Ahmed Hasanin

We hypothesized that impairment of peripheral perfusion index (PPI) during spontaneous breathing trial (SBT) might be predictive of weaning failure. We included 44 consecutive, adult, patients, who were scheduled for weaning after at least 48 h of invasive mechanical ventilation in this prospective observational study. Weaning failure was defined as failed SBT or reintubation within 48 h of extubation. PPI readings were obtained before initiation of the SBT, and every 5 min till the end of the SBT. PPI ratio was calculated at every time point as: PPI value/ baseline PPI. The primary outcome was the accuracy of PPI ratio at the end of the SBT in detecting failed weaning. Forty-three patients were available for the final analysis. Eighteen patients (42%) were considered failed weaning. PPI ratio was higher in patients with successful weaning compared to patients with failed weaning during the last 15 min of the SBT. PPI ratio at the end of SBT was higher in patients with successful weaning compared to patients with failed weaning. PPI ratio at the end of SBT had good predictive ability for weaning failure {area under receiver operating characteristic curve (95% confidence interval): 0.833(0.688-0.929), cutoff value ≤ 1.41}. The change in PPI during SBT is an independent predictor for re-intubation. PPI could be a useful tool for monitoring the patient response to SBT. Patients with successful weaning showed higher augmentation of PPI during the SBT compared to re-intubated patients. Failure of augmenting the PPI by 41% at the end of SBT could predict re-intubation with negative predictive value of 95%. Clinical trial identifier: NCT03974568. https://clinicaltrials.gov/ct2/show/NCT03974568?term=ahmed+hasanin&draw=3&rank=17.

BACKGROUND: Post-spinal hypotension is a common maternal complication during cesarean delivery. Aortocaval compression by the gravid uterus has been assumed as a precipitating factor for post-spinal hypotension. The role of left lateral tilting position in improving maternal cardiac output after subarachnoid block (SAB) is unclear. The aim of this work is to investigate the effect of left lateral tilting on maternal hemodynamics after SAB.

METHODS: A prospective observational study was conducted including 105 full term pregnant women scheduled for cesarean delivery. Mean arterial pressure, heart rate, cardiac output (measured by electrical cardiometry), stroke volume, and systemic vascular resistance were recorded in three positions (supine, 15, and 30left lateral positions) before SAB, after SAB, and after delivery of the fetus.

RESULTS: Before SAB, no significant hemodynamic changes were reported with left lateral tilting. A significant decrease was reported in mean arterial pressure, cardiac output, stroke volume, and systemic vascular resistance after SAB (in supine position). When performing left lateral tilting, there was an increase in cardiac output, heart rate, and mean arterial pressure. No difference was reported between the two tilt angles (15and 30).

CONCLUSIONS: Changing position of full term pregnant woman after SAB from supine to left lateral tilted position results increased cardiac output and mean arterial pressure. There is no difference between the two tilt angles (15and 30).

TRIAL REGISTRATION: clinicaltrials.gov ( NCT02828176 ) retrospectively registered.

OBJECTIVE: Bleeding is a leading cause of death among trauma patients. Delayed assessment of blood hemoglobin level might result in either unnecessary blood transfusion in nonindicated patients or delayed blood transfusion in critically bleeding patients. In this study, we evaluate the precision of noninvasive hemoglobin monitoring in trauma patients with low hemoglobin levels.

METHODS: We included trauma patients with low hemoglobin levels (less than 8 g/dL) scheduled for surgical intervention. Blood samples were obtained on admission and after each blood unit with concomitant measurement of serum hemoglobin using radical-7 Masimo device. The change in blood hemoglobin after every transfused blood unit was also assessed by both methods (change in noninvasive Masimo hemoglobin [Delta-Sp-Hb] and change in laboratory hemoglobin [Delta-Lab-Hb]). The precision of Masimo hemoglobin level (Sp-Hb) compared with Laboratory hemoglobin level (Lab-Hb) was determined using both Bland-Altman and Pearson correlation analyses.

RESULTS: One hundred eighty-four time-matched samples were available for final analysis. Bland-Altman analysis showed excellent accuracy of Sp-Hb compared with Lab-Hb with mean bias of 0.12 g/dL and limits of agreement between -0.56 g/dL and 0.79 g/dL. Excellent correlation was reported between both measures with Pearson correlation coefficient of 0.872. Excellent agreement was also reported between both Delta-Sp-Hb and Delta-Lab-Hb with mean bias of -0.05 and limits of agreement from -0.62 to 0.51 CONCLUSIONS:: Sp-Hb showed accurate precision in both absolute values and trend values compared with Lab-Hb measurement in trauma patients with low hemoglobin levels.

BACKGROUND: Deliberate hypotension is used to provide a bloodless field during functional endoscopic sinus surgery; however, the impact of controlled hypotension during anesthesia on peripheral tissue perfusion has not been extensively evaluated. The aim of this study was to compare the impact of nitroglycerin- versus labetalol-induced hypotension on peripheral perfusion.

METHODS: The present randomized, double-blinded, controlled trial included adult patients undergoing endoscopic sinus surgery. Patients were allocated to one of two groups according to the drug received for induction of deliberate hypotension: nitroglycerin (n = 20) or labetalol (n = 20). Mean arterial pressure was maintained at 55-65 mmHg in both groups. Both study groups were compared according to pulse oximeter-derived peripheral perfusion index (primary outcome), serum lactate level, mean arterial pressure, heart rate, surgical field score, and intraoperative blood loss.

RESULTS: Forty patients were included in the final analysis. The nitroglycerin group exhibited a higher peripheral perfusion index at nearly all records (p < 0.0001) and lower postoperative serum lactate levels (1.3 ± 0.2 mmol/L vs. 1.7 ± 0.4 mmol/L; p = 0.001) than the labetalol group. The peripheral perfusion index was higher in the nitroglycerin group than at baseline at most intraoperative readings. The median surgical field score was modestly lower in the labetalol group than in the nitroglycerin group in the first 20 min (2 [interquartile range (IQR) 2-2.5] versus 1.5 [IQR 1-2]; p = 0.001). Both groups demonstrated comparable and acceptable surgical field scores in all subsequent readings.

CONCLUSION: Nitroglycerin-induced deliberate hypotension was accompanied by higher peripheral perfusion index and lower serum lactate levels than labetalol-induced deliberate hypotension during sinus endoscopic surgery.

TRIAL REGISTRATION: The study was registered at clinicaltrials registry system with trial number: NCT03809065. Registered at 19 January 2019. This study adheres to CONSORT guidelines.

BACKGROUND: Data on the best norepinephrine bolus dose for management of hypotension are limited. The aim of this study was to compare the efficacy and safety of two norepinephrine bolus doses in the rescue management of maternal hypotension during cesarean delivery.

METHODS: This randomized, controlled trial included mothers scheduled for cesarean delivery with spinal anesthesia with a prophylactic norepinephrine infusion. Following spinal anaesthesia administration, a participant was considered hypotensive if systolic blood pressure was ≤80% compared to the baseline reading. Participants were allocated to receive either 6 mcg or 10 mcg norepinephrine bolus for the management of hypotensive episodes. The hemodynamic response after administration of norepinephrine bolus was recorded. The episode was considered successfully managed if systolic blood pressure returned to within 80% from the baseline reading within 2 min after norepinephrine bolus administration, and did not drop again within 6 min after the norepinephrine bolus. The primary outcome was the incidence of successful management of the first hypotensive episode. Other outcomes included systolic blood pressure, heart rate, incidence of maternal bradycardia, and reactive hypertension.

RESULTS: One hundred and ten mothers developed hypotensive episodes and received norepinephrine boluses for management. The number of successfully managed first hypotensive episodes was 50/57 (88%) in the 6 mcg-treated episodes and 45/53 (85%) in the 10 mcg-treated episodes (p = 0.78). Systolic blood pressure was comparable after administration of either bolus dose. Heart rate was lower after administration of 10 mcg bolus compared to 6 mcg bolus, without significant bradycardia requiring atropine administration. The incidence of reactive hypertension was comparable between both groups.

CONCLUSION: In mothers undergoing elective cesarean delivery under prophylactic norepinephrine infusion at 0.05 mcg/kg/min, there was no advantage to the use of 10 mcg norepinephrine bolus over 6 mcg norepinephrine bolus for the rescue management of first hypotensive episode. Neither of the 2 bolus doses reached a 100% success rate. The incidences of bradycardia and reactive hypertension were comparable between both norepinephrine doses.

TRIAL REGISTRATION: At clinicaltrial.gov registry system on January 4, 2019 Clinical trial identifier: NCT03792906.

BACKGROUND: Patients with septic shock commonly require endotracheal intubation under general anaesthesia in the operating theatre, the emergency department, and the intensive care unit. Hypotension is a serious complication after induction of general anaesthesia, especially in patients with circulatory failure. No randomised controlled trials had previously investigated protocols for induction of anaesthesia in septic shock patients. The aim of the current work is to compare two protocols, lidocaine-ketamine combination versus ketamine full-dose for rapid-sequence endotracheal intubation in patients with septic shock.

METHODS: Forty-four adult patients, with septic shock, scheduled for emergency surgical intervention were enrolled in this randomised, double-blinded, controlled study. Patients were randomised to receive either 1 mg/kg ketamine (ketamine group, n = 22) or 0.5 mg/kg ketamine plus 1 mg/kg lidocaine (ketamine-lidocaine group, n = 22) for induction of anaesthesia in addition to 0.05 mg/kg midazolam (in both groups). Our primary outcome was the mean arterial pressure (MAP). Other outcomes included frequency of post-induction hypotension, heart rate, and cardiac output.

RESULTS: Forty-three patients were available for final analysis. The average MAP reading in the first 5 min post-induction was higher in ketamine-lidocaine group than in the ketamine group {82.8 ± 5.6 mmHg and 73 ± 10.2 mmHg, P < 0.001}. Furthermore, the incidence of post-intubation hypotension was lower in the ketamine-lidocaine group than in the ketamine group {1 patient (5%) versus 17 patients (77%), P < 0.001}. The ketamine-lidocaine group showed higher MAP in almost all the readings after induction compared to ketamine group. Other haemodynamic variables including cardiac output and heart rate were comparable between both study groups.

CONCLUSION: Lidocaine-ketamine combination showed less incidence of hypotension compared to ketamine full-dose when used for rapid-sequence endotracheal intubation in patients with septic shock. REGISTRATION URL: https://clinicaltrials.gov/ct2/show/NCT03844984?cond=NCT03844984&amp;rank=1.

In this study, we evaluated the accuracy of oscillometric noninvasive blood pressure (NIBP) measured at the ankle in detecting low arm NIBP during cesarean delivery under spinal anesthesia. In this prospective observational study, a cohort of full-term mothers undergoing elective cesarean delivery under spinal anesthesia was examined. Simultaneous NIBP measurements were obtained from the arm and the ankle. The primary outcome was the accuracy of the ankle NIBP in detecting arm systolic blood pressure (SBP) < 90 mmHg. Other outcomes included the accuracy of ankle NIBP in detecting SBP < 80% of the baseline value. The area under the receiver operating characteristic curve (AUC) was calculated to evaluate the accuracy of ankle NIBP in detecting low arm NIBP. The Bland-Altman analysis was conducted to evaluate the agreement between values. We analyzed 1729 pairs of readings obtained from 97 mothers. Ankle SBP showed good accuracy in detecting SBP < 90 mmHg, with an AUC (95% confidence interval [CI]) of 0.90 (0.89-0.91) and a negative predictive value (NPV) of 99 (98-99%) at a cutoff value of ≤ 103 mmHg. Furthermore, ankle SBP showed good accuracy in detecting SBP < 80% of the baseline value, with an AUC (95% CI) of 0.84 (0.82-0.89) and an NPV of 95 (93-96%) at a cutoff value of ≤ 76% of the ankle baseline SBP. The mean bias between the two sites of measurement was - 5.4 ± 15.5, - 2.0 ± 11, and 0.5 ± 12.1 mmHg for SBP, diastolic blood pressure, and mean arterial pressure, respectively. In conclusion, ankle NIBP measurement is not interchangeable with arm NIBP measurement. However, ankle NIBP measurement showed good accuracy for ruling out low arm NIBP during a cesarean delivery.Clinical trial rejistration: NCT04199156.

BACKGROUND: In obese patients, non-invasive blood pressure monitoring in the arm is difficult due to the arm size and morphology. We compared the non-invasive oscillometric wrist blood pressure measurement with the arm and forearm in obese patients monitored with invasive radial blood pressure (reference standard).

METHODS: This prospective observational study included adult obese patients scheduled for bariatric surgery. Non-invasive blood pressure was measured at the arm, upper forearm and wrist of one upper extremity, while invasive blood pressure was simultaneously measured through a radial arterial catheter in the contralateral upper extremity. The accuracy of non-invasive blood pressure reading at each site was evaluated for absolute and trending values using the Bland-Altman analysis and Spearman's correlation coefficient.

RESULTS: In 40 patients, 262, 259, and 263 pairs of non-invasive blood pressure readings were obtained from the arm, forearm, and wrist sites, respectively. As primary outcome, the correlation coefficient for systolic blood pressure was higher for the wrist (0.92, 95% confidence interval (CI) [0.9-0.94]) than for the arm (0.74, 95% CI [0.68-0.79]) and the forearm (0.71, 95% CI [0.64-0.76]) (P<0.05). The non-invasive systolic wrist blood pressure showed the least mean bias and the narrowest limits of agreement (-0.3±7.6mmHg) when compared with forearm (4.3±16) and arm measurements (14.2±13.6) (P<0.05). For trending values, the correlation coefficient was the highest at the wrist.

CONCLUSION: In obese patients undergoing bariatric surgery, non-invasive blood pressure measured at the wrist showed the highest accuracy in comparison with the arm and forearm.