Background: A Caudal epidural block is considered as one of the most common regional techniques in pediatric anesthesia. The latest addition to the group of adjuvants for caudal analgesia is α2 agonists namely Clonidine and Dexmedetomidine. This study includes a comparison of clonidine and dexmedetomidine as an adjuvant to bupivacaine in caudal epidural anesthesia for postoperative pain relief in the pediatric population.
Methods: This study was performed on 60 children, aged 1 year to 6 years, of ASA physical status I and II, undergoing elective infra-umbilical surgeries under general anesthesia. The patients were assigned randomly into two groups of 30 patients each, caudal epidural was given in all patients according to their group, after giving general anaesthesia. Group A (n=30) - patient received 0.125% bupivacaine (1ml/kg) with 0.5mcg/kg Dexmedetomidine. Group B (n=30)- patient received 0.125% bupivacaine (1ml/kg) with 0.5mcg/kg Clonidine. The patients were observed postoperatively for the duration and effect of caudal analgesia, (using the CHEOPS Score - Children’s Hospital of Eastern Ontario Pain Scale), frequency and total dose of supplementary analgesic required, sedative effect (Modified Ramsay Sedation Score), perioperative hemodynamic parameters, and complications.
Results: The duration of Caudal analgesia without the need of supplementary analgesic is significantly higher in dexmedetomidine group (743 ± 73.6 min) than clonidine group (181.7 ± 53.60 min) and the total dose of supplementary analgesic (Inj. Paracetamol 15mg/kg i.v) required is significantly higher in clonidine group (491.5 ± 134.55 mg) as compared to dexmedetomidine group (236.5 ± 113.68 mg).
Conclusion: Addition of dexmedetomidine (0.5 mcg/kg) to caudal 0.125% bupivacaine (1ml/kg) produces a significantly longer duration of postoperative analgesia, less frequency, and dose of rescue analgesic required for postoperative analgesia in children, aged between 1 to 6 yrs as compared to a similar dose of clonidine used in caudal epidural for infra umbilical surgeries.

Background: Control of hemodynamic changes and blood loss is a daily challenge in general anesthesia for patients undergoing septorhinoplasty. This study aimed to evaluate the effects of magnesium sulfate and clonidine on the control of hemodynamic factors and bleeding volume during this procedure.
Methods: This double-blind, randomized clinical trial study was conducted on 60 patients undergoing septorhinoplasty at 5th Azar Medical & Educational Centre of Gorgan in 2021-2022. Patients were divided into two intervention groups (50 mg/kg of magnesium sulfate) and control group (5 μg/kg of clonidine) with permutation random block allocation. All patients underwent induced hypotension. Before induction of anesthesia and every 5 minutes afterwards, blood pressure was recorded. Blood loss volume was calculated at the end of the surgery.
Results: In the magnesium group, 36 individuals were evaluated, while in the clonidine group, 24 individuals were examined. There were no statistically significant differences in baseline characteristics of patients in the two groups and the duration of surgery. Both drugs were equally effective in inducing hypotension, however blood pressure changes in magnesium group were more trivial than clonidine group. The bleeding volume in the magnesium sulfate and clonidine groups was 139.44 ml and 141.25, respectively and this difference was not statistically significant (p-value=0.634).
Conclusion: The results of this study showed that magnesium sulfate can be effectively used as an alternative to clonidine in controlling hemodynamic changes and ultimately reducing blood loss volume during septorhinoplasty surgery. In addition, magnesium is at least as effective as clonidine in stabilizing hemodynamic changes.

Background: The purpose of this study is to investigate the rate of allogeneic transfusion after the administration of intravenous iron in patients who are candidates for intertrochanteric fracture surgery.
Methods: Patients who were candidates for intertrochanteric surgery referred to the orthopedic surgery and trauma department of Shahada Tajrish Hospital were included in the study after providing full explanations and obtaining written consent. The 80 patients were randomly divided into control group (No: 40) and intervention (No: 40). Patients in the intervention group were prescribed 600 mg of Venofer drug by ViforCo. This is while patients in the control group were not injected with Venofer before surgery. The results were evaluated using t-test and SPSS21 software.
Results: Based on the results, the 1 hour after surgery, three indicators of systolic blood pressure, pulse rate, breathing rate, RBC showed a significant decrease in patients undergoing intervention (P<0.05). However, the oxygenation index showed a significant increase in the patients of this group (P>0.05). Meanwhile, in the period of 1 week after the surgery, we also see a significant decrease in the two indices of average hemoglobin and PTT time in the mentioned patients compared to the control subjects (P=0.030, P=0.037). The amount of blood consumed significantly lower in the patients of the intervention group than in the control group.
Conclusion: The administration of injectable iron in patients with intertrochanteric fracture surgery candidates can improve some of the patients' clinical indicators in addition to a significant reduction in allogeneic blood transfusion.

Background: Magnesium sulphate (MgSO4) is one of the commonly used adjuvant in regional blocks and proved its analgesic efficacy. However, the exact dose of the drug for perineural administration is still debatable. We compared two different doses of Magnesium Sulphate (150mg and 250mg) as an adjuvant to local anesthetics in ultrasound guided supraclavicular block.
Primary objective was to compare block parameters along with postoperative analgesia duration and secondary objectives were comparison of total analgesic requirement and side effects.
Methods: 90 patients posted for elective upper limb surgeries under supraclavicular block with 12 ml 2% adrenalized lignocaine,12 ml 0.5% bupivacaine were divided in two groups. Group M1 received 150 mg and Group M2 received 250 mg magnesium sulphate.
Results: With addition of 250 mg of Magnesium, the duration of sensory (530.37 ± 67.33 min) as well as motor block (492 ± 80.52 min) was prolonged as compared to sensory (478 ± 72.6 min) and motor (442 ± 83.980 min) block durations with 150 mg. Duration of postoperative analgesia was also prolonged with 250 mg (485.33 ± 79.19 min) as compared to 150 mg (538 ± 67.2 min) respectively. Total number of postoperative analgesic doses were lesser with 250 mg magnesium.
Conclusion: Magnesium sulphate as an adjuvant in supraclavicular block in the dose 250 mg significantly prolonged the duration of sensory as well as motor block, duration of postoperative analgesia with reduction in analgesic requirement postoperatively as compared to the 150 mg with no significant side effects.

Background: Sufentanil is extensively used as a powerful painkiller for both initiating and sustaining general anesthesia, thanks to its advantages like potent prolonged action, analgesic effect, and hemodynamic stability. Nonetheless, it's important to consider sufentanil's negative side effects, such as postoperative nausea and vomiting (PONV), during the surgical period. Additionally, Naloxone, an antagonist for opioid receptors, is frequently utilized to counteract the lingering effects of opioids after surgery. Hence, we examined the preventative use of low-dose naloxone on PONV and studied its potential mechanism of action.
Methods: After ethical approval and receiving IRCT code, 64 patients were evenly assigned to the naloxone and ondansetron groups prior to surgery. We also monitored the occurrence and intensity of PONV and the use of antiemetic medication within the first 24 hours after surgery. The main focus of our study was to analyze the PONV profile.
Results: The mean age was 49.8±15.5 years, the mean weight 71.8±23 kg, and the mean BMI was 23.5±5.2 kg/m2. No significant difference was detected regarding mean oxygen saturation and arterial pressure between the groups at admission, 15, 30, 60, and 90 min after surgery (p> 0.05). Adverse reactions showed no significant difference during the recovery time between the groups (p> 0.05). The PONV severity and incidence are significantly higher in the naloxone group.
Conclusion: Naloxone can be used as an antiemetic medicine, besides the ondansetron, and using this agent individually cannot prevent nausea and vomiting effectively.

Background: Currently Awake fibreoptic intubation - (AFOI) is the gold standard for the management of patients with an anticipated difficult airway. Various medications have been used to perform intubation during AFOI. The ideal drug for AFOI must provide comfort, cooperation, amnesia and hemodynamic stability along with maintenance of spontaneous respiration. The study aimed to compare fentanyl, clonidine and dexmedetomidine in providing favourable intubating conditions along with hemodynamic stability during AFOI.
Methods: This prospective and randomized trial was carried out in 90 patients who were scheduled for elective surgery and required awake fibreoptic intubation. The patients were randomly divided into three different groups; Group A: Received Injection Dexmedetomidine-1ug/kg over 10 minutes; Group B: Received Injection Clonidine -2ug/kg over 10 minutes; and Group C: Received Injection Fentanyl- 2ug/kg over 10 minutes. Cough score, post-intubation score, Ramsay sedation score (RSS) and the changes in hemodynamic, were used to evaluate the effectiveness of the intubation condition and the results were then compared among the groups.
Results: Demographic variables such as gender, age, weight and American Society of Anaesthesiologists-Physical Status ASA-PS (I/II) were comparable among the three groups and not statistically significant. The cough score and the post intubation score were lower in Group A. RSS was noted to be higher in Group A and there was a lower incidence of desaturation. Hemodynamic parameters were also favourable in Group A.
Conclusion: Dexmedetomidine was found to be more effective than clonidine and fentanyl in those undergoing awake fibreoptic intubation.  There were fewer adverse effects such as coughing, discomfort, oxygen desaturation, and intolerance to intubation.

Background: The emergence of COVID-19 in late 2019 swiftly led to a global pandemic, prompting urgent investigation into its multifaceted impacts. While prior studies have highlighted compromised sleep quality in hospitalized COVID-19 patients, this research delves into the enduring effects on sleep patterns for those with severe pulmonary involvement post-intensive care. This study addresses a critical gap in understanding the long-term consequences of the virus, emphasizing the importance of post-recovery care.
Methods: Conducted as a cross-sectional study, we consecutively enrolled COVID-19 patients with over 20% pulmonary involvement admitted to the ICU at Shariati Hospital, Tehran, between June 2021 and January 2022. Demographic and clinical data were extracted from hospital records. After ethics committee approval, participants were contacted six months post-discharge to assess sleep quality using the Pittsburgh Sleep Quality Index (PSQI). Exclusions comprised obstructive sleep apnea patients and those with incomplete records.
Results: Of the 60 eligible post-COVID-19 patients, 56 participated. Three individuals were unresponsive to calls, while one declined. Participants, primarily female (64.3%), had a mean age of 51.7 years. Notably, 80.4% exhibited sleep disorders six months post-discharge. Gender differences were observed, with females reporting higher scores in specific sleep quality components. Intriguingly, single individuals demonstrated a higher preference for sleep medication. These findings underscore the imperative for targeted interventions to improve post-ICU sleep quality in severe COVID-19 cases.
Conclusion: The high prevalence of sleep disorders six months post-discharge underscores the enduring impact of COVID-19 on sleep quality. These findings call for targeted interventions and comprehensive post-ICU care protocols that prioritize sleep health.

Background: Sedation plays a crucial role in the care of intensive care unit (ICU) patients, addressing the challenges presented by factors such as agitation, anxiety, and delirium, particularly during mechanical ventilation (MV). Dexmedetomidine and propofol are commonly used sedatives, each with its unique characteristics and side effects. Combining these agents has been proposed to optimize effectiveness and minimize adverse effects. This study aims to compare the efficacy of the dexmedetomidine-propofol combination with dexmedetomidine alone and propofol alone for sedation during mechanical ventilation in ICU patients.
Methods: A triple-blinded clinical trial was conducted in Isfahan, Iran, involving patients eligible for spinal fusion surgery and mechanical ventilation. Patients were randomized into three groups: dexmedetomidine alone (DO), propofol alone (PO), and a combination of both drugs (DP) dexmedetomidine-propofol (ProDex). Various dosages and infusion protocols were carefully administered, and patients were assessed for demographic and clinical variables. Hemodynamic parameters and sedation levels were monitored, and statistical analysis was performed.
Results: The study involved 87 patients, with the ProDex group demonstrating the shortest mechanical ventilation duration. Hemodynamic stability was observed in the ProDex group, with significantly lower systolic blood pressure and heart rate compared to other groups. Sedation scores did not differ significantly among groups, suggesting similar sedative effects. The ProDex group exhibited favorable outcomes despite differences in hemodynamic variables.
Conclusion: The dexmedetomidine-propofol combination appears effective in minimizing side effects associated with monotherapy sedation, leading to favorable clinical outcomes. This study contributes valuable insights into optimizing sedation strategies for mechanically ventilated ICU patients.

Background: Nausea While elderly patients are at an increased risk of perioperative morbidity and mortality; old age alone is not a contraindication for surgery. General factors that should be considered in preoperative risk assessments include age, functional status, cognition, nutritional status, and comorbidities, such as cardiac, pulmonary, renal, and endocrine disorders. Induction of anesthesia is a critical step in surgery, particularly for elderly patients and those with a high physical status. Commonly used drugs for this purpose include etomidate and propofol. Therefore, this study aimed to compare the impact of Ketofol versus etomidate alone on the hemodynamic status of patients who fall under the ASA class II or higher.
Methods: The study was a prospective randomized double-blind clinical trial, with a study population of age of ≥65 years, ASA physical status class II or higher, that were randomized into two groups. Ketofol (n=45) and, Etomidate (n=45) groups. Patients followed for clinical outcomes including their hemodynamic status during the induction period.
Results: The present study showed that, the examination of hemodynamic parameters up to 10 minute after laryngoscopy showed that none of these parameters were significantly different between the two groups, while immediately after anesthesia induction, heart rate and blood pressure were found to be significantly different. However, there was no significant difference in terms of SPO2 among the two groups in any given interval.
Conclusion: The results of the present study revealed that Ketofol resulted in better regulation and stability of blood pressure and heart rate in patients undergoing endotracheal intubation, compared to etomidate alone.

Background: Bleeding management during and after urgent heart surgery is always challenging in patients who are taken anticoagulants especially antiplatelet ones. The present study was conducted with the aim of investigating the role of intraoperative hemoperfusion in the active removal of Plavix in patients undergoing on-pump CABG surgery.
Methods: The present study recruited patients on Plavix who underwent urgent CABG surgery. All patients have discontinued consuming Plavix less than 36 hours before surgery. During cardiopulmonary bypass, hemoperfusion set was added to the circuit and the surgery was done according to the standard open heart surgery protocols. The patients were transferred to the intensive care unit at the end of surgery and amount of bleeding was recorded in the ICU sheet hourly and calculated after 24 hours.
Results: In our study, the average age of participating patients was 73,625 years. 5 patients out of 8 (62.5%) were male and 3 (37.5%) were female. Hypertension and blood type O were the most prevalent among the patients. The average amount of bleeding was 425 in the first day after surgery and the average units of transfused blood for patients was 0.125, which is acceptable and less than the values reported in other studies that do not use the hemoperfusion.
Conclusion: The use of hemoperfusion during urgent CABG surgery, can reduce the postoperative bleeding and blood products consumption in patients on preoperative Plavix.

Background: The University of Washington quality of life questionnaire (UW-QOL) is widely used to evaluate the quality of life for head and neck cancer patients. The purpose of this study is translation of the UW-QOL questionnaire's into Persian.
Methods: After translation and cultural adaptation of the UW-QOL, the questionnaire was distributed among 100 head and neck cancer patients. Internal reliability of the translated UW-QOL was determined using Cronbach's alpha coefficient. The validity was determined by Spearman correlation coefficient between UW-QOL and 12-Item Short Form Survey (SF-12). The test – retest reliability was measured by Intraclass Correlation Coefficient (ICC) after one week.
Results: Cronbach's alpha coefficient was more than 0.75 and ICC coefficient was more than 0.80 in all variables. The UW-QOL questionnaire composite score had a positive significant association with SF-12 questionnaire total score (Spearman's Correlation Coefficient= 0.70, P< 0.0001).
Conclusion: In conclusion Persian translation of the UW-QOL questionnaire has acceptable reliability and validity and is as valid as the original English version in evaluating the quality of life for patients with head and neck cancer.

Background: The goal of this study is to assess oral and intravenous administration of tranexamic acid's (TXA) on intra-operative bleeding during endoscopic sinus surgery and to compare with control group.
Methods: Forty-eight patients who were scheduled for endoscopic sinus surgery were chosen and randomly assigned to three groups. In first group 20mg/kg intravenous tranexamic acid, in second group 1000 mg 4 times daily for 48 hours and in third group 10 ml of normal saline were administered. The quality of the surgical field was estimated every 15 minutes by Boezaart scale. Volume of bleeding, pre and postoperative hematocrit, surgeon’s satisfaction by likert scale and duration of the surgical procedure were evaluated. Data was analyzed by SPSS v21 and P<0.05 was significant.
Results: Demographic parameters were not different among three groups. The surgical field quality at 15th minute was grade I-II in 25, 68.75 and 75 percent of the patients in the control, intravenous and oral groups, respectively. And also, no patients in the intervention groups and 42% of the patients in the control group were in grade IV. At 15 minute following surgery, there was a significant difference between the tranexamic groups and the control group (P = 0.002). at 30th minute 25, 50 and 56% of the patients in the control intravenous and oral groups, respectively were in grade I-II and difference was significant (P = 0.003). But at 45th minutes quality of surgical field was not different significantly (P = 0.163). The intraoperative average bleeding was 95.46, 94.32 and 190.64 ml for intravenous, oral and control patients that difference was significant (P = 0.001). The satisfaction of the surgeon was higher in the intravenous and oral TXA groups than the control group (P = 0.012). In comparison to the control group, the tranexamic group's surgical time were considerably lower (P 0.001). Hematocrits and drug side effects did not differ significantly among groups.
Conclusion: Systemic tranexamic acid (intravenous or oral) during endoscopic sinus surgery enhances surgical field quality, decreases intra-operative hemorrhage, and shortens operation duration.

Background: Inserting a chest tube is a life-saving procedure for patients with chest trauma, but it is often associated with significant pain. To alleviate this discomfort, non-pharmacological methods such as acupressure can be employed. Therefore, this study aimed to determine the effect of acupressure on pain during chest tube removal in patients with thoracic trauma.
Methods: This quasi-experimental study involved the selection of 204 patients with chest tubes following chest trauma in Zahedan in 2022. The through patients were selected purposefully and Non-random allocation divided into two intervention and control groups of 102 people. The intervention group received acupressure treatment, while the control group did not.  Pain levels of the patients were measured using a pain intensity scale on both the day of chest tube insertion and the day of removal. The data were analyzed using statistical test such as independent-t, paired-t and chi-square statistical tests within the SPSS 26 software.
Results: The normality of the main variable was assessed using the Kolmogorov-Smirnov (KS) test. The significance level for the pain variable was found to be less than 0.05 (P<0.001), indicating a non-normal distribution. Therefore, the Mann-Whitney U test was utilized for data analysis. The results of the Mann-Whitney test revealed that before the intervention, the mean pain scores were 9.46±0.69 in the intervention group and 9.47±0.65 in the control group. After the intervention, the mean pain scores were 7.11±0.98 in the intervention group and 9.39±0.90 in the control group. Based on the Mann-Whitney U value obtained from the comparison of the two groups before and after the intervention, it can be concluded that the intervention had a significant effect on reducing pain (Table 2).
Conclusion: The insertion and removal of chest tube after trauma can be an extremely painful experiences for individuals. Considering the crucial role of nurses, non-pharmacological methods such as acupressure can be used to alleviate their pain. Acupressure is a cost-effective, accessible, and readily available approach that can be utilized in this context.

The safety of the beating heart is a health service that means the absence of clinical errors during the implementation of health care. The period of anesthesia is identified as one of the most critical phases for patients requiring general anesthesia, carrying the potential for critical clinical errors that may have irreversible consequences. This study's main objective was to conduct a concise assessment of the anesthesia checklists utilized to enhance patient safety during general anesthesia procedures. To accomplish this, a comprehensive search was conducted using relevant keywords spanning from 1990 to 2023 across databases including PubMed, Springer, Google Scholar, Web of Science, Scopus, online libraries, and the Cochrane library. Initially, 188 studies were identified at the outset of the research, and among these, 13 studies that focused on the development of checklists for anesthesia safety were scrutinized. Included articles were reviewed separately and divided into 3 categories; Specific vs. Generalized Scope, Single-Stage vs. Multi-Stage, Single-Factor vs. Multi-Factor. According to the findings from these studies, the systematic and proper utilization of all available checklists can contribute to improved safety. However, due to the specialization of surgical procedures and the increasing emphasis on patient safety over the past decade, there has been a shift in the compilation of anesthesia checklists from being broad and general to becoming specific, transitioning from single-stage to multi-stage, and evolving from single-factor to multi-factor checklists.

Tension pneumothorax (TPT) in trauma patients is an uncommon disorder caused by the progressive accumulation of air in the pleural cavity. In pre-hospital and emergencies, if it is not diagnosed and treated on time, it endangers the lives of patients. In this study, we report a patient who developed tension pneumothorax and extensive subcutaneous emphysema due to mild trauma and not going to the hospital in the early hours, which caused an anaphylactic appearance on the patient's face.

Aspiration under general anaesthesia is a dreaded complication which can significantly affects the morbidity and mortility in the postoperative period. Factors such as delayed gastric emptying seen in obesity, pregnancy, paralytic ileus, altered consciousness as under general anaesthesia, head injury can predispose the patient to pulmonary aspiration. The two entities aspiration pneumonia and aspiration pneumonitis although difficult to differentiate in the early course of event but it is of crucial importance to know the pulmonary pathology for effective management of the patient. A morbidly obese patient was posted for fracture humerus surgery under GA who landed in cannot ventilate situation, had pulmonary aspiration which was managed efficiently in ICU.

Frozen shoulder is a condition of varying severity characterized by the gradual development of global limitation of active and passive shoulder motion where radiographic findings are limited and associated with severe shoulder pain. Frozen shoulder is also referred to as adhesive capsulitis, painful stiff shoulder, and periarthritis. Treatment typically focuses on reducing shoulder pain and restoring joint mobilisation.
In the context of shoulder mobilization, the predominant nerve blocks encompass the interscalene, supraclavicular upper trunk block collectively referred to as the SCUT block, as well as the axillary nerve block. These nerve blocks demonstrate high efficacy in delivering targeted analgesia. However, a notable limitation of these interventions is the concomitant motor blockade and phrenic nerve block induced by them. This motor blockade poses a significant impediment to the initiation of early rehabilitation, thereby delaying the commencement of rehabilitative exercises and intervention.
Shoulder Anterior Capsular Block is a motor sparing block which can be effectively used in shoulder mobilisation.

Ankylosing spondylitis (AS) is a chronic autoimmune spondyloarthropathy involving spine and sacroiliac joints resulting in characteristic bamboo spine (fused and rigid spine). A 41yr old male patient with Ankylosing spondylitis with history of Left THR presented with periprosthetic fracture posted for ORIF with plating. He had a classical bamboo spine with cervical involvement, MPC- 3 and restricted neck mobility. Preoperative Ultrasound scan (USG) of lumbar region done to identify spinal spaces. Awake Fiberoptic Nasal intubation done to secure difficult airway and induction done with Propofol and Vecuronium. Epidural catheter inserted at L1-L2 space using paramedian approach under USG under General Anesthesia in lateral position and Epidural analgesia given with 1% Ropivacaine. Extubation was done uneventfully with Sugammadex 2mg/kg used as reversal at end of surgery. Anaesthetic challenges in AS were both difficult airway and difficult regional anesthesia which was successfully managed with detailed evaluation and planning with USG.