JOURNAL OF IRANIAN SOCIETY ANAESTHESIOLOGY AND INTENSIVE CARE
Year:2006 | Volume:28 | Issue:54|Papers Count:13

Background: Cardiac surgery and cardiopulmonary bypass (CPB) initiate a systemic inflammatory response which adversely affects postoperative pulmonary function. The purpose of the present study was to assess the pulmonary effects of N-acetylcysteine (NAC) in patients undergoing Coronary artery bypass graft surgery (CABG) Materials and methods: In a randomized. Double blind, clinical trial study (April-October 2005) in our institution, forty consenting patients undergoing elective CABG were randomized into two groups. Group I (20 patients) received a physiologic saline solution as a placebo one hour before CPB; group II (20 patients) received 50 mg/kg NAC intravenously for one hour before CPB. Preoperative hemodynamic and pulmonary data were recorded. Data were analyzed by SPSS 11.5 software using appropriate tests including Chi-square and T-tests. The results were evaluated as the mean±SE and considered statistically significant for p<0.05.Results: The preoperative demographic and basic clinical variables including mean age (59.1+1.4). Body mass index (25.7±0.6), cardiac ejection fraction (47.1±1.7), and pulmonary function test (PFT) and CPB time (109.2±4.7) were similar in the two groups.Patients in group I exhibited significantly lower dynamic lung compliances in the ICU (p<0.05). The rapid shallow breathing index (RSBI) was significantly more in group I (p<0.001).The static lung compliance was better in group II (p<0.001). There was no significant difference in terms of mechanical ventilation duration, intubation time and ICU stay.Conclusion: This clinical study reveals that administration of NAC to patients undergoing elective CABG with CPB improves some pulmonary parameters in the postoperative period but does not alter the duration of mechanical ventilation and ICU stay. So we believe that the effect of NAC in the pulmonary function after CPB needs to be further evaluated.  

Background: The patients with fractures of femoral shafts have severe and vigorous pain which limit their lateral positioning to perform spinal anesthesia. To detect an appropriate solution for decreasing their pain, we decided to compare femoral block and IV fentanyl injection.Materials and Method: This study was performed as a randomized single blind sequent ional clinical trial.Prior to spinal anesthesia, pain score evaluated through visual analogue scale (VAS) [from 0 to 10], after that, patients randomly divided into two groups, 10 members in each group. In the first group patients received 1.5 mg/kg fentanyl intravenously. Once their condition was suitable to achieve the position, VAS again assessed. In second group after femoral nerve block (F.B) (20cc lidocaine 2%) VAS evaluated, then the patients positioned laterally to perform spinal anesthesia.Results: This study showed that the time for painless lateral positioning in group F.B was shorter than group IV fentanyl.VAS score for F.B group was lower than IV fentanyl group. The entire information mentioned earlier was analytically significant (p<0.05) and showed satisfactory consequences.Conclusion: In respect to this study, F.B is reliable, safe, inexpensive and it is feasible to perform in all stages of accidents.

Background: Insufficient control of post-thoracotomy pain can create prolonged stay in NICU and Hospital, increasing incidence and severity of pulmonary complications such as atelectasis, pneumonia or pulmonary failure through compromising natural pulmonary mechanisms. The aim of this study was determining analgesic effect of continuous extra pleural nerve block using ropivacaine after thoracotmy surgery in neonates < 7 days and the incidence of atelectasis and duration of hospitalization in NICU. Materials and methods: 41 neonates < 7 days that were thoracotomy candidate, allocated randomly into two groups in a controlled clinical trial. The cases received extra pleural infusion of ropivacaine (0.1 m/kg hr) for 48 hours and controls who were managed according to routine protocol of "Mofid Children Hospital". Hemodynamically unstable patients and those who suffered from hospital infections were excluded from the study. After the surgery all patients had spontaneous breathing. Pain level was determined for each neonate based on NIPS grading. The incidence of atelectasis in first 48 hours after operation and duration of NICU stay were also determined. Results: There were no significant differences in mean age, sex proportions and mean weight between the two groups. One of cases excluded because of hemodyamic instability. Mean pain score in the group received ropivacaine (1.9±0.7) was significantly less than the control group (5.2±0.6) (p<0.0001). Five percent of cases (n=1) but 100% of controls (n=20) had pain score equal or greater than 3 (p<0.0001).The incidence of atelactasis among cases was marginally less than controls (35% vs. 65% respectively; p=0.58). Duration of hospitalization in case group (12±5.6 days) has no significant difference from control group (13.6±4.8 days) (p=0.3). Discussion: The results show that continuous extrapleural infusion of ropivacaine reduces the pain markedly and atelectasis after thoracotomy surgery in neonates younger than 7 days.

Background: Post anesthesia shivering is an unpleasant postoperative complication that may cause morbidity. Pharmacological control is an effective method in treatment and prevention of postoperative shivering. Furthermore, pethidine prevents or manages shivering far better than equianalgesic doses of the opioids. However, buprenorphine is an opioid with similar in structure to morphine but approximately 33 times more potent.Material and Methods: In this study the effect of buprenorphine is evaluated. This randomized double blind clinical trial was designed to compare the efficacy of buprenorphine and pethidine in prevention of post anesthesia shivering. 60 ASA grade 1-2 patients undergoing general anesthesia for elective cesarean section were entered into the study. Patients received either buprenorphine 3 mg/kg (n=30) or pethidine 0.5 mg/kg (n=30) intravenously 30 mins before the end of surgery. Pulse rate and blood pressure were measured 15 mins after injection.Occurrence of shivering was evaluated during one hour in recovery room. Also, pain intensity was assessed by using visual analog scale VAS; 0-5).Results: Shivering was significantly reduced in pethidine group (5 of 30 versus 13 of 30,  p<0.05). Visualpain score in both groups were similar. There were no differences between two groups in hemo-dynamic responses.Conclusion: Despite of similar pain control, pethidine is more effective than buprenorphine in prevention of post anesthesia shivering.

Background: This retrospective analysis was done to evaluate the outcomes of patients undergoing aortic root replacement with Sental procedure.Materials and methods: 84 patients (mean age 43±13.8 years) who undervent replacement of the thoracic aorta and aortic valve were studied.Degenerative disease of the aorta was the most common cause of requiring operation in 60 patients (71/42%), flowed by type A disection 21 patients (25%), atherosclerotic aneurysn in 4 patients (4/76%) and poststenotic dilatation (bicuspid vavlve) in 4 patients (4/74) and 21 patients (25%) had marfan syndrome.Results: There were four intraoperative and seven postoperative deaths. Complication during hospital follow-up including neurologic events 15 (17/85%), and 8 patients had acute renal failure, (10%). 15 patients had significant bleeding requiring reparation or transfusion and removed packed gauge (17/8%). Mediastinitis in 1 patient (1/19%), permanent pacemaker in 1 patient (1/19%), significant arrhythemia or CPR in 21 patients (25%), perforation of deoudenum in 1 patient (1/19%), gastrointestinal bleeding in 1 patient (1/19%), and septicemia in 3 patients (3/57%). Morbidity in our study was 31 patients (36.9%) and mortality was 11 patients (13.9%) which was higher than other which were published by other investigators. Conclusion: As the complications of bentall procedure in Shahid Rajaeii Hospital are more than the other centers, we recommend controlled studies to find the pitfalls.

Background: Up bite test is a new method for predicting difficult intubations. The purpose of this study was to compare the lip bite test with both Cormack as a gold standard and thyromental distance.Material and methods: 350 patients undergoing general anesthesia for elective surgeries were included in a prospective observational double blind study. All the cases were older than 16. Patients with head and neck diseases such as trauma, tumors, movement limitations and bum history were excluded. The lip bite tests cormack and thyromental distance were determined in all patients by an anesthesiologist with experience of at least 3 years work. Induction of anesthesia was the same for all groups. Results: Patients with ULB Tgrade 3. or cormack grade of 3 and 4 or thyromental distance of less than 4 cm were predicted as difficult intubations sensitivity specificity and accuracy of thyromental distance less than 4 cm for predicting difficult intubations were 55%, 88%, 86%, Vs. 70%, 93%. 92% for UBLT. There were statistically significant differences for specificity (p<0.05). There were no statistically significant differences for sensitivity and accuracy.Conclusion: UBLT is more specific and much simpler than thyromental distance for predicting difficult intubations.

Background: The goal of this study is comparison of adding tramadol to lidocaine in continuous supraclavicular block for upper extremity procedure.Materials and Methods: This Study was done on 100 patients aged 20-60 yrs, with ASA physical status I or II undergoing upper extremity procedures under continuous supraclavicular block. The block was performed by peripheral nerve stimulator, and after desirable muscular responses, catheter for additional injections was indwelt. Patients were randomly allocated in two groups. Group LN (n=50) received 2% lidocaine 7 mg/kg plus 2 ml distilled water, and group LT(n=50) received 2% lidocaine 7 mg/kg plus 100 mg (2 ml) tramadol. For additional intraoperative analgesia, 2% lidocaine through catheter, and intravenous sufentanil and midazolam was administrated.Onset and duration of complete sensory and motor block, total intraoperative drug consumption (lidocaine, sufentanil and midazolam), postoperative sensory and motor block, time to first postoperative analgesic request, complications, and demographic data were recorded.Results: There were no significant differences in subject demographic and clinical data between lidocaine (LN) and lidocaine plus tramadol (LT) groups with respect to age, gender, weight, anesthesia duration and surgical time. Onset of complete sensory and motor block was more rapid in LT than LN group. Although, duration of complete sensory block was longer in LT than LN group, There were no significant differences in respect to postoperative sensory and motor block between the two groups. Also, total lidocaine administrated through supraclavicular catheter was significantly lesser in LT group compared to LN group. There were no significant differences in respect to postoperative sensory and motor block, and complications between the two groupds. In LT compared to LN group, intraoperative sutentanil (but not midazolam) consumption was significantly less, and time to first postoperative analgesic request was significantly greater.Conclusion: Addition of 100 mg tramadol to 2% lidocaine for continuous supraclavicular block can provides specific analgesic effects on peripheral nerves, and may be an appropriate alternative to adjuvant for adding to local anesthetics.

Background: Some reports indicated that there are significant differences between endotracheal tubes in order to intracuff sealed presure. The aim of this study was to compare intracuff sealed pressure and changes of this pressure during operation at the presence of N2O between common endotracheal tubes in Iran. Materials and methods: Sixty endotracheal tubes with high volume-low pressure cuffs in six groups (each group equal to 10) including Homecare (Japan), Supa (Iran), Kendall and Exell (UK), Novatex (China) and Well lead (Holland) were selected and were used these tubes for intubation of patients (Age: 20-65) whose candidate for orthopedic surgery. After induction of anesthesia and endotracheal intubation, the cuff was filled with room air and the anesthesia maintained using halothane, O2 and N2O. In each tube, the intracuff sealed pressure and also changes of this pressure (each 15 minutes) were measured. Data were analyzed uning X2 and ANOVA.Results: The mean intracuff sealed pressure in all tubes was 28.68±7.35CmH2O. There was no significant difference between six groups of endotracheal tubes in order to intracuff sealed pressure. Intracuff pressure in all tubes was raised significantly during Operation(p=0.000) At 45 minutes after induction of anesthesia and thereafter, the Increased Intracuff pressure was significantly different between Supa and Exell tubes (p<0.05, ANOVA).Conclusion: Data of present study showed that the intracuff sealed pressures were not different between common endotracheal tubes in Iran. The lowest and highest increase of intracuff pressure during operation was related to Exell and Supa endotracheal tubes respectively. In long-time operations it may be prefer to use of Exell endotracheal tube for airway management.

Thrombotic thrombocytopenic purpurea as a rare and fatal complication in pregnancy is a multisystem disease that can cause rapid deterioration of the patient's renal and hematologic status. The patient was a 30 years old woman who underwent emergency hysterectomy for abruption placenta and intra Uterin Fetal Death (IUFD). Following the surgery, due to oliguria neurologic abnormality.thrombocytopenia, hemolytic TTP was diagnosed and transferred to the ICU. Her condition in ICU was very poor and ventilatory support was started. Following a classic TTP therapy her condition gradually was improved and she was discharged two weeks later. Early diagnosis and treatment of TTP is essential for the survival of patients. Differential diagnosis in postpartum setting includes Acute Fat liver pregnancy (AFLP), HELLP syndrome. DIC and preeclampsia. Differentiating among these conditions is critical because they respond to different therapeutic modalities. Treatment with platelet infusion can be fatal in TTP. Therefore, including the TTP in the differential diagnosis of thrombocytopenia is imperative.