فصلنامه آنستزیولوژی و مراقبتهای ویژه ایران
سال سی و ششم شماره 3 (پیاپی 87، پاییز 1393)

Liver transplantation is the treatment of choice in end stage liver disease. Marginal graft is a criteria for selecting appropriate liver in many centers. Many studies indicated that SIG is a good predictor for outcome. Our primary objective was to find a correlation between SIG and graft function. Secondary objective was comparison between SIG and marginal graft criteria.

This study was performed in 61 liver recipients. All recipients were selected for transplantation by marginal graft criteria. Strong ion was measured and according to ionized portion SIG was calculated. According to cut of point of SIG=10 and marginal graft criteria, patients were divided into two groups and then compared with each other.

This study was conducted on 61 liver recipients. 39 (63.9%) of them developed with transplantation complication. Only 3(4.9%) presented with PNF and 1 (1.6%) presented with DNF. Mean SIG was 18.41±1.71. 49.2% of livers was marginal. 68% of donors had SIG>10 and 32% had SIG> 10. No difference was seen in these two groups according to liver transplantation complication. (Pvalue: 0.286) In group SIG>10 mean AST was 297±730 and mean ALT was 292±438 and in group SIG<10 mean AST and ALT was 350±566 and 383±440 respectively. This difference is clinically significant. No difference was seen in marginal and non-marginal graft according to liver transplantation complication. (Pvalue:0.245)

SIG in donor is not an appropriate predictor for liver transplantation outcome.

Neurologic dysfunction is a common complication after coronary artery bypass graft surgeries. Magnesium sulphate is a non competitive NMDA receptor antagonist which is associated with improved neurological function, especially in shortterm memory. The aim of this study was to examine the effects of magnesium sulphate on neurocognitive dysfunction after coronary artery bypass graft surgery.

In a double blind clinical trial study 80 patients were randomly entered to two different groups: The first group consisted of patients who got 800 mg of magnesium sulphate 50% during induction of anesthesia in 15 minutes and the following 3200 mg of magnesium sulphate during 24 hours. The second group received normal saline as placebo exactly in the same manner and the same amount. All patients were assessed by Mini Mental Status Exam (MMSE) before and 5 to 7 days after operation.

Demographic data were the same between two groups. Post-operative cognitive status scores decreased in comparison with pre-operative state but there was less decrease in magnesium sulphate than the normal saline group (p= 0.02).

According to MMSE scores, magnesium sulphate can decrease cognitive complications after CABG surgeries.

Advances and improvements in treatment of critical illnesses has resulted in more patients who require prolonged airway and ventilator support. Finally tracheostomy allows the patient to speak and eat and to become out of bed. Tracheostomy procedure can be done in three

conventional (surgery in operation room), percutaneous Dilatation (PDT) and Translaryngeal (TLT) in intensive car units. In this research we have introduced one new approach as a Modified approach for classic Fantoni method, that removes the technical difficulty of classic fantoni methods. It is reported that the classic approach has 31.1% difficulty in retrograde passage of guide wire from trachea to larynx and oral cavity.

A retrospective and cohort study was conducted on 159 patients that admitted with cardiac pathology in intensive care units of Rajaie Heart Hospital Iran-Tehran, because of different reasons. The duration of their hospitalization in Intensive Care Units was prolonged, So elective tracheostomy was indicated and modified approach of TLT was done for all of them.

Modified tracheostomy approach was done for all of the patients without any technical problems and complications. No bleeding was observed despite the 3.4>INR> 1.8. (Range of bleeding was 5- 10 ml). There were no singificant changes in clinical factors such as: PAO2, O2sat, HR, BP, Peak Inspiratory Pressure (PIP) and Hb.

We concluded that use of the new TLT technique (modification of classic fantoni method) removes difficulties in retrograde passage of guide wire through the larynx and mouth that is reported in classical fantoni method. We also reached to this conclusion that TLT is safe in cardiac patients with coagulopathy (2.8> INR > 1.8).

The sympathetic component of the autonomic nervous system is activated as a response to laryngoscopy and endotracheal intubation causing an increase in blood pressure and heart rate. In patients with underlying cardiovascular disease these changes may cause acute cardiac ischemia accompanying significant morbidity and mortality. The purpose of this current study was to compare the effects of magnesium sulphate and remifentanil on hemodynamic responses following laryngoscopy and endotracheal intubation.

In this double blind clinical trial 90 patients 15-50 years old, ASA I-II, who underwent elective surgery were randomly assigned into three groups, control, remifentanil and magnesium sulphate. Group 1, the control group. Group 2: Patients received magnesium sulphate 0.1 g/kg IV thirty minutes before laryngoscopy and endotracheal intubation. Group 3: Patients received remifentanil 1μg/Kg IV two minutes before laryngoscopy and endotracheal intubation. Blood pressure and heart rate were recorded before induction of anaesthesia, and at one, three and five minutes following laryngoscopy and intubation.

Mean changes of systolic and diastolic blood pressure, and heart rate one and three minutes following laryngoscopy and intubation in the magnesium sulphate group and remifentanil group were significantly different from the control group. (P< 0.05)

According to this study, the use of remifentanil and magnesium sulphate as premedication drugs before laryngoscopy and endotracheal intubation may effectively prevent rise of systolic and diastolic blood pressures and heartrate. Magnesium sulphate premedication did not control the hemodynamic parameters as effectively as remifentanil did; therefore we suggest using remifentanil as a premedication of choice in laryngoscopy and intubation.

The incidence of fentanyl-induced cough (FIC) during induction of general of anesthesia varies between 28-65% and is undesirable. It increases intracranial, intraocular and intra-abdominal pressures. This prospective, randomized, double- blind, placebo-controlled study evaluated the effect of propofol and magnesium sulfate pretreatment on the incidence and severity of FIC.

312 ASA Class 1-2 patients, aged 18-60 years, scheduled for orthopedic elective surgery, were randomly allocated into three groups (n=104 for each). Group 1 received 30 mg/kg magnesium sulfate (5 ml), group 2 received 0.3 mg/kg propofol (5 ml), and group 3 received 5 ml normal saline 1 min before administration of 2 μg/kg fentanyl. The incidence, severity and the onset time of cough were recorded for 1 min after fentanyl administration. P value<0.05 was significant.

The incidence of FIC was 12.5%, 9.6% and 33.7% in groups 1, 2, 3, respectively (P<0.05 for treatment groups 1 and 2 versus control group 3). There were no significant differences in the severity or onset time of cough among the three groups.

Intravenous magnesium sulfate (30 mg/kg) and propofol (0.3 mg/kg) 1 min before the administration of intravenous fentanyl (2μg/kg) significantly reduced the incidence of FIC.

Diminished surgical trauma has made laparascopic cholecystectomy a standard technique for removal of gallbladder. Multimodal approach to post cholecystectomy pain management may enhance analgesia. The purpose of this study was to evaluate the clinical efficacy of suppository administration of morphine in reducing pain after laparascopic cholecystectomy.

88 patients, aged 20-50 years, scheduled for elective laparascopic cholecystectomy were enrolled to this double-blind randomized controlled-trial study. Patients were divided into two groups of each 44 and group1(M) received 10 mg of suppository morphine and, group 2 (D) 100mg suppository diclofenac at the end of surgry time. The intensity of pain 8 hours after surgery upon entering the recovery room and the total amount of analgesic consumed during the first 8 hours were recorded.

Amount of analgesic amount in the first 8 hour were significantly lower in group M compared with group D (p<0.05). Pain intensity was significantly lower at 3,4,5 hours in group M compared with group D (p<0.05), but was not significantly different at 0, 1, 2, 6, 8 hours in two groups (p>0.05).

Patients who were given suppository morphine after laparascopic cholecystectomy had better visual analog scale and less analgesic consumption than patients who were given suppository diclofenac.

The use of opioid drugs is one of the main methods in controlling pain after surgery. Always, finding effective methods of opioid drugs administration other than intravenous, has been considered and the use of morphine suppository is one option. The purpose of this study was to evaluate the efficacy of morphine suppositories for postoperative analgesia compared with the usual method of intravenous pethidine.

This double blind study, performed on 46 patients 20- 60 years old, candidate for elective laparascopic cholesystectomy, in two groups of 23. At the end of surgery, M group received 10 mg morphine suppository and P group received 20mg intravenous pethidine. Pain intensity, time to first analgesic request, the amount of additional analgesic and satisfaction rate, within 6 hours after surgery, in each group was measured and compared in both groups.

The pain scores between the two groups had no significant differences for 0, 1, 2 and 6 hours after surgery (p>0.05). Although the 4 - hour pain in the M group was significantly lower than P group (p=0.019). M Group required analgesic earlier than P group (p=0.018). Total additional analgesic dose in M Group was significantly lower than P group (p=0.046). Patient satisfaction was similar for both drugs.

There were no significant differences, except at 4 - hour, in reducing postoperative pain between the two groups.

When talking about the beneficial effects of ketamine as a nociceptive N-methyl Daspartate (NMDA) antagonist for analgesia during surgery, psychological and systemic side effects should be considered. The purpose of this study was to evaluate the side effects of incisional subcutaneous administration of low dose ketamine after cesarean section.

Sixty patients, aged 18-25 years, scheduled for elective cesarean section were enrolled to this double-blind randomized controlledtrial study. Patients were divided into two groups of each 30 and group1(C) received 10 CC saline and group 2(k) received 0.5 mg/kg ketamine after skin closure subcutaneously at the site of surgery. Mean arterial pressure, heart rate, nausea, vomiting, nystagmus, hallucination, pruritus, level of sedation and respiratory depression were evaluated for 4 hours after injection.

Maximum mean arterial pressure and heart rate and also incidence of nausea were lower in group K but not significant (p>0.05). Incidence of vomiting, nystagmus, hallucination, pruritus, level of sedation and respiratory depression were not significantly different in two groups (p>0.05). Conclution: The subcutaneous prescription of low doses of ketamine for analgesia after surgery is safe and without serious adverse effects.

Pain is remains an important problem specially after painful therapeutic procedures. One of these procedures is dental procedure. There are several conditions that can change the effect of drugs such as body’s genetic and enzymatic profile, drug metabolism, drug intraction and disease etc. In this study we present a case where the addition of bicarbonate to lidocaine (carpool) produced the best analgesic effect for dental surgery.