Background The excellence of subarachnoid blockade (SAB) can be improved with a variety of adjuvants, used either intrathecally or intravenously. Objective The present study aimed to compare the clinical efficacy of intravenous dexmedetomidine with midazolam for hysterectomy under SAB with 0.5% hyperbaric bupivacaine. Materials and methods After approval, 90 adult consenting middle-aged female patients of American Society of Anesthesiologists (ASA) physical status I and II scheduled for hysterectomy under SAB were blindly randomized into three groups of 30 patients each, to receive either intravenous dexmedetomidine 0.5 μg/kg (group I) or intravenous midazolam 0.05 mg/kg (group II) or normal saline (group III), 20 min after the SAB. Patients were assessed for the onset and duration of sensory and motor blockade, maximum cephalic spread, and intraoperative hemodynamic changes as primary endpoints. The study also evaluated the sedation level and visual analogue scale score for postoperative pain as secondary outcome. Results Patients in the dexmedetomidine group showed a higher cephalic level of sensory blockade. Time for two dermatomes’ sensory regression (144.33±19.2 min) and duration of sensory analgesia (270.10±16.6 min) in the dexmedetomidine group was extended, with a statistically highly significant difference among the groups and no hemodynamic variability. Ramsay sedation score was higher in the dexmedetomidine and midazolam groups than in the saline group. Respiratory depression was not observed in any patient. The incidence of postspinal shivering was low in patients of the dexmedetomidine group. Conclusion Midazolam provided only sedation, whereas dexmedetomidine extended the duration of sensory analgesia of SAB, maintained hemodynamic stability, and also provided arousable sedation without respiratory depression.

Perioperative medicine is the future of our specialty, and it is defined as patient-centered multidisciplinary superior medical care from the time of taking the decision of surgery till the patient’s full recovery and discharge. Formerly most of the anesthetic practice focused on the index of the operation and the disease being treated by this procedure; however the appearance of postoperative related outcomes modulated by the type and quality of surgery had encouraged the development of that new concept.

Objective The aim of this study was to compare the effects of volatile anesthetics isoflurane and sevoflurane on intraoperative and postoperative bleeding in patients who underwent tonsillectomy and adenoidectomy. Patients and methods A total of 64 children classified as American Society of Anesthesiologists class I or II, aged between 2 and 16 years, who were scheduled for tonsillectomy and adenoidectomy were included in this prospective randomized double-blind study. The patients were randomized into two groups, isoflurane group and sevoflurane group, with each including 32 patients. They received balanced general anesthesia with isoflurane concentration 1.2% or sevoflurane concentration 2%. In all patients, the amount of intraoperative blood loss in milliliters was measured by the suction bottle, as well as by weighing the used sponges for each patient. The duration of operation and recovery time were recorded. Results Isoflurane caused significantly lower amount of perioperative bleeding compared with sevoflurane (P=0.03). No significant difference was observed between the two groups in terms of age, BMI, and operation duration, Conclusion Anesthesia with isoflurane can lead to a lower amount of intraoperative bleeding compared with sevoflurane. Therefore, isoflurane may be preferred as an inhalational agent for maintenance of general anesthesia during tonsillectomy and adenoidectomy operations.

Introduction Acute renal failure occurs in ∼23% of patients with severe sepsis. The combination of acute renal failure and severe sepsis may carry a mortality of up to 70%. Several studies have demonstrated that serum cystatin C level is a better marker of glomerular filtration rate (GFR) compared with serum creatinine, particularly for individuals with small-to-moderate decreases in GFR. To maintain organ perfusion in sepsis, a mean arterial pressure of 65 mmHg should be maintained with fluid therapy and vasopressors. Marked delays in initiation are associated with increase in mortality risk in patients with septic shock. Patients and methods Sixty patients enrolled in the study proved to have severe sepsis with early renal impairment. Patients were randomly allocated into one of two groups (30 patients each): the norepinephrine infusion group (the N group) and the control group (the C group). The N group received norepinephrine infusion + conventional treatment for severe sepsis, whereas the C group was treated with conventional treatment for severe sepsis according to the latest Surviving Sepsis Campaign. For each patient, the following data were collected: age, body weight, hemodynamic changes, urine output, renal function as detected from levels of the sensitive renal marker cystatin C and from serum creatinine levels, blood urea nitrogen, and estimated GFR (eGFR). Results There was a statistically significant increase in blood pressure and urine output in the N group at 10 min and 2 h, respectively, after norepinephrine infusion and on comparing subsequent measures with baseline values (T0) and also when compared with corresponding values in the C group. In addition, patients in the N group showed a statistically signifi cant decrease in serum cystatin C levels and an increase in eGFR based on cystatin C levels after 2 h of norepinephrine infusion, compared with baseline values and values in the C group, denoting marked improvement in GFR. Serum creatinine levels, blood urea nitrogen levels, and eGFR based on serum creatinine levels showed no significant difference in either group whether compared with baseline of the same group or when comparing both groups together. Conclusion The results this study demonstrate that early continuous infusion of norepinephrine at 0.5–1 μg/ kg/min may have a renoprotective role in septic patients with early renal impairment detected by levels of the sensitive renal marker cystatin C.

Background At present, ovarian hyperstimulation syndrome (OHSS) is an uncommon and potentially life-threatening complication of ovarian stimulation. The ideal colloid solution for the treatment of patients with severe OHSS is still unknown. Human albumin, however, is considered the most ‘physiologic’ solution for this purpose and commonly used. However, severe life-threatening anaphylaxis has been reported with albumin infusion. The purpose of this study was to compare the efficacy and safety of hypertonic saline 3% for the treatment of severe OHSS rather than albumin. Patients and methods Over a period of 2 years, this randomized prospective study was conducted on 60 patients diagnosed with severe or critical OHSS admitted to Obstetric ICU of Ain-Shams University Hospitals. Patients were randomly allocated into two groups, each containing 30 patients. Group A (n=30) received 100 ml of albumin 20% over 4 h every 12 h plus conventional treatment according to the Ain Shams obstetric ICU protocol. Group N (n=30) received 500 ml of hypertonic saline 3% over 24 h (20 ml/h) plus conventional treatment. The efficacy of the study medications was compared in this study between the two groups in terms of daily urine output, serum creatinitine, percentage of occurrence established renal impairment, need of paracentesis, occurrence of established acute respiratory distress syndrome, and ICU length of stay. Results Significant difference was found regarding daily urine output among the study groups, with a significantly higher value (3350±142.6) in group N compared with group A (2150±133.4) associated with significant reduction in occurrence of established renal impairment in three cases in group A rather than 1 in group N. This is reflected by significant reduction in the length of ICU stay (3.1±1.1) in group N rather than group A (3.7±1.2). Conclusion The use of hypertonic saline 3% as a small-volume resuscitation is comparable to and effective and superior to albumin for the treatment of severe OHSS with regard to urine output, and may have a protective effect against occurrence of acute respiratory distress syndrome in such patients, but further studies are needed to prove that.

Introduction Laryngoscopy as well as tracheal intubation causes changes in the hemodynamics of the patient owing to stress response. C-MAC videolaryngoscope (VL) is a relatively recent development that improves the success of tracheal intubation. Aim The aim of this study was to compare and evaluate the effects of dexmedetomidine for attenuation of hemodynamic responses during laryngoscopy using Macintosh laryngoscope versus C-MAC laryngoscope. Patients and methods A total of 60 patients, ASA II, 18–60 years old, scheduled for different surgeries under general anesthesia with BMI up to 40 kg/m2 were included in the study. Patients were divided into two groups (30 patients each) and were appropriately positioned, and intubation was done. Hemodynamic stress response to intubation was recorded, and plasma epinephrine level was estimated at baseline and at 1 and 5 min after intubation. Success rate, duration, attempts of intubation, and SpO2% were assessed. Results Plasma epinephrine level (ng/ml) at baseline and at 1 and 5 min after intubation showed no statistically significant difference in both groups, but there were highly significant differences at 1 and 5 min after intubation compared with baseline values (P Conclusion The stress response in both laryngoscopic techniques appears to be the same as detected by the nonsignificant difference in plasma epinephrine levels and hemodynamic changes in both groups, so 1 μg/kg dexmedetomidine is not enough to obtund the stress response completely. C-MAC VL is an efficient and suitable intubating device and provides excellent visualization of laryngeal structures in shorter time with less intubation attempts than Macintosh (Techron Surgical, Sialkot, P, Pakistan) laryngoscopy.

Background Emergence agitation (EA) can occur following recovery from general anesthesia. The patient may exhibit aggressive behavior, disorientation, agitation, and restlessness. If untreated, this complication may result in significant morbidity. EA has been poorly investigated in patients undergoing laparoscopic sleeve gastrectomy. Aim The aim was to assess the efficacy of perioperative dexmedetomidine infusion on EA and quality of recovery after elective laparoscopic sleeve gastrectomy in morbidly obese adult patients. Materials and methods A total of 60 patients undergoing laparoscopic sleeve gastrectomy were randomized into two groups (30 patients each). The dexmedetomidine group (group D, N=30) received dexmedetomidine infusion, whereas the control group (group C, N=30) received normal saline in the same volume and rate as placebo. Propofol, fentanyl, and atracurium were used for induction of anesthesia, and isoflurane was used for maintenance of anesthesia. Postoperative hemodynamic variables, postoperative pain, the need for ‘rescue’ analgesics and antiemetics, and the incidence of agitation were recorded up to 2 h postoperatively. Pain was evaluated using the visual analog scale score in the postanesthesia care unit on arrival, at 5 min, and then every 15 min for 120 min. EA was evaluated at the same time intervals by Richmond agitation-sedation scale (RASS). Pethidine 50 mg intravenously was given for pain (if pain score >4) or severe agitation (RASS score >+1). Results No patients in group D experienced postoperative EA during the second hour postoperatively (RASS ˂1). On the contrary, RASS scores of patients in group C were 2 (2–3) on arrival to postanesthesia care unit and greater than +1 during the remaining time up to 2 h postoperatively, indicating postoperative EA. In group C, 25 (92.5%) patients required rescue analgesia compared with only five (18.5%) patients in group D. Hemodynamic parameters were stable in group D. Conclusion Dexmedetomidine infusion during laparoscopic sleeve gastrectomy for morbidly obese patients is beneficial and effective in preventing postoperative pain and postoperative EA.

Objective The aim was to evaluate and compare the analgesic efficacy of tramadol versus hyoscine-N-butylbromide intramuscularly given during the active phase of the first stage of labor. Materials and methods This prospective study included 140, American Society of Anesthesiologists I, laboring primigravidae, who were divided into two equal groups: group I (group B) received hyoscine-N-butylbromide (Buscopan) 40 mg intramuscular and group II (group T) received tramadol 100 mg intramuscular. Labor pain was assessed by visual analog scale before and at 30 min, 1 h, 2 h, and 3 h after drug administration. Maternal and neonatal adverse effects, drug-delivery interval, mode of delivery, need for additional analgesia, and postpartum maternal satisfaction were assessed too. Results Baseline visual analog scale scores were comparable between the groups (P>0.05). Pain scores at 30 min, 1 h, 2 h, and 3 h were significantly higher (P 0.05). A total of 56 (80%) women in group B had adverse effects versus 54 (77.1%) women in group T (P>0.05). Adverse effects were generally mild (well tolerated). Cesarean delivery percentages were comparable between the groups (P>0.05). Postpartum maternal satisfaction was significantly higher (P Conclusion Although Buscopan is cheap and safe, it is a less effective intrapartum analgesic than tramadol. It offers shorter duration of labor, so it is better recommended for primiparous women.

Background With the advent of opioid receptors, a variety of opioid agents are added to local anesthetic mixtures used in peripheral blocks to improve the quality and duration of block. In this study, we compared the effect of butorphanol and tramadol as adjuvant agents for orthopedic upper extremity surgery. Patients and methods This study was carried out on 50 patients aged between 18 and 60 years, of American Society of Anesthesiologists grades I and II, of either sexes in each group, undergoing orthopedic upper limb surgeries through axillary brachial plexus block. An injection of butorphanol 2 mg (group B) and that of tramadol 100 mg (group T) were added to local anesthetic mixture. Onset of sensory and motor blockade, extent of blockade, and occurrence of any complications were studied in both groups. All patients were observed for analgesia postoperatively by visual analog scale pain score. Results In our study, the onset time (minutes) of sensory and motor blockade was delayed in group B (8.76±1.0 and 5.86±0.71, respectively) as compared with group T (7.54±0.88 and 4.6±0.73, respectively). In group B, the duration of sensory block (291.24±48.51 min) was longer than group T (160.42±12.66 min). Duration of analgesia postoperatively (first rescue analgesic) was 619.96±26.96 min in group B, whereas it was 290.2±20.38 min in group T. Conclusion Butorphanol is more potent and produces longer duration of postoperative analgesia than tramadol, with an extra advantage of sedation and calmness.

Background and aim Various studies have questioned the efficacy of intraoperative acute normovolemic hemodilution (ANH) in reducing bleeding, the need for allogenic transfusion, and the incidence of re-exploration in cardiac surgery. The aim of the present study was to evaluate the effectiveness of the use of minimal ANH for blood transfusion requirements and re-opening in elective adult coronary artery bypass graft surgery using cardiopulmonary bypass. Patients and methods This prospective, randomized controlled study was conducted on 100 consecutive adult patients who underwent elective coronary artery bypass graft. Patients were randomly divided into two equal groups: the ANH group (n=50) and the control group (n=50). In the ANH group, 5–8 ml/kg of autologous blood was withdrawn after administering anesthesia and before systemic heparinization. Simultaneously, colloid solution (6% hydroxyethyl starch 130/0.4; Voluven) was infused in a ratio of 1:1, and then the blood was re-infused after bypass. Hemodilation was not carried out for the control group. Total amount of allogenic-packed red blood cell, fresh frozen plasma, platelet concentrate transfusion, and the number of patients undergoing re-opening because of excessive bleeding were calculated for the two groups. Results A significant decrease was observed in the number of red blood cell units and fresh frozen plasma transfusion per patient in the ANH group compared with the control group. Conversely, chest tube output, representing postoperative bleeding and platelet count, did not differ between the two groups. Conclusion In this study, the use of the minimal ANH technique reduced the consumption of allogenic red blood cells and fresh frozen plasma in adult cardiac surgery patients. However, this technique had no effect on postoperative bleeding, incidence of re-exploration, and platelet count.