Archives of Anesthesiology and Critical Care

Effect of Different Doses of Ketamine on Fentanyl-Induced Cough

Azim Honarmand — 2024-10-06

Background: Reflex cough is a common complication after fentanyl injection during anesthesia. Several studies have tried different medications to control fentanyl-induced cough (FIC).
Aim: Our study evaluated the effect of different ketamine dosage on preventing fentanyl induced cough.
Methods: We randomly assigned 80 participants into four groups. Group 1 was administered 0.15 mg/kg, Group 2 received 0.2 mg/kg, Group 3 was given 0.25 mg/kg of intravenous ketamine one minute prior to fentanyl injections, while Group 4 received an equivalent volume of 0.9% normal saline.
Results: The incidence and severity of cough was evaluated by FIC score. The incident of cough was significantly lower in Groups 3, 2 and 1 in comparison to Group 4 (0, 5, 30 respectively vs 85, p<0.001). The cough severity was significantly lower in Groups 3, 2 and 1 in comparison to Group 4 (p<0.001).
Conclusion: Intravenous ketamine 0.25 mg/kg, significantly decreased the severity and frequency of cough compared with 0.20 and 0.15 mg/kg IV ketamine.

Comparison of the Effect of Intravenous Atropine and Hyoscine on the Frequency of Oculocardiac Reflex in Scleral Buckling Surgery: A Triple-Blinded Randomized Clinical Trial

Mehryar Taghavi Gilani — 2024-06-23

Background: Oculocardiac reflex is a trigeminovagal reflex that occurs following mechanical manipulation of the orbital cavity. The current study evaluated the preventive effect of atropine and hyoscine on the Oculocardiac reflex in scleral buckling surgery.
Methods: In this triple-blinded randomized controlled clinical trial, a total of 75 patients candidated for scleral buckling surgery were divided into three groups. Intravenous atropine (0.02 mg/kg up to a maximum of 0.5 mg), hyoscine (0.2 mg/kg), and distilled water were injected after intubation for each group respectively with standard monitoring. Heart rate, blood pressure and/or cardiac dysrrythmia were recorded immediately before/after injection and every 10 minutes. Decrease of heart rate more than 20%, or any cardiac dysrrythmia were defined as OCR. P-value <0.05 was significant.
Results: Demographic parameters were not different in three groups. Oculocardiac reflex was observed in hyoscine (34.8%), atropine (31.6%) and control (35.3%) groups (p=0.27). Additive atropine was injected only in two patients of control group. Oculocardiac reflex occurred more in the first ten minutes (35%) and in 30 minutes (55%), and was not observed after 90 minutes. Moreover, atropine and hyoscine increased the heart rate of patients more than control group (P=0.02), but in atropine group was longer than hyoscine group (P=0.03). Systolic blood pressure was not significantly different among the groups.
Conclusion: In this study had been showed that in scleral buckling surgery, atropine is more effective than hyoscine in heart rate increase, but did not reduce oculocardiac reflex more significant than hyoscine and control group. And also oculocardiac reflex was more in first 30 minutes.

Assessing Patients’ Knowledge and Attitude Toward Anesthesia and Its Complications in a Tertiary Center: An Original Study

Parisa Koohsari — 2024-08-27

Background: Anesthesia is a significant development of modern medicine that makes diagnostic and therapeutic procedures with unbearable pain or discomfort feasible. Like most medical procedures, anesthesia is not free of complications. It is shown that many patients suffer from anxiety due to fear of anesthesia complications before operation. Increasing patients’ knowledge of these complications can help them reduce their anxiety. This study aimed to assess the patients’ knowledge and attitude toward anesthesia complications and their relationship with demographic features and previous anesthesia experience to ensure a helpful and informative preoperative visit.
Methods: This is an original study conducted on patients referred to our anesthesia clinic for a preoperative visit, completing a questionnaire about demographic features, previous anesthesia experience, knowledge, and attitude toward anesthesia complications. The results were expressed as frequencies and percentages. T-test, Pearson correlation, and linear regression were used to find the significance of the study parameters.
Results: Four hundred patients entered the study. Patient demographics were as follows: 260 (65.0%) female, 251 (62.75%) high school-graduated or below, mean (SD) age 42.75± 13.62 years. 260(65.0%) patients had previous anesthesia experience. Patients’ mean (SD) knowledge score was 6.83 ± 4.18 out of 19 questions and the mean (SD) attitude score was 54.26 ± 6.59. The patients were most aware of postoperative delirium (72.8%), nausea and vomiting (66.0%), feeling pain during surgery (59.5%), and death (52.3%) as general anesthesia complications. There was a significant relationship between the level of knowledge and the female sex (p-value= 0.03). University education had a significant relationship with knowledge and attitude (both p-values ≤ 0.001). There was a significant correlation between knowledge and attitude (Pearson correlation= 0.461, p-value ≤ 0.001), as well.
Conclusion: Unfortunately, the knowledge about anesthesia complications in outpatients referring to our tertiary care center was poor. Women and university-educated patients had a higher level of knowledge. In contrast, most patients had a positive attitude toward anesthesia which was significantly higher in university-educated patients. It is shown that with the increase in the level of knowledge, attitude scores increased as well.

Comparison of Electronic Learning Versus Discussion-Based Learning Methods on Learning Rate of Medical Students about Sedation in the Emergency Room: An Analytical Descriptive Prospective Study

Aidin Zeinaly — 2024-06-22

Background: The aim of the present study was to compare the effectiveness of two teaching models (e-learning and discussion-based learning) on the learning process of emergency department interns in relation to the use of the sedatives.
Methods: In this study, 129 interns introduced to the emergency medicine department were included in the study. These interns were randomly divided into two groups, I and II. For both groups, a pre-test based on standard parallel multiple-choice questions (MCQs) was prepared. Then, the electronic software which was prepared was distributed to the first group. For people of group II, six hours of discussion-based training was conducted for 3 consecutive weeks. At the end of the course (after 1 month), a post-test, which was the same questions as the pre-test, was obtained from interns in both groups.
Results: At the end of the study, we found a significant improvement in the learning rate of both groups all aspects of the knowledge including: science related to the use of narcotics in sedation (P=0.01 for e-learning group and P<0.001 for discussion based group), knowledge related to the use of intravenous anesthetics for sedation(P=0.025 for e-learning group P<0.001 for discussion based group), Knowledge related to definition and clinical judgments in sedation and Knowledge related to the use of Neuromuscular blocking agents (NMBAs) for sedation (P<0.001 for both groups). However, for all the investigated results, the learning rate was significantly better in the discussion-based learning group compared to the e-learning group (P<0.001).
Conclusion: According to the results of this study, we found using either e-learning or discussion-based learning methods increase the acquisition of sedation knowledge for emergency department students. However, the discussion-based method have better results on the learning process of the interns.

Evaluation of Depression, Anxiety and Stress Scores in Patients with Covid- 19: A Cross-Sectional Study

Hamed Abdollahi — 2024-08-27

Background: The COVID-19 pandemic is a traumatic event with a global impact, predicted to increase depression, anxiety, substance use, sadness, and loneliness. This study was conducted to evaluate the scale of depression, anxiety, and stress among patients infected with the COVID-19 virus.
Methods: This cross-sectional study was conducted between April 2019 and April 2022. According to the conditions of the study space, available sampling was selected. In addition to demographic characteristics, a questionnaire related to stress, anxiety, and depression (DASS-21) was used to collect data. Then, the collected data were entered into SPSS software for analysis, and Pearson's correlation was used to check the relationship between the variables, with the significance level (P-value) reported.|
Results: Out of a total of 714 participants, 26.1% had higher scores in depression, 37.5% in anxiety, and 15.7% in stress. In this way, two-thirds of the studied population on the depression and anxiety scale and almost half of the studied population on the stress scale experienced degrees of these disorders from mild to very severe during the period of COVID-19 infection. The scores of each subcategory of depression, anxiety, and stress are significantly correlated with each other, which shows that people who have a higher score in one subcategory also have a higher score in two subcategories.
Conclusion: It seems that COVID-19 has an obvious effect on the mental health of people. Thus, more policies and attention are needed in this field to manage the disease.

A Comparative Study of the Effect of Adding Dexmedetomidine, Dexamethasone and Sodium Bicarbonate to Ropivacaine in Ultrasound Guided Supraclavicular Block on the Quality of the Block in Orthopedic Surgery

Mohammad Golparvar — 2024-06-19

Background: Brachial plexus block, particularly the supraclavicular approach. The choice of local anesthetic and the addition of adjuvants can significantly impact the quality and duration of the block. This study aimed to compare the effects of three different additives dexmedetomidine, dexamethasone, and sodium bicarbonate when combined with ropivacaine in ultrasound-guided supraclavicular blocks.
Methods: A double-blind randomized clinical trial was conducted with 103 patients undergoing upper limb orthopedic surgery. Patients were divided into four groups, and each group received one of the following combinations: ropivacaine with dexmedetomidine, ropivacaine with dexamethasone, ropivacaine with sodium bicarbonate, or ropivacaine alone (control). The onset and duration of motor and sensory blocks, complications, patient and surgeon satisfaction, and vital signs were assessed.
Results: The study revealed that all additives, particularly dexmedetomidine, significantly influenced the onset and duration of motor and sensory blocks compared to the control group. Dexmedetomidine demonstrated the fastest onset and prolonged the block, while dexamethasone and sodium bicarbonate also had substantial effects. Importantly, the additives did not lead to an increase in complications, and patient and surgeon satisfaction remained consistent across all groups.
Conclusion: The findings of this study suggest that dexmedetomidine is a promising adjuvant for enhancing the quality and duration of supraclavicular blocks.

Comparison of Clinical Results of Pulsed Radio Frequency and Mixed Injection of Corticosteroid and Local Anesthetic in Patients with Shoulder Impingement Syndrome

Arman Taheri — 2024-07-06

Background: Shoulder impingement syndrome is a clinical situation that presenting with shoulder pain, difficultly and weakness. Present study designed for evaluating the effect of radiofrequency and corticosteroid injection in longterm treatment follow up for pain reduction and functional evaluation of shoulder joint.
Methods: Sixty patients were analyzed equally in two treatment groups. Post-treatment follow up at one, four and twelve weeks after procedures were carried out using Visual Analog Scale (VAS) for pain relief, Shoulder Pain and Disability Index (SPADI) for shoulder function and Beck Depression Inventory (BDI).
Results: Both treatment groups showed significantly pain reduction (P-value<0.001 for both) in 4 weeks after procedures. In time point comparison between 4 to 12 weeks postoperatively, there were significantly reduced pain in R group (P=0.03), but not significant in C group (P=0.1). Total SPADI score was significantly lower in RF group in time points 1 and 4 weeks (P<0.001), but not significant in 12 weeks of follow up.
Conclusion: Radiofrequency could not be sufficient alone for retrieving function of the shoulder at the long periods of time after procedure, unless good and effective results for first 1 and 4 weeks of follow up.

Evaluation of Oral Pregabalin Premedication for Attenuation of Haemodynamic Response during Tracheal Intubation in Adult Patients with Controlled Hypertension For Elective Surgery

Surabhi Sandill — 2024-09-08

Background: The laryngoscopy and tracheal intubation is a noxious stimuli resulting in transient but marked sympathetic response. This response is exaggerated in patients with hypertension. This study evaluated the role of oral pregabalin premedication in attenuation of haemodynamic response during tracheal intubation in adult patients with controlled hypertension posted for elective surgery.
Methods: A prospective double blinded randomized study was carried out in a total of 60 adult patients (aged 18-65 years, either gender) with controlled hypertension after being randomized into two groups with 30 patients in each. Prior to induction, Group PL received Placebo (multivitamin) and Group PB received pregabalin 75mg tablet 1 hour. The anaesthesia technique was standardized as per department protocols. Both groups were evaluated for pre-operative sedation, haemodynamic changes after premedication, before and after induction, after the laryngoscopy and tracheal intubation and post-operative side effects.
Results: There was attenuation of haemodynamic responses without significant side effects with pregabalin. Statistically significant increase in post intubation systolic, diastolic and mean blood pressure was seen in group PL as compared to group PB. In both groups, a reduction in heart rate was observed and was statistically significant 1 minute after intubation in group PB. Pre-operative sedation levels were higher in PB group in comparison to PL group. No post-operative side effects observed in both the groups.
Conclusion: In controlled hypertensive patients, oral pregabalin 75 mg attenuated the haemodynamic responses to laryngoscopy and tracheal intubation. It produced effective pre-operative sedation without any post-operative side effects.

Can Cerebral Oximetry Near-Infrared Spectroscopy Strategy in Hypothermic Cardiopulmonary Bypass in Congenital Cardiac Surgery be Considered an Advanced Nursing Practice?

Maryam Shakiba — 2024-06-19

Background: The importance of cerebral perfusion during congenital cardiac surgery, especially after hypothermic cardiopulmonary bypass (CPB) strategy, has remained a debate. In this study, we evaluated the effect of mild hypothermic CPB strategy on cerebral oximetry near-infrared spectroscopy in congenital heart defects surgery.
Methods: In a randomized prospective study, the pediatrics aged two months and six years with RACHS categories I-Ⅱ for congenital heart defects surgery were randomly divided into normothermic and mild hypothermic CPB groups. The NIRS was measured in all patients via the INVOS ™ cerebral oximetry system. The perfusion and anesthesia strategies during the study were followed as standard methods. A p-value below 0.05 is considered to be a significant level.
Results: Regarding cerebral oximetry, the results showed no significant difference between normothermic and mild hypothermic CPB groups.
Conclusion: It can be concluded that optimizing cerebral oxygen saturation monitoring during congenital cardiac surgery can improve patient outcomes as a protective strategy.

The Effect of Preoperative Metformin on Postoperative Hyperglycemia in Non-Diabetic Patients: A Randomized Clinical Trial

Arash Peyvandi Yazdi — 2024-07-06

Background: Blood glucose control during surgery can decrease the infection, disability, and death rate. The purpose of this study was to determine the effect of preoperative metformin on blood glucose levels in nondiabetic orthopedic surgery.
Methods: This clinical trial was conducted on 176 nondiabetic patients with ASA class I or II who were candidates for orthopedic surgery. The patients were randomly divided into two equal groups. The metformin group received 500 mg metformin tablet orally and the placebo group received placebo tablet 30 minutes before the surgery. Blood glucose was measured every 6-hour to 24 hours and blood urine nitrogen (BUN), creatinine was measured preoperatively and the day after surgery. The data was analyzed by SPSS v21 and P value<0.05 was significant.
Results: Demographic characteristics such as age, sex and body mass index (BMI) had no significant difference in two groups. Creatinine and BUN were similar in two groups. Preoperative blood glucose was 101.8±22.6 mg/dl in the metformin group and 109.7±24.8 mg/dl in the control group without significant difference (p=0.08). However, BS at hours 6, 12, showed a significant difference between the two groups (p<0.001, 0.022) and then blood glucose was similar in two groups (0.8, 0.12 respectively).
Conclusion: Preoperative metformin (500 mg) was effective for blood glucose control in nondiabetic patients undergoing orthopedic surgery. However, additional research is required to determine the efficacy of this therapy.

The Effect of Training Based on the SCORPIO Model on the Knowledge and Skills of Airway Management Peri-Anesthesia Induction in Undergraduate of Nursing Anesthesiology Students

Masoumeh Albooghobeish — 2024-05-24

Background: Using novel educational methods in teaching medical sciences is very important. The SCORPIO model is one such method that can be used as an interactive educational station and a combination of other educational methods. The purpose of this study was to determine the effectiveness of the SCORPIO model in the acquisition of knowledge and skills of airway management during peri-anesthesia induction among undergraduate nursing anesthesia students.
Methods: The present study was a randomized controlled study with a pre-test-post-test design including an intervention and a control group. The participants were undergraduate nursing anesthesia students studying in the 3rd and 5th semesters. Sixty students were selected using convenience method and were randomly assigned to intervention and control groups. In order to collect data, a researcher-made questionnaire was used to assess the students’ knowledge and an OSCE test to assess their skills. The intervention group attended three 2-hour training sessions where the knowledge and skills of airway management during peri-anesthesia induction was taught using the SCORPIO model. The control group, on the other hand, received the same content through conventional teaching methods including lectures and the use of manikins in three 2-hour sessions.
Results: There was no statistically significant difference between the two groups in terms of demographic characteristics (p<0.05). The mean score of students' knowledge of airway management during peri-anesthesia induction before the intervention was (1.83) 12.47 in the intervention group and (1.71) 12.63 in the control group. Also, the mean score of students' skill of airway management during peri-anesthesia induction before the intervention was (1.44) 12.07 in the intervention group and (1.43) 12.43 in the control group, which indicated no statistically significant difference according to independent t-test (p=0.71 and p=0.32, respectively). After the intervention, however, the results of the paired t-test showed a statistically significant difference between the two groups in terms of the knowledge and skill scores, with the students in the intervention group obtaining higher scores of knowledge and skills (p<0.001), while this was not the case in the control group (p=0.26 and p=0.64, respectively).
Conclusion: The SCORPIO model improves the knowledge and skills of airway management peri-anesthesia induction in undergraduate nursing anesthesia students

Comparison of the Impact of Atracurium and Cisatracurium on the Neutrophil-To-Lymphocyte Ratio in Addition to Hemodynamic Changes during Anesthesia Induction

Behzad Nazemroaya — 2024-06-19

Background: Muscle relaxants are used for two general purposes. One is to ease endotracheal intubation, and the other is provide surgical relaxation.
This study has been designed with the aim of assessing the impact of atracurium and cisatracurium on patients at the anesthesia induction and the neutrophil to lymphocyte ratio.
Methods: This is a randomized clinical trial that was performed in 2022-2023 in Kashani hospital in Isfahan, Iran on patients that were candidates for elective surgery under general anesthesia by atracurium or cisatracurium. A total number of 80 patients entered and were randomized into two group’s one receiving group atracurium 0.5mg/kg, and other group received cisatracurium 0.15mg/kg over 60 seconds as NMB. Blood sample were taken base time, after 3, and 20 minutes following intubation. Qualitative data is reported as frequency with percentage. And quantitative data as average with standard deviation. Statistical analysis was done using SPSS version 25. Qualitative data were analyzed using chi-square tests and quantitative data using independent T test. Significance level was defined as p value <0.05.
Results: Overall, 80 patients were enrolled in this study. 40 of them belonged to the cisatracurium group and 40 to the atracurium group. Average age of the participants was 42.86 (±14.52) years old. Mean arterial pressure (MAP) in cisatracurium group dropped significantly following intubation (p<0.005), while it rose significantly in the atracurium group (p<0.05). However neutrophil to lymphocyte ratio (NLR) was significantly higher in the cisatracurium group following intubation (P<0.05).
Conclusion: While the use of atracurium in patients is still safe, is yet more correlated with pronounced hemodynamic instability compared to cisatracurium.

The effects of heparinized normal saline flushing and prophylactic enoxaparin on central venous catheter thrombosis in PICU hospitalized pediatric

Maryam Mohebbi — 2024-07-31

Background: Central venous catheter (CVC) thrombosis is one of the most common complications of CVC that occurs in children and adults. Prevention of this blockage improves the treatment process and reduces treatment costs. Due to the lack of studies on preventive methods of CVC thrombosis, this study aimed to examine the effect of NS flushing heparinized and prophylactic dose of enoxaparin in prevention of CVC induced thrombosis in hospitalized patients in pediatric intensive care unit (PICU).

Methods: Eighty pediatrics with Central venous catheter admitted to the PICU enrolled in this trial and were divided into two groups as receiving heparinized normal saline was flushed every 8 hours under sterile conditions and receiving enoxaparin trough injection subcutaneously every 12 hours. The incidence of CVC-related thrombosis, diagnosed using color Doppler ultrasound of the vein containing the catheter was measured. Patients were monitored daily in terms of clinical symptoms related to thrombosis.

Results: There was no statistically significant difference in gender, age, anthropometric findings and vital sign as well as risk factors between two groups of the trial (P>0.05). Additionally, the finding showed a statistically significant relationship between major surgery (P=0.01) and heart disease (P=0.03) with symptomatic and asymptomatic thrombosis between the enoxaparin and heparinized normal saline groups. The rate of sepsis and bleeding were lower in enoxaparin group but it was not significant between study groups.

Conclusion: These findings indicate that enoxaparin may be considered as a clinical approach in thrombosis management and more clinical trials are needed.

The Importance of Pre-Anesthetic Evaluation in Patient Safety: A Systematic Review

Shahnam Sedigh Maroufi — 2024-08-03

Background: Pre-anesthetic evaluation is the initial stage of anesthesia procedures for patients. This evaluation involves elucidating the patient's medical history, determining patient readiness, screening for undisclosed disorders, and identifying risk factors. Safety measures help mitigate patient-related risks within medical environments. The aim of this study is to investigate the role of Pre-anesthetic evaluation in patient safety.
Methods: The present study was a review conducted in the year 2024. Databases including PubMed, Direct Science, MEDLINE, Proquest, SID, Scopus, Google Scholar, Magiran, and library resources were searched using keywords such as Pre-anesthetic evaluation, pre-anesthetic visit, anesthesia clinic, patient safety, and their English equivalents. A logical combination of these keywords was performed using "OR," "AND," and "NOT" operators. The search was conducted in relevant articles from the year 2000 to January 2024.
Results: Initially, 22,000 articles were screened, and ultimately, 16 relevant articles were used for preparing this paper. In all the reviewed articles, pre-anesthetic evaluation played a key role in patient safety.
Conclusions: Studies indicate that pre-anesthetic evaluation is a key improver of surgical outcomes. These measures not only mitigate potential risks but also enhance surgical outcomes. Overall, pre-anesthetic evaluation has a direct correlation with patient safety, playing a significant role in postoperative improvement and elevating the quality of medical care.

Selection Spinal Anesthesia Against an Unusual Finding: A Case Report Hairy Patch

Alireza Babajani — 2024-05-15

A 34-year-old woman was admitted for an emergency cesarean section at 38 weeks of pregnancy. She had no previous surgeries or illnesses. During the pre-operative evaluation, the anesthesia team noticed that the patient had not fasted. However, they decided to use spinal anesthesia for the emergency procedure. While preparing for the spinal examination, they discovered a large mass of hair covering the 3rd, 4th, and 5th lumbar vertebrae. Despite the emergency situation, the absence of fasting, and the risk of aspiration, the anesthesia team carefully considered all aspects of the patient's safety and decided to proceed with spinal anesthesia.

Intraoperative Difficult Airway Management in Patient with Pan Facial Fracture Using Airway Manoeuvre Involving Fiberoptic Intubation and Submental Intubation

Sumedha Mehta — 2024-07-30

Intraoperative Airway management of Pan facial fracture is always challenging due to difficult airway resulting from airway trauma and airway sharing between the anesthesiologist and maxillofacial surgeon. Submental intubation is considered a good alternative technique over tracheostomy for providing a clear field intraoperatively for maxillofacial fracture fixation. We want to discuss airway management maneuvers using Awake fiberoptic bronchoscope-assisted intubation and submental intubation technique and the challenges we faced in a patient presented with Pan- facial fracture with difficult airway posted for surgery.

Molar Pregnancy- A Snowstorm Encounter: A Case Report

Jyoti P Deshpande — 2024-06-21

Gestational trophoblastic disease (GTD) is a cluster of tumors which often had a lethal outcome in the past. As the years have passed, with better understanding of the pathophysiology fatalities have reduced and patients have been cured. On an anesthetic stand point these cases can be challenging to manage due to the emergency nature of the surgery and various systemic complications they may present with. We present to you a case of a 29-year-old female with molar pregnancy managed by spinal anesthesia.

Occurrence of Total Spinal Anesthesia after Caudal Anesthesia in a Newborn Patient: A Case Report of a Challenging Complication

Alireza Babajani — 2024-05-02

A 2-month and 13-day-old boy underwent surgery for a right inguinal hernia. During the procedure, a caudal block was performed using 4 mL of 0.25% bupivacaine injected with an epinephrine-soaked syringe. Before the injection, we confirmed that there was no blood or cerebrospinal fluid present. However, shortly after the injection, the patient experienced respiratory apnea and a slow heart rate. The medical team provided respiratory and cardiac support and closely monitored the patient. After a day and a half, the patient was discharged with no further complications.

Anesthesia Management of a Child with Mosaic Trisomy 22 for Adenotonsillectomy Surgery

Masoud Tarbiat — 2024-07-30

Mosaic trisomy 22 is a very rare autosomal anomaly with variability of organ malformations and developmental defects. There are fewer than 23 reports in the literature of live born children describing their neurodevelopmental outcome. Sometimes in clinical practice, anesthesiologists confront a rare clinical case with no paper published on it or having previous experience about it. Therefore, they face a serious challenge in anesthesia managing and selecting drugs for them (like our case). So, we reported our experience about a child (aged 8) with mosaic trisomy 22 who had anesthesia for adenotonsillectomy surgery. Previously, he had a history of seizure and variety of surgeries for congenital anomalies. He also had been treated for congenital hypothyroidism and gastroesophageal reflux disease. The anesthesia performed with midazolam, fentanyl, sodium thiopental, atracurium and isoflurane in O2:N₂o (50:50). The operation was uneventful and he was completely awakened in recovery room. This report emphasizes that in some situation, this approach could be used safely for anesthesia management in these patients.