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ORIGINAL ARTICLES
A prospective randomized comparative pilot trial on extended daily dialysis versus continuous venovenous hemodiafiltration in acute kidney injury after cardiac surgery
Sahar S.I. Badawy, Amira R Hassan, Enas M Samir
July-December 2013, 7(2):69-73
DOI:10.4103/1687-9090.124035  
Background and objectives Acute kidney injury (AKI) requiring dialysis after cardiac surgery is accompanied by high mortality. Continuous venovenous hemodiafiltration (CVVHDF) and extended daily dialysis (EDD) are commonly used for critically ill patients with AKI. The aim of this prospective randomized comparative pilot trial was to compare the efficacy of CVVHDF and EDD in patients with AKI after cardiac surgery. Patients and methods A total of 80 patients who developed AKI and who needed renal replacement therapy (RRT) after cardiac surgery were included in this prospective randomized comparative trial. Patients were randomized to receive either CVVHDF or EDD. The outcomes assessed were renal recovery, mortality rate at day 30, and cost of RRT in the ICU. Results Both groups were comparable with respect to demographic data and APACHE II score. The frequencies of renal recovery and mortalities were comparable in both groups. The cost of RRT was significantly lower in the EDD group compared with the CVVHDF group (P < 0.001). Conclusion Both CVVHDF and EDD are effective in patients with AKI after cardiac surgery, with EDD having the advantage of lower cost.
  8 3,484 354
Ascorbic acid versus magnesium for the prevention of atrial fibrillation after coronary artery bypass grafting surgery
Abdelhay Ebade, Walid S Taha, Riham H Saleh, Ashraf Fawzy
July-December 2014, 8(2):59-65
DOI:10.4103/1687-9090.143259  
Objective The aim of the study was to evaluate the prophylactic use of ascorbic acid or magnesium on frequency of postoperative atrial fibrillation (POAF) in patients undergoing coronary artery bypass grafting surgery with cardiopulmonary bypass. Patients and methods The study included 60 patients divided into three equal groups (n = 20): the control group (group C) received saline infusion, the magnesium group (group M) received 2 g magnesium sulfate after induction of anesthesia, 1 g after 12 h followed by 1 g/8 h daily until the fifth postoperative (PO) day and the ascorbic acid group (group A) received 2 g ascorbic acid after induction of anesthesia, then 1 g after 12 h followed by 1 g/8 h daily until the fifth PO day. Operative and PO data were recorded. Primary endpoint was detection of an episode of atrial fibrillation (AF) lasting more than 10 min or the requirement for urgent intervention due to AF. Results Sixteen (26.7%) patients developed POAF, eight (40%) patients in group C, five (25%) in group M, and three (15%) in group A, with significantly higher frequency in group C compared with group M (P1 = 0.041) and group A (P2 = 0.001) but with nonsignificantly (P3 = 0.083) higher frequency in group M compared with group A. Four patients developed POAF on the first and 12 patients on the second PO day with nonsignificant intergroup difference. The mean duration of ICU stay was significantly longer in group C compared with groups M (P1 = 0.016) and A (P2 = 0.006), with nonsignificantly (P3 = 0.480) longer duration in group M compared with group A. The mean duration of PO hospital stay was significantly longer in group C compared with groups M (P1 = 0.008) and A (P2 = 0.004), with nonsignificantly (P3 = 0.415) longer duration in group M compared with group A. Conclusion Prophylactic use of ascorbic acid or magnesium significantly reduced the frequency of POAF after coronary artery bypass grafting surgery and significantly reduced ICU and hospital stay.
  6 2,840 307
Ketamine/propofol (ketofol) versus propofol/fentanyl for induction of general anesthesia in parturients with rheumatic valvular lesions undergoing elective cesarean section
Nashwa Samy ELZayyat, Amira Refae Hassan, Ahmed Ibrahim ELSakka, Ahmed Hussein Saad
July-December 2013, 7(2):79-84
DOI:10.4103/1687-9090.124041  
In this study, we assumed that the addition of ketamine to propofol (ketofol) would maintain cardiac stability in parturients with valvular heart without any deleterious effect on the fetus, that is no respiratory depression for the baby and hence a better Apgar score. This open-label randomized study was carried out in the High-risk Obstetric Unit, Cairo University Hospitals, in collaboration with the Anesthesia Department. The study included full-term parturients, 36-38 weeks' gestational age, 25-40 years old with severe rheumatic valvular heart lesions (mitral stenosis, mitral regurge, aortic stenosis, aortic regurge) of functional class II or III according to the New York Heart Association Classification. At the time of induction, patients were allocated randomly to one of the two study groups: group K (n = 25) received intravenous ketamine 1 mg/kg combined with propofol 1 mg/kg. Group P (n = 25) received propofol 2 mg/kg and fentanyl 2 mg/kg. Mean arterial blood pressure (MAP), heart rate (HR), and central venous pressure were recorded at the following times:T1, T2, T3, T4, T5, and T6. Decrease in MAP was only significant in group P (P < 0.001 at T2 and T3). The magnitude decreases in MAP. The absolute value of MAP was significantly lower in group P after induction, intubation, and skin incision. The median decrease in MAP was significantly higher in group P after induction and intubation. HR increased significantly after induction of anesthesia and after endotracheal intubation in the two groups. It reverted to near baseline values thereafter. The magnitude decreases in HR. The absolute value of HR was significantly lower in group P after intubation and skin incision. Apgar scoring was significantly better (higher) in the ketofol group at 1 and 5 min. We can conclude that a combination of ketamine and propofol seems to be an appropriate choice for anesthesia of critically ill rheumatic cardiac parturients undergoing cesarean section. It proved to be effective and hemodynamically safe for such a critical situation.
  2 4,335 405
Prophylactic use of a preoperative intra-aortic balloon pump in patients with severe left ventricular dysfunction undergoing coronary artery bypass grafting
Imran Khan, Hadia M Mian, Madiha Iqbal, Hira Ijaz, Zafar Tufail
September-December 2014, 8(3):97-100
DOI:10.4103/1687-9090.153411  
Objective The aim of this work was to study the effectiveness of preoperative intra-aortic balloon pump (IABP) in patients with severe left ventricular dysfunction undergoing coronary artery bypass grafting (CABG). Materials and methods We studied 80 consecutive patients of both sexes undergoing elective on-pump CABG having an ejection fraction less than 30%. Thirty patients received preoperative IABP support prophylactically, whereas 50 patients did not. The decision to put an IABP was made by the individual surgeon operating the patient. Preoperative, intraoperative, and postoperative variables were recorded and 30 days' follow-up was obtained. Results were subjected to statistical analysis. Results Fifty one patients (63.7%) were male while 29 (36.25%) were female with a mean age of 55.62 ΁ 9.65 years. Patients who received preoperative IABP had high in-hospital mortality (P = 0.002) and decreased rate of postoperative acute kidney injury (P = 0.048), ICU stay (P = 0.031) and less requirement for postoperative inotropic support (P = 0.047) compared to those who did not receive IABP preoperatively. Conclusion The prophylactic use of IABP in patients with a low ejection fraction undergoing CABG does not decrease the mortality, but it has a favorable effect on postoperative major complications.
  2 2,674 1,888
Comparison of the cardioprotective effect of isoflurane versus sevoflurane during cardiopulmonary bypass in congenital heart surgery
Passaint Hassan
January-April 2015, 9(1):1-7
DOI:10.4103/1687-9090.160325  
Aims This study aimed to detect the difference in the preconditioning effect between isoflurane and sevoflurane when they are used just before aortic cross-clamp and continued throughout the bypass period by measuring cardiac troponin I (cTnI) in the postbypass period. Settings and design This individual closed-envelope randomization study was carried out in the Abou Ell-Resh Pediatric Hospital, Cairo University Unit of congenital heart surgery in collaboration with the anesthesia department. The study was approved by the local ethical committee and a written informed consent was obtained from the guardians of the patient. This study was carried out from March 2011 to September 2012 (18 months). Patients were allocated randomly to two equal groups of 30 patients each. Participants and methods Acyanotic and cyanotic patients were allocated randomly to two equal groups of 30 patients each using individual closed-envelope randomization. Patients were allocated randomly to two equal groups as follows: group I, isoflurane group (n = 30) (received isoflurane) and group S, sevoflurane group (n = 30) (received sevoflurane). cTnI, a baseline sample was obtained before cardiopulmonary bypass (T0), 8 h after bypass (T8), and 24 h after bypass (T24). Parametric data were described as mean, SD, median, and SEM. The two groups studied were compared using Student's t-test. Repeated measures of the same group were compared using two-way analysis of variance, followed by post-hoc Tukey's comparison tests. For nonparametric data, nonparametric tests were used for comparison such as the Mann-Whitney U-test, median, or quartiles. P value less than 0.05 was considered significant (size estimation with two means is 28). Results Comparison of sevoflurane and isoflurane acyanotic cases showed that the cTnI (P = 0.02 and 0.01, respectively). Comparison of isoflurane and sevoflurane cyanotic cases showed that the cTnI values 8 and 24 h after bypass were higher in cyanotic cases of the isoflurane group than those of the sevoflurane group, but the difference was statistically insignificant. In terms of the difference between cyanotic and acyanotic cTnI results in the isoflurane group, cTnI values 8 h after cardiopulmonary bypass were higher in cyanotic cases compared with acyanotic cases, but this difference was insignificant, with a P value of 0.42. At 24 h after CPB, cTnI values were significantly higher in cyanotic cases with a P value of 0.015. In terms of the difference between cyanotic and acyanotic cTnI results in the sevoflurane group, the cTnI level 8 h after CPB was significantly higher in cyanotic cases compared with acyanotic cases with a P value of 0.001; it was also significantly higher in cyanotic cases 24 h after CPB with a P value of 0.005. Conclusion The present study showed that sevoflurane is superior to isoflurane in myocardial protection in surgical correction of congenital heart diseases only in acyanotic cases, with no difference in cyanotic cases.
  2 2,394 273
A prospective randomized comparative study between Macintosh and GlideScope in adult patients undergoing cardiac surgery
Rabie Soliman, Mohammed Mofeed, Osama Alamoudy, Abeer Farouk
January-April 2015, 9(1):8-13
DOI:10.4103/1687-9090.160326  
Context The GlideScope laryngoscope is a new device for intubation that provides an improved view of the larynx. Aim The aim of the study was to compare the hemodynamic effect of Macintosh laryngoscope with GlideScope during intubation in adult cardiac surgery. Setting and design This was a prospective, randomized, comparative study conducted in Madinah Cardiac Center, Saudi Arabia. Materials and methods The study included 100 patients classified into two groups (n = 50), The patients were intubated either by Macintosh laryngoscope or by GlideScope. The following parameters were monitored: heart rate, mean arterial blood pressure, catecholamine level, intubation time, number of intubation trials, and the complications. Statistical analysis used Data were statistically described in terms of mean ΁ SD or frequencies. Measurements and main results The intubation time was longer in GlideScope than in Macintosh (P < 0.001), and the number of intubation trials was higher in GlideScope than in Macintosh (P < 0.001). The heart rate increased significantly in patients of the GlideScope group compared with the Macintosh group at first minute (P < 0.001), third minute (P < 0.001), and at fifth minute (P = 0.034). The mean arterial blood pressure increased significantly in patients of the GlideScope group compared with the Macintosh group at first minute (P < 0.001), third minute (P = 0.003), and at fifth minute (P = 0.029). The epinephrine level was higher with GlideScope at first and fifth minute (P = 0.032 and 0.036, respectively). The norepinephrine was higher in the GlideScope group at first and fifth minute (P = 0.043 and 0.033, respectively). The incidence of oral trauma and bleeding was higher with GlideScope than Macintosh (P = 0.003). Conclusion The intubation by GlideScope is associated with increased heart rate, blood pressure, catecholamine level, number of intubation trials, and oral complications compared with Macintosh laryngoscope.
  2 1,977 240
Is this the time to introduce ketamine in acute respiratory distress syndrome? A pilot study
Radwa A Elhefny, Mohamed Elsonbaty, Sherif Nassib, Mohamed Mansour
May-August 2015, 9(2):23-28
DOI:10.4103/1687-9090.165160  
Introduction Acute respiratory distress syndrome is regarded to be an acute, diffuse inflammation of the lung that leads to an increase in the permeability of the pulmonary vascular tissue. The relations between ARDS classes and the permeability of the pulmonary microvasculature as well as the water content of the pulmonary extravasculature remains to be clarified. The anti-inflammatory and the antioxidant properties of ketamine were observed in acute lung injury; ketamine promotes the attenuation of the expression of mediators of inflammation. The aim of the work The aim of this study was to test whether ketamine treatment by the inhaled route or the infusion route could be an efficient method of treatment for ARDS. Participants and methods Mechanically ventilated critically ill adult trauma patients admitted to the ICU with developing ARDS were eligible to participate in this study. Group A was treated by ketamine inhalation, group B was treated with ketamine infusion, and group C was treated by pulse steroid therapy. The serum interleukin-6 level was analyzed. Results Concerning group A (ketamine inhalation) and group B (ketamine infusion), there were significant correlations in both the groups starting from day 2 till day 5 of treatment with regard to the tidal volume and positive end-expiratory pressure and from day 3 of treatment with regard to the blood pressure and FiO 2 .
  2 4,544 396
Protamine adverse reactions in NPH insulin treated diabetics undergoing coronary artery bypass grafting
Hoda Shokri, Ihab Ali, Hoda M El Sayed
July-December 2016, 10(2):25-30
DOI:10.4103/1687-9090.192251  
Background The routine use of protamine in cardiac surgery to neutralize heparin is usually associated with systemic reactions that result in substantial morbidity and mortality. Aim This study aimed to investigate the relationship between neutral protamine Hagedorn (NPH) insulin use and severe adverse reactions to intravenous protamine given after cardiopulmonary bypass. Methods After obtaining hospital ethics committee approval and after obtaining informed consent, 100 patients between 45 and 70 years of age of American Society of Anesthesiologist physical status II–III undergoing elective primary isolated coronary artery bypass grafting were included in this prospective study, which was conducted between May 2013 and June 2014. Patients were divided into two groups: the NPH group (50 patients), which included patients who were on NPH insulin preparation for more than 5 years before the study, and the non-NPH group (50 patients), which included patients on oral hypoglycemics. The incidence of protamine reactions was recorded for 30 min after protamine infusion. The incidence of severe hypotension, increased airway pressure, and cardiac arrest were compared using the χ2-test. A P value less than 0.05 was considered significant. Results All patients (50 in each group) completed the study. There was no significant difference in patients’ demographic data, preoperative comorbidities, and surgical factors between the two study groups. The number of patients who had hypotension was significantly higher in the NPH insulin group compared with the non-NPH group. For both groups, there was no significant difference with respect to bronchospasm, cardiac arrest, and increased pulmonary artery pressure. Conclusion This prospective study showed increased risk for hypotension among patients receiving NPH insulin for more than 5 years compared with those who were not exposed to NPH insulin.
  2 4,363 338
Licorice versus ketamine gargle for postoperative sore throat due to insertion of a double-lumen endobronchial tube
Ahmed Nabil Ibrahim, Sherif Anis
September-December 2016, 10(3):45-49
DOI:10.4103/1687-9090.200283  
Background Postoperative sore throat (POST) is common after tracheal intubation, especially with double-lumen endobronchial tube (DLT). Licorice has many uses such as dental hygiene and in sore throat. Ketamine gargle is a newly proposed adjunct for reducing the incidence of POST in anesthesia. The aim of this study was to determine the efficacy of licorice and ketamine gargles in patients undergoing the insertion of DLT in preventing POST within 24 h. Methods This prospective, randomized, double-blind study included 90 patients undergoing thoracic surgery requiring DLT for one-lung ventilation. Patients were randomized to three groups (n=30) and were asked to gargle for 1 min to 15 min before operations. Group A received ketamine gargle (0.5 mg/kg ketamine in 30 ml of dextrose water 20%), group B received licorice gargle (500 mg licorice powder in 30 ml of dextrose water 20%), and group C (the control group) received 30 ml of dextrose water 20% gargle. Assessment of patients for the incidence and the severity of POST and any side effect was carried out in the recovery room. Sore throat (yes/no) and severity of its pain measured using visual analogue scale were recorded at baseline in the recovery room and then at 2, 4, and 24 h after operation with a specified questionnaire. Results The incidence of sore throat was significantly higher in group C at all time points in comparison with the other two groups. There was a marked decrease in the incidence of sore throat in groups A and B, with no significant difference between them. The severity of POST pain was significantly higher in group C when compared with the other two groups, with no significant difference between them and with no complications. Conclusion Ketamine and licorice gargles decrease the incidence and severity of sore throat occurring postoperatively due to DLT intubation, with no significant differences between them.
  2 3,938 3,842
Transdermal nicotine patch as adjunctive analgesic modality to thoracic epidural analgesia for post-thoracotomy pain
Heba Ismail Ahmed Nagy, Hany Wafik ElKadi
July-December 2014, 8(2):75-82
DOI:10.4103/1687-9090.143268  
Objective The aim of the study was to evaluate the applicability of transdermal nicotine patch (TNP) as an analgesic modality adjunctive to thoracic epidural analgesia (TEA) for patients undergoing thoracotomy. Patients and methods The current study included 100 adult nonsmoker male patients assigned to undergo thoracotomy and resection for lung cancer. Patients were randomly allocated into two equal groups: group N received TNP (5 mg/16 h) applied to glabrous skin immediately before induction of anesthesia and group C included patients who received placebo patch. All patients received bupivacaine (0.125%) TEA initiated at the time of induction of anesthesia until 48 h postoperative (PO). All patients received a β-lactam antibiotic as prophylactic and PO antibiotic. Rescue analgesia was provided as increments of dose of epidural bupivacaine until 48 h PO, and thereafter as intravenous meperidine 50 mg. PO pain was assessed using 10-point visual analog scale (VAS) and rescue analgesia was given if VAS was greater than 4. Intraoperative variability of heart rate and blood pressure measures, the frequency of requests for PO rescue analgesia, and the frequency of postoperative nausea and vomiting (PONV) were recorded. Results Epidural analgesia induced significant decrease in systolic arterial blood pressure and mean arterial blood pressure estimated at the end of surgery in both groups. Nicotine induced significantly higher heart rate compared with baseline measures in group N. Mean systolic arterial blood pressure and mean arterial blood pressure measures estimated at the end of surgery were significantly higher in group N compared with group C. Pain VAS scores were significantly lower in group N compared with group C throughout the first 48 h after admission to ICU, but thereafter pain VAS scores were significantly higher as against that determined at 48 h after ICU admission, in both groups. Pain VAS scores were significantly lower in group N compared with group C after removal of epidural catheter until 80 h after the end of surgery. The number of requests of rescue analgesia was significantly higher in group C compared with group N. TNP significantly reduced the number of requests of rescue analgesia after removal of epidural catheter in comparison with placebo. The frequency of PONV was significantly higher in group N compared with group C. Conclusion TNP could be considered as appropriate adjuvant analgesic to TEA for patients who had thoracotomy during early PO period and could be used as the sole analgesic after cessation of TEA. Prophylactic antiemetics were advocated to guard against the high possibility of development of PONV.
  2 2,950 289
CASE REPORTS
Anaesthetic management of posterior mediastinal mass: a case report
Anjum Saiyed, Reema Meena, Babita Ambesh, Indu Verma
September-December 2014, 8(3):104-107
DOI:10.4103/1687-9090.153413  
Posterior mediastinal mass surgery is a challenge to the anaesthetist in terms of airway obstruction, compression of great vessels due to mass effect of tumour and severe cardiovascular and/or respiratory collapse. This may occur following decrease in chest wall tone associated with neuromuscular blockade. In this case study, we report an 8-year-old male child presented with a large posterior mediastinal mass, displacing and partially encasing the aorta at our institution, SMS Medical College & Hospitals, Jaipur, Rajasthan. Mass was removed by left thoracotomy; endotracheal tube was advanced into the right bronchus to ventilate the right lung to improve access in the surgical field because tumour was situated on the left side. While dissecting the mass, there was considerable blood loss. This was replaced with hydroxyethyl starch and whole blood. Patient was extubated next day with uneventful recovery.
  1 3,751 337
Anaesthetic management of a patient with pentalogy of Fallot: a case report
Indu Verma, Anisha Dara, C. K. Vyas, Anjum Saiyed, Reema Meena
May-August 2018, 12(2):31-34
DOI:10.4103/ejca.ejca_26_17  
Pentalogy of Fallot (POF) is a form of congenital heart disease having tetralogy of Fallot with an atrial septal defect. It is characterised by right to left intracardiac shunt with a decrease in pulmonary blood flow and the development of arterial hypoxaemia. Arterial hypoxaemia depends on the magnitude of shunting and leads to erythrocytosis which in turn poses a risk of thromboembolism. We report on the anaesthetic management of a rare case of a 4-year-old male child with pentalogy of Fallot for total correction.
  1 2,328 279
Intraoperative ventilation strategy in a patient with empyema thoracis complicated by bronchopleural fistula
Soma Bhattacharya, Prakash K Dubey, Rupam Kumari
September-December 2016, 10(3):57-59
DOI:10.4103/1687-9090.200284  
Bronchopleural fistulae (BPF) are communications between the bronchioles of the respiratory tract and pleural space. No consensus has been established for the management of BPF due to varied presentation. We report the successful use of one lung ventilation with left sided double lumen tube in a patient with BPF following recurrent thoracic empyema, posted for decortications & repair under general anaesthesia. This case was unique as the patient had restrictive lung disease on the left side due to fibrosis of pleural space and mediastinum following tuberculosis. There were features of obstructive lung disease on the right side due to compensatory emphysema. We had to work up an individualised ventilatory strategy focussed on the better lung to cater to the unique need of our patient that turned out to be safe & effective. Lung protective ventilatory strategy along with proper postoperative management helped in early recovery of the patient.
  1 2,376 350
Conservative management of a case of transesophageal echocardiogram-induced esophageal perforation
Mostafa ElAdawy, Deirdre Timon
September-December 2015, 9(3):49-53
DOI:10.4103/1687-9090.172754  
Esophageal injury or perforation is a rare but life threatening complication of transesophageal echocardiography (TEE). Most of the patients manifest symptoms within 24 hours of the procedure and upper esophagus is the most common site of injury. Incidence of esophageal perforation is relatively rare, in a large series of 10,000 cases of TEE, the incidence of esophageal perforation was reported in 3 cases (0.03%) and in another study it was found to be 1 in 5,000 TEEs, 0.02%. This is a case report that highlights a case of esophageal perforation and false passage discovered accidentally 24 hours postoperatively, in contrast to most of the previous esophageal perforation case reports, a conservative management was undertaken successfully since the discovery of the complication until the full recovery and the discharge of the patient from the cardiac ICU, a follow up upper gastrointestinal endoscopy and CT chest showed progressive resolution of the hematoma surrounding the esophagus, healing of the false passage and recovery of the mediastinal gas locules.
  1 2,420 249
ORIGINAL ARTICLE
Ultrasound-guided internal jugular catheterisation in paediatric cardiac surgical patients: a prospective observational study
Santosh S Parajuli, Apurb Sharma
May-August 2017, 11(2):21-24
DOI:10.4103/ejca.ejca_10_17  
Background Obtaining central venous access in paediatric patients is challenging and failure rates range from 5 to 19%. Ultrasound guidance has been newly introduced to our resource-limited set-up, and our aim was to evaluate the success rate during internal jugular catheterization in paediatric cardiac surgical patients. Patients and methods Over a period of 6 months, 106 consecutive paediatric patients scheduled for cardiac surgery requiring cannulation of the right internal jugular vein were enrolled in the study. The outcome measure was to find out the correlating factors for the number of attempts required and the rate of complications along with the success rate and time taken for successful cannulation. Results The overall success rate was 100% with a rate of successful catheterization in the first attempt being 76.41% [95% confidence interval (95% CI): 68.33–84.49]; second attempt was required in 16.98% (95% CI: 9.83–24.13) and the third attempt in 5.66% (95% CI: 1.26–10.06). The mean number of attempts for successful cannulation was 1.29±0.59. The mean time from skin prick to blood aspiration after successful cannulation was 134.06±81.59 s. The overall complication was 10.4% (95% CI: 4.59–16.21) among which arterial puncture and haematoma formation was seen in all 11 cases; pneumothorax and haemothorax were seen in one (0.9%) of those patients The number of attempts required showed weak negative correlation with age, height, body weight, body surface area and cross-sectional area. Conclusion Ultrasound guidance for central venous cannulation in paediatric patients has acceptable success rates. Arterial puncture with haematoma formation is the most common complication. The overall complication rate is directly related to the number of pricks.
  1 1,878 192
ORIGINAL ARTICLES
Comparison of the myocardial protective effect of sevoflurane and isoflurane in high-risk cardiac patients undergoing coronary artery bypass grafting surgery: a randomized study
Rabie Soliman, Walid Abukhudair
September-December 2017, 11(3):38-47
DOI:10.4103/ejca.ejca_17_17  
Objective The aim of this study was to assess the effect of sevoflurane and isoflurane in high-risk cardiac patients undergoing coronary artery bypass grafting surgery. Patients and methods This study included 228 patients undergoing coronary artery bypass grafting surgery. This was a randomized study. This study was carried out at cardiac centers. The patients in this study were divided into two groups. In the sevoflurane group, the patients received sevoflurane (end-tidal concentration of 1–4%) as an inhalational agent during the entire procedure (before, during, and after cardiopulmonary bypass). In the isoflurane group, the patients received isoflurane (end-tidal concentration of 0.5–2%) as an inhalational agent during the entire procedure (before, during, and after cardiopulmonary bypass). The monitors measured the heart rate, mean arterial blood pressure, a continuous ECG with an automatic ST-segment analysis (leads II and V), central venous pressure, mean arterial pulmonary pressure, pulmonary capillary wedge pressure, pulmonary and systemic vascular resistances, cardiac index, urine output, troponin I level, creatine kinase-MB level, required pharmacological, and mechanical support. Results The administration of sevoflurane decreased the heart rate, mean arterial blood pressure, cardiac index, mean arterial pulmonary pressure, and pulmonary and systemic vascular resistances compared with the administration of isoflurane (P<0.05). Also, it decreased the incidence of myocardial infarction, reflected in the troponin I level, creatine kinase-MB, ECG changes, and the development of new regional wall motion abnormalities (P<0.05). Sevoflurane decreased the requirement for pharmacological and mechanical support compared with isoflurane (P<0.05). Conclusion Sevoflurane is more cardioprotective than isoflurane. It decreases the incidence of myocardial infarction and the requirement for pharmacological and mechanical support, and duration of stay in the ICU and hospital.
  1 2,820 293
The effect of different phenylephrine infusion rates on uteroplacental blood flow during cesarean delivery under spinal anesthesia
Sherry N Rizk, Karim Girgis, Ahmed Mahmoud Sayed, Rana M.N. Abdella
July-December 2013, 7(2):85-91
DOI:10.4103/1687-9090.124042  
Introduction Hypotension associated with spinal anesthesia is more common and profound in the pregnant population, resulting in adverse effects to both the mother and the fetus. It is now widely accepted that the vasopressor of choice during cesarean delivery is phenylephrine. However, an overdose of phenylephrine may cause reflex bradycardia and decreased maternal and fetal cardiac output. In contrast, lower phenylephrine doses may not be adequate to avoid or control hypotension. The optimal phenylephrine dose and its direct effect on uteroplacental blood flow are yet to be determined. Aim of the work This study aimed to examine the direct effect of different phenylephrine infusion rates on uterine blood flow during cesarean delivery spinal anesthesia. Assessment of uteroplacental blood flow was performed using Doppler ultrasound of the uterine artery from which uterine blood flow indices were obtained, namely, peak systolic velocity (PSV) and pulsatility index (PI). Materials and methods This is a prospective, randomized double-blind study. We included 90 age-matched American Society of Anesthesiologists (ASA) I or II parturients with term singleton pregnancies admitted for elective cesarean delivery under spinal anesthesia. We excluded candidates with hypertension, cardiovascular or cerebrovascular disease, type 1 diabetes mellitus, allergy or hypersenstivity to phenylephrine, known fetal abnormalities, intrauterine growth retardation, and any contraindication to spinal anesthesia. The patients were distributed randomly into three equal groups (n = 30 each). Groups 25, 50, and 75 received 25, 50, and 75 μg/min phenylephrine infusion, respectively, after spinal anesthesia was administered. The maternal uterine artery was identified by colored Doppler ultrasound and pulsed-wave Doppler was used to measure PSV and calculate PI before spinal anesthesia and at 5 and 15 min after the block was performed. Maternal hemodynamics and measures of fetal well-being (Apgar score and umbilical venous pH) were also recorded. Results PI at 15 min after spinal anesthesia was significantly higher in group 75 in comparison with the baseline value (P < 0.05) and also in comparison with groups 50 and 25 (P < 0.05). Furthermore, the percentage of decrease in PSV, compared with the baseline, was also significantly higher in group 75 compared with the other two groups at both 5 and 15 min (P < 0.05). Group 75 also showed a significantly higher incidence of hypertension and bradycardia in comparison with both the other groups. However, the number of hypotensive episodes as well as nausea and vomiting was significantly higher in group 25 compared with the other two groups (P < 0.05). There was no significant difference in fetal outcome among the different groups. Conclusion and recommendations At a dose of 75 μg/min, phenylephrine induced a significant reduction in uteroplacental blood flow as evidenced by decreased PSV compared with baseline values and an increase in PI compared with the other two groups. This decrease in uteroplacental blood flow was not associated, however, with poor fetal outcome. Further studies are needed to address the correlation between uteroplacental blood flow and fetal outcome with different phenylephrine doses in patients with uteroplacental insufficiency.
  1 3,213 290
The novel use of spinal anesthesia at the mid-thoracic level: a feasibility study
Ahmed Abdelaal Ahmed Mahmoud, Hazem Abdelwahab Hussein, Karim Girgis, Ahmed Mostafa Kamal, Hesham Ahmed Nafady
January-June 2014, 8(1):21-26
DOI:10.4103/1687-9090.137233  
Background Breast surgery is commonly performed in geriatric patients. In this age group, patients commonly suffer from comorbidities, making regional anesthesia the preferred option during surgery. Recently, segmental thoracic spinal anesthesia for laparoscopic cholecystectomy was tried successfully. Anatomical studies showed that the posterior dural-spinal cord distance is wider at the mid-thoracic region. This encouraged us to test the feasibility of performing spinal anesthesia at the mid-thoracic level for surgeries in the thoracic region, namely breast surgery. Materials and methods We performed a prospective feasibility trial including 25 patients, American Society of Anesthesiologists-I (ASA-I), undergoing minor breast surgery (lumpectomy or simple mastectomy) under segmental thoracic spinal anesthesia at T5 level with 1 ml plain bupivacaine (5 mg/ml) and 0.3 ml fentanyl (50 μg/ml). We assessed the number of attempts required, paresthesia during needle insertion, sensory block level, need for supplemental analgesics or general anesthesia, and block-related complications. Hemodynamics as well as patient satisfaction were also recorded. Results The block was successful in all patients. A single insertion attempt was needed in 22 (88%) patients. No paresthesia was recorded during needle insertion. The upper sensory level was at T1 (T1-T2) and the lower sensory level at T11 (T11-T12). No additional analgesics or general anesthesia were needed during procedure. Four patients required ephedrine to correct hypotension. Two of these patients developed nausea during hypotension. No other complications were recorded. Total satisfaction was reported by 23 (92%) patients. Conclusion Segmental thoracic spinal anesthesia at T5 level in healthy patients undergoing breast surgery can be used successfully with minimal hemodynamic instability. The safety of this technique needs to be confirmed by further studies involving larger number of patients, with comorbid conditions, before it can be advised for routine use.
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Caudal anesthesia with sedation versus general anesthesia with local infiltration during pediatric cardiac catheterization: effect on perioperative hemodynamics and postoperative analgesia
Ahmed K Mohammed, Abdelhay Ebade, Ahmed M Alhaddad
January-June 2014, 8(1):33-38
DOI:10.4103/1687-9090.137235  
Introduction Children undergoing cardiac catheterization are usually in need for perioperative analgesia. Aim and objective We studied the effects of local infiltration of bupivacaine at the groin in generally anesthetized children as against caudal bupivacaine combined with dexmedetomidine-ketamine sedation on intraoperative and postoperative hemodynamics and duration of postoperative analgesia in pediatric patients undergoing cardiac catheterization. Materials and methods A total of 40 patients (1-7 years) were randomly assigned into one of the two groups: one group (group GI) received general anesthesia (GA) together with local infiltration using 5 ml bupivacaine 0.25% at the beginning and at the end of the procedure and the other group (group SC) received sedation by ketamine at 3 mg/kg followed by infusion at a rate of 1 mg/kg/h to maintain sedation with caudal administration of a mixture of bupivacaine 0.25% at 3 mg/kg with dexmedetomidine 0.5 μcg/kg both diluted in normal saline to a volume of 1.2 ml/kg. Hemodynamic variables (blood pressure (BP) and heart rate (HR)) were evaluated at T1 (baseline, after induction), T2 (10 min after local infiltration/caudal administration), T3 (at time of puncture for vascular access), T4 (10 min after emergence), T5 (1 h after the procedure), and T6 (4 h after the procedure). Pain was evaluated 10 min after emergence (P1), after 1 h in the ICU (P2), after 4 h in the ICU (P3), and after 8 h (P4) by the FLACC (Face, Leg, Activity, Crying, Consolability) score. Side effects were observed for 12 h. Results The severity of pain was much less in the SC group than in the GI group. FLACC pain score was evaluated at P1 (10 min after emergence), P2 (1 h after procedure), P3 (4 h after procedure), and P4 (8 h after procedure) and it was found that pain is much less in the SC group than in the GI group during the first 4 h after the procedure with significant difference between the two groups (P < 0.05). There was a more stable hemodynamic profile for the SC group than for the GI group. The mean arterial pressure (MAP) and HR decreased from the baseline in both groups and they decreased more significantly in the SC group than in the GI group. In addition, the decrease in MAP and HR continued for a longer duration in the SC group than in the GI group. We observed a slightly prolonged analgesia with less need for supplemental analgesics in the SC group than in the GI group. Conclusion Combining caudal anesthesia using bupivacaine and dexmedetomidine with ketamine sedation provided prolonged and potent analgesia with much stable perioperative hemodynamic parameters than giving general anesthesia combined with local infiltration in the setting of pediatric cardiac catheterization.
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Ultrasound guidance versus transillumination for peripheral intravenous cannulation in pediatric patients with difficult venous access
Karim K Girgis
January-June 2014, 8(1):39-44
DOI:10.4103/1687-9090.137236  
Objective Venous access can be technically difficult in pediatric patients because of the small size and impalpability of their veins. The aim of this prospective randomized study was to compare the use of ultrasound (US) guidance and transillumination as aids to facilitate peripheral intravenous cannulation in pediatric patients with difficult venous access. Patients and methods We included 80 children, less than 6 years of age, undergoing elective surgery, and having difficult venous access as predicted by a Difficult Intravenous Access score of at least 4. The patients were randomized to either US guidance (the US group, n = 40) or transillumination using the Veinlite EMS (the Veinlite group, n = 40). Cannulation was performed after inhalation induction of anesthesia. The primary outcome measure was the first-attempt success rate of cannulation. The secondary outcome measures were the overall success rate of cannulation, number of attempts, and time required to achieve successful cannulation. Results The first-attempt success rate was significantly higher in the US group (82.5%) compared with the Veinlite group (57.5%, P < 0.05). Both groups showed a high overall success rate (92.5% in the US group and 80% in the Veinlite group, P = 0.19). The time to achieve successful cannulation was significantly shorter in the US group (67.1 ± 19.3 s) than in the Veinlite group (94.1 ± 49.9 s, P < 0.01). The number of attempts required was not significantly different between the two groups. Conclusion Both US guidance and transillumination facilitate peripheral intravenous cannulation in pediatric patients with difficult venous access, resulting in a high overall success rate of cannulation. US guidance is superior as it results in a higher first-attempt success rate with less time required to achieve successful cannulation compared with transillumination.
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Echocardiographic evaluation and comparison of the effects of sevoflurane and desflurane on left ventricular relaxation indices in patients with diastolic dysfunction scheduled for coronary artery bypass grafting surgery
Mahmoud M Amer, Hosam S El Ashmawi, Ahmed M El-Shaarawy, Wael F Hassen
January-June 2014, 8(1):5-11
DOI:10.4103/1687-9090.137225  
Background Effect of inhalational anesthetics on diastolic function in humans is still controversial, although inhalational anesthetics have been shown to have negative lusitropic action in experimental studies, which were explained by interference of inhalational anesthetics with calcium homeostasis. Aim This prospective randomized study aims to evaluate and compare the effects of sevoflurane and desflurane on left ventricular (LV) diastolic function in patients with impaired LV relaxation due to ischemic heart disease using transesophageal Doppler echocardiography. Patients and methods After approval from the local ethics committee and informed consent, 24 patients scheduled for coronary artery bypass grafting surgery were enrolled in the study. Patients were selected by a preoperative transthoracic echocardiographic diagnosis of impaired relaxation or grade 1 diastolic dysfunction. Anesthetic induction was standardized in both groups. Patients randomly received 1 MAC of sevoflurane (n = 12) or desflurane (n = 12) for maintenance of anesthesia. Hemodynamic parameters and transesophageal echocardiography (TEE) derived ventricular diastolic relaxation indices before and after the study drug administration were compared. LV filling pressures were kept within normal range throughout the study period to exclude the effect of the loading conditions on diastolic function. Results The two study drugs significantly reduced the systemic vascular resistance index with a significant increase in the cardiac index. Hemodynamic changes measured by invasive arterial line and pulmonary artery catheter were comparable between the two groups. In terms of LV relaxation indices, the two agents led to a significant improvement in diastolic function. Transmitral and tissue Doppler E/A and Em/Am ratios improved significantly accompanied by a significant decrease in deceleration time and isovolumetric relaxation time. The effect of the two agents on diastolic relaxation parameters was comparable. Conclusion Sevoflurane and desflurane appear to improve LV relaxation. This can be explained by a significant reduction in afterload produced by these vapors. The positive effect of these inhalational agents on LV relaxation can have a beneficial effect on the anesthetic management of patients with diastolic dysfunction.
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Methylene blue for the management of pediatric patients with vasoplegic syndrome
Ghada A Hassan, Yasser A Salem, Heba A Labib, Ashraf A. H. Elmidany
July-December 2014, 8(2):66-74
DOI:10.4103/1687-9090.143265  
Background Vasoplegic syndrome is a form of vasodilatory shock that can occur after cardiopulmonary bypass. Although norepinephrine is sufficient in most cases to restore adequate systemic vascular resistance and support systemic pressures, vasoplegia refractory to norepinephrine has been reported and is associated with high morbidity and mortality, especially in pediatric patients. The guanylate cyclase inhibitor methylene blue infusion could be a promising therapy for such cases. We reported in this study the response of pediatric cardiac patients with norepinephrine-refractory vasoplegic syndrome to methylene blue infusion. Patient and methods A total of 20 pediatric patients mean age 21.60 ± 9.88 months and mean weight 11.70 ± 3.63 kg, with norepinephrine-refractory vasoplegia after cardiopulmonary bypass were treated with an intravenous infusion of methylene blue (1.5 mg/kg) over 20 min. The effects on hemodynamic parameters, cardiac index, systemic vascular resistance index, and norepinephrine dosage were assessed 1 h after infusion. Results The mean arterial pressure increased significantly, with a mean difference of 16.70 ± 4.88 mmHg; also, a significant increase in systemic vascular resistance (P < 0.001), normalization of cardiac output, and a significant decrease in norepinephrine dosage (from 0.57 ± 0.05 to 0.11 ± 0.13 μg/kg/min) were observed in all patients within 1 h. No adverse effects related to methylene blue infusion were observed. Conclusion A single-dose methylene blue infusion appears to be a promising treatment for norepinepherine-refractory vasoplegia after cardiopulmonary bypass during pediatric cardiac surgery.
  1 4,184 393
Outcome after mitral valve replacement in patients with rheumatic mitral valve regurgitation and severe pulmonary hypertension
Shady E Elwany, Ahmed H Mohamed, Amany K Abu El-Hussein
July-December 2013, 7(2):74-78
DOI:10.4103/1687-9090.124037  
Objective The aim of this study was to assess the early outcome after elective mitral valve replacement (MVR) in patients with rheumatic mitral valve regurgitation and severe pulmonary arterial hypertension. Patients and methods The study included patients with baseline systolic pulmonary artery pressure (sPAP) of at least 40 mmHg who underwent elective MVR for rheumatic mitral valve regurgitation. The systemic and pulmonary hemodynamic changes and arterial blood gas parameters were reported at baseline, after intubation, after bypass, 30 min after extubation, and 24 and 48 h postoperatively. Preoperative and postoperative transthoracic echocardiography was performed. Results Thirty patients (11 men and 19 women), median age 31 years (range: 16-52), were included in the study. The operative mortality rate was 10%. The receiver operating characteristic curves identified sPAP as a good predictor of operative mortality. Postoperatively, there was a significant reduction in left atrial diameter and right ventricular systolic pressure in survivors. The median sPAP and pulmonary capillary wedge pressure decreased significantly after bypass and persisted throughout the study period. Central venous pressure decreased after cardiopulmonary bypass time and remained so for 48 h postoperatively. After intubation, on intermittent positive-pressure ventilation and FiO 2 of 1.0, there was a significant improvement in PaO 2 and SaO 2 . pH and HCO3 - concentration increased significantly postoperatively. Conclusion Proper perioperative care and anesthetic techniques resulted in improved left atrial diameter, right ventricular systolic pressure, sPAP, pulmonary capillary wedge pressure, and oxygenation with reduced operative mortality in patients who underwent MVR for mitral valve regurgitation with severe pulmonary hypertension.
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