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Anesthesiology and Pain Medicine - Volume:7 Issue: 4, Aug2017

Anesthesiology and Pain Medicine
Volume:7 Issue: 4, Aug2017

  • تاریخ انتشار: 1396/07/25
  • تعداد عناوین: 12
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  • Global Optimal PEEP for Anesthetized Patients
    Ata Mahmoodpoor, Samad Ej Golzari Page 1
  • Hassan Soleimanpour, Saeid Safari, Sarvin Sanaie, Mehdi Nazari, Seyed Moayed Alavian Page 2
    Context: This article discusses the anesthetic considerations in patients undergoing bariatric surgery in the preoperative, intraoperative, and postoperative phases of surgery.
    Evidence Acquisition: This review includes studies involving obese patients undergoing bariatric surgery. Searches have been conducted in PubMed, MEDLINE, EMBASE, Google Scholar, Scopus, and Cochrane Database of Systematic Review using the terms obese, obesity, bariatric, anesthesia, perioperative, preoperative, perioperative, postoperative, and their combinations.
    Results
    Obesity is a major worldwide health problem associated with many comorbidities. Bariatric surgery has been proposed as the best alternative treatment for extreme obese patients when all other therapeutic options have failed.
    Conclusions
    Anesthetists must completely assess the patients before the surgery to identify anesthesia- related potential risk factors and prepare for management during the surgery.
    Keywords: Obesity: Definitions, Prevalence, Complications
  • Fatemeh Javaherforoosh Zadeh, Mohsen Moadeli, Mansoor Soltanzadeh, Farahzad Janatmakan Page 3
    Background
    Elective open heart surgery is associated with troponin release in some cases due to myocyte necrosis.
    Objectives
    The aim of this study was to measure cardiac troponin I (cTnI) preoperatively in elective CABG after remote ischemic preconditioning.
    Methods
    Twenty-eight patients were selected for elective CABG. They were randomized to receive remote ischemic preconditioning (induced by three 5-min cycles of inflation with a pneumatic tourniquet and 5-min deflation between inflation episodes as reperfusion).
    Outcomes: Primary outcomes were cardiac troponin I levels at 6 and 24 hours after the procedure, and the secondary outcomes included creatine phosphokinase, lactate dehydrogenase, and serum creatinine levels. Hemodynamic changes were evaluated between the treatment and control groups.
    Results
    Cardiac troponin I at 6 hours after preconditioning was significantly lower compared to the control group (P = 0.036), and after 24 hours, there was still a significant difference between the two groups (P
    Conclusions
    Remote ischemic preconditioning reduces ischemic biomarkers during coronary artery bypass graft and attenuates procedure-related cardiac troponin I release and eventually reduces cardiovascular events such as myocardial infarction, chest pain, and hemodynamic changes after cardiac surgery.
    Keywords: Cardiac Surgery, Remote Ischemic Preconditioning, Cardiac Outcomes
  • Seyed Mohammad Reza Gousheh, Ali Reza Olapour, Sholeh Nesioonpour, Mahboobeh Rashidi, Shahrzad Pooyan Page 4
    Background
    Bleeding during surgery can lead to serious complications. Methods and drugs to control bleeding are always important both for the surgeon and anesthesiologist, especially in endoscopic procedures. A lot of efforts are made to optimize the surgical conditions for functional endoscopic sinus surgery. Induced hypotension is widely advocated to prevent bleeding and consequently to improve the quality of an operation . Amongst the pharmacological agents, dexmedetomidine is the most recently introduced drug to provide hypotensive anesthesia during functional endoscopic sinus surgery.
    Objectives
    The current study aimed at investigating the effects of intravenous infusion of dexmedetomidine on bleeding, nausea, awakening time, and other intravenous anesthetic doses during functional endoscopic sinus surgery.
    Methods
    Sixty patients aged 16 to 60 years with American society of anesthesiologists (ASA) class I or II in Imam Khomeini hospital of Ahvaz, Iran, who were the candidate for the elective functional endoscopic sinus surgery were enrolled in the current double-blind clinical trial. They were randomly divided into 2 groups: group D (receiving dexmedetomidine), and group N (receiving normal saline). Sampling was based on the block randomization method. In group D, a 1-μg/kg dexmedetomidine was injected during 10 minutes just before the induction. Then, 0.5 µg/ kg/ hour infusion was started. Both groups had the same induction and maintenance method as well as the drugs administered for general anesthesia induction. For maintenance, the patients received O2 50%: N2O 50% and 100 μg/kg/minute of propofol and 0.2 μg/kg/minute of remifentanil. In group N, instead of dexmedetomidine in bolus and maintenance, normal saline was used with the same volume. Mean arterial pressure was maintained between 65 to 75 mmHg. The incidence of bleeding, nausea and vomiting after surgery, the amount of maintenance drugs, and awakening time were recorded in a checklist.
    Results
    The intravenous use of dexmedetomidine significantly reduced the amount of bleeding (P
    Conclusions
    The current study showed that although propofol and remifentanil compounds can control hemodynamic state, but intravenous infusion of dexmedetomidine during the functional endoscopic sinus surgery reduced the amount of bleeding more significantly. It also reduced the dosage of maintenance drugs.
    Keywords: Dexmedetomidine, Functional Endoscopic Sinus Surgery, Bleeding, Nausea, Awakening Time
  • Jose M. Soliz, Ifeyinwa C. Ifeanyi, Mathew H. Katz, Jonathan Wilks, Juan P. Cata, Thomas Mchugh, Jason B. Fleming, Lei Feng, Thomas Rahlfs, Morgan Bruno, Vijaya Gottumukkala Page 5
    Objectives
    The objective of this study is to evaluate postoperative complications and inflammatory profiles when using a total intravenous anesthesia (TIVA) or volatile gas-opioid (VO) based anesthesia in patients undergoing pancreatic cancer surgery.
    Methods
    Design, retrospective propensity score matched cohort; Setting, major academic cancer hospital; Patients, all patients who had pancreatic surgery between November 2011 and August 2014 were retrospectively reviewed. Propensity score matched patient pairs were formed. A total of 134 patients were included for analysis with 67 matched pairs; Interventions, Patients were categorized according to type of anesthetic used (TIVA or VO). Patients in the TIVA group received preoperative celecoxib, tramadol, and pregabalin in addition to intraoperative TIVA with propofol, lidocaine, ketamine, and dexmedetomidine. The VO-group received a volatile-opioid based anesthetic; Measurements, demographic, perioperative clinical data, platelet lymphocyte ratios, and neutrophil lymphocyte ratios were collected. Complications were graded and collected prospectively and later reviewed retrospectively.
    Results
    Patients receiving TIVA were more likely to have no complication or a lower grade complication than the VO-group (P = 0.014). There were no differences in LOS or postoperative inflammatory profiles noted between the TIVA and VO groups.
    Conclusions
    In this retrospective matched analysis of patients undergoing pancreatic cancer surgery, TIVA was associated with lower grade postoperative complications. Length of hospital stay (LOS) and postoperative inflammatory profiles were not significantly different.
    Keywords: Anesthesia, Cancer, Complications, Pancreas Surgery, TIVA, Volatile Anesthesia
  • Shahrbanoo Shahbazi, Peyman Alishahi, Elham Asadpour Page 6
    Objectives
    Acute renal failure is a common complication of major cardiovascular surgeries (One-third of patients). Adenosine release as a vascular vasodilator increases after cardiac surgery, which reduces renal and glomerular blood flow and subsequently causes kidney ischemic damage. The present study aimed at evaluating the impact of aminophylline as an adenosine receptor antagonist on renal function after cardiac surgery hoping to find an appropriate method to reduce acute kidney injury.
    Methods
    The patients in the intervention group received 5 mg/kg aminophylline bolus after induction of anesthesia; then, 0.25 mg/kg/hr of the drug was administered intraoperatively and up to 48 hours after surgery in the ICU cardiac surgery. Similar volume of normal saline was injected to the patients of the second group. Serum BUN, Cr, and GFR were measured pre- and postoperatively and 3 days postsurgery. Patients’ 24- hour urine output and RIFLE were also calculated.
    Results
    Those patients who received medication were extubated earlier (P = 0.018) and received lower amount of inotropic drugs (P
    Conclusions
    Aminophylline in cardiac surgery can reduce the frequency of acute kidney injury according to RIFLE criteria and could be used in the prevention of AKI as a safe and efficient modality in high-risk patients. Also, the use of this drug may reduce the need for inotropic medication at the time of surgery, intensive care unit stay length, and extubation time.
    Keywords: Aminophylline, Acute Kidney Injury, Cardiac Surgery, Glomerular Filtration Rate, Creatinine
  • Seyed Hamid Reza Faiz, Farnad Imani, Poupak Rahimzadeh, Mahmoud Reza Alebouyeh, Saeed Reza Entezary, Amineh Shafeinia Page 7
    Background
    Peripheral nerve block is an accepted method in lower limb surgeries regarding its convenience and good tolerance by the patients. Quick performance and fast sensory and motor block are highly demanded in this method. The aim of the present study was to compare 2 different methods of sciatic and tibial-peroneal nerve block in lower limb surgeries in terms of block onset.
    Methods
    In this clinical trial, 52 candidates for elective lower limb surgery were randomly divided into 2 groups: sciatic nerve block before bifurcation (SG; n = 27) and separate tibial-peroneal nerve block (TPG; n = 25) under ultrasound plus nerve stimulator guidance. The mean duration of block performance, as well as complete sensory and motor block, was recorded and compared between the groups.
    Results
    The mean duration of complete sensory block in the SG and TPG groups was 35.4 ± 4.1 and 24.9 ± 4.2 minutes, respectively, which was significantly lower in the TPG group (P = 0.001). The mean duration of complete motor block in the SG and TPG groups was 63.3 ± 4.4 and 48.4 ± 4.6 minutes, respectively, which was significantly lower in the TPG group (P = 0.001). No nerve injuries, paresthesia, or other possible side effects were reported in patients.
    Conclusions
    According to the present study, it seems that TPG shows a faster sensory and motor block than SG.
    Keywords: Sciatic Nerve Block, Tibial-Peroneal Nerve Block, Ultrasound, Lower Limb Surgeries
  • Mohammad Talebpour, Naser Ghiasnejad Omrani, Farsad Imani, Reza Shariat Moharari, Pejman Pourfakhr, Mohammad Reza Khajavi Page 8
    Background
    Laparoscopic gastric plication (LGP) is a technique in the restrictive category of bariatric procedures that reduces the gastric volume and increases intragastric pressure. Nausea and vomiting are the most common complications after this procedure. The goal of this research is to compare the combined effect of promethazine/dexamethasone versus Metoclopramide/ dexamethasone on the prevention of nausea and vomiting after LGP.
    Methods
    In recovery, the patients were divided into two groups, the Metoclopramide group which was given Metoclopramide 10 mg plus dexamethasone 4 mg/8 hours intravenous for 48 hours, and the promethazine group which was given promethazine 50 mg /12 hours, intramuscular for the first 24 hours and then promethazine 25 mg/12 hours for the next 24 hours plus dexamethasone 4 mg/8 hours intravenous for 48 hours. The frequency of nausea and vomiting, number of reflux episodes, frequency of epigastric fullness, and the duration of walking around q12 hours were recorded in the first 48 hours post-operation.
    Results
    Eighty patients were enrolled into the study. Promethazine group were found to significantly reduce the incidence of PONV in the first 24 hours compared with the other group (41% vs. 97.5%), relative risk = 0.042 [95% CI = 0.006, 0.299]. The mean numbers of epigastric fullness and severity of epigastria pain were lower in the promethazine group (P = 0.01) and the total opioid requirement was also reduced in promethazine group (32.1 ± 2.6 VS .68.5 ± 4.6 mg). However, the patients in the promethazine group were more sedated, which caused the duration of walking q12 hours in this group to decrease.
    Conclusions
    In morbidly obese patients undergoing laparoscopic gastric plication, promethazine/dexametasone was more effective than Metoclopramide/dexametasone in preventing and reducing the incidence of nausea, epigastric fullness, and reflux. That combination was also more effective than Metoclopramide in reducing the severity of epigastric pain.
    Keywords: Laparoscopic gastric plication, Nausea, Vomiting, Promethazine, Dexamethasone, Metoclopramide
  • Maryam Soleimanpour, Farzad Rahmani, Mehrad Naghizadeh Golzari, Alireza Ala, Hamid Reza Morteza Bagi, Robab Mehdizadeh Esfanjani, Hassan Soleimanpour Page 9
    Background
    The process of medical education depends on several issues such as training materials, students, professors, educational fields, and the applied technologies. The current study aimed at comparing the impacts of e-learning and lecture-based learning of mild induced hypothermia (MIH) after cardiac arrest on the increase of knowledge among emergency medicine residents.
    Methods
    In a pre- and post-intervention study, MIH after cardiac arrest was taught to 44 emergency medicine residents. Residents were randomly divided into 2 groups. The first group included 21 participants (lecture-based learning) and the second had 23 participants (e-learning). A 19-item questionnaire with approved validity and reliability was employed as the pretest and posttest. Then, data were analyzed with SPSS software version 17.0.
    Results
    There was no statistically significant difference in terms of the learning method between the test scores of the 2 groups (P = 0.977).
    Conclusions
    E-learning and lecture-based learning methods was effective in augmentation of residents of emergency medicine knowledge about MIH after cardiac arrest; nevertheless, there was no significant difference between these mentioned methods.
    Keywords: Education, Emergency Medicine, Hypothermia After Cardiac Arrest
  • Masoud Tarbiat, Mohammad Hossein Bakhshaei, Mehdi Moradi Page 10
    Introduction
    Intraoperative right ventricular perforation due to pacing catheter after its successful and uneventful insertion is a rare complication. Here, we present a case of cardiac arrest due to right ventricular perforation associated with a pacemaker lead during off-pump coronary artery bypass graft surgery.
    Case Presentation
    The case was a 68-year-old male, who was admitted to our hospital with retrosternal chest pain. He had a history of implantation of a permanent pacemaker due to symptomatic complete atrioventricular block. Based on angiography, the diagnosis was 3- vessel disease involving the left anterior descending, second obtuse marginal, and right coronary arteries. The right ventricle was perforated by the tip of the permanent pacemaker lead during off-pump coronary artery bypass graft surgery. Subsequently, the patient suddenly experienced cardiac arrest and underwent emergency on-pump cardiac surgery.
    Conclusions
    This case showed that in some situations, emergency surgery as a life saving procedure may be required in cardiac perforation due to permanent pacemaker lead even following cardiac arrest.
    Keywords: Pacemaker, Artificial, Coronary Artery Bypass, Off-Pump
  • Michael S. Green, Johann J. Mathew, Lia J. Michos, Parmis Green, Mansoor M. Aman Page 11
    Introduction
    An acquired Tracheoesophageal fistula (TEF) is commonly caused by a malignancy or trauma, with pulmonary infection or aspiration being the presenting symptom. However, in the critical care setting the presentation can be subtle and may present with difficult ventilation. High endotracheal tube cuff pressures can lead to tracheal erosions and thus increasing the chances for developing a TEF. Prolonged intubation in the presence of other risk factors like poor general state of health, episodic hypotension, nasogastric tubes, and repeated intubations can increase the likelihood of developing an acquired TEF. Angioedema of the airway is a rare but potentially devastating complication of angiotensin converting enzyme inhibitors (ACE-I) that could further add insult to the tracheal mucosa, predisposing to an acquired TEF.
    Case Presentation
    An elderly woman with multiple comorbidities and requiring mechanical ventilation, developed angioedema following intake of ACE inhibitor for hypertension. The ensuing airway edema made weaning off mechanical ventilation difficult. After repeated attempts at extubation, tracheostomy was performed. With the loss of airway after tracheostomy, the possibility of TEF was considered given her multiple risk factors and intra-operative findings of the tracheal mucosa.
    Conclusions
    While it may be difficult to predict who will actually develop a TEF, it is prudent to identify those at risk and take precautionary measures to prevent one. Emphasis should be placed on daily endotracheal cuff manometric pressure check to prevent ischemic changes of the tracheal mucosa resulting from high cuff pressures. Also, bronchoscopy could be used after extubating susceptible patients to detect an acquired TEF.
    Keywords: Angioedema, Intubation, Manometry, Tracheal Diseases, Tracheoesophageal Fistula
  • Ozkan Onal, Emine Aslanlar, Cansu Ciftci, Merih Onal, Jale Bengi Celik Page 12
    The i-gel has a thick airway tube and occasionally, achieving the airway can be difficult because of obstruction in the prone position. The authors aimed at solving this problem and used a modified i-gel airway in the prone position for radiotherapy processes in children.