Ali M. Mokhtar

Syrian revolution: a field hospital under attack.

BACKGROUND Syrian revolution that began on March 15, 2011 represents not only a political crisis but also a humanitarian one where many relief attempts for saving civil injured were tried. METHODS A secret field hospital organized by the medical Arab union was set in Al-Bab town in the district of Aleppo. Egyptian volunteer physicians were the operating team who reached Syria through the Turkish border. Medical supplies were delivered from Turkey and medical equipment were taken from the government hospital which was not running at that time. Many Syrian volunteers helped in running this field hospital most of them were non-medical personnel who were trained to help in some medical purposes. RESULTS Total number of cases referred to the hospital was 75. Surgical intervention was needed for 28 patients. Most common procedures needed were vascular procedures (32 percent), orthopedic procedures (32 percent), and abdominal exploration (25 percent). Median injury severity score (ISS) for admitted patients were 21 with interquartile range (14-21). Two patients died intraoperatively due to massive bleeding. CONCLUSION Setting up a field hospital in such an area with unsafe conditions needs good communication with medical and relief organizations in the site of crisis, selection of a location as near as possible to the Turkish border, developing a convenient triaging plan, and training nonmedical volunteers to do simple tasks.

Post-spinal anesthesia hypotension during cesarean delivery, a review article

Abstract Maternal hypotension is a common complication after spinal anesthesia for cesarean delivery. Prevention and treatment of post-spinal hypotension (PSH) in cesarean delivery has been frequently investigated. Fluid loading is superior to no-fluid regimen; however, the incidence of PSH is still high with all fluid loading protocols; thus, the use of fluid loading as a sole method for prophylaxis might be not satisfactory for many anesthetists. Phenylephrine is the preferred vasopressor for prevention and management of PSH in most cases. Ephedrine may be more beneficial in patients with bradycardia, patients with uteroplacental insufficiency and pre-eclamptic patients. Norepinephrine infusion was recently investigated as an alternative for prophylaxis of PSH with minimal cardiac side effects. The high incidence of PSH with most of the pharmacological and non-pharmacological methods suggests the need for multimodal protocols for prevention and management of this problem. PSH in cesarean delivery is a common daily situation facing all anesthetists; thus, future research should focus on simple and rapid protocols that can be easily applied by anesthetists with moderate and low experience with minimal need to complex devices or costly drugs.

Remifentanil vs dexmedetomidine for severely preeclamptic parturients scheduled for cesarean section under general anesthesia: A randomized controlled trial

Abstract Objectives To compare the effect of remifentanil vs dexmedetomidine on hemodynamic response of noxious stimuli and neonatal outcome in preeclamptic parturient underwent C.S. under G.A. Methods This blinded, prospective, randomized trial included 50 preeclamptic parturients underwent C.S under G.A., randomized into two equal groups [25 patients each]: group R [remifentanil]: received 1 μg/kg loading and 0.05 μg/kg/min infusion doses and group D [dexmedetomidine] received 1/kg loading and 0.2 μg/kg/h infusion doses. Maternal MAP and HR were assessed before medication (T0), just after induction of GA (TI), just after intubation (TT), two minutes after intubation (TT2), just after skin incision (TS), two minutes after skin incision (TS2), just after delivery of the baby (TD), and at the end of operation (TE). Time between induction and fetal delivery (I-D interval), time between incision of the uterus and delivery (U-D interval), and time between stop of the infusion of the tested drugs and delivery (D-D interval) were recorded. Neonatal Apgar score was recorded at 1 and 5 min and the need for resuscitative measures. Results Maternal MAP and HR in group R were statistically lower at (TI), (TT), (TT2), (TS) and (TS2). Neonatal Apgar score was statistically lower in group R with higher incidence for tactile stimulation. Conclusion Both remifentanil and dexmedetomidine were effective on blunting the pressor response to noxious stimuli in severely preeclamptic parturients. While remifentanil was marginally more effective in suppressing the pressor response, dexmedetomidine was safer for the neonates.

Premedication with midazolam prior to cesarean delivery in preeclamptic parturients: A randomized controlled trial

Background: Anxiety is a concern in obstetrics, especially in preeclamptic mothers. Sedation is not commonly used in parturients for fear of adverse neonatal effect. We investigated maternal and neonatal outcome of midazolam as an adjuvant to spinal anesthesia for elective cesarean delivery. Methods: A prospective randomized controlled trial, in which eighty preeclamptic parturients received either an intravenous dose of 0.035 mg/kg of midazolam or an equal volume of normal saline, 30 min before spinal anesthesia. Maternal anxiety was assessed using Amsterdam Preoperative Anxiety and Information Scale (APAIS); postoperative maternal satisfaction was assessed using Maternal Satisfaction Scale for Cesarean Section (MSSCS). Newborns were assessed using Apgar score, Neonatal Neurologic and Adaptive Capacity Score (NACS), and umbilical artery blood gases. Results: Mothers premedicated with midazolam showed a lower level of preoperative anxiety and a higher degree of postoperative satisfaction than the control group. There were no between-group differences regarding the neonatal outcome. Conclusion: Preeclamptic parturients premedicated with midazolam (0.035 mg/kg) before spinal anesthesia have lower anxiety and higher postoperative satisfaction levels, with no adverse effects on the newborns.

Dose baixa de propofol versus lidocaína para alívio de laringoespasmo resistente pós‐extubação em paciente obstétrica

BACKGROUND Post-extubation laryngospasm is a dangerous complication that should be managed promptly. Standard measures were described for its management. We aimed to compare the efficacy of propofol (0.5mg.kg-1) vs. lidocaine (1.5mg.kg-1) for treatment of resistant post-extubation laryngospasm in the obstetric patients, after failure of the standard measures. METHOD This study was conducted over 2 years on all obstetric patients scheduled for cesarean delivery. Post-extubation laryngospasm was initially managed with a standard protocol (removal of offending stimulus, jaw thrust, positive pressure ventilation with 100% oxygen). When this protocol failed, the tested drug was the second line (lidocaine in the first year and propofol in the second year). Lastly, succinylcholine was used when the tested drug failed. RESULTS In lidocaine group, 5% of parturients developed post-extubation laryngospasm, 31.9% of them were successfully treated via standard protocol, and 68.1% required lidocaine treatment. 65.6% of patients treated with lidocaine responded successfully and 34.4% required succinylcholine to relieve laryngospasm. In propofol group, 4.7% of parturients developed post-extubation laryngospasm, 30.1% of them were successfully treated via standard protocol, and 69.9% required propofol treatment. 82.8% of patients treated with propofol responded successfully and 17.2% required succinylcholine to relieve laryngospasm. CONCLUSION Small dose of propofol (0.5mg.kg-1) is marginally more effective than lidocaine (1.5mg.kg-1) for the treatment of resistant post-extubation laryngospasm in obstetric patients, after failure of standard measures and before the use of muscle relaxants.

Preprocedural ultrasound examination versus manual palpation for thoracic epidural catheter insertion

Background and Aims: Ultrasound imaging before neuraxial blocks was reported to improve the ease of insertion and minimize the traumatic trials. However, the data about the use of ultrasound in thoracic epidural block are scanty. In this study, pre-insertion ultrasound scanning was compared to traditional manual palpation technique for insertion of the thoracic epidural catheter in abdominal operations. Subjects and Methods: Forty-eight patients scheduled to midline laparotomy under combined general anesthesia with thoracic epidural analgesia were included in the study. Patients were divided into two groups with regard to technique of epidural catheter insertion; ultrasound group (done ultrasound screening to determine the needle insertion point, angle of insertion, and depth of epidural space) and manual palpation group (used the traditional manual palpation technique). Number of puncture attempts, number of puncture levels, and number of needle redirection attempts were reported. Time of catheter insertion and complications were also reported in both groups. Results: Ultrasound group showed lower number of puncture attempts (1 [1, 1.25] vs. 1.5 [1, 2.75], P = 0.008), puncture levels (1 (1, 1) vs. 1 [1, 2], P = 0.002), and needle redirection attempts (0 [0, 2.25] vs. 3.5 [2, 5], P = 0.00). Ultrasound-guided group showed shorter time for catheter insertion compared to manual palpation group (140 ± 24 s vs. 213 ± 71 s P = 0.00). Conclusion: Preprocedural ultrasound imaging increased the incidence of first pass success in thoracic epidural catheter insertion and reduced the catheter insertion time compared to manual palpation method.

The role of ondansetron in prevention of post-spinal shivering (PSS) in obstetric patients: A double-blind randomized controlled trial

Abstract Background Elective cesarean delivery (C/D) under neuraxial anesthesia is commonly associated with shivering. Ondansetron is a widely used antiemetic during both pregnancy and surgery. Few controversial studies investigated its anti-shivering effect in C/D under spinal anesthesia. Objectives To study the efficacy of ondansetron to prevent post-spinal shivering in parturients underwent cesarean delivery under spinal Anesthesia. Methods This double-blinded, prospective, randomized, trial included 80 parturients underwent C/D under spinal anesthesia, randomized into two equal groups [40 patients each]; group O [Ondansetron]: received 8 mg/4 ml ondansetron and group S [Saline] received 4 ml normal saline as placebo. Post-spinal shivering and maximum shivering at any time were recorded on a (0–4) scale and total meperidine dose required to treat shivering at score ⩾ 3, was calculated. Maternal MAP assessed before spinal anesthesia (T0), just after spinal and lateral tilt positioning (T1), 2 min after positioning (T2), 5 min after positioning (T3), Just after delivery of the baby (T4), at the end of surgery (T5), together with total ephedrine (required to treat any hypotension) were recorded. Incidence of nausea and vomiting at any time during surgery was also recorded. Results Incidence of shivering, maximum shivering, total meperidine dose and incidence of nausea were lower in ondansetron group compared to saline group. Maternal MAP was lower at (T3) in placebo group, without difference in the total ephedrine dose between the two study groups. Conclusion Ondansetron (8 mg) was effective in reducing post-spinal shivering in parturients underwent elective cesarean delivery and decreasing the requirement to meperidine together with lower incidence of post-spinal hypotension and nausea when compared to placebo (saline).

Effect of single compared to repeated doses of intravenous S(+) ketamine on the release of pro-inflammatory cytokines in patients undergoing radical prostatectomy

Background: Radical prostatectomy is a major surgical procedure that is associated with marked inflammatory response and impairment of the immune system which may affect the postoperative outcome. The aim of this study was to evaluate the effect of preincision single or multiple doses of S(+) ketamine on the pro-inflammatory cytokines, namely tumor necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6). Patients and Methods: This is a randomized controlled trial including 60 American Society of Anesthesiologists Physical Status I and II patients scheduled for radical prostatectomy under combined general-epidural anesthesia in Cairo university Teaching Hospital. Patients were randomly divided into three groups each of twenty patients: Group I received no S(+) ketamine (control group), Group II received S(+) ketamine as a single preincision dose, and Group III received preincision and repeated doses of S(+) ketamine. S(+) ketamine was injected as a single intravenous dose of 0.5 mg/kg in Group II and III, repeated as 0.2 mg/kg at 20 min interval until 30 min before the end of surgery. Results: The three groups were comparable in age, weight, and duration of the operation. The study also revealed that a single preincision dose of S(+) ketamine decreased TNF-α to reach 1027.04 ± 50.13 μ/ml and IL-6 to reach 506.89 ± 25.35 pg/ml whereas the repeated doses of S(+) ketamine decreased TNF-α to reach 905.64 ± 35065 μ/ml and IL-6 to reach 412.79 ± 16.5 pg/ml (P < 0.05). Conclusion: S(+) ketamine suppresses pro-inflammatory cytokine production, especially when given in repeated doses.