Anaesthesia, Pain & Intensive Care

Intergenerational workforce: synergism for the benefit of clinical practice

Carlos R. Degrandi Oliveira — 2024-05-20

Rapidly increasing world population has forced the governing authorities to increase the pace of the expansion of the healthcare facilities. It has resulted in more and more health related institutions, with more requirement of work force as well as the latest technology-based gadgets. All these factors have lead to healthcare teams with diverse age groups, diverse technical knowledge and skills and divers clinical experiences. This editorial sheds some light on the positive aspects of this deversity in unity.

Keywords: Diversity; Generations; Intergenerational diversity; Synergy; Workforce

Citation: Oliveira CRD. Intergenerational workforce: synergism for the benefit of clinical practice. Anaesth. pain intensive care 2024;28(3):402−404; DOI: 10.35975/apic.v28i3.2476

Received: April 28, 2024; Accepted: May 05, 2024

The barriers to meaningful research in Pakistan and the way forward

Anum Afzal — 2024-05-20

Despite a mushrooming of a large number of universities in Pakistan during the past two decades, the country still stands at 45th position among the countries of the world regarding the meaningful research. In comparison, India stands on the comfortable 7th position. Over ninety medical journals are being published in Pakistan, but none of them has been able to attain ‘W’ category in the HJRS software being run by Higher Education Commission (HEC). It looks that millions of rupees spent in the name of research in the country are going down the drain. A large-scale effort is needed at the national level to start public-private partnership to promote meaningful and useful research, which helps the country to speed up its growth in every field and to shine at the international level.

For its part, Anaesthesia, Pain & Intensive Care has been trying, since its inception, to promote genuine research in the country. A prominent research scholar, Logan Danielson published a series of five papers on research in the journal. We have been instrumental in publishing nice research papers from across the world, especially from the Far East and Central Asian countries. But the ratio of Pakistani papers remains few and far between.

This invited editorial is another endeavor to draw the attention of our academic elite to focus on the promotion of the research culture in the country on the war footing. It sheds some light on the barriers as well as the possible remedial measures. Our graduate and postgraduate institutions, universities, and HEC need to pay attention towards this very important aspect.

Afzal A, Saleem H, Iqbal A, Akram A. The barriers to meaningful research in Pakistan and the way forward. Anaesth. pain intensive care 2024;28(3):405−407; DOI: 10.35975/apic.v28i3.2477

Received: April 18, 2024; Accepted: May 05, 2024

Effectiveness of the combination of midazolam and dexmedetomidine on the perioperative stress response evaluated by IL-6, HSP60, and cortisol levels

Ridzki Hastanus Sembada — 2024-12-05

Background & objective: Stress response to surgery is a reaction to tissue damage with wide-ranging effects in the neuroendocrine and immunological fields. The synergistic effects of midazolam and dexmedetomidine can inhibit this response. We aimed to determine the inhibiting effect of the combination of midazolam and dexmedetomidine on the perioperative stress response compared to midazolam alone.

Methodology: A total of 40 patients scheduled to undergo total knee or hip replacement surgery with regional anesthesia were included in this double-blind, randomized controlled trial with a pre-test and post-test design. The participants were divided into two study groups: the treatment group (Group MD) and the control group (Group M). Changes in body stress response during surgery were assessed by measuring Interleukin 6 (IL-6), HSP60, and cortisol levels in the blood samples using ELISA.

Results: The test results of the subject showed significant differences in the IL-6 (P = 0.043), HSP60 (P = 0.001), and cortisol levels (P = 0.016). Multivariate analysis using Hotelling’s T square test showed P < 0.01. Furthermore, discriminant analysis showed that combining midazolam and dexmedetomidine significantly reduced HSP60 and cortisol levels.

Conclusion: The combination of midazolam and dexmedetomidine proved more effective than midazolam alone in reducing the perioperative stress response in patients scheduled to undergo total knee or hip replacement surgery under regional anesthesia.

Abbreviations: IL-6 - Interleukin-6; LoS - Length of stay;

Keywords: Surgical stress response; Arthroplasty; Midazolam; Dexmedetomidine

Citation: Sembada RH, Suromo LB, Harahap MS, Susanto H, Budijitno S, Erwinanto. Effectiveness of the combination of midazolam and dexmedetomidine on the perioperative stress response evaluated by IL-6, HSP60, and cortisol levels. Anaesth. pain intensive care 2024;28(3):408−415; DOI: 10.35975/apic.v28i3.2461

Received: January 10, 2024; Revised: April 09, 2024; Accepted: April 09, 2024

The impact of thyroid hormone levels and APACHE II scores on the clinical outcome in critically ill patients

Rio Wironegoro — 2024-05-20

Background & objective: Thyroid hormone levels are often raised during stress and acute illness. APACHE II score has been linked to adverse outcome after severe disease. We analyzed the impact of the level of free triiodothyronine (fT3), free thyroxine (fT4), thyroid stimulating hormones (TSH), and APACHE II scores on the outcome of critically ill patients admitted to Intensive Care Unit (ICU).

Methodology: A cohort prospective study was conducted on critically ill patients in the ICU. Patients’ baseline data, thyroid hormone levels, including fT3, fT4, TSH, and APACHE II score within 24 h of admission were compared between 30-day survivors and non-survivors. Multivariate Cox proportional hazards regression analysis was conducted to assess the risk factors for mortality.

fT3Non-survivors were significantly older than survivors (55.81 ± 12.61 vs 41.40 ± 11.40, P = 0.003). The APACHE II score was higher in non-survivors (25.88 ± 9.28 vs 22.13 ± 10.42, P = 0.299). Thyroid hormone levels showed no significant difference between the two groups. The area under the receiver-operating curve for APACHE II was 0.610 (0.403-0.818), and for fT3 was 0.523 (0.311-0.735).

Conclusion: Although there was no significant difference in thyroid hormone levels between the survivors and non-survivors, the results of this study show that low fT3 levels and high APACHE II scores had a more significant association with adverse clinical outcomes in critically ill patients.

Abbreviations: APACHE - Acute Physiology and Chronic Health Evaluation; ESS - Euthyroid Sick Syndrome; ft3 - Free Triiodothyronine; ft4 - Free Triiodothyronine; NTIS - Non-Thyroidal Illness Syndrome; TSH - Thyroid Stimulating Hormone

Keywords: Critically ill; Mortality; fT3 level; fT4 level; APACHE II score

Citation: Wironegoro R, Suhardi CJ, Maulydia, Wibisono S, Adi S, Rahmaweni R. The impact of thyroid hormone levels and APACHE II scores on the clinical outcome in critically ill patients. Anaesth. pain intensive care 2024;28(3):416−422; DOI: 10.35975/apic.v28i3.2478

Received: March 03, 2024; Revised: April 13, 2024; Accepted: April 15, 2024

The relevance of preoperative frailty and postoperative delirium in elderly patients undergoing hip surgery

Thang Toan Nguyen — 2024-05-21

Background & Objectives: Frailty status and delirium are common findings in the elderly in the perioperative period, and are associated with higher frequency of complications and poor outcomes after surgery. This study aimed to determine the rate and relationship between preoperative frailty and postoperative delirium (POD) in elderly people scheduled for hip surgery.

Methodology: A cross-sectional observational study was conducted on 104 elderly patients scheduled for hip surgery from October 2022 to November 2023 at the Centre for Anesthesia and Surgical Intensive Care, Bach Mai Hospital. The Modified Frailty Index (mFI) was used to assess the frailty. It includes 22 clinical and paraclinical variables and is useful to assess the preoperative frailty. We assessed postoperative delirium (POD) using the Confusion Assessment Method for the ICU (CAM-ICU) flow sheet during the first 4 days after surgery. Univariate and multivariate regression analyses were used to determine the association between frailty and delirium.

Results: A total of 104 patients were included in the analysis, and the proportion of patients with preoperative frailty (mFI ≥ 0.25) was 36.5%. Postoperative delirium occurred in 32 patients (30.8%). The frail patient group had a higher rate of postoperative delirium and a significantly longer average duration of delirium than the non-frail group (60.5% vs. 13.6% and 1.26 days vs. 0.35 days, respectively, P < 0.05). Multivariate regression analysis showed that mFI ≥ 0.25 was associated with POD status 4 days after surgery (aOR = 6.29; 95% CI = 1.43-27.6; P < 0.05).

Conclusions: The incidences of preoperative frailty and postoperative delirium in elderly patients undergoing elective hip surgery were 36.5% and 30.8%, respectively. Preoperative frailty is an independent risk factor for increased postoperative delirium.

Abbreviations: ADLs - Activities of Daily Living, NMS - New Mobility Score; ASA - American Society of Anesthesiologists, POD - Post-Operative Delirium; mFI - modified Frailty Index

Keywords: Postoperative delirium; Preoperative frailty; Hip fracture surgery; Elderly patient

Citation: Nguyen TT, Khanh HC, Ba TN. The relevance of preoperative frailty and postoperative delirium in elderly patients undergoing hip surgery. Anaesth. pain intensive care 2024;28(3):423−430; DOI: 10.35975/apic.v28i3.2473

Received: April 03, 2024; Revised: April 14, 2024; Accepted: April 15, 2024

A comparative study between tongue thickness measured by ultrasonography and thyromental distance in anticipation of difficult intubation

Ahmed Bassim Kadhim — 2024-12-05

Background & objective: Difficult intubation remains a risk for patients undergoing general anesthesia (GA) or mechanical ventilation in an intensive care unit (ICU). Macroglossia is a known factor for difficult intubation. But it is not routine to assess the tongue size to predict difficult intubation. Studies are found deficient in comparing usefulness of measuring thyromental distance and the tongue thickness (TT) measured by ultrasonography to estimate difficult intubation. We compared tongue thickness measured by ultrasonography and thyromental distance as a means to anticipate difficult intubation.

Methodology: A convenient sample of 60 patients; 32 males and 28 females, who were undergoing elective surgery with GA were included. Thyro-mental distance (TMD), along with tongue thickness (TT) were measured consecutively in each patient in a transitional room. After induction of GA, Cormack Lehane (CL) score was assessed for all patients to detect difficult intubation.

Results: Thyro-mental distance was significantly reduced in patients with difficult intubation, while the reverse was in the measurement of tongue thickness; where patients with difficult intubation had significantly a greater TT than those with no difficult intubation. TT measurement had significantly higher sensitivity and specificity (38%, and 96% respectively; P = 0.002) than thyro-mental distance in the detection of difficult intubation.

Conclusion: In this study we demonstrated that there was statistically significant inverse relationship of thyro-mental distance on CL, and statistically significant direct relationship of tongue thickness on CL. The results showed that tongue thickness was more effective to detect difficult intubation.

Abbreviations: CL - Cormack Lehane; TMD - Thyro-mental distance; TT - Tongue thickness;

Keywords: Tongue Thickness; Thyromental Distance; Difficult Intubation

Citation: Kadhim AB, Hamid GR. A comparative study between tongue thickness measured by ultrasonography and thyromental distance in anticipation of difficult intubation. Anaesth. pain intensive care 2024;28(3):431−435; DOI: 10.35975/apic.v28i3.2465

Received: March 16, 2024; Reviewed: March 29, 2024; Accepted: March 31, 2024

Ultrasound-guided quadratus lumborum block versus thoracic paravertebral block in gynecological cancer surgery: a prospective randomized trial

Fatma Gomaa Hussein — 2024-12-05

Background & Objectives: In the event that gynecologic cancer surgery (GC surgery) is going to be accompanied with extreme pain, many localized blocks will be provided. The quadratus lumborum block, often known as a QLB, is a fascial plane block that was developed relatively recently for the therapy of post-abdominal surgery discomfort. In the current study, a comparison is made between the effectiveness and safety of thoracic paravertebral block (TPVB) and quadratus lumborum block (QLB) in patients undergoing GC surgery.

Methodology: In this prospective comparative randomized trial, fifty patients with scheduled GC surgery were split evenly between two groups: QLB group (n = 25) to receive bilateral QLB type-2, or TPVB group (n = 25) to receive TPVB. The VAS scores were recorded at 1, 2, 4, 6, 12, and 24 h following surgery, and served as the key indicator of patient outcomes. Secondary outcomes were; the time to first request for the analgesic, the patient satisfaction, and the total morphine consumed as rescue analgesic in 24 h.

Results: At 2, 6, 12 and 24 h, the VAS scores of the QLB group were significantly lower than those of TPVB group. Only 12 (48%) of the QLB group patients required rescue morphine, compared to all patients in the TPVB group requiring it. QLB group showed more dermatomal distribution in comparison to the TPVB group. It took the TPVB group a much shorter time to demand their first painkiller (P = 0.001), and they also took significantly more total morphine (P = 0.001). An increased number of people in the QLB group reported satisfaction as a result of taking the analgesic.

Conclusion: Quadratus lumborum block is a promising technique for postoperative analgesia for patients undergoing gynecological cancer surgery. This block provides relatively prolonged duration of pain relief, compared to thoracic paravertebral block.

Abbreviations: FLACC - Face, Legs, Activity, Cry, Consolability scale; GC - gynecological cancer; QLB - quadratus lumborum block; QLB2 - Bilateral quadratus lumborum block; TPVB - thoracic paravertebral block; VAS - visual analogue scale

Keywords: Quadratus lumborum block; Thoracic paravertebral block; Gynecological cancer surgery; Postoperative pain management.

Citation: Hussein FG, El Samahy KA, Abd Elghaffar EM, Mahran EAH, Hassan ME, Thabet TS. Ultrasound-guided quadratus lumborum block versus thoracic paravertebral block in gynecological cancer surgery: a prospective randomized trial. Anaesth. pain intensive care 2024;28(3):436−445; DOI: 10.35975/apic.v28i3.2287

Received: September 03, 2023; Revised: October 11, 2023; Accepted: April 08, 2024

Role of integrated pulmonary index in respiratory monitoring of spontaneously breathing COVID-19 patients with moderate to severe respiratory symptoms

Sahar Mahmoud Kasem — 2024-12-05

Background & objective: Most of the COVID-19 patients suffered from moderate to severe respiratory symptoms. Many of them needed oxygen supplementation or even mechanical ventilation. There is little data available about the use of either end-tidal CO₂ (EtCO₂) or integrated pulmonary index (IPI) in these patients. The aim of this study to investigate the difference in IPI values for subjects requiring mechanical ventilation compared to those managed without ventilation and the correlation between EtCO2 and SpO2.

Methods: This prospective observational study involved adult COVID-19 patients admitted to the ICU with moderate to severe respiratory symptoms. All patients were connected to a portable respiratory monitor with the IPI algorithm (Medtronic Capnostream 35) and treated according to a standardized protocol. Oxygen flow was adjusted to maintain oxygen saturation (92–96%). If the respiratory rate did not fall below 30 breaths per minute and/or the SpO₂ did not reach the target, non-invasive ventilation (NIV) was initiated. Patients with NIV failure was eligible for invasive mechanical ventilation.

Results: SpO₂ was significantly lower, while RR was significantly higher in intubated group compared to non- intubated group (P < 0.001 and 0.018, respectively). However, IPI, EtCO₂, and HR did not differ among both groups. There was a significant positive correlation between EtCO₂ and SpO₂ at baseline before oxygen therapy (r = 0.419; P = 0.007). There was a significant negative correlation between CT score and SpO₂ (r = -0.408; P = 0.01); however, there was no correlation between CT score and both IPI and end tidal CO₂ at baseline (r = 0.017; P = 0.9).

Conclusion: The integrated pulmonary index cannot be used as a single parameter for assessing respiratory severity in COVID-19 patients.

Abbreviations: EtCO₂- end-tidal CO₂; IPI - integrated pulmonary index; NIV - non-invasive ventilation;

Keywords: Integrated Pulmonary Index, COVID-19, EtCO₂, CT severity score.

Citation: Kasem SM, Ahmed MK, Mukhtar AM, Eladawy AS, Maher MA, Farouk S. Role of integrated pulmonary index in respiratory monitoring of spontaneously breathing COVID-19 patients with moderate to severe respiratory symptoms. Anaesth. pain intensive care 2024;28(2):446−451; DOI: 10.35975/apic.v28i3.2460

Received: January 09, 2024; Reviewed: March 24, 2024; Accepted: March 24, 2024

Effect of instrument-assisted soft tissue mobilization versus myofascial release therapy for pain, mobility, and disability in chronic low backache patients: a quasi-experimental study

Tahir Mahmood — 2024-12-05

Background & objective: Low back pain (LBP) is a common musculoskeletal disorder in the general population. The most common etiological factors are overuse syndromes, postural issues, and bad working environment. The conservative management using physical agents can be more satisfactory and beneficial before the interventional techniques. We aimed to compare manual myofascial release and instrument-assisted soft tissue mobilization (IASTM) techniques for improving pain, lumber mobility, and functional index in patients with chronic LBP.

Methodology: This non-randomized trial was conducted on 40 chronic low back pain patients and data was collected from Chaudhry Akram Research and Teaching Hospital, Lahore, Pakistan. We included patients with LBP for more than 3 months, ages 22-45 y. Group A received manual myofascial release (MFR), and Group B received instrument-assisted soft tissue mobilization (IASTM). The outcomes assessed were pain, low back functional index, and lumber range of motion. The data was analyzed using SPSS V.23. Repeated measurement ANOVA was used for within group comparison. While an Independent sample t-test was applied for inter-group comparison at a significance level of P < 0.05.

Results: There were 26 males and 14 females in the study. The study comprised of 20 participants in each group with mean ages of 33.17 ± 7.46 and 33.45 ± 7.63 y respectively. The results showed that pain improvement was more in group B compared to group A. While the disability and range of motion, including flexion, extension, and lumber right-side flexion, showed a statistically significant improvement (P < 0.05). Mean difference was 1.75 for pain, 8.65 for disability index and -5.15 for lumber flexion, -1.25 for extension, and 1.30 for right side flexion, but no statistical differences (P > 0.05) were found for left lumber flexion (P > 0.05) in both groups.

Conclusion: The results of our study show that chronic low back pain can be managed by myofascial release techniques but better effects can be achieved using instrument-assisted soft tissue mobilization technique.

Keywords: Chronic Low Back Pain; IASTM; Low Back Disability Index; Manual Myofascial Release; Pain; Range of motion; Well-being

Citation: Mahmood T, Abrar A, Atif MM, Mahmood W, Batool F. Effect of instrument-assisted soft tissue mobilization versus myofascial release therapy for pain, mobility, and disability in chronic low backache patients: a quasi-experimental study. Anaesth. pain intensive care 2024;28(2):452−458; DOI: 10.35975/apic.v28i3.2459

Received: August 28, 2023; Reviewed: December 09, 2023; Accepted: March 23, 2024

The correlation of risk factors with mortality of geriatric patients in non-operating room anesthesia services

Aswoco Andyk Asmoro — 2024-05-21

Background & objective: One of the most frequently performed anesthesia services is Non-Operating Room Anesthesia (NORA). In geriatric patients, there are several risk factors which are directly or indirectly related to post-NORA mortality. We aimed to find out the relationship between pre-NORA risk factors and the mortality of geriatric patients receiving NORA services.

Methods: This observational analytical study used the convenient sampling method in seventy patients undergoing NORA. Data collected included pre-NORA risk factors; e.g., age, gender, Body Mass Index (BMI), quality of life, and cognitive function. Mortality within 30 days post-NORA was noted. The data was analyzed using an independent t-test and Spearman correlation with α= 5% and a confidence interval (CI) of 95%.

Results: We included 70 patients as the subject of the study, with a mortality rate of 8.6%. There was a significant difference between BMI (P = 0.034), quality of life (P = 0.001), and cognitive function (P = 0.004) in patients who died with those who remained alive. There were correlations between cognitive function (P = 0.001, R= 0.379) and quality of life (P = 0.009, R= 0.309) with 30 days post-NORA mortality.

Conclusion: There is a positive correlation between the risk factors of cognitive function and quality of life pre-NORA of geriatric patients with 30-day mortality post-NORA. Careful selection and maximum optimization of the geriatric patients selected for non-operating room anesthesia may reduce post-operative mortality.

Abbreviations: MMSE - Mini-Mental State Examination; NORA - Non-Operating Room Anesthesia; ROC - Receiver Operating Characteristic curve; WHOQOL -World Health Organization Quality of Life criteria;

Keywords: Cognitive function, Geriatrics, Mortality, Non-operating room anesthesia, Quality of life,

Citation: Asmoro AA, Isngadi, Achsar AM, Laksono BH. The correlation of risk factors with mortality of geriatric patients in non-operating room anesthesia services. Anaesth. pain intensive care 2024;28(3):459−464; DOI: 10.35975/apic.v28i3.2345

Received: November 28, 2023; Revised: March 29, 2024; Accepted: May 3, 2024

Analgesic efficacy of ultrasound-guided retrolaminar block and erector spinae plane block in modified radical mastectomy: a randomized controlled study

Ahmed Mohamed Soliman — 2024-12-05

Background & objective: Modified radical mastectomy (MRM) is the most commonly performed surgical procedure in breast cancer patients and is usually associated with severe postoperative pain. The peripheral nerve block techniques have been suggested in addition to the traditional opioid and non-opioid analgesics to manage acute post-mastectomy pain. We compared the analgesic efficacy of retrolaminar block (RLB) with erector spinae plane block (ESPB) in patients undergoing MRM, with an aim to establish the efficacy of one over the other.

Methods: This randomized single-blind study included 60 female patients scheduled for MRM under general anesthesia and randomized into two equal groups. The RLB Group (n = 30) received a preoperative ultrasound-guided RLB with 20 ml levobupivacaine 0.25%. The ESPB Group (n = 30) received an ESPB with 20 ml levobupivacaine 0.25%. The primary outcome measure was the total postoperative morphine consumption. Secondary outcomes were total intraoperative fentanyl consumption, duration of analgesia, pain intensity (NPRS score), hemodynamic changes, and adverse effects.

Results: The intraoperative fentanyl and postoperative morphine consumption were lower in the ESPB group than the RLB group, but the difference was near statistical significance (P = 0.066 and 0.058, respectively). Pain intensity at rest and on movement was comparable in both groups in the postoperative period, except that NPRS on movement was significantly lower in the ESPB group compared to RLB group (P = 0.039). Both techniques offered hemodynamic stability and there was no significant difference in the occurrence of PONV (P = 0.559).

Conclusion: Ultrasound-guided single-point retrolaminar block and erector spinae plane block are safe and effective postoperative analgesic techniques for patients undergoing modified radical mastectomy with comparable effects in terms of opioid consumption, duration of analgesia, pain intensity, and occurrence of PONV.

Abbreviations: BMI - body mass index; ESPB - erector spinae plane block; ESM - erector spinae muscle; MRM - Modified radical mastectomy; NPRS - Numerical pain rating scale; RLB - retrolaminar block;

Keywords: Analgesics; Opioids; Breast Neoplasms; Postoperative Pain; Mastectomy; Nerve block

Citation: Soliman AM, Zaghloul A, Mohamed MS, Ahmed MB. Analgesic efficacy of ultrasound-guided retrolaminar block and erector spinae plane block in modified radical mastectomy: A randomized controlled study. Anaesth. pain intensive care 2024;28(3):465−471; DOI: 10.35975/apic.v28i3.2464

Received: March 04, 2024; Reviewed: April 15, 2024; Accepted: April 18, 2024

Relevance of KIM-1 and NGAL biomarkers in the diagnosis of persistent kidney failure

Karar Yasir Hasan — 2024-12-05

Background & objective: chronic kidney disease (CKD) is a long-term condition in which the kidney function is gradually lost over time, which includes filtration of waste products and excess fluids from the bloodstream, maintaining electrolytes balance and produce hormones that regulate blood pressure and stimulate red blood cell production. The target of management for CRF (CRF) is to restrict the injury to the kidneys, usually by detection of its underlying cause. The current study aimed to detect and relate biomarker levels, such as Neutrophil Gelatinase Associated Lipocalin (NGAL) and Kidney Injury Molecule type 1 (KIM-1) in patients with CKD.

Methodology: Ninety participants took part in the study between Sep 2023 and Jan 2024 through random sampling. They were divided into two groups; Group-1 included 45 healthy volunteers, and Group-2 included 45 individuals with CKD, stage 1 to end stage renal failure and were on dialysis. The ELISA method was used to measure the serum levels of NGAL and KIM-1 in each person. Colorimetric techniques were used to measure creatinine, potassium, calcium, serum urea, and random blood sugar (RBS).

Version 25 of IBM's statistical software for the social sciences (SPSS) on a Windows platform was used to conduct the statistical study. Using the analysis of variance student t test, patients with CKD were compared to a healthy group; a P ≤ 0. 05 indicated statistical significance.

Results: Between individuals with chronic kidney disease and the healthy group, there was a statistically significant variance in NGAL and KIM_1, serum creatinine, urea, potassium, calcium, and RBS.

Conclusion: Patients with CRF had considerably higher levels of Neutrophil Gelatinase Associated Lipocalin (NGAL) and Kidney Injury Molecule type 1 (KIM-1), which are diagnostic markers.

Abbreviations: CKD - Chronic Kidney Disease; CRF - Chronic Renal Failure; GFR - Glomerular Filtration Rate; KIM-1 - Kidney Injury Molecule -1; NGAL - Neutrophil Gelatinase-Associated Lipocalin; RBS - Random Blood Sugar

Keywords: Chronic renal conditions; KIM-1; NGAL

Citation: Hasan KY, Al Ammar HAJ. Relevance of KIM-1 and NGAL biomarkers in the diagnosis of persistent kidney failure. Anaesth. pain intensive care 2024;28(3):472−480; DOI: 10.35975/apic.v28i3.2463

Received: February 29, 2024; Revised: March 10, 2024; Accepted: March 14, 2024

Evaluation of post-elective surgery acute pain management profiles using the APS-POQ-R questionnaire: an observational study

Suwarman . — 2024-05-30

Background & objective: Acute postoperative pain affects 80% of the patients undergoing elective surgery, which raises the risk of morbidity and lowers patient satisfaction with medical care. Various modalities have been employed to make the patient pain free. We studied post-elective surgery acute pain management profiles at a tertiary hospital in West Java, Indonesia to present an overview.

Methodology: The American Pain Society Patient Outcome Questionnaire—Revised (APS-POQ-R) was used in this descriptive observational study. All patients who underwent elective surgery at a tertiary hospital in West Java, Indonesia between March and April 2023 and fulfilled the inclusion criteria, e.g., age from 18 to 65 y, fully conscious, able to communicate in Bahasa Indonesia, willing to participate, were included in the study. Within 24 h following the elective surgery, patients in the inpatient wards underwent interviews. Patients with impaired cognitive function, psychiatric disorders or uncooperative drug addiction, and patients who were planned for intensive care were excluded. Data was analyzed using SPSS version 26. The distribution of the data was examined using the Kolmogorov-Smirnov test. The data was analyzed for the mean ± standard deviation, range or median and range.

Results: About 161 people participated in the study. The majority of participants (60.9%) reported having moderate pain, and 59% with moderate nausea as a side effect of pain medication. Mild emotional status impairment and restricted activities were also observed. Eighty-one percent of the individuals reported having knowledge regarding pain management. With a median score of 8, patient satisfaction was at a favorable level. It is believed that 80% of patients respond well to pain treatment. The degree of patient participation was low.

Conclusions: Despite various post-operative changes, the majority of respondents expressed great satisfaction with their pain management. Improved patient cooperation is therefore, necessary, in addition to encouraging non-pharmacological pain management and providing sufficient pain management information.

Abbreviations: NRS - Numeric Rating Scale; ODS - One Daycare Surgery; PNB - peripheral nerve block; VAS - Visual Analog Scale;

Keywords: APS-POQ-R questionnaire, patient satisfaction, postoperative pain management

Citation: Suwarman, Yadi DF, Suryadi S, Nugraha P. Evaluation of post-elective surgery acute pain management profiles using the APS-POQ-R questionnaire: an observational study. Anaesth. pain intensive care 2024;28(3):481−488; DOI: 10.35975/apic.v28i3.2479

Received: December 28, 2023; Reviewed: January 08, 2024; Accepted: March 14, 2024

Efficacy of ultrasound guided rectus sheath block on the postoperative quality of recovery in laparotomy surgeries; a randomized control trial

Ayman Abougabal — 2024-05-12

Background: Recovery after surgery and anesthesia is a complex process therefore a variety of measurement tools have been developed such as QoR-40 and QoR-15 questionnaires to assess quality of recovery. We assessed the opioid sparing effect of rectus sheath (RS) blocks in improving the quality of recovery following midline laparotomy surgeries.

Methodology: A randomized, controlled, open-labelled trial was conducted in the General surgery unit. Adult patients scheduled for elective midline laparotomy surgery under general anesthesia were included. Patients were divided into two groups: LA group and control group. Patients in the LA group received ultrasound guided, bilateral rectus sheath block, while patients in the control group received patient-controlled analgesia for postoperative control.

Results: Fifty-two patients were screened for eligibility. Median (range) aggregated global QoR-15 scores at 24 h were significantly greater in the LA group, indicating good quality of recovery compared with the control group; 107 (101-112) vs. 72 (68-74) with P < 0.001. In addition, pain profile was better in the LA group as 10 out of 24 (41%) Patients in the LA group required additional boluses of morphine during the 24-h period compared to 100% of patients in the control group (P < 0.001).

Conclusion: Ultrasound guided rectus sheath block provides better quality of recovery profile in midline laparotomy compared to opioids.

Abbreviations: ERAS - Enhanced Recovery After Surgery; LA - Local Anesthetic; RS - Rectus Sheath; RSB - Rectus Sheath Block; US - Ultrasound; QoR-15 - Quality of Recovery-15 Questionnaire; QoR-40 - Quality of Recovery-40 Questionnaire.

Preregistration: The trial was registered on ClinicalTrials.gov (NCT05244746) after obtaining Ethical committee approval at Kasr AlAiny Cairo University (code:MS-202-2021).

Keywords: Anesthesia Recovery Period; laparotomy; Nerve Block.

Citation: Abougabal A, Hamed E, Mannaa A, Nabil N, Badry M. Efficacy of ultrasound guided rectus sheath block on the postoperative quality of recovery in laparotomy surgeries; a randomized control trial. Anaesth. pain intensive care 2024;28(3):489−494; DOI: 10.35975/apic.v28i3.2456

Received: May 12, 2023; Reviewed: January 17, 2024; Accepted: March 15, 2024

Knowledge, attitude and practice of pharmacists regarding antibiotic usage and its possible trends

Minahal Munir — 2024-12-05

Background & Objective: Antimicrobial resistance is a worldwide issue. According to United Kingdom Government Commissioned Review on Antimicrobial Resistance, antimicrobial resistance might cause mortality of 10 million people each year by 2050. Microbes developed resistance to antimicrobial agents, largely due to irrational antibiotic use. The presence of a certified pharmacist, as well as prescriber's level of education and experience, are all linked to proper medication use. We aimed to find the differentiation in knowledge, attitude and practices of the pharmacists regarding the differences in experience, education level, graduation institute and working sector. Another area of our study was to ascertain the commonly prescribed antibiotics.

Methodology: It was a quantitative, cross-sectional and multicenter study performed in Lahore, Pakistan. The sample size for prescriptions was 324, calculated by Daniel’s equation and 230 for questionnaires by convenient sampling. Questionnaires were administered to clinical, community, industrial and academic pharmacists with consent. A data collection form was utilized for finding prescription patterns.

Results: According to 72% community, 71% clinical, 53% industrial, and 69% academic pharmacists, samples for culture and sensitivity must be taken before starting antibiotics. Contrarily, 28% community, 19 % clinical, 10% industrial and 23% academic pharmacists disagreed upon the use of broad-spectrum antibiotics, where narrow spectrum antibiotics were effective. The most commonly prescribed antibiotic was ceftriaxone (38.7%), followed by ciprofloxacin (6.8%) and meropenem (5.8%).

Conclusion: The study found good knowledge, attitude and practices among pharmacists regarding antibiotic use. Negligible significant differences were observed in scores among pharmacists working under various set-ups. Irrational prescribing can be avoided by introducing training for physicians and pharmacists.

Keywords: Antimicrobial Resistance, Pharmacist, Knowledge, Narrow Spectrum, Ceftriaxone, Irrational Prescribing

Citation: Munir M, Riaz T, Waqar MA, Khan R, Javed M, Iqbal S, Shoukat S, Tayyab S, Abid SZ. Knowledge, attitude and practice of pharmacists regarding antibiotic usage and its possible trends. Anaesth. pain intensive care 2024;28(3):495−502; DOI: 10.35975/apic.v28i3.2290

Received: September 14, 2023; Reviewed: March 14, 2024; Accepted: April 14, 2023

Anesthesia experience, clinical characteristics and outcomes of COVID positive childbirths during COVID-19 pandemic: an observational study at two teaching hospitals in Iran

Mastaneh Dahi — 2024-05-30

Background & objectives: COVID-19 pandemic affected people all around the world since its first notification in 2020. The virus also affected pregnant ladies as well as their neonates. We aimed to accumulate data and report the clinical characteristics and outcomes of COVID-19 childbirths in two teaching hospitals during the pandemic.

Methodology: We retrospectively extracted data of COVID-19 infected parturients and their newborns at the time of delivery from electronic record system of the two target hospitals.

Results: Electronic records of 44 parturients, known to have COVID infection, and delivered in two hospitals. Out of them, 21 were on medication for the viral infection and 26 needed supplement oxygen. Six patients gave birth naturally and 38 had cesarean section to deliver. Rate of cesarean section and preterm labor was 81.81% and 31.81% respectively. Out of 36 patients who underwent cesarean section, 28 initially had spinal anesthesia.

Conclusion: COVID-19 infection increased risk of preterm labor; however, Covid itself did not affect the mode of delivery and type of anesthesia. The most important lesson of covid was real time sharing of vital data.

Keyword: Covid19; Pregnancy; Cesarean Section; Complications

Citation: Dahi M, Dabir S, Madadi F, Moshari M, Shakeri A, Yaghmaei M, Vosoughian M, Tabashi S. Anesthesia experience, clinical characteristics and outcomes of COVID positive childbirths during COVID-19 pandemic: an observational study at two teaching hospitals in Iran. Anaesth. pain intensive care 2024;28(3):503−508; DOI: 10.35975/apic.v28i3.2468

Received: October 22, 2023; Revised: January 03, 2024; Accepted: February 19, 2024

Association of neuregulin-1 with hormonal and lipid profile in women with polycystic ovarian syndrome

Omar Tareq Zaidan — 2024-05-30

Background & objective: Polycystic ovarian syndrome (PCOS) is a disorder of the reproductive aged women, which may affect fertility of these women from 14-45 y of age. Neuregulin-1 (NRG-1) is a trophic factor that contains an epidermal growth factor (EGF)-like domain, and has been shown to be associated with the regulation of inflammation and ovulation. We evaluated the role of NRG-1 and its relationship with hormonal and lipid profile in women with PCOS.

Methodology: This was a case-control study which included 60 women, known to be suffering from PCOS and another 60 age-matched women, who had regular menstrual cycle, as a control group. Blood samples were collected from Infertility Clinic/ Al-Yarmouk Teaching Hospital. Hormonal and lipid profiles were measured using standard methods. Enzyme linked immunosorbent assay (ELISA) was used to measure serum level of NRG-1. Receiver operating characteristic (ROC) curve was used to evaluate the diagnostic value of NRG-1.

Results: The median serum level of neuregulin in patients was 2.73 pg/mL (range = 1.13-7.39 pg/mL) which was higher than that of controls (median = 2.1 pg/mL, range = 0.33-7.39 pg/mL) with a significant difference the area under the curve (AUC) was 0.652, 95%CI = 0.545-0.758, P = 0.008. The sensitivity and specificity of the test at cut off value of NRG-1 = 2.25 were 62% and 52%, respectively. Neuregulin-1 displayed a significant negative correlation with anti-Müllerian hormone (AMH) (r = -0.324, P = 0.038).

Conclusions: Serum level of neuregulin-1 is increased in women with polycystic ovarian syndrome, but has a poor diagnostic value, and its negative correlation with anti-Müllerian hormone. However, the diagnostic value of neuregulin-1 is poor and cannot be used in early diagnosis of polycystic ovarian syndrome.

Abbreviations: AMH - Anti-Müllerian hormone; AUC - Area under the curve; EGF - Epidermal growth factor; HDL-C - High-density lipoprotein cholesterol; LDL-C - Low-density lipoprotein cholesterol; NRG-1 - Neuregulin-1; PCOS - Polycystic ovarian syndrome; SG - Stress granules; TC - Total cholesterol; TG -Triglyceride.

Keywords: Infertility; Neuregulin-1; Polycystic ovarian syndrome

Citation: Zaidan OT, Al-Tamimi RJ, Alizzi FJ, Al-Mayah QS. Association of neuregulin-1 with hormonal and lipid profile in women with polycystic ovarian syndrome. Anaesth. pain intensive care 2024;28(3):509−516.

DOI: 10.35975/apic.v28i3.2471

Received: March 15, 2024; Revised: March 24, 2024; Accepted: March 29, 2024

Comparison of the effect of magnesium sulfate 50 mg/kg with 30 mg/kg on opioid requirement and blood magnesium level after abdominal hysterectomy

Ricky Aditya — 2024-05-30

Background: Hysterectomy is the most common operation with a postoperative pain score for abdominal hysterectomy being 8. Preemptive analgesia can help mitigate the postoperative pain. We studied the effect of preoperative use of magnesium sulfate (MgSO₄), either in a dose of 50 mg/kg or 30 mg/kg, on the opioid requirements as well as on the serum magnesium levels in abdominal hysterectomy patients.

Methodology: This was a double-blind, randomized controlled, clinical trial with 40 women undergoing abdominal hysterectomy included as participants. The participants were randomly divided into two groups; Group I received MgSO₄30 mg/kg and Group II received a dose of 50 mg/kg, 20 min before induction of routine general anesthesia. Pre-operative and postoperative blood magnesium levels were compared by unpaired t-test. Inter-group comparison was also done.

Results: Group I patients had lower postoperative opioid requirements compared to the Group II. There was a significant difference in blood magnesium levels between the two groups; e.g., 2.36 ± 0.29 vs.2.13 ± 0.23 mEq/L in Group I and Group II, respectively.

Conclusion: Administering magnesium sulfate at a dose of 50 mg/kg to abdominal hysterectomy patients can reduce the need for opioids and significantly increase the magnesium levels in the blood compared to a dose of 30 mg/kg.

Keywords: Abdominal hysterectomy; Magnesium sulfate; Opioid; Preemptive analgesia

Citation: Aditya R, Indriasari, Limawan MA. Comparison of the effect of magnesium sulfate 50 mg/kg with 30 mg/kg on opioid requirement and blood magnesium level after abdominal hysterectomy surgery. Anaesth. pain intensive care 2024;28(3):517−523; DOI: 10.35975/apic.v28i3.2469

Received: January 10, 2024; Reviewed: January 10, 2024; Accepted: January 15, 2024

Comparison of dexmedetomidine, fentanyl, and lidocaine in attenuation of hemodynamic responses during intubation in patients undergoing laparoscopic cholecystectomy

Sana Urooj — 2024-05-30

Background & objective: The anesthesiologists have been trying various strategies to lessen the adverse effects of endotracheal intubation on hemodynamic parameters. The aim of this study was to explore a better and safer drug to attenuate the pressor response to laryngoscopy and intubation by comparing dexmedetomidine (Precedex; Brookes Pharma), fentanyl (Fentra; Brookes Pharma), and lidocaine (Xylocaine; Barret Hodgson).

Methodology: In this double-blind, randomized controlled trial, a total of 90 patients of ASA physical status I and II, undergoing laparoscopic cholecystectomy under general anesthesia were included. Sample size was calculated using OPEN EPI sample size calculator. Patients were randomized into three groups by sealed envelope method. Patients in Group D received intravenous dexmedetomidine 0.6 µg/kg, Group F received intravenous fentanyl 2 µg/kg and Group L received intravenous lidocaine 1.5 mg/kg over 10 min before induction. Hemodynamic variables were recorded at baseline, at laryngoscopy, 1, 3, 5 and 10 min after intubation. Perioperative complications and postoperative sedation and recovery were also noted at 0 and 10 min in Post Anesthesia Care Unit (PACU).

Results: As compared to dexmedetomidine, there was no significant impact of lidocaine (P = 0.774) and fentanyl (P = 0.992) in managing the heart rate (HR) of patients, while time had a significant impact on the HR. There was no substantial effect of fentanyl (P = 0.123) or lidocaine (P = 0.616) in managing SBP and no effect of fentanyl (P = 0.580) or lidocaine (P = 0.752) in managing DBP, in contrast to dexmedetomidine. Although statistically significant reduction in HR, SBP and DBP was observed in Group D, soon after study drug infusion, but overall long-term stability was noticed. Ramsey sedation scores were significantly higher in the Group D at arrival in PACU, but after 10 min all three study groups showed almost similar results. Aldrete score was statistically significant in the fentanyl group compared to Group D and L in PACU, both at arrival and after 10 min (P = 0.001 and 0.010 respectively).

Conclusion: We conclude that intravenous dexmedetomidine demonstrated better attenuation of hemodynamic response to laryngoscopy and intubation in patients undergoing laparoscopic cholecystectomy by controlling rise in heart rate and by providing long-term stability in systolic and diastolic blood pressure. Fentanyl and lidocaine showed inconsistencies in heart rate, systolic and diastolic blood pressure over time. Fentanyl showed better hemodynamic profile compared to lidocaine. Patients included in fentanyl group exhibited early recovery than dexmedetomidine and lidocaine.

Abbreviations: ASS - Aldrete sedation score; HR - heart rate; PACU - Post Anesthesia Care Unit; PONV - postoperative nausea and vomiting; RSS - Ramsay sedation scale;

Keywords: Attenuation, Dexmedetomidine, Fentanyl, Hemodynamic Response, Intubation Response, Laryngoscopy Response, Lidocaine, Pressor Response.

Citation: Urooj S, Javaid H, Andleeb S, Mughal A, Naz A, Shah SJ, Jabeen R, Siddiqui SZ. Comparison of dexmedetomidine, fentanyl, and lidocaine in attenuation of hemodynamic responses during intubation in patients undergoing laparoscopic cholecystectomy. Anaesth. pain intensive care 2024;28(3):524−533; DOI: 10.35975/apic.v28i3.1737

Received: April 15, 2023; Revised: April 29, 2023; Accepted: May 03, 2024

Monitored anesthesia care for percutaneous radiofrequency ablation of oncological lesions: a retrospective analysis and literature review

Pahade Akhilesh — 2024-12-05

Background & objective: Radiofrequency ablation (RFA) of solid tumors is a minimally invasive procedure intended to treat primary and/or metastatic, benign or malignant solid tumors; via thermal tissue destruction by means of targeted thermal energy guided coagulative necrosis. This procedure can be performed under sedation, general anesthesia (GA) or regional blocks. However, no defined modality exists. We analyzed the different anesthetic modalities and drug combinations which can provide optimal surgical conditions and a successful outcome. Secondary objectives were to analyze common adverse events associated with each anesthesia technique

Methodology: In this retrospective study, a total of 100 patients were included based on completeness of records, valid consent from 2008-2018. Outcome measures were; demographic characteristics, ASA status, comorbidities, anesthetic management including drug combinations used, pain management modality, and complications - both intra-operative and post-operative complications. Data was assessed and analyzed using descriptive statistics.

Results: Majority of the patients were male (55%), ASA physical class II/III (83%). Anesthesia drug combinations were classified as ketamine and non-ketamine based (85:15). Primary sites for RFA were liver (75%) followed by bone, kidney, adrenal and lungs. Main complications observed were pain and hypotension. Incidence of complications were higher in non-ketamine group.

Conclusions: Most cases of radiofrequency ablation can be performed successfully under sedation with local anesthesia. Despite being minimally invasive, it requires complete preparation with general anesthesia back-up, and pre-operative assessment/investigations. Ketamine based combinations exhibited better patient compliance with lower complication rates than non-ketamine-based combinations.

Abbreviations: GA - General anesthesia; MAC - Monitored anesthesia care; p-RFA - Percutaneous radiofrequency ablation; RFA - Radiofrequency ablation; TIVA - Total intravenous anesthesia;

Keywords: Keta-dex, Ketamine, Radiofrequency ablation, RFA, Pain, Sedation, Monitored anesthesia care, MAC

Citation: Pahade A, Mowar A, Vikas J, Singh V, Chowdhury C. Monitored anesthesia care for percutaneous radiofrequency ablation of oncological lesions: a retrospective analysis and literature review. Anaesth. pain intensive care 2024;28(3):534−540. DOI: 10.35975/apic.v28i3.2462

Received: January 24, 2024; Reviewed: March 29, 2024; Accepted: March 29, 2024

Comparison of induction of labor versus conservative management in premature rupture of membranes on fetal outcome

Maria Khan — 2024-05-30

Background & Objective: Premature rupture of the membranes (PROM) is defined as rupture of the membranes (amniotic sac) before the commencement of the labor and after 37 weeks gestation. Opinions differ whether to induce labor in these parturients or continue to manage conservatively. The purpose of this research was to compare the incidence of unfavorable fetal outcomes in cases of early rupture of the membranes and expectant treatment in the induction of labor.

Methodology: This randomized controlled trial was conducted at the Department of Obstetrics & Gynaecology, Lady Reading Hospital, Peshawar, from 1st August 2022 to 31st January 2023. A total of 610 pregnant women with PROM were included in the study. In total, 305 patients were in the expectant management group or Group A, while 305 patients were in induction of labor or Group B. After delivery, fetal outcomes (birth asphyxia, low Apgar score, and sepsis) were noted and compared in both groups.

Results: Birth Asphyxia was observed in 69 (22.6%) patients in Group A as compared to 44 (14.4%) patients in Group B (P = 0.009). A low Apgar Score was observed in 27 (8.9%) patients in Group A compared to 10 (3.3%) patients in Group B (P = 0.004). Sepsis was observed in 8 (2.6%) patients in Group A as compared to 1 (0.3%) patient in Group B (P = 0.019).

Conclusion: It is concluded that all patients presenting with premature rupture of membranes at term should be actively managed with induction of labor.

Keywords: Pregnancy; Premature rupture of membranes; Labor induction; Expectant management; Adverse fetal outcomes

Citation: Khan M, Khattak S. Comparison of induction of labor versus conservative management in premature rupture of membranes on fetal outcome. Anaesth. pain intensive care 2024;28(3):541−546; DOI: 10.35975/apic.v28i3.2470

Received: March 08, 2024; Reviewed: May 01, 2024; Accepted: May 05, 2024

Ultrasound-guided inferior vena cava collapsibility index as a predictor of fluid responsiveness in septic cancer patients

Mohamed Ahmed Gaafar — 2024-05-30

Background & objective: Intravenous fluid therapy is a critical step in the resuscitation of patients suffering from sepsis and septic shock. Meticulous hemodynamic monitoring is necessary before as well as during the fluid therapy to avoid under- as well as over-loading the patient. An evaluation of fluid status has been suggested to be done non-invasively using the inferior vena cava collapsibility index (IVC-CI). We assessed the effectiveness of IVC-CI in evaluating septic patients' responses to fluid therapy at our institution.

Methodology: Forty cancer patients with spontaneous breathing, who met sepsis criteria and were admitted to the intensive care unit, were included in this cross-sectional study. Over the course of three hours, the patients received crystalloids intravenously at a rate of 30 ml/kg, while CVP, ultrasonography guided IVC-CI measurement, and the vital sign monitoring was done every 30 min. Patients were divided into a responder group and a non-responder group based on a 10% change in cardiac output (CO) one hour later. IVC-CI variations in the volume responsiveness prediction served as the main outcome measure.

Results: According to the change in CO one hour after starting fluid treatment, 29 patients (72.5%) were classified as fluid responsive and the remaining 11 (27.5%) as fluid non-responsive. In the two groups, HR and IVC-CI decreased significantly; whereas MAP, CVP, and CO increased significantly. ROC-curve analysis showed a percent change ≥ 3.4% of IVC-CI predicted positive responsiveness with a sensitivity of 72.4% and a specificity of 63.6%. These values were 79.3% and 72.7%, respectively, for a change ≥ 6.3% after one hour. The baseline value of IVC-CI was not predictive of responsiveness.

Conclusion: In cancer patients with sepsis or septic shock, the change in inferior vena cava collapsibility index during the first hour of fluid therapy can predict fluid responsiveness with a moderate degree of accuracy.

Abbreviations: CO - Cardiac output; CVP - central venous pressure; IVC- inferior vena cava; IVC-CI - inferior vena cava collapsibility index; MAP - Mean arterial pressure; SV - Stroke volume

Keywords: Cancer; ICU; Critically sick; Inferior vena cava; IVC collapsibility index; Non-invasive cardiometry; Sepsis

Citation: Gaafar MA, Soliman AM, Ahmed NA, Kotb TA, Shaker EH. Ultrasound-guided inferior vena cava collapsibility index as a predictor of fluid responsiveness in septic cancer patients. Anaesth. pain intensive care 2024;28(3):547−552; DOI: 10.35975/apic.v28i3.2472

Received: March 20, 2024; Revised: March 23, 2024; Accepted: April 27, 2024

Evaluation of adiponectin serum levels and their association with oxidative stress in individuals with type 2 diabetes mellitus in Iraq

Anwar Hammad Al-Dulaimy — 2024-05-30

Background: Diabetes stands among the top ten contributors to worldwide mortality, with diabetics facing 2 to 3 times greater susceptibility to all-encompassing mortality. The adipose tissue has garnered growing recognition as a vigorously dynamic endocrine organ, discharging an array of biologically impactful molecules, among which is adiponectin. We investigated the influence of serum adiponectin levels and their correlation with oxidative stress in individuals with type 2 diabetes mellitus (T2DM) in the province Anbar of Iraq.

Methodology: A case-control research was carried out at Al-Ramadi Hospitals located in Anbar province, Iraq. The study encompassed a total of 84 individuals, comprising 42 patients diagnosed with T2DM, and 42 individuals enrolled as healthy controls (HCs). Venous blood samples were collected and each sample was divided into four, to obtain the serum. Serum levels of adiponectin and oxidative stress were assessed through the utilization of enzyme-linked immunosorbent assays (ELISA).

Results: The study findings revealed that there was no significant impact on the lipid profile among patients when compared to the control group, as evidenced by statistically insignificant differences (P > 0.05). However, a noteworthy increase in glucose levels was observed in patients compared to healthy individuals, demonstrating a significant difference (P < 0.05). Furthermore, the average levels of malondialdehyde (MDA) displayed a significant rise in patients in comparison to the healthy cohort (P < 0.05). In a similar vein, superoxide dismutase (SOD) levels demonstrated a notable contrast, showcasing higher values in the healthy group in contrast to the patients (P < 0.05). The adiponectin levels exhibited remarkable divergence, with notably elevated values in the T2DM group relative to the healthy group, achieving statistical significance (P < 0.05). The data indicated positive associations between serum adiponectin levels and MDA, as well as fasting serum glucose (FSG), triglycerides (TGs), and very-low-density lipoprotein (VLDL). Nevertheless, no significant correlations were identified between adiponectin and SOD, as well as the other variables.

Conclusion The findings of the study indicated that reduced adiponectin levels are associated with elevated oxidative stress among T2DM patients.

Abbreviations: FSG - fasting serum glucose; MDA - malondialdehyde; SOD - superoxide dismutase; TGs - Triglycerides; T2DM - type 2 diabetes mellitus; VLDL - Very-low-density lipoprotein

Key words: Adiponectin; SOD; Oxidative Stress; Diabetes Mellitus

Citation: Al-Dulaimy AHH, Abdul Ghafoor KF. Evaluation of adiponectin serum levels and their association with oxidative stress in individuals with type 2 diabetes mellitus in Iraq. Anaesth. pain intensive care 2024;28(3):553−557; DOI: 10.35975/apic.v28i3.2475

Received: October 23, 2023; Revised: January 19, 2024; Accepted: April 02, 2024

Enhancing anesthesia precision: integration of BIS monitoring in anesthesia machines

Muhammad Arslan Zahid — 2024-05-30

The review examines the integration of Bispectral Index (BIS) monitoring into anesthesia machines, focusing on its fundamental principles, clinical applications, and technical nuances. BIS, a parameter derived from electroencephalogram (EEG) analysis, quantifies the hypnotic effects of anesthesia, providing an objective measure of the patient's neurological state. The integration enhances perioperative outcomes, improve patient safety, and optimize the administration of anesthetic drugs. This review highlights the challenges posed by variations in patient reactions to anesthetics and the limited effectiveness of traditional monitoring methods. BIS monitoring offers real-time evaluation and precise titration of anesthesia, reducing risks of over-sedation and insufficient anesthesia. Thereby reducing the risk of oversedation and insufficient anesthesia. It also mitigates anesthesia awareness, which is a rare but serious phenomenon. This review discusses the implementation and practice guidelines for BIS monitoring, emphasizing the need for thorough training of anesthesia practitioners. It also discusses the economic implications and cost-effectiveness of BIS monitoring, with potential benefits in optimizing anesthesia management. The ethical and legal considerations associated with BIS monitoring are also discussed, emphasizing its role in providing impartial evidence in disputes. The article concludes by positioning BIS monitoring as a standard of care in anesthesia and critical care settings, highlighting its pivotal development in anesthesia machines, including wireless connectivity.

Keywords: Anesthesia Machines; Anesthesia Precision; Awareness, Intraoperative; BIS Monitoring; Bispectral Index (BIS); Depth of Anesthesia; EEG Analysis; Perioperative Outcomes; Patient Safety; Surgical Precision

Citation: Zahid MA, Kumar V, Wadhwani J, Kumar A, Hasan MF, Saleh M. Enhancing anesthesia precision: integration of BIS monitoring in anesthesia machines. Anaesth. pain intensive care 2024;28(3):558−565; DOI: 10.35975/apic.v28i2.2481

Received: January 20, 2024; Reviewed: February 23, 2024; Accepted February 23, 2024

Fluid balance in critically ill: a predictor of death?

Bambang Pujo Semedi — 2024-05-30

In the critically ill patients, fluid therapy may cause fluid overload if it is not based on the indication. The understanding of fluid therapy and precise knowledge of how much fluids a patient might need, is essential to avoid further complications that can lead to morbidity or even mortality. Goal-directed and guided fluid resuscitation is the main concept of fluid therapy, and it must be based on the recorded daily fluid balance. It is a known fact that positive fluid balance during the treatment period may lead to pulmonary edema, hemodynamic instability and can worsen the overall condition of the patient.

Abbreviations: ADH - anti-diuretic hormone; GAG - glycoproteins glycosaminoglycans; RAAS - renin angiotensin aldosterone system;

Keywords: Fluid balance, fluid overload, sepsis, acute kidney injury

Citation: Semedi BP, Soediono MR. Fluid balance in critically ill: a predictor of death? Anaesth. pain intensive care 2024;28(3):566−570; DOI: 10.35975/apic.v28i3.2474

Received: February 22, 2024; Reviewed: March 25, 2024; Accepted: March 26, 2024

An inconspicuous problem in the management of an anticipated difficult airway

Wajahat Nazir Ahmed — 2024-05-30

Patients with head and neck cancer are at an increased risk of airway complications, not only because of the tumor itself and the need for a shared airway, but also the treatment of cancer (including surgery, radiotherapy, and chemotherapy) poses major challenges in airway management. The perioperative assessment, therefore, needs to be comprehensive to allow us to predict possible airway difficulty. Moreover, the suitability and feasibility of primary and rescue plans are needed to be assessed for each individual patient. In this case report, we describe a case of a patient, with recurrent tongue cancer with prior history of surgery and radiotherapy to the head and neck region. The difficulty in managing the airway in this case was anticipated correctly and subsequently encountered in almost every step, including bag-mask ventilation, video-laryngoscopy, and laryngeal mask airway (LMA) insertion in a patient. Despite the presence of visual aids and algorithms for the management of a difficult airway, a premeditated airway management plan, and the availability of all necessary equipment and expertise, a break in structure and sequence was encountered, which was quickly corrected and saved the patient from any harm.

Abbreviations: FOI – Fiberoptic intubation; MRI – Magnetic Resonance Imaging; DAS – Difficult Airway Society; ASA – American Society of Anesthetists; SAD – Supraglottic Airway Device; CICO – Can’t intubate, can’t oxygenate.

Keywords: Anesthesiology, Difficult Airway, Human Factors, Fiberoptic Intubation

Citation: Ahmed WN, Khan SA, Ali S, Ashraf A. An inconspicuous problem in the management of an Anticipated difficult airway. Anaesth. pain intensive care 2024;28(3):571−576; DOI: 10.35975/apic.v28i3.2206

Received: April 14, 2023; Reviewed: February 09, 2024; Accepted: April 04, 2024

Deep serratus anterior plane block and superficial parasternal block for awake mastectomy in a high-risk patient

Carmine Cavallo — 2024-05-30

General anesthesia is the most common anesthesia technique for breast surgery, and opioid administration represents the cornerstone for proper intra- and post-operative pain management. However, opioid use is associated with many side effects (delayed awakening, hyperalgesia, nausea, vomiting, itching, and respiratory depression), affecting the patient’s clinical outcome and satisfaction. Furthermore, evidence suggests that opioids promote disease progression, affecting both cellular and humoral immune function in humans. Indeed, general anesthesia increases the risk of postoperative pulmonary complications, especially in elderly patients with comorbidities. In this setting, regional anesthesia represents an intriguing and innovative approach to managing perioperative pain, decreasing opioid consumption and related adverse effects, and reducing the risk of postoperative pulmonary complications.

Here, we describe the safety and effectiveness of the deep serratus anterior plane block and superficial parasternal block, combined with deep sedation with propofol and dexmedetomidine, as a primary anesthetic technique in a patient with an assessed high risk for the development of postoperative pulmonary complications and scheduled for mastectomy with sentinel lymph node biopsy, followed by axillary lymph node dissection.

Abbreviations: dSAPB - deep serratus anterior plane block; NRS - Numerical Rating Scale; PPCs - postoperative pulmonary complications; sPSB - superficial parasternal block; SA - serratus anterior

Keywords: Breast surgery, superficial parasternal block, deep serratus anterior plane block

Citation: Cavallo C, Romanelli A, Gammaldi R. Deep serratus anterior plane block and superficial parasternal block for awake mastectomy in a high-risk patient. Anaesth. pain intensive care 2024;28(3):577−581; DOI: 10.35975/apic.v28i3.2480

Received: January 16, 2024; Reviewed: May 21, 2024; Accepted: May 21, 2024

Segmental thoracic spinal anesthesia for abdominal surgery; a report of three cases

Mohamad Azlan Awang — 2024-06-05

Segmental thoracic spinal anesthesia (STSA) has recently been introduced in clinical practice, but still is not a common procedure. Although there have been some concerns about its potential complications, the method may benefit a specific subset of patients. We present the case reports of three patients, who were operated upon using the STSA technique. Two were performed as emergency procedures, and the third was an elective one. One of the three patients required minimal sedation near the end of the surgery, but none required general anesthesia or intensive care support. All patients recovered completely without complications and were discharged on Day 2. In certain patients, STSA may be a safe and beneficial alternative to general anesthesia. To demonstrate its potential benefit, risks, and use as a routine technique, adequately powered randomised, controlled clinical trials are required.

Keywords: Segmental; Thoracic; Spinal anesthesia; Elective; Emergency; Abdominal; Surgery.

Citation: Awang MA, Mohamad Yusof MF, Abd Razak MH. Segmental thoracic spinal anesthesia for abdominal surgery; a report of three cases. Anaesth. pain intensive care 2024;28(3):582−584; DOI: 10.35975/apic.v28i3.2334

Received: November 22, 2023; Revised: January 22, 2024; Accepted: February 24, 2024

The role of continuous popliteal sciatic block in a patient with acute on chronic limb-threatening ischemia: a case report

Aida R. Tantri — 2024-05-09

Treating ischemic pain (IP) is challenging because of complex mechanisms involved in its pathogenesis. We report a case of pain management in a patient with acute on chronic limb-threatening ischemia (CLTI) treated with continuous popliteal sciatic block (CPSB). Microcirculation was measured using Near-Infrared Spectroscopy (NIRS). The patient was a 44-year-old male with acute exacerbation of CLTI of left leg. Excruciating pain was described as being stabbed in the left toe with burning sensation radiating to ankle (VAS score 9-10), 3 to 4 times a day with duration of 30 to 60 min each episode. CT Angiography showed wide arterial occlusions and thrombi in veins of left lower limb. ABI was 0,71. He was on heparin so we decided to do CPSB with patient controlled regional analgesia (PCRA) pump of ropivacaine 0.375%. Before catheter insertion, NIRS was measured on dorsum pedis. SrO₂ increased from 24 to 32% within 30 min after initial bolus. Episodes of severe pain still felt with only little relief when pressing PCRA pump. Daily chart showed increasing ropivacaine utilization with discrepancy between attempted and given dose. SrO₂ fluctuated between 25 to 32%. On the third day evaluation, we switched to multimodal analgesia. However, pain attacks increased in frequency, intensity and duration. Ischemic area in foot expanded rapidly. High dose methyl prednisolone was initiated. Amputation was suggested but refused by the patient.

Peripheral nerve block does not completely block ischemic pain, despite adequate motor block. However, it may be beneficial in cases of CLTI by maintaining blood flow, thus inhibiting the progression of ischemia. In this patient, it is evident that upon cessation of CPSB, the condition of the leg deteriorated rapidly.

Keywords: Chronic limb-threatening ischemia, Continuous popliteal sciatic block, Ischemic Pain

Citation: Tantri AR, Lawrence. The role of continuous popliteal sciatic block in a patient with acute on chronic limb-threatening ischemia: a case report. Anaesth. pain intensive care 2024;28(3):585−587; DOI: 10.35975/apic.v28i3.2454

Received: March 23, 2024; Reviewed: April 27, 2024; Accepted: April 27, 2024

Neurogenic pulmonary edema: a case report and literature review

Daniyal Shahid — 2024-12-05

We report a case of neurogenic pulmonary edema (NPE) caused by an intraparenchymal bleed following a fall. We review the literature regarding the pathophysiology, clinical presentation, and management of neurogenic pulmonary edema.

Pulmonary edema is the accumulation of fluid within the alveolar and interstitial spaces; one of the lesser-appreciated causes is neurogenic. NPE occurs following acute central nervous system (CNS) injury and is often rapidly developing in nature. Common insults include epileptic seizures, traumatic brain injury, intracranial hemorrhage, and pediatric encephalitis

The low prevalence of NPE and the distracting primary disease often divert physicians' attention away from its prompt diagnosis, this is regrettable as up to 35% of patients with intracranial hemorrhage have NPE.

NPE is a prevalent yet underdiagnosed disease. The underlying mechanisms are still debatable and much more research is required to diagnose and treat the condition effectively. Treatment is mainly supportive with judicious use of invasive ventilation and management of primary pathology. We aimed to refresh the knowledge of young clinicians regarding NPE.

Abbreviations: AVM - arteriovenous malformation; CNE - central nervous system; NPE - Neurogenic pulmonary edema; SAH - subarachnoid hemorrhage; SUDIP - sudden unexplained death in epilepsy

Keywords: Neurogenic, Pulmonary edema, Pathophysiology, Presentation, Prevalence, Treatment.

Citation: Shahid D, Malik M, Saqib M, Faris S, Khan AU, Qaisar HAA. Neurogenic pulmonary edema: a case report and literature review. Anaesth. pain intensive care 2024;28(3):588−592; DOI: 10.35975/apic.v28i3.2455

Received: September 23, 2023; Revised: April 16, 2024; Accepted: April 16, 2024

Bertolotti's syndrome as an uncommon cause of LBP; a case series

Liaqat Ali — 2024-05-30

Lumbosacral transition of L5 vertebra is an anatomical variation. The transverse process of L5 vertebra may become enlarged and form a pseudo joint with ilium or sacrum, leading to low back pain, especially in young adults due to change in biomechanical properties of the lumber spine. This condition is referred to as Bertolotti’s syndrome. Here we report an ongoing case series of 11 of our patients in whom we studied the impact of steroid and local anesthetic infiltration as a treatment approach.

The primary objective of this case series is to comprehensively investigate and report the clinical characteristics, radiological findings, treatment modalities, and outcomes in a group of 11 patients diagnosed with Bertolotti's syndrome, thus adding to the existing body of knowledge about Bertolotti's syndrome by focusing on its occurrence and management in younger individuals, which is relatively less explored in the literature.

Abbreviations: VAS - Visual Analogue Scale; FABER - Flexion Abduction External rotation; SLR - Straight Leg Raising

Keywords: Bertolotti's Syndrome, Low back pain, Lumbosacral transition

Citation: Ali L, Abbas MA, Hanif H, Nasir S, Ali U. Bertolotti's syndrome as an uncommon cause of LBP; a case series. Anaesth. pain intensive care 2023;27(6):593−599; DOI: 10.35975/apic.v28i3.2484

Received: January 28, 2024; Reviewed: March 19, 2024; Accepted: April 03, 2024

Fentanyl infusion in a multi-organ failure patient on adaptive support ventilation: a conundrum

Chandini Kukanti — 2024-05-30

The authors present a case of an 85-year-old male patient with multiple co-morbidities. He underwent laparotomy for carcinoma rectum, recovered from anesthesia, and was shifted to the ward. On sixth day his condition deteriorated, so was shifted to ICU. In ICU, he was put on ventilator in ASV mode, and fentanyl infusion started. The next morning a high V_T of 900-1000 mL was noticed to be delivered, while the respiratory rate was 8-10/min. Naloxone administration eased the respiratory parameters. Careful monitoring of sedation levels and respiratory drive becomes crucial for preventing volutrauma in ASV mode of ventilation.

Abbreviations: ASV - Adaptive support ventilation, FiO₂ - Fraction of inspired Oxygen, MV - minute ventilation, PEEP - positive end expiratory pressure, RASS - Richmond Agitation Sedation Scale, RR - respiratory rate, Vt - tidal volume

Keywords: Closed loop ventilation, Complication, Opioids, Volutrauma

Citation: Kukanti C, Karim HMR, Panda CK, Jain A. Fentanyl infusion in a multi-organ failure patient on adaptive support ventilation: a conundrum. Anaesth. pain intensive care 2024;28(3):608−610; DOI: 10.35975/apic.v28i3.2044

Received: February 20, 2024; Accepted: March 31, 2024

Specialist training in anesthesia around the world

Romana Durrani — 2024-05-30

Anesthesia history has been marked by periods of nice developments and innovations followed by long periods of idleness. The interest in surgical anesthesia was in fact, a result of the painful surgical procedures being performed by merely restraining the patient by four or more body builder strong men. Perhaps the first anesthesia was a natural one; by severe cold which made surgeries less painful in wounded soldiers. Other developments followed in periodic succession.

But pharmaceutical anesthesia brought with it the side effects too. So a concept of balanced anesthesia was born. The debate about general anesthesia and regional anesthesia is also an old one. The recent four to five decades revolutionized monitoring techniques and thus allowed complex cardiovascular and neuro-surgery possible USG has been a great mile stone.

All this course has always put a burden on the anesthetist to keep himself abridged, if he has to be competent as well as safe healthcare professional. Different countries have different schedules of anesthesia training and this special invited paper by Dr. Romana Durrani offers a bird’s eye view of such training in a few countries. It is published as a guide for our young medical graduated, who might like to pursue their careers in one of these countries.

Key words: Anesthesia; Anesthesia, General; Development; Training, Postgraduate

Citation: Specialist training in anesthesia around the world. Anaesth. pain intensive care 2023;27(5):600-607; DOI: 10.35975/apic.v28i3.2482

Received: 23 October 2023; Revised: October 15, 2023; Accepted: 06 November 2023