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1.  Effect of Ketamine on Post-Tonsillectomy Sedation and Pain Relief 
Introduction:
Tonsillectomy is the one of the most common types of surgery in children, and is often accompanied by post-operative pain and discomfort. Methods of pain control such as use of non-steroidal anti-inflammatory drugs (NSAIDs), narcotics, and local anesthetics have been used, but each have their own particular side effects. In this study we investigated the effect of ketamine on post-operative sedation and pain relief.
Materials and Methods:
A total of 50 children aged between 5 and 12 years who were candidates for tonsillectomy were divided into two groups. The study group received ketamine-midazolam (ketamine 1 mg/kg, midazolam 0.1 mg/kg) and the control group received midazolam (0.1 mg/kg) in the pre-operative period. The same methods of anesthesia induction and maintenance were used in all patients. Pain score was assessed using the Wong-Baker Faces Pain Rating scale and sedation was evaluated using the Riker Sedation-Agitation scale at the time of extubation as well as 5, 10, 15, and 30 minutes and 1, 2, and 6 hours after surgery.
Results:
The two groups were similar in terms of age, weight, gender and duration of surgery. Pain after 15 and 30 minutes and agitation after 10 and 15 minutes following extubation were lower in the study group (ketamine-midazolam). Mean consumption and time of first request for analgesia after surgery as well as incidence of post-operative vomiting were similar in the two groups.
Conclusion:
Adding ketamine to midazolam in pre-operative of tonsillectomy reduces agitation and post-operative pain in the first 30 minutes after surgery.
PMCID: PMC4709750  PMID: 26788487
Children; Ketamine; Post-operative pain; Sedation; Tonsillectomy
2.  Pharyngeal Packing during Rhinoplasty: Advantages and Disadvantages 
Introduction:
Controversy remains as to the advantages and disadvantages of pharyngeal packing during septorhinoplasty. Our study investigated the effect of pharyngeal packing on postoperative nausea and vomiting and sore throat following this type of surgery or septorhinoplasty.
Materials and Methods:
This clinical trial was performed on 90 American Society of Anesthesiologists (ASA) I or II patients who were candidates for septorhinoplasty. They were randomly divided into two groups. Patients in the study group had received pharyngeal packing while those in the control group had not. The incidence of nausea and vomiting and sore throat based on the visual analog scale (VAS) was evaluated postoperatively in the recovery room as well as at 2, 6 and 24 hours.
Results:
The incidence of postoperative nausea and vomiting (PONV) was 12.3%, with no significant difference between the study and control groups. Sore throat was reported in 50.5% of cases overall (56.8% on pack group and 44.4% on control). Although the severity of pain was higher in the study group at all times, the incidence in the two groups did not differ significantly.
Conclusion:
The use of pharyngeal packing has no effect in reducing the incidence of nausea and vomiting and sore throat after surgery. Given that induced hypotension is used as the routine method of anesthesia in septorhinoplasty surgery, with a low incidence of hemorrhage and a high risk of unintended retention of pharyngeal packing, its routine use is not recommended for this procedure.
PMCID: PMC4709751  PMID: 26788486
Nausea and vomiting; Pharyngeal pack; Sore throat; Septorhinoplasty
3.  Accidental intrathecal injection of magnesium sulfate for cesarean section 
Saudi Journal of Anaesthesia  2014;8(4):562-564.
Magnesium sulfate is used frequently in the operation room and risks of wrong injection should be considered. A woman with history of pseudocholinesterase enzyme deficiency in the previous surgery was referred for cesarean operation. Magnesium sulfate of 700 mg (3.5 ml of 20% solution) was accidentally administered in the subarachnoid space. First, the patient had warm sensation and cutaneous anesthesia, but due to deep tissue pain, general anesthesia was induced by thiopental and atracurium. After the surgery, muscle relaxation and lethargy remained. At 8-10 h later, muscle strength improved and train of four (TOF) reached over 0.85, and then the endotracheal tube was removed. The patient was evaluated during the hospital stay and on the anesthesia clinic. No neurological symptoms, headache or backache were reported. Due to availability of magnesium sulfate, we should be careful for inadvertent intravenous, spinal and epidural injection; therefore before injection must be double checked.
doi:10.4103/1658-354X.140906
PMCID: PMC4236949  PMID: 25422620
Accidental; cesarean section; intrathecal; magnesium sulfate
4.  Use of two Endotracheal Tubes to Perform Lung Isolation and One-Lung Ventilation in a Patient With Tracheostomy Stenosis: A Case Report 
Introduction:
Lung isolation is a common technique used in thoracic surgery to prevent spillage to unaffected lung and to provide a better view for the surgeon.
Case Presentation:
A 41-year-old woman with a history of pharyngo-laryngo-oesophagectomy (PLO) and tracheostomy was a candidate for thoracic duct ligation because of chylothorax. Since the patient had tracheostmy stomal stenosis, two cuffed tracheal tubes (internal diameter = 4.5 mm) were used; one tube was placed in the right bronchus and the other tube in the left one by fiberoptic laryngoscopy in 10 minutes. Right lung was collapsed during the surgery for 3.5 hours with a slight decrease in oxygenation (SpO2 = 91%–93%) and with no evident hemodynamic change. Potential trauma from a double-lumen tube and a bronchial blocker as well as inaccessibility to a univent tube prevented us to use these standard methods in this case.
Conclusions:
This report presents a new method for lung isolation in specific cases and in the absence of certain equipment.
doi:10.5812/aap.18280
PMCID: PMC4286801  PMID: 25599024
Lung Isolation; Tracheostomy; Endotracheal Tube; One-Lung Ventilation
5.  Efficacy of ephedrine in the prevention of vascular pain associated with different infusion rates of propofol 
Context:
Vascular pain is a frequent and hypotension is most important complications of propofol administration.
Aims:
The goal of this study is to evaluate frequency of vascular pain during rapid and slow injection of propofol and also effect of ephedrine for decreasing of vascular pain.
Materials and Methods:
After approval of local ethical committee, 120 patients with American Society of Anesthesiologists status I (ASA I), who were candidates for cataract surgery, were divided randomly into three groups. The first group received 20 mg of lidocaine, and propofol 1% at 1 ml per 5 seconds (slow injection). The second and third groups received propofol at 10 ml per 5 seconds without lidocaine (rapid injection) and also in the third group, 10 mg of ephedrine were injected at first and vascular pain were evaluated with 5-point scale.
Statistical analysis:
Data were analyzed with Statistical Package for the Social Sciences (SPSS) v16, Chi-square test, one-way analysis of variance (ANOVA), Kruskel-Wallis. P <0.05 was considered statistically significant.
Results:
Demographic characteristics of the three groups were similar. The vascular pain was 52.5%, 40%, and 27.5% in first, second, and third group, respectively. The injection pain was more severe in the slow injection (P = 0.025), but was the same between two rapid groups (P = 0.76). Heart rate and blood pressure changes were similar between all groups (P = 0.45 and P = 0.58, respectively).
Conclusion:
Rapid propofol injection induced less vascular pain compared with slow injection, but 10 mg ephedrine was not more effective.
doi:10.4103/0259-1162.143137
PMCID: PMC4258966  PMID: 25886333
Ephedrine; hypotension; propofol; vascular pain
6.  Central Anticholinergic Syndrome due to Hypoxia-Induced Bradycardia in a Child with Difficult Intubation Undergoing Complete Dental Restoration: A Case Report 
Central anticholinergic syndrome (CAS) following general anesthesia (GA) is a well known syndrome in children and adults. Many cases of CAS have been previously reported in the literature. However, there are only two reports of post resuscitation CAS after administration of small doses of atropine. Hereby, we report a case of CAS in a child undergoing complete dental restoration under GA after receiving a small dose of atropine to reverse hypoxia induced bradycardia.
Intraoperative events such as hypoxia or cardiac arrest may play a role as triggers for CAS. However, we cannot establish a causal relationship between the occurrence of CAS and such critical events.
PMCID: PMC4290782  PMID: 25628689
Central anticholinergic syndrome; Hypoxia; Bradycardia; Atropine, Pediatric
8.  Apneas in Infants with Postconceptional Age bellow 60 Weeks Undergoing Herniorrhaphy 
Iranian Journal of Pediatrics  2014;24(2):179-183.
Abstract
Objective
Postoperative apnea is a major concern in infants undergoing surgery. In this study, we evaluated incidence and related factors for postoperative apnea in infants less than 60 weeks postconceptual age after herniorrhaphy.
Methods
One-hundred fifty infants with post conceptional age (PCA) less than 60 weeks who underwent elective herniorrhaphy were studied over eight months in 2012. General anesthesia was induced by sevoflurane and maintained by remifentanil, atracurium, and N2O 60%. Postoperatively, they were monitored for two hours in the recovery room and ten hours in the ward using pulse oximetry and nasal capnography.
Findings
Totally, 31 (20.7%) cases of postoperative apnea were reported. By comparing the patients, factors associated with postoperative apnea included postconceptional age, birth weight, and history of apnea, oxygen therapy, metabolic diseases, icterus, or cardiac disease. Twenty-seven (18%) apnea cases occurred in recovery room in infants with gestational age (GA) of 35.64±2.73 weeks, while only four (2.6%) patients of GA 36.02±2.0 weeks developed delayed apnea).
Conclusion
In our study, the incidence of postoperative apnea following inguinal herniorrhaphy under general anesthesia in infants younger than 60 weeks PCA was 20.7%, which is considerable. We recommend longer surveillance and monitoring in recovery room for these infants with high-risk of postoperative apnea. This should be followed by evaluation of risk factors to determine the indication for elective intensive care unit transfer for longer-term monitoring of higher-risk patients.
PMCID: PMC4268838  PMID: 25535537
Infant; Apnea; Prematurity; Herniorrhaphy; Anaesthesia, General; Postoperative Complications
9.  A comparison of Simplified Acute Physiology Score II, Acute Physiology and Chronic Health Evaluation II and Acute Physiology and Chronic Health Evaluation III scoring system in predicting mortality and length of stay at surgical intensive care unit 
Background:
In critically ill patients, several scoring systems have been developed over the last three decades. The Acute Physiology and Chronic Health Evaluation (APACHE) and the Simplified Acute Physiology Score (SAPS) are the most widely used scoring systems in the intensive care unit (ICU). The aim of this study was to assess the prognostic accuracy of SAPS II and APACHE II and APACHE III scoring systems in predicting short-term hospital mortality of surgical ICU patients.
Materials and Methods:
Prospectively collected data from 202 patients admitted to Mashhad University Hospital postoperative ICU were analyzed. Calibration was estimated using the Hosmer-Lemeshow goodness-of-fit test. Discrimination was evaluated by using the receiver operating characteristic (ROC) curves and area under a ROC curve (AUC).
Result:
Two hundred and two patients admitted on post-surgical ICU were evaluated. The mean SAPS II, APACHE II, and APACHE III scores for survivors were found to be significantly lower than of non-survivors. The calibration was best for APACHE II score. Discrimination was excellent for APACHE II (AUC: 0.828) score and acceptable for APACHE III (AUC: 0.782) and SAPS II (AUC: 0.778) scores.
Conclusion:
APACHE II provided better discrimination than APACHE III and SAPS II calibration was good at APACHE II and poor at APACHE III and SAPS II. Use of APACHE II was excellent in this post-surgical ICU.
doi:10.4103/0300-1652.129651
PMCID: PMC4003718  PMID: 24791049
APACHE II; APACHE III; ICU mortality; SAPS
10.  The Effect of Local Injection of Epinephrine and Bupivacaine on Post-Tonsillectomy Pain and Bleeding 
Introduction:
Tonsillectomy is one of the most common surgeries in the world and the most common problem is post-tonsillectomy pain and bleeding. The relief of postoperative pain helps increase early food intake and prevent secondary dehydration. One method for relieving pain is peritonsillar injection of epinephrine along with an anesthetic, which has been shown to produce variable results in previous studies. Study Deign: Prospective case-control study. Setting: A tertiary referral centers with accredited otorhinolaryngology-head & neck surgery and anesthesiology department.
Materials and Methods:
Patients under 15 years old, who were tonsillectomy candidates, were assigned into one of three groups: placebo injection, drug injection before tonsillectomy, and drug injection after tonsillectomy. The amount of bleeding, intensity of pain, and time of first post-operative food intake were evaluated during the first 18 hours post operation.
Results:
The intensity of pain in the first 30 minutes after the operation was lower in the patients who received injections, but the difference was not significant during the first 18 hours. The intensity of pain on swallowing during the first 6 hours was also lower in the intervention groups as compared with the placebo group. The amount of bleeding during the first 30 minutes post operation was lower in the two groups who received injections, but after 30 minutes there was no difference.
Conclusion:
Injection of epinephrine and bupivacaine pre- or post- tonsillectomy is effective in reducing pain and bleeding. The treatment also decreases swallowing pain in the hours immediately after surgery.
PMCID: PMC3846251  PMID: 24303442
Bleeding; Bupivacaine; Epinephrine; Post-tonsillectomy pain; Post-tonsillectomy; Tonsillectomy

Results 1-10 (10)