Islam M. Massad

Torsade de pointes during sevoflurane anesthesia in a child with congenital long QT syndrome

We present a case of congenital long QT syndrome which developed torsade de pointes during sevoflurane anesthesia for implantation of an internal cardioverter‐defibrillator. The diagnosis, implications and treatment are discussed.

Intraoperative administration of dexmedetomidine reduces the analgesic requirements for children undergoing hypospadius surgery.

Background The present study was designed to assess whether an intraoperative administration of dexmedetomidine would decrease the intraoperative and postoperative analgesic requirements for paediatric patients undergoing hypospadius surgery. Methods Forty-eight children (American Society of Anesthesiologists-1) aged 1–12 years undergoing hypospadius repair under general anaesthesia were randomly assigned into dexmedetomidine or placebo groups, D and P, respectively. Group D received a loading dose of dexmedetomidine 1 μg kg−1 after induction of anaesthesia, followed by a continuous infusion at a rate of 0.7 μg kg−1 h−1. Group P received a volume-matched 0.9% saline. Both groups received fentanyl for intraoperative analgesia and intravenous morphine and oral paracetamol for postoperative analgesia. For both groups, heart rate, blood pressure and fentanyl requirements were recorded intraoperatively. During their stay for 2 h in the recovery room, heart rate, blood pressure, pain scores, behaviour scores and total morphine requirements were recorded. After discharge from postanaesthesia care unit, paracetamol requirements over 24 h were also recorded. Results Intraoperatively, the dexmedetomidine-treated group had significantly fewer fentanyl requirements, slower heart rate and lower mean arterial blood pressure (P < 0.001). In the postanaesthesia care unit, this group also consumed significantly less morphine, had lower pain scores, lower behaviour score in the immediate postoperative period, lower heart rates and mean arterial blood pressures when compared with the placebo group (P < 0.001). Group D consumed significantly less paracetamol than group P in the ward over 24 h. Conclusion Intravenous administration of dexmedetomidine intraoperatively during hypospadius repair in children reduces intraoperative and postoperative analgesic requirements and lowers heart rate and blood pressure.

Periosteal chondroma of the clavicle: Case report and review of the literature

Periosteal chondromas (juxtacortical chondromas), are slow growing, rare cartilaginous lesion that arises adjacent to the cortex beneath the periosteum. They occur more in males in their 20s. We report a rare case of periosteal chondroma arising from the left clavicle of a 56 year old male. We could only find one reported case in the English literature of periosteal chondroma arising from the research and to the best of our knowledge, this is the second reported case.

Remifentanil consumption in septoplasty surgery under general anesthesia. Association with humane mu-opioid receptor gene variants

Objectives: To evaluate the influence of the ORM1 variants in codon 118 on the intra-operative remifentanil consumption under general anesthesia. Methods: A prospective gene association study, performed at the Jordan University Jordan, Amman, Jordan from September 2013 to August 2014. It includes patients who underwent septoplasty surgery under general anesthesia. All patients received standard intravenous anesthesia. Anesthesia maintained with fixed dose of Sevoflurane and variable dose of Remifentanil to keep the systolic blood pressure between 90-100 mm Hg. The Remifentanil dose was calculated and correlated with ORM1 genotype variance. Results: Genotype and clinical data were available for 123 cases. The A118A genotype was seen in 96 patients (78%), the A118G genotype was seen in 25 patients (20.3%), and only 2 patients had genotype G118G (1.6%). The G118G variant was removed from the statistical analysis due to small sample size. There was a significant effect of ORM1 genotype variant and the amount of remifentanil consumed. The A118A genotype received 0.173 ± 0.063 µg kg-1 min-1 and the A118G genotype received 0.316 ± 0.100 µg kg-1 min-1 (p<0.0001). Conclusion: The ORM1 gene has a role in intra-operative remifentanil consumption in patients who underwent septoplasty surgery under general anesthesia. The A118G gene required higher dose of remifentanil compared with the A118A genotype.

Cardiac myxoma: clinical characteristics, surgical intervention, intra-operative challenges and outcome:

Objective: The objectives of this retrospective study were to characterize the clinical presentation, diagnostic findings, surgical approaches, intra-operative challenges and complications following the surgical treatment of cardiac myxoma in two of the largest referral hospitals in Jordan. Methods: Medical records of all patients presented to the cardiology department during the period between 1984 and 2016 were reviewed. Criteria for inclusion in the study were: (1) patients who were presented for cardiac evaluation due to symptoms suggestive of a primary cardiac problem, (2) completed medical records, including results of echocardiography suggestive of intra-cardiac occupying mass, (3) the surgical operation was undertaken and intra-operative data was available, (4) a histological diagnosis of myxoma was available and (5) the discharge status and follow-up data were available for at least 2 years after initial surgery. Results: A total of 27 patients fulfilled the criteria for inclusion in the study. The average age was 42 years. Thirteen of the patients were females and 14 patients were males. The most common clinical presentations were dyspnea (29.6%) and murmurs (22.2%). Non-specific signs, such as weight loss, fever, fatigue, arthralgia and anemia, were reported in 10 (37%) patients. Signs related to systemic embolization were reported in 9 (33.3%) of the patients, involving the upper and lower extremities (55.6%), brain ischemia and vision loss (54.4%). Tumors in all patients were successfully resected under cardiopulmonary bypass support. The tumor was pedunculated in 17 (62.9%) of the patients and the size of the tumors varied from 1 to 7 centimeters in diameter. The tumor was located in the left atrium in 21 patients (77.7%), in the right atrium in 4 patients (14.8%), in the right ventricular side of the septum in 1 patient (3.7%) and involving the tricuspid valve in 1 patient (3.7%). The left atrial approach was used in 3 patients, a right atrial approach in 4 patients and a bi-atrial approach in 20 patients. The most common concomitant cardiac pathology was coronary artery disease in 3 patients and an atrial septal defect in one patient. The most common intra-operative challenges were inter-atrial communication (2 patients), large defect in the tricuspid valve leaflet (1 patient) and involvement of the inter-ventricular septum (1 patient). In the post-operative period, 1 patient suffered a stroke. In the post-operative period, the most common complications were stroke (1 patient) and recurrence of the tumor (2 patients). Conclusion: The success rate after surgical removal of cardiac myxoma in this study was substantial and complications were rare.

Post-Operative Nausea, Vomiting and Pain Score in Post Anesthesia CareUnit (PACU) at Jordan University Hospital

A prospective interview based survey on the incidence of postoperative nausea and vomiting of 1007 inpatients aged 1-80 years was conducted during 6 month period. Nausea, vomiting episodes and the need for anti-emetic medication were recorded for 24 hours postoperatively. The highest incidence of vomiting sequel was observed in neurosurgical patients. The most predictive factors associated with an increased risk for nausea and vomiting were: female gender (51/72), young age 19-35 year old, and body weight 61-80kg.

Antithrombin and Protein C in Systemic Inflammatory Response Syndrome

Coronary artery bypass grafting with cardiopulmonary bypass can induce systemic inflammatory response syndrome. To assess the prevalence of preoperative antithrombin and protein C deficiencies in relation to the incidence of this syndrome, antithrombin and protein C levels were measured in 130 patients undergoing coronary artery bypass grafting with cardiopulmonary bypass. Systemic inflammatory response syndrome developed in 36 (27.7%) patients who were predominantly male, had a lower EuroSCORE, longer cardiopulmonary bypass time, higher pre-bypass temperature, and shorter activated coagulation time. Logistic regression showed that predictive factors included bypass duration and pre-bypass temperature; however, low antithrombin levels appeared to be a negative predictive factor. Antithrombin levels were < 80% in 33.8% of patients, and 11.6% had protein C levels < 80%. Postoperative antithrombin and protein C deficiencies are not uncommon in adults undergoing cardiac surgery with cardiopulmonary bypass, but detection of these deficits did not identify patients at increased risk of systemic inflammatory response syndrome.

Ephedrine requirements during spinal anesthesia for cesarean delivery in Jordanian parturients: association with b2 adrenoceptor gene variants.

BACKGROUND Maternal hypotension after spinal anesthesia for cesarean delivery is common. Many studies performed on the β2-adrenoceptor (β2AR) gene variants and their association with vasopressor requirements during and after neuroaxial block have contradictory conclusions. OBJECTIVES The aim of the study was to evaluate the influence of the β2AR in codons 16 and 27 on the incidence of maternal hypotension and ephedrine consumption after spinal anesthesia for cesarean delivery in an Arab ethnic group. DESIGN A prospective gene association study. SETTING Jordan University Hospital from 1 July 2013 to 31 January 2014. PATIENTS AND METHODS We enrolled parturients who underwent cesarean delivery under spinal anesthesia. Spinal anesthesia was performed with 10 mg plain bupivacaine along with 25 μg fentanyl. Hypotension was treated with ephedrine and the amount consumed in the first 30 minutes after spinal anesthesia was calculated. The β2AR genotype at codons 16 and 27 was determined. We studied the correlation between the β2AR genotype and the amount of ephedrine consumption after spinal anesthesia. MAIN OUTCOME MEASURES Amount of ephederine used. RESULTS Of 250 patients enrolled in the study, genotype and clinical data were available for 234 cases. Ephedrine was used in 94% of patients. There was a significant effect of β2AR genotype on ephedrine dose in the first 30 minutes after spinal anesthesia in codon 16 and 27. Arg16 homozygotes received less ephedrine (14.0 [11.2] mg) than Gly16 homozygotes (38.6 [25.7] mg) and Arg16Gly heterozygotes (33.42 [22.70] mg) (P<.0001). Gln27 homozygotes received less ephedrine (18.2 [12.8] mg) than Glu 27 homozygotes (47.5 [27.0] mg) and Gln27Glu heterozygotes (48.2 [23.7] mg). (P<.0001). CONCLUSION In an Arab ethnic group, the β2AR gene has a role in maternal hypotension after spinal anesthesia. The Gly16 and Glu27 alleles have a higher incidence of arterial hypotension and required a greater amount of vasopressor to treat hypotension compared with homozygous Arg16 and Gln27 carriers. LIMITATIONS Fasting time and hydration protocol, the use of a fixed dose of ephedrine, and relatively small sample size.

Anesthetic Management of Simultaneous Coronary Artery bypass Grafting with Cardiopulmonary bypass and Extended Thymectomy in a Patient with Myasthenia Gravis

A 61-yr-old male having myasthenia gravis MG (Osserman IIB), Hypertension HTN, hyperlipidemia, type II diabetes mellitus DM II, a single pelvic kidney, chronic obstructive pulmonary disease COPD with a positive history of smoking and coronary artery disease, was admitted for uncontrolled myasthenic symptoms, cardiology team was consulted, cardiac catheterization was performed and revealed a three vessel coronary artery disease. All the findings dictated the management, a combined coronary artery bypass graft CABG and an extended thymectomy was performed. Optimization of the patient was achieved preoperatively. Total intravenous anesthesia using propofol and remifentanyl was applied to this patient. Continuous monitoring of the neuromuscular transmission NMT was maintained throughout the perioperative period. Although neither muscle relaxants nor inhalational agents were used in the anesthetic management of this patient; the patient developed postoperative atelectasis and lung collapse; which was managed successfully, and extubation of the trachea was done after ensuring adequate recovery of the NMT and respiratory function. Myasthenic therapy was continued throughout the perioperative period.