Archives of Anesthesiology and Critical Care (AACC) is the journal of Department of Anesthesiology and Critical Care , Tehran University of Medical Sciences ever since its foundation about eight decades back. The journal has eminent members in its editorial board both from within the country and abroad. The journal welcomes manuscripts in all fields and subspecialties related to anesthesia and basic sciences including ethics, historical perspectives, commentaries and letters of interest for our readers and furthermore aims to publish manuscripts from researchers working in all the disciplines or sub-specialties related directly or indirectly to anesthesiology, critical care and patients’ welfare and safety. Review articles, meta-analysis, and editorials are also welcome from our experienced colleagues on the plethora of subjects that are there in our field and which they deem would be of interest to our readers in general and would be of incalculable benefit to our patients in particular and the care givers.
A Comparative Crossover Randomized Study of Miller and Macintosh Blade for Laryngoscopic View and Ease of Intubating Conditions in Adults
Background: Although several types of laryngoscope blades of different sizes and shapes are present, Miller (MIL) blade is the most preferable blade among paediatric population. However, there is dearth in the literature regarding the use of these blades in the adult population. This study aimed to compare the laryngoscopic view and ease of intubation using MIL and Macintosh (MAC) blade among adults.
Methods: A total of 172 patients who were >18 years age, with ASA grades I and II, undergoing elective surgeries with general anaesthesia were included. Patients were distributed in two groups (MAC/MIL and MIL/MAC), where laryngoscopy was first done with MAC blade, followed by MIL blade in the MAC/MIL group and vice-versa in the MIL/MAC group. Grading of laryngoscopic views, number of attempts, ease of intubation and use of backward, upward, rightward pressure (BURP) were noted. R v 3.6.0 was used for statistical analysis and P values≤0.05 were considered as statistically significant.
Results: MIL blade showed better laryngoscopic view compared to MAC blade (32.6% vs. 15.1%; P< 0.002). BURP application helped improve the laryngoscopic views with MAC blade. Intubation with MIL blade was easier with regards to ease of intubation and number of attempts 19 (P value<0.05).
Conclusion: Glottis visualization is better with the MIL blade as compared to the MAC blade. Therefore, the MIL blade might be helpful in securing the airway among adult patients.
A Triple-Blinded Randomized Study to Evaluate the Effect of Acetaminophen and Morphine Sulfate on Pain Relief in MI-patients
Background: Myocardial infarction is considered to be the most common symptom of cardiovascular diseases. Regarding the limitation of access to Morphine sulphate as a special drug and complications followed, this study aims to compare the treatment effects of intravenous acetaminophen and morphine sulphate on the reduction of pain in MI patients and to improve the cardiac performance.
Methods: The present study is a triple-blind randomized control trial in which 70 patients were divided into two separated groups and the pain was measured using Visual Analogue Scale. All analysis was done using SPSS Software at the significance level of 5 percent.
Results: 42 patients were male (60%) of whom 20 were in case group and 22 in control group. There were no significant difference between intervention group and control group in terms of VAS score (p = 0.520). The index change of VAS over the time was statistically significant (p=0.001) in intervention and control groups (intra group change). The results of variance analysis with repeated measurements showed that mean differences of Ejection Fraction over time in both groups of intervention and control was not statistically significant (p=0.28).
Conclusion: The findings of this study demonstrate that although Acetaminophen does not have an improved effect on pain control and cardiac performance than Morphine sulphate, it can be still an appropriate alternative for Morphine sulfate due to the lack of destructive effects and its availability.
Evaluation of Endotracheal Tube Cuff Pressure in Intubated Patients in Emergency Department, Operating Rooms, and Icus of Imam Khomeini Hospital Complex in 2018; A Cross Sectional Study
Background: Establishing and maintaining a secure airway using a cuffed endotracheal tube (ETT) is an important step in management of intubated patients. Out-of-range ETT cuff pressure is associated with various complications which could lengthen the hospital stay. The aim of this cross-sectional study was to evaluate ETT cuff pressure in intubated patients in the emergency department (ED), operating rooms (ORs), and Intensive Care Units (ICUs) of Imam Khomeini Hospital Complex (IKHC), Tehran, Iran.
Methods: The ETT cuff pressure of 153 patients was measured using a standard manometer. Demographic data and duration of intubation were recorded. The data were analysed using the SPSS software version 16. P values less than 0.05 were considered significant.
Results: The ETT cuff pressure exceeded the recommended range in 125 out of 153 patients (81.7%). The mean cuff pressure (67.29 cmH2O) was significantly higher than the recommended range (p<0.001). The cuff pressure was higher in patients in the ORs compared to patients in the ED and ICU (OR=8.46, p<0.001).
Conclusion: Intubation in the OR can be considered a risk factor for higher-than-normal ETT cuff pressure and subsequent complications. The ETT cuff pressure monitoring by means of a manometer is recommended.
Comparative Evaluation of Two Different Doses of Pre-Emptive Oral Pregabalin on Duration of Spinal Anesthesia and Postoperative Pain
Background: Pregabalin provides good postoperative analgesia in nociceptive stimuli. Various studies show that preemptive oral pregabalin reduces acute postoperative pain. We conducted a study to evaluate the efficacy of two different doses of pregabalin and its effect on onset and duration of spinal anesthesia and postoperative pain.
Methods: In prospective, double-blind and randomized study, 60 patients posted for vaginal hysterectomy under spinal anesthesia were randomly allocated to two groups recieving cap. Pregabalin 75 mg (group 1) and cap pregabalin 150 mg (group 2) orally, 90 min prior to surgery. Onset and duration of motor and sensory blockade were observed. Postoperative pain was assessed by VAS for 24 hrs. Injection paracetamol 1 gm. was given intravenously as rescue analgesic. Time of first rescue analgesic and total dose of rescue analgesics was noted.
Results: Group 2 patients had better postoperative analgesia in terms of prolonged sensory and motor blockade which correlated well with the time of first request for rescue analgesia (504±123.2 min) as compared to group 1 patients (304.9±37.6 min). Also the total dose of rescue analgesic (paracetamol) was significantly less with 150mg pregabalin (p = 0.0001).
Conclusion: Pregabalin 150 mg prolongs the duration of spinal anesthesia and has better analgesic profile without significant side effects. Thus we conclude that 150 mg pregabalin given preemptively optimizes spinal anesthesia well in patients for vaginal hysterectomy.
Effects of High and Normal Dose Fluid Therapy on Nausea and Vomiting after Pediatric Tonsillectomy: A Comparative Study
Background: Nausea, vomiting, and postoperative pain are common and undesirable complications after anesthesia and tonsillectomy surgery especially in children. This study was designed to evaluate the effects of high and normal dose lactated Ringer infusion on nausea, vomiting, and pain intensity after pediatric tonsillectomy.
Methods: A total number of 100 tonsillectomy surgery candidates at the age range of 1-12 years were selected for this randomized clinical trial. The subjects were randomly assigned to the intervention or control group after signing of their informed consent. The intervention group received high-dose fluid therapy (lactated Ringer 30cc/kg) and the control group received the normal dose (lactated Ringer 10cc/kg) during the perioperative period. The amounts of consumed adjuvant antiemetic drugs, incidence of nausea and vomiting, and pain severity were evaluated in both groups in the recovery room, at 12 and 24 hours after tonsillectomy.
Results: The incidence of nausea and vomiting and the use of rescue antiemetic drugs in the intervention group compared to the control group, were always lower in the recovery room, 12 and 24 hours after surgery; but only the difference in incidence of nausea and vomiting at 24 hours after surgery was statistically significant (P = 0.027).
Conclusion: High-dose fluid therapy significantly reduces the late incidence (24 hours after surgery) of post- tonsillectomy nausea and vomiting in children
Background: Sedation has a beneficial impact on patient’s tolerance to the endoscopic procedure. Conscious sedation is the anesthetic techniques of choice for endoscopic procedure. Conscious sedation for endoscopic procedure could be with one drug or a combination of drugs. There have been broad variations in sedation procedure between different countries, and even between different units within the same country. All drugs which depress the central nervous system have the ability to produce respiratory or cardiovascular complications. Endoscopy has a recorded mortality of 1 in 2000 and a morbidity rate of 1 in 200. These sedation techniques have their effects on patients.
The main goal of this study is to describe the effects of conscious sedation on patients' outcome for endoscopic procedure.
Methods: The design for this study was a review of literature in the medical databases of PubMed, Scopus, Embase, Cochrane and hand search journals from conferences in English. All studies that evaluated the use of CS for endoscopic procedure were included.
Results: The results showed that the pain level of the patient (visual analogue scale) was substantially positive when conscious sedation was used. Conscious sedation, however is a lightly sedated patient who is conscious, amnesic, co-operative on demand and free from fear and anxiety. It is often used during endoscopic procedures to minimize discomfort and relax the patients. The intraoperative hypotension has also been extreme in some medications relative to others.
Conclusion: The study revealed that CS is reliable and well tolerated anesthetic technique for endoscopic procedures, and is a better option for elective endoscopic procedures
CS benefits for endoscopisit and patient outcome is superior to GA such as; short recovery times, less analgesia requirement, comfortable for patient which in turn, leads to faster induction, faster endoscopy, faster discharge, and faster turnaround time. Patients are usually willing to go home after a couple of hours. Rapid recovery is a benefit not only for patients, but also for hospital and day surgery departments. This increases the overall performance of the endoscopy unit.
Emerging Perspectives of Endotracheal Intubation in Patients with Severe COVID- 19 Pneumonia: A Narrative Review
The coronavirus disease 2019 (COVID -19) pandemic that has engulfed the world has put an immense strain on the existing healthcare systems. The rapid, insidious and often dramatic deterioration of the respiratory function of an infected patient, has led to an increased need for effective and rapid airway control. However, such airway control techniques put the healthcare workers to an increased risk of exposure to the virus. Therefore, interventions aimed at minimising such risks, while preventing the complications inherent to securing an airway are imperative to the management of a COVID-19 patient in acute respiratory failure (ARF). Personal protective equipment (PPE) is sine qua non to keep the intubator safe, however some barrier equipment’s have been employed with limited success. There are varied schools of thought on whether to intubate early or late, and the use of non-invasive methods for management of respiratory failure, however, most consensus statements reinforce the need for rapid sequence induction (RSI), which provides ideal intubating environment for an experienced intubator. Techniques, which decrease the number of required personnel as well as time, to secure the airway and increase the distance of the intubating physician from the patient, are recommended. Routine use of, videolaryngoscope, if available, is recommended. While intubation with an endotracheal tube is the gold standard airway technique, second generation supraglottic airway devices (SAD) are increasingly being recommended, particularly in cases of failure to intubate or in an unanticipated difficult airway. Awake intubation techniques are contraindicated due to increased risk of cough and subsequent aerosolization; however, few modifications were innovated when if it all required. In this review, we summarise the existing data with respect to the modifications and guidelines in severe COVID-19 patients who requires endotracheal intubation for invasive mechanical ventilatory support.
Percheron’s Occlusion: Difficulty of Clinical Diagnosis about One Case in the Teaching Hospital of Cocody (Abidjan-RCI)
Ischemic strokes have varying etiologies and multiple locations. Some locations are much rarer than others and just as difficult to diagnose. This is the case of the ischemic bi-thalamic stroke, attributable to the Percheron artery occlusion that we report in a 33-year-old woman with a history of taking estrogen-progestin. The lesion diagnosis could only be possible thanks to the performance of brain MRI, thus testifying to the diagnostic difficulties observed. Etiological research has shown dyslipidemia. The length of stay was 88 days. At the end of intensive care, the patient was conscious, not deficient and did not present memory disorders.
Cerebral Sinus Thrombosis with Coexisting Secondary Hypoparathyroidism: Case Report for Clinical Education
Cerebral venous sinus thrombosis is a rare and infrequent condition in pregnant women. Hemorrhagic infarction can occur in early stages of cerebral venous thrombosis. This article reports a rare case of cerebral transverse sinus thrombosis presenting in pregnant women with unidentified secondary hypoparathyroidism, highlighting the difficulties in identifying this rare case from common diagnosis like preeclampsia. According to the differential diagnoses for this case, it can be a good exercise to strengthen clinical reasoning in students and medical teachers to improve the quality of clinical education.
Achondroplasia is the result of a mutation in the gene encoding the type 3 receptor for a fibroblast growth factor. This abnormality results in malformation endochondral ossification. Achondroplasia is characterized by disproportionately short stature, lumbar lordosis, large head, midface hypoplasia, short hands, and normal cognitive development.
Our report is about a 28-year-old patient with achondroplasia who underwent surgery for correction of kyphosis due to spinal canal stenosis. In this present case we study management anesthesia.