Background Effect of adding magnesium sulfate infiltration of pectoralis major muscle on postoperative pain following modified radical mastectomy (MRM) especially during arm movement. Patients and methods A total of 75 female patients with American Society of Anesthesiologists physical status I and II scheduled for MRM were allocated into three groups (25 patients each). Group M received magnesium sulfate infiltration in pectoralis major muscle plus bupivacaine wound infiltration. Group B received saline in pectoralis major muscle plus bupivacaine wound infiltration. Group C received saline for both pectoralis major muscle and wound infiltration. Postoperative pain score at rest and during arm elevation, time to first analgesic request, cumulative morphine consumption in 24 h, and possible complications were recorded. Results Assessment showed overall lower pain scores at rest and during elevation of the related arm in group M compared with groups B and C. Time to first analgesic request was longer in patients of group M, with significantly less amount of postoperative opioid consumption (P<0.0001), and consequently, less number of attacks of postoperative nausea and vomiting in the first postoperative 24 h. In group M, only 16% required morphine compared with 48 and 72% in bupivacaine and control groups, respectively. Conclusion Magnesium sulfate infiltration of pectoralis major muscle following MRM is simple and provides effective postoperative analgesia at rest and during arm elevation superior than bupivacaine wound infiltration alone, resulting in greater opioid-sparing and better patient comfort.

Context The lateral transversus abdominus plane (TAP) block can provide sensory blockade of the T10–L1 abdominal dermatomes, which works well for lower abdominal surgery, but it is insufficient in extended upper incisions that may be needed in emergency laparotomies. So, concomitant use of the subcostal TAP block can extend the sensory blockade to the T7 abdominal dermatomes. Aims This clinical trial aimed to evaluate the efficacy and safety of ultrasound-guided four quadrants TAP block in emergency laparotomies and the effect of adding dexamethasone or magnesium sulfate as an adjuvant. Settings Minia University Hospital. Design This is a prospective double-blind, randomized, controlled study. Patients and methods After approval of the Faculty of Medicine Council and Research Ethics Committee − Minia University and clinical trial registration, this study was conducted on 90 adult patients with emergency laparotomies under general anesthesia who equally assigned into three groups that all received preincisional four quadrants TAP block using 38 ml of bupivacaine hydrochloride 0.25%, plus 2 ml of saline in group C, +2 ml of dexamethasone (8 mg) in group D, and +2 ml of magnesium sulfate (200 mg) in group M. Results The four-quadrants TAP block was effective in attenuating the hemodynamic stress response and providing intraoperative and postoperative analgesia [only two (6.7%) patients needed intraoperative fentanyl in the control group and the mean time of the first postoperative analgesia was 6.3±0.9 h] without notable complications. The mean time of the first analgesic request was significantly longer in group M (10.8±3.8 h) and group D (9.6±4.2 h) when compared with group C (6.3±0.9 h); consequently, the postoperative paracetamol doses were significantly lower in group M (1619.5±780.2) and group D (1942.5±969.9) than in group C (3638.8±1251) with no significant difference between D and M groups. Conclusions Four quadrants TAP block was safe and effective in intraoperative and postoperative analgesics in emergency laparotomies. Adding magnesium sulfate or dexamethasone as adjuvants prolonged the duration of analgesia. Magnesium sulfate was superior.

Background Peripheral nerve block has gained increased popularity owing to less postoperative pain and reduced need for postoperative analgesic drugs. The aim of the study was to compare the effect of ketamine and dexmedetomidine on the supraclavicular nerve block. Patients and methods A total of 75 adult patients undergoing elective operations of the elbow, forearm, wrist, or hand were randomly allocated into three groups of 25 patients each. Group K (ketamine group) received 40 ml 0.25% bupivacaine contain 1 mg/kg ketamine, group D (dexmedetomidine group) received 40 ml 0.25% bupivacaine contain 1 μg/kg dexmedetomidine, and group C (control group) received 40 ml 0.25% bupivacaine. The outcome measures included visual analog scale (0=no pain and 10 cm=the most severe pain), time to first analgesic request, and total dose of diclofenac analgesia given postoperatively. Results Patients in D and K groups had reduced visual analog scale scores than the C group, at all time points after surgery during the first 24 h, with more reduction in group D than K group (P<0.05). The time of the first analgesic request in the D group was significantly more than in the K group, and both were more than the C group (9.48±1.417 h, 7.08±1.255 h, and 5.00±1.04 h, respectively). Conclusion The addition of ketamine or dexmedetomidine in the ultrasound-guided supraclavicular brachial plexus block could improve the postoperative pain and need for analgesia. Therefore, we can consider the low-price readily available ketamine as a comparable adjuvant in brachial plexus block to some extent as dexmedetomidine.

Background Various vasoconstrictors have shown promising results in the management of vasoplegic shock. However, there are very few studies on the effect of terlipressin regarding the management of refractory hypotension after cardiac surgery. In this study, we evaluate and compare the efficacy of terlipressin and noradrenaline in the treatment of this type of shock. This study was done to assess the effectiveness of each group in elevating the mean arterial blood pressure (BP) with serial measurements to evaluate serum lactate, systemic vascular resistance, pulmonary artery pressure, and cardiac output. Patients and methods Persistent hypotensive patients after cardiac surgery receiving noradrenaline (150 ng/kg/min) infusion were divided into two groups, with group N receiving noradrenaline (dose started 150 ng/kg/min up to 300 ng/kg/min) and group T receiving terlipressin 1 mg intravenous bolus injection/4 h with noradrenaline (150 ng/kg/min). Results This study showed that group T was more effective regarding improvement of mean arterial BP. There was significant BP improvement in group T [19 of 20 patients (95% of shocked patient in group T) compared with only 25% of patient in N group]. There was significant decrease in the length of ICU stay in group T compared with group N (12±3 days in N group and 6±2 days Mortality is 70% in group N and 40% in group T). However, mortality rate was 40% in group T compared with 70% in group T, with no statistical significance. Conclusion In patients with vasoplegic shock unresponsive to norepinephrine after cardiac surgery, exogenous administration of terlipressin raises BP by increasing vascular tone more. By reducing the requirement for catecholamines, it decreases the stimulation of arrhythmogenic myocardial β1-receptors and associated myocardial oxygen demand.

Background Direct laryngoscopes have been developed for many optical fiberscopes to provide a better view of the glottis without alignment of the oral, pharyngeal, and tracheal axes. Recently, video laryngoscopes have become increasingly important devices in difficult airway management. Purpose This study aimed to compare between direct laryngoscopy, C-MAC, and the C-MAC D-blade for orotracheal intubation in patients with limited neck extension and to assess the hemodynamics and the possible complications of orotracheal intubation in patients with limited neck extension using the three different devices. Patients and methods Thirty adult patients subjected to general anesthesia were randomly categorized into three equal groups: in group I, endotracheal intubation was performed using direct laryngoscopy with a conventional Macintosh blade, in group II C-MAC video laryngoscopy was performed with a conventional Macintosh blade, and in group III C-MAC video laryngoscopy was performed with a D-blade. Then, an assessment of the laryngoscopic view and the whole procedure of laryngoscopy and intubation was carried out. Conclusion This study validates the efficacy of the C-MAC Macintosh blade and the D-blade when compared with a direct laryngoscope in patients with limited neck extension. The D-blade has been found to be more effective in reducing hemodynamic responses to laryngoscopy and intubation, resulting in improvement of the laryngoscopic view with a high success rate; it facilitates the smooth performance of laryngoscopy and intubation from the first attempt with the least use of assisting maneuvers while achieving the shortest endotracheal tube (ETT) insertion time, with no occurrence of complications.

Background Vascular access can be challenging in patients with obesity, impalpable pulsations, hemodynamic instability, thrombocytopenia, and coagulopathy. Our aim was to study the clinical effectiveness of vascular ultrasound (US) in arterial and venous catheterizations in critically ill patients with nonpulsatile circulation admitted at cardiac critical care units and to compare with the landmark techniques. Patients and methods This retrospective study included adult patients from January 2015 to January 2019 who had been admitted to the adult cardiac critical care unit with left ventricular assist device or veno-arterial extracorporeal membrane oxygenation and required vascular access. Results In 152 critically ill patients, 292 vascular catheters were inserted. The first-attempt success was achieved in 77.9 versus 34.6% (P=0.001) and the whole procedural success was 100 versus 67.5% (P=0.001) in the US and landmark groups, respectively. The number of attempts was 1.7±0.6 versus 1.2±0.4 (P=0.001) and the complications occurred in 2.5 versus 21.2% (P=0.001) in the US and landmark groups, respectively. Jugular catheterization was done in 42.9 versus 19.3% (P=0.001), while subclavian cannulation was done in 5 versus 42.3% (P=0.001) in the US and landmark groups, respectively. Iatrogenic pneumothorax happened in 0 versus 3.1% (P=0.001), accidental puncture of the adjacent artery happened in 0 versus 14.7% (P=0.001), and hematoma formation happened in 2.5 versus 9% (P=0.03) in the US and landmark groups, respectively. Conclusion Arterial and venous catheterizations guided by US in critically ill patients with nonpulsatile circulation and unstable hemodynamics were associated with higher success and more safety compared with the landmark techniques.

Background General anesthesia is the standard technique for thyroid surgery. However, local anesthesia has been used for thyroid surgery by expert surgeons. Local/regional anesthesia is a safe alternative to general anesthesia and well tolerated for the majority of the thyroid surgeries. The aim of the study was to assess the efficacy and safety of superficial cervical plexus block and infiltration around thyroid capsule anesthesia in thyroidectomy. The primary outcome of the present study was patient satisfaction. Patients and methods After informed consent, 70 patients were randomized into two groups. The first group received general anesthesia (group G) and the second group received bilateral superficial cervical plexus block with injection of local anesthetics between the thyroid capsule and its overlying muscle (group L). Patient satisfaction was our primary concern. The secondary outcomes included surgeon satisfaction, discharge time, rescue analgesic, postoperative nausea or vomiting, pain score, and side effects. Results Satisfaction score was significantly higher in group L when compared with group G. Moreover, group L showed statistically significant less postanesthesia care unit time, number of patients requiring rescue analgesic, and hospital stays than in group G. Pain score was significantly less in group L than in group G at 6 and 12 h postoperatively. Conclusions Ultrasound-guided modified local/regional anesthesia could be a suitable alternative for general anesthesia in thyroidectomy. It was associated with shorter hospital stay, more patient satisfaction, and better postoperative analgesia when compared with general anesthesia.

Background Our case was acute ST-segment elevation myocardial infarction with multiple coronary thrombosis, despite aggressive anticoagulation and antiplatelet therapy in a young, relatively low-risk patient, on three abused drugs. Case summary A 38-year-old male smoker patient with a BMI of 31 kg/m² and a background of multiple drug addiction, was admitted after an hour of severe retrosternal compressing chest pain. Upon admission, he had cardiac arrest in ventricular fibrillation. Resuscitation was done, including defibrillation shocks and invasive mechanical ventilation with a cardiopulmonary resuscitation (CPR) time of 17 min and the patient was transferred to the catheterization laboratory with extensive anterior and inferior myocardial infarctions. Coronary angiography showed an unusual thrombosis in multiple coronary branches with coronary spasms and total occlusion of left anterior descending artery for which primary percutaneous coronary intervention was done. Admission laboratory screening showed high blood levels of amphetamines, cannabinoids, and tramadol. The patient was kept under invasive ventilation for 10 days, with difficult weaning due to severe drug-withdrawal manifestations, ventilator-associated pneumonia, and hemodynamic instability that necessitated intravenous inotropic drip and intra-aortic balloon counter pulsation. The patient regained near-normal left ventricular function after baseline severe regional and global dysfunction. Conclusion The authors postulated a relationship between the use of amphetamines, potentiated by cannabinoids and tramadol, and occurrence of acute thrombosis of multiple major coronary arteries especially with concurrent cigarette smoking.