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: 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: Numerous conventional laboratory diagnostic tests has been developed to diagnose COVID-19 infection. These include but are not limited to measurement of the antibody titer against the viruses, screening the viral antigen and RT-PCR from samples obtained from nasopharynx swaps, sputum, the secretions of the lower respiratory tract, blood, and feces. Infection with SARS-CoV-2 could manifest as nonspecific symptoms such as fatigue, muscle sore, fever, and nonproductive coughs. Recent studies suggest that blood group type might play a role in determining prognosis in COVID-19 patients. Opting for the suitable diagnostic tests is essential in the timely management of these patients. In our study, we aimed at the comparison of distribution patterns of COVID 2019 and estimation of the partial frequency of the clinical findings of COVID 2019 in order to facilitate decision making of the physicians and differentiating the factors having impact on the final outcome of the hospitalized patients
Methods: In a cross-sectional descriptive-analytic study, a total of 350 patients diagnosed with COVID-19 were enrolled. The information on the previous encounters, clinical signs on admission and at the hospitalizations time, and lab results on admission were collected. Radiological findings such as chest X-ray were also collected. The questionnaires were filled out by experienced staff.
Results: A total of 350 patients with the median age of 64 years old, 204 (58.3%) male and 146 (41.7%) female were studied. 110 people (31.4%) were hospitalized in ICU. The most common underlying diseases were hypertension, diabetes, cardiac diseases, renal diseases, and cancer. Blood group types A+ and O+ were the most common blood group types among the ICU hospitalized patients P <0.0001. There was a statistically significant correlation between blood group type and mortality among the studies patients. The highest rate of the mortality was amongst patients with blood group type A+ and O+ P <0.0001.
Conclusion: Fever, fatigue and non-productive coughs, dyspnea, leukopenia, leukocytosis, lymphopenia, thrombocytopenia, thrombocytosis, increased ESR, increased CRP, and increased D-dimer are the most common clinical and laboratory findings in COVID-19 patients. A statistically significant correlation was observed between the patients hospitalized in ICU and the blood group type; the most frequent blood group type was A+ followed by O+.

Background: Providing adequate sedation in patients undergoing cataract surgery, can create analgesia and sedation during injection and retrobulbar surgery in order to prevent eye movement during open eye surgery. This study was aimed to assess the effects of melatonin premedication on the quality of sedation and pain control during cataract surgery.
Methods: The study was a triple-blind randomized clinical trial which was performed in Isfahan on 40 patients. The patients were allocated randomly into two groups of 20 subjects; one group receiving 3 mgs of sublingual melatonin pill and another group 3mgs of placebo. 60 minutes prior to surgery.
Hemodynamic parameters, level of pain and sedation were measured at specific intervals. In order to measure the level of pain and sedation, the VAS score and Richmond scales were used respectively.
Results: Surgery duration (P value=0.059), duration of anesthesia (P value=0.14), duration of recovery (P value=0.34), ASA (P value 0.27), Richmond scale (P value=0.45), Oxygen saturation level (P value=0.12), PR (P value=0.87) did not show a significant difference between the two groups. The changes in mean arterial pressure (P value=0.02) and pain intensity (P value=0.04) were significantly higher in the placebo group compared to the melatonin group.
Conclusion: Premedication with oral melatonin was beneficial in providing better pain control and hemodynamic stability in patients undergoing cataract surgery under sedation and local anesthesia.

Background: The caregivers of stroke patients experience a sense of confusion and stress after the patients are discharged from the hospital. Such that after a while, they experience a sense of inability to provide care and an increased caregiving burden. Therefore, this research aims to study the effects of a supportive training program on the caregiving burden of stroke patients’ caregivers after discharge from the Intensive Care Unit (ICU).
Methods: In this randomized clinical trial, the study population consisted of 60 caregivers of stroke patients. The sampling method was purposive based on the inclusion criteria. The intervention was performed in 6 supportive training program sessions. Data were collected using demographic questionnaires and the Novak and Guest Caregiver Burden Inventory. Data were analyzed using the paired t-test, independent t-test, and ANCOVA.
Results: There was no significant difference in the caregiving burden before the intervention between the two groups (intervention: 81.13 ± 13.99, control: 70.66 ± 14.61, P value= 0.030). After the post-test, the caregiving burden reduced significantly in the intervention group compared to before the intervention (56.46 ± 10.52) and compared with the control group (72.33 ± 15.86, (P value< 0.001).
Conclusion: According to the findings, the caregiving burden of stroke patients' caregivers can be alleviated through the intervention of supportive training, which is an effective and cost-effective method. As nurses play a key role in training and supporting these patients as primary caregivers, they should take this program seriously.

Background: Blood transfusion is a critical procedure where any error in the transmission chain can jeopardize patient safety. To ensure safe blood transfusions, it is essential to evaluate the performance of all personnel involved in the transfusion process, including anesthesia technologists, whose role has often been overlooked. This study was conducted with the aim of investigating the performance of in com anesthesia technologist plying with safe blood transfusion procedures during anesthesia.
Methods: This cross-sectional study was conducted on 80 Anesthesia technologist s working in Rasoul Akram and Firouzgar hospitals in Tehran. The purpose of this study was to investigate the level of adherence to safe blood transfusion standards by Anesthesia technologist s. The data was collected using a comprehensive and standard questionnaire including two parts: the first part demographic information and the second part focusing on the standards of safe blood transfusion. All completed questionnaires were entered into SPSS software version 27. Descriptive and inferential statistics were used for statistical analysis.
Results: The average age of the participants was 34 ± 10 years. Of the participants, 70% were women and 30% were men. The average score on the 36-question questionnaire was 27.32, corresponding to 73% of the maximum possible score. Performance levels were categorized as follows: good (75–100%), representing 41.25% of participants; moderate (50–75%), representing 58.75% of participants; and poor (<50%), with no participants falling into this category. Overall, the performance of anesthesia technologist in adhering to safe blood transfusion standards was considered average.
Conclusion: Anesthesia technologist performance in safe blood transfusion procedures during anesthesia was evaluated at a moderate level. Addressing these gaps and considering educational programs in health care systems can improve patient safety and improve clinical outcomes during anesthesia and surgical procedures.

Background: Transfusion is a vital process, but incorrect injection can cause harm. In the field of children's blood transfusion under anesthesia, the use of artificial intelligence (AI) and machine learning (ML) is regarded as innovative tools that enhance patient safety levels. This article examines and reviews the scoping literature on the use of artificial intelligence in pediatric blood transfusions during anesthesia, with the aim of identifying solutions, challenges, and future opportunities in this field.
Methods: The study, conducted from early 2024 to May 2024, aimed to evaluate the effectiveness of artificial intelligence (AI) and machine learning (ML) in predicting blood transfusion needs and bleeding risks in pediatric anesthesia. Relevant keywords, including artificial intelligence, machine learning, predictive model, neural network, predictive algorithm, blood transfusion, children, pediatric, neonates, anesthesia, surgery, and operation, were extracted from the Medical Subject Headings (MeSH). A comprehensive search strategy was independently implemented in Web of Science, PubMed, Scopus, and Google Scholar databases
Results: The search strategy initially identified 260 articles. After a systematic screening process, 60 duplicate articles were excluded. Subsequently, careful screening of titles, abstracts, and full texts eliminated an additional 195 articles, resulting in a final selection of 5 relevant English-language articles. Based on these studies, factors such as the type of surgery, the machine learning models used, decreases in hemoglobin and hematocrit levels before surgery, prolonged surgery, as well as the young age and low weight of pediatric patients, were identified as indicators of the increased risk of blood transfusion during surgery and anesthesia.
Conclusion: Based on the findings of the studies, artificial intelligence (AI) and machine learning (ML) have shown significant advancements in pediatric blood transfusion under anesthesia. This technology offers notable benefits, including high accuracy in predicting transfusion requirements and the ability to make timely decisions in critical situations. However, despite these advancements, further research is warranted to comprehensively understand the advantages and limitations of AI in the field of pediatric blood transfusion during anesthesia.

Background: This study compares the impact of Medium chain-long chain triglyceride (MCT-LCT) Propofol and Long Chain Triglyceride Propofol on blood triglyceride (TG) levels in patients undergoing brachial plexus repair surgery. The study also investigates the effects of these drugs on postoperative recovery and overall patient well-being.
Methods: The study included fifty patients aged 18-60 scheduled for brachial plexus repair between July 2016 and July 2018. Patients were randomly assigned to two sets: Set LP received 1% LCT Propofol, while Set MP was given MCT-LCT Propofol using TCI-pumps. Blood samples for TG level determination were collected before anesthesia induction, after concluding the infusion, 4 hours after stopping infusion and on day 1 post surgery.
Results: Both sets showed a significant increase in TG levels above baseline, with a higher increase observed in the LCT Propofol set (P value = 0.014). After 4th hr of infusion, TG levels significantly decreased only in the MCT-LCT Propofol set (P value= 0.001), with levels lower than those in the LCT Propofol set (P value= 0.021).
Conclusion: Prolonged infusion of LCT and MCT-LCT Propofol (1%) resulted in elevated TG levels. However, the increase in TG levels was lower with MCT-LCT Propofol. No significant ill effects were observed.

Background: Pulse oximetry is essential for monitoring patients during surgery, which display SPO2, as well as the plethysmographic variability index. Volume responsiveness is also indicated by this index. Considering the non-invasiveness of the PVI index and its predictive value, its use could be highly beneficial. Thus, we decided to evaluate the correlation between Pleth Variability Index in prone position and bleeding and volume responsiveness in patients undergoing lumbar spine surgery under general anesthesia.
Methods: 119 patients who were candidates for lumbar spine fixation surgery were studied in the prone position during surgery. Aside from demographic information, vital signs and PVI levels were recorded after induction of anesthesia, 5 minutes after induction of anesthesia, immediately after changing position from supine to prone, 5 minutes after changing position from supine to prone, at the end of the operation, immediately after shifting position from prone to supine, and after switching position from prone to supine for 5 minutes. Accordingly, the amount of bleeding and the type and amount of fluid received during the operation were recorded.
Results: Results revealed that demographic factors (gender, age, weight, height), hemodynamic factors (heart rate, blood pressure, SPO2), cardiac EF, and initial Hb levels, and changes in position from supine to prone did not affect the PVI process. In contrast, PVI has decreased due to an increase in intraoperative fluid intake. Notably, the amount of fluid received by different people (taking into consideration weight, bleeding, etc.) had no effect on PVI decreasing.
Conclusion: The PVI provides a cheap and readily accessible way to determine volume responsiveness, which is unaffected by various individual variables and can be performed in a prone position.

Background: Headache may be aggravated by factors such as contracting new diseases, taking medications, or being hospitalized. One of the diseases that is effective in causing pain, especially headaches in patients, is the Covid-19 disease. for this reason, this study was conducted with the aim of the prevalence and factors affecting headache in covid-19 patients admitted to the ICU.
Methods: This study is a part of the registry related to covid-19 patients, and the researchers analyzed the data after obtaining the code of ethics in the research. in this study, the tool that was used included a demographic profile form and a checklist for examining pain and its influencing factors in patients admitted to the ICU.  data analysis was done using SPSS version 16 software and independent t-tests, ANOVA, linear regression and confirmatory statistics.
Results: Result showed 1114 (78.8%) of the patients reported headache and 300 (21.2%) of the patients had no complaints about headache. regarding the type of pain, it was shown that 341(30.6%) had Pressure type, 360(32.3%) had Tightening type, 335(30.1%) had Throbbing type and 78(7%) had Irritability type. Also, in relation to the duration of pain, it was shown that 228(20.5%) had pain less than 1 hour, 171(15.4%) had pain between one hour and 24 hours and 715(64.2%) had pain more than 24 were hours. Also, 178(16%) of the patients had moderate headache and 936(84%) of the patients had severe headache.
Conclusion: Considering the high prevalence of headache in patients with covid-19 hospitalized in the ICU, it is necessary to take necessary intervention measures to reduce the patient's headache.

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: Postoperative pain is an important public health issue that affects the sensory and emotional experiences of patients. This study aimed to understand the impact of pain management on patients.
Methods: The present study was a retrospective cross-sectional study conducted on women over 18 years of age who underwent cesarean section with spinal anesthesia in Shahid Beheshti Hospital of Isfahan.
Results: In this study, 250 women with a Mean age of 31.75 years and a Mean pain intensity of 8.15 participated. Postoperative pain was more common in people without underlying disease and obese people had more pain. Intravenous pain relievers such as pethidine and diclofenac suppositories temporarily reduced the pain intensity.
Conclusion: This study showed that the pain after cesarean section was significantly influenced by the length of the operation, the type of anesthesia, and painkillers, which require strategies to reduce the pain.

Background: Preoperative anxiety is a prevalent and potentially detrimental factor in the perioperative experience, affecting both patients and the healthcare team. This study aimed to investigate and compare the impact of multimedia and face-to-face education modalities on preoperative anxiety in patients undergoing coronary artery bypass surgery.
Methods: This quasi-experimental study was conducted in 1403 in 98 CABG surgery patients. Patients were randomly assigned to two groups: multimedia and face-to-face. The multimedia group received education through an educational film, while the face-to-face group underwent traditional in-person instruction. Preoperative anxiety was assessed at three time points: before the intervention, immediately after the intervention, and one hour before surgery. The Amsterdam Preoperative Anxiety and Information Needs Scale (APAIS) was used to measure anxiety levels.
Results: Regarding anxiety scores, no significant correlation was found between the two groups at any of the three time points examined (p > 0.05). Both groups experienced a decrease in average anxiety scores following education.
Conclusion: The findings of this study demonstrate that the implementation of theses educational methods, can effectively reduce preoperative anxiety in patients undergoing CABG surgery. By mitigating anxiety, these interventions can enhance patient cooperation with the treatment team, ultimately leading to improved treatment outcomes. Therefore, the utilization of educational strategies is strongly recommended to alleviate preoperative anxiety levels in this patient population.

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.

Background: One of the important types of pain is post sternotomy pain syndrome (PSPS). PSPS is defined as pain that persists for 2 months after sternotomy-open cardiac surgery without a specific cause.
Methods: In this meta-analysis study, patients undergoing cardiac surgery in which the prevalence of PSPS has been reported were included in the study. Search keywords included pain, heart surgery, prevalence, heart problems, sternotomy and post-sternotomy pain syndrome. The search was conducted by two researchers based on PICO criteria. The time range of the surge was from the beginning of the publication of articles on the outbreak of PSPS until the beginning of August 2024. Data extraction was done using the researcher's checklist and CMA software was used for data analysis.
Results: In the search that was done with the primary keywords, 108 articles were extracted, after checking the inclusion and exclusion criteria, 8 articles with a sample size of 3423 patients were included in the meta-analysis stage. The analyzed articles were between the years 2001 and 2024, and their methodology was done in different ways, including retrospective, interview, case-control and original. The age range of patients varied from 13 months to 63 years and the sample size of patients varied from 48 patients to 1395 patients. the overall prevalence of PSPS in the 8 analyzed patient articles was 33.4% (with 95% confidence interval: 22.7-46.1).
Conclusions: The prevalence of PSPS in patients worldwide was reported, and drug and non-drug measures are suggested to reduce pain after surgery.

Background: Breast surgery (BS) is one of the types of surgery that will leave complications for patients. This systematic review study was conducted with the aim of determining the effect of Paracetamol (acetaminophen) on pain after BCS using a systematic review method.
Methods: This study aimed to determine the effect of Paracetamol (acetaminophen) on pain after BCS by systematic review method and using PARISMA checklist. the search was conducted in all articles published in Scopus, ISI, PubMed, EBSCO, Embase and Google scholar search engine in the period of 1.1.2000 to 6.1.2024. The checklist included the type of surgery performed, the year the article was published, the type of pain assessment tool, the drug intervention performed, and the results of the drug’s effect on the pain of BS patients. Data analysis was done descriptively with the help of Endnote software.
Results: According to the findings in the initial search, a number of 545 articles were extracted, and according to the performed screenings, finally, 9 articles were included in the systematic review stage. In relation to pain measurement tool, VAS tool was used in 7 articles. But in the article of De Oliveira et al and colleagues, the QOR-40 scale was used, and in the article of Ohnesorge et al and colleagues, the NRS tool was used. The articles were published between 2005 and 2024. In all the articles, at least two groups were used. The findings of all studies have shown the effect of Paracetamol (acetaminophen) on pain reduction in patients after BS.
Conclusions: Considering the effect of Paracetamol (acetaminophen) on reducing the pain of patients with BS, it is suggested that this drug be prescribed to reduce the pain of these patients.

Background: Delirium is a clinical neuropsychiatric syndrome, the main characteristic of which is a disturbance of consciousness affecting the patient's psychological state, and various factors are effective in causing it. the aim of study is prevalence of delirium in the Iran using a meta-analysis method.
Methods: In this study, which was conducted in the group of patients hospitalized in Iranian hospitals, the prevalence of delirium was investigated. The search was carried out in the domestic databases of Iran and international databases including PubMed, Scopus, ISI, Science Direct and Google Scholar search engine in Farsi and English languages. The results of the extracted articles were entered in the checklist designed by the researchers and the extracted results were analyzed in the CMA software.
Results: In the initial search of this study, 766 articles were found, of which 458 articles were excluded in the initial screening. 98 articles were excluded from the study due to repetition in the search, and finally 25 articles were included in the analysis stage. According to the findings, the overall delirium prevalence is 22% (CI: 16.8-28.3%), the overall delirium prevalence in heart surgery patients is 20.2% (CI: 12.7-30.6%), and the delirium prevalence in the elderly is 44.3% (CI: was 20.7-70.8%).
Conclusion: It is necessary to conduct preventive studies in this field to reduce this amount.

Background: Acute kidney injury (AKI) after cardiac surgery leads to serious outcomes, including higher mortality and increased risk of chronic kidney disease. The pathophysiology includes hemodynamic changes, inflammation, and direct renal damage. Key risk factors are chronic kidney disease, older age, diabetes, hypertension, and surgical issues like cardiopulmonary bypass (CPB) and nephrotoxic agents. CPB can cause inflammation, worsening renal blood flow and glomerular filtration rate (GFR). Preventing AKI requires a comprehensive approach that encompasses preoperative optimization, intraoperative management, and postoperative care. Important strategies include optimizing the CPB circuit, using blood cardioplegia for better myocardial and renal protection, and managing fluid balance. This study aimed to examine the factors leading to acute kidney injury during heart surgery and to identify strategies for addressing it.
Methods: Research articles from information sources and databases over the past five years were analyzed using keywords. The studies were classified and summarized according to the disease's pathophysiology and management strategies, and clinically evaluated. The findings were assessed based on clinical evidence and compiled into a review article.
Results: Amino acids are essential for renal protection, as they enhance blood flow, improve GFR, scavenge reactive oxygen species (ROS), modulate inflammation, support cellular energy, inhibit apoptosis, aid in protein synthesis, and maintain renal autoregulation. Specific amino acids, including L-Arginine, L-Citrulline, L-Carnitine, Taurine, L-Glutamine, L-Cysteine, L-Methionine, L-Ornithine, L-Tyrosine, and Branched-Chain Amino Acids (BCAAs), have demonstrated protective effects. These amino acids can enhance postoperative GFR and potentially lower the risk of AKI by bolstering renal functional reserve and stimulating local renal growth factors.
Conclusion: A comprehensive strategy incorporating preoperative, intraoperative, and postoperative measures, along with the judicious use of amino acids, is essential for preventing AKI and improving outcomes in patients undergoing cardiac surgery.

Background: Shivering is prevalent in 65% of patients undergoing spinal anesthesia, resulting in adverse outcomes and increased healthcare expenses. Ketamine, an N-methyl-D-aspartate receptor antagonist, and tramadol exhibit analgesic properties, potentially mitigating post-spinal shivering. This scoping review aims to explore the existing literature on the intravenously administered ketamine and tramadol in reducing the incidence of shivering subsequent to spinal anesthesia.
Methods: This scoping review, conducted from April to June 2024, examined studies on intravenous ketamine and tramadol for shivering post-spinal anesthesia. Using MeSH terms, researchers searched Scopus, Web of Science, PubMed, Cochrane, Google Scholar, Iran SID, and Iran ISC. After excluding duplicates and irrelevant studies, six pertinent studies were included.
Results: The search strategy identified 1316 articles, with 1258 remaining after removing 58 duplicates. Title and abstract screening excluded 6 conference papers, 42 systematic reviews, 94 book chapters or animal studies, and 2 theses. Full-text review of 97 studies resulted in excluding 78 unrelated cases, 1 language discrepancy, and 11 without full-text availability. Ultimately, 6 studies (5 randomized controlled trials and 1 prospective cohort) from Iran, Pakistan, India, Egypt, and Ethiopia found ketamine more effective than tramadol in preventing shivering.
Conclusion: Ketamine is more effective than tramadol in preventing post-spinal anesthesia shivering, with fewer adverse effects like nausea, vomiting, and bradycardia. These findings support its use for shivering management. Future research should optimize dosing to reduce hallucinations, explore other side effects, and prioritize diverse study parameters and safety evaluations.

Background: Nowadays perioperative adjuvants become popular, and they can decrease post-operative opioid consumption gradually, Lidocaine is one of those. It is sodium channel blocker and has a multimodal effect. It is a local anesthetic that has analgesic, antiarrhythmic, anti-hyperalgesic, anti-inflammatory, and anti-neuropathic effect. With these descriptions, can decreases hospital staying period, ameliorate pain scores with post-operative analgesia with opioid-sparing effect, and finally has cost efficiency. It is available, inexpensive, simple, safe, and its’ consumption is easy, making faster bowel habits return and better rehabilitation after the surgeries. This narrative review has been written to evaluate these properties of Lidocaine.
Methods: The aim of this narrative review was assess the significance of peri-operative lidocaine as an adjuvant to manage acute postoperative pain. The manuscript has been presented as a comprehensive search that was conducted across several major databases, included: PubMed, Scopus, Web of Science, and Google Scholar. The search focused on studies published between 1990 and 2024 to provide a broad perspective on both historical and current evidence.  
Results: This review has reported the results of several articles. It can be obvious perioperative Lidocaine consumption as an adjuvant reduce post-operative pain perception, improve returning bowel habits, and post-surgical better rehabilitation and pain control.
Conclusion: Review of these articles illustrated;perioperative systemic lidocaine  as an adjuvant with efficiency of reducing post-operative pain perception, has an opioid-sparing effect,  improving intestinal activity and decreasing post-operative recovery period. Finally bring more comfort for patients and accompanying, less pressure on staff and most importantly is economical for both sides.

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.

Central venous catheterization is a critical procedure for patients undergoing major surgeries, particularly when peripheral venous access is compromised. This case report delineates the emergency placement of a central venous catheter (CVC) through the right internal jugular vein in a 63-year-old female patient positioned prone during spinal surgery. The necessity arose following significant intraoperative blood loss and the failure of peripheral venous access, presenting unique challenges due to the patient's position and the absence of sonographic guidance. The procedure was successfully executed by anatomically identifying the insertion site and utilizing a posterior lateral approach, which underscores the feasibility and urgent need for CVC placement in atypical scenarios. The patient demonstrated significant improvement with stable postoperative outcomes, emphasizing the importance of adaptability in clinical practices. This case contributes to the limited but growing body of literature on prone position CVC insertion, highlighting its viability in emergencies, despite inherent risks and technical difficulties. The findings advocate for further research and development of guidelines to enhance patient safety and procedural success in complex clinical settings.

Lupus nephritis, a severe complication of systemic lupus erythematosus (SLE), often leads to significant renal impairment requiring intensive care. The management of lupus nephritis in the intensive care unit of Dr. Soetomo General Hospital extends to various patient populations, including adult patients undergoing hemodialysis and lupus nephritis with sepsis. The management of lupus nephritis entails not only renal complications, but also the challenges associated with hemodialysis. Close monitoring of fluid and electrolyte balance is essential, along with adjustments in dialysis parameters to optimize renal function and prevent further complications. Additionally, we may need to tailor immunosuppressive therapy to the patient's renal replacement therapy regimen, taking into account the potential impact on drug clearance and toxicity. Patients with SLE undergoing immunosuppressive therapy are also at risk of developing infections, which can progress to sepsis and require more intensive care. Treatment of lupus nephritis in ICU generally necessitates intensive care, which includes hemodialysis and sepsis control.

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.

Elevated liver enzymes after on-pump cardiac surgery indicate potential recovery delays, complications, and long-term damage. The heart-lung machine can cause liver injury, leading to longer hospital stays and risks from systemic inflammatory response syndrome (SIRS). Factors like mechanical stress and ischemia-reperfusion injury release inflammatory mediators that harm liver cells. Key markers of liver injury include alanine aminotransferase (ALT) and aspartate aminotransferase (AST), with ALT being more specific. Increased alkaline phosphatase (ALP) and gamma-glutamyl transferase (GGT) may suggest biliary problems. Ischemia-reperfusion injury occurs when blood flow is interrupted, causing oxidative stress that affects liver health. Cannulating the vena cavae can worsen liver congestion and damage, especially if improperly placed, risking ischemic injury and liver function impairment. Surgeons should consider pre-existing liver conditions, as they can worsen cannulation effects. Cardiopulmonary bypass (CPB) can disrupt liver microcirculation, affecting oxygen and nutrient delivery. Mechanical hemolysis from the machine can release toxic substances that harm the liver. Anesthetics and antibiotics may also elevate liver enzymes. Risk factors include prolonged CPB times, existing liver issues, older age, obesity, diabetes, kidney dysfunction, and chronic alcohol use. To manage liver enzymes, optimizing CPB techniques and monitoring liver function post-surgery are crucial. Understanding the inflammatory response linked to on-pump techniques can enhance patient care and outcomes.