Anaesthesia, Pain & Intensive Care

Training, certification, and future perspective in Japanese anesthesiologists

2024-04-17T23:48:16-06:00

This invited editorial has been written by the esteemed Professor Nobuyasu Komasawa, on the special request of the editor-in-chief of Anaesthesia, Pain & Intensive Care, with the aim to allow our readers to be knowledgeable about the diverse routes and modus operandi of training in the field of anesthesiology in different countries around the world. The training in specialized medical fields might differ from country to country, depending upon the available facilities and the expertise of the trainers. The recent induction of simulation and artificial intelligence (AI) into medicine has forced the trainers to think beyond their local circle of proficiency and competency, and to march ahead to equip their trainees with the current knowledge, techniques and skills.

This editorial highlights the emphasis laid during the training of anesthesiologists in Japan. Readers from other countries are invited to share the current trends of training in their healthcare systems, especially pertaining to anesthesiology, pain management, intensive care and resuscitation.

Citation: Komasawa N. Training, certification, and future perspective in Japanese anesthesiologists. Anaesth. pain intensive care 2023;27(6):196−197; DOI: 10.35975/apic.v28i2.2403

Received: January 27, 2024; Accepted: March 04, 2024

A retrospective, observational study to assess the intermediate-term clinical outcomes of COVID-19 patients in a tertiary hospital in Khyber Pakhtunkhwa, Pakistan

2024-04-17T23:48:16-06:00

Background & Objective: There is limited data from lower middle-income countries to describe the outcomes of COVID-19 and the prevalence of patients requiring critical care. We aim to assess and compare the demographics, clinical course and mortality of COVID-19 patients admitted to the intensive care unit (ICU) and those admitted to the specialized COVID unit (SCU).

Methodology: A single-center, retrospective, observational study in which all patients admitted to Lady Reading Hospital (LRH), Peshawar (Pakistan) with laboratory-confirmed COVID-19 from March 25, 2020 to December 31, 2021 were included. Study data were retrieved through the Pakistan Registry of Intensive Care (PRICE).

Results: Of 699 patients, 448 were critically ill, and 251 did not require ICU admission. Of those admitted to ICU, 61.8% were male, with a median age of 55 y. ICU mortality was significantly higher (P = 0.001) among those on IMV and those aged 60 y; whereas 68.9% of the non-ICU patients were male, with a median age of 57 y. While the median duration of hospitalization was significantly longer (P = 0.001), the chances of recovery were substantially better (P = 0.001) compared with the critically ill population.

Conclusion: The major risk factors contributing to the increased mortality in COVID-19 patients are age and the requirement for IMV.

Keywords: COVID-19; Intensive Care Unit; Lower Middle Income Country; Mortality; SARS-CoV-2

Citation: Ashraf MS, Hussaini A, Gamage Dona DP, Shaikh M. A retrospective, observational study to assess the intermediate-term clinical outcomes of COVID-19 patients in a large public sector hospital in Khyber Pakhtunkhwa, Pakistan. Anaesth. pain intensive care 2024;28(2):198−205; DOI: 10.35975/apic.v28i2.2423

Received: April 23, 2023; Reviewed: July 26, 2023; Accepted: January 20, 2024

Mortality risk factors and the ventilator-associated pneumonia (VAP) in the ICU of a tertiary hospital in Indonesia

2024-04-17T23:48:16-06:00

Background & Objective: Mortality of patients with ventilator-associated pneumonia (VAP) in the ICU is influenced by several risk factors, including comorbidities, SOFA scores, malnutrition, and sepsis with multi-drug resistant (MDR) pathogens. We aimed to determine the risk factors for VAP patient mortality in the ICU of a tertiary hospital in Indonesia over a period of time.

Methodology: This descriptive observational study was conducted retrospectively in the ICU of Dr. Hasan Sadikin Hospital, Bandung, Indonesia, during 2021-2022. The hospital records of all patients diagnosed with VAP during this period were retrieved and the records of the deceased patients were analysed for various risk factors, which may have led to mortality.

Results: The results of this study showed that 64 patients experienced VAP, with 49 (76.6%) patients expired. The VAP patients who died were mostly male (63.3%), the median age was 61 years, median BMI of 22.2 kg/m², with hospital length of stay (LOS) of 13 days, ICU LOS of 10 days, and ventilator LOS of 8 days. The majority had SOFA scores between 10-12 (46.9%), the PF ratio was 195.1 ± 77.5, albumin value was 2.11 ± 0.64. The most common comorbidity was hypertension (40.8%) with a high neutrophil-lymphocyte ratio (NLR) value (69.4%), the most common pathogen found was Acinetobacter baumannii (18.4%), and in the most of the patients experiencing MDR (53.3%), the cause of ICU admission was respiratory system disorders (40.8%). Bivariate analysis showed hospital LOS, ICU, ventilator, PF ratio, comorbidities, NLR, SOFA score, nutritional status, and MDR pathogens were associated with VAP mortality with P < 0.05.

Conclusion: This study concludes that the risk factors for mortality of VAP patients in the ICU of Dr. Hasan Sadikin Hospital, Bandung in 2021-2022 are comorbidities, a high neutrophil-lymphocyte ratio, SOFA score, poor nutritional status, and sepsis with multi-drug resistant pathogens. Identifying risk factors is essential for preventing and managing VAP in the ICU to reduce mortality.

Abbreviations: LOS - Length of Stay; MDR - Multi-Drug Resistant; NLR - Neutrophil-Lymphocyte Ratio; VAP - Ventilator-Associated Pneumonia

Keywords: Mortality, risk factors, ventilator-associated pneumonia (VAP)

Citation: Indriasari, Aditya R, Mizan Al-Haq M. Mortality risk factors and the ventilator-associated pneumonia (VAP) in the ICU of a tertiary hospital in Indonesia. Anaesth. pain intensive care 2024;28(2):206−213.

DOI: 10.35975/apic.v28i2.2324

Received: November 01, 2023; Revised: February 08, 2024; Accepted: February 22, 2024

The APACHE-II score and the effect of discharge practices on readmission and mortality in intensive care patients

2024-04-17T23:48:17-06:00

Background: Two undesirable conditions after discharge from the intensive care unit (ICU) are need of readmission to the ICU and death. Many causative factors have been extensively studied by the researchers in different countries at different periods. We evaluated the effect of APACHE II score on admission and the discharge practices on readmission and mortality.

Methodology: A total of 342 patients were hospitalized in a tertiary ICU between January 2020 and April 2021. We, retrospectively, retrieved their demographic information, and recorded the length of stay in the hospital and ICU, inotropic support, need and duration of mechanical ventilation, units from which the patients were admitted, from which units they were discharged. History of readmission, hospitalization in the ICU, and one-month mortality were also recorded retrospectively.

Results: In our study, no significant difference was found between hospitalization APACHE II scores and post-discharge mortality and readmission rates. It was determined that one-month mortality was significantly higher in the group of patients admitted from the ward. Patients admission to palliative care, and inotropic support was a factor associated with one-month mortality. Prolonged hospital stay was a factor associated with readmission to the ICU.

Conclusion: As prolongation of the time spent in the service of ICU patients may increase ICU mortality, precautions should be taken. Appropriately timed discharge from the medical ward to the ICU and from the ICU to other units will reduce both ICU readmission and mortality.

Abbreviations: APACHE II- Acute Physıology And Chronıc Health Evaluatıon II Score; CRRT- Continuous Renal Replacement Therapy; SOFA- Sequential Organ Failure Evaluation score, CCIS-Charlson Comorbidity Index Score

Keywords: APACHE, Discharge, Intensive care, Mortality, Readmission

Citation: Doganci M, Doganay GE. The APACHE-II score and the effect of discharge practices on readmission and mortality in intensive care patients. Anaesth. pain intensive care 2024;28(2):214−220; DOI: 10.35975/apic.v28i2.2424

Received: September 10, 2023; Revised: February 21, 2024; Accepted: February 21, 2024

Ultrasound-guided three-in-one block versus landmark-based fascia iliaca compartment block for analgesia prior to positioning for spinal anesthesia in femur fracture patients

2024-04-17T23:48:17-06:00

Background & objective: Femoral bone fracture may cause considerable amount of pain. Many techniques have been described to ease pain in this group of patients. However, regional block technique remains underutilised and not regularly done. We evaluated the efficacy of ultrasound-guided (USG) 3-in-1 femoral nerve block versus the landmark-based single shot fascia iliaca compartment block as an analgesia method prior to positioning for spinal anesthesia in patients going for femur fracture surgery.

Methodology: A total of 60 patients aged between 18 to 65 years old from ASA class I to III were included. They were divided into two groups by using computer assisted randomization. Group I received single shot landmark based-fascia iliaca compartment block whereas Group II received USG femoral 3-in-1 block. Ropivacaine 0.375% was used in both groups with a total volume depends on patient body weight. The pain score at rest, upon movement and at interval of 5-10 min after block performed recorded using Visual Analog Score.

Results: Ultrasound guided femoral 3-in-1 block provides faster pain reduction at least 5-min post block (1.7 ± 0.75, P = 0.011) and significant relief at 20-min post block (1.33 ± 1.16, P = 0.026). Less intravenous fentanyl was required for rescue analgesia in Group II (10.83 ± 29.13, P = 0.018).

Conclusion: Femoral 3-in-1 block provides much faster relief of pain in femoral bone fracture but both blocks are equally effective if given enough time to work out. Both are equally effective and appeared to be safe.

Abbreviations: USG- ultrasound-guided; VAS- Visual Analog Scale score

Keywords: Analgesia; Ultrasound guided femoral 3-in-1; Blind fascia iliaca compartment block; Visual Analog Score; Positioning; Femur fracture.

Citation: Zaini RHM, Rubi IWM, Wan Hassan WMN, Umairah Esa, Ismail MA, Seevaunnamtum P, Omar SC. Ultrasound-guided three-in-one block versus landmark-based fascia iliaca compartment block for analgesia prior to positioning for spinal anesthesia in femur fracture patients. Anaesth. pain intensive care 2024;28(2):221−226.

DOI: 10.35975/apic.v28i2.2425

Received: January 13, 2024; Revised: February 13, 2024; Accepted: February 14, 2024

The hemodynamic effects of hypertonic saline preload versus co-load measured by non-invasive cardiometry in patients undergoing TURP surgery: a randomized controlled trial

2024-04-17T23:48:17-06:00

Background & objective: Transurethral resection of prostate (TURP) is usually performed under spinal anesthesia. To control spinal hypotension intravenous fluids are infused. We evaluated the effect of timing of hypertonic saline infusion as a preload or a co-load on hemodynamic parameters in patients undergoing TURP using non-invasive cardiometry.

Methodology: A randomized controlled study was conducted. A total of 100 ASA physical status I-III patients planned for TURP under subarachnoid block were randomly assigned to either a preload of 4 ml/kg of hypertonic saline (NaCl 3%) over 15-20 min before spinal anesthesia (Group P, n = 50) or a co-load at the maximum rate at the moment of cerebrospinal fluid identification (Group C, n = 50). Cardiometry was used to measure cardiac output and systemic vascular resistance; and mean arterial blood pressure, systolic blood pressure, heart rate, and the requirement for ephedrine and serum sodium levels were recorded.

Results: There was a rise in cardiac output readings at 5, 10 and 15 min in both groups, but Group P showed a significantly more rise compared to Group C after spinal anesthesia and compared with their baseline values. As for the systemic vascular resistance, a substantial drop occurred in Group P at 5, 10, and 15 min when compared to Group C, as well as when compared to their baseline levels. Except for considerably lower systolic blood pressure readings at 5 min after spinal block in Group P, in both groups, systolic blood pressure and heart rate changes were comparable. The median dose of ephedrine required for Group P patients was significantly greater.

Conclusion: Hypertonic saline co-loading is more effective than its preloading in decreasing hypotension occurring with subarachnoid anesthesia for TURP surgery.

Abbreviations: CO: Cardiac Output; HR: Heart Rate; SBP: Systolic Blood Pressure; SD: Standard Deviation; SV: Stroke Volume; SVR: Systemic Vascular Resistance; TURP: Transurethral Resection of the Prostate.

Key words: Hypertonic Saline; Co-load; Preload; Cardiometry; Subarachnoid Anesthesia; TURP

Citations: Seif NE, El-Kholy MM, El-Gohary MM, Wahba SAA, Jaccoub VF. The hemodynamic effects of hypertonic saline preload versus co-load measured by non-invasive cardiometry in patients undergoing TURP surgery: a randomized controlled trial. Anaesth. pain intensive care 2024;28(2):227−236.

DOI: 10.35975/apic.v28i2.2213

Received: May 02, 2023; Revised: December 12, 2023; Accepted: February 27, 2024

Effectiveness of the medial approach to PECS block in modified radical mastectomy: a retrospective study

2024-04-17T23:48:18-06:00

Background & objective: Perioperative management of female patients undergoing breast surgery includes a big anesthetic task to adequately manage persistent postoperative pain and postoperative nausea and vomiting (PONV). Pectoral nerve blocks (PECS I and PECS II), while effective in managing postoperative pain, carry a risk of throacoacromial artery puncture with the lateral approach. We evaluated analgesic efficacy of medial approach to PECS I and PECS II blocks in female patients undergoing breast surgery under general anesthesia (GA).

Methodology: This is a retrospective study of 116 female patients undergoing modified radical mastectomy that were divided into two groups. Group 1 patients received PECS block with general anesthesia and Group 2 patients received general anesthesia alone. Mean time to extubate, postoperative morphine consumption and PONV were evaluated up to 24 h.

Results: Patients who received the PECS block required significantly less postoperative morphine immediately after and 12 h after surgery (P = 0.043 and P = 0.006, respectively). There was no significant difference in PONV between both groups in the first 24 h (P > 0.05). Time to extubation (TTE) was significantly less in Group 1 patients (P < 0.001).

Conclusion: The medial approach of PECS I and II nerve block is effective and safe demonstrating reduced postoperative morphine requirement.

Abbreviations: PECS: Pectoral Nerve Blocks; PONV: Postoperative Nausea and Vomiting; TPVB: thoracic paravertebral block; TTE: Time to Extubation;

Keywords: Nausea; PECS I block; PECS II block; Postoperative morphine; Pain, Postoperative; Regional anesthesia; Ultrasound; Vomiting, Postoperative

Citation: Assaf G, Gholmieh L, Al Nawwar R, Nassif S, Daoud J, Ghabour Y, Maroun W, Barakat H. Effectiveness of the medial approach to PECS block in modified radical mastectomy: a retrospective study. Anaesth. pain intensive care 2024;28(2):237−242; DOI: 10.35975/apic.v28i2.2426

Received: January 18, 2024; Revised: February 06, 2024; Accepted: February 28, 2024

The effectiveness of patient discharge time in One-Day Care (ODC) surgical patients based on PADSS scoring

2024-04-17T23:48:18-06:00

Background & objective: One-day surgery, defined as ambulatory surgery, is a service that provides surgery in certain cases without requiring hospitalization to minimize the cost incurred by one- day surgery service users. The objective of this study was to measure the ideal time for discharge of patients undergoing outpatient surgical procedures prospectively based on the cut- off time of the maximum PADSS (Post Anesthesia Discharge Scoring System) score.

Method: This prospective observational study was conducted at a single site. The following patients were included in the inclusion criteria: Patients admitted to the one-day care clinic for scheduled day surgery procedures. Discharge was validated by PADSS scores ≥9, following the surgeon’s approval and return from the operating room.

Results: 76 volunteered patients were assessed using PADSS after returning from the operating room. Heart rate, blood pressure, and oxygen saturation were assessed intraoperatively. The findings revealed that the patients obtained a maximum PADSS score of ≥9 at the three-hour based on the cut-off time of PADSS. There was no significant correlation between the duration of the surgery and how long the patients get the ideal time to discharge.

Conclusion: PADSS for one-day care patients can estimate the patients discharged in less than 24 h. Patients obtained a maximum score at the three-hour and returned home in optimal condition.

Abbreviations: ODC- One Day Care; PADSS- Post-Anesthesia Discharge Scoring System;

Keywords: ODC; Ambulatory Surgical Procedures, Patient Discharge, Post Anesthesia Discharge Scoring System.

Citation: Maryani N, Amsriza FR, Wahyuni A, Lutfa R. The effectiveness of patient discharge time in One-Day Care (ODC) surgical patients based on PADSS scoring. Anaesth. pain intensive care 2024;28(2):248−253; DOI: 10.35975/apic.v28i2.2427

Received: July 27, 2022; Revised: December 26, 2024; Accepted: February 26, 2024

A trial for smooth intubation of obese patients by lubricating the Glidescope® blade: a prospective randomized controlled trial

2024-04-17T23:48:18-06:00

Background: Obese patients often pose endotracheal intubation (ETI) and/or ventilation difficulties, when compared to non-obese patients. Reducing the duration of intubation helps to prevent the associated respiratory and hemodynamic complications. We evaluated the effect of lubricating the undersurface of the Glidescope® blade at the intubation time as well as other associated drawbacks while intubating obese patients.

Methodology: A total of 54 adult patients undergoing elective bariatric surgery requiring general anesthesia and oral ETI were included in this study. Out of these 27 patients were included in Group L, in which the underside of the GlideScope® blade used for intubation was lubricated by soluble lidocaine jelly, taking care not to touch the camera or the source of light. The rest of the patients (n = 27) were included in Group C (control group). In the control group, the patients were handled with the same technique but using a standard non-lubricated blade. Intubation time, staring from blade introduction in the mouth to tube entrance into the glottis was registered.

Results: There was a statistically significant difference in intubation outcomes between the Group L and the Group C. The mean intubation times were 15.15 ± 4.24 sec vs. 23.98 ± 5.94 sec (P = 0.0001) for the Group L and C respectively.

Conclusion: Lubricating the blade can be an independent factor that can reduce the time of tracheal intubation, such as smoothening the insertion of the blade during tracheal intubation and preventing the tongue from being curled up. The maneuver can also reduce bleeding during the tracheal intubation due to dry tongue.

Abbreviations: ETI: endotracheal intubation; ETT; endotracheal tube;

Keywords: Blade; Endotracheal Intubation; GlideScope; Obesity

Citation: Barsoom Ayoub SN, Rabah Alharbi RS. A trial for smooth intubation of obese patients by lubricating the Glidescope® blade: a prospective randomized controlled trial. Anaesth. pain intensive care 2024;28(2):254−258; DOI: 10.35975/apic.v28i2.2428

Received: December 09, 2023; Reviewed: February 16, 2024; Accepted: February 16, 2024

A comparative study of hemodynamic stress response to laryngoscopy with McCoy blade versus Macintosh blade in patients undergoing elective surgeries under general anesthesia

2024-04-17T23:48:18-06:00

Background & objective: Endotracheal intubation is considered the gold standard for airway management. It has been shown that different types of laryngoscope blades effect the hemodynamic response differently. We evaluated hemodynamic stress response before, during and after laryngoscopy with McCoy and Macintosh laryngoscope blades.

Methodology: A total of 68 patients were enrolled in the study and randomly allocated to the two study groups using computer-generated random numbers. Patients undergoing endotracheal intubation using the MacIntosh blade were labelled as Group MI, and those in which McCoy blade was used, were labelled as Group MC. Endotracheal tube placement and anesthesia maintenance were standardized for both study groups. The hemodynamic parameters, including heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) were recorded before induction, before laryngoscopy, and at 1, 2, 3, 4, 5 and 10 min after laryngoscopy.

Results: The groups were comparable in terms of age and body mass index with similar mean values in the two studies and also concerning the ASA physical status and Mallampati classification. All the hemodynamic parameters, including HR, SBP, DBP, and MAP increased after laryngoscopy and intubation in both the study groups, but McCoy laryngoscope showed significantly lower values of SBP, DBP, and MAP at 1st and 2nd min after intubation.

Conclusion: McCoy's laryngoscope may be advantageous when compared to the Macintosh blade in situations where minimizing hemodynamic responses is crucial.

Abbreviations: DBP: diastolic blood pressure; MAP: mean arterial pressure: SBP: systolic blood pressure

Keywords: Airway management; Endotracheal intubation; Hemodynamic stress response; Laryngoscopy; McCoy blade; MacIntosh blade

Citation: Arpitha R, Divakar SR, Kiran AV, Yuvashri M. A comparative study of hemodynamic stress response to laryngoscopy with McCoy blade versus Macintosh blade in patients undergoing elective surgeries under general anesthesia. Anaesth. pain intensive care 2024;28(2):259−264; DOI: 10.35975/apic.v28i2.2362

Received: December 14, 2023; Revised: January 28, 2024; Accepted: February 17, 2024

Effectiveness of HA330 hemoperfusion as an adjunctive therapy for severe COVID-19 patients: a single center experience

2024-04-17T23:48:19-06:00

Background & objective: Cytokine storms play a significant role in conditions leading to multi-organ failure in patients with severe corona virus disease-2019 (COVID-19). The eradication of pro-inflammatory cytokines through hemoperfusion has been suggested to be a possible strategy to improve outcomes in these patients. We evaluated the impact of adjunctive HA330 hemoperfusion on outcomes in severe COVID-19 patients.

Methodology: A single-center retrospective cohort study was conducted from December 2021 to December 2022. We included severe COVID-19 patients with elevated pro-inflammatory markers, who received three consecutive sessions of HA330 hemoperfusion in addition to the standard treatment protocol. Clinical data, including demographic information, baseline characteristics, and treatment outcomes, were analyzed.

Results: We evaluated 24 severe COVID-19 patients. We observed a significant reduction in levels of CRP (P < 0.001) and IL-6 (P = 0.042), as well as a significant increase in arterial partial pressure of oxygen (P = 0.041). Importantly, no patient experienced cytotoxicity after the HA330 hemoperfusion sessions, confirming the biocompatibility of the treatment.

Conclusion: Three consecutive sessions of HA330 hemoperfusion, used as an adjunctive therapy to standard care in severe COVID-19 patients, effectively reduced pro-inflammatory cytokine levels and improved oxygenation. However, large multicenter trials are required to validate these clinical outcomes.

Abbreviations: APACHE-II - Acute Physiology and Chronic Health Evaluation; ARDS - acute respiratory distress syndrome; COPD - chronic obstructive pulmonary disease; ECMO - extracorporeal membrane oxygenation; IL-6 - interleukin 6; MCP-1 - monocyte chemoattractant protein-1; SARS-CoV-2 – severe acute respiratory syndrome coronavirus 2; SOFA - Sequential Organ Failure Assessment; TNFα - tumor necrosis factor-α

Keywords: Hemoperfusion; Coronavirus Disease-2019; Cytokine; Extracorporeal Membrane Oxygenation

Citation: Phongphithakchai A, Saelue P, Wongpraphairot S, Boonsrirat U. Effectiveness of HA330 hemoperfusion as an adjunctive therapy for severe COVID-19 patients: a single center experience. Anaesth. pain intensive care 2024;28(2):265−271; DOI: 10.35975/apic.v28i2.2429

Received: November 17, 2024; Reviewed: January 31, 2024; Accepted: February 28, 2024

Evaluation of the perspective of anesthesia research assistants on the use of ultrasonography in regional anesthesia

2024-04-17T23:48:19-06:00

Background & Objective: In the recent years, the use of clinical ultrasonography (USG) has become very popular among the anesthesiologists. USG guidance plays an important role in the practice of anesthesia to help patient evaluation, improving patient safety and the effectiveness of the procedure. USG guidance in anesthesia has been shown to reduce the complication rate and the frequency of unsuccessful procedures. Although there is a significant amount of data regarding the advantages of using USG in regional anesthesia (RA), there is limited data available on anesthesia assistants’ perspectives on USG. The purpose of this study was to assess the USG usage in RA in the perspective of anesthesia research assistants.

Methodology: After approval by the institutional ethics committee, a questionnaire form was sent to one hundred and eighty-four anesthesia assistants via e-mail. The attitudes of anesthesia research assistants towards USG were evaluated using a 5-point Likert scale. Only anesthesiology and reanimation department assistants were included in the study.

Results: The mean age of the participants was 28.9 ± 2.1 y (25-35 y). Most (54.9%) of the participants were female and 45.1% were male. Respective units of all participants had an USG device, but only 39% of the participants had access to an USG device specific to RA; 98.4% of the participants used USG in RA (97.8% for peripheral nerve blocks, 28.8% for neuraxial anesthesia). While most participants (99.5%) thought that the use of USG for peripheral nerve blocks was advantageous, fewer participants (54.9%) thought that it was advantageous for neuraxial anesthesia. Only 38.6% of the participants reported that their training was sufficient for USG usage. Approximately half (48.9%) of the resident physicians needed an USG course. There were differences among the hospitals in terms of USG device. USG device specific to RA was more common in city hospitals (50.9%) and university hospitals (40.3%) compared to training and research hospitals (25%).

Conclusion: Anesthesia research assistants frequently prefer USG in regional anesthesia. With the removal of barriers to the use of USG, the rate of USG utilization and the success of procedures in regional anesthesia applications can be further increased.

Abbreviations: RA - regional anesthesia; TARD - Turkish Society of Anesthesiology and Reanimation; USG – ultrasonography

Keywords: Anesthesia research assistants; Attitude; Regional anesthesia; Ultrasonography

Citation: Atasever D, Aydin EU, Akelma FK, Gulec H, But A. Evaluation of the perspective of anesthesia research assistants on the use of ultrasonography in regional anesthesia. Anaesth. pain intensive care 2024;28(2):272−277; DOI: 10.35975/apic.v28i2.2430

Received: October 25, 2023; Reviewed: November 01, 2023; Accepted: December 13, 2023

Analysis of clinical risk factors in COVID-19 mortality in ICU in various age groups: a retrospective observational study

2024-04-17T23:48:19-06:00

Background and Objective: COVID-19 has been associated with more than 770 million cases and 6.9 million deaths worldwide, since the first case was reported in 2019 in Wuhan, China. Various demographic and clinical factors have been associated with high mortality. We retrospectively analyzed data of patients admitted to our Intensive Care Unit (ICU) with moderate to severe disease for association of mortality with baseline clinical parameters and lab values.

Methodology: Retrospectively, data was collected for patients admitted to ICU of our hospital from March 2021 to August 2021, with moderate to severe covid infection. A total of 399 patients were included in the analysis after exclusion of patients with incomplete outcome data. Analysis was initially performed to find association of baseline parameters with ICU mortality; stratified analysis was further performed for association with various age groups.

Results: There was significant association of increased mortality with higher baseline heart rate (> 100 bpm), respiratory rate (> 30 bpm), low PaO₂/FiO₂ (< 100), Low oxygen saturation (< 80%), high neutrophil/lymphocyte ratio (> 10) and high baseline proBNP (> 500); however, subgroup analysis in the study showed that increased respiratory rate and increased neutrophil/lymphocyte ratio were not associated with increased mortality in patients with ages less than 50 y.

Conclusion: Baseline higher baseline heart rate, respiratory rate, low PaO₂/FiO₂, Low oxygen saturation, high neutrophil/lymphocyte ratio and high baseline proBNP were found to be associated with higher mortality in COVID patients. However, higher respiratory rate and higher neutrophil/lymphocyte ratio were not associated with increased mortality in patients with age less than 50 y.

Keywords: COVID-19, Heart rate, Respiratory rate, oxygen saturation, neutrophil/lymphocyte ratio, proBNP

Citation: Chandra M, Sharma V, Kohli S, Yadav A, Sandill S, Sachdeva HC. Analysis of clinical risk factors in COVID-19 mortality in ICU in various age groups: A retrospective observational study. Anaesth. pain intensive care 2024;28(2):278−284; DOI: 10.35975/apic.v28i2.2323

Received: October 16, 2024; Reviewed: January 18, 2024; Accepted: February 20, 2024

Targeting G-protein coupled receptors in the spinal dorsal horn for prevention of shoulder tip pain with cesarean section; a myth or a fact

2024-04-17T23:48:19-06:00

Background & objective: Shoulder tip pain (STP) is a commonly observed, annoying and mostly neglected consequence of cesarean section and little is known as well as explored about intraoperative shoulder pain. We studied the effectiveness of activation of G protein-coupled receptors (GPCRs), by adding intrathecal fentanyl to the spinal anesthesia as a preventive analgesia for shoulder pain with cesarean section (CS).

Methodology: A total of 44 parturients undergoing elective CS were divided into two equal groups; Group F patients received 2.5 ml of hyperbaric bupivacaine 0.5 % and 25 µg fentanyl. Group C (control group) patients received 2.5 ml of hyperbaric bupivacaine 0.5. The incidence and severity of intraoperative STP was noted. The severity of that pain was assessed using the verbal numerical rating scale (0-10) at the time of complaint. The STP was monitored every 2 h for 8 h postoperatively.

Results: There was no statistical difference in the incidence and severity of STP in both groups. The average for diastolic blood pressure was 74 ± 6.5 mmHg in Group C vs 72 ± 8.5 mmHg in Group F and the average for the heart rate was 84 ± 6 bpm vs 79 ± 12 bpm in Group C and F respectively. Point biserial correlation revealed a positive correlation (0.3) between t STP and total blood loss; however, this correlation wasn’t statistically significant (P = 0.06).

Conclusion: Activation of G protein linked receptor by adding fentanyl to the local anesthetic for spinal anesthesia decrease the incidence of shoulder tip pain; however, the difference is statistically insignificant.

Abbreviations: CS - cesarean section; GPCR - G protein-coupled receptor; STP - Shoulder tip pain

Keywords; Anesthesia, spinal; Cesarean section; Pain; Pain, postoperative; Pain, shoulder tip; fentanyl; G protein-coupled receptors.

Citation: Haggag AM, Kamel WY. Targeting G-protein coupled receptors in the spinal dorsal horn for prevention of shoulder tip pain with cesarean section; a myth or a fact. Anaesth. pain intensive care 2024;28(2):285−290; DOI: 10.35975/apic.v28i2.2436

Received: July 24, 2023; Revised: December 20, 2023; Accepted: January 31, 2024

Efficacy and safety of single-shot erector spinae plane block for perioperative analgesia in pediatric surgery: a systematic review and meta-analysis

2024-04-17T23:48:20-06:00

Background and Objective: Since its introduction in 2016, ultrasound-guided ESPB has been utilized in various surgical contexts. Numerous case reports and studies have suggested that ESPB in pediatrics can offer perioperative analgesia, but its clinical effects have remained controversial. Therefore, this review aims to comprehensively analyze the efficacy and safety of single-shot ESPB in pediatrics.

Methodology: The literature search was electronically conducted in the Cochrane Library, PubMed, and Google Scholar databases, covering data available until December 2022. This meta-analysis encompassed English-language RCT that compared preoperative single-shot ESPB with a control group (no block or sham block) in pediatric patients (age < 18 y). The primary outcomes encompassed total intra and postoperative opioid consumption and the time first to rescue analgesia. Secondary outcomes comprised 24-hour postoperative pain scores, the incidence of PONV, and complications linked to local anesthesia and the ESPB procedure.

Results: The analysis incorporated six RCTs, encompassing 320 samples. Single-shot ESPB demonstrated a reduction in intraoperative opioid consumption (MD: -0.54; 95% CI [-0.97, -0.11], I2 = 97%, P = 0.01, very low-quality certainty of evidence), 24-hour postoperative opioid consumption (MD: -0.12; 95% CI [-0.21, -0.02], I2 = 93%, P = 0.02, low quality certainty of evidence), and an extension in the time to the first rescue analgesia requirement (MD: 3.38; 95% CI [2.38, 4.39], I2 = 96%, P < 0.00001, very low-quality certainty of evidence). The ESPB group exhibited reduced postoperative pain scores at 0, 1, 4, and 6 h (P < 0.05); however, no significant differences were observed compared to the control group at 2, 12, and 24 h. The incidence of PONV was also significantly lower in the ESPB group (P = 0.04). Encouragingly, all six RCTs reported no instances of complications associated with local anesthesia and the ESPB procedure.

Conclusion: This meta-analysis showed that ultrasound-guided single-shot ESPB in pediatrics diminished both intraoperative and postoperative opioid needs and also led to a decrease in occurrences of PONV. Furthermore, it effectively alleviated postoperative pain while maintaining safety against the potential risks of local anesthetic toxicity and complications linked to the ESPB procedure.

Abbreviations: CI - Confidence interval; ESPB - Erector spinae plane block; MD - Mean difference; PONV - Postoperative nausea and vomiting; RCT - Randomized controlled trial

Key words: Anesthesia, Regional; Erector Spinae Plane Block; Opioid; Pediatric; Pain, Perioperative; ESPB

Citation: Adhi MP, Syukur RB, Andriyanto L, Hanindito E, Utariani A. Efficacy and safety of single-shot erector spinae plane block for perioperative analgesia in pediatric surgery: A systematic review and meta-analysis. Anaesth. pain intensive care 2024;28(2):291−301; DOI: 10.35975/apic.v28i2.2437

Received: August 20, 2023; Revised: January 13, 2024; Accepted: January 21, 2024

Dexmedetomidine versus fentanyl as an adjuvant to bupivacaine in saddle anesthesia for anoplasty: a correlative randomized double-blinded trial

2024-04-17T23:48:20-06:00

Background: A saddle block is a preferred choice for peri-anal surgical procedures including anoplasty. Anesthesiologists have experimented by adding different adjuvants like dexmedetomidine and fentanyl to local anesthetics for spinal anesthesia, in an attempt to maintain balanced hemodynamics, fast recovery and prolonged post-operative pain relief. We compared the effect of dexmedetomidine with fentanyl on these parameters when added to hyperbaric bupivacaine for saddle block for anoplasty.

Methodology: Fifty-eight adult patients were categorized into two groups. Group-Fen, consisting of 29 patients, underwent a saddle block with 2.5 ml hyperbaric bupivacaine combined with fentanyl 0.5 ml (25 μg). Second group, the Group-Dex, consisted of 29 patients, received 2.5 ml hyperbaric bupivacaine mixed with dexmedetomidine 10 μg (0.5 ml). Monitoring of HR and SpO₂ was conducted every min for 10 min, then every 10 min. Evaluation of sensory blockage was done by using the pinprick technique, and the motor block was done utilizing the Bromage scale. Following surgery, assessments were conducted. Postoperative pain was determined utilizing the visual analog scale (VAS) in the ward and PACU.

Results: The Group-Dex exhibited significantly longer duration of two-segment retrogression and sensory retrogression to S1 compared to Group-Fen. Group-Dex exhibited a significantly prolonged duration until reaching Bromage 0 compared to the Group-Fen. A notable difference between groups was noted in terms of the time to request analgesia. The total consumption of tramadol and analgesic requirement frequency in Group-Dex was more alleviated than in Group-Fen, with highly substantial differences between groups.

Conclusion: Dexmedetomidine is recommended over fentanyl as adjunctive medication to bupivacaine for spinal anesthesia in anoplasty surgeries and procedures, in terms of duration of two-segment retrogression and sensory retrogression to S1.

Abbreviations: Anoplasty; BMI - Basal Metabolic Rate; IV - Intravenous; LA - Local anesthetics; PACU - Post-anesthesia care unit; VAS - Visual Analog Scale

Keywords: Dexmedetomidine; Regional Anesthesia; Spinal block; Bromage scale

Citation: Seyam SHA, Abdelgawad IM, Abdelhalim MA. Dexmedetomidine versus fentanyl as an adjuvant to bupivacaine in saddle anesthesia for anoplasty: a correlative randomized double-blinded trial. Anaesth. pain intensive care 2024;28(2):302−309. DOI: 10.35975/apic.v28i2.2438

Received: January 23, 2024; Revised: March 03, 2024; Accepted: March 04, 2024

Incidence and features of emergence delirium in children after general anesthesia in the Middle East population

2024-04-17T23:48:20-06:00

Background & Objective: Emergence delirium (ED) is a known complication characterized by altered mental state that occurs after general anesthesia, which might lead to involuntary agitation in the children. We did this prospective cross-sectional study to find the incidence of emergence delirium after general anesthesia in children at a tertiary care hospital. This study was conducted at Security Forces Hospital, Riyadh, Kingdom of Saudi Arabia

Methodology: We included 96 children, aged 2-12 y, who underwent general anesthesia for surgery. Emergence agitation was scored by using a standardized scoring system named Pediatric Anesthesia Emergence Delirium (PAED) score at the time of extubation and at every 15 min until discharge from PACU. We report the incidence of emergence delirium as numbers and percentages.

Results: A total of 96 children were included in the study. The median PAED score of children was 8 (5-12). The incidence of postoperative ED in pediatric patients was 38.5% (37 cases). The incidence of emergence delirium was higher in younger children with median age 56 (45-70.5) months as compared to children who were 63 (35-80) months old.

Conclusion: We found an incidence of 38.5% emergence delirium after general anesthesia in children at our hospital.

Abbreviations: ED - Emergence delirium; GA - General anesthesia; PAED - Pediatric Anesthesia Emergence Delirium; PACU - Post-anesthesia Care Unit

Keywords: Emergence Delirium, PAED Score, General Anesthesia, PACU

Citation: Huda AU, Arif A, Asim Z. Incidence and features of emergence delirium in children after general anesthesia in the Middle East population. Anaesth. pain intensive care 2024;28(2):310−314; DOI: 10.35975/apic.v28i2.2439

Received: September 13, 2023; Revised: February 04, 2024; Accepted: February 21, 2024

Comparative analgesic efficacy of ketamine versus neostigmine as adjuvants to bupivacaine during ultrasound-guided serratus anterior plane block in modified radical mastectomy

2024-04-17T23:48:20-06:00

Background & objective: Peripheral nerve blocks are efficient options for pain management in breast operations. Following modified radical mastectomy, the application of serratus anterior plane block has been shown to be very successful at controlling pain and minimizing narcotic usage. To increase the peripheral nerve block's duration and strength, numerous adjuvants to local anesthetics have been employed. We compared the effectiveness of neostigmine with ketamine as analgesic adjuvants to local anesthetic in US-guided serratus anterior plane block in patients undergoing modified radical mastectomy.

Methodology: A randomized, prospective, double-blinded comparative study, performed at Ain-Shams University Hospitals on 75 adult females aged 30-65 y, who were planned for a modified radical mastectomy and received serratus anterior plane block immediately after the procedure. Patients were randomly divided into 3 groups, 25 patients per group. Group BK: received 1 ml (50 mg) ketamine added to 20 ml of bupivacaine 0.25%. Group BN: received 1 ml (0.5 mg) neostigmine added to 20 ml of bupivacaine 0.25% and Group BS: received 1 ml normal saline added to 20 ml of bupivacaine 0.25%. The primary outcome was the total amount of nalbuphine consumed in a 24-h period. The secondary outcomes were the patient's hemodynamics, pain scores, and time to first rescue analgesia request.

Results: Total 24 h nalbuphine consumption was statistically significantly varying between the study groups (P < 0.001); the highest consumption of nalbuphine was in Group BS. As regards numeric pain scale at 2 h and 6 h postoperative there was significant statistical difference among Group BS with each of Group BK and Group BN (P = 0.001, P < 0.001 respectively). At 12 h and 24 h postoperative the difference was significant between all study groups. As regards requesting rescue analgesia there was significant variance among Group BS and each of Group1 and Group BN with no significant variance among Group BK and Group BN.

Conclusion: In serratus anterior plane block, adding 50 mg ketamine to bupivacaine decrease 24 h nalbuphine consumption and numeric pain scale, adding 0.5 mg neostigmine to bupivacaine has lower rate of requesting rescue analgesia following ketamine.

Trial Registry: NCT05802979.

Keywords: serratus anterior, ketamine, neostigmine, ultrasound, analgesia, modified radical mastectomy.

Citation: Saleh M, Saeed M, Rafat E, Hisham A. Comparative analgesic efficacy of ketamine versus neostigmine as adjuvants to bupivacaine during ultrasound-guided serratus anterior plane block in modified radical mastectomy. Anaesth. pain intensive care 2024;28(2):315−323; DOI: 10.35975/apic.v28i2.2440

Received: December 18, 2023; Revised: February 08, 2024; Accepted: (February 13, 2024

A randomized controlled study of pericapsular nerve group block (PENG block) plus lateral femoral cutaneous nerve block vs patient-controlled intravenous analgesia for postoperative analgesia after hip replacement surgery

2024-04-17T23:48:20-06:00

Background: Postoperative pain often remains troublesome for the patients, if not adequately managed. Various modalities have been tried to keep the patient pain free. Regional nerve blocks under ultrasound guidance have recently gained much popularity. We aimed to compare the pain relief outcomes after hip replacement surgery by continuous Pericapsular Nerve Group Block (PENG Block) in combination with lateral femoral cutaneous nerve (LFCN) block under the guidance of ultrasound versus patient-controlled intravenous analgesia (PCA).

Methodology: Sixty patients, who underwent hip surgery at E University Hospital, Hanoi, Vietnam, from August 2021 to August 2022, were randomly allocated to one of the two groups: group of patients with pain relief with PENG block in combination with LFCN block (PENG group) and the group of patients with patient-controlled intravenous analgesia (PCA group). Outcomes regarding clinical parameters and pain scores on Visual Analogue Scale (VAS), from the initiation of the blocks or the PCA (H0) to 72 h (H72) were recorded and compared.

Results: Sixty patients were included in this study. The average VAS scores at rest in both groups was at low pain level (VAS < 4). The average VAS score in both of the groups at most of the time of the study did not have a statistically significant difference. The VAS on movement at the time points H18, H21, H24, H30, H36, H48, H72 of the PENG group was lower than that of the PCA group and the difference was statistically significant between the two groups (P < 0.05). The rate of vomiting/nausea of patients in the PCA group was significantly higher than in the PENG group (P = 0.006).

Conclusion: Pericapsular nerve block combined with lateral femoral cutaneous nerve block offers prolonged pain relief when compared with traditional patient-controlled intravenous analgesia in postoperative pain relief after hip replacement, and is associated with lower frequency of vomiting/nausea.

Abbreviations: ASA - American Society of Anesthesiologists; AIIS - Anterior Inferior Iliac Spine; IPE - Iliopubic Eminence; LFCN - Lateral Femoral Cutaneous Nerve; PCA - Patient-Controlled Analgesia; PENG - Pericapsular Nerve Group; VAS - Visual Analogue Scale.

Keywords: Pericapsular nerve group block; Lateral femoral cutaneous nerve; Hip replacement; Multimodal analgesia; Ultrasound-guided analgesia; Patient-controlled analgesia; Side effects.

Citation: Dang TV, Hung ND, Quangm NX, Nguyen TH, Tran DV, VU Hoang Phuong VH. A randomized controlled study of pericapsular nerve group block (PENG block) plus lateral femoral cutaneous nerve block vs patient-controlled intravenous analgesia for postoperative analgesia after hip replacement surgery. Anaesth. pain intensive care 2024;28(2):324−328; DOI: 10.35975/apic.v28i2.2441

Received: December 22, 2023; Revised: January 26, 2024; Accepted: January 31, 2024

Sequential alveolar recruitment maneuvers during laparoscopic radical prostatectomy: a pilot randomized control trial

2024-04-17T23:48:20-06:00

Background & objective: Lung atelectasis is a known complication of general anesthesia, and especially in patients undergoing laparoscopic surgical procedures. Respiratory system compliance (Crs) is a measured sign of lung atelectasis in laparoscopic surgery. A protocolized sequential alveolar recruitment maneuver (RM) with positive end-expiratory pressure (PEEP) was compared to a usual management.

Methodology: Patients scheduled for elective laparoscopic radical prostatectomy under extreme Trendelenburg position were randomly allocated to one of the two groups; either PEEP plus alveolar RM in every 30 min (RM group) or PEEP only (PEEP group). The primary outcome was the time-dependent differences in Crs between the groups, that was tested using multivariate analysis of variance (MANOVA).

Results: Between 19 patients in the RM group and 17 patients in the PEEP group, patients’ demography was balanced. The time depended difference in Crs was significantly higher in the RM group than in the non-RM group. Postoperative atelectasis occurred in one patient in the PEEP group, whose Crs was 34 cmH₂O/mL at the time of intubation. In the subgroup with initial low Crs (< 60 cmH₂O/mL), the time-dependent difference in Crs was significantly higher in the RM group than the PEEP group.

Conclusion: In the subgroup with initial low respiratory system compliance (< 60 cmH2O/mL), the time-dependent difference in respiratory system compliance was significantly higher in the RM group than in the PEEP group, suggesting that the therapeutic target of RM would be initially low respiratory system compliance patients.

Abbreviations: Crs - Respiratory system compliance; RM - recruitment maneuver; PEEP - positive end-expiratory pressure

Keywords: Respiratory System Compliance; Lung Recruitment Maneuver; Lung Mechanics; Atelectasis; Randomized Control Trial

Citation: Matsuki Y, Hosokawa K, Uchino A, Matsuda S, Shigemi K. Sequential alveolar recruitment maneuvers during laparoscopic radical prostatectomy: a pilot randomized control trial. Anaesth. pain intensive care 2024;28(2):329−332; DOI: 10.35975/apic.v28i2.2407

Received: February 16, 2024; Revised: February 16, 2024; Accepted: March 11, 2024

Erector spinae plane block versus quadratus lumborum block for postoperative analgesia after abdominal hysterectomy: a randomized comparative study

2024-04-17T23:48:21-06:00

Background & objective: Fascial plane blocks have emerged as one of the main parts in multimodal analgesia after major abdominal surgeries. Quadratus lumborum (QL) and erector spinae plane (ESP) blocks could cover both somatic and visceral pain, and have been extensively used by the anesthesiologists. We compared both of the blocks for effectiveness, ease to perform and safety after total abdominal hysterectomy (TAH).

Methodology: We enrolled 64 female participants undergoing TAH, ASA PS I–III, aged 40-60 y, and BMI 18-40 kg/m². The patients were randomized equally into either Group QLB, to receive lateral QL block or Group ESPB to receive ESP block (ESPB), under ultrasound guidance, with bupivacaine bilaterally after surgery. Pain severity during rest and on coughing was measured with visual analogue scale (VAS), time to first analgesic request, total meperidine consumption as rescue analgesic, and frequency of PONV through 24 h were recorded.

Results: ESPB lowered the median VAS throughout the first 18 h with a significant difference (P < 0.001) during rest and cough than QLB. Also, ESPB lowered postoperative meperidine consumption more than the QLB group (62.50 ± 22.00 mg) vs (95.31 ± 26.52 mg) respectively with P < 0.001. ESPB prolonged the duration of analgesia over QLB (853.13 ± 50.51 min) vs (812.34 ± 67.53 min) respectively with a P = 0.008. No differences were recorded regarding PONV and hemodynamic parameters.

Conclusion: Erector spinae plane block is more effective, simple, and safe approach to multimodal analgesia after total abdominal hysterectomy than quadratus lumborum block.

Clinical trial registration No.: NCT05541588 on 15/9/2022.

Abbreviations: EOM - External oblique muscle; ESPB - Erector Spinae Plane Block; HR - Heart rate; IOM - Internal oblique muscle; LA - Local anesthetic; MAP - Mean arterial blood pressure; PACU: Post anesthesia care unit; QLB: Quadratus Lumborum Block; QL - Quadratus Lumborum muscle; TAM: transverses abdominus muscle; TAP - Transversus abdominus plane; VAS - Visual Analogue score.

Keywords: Erector spinae plane block; Hysterectomy; Postoperative pain; Quadratus lumborum block.

Citation: Abdelaziz TSA, Abdou K, Salem M. Erector spinae plane block versus quadratus lumborum block for postoperative analgesia after abdominal hysterectomy: a randomized comparative study. Anaesth. pain intensive care 2024;28(2):333−340; DOI: 10.35975/apic.v28i2.2442

Received: December 27, 2023; Revised: January 16, 2024; Accepted: January 18, 2024

Serum netrin-1 level and insulin resistance in type 2 diabetes mellitus

2024-04-17T23:48:21-06:00

Background & objective: Netrin-1 is commonly recognized as a neural guidance cue that has been suggested to play a role in pancreas development. Multiple studies have reported on the regenerative, angiogenic, and anti-inflammatory properties of netrin-1 in various tissues. In hyperglycemia, netrin-1 may support insulin secretion and reduce inflammation. This study was aimed to investigate the correlation of serum Netrin-1 with Homeostatic Model Assessment of Insulin Resistance (HOMA-IR).

Methodology: This study comprised a total of 81 patients diagnosed with type 2 diabetes mellitus (T2DM) and 79 apparently healthy individual as controls. For each participant' following an overnight fasting, samples of blood were taken. Biochemical parameters were estimated including glycated hemoglobin, fasting blood glucose, serum insulin, and serum netrin-1 levels.

Result: This study revealed that T2DM patients had significantly higher serum netrin-1 levels than the control group. There was a significant positive correlation between netrin-1 and HOMA-IR.

Conclusion: The mean serum concentration of netrin-1 was significantly higher in type 2 diabetes mellitus patients than in healthy individuals. There is a positive correlation between insulin resistance and netrin-1 in type 2 diabetes mellitus. Further studies involving larger sample sizes are needed to clarify the real relationship and to improve reliability and replicability and to provide an insight to the pathogenesis, diagnosis, prevention, and treatment of type 2 diabetes mellitus.

Abbreviations: ADA - American Diabetes Association DCC - Deleted Receptors in Colorectal Cancer; HOMA-IR - Homeostatic Model Assessment of Insulin Resistance; T2DM - Type 2 Diabetes Mellitus; UNC5 - Uncoordinated 5;

Keywords: Diabetes Mellitus; Hyperglycemia; Insulin Resistance; Netrin-1

Citation: Al-Shakour AA, Khalid HA, Naser NA. Serum netrin-1 level and insulin resistance in type 2 diabetes mellitus. Anaesth. pain intensive care 2024;28(2):341−346; DOI: 10.35975/apic.v28i2.2422

Received: January 07, 2024; Revised: February 01, 2024; Accepted: February 08, 2024

Serum netrin-1 level in patients with type 2 diabetes mellitus and its relationship with diabetic complications

2024-04-17T23:48:21-06:00

Background & objective: Diabetes mellitus is a metabolic disorder, which is becoming more prevalent. It results from a defect in insulin secretion, or insulin action, or both, which is associated with increases risk of developing microvascular and macrovascular complications. Netrin-1 is originally considered an axon guidance protein, With a structure similar to laminine. It has been linked to the growth of numerous tissues, including the pancreas. During the initial phases of the formation of several tissues, such as pancreatic tissue, netrin-1 plays a critical function in controlling cell motility, cell-cell interactions, and cell-extracellular tissue binding. We studied the levels of netrin-1 in the blood of people with type 2 diabetes (T2DM) and if there was a correlation between those levels and certain sociodemographic factors, glycemic control, and lipid profiles.

Methodology: We enrolled 160 participants in this study, and split them into two groups; 81 people with T2DM in the first group, and 79 healthy, normoglycemic people in the second group. Both groups were matched for age and sex. The weight, height, and waist circumference of every participant were recorded. After at least 8 h of fasting, blood samples were obtained. and the levels of netrin-1, lipid profile, fasting blood glucose, and glycated hemoglobin were estimated, among other biochemical indicators.

Result: This study revealed that T2DM patients had significantly higher serum netrin-1 levels than the control group. There was a significant positive correlation between netrin-1 and fasting blood sugar, HbA1c, triglycerides, and very-low-density lipoprotein (VLDL-C); however, a negative association was seen between netrin-1 and high-density lipoprotein-cholesterol (HDL-C).

Conclusion: In comparison to controls, T2DM patients had a significantly higher mean serum netrin-1 concentration, and higher value among patients was reported among those with poor glycemic control, suggesting that serum netrin-1 might serve as a biomarker for therapeutic response. However, further studies are required to assess its role in the development of microvascular and macrovascular complications.

Abbreviations: DCC - Deleted Receptors; FBS - fasting blood sugar; HDL-C-High-Density Lipoprotein-Cholesterol; T2DM - Type 2 Diabetes Mellitus; UNC5 - Uncoordinated 5 Receptors; VLDL-C - Very-Low-Density Lipoprotein;

Keywords: Diabetic complications; Diabetes mellitus; Netrin-1; Receptors

Citation: Al-Shakour AA, Khalid HA, Mahmood I, Al-Sudani MY. Serum netrin-1 level in patients with type 2 diabetes mellitus and its relationship with diabetic complications. Anaesth. pain intensive care 2024;28(2):347−352; DOI: 10.35975/apic.v28i2.2421

Received: October 26, 2023; Revised: January 15, 2024; Accepted: January 18, 2024

Prevalence of metabolic syndrome among patients with coronary artery disease in Basrah, Iraq

2024-04-25T21:35:02-06:00

Background & Methods: Metabolic Syndrome (MetS) is a group of comorbidities including visceral obesity, dyslipidemia, hypertension, and impaired glycemic tolerance or diabetes. MetS has been associated with a considerable risk of coronary artery disease (CAD) and type 2 diabetes. We conducted this study to determine the frequency of MetS among patients with CAD in Basrah, Iraq.

Methodology: This study was conducted in Basrah Oil Specialized Hospital for Cardiovascular Medicine and Surgery, in Basrah, and included 150 patients with CAD, diagnosed by coronary angiography. Out of 150, 93 (62%) patients were males and 57 (38%) were females. We also included 150 apparently healthy individuals as controls; 93 (62%) males and 57 (38%) females. The age of both patients and controls were 40-80 y. Wight, height, waist circumference (WC), and blood pressure (BP) were measured. Biochemical parameters including fasting plasma glucose (FPG), high-density lipoprotein-cholesterol (HDL-C), and triglyceride (TG) were also measured.

Results: The frequency of MetS was significantly higher among patients with coronary artery disease than in controls (P < 0.01). Also, it is more frequent among females (88%) compared to males (73%).

Conclusion: The frequency of metabolic syndrome among patients with coronary artery disease is significantly higher compared to healthy population without heart disease.

Abbreviations: CAD - Coronary artery disease; FPG - Fasting plasma glucose; HDL-C - High-density lipoprotein-cholesterol; MetS - Metabolic Syndrome; TG - Triglyceride

Keywords: Coronary Artery Disease; Metabolic Syndrome; Insulin Resistance.

Citation: Hammodi MA, Ajlan S, Hazza MA, Majeed MM. Prevalence of metabolic syndrome among patients with coronary artery disease in Basrah, Iraq. Anaesth. pain intensive care 2024;28(1):353−357;

DOI: 10.35975/apic.v28i2.2419

Received: October 30, 2023; Reviewed: December 07, 2023; Accepted: December 14, 2023

Beyond the incision: exploring acute pain management strategies following cardiac surgeries

2024-04-17T23:48:21-06:00

This narrative review explores the importance of multimodal pain management options for postoperative cardiac surgery, focusing on maximizing pain alleviation while minimizing opioids usage and adverse consequences. It examines various pharmacological and non-pharmacological techniques, including opioids, NSAIDs, acetaminophen, gabapentinoids, alpha-2 agonists, local anesthetics, and ketamine, to maximize pain relief and improve patient outcomes. The review emphasizes the significance of a multimodal approach, combining different agents for better pain relief and patient outcomes.

Non-pharmacological treatments, such as progressive muscle relaxation, deep breathing exercises, distraction techniques, massage therapy, and transcutaneous electrical nerve stimulation (TENS), also play a role in pain management, promoting comprehensive patient comfort and well-being. These methods are helpful additions to existing pharmaceutical therapies and promote comprehensive patient comfort.

In conclusion, multimodal pain management techniques are crucial in postoperative cardiac surgery, as they provide optimal pain relief, increased patient satisfaction, and overall improvement in outcomes. Healthcare professionals must continuously evaluate, modify, and improve pain management strategies to provide the highest level of care to patients in this high-stakes environment.

Keywords: Postoperative pain Management, Multimodal Analgesia, Opioids, Cardiac Surgery, Acute Pain, Patient-centered care, Interdisciplinary collaboration, Non-pharmacological Pain Relief.

Citation:Zahid MA, Kumar V, Saddique F, Khan B, Saleh M, Ahmed S. Beyond the incision: exploring acute pain management strategies following cardiac surgeries. Anaesth. pain intensive care 2024;28(2):358−371; DOI:10.35975/apic.v28i2.2408

Received: January 12, 2024; Revised: January 29, 2024; Accepted: February 10, 2024

Spontaneous tumor lysis syndrome in pediatric patients: a case series

2024-04-17T23:48:21-06:00

Spontaneous occurrence of Tumor Lysis Syndrome (TLS) is very rare. Only 3 pediatric case reports were reported in literature. All 3 patients presented with therapy-sensitive disease. Unfortunately, only one patient survived. It is preventable in 100% of patients, but TLS is a hard nut to crack. We present three distinct cases of spontaneous tumor lysis syndrome within the pediatric population, each associated with different types of tumors.

A 3-year-old boy with mediastinal germ cell tumor of stage III, had hyperuricemia and hyperphosphatemia on presentation, tumor lysis syndrome improved but later died with sepsis, another patient of 4-year-old girl with precursor B cell acute lymphoblastic lymphoma had hyperkalemia, hyperuricemia and hyperphosphatemia on presentation and third patient was 6-year-old boy with abdominal Burkitt lymphoma stage III presented with hyperkalemia, hyperuricemia, hyperphosphatemia and Acute Kidney Injury (AKI) before initiation of chemotherapy. Later both these patients improved and survived. Spontaneous tumor lysis syndrome has high mortality, so it is of utmost importance to diagnose it timely. Swift and effective responses to spontaneous TLS can significantly reduce the risk of mortality linked to this critical emergency condition.

Abbreviations: AKI - Acute Kidney Injury; ASDII - secundum atrial septal defect; TLS - Tumor Lysis Syndrome;

Keywords: Pediatric Oncology; Sepsis; Tumor Lysis Syndrome;

Citation: Ajmal MU, Saleem R, Saad Ur Rehman SU, Arslan M, Malik I. Spontaneous tumor lysis syndrome in pediatric patients: a case series. Anaesth. pain intensive care 2024;28(2):372−375; DOI: 10.35975/apic.v28i2.2409

Received: January 18, 2024; Revised: February 10, 2024; Accepted: February 15, 2024

Generalized tonic clonic fits precipitated by drotaverine as initial presentation of acute intermittent porphyria: a case report

2024-04-17T23:48:21-06:00

Acute intermittent porphyria is caused due to deficiency of porphobilinogen deaminase and usually presents with classic triad of neurologic dysfunction, abdominal pain and psychiatric disturbances. A 16-year old unmarried girl presented with 1-day history of recurrent episodes of generalized tonic clonic fits. There was history of mild diffuse abdominal pain for 15 days partially relieved by taking drotaverine. On examination, she was vitally stable and afebrile. Once the fits had stopped, there was no focal motor, sensory or cerebellar neurologic deficit and negative signs of neck rigidity. Initial investigations revealed microcytic anemia and a low normal sodium. Her ESR, CRP, CSF analysis, MRI scan (brain), EEG and aerobic cultures were normal. Urine had a pinkish red color and her 24-hour urine porphobilinogen were raised at 23 mg/24 h (normal range 0-3.4 mg/24 h) with normal fecal porphyrin levels. A diagnosis of Acute Intermittent Porphyria (AIP) was made and 10% dextrose infusion was stared which resulted in recovery. Her attack was most likely precipitated by drotaverine and it was withdrawn. Counseling and education about her diagnosis and possible triggering factors was done. She was asymptomatic at discharge and remained stable on follow-up at 4 weeks.

Abbreviations: AIP - Acute Intermittent Porphyria; ALA - Alpha-lipoic acid; PBGD - porphobilinogen deaminase; GABA - γ-Aminobutyric acid

Keywords: Acute Intermittent Porphyria, Fits, Drotaverine, Urine Porphobilinogen, Fecal Porphyrin, Heme, Dextrose Infusion.

Citation: Hamza A, Butt NI, Imran A, Qaiser F, Tariq S, Bader A, Ghoauri MSA. Generalized tonic clonic fits precipitated by drotaverine as initial presentation of acute intermittent porphyria: a case report. Anaesth. pain intensive care 2024;28(2):376−379; DOI: 10.35975/apic.v28i2.2395

Received: February 24, 2024; Revised: March 05, 2024; Accepted: March 14, 2024

The issues with early continuous renal replacement therapy for National Health Insurance patients: A case report

2024-04-17T23:48:22-06:00

Sepsis is the leading cause of patient admission to the intensive care unit (ICU). Most of the sepsis patients experience multi-organ failure, such as respiratory and kidney failure, that require specific support. Continuous renal replacement therapy (CRRT) is one of the modalities performed in the ICU to help ameliorate cytokine levels, maintain fluid balance, and remove toxins. CRRT allows early ventilator weaning, a reduction in vasopressor or inotropic administration, and early discharge from the ICU. We report an experience of initiating an early CRRT in a patient with septic shock and acute kidney injury with fluid overload. During CRRT, the patient showed significant improvement in ventilation, hemodynamic, and fluid balance. However, the CRRT had to be discontinued due to limited resources and the infection rebounded. The patient in this case study died on the 14th day following admission. Early CRRT may be an effective therapy in septic shock patients; however, it requires continuous application that may not be possible in low-resource setting. Alternatively, sustained low-efficiency daily dialysis (SLEDD) has no major disadvantages compared to CRRT and may be a feasible option.

Keywords: Blood purification; Continuous renal replacement therapy; CRRT; Low-resource setting; Sepsis

Citation: Djaja AS, Adhrie Sugiarto A, Irawany V. The issues with early continuous renal replacement therapy for National Health Insurance patients: a case report. Anaesth. pain intensive care 2024;28(2):380−383; DOI: 10.35975/apic.v28i2.2417

Received: February 22, 2023; Revised: January 30, 2024; Accepted: January 31, 2024

Fulminant peripartum pulmonary embolism leads to maternal cardiac arrest and hypoxic-ischemic encephalopathy

2024-04-17T23:48:22-06:00

Pulmonary embolism (PE) risk is greater in women during pregnancy or puerperium. If indeed the peripartum pulmonary embolism is not recognized early and treated appropriately, it could have catastrophic consequences. We therefore present a case of a pregnant woman who unfortunately went from undiagnosed peripartum pulmonary embolism and had a crisis during delivery. She eventually had cardiac arrest and hypoxic-ischemic encephalopathy as complications. We emphasize early recognition and prompt treatment of pulmonary embolism in order to prevent such serious complications in pregnant women. We discuss about the clinical condition of our patient and make contrasts based on previous literature.

Abbreviations: CPR - Cardiopulmonary Resuscitation; GCS - Glasgow Coma Scale; GDM - gestational diabetes mellitus; IVI - intravenous infusion PE - Pulmonary embolism; ROSC - return of spontaneous circulation;

Keywords: Pulmonary embolism; pregnancy, cardiac arrest; hypoxic-ischemic encephalopathy

Citation: Hehsan MR, Saidi MFIM, Mansor MM, Shoib MS. Fulminant peripartum pulmonary embolism leads to maternal cardiac arrest and hypoxic-ischemic encephalopathy. Anaesth. pain intensive care 2024;28(2):384−287; DOI: 10.35975/apic.v28i2.2416

Received: April 05, 2023; Revised: February 09, 2024; Accepted: February 29, 2024

Double trouble – refractory hypertension during adrenalectomy due to an accessory vein: a case report

2024-04-17T23:48:22-06:00

Pheochromocytoma is a rare tumor that releases catecholamines. The symptoms include hypertension, paroxysmal headaches, diaphoresis and palpitations. The diagnosis is made with elevated catecholamines and a suprarenal mass in abdominal CT scan. The treatment includes pharmacological preparation, with suppression of the adrenergic receptors, and adrenalectomy. The most important step during surgery is the resection of adrenal vein. After that, the release of catecholamines is totally suppressed. This results in hypotension or even shock. We present an adrenalectomy, in which invasive arterial pressure monitoring acknowledge hemodynamic changes that were not expected. This allowed surgeons to realize there was an accessory vein.

Keywords: Adrenalectomy; Anatomical variation; Hypertension; Pheochromocytoma; Adrenal vein.

Citation: Morgado C, Inácio R, Marques CN. Double trouble – refractory hypertension during adrenalectomy due to an accessory vein: a case report. Anaesth. pain intensive care 2024;28(2):388−390; DOI: 10.35975/apic.v28i2.2414

Received: October 06, 2023; Revised: February 27, 2024; Accepted: March 06, 2024

Addressing challenges in anesthesia management for patent ductus arteriosus ligation in a preterm baby: a case report

2024-04-17T23:48:22-06:00

Patent ductus arteriosus (PDA) is a cardiac anomaly where the ductus arteriosus, a blood vessel connecting the pulmonary artery and the aorta, fails to close completely after birth. Anesthesia management during bedside PDA ligation in the Neonatal Intensive Care Unit (NICU) presents unique challenges and higher risks compared to the operating room environment. Manual cardiovascular and respiratory monitoring may be inefficient and challenging for the anesthesiologists. This case report aims to discuss the anesthetic management of a one month and four days old male infant, who presented with respiratory distress since birth, was diagnosed with moderate PDA, respiratory distress syndrome, and in need of surfactant therapy. This report focuses on the utilization of total intravenous anesthesia (TIVA) without inhalation anesthesia for PDA ligation via left posterolateral thoracotomy performed at the bedside in the NICU.

Keywords: Ligation; Patent ductus arteriosus; Preterm; Respiratory distress syndrome; Surfactant; Total intravenous anesthesia

Citation: Amin MYS, Soenarto RF. Addressing challenges in anesthesia management for patent ductus arteriosus ligation in a preterm baby: a case report. Anaesth. pain intensive care 2024;28(2):391−394; DOI: 10.35975/apic.v28i2.2412

Received: February 04, 2024; Revised: February 04, 2024; Accepted: February 04, 2024

Persistent air leak with intact inflation system of endotracheal tube

2024-04-17T23:48:22-06:00

Disposable endotracheal tubes are being mass-produced with PVC material. Although it is a rare finding that an endotracheal tube may have a manufacturing defects, sporadic case reports published in scientific journals draw our attention, that alyhough rare, yet this possibility must be kept in mind by every clinician who intends to intubate a patient. The tube must be thoroughly checked before insertion, and any inadequacy in ventilation after insertion, must prompt us to recheck the breathing system, which may have to be replaced.

Keywords: Defective material; Endotracheal tube; Manufacturing defects

Citation: Khurana HS, Singh T, Kundra S, Garg D. Persistent air leak with intact inflation system of endotracheal tube (Correspondence). Anaesth. pain intensive care 2024;28(2):395−396; DOI: 10.35975/apic.v28i2.2413

Received: March 08, 2024; Accepted: March 08, 2024

Breakage of the spinal needle during spinal anesthesia

2024-04-17T23:48:22-06:00

Spinal anesthesia still a very common method of anesthesia for surgery on the torso below the neck; but it is known to be associated with some setbacks / complications, e.g., failed spinal, spinal hypotension, patch effect with missed dermatomes, post-spinal headache etc. The author presents a rare occurrence of spinal needle being broken during the procedure, and the distal part being removed by surgical exploration.

Keywords: Anesthesia complication; Spinal anesthesia; Quincke spinal needle

Citation: Khaskheli MS. Breakage of the spinal needle during spinal anesthesia (Correspondence). Anaesth. pain intensive care 2024;28(2):397−398; DOI: 10.35975/apic.v28i2.2415

Received: December 28, 2023; Accepted: March 04, 2024

‘Atlas of Ultrasound-Guided Interfascial Plane Hydrodissection’

2024-04-17T23:48:23-06:00

‘Ultrasound-Guided Interfascial Plane Hydrodissection’ is the latest masterly addition by Dr. Helen Gharaei into a series of masterpieces by him on the subject of interventional pain management. Dr. Helen Gharaei, MD, FIPM, FIPP is consultant interventional pain specialist. She is the founder of International Sonoguide Pain School. Following her initial work highlighting the hazards associated with steroid injections, Dr. Helen embarked on a relentless quest to discover safer alternatives for pain intervention.

A Giant Thyroid!

2024-04-17T23:48:23-06:00

A 55-year-old female with a 30-year long history of thyroid enlargement presented for elective thyroidectomy. On preoperative assessment, she was euthyroid with no significant comorbids. Her vital signs and labs were within normal limits. On airway examination, her Mallampati score was 4, mouth opening two fingers, limited neck extension, and absolutely no neck flexion. We planned awake nasal fiber-optic intubation for her and reserved an ICU bed for post-op mechanical ventilation as suspected postoperative tracheomalacia.

On the day of surgery, she was prepared for awake nasal fiber-optic intubation using 4% lignocaine topical spray, nebulization, and nasal packing. Successful nasal tracheal intubation was done, although maneuvering was required as reaching the hypopharynx was very difficult due to shifting of the trachea to the right side. The rest of the procedure was uneventful and the patient was extubated successfully. This procedure would have been impossible to perform without fiberscope, which indicates its importance and makes it must-have equipment for all tertiary care hospitals.

Ethical considerations: Patients consent was obtained to use her pictures for the educational purpose.

Citation: Raza A, Jadoon H. A Giant Thyroid! (Clinipics). Anaesth. pain intensive care 2024;28(3):000−000; DOI: 10.35975/apic.v28i3.2447

Increase in the time withdrawal latency and pNR1 after wet cupping therapy (WCT) in rats with neuropathic pain induced with chronic constriction injury

2024-04-17T23:48:16-06:00

Objective & Objective: Neuropathic pain (NP) is induced by a lesion or disease of the somatosensory system. A lot of individuals seek an alternative form of treatment for their pain because it is typically chronic, severe, and worsens with the pharmacological therapy. Both acute and chronic pain have been successfully treated using wet cupping therapy (WCT). WCT is helpful in reducing many types of pain, although the mechanism by which it does so is still unclear. Recent research has demonstrated that NP and NMDA receptor NR1 (pNR1) change are related. The most popular of NP's animal models, chronic constriction injury (CCI) models, were used in our study to apply in WCT. By observing the rise in pNR1 and time withdrawal latency (TWL) in Rattus norvegicus with CCI, we looked at the association between WCT and pain relief.

Methodology: Our study used a post-test only, randomized controlled trial design, overall with 21 male Rattus Norvegicus CCI models, who were 4 months old and weighed 220-250 g. Three groups, G1 as a sham CCI group, G2 as a CCI group, and G3 as a CCI group plus WCT, were created at random from these rats. In three weeks, each group received two times a week application of WCT to the paralumbar area (on both the left and right sides). Rats' TWL was measured and evaluated using a hot plate to determine their pain threshold and the number of pNR1-expressing glial cells in the spinal cord was computed.

Results: According to this research, the mean and standard deviation of the TWL values for G1, G2, and G3 were: 8.8 ± 0.28, 1.44 ± 0.10, and 14.57 ± 0.45 respectively. While the minimum, maximum and median of pNR1 values for G1, G2, and G3 were, 4.2, 4.2, 4.2; 0.0, 0.9, 0.0; and 5.20, 8.00, 8.00 respectively. With P = 0.0001 and P = 0.0001, respectively, there were significant differences in the TWL by ANOVA test, and pNR1 by Kruskall Wallis test among the groups. P1-P2, P1-P3, and P2-P3 had significantly dissimilar TWLs, e.g., P = 0.0001, P = 0.0001, and P = 0.0001; while P1-P2, P1-P3, and P2-P3 had significantly dissimilar pNR1 increases (P = 0.0001, P = 0.0001, and P = 0.0001).

Conclusion: We can draw the conclusion that WCT reduces pain in CCI rats by raising pNR1 and TWL (NP models). We suggest WCT as a technique that shows promise for reducing pain in peripheral NP models, although additional research is required to validate its mode of action.

Abbreviations: pNR1- phosphorylated NMDA receptor 1;

Keywords: CCI; Chronic constriction injury; pNR2; Neuropathic pain; WCT; Wet cupping therapy

Citation: Qurnianingsih E, Hidayati HB, Khaerunnisa S, Widjiati, Subadi I, Arfianti L, Abror ANF, Puspamaniar VA. Increase in the time withdrawal latency and pNR1 after wet cupping therapy (WCT) in rats with neuropathic pain induced with chronic constriction injury. Anaesth. pain intensive care 2024;28(2):243−247; DOI: 10.35975/apic.v28i2.2434

Received: August 25, 2023; Revised: February 03, 2024; Accepted: February 08, 2024