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.
Comparative Study of the Prophylactic Effect of Intravenous or Gargling Dexamethasone in Reducing Postextubation Sore Throat and Cough
Background: Sore throat, cough and hoarseness after tracheal extubation are common complications after surgery. Due to the proven effect of dexamethasone on reducing these complications, in this study, we compared the prophylactic effect of intravenous dexamethasone and dexamethasone gargle on sore throat and cough after extubation.
Methods: In this clinical trial study, 96 patients between the ages of 18-64 years who underwent elective surgery and intubation under general anesthesia were randomly divided into three groups, respectively, the first group received 6 mg dexamethasone gargle. The second group received 6 mg intravenous dexamethasone and the third group received normal saline. The frequency of cough and sore throat were assessed and compared in these three groups.
Results: There was no significant difference between the three groups based on hemodynamic variables and demographic data (P> 0.05). The frequency of cough in the first (1.54± 2.82) and second (1.57±2.73) groups was less than the third group (1.79±3.14), but this difference was not statistically significant (P>0.66). The mean severity of sore throat in the second group and then in the first group was lower at the time of entry into recovery and 2 hours after surgery, than the third group. (P <0.005) Also, the mean severity of sore throat in the second group and then the first group in 24 hours after surgery was significantly lower than the third group. (P <0.005).
Conclusion: Prophylactic single-dose intravenous dexamethasone is more effective than dexamethasone gargle in reducing sore throat due to endotracheal intubation. Also, gargling and intravenous injection of dexamethasone, both are effective in reducing postoperative cough without any side effects after extubation.
Prognostic Accuracy of the Quick Sequential Organ Failure Assessment Score and National Early Warning Scores in mortality rate of the Non-Traumatic Patients
Background: The current study aimed to evaluate the predictive value of mortality in patients admitted to the Intensive Care Unit (ICU) through the emergency department and based on Quick Sequential Organ Failure Assessment (qSOFA), National Early Warning Score (NEWS) and NEWS2 criteria.
Methods: In this cross-sectional study, all patients referred to the emergency department with a need of admission to ICU for any reason, were evaluated. Demographic data such as age and sex were recorded for data collection. Also, the main diagnosis, length of stay and hospitalization outcome along with data related to qSOFA, NEWS and NEWS2 indices were included in the researcher's checklist.
Results: Of 89 included patients, 52 (58.4%) were male and 37 (41.6%) were female, with mean age of 60.25±20.8. Our findings indicated that qSOFA is a good predictor for mortality in non-traumatic patients so that qSOFA has 48% sensitivity and 100% specificity in the diagnosis of mortality in non-trauma patients. NEWS also has a sensitivity of 72% and a specificity of 71.4% in the diagnosis of non-traumatic mortality. And NEWS2 has 72% sensitivity and 78.6% specificity in non-traumatic mortality diagnosis.
Conclusion: Our findings suggested that the sensitivity and specificity of qSOFA, NEWS and NEWS2 in predicting the mortality of non-traumatic patients who were admitted in emergency departments and hospitalized in ICU, are high and reliablen.
Comparison of the Effect of Epidural Bolus and Continuous Infusion of Lidocaine %1 on Pain, the Progress of Vaginal Delivery and Motor Function in Labor Epidural Analgesia
Background: The pain of childbirth is the most severe pain that a woman experiences. This study aimed to compare the effect of epidural bolus and epidural continuous infusion of lidocaine %1 on pain and progress of vaginal delivery and motor function in labor epidural analgesia.
Methods: This randomized clinical trial was conducted on 50 pregnant women aged between 18-45 years. They were randomly assigned into two groups of bolus injections of lidocaine1% and continuous infusion using an epidural approach. The evaluated variables included systolic and diastolic blood pressures, mean arterial pressure, pain score, heart rate, satisfaction rate, nausea, vomiting, itching, the progress of delivery, and the level of motor and sensory block. The collected data were analyzed in SPSS software (Version 21). P-value less than 0.05 was considered statistically significant.
Results: Two groups were similar in age. There were no significant differences between two groups in terms of mean diastolic blood pressure, incidence of hypotension and C/S rate (P> 0.005). Mean arterial pressure, sedation score and neonatal Apgar scores in the first and fifth minutes in the continuous group were significantly lower than the bolus group.
Pain score (VAS) in the bolus group) 2.55±1.04 (was significantly lower than infusion group (5.22±2.50). The length of the first and second stages of labor in the bolus group (42.28 and 34.12) was less than continuous infusion (47.04 and 47.00) (P< 0.005).
Conclusion: In women undergoing epidural analgesia, epidural bolus injection of lidocaine 1% is associated with greater analgesia and satisfaction than continuous infusion.
Preliminary Study of Pre-hospital Pain Management and Comparison of Pain Management Methods in Emergency Patients
Background: Pain is an unpleasant sensation in the body or mind. Uncontrolled pain can increase mortality and morbidity with its negative physiological effects. Effective pain management especially in emergency conditions is essential to keep the patient in optimal conditions and to achieve good clinical results. As most of the injured and traumatic conscious patients with acute pain in emergency situations, need control and perfect pain management during transfer to hospital essential to feel satisfied and improve the quality of service and to decrease mortality and morbidity. Due to some limitation to use opioid drugs in pre-hospital systems, the goal of this study was to evaluate the efficacy of non-opioids drugs in different doses on pre-hospital emergency traumatic conscious patients.
Methods: Infusion of 1 gr IV acetaminophen and 30 mg IV ketorolac were studied separately and in combination 500 mg acetaminophen and 15 mg ketorolac on 95 patients in three separate groups in the pre-hospital pain control system. Patient pain score was collected at 5 intervals.
Results: The results showed that there was no significant difference between the three groups in pain scores reduction finally (p> 0.05). The rate of pain reduction in emergency department is very important and these criteria was significant (p< 0.05).
Conclusion: The results of this study suggest that the combination of ketorolac and acetaminophen reduces pain more rapidly than either alone.
According to our findings we suggest a combination of apotel and ketorolac is injected in advance in moderate to severe conscious traumatic patient before any change in the position of patients if there are not any contraindications.
Comparing the Effects of Menthol-cold Water and Psyllium on Thirst and Xerostomia among Patients in Intensive Care Unit
Background: Thirst is a prevalent problem among patients in intensive care unit. This study aimed to compare the effects of menthol-cold water and psyllium on thirst and xerostomia among patients in intensive care unit.
Methods: This randomized controlled trial was conducted in 2018–2019. Participants were 132 patients consecutively recruited from the intensive care units of two teaching hospitals, Tehran, Iran. They were randomly allocated to either a menthol-cold water, a psyllium, or a control group (44 patients in each group). Participants in the menthol-cold water and the psyllium groups received mouth wash with respectively menthol-cold water and psyllium in two fifteen-minute rounds with a thirty-minute interval. A visual analogue scale was used to assess thirst severity, distress, and xerostomia before and after each round of mouth wash. Data were analyzed through non-parametric statistical tests.
Results: There were no significant differences among the groups respecting baseline characteristics, thirst severity and distress, and xerostomia. However, among-group differences respecting thirst severity, distress, and xerostomia were statistically significant after the intervention (P < 0.001). Mouth wash with psyllium was associated with significantly greater reduction in thirst severity, distress, and xerostomia compared with mouth wash with menthol-cold water (P< 0.001).
Conclusion: Both menthol-cold water and psyllium are effective in reducing thirst and xerostomia among patients in intensive care unit, though the effectiveness of psyllium is significantly greater than menthol-cold water. Educating nurses about thirst and xerostomia assessment and herbal remedies for their management may help them effectively manage their patients’ thirst and xerostomia.
Effect of General Anesthesia with Thiopental Sodium and Propofol on the 1- and 5 minute Apgar newborns by Cesarean
Background: The Apgar score of newborn babies is a determining factor involved with mortality of newborns after birth. Regarding the disagreement on advantages and possible disadvantages of propofol and thiopental in the available references, the study was triggered with the aim of analyzing effects of two mentioned drugs on babies’ Apgar score.
Methods: In this double-blind clinical trial, a total of 100 healthy women who volunteered to undertake cesarean operation were selected and then divided randomly into two equal groups using statistical blocking. One group was treated by propofol while other one was treated by thiopental. The prescribed drugs for both groups were identical. Babies’ Apgar score 1 and 5 minutes after birth and recovery period and some of the critical maternal parameters after operation were recorded. The obtained data were analyzed by SPSS 19 software.
Results: Apgar score I minute 1 (p=0.317) and Apgar score in minute 5 (p=1.00) for propofol group were not different meaningfully. The groups had significant differences in the indices such as first systolic (P=0.00) and diastolic (P=0.00) pressure in recovery, last diastolic pressure in recovery (P=0.001) and duration of postoperative recovery (P=0.001). Statistical analysis of nausea and vomit in both groups showed that they are lower in propofol group rather than the thiopental group (p=0.000).
Conclusion: Propofol and thiopental did not differ significantly in Apgar score, but it seems that propofol can be a better option to induce anesthesia for an elective cesarean operation.
Comparison of Dexamethasone Composition with Bupivacaine and Dexmedetomidine with Bupivacaine and Bupivacaine alone in a Supraclavicular Block with Low Volume
Background: Regional blocks is a good alternative to general anesthesia in upper extremity surgeries. Supraclavicular is a kind of regional block which can be used to treat nerve block in the upper extremity. The ancillary drugs are nowadays used to enhance the quality and quantity of sensory and motor block. The present study has attempted to investigate the effect of three prescription drugs (composition Dexamethasone with Bupivacaine and Dexmedetomidine with Bupivacaine and Bupivacaine alone) on supraclavicular block.
Methods: This parallel Design study was conducted in 2017 as a clinical trial at Ayatollah Taleghani Hospital in Tehran. For this purpose, 60 patients over the age of 18 and in class I, II of the American Anesthesiology Association (ASA) who were candidates for upper limb elective surgery, were enrolled. Patients included in the study (60 patients) were randomly divided into three equal groups (n= 20). Anesthesia procedure was performed for all patients in three equal groups. However, to evaluate the efficacy of selected drugs, different drugs were injected into each group. After completing the design and recording the results of the variables under study, the t-test was used to compare quantitative variables between the two groups. All statistical tests were performed in two domains (5% significance level) and SPSS 21 software was used for data analysis.
Results: In the levels of intraoperative factors in the comparative conditions of the BB[i] with BDexa[ii] and BB with BDex[iii] groups. However, Duration of Sensory Block (P=0.004) and Duration of Movement Block (P=0.001) were significantly different in BD and BDex groups.
Conclusion: What can be clearly seen in the results are the significant changes of Duration of Sensory Block and Duration of Movement Block compared to the BDexa and BDex groups. Based on these results, in both cases we find a significant decrease in the measured duration in the BDexa group compared to the opposite group.
Use of Bupivacaine + Dexamethasone has a more positive effect on Supraclavicular block compared to Bupivacaine + Dexmedetomidine and Bupivacaine alone.
[ii] Bupivacaine + Dexamethasone
[iii] Bupivacaine + Dexmedetomidine
Background: Chest tube insertion is recommended after cardiac surgery, and inserted annually for a large number of these patients. In addition to its benefits, the chest tube may have risks that are mismanaged. One of these risks is the possibility of pleural effusion, which can occur in high rates. Therefore, we conducted a systematic review to properly manage the chest tube and reduce its complications.
Methods: This systematic review of cohort study asked the question: Is there enough evidence to determine the right time to remove the chest tube? We searched ISI Web of Science, PubMed, Scopus and Embase from 1 January 2015 to 30 September 2019 to identify retrospective or prospective cohort studies.
Results: Three studies recommended early chest tube removal and two studies late removal. Of course, early and late removals in the studies had different meanings and time frames that were examined).
Conclusion: More evidences and studies are needed to determine the right timing and management of the chest tube removal but our systematic review based on the available evidences revealed that if the chest tube removal occurs about 24 hours postoperatively, and with less than 100 ml drainage within the last 8 hours, it will reduce the risk of pleural effusion and improve many other outcomes.
Misoprostol Induced Hyperpyrexia associated with Seizures in Postpartum Parturient: Rare Side Effect and its Management in Critical Care Settings
Misoprostol is a synthetic prostaglandin E1 analogue and has been reccommended as a safe, effective, easy to administer, cost efficient next in line drug after oxytocin, for the treatment and prevention of postpartum haemorrhage (PPH). Notwithstanding, it causes certain undesirable side effects compared to oxytocin such as nausea, vomiting, shivering, diarrhoea and transient fever. Transient pyrexia is commonly related with misoprostol administration, due to shift of hypothalamic set point. However, hyperpyrexia clubbed with seizures is a rare yet self-limiting side effect and requires prompt management strategies. There have been case reports describing fever following misoprostol administration but only few describing hyperpyrexia and even fewer describing with seizures. We report a case of hyperpyrexia associated with delayed presentation of generalised sezuires after administration of rectal misoprotol and its successful management in critical care settings.
Intraoperative anaphylaxis can lead to significant morbidity and mortality but rarely occurs. Vascular collapse and bronchospasm are the hallmarks of this condition. numerous agents have been identified as triggers of intraoperative anaphylaxis, the most common being neuromuscular blocking drugs and latex. But opioids rarely cause anaphylaxis. We report an unusual case of intraoperative anaphylaxis with pulmonary edema during a routine plastic surgery procedure was due to iv fentanyl.
Letter to Editor
Leukariosis is an incidental MRI finding which appears as white matter hyperintensities (WMHs) or diffuse white matter changes and is related to small vessel disease. Patients having severe WM disease are more susceptible to intraoperative hypoperfusion, metabolic disturbance, microemboli, any medication effect, and postoperative hemodynamic perturbations. The effect of anaesthesia in patients with leukoariosis is not commonly known and there is paucity of reported literature.