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.



Current Issue

Vol 9 No 2 (2023): Spring

Research Article(s)

  • XML | PDF | downloads: 54 | views: 84 | pages: 84-95

    Background: Globally critically ill COVID-19 (Coronavirus disease-19) patients have stretched critical care services. This study was undertaken to find factors implicated in mortality amongst COVID positive and negative patients presenting with severe acute respiratory illness (SARI) and factors having the probability of indicating COVID positivity.
    Methods: The demographic parameters, comorbid illness, clinical parameters and laboratory values of 327 patients were retrospectively analyzed to find the risk factors for mortality in COVID positive and negative patients and factors predicting COVID positivity amongst SARI patients.
    Results: 58% of SARI patients tested positive by RTPCR. Most common comorbidities were diabetes and hypertension, 35.2% and 33% respectively. Duration of swelling and low haemoglobin were significantly associated with mortality in COVID positive group (p=0.01, 0.005). Acidosis and tachycardia (p=0.003, 0.034) were associated with mortality amongst COVID negative. Creatinine, Sequential Organ Failure Assessment (SOFA) and quick SOFA (qSOFA) were higher in non-survivors of both groups (p<0.001). Age, history of contact or from containment zone, cough, pain abdomen and P/F ratio were significant predictors of COVID positivity (1.020(1.006–1.035); 3.889(1.316–11.495); 2.908(1.182–7.152); 2.147(1.149–4.012); 0.997(0.994-1.000) respectively) by multivariable regression analysis.
    Conclusion: A long duration of swelling and low haemoglobin (<12 g%) were responsible for COVID positive mortality while pain abdomen, raised levels of AST, tachycardia and acidosis were associated with mortality in COVID negative. Deranged creatinine, higher SOFA and qSOFA were associated with mortality in both groups. Age, contact history, residence in containment zone, cough, pain abdomen and poor P/F ratio are predictive factors for COVID positivity.

  • XML | PDF | downloads: 54 | views: 58 | pages: 96-101

    Background: Considering that the gold standard for intubation in children with a difficult airway is the use of fiberoptic bronchoscopy, and few studies have evaluated its application in children, the present study aimed at comparing two bronchoscopic techniques of nasal fiberoptic tracheal intubation (FOI-Nasal) and fiberoptic intubation via laryngeal mask airway (FOI-LMA) in children with a difficult airway.
    Methods: A single-blind randomized clinical trial was performed on 40 six-month-old to six-year-old children that were divided into two groups each consisting of 20 patients.  The participants were all candidates for elective surgery with clinical criteria for the anticipated difficult intubation. FOI-Nasal and FOI-LMA were performed in the first and second groups, respectively. Mean arterial pressure (MAP), heart rate (HR), and blood oxygen saturation levels (SpO2) were assessed and recorded before anesthesia (T1), immediately before bronchoscopy (T2), and immediately after intubation with endotracheal tube (T3). Moreover, ETCO2, the first successful insertion attempt, and the intubation time were recorded, as well.
    Results: The results of the present study revealed that parameters including MAP, HR, and SpO2 at times T1, T2, and T3 were not significantly different between the two groups after adjusting for potential confounding factors (P> 0.05). However, ETCO2 in FOI-Nasal group with a mean of 38.40 ± 3.57 was significantly higher than that of the FOI-LMA group with a mean of 34.35 ± 3.15 (P = 0.001). In addition, the intubation time in the FOI-LMA group with a mean of 32.40 ± 7.45 was significantly shorter than that of the FOI-Nasal group with a mean of 51.75 ± 9.97 (P <0.001). The success rate in the first attempt in the FOI-Nasal group with the value of 70% was lower than that of the FOI-LMA group with the value of 90%; however, this difference was not statistically significant (P> 0.05).
    Conclusion: According to the results of the present study, the intubation time in the FOI-LMA group was significantly shorter than that of the FOI-Nasal group. Moreover, the success rate of the first attempt in the FOI-LMA group was higher than that of the FOI-Nasal group. Therefore, it can be stated that FOI-LMA as compared to FOI-Nasal can be regarded as an easier technique, with a shorter intubation time, a higher success rate, and a greater stability of children’s hemodynamic parameters.

  • XML | PDF | downloads: 44 | views: 64 | pages: 102-106

    Background: Brachial plexus surgery requires neural repair with the use of intraoperative peripheral nerve stimulation without muscle relaxants.
    Methods: Twelve cases were conducted under total intravenous anaesthesia, receiving intravenous propofol, fentanyl and dexmedetomidine infusion. Intraoperative hemodynamic conditions and postoperative functional recovery were assessed.
    Results: 9 out of 12 cases were stable while one was in a lighter plane requiring 20 mg propofol and increased dexmedetomidine, two had bradycardia requiring reduced dexmedetomidine infusion. At three months, five cases showed improvement.
    Conclusion: Satisfactory conditions were achieved including hemodynamic stability, and muscle-sparing improving prognoses of brachial plexus surgeries.

  • XML | PDF | downloads: 30 | views: 91 | pages: 107-115

    Background: Recurrence is common after surgery for epithelial ovarian cancer and is multifactorial. Perioperative factors affecting stress and inflammation have an influence on immunity and thus cancer recurrence. The effect of peri-operative epidural anesthesia has been quoted to be beneficial by decreasing stress. A retrospective analysis of perioperative Epidural analgesia use (EA) was compared to general anesthesia (GA) without epidural, with disease free survival (DFS)as the outcome.
    Methods: We did a retrospective observational study of patients with epithelial ovarian malignancy who had undergone surgery between 2013 and 2017. Cohorts were primarily divided based on receipt of epidural analgesia. Perioperative patient, anesthetic, and tumor related data were collected. The aim was to estimate the association of epidural analgesia with disease free survival (DFS). To prevent bias due to skewed covariate distribution propensity score match was done matching all covariates.
    Results: We had 312 patients with age ranging from 18 to 77. The median DFS in months was 32.73±25.6 for the entire cohort while it was 54.81±28.69 for the GA group and 27.23±21.84 for EA group. After PSM median DFS was 35.33 for the full cohort and it was 46 and 34 months for the GA and EA groups, respectively. Multivariate Cox regression analysis demonstrated that only patients who were undergoing primary surgery had survival advantage (P<0.013). Perioperative epidural analgesia was not associated with survival benefit (P=0.480).
    Conclusion: Perioperative use of epidural analgesia did not offer survival benefit in epithelial ovarian cancer as measured by disease free survival.

  • XML | PDF | downloads: 27 | views: 34 | pages: 116-119

    Background: COVID-19 patients have various laboratory findings associated with severe conditions and higher mortality rates. We conducted this study to evaluate the laboratory changes and their effect on the mortality of critically ill patients with COVID 19.
    Methods: This cohort study evaluated the laboratory changes in 192 patients admitted to intensive care units of Imam Khomeini hospital complex, Tehran, Iran. The patients with manifestations of severe COVID-19 of both sexes and older than 16 years were enrolled in the study. The primary outcome was the laboratory changes, and the secondary outcome was the death or survival of the patients. The laboratory data were recorded on the admission day, followed daily by the changes and the neutrophil-lymphocyte ratio (NLR). The laboratory changes of two groups of survived or non-survived patients were compared by chi-square for categorical variables. An independent sample t-test was applied to study the differences between the two groups' continuous variables. Values are shown as mean±SD.
    Results: Of all the 192 patients, 123 (64.06%) were male, and 69 (35.93%) were female. The survived group was 86 (44.79%), and the non-survived group was 106 (55.20%). Age (62.31±13.77), sex, and BMI (27.34±4.63) were not significantly different in the two groups (P value= .248, .368, and .444, respectively). NLR, lactate dehydrogenase/lymphocyte (LDH/LYM) ratio were significantly different in the two groups (P value= .000, .004, respectively).
    Conclusion: COVID-19 patients have a variety of laboratory findings. NLR and LDH/LYM ratios have a prognostic value in severe COVID-19 patients.

  • XML | PDF | downloads: 45 | views: 62 | pages: 120-125

    Background: Perioperative pain in pediatric population is a special concern and Caudal block is easy to perform extensively safe if used in children, resulting in low pain scores and when combined with general anaesthesia, it reduces the requirement for volatile agents, opioids, improved postoperative analgesia, and earlier extubation. Ultrasound guided caudal block has reduced the complication rates such as inadvertent dural or vascular puncture. Aim of the study was to compare the success rate of ultrasound guided with conventional landmark technique caudal block in pediatric patients undergoing lower abdominal surgery under general anaesthesia.
    Methods: Hundred pediatric patients, ASA class I, age between 6 months to 7 years of either sex, posted for lower abdomen surgery under general anaesthesia were randomly divided in to two groups. In group C- The group with caudal block using conventional landmark technique was used and Group U- The group with caudal block using ultrasound technique was used. Primary objectives of the study to find out the success rate of block in both the groups.
    Results: The demographic data were comparable in group C and group U. Significant difference was seen in the distribution of successful block between group C and group U. (p value 0.008) block was successful in 96% of patients in group U which was significantly higher as compared to group C (76%). significant difference was seen in the distribution of number of attempts between group C and group U. (p value 0.001).
    Conclusion: We conclude that Caudal block by ultrasound technique increases the first puncture success rate, decreases the number of multiple needle puncture attempts and overall success rate when compared to the conventional landmark technique in pediatric patients undergoing lower abdomen surgery.

  • XML | PDF | downloads: 31 | views: 58 | pages: 126-131

    Background: Although sepsis is one of the leading causes of mortality in hospitalized patients, information regarding early predictive factors for mortality and morbidity is limited. The main objective of this study was to identify the outcome of patients with sepsis and septic shock.
    Methods: A prospective observational study was done in a surgical ICU over a period of one year. We included all adult patients admitted to ICU with features of sepsis and septic shock. Data related to demography, co-existing illnesses, parameters to assess Sequential Organ Failure Assessment (SOFA) scores, other relevant laboratory data, source of infection, organ failures and supportive measures instituted were recorded. Patients were followed till discharge or death from the ICU.
    Results: 160 patients were included in this study. The mortality rate was significantly higher among females compared with males. The most common co-existing illnesses were hypertension and type II diabetes mellitus. The SOFA scores at admission were high among non-survivors. Older age, presence of anaemia (defined as haemoglobin less than 13 g/dL in males and 12 g/dL in females), renal dysfunction (creatinine level more than 1.3 g/dL), and acute respiratory distress syndrome (ARDS) were associated with higher mortality. Haematocrit, total leucocyte count, serum bilirubin and SOFA scores were significantly higher among non-survivors.
    Conclusion: Our findings suggest that septic shock occurs frequently in ICU patients and mortality remains high. Several critical scoring systems are useful for the early prediction of mortality. A sepsis mortality based on SOFA scores and haemoglobin has greater predictive power.

  • XML | PDF | downloads: 39 | views: 42 | pages: 132-137

    Background: Pre-oxygenation before induction of general anaesthesia is widely used for enhancing oxygen reserves and preventing hypoxia. Several techniques for pre-oxygenation have been described. This study was designed to compare the PaO2   and ETO2 with single vital capacity breath technique (SVCB) and tidal volume breathing technique (TVB) for adult patients undergoing general anaesthesia.
    Methods: Fifty patients were pre-oxygenated with both techniques - first SVCB then TVB separated by five minutes of breathing room air or till ETO2 & PaO2 values reached baseline values (whichever was later). ABG samples & ETO2 readings were taken before pre-oxygenation & every thirty seconds for three minutes in both techniques.
    Results: Pre-test, mean PaO2 and ETO2 values of both techniques (SVCB and TVB) were similar. In SVCB technique, the mean PaO2 (mmHg) and ETO2 (%) significantly increased at 30 seconds (p ≤ 0.001) from 95.26 and 17.14 (pre-test time) to 304.34 and 92.48 respectively. In TVB technique, an exponential increase was noted. The mean PaO2 (mmHg) and ETO2(%) significantly increased at 180 seconds (p ≤ 0.001) from 96.26 and 16.26 (pre-test time) to 305.64 and 93.08 respectively. Peak values of oxygenation in both groups were similar but achieved at different time points.
    Conclusion: SVCB technique achieves high oxygenation rapidly but is not sustained thus can be used for rapid sequence induction though not recommended for difficult airway scenarios. TVB technique also achieves high oxygenation but steadily. TVB may be used for induction, including, rapid sequence induction but after 3-5 minutes of pre-oxygenation.

  • XML | PDF | downloads: 32 | views: 98 | pages: 138-146

    Background: The effects of anesthetics on memory have not yet been completely clear, and there have been some discrepancies on this issue in the literature. This study aimed to compare the effect of two sedatives, Propofol and Midazolam, on the incidence of cognitive dysfunction in elderly patients undergoing spinal anesthesia.
    Methods: This double-blind clinical trial was conducted on 136 elderly patients‏ who underwent spinal anesthesia in Besat Hospital, Hamadan, Iran, during 2020-21. The patients were randomly assigned into two groups of Propofol (0.2 mg/kg) and Midazolam (0.02 mg/kg). The Wechsler Memory Scale-III (WMS-III) were utilized to assess the cognitive dysfunction and memory coefficient in the two groups.
    Results: There was no significant difference between the two groups in terms of short and long-term memory, as well as cognitive dysfunction before and after spinal anesthesia (P>0.05). The time of onset of sedation (Z=-11.11; P<0.005) and recovery from sedation (Z=-10.56; P<0.005) were longer in the Midazolam group, compared to the Propofol group. There were no significant differences between the two groups before and after operation regarding the WMS-III categories (P>0.05). The comparison of the two groups in terms of memory coefficient after operation showed no significant differences between them in this regard (Z=-0.63; P=0.52).
    Conclusion: Midazolam and Propofol showed no differences regarding the effects on the postoperative memory coefficient or cognitive dysfunction.

  • XML | PDF | downloads: 27 | views: 40 | pages: 147-152

    Background: Lack of understanding regarding labour pain has long been shown to be a burden on both health care providers and expectant mothers. Labor analgesia is still not well established and is undermining in underdeveloped nations. Therefore, the aim of this study was to explore final year medical students' knowledge and attitudes towards pain relief during labor.
    Methods: A cross-sectional study was conducted among final year undergraduate medical students of a tertiary care medical college hospital for 2 months. A Structured, and self-administered questionnaire was used (N = 97). Data was analyzed by using coGuide software, V.1.0.3.
    Results: No statistical significance found in awareness parameters before learning about labour analgesia (P Value >0.05). There was no statistically significant difference between self-grading. However, there was statistically significant difference in different awareness related parameters before and after learning labour analgesia and many showed the improvement in post class response compared to before class response. (P value <0.05).
    Conclusion: The current study revealed that before learning labour analgesia students had lack of knowledge regarding labour analgesia. The awareness class proved to be very effective for students to gain appropriate knowledge about labour analgesia and its importance as a reliable pain relief method.

  • XML | PDF | downloads: 38 | views: 38 | pages: 153-160

    Background: Monitoring the depth of Anesthesia using Entropy modality is essential and resourceful as it allows for more accurate hypnotic drug administration and decreased anesthetic drug consumption and shortens the recovery time. This study was performed to evaluate the effect of entropy monitoring on Sevoflurane consumption in patients undergoing Off Pump Coronary Artery Bypass Graft Surgery.
    Methods: A total of 60 patients of ages between 40 – 70 years and of either sex with American Society of Anesthesiologist (ASA) grade 2 and 3, planned for Off Pump Coronary Artery Bypass Graft Surgery were randomly allocated to two groups in this Randomized Controlled Trial. In the control group i.e. Group B, Sevoflurane was titrated according to changes in clinical parameters (Heart Rate (HR) and Blood Pressure (BP) changes within 20% of baseline values) and in the study group i.e. Group A, Sevoflurane was titrated to maintain State Entropy (SE) values between 40-60 accordingly. Response Entropy (RE) and State Entropy (SE) values were continuously recorded in both the groups but were displayed on the monitor only in the study group and were not displayed to the anesthesiologist in the control group. The entropy values, Sevoflurane Consumption and recovery times were compared amongst the two groups. Patients in both the groups were ventilated on Volume Control Mode of ventilator with 100% oxygen @ 2L/min.
    Results: There were no significant results in terms of age, sex, ASA Grade and NYHA Grade amongst the two groups. Sevoflurane consumption and time of recovery were significantly reduced in the study group i.e. Group A than the Control group i.e. Group B (p value <0.001; Sevoflurane consumption: 7.03±0.67 ml/hr vs 12.42±0.68 ml/hr; Recovery Time 6.47±0.65 hr vs 12.05±1.11 hr). Response and State Entropy values were lower in the control group than the study group (p < 0.001) during the maintenance phase of anesthesia. Systolic Blood Pressure values during skin incision, sternotomy and at the time of completion of all grafts were significantly lower in study group as compared to the control group.
    Conclusion: Monitoring the Depth of Anesthesia using Entropy Monitoring leads to significant reduction in Sevoflurane consumption and significant faster recovery rate from surgery.

  • XML | PDF | downloads: 36 | views: 38 | pages: 161-164

    Background: Pain is a common and challenging problem in burn patients. The severity of pain in these patients often requires multi drug therapy. On the other hand, with increasing the number and dosage of drugs, the complications increase, so finding an instruction that provides acceptable analgesia with minimal complications is necessary.
    Methods: Based on the dose and half-life, the initial dose for paracetamol was 15 mg/kg every 6 hours, this dose was reduced to 30% after three days of initiation of the treatment to prevent liver toxicity and was discontinued after one week. Morphine started with an initial dose of 0.01 mg/kg/h and for opioid-tolerant patients, the initial dose was 0.02 mg/kg/h. Morphine infusion dose raised by 30 percent every week. The continuous intravenous infusion of ketamine (0.15 mg/kg/hr) with continuous intravenous infusion of morphine was administered by a silicone pump.
    Results: The mean NRS was significantly reduced in the first visit after the intervention (three hours later) (8.5 ± 1.04 vs.3.9 ± 1.74; p <0.001) and this decrease was observed in NRS in continuous observations (P> 0.001). Pain reduction was independent of history of opioids use.
    Conclusion: Continuous infusion of ketamine, morphine and paracetamol showed an effective pain management program for burn patients.

  • XML | views: 113 | pages: 165-170

    Background: Video laryngoscopy (VL) and direct laryngoscopy (DL) are two approaches to provide secure airway for patients with compromised airways. This study aims to compare the intubation success rate in video laryngoscopy versus direct laryngoscopy in patients with Philadelphia collars.
    Methods: 172 patients with cervical collars who have undergone general anesthesia were enrolled. After induction of anesthesia for all patients, an oral airway was used to facilitate the ventilation. A VL approach in Group A and DL approach in Group B were used. In order to evaluate the effectiveness of each method, we considered related parameters, including intubation time, the number of intubation attempts, Cormack-Lehane (CL) score, orodental injuries, heart rate, and blood pressure 3 minutes after intubation, oxygen saturation, neck circumference, and BMI.
    Results: The ratio of first-attempt intubations was not different among the two groups (P = 1.00). The mean [SD] time for intubation was shorter with DL vs VL (p<0.0001). There were almost equal rates of CL grades 1 and 2 (67.5% and 29%) using the VL than with the. The mean [SD] mean arterial pressure in VL vs DL was 86.17 mmHg vs 90.88 mmHg (p = 0.086).
    Conclusion: According to our results, there was no significant difference in complications and hemodynamic changes after intubation in both groups, but the intubation duration was significant shorter in DL group.

Review Article(s)

  • XML | PDF | downloads: 30 | views: 42 | pages: 171-177

    Background: The term "outpatient surgery" has become a common procedure in most hospitals around the world. On other hand, Spinal aesthesia can mimic the outcome sought by the principle of outpatient surgeries since it takes a short time to recover and limits the need for post-operative pain medication Therefore, the objective of this study is to focus on finding a method to reduce the side effects that commonly accompany the procedure of spinal aesthesia and to avoid the possible hemodynamic changes that may occur.
    Methods: The method for the study will be a narrative review of various medical journals, conferences papers, and unpublished documents using the dual keywords, outpatient surgeries spinal aesthesia, and ambulatory aesthesia, we include in this research thirty-one original articles, fifty-three reviews articles, two books, three handbooks, and two guidelines searched in the deferent database (google scholar, Research gate, pub med, science direct).
    Results: Consideration should be given to the quality of patients who participate in outpatient concepts. Finally, in terms of cost, side effects, and patient satisfaction, the spinal aesthetic approach gives a favourable outcome since it covers post-operative time without the need for analgesia and reduces the percentage of postoperative nausea and vomiting, and reduces the time staying in the hospital.
    Conclusions: In conclusion, the study discovered that a major proportion of surgeries performed over our lifetimes are outpatient procedures. Therefore, Discharge criteria should be posed with one precise criterion. There is no standard protocol to serve these types of surgeries and patients. The only criteria found and practiced served general conditions for outpatients and inpatients. There have been several attempts to create a protocol that can meet the pleasing outcome of outpatient surgeries. Consequently, we need more research to cover this lack and serve the Genuine needs of a protocol to define the criteria and categories that concern the term outpatient and outpatient surgeries and lead to improving the quality of outpatient surgeries with fewer side effects and minimum hemodynamic changes.

Case Report(s)

  • XML | PDF | downloads: 34 | views: 47 | pages: 178-180

    Since the first wave of COVID-19, different methods for management of COVID-19 ARDS were proposed. Early intubation and mechanical ventilation was performing more than other methods. after several mounths, limitation of equipment in hospitals, made the specialists think of less aggresive methods. NIV was one of suggestion performed before intubation which improve oxygenation of patients. They don't get any sedation and have regular diet. As a result, the need for ICU and ventilator for respiratory support decreases. In this case study, we report a patient that had permanent tracheostomy and hospitalised for COVID-19 ARDS. At first we connected the tracheostomy to a CPAP devise.

  • XML | PDF | downloads: 40 | views: 41 | pages: 181-184

    Spinal anesthesia is traditionally performed using landmark technique to identify the level and point of needle insertion. However use of ultrasonography (USG) has emerged among anaesthesiologists to guide neuraxial blockade. The views that are of utmost importance are “transverse spinous view”, “transverse interspinous view” and “longitudinal parasagittal oblique view”. For in-plane technique and real time imaging longitudinal parasagittal oblique view is used while transverse views are used for visualizing spinous level, epidural and subarachnoid space, posterior complex (PC), anterior complex (AC) and depth of canal. In patients with deformed spine like kyphoscoliosis or morbid obesity obtaining optimum views is not possible. We discuss a morbidly obese patient with very poor ultrasonographic views of spine. We describe a novel technique to estimate depth of spinal canal using only bony shadows in a single transverse view.

  • XML | PDF | downloads: 27 | views: 32 | pages: 185-187

    Wilson’s disease is a rare autosomal recessive condition, that affects the liver and brain mainly. Pregnancy in these patients is of high risk due to involvement of liver and high incidence of abortion, preeclampsia, HELLP syndrome. We report a case of a 24year old G2A1 (35+2 weeks) diagnosed with wilson’s disease 6 years ago, currently on tab zinc. She presented with thrombocytopenia, anemia, extrahepatic portal vein occlusion with splenomegaly and mild ascites. She was taken up for elective section at 35+2 weeks, under general anesthesia. With intramyometrial injection of carboprost, there was sudden desaturation and bronchospasm. However, we managed the case successfully with safe outcome of both the mother and child. There are only very few case reports of Wilson’s disease in pregnancy undergoing C-section under general anesthesia in the presence of hepatic dysfunction.

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