Background and aims Although intrathecal analgesia is an effective option during labor, there is a need to establish sustainable and assured analgesia during the entire labor process. We aimed to compare the effect of dexmedetomidine versus fentanyl as an adjuvant to low-dose ropivacaine-dexamethasone for intrathecal labor analgesia in primigravida women. Patients and methods The study was conducted after approval of ethical committee of Al Azhar University Hospital. A total of 60 primiparous women classified in American Society of Anesthesiologists classes II with a singleton pregnancy in active labor were given combined spinal epidural analgesia. This was a double-blind randomized controlled trial that allocated them in two groups of 30 patients each. Group I received intrathecal 2.5 mg of 0.1% ropivacaine (diluted to 2.5 ml with normal saline)+5 μg dexmedetomidine+4 mg dexamethasone. Occurrence of any adverse reaction was observed for ten min. Group II received 25 μg of fentanyl instead of 5 μg dexmedetomidine. For both groups, epidural top-ups of 10 ml of 1% ropivacaine were given when parturients complained of two painful contractions (visual analog scale ≥4), after epidural test dose of 3 ml of 0.5% ropivacaine was slowly injected via epidural catheter and no occurrence of adverse reaction was observed 10 min later. Data collected were demographic profile of the patients, intrathecal block characteristics, needs for epidural activation before delivery, and maternal and fetal adverse effects. The primary study goal was to prove the analgesic efficacy and safety of intrathecal selective sensory block on both mother and fetus, whereas the study secondary goal was to prove that intrathecal single dose injection could be used as an effective alternative option in labor analgesia as well as epidural analgesia. Catecholamine level (epinephrine and norepinephrine) was measured using enzyme-linked immunosorbent assay technique. Results The mean age (years), weight (kg), height (cm), and BMI (kg/m²) in group I were 24.3±3.30, 65.4±16.2, 161.3±4.6, and 22.3±3.4, respectively, whereas in group II were 25.23±4.44, 66.3±15.6, 160.4±4.3, and 22.2±3.1, respectively, with insignificant difference (P>0.05). Mean visual analog scale score before onset of analgesia in group I and group II was 8.59±1.22 and 8.7±1.14, respectively. The time to full cervical dilatation was 120.14±10.2 in group I and 120.0±10.6 in group II, and the mean duration of second stage of labor was 12.02±1.37 min in group I and 11.83±0.93 min in group II. The mean duration of analgesia was statistically significant (lower) in group II (221.83±22.26) as compared with group I (296.33±44.83) (P<0.001). The mean analgesia in group I (12.3±1.8) and group II (12.1±1.7) was statistically insignificant (P>0.05). The mean highest sensory levels in group I and group II were statistically insignificant, that is, T5 (T4–T8) versus T6 (T4–T7) (P>0.05). The sensory region time in group II was greater (241.83±22.26 min) as compared with group I (329.83±44.10), with P value less than 0.001. Neither maternal nor fetal adverse events were statistically significant different between both groups (P>0.05). The mean basal norepinephrine level in pg/ml in group I was 130.30±27.6 and in group II was 103.50±20.6, with P value more than 0.05. At 2 h, norepinephrine level in pg/ml was 119.90±24.1 in group I and 90.50±13.6 in group II, with P value more than 0.05. At baseline, the epinephrine level in pg/ml in group I and group II was 59.20±11.3 and 53.20±10.3, respectively, whereas at 2 h, the epinephrine level in pg/ml was 57.90±9.1 in group I and 49.20±8.6 in group II, with P value more than 0.05. Conclusion Ropivacaine-dexamethasone combined with dexmedetomidine for intrathecal block achieved a potent selective sensory block with prolonged duration of analgesia, delayed S1 regression time, and limited maternal and fetal adverse effects than intrathecal ropivacaine-dexamethasone combined with fentanyl. However, dexmedetomidine or fentanyl provides a safe and efficacious adjuvant to intrathecal ropivacaine-dexamethasone in primigravida women with rapid onset, profound analgesia, and hemodynamic stability throughout the labor.

Background Various techniques of regional anesthesia have been used in abdominal surgery including thoracic epidural, thoracic paravertebral block (TPVB), and transversus abdominis plane block. However, new techniques such as quadratus lumborum (QL) block are tested to detect its efficacy. Purpose To compare between intraoperative and postoperative analgesic effects of ultrasound-guided continuous QL block and continuous TPVB in patients operated for radical cystectomy (primary outcome). Side effects, length of hospital stay, and patient satisfaction are the secondary outcome. Patients and methods Sixty patients admitted to the Urosurgery Department at Alexandria Main University Hospital for radical cystectomy were randomly assigned into two groups, 30 patients for each group: group I received ultrasound-guided QL block with 0.3 ml/kg bupivacaine 0.25% on each side with catheter insertion for maintenance doses of 0.1 ml/kg/h on each side while group II received ultrasound-guided TPVB with 0.3 ml/kg bupivacaine 0.25% on each side with catheter insertion for maintenance doses of 0.1 ml/kg/h on each side. Results There was no statistically significant difference between the two groups regarding postoperative visual analog scale score, first request of analgesia, and length of hospital stay; however, there was statistically significant difference between the two groups as regards heart rate and mean blood pressure at the 1st, 4th, 6th, and 7th hours during the intraoperative periods. Conclusion It can be concluded that there is no difference in analgesic efficacy, opioid consumption, and hospital stay between continuous bilateral QL block and continuous bilateral TPVB after radical cystectomy. These data suggest that QL block is a viable alternative for delivering multimodal analgesia in radical cystectomy.

Aim In our study we aimed to determine whether fragmented wave in electrocadiogram (QRS) (fQRS) is associated with increased incidence of ventricular arrhythmias in patients with coronary artery disease (CAD) or not. Methods 300 patients with CAD were included. Patients were divided into two groups according to presence or absence of fQRS on admission ECG. Group I (n=51) was defined as fQRS (+ve) and group II (n=249) was defined as a fQRS (-ve). All patients were subjected to full history taking, complete physical examination, and ECG, echocardiography and laboratory investigations. Results There was higher incidence of fQRS in hypertensive patients (72.5 %). FQRS was found to be associated with increased incidence of ventricular arrhythmias, 51.1 % in group I versus 25% in group II. EF was significantly lower in group I than in group II with P value <0.0001. Fragmented QRS was an independent predictor of mortality with P value <0.0001. Conclusion FQRS on the resting surface electrocardiogram is a simple, fast and inexpensive modality of noninvasive investigation for evaluation of CAD patients. Patients who have known CAD present with a FQRS have increased rates of ventricular tachyarrhythmias, death risk, and low ejection fraction.

Background In spite of the presence of multiple video laryngoscopes in the market, financial restrains are present that prevent its routine use in many practices. Methods The endoscope USB camera was inserted alongside with a stylet in a conventional endotracheal tube which could be inserted orally keeping it in midline (7 or 7.5 cuffed oral endotracheal tube), and sterile k-y gel was used to facilitate the insertion of the stylet and/or the borescope. This was used for 25 oral intubations in manikin and oral intubation in 10 patients. Results Oral intubation trials on manikin were done by 25 physicians after their completion of airway course as its last session. All were anesthesiologists except one emergency room physician. A total of 14 (56%) physicians were successful to orally intubate the manikin in the first attempt. Moreover, 10 (40%) physicians were successful to orally intubate the manikin in the second attempt with verbal guidance, except one who needed manual assistance, and one physician was successful to orally intubate the manikin in the third attempt with verbal assistance. The intubated 10 patients were all of Mallampati 1 or 2, where seven were intubated on the first attempt, two on the second attempt, and one failed. Conclusion Borescope can be used as a cheap option for airway management and its training. Randomized studies need to be done for its evaluation compared with other video laryngoscopy devices.

Background and objectives Postoperative sore throat is a common complication after endotracheal intubation, and different methods have been proposed to attenuate it. The aims were to compare the intensity of sore throat and the sedation level of preoperative nebulized ketamine, magnesium sulfate, and lidocaine in attenuating postoperative sore throat after endotracheal intubation. Patients and methods A prospective comparative double-blind randomized study was conducted on 100 patients who were divided into four groups: group K (n=25) included patients who received nebulized ketamine 50 mg (1 ml) plus 4-ml normal saline; group M (n=25) included patients who received nebulized magnesium sulfate 250 mg (2.5 ml) plus 2.5-ml normal saline, group L (n=25) included patients who received nebulized lidocaine 2% 100 mg (5 ml), and group C (n=25) included patients who received nebulized normal saline 5 ml (control group). So, total volume used was 5 ml. Patients were preoperatively nebulized by compressor nebulizing for 15 min. Results Sore throat scores were statistically significant lower (0 and 1 point) in group L and group K at 0, 2, and 4 h compared with group C and group M (P<0.05). Group K showed statistically significant lower sore throat scores at 8, 12, and 24 h compared with group L, but statistically significant high sore throat scores (2, 3, and 4 points) compared with group M (P<0.05). The level of sedation assessed using A=alertness, V=response to verbal, P=response to painful stimulus, and U=unresponsive (AVPU) was statistically insignificant among groups (P>0.05). Conclusions Preoperative nebulized 100-mg lidocaine and 50-mg ketamine relieves throat pain earlier in the first 24 h after endotracheal intubation, but it persists for shorter duration than 250-mg magnesium sulfate, without any changes in sedation level.

Background Hypotension is one of the most frequent complications during spinal anaesthesia. It is more common in elderly with a reported incidence of 65–75%. While keeping in mind that the hypotension induced by subarachnoid block is related to sympathetic blockade accompanied with bradycardia, the administration of glycopyrrolate could affect hemodynamic during spinal anaesthesia. Thus, we aimed at evaluating the role of intramuscular glycopyrrolate in preventing hypotension after subarachnoid block in elderly patients. Patients and methods It’s a randomized double blind study. Forty four patients (60–80 years of age, ASA I and II) posted for lower abdominal surgery or lower limb surgery were given subarachnoid block using standard anaesthesia technique. They were administered either 1 ml of normal saline (group N) or 0.2 mg glycopyrrolate (group G) intramuscularly 15 minutes before subarachnoid block. Parameters like blood pressure and heart rate (at preset time intervals), total requirement of ephedrine, time to first rescue vasopressor i.e. ephedrine, incidence of nausea and vomiting and requirement of Ondansetron, incidence of bradycardia and requirement of atropine, presence of dry mouth etc was recorded. Results Eleven of 22 (50%) patients in group N experienced hypotension compared with two of 22(9.09%) patients in group G (difference=40.91% ; P=0.001). The mean ephedrine requirement in group G is 0.45±1.47 mg while, in group N is 3.63±4.41 mg (P=0.001). There was no case of bradycardia reported in group G although, two out of 22 patients (9.09%) in group N reported bradycardia (P=0.55). There is no incidence of nausea and vomiting in group G while, 3 patients in group N complained about nausea and vomiting (P=0.03). Conclusion The intramuscular administration of 0.2 mg glycopyrrolate in elderly patients undergoing subarachnoid block significantly reduces the incidence and degree of hypotension; and reduces the total consumption of rescue vasopressor without any clinically significant side effect.

A 1-day-old neonate presented to the emergency after vaginal delivery with tracheoesophageal fistula (TEF) and hemivertebra. As the neonate was not maintaining saturation, immediate intubation was done in neonatal ICU, and the infant was shifted to operation theater for emergency TEF repair. Basic screening and auscultation was done for any other coexisting congenital anomaly, which did not reveal any obvious cardiac defects. Neonate was hemodynamically stable. Anesthetic management focused on adequate ventilation and avoidance of gastric distension during positive pressure ventilation. TEF can cause several complications including aspiration, reduction in ventilation, and problems from concomitant congenital anomalies, mostly of cardiac origin. Intraoperatively, the patient may develop hypoxia owing to lung retraction and hemodynamic instability from bleeding or hypothermia. Here, we present a case of a newborn who underwent emergency type-C TEF repair, in which patient had multiple episodes of desaturation, which were managed successfully with Jackson Rees circuit ventilation allowing definitive repair of the TEF. Postoperatively, patient could not be weaned off from ventilator and was diagnosed with total anomalous pulmonary venous connection on echocardiography. This could explain the recurrent intraoperative oxygen desaturations.

Crouzon syndrome (CS) is an autosomal dominant disorder seen in about 1 in 60000 live births. The affected individuals are found to have facial dysmorphism, cranial synostosis and exophthalmos among other systemic involvement involving the heart and lungs. The primary concern for an anesthesiologist during administration of general anaesthesia for a patient with CS is the airway management. We report the successful anesthetic management of a pediatric case of CS who underwent a neurosurgical procedure.