JOURNAL OF IRANIAN SOCIETY ANAESTHESIOLOGY AND INTENSIVE CARE
Year:2003 | Volume:23 | Issue:42|Papers Count:13

Anesthesia consultation clinics are established in hospital setting for improving the clinical assessment and preparation of the patients to reduce the risks of preoperative period. This study is a prospective descriptive trial during eight months (February - September 2003) at Imam Hossein University Hospital in Tehran. 408 patients of ASA class 1, 2 divided in two groups (A, B, 204 patients in each group).Group A: Those patients who have passed the anesthesia clinic.Group B: Those patients who have not passed the anesthesia clinic.This study is verifying the number of days of hospitalization before surgery, all other consultations, para clinic evaluations, and all related costs as a randomized non - sequential manner. The preoperative hospital stay in group A was 472 days (mean= 2.31 days for each patient) and in group B was 796 days (mean=3.90 days for each patient). The number of consultation in group A was 60 (29.2%) and in group B was 97 (47.2%). Para clinic studies in group A was a little more than group B (0.5%). The total cost of preoperative evaluation for each patient in group A was 37369 Rls which was 37.9% less, when compared with group B.

To evaluate the effect of preemptive analgesia on the postoperative pain intensity and analgesic requirment, in this clinical trial study the effect of low dose ketamine is examined on patients, who underwent cesarean section under general anesthesia. Anesthesia was induced with sodium thiopental and maintained with N2O/O2 (50/50) and 0.5 Mac of Halothane in both control (n = 30) and Ketamine (n=30) groups. In Ketamine group 0.3 mg/kg ketamine was administered intravenously prior to induction of anesthesia. After the baby was born and the cord was clumped, opioid was given to both groups for pain relief.In postoperative period, the pain intensity was evaluated by pain score, initially hourly and then 3 hourly up to 24 hours. Opioid was administered in case of patient complaint of pain in both group.The patients in control group complained of pain significantly earlier than Ketamine group (1.35± 0.5 hr Vs 4.5± 1.2 hr, p<0.05). Ketamine group required the visit for postoperative pain less frequently (p<0.05) and the mean dose of opioid needed for pain relief was significantly less in Ketamine group (p<0.05).Administration of low dose ketamine before anesthesia induction for cesarean section is associated with lower postoperative analgesic requirment and pain intensity during the first 24 hr after surgery. Ketamine have unique properties that may reduce sensitization of pain pathways and extend sensitigation into the postoperative period.

Pain is the most common cause of the presence patients in the clinics, and headache is one of the most frequent cause of chronic pains. Tension headaches is usually non organic and could appear at any time of the day, although usually increases at the end of the daily activities. One of the non-drug therapeutic modalities for tension headache is induction of hypnotism and relaxation. In our study 30 patients (13 men, and 17 females), with mean age of 21.5 years (17-38) who were known cases of tension headache underwent hypnotism, in 3 to 7 sessions. Our technique was progressive relaxation and guided imagery. Patients were followed for one month. There was no headache in 16 patients (53.3%), while hypnotism was not effective in 4 patients (13.3%). In 3 patients there were no change in the intensity and frequency of headache, and in 6 patients the frequency and intensity of pain was alleviated, so the days of treatment for analgesic was decreased significantly. One patient did not follow the treatment and was omitted from the study. We concluded that this induction of hypnotism is an effective modality for the treatment of tension headache.

The effect of positive end expiratory pressure (PEEP) on the hepatic elimination of low to moderate extraction ratio drugs has not been clearly defined. We prospectively investigated the effect of PEEP on pharmacokinetic behavior of aminophylline in 30 (20 males, 10 females) critically ill adult patients with acute lung injury / acute respiratory distress syndrome. Based on their ventilation and oxygenation profiles, patients were decided to either low PEEP (5-9cmH2O) or high PEEP (10-15 cmH2O), supervised by attending physicians. All patients received the ordered dose of aminophylline infusion (3mg/kgin over 30 minutes and then 15mg/h)after 2 hours of initiating PEEP. Blood samples were collected after loading dose, 2 and 6 hours into the aminophylline continuous infusion. Cirrhotic patients and those who received any drugs that could interacted with metabolism and clearance of aminophylline were not included. Vital signs were recorded before and after 2 hours of PEEP and each time of blood sampling. Mean (±SD) of the pharmacokinetic key parameters of aminophylline in high (n=17) and low (n=13) PEEP groups were as followed: volume of distribution (Vd) = 0.42 (±o.15) L/Kg & 0.54(±0.13) L/Kg and aminophylline clearance =0.035) (±0.024) L/Kg/h & 0.056 (±0.025) L/Kg/h. Mean measured aminophylline concentration after 6 hours of loading dose were 6.24 (±3.50) mg/L and 3.98 (±1.04) mg/L. The calculated volume of distribution (p<0.03), clearance (p<0.05) and aminophylline serum concentration (p<0.05) in high versus low peep groups, were found to be significantly different. We also found that patients who had higher aminophylline serum concentration after 6 hours, had higher level of PaO2/FiO2 too (p=0.09). However this difference was not statistically significant, but clinically it was very important. And in patients with lower arterial pH, volume of distribution were greater however it was not significant either. (p=0.43). Because of significant difference in calculated volume of distribution and aminophylline clearance in high and low PEEP group, this study showed that positive ventilation tends to reduce Vd and clearance of aminophylline in critically ill patients. Therapeutic drug monitoring of aminophylline, must be applied to reduce the likely-hood of therapeutic failure among critically ill patients.  

Ultra fast track extubation (U.F.T.E) in operating theater after CABG surgery is a new topic in medical world. Benefits like shortened time of mechanical ventilation and less related complications, better hemodynamic stability, shorter length of stay in ICU, improved psychological condition, faster onset of oral medications and decreased financial expenses, lead us to have a try on it, so we had a descriptive and prospective study with non-randomized simple sampling on 40 patints who were candidates for Off-Pump Coronary Artery Bypass surgery (OPCABs) from March to August 2003 in the department of open heart surgery at MUMS's Imam Reza Hospital. We chose Remifentanil based Total Intravenous Anesthesia (T.I.V.A) method. All patients were post-operatively extubated while in operating room, and then transferred to ICD. All patients had continuous intravenous of Remifentanil for post-operative pain control. All of them had suitable intra and post-operative hemodynamic stability. Three hours after admission in ICU, they were able to be given oral medications. Concerning complications and problems, two patients suffered from mild nausea while two other patients experienced transient apnea. One patient needed to have tracheal intubation due to insufficient ventilation and arterial blood gas disturbance. Mean Visual Analogue Scale (VAS) were 0.7 and Sedation Agitation Scale (SAS) about 3.6 Recall of intra - operative events, and mortality rate were absolutely zero. None of patients needed to have re-operation.

In some thoracic surgery double-lumen tube must be used mandatory for lung isolation and spillage preventing or surgical exposure facilitating. Some dangerous and life-threatening complications may occure due to malplacement of these tubes such as hypoxemia, ventilation failure, bronchial laceration and healthy lung infection, hence early recognition and correction is necessary. The best method for this purpose is fiber optic bronchoscope. In this study of 72 endorbronchial double-lumen intubations for thoracic surgery, we reviewed the positions of tubes by bronchoscope after lung auscultation and physical examination has been completed by anesthesist and repositioning of tube has been done if needed, the results of bronchoscope were documented in the checklist in order of 7 different positions of tubes.Bronchoscopic finding in 52.8% of cases demonstrated malplacement of tubes despite of lung auscultation and physical examination. In the remaining 47.2% of correctly placed tubes 30 of them (88.2%) were left sided Robert Show tubes which were located in left lung and 4 of them (11.8%) were right-sided which were located in right lung. Difference of right and left well placed tubes was explanable because of short right bronchus versus longer left bronchus. Obstruction of orifice of right upper lobe was the most common malplacement which observed and the others were: Opposite side intubation, too far or not too far enough down the tube, and herniation of bronchial cuff into carina. In the concern of high prevalence of malplacement of double lumen tubes fiberoptic bronchoscopy is recommended after each case of double lumen tube intubation.

The internal mammary artery (IMA) has become important graft material in coronary artery bypass grafting (CABG). It has proved to be the most long-lasting of the available graft material and is now used routinely in many centers. This study was done to evaluate effects of pleurotomy during CABG on postoperative complications. In this prospective study, 200 patients undergo CABG electively in Shaheed Rajaii Hospital, were divided in two groups: group A (with pleurotomy) and Group B (without pleurotomy). The following variables were evaluated for each patient: duration of mechanical ventilation, ABG, postoperative pulmonary complication and parameters, and the length of ICU stay. Data was analyzed by the Hest, chi-square test, and nonparametric tests. P Value <0.05 considered significant. In our study pulmonary complications, and ICU stay have shown no significant difference in two groups (p>0.05). Only incidence of pleural effusion was higher in group A (p<0.05). Therefore we concluded that opening the pleura during CABG does not increase post operative morbidity.

The study of peripheral analgesic effects of Ketamine shows, theoretically ketamine might represent an alternative agent for intravenous regional anesthesia. The main goal of this study is determination and comparison of onset and intensity of block with Lidocaine plus Ketamine and Lidocaine (plain) in Bier block. This sequential randomized double-blind clinical trial was performed on 40 patients with ASA I & II. Subjects were divided in two groups and matched in terms of age-sex. Lidocaine 0.5% (0.6 ml/kg) was administered to control group. Study group received Lidocaine 0.5% (0.3 ml/kg) plus Ketamine 0.5% (0.3 ml/kg).The onset of analgesia for cases (12±2.77 min) was slower than controls (6.75±1.21 min) (p<0.05).Intensity of block between control and case groups did not show meaningful statistical difference (p>0.05).This study represent that Lidocaine plus Ketmine not only do not intensify analgesic effects of each other, but also in some instances attenuate these effects. This study shows that the combination of Lidocaine plus Ketmine in Bier block does not have any preference over Lidocaine alone.