Background Supraglottic airway devices have become prevalent in children because they are typically more user-friendly than a face mask and avoid many of the problems associated with endotracheal intubation. i-gel is a new single-use supraglottic airway device without an inflatable cuff. Pediatric i-gel is now available in four different sizes, 1, 1.5, 2, and 2.5, on the basis of body weight. Patients and methods This study was carried out in Alexandria University Hospitals on 70 patients of American Society of Anesthesiologists grade I and II, aged 3–6 years. They were classified randomly into two equal groups of 35 patients each and admitted to undergo elective surgery under general anesthesia with controlled ventilation in the supine position without head and neck manipulation. In group I, a classic laryngeal mask was used and in group II, i-gel was used to maintain a patent airway during anesthesia. The devices were compared in terms of insertion success, hemodynamic responses, oropharyngeal sealing pressure, airway interventional requirements during maintenance, and postoperative complications. Results The time of insertion of i-gel was significantly shorter than that of the classic laryngeal mask airway (cLMA) (P<0.001) and the airway sealing pressure for the i-gel was significantly higher than that for the cLMA (P=0.043). Conclusion Both the i-gel and the cLMA are suitable devices for controlled ventilation for pediatric patients undergoing short surgical procedures who are not at risk of aspiration. The insertion time of i-gel was less than that of cLMA and airway sealing pressure of i-gel was higher than that of cLMA.

Background Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the USA and acute exacerbations result in more than 800 000 hospitalizations annually. The combination of COPD treatment often coexists with treatment for congestive heart failure or ischemic heart disease (IHD) and present complex therapeutic challenges. β₂-Agonists, which are frequently used in the treatment of COPD, have the potential for adverse cardiovascular effects including ischemic events and arrhythmias. β-Blocker therapy improves symptoms and survival among patients with IHD and congestive heart failure, but is frequently withheld in patients with COPD. During an acute exacerbation of chronic obstructive pulmonary disease (AECOPD), patients may be particularly vulnerable to develop acute cardiac events due to increased use in β₂-agonists, tachycardia, and hypoxemia. The addition of a cardioselective β-blocker, especially nebivolol, may have a cardioprotective effect in this population, blunting the cardiac toxicity of the β₂-agonists. We evaluated the association of the cardioselective β-blocker nebivolol treatment with the incidence of late invasive ventilation among patients with IHD who were hospitalized for an AECOPD. Hypothesizing that the nebivolol as a highly selective β-blocker is not deleterious and is safe in the setting of AECOPD, we also compared the outcomes with patients who are not treated with nebivolol in the setting of AECOPD. Objective The aim of the paper was to study the incidence of late invasive mechanical ventilation among a group of ischemic heart disease patients with AECOPD who received oral nebivolol and compare the results with another group of patients with the same diagnosis who did not receive it. Patients and methods This study was conducted on 90 adult patients of both sexes, who were admitted to the Critical Care Medicine Department of Alexandria Main University Hospital after fulfilling the inclusion and exclusion criteria and obtaining an informed consent from patients’ relatives, and from the local ethics committee. Patients were subjected to full routine examination and categorized into two groups; each group comprised 45 patients using the sealed-envelop technique as a method for randomization of participants in both groups. Group I, patients who received oral nebivolol tablets on the first and/or second day of admission. Group II, patients who did not receive oral nebivolol tablets on the first and/or second day of admission. Results In comparing the patients in both groups, there was no statistically significant difference between them with regard to age, sex, comorbidities, and Acute Physiology and Chronic Health Evaluation II score on admission. Incidence of late invasive ventilation was the same between the case and the control groups. There was no significant difference in causes of intubation between both groups. There was no statistically significant reduction in the duration of invasive ventilation, ICU and hospital stay between both studied groups. Acute ischemic events showed no statistically significant reduction between case and control groups. Regarding in-hospital and 28-day mortality, there was no statistically significant difference between both studied groups. Conclusion Our results suggest that among the studied population of patients with AECOPD with underlying coronary artery disease, using oral nebivolol tablet seems to be safe as it does not cause worsening of the clinical condition of the patients regarding the incidence of late invasive mechanical ventilation or incidence of acute ischemic events. In addition, it does not affect the duration of ICU or hospital stay and showed no effect on in hospital or 28-day mortality.

Purpose The aim of the paper was to compare between dexmedetomidine (DM) versus morphine added to bupivacaine in paravertebral block (PVB) for perioperative analgesia in modified radical mastectomy in relation to hemodynamic stability, efficacy of pain relief, and possible complications. Patients and methods A randomized, double-blind, controlled trial was conducted on 45 American Society of Anesthesiologists I–II patients undergoing elective unilateral modified radical mastectomy. Patients were randomly allocated into three groups: group B (n=15) received 20 ml of 0.25% bupivacaine (as control group), group D (n=15) received 20 ml of 0.25% bupivacaine+100 μg DM, and group M (n=15) received 20 ml of 0.25% bupivacaine+2 mg morphine. Hemodynamic parameters, area of local anesthesia, postoperative oxygen saturation and respiratory rate, visual analog scale (VAS) score, shoulder restriction score, time to first dose, and total amounts of supplementary analgesia (meperidine hydrochloride) were recorded. Postoperative sedation was evaluated using Ramsay sedation scale, and postoperative nausea and vomiting were evaluated using postoperative nausea and vomiting impact scale score. Other side effects were also recorded. Results There were no significant differences between the three studied groups at baseline regarding heart rate, mean arterial blood pressure, arterial oxygen saturation (SpO₂), and respiratory rate. There was a significant reduction in heart rate in group D since the initiation of skin incision till the end of operation. There was a significant reduction in mean arterial blood pressure in the three groups from the starting of skin incision till the end of operation, but it was more evidenced in group D. Arterial oxygen saturation (SpO₂) and respiratory rate were comparable between the three groups at all measuring times. There was significantly lower postoperative VAS score, longer time to first dose, and lower consumption of meperidine hydrochloride in group D than group B and group M. The present study did not show any serious intraoperative or postoperative complications in the three studied groups. Conclusion The addition of DM to bupivacaine in PVB provides a significant clinical benefit by decreasing VAS score, decreasing postoperative use of analgesics, and prolonging the onset of postoperative analgesic requirement without serious adverse effects and is superior to morphine as an adjuvant in PVB.

Background Postspinal shivering is an annoying problem that can lead to many complications. The aim of the present study was to compare the effect of intrathecal nalbuphine with intrathecal pethidine in preventing postspinal shivering in patients undergoing knee arthroscopy. Patients and methods For this randomized study, we included 100 patients (American Society of Anesthesiologists physical status I or II) who were candidates for knee arthroscopy under spinal anesthesia. Participants were divided into two groups: group P (pethidine group, n=50) received 2.5 ml of 0.5% bupivacaine with 25-mg pethidine (total 3 ml) intrathecally, and group N (nalbuphine group, n=50) received 2.5 ml of 0.5% bupivacaine with 0.4-mg nalbuphine (total 3 ml) intrathecally. After establishment of standard monitoring, insertion of venous catheter, and applying the crystalloid infusion warmed to 37°C, intravenous atropine 0.6 mg was administered to all patients. Next, intrathecal block was performed at the L4–L5 level. All patients were operated in the same operating room at a temperature of 23°C. Mean arterial blood pressure, heart rate, arterial oxygen saturation, core (tympanic) temperature, incidence and severity of shivering, and incidence of complications were recorded at baseline, immediately after administration, and then every 5 min until end of surgery. Results Hemodynamic parameters, oxygen saturation, and core temperature were comparable between the two groups. On the other hand, although incidence and intensity of shivering were lower in group P, there was no significant statistical difference between both groups − nine (18%) patients in group P and 17 (34%) patients in group N (P=0.109). In addition, the incidence of complications (hypotension, nausea, and pruritus) was lower in group P but without any significant statistical difference between the two groups. Conclusion Intrathecal nalbuphine is comparable with intrathecal pethidine in preventing postspinal shivering in patients undergoing knee arthroscopy.

Introduction Pain control is the key in patient’s recovery after arthroplasty. We compared periarticular bupivacaine with levobupivacaine in postoperative analgesia after total knee arthroplasty in this randomized double-blinded study. Patients and Methods Totally, 44 patients were randomly distributed to two equal groups. The L group received periarticular 150 mg levobupivacaine HCl, 0.25% concentration+0.3 mg of adrenaline (1/200 000 concentration) diluted in normal saline to be 60 ml. The B group received periarticular 150 mg bupivacaine HCl, 0.25% concentration+0.3 mg of adrenaline (1/200 000 concentration) diluted in normal saline to be 60 ml. The primary outcomes were the quality of analgesia during 48 h postoperatively, using a visual analog scale score at 6, 12, 18, 24, 36, and 48 h postoperatively and cumulative opioid consumption at 24 and 48 h postoperatively. The secondary outcomes were the functional recovery of the knee and postoperative adverse effects. Result There was no significant difference between the two groups as regards preoperative data. Pain control was comparable in the two groups. No significant complication was observed. There was good functional recovery in both groups with a higher mean degree of knee maximal flexion in the B group. Conclusion Periarticular levobupivacaine and bupivacaine have comparable analgesic effect in patients undergoing total knee arthroplasty.

Background The 2013 sedation guidelines from the Society of Critical Care Medicine recommend using sedation scales to optimize sedation therapy. However, scales such as the Richmond Agitation–Sedation Scale (RASS) require subjective evaluation that may lead to variability in measurement and consequent clinical actions. The bispectral index (BIS) is an objective measure of the level of consciousness that is often used as anesthetic tool, and its use has broadened to include the ICU. Published data are still insufficient to warrant routine use of the BIS in critically ill patients. Aim The aim of this study was to compare the RASS with the BIS in measuring the level of sedation. Patients and methods This was a prospective study performed on 60 critically ill, adult, mechanically ventilated patients receiving sedation infusion. The BIS monitor was attached continuously to all patients for 3 days, and the digital readings were recorded every 4 h. The RASS was assessed and recorded at the same time. Statistical analyses were performed to assess the correlation between the two used modalities over time. Patients receiving muscle relaxants were excluded from the study. In addition, patients with head injuries or patients known to have any focal brain disease or abnormal electrical brain activities such as epilepsy were excluded. Results A total of 1080 readings comparing the RASS with the BIS were obtained from the 60 patients included in the present study over 3 days. No serious side-effects due to the BIS electrodes placed for 3 days were recorded. The correlation between RASS scores and BIS values was positive and statistically significant. The overall correlation scores in the 3 days were as follows − r=0.652, P less than 0.001 on day 1; r=0.685, P less than 0.001 on day 2; and r=0.686, P less than 0.001 on day 3. The correlation was statistically significant with the use of midazolam but not with dexmedetomidine. Conclusion An overall statistically significant, positive correlation between the BIS and the RASS was present. The BIS can be used as an adjunct for scoring.

Background No medication exists to halt the progression of secondary injuries in severe traumatic brain injury (TBI), but the variety of pathological events presents opportunities to find treatments that interfere with the damage processes. The effects of progesterone on the reproductive and endocrine systems are well known, but a growing body of evidence indicates that the hormone also exerts neuroprotective effects on the central nervous system by decreasing overall cerebral edema, protecting and rebuilding the blood–brain barrier, downregulating the inflammatory cascade, and limiting cellular necrosis and apoptosis. Aim The aim of this study was to evaluate the effect of progesterone administration on improvement in outcomes of patients with TBI as measured by the Glasgow Outcome Scale. Patients and methods The present study was a prospective, randomized trial. A total of 100 patients with severe TBI were enrolled for the present study. The selected patients were categorized at random into two equal groups − the control group and the progesterone group. In the control group, patients were given conventional therapy. The progesterone group was given 1 mg/kg progesterone by intramuscular injection within 8 h of admission and then every 12 h for 5 consecutive days in addition to the conventional therapy. The neurological outcome after 30 days was evaluated using the Glasgow Outcome Scale score as well as duration of ICU stay. Results In the progesterone group, 33/50 (66%) patients had favorable outcomes and 17/50 (34%) had unfavorable outcomes, whereas in the control group 23/50 (46%) patients had favorable outcomes and 27/50 (54%) had unfavorable outcomes (P=0.072). Length of ICU stay had a mean value of 10.88±7.98 days in the progesterone group versus 19.96±10.36 days in the control group (P<0.001). Conclusion No significant difference in outcome between the two groups was observed, but there was a significant decrease in ICU length of stay in the progesterone group.

Oleander poisoning is encountered rarely in clinical practice. The poisonous substances of oleander plant contain cardiac glycosides and their toxicity mimics digoxin overdose. We hereby report a case of intestinal oleander poisoning in an adult male, presenting with vomiting, disorientation, increased tone of muscles (spasticity) in lower limbs, and slow, irregular pulse. He responded to conventional treatment, consisting of intravenous atropine, intravenous phenytoin, intravenous dexamethasone, and correction of electrolytes. This report discusses the cardiotoxic and neurotoxic manifestations of yellow oleander poisoning, its early diagnosis, and prompt treatment. We would like to emphasize the importance of taking an ECG in all cases of poisoning.

Congenital tracheal stenosis (CTS) has an incidence between 0.3 and 1% of all laryngotracheal stenosis [1]. In about 84% of such cases, it is associated with cardiac, skeletal or oesophageal anomalies. The associated cardiac anomalies include ventricular septal defect, atrial septal defect, patent ductus arteriosus, atrioventricular canal defect and pulmonary artery sling [2]. The diagnosis of CTS is based on high degree of suspicion in infants with respiratory distress. Classically, infants have a stridor that is exacerbated by lower respiratory tract infection and present with intermittent cyanosis, leading to reflex apnoea or dying spells. A 1 mm decrease in the cross-sectional area (CSA) of the airway results in 44% decrease in CSA. Infants become symptomatic only when the decrease in CSA is more than 50% and become dyspnoeic when the CSA decreases by more than 75% [3]. We present the hospital course of an infant who presented with CTS and a large patent ductus arteriosus. The present case is reported with parental consent.