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

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.

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.

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.

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.

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.

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.

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.

Background: Since 2019, the COVID-19 disease has led to the death and disability of many people all over the world and the treatment staff has been providing services around the clock. Therefore, psychological burnout among them is highly possible. So far, no study has compared the incidence of mental burnout between doctors and nurses in the emergency department. This study has compared the psychological burnout between doctors and nurses in the emergency department during COVID-19.

Methods: This cross-sectional study included 67 doctors and nurses working in the Emergency Department of Imam Reza Hospital of Tabriz University of Medical Sciences who had been working there during the COVID-19 crisis. The instrument of study was the standard Copenhagen psychological burnout questionnaire. After obtaining the written consent, the questionnaire was distributed among the doctors and nurses of the emergency department. The data was graded by Excel software and data analysis was conducted by SPSS V. 22 software.

Results: According to the comparison of the high burnout rate in the Copenhagen burnout scale, 50% of doctors and 57.1% of nurses had personal burnout, 56.8% of doctors and 66.7% of nurses had work-related burnout, 69.4% of doctors and 69% of nurses had patient-related burnout, and the overall rate of high burnout in doctors was reported as 62.9% and nurses as 70.4%. No statistically significant difference was observed in terms of personal burnout between doctors and nurses of the emergency department (P = 0.347). Also, no statistically significant difference was observed in terms of work-related, patient-related, and overall burnouts between the two groups (P = 0.066), (P = 0.696), and (P = 0.108). Yet, there was a statistically significant difference in terms of gender distribution between the two groups (P = 0.001).

Conclusion: The level of mental burnout of doctors and nurses working in the Emergency Department of Imam Reza General Hospital during the COVID-19 crisis was at an average high. Thus, improving the conditions of medical environments in health centers can reduce the burnout of working doctors and nurses, especially during epidemic conditions, which will increase the quality of medical services.

Background: As a subfield of E-Learning, Micro-Learning provides asynchronous instruction to reduce mental strain and boost understanding by delivering educational content in bite-sized, concise learning modules. This study aimed to investigate the effect of Micro-Learning on the airway management knowledge and skills of nurse anesthesia students.
Methods: This Non-Randomized Controlled study, employing a Pre-test-Post-test design, included 52 nurse anesthesia students in Iran. Participants were first assessed with a Pre-test, and then assigned to either the M-L M (n=26) or T M (n=26) groups. Over three weeks, the M-L M group received Micro-Learning-based materials through social media, while the T M group received traditional face-to-face instruction. The intervention focused on airway management during peri-induction of general anesthesia. Then, the first and second Post-tests were given to assess the acquisition and retention of knowledge and skills, using a researcher-made instrument called AMAI-NA.
Results: Based on within-group comparisons, in both M-L M and T M groups mean scores of both Knowledge and Skills significantly increased from the Pre-test to 1st Post-test, then declined from 1st Post-test to 2nd Post-test. Yet, 2nd Post-test mean scores remained significantly higher than the Pre-test for both groups. Based on Inter-group comparisons, despite the absence of a statistically significant difference in Pre-test mean scores between the two groups, the mean scores for Knowledge and Skills of the M-L M group were significantly higher than those of the T M group in 1st and 2nd Post-tests. Furthermore, the M-L M group exhibited a greater increase in mean scores from the Pre-test to 1st and 2nd Post-tests compared to the T M group, as well as a lesser decrease from 1st Post-test to 2nd Post-test.
Conclusion: This study demonstrated that Micro-Learning significantly enhanced the acquisition and retention of knowledge and skills related to airway management, compared to the traditional method.

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.

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.

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.

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.

Background: Medication errors in healthcare settings, including outpatient and hospital environments, pose a significant risk to patient safety. These errors can arise from incorrect dosages, drug interactions, contraindications, or inappropriate drug combinations.
Methods: This study aimed to assess the logical prescription of albumin according to guidelines and patient safety for inpatients in the intensive care units of Imam Reza Hospital in Mashhad through a cross-sectional study. Methods: Data were collected over a 3-month period from albumin prescriptions in intensive care units, using a checklist based on information from prescription forms, patient files, and consultations.
Results: The study found that 60.57% of albumin prescriptions were reviewed by DUE unit, with 51.53% complying with guidelines and 48.47% not. The highest prescription rate was in the Intensive Care Unit of Heart Surgery (ICUOH), at 36.83%, and the lowest in the Neonatal Intensive Care Unit (NICU), at 0.63%. The patient safety parameter, calculated based on correct/incorrect albumin prescriptions according to guidelines, showed an average safety of 67.10% across prescribing units and 62.34% based on indications. It reduced the financial burden caused by inappropriate prescriptions approximately $21,390 through DUE process.
Conclusion: The research highlights the importance of continuous guideline-base DUE on rational drug utilization, patient safety and hospitals costs.

Background: Self-compassion can have a significant role and impact on moral damage, and the positive components of self-compassion (self-kindness, common human sense, and mindfulness) reduce the negative effects of moral damage, so using self-compassion methods can reduce the moral damage caused to nursing students during their studies. Therefore, the present study was conducted with the aim of determining the effect of the self-compassion program on the moral damage of nursing students in 2024.
Methods: In this clinical trial study, 150 nursing students of the 7th and 8th semesters in the intership course of Zahedan School of Nursing in 2023 were randomly selected in two groups of 75, intervention and control. 8 sessions of face-to-face educational program were designed and implemented for students and the degree of application of the programs by them was followed up under the supervision of the researcher. Before and 2 months after the implementation of the intervention, students' moral damage was measured using the moral damage questionnaire. Data were analyzed using independent t, paired t and chi square statistical tests under SPSS 21 statistical software.
Results: The results showed a statistically significant difference for the average score of moral injury between the control and intervention groups (P=0.001). On the other hand, the t-pair test shows a significant increase in the mean score of moral injury two months after the completion of the educational intervention in the intervention group (P=0.001).
Conclusion: The results of the present study showed that the current self-compassion training program can reduce the moral damage of nursing students during the 7th and 8th semesters, before entering the hospital as a professional nurse; Therefore, it is necessary to use it in future planning for nursing students during the 7th and 8th semester.

Background: Most adverse effects following cardiac surgery, including hemorrhaging, are related to immobility. The early mobilization of the patient in enhanced recovery after surgery (ERAS) can counteract these adverse effects. Despite the awareness, however, the protocol has a low performance rate due to numerous barriers. The present research aims to investigate the effectiveness of performing the early mobilization protocol on hemorrhaging in cardiac surgery patients.
Methods: This research is a clinical trial study conducted in 2023-2024 at Ali Ibn AbiTalib Hospital in Zahedan, Iran, on 100 patients undergoing cardiac surgery. Purposive sampling was used based on the inclusion criteria. Hemorrhaging risk assessment in patients was evaluated according to the preoperative checklist. The early mobilization protocol was performed on day 2 after surgery on patients in the intervention group with mild to low risk of hemorrhage. The statistical tests of repeated measures, chi-square, and independent t-test were used for data analysis in SPSS 26.
Results: There were no statistically significant variations in the demographic characteristics of patients in the intervention and control groups. The mean and standard deviation (SD) of the blood volume loss in patients over three different time periods (days 2, 3, and 4 after surgery) were 326.500±16.81, 69.300±11.41, and 51.200±3.82 in the intervention group, respectively, and 350.00±16.81, 325.00±11.41, and 82.10±3.82 in the control group, respectively, indicating the effectiveness of performing the early mobilization protocol (P ˂ 0.001).
Conclusion: Performing the early mobilization protocol can reduce the volume of bleeding after cardiac surgery and the early discharge of patients, thus leading to reduced complications. Nurses as the main care providers in intensive care units play a key role in performing the protocol.

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.

Background: Sepsis is a severe and life-threatening condition leading to widespread inflammation and organ dysfunction. It is a medical emergency that requires immediate attention and treatment. One of the key indicators used to assess the severity and prognosis of sepsis is lactate level. Another key indicator of sepsis severity is a significant difference in the level of carbon dioxide (CO2) between veins and arteries.
Methods: In this study, we aimed to evaluate the differences in the venous and arterial PCO2 and lactate levels during the first 6 hours of treatment of septic shock. In this prospective observational-analytical study patients with septic shock admitted to the ICU were evaluated. Sepsis is defined as patients who had 1 or more of the SIRS criteria with a possible or proven source of infection and hypotension despite appropriate fluid therapy who needed to receive vasopressors.
Results: Among 85 patients the mean age was 64±17 years and 48 (56%) were men. Of these patients, 15 (17%) died, of them 8 (53.33%) were male, 14 (93%) were diabetic, 11(73.33%) were hypertensive, 11 (73.33%) had ischemic Heart disease and 9 (60%) patients had Chronic Obstructive Pulmonary Disease (COPD). The mean HR, SBP, and DBP were significantly higher in lived patients; the SOFA scores were significantly lower in these patients.
Conclusion: Overall, the gradient of AV PCO2 and lactate clearance combined with SOFA score can be a valuable tool for clinicians in predicting mortality risk in critically ill patients and guiding treatment decisions.

Background: The use of regional anesthesia for lower limb orthopedic surgery is preferable to general anesthesia. In some studies comparing regional anesthesia and general anesthesia, the one-month mortality of patients undergoing regional surgery was significantly lower. Given the relative advantages observed about intrathecal injection of pethidine, including fewer side effects, and longer postoperative analgesia, in combination with effective sensory, motor, and sympathetic blocks, we sought to compare the influence of intrathecal injection of pethidine and bupivacaine on the hemodynamics of patients.
Methods: In this double blind randomized parallel trial, patients undergoing surgery with femoral and hip fractures, were divided into two groups. In the first group bupivacaine and in the second group pethidine were used for spinal anesthesia. Hemodynamic changes were examined and recorded during surgery. The results were analyzed by SPSS18 software
Results: 67 patients undergoing surgery with femoral and hip fractures, were divided into two groups of 30 and 37 individuals. The mean heart rate in patients with a high risk of surgery was higher in the group receiving pethidine compared to the group of bupivacaine, with a Cohen's effect size of 0.294. This effect size is evaluated as average, while the rate of mean arterial pressure with Cohen's effect size of 0.511 was evaluated as large.
Conclusion: Pethidine can be a good alternative to bupivacaine, especially in patients at high risk of surgery, given its hemodynamic stability.

Background: Sedation is recommended during flexible fiberoptic bronchoscopy (FFB) to aid in airway evaluation, minimize patient mobility, and enhance patient safety. This study was conducted to compare the impact of different sub-dissociative ketamine (SDK) doses on the quality of sedation within FFB.
Methods: This research utilized randomized clinical trial design involving three cohorts, each consisting of 30 participants. The cohorts were administered varying doses of ketamine: 0.2 mg/kg (SDK1), 0.4 mg/kg (SDK2), and 0.5 mg/kg (SDK3). After receiving ketamine, all participants received propofol in bolus dose 0.4 mg/kg followed by infusion 50-100 µg/kg.
FFB started when sedation level 4 was reached, according to Ramsey's sedation score.
Results: Regarding demographic variables revealed no statistically notable discrepancy among the cohorts (P>0.05). The SDK3 cohort exhibited a higher average sedation score and longer duration of sedation compared to the SDK2, with both metrics also surpassing those of the SDK1 cohort. (P>0.001). Furthermore, the satisfaction levels reported by the bronchoscopist (P=0.78) and the participants (P=0.019) were notably greater in the SDK3 cohort than in the other groups. Additionally, the amount of propofol administered to the SDK3 cohort was less than that given to the SDK2, and both cohort received lower doses than the SDK1 cohort (P>0.001).
Conclusion: Elevating the SDK from 0.2 mg/kg to 0.5 mg/kg when administered alongside propofol correlates with a rise in the score of sedation, increasing patient and bronchoscopist satisfaction, and decreasing propofol consumption in FFB in adults. A dosage of 0.5 mg/kg might be more advantageous compared to alternative dosages for FFB in adult patients.

Background: One of the main reasons women prefer cesarean surgery is their fear of pain during natural process of childbirth. Neuraxial analgesia is a beneficial option for decreasing pain during natural childbirth. However, painless childbirth is still not widely accepted by parturient in developing countries compared to high-resource countries due to cultural issues and lack of knowledge.  We investigated the causes of rejecting neuraxial painless childbirth in parturient admitted to the labor ward of our hospital.
Methods: A total of 567 parturient who declined neuraxial analgesia for painless labor were included in this single center cross-sectional study conducted between 2020 and 2022. The causes of refusal and level of knowledge were evaluated using a validated and reliable questionnaire.
Results: The main reasons for patients' refusal of neuraxial analgesia were fear of neuraxial complications, concern about insertion of the spinal needle, and worry about prolonging labor time following neuraxial analgesia, respectively. 51 participants had high, 134 had medium and 381 had low awareness level. Parturient who attended prenatal classes as well as those who used internet as a source of information had significantly higher levels of awareness.
Conclusion: Fear of neuraxial complications, spinal needle and delaying childbirth were the primary reasons for maternal rejection. The women's knowledge about neuraxial painless labor was inadequate.

Background: Multiple sclerosis, as one of the most important causes of disability in the world, can cause a feeling of despair in a person to be compassionate and follow his treatment, so it is important to use self-compassion methods for these patients. Therefore, the present study was conducted with the aim of determining the effect of the educational program on treatment compliance and self-compassion of patients with multiple sclerosis.
Methods: In the current clinical trial study, 80 patients with multiple sclerosis, members of the MS Association of Zahedan city in 2023-2024, were selected by the available method and randomly divided into two groups of 40 people, intervention and control. 8 sessions of face-to-face educational program were designed and implemented for patients, and the rate of application of the programs by patients was followed up under the supervision of the researcher. Before, one month and 3 months after the implementation of the intervention, patients' adherence to treatment was measured using the "Treatment Adherence in Chronic Patients" questionnaire and self-compassion was measured using the "Multiple Sclerosis Patient Self-Compassion Assessment Questionnaire". The data were analyzed using statistical tests of repeated measures, Chi-Square under SPSS 21 statistical software at a significance level of less than 0.05.
Results: The average age of the intervention group was 40.05 ± 9.61 years and in the control group was 40.13 ± 8.78 years, and according to the findings, before the intervention, there was a statistically significant difference between the variables of gender, age, education level, marital status in Two intervention and control groups were not observed. The results of the independent t-test show a statistically significant difference between the average changes in the total score of adherence to treatment and the average total score of self-compassion after the intervention (P=0.000).
Conclusion: The results of the present study showed that the present educational program can increase self-compassion and adherence to treatment in patients with multiple sclerosis, so it is necessary to take advantage of it in rehabilitation programs to promote or improve the mental and psychological conditions of patients.

Background: This study aimed to evaluate the relationship between the central venous-to-arterial PCO2 gap, serum lactate level, ScvO2, and prognosis of COVID-19 patients admitted to the intensive care unit. The study was performed in the intensive care unit of Imam Reza Hospital of Mashhad University of Medical Sciences.
Methods: The baseline sample and ABG sample were checked in terms of the PCO2 gap for 3 consecutive days. Lactate serum was also evaluated on the second day. Vital signs, oxygenation status, need for vasopressor, type of respiratory support, and calorie intake were recorded simultaneously. The length of stay in the intensive care unit, the duration of mechanical ventilation, and the patient’s discharge or death were also recorded.
Results: In this study, 147 COVID-19 patients were evaluated, of whom 115 patients died and 32 patients were discharged. The patients’ outcomes were assessed as the normal PCO2 gap (less than 6) and high gap (above 6). There were no significant differences between the high gap and mortality on the first day (p=0.833), second day (p> 0.99), and third day (p=0.82). PCo2 gap was not associated with ICU length of stay, duration of mechanical ventilation, SOFA, and APACHE score. The high gap patients had a significantly lower ScvO2 on the three days. Lactate serum was higher in the dead patients than in those discharged. The P/F ratio was significantly higher on the three days in the discharged patients than in the dead patients.
Conclusion: There is no relationship between the central venous-to-arterial PCO2 gap with the 28-day mortality rate in covid-19 patients.

Background: An optimal anaesthesia protocol is critical for paediatric patients undergoing surgery to ensure smooth recovery and minimize complications. This study compares the impact of Bispectral Index (BIS) and End-Tidal Anaesthetic Gas (ETAG) concentration-guided protocols on tracheal extubation time in paediatric patients.
Methods: A prospective randomized controlled study was conducted on 60 paediatric patients (4-12 years) undergoing general anaesthesia. Patients were divided into BIS-guided (Group B) and ETAG-guided (Group E) protocols. Various parameters, including age, gender, duration of surgery, duration of anaesthesia, and time to extubation, were analyzed using statistical methods such as Chi-Square Test, Analysis of Variance (ANOVA), and Logistic Regression.
Results: No significant differences were found in demographic characteristics, surgery duration, anaesthesia duration, or time for extubation between the two groups. Both monitoring techniques demonstrated comparable efficacy in maintaining appropriate anaesthesia levels and ensuring a smooth recovery process.
Conclusion: The study concludes that BIS and ETAG-guided protocols are equally effective in maintaining optimal anaesthesia levels and facilitating a seamless recovery for paediatric patients. While the monitoring techniques are not interchangeable in all clinical scenarios, this research provides valuable insights for anaesthesia management.

Background: There are increasing number of patients undergoing lumbar spine surgeries. Many modalities have been developed to manage post operative pain. More recently, erector spinae plane blocks found to be effective in reducing post operative pain. The purpose of this study was to compare the analgesic efficacy of ultrasound guided Erector spinae block with wound infiltration using levobupivacaine in lumbar spine surgeries under general anaesthesia.
Methods: A prospective randomized single blinded study was carried out in 50 patients of ASA grade I and II, aged 20 to 60 years scheduled for elective lumbar spine surgeries. Under USG guidance, group A received bilateral erector spinae block at L2 with 20 ml of 0.125% levobupivacaine on each side and Group B received incision site infiltration with 40 ml 0.125% levobupivacaine. Patients were evaluated primarily for duration of analgesia using VAS score.
Results: Both groups were statistically comparable with respect to all demographic variables, ASA grading and duration of surgery. The duration of analgesia was prolonged in group A when compared to group B (496 ± 36.2 v/s 55±10.6) (P=0.0016). VAS score and total rescue analgesia requirement were higher in group B.
Conclusion: Erector spine block is more effective in providing post-operative analgesia compared to local site infiltration in patients undergoing spine surgeries following general anaesthesia using Inj Levobupivacaine 0.125% as local anaesthetic.

Background: Anesthesia providers cross-contaminate their work environment. The hands of anesthesia providers are vectors for the transmission of infection between medical equipment in the anesthesia work environment and patients. The high work density of anesthesia providers around the patient has made it important to monitor infection control in the work environment and anesthesia procedures. This research aimed to find the best evidence for preventing or reducing infection in the anesthesia work environment.
Methods: The measures required for the guidelines in the field of infection control in the anesthesia work environment were determined according to the available resources and the use of expert opinions of anesthesiologists and faculty members. Then, the guidelines for infection control in the anesthesia work environment were designed based on the evidence-based method (Stettler model). Also, it has been implemented in a limited way in the operating room. To assess the validity of the approach used in calculating the content validity coefficient (CVR) and the content validity index (CVI), Finally, the Test-Retest method, and Cronbach's alpha coefficient were used to determine reliability.
Results: The guidelines for infection control in the anesthesia work environment were designed using evidence-based methods (Stettler's model). The content validity of anesthesia procedures requiring infection control guidelines was reported with a content validity index (CVI) of more than 0.79 and a content validity ratio (CVR) of more than 0.59. The reliability test was measured by Cronbach's alpha coefficient (0.806).
Conclusion: Based on this study, the use of global infection control guidelines changes the attitude of anesthesia nurses and reduces the rate of infection in the anesthesia work environment. Also, the use of evidence-based methods facilitates the implementation of guidelines in the target environment.

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.

Background: Shivering is one of the most prevalent known complications due to dysregulation in the thermoregulatory system following regional anesthesia, with an incidence of 65%, leading to unpleasant outcomes and decreased patient satisfaction. Ketamine, a weak analgesic, affects the thermoregulatory center.
Methods: The authors conducted a search and selection of articles using reputable scientific databases. The search keywords included Shivering, Ketamine, and Spinal Anesthesia. The selected articles summarized the literature findings related to ketamine and shivering after spinal anesthesia.
Results: This narrative review synthesizes findings from multiple studies examining the role of ketamine in managing shivering following spinal anesthesia. Based on the results obtained, 10 areas were examined: Definition of shivering, Epidemiology of postoperative shivering, Pathophysiology of shivering, Risk factors for post-spinal anesthesia shivering, Spinal anesthesia, its benefits, and its impact on shivering, Post-anesthetic shivering (PAS) complications, Risk factors for postoperative shivering, Control and management of post-anesthetic shivering (PAS) dosage, Effective timing and benefits of ketamine administration in postoperative shivering.
Conclusions: The effectiveness of ketamine in preventing shivering after spinal anesthesia is evident from the mixed results of studies. Ketamine, regardless of dosage, can be effective in reducing shivering after spinal anesthesia based on the mentioned criteria. Standardized research with precise methods to determine optimal dosages and ensure safety is necessary.

Artificial intelligence (AI) is increasingly being utilized in Post-Anesthesia Care Units (PACUs) to improve patient monitoring and care. This narrative review explores the current use of AI in PACUs and discusses the potential benefits and challenges associated with its implementation and highlights how AI technologies such as predictive analytics, machine learning algorithms, and robotics can enhance patient safety, reduce human error, and improve outcomes in the PACU setting. Overall, this narrative review provides insights into the evolving role of AI in PACUs and offers recommendations for future research and practice in this area.

Background: Etomidate, a short-acting hypnotic drug, plays a pivotal role in induction for intubation, particularly in emergency settings. Its favourable hemodynamic profile renders it a suitable choice for patients with hemodynamic instability
Methods: In this systematic review, we aim to delineate its role in emergency ward settings. Through a systematic search across databases, we identified nine eligible studies for inclusion. We searched the databases of PubMed, Scopus, ProQuest, and Medline (Ovid) from 2004 to 2023 for Randomized Controlled Trials (RCTs) and observational studies in which the study population was referred to the emergency department and received etomidate for Rapid sequence intubation (RSI).
Results: These studies collectively underscored the safety and efficacy of etomidate in emergency patients, with its suppressive effects on the adrenal axis deemed clinically insignificant.
Conclusions: The rapid onset of action and favourable hemodynamic profile position etomidate as a desirable agent for rapid sequence induction. However, further studies are warranted to strengthen recommendations in this regard.

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.

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.

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.

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.

Myasthenic crisis can affect the respiratory muscles in a life-limiting way that requires intubation and mechanical ventilation. This is a case report of a myasthenic crisis in a 61-year-old woman that became complicated following a lack of response to plasmapheresis, intravenous immunoglobulin (IVIG) therapy, and the development of septic shock. The co-occurrence of myasthenic crisis and sepsis is a challenging condition. Many antibiotics cause flare-ups of myasthenia gravis. Infection and sepsis can exacerbate myasthenia. We discuss the successful management of certain unique challenges. To treat sepsis, drugs that may cause deterioration of myasthenia gravis, such as amikacin, ciprofloxacin, colistin, vancomycin, amphotericin B, and voriconazole were prescribed, but eventually the sepsis was cured. After eradicating the infections and stabilizing the patient's hemodynamic, she received rituximab. After 3 weeks of treatment, she responded well to the rituximab, the respiratory failure recovered, and she was extubated and discharged from the ICU after 3 months of hospitalization. This report demonstrates that when the myasthenic patient is under mechanical ventilation, can use even cautionary drugs.

Hemothorax, a condition characterized by blood accumulation in the pleural space, primarily results from trauma, affecting around 300,000 individuals annually in the United States. Spontaneous cases, although rare, pose diagnostic challenges due to diverse etiologies such as coagulation disorders, vascular anomalies, and neoplastic diseases. Diagnostic modalities like computed tomography, chest X-ray, and ultrasound play a crucial role in identification. A 29-year-old female with multiple sclerosis presented with severe chest symptoms, leading to pleural effusion requiring chest tube insertion. Despite inconclusive rheumatologic tests, evaluations excluded malignancies and thromboembolic events, enabling transfusions and supportive care. Global cases underscore varied causes of spontaneous hemothorax, with management strategies emphasizing interdisciplinary care. While certain conditions were ruled out, unresolved rheumatologic concerns persisted post-discharge, highlighting the need for further research to enhance diagnosis and management of spontaneous hemothorax.

High risk patients with multiple comorbidities, sepsis, poor cardiopulmonary reserve when posted for emergency below knee surgeries definitely pose challenges in terms of Anaesthesia. In this case series we highlighted the important role of ultrasound guided popliteal sciatic combined with adductor canal block as a sole anaesthetic technique for safe outcome in high risk cases having significant and multiple comorbidites.
10 cases with ASA physical status III and IV, aged 50-70 years scheduled for below knee surgeries were enrolled. All the patients received ultrasound guided popliteal sciatic nerve block with 8 ml of 2% Lignocaine with Adrenaline and 8 ml of 0.5% of Bupivacaine and 4mg Dexamethasone (1ml) (total volume 17 ml) and Adductor canal block with 8 ml of 0.5% of Bupivacaine.
Adequate sensory and motor blockade required for surgery was achieved, with stable haemodynamic parameters throughout the procedure. No patient developed any serious complication in the perioperative period.
Combination of the popliteal sciatic nerve and adductor canal block provide sufficient sensory and motor block with good hemodynamic stability for below-knee surgeries. When used on high-risk patients with numerous comorbidities, this anesthetic technique has the potential to save lives.

Liposarcoma, a malignant tumor originating from fat cells, is a rare occurrence in the retroperitoneal region. Surgical resection is the standard method for treating this cancer. This type of tumor is classified into common subtypes, which include well-differentiated liposarcoma and dedifferentiated liposarcoma.
A 53-year-old male patient presented with lower left quadrant (LLQ) pain and melena for two weeks. Further diagnostic evaluation, including colonoscopy, revealed a 50 mm polyp in the hepatic flexure or distal of the ascending colon.
The pathological assessment of the mass demonstrated a lipomatous lesion with a nuclear atypical lipomatous tumor, which was diagnosed as well-differentiated liposarcoma.
The patient underwent surgical treatment and was discharged following his recovery.
Liposarcoma, a malignant tumor originating from fat cells, is a rare occurrence in the retroperitoneal region. Surgical resection is the standard method for treating this cancer. This type of tumor is classified into common subtypes, which include well-differentiated liposarcoma and dedifferentiated liposarcoma.
A 53-year-old male patient presented with lower left quadrant (LLQ) pain and melena for two weeks. Further diagnostic evaluation, including colonoscopy, revealed a 50 mm polyp in the hepatic flexure or distal of the ascending colon.
The pathological assessment of the mass demonstrated a lipomatous lesion with a nuclear atypical lipomatous tumor, which was diagnosed as well-differentiated liposarcoma.

The patient underwent surgical treatment and was discharged following his recovery.

Anticoagulation is the cornerstone of preventing thrombosis. Following the aging of society and the greater use of anticoagulant drugs, we see more serious complications in this group. The reduced occurrence of significant bleeding represents a notable benefit of direct oral anticoagulants (DOACs) in comparison to vitamin K antagonists. However, the unavailability of Andexanet alfa and Idarucizumab complicates the management of bleeding associated with DOACs. This case describes a 69-year-old man who presented with massive gastrointestinal bleeding, hemorrhagic shock, and loss of conciseness. He has been taking apixaban 2.5 mg twice a day, aspirin 80 mg once a day, and diltiazem 60 mg three times daily. Bleeding was controlled through transfusion of two units of fresh frozen plasma, five units of packed cell, four units of platelet, and tranexamic acid injection. Although hemorrhagic shock was successfully managed, he unfortunately passed away after three weeks of hospitalization following Ventilator-associated pneumonia and sepsis. In this case, we discuss the importance of the drug interaction of apixaban, diltiazem, and aspirin.

Difficult intubation and mechanical ventilation are common causes of pneumothorax in critically ill patients. Patients with chronic respiratory tract disease are at high risk for pneumothorax caused by positive-pressure mechanical ventilation. A timely diagnosis of pneumothorax is critical as it may evolve into tension pneumothorax. In this case report, we report a patient who has a decreased level of consciousness due to opioid overdose. In the emergency room, she underwent mechanical ventilation and became conscious after a naloxone injection. After extubation, she has extensive subcutaneous emphysema. However, her hemodynamic and respiratory status is normal. The chest CT scan showed a large pneumothorax caused by mechanical ventilation.

According to the American Association of Poison Control Centers (AAPCC), 761 single exposures to the pharmaceutical warfarin were reported in 2021, accounting for more than 10 percent of anticoagulant cases. The cost and mortality caused by warfarin toxicity are very high and usually incurable and fatal. The most important action in the field of warfarin toxicity is to prevent its occurrence. To emphasize how warfarin toxicity occurs, a case is introduced in this regard. A 61-year-old man is found unconscious with a seizure on the street and transported to the hospital by Emergency Medical Services (EMS). In the emergency car, he received a diazepam injection for generalized seizures. His vital signs in the postictal state were as follows: blood pressure 82/44 mmHg, pulse rate 91 bpm, and oxygen saturation (SaO2) 93%. His past medical history includes an ischemic stroke and a myocardial infarction 12 years ago. He underwent Mitral valve repair 11 years ago and a mechanical-type Mitral valve replacement 2 years ago. After undergoing mitral valve replacement surgery, he continued taking warfarin and aspirin for 2 years without consulting a cardiologist or undergoing PT and INR tests. As a result, he suffered a massive intracerebral hemorrhage when his INR level rose above 6. It's important to note that he has no history of depression or suicide attempts. After experiencing decreased consciousness and seizures, he was quickly intubated. A brain CT scan revealed extensive evidence of intracerebral hemorrhage, and he was then transferred to the operating room for craniotomy. To manage the bleeding and because Prothrombin complex concentrate (PCC) was not available, the patient received two grams of fibrinogen, two units of Fresh Frozen Plasma (FFP), 10 mg of vitamin K, and one unit of Packed Red Blood Cells. Unfortunately, after a month-long stay in the ICU, the patient passed away as a result of Ventilator-associated pneumonia (VAP) and sepsis.

A 26-month-old male patient presented with swelling in the right hemi-scrotum, diagnosed as a hydrocele and a 44 x 14 mm hernia displacing the right testicle. He had been hospitalized 12 days earlier due to prolonged fever, leading to concerns about Kawasaki syndrome. Prior to surgery, a cardiovascular consultation was performed, revealing no complications. The patient received treatment with clindamycin, ASA, prednisolone, and intravenous immunoglobulin. Admitted to Beheshti Hospital for surgery, his vital signs were stable. Anesthesia considerations were complicated by Kawasaki syndrome, but after consultation, general anesthesia was administered using a Laryngeal Mask Airway. The surgical procedure lasted an hour and fifteen minutes, during which basic monitoring was conducted. Post-surgery, the patient was transferred to recovery and later admitted to the pediatric department for two days, ultimately being discharged without complications.

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.

Spinal anesthesia is generally prohibited in patients with severe valvular heart disease (e.g. severe aortic stenosis), cardiomyopathies and heart failure concerning the hemodynamic effects of sympathetic system blockade in patients with limited cardiac output. Intrathecal single injection of low doses of local anesthetic  in combination with low dose short acting opioids can be administered safely in lower abdominal and lower limb surgeries lasting 60 to 90 minutes . In longer surgeries, epidural catheters can be inserted through the epidural needle into the intraspinal space and intermittently administered low doses of local anesthetic plus low doses of fentanyl or sufentanil as needed.