  2,250 141 -
A comparative study between the macintosh laryngoscope and the king vision video laryngoscope in endotracheal intubation
Sherif M Elhadi, Wafaa K Rady, Ahmed M Elfadly
October-December 2016, 3(4):168-172
DOI:10.4103/2356-9115.195881  
Background Airway management remains a vital primary skill for anaesthesiologists. We aimed at comparing the efficacy of direct laryngoscopy using the conventional Macintosh blade with indirect laryngoscopy using the King Vision video laryngoscope (KVVL) with regard to visualization of the laryngeal view, speed of intubation and intubation success rate. Patients and methods A total of 100 adult patients were randomly categorized into two equal groups (50 patients each): group M patients were subjected to general anaesthesia with endotracheal intubation using direct laryngoscopy with the conventional Macintosh blade; and group K patients were subjected to general anaesthesia with endotracheal intubation using the KVVL; the entire procedure of laryngoscopy and intubation was evaluated and all patients were intubated by one anaesthetist experienced in the use of each laryngoscope. Results The KVVL performed better in these patients by reducing haemodynamic response to laryngoscopy and intubation, improving the Cormack and Lehane glottis view, reducing the need for optimization manoeuvres and reducing the difficulty Likert scale score compared with the Macintosh laryngoscope (ML). There were no differences in intubation time, success rates and complications between both devices. Conclusion This study validated the efficacy of the KVVL compared with the direct ML. The KVVL performed better than the ML.
  2,096 293 -
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.
  1,981 300 1
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.
  1,988 242 2
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.
  1,912 285 -
Comparison between C-MAC D-blade and McCoy laryngoscopes in intubating patients during cervical immobilization
Laila A Sabry, Salwa S Shaarawy, Mohammed H Ellakany, Amir A Elmasry
July-September 2016, 3(3):122-128
DOI:10.4103/2356-9115.193412  
Aims This study was carried out to compare the efficacy of the C-MAC D-blade with the McCoy laryngoscope in intubating patients during cervical spine immobilization. Patients and methods This randomized controlled study was carried out in the Medical Research Institute Hospital, University of Alexandria, on 60 adult ASA I and II patients who were randomly categorized into two equal groups after written informed consent and approval of the ethics committee. All patients were subjected to the same anaesthetic protocol. Group I patients were intubated using the C-MAC D-blade laryngoscope, and group II patients were intubated using the McCoy laryngoscope. Haemodynamic measurements and oxygen saturation were recorded. The following intubation criteria were recorded for both groups: laryngeal view according to modified Cormack and Lehane grade at laryngoscopy, duration of the intubation procedure, number of intubation attempts and complications. Statistical analysis Data were statistically analysed with the SPSS software using t-test and χ2-test, and P value less than 0.05 was considered significant. Results Haemodynamic parameters (heart rate and mean arterial blood pressure) were significantly lower in the C-MAC D-blade group than in the McCoy group until 4 min after intubation. Oxygen saturation showed no significant difference between the two groups. The use of the C-MAC D-blade resulted in more appearance of modified C–L class 1, whereas the use of the McCoy laryngoscope resulted in more appearance of class 2b and class 3. Duration of intubation was statistically significantly longer in the C-MAC D-blade group than in the McCoy group, whereas for the number of intubation attempts C-MAC D-blade results in more successful intubation in the first attempt than the McCoy laryngoscope. Conclusion The C-MAC D-blade laryngoscope offers a new approach for the management of difficult airway, such as in patients in need for cervical immobilization. It causes less haemodynamic stress, it better intubates in the first trial and gives a better view of the larynx without moving the cervical spine, but it may be more time-consuming than direct laryngoscopes.
  1,944 193 -
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.
  1,937 148 1
ORIGINAL ARTICLES
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.
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Continuous regional local anesthetic infusion for pain control after median sternotomy
Eslam N Nada, Heba M El Aasr, Ahmed M Bakry
October-December 2015, 2(4):96-100
DOI:10.4103/2356-9115.178899  
Background The use of continuous wound irrigation by local anesthetics has attracted considerable attention in many surgical specialties, including cardiac surgeries. The aim of this study was to evaluate the postoperative analgesic effect of local anesthetic infusion into the wound resulting from a standard median sternotomy using a catheter of surgical vacuum device of size 12 Fr in patients after coronary artery bypass graft operation in comparison with intravenous analgesia. Patients and methods This is a randomized clinical study conducted in Zagazig University Hospital. After obtaining approval and written consent, 40 patients who were enrolled for coronary artery bypass graft with standard median sternotomy incision were divided into two groups: in group 1 postoperative pain was managed according to the ordinary protocol of the cardiac ICU - that is, intravenous pethidine 50 mg/12 h and 1 g paracetamol/8 h with supplemental doses of 25 mg pethidine on patients' demand, with the total daily dose of pethidine not exceeding 400 mg. In group 2 postoperative pain was managed by continuous regional local anesthetic infusion of bupivacaine 0.25% at a rate of 4 ml/h for 48 h by means of a catheter inserted over the sternum. The following data were collected: the amount and time of analgesia given to the patients, data from pain assessment carried out after extubation and every 4 h until discharge from the ICU, heart rate, systolic blood pressure, forced vital capacity (FVC), forced expiratory volume in the first second (FEV 1 ) and FEV 1 /FVC ratio, time of weaning from the mechanical ventilator, and time of discharge from the ICU and discharge from hospital. Results There was significant statistical difference between the two groups regarding all of the collected data, except demographic data, FEV 1 /FVC ratio, and length of stay in the ICU, which was 48 h for all patients in both groups. Conclusion Continuous local anesthetic infusion after standard median sternotomy resulted in lower pain scores, less need for narcotics, rapid weaning from the mechanical ventilation, better respiratory functions, and shorter hospital length of stay.
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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.
  1,859 154 -
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).
  1,721 238 -
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
  1,693 265 -
Relation of left ventricular function and serum interleukin level to mortality in septic patients
Mohamed Soliman, Abdou M Azab, Rania M El Hossainy, Mahesh Nirmalan, Hasan Khaled Nagi
October-December 2017, 4(4):177-183
DOI:10.4103/roaic.roaic_79_16  
Introduction Left ventricular systolic dysfunction and elevated serum interleukins (ILs) are common in septic patients. However, whether left ventricular diastolic dysfunction is related to mortality in septic patients is a matter of debate. Aim The aim of the study was to assess the effect of myocardial systolic and diastolic functions on mortality in cases of sepsis and to predict an inflammatory marker that could be clearly linked to mortality in sepsis. Patients and methods Twenty patients were prospectively studied, with measurement of the following on admission and on day 7: left ventricular end-diastolic volume, left ventricular end-systolic volume, left ventricular ejection fraction% (echocardiography), mitral annulus S-velocity, Ed/t, and serum levels of ILs (IL-1α, IL-1β, IL-6, and IL-10). Mortality on day 28 was the study endpoint. Results Twenty patients with sepsis and septic shock were studied (45% were male and 55% were female; mean age 52±17 years). The patients were divided into group I (survivors, 55%) and group II (nonsurvivors, 45%). Regarding echocardiography there was no significant difference between the two groups in end-diastolic volume, end-systolic volume, or ejection fraction% (112.3±51 vs. 94.5±30, 43.8±30 vs. 29.4±22, and 61.5±12 vs.71.2±11; P=0.4, 0.1, and 0.08, respectively) on admission or on day 7 (114.6±21 vs. 99.8±65, 43.8±30 vs. 29.4±22, 61.7±12 vs. 59.6±17; P=0.1, 0.2, and 0.7, respectively), whereas Ed/t data on admission showed statistically significant short Ed/t in group II (103.5±28) compared with group I (127.2±25) (P=0.04). However, on day 7 the difference was not significant (115.3±41 vs. 119±48, P=0.8). The mitral annulus S-velocity did not show significant difference either on admission (10.7±5 vs. 9.9±2, P=0.9) or on day 7 (8.6±4 vs. 10.7±4, P=0.1). Regarding the levels of ILs, there was no difference between group I and group II in terms of admission IL-1α (33.7±48 vs. 27.1±21, P=0.7), IL-1β (74±55 vs. 54.5±32, P=0.7), IL-6 (235.1±357 vs. 234.2±355, P=0.9), or IL-10 (110.7±121 vs. 135.3±241, P=0.9) or in terms of day 7 IL-1α (41.6±76 vs. 208.2±410, P=0.8), IL-1β (154.1±255 vs. 39.3±15, P=0.06), or IL-10 (87.2±230 vs. 189.6±335, P=0.9). However, on day 7 IL-6 showed a significantly high level in group II (294.8±385) versus group I (68.9±110) (P=0.05). Conclusion Systolic function did not predict prognosis. However, diastolic dysfunction in the form of Ed/t predicted poor prognosis. The higher IL-6 level on day 7 was a good predictor of mortality.
  1,027 922 -
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.
  1,667 213 -