Background and aims Cisatracurium has many advantages over other nondepolarizing muscle relaxants; however, for rapid intubation, rocuronium is the preferred drug in lieu of succinylcholine. The aim of this study was to compare the onset time and intubating conditions at 90 s using 0.3 mg/kg cisatracurium (6× ED₉₅) versus 1.2 mg/kg rocuronium (4× ED₉₅). Material and methods The study was conducted at a tertiary care hospital as a randomized double-blind prospective study after obtaining the ethical committee clearance. A total of 60 patients were randomly assigned to receive 1.2 mg/kg rocuronium (4× ED₉₅) or 0.3 mg/kg cisatracurium (6× ED₉₅) after premedication with fentanyl-midazolam and induction with propofol-sevoflurane. Laryngoscopy and intubation were done at 90 s. Primary outcomes assessed were laryngoscopy and intubation conditions and onset times. The Student t test was used to compare prospective, repeated measures. χ² test was used to test the significance of difference for qualitative variables. Results The onset of action of the muscle relaxant was predicted by measuring train-of-four ratio and was found to be significantly longer in the cisatracurium group (149.50±25.064 s) than in the rocuronium group (101±s) (P<0.05). Although the intubating conditions were better in the rocuronium group, cisatracurium also provided good to excellent intubation conditions at 90 s. Conclusion Cisatracurium can be used to intubate the trachea at 90 s at a dose of 0.3 mg/kg in patients premedicated with fentanyl-midazolam and induced with propofol-sevoflurane, while maintaining hemodynamic stability, without increasing the incidence of adverse effects.

Aims To compare the safety and efficacy of 1 and 3 mg of granisetron in the prevention of postoperative nausea and vomiting (PONV) in strabismus surgeries under general anesthesia. Settings and design This single-blinded, randomized, controlled trial was conducted at the ophthalmology operating theater of Kasr Al-Ainy Hospitals. Patients and methods We recruited 210 patients and allocated them randomly to receive either granisetron 1 mg (n=105) or 3 mg (n=105). The two groups were compared regarding demographic data, hemodynamic parameters, and percentage of patients with no complaints of PONV during the first 24 h. Results There was no statistically significant difference upon comparison of the two groups regarding PONV (P>0.05). The two doses (1 and 3 mg) provided total control of nausea and vomiting in 46.7 and 43.8% of patients during the first 24 h postoperatively, respectively. Moreover, we found no significant difference between the two groups regarding mean values of the heart rate or mean arterial pressure both preoperatively and intraoperatively (P>0.05). However, during the postoperative 24 h, both groups had significant differences regarding mean values of heart rate and mean arterial pressure at 2–4 h, 8–12 h, and 12–24 h postoperatively. Conclusions The comparison between two doses of granisetron (1 and 3 mg) showed no statistical difference regarding the total control of nausea and vomiting for 24 h postoperatively but showed a statistical difference regarding some postoperative vital sign readings.

Background Acute circulatory collapse is one of the most familiar challenges in ICUs. It is considered that artefacts generated by lung ultrasound (LUS) can help in diagnosis and management. FALLS-protocol using LUS is a tool proposed for the management of unexplained shock. Objectives To investigate the role of LUS FALLS-protocol in differentiating types of shock in critically ill patients. Patients and methods A total of 50 patients presented with undiagnosed shock. Fast bedside echocardiography and LUS FALLS-protocol were applied along with inferior vena cava diameter and collapsibility measurement. Results A total of 19 patients with septic shock on presentation had A profile in all of them and AB profile in three of them, and after resuscitation, they were transformed to B profile with 100% sensitivity, 90.5% specificity, 90.5% positive predictive value (PPV), and 100% negative predictive value (NPV). Overall, 16 patients with hypovolemic shock had A profile in all of them on presentation and after resuscitation, with 100% sensitivity, 94.1% specificity, 88.9% PPV, and 100% NPV. Moreover, eight patients with cardiogenic shock had B profile in all of them on presentation with 100% sensitivity, 95.2% specificity, 80% PPV, and 100% NPV; three patients with obstructive shock had A profile in all of them on presentation, with 100% sensitivity, 25.5% specificity, 7.9% PPV, and 100% NPV; and two patients with anaphylactic shock had A profile in all of them on presentation and transformed to B profile after resuscitation with 100% sensitivity, 50% specificity, 9.5% PPV, and 100% NPV. Our findings showed preference of FALLS-protocol than inferior vena cava diameter and collapsibility in directing fluid therapy. Conclusion Bedside chest ultrasound FALLS-protocol should be considered in the resuscitation pathways with a possible significant effect on patient management.

Background Transversus abdominis plane (TAP) block is a newly effective peripheral block which involving mainly the nerves of the anterior abdominal wall in lower abdominal surgery. The present study aimed to evaluate the postoperative analgesic efficacy of right-sided ultrasound guided TAP block by using 20 millimeters of bupivacaine 0.25% in patients undergoing open appendicectomy. Patients and methods After taking informed consent, fifty patients (ASA I and II) undergoing open appendicectomy were randomized into 2 groups (25 each). After induction of general anesthesia; Group B received right side ultrasound guided TAP block using 20 ml bupivacaine 0.25%. Group S (standard group) received general anesthesia without TAP block. Postoperative analgesia by ketorolac and paracetamol was given as required. Postoperative VAS at rest and movement, intra and post operative hemodynamics, analgesic requirements and their side effects were recorded for 24 hours. Results A significant reduction of VAS up to twelve hours postoperatively detected in the TAP block group with bupivacaine 0.25%. There was also significant elongation of time to the first analgesia, significant reduction in number of rescue analgesics, as will as there were significant decrease in nausea, vomiting and pruritus between two groups. Conclusion Right-sided ultrasound guided TAP block using 20 ml of bupivacaine 0.25% had effective postoperative analgesia for twelve hours after the open appendicectomy.

Background Awake fiber-optic intubation is one of the recommended strategies for surgical patients with suspected difficult airway, especially when simultaneous difficult ventilation is anticipated. Patients and methods In all, 90 patients of both sexes aged between 20 and 55 years, American Society of Anesthesiologist I and II stages were scheduled for elective abdominal surgeries. Patients were randomized into three equal groups. Group A: oral agomelatine at a dose of 10 mg administered with a sip of water 120 min before surgery. Group B: agomelatine+dexmedetomidine. Group C: dexmedetomidine infused at a dose of 1 μg/kg loading infusion per 10 min followed by a continuous infusion of 0.2 μg/kg/h. The following variables (mean arterial pressure, heart rate, oxygen saturation, cough score, postintubation score) and Richmond agitation sedation scale score were recorded in addition to the serum level of norepinephrine. Conclusion Agomelatine is more effective than dexmedetomidine in making better intubation state with sedation, less desaturation, and hemodynamic stability during awake fiber-optic intubation. Synergestic effect between agomelatine and dexmedetomidine was detected.

Background Postoperative sore throat (POST) is commonly reported by patients after endotracheal intubation. This study was conducted to compare the efficacy of intravenous lidocaine and dexamethasone in the prevention of such problem. Patients and methods We included a total of 394 cases who were randomly divided using the closed-envelope method into two groups: group D that included 197 cases who received intravenous dexamethasone (8 mg), and group L that included the remaining 197 cases who received intravenous lidocaine (1.5 mg/kg). Both the incidence and risk factors for POST were assessed. Results Sore throat was reported by 115 (58.4%) cases in group L, whereas it was reported by 82 (41.6%) cases of cases in the other group. There was a marked reduction of sore-throat sensation in group D (P<0.001). Logistic regression revealed that the presence of blood on suction was a significant risk factor for developing sore throat after intubation. Conclusion Intravenous administration of dexamethasone appears to be more promising than lidocaine in decreasing the incidence of POST.

Background Spinal anesthesia is acceptable in patients undergoing diabetic foot surgery. The duration of the spinal anesthesia has been improved by the addition of other drugs such as opioids, dexmedetomidine, clonidine, and dexamethasone. Dexamethasone may affect blood glucose levels. The primary outcome of the study was the effect of a single dose of intrathecal dexamethasone on blood glucose levels during the first 24 h postoperatively. Patients and methods After approval, 60 diabetic patients, American Society of Anesthesiologists grades 2 and 3 with ages ranging from 20 to 70 years were enrolled in this randomized, double-blinded, placebo-controlled trial. All patients who underwent diabetic foot surgery under spinal anesthesia have controlled type II diabetes. Patients were randomly allocated into two equal groups: the control group was given intrathecal 2.5 ml of hyperbaric bupivacaine 0.5% plus 1 ml of 0.9% sodium chloride. The dexamethasone group was given intrathecal 2.5 ml of hyperbaric bupivacaine 0.5% plus 4 mg of dexamethasone. Results The control group had significantly lower levels of blood sugar at different times compared with the dexamethasone group. However, at the end of 24 h, nonsignificant changes were present between the two groups. Also, using 200 mg/dl as a cutoff for high blood sugar, there were nonsignificant changes all through the 24 h in both groups. Moreover, dexamethasone prolongs the duration of analgesia and decreases paracetamol requirements during the first 24 h postoperatively. Conclusions Addition of intrathecal dexamethasone did not change postoperative glycemic evolution in controlled diabetic patients undergoing diabetic foot surgery. However, it significantly prolongs the duration of analgesia and decreases analgesic consumption during the first 24 h postoperatively.

Purpose We evaluated the quality of analgesia produced by peritonsillar infiltration of levobupivacaine with either dexamethasone or dexmedetomidine in children undergoing tonsillectomy surgery. Patients and methods Patients scheduled for tonsillectomy were randomly allocated into three groups with 27 patients in each group. Group L received peritonsillar infiltration of 5 ml in volume of 0.4 mg/kg of 0.5% levobupivacaine, while group D received peritonsillar infiltration of 5 ml in volume of 0.4 mg/kg of 0.5% levobupivacaine mixed with dexamethasone 0.5 mg/kg and group X received peritonsillar infiltration of 5 ml in volume of 0.4 mg/kg of 0.5% levobupivacaine mixed with dexmedetomidine 1 μg/kg (with infiltration of 2.5 ml in each tonsil in all groups) with the first postoperative analgesic request as the primary outcome. Results Postoperative time to first analgesic paracetamol request was prolonged in group D (19.51±2.34 h) compared with group L (4.15±0.53 h) and group X (15.74±2.29 h). Face, leg, activity, cry, consolability (FLACC) Behavioral Pain Assessment score at rest and during swallowing decreased in group D compared with group L and group X. Total postoperative analgesic consumption decreased in group D (581.48±165.7 mg) compared with group L (1303.51±90.10 mg) and group X (680.50±160.67 mg). Conclusions We concluded that peritonsillar infiltration of levobupivacaine when mixed with either dexamethasone or dexmedetomidine for patients undergoing tonsillectomy produced prolonged analgesia; however, dexamethasone was superior to dexmedetomidine with more prolonged time to first paracetamol request and prolonged late postoperative pain relief.

Background Brachial plexus block is a well-studied method of providing reliable anesthesia or analgesia for the upper extremity. Many approaches for brachial plexus block are present. These approaches are classified according to the level of local anesthetic injection into interscalene, supraclavicular, infraclavicular, and axillary blocks. By providing a rapid onset of dense anesthesia of the arm with a single injection, the supraclavicular block is perfect for operations involving the arm and forearm, from the distal humerus down to the hand. Ultrasound guidance has resulted in a better practice of supraclavicular approach to the brachial plexus, with decreasing the risk of complications. There has always been a search for adjuvants to local anesthetics used in regional nerve block with drugs that prolong the duration of analgesia but with lesser adverse effects. Objective To compare the effect of nalbuphine as an additive to bupivacaine versus bupivacaine alone in supraclavicular brachial plexus block with ultrasound guidance in upper limb surgeries regarding onset and duration of sensory and motor blocks, duration of analgesia, and postoperative analgesic requirements, as well as the effects on hemodynamics and possible complications with each technique. Patients and methods This study was carried out in Alexandria Main University Hospital on 50 adult patients of both sexes, American Society of Anesthesiology I and II, scheduled for surgeries of the hand and forearm under supraclavicular brachial plexus block with ultrasound guidance. Patients were randomly categorized into two equal groups (25 patients each) using the sealed envelope technique. Group I patients received bupivacaine only for the block, and group II patients received bupivacaine and nalbuphine as an adjuvant for the block. Results The results of our study showed that patients in nalbuphine group (group II) had significantly longer sensory and motor blocks duration, with longer duration of postoperative analgesia, when compared with patients in group I, who were received bupivacaine only for the block. Conclusion Coadministration of nalbuphine with bupivacaine in supraclavicular brachial plexus block leads to a significant increase in the duration of sensory and motor blocks and provides prolonged postoperative analgesia without causing adverse hemodynamic instability.

Introduction Accurate estimation of intravascular volume status is important in the resuscitation of patients in ICUs. Although intensive fluid therapy in patients with life-threatening volume depletion can prevent death and end-organ damage, volume overload is known to result in increased mortality, morbidity, and duration of hospital stay. Ultrasonography has become a common diagnostic choice in assessment of fluid status in septic patients. This method is noninvasive, easy to learn, and provides real-time assessment at the patient’s bedside. Various ultrasound modalities have been developed to provide accurate and minimally invasive assessment of volume status. In this regard, one of the most promising methods is the evaluation of the blood flow velocity waveform in the descending thoracic aorta via a nonimaging Doppler probe. This modality is based on calculating the systolic flow time with cycle time correction [corrected flow time (FTc)]. FTc is known to be directly associated with volume status. FTc measurement in carotid artery is a completely noninvasive and much more feasible approach. Aim To compare the use of ultrasonography in the measurement of the changes in carotid FTc with echocardiography in the assessment of changes in heart dynamics to assess changes in volume status before and after passive leg raising (PLR) in septic patients. Patients and methods A total of 40 septic patients, including 18 (45.5%) patients as fluid responders and 22 (54.5%) patients as nonfluid responders, were included. Increased FTc by 7 ms, as well as 10% increase in stroke volume was considered to be fluid responsive. Results Our study results showed that 45.5% (n=18) of study population were fluid responders. The PLR test could assess fluid responsiveness with a specificity of 100% and sensitivity of 95% at a cutoff of 10.6% change in CO to predict fluid responsiveness. The study showed a statistically significant moderate positive correlation between CCA FTc and the percent of change in CO measured by echocardiography. An agreement analysis was formed. We concluded that there was a strong relation between change in carotid corrected blood flow and change in COP before and after PLR, with P value less than 0.001. Therefore, we can use this parameter to predict fluid responsiveness after PLR. Conclusions Carotid artery blood flow is a promising noninvasive and easy-to-perform tool for the evaluation of fluid responsiveness in critically ill septic patients. The PLR maneuver has demonstrated excellent performance for predicting fluid responsiveness. It is simple to perform but requires a reliable system of carotid corrected blood flow (COP) monitoring able to quantify the short-term changes.

Background There has been an increasing trend toward performing inguinal repair surgeries under regional anesthetic techniques like paravertebral block (PVB). Neostigmine has been used as an adjuvant to local anesthetics, but the existing research studies are few. This study was conducted to evaluate the efficacy of neostigmine as an adjuvant to local anesthesia used for PVB in inguinal hernia repair procedures. Patients and methods This prospective randomized study included 72 patients prepared for elective inguinal hernia repair under PVB. They were allocated into two groups: the neostigmine group received a mixture of bupivacaine and neostigmine (5 μg/kg), whereas the control group received bupivacaine alone. During the postoperative period, pain score, hemodynamic parameters, first analgesic request, total analgesic consumption, and the incidence of adverse effects were noted and recorded. Results Both groups showed comparable findings regarding age and weight. However, the number of patients requiring rescue analgesia showed a significant increase in the control group. Moreover, controls reported significantly earlier first analgesic requests. Both diclofenac and fentanyl consumptions were increased without neostigmine administration. Pain score was significantly better with neostigmine at 4 and 6 h after surgery. Hemodynamic parameters were almost comparable between the two groups. Conclusion Neostigmine appears to be an efficient adjuvant to local anesthetics when administered during PVB as it significantly improves its analgesic profile. Its administration should be encouraged in clinical practice.

Background Intravenous milrinone has been investigated for management of vasospasm after aneurysmal subarachnoid hemorrhage (SAH); however, its role in vasospasm after traumatic SAH is still under evaluation. Patients and methods A total of 30 patients with cerebral vascular spasm after traumatic SAH were randomly divided into two equal groups. Group H was given nimodipine (60 mg/4 h) orally or via nasogastric tube and then combination of induced hypertension, hypervolemia, and hemodilution (triple-H therapy). Group M was given nimodipine (60 mg/4 h) orally or in the nasogastric tube and then intravenous milrinone bolus of 0.1–0.2 mg/kg followed by intravenous infusion of 0.75–1.25 μg/k/min. The infusion was continued for 72 h before gradual discontinuation at a rate of 0.25 μg/kg/min every 24 h until complete weaning. For refractory cases in both groups, emergency angioplasty was done. Primary outcome was the transcutaneous cerebral regional oxygen saturation 14 days after starting treatment. Secondary outcomes were the Glasgow coma score 14 days after starting treatment, infarction rate, ICU and hospital stays, and modified Rankin scale and Glasgow outcome scale at 3 and 6 months after starting treatment. Results Group M showed significant increase in regional oxygen saturation and Glasgow coma score; decrease in infarction rate, ICU stay, and hospital stay; and improvement in modified Rankin scale and Glasgow outcome scale. Significance was set at P value less than 0.05. Conclusion The combination of oral nimodipine and intravenous milrinone improves the outcome of vasospasm in posttraumatic SAH.

Introduction The postdural puncture headache (PDPH) is one of the spinal and epidural anesthesia complications. It can be induced by using large gauge-cutting needles or performing numerous trials. Conservative treatment was the primary option for the management of PDPH, sphenopalatine ganglion block (SPGB) can be a suitable and safe option for the treatment of PDPH. Aim The aim was to verify the efficacy and safety of transnasal SPGB using either lidocaine 2% or bupivacaine 0.5% as a treatment line for PDPH versus the conventional conservative treatment. Patients and methods In total, 120 patients with PDPH following cesarean section under spinal anesthesia were assigned and divided into three groups. Group L (n=40) received transnasal SPGB (lidocaine 2%), group B (n=40) received transnasal SPGB (bupivacaine 0.5%), and group C (n=40) received conservative treatment for 24 h [intravenous (IV) paracetamol 1 g/8 h]. The headache severity was measured by the visual analog scale (VAS) at 0 min, 30 min, 6 h, 12 h, and 24 h post treatment. Results No significant difference in the VAS from the baseline between the groups L and B was observed. VAS values were significantly lower in both groups when compared with patients in group C (P<0.05). No significant differences from baseline mean blood pressure, heart rate, or other complications (such as bleeding), were observed between the three groups at any timepoint. Conclusion The headache severity in PDPH cases might be reduced more efficiently through SPGB using either lidocaine or bupivacaine, unlike other conservative treatments such as paracetamol.

Introduction Among all the regional blocks, the peribulbar block is one of the most popular for most ophthalmic procedures as it has few complications. Aim To study the effects of mixing local anesthetic with either dexmedetomidine or fentanyl in the peribulbar block for vitreoretinal surgery. Patients and methods The study included 40 adult patients (ASA II–IV) who had a peribulbar block for elective retinal surgery at Sohag University Hospital. All patients received the following combination: lidocaine 2%, bupivacaine 0.5%, hyaluronidase 15 IU/Ml, in addition to either 20 μg of fentanyl (group F) or 20 μg of dexmedetomidine (group D). The duration of postoperative analgesia, the onset, and duration of sensory and motor blocks, along with other complications, were recorded. Results The onset time of motor and sensory blocks was significantly longer in group F. For the duration of sensory and motor blocks, group D had a significantly greater duration than group F (P=0.05). Group D took substantially longer to request analgesia than group F (P=0.0002). Total paracetamol consumption was substantially higher in group F than in group D (P=0.001). The overall number of patients who required nalbuphine was substantially higher in group F (P=0.003) than in group D. At 2, 4, and 6 h postoperatively, the visual analog scale was statistically significantly greater in group F than in group D. Conclusion Dexmedetomidine-local anesthetic mixture in the peribulbar block for retinal surgery was superior to fentanyl-local anesthetic mixture regarding onset and duration of motor, sensory block, postoperative analgesia, and analgesic requirement.

Aims To assess the safety and efficacy of lidocaine gel 2% used in pediatric squint surgeries to prevent the oculocardiac reflex intraoperatively and reduce postoperative pain and agitation. Settings and design This single-blinded, randomized trial was carried out at the Research Institute of Ophthalmology, Egypt. Patients and methods Forty-eight children (2–13 years old) of both sexes scheduled for squint surgeries were randomly allocated into two groups (24 patients each): the lidocaine gel group and the control group. In the experimental group, we applied lidocaine gel 2% abundantly below both eyelids of the surgical eye for at least 3 min before surgical incision, while nothing was applied to patients in the control group. Patients were monitored intraoperatively and postoperatively, and the outcomes were recorded. Results There was a lower median postoperative face, leg, activity, cry, and consolability scale in the lidocaine gel group (3.0, interquartile range=2.5–5.0) than in the control group (4.0, interquartile range=1.5–7.0) with no significant difference (P=0.770). The incidence of bradycardia was lower with lidocaine gel 2% use (16.7%) compared with the control group (41.7%), but this difference was not statistically significant (P=0.057). We found no complications except for two patients in the control group who had fever and flushing due to atropine administration. Conclusion Application of lidocaine gel 2% below both lids of the surgical eye in pediatric squint surgery under general anesthesia is safe with no observed systemic side effects. However, it has no adjuvant effects in reducing postoperative pain and agitation or preventing intraoperative oculocardiac reflex.

Coronavirus disease 2019 (COVID-19) is a contagious pulmonary infectious disease with respiratory symptoms. The virus, SARS-CoV-2 has shown 85% resemblance to SARS coronavirus (SARS-CoV) and MERS coronavirus (MERS-CoV). The management of a COVID-19 positive mother is challenging as the virus is extremely contagious and can be life threatening to mothers and health-care personnel. Here, we describe the successful anesthetic management of 20 pregnant women with confirmed COVID-19 infection undergoing cesarean section in our hospital. A dedicated operating room was used for cesarean delivery of a parturient with COVID-19. This dedicated operating room was located in the secluded area of our hospital, away from the rest of the operating rooms. The first choice of anesthesia was a single-shot subarachnoid block with 0.5% heavy bupivacaine.