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1.  Comparing the effects of three different additional doses of propofol infusion on intubation condition and hemodynamic changes during general anesthesia under elective surgery: A randomized, placebo-controlled, double blind clinical trial 
Background:
Laryngoscopy and endotracheal intubation can induce unfavorable hemodynamic changes as propofol itself can induce hypotension. The aim of this study was to compare the effects of three different additional doses of propofol infusion on intubation conditions and hemodynamic changes occurred after intubation.
Materials and Methods:
This double-blinded prospective study was performed on 140 patients aged 18-60 who received different additional doses of propofol and were randomly allocated into 4 groups as follows: A: Received additional dose of propofol 0.5 mg/kg infused after an initial dose 1.5 mg/kg. B: Received additional dose of propofol 1 mg/kg infused after an initial dose 1 mg/kg. C: Received additional dose of propofol 1.5 mg/kg after an initial dose 1 mg/kg. D: Received propofol 2 mg/kg as a bolus with no additional dose.
Results:
Intubation conditions were acceptable in 91.4% of Group A patients, 94.2% of Group B patients, 97.1% of Group C patients and 68.5% of Group D patients. There were no significant differences in the mean of heart rate between four groups at any time before and after laryngoscopy. Mean arterial pressure (MAP) 3 min after laryngoscopy was significantly lower in Group D versus Group A (P = 0.015) while MAP was not different at any time between other groups.
Conclusion:
Infusion of propofol 1.5 mg/kg added to initial bolus dose of propofol 1 mg/kg improves intubation conditions significantly without inducing hemodynamic changes.
doi:10.4103/2277-9175.133195
PMCID: PMC4063089  PMID: 24949293
Hemodynamic; intubation conditions; laryngoscopy; propofol
2.  Prediction of difficult laryngoscopy: Extended mallampati score versus the MMT, ULBT and RHTMD 
Background:
Preoperative using of anatomical landmarks detects potentially difficult laryngoscopies. The main object of the present study was to evaluate the predictive power of Extended Mallampati Score (EMS) in comparison with modified Mallampati test (MMT), the ratio of height to thyromental distance (RHTMD) and the Upper-Lip-Bite test (ULBT) in isolation and combination.
Materials and Methods:
Four hundred seventy sixadult patients who candidate for elective surgery under general anesthesia requiring endotracheal intubation were included in this study and evaluated based of all four factors before surgery. This study was randomized prospective double - blind. After that, laryngoscopy was performed by an anesthesiologist who didn’t involve in preoperative airway assessment and graded based on Cormack and Lehane's classification. We calculated sensitivity, specificity, and area under receiver-operating characteristic (ROC) (AUC) for each score.
Results:
The AUCof the ROC was significantly more for the ULBT (AUC = 0.820, P = 0.049) and RHTMD score (AUC = 0.845, P = 0.033) than the EMS (AUC = 0.703). This variable was significantly higher for the EMS compared with MMT (0.703 vs. 0.569, P = 0.046 respectively). There was no significant difference between the AUC of the ROC for the ULBT and the RHTMD score (P = 0.685). The optimalcut-off point for the RHTMD for predicting difficult laryngoscopy was 29.3.
Conclusion:
EMS predicted difficult laryngoscopy better than MMT while both ULBT and RHTMD had more power than EMS and MMT in this regard. ULBT and RHTMD had similar predictive value for prediction of difficult laryngoscopy in general population.
doi:10.4103/2277-9175.133270
PMCID: PMC4063103  PMID: 24949304
Difficult laryngoscopy; extended mallampati score; modified mallampati; ratio of patient's height to thyromental distance; upper lip bite test
3.  The evaluations of frequency distribution heparin resistance during coronary artery bypass graft 
Background:
Heparin is one of the most important medication that is used in coronary artery bypass graft (CABG) operations, but some patients demonstrate heparin resistance (HR) during CABG. Heparin resistance was defined as at least one activated clothing time <400 seconds after heparinization and/or the need for purified antithrombin III (AT-III) administration. The goal of this study was the investigation of HR prevalence in our country and relation between HR and post-operative CABG complications.
Materials and Methods:
One hundred patients that candidate for CABG were selected and surveyed for HR and complications. The data entered to computer and analyzed by SPSS soft ware. The Chi-square and student t-tests were used for data analysis.
Results:
The prevalence of heparin resistance in our study was 3%. There was no relation among bleeding, cardiac arrest and HR. Bleeding happened in 13 patients of which 1 person was in HR group (33.3%) and 12 in non HR group (12.4%) (P = 0.34). Cardiac arrest happened in 8 patients, 1 person was in HR group (33.3%) and 7 in non HR group (7.2%) (P = 0.22). According our data there were no relation among HR and gender and ventilator dependency time.
Conclusions:
HR is a nearly prevalent complication among patients that undergone CABG that may led to some complications such as bleeding and cardiac arrest. In our study, we did not find significant relation among them, but in frequency these complications were higher in HR group.
doi:10.4103/2277-9175.125798
PMCID: PMC3950837  PMID: 24627861
Bleeding; coronary artery bypass graft; heparin; heparin complication; heparin resistance
4.  Adding metoclopramide to lidocaine for intravenous regional anesthesia in trauma patients 
Background:
Metoclopromide have local anesthetic properties. The main object of performing the present study was to evaluate the analgesic effect of metoclopromide 10 mg when added to lidocaine for intravenous regional anesthesia (IVRA) of upper extremities in trauma patients.
Materials and Methods:
Ninety patients undergoing upper limb producer were randomly allocated to the three groups to receive 3 mg/kg 2% lidocaine diluted with saline to a total dose of 40 ml (Group L, n = 30) or 10 mg metoclopromide plus 3 mg/kg 2% lidocaine diluted with saline to a total dose of 40 ml (group LM, n = 30) or 3 mg/kg 2% lidocaine diluted with saline to a total dose of 40 ml plus 10 mg metoclopromide intravenously (Group IM, n = 30).
Results:
Our study showed that the onset times for sensory and motor block were significantly shorter in Group LM compared with Group L and Group IM (4.5 ± 0.7 vs. 5.0 ± 0.7 and 5.0 ± 0.6, respectively, P = 0.006 for sensory block; 6.3 ± 0.7 vs. 5.1 ± 0.9 and 5.9 ± 0.6 respectively, P = 0.000 for motor block). The postoperative VAS scores were significantly less at 1, 5, 10, 15, and 30 minutes after tourniquet release in Group LM compared with Group L and Group IM (P < 0.05).
Conclusion:
The results of our study showed that adding 10 mg metoclopromide to lidocaine for IVRG in trauma patients reduced intraoperative and postoperative analgesic use till 24 hours and improve quality of anesthesia.
doi:10.4103/2277-9175.125753
PMCID: PMC3949339  PMID: 24627853
Anesthetic techniques; intravenous regional anesthesia lidocaine; metoclopromide; postoperative pain
5.  An evaluation of the efficacy of different doses of ketamine for treatment of catheter-related bladder discomfort in patients underwent urologic surgery: A prospective, randomized, placebo-controlled, double-blind study 
Urology Annals  2014;6(1):51-56.
Background:
Urinary catheterization might have catheter-related bladder discomfort (CRBD). We evaluated the efficacy of different doses of ketamine in comparison to placebo as a treatment of CRBD.
Materials and Methods:
One hundred twenty patients who were candidate for urological surgery requiring catheterization of the urinary bladder were randomly divided into four groups including 30 patients in each. Group I received normal saline, Group II received ketamine 150 μg/kg/iv, Group III received ketamine 200 μg/kg/iv, and Group IV received 250 μg/kg/iv in the equal volume of 2 mL. The patients were observed for each 15 min in the recovery room and in the 1 h, 2 h, 6 h, 12 h, and 24 h after discharging from it for severity of CRBD and pain, levels of sedation, and post-operative nausea and vomiting.
Results:
The severity of CRBD at the recovery room was significantly reduced in Group III and Group IV after 24 h compared with Group I and Group II (P < 0.05). There was no significant difference between Group III and Group IV in this respect. The median sedation level was significantly lower in 15 min and 30 min after arrival to the recovery in Group III and Group IV compared with Group I and Group II (P < 0.05). There was no significant difference between Group III and Group IV in this regard.
Conclusions:
Ketamine 200 μg/kg/iv had similar efficacy with ketamine 250 μg/kg/iv in reducing the severity of CRBD without occurring significant side effect.
doi:10.4103/0974-7796.127030
PMCID: PMC3963344  PMID: 24669123
Anesthesia; catheter-related bladder discomfort; ketamine; urologic surgery
6.  Investigating the relationship between intra-operative electrolyte abnormalities (sodium and potassium) with post-operative complications of coronary artery bypass surgery 
Background:
Generally, the electrolyte abnormalities are seen in many hospitalized patients, and this problem increases in ones with heart diseases. The purpose of this study is determination of the prevalence of electrolyte abnormalities during the coronary artery bypass surgery (CABG) and detecting the relationship between these abnormalities with the complications after the surgeries.
Materials and Methods:
This is a cross-sectional study, which is done in Chamran hospital, the medical and educational center of Isfahan, Iran, in 2011. The target population included the patients who have undergone CABG in this hospital. In this study, 100 patients who had been candidates for CABG were selected, and we extracted their recorded intra-operative electrolyte information. The collected data was entered into the computer and analyzed by SPSS software. The Chi-square and t student tests were used for data analysis.
Results:
The mean ± SD of sodium during CABG was 137.95 ± 4.6 (range 127-152) mg\dl. Also, the mean ± SD of potassium was 4.65 ± 0.9 (range: 2.9-7.4). According to these results, 48 patients (48% of all) had electrolyte imbalance and 52 patients (52% of all) were normal. Sodium level in 71% of patients was normal, and in 29% of them was abnormal. Potassium level in 73% of individuals was normal, and in 27% of them was abnormal.
Conclusion:
Giving an attention to electrolyte abnormalities in patients who have undergone CABG surgery is a considerable necessity for them, and sufficient arrangements are needed to prevent such abnormalities.
doi:10.4103/2277-9175.120871
PMCID: PMC3908493  PMID: 24520549
Coronary artery bypass surgery; electrolytes imbalance; potassium; sodium
7.  A comparison of the effect of pretreatment with intravenous dexamethasone, intravenous ketamine, and their combination, for suppression of remifentanil-induced cough: A randomized, double-blind, placebo-controlled clinical trial 
Background:
The injection of remifentanil can cause cough during induction of anesthesia. This study was designed to examine the efficacy of ketamine, dexamethasone, and their combination on remifentanil-induced cough (RIC).
Materials and Methods:
One hundred and twenty patients scheduled for elective surgery were randomly assigned into four groups: Group K received 10 mg ketamine; Group D received 10 mg dexamethasone; Group KD received 10 mg ketamine in combination with dexamethasone; and Group S received saline in a similar volume, five minutes prior to the injection of remifentanil. The incidence and severity of the cough was recorded in each person.
Results:
The incidence of RIC was significantly lower in Group KD compared to Group K, Group D, and Group S (3.3 vs. 20%, 20%, and 46.7%, respectively, P < 0.05). The severity of RIC was significantly lower in Group KD compared to Group K, Group D, and Group S (P < 0.05). There was no significant difference between Group K and Group D in this regard (P > 0.05). There was no significant difference in the onset time of coughing among the four groups (19.8 ± 1.3, 20.8 ± 0.9, 19.0 ± 1.1, and 19.9 ± 2.2 in Group K, Group D, Group KD, and Group S, respectively, P > 0.05).
Conclusion:
We found that pretreatment with 10 mg ketamine in combination with 10 mg dexamethasone five minutes prior to the injection of remifentanil could significantly reduce the incidence of RIC, and it was better than using each drug singly.
doi:10.4103/2277-9175.115808
PMCID: PMC3814903  PMID: 24223375
Cough; dexamethasone; ketamin; remifentanil
8.  Effect of adding 8 milligrams ondansetron to lidocaine for Bier's block on post-operative pain 
Background:
Ondansetron has analgesic properties. The aim of the present study was to assess the analgesic effect of 8 mg ondansetron when added to lidocaine for intravenous regional anesthesia (IVRA).
Materials and Methods:
Ninety patients undergoing hand surgery were randomly allocated to the three groups to receive 3 mg/kg 2% lidocaine diluted with saline to a total dose of 40 mL (Group L, n = 30) or 8 mg ondansetron plus 3 mg/kg 2% lidocaine diluted with saline to a total dose of 40 mL (group LO, n = 30) or 3 mg/kg 2% lidocaine diluted with saline to a total dose of 40 mL plus 8 mg ondansetron intravenously (Group IO, n = 30). Tourniquet pain and analgesic use were recorded before and after the tourniquet application.
Results:
The sensory and motor block onset times were significantly shorter in Group LO compared with Group L and Group IO (4.2 ± 1.7 vs. 5.2 ± 0.8 and 5.1 ± 1.2 respectively, P < 0.05; 4.5 ± 1.4 vs. 5.8 ± 1.5 and 5.7 ± 1.4 respectively, P < 0.05). The sensory and motor block recovery times were significantly longer in Group LO compared with Group L and Group IO (6.1 ± 1.1 vs. 4.1 ± 1.3 and 4.5 ± 0.9 respectively, P < 0.05; 6.7 ± 1.4 vs. 4.4 ± 0.9 and 4.7 ± 0.7 respectively, P < 0.05). Post-operative VAS scores were significantly less in Group LO compared with Group L and Group IO till 24 h after tourniquet deflation (P < 0.05).
Conclusion:
The addition of 8 mg ondansetron to lidocaine for IVRA reduced intraoperative and post-operative analgesic use till 24 h.
doi:10.4103/2277-9175.114197
PMCID: PMC3905338  PMID: 24516852
Anesthetic techniques; intravenous regional; lidocaine; ondansetron; pain; post-operative
9.  The comparison of intraincisional injection tramadol, pethidine and bupivacaine on postcesarean section pain relief under spinal anesthesia 
Background:
Bupivacaine, tramadol, and pethidine has local anesthetic effect. The aim of this study was to compare effect of subcutaneous (SC) infiltration of tramadol, pethidine, and bupivacaine on postoperative pain relief after cesarean delivery.
Materials and Methods:
120 patient, scheduled for elective cesarean section under spinal anesthesia, were randomly allocated to 1 of the 4 groups according to the drugs used for postoperative analgesia: Group P (Pethidine) 50 mg ,Group T (Tramadol) 40 mg, Group B (Bupivacaine 0.25%) 0.7 mg/kg, and Group C (control) 20CC normal saline injection in incision site of surgery. Pain intensity (VAS = visual analogous scale) at rest and on coughing and opioid consumption were assessed on arrival in the recovery room, and then 15, 30, 60 minutes and 2, 6, 12, 24 hours after that.
Results:
VAS scores were significantly lower in groups T and P compared with groups B and C except for 24 hours (VAS rest) and 6 hours (VAS on coughing) postoperatively (P < 0.05). The number of patients requiring morphine were significantly different between the groups (105 doses vs. 87, 56, 46, doses for group C, B, T and P, respectively, P < 0.05) in all the times, except for 2 and 6 hours postoperatively.
Conclusions:
The administration of subcutaneous pethidine or tramadol after cesarean section improves analgesia and has a significant morphine-sparing effect compared with bupivacaine and control groups.
doi:10.4103/2277-9175.100165
PMCID: PMC3544092  PMID: 23326784
bupivacaine; pethidine; post-cesarean section pain; spinal anesthesia; tramadol
10.  Effects of preemptive analgesia with celecoxib or acetaminophen on postoperative pain relief following lower extremity orthopedic surgery 
Background:
Efficacy of preemptive analgesia with nonsteroidal antiinflammatory drugs (NSAIDs) in comparison with acetaminophen is controversial. The present study evaluates the preemptive analgesia efficacy of celecoxib and acetaminophen in comparison with placebo for postoperative pain relief in patients who underwent orthopedic surgery under general anesthesia.
Materials and Methods:
Ninetypatients eligible for elective distal extremity surgery were categorized in three groups: group C includedpatients who received oral celecoxib 200 mg 2 h before surgery; group A included those who received oral acetaminophen 320 mg 2 h before surgery; and group P included those who received oral placebo 2 h before surgery. Pain scores were recorded at 4, 12, and 24 h after operation.
Results:
The pain scores 4 h after operation was significantly less in group C than in groups A and P (4.7±1.7 vs. 5±1.5 vs. 6.8±1.7, respectively, P = 0.015). No significant difference was noted in pain scores at 12 h (4.6±2, 4.9±1.9, 4.3±1.4 in group A, group C, group P, respectively P > 0.05) and 24 h (3.1±1.7, 3.0±1.4, 3.3±1.7 in group A, group C, group P, respectively, P > 0.05) after operation among the three groups.
Conclusion:
Using oral celecoxib 200 mg 2 h before operation is better thanusing oral acetaminophen 320 mg 2 h before the beginning of surgery for control of postoperative pain in patients who underwent lower extremity orthopedic surgery under general anesthesia.
doi:10.4103/2277-9175.100197
PMCID: PMC3587127  PMID: 23459777
Celecoxib; acetaminophen; postoperative pain; preemptive analgesia; analgesia; orthopedic surgery; elderly patients
11.  Unusual right internal jugular vein catheter malposition into the right axillary vein: A rare case report 
One of disastrous complications of central venous cannulation (CVC) is malposition of central venous catheter. In this case report, we present an adult patient with history of multiple trauma and intracranial hemorrhage in whom the right axillary vein was accidentally cannulated during CVC insertion.
doi:10.4103/2277-9175.96072
PMCID: PMC3507013  PMID: 23210075
Central venous cannulation; malposition of central venous catheter; right internal jugular vein; right axillary vein
12.  Prophylactic administration of haloperidol plus midazolam reduces postoperative nausea and vomiting better than using each drug alone in patients undergoing middle ear surgery 
Saudi Journal of Anaesthesia  2012;6(2):145-151.
Aims:
The efficacy of using midazolam or haloperidol for prevention of postoperative nausea and vomiting (PONV) has been investigated before. The main object of the present study was to evaluate the anti-emetic effects of combining administration of intravenous haloperidol with intravenous midazolam on PONV in patients underwent middle ear surgery in comparison with using each drug alone.
Methods:
Study design was randomized, double-blind, placebo-controlled. 80 patients, aged 18-60 years, scheduled for middle ear surgery in Kashani Hospital Medical Center under general anesthesia were enrolled in this randomized, double-blind, placebo-controlled study. Patients were divided into 4 groups of 20 each and received haloperidol 2 mg i.v. (Group H); midazolam 2 mg i.v. (Group M); haloperidol 2 mg plus midazolam 2 mg i.v. (Group HM); saline i.v. (Group C). The incidences of PONV and complete response were evaluated at 0-2 hours after arrival to the PACU and 2-24 hours after arrival to the ward in 4 groups.
Results:
Patients in group HM had significantly lower incidence of PONV compared with groups H, M, and C throughout 0-24 h (P<00.5). The HM group had the lowest incidence of PONV (0-2, 2-24, and 0-24 h) and the highest incidence of complete response. Postoperative anti-emetic requirement was significantly less in group HM compared with group M or H (P<0.05).
Conclusion:
Combine administration of haloperidol 2 mg plus midazolam 2 mg significantly reduced PONV better than using each drug alone in patients underwent middle ear surgery under general anesthesia.
doi:10.4103/1658-354X.97028
PMCID: PMC3385257  PMID: 22754441
Anti-emetics; haloperidol; midazolam; otorhinolaryngologic surgical procedures; postoperative nausea and vomiting
13.  Treatment of postoperative nausea and vomiting after spinal anesthesia for cesarean delivery: A randomized, double-blinded comparison of midazolam, ondansetron, and a combination 
Background:
The antiemetic efficacy of midazolam and ondansetron was shown before. The aim of the present study was to compare efficacy of using intravenous midazoalm, ondansetron, and midazolam in combination with ondansetron for treatment of nausea and vomiting after cesarean delivery in parturient underwent spinal anesthesia.
Materials and Methods:
One hundred thirty two parturients were randomly allocated to one of three groups: group M (n = 44) that received intravenous midazoalm 30 μg/kg; group O (n = 44) that received intravenous ondansetron 8 mg; group MO (n = 44) that received intravenous midazoalm 30 μg/kg combined with intravenous ondansetron 8 mg if patients had vomiting or VAS of nausea ≥ 3 during surgery (after umbilical cord clamping) and 24 hours after that. The incidence and severity of vomiting episodes and nausea with visual analog scale (VAS) > 3 were evaluated at 2 hours, 6 hours, and 24 hours after injection of study drugs.
Results:
The incidence of nausea was significantly less in group MO compared with group M and group O at 6 hours postoperatively (P = 0.01). This variable was not significantly different in three groups at 2 hours and 24 hours after operation. The severity of nausea and vomiting was significantly different in three groups at 6 hours after operation (P < 0.05).
Conclusion:
Our study showed that using intravenous midazolam 30 μg/kg in combination with intravenous ondansetron 8 mg was superior to administering single drug in treatment of emetic symptoms after cesarean delivery under spinal anesthesia.
doi:10.4103/2277-9175.94424
PMCID: PMC3507018  PMID: 23210061
Anesthesia; cesarean section; midazoalm; ondansetron; postoperative nausea and vomiting; spinal
14.  Effect of erythropoietin on Glasgow Coma Scale and Glasgow Outcome Sale in patient with diffuse axonal injury 
BACKGROUND:
Erythropoietin (EPO) as a major stimulator of red blood cell (RBC) production play a key role on brain protection and have a caring effect on neurons from hypoxic or traumatic injury. The objective of this trial was to study the safety and efficacy of recombinant human EPO (rhEPO) on level of consciousness and other outcomes in patient with post traumatic diffuse axonal injury (PTDAI).
METHODS:
In a controlled double-blind randomized clinical trial, 54 patients aged 20-47 years were randomly allocated to 2 groups. Subjects in intervention group (n = 27) received 2000U open-label rhEPO (Erythropoietin-ß; Roche, Gren-zach-Wyhlen, Germany) subcutaneously for six doses in two weeks (on days: 2, 4, 6, 8 and 10). The efficacies of the intervention were evaluated by GCS (Glasgow Coma Scale) and GOS (Glasgow Outcome Scale).
RESULTS:
The patients that were treated by rhEPO improved earlier with the difference between the treatment groups occurring on the day 10 (score differences of 9.6 for GCS and 1.9 for GOS). The better course of the rhEPO-treated patients continued throughout the remaining study period. The hematocrit and red blood cell counts did not increase to levels exceeding the normal range in rhEPO patients.
CONCLUSIONS:
Intravenous EPO was well tolerated in diffuse axonal injury and was associated with an improvement in patients’ outcome in 2 weeks.
PMCID: PMC3523438  PMID: 23248657
Erythropoietin; Outcome; Diffuse Axonal Injury
15.  Preincisional administration of intravenous or subcutaneous infiltration of low-dose ketamine suppresses postoperative pain after appendectomy 
Background
Ketamine, an N-methyl-D-aspartate receptor antagonist, can suppress hyperalgesia and allodynia. The purpose of the present study was to evaluate the clinical efficacy of preincisional intravenous or subcutaneous infiltration of ketamine for postoperative pain relief after appendectomy.
Methods
Ninety patients, aged 18–60 years, scheduled for appendectomy was enrolled in this study. Patients were divided into three groups of 30 each and received subcutaneous infiltration of ketamine 0.5 mg/kg (KS), intravenous ketamine 0.5 mg/kg (KI), or subcutaneous infiltration of normal saline 3 mL (C) before surgery. Visual analog scale (VAS) values and analgesic consumption were evaluated for 24 hours after surgery.
Results
VAS scores were significantly lower at the time of arrival in the recovery room, and at 10, 20, and 30 minutes thereafter in group KI and group KS compared with group C (P < 0.05). VAS scores were not significantly different between group KI and group KS at these intervals. Postoperative VAS scores were significantly lower at 6, 12, 18, and 24 hours in group KI compared with group C (P < 0.05). In group KS, the postoperative VAS score was significantly lower at 6 hours (P < 0.05). VAS scores were significantly lower at 12, 18, and 24 hours after surgery in group KI compared with group KS (P < 0.05).
Conclusion
A 0.5 mg/kg dose of ketamine given at approximately 15 minutes before surgery by the intravenous route provided analgesia for 24 hours after surgery in patients undergoing appendectomy.
doi:10.2147/JPR.S26476
PMCID: PMC3273401  PMID: 22328829
pain; postoperative; analgesia; ketamine; appendectomy
16.  The analgesic effect of midazolam when added to lidocaine for intravenous regional anaesthesia* 
BACKGROUND:
Midazolam has analgesic properties. The aim of the present study was to assess the analgesic effect of midazolam when added to lidocaine in intravenous regional anesthesia (IVRA).
METHODS:
Sixty patients undergoing hand surgery were randomly allocated into two groups to receive 3 mg/kg 2% lidocaine diluted with saline to a total volume of 40 mL in the control group (group lidocaine saline ~ LS, n=30) or 50 μg/kg midazolam plus 3 mg/kg 2% lidocaine diluted with saline to a total volume of 40 mL in the midazolam group (group lidocaine midazolam ~ LM, n=30). Before and after the tourniquet application, hemodynamic variables, tourniquet pain, sedation, and analgesic use were recorded.
RESULTS:
Shortened sensory and motor block onset time [4.20 (0.84) vs. 5.94 (0.83) min, p = 0.001 and 6.99 (0.72) vs. 9.07 (0.99) min, p = 0.001 in LM and LS groups, respectively], prolonged sensory and motor block recovery times [8.41 (0.94) vs. 5.68 (0.90) min, p = 0.001 and 11.85 (1.18) vs. 7.06 (0.82) min, p = 0.001 in LM and LS groups, respectively], shortened visual analog scale (VAS) scores of tourniquet pain (p < 0.05), and improved quality of anesthesia were found in group LM (p < 0.05). VAS scores were lower in group LM in the postoperative period (p = 0.001). Postoperative analgesic requirements were significantly smaller in group LM (p = 0.001).
CONCLUSIONS:
The addition of 50 μg/kg midazolam to lidocaine for IVRA shortens the onset of sensory and motor block, and improves quality of anesthesia and perioperative analgesia without causing side effects.
PMCID: PMC3430038  PMID: 22973382
Anaesthetic Techniques; IV Regional Lidocaine; Postoperative; Analgesics; Midazolam; Tourniquet Pain
17.  Gabapentin: An update of its pharmacological properties and therapeutic use in epilepsy 
The new antiepileptic medications are prescribed for the treatment of patients with seizure disorders since 17 years ago. Gabapentin (GBP) was approved on January 1994 as adjunctive treatment in patients 12 years or older with partial seizures, with or devoid of secondary generalization. GBP, was formerly known as an anticonvulsant γ-aminobutyric acid (GABA) mimetic, is considered as a safe and well-tolerated antiepileptic drug (AED) with promising pharmacokinetic properties and a wide therapeutic index. GBP is useful for the therapy of mixed seizure disorders and refractory partial seizures in children. GBP must be regarded as the first treatment for older patients with recently diagnosed seizures. GBP has a well recognized clinical efficacy in those types of focal epilepsy which were resistant to the traditional AEDs. The main object of this review was to evaluate the efficacy, tolerability, dosing schedules and safety of GBP that have been investigated in peer-reviewed journals.
PMCID: PMC3263084  PMID: 22279483
Antiepileptic drugs; efficacy; epilepsy; gabapentin; new antiepileptic drugs; seizures
18.  A comparison of the ratio of patient's height to thyromental distance with the modified Mallampati and the upper lip bite test in predicting difficult laryngoscopy 
Saudi Journal of Anaesthesia  2011;5(3):258-263.
Background:
The aim of the present study was to compare the ability to predict difficult visualization of the larynx from the following preoperative airway predictive indices, in isolation and combination: modified Mallampati test (MMT), the ratio of height to thyromental distance (RHTMD) and the Upper-Lip-Bite test (ULBT).
Methods:
We collected data on 603 consecutive patients scheduled for elective surgery under general anesthesia requiring endotracheal intubation and then evaluated all three factors before surgery. An experienced anesthesiologist, not informed of the recorded preoperative airway evaluation, performed the laryngoscopy and grading (as per Cormack and Lehane's classification). Sensitivity, specificity, and positive and negative predictive value, Receiver operating characteristic (ROC) Curve and the area under ROC curve (AUC) for each airway predictor in isolation and in combination were determined.
Results:
Difficult laryngoscopy (Grade 3 or 4) occurred in 41 (6.8%) patients. The main endpoint of the present study, the AUC of the ROC, was significantly lower for the MMT (AUC, 0.511; 95% CI, 0.470–0.552) than the ULBT (AUC, 0.709; 95% CI, 0.671–0.745, P=0.002) and the RHTMD score (AUC, 0.711; 95% CI, 0.673–0.747, P=0.001). There was no significant difference between the AUC of the ROC for the ULBT and the RHTMD score. By using discrimination analysis, the optimal cutoff point for the RHTMD for predicting difficult laryngoscopy was 21.06 (sensitivity, 75.6%; specificity, 58.5%).
Conclusion:
The RHTMD is comparable with ULBT for prediction of difficult laryngoscopy in general population.
doi:10.4103/1658-354X.84098
PMCID: PMC3168341  PMID: 21957403
Difficult laryngoscopy; endotracheal intubation; RHTMD; thyromental distance; ULBT
19.  A New System for Neuronavigation and Stereotactic Biopsy Pantograph Stereotactic Localization and Guidance System 
Everyday, neurosurgeons face the problem of orientation within the brain but the advent of stereotactic surgery and neuronavigation have solved this problem. Frame-based stereotactic systems (FBSS) and neuronavigation systems have their own strengths and priority and pitfalls, which were the main driving force for us to design a new system. This hybrid system comprises three main parts: main frame, monitoring system, and pantograph, which are connected to each other and to the operating table by particular attachments. For using this system, after performing CT SCAN or Magnetic Resonance Imaging (MRI) the axial view will be transferred to Liquid Cristal Display (LCD). In the operating room, the head of the patient fixes to the operating table and registration is completed by two arms of pantograph. We made a simulation operation with our system on an occipital cavernous angioma and a frontal oligodendroglioma. The software, which have been used for simulation were as follows; Poser (version-7), Catia (version 5- R18), and 3 Dimension Max (version 2008). The accuracy of this system is approximately two millimeter. The advantages of this system are: easy to use, much less expensive, and compatible with different devices, which may be needed during neurosurgical operation. For countries that do not have the opportunity to have sophisticated technology and neuronavigation system, we believe that our system is a one-stop solution.
doi:10.4103/2006-8808.92800
PMCID: PMC3296440  PMID: 22413051
Neuronavigation; pantograph; stereotactic surgery
20.  Postoperative residual block in postanesthesia care unit more than two hours after the administration of a single intubating dose of atracurium* 
BACKGROUND:
Residual neuromuscular blockade continues to be a clinical problem after surgical procedures. The purpose of this study was to determine the incidence of residual paralysis in the postanesthesia care unit (PACU) after a single intubating dose of twice of the 95% estimated dose (ED95) of a nondepolarizing muscle relaxant with an intermediate duration of action.
METHODS:
Two hundred and sixteen patients scheduled for elective surgery under general anaesthesia requiring tracheal intubation were included in the study. They received a single intubating dose of intravenous atracurium (0.5 mg/kg) to facilitate tracheal intubation. At the end of surgery, if train of four (TOF)-ratio was ≤ 0.9, neostigmine 40 μg/kg intravenously was given. If TOF-ratio was ≥ 0.9, no neostigmine was given. Also, in awake patients with TOF > 0.9, residual neuromuscular paralysis was evaluated by using clinical tests such as head lift test and tongue depressor test.
RESULTS:
TOF was less than 0.9 in 48 (22.2%) patients while after 120 minutes, no patients had TOF less than 0.9. Of 33 patients whose operation lasted less than 120 minutes, 4 patients had TOF less than 0.9 at the end of surgery. There was no case of hypoventilation or hypoxia at PACU. The incidence of negative value in clinical tests was high.
CONCLUSIONS:
Our study gave the impression that more than two hours between the administration of a single intubating dose of an intermediate-acting nondepolarizing muscle relaxant (atracurium) and arrival to the PACU can probably guarantee the lack of a residual paralysis.
PMCID: PMC3214377  PMID: 22091288
Neuromuscular Blockade; Atracurium; Neostigmine; Neuromuscular Nondepolarizing Agents
21.  Short-Time Intermittent Preexposure of Living Human Donors to Hyperoxia Improves Renal Function in Early Posttransplant Period: A Double-Blind Randomized Clinical Trial 
Journal of Transplantation  2011;2011:204843.
The purpose of this human study was to investigate the effect of oxygen pretreatment in living kidney donors on early renal function of transplanted kidney. Sixty living kidney donor individuals were assigned to receive either 8–10 L/min oxygen (Group I) by a non-rebreather mask with reservoir bag intermittently for one hour at four times (20, 16, 12, and 1 hours before transplantation) or air (Group II). After kidney transplantation, urine output, blood urea nitrogen (BUN), serum creatinine, need to additional diuretics (NTADs) in the first 24 hours after transplantation, delayed graft function (DGF), the creatinine clearance (CrCL) on 10th day, and duration of hospital stay from the first posttransplant day till normalization of renal function was recorded and compared in two groups. Mean CrCL in posttransplant day 10, NTAD after 24 hours of transplantation, and urine output during 6 hours after operation were significantly better in Group I compared with Group II (P < .05). Also, DGF during the first week after operation and duration of hospital stay was less in Group I compared with Group II. Intermittent exposure of human living kidney donor to hyperoxic environment may improve renal function following kidney transplantation.
doi:10.1155/2011/204843
PMCID: PMC3087885  PMID: 21559250
22.  Spinal anesthesia versus general anesthesia for elective lumbar spine surgery: A randomized clinical trial 
BACKGROUND:
Either general or regional anesthesia can be used for lumbar disk surgery. The common anesthetic technique is general anesthesia (GA). The aim of this study was to compare the intra and postoperative outcomes of spinal anesthesia (SA) with GA in these patients.
METHODS:
Seventy-two patients were enrolled in the study. They were randomized into two groups with 37 patients in GA Group and 35 ones in SA Group. The heart rate (HR), mean arterial pressure (MAP), blood loss, surgeons satisfaction with the operating conditions, the severity of postoperative pain based on visual analogue scale (VAS) and analgesic use were recorded.
RESULTS:
The mean blood loss was significantly less in the SA Group compared to GA Group (p < 0.05). Intraoperative maximum blood pressure and heart rate changes were significantly less in SA Group (p < 0.05). The surgeons satisfaction was significantly more in the SA Group (p < 0.05). The number of patients who used postoperative analgesic as well as postoperative mean VAS was significantly less in SA Group in comparison with GA group (p < 0.05 for both).
CONCLUSIONS:
Our study showed that SA was superior to GA in providing postoperative analgesia and decreasing blood loss while maintained better perioperative hemodynamic stability without increasing adverse side effects.
PMCID: PMC3214358  PMID: 22091269
Anesthesia; General; Spinal; Lumbar Surgery
23.  Attenuation of the pressor response to direct laryngoscopy and tracheal Intubation: oral clonidine vs. oral gabapentin premedication 
BACKGROUND:
We carried out this study to compare the efficacy of oral gabapentin and clonidine premedication for controlling the pressor responses to laryngoscopy and tracheal intubation.
METHODS:
In this double-blind clinical trial, ninety-six patients were randomly allocated to one of three groups according to the agents to be used before the induction of anaesthesia: Group P (n = 32) received oral placebo, Group G (n = 32) received 800 mg of gabapentin, and Group C (n = 32) received 0.3 mg of clonidine 90 minutes prior to surgery. Systolic arterial pressure (SAP), diastolic arterial pressure (DAP), mean arterial pressure (MAP), heart rate (HR) and rate pressure product (RPP) were measured at baseline (3 min before induction), just before laryngoscopy, and postintubation (at 1, 3, 5, 10 and 15 min after starting laryngoscopy). Statistical analysis of data was done with repeated measure ANOVA and chi-square test.
RESULTS:
HR and RPP significantly decreased in Group G and Group C at 5, 10, and 15 minutes after tracheal intubation compared with those just before laryngoscopy (p < 0.05). No significant difference was noted between Group G and Group C considering these variables. SAP, DAP, MAP and RPP at 1, 3, 5, 10, and 15 minutes after intubation were significantly lower in Group G compared with Group P (p < 0.05). There was no significant difference between Group C and Group P in this regard.
CONCLUSIONS:
The present study demonstrated that premedication with oral gabapentin 800 mg or clonidine 0.3 mg similarly blunted the hyperdynamic response after laryngoscopy and intubation.
PMCID: PMC3252769  PMID: 22247722
Premedication; oral gabapentin; oral clonidine; pressor response; laryngoscopy; intubation
24.  Post-Delivery Cardiomyopathy in a Patient Admitted to Critical Care Unit; A Rare Case Report 
Background
Peripartum cardiomyopathy (PPCM) is an uncommon disease that affects women in the last month of pregnancy or within the first five months postpartum, occurring in about 1 in 3500 live births. The disease bears potentially devastating effects both on mother and the fetus if not treated early in its course.
Case Presentation
The case was a 34-year old woman with a triple pregnancy who presented to the ward immediately after cesarean section with signs of dyspnea, cyanosis and pulmonary edema. She was diagnosed with PPCM upon echocardiography. The patient improved remarkably despite the PPCM's devastating complications. This case report aims to describe a female patient who developed PPCM after a triple delivery.
Conclusion
Regarding the high risks of developing PPCM in subsequent pregnancies and avoiding multiparty, especially in older age, a reliable contraception in childbearing women would be helpful. The best prevention of PPCM is to avoid subsequent pregnancies.
PMCID: PMC3719282  PMID: 23926498
Cesarean section; Echocardiography; Gestational hypertension; Myocarditis; Peripartum cardiomyopathy; Preeclampsia; Thrombophilic phenomena
25.  Pre-incisional infiltration of tonsils with dexamethasone dose not reduce posttonsillectomy vomiting and pain in children 
Saudi Journal of Anaesthesia  2009;3(2):53-56.
Background and Objective:
Recently, dexamethasone has been found to have a prophylactic effect on postoperative vomiting and pain in children undergoing tonsillectomy. However, few studies have examined the preemptive analgesic effects of dexamethasone after tonsillectomy. The aim of this study was to evaluate the effect of pre-incisional infiltration of tonsils with dexamethasone on the incidence and severity of postoperative pain and vomiting in children undergoing tonsillectomy under general anesthesia.
Materials and Methods:
In a double blinded study, 62 patients were randomly allocated to infiltrate dexamethasone (0.5 mg/kg, maximum dose, 12 mg) or an equivalent volume of saline at the peritonsillar region. All infiltrations were performed following the induction of general anesthesia and 5 minutes prior to the onset of surgery. Anesthetic agents, end-tidal carbon dioxide levels, and the administration of intravenous fluids were carefully regulated. Surgery was performed by one attending otolaryngologists using the same dissection and snare technique. The incidence of pain and vomiting, need for rescue antiemetics, and analgesic consumption were compared in both groups. Pain scores used included Children's Hospital Eastern Ontario Pain Scale, “faces”, and a 0-10 visual analogue pain scale.
Results:
Demographics of dexamethasone and placebo groups were similar. No statistically significant difference was found between the dexamethasone and placebo groups in pain score, nausea, vomiting, irritability, or analgesic requirement postoperatively.
Conclusion:
Preincisional infiltration of the tonsils with dexamethasone play a limited role in the recovery phase from tonsillectomy, but further prospective, randomized studies are needed to support it.
doi:10.4103/1658-354X.57874
PMCID: PMC2876943  PMID: 20532103
Dexamethasone; postoperative pain; tonsillectomy; vomiting

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