فصلنامه آنستزیولوژی و مراقبتهای ویژه ایران
سال سی و چهارم شماره 4 (پیاپی 80، زمستان 1391)

Clinical governance is one of the practical methods for improving quality of health services in the world. In Iran, the ministry of health has taken many positive steps in implementing this framework during the last years. Our goal in this initiative was evaluating our situation according to the approved check lists in the field of critical care. All physicians and nurses in ICU were empowered by enrolling in training sessions and later got involved in internal assessment using critical care check lists. Most of activities in the field of clinical governance in our ICU has been done in the field of leadership and management (48.27%), and the least in the field of clinical auditing (00.00%). Conducting internal assessment in intensive care units, can help us to find-out the weaknesses and strengths of the plan. Using these points, we can prioritize our needs and proceed to improve quality of care.

Weaning index is a useful tool to prevent losses of weaning failure, rapid and reliable identification of patients who are potentially ready for spontaneous breathing and accelerating weaning of mechanical ventilation. The objective of this study is to determine the validity of new weaning index as a predictor of discontinuation from mechanical ventilation in patients hospitalized in the intensive care units. This scale was evaluated for the first time on 124 adult patients who were on mechanical ventilation for more than 24 hours in two 24-hour phases, in 6 ICUs (Surgery, Trauma, Medical, Toxicology toxicity) of selected hospitals in Tehran, totaling 60 beds, by the researcher as a single blind test. Inclusion criteria were: Patients 18 to 80 years old, no neurological and neuromuscular disease, none or a minimal dose of sedative drugs with the same guidelines based on hemodynamic conditions and need of patients in putting them in the light phase of sedation (15-18 points based on Palma and Cook criteria), no addiction,no smoking of more than one pack year not admitted in ICU-OH, no clinical signs of sinusitis (thick nasal secretions, discolored nasal discharge, fever with no underlying cause). All patients received the same regimen, which had been prepared in the hospital. The study was conducted from 1201-2012. The ventilators used were Rafael. In the first phase, 80 cases were successful, 40 unsuccessful and 4 cases died, and in second phase of the study, there were 72 successful and 8 unsuccessful weanings. By using a sensitivity of 94.59%, specificity 66.67%, positive and negative predictive values of 97.22%, 50 % respectively, positive and negative likelihood ratios of 2.84, 0.08 respectively, accuracy or correctness of 92.5 % and prevalence of 92.5%, the new weaning index (IWI) was more successful than the other indexes in predicting weaning of patients from mechanical ventilation. The new weaning index (IWI) has a good predictive validity for weaning of patients from mechanical ventilation in the intensive care units.

Anxiety is one of the important factors which could bring problems late delayed discharge for patients and medical staff. There are still controversies about the effects of information on anxiety related to anesthesia. One group of researcher believes that education can reduce anxiety and the other group doesnt believe it. In this study, the effect of an anesthesia film was studied. In this study we used 30 minutes video information that was produced based on American Society of Anesthesiologists protocol on education. We divided 70 urologic patients into two groups. In case group (27 patients) a questioner of (HADS) was filled in before and after film broadcasting. In control group (43) patient the questioners were filled following entering to and before exit from preoperative clinic. In control group (43) 26 patients and in the case group (27) 15 patients were anxious before video show in contrast with 22 patients in control group and 13 patients in case group after video show. (p=0.24) Video information had no obvious effect in reducing anxiety due to anesthesia of moderate risk surgeries.

Glidescopic larangoscopy has many approved useful effects that are comparable with direct larangoscopy with Macintosh laryngoscope in different directions. In this study we have compared the head extension, the most important factor in successful intubation and with a central role in cervical spinal cord injury in these two methods. We undertook a double blind clinical trial study of 65 patients divided randomly in two groups, Macintosh laryngoscopic group and Glideoscope group. Patients were preoxygenated after entering the operating room, and standard monitoring established. Anesthesia induction was started by administering 2mg/kg propofol, 2μ/kg fentanyl and 0.5 mg/kg atracurium and then nasal intubation was performed by simple nasal tube (the nasal mucosa was shrinked by 0.25% phenylephrin nasal drops). All information about the time of intubation, the head extension degree, bleeding, using Magill forceps or not, external laryngeal maneuver or not, number of attempt for intubation and Cormack and Lehane classification were registered in both methods. The finding were analyzed statistically by SPSS V. 16 and chi square statistical test. Comparison of the two different laryngoscopic methods showed no significant difference between, sex, age and BMI in two groups. Glideoscope Laryngoscopy needed Magill forceps less often than in the direct larangoscopy (p=0.003). In Cormack-Lehane grading there were meaningful correlation that high Cormack-Lehane degrees had lower mean in Glideoscope group. (p=0.005). In the number of attempts in passing the tube, although the statistical test showed its superiority, by chi square exam. This correlation did not become significant. (p=0.163) The external laryngeal maneuver application was much less than in Macintosh laryngoscopic group (P=0.0001). Bleeding was less in Glideoscope group and it was statistically significant. (p=0.017) Intubation was faster than in the Macintosh Laryngoscopy (p=0.0001). The degree of head extension was less in Glideoscope method than in the Macintosh method (p=0.0001). The amount of head extension is significantly lower in Glideoscope method than with Macintosh laryngoscope. In addition, the evaluations showed that Glidescopic method is faster, needs less time with Magill forceps usage and fewer external laryngeal maneuvers, has less bleeding possibilities and also makes intubation easier.

Decreasing postoperative nausea and vomiting is one of the most important concerns of the anesthesiologist. There are several managements for prevention and/or treatment of this postoperative complication, but none is completely effective, some are relatively expensive (eg, ondansetrone), and others have considerable side effects (eg, steroids). Clonazpam is a benzodiazepine that is effective for treatment of refractory chemotherapy-induced nausea and vomiting in addition to providing good sedation for stressful surgical patients. This study was designed to compare clonazpam with one of the most effective choices ondansetrone. In this randomized clinical trial study, 150 ASA Class I or II patients, scheduled for gynecologic laparoscopic surgeries were selected. They were enrolled according to inclusion & exclusion criteria & randomized in 3 groups, each group comparing of 50 patients. In clonazpam group, 2 mg oral clonazpam was administered 2hour before operation. In ondansetron group, 4 mg IV ondansetron was administered after intubation and control group received placebo. Postoperative nausea and vomiting was evaluated till 12 hours post op in all patients. There was no significant difference between administration, clonazepam or ondansetron or placebo in decreasing of post operation nausea and vomiting in the 3 groups (p>0.05). Adminstration of oral clonazepam compared to intravenous ondansetron or oral placebo in gynecologic laparoscopic surgeries did not decrease the rate of post operative nausea and vomiting.

APACHE II is a general severity of disease classification system in ICUs. Few studies have been conducted on the physiologic parameters of this system separately.The goal of the current study was to assess APACHE II and its physiologic parameters in prediction of the outcomes (died, survivor) in surgical ICU. This is an observational and prospective study of 150 consecutive patients admitted in surgical ICU during six months period. Demographic information recorded in a check list and information about severity of disease calculated based on APACHE II scoring system in the first admission 24 hours. Student T- test and chi square were used for statistical analysis (95% confidence interval). Data analyses showed significant statistical differences between outcomes and APACHE II (p= 0/03), the serum creatinine levels (p< 0/001), urea (p=0/03), white blood cell levels (p=0/028) and acute physiology score (p=0/008). APACHE II is a good predictor of outcome in surgical ICU; also the Cr, urea, WBC levels and acute physiology score are good parameters as indicators of illness severity.

Post operative pain has been one of the problems in surgical procedures under intravenous regional anesthesia (IVRA). This study evaluates the effect of addition of paracetamol and dexamethasone to lidocaine for IVRA on post operative pain. In this clinical trial double blind study sixty patients (ASA1, 2), aged 20-60 years undergoing upper limb surgery under IVRA were assigned to four groups: Groupe 1: lidocaine, Groupe 2: lidocaine plus dexamethasone, Groupe 3: lidocaine plus paracetamol and Groupe 4: lidocaine plus paracetamol. In all of the groups, Lidocaine was diluted with normal saline to a total volume of 40 ml. Sensory and motor block onset time and severity of post operative pain and amount of meperidine consumption in 24h after surgery were assessed. Sensory and motor block onset time in the fourth group in comparsion to other groups was shorter (p< 0/01). Post operative pain and analgesic consumption were reduced in fourth group when compared with other groups (p<0/05). The addition of paracetamol and dexamethasone to Lidocaine in IVRA shortens the onset time of sensory and motor block and reduces post operative pain and analgesic consumption.

Throat of a healthy person is a rich environment of microbes and after 48 hours of hospitalization in intensive patients, pharyngeal flora changes of the Gram positive to Gram negative can lead to pneumonia. Additionally patients who are undergoing mechanical ventilation through contact with the leaked bacteria from around the cuff of tracheal tube are at risk for pneumonia. To compare of the effects of routine mouthwash and mouthwash as well as suctioning with chlorhexidine 0/2% on throat bacterial colonies among patients admited to trauma intensive care units of Kerman hospitals. This study is a quasiexperimental design and began with 90 patients undergoing mechanical ventilation that had inclusion criteria. Patient were divided by random numbers table to two control and intervention groups. Mouthwash in the control group was performed every six hours by applicator dipped with 0.2% chlorhexidine solution for 7 days every 6 hours and in the intervention group in addition to the use of chlorhexidine applicator dipped with 0.2% chlorhexidine, 10 cc of 0.2% chlorhexidine solution was poured into the patient's oral cavity and pharynx and after one minute the mouth and throat were suctioned. Throat culture from the secretion of patients throat in the first day of the intervention (before) and on the seventh day (end) taken and was sent to the laboratory. Bacterial colonies from the throat of patients on the seventh day in the intervention group were lower than the control group. (p<0.0001, control group mean: 0.93 and intervention group mean: 0.04) Chlorhexidine 0.2% mouthwash and suctioning with it is more effective on throat bacterial colonies in the ICU patients.

The patient was a 60kg 24 year old woman ASA Class I, who was candidate for tendon repair surgery due to a suicidal history. She hadn’t any history of medical problem, allergy and anything else. After premedi-cation with midazolam and fentanyl, and effective preoxygenation, anesthesia was induced by propofol and atracurium that was followed by severe hypotension, cyanosis, and PEA in ECG. The mechanical ventilation became impossible. The cardio-pulmonary resuscitation was started that was successful and after achieving a hemodynamic stability, the patient was admitted to ICU for continuing the treatment. During CPR we took a blood sample for measuring serum triptase. After having recovered in the ICU, the patient was referred to the Allergic clinic for follow up.