Unintended consequences: Hypotonic serum-induced acute kidney injury in shoulder arthroscopy.

Arthroscopic shoulder surgery is an orthopaedic technique that involves the use of normal saline or hyperosmolar serums as irrigation. The mentioned operation is commonly regarded as a safe medical intervention. Occasionally, it may have serious repercussions for the patient. Fluid extravasation into muscle tissues and tissue injury and instability are possible consequences. This can be affected by the type and amount of serum used and the length of the surgery. The objective of this study was to document four cases of shoulder arthroscopy in which sterile distilled water, wrongly labelled as irrigation fluid, was utilized during the surgical procedure. Patients were readmitted a week after discharge due to acute kidney injury symptoms like fatigue and lethargy. All four patients were released after haemodynamic stability and normalization after haemodialyses. Due to the incident, serums should be closely monitored and labeled for the safety of patients. Additionally, distilled water as an irrigation solution in arthroscopic surgeries can harm patients. Although normal saline and hyperosmolar serums are unavailable, this remains true. LEVEL OF EVIDENCE: Level IV.

Comparison of the angle deviation of the nose line to the mentum and Mallampati test in predicting the difficult airway before anesthesia.

Introduction: A high percentage of dangerous events in anesthesia occur due to airway problems, and proper airway management is always one of the key points during anesthesia. Airway management in critically ill patients is one of the most stressful situations for primary care physicians and even for anesthesiologists. The aim of this study was to evaluate the anatomical features of patients' airways, including the angle of deviation of the nasal line from the nasal to the mentum (NMLD), and perform a Mallampati test. Method: This cross-sectional study was performed on all patients admitted to Shohada Hospital in Tabriz, Iran, who were candidates for elective surgery for 1 year and 6 months, and underwent endotracheal intubation. Based on laryngeal observation, patients were classified into four groups. Then, all data related to individuals including type of surgery, age, sex, weight, height, body mass index (BMI), and nasal mentum line deviation (NMLD) were recorded. Then, all the collected data were analyzed using SPSS software version 19. Results: A total of 85 patients from 17 to 67 years with a mean age of 37.64 ± 12.89 were studied. There was a statistically significant relationship between laryngoscopy difficulty and Mallampati score (P = 0.001). The findings showed a statistically significant relationship between laryngoscopy difficulty and the mean NMLD (P = 0.01). A Mallampati of 85% indicates laryngoscopy difficulty. Also, NMLD can predict laryngoscopy difficulty by up to 66%. Conclusion: The present study demonstrated that both the Mallampati score variable and NMLD are related to the difficult airway problem. Furthermore, the Mallampati score has a higher predictive value for difficult intubation than the NMLD.

The Determination of an Appropriate Time for Placement of the Classic Laryngeal Mask Airway in Patients Undergoing General Anesthesia.

BACKGROUND: The management of the airways is an essential component of anesthesia planning. Laryngeal mask airway (LMA) plays an important role in modern anesthesia, however, intubation by LMA has some complications. It may cause inadequate anesthesia depth, which can lead to adverse events. The aim of this study was to evaluate the optimal time for intubation by LMA under general anesthesia. METHODS: This study was conducted on 96 patients, who underwent operation and were appropriate candidates for intubation with appropriate LMA. The participants were divided to four groups, each with 24 cases, based on the time interval between anesthetic agent administration and intubation with LMA; 15 seconds for the first group, 16 to 30 seconds for the second group, 31 to 45 seconds for the third group, and 45 to 60 seconds for the fourth group. The patients involved in these groups were selected based on the following prerequisites, patients' age, gender, easy intubation, need for additional drug administration, basic blood pressure before drug administration, within the time intervals one, three, and five minutes after placement of LMA, duration of LMA, SaO2 before and after placement of LMA, coughing, patient's movement, laryngospasm, gag reflex after intubation, allowing appropriate ventilation, presence of sore throat after surgery, number of attempts, extent of mouth opening and leak in peri-LMA space. RESULTS: Overall, 72 males and 24 females participated in this study with a mean age of 40.64. Intubation by LMA was performed easily during the first attempt in 58% of the participants, with minimal resistance in 28.6% and with some problems during the second attempt in 10.5% of the cases. Throat pain after the operation was significantly lower. Systolic and diastolic pressure and heart rate had no statistically significant difference. CONCLUSIONS: The results showed that in the first 15 seconds after the drug (e.g. propofol) administration, there were lower complications, rapid placement, and optimized time for the placement of LMA. The rate of success and its quality were reduced during the first attempt of insertion and termination of the effect of propofol.

Adult patient with Becker dystrophy undergoing orthopedic surgery: an anesthesia challenge.

Muscular dystrophies are considered to be a series of neuromuscular diseases with genetic causes and are characterized by progressive muscle weakness and degeneration of the skeletal muscle. The case of an adult man with Becker dystrophy referred for repair of the patella tendon tearing and patella fracture is described. He underwent successful surgery using total intravenous anesthesia without any complications.

Perioperative Cardiac Troponin I Levels in Patients Undergoing Total Hip and Total Knee Arthroplasty: A Single Center Study.

BACKGROUND: Cardiac injury is one of the significant perioperative complications in major orthopedic surgeries and its early diagnosis is useful in the reduction of postoperative comorbidity. The cardiac troponin is a sensitive and specific biomarker for detecting this damage. OBJECTIVES: The aim of this study was to evaluate the levels of perioperative cardiac troponin I (cTnI) before and after arthroplasty in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). The effects of related variables and probable major cardiac complications were evaluated in this study. METHODS: For one year, in a prospective, cross-sectional study, the serum levels of cTnI before and 48 hours after arthroplasty were evaluated in 52 patients. Possible contributing factors including age, gender, body mass index (BMI), daily activity, history of hospitalization due to cardiovascular diseases, underlying illness, and medications were recorded. The Chi-square test, Pearson correlation, and Spearman test were used to examine the relationship between variables. RESULTS: The mean cTnI increased significantly after arthroplasty (P < 0.001). There was no significant relationship between age (P = 0.708), gender (P = 0.225), BMI (P = 0.195), daily activity (0.441), underlying illness (P = 0.244), and cTnI levels after arthroplasty. Linear regression showed BMI was significantly correlated with troponin changes (P = 0.006). Five patients had heart palpitations and one had chest pain, but none of the patients had any findings in favor of cardiac injury. CONCLUSIONS: cTnI levels after THA and TKA increased significantly, but this elevation was in the normal range. In addition, none of them had a new cardiac complication after arthroplasty.

The effect of intravenous paracetamol on postoperative pain after lumbar discectomy.

STUDY DESIGN: A randomized, double-blinded controlled trial. PURPOSE: Postoperative pain relief especially using analgesic drugs with minimal side effects has considerable clinical importance. This study aimed to examine the effect of intravenous paracetamol on pain relief after lumbar discectomy as a major surgery. OVERVIEW OF LITERATURE: Patients undergoing lumbar discectomy experience a high degree of lumbar pain. Some authors emphasize the use of intravenous paracetamol to improve postoperative pain and increase patients' satisfaction following this surgery. METHODS: Fifty-two patients scheduled for lumbar discectomy were randomly allocated into two groups: a group that received intravenous paracetamol (1 g/100 mL normal saline) within the last 20 minutes of surgery as the case group (n=24) and a group that received sodium chloride 0.9% 100 mL as the control group (n=28). Postoperative pain was assessed at 1, 6, 12, 18, and 24 hours after surgery by a visual analogue scale (VAS). The dosage of the administered opioid (morphine), as well as drug-related side effects within the first 24 hours after surgery were also recorded. RESULTS: The mean VAS score was significantly lower in the paracetamol group than the controls for all of the assessed time points. Although the dose of the administered morphine was numerically lower in the paracetamol group, this difference was not statistically significant (5.53±4.49 mL vs. 7.85±4.17 mL). CONCLUSIONS: Intravenous paracetamol as a non-opioid analgesic can relieve postoperative pain in patients undergoing lumbar discectomy; however, its use alone may not represent the best regimen for reducing the needed dose of opioids after operation.

The Effect of Omega-3 Fatty Acids on ARDS: A Randomized Double-Blind Study.

PURPOSE: The aim of this study was to evaluate the effect of an enteral nutrition diet, enriched with omega-3 fatty acids because of its anti-inflammatory effects on treatment of patients with mild to moderate ARDS. METHODS: This randomized clinical trial was performed in two ICUs of Tabriz University of Medical Sciences from Jun 2011 until Sep 2013 in north west of Iran. Fifty-eight patients with mild to moderate ARDS were enroled in this clinical trial. All patients received standard treatment for ARDS based on ARDS network trial. In intervention group, patients received 6 soft-gels of omega-3/day in addition to the standard treatment. RESULTS: Tidal volume, PEEP, pH, PaO2/FiO2 , SaO2, P platue and PaCO2 on the 7(th) and 14(th) days didn't have significant difference between two groups. Indices of lung mechanics (Resistance, Compliance) had significant difference between the groups on the 14(th) day. Pao2 had significant difference between two groups on both 7(th) and 14(th) days. Trend of PaO2 changes during the study period in two groups were significant. We showed that adjusted mortality rate did not have significant difference between two groups. CONCLUSION: It seems that adding omega-3 fatty acids to enteral diet of patients with ARDS has positive results in term of ventilator free days, oxygenation, lung mechanic indices; however, we need more multi center trials with large sample size and different doses of omega-3 fatty acids for their routine usage as an adjuant for ARDS treatment.

Hemodynamic parameters of low-flow isoflurane and low-flow sevoflurane anesthesia during controlled ventilation with laryngeal mask airway.

BACKGROUND: Nowadays laryngeal mask airway (LMA) is popular as one of the best choices for airway management. Low-flow anesthesia has some advantages like lower pollution, hemodynamic stability and cost effectiveness. Volatile anesthetics are widely used for anesthesia maintenance during operations. Sevoflurane has more hemodynamic stability compared to isoflurane, but there are few studies comparing the hemodynamic stabilities of these two anesthetics during controlled low flow anesthesia with LMA. OBJECTIVES: The aim of this study was to compare the effects of low-flow sevoflurane and low-flow isoflurane on hemodynamic parameters of patients through LMA. PATIENTS AND METHODS: Eighty patients, scheduled for elective ophthalmic surgery, were randomly divided into two groups. After induction, an LMA with an appropriate size was inserted in all the patients and they were randomly allocated to two groups of low-flow sevoflurane (n = 40) and low-flow isoflurane (n = 40). Hemodynamic parameters (heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP) and Mean Arterial Pressure (MAP) were recorded at 5, 10, 15, 20, 25 and 30 minutes after the anesthesia induction. RESULTS: The mean heart rate values were significantly less in the sevoflurane group (P value < 0.05) at 25 minutes after the surgery. The mean Blood Pressure in the isoflurane group was significantly higher compared with the sevoflurane group in 10, 20 and 30 minutes after the surgery (P values = 0.0131, 0.0373 and 0.0028, respectively). These differences were clinically unimportant because heart rate and mean blood pressure were on normal ranges. CONCLUSIONS: Seemingly, low-flow sevoflurane with LMA did not have any significant hemodynamic effect on clinical practice. Therefore, low-flow sevoflurane anesthesia with LMA might be considered in patients with short operations who need rapid recovery from anesthesia.

Comparison of recovery after anesthesia with remifentanil infusion versus halothane in children undergoing strabismus surgery.

OBJECTIVE: To compare recovery after anesthesia with remifentanil infusion versus halothane for strabismus surgery METHODS: This study was performed from September 2004 to March 2005 in Tabriz Nikookary Hospital, Tabriz, Iran on children aged 2-12 years scheduled for strabismus surgery randomized into 2 groups of 25 patients each: the H group in which anesthesia was maintained with halothane and the R group in which anesthesia was maintained with remifentanil. RESULTS: There was no meaningful difference in extubation time after discontinuing drugs between the 2 groups (p=0.14). However, there was a significant difference in the time of purposeful movements, proper oxygenation, consciousness, and discharge from the post anesthetic care unit between the 2 groups, all being shorter in group R. Also in group R, the time to spontaneous breathing return was longer, cases of neuromuscular reversal were fewer and cases of limb movements were more than group H. CONCLUSION: Maintenance of anesthesia with remifentanil in children aged 2-12 years undergoing strabismus surgery provided desired hemodynamic status and shorter time of discharge criteria.