asghar hajipour

Anesthesia is a significant development of modern medicine that makes diagnostic and therapeutic procedures with unbearable pain or discomfort feasible. Like most medical procedures, anesthesia is not free of complications. It is shown that many patients suffer from anxiety due to fear of anesthesia complications before operation. Increasing patients’ knowledge of these complications can help them reduce their anxiety. This study aimed to assess the patients’ knowledge and attitude toward anesthesia complications and their relationship with demographic features and previous anesthesia experience to ensure a helpful and informative preoperative visit.

This is an original study conducted on patients referred to our anesthesia clinic for a preoperative visit, completing a questionnaire about demographic features, previous anesthesia experience, knowledge, and attitude toward anesthesia complications. The results were expressed as frequencies and percentages. T-test, Pearson correlation, and linear regression were used to find the significance of the study parameters.

Four hundred patients entered the study. Patient demographics were as follows: 260 (65.0%) female, 251 (62.75%) high school-graduated or below, mean (SD) age 42.75± 13.62 years. 260(65.0%) patients had previous anesthesia experience. Patients’ mean (SD) knowledge score was 6.83 ± 4.18 out of 19 questions and the mean (SD) attitude score was 54.26 ± 6.59. The patients were most aware of postoperative delirium (72.8%), nausea and vomiting (66.0%), feeling pain during surgery (59.5%), and death (52.3%) as general anesthesia complications. There was a significant relationship between the level of knowledge and the female sex (p-value= 0.03). University education had a significant relationship with knowledge and attitude (both p-values ≤ 0.001). There was a significant correlation between knowledge and attitude (Pearson correlation= 0.461, p-value ≤ 0.001), as well.

Unfortunately, the knowledge about anesthesia complications in outpatients referring to our tertiary care center was poor. Women and university-educated patients had a higher level of knowledge. In contrast, most patients had a positive attitude toward anesthesia which was significantly higher in university-educated patients. It is shown that with the increase in the level of knowledge, attitude scores increased as well.

Due to the associated hypertension and cardiovascular disease in patients with ESRD hemodynamic changes during operations are detrimental and may be life-threatening. Therefore, hemodynamic stability is an important criterion in selecting the anesthetic approach.

72 ASA class III/IV, ESRD Patients were studied in randomized double blind clinical trial. They were divided into two groups by four-block randomization. A group of patients were induced and maintained by etomidate and second of patients were induced by Na thiopental and maintained by isoflurane. Systolic, diastolic and mean arterial blood pressure and heart rate were measured at interval of pre and post induction, postintubation, pre and post abdominal insufflation during and at the end of surgery and in recovery. The total BP modulators were recorded and postoperative nausea and vomiting was registered in the recovery. Data were analyzed by STATA version 12.

There was no significant difference in physical characteristics between two groups. There was no statistical difference between the groups in SBP and HR (P>0.05), although DBP fluctuation>20% at interval postinduction and prior to abdominal insufflation during surgery and at the end of surgery, was significantly higher in the isoflurane group of patients. (P=0.004, 0.001, 0.003 and 0.009, respectively). Also, the MAP fluctuation at interval of post induction, preinsufflation and at the end of surgery was significantly higher in isoflurane of patients. (P=0.04, 0.001, and 0.02, respectively).

The group anesthetized with isoflurane had a higher hemodynamic fluctuation, compared to the group anesthetized with etomidate. As hemodynamic changes are critical in patients with ESRD, etomidate is a more appropriate anesthetic choice for implantation of peritoneal dialysis catheter by laparoscopic approach.

Idiopathic clubfoot deformity is a relatively common congenital pediatric foot deformity. A percutaneous Achilles tenotomy (PAT) is required to correct the equinus deformity as it is the most resistant component of clubfoot deformity. Although this procedure is mainly performed with local anesthesia, performing this procedure with general anesthesia has significant advantages.

The purpose of this study was to compare the safety and efficacy of post-procedural pain management of PAT in the treatment of clubfoot with the Ponseti method when performed in a clinic setting with local anesthetic or under general anesthesia

This is a multicentric prospective observational evaluation on children less than one year of age with idiopathic clubfoot whom referred for Ponseti casting and PAT. This procedure was done in the control group with local anesthesia and in the intervention group with Sevoflurane mask 8% (MAC 2) and maintenance of anesthesia with Sevoflurane mask 4% (N2O/O2, 50%). The neonatal infant pain scale (NIPS), the amount of milk, and mood changes were evaluated as a criterion to measure the pain level.

NIPS score in the intervention group was significantly lower than the control group. Children in the intervention group consume significantly more milk than the control group. Furthermore, 76% of children in the intervention group were classified as "calm," 24% as "relatively restless," and no child was classified as "severely restless." While in the control group, 54% of children were classified as "severely restless," and the remaining 46% as "relatively restless."

Our result showed that using general anesthesia to perform achillotomy in the treatment of clubfoot in children could be associated with less pain in these patients and without significant complications.

Bloodless surgical field obtained by controlled hypotension reduces the bleeding, the surgical time and improves outcome of rhinoplasty and other facial plastic surgeries.Since acupuncture is used for epistaxis, this study was designed to investigate its effectiveness in reducingthe bleeding in open rhinoplasty.

In a triple-blinded randomized clinical trial, 88 patients with ASA I and II physical status, aged between 20 –48 years, who were candidates of open rhinoplasty were enrolled in the study.After randomization, 44 patients were assigned to each group of acupuncture or control. They were given identical anesthesia. In addition to the hemodynamic monitoring, blood loss was assessed in all patients and compared between the two groups.

There were statistically significant differences between two groups in terms of the amount of bleeding (P = 0.001) and surgeon satisfaction (P = 0.010). Coagulation indicators were similar in both groups (All P > 0.05). Mean SBP and DBP, average HR and average MAP in both acupuncture and control groups did not show significant differences (All P > 0.05). Adverse events such as bradycardia or hypotension requiring treatment were not seen.

Our findings demonstrated that acupuncture could reduce bleeding during rhinoplasty without side effects.

This retrospective cohort study aimed to assess the frequency of emergency cesarean sections with epidural analgesia and its implications on Apgar scores and Neonatal Intensive Care Unit (NICU) admissions among patients at Tehran University of Medical Sciences Hospitals from 2017 to 2018.Data from 7170 patients were extracted from the hospital information system (HIS) through a consensus method. Descriptive statistics, cross-tabulation, and logistic regression analyses were conducted using Stata v17 software.Out of 9387 patients, 62.7% underwent cesarean sections, and 37.1% had normal vaginal deliveries. Epidural analgesia was administered to 127 patients, with 98.4% achieving successful normal vaginal delivery. Nulliparous women constituted 64.29% of those receiving epidural analgesia. Apgar scores at five and ten minutes were comparable between epidural and non-epidural groups. Emergency cesarean rates with epidural analgesia were low (1.6%).Findings align with previous research indicating no significantimpact of epidural analgesia on Apgar scores. Nulliparous women predominated in the epidural group, consistent with pain pattern disparities. The study supports recent research showing epidural analgesia does not increase emergency cesarean rates, even inhigh-risk pregnancies.This study suggests that epidural analgesia does not significantly impact Apgar scores, NICU admissions, or emergency cesarean rates. While the comprehensive dataset enhances reliability, retrospective design limitations are acknowledged. Prospective studies exploring factors contributing to neonatal mortality and overall labor duration are recommended for more robust evidence.

The aim of this study was to compare the post-operation analgesic effects of patient-controlled epidural analgesia and patient-controlled intravenous analgesia for patients who were undergoing esophageal cancer surgery. This was a randomized clinical trial. 80 patients undergone esophagostomy were randomly divided into two groups: 40 patients in the epidural PCA and 40 patients in the intravenous PCA group were evaluated. Post-operation pain score was assessed using the universal pain assessment tool (UPAT) in both groups at 24 and 48 hours after surgery. Secondary outcomes included AKI, MI, CVA, pulmonary complications, ICU stay and three months survival. Mean pain scores were similar in the two groups (P>0.05). There was no significant difference between the two groups for rescue treatment, three months’ survival, CVA, MI and AKI. However, ICU stay (P=0.008) and pulmonary complications (P=0.05) were greater in PCIA group. The results indicate that none of the PCEA and PCIA methods have any superiority in terms of pain control and the incidence of analgesic-related side effect complications after surgery in patients undergoing esophagostomy and confirm sufficient analgesia by both.

During the COVID-19 pandemic, burnout of healthcare workers, including anesthetists, has become a critical issue. This study aimed to provide a practical framework for decreasing and preventing burnout among anesthesiology residents through preserving their good mental health.

Since the onset of the COVID-19 outbreak, anesthesiology residents have been members of medical teams with the attending staff, senior residents, and partner residents. Besides, the following measures were taken to reduce burnout: providing financial support for the attending staff to procure personal protective equipment (PPE), rearrangement of work schedules to reduce the workload, holding training sessions in virtual meetings, and improving the social network system for reducing burnout.

The interventional program could help anesthesiology residents to adapt to or cope with the healthcare system status and also prevent burnout. Moreover, development of empathy, integrity, and cohesion in the healthcare system motivated the staff to comply with the principles of medical professionalism.

During the current health crisis due to COVID-19, it is essential to implement specific interventional and training programs for decreasing or preventing burnout among healthcare workers.

Background and Importance: 

Mortality associated with post- coronavirus disease 2019 (COVID-19) rhino-orbito-cerebral mucormycosis (ROCM) is an evolving concern. Association of COVID-19, corticosteroid therapy and uncontrolled diabetes mellitus (DM) is considered as predisposing factors for ROCM. We present two cases of successful treatment leading to patient survival for post-COVID-19, stage 4c-ROCM.

Two middle-aged men with poorly controlled DM were referred to our hospital for post-COVID-19 ROCM. They had received intravenous antivirals and dexamethasone as treatment in a primary center. Both patients had unilateral oculofacial pain and swelling followed by acute visual loss, unilateral proptosis, facial palsy, and trigeminal hypoesthesia. Computed tomography scan revealed opacity as well as bony erosion of paranasal sinuses (PNS). Obtained specimens confirmed mucormycosis agent on histopathological examination. After failure of conservative treatments, retrobulbar injections of liposomal-amphotericin B, along with PNS debridement and orbital exenteration, both patients developed blurred consciousness owing to extension of the infection into the intracranial cavity. Brain magnetic resonance imaging revealed right frontal lobe abscess in case1, and left frontal sinus abscess and involvement in case2. Both underwent transcranial debridement and resection of necrotic tissue and drainage of abscess. At follow-up, the patients were in good condition and the fungal cultures were negative for mucormycosis agent.

ROCM may be a complication of COVID-19 in high-risk patients. Control of the patient's underlying systemic condition and prompt treatment with antifungal agents along with timely aggressive resection of cerebral abscess and necrotic paranasal tissues are the mainstays of management for ROCM.

Mortality related to intubation occurs as a result of multiple factors such as patient's condition, operator's skills, equipment use, intubation time, duration of laryngoscopy and intubation, and drugs and dosage used for endotracheal intubation (ETI).

This systematic review and meta-analysis aimed to determine mortality related to intubation and the overall intensive care unit (ICU) mortality rate in adult general ICUs.

We performed a systematic review and meta-analysis on randomized clinical trials and cohort and cross-sectional research from three electronic databases with hand searching. The studies reported mortality related to intubation and the overall ICU mortality rate in adult general ICUs. Our search resulted in 28 published articles without any restriction on date and language. The systematic review and meta-analysis was performed to examine mortality related to intubation and the overall ICU mortality rate.

We found 7,866 articles in the literature review from the three databases based on our keywords, of which 28 studies were eligible to include in the study. We observed that mortality related to intubation and the overall ICU mortality rate in intubated patients were 1% and 30%, respectively.

This was the first comprehensive systematic review on mortality related to intubation and the overall ICU mortality rate in adult general ICUs, which showed the current care of ETI. However, it was associated with increased complications, which may increase mortality.

 Lumbar spine operations can be safely performed under general or neuroaxial anesthesia, but there are controversies as to the clinical outcomes and cost benefits of each method. The goal of this systematic review and meta-analysis was to determine the advantages of each technique (i.e., regional or general anesthesia) for lumbar spine surgery with regards to cost, duration of surgery, duration of post anesthesia care unit, and duration of hospital stay.
Data Sources: We conducted a systematic search for articles comparing regional anesthesia (RA) versus general anesthesia (GA) for lumbar spine surgery using three major databases (i.e., PubMed, EMBASE, and Google Scholar), without limitation for date and language of publication. We also manually double checked the references of all the related articles to detect missed articles by electronic searching. The last search was performed before September 2018; the quality of the included articles was assessed by different checklists according to the type of the article. STATA software (V. 10) was used for performing meta-analysis.

Twenty-eight articles were included in this meta-analysis. Cost data were presented in seven studies and reported a significant decrease in the cost of treatment in RA patients compared with GA patients. The standard mean difference (SMD) (95% CI) for cost was 1.64 (1.53 to 1.75); z = 29.17; P < 0.001; I2 = 98.9. Surgical time data were presented in 25 studies, which reported significant reduction in the surgery time in RA patients compared with GA patients, the SMD (95% CI) for surgery time was 0.77 (0.71 to -0.84); z = 23.9; P < 0.001; I2 = 97.9. Post anesthesia care unit (PACU) stay data were presented in 16 studies and reported significant increase in PACU stay in RA patients compared with GA patients. The SMD (95% CI) for PACU stay time was -0.4 (-0.49 to -0.31); z = 8.65; P < 0.001; I2 = 99.2. Hospital stay data were presented in 18 studies and reported significant decrease in hospital stay time in RA patients compared with GA patients. The SMD (95% CI) for hospital stay time was 0.76 (0.68 to 0.84); z = 18.81.; P < 0.001; I2 = 98.3. Egger and Begg’s tests showed no significant publication bias.

This comprehensive systematic review showed that RA has several advantages over GA with respect to cost, surgery time, and duration of hospital stay in patients undergoing lumbar spine surgery, while increase in PACU stay time was observed in RA patients.

The objective of this study is to review the literature about the muscle relaxants in anesthetic practice. In this review, our search includes, the studies performed and applied between 2000 and 2016. Therefore, for review of muscle relaxants in anesthesia practice in major surgeries, we referred to Google scholar, UpToDate, science direct, Ovid MEDLINE, Springer, free journals and the references of reviewed articles in the English language. Neuromuscular blocking agents are a chore and essential part of balanced anesthesia. These are used to facilitate endotracheal intubation and provide skeletal muscle relaxation during surgery. The main disadvantage, i.e. residual paralysis, can be treated or prevented by reversing of such a block. The muscle relaxant plays an important role in adequate muscle relaxation, which allows efficient and safe surgery, requiring automated ventilatory control.

The aim of this study was to assess the effect of premedication with intravenous midazolam or fentanyl on anxiety and hemodynamic changes following spinal anesthesia in pregnant women
145 pregnant women scheduled for cesarean section were randomly recruited into three study groups in this randomized clinical trial. The severity of anxiety in all women were assessed using Depression Anxiety Stress Scales (DASS) at the time of entrance to the operating room. In first group (group Midazolam) 1 mg midazolam (in 1 ml volume), in second group (group Fentanyl) 50 µg fentanyl (in 1 ml volume) and in third group (group control) , 1 ml normal saline were administered intravenously before preparing for anesthesia and then spinal anesthesia was done for all women in lateral position. Variables such as age, body mass index, duration of surgery, level of sensory block, gravidity, Apgar score, heart rate, systolic, diastolic and mean arterial pressure before spinal anesthesia and then after every minutes until 5 minutes and then every 5 minutes until the end of surgery were recorded for all patients. Data were analyzed using SPSS (version 22).
Demographic variables, duration of surgery and Apgar score of neonates were not different between study groups. Women in three group were not different with respect to incidence of hypotension and bradycardia needed to treatment. The incidence of hypotension and bradycardia in patients with severe anxiety were statistically different between control and midazolam groups, but the same difference was not seen in patients with mild, moderate and very severe anxiety.
In this study, we showed that intravenous midazolam before spinal anesthesia for cesarean section can decrease the incidence of hypotension and bradycardia in patients with severe anxiety without any risk for mother and her neonate.

We investigated the effects of cigarette smoking in non-per os (NPO) period on volume and pH of gastric contents in smoker male patients.
In a prospective cohort study, 86 male smoker patients undergoing elective non-abdominal surgery under general anesthesia, were surveyed. They were NPO for at least 8-12 hrs. prior to surgery without direction to smoking. Then they were divided in two groups in the operation room based on smoking during NPO period. The study was continued until 43 patients entered in each group. After induction of anesthesia, gastric contents were aspirated by NG tube then volume and pH of gastric contents were measured. There were no significant differences in basic characteristics of patients such as age and weight between two groups.
The pH of gastric content was significantly lower in the smokers group (1.57±0.74 vs 3.12±1.90 p=0.001). The mean volume was significantly higher in the smokers’ group (34.60±20.90 vs 19.86±14.72 ml, p=0.001).
Smoking during NPO period in habitual smokers before elective surgery increases the volume and acidity of gastric contents and probably increases risk of acid pulmonary aspiration.

Deliberate hypotension is a strategy that reduces intraoperative bleeding and increases the speed of surgery in otolaryngology procedures. Magnesium (Mg) sulfate is a vasodilator agent that reduces intraoperative hypnotic requirements and in combination with analgesic agents, it reduces intraoperative and postoperative pain. In this study we evaluated the use of intravenous Mg sulfate for inducing deliberate hypotension in rhinoplasty. Sixty ASA I, II patients aged between 18 to 45, scheduled for rhinoplasty were recruited into a randomized clinical trial. Patients were randomly assigned into placebo (group P) and Mg sulfate (group M) groups. For patients in group M, 40m/kg Mg sulfate was administered before induction and continued with 15mg/kg/hr infusion during the operation. Patients of group P received normal saline as placebo. In each group mean arterial pressure (MAP), mean heart rate, amount of bleeding, anesthetic agents, opioid requirement and duration of surgery were recorded. The incidence of nausea, vomiting, shivering and the score of pain were recorded in post-operative period in both groups. Patients in group M had lower MAP (P= 0.0001), less intraoperative bleeding (P=0.0001), lower anesthetic agents (P=0.0001) and opioid consumption (P=0.001), and shorter duration of procedure (P=0.0001). Mean heart rate was lower in group P (P=0.001). Moreover, surgeon`s satisfaction was more in group P (P=0.001).They also had less incidence of post-operative nausea and vomiting (P=0.008), shivering (P=0.001) and lower pain scores postoperatively (P=0.0001). Magnesium sulfate can be a useful drug to induce controlled hypotension in rhinoplasty surgery. By employing this agent patients have better anesthetic condition and recovery profile

To study the role of preoperative intravenous magnesium sulphate in decreasing post-cesarean pain and opioid requirement during first 24hrs.In a double blind randomized clinical trial, prior to induction of general anesthesia, fifty elective cesarean candidates were randomly assigned to one of the two groups of placebo or magnesium sulfate. After surgery visual analogue scale (VAS) and infused morphine by PCA during 24 hrs were recorded. The data were analyzed by mann-Whitney -test, analysis of variance, and student t- test.VAS was significantly lower among patients in the magnesium sulphate group at intervals of 1st, 6th & 12th hours after cesarean section (C/S) with the mean scales of (48.9± 19.6 VS 74.7± 18.4), (42.1± 0.9 VS 58.3± 16.5) and (25.2± 6.1VS 30± 8.1) respectively and p-value of <0.001, 0.002 and 0.05 respectively. However at 24 hrs there was no significant difference in VAS with mean VAS scales of 22.6± 4.5 VS 23.6± 4.9 and p-value of 0.49. The dose of infused Morphine during 24 hrs was significantly less in the magnesium sulphate group than the placebo group with the means of 4.36± 1.4 VS 7.02± 1.9 mg respectively (p<0.001).Administration of bolus 50 mg/kg magnesium sulphate prior to induction of general anesthesia may significantly decreased the morphine requirement during immediate post operative period and can be recommended as one of the modalities of post-operative pain control in the pregnant patients.

Surgeons and anesthesiologists working in orthopedic operating theatres are exposed to significant noise pollution due to the use of powered instruments. This may carry a risk of noise-induced hearing loss. The present study was designed to quantify the noise pollution experienced by anesthesiologists at Imam Khomeini Hospital which is one of the largest Iranian hospitals. Prior to beginning of any operation a sound level meter was worn by the anesthesiologist at the level of chest pocket. Basal sound level was recorded. All changes in the sound level of 25 operation rooms and two related pass ways were recorded and the mean sound level along with maximum sound level were noted. These data were analyzed by SPSS version 17. For comparing the mean values، the One way ANOVA and Post-Hoc analysis was used. Noise exposures were compared with occupational health guidelines. Our comparative data showed that orthopedic operation room had the highest level of noise، indicating that orthopedic operation room is significantly suffered by the most types of noise with the P value of 0. 002. This is contrast to the sound levels at the other operation rooms which were at same range and were not significantly different. Comparison of the maximum sound level between these 27 places showed that orthopedic and one of general surgery room had top two maximum sound levels. Overall total noise dose during all types of surgeries was measured as twice of permitted dose and also orthopedic and general operation rooms experience brief periods of noise exposure in excess.

Induction of general anesthesia in a patient with compromised airway has always caused dilemma to anesthesiologist, especially for toddler this is paramounted. An 18 month old boy had a huge sized lingual mass which not only filled entire oral cavity but protruded outside the mouth up to about 5 cm. Having in mind the diagnosis of hemangioma, prior to induction it was attempted to reduce the mass but could be reduced only minimally by manual decompression. While the tongue, still outside the mouth, with full preparedness for anesthesia was induced maintaining the spontaneous ventilation. During laryngoscopy and intubation the tongue was pulled out of the oral cavity to ease the passage of the endotracheal tube. The mass was excised successfully and patient had an uneventful postoperative course. Maintenance of spontaneous ventilation is the crucial safety element during induction.

Pain control in children is still a therapeutic dilemma. Preschool patients are affected from undesirable effects of postoperative pain more than adults. Tonsillectomy is associated with a high incidence of postoperative pain, not only complicating the recovery, but also delaying patients discharge. Despite employing different surgical and anesthetic strategies in post-tonsillectomy pain relief, this is still a clinical problem. The study was designed to evaluate the efficacy of a low dose ketamine in post tonsillectomy pain relief.Patients and Our prospective randomized double blinded study enrolled 75 pediatric patients (3-10 years old) who were scheduled for a tonsillectomy procedure. Patients were randomly assigned to one of three groups receiving; intravenous (IV) ketamine 0.5mg/kg, subcutaneous (SC) ketamine 0.5 mg/kg and placebo at the end of the operation. Post-operative pain score was assessed using modified CHEOPS. In our study we did not find any significant difference among the three groups regarding sex, age, and weight, duration of operation, hemodynamic stability, and nausea and vomiting. However, in ketamine groups, pain score and analgesic consumption were significantly lower (P < 0.00). The efficacy of the both ketamine groups was similar. The study demonstrated that the both subcutaneous and intravenous injections of ketamine, at the end of the operation, were safe and effective for post-tonsillectomy pain control. Ketamine reduced postoperative analgesic medications consumption without increasing the risk of complications.

Vascular abnormalities are relatively uncommon lesions, but head and neck is a common region for vascular malformation which is classified as benign tumors. In this paper, the authors report a rare presentation of vascular malformation in the tongue and its managements.Case Report: An 18 months 2 old child presented with a giant mass of tongue which caused functional and aesthetic problem. The rapid growth pattern of cavernous hemangioma was refractory to corticosteroid. The lesion was excised without any complication. Since the mass was so huge that not only filled entire oral cavity but was protruding outside, airway management was a great challenge for anesthesia plan and at the same time surgical technique was difficult to select.Despite different recommended modalities in managing hemangiomas of the tongue, in cases of huge malformations, surgery could be the mainstay treatment and provided that critical care measures are taken in to account, could be performed very safely.