فصلنامه آنستزیولوژی و مراقبتهای ویژه ایران
سال سی و پنجم شماره 3 (پیاپی 83، پاییز 1392)

This study was designed to evaluate changes in liver enzymes, biochemical markers of hepatocyte function, when anesthesia is maintained with three drug regimens: propofol, isoflurane and co-administration of propofal –isoflurane. One hundred and twenty patients aged 18 to 35, ASA class I risk groups, scheduled for elective rhinoplasty were randomly allocated into three equal groups of 40. Venous blood samples of the patients were obtained before induction of anesthesia and 4 hours after recovery from anesthesia in order to evaluate pre and post operation liver enzyme values. In all 3 groups general anesthesia was induced with propofol 2mg/kg, midazolam 0.03mg/kg and fentanyl 1.5 mcg/kg. In the propofol group anesthesia was maintained with propofol infusion 150mcg/kg/min. In the isoflurane group inhalatory isoflurane 1.2 MAC (minimal alveolar concentration) was used and in the propofol-isoflurane group, patients received propofol infusion 75mcg/kg/ minute and isoflurane 0.6 MAC as maintenance of anesthesia. In all threegroups remifentanil infusion 0.15mcg /kg/min was used for induced hypotension (MAP=55-65). Findings demonstrated that post anesthesia aspartate aminotransferase (AST) alanine aminotransferase (ALT) and alkaline phosphatase (ALP) values significantly decreased in all groups. These differences were statistically significant. It is suggestive that the co- administration of isoflurane-propofol as anesthesia maintenance along with remifentanil infusion not only does not increase ALT, AST and ALP levels but can also cause a decrease in enzyme levels. Therefore this regimen can be used for maintenance of anesthesia especially in operations in which induced hypotension is needed.

Nowaday laparoscopy is widelyused for various surgeries. Gas insuflation and special position in laparoscopic surgeries can result in some hemodynamic and respiratory changes. Propofol and isoflurane use widely for anesthesia in laparoscopy and we decided to compare hemodynamic changes during laparoscopy that anesthetized with these drugs. We categorized 43 ASA 1&2 patients in two groups randomly (23 patients in isoflurane group and 20 patients in propofol group). Two groups were similar in age, weight, gender and preoperative vital signs. Inductions of anesthesia were performed with propofol in both groups then we infused propofol in one group and isoflurane to other group for maintenance of anesthesia. Heart rate and mean arterial pressure were checked before induction, intraoperatively and during recovery. Mean of heart rate was found to have no differences significantly in all of time of surgeries. Mean arterial pressure in propofol group was higher than isoflurane group in 20, 30 & 40 minutes after induction significantly. There is no significant difference in incidence of post operative nausea and vomiting in two groups. Both isoflurane and propofol attenuated hemodynamic changes due to laparoscopic surgeries but mean arterial pressure was found to be slightly higher during some periods of surgeries in propofol group.

Determining the patient's readiness for weaning from mechanical ventilation and predicting the weaning outcomes are important issues that should be carefully evaluated and the risks of delay in weaning and increased mortality rates should be avoided. The aim of this study was to compare the outcomes of weaning with current and IWIbased methods in patients admitted to the intensive care units. This was a prospective clinical trial - one blind - multicenter study where 124 adult patients, who were mechanically ventilated for more than 24 hours, were evaluated in 2 groups of current and IWI-based methods (62 in each group). Initially, in current method, the rates of successful and unsuccessful weaning were evaluated in 62 patients and the threshold value of IWI was determined. In this group, the readiness for weaning and the decision to return to mechanical ventilation was made by physician in charge (who was completely blind to the result of the indexes evaluated). Then, after training the IWI to the medical team responsible for weaning, in 62 patients of the second group, weaning was made based on this index and the rates of successful and unsuccessful weaning were assessed. Ultimately, the rate of successful and failure weaning of the two groups was compared. In Current method among 62 patients studied, 35 were successful and 27 unsuccessful. APACHE II in successful group was 15.09±5.68, in unsuccessful group 18.70±5.39, Carrico index (PaO2 / FiO2) in successful group was 214.102±40.35, in unsuccessful group 182.87±76.22, DO index (dissolved oxygen (SaO2)) in successful group was 96.74±2.46, in unsuccessful group 95.37±3.28, GCS Score in successful group was 9.57± 1.22, in unsuccessful group 9.30±1.54, duration of mechanical ventilation (hour) in successful group was 82.54±72.31, in unsuccessful group 89.74±82.30, IWI in successful group was 42.30±12.16, in unsuccessful group 28.24±10.70. In IWI method among 62 patients studied, 58 were successful and 4 unsuccessful. APACHE II in successful group was 13.47±4.97, in unsuccessful group 13.25±4.57, Carrico index (PaO2/FiO2) in successful group was 212.80±42.15, in unsuccessful group 176.87±14.04, DO index(dissolved oxygen(SaO2)) in successful group was 95.30±3.12, in unsuccessful group 94.25±3.86, GCS Score in successful group was 9.03±1.75, in unsuccessful group 9.25±1.50, duration of mechanical ventilation (hr) in successful group was 141.43± 63.48, in unsuccessful group 51±15.10, IWI in successful group was 65.77±26.28, in unsuccessful group 40.15± 8.13. According to the research findings and studies that examined the predictive indexes of weaning from mechanical ventilation, it is indicated that in addition to objective and subjective criteria to determine the optimal time for successful weaning, predictive indexes should be used. The use of IWI index that integrates important weaning parameters can evaluate the weaning outcome with better accuracy.

Rigid broncoscopic dilatation is the lifesaving method for management of severe tracheal stenosis carried out under general anesthesia. However, for both anesthesiologist and bronchosco-pist, this procedure represents a most challenging practice. Inhalational induction which maintains spontaneous ventilation is commonly recommended in these patients. However, it needs a long time to reach the appropriate levels of anesthesia, and also airway instrumentation can precipitate coughing and complete airway obstruction. This paper describes our experience with rigid bronchoscopic dilation procedures performed with intravenous rapid induction of anesthesia in patients with severe postintubation tracheal stenosis. We conducted a retros-pective chart review of one hundred patients with severe post intubation tracheal stenosis who underwent rigid bronchoscopy for dilation of stenosis under general anesthesia at Masih Daneshvari and Kasra hospitals from Nov. 2011 to Sep. 2012. A rapid sequence induction of anesthesia was performed by intravenous injection of sodium thiopental and succinylcholine. Then an appropriate size of rigid bronchoscope was introduced into the trachea. If the airway was secured, dilatation of stenosis was done serially by different sizes of rigid bronchoscopes. Demographic, stenosis characteris-tics, and complications were recorded. There were 76 males and 24 females with mean age of 31.5±17.5 years. Following induction of anesthesia, the airway was rapidly secured in the first attempt with rigid bronchoscope in 97 patients. In 3 patients insertion of rigid bronchoscope was encountered with some problems, although airway control was done well and no major complications occurred. The intravenous rapid sequence induction of anesthesia by use of succinylcholine is safe for rigid brochoscopic dilatation in patients with severe post intubation tracheal stenosis. Close communication between the anesthesia and surgical teams are mandatory for the safe outcome of this procedure.

Postoperative sore throat (POST), hoarseness of voice, and cough are common and undesirable complaints in patients receiving general anesthesia following endotracheal intubation. Magnesium (Mg) acts as antagonist at N-methyl-Daspartate (NMDA) receptor and thought to be involved in the management of pain. Furthermore, the presence of NMDA receptors on peripheral cells has been identified. The purpose of this study was to evaluate whether gargling of magnesium sulfate solution reduces postoperative sore throat (POST), hoarseness of voice, and cough. One-hundred seventy patients undergoing elective lumbar laminectomyand percutaneous nephrolithotomy (PCNL), were allocated randomly into two equal groups of control (gargling with placebo) and magnesium sulfate solution. Both groups gargled for 30 seconds 30 minutes prior to induction of anesthesia. The incidence of sore throat, hoarseness of voice, and cough at 0, 2, 4 and 24 hours postoperatively, was assessed. The incidence of postoperative sore throat at 0, 2, 4, 24 hours postoperatively, was higher in control group (25-44.7% versus 4.7-20%; p<0.0001). Although the incidence of postoperative hoarseness and cough was higher among control group (6.5-16.5% versus 1.2-8.2% for hoarseness,and 2.4-9.4% versus 5.9-14.1% for cough); no significant statistically difference was found between two groups except for postoperative hoarseness at 24 hour (p=0.01). Gargling with 10cc of Mg sulfate solution 20%, 20 minutes before induction of anesthesia reduces the incidence of postoperative sore throat, significantly. Hoarseness is also decreased at 24 hour postoperatively, but is not effective to reduce the incidence of cough after surgery.

Vitamin B deficiencies in humans and animals have been known for some time to induce pain and inflammation. These symptoms can be readily alleviated by appropriate administration of vitamin B. The purpose is to associate two or more drugs with different mechanisms of action, in hopes of achieving a synergistic interaction that yields a sufficient analgesic effect with low doses of each agent, therefore, reducing the intensity and incidence of untoward effects. The aim of this study was to evaluate opioids requirements and hemodynamic effect of B1-vitamin in general anesthesia. In this, randomized, prospective and double-blinded clinical trial study 70 pateints with orthopedic surgery were assessed. Patients were then randomized to receive placebo and B1 vitamin (thiamine) po twice daily (12 hours and 2 hours before operation). Preinduction and postinduction mean heart rate, mean blood pressure and sufentanil and atracourium dose and bucking were assessed. With mean sufentanil dose 0.18 μg/kg, maximum mean blood pressure increase was 30± 17% vs 35± 9% in case and control groups respectively with significant difference in two groups. Other variables showed no significant difference in two groups. In our study, premedication with vitamin B1 caused decreased blood pressure change and reduced the mean sufentanil dose that was a significant difference and it can be concluded that Vitamine B1 has analgesic effects during anesthesia.

Due to the prevalence of total abdominal hysterectomy in the gynecology and patient's need to opioids for controlling post operative pain their side effects are inevitable. Hence we designed this study to see whether or not intraincisional bupivacaine could provide ample analgesia and thus could spare opioids side effects. Sixty ASA physical status I and II patients aged 45 to 65 years old undergoing total abdominal hysterectomy were enrolled into this clinical trial and randomly assigned into two groups of case (Bupivacaine) and control (Morphine). A standard general anesthetic was administered to them all. On completion of the operation, 0.1 mg/kg morphine sulfate was injected IV in control group, and 20cc bupivacaine 0.125% was injected intraincisional. During the 1, 4, 24, 48 hours after surgery, rescue IV morphine sulfate was administered to achieve a visual analog scale score of <3. Total rescue morphine consumption, pain scores, heart rate, systolic and diastolic blood pressure, and side effects of morphine sulfate during the 1, 4, 24, 48 hours after surgery were compared in both groups. The total morphine sulfate consumption during the 1, 4, 24, 48 hours after surgery, in case group was significantly higher than control group (p<0.001). This study demonstrated that, intraincisional adminesteration of bupivacaine has no significant analgesic effect after total abdominal hysterectomy.

One of the important complications of percutaneous nephrolithotomy (PCNL) is rapid absorption of irrigation fluid via opened veins that may cause serum hematologic and electrolyte changes. The aim of this study was to evaluate the effect of distilled water and normal saline as an irrigation fluid for PCNL on the serum concentration of sodium, potassium, hemoglobin and hematocrit. Sixty patients with kidney calculi were candidated for elective PCNL and randomly divided into two groups for PCNL. Approaches to the calculi were through a single subcostal access with an Amplatz sheath and either distilled water or normal saline. Solution was used as the irrigation fluid. Serum hemoglobin, hematocrit, sodium and potassium were measured just before and after the procedure. The mean calculus size, irrigation volume, irrigation time, age, gender and ASA were not significantly different between the two groups. In two groups, compared to before PCNL, the mean in hemoglobin and hematocrit were significantly reduced after PCNL (p<0.001), but did not change the sodium and potassium of the procedure. The mean change of sodium, potassium, hemoglobin and hematocrit did not difference in before and after PCNL for two groups (p>0.05). None of the patients developed transurethral resection of the prostate syndrome or needed transfusion. Distilled water is an inexpensive and available alternative to normal saline for irrigation during PCNL. Compared to before PCNL, hemoglobin and hematocrit were significantly reduced after PCNL, but did not change the sodium and potassium. We did not find any difference between the two irrigation solutions regarding the safety, however, this should be confirmed further, especially for large calculi. We recommend, evaluation of serum hemoglobin and hematocrit levels on the postoperative day as mandatory.

The patient was a 68 kg 27 years old woman, who was candidate for NVD. She hadnt any history of medical problem, surgery and anything else. After block with local anesthetics (lidocaine) for episiotomy which was followed by severe spasm, cyanosis, loss of consciousness, vaginal bleeding, tachypnea, and restlessness was brought to the operating room. Monitoring findings in patients with tachycardia1 88 (b/m), blood pressure 120/180(mm hg), temperature 42.8 °C up immediately with the possibility of malignant hyperthermia patients were treated and cared for more accurate recovery of the Intensive Care Unit particularly moved and three days. Was dischargedwith recommendations.