Ain-Shams Journal of Anesthesiology

The perioperative anaesthetic management of a case of COVID-19 pneumonia with multiple systemic comorbidities, posted for unilateral below knee amputation and debridement of hand, poses a uniquely challenging scenario for the anaesthesiologist. We hereby report such a case which was managed successfully using ultrasound-guided popliteal and wrist block along with perioperative use of high flow nasal cannula, incentive spirometry and awake proning.

Ventriculoperitoneal (VP) shunts are commonly performed procedures for a variety of disorders and are mostly long standing. These patients when present for non-neurological surgeries like gastrointestinal, urology, or caesarean section, there are several concerns like difficult abdominal surgery due to peritoneal adhesions, chances of shunt infection with potential retrograde infective meningoencephalitis, and ventriculitis or shunt failure with recurrent hydrocephalus. A 35-year-old male, known case of third ventricular tumour with functional left-sided ventricular peritoneal shunt was scheduled to undergo cholecystectomy for gall bladder stone. Intraoperatively optic nerve sheath diameter was measured as an indicator of raised intracranial pressure. Intraoperative was uneventful. Efforts were taken to prevent rise in intracranial pressure perioperatively. Patient was discharged on third postoperative day. A vigilant perioperative care along with adequate team work go a long way in achieving success in patients of ventriculoperitoneal shunts presenting for non-neurological surgeries.

Sternomental displacement (SMDD) is a surrogate indicator for cervical spine (C-spine) mobility. SMDD revealed good potential to predict difficult airway, but its validity in obese patients is not evident. Therefore, this study assessed the performance of SMDD with neck circumference (NC) in predicting difficult airway in obese surgical patients. The study involved 135 adult patients with body mass index (BMI) ≥ 35 kg/m2 scheduled for elective surgeries under general anesthesia with endotracheal tubes (ETT) inserted using Macintosh laryngoscopes. The airway was assessed using SMDD, NC, and modified Mallampati test (MMT). Difficult laryngoscopy view (DLV) was defined as Cormack–Lehane (C-L) grade ≥ 3. The accuracy of the SMDD in predicting DLV was set as the primary endpoint, while the accuracy of the SMDD compared to that of NC, MMT, and NC/SMDD ratio in predicting difficult airway was set as the secondary endpoint. The DLV cases were 28 of 135 (20.7%), with a mean BMI of 41.1 ± 3.3 kg/m2. SMDD  < 5cm and NC > 43 cm could predict DLV with an area under the receiver operating characteristic curve (AUROC) of 0.97 and 0.83 respectively. SMDD and NC had a good negative correlation (r =  − 0.6; 95% CI = 0.7 to 0.4; p = 0.0001). The NC/SMDD ratio had the best prediction for DLV (AUROC of 0.98 at a cut-off value  > 7.8). In obese surgical patients, SMDD and NC/SMDD ratios are excellent predictors for DLV when the cut-off values are  < 5cm and  > 7.8, respectively. ClinicalTrials.gov, NCT04524546. Registered in August 2020.

Hypotension is often occurring after induction of general anesthesia (IGA) and can cause organ hypoperfusion and ischemia which associated with adverse outcomes in patients having both cardiac and non-cardiac surgery. Elderly patients are particularly more vulnerable and at increased risk to the depressant effect of anesthetic drugs. So, recognition and prevention of such event are of clinical importance. This study recruited patients aged above 60 years, with ASA physical status classification I-II-III who were scheduled for surgery under general anesthesia with the aim to assess the effectiveness of preoperative IVC ultrasonography in predicting hypotension which develops following IGA and its association with the volume status in elderly patients receiving general anesthesia, through measurements of the maximum inferior vena cava diameter (dIVCmax), minimum inferior vena cava diameter (dIVCmin), inferior vena cava collapsibility index (IVC-CI), and basal and post-induction mean arterial pressure (MAP). Thirty-nine (44.3%) of the 88 patients developed hypotension after IGA, and it was significantly more in patients who did not receive preoperative fluid (p = 0.045). The cut-off for dIVCmax was found as 16.250 mm with the ROC analysis. Specificity and sensitivity for the cut-off value of 16.250 mm were calculated as 61.2% and 76.9%, respectively. The cut-off for IVC-CI was found as 33.600% with the ROC analysis. Specificity and sensitivity for the cut-off value of 33.600% were calculated as 68.7% and 87.2%, respectively. IVC ultrasonography may be helpful in the prediction of preoperative hypovolemia in elderly patients in the form of high IVC-CI and low dIVCmax. The incidence of hypotension was lower in patients who received fluid infusion before IGA.

Laryngoscopy và nội khí quản có thể liên quan đến các sự kiện bất lợi như tăng huyết áp, nhịp tim nhanh và nồng độ catecholamines huyết thanh tăng cao. Những sự kiện này là nghiêm trọng ở những bệnh nhân mắc bệnh tim hoặc tăng huyết áp. Công trình này được thiết kế để đánh giá tác động của liều đơn dexmedetomidine lên phản ứng huyết động với nội khí quản ở những bệnh nhân tăng huyết áp có kiểm soát. Bảy mươi bệnh nhân được phân bổ ngẫu nhiên thành hai nhóm bằng nhau; nhóm dexmed nhận dexmedetomidine tĩnh mạch 0,5 mcg/kg được pha loãng trong 20 ml với natri clorua 0,9% và nhóm đối chứng nhận 20 ml natri clorua 0,9%. Sự thay đổi về nhịp tim, huyết áp tâm thu, huyết áp tâm trương và huyết áp trung bình được ghi lại ở cả hai nhóm tại thời điểm xuất phát, sau 5 phút truyền thuốc nghiên cứu, 3 phút sau khi khởi mê và trước khi nội khí quản, 1 phút sau khi nội khí quản, 3 phút sau khi nội khí quản, và 5 phút sau khi nội khí quản. Nhóm dexmed có nhịp tim, huyết áp tâm thu, huyết áp tâm trương và huyết áp trung bình thấp hơn đáng kể tại 1 phút, 3 phút và 5 phút sau khi nội khí quản. Liều đơn dexmedetomidine đã làm giảm phản ứng huyết động đối với laryngoscopy và nội khí quản ở bệnh nhân tăng huyết áp có kiểm soát. ClinicalTrial.Gov (NCT03204006) (Tháng 3 năm 2018).

Aerosolized antibiotic administration offers the theoretical advantages of achieving high drug concentrations at the infection site together with lower systemic absorption. This study aims to compare the effect of combining nebulized amikacin with intravenous amikacin to the effect of the usual intravenous route alone in the treatment of patients with ventilator-associated pneumonia and its impact on the duration of mechanical ventilation, laboratory, and clinical picture of the patients. This study was carried out on 64 mechanically ventilated patients with Gram-negative VAP. The patients were divided into 2 groups. Group A included 32 patients treated with nebulized amikacin plus IV amikacin, and group B included 32 patients treated with IV amikacin alone. The duration of treatment for both groups was 8 days with a daily assessment of Clinical Pulmonary Infection Score (CPIS) and monitoring of clinical and laboratory parameters. Sputum cultures were obtained thereafter. In our study, the CPIS score and overall ICU mortality were less in the nebulized than in the IV group but the difference failed to be statistically significant. Increase of oxygenation level (Pao2/Fio2 ratio), organism clearance, decrease in serum creatinine level, duration of mechanical ventilation, and length of ICU stay were significantly different in favor of group A than group B. Nebulized and IV amikacin offered better oxygenation, organism clearance, less nephrotoxicity, and less duration of mechanical ventilation and ICU stay than the IV group. Combined and IV routes were comparable regarding the decrease in CPIS score and ICU mortality with no significant difference between them. However, we prefer to use the combined regimen for the mentioned reasons. Further large-scale studies are required to confirm these findings and to establish a definite conclusion.

The appropriate choice of postoperative analgesia for pyothorax surgery is unclear since local infection could contaminate the catheter used for regional blocks and bacteremia can lead to disordered coagulation. We performed erector spinae plane block (ESPB) in a pyothorax patient undergoing emergency re-open thoracotomy. An 81-year-old male with internal jugular vein stenosis on aspirin therapy was scheduled for pyothorax drainage and residual middle lobectomy 14 days after he underwent open right lower lung lobectomy for lung cancer. ESPB was performed with injection of 20 ml of 0.375% levobupivacaine at the Th5 transverse process of the right side under ultrasound guidance. Although he needed intravenous pentazocine for pain on postoperative day 0, no more analgesics were required postoperatively. NRS score ranged from 0 to 1 thereafter. ESPB provided effective postoperative analgesia following emergency re-open thoracotomy for our pyothorax patient. ESPB might be the appropriate choice for postoperative analgesia following pyothorax surgery.