Gamal Z. El-Morsy

Can thoracic paravertebral block replace thoracic epidural block in pediatric cardiac surgery? A randomized blinded study

To compare the outcomes of thoracic epidural block with thoracic paravertebral block for thoracotomy in pediatric patients. A prospective double-blind study. 60 pediatric patients aged 1-24 months, ASA II, III scheduled for thoracotomy were randomly allocated into two groups. After induction of general anesthesia, thoracic epidural catheter was inserted in group E (epidural) patients and thoracic paravertebral catheter was inserted in group P (paravertebral) patients. Post operative pain score was recorded hourly for 24 hours. Plasma cortisol level was recorded at three time points. Tidal breathing analysis was done preoperatively and 6 hours postoperatively. Analgesia, serum cortisol level, and pulmonary function parameters were comparable in the two groups. However, failure rate (incorrect placement of catheter) was significantly higher in epidural group than in paravertebral group (7% versus 0%, respectively). The complications were also significantly higher in epidural group (vomiting 14.8%, urine retention 11.1% and hypotension 14.8%) than paravertebral group (0%, 0%, and 3.6%, respectively). We conclude that both thoracic paravertebral block and thoracic epidural block results in comparable pain score and pulmonary function after thoracotomy in pediatric patients; the paravertebral block is associated with significantly less failure rate and side effects.

Laparoscopic repair of perforated peptic ulcer: Patch versus simple closure

BACKGROUND Laparoscopic correction of perforated peptic ulcer (PPU) has become an accepted way of management. Patch omentoplasty stayed for decades the main method of repair. The goal of the present study was to evaluate whether laparoscopic simple repair of PPU is as safe as patch omentoplasty. METHODS Since June 2005, 179 consecutive patients of PPU were treated by laparoscopic repair at our centers. We conducted a retrospective chart review in December 2012. Group I (patch group) included patients who were treated with standard patch omentoplasty. Group II (non-patch group) included patients who received simple repair without patch. RESULTS From June 2007 to Dec. 2012, 179 consecutive patients of PPU who were treated by laparoscopic repair at our centers were enrolled in this multi-center retrospective study. 108 patients belong to patch group. While 71 patients were treated with laparoscopic simple repair. Operative time was significantly shorter in group II (non patch) (p = 0.01). No patient was converted to laparotomy. There was no difference in age, gender, ASA score, surgical risk (Boeys) score, and incidence of co-morbidities. Both groups were comparable in terms of hospital stay, time to resume oral intake, postoperative complications and surgical outcomes. CONCLUSION Laparoscopic simple repair of PPU is a safe procedure compared with the traditional patch omentoplasty in presence of certain selection criteria.

The outcome of thoracic epidural anesthesia in elderly patients undergoing coronary artery bypass graft surgery

Background: Thoracic epidural anesthesia (TEA) improves analgesia and outcomes after a cardiac surgery. As aging is a risk factor for postoperative pulmonary complications, TEA is of particular importance in elderly patients undergoing coronary artery bypass graft (CABG). Methods: Fifty patients aged 65–75 years; ASA II and III scheduled for elective CABG were included in the study. Patients were randomized to receive either general anesthesia (GA) group alone or GA combined with TEA group. Heart rate (HR), mean arterial pressure (MAP), and central venous pressure were recorded. Total dose of fentanyl μg/kg, aortic cross clamping, cardiopulmonary bypass (CPB) time, time to first awaking and extubation, arterial blood gases, visual analog scale (VAS) score in intensive care unit were reported. Postoperative pulmonary function tests were done. Results: TEA showed a significant HR and lower MAP compared with the GA group. The total dose of intraoperative fentanyl and nitroglycerine were significantly lower in the TEA. Patients in TEA group have statistically significantly higher PaO2, lower PaCO2, increase in Forced Vital Capacity (FVC) and Forced Expiratory Volume in one second (FEV1) Conclusions: TEA reduced severity of postoperative pulmonary function and restoration was faster in TEA group in elderly patients undergoing CABG. Also, it resulted in earlier extubation and awakening, better analgesia, lower VAS.

Comparison of preemptive analgesic effect of intravenous ketorolac versus tramadol in pediatric inguinal herniotomy: A randomized double blind study

Abstract Background This study was designed to evaluate the preemptive analgesic efficacy of ketorolac tromethamine versus tramadol in providing postoperative pain relief and improving discharge criteria in children undergoing inguinal herniotomy. Methods Eighty children, aged between 2 and 12 years, undergoing inguinal herniotomy were randomly allocated to receive intravenous 1 mg/kg tramadol (group T; n = 40) or 1 mg/kg ketorolac (group K; n = 40), immediately after induction of general anesthesia. Heart rate, arterial pressure and oxygen saturation were monitored. Postoperative pain was assessed at regular intervals until discharge. Postoperative rescue analgesic (15 paracetamol mg/kg rectally) was supplemented when pain score was >4. Time to first analgesia, requirement for additional analgesics, sedation level, bleeding time and side effects were noted. Results Time to first analgesia was significantly longer and total consumption of rescue analgesic was significantly lower in tramadol group compared with ketorolac group .There were no significant changes in intraoperative heart rate, and arterial pressure between groups. Intraoperative bleeding time was within normal in both groups, but it was significantly higher in the ketorolac. Adverse effects were not observed. Conclusions Tramadol provided longer duration of postoperative analgesia and reduced requirement for rescue analgesic compared with ketorolac in children undergoing inguinal herniotomy.

Dexmedetomidine; an adjuvant drug for fast track technique in pediatric cardiac surgery

Abstract Background Simple surgical procedures in pediatric open cardiac surgery can be planned for early extubation by using dexmedetomidine alpha2 agonist. Early extubation is associated with shortening of postoperative ventilation and intensive care unit length of stay. The aim of this study was to examine the effects of dexmedetomidine on recovery profile, ICU length of stay, analgesic needs, and hospital stay in pediatric patients undergoing elective correction of congenital heart diseases using CPB. Methods Forty patients with age ranging from 2–10 years of either sex submitted for elective correction of simple congenital heart diseases undergoing CPB. All patients were premedicated in preoperative area with intramuscular 0.1 mg/kg midazolam and 0.015 mg/kg atropine sulfate. Patients were randomly classified into one of two equal groups (n = 20). In the Dex group, patients received an initial bolus dose of dexmedetomidine (0.4 μg/kg) over 10 min, followed by continuous infusion of 0.5 μg/kg/hr. In the control group, patients received an initial bolus dose of saline over 10 min, followed by continuous infusion of 0.5 μg/kg/hr. Results MAP, HR, the total dose of intra-operative fentanyl, vasodilator needs, time of extubation, pain score, ICU length of stay and hospital stay were significantly higher in the control group when compared with DEX group. Also in control group these were significant decrease in HR and MAP relative to baseline. There was significant increase in duration of inotropic support in control group than DEX group. Conclusion Dexmedetomidine is a short-acting alpha2-adrenoceptor agonist with many desirable clinical benefits that encourage its use in the perioperative period. Dexmedetomidine has anesthesia-sparing effects, it decreases MAP, HR and with reasonable analgesic effect.

Monitoring the effects of propofol and sevoflurane on cerebral oxygen supply-demand balance using transcranial Doppler sonography and jugular bulb saturation in pediatric open heart surgery

Background Increasing awareness of neurologic abnormalities associated with congenital heart surgical intervention has heightened investigations for prevention of neurologic injury during the perioperative period. This study investigated the effects of propofol and sevoflurane on cerebral oxygen supply demand balance using transcranial Doppler sonography and jugular bulb saturation in pediatric open heart surgery. Methods After obtaining institutional approval and a written consent from parents, 60 children who were admitted for elective open cardiac surgery for correction of congenital heart disease using CPB were included in this study. Children were randomized into two groups; group (P) and group (S). Induction of Anesthesia was achieved by 5 μg/Kg I.V. fentanyl, propofol 2- 2.5 mg/Kg (in propofol or P group) or sevoflurane 2-3 MAC (in sevoflurane or S group). Anesthesia was maintained by propofol infusion between 75-100 μg/kg/min in P group or sevoflurane 2 MAC in S group. Calculated parameters from the blood gas variables included cerebral metabolic rate of oxygen (CMRO 2 ), cerebral extraction of oxygen (CeO 2 ) and cerebral blood flow equivalent (CBF). Arterial blood gases (ABG) and velocities of flow were monitored by Trancranial Doppler at 5 time points : before the surgery, before CPB, during CPB (after establishment of full flow), after CPB and after recovery. Neurological examination and CT scan were done before surgery and 2 days after that. Results There is no significant difference between the two groups in demographic data. Children in propofol group showed lower heart rate values after induction and after CPB than those in sevoflurane group. Mean arterial pressure was statistically higher in sevoflurane group compared with propofol group after induction. Children in sevoflurane group showed significantly higher; velocity maximum, velocity mean and pulsatile index, in the after induction and after bypass periods than those in propofol group. Velocity minimum showed no difference between the two groups. SjvO 2 , CMRO 2 , CeO 2 and CBF was significantly different after induction in sevoflurane group compared with propofol group. Perioperative blood gases showed no difference between the studied groups. Conclusion Compared with propofol anesthesia, sevoflurane anesthesia provides a wider margin of safety against impaired cerebral oxygenation and better preservation of systemic hemodynamics. Moreover, cerebral oxygen saturation may not reflect changes in cerebral oxygenation as monitored by jugular venous oxygen tension measurement in children undergoing CPB.

Does type of cardioplegia affect myocardial and cerebral outcome in pediatric open cardiac surgeries

Background A single-dose strategy for cardioplegia is desired in pediatric congenital cardiac surgery, especially in repair of complex congenital defects. The hypothesis of this study is that a single infusion of Bretschneider HTK solution may offer myocardial and cerebral protection superior to repeated doses of a cold oxygenated blood cardioplegic solution in pediatric congenital cardiac surgery. Patients and methods Sixty patients who underwent congenital cardiac repair using cardiopulmonary bypass were grouped randomly to receive either a single dose of Custodiol (group A) or repeated oxygenated blood cardioplegia (group B). Echocardiography, ECG, and microscopic examination were used to evaluate left-ventricular function and structure. Myocardial injury was assessed with creatine kinase MB and serum troponin T, whereas cerebral outcome was assessed by jugular venous oxygen saturation. Patients were also neurologically examined and studied by brain computed tomography for gross neurological manifestation of cerebral ischemia or infarction preoperative and 2 days postoperatively. Results Myocardial enzymes and oxygen extraction were significantly high in group B compared with group A. Ultrastructure evaluation and cerebral outcome were significantly better in group A than in group B. Conclusion A single dose of an HTK cardioplegic solution provides better myocardial and cerebral protection than repeated doses of oxygenated blood cardioplegia during pediatric congenital cardiac surgery.

The effects of intravenous lidocaine infusion on hospital stay after major abdominal pediatric surgery. A randomized double-blinded study

Abstract Background Lidocaine attenuates the stress response to surgery when given intravenously. This study investigated the effect of perioperative lidocaine infusion on hormonal responses, bowel function and hospital stay after major abdominal surgeries in pediatrics. Methods After obtaining the Research Ethics Board (REB) approval and written informed parental consent, 80 pediatric patients aged 1–6 years, ASA II, III scheduled for abdominal major surgery were randomly allocated into two groups, each of forty children. Twenty minutes before induction, children in placebo group received saline in a rate of 1.5 ml/kg/h and those in lidocaine group received lidocaine 1.5 mg/kg intravenously then infusion of 1.5 mg/kg/h up to 6 h postoperatively. Length of hospital stay and return of bowel function were reported. Plasma cortisol was recorded at baseline, 10 min after continuous infusion, 5 min after intubation and 10 min after extubation. Serum lidocaine concentrations were recorded 10 min after start of infusion, 10 min and 4 h after extubation. Results Patients in placebo group showed significant higher plasma cortisol concentrations (P = 0.001) in response to induction of anesthesia and extended postoperatively when compared to lidocaine group. Hospital stay was significantly less in lidocaine group (5 ± 2 days) compared to placebo group (7 ± 2 days; P = 0.03). Also, fentanyl (μg/kg/d) requirement was significantly less in lidocaine group (5.4 ± 2.9 on 1st postoperative day and 4.1 ± 2.6 on 2nd postoperative day) compared to placebo group (14.4 ± 2.5 on 1st postoperative day and 12.6 ± 3.3 on 2nd postoperative day). Moreover, return of bowel function was earlier in lidocaine group compared to placebo group (19 ± 6.2 h vs. 23 ± 3.65 h respectively). Conclusion Intravenous lidocaine infusion, started preoperatively and continued for 6 h postoperatively, attenuated stress response to major abdominal pediatric surgery. It also decreased hospital stay, opioid requirement and hastened return of bowel function.