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   2014| July-December  | Volume 8 | Issue 2  
    Online since October 20, 2014

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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.
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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.
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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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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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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
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Goal-directed fluid optimization using plethysmography variability index in laparoscopic bariatric obese patients: is it the answer?
Sherry N Rizk, Dina Z Mohamed, Walid S Taha
July-December 2014, 8(2):83-87
Objective The aim of the study was to compare effect of goal-directed fluid replacement using plethysmography variability index (PVI) guidance versus liberal fluid regimen in elective laparoscopic bariatric surgery on pulmonary oxygenation and gastrointestinal, cerebral, and renal function. Materials and methods This randomized-controlled trial included 60 consecutive patients who were 20-40 years of age with BMI greater than 40 scheduled for elective laparoscopic bariatric surgery between June 2010 and December 2011. Patients were randomized into 'liberal fluid' (LF) or 'goal-directed' (GD) fluid infusion group. All patients received 500 ml lactated Ringer's solution then 1-2 ml/kg/h in the GD group or 6-8 ml/kg/h in the LF group. A 5-min bolus infusion of 200 ml of 6% hydroxyl ethyl starch was administered, if PVI goes above 14, urine output less than 0.5 ml/kg/h, heart rate greater than 100/min, or decreased systolic blood pressure less than 20% of baseline value. This colloid bolus was repeated until 20 ml/kg is reached then lactated Ringer's solution was used for further boluses. The primary outcome measures were length of hospital stay, postoperative hypoxemia assessed by PO 2 /FiO 2 ratio, and serum lactate level. Results Intraoperatively, lactate level and volumes of infused Ringer's lactate and hydroxyl ethyl starch were significantly lower in the GD group (P < 0.001). PVI was significantly higher in the GD group (P < 0.001). Intraoperatively, lactate level and urine output were significantly lower in the GD group (P < 0.001). Postoperatively, the GD group showed significantly lower urine output (P < 0.001) and shorter time to recovery (P < 0.001) to first bowel movement (P < 0.001) and to resume normal diet (P < 0.001). Hypoxemia, diuresis, and fatigue were significantly more frequent in the LF group. No significant difference was seen in other postoperative complications. Conclusion Goal-directed, PVI-guided intraoperative fluid replacement significantly improved clinical outcome compared with liberal fluid intake. PVI guidance provides a sensitive and accurate determinant of fluid responsiveness and allowed for lower fluid intake. We recommend GD intraoperative fluid replacement with PVI and arterial blood gases (ABG) guidance in morbidly obese patients undergoing laparoscopic bariatric surgery.
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New applications in cardiac anaesthesiology: portable technology improves echocardiography reporting
Pietro Bertini, Fabio Guarracino
July-December 2014, 8(2):57-58
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