Ahmed Hasanin

Predicting successful supraclavicular brachial plexus block using pulse oximeter perfusion index

Background Supraclavicular nerve block is a popular approach for anaesthesia for upper limb surgeries. Conventional methods for evaluation of block success are time consuming and need patient cooperation. The aim of this study was to evaluate whether the perfusion index (PI) can be used to predict and provide a cut-off value for ultrasound-guided supraclavicular nerve block success. Methods The study included 77 patients undergoing elective orthopaedic procedures under ultrasound-guided supraclavicular nerve block. After local anaesthetic injection, sensory block success was assessed every 3 min by pinprick, and motor block success was assessed every 5 min by the ability to flex the elbow and the hand against resistance. The PI was recorded at baseline and at 10, 20, and 30 min after anaesthetic injection in both blocked and non-blocked limbs. The PI ratio was calculated as the PI after 10 min divided by the PI at the baseline. Receiver operating characteristic curves were constructed for the accuracy of the PI in detection of block success. Results The PI was higher in the blocked limb at all time points, and this was paralleled by a higher PI ratio compared with the unblocked limb. Both the PI and the PI ratio at 10 min after injection showed a sensitivity and specificity of 100% for block success at cut-off values of 3.3 and 1.4, respectively. Conclusions The PI is a useful tool for evaluation of successful supraclavicular nerve block. A PI ratio of > 1.4 is a good predictor for block success.

Prevalence of extensively drug-resistant gram negative bacilli in surgical intensive care in Egypt

Introduction The prevalence of extensively drug resistant gram negative bacilli (XDR-GNB) is rapidly progressing; however in Egypt data are sparse. We conducted the present study to quantify the incidence, risk factors and outcome of patients harboring XDR-GNB. Methods A one year prospective study was done by collecting all the bacteriological reports for cultures sent from the surgical intensive care unit, Cairo university teaching hospital. XDR-GNB were defined as any gram negative bacilli resistant to three or more classes of antimicrobial agents. Patients with XDR-GNB compared with those sustaining non extensively drug-resistant infection. A multivariate logistic regression model was created to identify independent predictors of multi-resistance. Results During one-year study period, a total of 152 samples (65%) out of 234 gram negative bacilli samples developed extensively drug resistant infection. XDR strains were significantly higher in Acinetobacterspp (86%), followed by Pseudomonas (63%), then Proteus (61%), Klebsiella (52%), and E coli (47%). Fourth generation cephalosporine (Cefipime) had the lowest susceptibility (10%) followed by third generation cephalosporines (11%), Quinolones (31%), Amikacin (42%), Tazobactam (52%), Carbapinems (52%), and colistin (90%). Relaparotomy was the only significant risk factor for acquisition of XDR infection. Conclusion Extensively drug-resistant gram negative infections are frequent in our ICU. This is an alarming health care issue in Egypt which emphasizes the need to rigorously implement infection control practices.

Evaluation of Perfusion Index as a Predictor of Vasopressor Requirement in Patients with Severe Sepsis.

ABSTRACT We evaluated the ability of perfusion index (PI) to predict vasopressor requirement during early resuscitation in patients with severe sepsis. All consecutive patients with clinically suspected severe sepsis as defined by the criteria of the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference were included. Perfusion variables included PI, arterial lactate level, central venous oxygen saturation, and the difference between central venous carbon dioxide and arterial carbon dioxide pressures, and were recorded before resuscitation and 6 h thereafter. We enrolled 36 patients with severe sepsis. Twenty-one patients required vasopressors, whereas 15 did not. The cut-off of the PI value for predicting vasopressor requirement was ⩽0.3. This cut-off value had a sensitivity of 100% and a specificity of 93%; the area under the curve was 0.96 (95% confidence interval 0.8–0.99, P < 0.0001). The cut-off of the arterial lactate level for predicting vasopressor requirement was ≥1.8 mg dL−1. This cut-off value had a sensitivity of 82% and a specificity of 80%; the area under the curve was 0.84 (95% confidence interval 0.68–0.94, P < 0.0001). Other perfusion variables failed to predict vasopressor requirement in patients with severe sepsis. We concluded that PI and arterial lactate level are good predictors of vasopressor requirement during early resuscitation in patients with severe sepsis. Further studies are warranted to investigate whether monitoring PI during resuscitation improves the outcome of patients with septic shock.

Fluid responsiveness in acute circulatory failure

Although fluid resuscitation of patients having acute circulatory failure is essential, avoiding unnecessary administration of fluids in these patients is also important. Fluid responsiveness (FR) is defined as the ability of the left ventricle to increase its stroke volume (SV) in response to fluid administration. The objective of this review is to provide the recent advances in the detection of FR and simplify the physiological basis, advantages, disadvantages, and cut-off values for each method. This review also highlights the present gaps in literature and provides future thoughts in the field of FR.Static methods are generally not recommended for the assessment of FR. Dynamic methods for the assessment of FR depend on heart-lung interactions. Pulse pressure variation (PPV) and stroke volume variation (SVV) are the most famous dynamic measures. Less-invasive dynamic parameters include plethysmographic-derived parameters, variation in blood flow in large arteries, and variation in the diameters of central veins. Dynamic methods for the assessment of FR have many limitations; the most important limitation is spontaneous breathing activity.Fluid challenge techniques were able to overcome most of the limitations of the dynamic methods. Passive leg raising is the most popular fluid challenge method. More simple techniques have been recently introduced such as the mini-fluid challenge and 10-s fluid challenge. The main limitation of fluid challenge techniques is the need to trace the effect of the fluid challenges on SV (or any of its derivatives) using a real-time monitor. More research is needed in the field of FR taking into consideration not only the accuracy of the method but also the ease of implementation, the applicability on a wider range of patients, the time needed to apply each method, and the feasibility of its application by acute care physicians with moderate and low experience.

Intraoperative Terlipressin Therapy Reduces the Incidence of Postoperative Acute Kidney Injury After Living Donor Liver Transplantation

OBJECTIVE To evaluate the effect of intraoperative infusion with terlipressin on the incidence of acute kidney injury (AKI) after living donor liver transplantation (LDLT). DESIGN Retrospective case-controlled study. SETTING Government hospital. PARTICIPANTS The medical records of 303 patients who underwent LDLT were reviewed retrospectively. INTERVENTIONS Patients were divided into 2 groups on the basis of intraoperative administration of terlipressin. The primary outcome was AKI, as defined by the Acute Kidney Injury Network criteria. Secondary outcomes included the requirement for postoperative dialysis and in-hospital mortality. MEASUREMENTS AND MAIN RESULTS The incidence of AKI was 38% (n = 115); AKI occurred in 24 (24.2%) patients who received terlipressin versus 91 (44.6%) in the control group (p = 0.001). The incidence of postoperative dialysis was 9.2% (n = 28). Postoperative dialysis was needed by 8 patients (8.1%) in the terlipressin group versus 20 patients (9.8%) in the control group (p = 0.62). Multivariate logistic regression analysis indicated that terlipressin protected against AKI (odds ratio [OR], 0.4; 95% confidence interval [CI], 0.2-0.8; p = 0.013) but not the need for dialysis (OR, 0.7; 95% CI, 0.2-2.2; p = 0.53) or the in-hospital mortality (OR, 1.1; 95% CI, 0.5-2.3; p = 0.7). Adjustment, using the propensity score, did not alter the association between the use of terlipressin and AKI reduction (OR, 0.46; 95% CI, 0.22-0.89; p = 0.03). CONCLUSION These results suggested that intraoperative terlipressin therapy is associated with significant reductions in the risk of AKI in LDLT patients.

Perfusion indices revisited

Monitoring of tissue perfusion is an essential step in the management of acute circulatory failure. The presence of cellular dysfunction has been a basic component of shock definition even in the absence of hypotension. Monitoring of tissue perfusion includes biomarkers of global tissue perfusion and measures for assessment of perfusion in non-vital organs.The presence of poor tissue perfusion in a shocked patient is usually associated with worse outcome. Persistently impaired perfusion despite adequate resuscitation is also associated with worse outcome. Thus, normalization of some perfusion indices has become one of the resuscitation targets in patients with septic shock.Although the collective evidence shows the clear relation between impaired peripheral perfusion and mortality, the use of different perfusion indices as a resuscitation target needs more research.

The Friday of Rage of the Egyptian Revolution: A Unique Role for Anesthesiologists

The 2011 Egyptian revolution began on January 25, 2011, and although predominantly peaceful, it was not without violent clashes between security forces and protesters. Reportedly, at least 846 people were killed and 6400 injured. On Friday, January 28, called by some “the Friday of Rage,” hundreds of thousands of Egyptian people assembled to protest, and Internet and cellular phone services were shut down by the government. Throughout the day, police fired tear gas, rubber bullets, shotgun shells, and live ammunition at protesters, and within a matter of hours, police stations were burned, the security of prisons was breached, violent criminals escaped into the streets, and the country’s vast police force vanished, creating a security vacuum (Fig. 1). During the first week of the revolution, most of the casualties were treated at the Cairo University Hospital Kasr Al-Ainy, located near Tahrir Square, the epicenter of Cairo and of the Egyptian revolution. Cairo University Hospital is the largest and oldest hospital in Egypt and the Middle East, with a capacity of 5500 inpatient beds and 72 operating rooms (ORs). It is the tertiary referral center for all Egyptian hospitals. However, on a Friday, a nonworkday in Egypt, only 8 emergency ORs are usually functioning.

Infection Complications and Pattern of Bacterial Resistance in Living-Donor Liver Transplantation: A Multicenter Epidemiologic Study in Egypt

INTRODUCTION Data on the prevalence and pattern of infection after living-donor liver transplantation (LDLT) are scarce in Egypt. We therefore conducted this study to quantify the incidence, risk factors, and pattern of bacterial resistance post-LDLT in 3 hospitals in Egypt. PATIENTS AND METHODS We conducted a retrospective, multicenter study of the medical records of 246 patients who underwent LDLT between January 2006 and April 2011 at 3 transplant centers in Egypt. RESULTS Of 246 patients enrolled in this study, 127 (52%) developed infectious complications after LDLT, with 416 episodes of infection occurring within 3 months of transplantation. Biliary tract infection was the most common, occurring in 169 (40.6%) patients. The rate of infection with Gram-negative bacteria was higher than that of infection with Gram-positive bacteria (310 [74%] vs 87 [21%]; P < .001). Overall, 75% of Gram-negative isolates were multidrug resistant. Significant independent risk factors for infection were portal vein thrombosis (odds ratio, 2.4; P = .037) and biliary complications (odds ratio, 5.4; P < .001). CONCLUSIONS Our data showed a high-resistance pattern of bacterial infection after LDLT in Egypt. Early biliary complications were an independent risk factor for bacterial infection.

Diagnostic values of CD64, C-reactive protein and procalcitonin in ventilator-associated pneumonia in adult trauma patients: a pilot study.

Abstract Background: Ventilator-associated pneumonia (VAP) is one of the most common nosocomial infections; however, its diagnosis remains difficult to establish in the critical care setting. We investigated the potential role of neutrophil CD64 (nCD64) expression as an early marker for the diagnosis of VAP. Methods: Forty-nine consecutive patients with clinically suspected VAP were prospectively included in a single-center study. The levels of nCD64, C-reactive protein (CRP), and serum procalcitonin (PCT) were analyzed for diagnostic evaluation at the time of intubation (baseline), at day 0 (time of diagnosis), and at day 3. The receiver operating characteristic curves were analyzed to identify the ideal cutoff values. Results: VAP was confirmed in 36 of 49 cases. In patients with and without VAP, the median levels (interquartile range, IQR) of nCD64 did not differ either at baseline [2.4 (IQR, 1.8–3.1) and 2.6 (IQR, 2.3–3.2), respectively; p=0.3] or at day 0 [2 (IQR, 2.5–3.0) and 2.6 (IQR, 2.4–2.9), respectively; p=0.8]. CRP showed the largest area under the curve (AUC) at day 3. The optimum cutoff value for CRP according to the maximum Youden index was 133 mg/dL. This cutoff value had 69% sensitivity and 76% specificity for predicting VAP; the AUC was 0.73 (95% CI, 0.59–0.85). The nCD64 and PCT values could not discriminate between the VAP and non-VAP groups either at day 0 or day 3. Conclusions: The results of this pilot study suggest that neutrophil CD64 measurement has a poor role in facilitating the diagnosis of VAP and thus may not be practically recommended to guide the administration of antibiotics when VAP is suspected.

Rapid identification of nosocomial Acinetobacter baumannii isolated from a surgical intensive care unit in Egypt.

BACKGROUND The rapid and accurate identification of nosocomial clinical isolates is the first essential step in investigating nosocomial outbreaks. We aimed to evaluate the performance of MDR-CHROMagar Acinetobacter versus matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) in rapid detection of nosocomial Acinetobacter baumannii isolated from patients admitted to the surgical intensive care unit (SICU) of Kasr Alainy-Cairo University. METHODS Over a period of 9 months from January 2014 until September 2014, 234 samples were collected. All samples were directly cultured on MDR-CHROMagar Acinetobacter media. MALDI-TOF MS was used to identify all non-lactose fermenting colonies on conventional media. Confirmation of species identification was done by detecting the blaOXA-51 like gene by PCR. RESULTS Statistical evaluation of MDR-CHROMagar Acinetobacter against blaOXA-51 like PCR as the reference method for identification of A baumannii showed a sensitivity of 100% (95% confidence interval [CI]: 93.36% to 100%), specificity 98.8% (95% confidence interval [CI]: 96.04% to 99.68%), positive predictive value 96.4% (95%CI: 86.61% to 99.37%), negative predictive value 100% (95% CI: 97.36% to 100%). The statistical evaluation of MALDI-TOF against blaOXA-51 PCR was 100% concordance. CONCLUSION MALDI-TOF MS was more specific than CHROMagar in identifying Acinetobacter spp and allowed further identification of non-A Baumannii species such as A hemolyticus and A nosocomialis, which are less common Acinetobacter spp involved in hospital-acquired infections.