Ola M. Zanaty

Delta neutrophil index versus lactate clearance: Early markers for outcome prediction in septic shock patients

Abstract Background This study was carried out to evaluate, compare the clinical utility of delta neutrophil index (DNI) values and lactate-6h-clearance as early indicators for outcome prediction in septic shock patients and to find out and correlate the specificity and sensitivity of each to the patients mortality. Methods The study was carried out in Alexandria Main University Hospital on 53 adult patients with severe sepsis/septic shock after taking an informed written consent and approval of the ethics committee. All patients received all standard therapy and resuscitation measures. Arterial blood samples were obtained for measurement of DNI using an ADVIA 2120 automated cell analyzer. Initial arterial serum lactate level and arterial lactate after 6 h from admission were measured for lactate-6h-clearance calculation. Primary outcome measures were hospital mortality (non-survivors) and discharge or transfer to a general medical ward (survivors). Data were analyzed by SPSS® software using (“t” test and chi-square χ2) P < 0.05 was considered significant. Results A total of 53 severe sepsis/septic shock patients were enrolled in the study, patients were (36) survivors and (17) non-survivors. This study demonstrated the reliability of DNI and lactate-6h-clearance as predictors of negative outcome. Variables identified by the backward logistic regression model as significantly correlated with negative outcome were lactate-6h-clearance <15%; (sensitivity, 92.5%; specificity, 85.0%; positive predictive value, 90.0%; and negative predictive value, 88.0%) and DNI value >5.2; (sensitivity, 95.0%; specificity, 90.0%; positive predictive value, 92.0%; and negative predictive value, 95.0%). Conclusion Monitoring of lactate-6h-clearance can be used to identify patients with severe sepsis/septic shock at high risk of mortality. DNI may serve as a more useful diagnostic and prognostic marker for early diagnosis of disease severity in patients with severe sepsis/septic shock, it is suggested that, increased DNI value should alert clinicians to apply more aggressive therapy.

Improvement in the airway after mandibular distraction osteogenesis surgery in children with temporomandibular joint ankylosis and mandibular hypoplasia

Temporomandibular joint (TMJ) ankylosis accompanied by mandibular micrognathia can severely obstruct a patients upper airway. The obstructive sleep apnea and hypopnea syndrome (OSAHS) resulting from TMJ ankylosis and accompanied by mandibular micrognathia, can severely influence the patients life.

Nicotine smoking: Influences on perioperative pain management

Abstract Background The complex relationship between smoking and pain has clinical relevance in the practice of anesthesiology and pain medicine. The present study investigated the effect of heavy nicotine smoking on perioperative pain management. Methods This prospective controlled study was carried out in Alexandria Main University hospital on 80 adult ASA I and II patients scheduled for lower limb fractures fixation under general anesthesia after an informed written consent and approval of the Medical Ethics Committee. Patients were divided into 2 groups: group N included nonsmokers and group S included the heavy smokers. Intraoperative heart rate (HR), mean arterial blood pressure (MAP) and intraoperative analgesia were recorded. Postoperatively; HR, MAP, pain visual analog scale (VAS) and total postoperative analgesic requirements were recorded. Results Intraoperative and postoperative HR and MAP showed significantly higher values in group S patients than group N patients. VAS values were significantly lower in group N than group S at recovery, 8 and 24 h postoperatively. Total intraoperative and postoperative analgesic requirements of meperidine were significantly lower in group N than group S. Conclusions Chronic nicotine smoking increases the incidence of perioperative pain. Heavy smokers need more perioperative analgesia than nonsmokers.

Comparative study between the use of Macintosh Laryngoscope and Airtraq in patients with cervical spine immobilization

Abstract Background Airway management is a major responsibility for anesthetist. This study was carried out to evaluate and compare the efficacy of Airtraq (AL) and Macintosh Laryngoscopes (ML) in intubating patients with cervical spine immobilization using manual inline axial stabilization technique (MIAS). Methods This randomized controlled study was carried out in Alexandria Main University Hospital on 40 adult ASA I and II patients after written informed consent and approval of the ethical committee, randomly categorized into two equal groups. All patients were subjected to same anesthetic protocol. Group I patients were intubated using AL and group II patients were intubated using ML. Hemodynamic measurements and oxygen saturation were recorded. Intubation criteria for both groups including (duration of intubation procedure, number of attempts, number of optimization maneuvers, Cormack and Lehane grade at laryngoscopy, Intubation Difficulty Scale score (IDS), rate of successful placement of endotracheal tube, neck mobility during laryngoscopy and intubation complications were recorded. Data statistically analyzed using SPSSR software using (t and χ2 tests) and P < 0.05 considered significant. Results There was statistically significant increase in both heart rate and mean arterial blood pressure values following intubation in ML group than AL, oxygen saturation showed no significant difference between the two groups. Duration of intubation was statistically significant longer in ML group and needed more optimization maneuvers than the AL group, while for the number of intubation attempts; there was no statistically significant difference between the two groups. Both the Cormack and Lehane grading and IDS score values have shown statistically significant higher values in ML group. Conclusion The Airtraq Laryngoscope offers a new approach for the management of difficult airway like patients with potential cervical spine injury, it is fast, easy to use, gets an easy view of the larynx without moving the cervical spines or causing hemodynamic stimulation.

Bonfils fiberscope vs GlideScope for awake intubation in morbidly obese patients with expected difficult airways

STUDY OBJECTIVE To assess the efficacy of both Bonfils and GlideScope in obese patient with difficult airways for bariatric surgery using awake intubation. DESIGN Comparative study. SETTING Operating room. PATIENTS The study was carried out on 60 patients, for laparoscopic bariatric surgery, after approval of the Medical Ethics Committee and having an informed written consent from each patient. Patients were randomly categorized into 2 equal groups 30 patients in each group. INTERVENTIONS Awake intubation with either Retromolar Bonfils or GlideScope. MEASUREMENTS Time to visualize the laryngeal inlet, time of intubation, time of scope manipulation, success rate at each attempt, the lowest oxygen saturation, hemodynamic parameters, and any complication. MAIN RESULTS Regarding intubation criteria, GlideScope achieves shorter times compared with Retromolar for visualization of the vocal cords and intubation, in addition to less intubation attempts, but both without a statistically significant difference. Retromolar shows better patient satisfaction than does GlideScope, with statistically significant difference. CONCLUSIONS Both Bonfils fiberscope and the GlideScope can be successfully used for awake intubation in morbidly obese patients with expected difficult airways. Bonfils intubating fiberscope was more tolerated by patients with statistical difference; on the other hand, GlideScope provided shorter intubation time and less intubation attempts but not statistically significant.

Ultrasound versus fiberscope-guided tracheal intubation

I would like to thank Wang et al. [1] for their interest in our study comparing the fiberscope and the ultrasound guided techniques for tracheal intubation in patients with cervical spine immobilization. Actually, in the technique described in the study, the rigid neck collar was removed before tracheal intubation to shape the tracheal tube mounted over the stylet according to the previous lateral view X-ray taken in the neutral position. However, some types of cervical neck collars are available having a front window that allow ultrasound examination of the airway. I agree with Wang et al. [1] that the experience in ultrasound-guided tracheal intubation is critical for its success. The operator in the ultrasound group has been stated to have 7 years of experience in the application of ultrasound in the airway and the intensive care including confirmation of tracheal intubation. The operator also observed the performance of the technique in 20 cases before the beginning of the study; however, they were not belonging to the population of the present study. A number of our staff members have been now well trained with technique and a large study is now being processed on a wide variety of patients. Author contributions MAM: idea of the research, writing the final draft, performing the design of the research. EAA: participation in the design, collection of data. OMZ: statistical analysis, participation in the protocol, collection of data.

The effect of paravertebral block on maxillofacial free flap survival

The purpose of this study was to investigate whether continuous paravertebral block at levels T1 and T2 with bupivacaine infusion can improve the survival of free flaps in maxillofacial reconstruction. The study was designed as a randomized controlled trial and included 36 adult patients scheduled for maxillofacial free flap reconstruction under general anesthesia. Patients were randomly divided into two groups: patients in group A received continuous paravertebral block at levels T1 and T2, while patients in group B served as controls. Postoperatively, a skin thermometer was used to assess the skin temperature. Perfusion of the flaps was evaluated by analysis of skin color, turgor, and capillary refill. Survival of the free flap was recorded. The surface temperature of the reconstructive flap, skin color score, and capillary refill score were significantly higher in group A patients than in group B patients during follow-up. The total perfusion score was significantly higher in group A than in group B at 16h and 20h postoperative (P=0.041 and P=0.039, respectively). Re-operation was recorded in three cases in group B (16.7%) (P=0.031). Continuous paravertebral block at levels T1 and T2 can increase the skin temperature and improve skin color and capillary refilling, which are indices of adequate tissue perfusion and indicate maxillofacial free flap survival.

Comparison between effects of two anesthetic techniques on acute stress proteins and d-dimer in patients undergoing lower limb orthopedic surgery

Background Anesthetic techniques may modulate the extent of endocrine–metabolic response to surgery. Attenuation of the endocrine–metabolic response may reduce the frequency of postoperative complications. The aim of this study was to compare the effect of two different anesthetic techniques (combined general anesthesia with epidural blockade vs. combined spinal–epidural blockade) on acute stress proteins including serum albumin, C-reactive protein, leptin, cortisol, and d-dimer in patients undergoing lower limb orthopedic surgery. Materials and methods After approval of the ethics committee of Alexandria Faculty of Medicine and having an informed consent from every patient, the present study was carried out on 40 patients ASA I or II physical status. Group I; 20 patients received combined general anesthesia with epidural blockade and group II; 20 patients received combined spinal–epidural blockade. Epidural analgesia was activated just before wound closure. Results The blood loss was statistically significantly low in group II. The mean values of serum albumin were significantly lower in the group II at 3 and 24 h postoperatively. There were no significant differences between preoperative and 24 h postoperative serum cortisol. Serum cortisol levels were significantly lower in the group II at 3 h postoperatively. There were no significant differences in serum leptin concentrations and preoperative plasma d-dimer. Plasma d-dimer concentrations were significantly higher in the group I at 3 h postoperatively and at 24 h postoperatively. Conclusion Subarachnoid block decreases postoperative pain score and reduces blood loss in comparison with general anesthesia. It reduces the acute stress response and acute stress proteins (albumin, cortisol). It did not reduce C-reactive protein. It reduces plasma d-dimer level after lower-limb orthopedic surgery in comparison with general anesthesia.