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Background: Sleep apnea is usually associated with negative outcomes and underdiagnoses. STOP-Bang Questionnaire is a screening method for obstructive sleep apnea (OSA) that is recognized for the diagnosis of OSA in surgical and medical patients. This cross-sectional study aimed to evaluate the ability of the STOP-Bang test to predict complications after supratentorial craniotomy. Methods: In a cross-sectional study, 200 patients who were candidates for supratentorial craniotomy surgery who were referred to Loghman Hospital from July 2019 to September 2020 were included in the study. The STOP-Bang questionnaire was completed the day before the operation or during the visit to the anesthesia clinic. Demographic characteristics, body mass index (BMI), neck and waist size, underlying disease, and airway examination were performed to assess the Mallampati score for patients. According to the STOP-Bang scoring system, patients were categorized into two groups: low risk (score less than 3) and high risk (score higher or equal to 3). Data were analyzed using SPSS software version 20. Results: A total of 125 patients (62.5%) were low risk and 75 patients (37.5%) were high-risk. There was no statistically significant difference between the two groups of patients in terms of gender (P = 0.108). BMI over 35 kg / m2 and age over 50 years were higher in the high-risk group. The incidence of Malampati III or IV was higher in the high-risk group (29.3 vs. 6.4%). Smoking was higher in the high-risk group (29.3 vs. 16.8%). The frequency of airway obstruction, re-intubation, hypoxia, and length of hospitalization in recovery, and in the intensive care unit was significantly higher in the high-risk group. The level of the ROC curve for airway obstruction required intervention equal to 70.2% (95% confidence interval: 79.6-6.7). STOP-Bang showed good predictive power (Diagnostic power> 50percentage) for the need for nasal or oral airway implantation, re-intubation, hypoxia and hypotension of arterial blood, and difficulty in breathing or speaking. A score higher than two showed the predictive power of all evaluated outcomes. Conclusion: Our findings showed that the occurrence of premature respiratory complications after supratentorial craniotomy surgery is more common in patients with a screening score of three or higher on the STOP-Bang test, and this test can detect adverse complications after surgery.

Fanconi anaemia (FA) is a rare autosomal recessive inherited disease, which consists of bone marrow failure, skeletal deformities and multi organ involvement. Here, we report an emergency surgery on a FA patient with mucormycosis infection of paranasal sinuses. Since there are a few reports about FA, there is no general consensus on anaesthetic considerations so we deal with recommendations that are based on the pathology of FA. Possible difficult air way is the main concern, and low oxygen concentration and avoidance of nitrous oxide are among recommendations.

Patients suffer notable levels of pain after lumbar spine surgery. The primary objective of this randomized clinical trial is to investigate the efficacy of erector spinae plane block (ESPB) on 24-h post-operative pain score of patients undergoing lumbar spine surgery. Cumulative opioid consumption and intraoperative bleeding were assessed as well.Adult patient candidates for elective lumbar spine surgery were randomly assigned to case (ESPB) and control (no ESPB) groups. The block was performed under ultrasound guidance in prone position after induction of general anesthesia. Both groups received the same anesthesia medication and technique. Post-operative pain score, number of patients requiring rescue analgesia (meperidine), total amount of post-operative rescue analgesic demand in the first 24 h, and intraoperative bleeding were recorded. To compare pain score variable in time span, the ANOVA repeated measure test was used. All the statistical tests were two tailed and p0.05 considered as statistically significant.In all time intervals, pain score in case group was significantly lower than control group. In case group, eight patients demanded rescue analgesic (40%) which was significantly lower than that in control group (15 patients [75%]) (p=0.025). Total amount of meperidine consumption was 57.50±45.95 in control group and 22.50±32.34 in case group (p=0.01) which was higher in control group and statistically significant.ESPB reduces post-operative pain score and opioid consumption, while it does not affect intraoperative bleeding in lumbar spine surgery.

Purpose: The present investigation aimed to prepare Vancomycin-loaded nanoparticles (VAN-NPs) using chitosan (CS) and tripolyphosphate (TPP) besides exploring the effects of changing CS/TPP ratio on the physicochemical properties, corneal permeation, and ocular delivery of the prepared NPs. Methods: Different pre-formulations were prepared using the modified ionic gelation process, then were characterized in terms of size distribution. Optimized formulations were furtherly evaluated by some characteristic tools such as Fourier-transform infrared (FTIR) spectroscopy and thermogravimetric analysis (TGA). The in vitro antimicrobial efficacy and drug release amounts along with the Ex-vivo corneal permeation of NPs through the sheep cornea were investigated. Quantification was performed using High-Performance Liquid Chromatography. Results: Spherical and uniformly distributed NPs were developed with a mean particle size varied between 215–290 nm. FTIR spectroscopy confirmed that the CS/TPP cross-linking has taken place without affecting the pharmacologically active moiety of the drug. The obtained zeta potential values were in the range of +34 to +37 mV, which could ensure the stability of formulations. TGA analysis indicated enhanced thermal stability for the encapsulated drug compared to the plain drug. Formulations indicated suitable antimicrobial efficacy while releasing more than 90% of the drug during 24 h. NPs offered a 10-fold enhancement in corneal permeation compared to the drug solution. Conclusions: Although further in vivo evaluation is still required to completely confirm the efficacy of the formulations, the enhanced release and corneal permeation of the drug suggest that the prepared NPs are suitable for ocular delivery of VAN.

Although anticipated, difficult airway could turn into a catastrophe for health care providers, where planned strategies and equipment become useless. We report a challenging airway management process due to narrowed upper airway by the application of a Nelaton catheter as a rescue device.

Adequate ventilation is the greatest concern of all the anaesthesiologists. Any disturbance in the ventilation process could result in serious hazards: hypoxemia or barotrauma. Deficient devices are one of many causes of such derangements. Some of the typical complications of airway/ventilation tools are described extensively in textbooks, but many other uncommon events can still occur. We described two interesting cases of device-related ventilation inadequacy, hoping that acquaintance with such jeopardizes would be helpful in emergency situations for other colleagues.

Leprosy is as old as mankind. Although rare, it could be seen in some parts of the world. Therefore, anaesthesiologists have to be familiar with its consequences and considerations that could pose as a challenge. Here, we report a case of leprosy that was referred to our hospital for debridement of his infected foot.

Palmoplantar keratoderma(PPK) refers to a group of heterogeneous disorders defined by thickening of skin on the palms and soles. Due to diversity of symptoms and involved organs, the term PPK does not describe each individual patient precisely. The syndrome is quite rare and unknown to the anesthesiologists, while serious associations such as difficult airway or cardiac disease are significant challenges during perioperative management. The literature lacks enough data on anesthetic considerations in these patients, implicating case reports as the only available sources. We revised the accessible information through description of our patient.

The roots of apoptosis caused by the use of certain drugs in patients with colorectal cancer and certain drugs could be induced the change in genes SSTR2 and SSTR5. SSTRs play a role in colorectal cancer and it's also known that exercise training has similar effects to certain drugs. Therefore, this study aims to evaluate the effects of a combined training program on hormonal and physiological changes in patients with colorectal cancer. Twenty patients with colorectal cancer were included in this study and divided into two groups as experimental (n=10) and control (n=10). The experimental group performed an exercise training program 5 days a week for 14 weeks. Blood samples were taken from the patients before and after the training program, and analyzed for somatostatin and its receptors. When the pretest effect excluded as statistical, there were no significant differences in SSRT2 (P>0.05) and SSRT5 (P>0.05) between the experimental and control groups. The hypothesis for this study was "SSTR2 and SSTR5 will improve after combined training program" however, in accordance with the results it was rejected. It seems that the determined training program for these patients need to be extended and performed for at least 3 months in a gradual incremental structure so that it could affect their health indicators significantly.

Background: The purpose of this randomized, single-center study was to prospectively investigate the impact of anesthetic techniques for craniotomy on the release of cytokines (interleukin (IL)-1, IL-6, tumor necrosis factor factor-alpha (TNF-α)) and to determine whether intravenous anesthesia compared to inhalational anesthesia attenuates the inflammatory response.Methods and Materials: The study enrolled 60 patients undergoing craniotomy, allocated into two equal groups to receive either Isoflurane (n=30) and Propofol (n=30). Non-invasive hemodynamic monitoring was used. Serum levels of IL-1, IL-6 and TNF-α were evaluated before and at the end of surgery and anesthesia.Results: Although there was a significant rise in serum level of inflammatory cytokine but compared with patients anaesthetized with Isoflurane, patients who received Propofol had significant lower levels of IL-1, IL-6 and TNF-a after surgery (p

Up until now, hydroxyethyl starch (HES) solutions have mainly been indicated as "volume expanders". Recent unfavorable reports of these solutions such as probability of kidney injury or inducing coagulopathy have relatively ejected these solutions in many centers, particularly in European countries. Despite several confirming studies, multiple anecdotal letters or reviews has challenged total disappearance of these colloids from medicine practice. Also, some novel observations emphasized the distinguished ability of HES to preserve the microvascular integrity even at the presence of an inflammatory process. Despite extreme statements has been published demanding immediate suspension of these fluids from the market, it seems logical to revise the most recent studies which may declare new pathways to approach HES family of solutions.

Churg-Strauss syndrome (CSS) or allergic granulomatosis is a necrotizing vasculitis with different presentations. In this case highlights the anesthetic management of a known case of CSS who underwent posterior spinal fixation surgery. Our patient fulfilled the ACR diagnosis criteria because of showing asthma, paranasal sinusitis, positive skin biopsy and eosinophilia.Before anesthesia induction, laryngeal nerves block by lidocaine was conducted. Fiber-optic bronchoscopy was preceded by inserting a No. 7.5 spiral cuffed endotracheal tube.

Nasogastric tubes are being used in clinical anaesthesia settings on a daily basis. Although rare, knotting could occur during insertion or removal. Here, we report a knotted nasogastric tube which stocked in patient's nasopharynx that was removed by using a pediatric bougie. Clinicians must be aware of potential knotting of nasogastric tube. Pediatric bougie could be utile if knotted tube gets stocked in nasopharynx.

Osteogenesis Imperfecta (OI) is a genetic disorder with skeletal, vascular and soft tissue involvement with different clinical presentations. Since these patients need different surgical procedure in their lifetime, anesthesiologists are involved with their perioperative care and should be familiar with pathogenesis and anesthetic considerations of OI. Here we represent a case of OI which was candidate for Video Assisted Thoracic Surgery (VATS) and review the literature.

Introduction: Klippel feil syndrome (KFS) is a rare entity which is characterized by failure of normal segmentation of cervical vertebrae resulting in short neck with restricted movement and cervical instability. This anomaly increases the risk of neurological damage during airway instrumentation like laryngoscopy and positioning for surgery.Case Rports: We report three patients, a 42 year old male patient with KFS who scheduled for craniocervical fusion under general anesthesia and a 6 year old girl candidate for cleft palate repair and a 26 year old woman candidate for craniocervical fusion.Conclusion: All the cases were successfully managed using fiberoptic bronchoscope in first two cases and gum elastic bougie (GEB) in the last case. All things together, Awake fiberoptic intubation could be the safest technique for airway management.

Background: Post-operative pain after open cholecystectomy can result in increased oxygen consumption, atelectasis, pneumonia, decreased vital capacity, and increased morbidity and mortality. The aim of this study was to compare the analgesic effects of intrapleural meperidine and intravenous morphine in controlling post-cholecystectomy pain. Materials and Methods: In a double-blinded randomized clinical trial, 72 patients who were candidate for elective open cholecystectomy, were divided randomly into two groups based on accidental randomized numbers. Anesthesia technique was precisely the same for all patients. At the end of surgery, 50 mg of meperidine (diluted in 20 cc normal saline) was injected intrapleurally for meperidine group patients; whereas, 0.1 mg/kg intravenous morphine was injected intravenously in control group. Onset of pain and total dose of rescue analgesic were measured. Results: In order to obtain a Numerical Rating Scale (NRS)

Crouzon syndrome is a rare autosomal dominant premature cranyosynostosis, caused by fibroblast growth factor receptor 2 gene mutation on chromosome 10. The predominant skull and facial malformations with potential compromise airway make the crouzon syndrome a demanding issue for anesthesiologists and surgeons, required dynamic team work. In this report we describe a child, a known case of Crouzon syndrome who was a candidate for optic nerve decompression through endoscopic surgery. The anesthetic considerations and management are presented.Key words: Crouzon Syndrome, FGFR2 gene, Difficult Intubation, Anesthesia

Nieman-Pick disease type C is a rare, autosomal recessive, neurometabolic disorder associated with the accumulation of unesterified cholesterol in lysosomes and late endosomes. Because of multiple organ involvement and wide range of clinical manifestations, these patients will demand multiple diagnostic and therapeutic procedures requiring anesthesia. Sincepathogenesis of this disease is still unknown, further investigations on cellular and molecular basis of NPC is needed. In this report we present a known case of NPC1 requiring anesthesia for Percutaneous Endoscopic Gastrostomy and a brief review about molecular basis and recent advances in this field.

Background: Post - operative nausea and vomiting (PONV) still continues to be a serious problem. Incidence of PONV is more than 20% to 30%. Intravenous fluid administration seems to decrease PONV. Objectives: The aim of this study was to evaluate the effect of pre - operative and intraoperative intravenous hydration in comparison to routine hydration on PONV in breast cancer surgery. Methods: This study was performed on 105 female patients with ASA class grade I and II; they were randomly divided to 3; group 1: routine hydration (1.5 cc/kg/h normal saline). Group 2: routine hydration + 5 cc/kg of ringer lactate serum 80 to 90 minutes before surgery, and group 3: routine hydration + 5 cc/kg post - operative pain, anti - emetic and analgesic administration were compared between 3 groups, using VAS and cortila questionnaire. Results: There were no significant difference between 3 groups considering demographic data (age, literacy, weight, height, etc.) duration of breast cancer, cancer stage, pre - operative fasting time, duration of surgery, etc. Blood loss was significantly lower in intraoperative fluid supplementation group (P < 0.05), but PONV and post - operative pain were significantly lower in those who received pre - operative fluid supplementation. They also needed less anti - emetic or analgesic administration. Conclusions: Pre - operative fluid supplementation showed to be an effective prophylactic strategy in PONV. Type of fluid and its volume need more evaluation in future studies.

Wolfram syndrome was first described by physician D J Wolfram and Wagener in 1938. This autosomal recessive syndrome is also referred to as DIDMOAD syndrome which stands for Diabetes Insipidus, Insulin Dependent Diabetes Mellitus, Optic Atrophy and Deafness

Introduction: Lumbar spine laminectomy and spinal fixation are common procedures, associated with several recognized complications. Thromboembolic events have been reported during these types of procedures; although their incidence is low, the associated mortality is not. Case Presentation: We present a 53-year-old woman with no medical history or risk factors for thromboembolic events, who underwent lumbar spine laminectomy and posterior spinal fixation. The clinical findings indicated the risk of pulmonary embolism following surgery, which was confirmed via capnography, arterial blood gas, electrocardiography, and computed tomography angiography. Conclusions: Pulmonary embolism may be diagnosed, based on clinical findings and simple data provided by the analysis of vital signs and monitoring in the operating room.

“Awake craniotomy” is a technique used in neurosurgical procedures, commonly performed to remove a tumor or an epileptogenicfocus while the patient is awake. There has been an increasing trend towards performing this type of procedure because of its advantages;above all, the ability to map the eloquent cortex to reduce post-surgical neurological sequel. The aim of this article is tointroduce 8 cases of awake craniotomies, performed in Loghman-e-Hakim hospital in Tehran, Iran. Patients were selected accordingto our specific criteria. Oral clonidine (4 g/kg), dexamethason (8 mg/IV), midazolam (0.03 mg/kg/IV), and sufentanil (3 g/kg/IV)were used as premedication. Patients underwent cerebral state monitoring and other monitoring modalities during the procedure.A laryngeal mask was used during the asleep phase of the anesthesia. General anesthesia was induced using propofol and lidocaine.Local anesthesia was provided with bupivacaine in the incision and pin insertion sites. Anesthesia was maintained using propofoland remifentanil infusion. A total of 8 patients underwent the procedure. No significant complications, including hemodynamicinstability, depressed respiration, the need to put the patient to sleep before mapping or tumor resection, intraoperative seizures,aspiration, and brain edema were observed in any of our patients. In conclusion, we believe that a modified asleep-awake-awaketechnique instead of the asleep-awake-asleep technique may provide less complications and less need to manage the patients’ airway.“Awake craniotomy” is a technique used in neurosurgical procedures, commonly performed to remove a tumor or an epileptogenicfocus while the patient is awake. There has been an increasing trend towards performing this type of procedure because of its advantages;above all, the ability to map the eloquent cortex to reduce post-surgical neurological sequel. The aim of this article is tointroduce 8 cases of awake craniotomies, performed in Loghman-e-Hakim hospital in Tehran, Iran. Patients were selected accordingto our specific criteria. Oral clonidine (4 g/kg), dexamethason (8 mg/IV), midazolam (0.03 mg/kg/IV), and sufentanil (3 g/kg/IV)were used as premedication. Patients underwent cerebral state monitoring and other monitoring modalities during the procedure.A laryngeal mask was used during the asleep phase of the anesthesia. General anesthesia was induced using propofol and lidocaine.Local anesthesia was provided with bupivacaine in the incision and pin insertion sites. Anesthesia was maintained using propofoland remifentanil infusion. A total of 8 patients underwent the procedure. No significant complications, including hemodynamicinstability, depressed respiration, the need to put the patient to sleep before mapping or tumor resection, intraoperative seizures,aspiration, and brain edema were observed in any of our patients. In conclusion, we believe that a modified asleep-awake-awaketechnique instead of the asleep-awake-asleep technique may provide less complications and less need to manage the patients’ airway.

Background: There are a number of adjuvants to be used for local anesthetics in spinal block. The aim of this study was to demonstrate the possible effect of intrathecal midazolam compared with bupivacaine as adjuvants in spinal anesthesia with bupivacaine in chronic opium abuses. Methods: In a double blind, randomized clinical trial, 90 opium abuser patients undergoing lower limb orthopedic surgery were selected and randomly assigned into 3 groups (30 cases each). The patients received 15 mg plain bupivacaine, or 15 mg bupivacaine plus 25 mcg fentanyl or 15 mg bupivacaine plus 1 mg midazolam, intrathecally. Results: The duration of anesthesia was much longer in the bupivacaine-midazolam group than the bupivacainefentanyl group; both were longer than the plain bupivacaine group (P < 0.05). Conclusions: Subarachnoid injection of adjuvant midazolam or fentanyl with plain 0.5% bupivacaine in opium abusers in lower limb orthopedic surgery increases the duration of sensory block. Therefore midazolam is more effective than fentanyl in such cases. (Korean J Anesthesiol 2012; 63: 521-526)

Background: Addicted patients have innate tolerance to local anesthetics in both neuraxial and peripheral blocks. Dexmedetomidine (Dex) is a highly selective α2 adrenergic receptor agonist used as additive to increase quality and duration of peripheral nerve blocks. Objectives: The current study aimed to compare the effect of dexmedetomidine and fentanyl additives on bupivacaine to prolong the duration of block and minimizing side effects. Patients and Methods: Patients were candidates for elective surgery less than three hours of lower abdomen or lower extremities surgeries. Patients were randomly allocated to receive dexmedetomidine 5 µg added to 12.5 mg (2.5 mL) of 0.5% hyperbaric bupivacaine (DEX group), or 25 µg (0.5 mL) fentanyl added to 12.5 mg (2.5 mL) of 0.5% hyperbaric bupivacaine (F group) or only 12.5 mg of 0.5% hyperbaric bupivacaine. Data were recorded based on sensory block. Motor block was tested using modified Bromage scale every 30 minutes until the end of block. Time to return of sensory block to 4 dermatomes below and time to return of Bromage scale to 0 were recorded. All vital measurements (oxygen saturation, heart rate, electrocardiogram, and non-invasive blood pressure) were performed at 0, 30, 60, 90, 120 and 180 minutes in all three groups of the study. Group DEX received dexmedetomidine additive and group F received fentanyl additive and group C (control) received normal saline. Results: Totally, 84 patients were randomly divided into three groups of 28 patients. Onset of sensory block in DEX group was significantly lower than those of fentanyl (P = 0.012) and control groups (P = 0.001). Duration of sensory block was significantly longer in DEX group compared to Fentanyl (P = 0.043) and control (P = 0.016) groups. Duration of motor block in the DEX group was significantly longer than those of the fentanyl (P = 0.014) and control groups. Heart rate and mean arterial pressure were significantly higher in the DEX group at 30, 60, 90,120, and 180 minutes compared to those of the other two groups (P < 0.05). Conclusions: Dexmedetomidine added to bupivacaine in spinal anesthesia is more effective to increase duration of block, providing more appropriate sedation and less postoperative pain scale and post-operative nausea and vomiting (PONV) compared to fentanyl additive.

Background: Postoperative pain is one of the most common problems after hernia repair. Decrease in postoperative pain accelerates functional recovery, decreases duration of hospital stay and postoperative morbidity. Objectives: To compare postoperative analgesic effect of infiltration of magnesium versus bupivacaine into incision of inguinal hernia repair. Patients and Methods: In a double blind clinical trial, 80 patients’ candidates for elective inguinal hernia repair were enrolled. Right before closure of incision, in Bupivacaine group 5 mL Bupivacaine 0.5% added to 5 mL normal saline and in Magnesium group, 10 mL Magnesium sulfate 20% was infused subcutaneously. Pain score was measured using numeric rating score (NRS) at 1, 3, 6, 12 and 24 hours postoperatively. If NRS was above 3, 1 mg morphine was administered as rescue analgesic until patient felt comfortable or NRS < 3. Results: Postoperative pain scores at 1 and 3 hours were not significantly different between bupivacaine and magnesium groups (P = 0.21, 0.224; respectively). However, at 6 (P = 0.003), 12 (P = 0.028) and 24 (P = 0.022) hours postoperative, pain score (NRS) was significantly lower in bupivacaine group. Number of patients needed at least 1 dose of rescue morphine (P = 0.001), mean number of episodes asked for morphine during next 24 hours (P = 0.001) and total dose of morphine requirement (P = 0.01) were significantly lower in bupivacaine group. Conclusions: Magnesium infiltration did not decrease total dose and number of episodes needed for morphine rescue analgesic. Bupivacaine infiltration into surgical site was more effective than magnesium sulfate infiltration in postoperative pain control.

Background Anesthesia today has strived to decrease labor pain in a tolerable and controllable fashion. Intrathecal midazolam has been introduced as an adjunct to analgesics. The study was planned to assess the efficacy, safety and duration of analgesia produced by intrathecal midazolam adjunct to sufentanil in decreasing labor pain. Methods In a randomized clinical trial 80 parturient included in the study. The two groups were matched for age, cervical dilation, gravid, gestational age, and other demographic characteristics. Combination of sufentanil and midazolam administered intrathecally to experimental group and compared to sufentanil group. Time to reach maximum block, and pain score was measured and recorded. Results Groups were matched for age and weight and other demographic characteristic. No significant adverse effect was seen in both groups including decrease in Apgar score. Duration of analgesia was 92.0 ± 12.7 in sufentanil group and 185.2 ± 15.2 minutes in midazolam and sufentanil group which was significantly different (P = 0.002). Numeric rating scale score was significantly lower in midazolam group compare to sufentanil group at 120 min (P = 0.01), 150 min (P = 0.0014), and 180 min (P = 0.001). Conclusions Intrathecal midazolam as an adjunct to opioid could significantly enhance analgesia in labor pain with no significant adverse effect. Intrathecal injection of midazolam is an appropriate alternative to parenteral or epidural analgesia in small hospital settings.