فهرست مطالب mohammadreza khajavi

Pulmonary embolism can cause cardiac arrest. Fibrinolytic therapy and surgical embolectomy can be used to manage it. This case report presents the clinical course of a patient who experienced intraoperative cardiac arrest resulting from massive pulmonary embolism. The patient encountered three instances of cardiac arrest requiring 35 minutes of cardiopulmonary resuscitation. Subsequent treatment involved the administration of reteplase, a thrombolytic agent. Following resuscitation, the patient developed multiple organ dysfunction in the intensive care unit, necessitating the use of diverse medications. Successful resolution of organ dysfunction led to the patient's transfer to the neurosurgery department. This case highlights the complexities involved in managing pulmonary embolism-induced cardiac arrest and subsequent multiorgan dysfunction, emphasizing the significance of a multidisciplinary approach in the comprehensive care and treatment of these patients.

We intend to evaluate the effect of intraoperative diphenhydramine administration on incidence and severity of catheter related bladder discomfort (CRBD) and pain after percutaneous nephrolithotomy.

In a double blind randomized clinical trial, adult male patients undergoing percutaneous nephrolithotomy were enrolled. They were randomized into two groups by a computerized digital random allocation method. Before anesthesia induction, group D (Diphenhydramine group) (n = 48) received 5 ml normal saline containing 0.5 mg/kg of diphenhydramine intravenously. In group C (Control group) (n = 48), 5 ml of normal saline was injected in the same manner. Induction and maintenance of anesthesia were identical in both groups. The incidence and severity of CRBD and postoperative pain were assessed at recovery room.

The incidence of CRBD was significantly lower in group D than in group C (14% vs. 63%, P=0.001). The severity of CRBD was milder in group D in comparison to group C (P<0.05). Postoperative pain score was significantly lower in group D (P<0.05).

Intraoperative administration of diphenhydramine is an effective practice for the prevention of CRBD after percutaneous nephrolithotomy in male patients and can reduce postoperative pain as well.

The recently developed blade design of the Sanyar® video laryngoscope yields an exceptionally precise visualization of the larynx, thereby easing the process of tracheal intubation.

A non-inferiority clinical investigation, to assess the efficacy of the Sanyar® as compared to the Macintosh® direct laryngoscope for nasotracheal intubation in the context of maxillofacial surgeries.

78 patients for maxillofacial surgery were divided randomly into two groups and intubated through the nose using either the Sanyar® or Macintosh® laryngoscope after anesthesia was induced. The study measured intubation time and secondary objectives included success rate, attempts, and hemodynamic changes in two groups.

40 eligible patients in the Sanyar® and 38 in the Macintosh® group were involved. Of all, 42(53.8%) were men and 36(46.2%) were women. The average age of patients in the Sanyar® and Mackintosh groups was (31.62±13.41) and (30.81±10.89), respectively. 39(98%) of the Sanyar® group and 33(86%) of the Macintosh® group had successful laryngoscopy and intubation, with a P-value<0.034. Sanyar® group had a significantly shorter intubation time than Macintosh® (P-value<0.001). Hemodynamic changes before and after laryngoscopy and intubation had no significant differences between the two groups.

The Sanyar® video laryngoscope reduced the time of nasal tracheal intubation in maxillofacial surgery compared to direct laryngoscopy and improved the success rate of the first intubation attempt.

This randomized clinical trial aimed to assess and compare patient satisfaction and sedation outcomes in bronchoscopy procedures using two distinct sedation protocols: fentanyl/chlorpheniramine (FC) and ketamine/chlorpheniramine (KC).Ninety patients undergoing simple bronchoscopy and bronchoalveolar lavage were randomly assigned to receive either FC (1μg/kg fentanyl and 10 mg chlorpheniramine) or KC (0.5mg/kg ketamine and 10 mg chlorpheniramine). Lidocaine was also administered during bronchoscopy. Primary outcomes included patient satisfaction scores, while secondary outcomes encompassed sedation levels, bronchoscopist satisfaction, cough rates, lidocaine usage, and physiological parameters.Patients in the FC group exhibited significantly higher satisfaction levels compared to the KC group (P=0.002). Bronchoscopist satisfaction was also superior in the FC group (P=0.001). Although cough rates did not differ significantly, severe persistent coughs were more prevalent in the KC group. Physiological parameters such as oxygen saturation were comparable, but the KC group demonstrated higher increases in systolic blood pressure and heart rate.The use of fentanyl/chlorpheniramine resulted in higher patient and bronchoscopist satisfaction during simple bronchoscopy and bronchoalveolar lavage compared to ketamine/chlorpheniramine. This study suggests that the combination of fentanyl and chlorpheniramine may be a preferable sedation choice for bronchoscopy procedures.

Upper airway management in morbid obese patients undergoing bariatric surgery is a major challenge during induction of anesthesia. Bed side Thyromental Height Test (TMHT) is an easy and valid predictor for prediction of difficult airway in non‑obese patients, but its precision in morbid obese patients haven’t been evaluated yet. The purpose of present study is to find the accuracy of TMHT for the prediction of difficult laryngoscopy in morbid obese patients undergoing bariatric surgery. The present prospective observational study was performed on 95 morbid obese patients at Sina hospital during 2020. Preoperative exams of patients include the assessment of Mallampati classification, thyromental height, thyromental, sternomental and interincisor distances. After induction of anesthesia, the laryngoscopy view was evaluated using the Cormack Lehane classification, and the relationship between these tests to prediction of difficult laryngoscopy view based on the Cormack Lehane degrees (grades 3,4) were evaluated. A total of 95 morbid obese patients with a mean BMI of 44.7±5.6 kg/m2.were included in the study. 67.3% of them were women. The incidence of difficult laryngoscopy (C & L III, IV) was 16.8%. TMHT less than 56.5 mm, with 98% positive predictive value and 93% accuracy was the best predictor of difficult intubation in these patients. The accuracy of thyromental, sternomental and interincisor distance, with cut off value less than 51.5 mm, 89.5 mm, 41.5 mm respectively was less than TMHT in prediction of difficult laryngoscopy in morbid obese patients. In morbid obese patients with a BMI greater than 40, thyromental height less than 56.5 mm with 98% positive predictive value and 93% accuracy is the best predictor for difficult laryngoscopy view.

Airway management and tracheal intubation in the ICU is a difficult procedure that may be concomitant with major complications. The purpose of this study was to evaluate the effect of the SANYAR ® video laryngoscope(S-VL) on laryngeal view and first Pass Success of tracheal Intubation compared with direct laryngoscopy.

This comparative, prospective clinical study was conducted on 120 adult patients in a single-center, in a surgical ICU under the supervision of an anesthesiologist in a university hospital. Difficult airway predictors, glottic view, first Pass Success of tracheal Intubation and time of intubation were evaluated with Macintosh laryngoscopy (ML) or the SANYAR® Video Laryngoscope(S-VL).

Tracheal intubation was performed in 58 critically ill patients using ML and 62 patients using S-VL. According to Cormack and Lehane (C&L) grading glottic visualization was more difficult using ML (41%, C&L grade 3 and 4) compared with S-VL (13%, C&L grade 3 and 4) p<0.001. Intubation of trachea was more successful in the first attempt, in patients with at least one difficult airway predictor with a S-VL compared to ML (87% vs. 38%; P = 0.001), time of intubation was also shorter by using S-VL.

Among critically ill patients in the intensive care unit, who require intubation, the SANYAR video laryngoscopy improved glottis view compared to the Macintosh direct laryngoscopy and first-pass orotracheal intubation rate especially in patients with potentially difficult airways.

Cytokine storm in severe Covid-19 disease is one of the leading causes of death in these patients. Hemoperfusion is a method used to purify the blood from toxins and inflammatory factors. The aim of this study was to evaluate the effect of hemoperfusion on mortality and morbidity in patients with severe Covid - 19 disease.

This was a retrospective study which performed by reviewing the files of 30 patients with severe Covid-19 disease referred to Sina Hospital affiliated to Tehran University of Medical Sciences in 2020. Thirty patients with severe covid-19 disease and positive PCR participated in the study. All patients received routine treatment protocol for covid-19. Hemoperfusion was used for 15 patients in addition to receiving routine care. The remaining 15 patients were included in the control group. Patients in the hemoperfusion group underwent four sessions of hemoperfusion using continuous renal replacement therapy with continuous venovenous hemofiltration.

the ICU length of stay in the control and hemoperfusion groups was 3.40 ± 11.40 and 9.65 ± 16.33 days, respectively (P= 0.075). 8 patients died and 7 patients were discharged in the control group, but 11 patients died and 4 patients were discharged in the hemoperfusion group (P= 0.256). The respiratory rate of patients in the control and hemoperfusion groups decreased from 7.43 ± 29.40 to 4.03 ± 24.60 and from 6.11 ± 31.60 to 5.04 ± 24.46, respectively (P < 0.001). The percentage of arterial blood oxygen saturation in the control and hemoperfusion groups increased from 90.86 ± 5.61 to 93.06 30 4.30 and from 92.33 26 3.26 to 92.06 31 5.31, respectively (P= 0.456).

Hemoperfusion could not prevent the mortality of patients and finally out of 15 patients, 11 patients died and 4 patients were discharged. Also, no significant difference was observed between the two groups in terms of arterial blood oxygen saturation.

Postoperative Nausea and vomiting (PONV) are the most complications after laparoscopic surgeries, especially laparoscopic bariatric surgeries. The incidence of PONV has been estimated in over two-thirds of patients undergoing laparoscopic bariatric surgeries. Prophylactic combined antiemetic therapy is recommended for patients undergoing these surgeries. This is a double-blinded randomized clinical trial. Eighty-three patients of ASA physical status I and II undergoing elective bariatric laparoscopic surgery were enrolled in this clinical trial and divided into two equal groups through simple randomization using a random number table. One group (group A) received a combination of ondansetron, dexamethasone, and haloperidol (ODH); and the other group (group B) received a combination of ondansetron, dexamethasone, and promethazine (ODP). The ODP group received promethazine 25 mg IM 30 minutes before extubation and ODH group received haloperidol 2 mg IM at the beginning of the surgery. Nausea and vomiting were assessed in terms of severity and frequency in the recovery room, 6, and 24 hours postoperatively in both groups using the Numeric Verbal Rating Scale (NVRS). The frequency of PONV was significantly lower in the ODH group compared to the ODP group in the recovery room (20% versus 40%). PONV severity was lower in the ODH group compared to the ODP group. The time to first rescue antiemetic prescription in the ODP group was more than in the ODH group (7.2 h versus 2.6 h). In morbidly obese patients undergoing laparoscopic bariatric surgery, both antiemetic combinations decreased the incidence of PONV, but the combination of haloperidol, dexamethasone, and ondansetron was more effective than promethazine, dexamethasone, and ondansetron.

During the coronavirus disease-2019 (COVID-19) pandemic, which was caused by the novel coronavirus, there is an ongoing controversy about the use of corticosteroids. This study aims to investigate the association between Dexamethasone treatment and clinical outcomes in patients with severe COVID-19. In this single-center retrospective cohort study, patients with COVID-19 were enrolled from February 16, 2020, to November 1, 2020. After performing propensity score matching with age, sex, and disease severity. The independent effect of Dexamethasone treatment on in-hospital mortality was evaluated by multivariate proportional hazards regression models. Of 1413 patients with COVID-19 diagnosis, 1172 patients entered the final analysis. 473(40.4%) patients received dexamethasone treatment with a median duration of 6.0[4.0-9.0] days. After matching and adjustment with possible confounders in the multivariate model, administration of dexamethasone significantly increased the survival in severe patients (hazard ratio: 0.25, 95 confidence intervals: 0.16-0.38, P<0.001), but there was no difference in non-severe patients (P:0.888). The administering of dexamethasone was associated with an increased in-hospital survival rate (HR: 0.25 [0.16-0.38]) in severe COVID-19 patients. The survival rate was more significant in severe patients with diabetes mellitus or hypertension after receiving dexamethasone treatment (HR:0.19). On the other hand, patients without severe disease did not benefit from dexamethasone administration.

SANYAR® video laryngoscope (S-VL) is a new video laryngoscope. We conducted a comparative clinical study to assess its ability to provide laryngeal exposure and facilitate endotrachetal intubation (ETI) in adult patients. 

This comparison clinical study was conducted on adult patients undergoing elective general anesthesia. The patients were randomly divided into two groups of direct laryngoscopy (DL) or S-VL. The primary outcome was the time required for performing ETI. The glottic view and successful ETI on the first attempt was also compared between the two groups. 

Full and partial glottic visualization was achieved in 100% of the patients in the S-VL group, while the corresponding figure in the DL group was 90%. Cormack-Lehane III was observed in 5 patients of the DL group, and ETI was successfully carried out with S-VL. The first-pass success rate of ETI was significantly higher in S-VL group compared to the DL group (94% vs. 78%; P = 0.034). The mean times to ETI were 38.32±6.4 and 35.31±8.4 seconds in DL and S-VL groups, respectively (P = 0.650). 

During ETI for general anesthesia, SANYAR® video laryngoscope compared with direct laryngoscopy improved glottic visualization and first-pass ETI rate.

The head's position during mask ventilation on the time of anesthesia induction in children may improve the lung ventilation.

Current study was designed to verify whether lateral head rotation improves face mask ventilation efficiency during anesthesia induction in children.

Fifty-six patients aged 1-4 years, candidate for elective surgery, were randomly divided into two equal groups. During induction of general anesthesia, face mask lung ventilation of patients continued with pressure-controlled mode, at a peak pressure level of 10 cmH2O for children 13-24 months and 14cmH20 for children 24-48 month. In patients in the N group, the head position during ventilation was initially in the neutral position for one minute, then the head was axially rotated 45-degree to the right position for one minute and pulmonary ventilation continued in this position, then the head was rotated again to the neutral position and ventilation continued for one minute. In group R patients, mode and time of ventilation was the same, but the order of head placement was first in the lateral rotated to the right, then neutral and then lateral rotated to the right. The primary outcome was the measurement of expiratory tidal volume in each position.

Generally, the mean measured expiratory tidal volume did not change in the neutral position compared to laterally rotated head position, 256.6 vs. 233.5 ml: difference -23.1 [95% confidence interval: 10.8 to 39.4 ml]. Also, the change of head position from lateral to neutral position did not show a significant change in the mean expiratory tidal volume, 232.28 vs.247.86 ml: difference -15 .82 (p= 0.4).

The rotation of the head to the lateral position during induction of anesthesia in apnoeic children 1-4 years old could not improve the efficiency of mask ventilation relative to the neutral head position.

Training of airway management and tracheal intubation skill in emergencies for resuscitation of patients are basic skills for medical students. However, the success rate of beginners in this skill is low. Video laryngoscopes are new devices that can increase the success of endotracheal intubation training.

This clinical trial was conducted with 30 medical students who came to learn anesthesia care at Sina Hospital in 2020. After dividing the students into two groups (n=15) of glide scope and Macintosh, the glide scope group first performed laryngoscopy and tracheal intubation with a glide scope on the manikin 10 times. Then, in the operating room they were trained for endotracheal intubation on 5 patients by glide scope. The Macintosh group first got trained for intubation on the manikin, 10 times and then on five patients in the operating room with a Macintosh laryngoscope. Then all students in the operating room intubated two patients with a Macintosh laryngoscope and their performance was assessed and scored by an anesthesiologist. They evaluated the training course with a questionnaire. The duration of laryngeal access and the time spent for tracheal intubation were compared in the two groups.

In the glide scope group, 76% of students were able to see the epiglottis and larynx in 20 seconds, but in the Macintosh group, 43% of students were able to see the larynx in 20 seconds. In terms of endotracheal intubation time, 72% of the students in the glide scope group were able to successfully perform endotracheal intubation within 40 seconds in their first attempt, but in the Macintosh group, 44% completed endotracheal intubation within 40 seconds (P=0.00). In the evaluation of the quality of skill, the average score of the students in the Macintosh group was 15.30±0.56, while the average score in the glide scope group was 17.20±0.83 (P=0.00). The scores and satisfaction of the students in the glide scope group were higher than the Macintosh.

The use of video laryngoscope in teaching of intubation in trainees will increase the speed, and accuracy of their training and satisfaction compared with the Macintosh laryngoscope.

 Since the outbreak of coronavirus 2019 (COVID-19), identifying risk factors associated with in-hospital mortality has been a global priority. In this study, the purpose was to evaluate the clinical, laboratory, and radiological characteristics of hospitalized patients with COVID-19 to develop a predictive model and scoring system for in-hospital mortality.

In this retrospective cohort study, 611 adult patients with COVID-19, admitted to Sina hospital were enrolled and followed up.

Out of the total number of 611 patients, 104 patients (17%) deceased during hospitalization, including 75 (12.2%) deaths in ICU and 29 (4.7%) deaths in the wards. After multivariate logistic regression analysis, several characteristics including age >55 years, previous history of malignancy, history of cerebrovascular accident, tachypnea on admission, CRP>54 on admission, D-dimer>1300, and bilateral pulmonary consolidation on chest Computed Tomography (CT) were shown to be the main determinants for stratifying the risk for in-hospital death. The factors were finally considered for introducing a new predictive scoring system for COVID-19 related death. 

In-hospital mortality rate in patients with COVID-19 is estimated to be 17%. A new scoring system for predicting in-hospital mortality in such patients was structured based on determinant factors of advanced age, history of malignancy, cerebrovascular accident, tachypnea, raised CRP, raised D-dimer on admission, and bilateral pulmonary consolidation on chest CT scan.

One of the most common problems after spine surgery is very severe pain that usually affects outcome of patients after surgery and duration of hospital stay. Acute postoperative pain has several mechanisms, and multimodal analgesia by different mechanism of action will help control to it. In this study, we intend to investigate the effect of intravenous diphenhydramine injection during induction of anesthesia and morphine before incision on the control of acute pain in postoperative laminectomy.

130 patients scheduled for spine surgeries were assigned to receive a single pre induction dose of diphenhydramine 0.4mg/kg IV (D group) and morphine 0.15mg/kg before incision in addition acetaminophen 1gr IV at the end of surgery and just morphine 0.15mg/kg and acetaminophen 1gr IV (C group) in a randomized, double-blind trial. Postoperative pain, analgesic requirements in recovery and 24 hr after surgery were assessed.

The mean pain intensity in recovery was lower in the diphenhydramine group than in the control group (MD, 2.13; 95% confidence interval (CI), 1.72–2.53; P < .0001) and the need for analgesia was much lower in the diphenhydramine group than in the control group. P < 0.001. The severity of pain and the need for analgesics in the diphenhydramine group had a significant decrease in the ward compared to the control group.

Prophylactic diphenhydramine 0.4 mg/kg at induction of general anesthesia in combination with morphin0.15mg/kg before incision and acetaminophen1gr at the end of surgery reduced the postoperative severity of acute pain and opioids requirement in the early postoperative period after spine surgeries.

There is some demand for nasogastric tube insertion in unconscious or ICU patients. Nasogastric tubes are generally made of flexible plastic materials, prone to twisting and deviation by the tracheal tube, when passing through the pharynx and esophageal opening, making it difficult to insert the NG-tube properly. We hypothesized that NG-tube insertion with help of guidewire can significantly increase a successful first-try insertion rate in contrast with the conventional "neck flexing" technique in unconscious intubated patients.

One hundred adult intubated patients, in the emergency ward at Sina Hospital, Tehran University of Medical Sciences were enrolled in this prospective clinical trial study from February 2020 to July 2020. These patients were randomly divided into two groups, with and without use of the guidewire insertion technique. Parameters such as successful NG tube insertion average time, first and second try failure, total failure and occurrence of complications such as kinking, twisting, sticking, moderate hemorrhage and traumatic injuries to the nasopharynx pathway were studied.

One hundred patients were enrolled in this study. The median age of patients was 55.4±10.8 years (12-75 yr). First-try insertion success was 98% in the guidewire group and 74% in the control group (P=0.001). First, the try insertion failure percentage was 2% in the guidewire group and 26% in the control group (P=0.001). The time needed for NG tube insertion was significantly lower in the guidewire group, as 38.3±4.8 seconds in the guidewire group vs 61.5±6.2 seconds in the control group (P=0.001). A significantly lower number of complications like twisting, sticking, hemorrhage and traumatization were seen in the guidewire group.  Remarkably, that no case of absolute insertion failure was seen in the guidewire group but there were three such cases in the control group.

The incidence of a successful first-try NG tube insertion has been significantly improved by the use of Steel Wire rope against the conventional neck flexing technique, in unconscious intubated patients, and causes less traumatization and complications as well.

- Ketamine and magnesium in brain act as an N-methyl-D-aspartate receptor antagonist that has been shown to be useful in the reduction of acute postoperative pain and analgesic consumption in a variety of surgical interventions. We hypothesized that combination of low dose ketamine and magnesium would reduce early postoperative opiate consumption and analgesic requirement after 6 weeks. This was a randomized, prospective, controlled-placebo trial involving elective and eligible patients undergoing lumbar spine surgery. Seventy patients in the treatment group were administered 0.5 mg/kg intravenous ketamine and 1 gram of magnesium as an intravenous bolus slowly during 3 minute before incision and 0.25 mg/kg/hr ketamine and 0,5 g/hr magnesium intravenous infusion during surgery. Seventy patients in the placebo group received saline of equivalent volume. Patients were observed for48 h postoperatively and followed up at 6 weeks. The primary outcome was 48h morphine consumption. The severity of pain was lower in the intervention group than in the placebo group during 48 hr post-operatively, morphine consumption in this group also decreased significantly during this period. Intraoperative ketamine-magnesium reduces opiate consumption in the 48-h postoperative period. This combination may also reduce pain intensity throughout the postoperative period in this patient population.

Colonoscopy is a painful, embarrassing and short-term procedure that needs temporary sedation and rapid recovery. The aim of this study was to compare the sedation and analgesia effect and hemodynamic changes due to bolus intravenous injection of dexmedetomidine and ketamine during elective colonoscopy. This clinical trial was conducted on 70 patients aged 20-70 years, candidates for elective colonoscopy, who randomly divided into two equal groups. For all patients 0.03 mg/kg midazolam 10 min before procedure was injected. Fentanyl 1 µ/kg was administrated in both groups 5 min before procedure, and one min before colonoscopy. K group received 0.5 mg/kg ketamine and D group received 1 µ/kg dexmedetomidine. Then, the normal saline infusion was used as maintenance. Fentanyl 25-50 µg was prescribed as the rescue dose if needed during the procedure. Hemodynamic changes, sedation level during procedure, patients and colonoscopists satisfaction were recorded in recovery. The mean heart rate and mean blood pressure was significantly less in the dexmedetomidine group than in the ketamine group. All of the patients in the ketamine group were deep to moderately sedated during colonoscopy, and the amount of fentanyl required in this group is much less than dexmedetomidine group (68.02±25.63 vs 91.45±38.62 µg P-0.003). In terms of satisfaction, only 42% of patients in the dexmedetomidine group were completely satisfied with colonoscopy, while 65% of Ketamine group had complete satisfaction with colonoscopy (P=0.001). The level of colonoscopist satisfaction during colonoscopy was similar in both group, and complete satisfaction was 43%. In patients undergoing colonoscopy, IV bolus injection of dexmedetomidine in comparison with ketamine provides less patients satisfactory and low level of sedation with supplemental multiple doses of fentanyl during the procedure.

 Fentanyl-induced cough (FIC) is a known complication and many studies have been conducted to prevent it. The aim of this study was to evaluate the effectiveness of Diphenhydramine as an antihistamine in suppressing of FIC during induction of anesthesia.

In a prospective double-blind randomized controlled trial, a total of 100 patients, ASA Class I and II, scheduled for elective laparoscopy surgery were randomly assigned into two equally sized groups (n = 50). Diphenhydramine diluted with distil water as 10mg/ml. Then, patients in Group D, received diphenhydramine 30 mg (3ml) through peripheral IV line within 1 min and Group C received same volume normal saline 0.9% as placebo. Two min later, fentanyl 2 µg/kg was administered through the peripheral IV line within 5 sec in all patients. The occurrence and intensity of cough within 2 min after the fentanyl injection were observed and recorded by a resident who was blinded to the study groups. The frequency of PONV, analgesic requirement in recovery room and as a secondary outcome were recorded.

The incidences of FIC were 47% in control group and there is no any cough in the diphenhydramine group (P = 0.02). The frequency of PONV was also reduced in diphenhydramine group (16% vs 40%) and less number of patients in diphenhydramine group were needed to analgesia in recovery room (60% vs 82%)

Our study determines that diphenhydramine (30 mg, IV) bolus injection 2 min before fentanyl injection can prevent FIC and PONV and also reduce analgesic requirement in recovery room.

Traditionally normal saline is the most common crystalloid solution that is used in transplant surgery. Normal saline (NS) because of the higher risk of acidosis and higher levels of serum chloride may have more deleterious effects in kidney transplant recipients Thus; the aim of this study was to determine the safety of ringer lactate normal saline combination if used during a renal transplant.

One Hundred adults undergoing kidney transplantations were enrolled in a double-blinded randomized prospective clinical trial. They were divided into two groups in order to receive RL& NS and NS infusion as intraoperative IV fluid replacement therapy. All patients received 40 ml/kg fluid during surgery. Serum chloride, sodium, Cr and BUN were checked before operation and 6hour after surgery. Urine output BUN and Cr was also checked in 1, 3 and 7 day after surgery. At the end of surgery, we corrected the acid base status with bicarbonate according to base excess< -15 or PH<7.15 if needed in both groups.

There was a significant difference in the serum chloride level (p= 0.001) and urine output (p= 0.003) between the two groups at the 6 hours after transplantations. Postoperative BUN and Cr level at 2,3 and 7 days in RL&NS group was significantly lower than group of NS (P= 0.011). Also, urine output during this study time was significantly higher in RL&NS group (p=0.001).

Combination of Ringer lactate &normal saline crystalloid solutions are associated with higher urinary output and most favorited out come in the early post-operative days after renal transplantation surgeries.

The aim of this study was to compare the effect of intra-rectal administration of lidocaine gel alone versus lidocaine gel plus topical fentanyl on pain reduction in prostate biopsy. In a double-blind randomized clinical trial, 96 patients who met the inclusion criteria were randomly assigned into two groups. 1) The treatment group: Lidocaine gel (2%) 50 g and 2) the intervention group: Lidocaine gel (2%) 50 g and fentanyl gel 50 µg. During the prostate biopsy, the VAS score was recorded. Blood pressure, heart rate, and patient level of consciousness were also analyzed. The mean VAS score was 5.1 ± 2 and 3.0 ± 2, which was lower in the intervention group (P value < 0.001). In terms of consciousness after biopsy, there was no difference between the two groups (P value = 0.358). There was no difference between the groups in terms of mean blood pressure and heart rate before and during the prostate biopsy. Finally, in terms of consciousness after the prostate biopsy, there was no difference between the current treatment and intervention groups. The combination of lidocaine gel and fentanyl with a dose of 50 µg has a significant effect on reducing the pain associated with prostate biopsy in comparison with lidocaine gel alone. The antinociceptive effect of the above regimens is not associated with hemodynamic changes and changes in patients' consciousness.

The intensity of low back pain and functional disability in life is a common question of patients before spinal anesthesia. We aimed to compare acute and chronic back pain after spinal anesthesia in midline and paramedian approach. Two hundred twenty patients elective patients (25-65 year old) candidates for general, and urological surgery under spinal anesthesia, were allocated into the following two groups: Group M (midline) and Group P (paramedian). Spinal anesthesia was performed with hyperbaric bupivacaine 0.5% in the sitting position using a 25G Quincke needle in L3/L4 orL4/L5 level. During the operation, patients were placed in the supine position. The questionnaire assessed back pain and severity of pain with VAS score three days after spinal anesthesia. If the patients complained of back pain then, the effect of back pain on quality of life and the degree of patient's functional disability were assessed by Oswestry Disability Index on,45 and 90 days after surgery. Forty-one patients (18%) had back pain after the operation, 22 patients were in the paramedian (54%) and 19 patients (46%) in the midline method of spinal anesthesia. (p=0.6). The mean intensity of back pain was 2.27vs1.45 (p=0.5) and the total number of mean functional disability index was less than five in both groups. The incidence of back pain was 18% and was not significantly different between the midline and paramedian methods. The severity of back pain decreased after three days, reaching to less than one on day the 45th and 90th, which does not affect daily patient’s functions.

Considering that a simple yet valid airway predictor is basically preferred to a multivariable test with the same level of validity, we designed a study to compare the validity indexes of the TMHT, as a single variable test, with that of Wilson, Arne, and Naguib tests.
270 consecutive ASA physical statues I and II patients aged ≥16 years, candidate to receive general anesthesia for elective surgeries, were enrolled in the study. All patients preoperatively were evaluated using four airway predictor tests including Wilson, Arne, Naguib, and Thyromental height test (TMHT). Cut-off points to predict a difficult laryngoscopy were extracted from previous published studies for each test. Based on each predictor, all patients were classified into either easy or difficult. Based on Cormack-lehane scoring system, as the gold standard, all patients during laryngoscopy were categorized into two groups of “easy, grades I, II” and “difficult, grades III, IV”. Finally, validity indexes for each test were calculated and compared to one another.
The incidence of difficult laryngoscopy according to Cormack-lehane grading was 17.4% (47/270). The predicted rates of difficult laryngoscopy were 47 (17.4%), 2 (0.7%), 10 (3.7%) and 61 (22.6%) for TMHT, Wilson, Arne and Naguib respectively. Based on Chi-square test, the TMHT as well as the Naguib could significantly predict difficult laryngoscopy. However, the highest rate of sensitivity, positive predictive value, negative predictive value, and accuracy belonged to TMHT.
Both TMHT and Naguib are acceptable predictors of difficult laryngoscopy while the TMHT is a more accurate predictor of difficult laryngoscopy than the other multivariable models.

Postoperative acute pain management after maxillofacial surgery due to severity of pain and limitations of opioids use in these patients is of particular importance. The aim of this study was to evaluate the analgesic effect of oral gabapentin and clonidine combination and opioids requirements after surgery.
This study was a randomized clinical trial (RCT) on 70 patients (18-55 yr old ASAI to II) undergoing various types of Orthognathic surgeries in Sina hospital affiliated to Tehran University of Medical Sciences, Tehran, Iran in 2016. The patients were randomly divided in two groups. Both groups received 1 gr (IV acetaminophen) 0.5 hour before the end of surgery. The control group received placebo and gabapentin/clonidine group received 300 mg gabapentin and clonidine 0.2mg orally 60 minutes before the induction of anesthesia. The pain severity score (assessed by VAS scale, the level of sedation (assessed by Sedation Agitation Scale), opioids requirement, nausea and vomiting were recorded in the post anesthesia care unit (PACU) 5 10, 20, 30 minutes and 3 hours after surgery. For rescue pain management intravenous morphine was administered.
Seventy patients were enrolled in this study. Gabapentin/ Clonidine increase extubation time (20.3±9.3min) (P Premedication of oral gabapentin/ Clonidine increases extubation time and sedation score in patients recovering from Orthognathic surgery and could reduce postoperative pain scores and opioids consumption in recovery room.

Regarding the role of gas entry in abdomen and cardiorespiratory effects, the ability of anesthesiologists would be challenged in laparoscopic surgeries. Considering few studies in this area and the relevance of the subject, this study was performed to compare the arterial oxygen alterations before operation in comparison with after surgery between laparoscopic cholecystectomy and ovarian cystectomy.
In this prospective cohort, 70 consecutive women aged from 20 to 60 years who were candidate for laparoscopic cholecystectomy (n = 35) and ovarian cystectomy (n = 35) with reverse (20 degrees) and direct (30 degrees) Trendelenburg positions, respectively, with ASA class I or II were enrolled. After intubation and before operation, for the first time, the arterial blood gas from radial artery in supine position was obtained for laboratory assessment. Then, the second blood sample was collected from radial artery in supine position and sent to the lab to be assessed with the same device after 30 minutes from surgery termination. The measured variables from arterial blood gas were arterial partial pressure of oxygen (PaO2) and Oxygen saturation (SpO2) alterations.
Total PaO2 was higher in the first measurement. The higher values of PaO2 in cholecystectomy (upward) than in ovarian cystectomy (downward) were not significant in univariate (P = 0.060) and multivariate analysis (P = 0.654). Furthermore, higher values of SpO2 in cholecystectomy (upward) than in ovarian cystectomy (downward) were not significant in univariate (P = 0.412) and multivariate analysis (P = 0.984).
In general, based on the results of this study, the values of PaO2 in cholecystectomy (upward) were not significantly higher than the values in cystectomy (downward) in laparoscopic surgeries when measured 30 minutes after surgery.

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.
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.
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.
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.