Adopting clinical guidelines for admission criteria of intensive care unit: a measure to manage queues of patients waiting for this section

Background: Due to the need of patients to the intensive care unit [ICU] for receiving medical and nursing services, these services should be provided in a timely manner. This study aimed to develop the clinical guidelines for admission criteria of intensive care unit

Materials and Methods: This study was observational type study was conducted for nine months in 2015 based on a three-step process of adoption of clinical guidelines including planning, adoption and finalization. After conducting systematic searches, the quality of retrieved clinical guidelines was evaluated by experts from policy makers in the admission of patients in the ICU. Finally, the ultimate version of the guideline was developed after reviewing and organizing expert panel sessions

Results: The criteria for accepting patients were presented in form of seven clauses based on the neurological status, cardiovascular status, respiratory status, water and electrolyte disorders, gastrointestinal disturbances, endocrine disorders, surgery and postoperative care

Conclusion: One of the most important factors of creating demand inducing to the patients is the lack of clinical guidelines. It is recommended that departmental doctors should apply the mentioned clinical guidelines in order to make the resources of the intensive care unit more effective

Refractory vasoplegic syndrome in an adult patient with infective endocarditis: a case report and literature review

Postoperative vasoplegic syndrome [VS] is characterized by low systemic vascular resistance, normal or elevated cardiac output, and poor response to volume expansion. The incidence ofVS after cardiac surgery requiring cardiopulmonary bypass is about 20%. Sometimes, VS becomes refractory and initial treatments do not work, rendering treatment a great challenge. In this study, we describe a young male patient with endocarditis undergoing tricuspid valve replacement. When being weaned off cardiopulmonary bypass, the patient experienced VS. The patient s blood pressure did not increase after the administration of a high dose of epinephrine and norepinephrine. Therefore, he was commenced on a low dose ofvasopressin and gradually his blood pressure reached the normal range. Although the standard management of VS is a high dose ofvasopressors, this patient was refractory to a combination of epinephrine and norepinephrine; only a vasopressin infusion was able to treat the patient. Eventually, he was weaned from bypass and the operation was terminated satisfactorily

Thereafter, the patient passed the recovery period in the cardiac intensive care unit and was discharged. It seems that vasopressin is an excellent option in refractory vasoplegia with minimal response to other vasopressors

The Effect of Perineural Administration of Dexmedetomidine on Narcotic Consumption and Pain Intensity in Patients Undergoing Femoral Shaft Fracture Surgery; A Randomized Single-Blind Clinical Trial / 전남의대학술지

Dexmedetomidine is a selective α-2 adrenoceptor agonist with anxiolytic, sedative, and analgesic properties that prolongs analgesia and decreases opioid-related side effects when used in neuraxial and perineural areas as a local anesthetics adjuvant. The current study was designed to evaluate the effects of a single perineural administration of dexmedetomidine without local anesthetics on narcotic consumption and pain intensity in patients with femoral shaft fractures undergoing surgery. This prospective randomized single-blind clinical trial was conducted in patients undergoing femoral fracture shaft surgery. Based on block permuted randomization, the patients were randomly divided into intervention and control groups. The intervention group received 100µg dexmedetomidine, for a femoral nerve block without any local anesthetics. Total intraoperative opioid consumption, postoperative opioid consumption, visual analogue score (VAS) for pain, and hemodynamic parameters were recorded and compared. Finally the data from 60 patients with a mean age of 30.4±12.3 were analyzed (90% male). There were no significant differences between the baseline characteristics of the two groups (p>0.05). The mean total consumption of narcotics was reduced during induction and maintenance of anesthesia in the intervention group (p<0.05). The amount of postoperative narcotics required showed a significant difference in the intervention group compared with the control group (p<0.05). It is likely that perineural administration of dexmedetomidine significantly not only reduced intra and postoperative narcotic requirement but also decreased postoperative pain intensity in patients undergoing femoral shaft surgery. Femoral blockade by dexmedetomidine can provide excellent analgesia while minimizing the side-effects of opioids.

The Effect of Perineural Administration of Dexmedetomidine on Narcotic Consumption and Pain Intensity in Patients Undergoing Femoral Shaft Fracture Surgery; A Randomized Single-Blind Clinical Trial / 전남의대학술지

Dexmedetomidine is a selective α-2 adrenoceptor agonist with anxiolytic, sedative, and analgesic properties that prolongs analgesia and decreases opioid-related side effects when used in neuraxial and perineural areas as a local anesthetics adjuvant. The current study was designed to evaluate the effects of a single perineural administration of dexmedetomidine without local anesthetics on narcotic consumption and pain intensity in patients with femoral shaft fractures undergoing surgery. This prospective randomized single-blind clinical trial was conducted in patients undergoing femoral fracture shaft surgery. Based on block permuted randomization, the patients were randomly divided into intervention and control groups. The intervention group received 100µg dexmedetomidine, for a femoral nerve block without any local anesthetics. Total intraoperative opioid consumption, postoperative opioid consumption, visual analogue score (VAS) for pain, and hemodynamic parameters were recorded and compared. Finally the data from 60 patients with a mean age of 30.4±12.3 were analyzed (90% male). There were no significant differences between the baseline characteristics of the two groups (p>0.05). The mean total consumption of narcotics was reduced during induction and maintenance of anesthesia in the intervention group (p<0.05). The amount of postoperative narcotics required showed a significant difference in the intervention group compared with the control group (p<0.05). It is likely that perineural administration of dexmedetomidine significantly not only reduced intra and postoperative narcotic requirement but also decreased postoperative pain intensity in patients undergoing femoral shaft surgery. Femoral blockade by dexmedetomidine can provide excellent analgesia while minimizing the side-effects of opioids.

impact of reverse trendelenburg versus head-up position on intraoperative bleeding of elective rhinoplasty

In spite of several efforts for decreasing blood loss, our experience sometimes shows that some patients bleed more profusely during rhinoplasty. Patient position could have deep impact on bleeding amount during surgical procedures. In this study, we aimed to compare reverse trendelenburg position and head-up position on intra-operative bleeding of elective rhinoplasty. This was to check the effects of reverse trendelenburg position and head up position on the intraoperative bleeding of elective rhinoplasty. In this study, 30 ASA I [American Society of Anesthesiology physical condition classification] patients between 18 and 40 years of age who were candidate to rhinoplasty operations for first time were included. Patients were randomly assigned to reverse trendelenburg or head-up position. Exclusion criteria was any history or lab indicating coagulation problems or using any drug. All gauzes used and the blood that accumulated in the aspirator throughout the operation were calculated. Our results showed that the mean amount of blood loss in reverse trendelenburg was lower [77.00 +/- 13.20 ml] than head up position [83.33 +/- 21.18 ml], although, there was no statistical difference between two groups. However, there was no significant differences among two groups in different aspects of hemodynamic determinants and bleeding amount during and after rhinoplasty. Our results showed that patient bleeding is not increased because of positioning per se. In conclusion, perhaps in the future reverse trendelenburg will be given more often during rhinoplasry

effect of adding magnesium sulfate to lidocaine compared with paracetamol in prevention of acute pain in hand surgery patients under intravenous regional anesthesia [IVRA]

This study was done to compare the analgesic effects of [magnesium plus lidocaine,] [paracetamol plus lidocaine,] and [placebo plus lidocaine] on block characteristics for intravenous regional anesthesia [IVRA] in patients undergoing upper extremity orthopedic surgery. In a double-blind, placebo-controlled randomized clinical trial, 90 patients were selected and entered randomly into three study groups after applying the inclusion and exclusion criteria. Time to start of the sensory and motor block were measured separately and also the duration of these two block types were measured." Post-op pain assessment was measured using a numeric rating scale. Venous samples were checked and compared regarding blood gas and pH measurements. The time from drug injection to sensory block onset was the shortest in the magnesium plus lidocaine group; the time from drug injection to the time of motor block onset was the shortest in the lidocaine plus magnesium group; the duration of the motor block was the longest in the lidocaine plus magnesium group. Addition of magnesium lidocaine in patients undergoing upper extremity orthopedic operations using IVRA decreases significantly the time gap between drug administration and the start of the block; also, this drug combination increases the IVRA block length, while paracetamol does not have such a significant effect

Cardiopulmonary bypass, inflammation and how to defy it: focus on pharmacological interventions

One of the most common health problems are diseases of the cardiovascular system with a great bulk of disease burden; while a considerable number of cardiac patients undergo cardiac surgery; cardiac surgical procedures with cardiopulmonary bypass [CPB] are nowadays among the top list of surgical procedures. More than half of a century has passed since the introduction of total cardiopulmonary bypass [CPB]. One of the main untoward effects of CPB is systemic inflammation; causing an [acute phase reaction] responsible for the production of other unwanted postoperative complications. The humoral and cellular components of the immune system are among the main parts of these compensatory mechanisms. There are a number of therapeutic agents used to suppress this inflammatory process. Since CPB is composed of a multitude of items, there are many studies assessing the possible methods and therapeutics for prevention or treatment of inflammation in patients undergoing CPB. According to a conventional classification, the anti-inflammatory methods are classified as either pharmacologic strategies or technical strategies. The pharmacologic strategies are those with the usage of one or more therapeutic agents; while the technical strategies are those that try to modify the CPB techniques. However, in this manuscript, the main pharmacological strategies are discussed

The effect of adjuvant midazolam compared with fentanyl on the duration of spinal anesthesia with 0.5% bupivacaine in opium abusers / 대한마취과학회지

BACKGROUND: There are a number of adjuvants to be used for local anesthetics in spinal block. The aim of this study was to demonstrate the possible effect of intrathecal midazolam compared with bupivacaine as adjuvants in spinal anesthesia with bupivacaine in chronic opium abuses. METHODS: In a double blind, randomized clinical trial, 90 opium abuser patients undergoing lower limb orthopedic surgery were selected and randomly assigned into 3 groups (30 cases each). The patients received 15 mg plain bupivacaine, or 15 mg bupivacaine plus 25 mcg fentanyl or 15 mg bupivacaine plus 1 mg midazolam, intrathecally. RESULTS: The duration of anesthesia was much longer in the bupivacaine-midazolam group than the bupivacaine-fentanyl group; both were longer than the plain bupivacaine group (P < 0.05). CONCLUSIONS: Subarachnoid injection of adjuvant midazolam or fentanyl with plain 0.5% bupivacaine in opium abusers in lower limb orthopedic surgery increases the duration of sensory block. Therefore midazolam is more effective than fentanyl in such cases.

Perioperative risk factors for prolonged mechanical ventilation and tracheostomy in women undergoing coronary artery bypass graft with cardiopulmonary bypass

Prolonged mechanical ventilation is an important recognized complication occurring during cardiovascular surgery procedures. This study was done to assess the perioperative risk factors related to postoperative pulmonary complications and tracheostomy in women undergoing coronary artery bypass graft with cardiopulmonary bypass. It was a retrospective study on 5,497 patients, including 31 patients with prolonged ventilatory support and 5,466 patients without it; from the latter group, 350 patients with normal condition [extubated in 6-8 hours without any complication] were selected randomly. Possible perioperative risk factors were compared between the two groups using a binary logistic regression model. Among the 5,497 women undergoing coronary artery bypass graft [CABG], 31 women needed prolonged mechanical ventilation [PMV], and 15 underwent tracheostomy. After logistic regression, 7 factors were determined as being independent perioperative risk factors for PMV. Age >/-70 years old, left ventricular ejection fraction [LVEF]

effect of primary bolus dose of pancuronium versus cisatracurium without maintenance dose on extubation time in adult coronary artery bypass crafting

Given the importance of the effect of muscle relaxants on the extubation time in coronary artery bypass grafting [CABG] patients, we sought to assess the difference in "time to extubation" and "intensive care unit [ICU] length of stay" between the primary bolus doses of Pancuroniuni and Cisatracurium without using the maintenance dose of them during surgery. This double blind clinical trial divided 110 patients into two equal groups receiving either Cisatracurium or Pancuronium. The patients' surgical and cardiopulmonary bypass variables were evaluated, and the extubation time and ICU length of stay were compared between the two groups. There was no difference between the two groups regarding the depth of anesthesia, train-of-four [TOF] scores at the beginning of anesthesia, and the surgical and cardiopulmonary bypass variables. However, the Cisatracurium patients were extubated earlier and had a shorter ICU length of stay than the Pancuronium patients. An appropriate depth of anesthesia facilitates the administration of the niduction dose of Cisatracurium, which confers earlier extubation and shorter ICU length of stay by comparison with Pancuronium

Effect of adding neostigmine in paravertebral block on postoperative extubation time in elective coronary artery bypass graft surgery

Paravertebral block is a technique of regional anesthesia and is used for a number of purposes. The aim of this study was to assess the effects of adjuvant neostigmine in paravertebral block with bupivacaine for in coronary artery bypass grafting surgery [CABO]. In total, 68 patients were randomly assigned into two groups: bupivacaine alone [B group] and bupivacaine with neostigmine [BN group] for bilateral paravertebral thoracic block at 16 level. Postoperative times for extubation, morphine requirements, and acute pain scores were assessed. The BN group patients were extubated sooner. Also, they needed less morphine in the first twenty-four hours. The study suggests that adding neostigmine to bupivacaine in paravertebral block as an adjuvant can have beneficial postoperative effects in patients undergoing elective CABU

Off-pump CABG in a patient with dextrocardia totalis: a case report

Coronary revascularization in patients with dextrocardia is not a common clinical condition. There are very few cases of off-pump coronary artery bypass. A 64-year-old woman was admitted to a university hospital due to exertional chest pain. Her primary diagnosis was coronary artery disease superimposed on dextrocardia, which was first suspected on physical examination, with the patient having right-sided heart sounds on auscultation. It was corroborated by chest X-ray. After diagnostic evaluations, including coronary angiography, she underwent off-pump coronary artery bypass grafting due to a significant left main coronary artery stenosis associated with dextrocardia. Two years later, multi-slice CT angiography revealed patent grafts, demonstrating good clinical results

Cytokine profile in the endometrium of normal fertile and women with repeated implantation failure

Repeated Implantation Failure [RIF] is one of the most intricate obstacles in assisted reproduction. The cytokine and chemokine composition of uterine cavity seem to play important roles in the implantation process. To compare the cytokine profile in the endometrium of normal fertile women and those with repeated implantation failure. After enzymatic digestion of endometrial tissues, whole endometrial cells and endometrial stromal cells from RIF and normal fertile women were cultivated and stimulated for cytokine secretion. The levels of IL-10, TGF-beta, IFN-gamma, IL-6, IL-8 and IL-17 in culture supernatants of the two groups were assayed by ELISA and compared together. Endometrial stromal cells and whole endometrial cells of normal fertile women produced higher levels of IL-6, IL-8 and TGF-beta compared to RIF group, although this difference was statistically significant only in endometrial stromal cells [p=0.005, 0.002 and 0.001, respectively]. In addition, endometrial stromal cells of normal fertile women produced lower levels of IL-10 in comparison with RIF group [p<0.005]. Disturbances in cytokine production at the feto-maternal interface could be a cause of implantation failure. A pro-inflammatory cytokine milieu seems to be pivotal for successful implantation

Cervical mass following carotid attempt at interventional repair of aortic coarctation: a case report

A 4-month-old boy was admitted to our hospital following an unsuccessful attempt at interventional repair of aortic coarctation via the right carotid artery, which seemed to have given rise to the formation and growth of a cervical mass overlying the entry site, Despite the initial anticipation of difficulty during intubation due to the pressure effect of the mass, anesthesia progressed uneventfully, the mass, which was a hematoma, was evacuated, and the coarctation was repaired The patient was discharged after the operation. At three weeks' follow-up, there was no significant lesion in the neck and transthoracic echocardiography demonstrated no residual coarctation

effects of ultrafiltration on postoperative respiratory status in adults undergoing coronary artery bypass grafting

Systemic inflammatory response syndrome [SIRS] remains one of the major causes of cardiopulmonary bypass-associated organ injury during adult cardiac surgery. This study was designed and performed to assess the short-term effects of this technique on postoperative lung status in such patients. In a double-blind, randomized clinical trial, 90 patients scheduled for elective CABG were selected and randomly assigned into 2 groups, the first group had ultrafiltration in their cardiopulmonary bypass circuit. The case group patients were extubated sooner compared to the control group. The postoperative oxygenation status in the case group was better than the control group. The results of this study demonstrated that ultrafiltration could improve the postoperative respiratory status of those adults undergoing coronary artery bypass grafting

Pain after laparoscopic cholecystectomy

Background and Objectives: Although laparoscopic cholecystectomy results in less pain than open cholecystectomy, it is not a pain free procedure. A clinical trial was designed to assess pain after LC in terms of types of pain, intensity and factors that may influence it

Methods: A prospective study on pain was performed on all patients undergoing the operation over the period of 1.5 year [n = 150]. Pain was measured by a five point verbal rating scale [VRS]

Results: Pain was the most frequent symptom, after the operation. The main type of postoperative pain was intra-abdominal 72%, followed by incisional 60% and shoulder pain 10%. The mean level of pain was 2.12 VRS points 8 h after the operation and declined to 1.01 points next day. In 54 patients [36%] the intensity of pain was higher than 2 VRS points. Female sex was the only predictor of pain intensity

Conclusions: Laparoscopic cholecystectomy did cause significant postoperative pain in one-third of our patients only up to the first postoperative day. As predictors for high intensity of pain were not identified clearly, pain should be monitored and multimodal analgesics should be delivered accordingly

[Medical Errors in the Health system]

Background: the health system is never as safe worldwide as everybody assumes. In recent years, many studies have been conducted to assess the magnitude of medical errors and its impact on the health system. This article reviews the studies performed in this issue to find out a strategy for approaching medical errors

Materials and methods: in a review literature, Pubmed was searched using these keywords error, medical and health system. In the complementary search, error mechanisms, error classification, reporting system and error reporting systems were also added to the search

Conclusions: medical errors are inevitable mishaps in the health system. Would there be a systematic approach in the health system for analyzing the errors and finding the root causes, the health system would maximize its benefits as much and possible future events with similar mechanism would be prevented

Results: in our health system, it is mandatory to introduce and improve such a system for quality improvement of the system