General anesthesia (GA) is the choice for laparoscopic cholecystectomy (LC). Spinal anesthesia (SA) is usually preferred in patients where GA is contraindicated. In this study, SA was used in 67 patients in whom LC was planned (study group). LC has been conventionally done under GA. Regional anesthesia is usually preferred in patients where GA is contraindicated. SA was used in 67 patients for LC (study group). Moreover, 50 patients were given GA as a control group. There was no modification in the technique, and the intra-abdominal pressure was kept at 8–10 mmHg. Sedation was given if required, and conversation to GA was done in patients not responding to sedation or with failure of SA. Of 67 patients, two patients required conversation to GA. Hypotension requiring support was recorded in 14 (20.89%) patients and 16 (23.88%) experienced neck or shoulder pain or both. Postoperatively, two (2.9%) patients had vomiting as compared 17 (34%) patients who were administered GA. Injectable diclofenac was required in 25 (37.3%) patients for abdominal pain within 2 h postoperatively and oral analgesic for 53 (79.10%) patients within the first 24 h in SA group. However, 96% of patients operated under GA required injectable analgesics in the immediate postoperative period. Postural headache was experienced by five (7.46%) patients postoperatively. The average time of discharge was 1.9 in patients operated under SA compared with 2.1 days in GA group. There is no risk of intubation-related airway obstruction, little risks of unrecognized hypoglycemia in a diabetic patient, excellent muscle relaxation, decreased surgical bed oozing, and a more rapid return of gut function when LC is done using SA compared with GA.

Background Orthopedic patients experience severe immediate postoperative pain, and they require more analgesia. Effective management of perioperative and postoperative pain after lower extremity orthopedic surgery represents an important component of early postoperative recovery. It is essential to facilitate rehabilitation and accelerate functional recovery, enabling patients to return to their normal activity more quickly. Moreover, treating patient’s preoperative anxiety improves postoperative pain. Pregabalin was found to be useful in decreasing postoperative pain and analgesic requirements as well as anxiolytic and sleep-modulating effects. Objective This study compares analgesic, anxiolytic, and sedative effects of pregabalin 75 and 150 mg versus placebo in patients undergoing surgery for fixation of traumatic tibial fractures under spinal anesthesia. Patients and methods This blind study contained 45 patients scheduled for fixation of tibial fractures under spinal anesthesia using a closed envelope technique. The patients were divided into three groups (15 patients each). Group P75 received 75 mg pregabalin capsule, group P150 received 150 mg pregabalin capsule, and group P0 received matching placebo capsule. In the preoperative holding area, patients were randomly divided into three groups. Then, an intravenous line was secured. Then, an hour before the surgery, all patients underwent assessment of level of anxiety using visual analog scale and assessment of degree of sedation using Ramsay Sedation Scale. Thereafter, the drug selected for the study was given with a sip of water by a staff nurse who was not involved in the study. Before anesthesia, anxiety and sedation were reassessed for the second time for all patients using visual analog scale for anxiety and Ramsay Sedation Scale, respectively. Spinal anesthesia was instituted at L3–L4 interspace, and a volume of 2.5–3.5 ml (according to the patient’s height and weight) of 0.5% heavy bupivacaine was injected over 30 s through a 25-G spinal needle. In the postoperative period, all patients received ketorolac 30 mg/kg, and they were observed for pain score and level of sedation for 24 h postoperatively. Results The use of pregabalin 150 mg preoperatively succeeded in significantly decreasing the postoperative pain and analgesic requirements and increasing the sedation score in comparison with 75 mg dose. Both doses succeeded in significantly decreasing the preoperative anxiety. Conclusion The use of pregabalin before surgery for fixation of traumatic tibial fractures could achieve good postoperative analgesia, preoperative anxiolysis, and perioperative sedation.

Introduction Acute kidney injury (AKI) is well recognized for its effect on the outcome of patients admitted to ICU. The pursuit of improved biomarkers for the early diagnosis of AKI and its outcomes is an area of intense contemporary research; studies demonstrated the utility of furosemide stress test (FST) for predicting the severity of AKI, and a possibility of administration as a treatment for acute kidney injury network (AKIN) I and II. Patients and methods A total of 80 patients in ICU of Nasser Institute Hospital (July 2014–2015) were recruited, including 40 patients who received FST and 40 patients who received standard management. Patients included were those who developed AKI grades Ι–Π according to AKIN criteria. They were assessed clinically and followed through the duration of the study by hourly central venous pressure measurement (CVP) and urine output for 6 h, besides daily kidney function tests and estimated glomerular filtration rate for 3 days. Results In the first 6 h, there was a significant increase in urine output in group I after first and second hours (P=0.026, 0.008, respectively), as well as cumulative UOP over 6 h (P=0.003), as compared with group II. The cutoff point regarding UOP for detection of progress to AKIN III and dialysis was found to be 325 ml in both groups, with sensitivity of 86.7% and specificity of 68% in group I and sensitivity of 95% and specificity of 95% in group II. There was a highly significant difference between the two groups concerning hypotension, which occurred in 11 patients in group I versus none in group II, with P value of 0.001, whereas there was no significant difference between both the groups concerning progression to AKIN III and dialysis, with P value of 0.260; ICU stay, with P value of 0.621; and mortality, with P value of 0.201. Our results in group I patients who did not show worsening of AKIN class had significantly higher urine output as compared with those whose AKIN class worsened, with P value of 0.001. Conclusion FST is a good predictor of severity of tubular damage in early stages of AKI, with no additional privilege over standard management in the treatment of AKI. Moreover, it carries more risk of hemodynamic compromise.

Background Chloride (Cl) abnormalities in the critical care units have received great attention, especially hyperchloremia as a cause of metabolic acidosis and hypochloremia as a cause of metabolic alkalosis. However, Cl abnormalities themselves have not been studied sufficiently. Aim The aim of this study was to show the effect of Cl abnormalities in critically ill patients. Settings The study was conducted in Critical Care Medicine Department in Alexandria University Hospital. Patients and methods A Prospective clinical study was conducted on 375 critically ill adult patients admitted to Alexandria University hospitals. All patients included were subjected to demographics, diagnosis and cause of admission, relevant medical history, calculated APACHE-II score, and laboratory data (days 1 and 3 after admission), including serum electrolyte level, ABG analysis (anion gap–gap/gap ratio–corrected anion gap), and serum albumin level. According to the recorded Cl levels at days 1 and 3 from ICU admission, patients were defined as normochloremic (99–110 mEq/l), hypochloremic (<99), or hyperchloremic (>110). Outcome measures were all-cause mortality and length of stay (LOS) in ICU. Results Cl abnormalities at day 1 were associated with increased mortality. The mortality rate was significantly higher in hyperchloremic (67.3%) compared with hypochloremic (72.1%) and normochloremic patients (36.3%) (P<0.001). Cl abnormalities (at days 1 and 3) were associated with increased ICU LOS. The mean of ICU LOS in days was significantly higher in hyperchloremic (21.29) and hypochloremic (16.38) than normochloremic (13.81) patients (P<0.001). Conclusion In a mixed general intensive care population, after careful controlling for confounders, Cl abnormalities (outside 99–110 mEq/l) were independent predictors for poorer outcomes such as ICU mortality and LOS.

Introduction Atelectasis is the most important postoperative pulmonary complication in obese patients following general anaesthesia. The study aimed to determine the effect of inspired high versus low oxygen concentration on pulmonary atelectasis in obese patients undergoing laparoscopic cholecystectomy. Patients and methods A total of 60 patients, American Society of Anesthesiologists I–II, of both sexes, aged 20–60 years, BMI more than 30 kg/m² and scheduled for elective laparoscopic cholecystectomy were randomly assigned to group I inspired 40% oxygen and group II inspired 90% oxygen after endotracheal intubation and for 2 h postoperatively. The effect of inspired oxygen concentration on atelectasis approved by computed tomographic scan and radiography was determined 24 h after surgery. Oxygen saturation, the partial pressure of arterial oxygen and carbon dioxide, tension, pulmonary functions and haemodynamic parameters were also recorded. Results Atelectasis was detected by computed tomography scans of the chest performed in the first postoperative day in 60% of patients in group I, whereas it was detected in 76.7% of patients in group II without significant difference between the groups, and it was determined in 33% of patients in group I compared with 46% of patients in group II, without significant difference between the two groups by radiographic examination. Postoperative forced vital capacity and forced expiratory volume in 1 s were significantly reduced in the two groups compared with the preoperative values in both groups without significant difference between the two groups. The intraoperative partial pressure of arterial oxygen values showed an insignificant change in the postoperative measurements between the groups. Conclusion Administration of low percentage of oxygen concentration (40%) was associated with decreased incidence of atelectasis without worsening of pulmonary function.

Purpose The purpose of this study is to determine the accuracy of portable bedside ultrasound (US) in the ICU in predicting postextubation stridor (PES). Patients and methods This prospective observational cohort study enrolled 80 patients who were admitted to Alexandria Main University Hospital, who were planned for extubation. The air-column width difference (ACWD) was measured before planned extubation using a portable US. The primary goal was to assess the diagnostic accuracy of ACWD to predict the presence of significant laryngeal edema (LE), enough to cause PES. Bronchoscopy was done to confirm the presence of PES, whenever possible. Results The prevalence of LE was 25%. The data collected from patients, with and without PES showed no definite risk factors for PES. A cutoff point of 0.9 mm change in ACWD (ACWD at vocal cords) was identified (P<0.001), below which a high probability of developing PES was noticed. The sensitivity and specificity of ACWD below or equal to 0.9 mm were 80% and 90% in predicting PES, respectively, with a negative predictive value of 0.931 and a positive predictive value of 0.727. In selected cases, postextubation bronchoscopy showed good correlation with ACWD by confirming significant LE in six cases out of seven with PES, five of which had an ACWD of below 0.9 mm. Conclusion Portable ICU US measuring ACWD between predeflation and postdeflation of endotracheal tube cuff balloon is a tool of a very good prospective in predicting PES.

Background Sepsis commonly produces brain cognitive dysfunction known as sepsis-associated encephalopathy (SAE). Aim of the study The aim of this study was to assess the effect of administration of an intravenous bolus dose of magnesium sulfate on cerebral perfusion in patients with SAE. Methods Using transcranial Doppler, we measured the mean flow velocity in the middle cerebral artery (cm/sec) and calculated the pulsatility index and resistive index on admission and 30 m after the administration of a 6 g intravenous dose of magnesium sulfate in septic patients with a positive Confusion Assessment Method for the ICU (CAM-ICU) score and Glasgow Coma Scale (GCS) less than 15 during the first 24 h from the onset of sepsis. The measurements were repeated after 24 h and were correlated with the GCS and CAM-ICU score of the patients after 24 h from the onset of sepsis. Results Forty-six sepsis patients without any neurological deficit treated in our 14-bed Critical Care Unit [magnesium group (Group_Mg)=23, control group (Group_control)=23] were assessed. No difference was found between the two groups in mean age, mean arterial pressure or Acute Physiology and Chronic Health Evaluation II score. After 24 h, the pulsatility index was significantly reduced in the magnesium group (1.09±0.22, P<0.001) as well as the resistive index (0.62±0.07, P<0.001). Mean flow velocity was significantly higher in the magnesium group after 24 h (49.81±16.24, P<0.001). The magnesium group also displayed a significant improvement in the mean GCS after 24 h (11.65±1.99, P=0.048) and in the CAM-ICU score (negative CAM-ICU=16/23 patients, P≤0.001). Conclusion Our results suggest that the administration of magnesium sulfate during the first 24 h of the onset of sepsis seems to improve cerebral perfusion in patients with SAE and possibly correlates with better neurological outcomes in these patients.

Background Pain control for laparoscopic hysterectomy carries some concerns. Intraperitoneal bupivacaine either alone or with additives has been studied with favorable results. However, adding nalbuphine has not been sufficiently examined. This study aimed to compare between the addition of magnesium sulfate (MgSO₄) or nalbuphine to bupivacaine regarding efficacy and drawbacks. Patients and methods A total of 80 female patients of American Society of Anesthesiologists I–II scheduled for laparoscopic hysterectomy in Ain Shams University hospitals were randomly distributed into two groups: group bupivacaine magnesium (BM) (n=40), in which patients received 30 ml of intraperitoneal bupivacaine 0.25% plus 30 mg/kg MgSO₄, and group bupivacaine nalbuphine (BN) (n=40), in which patients received 30 ml of intraperitoneal bupivacaine 0.25% plus 5-mg nalbuphine at the end of operation. A standard general anesthesia technique was used in all patients. Visual analog scale, total intravenous diclofenac consumption, the time for first analgesia requirement, incidence of adverse effects, and patient satisfaction in the first 24 h postoperatively were recorded in both groups. Results BN group experienced prolonged postoperative pain-free period. Total diclofenac consumption and pain scores were significantly less in BN group as compared with BM group. Regarding the adverse effects, there was insignificant difference between both groups for incidence of shoulder pain; however, BN group experienced more postoperative nausea and vomiting. Other adverse events were not reported. Patient satisfaction was significantly higher in BN group when compared with BM group. Conclusion This study showed that addition of nalbuphine to bupivacaine for intraperitoneal instillation gave better postoperative pain control when compared with adding MgSO₄ to bupivacaine.

Introduction Identification of predicted sepsis-related mortality is important for patient stratification. We evaluated the significance of presepsin in predicting sepsis-related mortality. Patients and Methods We enrolled 83 patients with sepsis according to the SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference in a prospective observational study. Results After excluding 28 patients owing to different exclusion criteria, 55 continued the study. Their age was 58 (47–65) years old and comprised 33 (60%) males. We measured serum presepsin, procalcitonin (PCT), and C-reactive protein (CRP) on admission and 24 and 72 h later. Acute Physiology and Chronic Health Evaluation II score and capillary leak index were estimated. The primary outcome was in-hospital mortality. The median (Q1–Q3) presepsin²⁴ and presepsin⁷² levels were 127.5 (835.75–2137.5) and 883 (429–1214.5) pg/ml, respectively, in survivors compared with 2321 (1264–3456) and 3421 (1900–5432) pg/ml, respectively, in nonsurvivors (P=0.01 and 0.000, respectively). The serum CRP²⁴ and CRP⁷² were 123 (76–154) and 94 (42.5–127) mg/l, respectively, in survivors compared with 156 (101–201) and 187 (139–233) mg/l, respectively, in nonsurvivors (P=0.02 and 0.000, respectively). PCT⁷² was 111.5 (66–186.25) pg/ml in survivors compared with 231 (187–324) pg/ml in nonsurvivors (P=0.000). Presepsin⁰, CRP⁰, PCT⁰, and PCT²⁴ were not significantly different between survivors and nonsurvivors (P=0.4, 0.7, 0.5, and 0.2, respectively). The Acute Physiology and Chronic Health Evaluation II score was 18 (15–20.8) in survivors compared with 21 (19–24) in nonsurvivors, (P=0.02), whereas the capillary leak index was 42 (27.6–57.7) and 42.4 (33.3–62.3) in survivors and nonsurvivors, respectively (P=0.8). The area under the curve was the highest for presepsin⁷² (0.918). Presepsin⁷² of 1262 pg/ml was seen to be 92.3% sensitive and 81.3% specific for mortality prediction. Conclusion This study showed that the serum presepsin could be a valuable biomarker for predicting in-hospital mortality in sepsis.

Background Children undergoing cardiac surgery experience a substantial stress response mediated by the release of stress hormones and cytokines. Providing sedation and blunting stress response by one drug in a single oral dose and excellent oral bioavailability of clonidine prompted us to study its efficacy as premedication in pediatric patients and compare it with both oral midazolam, a gold standard premedication in pediatric patient, and oral dexmedetomidine, as a newer α₂ receptor agonist. Aim To compare the effect of premedication with three drugs (clonidine, midazolam and dexmedetomidine) in pediatric congenital cardiac surgeries including their effect on the stress response during surgery. Patients and methods Patients were categorized into three groups (30 patients each): group clonidine (C) received oral clonidine at a dose of 4 µg/kg, group midazolam (M) received oral midazolam at a dose of 0.5 mg/kg, whereas group dexmedetomidine (Dx) received oral dexmedetomidine at a dose of 1 μg/kg. All the drugs were mixed with equal volume of 5% dextrose. Results The bispectral index measurements in group Dx became significantly lower at 15 min and 30 min compared with the other two groups. Then, significantly lower bispectral index measurements were observed in group C compared with groups M and Dx at 45 min and afterward. The serum cortisol and catecholamines levels in group C became significantly lower than that in groups M and Dx after intravenous cannulation, after sternotomy, and at the end of surgery. Conclusion Clonidine, as a preanesthetic drug in congenital heart surgery, is effective in decreasing stress response and achieving adequate level of sedation till the end of surgery. Oral dexmedetomidine has faster onset compared with midazolam in reaching the adequate level of sedation.

Background Emergence agitation (EA) and postoperative pain and vomiting (POV) are often complicating the recovery of children after strabismus surgery under sevoflurane anesthesia. This study compared the effects of preoperative intranasal dexmedetomidine versus peribulbar local anesthetic (LA) block technique for strabismus surgery on EA and POV. Patients and methods Seventy-five children undergoing elective unilateral strabismus surgery under sevoflurane anesthesia were randomly assigned to one of three equal groups (n=25 each). The dexmedetomidine group (group D) received intranasal dexmedetomidine 1 μg/kg preoperatively. The LA group (group L) received peribulbar 2–5 ml of LA mixture (in the form of lidocaine : bupivacaine 1 : 1 ratio) in the operable eye after induction of anesthesia. The control group (group C) received (normal saline) intravenous infusion. In the postanesthesia care unit, pediatric anesthesia emergence delirium scale, Modified Childern’s Hospital of Eastern Ontario Pain Score pain score and POV were assessed. Recovery time and postanesthesia care unit stay were also assessed. Results Seventy-five patients completed the study, pediatric anesthesia emergence delirium scale score was significantly lower in both the local peribulbar group and the dexmedetomidine group than in the placebo group (P<0.001). Modified Childern’s Hospital of Eastern Ontario Pain Score pain scores were lower in the local group than in the dexmedetomidine group and in the control group. The incidence of POV was lower in group D (3/25) than in group L (5/25) and in the control group (8/25). Emergence time was shorter in group L compared with the other two groups. Conclusion Peribulbar LA and intranasal dexmedetomidine seem to decrease the incidence of postoperative pain and EA in children undergoing unilateral strabismus surgery under sevoflurane anesthesia.

Background Simethicone is an oral antifoaming agent that reduces bloating, abdominal discomfort, and abdominal pain by promoting the clearance of excessive gas along the gastrointestinal tract. We hypothesized that preoperative oral simethicone has a good effect on the operative field and can improve postoperative analgesia after gynecological laparoscopies. Patients and methods Hundred infertile women scheduled for laparoscopy were randomized to receive oral simethicone tablets (group I) or placebo tablets (group II). The outcome measures were the pain scoring and overall exposure of the surgical field. Visual analogue scale was used for the assessment of postoperative pain. Assessment of the overall exposure of the surgical field was done using a five-point scale. Data were analyzed using SPSS version 21.0. Results were reported as mean±SD, percentages, and ranges. Results Women in the simethicone group reported less pain and less need for postoperative supplementary analgesia. There was a statistically significant difference in the overall exposure of the surgical field between the two groups in favor of the simethicone group. Women in both groups reported a high rate of satisfaction with the whole preoperative preparation, postoperative care, and willingness to retake the same medication in the future. Conclusion Simethicone is an effective, safe preoperative preparation drug. It is associated with less postoperative pain, better bowel preparation, and a better surgical field exposure. It is a well-tolerated drug, with minimal adverse effects and a higher satisfaction rate. Larger studies with a larger sample size may be useful to confirm and validate our results.

Background Intravenous regional anesthesia (IVRA) is a simple and reliable technique. The ideal IVRA solution should be rapid in onset and offers prolonged analgesia. The aim of this study was to assess the effects of different additives to local anesthetic in IVRA to provide a successful operative anesthesia with minimal analgesic requirements. Patients and Methods 80 patients ASA I–III scheduled for orthopedic and plastic surgeries in the forearm or the hand were randomly categorized into four groups, with 20 patients in each group. All groups received 30 ml of Lidocaine 1 % as IVRA solution in addition to the studied anesthetic adjunct. Group I (LD) received 8 mg dexamethasone in 2 ml Group II (LP) received 0.5 mcg/kg dexmedetomidine in 2 ml Group III (LL) received 8 mg lornoxicam in 2 ml Group IV (LS) received 2 ml normal saline 0.9% Mean arterial pressure and heart rate changes in the four study group changes were noted. Motor and sensory block onset and recovery times (minutes) and postoperative analgesic (gram paracetamol) consumption in the four study groups were recorded. Incidence of tourniquet pain and operative conditions were also assessed. Results The LP group showed a shorter time to onset of sensory block than the other three groups that was statistically significant with p<0.001. Both the LP and LL groups showed statistically significant longer time to recovery of sensory block (min) than the other groups (p<0.001). Both times to onset of motor block (min) and time to recovery of motor block (min) shows statistical insignificance regarding the relation between the 4 groups (p=0.073 and 0.794 respectively). Time to 1st postoperative analgesic request (min) was significantly late and the postoperative paracetamol consumption (gm) was significantly lower in the LP and LL groups than the other groups (p<0.001). Conclusion On studying different additives to lidocaine in IVRA, we found that dexmedetomedine and lornoxicam provide the best patient outcome regarding the onset and recovery of sensory block and prolonged analgesia.

Background Sepsis is a major cause of mortality in non-cardiac intensive care units, and ranks 10th among causes of death overall. Acute new onset atrial fibrillation is a common observation in critically ill patients admitted with sepsis, there is a direct relationship with disease severity. The red cell distribution width variations reflects a range of systemic diseases including heart failure, stable coronary disease, acute coronary syndrome and stroke. Objectives In this study, we aimed to investigate the relation between red cell distribution width (RDW) and atrial fibrillation (AF) in critically-ill patients with sepsis. Settings and Design We retrospectively examined 70 sepsis patients (35 sepsis patients with newly developed AF during intensive care unit (ICU) stay and 35 sepsis patients without AF matched with age and sex. We investigated the predictive potential for atrial fibrillation for RDW, Ejection fraction, central venous pressure (CVP), Heart rate and qSofa score. Results The mean age of AF group was 54.49 ± 10.07 vs. 56.26 ± 11.766 for Non-AF group. Baseline Ejection fraction, systolic blood pressure, heart rate and CVP showed no significant differences. RDW on admission was significantly different between groups; 18.94 ± 1.126 (AF group) vs. 14.76 ± 0.97 (Non AF Group). ROC curve analysis was done on AF group to determine cut-off values for RDW. Cut-off point was at 17.6 with 97 % sensitivity and 60.7 % specificity. Conclusions RDW levels were higher in sepsis patients with newly developed atrial fibrillation. An increased RDW level in the patient with sepsis may alert physician on developing or presence of atrial fibrillation.

Background Endotracheal intubation is frequently complicated by laryngeal edema, which may present as postextubation stridor (PES) or respiratory difficulty or both. Multiple tests were used to predict the PES. The present study aimed at description and evaluation of the predictive values of the cuff leak test (CLT), laryngeal ultrasound (LUS), and indirect flexible fiberoptic laryngoscopy (FOL) to predict PES in ICU patients after prolonged intubation. Patients and methods This prospective study was conducted on 60 intubated patients who were admitted into the surgical intensive care unit. After successful 30-min spontaneous breathing trial and within 6 h before the planned extubation, CLT, LUS, and FOL were performed for all patients. After extubation, the patients were observed and classified into two groups according to the presence of PES within 48 h. Results Two patients were excluded owing to self-extubation, and 58 patient’s data were analyzed. There was no significant difference in CLT volume and the leak fraction between the patients with PES (PES group) and those without PES (non-PES group). However, statistically, air column width with balloon inflated or deflated was significantly lesser in the PES group than the corresponding values in the non-PES group (P=0.04 and 0.009, respectively). Moreover, there was a high significant difference in the air column width difference between both groups (P<0.001). Moreover, the incidence and severity of laryngeal injuries as per FOL grading scale and the rate of reintubation were statistically higher in the stridor than non-stridor patients group (P<0.001). Conclusion For the noninvasive methods, the CLT has a low predictive value with high possibility of false results, but the data from LUS can be used for approximate evaluation of the laryngeal lumen narrowing; however, the interpretations of the ultrasound data are not conclusive. On the contrary, the FOL is the best accurate diagnostic tool but it is invasive.

Background Most anesthetists preferred general anesthesia for major abdominal surgery which was not devoid of complications in cases with chronic obstructive pulmonary disease (COPD). Recently, the use of neuraxial anesthesia is supported to avoid or decrease these complications. This study aimed at the description, evaluation, and comparison between the use of continuous spinal anesthesia (CSA) and continuous thoracic epidural anesthesia (CTEA) as a sole anesthesia for major abdominal surgeries in cases with COPD. Patients and methods Sixty patients of both sexes aged 40–75 years with American Society of Anesthesiologists physical status classes II and III complaining of COPD scheduled for various elective major abdominal operations were included. According to the neuraxial block type, the patients were randomly assigned into two equal groups with 30 patients in each. The first group (CSA group) received continuous lumbar spinal anesthesia and the second group (CTEA group) received continuous thoracic epidural anesthesia. The data recorded included patients’ demographic data, characteristics of the used neuraxial blockade, hemodynamic changes, changes in pulmonary functions, incidence of the various side effects, and postoperative pain severity. Results The final statistical analysis included 55 patients where five patients were excluded from the study. Although there were no statistically significant differences between both groups regarding demographics, hemodynamics, changes in pulmonary functions, side effects, surgeon, and patients’ satisfactions, and postoperative visual analog scale. The CSA group has faster block onset with less local anesthetic dose compared with the CTEA group (P<0.001). Also, there were statistically significant decrease in peak expiratory flow rate, forced expiratory volume in 1 s, and forced expiratory volume in 1 s/forced vital capacity at 1, 2, and 6 h postoperatively compared with the preoperative baseline values in both groups (P<0.05). Hypotension was significantly more frequent in the CTEA group than in the CSA group (P=0.047). Conclusion Although both CSA and CTEA can be used for anesthesia and for postoperative analgesia in major abdominal surgery in COPD patients, the CSA was easier, safer, had faster onset, gave more predictable block, with less hemodynamic instability, and less technical failure compared with CTEA. The preoperative optimization of the lung functions, intraoperative close observation, and postoperative neuraxial analgesia with chest physiotherapy improved the outcome.

Background Phantom-limb pain is one of the most difficult-to-treat chronic pain syndromes. In this randomized prospective trial, we studied the effect of administering fentanyl or dexmedetomidine as additive to bupivacaine in epidural catheter in perioperative period to reduce acute postoperative stump and phantom pain and opioid consumption in patients undergoing unilateral above- or below-knee amputation. Patients and methods Over 2 years, 62 patients with American Society of Anesthesiologists physical status I–II scheduled for unilateral knee amputation were analyzed. In this prospective study, two equal groups of patients randomly received dexmedetomidine or fentanyl as epidural infusion 24 h before operation and 72 h after surgery. Visual analog scale, sedation scale, patient satisfaction, incidence of phantom, and stump pain and cumulative opioid consumption over 3 days were used to compare the two groups. Results Incidence of postoperative stump and phantom pain in group D was less significantly in comparison with group F in the first 72 h postoperatively. Moreover, after 6 months, we found the same result. Patients’ satisfaction was significantly higher in group D in comparison with group F (P˂0.01). Visual analog scale was statistically significant lower in group D than group F in the 72-h postoperative period. This led to the more use of rescue analgesic (meperidine) in group F 232±23.1 mg than group D 142.2±46.68 mg. There was a statistically significant increase in preoperative sedation score in group D. Patients in group D experienced bradycardia and hypotension significantly more than group F. However, patients in group F experienced significantly from itching than group D. Conclusion Adding dexmedetomidine to bupivacaine as epidural infusion has been found to provide better postoperative analgesia, reduce opioid consumption, and decrease incidence of phantom and stump pain. It also improves patient satisfaction and decreases intensity of pain.

Spinal anesthesia is one of the most important and commonly performed technique in anaesthesia practice. Complications such as nausea, vomiting, restlessness, hypotension, and bradycardia may occur. We present two cases of apnea that occurred after approximately 30 min of spinal anesthesia during an otherwise uneventful ongoing surgery. Although the exact cause of apnea was unclear, it seems to be due to an interplay of multiple factors.