BackgroundDuring scoliosis surgery, motor evoked potentials (MEP), and somatosensory evoked poten... more BackgroundDuring scoliosis surgery, motor evoked potentials (MEP), and somatosensory evoked potentials (SSEP) have been reported to be affected by the use of higher doses of anesthetic agents. Dexmedetomidine, a sympatholytic agent, an alpha‐2 receptor agonist, has been used as an adjunctive agent to lower anesthetic dose. However, there is conflicting evidence regarding the effects of dexmedetomidine on the intraoperative neurophysiological monitoring of MEP and SSEP during surgery, particularly among pediatric patients.ObjectivesThis systematic review aimed to determine whether, during spinal fusion surgery in pediatric patients with scoliosis, dexmedetomidine alters MEP amplitude or SSEP latency and amplitude and, if so, whether different doses of dexmedetomidine display different effects (PROSPERO registration number CRD42022300562).MethodsWe searched PubMed, Scopus, and Cochrane Library on January 1, 2022 and included randomized controlled trials, observational cohort and case–...
Background: We aimed to assess the efficacy of ultrasound-guided bilateral erector spinae plane b... more Background: We aimed to assess the efficacy of ultrasound-guided bilateral erector spinae plane block (ESPB) compared to intrathecal morphine (ITM) for analgesia after elective cesarean delivery under spinal anesthesia. Methods: In total, 140 parturients scheduled for elective cesarean section under spinal anesthesia were randomly allocated into two equal groups. The ESPB-group received 10 mg hyperbaric bupivacaine intrathecally through spinal anesthesia, followed by an ESPB at the ninth thoracic transverse process with 20 mL of 0.5% bupivacaine immediately after the operation. The ITM-group received 10 mg hyperbaric bupivacaine with 100 mcg morphine intrathecally through spinal anesthesia, followed by a sham block at the end of the surgery. The visual analogue scale (VAS) score for pain at several postoperative time points, total opioid consumption, and time to the first analgesic request were evaluated. Statistical analysis was performed with the independent t-test and linear mixed-effects models. The Kaplan-Meier estimator and the log-rank test were used to compare the primary and secondary outcomes of the groups. Results: No significant differences were observed between the groups regarding patient characteristics; in the post-operative period (0-24 hrs), VAS scores (at rest) were, on average, 0.25 units higher in the ITM group. The total tramadol consumption in the first 24 hrs was significantly higher in the ITM group than in the ESPB group (101.71 ± 25.67 mg vs 44 ± 16.71 mg, respectively). The time to the first analgesic request was 4.93±0.82 hrs in the ITM group and 12±2.81 hrs in the ESPB group. Patient satisfaction did not differ significantly. Conclusion: ESPB has a successful postoperative analgesic effect and may limit opioid consumption in parturients undergoing elective caesarean delivery.
Introduction The occurrence of emergence agitation (EA) in pediatric patients who received sevofl... more Introduction The occurrence of emergence agitation (EA) in pediatric patients who received sevoflurane anesthesia is a common postoperative problem. Purpose This study aimed to compare the efficacy of propofol versus fentanyl to decrease the incidence of EA using an emergence behavior scale - pediatric agitation emergence delirium (PAED). Patients and methods This study was performed on three patient groups undergoing the same surgical procedure, under sevoflurane anesthesia: the first received saline as a control, the second received propofol, and the third received fentanyl. Thereafter, we compared the efficacy on incidence and severity of EA using an emergence behavior scale - PAED. Results Regarding the frequency of agitation, the highest frequency was observed in the control group followed by the propofol group and then the fentanyl group (46.9, 18.8, and 12.5%, respectively). The onset of agitation was delayed in the propofol and fentanyl groups when compared with the control group (P < 0.01 and 0.02, respectively). There was no statistically significant difference between the three groups regarding the duration of agitation. The PAED scoring revealed no significant difference between the propofol and fentanyl groups (P = 0.239), but a highly significant difference between both of them and the control group was found (P < 0.001). Conclusion Both propofol and fentanyl decrease the incidence and the severity of EA, but there is no reliable significance when comparing both drugs. We recommend further studies to declare other drugs that have potency to decrease the incidence and to treat the EA.
Background: Regional anesthesia could affect the homeostatic system functions resulting frequentl... more Background: Regional anesthesia could affect the homeostatic system functions resulting frequently in perioperative hypothermia and consequently shivering. The objective of this trial was to evaluate the efficacy of dexmedetomidine and ondansetron to reduce the incidence and severity of shivering after intrathecal blocks. Methods: This randomized placebo-controlled trial included 120 patients allocated equally in three groups. All patients were anesthetized by standard intrathecal blocks for surgical procedure at lower half of the body and received one of the study drugs intravenously (IV) according to the group assignments. Group S patients (placebo) were administered saline, Group O (ondansetron) were given 8 mg ondansetron, and Group D (dexmedetomidine) were given 1 μg/kg of dexmedetomidine. Shivering incidence and scores, sedation scores, core body temperature, hemodynamic variables, and incidence of complications (nausea, vomiting, hypotension, bradycardia, over-sedation, and desaturation) were recorded. Results: The incidence and 95% confidence interval (95% CI) of shivering in group S 57.5% (42.18-72.82%) was significantly higher than that of both group O 17.5% (5.73-29.27%), P < 0.001 and group D 27.5% (13.66-41.34%), P = 0.012. However, the difference in the incidence of shivering between group O and group D was comparable, P = 0.425. The sedation scores were significantly higher in group D than those of both group S and group O, P < 0. 001. Sedation scores between group S and group O were comparable, P = 0.19. Incidences of adverse effects were comparable between the three groups. Conclusion: Prophylactic administrations of dexmedetomidine or ondansetron efficiently decrease the incidence and severity of shivering after spinal anesthesia as compared to placebo without significant difference between their efficacies when compared to each other. Trial registration: Pan African Clinical Trial Registry (PACTR) under trial number (PACTR201710002706318). 18-10-2017. 'retrospectively registered'.
Background The plethysmography variability index (PVI) is a non-invasive, real-time, and automate... more Background The plethysmography variability index (PVI) is a non-invasive, real-time, and automated parameter for evaluating fluid responsiveness, but it does not reliably predict fluid responsiveness during low tidal volume (VT) ventilation. We hypothesized that in a ‘tidal volume challenge’ with a transient increase in tidal volume from 6 to 8 ml Kg− 1, the changes in PVI could predict fluid responsiveness reliably. Method We performed a prospective interventional study in adult patients undergoing hepatobiliary or pancreatic tumor resections and receiving controlled low VT ventilation. The values for PVI, perfusion index, stroke volume variation, and stroke volume index (SVI) were recorded at baseline VT of 6 ml Kg− 1, 1 min after the VT challenge (8 ml Kg− 1), 1 min after VT 6 ml Kg− 1 reduced back again, and then 5 min after crystalloid fluid bolus 6 ml kg− 1 (actual body weight) administered over 10 min. The fluid responders were identified by SVI rise ≥ 10% after the fluid bol...
Background: Shivering is known to be a frequent complication, reported in 40 to 70 % of patients ... more Background: Shivering is known to be a frequent complication, reported in 40 to 70 % of patients undergoing surgery under regional anesthesia. Post-anesthetic shivering is spontaneous, involuntary, rhythmic, oscillating and tremor-like muscle hyperactivity that increases metabolic heat production up to 600% after general or regional anesthesia. The aim of this study was to evaluate the efficacy, potency and side effects of tramadol plus midazolam as compared to nalbuphine plus midazolam in control of shivering after intrathecal anesthesia. Patients And Methods: 60 American Society of anesthesiologists grade І,ІІ (ASA physical status І or ІІ) patients of either sex aged 18 to 60 years who were scheduled for lower abdominal or lower limb surgery, under intrathecal block, were included in this prospective double-blind randomized study. These patients were allocated by closed envelop technique to two groups: Group T (n=30) received tramadol 0.5mg/kg plus midazolam 0.05mg/kg (intravenous...
Background The use of succinylcholine for rapid sequence induction in patients with open globe in... more Background The use of succinylcholine for rapid sequence induction in patients with open globe injuries may be detrimental to the eye. Aim: The aim of this study is to determine if the premedication with magnesium sulfate (MgSO4) could attenuate the increase in intraocular pressure (IOP) associated with succinylcholine injection and intubation. Setting: Operation theaters in a tertiary care University Hospital between December 2014 and July 215. Design: This was a prospective, randomized, parallel three-arm, double-blind, placebo-controlled clinical trial. Participants: One hundred and thirteen patients' physical status ASA Classes I and II underwent elective cataract surgery under general anesthesia. Patients and Methods: These patients allocated into three groups: Group C (control group) received 100 ml normal saline, Group M1 received 30 mg/kg MgSO4in 100 ml normal saline, and Group M2 received 50 mg/kg MgSO4in 100 ml normal saline. IOP, mean arterial pressure (MAP), and heart rate (HR) reported at 5-time points related to study drug administration. In addition, any adverse effects related to MgSO4were recorded. Intragroup and between-groups differences were examined by analysis of variance test. Results: We noticed a significant decrease in IOP in M1 (n = 38) and M2 (n = 37) groups as compared with C group (n = 38) after study drugs infusion, 2 and 5 min after intubation, P < 0.001. While the difference between M1 and M2 groups was insignificant, P = 0.296 and P = 0.647, respectively. There was a significant decrease in MAP and HR in M1 and M2 groups as compared with C group 2 and 5 min after intubation, P = 0.01. While the difference between M1 and M2 groups was insignificant, P = 1. Conclusion: MgSO4 30 mg/kg as well as 50 mg/kg effectively prevented the rise in IOP, MAP, and HR associated with rapid sequence induction by succinylcholine and endotracheal intubation.
Background: Ultrasound-guided rectus sheath blockade has been described to provide analgesia for ... more Background: Ultrasound-guided rectus sheath blockade has been described to provide analgesia for midline abdominal incisions. We aimed to compare thoracic epidural analgesia (TEA) and rectus sheath analgesia (RSA) with respect to safety and efficacy. Methods: Sixty patients who underwent elective laparotomies through a midline incision were assigned randomly to receive either continuous TEA (TEA group, n = 31) or intermittent RSA (RSA group, n = 29). The number of patients who required analgesia, the time to first request analgesia, the interval and the cumulative morphine doses consumption during 72 hours postoperatively, and pain intensity using visual analog score (VAS) at rest and upon coughing were reported in addition to any side effects related to both techniques or administered drugs. Results: While 17 (54.84 %) patients were in the TEA group, 25 (86.21%) patients in the RSA group required analgesia postoperatively, P = 0.008. Cumulative morphine consumed during the early 72 hours postoperatively median (interquartile range) = 33 mg (27-39 mg), 95% confidence interval (28.63-37.37 mg) for the TEA group. While in the RSA group, it was 51 mg (45-57 mg), 95% CI (47.4-54.6 mg), P < 0.001. The time for the first request of morphine was 256.77 ± 73.45 minutes in the TEA group versus 208.82 ± 64.65 min in the RSA group, P = 0.031. VAS at rest and cough were comparable in both groups at all time points of assessment, P > 0.05. The time to the ambulation was significantly shorter in the RSA group (38.47 ± 12.34 hours) as compared to the TEA group (45.89 ± 8.72 hours), P = 0.009. Sedation scores were significantly higher in the RSA group, only at 12 hours and 24 hours postoperatively than in TEA group, with P = 0.041 and 0.013, respectively. The incidence of other morphine-related side effects, time to pass flatus, and patients satisfaction scores were comparable between both groups. Conclusions: Continuous TEA had better opioid sparing effects markedly during the early 72 hours postoperatively than that of intermittent RSA with catheters inserted under real-time ultrasound guidance, both had comparable safety perspectives, and RSA had the advantage of early ambulation. RSA could be used as an effective alternative when TEA could not be employed in patients undergoing laparotomies with an extended midline incision, especially after the first postoperative day.
Background: Emergence agitation (EA) after sevoflurane anesthesia is common in children during re... more Background: Emergence agitation (EA) after sevoflurane anesthesia is common in children during recovery from general anesthesia and may result in postoperative complications. This study investigated safety and effectiveness of intranasal dexmedetomidine in reducing the incidence and severity of EA. Methods: This prospective, randomized double-blinded controlled trial included 86 patients scheduled for the tonsillectomy and/or adenoidectomy under general anesthesia with sevoflurane. They were randomly allocated into two groups. Group D received intranasal dexmedetomidine at 1 µg/kg, and Group C received intranasal saline 0.9% after the induction of general anesthesia. Four-point agitation scale and Face, Legs, Activity, Cry and Consolability (FLACC) scale for pain assessment were measured at six time points (after extubation, leaving the operating room, on arrival to postanesthesia care unit [PACU], 10, 20, and 30 min after arrival in PACU). Extubation, emergence, and discharge times were recorded in addition to any adverse effects. Results: There was a significant difference in the incidence of EA between Groups D and C (6.98% and 58%, respectively, with P = 0.001). The median four-point agitation scales and the median scores of FLACC pain scales of Group D were significantly lower than those of Group C at the all six time points with P < 0.05. Extubation, emergence, and discharge times were comparable in both groups, and none of the subjects reported any adverse effects. Conclusion: This study demonstrates that a 1 µg/kg dose of intranasal dexmedetomidine administered after the induction of anesthesia reduces post-sevoflurane incidence and severity of EA in children undergone tonsillectomy and/or adenoidectomy with no adverse effects and smooth recovery profile.
The plethysmography variability index (PVI) is a safe, non-invasive, and useful parameter for eva... more The plethysmography variability index (PVI) is a safe, non-invasive, and useful parameter for evaluating uid responsiveness but it does not reliably predict uid responsiveness during low tidal volume (V T) ventilation. We hypothesized that in a 'tidal volume challenge' with a transient increase in tidal volume from 6 to 8 ml/kg, the changes in PVI will predict uid responsiveness. We performed a prospective interventional study in adult patients undergoing hepatobiliary pancreatic tumor resections, having continuous cardiac output monitoring, and receiving controlled low V T ventilation. We recorded the values for PVI, perfusion index, corrected ow time (FTc), index of contractility (ICON), stroke volume variation, and stroke volume index at V T of 6 ml/kg and 1 min after the V T challenge. The V T was reduced to 6 ml/kg and a uid bolus was given to identify uid responders. The area under the receiver operating characteristic curve (AUC) for absolute change in PVI after increasing V T from 6 to 8 ml/kg was 0.86 (pvalue < 0.001) with best cutoff value 2.5% with 95% sensitivity and 68% speci city after doing the tidal volume challenge. AUC for ICON and FTc at V T 8 ml/kg were 0.72 and 0.70 with p-value 0.008 and 0.01 and best cutoff values 40.7% and 332ms respectively. Changes in PVI value obtained by transiently increasing V T are superior to PVI value measured alone for predicting uid responsiveness during low-V T ventilation. Also, ICON and FTc can be used as good and reliable predictors of uid responsiveness.
Journal of Cardiothoracic and Vascular Anesthesia, 2021
OBJECTIVE Cardiac surgery for repair of congenital heart defects poses unique hazards to the deve... more OBJECTIVE Cardiac surgery for repair of congenital heart defects poses unique hazards to the developing brain. Deep hypothermic circulatory arrest (DHCA) is a simple and effective method for facilitating a bloodless surgical field during congenital heart defect repair. There are, however, some concerns that prolonged DHCA increases the risk of nervous system injury. The electroencephalogram (EEG) is used in adult and, to a lesser extent, pediatric cardiac procedures as a neuromonitoring method. The present study was performed to assess outcomes following DHCA with EEG monitoring in the pediatric population. DESIGN In this systematic review and meta-analysis, the PubMed, Cochrane Central Register of Controlled Trials, Scopus, Institute of Science Index, and Embase databases were searched from inception for relevant articles. A fixed- or random-effects model, as appropriate, was used. SETTING Surgical setting. PARTICIPANTS Pediatric population (≤18 y old). INTERVENTIONS DHCA (18°C) with EEG monitoring. MEASUREMENTS AND MAIN RESULTS Nineteen articles with 1,267 pediatric patients ≤18 years were included. The event rate of clinical and EEG seizures among patients who underwent DHCA was 12.9% and 14.9%, respectively. Mortality was found to have a 6.3% prevalence. A longer duration of DHCA was associated with a higher risk of EEG seizure and neurologic abnormalities. In addition, seizures were associated with increased neurologic abnormalities and neurodevelopmental delay. CONCLUSIONS EEG and neurologic abnormalities were common after DHCA. A longer duration of DHCA was found to lead to more EEG seizure and neurologic abnormalities. Moreover, EEG seizures were more common than clinical seizures. Seizures were found to be associated with increased neurologic abnormalities and neurodevelopmental delay.
Background: The world urgently requires surrogate markers to diagnose COVID-19 and predict its pr... more Background: The world urgently requires surrogate markers to diagnose COVID-19 and predict its progression. The severity is not easily predicted via currently used biomarkers. Critical COVID-19 patients need to be screened for hyperinflammation to improve mortality but expensive cytokine measurement is not routinely conducted in most laboratories. The neutrophil-to-lymphocyte ratio (NLR) is a novel biomarker in patients with various diseases. We evaluated the diagnostic and prognostic accuracy of the NLR in COVID-19 patients. Methods: We searched for relevant articles in seven databases. The quantitative analysis was conducted if at least two studies were evaluating the NLR role in COVID-19. Results: We included 8,120 individuals, including 7,482 COVID-19 patients, from 32 articles. Patients with COVID-19 had significantly higher levels of NLR compared to negative individuals. Advanced COVID-19 stages had significantly higher levels of NLR than earlier stages. Expert Opinion: We found significantly higher levels of NLR in advanced stages compared to earlier stages of COVID-19 with good accuracy to diagnose and predict the disease outcome, especially mortality prediction. A close evaluation of critical SARS-CoV-2 patients and efficient early management are essential measures to decrease mortality. NLR could help in assessing the resource allocation in severe COVID-19 patients even in restricted settings.
BACKGROUND: Although invasive monitoring is the standard method for intracranial pressure (ICP) m... more BACKGROUND: Although invasive monitoring is the standard method for intracranial pressure (ICP) measurement, it is not without potential for serious complications. Noninvasive methods have been proposed as alternatives to invasive ICP monitoring. The study aimed to investigate the diagnostic accuracy of the currently available noninvasive methods for intracranial hypertension (ICH) monitoring. METHODS: We searched 5 databases for articles evaluating the diagnostic accuracy of noninvasive methods in diagnosing ICH in PubMed, Institute of Science Index, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), and Embase. The quantitative analysis was conducted if there were at least 2 studies evaluating a specific method. The accuracy measures included the sensitivity, specificity, likelihood ratios, and diagnostic odds ratio. RESULTS: We included 134 articles. Ultrasonographic optic nerve sheath diameter (US ONSD) had high diagnostic accuracy (estimated sensitivity of 90%; 9...
BACKGROUND: Catheter-related thrombosis (CRT) is a serious complication of vascular catheters. Re... more BACKGROUND: Catheter-related thrombosis (CRT) is a serious complication of vascular catheters. Retrograde catheter insertion has been shown to decrease pericatheter hemostasis and thrombosis, but it is technically challenging. The current in silico trial is an analytical approach to evaluating different approaches to designing retrograde flow into a vascular catheter. METHODS: The novel catheter design aims to provide antistasis retrograde flow (ASRF) of fluid through multiple backward-directed side openings, with a self-closing terminal opening to facilitate standard insertion. Four different models of the catheter were evaluated by computational fluid dynamic studies, with retrograde-angled openings of 15°, 30°, 45°, and 60° to the long axis of the catheter. RESULTS: ASRF successfully reduced the areas of fluid stagnation in models with 15° and 30° openings. Models with 45° and 60° did not significantly reduce stagnation. ASRF is reversed by the main bloodstream after a few millim...
Objectives: Tracheostomy is a very common clinical intervention in critically ill adult patients.... more Objectives: Tracheostomy is a very common clinical intervention in critically ill adult patients. The indications for tracheostomy procedures in pediatric patients with complex conditions have increased dramatically in recent years, but there are currently no guidelines on the optimal timing of tracheostomy in pediatric patients undergoing prolonged ventilation. Data Sources: We performed a systematic search of the existing literature in MEDLINE via PubMed and Embase databases and the Cochrane Library to identify clinical trials, observational studies, and cohort studies that compare early and late tracheostomy in children. The date of the last search was August 27, 2018. Included articles were subjected to manual searching. Study Selection: Studies in mechanically ventilated children that compared early with late tracheostomy were included. Data Extraction: Data were extracted into a spreadsheet and copied into Review Manager 5.3 (The Cochrane Collaboration, Copenhagen, Denmark). D...
Postdural puncture headache (PDPH) lacks a standard evidence-based treatment. A patient treated w... more Postdural puncture headache (PDPH) lacks a standard evidence-based treatment. A patient treated with neostigmine for severe PDPH prompted this study. This randomized, controlled, double-blind study compared neostigmine and atropine (n = 41) versus a saline placebo (n = 44) for treating PDPH in addition to conservative management of 85 patients with hydration and analgesics. The primary outcome was a visual analog scale score of ≤3 at 6, 12, 24, 36, 48, and 72 hours after intervention. Secondary outcomes were the need for an epidural blood patch, neck stiffness, nausea, and vomiting. Patients received either neostigmine 20 and 10 μg/kg or an equal volume of saline. Visual analog scale scores were significantly better (P< .001) with neostigmine/atropine than with saline treatment at all time intervals after intervention. No patients in the neostigmine/atropine group needed epidural blood patch compared with 7 (15.9%) in the placebo group (P< .001). Patients required no >2 dos...
BACKGROUND: Antegrade cannulation of peripheral veins is the usual practice. Blood stasis between... more BACKGROUND: Antegrade cannulation of peripheral veins is the usual practice. Blood stasis between a catheter and the wall of the vein or at its tip in addition to catheter-induced phlebitis may initiate a thrombosis. The use of retrograde ventriculojugular shunts against the direction of the blood flow with resultant decrease in the incidence of venous thrombosis encouraged us to compare retrograde versus conventional antegrade peripheral venous cannulation. METHODS: Monocentric, nonblinded, prospective observational cohort of 40 intensive care unit patients receiving 2 peripheral venous catheters in upper limbs, 1 inserted in the direction of blood flow (antegrade cannula) and the other inserted in an opposite direction to blood flow (retrograde cannula). Daily ultrasound assessment of the angle between the catheter and the vascular wall was done to detect onset and progression of thrombus formation. RESULTS: The study included 40 patients, aged 46.7 ± 10.132 years. The incidence o...
SARS-CoV-2 currently lacks effective first-line drug treatment. We present promising data from in... more SARS-CoV-2 currently lacks effective first-line drug treatment. We present promising data from in silico docking studies of new Methisazone compounds (modified with calcium, Ca; iron, Fe; magnesium, Mg; manganese, Mn; or zinc, Zn) designed to bind more strongly to key proteins involved in replication of SARS-CoV-2. In this in silico molecular docking study, we investigated the inhibiting role of Methisazone and the modified drugs against SARS-CoV-2 proteins: ribonucleic acid (RNA)-dependent RNA polymerase (RdRp), spike protein, papain-like protease (PlPr), and main protease (MPro). We found that the highest binding interactions were found with the spike protein (6VYB), with the highest overall binding being observed with Mn-bound Methisazone at −8.3 kcal/mol, followed by Zn and Ca at −8.0 kcal/mol, and Fe and Mg at −7.9 kcal/mol. We also found that the metal-modified Methisazone had higher affinity for PlPr and MPro. In addition, we identified multiple binding pockets that could be ...
BackgroundDuring scoliosis surgery, motor evoked potentials (MEP), and somatosensory evoked poten... more BackgroundDuring scoliosis surgery, motor evoked potentials (MEP), and somatosensory evoked potentials (SSEP) have been reported to be affected by the use of higher doses of anesthetic agents. Dexmedetomidine, a sympatholytic agent, an alpha‐2 receptor agonist, has been used as an adjunctive agent to lower anesthetic dose. However, there is conflicting evidence regarding the effects of dexmedetomidine on the intraoperative neurophysiological monitoring of MEP and SSEP during surgery, particularly among pediatric patients.ObjectivesThis systematic review aimed to determine whether, during spinal fusion surgery in pediatric patients with scoliosis, dexmedetomidine alters MEP amplitude or SSEP latency and amplitude and, if so, whether different doses of dexmedetomidine display different effects (PROSPERO registration number CRD42022300562).MethodsWe searched PubMed, Scopus, and Cochrane Library on January 1, 2022 and included randomized controlled trials, observational cohort and case–...
Background: We aimed to assess the efficacy of ultrasound-guided bilateral erector spinae plane b... more Background: We aimed to assess the efficacy of ultrasound-guided bilateral erector spinae plane block (ESPB) compared to intrathecal morphine (ITM) for analgesia after elective cesarean delivery under spinal anesthesia. Methods: In total, 140 parturients scheduled for elective cesarean section under spinal anesthesia were randomly allocated into two equal groups. The ESPB-group received 10 mg hyperbaric bupivacaine intrathecally through spinal anesthesia, followed by an ESPB at the ninth thoracic transverse process with 20 mL of 0.5% bupivacaine immediately after the operation. The ITM-group received 10 mg hyperbaric bupivacaine with 100 mcg morphine intrathecally through spinal anesthesia, followed by a sham block at the end of the surgery. The visual analogue scale (VAS) score for pain at several postoperative time points, total opioid consumption, and time to the first analgesic request were evaluated. Statistical analysis was performed with the independent t-test and linear mixed-effects models. The Kaplan-Meier estimator and the log-rank test were used to compare the primary and secondary outcomes of the groups. Results: No significant differences were observed between the groups regarding patient characteristics; in the post-operative period (0-24 hrs), VAS scores (at rest) were, on average, 0.25 units higher in the ITM group. The total tramadol consumption in the first 24 hrs was significantly higher in the ITM group than in the ESPB group (101.71 ± 25.67 mg vs 44 ± 16.71 mg, respectively). The time to the first analgesic request was 4.93±0.82 hrs in the ITM group and 12±2.81 hrs in the ESPB group. Patient satisfaction did not differ significantly. Conclusion: ESPB has a successful postoperative analgesic effect and may limit opioid consumption in parturients undergoing elective caesarean delivery.
Introduction The occurrence of emergence agitation (EA) in pediatric patients who received sevofl... more Introduction The occurrence of emergence agitation (EA) in pediatric patients who received sevoflurane anesthesia is a common postoperative problem. Purpose This study aimed to compare the efficacy of propofol versus fentanyl to decrease the incidence of EA using an emergence behavior scale - pediatric agitation emergence delirium (PAED). Patients and methods This study was performed on three patient groups undergoing the same surgical procedure, under sevoflurane anesthesia: the first received saline as a control, the second received propofol, and the third received fentanyl. Thereafter, we compared the efficacy on incidence and severity of EA using an emergence behavior scale - PAED. Results Regarding the frequency of agitation, the highest frequency was observed in the control group followed by the propofol group and then the fentanyl group (46.9, 18.8, and 12.5%, respectively). The onset of agitation was delayed in the propofol and fentanyl groups when compared with the control group (P < 0.01 and 0.02, respectively). There was no statistically significant difference between the three groups regarding the duration of agitation. The PAED scoring revealed no significant difference between the propofol and fentanyl groups (P = 0.239), but a highly significant difference between both of them and the control group was found (P < 0.001). Conclusion Both propofol and fentanyl decrease the incidence and the severity of EA, but there is no reliable significance when comparing both drugs. We recommend further studies to declare other drugs that have potency to decrease the incidence and to treat the EA.
Background: Regional anesthesia could affect the homeostatic system functions resulting frequentl... more Background: Regional anesthesia could affect the homeostatic system functions resulting frequently in perioperative hypothermia and consequently shivering. The objective of this trial was to evaluate the efficacy of dexmedetomidine and ondansetron to reduce the incidence and severity of shivering after intrathecal blocks. Methods: This randomized placebo-controlled trial included 120 patients allocated equally in three groups. All patients were anesthetized by standard intrathecal blocks for surgical procedure at lower half of the body and received one of the study drugs intravenously (IV) according to the group assignments. Group S patients (placebo) were administered saline, Group O (ondansetron) were given 8 mg ondansetron, and Group D (dexmedetomidine) were given 1 μg/kg of dexmedetomidine. Shivering incidence and scores, sedation scores, core body temperature, hemodynamic variables, and incidence of complications (nausea, vomiting, hypotension, bradycardia, over-sedation, and desaturation) were recorded. Results: The incidence and 95% confidence interval (95% CI) of shivering in group S 57.5% (42.18-72.82%) was significantly higher than that of both group O 17.5% (5.73-29.27%), P < 0.001 and group D 27.5% (13.66-41.34%), P = 0.012. However, the difference in the incidence of shivering between group O and group D was comparable, P = 0.425. The sedation scores were significantly higher in group D than those of both group S and group O, P < 0. 001. Sedation scores between group S and group O were comparable, P = 0.19. Incidences of adverse effects were comparable between the three groups. Conclusion: Prophylactic administrations of dexmedetomidine or ondansetron efficiently decrease the incidence and severity of shivering after spinal anesthesia as compared to placebo without significant difference between their efficacies when compared to each other. Trial registration: Pan African Clinical Trial Registry (PACTR) under trial number (PACTR201710002706318). 18-10-2017. 'retrospectively registered'.
Background The plethysmography variability index (PVI) is a non-invasive, real-time, and automate... more Background The plethysmography variability index (PVI) is a non-invasive, real-time, and automated parameter for evaluating fluid responsiveness, but it does not reliably predict fluid responsiveness during low tidal volume (VT) ventilation. We hypothesized that in a ‘tidal volume challenge’ with a transient increase in tidal volume from 6 to 8 ml Kg− 1, the changes in PVI could predict fluid responsiveness reliably. Method We performed a prospective interventional study in adult patients undergoing hepatobiliary or pancreatic tumor resections and receiving controlled low VT ventilation. The values for PVI, perfusion index, stroke volume variation, and stroke volume index (SVI) were recorded at baseline VT of 6 ml Kg− 1, 1 min after the VT challenge (8 ml Kg− 1), 1 min after VT 6 ml Kg− 1 reduced back again, and then 5 min after crystalloid fluid bolus 6 ml kg− 1 (actual body weight) administered over 10 min. The fluid responders were identified by SVI rise ≥ 10% after the fluid bol...
Background: Shivering is known to be a frequent complication, reported in 40 to 70 % of patients ... more Background: Shivering is known to be a frequent complication, reported in 40 to 70 % of patients undergoing surgery under regional anesthesia. Post-anesthetic shivering is spontaneous, involuntary, rhythmic, oscillating and tremor-like muscle hyperactivity that increases metabolic heat production up to 600% after general or regional anesthesia. The aim of this study was to evaluate the efficacy, potency and side effects of tramadol plus midazolam as compared to nalbuphine plus midazolam in control of shivering after intrathecal anesthesia. Patients And Methods: 60 American Society of anesthesiologists grade І,ІІ (ASA physical status І or ІІ) patients of either sex aged 18 to 60 years who were scheduled for lower abdominal or lower limb surgery, under intrathecal block, were included in this prospective double-blind randomized study. These patients were allocated by closed envelop technique to two groups: Group T (n=30) received tramadol 0.5mg/kg plus midazolam 0.05mg/kg (intravenous...
Background The use of succinylcholine for rapid sequence induction in patients with open globe in... more Background The use of succinylcholine for rapid sequence induction in patients with open globe injuries may be detrimental to the eye. Aim: The aim of this study is to determine if the premedication with magnesium sulfate (MgSO4) could attenuate the increase in intraocular pressure (IOP) associated with succinylcholine injection and intubation. Setting: Operation theaters in a tertiary care University Hospital between December 2014 and July 215. Design: This was a prospective, randomized, parallel three-arm, double-blind, placebo-controlled clinical trial. Participants: One hundred and thirteen patients' physical status ASA Classes I and II underwent elective cataract surgery under general anesthesia. Patients and Methods: These patients allocated into three groups: Group C (control group) received 100 ml normal saline, Group M1 received 30 mg/kg MgSO4in 100 ml normal saline, and Group M2 received 50 mg/kg MgSO4in 100 ml normal saline. IOP, mean arterial pressure (MAP), and heart rate (HR) reported at 5-time points related to study drug administration. In addition, any adverse effects related to MgSO4were recorded. Intragroup and between-groups differences were examined by analysis of variance test. Results: We noticed a significant decrease in IOP in M1 (n = 38) and M2 (n = 37) groups as compared with C group (n = 38) after study drugs infusion, 2 and 5 min after intubation, P < 0.001. While the difference between M1 and M2 groups was insignificant, P = 0.296 and P = 0.647, respectively. There was a significant decrease in MAP and HR in M1 and M2 groups as compared with C group 2 and 5 min after intubation, P = 0.01. While the difference between M1 and M2 groups was insignificant, P = 1. Conclusion: MgSO4 30 mg/kg as well as 50 mg/kg effectively prevented the rise in IOP, MAP, and HR associated with rapid sequence induction by succinylcholine and endotracheal intubation.
Background: Ultrasound-guided rectus sheath blockade has been described to provide analgesia for ... more Background: Ultrasound-guided rectus sheath blockade has been described to provide analgesia for midline abdominal incisions. We aimed to compare thoracic epidural analgesia (TEA) and rectus sheath analgesia (RSA) with respect to safety and efficacy. Methods: Sixty patients who underwent elective laparotomies through a midline incision were assigned randomly to receive either continuous TEA (TEA group, n = 31) or intermittent RSA (RSA group, n = 29). The number of patients who required analgesia, the time to first request analgesia, the interval and the cumulative morphine doses consumption during 72 hours postoperatively, and pain intensity using visual analog score (VAS) at rest and upon coughing were reported in addition to any side effects related to both techniques or administered drugs. Results: While 17 (54.84 %) patients were in the TEA group, 25 (86.21%) patients in the RSA group required analgesia postoperatively, P = 0.008. Cumulative morphine consumed during the early 72 hours postoperatively median (interquartile range) = 33 mg (27-39 mg), 95% confidence interval (28.63-37.37 mg) for the TEA group. While in the RSA group, it was 51 mg (45-57 mg), 95% CI (47.4-54.6 mg), P < 0.001. The time for the first request of morphine was 256.77 ± 73.45 minutes in the TEA group versus 208.82 ± 64.65 min in the RSA group, P = 0.031. VAS at rest and cough were comparable in both groups at all time points of assessment, P > 0.05. The time to the ambulation was significantly shorter in the RSA group (38.47 ± 12.34 hours) as compared to the TEA group (45.89 ± 8.72 hours), P = 0.009. Sedation scores were significantly higher in the RSA group, only at 12 hours and 24 hours postoperatively than in TEA group, with P = 0.041 and 0.013, respectively. The incidence of other morphine-related side effects, time to pass flatus, and patients satisfaction scores were comparable between both groups. Conclusions: Continuous TEA had better opioid sparing effects markedly during the early 72 hours postoperatively than that of intermittent RSA with catheters inserted under real-time ultrasound guidance, both had comparable safety perspectives, and RSA had the advantage of early ambulation. RSA could be used as an effective alternative when TEA could not be employed in patients undergoing laparotomies with an extended midline incision, especially after the first postoperative day.
Background: Emergence agitation (EA) after sevoflurane anesthesia is common in children during re... more Background: Emergence agitation (EA) after sevoflurane anesthesia is common in children during recovery from general anesthesia and may result in postoperative complications. This study investigated safety and effectiveness of intranasal dexmedetomidine in reducing the incidence and severity of EA. Methods: This prospective, randomized double-blinded controlled trial included 86 patients scheduled for the tonsillectomy and/or adenoidectomy under general anesthesia with sevoflurane. They were randomly allocated into two groups. Group D received intranasal dexmedetomidine at 1 µg/kg, and Group C received intranasal saline 0.9% after the induction of general anesthesia. Four-point agitation scale and Face, Legs, Activity, Cry and Consolability (FLACC) scale for pain assessment were measured at six time points (after extubation, leaving the operating room, on arrival to postanesthesia care unit [PACU], 10, 20, and 30 min after arrival in PACU). Extubation, emergence, and discharge times were recorded in addition to any adverse effects. Results: There was a significant difference in the incidence of EA between Groups D and C (6.98% and 58%, respectively, with P = 0.001). The median four-point agitation scales and the median scores of FLACC pain scales of Group D were significantly lower than those of Group C at the all six time points with P < 0.05. Extubation, emergence, and discharge times were comparable in both groups, and none of the subjects reported any adverse effects. Conclusion: This study demonstrates that a 1 µg/kg dose of intranasal dexmedetomidine administered after the induction of anesthesia reduces post-sevoflurane incidence and severity of EA in children undergone tonsillectomy and/or adenoidectomy with no adverse effects and smooth recovery profile.
The plethysmography variability index (PVI) is a safe, non-invasive, and useful parameter for eva... more The plethysmography variability index (PVI) is a safe, non-invasive, and useful parameter for evaluating uid responsiveness but it does not reliably predict uid responsiveness during low tidal volume (V T) ventilation. We hypothesized that in a 'tidal volume challenge' with a transient increase in tidal volume from 6 to 8 ml/kg, the changes in PVI will predict uid responsiveness. We performed a prospective interventional study in adult patients undergoing hepatobiliary pancreatic tumor resections, having continuous cardiac output monitoring, and receiving controlled low V T ventilation. We recorded the values for PVI, perfusion index, corrected ow time (FTc), index of contractility (ICON), stroke volume variation, and stroke volume index at V T of 6 ml/kg and 1 min after the V T challenge. The V T was reduced to 6 ml/kg and a uid bolus was given to identify uid responders. The area under the receiver operating characteristic curve (AUC) for absolute change in PVI after increasing V T from 6 to 8 ml/kg was 0.86 (pvalue < 0.001) with best cutoff value 2.5% with 95% sensitivity and 68% speci city after doing the tidal volume challenge. AUC for ICON and FTc at V T 8 ml/kg were 0.72 and 0.70 with p-value 0.008 and 0.01 and best cutoff values 40.7% and 332ms respectively. Changes in PVI value obtained by transiently increasing V T are superior to PVI value measured alone for predicting uid responsiveness during low-V T ventilation. Also, ICON and FTc can be used as good and reliable predictors of uid responsiveness.
Journal of Cardiothoracic and Vascular Anesthesia, 2021
OBJECTIVE Cardiac surgery for repair of congenital heart defects poses unique hazards to the deve... more OBJECTIVE Cardiac surgery for repair of congenital heart defects poses unique hazards to the developing brain. Deep hypothermic circulatory arrest (DHCA) is a simple and effective method for facilitating a bloodless surgical field during congenital heart defect repair. There are, however, some concerns that prolonged DHCA increases the risk of nervous system injury. The electroencephalogram (EEG) is used in adult and, to a lesser extent, pediatric cardiac procedures as a neuromonitoring method. The present study was performed to assess outcomes following DHCA with EEG monitoring in the pediatric population. DESIGN In this systematic review and meta-analysis, the PubMed, Cochrane Central Register of Controlled Trials, Scopus, Institute of Science Index, and Embase databases were searched from inception for relevant articles. A fixed- or random-effects model, as appropriate, was used. SETTING Surgical setting. PARTICIPANTS Pediatric population (≤18 y old). INTERVENTIONS DHCA (18°C) with EEG monitoring. MEASUREMENTS AND MAIN RESULTS Nineteen articles with 1,267 pediatric patients ≤18 years were included. The event rate of clinical and EEG seizures among patients who underwent DHCA was 12.9% and 14.9%, respectively. Mortality was found to have a 6.3% prevalence. A longer duration of DHCA was associated with a higher risk of EEG seizure and neurologic abnormalities. In addition, seizures were associated with increased neurologic abnormalities and neurodevelopmental delay. CONCLUSIONS EEG and neurologic abnormalities were common after DHCA. A longer duration of DHCA was found to lead to more EEG seizure and neurologic abnormalities. Moreover, EEG seizures were more common than clinical seizures. Seizures were found to be associated with increased neurologic abnormalities and neurodevelopmental delay.
Background: The world urgently requires surrogate markers to diagnose COVID-19 and predict its pr... more Background: The world urgently requires surrogate markers to diagnose COVID-19 and predict its progression. The severity is not easily predicted via currently used biomarkers. Critical COVID-19 patients need to be screened for hyperinflammation to improve mortality but expensive cytokine measurement is not routinely conducted in most laboratories. The neutrophil-to-lymphocyte ratio (NLR) is a novel biomarker in patients with various diseases. We evaluated the diagnostic and prognostic accuracy of the NLR in COVID-19 patients. Methods: We searched for relevant articles in seven databases. The quantitative analysis was conducted if at least two studies were evaluating the NLR role in COVID-19. Results: We included 8,120 individuals, including 7,482 COVID-19 patients, from 32 articles. Patients with COVID-19 had significantly higher levels of NLR compared to negative individuals. Advanced COVID-19 stages had significantly higher levels of NLR than earlier stages. Expert Opinion: We found significantly higher levels of NLR in advanced stages compared to earlier stages of COVID-19 with good accuracy to diagnose and predict the disease outcome, especially mortality prediction. A close evaluation of critical SARS-CoV-2 patients and efficient early management are essential measures to decrease mortality. NLR could help in assessing the resource allocation in severe COVID-19 patients even in restricted settings.
BACKGROUND: Although invasive monitoring is the standard method for intracranial pressure (ICP) m... more BACKGROUND: Although invasive monitoring is the standard method for intracranial pressure (ICP) measurement, it is not without potential for serious complications. Noninvasive methods have been proposed as alternatives to invasive ICP monitoring. The study aimed to investigate the diagnostic accuracy of the currently available noninvasive methods for intracranial hypertension (ICH) monitoring. METHODS: We searched 5 databases for articles evaluating the diagnostic accuracy of noninvasive methods in diagnosing ICH in PubMed, Institute of Science Index, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), and Embase. The quantitative analysis was conducted if there were at least 2 studies evaluating a specific method. The accuracy measures included the sensitivity, specificity, likelihood ratios, and diagnostic odds ratio. RESULTS: We included 134 articles. Ultrasonographic optic nerve sheath diameter (US ONSD) had high diagnostic accuracy (estimated sensitivity of 90%; 9...
BACKGROUND: Catheter-related thrombosis (CRT) is a serious complication of vascular catheters. Re... more BACKGROUND: Catheter-related thrombosis (CRT) is a serious complication of vascular catheters. Retrograde catheter insertion has been shown to decrease pericatheter hemostasis and thrombosis, but it is technically challenging. The current in silico trial is an analytical approach to evaluating different approaches to designing retrograde flow into a vascular catheter. METHODS: The novel catheter design aims to provide antistasis retrograde flow (ASRF) of fluid through multiple backward-directed side openings, with a self-closing terminal opening to facilitate standard insertion. Four different models of the catheter were evaluated by computational fluid dynamic studies, with retrograde-angled openings of 15°, 30°, 45°, and 60° to the long axis of the catheter. RESULTS: ASRF successfully reduced the areas of fluid stagnation in models with 15° and 30° openings. Models with 45° and 60° did not significantly reduce stagnation. ASRF is reversed by the main bloodstream after a few millim...
Objectives: Tracheostomy is a very common clinical intervention in critically ill adult patients.... more Objectives: Tracheostomy is a very common clinical intervention in critically ill adult patients. The indications for tracheostomy procedures in pediatric patients with complex conditions have increased dramatically in recent years, but there are currently no guidelines on the optimal timing of tracheostomy in pediatric patients undergoing prolonged ventilation. Data Sources: We performed a systematic search of the existing literature in MEDLINE via PubMed and Embase databases and the Cochrane Library to identify clinical trials, observational studies, and cohort studies that compare early and late tracheostomy in children. The date of the last search was August 27, 2018. Included articles were subjected to manual searching. Study Selection: Studies in mechanically ventilated children that compared early with late tracheostomy were included. Data Extraction: Data were extracted into a spreadsheet and copied into Review Manager 5.3 (The Cochrane Collaboration, Copenhagen, Denmark). D...
Postdural puncture headache (PDPH) lacks a standard evidence-based treatment. A patient treated w... more Postdural puncture headache (PDPH) lacks a standard evidence-based treatment. A patient treated with neostigmine for severe PDPH prompted this study. This randomized, controlled, double-blind study compared neostigmine and atropine (n = 41) versus a saline placebo (n = 44) for treating PDPH in addition to conservative management of 85 patients with hydration and analgesics. The primary outcome was a visual analog scale score of ≤3 at 6, 12, 24, 36, 48, and 72 hours after intervention. Secondary outcomes were the need for an epidural blood patch, neck stiffness, nausea, and vomiting. Patients received either neostigmine 20 and 10 μg/kg or an equal volume of saline. Visual analog scale scores were significantly better (P< .001) with neostigmine/atropine than with saline treatment at all time intervals after intervention. No patients in the neostigmine/atropine group needed epidural blood patch compared with 7 (15.9%) in the placebo group (P< .001). Patients required no >2 dos...
BACKGROUND: Antegrade cannulation of peripheral veins is the usual practice. Blood stasis between... more BACKGROUND: Antegrade cannulation of peripheral veins is the usual practice. Blood stasis between a catheter and the wall of the vein or at its tip in addition to catheter-induced phlebitis may initiate a thrombosis. The use of retrograde ventriculojugular shunts against the direction of the blood flow with resultant decrease in the incidence of venous thrombosis encouraged us to compare retrograde versus conventional antegrade peripheral venous cannulation. METHODS: Monocentric, nonblinded, prospective observational cohort of 40 intensive care unit patients receiving 2 peripheral venous catheters in upper limbs, 1 inserted in the direction of blood flow (antegrade cannula) and the other inserted in an opposite direction to blood flow (retrograde cannula). Daily ultrasound assessment of the angle between the catheter and the vascular wall was done to detect onset and progression of thrombus formation. RESULTS: The study included 40 patients, aged 46.7 ± 10.132 years. The incidence o...
SARS-CoV-2 currently lacks effective first-line drug treatment. We present promising data from in... more SARS-CoV-2 currently lacks effective first-line drug treatment. We present promising data from in silico docking studies of new Methisazone compounds (modified with calcium, Ca; iron, Fe; magnesium, Mg; manganese, Mn; or zinc, Zn) designed to bind more strongly to key proteins involved in replication of SARS-CoV-2. In this in silico molecular docking study, we investigated the inhibiting role of Methisazone and the modified drugs against SARS-CoV-2 proteins: ribonucleic acid (RNA)-dependent RNA polymerase (RdRp), spike protein, papain-like protease (PlPr), and main protease (MPro). We found that the highest binding interactions were found with the spike protein (6VYB), with the highest overall binding being observed with Mn-bound Methisazone at −8.3 kcal/mol, followed by Zn and Ca at −8.0 kcal/mol, and Fe and Mg at −7.9 kcal/mol. We also found that the metal-modified Methisazone had higher affinity for PlPr and MPro. In addition, we identified multiple binding pockets that could be ...
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Papers by Hany Yassin