Scalp Nerve Block for Enhanced Pain Control and Analgesic Optimization in Elective Craniotomy: A Randomized Controlled Trial with Analgesia Nociception Index Monitoring.

BACKGROUND: In patients who are candidates for craniotomy, scalp nerve blocks have been shown to be effective in relieving pain intensity as well as postoperative hemodynamic stability after surgery, but the results have been inconsistent. We aimed to assess the effect of scalp block on pain control, intraoperative drug use under Analgesia Nociception Index (ANI) monitoring, and postoperative pain in patients who were candidates for elective craniotomy. METHODS: In this randomized, single-blinded clinical trial study, candidates for craniotomy were randomly (using the block randomization method) divided into 2 groups before entering the operating room. The first group received a scalp block with bupivacaine (intervention), and the second group did not receive a scalp block (control) besides the routine anesthetic procedure in these patients. ANI, hemodynamic parameters, and the amounts of received remifentanil were conducted and compared. RESULTS: Patients under scalp block received less dosage of fentanyl than the nonscalp block group (mean = 57.14 ± 15.59 mcg vs. 250.00 ± 65.04 mcg, respectively). Similarly, the dose of remifentanil required in the scalp block group was less (mean = 3.04 ± 1.95 mg and 5.54 ± 2.57 mg, respectively). No difference was observed in hemodynamic parameters such as blood pressure and heart rate (before, during, and after surgery). However, the group receiving scalp block had higher ANI means than the control group. CONCLUSIONS: Scalp nerve block has an effective role in pain control (increasing ANI), consequently reducing the need for analgesic drugs such as fentanyl and remifentanil following craniotomy without changing the hemodynamic condition.

Cadaveric kidney transplantation in an ESRD patient with Klippel-Feil syndrome-A case report.

Klippel-Feil syndrome (KFS) is a congenital skeletal disorder with classic clinical triad consisting of short neck, low hairline, and limitation of neck movement. In addition to skeletal deformities, diagnosed cases of KFS may have other anomalies such as cardiac, neurologic, and genitourinary disorder. We report a case of KFS with associated anomalies such as short neck, limitation of neck movement, scoliosis of cervical spine, and dextrocardia who received successful cadaveric kidney transplantation. This article aims to present kidney transplantation as option of treatment in KFS patient with ESRD and emphasize on the difficulty in airway management of this patient.

Comparison of Intraoperative Infusion of Remifentanil Versus Fentanyl on Pain Management in Patients Undergoing Spine Surgery: A Double Blinded Randomized Clinical Trial.

BACKGROUND: Remifentanil is an ultra-short-acting opioid which facilitates hemodynamic management. However, there are concerns about postoperative Remifentanil hyperalgesia because of its potent fast onset and offset. OBJECTIVES: The aim of this study was to determine visual analog scale (VAS), postoperative pain, and morphine used in two groups after spine surgery. METHODS: In this randomized clinical trial study, 60 patients aged 18 - 60 years old, according to the American Society of Anesthesiology (ASA) I - II, who underwent spinal canal stenosis or scoliosis surgery, were divided into two groups. In the control group, patients received 0.07 - 0.1 µg/kg/h intraoperative Fentanyl infusion, and in the intervention group 0.1 - 0.2 µg/kg/min remifentanil was infused during the surgery. Both groups received 15 mg/kg intravenous Acetaminophen 20 minutes before the end of the surgery. Postoperative pain score and morphine consumption were measured 6, 12, 24, and 48 hours after discharge from the post-anesthesia care unit (PACU). RESULTS: During the first 12 hours, VAS and morphine consumption were significantly higher in remifentanil group (P < 0.001). However, no significant difference was found between the two groups in morphine consumption 12 - 48 hours after surgery. CONCLUSIONS: These findings suggest that Remifentanil infusion during surgery may increase postoperative pain. Also, VAS and morphine consumption were higher during the first 12 hours.

Comparison of Goal-Directed Fluid Therapy using LiDCOrapid System with Regular Fluid Therapy in Patients Undergoing Spine Surgery as a Randomised Clinical Trial.

Background: Goal-directed fluid therapy (GDFT) is a new concept to describe the cardiac output (CO) and stroke volume variation to guide intravenous fluid administration during surgery. LiDCOrapid (LiDCO, Cardiac Sensor System, UK Company Regd 2736561, VAT Regd 672475708) is a minimally invasive monitor that estimates the responsiveness of CO versus fluid infusion. We intend to find whether GDFT using the LiDCOrapid system can decrease the volume of intraoperative fluid therapy and facilitate recovery in patients undergoing posterior fusion spine surgeries in comparison to regular fluid therapy. Methods: This study is a randomised clinical trial, and the design was parallel. Inclusion criteria for participants in this study were patients with comorbidities such as diabetes mellitus, hypertension, and ischemic heart disease undergoing spine surgery; exclusion criteria were patients with irregular heart rhythm or severe valvular heart disease. Forty patients with a previous history of medical comorbidities undergoing spine surgery were randomly and evenly assigned to receive either LiDCOrapid guided fluid therapy or regular fluid therapy. The volume of infused fluid was the primary outcome. The amount of bleeding, number of patients who needed packed red blood cell transfusion, base deficit, urine output, days of hospital length of stay and intensive care unit (ICU) admission, and time needed to start eating solids were monitored as secondary outcomes. Results: The volume of infused crystalloid and urinary output in the LiDCO group was significantly lower than that of the control group (p = .001). Base deficit at the end of surgery was significantly better in the LiDCO group (p < .001). The duration of hospital length of stay in the LiDCO group was significantly shorter (p = .027), but the duration of ICU admission was not significantly different between the two groups. Conclusion: Goal-directed fluid therapy using the LiDCOrapid system reduced the volume of intraoperative fluid therapy.

Comparison of Preoperative Hypertonic Saline versus Mannitol for Intraoperative Brain Relaxation and Early Postoperative Outcome among Patients with Cerebral Low-grade Glioma: A Prospective Study.

INTRODUCTION: Hypertonic saline (HS) has an important role in the treatment of raised intracranial pressure after traumatic brain injury. This study evaluates the efficacy and safety of HS and its impact on the postoperative course of patients undergoing craniotomy for low-grade gliomas. MATERIALS AND METHODS: Sixty patients with supratentorial low-grade glioma were enrolled. All patients were anesthetized and operated with the same team and protocol. They successively received either HS or mannitol just before surgery. The amount of brain edema was classified according to the dural tension score (I-III) just after craniotomy and before dural opening. Other intraoperative measurements (such as urine output, need, and dosage of other diuretic agents) and postoperative findings (intensive care unit [ICU] and hospital stay, corticosteroid demand, and confusion period) were also assessed. Pre- and postoperative serum S100B levels were documented in both groups. RESULTS: The dural tension score was not significantly different among the two groups: severe tension in six and five patients in the mannitol and HS groups, respectively. HS group had a significantly lower amount of diuresis (609 vs. 725 ml) during surgery. Patients in the HS group had shorter ICU stay (16.3 vs. 27.9 h) and shorter duration of corticosteroid therapy after surgery (3.4 vs. 5.2 days). CONCLUSION: HS infusion just before the onset of craniotomy is at least as effective as mannitol in controlling intraoperative brain edema in patients with supratentorial glioma. Improved early postoperative course and lower degrees of S100B rise after craniotomy seen in the HS group needs to be explained in more detailed studies.

Half Saline-Bicarbonate Solution as Intraoperative Fluid Replacement Therapy Leads to Less Acidosis and Better Early Renal Function During Deceased-Donor Transplant.

OBJECTIVES: Normal saline is the most common crystalloid solution that is used in renal transplant surgery. In this study, our aim was to determine the effects of a combination of half saline and bicarbonate versus normal saline as a routine solution. MATERIALS AND METHODS: For this double-blind random-ized clinical trial, we enrolled 100 adult patients undergoing kidney transplant. Patients were divided into 2 groups: those who received normal saline and those who received half saline and bicarbonate infusion as fluid replacement therapy during renal transplant. All patients received about 40 mL/kg of crystalloids during surgery. Serial creatinine con-centrations (primary outcomes) were compared between groups at 1, 2, 3, and 7 days after surgery. Urine output (secondary outcome) was compared between groups at recovery and at 6 and 24 hours after surgery. In addition, base excess, chloride, and sodium levels were measured before and 6 hours after surgery. Each liter of half saline-bircarbonate, which is relatively isoosmotic to human plasma, was composed of 70 mEq bicarbonate, 77 mEq chloride, and 147 mEq sodium. RESULTS: Patients who received half saline-bicarbonate had significantly lower postoperative creatinine levels at all time points than patients who received normal saline (P = .019). Serum chloride and sodium levels (P = .001) were significantly higher and base excess (P = .007) was significantly lower in the normal saline group at 6 hours after transplant. At all time points, urine output levels were significantly higher in the half saline-bicarbonate group (P = .001). CONCLUSIONS: The use of half saline-bicarbonate was associated with better early graft function compared with normal saline in the first 7 days after transplant.

Prevalence of Abnormal Methemoglobinemia and Its Determinants in Patients Receiving Nitroglycerin During Anesthesia.

BACKGROUND: One of the complications of nitroglycerin infusion during surgery is methemoglobinemia. OBJECTIVES: The aim of this study was to investigate the prevalence of methemoglobinemia and its association with nitroglycerin infusion for the treatment of hypertension during general anesthesia. METHODS: Patients received nitroglycerin infusion at a dose of 2 µ/kg/min. The aim of controlling blood pressure was to set the blood pressure at 20% of the patient's baseline. Then, the amount of methemoglobin was recorded at 15-minute intervals. Backward stepwise logistic regression test was used to determine the factors affecting methemoglobinemia. RESULTS: Based on the criterion of methemoglobin level above 2%, the prevalence of pathologic methemoglobinemia was 56.6%. After adjusting for confounding variables in the final model, the total prescribed dose was the only factor affecting pathologic methemoglobinemia. CONCLUSIONS: For the first time, we showed that more than half of the patients undergoing surgery suffered from methemoglobin level above 2% after prescribing nitroglycerin, and the only predictor of abnormal methemoglobin level was the rate of nitroglycerin prescription. Anesthesiologists are recommended to be more careful about the speed of nitroglycerin infusion, and if the patient needs higher doses, patient care for the early detection of methemoglobinemia should be the priority.

Low-dose preoperative pregabalin improves postoperative pain management in septorhinoplasty surgery: a double-blind randomized clinical trial.

PURPOSE: To evaluate the efficacy of single low dose (75 mg) preoperative pregabalin in reducing post-operative pain of septorhinoplasty. METHODS: A double blind single center Randomized controlled trial based on block randomization. In the pregabalin group (PG) 34 participants received 75 mg pregabalin orally one hour before anesthesia induction while in control group (CG) 34 participants received a placebo. Pain and sedation were repeatedly measured with Visual Analouge Scale (VAS) and Riker Sedation-Agitation Scale (RSAS) respectively, 0.5, 1, 2, 6, 24 hours postextubation. Cumulative doses of fentanyl and ibuprofen received in both groups were compared. RESULTS: Thirty-two of the participants in PG and 33 of the participants in CG completed the study. The Mean VAS pain score was less in PG versus CG 30 min postoperatively (2.30 ± 1.30 vs. 4.85 ± 1.17), one hour (2.28 ± 0.92 vs. 4.27 ± 0.78), two hours (2.11 ± 0.88 vs. 3.60 ± 0.61) and six hours (1.47 0.62 vs. 2.76 ± 0.91) but not 24-hours postoperatively (0.84 ± 0.62 vs. 1.09 ± 0.92). Participants in the PG were less agitated during early post-extubation period (at 10 min: RSAS 3.93 ± 0.43 vs. 4.42 ± 0.50) and more alert during the first hour post-extubation (at 60 min: RSAS 3.90 ± 0.29 vs. 3.36 ± 0.69). The total dose of rescue fentanyl and ibuprofen was lower in the PG compared to the CG. CONCLUSIONS: A single dose of 75 mg pregabalin is very effective for pain control after septorhinoplasty procedure when administered one hour before anesthesia induction. Side effects are rare and opioid sparing was noted. TRIAL REGISTRATION: Clinical trial number: IRCT2017043033706N1.

The Efficacy of Intraoperative Ketamine-Haloperidol for Prevention of Catheter-related Bladder Discomfort After Lumbar Spinal Stenosis Surgery.

OBJECTIVES: Catheterization of urinary bladder during surgery frequently leads to agitation of the patient in the recovery room, especially in those patients who remain catheterized after gaining consciousness. We hypothesized that administration of a combination of ketamine-haloperidol (KH) before urinary catheterization would reduce the incidence of catheter-related bladder discomfort (CRBD) while reducing some adverse effects of ketamine in the postoperative period. METHODS: A total of 119 male patients who underwent lumbar spinal stenosis surgery were randomized into three groups. The KH group consisted of 39 patients who received KH just before urinary catheterization. The second arm of the study including 40 patients who received pethidine-haloperidol (PH). The control (C) group consisted of 40 patients who received normal saline as a placebo. We sought to determine the incidence and severity of CRBD at arrival in recovery and one, six, and 24 hours after. RESULTS: The incidence of CRBD upon arrival in the recovery room was 17.9% in the KH group, and 52.5% and 55% in the PH and C groups, respectively. The incidence of CRBD was significantly lower in the KH group at arrival in the recovery room. The severity of CRBD was lower in the KH group at one and six hours of surgery (p < 0.007). There was no significant difference 24 hours after surgery. CONCLUSIONS: Intravenous administration of KH before urinary catheterization effectively decreases the incidence and severity of postoperative CRBD while reducing adverse effects attributed to ketamine.

Preemptive Effect of Intraurethral Instillation of Ketamine-lidocaine Gel on Postoperative Catheter-related Bladder Discomfort after Lumbar Spine Surgery.

BACKGROUND: Catheter-related bladder discomfort (CRBD) is one of the main reasons of agitation after surgery, leading to urgency and frequency during recovery. Ketamine has been used as an effective drug for reducing the signs and severity of this problem. We hypothesized that intraurethral instillation of ketamine-lidocaine gel before urinary catheterization can reduce the incidence of CRBD in the postoperative period. MATERIALS AND METHODS: A total of 136 male patients, who underwent two-level laminectomy/discectomy were enrolled in this randomized clinical trial. Patients were randomized into the two groups before urinary catheterization. The ketamine group received urethral lubrication with 5 mL xylocaine jelly (2%) in conjunction with 2 mL (100 mg) ketamine. Patients in control group received urethral lubrication with 5 mL xylocaine jelly (2%) in conjunction with 2 mL distilled water. The primary outcome was the incidence of CRBD. CRBD was assessed using four-stage criteria when arriving in the recovery room and at 1, 2, and 6 h after surgery. Postsurgical pain and the number of sedatives given and opioid requirement were also the secondary outcomes in this study. RESULTS: Intraurethral instillation of ketamine-lidocaine gel reduced the incidence of CRBD at recovery (P < 0.001) along with a reduction in the severity of CRBD (P < 0.05) during the 1st and 2nd visit compared with control group. The mean pain intensity score (visual analog scale) and opioid requirement to relieve postsurgical pain were lower in the ketamine group during all the study timepoints from recovery and after transfer to the ward (P < 0.008). A higher rate of sedation (72% vs. 11%) also was seen at recovery period in the ketamine group (P < 0.008). CONCLUSION: Intraurethral instillation of ketamine-lidocaine gel before bladder catheterization is an effective technique for reducing the incidence and severity of postoperative CRBD.

Comparison of Nasal Intubations by GlideScope With and Without a Bougie Guide in Patients Who Underwent Maxillofacial Surgeries: Randomized Clinical Trial.

BACKGROUND: Nasotracheal intubation is commonly performed to provide a secure airway for the maintenance of general anesthesia in maxillofacial surgeries. Routine nasotracheal intubation is performed under general anesthesia by direct laryngoscopy, frequently with the aid of Magill forceps. This method can be time-consuming and may cause bleeding in the field of view. A gum elastic bougie (GEB) is a cheap, slender, and flexible device that could expedite nasotracheal intubation. The aim of this study was to evaluate the use of a GEB during nasotracheal intubation to facilitate the procedure and reduce the rate of complications. METHODS: In this randomized clinical trial study, 110 patients with American Society of Anesthesiologists (ASA) physical status I-II from 15 to 65 years of age were randomized into 2 equal groups. In both groups, a GlideScope and armored tube were used. In the GEB group, GEB was used to facilitate nasal intubation while the nasal intubation was performed without the aid of GEB in the routine group. The difficult intubation (defined as >1 attempt for intubation) was the primary outcome, and the duration of the intubation, the presence of traces of bleeding, the need for a tube replacement, and the usage of Magill forceps were the secondary outcomes. RESULTS: The incidence of bleeding in the GEB group was 1.81% vs 43.63% in the routine group (P < .001). In 5.5% of the GEB group, Magill forceps were used to advance the tube versus 67.3% in the routine group (P < .001). The mean time for intubation in GEB group was 48.63 ± 8.53 vs 55.9 ± 10.76 seconds in the routine group (P < .001). CONCLUSIONS: The GEB is a useful aid to nasotracheal intubation, reducing bleeding, the requirement for Magill forceps and, to a small degree, intubation time. A case exists for its routine use for this purpose.

Comparison of the Effect of Intra-Rectal Administration of Lidocaine Gel and Lidocaine Plus Fentanyl on Pain Reduction in Prostate Biopsy: A Randomized Clinical Trial.

OBJECTIVES: The aim of this study was to compare the effect of intra-rectal administration of lidocaine gel alone versus lidocaine gel plus topical fentanyl on pain reduction in prostate biopsy. METHODS: In a double-blind randomized clinical trial, 96 patients who met the inclusion criteria were randomly assigned into two groups. 1) The treatment group: Lidocaine gel (2%) 50 g and 2) the intervention group: Lidocaine gel (2%) 50 g and fentanyl gel 50 µg. During the prostate biopsy, the VAS score was recorded. Blood pressure, heart rate, and patient level of consciousness were also analyzed. RESULTS: The mean VAS score was 5.1 ± 2 and 3.0 ± 2, which was lower in the intervention group (P value < 0.001). In terms of consciousness after biopsy, there was no difference between the two groups (P value = 0.358). There was no difference between the groups in terms of mean blood pressure and heart rate before and during the prostate biopsy. Finally, in terms of consciousness after the prostate biopsy, there was no difference between the current treatment and intervention groups. CONCLUSIONS: The combination of lidocaine gel and fentanyl with a dose of 50 µg has a significant effect on reducing the pain associated with prostate biopsy in comparison with lidocaine gel alone. The antinociceptive effect of the above regimens is not associated with hemodynamic changes and changes in patients' consciousness.

Effect of Hypertonic Saline 5% on Early Graft Function and Urinary Interleukin 18 and Neutrophil Gelatinase-Associated Lipocalin in Deceased-Donor Kidney Transplantation.

Ischemia reperfusion injury (IRI) is one of the main causes of delayed graft function (DGF) in deceased-donor kidney transplantation (DDKT). Evidences suggest that hypertonic saline (HS) has beneficial effects on IRI. The objective of the present study is to determine the effect of intraoperative HS, on graft function and urinary biomarkers of interleukin 18 (IL-18) and neutrophil gelatinase-associated lipocalin (NGAL), in patients with DDKT. The design of the study is a randomized, open-label, pilot trial in patients with DDKT. The intervention of the study is administration of 4 mL/kg HS, 5% before graft reperfusion. The primary endpoint was DGF. Fifty-eight (58) adult patients were randomized (HS, n = 32; control, n = 26). There were no significant differences between the two groups in terms of recipient, donor, and transplant characteristics. The rate of DGF was 20% in the HS group compared with 31.8% in the control group (Relative risk 0.63; 95% CI 0.23-1.67; P = 0.36). Serial serum creatinine in the first two days after surgery in addition to urine volumes during the first day after transplantation was significantly different in the HS group (P ≤ 0.05). The urinary NGAL and IL-18 were significantly lower in HS vs. control, at 24 h after transplantation (P ≤ 0.05). The frequency of adverse reactions was similar between groups. This study did not show any significant benefits from HS administration immediately before allograft reperfusion in terms of reducing DGF, serum creatinine at hospital discharge or length of hospital stay in deceased-donor kidney transplant patients.

Combined Ketamine-Tramadol Subcutaneous Wound Infiltration for Multimodal Postoperative Analgesia: A Double-Blinded, Randomized Controlled Trial after Renal Surgery.

BACKGROUND: Pain is an important consideration after renal surgery. A multimodal approach to postoperative pain management could enhance analgesia by risking fewer side effects after surgery. OBJECTIVES: The aim of this study was to evaluate the clinical efficacy of the subcutaneous infiltration of ketamine and tramadol at the incision site to reduce postoperative pain. METHODS: Sixty-four patients between 18 and 80 years old who were scheduled for elective renal surgery were enrolled in a double-blind randomized controlled study. At the end of the surgery, patients were divided into four groups with 16 patients in each group: the saline group, who were treated with 10 mL of saline solution; the K group, who were treated with 1 mg/kg etamine in 10 mL of saline solution; the T group, who were treated with 1 mg/kg tramadol in 10 mL of saline solution; and the K/T group, who were treated with 0.5 mg/kg ketamine with 0.5 mg/kg tramadol in 10 mL of saline solution. In each group, the solution was infiltrated subcutaneously at the incision site. The postoperative pain scores and rescue analgesic consumption of the patients in each group were recorded for 24 hours and compared. The primary goal of the study was to compare the results of patients treated with a combined ketamine and tramadol subcutaneous wound infiltration, patients treated with a tramadol subcutaneous wound infiltration, and patients treated with a ketamine subcutaneous wound infiltration. RESULTS: Sixty-four patients were enrolled in the study. Pain intensity and cumulative meperidine consumption were significantly lower in the K/T group (27 mg; 95% confidence interval, 25.2 - 53.2) in comparison with the group that received a saline infusion during the first 24 hours after surgery (P < 0.001). The sedation score of the K, T, and K/T groups were significantly higher than the saline group (P < 0.001). CONCLUSIONS: The combined subcutaneous infiltration of ketamine and tramadol at the incision site produces better analgesia and an opioid-sparing effect during the first 24 hours when compared with the control group and the groups that received a subcutaneous infiltration of only ketamine or tramadol.

Local Administration of Tranexamic Acid During Prostatectomy Surgery: Effects on Reducing the Amount of Bleeding.

BACKGROUND: One of the issues in prostatectomy surgery is bleeding. Although tranexamic acid (TRA) is an antifibrinolytic agent for reducing bleeding, controversies surround its use. OBJECTIVES: In this study, the effect of local administration of TRA on reducing bleeding during prostatectomy surgery was evaluated. METHODS: A total of 186 patients who underwent prostatectomy surgery were assessed in this clinical trial study. Patients were divided randomly into two groups. After prostate removal, TRA (500 mg TRA with 5 mL total volume) to the intervention group and normal saline to the control group were sprayed with the same volume. At the end of surgery, the prescribed blood bags were measured and recorded. Hemoglobin and platelet levels were recorded 6 hours after the test. Moreover, the amounts of blood inside the blood bags in the first 24 hours, the second 24 hours, and the total length of hospital stay were recorded and compared in each group. RESULTS: By comparing the measured values before and after surgery, we found that the amounts of hemoglobin, hematocrit, and platelet decreased. The mean blood loss in the intervention group was recorded at 340 mL and that in the control group was 515 mL. The maximum bleeding in the control group was almost twice as much as that in the intervention group. Blood loss in the intervention group with the administration of TRA was significantly lesser than that in the control group (P = 0.01). The decrease in platelet level in the intervention group was significantly lower than that in the control group (P = 0.03). CONCLUSIONS: The present study showed that local administration of TRA significantly reduces bleeding after prostatectomy surgery and is effective in preventing postoperative hemoglobin decrease.

Multimodal Analgesia With Ketamine or Tramadol in Combination With Intravenous Paracetamol After Renal Surgery.

BACKGROUND: Opioids are generally the preferred analgesic agents during the early postoperative period. OBJECTIVES: The present study was designed to assess and compare the multimodal analgesic effects of ketamine and tramadol in combination with intravenous acetaminophen after renal surgery. PATIENTS AND METHODS: This randomized, double-blinded, clinical trial was conducted on 80 consecutive patients undergoing various types of kidney surgeries in Sina hospital in Tehran in 2014 - 2016. After extubation, the patients were randomly assigned to receive intravenous paracetamol (1 gr) plus tramadol (0.7 mg/kg) (PT group) or paracetamol (1 gr) plus ketamine (0.5 mg/kg) (PK group) within ten minutes. Pain severity was assessed by the visual analog scale (VAS), and the level of agitation was assessed by the Ramsey sedation scale (RSS). Morphine consumption was assessed within the first six hours after drug injection, and hemodynamic parameters were assessed at 5, 10, and 20 minutes after infusion, at the time of transfer from recovery to the ward, and also at one and six hours after transfer to the ward. RESULTS: Postoperative pain scores were significantly lower in the PK group than in the PT group during all study time points. The mean dose of morphine needed at recovery in the PK group was lower compared with the PT group (0.47 ± 0.94 mg versus 1.50 ± 1.35 mg/P = 0.001). The level of agitation based on the RSS score was significantly lower in the PK group than in the PT group at 10 and 20 minutes after drug administration. The total postoperative complication rate in the PK group was lower than in the PT group (20% versus 53.3%, P = 0.007). In this regard, catheter bladder discomfort was more frequent in the PT group than in the PK group (43.3% versus 3.3%, P < 0.001). CONCLUSIONS: The combination of intravenous paracetamol 1 gr and ketamine 0.5 mg/kg resulted in an overall reduction in pain scores, decreased postoperative analgesic requirements, and lower agitation score compared with intravenous paracetamol 1 gr and tramadol 0.7 mg/kg for patients undergoing renal surgery.

Analgesic Efficacy of Nephrostomy Tract inFiltration of Bupivacaine and Ketamine after Tubeless Percutaneous Nephrolithotomy: A Prospective Randomized Trial.

BACKGROUND: Recently, the use of ketamine as a systemic and local analgesic drug in reducing post-operative pain is studied more frequently. OBJECTIVES: The aim of the present study was to assess the analgesic efficacy of IV ketamine injection inaddition to nephrostomy tract infiltration of ketamine-bupivacaine on postoperative pain relief after tubeless percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: Patients (n = 100), with renal stone who were candidates for PCNL were randomized to five groups with 20 cases in each: Group C, 10 mL of saline solution was infiltrated into the nephrostomy tract; Group B, 10 mL of 0.25% bupivacaine was infiltrated into the nephrostomy tract; Group BK1, 10 mL of 0.25% bupivacaine plus 0.5 mg/kg ketamine was infiltrated into the nephrostomy tract; Group BK2, 10 mL of 0.25% bupivacaine plus 1.5 mg/kg ketamine was infiltrated into the nephrostomy tract; Group K, 10 mL of saline solution containing 0.5 mg/kg ketamine was intravenously administered. Post-operative pain scores were compared between groups as the primary objective. Comparison of Sedation Scores, rescue analgesic consumption, time to the first rescue analgesics administration, hemodynamic and SpO2 values were regarded as the secondary objective. RESULTS: Mean VAS scores in the first 30 min and total analgesic consumption in the first 24 h of post-operative period were significantly lower in groups BK1 and BK2 in comparison with the other groups (P < 0.05). Also, time to first rescue analgesics administration was longer in the same groups (P < 0.05). CONCLUSIONS: Infiltration of ketamine plus bupivacaine provides superior analgesic effects in PCNL surgery compared with other methods.

Comparison of the Effects of Subcutaneous Versus Continuous Infusion of Heparin on Key Inflammatory Parameters Following Sepsis.

BACKGROUND: Sepsis is the result of the interaction between inflammatory mediators and coagulation pathway. Unfractionated heparin may play a role as an anti-inflammatory agent beyond its anticoagulatory effect in sepsis. As a result, it may cause reduction in organ failure rate in patients with sepsis due to its impact on both inflammatory and coagulation process. OBJECTIVES: The aim of this study was to evaluate the anti-inflammatory effects of heparin in sepsis. Plasma plasminogen activator inhibitor-1 (PAI-1) as an inflammatory mediator and urinary necoutrophil gelatinase-associated lipocalin (NGAL) as a marker of kidney injury were investigated. PATIENTS AND METHODS: This prospective, randomized controlled trial was conducted in a 32-bed intensive care unit. Thirty patients with sepsis were randomized to receive heparin infusion of 500 units/hour or 5000 units of heparin three times a day, subcutaneously. The plasma level of PAI-1 and urinary level of NGAL were determined at day 0, 2 and 7. RESULTS: The infusion group had a lower plasma PAI-1 level compared to the subcutaneous group at day 7 (11.3 ± 1.6 vs. 16.5 ± 4.2; P = 0.003). The urinary NGAL level was lower in the infusion group at day 2 (131.3 ± 11.9 vs. 151.2 ± 20.6; P = 0.014); however, at day 7 the NGAL level was decreased in the subcutaneous group as much as the infusion group and there was no significant difference between the two groups. There was no significant difference in the acute physiology and chronic health evaluation (APACHE) II and sequential organ failure assessment (SOFA) scores between the two groups at day 0, 2 and 7. CONCLUSIONS: Low-dose heparin infusion compared to subcutaneous heparin can decrease the plasma PAI-1 and urinary NGAL levels more rapidly. It can be related to anti-inflammatory effects of heparin, which may be more prominent in infusion route.

An Assessment of Intubation Skill Training in Novice Anesthesiology Residents of Tehran University of Medical Sciences With the Use of Mannequins.

BACKGROUND: The goal of this study was to evaluate the impact of intubation skill training involving the use of mannequins on novice anesthesiology residents in a knowledge, attitudes, and practices designed study in which three different types of evaluation were implemented. METHODS: All first-year anesthesiology residents (24) of Sina Hospital, affiliated to the Tehran University of Medical Sciences, were invited to participate in an intubating skills training course. The program comprised two theoretical and three practical sessions, lasting a total of 16 hours over four days. Faculty assessment of residents' practices was carried out using the questionnaire results, measured using a Likert scale, as the primary outcome. An improvement in the theoretical knowledge of the novice anesthesiology residents (using the Likert scale) and their attitudes towards the educational course in general (via a multiple choice question examination), were also evaluated. RESULTS: The mean score following faculty assessment of the residents' practical skills was 4.6 out of 5.0 (92%) [standard deviation (SD) of 0.13]. The mean score with respect to the attitudes of the residents was 4.8 out of 5.0 (96%) (SD of 0.16). The overall mean theoretical score of the residents improved significantly upon completion of the training program (P = 0.001). CONCLUSIONS: Our results suggest that the personnel in the five participating faculties were highly satisfied with the practical performance of the residents, who were found to hold good attitudes towards the program as a whole.

Predictive Values of Urinary Interleukin 18 and Neutrophil Gelatinase-Associated Lipocalin for Delayed Graft Function Diagnosis in Kidney Transplantation.

BACKGROUND: Delayed graft function is a main complication after deceased donor kidney transplantation that adversely affects graft outcome. Difficulties in prediction and early detection of delayed graft function have hindered the ability to perform proper therapeutic interventions. We investigated whether measuring urinary interleukin 18 and neutrophil gelatinase-associated lipocalin as markers of ischemia reperfusion injury could predict delayed graft function in deceased donor kidney transplant patients. METHODS: We studied 69 patients undergoing kidney transplantation from deceased donor during early October 2013 to December 2014 at the Urology Research Center, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran. Serial urine samples at 2, 24, and 48 h after transplantation were analyzed for interleukin 18 and neutrophil gelatinase-associated lipocalin levels. RESULTS: Thirteen patients (18.9%) developed delayed graft function. Urine interleukin 18 to urine creatinine ratio was significantly higher in patients with delayed graft function compared to those with non-delayed graft function, at 2 (P=0.003), 24 (P<0.001) and 48 h (P=0.018) points. The levels of neutrophil gelatinase-associated lipocalin to urine creatinine ratio were significantly higher in the group with delayed graft function at the 24 (P=0.004) and 48 h (P=0.015) points. The receiver-operating characteristic curve analysis suggested that both urinary biomarkers at 24 h after transplantation had better accuracies for prediction of delayed graft function. In multivariate analysis, only urinary interleukin 18 to urine creatinine ratio improved the ability of clinical model for predicting delayed graft function. CONCLUSION: Urinary interleukin 18 to urine creatinine ratio at 24 h post-transplantation, along with traditional markers such as relative fall in serum creatinine, urine output and other risk factors for delayed graft function, increased the ability to predict delayed graft function.