Does red blood cell transfusion affect clinical outcomes in critically ill patients? A report from a large teaching hospital in south Iran.

BACKGROUND: Despite the beneficial effects, RBC transfusion can be associated with infectious and non-infectious complications in critically ill patients. OBJECTIVES: Investigate current RBC transfusion practices and their effect on the clinical outcomes of patients in intensive care units (ICUs). DESIGN: Retrospective observational study. SETTING: Three mixed medical-surgical adult ICUs of a large academic tertiary hospital. PATIENTS AND METHODS: From March 2018 to February 2020, all adult patients admitted to medical or surgical ICU. Patients who received one or more RBC transfusions during the first month of ICU admission were included in the "transfusion" group, while the remaining patients were assigned to the "non-transfusion" group. MAIN OUTCOME MEASURES: Mortality and length of ICU and hospital stay. SAMPLE SIZE: 2159 patients. RESULTS: Of 594 patients who recieved transfusions, 27% of patients received red blood cell (RBC) products. The mean pre-transfusion hemoglobin (Hb) level was 8.05 (1.46) g/dL. There was a significant relationship between higher APACHE II scores and ICU mortality in patients with Hb levels of 7-9 g/dL (OR adjusted=1.05). Also, ICU mortality was associated with age (OR adjusted=1.03), APACHE II score (OR adjusted=1.08), and RBC transfusion (OR adjusted=2.01) in those whose Hb levels were >9 (g/dl). CONCLUSION: RBC transfusion was associated with an approximately doubled risk of ICU mortality in patients with Hb>9 g/dL. High APACHE II score and age increase the chance of death in the ICU by 8% and 3%, respectively. Hence, ICU physicians should consider a lower Hb threshold for RBC transfusion, and efforts must be made to optimize RBC transfusion practices. LIMITATIONS: Single-center and retrospective study.

Incidence and root causes of surgery cancellations at an academic medical center in Iran: a retrospective cohort study on 29,978 elective surgical cases.

INTRODUCTION: Canceling scheduled surgeries on the day of surgery places a heavy burden on healthcare providers and has psychological, social, and financial consequences on patients and their families. This study aimed to investigate the main reasons for cancellations of elective procedures and provide appropriate recommendations to reduce the rate of such avoidable cancellations. METHODS: Data were collected retrospectively from all consecutive elective cases scheduled for various elective surgeries from January 1, 2020 to March 31, 2022 at Namazi Teaching Hospital, a major referral center in southern Iran with a capacity of 938 beds. Daily data were collected on the number of planned electives, cancellations, and reasons for cancellations. Surgical cancellation reasons were categorized as patient-related, surgeon-related, hospital/system-related, and anesthesia-related. Data were expressed as frequency (percentage) and analyzed with SPSS version 19 software. RESULTS: The cancellation rate on surgery day for elective procedures in all fields was 6.3%. The highest cancellation rate was related to minor surgeries (19%), followed by urology (8%), pediatrics (7%), and plastic surgery (7%). The most common reasons for cancellation were patients not suitable for the procedure (37%), followed by patients who did not follow instructions (10%), lack of time (10.5%), and equipment/supplies problems (10%), and refusal to consent (6%). CONCLUSIONS: According to this study, patients' unsuitability for surgery, non-compliance with instructions, lack of time, and problems with equipment/supplies are the main reasons for canceling surgery. Proper preoperative assessment and preparation of patients and improved communication between medical teams and patients reduce the cancellation of booked surgeries.

Adequate Anesthesia and More Effective Analgesia by Adjusted Doses of Bupivacaine during Cesarean Section: A Randomized Double-blind Clinical Trial.

Background: Several adjuvants, added to local anesthetics, were suggested to induce an ideal regional block with high-quality analgesia. The purpose of this study was to evaluate the particular blocking properties of low-dose bupivacaine in combination with meperidine and fentanyl in spinal anesthesia during Cesarean sections. Methods: A randomized, double-blind clinical trial was conducted at Hafez Hospital affiliated with Shiraz University of Medical Sciences (Shiraz, Iran) from February 2015 to February 2016. A total of 120 pregnant women, who underwent spinal anesthesia during elective Cesarean section were enrolled in the study. Based on block-wise randomization, the patients were randomly assigned to three groups, namely "B" group received 2 mL bupivacaine 0.5% (10 mg), "BM" group received 8 mg bupivacaine and 10 mg meperidine, and "BF" group received 8 mg bupivacaine and 15 µg fentanyl intrathecally. The block onset, the duration of analgesia, and the time of discharge from the post-anesthesia care unit (PACU) were all assessed. Data were analyzed using SPSS software version 21, and P<0.05 were considered statistically significant. Results: The mean duration of motor blocks in the B group (150 min) were significantly higher than the BM (102 min) and BF (105 min) groups (P<0.0001). In both the BM and BF groups, the duration of sensory and motor blocks was the same. The length of stay in the PACU was significantly longer in the B group (P<0.001) than the BM and BF groups. When meperidine or fentanyl was added to bupivacaine, the duration of the analgesia lengthened (P<0.001). Conclusion: Intrathecal low-dose spinal anesthesia induced by bupivacaine (8 mg) in combination with meperidine and/or fentanyl for Cesarean section increased maternal hemodynamic stability, while ensuring effective anesthetic conditions, extending effective analgesia, and reducing the length of stay in PACU.Trial Registration Number: IRCT2015013119470N14.

Comparison of the ease of insertion and complications of the classical method of laryngeal mask airway insertion with an alternative method.

Background and Goal: Laryngeal mask airway (LMA), a supraglottic device for airway management and ventilation, is used both in emergencies, out of the operating room, and in the operating room during general anesthesia. This study aims to compare the success rate and complications of the classic insertion method (with a semi-inflated cuff) and another technique using the index and middle fingers of the second hand to prevent retroversion of the mask tip (alternative method). Methods and Materials: In total, 288 patients scheduled for short-time ophthalmologic elective surgeries under general anesthesia were randomly allocated to two groups for LMA placement; group C, classical method (with semi-inflated cuff), and group A, alternative method. Difficulty in placement, insertion duration, and the number of attempts were studied. Assessment of pharyngolaryngeal complications (blinded assessor) was made at the time of LMA removal. Findings: The success rate of LMA insertion in the classic group with first, second, and third attempts were 86.3%, 93.5%, and 94.2%, respectively, whereas in the alternative group these values in the first and second attempts were 98.6% and 100%, respectively, and there was no need for the third attempt. Insertion time was not significantly different. There was no meaningful difference between the rate of the bloody streak on the mask (P = 0.37) and the incidence of sore throat (P = 0.048) in the two groups of the study. Conclusion: This newly introduced technique can be considered as an alternative method when a difficult insertion situation is suspected or the classic technique of insertion has failed.

The Effectiveness of the Intermediate and Therapeutic Doses of Enoxaparin in COVID-19 Patients: A Comparative Study of Factor Xa Inhibition.

BACKGROUND: Management of anticoagulant therapy in COVID-19 patients is critical. Low-molecular-weight heparin (LMWH) thromboprophylaxis is already recommended, and anti-Factor Xa (anti-FXa) monitoring has been used to titrate LMWH doses. METHODS: Through a cross-sectional study, we evaluated anti-FXa activity in patients admitted to the ICU, receiving intermediate dose (30, 40, 50 mg, subcutaneously [SC], twice daily) or therapeutic dose (1 mg/kg, SC, Q12h) of enoxaparin to find whether the patients in these two groups achieved anti-FXa levels in the accepted thromboprophylaxis range. RESULTS: The occurrence of deep vein thrombosis was 26% in the therapeutic-dose group and 17% in the intermediate-dose group. D-dimer values were nearly 3.5-fold higher in those who received a therapeutic dose of anticoagulants than in those who received intermediate-dose thromboprophylaxis. Patients in the therapeutic-dose group had significantly higher IL-6 levels (p ≤ 0.001). More than one-third of the patients in the therapeutic-dose group (n = 8; 42.18%) and approximately half of the patients in the intermediate-dose group (n = 12; 52.2%) achieved the target range level of anti-FXa. Patients who received therapeutic doses were more likely to have anti-FXa levels above the expected range (47.4 vs 13% in the intermediate-dose group; p < 0.05). CONCLUSION: Therapeutic dose of enoxaparin in critically ill COVID-19-infected patients did not reduce the incidence of thromboembolic events and, on the other hand, may predispose these patients to increased risk of bleeding by increasing anti-FXa activity above the desired level. Administration of intermediate-dose thromboprophylaxis is suggested to achieve anti-FXa levels in the accepted thromboprophylaxis range.

Analgesic Characteristics of Bupivacaine Alone and in Combination with Dexmedetomidine or Meperidine in Spinal Anesthesia during Cesarean Section: A Double-Blind Randomized Clinical Trial Study.

Background: Comparing bupivacaine's adjuvants in spinal anesthesia, we assessed the specific blocking characteristics and adverse effects of bupivacaine alone and in combination with dexmedetomidine or meperidine in spinal anesthesia during cesarean section. Methods: In this double-blind randomized clinical trial study, ninety pregnant women were divided into groups to receive 10 mg bupivacaine (group B), 10 mg bupivacaine with 5 µg dexmedetomidine (group BD), or 10 mg bupivacaine with 10 mg meperidine (group BM) intrathecal. Patients were assessed for the quality of analgesia during operations. Durations of sensory and motor blocks and anesthesia-related complications were analyzed using SPSS 21, and p values <0.05 were considered statistically significant. Results: The onset of sensory and motor blocks was essentially the same in all treated groups. Block regression time was significantly prolonged in the BD group compared to the B and BM groups (p < 0.001). The duration of analgesia was significantly longer in the BD and BM groups than in the B group (p < 0.001). The level of sedation in the BD group was higher than in the B group. Shivering occurred in 40% of patients in the B group, which was significantly more than that of the BD (16.6%) and BM (33.3%) groups. Itching happened in 33.3% of women in the BM group which was statistically more than that of the B (3.33%) and BD (0) groups. The incidence of adverse effects was the same in all groups. Conclusion: The combination of bupivacaine with dexmedetomidine significantly prolonged sensory and motor regression time and duration of analgesia.

Promotion of aging heart function and its redox balance following hind-limb blood flow restriction plus endurance exercise training in rats: klotho and PGC1-α as involving candidate molecules.

Mild to moderate-intensity endurance exercise training combined with hind-limb blood flow restriction (BFR) induces elderly heart rejuvenation and improves cardiac inotropy and resistance to ischemia. However, the mediators of these beneficial effects are still not well known. The present study investigated the possible role of some important molecules in the mediatory of this model of exercise training in the promotion of heart health in aged rats. Male old Wistar rats randomly were divided into control-sham (CTL), hind limbs blood flow restriction (BFR), sham-operated plus 10 weeks' treadmill exercise training (Ex), and BFR plus exercise (BFR + Ex) groups. Left ventricular end-diastolic pressure (LVEDP), contractility, and Tau indices were measured. ELISA and western blot tests were used for measuring determined cardiac biochemical factors. BFR + Ex displayed significantly lower LVEDP (P < 0.05 and P < 0.01 vs. Ex, and other groups, respectively), improved heart cardiac contractility (P < 0.01), and significantly reduced Tau index in comparison with other groups. BFR + Ex significantly reduced both BAX and BAX to BCL2 ratio (P < 0.05) and as well MDA to TAC ratio (P < 0.05, compared to the CTL group). Also, BFR + Ex significantly increased the level of klotho (P < 0.05) and PGC1-α (P < 0.001) proteins compared to the CTL group but had no significant effect on P-STAT3 expression. Exercise training alone increased Apelin protein (P < 0.05). Our findings suggest that mild to moderate BFR endurance training improves heart performance in the aging rat partly through ameliorating apoptosis, recovering redox balance, improving the longevity factor klotho, and increasing the key energy metabolism regulator PGC1-α.

The effect of posterior tibial and sural nerve blocks on postoperative pain of patients following open reduction and internal fixation of calcaneal fractures.

INTRODUCTION: Postoperative pain control and achieving opioid-free anesthesia are major issues for surgically treated patients with calcaneal fractures. We evaluated the potential role of posterior tibial and sural nerve blocks as a part of multimodal pain control techniques in patients underwent open reduction and internal fixation (ORIF) of calcaneal fractures via extensile lateral approach. METHODS: Forty-eight patients randomly allocated to receive either posterior tibial and sural nerve blocks with bupivacaine (peripheral nerve block (PNB) group) or normal saline, after induction of general anesthesia. Patients were assessed for pain intensity, Interval from entrance to the recovery room to the first request for analgesic, recovery room and ward morphine consumption, global satisfaction and morphine side effects. RESULTS: PNB group had less pain score compared to sham block (SB) group at each time point measurement during recovery room stay. There was also significant difference between the 2 groups regarding the pain scores after 2, 4 and 6 h of the operation in the ward. Time to the first request for analgesic was significantly prolonged in the PNB group (P < 0.001). The recovery room and ward morphine consumption was significantly lower in the PNB group (P < 0.001). Global satisfaction in PNB group was significantly more than that of SB group. No complication related to the nerve block was detected at the first postoperative visit in the outpatient clinic. CONCLUSION: Peripheral nerve block could result in less postoperative pain especially in the early hours after ORIF of calcaneal fractures and reduce opioid administration within the first 24 h following the surgery.

Limb Blood Flow Restriction Plus Mild Aerobic Exercise Training Protects the Heart Against Isoproterenol-Induced Cardiac Injury in Old Rats: Role of GSK-3ß.

The present study was conducted to evaluate the effect of blood flow restriction (BFR) training on cardiac resistance to isoproterenol (ISO) induced heart injury in old rats and examined the hypothesis that BFR training may interfere with age-associated impairment of mitochondria by the inhibitory phosphorylation of GSK-3ß at Ser9. Old male Wistar rats were divided into the following six groups: CTL (control), ISO (isoproterenol-treated), Sh + ISO (sham-operated plus ISO), BFR + ISO (blood flow restriction plus ISO), Sh-Ex + ISO (sham-operated subjected to exercise and ISO), and BFR-Ex + ISO (blood flow restriction along with exercise and ISO). 10 weeks of exercise training was considered. Then, cardiac injury was induced and physiological, histological, and biochemical parameters were recorded and assessed. Compared to CTL group, isoproterenol administration significantly reduced the systolic arterial pressure (SAP), left-ventricular systolic pressure (LVSP), and ± dp/dt max (P < 0.05). BFR training improved these parameters in the way that BFR-Ex + ISO group had higher SAP, LVSP and ± dp/dt max (P < 0.05) and lower LVEDP (left-ventricular end diastolic pressure) (P < 0.01) than untrained and Sh-Ex + ISO groups. The pS9-GSK-3ß and pS9-GSK-3ß/GSK-3ß ratio were increased in the BFR-Ex + ISO group compared to CTL, ISO, Sh + ISO, and BFR + ISO groups (P < 0.05). The level of plasma cardiac Troponin-I and the severity of the injuries were significantly reduced in BFR-Ex + ISO group versus other cardiac damaged groups. In conclusion, our findings clearly confirmed the cardio-protective effect of BFR training against ISO-induced myocardial injury. Increased phosphorylated GSK-3ß and angiogenesis in this model of exercise justify the resistance of old hearts facing stressful situations.

The effect of blood flow restriction along with low-intensity exercise on cardiac structure and function in aging rat: Role of angiogenesis.

AIMS: Low-intensity aerobic training along with limbs blood flow restriction can improve mass and strength of skeletal muscle, but its effects on aging heart structure and performance is unidentified. We investigated the effects of this model of training on myocardial function, histology and angiogenesis in old male rats. MAIN METHODS: Animals randomly were divided into control (Ctl), sham-operated (Sh), limbs blood flow restriction (BFR), sham-operated plus 10 weeks low intensity treadmill exercise (Sh + Ex), and BFR plus exercise (BFR + Ex) groups. Finally, blood pressure, heart physiological and stereological parameters, myocardial oxygen consumption index and expression of vascular endothelial growth factor (VEGF) and its receptors (Flt-1 and kdr) were assessed. KEY FINDINGS: BFR + Ex group had significantly lower heart rate (P < 0.05 vs. Ctl and Sh groups), rate-pressure product (RPP) and left ventricular end diastolic pressure (P < 0.05 and P < 0.01 vs. untrained groups, respectively). BFR + Ex group also had greater +dp/dt max (P < 0.01) and -dp/dt max (P < 0.05) than untrained groups. A significant increase in volumes of left ventricle and myocytes (P < 0.05, vs. Ctl and Sham), ventricular hypertrophy index and capillaries length density (P < 0.05 vs. untrained groups) were observed in BFR + Ex group. The level of VEGF and Flt-1 proteins and their mRNAs increased in the BFR + Ex group compared to Ctl, Sh and BFR (P < 0.01) and Sh + Ex (P < 0.05) groups. The kdr mRNA and its protein level were significantly higher in the BFR + Ex group. SIGNIFICANCE: Findings suggest that BFR plus exercise through improving the angiogenesis, physiological cardiac remodeling and oxygen demand/supply matching can promote cardiac performance in the elderly rats.

Mild exercise along with limb blood-flow restriction modulates the electrocardiogram, angiotensin, and apelin receptors of the heart in aging rats.

OBJECTIVES: Considering the lack of information, the effects of mild endurance exercise plus blood flow restriction (BFR) on electrocardiographic parameters, hypertrophy index, and expression of angiotensin II receptors type 1 (AT1R) and type 2 (AT2R) and apelin receptor (APJ) were assessed in hearts of old male rats. MATERIALS AND METHODS: Animal were grouped as control (CTL), Sham (Sh), lower extremities blood flow restriction (BFR), exercise (Ex), Sham + exercise (Sh + Ex), and blood flow restriction + exercise (BFR + Ex). RESULTS: Exercise plus BFR significantly decreased the corrected QT (QTc) interval (P<0.01 vs CTL and Sh groups) and increased the heart hypertrophy index (P<0.05 vs CTL and BFR groups). Exercise alone increased expression of the APJ (P<0.01, vs CTL, Sh, and BFR groups) and AT2 receptors (P<0.001, vs Sh, CTL, BFR, and BFR + exercise groups), whereas it reduced expression of AT1R (P<0.01 in comparison with CTL, Sh, and BFR groups). Exercise plus BFR caused a significant increase in APJ (P<0.05 vs Ex, Sh+Ex and P<0.001 vs CTL, Sh, and BFR groups) and also expression of AT1R (P<0.001 vs Ex, Sh + Ex, CTL, Sh, and P<0.01 vs BFR groups). Accompaniment of exercise with BFR destroyed the effect of exercise on the expression of AT2R. CONCLUSION: Mild endurance exercise plus BFR can alter the expression of angiotensin II and apelin receptors that leads to cardiac hypertrophy and improves the ventricular conductivity of aging rats.

Heart Reaction to Nandrolone Decanoate plus Two Different Intensities of Endurance Exercise: Electrocardiography and Stereological Approach.

BACKGROUND: Regarding the negative effects of androgenic anabolic steroids (AASs) abuse, the long-term effect of nandrolone decanoate with/without two intensities of endurance exercise training was investigated on heart tissue and electrocardiogram (ECG) in rats. METHODS: The experiment was conducted on 63 ýýmale Wistar rats, which were ý4 months old. The rats were divide into groups of control (CTL), arachis oilasnandrolone solvent (Ar), nandrolone (Nan) (received a dose of 5 mg/kg twice/week for 8 weeks), mild swimming exercise training (mEx), severe exercise (sEx), sEx + Nan, mEx + Nan, mEx + Ar, and sEx + Ar. During the 8 weeks of swimming exercise, the animals carried dumbbells equivalent to 2% of their body weight, which was gradually increased and reached 5% and 8% in the 6th week for mild and severe exercises, respectively. Finally, ECGs recording and samplings were done. FINDINGS: Both types of exercise, without nandrolone, significantly reduced the heart rate and increased the RR interval of ECG. Nandrolone alone and with mild (P < 0.050) and intense exercise (P < 0.010 vs. CTL) increased the left ventricular hypertrophy (LVH) index. Left ventricular volume was significantly higher in the Nan group (P < 0.050) compared to the CTL group and all exercise groups (P < 0.010) compared to the Nan, CTL, and Ar groups. Myocytes volume increased in the presence of both of mild and high-intensity exercise plus nandrolone (P < 0.050 vs. CTL and Ar groups). Hydroxyproline value of the heart was significantly higher in the nandrolone group compared to all other groups (P < 0.001). Exercise prevented the effect of nandrolone on hydroxyproline. CONCLUSION: Both levels of swimming exercise prevent the effect of nandrolone on the production of hydroxyproline and fibrotic cardiac remodeling.