Evaluation of parenteral nutrition on the immune system of patients with polytrauma

Nutritional support for trauma and critically ill patients has been advocated to promote immune system recovery and to prevent as much tissue break down and nutritional deficit. The present study aiming to assessment of the parenteral nutrition on the immune system of patient with multiple trauma. Compare the effect of early parenteral nutritional and conventional hospital diet on the nutrition and immunology markers in trauma patients. A convenient sample of 40 severely traumatized patients within 8 hours after trauma they were enrolled sequentially into conventional [n = 20] and total parenteral nutrition [n = 20] groups [TPN]. Criteria for subject inclusion were, age 18-<45 years, Injury severity score [ISS] 20-40 score. Tools of data collection, four tools were utilized to collect data pertinent to the study. These tools were, nutritional assessment sheet, trauma scales and [APACHE] score [checklist], parenteral nutrition plans, evaluation tool which includes [Anthropometric measurement, Laboratory studies Immunological parameters]. Total parenteral nutritional has positive impact for trauma patients on anthropometric measurement, [weight loss, TSF and MAC] which was observed at the end of therapy [7th day.] for the conventional group while there were no changes for the same parameters in TPN group. As regard, laboratory tests, there were significantly increase in the values of total serum protein and albumin among patients of the TPN group after the end of therapy at [7th day] .As regard immune function, it was found that the mean values of [IL-10, IL-6, CD8] were significantly dropped in the TPN group after the end of therapy as compared to the admission. Also there were significantly increase in the values of complement C3, IGA, CD4, and CD4/CD8 ratio among patient of the TPN group at [7th day]. Establishment and implement of standardized protocol of parenteral nutrition support using nutritional screening and physical assessment forms, for the critically ill patients

Evaluation of efficacy and side effects of different doses of intrathecal morphine for postoperative analgesia after anorectal surgery

Intrathecal opioids are frequently used in the management of postoperative pain, but may be associated with many adverse effects such as pruritus, nausea, vomiting, urinary retention, and respiratory depression, which may limit their use. Aim of this study was to compare between six different doses of IT morphine [0.1 mg, 0.2 mg, 0.3 mg, 0.4 mg, 0.5 mg and 1 mg] as regarding postoperative analgesia and the side effects of IT morphine, and to determine the optimal dose of IT morphine that provides satisfactory analgesia to the patient with minimal side effects. This study was conducted in Anesthesiology Department, Assiut university hospital, after approval of the local ethics committee. Our study was performed on 95 patients of ASA physical status I and II aged from 20 to 40 scheduled for anorectal surgeries. Spinal anesthesia was performed, with the patient in the sitting position, at L4, 5. Each patient received 5 mg of hyperbaric bupivacaine with different doses of IT morphine in a total volume of 2 ml. Patients were kept in the sitting position for five minutes to get sacral block. Intraoperative monitoring: Heart rate, O2 saturation, and non-invasive blood pressure were monitored. Postoperative monitoring: Patients were evaluated for any pain or side effect of IT morphine [Pruritus, PONV, urinary retention, and respiratory depression] during the first 24 hours. Supplemental analgesia in the form of I. V. tenoxicam was available on patient request, and the doses needed for each patient were recorded. Antipruritic and antiemetic therapy was available on patient request. Increasing the dose of IT morphine decreases the incidence of pain during the first 24 hours and subsequently decreases the need for supplemental analgesia. The doses of 0.1 mg and 0.2 mg are comparable with each other as regard to pain relief. 100% of the patients receiving 0.1 mg and 75% of the patients receiving 0.2 mg of IT morphine experienced pain during the first 24 hours and subsequently required supplemental analgesia and even with 40 mg of I. V. tenoxicam, some patient complained of postoperative pain. The doses of 0.3 mg, 0.4 mg or 0.5 mg are comparable with each other. Theses doses are enough to provide 24-hours analgesia in more than 50% of patients. This percentage increases to 100% with the use of 20-40 mg of tenoxicam intravenously. The dose of 1 mg provides 24-hours analgesia in 87% of patients. Increasing the dose of IT morphine causes significant increase in the incidence and severity of pruritus. Postoperative nausea and vomiting occurred in 30% of the patients in the control group. There is a non-significant increase in both the incidence and severity of PONV by increasing the dose of IT morphine. Urinary retention occurred in 20% of the patients in the control group. Increasing the dose of IT morphine causes significant increase in the incidence of urinary retention. Respiratory depression was not detected in any patient. Our study clearly demonstrated that the use of IT morphine in a dose of 0.3 mg in adjuvant with intravenous tenoxicam in a dose of 20-40 mg provides excellent pain relief for 24 hours after anorectal surgeries with minimal side effects of IT morphine

Effects of recruitment maneuvre on atelectasis during prolonged paediatric microvascular anaesthesia: a computed Tomography study

Atelectasis is an unavoidable effect of general anaesthesia. The aim of this study was to identify lung atelectasis which could occur during general anaesthesia in children with healthy lungs during microscopic reconstruction of brachial plexus and to evaluate the efficacy of alveolar recruitment strategy [ARS] in treating such atelectasis guided by CTscanning, The study included 30 patients aged 4 months to 2 years, ASA I physical status. Three cases were excluded. 27 children were enrolled into two groups: control group [n=16] and Alveolar recruitment strategy [ARS] group [n=11]. After induction of anesthesia in the ARS group PEEP of 5 cm H[2]O was applied from the start of the operation and the recruitment manoeuvre was performed 1 hour after induction of anesthesia and repeated at the end of surgery and was performed for 10 breaths by increasing PEEP progressively to 10 cm H[2]O, and the tidal volume [TV] until 15 ml/kg or a peak inspiratory pressure [PIP] of 35 cm H[2]O. In the control group, arterial blood gas samples were withdrawn at the 1[st] hour, 4[th] hour and before extubation. In the ARS group, they were withdrawn at 1[st] hour [Control], after the 1[st] and the 2[nd] recruitment manoeuvres, and shunt fraction was mathematically calculated in both groups. Three computed tomography scans were performed in both groups; preoperatively, early and late postoperatively, and atelectatic area was identified and measured using the [Region-of-interest] program. The recruitment manoeuvre used in this study had succeeded to decrease the incidence of anesthesia induced atelectasis from 87.5% in the control group to 27.3% in the [ARS] group. Even in cases presented with atelectasis in the [ARS] group, the mean atelectatic area size was smaller, and its' resolution was earlier. In the control group, the mean atelectatic area size was 6.86 +/- 0.71 cm[2] in the early postoperative CT which further increased to 8.76 +/- 0.92 Cm[2] in the late postoperative CT, and 4 cases were complicated by pneumonia. In the [ARS] group, the mean area size was 3.82 +/- 1.55 cm[2] in the early postoperative CT, and reduced to 1.63 +/- 1.65 cm[2] in the late postoperative CT [3[rd] day], with no cases complicated by pneumonia. Furthermore, the degree of gas exchange impairment was improved in the [ARS] group versus the control group. The mean shunt fraction calculated from arterial blood gas in the control group was 14.76 +/- 1.63% versus 9.67 +/- 1.63% in the [ARS] group. The current study revealed a high incidence of anaesthesia-induced atelectasis in children with healthy lungs exposed to prolonged general anaesthesia for microscopic recostruction of brachial plexus birth injuries. The combined use of Alveolar recruitment manoeuvres and PEEP of 5 cm H[2]O before and afterwards is effective in reducing the incidence of anesthesia induced atelectasis with no reported complications

Cerebral metabolic rate of oxygen, intracranial tension and blood flow equivalent during isoflurane or sevoflurane anaesthesia in brain surgery

This study included 28 patients of ASA physical status I-II, aged 18-55 years, subjected to craniotomies for supratentorial brain tumor. They were randomly allocated into two groups to receive either isoflurane [group I] or sevoflurane [group II] anesthesia. Cerebral venous monitoring through bulb catheterization to allow assessment of global oxygen delivery adequacy. A fiberoptic extradural sensor was inserted in extramural space to monitor the ICP. Anesthesia was induced by thiopentone/fentanyl/pepecurium/isoflurane in group I, and thiopentone/pepecurium/sevoflurane in group II. Anesthesia was maintained with 1.5 MAC [1.5%] isoflurane in group I and 1.5 MAC [3%] sevoflurane in group II in FiO2 100%. The patients were mechanically ventilated in such a rate to maintain PaCO2 between 32-35 mmHg. Mean arterial blood pressure [MAP], intracranial pressure, arterial and jugular venous blood gases, arterial and jugular venous lactate concentrations were measured and times of recovery parameters were recorded. Cerebral perfusion pressure [CPP], arterial oxygen content [CaO2], jugular venous oxygen content [VjvO2], arteriojugular venous oxygen content difference [AJVDO2], cerebral oxygen extraction ratio [OER], arteriojugular lactate difference [AJVLS], lactate oxygen index [LOI], cerebral blood flow equivalent [CBF equivalent] were calculated. Times elapsed, till recovery parameters occurred, were recorded