Background: Atrial fibrillation (AF) may occur in patients after coronary artery bypass surgery (CABG). Dexmedetomidine is a selective agonist of the alpha-2 adrenergic receptor with sedation, anti-anxiety and analgesic effects.
Therefore, the aim of the present study was to investigate the effect of sedation with dexmedetomidine on the incidence of AF in patients admitted to the intensive care unit after CABG surgery.
Methods: In this study, 100 patients underwent CABG surgery and randomly divided into two groups of dexmedetomidine and control. In the dexmedetomidine group, the drug was initiated at the time of closing the sternum at a dose of 0.7 μg/ kg /h and continued in the ICU at a dose of 0.5 μg/ kg /hr as an adjuvant and primary analgesic. Then, the effect of dexmedetomidine on atrial fibrillation and the effects of medication on the duration of hospitalization, the cost of hospitalization and stay in ICU, as well as heart rate, blood pressure and pain in patients were investigated first.
Results: The results showed that there was no significant difference in the incidence of AF after CABG surgery between the two experimental and control groups. On the other hand, patients in the dexmedetomidine group were hospitalized less frequently in the hospital than the control group, which led to a reduction in hospital costs. In addition, pulse, systolic blood pressure, and pain and sedation were significantly lower in control group (P<0.05).
Conclusion: Although the use of dexmedetomidine did not result in a difference in the incidence of AF after CABG surgery, the use of this drug reduced hospital stays, pulse rate, blood pressure and pain in patients.

Background: We have compared the effectiveness of metoclopramide and ondansetron in the prevention of pruritus caused by intrathecal injection of sufentanil in parturients undergoing elective caesarean section under spinal anesthesia.
Methods: 123 parturients ASA I & II divided in to 3 groups with random allocation software, with 41 parturient in each group. Spinal anesthesia was performed with 2 ml of bupivacaine 0.5% plus 2.5 microgram sufentanil.
The first group received 4mg of ondansetron, the second group 10mg of metoclopramide and the third group placebo, immediately after clamping of the umbilical cord. During surgery and postoperative period, the parturients were assessed for hemodynamic changes, pruritus, nausea and vomiting and shivering.
Results: There were significant differences in the incidence of pruritus among three groups. The incidence of moderate pruritus was significantly higher in control group (47.5%) in comparison with ondansetron (15.8%) and metoclopramide (10%)groups. Severe pruritus was significantly higher in the control group (15%).The incidence of shivering was significantly lower in metoclopramide group (37.5% in comparison with 89.5% and 72.5% in the ondansetron and control groups). Moreover, the incidence of nausea and vomiting was significantly higher in placebo group.
Conclusion: Ondansetron and metoclopramide can effectively prevent and reduce the severity and the incidence of intrathecal sufentanil induced pruritus. Both drugs can reduce the incidence of nausea and vomiting. Metoclopramide also reduces shivering in this study.

Background: In patients undergoing electroconvulsive therapy (ECT), succinylcholine is routinely used as a muscle relaxant. Occasionally, cisatracurium is used on a limited basis in this regard. The present prospective randomized study is designed to compare cisatracurium and succinylcholine for their effect on cardiovascular changes, seizure duration, and recovery after ECT on patients undergoing ECT.
Methods: This study was a randomized double-blind clinical trial without controls conducted on 64 patients, who were candidates for receiving ECT. Bipolar mood disorder as a coexisting medical condition in 32 patients (50%) had the highest prevalence. Consequently, patients were randomly divided into two groups namely, group C (n= 32, cisatracurium 50 mcg/kg), and group S (n = 32, succinylcholine 2 mg/kg-1).
Blood pressure, heart rate (HR), O2 saturation (Spo2) and seizure duration were measured in each group. The data were compared using independent t-test and chi-square tests.
Results: Both groups were comparable in gender, weight, American Society of Anesthesiologists (ASA) physical status, with no statistically significant differences (p > 0.05). The systolic blood pressure (SBP) in 1 minute after the end of shock was significantly higher in the C group, than the S group. In addition, HR was also higher in the fifth minute (5th) in the C group compared to the S group. The mean percentage of Spo2 at the time before the seizures, the first minute (1st) and 5th minutes in the C group, was higher than the S group. There was a significant difference (p=0.001) between the seizure duration in the C group (36.72 ±6.09 seconds), compared to the S group (27.37 ±4.99 seconds).
Conclusion: Although cisatracurium is considered a muscle relaxant with intermediate duration of action, its low-dose administration in ECT is not only without any limitations, but may also be a more appropriate alternative to succinylcholine. On the other hand, if the duration of seizure is less than 20 seconds in ECT, it will no longer be an effective treatment, as a result, since cisatracurium increases the seizure duration, it could have better therapeutic effects in ECT.

Background: Pediatric tonsillectomy is associated with major complications such as severe postoperative pain. Hence, this study aimed to compare the effect of acetaminophen suppository administered before and after surgery on the pain severity of tonsillectomy.
Methods: The present double-blind clinical trial was performed on 100 children undergoing tonsillectomy, who were randomly divided into two groups of 50 receiving respectively rectal acetaminophen 40 mg/kg preoperatively (Group 1) and postoperatively (Group 2).
Results: The first group consisted of 28 boys and 22 girls, and the second group had 26 boys and 24 girls. According to Chi-square test, there was no significant difference in terms of gender in the two groups (p=0.668). Comparison of pain scores with repeated measures ANOVA showed lower pain severity in the first group at all hours compared with the second group.
Conclusion: The preoperative use of acetaminophen suppository significantly controls the pain after tonsillectomy.

Background: Post-dural puncture headache is one of the common complications after neuraxial anesthesia. Some researchers have used corticosteroids for treatment of this complication.
We decided to study the prophylactic effect of administering intravenous hydrocortisone before spinal anesthesia in reducing the incidence and intensity of headache after surgery.
Methods: This randomized, double-blind, placebo-controlled trial was carried out in 80 patients undergoing abdominal and lower limb surgery without other health problem (ASA I). We randomly put 40 participants in the placebo group and 40 in the hydrocortisone group for study. The placebo group received 2 ml placebo and hydrocortisone group received 2 ml (100 mg) intravenous hydrocortisone. The incidence of PDPH on the recovery, 12, 24, 48 hours and 7 days after surgery was studied, and the severity of PDPH was assessed using a visual analog scale (VAS).
Results: The mean intensity of headache in hydrocortisone group after recovery in the first 12, 24 and 48 hours and the first week of surgery were 0.0, 1.27, 2.35, 2.28 and 0.97 mm whereas in placebo group they were 0.0, 2.02, 3.02, 2.92 and 1.47 mm. The difference of headache intensity between two groups was not significant (P=1, P=0.231, P=0.344, P=0.351, and P= 0.302). The difference of incidence rate between two groups was not significant (P= 1, P=0,502, P=0.633, P=0,579 and p= 0,576).
Conclusion: The results indicated that prophylactic administration of 100 mg hydrocortisone did not have any protective effect against post dural puncture headache.

Postoperative analgesia is one of the important basics of practical recovery after surgery. Pain relief has an important physiological advantage in preventing acute pain turning into a chronic pain and aims at early mobilization with decreasing infection, healing wound time, and hospital stay and /or hospital readmission in addition to eliminating adverse effect related to over sedation.  Estimation of postoperative analgesia technique depends on the intensity of dynamic pain and the possible side effects of analgesic medications and techniques which can delay discharge. The key role in improving postoperative pain relates to three steps; 1. Patient education in the decision concerning their specific treatment. 2. Team skills and knowledge for different drugs and technique like acute pain services available towards 24 hours/ day. 3, Physician in communication with the patient is the essential point.  Using low dose of opioid drug with NSAIDs or synergistic analgesia or multimodal analgesia at various points along pain pathway to support pain relief with less adverse effect is becoming increasingly common for post-operative pain relief.

The most difficulties in airway management of obese individuals are due to obesity-associated anatomic and physiologic changes in airways and respiratory system. Anesthesiologists usually face some problems, such as quick oxygen desaturation, difficult mask ventilation, difficulty in laryngoscopy/intubation, and respiratory depression, following initiation of hypnotic anesthetic medications. Awareness of the physiologic and anatomic changes may help anesthesiologist in providing better preparation before tackling those difficulties. Preparative evaluation of airway in obese persons should include inspection of predictors of difficult mask ventilation and difficult intubation. Difficulties in airway management are reduced after giving ideal preoxygention and positioning using some strategies may lead to facilitate airway management of these patients and reduce some hazards in this field.

A 24-year-old male with Down Syndrome (DS) presented with 1-day duration of right upper quadrant pain, nausea, and vomiting. He was timely diagnosed with acalculous cholecystitis and treated with laparoscopic cholecystectomy. His immediate postoperative period was complicated by acute onset bilateral pulmonary edema and subsequent respiratory failure which triggered a type II myocardial infarction. Patient’s course was further complicated with acute metabolic acidosis and acute kidney injury resulting in continuous veno-venous hemodialysis. Family members collectively decided to transition patient to comfort care. Over the next few hours the patient expired from cardiogenic shock as no further vasopressor support was administered.
Discussions: It is well known that patients with DS rarely suffer from coronary artery disease. In this case, we believe the patient’s residual right ventricular dysfunction from a previous significant ventricular septal defect partially contributed to the patient’s decline. Furthermore, findings in previous reports describe general anesthesia and sevoflurate’s role in possibly inducing cardiac arrest due to autonomic dysfunction. Due to low cardiopulmonary reserves, DS patients are at higher risk of complications than the normal patient population. Considering many patients with DS either have existing or repaired structural anomaly, perioperative assessment and vigilant monitoring may help reduce cardiopulmonary complications in DS patients.

Difficult airway is defined as situation that face mask ventilation, laryngoscopy, or intubation cannot be done by clinician as easy as he expects where it. Difficulties in children airway management do not occur frequently and aggressive airway management in children is not required often.
We present a case of “cannot ventilate, cannot intubate” scenario in a five years old girl with a supraglottic cyst in operating room. We started to sedate the patient with ketamine for awake intubation but the cyst obstructed the airway and we couldn’t ventilate her with mask. Two try of intubation with tube and bougie were failed and rigid bronchoscope could maintain the airway finally.