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   Table of Contents - Current issue
January-March 2023
Volume 10 | Issue 1
Page Nos. 1-97

Online since Monday, March 13, 2023

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Comparative study of tocilizumab versus itolizumab in coronavirus disease 2019-infected patients: a randomized controlled trial p. 1
Kumari Poonam, Sinha Chandni, Kumar Amarjeet, Kumar Ajeet, Arun Shettru K., Kandrakonda Pavan K.
Objective We aimed to compare the effect of tocilizumab and itolizumab in terms of PaO2/FiO2 ratio (P/F ratio), interleukin 6 (IL-6) level, serum ferritin, C-reactive protein, and a reduction in mortality. Our primary objective was to compare P/F ratio at various time intervals: baseline (before administering the drug), 12 h after drug administration, once a day for the next 7 days, and on the 14th day. Our secondary objective was to evaluate serum level of biomarkers like IL-6, ferritin, and C-reactive protein before start of drug infusion and following drug infusion at 72 h and on 7th day. Patients and methods A total of 50 patients, age between 18 and 60 years, having moderate Acute Respiratory distress syndrome (ARDS) following coronavirus disease 2019 infection were recruited. Patients of group I received a single dose of injection of tocilizumab 8 mg/kg intravenously (i.v.) via infusion over 1–2 h. Group II patients received premedication with hydrocortisone 100 mg and pheniramine 30 mg and a single dose of injection itolizumab 1.6 mg/kg dissolved in 250 ml of 0.9% normal saline infusion over 5–6 h. Results We observed significantly higher P/F ratio in the itolizumab group (239.18±97.31) than in the tocilizumab group (104.87±75.25) on the 3rd day following drug administration (P<0.001). Similarly, the IL-6 level was lower in the itolizumab group (72±100) in comparison with the tocilizumab group (682±1360), and the differences were statistically significant (P<0.05). We identified adverse effects of the drugs in 10 patients who have received itolizumab. Conclusion We observed an increasing trend in P/F ratio on the 3rd day following itolizumab administration in comparison with tocilizumab, and the difference was statistically significant (P<0.001).
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Effect of adding dexmedetomidine to bupivacaine during superficial combined with ultrasound-guided intermediate cervical plexus block in total thyroidectomy p. 7
Mohamed S.A Elshayeb, Wafaa M Shafshak, Ola M.E Zanati, Hesham M.G Eldin
Background Many thyroidectomy patients suffer from pain after surgery that may delay early hospital discharge and place a significant burden on both the patient and the healthcare team. The aim of this study was to evaluate dexmedetomidine as adjuvant to bupivacaine in superficial and ultrasound-guided intermediate cervical plexus block for postoperative analgesia in patients undergoing total thyroidectomy. Patients and methods This prospective, randomized, double-blinded, and controlled study included 50 adult patients of either sex, aged 20–60 years, with American Society of Anathesiologists (ASA) class I or II, scheduled for elective total thyroidectomy under general anesthesia. Results Adding dexmedetomidine to bupivacaine significantly decreased the pain intensity as measured by the visual analog scale compared with group II. Heart rate levels in group I were significantly lower than that in group II in most periods of measurement. The duration of analgesia was prolonged in group I compared with group II, as the time to first dose of rescue analgesia ranged from 12 to 20 h in group I and from 4 to 12 h in group II. The total postoperative nalbuphine consumption was significantly lower in group I than group II. Postanesthesia recovery was significantly faster in group I than group II as measured by the modified Aldrete score 4 min postoperatively. Conclusion Adding dexmedetomidine to bupivacaine for bilateral superficial and ultrasound-guided intermediate cervical plexus block is considered to be an effective and safe method that efficiently managed acute postoperative pain, prolonged the time to first rescue analgesia, and reduced the needed for opioid consumption.
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The effect of adding verapamil to local anesthetics in peribulbar block for intraoperative anesthesia and postoperative analgesia in vitreoretinal surgery: a randomized clinical trial p. 15
Iman S Aboul Fetouh, Rehab S Khattab, Abeer S Salem, Nader N Naguib, Tamer Omar
Aims To evaluate the efficacy and safety of verapamil as an adjuvant to the local anesthetics xylocaine and bupivacaine for peribulbar block in vitreoretinal surgery. Settings and design This blinded, randomized, controlled trial was carried out at the Research Institute of Ophthalmology, Egypt. Patients and methods A total of 82 eligible patients were randomly allocated into two groups. The control group received xylocaine, bupivacaine, and normal saline. Verapamil group were treated the same way as the control group but received 5 mg of verapamil instead of normal saline. The primary outcomes included the onset of sensory block, motor block, lid akinesia, duration of the block, and patients’ hemodynamics. Secondary outcomes included postoperative pain, time to first analgesia, and patient’s and surgeon’s satisfaction. Results The onset of sensory block was significantly shorter in the verapamil group compared with the control group (42.6±10.1 vs. 52.2±23.6 s, respectively; P=0.020). A significant decrease in the mean rank of VAS score was recorded at two h in the verapamil group compared with the control group (30.72 vs. 47.50, respectively; P=0.001). Otherwise, the medians of motor block and lid akinesia and the mean duration of block did not show significant differences between the two groups. Conclusions Addition of 5 mg of verapamil to a mixture of 5 ml of xylocaine 2% and 5 ml of bupivacaine 0.5% in peribulbar block significantly shortened the onset of sensory block and reduced the postoperative pain but did not affect the onset of motor block or the duration of anesthesia.
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Effect of noradrenaline infusion in central venous catheter versus external jugular vein on the outcome of septic shock patients p. 21
Amr A El-Morsy, Amr H Dahroug, Asmaa A Ali
Introduction Sepsis is a medical life-threatening emergency that involves dysfunction of an organ induced by the host’s dysregulated extreme response toward an infection. Sepsis is prominent worldwide causing septic mortality and numerous critical illnesses. Septic shock is defined as severe persisting hypotension that is induced by sepsis although there is an adequate resuscitation of fluids. Objective This study aim was to assess the use of central venous catheter (CVC) and peripheral (external jugular) vein for low or moderate doses of noradrenaline regarding the outcome of septic shock among patients who are diagnosed with critical illnesses. Patients and methods This study is a prospective cohort study involving 120 patients according to sample size calculation with septic shock who were sorted randomly into two groups. Group I (the group involving the external jugular): 60 patients experienced septic shock and received low or moderate doses of noradrenaline in the external jugular vein. Group II (CVC group): 60 patients diagnosed with septic shock and received low or moderate noradrenaline doses in the CVC. Results Low or moderate doses of noradrenaline in the jugular line was associated with significantly higher blood pressure on day 7, and lower Sequential Organ Failure Assessment Score on days 5 and 7 than the CVC group. There was a difference that is statistically significant between ICU-involved duration of stay among the two involved study groups as it was found lower significantly among the jugular group. Conclusion Low or moderate doses of noradrenaline can be administered safely within the peripheral line (jugular) in patients with septic shock with minor complications causing a decrease in the duration of ICU stay.
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Magnesium sulfate versus dexamethasone as an adjuvant in the ilioinguinal and iliohypogastric nerve blocks p. 28
Islam M Ahmed, Ahmed H Hassan, Bahaa M Refaie, Fouad I Soliman, Ayman M Abdelkareem
Introduction Ilioinguinal and iliohypogastric (IIIH) nerve blocks help to manage postoperative pain that occurs following inguinal hernia repair or varicocelectomy. Aim The study aimed to compare the effect of adding magnesium sulfate or dexamethasone to levobupivacaine for iliohypogastric and ilioinguinal nerve blocks, in terms of postoperative analgesic length, visual analog scale ratings, first analgesic requirements, and hemodynamic changes. Patients and methods The study included 86 patients, aged 20–70 years, who were divided into two groups (D and M). Patients in group D received 9 ml of 0.5% levobupivacaine for the nerve block plus 1 ml dexamethasone (8 mg), whereas patients in group M received 9 ml 0.5% levobupivacaine plus 1 ml magnesium sulfate 10% (100 mg). Postoperative analgesia, visual analog scale scores, and any complications were documented. Results Group D had a significantly longer analgesic time. A significantly lower amount of analgesic was consumed on the first postoperative day with significantly low pain score as compared with group M. Conclusion The addition of dexamethasone to levobupivacaine for IIIH nerve blocks improved the postoperative analgesia.
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The use of ketorolac as an adjuvant in the superficial cervical plexus block p. 33
Fouad I Soliman, Ahmed H Hassan, Mohammed A Mahmoud, Bahaa M Refaie
Background Thyroidectomy operation is considered a common operation done nowadays. Pain after thyroidectomy is moderate to severe in some patients. Many techniques are used to provide analgesia and to avoid opioid adverse effects such as local wound infiltration, and regional anesthesia techniques like bilateral superficial cervical plexus block (BSCPB), alone or in combination with deep cervical plexus block. Patients and methods In this prospective, randomized, and double‑blind study, 46 patients were randomly allocated into two equal groups (23 in each group): the bupivacaine group (group B) received BSCPB with 10 ml of 0.25% bupivacaine and 1 ml normal saline on each side and the bupivacaine ketorolac group (group BK) received 10 ml of 0.25% bupivacaine and 1 ml ketorolac (15 mg) on each side. The first-time supplemental analgesia needed postoperatively was our primary outcome. Secondary outcomes include total analgesic consumption, visual analog score, patient satisfaction, and adverse effects. Results visual analog score at 8, 16, and 24 h and total ketorolac requirements were significantly lower (P=0.001 and 0.02, respectively), whereas the time to first rescue analgesic requirement was significantly longer in group BK when compared with group B (P=0.001). The frequency of nausea and vomiting was not statistically significant with less incidence in group BK compared with group B. Throat pain frequency was significantly less in group BK (P=0.05). Patient satisfaction was statistically significant in group BK (P=0.03). Conclusion Adding ketorolac to bupivacaine in BSCPB improved the control of pain, increased the pain-free period, decreased postoperative analgesic needs, and decreased adverse effects.
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Renal resistive index as a predictor of hemodialysis and mortality risk in septic patients developing acute kidney injury p. 40
Islam A Nour, Khalaf I Eldehily, Ahmed S Abd Elbaset, Hamdy M Saber
Introduction Mechanisms of acute kidney injury (AKI) comprise renal hypoperfusion, intrarenal vasoconstriction, inflammation, oxidative stress, and nephrotoxicity. An important pathophysiological pathway includes intrarenal vasoconstriction and endothelial damage of the microvessel, leading to impaired macrovascular and microvascular flow, which further aggravates ischemia. Nowadays, Doppler ultrasound is rapidly gaining ground as a screening tool in critically ill patients. The performance of cardiac, lung, and abdominal ultrasound in patients after cardiac arrest, major operations, and during shock has become the standard policy. However, renal ultrasound, which could be easily incorporated in this screening, is not commonly performed. Aim To test the ability of renal resistive index (RRI) measurement by Doppler ultrasound to predict the development of AKI in septic patients and find a relation with the progression to persistent renal impairment and relation to outcome and mortality. Patients and methods A total of 40 septic patients with AKI were randomized and subjected to RRI measurements, on admission and after 48 h, and the patients were followed till hospital discharge to detect the correlation to outcome. Mortality risk assessment was measured by the APACHE III score. Results There was a statistically significant increase of RRI in cases with persistent AKI in comparison with cases with transient AKI (P<0.05). There was a statistically significant increase in APACHE III score in patients with high RI (P<0.005). Conclusion Renal Doppler RI may be a promising tool for predicting the risk of developing AKI in acutely ill septic patients and may help in predicting the reversibility of AKI. High RRI values in septic patients with AKI are independently related to ICU mortality and persistent renal dysfunction at discharge from ICU.
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Efficacy of simvastatin in treating patients with traumatic brain injury p. 46
Abeer A.M Hassanin, Nagy S Ali, Emad A Abd El Naeem, Mokhtar M Mahran
Background/aim Mortality and morbidity in traumatic brain injury (TBI) patients are still high. Understanding the role of new treatments in these patients is critical. So the potential role of simvastatin in the treatment of TBI patients was examined in this research. Methods 40 patients with acute TBI who were admitted to the ICU were split into two groups; the control group received standard care and head trauma protocol medications for 7 days, while the study group also received standard care and head trauma protocol medications but also received simvastatin 80 mg the first day and 40 mg every day for 6 days. ICU duration of stay and mortality, Acute Physiology and Chronic Health Evaluation II score, Glasgow coma scale, amyloid precursor protein serum level at admission, 3 and 5 days after admission, and Glasgow outcome scale at discharge, 3 and 6 months after discharge were all noted. Results We found that the simvastatin group’s Acute Physiology and Chronic Health Evaluation II score at discharge had decreased significantly. The simvastatin group also showed greater Glasgow coma scale improvement beginning on day 3 of admission and continuing until day 7. When compared with the control group, simvastatin-treated patients had significantly lower levels of amyloid precursor protein on the third and fifth days of hospitalization. Patients using simvastatin had better Glasgow outcome scale results as compared with the control group. Conclusion We concluded that simvastatin has a promising effect in individuals with acute TBI.
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Comparison between intravenous dexmedetomidine and nitroglycerin infusions for induced hypotension in patients undergoing vertebral fixation surgeries p. 54
Mostafa K Khalifa, Ramadan A.E Ammar, Ahmed M.A Elshafie
Background In vertebral fixation surgeries, patients lose a lot of blood during the course of surgery. This could result in severe patient complications during and after surgery. This also makes surgical visualization in the bloody field difficult and the duration of surgery more prolonged. With the new anesthetic agents, drugs, and monitoring techniques, this problem has been addressed. Controlled hypotension is defined as a reduction in systolic blood pressure to 80–90 mmHg, a reduction of mean arterial pressure (MAP) to 60–70 mmHg or by 30% of the baseline. Controlled hypotension is a commonly used technique to limit blood loss and improve visualization of the operative field during vertebral fixation surgery. Objective To compare the effects of intravenous infusion of dexmedetomidine (DEX) and nitroglycerin (NTG) on intraoperative hemodynamics, amount of blood loss, speed of recovery from hypotension after cessation of infusion, and postoperative complications. Subjective This study was carried out on 50 adult patients of both sexes, American Society of Anesthesiologists I and II, admitted to Alexandria Main University Hospital, Department of Neurosurgery for elective spinal fixation surgeries (by the same surgical team) under general anesthesia. Results The results of the present study showed that arterial blood pressure in group I DEX at baseline (before induction of anesthesia) was 87.32±6.11 and increases significantly after 10 min from 20 to 80 min. The MAP was significantly decreased in group I at 90 min till the end of follow-up; there was no significant change in MAP from the baseline, while in group II ‘NTG.’ Comparing the two studied groups regarding MAP at different periods of follow-up, it was found that there was no significant difference between the two groups regarding MAP all over the period of follow-up. Conclusion NTG and DEX could induce hypotension, but DEX showed a more favorable hemodynamic profile as regards blood pressure and heart rate. DEX also showed a shorter duration of surgery with less blood loss and less blood transfusion.
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Evaluation of chronic post-inguinal herniorrhaphy pain in patients receiving ultrasound-guided ilioinguinal and iliohypogastric nerve block with lidocaine (5%) patch p. 62
Aliaa A Faiter, Magdy Abd El-Aziz Mansour, Adel Ibrahim Hozien
Aim To assess the efficacy of preemptive analgesia in the form of ultrasound-guided (IIN / IHN) block alone or with lidocaine (5%) patch on (US) acute, chronic post-herniorrhaphy pain and patient satisfaction. Patients and methods Preemptive US guided IIN / IHN block was performed on 60 patients (equally distributed into two groups) planned to undergo unilateral inguinal hernia operation under general anesthesia, 30 patients without lidocaine (5%) patch (group I) and 30 patients with lidocaine (5%) patch in the postoperative day 0 (group II). The groups were compared regarding patient satisfaction, intensity of postoperative pain, chronic post-herniorrhaphy pain, and its impact on daily activities. Results There were considerable differences between two groups as regards Douleur Neuropathique en 4 questions as it was higher in group I, P value less than 0.001. There was a significant increase in Brief Pain Inventory short form score postoperatively through 1, 3, and 6 months in group I, P value of 0.033. On the other hand, there were insignificant differences within each group as regards Brief Pain Inventory at 1, 3, and 6 months postoperatively with P values of 0.378, 0.931, and 0.934, respectively. There were insignificant differences regarding the patient’s satisfaction and postoperative visual analog scale. Conclusions US guided IIN / IHN block provides good perioperative pain control for inguinal hernia-repair surgeries. Addition of lidocaine (5%) patch may increase patient satisfaction and improve chronic postoperative pain outcome.
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Serum interleukin-6 as a predictor of the severity of coronavirus disease 2019 p. 68
Islam M Ahmed, Hesham M Hefny, Amal H Ali, Bahaa M Refaie, Khalid M Abdelal, Elhaisam M Taha
Background Inflammatory markers like interleukin-6 (IL-6) are linked to the worse outcome in coronavirus disease 2019 (COVID-19) cases. Other markers such as C-reactive protein are not as reliable as IL-6 in predicting respiratory failure. Aim To assess the function of IL-6 as a predictor of COVID-19 severity. Patients and methods A total of 50 severe and critical patients with PCR-confirmed COVID-19 were included. All enrolled patients followed the case definition for confirmed cases of Egyptian national protocol for COVID-19 issued by MOHP. Clinical assessment, imaging, and laboratory data were recorded at admission. Pulmonary function was evaluated by SpO2/FiO2 ratio. Outcomes included hospital stay, prognosis of the disease, complications, death rate, and discharge, which were recorded during the follow-up. Results The elevated IL-6 group showed a significantly higher critical rate (87.1%) than the normal IL-6 group (26.3%) (P<0.0001), and the improvement rate was higher in the normal IL-6 group (73.7%). Moreover, the death rate was significantly greater in the elevated IL-6 group (38.7%) than the normal IL-6 group (10.5%) (P=0.033). The cutoff value of IL-6 levels in prediction of severity and mortality of COVID-19 was assessed. Our receiver operating characteristic results revealed that IL-6 cutoff value is higher than 50.27 for severity and the cutoff value is greater than 120.83 for mortality. The sensitivity values of IL-6 for severity and mortality were 93.3 and 90.5%, respectively, and the specificity values were 90.0 and 86.7%, respectively. Conclusion Elevated levels of serum IL-6 in COVID-19-infected patients were related with a variety of adverse outcomes, including severe illness, mechanical ventilation, and acute respiratory distress syndrome. When it came to accurately predicting the severity and mortality of COVID-19, the optimum IL-6 cutoff levels were 50.27 and 120.83 pg/ml, respectively.
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A randomized controlled study comparing the use of ultrasound versus the conventional method in thoracic epidural catheter insertion as a pain relief method in thoracic surgeries p. 75
Mohamed M Abd Elhady, Ayman A Mehanna, Noha A Maged
Background The use of epidural analgesia for the management of postoperative pain has evolved as a critical component of multimodal approach to achieve the goal of adequate analgesia with improved outcome. The introduction of ultrasound technology for epidural insertion presents a novel challenge of acquiring new knowledge and skill set. As with acquiring any new skill, there will be initial challenges for both the novice and experienced anesthesiologist. From correlating anatomy with sonoanatomy and visualizing needles and fluid dynamics in real-time below the skin surface, ultrasound provides opportunities and unique challenges for vascular access and regional anesthesia. Purpose The purpose of this study was to evaluate the utility of ultrasound in the process of epidural catheter inserion and whether it can replace the conventional loss-of-resistance (LOS) technique or at least help with better performance by the staff. Patients and methods A total of 30 patients scheduled for thoracotomy were randomly categorized by closed envelopes method into two equal groups (15 patients each): group I patients received epidural anesthesia with ultasound guidance, and group II patients received epidural anesthesia with the conventional palpation technique. We recorded time from first puncture till LOS, number of skin punctures till LOS, redirections, and bone contacts. Failure and complications were recorded as well. Patient satisfaction was assessed after catheter insertion and removal, which was 24 h postoperatively in the postanesthesia care unit. Results A significant increase in insertion time was recorded in group I (P<0.001). The number of skin punctures till LOS was significantly lower in group I (P=0.043), and needle redirections were also lower in group I (P=0.020). Vertebrae were less hit by the needle in group I (P=0.026). A case of epidural failure was recorded in group II, and also an accidental hemorrhagic tap was recorded in the same group. Patient satisfaction both after catheter insertion and removal was higher in group I (P=0.031 and 0.002, respectively). Conclusion From the primary endpoints assessed in this work, one can declare that usage of ultrasound had consumed time owing to lack of experience by the operator, yet it led to less puncture attempts, redirections, and bone contacts and reduced failure rates and complication rates, which led to increased satisfaction. The technique requires more practice and training to familiarize anesthesia staff with it to lower the procedure time.
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Effects of single preoperative oral pregabalin administration on postoperative hyperalgesia and opioid consumption after total abdominal hysterectomy p. 83
Sherif Y Omar, Monir K Afifi, Mohamed M Abd Elhady, Ahmed A Elkader Mahmoud
Background The objective of this randomized double blind study was to evaluate the effect of preoperative single oral dose of pregabalin 150 mg on pain sensitivity, postoperative hyperalgsia and opioid consumption after total abdominal hysterectomy. Purpose The aim of this study was to evaluate the effect of preoperative single oral dose of pregabalin on pain sensitivity, postoperative hyperalgsia and opioid consumption after total abdominal hysterectomy. Patients and methods Sixty female patients were randomly categorized into two equal groups (30 patients each): group I, patients received pregabalin 150 mg orally, 1 h before induction of anaesthesia. Group II, patients received a matching placebo orally, 1 h before induction of anaesthesia, then evaluation of postoperative analgesia by visual analogue scale score, postoperative hyperalgesia using von Frey filaments and opioid consumption for 24 h was carried out. Conclusion From the primary endpoints assessed in this work, one can declare that usage of pregabalin in a dose of 150 mg, was more effective in reducing hemodynamic changes, postoperative pain intensity, hyperalgesia and analgesic consumption in comparison with a placebo as pre-emptive analgesia, when neither doses caused respiratory depression or sedation or PONV, but found also to significantly increase postoperative side effects including dizziness and somnolence as a secondary endpoint assessed.
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Perioperative Anaesthetic challenges during the management of Mucormycosis in a recovered SARS-CoV-2 Patient: A Case report p. 91
Sarfaraz Ahmad, Neeraj Kumar, Amarjit Kumar, Mithun Rathinasamy
Mucormycosis is a progressive, opportunistic fungal infection with high risk of mortality. Rampant use of steroids in the treatment coronavirus disease 2019 creates a fertile environment for mucor growth. Perioperative challenges for the anesthesiologist in a patient having post-coronavirus disease mucormycosis include increased risks of arterial and venous thromboembolism, poor glycemic control and myocardial dysfunction, adrenal insufficiency from corticosteroid use, pulmonary dysfunction, and residual neuromuscular weakness. So, a complete biochemical workup of renal functions, hypothalamic–pituitary–adrenal axis, electrolyte, coagulation profile, optimization of blood glucose, and pulmonary function should be done.
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Ala nasi pressure sore following nasotracheal intubation p. 94
Niranjan K Sasikumar, Sunil Rajan, Varshini Ravindran, Naveen Karthik
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A case of an ischemic bulky free flap contributing to severe postoperative lactic acidosis following major head and neck reconstructive surgery p. 96
Niranjan K Sasikumar, Sunil Rajan, Pulak Tosh, Kaushik Barua
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