حمیدرضا شتابی

This study was conducted to compare the effect of two doses of remifentanil infusion on the amount of bleeding, intraoperative hemodynamic changes, and complications after rhinoplasty surgery with general anesthesia.

This prospective randomized clinical trial study was conducted on 80 patients who were candidates for rhinoplasty from March 1401 to August 1402 in Al-Zahra Hospital, Isfahan, Iran. The participants were divided into two groups of 40 people using random allocation software. remifentanil infusion was adjusted in the first group with a dose of 0.15-0.25 mg/kg/min and in the second group with a dose of 0.25-0.35 mg/kg/min. The goal was to maintain mean arterial pressure (MAP) between 60 and 65 mmHg, to achieve this goal, reducing or increasing the rate of remifentanil infusion was used. During the operation, a heart rate of less than 50 beats per minute was considered bradycardia and was treated with atropine 0.015 mg/kg. In addition, the remifentanil infusion rate was reduced if MAP fell below 60 mmHg for more than 60 seconds. Patients were evaluated and compared during operation and recovery in terms of hemodynamic parameters, intraoperative bleeding and postoperative complications.

There was no significant difference between the two groups in the changes of hemodynamic parameters during surgery and recovery (P>0.05). The average bleeding volume in the two groups receiving remifentanil 0.15-0.25 mcg/kg/min and 0.25-0.35 mcg/kg/min Remifentanil was 44.25±23.1 and 28.25±15.5 ml, respectively, and the difference between the two groups was significant (P<0.001). According to the surgeon's opinion, intraoperative bleeding in the 0.25-0.35 mcg/kg/min remifentanil group was significantly lower than 0.15-0.25 (P=0.001).

According to the findings of the present study, it seems that the use of 0.25-0.35 min/µg/kg dose of remifentanil compared to 0.15-0.25 min/µg/kg dose, is associated with a significant reduction in bleeding during rhinoplasty, and also the use of this dose is not associated with the occurrence of serious hemodynamic disorders, including bradycardia and severe drop in blood pressure.

Due to the high prevalence of complications during and after laryngoscopy, especially hemodynamic disturbances, and the absence of a suitable solution for preventing these complications, this study was conducted to compare the effect of“Ketamine-Midazolam-Sufentanil” with “Etomidate-Sufentanil” combinations on changes in heart rate and blood pressure after laryngoscopy and endotracheal intubation.

In this controlled, triple-blind randomized clinical trial, 96 laryngoscopy candidate patients were divided into three groups of 32 members and were given “Ketamine-Midazolam-Sufentanil” (KMS), “Etomidate-Sufentanil” (ES) and” Etomidate-Normal Saline” (NS) respectively before laryngoscopy.Hemodynamic parameter changes at baseline and 1,3,5and 10 minutes after laryngoscopy, were measured and compared between the 3 groups.

During the study, the 3 groups KMS, ES, and NS had 0%, 15.6% and, 3.1% bradycardia respectively (p value = 0.024). Changes in systolic blood pressure were significantly different in the 3 groups (p value = 0.043). However, the incidence of tachycardia, hypertension, and hypotension were not significantly different among the 3 groups.

Results of this study showed that using the “Ketamine-Midazolam-Sufentanil” combination before laryngoscopy can reduce hemodynamic disturbances during and after laryngoscopy. Patients who receive this drug combination seem to have more desirable hemodynamic stability during and after laryngoscopy

Consumption of mouthwashes is effective in reducing ventilator-associated pneumonia in the patients hospitalized in the Intensive Care Unit. Considering the importance of controlling and preventing the occurrence of ventilator-associated pneumonia, it was decided to compare the effect of chlorhexidine mouthwash with Dinah herbal mouthwash in preventing ventilator-associated pneumonia in patients hospitalized in the Intensive Care Unit.

In this clinical trial study, 80 patients hospitalized in the intensive care unit were included in the study in two groups of receiving chlorhexidine gluconate 0.2% and Dineh mouthwash. The frequency, time, and method of mouthwash in both groups were performed three times a day (every eight hours) for 5 days. The incidence of ventilator-associated pneumonia and mortality in the patients after taking drugs were investigated. Finally, the information was entered into SPSS 23 software and analyzed.

There were 21 female patients (52.5%) and 19 male patients (47.5%) in the chlorhexidine group, and 18 female patients (45%) and 22 male patients (55%) in the Dina group (p=0.655). The average age in the chlorhexidine group was 60.85±7.92 years and in the Dineh group was 57.68±6.93 years (p=0.060). The incidence of ventilator-associated pneumonia was 10% in the chlorhexidine group and 12.5% in the Dinah group (P=0.999). The outcome of the patients in the chlorhexidine group was 62.5% complete recovery, 32.5% recovery with complications, and 0.5% death, and in the Dina group, 70% complete recovery, 20% recovery with complications, and 10% death (p=0 /363).

In the patients under mechanical ventilation, Dinah mouthwash was not superior to chlorhexidine mouthwash in preventing ventilator-associated pneumonia.

In this study, the effect of intravenous dexamethasone on pain, nausea and vomiting after laparoscopic ovarian surgery was investigated.

This randomized clinical trial was conducted from June 2019 to March 2019 on patients undergoing laparoscopic ovarian cystectomy in Beheshti Hospital, Isfahan. In this study, 88 patients aged 18 to 45 years were included in the study. Patients were randomly divided into two groups receiving dexamethasone (D) and normal saline (S). Two minutes before induction of anesthesia, the first group received 8 mg (2 ml) of dexamethasone and the second group received normal saline (2 ml). The duration of surgery and stay in recovery, the frequency of pain and nausea and vomiting, the need for analgesic and anti-nausea drugs, and the cardiovascular response during the study were evaluated and recorded.

 No significant difference was seen in terms of demographic characteristics between the two groups (P>0.05). The frequency of pain during recovery (P=0.4) was not significantly different between the two groups, but at 2 hours (P=0.005), 12 hours (P<0.001) and 24 hours after the operation (P=0.005) (P=0) was significantly lower than S group. The frequency of nausea in group D during recovery (P=0.003), 2 hours later (P<0.001), and 12 hours (P=0.002) was significantly lower than group S, but 24 hours after the surgery, there was no significant difference between the two groups (P=0.15). During recovery, there was no vomiting in both groups (P=1), the frequency of vomiting in 2 hours (P=0.003), 12 hours (P<0.002) and 24 hours after the operation (P=0.48) in group D was lower than S. At the time of the study, the dose of diclofenac and metoclopramide received in group D patients was lower than group S. There was no significant difference in cardiovascular response between the two groups during the study (P>0.05).

Dexamethasone with a dose of 8 mg before induction of anesthesia can be effective in reducing pain, nausea and vomiting after laparoscopic ovarian surgery and reducing the need for analgesics and anti-nausea drugs.

The most common method of anesthesia in Cesarean section is spinal anesthesia (SA). Post-Dural puncture headache (PDPH) is one of the complications of SA. The aim of this study was to evaluate the effect of intravenous administration of atropine and neostigmine in prevention of PDPH following Cesarean section.

This study was performed in 62 candidates of elective Cesarean section with SA in Isfahan Shahid Beheshti Hospital. Patients were randomly assigned into the two groups (n= 31 per group) using Random Allocation Software. After umbilical cord clamping, experimental group received neostigmine 0.5 mg and atropine 0.5 mg (i.v.), while the control group received 10 ml i.v. infusion of normal saline. The incidence and severity of headache were compared between the two groups in the first 48 hours and followed up for one week.

In this study, one patient in experimental group (3.2%) and five patients in control group (16.1%) reported PDPH which can be clinically important (P=0.195). Headache was seen in two patients (1 in each group) at recovery and in four at ward in control group (P=0.11). The mean severity of headache was 5 and 4.2±0.45 in experimental group and control group, respectively (P= 0.18). The interval between spinal anesthesia and first onset of headache was one hour in experimental group and 20.8 ± 11.1 hours in control group (P=0.18).

According to the present study, the neostigmine (0.5mg) + atropine (0.5mg) is associated with a non- significant reduction in the incidence of headache and its severity after spinal anesthesia that are clinically important. 

To improve the quality of sedation in procedures, different medications are used alone or in combination with each other, but so far, no administration method that is agreed upon by anesthesiologists has been presented. This study aimed to investigate the effectiveness and safety of intranasal ketamine in comparison with intravenous ketamine in cataract surgery.

This clinical trial was performed from December 2016 to March 2017 in Feyz Hospital, Isfahan. Ninety patients over the age of 18 who were candidates for cataracts surgery were randomly assigned to receive 1 mg/kg ketamine through the nasal route (INk) or intravenously (IVK). Ten minutes before the surgery, ketamine was administered in the INK group and intranasal saline in the IVK group. Two minutes before the start of surgery, normal saline was administered in the INK group and ketamine was administered intravenously in the IVK group. Patients received intravenous midazolam 0.04 mg/kg during prep and drape. The quality of sedation and analgesia, vital signs, patient and doctor satisfaction, and side effects were recorded during the study period. Data were analyzed using of SPSS software, version 23 (IBM SPSS, Armonk, NY, USA).

In this study, 90 people were included in the study, 53 of whom (58.9%) were men. The mean age of the patients was 61.5±10.6. Two groups had a significant difference in terms of gender (P=0.696), age (P=0.960), weight (P=0.212), height (P=0.632), underlying disease (P=0.094), and type of disease (P=0.090). Two groups were not significantly different in terms of mean heart rate (P=0.77), mean arterial blood pressure (P=0.13), mean blood oxygen saturation (P=0.58), patient satisfaction (P=0.470) and surgeon satisfaction (P=0.115), pain intensity (P=0.506), level of sedation level (P=0.477) and side effects (P=0.221).

Intranasal administration of ketamine provides similar sedation and cardiovascular response compared to intravenous administration of ketamine. Administering ketamine intranasally is a non-invasive, safe and effective method with easy application and can be a suitable alternative to intravenous administration.

Coronavirus in 2019 was recognized as one of the leading causes of death worldwide. According to reports, the mortality rate in people who need mechanical ventilation varies from 50 to 97 percent. The aim of this study was to evaluate the outcome of Covid-19 disease based on different characteristics in patients and mechanically ventilated variables.

This descriptive-analytical study was conducted on 160 patients with a definite diagnosis of Covid-19 who were under mechanical ventilation and admitted to the intensive care unit of Alzahra Hospital in Isfahan from March 2020 to March 2021. Data was collected by checklist. The checklist included demographic information, including age, gender, as well as information such as underlying diseases, disease outcome, length of hospitalization, etc. After collecting the data, they were analyzed in SPSS software version 22 and at a significance level of less than 0.05.

In this study, the overall mortality rate among mechanically ventilated patients was 62.5%. The mean age of patients was 69.99±17.87 years and the mean duration of hospitalization in surviving patients was 15.47±11.73 days and for deceased ones was 55.21±69.14 days. The mean age of the deceased group (65.71±16.59) was significantly higher than the surviving group 53±21.17 was (P=0.0001). The length of hospital stay in the deceased group was significantly longer than the surviving group (P=0.005). As a result, ventilator mode and inotropic agent intake during treatment increased the chance of mortality in patients under mechanical ventilation (P=0.001). There was a significant relationship between underlying diseases of hypertension, kidney disease and autoimmune disease with mortality in patients (P<0.05).

Various factors including the length of stay in the hospital, comorbidities such as hypertension, renal disease and autoimmunity may affect the outcome of critically ill ICU patients under mechanical ventilation. Patients who require long-term invasive ventilation and the use of inotropic drugs to maintain their cardiovascular status while hospitalized in the ICU are at higher risk for mortality.

Due to the high prevalence and importance of postoperative pain and opioid complications, we aimed to compare the prophylactic effect of intravenous injection of magnesium sulfate and paracetamol and their combination on pain intensity after deep vitrectomy in this study.

In this clinical trial study, 140 candidates of deep vitrectomy randomly distributed in four groups of 35. in the first group, 7.5 mg/kg magnesium sulfate was injected 20 minutes before the operation. In the second group, 15 mg/kg paracetamol, in the third group 10 mg/kg paracetamol plus 5 mg/kg magnesium sulfate within ten minutes, and in the fourth group, normal saline with the same volume was injected. The patients were then examined and compared in terms of hemodynamic parameters, pain intensity, amount of palliatives consumed, frequency of receiving palliatives, and occurrence of postoperative complications.

The mean postoperative pain intensity in the four groups of magnesium sulfate, paracetamol, magnesium sulfate-paracetamol, and control were 1.32 ± 0.9, 1.42 ± 0.34, 1.05 ± 0.38, and 1.72 ± 0.95, respectively, and the difference between the groups was significant (P = 0.003). The number of patients received pethidine were significantly lower in the combination group than the other groups (P = 0.018). The time interval between entering recovery and receiving analgesia in the group was significantly longer in the combination group than the other groups (P <0.001).

The use of magnesium sulfate-paracetamol combination reduces the postoperative pain intensity, prolongs the time of requesting analgesia, and reduces the use of analgesia within 24 hours after surgery, without any significant hemodynamic complication.

Induction of general anesthesia may cause hemodynamic instability. Remifentanil is often prescribed to suppress the hemodynamic response to anesthesia. The aim of this study was to investigate the effect of remifentanil on hemodynamic response to induction of anesthesia with propofol fentanyl or propofol ketamine and laryngeal mask airway (LMA) insertion.

This double-blind randomized clinical trial study was performed on 44 candidates for cataract surgery in Feyz Hospital, Isfahan, Iran from March to June 2020. Patients were randomly assigned into two groups using random allocation software. The first group received 1 mcg/kg fentanyl and the second group received 0.5 mg/kg ketamine. Also, both groups received 1 mg/kg propofol and 0.5 mcg/kg remifentanil intravenously. Hemodynamic parameters were measured and recorded at study times, and the results were analyzed statistically.

The mean age (P=0.199), weight (P=0.050), height (P=0.9), and frequency distribution of gender (0.763) and American Society of Anesthesiologists (ASA) score (0.069) were not significantly different between the two groups. Systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) in fentanyl group were significantly lower than the ketamine group immediately before LMA insertion, as well as 1, 3, and 5 minutes after LMA insertion (P <0.050). In addition, the mean heart rate (HR) in the fentanyl group decreased significantly at different time (P<0.001), but no significant difference was observed in ketamine group (P=0.056). In addition, the mean HR did not differ significantly between the two groups in any of the follow-up times (P>0.050).

Intravenous administration of remifentanil in induction of anesthesia with propofol-ketamine and propofol-fentanyl reduced changes in hemodynamic responses to LMA insertion. This hemodynamic stability was increased by adding remifentanil to the propofol-ketamine combination.

Remifentanil is associated with weakening of hemodynamic responses to LMA insertion in induction of anesthesia with propofol and ketamine or propofol and fentanyl; this effect can be associated with safety in cardiac patients.

Postoperative nausea and vomiting is a common complication of anesthesia. The aim of this study was to compare the effect of midazolam, ondansetron and their combination in prevention of nausea and vomiting after strabismus surgery.

In this randomized double-blind clinical trial, 140 patients undergoing strabismus surgery were divided into four groups (n=35 per group). The patients received midazolam 0.75 mg/kg (M), ondansetron 4 mg (O), midazolam 0.75 mg/kg + ondansetron 4 mg (MO), and saline 0.9% iv. (S) before anesthesia. Follow-up was done in the first 24 hours after surgery and incidence and severity of nausea and vomiting and other postoperative complications were compared between the four groups.

In this study, 10 patients (37%) in group S, 6 (19.4%) in group O, 8 (28.6%) in group M, and 2 (6.3%) in group MO developed nausea indicating significant differences between the four groups (P=0.019). The study showed no significant differences between the groups in incidence of vomiting (P= 0.18); 6 patients (22.2%) in group S, 5 (16.1%) in group O, 4 (14.3%) in group M, and 1 patient (3.1%) in group MO had vomiting. The severity of postoperative nausea and vomiting was significantly different between the four groups and group MO was found to have less severe nausea and vomiting two hours (P= 0.009) and 24 hours after surgery (P< 0.001).

Combination of midazolam and ondansetron reduces the incidence of postoperative nausea and vomiting compared to midazolam or ondansetron alone and leads to greater patient satisfaction. According to the higher effect of MO and lack of adverse effects on hemodynamic parameters it is recommended in patients undergoing strabismus surgery.

The aim of this study was to evaluate the effects of preventive administration of ketamine, fentanyl and paracetamol on pain intensity and hemodynamic parameters after deep vitrectomy.

In this clinical trial, 80 candidates of deep vitrectomy surgery were randomly assigned into 4 groups (1-4) and received 0.5 mg / kg ketamine, 2 μg / kg fentanyl, 10 mg/kg of paracetamol and equivolume of normal saline respectively intravenous infusion during the last 15 minutes of surgery. Pain intensity and hemodynamic parameters were recorded and analyzed.

Pain intensity was significantly higher in placebo group during the first 4 hours after operation (p<0.01), but no significant differences were observed between the study groups at 8 and 24 hours after operation in this regard. There were no significant differences between the three intervention groups in terms of pain intensity during the study. Also there were no significant differences between the 4 study groups regarding to hemodynamic parameters.

The use of each of the three intervention drugs significantly reduced the pain intensity compared to the control group without any hemodynamic derangement.

Cataracts are the leading diseases that cause blindness. Cataracts can be treated with surgery. Pain, itching, burning, and a foreign body sensation in the eye are common ocular complaints of patients in recovery. In this study, we compared the effect of Ketorolac eye drops and naphazoline antazoline eye drops on reducing complaints of surgery.

This randomized clinical trial study was performed from February 2016 to March 2017 on patients who were candidates for cataract surgery at Feyz University Hospital in Isfahan, Iran.  In this study, 54 patients were enrolled in two groups receiving Ketorolac eye drops and naphazoline antazoline (NA) eye drops. After the operation, patients' ocular complaints such as burning, itching, pain, and severity were evaluated every 15 minutes in recovery and every half hour in the ward until discharge from the hospital.

In this study, 54 patients in two groups of 27 were studied. In the post-anesthesia care unit, the burning sensation in the naphazoline-antazoline group was significantly lower than in the ketorolac group (P=0.02). Patients in the NA group had less foreign body sensation in the eye in recovery (P=0.97) and the ward (P<0.001) than in the ketorolac group. Mean Pain intensity in the recovery unit (P=0.39) and ward unit in the ketorolac group were less than NA (P<0.001). In the recovery unit in the NA group, the eye-burning sensation was significantly lower than in the ketorolac group. The foreign body sensation in the NA group was less than the ketorolac group but there was no significant difference between the two groups. In the NA group, itching of the eyes was less than in the ketorolac group.

It can be concluded that ketorolac drops have been more effective in reducing post-operative eye pain than NA and NA drops have been more effective in reducing burning, itching and foreign body sensation in the eyes than Ketorolac.

Hypotension and bradycardia are among the common side effects of spinal anesthesia. The effect of ondansetron on the reduction of hypotension and bradycardia caused by spinal anesthesia has been studied considering its antagonistic effect on the Bezold–Jarisch reflex. The present study was conducted to determine the effectiveness of two different doses of intravenous ondansetron on the reduction of the incidence of hypotension and bradycardia among candidates for elective caesarean section under spinal anesthesia.

This double-blind clinical trial was conducted in Shahid Beheshti Hospital in Isfahan in 2020 and included 90 patients aged 18 to 45 years in full-term pregnancy who were candidates for elective caesarean section in three groups of 30. 5 minutes before spinal anesthesia, 6 and 8 mg of ondansetron were injected in the first and second groups, respectively, and normal saline was injected in the third group. Vital signs were examined every 15 minutes during surgery and during recovery, and the incidence of hemodynamic disorders, nausea and vomiting was compared between the three groups.

There was no significant difference between the three groups in terms of demographic and baseline variables, blood pressure (systolic, diastolic and mean arterial pressure), heart rate, ephedrine intake and incidence of hemodynamic disorders. The frequency of nausea during recovery was significantly different between the three groups (p=0.035); 12 people in the ondansetron 6 mg group, 12 people in the ondansetron 8 mg group and 21 people in the control group had nausea during recovery (40%, 40%, and 70%, respectively). The frequency of vomiting in recovery was significantly different between the three groups (p=0.002); 5 people in the ondansetron 6 mg group, 1 person in the ondansetron 8 mg group, and 12 people in the control group experienced vomiting during recovery (16.7%, 3.3%, and 40%, respectively).

The results of this study showed that administration of ondansetron at 6 and 8 mg doses in caesarean section under spinal anesthesia has no significant effect in reducing the incidence of hypotension, bradycardia, and administration of ephedrine and atropine. However, it is associated with a reduction in the incidence of nausea and vomiting in the recovery room (ondansetron 8 mg is more effective than 6 mg).

The aim of this study was to evaluate the effect of intracameral lidocaine injection on hemodynamic parameters and pain intensity during and after cataract surgery under intravenous sedation and topical anesthesia.

This clinical trial included 62 patients randomly divided into two groups of 31; the intervention group received intracameral lidocaine with topical tetracaine, and the placebo group received intracameral sterile balance sodium solution (BSS) with topical tetracaine. Baseline and intraoperative and postoperative hemodynamic variables were recorded, and pain intensity were recorded and analyzed upon entering recovery and at different intervals up to 24 hours after the surgery.

Reported pain intensity decreased significantly In both groups over time (P < 0.050). Patients’ pain in the intervention group was significantly lower in comparison to the control group (P < 0.050); but no significant difference was observed between the hemodynamic variables in two groups (P > 0.05)

The present study shows that intracameral lidocaine is effective in controlling postoperative pain in patients undergoing cataract surgery without any considerable hemodynamic side effects.

The risk of anesthesia increases with age, so it is necessary to choose a safe and effective method. In this study, we compared the effectiveness of intranasal fentanyl with intravenous fentanyl in patients undergoing cataract surgery.

This study was a triple-blind prospective randomized clinical trial (The patient, physician, and data analyzer were unaware of the patient grouping). The study was performed from April 2017 to March 2019 in Feyz Hospital, Isfahan, Iran. 90 patients over 18 years of age who were candidates for cataract surgery were included in the study and were divided in two groups receiving intravenous fentanyl (IVF) or intranasal fentanyl (INF). The dose of fentanyl in both groups was 1.5 μg/kg with a maximum of 100 μg. In the IVF group, 1 ml of normal saline was dripped into each nasal passage 10 minutes before surgery and intravenously fentanyl was injected 2 minutes before surgery. In the INF group, 1 ml of fentanyl was administered into each nostril 10 minutes before surgery and 2 ml of saline was administered intravenously two minutes before surgery.

In this study, there was no significant difference between the two groups in terms of mean heart rate (P=0.762), mean arterial blood oxygen saturation (P=0.262), mean systolic blood pressure (P=0.264), mean arterial blood pressure (0.462), satisfaction rate Patient (P=0.231), duration of surgery (P=0.612) and pain intensity (P=0.87). But in the intravenous fentanyl group (IVF), the level of sedation (P=0.002) and the level of surgeon satisfaction (P<0.001) were higher than intranasal fentanyl group (INF). There was no significant difference between the two groups in terms of side effects (P=0.171) and surgery time (P=0.612). The mean VAS was not significantly different between the two groups.

The study showed that intranasal administration of fentanyl compared with intravenous administration of fentanyl provided similar sedation and cardiovascular response. Intranasal administration of fentanyl is a non-invasive, safe and effective method, that is easy to use and can be a viable alternative to intravenous administration.

Control of bleeding during dacryocystorhinostomy (DCR) surgery is of particular importance and controlling the bodychr('39')s hemodynamic responses to stress effectively reduces the amount of bleeding during surgery and improves the surgical area. Therefore, in this study, we aimed to investigate the effect of two-drug combinations Labetalol-Hydralazine and Labetalol-Trinitroglycerin on hemodynamic factors during dacryocystorhinostomy surgery.

The present study is a double-blind randomized clinical trial that was performed on 71 patients who were candidates for dacryocystorhinostomy (DCR) surgery. Patients enrolled in the study using computerized randomization software (Random allocation software).they were divided into two groups. The study was conducted from September 2016 to September 2017 in Isfahan. The amount of bleeding, the cardiovascular response of patients during and after surgery, the degree of satisfaction of the surgeon and the patient, the severity of pain, and the occurrence of nausea and vomiting were assessed, collected and analyzed.

Between the two groups in terms of demographic characteristics there was no significant difference. There was no significant difference between the two groups in terms of mean arterial blood pressure (MAP), heart rate (HR) during surgery and the time of staying in the recovery room (P>0.05). There was no significant difference between the two groups in terms of bleeding volume, surgeon and patient satisfaction (P=0.73), frequency of vomiting, length of stay in recovery (P=0.57), the severity of nausea (P=0.38), pain (P=0.33) and rebleeding in recovery (P=0/75).

The results of the present study show that the use of labetalol with hydralazine in comparison with labetalol with trinitroglycerin has similar results in terms of hemodynamic factors as well as bleeding volume and surgeon and patient satisfaction criteria. Therefore, both of these compounds can be used to reduce bleeding and control vital signs during and after dacryocystorhinostomy surgery.

Phacoemulsification surgery is one of the most common surgeries in the world. Various drugs have been used alone or in combination with each other to provide effective and safe sedation in patients, but so far, a drug method agreed upon by anesthesiologists has not been proposed. The purpose of this research was to evaluate the sedative quality of midazolam or propofol with a low dose of ketamine in phacoemulsification surgery.

This study was a double-blind randomized clinical trial conducted from November 2017 to August 2019 at Faiz Hospital, Isfahan. In this study, 68 patients were assigned in the groups of midazolam (M) and propofol (P) using randomization software entered the study. The midazolam (M) group received 0.04 mg/kg and the propofol (P) group received 0.5 mg/kg, then in both groups, ketamine 0.3 mg/kg was injected intravenously. The quality of sedation, cardiovascular response and patient and surgeon satisfaction were assessed and recorded. Data were entered into SPSS 23 software and analyzed by using ANOVA and Independent samples t‐test.

In this study, between the two groups in terms of demographic characteristics there was no significant difference (P>0.05). In the KM group, higher percentage of patients achieved the desired quality of sedation, but, between the two groups no statistically significant difference was shown (P=0.75). Surgeon satisfaction was higher in the KP group (P=0.18) and patient satisfaction was higher in the KM group (P=0.18) but there was no significant difference (P>0.05). Recovery time between groups was Similar and no statistically significant difference was shown (P>0.98). In the KM group at 5 minutes, systolic blood pressure (SBP) was notably greater than the other group (P=0.02) and diastolic blood pressure was notably greater than the KP group (P=0.08).

It can be stated that adding a small dose of ketamine to propofol and midazolam is associated with effective sedation and a similar cardiovascular response during phacoemulsification surgery.

Because deep vein thrombosis (DVT) is one of the most common problems in the intensive care unit, it may lead to complecating the patientchr('39')s general condition. This study aimed to investigate the predictive factors of DVT in patients admitted to the intensive care unit (ICU) of Amin hospital in Isfahan.

In this retrospective study, all the records of patients admitted to the ICU ward of Amin Hospital located in Esfahan, from April 2015 to March 2018, were investigated and from all patients with DVT, 20 records were extracted and 40 cases of patients without DVT were also randomly selected. Information such as age, sex, Wells score, Apache score, nutritional status, clinical parameters, cause of hospitalization, length of stay, ICU induced disease and treatment were extracted from these records and compared between both groups with and without DVT

From 2000 patients admitted to the ICU ward, 20 cases were developed DVT. The age of patients in the DVT group was significantly higher (P=0.008). Factors such as increased Wells score, increased length of stay in the ICU, having ICU induced internal diseases and pneumonia increased the chance of DVT incidence as 18.75, 1.92 and 2.75 and 2.28 times, respectively and the increase of potassium level and use of heparin bandage for treatment reduced the chance of DVT by 2.31 and 2.55 times, respectively (P<0.05).

In the general intensive care unit, the incidence of deep vein thrombosis was higher in internal ward patients. Pneumonia was the most common disease associated with deep vein thrombosis and the risk of deep vein thrombosis was higher in the anemic patient. Patients with upper limited normal levels of potassium were less likely to develop deep vein thrombosis. It seems that potassium in the upper limit of normal reference can play a protective role against deep vein thrombosis. Further studies with larger sample sizes are suggested.

A significant number of patients undergoing maxillofacial surgery needs nasotracheal intubation. In nasotracheal intubation, selecting the most appropriate nostril regarding normal anatomical conditions can be effective in reducing the time needed to pass the tube through the nose and epistaxis. The purpose of this study was to evaluate the effect of choosing right or left nostril on the post nasotracheal intubation complications.

In this study, 111 patients underwent maxillofacial surgery with nasotracheal intubation of the left (n = 55) and the right nostril (n = 56), were enrolled. Intubation time and complications such as bleeding, epistaxis, bronchospasm, vomiting, and submucosal intubation were recorded and compared between the two groups.

The time of intubation through the right nostril with 55.72 ± 51.47 seconds was not significantly different from the left nostril with 57.86±48.88 seconds (P = 0.826). In contrast, the incidence of epistaxis in intubation through the right nostril with 25.0% was significantly lower than the left one with 43.6% (P = 0.039).

 According to the results of this study, although the time of intubation through the both nostrils was not different between the two groups, the incidence of epistaxis and its severity in the intubation through the right nostril were far less than the left one. Therefore, it seems that the right nostril be an appropriate pathway of intubation in the patients with a natural-looking nose.

This study aimed to compare the effect of two different levels of end-tidal carbon dioxide on cognitive impairment in elderly patients undergoing surgery.

In this clinical trial study, 240 patients over 65 years of age were randomly distributed into two groups. In the first group, the end-tidal carbon dioxide (ETCO2</sub>) pressure was maintained in the range of 35-40 mmHg, and in the second group in the range of 40 to 45 mmHg. Patients' cognitive scores before surgery, and 24 hours, one week, and six weeks later were compared between the two groups.

In the first 24 hours, the incidence of cognitive impairment was 12.5 and 11.7 percent in first and second groups, respectively; while at the first week after surgery, this rate was 6.7 and 11.7 percent, and at the sixth week, 5.0 and 9.2 percent, respectively, based on the short test of mental status. In all cases, the difference between the two groups was not statistically significant.

 in the range of 35 to 45 mmHg has no effect on the cognitive impairment of elderly patients under cataract surgery with general anesthesia. Therefore, further studies on the effects of different extents of ETCO2</sub> on cognitive impairments are necessary.