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Archives of Anesthesiology and Critical Care - Volume:3 Issue: 1, Winter 2017

Archives of Anesthesiology and Critical Care
Volume:3 Issue: 1, Winter 2017

  • تاریخ انتشار: 1395/12/11
  • تعداد عناوین: 6
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  • Mojtaba Mojtahedzadeh, Mohammad Abdollahi, Tina Didari Pages 267-269
    Sepsis as the host responsive syndrome is one of the main concerning issues and costly disease on intensive care unit (ICU) in the 21st century. Epidemiological studies have showed that mortality rates of sepsis in ICU and hospitals among 37 countries were 39.2% and 49.6% respectively [1].
    Complicated nature of sepsis is still not well understood and this makes it hard to treat and manage. According to the failure of current therapies in the management of sepsis and the emergence of antibiotic resistant bacterial strains, new pharmaceutical approaches are needed to trigger precise molecular pathways in septic patients [2].
    Metformin (1,1 dimethyl hydrochloride) is a unique member of biguanide family and approved as an anti-diabetic product with minimal adverse effects. Beyond the conventional role of metformin in medication for type 2 diabetes (T2DM) [3], it has been shown that metformin has anti-cancer possession [4] obese adolescent’s treatment [5], decreased risk of cardiovascular disease [6-7], inflammation recovery in burned subjects [8], antioxidant and anti oxidative stress traits [9], protection against hypertension and polycystic ovary syndrome(PCOS) improvement [10]. Despite its valuable properties, many controversies exist on its administration in septic subjects. The rising lactate level has a pivotal role in sepsis initiation, on the contrary inhibitory effects of metformin on complex I of mitochondria cause metformin associated lactic acidosis (MALA) in some cases, so until now this drug is banned in septic patients [11-13].
    New investigations claim that less than 10 persons per 100,000 patient-years suffered from lactic acidosis in metformin users with pre-existing illness and organ impairment [14]. In 2012, Green et al. explained that the median level of lactate in metformin group was higher than the control group among septic patients, but all subjects had the same mortality risk [15]. Four years later, in a cohort study Dounias-Barak et al. claimed that mortality rate in septic persons after metformin administration was lesser than the control group [16]. Thereafter, Parker et al. found that the kinetics of lactate did not differ between metformin and non-metformin consumers in septic patients [17]. A substantial role of metformin attributed to AMPK(AMP activated protein kinase) activity. It plays fundamental role in cellular homeostasis via allosteric potential. Also AMPK poses positive effects against inflammation and senescence, which promote synthesis, metabolism and regulation of cellular pathways [18].
    AMPK is a heterotrimer kinase with serine/training (Ser/Thr) residues. Phosophorylation of AMPK in Thr172 with metformin leading to AMPK activation. Phosphorylated AMPK is so called p-AMPK. AMPK is known as a natural metabolic switch, when ATP to ADP content falls down, activated cascade reactions leading to inhibition of ATP consumption pathways and stimulate ATP production [19]. Recent experimental studies have shown a close relationship of metformin in AMPK phosphorylation, in sepsis management. In 2013, Park et al. discussed about the role of metformin against bacterial lipo polysaccharide (LPS) infection on in-vivo and ex-vivo models of mice. They concluded that metformin induced p-AMPK, affected bacterial viability via neutrophil chemotaxis facilitation. It has been demonstrated that neutrophil on metformin group invaded bacteria more powerful than the control group and diminished TLR4 [20]. Tzanavari et al. showed that metformin affected AMPK preserved myocardial tissue with the improvement of fatty acid oxidation gene expression level and maintained normal metabolic function of cells in LPS induced sepsis [21]. Next publication claimed that activation of AMPK-α1 after metformin administeration in pulmonary microvascular endothelial cells (PMVECs) culture and murine models relieved alveolar edema, lung tissue permeability improvement and reconstructed micro-circulation of lung tissue after LPS injection [22]. Vaez et al. revealed that metformin pre-treatment influenced cardiomyocyte of septic rats via altered cardiac index, reduced gene expression level of TLR4, MyD88 and TNF-α and elevated rate of p-AMPK. Moreover metformin improved myocardial injury in histopathological assessment [23]. Another publication of Vaez et al. indicated metformin prescription in septic male Wistar rats, leading to upregulation of phosphorylated p-AMPK then after ameliorated lung tissue infiltration and pulmonary congestion, attenuated inflammatory markers such as MyD88, myeloperoxidase (MPO), nuclear factor-κB (NF-κB), Tumor necrosis factor α (TNFα) and doweregulated TLR4 [24]. These two studies represented that metformin may have protective effects on cardiopulmonary damage after LPS induced sepsis on ex vivo models. Liu et al. studied on experimental models of acute lung injury (ALI) after cecal ligation and puncture (CLP) of rats. They confirmed that metformin converted AMPK to p-AMPK improved acute lung injury, restored mitochondrial complexes (III and IV) function and reduced Hypoxia-inducible factor 1- α (HIF-1α) in macrophages [25] (Figure 1).
    In conclusion, a growing body of evidence on in-vitro and in-vivo models revealed that metformin might have a potential role in sepsis management via AMPK activation, modulation of cellular functions and alleviation of multi-organ dysfunction followed by cytokine storms. Moreover, this biguanide drug had a crucial role to protect signaling pathways against oxidative stress and motivating internal cell reactions during sepsis. According to the importance of biguanide administration in septic patients, it should be noted that many differences and questions between experimental cases and human subjects remain unsolved and there is a long way to metformin admnistration in clinical trials . It seems that more research to confirm metformin advantages in septic patients is required. Further laboratory studies will need to focus on larger sample sizes of animals, tracing precise mechanisms of cellular reactions due to sepsis initiation and simulation mammalian models same as the human population will establish more valid and reliable results.
    Keywords: metformin, sepsis, experimental model, AMP activated protein kinase
  • Farhad Etezadi, Naser Ghiasnejad Omrani, Mohammad Talebpour, Farsad Imani, Reza Shariat Moharari, Pejman Pourfakhr, Mohammad Reza Khajavi Pages 270-272
    Background
    Laparoscopic gastric plication (LGP) is a technique in the restrictive category of bariatric procedures that reduces the gastric volume. Nausea and vomiting are the most common complications after this procedure.
    The goal of this research is to determine the preventive effective dose of promethazine on postoperative nausea and vomiting (PONV) after laparascopic gastric placation
    Methods
    After induction of general anesthesia the patients were divided into two groups, the promethazine 50mg group, which was given promethazine 50mg IM plus dexamethasone 8mg IV and the promethazine 25mg group, which was given promethazine 25mg IM plus dexamethasone 4mg IV. The primary endpoints were the incidence and intensity of nausea and vomiting, and severity of abdominal pain score in postoperative periods.
    Results
    Sixty-four morbid obese patients were enrolled into the study. Promethazine50mg group was found to significantly reduce the incidence of PONV in the first 12hrs compared with the other group, (21.87% vs37.5%, P=0/068). At the same time the intensity of PONV in base of numeric rating scale was lower in promethazine 50mg group compared to another group (2.63±0.85 vs4.65± 1.23, P=0/089). The mean severity of abdominal pain was higher in promethazine 25mg group, thus these patients needed more analgesia in comparison with another group.
    Conclusion
    In morbidly obese patients undergoing laparoscopic gastric plication, prophylactive administration of dexamethasone8mg and promethazine 50mg was more effective in the first 12 hours after surgery in reducing the incidence of PONV, and severity of abdominal pain.
    Keywords: laparoscopic gastric plication, nausea, vomiting, promethazine, dexamethasone, metoclopramide
  • Anahita Hirmanpour, Mohammadreza Safavi, Reihanak Talakoub, Azim Honarmand, Marjan Ghasri, Navid Chitsaz Pages 273-277
    Background
    The aim of this study was to evaluate the effect of two injections doses of magnesium sulfate for controlling and reducing hemodynamic changes caused by laryngoscopy and endotracheal intubation in pregnant women who were candidates for caesarean section with general anesthesia.
    Methods
    In this controlled randomized double-blind clinical trial, 165 pregnant women who were candidates for caesarean section were allocated into three groups of receiving 40mg/kg of magnesium sulfate (M1 group), 60 mg/kg of magnesium sulfate (M2 group) and placebo (P group) before induction of anesthesia. Systolic blood pressure (SBP), diastolic blood pressure (DBP), mean of arterial pressure (MAP), heart rate (HR) and arterial oxygen saturation (SPO2) were measured and recorded at the baseline (before the induction), right before the intubation and 1, 3, 5 and 10 minutes after laryngoscopy and endotracheal intubation. The Apgar score of the neonates was also measured and recorded 1 and 5 minutes after delivery.
    Results
    The mean of changes in systolic blood pressure and mean of arterial pressure showed a significant difference between the M1 and M2 groups with the placebo group right before the intubation and 1, 3 and 10 minutes after laryngoscopy. The mean of changes in heart rate was specifically significant 1, 5 and 10 minutes after intubation in the M2 group (p 0.05).
    Conclusion
    For inducing anesthesia in pregnant women, using 60 mg/kg of magnesium sulfate decreased the hemodynamic changes after laryngoscopy and endotracheal intubation and it had no adverse effect on the Apgar score of the neonates.
    Keywords: caesarean section, general anesthesia, laryngoscopy, magnesium sulfate
  • Valiolah Hasani, Reza Safaeian, Gholamreza Movasaghi, Abolfazl Rahimizadeh, Ishagh Bahrami, Fatemeh Sadat Mostafavi Mobasher, Giti Fotohi Pages 278-282
    Background
    Long surgery causes hypothermia and increased bleeding and can increase the arterial blood lactate levels during anesthesia. It causes cellular hypoxia and its complications. Considering the core temperature of the patient during surgery it can prevent hypoxia. This study aimed to compare the effects of different temperatures on the core temperature and the concentrations of lactate in patients who were candidate for posterior spine fusion surgery under general intravenous anesthesia.
    Methods
    In this clinical trial study, 60 patients with ASA II risk undergoing spine fusion surgery referred to Rasoul Akram hospital from 2015 were studied. Patients were divided in two groups of receiving temperature of 36 ° and 40 ° C during operation. Demographic data as well as information before anesthesia, after surgery, as well as recovery was gathered in the check list. Data then were entered to the statistical software SPSS v. 16 and analyzed.
    Results
    The mean age of patients was 49.14 (SD= 12.97) years. Pre-operation O2 Saturation had significant difference between the two groups (p value = 0.015). Trend of Hb, HCT, HR, SBP, O2 Sat, operating room temperature, pH, arterial HCO3, arterial O2 pressure, arterial blood lactate, degree of arterial blood saturation and arterial access base in 36ºC group (p value
    Conclusion
    In bleeding and low blood pressure and hypothermia, the level of serum lactate is more than 3.5 meq/L, which is caused by cellular hypoxia. In our study in two temperatures during operation lactate level was low because of longer time of operation that shows loss of hypoxia and high level of consciousness and less complication. Also time of waking up was more rapid. So as lactate level was low, prophylaxis of hypoxia is more.
    Keywords: hypothermia, hypoxia, blood lactate arterial, intravenous anesthesia, posterior spine fusion
  • Behzad Nazemroaya, Elham Babaei Pages 283-290
    Background
    Electroconvulsive therapy (ECT) is usually given to people with severe depression which has not responded to other forms of treatment such as anti-depressants. ECT may be accompanied by potentially significant medical complications including prolonged seizures, prolonged apnea, or cardiac or pulmonary complications. Modification of ECT with brief anesthesia and muscle relaxants should be accomplished. Present prospective randomized study is designed to compare Thiopental Sodium and Etomidate for their effect on hemodynamics, seizure duration, respiratory arrest, and recovery after electroconvulsive therapy and various adverse effects on Sick children in ECT.
    Methods
    A total of 64 patients with psychiatric disorder were examined in a prospective randomized double-blind study. The patients were randomly divided into two groups as group T (n= 32, Thiopental sodium 2 mg kg-1), and group E (n = 32, Etomidate 0.1 mgkg-1).
    effects of etomidate versus thiopental in electroconvulsive therapy on cardiovascular system parameters (heart rate, blood pressure, and blood oxygenation), seizure variables, adverse effects and recovery variables were recorded at every session, on prespecified time points, and the findings were used in this evaluation.
    The methods used were descriptive study, cross tabs, Chi-square test, independent sample t-test, paired sample t-test, Fisher and repeated measure analysis of variance (ANOVA). It should be noted, the results are statistically significant at 95% has been mentioned.
    Results
    Both groups were comparable in sex, weight and ASA physical status, with no statistically significant differences (p > 0.05). There was no difference in the Systolic blood pressure (DBP) between the two groups.
    Patients in etomidate group showed little change in mean Diastolic blood pressure 5th minutes after ETC (DBP5) and mean arterial pressure 5th minutes after ETC (MAP5), and heart rate 1th minutes after ETC (HR1), arterial blood oxygen saturation 1 and 5 minutes after ETC, compared to thiopental (p> 0.05).
    Based on statistical analysis, the relative superiority of etomidate compared to thiopental the anesthetic induction in the treatment of ECT, was seen in Four variables, duration of seizures, Recovery time, Reach verbal response after seizure and apnea durations (Back spontaneous breathing after a seizure).
    In addition, Pain on injection, nausea and vomiting and Myoclonus was more in etomidate group while Muscular pain activity was higher in thiopental group (p> 0.05).
    Conclusion
    It seems that etomidate compared with thiopental has no conflict with ECT therapeutic effects in psychiatric patients. In addition, it probably can be used as a safe and effective drug for controlling ECT-induced hemodynamic changes and seizure variables. Drawback etomidate Compared with thiopental had a high incidence of myoclonus, Pain at injection site and nausea and vomiting.
    Keywords: thiopental sodium, etomidate, electroconvulsive therapy
  • Alireza Saliminia, Omid Azimaraghi, Zahra Ebadi, Ali Movafegh Pages 291-296
    Background
    Anesthesiology residents are susceptible to different mood and anxiety disorders. The aim of this research was to determine and compare stress coping styles and clinical performances in anesthesiology residents with type D and Non-D personality.
    Methods
    This is a causative – comparative research. Anesthesiology residents at academic department of anesthesiology in Tehran university of medical science(TUMS) consisting of Shariati, Emam Khomeini and Sina Hospitals completed the CISS (coping inventory for stressful situations, ANDLER & PARKER, 1990) and DS-14 (Type D personality) questionnaires.
    Clinical performance of participants was evaluated by faculty with GRF (Global Rating Format), DOPS (Direct Observation of Procedural Skills) and OSCE (Objectively Structured Clinical Examination) scores.
    For evaluating research hypothesis, data was analyzed with Pierson correlation coefficient and single and multivariate analysis of variance.
    Results
    Research results demonstrated that type D personality anesthesiology residents use emotional and avoidance- social diversion coping style more than non-D ones. Interestingly, task-oriented coping style was not statistically different in two groups.
    Clinical performance composed of OSCE, DOPS and GRF scores was also higher in non-D personality participants.
    Conclusion
    Based on our results in this research, type D personality affect negatively on clinical performance and coping styles in anesthesiology residents.
    So it is rational to identify type D personality residents to educate them how to deal with negative affects and social avoidance in order to promote their clinical performance.
    Keywords: stress, coping styles, anesthesiology resident, clinical performance