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.
A Randomized, Double-Blind, Comparative Study of the Analgesic Efficacy of Perineural Dexmedetomidine as Adjuvant to Ropivacaine versus Ropivacaine Alone in Ultrasound Guided Saphenous Nerve Block after Anterior Cruciate Ligament Reconstruction Surgery
Background: The saphenous nerve block has been effectively used for pain treatment after knee surgeries, however, a single-shot saphenous nerve block with a long-acting local anesthetic usually provides a relatively short duration of postoperative analgesia. Dexmedetomidine is a highly selective alpha-2 adrenoceptors agonist and its perineural injection as an additive to local anesthetics has been shown to improve postoperative analgesia. The aim of this prospective, randomized double-blind study was to evaluate the effects of adding dexmedetomidine to ropivacaine on the quality of postoperative analgesia with ultrasound-guided saphenous nerve block after anterior cruciate ligament reconstruction surgery of the knee.
Methods: 40 ASA class I–II patients undergoing arthroscopic anterior cruciate ligament reconstruction surgery under general anesthesia were randomly divided into 2 groups of 20 patients each. At the end of surgery, ultrasound-guided saphenous nerve block was performed with either 10 ml ropivacaine 0.5% alone, or 1 µg/kg dexmedetomidine added to 10 ml of ropivacaine 0.5%. The total volume of injected solutions was increased to 12 ml by adding normal saline. The postoperative pain scores as well as fentanyl consumption through intravenous patient-controlled analgesia pump, hemodynamic parameters, sedation scores, and adverse effects were assessed every 1 hour to 6 hours and then every 2 hours to 24 hours.
Results: There were significantly lower postoperative pain scores in the ropivacaine plus dexmedetomidine group compared to ropivacaine alone group at all postoperative measured time points. The total amount of fentanyl consumption and sedation scores after surgery was significantly higher in group ropivacaine alone than in group ropivacaine plus dexmedetomidine. Systolic blood pressure and heart rate within 24 hours after surgery were significantly lower in the dexmedetomidine+ ropivacaine group than in the ropivacaine alone group. However, no bradycardia and hypotension were detected in any of the patients.
Conclusion: Perineural administration of 1 µg/kg of dexmedetomidine as an adjuvant to ropivacaine 0.5% for ultrasound guided saphenous nerve block significantly reduced pain scores and opioid requirements in the first 24 h after ACLR surgery compared to ropivacaine alone without any significant side effects.
Optimal Site for Precordial Stethoscope Placement in Pediatric Patients Younger Than Two Years: A Preliminary Cross-Sectional Study
Background: The precordial stethoscope is a traditional and non-invasive monitoring method during pediatric general anesthesia. In this preliminary cross-sectional study, we aimed to investigate the characteristics of lung and heart sounds via precordial stethoscope and determine the optimal site for auscultation in children below 2 years of age.
Methods: This study involved 68 patients who underwent general anesthesia with tracheal intubation. Auscultation sounds via precordial stethoscope were recorded in MP3 format at the following three sites: Site A-region between the clavicle and nipple on the left midclavicular line; Site B-region between the nipple and costal arch on the left midclavicular line; and Site C-point on the left midaxillary line that was horizontally leveled with Site B. Eight blinded evaluators individually and randomly scored lung and heart sounds on a 10-point scale (0: cannot hear at all and 10: can hear clearly).
Results: Lung sound scores at Sites A, B, and C were 8.0 (7.0–9.0), 4.5 (2.9–6.0), and 7.0 (5.5–8.5), respectively, while heart sound scores at Sites A, B, and C were 3.5 (2.0–6.0), 6.5 (4.0–8.0), and 1.0 (0.4–2.0), respectively. Statistically significant differences were found in all pairs of sites.
Conclusion: We suggest that Site A, where anesthesiologists can hear both the lung and heart sounds, is the optimal site of precordial stethoscope attachment during general anesthesia for intubated children below 2 years of age.
Assessment of Psychomotor Recovery after Etomidate and Propofol Induction: A Randomized Double-Blind Trial
Background: The very idea of faster recovery and early ambulation has prompted patients to opt for day care surgeries. The concept of ERAS (enhanced recovery after surgery) is the backbone to achieve this goal. We conducted this study with primary objective to compare the post-operative recovery with etomidate and propofol in terms of early recovery (awakening), intermediate recovery (psychomotor and cognitive recovery) and ambulation “home readiness” and secondary objective to study the adverse effects.
Methods: 60 eligible patients scheduled for day care gynaecological procedures were randomised in two groups of 30 each. Group E received etomidate 0.2mg/kg and group P received propofol 2mg/kg. Early, intermediate and late postoperative recovery (ambulation) was studied in both groups.
Results: Demography between the groups were comparable while hemodynamic fluctuations were more with propofol (p>0.05), early recovery was faster with etomidate (p = 0.07), psychomotor tests revealed better alertness with etomidate (p= 0.1) and patient could ambulate earlier in etomidate group.
Conclusion: Both propofol and Etomidate facilitate early recovery but etomidate provides hemodynamic stability with early awakening, more alert patients and better ambulation and was found to be superior for day care surgeries.
Background: The increasing prevalence of SARS-COV-2 infection necessitates further epidemiological studies in the field of this epidemic.
Methods: during 66 days (20/02/2020 to 01/06/2020) all patients diagnosed with SARS-COV-2 infection referred to Valiasr Hospital in Arak were monitored. Thus, based on the pre-prepared questionnaire, the information of the mentioned patients was extracted from the Hospital Information System (HIS) by the required formats and after eliminating the incomplete cases, it was aggregated based on coding (to preserve the patients' information). The results were evaluated using spss. v25 software.
Results: Out of 535 patients with SARS-COV-2 included in the study, 295 (55%) were male and 240 (45%) were female. Women with a mean age of 61.03 years were significantly (p = 0.009) at a higher age than men with a mean age of 56.59 years. Nearly 60% (304 patients) of patients had a history of underlying disease. Gender comparison of patients with a history of underlying disease infected with SARS-COV-2 infection did not show any significant difference between male and female patients. Comparison of the mean age of the improved and dead patients shows that the mean age of the dead patients with a significant difference (P <0.001) was higher than the improved subjects. This result is also true for people with a history of underlying disease (p<0.0001). The number of patients with arterial oxygen saturation <93% was significantly higher in the group of patients with a history of at least one chronic underlying disease than who did not have any chronic disease (P <0.0001). The mortality rate in ICU patients was significantly higher than those admitted to the normal ward (p < 0.0001).
Conclusion: Aging, gender, underlying diseases and arterial oxygen saturation (<93%) at the time of admission have important role in the hospitalization rate, severity of the disease and mortality in patients with COVID-19.
Effect of Ultrasound Guided Supraclavicular Brachial Plexus Block on Intraoperative Opioid Consumption and Quality of Postoperative Analgesia in Closed Reduction and Pinning of Paediatric Supracondylar Fracture of Humerus
Background: Supracondylar fracture of the humerus is one of the commonly encountered injuries in paediatric age group accounting for 16% of all paediatric fractures and 60% of all paediatric elbow fractures, classically occurring as a result of fall on an outstretched hand. Regional anesthesia may represent one of the best solutions for intraoperative and postoperative paediatric pain management however, due to lack of proficiency and the increased risk of complications in children and difficulty in obtaining cooperation compared to adults, it is not the method of choice for most of the anesthesiologists in children.
Methods: A total of 50 paediatric patients were included who were to undergo CRPP and divided into two groups Group I- General anaesthesia alone (n = 25), Group II- General anaesthesia with USG guided supraclavicular brachial plexus block studied for the intraoperative opioid consumption as well as postoperative analgesia quality, duration and Opioid consumption.
Results: Demographic data were similar in both groups (I and II). Time to first dose of analgesia after surgery in the group I was 54.8±5.4 min and 746.6±40.2 min (p<0.001). The incidence of PONV was 24% (group I) and 16% (GroupII). Duration of analgesia was significantly higher (746.6±40.2 min) and mean pain scores lower in first 24 hour. The fentanyl consumption was higher intraoperatively and rescue analgesic doses were more in group I.
Conclusion: USG guided brachial plexus block is an excellent and effective means for analgesia in CRPP for supracondylar fracture with lower intraoperative Opioid consumption and better postoperative analgesia , lower pain scores and Opioid consumption in first 24 hour post operative period.
Evaluation of the Effect of Cognitive Behavioral Interventions on the Emotional Reactions of Parents of Children with Retinoblastoma
Background: Retinoblastoma is the most common primary intraocular malignancy in childhood. Diagnosis of the disease and treatment decisions put a lot of stress on the family. Excessive anxiety and stress can lead to serious psychological problems. The cognitive behavioral approach focuses on the individuals’ thoughts, behaviors, and emotions and their interaction. This study aimed to investigate the effect of cognitive behavioral interactions on the emotional reactions of parents of children with retinoblastoma.
Methods: This study was carried out using a quasi-experimental design on 106 parents of children with retinoblastoma referred to the Farabi Eye Hospital, Tehran, Iran, between 2017 and 2018. Cognitive behavioral therapy was performed through eight sessions of 90-minute training for parents. The data collection method was self-responding using the depression, anxiety, and stress scale-21 Items (DASS-21) questionnaire. Pre-and post-intervention test scores were collected for statistical analysis.
Results: The mean anxiety score decreased from 13.65 (moderate anxiety) before the cognitive-behavioral intervention to 10.13 (mild anxiety) after the intervention (p<0.05). The mean depression score decreased from 11.26 (mild depression) before the intervention to 8.32 (no depression) after the intervention (p<0.05). The mean stress score decreased from 10.79 (normal) before the intervention to8.25 (normal) after the intervention (p<0.05).
Conclusion: Our study showed that the occurrence of retinoblastoma in children poses a significant risk to the mental health of their parents. Cognitive-behavioral interventions can be effective in improving the level of parent's anxiety, depression, and stress.
Background: COVID‐19 has a significant impact on public health and poses a challenge to medical staff, especially to front‐line medical staff who are exposed to and in direct contact with patients. Medical staff were under enormous physical and psychological pressure due to overwork, high risk of infection, and isolation during COVID-19.
Methods: The aim of this study was to review the literature on health problems of medical staff and supporting program for them during COVID-19 pandemic disease. Literature searches were performed on the following databases: Pubmed, Sciencedirect, Scopus, Google Scholar, ProQuest, SID, Iranmedax and Magiran. The types of articles published during the outbreak that were relevant to the subject were searched.
Results: A review of the literature showed that current research focuses on assessing several aspects of COVID-19-induced mental health in medical staff. Stress, anxiety, sleep disorders, depression, burnout, fatigue and physical problems are among the serious issues of the medical staff in the front line of the Corona fight. Various demographic variables such as gender, occupation, long working hours, history of mental illness and psychological variables such as poor social support, self-efficacy were important risk factors.
Conclusion: Regular screening of medical staff involved in the treatment and diagnosis of patients with COVID-19 should be performed to assess physical and psychological problems using multidisciplinary psychiatric teams
Background: Postoperative nausea and vomiting (PONV) is viewed as nausea and/or vomiting or retching that occurs in the Post- anesthesia care unit within the first 24–48 h after surgery. The incidence of these adverse reactions is between 30 and 80% following elective surgery based on the type of surgery and anesthesia, and predisposing patient risk factors. The most commonly used criteria in the perioperative assessment of the risk-score is Apfel which is a tool to evaluate PONV. The risk-score depends on Four variables: female gender, PONV history or motion sickness, postoperative opioids, and smoking status.
Methods: Currently available evidence on MEDLINE, PubMed, Google scholar and Cochrane Evidence Based Medicine Reviews, in addition to the citation reviews by manual search of new anesthesia and surgical journals related to management post-operative nausea and vomiting were searched.
Results: This review of recent studies showed incidence and management of post-operative nausea and vomiting and way to prevent or reduce its incidence by using monotherapy or combination antiemetic therapy, multimodal approach and by using optimal anesthetic technique for reducing baseline risk PONV.
Conclusion: The causes of PONV are complex and multifaceted. Patient (gender, individual background, and medical condition); anesthesia type; and surgical procedure are all risk factors for PONV. PONV is better treated by preventing and/or minimizing PONV risk factors, as well as using prophylactic antiemetics in high-risk patients. There is no one PONV antiemetic drug or technique that is 100% appropriate for all patients at this time. If the first anti emetic is unsuccessful, a 2nd or 3rd anti emetic that targets a specific mid brain emetic receptor location may be needed. PONV prophylaxis should be considered for patients who have a low to high chance of contracting the virus, according to the scoring system. The patient may be treated with monotherapy or combination treatment of anti emetics, as well as non pharmacologic approaches and therapies to reduce baseline risk, depending on the severity of risk. A targeted multimodal solution beginning in the preoperative phase is more likely to ensure progress in the management of PONV, which increases patient care satisfaction while still being cost-effective.
Review of the Potential of Hemoperfusion for the Treatment of Patients with Respiratory Infectious Diseases with COVID-19 Approach
Severe infection with COVID-19 disease can be associated with respiratory failure, kidney disorders, and in more advanced stages, organ failure and death. Unfortunately, there is currently no definitive cure for this disease, and damage to the immune system caused by inflammatory storms leads to widespread and varied complications that make an early diagnosis of the disease difficult. Therefore, eliminating or inhibiting the production of factors involved in inflammatory storms can be effective in improving the clinical condition of patients. According to specialized studies on the role of hemoperfusion in inhibiting advanced levels of COVID-19 disease, the present study was performed to investigate the use of hemoperfusion as a potential treatment option for this disease.
Cutis laxa is a rare congenital multisystem connective tissue disorder. Patients with cutis laxa have facial features, pulmonary emphysema and right-sided heart failure. Anaesthetic management is important because of difficult airway and respiratory/cardiac abnormalities. We have reported the preoperative evaluation and anaesthetic management of a child with Cutis laxa with right cleft lip and palate.
Intrathecal Pethidine as a Sole Anesthetic Agent in Cesarian Section: Case Report for Clinical Education
Pethidine was the first synthetic opioid to be used to provide analgesia in humans and was shown also to have local anesthetic activity comparable with that of cocaine. The neonatal Apgar score after birth is an important factors of mortality of the newborn. In this regard, the type of drug used for the cesarean section is very important in the Apgar score of the cesarean section. Pethidine is an intermediate lipid-soluble opioid with both a postoperative analgesic mechanism and a sensory block which is known as the only opioid which can be used alone in the cesarean section under spinal anesthesia. We used pethidine as an alternative to bupivacaine in patients going under cesarean section.
Obstetric emergencies have always put the anaesthetist on nerves. More so in this era of novel coronavirus pandemic managing obstertric cases in emergency has been a diverse challenge. COVID 19 parturients presenting in emergencies have prompted us to redesign the strategies regarding their management.
Here we report a series of three obstetric cases presenting as emergency and emphasize on anaesthesia concerns in these COVID-19 positive parturients.
Montgomery T-tube used to maintain a patent airway in post tracheostomised patients can act like a double edged sword. We report a case where a T-tube migrated into distal airway leading a precarious situation.
The rapid expansion of a novel human infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has evolved into a pandemic, affecting thousands of people world wild. Some patients with coronavirus disease 2019 (COVID-19) develop severe infection, which may progress to acute respiratory distress syndrome, multiple organ failure, and death. Increasing studies indicate that abnormal elevation of cytokine levels in response to SARS-CoV-2 may contribute to the pathological process that leads mortality of COVID-19. Thus, application of extracorporeal hemoperfusion (HP) for removal of excessive cytokines from the blood can potentially mitigate or reverse cytokine storm related complications of COVID-19.
Here, we presented series of COVID-19 patients, who were treated with HP (HA 380 cartridge, Jafron Biomedocal Co, China). The medical records were evaluated retrospectively to determine the effect of HP on patients’ clinical outcome.
Our results showed that HP improvee PO2 and O2 saturation in patients with severe COVID-19. After the last courses of HP, 5 out of 6 patients were extubated and transferred to the general ward with an acceptable medical condition.
The following case series demonstrate the promising role of HP in controlling the consequential effect of cytokine storm following a COVID-19 infection, which could facilitate patient survival.
Background: As anaesthetists, we may constantly be in the learning curve of the management of difficult airway scenario. It can have a disastrous outcome if one is not adequately prepared with the right equipment. Over time there has been multiple ways to tackle difficult airway scenarios. Needless to say, appropriate airway gadgets are carefully chosen according to the surgery and patient characteristics. But what if these certain techniques fail? Then, what next? The inability to efficiently manage a difficult airway is the major cause of morbidity and mortality in anaesthetic practice. Here, we discuss 4 different case scenarios of difficult airway management.
Case reports: Case 1 was a pediatric patient with TMJ ankylosis, with mouth opening 4mm, in whom we used the fibreoptic technique. Case 2- A failed fibreoptic attempt in a case of recurrent Ca oral cavity where we secured the airway using Airtraq videolaryngoscope. Case 3- A patient with post burn contracture over front of neck and anterior shoulder where we decided to use intubating laryngeal mask airway for securing airway and Case 4- An obese female patient posted for hysterolaparoscopy where we used the Laryngeal Mask Airway Supreme.
Conclusion: Effective usage of newer drugs, equipment and airway gadgets by technically skilled personnel, with sound clinical judgement are essential factors in reducing airway related adverse scenario and it is of utmost importance to keep these alternate gadgets handy and to be proficient with its usage.
Letter to Editor
This a case of multiple kinks observed in an epidural cather placed in a paediatric patient. There have been reports mentioning two or three kinks in an epidural catheter, but we found a particularly rare scenario in which six kinks could be appreciated in the epidural catheter.
Tramadol has a narcotic-like structure. It is a synthetic, centrally acting analgesic drug. Many drugs have been used to treat postanesthesia shivering. Actually, Tramadol is used to treat moderate to severe pain but it has been shown an anti-shivering effect in some setting.Tramadol is a weak opioid agonist and an inhibitor of monoamine neurotransmitter reuptake.It provided effective analgesia in children and adults for both inpatient and day surgery. Tramadol was generally well tolerated in the clinical setting but, we do not prescribe it for use in adult younger than 18 years old due to frequent adverse effect. Tramadol has not clinically relevant adverse effects on hemodynamic and cardiovascular or respiratory parameters at average dosage. Perioperative prescription of Tramadol could decrease postanesthesia shivering beside acceptable post-operation pain management and better patient well-being and satisfaction.