Amin, S. M., A. Hasanin, N. T. Ghanem, M. Mostafa, N. Elzayat, M. Elsherbiny, and Y. Abdelwahab, "Comparison of Two Norepinephrine Rescue Bolus Doses for Management of Severe Post-Spinal Hypotension During Elective Caesarean Delivery: A Randomized, Controlled Trial.", International journal of general medicine, vol. 17, pp. 153-160, 2024. Abstract

BACKGROUND: Post-spinal hypotension is associated with maternal and neonatal complications; therefore, prompt control maternal blood pressure is necessary. In this study, we aimed to compare the efficacy and safety of two norepinephrine bolus doses in the rescue management of severe maternal hypotension during elective Cesarean delivery.

METHODS: We included full-term pregnant women scheduled for Cesarean delivery under spinal anesthesia. Patients were randomized to receive either 5-mcg norepinephrine (n=79) or 10-mcg norepinephrine (n=79) for treatment of severe postspinal hypotension (systolic blood pressure ≤60% of baseline reading). The management of the hypotensive episode was considered successful if systolic blood pressure was >80% of the baseline within 2 mins of the bolus. The primary outcome was the incidence of successful management of severe post-spinal hypotension. Secondary outcomes included the incidence of reactive bradycardia, reactive hypertension, umbilical blood gases, and neonatal Apgar score at 5-min post-delivery.

RESULTS: We included 73 patients in the 5-mcg group and 76 patients in the 10-mcg group into the final analysis. The incidence of successful management of severe hypotensive episodes was comparable between the two groups (43/73 [59%] and 46/76 [60%] in the 5-and 10-mcg group, respectively, =0.917). The incidence of reactive hypertension, bradycardia, and neonatal outcomes were comparable between the two groups.

CONCLUSION: In mothers undergoing Cesarean delivery under spinal anesthesia, 10-mcg norepinephrine bolus was not superior to the 5-mcg bolus in the management of severe hypotension. Furthermore, the incidence of reactive bradycardia and hypertension was comparable in the two doses.

CLINICAL TRIAL REGISTRATION: NCT05290740, URL: https://clinicaltrials.gov/ct2/show/NCT05290740.

Amin, S., A. Hasanin, R. Mansour, M. Mostafa, D. Zakaria, A. S. Arafa, A. yassin, and H. Ziada, "Oral midodrine for prophylaxis against post-spinal anesthesia hypotension during hip arthroplasty in elderly population: a randomized controlled trial.", BMC anesthesiology, vol. 24, issue 1, pp. 64, 2024 Feb 14. Abstract

BACKGROUND: We aimed to evaluate the efficacy of midodrine as a prophylaxis against post-spinal hypotension in elderly patients undergoing hip arthroplasty.

METHODS: This randomized controlled trial included elderly patients undergoing hip arthroplasty under spinal anesthesia. Ninety minutes before the procedure, patients were randomized to receive either 5-mg midodrine or placebo (metoclopramide). After spinal anesthesia, mean arterial pressure (MAP) and heart rate were monitored every 2 min for 20 min then every 5 min until the end of the procedure. Post-spinal hypotension (MAP < 80% baseline) was treated with 10 mg ephedrine. The primary outcome was intraoperative ephedrine consumption. Secondary outcomes were the incidence of post-spinal hypotension, bradycardia, and hypertension (MAP increased by > 20% of the baseline reading).

RESULTS: We analyzed 29 patients in the midodrine group and 27 in the control group. The intraoperative ephedrine consumption was lower in the midodrine group than in the control group (median [quartiles]: 10 [0, 30] mg versus 30 [20, 43] mg, respectively, P-value: 0.002); and the incidence of intraoperative hypotension was lower in the midodrine group than that in the control group. The incidence of hypertension and bradycardia were comparable between the two groups.

CONCLUSION: The use of 5 mg oral midodrine decreased the vasopressor requirements and incidence of hypotension after spinal anesthesia for hip surgery in elderly patients.

CLINICAL TRIAL REGISTRATION: This study was registered on September 22, 2022 at clinicaltrials.gov registry, NCT05548985, URL: https://classic.

CLINICALTRIALS: gov/ct2/show/NCT05548985 .

Hasanin, A., R. Fekry, M. Mostafa, S. Kasem, A. Eissa, H. Mohamed, and H. Raafat, "The use of thermal imaging for evaluation of peripheral tissue perfusion in surgical patients with septic shock.", BMC anesthesiology, vol. 24, issue 1, pp. 109, 2024 Mar 21. Abstract

BACKGROUND: In this study, we aimed to evaluate the ability of central-to-peripheral temperature gradients using thermal imaging to predict in-hospital mortality in surgical patients with septic shock.

METHODS: This prospective observational study included adult patients with septic shock admitted to the intensive care unit postoperatively. Serum lactate (in mmol/L), capillary refill time (CRT) (in seconds), toe (peripheral) and canthal (central) temperature by infrared thermography and the corresponding room temperature in (Celsius [°C]) were assessed at the time of admission, 6- and 12 h after admission. The canthal-toe and room-toe temperature gradients were calculated. According to their final outcomes, patients were divided into survivors and non-survivors. The ability of canthal-toe temperature gradient (primary outcome), room-toe temperature gradient, toe temperature, serum lactate and CRT, measured at the prespecified timepoints to predict in-hospital mortality was analyzed using the area under receiver operating characteristic curve (AUC).

RESULTS: Fifty-six patients were included and were available for the final analysis and 41/56 (73%) patients died. The canthal-toe and room-toe temperature gradients did not show significant accuracy in predicting mortality at any timepoint. Only the toe temperature measurement at 12 h showed good ability in predicting in-hospital mortality with AUC (95% confidence interval) of 0.72 (0.58-0.84) and a negative predictive value of 70% at toe temperature of ≤ 25.5 °C. Both serum lactate and CRT showed good ability to predict in-hospital mortality at all timepoints with high positive predictive values (> 90%) at cut-off value of > 2.5-4.3 mmol/L for the serum lactate and > 3-4.2 s for the CRT.

CONCLUSION: In post-operative emergency surgical patients with septic shock, high serum lactate and CRT can accurately predict in-hospital mortality and were superior to thermal imaging, especially in the positive predictive values. Toe temperature > 25.5 °C, measured using infrared thermal imaging can exclude in-hospital mortality with a negative predictive value of 70%.

Hassabelnaby, Y. S., A. M. Hasanin, M. Shamardal, M. Mostafa, R. M. Zaki, M. Elsherbiny, and S. Refaat, "Epinephrine vs. phenylephrine infusion for prophylaxis against maternal hypotension after spinal anesthesia for cesarean delivery: a randomized controlled trial.", Journal of anesthesia, vol. 38, issue 4, pp. 500-507, 2024 Aug. Abstract

BACKGROUND: The hemodynamic effects of relatively low-dose epinephrine and phenylephrine infusions during cesarean delivery under spinal anesthesia were compared.

METHODS: This randomized controlled trial included full-term pregnant women who underwent elective cesarean delivery. After spinal anesthesia, participants received either epinephrine (0.03 mcg/kg/min) or phenylephrine (0.4 mcg/kg/min) infusion that continued until 5 min after delivery. The primary outcome was a composite outcome of the occurrence of any of hypotension, hypertension, bradycardia, and/or tachycardia. Neonatal outcomes, including umbilical artery blood gas and Apgar scores, were assessed.

RESULTS: In total, 98 patients in each group were analyzed, and the number of patients with the composite outcome was comparable between the epinephrine and phenylephrine groups (30/98 [31%] vs. 31/98 [32%], respectively; P = 0.877). However, the incidence of hypotension was likely lower in the epinephrine group than in the phenylephrine group (P = 0.066), and the number of hypotensive episodes per patient was lower in the epinephrine group than in the phenylephrine group. On the other hand, the incidence of tachycardia was higher in the epinephrine group than that in the phenylephrine group. The incidence of hypertension was comparable between the two groups and none of the participants developed bradycardia. Neonatal outcomes were comparable between the two groups.

CONCLUSIONS: Epinephrine and phenylephrine infusion produced comparable maternal hemodynamics and neonatal outcomes. Epinephrine was associated with a higher incidence of maternal tachycardia and likely lower incidence of maternal hypotension than phenylephrine. IRB number: MD-245-2022.

CLINICAL TRIAL REGISTRATION: This study was registered on May 31, 2023 at clinicaltrials.gov registry, NCT05881915, URL: https://classic.

CLINICALTRIALS: gov/ct2/show/NCT05881915term=NCT05881915&draw=2&rank=1.

Amin, S., A. Hasanin, O. A. Attia, M. Mostafa, N. S. Elzayat, M. Elsherbiny, and A. A. Eissa, "Intravenous ibuprofen versus ketorolac for perioperative pain control in open abdominal hysterectomy: a randomized controlled trial.", BMC anesthesiology, vol. 24, issue 1, pp. 202, 2024 Jun 07. Abstract

BACKGROUND: We aimed to compare the analgesic effects of intravenous ibuprofen to ketorolac after open abdominal hysterectomy.

METHODS: This randomized double-blinded controlled trial included adult women scheduled for elective open abdominal hysterectomy. Participants were randomized to receive either 30 mg ketorolac (n = 50) or 800 mg ibuprofen (n = 50) preoperatively, then every 8 h postoperatively for 24 h. All participants received paracetamol 1 gm/6 h. Rescue analgesic was given if the visual analogue scale (VAS) for pain assessment was > 3. The primary outcome was the mean postoperative dynamic VAS during the first 24 h. Secondary outcomes were static VAS, intraoperative fentanyl consumption, postoperative morphine consumption, time to independent movement, and patient's satisfaction.

RESULTS: Forty-six patients in the ibuprofen group and fifty patients in the ketorolac group were analyzed. The 24-h dynamic and static VAS were similar in the two groups. The median (quartiles) dynamic VAS was 1.1 (0.9, 1.9) in the ibuprofen group versus 1.0 (0.7, 1.3) in the ketorolac group, P-value = 0.116; and the median (quartiles) static VAS was 0.9 (0.6, 1.3) in the ibuprofen group versus 0.7 (0.4, 1.1) in the ketorolac group, P-value = 0.113. The intra- and postoperative analgesic requirements were also similar in the two groups. However, patient satisfaction was slightly higher in the ketorolac group than that in the ibuprofen group (median [quartiles]: 6 [5, 7] versus 5 [4, 7], respectively), P-value: 0.009.

CONCLUSION: The two drugs, intravenous ibuprofen and ketorolac produced similar analgesic profile in patients undergoing open abdominal hysterectomy receiving multimodal analgesic regimen. NCT05610384, Date of registration: 09/11/2022 CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05610384. https://clinicaltrials.gov/ct2/show/NCT05610384.

Farag, A., M. Mostafa, A. Hasanin, L. Sobh, H. Raafat, G. Obayah, and M. Youssef, "Accuracy of oscillometric noninvasive blood pressure at the ankle in the lateral position during general anesthesia.", BMC anesthesiology, vol. 24, issue 1, pp. 221, 2024 Jul 03. Abstract

BACKGROUND: This study aimed to evaluate the accuracy of ankle blood pressure measurements in relation to invasive blood pressure in the lateral position.

METHODS: This prospective observational study included adult patients scheduled for elective non-cardiac surgery under general anesthesia in the lateral position. Paired radial artery invasive and ankle noninvasive blood pressure readings were recorded in the lateral position using GE Carescape B650 monitor. The primary outcome was the ability of ankle mean arterial pressure (MAP) to detect hypotension (MAP < 70 mmHg) using area under the receiver operating characteristic curve (AUC) analysis. The secondary outcomes were the ability of ankle systolic blood pressure (SBP) to detect hypertension (SBP > 140 mmHg) as well as bias (invasive measurement - noninvasive measurement), and agreement between the two methods using the Bland-Altman analysis.

RESULTS: We analyzed 415 paired readings from 30 patients. The AUC (95% confidence interval [CI]) of ankle MAP for detecting hypotension was 0.88 (0.83-0.93). An ankle MAP of ≤ 86 mmHg had negative and positive predictive values (95% CI) of 99 (97-100)% and 21 (15-29)%, respectively, for detecting hypotension. The AUC (95% CI) of ankle SBP to detect hypertension was 0.83 (0.79-0.86) with negative and positive predictive values (95% CI) of 95 (92-97)% and 36 (26-46)%, respectively, at a cutoff value of > 144 mmHg. The mean bias between the two methods was - 12 ± 17, 3 ± 12, and - 1 ± 11 mmHg for the SBP, diastolic blood pressure, and MAP, respectively.

CONCLUSION: In patients under general anesthesia in the lateral position, ankle blood pressure measurements are not interchangeable with the corresponding invasive measurements. However, an ankle MAP > 86 mmHg can exclude hypotension with 99% accuracy, and an ankle SBP < 144 mmHg can exclude hypertension with 95% accuracy.

Abougabal, A., A. Hasanin, M. Abdel-Fatah, M. Mostafa, A. A. Ismail, and S. Habib, "Peripheral perfusion index as a predictor of reintubation in critically ill surgical patients.", BMC anesthesiology, vol. 24, issue 1, pp. 227, 2024 Jul 09. Abstract

PURPOSE: We aimed to evaluate the ability of the peripheral perfusion index (PPI) to predict reintubation of critically ill surgical patients.

METHODS: This prospective observational study included mechanically ventilated adults who were extubated after a successful spontaneous breathing trial (SBT). The patients were followed up for the next 48 h for the need for reintubation. The heart rate, systolic blood pressure, respiratory rate, peripheral arterial oxygen saturation (SpO), and PPI were measured before-, at the end of SBT, 1 and 2 h postextubation. The primary outcome was the ability of PPI 1 h postextubation to predict reintubation using area under the receiver operating characteristic curve (AUC) analysis. Univariate and multivariate analyses were performed to identify predictors for reintubation.

RESULTS: Data from 62 patients were analysed. Reintubation occurred in 12/62 (19%) of the patients. Reintubated patients had higher heart rate and respiratory rate; and lower SpO and PPI than successfully weaned patients. The AUC (95%confidence interval) for the ability of PPI at 1 h postextubation to predict reintubation was 0.82 (0.71-0.91) with a negative predictive value of 97%, at a cutoff value of ≤ 2.5. Low PPI and high respiratory rate were the independent predictors for reintubation.

CONCLUSION: PPI early after extubation is a useful tool for prediction of reintubation. Low PPI is an independent risk factor for reintubation. A PPI > 2.5, one hour after extubation can confirm successful extubation.

Mostafa, M., A. Hasanin, B. Reda, M. Elsayad, M. Zayed, and M. E. Abdelfatah, "Comparing the hemodynamic effects of ketamine versus fentanyl bolus in patients with septic shock: a randomized controlled trial.", Journal of anesthesia, vol. 38, issue 6, pp. 756-764, 2024 Dec. Abstract

BACKGROUND: Ketamine and fentanyl are commonly used for sedation and induction of anesthesia in critically ill patients. This study aimed to compare the hemodynamic effects of ketamine versus fentanyl bolus in patients with septic shock.

METHODS: This randomized controlled trial included mechanically ventilated adults with septic shock receiving sedation. Patients were randomized to receive either 1 mg/kg ketamine bolus or 1 mcg/kg fentanyl bolus. Cardiac output (CO), stroke volume (SV), heart rate (HR), and mean arterial pressure (MAP) were measured at the baseline, 3, 6, 10, and 15 min after the intervention. Delta CO was calculated as the change in CO at each time point in relation to baseline measurement. The primary outcome was delta CO 6 min after administration of the study drug. Other outcomes included CO, SV, HR, and MAP.

RESULTS: Eighty-six patients were analyzed. The median (quartiles) delta CO 6 min after drug injection was 71(37, 116)% in the ketamine group versus - 31(- 43, - 12)% in the fentanyl group, P value < 0.001. The CO, SV, HR, and MAP increased in the ketamine group and decreased in the fentanyl group in relation to the baseline reading; and all were higher in the ketamine group than the fentanyl group.

CONCLUSION: In patients with septic shock, ketamine bolus was associated with higher CO and SV compared to fentanyl bolus.

CLINICAL TRIAL REGISTRATION: Date of registration: 24/07/2023.

CLINICALTRIALS: gov Identifier: NCT05957302. URL: https://clinicaltrials.gov/study/NCT05957302 .

Helmy, M. A., A. Hasanin, L. Magdy Milad, M. Mostafa, W. I. Hamimy, R. S. Muhareb, and H. Raafat, "Ability of parasternal intercostal muscle thickening fraction to predict reintubation in surgical patients with sepsis.", BMC anesthesiology, vol. 24, issue 1, pp. 294, 2024 Aug 22. Abstract

OBJECTIVES: We aimed to evaluate the ability of the parasternal intercostal (PIC) thickening fraction during spontaneous breathing trial (SBT) to predict the need for reintubation within 48 h after extubation in surgical patients with sepsis.

METHODS: This prospective observational study included adult patients with sepsis who were mechanically ventilated and indicated for SBT. Ultrasound measurements of the PIC thickening fraction and diaphragmatic excursion (DE) were recorded 15 min after the start of the SBT. After extubation, the patients were followed up for 48 h for the need for reintubation. The study outcomes were the ability of the PIC thickening fraction (primary outcome) and DE to predict reintubation within 48 h of extubation using area under receiver characteristic curve (AUC) analysis. The accuracy of the model including the findings of right PIC thickening fraction and right DE was also assessed using the current study cut-off values. Multivariate analysis was performed to identify independent risk factors for reintubation.

RESULTS: We analyzed data from 49 patients who underwent successful SBT, and 10/49 (20%) required reintubation. The AUCs (95% confidence interval [CI]) for the ability of right and left side PIC thickening fraction to predict reintubation were 0.97 (0.88-1.00) and 0.96 (0.86-1.00), respectively; at a cutoff value of 6.5-8.3%, the PIC thickening fraction had a negative predictive value of 100%. The AUCs for the PIC thickening fraction and DE were comparable; and both measures were independent risk factors for reintubation. The AUC (95% CI) of the model including the right PIC thickening fraction > 6.5% and right DE ≤ 18 mm to predict reintubation was 0.99 (0.92-1.00), with a positive predictive value of 100% when both sonographic findings are positive and negative predictive value of 100% when both sonographic findings are negative.

CONCLUSIONS: Among surgical patients with sepsis, PIC thickening fraction evaluated during the SBT is an independent risk factor for reintubation. The PIC thickening fraction has an excellent predictive value for reintubation. A PIC thickening fraction of ≤ 6.5-8.3% can exclude reintubation, with a negative predictive value of 100%. Furthermore, a combination of high PIC and low DE can also indicate a high risk of reintubation. However, larger studies that include different populations are required to replicate our findings and validate the cutoff values.

Hasanin, A., F. Sanfilippo, M. W. Dünser, H. M. Ahmed, L. Zieleskiewicz, S. N. Myatra, and M. Mostafa, "The MINUTES bundle for the initial 30 min management of undifferentiated circulatory shock: an expert opinion.", International journal of emergency medicine, vol. 17, issue 1, pp. 96, 2024. Abstract

Acute circulatory shock is a life-threatening emergency requiring an efficient and timely management plan, which varies according to shock etiology and pathophysiology. Specific guidelines have been developed for each type of shock; however, there is a need for a clear timeline to promptly implement initial life-saving interventions during the early phase of shock recognition and management. A simple, easily memorable bundle of interventions could facilitate standardized management with clear targets and specified timeline. The authors propose the "MINUTES" acronym which summarizes essential interventions which should be performed within the first 30 min following shock recognition. All the interventions in the MINUTES bundle are suitable for any patient with undifferentiated shock. In addition to the acronym, we suggest a timeline for each step, balancing the feasibility and urgency of each intervention. The MINUTES acronym includes seven sequential steps which should be performed in the first 30 min following shock recognition: Maintain "ABCs", INfuse vasopressors and/or fluids (to support hemodynamic/perfusion) and INvestigate with simple blood tests, Ultrasound to detect the type of shock, Treat the underlying Etiology, and Stabilize organ perfusion.