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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.

Postoperative pain control remains an important issue in the field of surgery. Assessing and managing patients with acute pain who are addicted to opioids are often challenging. It has been shown that, addicted patients are less tolerant to pain. There is limited evidence to guide the management of acute pain in these patients. Here we studied the effect of preemptive use of carbamazepine on pain behavior and serum IL-6, IL-10 levels in the addicted patients. 90 male patients (25-45 years, BMI 20-27), were divided into 3 group of 30 patients: 1- control, 2- addicted, 3- addicted patients receiving carbamazepine 400mg before surgery. The visual analog pain scale and serum levels of IL-6 and IL-10 were evaluated at time 0 (before surgery), 1 and 12h postoperatively. Compared with control and carbamazepine groups, addicted patients exhibited exaggerated pain behavior before and after surgery, however, postoperatively, a significant increase in pain behavior was seen in control compared to carbamazepine group. A decrease in serum IL-10 and an increase in IL-6 concentrations were observed in addicted patients. In the morphine abuser, a decrease in pain threshold, an increase in IL-6 and a decrease in IL-10 levels were evident compared with non-abuser subjects. Addition of carbamazepine improved pain sensation and serum IL-6 levels and a reduction in serum IL-10 level in control patients was paralleled to their recovery. It seems that, preemptive use of low dose of carbamazepine can improve postoperative pain and cytokine activities in the addicted patients.

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.

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: 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.

Background Excessive bleeding is an unwanted complication of trans-sphenoidal resection of pituitary adenoma due to increases in intracranial pressure (ICP) and hemodynamic instability. Dexmedetomidine (Dex) anα2-agonists is the drug of choice in intensive care units (ICU) and cardiac surgeries to control abrupt changes in hemodynamic. Severe cardiovascular responses occur during trans-sphenoidal resection (TSR) of the pituitary adenoma despite adequate depth of anesthesia. The aim of this paper was to determine the effect of Dexmedetomidine on bleeding as primary outcome, and surgeon's satisfaction and hemodynamic stability as secondary outcomes in patients undergoing trans-sphenoidal resection of pituitary adenoma. Methods Total numbers of 60 patients between 18-65 years old and candidate for elective trans-sphenoidal resection of pituitary adenoma were randomLy allocated to two groups; Dexmedetomidine infusion (0.6µg/kg/hour) or normal saline infusion. Mean arterial pressure (MAP), heart rate (HR), dose of hypnotics and narcotics during surgery, bleeding, and surgeon's satisfaction were recorded. Results Propofol maintenance dose (µg/kg/min) and total Fentanyl use (µg) were significantly lower in Dex group compare to control group (P=0.01 and 0.003, respectively). Total bleeding amount during operation in Dex group was significantly lower than control group (P=0.012). Surgeon's satisfaction was significantly higher in Dex group at the end of surgery. MAP and heart rate throughout surgery were significantly lower in Dex group compare to control group (P=0.001). Conclusions Dexmedetomidine infusion (0.6µg/kg/hour) could reduce bleeding and provide surgeon's satisfaction during trans-sphenoidal resection of pituitary adenoma.