shahrokh ghazizadeh

Cataract extraction surgery remains the most commonly performed eye surgery by ophthalmologists. The maintenance of mydriasis is required throughout surgery to allow better visualization of the surgical field and a greater working space within the center of the eye. Non-steroidal anti-inflammatory agents (NSAIDs) have their effect in maintaining mydriasis by their ability to inhibit prostaglandin synthesis.
This was a prospective, randomized clinical trial study in 84 patients undergoing phacoemulsification cataract surgery. Patients were randomized to ketorolac tromethamine 0.5% (n=42) or the control group (n=42). Patients in the ketorolac group received one drop of ketorolac every 15 min for a total of 4 drops from one hour before surgery. The horizontal diameters of the pupil were measured in millimeters with a caliper under the microscope at the following stages: before surgery, after intracameral epinephrine injection, after nuclear emulsification and at the end of surgery.
The difference in pupillary diameter at the end of surgery was statistically significant between two groups (7.34 ± 1.0 mm and 8.01 ±0.67 mm in the control and the ketorolac groups, respectively; p=0.018). The difference in mean pupil size after intracameral epinephrine injection and after nuclear emulsification between the control group (0.51 ± 0.25 mm) and the ketorolac group (0.01 ± 0.20 mm) was statistically significant (p Topical ketorolac is an effective inhibitor of miosis during phacoemulsification cataract surgery, and provides a more stable mydriatic effect throughout the surgical procedure.

Obtaining a good sensory and motor block is the goal of performing spinal anesthesia for surgeries. The aim of this study is to compare the effect of trendelenburg position on sensory block level after spinal anesthesia with intrathecal hyperbaric bupivacine. We enrolled 80 men, classified as ASA I, scheduled for elective hernia repair under spinal anesthesia. Participants were randomly allocated equally to one of the two groups, horizontal or trendelenburg position. Spinal anesthesia was performed in the sitting position using 15 mg of 0.5% hyperbaric bupivacaine. Then the patients were turned to supine position. In trendelenburg position group, a 20 degree head tilt position was performed for 40 seconds, then the patients were returned to horizontal position and 30 mg ephedrine was administered intramuscularly. Sensory block level and incidence of hypotension were recorded in the two groups. There were significant effects of trendelenburg position on sensory block heights during the study period (10.61 ± 0.32segments blocked above the injection point versus 7.24 ± 0.51 in horizontal group). No episodes of severe hypotension were seen among the patients. Six patients in horizontal group experienced intraoperative discomfort or pain, versus no patient in Trendelenburg group. (p=0001). A higher level of sensory block can be obtained with performing a short time head down position after intrathecal injection.

Subarachnoid block with local anesthetics and opioids enable efficacious spinal anesthesia because of their synergistic effect and permit the use of low-dose local anesthetics, which results in a stable hemodynamic state. The purpose of this study was to describe the cardiovascular effects of spinal anesthesia with low-dose bupivacaine and sufentanil on patients with coronary artery disease. This study was a double-blind randomized clinical trial. A total of 18 patients who had known coronary artery disease were enrolled. Our subjects underwent spinal block for lower limb surgery with 7.5 mg hyperbaric bupivacaine 0.5% and 5 µg sufentanil. Complications related to anesthesia such as hypotension, bradycardia, vasopressor need, and blood or volume use were recorded. The average mean arterial pressure decreased 15% in the first 15 min of spinal block in our cases. No patients presented with hypotension and the subjects were without complaints during the spinal anesthesia. All patients remained alert, and no ST segment changes were observed intraoperatively and until 6 h after the operation. Baseline ejection fraction (EF) 40% or less was observed in 10 patients and these subjects were compared with other patients. Systolic and diastolic blood pressures, mean arterial pressure, and heart rate decreased during the first 15 min in response to spinal anesthesia in both groups of patients, but decreased more significantly in patients with EF >40%. We recommend spinal block with low-dose bupivacaine and sufentanil in patients with coronary artery disease and especially in patients with low EF.

The use of local anesthesia with lidocaine containing epinephrine in patients with cardiac disease is controversial in the literature. The aim of our study was determining the safety of use the local anesthesia contain epinephrine in patients with ischemic heart disease that undergoing reconstructive surgery. Thirty two patients that had known ischemic heart disease and candidate to undergo reconstructive surgery for skin tumor enrolled in this study. All patients continued their medication for cardiac disease till morning of the operation. 10 ml lidocaine 2% containing 1:100,000 epinephrine was injected in patients for local anesthesia. The hemodynamic changes and electrocardiographic variables before injection were compared with them after injection, during surgery and till 6 hours postoperation period. A 12 lead electrocardiogram was recorded in all our cases for detection of myocardial ischemic changes. The mean age, weight and height were 58.2±10.4, 74.8.±14.4 kg and 164.5± 8 cm respectively. Twelve patients (37.5%) were diagnosed with systemic hypertension and 10 patients with diabetes (31.2%). The comparison of change of systolic, diastolic and mean blood pressure between baseline, during procedure and after operation defined that our subjects did not have any significant disturbance in blood pressure in perioperative period. The comparison of baseline heart rate with heart rate after injection, during procedure and in postoperation period indicated a significant changes in this variable (P=0.044). The heart rhythm during the perioperative period also failed to exhibit alterations. The ischemic change was not recorded in our patients before injection compared to after injection. None of our patients have any early complications because of infiltration of local anesthetic containing epinephrine in our patients. The use of 10 ml 2% lidocaine with epinephrine 1:100,000 in patients with cardiac disease represent a safe anesthetic procedure. These patients experienced a more profound anesthesia with hemodynamic stability and without myocardial ischemic changes

The aim of this study was to assess the effect of spinal block with low dose of bupivacaine and sufentanil on patients with low cardiac output who underwent lower limb surgery. Fifteen patients who had ejection fraction less than 40% (group 1) were compared with 65 cases with ejection fraction more than 40% (group 2) in our study. Our subjects underwent spinal block with 7.5 mg hyperbaric bupivacaine 0.5% and 5 µg sufentanil. We recorded early events such as hypotension, bradycardia, vasopressor need and ST segment change in our cases. The average mean arterial pressure decreased 13% (110 mmHg to 95.7 mmHg) in group 1 and 20% (160 mmHg to 128 mmHg) in group 2 (P<0.001). Hypotension due to spinal anesthesia was observed in none of our subjects in both groups and none of our cases need to vasopressor support. All patients remained alert, and no ST segment changes were observed in two groups. In our study none of subjects complained of pain intraoperatively. The subjects were without complaints during the spinal anesthetic in both groups. Spinal block with low dose local anesthetic and sufentanil was a safe and effective method for lower limb surgery in patients with low ejection fraction.