Background: Transversus Abdominis Plane block (TAPB) is becoming a popular regional analgesic technique for postoperative pain relief in lower abdominal surgeries. Various adjuvants can be added to local anesthetics to prolong and improve their block characteristics. Material and Methods: The present randomized, double blind trial was carried out in 60 parturients of American Society of Anesthesiologists’ physical status (ASA) class Ⅰ and Ⅱ scheduled to undergo elective lower segment cesarean section (LSCS) under spinal anesthesia. After randomization, the subjects were allocated into two groups. Group R (n = 30) underwent TAPB with 39 ml of 0.375% ropivacaine and 1 ml normal saline (20 ml each side). Group C received TAPB with 39 ml of 0.375% ropivacaine and 1 ml of clonidine (50 µg) to receive 20 ml of drug solution each side. At the end of the surgery (skin closure), bilateral TAPB was performed in the lumbar triangle of Petit (ultrasound guided) using 18 G Tuohy needle (80 mm Smiths Medical Portex) at the level of anterior axillary line between 12th rib and iliac crest. All the subjects were assessed at 0, 2, 4, 8, 12, 16, 20, and 24 hours postoperatively for duration of postoperative analgesia (time to request for first analgesia), severity of pain using Visual Analog Scale score (VAS), number of doses of tramadol consumed in the first 24 hours after the block; pain, nausea, patient satisfaction scores, and possible clonidine side effects (dryness of the mouth, sedation, hypotension, and bradycardia). Results: Both the groups were similar in age, Body Mass Index (BMI) and duration of surgery. The time to request for first rescue analgesia was significantly longer in Group C (18.89±0.64 hours) as compared to Group R (6.16±0.51 hours) (p<0.001). In comparison to Group C, the total amount of rescue analgesia used was significantly more in Group R. Mean VAS score was significantly lower and patient satisfaction score higher in Group C (p<0.001). Nausea, bradycardia was not seen in any of the patients. Sedation and dry mouth was seen in a few patients in both the groups but it was statistically insignificant. No TAPB related complications were seen in either of the two groups. Conclusion: The addition of clonidine 25 μg to 20 ml ropivacaine 0.375% in TAPB bilaterally for cesarean section provides 17–18 hours of postoperative analgesia, decreases postoperative analgesic requirement, and increases maternal satisfaction compared to TAPB administration with 20 ml of ropivacaine 0.375% alone.

Background/Aim: Clinical features of patients with Covid-19 diseases have revealed several biochemical markers associated with in-hospital mortality. In particular, the blood levels of C-reactive protein and ferritin levels are the most correlated positive phase reactants that are commonly used in clinical practices for theirs diagnostic and prognostic values. For this reason, our main goal was to assess the complications and mortality prognostic value for the two tested prognosticators in mechanically ventilated critically ill COVID-19 infected patients. Methods: A retrospective study was conducted in our Royal Medical Services institutions for all mechanically ventilated critically I will COVID-19 infected patients. An Independent T, Mann Whitney-U, and Chi Square Tests were used to analyze the parametric and non-parametric outcomes’ data. A receiver operating characteristic was plotted to determine the area under the curve of each tested prognosticator and to identify the optimal cutoff point, sensitivity, specificity, Youden index, accuracy, and positive/negative predictive values. Results:The mean age of the whole study cohort was 58.37±9.96 years, and the Survivors Cohort were insignificantly older than the Non-Survivors Cohort (58.55±9.95 years versus 58.09±10.05 years, respectively, p>0.05). Significantly, males were distributed in the study in approximately a 2: 1 ratio compared to females. Overall 28-day ICU mortality was detected in 94 (48.70%) during an average of 12.40±4.79 days of ICU length of stay. Biochemically, the c-reactive protein and ferritin were significantly higher in the Non-Survivors Cohort than in the Survivors Cohort (143.09±59.28 mg/dl and 891.51±377.82 ng/ml vs 88.38±34.38 mg/dl and 465.76±154.07 ng/ml, respectively, p<0.05).  Conclusion: The exaggerated elevation of serum levels of c-reactive protein and ferritin in COVID-19 infected patients, especially the mechanically ventilated critically ill cohort, can be potentially used for their reasonable performances and prediction utility in early identification and stratification of COVID-19 infected patients severities despite global ever-shrinking in medical teams and facilities, especially in critical care units to make sure optimum resource provision and implement swift management protocols.

Introduction: The supraclavicular technique to blocking the brachial plexus is thought to be the simplest and most successful. The traditional method of employing paresthesia to locate the nerve cluster by anatomical landmarks has been linked to a higher failure rate and nerve damage. The peripheral nerve stimulator (PNS) improves brachial plexus localization by locating nerves using a low-intensity electric current (up to 2.5 mA) for a short duration (0.05–1 ms) with an insulated needle to obtain a defined response of muscle twitch or sensation and injecting local anaesthetic solution close to the nerve. However, this method did not minimise the danger of harm to nearby structures. The use of ultrasonography (USG) to locate the brachial plexus has changed the field of regional anaesthesia forever. The expense and knowledge necessary, however, are the limiting elements. The purpose of this research was to compare the two procedures in terms of process time, block properties, and complication rate. Aim and Objective of the Study: The study's goal was to compare USG guided and nerve stimulator techniques for supraclavicular brachial plexus block in upper-limb procedures. Primary Objective: Procedure time, Time of onset of motor and sensory blockade, Duration of blockade. Secondary Objective: Failure rates, Complications (Intra-op and post-op). Subjects: A prospective randomized controlled trial was done on 60 ASA I and II patients who were scheduled for forearm, wrist, and hand procedures. Patients were divided into two groups of 30 each: Group A and Group B. Methods: Inj.2 percent lignocaine with adrenaline 1:200000 and Inj. 0.5 percent bupivacaine were used in both groups. The amount of local anaesthetic administered is determined by body weight and does not exceed the hazardous dose (Inj. Bupivacaine 2mg/kg and Inj. Lignocaine 7mg/kg). The supraclavicular brachial plexus block in Group A was performed using a USG-guided approach, while the block in Group B was performed using a PNS technique. There were both primary and secondary outcomes mentioned. Results: In Group A procedure time was 12.97±2.00 and in group B the procedure time was 22.87±1.52 which is statistically significant (p-value being<0.05). Sensory block onset time was 12.73 1.72 mins (Mean±S.D.) in Group A, while motor block onset time was 21.572.54 mins. In Group B, the time taken for sensory block to be achieved was 17.83±1.70 minutes, and for the motor block was 27.77±1.81 minutes, both of which are statistically significant (p-value 0.05). In Group A the time period for which the sensory action was present was 8.37±0.99 mins (Mean±S.D), whereas in It was 7.13 0.81 in Group B, which is statistically significant (p-value of 0.05). The duration of the motor block in Group A was 6.10 0.80 minutes (Mean S.D.), but it was 6.07 0.74 minutes in Group B, which is statistically insignificant because the "p-value" is 0.08.  Intra-op supplementary medications were not used in group A patients while in group B 6 out of 30 patients received intra-op supplementary medications i.e., Inj. Fentanyl. “p-value” on comparison was 0.009 which was statistically significant. In group A no block failure was observed while in group B 3 blocks out of 30 had failed. “p-value” was 0.07 and was statistically insignificant. There were no adverse effects or post op complications observed in both groups. Conclusion: The ultrasound guided technique is superior to the nerve stimulator technique for administration of supraclavicular brachial plexus block in upper limb surgeries.

Introduction: Alone or various combinations of propofol with either etomidate or sevoflurane have been used to enhance placement quality of laryngeal mask airway and reduce the incidence of hypotension. In this prospective trial we compared the placement characteristics of classic LMA (CLMA) and hemodynamic variations with 3 mg/kg propofol alone or with 1.5 mg/kg propofol followed by one minute of 6% sevoflurane in 50% oxygen+50% N2O with patient breathing spontaneously. Our hypothesis was that a combination of smaller doses of propofol with sevoflurane would be associated with better CLMA placement characteristics and lesser changes in hemodynamic parameters. Material and Methods: After obtaining ethical approval, 51 consenting patients were randomly allocated into two groups, Propofol Group (p Group n = 26) or Sevoflurane-Propofol Group (SP Group n = 25). No muscle relaxant was used to aid CLMA placement in either group. Six different parameters (number of attempts, jaw relaxation, ease of insertion, patient movement, coughing and laryngospasm) were assessed with Lund and Stovner grading system. In addition, the hemodynamic parameters were also recorded during induction of anesthesia and following CLMA insertion. Results: In either group, significant decrease in HR, systolic BP and diastolic BP was observed 4-6 min after placement of CLMA. None of the patients in either group had coughing or laryngospasm during CLMA insertion (p = 0.0). No significant difference was observed in jaw relaxation (p = 0.263), ease of insertion (p = 0.789), patient movement (p = 0.999), coughing (p = 0.0), gagging (p = 0.322) and or laryngospasm (p = 0.314). Conclusion: Propofol 3mg/kg (P Group) provides almost equal conditions for CLMA insertion as compared to Propofol (1.5mg/kg)-Sevoflurane (6%) combination (PS Group) and both induction techniques demonstrated nearly identical hemodynamic instability.

Forty patients from Baghdad Hospital were collected for the results used in this study. The research aims to determine where the effects of anesthesia on heart disease were identified, and all results were recorded. In addition to that, a statistical analysis was conducted, and the average age of the participants was from 40 to 65 years. The primary task of administering anesthesia for myocardial revascularization in a beating heart is the prevention of myocardial ischemia. Over the past years, the possibility of using epidural anesthesia (EA) in cardiac surgery has been discussed, which can solve a number of the above problems. Actively. This is primarily associated with the emergence of new, low-toxicity local anesthetics, particularly ropivacaine, and the improvement of technical capabilities of puncture and catheterization of the epidural space. At the same time, the combined method, which combines general anesthesia with upper thoracic EA, which allows avoiding attacks of myocardial ischemia more effectively, received well-deserved recognition. To prevent the development of the body's stress response to an operating injury and to provide high-quality anesthesia after surgery. However, EA in open-heart surgery can be associated with several risks and complications.

Objectives: After the large UK randomized controlled trial (RECOVERY Trial), it seems that glucocorticoids are the only cost-effective intervention that is associated with positive major clinical impacts. However, there is still a paucity of information guiding glucocorticoid agents and dose regimens. The present study aims to compare the clinical impacts of two proposed steroidal agents across two investigated dose regimens on the moderate-severe mechanically ventilated critically ill COVID-19, infected patients. Methods: A single-center, observational, retrospective study was conducted on all mechanically ventilated critically I'll COVID-19 infected patients that were admitted into the intensive care units (ICUs). Parametric data were analyzed by using the One-Way ANOVA Test while non-parametric data were analyzed by Chi Square or Kruskal–Wallis Tests. The primary outcome of our study was to compare the major clinical impacts of admission days and mortalities. Results: The average age of our whole study cohort was 59.80±10.74 years, significantly, males were distributed in the study in M: F ratio of approximately 2.42: 1. Overall 28-day ICU mortality was detected in 136 (55.97%) during an average of 13.40±4.79 days and 19.67±6.81 days of the ICU and hospital stay days, respectively. The comparative prognostic biochemical indicators and the variations of body temperature were significantly lower in higher versus standard corticosteroidal dose regimens. Conclusion: In conclusion, higher dose regimens of either Dexamethasone (12 mg/day) or Methylprednisolone (80 mg/day) have a significantly higher positive clinical impact compared with lower dose regimens of either Dexamethasone (6 mg/day) or Methylprednisolone (40 mg/day). Individually, Methylprednisolone 40 mg/day has superior positive clinical impacts over Dexamethasone 6 mg/day at the lower Cs level while at the higher Cs level, Dexamethasone 12 mg/day has superior positive clinical impacts over Methylprednisolone 80 mg/day.

Background: Over the last two decades, Carbapenem Resistant Enterobacteriaceae (CRE) related ventilation associated pneumonia (VAP) have increased globally in which infection by these multi-drug resistant GNB increases mortality, morbidity and cost expenditure. The aim of this study is to investigate the clinical impacts of the CRE related VAP among mechanically ventilated COVID-19 infected. Methods: A retrospective study was conducted in our COVID-19 isolation department at Queen Alia Military Hospital, Royal Medical Services, Amman, Jordan between March 2020 and Sep 2021 for all eligible SARS-CoV-2 infected hospitalized patients after they were divided into two comparative groups: Non-CRE related VAP infection cohort (Cohort I) and CRE related VAP infection cohort (Cohort II). An Independent and One-Sample T Tests, and Chi Square Test will be used to analyze the parametric and non-parametric outcomes’ data, respectively. Results: The mean age of the whole studied 51.41±16.44 year.  Male patients were distributed in the study in approximately 3:1 ratio to female patients (699 (75.0%) versus 233 (25.0%), respectively, p-value = 0.021). The overall 28-day ICU mortality was detected in 526 in Mechanically Ventilated SARS-CoV-2 infected patients with an overall incidence rate of 56.44% during an average of 19.89±5.55 days and 12.93±4.18 days of ICU and overall hospital admission days, respectively. Cohort I patients compared to Cohort II patients, had an overall 28-day ICU mortality, ICU stay days, and overall hospital admission days of 175 (40.6%),16.19±4.09 days and 22.23±5.63 days compared to 351 (70.06%), 10.13±1.08 days, and 17.88±4.62 days, respectively, p-Value = 0.00). Conclusion: Carbapenem Resistant Enterobacteriaceae associated ventilation associated pneumoniae in mechanically ventilated critically ill SARS-CoV-2 infected patients have at least higher mortality rate and longer overall hospital length of stay compared with patients infected with Non-Carbapenem Resistant Enterobacteriaceae.

Background/Aim: Norepinephrine, first line adrenergic agent used in critically ill patients with septic shock status, may additionally exacerbate catecholamine toxicity and in certain circumstances may contribute to poorer clinical outcomes that mostly related to sinus tachycardia or tachyarrythmia. Methods: A retrospective study was conducted between Jan 2018 to May 2021. New Onset Prolonged Sinus Tachycardia (NOPST) incidence was recorded if the HR increased by at least 20% from baseline and exceeded 100 bpm and it was correlated with the corresponding Norepinephrine infusion rate. The correlation between NOPST incidence and its corresponding NE infusion rate was statistically investigated by Spearman Correlation Test. The studied critically ill patients divided to either Non-Septic Shock Cohort (Group I) or Septic Shock Cohort (Group II). In addition to One Sample and Independent-T Tests, Chi Square Test was used for the non-parametric data. The ROC analysis was used to investigate the AUROC and the operational Cutoff Norepinephrine rate was picked by investigating the highest youden’s index. Results: The overall NOPST incidence for our 1638 eligible studied critically ill patients was assessed at 65.6% during an average of 14.08±4.06 days and 21.00±5.61 days of the ICU and overall hospital admission days, respectively, in which only ICU stay days was significantly lower in Non-Septic Shock Cohort compared to the Septic Shock Cohort [13.85±3.39 days vs 14.40±4.82 days]. The operating cut-off NE infusion rate to elicit NOPST was investigated at 11.3 mcg per min with sensitivity and specificity of 55.70%, 90.80%, respectively. Conclusion: Septic critically patients on Norepinephrine infusion have significantly higher risk of New Onset Prolonged Sinus Tachycardia (NOSPT) and significantly higher ICU admission days, especially if this infusion rate exceeding 11.5 mcg/min.

Background/Aim: Prolonged pre-intensive care unit (ICU) hospital stay length days was previously shown to be independently associated with poorer outcome. In this study we investigated the impacts of the pre-ICU admission days on major clinical outcomes. Methods: Surgical and medical, to the Medical-Surgical ICU (MSICU) between Jan 2018 and May 2021, were retrospectively reviewed via the Electronic Medical System (Hakeem). All eligible studied critically ill patients were grouped by their hospital length of stay (HLOS) prior to ICU admission: HLOS <6 days (Group I) or HLOS ≥6 days (Group II). Also, the overall 28-day ICU mortality were further subcategorized into early mortality (≤14 days) and late mortality (>14 days). The Comparative variables across the two studied groups were analyzed by One Sample and Independent T-Tests or Chi Square Test to represent the analysis results as Mean±SD and Mean Difference±SEM or Number (Percentage and odd ratio (OD), respectively. The area under the ROC curves (AUROCs) of the pre-ICU HLOS were expressed as AUC (95% CI; Range). The optimal Cutoff operating point on each ROC curve was picked by investigating the highest youden’s index. Results: The mean age of the whole study cohort was 51.88±16.22 years, and the Pre-ICU LOS<6 days Cohort were significantly older than the Pre-ICU LOS≥6 days Cohort (52.87±15.48 years versus 51.14±16.72 years, respectively, p-value = 0.033). Insignificantly, males were distributed in the study in approximately 2.55: 1 ratio compared to female (1177 (71.9%) versus 461 (28.1%), respectively, An overall 28-day ICU mortality was detected in 1318 of all eligible studied critically ill patients with an overall incidence of 80.46% during an average of 14.08±4.06 days and   21.00±5.61 days of the ICU and overall hospital admission days, respectively. Our tested prognosticators had significantly AUROC with Area±SEM (95% CI; Range) of 0.694±0.015, (95% CI; 0.664-0.723) and 0.587±0.016 (95% CI; 0.556-0.619), respectively. Conclusion: ICU admission from a general care floor, medically ICU admitted patients and surgically admitted ICU patients, after ≥6 days is associated with poorer clinical outcome as compared to earlier pre-ICU admission days.

Background/Aim: Clinical features of patients with COVID-19 have revealed a number of hematological markers associated with in-hospital mortality. In particular, the blood levels of white blood deferential including; lymphocyte, monocyte, and neutrophil counts. A growing evidence shows that ratios among lymphocytes, monocytes, and neutrophils are more accurate to predict mortality than cell count by itself l. For this reason, our main goal was to assess the negative clinical impacts prognostic performance of Monocytes to Lymphocytes ratio (MLR) compared with Monocytes and Lymphocytes counts in mechanically Ventilated Critically I'll COVID-19 Infected Patients.Methods: A retrospective study was conducted in our Royal Medical Services institutions for all mechanically ventilated critically I'll COVID-19 infected patients. An Independent T, Mann Whitney-U, and Chi Square Tests were used to analyze the parametric and non-parametric outcomes’ data. A receiver-operating characteristic was plotted to determine the area under the curve of each tested prognosticator and to identify the optimal cutoff point, sensitivity, specificity, Youden index, accuracy, and positive/negative predictive values.Results: The mean age of the whole study cohort was 58.37±9.96 years, and the Survivors Cohort were insignificantly older than the Non-Survivors Cohort (58.55±9.95 years versus 58.09±10.05 years, respectively, p>0.05). Significantly, males were distributed in the study in approximately a 2: 1 ratio compared to females. Overall 28-day ICU mortality was detected in 94 (48.70%) during an average of 12.40±4.79 days of ICU length of stay. Haematologically, the monocytes count and their ratio to lymphocytes count were significantly lower in the Survivors Cohort compared with Non-Survivors Cohort (1108±112 cells/µl and 0.25±0.10 versus 2550±421 cells/µl and 0.89±0.19, respectively, p<0.05). Conversely, the count of lymphocytes was significantly higher in the Survivors Cohort compared with Non-Survivors Cohort (4410±422 cells/µl versus and 2866±210 cells/µl, respectively, p<0.05). Conclusion: In this study, we concluded that the increasing of monocytes count and monocytes to lymphocytes ratio or decreasing lymphocytes count in COVID-19 infected patients, especially the mechanically ventilated critically ill cohort, could be potentially used for their reasonable performances and prediction utility in early identification and stratification of COVID-19 infected patient’s severities.