Zahid Hussain Khan, M.D., FCCM.
Atabak Najafi, M.D.
Mehdi Sanatkar, M.D.
Parya Khalili, B.Eng.
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.
Background: Postoperative nausea and vomiting (PONV), an unpleasant complication following anaesthesia and surgery has various components such as nausea, retching and vomiting. Although PONV is usually self-limiting and non-fatal, it often causes substantial patient distress and dissatisfaction, augmenting healthcare costs by delaying discharge from post anaesthesia care units and causing unexpected hospital re-admissions. Different pharmacological and non-pharmacological approaches have been used for preventing PONV. Nonetheless, the most effective prophylactic regime has not been determined.
Methods: We conducted a prospective randomised study for evaluation of effect of preoperative oral carbohydrate fluid (GROUP- C) and placebo drink (clear water) (GROUP-P) on PONV in 90 adult patients undergoing laparoscopic cholecystectomy surgery under general anaesthesia. The number of episodes of nausea, retching and vomiting, total requirement of antiemetic dose in 24 hours, pre and postoperative blood glucose levels, patient satisfaction score, VAS score and haemodynamic parameters were recorded in the two groups and statistical analysis was done.
Results: Demographic data was comparable between the two groups with respect to age, gender and BMI. The surgical time and intra-abdominal pressures throughout the surgery were similar in the two groups. In our study the pre-induction blood glucose levels were found to be higher in group C and preoperative thirst was found to be less in group P. Both the groups were comparable in terms of number of episodes of PONV, total requirement of anti-emetic dose in 24 hours, patient satisfaction and well-being. VAS score for pain and requirement of analgesic dose was also similar in the two groups.
Conclusion: Pre-operative oral monosaccharide carbohydrate fluid does not prevent PONV, alter requirement of antiemetic, patient satisfaction and well-being, VAS score for pain, requirement of analgesic dose in patients undergoing laparoscopic cholecystectomy under general anaesthesia, as compared to placebo drink.
Background: Levobupivacaine because of its longer duration of action and better safety profile has gained popularity in regional anaesthesia. Intrathecal opioids synergise with Local anaesthetics and potentiate subarachnoid block. We conducted this study with the primary aim to compare analgesic efficacy of two different doses of buprenorphine as adjuvant to isobaric Levobupivacaine and the secondary aim to compare the onset and duration of sensory and motor blockade, hemodynamic variability and adverse effects if any.
Methods: One hundred and twenty patients of American society of anaesthesiologist (ASA) I and II were divided in 3 groups of 40 each. Group A :0.5%levobupivacaine, group B: 0.5%levobupivacaine with 60 mcg buprenorphine Group C:0.5 %levobupivacaine with 90mcg buprenorphine. Duration of analgesia, onset of sensory and motor block, VAS scores, haemodyanamic parameters and adverse effects were noted.
Results: The duration of analgesia was significantly prolonged in group C (11±0.41) h than group B (8.5±0.61) hour and Group A (4.8 ±40) hour (p < 0.001). Onset and duration of Sensory and motor blockade was not significantly different. VAS score was significantly lower in group C (p<0.001), hemodynamic parameters were well preserved with higher incidence of PONV in group C (10%).
Conclusion: Addition of buprenorphine to intrathecal Isobaric Levobupivacaine prolonged the duration and quality of postoperative analgesia after lower abdominal surgery. Increasing the dose of buprenorphine from 60mcg to 90mcg provided longer duration of analgesia with minimal adverse effects like dizziness and PONV which were not significant to hinder recovery.
Background: The intensive care unit is one of the most specialized hospital units that need nurses with a high level of skill and experience. The leave of experienced nurses from this unit reduces the quality of nursing care and imposes heavy costs on the health care system. This study aimed to investigate the reasons for nurses' intention to leave the ICU.
Methods: This cross-sectional study was performed on 247 nurses in the ICU affiliated with Zahedan, Tehran, and Mashhad University of Medical Sciences, Iran, from 2018 to 2021. Nurses were included in the study by Census sampling method based on inclusion criteria. They completed a four-part questionnaire including demographic variables, Job Satisfaction Survey (JSS), intention to leave, and reasons for intention to leave the ICU. Data were analyzed with SPSS software using descriptive-analytic statistics, Chi-square, independent t-test, one-way ANOVA, and Pearson correlation. The significance level was considered less than 0.05.
Results: Out of 247 nurses studied, 183 (74.1%) were female and 64 (25.9%) were male. The mean age of participants was 32.47± 6.68 years. The mean score of job satisfaction was 115.45±58.20 and the mean score of intention to leave was 15.98±3.76. The mean score of the three areas of reasons for intention to leave had a negative correlation with job satisfaction and a positive correlation with the intention to leave the ICU, which was statistically significant in all cases (p= 0/001). The mismatch between the workload and legal benefits, shortage of nurses, forced overtime, the disproportion of nurse-patient ratio, and lack of welfare facilities had the greatest effect on nurses' intention to leave the ICU.
Conclusion: The results of the study showed that the most common reasons for the increase the intention to leave of nurses are related to the mismanagement of nursing managers and authorities of ICU. Therefore, reforming old management styles, observing justice among employees, involving nurses in decisions and the process of patient's treatment are among the things that can increase nurses' self-esteem, job satisfaction and reduce the leave of ICU without providing additional funding for the organization.
Background: Pre-eclampsia has always been a challenge to the anaesthesiologist, in terms of choosing which type of anaesthesia to prefer. This present study was done to evaluate the maternal and foetal outcome in patients of caesarean section for pre-eclampsia under spinal and general anaesthesia.
Methods: This prospective study was conducted in 60 parturients, ASA 1 and 2 who underwent caesarean section for pre-eclampsia. These parturients were randomly and divided into two groups, Group S receiving spinal anesthesia and Group G receiving general anesthesia. For maternal outcome, the parturients were monitored for Blood Pressure, Heart Rate, Oxygen Saturation. Post-operative ICU admissions, convulsions, and pulmonary edema chances were seen. For fetal outcome, APGAR score was noted at 1 minute and 5 minutes after birth of child.
Results: The systolic blood pressure, diastolic blood pressure, mean arterial pressure, and heart rate were comparable in both the groups in the pre-operative period and at induction. However, intraoperatively, these parameters were significantly lower in the spinal anaesthesia group as compared to general anesthesia group (p<0.05). The Apgar Score was also found to be significantly higher in the newborns in spinal anaesthesia group as compared to general anaesthesia group. Post-operatively, more number of ICU admissions were seen in general anaesthesia group as compared to spinal anaesthesia group (p<0.05).
Conclusion: Spinal Anaesthesia can be considered as a first choice of anaesthesia in parturients undergoing caesarean section for preeclampsia with better hemodynamic control in intra-operative period and lesser chances of post-operative morbidity and mortality.
Background: Various newer generations of Supraglottic Airway Devices (SAD) with improved designs and performance are available for use by anaesthesiologist. We conducted the present study to compare 3rd generation SAD Baska Mask with 2nd generation SAD I-gel with the aim of comparing their clinical performance in terms of insertion parameters and oropharyngeal leak pressure in short laparoscopic gynaecological surgeries in adult females.
Methods: 80 adult female patients were randomly allocated to either Baska Mask (n=40) or I-gel (n=40) groups. Insertion characteristics that included number of attempts, mean insertion time and manipulation frequency were recorded and compared. Oropharyngeal leak pressure was measured just after insertion of device and after 5 min of creating pneumoperitoneum in both devices and were compared.
Results: Baska Mask insertion was successfully achieved in first attempt in 38/40 patients in Baska group vs 35/40 patients in I-gel group. Mean oropharyngeal leak pressure (OLP) in Baska Mask versus I-gel just after insertion was (29.24±4.20cm H20 vs 26.33±2.51cm H2O, P=0.003) whereas it was (29.42±2.70 vs 26.18±2.54 cm H2O) after 5 min of creating pneumoperitoneum. Both groups were comparable in terms of removal characteristics and postoperative laryngopharyngeal airway morbidities.
Conclusion: Baska Mask provided more effective ventilation in terms of greater oropharyngeal leak pressure as compared to I-gel. However Baska Mask was more difficult to insert and the incidence of postoperative laryngopharyngeal morbidity was higher in case of Baska Mask.
Background: Oxygenation indices are used to assess the condition of patients with pneumonia and ARDS. These indexes determine the status of patients as well as the mortality rate of respiratory diseases and the need for intubation. The aim of this study was to determine and compare oxygenation indices and the extent of radiographic findings in patients with COVID-19 in ICU at Shariati Hospital.
Methods: The present study was a cross-sectional study that was performed prospectively in the intensive care units of Shariati Hospital in Tehran. Patients admitted to the intensive care unit were examined if they met the inclusion criteria. Data were analysed by SPSS software version 26.
Results: In this study, 39 patients were evaluated. Of these, 35.9% were men and 64.1% were women. The mean age of the population was 62 ±17. On average, SpO2 and PaO2 were not significantly different based on pulmonary involvement, severity of pulmonary involvement and also the pattern of pulmonary involvement (p> 0.05). No significant relationship was found between the severity of ARDS and the parameters of pulmonary involvement severity on CT scan (p> 0.05).
Conclusion: It seems that there is no significant relationship between oxygenation indices and the extent of radiographic findings in hospitalized patients with COVID-19. Also, the severity of ARDS has no significant relationship with the extent of radiographic findings (CT scan). Oxygen saturation should be used as an adjunct when considering a CT scan of the lung, but should not be used as the sole means of diagnosis.
Background: The precordial stethoscope is a non-invasive monitoring method in pediatric anesthesia. We previously investigated optimal place for its attachment among intubated children under two years old. Now we also did in nonintubated children under two years old.
Methods: Twenty-five patients who underwent general anesthesia in our institution were involved in this study. Lung and heart sounds via precordial stethoscope were recorded (MP3 format) at the six places: Site A (paratracheal region), B (suprasternal notch), C (between place of the nipple and clavicle on the left midclavicular line), D (between place of the costal arch and nipple on the left midclavicular line), E (horizontal level of Site D on the left midaxillary line), and F (epigastric fossa). Two blinded evaluators scored random sorted lung and heart sounds on a 10-point scale (0: cannot hear at all and 10: can hear clearly) individually.
Results: Statistically significant differences were observed between Sites A: 10.0 (8.5–10.0), B: 9.0 (2.5–9.5), C: 8.0 (6.5-9.0) and D: 1.5 (1.0–6.5), E: 4.5 (1.5–7.0), F: 1.0 (0.0–4.5) for lung sounds and between Sites B: 9.0 (5.0–10.0), C: 9.5 (8.0–10.0), D: 9.0 (4.5–9.5) and A: 0.0 (0.0–0.0), E: 0.5 (0.0–2.5), F: 0.5 (0.0–0.5) for heart sounds.
Conclusion: Site C is the optimal place for precordial stethoscope attachment for children under two years of age during general anesthesia.
Background: The distance from the skin to the subarachnoid space varies at different levels of the vertebrae and from patient to patient. Knowing the distance from the skin to the subarachnoid space beforehand may help the procedure go more smoothly and ensure that the spinal needle use is of the right length.
Methods: An observational study was conducted on 100 patients posted for infra umbilical surgeries of various specialties under spinal anaesthesia. Intraoperatively after a successful spinal with midline approach at the L3-L4 level, the length of the needle from the skin to the subarachnoid space was immediately measured and this actual length was compared with the expected length obtained using Bonadio's formula. The relationship between a patient's BMI and depth of spinal needle insertion and the reliability of Bonadio's formula to predict skin-to-subarachnoid space was studied.
Results: From our study, a positive correlation was obtained between patients' weight, BMI, waist circumference and depth of spinal needle insertion and also between the Skin to Subarachnoid space distance (SSD) measured intraoperatively with the predictive value obtained using Bonadio's formula. The correlation between height and arm circumference was not much significant.
Conclusion: Skin-to-subarachnoid space distance correlates with weight more than BMI. Bonadio's formula can be used to calculate the skin to subarachnoid space depth before performing spinal anaesthesia. After seeing the results, weight was the variable which had a significant correlation with Spinal Needle Depth (SND), hence we formulated two equations using weight to predict the depth of spinal needle insertion to reduce the incidence of multiple attempts during the procedure and to enhance patient comfort.
The regression equation using actual values of needle depth:
SND = 2.292 + [0.044 x weight]
And regression equation using Bonadio's values of needle depth is:
Needle depth= 2.681 + [0.037 x weight]
Background: Control of pulmonary ventilation during surgery, especially heart surgery, is very important. Therefore, in this study, we will compare different ventilation strategies during cardiopulmonary bypass in smokers undergoing cardiac surgery.
Methods: A total of 42 patients who had a clinical indication for CABG were included in this study. Patients were randomly divided into two groups. All patients were operated on by the same surgeon and cardiac anesthesia team in the same condition. The patient data includes age, sex, height, weight, and spirometry indices (FEV1, FVC, FEV1 / FVC, MMEF, PEF, PaO2, PaCO2, PaO2 / fio2, PaO2 / fio2, and Pent. T) were recorded prospectively for each patient.
Results: Examines the spirometry indices of patients in the two groups in both pre-procedure and off-pump time, do not show significant changes (P<0.005).
Conclusion: The use of different ventilation strategies in smokers undergoing CABG surgery could not cause significant changes in patients' respiratory parameters.
Background: Uncuffed endotracheal tubes (ETTs) are standard of care for airway management in children up to eight years of age. Direct Laryngoscopy and endotracheal intubation are invasive techniques which may cause hemodynamic changes and can give rise to airway complication. Supraglottic airway devices have been introduced since the past few decades for the management of airway in both adults and children. I-Gel, a second generation supraglottic airway device, is used frequently for securing airway for children.
Methods: Total of 90 children of age 2-8 years of age were randomized into two groups, 45 children were ventilated with I-Gel and remaining 45 were ventilated with an uncuffed ETT. Ventilatory parameters like oropharyngeal leak, peak airway pressure and airway sealing quality (ASQ) score were monitored intraoperatively and possible complications were observed at a timely interval after removal of device.
Results: Mean oropharyngeal leak pressure in the I-Gel and uncuffed ETT group observed were 20 cmH2O and 19.56 cmH2O respectively. ASQ score was comparable in both groups. Ten patients in the I-Gel group while two in the uncuffed ETT group had blood staining of the device after removal and the difference was statistically significant. Incidence of cough and sore throat post-extubation and after six hours was significantly higher in the ETT group as compared to the I-Gel group.
Conclusion: Both devices were comparable and equally effective for adequacy of ventilation while blood staining of the device was observed in the I-Gel group however, cough and sore throat were observed in the ETT group.
Background: Laryngoscopy and endotracheal intubation have been associated with marked hemodynamic responses and hazards. This study was undertaken with the purpose to compare the intubating conditions when the suitable time for intubation was judged by either clinical assessment or train-of-four monitoring.
Methods: 60 patients without any difficult airway predictors, posted for surgery under general anaesthesia, were randomised into two groups. In Group A patients, the trachea was intubated after train of four counts became zero in adductor pollicis muscle, whereas in Group B patients, intubation was done after clinically judging jaw muscle relaxation. The primary objective was to compare Intubating conditions and mean duration of time between the administration of a neuromuscular blocker and endotracheal intubation. The secondary objectives included number of attempts, changes in hemodynamic parameters. Results were analysed by the Analysis of variance and chi-square tests.
Results: In all Group A patients excellent and good intubating conditions were observed, whereas 25 out of 30 patients (83%) in Group B showed excellent and good intubation conditions. The mean time required for intubation was significantly longer in Group A compared to Group B (369 ± 79 s vs. 191 ± 5 s). HR and mean arterial pressure were significantly higher in Group B as compared to Group A after laryngoscopy and tracheal intubation (P < 0.05).
Conclusion: Better intubating conditions and more haemodynamic stability are seen after attaining complete relaxation of laryngeal muscles, as detected by neuromuscular monitoring of adductor pollicis muscle.
Background: A burn tissue injury is one of the most severe forms of trauma which results in severe life-threatening disturbances. Burn injury has many morbid complications, so it needs a multi-disciplinary care team according to the burn center to reduce its mortality and morbidity.
Methods: This article aims to review drawbacks and complications associated with the burning injury including Acute Kidney Injury (AKI), Acute lung injury, Heart Failure, Electrolyte imbalance, intra-abdominal hypertension in children and adult burn patients, and recent challenging treatments.
Results: Improved understanding of the pathophysiology of burn-induced complications can contribute to organizing a well-treatment plan, which leads to improved outcomes.
Conclusions: Herein, the evidence available on the management of all burn induced-complications is summarized.
Atrial Septal Defect is most common congenital developmental acyanotic cardiac anomaly. There is left to right shunt of blood in normal compensated state. In decompensated state, the shunt is reversed and flow is from right to left side causing heart failure and thrombo-embolic event. Here, we report a case of Humerus fracture with large ASD, managed under General Anaesthesia with Interscalene block without any deleterious effects like Venous Air Embolism, Spontaneous Reversal of Shunt etc. As patient was in Beach chair position.
Several formulations of vaccines against novel coronavirus have been launched. Thereby, increasing the plausibility of having one or more successful vaccines. India put in place the world’s largest Covid-19 vaccination drive in January 2021. However, the side effects of these vaccines are slowly unfolding. Each new vaccine has potential adverse events of special interest (AESI) that warrant a focused evaluation. We report a very rare neurological complication Guillain-Barré syndrome, immediately following the first dose of COVID vaccination in a young female. An apparently healthy 35 years old female presented with acute onset lower backache, weakness of bilateral lower limbs 11 days after receiving the first dose of Covishield vaccine, which rapidly ascended to upper limbs over 5 days with symmetric motor weakness, power 1/5 in bilateral lower limbs, 3/5 in bilateral upper limbs, with absent deep tendon reflexes. Mild sensory involvement was seen. Evolving dysphagia and hoarseness of voice. Bladder/bowel function, respiratory pattern, and hemodynamics were unaffected. A provisional diagnosis of Guillain-Barre Syndrome was made on basis of clinical presentation, neurological examination, and nerve conduction studies suggesting axonal polyneuropathy. Gradual improvement of the muscle power over the next 2 weeks following Human Intravenous immunoglobulin was seen. The risk-benefit analysis for an individual should be considered prior to Covid-19 vaccination, including the implementation of a pre-vaccination screening checklist to ensure vaccine safety for every vaccine recipient. The vaccine continues to be far more beneficial than detrimental for the public at large. Nonetheless, increased awareness amongst healthcare professionals and the public regarding the potential adverse effects of the vaccine is warranted.
Pneumatocele is a lung bulla or rather an air filled cavity present within the lung parenchyma. It has various causes of origin. The bullous area is void of bronchoalveolar oxygenation and that certainly could result in dyspnea, hypoxia, symptomatic chest pain or even hemoptysis. This can result in spontaneous pneumothorax, pneumothorax provoked by mechanical ventilation or infection. We present a case of a 47yr old gentleman, who presented with a pneumatocele following trauma to chest. Prior to induction, thoracic epidural was inserted at T6-T7 and then he was intubated with the single lumen tube rather than the conventional double lumen tube for bullectomy. Post-operative pain relief using ropivacaine 0.375% and dexmedetomidine was effective. We discuss the anesthetic management and considerations in such a case.
Osteogenesis Imperfecta is a collagen disorder of autosomal dominant type caused by mutation of type COLIA-1 and COLIA-2 genes. Orthopaedic surgery in paediatric patient patients of OI is challenging mainly due to difficult airway and risk of malignant hyperthermia. Here we report, a paediatric case of OI with similar family history posted for radius ulna nailing which was managed with total intravenous anaesthesia and supraclavicular brachial plexus block.
The traditional interscalene block has evolved over time to lower, lateral and posterior approaches, coinciding with the advent of Peripheral Nerve Stimulator and Ultrasonography. In limited infrastructure settings, such technology remains elusive and the classical paresthesia technique comes to the rescue. This approach is however very difficult to elicit in pediatric patients. It is here that the grassroot approach of a fascial “click” or “pop” emerges as the savior to administer a satisfactory block. We describe a case of a young boy with successful conduct of anaesthesia for K wire fixation of supracondylar fracture of humerus under lower interscalene block with loss of resistance technique. In light of recent research showing about 40-50% variation in the brachial plexus anatomy around the subclavian artery, use of technology in anaesthesia is the future. However, till such technology is made universally affordable, it is pertinent to remember the roots of interscalene block!