Background: Breast surgeries can be associated with acute postoperative pain which if left untreated might lead to chronic pain therefore pre-emptive treatment post surgery can be favourable. The aim of our study was to evaluate the analgesic efficacy of PECS 2 compared to SAB to reduce post operative pain in breast surgeries done under general anaesthesia.
Methods: A total of 50 patients belonging to ASA 1 & 2 undergoing elective breast surgery were randomly assigned into two groups. Pectoralis nerve block 2 group received 25ml of 0.5% Ropivacaine and Serratus anterior plane block group received 25ml of 0.5% Ropivacaine under ultrasound guidance post induction. The primary outcome was to compare the duration of post operative analgesia with PECS 2 and SAB. Other outcome parameters observed were total rescue analgesic requirement, change in post operative hemodynamic parameters and complications if any.
Results: There was a significant difference in duration of post operative analgesia between two groups with Mean Duration of post operative Analgesia in PECS 2 being 510±32.6mins and SAB being 316±26.5mins (p=0.036). The VAS score as well as number of rescue analgesic requirement with PECS 2 was lesser when compared to SAB.
Conclusion: Ropivacaine in ultrasound guided PECS 2 block provided superior analgesic profile when compared to SAB.

Background: The ideal endotracheal tube cuff pressure to prevent aspiration is 20-30cmH2O. Lower pressures will result in aspiration and high pressures will lead to tracheal mucosal injuries. Change in patient position may also lead to change in cuff pressures. Our study mainly aims at measuring the cuff pressures in supine, Trendelenberg, reverse Trendelenberg, neck flexion and rotation to one side.
Methods: This prospective observational study was conducted after obtaining ethical clearance and patient consent. 50 patients of ASA Classes I and II were included. All patients were intubated with Romson cuffed endotracheal tubes of size 7.5mm for females and 8.5mm for males. The cuff was inflated and cuff pressure set at 28cm H2O using CuffillsR syringe. With head in neutral position, cuff pressure was measured in 15 degree Trendelenberg and reverse Trendelenberg positions. Using angle meter app, the angles were fixed for flexion, extension, and rotation to one side at 30 degrees. The cuff pressure was recorded after 120 seconds after placing the patient in all these positions.
Results: The cuff pressure increased by 12.48cm H2O flexion and the cuff pressure increased to 33.22cm H2O in extension. The cuff pressure increased to 38.10cmH2O on rotation, increased by 10.58cmH2O from neutral position in Trendelenberg position and increased by 8.74cmH2O in reverse Trendelenberg position.
Conclusion: The cuff pressure changed significantly in all the positions.

Background: Preoperative anxiety in children is a common problem that can affect the anesthesia and postoperative period. Numerous methods, mainly pharmacological ones, have been used for controlling preoperative stress. Acupressure is a simple, noninvasive, and cost-effective method that has been used as a perioperative medicine for controlling pain or preventing postoperative nausea and vomiting. The present study aimed to comparatively investigate the effect of acupressure and oral midazolam on preoperative anxiety control.
Methods: 76 patients were randomly included in the study before surgery. Whereas in one group, 0.5 mg/kg oral midazolam was prescribed 15 minutes before the induction, in another group, acupressure of EXHN-3 point was applied for 15 minutes. In both groups, the patients’ separation anxiety level, Ramsay score, recovery length, and RN satisfaction factor were recorded and compared.
Results: Children aged 1–7 years received either oral midazolam or acupressure. Although the children in the midazolam group had lower rates of preoperative anxiety and showed easier separation from their parents, the difference was not statistically significant P= (0.076). Ramsay sedation scale, was compared in the two groups. The overall difference was not statistically significant. The satisfaction of the PACU nurse was recorded using a 4-point scale. The two groups were statistically comparable in this regard (P=0.155). The only variable with a significant difference between the two groups was the mean recovery time, which was significantly shorter in acupressure group (P<0.001).
Conclusion: Acupressure can reduce preoperative anxiety in children; however, this effect is less than the effect of oral midazolam.

Background: Herniorrhaphy is the most common inguinal surgery in children. Several methods such as caudal block, ilioinguinal iliohypogastric block, and wound infiltration have been studied for postoperative pain management in these patients. Caudal block is common in pediatrics. However, ilioinguinal iliohypogastric block is effective and less invasive. Previous studies have shown different comparative results regarding these blocks. This study compares the analgesic effect of caudal and bilateral ilioinguinal iliohypogastric block with ropivacaine in children.
Methods: This study is a randomized double-blind clinical trial. A total number of 66 patients aged between 1-7 years that volunteered for bilateral inguinal hernia repair were randomly assigned to two groups. After general anesthesia, caudal block with 1cc/kg ropivacaine 0.2% was performed for 33 patients and sonography-guided ilioinguinal iliohypogastric block with 0.1 cc/kg ropivacaine for each side was considered for another group. Hemodynamic parameters (systolic blood pressure, diastolic blood pressure, and heart rate) during anesthesia, pain score (CHEOPS), delirium score (PAED), nurses’ satisfaction score (RN), need for additional narcotic, recovery time, and complications were compared in these two groups.
Results: There was no statistically significant difference between the two groups in terms of hemodynamic parameters during the anesthesia process. Furthermore, the two groups had no statistically significant difference in CHEOPS score (6.27 in ilioinguinal block and 5.70 in caudal block, P=0.061), PAED score (5.64 vs 5.30, P=0.144), and RN satisfaction score. However, the need for narcotics, mean recovery time, and block complications were comparable in two groups.
Conclusion: Caudal block and ilioinguinal block are equally effective for post herniorrhaphy pain and emergence agitation management in pediatrics. Additionally, no differences were observed in complications. It is recommended that the study be performed with a larger sample size.

Background: Due to the associated hypertension and cardiovascular disease in patients with ESRD hemodynamic changes during operations are detrimental and may be life-threatening. Therefore, hemodynamic stability is an important criterion in selecting the anesthetic approach.
Methods: 72 ASA class III/IV, ESRD Patients were studied in randomized double blind clinical trial. They were divided into two groups by four-block randomization. A group of patients were induced and maintained by etomidate and second of patients were induced by Na thiopental and maintained by isoflurane. Systolic, diastolic and mean arterial blood pressure and heart rate were measured at interval of pre and post induction, postintubation, pre and post abdominal insufflation during and at the end of surgery and in recovery. The total BP modulators were recorded and postoperative nausea and vomiting was registered in the recovery. Data were analyzed by STATA version 12.
Results: There was no significant difference in physical characteristics between two groups. There was no statistical difference between the groups in SBP and HR (P>0.05), although DBP fluctuation>20% at interval postinduction and prior to abdominal insufflation during surgery and at the end of surgery, was significantly higher in the isoflurane group of patients. (P=0.004, 0.001, 0.003 and 0.009, respectively). Also, the MAP fluctuation at interval of post induction, preinsufflation and at the end of surgery was significantly higher in isoflurane of patients. (P=0.04, 0.001, and 0.02, respectively).
Conclusion: The group anesthetized with isoflurane had a higher hemodynamic fluctuation, compared to the group anesthetized with etomidate. As hemodynamic changes are critical in patients with ESRD, etomidate is a more appropriate anesthetic choice for implantation of peritoneal dialysis catheter by laparoscopic approach.

Background: Whether in a hospital setting or in the community, medical students are exposed to cardiac arrests. Fast response and effective resuscitation are main determinants for decreasing mortality and morbidity due to cardiac arrests. We assessed the effectiveness of anesthesiology rotation in acquiring cardiopulmonary and cerebral resuscitation for medical students.
Methods: A pre-test/post-test quasi experimental design was undertaken, comprising A fortuitious sample of medical students who were undergoing anesthesiology rotation at Tehran University of Medical Sciences hospital complexes during the academic year 2021-2022 using a self-administered questionnaire to evaluate their theoretical comprehension, knowledge, skills and before and after the rotation.
Results: The study revealed an increase in theoretical scores (mean dif +2.6/20), increased in self-assessment knowledge scores (mean dif + 0.84/5), as well as an increased in self-assessment skill scores (mean dif +0.96/5). The highest scored were witness in students with previous cardiopulmonary resuscitation (CPR) experience.
Conclusion: It is of extreme importance for medical students to participate in anesthesiology rotations. It is essential for possessing the appropriate knowledge and skills to provide effective resuscitation care and gain confidence to perform CPR.

Background: The effect of using high flow oxygen delivery through the nasal cannula (HFNC) in COVID-19 patients has been associated with different results. This study aimed to evaluate the effect of different HFNC temperatures in COVID-19 patients.
Methods: Patients were randomly divided into three groups under high current oxygenation with temperatures of 31, 34, and 37. Except for the temperature, other device settings were set equally. After 24 hours, clinical conditions were on the agenda and compared with the conditions before the intervention.
Results: Fever, sore throat, malaise, diarrhea in patients of 31 degree group and indicators of nausea, cough, body pain, headache have changed the most in 37 degree group. Abdominal pain has shown the greatest change in the 34 degree group. PR, DBP, and SpO2 indices changed the most at 31 degrees and RR and SBP at 37 degrees. PR, RR, SBP and SPO2 indices showed significant values in intra-group comparison, and in inter-group comparison, only PR, RR indices had significant differences. In intra-group analysis, PaCO2, WBC, CRP, ESR and ferritin had significant changes, and in inter-group comparison, none of the indicators had significant differences.
Conclusion: Based on the results of the present study, reducing the temperature in the use of HFNC can improve the clinical conditions of patients with COVID-19.

Background: Anesthesia techniques significantly impact the long-term and short-term outcomes after cancer surgery such as cancer recurrence, post-discharge hospitalizations, and duration of hospitalization, probably by decreasing the neuroendocrine stress response during surgery, reducing opioid requirement, reducing post-operation nausea vomiting, and pain, and interacting with the immune system. Research in recent years has provided ample evidence that epidural anesthesia produces better post-operation outcomes compared to general anesthesia. The purpose of this study was to evaluate the effects of epidural anesthesia on cancer recurrence after surgery in gastrointestinal cancer patients.
Methods: To perform this study medical records from the archive of gastrointestinal cancer patients who have undergone surgery at Imam Khomeini Hospital Complex (IKHC) from the years 1390 to 1400 were used. The variables required for the study were obtained from the records. The data obtained were analyzed by the SPSS software and the significance value of < 0.05 was considered.
Results: Our study included 8987 patients out of which 1673 patients received epidural anesthesia. Cancer recurrence was reported after 90 days and 180 days and for the type of surgery (using or not using epidural anesthesia) B value for 90 days and 180 days was 0.079 and 0.018 respectively. Thus causality was not established for the type of surgery with recurrence of cancer.
Conclusion: The findings of our study indicate that the rate of gastrointestinal cancer recurrence after surgery is not influenced by having or not having epidural anesthesia.

Background: Flexible LMA offers the advantage of providing a better surgical field without being compressed compared to other LMAs in surgeries around the oral cavity. The insertion of flexible LMA is comparatively difficult as the shaft is flexible. The aim of this study is to compare the index-finger guided technique, two-finger guided technique, and 90° rotation technique for the success and time of insertion of flexible LMA in pediatric patients.
Methods: After obtaining consent from parents,84 patients aged between 3 to 12 years of either gender were randomized into 3 groups. After administration of general anesthesia, flexible LMA of appropriate size as per manufacturer recommendations was inserted.
In the index finger guided method (Group A), the LMA was held like a pen and the mask was pushed backward pressing against the palate. In the two-finger guided method (Group B), the anesthetist stood by the side facing the patient. LMA was fixed in between the index and middle fingers, held facing the lower jaw, and pushed along the palatopharyngeal curve. In the 90° rotation method (Group C), the LMA was rotated 90° anticlockwise in the oral cavity and was advanced through the right side of the tongue till resistance was felt and then turned back. The time from insertion of LMA and the number of attempts taken for successful insertion were noted. The data were analyzed using ANOVA.
Results: The mean time of insertion was the least in Group B and highest in Group C. The first attempt success rate was highest in Group B and least in Group C. However, the mean time of insertion and the first attempt success rates were not significantly different between Group A and Group B.
Conclusion: The LMA insertion by the two-finger guided method is the easiest and most efficient method and a good alternative to the standard method (index finger guided) for insertion of flexible LMA.

Background: To evaluate the decision-making proficiency among medical residents at Tehran University of Medical Sciences in the year 2022-2023.
Methods: A structured online web-survey via national approved services Author’s designed questionnaire was used to collect the relative data based on variables of the study and was developed by the authors of the study by reviewing the previously conducted studies. The forms were sent to the medical residents at Tehran University of Medical Sciences as a link via electronic mail and social media; assistance was offered via direct or indirect contact upon request.
Results: In this study, 88 medical residents of Tehran University of Medical Sciences were evaluated. Out of 88 participants, the frequency of females was 52(59.09%) and frequency of males was found out to be 36(40.91%). The frequency of the first- year residents was 28(37.50), second year residents was 33(21.59), third year residents was 19(9.09) and the fourth- year residents was found out to be 8(31.82). The frequency of different specialties were: Pathology 1(1.14%), Infectious diseases 1(1.14%), Cardio vascular diseases 1(1.14%), Emergency medicine 1(1.14%), Orthopedics2(2.27%), Psychiatry 3(3.41%), ENT 12(13.64%), Internal Medicine 13(14.77%), Pediatrics13(14.77%), OB&GYN 19(21.59%), Anesthesiology19(21.59%), Dermatology 2(2.27%), General Surgery 1(1.14%).
Conclusion: There is a significant relationship based on linear regression between not having self - reported availability bias and surgical residency specialties. The surgical specialty is less prone to the availability bias. A difference of communication exists between the surgical and nonsurgical speciality and the nonsurgical specialties need to confirm their decision using other methods to prevent the patient harm.

Background: Major surgeries cause metabolic stress and insulin resistance, leading to postoperative hyperglycemia and increased morbidity and mortality in diabetic patients. Therefore, this study aimed to assess blood sugar level changes in diabetic patients undergoing elective surgery and its confounding factors.
Methods: A cross-sectional study compared blood sugar levels (BS) in 100 diabetic patients undergoing elective surgeries. Demographic data, medical history, surgery type, and anesthetic technique were documented. Laboratory assessments included fasting blood sugar (FBS) and glycosylated hemoglobin (HbA1C). Statistical analysis used SPSS software and nonparametric tests.
Results: Postoperative blood sugar levels significantly increased compared to preoperative levels (mean change 11.40 ± 14.356 mg/dL). Age over 60 and general anesthesia were significant factors associated with elevated blood sugar.
Conclusion: This study reveals a significant postoperative increase in blood glucose levels in diabetic patients, particularly those aged over 60 and under general anesthesia.

Background: Electrolyte imbalance is one of the influential causes in determining the outcome of traumatic patients. One of the electrolytes that get less attention from healthcare providers is magnesium. Therefore, this study investigated the frequency of hypomagnesemia in trauma patients hospitalized in the intensive care unit.
Methods: The descriptive-cross-sectional study was conducted after approval at Zahedan University of Medical Sciences on 118 patients with multiple traumas from 2021 to 2022. Patients were selected by convenience sampling method according to the inclusion criteria. Age, sex, weight, body mass index, level of consciousness, and level of blood serum electrolytes were measured and recorded on the first and fifth days after hospitalization. The data were analyzed and compared using descriptive statistics, chi-square, and independent t-test.
Results: Of 118 patients studied, 81 (68.6%) were male, and 38 (31.4%) were female. On the fifth day after hospitalization, the mean serum magnesium level of the patients was 1.4 ± 0.81 mg/dL. 87 patients (73.7%) had normal magnesium serum levels, 27 patients (29.9%) had hypomagnesemia, and 4 patients (3.4%) had severe hypomagnesemia. No statistically significant relationship existed between hypomagnesemia and gender, age group, and comorbidity diseases. The level of other blood serum electrolytes on the fifth day after hospitalization, age, weight, body mass index, and status of consciousness was not statistically significant between the two groups of patients with hypomagnesemia and without hypomagnesemia.
Conclusion: Trauma and the subsequent treatment measures lead to decreased magnesium serum levels in intensive care patients. Therefore, the normal serum level of other electrolytes should not be considered a diagnostic indicator for the normality of magnesium serum level. Magnesium should be measured along with other electrolytes to make a timely decision to replace magnesium supplements in a patient with hypomagnesemia.

Background: The effect of ozone therapy in reducing inflammation and radicular pain with lumbar transforaminal epidural steroid has not been sufficiently investigated. This study compares the effectiveness of transforaminal steroid injection with or without ozone therapy on radicular (leg) pain.
Methods: In a double-blind clinical trial, 40 patients with chronic radicular pain whose pain did not respond to conservative treatments were selected and randomly assigned to two treatment groups of A and B. Group A underwent transforaminal epidural steroid injection with ozone and group B underwent transforaminal epidural steroid injection without ozone. The intensity of pain with the Numerical Rating scale (NRS) scale and the degree of disability with the Oswestry Disability Index (ODI) questionnaire were compared in both groups of patients before treatment, 24 hours after treatment, 1 and 3 months after treatment.
Results: Both groups of A and B were similar in terms of age, gender, pain duration, pain intensity and disability before treatment (P>0.05). In treatment groups of A and B the mean of pain score 24 hours after treatment was 6.95±2.50 and 6.15±3.50 (P=0.495), one month after treatment it was 4.10±2.59 and 3.25±2.32 (P=0.355) and the third month of treatment was 3.85±3.01 and 3.55±3.25 (P=0.429). respectively. The mean of ODI 24 hours after treatment was 22.50±10.78 and 18.95±15.24 (P=0.401), one month after treatment it was 19.40±7.76 and 7.95±5.42 (P <0.001) and three months after treatment it was 17.40±7.26 and 13.55±8.70 (P=0.137).
Conclusion: It seems that adding ozone to corticosteroids has very little effect in reducing pain, and it did not have a significant effect at least in the study. One of the reasons may be the limitation of the sample size in the study, so it is suggested to conduct more studies in this field.

Background: This double-blind clinical trial aimed to investigate the effectiveness of splanchnic nerve blocks using different medication combinations on pain severity and duration of pain relief in patients with pancreatic cancer-related abdominal pain.
Methods: Thirty eligible patients were randomly assigned to either a control group receiving splanchnic blocks with Ropivacaine/Depo Medrol/Saline or an intervention group receiving splanchnic blocks with Ropivacaine/Depo Medrol/Fentanyl. Pain severity was assessed using the Numeric Rating Scale (NRS) at 2, 6, and 24 hours and one week post-intervention. Statistical analysis included independent t-tests, Friedman tests, and False Discovery Rate (FDR) correction.
Results: Prior to intervention, no significant difference in NRS scores was observed between groups (p = 0.0642). However, at the 6-hour and one-week intervals, the case group exhibited significantly lower NRS scores than the control group, indicating the efficacy of the intervention in reducing pain levels. The case group showed a substantial decrease in NRS scores from a pre-intervention mean of 7.8 to 0.5 at 2 hours, while the control group experienced a reduction from 9.083 to 2.583. The mean duration of pain relief was longer in the case group (5.429 days) compared to the control group (3.25 days). Friedman tests revealed significant differences in pain scores across time intervals within both groups (p < 0.001).
Conclusion: Splanchnic nerve blocks using Ropivacaine/Depo Medrol/Fentanyl combination demonstrated significant pain reduction effects, particularly at 6 hours and one-week post-intervention, compared to the control group. These findings showed that the addition of fentanyl in pharmaceutical combination as a opioid to the splanchnic block has reduced the pain score and increase the duration of pain relief in patients being involved in pancreatic cancer with abdominal pain.

Background: In this study, our aim is to investigate the complications caused by COVID-19 disease in the period of 1 month and 3 months after infection and recovery in patients aged 20 to 80 admitted to the special care department of Shariati Hospital in Tehran.
Methods: The information of the patients in this research was collected between 1 and 3 months after discharge non-randomly and from among the samples that are available (consecutive), through phone calls and a prospective questionnaire including questions about complications such as fatigue, body pain, joint pain, anorexia, disorders, sleep, headache, depression, dizziness, palpitations, chest pain, cough, diabetes, skin disease, obesity, imbalance, neuropathy, neurological and mental problems, and other cases are collected.
Results: In this study, what was observed was those 4 complications of nausea and vomiting, diabetes, depression, and hypothyroidism were significantly related to hospitalization of COVID-19 patients in the hospital's special care department. The frequency of other complications was also investigated in this study.
Conclusions: According to the conducted study as well as previous studies, what is clear is that the frequency of complications caused by COVID-19 in patients admitted to the intensive care unit after discharge is high, and more studies should be done in order to reduce these complications.

Safe transfer of patients who have undergone anesthesia and surgery is a basic principle to maintain stability, and avoid side effects and preventable errors. Specific scoring systems or criteria may be used to assess and decide whether patients are sufficiently recovered to be safely transferred to another ward or discharged home. This study aims to answer the question, what criteria are appropriate for patient evaluation and discharge in the post-anesthesia care unit? designed.
To find documents related to writing a review article on various scoring systems for patients after anesthesia in Google Scholar, PubMed, Scopus, and ScienceDirect databases and using English keywords post-anesthesia care unit, PACU, recovery room, discharge, scoring system, Assessment was searched.
A total of 168 articles were found by searching the databases. After removing duplicates, 77 articles were evaluated. Finally, 17 articles were selected and included in the study. The included studies included a variety of tools and criteria for evaluating and discharging patients in the post-anesthesia care unit. This article separately describes each of the tools and criteria for the evaluation and discharge of patients in the post-anesthesia care unit along with the method of scoring, advantages and disadvantages of each.
A safe scoring system for discharge from PACU should evaluate important parameters after anesthesia, including alertness, blood pressure, heart rate, ventilation, oxygen saturation, and surgical site bleeding, which can cause serious complications. Considering that one of the goals of PACU is to relieve patients’ pain in the post-surgery phase, the evaluation and control of pain and postoperative nausea and vomiting is effective in the satisfaction and safety of patients.

In the present manuscript, an 87-year-old man, who was a candidate for knee joint replacement surgery due to severe osteoarthritis of the right knee, was case reported. He underwent neuroaxial anesthesia. Following spinal anesthesia with bupivacaine 0.5% in the fourth and fifth lumbar vertebra, the patient developed myoclonic seizures in the lower limbs and abdomen that lasted during the surgery, as well. Due to the continuation of the seizures, the necessary examinations were performed and an extra-axial tumor in the left parasagittal was detected in the patient’s brain imaging.

Pulmonary embolism can cause cardiac arrest. Fibrinolytic therapy and surgical embolectomy can be used to manage it. This case report presents the clinical course of a patient who experienced intraoperative cardiac arrest resulting from massive pulmonary embolism. The patient encountered three instances of cardiac arrest requiring 35 minutes of cardiopulmonary resuscitation. Subsequent treatment involved the administration of reteplase, a thrombolytic agent. Following resuscitation, the patient developed multiple organ dysfunction in the intensive care unit, necessitating the use of diverse medications. Successful resolution of organ dysfunction led to the patient's transfer to the neurosurgery department. This case highlights the complexities involved in managing pulmonary embolism-induced cardiac arrest and subsequent multiorgan dysfunction, emphasizing the significance of a multidisciplinary approach in the comprehensive care and treatment of these patients.

Familial hypokalemic periodic paralysis is a rare disorder that manifests manifests with the sudden onset of flaccid paralysis that is triggered by low levels of blood potassium, which can be caused by various factors such as, rest after intense exercise, or high-carbohydrate foods. This report presents cases of hypokalemic periodic paralysis attack triggered by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. A 29-year-old male patient was admitted with quadriparesis, fever, shortness of breath, and sever hypokalemia. The patient had a history of three episodes of Familial hypokalemic periodic paralysis (HPP). Diagnostic tests, such as chest computed tomography scan and polymerase chain reaction test, confirmed SARS-CoV-2 infection. The patient was treated with potassium chloride infusion, spironolactone, and remdesivir, and was eventually discharged from the hospital.in conclusion, SARS-CoV-2 infection can potentially exacerbate HPP and should be considered a risk factor for its occurrence.

Anemia, a common symptom in pregnancy, can lead to life-threatening cardiomyopathy.
A 30-years old gravida 2 para 1 woman was admitted at 34 weeks of gestational age with asymptomatic pancytopenia and vitamin B12 deficiency in the laboratory tests. She also had a diet-controlled gestational diabetes, megaloblastic changes in Bone marrow aspiration and cardiomyopathy shown by echocardiography. The patient recovered from pancytopenia and cardiomyopathy after one week treatment with vitamin B12 and folate.
In this case, cardiomyopathy worsened with anemia. By treating vitamin B12 deficiency, cardiomyopathy can be prevented or controlled during pregnancy. Careful consideration is needed when assessing anemia in pregnant women on vegetarian diet and at higher risk.