Comparing Effectiveness and Safety of Intravenous Atropine with Topical Tetracaine in Preventing and Relieving Oculocardiac Reflex in Patients Undergoing Strabismus Surgery: A Randomized Clinical Trial.

Background: Oculocardiac reflex (OCR) is one of the serious complications following surgical therapeutic procedures for strabismus. Various medications have been tested to prevent or mitigate this complication. We aimed to compare the effect of intravenous atropine and topical tetracaine on the incidence and severity of OCR in strabismus surgery. Materials and Methods: In this triple-blind randomized clinical trial study, 120 patients who were candidates for strabismus surgery were randomly assigned to receive intravenous atropine, topical tetracaine, or artificial tears as the control. The incidence of OCR and its severity along with the changes in hemodynamic conditions were compared across the groups. Results: The incidence rate of OCR in the groups receiving atropine, tetracaine, and the control was found to be 17.5%, 25.0%, and 32.5% in the releasing phase without any difference, respectively (P = 0.303); however, it was 2.5%, 7.5%, and 25.0%, respectively, in the cutting phase, indicating a lower rate in the group receiving tetracaine (P = 0.004). Similarly, there was no difference in the severity of OCR across the three study groups in the releasing phase (P = 0.666); however, in the cutting phase, OCR was revealed to be milder in the group receiving atropine as compared to other groups (P = 0.033). Prescribing atropine led to higher mean systolic blood pressure and mean arterial pressure during surgery. Conclusion: The injection of atropine can effectively reduce the incidence of OCR during strabismus surgery and reduce its severity if this reflex occurs.

The Effect of Tranexamic Acid and Controlled Hypotension on Perioperative Blood Loss in Craniosynostosis Surgery.

Background: Open cranial vault reconstruction is the standard technique of craniosynostosis correction that may cause significant blood loss. Objectives: The current study aimed at comparing the effect of tranexamic acid (TXA), controlled hypotension, and their combination on perioperative blood loss and transfusion requirement in craniosynostosis surgery. Methods: The present randomized, double-blind clinical trial was conducted on 75 infants referred for craniosynostosis surgery during 2017 - 2018. Ten minutes before the start of surgery, 10 mg/kg of TXA was administered intravenously to patients in the first group (TXA group). In the second group, patients were subjected to the controlled hypotension anesthesia (CHA) using intravenous remifentanil 0.1 µ/kg (CHA group). In the third group, the patients underwent CHA similar to that of the second group, along with intravenous injection of 10 mg/kg of TXA (CHA-TXA group). Then, patients' mean arterial pressure (MAP), heart rate (HR), total blood loss, and transfusion volume were evaluated and recorded. Results: The results of the present study revealed that although the changes in MAP and HR parameters over time (three hours after surgery) were significant in all three groups, the lowest decrease was observed in the CHA-TXA group (P-value < 0.05). In addition, the total perioperative blood loss in the CHA-TXA group with the mean of 181.20 ± 82.71 cc was significantly less than the total perioperative blood loss in the CHA and TXA groups with the means of 262.00 ± 104.04 cc and 212.80 ± 80.75 cc, respectively (P-value < 0.05). Moreover, the transfusion volume in the CHA-TXA group with the mean of 112.40 ± 53.50 cc was significantly lower than the transfusion volume in the CHA and TXA groups with the means of 174.00 ± 73.93 cc and 160.63 ± 59.35 cc, respectively (P-value < 0.05). In contrast, the total blood loss and transfusion volume were not significantly different between the CHA and TXA groups (P-value > 0.05). Conclusions: According to the results of the present study, although the administration of TXA alone could effectively prevent blood loss and was associated with fewer transfusion requirements, the combination of this approach with hypotensive anesthesia resulted in more reduction in perioperative blood loss and transfusion volume as well as better hemodynamic stability.

Effect of aminophylline, ketamine and paracetamol on pain intensity after deep vitrectomy surgery.

BACKGROUND: Pain management after surgery is a challenging medical issue, and clinical research in this area has continued. This study aimed to compare the effect of Aminophylline, ketamine, and paracetamol on the pain intensity after deep vitrectomy and compare it with the control group. METHODS: In this clinical trial, 240 patients undergoing deep vitrectomy were included in the study. The protocol of the current study was approved in the Ethics committee of Isfahan University of Medical Sciences (IR.MUI.REC.1396.3.876) and this study was registered in Iranian Registry of Clinical Trials (IRCT20210919052523N1) (https://www.irct.ir/trial/58884). The patients were randomly divided into four equal groups. Twenty minutes before surgery, in the first group, 0.15 mg/kg ketamine, in the second group 1 g acetaminophen, in the third group 3 mg/kg of aminophylline, and in the fourth group, normal saline was infused in the same manner. All drugs were diluted with 100 ccs of normal saline and infused intravenously within 15 minutes. The four groups of hemodynamic variables, pain intensity, and rescue analgesic drugs were compared. RESULTS: There was no significant difference between the groups based on hemodynamic variables (P>0.05). The severity of pain up to 2 hours after surgery and the rescue to analgesia in the ketamine and paracetamol groups were significantly lower than that of aminophylline and placebo. CONCLUSION: Using ketamine or paracetamol effectively decreases pain intensity after deep vitrectomy surgery without producing significant adverse hemodynamic changes.

Comparison of Tranexamic acid, Remifentanil, and Hydralazine on the bleeding volume during Dacryocystorhinostomy surgery.

BACKGROUND: Bleeding in Dacryocystorhinostomy (DRC) limits the surgeon's sight and access. Tranexamic acid, Remifentanil, and Hydralazine reduce intraoperative blood loss. However, no study has been carried out to compare the efficacy of the latter drugs during DCR surgery. METHODS: Ninety healthy candidates for DCR surgery with chronic Dacryocystitis (aging 20-80) were randomly assigned in groups of 30 to receive low doses of Tranexamic acid (TXA) (10 mg/kg with a maximum dose of 1000 mg), Remifentanil (0.1 µ/kg), or Hydralazine (0.1 mg/kg). All drugs were infused over 15 minutes before the initiation of surgery. The primary outcome was the bleeding volume during the surgery and until 2 hours in recovery. This study was approved by the Iranian Registry of Clinical Trials with the code of IRCT20210614051574N10 (https://en.irct.ir/trial/62759). RESULTS: Thirty patients (mean age ± SD: 50.48±13.4) were investigated. Mean blood loss volume was lower in Remifentanil and Hydralazine groups compared with the TXA group (P<0.05); there was no significant difference (P>0.05) in bleeding volume between Remifentanil and Hydralazine groups (Tranexamic acid group: 146.83±91 ml, Remifentanil group: 77.6±52.1 ml, Hydralazine group: 80.0±48.7 ml, 95% confidence interval, P<0.05). CONCLUSION: Our results show that Remifentanil and Hydralazine are more effective than Tranexamic acid in bleeding control.

Evaluating the preventive effect of metoclopramide and aminophylline on pain after deep vitrectomy.

BACKGROUND: Deep vitrectomy is one of the most frequently performed ophthalmic procedures. Postoperative pain is a common complaint among patients. Consequently, we investigated whether metoclopramide and aminophylline could decrease pain intensity following deep vitrectomy. METHODS: This double-blinded clinical trial study that was approved by the Ethical Committee of Isfahan University of Medical Sciences (IR.MUI.REC.1396.3.217) (Thesis Reg. number: 396217) and registered at the Iranian Registry of Clinical Trials (IRCT) (Reg. number: IRCT20170716035104N5, available at https://www.irct.ir/trial/59146) aimed to evaluate 105 patients who were candidates for deep vitrectomy. They were randomly assigned into three groups: metoclopramide (received 0.1 mg/kg diluted in 10 ml of normal saline), aminophylline (received 4 mg/kg diluted in 10 ml of normal saline), and placebo (received 10 ml of normal saline). Postoperative pain was evaluated in all groups. RESULTS: The postoperative pain levels of the three groups differed significantly from the start of the recovery to 30 minutes, 60 minutes, 2 hours, and 4 hours postoperatively, with metoclopramide and aminophylline groups experiencing less postoperative pain than the placebo group. Moreover, there was a significant difference between the groups regarding patient satisfaction (P<0.05). CONCLUSION: Both metoclopramide and aminophylline significantly reduce postoperative pain after deep vitrectomy, although metoclopramide has a greater effect.

Evaluation of the effectiveness of the Nutritional Risk Screening System 2002 (NRS-2002) in COVID-19 patients admitted to the intensive care unit.

BACKGROUND: Nutritional status of patients with COVID-19 can affect the recovery process of patients; however, no nutritional scale was introduced to evaluate the nutritional status of the patients. Thus, the main objective of this study was to examine the usefulness of Nutritional status-2002 (NRS-2002) among COVID-19 patients admitted to the intensive care unit (ICU). MATERIAL AND METHODS: In this cross-sectional study, 73 patients with definitive corona diagnosis admitted to the ICUs of Al-Zahra hospital, Isfahan, Iran in October 2020 to January 2021 were recruited. Dietary intake, NRS-2002, demographic, anthropometric and biochemical indices of patients were recorded. RESULTS: The majority of patients were at risk for moderate (69.9%) to severe (12.3%) malnutrition. Daily calorie intake (P = .001) and albumin (P = .001) levels in deceased patients were significantly lower than the recovered group. A direct correlation between NRS-2002 and age (P < .001) and an inverse correlation with daily calorie intake (P = .002), albumin (P = .05) and PaO2 (P = .034) was found. Moreover, there is a strong correlation between NRS-2002 score and chance of death among COVID-19 patients (OR=34.5, 95%CI:(5.2 - 228.93), P-value<0.001). Likewise, the levels of bilirubin direct (OR=8, 95%CI:(1.30 - 49.38), P-value=0.025) and creatine-phosphokinase (OR=0.9, 95%CI:(0.99 - 1.00), P-value=0.035) have a significant direct association with chance of death. CONCLUSION: Results showed patients with COVID-19 admitted to the ICU did not have appropriate nutritional status and mortality was higher among patients with lower amounts of the serum albumin and daily calorie intakes. Furthermore, there is a strong association between the NRS-2002 index and the chance of mortality in these patients.

Comparison of the Sedation Quality of Etomidate, Propofol, and Midazolam in Combination with Fentanyl During Phacoemulsification Cataract Surgery: A Double-Blind, Randomized, Controlled, Clinical Trial.

BACKGROUND: According to the favorable effects of combination therapy to provide better sedation during phacoemulsification and lack of any studies investigating the sedative effect of etomidate, propofol, and midazolam in combination with fentanyl during the procedure. OBJECTIVES: The current study aimed at comparing the sedative properties of the mentioned three combination therapies in this field. METHODS: The current double-blind, randomized, controlled clinical trial was conducted on patients referred for elective phacoemulsification surgery under sedation. They were randomly allocated to the three groups to receive fentanyl plus one of the following medications: Propofol, midazolam, and etomidate. Demographic characteristics, medical condition, and hemodynamic parameters before, during, and after surgery, sedation level, anesthetic complications, sedation-related adverse events, and patients' and surgeons' satisfaction were evaluated and recorded by the anesthesiologist and compared in the three studied groups. RESULTS: In the current study, out of 150 enrolled patients, 98 completed the study. Frequency of different levels of Ramsay scores was not significantly different between the groups (P = 0.41). Frequency of Ramsay scores 3 and 4 was 92%, 79.4%, and 88.2% in etomidate, midazolam and propofol groups, respectively (P = 0.32). The median recovery time was significantly higher in the midazolam group than the propofol group (P = 0.04); intergroup comparisons indicated that the patients' mean score of satisfaction in the propofol group was significantly higher than that of the etomidate group (P = 0.006). CONCLUSIONS: The current study findings indicated that though the quality of sedation during phacoemulsification cataract surgery was acceptable in the three agents and the results had no significantly differences among the groups, and considering other factors including recovery time, hemodynamic evaluation, sedation-related complications, and patients' satisfication scores, it is suggested that propofol was superior to the other two agents.

Reduction of oculocardiac reflex with Tetracaine eye drop in strabismus surgery.

INTRODUCTION: Recently, to reduce the incidence of oculocardiac reflex (OCR) in strabismus surgery, retrobulbar block and anticholinergic drugs or local anesthesia are also used. The present study evaluated the effects of Tetracaine eye drop as a topical nerve blocker on OCR during strabismus surgery. METHODS AND MATERIALS: In this randomized trial, 70 strabismus surgery candidates were randomly divided into placebo or synthetic teardrop (E) and Tetracaine eye drop (T) groups, so 3 drops of each solution were dropped in four directions of patients' eye immediately after applying anesthesia and before surgery. The incidence and severity of OCR during the stages of muscle release and incision (cutting), hemodynamic changes, the required time for OCR recovery and atropine dose were assessed. RESULTS: OCR was more seen in release phase compared to cutting phase. There were no significant differences between two group regarding the incidence and severity of OCR in the release phase (p > 0.05), but the incidence and severity of OCR in the cutting phase was more in group E than group T (p = 0.02, for both). The duration of OCR improvement (p-value = 0.74) and Atropine consumption (p-value = 0.92) did not differ between the groups. CONCLUSION: Tetracaine eye drop only reduces the incidence and severity of OCR during the incision stage of strabismus surgery.