فصلنامه آنستزیولوژی و مراقبتهای ویژه ایران
سال سی و یکم شماره 2 (پیاپی 66، تابستان 1388)

Recent studies suggest the use of non – invasive ventilation in patients with acute cardiogenicpulmonary edema (ACPE). However,
it remains unclear whether patients with ACPE benefit from non – invasive ventilation. This study designed to investigate short – term effects of non – invasive ventilation on respiratory, hemodynamic
and oxygenation parameters in patients with respiratory failure due to ACPE and to identify need for intubation, recovery and admission.
In this randomized clinical trial study, 80 patients assigned to conventional oxygen therapy or non – invasive ventilation supplied by a standard ventilator through a face mask with mode of bi-level positive airway pressure (BIPAP),
in addition to standardized pharmacological treatment. Physiological parameters were obtained in 0, 15, 30, 60 minutes after non – invasive ventilation. The main end points were intubation and recorded recovery time (defined as oxygen saturation of 96% or more and respiratory rate less than 30 breaths / min)and ICU stay. Endotracheal intubation was required in one (2.5%) of 40 assigned non – invasive ventilation and in six (15%) of 40 assigned conventional therapy (p= 0.1) recovery time was significantly shorter in the non – invasive ventilation group mean 42 ± 9.9 vs 131±22.5 (p= 0,0001) non – invasive ventilation led to a rapid improvement in oxygenation, respiratory rate, arterial PH, heart rate and blood pressure in the first hour (p= 0.0001). There were significant differences in intensive care unit length of stay 2.8±1.2 days in non – invasive ventilation group vs. 4.8 ± 1.5 in control group. (p= 0.0001). No hospital mortality was recorded. In this study of acute cardiogenic pulmonary edema non – invasive ventilation in mode of BIPAP was superior to conventional oxygen therapy. We suggest further studies to compare bi level positive airway pressure with continuous positive airway pressure non invasive ventilation on treatment in these patients.

Intruduction: The aim of this study is to compare two methods of LMA insertion, "classic" versus "simplified" (AIRWAY), due to factors such as: time to insertion, number of attempts, blood stained LMA, air leak around LMA, and gastric inflation. The word "AIRWAY" refers to the similarity of this method to oropharyngeal airway insertion. One hundred ASA Class I and II patients elected for lower limb orthopedic surgery but without any head and face injury or head and neck abnormality, having their tooth intact, were selected anddivided to two groups of fifty; classic and simplified. In the classic group, the index finger used as a guide, pushes the back of LMA towards the hard palate, inserting it into the pharynx till a resistance is felt and the LMA is then fixed it its place.In the AIRWAY group, the deflated LMA is entered into the mouth in a 180 degree inside-out position compared to the classic method without using fingers and is proceeded until it enters the pharynx (sudden loss of resistance) and then returned 180 degree back to its normal position to be fixed in the right place. The attempt numbers, time to insertion, complications such as laryngospasm, blood stained LMA and gastric inflation is being investigated. The data collected was analyzed be SPSS ver 1 and compared in two groups with unpaired T-Test or Mann Whitney U test by case. Again Chi-square test was used to analyze numerical data and p<0.05 was considered as meaningful. Demographic data such as age, sex and ASA Class, demonstrate no meaningful statistic differencebetween the two groups.Successful first attempt in AIRWAY group (86%) had no meaningful statistic difference with the classic group (80%) (p>0.05). The overall success rate in LMA insertion (within two attempts) was 100% and 82% in AIRWAY and classic groups respectively (p>0.05) and 11 patients with failed insertion attempts, were excluded from the study. The time for successful insertion was meaningfully less in the AIRWAY group compared to the classic one (p<0.0001). In the classic group 32% of LMAs became blood stained compared to 16% in the AIRWAY group, which the difference was not meaningful. No other complications such as laryngospasm or oxygen desaturation occurred. Comparison of the whole advantages and disadvantages of both groups, mention that, by putting the LMA insertion time together with the low complication rates, the AIRWAY method can be assumed as a preferred simplified method with few complications for inserting LMA.

Regional anesthesia is the preferred technique for cesarean section. In this regard spinal anesthesia with bupivacaine is the most prevalent, but this method has only 2 to 2.5 hours duration of analgesia, therefore different additives has been used in order to prolong its analgesic duration. In this study efficacy of Midazolam, added to bupivacaine, studied on postoperative pain. This study was a double blinded clinical trial on 54 parturients with ASA I, II candidate for elective cesarean section. The parturients assigned into two groups: 27 in each one. Before spinal anesthesia, 1000 ml ringer solution infused, then spinal anesthesia was done in sitting position through L3-L4 or L4-L5. Bupivacaine group (B), received 3 ml of 0.5% bupivacaine, and bupivacaine + midazolam group (BM), received 3ml of 0.5% bupivacaine + 0.4 ml of midazolam (2mg). Hemodynamic status including systolic, diastolic, and mean arterial pressure and heart rate were measured each 2 minute post spinal until child bearing, then every 15 minute till 30 minutes and finally every 1 hour for 5 hours. Pain score measured by numerical analog pain score (NAS) during postoperative period every hour for 5 hours. The data analysis was done by t-test. There was no significant difference between two groups concerning demographic data and length of operation. Systolic blood pressure at 4th and sixth minute, third hour and fourth hour; diastolic blood pressure at second and third hours; and heart rate at fourth minute until fifth hour was significantly lower in BM group compared with B group. Mean arterial blood pressure showed decrement within both groups yet were not significant in comparison with the base line. Both groups were painless during first two postoperative hours, while BM group had less pain score in third hour (p<0.05); moreover, BM had less pain score at fourth and fifth postoperative hours, it was not statistically significant.(P> 0.05) Addition of midazolam to bupivacaine in spinal anesthesia was effective in lowering the pain score during first postoperative hour and is recommended.

Sufentanil and remifentanil are characterized by two different pharmacokinetic profiles. The aim of the present study was to evaluate the effects of sufentanil and remifentanil on recovery profiles of patients in recovery.  In a randomized clinical trial, 84 adult (17-41 years old) female patients who were considered for elective laparoscopic cholecystectomy surgery in Hazrat Rasool hospital were divided into two groups of Sufentanil (n=43) and Remifentanil (n=41) and their hemodynamic state, post operative nausea and vomiting (PONV) and need to its treatment, the post operative pain intensity and need to treatment of it were assessed. There were no significant differences regarding age and ASA Class. The operation duration was significantly longer in sufentanil group compared with remifentanil group (88.81±78.653 vs. 49.36±6.313 minutes, respectively). After surgery, heart rate showed a significant increase (in sufentanil group, 79.30±9.392 vs. 85.02±8.096 and in remifentanil group 79.17±7.629 vs. 83.98±8.774 beat/min). The post operative pain intensity and need to treatment of it were comparable among groups. Postoperative nausea was significantly higher in sufentanil group compared with remifentanil group (55.81% vs. 40.48%). However, there were no significant differences in post operative vomiting rate or need to treat it among study groups. Using remifentanil in patients undergoing laparoscopic cholecystectomy surgery is accompanied with minor differences with utilizing sufentanil.

In recent years, by using adjuvant drugs to reduce the dose of local anesthetics and gaining faster recovery, while improving the quality of anesthesia and reducing the complications has been favored. This study was designed to compare the onset and duration of sensory and motor block, as well as the hemodynamic changes following administration of hyperbaric bupivacaine in spinal anesthesia supplemented with either intrathecal fentanyl or oral clonidine.

 In a double-blinded study, patients candidate for elective orthopedics surgery for leg were enrolled according to inclusion and exclusion criteria, and were randomized into two groups, each containing 30 patients. In fentanyl group, the patients received 3cc hyperbaric bupivacaine 0.5% and 25 μg fentanyl interathecally. In clonidine group, the patients received 0.1mg clonidine 60 minutes before beginning spinal block orally. Hemodynamic changes, sensory block by pinprick test and motor block by Bromage scale were measured and recorded by physician. There was no significant difference according to age, sex, mean arterial pressure and pulse rate (p>0.05). The level of sensory and motor blocks was higher in clonidine group than fentanyl group (p<0.002). There was no significant difference according to favorable sensory block for operation (p 0.147) or regression of sensory block (p=0.324). The regression time of motor block was less in clonidine group than fentanyl group (p=0.014). Administration of oral clonidine compare to intrathecal fentanyl to the hyperbaric bupivacaine in spinal anesthesia yields a higher sensory and motor block level and a faster regression time of motor block without producing any significant hemodynamic changes.

To evaluate the efficacy of clonidine as a premedication for producing a bloodless surgical field compared with placebo in patients undergoing middle ear microsurgery. This prospective double-blinded clinical trial was performed on 51 patients (ASA I, II), aged 15-60 yr undergoing middle ear microsurgery who had no history of hypertension, known diabetes and cardiovascular disease, concomitant treatment with monoamino oxidase inhibitors, tricyclic acid (TCA), nonsteroidal anti-inflammatory drugs (NSAIDs) and antihypertensive drugs or beta blockers, known hypersensitivity to the study drug, and severe psychological disorders entered our study. They were randomly assigned to receive either 200
g PO clonidine or placebo 90 min prior the operation under double blind condition. Anesthesia was similar in both groups. Intraoperative bleeding was assessed on a four-point scale from =no bleeding (excellent surgical condition) to 3=abundant (troublesome) bleeding (continuous suction) according to the surgeon opinion. Systemic blood pressure and heart rate were measured before and during the surgery. Intraoperative bleeding, antihypertensive requirements, cardiovascular changes after intubation, post operative bleeding and reoperations were compared between two groups. Clonidine group had a bloodless surgical field than placebo group (Mann-Whitney U test, p <0.05). It was significant in all surgical steps from skin incision and graft preparation, tympanomeatal flap elevation, to removing middle ear pathology and graft insertion. Intraoperative consumption of antihypertensive drugs for reducing bleeding (nitroglycerine and inderal) were significantly lower in the clonidine group (Fisher's exact test, p<0.05). Heart rate and blood pressure were lower in the clonidine group, but their difference was not statistically significant. Their was no significant difference in post operative bleeding and the rate of graft failure (reoperation) between two groups. Clonidine as a premedication can provide a blood less surgical field and can improve surgical visibility during microsurgery.

Based on the importance of intraocular pressure (IOP) in anesthesia and management of ophthalmic surgery specially in patients with ocular trauma, this research was designed to compare optical air Traq (OAT) with Macintosh (MAC) laryngoscope and their impacts on IOP.
In a randomized clinical trial, 100 patients of ASA class I and II were scheduled for ophthalmic surgery, these patients didn’t have any history of glaucoma and they were divided into two groups of 50 cases. After standard induction of anesthesia with BIS 35-40 the researcher A measured HR, BP and IOP, then the patients were intubated randomly with one of the two devices and after making sure of correct tube site researcher B that was not informed of intubating device measured the same parameters. Data were analyzed with SPSS-16 software and Pvalue < 0.05 was defined as significant. In this study 100 patients were divided into two groups, each comprising of 50 cases, Air Traq group (OAT) M/F = 33/17 and Macintosh group (MAC) M/F = 30 / 20. There was no statistically significant difference in past medical history; ASA Class, age, gender, primary, BP, HR and IOP. Mean IOP in OAT group before intubation was 15.3±6.8 and after that was 16.5±6.5, in MAC group it was 12.9±5.4 before intubation and 18.1±5.7 after intubation. This difference was statistically significant. (p<0.001). Also increases in HR and BP in OAT group were less than MAC group and this difference was statistically significant (P<0.003 sys BP) (P<0.002 DIAS BP) (P<0.002 HR). In the Laryngoscopy with OAT, increases in IOP and hemodynamic changes were less than MAC, and it was found to be useful in ocular trauma

Pain control after surgical procedures is one of the most important concerns of anesthesiologists. Different schemes for postoperative pain management have been proposed including opioids. Short acting opioids like remifentanil cant completely achieve this goal (due to short duration of action and acute tolerance). The aim of this study is to compare the effect of the timing of morphine administration before skin incision or 20-30 minutes before end of surgery in nephrolithatomy patients with the aid of PCA. 60 patients, 40-70 years scheduled for nephrolithotomy with ASA Class I & II were included in a randomized, double – blind clinical trial study. Anesthesia was induced with propofol and remifentanil and maintained with propofol 75-100 μg/kg/min and remifentanil 0.1-0.5 μg/kg/min, 50% oxygen and 50% nitrous oxide. Morphine 0.1 mg/kg was given randomly to two equal groups at two different times during surgery: the first group before skin incision and the second, 20-30 minutes before completion of the procedure. Pain was evaluated in the postanesthetic care unit using a visual analogue scale score (VAS). The patient was sent to ward when the VAS score was 3. They were then checked for pain every 4 hours and finally the total amount of morphine used during the first postoperative day in each group was calculated. Hemodynamic changes, time to recovery, pain score, the amount of morphine used after awakening, time spent in recovery room and the total amount of morphine used in the first 24 hour and satisfaction were similar in both groups (p value> 0.05) The timing of intraoperative morphine administration didnt affect postoperative pain or total amount of morphine used postoperatively.

The neonatal abstinence syndrome (NAS) is an important and significant morbidity in the neonatal period. In this case report, we described a case off opum addiction infancy period 5 months old. Her mother prescribed the oral opium to her for prevention of symptoms of NAS. We also discus differential diagnosis and management of such discuss.