Ketofol versus Dexmedetomidine for preventing postoperative delirium in elderly patients undergoing intestinal obstruction surgeries: a randomized controlled study.

PURPOSE: Postoperative delirium (POD) is considered the most common postoperative neurological complication in elderly patients. The aim of this study was to evaluate the efficacy of the administration of ketofol versus dexmedetomidine (DEX) for minimizing POD in elderly patients undergoing urgent exploration for intestinal obstruction. METHODS: This prospective double-blinded randomized clinical trial was conducted on 120 elderly patients undergoing urgent exploration for intestinal obstruction. Patients were randomly allocated to one of the three groups: Group C (control group) patients received normal saline 0.9%, group D received dexmedetomidine, and group K received ketofol (ketamine: propofol was 1:4). The primary outcome was the incidence of POD. Secondary outcomes were incidence of emergence agitation, postoperative pain, consumption of rescue opioids, hemodynamics, and any side effects. RESULTS: The incidence of POD was statistically significantly lower in ketofol and DEX groups than in the control group at all postoperative time recordings. Additionally, VAS scores were statistically significantly decreased in the ketofol and DEX groups compared to the control group at all time recordings except at 48 and 72 h postoperatively, where the values of the three studied groups were comparable. The occurrence of emergence agitation and high-dose opioid consumption postoperatively were found to be significant predictors for the occurrence of POD at 2 h and on the evening of the 1st postoperative day. CONCLUSION: The administration of ketofol provides a promising alternative option that is as effective as DEX in reducing the incidence of POD in elderly patients undergoing urgent exploration for intestinal obstruction. TRIAL REGISTRATION: This clinical trial was approved by the Institutional Review Board (IRB) at Zagazig University (ZU-IRB# 6704// 3/03/2021) and ClinicalTrials.gov (NCT04816162, registration date 22/03/ 2021). The first research participant was enrolled on 25/03/2021).

Epidural nalbuphine versus dexmedetomidine as adjuvants to bupivacaine in lower limb orthopedic surgeries for postoperative analgesia: a randomized controlled trial.

BACKGROUND: Administration of adjuvant drugs epidurally in combination with local anesthetics offers new dimensions in the management of postoperative pain. This study aimed to compare the addition of either nalbuphine or dexmedetomidine to epidural bupivacaine for postoperative analgesia in lower limb orthopedic surgeries under combined spinal-epidural anesthesia. METHODS: This prospective randomized double-blind study included 69 patients scheduled for lower limb orthopedic surgeries. Anesthesia was started with 15 mg hyperbaric bupivacaine 0.5% intrathecally, and then an epidural bolus dose of 12 ml (10 ml 0.25% bupivacaine with 2 ml normal saline in group C, 2 ml (10 mg) nalbuphine in group N or dexmedetomidine 2 ml (100 µg) in group D was administered when sensory regression to T10. Postoperatively, when visual analogue scale (VAS) was ≥ 3, an epidural top-up dose of 8 ml (6 ml 0.25% bupivacaine plus 2 ml normal saline in group C, 2 ml (2 mg) nalbuphine in group N or 20 µg dexmedetomidine (2 ml) in group D was given. The primary outcome was to evaluate the duration of postoperative analgesia and secondary outcomes were any side effects and patient satisfaction. RESULTS: The onset of epidural analgesia was 17.83 ± 2.53 versus 13.39 ± 1.27 versus 12.17 ± 1.27 min in groups C, N and D, respectively (p value < 0.001). The mean duration of analgesia was 241.3 ± 14.24 versus 318.38 ± 22.54 versus 365.87 ± 18.01 min in groups C, N and D, respectively (p value < 0.001). The mean sedation score was less in group C than group N and D (P < 0.001). The patient satisfaction score showed the lowest degree of satisfaction in group C (p value < 0.001). Top-up doses consumed and total analgesic requirements were lower in groups N and D than in group C. There was a statistically significant difference between the studied groups regarding VAS over time (p value < 0.001), intraoperative bradycardia (p value 0.029), and shivering (p value 0.029). CONCLUSION: The addition of either nalbuphine or dexmedetomidine to epidural bupivacaine was effective for postoperative analgesia in terms of onset, duration, and patient satisfaction with the superiority of dexmedetomidine over nalbuphine. TRIAL REGISTRATION: Approval from the research ethics committee of the Faculty of Medicine, Zagazig University was obtained with the reference number (ZU-IRB#:7045-15-8-2021) and it was registered under clinicaltrials.gov (NCT05041270) on registration date 13/09/2021.

Evaluation of intravenous infusion of labetalol versus magnesium sulfate on cerebral hemodynamics of preeclampsia patients with severe features using transcranial doppler.

PURPOSE: It is essential to understand the underlying pathophysiological mechanisms of preeclampsia cerebral complications. This study aimed to compare the cerebral hemodynamic effects of magnesium sulfate (MgSO4) and labetalol in pre-eclampsia patients with severe features. METHODS: Singleton pregnant women who suffered from late onset preeclampsia with severe features were enrolled and subjected to baseline Transcranial doppler (TCD) evaluation and then randomly assigned to either the magnesium sulfate group or labetalol group. TCD to measure middle cerebral artery (MCA) blood flow indices including mean flow velocity (cm/s), mean end-diastolic velocity (DIAS), and pulsatility index (PI) and to estimate CPP and MCA velocity were performed as basal measurements before study drug administration and at post-treatment one and six hours after administration. The occurrence of seizures and any adverse effects were recorded for each group. RESULTS: Sixty preeclampsia patients with severe features were included and randomly allocated into two equal groups. In group M the PI was 0.77 ± 0.04 at baseline versus 0.66 ± 0.05 at 1hour and 0.66 ± 0.05 at 6 hours after MgSO4 administration (p value < 0.001) also the calculated CPP was significantly decreased from 103.3 ± 12.7mmHg to 87.8 ± 10.6mmHg and 89.8 ± 10.9mmHg (p value < 0.001) at 1 and 6 hours respectively. Similarly, in group L the PI was significantly decreased from 0.77 ± 0.05 at baseline to 0.67 ± 0.05 and 0.67 ± 0.06 at 1 and 6 hours (p value < 0.001) after labetalol administration. Moreover, the calculated CPP was significantly decreased from 103.6 ± 12.6 mmHg to 86.2 ± 13.02mmHg at 1 hour and to 83.7 ± 14.6mmHg at 6 hours (p value < 0.001). In terms of changes in blood pressure and the heart rate, they were significantly lower in the labetalol group. CONCLUSION: Both magnesium sulfate and labetalol reduce CPP while maintaining cerebral blood flow (CBF) in preeclampsia patients with severe features. TRIAL REGISTRATION: The institutional review board of the Faculty of Medicine, Zagazig University approved this study with the reference number (ZU-IRB#: 6353-23-3-2020) and it was registered at clinicaltrials.gov (NCT04539379).

Effectiveness of nebulized dexmedetomidine for treatment of post-dural puncture headache in parturients undergoing elective cesarean section under spinal anesthesia: a randomized controlled study.

PURPOSE: The need for effective treatment for post-dural puncture headache (PDPH) is a growing research entity. This study aimed to test the effectiveness of additional dexmedetomidine (DEX) to PDPH conservative management and evaluate its cerebral hemodynamic effects trans-cranial Doppler. METHODS: This prospective randomized double-blind controlled trial was conducted on 43 post-partum females suffering from PDPH with visual analog score (VAS) ≥ 4 and Lybecker score ≥ 2. The study subjects were allocated into control group [n = 22] received nebulization of 4 mL 0.9% saline and DEX group [n = 21] received nebulization of 1 µg/kg DEX diluted in 4 mL 0.9% saline twice daily that was continued until achieving VAS score ≤ 3 and Lybecker score < 2 and/or for a maximum of 72 h. Both groups received routine conservative management. The primary outcome was the VAS and Lybecker scores and the secondary results were the DEX effects on cerebral vessels and the occurrence of any adverse effects. RESULTS: VAS and Lybecker scores were significantly lower in DEX group. The middle cerebral artery mean flow velocity was significantly lower, and the pulsatility index was considerably higher after DEX nebulization compared to placebo. Two patients in the control group were indicated for epidural blood patch. CONCLUSION: The addition of DEX nebulization (1 µg/kg twice daily) to the PDPH conservative care effectively relieved the symptoms and lowered pain scores which could be due to its analgesic and cerebral vasoconstrictive effects. TRIAL REGISTRATION: This study was approved by the research ethical committee of Faculty of Medicine, Zagazig University with the reference number (ZU-IRB#: 6075/26-4-2020) and it was registered under clinicaltrials.gov (NCT04327726).

Transcranial Doppler role in prediction of post-dural puncture headache in parturients undergoing elective cesarean section: prospective observational study.

PURPOSE: Post-dural puncture headache (PDPH) may be resulted from significant changes in cerebral blood flow, which could be visualized by Transcranial Doppler (TCD). This study was performed to investigate if TCD can be used to predict the occurrence of PDPH in high-risk patients. METHODS: This prospective observational study was conducted on ninety ASA I and II pregnant females undergoing elective cesarean section (CS) under spinal anesthesia. TCD was performed to all patients within 24 h before the operation, at 24 h and 48 h in the post-operative period to measure mean velocity (MV) and Gosling pulsatility index (PI) in the right middle cerebral artery. For 5 days postoperatively, all patients were assessed and the PDPH patients were identified, their pre- and post-puncture TCD measurements were compared with the corresponding measurements of PDPH-free patients and ROC analysis was done to evaluate the predictive value of TCD parameters. RESULTS: 17 patients (18.8%) developed PDPH. PDPH group was significantly higher regarding MV and significantly lower with regard to PI at all times except for the pre-spinal PI. The MV values in all patients showed statistical significant increase within the first 48 h after CS as compared with those before delivery. In PDPH group there was high statistical significant decrease in PI values at 24 h and 48 h compared to the pre-puncture values. The pre-puncture MV was the parameter of the best accuracy for predicting PDPH with a cutoff of MV > 68.4 cm/s and the post-puncture PI at 24 h was the best predictive of PDPH with a cutoff value of < 0.75. CONCLUSION: TCD might prove a useful tool in predicting PDPH suggesting that higher pre-puncture MV with a cutoff value > 68.4 cm/s and post-puncture lower PI at 24 h with a cutoff < 0.75 are the best predictive parameters. TRIAL REGISTRATION: This clinical trial was registered with ClinicalTrials.gov (NCT03464253).

Bacterial and fungal ventilator associated pneumonia in critically ill COVID-19 patients during the second wave.

BACKGROUND: The pandemic of coronavirus disease (COVID-19) has caused huge number of patients admitted to intensive care units (ICUs) in a critical need to mechanical ventilation. Ventilator associated pneumonia (VAP) has been noticed as a common complication in these patients with unfavorable outcomes. The current study aimed to assess bacterial and fungal VAP in COVID-19 patients admitted to ICUs during the second wave and to identify the possible risk factors. METHODS: Respiratory samples were collected from 197 critically ill COVID-19 patients under mechanical ventilation. Bacterial and fungal superinfections were diagnosed by microbiological cultures with subsequent antimicrobial susceptibility testing of the isolates using available kits. RESULTS: All specimens 197/197 (100%) were positive for bacterial infections, while fungal elements were detected in 134/197 (68%) of specimens. The most frequently isolated bacteria were pan drug resistant (PDR) Klebsiella pneumoniae (41.1%), followed by multi drug resistant (MDR) Acinetobacter baumannii (27.4%). On the other hand, Candida species represented the most frequently isolated fungi (75.4%) followed by molds including Aspergillus (16.4%) and Mucor (8.2%) species. Possible risk factors for fungal VAP included underlying diabetes mellitus (95% confidence interval [CI] 1.09-3.31; p = 0.02), chest disease (95% CI 1.01-3.32; p = 0.05), hypothyroidism (95% CI 1.01-4.78; p = 0.05), and longer duration of mechanical ventilation (p < 0.001). Furthermore, all patients 134/134 (100%) who developed fungal VAP, were already under treatment with corticosteroids and Tocilizumab. CONCLUSION: Bacterial and fungal VAP in critically ill COVID-19 patients is a serious problem in the current pandemic. Urgent and strategic steps to keep it under control are compulsory.