Ahmed Hasanin

Background: We aimed to evaluate the ability of inferior vena cava (IVC) distensibility using the transhepatic approach to predict fluid responsiveness in mechanically ventilated patients with septic shock after emergency laparotomy. Methods: This prospective observational study included mechanically ventilated paralyzed adult who had septic shock after emergency laparotomy. The IVC dimensions were measured through the transhepatic and subxiphoid approaches. The fluid responsiveness was confirmed with >15% increase in cardiac output after 500 mL of fluid bolus. The outcomes were the ability of transhepatic (primary outcome) and subxiphoid approach to predict fluid responders using the area under the receiver operating characteristics curve analysis. The gray zone for the two approaches was calculated. Results: Data from 51 patients were analyzed, and the number of fluid responders was 30 of 52 (58%). The transhepatic approach was feasible in all patients, whereas the subxiphoid approach was only feasible in 42 patients. The area under the receiver operating characteristics curve (95% confidence interval) for the transhepatic IVC distensibility was 0.88 (0.76-0.95), and it was comparable with that of the subxiphoid approach (0.81 [0.66-0.92], P = 0.417). The gray zone for the transhepatic IVC distensibility was 17% to 35% including 24 of 51 patients (47%), whereas the gray zone for the subxiphoid IVC distensibility was 13% to 34% including 18 of 42 patients (43%). Conclusion: In conclusion, the transhepatic approach for evaluation of IVC distensibility showed good accuracy in predicting fluid responsiveness in patients with septic shock after emergency laparotomy. The transhepatic approach showed the same accuracy as the subxiphoid approach with the advantage of being feasible in larger number of patients.

BACKGROUND: We aimed to compare the hemodynamic effect of two ratios of propofol and ketamine (ketofol), namely 1:1 and 1:3 ratios, in rapid-sequence induction of anesthesia for emergency laparotomy.

METHODS: This randomized controlled study included adult patients undergoing emergency laparotomy under general anesthesia. The patients were randomized to receive either ketofol ratio of 1:1 (n = 37) or ketofol ratio of 1:3 (n = 37). Hypotension (mean arterial pressure < 70 mmHg) was managed by 5-mcg norepinephrine. The primary outcome was total norepinephrine requirements during the postinduction period. Secondary outcomes included the incidence of postinduction hypotension, and the intubation condition (excellent, good, or poor).

RESULTS: Thirty-seven patients in the ketofol-1:1 and 35 patients in the ketofol 1:3 group were analyzed. The total norepinephrine requirement was less in the ketofol-1:1 group than in the ketofol-1:3 group, P-values: 0.043. The incidence of postinduction hypotension was less in the ketofol-1:1 group (4 [12%]) than in ketofol-1:3 group (12 [35%]), P-value 0.022. All the included patients had excellent intubation condition.

CONCLUSION: In patients undergoing emergency laparotomy, the use of ketofol in 1:1 ratio for rapid-sequence induction of anesthesia was associated with less incidence of postinduction hypotension and vasopressor consumption in comparison to the 1:3 ratio with comparable intubation conditions.

CLINICAL TRIAL REGISTRATION: NCT05166330. URL: https://clinicaltrials.gov/ct2/show/NCT05166330 .

BACKGROUND: The present study aims to compare the hemodynamic profile of lidocaine and fentanyl during propofol induction of general anesthesia.

METHODS: This randomized controlled trial included patients aged above 60 years undergoing elective non-cardiac surgery. The included patients received either 1 mg/kg lidocaine (n = 50) or 1 mcg/kg fentanyl (n = 50) based on total body weight with propofol induction of anesthesia. Patient's hemodynamics were recorded every minute for the first 5 min then every 2 min until 15 min after induction of anesthesia. Hypotension (mean arterial pressure [MAP] <65 mmHg or >30% reduction from baseline) was treated by intravenous 4 mcg bolus of norepinephrine. Outcomes included norepinephrine requirements (primary), the incidence of postinduction hypotension, MAP, heart rate, intubation condition, and postoperative delirium via the cognitive assessment method.

RESULTS: Forty-seven patients in the lidocaine group and 46 patients in the fentanyl group were analyzed. None in the lidocaine group experienced hypotension, while 28/46 (61%) of patients in the fentanyl group developed at least one episode of hypotension requiring a median (25th and 75th quartiles) norepinephrine dose of 4 (0,5) mcg, p-value <0.001 for both outcomes. The average MAP was lower in the fentanyl group than in the lidocaine group at all time points after anesthesia induction. The average heart rate was comparable between the two groups nearly at all time points after anesthesia induction. The overall intubation condition was comparable between the two groups. None of the included patients developed postoperative delirium.

CONCLUSION: Lidocaine-based regimen for induction of anesthesia reduced the risk of postinduction hypotension in older patients compared to the fentanyl-based regimen.

BACKGROUND: This study aims to compare the effect of two different ventilation strategies on cerebral oxygenation in children undergoing posterior fossa tumor excision surgeries.

METHODS: Children scheduled for posterior fossa tumor surgeries were enrolled in this randomized, double-blinded, controlled cross-over trial. After induction of general anesthesia and positioning, participants were randomized to have mild hyperventilation for 30 min (phase 1) followed by normal ventilation for another 30 min (phase2) (early hyperventilation group, n = 23), or normal ventilation for 30 min (phase 1) followed by hyperventilation for 30 min (phase 2) (early normoventilation group, n = 19). Our primary outcome was cerebral oxygenation, measured using near-infrared spectroscopy (NIRS). Other outcomes included the intracranial pressure (ICP), brain relaxation score at the end of phase 1, and frequency of nadir NIRS.

RESULTS: Forty-two children were available for final per protocol analysis. The cerebral oxygenation decreased after the hyperventilation phase compared to the baseline values and the corresponding phases of normoventilation. The mean difference [95% confidence intervals (CI)] in cerebral oxygen saturation between the hyperventilation and normal ventilation readings was 13.45 ± 1.14% [11.14-15.76] and 11.47 ± 0.96% [11.14-15.76] in the left and right sides, respectively (p-values <0.0001). Both carryover and period effects were not significant. The ICP at the end of phase 1 did not differ between the two groups: 22.12 ± 3.75 mmHg vs. 23.26 ± 4.33, mean difference [95%CI]: -0.78 [-3.05 to 1.5], p = 0.49. Brain relaxation score was similar in the two groups.

CONCLUSION: In children undergoing posterior fossa craniotomy, moderate hyperventilation reduced cerebral oxygenation without significant improvement of the surgical brain relaxation or the ICP.

This study aimed to evaluate the accuracy of oscillometric blood pressure measurement at the ankle in children using invasive blood pressure as reference standard. This prospective observational study included children undergoing noncardiac surgery. Paired radial invasive and ankle non-invasive blood pressure measurements were obtained. Delta blood pressure was calculated as the difference between two consecutive readings. The primary outcome was the mean bias and agreement between the two methods using the Bland-Altman analysis. The ISO standard was fulfilled if the mean bias between the two methods was ≤ 5 ± 8 mmHg. Other outcomes included the trending ability of ankle blood pressure using the four-quadrant plot and the accuracy of ankle measurement to detect hypotension using area under receiver operating characteristic curve (AUC) analysis. We analyzed 683 paired readings from 86 children. The mean bias between the two methods for systolic, diastolic, and mean blood pressure (SBP, DBP, MAP) was - 7.2 ± 10.7, 4.5 ± 12.8, and - 1.8 ± 8.2 mmHg, respectively. The concordance rate of ankle blood pressure was 72%, 71%, and 77% for delta SBP, DBP and MAP, respectively. The AUC (95% confidence interval) for ankle MAP ability to detect hypotension was 0.91 (0.89-0.93) with negative predictive value of 100% at cut-off value ≤ 70 mmHg, We concluded that in pediatric population undergoing noncardiac surgery, ankle blood pressure was not interchangeable with the corresponding invasive readings with the ankle MAP having the least bias compared to SBP and DBP. An ankle MAP > 70 mmHg can exclude hypotension with negative predictive value of 100%.

We aimed to evaluate the ability of parasternal intercostal thickening fraction (PIC TF) to predict the need for mechanical ventilation, and survival in subjects with severe Coronavirus disease-2019 (COVID-19). This prospective observational study included adult subjects with severe COVID-19. The following data were collected within 12 h of admission: PIC TF, respiratory rate oxygenation index, [Formula: see text] ratio, chest CT, and acute physiology and chronic health evaluation II score. The ability of PIC TF to predict the need for ventilatory support (primary outcome) and a composite of invasive mechanical ventilation and/or 30-days mortality were performed using the area under the receiver operating characteristic (AUC) analysis. Multivariate analysis was done to identify the independent predictors for the outcomes. Fifty subjects were available for the final evaluation. The AUC (95% confidence interval [CI]) for the right and left PIC TF ability to predict the need for ventilator support was 0.94 (0.83-0.99), 0.94 (0.84-0.99), respectively, with a cut off value of > 8.3% and positive predictive value of 90-100%. The AUC for the right and left PIC TF to predict invasive mechanical ventilation and/or 30 days mortality was 0.95 (0.85-0.99) and 0.90 (0.78-0.97), respectively. In the multivariate analysis, only the PIC TF was found to independently predict invasive mechanical ventilation and/or 30-days mortality. In subjects with severe COVID-19, PIC TF of 8.3% can predict the need to ventilatory support with a positive predictive value of 90-100%. PIC TF is an independent risk factor for the need for invasive mechanical ventilation and/or 30-days mortality.

OBJECTIVE: Hydrocephalus is the most common brain disorder in children and is more common in low- and middle-income countries. Research output on hydrocephalus remains sparse and of lower quality in low- and middle-income countries compared with high-income countries. Most studies addressing hydrocephalus epidemiology are retrospective registry studies entailing their inherent limitations and biases. This study aimed to investigate child-related, parental, and socioeconomic risk factors of congenital hydrocephalus (CH) in a lower-middle-income country.

METHODS: An investigator-administered questionnaire was used to query parents of patients with CH and controls who visited the authors' institution from 2017 until 2021. Patients with secondary hydrocephalus and children older than 2 years of age at diagnosis were excluded. Uni- and multivariable logistic regression was performed to identify the factors affecting CH development.

RESULTS: Seven hundred forty-one respondents (312 cases and 429 controls) were included in this study. The authors showed that maternal diseases during pregnancy (OR 3.12, 95% CI 1.96-5.03), a lack of periconceptional folic acid intake (OR 1.92, 95% CI 1.32-2.81), being a housewife (OR 2.66, 95% CI 1.51-4.87), paternal illiteracy (OR 1.65, 95% CI 1.02-2.69), parental consanguinity (OR 3.67, 95% CI 2.40-5.69), a history of other CNS conditions in the family (OR 2.93, 95% CI 1.24-7.34), conceiving a child via assisted fertilization techniques (OR 3.93, 95% CI 1.57-10.52), and the presence of other congenital anomalies (OR 2.57, 95% CI 1.38-4.87) were associated with an independent higher odds of a child having CH. Conversely, maternal hypertension (OR 0.22, 95% CI 0.09-0.48), older maternal age at delivery (OR 0.93, 95% CI 0.89-0.97), and having more abortions (OR 0.80, 95% CI 0.67-0.95) were negatively correlated with CH.

CONCLUSIONS: Multiple parental, socioeconomic, and child-related factors were associated with higher odds for developing CH. These results can be utilized to guide parental counseling and management, and direct social education and prevention programs.

BACKGROUND: Successful brachial plexus blockade produces sympathetic blockade, resulting in increased skin temperature in the blocked segments. This study aimed to evaluate the accuracy of infrared thermography in predicting failed segmental supraclavicular brachial plexus block.

METHODS: This prospective observational study included adult patients undergoing upper-limb surgery under supraclavicular brachial plexus block. Sensation was evaluated at the dermatomal distribution of the ulnar, median, and radial nerves. Block failure was defined as absence of complete sensory loss 30 min after block completion. Skin temperature was evaluated by infrared thermography at the dermatomal supply of the ulnar, median, and radial nerves at baseline, 5, 10, 15, and 20 min after block completion. The temperature change from the baseline measurement was calculated for each time point. Outcomes were the ability of temperature change at each site to predict failed block of the corresponding nerve using area under receiver-operating characteristic curve (AUC) analysis.

RESULTS: Eighty patients were available for the final analysis. The AUC (95% confidence interval [CI]) for the ability of temperature change at 5 min to predict failed ulnar, median, and radial nerve block was 0.79 (0.68-0.87), 0.77 (0.67-0.86), and 0.79 (0.69-0.88). The AUC (95% CI) increased progressively and reached its maximum values at 15 min (ulnar nerve 0.98 [0.92-1.00], median nerve 0.97 [0.90-0.99], radial nerve 0.96 [0.89-0.99]) with negative predictive value of 100%.

CONCLUSION: Infrared thermography of different skin segments provides an accurate tool for predicting failed supraclavicular brachial plexus block. Increased skin temperature at each segment can exclude block failure in the corresponding nerve with 100% accuracy.

BACKGROUND: This study aimed to compare three epinephrine doses for the prevention of spinal hypotension during Caesarean delivery.

METHODS: This randomized controlled trial included full-term pregnant women undergoing elective Caesarean delivery under spinal anesthesia. The participants received prophylactic epinephrine infusions at rates of 0.01, 0.02, or 0.03 mcg/kg/min. Spinal hypotension (systolic blood pressure <80% of baseline) was managed with a 9-mg ephedrine bolus. The primary outcome was the incidence of spinal hypotension. Secondary outcomes included total ephedrine requirement, the incidence of severe spinal hypotension, excessive tachycardia and hypertension, and neonatal outcomes.

RESULTS: The final analysis included 271 patients. The incidence of hypotension was lowest in the 0.03 mcg group (11/90 [12%]), followed by the 0.02 mcg (32/91 [35%]) and the 0.01 mcg (55/90 [61%]) groups (p < 0.001). The median ephedrine requirements (quartiles) were also the lowest in the 0.03 mcg group (0 [0-0] mg), followed by the 0.02 mcg (0 [0-9] mg) and the 0.01 mcg (9 [0-18] mg) groups. The incidence of severe hypotension was lower in the 0.03 mcg and 0.02 mcg groups than in the 0.01 mcg group (3/90 [3%], 5/91 [6%], and 15/90 [17%], respectively). The incidences of excessive tachycardia, hypertension, and neonatal outcomes were comparable among the groups.

CONCLUSION: The use of epinephrine to prevent spinal hypotension during Caesarean delivery is feasible and effective. An initial dose of 0.03 mcg/kg/min produced the lowest incidence of hypotension compared to 0.02 mcg/kg/min and 0.01 mcg/kg/min doses. The three doses were comparable in terms of the incidence of tachycardia, hypertension, and neonatal outcomes.

STUDY REGISTRATION: ClinicalTrials.gov Identifier: NCT05279703.

In this study we aimed to evaluate the ability of IMPROVE and IMPROVE-DD scores in predicting in-hospital mortality in patients with severe COVID-19. This prospective observational study included adult patients with severe COVID-19 within 12 h from admission. We recorded patients' demographic and laboratory data, Charlson comorbidity index (CCI), SpO at room air, acute physiology and chronic health evaluation II (APACHE II), IMPROVE score and IMPROVE-DD score. In-hospital mortality and incidence of clinical worsening (the need for invasive mechanical ventilation, vasopressors, renal replacement therapy) were recorded. Our outcomes included the ability of the IMPROVE and IMPROVE-DD to predict in-hospital mortality and clinical worsening using the area under receiver operating characteristic curve (AUC) analysis. Multivariate analysis was used to detect independent risk factors for the study outcomes. Eighty-nine patients were available for the final analysis. The IMPROVE and IMPROVE-DD score showed the highest ability for predicting in-hospital mortality (AUC [95% confidence intervals {CI}] 0.96 [0.90-0.99] and 0.96 [0.90-0.99], respectively) in comparison to other risk stratification tools (APACHE II, CCI, SpO). The AUC (95% CI) for IMPROVE and IMPROVE-DD to predict clinical worsening were 0.80 (0.70-0.88) and 0.79 (0.69-0.87), respectively. Using multivariate analysis, IMPROVE-DD and SpO were the only predictors for in-hospital mortality and clinical worsening. In patients with severe COVID-19, high IMPROVE and IMOROVE-DD scores showed excellent ability to predict in-hospital mortality and clinical worsening. Independent risk factors for in-hospital mortality and clinical worsening were IMPROVE-DD and SpO.

BACKGROUND: We aimed to evaluate the gastric volume and contents after an 8-h fasting period in full-term, non-laboring, pregnant women following a standardized meal.

METHODS: In this prospective observational study, we included full-term pregnant women scheduled for elective cesarean delivery. The participants were instructed to fast after a standardized meal (apple juice, bread, and cheese). Participants were scanned in the semi-recumbent and right-lateral positions 8 h after the standardized meal. The primary outcome was the proportion of patients with gastric volume > 1.5 mL kg calculated by two equations. Secondary outcomes included the antral cross-sectional area and gastric volume. Data are expressed as frequency (%, 95% confidence interval [CI]), mean ± standard deviation (95% CI of the mean), or median (quartiles) as appropriate.

RESULTS: Forty-one women were available for the final analysis. For the primary outcome, one participant (2.4%, 95% CI of 0.06 to 12.8%) had gastric volume > 1.5 mL kg, and none had solids in the antrum. For the secondary outcomes, the mean (95% CI of the mean) of the antral cross-sectional area was 2.11 ± 0.72 (1.88 to 2.34) cm and 4.08 ± 1.80 (3.51 to 4.65) cm during the semi-recumbent and right-lateral position, respectively. The median (quartiles) gastric volume was 0.53 (0.32, 0.66) mL kg and 0.33 (0.13, 0.52) mL kg as estimated by Perlas et al. and Roukhomovsky et al. equations, respectively.

CONCLUSION: After 8-h fasting following a standardized meal, full-term pregnant non-laboring women are less likely to have a high residual gastric volume.

PURPOSE: To evaluate the accuracy of noninvasive blood pressure (NIBP) measurement at the dependent- and nondependent arms in the lateral position, using invasive blood pressure (IBP) as reference.

METHODS: This prospective observational study included 42 adult patients undergoing surgery in the lateral position. Paired readings of IBP and NIBP were obtained at either arm. The accuracy of both arms in detecting mean arterial pressure (MAP) <70 mmHg was evaluated using the area under the receiver operating characteristic curve (AUC). The agreement between the IBP and NIBP was evaluated using the Bland-Altman and error grid analyses.

RESULTS: We analyzed 350 and 347 paired readings at the dependent- and nondependent arms. The AUC for detecting hypotension was comparable in both arms. The negative and positive predictive values (95% confidence interval) were 100% (99-100%) and 24% (14-34%), respectively for the dependent arm at cutoff value MAP ≤86 mmHg; and were 99% (96-100%) and 21% (13-30%), respectively for the nondependent arm at cutoff value MAP ≤75 mmHg. The mean bias for MAP was -6.0 ± 9.1 and 6.3 ± 10.1 mmHg; and for systolic blood pressure was 0.3 ± 11.6 and 13.2 ± 12.6 mmHg, in the dependent- and nondependent arm, respectively. Error grid analysis showed that the proportions of paired MAP readings in risk zone A were 71 and 82% in the dependent- and the nondependent arms, respectively.

CONCLUSION: In the lateral position, the NIBP readings at both arms are not interchangeable with the corresponding IBP readings. However, NIBP measurement at both arms can be used to accurately rule out hypotension.

BACKGROUND: This study aimed to evaluate the accuracy of pulse oximetry-derived oxygen saturation (SpO) on room air, determined at hospital admission, as a predictor for the need for mechanical ventilatory support in patients with Coronavirus Disease-2019 (COVID-19).

METHODS: In this retrospective observational study, demographic and clinical details of the patients were obtained during ICU admission. SpO and respiratory rate (RR) on room air were determined within the first 6 h of hospital admission. As all measurements were obtained on room air, we calculated the simplified respiratory rate‑oxygenation (ROX) index by dividing the SpO by the RR. Based on the use of any assistance of mechanical ventilator (invasive or noninvasive), patients were divided into mechanical ventilation (MV) group and oxygen therapy group. The accuracy of the SpO, CT score, and ROX index to predict the need to MV were determined using the Area under receiver operating curve (AUC).

RESULTS: We included 72 critically ill patients who tested COVID-19-positive. SpO on the room air could predict any MV requirement (AUC [95% confidence interval]: 0.9 [0.8-0.96], sensitivity: 70%, specificity 100%, cut-off value ≤78%, P < 0.001). Within the MV group, the use of noninvasive ventilation (NIV) was successful in 37 (74%) patients, whereas 13 patients (26%) required endotracheal intubation. The cut-off ROX value for predicting early NIV failure was ≤1.4, with a sensitivity of 85%, a specificity of 86%, and an AUC of 0.86 (95% confidence interval of 0.73-0.94, P < 0.0001).

CONCLUSIONS: A baseline SpO ≤78% is an excellent predictor of MV requirement with a positive predictive value of 100%. Moreover, the ROX index measured within the first 6 h of hospital admission is a good indicator of early NIV failure.

BACKGROUND: Super-obesity is a serious disorder which requires bariatric surgery. The association of super-obesity and difficult intubation was not adequately established.

OBJECTIVES: To determine if super-obesity and super-super-obesity are associated with difficult intubation or not.

SETTING: University Hospital.

METHODS: A cohort of obese patients scheduled for bariatric surgery was prospectively recruited. Super-obesity and super-super-obesity were defined as body mass index ≥50 kg/m and 60 kg/m, respectively. Intubation difficulty was assessed by 2 methods: (1) intubation difficulty scale; (2) number of intubation attempts. Risk factors for difficult intubation were recorded. Univariate and multivariate analysis for risk factors for difficult intubation and difficult mask ventilation were performed.

RESULTS: A total of 658 patients were enrolled in the study including 205 (31%) super-obese and 52 (8%) super-super-obese patients. Ninety-nine (15%) patients required more than 1 intubation attempt, while 215 (33%) patients had intubation difficulty scale ≥5. Ninety-four (14.4%) patients had mask ventilation of moderate difficulty, while only 2 (.3%) patients needed 2-person ventilation. The independent risk factors for difficult intubation using the two stated definitions were STOP-Bang and Mallampati score values. The independent risk factors for mask ventilation of moderate difficulty were STOP-Bang score, Mallampati score, and limited neck extension.

CONCLUSION: Within obese patients, neither super-obesity nor super-super-obesity was associated with difficult intubation or difficult mask ventilation. High STOP-Bang and Mallampati score are the independent factors for difficult intubation.

BACKGROUND: Elderly population are at increased risk of spinal anesthesia-induced hypotension increasing their risk for postoperative morbidity and mortality. This study aimed to compare the hemodynamic effects of prophylactic infusion of norepinephrine (NE) versus phenylephrine (PE) in elderly patients undergoing hip fracture surgery under spinal anesthesia.

METHODS: Elderly patients scheduled for hip fracture surgery were randomized to receive either NE infusion (8 µg/min) (NE group, n = 31) or PE infusion (100 µg/min) (PE group, n = 31) after spinal anesthesia. Outcomes included mean heart rate, mean blood pressure, cardiac output, incidence of spinal anesthesia-induced hypotension, incidence of bradycardia, and incidence of hypertension.

RESULTS: Sixty-two patients with a mean age of 71 ± 6 years were included in the final analysis (31 patients in each group). The NE group showed a higher mean heart rate and cardiac output than the PE group. The NE group had a lower incidence of reactive bradycardia (10% vs. 36%, P = 0.031) and hypertension (3% vs. 36%, P = 0.003) than the PE group. No study participant developed hypotension, and the mean blood pressure was comparable between the two groups.

CONCLUSIONS: Both NE and PE infusions effectively prevented spinal anesthesia-induced hypotension in elderly patients undergoing hip fracture surgery. However, NE provided more hemodynamic stability than PE; maintaining the heart rate, higher cardiac output, less reactive bradycardia, and hypertension.

OBJECTIVE: The aim of this work is to compared ketamine-based versus fentanyl-based regimens for endotracheal intubation in patients with septic shock undergoing emergency surgery.

DESIGN: This was a randomised double-blinded controlled trial.

PARTICIPANTS: Patients with septic shock on norepinephrine infusion scheduled for emergency surgery.

SETTING AND INTERVENTIONS: At induction of anaesthesia, patients were allocated into ketamine group (n=23) in which the participants received ketamine 1 mg/kg, and fentanyl group (n=19) in which the participants received fentanyl 2.5 mcg/ kg. Both groups received midazolam (0.05 mg/kg) and succinyl choline (1 mg/kg).

MEASUREMENT: The primary outcome was mean arterial blood pressure. The secondary outcomes included: heart rate, cardiac output, and incidence of postintubation hypotension defined as mean arterial pressure ≤80% of baseline value.

RESULTS: Forty-two patients were available for final analysis. The mean blood pressure was higher in the ketamine group than in the fentanyl group at 1, 2 and 5 minutes after the induction of anaesthesia. Furthermore, the incidence of postinduction hypotension was lower in the ketamine group than in the fentanyl group (11 [47.8%] versus 16 [84.2%], P-value= 0.014). Other hypodynamic parameters, namely the heart rate and cardiac output, were comparable between both groups; and were generally maintained in relation to the baseline reading in each group.

CONCLUSION: The ketamine-based regimen provided better hemodynamic profile compared to fentanyl-based regimen for rapid-sequence intubation in patients with septic shock undergoing emergency surgery.

OBJECTIVES: Accurate estimation of a critically ill patient's caloric requirements is essential for a proper nutritional plan. This study aimed to evaluate the use of point-of-care ultrasound (US) to predict the resting energy expenditure (REE) in critically ill patients.

METHODS: In 69 critically ill patients, we measured the REE using indirect calorimetry (REE_IC), muscle layer thicknesses (MLTs), and cardiac output (CO). Muscle thickness was measured at the biceps and the quadriceps muscles. Patients were randomly split into a model development group (n = 46) and a cross-validation group (n = 23). In the model development group, a multiple regression analysis was applied to generate REE using US (REE_US) values. In the cross-validation group, REE was calculated by the REE_US and the resting energy expenditure using the Harris-Benedict equation (REE_HB), and both were compared to the REE_IC.

RESULTS: In the model development group, the REE_US was predicted by the following formula: predicted REE_US (kcal/d) = 206 + 173.5 × CO (L/min) + 137 × MLT (cm) - 230 × (women = 1; men = 0) (R  = 0.8; P < .0001). In the cross-validated group, the REE_IC and REE_US values were comparable (mean difference, -66 [-3.3%] kcal/d; P = .14). However, the difference between the mean REE_IC and the mean REE_HB was 455.8 (26%) kcal/d (P < .001). According to a Bland-Altman analysis, the REE_US agreed well with the REE_IC, whereas the REE_HB did not.

CONCLUSIONS: Resting energy expenditure could be estimated from US measurements of MLTs and CO. Our point-of-care US model explains 80% of the change in the REE in critically ill patients.