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Objective:To assess the effectiveness of integrative weaning index (IWI) as a predictor of weaning success.Materials and Methods:This is a prospective randomized controlled observer-blinded study and carried out on 120 patients of both sexes; patients who received mechanical ventilation for more than 24 h and met defined criteria for a weaning trial, underwent a 2-h spontaneous breathing trial with either IWI plus routine criteria of weaning (Group I n = 60) or routine criteria of weaning alone (control group) (Group C n = 60), in Group C the IWI was measured retrospective as it is not used in weaning decision. Those tolerated the trial would be immediately extubated. The primary outcome measure was the ability to maintain spontaneous, unassisted breathing for more than 48 h after extubation. Secondary outcome measures were the duration of mechanical ventilation, length of Intensive Care Unit (ICU) stay, and length of hospital stay.Results:The mean duration (hours) of mechanical ventilation and length of ICU stay (days) were significantly shorter in the Group I where the IWI was used (83.6 ± 34.3 vs. 97.49 ± 47.2 h, P = 0.002 and 5.5 ± 1.6 vs. 7.12 ± 2.3 days, P = 0.03, respectively). Weaning success rate was significantly higher in the Group I (53 vs. 34, P = 0.0001) while weaning failure rate was significantly lower in the Group I C (7 vs. 26, P = 0.0001).Conclusion:IWI is a strong predictor of both successful and failed weaning.

Aims:The aim was to assess the effectiveness of adding either dexamethasone or midazolam in comparison with epinephrine addition to 0.5% bupivacaine in supraclavicular brachial plexus block.Settings and Design:This is a prospective randomized controlled observer-blinded study.Subjects and Methods:This study was carried out in Tanta University Hospital on 60 patients of both sexes; American Society of Anesthesiologists physical Status I and II, age range from 18 to 45 years undergo elective surgery to upper limb. All patients were anesthetized with ultrasound guided supraclavicular brachial plexus block and randomly divided into three groups (each group 20 patients) Group E (epinephrine): 30 mL bupivacaine 0.5%with 1:200,000 epinephrine (5 μg/mL). Group D (dexamethasone): 30 mL bupivacaine 0.5% and dexamethasone 8 mg. Group M (midazolam): 30 ml bupivacaine 0.5% and midazolam 50 μg/kg. The primary outcome measures were onset and duration of sensory and motor block and time to first analgesic request.Statistical Analysis Used:The windows version of SPSS 11.0.1 (SPSS Inc., Chicago, IL, USA) was used for statistical analysis. Data were presented in form of mean ± standard deviation multiple analysis of variance (ANOVA) was used to compare the three groups and Scheffe test was used after ANOVA. Power of significance P < 0.05 was considered to be statistically significant.Results:Onset of sensory and motor block was significantly rapid (P < 0.05) in Groups D and M in comparison with Group E. Time of administration of rescue analgesic, duration of sensory and motor block showed significant increase (P < 0.05) in Group D in comparison with Group M which showed significant increase (P < 0.05) in comparison with Group E.Conclusions:In comparison with epinephrine and midazolam addition of dexamethasone to bupivacaine had rapid onset of block and longer time to first analgesic request with fewer side-effects.

Objective: To assess the effectiveness of a combination of etomidate-fentanyl versus dexmedetomidineketamine for Procedural Sedation and Analgesia (PSA) in patients undergoing upper endoscopy and biopsy. Patients and methods: This is a prospective randomized observer-blinded study. This study was carried out in Tanta university hospital on 100 patients of both sexes; ASA physical status I and II, age range from 20-60 years undergone upper endoscopy and biopsy. All patients were randomly divided into two groups (each group 50 patients) Group E (etofen): patients received an initial IV bolus dose of etomidate 0.15 mg/kg + fentanyl 1 mcg/kg IV, followed by etomidate infusion at 0.01-0.03 mg/kg/min. Group D (dexmedetomidine-ketamine): patients received an initial IV bolus dose of dexmedetomidine (1 μg/kg) +ketamine (1 mg/kg) followed by dexmedetomidine infusion (0.5-1 μg/kg/hr) with supplemental bolus doses of ketamine (0.5 mg/kg) as needed. Sedation started and adjusted according to bispectral index level (BIS) range 60-80. Patients were then observed by an anesthesiologist who was blinded about sedative/analgesic received. The primary outcomes were onset, level and time of sedation and the secondary outcomes were recovery time, Length of recovery room (RR) stay (min), duration of hospital stay, VAS score, hemodynamic changes (HR, MBP, SPO 2 , RR), surgeon satisfaction, side effects, and patient satisfaction. Results: There was significant rapid onset of sedation in group E as compared to group D, Sedation level by BIS, showed significant increase (P<0.05) in group E in comparison with group D. Recovery time, Length of recovery room (RR) stay (min) and Length of hospital stay (hr) showed significant decrease (P<0.05) in group E in comparison with group D. Conclusion: The etomidate/fentanyl combination provides an effective and safe procedural sedation and analgesia for upper endoscope and biopsy. Etomidate/Fentanyl combination provides shorter sedation times and lighter sedation level (but enough for the procedure) when compared to the dexmedetomidine/ketamine combination. J o u rn al of A n e s th es ia & C li n ic a l Resea rc h

Background and Objective:Ultrasonography has been suggested as a useful noninvasive tool for intravascular volume assessment in critically ill-patients. Fluid absorption is an inevitable complication of transurethral resection of the prostate (TURP). However, there are few data comparing the caval aortic index with central venous pressure (CVP) measurement for intravascular volume assessment in patients undergoing TURP.Materials and Methods:This is a prospective observer blinded study carried out on 50 patients who underwent elective TURP. The primary outcome measure of our study was the correlation of the caval aorta (Ao) index with CVP, and the secondary outcome measures were the sensitivity and specificity of the caval Ao index.Results:There was a positive correlation of inferior vena cava/Ao (IVC/Ao) index to CVP (R = 0.9 and significant P = 0.001*). The sensitivity and specificity of the IVC/Ao index were measured to predict the CVP. A CVP ≤7 cm H2O correlated with IVC/Ao index 0.8 ± 0.3 mean ± standard deviation (SD) (sensitivity 0.93, specificity 0.66), a CVP of 8-12 cm H2O correlated with IVC/Ao index 1.5 ± 0.2 mean ± SD (sensitivity 0.96, specificity 0.42), and a CVP >12 cm H2O correlated with IVC/Ao index 1.8 ± 0.07 mean ± SD (sensitivity 0.93, specificity 0.58).Conclusion:Sonographic caval Ao index is useful for the evaluation of preoperative and intraoperative volume status, especially in major surgeries with marked fluid shift or blood loss and had the advantage of being noninvasive, safe, quick, and easy technique with no complications.

Background and Aims:The aim of this study is to assess the effect of atrial natriuretic peptide (ANP) on intestinal ischemia-reperfusion injury in septic shock.Material and Methods:A prospective randomized controlled, observer-blinded study was carried out in surgical Intensive Care Unit (ICU), University Hospital. Forty adult patients in septic shock were randomly divided into two groups, control group (Group C) received normal saline and ANP group (Group A) patients received ANP in the form of 1.5 mg vial added to 250 ml solvent in plastic bag (1 ml = 6 micg) given at 2 mcg/kg intravenous bolus over 1 min followed by 0.01 mcg/kg/min for 24 h. The primary outcome measurements were blood marker of intestinal hypoperfusion in form of intestinal fatty acid binding protein (I-FABP), malondialdehyde (MDA), myloperoxidase enzyme activity (MPO), protein carbonyl (PC), and glutathione peroxidase activity (GPA) measured before start of ANP infusion, 6 h, 12 h, and 24 h after start of infusion. The secondary outcome measurements were the duration of noradrenaline infusion, duration of ICU stay, hospital mortality rate, and complications related to ANP.Results:In comparison with Group C, Group A showed a significant decrease (P < 0.05) in serum level of MPO, MDA, PC, and I-FABP, with a significant increase (P < 0.05) in serum level of GPA, 6 h, 12 h, and 24 h after the start of ANP infusion. There was significant decrease (P < 0.05) in mean duration of noradrenaline infusion, the length of ICU stay and mortality rate in Group A in comparison with Group C. In Group A, seven patients had mean arterial blood pressure < 65 mmHg but respond to volume resuscitation, three patients serum sodium was 125–130 mmol/L.Conclusion:In cases of septic shock, concomitant administration of ANP with noradrenaline may have a protective effect against intestinal injury through a decrease in the level of intestinal hypoperfusion owing to its anti-inflammatory and antioxidant effect.

Background and Aims:Sepsis is a complex rapidly progressive infectious disease that remain a major cause of morbidity and mortality in surgical patients and trauma victims. Edaravone a novel free radical scavenger was approved in 2001 in Japan for treatment of acute cerebral and myocardial infarction. Hence, in this work we attempt to evaluate its role in cases of septic peritonitis (SP).Material and Methods:This is a prospective randomized observer-blinded study carried out in surgical Intensive Care Unit (ICU) after approval by Hospital Ethical Committee. After admission to ICU patients were randomly divided into two groups of thirty patients each-Group (C): Control group managed according to the routine protocol of sepsis and Group (E): Edaravone treated SP managed according to the routine protocol of sepsis + edaravone at dose of 30 mg/12 h intravenous infusion for 2 weeks. All patients were monitored for invasive blood pressure, central venous pressure, heart rate, temperature, urine output, total fluid balance, and routine investigation. Blood sample was taken weekly for 2 weeks to measure the following parameters: Nuclear transcription factor kappa B activity (NFKB), mitogen-activated protein kinase (MAPK), heat shock protein 72 (HSP 72) and total antioxidant capacity (TAC).Results:There was significant decrease (P < 0.05) in serum level of NFKB, MAPK in Group E in comparison with Group C. While serum level of HSP 72 and TAC showed significant increase (P < 0.05) in Group E compared with Group C with better outcome.Conclusion:SP treatment with edaravone could significantly improve the inflammatory and oxidative states with better patient outcomes.