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Subclinical hypothyroidism affects the intraoperative and postoperative hemodynamics in coronary artery bypass graft surgery: should we supplement with thyroxine preoperatively
Ashraf F Mahmoud, Mohammed Rehan, Walid S Taha, Safinaz H Osman, Osama M Assad, Osama M Al Fayoumy
July-December 2013, 7(2):43-49
Background Our aim was to reveal the effect of the subclinical hypothyroid state on cardiac surgery, to derive a conclusion to include thyroid profile tests as a routine in cardiac surgery patients, and to know the role of thyroxine supplementation preoperatively in subclinical hypothyroid patients on the perioperative course. Patients and methods Between March 2007 and April 2010, we operated upon 87 patients of coronary artery revascularization, who had subclinical hypothyroidism as confirmed by laboratory investigations [high thyroid-stimulating hormone (TSH) and normal levels of T3 and T4]. We divided them into two groups: group A included patients who received preoperative thyroxine (47 patients) and group B included patients who were not supplemented with thyroxine preoperatively (40 patients). Preoperative, intraoperative, 24-h postoperative, and before discharge assessment of the cardiac function [ejection fraction percent (EF%)] as well as assessment of the thyroid profile (TSH, T3, and T4) were performed in all patients in both groups. Results We found an increased incidence of operative and postoperative complications in group B than in group A. The intraoperative and immediate postoperative EF% showed significant myocardial depression in group B (P < 0.003) and group A (P < 0.001) when compared with preoperative value. After 24 h of operation, the effect of thyroxine started to appear with a marked improvement in the cardiac functions in both groups. In group B, the EF% improved from 37.5 ± 3.07% at 12 h after operation to 45.6 ± 2.0% at 24 h after operation and to 53.76 ± 7.7% just before hospital discharge. With respect to the thyroid profile, there was a marked decrease in the level of T3 in group B intraoperatively (0.9 ± 0.3 pg/ml; P < 0.002). The level was corrected 24 h postoperatively, after the intake of the Eltroxine, to 2.3 ± 0.8 pg/ml and then to 2.5 ± 1.1 pg/ml before hospital discharge. The level of TSH was markedly increased in group B intraoperatively (14.3 ± 4.7 μIU/l; P = 0.007 between both groups). The TSH level started to decrease in both groups after intake of Eltroxine in hospital. There was an increased incidence of supraventricular arrhythmias, mainly atrial fibrillation (four cases in group A and eight cases in group B). Conclusion Thyroid function tests should be a routine preoperative investigation in any patient admitted for cardiac surgery. The preoperative supplementation of thyroxine is vital and decreases the operative and postoperative morbidity and mortality in patients with subclinical hypothyroidism.
  4,583 289 -
Ultrasound guidance versus transillumination for peripheral intravenous cannulation in pediatric patients with difficult venous access
Karim K Girgis
January-June 2014, 8(1):39-44
Objective Venous access can be technically difficult in pediatric patients because of the small size and impalpability of their veins. The aim of this prospective randomized study was to compare the use of ultrasound (US) guidance and transillumination as aids to facilitate peripheral intravenous cannulation in pediatric patients with difficult venous access. Patients and methods We included 80 children, less than 6 years of age, undergoing elective surgery, and having difficult venous access as predicted by a Difficult Intravenous Access score of at least 4. The patients were randomized to either US guidance (the US group, n = 40) or transillumination using the Veinlite EMS (the Veinlite group, n = 40). Cannulation was performed after inhalation induction of anesthesia. The primary outcome measure was the first-attempt success rate of cannulation. The secondary outcome measures were the overall success rate of cannulation, number of attempts, and time required to achieve successful cannulation. Results The first-attempt success rate was significantly higher in the US group (82.5%) compared with the Veinlite group (57.5%, P < 0.05). Both groups showed a high overall success rate (92.5% in the US group and 80% in the Veinlite group, P = 0.19). The time to achieve successful cannulation was significantly shorter in the US group (67.1 ± 19.3 s) than in the Veinlite group (94.1 ± 49.9 s, P < 0.01). The number of attempts required was not significantly different between the two groups. Conclusion Both US guidance and transillumination facilitate peripheral intravenous cannulation in pediatric patients with difficult venous access, resulting in a high overall success rate of cannulation. US guidance is superior as it results in a higher first-attempt success rate with less time required to achieve successful cannulation compared with transillumination.
  2,339 212 -
Truncus arteriosus ( perioperative management)
Marie Bosman
June 2012, 6(1):1-6

Truncus arteriosus is a congenital cardiovascular anomaly characterized by a single arterial vessel (truncus) with one valve arising from the heart. The truncus overrides a large perimembranous ventricular septal defect and receives mixed blood from both ventricles and supplies blood to the pulmonary, systemic, and coronary circulation, the ratio of the bloodflow vary according to the different vascular resistances. The anomaly is divided into four types according to Collett and Edwards classification on the basis of the origin of the pulmonary arteries from the truncal artery. In truncus, the goal is to balance the circulation to obtain QP:QS = 1 to maintain reasonable oxygen saturation as well as adequate organ perfusion. Careful titration of anesthetic agents and careful monitoring of their hemodynamic effects and appropriate measures to adjust pulmonary (PVR) and systemic vascular (SVR) resistances and cardiac performance are probably more important than the selection of a particular anesthetic agent. Postoperatively, low cardiac output can be expected because of high PVR and right ventricular failure. High PVR, both sustained and paroxysmal, should be anticipated. Pulmonary hypertensive crisis presents as low cardiac output and right ventricular failure. Avoidance of these potentially fatal events is essential to decrease the mortality and morbidity associated with repair. Events that trigger a hypertensive crisis, such as hypoxia, hypercapnia, acidosis, pain, airway stimulation, and left ventricular failure, must be avoided.

  2,145 377 -
Anesthetic management of ruptured ectopic pregnancy in immune thrombocytopenic purpura patient: a case report
Babita Ambush, Bhupendra Singh, Sakshi Maheshwari, Rakesh Karnawat
May-August 2015, 9(2):29-31
Bleeding in patients with low platelet counts is an important anesthetic challenge. We report a case of a 22-year-old woman who presented with a ruptured extrauterine pregnancy. The patient was a known case of immune thrombocytopenic purpura and she was on treatment with steroids. Her Hb was 6 g/dl and platelet count was 5000/ml. The postoperative period was uneventful and the patient was discharged 8 days after surgery. Here, we discuss the management and outcome of this rare presentation performed successfully under general anesthesia without the use of intravenous immunoglobulin that is an important agent for preoperative management of a planned surgical procedure for immune thrombocytopenic purpura patient to increase platelet count. The duration of surgery was 1 h. Hemostasis was achieved in this period as well.
  2,292 168 -
The novel use of spinal anesthesia at the mid-thoracic level: a feasibility study
Ahmed Abdelaal Ahmed Mahmoud, Hazem Abdelwahab Hussein, Karim Girgis, Ahmed Mostafa Kamal, Hesham Ahmed Nafady
January-June 2014, 8(1):21-26
Background Breast surgery is commonly performed in geriatric patients. In this age group, patients commonly suffer from comorbidities, making regional anesthesia the preferred option during surgery. Recently, segmental thoracic spinal anesthesia for laparoscopic cholecystectomy was tried successfully. Anatomical studies showed that the posterior dural-spinal cord distance is wider at the mid-thoracic region. This encouraged us to test the feasibility of performing spinal anesthesia at the mid-thoracic level for surgeries in the thoracic region, namely breast surgery. Materials and methods We performed a prospective feasibility trial including 25 patients, American Society of Anesthesiologists-I (ASA-I), undergoing minor breast surgery (lumpectomy or simple mastectomy) under segmental thoracic spinal anesthesia at T5 level with 1 ml plain bupivacaine (5 mg/ml) and 0.3 ml fentanyl (50 μg/ml). We assessed the number of attempts required, paresthesia during needle insertion, sensory block level, need for supplemental analgesics or general anesthesia, and block-related complications. Hemodynamics as well as patient satisfaction were also recorded. Results The block was successful in all patients. A single insertion attempt was needed in 22 (88%) patients. No paresthesia was recorded during needle insertion. The upper sensory level was at T1 (T1-T2) and the lower sensory level at T11 (T11-T12). No additional analgesics or general anesthesia were needed during procedure. Four patients required ephedrine to correct hypotension. Two of these patients developed nausea during hypotension. No other complications were recorded. Total satisfaction was reported by 23 (92%) patients. Conclusion Segmental thoracic spinal anesthesia at T5 level in healthy patients undergoing breast surgery can be used successfully with minimal hemodynamic instability. The safety of this technique needs to be confirmed by further studies involving larger number of patients, with comorbid conditions, before it can be advised for routine use.
  2,110 260 1
Outcome after mitral valve replacement in patients with rheumatic mitral valve regurgitation and severe pulmonary hypertension
Shady E Elwany, Ahmed H Mohamed, Amany K Abu El-Hussein
July-December 2013, 7(2):74-78
Objective The aim of this study was to assess the early outcome after elective mitral valve replacement (MVR) in patients with rheumatic mitral valve regurgitation and severe pulmonary arterial hypertension. Patients and methods The study included patients with baseline systolic pulmonary artery pressure (sPAP) of at least 40 mmHg who underwent elective MVR for rheumatic mitral valve regurgitation. The systemic and pulmonary hemodynamic changes and arterial blood gas parameters were reported at baseline, after intubation, after bypass, 30 min after extubation, and 24 and 48 h postoperatively. Preoperative and postoperative transthoracic echocardiography was performed. Results Thirty patients (11 men and 19 women), median age 31 years (range: 16-52), were included in the study. The operative mortality rate was 10%. The receiver operating characteristic curves identified sPAP as a good predictor of operative mortality. Postoperatively, there was a significant reduction in left atrial diameter and right ventricular systolic pressure in survivors. The median sPAP and pulmonary capillary wedge pressure decreased significantly after bypass and persisted throughout the study period. Central venous pressure decreased after cardiopulmonary bypass time and remained so for 48 h postoperatively. After intubation, on intermittent positive-pressure ventilation and FiO 2 of 1.0, there was a significant improvement in PaO 2 and SaO 2 . pH and HCO3 - concentration increased significantly postoperatively. Conclusion Proper perioperative care and anesthetic techniques resulted in improved left atrial diameter, right ventricular systolic pressure, sPAP, pulmonary capillary wedge pressure, and oxygenation with reduced operative mortality in patients who underwent MVR for mitral valve regurgitation with severe pulmonary hypertension.
  1,870 231 1
Ketamine/propofol (ketofol) versus propofol/fentanyl for induction of general anesthesia in parturients with rheumatic valvular lesions undergoing elective cesarean section
Nashwa Samy ELZayyat, Amira Refae Hassan, Ahmed Ibrahim ELSakka, Ahmed Hussein Saad
July-December 2013, 7(2):79-84
In this study, we assumed that the addition of ketamine to propofol (ketofol) would maintain cardiac stability in parturients with valvular heart without any deleterious effect on the fetus, that is no respiratory depression for the baby and hence a better Apgar score. This open-label randomized study was carried out in the High-risk Obstetric Unit, Cairo University Hospitals, in collaboration with the Anesthesia Department. The study included full-term parturients, 36-38 weeks' gestational age, 25-40 years old with severe rheumatic valvular heart lesions (mitral stenosis, mitral regurge, aortic stenosis, aortic regurge) of functional class II or III according to the New York Heart Association Classification. At the time of induction, patients were allocated randomly to one of the two study groups: group K (n = 25) received intravenous ketamine 1 mg/kg combined with propofol 1 mg/kg. Group P (n = 25) received propofol 2 mg/kg and fentanyl 2 mg/kg. Mean arterial blood pressure (MAP), heart rate (HR), and central venous pressure were recorded at the following times:T1, T2, T3, T4, T5, and T6. Decrease in MAP was only significant in group P (P < 0.001 at T2 and T3). The magnitude decreases in MAP. The absolute value of MAP was significantly lower in group P after induction, intubation, and skin incision. The median decrease in MAP was significantly higher in group P after induction and intubation. HR increased significantly after induction of anesthesia and after endotracheal intubation in the two groups. It reverted to near baseline values thereafter. The magnitude decreases in HR. The absolute value of HR was significantly lower in group P after intubation and skin incision. Apgar scoring was significantly better (higher) in the ketofol group at 1 and 5 min. We can conclude that a combination of ketamine and propofol seems to be an appropriate choice for anesthesia of critically ill rheumatic cardiac parturients undergoing cesarean section. It proved to be effective and hemodynamically safe for such a critical situation.
  1,866 216 -
Anesthesia for high-risk patients undergoing percutaneous mitral valve repair with the MitraClip system in the catheterization laboratory
Rabie Soliman, Reda Abuel Atta
September-December 2015, 9(3):33-38
Background MitraClip system implantation is a new technique for high-risk patients with severe mitral regurgitation and patients risky for surgical repair or replacement of mitral valve through cardiopulmonary bypass. Aim The aim of this study was to evaluate the anesthetic experience in high-risk patients undergoing MitraClip implantation. Setting Madinah Cardiac Center, Saudi Arabia. Patients and methods The study included 34 patients scheduled for MitraClip implantations in the catheterization laboratory. An arterial line and a central venous line were inserted before induction. Epinephrine was started before induction and milrinone infusion was started after induction. The anesthetic technique for induction and maintenance was the same for all patients. Monitors included the heart rate, the arterial blood pressure, the central venous pressure, arterial blood gases, the temperature, and the urine output. Results All patients were hemodynamically stable intraoperatively and postoperatively. The intervention was successful in 33 cases and aborted in one case because of severe posteromedial leaflet tethering. Epinephrine and milrinone were weaned, and all patients were extubated, except for one mortality case that happened within the first 8 h postoperatively. Conclusion Percutaneous mitral valve repair with MitraClip implantation is a successful alternative in high-risk patients with symptomatic severe mitral regurgitation. Proper preoperative evaluation of the patients by an anesthetist and a cardiologist is very important. Starting epinephrine before anesthetic induction and milrinone infusion after induction resulted in a decreased pulmonary artery pressure, an increased ejection fraction, and maintained the arterial blood pressure during the procedure.
  989 1,046 -
Duct occluder in the management of persistent postoperative pleural effusion after bidirectional Glenn's shunt
Soumendu Pal, Sandeep Khandelwal, Manvinder S Sachdev, Prabhat Dutta
January-June 2014, 8(1):51-54
The bidirectional Glenn's shunt (BDG) is the first step in the systematic, staged approach to a Fontan operation for patients with univentricular hearts. For the BDG to function well, the flow of blood through the pulmonary circulation must be free from significant impediments so that systemic venous pressure does not reach physiologically unacceptable levels. High systemic venous pressures are associated with high morbidity because of persistent bilateral pleural effusions and pericardial effusions, low oxygenation, increased plasma transfusion requirements, albumin infusions to maintain plasma protein levels, and prolonged ICU stay. We present a case of BDG complicated by prolonged pleural effusions in the immediate postoperative period, which was managed successfully using a percutaneous catheter-based approach, and thereby avoiding the complications of a major redo cardiac surgery.
  1,701 75 -
Intraoperative applications of tissue Doppler imaging
Mohamed Elsayed Abd Elhay
December 2012, 6(2):21-26

Intraoperative Doppler tissue imaging with pulsed wave Doppler is a rapid method to determine the direction, timing, and velocity of regional longitudinal myocardial motion and quantify systolic and diastolic function. Although DTI provides regional measurements, sampling from different sites will help compensate for any differences, facilitating the evaluation of global EF and diastolic function and the calculation of filling pressures. Repeated DTI observations in the same patient enable the detection of regional ischemia, and the appearance or detection of postsystolic shortening is a sensitive index of ischemic but viable myocardium. DTI has also been used to detect subclinical ventricular dysfunction in asymptomatic patients with valvular disease and differentiate physiologic from pathologic hypertrophy and distinguish constrictive pericarditis from cardiomyopathy.

  753 979 -
What the cardiac surgeons have to know about cold agglutination management
Mahnoosh Foroughi, Masoud Majidi, Manouchehr Hekmat, Mahmood Beheshti
September-December 2014, 8(3):101-103
Cold agglutinin has specific importance in cardiac surgery field due to routine use of the systemic, topical hypothermia in cardiopulmonary bypass and cold cardioplegic solutions (4-12΀C). We describe a case of coronary artery bypass in which cold agglutinin was detected intraoperatively; hence, cardiopulmonary bypass and myocardial protection strategies were changed. A simple and not expensive test is introduced to screen these patients before operation, as screening is not routine before cardiac surgery in many heart centers. In addition, we provide a literature review for surgical consideration and highlight some important concerns that need to be addressed.
  1,464 183 -
A prospective randomized comparative study between two different milrinone regimens in adult patients with pulmonary hypertension undergoing cardiac surgery
Rabie Soliman, Reda Abuel Atta
September-December 2014, 8(3):91-96
Context Milrinone is an inodilator commonly used to improve myocardial function and to decrease pulmonary hypertension. Aim The aim of this study was to compare two different regimens of milrinone administration in adult cardiac surgery patients with pulmonary hypertension. Setting and design A prospective, randomized, comparative study was conducted in Madinah Cardiac Center, Almadinah Almonourah, Saudi Arabia. Material and methods The study included 100 adult patients undergoing cardiac surgery with mean pulmonary artery pressure greater than 25 mmHg, as estimated preoperatively by Doppler echocardiography. The patients were classified randomly into two groups (n = 50): group A and group B. In group A, milrinone was started by infusion at a rate of 0.5 μg/kg/min without a loading dose at the beginning of CPB and continued postoperatively at a rate of 0.5-0.75 μg/kg/min in the cardiac surgical ICU. In group B, milrinone was given as a loading dose of 50 μg/kg over 10 min before weaning from CPB followed by infusion at a rate of 0.5-0.75 μg/kg/min postoperatively in the cardiac surgical ICU. Statistical analysis used Data were statistically described in terms of mean ΁ SD or frequencies and percentages, when appropriate, using the paired t-test. Measurements and main results Early milrinone using significantly decreased pulmonary artery pressure and pulmonary and systemic vascular resistances; it increased the right ventricular fractional area change, cardiac index, and urine output; and it decreased the serum lactate, pharmacological and mechanical supports, and ICU and hospital length of stay (P < 0.05). Conclusion The early administration of milrinone in adult cardiac surgery was associated with better hemodynamic effect, and it decreased the need for pharmacological supports. In addition, it was associated with shorter ICU and hospital length of stay without any side effects related to milrinone.
  618 997 -
Methylene blue for the management of pediatric patients with vasoplegic syndrome
Ghada A Hassan, Yasser A Salem, Heba A Labib, Ashraf A. H. Elmidany
July-December 2014, 8(2):66-74
Background Vasoplegic syndrome is a form of vasodilatory shock that can occur after cardiopulmonary bypass. Although norepinephrine is sufficient in most cases to restore adequate systemic vascular resistance and support systemic pressures, vasoplegia refractory to norepinephrine has been reported and is associated with high morbidity and mortality, especially in pediatric patients. The guanylate cyclase inhibitor methylene blue infusion could be a promising therapy for such cases. We reported in this study the response of pediatric cardiac patients with norepinephrine-refractory vasoplegic syndrome to methylene blue infusion. Patient and methods A total of 20 pediatric patients mean age 21.60 ± 9.88 months and mean weight 11.70 ± 3.63 kg, with norepinephrine-refractory vasoplegia after cardiopulmonary bypass were treated with an intravenous infusion of methylene blue (1.5 mg/kg) over 20 min. The effects on hemodynamic parameters, cardiac index, systemic vascular resistance index, and norepinephrine dosage were assessed 1 h after infusion. Results The mean arterial pressure increased significantly, with a mean difference of 16.70 ± 4.88 mmHg; also, a significant increase in systemic vascular resistance (P < 0.001), normalization of cardiac output, and a significant decrease in norepinephrine dosage (from 0.57 ± 0.05 to 0.11 ± 0.13 μg/kg/min) were observed in all patients within 1 h. No adverse effects related to methylene blue infusion were observed. Conclusion A single-dose methylene blue infusion appears to be a promising treatment for norepinepherine-refractory vasoplegia after cardiopulmonary bypass during pediatric cardiac surgery.
  1,387 156 -
A prospective randomized comparative pilot trial on extended daily dialysis versus continuous venovenous hemodiafiltration in acute kidney injury after cardiac surgery
Sahar S.I. Badawy, Amira R Hassan, Enas M Samir
July-December 2013, 7(2):69-73
Background and objectives Acute kidney injury (AKI) requiring dialysis after cardiac surgery is accompanied by high mortality. Continuous venovenous hemodiafiltration (CVVHDF) and extended daily dialysis (EDD) are commonly used for critically ill patients with AKI. The aim of this prospective randomized comparative pilot trial was to compare the efficacy of CVVHDF and EDD in patients with AKI after cardiac surgery. Patients and methods A total of 80 patients who developed AKI and who needed renal replacement therapy (RRT) after cardiac surgery were included in this prospective randomized comparative trial. Patients were randomized to receive either CVVHDF or EDD. The outcomes assessed were renal recovery, mortality rate at day 30, and cost of RRT in the ICU. Results Both groups were comparable with respect to demographic data and APACHE II score. The frequencies of renal recovery and mortalities were comparable in both groups. The cost of RRT was significantly lower in the EDD group compared with the CVVHDF group (P < 0.001). Conclusion Both CVVHDF and EDD are effective in patients with AKI after cardiac surgery, with EDD having the advantage of lower cost.
  1,331 133 3
Awake versus combined general and epidural technique for off-pump coronary artery bypass grafting surgery: A retrospective comparative study
Ashraf Fawzy, Walid S Taha, Abdelhay Ebade, Sherry N Risk
July-December 2013, 7(2):56-62
Objectives Our aim was to evaluate the effectiveness of thoracic epidural anesthesia and analgesia in off-pump coronary artery bypass grafting surgery. We examined its validity in patients under combined general/epidural anesthesia and in awake patients receiving epidural anesthesia as a sole anesthetic technique. Patients and methods We evaluated 318 patients who underwent off-pump coronary artery bypass graft surgery between January 2008 and September 2009. Group A (n = 242 patients, 76.2%) received combined general/epidural anesthesia and group B (n = 76 patients, 23.8%) received only a thoracic epidural catheter as the sole anesthetic technique without general anesthesia or endotracheal intubation (awake). We compared the intraoperative hemodynamic and respiratory variables, postoperative pain (by Visual Analogue Scale), myocardial infarction, atrial fibrillation, intensive care, and hospital stay. We followed our patients for 1 year, clinically and angiographically, and compared the rate of graft occlusion. Results There was no statistical difference in the intraoperative hemodynamic and respiratory variables (mean arterial pressure, heart rate, and partial pressure of arterial carbon dioxide) between the two groups, except for the partial pressure of arterial oxygen, which was higher in group A because of mechanical ventilation. There was no intraoperative mortality or postoperative myocardial infarctions in both groups. There was no statistical difference in the operative time between the two groups, but the patients in group A received a higher number of grafts than those in group B. There was no statistical difference in the postoperative pain scores; the mean pain score was 1.425 ± 0.42 in group A and 1.29 ± 0.3 in group B. The rate of atrial fibrillation was higher in group B (17%) than group A (7.02%) (P = 0.025). The mean intensive care stay and the mean hospital stay were higher (2.77 ± 0.9 and 7.314 ± 2.8 days) in group A than group B (1.269 ± 0.4 and 3.743 ± 1.2 days) (P = 0.0038 and 0.0021, respectively). Follow-up through the first postoperative year with coronary angiography indicated vein graft occlusion in three patients of group A (1.23%) and one patient in group B (1.31%), but this was not statistically significant. Conclusion We successfully performed off-bypass coronary revascularization surgery, including multivessel disease, under combined general/epidural anesthesia and in awake patients with thoracic epidural anesthesia as the sole anesthetic technique. Patients who are considered at high risk for general anesthesia and/or prolonged endotracheal intubation were good candidates for the awake technique as a valid alternative.
  1,327 117 -
The effect of different phenylephrine infusion rates on uteroplacental blood flow during cesarean delivery under spinal anesthesia
Sherry N Rizk, Karim Girgis, Ahmed Mahmoud Sayed, Rana M.N. Abdella
July-December 2013, 7(2):85-91
Introduction Hypotension associated with spinal anesthesia is more common and profound in the pregnant population, resulting in adverse effects to both the mother and the fetus. It is now widely accepted that the vasopressor of choice during cesarean delivery is phenylephrine. However, an overdose of phenylephrine may cause reflex bradycardia and decreased maternal and fetal cardiac output. In contrast, lower phenylephrine doses may not be adequate to avoid or control hypotension. The optimal phenylephrine dose and its direct effect on uteroplacental blood flow are yet to be determined. Aim of the work This study aimed to examine the direct effect of different phenylephrine infusion rates on uterine blood flow during cesarean delivery spinal anesthesia. Assessment of uteroplacental blood flow was performed using Doppler ultrasound of the uterine artery from which uterine blood flow indices were obtained, namely, peak systolic velocity (PSV) and pulsatility index (PI). Materials and methods This is a prospective, randomized double-blind study. We included 90 age-matched American Society of Anesthesiologists (ASA) I or II parturients with term singleton pregnancies admitted for elective cesarean delivery under spinal anesthesia. We excluded candidates with hypertension, cardiovascular or cerebrovascular disease, type 1 diabetes mellitus, allergy or hypersenstivity to phenylephrine, known fetal abnormalities, intrauterine growth retardation, and any contraindication to spinal anesthesia. The patients were distributed randomly into three equal groups (n = 30 each). Groups 25, 50, and 75 received 25, 50, and 75 μg/min phenylephrine infusion, respectively, after spinal anesthesia was administered. The maternal uterine artery was identified by colored Doppler ultrasound and pulsed-wave Doppler was used to measure PSV and calculate PI before spinal anesthesia and at 5 and 15 min after the block was performed. Maternal hemodynamics and measures of fetal well-being (Apgar score and umbilical venous pH) were also recorded. Results PI at 15 min after spinal anesthesia was significantly higher in group 75 in comparison with the baseline value (P < 0.05) and also in comparison with groups 50 and 25 (P < 0.05). Furthermore, the percentage of decrease in PSV, compared with the baseline, was also significantly higher in group 75 compared with the other two groups at both 5 and 15 min (P < 0.05). Group 75 also showed a significantly higher incidence of hypertension and bradycardia in comparison with both the other groups. However, the number of hypotensive episodes as well as nausea and vomiting was significantly higher in group 25 compared with the other two groups (P < 0.05). There was no significant difference in fetal outcome among the different groups. Conclusion and recommendations At a dose of 75 μg/min, phenylephrine induced a significant reduction in uteroplacental blood flow as evidenced by decreased PSV compared with baseline values and an increase in PI compared with the other two groups. This decrease in uteroplacental blood flow was not associated, however, with poor fetal outcome. Further studies are needed to address the correlation between uteroplacental blood flow and fetal outcome with different phenylephrine doses in patients with uteroplacental insufficiency.
  1,289 120 1
Transdermal nicotine patch as adjunctive analgesic modality to thoracic epidural analgesia for post-thoracotomy pain
Heba Ismail Ahmed Nagy, Hany Wafik ElKadi
July-December 2014, 8(2):75-82
Objective The aim of the study was to evaluate the applicability of transdermal nicotine patch (TNP) as an analgesic modality adjunctive to thoracic epidural analgesia (TEA) for patients undergoing thoracotomy. Patients and methods The current study included 100 adult nonsmoker male patients assigned to undergo thoracotomy and resection for lung cancer. Patients were randomly allocated into two equal groups: group N received TNP (5 mg/16 h) applied to glabrous skin immediately before induction of anesthesia and group C included patients who received placebo patch. All patients received bupivacaine (0.125%) TEA initiated at the time of induction of anesthesia until 48 h postoperative (PO). All patients received a β-lactam antibiotic as prophylactic and PO antibiotic. Rescue analgesia was provided as increments of dose of epidural bupivacaine until 48 h PO, and thereafter as intravenous meperidine 50 mg. PO pain was assessed using 10-point visual analog scale (VAS) and rescue analgesia was given if VAS was greater than 4. Intraoperative variability of heart rate and blood pressure measures, the frequency of requests for PO rescue analgesia, and the frequency of postoperative nausea and vomiting (PONV) were recorded. Results Epidural analgesia induced significant decrease in systolic arterial blood pressure and mean arterial blood pressure estimated at the end of surgery in both groups. Nicotine induced significantly higher heart rate compared with baseline measures in group N. Mean systolic arterial blood pressure and mean arterial blood pressure measures estimated at the end of surgery were significantly higher in group N compared with group C. Pain VAS scores were significantly lower in group N compared with group C throughout the first 48 h after admission to ICU, but thereafter pain VAS scores were significantly higher as against that determined at 48 h after ICU admission, in both groups. Pain VAS scores were significantly lower in group N compared with group C after removal of epidural catheter until 80 h after the end of surgery. The number of requests of rescue analgesia was significantly higher in group C compared with group N. TNP significantly reduced the number of requests of rescue analgesia after removal of epidural catheter in comparison with placebo. The frequency of PONV was significantly higher in group N compared with group C. Conclusion TNP could be considered as appropriate adjuvant analgesic to TEA for patients who had thoracotomy during early PO period and could be used as the sole analgesic after cessation of TEA. Prophylactic antiemetics were advocated to guard against the high possibility of development of PONV.
  1,258 146 1
Perioperative mortality: an emergent global public health problem
Landoni Giovanni, Ruggeri Laura, Borghi Giovanni, Zangrillo Alberto
July-December 2013, 7(2):41-42
  707 693 -
Permissive hypercapnia: From the ICU to the operating room
Mohamed Wagih
January-June 2014, 8(1):1-4
Although the effect of permissive hypercapnia on hemodynamics and right ventricular function was previously reported in patients with acute respiratory distress syndrome, the effects of acute controlled hypercapnia on right ventricular function during one-lung ventilation have not yet been investigated systematically. Experimental evidence is conflicting concerning the pulmonary vasodilatory or vasoconstrictive effect of hypercapnic acidosis. The final effect of hypercapnic acidosis on physiological functions depends on the level of hypercapnia and the context of the individual (healthy vs. diseased).
  1,193 174 -
What a reference manager can add for a physician in web 2.0 era
Ahmad Samir Alfaar, Radwa Nour
July-December 2014, 8(2):55-56
  1,125 190 -
Caudal anesthesia with sedation versus general anesthesia with local infiltration during pediatric cardiac catheterization: effect on perioperative hemodynamics and postoperative analgesia
Ahmed K Mohammed, Abdelhay Ebade, Ahmed M Alhaddad
January-June 2014, 8(1):33-38
Introduction Children undergoing cardiac catheterization are usually in need for perioperative analgesia. Aim and objective We studied the effects of local infiltration of bupivacaine at the groin in generally anesthetized children as against caudal bupivacaine combined with dexmedetomidine-ketamine sedation on intraoperative and postoperative hemodynamics and duration of postoperative analgesia in pediatric patients undergoing cardiac catheterization. Materials and methods A total of 40 patients (1-7 years) were randomly assigned into one of the two groups: one group (group GI) received general anesthesia (GA) together with local infiltration using 5 ml bupivacaine 0.25% at the beginning and at the end of the procedure and the other group (group SC) received sedation by ketamine at 3 mg/kg followed by infusion at a rate of 1 mg/kg/h to maintain sedation with caudal administration of a mixture of bupivacaine 0.25% at 3 mg/kg with dexmedetomidine 0.5 μcg/kg both diluted in normal saline to a volume of 1.2 ml/kg. Hemodynamic variables (blood pressure (BP) and heart rate (HR)) were evaluated at T1 (baseline, after induction), T2 (10 min after local infiltration/caudal administration), T3 (at time of puncture for vascular access), T4 (10 min after emergence), T5 (1 h after the procedure), and T6 (4 h after the procedure). Pain was evaluated 10 min after emergence (P1), after 1 h in the ICU (P2), after 4 h in the ICU (P3), and after 8 h (P4) by the FLACC (Face, Leg, Activity, Crying, Consolability) score. Side effects were observed for 12 h. Results The severity of pain was much less in the SC group than in the GI group. FLACC pain score was evaluated at P1 (10 min after emergence), P2 (1 h after procedure), P3 (4 h after procedure), and P4 (8 h after procedure) and it was found that pain is much less in the SC group than in the GI group during the first 4 h after the procedure with significant difference between the two groups (P < 0.05). There was a more stable hemodynamic profile for the SC group than for the GI group. The mean arterial pressure (MAP) and HR decreased from the baseline in both groups and they decreased more significantly in the SC group than in the GI group. In addition, the decrease in MAP and HR continued for a longer duration in the SC group than in the GI group. We observed a slightly prolonged analgesia with less need for supplemental analgesics in the SC group than in the GI group. Conclusion Combining caudal anesthesia using bupivacaine and dexmedetomidine with ketamine sedation provided prolonged and potent analgesia with much stable perioperative hemodynamic parameters than giving general anesthesia combined with local infiltration in the setting of pediatric cardiac catheterization.
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Congenital lobar emphysema: anaesthetic considerations
Vinod K Verma, Vinit Thakur, Arvind Kumar, Gautam Bhardwaj
July-December 2014, 8(2):88-90
Congenital lobar emphysema (CLE) is a rare clinical entity that usually presents as acute respiratory distress. It is potentially reversible, though possibly life-threatening, cause of respiratory distress in the neonate. It poses dilemma in diagnosis and management. We are presenting a 40 days old baby who presented with a sudden onset of respiratory distress related to CLE affecting the left upper lobe. Lobectomy was performed under general anaesthesia with spontaneous and controlled lung ventilation. Strategies to prevent hyperinflation and anaesthetic consideration of various techniques adopted for lung separation in infants have been reviewed.
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Licorice versus ketamine gargle for postoperative sore throat due to insertion of a double-lumen endobronchial tube
Ahmed Nabil Ibrahim, Sherif Anis
September-December 2016, 10(3):45-49
Background Postoperative sore throat (POST) is common after tracheal intubation, especially with double-lumen endobronchial tube (DLT). Licorice has many uses such as dental hygiene and in sore throat. Ketamine gargle is a newly proposed adjunct for reducing the incidence of POST in anesthesia. The aim of this study was to determine the efficacy of licorice and ketamine gargles in patients undergoing the insertion of DLT in preventing POST within 24 h. Methods This prospective, randomized, double-blind study included 90 patients undergoing thoracic surgery requiring DLT for one-lung ventilation. Patients were randomized to three groups (n=30) and were asked to gargle for 1 min to 15 min before operations. Group A received ketamine gargle (0.5 mg/kg ketamine in 30 ml of dextrose water 20%), group B received licorice gargle (500 mg licorice powder in 30 ml of dextrose water 20%), and group C (the control group) received 30 ml of dextrose water 20% gargle. Assessment of patients for the incidence and the severity of POST and any side effect was carried out in the recovery room. Sore throat (yes/no) and severity of its pain measured using visual analogue scale were recorded at baseline in the recovery room and then at 2, 4, and 24 h after operation with a specified questionnaire. Results The incidence of sore throat was significantly higher in group C at all time points in comparison with the other two groups. There was a marked decrease in the incidence of sore throat in groups A and B, with no significant difference between them. The severity of POST pain was significantly higher in group C when compared with the other two groups, with no significant difference between them and with no complications. Conclusion Ketamine and licorice gargles decrease the incidence and severity of sore throat occurring postoperatively due to DLT intubation, with no significant differences between them.
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Ascorbic acid versus magnesium for the prevention of atrial fibrillation after coronary artery bypass grafting surgery
Abdelhay Ebade, Walid S Taha, Riham H Saleh, Ashraf Fawzy
July-December 2014, 8(2):59-65
Objective The aim of the study was to evaluate the prophylactic use of ascorbic acid or magnesium on frequency of postoperative atrial fibrillation (POAF) in patients undergoing coronary artery bypass grafting surgery with cardiopulmonary bypass. Patients and methods The study included 60 patients divided into three equal groups (n = 20): the control group (group C) received saline infusion, the magnesium group (group M) received 2 g magnesium sulfate after induction of anesthesia, 1 g after 12 h followed by 1 g/8 h daily until the fifth postoperative (PO) day and the ascorbic acid group (group A) received 2 g ascorbic acid after induction of anesthesia, then 1 g after 12 h followed by 1 g/8 h daily until the fifth PO day. Operative and PO data were recorded. Primary endpoint was detection of an episode of atrial fibrillation (AF) lasting more than 10 min or the requirement for urgent intervention due to AF. Results Sixteen (26.7%) patients developed POAF, eight (40%) patients in group C, five (25%) in group M, and three (15%) in group A, with significantly higher frequency in group C compared with group M (P1 = 0.041) and group A (P2 = 0.001) but with nonsignificantly (P3 = 0.083) higher frequency in group M compared with group A. Four patients developed POAF on the first and 12 patients on the second PO day with nonsignificant intergroup difference. The mean duration of ICU stay was significantly longer in group C compared with groups M (P1 = 0.016) and A (P2 = 0.006), with nonsignificantly (P3 = 0.480) longer duration in group M compared with group A. The mean duration of PO hospital stay was significantly longer in group C compared with groups M (P1 = 0.008) and A (P2 = 0.004), with nonsignificantly (P3 = 0.415) longer duration in group M compared with group A. Conclusion Prophylactic use of ascorbic acid or magnesium significantly reduced the frequency of POAF after coronary artery bypass grafting surgery and significantly reduced ICU and hospital stay.
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Anaesthetic management of posterior mediastinal mass: a case report
Anjum Saiyed, Reema Meena, Babita Ambesh, Indu Verma
September-December 2014, 8(3):104-107
Posterior mediastinal mass surgery is a challenge to the anaesthetist in terms of airway obstruction, compression of great vessels due to mass effect of tumour and severe cardiovascular and/or respiratory collapse. This may occur following decrease in chest wall tone associated with neuromuscular blockade. In this case study, we report an 8-year-old male child presented with a large posterior mediastinal mass, displacing and partially encasing the aorta at our institution, SMS Medical College & Hospitals, Jaipur, Rajasthan. Mass was removed by left thoracotomy; endotracheal tube was advanced into the right bronchus to ventilate the right lung to improve access in the surgical field because tumour was situated on the left side. While dissecting the mass, there was considerable blood loss. This was replaced with hydroxyethyl starch and whole blood. Patient was extubated next day with uneventful recovery.
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