Effect of preoperative pregabalin versus gabapentin on postoperative pain control after laparoscopic gastric bypass surgery

Khalid G Abd El-Maksoud, Mokhtar M Younes, Sherif A Elokda

Ain-Shams Journal of Anaesthesiology 2017 10(1):195-200

Background Perioperative gabapentin helps produce a significant opioid-sparing effect and probably also improves postoperative pain scores. Pregabalin is a novel drug with a heightened research interest in the analgesic, sedative, anxiolytic, and opioid-sparing effects, in various pain settings, including postoperative pain. We investigated pregabalin analgesic efficacy in morbid obese patients experiencing acute pain after laparoscopic gastric bypass surgery and compared it with gabapentin and placebo. Patients and methods A randomized, placebo-controlled study was conducted on 90 morbidly obese patients undergoing laparoscopic gastric bypass surgery. Patients were allocated into one of the three groups; the pregabalin group in which the patients received 300 mg pregabalin, the gabapentin group in which the patients received 1200 mg gabapentin, or the control group in which the patients received placebo 2 h prior to surgery. Postoperative pain was controlled with intravenous fentanyl via patient controlled analgesia (PCA). Fentanyl consumption over 24 h and pain intensity measured by visual analogue score at rest (static) and during cough (dynamic) at recovery time, 1, 2, 6, 12, and 24 h were recorded. Also sedation status, somnolence, dizziness, headache, nausea, and vomiting were monitored. Results Postoperative 24 h fentanyl consumption was significantly higher in the control group compared with both pregabalin and gabapentin groups (P<0.001). Pain intensity on visual analogue score (static and dynamic) was significantly higher in the control group compared with both pregabalin and gabapentin groups at time of recovery, 1, 2, 6, 12, and 24 h postoperatively. Numeric sedation score was significantly lower in the control group compared with pregabalin and gabapentin groups at time of recovery, 1, 2, and 6 h postoperatively. No significant differences were found among the three groups as regards somnolence, dizziness, headache, nausea, and vomiting. Conclusion A single dose of 300 mg pregabalin or 1200 mg gabapentin given 2 h before surgery is better than placebo for postoperative pain control for laparoscopic gastric bypass surgery without significant side effects.

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Optimum target in percutaneous upper thoracic thermocoagulation in primary hyperhidrosis

Osama Yehia A Khalifa, Ahmed Sobhi M.E Hegab

Ain-Shams Journal of Anaesthesiology 2017 10(1):293-296

Introduction Primary palmar hyperhidrosis is a disabling problem that affects young age groups and usually continues for years without an effective treatment. It is usually accompanied by plantar hyperhidrosis and to a lesser extent by axillary affection. We have tried to improve the efficacy of percutaneous radiofrequency ablation of upper thoracic sympathetic ganglia via imitating what thoracoscopic surgeons do in endoscopic thoracic sympathectomy. Patients and methods A total of 40 patients with primary hyperhidrosis were randomly classified into two groups. Group Tb (n=20) underwent thermocoagulation of sympathetic chain on vertebral body. Group Th (n=20) underwent thermocoagulation of sympathetic chain on the head and neck of ribs. Hand temperature and dryness were followed up during the procedure and on the following intervals: 1 week, 1 month, 3 months, 6 months, 9 months, and 12 months after the procedure. Results During the procedure, the hands of 50% of patients became warm and dry in group Tb and only 40% remained so till 12 months, whereas in group Th, the hands of 100% of the patients became warm and dry during the procedure till 12 months. Conclusion Thermocoagulation of upper thoracic sympathetic chain on the head and neck of the second and third ribs is more effective than attacking the chain on vertebral bodies in patients with primary hyperhidrosis with no recorded complications.

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Effectiveness of minimal acute normovolemic hemodilution to minimize allogenic blood transfusion and re-exploration in elective adult coronary artery bypass graft surgery using colloid as a replacement solution

Mohammed S Shorbagy, Dina Salah

Ain-Shams Journal of Anaesthesiology 2017 10(1):3-9

Background and aim Various studies have questioned the efficacy of intraoperative acute normovolemic hemodilution (ANH) in reducing bleeding, the need for allogenic transfusion, and the incidence of re-exploration in cardiac surgery. The aim of the present study was to evaluate the effectiveness of the use of minimal ANH for blood transfusion requirements and re-opening in elective adult coronary artery bypass graft surgery using cardiopulmonary bypass. Patients and methods This prospective, randomized controlled study was conducted on 100 consecutive adult patients who underwent elective coronary artery bypass graft. Patients were randomly divided into two equal groups: the ANH group (n=50) and the control group (n=50). In the ANH group, 5–8 ml/kg of autologous blood was withdrawn after administering anesthesia and before systemic heparinization. Simultaneously, colloid solution (6% hydroxyethyl starch 130/0.4; Voluven) was infused in a ratio of 1:1, and then the blood was re-infused after bypass. Hemodilation was not carried out for the control group. Total amount of allogenic-packed red blood cell, fresh frozen plasma, platelet concentrate transfusion, and the number of patients undergoing re-opening because of excessive bleeding were calculated for the two groups. Results A significant decrease was observed in the number of red blood cell units and fresh frozen plasma transfusion per patient in the ANH group compared with the control group. Conversely, chest tube output, representing postoperative bleeding and platelet count, did not differ between the two groups. Conclusion In this study, the use of the minimal ANH technique reduced the consumption of allogenic red blood cells and fresh frozen plasma in adult cardiac surgery patients. However, this technique had no effect on postoperative bleeding, incidence of re-exploration, and platelet count.

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Comparison of butorphanol and tramadol as an adjuvant to local anesthetic drug in axillary brachial plexus block

Upasna Bhatia, Gauri Panjabi, Atisha Patel

Ain-Shams Journal of Anaesthesiology 2017 10(1):242-246

Background With the advent of opioid receptors, a variety of opioid agents are added to local anesthetic mixtures used in peripheral blocks to improve the quality and duration of block. In this study, we compared the effect of butorphanol and tramadol as adjuvant agents for orthopedic upper extremity surgery. Patients and methods This study was carried out on 50 patients aged between 18 and 60 years, of American Society of Anesthesiologists grades I and II, of either sexes in each group, undergoing orthopedic upper limb surgeries through axillary brachial plexus block. An injection of butorphanol 2 mg (group B) and that of tramadol 100 mg (group T) were added to local anesthetic mixture. Onset of sensory and motor blockade, extent of blockade, and occurrence of any complications were studied in both groups. All patients were observed for analgesia postoperatively by visual analog scale pain score. Results In our study, the onset time (minutes) of sensory and motor blockade was delayed in group B (8.76±1.0 and 5.86±0.71, respectively) as compared with group T (7.54±0.88 and 4.6±0.73, respectively). In group B, the duration of sensory block (291.24±48.51 min) was longer than group T (160.42±12.66 min). Duration of analgesia postoperatively (first rescue analgesic) was 619.96±26.96 min in group B, whereas it was 290.2±20.38 min in group T. Conclusion Butorphanol is more potent and produces longer duration of postoperative analgesia than tramadol, with an extra advantage of sedation and calmness.

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The effect of perioperative use of dexmedetomidine on pediatric patients with pulmonary hypertension undergoing congenital cardiac surgery

Hadil M Abdel-Hamid, Mai M Abdel-Azziz, Ahmed H Aly Omar

Ain-Shams Journal of Anaesthesiology 2017 10(1):10-14

Background Anesthetic management of a pediatric patient with pulmonary arterial hypertension (PAH) poses an enormous challenge. The objective of this study was to evaluate the ability of dexmedetomidine to reduce the pulmonary artery pressure in pediatric patients with PAH undergoing cardiac surgery. Patients and method Seventy patients diagnosed with PAH were enrolled in this study. The patients were randomized into two groups: group D received dexmedetomidine infusion of 1 μg/kg/h for one hour, which was reduced to 0.5 μg/kg/h throughout the surgery until extubation in the post anesthesia care unit (PACU), and group C received 0.9% normal saline in the same volume. Pulmonary artery systolic pressure (PASP) and systemic systolic blood pressure (SSBP) were recorded throughout surgery and postoperatively in the PACU. The need for vasodilator and sedative drugs and the time of extubation and ICU stay were recorded for all patients. Results The patients in the dexmedetomidine group showed a significant decrease in PASP and PASP/SSBP ratio during surgery and throughout the first 24 h in the PACU (P<0.001). The dexmedetomidine group required a significantly lower amount of vasodilator drugs than the control group (P<0.001), as well as a lower amount of sedatives (P<0.001). Conclusion We concluded that perioperative use of dexmedetomidine in pediatric patients with pulmonary hypertension reduces the PASP throughout the operative and postoperative period.

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Perioperative terlipressin infusion in living donor liver transplantation: effects on sodium and water balance

Tarek S Shabana, Sherif G Anis, Fady A Abdelmalek

Ain-Shams Journal of Anaesthesiology 2017 10(1):173-176

Background Although terlipressin is being used perioperatively in recipients of liver transplantation to improve splanchnic hemodynamics and postoperative renal functions, its associated antidiuretic effect has not been specifically investigated in this group of patients. The aim of this study is to assess the effect of terlipressin infusion started intraoperatively and continued for 48 h postoperatively in recipients of living donor liver transplantation on serum sodium and water/sodium excretion. Materials and methods Thirty patients with end-stage liver disease and portal hypertension scheduled for living donor liver transplantation were randomized into two groups including 15 patients each. Group 1 (control): patients did not receive terlipressin. Group 2: terlipressin was administered as an infusion at a rate of 2 µg/kg/h continued for 48 h after postoperative ICU admission. Comparisons were performed between both groups in terms of serum sodium, urine sodium, urine osmolarity, and the urine : sodium osmolarity ratio. Results There were no significant changes between the control group and the terlipressin group in serum sodium, urine sodium, urine osmolarity, and the urine : sodium osmolarity ratio. Conclusion Terlipressin infusion started intraoperatively at a rate of 2 µg/kg/h and continued for 48 h postoperatively in recipients of living donor liver transplantation did not result in significant changes in serum sodium and sodium/water excretion.

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Postoperative analgesic effect of dexmedetomidine in patients undergoing cardiac surgery

Assem A Moharram, Ashraf A.H El Midany

Ain-Shams Journal of Anaesthesiology 2017 10(1):15-19

Aim Open heart surgeries are painful procedures that require a large dose of analgesics. The aim of this study was to investigate the effect of postoperative dexmedetomidine (DEX) on the analgesic requirements in postcardiac surgery patients. Settings and design This prospective, randomized, double-blind study was conducted on 60 patients scheduled for elective coronary artery bypass graft surgery at the Cardiothoracic Surgery Unit, Ain Shams University Hospital. Patients and methods this study, group D (n=30) received DEX diluted to 4 μg/ml and infused at a rate of 0.1–0.2 μg/kg/h, whereas group C (n=30) received an equal volume of saline at an infusion rate of 0.1–0.2 μg/kg/h immediately from the end of surgery and postoperatively in the ICU thereafter. Postoperative analgesia was assessed using the Numeric Pain Intensity Scale, and sedation was assessed using the Modified Ramsay Score at T1, T2, T3, T4, T5, and T6 for the first 24 h, as well as postoperative rescue morphine analgesic requirements. Statistical analysis Analysis of data was performed using the Student t-test for independent samples for parametric data and using the χ2-tests for categorical data. Results There was a significant decrease in the pain scores in group D compared with group C (P<0.001). Morphine rescue analgesia was needed in 10% of patients in group D and in 95% of patients in group C, with a significant reduction in time to extubation and ICU length of stay in group D. The incidence of postoperative nausea and vomiting was lower in group D compared with group C but did not reach statistical significance. Conclusion Adding DEX after coronary artery bypass graft decreased both postoperative analgesic requirement and pain score without hemodynamic effects.

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The efficacy of rectus sheath block for pain management following laparoscopic orchiopexy surgery

Hoda Shokri

Ain-Shams Journal of Anaesthesiology 2017 10(1):219-223

Background Ultrasound (U/S)-guided rectus sheath block is an effective analgesic technique in elective pediatric laparoscopic surgical procedures. The aim of the study was to evaluate the efficacy of rectus sheath block for pain management following laparoscopic orchiopexy surgery. Patients and methods A total of 50 patients undergoing elective laparoscopic orchiopexy were allocated randomly into two groups: the U/S-guided rectus sheath block group (the REC group) and the general anesthesia-only group (the GA group), in which no rectus sheath block was performed. All patients received the same general anesthetic technique. In the REC group, patients received bilateral U/S-guided rectus sheath block, using 0.4 ml/kg of 0.25% bupivacaine, and morphine (0.1 mg/kg) was administered for rescue analgesia postoperatively and its total dose was recorded. Pain was measured by means of Children's Hospital of Eastern Ontario Pain Scale score. Hospital stay and the incidence of respiratory depression or vomiting were recorded. Results In all, 50 patients completed the study. The total dose of morphine used over 24 h was significantly lower in the REC group. Children's Hospital of Eastern Ontario Pain Scale scores were significantly lower in the REC group during the first 3 h postoperatively, and the incidence of vomiting, respiratory depression, and oxygen saturation in the postanesthesia care unit showed no significant difference between the study groups. Hospital stay was significantly shorter in the REC group compared with the GA group. Conclusion U/S-guided rectus sheath block is an effective analgesic technique with morphine-sparing effect after laparoscopic orchiopexy surgery.

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Efficacy and safety of single versus repeated stepwise cycling recruitment maneuver during one-lung ventilation in patients with normal pulmonary function undergoing video-assisted thoracoscopic lung surgery: a randomized, controlled trial

Elokda A Sherif, Arafa A Rasha, Gamil Khaled

Ain-Shams Journal of Anaesthesiology 2017 10(1):20-27

Background One-lung ventilation (OLV)-associated hypoxemia is a major concern and a challenge for the anesthesiologist. Lung recruitment maneuvers (RMs) are ventilator strategies in which the main goal is to restore the functional residual capacity and improve arterial oxygenation. Hemodynamic side effects are mainly associated with 'fast' RM not with 'slow' cycling RM and their effects are self-limited; therefore, they must be performed repetitively. Aim The aim of this study was to evaluate the efficacy and safety of single versus repeated stepwise cycling RMs during OLV in patients with normal lung function. Settings and design The study design is a randomized, double-blinded, controlled one. Patients and methods Sixty adult patients of ASA I–II who were scheduled for elective thoracoscopic lung surgery were randomized into groups C, single recruitment maneuver (SRM), and repeated recruitment maneuver (RRM) comprising 20 patients each. Group C patients received standard ventilation protocol: volume-controlled ventilation mode, VT 6 ml/kg, I : E ratio 1 : 2, positive end expiratory pressure (PEEP) 5 cmH2O, and respiratory rate 10–12 breaths/min. SRM patients received standard ventilation protocol with one alveolar RM 10 min after initiation of OLV with a PEEP of 10 cmH2O until end of surgery. RRM patients received standard ventilation protocol with first RM 10 min after initiation of OLV and then repeated every 30 min during OLV and a PEEP of 10 cmH2O until end of surgery. The following were assessed: hemodynamic parameters – heart rate, mean arterial blood pressure, and central venous pressure; respiratory mechanical parameters – peak airway pressure (Paw-peak), plateau pressure (Paw-plat), and static lung compliance; and oxygenation parameters – partial arterial oxygen tension (PaO2), PaO2/FiO2, and oxygen saturation (SpO2). Results PaO2 and PaO2/FiO2 ratio increased in the SRM and RRM groups after RM from T2 (10 min after first RM) to T4 (45 min from first RM), with a significant difference compared with group C (P<0.05). Peak and plateau airway pressures declined in the SRM and RRM groups after RM from T2 to T4, with a significant difference when compared with group C (P<0.05). Static lung compliance increased in the SRM and RRM groups after RM, with a significant difference among the groups (P<0.05). Conclusion Single or repeated cycling RM was considered effective with high safety profile in patients with normal pulmonary function undergoing thoracoscopic lung surgery using OLV.

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Dexmedetomidine as adjuvant to hyperbaric bupivacaine in spinal anesthesia for inguinoscrotal surgery

Nirvana A Elshalakany, Ahmed N El-Shaer, Amal H Rabie, Assem A Moharram, Amr M.M Elsofy

Ain-Shams Journal of Anaesthesiology 2017 10(1):264-271

Background and aim The purpose of this study was to evaluate the anesthetic and analgesic effects of dexmedetomidine as adjuvant in spinal anesthesia for patients undergoing inguinoscrotal surgery. Patients and methods A total of 70 adult male patients (American Society of Anesthesiologists I or II) scheduled for inguinoscrotal surgery were randomized into two equal groups using a computer-generated randomization table and received 3 ml plain hyperbaric bupivacaine 0.5% diluted in 0.5 ml normal saline in group C or plus dexmedetomidine (5 µg) in group D. Anesthesia, analgesia, and sedation qualities; hemodynamic changes; and adverse effects were recorded. Results The studied groups showed no significant difference regarding demographic data. The highest sensory level (T8) was the same in both groups, but there were statistically significant differences between the two groups (P<0.05) regarding quality of anesthesia, times of onset, and duration and regressions of sensory and motor blocks (rapid onset and delayed offset of sensory and motor blocks in group D). Postoperative pain score (visual analog scale) and rescue analgesic requirements were lower in group D compared with group C, and excellent analgesic quality was higher in group D. Sedation score intraoperatively and up to 60 min postoperatively was significantly higher in group D compared with group C. Regarding hemodynamics, mean arterial blood pressure and heart rate showed a statistically significant difference intraoperatively and till discharge to ward (P<0.05). Regarding adverse effects, two patients in group C compared with three patients in group D had incidence of hypotension (mean arterial blood pressure˂55 mmHg). Conclusion Dexmedetomidine as an adjuvant to hyperbaric bupivacaine in spinal anesthesia seems to be a profound intrathecal anesthetic, analgesic, and sedative agent, with preservation of hemodynamic stability and minimal adverse effects.

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Perioperative magnesium sulfate: an adjuvant to patients undergoing video-assisted thoracoscopic surgery

Assem A Moharram, Aktham A Shoukry, Nirvana A Elshalakany, Ahmed M Mostafa

Ain-Shams Journal of Anaesthesiology 2017 10(1):28-33

Background This randomized, prospective, double-blind, placebo-controlled study was designed to assess perioperative magnesium sulfate, an N-methyl-d-aspartate receptor blocker, as an anesthetic adjuvant reducing intraoperative anesthetic requirement, with a decrease in postoperative analgesic requirement and less adverse events. Patients and methods A total of 24 patients undergoing video-assisted thoracoscopic surgery were included in two parallel groups − the magnesium group (group M, n=12) received magnesium sulfate 40 mg/kg intravenously before induction of anesthesia followed by 15 mg/kg/h continuous intravenous infusion during the operation. The same volume of isotonic solution was administered to the control group (group C, n=12). Primary outcome measures were postoperative analgesic requirement (doses of morphine and ketorolac). Secondary outcomes included intraoperative anesthetic requirements (fentanyl, sevoflurane, and vecuronium), postoperative visual analog score, Ramsay sedation score, and postoperative adverse events. Results In the magnesium group, there was a reduction in intraoperative fentanyl (P=0.01), sevoflurane (P=0.02), and vecuronium (P=0.008), with a significant reduction in the postoperative dose of morphine (P=0.02), the need for rescue ketorolac (P=0.02), and a significant reduction in visual analog score and Ramsay sedation score compared with group C at 2, 3, 4, 6, and 8 h. There was a significant reduction in the number of patients who suffered an episode of tachyarrhythmia (P=0.03) with a decrease in nausea (P=0.06), vomiting (P=0.06), and pruritus (P=0.3), but did not reach statistical significance in group M compared with group C. Conclusion Magnesium sulfate as an anesthetic adjuvant decreased postoperative analgesic requirement with a decrease in intraoperative anesthetic doses, with less adverse events.

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Comparative study between dexamethasone and dexmedetomidine as an adjuvant to ondansetron for the prevention of postoperative nausea and vomiting following functional endoscopic sinus surgery operation

Sameh H Seyam

Ain-Shams Journal of Anaesthesiology 2017 10(1):156-163

Background Postoperative nausea and vomiting (PONV) are the most common annoying events and complications following general anesthesia and surgery. Emetic incidents can lead to aspiration of gastric contents, wound unsealing, psychological distress, and delayed recovery from anesthesia and discharge times. Aim This study was designed to compare the effects of a single dose of dexmedetomidine or dexamethasone as an adjuvant to ondansetron for reducing PONV after functional endoscopic sinus surgery operation and to assess if there is any advantage of one drug over the other. Patients and methods This study is a prospective randomized single-blind study. The study involved 60 patients with American Society of Anesthesiologists physical status I and II, of both sexes, between 18 and 50 years of age, undergoing elective functional endoscopic sinus surgery operation. At the end of surgery, patients were randomly allocated to receive an intravenous single dose of either 0.1 mg/kg of ondansetron as a control group, or 8 mg of dexamethasone following 0.1 mg/kg of ondansetron, or dexmedetomidine 0.1 μ/kg following 0.1 mg/kg ondansetron. Postoperatively, all the incidents of nausea, retching and/or vomiting were recorded and patients were asked if vomiting had occurred or if the patients felt nauseated with only two possible answers (yes or no). Results There was no significant differences among the three groups regarding the incidence of PONV during the first 24 h postoperatively, with a slight difference in the ondansetron–dexmedetomidine (ondan–dexmed) group, which was less in frequency in relation to the other groups (P<0.211). Regarding the PONV incidence in relation to intraoperative and postoperative medications, there was a highly significant difference among the three groups regarding the severity of PONV. The PONV severity was lower in the ondan–dexmed group in relation to the other groups (P<0.001). The metoclopramide dose during the following 24 h was significantly low in ondan–dexmed group in relation to the other groups (P<0.001). The tramadol dose during the following 24 h was significantly low in ondan–dexmed group in relation to the other groups (P<0.001). The intraoperative fentanyl requirements was significantly lower in ondan–dexmed group in relation to the other groups (P<0.001). Regarding the first analgesic request, it was significantly delayed in ondan–dexmed group in relation to the other groups (P<0.021). Conclusion A single dose of dexmedetomidine combined with ondansetron is superior to ondansetron alone or ondansetron combined with dexamethazone for preventing PONV in patients undergoing functional endoscopic sinus surgery under general anesthesia.

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Propofol, remifentanil, and low-dose atracurium besylate versus sevoflurane and fentanyl for bronchoscopy in children: a randomized-controlled trial

Amr Ahmed Kasem, Fekry Elbokl, Hany Elzahaby, Hisham Elazzazy, Ahmed Elsayed, Amr Ahmed Kasem

Ain-Shams Journal of Anaesthesiology 2017 10(1):34-40

Objective The aim of this study was to compare the use of remifentanil and propofol infusion plus low-dose atracurium besylate technique with the commonly used inhalational technique using sevoflurane with fentanyl for children undergoing bronchoscopy for foreign body (FB) removal. Patients and methods This prospective randomized-controlled trial was conducted at Ain Shams University Hospitals. Sixty children aged 1–5 years planned for elective or emergency FB removal by bronchoscopy were included in the current study. The recruited children were assigned randomly into two groups: group I: total intravenous anesthesia (TIVA group) (remifentanil, propofol, and low-dose atracurium besylate); group II: volatile induction and maintenance of anesthesia (VIMA) (sevoflurane and fentanyl). Intraoperative and postoperative measurements and complications were recorded. Results There was no statistically significant difference between both groups in induction time, bronchoscopy time, time for discharge from the recovery room, and emergence time between both groups. The number of bronchoscopy attempts, interruptions of bronchoscopy, and body movements were significantly higher in the VIMA group than the TIVA group; satisfaction with surgery was greater in the TIVA group than the VIMA group. There was no difference between groups in the incidence of complications, except for postoperative agitation, with a higher incidence in the VIMA group compared with the TIVA group. Conclusion The use of 0.1 µg/kg/min remifentanil-propofol TIVA, plus a small dose (0.25 mg/kg) of atracurium besylate at induction, provided stable hemodynamics, better surgeon satisfaction, and less postoperative agitation compared with sevoflurane 2% in 100% oxygen plus fentanyl 1 µg/kg in children undergoing tracheobronchial FB removal during rigid bronchoscopy.

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Intravenous ephedrine, phenylephrine, and ketamine for attenuation of hypotension associated with induction of general anesthesia with propofol

Mostafa Mansour Hussein, Raham Hasan Mostafa, Ibrahim Mohamed Ibrahim

Ain-Shams Journal of Anaesthesiology 2017 10(1):182-187

Background and objective Hypotension and bradycardia remain the major adverse effects of propofol during induction of general anesthesia. Several drugs were studied to prevent these adverse effects. In our study, we compare the effect of mixing ephedrine, phenylephrine, or ketamine with propofol to attenuate its hypotensive effect during induction of general anesthesia. Materials and methods A total of 120 patients of both sexes between 20 and 50 years of age and ASA I–II physical status undergoing elective ambulatory surgeries under general anesthesia were included in our study. Patients were randomly allocated into four groups (30 patients each): group C (the control group), which received plain propofol; group E (the ephedrine group), which received 15 mg of ephedrine premixed with propofol; group Ph (the phenylephrine group), which received 100 μg of phenylephrine premixed with propofol; and group K (the ketamine group), which received 30 mg of ketamine premixed with propofol. In all groups, mean arterial blood pressure (MABP) and heart rate (HR) were recorded at baseline (before induction) and then every 1 min until 6 min after induction. Results Addition of ephedrine, phenylephrine, or ketamine to propofol during general anesthesia induction can significantly attenuate hypotension and bradycardia. In the control group, the MABP dropped from 91.96±3 mmHg just before induction to 75.6±8.7 mmHg at 6 min after induction. HR in the control group dropped from 83.76±7.29/min just before induction to 75.3±12/min at 6 min after induction. The drop in MABP and HR were nonsignificant in the other three groups. Conclusion Mixing propofol with ketamine, ephedrine, or phenylephrine before induction can attenuate its hypotensive and bradycardic effects.

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Evaluation of the value of hypertonic saline as adjuvant treatment of severe ovarian hyperstimulation syndrome

Amr Sobhy, Hany V Zaki, Doaa M Kamal Eldin, Walid E Mohammed

Ain-Shams Journal of Anaesthesiology 2017 10(1):41-45

Background At present, ovarian hyperstimulation syndrome (OHSS) is an uncommon and potentially life-threatening complication of ovarian stimulation. The ideal colloid solution for the treatment of patients with severe OHSS is still unknown. Human albumin, however, is considered the most 'physiologic' solution for this purpose and commonly used. However, severe life-threatening anaphylaxis has been reported with albumin infusion. The purpose of this study was to compare the efficacy and safety of hypertonic saline 3% for the treatment of severe OHSS rather than albumin. Patients and methods Over a period of 2 years, this randomized prospective study was conducted on 60 patients diagnosed with severe or critical OHSS admitted to Obstetric ICU of Ain-Shams University Hospitals. Patients were randomly allocated into two groups, each containing 30 patients. Group A (n=30) received 100 ml of albumin 20% over 4 h every 12 h plus conventional treatment according to the Ain Shams obstetric ICU protocol. Group N (n=30) received 500 ml of hypertonic saline 3% over 24 h (20 ml/h) plus conventional treatment. The efficacy of the study medications was compared in this study between the two groups in terms of daily urine output, serum creatinitine, percentage of occurrence established renal impairment, need of paracentesis, occurrence of established acute respiratory distress syndrome, and ICU length of stay. Results Significant difference was found regarding daily urine output among the study groups, with a significantly higher value (3350±142.6) in group N compared with group A (2150±133.4) associated with significant reduction in occurrence of established renal impairment in three cases in group A rather than 1 in group N. This is reflected by significant reduction in the length of ICU stay (3.1±1.1) in group N rather than group A (3.7±1.2). Conclusion The use of hypertonic saline 3% as a small-volume resuscitation is comparable to and effective and superior to albumin for the treatment of severe OHSS with regard to urine output, and may have a protective effect against occurrence of acute respiratory distress syndrome in such patients, but further studies are needed to prove that.

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Dexmedetomidine infusion versus placebo for analgesia and prevention of emergence agitation in morbidly obese patients undergoing laparoscopic sleeve gastrectomy

Mostafa M Hussein, Raham H Mostafa

Ain-Shams Journal of Anaesthesiology 2017 10(1):207-212

Background Emergence agitation (EA) can occur following recovery from general anesthesia. The patient may exhibit aggressive behavior, disorientation, agitation, and restlessness. If untreated, this complication may result in significant morbidity. EA has been poorly investigated in patients undergoing laparoscopic sleeve gastrectomy. Aim The aim was to assess the efficacy of perioperative dexmedetomidine infusion on EA and quality of recovery after elective laparoscopic sleeve gastrectomy in morbidly obese adult patients. Materials and methods A total of 60 patients undergoing laparoscopic sleeve gastrectomy were randomized into two groups (30 patients each). The dexmedetomidine group (group D, N=30) received dexmedetomidine infusion, whereas the control group (group C, N=30) received normal saline in the same volume and rate as placebo. Propofol, fentanyl, and atracurium were used for induction of anesthesia, and isoflurane was used for maintenance of anesthesia. Postoperative hemodynamic variables, postoperative pain, the need for 'rescue' analgesics and antiemetics, and the incidence of agitation were recorded up to 2 h postoperatively. Pain was evaluated using the visual analog scale score in the postanesthesia care unit on arrival, at 5 min, and then every 15 min for 120 min. EA was evaluated at the same time intervals by Richmond agitation-sedation scale (RASS). Pethidine 50 mg intravenously was given for pain (if pain score >4) or severe agitation (RASS score >+1). Results No patients in group D experienced postoperative EA during the second hour postoperatively (RASS ˂1). On the contrary, RASS scores of patients in group C were 2 (2–3) on arrival to postanesthesia care unit and greater than +1 during the remaining time up to 2 h postoperatively, indicating postoperative EA. In group C, 25 (92.5%) patients required rescue analgesia compared with only five (18.5%) patients in group D. Hemodynamic parameters were stable in group D. Conclusion Dexmedetomidine infusion during laparoscopic sleeve gastrectomy for morbidly obese patients is beneficial and effective in preventing postoperative pain and postoperative EA.

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Evaluation of the value of early use of norepinephrine infusion in the improvement of renal function in patients with severe sepsis with early renal impairment using cystatin C, a sensitive renal marker

Amr Sobhy, Ayman I. Tharwat, Ahmad Nabil, Akthm Adel

Ain-Shams Journal of Anaesthesiology 2017 10(1):46-53

Introduction Acute renal failure occurs in ∼23% of patients with severe sepsis. The combination of acute renal failure and severe sepsis may carry a mortality of up to 70%. Several studies have demonstrated that serum cystatin C level is a better marker of glomerular filtration rate (GFR) compared with serum creatinine, particularly for individuals with small-to-moderate decreases in GFR. To maintain organ perfusion in sepsis, a mean arterial pressure of 65 mmHg should be maintained with fluid therapy and vasopressors. Marked delays in initiation are associated with increase in mortality risk in patients with septic shock. Patients and methods Sixty patients enrolled in the study proved to have severe sepsis with early renal impairment. Patients were randomly allocated into one of two groups (30 patients each): the norepinephrine infusion group (the N group) and the control group (the C group). The N group received norepinephrine infusion + conventional treatment for severe sepsis, whereas the C group was treated with conventional treatment for severe sepsis according to the latest Surviving Sepsis Campaign. For each patient, the following data were collected: age, body weight, hemodynamic changes, urine output, renal function as detected from levels of the sensitive renal marker cystatin C and from serum creatinine levels, blood urea nitrogen, and estimated GFR (eGFR). Results There was a statistically significant increase in blood pressure and urine output in the N group at 10 min and 2 h, respectively, after norepinephrine infusion and on comparing subsequent measures with baseline values (T0) and also when compared with corresponding values in the C group. In addition, patients in the N group showed a statistically signifi cant decrease in serum cystatin C levels and an increase in eGFR based on cystatin C levels after 2 h of norepinephrine infusion, compared with baseline values and values in the C group, denoting marked improvement in GFR. Serum creatinine levels, blood urea nitrogen levels, and eGFR based on serum creatinine levels showed no significant difference in either group whether compared with baseline of the same group or when comparing both groups together. Conclusion The results this study demonstrate that early continuous infusion of norepinephrine at 0.5–1 μg/ kg/min may have a renoprotective role in septic patients with early renal impairment detected by levels of the sensitive renal marker cystatin C.

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Intrathecal hyperbaric bupivacaine with fentanyl for labor pain control: a comparative study with continuous epidural analgesia with bupivacaine

Mokhtar Younes, Khaled Gamil, Ahmed M. Elgarhy

Ain-Shams Journal of Anaesthesiology 2017 10(1):230-236

Objective The aim of the study was to assess single-dose intrathecal bupivacaine in combination with fentanyl as a safe and effective alternative to epidural for labor analgesia. Patients and methods Sixty women aged 20–30 years, of American Society of Anesthesiology I–II, and with a single uncomplicated pregnancy were included in this study. Patients were randomly allocated to two equal groups: the spinal group received hyperbaric bupivacaine 0.5% at a dose of 1 ml plus 25 μg fentanyl (0.5 ml), whereas the epidural group received bupivacaine 0.25% at a 14 ml bolus dose with a background epidural infusion of bupivacaine 0.125% at 10 ml/h. Pain intensity was recorded on a visual analogue scale. The quality of pain relief was also related to patient satisfaction after delivery. Side effects such as hypotension, motor block, pruritus, sedation, and nausea were noted. Obstetric parameters and Apgar score were noted, and all results were compared. Results Onset of sensory block was earlier (5.6 ± 1.27 vs. 8.8 ± 1.62 min, P < 0.001) and visual analogue scale at 5, 60, 90, 120, and 150 min was lower in the spinal group compared with the epidural group. All these results were statistically signifi cant. Ninety percent of the parturients in the spinal group versus 62% in the epidural group scored the analgesic quality as excellent. No significant hemodynamic changes were recorded in either group. There were no significant differences between the two groups in motor block, sedation, and nausea. No cesarean section or instrumental delivery was performed. Oxytocin augmentation was needed in 33.3 versus 50% of the parturients in the spinal and epidural groups, respectively. Fetal heart rate disturbances were seen in 10% in the epidural group versus 6.6% in the spinal group. Apgar scores were high and no neonate had Apgar score less than 7 in either group. The overall cost was lower in the spinal group compared with the epidural group. Conclusion Single-dose intrathecal local anesthetic with narcotics is shown to relieve pain safely in most laboring women, with rapid onset and prolonged duration of labor analgesia comparable to that of epidural analgesia while being more easily performed, less time-consuming, and less expensive, and providing similarly excellent analgesia.

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Local application of tranexamic acid to reduce upper gastrointestinal bleeding in patients with liver cirrhosis

Rasha S Bondok, Dina Salah, Wael Sayed

Ain-Shams Journal of Anaesthesiology 2017 10(1):54-59

Background There has been a growing interest in the topical use of tranexamic acid (TXA) for the prevention of bleeding during different surgeries. Patients with liver cirrhosis may develop upper gastrointestinal (UGI) bleeding, which arises because of portal hypertension, which includes gastroesophageal varices and portal hypertensive gastropathy. The aim of this study was to evaluate the efficacy of the local application of TXA in reducing blood loss, transfusion requirements, and shortening the time for emergency endoscopy in cirrhotic patients presenting with UGI bleeding. Patients and methods A total of 100 patients with end-stage chronic liver disease presenting with UGI bleeding were randomly assigned to two groups to receive a standard protocol for UGI bleeding management, in addition to nasogastric lavage with either normal saline only (group S) or normal saline with TXA (group S+TXA). The lavage was repeated till its measured hematocrit (Hct) was less than 1%. The duration to reach this Hct was recorded. The volume of washes and transfusion requirements for each group were also recorded. Results Hemodynamic stability was observed in group S+TXA with less bleeding. The volumes of washes were significantly lower in group S+TXA. Time to reach Hct less than 1% in washed fluid was significantly shorter in group S+TXA (81.5±20.7 min) compared with group S (230.1±29.9 min). Transfusion requirements were significantly low in group S+TXA (765±184 ml) compared with group S (1345±278 ml). Duration to perform emergency upper endoscopy was shorter in group S+TXA (667±198 min) compared with group S (1094±163 min). Conclusion Local application of TXA during nasogastric lavage was efficient in reducing blood loss and transfusion requirements and in shortening the time for emergency endoscopy in cirrhotic patients presenting with UGI bleeding.

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The effects of adding dexamethasone to intra-articular morphine injection on postoperative pain after knee arthroscopy

Abd-Elazeem A El Bakry, Wesam-Eldin A Sultan

Ain-Shams Journal of Anaesthesiology 2017 10(1):253-257

Background Postoperative analgesia after knee arthroscopy is mandatory for recovery and early rehabilitation. Medications were used intra-articularly to prolong postoperative analgesia and improve the quality of pain. The present study was scheduled to study the effects of dexamethasone addition to intra-articular morphine on postoperative pain after knee arthroscopy. Patients and methods This randomized double-blinded controlled study was carried out on 90 patients undergoing knee arthroscopy. The patients were randomly allocated into three equal groups. All medications were injected intra-articularly at the end of surgery. In the control group, the patients were administered 0.5% bupivacaine in normal saline. In M group, the patients were administered 5 mg morphine added to bupivacaine 0.5%. In MD group, the patients were administered 5 mg morphine and 8 mg dexamethasone added to bupivacaine 0.5%. Vital signs, visual analog score for pain at rest and movement, duration of analgesia, total analgesic consumption and adverse effects were recorded. Results MD Group showed lower visual analog score at rest and movement, prolonged postoperative analgesia, and decreased total analgesic consumption compared with the other groups (P<0.05). Conclusion The addition of dexamethasone to intra-articular morphine after knee arthroscopy prolongs the duration of analgesia, lowers pain scores, and decreases total analgesic consumption with minimal adverse effects.

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