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: Transverse abdominus plane (TAP) block is a regional anesthetic technique which provides an excellent analgesia without major adverse effects. The primary aim of this study was to evaluate the efficacy of dexmedetomidine in comparison to tramadol when added as adjuvant to levobupivacaine in TAP block on duration of post operative analgesia following laproscopic orchidopexy.
Methods: Sixty American Society of Anaesthesiologists (ASA) grade 1 pediatric patients undergoing laproscopic orchidopexy under general anaesthesia were randomized into two groups (GroupLD and Group LT). Group LD recieved ultrasound guided bilateral TAP block with 0.3 ml/kg 0.25% levobupivacaine with 1µg/ kg of dexmedetomidine on both sides and Group LT recieved TAP block with 0.3 ml/kg 0.25% levobupivacaine with 1mg/ kg of tramadol. During the first 24 h postoperatively, we assessed hemodynamic stability, respiratory depression, and postoperative pain using face, legs, activity, cry, consolability (FLACC) pain scale.
Results: Total duration of analgesia (986.67 ± 47.29 min vs. 690 ± 53.49 min, P value- 0.000), and the total consumption of paracetamol in the first 24 hours postoperatively (324.28 ± 35.5 mg vs. 580.14 ± 38.23, P value – 0.000) were statistically highly significant in group LD in comparison to group LT. The FLACC score were lower in Group LD as compared to group LT and side effects profile were similar in both the groups.
Conclusion: Dexmedetomidine in a dose of 1 μg.kg-1 when added to levobupivacaine in ultrasound guided transverse abdominus plane block significantly prolongs the duration of postoperative analgesia as compared to tramadol with levobupivacaine without major side effects.
Background: Arterial Blood Gas (ABG) analysis is a commonly ordered test to investigate respiratory, circulatory, and metabolic status in traumatic patients with inappropriate perfusion and ventilation situations. Difficult sampling, hemorrhage risk of arterial puncture, and other vascular complications lead us to use saliva sampling as a safer non-invasive approach to evaluate PaO2, PaCO2, pH, and HCO3 values.
This study was aimed to evaluate the correlation of PaO2, PaCO2, pH, and HCO3 values between ABG and saliva gas in traumatic patients under mechanical ventilation.
Methods: This was a retrospective cross-sectional study of 18-85-year-old traumatic patients under mechanical ventilation conducted in an academic medical hospital. They were investigated based on age, sex, and ABG values as well their saliva gases values. The Paired t-test, Pearson χ2, and Pearson correlation were used to evaluate the correlation between the gases values in ABG and saliva. Data were analyzed using Mann–Whitney U test and Kolmogorov–Smirnov test.
Results: There were 120 patients including 53 men and 67 women enrolled. None of the factors of arterial and salivary gases were significantly different between men and women. And the amount of these factors is homogeneous in both groups (P <0.05). The mean factors of arterial PaCO2 and HCO3 and saliva PaCO2 and HCO3 were significantly different between smokers and non-smokers.
Conclusion: The values of salivary gases correlated with these of ABG. This can expand the use of salivary gases analysis as an alternative to ABG analysis in clinical settings to reduce the logistic burden of arterial sampling as well as to better perform ventilator device settings. These results were aligned with previous studies.
Background: Patient satisfaction is one of the main quality indicators of anesthesia services. Various factors can determine patient satisfaction, such as anesthetist-patient interaction, perioperative anesthetic management, and postoperative follow-up. The aim of this study was to assess patient satisfaction with anesthesia services and its associated factors.
Methods: An Institutional based cross-sectional study was conducted from July 2019 to October 2019 at a teaching hospital in South India. Patients who have undergone surgery by either general or regional anaesthesia were included. For postoperative interview, a structured questionnaire was administered. The satisfaction score was considered to be an outcome variable. Age, gender, ASA status, and type of anesthesia were considered to be explanatory variables.
Results: A total of 462 patients were included in the study. The mean age of the study population was 41.84 (±13.48 SD) years. Males were found to have statistically higher mean satisfaction scores as compared to females. The mean satisfaction score among the patients with combined anesthesia (general anesthesia in addition to regional anesthesia) was significantly higher as compared to patients with GA, CNB, and PNB (p<0.05). There was a significant difference in the degree of satisfaction with induction, intraoperative pain relief, and pain relief in the postoperative period among patients with different types of anesthesia (p<0.05). 39.2% of patients were dissatisfied with the self-introduction of anesthetists, and 17.7% were dissatisfied with anesthetist revisit in postoperative period.
Conclusion: Poor self-introduction of anesthetists, absence of postoperative revisit by the anesthetist, and lack of proper planning for postoperative pain relief contributed a major part to the dissatisfaction.
Background: The study is a double-blind randomized trial aiming to compare intravenous midazolam and dexmedetomidine as premedication for sedation and anxiety control in controlled hypertensive patients undergoing elective surgery under general anaesthesia.
Methods: The patients who met the inclusion criteria were randomly divided into two groups of 50 patients each. Thirty minutes prior to induction, Group 1 patients received midazolam 0.02mg/kg i.v and Group 2 patients received dexmedetomidine 1mcg/kg i.v in 100 ml normal saline over 10 minutes. Preoperative sedation and anxiety levels and vital parameters (heart rate, blood pressure, respiratory rate, arterial oxygen saturation) were assessed for 30 min at every 5 minutes interval.
Results: Preoperative sedation was found to be better with dexmedetomidine as compared to midazolam. Decrease in anxiety was comparable in both the groups. Significant fall in heart rate was observed in dexmedetomidine group but it was within the acceptable limits for age. Mean arterial pressure was comparable in both the groups. There was no statistical difference between the groups with respect to respiratory rate and arterial oxygen saturation.
Conclusion: Dexmedetomidine provides better sedation and good anxiety control with better maintainence of hemodynamic parameters as compared to midazolam. Thus it is a safe and effective drug to be used for premedication in controlled hypertensive patients.
Background: Non-invasive mechanical ventilation is one of the most used organ support measures in critical care medicine. Hemet interface has been implemented in everyday practice at ICUs later than classic means of delivery for NIV including face mask. We used helmet interface for first time at ICU and recorded CPAP setting and outcome.
Methods: Helmet was used for 9 patients and any complication or side effects were recorded. Also nurses first experience of using the helmet has recorded in a survey.
Results: No skin lesion, vomiting, and air leaking were recorded. Also none of the patients complained about claustrophobia, dyspnea, pain, or feeling hot while the helmet was in use. In addition, nursing was easier while using a helmet than it was with face mask.
Conclusion: The overall first time use of helmet interface in our department gave us a positive feedback, but more data need to be collected for more effective way of applying NIV and specifically helmet interface.
Background: The complexity of Second-stage caesarean is due to its deep engagement of the fetal head. 2nd stage cesarean section is also associated with increased maternal and neonatal complications.
To see how caesarean sections done in the second vs first phases of labor affect maternal and perinatal outcomes.
Methods: It was a one-year observational research that took place in our hospital. This study enlisted the participation of 300 women. For various reasons, 100 women received second-stage caesarean sections, whereas 200 women got first-stage caesarean sections.
Results: Women who had a caesarean birth in the second stage of labour had a higher risk of maternal morbidity, according to our findings. Fetal injury during birth (5.5 percent vs. 2.0 percent), FSB (4.5 percent vs. 2.25 percent), admission to the neonatal intensive care unit (18.0 percent vs. 12.5%), neonatal sepsis (3.5 percent vs. 1.5 percent), and early neonatal mortality (3.5 percent vs. 1.5 percent) were all higher (2.0 percent vs. 2.25 percent).
Conclusion: The most common complications associated with 2nd stage caesarean delivery were intraoperative bleeding, adhesion, bladder damage, caesarian hysterectomy, perinatal hypoxia, FSB, birth trauma, NICU hospitalisation, and poor Apgar score.
Background: Cardiopulmonary bypass (CBP) prime solution in pediatric heart surgeries is critical to avoid adverse effects resulting from dilution of coagulation factors, red blood cells, and other plasma protein. This study aimed to evaluate clinical and laboratory outcomes of administration of albumin and fresh frozen plasma (FFP) in CPB prime solution in children candidates for arterial switch surgery.
Methods: This cross-sectional study was performed on 30 transposition of the great arteries (TGA) patients, candidates for the arterial switch in Tehran Children's Medical Center, Iran. As CBP prime solution, 15 patients received albumin (1 gr/kg Albumin 20%) and 15 patients received FFP (15 cc/kg). also, clinical and laboratory parameters were measured in different intervals. The statistical analysis were performed by SPSS v.20.
Results: The volume platelet infusion in the ICU was higher in FFP-received patients (40.00 ±20.70 ml) than albumin-received patients (26.67 ±25.82 ml; p-value =0.01). Upon entry into ICU, the mean of Hb and Hct in FFP-received patients (11.55 ±0.64 g/l and 34.44 ±2.44 %) was significantly higher than patients who received albumin (11.08 ±0.87 g/l and 31.44 ±3.97 %; p-value =0.04 for both). Upon entry into ICU and also 48 hours after admission into the ICU, the Cr level in the FFP-received group (median: 19 mg/dl) was significantly higher than the albumin-received group (median: 12 mg/dl; p-value =0.03).
Conclusion: FFP in CPB prime solution reduces the hemostatic complications and infusion of blood products, as well as to stabilizes Hb and Htc. Therefore, FFP is more suitable as CPB prime solution.
Background: Postsurgical pain following laparoscopic cholecystectomy is often associated with delayed recovery and discharge from the hospital. Magnesium sulphate as an adjuvant has shown a potential role as an anti-analgesic drug perioperatively. However, the data on the effectiveness and safety of magnesium sulphate delivered via two distinct routes (intravenous and intraperitoneal) for postoperative pain management is scant.
Methods: This prospective randomized controlled trial was conducted on 80 adult patients. Group A (n=40) received 30ml intravenous magnesium sulphate(50mg/kg) and 30ml 0.25% bupivacaine intraperitoneal infiltration. Group B (n=40) received 30ml intraperitoneal infiltration of magnesium sulphate(50mg/kg) along with 0.25% bupivacaine and 30ml intravenous 0.9% normal saline infusion. Postoperative pain-free duration, pain scores (visual analog score), need of rescue analgesia, intraoperative hemodynamics and postoperative complications were noted.
Results: The Visual analogue scores at 1,2,4 and 6 postoperative hours were 1.75±0.78, 1.33±0.66, 0.60±0.50, 0.45±0.55 in Group B and 2.13±0.61, 1.65±0.62, 1.28±0.88, 0.73±0.51 in Group A respectively (P-value-0.02,0.03,0.00 and 0.02). The time of the first request for rescue analgesia in Group A was 37.09± 5.54 and in Group B 52.00±4.30 (P value-0.00). Mean heart rate, systolic and diastolic blood pressure were significantly lower in Group A compared to Group B (P-value<0.05). Extubation and emergence time was significantly higher in group A compared to Group B (P-value -0.00). The Abbreviated mental test (AMT)-4 cognition scores were similar in both groups while Alert, Voice, Pain and Unresponsive (AVPU) sedation score was higher at the first postoperative hour in Group A (1.30± 0.46) compared to Group B (1.10 ± 0.30) (P value- 0.026).
Conclusion: Intraperitoneal magnesium is a safe and efficient means of controlling postoperative pain. Additionally, it decreases the time required for emergence and extubation as compared to intravenous delivery. Intravenous magnesium has better hemodynamic control in perioperative period.
Background: Environmental factors such as the lighting of the scene, time of the day, and physical surrounding of the patient and healthcare providers in the prehospital setting can affect difficult intravenous access (DIVA). The study aimed to evaluate the association of environment, patient, and emergency medical services (EMS) technicians on the DIVA in the prehospital setting.
Methods: Six-hundred adult patients (aged ≥18 years) who necessitated prehospital peripheral IV access and were transferred to the Sina and Shariati hospitals by EMS technicians from June 2018 to October 2018 were included. There were seven research nurses for interviewing the EMS technicians. Patients were examined using the prepared checklists.
Results: Overall, there were 125 (20.83%) DIVA cases. There was a significant relationship between DIVA and the higher respiratory rate of the patients, lower the blood pressure of the patient, prior cannulation of the targeted limb, time since the last meal of EMS technician, and untidiness of the environment (Odds Ratio=1.75, 1.3, 9.4, 3.84 and 7.01, respectively).
Conclusion: The results showed fasting of EMS technicians affects DIVA and the study suggests it can be resolved by proper scheduling of the working hours of EMS technicians. Also, some risk factors of DIVA can help the paramedics to predict the DIVA and take the necessary measures.
Background: Anaesthesiologists most commonly perform the procedure of internal jugular vein cannulation(IJV) in emergency and also in elective cases. With the use of ultrasound guidance placement of guide wire and catheter into the internal jugular vein has been made easy, safe and with less complications.
Aims: The aim of the study was to compare IJ vein cannulation under ultrasound guidance with respect to Short and Long axis (SA and LA) view approaches.
Methods: Patients who may require central venous cannulation for undergoing surgery and will be in intensive care unit were randomized using computer generated randomization for ultrasound guided cannulation into one of short axis and long axis (SA and LA) approaches group. Success rate of first pass, number of needle attempts made, guide wire insertion time, catheter placement time and complications were noted for each procedure.
Results: Successful cannulation of IJV was achieved in all the patients. Significant results were not noted among the two groups with respect to demographic profile of the patient, catheter placement time, rate of carotid artery puncture. Whereas a significant result was noted in terms of success rate of first pass (97% in SA v/s 53% in LA, P-0.0001), number of needle attempts (mean of 1.05±0.18 in SA v/s 1.55±0.68 in LA, P-0.0001), guide wire insertion time (mean of 43.20±5.64 in SA v/s 74.83±39.36 in LA).
Conclusion: We conclude from the above study that short axis view approach is better with respect to success rate of first pass, number of needle attempts and guide wire insertion time than long axis view approach for internal jugular vein cannulation under ultrasound guidance.
Aplastic anemia is rare hematological disorder with approximate incidence 1.5-7 cases per million individuals per year. Osteonecrosis, a frequently seen in patients with aplastic anemia. With improved treatment modalities, the life expectancy of patients with aplastic anemia has increased considerably, so are the patients undergoing surgery for various pathologies. Due to rarity of the diseases, there are no specific formulated guidelines on the anesthetic management of these patients. Here, we describe successful anesthetic management of a young male patient with aplastic anemia who was posted for bilateral hip surgery.
Diabetes mellitus is a metabolic disorder of multiple etiology characterized by chronic hyperglycemia with disturbances in carbohydrate, fat and protein metabolism, due to defect in insulin secretion, insulin action or both. Complications of Diabetes mellitus are macrovascular (coronary artery disease, peripheral vascular disease), microvascular (diabetic nephropathy, neuropathy and retinopathy), electrolyte and metabolic derangements. Foot ulcer is a common complication of diabetes mellitus with deranged Blood Sugar Level, which needs debridement or amputation. As central neuraxial block is contraindicated and general anaesthesia is risky in our patient due to coagulation abnormalities, anaemia, sepsis and left lung pneumonia. Hence, we planned for femorosciatic block.
Inherited defects of Uridine 5'-diphospho-glucuronosyltransferase (UDPGT) can cause congenital unconjugated hyperbilirubinemia. The perioperative anesthetic management of such patients poses several challenges. Here we report a case of bilateral carcinoma breast with congenital unconjugated hyperbilirubinemia posted for bilateral modified radical mastectomy. The patient was administered general anesthesia with no perioperative deterioration of liver function.
Recent scientific studies support the safe use of lidocaïne with adrenaline for anesthesia of the extremities (fingers, toes, nose, ear, penis), these studies push back the myth that advises against the use of local anesthetic substances with adrenaline in these areas [1-3]. Ingrown toenail is a common condition of the big toe. Surgery is often necessary. Ingrown toenail surgery is relatively straightforward and is usually performed under local anesthesia . We report here a rare case of hallux necrosis secondary to local anesthesia by lidocaine 2% with adrenaline. The objective of this presentation is to warn practitioners about the observance of precautions before using local anesthetics with adrenaline for anesthetic procedures of the extremities.