Introduction Injuries to the chest are responsible for most of deaths occurring at the scene of trauma or within 1 h from arriving to hospital (immediate deaths) and many of those within few hours up to 24 h from arriving to hospital (early deaths). Hemothorax often develops after blunt or penetrating trauma. The most common cause of blunt trauma is traffic accidents, and hemothorax is associated with injures of the lung or intercostal vessels caused by broken rib ends as a result of rib fractures, frequently occurring in blunt trauma. Objectives The aim of this study is to evaluate the sensitivity and specificity of chest ultrasound (US) in the detection of traumatic hemothorax and quantification of its size in comparison with chest radiograph and the computed tomography (CT) chest as a gold standard diagnostic tool. Patients and methods This prospective observational study enrolled 80 patients who had hemothorax and admitted to Alexandria University Hospital, screened with chest radiograph, US, and CT scan to determine the accuracy and sensitivity of chest US imaging modality. Moreover, hemodynamic variations were assessed at the time of admission (0 h) and after 12 h. Results Overall, 71% of the patients were males, and 45% of the patients were between 20 and 30 years of age. The mode of trauma in 56% of cases was motor vehicle accidents, and in 33% of cases was falling from height. Moreover, 38% of the patients were intubated. Bedside US sensitivity in detection of traumatic hemothorax in comparison with the CT chest showed sensitivity of 93% on the right-side chest hemothorax and 100% on the left-side chest hemothorax and specificity of 100% on both sides. Conclusions US is a sensitive, specific, and accurate technique for detecting hemothorax in patients with thoracic trauma. CT does detect some hemothoraces not seen on US. However, it can permit early and precise definition of the location of bleeding in patients with trauma who cannot be moved. It is also more readily attainable than CT scan. Therefore, it can be used in patients who are not stable enough for transport and in resource-limited areas.

Background A lung-protective strategy of ventilation is now suggested as a standard of care for patients with acute respiratory distress syndrome (ARDS). The cost of such protective strategy may be prolongation of mechanical ventilation (MV) and poorer prognosis owing to weaning difficulties from the ventilator. Aim The aim was to evaluate the efficacy and outcome of noninvasive ventilation (NIV) as a possible alternative to IMV in patients with ARDS with respect to hemodynamics, gas exchange parameters, incidence of complications, duration of MV, length of hospital stay, ICU survival, and weaning from MV. Patients and methods This randomized controlled study included 52 patients with ARDS of different etiologies; they received either NIV or conventional MV. Data regarding hemodynamics and respiratory changes, including Respiratory Rate (RR), lung compliance, airway resistance, Arterial Blood Gases (ABG), pH, PaCO₂, PaO₂/FiO₂, and LIS, were collected and compared. The reported complications, duration of ventilation, ICU stay, and patients’ outcomes were also compared. Results There was a similar improvement in oxygenation and hemodynamic stability between the NIV group and the IMV group. However, the serious complications were fewer and mortality was lower in the NIV group. There was a statistically significant rise in duration of ventilation in MV (8.33 days) in comparison with NIV (2.52 days). Regarding ICU stay, it ranged from 3 to 18 days, with a mean of 9.02±3.776 days, and there was statistically significant increase in MV group (10.59±1.6 days) in comparison with NIV group (7.32±4.64 days). Weaning was succeeded in 65.4% of NIV group, whereas it was 61.5% in MV group, and there was no statistically significant difference between the studied groups. Mortality was reported in four (15.4%) cases in NIV group, whereas it was reported in 11 (42.3%) cases of invasive MV. Conclusion Considering the advantages and disadvantages of NIV, we believe NIV could be a good alternative option in patients with ARDS. Physicians should try NIV early if there is a respiratory failure risk to reduce mortality, to reduce complication risk, to avoid endotracheal intubation, and to reduce treatment failure.

Background and objective Upper gastrointestinal tract endoscopy (UGIE) is widely performed under propofol sedation, which is considered as a safe sedation agent and alleviates the sympathetic response to the procedure. However, retching and gag reflex still disturb ∼29% of those patients despite being under propofol sedation. Patients and methods A total of 120 adult patients scheduled for elective UGIE were randomly allocated into three equal groups (40 patients each): group C was given propofol 50 mg, group D was given propofol 50 mg+dexmedetomidine 0.5 μg/kg, and group L was given propofol 50 mg+15 g palatable lidocaine gel. The outcome measures included incidence of gag reflex, propofol consumption, recovery time, intraoperative hemodynamics, and patients’ and endoscopist’s satisfaction. Results The incidence of gag reflex was statistically significantly reduced in groups L and D compared with group C; however, the reduction was more in group L but with no significant difference when compared with group D group. Propofol consumption was statistically significantly lower in groups L and D compared with group C, as well as recovery time was significantly shorter in groups L and D compared with group C. Group L showed the least hemodynamic changes among the three groups, and the endoscopist as well as the patients were statistically significant more satisfied in both groups L and D when compared with group C. Conclusion Using palatable lidocaine gel in addition to propofol in patients undergoing UGIE was safe and effectively reduced the incidence of gag reflex and the dose of intravenous propofol with its subsequent complications, shortening recovery time and improving patient and endoscopist satisfaction. Trial registration This clinical trial was registered with ClinicalTrials.gov (NCT04213833).

Background Different additives have been reported to prolong the duration of caudal anesthesia in pediatrics. Although these drugs successfully increased the duration of the block, ketamine has been found to effectively increase the duration of caudal block in pediatrics. Aim This study aimed to assess the clinical effectiveness of ketamine after caudal or intravenous administration in pediatric patients who underwent hypospadias repair to distinguish between local and systemic analgesia. Patients and methods After induction of general anesthesia, 48 patients, aged 1–6 years, assigned to undergo hypospadias repair, received a caudal injection of bupivacaine and were randomly blinded into two groups: K1 group received 1 mg/kg S-ketamine as the caudal group, and K2 group received 1 mg/kg S-ketamine as the intravenous group. Postsurgical measurements included the effectiveness of postsurgical analgesia, which was assessed by using observational pain scale, duration of analgesia, sedation score, and hemodynamic and complications. Results The caudal block was successful in all the patients included in the study. None of the patients in either groups required intraoperative rescue analgesia. All patients remained vitally stable during the procedure, and intraoperative hemodynamic parameters were comparable in the two groups. The time to the administration of first analgesia was statistically longer in K1 group (11.5±4.6 h) than in the K2 group (8.7±3.1 h). Time to spontaneous leg movement and time to first micturition were statistically nonsignificant between both groups. The number of patients requested for additional analgesic drugs (acetaminophen and ibuprofen) was statistically significant, being higher in the K2 group than the K1 group. Conclusion This study demonstrates that ketamine if added to caudal epidural in a dose of 1 mg/kg provided prolonged postoperative analgesia with improved quality, had longer duration of analgesia, decreased the supplemental acetaminophen analgesia during the first 24 h postoperatively, had stable hemodynamic changes, and had comparable adverse effects and complications in comparison with systemic ketamine in a dose of 1 mg/kg.

Background Ultrasound (US) guidance for central venous catheter (CVC) placement is considered gold standard in localization and cannulation, making the procedure safer with less complications. Objective To compare the short-axis/out-of-plane (SAX) with the long-axis/in-plane (LAX) technique for US-guided CVC insertion in internal jugular vein in intensive care practice regarding safety and efficacy. Patients and methods A prospective randomized trial was conducted in Zagazig University Hospitals, from October 2017 to October 2018. All were randomized into one of two groups according to US guidance technique: SAX technique (group S), including 116 patients, and the LAX technique (group L), including 116 patients, for US-guided CVC insertion in internal jugular vein. The primary outcome was first-attempt success rate of both the SAX and LAX approaches for US-guided vascular catheterization. The secondary outcomes were total success rate, which was defined as successful venous cannulation without complication; cannulation times calculated in seconds; the number of attempts; and complications (hematoma and arterial puncture). Results US-guided venous cannulation was successful without complications in 115 (99.14%) patients. Venous access time, catheterization time, and US imaging time were significantly lower in the group S than in the group L (P<0.05). Complications in both groups had no significant difference. Hematoma formation was evident in one patient in group L. Multiple puncture was more in LAX group, with no significant difference.

Background Many therapeutic strategies have been developed to attenuate the inflammatory reaction to cardiopulmonary bypass and thereby enhance fast-track recovery of the cardiac surgical patient. The aim of the study was to determine the effect of small versus intermediate dose of dexamethasone on patient-perceived quality-of-recovery (QoR) scores in valvular replacement cardiac surgical patients and postoperative analgesic consumption. Patients and methods After obtaining local ethics committee approval and wr tten consent, 60 patients with American Society of Anesthesiologists physical state II and III, aged 16–60 years underwent elective valvular replacement surgery. Those patients were randomly divided into three equal groups, with 20 patients each. Group S received small-dose dexamethasone (0.1 mg/kg) in a total volume of 5-ml saline, group I received intermediate-dose dexamethasone (0.2 mg/kg), and group C received placebo (5-ml saline). Results Our results concerned with QoR-40 score showed significant statistical difference between the three groups in the dimensions of emotions, physical comfort, psychological support, and pain but not in the dimension of physical independence, in favor of dexamethasone groups. Conclusion Postoperative QoR-40 scores in the dimensions of emotional state, physical comfort, psychological support, and pain were all improved in the dexamethasone groups compared with the control group. The intermediate dose (0.2 mg/kg) of dexamethasone was better than the small dose (0.1 mg/kg) in the dimension of pain on postoperative day (POD) 1 and POD 2, whereas it was better on POD 3 and POD 2 in the dimensions of psychological support and physical comfort, respectively.

Background Obese patients are increasing among surgical population. Aim To detect the most beneficial level and pattern of positive end-expiratory pressure (PEEP) to mechanically ventilate obese patients under general anesthesia in beach-chair position. Patients and methods A prospective randomized study was conducted that included 45 ASA II patients (21–65 years) of both sexes who were randomized into three groups: group I (n=15), ascending PEEP (5, 7, 10 cmH₂O); group II (n=15), steady PEEP5; and group III (n=15), descending PEEP (10, 7, 5 cmH₂O). Results Arterial oxygenation (PaO₂/FiO₂) was significantly higher in group III at PEEP₁₀ (470±10) than groups I (418±19) and II (422±12) at that time. At PEEP₁₀, PaO₂/FiO₂ was significantly higher in group III (470±10) than group I (448±11). After 40 min, it was significantly higher in group III (456±66) than groups I (432±12) and II (428±14). After 60 min, it was significantly lower at group II (426±12) than groups I (448±11) and III (444±24). Postoperatively, it was significantly higher in group III (460±24) than group I (436±11) and II (415±61). Peak airway pressure was significantly higher with PEEP₁₀ in group I (34.6±2.2) than groups II (26.5±3.8) and III (27.7±3.2). It was also significantly higher with PEEP₁₀ in group III (34.1±2.1) than groups I (26.7±3.7) and II (27.3±3.8). Plateau pressure was significantly higher with PEEP₁₀ in group I (23.8±2.1) than groups II (15.1±3) and III (15.2±2.6). It was also significantly higher with PEEP₁₀ in group III (23.3±1.7) than groups I (15.3±2.9) and II (15.9±2.6). Driving pressure was significantly higher in group III (13.3±1.7) than groups I (10.3±2.9) and II (10.9±2.6) with PEEP₁₀. It was also significantly higher in group I with PEEP₁₀ (13.8±2.1) than groups II (10.1±3) and III (10.2±2.6). Conclusion Descending pattern of PEEP (10, 7, and 5) improves oxygenation more effectively than ascending pattern of PEEP (5, 7, and 10) or steady pattern (PEEP₅) for mechanical ventilation of obese patients under general anesthesia in beach-chair position.

Background Profound hypotension during cesarean section can compromise fetal circulation and cause cardiac arrest in the parturients. We compared the incidence of hypotension, adequacy of anesthesia, and neonatal outcome using a height-adjusted and weight-adjusted dose and a fixed dose of 0.5% intrathecal hyperbaric bupivacaine. Patients and methods This was a randomized controlled double-blind trial involving 80 parturients aged 18–40 years scheduled for elective cesarean section under spinal anesthesia. They were randomly allocated by blind balloting into one of two groups: group FD received 12 mg of 0.5% hyperbaric bupivacaine, whereas group AD received a height-adjusted and weight-adjusted dose of 0.5% hyperbaric bupivacaine according to Harten’s chart. Parturients were preloaded with 10 ml/kg of 0.9% sodium chloride. Results The median dose of bupivacaine was significantly higher in group FD (12 mg) than group AD (9.5 mg) (P=0.001). The incidence of hypotension was significantly higher in group FD (60%) than in group AD (32.5%) (P=0.014). The median time to attain the maximal level of sensory block (T5) was significantly faster in group FD (10 min) than group AD (13 min) (P=0.021). The Apgar score and incidences of other complications were comparable between both groups (P>0.05). Conclusion It is concluded that a lower dose of bupivacaine was required to provide comparable sensory and motor block, with less incidence of hypotension when the bupivacaine dose was adjusted to the height and weight of parturients than when a fixed dose was used.

Muscular dystrophies are a group of genetic diseases characterized by a compromised synthesis or regeneration of contractile proteins, which causes weakness and progressive degeneration of the skeletal muscles. These muscular dystrophies can have significant anesthetic implications (hyperkalemia, rhabdomyolysis, cardiovascular instability, sudden death, etc.), representing a very high perioperative risk for patients. We herein describe the anesthetic management of a 12-year-old boy who was a known case of Duchenne muscular dystrophy posted for appendicectomy. The patient was induced and maintained with TIVA and using nitrous oxide as the only inhaled agent. We emphasize on careful presurgical evaluation and a multidisciplinary approach, ensuring the best perioperative care.