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   Table of Contents - Current issue
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January-March 2020
Volume 7 | Issue 1
Page Nos. 1-133

Online since Thursday, April 16, 2020

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ORIGINAL ARTICLES  

Ultrasound-guided femoro–sciatic nerve block with and without using nerve locator for below-knee surgeries p. 1
Ibrahim A Ibrahim Walash, Ashraf M Mostafa, Ayman A Abdel-Maksoud Rayan, Wesam E Sultan
DOI:10.4103/roaic.roaic_120_18  
Background Femoral and sciatic nerve blocks is a suitable technique for below-knee surgeries compared with neuroaxial and general anesthetic techniques. Objectives To evaluate the efficacy of ultrasound-guided femoral and sciatic nerve blocks with and without using a nerve locator in below-knee surgeries. Patients and methods Between May 2017 and May 2018, we conducted our randomized, observer-blinded prospective clinical study. Sixty patients underwent below-knee surgeries in Menoufia University Hospitals were involved and divided into two groups of 30 patients each. The groups were assigned into two: group A received ultrasound-guided femoral and sciatic nerve block and in group B, nerve block was done using combined ultrasound with a nerve locator. Results The onset time of motor block was significantly shorter in the nerve locator group than in the ultrasound-only group (P<0.001). There was no significant statistical difference among the studied groups as regards the heart rate, blood pressure, and onset time of sensory block. Conclusion Adding nerve locator to the ultrasound-guided nerve block technique has minimal impact on the efficacy of the technique.
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Comparative study of subarachnoid injection of dexmedetomidine versus magnesium sulfate as adjuvants to bupivacaine in patients undergoing classical repair surgery p. 8
Sameh H Seyam, Ali A Mahareak, Eman A Salim
DOI:10.4103/roaic.roaic_45_18  
Background Spinal anesthesia has several benefits over general anesthesia. Addition of adjuvants to local anesthetics improves the quality of the subarachnoid block. Objective We attempted to improve the quality of spinal anesthesia by the addition of magnesium sulfate or dexmedetomidine to intrathecal bupivacaine in patients undergoing classical repair surgery as regards primary outcome (quality of spinal anesthesia) and secondary outcomes (effect on hemodynamics and incidence of complications). Patients and methods This prospective randomized double-blinded controlled clinical study was carried out on 75 adult female patients scheduled for classical repair surgeries under spinal anesthesia who were assigned into three equal groups. Group D: 15 mg of 0.5% hyperbaric bupivacaine plus 10 μg dexmedetomidine was given to the patients. Group M: patients received 15 mg of 0.5% hyperbaric bupivacaine plus 0.5 ml magnesium sulfate (50 mg). Group C: patients received 15 mg of 0.5% hyperbaric bupivacaine plus 0.5 ml normal saline as control. The comparison was made among the three groups in regards to onset time of sensory and motor block, degree of postoperative pain relief, effect on hemodynamic stability, and total postoperative morphine consumption, and complications were recorded. Results There was a statistical difference among the three groups as regards the onset time of both sensory and motor block, which was faster in group D than in group C, and both were faster than group M. The duration of postoperative analgesia was significantly prolonged in D and M groups compared with the control group. The requirements of morphine sulfate in the first 24 h were significantly lower in the D and M groups compared with the control group. Conclusion Subarachnoid dexmedetomidine supplementation of spinal block was found to be a better option than intrathecal magnesium sulfate in patients undergoing classical repair surgeries, as it provides rapid onset of sensory and motor block; also, it improves the quality of postoperative analgesia and reduces postoperative analgesic requirements.
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Comparative study of excessive oxygen therapy effects on critically ill patients’ outcome p. 15
Waleed S Abdelhady Mohamed
DOI:10.4103/roaic.roaic_97_18  
Introduction The use of oxygen in medicine became common around 1917 and is believed to be the most common treatment given in hospitals in the developed world. Aim of the work This study was aimed to compare and evaluate the effects of excessive oxygen therapy on severely ill patients’ prognosis and outcome. Patients and methods This study was conducted on 70 adult severely ill patients admitted to Department of Critical Care, Alexandria Main University Hospital. The selected cases were divided into two groups: control group I included 35 patients who will receive conservative oxygen therapy, and study group II included 35 patients, who will receive liberal oxygen therapy. Statistical analysis The collected data were coded, tabulated, and statistically analyzed using IBM statistical package for the social sciences statistics. Results There was no significant difference between the two groups regarding demographic data, the incidence of shock, clinical data, the vital signs and hemodynamic data, laboratory data, the ICU mortality, the sequential organ failure assessment (SOFA) score, and ICU stay. Discussion In our study, it was found that there was no significant difference between the outcome in the conservative oxygen therapy group and liberal oxygen therapy. This results may be owing to the small number of patients and the short duration of treatment. Conclusion These results can be a starting point for further research studies assessing the potential beneficial effects of normoxia in critically ill patients.
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Patterns of C-reactive protein ratio response in ventilation-associated pneumonia p. 20
Waleed S Abdelhady Mohamed
DOI:10.4103/roaic.roaic_98_18  
Introduction Physicians frequently use serum biomarkers to assist in clinical response to antibiotic therapy in patients having ventilator-associated pneumonia (VAP). C-reactive protein (CRP) is one of these biomarkers and probably the most widely used. Aim of the work This study was aimed to evaluate the course of CRP and identify the patterns of CRP ratio response to antibiotic therapy during the first week in patients with VAP who are admitted to Critical Care Medicine Department in Alexandria University Hospital. Patients and methods This study will be conducted on 60 adult patients of both sexes who admitted to Critical Care Department, Alexandria Main University Hospital of patients complicated with VAP. All cases were subjected to: history taking from the patient or next of kin including: age, gender, associated medical diseases, Acute Physiology and Chronic Health Evaluation II, and sequential organ failure assessment score. CRP was assessed on admission (D0), day1 (D1), and day 5 (D5). Results The study patients were classified into two groups: group I ‘good response’ to treatment of pneumonia and group II ‘poor response’ to treatment of pneumonia. The patients who showed good response were 36 (60.0%), whereas 24 (40.0%) patients showed poor response. Discussion In our study, survivors showed a continuous and significant decrease of CRP ratio during the first week of antibiotic therapy. Conversely, in nonsurvivors, CRP ratio remained elevated, and at D5, a CRP ratio of higher than 0.5 was associated with a fivefold increase in the risk of death in the ICU. Interestingly, in our study, patients with nonresponse CRP ratio pattern presented a significantly higher ICU mortality than patients with fast or slow response patterns. Conclusion The use of serial CRP determinations is useful in monitoring therapeutic response of serious infection, allowing early identification of complications or antibiotic failures.
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Comparative study between dexmedetomidine and fentanyl added to bupivacaine for ultrasound-guided brachial plexus block p. 25
Mamdouh E Lotfy, Nagwa M Doha, Abd-Elazeem A Elbakry, Sohila S Mohamed
DOI:10.4103/roaic.roaic_92_18  
Background Ultrasonic guided supraclavicular brachial plexus block provides complete and reliable anesthesia for upper limb surgeries. Adjuvants to regional blocks can affect the block characteristics. Aim To evaluate supraclavicular block characteristics and adverse effects of the addition of dexmedetomidine or fentanyl to bupivacaine 0.5% in patients undergoing elective upper limb surgeries. Patients and methods This prospective double-blind trial was conducted on 90 patients scheduled for upper limb surgeries randomized into three equal groups. The patients in group C received 30 ml 0.5% bupivacaine with 1 ml normal saline, in group F received 30 ml bupivacaine 0.5% with fentanyl 50 µg (1 ml), whereas in group D received 30 ml bupivacaine 0.5% with dexmedetomidine 75 µg (1 ml). Sensory and motor block characteristics were assessed as well as the hemodynamics, adverse effects, and complications. Results Group D showed significantly rapid onset and longer duration of sensory and motor block, prolonged duration of anesthesia and analgesia, and higher sedation compared with C and F groups (P<0.0001). Hemodynamics (heart rate and blood pressure) were insignificant among groups, and adverse effects were minimal. Conclusion Dexmedetomidine hastens the onset and prolongs the duration of sensory and motor blocks, as well as the duration of postoperative analgesia with minimal adverse effects compared with fentanyl when added to local anesthetic in supraclavicular brachial plexus block. We recommend further research studies for the determination of the optimum dose of dexmedetomidine used as an additive to local anesthetics.
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Quasi-experiment as an initial experience for conscious sedation in awake craniotomy: dexmedetomidine versus midazolam p. 31
Salwa H Waly, Yasser M Nasr, Ahmed A Morsy
DOI:10.4103/roaic.roaic_106_18  
Background Awake craniotomy with intraoperative brain mapping in the surgical management of brain lesions at eloquent areas has been reported to be associated with better neurological outcome and more extensive resection. Conscious sedation avoids the risks of general anesthesia, reduces the rate of ICU admissions, and shortens the length of hospital stay. Aim of the study The aim of the is to compare the efficacy and safety of dexmedetomidine with midazolam during procedural sedation of awake craniotomy patients. Patients and methods A quasi-experiment conducted upon 24 awake craniotomy patients. Patients were of American Society of Anesthesiologists I/II, of both sexes, 21–65 years. Scalp block was done. The patients were divided into two groups: group D is the dexmedetomidine group (n=12) and group M is the midazolam group (n=12). Group D: 1 µg/kg dexmedetomidine was administered intravenously over 20 min, followed by continuous infusion of 0.1–0.7 µg/kg/h. Fifteen minutes before starting cortical mapping, the dose of dexmedetomidine was reduced to 0.1 µg/kg/h. Group M: midazolam was administered as an intravenous loading dose of 0.1 mg/kg given slowly over 10 min followed by infusion of 0.03–0.2 mg/kg/h. Fifteen minutes before starting cortical mapping, the dose of midazolam was reduced to 0.03 mg/kg/h. Results Success rate was significantly higher in group M compared with group D (100 vs. 91.7%). Duration of postoperative recovery from sedation was statistically significantly longer in group M compared with group D (24±1 vs. 18±8). Three (25%) cases in group D experienced intraoperative seizures and one (8.3%) case could not be controlled and awake technique was aborted. Patients had memories of the procedure (66.7% in group D to 16.7% in group M) with statistically significant difference. Conclusion Both dexmedetomidine and midazolam were safe and efficient during awake craniotomy. Midazolam had a higher success rate, lower incidence of intraoperative seizures, and higher incidence of amnesia. Dexmedetomidine had more rapid recovery.
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The relation between arterial hyperoxia and mortality among intensive care unit patients with septic shock p. 41
Tayseer M Zaytoun, Hany E Elsayed, Samar E Elsayed
DOI:10.4103/roaic.roaic_87_18  
Context Oxygen should be regarded as any other drug with potential dose and time-dependent adverse effects. Health care practitioners are more likely to accept supranormal arterial oxygen levels as a wider safety buffer. Furthermore, the latest guidelines in the management of septic shock did not define upper limits for oxygenation in mechanically ventilated patients with septic shock. Aim To investigate whether hyperoxia is associated with higher mortality in patients with septic shock. Patients and methods This study was carried out on 200 patients with septic shock. After fulfilling the inclusion criteria, we recorded the clinical data, severity scoring systems, source of sepsis, ventilatory data, oxygenation status data, and the outcome parameters. We categorized the patients into two groups: group I (nonhyperoxic group), whose arterial oxygen tension was less than 120 mmHg in all arterial blood gas analyses during the ICU stay, and group II (hyperoxic group), whose arterial oxygen tension was more than or equal to 120 mmHg in at least one arterial blood gas analysis during ICU stay. Results Group I included 40 patients, whereas group II included 160 patients. Mortality rate was 57.5 and 89.4% in groups I and II, respectively. In group II, there were 16 patients who were exposed to 1 day of hyperoxia with a mortality rate of 75%, whereas there were 144 patients who were exposed to hyperoxia more than 1 day with a mortality rate of 91%. Conclusion Hyperoxia was associated with increased mortality, number of mechanical ventilation days, length of ICU stay, and hospital stay.
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Accuracy of pulse oximetry in comparison with arterial blood gas p. 51
Khadeja M Mohamed Elhossieny
DOI:10.4103/roaic.roaic_91_18  
Background Oxygen plays a principal role in aerobic respiration. Oxygenation is tested by pulse oximetry, which is considered the “fifth vital sign” of health status. It is widely used in critical care medicine to measure arterial oxygen saturation (SaO2). Aim To evaluate the factors affecting the accuracy of pulse oximetry (SpO2) relative arterial oxygen saturation SaO2. Patients and methods The study included 70 patients admitted to emergency and surgical ICU. They were subjected to full history taking, complete physical examination and laboratory investigations, including complete blood count, liver and kidney function tests, taking sample of arterial blood gases, and at the same time, recording the readings of pulse oximetry. Results This study shows that SpO2 is accurate relative to SaO2 in arterial blood gases as the difference between SpO2 and SaO2 was less than ±3%. Many factors affected accuracy, such as mechanical ventilation, vasopressor, oxygen mask (P≥0.047), age (P≥0.045), and corresponding hypoxia (P=0.002), whereas the results were insignificant regarding sex and sepsis (P=0.568 and 0.660, respectively). Conclusion The pulse oximeter remains a valuable tool in intensive care patients, but an awareness of its limitations such as old age more 65 years, mechanical ventilation, vasopressors support, and oxygen mask is important, as they were the impact factors affecting its accuracy. It is an important component of enhancing the quality of intensive care.
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Comparative study between intraperitoneal bupivacaine and bupivacaine-nalbuphine for postoperative pain relief after laparoscopic cholecystectomy p. 57
Wegdan A Ali, Nagy S Ali, Alaa M Sewefy, Aya H Ahmed
DOI:10.4103/roaic.roaic_101_18  
Background Postoperative pain relief following laparoscopic cholecystectomy (LC) has been achieved using intraperitoneal (i.p.) local anesthetics. Addition of opioids can prolong postoperative analgesia. Nalbuphine is an agonist–antagonist opioid that provides analgesia without the undesirable effects of pure agonists. This study was performed to compare between postoperative analgesia of i.p. bupivacaine and bupivacaine combined with nalbuphine in patients undergoing LC. Patients and methods This study included 90 patients undergoing LC. They were randomly divided into three groups, with 30 patients each. Postoperatively, group C received 50-ml normal saline (NS), group B0 received bupivacaine 100 mg diluted with NS to 50 ml, and group BN received bupivacaine 100 mg with nalbuphine 10 mg diluted with NS to 50 ml. Pain was assessed using the visual analog scale (VAS) for 24 h, and the first analgesic request was recorded. Total analgesic consumption in 24 h, hemodynamic parameters, and adverse effects were also noted. Results Postoperative VAS values were significantly lower in group BN up to 24 h. Moreover, i.p. bupivacaine showed lower VAS values than in control group. The duration of analgesia was 11.5±0.9, 7.5±0.9, and 1.5±0.6 h in groups BN, B0, and C, respectively (P<0.001). The total analgesic consumption in 24 h. was significantly less in BN group than other groups. The hemodynamic parameters were steadier in BN group than other groups, with no significant adverse effects. Conclusion Addition of i.p. nalbuphine to bupivacaine provides superior analgesia than bupivacaine only after LC without an increase in adverse events.
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The use of USB endoscope (borescope) to guide nasal tracheal intubation: a pilot study p. 65
Mohammad H.I Ahmad Sabry, Ahmed M Aboughazy
DOI:10.4103/roaic.roaic_86_18  
Background In spite of the presence of multiple videolaryngoscopes in the market, financial restrains prevent their routine use in many clinical practices. Patients and methods The endoscope USB camera was inserted in a conventional endotracheal tube which could be inserted nasally (6.5 or 7 cuffed endotracheal tube). Sterile K-Y lubricating gel was used to facilitate the insertion of the borescope. This was used for nasal intubated in eight patients. Results Nasal intubation trials were done by an experienced physician for eight patients. All eight patients were Mallampati class 1 or 2. One patient was intubated at the first attempt, three were intubated at the second attempt, and one was intubated at the third attempt. There was failure in three cases (secretions and blood). Conclusion Borescope can be used as a cheap option for nasal airway management. Randomized studies need to be done for its evaluation compared with other videolaryngoscopy devices.
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Comparison of the use of nebulized dexmedetomidine, ketamine, and a mixture thereof as premedication in pediatric patients undergoing tonsillectomy: a double-blind randomized study p. 70
Mohammad Hazem I Ahmad Sabry, Nader A El Gamal, Nourhan Elhelw, Ramadan A Ammar
DOI:10.4103/roaic.roaic_79_18  
Purpose To compare the use of nebulized dexmedetomidine, nebulized ketamine, and a mixture thereof as premedication in children aged 3–6 years undergoing tonsillectomy. Patients and methods Seventy-five patients were assigned randomly to three groups (n=25/group) that received nebulized dexmedetomidine (3 μg/kg; group A), nebulized ketamine (3 mg/kg; group B), and nebulized dexmedetomidine (1.5 μg/kg) plus nebulized ketamine (1.5 mg/kg; group C). The drugs were prepared in 0.9% normal saline, and the children underwent nebulizer sessions 30 min before surgery. The primary end point was the level of sedation, measured 30 min after nebulization using Ramsay scale. We also measured ease of parental separation, face mask acceptance, hemodynamic stability, postoperative analgesia requirement (using a visual analog scale), and recovery and discharge times. Results The three groups did not differ in terms of age, sex, or weight. The level of sedation (in 15 and 30 min) was higher in group A than in group B (P=0.039), but no significant difference in sedation score was detected among the three groups. Ease of parental separation and face mask acceptance were better in group A than in group B (P=0.037). The groups did not differ in terms of analgesia requirement, recovery time, or discharge time. Conclusion Nebulized dexmedetomidine achieves better sedation and facilitates parental separation and face mask acceptance during inhalational induction compared with nebulized ketamine and a mixture of nebulized ketamine and dexmedetomidine, with no effect on hemodynamic stability or recovery or discharge time.
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Evaluation of different patterns of sepsis-induced myocardial dysfunction by echocardiographic tissue Doppler imaging as early predictors of mortality p. 75
Tayseer M Zaytoun, Tamer A Helmy, Hany E Elsayed, Marwan M El Bourini
DOI:10.4103/roaic.roaic_65_18  
Background Cardiovascular dysfunction in sepsis is associated with a significantly increased mortality rate. Tissue Doppler imaging is useful in detecting sepsis-induced myocardial dysfunction (SIMD) by quantification of systolic and diastolic functions. Aim To evaluate the different patterns of SIMD, by pulsed-wave tissue Doppler imaging (pwTDI), as early predictors of mortality. Settings and design A prospective observational cross-sectional study was conducted. Patients and methods Our study included 120 patients with severe sepsis/septic shock. All patients were assessed during the first 24 h of diagnosis using transthoracic echocardiography. Tissue velocities were obtained by pwTDI, and patterns of SIMD were determined and correlated with the patients’ outcome. Results In the systolic dysfunction group, a cutoff value for peak systolic annular velocity (S′) of more than 5.8 cm/s was associated with significant mortality, whereas in diastolic dysfunction group, a cutoff value for early diastolic transmitral flow velocity to early diastolic mitral annular tissue velocity (E/e′) of more than 12.5 was associated with significant mortality. In the combined dysfunction group, a cutoff value for S′ of less than 5.2 cm/s and a cutoff value for E/e′ of more than 12 were associated with significant mortality. Regarding the hyperkinetic group, a cutoff value for S′ of more than 11 cm/s was associated with significant mortality. Conclusion Tissue velocities measured by pwTDI were able to predict mortality in patients with severe sepsis/septic shock, with the highest mortality in the hyperkinetic pattern, whereas left ventricular systolic dysfunction was common in survivors, with the lowest mortality rate.
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Stroke volume variation compared with inferior vena cava distensibility for prediction of fluid responsiveness in mechanically ventilated patients with septic shock p. 84
Akram M Fayed, Waleed S Abd El Hady, Mohamed Abd El Aleem Abd El hady, Mourad El Amir Melika
DOI:10.4103/roaic.roaic_102_18  
Background The hemodynamic management of septic shock patients remains a complex challenge. Only 40–72% of intensive care unit (ICU) patients with homodynamic instability are able to respond to fluid loading. We postulated that the variation in vena cava diameter and its correlation to stroke volume variation could also be useful in identifying patients who may benefit from a volume load. The aim of this study was to test stroke volume variation (SVV) as a predictor of fluid responsiveness in mechanically ventilated patients with septic shock and its correlation with inferior vena cava (IVC) distensibility. Patients This prospective study was conducted on 76 adult patients with septic shock on mechanical ventilation. Results The responder and non-responder groups showed areas under the curve 0.963 as regards SVI (2nd) measurements, at the cut off value 36.0 the sensitivity was 97.0, specificity was 95.0, PPV 94.0%, NPV 96.0% and accuracy 95.0 in predicting the response. The SVI (1st) measurements showed areas under the curve 0.963, at the cut off value 8.5 the sensitivity was 95.0, specificity was 98.0, PPV 94.0%, NPV 97.0% and accuracy 96.0 in predicting the response. For Max DIVC within responder and non-responder groups, the areas under the curve 0.884, at the cut off value 2.2 the sensitivity was 82.0, specificity was 85, PPV 86.0%, NPV 83.0% and accuracy 84.0 in predicting the response. Conclusions Stroke volume variation (SVV) can predict fluid responsiveness in mechanically ventilated patients with septic shock and can be correlated to inferior vena cava (IVC) distensibility.
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Improving the outcome of pediatric emergency abdominal surgeries by application of enhanced recovery after surgery protocol p. 91
Aliaa R.A Abdel Fattah, Ahmed A.M El-Rouby
DOI:10.4103/roaic.roaic_72_18  
Introduction Pediatric emergency abdominal surgery is accompanied by high level of morbidity and mortality. Many protocols had been used to improve the outcome in these situations; from them fast track or enhanced recovery after surgery (ERAS) protocols gained high level of importance. Few studies investigated its application in emergency pediatric diseases. Aim of the work The aim of or work was to study the applicability and the outcome of ERAS protocol applied in emergency pediatric abdominal surgery. Material and Methods 60 pediatric patients with abdominal emergencies were randomly distributed into two groups. Group A was subjected to ERAS protocol and group B was managed by the conventional protocol, success was measured by Hannover criteria. Results Most of the parameters of the protocol were applied except for some of the preoperative items due to the nature of the situation. In comparison to the conventional protocol; ERAS protocol resulted in better outcome regarding better pain control, shorter hospital stay being 1.93±2.23 day in group A and 4.23±2.21 day in group B (P<0.001) and earlier return to full oral feeding within 2 days postoperative in 87% of patients in contrast to only 23 % in group B (P<0.001). More than 90 % of parents classified this management plan as excellent. Post-operative vomiting didn’t show significant difference between ERAS group and conventional group and didn’t affect the outcome significantly. Conclusion ERAS is applicable in emergency pediatric abdominal surgeries resulting in better outcome of this situations which have high rate of morbidity and mortality.
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Comparison between femoral vein diameter and inferior vena cava diameter by ultrasound in estimation of central venous pressure in mechanically ventilated patients p. 100
Dina Zidan, Ayman Baess
DOI:10.4103/roaic.roaic_1_19  
Background Bedside ultrasonography is used as a noninvasive method for hemodynamic monitoring, evaluation of inferior vena cava (IVC) diameter by sonography provides an alternative tool for evaluation of intravascular volume. Femoral vein is a superficial compliant vessel, and images can be easily obtained. A significant correlation between central venous pressure (CVP) and common iliac vein pressure was reported previously, meaning that the femoral vein could be a noninvasive alternative to the CVP. Patients and methods We enrolled 100 adult patients in this study. During measurement, the patient was in supine position. The CVP was uniformly measured at the end of expiration, with the pressure transducer having been zeroed at the level of mid axillary line. IVC image was obtained using General Electric ultrasound machine and 3.5-MHz convex probe. The transducer is placed in a vertical plane in the subxiphoid view. The intrahepatic portion of the IVC was visualized as it entered the right atrium. Approximately 3–4 cm from the junction of the IVC and right atrium, the IVC diameter was obtained. Using M mode, the maximum and minimum diameter during inspiration and expiration diameter were recorded, respectively. To get the femoral vein diameter (FVD), we scanned the femoral triangle starting at the inguinal crease using a linear array transducer (5–10 MHz). FVD was measured just caudal to the saphenofemoral junction. Results We enrolled 100 patients in this study. Their mean age was 56 years, mean CVP was 6 cm H2O, mean IVC diameter during inspiration was 15 cm, whereas during expiration was 13.6 cm, and the FVD was 8.2 cm. There were significant correlations between both CVP and IVC diameter (insp and exp) and FVD. CVP correlation with FVD was 0.59, IVC diameter during inspiration with FVD was 0.41, and IVC diameter during expiration with FVD was 0.42. Conclusion FVD can be used as a noninvasive alternative method to assess intravascular volume status.
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Comparative study of statin therapy effects on patient outcome when continued or initiated following an intracerebral hemorrhage p. 104
Waleed S Abdelhady Mohamed
DOI:10.4103/roaic.roaic_2_19  
Introduction Intracerebral hemorrhage (ICH) is a neurologic injury resulting in significant morbidity and mortality. Despite clear benefits of statins in ischemic stroke, post-hoc analyses of some studies suggest there may be a link between statin therapy and development of ICH. Aim The aim of this study was to compare and evaluate the effects of statins therapy when continued or initiated following ICH on patients’ prognosis and outcome. Patients and methods This study was conducted on 60 adult patients of both sexes who presented with recent ICH and were admitted to Critical Medicine Department, Alexandria Main University Hospital. All cases were subjected to history taking from the patient or next of kin, including age, sex, previous use of statins, associated medical diseases, acute physiology and chronic health evaluation II and sequential organ failure assessment score, and multislice computed tomography on brain. Patients were classified into three groups: control group I (20 patients) was not receiving previous statin therapy and they did not receive statin therapy during this study, study group II (20 patients) was not receiving previous statin therapy and they received statin therapy in the form of atorvastatin 20 mg once daily, and study group III (20 patients) was receiving previous statin therapy and they continued on statin therapy in the form of atorvastatin 20 mg once daily. Results The patients showed nonsignificant difference regarding demographic data, hemodynamics, arterial blood gases, and outcome. Discussion In our study, it was found that there was a decrease in mortality in all the study groups treated with statin, but this decrease was nonsignificant. The duration of hospital stay showed a significant decrease in both groups II and III. Conclusion The use of statin therapy when continued or initiated following an ICH on patients has no significant effect on prognosis and outcome of these patients.
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The comparison of sedation quality of dexmedetomidine with midazolam using bispectral index and Ramsay sedation score in tympanoplasty under monitored anesthesia care p. 111
Renu Upadhyay, Jitendra Homdas Ramteke, Dinesh Kumar Sahu
DOI:10.4103/roaic.roaic_8_19  
Background and aims Tympanoplasty is most commonly performed under local anesthesia supplemented with sedation. Midazolam is a commonly used drug in such procedures. Recently, dexmedetomidine is used for procedural sedation. We carried out a study to find whether dexmedetomidine is superior to midazolam in monitored anesthesia care in terms of sedation quality using bispectral index (BIS) and Ramsay sedation scale (RSS). Patients and methods This randomized, prospective, single-blind study included 56 patients aged 18–50 years, equally divided into two groups. In group 1 (n=28), inj. dexmedetomidine 1 µg/kg over 10 min followed by infusion of 0.5 µg/kg/h was given. In group 2 (n=28), inj. midazolam 0.02 mg/kg intravenous followed by infusion of 0.01 mg/kg/h was given. Local anesthesia (2% lignocaine with adrenaline 1 : 200 000) was given by surgeon at the incision site. Inj. tramadol is used as rescue analgesia. Both groups were compared using BIS, RSS, hemodynamic parameters at regular time interval during surgery, and number of times rescue analgesia was required during surgery. Results There is a significant decrease in heart rate after giving bolus dose in dexmedetomidine group. There was a significant difference of RSS in both groups at the time interval at RSS 4, RSS 5, and at RSS 6. There was a significant difference of BIS score in both groups at the time interval of BIS 4, BIS 5, and BIS 6. There was one patient who needed rescue tramadol in group 1, whereas in group 2, two patients needed rescue tramadol. Conclusion We concluded that for monitored anesthesia care in surgeries like tympanoplasty performed under local anesthesia, inj. dexmedetomidine can be a better alternative over inj. midazolam with respect to sedation quality and fewer requirements of rescue analgesia. However, dexmedetomidine has an adverse event, that is, bradycardia, which can be manageable.
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Microalbuminuria as an early postoperative detector of sepsis after major surgeries p. 117
Ali A Mahareak, Sameh H Seyam
DOI:10.4103/roaic.roaic_28_19  
Background Recently, many prognostic markers have been developed for early prediction of sepsis. Purpose To study if microalbuminuria has an early detection value in surgical sepsis and is correlated with other scoring systems. Patients and methods This observational prospective correlation study was done in Al-Azhar University hospitals. A total of 26 patients aged between 21 and 65 years were included in the study. Patients were chosen after 48 h of admission to the ICU after major surgeries. The patients were evaluated upon admission and 24 h later for manifestations of sepsis. Spot urine samples were obtained at the preoperative time, on ICU admission [albumin/creatinine ratio 1 (ACR1)], 24 h postoperative (ACR2), and 48 h postoperative (ACR3). ICU scoring systems included Acute Physiological and Chronic Health Evaluation II (APACHE II) score evaluated every 24 h for 72 h, and the Sequential Organ Function Assessment (SOFA) score was evaluated daily until ICU discharge or up to a total of 28 days. Results A total of 26 patients were involved in this correlational study after exclusions. There was no correlation between ACR1 and APACHE II score or SOFA score or the length of ICU stay. There was a positive correlation between ACR2 and ACR3 with APACHE score on day 1 and day 2 and SOFA score on day 1 and day 2. There was a positive correlation between ACR2 and ACR3 and the length of ICU stay. There was no statistically significant difference between ACR on admission, ACR on day 1, and ACR on day 2 in patients who needed vasopressors and those who needed dialysis therapy. Only ACR2 was a significant predictor for mortality in our patient population. Conclusion Microalbuminuria a simple and ready tool that has a unique prognostic value in patients with sepsis following major surgeries.
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Analgesic efficacy of erector spinae block in comparison to thoracic epidural anesthesia in patients undergoing transthoracic esophageal surgical procedure p. 124
Hoda Shokri, Amr A Kasem
DOI:10.4103/roaic.roaic_35_19  
Background The ultrasound-guided erector spinae plane block is a new regional anesthetic technique providing long-lasting excellent analgesia in addition to hemodynamic stability and minimal rescue analgesic request. Materials and methods Following ethics committee approval, a total of 80 patients aged 36–65 years, American Society of Anesthesiologists physical status I and II undergoing elective transthoracic esophageal surgical procedures were enrolled in this prospective study. The patients were randomized into epidural group: patients who received thoracic epidural anesthesia with injection of 15 ml of bupivacaine 0.25% combined with general anesthesia, followed by 7 ml/h of 0.125% bupivacaine and bilateral erector spinae block group, which were performed with an injection of a total of 15 ml of bupivacaine 0.25% on either side combined with general anesthesia and then 7 ml/h of 0.125% bupivacaine was injected in each catheter 2 h for 24 h postoperatively. The primary end point included postoperative minor complications (hypotension, vomiting, urinary retention) and major complications (mortality). Secondary end points included the extubation time, hospital stay length, pain scores at 4, 8, 12, 18, and 24 h postoperatively, rescue analgesic consumption and patient satisfaction scores. Results Pain scores and the total dose of rescue analgesic were comparable in the two groups. The length of hospital stay was significantly longer in the epidural group compared with the erector group. Satisfaction scores were significantly higher in the erector group compared with the epidural group. There was no significant difference between the study groups regarding time to perform the block, time to extubation, and incidence of postoperative complications except for hypotension which was significantly higher in the epidural group. Conclusion Erector spinae plane block has an outstanding beneficial effect in reducing pain and providing better satisfaction scores with less incidence of complications compared with thoracic epidural anesthesia.
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CASE REPORT Top

A case of near-fatal asthma precipitated by H1N1 pneumonia with critical PCO2 successfully treated by multipharmacological approach p. 131
Rabea A Alzobaidi, Talal I Hagag, Ibrahim K Alsharqawy, Javaid H Hasan, Motaz M Rahmatallah, Saud K Alsamadani
DOI:10.4103/roaic.roaic_109_18  
We describe a case of prolonged severe hypercapnia with respiratory acidosis occurring during an episode of near-fatal asthma in a 15-year-old boy, followed by complete recovery. After admission to the ICU, despite treatment with maximal conventional bronchodilatation therapy, the clinical picture deteriorated with evident signs of respiratory muscle fatigue. The patient was sedated, intubated, and mechanically ventilated. At 30 min after admission, arterial PCO2 reached 132 mmHg, pH was 6.94, and PO2 was 95 mmHg, and then the measurements repeated after 30 min revealed pH of 6.80, PCO2 of 209 mmHg, and PO2 of 73 mmHg. Oxygenation was initially hypoxic but rapidly maintained, and successful recovery followed without neurological or cardiovascular sequelae. This case shows the cardiovascular and neurological tolerance of a prolonged period of supercarbia in a young patient. The most important lesson to be learned is the extreme importance of maintaining adequate tissue perfusion and oxygenation during an asthma attack. The second lesson is that when conventional bronchodilators fail, the intensivist may resort to the use of drugs such as ketamine, magnesium sulfate, and inhalation anesthesia. In this context, deep sedation and curarization are important, not only to improve oxygenation but also to reduce cerebral metabolic requirements.
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