Effect of erythropoietin on SOFA score, Glasgow Coma Scale and mortality in traumatic brain injury patients: a randomized-double-blind controlled trial.

Background: Recent studies suggest that erythropoietin has an anti-inflammatory effect on the central nervous system. The authors aimed to investigate the effect of erythropoietin on Glasgow Coma Scale (GCS), Sequential Organ Failure Assessment (SOFA) scores, and the mortality rate of traumatic brain injury (TBI) patients. Methods: Sixty-eight patients with available inclusion criteria were randomly allocated to the control or intervention groups. In the intervention group, erythropoietin (4000 units) was administrated on days 1, 3, and 5. In the control group, normal saline on the same days was used. The primary outcomes were the GCS and SOFA score changes during the intervention. The secondary outcomes were the ventilation period during the first 2 weeks and the 3-month mortality rate. Results: Erythropoietin administration significantly affected SOFA score over time (P=0.008), but no significant effect on the GCS, and duration of ventilation between the two groups was observed. Finally, erythropoietin had no significant effect on the three-month mortality (23.5% vs. 38.2% in the erythropoietin and control group, respectively). However, the mortality rate in the intervention group was lower than in the control group. Conclusion: Our finding showed that erythropoietin administration in TBI may improve SOFA score. Therefore, erythropoietin may have beneficial effects on early morbidity and clinical improvement in TBI patients.

Evaluating the factors affecting clinical outcomes in critically ill COVID-19 unvaccinated patients admitted to the intensive care unit in a lower-middle-income country.

Background: COVID-19, the most destructive pandemic of this century, caused the highest mortality rate among ICU patients. The evaluation of these patients is insufficient in lower-middle-income countries with limited resources during pandemics. As a result, our primary goal was to examine the characteristics of patients at baseline as well as their survival outcomes, and propose mortality predictors for identifying and managing the most vulnerable patients more effectively and quickly. Methods: A prospective analysis of COVID-19 ICU-admitted patients was conducted in our healthcare centre in Iran, from 1 April until 20 May 2020. Ninety-three patients were included in the study, and all were unvaccinated. A multi-variate logistic regression was conducted to evaluate mortality-associated factors. Results: There were 53 non-survivors among our ICU-admitted patients. The mean duration from symptoms' onset to hospitalization was 6.92 ± 4.27 days, and from hospitalization to ICU admission was 2.52 ± 3.61 days. The average hospital stay for patients was 13.23 ± 10.43 days, with 8.84 ± 7.53 days in the ICU. Non-survivors were significantly older, had significantly lower haemoglobin levels and higher creatine phosphokinase levels compared to survivors. They had marginally lower SpO2 levels at admission, higher vasopressor administrations, and were intubated more significantly during their ICU stay. The use of immunosuppressive drugs was also significantly higher in non-survivors. Logistic regression revealed that a one-point increase in APACHE II score at ICU admission increased mortality by 6%, and the presence of underlying diseases increased mortality by 4.27 times. Conclusion: The authors presented clinical mortality prediction factors for critically ill patients infected with COVID-19. Additional studies are necessary to identify more generalized mortality indicators for these patients in lower-middle-income countries.

Predictive performance of SOFA (Sequential Organ Failure Assessment) and qSOFA (quick Sequential Organ Failure Assessment) for in-hospital mortality in ICU patients with COVID-19 of referral center in the north of Iran a retrospective study.

Introduction: Patients diagnosed with Coronavirus disease 2019 exhibit varied clinical outcomes, with a reported mortality rate exceeding 30% in those requiring admission to the ICU. The objective of this study was to assess the predictive capacity of Sequential Organ Failure Assessment (SOFA) and quick Sequential Organ Failure Assessment (qSOFA) scores in determining mortality risk among severe COVID-19 patients. Method and materials: This retrospective study was performed by analyzing the data of patients with COVID-19 who were hospitalized in the ICUs. Data collection of the parameters required to calculate the SOFA and qSOFA Scores were extracted from patient's medical records. All data analysis was performed using SPSS V.25. Significance level considered as P less than 0.05. Findings: In this study, 258 patients were included. The results showed that the subjects ranged in age from 21 to 98 years with a mean and SD of 62.7±15.6. Of all patients, 127 (49.2%) were female and the rest were male. The mortality rate was 102 (39.5%). The underlying disease of diabetes mellitus with an odds ratio of 1.81 (CI=1.02-3.22) had a significant effect on mortality. In addition, a significant correlation was obtained between admission duration and SOFA score (r=0.147, P=0.018). The SOFA had a very high accuracy of 0.941 and at the cut-off point less than 5 had a sensitivity and specificity of 91.2% and 82.7%. In addition, qSOFA had high accuracy (0.914) and a sensitivity and specificity of 87.3% and 91.7% at the optimal cutting point of greater than 1. Conclusion: The findings of present study illustrated that deceased COVID-19 patients admitted to the ICU had higher scores on both SOFA and qSOFA scales than surviving patients. Also, both scales have high sensitivity and specificity for anticipating of mortality in these patients. The underlying diabetes mellitus was associated with an increase in patient mortality.

Evaluating patients' choice of general and spinal anesthesia for elective cesarean section and associated factors: a descriptive study.

During an elective cesarean section, the choice of method of anesthesia is critical for maternal and fetal outcomes. However, the anesthesiologist's decision is dependent on the patient's desire. This study aimed to determine the choice of general and spinal anesthesia among women undergoing elective cesarean sections and the factors affecting their choice. Methods: In this descriptive study, pregnant women who had the ability to undergo both spinal and general anesthesia were referred to public and private hospitals in (Sari Imam Khomeini Hospital, Mazandaran University of Medical Sciences). A questionnaire recorded the patient's demographic data, education and occupation, history of anesthesia, choice of anesthetic method, and reason for selection. Results: A total of 384 women were included in the study, of whom 60% selected general anesthesia and 40% selected spinal anesthesia. Among the reasons for not choosing spinal anesthesia, most common were fear of injury to the spinal cord (64.3%) and fear of seeing and hearing during the surgery (53.3%), and among the reasons for not choosing general anesthesia, most common were fear of not waking (54.3%) and a desire to be alert at the time of infant birth (40.7%). Most of the women with a history of spinal anesthesia selected spinal anesthesia (53%), and 62% of those without a history of spinal anesthesia selected general anesthesia. Factors such as age, nonmedical staff advice, and being employed were significantly correlated with the choice of anesthesia (P<0.005). Conclusion: The rate of general anesthesia selection was higher than spinal anesthesia. More attention and efforts are required to educate patients regarding the method of anesthesia prior to the surgery.

The Effect of Ultra-low-dose Intrathecal Naloxone on Pain Intensity After Lumbar Laminectomy With Spinal Fusion: A Randomized Controlled Trial.

BACKGROUND: Despite advances in pain management, several patients continue to experience severe acute pain after lumbar spine surgery. The aim of this study was to assess the safety and effectiveness of single ultra-low-dose intrathecal (IT) naloxone in combination with IT morphine for reducing pain intensity, pruritus, nausea, and vomiting in patients undergoing lumbar laminectomy with spinal fusion. MATERIALS AND METHODS: In this double-blind trial, patients scheduled for lumbar laminectomy with spinal fusion were randomly assigned to receive single ultra-low-dose IT naloxone (20 µg) and IT morphine (0.2 mg) (group M+N) or IT morphine (0.2 mg) alone (group M). The severity of postoperative pain, pruritus and nausea, and frequency of vomiting were assessed at recovery from anesthesia and, subsequently, at 1, 3, 6, 12, and 24 hours postoperatively using an 11-point (0-10) visual analogue scale. RESULTS: A total of 77 patients completed the study, and there were significant differences in postoperative pain, pruritus, and nausea visual analogue scale between the groups (P<0.05). After adjusting for body mass index and surgery duration, IT naloxone administration reduced the pain score (coefficient=1.84; 95% confidence interval [CI], 1.05-2.63; P<0.001), and the scores of pruritus and nausea (coefficient=0.9; 95% CI, 0.44-1.37; P<0.001 and coefficient=0.71; 95% CI, 0.12-1.31; P=0.02, respectively) compared with IT morphine alone. No serious adverse effects were observed. CONCLUSIONS: The addition of ultra-low-dose IT naloxone to IT morphine provides excellent postoperative pain management and effectively controls pruritus and nausea in patients undergoing laminectomy with spinal fusion.

The prophylactic effect of different levels of positive endexpiratory pressure on the incidence rate of atelectasis after cardiac surgery: A Randomized Controlled Trial.

Background: The use of positive end-expiratory pressure (PEEP) can have an important role as one of the ways to prevent and treat atelectasis, but it seems that there is still no consensus about its beneficial level. The aim of this study was to determine the effect of different levels of PEEP on the incidence of atelectasis after heart surgery. Methods: This is a double-blind randomized controlled trial that was adopted from a research project recorded in the Iranian Registry of Clinical Trials. This paper is the result of a research project undertaken at Fatemeh Zahra Hospital (Mazandaran Heart Center) in 2015. 180 patients underwent open heart surgery were selected and were divided randomly into three groups: control, PEEP=8, and PEEP=10 (60 in each group). The patients in the two PEEP8 and PEEP10 intervention groups separately received 8 cm H2O and 10 cm H2O PEEP, respectively, 30 minutes after admission to the ICU for 4 hours and then received 5 cm H2O PEEP until extubation. Atelectasis was examined two hours after the extubation and on the third day after surgery. Results: The incidence rates of atelectasis two hours after extubation on the first day of surgery were 22 (36.7%), 20 (33.3%) and 10 (16.7%) patients in the control, PEEP8 and PEEP10 groups, respectively. The differences were statistically significant among the three groups (p=0.035). The incidence rates of atelectasis on the third day after surgery were 39 (65%), 36 (60%) and 21 (35%) patients in the control, PEEP8 and PEEP10 groups, respectively. The differences were also statistically significant among the three groups (p=0.003). Conclusion: The use of 10 cm H2O PEEP can lead to a reduction in the incidence of atelectasis, intubation time at the ICU and length of ICU and hospital stay. Given that this level of PEEP is effective, this method is recommended to be used in postoperative care of patients.

Ultra-low-dose Naloxone as an Adjuvant to Patient Controlled Analgesia (PCA) With Morphine for Postoperative Pain Relief Following Lumber Discectomy: A Double-blind, Randomized, Placebo-controlled Trial.

BACKGROUND: Lumbar discectomy is one of the most commonly performed neurosurgical procedures. Many patients experience postoperative pain after lumbar discectomy. This study evaluated the effect of ultra-low-dose naloxone infusion on pain intensity after lumbar discectomy in individuals receiving patient-controlled analgesia (PCA) with morphine. MATERIALS AND METHODS: In a double-blind, randomized, controlled trial, a total of 80 patients scheduled for open discectomy was randomly assigned to receive naloxone (group N) or placebo (group P). After surgery, all patients were connected to a morphine PCA pump. Both groups received 500 mL of normal saline using a continuous infusion pump through a separate intravenous line for 24 hours. However, group N received a total dose of 0.25 µg/kg/h naloxone, which was added to the normal saline infusion. All patients were asked to grade the intensity of their pain, severity of nausea, vomiting, and pruritus on a 0 to 10 visual analog scale before being discharged from the postanesthesia care unit and at 1, 6, 12, and 24 hours postoperatively. RESULTS: It was observed that both groups had a statistically significant (P<0.01) time trend difference for pain, nausea, and pruritus scores. A significant difference was found between the 2 groups in terms of intensity of pain, nausea, and pruritus, with the naloxone group experiencing a lower level in comparison with the placebo group. Moreover, the median (interquartile range) of morphine consumption after surgery for patients who received naloxone was 26 (24.25 to 28) mg, which is significantly (P<0.001) lower than for the placebo group, which had a median (interquartile range) of 34 (32 to 36) mg. CONCLUSIONS: It is concluded that infusion of ultra-low-dose naloxone (0.25 µg/kg/h) along with morphine PCA can significantly reduce pain intensity, morphine consumption, and opioid-induced nausea and pruritus after lumbar discectomy.

The Effect of Zinc Supplementation on Sleep Quality of ICU Nurses: A Double Blinded Randomized Controlled Trial.

This study examined the effect of zinc supplementation on the sleep quality (SQ) of intensive care unit (ICU) nurses. In a double-blind, randomized controlled trial, 54 ICU nurses were randomly assigned to the intervention group ( n = 27) that received 220 mg zinc sulfate capsules every 72 hours for 1 month and the control group ( n = 26) that received placebo. Sleep quality of ICU nurses was measured by calculating the total quality sleep score using the Pittsburgh Sleep Quality Index (PSQI). The serum zinc level was a secondary outcome. All measurements were calculated at both baseline and 1 month after intervention. The total PSQI, subjective SQ, and sleep latency scores for the intervention group were significantly lower than the control group, which means that the SQ of ICU nurses in the intervention group improved from baseline. The serum zinc level of the intervention group at the end of the study was significantly higher than the control group, which means that zinc supplementation improved participants' serum zinc level. Based on these findings, the researcher suggested that zinc supplementation could be associated with better SQ, subjective SQ, and sleep latency in this group of workers.

Bolus administration of intravenous lidocaine reduces pain after an elective caesarean section: Findings from a randomised, double-blind, placebo-controlled trial.

We conducted a randomised double-blind, placebo-controlled trial to assess whether a bolus dose of lidocaine during the induction of general anaesthesia would reduce postoperative pain over 24 h. Level of satisfaction with pain control at 48 h after surgery and Apgar score were also examined. A total of 100 women aged 20-35 years, who were candidates for elective caesarean section (CS) were randomised to receive either 1.5 mg/kg lidocaine or placebo during the induction of general anaesthesia. Results showed that lidocaine decreased pain intensity over 24 h after surgery (p < .001), and decreased postoperative morphine consumption from median (range) of 3.79 (0-9) mg in the placebo group to 0 (0-12) mg and in the lidocaine group (p <.001). Lidocaine was not associated with postoperative nausea and vomiting or any side effects in women and newborn babies. We conclude that a small bolus dose of lidocaine attenuates postoperative pain, thus reducing the requirement for opioid consumption in the postoperative period. Impact statement • With its anti-inflammatory, anti-hyperalgesic and analgesic properties, intravenous perioperative lidocaine infusion (IVLI) has been used for optimal postoperative care in different surgeries. Limited evidence suggests that IVLI may be a useful adjuvant during general anaesthesia. There is a report of a positive effect on several outcomes after surgery including postoperative pain over 24 h after laparoscopic abdominal surgery or open abdominal surgery. However, there was a paucity of information regarding the efficacy of a bolus dose of lidocaine in patients undergoing caesarean section (CS). In this randomized, placebo-controlled trial the use of a bolus dose of 1.5 mg/kg lidocaine 2%, compared with placebo, during the induction of general anaesthesia for elective CS resulted in a significant decrease in postoperative pain score as well as decreased postoperative morphine consumption over 24 h. Lidocaine use was not associated with any side effect in participants and newborns. • This study provides the first evidence that a bolus dose of lidocaine may be a safe and simple alternative therapeutic intervention for enhanced postoperative recovery in terms of pain and postoperative opioid consumption. Future studies are needed to examine pain reducing effect of perioperative bolus dose of lidocaine after CS under spinal or epidural anesthesia.

The impact of oral care on oral health status and prevention of ventilator-associated pneumonia in critically ill patients.

BACKGROUND: Ventilator-associated pneumonia is one of the most common nosocomial infections which increase mortality rate and length stay of hospitalisation. Oral care would not only improve patient's oral health and well-being, but it can also reduce the incidence rate of ventilator-associated pneumonia. OBJECTIVES: The objective of this study was to identify the impact of oral care practices on oral health status of patients in intensive care unit and the incidence rate of ventilator-associated pneumonia. METHODS: This clinical trial recruited 100 participants who were randomly assigned to a control group (receiving oral care by nurses) and an intervention group (receiving systematic care by the researcher) during 2015-2016. Beck Oral Assessment Scale was used to determine the required number of times for receiving oral care with regard to patient's oral health in the intervention group. Each care included adjusting endotracheal tube cuff pressure, brushing with toothpaste, using antiseptics and moistening the lips. The oral cavity was examined using BOAS and Mucosal-Plaque Score, and Clinical Pulmonary Infection Score was used for detecting pneumonia. RESULTS: The BOAS scoring showed significant differences between the two groups from the first to fifth day (P<0.001). The mucosal-plaque index was significantly different between the two groups from the third day to fifth day (P<0.001). The incidence rate of pneumonia on the third and fifth day was 10% (5) and 14% (7) in the control group, and 4% (2) and 10% (5) in the intervention group, respectively. The Fisher test did not show significant difference (P=0.538), however, the incidence rate in the intervention group reduced compared with the control group. CONCLUSION: Although following a systematic oral care program could not significantly decrease the incidence of ventilator-associated pneumonia in critically ill patients compared to the conventional oral care practices, it significantly improved the oral health and mucosal-plaque index.

Administration of lidocaine to prevent cognitive deficit in patients undergoing coronary artery bypass grafting and valve plasty: a systematic review and meta-analysis.

INTRODUCTION: The administration of lidocaine to maintain cognitive function following coronary artery bypass grafting (CABG) and valve plasty is a controversial concept in terms of its effectiveness. We performed a systematic review to determine the effectiveness of treatment with lidocaine in preventing the occurrence of cognitive deficit after cardiac surgery. Area covered: To review the current literature on the subject, we searched the PubMed database and the Cochrane Library database (up to May 2015) and compiled a list of retrieved articles. Our final review includes only randomized controlled trials (RCTs) that compared lidocaine to a control (placebo) following CABG and valve plasty. Statistical analysis of the odds ratio (OR) and corresponding 95% confidence interval (CI) were used to determine the overall effectiveness of lidocaine for the prevention of cognitive deficit with both procedures. The Mantel-Haenszel method was used to pool data of the outcomes of cognitive deficit occurrence into fixed-effect model meta-analyses. Five RCTs were included in this study, with a total of 688 patients. Perioperative administration of lidocaine in patients undergoing cardiac surgery reduced occurrence of cognitive deficit (OR 0.583 [95% CI 0.438-0.777]; Z = -3.680; P = 0.00; I2 = 52%). No significant difference in the early occurrence of cognitive deficit was revealed in patients after cardiac surgery (OR 0.909 [95% CI 0.600-1.376]; Z = -0.451; P = 0.652; I2 = 11%). Expert commentary: Cognitive deficit associated with cardiac surgery is a common postoperative event. Lidocaine is contributed to a significantly reduced occurrence of cognitive deficit. Cognitive deficit management is recommended.

Pilonidal Sinus Operations Performed Under Local Anesthesia versus the General Anesthesia: Clinical Trial Study.

BACKGROUNDS: Various methods were defined to prepare patients for the pilonidal sinus surgery including local, spinal, and general anesthesia. But there is no powerful evidence to differ these procedures. Therefore, in the current study, we compared local and general anesthesia in the pilonidal sinus surgery. METHODS & MATERIAL: in this clinical trial (IRCT201312031786N5) study 60 patients with the pilonidal sinus disease divided to two groups of local anesthesia versus general anesthesia. For local anesthesia we used 6ml of 2% lidocaine with an epinephrine (1:200,000), 6ml of 0.5% bupivacaine, 1ml fentanyl (50µg/ml), 1ml clonidine (75µg/ml) and for general anesthesia fentanyl 1.5 µg.kg-1, thiopental 3-5 mg.kg-1, followed by the trachea intubation facilitated by atracurim 0.5 mg.kg-1 with maintenance of isoflurane 1-3% in nitrous oxygen 70% and oxygen 30%. The student t-test and Chi-square test were applied to evaluate the differences. RESULTS: there were 30 patients with the mean age of 27.43±8.42 years in local anesthesia group and 30 cases with the mean age of 27.5±8.44 years underwent general anesthesia. The recovery time was significantly lower in the local anesthesia group (P=0.000). The oxygen saturation of the general anesthesia group was significantly higher at 1 and 20 minutes after the operation. The average of pain score was significantly higher in general anesthesia group at 3h and 6h after surgery (P<0.001). There were no significant differences in post-operative complications and hospital length of stay. CONCLUSION: this investigation revealed that local anesthesia has decreased pain during 48 hours after the surgery, shorter recovery time, and the less consumption of painkillers. So, we concluded that we can consider local anesthesia as a good alternative for the general anesthesia in the pilonidal sinus surgery.

A double-blind randomized clinical trial comparing different doses of magnesium in cardioplegic solution for prevention of atrial fibrillation after coronary artery bypass graft surgery.

AIMS: This study aims to compare different doses of magnesium administered via cardioplegic solutions to prevent atrial fibrillation (AF) after coronary artery bypass graft (CABG) surgery. METHODS: A total of 120 patients who were scheduled for elective CABG surgery using cardiopulmonary bypass were enrolled in this double-blind, randomized clinical trial. After fulfilling the inclusion criteria, they were randomly allocated into three groups (A, B, and C). Patients in groups A, B, and C received 60, 80, and 100 mg/kg of magnesium sulfate via cardioplegic solutions during aortic cross-clamp, respectively. Postoperative AF was assessed by continuous ECG monitoring during 3 days after surgery. Also serum magnesium, potassium, and calcium levels were assessed during the study period. RESULTS: The findings revealed significant differences in four point measurements of serum magnesium level after surgery (P<.001). In particular, it was observed that 10 (26.3%) patients in group A, 4 (10%) patients in group B, and 2 (5.4%) patients in group C had AF after surgery. This indicates patients receiving magnesium at doses of 80 and 100 mg/kg had lower rates of AF occurrence than those receiving 60 mg/kg dose of magnesium (P=.02). Additionally, no significant difference was found in serum calcium and potassium concentration between the three groups throughout the study period. CONCLUSION: Magnesium administration via the cardioplegic solution during aortic cross-clamping at doses of 80 and 100 mg/kg can reduce the risk of AF occurrence after CABG compared to the dose of 60 mg/kg. Considering the lower rate of AF incidence and shorter length of ICU stay in patients receiving 100 mg/kg of magnesium, it seems reasonable to administer 100 mg/kg magnesium during aortic cross-clamp to prevent postoperative AF.

Effect of Etomidate Versus Combination of Propofol-Ketamine and Thiopental-Ketamine on Hemodynamic Response to Laryngoscopy and Intubation: A Randomized Double Blind Clinical Trial.

BACKGROUND: Laryngoscopy and intubation frequently used for airway management during general anesthesia, is frequently associated with undesirable hemodynamic disturbances. OBJECTIVES: The aim of this study was to compare the effects of etomidate, combination of propofol-ketamine and thiopental-ketamine as induction agents on hemodynamic response to laryngoscopy and intubation. PATIENTS AND METHODS: In a double blind, randomized clinical trial a total of 120 adult patients of both sexes, aged 18 - 45 years, scheduled for elective surgery under general anesthesia were randomly assigned into three equally sized groups. Patients in group A received etomidate (0.3 mg/kg) plus normal saline as placebo. Patients in group B and C received propofol (1.5 mg/kg) plus ketamine (0.5 mg/kg) and thiopental sodium (3 mg/kg) plus ketamine (0.5 mg/kg), respectively for anesthesia induction. Before laryngoscopy and tracheal intubation, immediately after, and also one and three minutes after the procedures, hemodynamic values (SBP, DBP, MAP and HR) were measured. RESULTS: A repeated measurement ANOVA showed significant changes in mean SBP and DBP between the time points (P < 0.05). In addition, the main effect of MAP and HR were statistically significant during the course of study (P < 0.05). Furthermore, after induction of anesthesia, the three study groups had significantly different SBP, DBP and MAP changes overtime (P < 0.05). However, HR changes over time were not statistically significant (P > 0.05). Combination of propofol-ketamine had superior hemodynamic stability compared to other induction agents. CONCLUSIONS: Combination of propofol-ketamine may be recommended as an effective and safe induction agent for attenuating hemodynamic responses to laryngoscopy and intubation with better hemodynamic stability. Although, further well-designed randomized clinical trials to confirm the safety and efficacy of this combination, especially in critically ill patients or patients with cardiovascular disease, are warranted.

Comparison of Proposed Modified and Original Sequential Organ Failure Assessment Scores in Predicting ICU Mortality: A Prospective, Observational, Follow-Up Study.

Background. The sequential organ failure assessment (SOFA) score has been recommended to triage critically ill patients in the intensive care unit (ICU). This study aimed to compare the performance of our proposed MSOFA and original SOFA scores in predicting ICU mortality. Methods. This prospective observational study was conducted on 250 patients admitted to the ICU. Both tools scores were calculated at the beginning, 24 hours of ICU admission, and 48 hours of ICU admission. Diagnostic odds ratio and receiver operating characteristic (ROC) curve were used to compare the two scores. Results. MSOFA and SOFA predicted mortality similarly with an area under the ROC curve of 0.837, 0.992, and 0.977 for MSOFA 1, MSOFA 2, and MSOFA 3, respectively, and 0.857, 0.988, and 0.988 for SOFA 1, SOFA 2, and SOFA 3, respectively. The sensitivity and specificity of MSOFA 1 in cut-off point 8 were 82.9% and 68.4%, respectively, MSOFA 2 in cut-off point 9.5 were 94.7% and 97.1%, respectively, and MSOFA 3 in cut-off point of 9.3 were 97.4% and 93.1%, respectively. There was a significant positive correlation between the MSOFA 1 and the SOFA 1 (r: 0.942), 24 hours (r: 0.972), and 48 hours (r: 0.960). Conclusion. The proposed MSOFA and the SOFA scores had high diagnostic accuracy, sensitivity, and specificity for predicting mortality.

A Double-Blind Randomized Clinical Trial Comparing the Effect of Neostigmine and Metoclopramide on Gastric Residual Volume of Mechanically Ventilated ICU Patients.

BACKGROUND: In critically ill patients, enteral feeding through the nasogastric tube is the method of choice for nutritional support. Gastrointestinal feeding intolerance and disturbed gastric emptying are common challenges in these patients. The aim of this study was to compare the effect of Neostigmine and Metoclopramide on gastric residual volume (GRV) in mechanically ventilated ICU patients. METHODS: In a double blind, randomized clinical trial, a total of 60 mechanically ventilated ICU patients with GRV >120 mL (3 hours after the last gavage), were randomly assigned into two groups A and B. At baseline and 6 hours later, patients in group A and B received intravenous infusion of neostigmine in a dose of 2.5 mg and metoclopramide in a dose of 10 mg in 100 ml of normal saline, within 30 minutes. Patients' gastric residual volumes were evaluated before the beginning of the intervention, and 3, 6, 9 and 12 hours after the intervention. RESULTS: After adjusting of other variables (Sex, BMI and ICU stay period) generalized estimating equation (GEE) model revealed that neostigmine treatment increased odds of GRV improvement compare to metoclopramide group (Estimate 1.291, OR= 0.3.64, 95% CI 1.07-12.34). However there is a statistically significant time trend (within-subject differences or time effect) regardless of treatment groups (P<0.001). The median time from intervention to GRV improvement was 6 hours (95% CI 3.75-8.25) and 9 hours (95% CI 7.38-10.17) in neostigmine and metoclopramide groups, respectively. This difference was statistically significant (P<0.05). CONCLUSION: It seems that neostigmine is more effective than metoclopramide in reducing GRV and improving gastric emptying in mechanically ventilated ICU patients without significant complication and this protocol may be effective on the tolerance of enteral feeding in ICU patients. Further well-designed randomized clinical trials are needed.

Does lidocaine as an adjuvant to morphine improve pain relief in patients presenting to the ED with acute renal colic? A double-blind, randomized controlled trial.

OBJECTIVE: Renal colic (RC) is a common clinical presentation in the emergency department (ED). Prompt and effective pain control is one of the first responsibilities of emergency physicians. The aim of this study was to evaluate the analgesic effect of adding lidocaine to morphine compared to morphine alone in patients presenting to the ED with RC. METHODS: In a double-blind, randomized controlled trial, a total of 110 adult patients of both sexes, aged 18 to 50 years, who presented to the ED with signs and symptoms suggestive of RC were randomly assigned into 1 of 2 groups. Patients in group A received morphine (0.1 mg/kg) plus lidocaine (1.5 mg/kg), whereas those in group B received morphine (0.1 mg/kg) plus normal saline 0.9% as placebo. All patients were asked to rate the intensity of their pain and nausea on a 0- to 10-point visual analog scale before and at 5, 10, 30, 60, and 120 minutes after intervention. RESULTS: There was a statistically significant time trend decline in both groups for both pain and nausea scores (P < .01). Repeated-measures analysis showed a significant effect for the interaction between group and time of persistent pain (P = .034), but there was no significant group effect in this regard (P = .146). Median times to being pain free in the group receiving morphine plus lidocaine and in the group taking morphine alone were 87.02 minutes (95% confidence interval [CI], 74.23-94.82) and 100.12 minutes (95% CI, 89.95-110.23), respectively (P = .071). Repeated-measures analysis also showed a significant group effect for nausea (P = .038), but there was no interaction between group and time in this regard (P = .243). The median nausea-free times in the group receiving morphine plus lidocaine and the group receiving morphine alone were 26.6 minutes (95% CI, 14.16-39.03) and 58.33 minutes (95% CI, 41.85-74.82), respectively. This time difference was statistically significant (P < .001). CONCLUSIONS: Using lidocaine may be recommended as an effective, safe, and inexpensive adjuvant to morphine in improving nausea and reducing the time needed to achieve pain and nausea relief in patients visiting the ED with acute RC.

Assessment of Critical Care Provider's Application of Preventive Measures for Ventilator-Associated Pneumonia in Intensive Care Units.

BACKGROUND: The implementation of guidelines for the prevention of Ventilator-associated pneumonia has been shown to have a significant effect in reducing the incidence of VAP. OBJECTIVE: The aim of the present study was to evaluate the implementation of the preventive strategies for VAP in ICUs of university hospitals of Sari, Iran. MATERIALS AND METHODS: This cross-sectional study was carried out in 600 beds/day in the ICUs of university hospitals of Sari from April to June 2012. Sampling was done by availability technique in patients receiving mechanical ventilation in the ICU. The implementation of the preventive measures was assessed by a standard checklist with previously approved validity and reliability. RESULTS: The percentage of implementing each of the measures was as follows: sterile suction, 88.44%; semi-recumbent position, 76.8%; oral hygiene, 58.45%; using heat and moisture exchanges (HMEs), 58%; controlling cuff pressure, 46.8%; hand hygiene, 32.8%; using anti-coagulants, 26.8% and physiotherapy, 25.5%. Closed suction system, continuous drainage of subglottic secretions and kinetic beds were not used at all. CONCLUSION: The overall mean percentage of implementing preventive measures was low and required designing integrated guidelines by considering the conditions of the ICUs in each country, as well as educating and encouraging the staffs to use the recommended guidelines.

Does Early Post-operative Administration of Aspirin Influence the Risk of Bleeding After Coronary Artery Bypass Graft Surgery? A Prospective Observational Study.

BACKGROUND: Aspirin has a proven role in preventing thrombotic diseases. However, given its anti-platelet activity, it is often assumed that its early post-operative administration significantly increase the amount of post-operative bleeding. AIM: The aim of this study was to determine whether early post-operative administration of aspirin influence the risk of bleeding in patients undergoing coronary artery bypass graft (CABG) surgery. METHODS: In a prospective observational study, 100 consecutive patients undergoing first time elective CABG surgery were include in the study. Patients received a low dose of aspirin (75-150 mg per day) either 1 hours (the early aspirin group; n=43) or 6 hours after surgery (the late aspirin group; n=57). Total mediastinal blood drainage, blood drainage after 6 hours, incidences of re-operation for the control of bleeding and transfusion of red blood cells (RBCs) and blood products were recorded and followed until chest tube removal. RESULTS: The groups were found to be matched for the confounding variables and no significant differences were found between post-aspirin bleeding (p=0.37), RBCs and blood product usage (p=0.90) or incidences of re-operation for control of bleeding (p=1.00) between the two groups. CONCLUSIONS: Early administration (1 hour after surgery) of aspirin did not appear to increase the risk of post-operative bleeding in patients undergoing CABG. Thereby, its early administration in such cases may be considered. Although further well-designed randomized controlled trials to confirm the safety and efficacy of early administration of aspirin after CABG surgery are warranted.

Can Valeriana officinalis root extract prevent early postoperative cognitive dysfunction after CABG surgery? A randomized, double-blind, placebo-controlled trial.

RATIONALE: We hypothesized that valerian root might prevent cognitive dysfunction in coronary artery bypass graft (CABG) surgery patients through stimulating serotonin receptors and anti-inflammatory activity. OBJECTIVES: The aim of this study was to evaluate the effect of Valeriana officinalis root extract on prevention of early postoperative cognitive dysfunction after on-pump CABG surgery. METHODS: In a randomized, double-blind, placebo-controlled trial, 61 patients, aged between 30 and 70 years, scheduled for elective CABG surgery using cardiopulmonary bypass (CPB), were recruited into the study. Patients were randomly divided into two groups who received either one valerian capsule containing 530 mg of valerian root extract (1,060 mg/daily) or placebo capsule each 12 h for 8 weeks, respectively. For all patients, cognitive brain function was evaluated before the surgery and at 10-day and 2-month follow-up by Mini Mental State Examination (MMSE) test. RESULTS: Mean MMSE score decreased from 27.03 ± 2.02 in the preoperative period to 26.52 ± 1.82 at the 10th day and then increased to 27.45 ± 1.36 at the 60th day in the valerian group. Conversely, its variation was reduced significantly after 60 days in the placebo group, 27.37 ± 1.87 at the baseline to 24 ± 1.91 at the 10th day, and consequently slightly increased to 24.83 ± 1.66 at the 60th day. Valerian prophylaxis reduced odds of cognitive dysfunction compared to placebo group (OR = 0.108, 95 % CI 0.022-0.545). CONCLUSION: We concluded that, based on this study, the cognitive state of patients in the valerian group was better than that in the placebo group after CABG; therefore, it seems that the use of V. officinalis root extract may prevent early postoperative cognitive dysfunction after on-pump CABG surgery.