[Spinal anesthesia in renal transplantation]

Renal transplantation is the preferred therapeutic method for patients with end-stage renal disease. Patients with renal failure have significant associated medical conditions, such as cardiovascular disease. The suitable anesthesia for renal transplantation requires minimal toxicity for the transplanted organ, as well as sufficient pain relief and maintenance of optimal blood pressure and intravascular volume to keep renal functions. The aim of this study was to improve our experience of spinal anesthesia in patients undergoing renal transplantation. Sixty consecutive patients scheduled for elective renal transplantation over a period of two years who consented for spinal anesthesia were enrolled in the study. Intraoperative hemodynamic, intravenous fluids and infused blood products, duration of surgery, urine output and arterial blood gas and intensity of pain score in the recovery room were monitored. We also noted intraoperative and postoperative complications. Spinal anesthesia was satisfactory in all, but in five patients they required supplementation with general anesthesia for excessively prolonged surgery. There were no significant intraoperative hemodynamic changes. The total intravenous fluid used during surgery was 65.15 +/- 7.2 mL/kg, the mean surgical time was 170 +/- 22 min. The mean of mean arterial pressure [MAP] during the operation was 98 +/- 12 mm hg. There was no significant acidosis at the end of the operation [PH=38 +/- 0.03]. Also the mean intensity of pain was 4 +/- 2 in recovery and a few of patients suffered from bladder catheter bladder discomfort in the recovery room [8 patients]. Spinal anesthesia is a successful regional anesthetic technique in well selected patients for renal transplantation. A successful outcome in this technique is dependent on close intra-operative monitoring, optimization of intravascular fluid volume and keep the hemodynamic status in optimal range.

Inadvertent intrathecal injection of large dose magnesium sulfate

The case is a 35-year-old man who underwent spinal anesthesia for emergency strangulated inguinal hernia repair. About five minutes after 3 ml intrathecal drug injection, the patient suffered respiratory distress, bradycardia, hypotension and loss of consciousness. The patient was rapidly intubated and crystalloid infusion and epinephrine drip were established. Thereafter, he was admitted in intensive care unit. Search for the cause revealed us that 3 ml of magnesium sulfate [50%] was injected mistakenly for spinal anesthesia. Two days later, he was extubated and on the fifth day, he was discharged from the hospital without an obvious evidence of complication

[Evaluation of patient satisfaction with anesthesia care]

The assessment of patient satisfaction with anesthesia, the balance between expectations and perception of what was received, is an essential component of continuous quality improvement in anesthesiology. In our center there have been few studies conducted in the anesthesia field, which have assessed patient's satisfaction. In this prospective study we have evaluated patient satisfaction with anesthesia in patients 24 h after surgery. This study was performed in Sina hospital in Tehran, Iran on patients aged more than 18 yr. They all underwent elective surgical procedures with anesthesia. One of the anesthesia staff members took the interview one day after surgery and asked the patients questions for the structured questionnaire designed to measure patient satisfaction with anesthesia. At the same time, some specific questions were also asked to find factors that could be associated with such satisfaction. The data was gathered from 500 patients [mean age: 41 +/- 16 yr; and males: 65.2%]. The overall satisfaction [complete and relative] was high [98.8%]; although 6 patients [1.2%] were dissatisfied with their anesthesia care. After analysis of several factors related to the patients' surgery and anesthesia, a strong relation was found between spinal anesthesia and satisfaction [p=0.003].There was not any relation between age, gender, education, duration of anesthesia and kind of surgery with patients' satisfaction. Our study found that patient satisfaction with anesthesia was very high in our center and the only factor that increased patient's satisfaction was spinal anesthesia

Impact of subcutaneous infiltration of 0.5% bupivacaine on postoperative C-reactive protein serum titer after craniotomy surgery

Tissue injuries may provoke neuro-hormonal response which in tum may lead to release of inflammatory cytokines. We hypothesize that block of afferent sensory pathways by infiltration of 0.5% bupivacaine in the scalp may decrease neuro-hormonal response in the neurosurgical patient. After obtaining informed consent, forty ASA physical statuses I, II, or III patients between the ages of 18 and 65 years were emolled randomly into two equal groups to receive either 20 ml of 0.5% bupivacaine [group A] or 20 ml of 0.9% normal saline as a placebo [group B] in the site of pin insertion and scalp incision. As the primary outcome we checked serum C-reactive protein [CRP] levels before implementation of noxious stimulus, 24h, and 48h after the end of surgery to compare these values between groups. In addition, mean arterial pressure [MAP] and heart rate [RR] were checked at baseline [after the induction of anesthesia], one minute after pin fixation and 5, 10, and 15 minute after skin incision and the recorded values were compared between groups. No significant difference was found between serum CRP levels of the two groups. Comparison of mean HR between groups shows no significant difference. The mean of MAP was significantly lower in the group A in comparison with the group B [p< 0.001]. The results of this study confirm that 0.5% bupivacaine scalp infiltration before skull-pin holder fixation and skin incision could not decrease post-operative C-reactive protein level

Effects of pantoprazole on systemic and gastric pro- and anti-inflammatory cytokines in critically three patients

Stress-related mucosal damage [SRMD] is a significant cause of morbidity and mortality in critically ill patients due to the gastrointestinal blood loss. Prophylaxis of SRMD with proton pump inhibitors or histamine-2 blockers has gained widespread use in intensive care units. Both demonstrated to be effective in reducing clinically significant bleedings, while PPIs has shown to exert some anti inflammatory effects including the inhibition of producing pro-inflammatory cytokines. As cytokines have role in developing SRMD, the aim of this study was to evaluate the effect of PPIs on the inhibition of cytokine release following the critical illness. A total of 27 critically ill patients with risk factors of developing stress ulcer and intragastric pH < 3.0 enrolled to this Randomized clinical trial study. Patients were randomly assigned in three treatment groups; group one received 40 mg of intravenous pantoprazole every 12 h for 48 h [four doses], group two received 80 mg of intravenous pantoprazole every 24 h continuous infusion for 48 h and the third group received 150 mg of ranitidine intravenously as 24 h continuous infusion for 48 h. Plasma and gastric juice samples were obtained at 0th, 12th, 24th and 48th h for the measurement of EGF, IL-1beta, IL-6, IL-10 and TNF-alpha. Pantoprazole infusion have decreased the plasma IL-1beta concentrations [p = 0.041]. No other significant differences in concentrations of EGF, IL-6, IL-10 and TNF-alpha were detected. There were reverse correlations between the intragastric pH with gastric juice IL-1beta and TNF-alpha concentrations and a direct correlation between the intragastric pH and gastric juice EGF in pantoprazole groups. Our data suggest that pantoprazole may have some anti-inflammatory effects on patients. However, the exact impact of this effect on patients should be assessed by further studies

[Evaluation of oral clonidine effects on prevention of post-anesthesia shivering]

Shivering is a common post anesthesia complication. Intravenous Clonidine administration at induction of anesthesia is a useful drug for decreasing of incidence and severity of post-anesthesia shivering. As Clonidine injection can induce side effects therefore we evaluated the oral Clonidine premedication on post-anesthesia shivering. In a RCT, 60 adult patients in ASA class 1 and 2 scheduled for cholecystectomy were assigned to 2 groups. 2 hours before anesthesia, 0.2 mg oral Clonidine was administrated and to the other group placebo was administered. Surgery room temperature was adjusted for 21-23[degree][c]. At the end of the anesthesia, the patients' shivering was evaluated in the recovery room by "Crossley andMahajan shivering score". There was no difference at decrease of SpO2 and H.R. and MAP between 2 groups. There was no difference in average time of emergence between 2 groups. Overall 75% of the patients shivered after anesthesia. Median shivering score in clonidine group was 1.97 and in placebo were 2.87. It became revealed that there was clear difference at shivering score between 2 groups [less severe or generalized shivering patients in test group]. 0.2 mg Clonidine tablet, 2 hours before anesthesia is similar to injecting drug and is effective in prevention of post-anesthesia shivering but its complication is less. Lack of difference at hemodynamics and SpO2 and emergence in our study may be due to slow absorption of oral Clonidine

Post dural puncture headache after cesarean section, a teaching hospital experience

This prospective study examined the frequency of Post-Dural Puncture Headache [PDPH] in 361 parturient women undergoing spinal anesthesia for cesarean section in a teaching hospital of Tehran University of Medical Sciences. Spinal anesthesia was performed using 25 gauge Quincke needles in all women. Patients were followed up to determine incidence of PDPH and then tried to compare those with or without PDPH using statistical methods to determine risk factors of PDPH. The overall incidence of PDPH was 10.8 percent in this study. In terms of probable risk factors which were compared between the two groups of patients, no statistically significant differences were found. The incidence of PDPH in our study was higher than studies which used pencil - tipped needles and we determined that the occurrence of PDPH is not associated to some factors like the previous history of nonspecific headache, Body Mass Index, age, type of local anesthetic, previous history of PDPH, experience of operator, history of habitual tea and coffee drinking

Bonfils fiberscope: intubating conditions and hemodynamic changes without neuromuscular blockade

To compare intubating conditions and hemodynamic changes between Bonfils Intubation Fiberscope and Macintosh laryngoscopy without administering neuromuscular blocking drugs [NMBDs]. In this randomized controlled trial, 80 male and female patients, scheduled for elective surgery, aged 15 to 60 years, ASA class II or I, non-obese, non smokers, without anticipated difficult intubation; were randomly allocated into two groups of 40: Bonfils and Macintosh. Following adequate hydration and preoxygenation, midazolam 0.03 mg.kg[-1] was administered, followed by intravenous alfentanil 20 microg.kg[-1], lidocaine 1.0 mg.kg[-1], and propofol 2 mg.kg[-1] sequentially. Trachea was then intubated using Bonfils Intubation Fiberscope in the Bonfils group and conventional Macintosh laryngoscopy in the Macintosh group. Intubating condition, mean arterial blood pressure, heart rate, pulse oximetry, and success rate were measured. Clinically acceptable intubating condition scores did not differ significantly between the groups [P=0.465]. Compared to the baseline values, heart rate rose significantly after intubation only in the Macintosh group [P<0.001]. Although mean arterial blood pressure increased immediately after intubation in the Macintosh group [P=0.022], its post-intubation values were significantly less than baseline in both groups [P<0.001]. Intubation time took much longer in the Bonfils group [40 s] than the Macintosh group [11 s], P<0.001. In the absence of NMBDs, Bonfils Intubation Fiberscope compares well with Macintosh laryngoscopy in terms of success rate and intubating conditions, but with less mechanical stress and hemodynamic compromise and longer intubation time

Loss of consciousness secondary to lead poisoning

Diagnosis of lead toxicity could be difficult in IC setting because of overlap of signs and symptoms with other diseases. This is a report of two Iranian patients [father and son] with severe level of whole blood concentration, developing into unconsciousness

Quadriplegia due to lead-contaminated opium - case report

Utilization of lead-contaminated opium may lead to severe motor neuron impairment and quadriplegia. Forty years oriented old male, opium addict, was admitted to the ICU, with headache, nausea and abdominal pain, and weakness in his lower and upper extremities without definitive diagnosis. The past medical and occupational history was negative. Laboratory investigation showed: anemia [Hb 7.7 g/dl]. slightly elevated liver function tests, elevated total bilirubin, and ESR. Abdominal sonography and brain CT scan were normal. FMG and NCV results and neurologic examination were suggestive for Guillain-Barre. He underwent five sessions of plasmapheresis. Blood lead level was > 200 micro g/dl. He received dimercaprol [BAL] and calcium disodium edetate [CaEDTA] for two five days session. Upon discharge from ICU all laboratory tests were normal and blood lead level was reduced, but he was quadriplegic. The delayed treatment of lead poisoning may lead to irreversible motor neuron defect

evaluation of the possible effect of positive end expiratory pressure [PEEP] on pharmacokinetics of phenytoin in patients with acute brain injury under mechanical ventilation

Positive ventilation has shown to have an influence on pharmacokinetic and disposition of some drugs.Beacause phenytoin with a narrow therapautic range, is the most commonly used drug for prophylaxis and treatment of early seizures after acute brain injuries, in the present study the effect of short term PEEP [5-10 cm H2O for at least 8 hours] on phenytoin serum concentration and pharmacokinetic parameters such as Vmax and clearance in brain injured patients under mechanical ventilation was examined. Ten patients with moderate to severe acute brain injury who were placed on mechanical ventilation with an initial PEEP level of 0-5 cm H2O were included in the study. Patients received phenytoin loading dose of 15 mg/kg followed by a maintenance daily dose of 3-7 mg/kg initiated within 12 hours of loading dose. Sampels were taken on two different occasions before and after PEEP elevation. Total phenytoin serum concentrations were determined by HPLC method. A time invarient Michaelis-Menten pharmacokinetic model was used to calculate Vmax and clearance for each patient.Derrived variables were calculated as follows: Vmax, 3.5-6.8 and 3.7-8.2 mg/kg/day; Clearance, 0.1-0.7 and 0.1-1.2 l/kg/day [before and after PEEP elevation, respectively]. Our data have shown a wide range of variability [2.6-32.5 mg/l] in phenytoin serum concentrations. There were no statistically significant differences in the measured total concentrations [p=0.721] and calculated Vmax and clearance [p=0.285]before and after PEEP elevation. Administration of fluid and inotropic agents, limitation in application of higher levels of PEEP and drug interactions, shall be considered as possible explanations for these findings

Comparison of the analgesic profile and side effectts of tramadol vs pethidine followingurological surgery

The optimization of pain management following surgery with minimal side effects, is one the major goals of surgical and medical teams. In this randomized double blind study, sixty ASA [American Society of Anesthesiologist] class I or II patients, undergoing urological surgery, were assessed to receive either pethidine or tramadol using a standard method for general anesthesia. Pain intensity was assessed by verbal rating, through a 4-step scaling system. Results of this investigation have revealed that the mean total drug administered in tramadol group were 244.53 + 56.95 mg and in pethidine group 176.78+42.99 mg respectively. There were no significant differences in analgesic effect, observed in either group during early hours following surgery, but after 8,12 and 16 hours significant differences were observed. Analgesic properties of tramadol were almost comparable with pethidine nevertheless; pethidine was superior in some extent. No significant differences in patient's PaO2 were found, but PaCO2 at 1 and 4 hours after surgery had a greater retention in pethidine group. [P<0.001]. There was a significant reduction in respiratory rate in pethidine group at 4,8,12 and 16 hours following surgery, compared with tramadol group [P<0.001]. Incidence of dizziness was greater in patients who received pethidine [P<0.001], and sweating was higher in tramadol group [P<0.01]. Also there was a greater need for metoclopramide to overcome nausea in tramadol group [P<0.05]. Results of this study may suggest that tramadol could be considered as a safe and effective analgesic, following urological surgery as compared with pethidine