فصلنامه آنستزیولوژی و مراقبتهای ویژه ایران
سال سی و سوم شماره 1 (پیاپی 74، بهار و تابستان 1390)

Premedication is widely used in pediatric anesthesia to reduce emotional trauma and ensure smooth induction. The aim of our study was to investigate and compare the efficacy of orally administered valeric versus that of promethazine as a premedication in pediatric patients. We performed a prospective study in 58 children, 1 to 8 years of age, with average of 3.8 years; randomly allocated into two groups. The valeric group received 0.25 cc/kg and the promethazine group received 0.5 mg/kg oral promethazine. The preoperative sedation. Anxiolysis and mask acceptance scores were evaluated separately on a four-point scale, with ease of parental separation, based on the presence or lack of crying, were evaluated on a standard scale questionnaire. Neither medication showed acceptable sedation, with no significant difference in sedation score between the two groups (p=0.715). Anxiolysis and mask acceptance using either valeric or promethazine were acceptable, with valeric performing significantly better than promethazine (p=0.028 and p=0.036 respectively). Ease of parental separation was seen in both groups without significant difference (p=0.265) and no major adverse effects, such as apnea, occurred in either group. Orally valeric is more effective than promethazine in anxiolysis and mask acceptace. Although they both can ease separation anxiety in children before surgery, we found neither drug to be acceptables for sedation.

Post operative shivering for most of patients is uncomfortable and it can cause a lot of problems. α2 agonists (clonidine and dexmedetomidine) have been widely studied for its antishivering effect. Tizanidine is a clonidine derivative and α2-adrenoreceptor agonist that has the same effects (sedation, anxiolysis and analgesia) but lesser side effects (hypotension and bradycardia). In this study effects of oral tizanidine for prvention of postoperative shivering was assessed. In this clinical trial double blind study sixty patients (ASA I, II), aged 18-60 yr, were randomly allocated into two groups. 90 minutes before induction of general anesthesia both control and tizanidine group received placebo and 4mg oral tizanidine respectively. At the end of surgery. Incidence & intensity of shivering were assessed. Incidence & intensity of post operative shivering in the tizanidine group were significantly lower than that in the control group (p<0.01). It was possible to reduce the post operative shivering by oral administration of 4 mg tizanidine as premedication.Therefore, we recommended premedication with tizanidine for patients undergoing surgery.

Respiratory events are the most common anesthetic related injuries following dental damage. Most physical examination indices developed to aid in preoperative evaluation of all patients presenting for layngoscopy and tracheal intubation fail to identify many difficult to intubate patients. 1/3 of diabetic patients are difficult for laryngoscopy. This study about was designed to compare palm print test with mallampatie in 103 diabetic patients in Imam Khomeini & Golestan hospitals. In this study 103 diabetic patients either type I or type II was randomly selected. Mallampatie, Palm print and thyromental distance test in recognition of difficult intubation patients was compared. Our study revealed that about 1/10 of diabetic patients are difficult to intubate. Sensitivity and specificity of palm print test in recognition of difficult intubation diabetics was 100% and 97% and sensitivity and specificity of mallampatie 30% and 91/4%. This study suggests that all the tests have their place in armamentarium of anesthesiologist, in diabetics palm print is the best single predictor of difficult intubation. We also feel that diabetic patients in our population are generally not difficult to intubate.

This randomized clinical trial was designed to find out the incidence of cough (primary outcome) and perioperative respiratory complications (secondary outcome) in children with uncomplicated URI having laryngeal mask airway (LMA) compared to face mask (FM). Previous studies: Although it was shown that endotracheal tube would cause more respiratory adverse events in this population compared to LMA and FM; LMA and FM are not compared in a systematic way. In this study, 150 pediatric patients with URI were enrolled. After stratifying the severity of preoperative URI symptoms, subjects were randomized to receive FM or LMA anesthesia. Both groups received inhalational induction and intravenous lidocaine. Respiratory adverse events including cough, laryngospasm, bronchospasm and desaturation was evaluated. Patients were followed postoperatively. The two groups did not demonstrate difference with respect to their age, weight, ASA physical status, gender, duration of surgery and severity of URI symptoms. The incidence of cough (19% in LMA vs. 42% in FM; p<0.05), vomiting (4% in LMA vs. 12% in FM; p<0.05) and maneuvers to maintain the patency of airway was more in those with FM. Apnea (7% in LMA and 5% in FM group), desaturation (21% in LMA and 20% in FM), laryngospasm (32% in LMA and 37% in FM), bronchospasm (17% in LMA and 14% in FM), readmission (3% in LMA and 4% in FM) and sore throat (18% in LMA and 20% in FM) were also not different between groups. In children with uncomplicated URI who do not require endotracheal intubation, LMA is a reasonable alternative to FM with easier handling and fewer adverse events.

Abdominal surgery is one of the most painful operations. This postoperative pain may cause different side effects such as tachycardia and cardiac ischemia. Transabdominal hysterectomy is one of this kinds of surgery. Different kinds of medications and techniques have been utilized to manage this intense pain. Intravenous opioids are one of these modalities which causes known adverse sideffects. Other methods and procedures could be used such as infiltration of local anesthetics into the operation site. In this study, we compared intravenous morphine with intraperitoneal bupivacaine for reduction of post operative pain. 60 patients ASA Class I and II patients aged 35 to 55 years with BMI between 25 to 30 who had no anesthesia risk factor and had their operation done in 90 to 150 minutes, were randomly divided into two groups B (bupiva-caine) and M (morphine). At the end of surgery, 0.1 mg/kg intravenous morphine sulfate and 40 ml of intraperitoneal sterile normal saline injected for group M and 0.1 ml/kg of intravenous saline and 40 ml of 0.25% intraperitoneal bupivacaine injected for group B. The pain score (VAS) Visual Analog Scale, the first demand for analgesics and total amount of analgesic used for each group, were compared. There were no statistically significant demographic differences between two groups. Intravenous morphine used to keep pain score below 3 was much less in group M and group B patients demanded for analgesics much sooner which were statistically meaningful. Since the hemodynamic status of two groups were not in the same range before intervention, the differences in hemodynamic status after intervention could not be reliable. Intraperitoneal bupivacaine at the dose of 40 ml of 0.25% and in transabdominal hysterectomy, could not provide ample analgesic effect.

Blindness is a catastrophic complication of surgeries performed in prone position. It occurs mainly due to hemodynamic alterations and the relevant effects on optic nerve perfusion. In this study, we compared the effects of propofol and isoflurane on intra ocular pressure of patients by having Lumbar disk surgeries. In our randomized clinical trial, 60 patients were candidates for lumbar disk surgery accidentally assigned into two groups of propofol (P) and isoflurane (I). IOP measured before and after induction of anesthesia in supine position, immediately after prone and at the end of operation in prone and after turning the patients back to supine position. Mean arterial pressure (MAP), systolic (SBP) and bDiastolic blood pressure (DBP) and heart rate (HR) all assessed. Finally, all data are evaluated by using T-test, Chi-square test and Generalized Estimating Equations. Mean IOP of awake patients in supine position in I and P groups were 15.8±3.1 and 18.2±5.4 mmHg, and at the end of operation, in prone position IOPs were changed to 18±5.8 and 17.2±4.9 mmHg that these alterations were significant (p=0.024). According to mixed analysis, MAP, SBP, DBP, ET CO2 and HR had no significant changes in two groups. (p<0.05) In comparison with isoflurone, propofol can control IOP during lumbar disk surgeries in prone position despite of no significant alterations in hemodynamic responses.

To compare a practice of protocoldirected sedation during mechanical ventilation implemented by nurses with traditional nonprotocol- directed sedation administration. Design: Quasi experimental. Setting: A medical intensive care unit (ICU) in a university teaching hospital in Kerman, Iran. Patients:132 patients 15 – 48 years of age (mean age group 21-30 y, 81% men, 97% intubated) who required mechanical ventilation for at least 48 hours. Patients were excluded if had history of heart and lung disease (eg COPD). Intervention: At the time of mechanical ventilation, patients were allocated to 1 of 2 groups. 66 patients received protocol directed sedation by nurses, in which nurses determined if analgesics, sedatives, or both were needed; according to an algorithm-based sedation guideline. 66 patients received traditional, sedatives and analgesics were adjusted according to physician's orders and researchers document observations. Mean of sedation level by Richmond scale, mean of pain level with BPS scale, evry 2h over 48h. Analysis was by intention to treat. Mean Richmond scale after intervention decrased in both group of patients (p=0.0001) but this difference in P group (mean:-.94) compared with NP group (mean:-1.88) more adjust with aim of ideal sedation. (Richmond scale:-1 to 1). Mean BPS scale after intervention decrased in both grop of patients (from bps 6.17 decrased to 3.135 p=0.7) but this difference not significant. (3.1 in nonprotocol v 3.17 in protocol p=0.08). Protocol directed sedation by nurses provided a beter sedation and more adjust with aim of ideal sedation.

The early discharge of patients is a fundamental priority in outpatient surgery. The aims of this study were using very low levels of drug to block specific spinal nerve root in patients candidate for anal surgery and its effect on the early discharge of patients in these outpatient surgeries.

In this randomized, clinical trial seventy patients were randomly assigned to receive hyperbaric bupivacaine doses of 2mg or 5mg. An investigator blinded to group allocation performed the sensory evaluation with a needle, starting from the anal orifice in different diagonal directions until satisfactory block had reached S4 and examing continue to find maximum level of block. Patients evaluated during surgery for the maximum level of sensory block in two groups, time to initiating the block, time to recovery from block, the ability of ambulation without aid in recovery room and intensity of pain during the surgery.

Maximum level of sensory block in group A is nerve roots of (S3-S5)(97.1%). Maximum level of sensory block in group B is above nerve root of S2 (80%). The average time to sensory block in group A is 3.62 min and this time in group B is 3.02 min. The average time to ambulation in group A is 57.5 min and in group B is 94.4 min. The average time for recovery from the block in group A was 66.08 min and in group B was 99.2 min. Intensity of pain during the surgery presumable of MC - Gill Questioner is greater in group A than group B.

The lower dose of hyper baric bupivacaine in intrathecal space produced satisfactory condition for surgery with a more limited block, earlier time to sensory block, earlier time to ambulation but did not produce sufficient analgesia alone compared with the higher spinal dose and if we recommended this low dose for short anal surgery we must remember the complementary dose of analgesic (opioid in this study) is acceptable in neuro axial block.

Reduction of recovery time after spinal anesthesia and early discharge of patients in outpatient surgery are very important objectives. In this study, effects of leg elevation on arterial blood pressure and recovery from spinal anesthesia was evaluated. The present randomized clinical trial study was conducted on140 healthy individuals (ASA I-II) who were candidates for varicocelectomy and erniorrhaphy surgeries. The patients by computer program were randomly divided into two groups. Both groups were received spinal anesthesia with 100 mg lidocaine and after 30 min, in the case group, the legs were elevated 30 degree by putting a Cushing under their legs until the end of recovery and in control group the legs kept on a horizontal position. Then, level of anesthesia as primary outcome and mean arterial pressure (MAP) as secondary outcome were evaluated every 5min until the end of recovery. 140 patients were enrolled in this study; there were not significant differences in the demographic data. MAP was higher in the case group during recovery period and the level of anesthesia was rapidly reduced during the time of leg elevation. Leg elevation reduces recovery time from spinal anesthesia and keeps MAP higher than control group.

Awareness during general anaesthesia is a problem. It has received increased attention from physicians and patients, as it may result in disabling psychological sequel for the patient. Cesarean section is the most common surgery with awareness. A higher incidence of awareness was reported in patients whose anaesthesia was maintained with TIVA (total intra venous anaesthesia) than in patients maintained with a volatile anaesthesia. In this case we report awareness during general anaesthesia for cesarean section.

Most of epidural andits related drugs surveys are performed in rabbit asan animal model and the results will be used as thebasic of the experiments in human. This reviewstudy was planned in order to discuss the advantagesand disadvantages of epidural anesthesia methods bydetails and with emphasis on clinical experiments ofthe authors of this paper to be used by scholars intheir researches. This study was planned on surveying the 41 papers included 13 papers in surgery approach, 9 papers in caudal approach, 7 papers in percutaneous approach, 3 papers in tail amputation approach and in 9 papers the epidural approaches were unknown. Research sources of this study contained Pubmed, Elsevier, Springer, Magiran, SciVerse Scopus, Web of Knowledge, JAMA-Archives. By assessing the advantages and disadvantages and the ease of epidural procedures, the significant procedures of epidural anesthesia in rabbit as an animal model were mentioned and finally, an applied overall deduction and comprehensive guideline was recommended. Respectively caudal, tail amputation, percutaneous and surgery approaches are recommended.