Anaesthesia, Pain & Intensive Care

Teaching job is essential to convert a medical practitioner into a nice clinician

Leena Ayub, Shahid Rasool Dar, Umer Farooq — Wed, 10 Jul 2024 00:00:00 -0600

Traditionally, every practicing hakim used to have a group of students, most of whom lived in the compound of the hakim, witnessed and learnt the intricacies of ‘hikmat’, as well as preparation of different pharmaceutical products from raw materials. Once, they acquired a certain level of proficiency, they were allowed to leave and start their own practice. Same routine used to be followed by other branches of medicine. As the number of medical practitioners grew, their links to the teaching side got weaker or mostly ceased to exist, and with it the opportunities to learn. A debate has been generated whether the diagnostic proficiency and the clinical acumen of a non-teaching clinician can be considered equivalent to the one who is a teaching clinician actively engaged in teaching and grooming full classes of his or her students.

Keywords: Clinician; Hikmat; Teaching, Medical; Practice, Medical; Practitioners, Medical

Citation: Ayub L, Dar SR, Farooq U. Teaching job is essential to convert a medical practitioner into a nice clinician. Anaesth. pain intensive care 2024;28(5):785−787; DOI: 10.35975/apic.v28i5.2541

Received: August 30, 2024; Accepted: September 10, 2024

The anesthetists’ concerns regarding robotic surgery

Shahneela Raza, Sarah Tabassum — Mon, 07 Oct 2024 00:00:00 -0600

Advancement of technology has great impact on medical field. With all its pros and cons its use can be practiced with minimizing the risk and maximizing its benefits for the wellness of patient. With all the goodness that it offers to the surgery; its demand for environment and changes in the physiology of patient remains concerning for the anesthetist and surgical team.

Despite the progression, it's huge space occupying size and its extra costly investment makes it difficult for usual setups to initiate it's use for common man.

The robotic system has been used in a range of specialist areas, including bariatrics, general surgery, & cardiothoracic and urological surgeries and gynecological surgeries. Here we discuss various issues faced by the anesthetist to accommodate the concerns of robot assisted surgeries for the better outcome of the patients.

Keywords: Anesthesia; Robotic surgical procedures; Education; Training; Pakistan

Citation: Raza S, Tabassum S. The anesthetists’ concerns regarding robotic surgery. Anaesth. pain intensive care 2024;28(5):788−790; DOI: 10.35975/apic.v28i5.2542

Received: August 06, 2024; Reviewed: September 14, 2024; Accepted: September 14, 20

Comparison of ultrasound guided erector spinae plane block and fascia iliaca block for postoperative analgesia in hemiarthroplasty: a double-blind randomized trial

Mon, 07 Oct 2024 00:00:00 -0600

Background & Objective: Peripheral nerve blocks are one of the peri-operative analgesic options that abolish surgical stress response, reduce the use of opioids, and control postoperative pain. During the previous few decades regional anesthesia and analgesia techniques have been widely used, especially with the enhanced safety and precision in these procedures with the use of ultrasound. We compared the efficacy of Erector Spinae Plane Block (ESPB) with Fascia Iliaca Block (FIB) for postoperative pain in hemiarthroplasty surgery.

Methodology: This randomized double-blind trial included sixty-eight cases scheduled for hemiarthroplasty under spinal anesthesia. Patients were randomly divided into two equal groups: Group ES received ESPB, and Group FI received FIB. Blocks were performed preoperatively using 15 mL bupivacaine 0.25%- and 15 mL lidocaine 2%. Postoperatively, pain was assessed with Visual Analogue Scale (VAS) at 1 h, 2 h, 6 h, 12 h and 24 h.

Results: The mean time to first dose and the amount of morphine used in the first 24 hours were comparable between Group ES and Group FI. Visual analogue scale measurements at rest and movement showed insignificant differences between both groups at 1 h, 2 h, 6 h, 12 h and 24 h. Quadriceps motor impairment revealed significant reduction in Group ES compared to Group FI (11.76 vs 44.12%, P = 0.006).

Conclusions: In hemiarthroplasty, the analgesic profile of erector spinae plane block was comparable with fascia iliaca block with superiority of the former in preserving the quadriceps motor power.

Keywords: Ultrasound, Erector Spinae Plane Block, Fascia Iliaca Block, Analgesia, Hemiarthroplasty

Citation: Ahmed MB, Mohammed MM, Amin SMM, Belata MM. Comparison of ultrasound guided erector spinae plane block and fascia iliaca block for postoperative analgesia in hemiarthroplasty: a double-blind randomized trial. Anaesth. pain intensive care 2024;28(5):791−797; DOI: 10.35975/apic.v28i5.2562

Received: April 29, 2024; Reviewed: August 19, 2024; Accepted: August 25, 2024

An interventional prospective cohort study of efficacy of unilateral vs bilateral percutaneous posterior approach neurolytic celiac plexus blocks

Tue, 08 Oct 2024 00:00:00 -0600

Background: The neurolytic celiac plexus block (NCPB) has been a valuable intervention for managing upper abdominal cancer pain. However, the optimal approach for performing a NCPB remains a topic of debate. We conducted this study to establish the efficacy of unilateral vs bilateral percutaneous posterior approach NCPB.

Methodology: This prospective, interventional study includes a cohort of individuals through chronic abdominal pain related to malignancies who were scheduled to undergo NCPB. Patients were divided into two groups, one group received the unilateral percutaneous posterior approach NCPB, and the other group received the bilateral NCPB by percutaneous posterior. Pain scores and adverse events at multiple time points post-procedure were recorded. Statistical analysis was conducted to compare pain score and adverse events between the two groups and evaluate the impact of the chosen approach on pain management.

Results: Bilateral percutaneous posterior approach provides slightly better pain relief compared to the unilateral approach in the early post-procedure period which is not statistically significant. Complication rates appear to be comparable between the two approaches, with no major safety concerns identified.

Conclusion: While the bilateral approach initially offers more effective pain relief, the long-term benefits and safety profiles of both methods are comparable. Clinical decision-making should consider these findings and prioritize individualized patient care.

Abbreviations: CPB - Celiac Plexus Block; NCPB - neurolytic celiac plexus block; PACU - post-anesthesia care unit; VAS - visual analogue scale

Keywords: Neurolytic celiac plexus block, Pancreatic cancer pain, upper abdominal malignancy

Citation: Abbas MQ, Abbas SM, Farooq MF, Siddique M, Malik S. An interventional prospective cohort study of efficacy of unilateral vs bilateral percutaneous posterior approach neurolytic celiac plexus blocks. Anaesth. pain intensive care 2024;28(5): 798−803; DOI: 10.35975/apic.v28i5.2559

Received: March 24, 2024; Reviewed: August 05, 2024; Accepted: August 08, 2024

The effect of severe COVID-19 infection on biochemical markers (FBS, HbA1C, FA, INS, C-Pep) in diabetic patients

Tue, 08 Oct 2024 00:00:00 -0600

Background & objective: Several studies have been conducted around the world on the impact of COVID-19 on people with diabetes mellitus (DM). Any acute illness can cause stress and increased inflammatory reactions, which increase sympathetic outflow and produce catecholamines, growth hormones, cortisol, and cytokines, all of which raise the risk and severity of complications from diabetes. Diabetes is a significant risk factor for the severity of COVID-19. We conducted this study to identify whether severe COVID-19 infection has any effect on the biomarkers, including fasting blood sugar (FBS), HbA1C, FA, INS, C-Pep, in individuals with DM.

Methodology: This study was simultaneously conducted at Department of Chemistry and Biochemistry, College of Medicine of Al-Nahrain University, and Department of Medicine of Mustansiriyah University College of Medicine, Baghdad, Iraq. During the months of February and March 2022, 50 COVID-19 patients with diabetes and 50 COVID-19 patients without diabetes were included in the study. The control group included 100 healthy, sexually identical people (age 50-80), collected under the supervision of the second supervisor from relatives and students of Mustansiriyah University, College of Medicine. Venous blood samples of 5 mL were taken from all participants and subjected to laboratory tests to detect the levels of the biomarkers.

Results: Average FBS level in DM patients was 304.9 mg/dL, (range 132-545.9 mg/dL), which was remarkably higher than in non-DM patient groups (193.3 mg/dL), range (of 66.2–458). The DM patients' group had a significantly higher concentration of HbA1C (median = 6.70 mg/dL, range 5.2-8.1) than the non-DM patient group (median = 5.8, range 4.2–7.6) with a significant difference. Although The group of DM patients had significantly greater FA concentrations than the group of non-DM patients. In contrast, the median and range for insulin and c-peptide Displays non-significant differences for covid-19 patients (DM and non-DM), but it's significant with a control group.

Conclusion: According to this study, COVID-19 patients with diabetes had greater biochemical indicator levels than non-diabetic people. Pre- and postprandial hyperglycemia and diabetic ketoacidosis were more common in COVID-19 DM patients than in non-infected DM patients. We found that COVID-19 increased the severity risk for T2DM patients and glucose level is raised and progresses in a vicious cycle exacerbated by insulin resistance (IR) and decreased pancreatic b-cell function^.

Keywords: COVID-19, Diabetes mellitus, FBS, HbA1C, FA, INS, C-Pep

Citation: Yones MS, Al-Wasiti E, Al Qaseer AH, Al-Rubaiawi HK. The effect of severe COVID-19 infection on biochemical markers (FBS, HbA1C, FA, INS, C-Pep) in diabetic patients. Anaesth. pain intensive care 2024;28(5):804−808; DOI: 10.35975/apic.v28i5.2553

Received: June 01, 2024; Reviewed: June 19, 2024; Accepted: June 19, 2024

Dexmedetomidine-propofol versus ketamine-propofol for sedation of cancer patients undergoing computerized tomography guided bone biopsy: a randomized double-blind trial

Tue, 08 Oct 2024 00:00:00 -0600

Background & Objective: Patients suffering from malignancy, often need to undergo computed tomography (CT) for evaluation or for CT-guided bone biopsy. They are shifted to the radio-diagnostic suite and require sedation and analgesia during this procedure. We compared the efficacy and safety of combining dexmedetomidine (DEX) or ketamine with propofol for better sedation among these patients undergoing CT-guided bone biopsy.

Methodology: This randomized, double-blind study was done on 60 adult cancer patients undergoing CT-guided bone biopsy. Patients were randomized into two equal groups. Group D received DEX 1 µg/kg (over 10 min) + propofol 2.5 mg/kg intravenous (IV). It was followed by DEX 0.5 µg/kg/h + propofol 2.5 mg/kg/h infusion. Group K received ketamine 1 mg/kg + propofol 2.5 mg/kg IV, followed by ketamine 0.25 mg/kg/h + propofol 2.5 mg/kg/h infusion.

Results: The total intra-procedure propofol consumption was significantly decreased in Group D than in Group K (P < 0.05). The visual analog scale score at 15 min and 30 min post-procedure, number of patients requiring morphine and paracetamol within one hour of procedure and the recovery times were significantly decreased in Group D than in Group K (P < 0.05). Mean arterial pressure (MAP) and heart rate (HR) measurements at 10 min, 20 min, end of the procedure, and 15 min, 30 min post-procedure was significantly decreased in Group D than in Group K (P < 0.05). Adverse events, e.g., postoperative nausea and vomiting, hypotension, and bradycardia, were comparable.

Conclusion: DEX-propofol combination had superior sedation efficacy as noted through lower pain scores, intraprocedural propofol or postprocedural morphine and paracetamol consumption, and the shorter recovery time during CT-guided bone biopsy compared to ketamine-propofol combination. However, ketamine-propofol combination exhibited superior hemodynamic stability, as shown by more consistent HR and MAP.

Keywords: Dexmedetomidine; Ketamine; Propofol; Computed tomography; Bone biopsy; Morphine

Citation: Abdelgalil AS, Mohammed AM, Abdelrahman AS, Zayed NOA. Dexmedetomidine-propofol versus ketamine-propofol for sedation of cancer patients undergoing computerized tomography guided bone biopsy: a randomized double-blind trial. Anaesth. pain intensive care 2024;28(5):809−815; DOI: 10.35975/apic.v28i5.2554

Received: Jun 17, 2024; Reviewed: Jul 31, 2024; Accepted: Aug 19, 2024

Perioperative assessment of diaphragmatic dysfunction in cardiac surgery patients and its effect on outcome; a prospective observational study

Tue, 08 Oct 2024 00:00:00 -0600

Objectives: While the assessment of the diaphragm in different clinical scenarios is quite frequent, there remains a scarcity of studies focused on assessing diaphragm dysfunction using ultrasound in cardiac surgery patients. We investigated the impact of cardiopulmonary bypass (CPB) surgery on diaphragm function and evaluated its effects on mechanical ventilation.

Methodology: A prospective cohort study, on 100 consecutive adult cardiac surgery patients, was conducted at National Heart Institute. Diaphragmatic displacement (DD) or excursion and diaphragmatic thickening fraction (DTF) were measured using motion-mode ultrasound during quite normal breathing pre-operatively (the day before surgery) and post-operatively on mechanical ventilation, while the patient was fully conscious and spontaneously breathing on continuous positive airway pressure (CPAP) mode + pressure support 10 cmH₂O. Then, the results were correlated to CBP time and important patient outcomes.

Results: Post-operative DD was significantly less as compared to the pre-operative reading; (1.39 ± 0.42 cm vs. 2.3 ± 0.52 cm; P < 0.001), as was DTF (23% ± 10% vs. 40% ± 13%; P < 0.001). The incidence of diaphragmatic dysfunction post-cardiac surgery was 17% by the definition of DD < 1 cm, and 49% by the definition of DTF ≤ 20%. DD was positively correlated with CBP time, as well as total ventilation time and ICU stay, indicating a negative impact on overall patient outcomes.

Conclusion: The results suggest that diaphragmatic dysfunction is positively correlated with CPB time, total ventilation time and ICU stay, underscoring the importance of monitoring diaphragmatic function in post-operative patients, who are difficult to wean from mechanical ventilation with apparently normal chest X-ray, particularly those with prolonged CPB time.

Keywords: cardiac surgery; cardiopulmonary bypass; diaphragm dysfunction; diaphragmatic displacement; diaphragm ultrasound; mechanical ventilation.

Citation: Omara ISM, Nagi HK, Mohamed KAA, Abd El Haq HH, Awdallah FF. Perioperative assessment of diaphragmatic dysfunction in cardiac surgery patients and its effect on outcome; a prospective observational study. Anaesth. pain intensive care 2024;28(5):816−823; DOI: 10.35975/apic.v28i5.2555

Received: June 28, 2024; Reviewed: September 04, 2024; Accepted: September 06, 2024

Post-induction hypotension following entropy guided equipotent doses of propofol and thiopental in elderly surgical patients

Tue, 08 Oct 2024 00:00:00 -0600

Background & Objective: Geriatric patients with reduced vascular auto regulation ability are susceptible to blood pressure fluctuations after anesthesia induction and specifically may suffer from hypotension, showing heightened sensitivity to anesthetics. It is unclear which induction agent, thiopental or propofol, is preferable with regard to hemodynamic stability after anesthesia induction. EEG “entropy” may help titrate induction doses and thus reduce their adverse effects in this category of patients. We conducted this research to compare the two drugs, using entropy to guide the induction dose, regarding hemodynamic stability.

Methodology: Sixty patients, over 65 years old, were randomly divided into two groups based on the anesthetic induction agent: Group P (propofol) and Group T (thiopental). Arterial blood pressure (ABP), heart rate (HR), induction doses, and postoperative Troponin I levels denoting myocardial injury secondary to hypotension were measured.

Results: Group P had more post-induction hypotension and less HR changes than Group T (P < 0.001). Induction doses in both groups were less than the conventional range. Troponin I levels in both groups were similar and statistically insignificant.

Conclusion: Induction technique with thiopental guided with entropy provided greater hemodynamic stability, with reduced fall in systolic, diastolic and mean arterial pressure in elderly surgical patients compared to those who were administered propofol guided with entropy.

Trial Registry: PACTR202406560110826.

Abbreviations: EEG - Electroencephalography; EMG - electromyography; PIH - post-induction hypotension; SE- state entropy; RE - response entropy;

Keywords: Propofol; Thiopental; Post-induction hypotension; Entropy; Elderly.

Citation: Ghaly SI, Zaki GFS, Shmas Eldin MMK, El Emary YIMM. Post-induction hypotension following entropy guided equipotent doses of propofol and thiopental in elderly surgical patients. Anaesth. pain intensive care 2024;28(5):824−829; DOI: 10.35975/apic.v28i5.2551

Received: June 22, 2024; Reviewed: July 16, 2024; Accepted: July 20, 2024

Establishing capsaicin's anti-cancer intricacies in chronic myelogenous leukemia care: insights from human K562 cells

Tue, 08 Oct 2024 00:00:00 -0600

Objective: We aimed to establish capsaicin as a potent natural chemotherapeutic agent in chronic myeloid leukemia by unveiling anti-cancer mechanisms, concentrating at pro-apoptotic and anti-proliferative effects on K562 cells.

Methodology: After REC approval, this research proceeded with culturing K562 cells and treatment with serial concentrations of capsaicin for calculation of subsequent 50% Inhibitory Concentration (IC50) values via MTT [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide] assay, expression analysis of gene, comparative analysis of relative gene fold (intrinsic biomarkers caspase-3, caspase-9) as apoptosis mediator biomarkers followed by Quantitative Reverse Transcription Polymerase Chain Reaction (RT-qPCR). Anti-proliferative activity was confirmed via Nitric Oxide (NO) releasing Assay.

Results: For K562 cells, the IC50 of capsaicin (12.1 µM) showed high gene expression of intrinsic pro-apoptotic biomarkers caspase-3 and caspase-9 with the relative gene fold of 12.1 and 13.9 respectively. Persistent peaks of NO levels confirmed the anti-proliferative potential of the compounds. Strongest growth inhibitory activity was seen at the peak time of 100-120 min.

Conclusion: Capsaicin proved to be a strong pro-apoptotic and anti-proliferative phytochemical agent leading to therapeutic effects against K562 cells. Further studies would help in identifying key molecular intricacies by which capsaicin exhibits diversified anti-cancer potential.

Abbreviations: CML - chronic myelogenous leukemia; NO - Nitric oxide; ROS - Reactive Oxygen Species; ROS - Reactive Oxygen Species

Keywords: Capsaicin, Pro-apoptotic Effects, Anti-Cancer Mechanisms, K562 cells, Natural Chemotherapeutics

Citation: Devi D, Nangdev P, Khaliq HMH, Anique M, Moqaddas A, Aziz O, Javed W. Establishing capsaicin's anti-cancer intricacies in chronic myelogenous leukemia care: insights from human K562 cells. Anaesth. pain intensive care 2024;28(5):830−835; DOI: 10.35975/apic.v28i5.2494

Received: June 26, 2024; Reviewed: August 10, 2024; Accepted: August 16, 2024

Evaluation of alpha Klotho and fibroblast growth factor-23 levels in Iraqi patients with Graves’ disease

Munaf Faraj Rashid, Haider Abd Jabbar Alammar, Abbas Mahdi Rahmah — Tue, 08 Oct 2024 00:00:00 -0600

Background & Objective: Graves’ disease (GD) is an autoimmune condition that targets the thyroid gland, resulting in excessive stimulation and synthesis of thyroid hormones. Excessive synthesis of these hormones can lead to symptoms such as loss of body weight, accelerated heart rate, irritability, reduced tolerance to heat, and excessive perspiration. Alpha-Klotho (KL), a protein crucial for physiological processes, is also involved in GD. The defective immunological condition of GD patients may increase Klotho expression, and the enhanced expression of fibroblast growth factor-23 (FGF23) in GD may be linked to the disease pathophysiology.

We investigated serum levels of KL and FGF23 in Iraqi patients with Graves’ disease, analyzing correlations with clinical status and evaluating their potential as biomarkers for disease activity.

Methodology: We conducted this cross-sectional study at The National Diabetes Center, Mustansiriyah University, between December 2022 and April 2023. The study involved 103 patients diagnosed with GD, and 103 patients, aged 21-70 y, as a control group. Patients with multinodular goiter, single thyroid nodules, thyroiditis, pregnant women, and those on medications or oral contraceptives, were excluded.

Result: clinical significance of FGF23 and Klotho (KL) levels in patients with Graves’ disease (GD) compared to a control group. Results indicate that the median of KL levels are significantly higher in GD patients (KL = 6.31) compared to the control group (KL = 2.40), with a highly significant difference (P < 0.001). In contrast, differences in median of FGF23 levels between GD patients (149) and controls (86.05) were not statistically significant (P = 0.07). Furthermore, KL levels were significantly higher in hyperthyroid patients compared to other thyroid statuses (P = 0.023), while FGF23 levels did not significantly differ across thyroid statuses (P = 0.255). Additionally, the study found a strong correlation between TRAb levels and both KL (r = 0.291, P < 0.001) and FGF23 (r = 0.211, P = 0.003), and between KL and FGF23 directly (r = 0.412, P < 0.001). These findings suggest that while KL may be a significant biomarker in GD, FGF23 relevance appears limited in this context.

Conclusion: In Graves’ Disease patients have significantly higher levels of KL and FGF23 compared to controls, suggesting a distinct pathophysiological role for these biomarkers in mineral homeostasis and thyroid hormone regulation.

Abbreviations: AITD - Autoimmune thyroid diseases; KL - Alpha-Klotho; FGF23 - fibroblast growth factor-23; GD - Graves’ disease; HT - Hashimoto's thyroiditis; IGF-1R - Insulin-like Growth Factor-1 Receptor;

Keywords: Autoimmune Thyroid Disorders, Hyperthyroidism, Graves’ disease, Alpha-Klotho

Citation: Rashid MF, Alammar HAJ, Rahmah AM. Evaluation of alpha Klotho and fibroblast growth factor-23 levels in Iraqi patients with Graves’ disease. Anaesth. pain intensive care 2024;28(5):836−841.

DOI: 10.35975/apic.v28i5.2567

Received: June 16, 2024; Reviewed: July 07, 2024; Accepted: July 18, 2024

Comparison of the effect of lidocaine and its combination with melatonin and the Valsalva maneuver on etomidate induced injection pain

Behzad Nazemroaya, Hossein Dehghani Poudeh — Sat, 10 Aug 2024 00:00:00 -0600

Background & Objective: Etomidate is commonly used in anesthesia practice because of its rapid recovery time, low incidence of apnea, and lower incidence of allergic reactions; but pain upon injection is one of the unfavorable complications of this drug, which can cause both physical and mental discomfort to the patients. It is imperative to use appropriate means to lower the pain at the injection site of etomidate in patients undergoing anesthesia. We conducted this study to compare the effects of lidocaine, lidocaine and the Valsalva maneuver, with a combination of lidocaine, melatonin and the Valsalva maneuver on decreasing the pain of etomidate injection.

Methodology: This clinical trial enrolled 135 patients. The patients were allocated into 3 groups, with one group receiving lidocaine (Group 1), the second group receiving lidocaine and the Valsalva maneuver (Group 2), and the last group receiving a combination of lidocaine, melatonin and the Valsalva maneuver. The pain resulting from injecting etomidate was evaluated based upon the Visual Analog Scale (VAS) score (with 1 being no pain and 10 the most severe imaginable pain). Data were compared and analyzed using proper statistical tests using SPSS version 23.

Results: The results of this study showed that the overall pain score in all of the groups after injection of etomidate did not show any significant difference. The mean VAS score in Group 1 was 0.27 ± 0.88, in Group 2 it was 0.16 ± 0.63, and in Group 3 0.04 ± 0.2. However, the difference between the groups was statistically not significant (P = 0.32).

Conclusion: The current study shows that the pain on injection of etomidate in the three groups of the study was reduced in a similar fashion; however, in the group which combined lidocaine, melatonin and the Valsalva maneuver, pain was the lowest, but the overall differences in score in the three groups were statistically not different.

Keywords: Etomidate, lidocaine, melatonin, Valsalva maneuver.

Citation: Nazemroaya B, Poudeh ND. Comparison of the effect of lidocaine and its combination with melatonin and the Valsalva maneuver on etomidate induced injection pain. Anaesth. pain intensive care 2024;28(5):842−849; DOI: 10.35975/apic.v28i5.2279

Received: July 27, 2024; Reviewed: September 04, 2024; Accepted: September 09, 2024

A comparative study between dexmedetomidine and dexamethasone as adjuvants to bupivacaine in ultrasound guided interscalene block for arthroscopic shoulder surgery

Tue, 08 Oct 2024 00:00:00 -0600

Background & Objectives: Arthroscopic surgery is a preferred approach for shoulder surgeries due to its documented advantages of early postoperative recovery. However, postoperative pain remains a concern for which different techniques are used. Interscalene block (ISB), using dexmedetomidine (DXM) or dexamethasone (DXA) as adjuvants to local anesthetics (LA), is a common analgesic method. We conducted this comparative study to establish if any one of the adjuvants is better in terms of postoperative analgesia.

Methodology: Patients undergoing shoulder arthroscopy were assigned randomly to three groups: Group A (LA alone), Group B (ISB with DXM), and Group C (ISB with DXA). Assessment of intraoperative and postoperative hemodynamics, visual analog scale (VAS) pain scores, time to first rescue analgesic, and rescue analgesic (ketorolac) consumption were recorded.

Results: Intraoperative and postoperative heart rate and mean arterial pressure showed no significant differences among the three groups, suggesting comparable hemodynamic control. VAS pain scores were equivalent at 1, 2 and 6 h postoperatively, but at 12, 18 and 24 h, Groups B and C demonstrated significantly lower scores compared to Group A (P < 0.001). Time to first rescue analgesic was prolonged in Groups B and C, indicating improved and longer-lasting analgesia. Groups B and C consumed considerably less ketorolac overall than Group A (P < 0.001).

Conclusion: While all three groups exhibited equivalent intraoperative and postoperative hemodynamic control, the addition of dexmedetomidine or dexamethasone to local anesthetics for interscalene block prolonged postoperative analgesia, reduced pain scores at 12, 18 and 24 h, delayed time to first rescue, and decreased total analgesic consumption. Both adjuvants showed advantages over local anesthetics alone, emphasizing their potential in multimodal analgesia for shoulder arthroscopy.

Abbreviations: ISB - Interscalene block; DXM - Dexmedetomidine; DXA - Dexamethasone; HR – Heart Rate; MAP – Mean Arterial Pressure; VAS Visual Analog Scale.

Trial registry: PACTR202210507488378

Keywords: Analgesia; Analgesia, postoperative; Dexmedetomidine; Dexamethasone; Interscalene block; Pain, postoperative; Shoulder arthroscopy

Citation: Nashaat P, Mohamed O, George S, Mohammed A, Samy E. A comparative study between dexmedetomidine and dexamethasone as adjuvants to bupivacaine in ultrasound guided interscalene block for arthroscopic shoulder surgery. Anaesth. pain intensive care 2024;28(5):850−858; DOI: 10.35975/apic.v28i5.2566

Received: June 13, 2024; Reviewed: June 20, 2024; Accepted: July 18, 2024

Reliability of the Revised Neurophysiology of Pain Questionnaire-Turkish in patients with neck pain: a cross-validation study

Tue, 08 Oct 2024 00:00:00 -0600

Background & Objectives: The Neurophysiology of Pain Questionnaire (NPQ) measures the level of knowledge of patients and healthcare professionals regarding the neurophysiology of pain. The revised Turkish (Tr) version has low reliability for patients with chronic spinal pain. In this study, we investigated the reliability of the Revised NPQ-Tr in patients with neck pain.

Methodology: The Revised NPQ-Tr was administered to 219 participants suffering from neck pain for at least 3 months, who were between the ages of 25 and 60 y and native Turkish speakers. Correct responses were awarded one point, while undecided or incorrectly marked responses were awarded 0 points. In order to analyse the validity of the test, the high-scoring and low-scoring groups were compared. Using the percentage of correct responses in the high and low scoring groups, we calculated the difficulty of the item (P-value) and the discrimination power of the item (r).

Results: Responses to the questionnaire were highly correlated. Items 1 and 2 had high discrimination power (r > 0.40), and items 3 and 5 had very good item quality (0.30 < r < 0.39). Among the items ranked between 1-7 and 9-12 in terms of difficulty of the item and discrimination power, only item 8 was found to be a difficult yet discriminating item (P < 0.60). According to Cronbach's alpha (0.81) and Kuder-Richardson-20 (0.81) coefficients, the questionnaire had a high internal consistency and reliability, and a split-half correlation coefficient (0.802) determined its internal consistency and reliability.

Conclusion: We conclude that the Neurophysiology of Pain Questionnaire-Turkish can be used on neck pain, and it is reliable and highly valid.

Keywords: Chronic Pain, neck pain, pain knowledge, pain education, pain beliefs, Turkish language, reliability, validity.

Citation: Yasarer O, Sari Z, Copuroglu OB, Eker TA, Aydogdu O. Reliability of the Revised Neurophysiology of Pain Questionnaire-Turkish in patients with neck pain: a cross-validation study. Anaesth. pain intensive care 2024;28(5):859−865; DOI: 10.35975/apic.v28i5.2552

Received: August 04, 2024; Reviewed: August 14, 2024; Accepted: August 17, 2024

Comparative evaluation of intrathecal hyperbaric bupivacaine alone versus combined with dexmedetomidine for cesarean sections

Rida Amjad Qureshi, Humaira Jadoon, Mahnoor Shabbir — Sat, 10 Aug 2024 00:00:00 -0600

Background & Objective: This study examined the use of dexmedetomidine 5 μg as an adjuvant to 10 mg of intrathecal hyperbaric 0.5% bupivacaine in elective cesarean sections and aimed to assess dexmedetomidine’s impact on block characteristics and post-operative pain management. As spinal anesthesia is commonly employed for cesarean deliveries, the study seeks to determine whether the addition of dexmedetomidine as an adjuvant can prolong the duration and enhance the quality of the block, leading to improved post-operative pain relief.

Methodology: This randomized controlled trial included 100 parturients undergoing elective cesarean section over a period of six months. Participants were allocated to either Group B or Group D using a non-random consecutive sampling technique. In Group D, 2 mL of 0.5% bupivacaine mixed with 0.05 mL of dexmedetomidine (5µg) was injected intrathecally, while Group B received 2 mL of 0.5% hyperbaric bupivacaine along with an equivalent volume of saline. Sensory and motor block assessments were conducted prior to the start of surgery. Post-operatively, the duration of motor block and post-operative pain relief were assessed.

Results: The addition of dexmedetomidine as an adjuvant to intrathecal bupivacaine resulted in significant reductions in the onset time of sensory block (4.22 ± 0.79 min vs 5.66 ± 1.21 min) and motor block (4.20 ± 0.81min vs 6.32 ± 1.20 min) (P < 0.001). Furthermore, the duration of motor block was longer in the dexmedetomidine + bupivacaine group compared to the bupivacaine alone group (7.32 ± 0.95 h vs 4.38 ± 1.27 h). Additionally, patients who received intrathecal dexmedetomidine as an adjuvant to bupivacaine experienced significantly longer durations of post-operative analgesia (7.32 ± 0.95 h) as compared to the bupivacaine alone group (4.38 ± 1.27 h) (P < 0.001).

Conclusion: Dexmedetomidine as an intrathecal adjuvant to hyperbaric bupivacaine extends the duration of analgesia and motor block, providing prolonged pain relief. Additionally, it exhibits an early onset of sensory and motor block, ensuring prompt pain relief and rapid anesthesia onset.

Clinical Trial Registration: [www.clinicaltrials.gov], identifier: ID NCT05469529

Abbreviations: CS - cesarean section; OT - Operation Theater; SA - Spinal anesthesia; VAS - visual analogue scale;

Keywords: cesarean section, dexmedetomidine, bupivacaine, spinal anesthesia

Citation: Qureshi RA, Jadoon H, Shabbir M. Comparative evaluation of intrathecal hyperbaric bupivacaine alone versus combined with dexmedetomidine for cesarean sections. Anaesth. pain intensive care 2024;28(5):866−870.

DOI: 10.35975/apic.v28i5.2558

Received: December 03, 2023; Reviewed: December 15, 2023; Accepted: August 16, 2024

Integrating eugenol with intensive care in leukemia patients: exploration of pro-apoptotic potential against HL-60, human leukemia cell line

Sun, 08 Dec 2024 00:00:00 -0700

Objective: The objective of this in-vitro study was to explore the pro-apoptotic potential of eugenol (4-allyl-2-methoxyphenol) on Human Leukemia-60 (HL-60) cell line as a potent phytochemical in intensive care setting to leukemia patients.

Methodology: After formal approval by all of the respective ethical committees, this study was simultaneously conducted at all respective institutional departments. The study included culturing HL-60 cell line and its treatment with serial concentrations of eugenol for calculation of subsequent IC50 values (half-maximal inhibitory concentration) via MTT [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide] assay, expression analysis of gene, comparative analysis of relative gene fold (Intrinsic Biomarkers Caspase-3, Caspase-9) as apoptosis mediator markers followed by RT-qPCR. Cellular apoptotic morphology was confirmed via Hoechst 333258 staining.

Results: For HL-60 cell line, the IC₅₀ of eugenol (14.1 uM) showed high gene expression of pro-apoptotic biomarkers (Caspase-3 and Caspase-9). Hoechst 333258 staining showed prominent apoptotic bodies leading to nuclear fragmentations.

Conclusion: Eugenol proved to possess robust pro-apoptotic potential leading to diagnostic efficacy against leukemia HL-60 cell line. Further studies would help in identifying key mechanisms by which eugenol exhibits anti-cancer potential against HL-60 cell lines.

Abbreviations: HL-60 - Human Leukemia-60; IC50 - Half-Maximal Inhibitory Concentration

Keywords: Eugenol, Pro-apoptotic Effects, Intensive Care, Anti-Cancer Mechanisms, HL-60, Natural Chemotherapeutics

Citation: Khaliq HMH, Bughio R, Nangdev P, Aziz O, Javed W. Integrating eugenol with intensive care in leukemia patients: exploration of pro-apoptotic potential against HL-60, human leukemia cell line. Anaesth. pain intensive care 2024;28(5):871−875; DOI: 10.35975/apic.v28i5.2491

Received: June 18, 2024; Reviewed: August 03, 2024; Accepted: August 11, 2024

Development of ventilator-associated pneumonia (VAP) prevention model in the hospital based on Six Sigma and VAP Bundle

Tue, 08 Oct 2024 00:00:00 -0600

Background & Objective: Ventilator-Associated Pneumonia (VAP) is the leading cause of death in Healthcare-Associated Infections (HCAI), with 30-day mortality of 59% of patients with ventilator devices. The aim of this research was to develop a VAP prevention model in the intensive care unit (ICU) based on Six Sigma and VAP Bundle, involving individual, organizational and work characteristics factors.

Methodology: This research was carried out in the ICU, Poltekkes Kemenkes Malang, Malang, Indonesia, using a cross-sectional design. The research subjects were nurses, selected using a simple random sampling technique. All variables were measured through filling out questionnaires. Next, the measurement data was analyzed using Partial Least Square (PLS), based on Six Sigma and VAP Bundle.

Results: Based on Six Sigma and VAP Bundle, the results of the analysis of the effects of the three factors on the implementation of VAP prevention were: 1) for individual factors, path coefficient = 0.189 and P = 0.000, so it was interpreted that this factor had a significant effect on the implementation of VAP prevention; 2) for organizational factors, path coefficient = 0.496 and P = 0.003, so it was interpreted that this factor also had a significant effect; 3) for the work characteristics factors, path coefficient = 0.289 and P = 0.000, so this factor also had a significant effect on the implementation of VAP prevention.

Conclusion: Based on the research results, a VAP prevention model based on Six Sigma and VAP bundle was successfully built in the ICU, which involved organizational factors, work characteristics and individual factors.

Abbreviations: HCAI - Healthcare-Associated Infections; HAP - Hospital-acquired pneumonia; PLS - Partial Least Square; SOP - standard operating procedure; VAP - ventilator-associated pneumonia;

Keywords: Ventilator-Associated Pneumonia, VAP, Prevention; Six Sigma, VAP Bundle; Intensive Care Unit; organizational factors; work characteristics; individual factors

Citation: Yuswanto TJA, Ernawati N, SolikhahFK, Nugroho HSW. Development of a prevention model for ventilator-associated pneumonia based on Six Sigma and VAP bundle. Anaesth. pain intensive care 2024;28(5):876−882; DOI: 10.35975/apic.v28i5.2574

Received: July 14, 2024; Reviewed: July 28, 2024; Accepted: July 28, 2024

Clinical significances of circulating serum fetuin-A, netrin-1, and ɑ-hydroxybutyrate levels in type 2 diabetes mellitus patients with and without hypertension

Hasan Abd Ali Khudhair, Abdulkareem M. Jewad, Hasan Abd Ali Khudhair — Tue, 08 Oct 2024 00:00:00 -0600

Background & Objective: Type 2 diabetes (T2D) is a rising global health issue, with biomarkers such as fetuin-A (Fet-A), netrin-1 (NTN-1), and alpha-hydroxybutyrate (α-HB) showing potential for early diagnosis and management. These biomarkers can help predict T2D risk and understand insulin resistance (IR), emphasizing the need for further research. The current investigation evaluated the effectiveness of Fet-A, NTN-1, and, α-HB as novel biomarkers to diagnose T2D with hypertension.

Methodology: A cross-sectional study was conducted from August to December 2023, involved 60 diabetic participants, which were divided into two groups: T2D without hypertension and T2D with hypertension. A third group consisted of 30 healthy controls (HC) for comparison. Serum samples were analyzed for fasting blood glucose (FBG) using the Roche/Cobas c111 system, as well as insulin, Fet-A, NTN-1, and α-HB levels using kits for the enzyme-linked immune-sorbent assay (ELISA). Descriptive statistics were used in the statistical package for social sciences (SPSS) for data analysis.

Results: The study found significantly elevated Fet-A, NTN-1, and α-HB levels in T2D patients compared to HC, with no significant differences between T2D subgroups. Fetuin-A and α-HB showed non-significant correlations with FBG and homeostatic model assessment of IR (HOMA-IR) across all groups. NTN-1 positively correlated with FBG and HOMA-IR in T2D patients with hypertension.

Conclusions: Elevated levels of fetuin-A and netrin-1, regardless of the presence of hypertension, are suggested by the study as possible biomarkers for the diagnosis of T2D. Netrin-1's significant correlation with HOMA-IR in hypertensive T2D patients underscores its utility in assessing insulin resistance severity. Although alpha-hydroxybutyrate levels were higher in T2D patients, their non-significant correlation with FBG and HOMA-IR requires further research. These biomarkers could aid in early diagnosis and disease monitoring for T2D management.

Abbreviations: α-KB - α-ketobutyrate; ELISA - enzyme linked immune-sorbent assay; FA - fatty acids; FBG - fasting blood glucose; Fet-A - fetuin-A; HOMA-IR - homeostatic model assessment of IR; IR - insulin resistance; NAD - nicotinamide adenine dinucleotide; NADH - nicotinamide adenine dinucleotide hydrogen; ng - nanograms; NTN-1 - netrin-1; PB - peripheral blood; pg - picogram; SPSS - Statistical Package for Social Sciences; T2D - Type-2 diabetes mellitus; α-HB - alpha-hydroxybutyrate

Keywords: Diabetes, Fetuin-A, Netrin-1, α-HB, HOMA-IR.

Citation: Sfayyih HS, Jewad AM, Khudhair HAA. Clinical significance of circulating serum fetuin-A, netrin-1, and ɑ-hydroxybutyrate levels in type-2 diabetes mellitus patients with and without hypertension. Anaesth. pain intensive care 2024;28(5):883−893; DOI: 10.35975/apic.v28i5.2569

Received: Jul 22, 2024; Reviewed: August 10, 2024; Accepted: August 15, 2024

A comparative study between dexmedetomidine versus magnesium sulphate for controlled hypotensive anesthesia in rhinoplasty surgeries

Tue, 08 Oct 2024 00:00:00 -0600

Background: Rhinoplasty, a widely performed surgical procedure globally, necessitates hypotensive anesthesia to minimize bleeding, which can otherwise compromise surgical outcomes. Controlled hypotension anesthesia enhances the bloodless surgical area, reduces postoperative edema and ecchymosis, and can shorten the duration of the procedure. Many drugs have been used to attain hypotensive anesthesia, including magnesium sulfate, volatile anesthetics, and beta-adrenergic blocking agents. We compared dexmedetomidine with magnesium sulfate for producing hypotensive anesthesia in patients undergoing rhinoplasty.

Methodology: We included 42 patients, aged 18-60 y, undergoing rhinoplasty and allocated into Group D and Group M. Group D received dexmedetomidine 1 µg/kg diluted in 50 mL of normal saline, administered IV over 10 min prior to anesthesia. Group M received magnesium sulfate 40 µg/kg diluted as infusion. Both groups received continued infusions afterwards. General anesthesia was induced with propofol and atracurium, intubation done and maintained on sevoflurane in N₂O and O₂. Vital signs were monitored continuously. The efficacy of hypotensive anesthesia was assessed, along with the recording of postoperative complications and the surgeons’ satisfaction.

Results: Group D and Group M showed no significant variation in mean arterial pressure. However, significant variation was observed in heart rate (P < 0.05). Group D had better operating area score compared to Group M. Surgeons; satisfaction was notably elevated in the Group D than in the Group M (P < 0.05). Opioids needed were significantly less in the Group D in contrast to the Group M. The amount of atropine needed was higher in the Group D than in the Group M (P < 0.05).

Conclusion: Dexmedetomidine proved to be better than magnesium sulfate in achieving hypotensive anesthesia together with providing optimal surgical field conditions. Although magnesium sulfate necessitated additional nitroglycerine, dexmedetomidine increased the risk of bradycardia but reduced the analgesic requirements compared to magnesium sulfate. These factors are crucial when considering the use of dexmedetomidine in rhinoplasty surgery.

Trial Registry: PACTR202408620568675.

Keywords: hypotensive anesthesia; magnesium sulphate; dexmedetomidine

Citation: Abd Elhalem SAA, Ahmed Abd ElAala El-Shawarby AE, Hakim KYK, Abdel Rahman YA, Khalifa AAG. A comparative study between dexmedetomidine versus magnesium sulphate for controlled hypotensive anesthesia in rhinoplasty surgeries. Anaesth. pain intensive care 2024;28(5):894−900; DOI: 10.35975/apic.v28i5.2537

Received: August 21, 2024; Reviewed: September 6, 2024; Accepted: September 9, 2024

C-reactive protein/albumin ratio versus lactate/albumin ratio as an outcome predictor for patients with sepsis and septic shock in hospital stay

Khaled Abdou, Madonna Mounir Salama, Samia Abdelmohsen, Sameh Salem, Ahmed Ali — Tue, 08 Oct 2024 00:00:00 -0600

Background & Objective: Pre-emptively identifying individuals at risk of developing sepsis and septic shock remains challenging. In septic patients, the Lactate/Albumin Ratio (LAR) and C-reactive protein (CRP)/Albumin ratio (CAR) have been suggested to be promising prognostic indicators for prediction of intensive care unit (ICU) mortality. We compared the prognostic values of CAR and LAR in patients with sepsis and septic shock.

Methodology: Eighty adult patients diagnosed with sepsis and admitted to the ICUs of Ain Shams University Hospitals, were included in this observational prospective study. CRP levels, serum lactate, serum albumin, complete blood count (CBC), procalcitonin levels, and SOFA scores were assessed upon admission, with subsequently observing 28-day mortality among the selected patients.

Results: CAR values were comparable between the mortality and survival groups (P = 0.807). However, LAR values were significantly elevated in the mortality group vs the survival group (P = 0.044). ROC analysis for mortality indicated that LAR had an AUC of 0.633 at a cutoff value > 0.68, achieving sensitivity and specificity of 89.4% and 21.2%, respectively. In contrast, CAR had an AUC of 0.484 at a cutoff value ≥ 1.54, with sensitivity and specificity values of 63.8% and 57.6%, respectively. Length of ICU stay (P < 0.001), duration of mechanical ventilation (P < 0.001), cardiovascular support (P < 0.001) and the need for renal replacement therapy (P < 0. 039), were increased in the mortality group compared to the survival group.

Conclusion: Lactate/albumin ratio is superior and more reliable bio-marker predictor compared to C-reactive protein (CRP)/albumin ratio for ICU mortality.

Abbreviations: CAR - C-reactive protein/albumin ratio; CRP - C-reactive protein; ICU - intensive care unit; LAR - Lactate/Albumin Ratio;

Keywords: Albumin; CRP To Albumin Ratio; Lactate; Lactate to Albumin Ratio; Mortality; Sepsis; Septic Shock; SOFA; Survival

Citation: Abdou K, Mounir M, Abdelmohsen S, Salem S, Ali A. C-reactive protein/albumin ratio versus lactate/albumin ratio as an outcome predictor for patients with sepsis and septic shock in hospital stay. Anaesth. pain intensive care 2023;28(5):901−907; DOI: 10.35975/apic.v27i5.2571

Received: July 29, 2024; Reviewed: August 23, 2024; Accepted: August 28, 2024

The association between retinol binding protein 4 and peripheral neuropathy in type 2 diabetic patient

Iman Ali Nafakhi, Nibras H. Abdalsada — Tue, 08 Oct 2024 00:00:00 -0600

Background & Objective: The most common microvascular consequence of diabetes is peripheral neuropathy. A very common ailment that has a significant impact on a patient's quality of life is peripheral neuropathy (PN). The purpose of this study was to look into the possible link between retinol binding protein 4 (RBP4) and peripheral neuropathy in individuals with type 2 diabetes mellitus (T2D), as the relationship between RBP4 and PN is still unclear.

Methodology: We enrolled 152 participants who were matched for age and sex in a case control study during August and December 2023. There were 50 healthy controls, 50 diabetic patients without PN, and 52 diabetic patients with PN. ELISA was used to measure serum RBP4.

Results: Diabetic individuals with PN had significantly greater serum levels of RBP4 than diabetic patients without PN (P ˂ 0.001). Increased age (r = 0.262, P ˂ 0.01), DM duration (r = 0.565, P ˂ 0.01), and BMI (r = 0.183, P ˂ 0.05) were all substantially linked with RBP4 levels. RBP4 levels exhibited a negative correlation with high-density lipoproteins (HDL) and a positive correlation with total cholesterol, triglycerides, low-density lipoprotein (LDL), and very low-density lipoprotein (VLDL).

Conclusion: Elevated RBP4 level is strongly and independently linked with PN in type 2 diabetic patients, and may play an important role in PN progression.

Abbreviations: DM - Diabetes mellitus; PN - peripheral neuropathy; PBP4 - retinol binding protein 4; T2D - type 2 diabetes mellitus

Keywords: diabetes mellitus; peripheral neuropathy; retinol binding protein 4.

Citation: Nafakhi IA, Abdalsada NH. The association between retinol binding protein 4 and peripheral neuropathy in type 2 diabetic patient. Anaesth. pain intensive care 2024;28(5):908−913; DOI: 10.35975/apic.v28i5.2563

Received: May 03, 2024; Reviewed: June 04, 2024; Accepted: August 23, 2024

The effect of using low dose norepinephrine before hypotensive resuscitation in hemorrhagic shock; a randomized controlled trial

Rabab Mohamed Mohamed, Atia Gad Anwar, Ahmed Aboelhasan Eid — Tue, 08 Oct 2024 00:00:00 -0600

Background & Objectives: Hemorrhagic shock is not a very rare occurrence in big hospitals. It might be encountered in the emergency room (ER) or in the operating rooms (OR). A rapid response and systematic management will save the life of the victim. The objective of this research was to investigate the impact of a low dose of norepinephrine (NE) administered prior to the initiation of hypotensive resuscitation in patients with hemorrhagic shock.

Methodology: This randomized controlled trial was conducted on 200 participants, at least 18 years old, classified as severely traumatized and had significant hemorrhage with mean arterial pressure ranging from 65 to 75 mmHg. We divided the patients into two equal groups. Group I received a low dose of NE (< 0.3 µg/kg/min) concurrently with resuscitation fluids. Group II received resuscitative fluids only. If the resuscitative fluids failed to keep mean arterial pressure (MAP) > 65 mmHg, the patient was progressively administered NE even with high doses (0.05 to more than 0.3 µg/kg/min). The primary outcome was 24-hour mortality. In-hospital mortality, incidence of acute kidney injury (AKI), and duration of hospital and intensive care unit (ICU) stay constituted the secondary outcomes.

Results: Group I had lower 24-hour mortality compared to Group II (3% vs 13%; P < 0.05). Compared to Group II, Group I needed reduced amount of fluid resuscitation within 24 h, had lower serum lactate levels at 6 and 12 h, and lower serum creatinine at 6, 12, and 18 h (P < 0.001). Group I had a lower incidence of mechanical ventilation (13% vs 27%), hospital and ICU stays, and in-hospital mortality (9% vs 21%) (P < 0.05). There was a lack of disparity seen in the incidence of AKI and duration of mechanical ventilation.

Conclusion: Low-dose norepinephrine infusion during the early period of hypotensive resuscitation reduces resuscitative fluid requirement, improves tissue perfusion, preserves renal function, and lowers mortality in hemorrhagic shock patients.

Abbreviations: AKI - acute kidney injury; APACHE III - Acute Physiology And Chronic Health Evaluation III; HS - hemorrhagic shock; ICU - intensive care unit; MAP - mean arterial pressure; NE - Norepinephrine

Keywords: Hemorrhagic Shock; Hypotensive Resuscitation; Norepinephrine; Fluid Therapy; Renal Protection; Mortality; Low Dose

Citation: Mohamed RM, Anwar AG, Eid AA. The effect of using low dose norepinephrine before hypotensive resuscitation in hemorrhagic shock; a randomized controlled trial. Anaesth. pain intensive care 2024;28(5):914−921; DOI: 10.35975/apic.v28i5.2560

Received: April 17, 2024; Reviewed: August 03, 2024; Accepted: September 04, 2024

Comparative efficacy of intravenous tramadol and traditional blanket coverage in managing postoperative shivering among post-spinal anesthesia patients

Tue, 08 Oct 2024 00:00:00 -0600

Background & Objective: Shivering after general as well as spinal anesthesia is a common phenomenon. Unmanaged post-anesthetic shivering can worsen postoperative pain and patient’s metabolism. Various techniques including inj. tramadol, body warming, and covering have been evaluated to treat this common complication. We aimed to compare the effectiveness of tramadol administration with patient coverage as therapeutic methods for managing post-anesthesia shivering.

Methodology: The study enrolled 60 patients who underwent spinal anesthesia. Patients were divided into two groups: Group A received blanket coverage as treatment for shivering, while Group B received intravenous tramadol. Shivering onset time and duration after treatment were measured. Descriptive statistics and chi-square test/independent t-test determined significance, with P < 0.05 considered statistically significant.

Results: The findings of this study revealed no significant difference in the onset of shivering between patients who received intravenous tramadol and those who were covered by blankets (39.83 ± 13.21 min vs 38.60 ± 13.48 min). However, the duration of shivering after treatment was significantly shorter in patients who received intravenous tramadol compared to those who received blanket, e.g., 20.30 ± 9.62 vs. 34.83 ± 12.53; P < 0.000).

Conclusion: In conclusion, intravenous tramadol is more effective than non-pharmacological methods (blankets) in managing shivering. Tramadol treatment resulted in a significantly shorter duration of shivering.

Keywords: Postoperative Shivering; Hypothermia; Spinal Anesthesia; Tramadol; Blanket

Citation: Hwisa SA, Alnaeli GR, Ajaj ARI, Faraj MM, Almghairbi DSE, Alhuwayj KAO, Mohammed LA. Comparative efficacy of intravenous tramadol and traditional blanket coverage in managing postoperative shivering among post-spinal anesthesia patients. Anaesth. pain intensive care 2024;28(5):922−926; DOI: 10.35975/apic.v28i5.2565

Received: May 28, 2024; Reviewed: June 03, 2024; Accepted: Jun 18, 2024Blanket

Pulse oximetry-based perfusion index as a non-invasive indicator of systemic hemodynamics during spinal anesthesia in cesarean delivery

Tue, 08 Oct 2024 00:00:00 -0600

Background & Objectives: Placental perfusion is not autoregulated and is susceptible to effects of spinal anesthesia (SA) induced hypotension. The perfusion index (PI) is a non-invasive marker of peripheral vascular tone, and a higher PI indicates increased risk of hypotension following SA. This study aims to establish preoperative baseline PI in our local population and its correlation with incidence of intraoperative hypotension.

Methods: This prospective observational study recruited 35 parturients who underwent elective lower segment cesarean section (LSCS). Preoperatively, baseline heart rate (HR), systolic blood pressure (SBP), mean arterial pressure (MAP) and PI were documented. SA was performed with 8 to 10 mg of injection bupivacaine 0.5% (hyperbaric) at L3–L4 interspace followed by co-loading with 1 L Hartmann solution. Hypotension was defined as SBP less than 80% of baseline or less than 90 mmHg. A bolus of phenylephrine 50 µg was given as rescue medication to treat the hypotension. Intraoperatively, degree of decrease in SBP, MAP and HR, as well as the amount of phenylephrine required was recorded every minute until delivery of the baby and 3 min thereafter.

Results: The correlations between parturients’ baseline PI with the degree of decreases in systolic and mean arterial pressure (r = 0.81, P < 0.001 and r = 0.76, P < 0.001, respectively) and phenylephrine requirement (r = 0.761, p < 0.005) were recorded. This study identified that the patients with cut-off PI value of 3.2 were at higher risk for SA induced hypotension with a sensitivity of 85.9% and a specificity of 87.5% (P = 0.001).

Conclusion: The patients with baseline cut-off perfusion index value of more than 3.2 were at higher risk for spinal anesthesia induced hypotension in elective cesarean section.

Abbreviations: CO - cardiac output; LSCS - lower segment cesarean section MAP - mean arterial pressure; PI - perfusion index; SA - spinal anesthesia

Keywords: Hypotension; Pulse Oximeter; Perfusion Index; Spinal Anesthesia; Cesarean section;

Citation: Manap NSA, Zaini RHM, Shukeri WFWM, Omar SC, Abu Bakar MZ, Seevaunnamtum P. Pulse oximetry-based

perfusion index as a non-invasive indicator of systemic hemodynamics during spinal anesthesia in cesarean delivery. Anaesth. pain intensive care 2024;28(5):927−932; DOI: 10.35975/apic.v28i5.2570

Received: July 23, 2024; Reviewed: September 02, 2024; Accepted: September 10, 2024

Comparative analysis of Kinesio taping and dry-needling: effects on pain and disability in patients with mechanical low back pain

Tue, 08 Oct 2024 00:00:00 -0600

Background & Objective: Low back pain (LBP) is an ever-increasing menace in the young men as well as women. Many factors causing it have been identified, the most common being improper spinal posture. LBP has been targeted by physicians, anesthetists, surgeons and rehabilitation medicine specialists. We compared the effects of Kinesio Taping and dry needling on pain reduction and disability improvement in patients diagnosed with mechanical chronic LBP.

Method: A randomized control trial (RCT) was conducted at Rawal General and Dental Hospital and Al-Nafees hospital in Islamabad from January 2020 to October 2021. Probability-based sampling method was used to select participants for the study (simple random sampling). Thirty patients, aged 18 to 75 y were included. Sample size was calculated with Epitools. The selected patients were divided in two groups i.e., 15 patients in the Kinesio taping group (KT group) and 15 in the dry needling group (DN group). Two patients in the needling group were dropped. Numeric Pain Rating Scale (NPRS) and Roland-Morris Disability Index Questionnaire (RMDQ) were used to assess the pain and the disability at baseline, two weeks post-intervention and four weeks post-treatment. Chi-Square test was use to find association.

Results: The mean age of the patients was 39.60 ± 13.69 y for KT group and 37.15 ± 12.54 y for DN group. The mean BMI for KT group was 27.15 ± 6.70 kg/m²and for DN group 27.52 ± 5.13 kg/m². Before treatment, there were no differences between the groups for NPRS and RMDQ. Both dry needling and Kinesio taping produced significant improvements in NPRS and RMDQ after two and four weeks of treatment (P < 0.05). However, statistical analysis results showed that there was no association between pain and disability in patient with non-specific low back pain. (P > 0.05).

Conclusion: Both, Kinesio taping and dry needling, significantly reduced pain and disability after two- and four-weeks treatment in patients with low back pain, but there was no statistical differences between the pain and disability in both groups.

Keywords: Disability; Dry Needling; Kinesio Tape; Low Back Pain; Numeric Pain Rating Scale; Physiotherapy

Citation: Asad A, Irshad A, Hassan T, Kiran Q, Kouser S, Hassan F. Comparative analysis of Kinesio taping and dry-needling: effects on pain and disability in patients with mechanical low back pain. Anaesth. pain intensive care 2024;28(5):933−938; DOI: 10.35975/apic.v28i5.2561

Received: April 26, 2024; Reviewed: July 16, 2024; Accepted: July 18, 2024

Ultrasound-guided erector spinae plane block in radical cystectomy: a randomized controlled study

Tue, 08 Oct 2024 00:00:00 -0600

Background & Objectives: Radical cystectomy (RC) is usually performed under general anesthesia, with the management of postoperative pain being a big challenge. Various approaches have been tried, including epidural analgesia, or regional nerve blocks in addition to the intravenous patient-controlled analgesia (IV-PCA). We compared the efficacy and safety of bilateral single-injection erector spinae plane block (ESPB) with IV-PCA administered morphine to manage postoperative pain following RC.

Methodology: This prospective randomized controlled clinical study was performed on 60 participants ranging in age from 21 to 65 years, both sexes, BMI 20-40 kg/m², ASA physical status II-III, planned for elective RC. Participants were randomized into two equal groups. Group ESPB received ultrasound-guided single shot ESPB at T10 with 20 mL bupivacaine 0.25% bilaterally; IV morphine 3 mg bolus was used as rescue analgesia when the Numeric Rating Scale (NRS) pain score was ≥ 4. Group C (control group) received IV-PCA by morphine 3 mg IV when NRS pain score was ≥ 4 and repeated 1/2 mg if still pain score was recorded ≥ 4 for 15 min. Pain was measured on NRS at 2 , 4 , 8, and 12 h as well as the postoperative heart rate (HR) and mean arterial blood pressure (MAP). Complications were noted,

Results: Time to first analgesic request was substantially prolonged in Group ESPB compared to Group C (P < 0.001). Total postoperative consumption of morphine in 1st 48 h and postoperative nausea and vomiting were substantially reduced in Group ESPB compared to Group C (P < 0.05). NRS pain scores, postoperative HR and MAP measurements were substantially reduced at 2, 4, 8, and 12 h in Group ESPB than Group C (P < 0.05). Bradycardia and hypotension varied insignificantly different between both groups. Respiratory depression and urinary retention did not occur in any patient in both groups.

Conclusions: Compared with IV-PCA administered morphine, bilateral single-injection ESPB was associated with better hemodynamics and analgesic properties, as observed by lower pain scores, less postoperative opioid consumption, and longer time to first analgesic request with good safety profile after radical cystectomy.

Keywords: Ultrasound; Erector Spinae Plane Block; Radical Cystectomy; Patient-Controlled Analgesia

Citation: Ahmed AM, Tantawy AM, Mahran E, Abd El Galil TE, Abd El Galil AS. Ultrasound-guided erector spinae plane block in radical cystectomy: a randomized controlled study. Anaesth. pain intensive care 2024;28(5):939−944; DOI: 10.35975/apic.v28i5.2568

Received: July 16, 2024; Reviewed: August 05, 2024; Accepted: August 29, 2024

Clavipectoral fascial plane block versus superficial cervical plexus block for fracture clavicle surgery: a randomized clinical trial

Amr Gaber Sayed, Walaa Adel Abdelmoez, Omar Mohamed Ali, Ahmed Elsayed Elshafeey — Tue, 08 Oct 2024 00:00:00 -0600

Background & objective: Both, the clavipectoral fascial plane block as well as superficial cervical plane block have been utilized as a regional anesthesia technique for clavicular fracture surgery. We compared the efficacy and safety of clavipectoral plane block with superficial cervical plexus block for intraoperative and postoperative pain relief in clavicular fracture surgery under general anesthesia (GA).

Methodology: This double-blinded randomized controlled trial included 84 patients, aged between 21 and 60 y, ASA classification I and II, with fracture clavicle, either isolated or part of other trauma, undergoing fracture clavicle fixation. The patients were divided into two groups. The first group received a clavipectoral fascial plane block and the other received a superficial cervical plane block. The visual analogue scale (VAS) scores were recorded as primary outcome, while the patients’ hemodynamics, time to first rescue analgesic, and total morphine consumption were the secondary outcomes at post-anesthesia care unit (PACU) then every 2 h in the ward till 8 h.

Results: Compared to the superficial cervical plexus block the clavipectoral plane block was superior in analgesia and more effective during surgical dissection and intraoperative manipulations with a clinically and statistically significant difference all the time from PACU to 8 h postoperatively. The heart rate and arterial blood pressure were much more stable in the clavipectoral group. Also, time to first rescue analgesic was more in the clavipectoral group than in the superficial cervical block. Total morphine consumption was significantly less in the clavipectoral group than in the superficial cervical group.

Conclusion: Clavipectoral plane bock is superior to superficial cervical block in fracture clavicle surgeries regarding efficacy and safety. Postoperative pain, measured by VAS, was less with clavipectoral plane block, with more hemodynamic stability and less opioid consumption postoperatively.

Abbreviations: PACU - post-anesthesia care unit; CFP - Clavipectoral fascial plane; SCP - Superficial cervical plexus

Keywords: Clavipectoral Plane Bock; Fracture Clavicle; Pain, Postoperative; Superficial Cervical Plexus Block

Citation: Sayed AG, Abdelmoez WA, Ali OM, Elshafeey AE. Clavipectoral fascial plane block versus superficial cervical plexus block for fracture clavicle surgery: a randomized clinical trial. Anaesth. pain intensive care 2024;28(5):945−950; DOI: 10.35975/apic.v28i5.2573

Received: April 03, 2024; Reviewed: May 13, 2024; Accepted: July 02, 2024

Locked-in syndrome post facet joint injection: a case report

Muhamad Rafiqi Hehsan, Suki Ismet, Shamsul Kamalrujan Hassan, Kamaruddin Ibrahim — Sat, 10 Aug 2024 00:00:00 -0600

Locked-in syndrome (LIS) is a neurological condition characterized by quadriplegia and anarthria with preservation of consciousness. This is a rare, but serious condition as patients with LIS are conscious and possess cognitive function, but cannot move or communicate verbally due to the paralysis of nearly all voluntary muscles in the body. We present a case of a 43-year-old lady who developed locked-in syndrome following a lumbar facet joint injection for chronic spinal pain. The patient developed a sudden onset of quadriplegia and loss of speech around 10 min after the injection. Neurological examination revealed preserved consciousness and alertness, with intact cranial nerve function. Diagnostic work-up, including neuroimaging and laboratory tests, ruled out hemorrhage or other structural lesions. We discuss the potential mechanisms underlying this unexpected complication, explore diagnostic challenges and treatment options. Despite its rarity, this case highlights the importance of careful patient selection, precise procedural technique, and prompt recognition of complications associated with interventional pain procedures.

Abbreviations: ITP - immune thrombocytopenic purpura; LIS - Locked-in syndrome; SLE - systemic lupus erythematous; SIJ - sacroiliac joint

Keywords: Locked-In Syndrome; Facet Joint Injection; Complication; Neurological; Case Report

Citation: Hehsan MR, Ismet S, Hassan SK, Ibrahim K. Locked-in syndrome post facet joint injection: a case report

Anaesth. pain intensive care 2024;28(5):951−954. DOI: 10.35975/apic.v28i5.2512

Received: July 22, 2024; Reviewed: September 05, 2024; Accepted: September 05, 2024

Successful emergency management of hemorrhagic shock due to carotid artery aneurysm: the role of awake intubation in difficult airway control

Nguyen Thi Thu Ba — Tue, 08 Oct 2024 00:00:00 -0600

We describe the clinical scenario, analyze the decision-making process in airway management, and application of the Difficult Airway Society (DAS) guidelines for awake tracheal intubation (ATI) in a patient involving life-threatening bleeding from an internal carotid artery aneurysm caused by a fistula following radiotherapy for tongue cancer at Hong Ngoc Phuc Truong Minh General Hospital, on March, 2024.

A 53-year-old male, diagnosed with tongue cancer, underwent surgery. Days before admission, he experienced pain and bleeding from the right lateral neck due to an internal carotid artery aneurysm. An attempt at tracheal intubation for endovascular intervention at another hospital failed. Upon arrival at our emergency department, he exhibited massive neck hemorrhage, remained conscious, pale, with ongoing bleeding from a right neck fistula, and limited cervical motion due to irritation. A treatment strategy for permanent occlusion of the aneurysm was devised.

Awake tracheal intubation using a fiberoptic scope via the nasal route was performed. The patient received light sedation with midazolam, and the airway was topicalized with 10% lidocaine spray over the mouth, tongue, and oropharyngeal mucosa. Continuous monitoring of heart rate, ECG, and oxygen saturation showed no decrease in oxygen levels, and the patient maintained spontaneous breathing throughout. Intensive treatment with crystalloid fluids and blood transfusion, along with right internal carotid embolization with a spring coil, effectively prevented massive hemorrhage. The patient was successfully extubated after three days in the ICU and discharged 15 days post-surgery without any neurological deficits.

Keywords: Awake Tracheal Intubation; Difficult Airway Management; Fiberoptic Scope; Emergency Airway Management

Citation: Ba NTT. Successful emergency management of hemorrhagic shock due to carotid artery aneurysm: the role of awake intubation in difficult airway control. Anaesth. pain intensive care 2024;28(5):955−959.

DOI: 10.35975/apic.v28i5.2572

Received: January 03, 2024; Reviewed: May 05, 2024; Accepted: June 11, 2024

Necrotizing fasciitis or acute limb ischemia? Similarities and the diagnostic tactics

Meity Ardiana, Tony Santoso Putra, Inna Maya Sufiyah — Sat, 10 Aug 2024 00:00:00 -0600

The symptoms of necrotizing fasciitis (NF) and acute limb ischemia (ALI) are almost identical. We present a case of a 48-year-old male, who reported to the emergency room complaining of sudden severe pain in the right limb. The complaint was accompanied by blackish, water-filled lumps, and numbness. On examination, his femoral pulse was palpable but the pulse was weak in the common femoral artery (CFA), superficial femoral artery (SFA) and popliteal artery (POP A). No pulse was palpable in the posterior tibial artery (PTA), anterior tibial artery (ATA), and dorsalis pedis artery (DPA). SpO₂ couldn’t be detected in first to fourth toes; it was 97% in the fifth toe. The laboratory investigations showed increased serum creatinine, so CT angiography could not be performed. Duplex Ultrasonography (DUS) was performed and showed triphasic morphology at the vascular level, while gas was seen in the subcutaneous tissues. Due to similar clinical appearances, it is difficult to differentiate the diagnosis of NF and ALI, while the treatments for both are very different. CT angiography, DUS examination and laboratory tests may be the first option to differentiate between the two conditions.

Keyword: Necrotizing Fasciitis, Acute Limb Ischemia,

Citation: Ardiana M, Putra TS, Sufiyah IM. Necrotizing fasciitis or acute limb ischemia: similarities and the diagnostic tactics. Anaesth. pain intensive care 2024;28(5):960−963; DOI: 10.35975/apic.v28i5.2237

Received: ; Reviewed: ; Accepted:

Massive thoracic aortic dissection in the subacute postpartum period in a patient with Marfan syndrome

Taizoon Dhoon, Nikhil A. Crain, Ramin Rahimian, Govind R. Rajan — Tue, 08 Oct 2024 00:00:00 -0600

Aortic dissection is a life-threatening condition that can result in rupture, massive hemorrhage, and death. Parturients with Marfan syndrome are at increased risk of aortic dissection due to connective tissue dysfunction and physiologic changes secondary to pregnancy. Aortic dissection typically manifests during the intrapartum period, rather than the postpartum course. This article discusses a case of a parturient with Marfan syndrome who suffered a massive thoracic aortic dissection in the subacute postpartum period after an uncomplicated vaginal delivery.

Abbreviations: CT - computerized tomography; AD - Aortic dissection; MFS - Marfan syndrome; PPD - postpartum day; TEVAR - thoracic endovascular aortic repair; TTE - transthoracic echocardiogram; VAVD - vacuum assisted vaginal delivery; VD - vaginal delivery

Keywords: Marfan Syndrome; Pregnancy; Aortic Dissection; Neuraxial Anesthesia

Citation: Dhoon T, Crain NA, Rahimian R, Rajan GR. Massive thoracic aortic dissection in the subacute postpartum period in a patient with Marfan syndrome. Anaesth. pain intensive care 2024;28(5):964−968; DOI: 10.35975/apic.v28i5.2564

Received: May 09, 2024; Reviewed: August 15, 2024; Accepted: August 15, 2024

The role of therapeutic plasma exchange using membrane plasma separation in the late onset myasthenic crisis: a case report

Dedy Kurnia, Sidharta Kusuma Manggala, Vera Irawany — Tue, 08 Oct 2024 00:00:00 -0600

Myasthenia gravis (MG) is an autoimmune disease, in which antibodies bind to receptors in the neuromuscular junction (NMJ), causing muscle weakness. This disease is relatively challenging to diagnose due to its late onset and comorbidities. Several treatment options include therapeutic plasma exchange (TPE) with membrane plasma separation, that aims to remove large molecular-weight toxins such as pathogenic antibodies and lipoproteins. A 61-year-old male patient was admitted to the ICU post-sternotomy due to mediastinal tumor resection. Extubation failed, so we decided to undergo a tracheostomy. The lung pathology result showed lymphocyte-predominant thymoma, and along with symptoms of chest weakness and ptosis, the patient was suspected for MG. Electromyography results confirmed the occurrence of functional lesions in post-synaptic NMJ consistent with MG. We assessed patient with myasthenic crisis (MC), then gave pyridostigmine 60 mg 6x/day, and planned for TPE using membrane plasma separation. Plasma exchange was done by 1.5 of blood volume. The patient developed sepsis pneumonia and was administered levofloxacin based on his culture results. Patient still had weakness. We re-evaluated the drugs that might have exacerbated MG. Aztreonam in combination with co-trimoxazole was administered to combat Stenotrophomonas maltophilia pneumonia. The patient was eventually weaned from the ventilator and gradually recovered.

Keywords: Membrane Plasma Separation; Myasthenia Gravis Crisis; Therapeutic Plasma Exchange; TPE

Citation: Kurnia D, Manggala SK, Irawany V. The role of therapeutic plasma exchange using membrane plasma separation in the late onset myasthenia gravis crisis: a case report. Anaesth. pain intensive care 2024;28(5):969−973; DOI: 10.35975/apic.v28i5.2557

Received: July 17, 2024; Reviewed: August 01, 2024; Accepted: August 01, 2024

Acute abdomen: an atypical presentation of acquired hemophilia

Muhamad Rafiqi Hehsan — Tue, 08 Oct 2024 00:00:00 -0600

Acquired hemophilia is a rare but potentially life-threatening disorder characterized by the development of acquired hemophilia A, leading to bleeding complications. Spontaneous, mild-to-life-threatening bleeding in typically elderly individuals without a personal or family history of bleeding is the hallmark of acquired hemophilia A (AHA), a rare autoimmune bleeding illness caused by the formation of auto-antibodies against endogenous factor VIII (FVIII). This hallmark represents our present case, with no obvious history related to the bleeding issue. Prompt detection and treatment of bleeding are essential for the best outcomes.

We present a case of a 66-year-old male who had acute-onset severe abdominal pain and with constipation for five days, associated with nausea and loss of appetite. On physical examination, the patient appeared pale, and abdominal examination revealed diffuse tenderness with guarding. Initial evaluation revealed tachycardia and hypotension. Initial abdomen X-rays revealed features suggestive of small bowel obstruction. The patient was stabilized with intravenous fluids, referred to a surgical team, and admitted to the acute bed in the general ward for further management.

Keywords: Acquired Hemophilia; Auto-Antibodies; Factor VIII; Intraabdominal Bleeding

Citation: Hehsan MR. Acute abdomen: an atypical presentation of acquired hemophilia. Anaesth. pain intensive care 2024;28(5):974−976; DOI: 10.35975/apic.v28i5.2556

Received: March 19, 2024; Reviewed & Accepted: September 08, 2024