Objective The objective of this study was to compare general and spinal anesthesia as regards its maternal and neonatal outcomes in low-risk pregnancies undergoing elective cesarean section (C-section) at term. Patients and methods In a prospective, controlled clinical trial, 64 low-risk pregnant women underwent elective C-section for the first time for variant indications. The included women were randomly divided into two groups; group I (n=32) received spinal anesthesia and group II (n=32) received general anesthesia. The distinction between preoperative and postoperative maternal hematological indices, intraoperative and postoperative maternal hemodynamic parameters, the maternal requirement for analgesia, return of bowel function, and neonatal outcomes were compared between the two groups. Results The mean time for bowel to be open (9.7±1.3 vs. 6.8±1.6 h, P=0.001), and the first analgesia requirement was significantly (5.33±4 vs. 2.91±2.16 h, P=0.004) longer, and the hemoglobin and hematocrit difference values at 24 h postoperative were significantly (P=0.03, and 0.02, respectively) larger in group II. Urine output at the first postoperative hour was more (P=0.002) in the spinal group. The median Apgar scores at the first minute and at fifth minute were significantly higher (P=0.001, and 0.005, respectively) in the spinal group. Conclusion As long as it is not contraindicated, spinal anesthesia during elective C-section was safer for both neonates (higher Apgar scores), and mother (less bleeding, less postoperative pain) than general anesthesia and can be the ideal anesthesia and method of choice during elective C-section.

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Background Satisfaction for patients and surgeons during the perioperative functional endoscopic sinus surgery (FESS) remains an anesthetic challenge. We compared FESS under local anesthesia (LA) with monitored anesthesia care (MAC) and LA after induction of general anesthesia. Patients and methods One hundred patients scheduled for FESS were randomly recruited in this randomized controlled study. Fifty of them received LA after induction of general anesthesia (G group), while the rest of the patients received LA with MAC (M group). The outcome measures included satisfaction for the patient and surgeon, cost, surgical, and postoperative profiles. Results Surgeon’s satisfaction was comparable in both groups, while patient’s satisfaction was significantly higher in the M group (P<0.001). Total operative time and time to postanesthetic care unit discharge were significantly shorter in the M group (70.65±4.3 and 13.3±2 vs. 95.8±4.4 and 47.3±5.8 min in the G group, respectively; P<0.001). Time to home discharge was also shorter in the M group (66.0±23.78 vs. 262.20±11.8 min in the G group; P<0.001). The overall costs were significantly lesser in the M group (234.0±5.3 vs. 836.15±41.25 Egyptian pounds in the G group; P<0.001). Conclusion In FESS, LA with MAC provided excellent patient’s experience with optimum surgical and postoperative profiles and lower cost.

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Background Children with cerebral palsy lack the luxury of self-reporting their pain postoperatively. The revised FLACC (Face, Leg, Activity, Cry, and Consolability) pain scale is a behavioral pain assessment tool that is universally accepted for use in children with cognitive dysfunction. Objective The aim of this study was to cross-culturally adapt and evaluate the validity and reliability of the Egyptian version of the revised FLACC (r-FLACC) scale for use in postoperative pain assessment in children with cerebral palsy. Patients and methods The study was carried out in Ain Shams University Pediatric Hospital on 30 children with cerebral palsy aged 3–12 years scheduled for open Nissen fundoplication. Pain was assessed at baseline, on arrival to postanesthesia care unit, and 30 min after administration of analgesia using the r-FLACC scale (by two independent caregivers) and the visual analog scale (by the child’s parent). Results The r-FLACC scores increased postoperatively and decreased after administration of analgesia (P<0.001) supporting good construct validity. Criterion validity was acceptable in view of the positive correlations between r-FLACC scores and visual analog scale scores provided by the parents (P<0.001). Moderate to significant correlations between observers for total r-FLACC scores (P<0.001), and good agreements for each of the five categories of the r-FLACC scores at baseline (k=0.422–0.627), in postanesthesia care unit (k=0.531–0.737), and after administration of analgesia (k=0.683–0.783) reflected strong inter-rater reliability. Conclusion The Egyptian version of the r-FLACC scale is a valid and reliable tool for postoperative pain assessment in Egyptian children with cerebral palsy.

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Background Pain due to advanced pelvic cancer is a common and disabling complain. This study compared the safety and efficacy of the ultrasound (US)-guided anterior approach of superior hypogastric plexus (SHP) neurolysis with the fluoroscopy-guided posterior approach in the management of patients with intractable pelvic cancer pain. Patients and methods A total of 30 patients with advanced-stage pelvic cancer were enrolled and divided into two equal groups. The first group was named group F, which included 15 patients in whom SHP block was performed with the fluoroscopy-guided posterior oblique technique. The second group was named group U, which included 15 patients in whom the SHP block was performed with the US-guided anterior approach. Visual analogue scale score, patient satisfaction score, and daily morphine consumption were assessed at the following time points: before the procedure and on day 1, 1 month, and 3 months after procedure. Any adverse effects of the procedure were also recorded. Results For both groups, visual analogue scale score and daily morphine consumption were significantly decreased at day 1, 1 month, and 3 months after procedure compared with before the procedure. Patient satisfaction score significantly improved at day 1, 1 month, and 3 months after procedure compared with before the procedure. Conclusion The present study demonstrated a comparable efficacy of the US anterior approach for SHP neurolysis in patients with advanced pelvic cancer pain with the standard, classic, fluoroscopic posterior technique.

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Background A painful stimulus can produce vasoconstriction and a decrease in perfusion index (PI). The visual analogue scale (VAS) is the most common pain assessment scale. However, it is affected by psychometric instability. This study was designed to evaluate the correlation between VAS as a subjective indicator of pain and PI as an objective indicator of pain. Patients and methods At postanesthesia care unit, a Masimo pulse co-oximetry perfusion index was attached to 70 adult patients of ASA I who underwent lumbar spine discectomy. At the time of the first request for analgesia (T1) VAS was recorded together with the PI, heart rate (HR), mean arterial blood pressure (MAP), peripheral oxygen saturation, and axillary temperature, following which analgesia was given. Thirty minutes thereafter (T2) second measurements for the mentioned parameters were taken. Results The PI was significantly higher at T2 than at T1 (mean increase% = 94.3 ΁ 82.7%). This increase was associated with a statistically significant decrease in VAS, HR, and MAP. The mean decrease% was 70.5 ΁ 19.88%, 11.1 ΁ 7.2%, and 3.96 ΁ 5.01% in VAS, HR, and MAP, respectively. This means that the PI increases with adequate relief from pain, as indicated by a decrease in VAS, HR, and MAP. A decrease in VAS was associated with an increase in PI, but the correlation was not statistically significant as the degree of the increase in PI in relation to the decrease in VAS was variable among patients. Conclusion PI can be added to other indicators of pain assessment in the postanesthesia care unit.

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Background Thyroid surgeries are widely performed nowadays as an ambulatory procedure; so, the use of regional block for postoperative analgesia has gained popularity. Bilateral superficial cervical plexus blocks (BSCPB) alone or in combination with deep cervical plexus block are good examples. The duration of analgesia following these nerve blocks last for only a few hours. Patients and methods We randomly allocated 90 patients who are American Society of Anesthesiologists I or II scheduled for thyroid surgeries into three groups according to the contents of cervical block in addition to general anesthesia. Group C, which is the control group, received BSCPB with ropivacaine 0.2%. Group DB received BSCPB with ropivacaine 0.2% plus 8 mg dexamethazone. BSCPB with ropivacaine 0.2% plus 8 mg dexamethazone intravenously was given in group DI. Time to the first administration of supplemental analgesic postoperatively is our primary concern. Secondary outcomes include discharge time, rescue analgesic, rescue antiemetic, postoperative nausea or vomiting, pain score, and side effects of either block or drugs. Results Patients in group DB and DI need less postoperative rescue analgesic requirement than in the control group. Pain scores was statistically significantly less in group DB and in the DI group than in control groups at 6 and 8 h postoperatively. The occurrence of nausea and/or vomiting is statistically significantly less frequent in groups DB and DI when compared with the control group postoperatively. Conclusion The addition of dexamethasone to BSCPB resulted in decrease in time that elapsed until the first administration of supplemental analgesic, improved pain control, and reduced analgesic requirements postoperatively. This finding does not differ if dexamethazone is given either with block or intravenously.

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Introduction Analgesia in breast surgeries can be delivered orally, intravenously, intramuscularly, neuroaxially, or using regional nerve blocks. Pectoral nerve block (Pecs) and serratus intercostal plane block (SIPB) are a recently introduced ultrasound-guided technique for providing intraoperative and postoperative analgesia. Aim The aim of the present study was to compare intraoperative and postoperative analgesic effect of Pecs versus SIPB in breast surgeries. Patients and methods The current study was carried out on 60 female patients of American Society of Anaesthesiologists class I or II. The patients were undergoing nonreconstructive breast surgery. The patients were randomly divided into two equal groups. The Pecs group included 30 patients who received ultrasound-guided Pecs with 40 ml of levobupivacaine with adrenaline 1 : 200 000. The SIPB group included 30 patients who received ultrasound-guided SIPB with 40 ml of levobupivacaine with adrenaline 1 : 200 000. After assessing the efficacy of the block using sensory block scale, standard general anesthesia was induced in both groups using intravenous fentanyl (1 µg/kg), propofol (2.5 mg/kg) and cisatracurium (0.15 mg/kg). Results The completion of block was significant shorter in SIPB group than Pecs group. The duration of paresthesia in the SIPB group extended to 8 h postoperatively, whereas in the Pecs group the duration extended to 3 h postoperatively. Visual analog scale at rest and in movement was significantly higher in the Pecs group compared with the SIPB group. The number of patients who received postoperative fentanyl was significantly increased in the Pecs group than in the SIPB group. The first request for postoperative fentanyl was significantly delayed in the SIPB group than in the Pecs group. There was no significant difference in the total dose of fentanyl consumption during 24 h postoperatively between the two groups. Conclusion The present study found that SIPB provided superior postoperative analgesia compared with Pecs in patients undergoing nonreconstructive breast surgeries.

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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.

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Background The term chronic pain refers to pain in and around the area of surgery lasting beyond 3 months after surgery when all other causes of pain, such as recurrence, have been ruled out. Persistent pain after treatment has a considerable negative influence on quality of life in breast cancer survivors. Patients and methods Sixty female patients were enrolled for ultrasound-guided modified pectoral block. They were randomly assigned into two groups of 30 patients each: group C was administered 30 ml saline, and group BD was administered 30 ml 0.5% bupivacaine with dexmedetomidine 1 μg/kg. Pectoral block II was performed with ultrasound preoperatively and general anesthesia was induced after 15 min of assessment of the block in both groups. Patients were assessed for acute pain, chronic pain, and patient satisfaction. Results A total of 60 female patients were randomized into two groups: group C (the control group) and group BD (the bupivacaine–dexmedetomidine group). Group BD showed highly significant reduction in intubation heart rate, intubation mean arterial blood pressure, intraoperative heart rate, intraoperative mean arterial blood pressure, and total fentanyl dose (μg) (76.1 ± 5.3 vs. 82.9 ± 4.6, P = 0.00007**; 75.2 ± 2.8 vs.77.5 ± 3.9, P = 0.01*; 76.2 ± 5.3 vs. 88.9 ± 6.3, P = 0.00**; 71.6 ± 8.06 vs.78.2 ± 7.03, P = 0.001**; and 107.76 ± 11.77 vs. 150.83 ± 26.6, P = 0.00**, respectively). Follow-up of patients for 6 months regularly for chronic pain, satisfaction, and need for analgesics revealed significant differences at 1 month, 3 months, and 6 months in group C in relation to group BD [1 month, 7 (23.3%) vs. 3 (10%) with P = 0.02*; 3 months, 11 (36.6%) vs. 6 (20%) with P = 0.03*; and 6 months, 16 (53.3%) vs. 8 (26.6%) with P = 0.002*]. Conclusion Reduced visual analogue scale was seen at the first 24 h postoperatively, with significant reduction in total postoperative analgesia and delayed rescue analgesia in the bupivacaine dexmedetomidine group (the BD group) in relation to the control group. This marked reduction in the severity of postoperative pain correlates with reduced chronic pain on follow-up of our patients with patient satisfaction, good sleep, and reduced analgesic need, which improves quality of life.

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Background and objectives Sugammadex is a novel neuromuscular reversal drug. The recommended dose for sugammadex is 2 mg/kg. For morbidly obese patients, the calculation of an appropriate sugammadex dose is problematic. The aim of this study was to compare the reversal of rocuronium-induced neuromuscular blockade in morbidly obese patients using three doses of sugammadex; based on ideal body weight (IBW), adjusted body weight, and actual body weight. Patients and methods Sixty patients scheduled for laparoscopic bariatric surgery in Ain Shams University Hospital were enrolled into this prospective randomized study. At the end of the surgery, patients received sugammadex only when train of four response reached second twitch. According to their randomization, group A received sugammadex at a dose of 2 mg/kg for an IBW. Group B received sugammadex at a dose of 2 mg/kg for adjusted body weight, and group C received sugammadex, at a dose of 2 mg/kg for actual body weight. Time from administration of sugammadex to train of four ratio more than or equal to 0.9 was measured. Results Mean reversal time was 176.30±5.44 s in group A and decreased to 141.85±5.184 s in group B, and decreased again to 137.9±3.307 in group C. Pairwise comparisons between each of the two groups revealed that the decrease in reversal time from group A to group B, and from group A to group C were statistically significant. However, the decrease in reversal time from group B to group C was not statistically significant. Conclusion This study demonstrated that there was a statistically significant difference with respect to reversal time for sugammadex in morbidly obese patients, when given based on IBW versus adjusted body weight, and when given based on IBW versus actual body weight. However, there was no statistically significant difference with respect to reversal time for sugammadex, when given based on adjusted body weight versus actual body weight.

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Background and objectives Hypotension after spinal anesthesia is still widespread in cesarean delivery, especially in pregnant women with short stature. The use of a reduced dose of local anesthesia allows adequate spinal anesthesia with minimal hypotension. We investigate the lowest dose of heavy bupivacaine that can be used to reduce the frequency of hypotension associated with adequate spinal anesthesia in short stature pregnant female individuals undergoing cesarean section. Patients and methods Sixty women scheduled for cesarean section were divided into three groups of patients (20 in each group) receiving spinal injections of 0.04 mg heavy bupivacaine/cm height (group A), 0.05 mg heavy bupivacaine/cm height (group B), and 0.06 mg heavy bupivacaine/cm height (group C). A decrease in systolic pressure greater than 20% of the baseline was considered low blood pressure and was treated with a bolus of 5–10 mg intravenous ephedrine. The quality of surgical anesthesia was assessed among groups. Results Groups B and C were assigned a higher sensory level block than group A after spinal anesthesia, and the difference was statistically significant (P<0.05). In group C, 18 (90%) patients developed a complete motor block, while in group B, 16 (80%) patients developed a complete motor block, compared with patients of group A in which only four (20%) patients developed complete motor block, and the difference between groups was statistically significant (P<0.05). The spinal block resulted in excellent surgical anesthesia in groups B and C compared with group A. Patients in group C were more likely to develop hypotension than patients in groups B and A. There was no significant statistical difference between the groups as regards neonatal outcome. Conclusions This study showed that the use of spinal anesthesia in pregnant women of short stature using heavy bupivacaine at a concentration of 0.05 mg/cm body weight showed a clear benefit in terms of adequate anesthesia and stable hemodynamics.

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Background Airway management remains a vital primary skill for anaesthesiologists. We aimed at comparing the efficacy of direct laryngoscopy using the conventional Macintosh blade with indirect laryngoscopy using the King Vision video laryngoscope (KVVL) with regard to visualization of the laryngeal view, speed of intubation and intubation success rate. Patients and methods A total of 100 adult patients were randomly categorized into two equal groups (50 patients each): group M patients were subjected to general anaesthesia with endotracheal intubation using direct laryngoscopy with the conventional Macintosh blade; and group K patients were subjected to general anaesthesia with endotracheal intubation using the KVVL; the entire procedure of laryngoscopy and intubation was evaluated and all patients were intubated by one anaesthetist experienced in the use of each laryngoscope. Results The KVVL performed better in these patients by reducing haemodynamic response to laryngoscopy and intubation, improving the Cormack and Lehane glottis view, reducing the need for optimization manoeuvres and reducing the difficulty Likert scale score compared with the Macintosh laryngoscope (ML). There were no differences in intubation time, success rates and complications between both devices. Conclusion This study validated the efficacy of the KVVL compared with the direct ML. The KVVL performed better than the ML.

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Introduction All anesthetic methods have been used for inguinal hernia repair surgeries. The use of local anesthesia (LA) techniques such as the ilioinguinal iliohypogastric nerve block (IHNB) may be the most convenient method for patients who are unfit for general anesthesia or spinal anesthesia (SA). The use of ultrasound (US)-guided techniques increases the success rate of the IHNB. The use of intravenous sedation increases the acceptability of LA techniques. Aim The aim of this study was to evaluate the effectiveness, safety, and complications of US-guided IHNB and genital branch of genitofemoral nerve (GF) block in comparison with SA for inguinal hernia repair surgeries. Patients and methods The current study was carried out on 42 patients of American Stroke Association classes I and II. Patients with recurrent, bilateral, irreducible, or large scrotal hernias were excluded. The patients were randomly divided into two equal groups using the closed envelope method, groups 1 and 2. Group 1 included 21 patients who were anesthetized using US-guided IHNB with 25 ml of 0.5% isobaric bupivacaine and genital branch of GF nerve block with 10 ml of 0.5% isobaric bupivacaine. Group 2 included 21 patients who received SA using 3 ml of 0.5% hyperbaric bupivacaine and 25 μg fentanyl. All patients received sedation as continuous propofol infusion. The propofol infusion dose was titrated until the sedation score was 4 using Ramsay Sedation Score. Result Patients receiving IHNB had better hemodynamic stability when compared with the SA group. The total postoperative analgesia was significantly lower and the first dose of postoperative analgesia was significantly delayed in the IHNB group. Postoperative ambulation was significantly early in the IHNB group. Conclusion US-guided IHNB and genital branch of GF nerve block under sedation are good anesthetic techniques for inguinal hernia repair surgeries.

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Background Surgeries that require the patient to be in the prone position represent a challenge to the anesthesiologist in terms of securing the airway and additional time and personnel required for induction in the supine position and shifting to the prone position. Use of the classic laryngeal mask airway (LMA) in the prone position is a subject of controversy; the ProSeal LMA may be more suitable as it forms a better seal and provides access to the stomach. LMA Supreme is a newly introduced single-use supraglottic device that shares common features of both the LMA ProSeal and the intubating LMA. Aim of this study The aim of the study was to compare the use of LMA ProSeal and LMA Supreme after induction of anesthesia in the prone position. Patients and methods The study included 80 adult male patients for pilonidal sinus excision surgery. They were randomly divided into two equal groups: group P and group S. The ProSeal was used in group P and the Supreme was used in group S. Ease of insertion, ease of ventilation, leakage of inspiratory gases, SpO ₂ , EtCO ₂ , blood on the airway device after removal, and postoperative incidences of sore throat were recorded. Results There was no statistical difference between the two groups in terms of age, BMI, or duration of surgery. Both devices provided good air seal and good ventilation. Blood-stained saliva and postoperative sore throat were found more with ProSeal use than with Supreme. Conclusion Allowing the patients to take the prone position themselves and then inducing general anesthesia and securing the airway either with ProSeal or with Supreme is a safe practice.

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Introduction This study was carried out to compare the effi cacy of the dexmedetomidine– lidocaine combination with each drug alone in suppressing the hemodynamic and catecholamine stress responses during tracheal extubation and emergence from general anesthesia. Patients and methods Sixty hypertensive patients (ASA II– III), defi ned as systolic blood pressure more than 160 mmHg and/or diastolic blood pressure more than 95 mmHg, undergoing elective surgery were assigned to a randomized, double-blind approach and were divided into three equal groups: group D received 0.25 mg/kg dexmedetomidine intravenously, group L received 1.0 mg/kg lidocaine intravenously, and group DL received dexmedetomidine plus lidocaine at the same doses intravenously 2 min before tracheal extubation. Changes in heart rate, mean arterial pressure, rate– pressure product, and plasma catecholamine levels were measured before and after tracheal extubation. Results It was found that heart rate, mean arterial pressure, and rate– pressure product following tracheal extubation were lower in patients receiving the dexmedetomidine– lidocaine combination than in those receiving dexmedetomidine or lidocaine as a sole drug. In addition, catecholamine concentrations increased significantly after extubation (P < 0.05) in the three groups, with no signifi cant difference between them. Also, the tracheal extubation score was lower in groups L and DL compared with group D. Conclusion Although dexmedetomidine, lidocaine, or their combination failed to suppress the catecholamine responses to tracheal extubation and emergence from anesthesia, the dexmedetomidine– lidocaine combination was superior to each drug alone in attenuating the cardiovascular changes in hypertensive patients.

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Background Opioids have been used as an adjunct to bupivacaine in spinal blockade to enhance the onset of action, to improve the quality of intraoperative and postoperative analgesia, and to increase the duration of block. Fentanyl is a synthetic opioid agonist and nalbuphine is a synthetic opioid agonist-antagonist. The present study aimed to compare the effects of adding nalbuphine or fentanyl as an adjunct to bupivacaine on the characteristics of spinal blockade, quality of postoperative analgesia, and on fetomaternal outcome after elective cesarean section. Participants and methods A total of 80 full-term parturients scheduled for elective cesarean section were randomly allocated into two groups. Nalbuphine group (BN group) included parturients who received 12.5 mg of 0.5% hyperbaric bupivacaine with 800 μg nalbuphine intrathecally. Fentanyl group (BF group) included parturients who received the same dose of hyperbaric bupivacaine with 25 μg fentanyl intrathecally. Subarachnoid blockade characteristics, duration of postoperative analgesia, the amount of postoperative analgesic requirements, maternal adverse effects, and neonatal outcome were compared. Results Onset of sensory and complete motor block, maximum height of sensory block, and time to two-segment sensory regression were significantly faster in BF group than in BN group. Maximum dermatomal block level was significantly higher in BF group than in BN group. The duration of motor block and the quality of anesthesia of both groups were comparable. Durations of postoperative complete and effective analgesia were highly significantly longer in BN group than the corresponding durations in BF group (P<0.001 and 0.002, respectively). The postoperative 24-h analgesic doses of ketorolac and pethidine were less in BN group than in BF group (P=0.03, 0.005, respectively). There was no pruritus in BN group (0%), but it occurred in five (12.5%) parturient in BF group, which was mild. The incidence of shivering was significantly lower in BN group (7.5%) than in BF group (27.5%) (P=0.01). Neonatal APGAR (Airway, Pulse, Grimace, Activity, Respiration) score and neurologic and adaptive capacity score were comparable between the two groups. Conclusion As an adjunct to hyperbaric bupivacaine in spinal block, fentanyl was superior to nalbuphine in enhancing the onset of both sensory and motor block. Nalbuphine is superior to fentanyl in increasing the duration of postoperative complete and effective analgesia and in decreasing incidences of pruritus and shivering, and both drugs have similar effects on neonatal APGAR score and neurologic and adaptive capacity score.

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Background In recent years, the use of intrathecal adjuvants has gained popularity. The quality of spinal anesthesia has been reported to improve with the addition of opioids and other drugs, but until now there is no single drug with no side effects. The aim of this study was to compare the addition of either dexmedetomidine or fentanyl to intrathecal bupivacaine as regards the onset and duration of sensory and motor block, hemodynamic effects, postoperative analgesia, and adverse effects of either drug. Materials and methods Sixty patients classified in American Society of Anesthesiologists as classes I and II scheduled for lower abdominal and lower limb surgeries were studied. Patients were randomly allocated to three groups (20 patients each): group B, group F, and group D. Group B patients received 3 ml (15 mg) of 0.5% hyperbaric bupivacaine plus 0.5 ml of normal saline intrathecally. Group F patients received 3 ml (15 mg) of 0.5% hyperbaric bupivacaine plus 0.5 ml (25 μg) of preservative-free fentanyl intrathecally. Group D patients received 3 ml (15 mg) of 0.5% hyperbaric bupivacaine plus 0.5 ml (5 μg) of diluted, preservative-free dexmedetomidine intrathecally. Results Patients in the dexmedetomidine group (D) had faster sensory and motor onsets compared with those in the fentanyl group (F) and the bupivacaine group (B) (P = 0.000 for both sensory and motor). Patients in group D had significantly longer sensory and motor durations compared with those in groups F and B (P = 0.000). Patients in the dexmedetomidine group (D) did not have significant hemodynamic changes; they had prolonged analgesic effect with less 24 h requirements of analgesics, and they had nonsignificant adverse effects. Conclusion Dexmedetomidine has faster onset compared with fentanyl and bupivacaine when injected intrathecally along with bupivacaine; it prolonged the sensory and motor blocks and was hemodynamically stable, with no significant side effects and with less requirements of postoperative analgesic needs during the first 24h.

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Background Airway management remains an important problem in the practice of anesthesia. The present study was carried out to compare intubating laryngeal mask airway (ILMA) and air-Q for blind tracheal intubation during surgical procedures under general anesthesia. Materials and methods This study was carried out on 70 adult patients scheduled for elective surgical procedures under general anesthesia with controlled ventilation such as gynecological, orthopedic, ophthalmic, or general surgery lasting up to 2 h. Data were collected on airway assessment, hemodynamic changes, insertion time of the device and the endotracheal tube, number of attempts of blind tracheal intubation, ease of insertion, and complications. Results Airway assessment parameters were similar in patients of both groups. The incidence of hemodynamic changes was significantly higher in the air-Q group than the fastrack group and the insertion time of the endotracheal tube as well as the percentage of ease of insertion in group I (fastrack) showed a statistically significantly higher value than group II (air-Q). However, there was no statistically significant difference between the two groups in the number of insertion attempts (a success rate of 88.57% for the fastrack vs. a success rate of 82.86% for the air-Q) and the complications. Conclusion Both the fastrack and the air-Q are suitable devices for blind tracheal intubation. The fastrack has a higher success rate in terms of blind tracheal intubation than the air-Q.

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Aims This study was carried out to compare the efficacy of the C-MAC D-blade with the McCoy laryngoscope in intubating patients during cervical spine immobilization. Patients and methods This randomized controlled study was carried out in the Medical Research Institute Hospital, University of Alexandria, on 60 adult ASA I and II patients who were randomly categorized into two equal groups after written informed consent and approval of the ethics committee. All patients were subjected to the same anaesthetic protocol. Group I patients were intubated using the C-MAC D-blade laryngoscope, and group II patients were intubated using the McCoy laryngoscope. Haemodynamic measurements and oxygen saturation were recorded. The following intubation criteria were recorded for both groups: laryngeal view according to modified Cormack and Lehane grade at laryngoscopy, duration of the intubation procedure, number of intubation attempts and complications. Statistical analysis Data were statistically analysed with the SPSS software using t-test and χ²-test, and P value less than 0.05 was considered significant. Results Haemodynamic parameters (heart rate and mean arterial blood pressure) were significantly lower in the C-MAC D-blade group than in the McCoy group until 4 min after intubation. Oxygen saturation showed no significant difference between the two groups. The use of the C-MAC D-blade resulted in more appearance of modified C–L class 1, whereas the use of the McCoy laryngoscope resulted in more appearance of class 2b and class 3. Duration of intubation was statistically significantly longer in the C-MAC D-blade group than in the McCoy group, whereas for the number of intubation attempts C-MAC D-blade results in more successful intubation in the first attempt than the McCoy laryngoscope. Conclusion The C-MAC D-blade laryngoscope offers a new approach for the management of difficult airway, such as in patients in need for cervical immobilization. It causes less haemodynamic stress, it better intubates in the first trial and gives a better view of the larynx without moving the cervical spine, but it may be more time-consuming than direct laryngoscopes.

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Different methods have been described for lung isolation in patients for thoracic surgery with tracheotomies. It is important to consider whether it is a fresh stoma or a chronic tracheostomy. We would like to describe the use of endobronchial blocker directed fibreoptically in a fresh tracheostomy as a simple and safe technique for one-lung ventilation without causing any trauma to the fresh stoma site.

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Peripheral arterial disease (PAD) is caused by atherosclerosis in the major extremity vessels. Incidence of PAD ranges from 3 to up to 20%. The most common symptom of the disease is intermittent claudication, mainly affecting the calf muscles. These patients usually present for surgeries extending from bypassing the blocked vascular segment to amputations. Successful outcome of these surgeries require a well-planned preoperative testing, controlled intraoperative environment and adequate postoperative management. We present an interesting case of a PAD patient who underwent a re-do surgery complicated by graft thrombosis, electrolyte disturbances and renal dysfunction, which, managed appropriately, resulted in best surgical outcomes.

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Background Brachial plexus block is a popular technique for surgery of the upper extremity. Supraclavicular approach is the most consistent method for surgery below the shoulder joint. Neostigmine is often used as an adjuvant for local anesthetics in regional anesthesia. Patients and methods Ninety-three patients of ASA physical status III with chronic renal failure were randomly allocated to three groups according to brachial plexus block solution. The control group received 20 ml of 0.5% bupivacaine added to 10 ml of normal saline solution and the two neostigmine groups received 250 and 500 μg of neostigmine (groups N₂₅₀and N₅₀₀, respectively). The block was performed guided by ultrasound. Patients were monitored in the operation theater for ECG, heart rate, respiratory rate, noninvasive blood pressure, and SpO₂. Characteristics of the blocks, duration of analgesia, and adverse effects were assessed. If the patient felt pain before or during surgery, the patient was excluded from study and additional lidocaine was used. Postoperative pain was assessed using the visual analogue scale. The postoperative rescue analgesic used was tramadol. Complications of brachial plexus block were reported. Results Patients showed no significant difference with respect to patients' age, sex, weight, and duration of surgery. The onsets of sensory and motor blockade were significantly shorter in patients receiving 500 μg neostigmine. The duration of sensory and motor blockade and hemodynamics were comparable in the three groups. The postoperative rescue analgesic requirement and mean pain score were significantly less in group N₅₀₀than in the N₂₅₀and control groups. Complications of the block did not vary among groups. Conclusion Addition of neostigmine to supraclavicular brachial plexus block in chronic renal failure patients has no effect on duration of block. However, 500 μg neostigmine resulted in rapid onset of sensory and motor blockade and enhancement of postoperative analgesia, with no significant side effects.

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Background The aim of this study was to compare between dexmedetomidine and morphine for use as sedative/analgesics and to evaluate their effects on surgical stress response during the first 24 h following open cardiac surgery in the Cardiac Intensive Care Unit (CICU). Patients and methods The present double-blind study was carried out on 30 adult patients 60 years of age or older admitted to the Cardiothoracic Surgery Department of the Alexandria Main University Hospital of ASA physical status grade II and III, scheduled for elective coronary artery bypass grafting surgery under general anesthesia. Immediately after sternal closure at the end of surgery, patients were classified randomly using the closed-envelope technique into two equal groups, started immediately on a continuous intravenous infusion (without a loading dose) of either dexmedetomidine or morphine and continued for 24 h postoperatively. Dexmedetomidine group (group D): dexmedetomidine was prepared at a concentration of 0.1 μg/kg/ml and was infused at a dose of 0.1-0.7 μg/kg/h (equivalent to an infusion rate of 1-7 ml/h). Morphine group (group M): morphine was prepared at a concentration of 10 μg/kg/ml and was infused at a dose of 10-70 μg/kg/h (equivalent to an infusion rate of 1-7 ml/h). Patients were followed up in the CICU for the first 24 h following open cardiac surgery on the basis of hemodynamic changes, plasma interleukin (IL)-6 and cortisol levels, time to successful tracheal extubation, postoperative pain, incidence of delirium, and postoperative nausea and vomiting. Results The mean heart rate values were significantly lower in group D compared with group M during most of the postoperative period. The mean values of systolic blood pressure, diastolic blood pressure, and mean arterial pressure, on comparing the two groups, had showed no statistically significant difference during the entire postoperative period. The mean values of IL-6, cortisol, and glucose were increased significantly in group M relative to group D at 6 and 24 h postoperatively. Time to successful tracheal extubation was significantly shorter in patients of group D than in patients of group M. Visual analogue scale for pain score and Motor Activity Assessment Scale for sedation score showed no significant difference when both groups were compared during the entire postoperative period. The total number of patients with delirium was significantly fewer in group D than group M. The incidences of nausea and vomiting events were insignificantly lower in group D than group M. Conclusion The administration of dexmedetomidine exerted a potent negative chronotropic effect with decreased heart rate. Both dexmedetomidine and morphine equivalently decreased the blood pressure (systolic blood pressure, diastolic blood pressure, and mean arterial pressure) in a range of 15-20% in relation to the preoperative readings. Dexmedetomidine significantly attenuated the surgical stress response and the neuroendocrine response in comparison with morphine through the suppression of the postoperative increase of IL-6 and cortisol, respectively. Dexmedetomidine had promoted earlier recovery and tracheal extubation than morphine, with no accompanying respiratory depression. Both dexmedetomidine and morphine were efficient sedative/analgesics for postoperative cardiac surgery. Dexmedetomidine significantly reduced the incidence and duration of delirium after cardiac surgery.

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Background Levobupivacaine (chirocaine) is a long-acting amide local anesthetic that can be used in different applications like epidural, spinal, peripheral nerve, ocular block, topical application, and local infiltration. Clinical effects are comparable to those of bupivacaine or ropivacaine. Studies are needed on different adjuvants with levobupivacaine, such as dexamethasone and magnesium sulfate. Aim of this study The aim of the study was to compare the effect of adding either magnesium sulfate or dexamethasone to levobupivacaine in supraclavicular brachial plexus block. Materials and methods Sixty adult patients presented for upper-limb surgery under supraclavicular brachial plexus block using ultrasound. The patients were randomly arranged into two equal groups: magnesium sulfate was added to levobupivacaine in one group and dexamethasone was added in the other group. Duration of postoperative analgesia was recorded. Results There was no statistically significant difference in the duration of postoperative analgesia between the two groups. Conclusion There is no preferential difference in postoperative analgesia between dexamethasone and magnesium sulfate when added to levobupivacaine

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