Effect of Vitamin C Infusion on Cerebral Oximetry During General Anesthesia for Carotid Endarterectomy in Diabetic Patients.

Background: There is conflicting information about the effect of vitamin C on brain oxygenation during anesthesia. Objectives: The current study was designed and performed to assess the effect of vitamin C infusion and brain oxygenation with cerebral oximetry on improving brain perfusion during general anesthesia in vascular surgery of diabetic patients. Methods: This randomized clinical trial was performed on patients candidates for endarterectomy under general anesthesia and referred to Taleghani Hospital in Tehran, Iran, during 2019 - 2020. Considering inclusion criteria, the patients were divided into placebo and intervention groups. The patients in the placebo group received 500 mL of isotonic saline. In the intervention group, the patients received 1 g of vitamin C diluted in 500 mL of isotonic saline by infusion half an hour before anesthesia induction. Patients' oxygen levels were continuously measured by a cerebral oximetry sensor. The patients were put in a supine position for 10 minutes before and after anesthesia. At the end of the surgery, the indicators considered in the study were evaluated. Results: No considerable difference was observed between systolic and diastolic blood pressure, heart rate, mean arterial pressure, partial pressure of carbon dioxide, oxygen saturation, regional oxygen saturation, supercritical carbon dioxide, and end-tidal carbon dioxide in total and between the two groups in the three stages before and after anesthesia induction and at the end of surgery (P > 0.05). Additionally, there was no significant difference between blood sugar (BS) levels in the study groups (P > 0.05) but in BS levels at three stages before and after anesthesia induction and at the end of the surgery, with a significant difference (P < 0.05). Conclusions: The amount of perfusion in the two groups and, therefore, in total at the three stages before and after anesthesia induction and at the end of surgery is not different.

Effects of General Anesthesia Versus Spinal Anesthesia on Serum Cytokine Release After Cesarean Section: A Randomized Clinical Trial.

BACKGROUND: Tissue damage caused by major surgery, such as cesarean section, may lead to a poor host immune response and excessive release of cytokines. These responses may increase the risk of infection, cause postoperative pain, and exert damaging effects on various body organs. OBJECTIVES: Anesthesia methods may affect cytokine production after surgery. This study aimed to compare the serum levels of cytokines in general and spinal anesthesia among women undergoing cesarean section. METHODS: Thirty parturients (ASA class I and II) undergoing cesarean section were randomly assigned into two equal groups of spinal anesthesia and general anesthesia. Blood samples were taken for measuring the levels of interleukin-6 (IL-6), interleukin-10 (IL-10), and tumor necrosis factor-alpha (TNF-α) before induction of anesthesia and 30 minutes after entering the recovery room. RESULTS: In the general anesthesia group, the postoperative serum levels of IL-6 and TNF-α were significantly higher than the corresponding preoperative levels. Significant differences were found between the two groups in the preoperative and postoperative levels of TNF-α. Changes in the IL-6 and TNF-α concentrations were significantly higher in the general anesthesia group as compared to the spinal anesthesia group. However, there was no significant difference in the IL-6:IL-10 and TNF-α: IL-10 ratios between the two groups. CONCLUSIONS: General anesthesia, as compared to spinal anesthesia, significantly increased the IL-6 and TNF-α levels after cesarean section. Therefore, the spinal anesthesia technique may be a better option for patients undergoing cesarean section.

The Effect of Repeated Direct Observation of Procedural Skills (R-DOPS) Assessment Method on the Clinical Skills of Anesthesiology Residents.

BACKGROUND: The ultimate result of patient care is one of the most important outcomes in medical education. Several methods, including the direct observation of procedural skills (DOPS), have been proposed to assess professional competencies in clinical practice. OBJECTIVES: This study aimed to assess the effects of the Repeated DOPS (R-DOPS) method on the performance of procedural skills in anesthesiology residents. METHODS: The procedural skill performance of anesthesiology residents was assessed using a standard DOPS protocol from May to October 2019. Their scores were then objectively recorded, and the satisfaction rates regarding the 2 DOPS exams were assessed. RESULTS: We found a considerable improvement in anesthesiology residents' procedural skill performance, especially in the anesthesiology residency curriculum's basic items. Besides, anesthesiology residents' satisfaction was significantly improved after the 2nd DOPS. CONCLUSIONS: R-DOPS leads to improved training outcomes, including assessing the procedural skills, time to feedback to trainees, and trainee satisfaction.

The Effect of Propofol Anesthesia on the Pain Severity and Frequency of Migraine Attacks in Patients with Chronic Migraine Headache over a Six Month Follow Up: An Observational Study.

Propofol is a short-acting intravenous anesthetic that is commonly used for induction and maintenance of anesthesia. Subanesthetic low doses of propofol has also been used to treat intractable migraine attacks in emergency wards with dramatic results. However, there is little information on the long-term efficacy of this drug in migraine headaches. The aim of this nonrandomized prospective observational study was to assess the effect of propofol anesthesia on the pain severity and frequency of migraine attacks in a 6-month follow-up period after anesthesia in patients with migraine headaches. The study was conducted on 51 known cases of migraine ranging in age from 21 to 66 years. Before anesthesia, patients completed a questionnaire including their characteristics, pain intensity of the headache using a visual analog scale, and a number of headache repetitions per month. All patients received propofol as the main anesthetic agent. At the end of anesthesia, the total amount of propofol usage was recorded. Patients were then followed up by telephone in the first, third, and sixth months after anesthesia, and the severity and frequency of the headache were recorded. Pain intensity or pain frequency significantly improved in 22 patients (43.1%), remained unchanged in 24 (47%), and worsened in 5 cases (9.8%) 6 months after anesthesia compared to before the anesthesia. In conclusion, since about half of the patients had significant improvement in the headache, propofol anesthesia may be considered as an acceptable anesthetic method in patients with migraine.

Comparison of the Combined Femoral and Lateral Femoral Cutaneous Nerve Block Plus Popliteal Block with Spinal Anesthesia for Thigh Tourniquet Pain During Foot or Ankle Surgery: A Randomized Clinical Trial.

BACKGROUND: A pneumatic thigh tourniquet is routinely used during lower-extremity orthopedic surgeries to provide a bloodless field. When using peripheral nerve blocks, tourniquet-related thigh pain and discomfort limit their routine use as an anesthetic method. OBJECTIVES: The aim of the present prospective, randomized study was to compare the efficacy of combined femoral nerve/lateral femoral cutaneous nerve block technique and spinal anesthesia on intraoperative thigh tourniquet pain. METHODS: We studied 60 American Society of Anesthesiologists physical status I-II patients scheduled for orthopedic surgery on the foot or ankle using a pneumatic thigh tourniquet. They were randomly divided into two equal groups. The peripheral nerve block group received a combined popliteal, femoral, and lateral femoral cutaneous nerve block under ultrasound-guidance. In both groups, the level of sensory blockade was determined by the pinprick test. The block performance time, anesthetic effect time, intraoperative tourniquet pain scores, the amount of fentanyl and ketamine, surgery duration, and patient's satisfaction were recorded. RESULTS: The patients' characteristics were comparable in the two groups. The mean duration of block performance and anesthetic effect, intraoperative tourniquet pain scores, and the amount of intravenous analgesics in the peripheral nerve block group were significantly greater than those in the spinal anesthesia group. Patient satisfaction was similar in both groups. CONCLUSIONS: Spinal anesthesia is significantly more effective than the peripheral nerve block method in reducing thigh tourniquet pain. A combined femoral and lateral femoral cutaneous nerve block with popliteal block can improve thigh tourniquet tolerance if supplemented with intravenous analgesics.

Saline vs. dextrose for local anesthetic dilution in brachial plexus block: A randomized study.

Higher sodium ions in saline diluted local anesthetic may reduce the anesthetic action of the drug as injected around the nerves. However, the impact of local anesthetic dilution agents on the quality of peripheral nerve blockades has not yet been widely investigated. This study was aimed at evaluating the impact of lidocaine dilution with normal saline vs dextrose 5% on onset time of supraclavicular approach to brachial plexus block. Sixty American Society of Anesthesiologists class 1or2 patients, scheduled for elective upper extremity surgeries under sono-guided supraclavicular block were randomly assigned to receive lidocaine 2% diluted with either dextrose 5% or normal saline. At the end of lidocaine injection, sensory and motor blocks were evaluated at 5 min intervals for 30 min in the areas innervated by median, radial, ulnar and musculocutaneous nerves. Block onset time and number of patients with complete sensory or motor blockade were similar in both groups. Lidocaine diluted with either normal saline or dextrose 5% produces comparable sensory and motor block onset time and success rate in ultrasound guided supraclavicular block.

Effects of Epidural Needle Rotation on Evolution of Unilateral Epidural Block and Patients' Hemodynamics beside Recovery Profile in Patients Undergoing Arthroscopic Knee Surgeries; A Randomized Clinical Trial.

OBJECTIVE: To evaluate the evolution pattern of epidural block after rotating the needle tip 45° to the operative side and evaluate its effects on patients' hemodynamics and recovery profile in those undergoing arthroscopic knee surgery. METHODS: Forty participants were randomly subdivided into control and rotation group (n=20). An 18-gauge, 3.5 inch, Tuohy needle was placed at the level of L4-5 and pushed forward into the epidural space through parasagittal approach, in control group, the needle was pushed forward to the epidural space in cephaldad 90 degrees. For the rotation group, the needle was pushed forward to the epidural space and the tip was rotated 45 degrees to the surgical side.15 mL of bupivacaine 0.5% was injected and evolution of sensory and motor blocks until 2-segment regression of the sensory level below to T10 as well as total duration of motor block and surgery were recorded. Hemodynamic parameters (HR, MAP, and SPO2), hypotension, fluid intake, vasopressors, first ambulation and spontaneous urination were recorded. Statistical analysis was performed using SPSS and P≤0.5 considered significant. RESULTS: Sensory block up to T10 level, Complete motor block and time for 2-segment regression of sensory level were earlier in the 45°-rotation than in the control group (p<0.001). Total duration of motor block in control group was lower than rotation group (p<0.001).Hypotension, N&V, vasopressors and fluid intake showed no statistically difference between the two groups (p=0.219). First spontaneous urination and ambulation were significantly lower in rotation group (p<0.001). CONCLUSION: 45 degrees' needle rotation to the surgical side provides a faster block evolution and hastened recovery profile with no significant difference in hemodynamic fluctuations. CLINICAL TRIAL REGISTRY: IRCT20130518013364N7.

Comparison of rectal indomethacin, diclofenac, and naproxen for the prevention of post endoscopic retrograde cholangiopancreatography pancreatitis.

BACKGROUND AND AIM: NSAIDs are commonly utilized for the prevention of post endoscopic retrograde cholangiopancreatography pancreatitis (PEP). However, not much is known about the most effective drug in preventing this complication. This study aims to clarify which drug (indomethacin, diclofenac, or naproxen) is most effective for the prevention of post endoscopic retrograde cholangiopancreatography (ERCP). MATERIALS AND METHODS: In a double-blind, randomized study, patients received a single rectal dose of one of the three drugs 30 min before undergoing ERCP: diclofenac (100 mg), indomethacin (100 mg), or naproxen (500 mg). The primary outcome measured was the development of pancreatitis. The levels of serum amylase, lipase, lipoxin A4, and resolvin E1 were measured before ERCP, and at 24 h after the procedure. RESULTS: Three hundred and seventy-two patients completed the study. The overall incidence of PEP was 8.6%, which occurred in five of the 124 (4%) patients who received diclofenac, seven of the 122 (5.8%) patients who received indomethacin, and 20 of the 126 (15.9%) patients who received naproxen. There were no significant differences in amylase and lipase levels among the three groups (P=0.183 and 0.597, respectively). Unlike patients in the naproxen group, patients in the diclofenac and indomethacin groups showed a significant increase in lipoxin A4 and resolvin E1 (P=0.001 and 0.02, respectively). CONCLUSION: Diclofenac and indomethacin patient groups had a lower incidence of PEP than the naproxen group.

Preemptive Oral Clonidine Provides Better Sedation Than Intravenous Midazolam in Brachial Plexus Nerve Blocks.

BACKGROUND: Preemptive analgesia is the blocking of pain perception afferent pathways before noxious painful stimuli. Clonidine is an alpha agonist drug that is partially selective for α-2 adrenoreceptors. Clonidine is used as anti-anxiety medication and an, analgesic, and it prolongs the duration of the block in the brachial plexus block. OBJECTIVES: To compare the effect of preemptive clonidine with midazolam on intraoperative sedation, duration of block, and postoperative pain scores. PATIENTS AND METHODS: In a randomized clinical trial, 80 patients with orthopedic fractures of an upper extremity who underwent supraclavicular nerve block were randomly assigned to receive 0.2 mg oral clonidine or 2 mg oral midazolam. Intraoperative sedation was measured at one hour after the start of urgery and again in the PACU (Post-Anesthesia Care Unit) using the Ramsay scale. The duration of sensory blockade was measured. Postoperative pain scores were measured using the VAS (Visual Analogue Scale) after entrance to recovery up to 2 hours. RESULTS: The percentages of patients in the calm and sedated scale were significantly higher in clonidine group (35 and 42.5%, respectively), compared to the midazolam group (17.5 and 17.5%, respectively) (P = 0.042, 0.029; respectively). Those administered fentanyl in the clonidine group 105 ± 30.8 was significantly lower than that for the midazolam group 165 ± 34.5 (P = 0.0018). The percentages of patients in the calm scale were significantly higher in the clonidine group (52.5), compared to the midazolam group (17.5) (P = 0.001) in the post-operative period. VAS scores were significantly lower at one (P = 0.01) and two hours (P = 0.001) after operation in the clonidine group, compared to the midazolam group. CONCLUSIONS: Preemptive clonidine has many marvelous advantages over midazolam, including better sedation inside the operating room and then in the post-operative care unit, lower fentanyl doses are required during surgery, more stable heart rate and blood pressure are observed during the procedure, and patients report lower post-operative pain scores.

Memantine in the prevention or alleviation of electroconvulsive therapy induces cognitive disorders: A placebo controlled trial.

The purpose of this study was to evaluate the effect of memantine administration on the adverse cognitive effects of electroconvulsive therapy (ECT). Forty patients diagnosed with a major depressive disorder for which ECT was indicated as a treatment for their current episode were randomly allocated to either the memantine (5mg/day) group or the placebo group. All patients underwent the same protocol for anaesthesia and ECT procedures. The patients received memantine or the placebo for the whole period of ECT treatment, starting the day before ECT and continuing until the fourth session of ECT. The Modified Mental State Examination (MMSE) was used for the assessment of cognition before and after the trial. Regarding MMSE and item 3 MMSE (related to recent memory), the memantine group scored significantly higher at the end of ECT sessions than the control group (P=0.02, P<0.001, respectively). Our data support the hypothesis that memantine may reduce cognitive impairment following ECT. Memantine could be both a safe and well-tolerated treatment for use with ECT.

Effects of propofol versus isoflurane on liver function after open thoracotomy.

BACKGROUND: Anesthetic agents and type of surgery may contribute to postoperative hepatic injury. Inhalational anesthetics have been associated with hepatic dysfunction after surgery, however, propofol is expected to have a lower potential for postoperative liver injury. This prospective double-blind randomized clinical study was planned to determine whether postoperative liver function differs after anesthesia with isoflurane and total intravenous anesthesia with propofol in patients undergoing a posterolateral thoracotomy. METHODS: Eighty-eight patients in American Society of Anesthesiologists physical status 1 or 2, aged 16-60 years, and scheduled for an elective posterolateral thoracotomy, were randomly assigned to an anesthetic protocol: propofol (n = 44) or isoflurane (n = 44). Induction of anesthesia was similar in both groups. Serum levels of aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, lactate dehydrogenase, total bilirubin, and γ-glutamyltransferase were measured before induction of anesthesia and on the first and third days after either propofol or isoflurane anesthesia. RESULTS: Mild changes in postoperative serum levels of liver enzymes were significant within each group but the differences between groups were not significant. CONCLUSIONS: Propofol and isoflurane anesthesia have a comparable minor effect on liver function after an elective posterolateral thoracotomy.

Co-presentation of Tapia's syndrome and pressure alopecia--A rare event after septorhinoplasty: A case report and literature review.

Tapia's syndrome and pressure alopecia (PA) are two rare but distressing complications associated with orotracheal intubation and positioning of the head during surgery. To our knowledge, simultaneous occurrence of both complications after surgery has not been previously reported. To avoid these disturbing complications, the mechanisms of the injury and the preventive measures should be recognized by anesthesiologists and surgeons. We herein present the case of Tapia's syndrome together with PA following open septorhinoplasty under uncomplicated endotracheal general anesthesia in a 27-year-old man. We review other case reports and discuss the potential underlying mechanisms of injury.

Role of laryngeal mask airway in interventional bronchoscopy procedures for upper tracheal stenosis: case series.

BACKGROUND: Bronchoscopic interventional procedures are novel means of treating airway lesions which are less invasive and well tolerated for patients with endo-luminal lesions, but managing the airway and oxygenating the patient in a field that is shared by both anesthesiologist and bronchoscopist is a major concern. Also in cases with subglottic and upper tracheal stenotic lesions an airway device placed inside the lumen interferes with the procedure and occasionally bears the hazard of ignition. Therefore, an airway device placing above the glottis with effective oxygenation is required. Laryngeal mask airway is a supra-glottic device which facilitates assisted or spontaneous positive pressure ventilation. METHODS: In this study, eight patients with subglottic stenoses due to different etiologies are presented who underwent fiberoptic bronchoscopy and therapeutic interventions through laryngeal mask. RESULTS: In all these patients, we experienced simple access to the vocal cord, glottis and trachea and also the lesion, besides effective oxygenation of the patient. Furthermore, bronchoscopist and patients were both comfortable with the procedures. CONCLUSION: Laryngeal mask airway could be regarded as a reliable alternative for airway management during interventional bronchoscopic procedures, especially when they are located near the glottis or in the upper third of the trachea.

Heart-lung transplantation in Iran: a case report.

We report our initial experience with a heart-lung transplant operation performed on a 12- year- old girl with Eisenmenger syndrome at Masih Daneshvari Teaching Hospital in Tehran, in 2009. We also outline the operative indications, anesthetic management, and postoperative complications of heart-lung transplantation. We hope that this issue on transplantation may provide an encouraging prospect for patients with end-stage cardiopulmonary disorders in Iran.

Acute respiratory failure as a rare complication of celiac plexus block in a patient with adenocarcinoma of the ampulla of vater.

Celiac and splanchnic plexus blocks are considered as terminal approaches for pain control in end stage pancreatic cancer. It may be done temporarily (using local anesthetics) or as a permanent act (using alcohol and/or phenol). Like every other interventional procedure, celiac plexus block has its own potential complications and hazards among them pneumothorax and ARDS are very rare. In this case report we present an end stage patient with adenocarcinoma of ampulla of Vater with involvement of both abdomen and thorax who presented with severe intractable abdominal pain. Bilateral celiac plexus block in this patient resulted in left side pneumothorax and subsequent development of ARDS. We discuss the rare complications of celiac plexus block as well.

The efficacy of a single dose of pethidine, fentanyl and morphine in treating postanesthesia shivering.

Postanesthesia shivering is an undesirable event that may induce a variety of adverse consequences including patient discomfort, increased oxygen consumption and wound pain. Thus, its pharmacological treatment should be regarded. The purpose of this study was to compare the efficacy of morphine, fentanyl and pethidine for the treatment of postanesthesia shivering. Fifty patients who developed shivering were treated in a randomized double blinded manner with an intravenous bolus dose of 2 or 4 mg morphine, 25 or 50 mg pethidine, and 50 µg fentanyl. Then, they were monitored for 30 minutes and the shivering suppression grade, the time taken to stop shivering, the shivering cessation time, recurrence of shivering and opioid side effects were evaluated. Core body temperature was measured immediately before, and at 15 and 30 minute after administering the drug. The groups did not differ significantly regarding shivering suppression grade, shivering cessation time, and recurrence of shivering. There was a significant difference in the time taken to stop shivering between groups. Following injection of the drugs, the core temperatures increased in the five groups with statistical difference. All opioids were effective in treating postanesthesia shivering in a similar extent.

Postlung transplant rehospitalization: a study of causes, health care burden, and outcomes.

OBJECTIVES: Rehospitalization is a significant burden for transplant systems, which use data on hospitalization to monitor practice outcomes. In this study, all rehospitalizations after successful lung transplant performed in our medical center during an 8-year period were assessed for cause, health care resource use, cost, and outcome. MATERIALS AND METHODS: We performed a retrospective chart review of all rehospitalizations of lung transplant recipients in Masih Daneshvari Hospital in Darabad, Tehran, between 2000 and 2008. Baseline data (each patient's age at transplant and rehospitalization, sex, primary lung disease, medications used), cause of rehospitalization (infection, graft rejection, surgical complications, type of infection), health care resources use (length of hospital stay, intensive care unit stay, physician visits, imaging), rehospitalization costs (accommodations, personnel, drugs, paraclinical [ie, laboratory] tests, supplies, procedures) and outcome (death, survival) were noted. RESULTS: In 69% of patients who were rehospitalized after having received a lung transplant, the cause was infection. Other causes were acute rejection in 31% and surgical complications in 6.9%. In 10.3% of those patients, the primary cause for rehospitalization could not be specified. The mean (SD) duration of rehospitalization was 12.8 -/+ 10.4 days. Treatment in the intensive care unit was necessary for 93.1% of the study subjects. The mean (SD) number of physician visits was 27.8 -/+ 27.7, and the fatality rate in the patients studied was 13.8%. CONCLUSIONS: These data may guide the monitoring of the causes, burden, and outcomes of lung transplants performed in our medical center in Iran and in other medical centers.

Interpleural morphine vs bupivacaine for postthoracotomy pain relief.

This prospective randomized double-blind trial was designed to compare the analgesic effects of interpleural bupivacaine and interpleural morphine for postthoracotomy pain management. Thirty-six American Society of Anesthesiologists class I and II patients undergoing an elective posterolateral thoracotomy were randomly divided into 2 groups of 18 each. Before chest closure, an interpleural catheter was inserted under direct vision. At the end of the operation and every 4 hours thereafter, they received either 0.25% bupivacaine with epinephrine or 0.2 mg x kg(-1) morphine sulfate interpleurally for 24 hours. The chest tubes were clamped during injection and for 15 min afterwards. Supplementary doses of intravenous morphine were given on request. The pain severity was evaluated at rest and on coughing before and 30 min after each interpleural injection, using an 11-point visual analog scale. Supplemental analgesic consumption and side effects were recorded. Both interpleural morphine and bupivacaine significantly reduced pain scores 30 min after each injection. However, pain scores and supplementary analgesic requirements were significantly lower in the interpleural morphine group. No serious side effects were detected in either group. Interpleural morphine provides better pain control than interpleural bupivacaine after a posterolateral thoracotomy.

The anesthetic management of an intrabronchial escape of a hydatid's ruptured laminated membrane during rigid bronchoscopy.

We describe the anesthetic management of a case in whom a previously undiagnosed pulmonary hydatid cyst manifested as a large amount of intrabronchial fragmented pieces of laminated membrane suddenly and unexpectedly during diagnostic rigid bronchoscopy.