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Background: After graduation, physicians should be able to provide professional and safe services without the need for supervision by their clinical professors, mandating a competency-based medical education (CBME) approach. Objectives: This study aimed to develop a national model of entrustable professional activities (EPAs) based on our experiences in the Department of Anesthesiology and Critical Care (DACC), Shahid Beheshti University of Medical Sciences (SBMU). Methods: The primary EPA design plan was designed in a 10-step model as a career roadmap for the project. The texts were prepared according to a consensus-based approach. On the other hand, the texts were reviewed and revised by a broad team of faculty in a daily workshop. Results: The final product included 14 topics for EPA as the first round of targeting topics for anesthesiology residents. The texts were developed using previous studies and were standardized considering national standards. Conclusions: We described a clear path toward designing and implementing EPAs in anesthesiology residency programs to improve the quality of the graduated residents. Though the basic theory is the same, each country needs its formula for implementing the process.

Background: Acetabular fracture surgeries are frequently associated with long and severe perioperative pain, and there is no consensus on pain relief management. Aim: The purpose of this study was to compare the analgesic efficacy of fascia iliaca compartment block (FICB) and quadratus lumborum block (QLB) in patients with acetabular fractures undergoing surgery using the Stoppa method. Methods: Adult patients undergoing spinal anesthesia for acetabular fracture surgery were divided into two groups of FICB (n = 22) and QLB (n = 24) in this prospective double-blind randomized parallel clinical study. The pain intensity at different times was evaluated in all participants using the visual analog scale (VAS). The dose of fentanyl required to make the patient sit for spinal anesthesia and the pain intensity was evaluated. The duration of analgesia and the total amount of morphine consumed in the first 24 hours after surgery were also evaluated, analyzed, and compared between the two study groups. Results: Both FICB and QLB showed effective comparative postoperative analgesic profiles after acetabular fracture surgery; However, no significant variation in VAS values was found at any time of the study between the two groups. FICB showed decreased cumulative fentanyl consumption during spinal anesthetic placement, however, QLB had considerably lower total morphine demand in the initial postoperative 24h period. Conclusion: The lateral QLB and FICB can introduce as effective routes for analgesia in acetabular fracture surgery by the Stoppa approach. Clinical Trial Registration: The study was retrospectively registered in the clinical trials registry system, on 2021-02-17, with registration number: IRCT20191114045435N1.

Although advances in diagnosis and treatment of cardiac arrest (CA) could improve neurological outcomes after cardiopulmonary resuscitation (CPR), survival rate and neurological outcome after CA and CPR remain poor. This study aimed to investigate the effect of epinephrine (EP) alone and EP in combination with methylprednisolone (MP) (EP + MP) on some the apoptotic and anti-apoptotic genes and proteins levels expression of the cerebral cortex as well as neuronal death in a CA rat model. Forty-five male Sprague Dawley rats were randomly divided into three groups including the hypoxic CA + EP, hypoxic CA + EP + MP, and sham groups using a simple randomization procedure. In both hypoxic CA groups, CA was induced by asphyxia and immediately after confirmation of CA, the treatment strategies including chest compression or cardiac massage simultaneously with ventilation, and administration of EP alone (20 mg/kg, every 3 min) and EP (20 mg/kg, every 3 min) + 30 (mg/kg) of MP were done. The sham group only received anesthetic drugs without CA. Some neurological outcomes were investigated using histopathological, immunohistochemical, molecular, and terminal deoxynucleotidyl transferase (TdT)-mediated dUTP nick-end labeling (TUNEL) assays at 5 and 48 h post-CPR. The data obtained showed the highest up-regulation of apoptotic genes and proteins expression, the lowest expression of anti-apoptotic gene and protein expression, the most DNA fragmentation and histopathological changes belonged to the EP group on 48 h post-CPR. While mild and intermediate histopathological changes, DNA fragmentation and apoptotic activity was detected in theEP alone and EP + MP groups at 5 h and 48 h post-CPR, respectively. As a novel finding, the present study showed that EP + MP protects neurons from death provoked/induced by hypoxia and reperfusion injury in an experimental model of CA through up and down-regulation of pro- (caspases 3 and 8) and anti-apoptotic (BCL2) molecules, respectively.

Background: Spinal anesthesia (SA) is a frequently used method by anesthesiologists in patients who may not need general anesthesia or have a contraindication for applying general anesthesia. Nevertheless, numerous contemplations need to be considered by anesthesiologists when using this method. Objectives: We compared the effect of intravenous (IV) administration of dexamethasone versus dexmedetomidine alongside the subarachnoid injection of Bupivacaine in terms of spinal anesthesia (SA) quality in opium-addicted patients. Patients and Methods: This parallel randomized clinical trial (RCT) was conducted on opium-addicted patients aged 18 to 65 with The American Society of Anesthesiologists (ASA) class of I/II candidates for surgery under SA. In one group, dexmedetomidine at a dose of 0.5 μg/kg body weight was injected intravenously 10 minutes before surgery and then at a dose of 0.5 μg/kg body weight during surgery. In another group, 8 mg dexamethasone was injected intravenously 10 minutes before surgery, and then normal saline at a rate of 0.5 μg/kg/h was infused during surgery. The primary outcomes were the onset of sensory block, the onset of motor block, the regression of two levels of sensory block, and the duration of motor block. The secondary outcomes were total analgesia time and the time to the first analgesia requirement. Results: Totally, 57 patients divided into two groups were included in the final analysis. The results showed that the two groups differed significantly in none of the assessed baseline variables (P > 0.05). The mean duration between performing SA and the onset of sensory block in the Dexamethasone and Dexmedetomidine groups was 4.8 ± 2.2 and 4.2 ± 1.9 minutes, respectively (P = 0.290). The mean duration between performing SA and the onset of motor block in the dexamethasone and dexmedetomidine groups was 5.9 ± 2.6 and 5.1 ± 2.3 minutes, respectively (P = 0.251). The mean duration between performing SA and the regression of two levels of sensory block in the dexamethasone and dexmedetomidine groups was 63.6 ± 27.7 and 82.0 ± 17.1 minutes, respectively (P = 0.004). The mean duration of motor block in the dexamethasone and dexmedetomidine groups was 75.0 ± 32.1 and 97.5 ± 19.4 minutes, respectively (P = 0.377). The mean total analgesia time in the dexamethasone and dexmedetomidine groups was 86.9 ± 32.9 and 109.3 ± 16.3 minutes, respectively (P = 0.002). The mean duration between performing SA and the first requirement for analgesic agent administration in the dexamethasone and dexmedetomidine groups was 206.21 ± 93.19 and 267.86 ± 76.02 minutes, respectively (P = 0.008). Conclusions: It seems that the quality of spinal anesthesia in opium-addicted patients who received concurrent IV dexmedetomidine was better than that of those who received concurrent IV dexamethasone.

Background: Although several numbers of the common anesthetic drugs are frequently used in breast cancer (BC) surgery, their possible effects on the behavior of cancer cells are still unknown. Objectives: The main objective of the present study was to examine the effect of administered lidocaine versus fentanyl during BC surgery on the apoptosis index of BC cells in-vitro. Methods: Patients with BC with the same grade of cancer and American Society of Anesthesiologists (ASA) score I–III, who underwent surgery were randomly divided into 2 groups of lidocaine and fentanyl infusion based on the analgesic drugs they received. Blood samples were drawn before and after the surgery and then cells from the BC cell line (MCF-7) were exposed to them at 24, 48, and 72 hours post-culture. Flow cytometry was performed to measure the mean percentage of apoptosis index; To investigate the cells’ viability, 3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay was also applied. Results: Sixty patients were enrolled. Quantitative cell death analysis revealed that the proportion of apoptotic cells in both lidocaine and fentanyl groups significantly increased when the cells were treated with post-operation sera compared to pre-operation sera exposure at various time intervals. In both groups, intra-group cell death analysis showed that there was not any statistically significant difference among the cultured cells exposed to pre-operation sera at various interval times (P < 0.001) with respect to apoptosis and cell viability. Conclusions: The study findings proposed that lidocaine infusion can reach the apoptosis index of BC cells in-vitro, as much as that fentanyl did; and both drugs had significant effects.

The world has experienced a pandemic due to novel Severe Acute Respiratory Disease Corona Virus-2 (SARS-CoV2) since December 2019. The clinical spectrum of the disease known as Coronavirus Disease 2019 (COVID-19) is so much wide, starting from an asymptomatic state to paucisymptomatic clinical presentation, pneumonia, respiratory failure to even death. Supplemental oxygen therapy is essential in managing COVID-19. Also, there is sparse evidence regarding use of non-invasive ventilation (NIV) in pandemics like SARS-CoV-2. This study reviews the currently available methods for respiratory support in COVID-19 with a discussion about using these modalieties in the COVID-19 pandemic.

Background: Acute kidney injury (AKI) is a complication that occurs for various reasons after surgery, especially cardiac surgery. This complication can lead to a prolonged treatment process, increased costs, and sometimes death. Prediction of postoperative AKI can help anesthesiologists to implement preventive and early treatment strategies to reduce the risk of AKI. Objectives: This study tries to predict postoperative AKI using interpretable machine learning models. Methods: For this study, the information of 1435 patients was collected from multiple centers. The gathered data are in six categories: demographic characteristics and type of surgery, past medical history (PMH), drug history (DH), laboratory information, anesthesia and surgery information, and postoperative variables. Machine learning methods, including support vector machine (SVM), multilayer perceptron (MLP), decision tree (DT), random forest (RF), logistic regression, XGBoost, and AdaBoost, were used to predict postoperative AKI. Local interpretable model-agnostic explanations (LIME) and the Shapley methods were then leveraged to check the interpretability of models. Results: Comparing the area under the curves (AUCs) obtained for different machine learning models show that the RF and XGBoost methods with values of 0.81 and 0.80 best predict postoperative AKI. The interpretations obtained for the machine learning models show that creatinine (Cr), cardiopulmonary bypass time (CPB time), blood sugar (BS), and albumin (Alb) have the most significant impact on predictions. Conclusions: The treatment team can be informed about the possibility of postoperative AKI before cardiac surgery using machine learning models such as RF and XGBoost and adjust the treatment procedure accordingly. Interpretability of predictions for each patient ensures the validity of obtained predictions.

Background: Breast cancer (BC) is the most frequent cause of cancer death in women. The thoracic pectoral nerve (PECS) block has been described as the gold standard analgesic modality for BC surgery. It has been previously reported that PECS is associated with decreased BC recurrence post-mastectomy. Although several anesthetic drugs and techniques are used in surgical oncology, their effects on the behavior of cancer cells are yet to be known and the key question of whether the anesthetic technique affects cancer outcome remains unresolved. Objectives: Since anesthetic drugs and techniques and post-operative pain may affect BC recurrence, this study aimed to determine whether the anesthetic choice and technique, PECS II block, affects in vitro apoptosis of the MDA-MB-231 BC cell line. Methods: Twenty-two female BC patients, 20 to 75-years-old, with the same pathologic grades were included in this study. The patients were randomly divided into two groups. The first group received propofol general anesthesia (PGA) associated with PECS and the second group received standard PGA. Blood was sampled pre and post-operation from all patients. The sera were isolated and then exposed to the MDA-MB-231 human BC cell line. The mean percentage of apoptosis indices was analyzed by flow cytometry using Annexin V-fluorescein isothiocyanate 24 hours after treatment with patients’ sera. Results: A significant decrease was seen in the mean viability percentage of BC cell line in the PECS group, besides a significant increase in the mean percentage of necrosis and late apoptosis indices compared to the control group after exposure to sera collected from patients post-operation. Intra-group analysis of the control group showed that the exposure of the tumoral cell to post-operation sera resulted in a significant increase in the mean percentage of necrosis and late apoptosis index compared to pre-operation sera exposure. In the PECS group, the exposure of the tumoral cell to post-operation sera resulted in a significant increase in the mean percentage of cell viability and late apoptosis index compared to pre-operation sera exposure. Conclusions: In conclusion, anesthesia and BC surgery may induce apoptosis indices in the MDA-MB-231 human BC cell line. We also found that sera collected from PECS II block patients with BC could induce more apoptosis in the MDA-MB-231 cell line compared to collected sera from systemic analgesia alone after BC surgery.

Background Fascia iliaca compartment block (FICB) is a common regional analgesic strategy in hip fracture surgery but, recently it has been suggested that FICB may not provide enough analgesia. Pericapsular nerve group block (PENG) is a novel method for hip analgesia which its efficacy is not well established yet. The aim of this study was to the effect of the PENG block in the control of the hip fracture pain as well as to compare the effectiveness of the PENG compared with FICB. Hypothesis The hypothesis of this study was that the PENG block could be a good alternative to the FICB in hip fracture analgesia. Materials and methods This randomized controlled clinical trial was conducted in the Imam- Hossein Hospital, Tehran, Iran; between 2018 and 2019. Hip fracture patients were randomly divided into two groups; Group A (n = 22) received FICB and Group B (n = 30) received PENG block. Results There was no significant difference between VAS score before blocks procedure between two groups (p = 0.37). After 15 minutes of blocks and after 12 hours of post-surgery, VAS score significantly reduced in the PENG block group compared with the FICB group (p = 0.031; p = 0.021, respectively). The first time of the analgesic consumption after surgery was significantly longer in the PENG block compared with the FCIB (p = 0.007). Compared with the FICB group, the total dose of morphine consumption during 24 hours significantly reduced in the PENG block (p = 0.008). Conclusion PENG block is a good method in hip fractures analgesia and provides better analgesia than FICB. However, further studies with larger sample sizes are required to validate the efficacy and superiority of the PENG blocks over conventional techniques. Level of evidence I.

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Anesthesiologist are often encountered with decisions regarding dosage of the anesthetic drugs and also with postoperative complications. One of the most critical complications which influence mortality and morbidity is post-operative kidney injury. Also patients with chronic kidney disease (CKD) often requires anesthesia for multiple diagnostic or prognostic procedures. On the other hand, developments in precision medicine have utilizes clinician with weapons which could be used against various previous unsolved problems. In this chapter after brief description of personalized medicine, we are discussing actual and possible manifestations of precision medicine in anesthesia regarding genitourinary system.

Background Bupivacaine, an amid-type local anesthetic, is widely used for clinical patients especially in pregnant women. In addition to neurotoxicity effect of bupivacaine, it can cross the placenta, accumulates in this tissue and retained in fetal tissues. Nevertheless, whether bupivacaine can cause neurotoxicity in fetus remains unclear. Hence, this study was design to investigate the effects of maternal bupivacaine use on fetus hippocampal cell apoptosis and the possible related mechanism. Methods On day 15 of pregnancy, sciatic nerve of pregnant wistar rat (180–200 g) were exposed by lateral incision of the right thigh and 0.2 ml of bupivacaine was injected. After their delivery, we randomly selected one male offspring of every mother. On day 30 after of their birth, the rat’s hippocampi were isolated for molecular studies. Western blotting was used to examine the expression of cleaved caspase-3, caspase-8 and p-Akt in fetal hippocampus. Results Our results showed that maternal bupivacaine use caused a significant increment of cleaved caspase-3 and caspase-8 expression in fetal hippocampus compared with the sham group. In addition, maternally administered bupivacaine could significantly decrease hippocampal P.Akt/T.Akt ratio which was concurrent with an increment of cleaved caspase-3 and caspase-8 expression. Conclusion Our data suggest that maternal bupivacaine use increases fetal hippocampal cell apoptosis markers such as caspase 8 and cleaved caspase 3, at least in part, via inhibiting the Akt activation.

Background: Aspiration is one of the important complications of general anesthesia, although infrequent as well as accompanying high morbidity and mortality. The volume of gastric content is considered as a risk factor in this regard. Therefore, it is normally mostly recommend to consider proper fasting time before induction of general anesthesia. Objectives: This study was conducted to assess the effect of metoclopramide on reducing gastric contents in patients with incomplete fasting before induction of general anesthesia. Methods: This quasi-experimental study was conducted on patients with urgent surgical indications with incomplete NPO time. Every other patient received metoclopramide or placebo. Patients in the intervention group received 10 mg (2 ml) of intravenous metoclopramide, and patients in the control group received 2 ml of distilled water as a placebo. Patients in both groups underwent ultrasonography before starting surgery by an expert radiologist to calculate gastric antral grade (GAG) and cross-sectional antral area (CSA). These measurements were then taken for the second time 30 minutes after intervention, before starting the surgery. The values were compared statistically. Results: The data of 60 patients were analyzed, of which 30 were in each group. The mean age, body mass index, type of the last consumed food (solid or fluid), NPO time in the two groups were not significantly different (P value > 0.05). The number of patients in the metoclopramide group with higher GAG (P value = 0.001) and the mean CSA (P value = 0.004) before the intervention was more than the control group. The GAG and mean CSA after intervention were not significantly different between the two groups; but the mean difference of decrease in CSA in the metoclopramide group was more than the control group (4.3 vs. 0.99; P value = 0.001), and changes of GAG after intervention to lower levels in the metoclopramide group was more than the control group (P value < 0.05). Conclusions: In the current study in which ultrasonographic indexes, including GAG and CSA, were assessed as a suboptimal gastric emptying test method, it was found that metoclopramide could accelerate gastric emptying compared to placebo in patients with incomplete fasting before induction of general anesthesia.

Background: Benson’s relaxation (BR) technique is a suitable non-pharmacological approach to reduce preoperative anxiety (PA). Objectives: This study aimed to investigate the effect of BR therapy on PA and the induction and maintenance dose of propofol during cataract surgery (CS). Methods: Seventy-two patients were randomly divided into two experiments or BR and control groups. The Amsterdam and Spielberger State-Trait Anxiety inventory (STAI) scores were used to assess PA directly two days and a half-hour before the CS. The control group did not receive any preoperation intervention or relaxation. Benson’s relaxation method was performed three times, each time for 20 minutes, including two days before surgery, a night before surgery, and an hour before the surgery in the presence of a researcher by an audio file. The induction and maintenance dose of anesthetic drug was recorded and compared between the two groups. Results: The mean propofol consumption was significantly reduced during the induction of anesthesia in the intervention group compared to the control group (0.99 ± 0.29 versus 1.29 ± 0.49; P = 0.005) as well as the maintenance of anesthesia (84.66 ± 17.98 versus 108.33 ± 34.38, P = 0.001). The results of the post-intervention Amsterdam anxiety score showed a significant decrease in the intervention group compared to the control group (P = 0.032, F = 9.61, Eta2 = 0.12). The control group showed a higher Spielberger state score compared to the intervention group as well as the Spielberger trait (P < 0.001, F = 14.78, Eta2 = 0.18). Conclusions: The BR method effectively reduces the level of PA in patients undergoing CS. Moreover, it reduces the need for anesthetic drug, propofol, during surgery.

Background: To decrease postoperative pain (PP) control, opioid requirement, and outcome improvement, regional anesthesia or preoperative analgesia is routinely performed as an alternative to general anesthesia. Thoracic wall nerve blocks, such as the pectoral nerves (PECS) block have recently become popular for preoperative pain control in patients undergoing breast cancer (BC) surgery. Objectives: The current study was designed to evaluate the effect of PECS anesthesia on the fentanyl and propofol consumption, as well as time to the first request to analgesia in the patients with BC surgery. Methods: A total of 22 women aged 20 to 75 years old with biopsy-proven BC were randomized to receive either propofol general anesthesia with PECS or total intravenous anesthesia without PECS in a randomized clinical trial. Total propofol and fentanyl dose and time to the first request for postoperative analgesia were assessed and compared in both groups. Results: The obtained data showed no significant difference in the total dose of fentanyl and propofol between the two groups. However, the PECS group showed a significant increase in time to the first request for postoperative analgesia. Conclusions: The PECS block in combination with general anesthesia for BC surgery significantly increased time to the first request to analgesia and was effective for reducing PP in the recovery room. PECS block combined with general anesthesia did not reduce the intraoperative use of fentanyl and propofol compared with the control group injected with normal saline.

Treacher Collins Syndrome (TCS) is a rare disease with mandibulofacial dysostosis. The deformities accompanied by this syndrome could cause especial challenges for anesthesiologist. On the other hand Treacher protein is well recognized in the pathogenesis of this syndrome. In this report we want to present a successful management of a patient with Treacher Collins syndrome and also describe new advances in the molecular aspect of this disease.

Dexmedetomidine is a selective α-2 adrenoceptor agonist with anxiolytic, sedative, and analgesic properties that prolongs analgesia and decreases opioid-related side effects when used in neuraxial and perineural areas as a local anesthetics adjuvant. The current study was designed to evaluate the effects of a single perineural administration of dexmedetomidine without local anesthetics on narcotic consumption and pain intensity in patients with femoral shaft fractures undergoing surgery. This prospective randomized single-blind clinical trial was conducted in patients undergoing femoral fracture shaft surgery. Based on block permuted randomization, the patients were randomly divided into intervention and control groups. The intervention group received 100µg dexmedetomidine, for a femoral nerve block without any local anesthetics. Total intraoperative opioid consumption, postoperative opioid consumption, visual analogue score (VAS) for pain, and hemodynamic parameters were recorded and compared. Finally the data from 60 patients with a mean age of 30.4±12.3 were analyzed (90% male). There were no significant differences between the baseline characteristics of the two groups (p>0.05). The mean total consumption of narcotics was reduced during induction and maintenance of anesthesia in the intervention group (p

Introduction: Although rare, but it is very important to understand that intubation will be difficult for which of the patients. Some scoring systems are available in this regard that influenced by many factors such as body anthropometric factors. Objective: This study was conducted to investigate the relationship between Mallampati score, biting the upper lip as well as 2-3-3 maneuver with body anthropometric factors in different population of society. Method: This cross-sectional study was conducted during the years 2014-2015 in Yazd, Iran. The subjects using simple randomized sampling method, and they were included in study after obtaining their informed consent. Demographic (age and gender) as well as anthropometric parameters of body, including weight, height, neck, waist circumference, hip circumference, body mass index (BMI) and waist-to-hip ratio (WHR) were collected in a pre-prepared checklist. Then, Mallampati score, biting the upper lip score, maneuver 2-3-3 were examined and calculated by researchers. The results of these examinations were recorded for each person in checklist. Results: In this study, 498 people with mean age of 42.1 ± 16.1 were enrolled (51% female). Based on results of this study, although all three methods significantly correlated with age but none had any relation with gender. Significant relationship was found between upper lip biting and Mallampati score and all body anthropometric factors evaluated in this study (p < 0.05). By increasing the mean of these factors, Mallampati score increases, while this relationship is reverse in the case of height. In addition, significant correlation was found between maneuver 2-3-3 and weight, height, waist circumference, hip circumference and BMI, while it showed no correlation with neck circumference (p = 0.328) and WHR (p = 0.121). Conclusion: Based on findings of current study, it is likely that upper lip biting test and Mallampati score have significant relation with all body anthropometric factors evaluated in this study. But maneuver 2-3-3 has no correlation with neck circumference and WHR.

Introduction: Considering the anti-inflammatory role of intravenous (IV) lidocaine, its analgesic properties, and its ability to reduce the need for opioids during and after surgery, in this study we decided to evaluate the effect of IV lidocaine infusion on levels of inflammatory factors based on neutrophil to lymphocyte ratio (NLR) in breast cancer surgery candidates.Methods: The present study is a randomized clinical trial. All the patients with ASA: I, II breast cancer, who were candidates of mastectomy elective surgery were included. The patients were allocated to 2 groups of IV lidocaine and normal saline based on a random numbers table. After inducing anesthesia similarly for all the patients, using 0.02 mg/kg midazolam, 2-4 µg/kg fentanyl, 1-2 mg/kg propofol and 0.5 mg/kg atracurium, either 1.5 mg/kg/hr IV lidocaine or the same volume of normal saline was infused intravenously. Glasgow prognostic score and NLR were calculated before and 6, 24, and 48 hours and 14 days after surgery.Results: A total of 63 women suffering from breast cancer, with the mean age of 49.25 ± 9.32 years, were included, and allocated to lidocaine and control groups using simple randomization. There was no statistically significant difference between the 2 groups regarding mean age (p = 0.591), incision size (p = 1.000), and duration of surgery (p = 0.752). Using mixture model regression analysis and after adjusting the effect of baseline variables, a significant difference was detected between the groups regarding NLR during the follow-up period (p = 0.006).Conclusion: Based on the findings of the present study, it seems that NLR changes were smaller in breast cancer patients, who had received lidocaine infusion during surgery, compared to the control group.

Objective This study was conducted to compare propofol dose requirements between patients with and without sleep quality disorder (SQD) in order to achieve the same depth of anesthesia. Methods In this comparative study, adult patients who were candidates for elective cataract surgery under general anesthesia in American Society of Anesthesiologists (ASA) class I or II were included. Using a validated questionnaire, patients were divided into two groups with Pittsburgh Sleep Quality Index (PSQI) higher and lower than five. Pre-induction with midazolam 0.02 mg/kg and fentanyl 2 µg/kg was administered 3 min before induction. Induction and 1-hour maintenance doses of propofol to achieve and maintain bispectral index score (BIS) 40–60 were measured and compared in the two groups. Results Seventy patients, 47 of which (67.1%) were female, with the mean age of 63.83 ± 10.67 years were enrolled; 35 in SQD group and 35 in normal group. Baseline and demographic characteristics were not significantly different between the two groups. BIS score after pre-induction was significantly lower in SQD group compared with normal group (p = 0.002). Propofol dose at the time of induction and also 1 hour after induction was significantly lower in SQD group compared to normal group (p Conclusion In the current study, induction and maintenance doses of propofol for general anesthesia were significantly lower in patients with SQD, in comparison with normal patients.

Background: There are limited available scientific sources of data and rare controlled studies to guide the anesthesiologist regarding preoperative analgesic care in opioid addict patients, despite the increasing prevalence of opioid dependency. Objectives: In the present study, we aimed to evaluate the effect of using Dexmedetomidine (Dex) during femoral neck surgery on the postoperative analgesic consumption in opium addict patients. Patients and Methods: The present study is a double-blind randomized clinical trial. Patients suffering from femoral neck fracture with a history of opium addiction who were candidates for surgery under spinal anesthesia were included. After induction of spinal anesthesia using hyperbaric bupivacaine, either Dex or normal saline was infused for patients. Dex with a dose of 0.5 µg/kg/h in the intervention group and normal saline with a dose of 0.5 cc/kg/h in the control group was administered. After the surgery, pain intensity of the patients in recovery was assessed in 10-minute intervals based on visual analog scale (VAS) until 2 hours postoperatively. Time to pain and the total amount of opium consumption for pain control in 24 hours postoperatively were calculated and compared between the 2 groups. Results: Finally, 25 patients in each group were studied. Demographic and baseline characteristics of the patients in the 2 groups were not significantly different. Mean morphine consumption in recovery until 2 hours postoperatively showed no significant difference between Dex and control groups (P = 0.24). However, the mean opioid use during 24 hours postoperatively was significantly difference and it was lower in the group receiving Dex infusion (P < 0.001). Conclusions: It is likely that intravenous Dex infusion during femoral neck fracture surgery under spinal anesthesia can lead to the less opioid use throughout the 24 hours postoperatively in opium addict patients.

Background: The use of patient-controlled analgesia (PCA) has increased in recent years. Data regarding PCA’s usefulness following anorectal surgery are equivocal, and it still needs to be further studied and discussed. Therefore, the current study was conducted to compare PCA with pudendal nerve block (PNB) for pain management in patients undergoing anorectal surgery. Methods: Patients candidate for elective anorectal surgery under general anaesthesia were considered eligible. Prior to the surgery, the patients were divided into PCA and PNB groups. PNB was performed at the end of the surgery just before extubation. PCA was initiated in the recovery room. The patients’ pain scores were recorded based on an 11-point numerical rating scale (NRS) at 2, 6, 12, and 24 hours into the post-operative period. The total dose of morphine sulfate consumed, the overall satisfaction, and any side effects were recorded. Results: 100 patients with a mean age of 44.55 ± 11.45 years were enrolled (71% male). Both methods resulted in effective pain control. The difference in the consumed doses of morphine was not statistically significant (P = 0.2). The PNB group patients were more satisfied than those in the PCA group (8.6 ± 1.9 vs. 7.3 ± 2.2; P = 0.037). The recorded side effects were significantly higher in the PCA group (P < 0.001). Conclusions: Although both morphine-contained PCA and PNB with Marcaine resulted in effective pain control following anorectal surgery, it is likely that local anaesthesia with Marcaine is accompanied by fewer side effects and more satisfaction.

A 25-year-old man underwent an excision of a thigh mass under general anesthesia without any complication. After the operation, he developed oxygen desaturation requiring a jaw thrust maneuver. A rapidly expanding hematoma on the right side of the neck was formed shortly after the application of the maneuver. The patient was returned to the operation room for a neck exploration. Damage to the facial artery and vein was noted. Further evaluations confirmed the diagnosis of Neurofibromatosis type 1 (NF-1). It is recommended that considering the probable risk of arising hematoma in NF-1 patients, application of jaw thrust maneuver should be performed meticulously.

Background: This double-blind randomized clinical trial aimed at comparing the effect of intranasal desmopressin with that of intravenous ketorolac in pain management of patients with renal colic referring to the emergency department. Methods: The patients were randomly divided to two groups. One group received intravenous ketorolac 30 mg and intranasal normal saline, while, the other one received intranasal desmopressin 40 μg and 1 mL of intravenous distilled water. The patients’ pain was evaluated using the visual analog scale at the time of admission, 10, 30, and 60 minutes after drug administration. Results: Overall, 40 patients with mean age of 32.53 ± 6.91 participated in this study. Gender ratio (P = 0.288), mean age (P = 0.165), and mean pain score on arrival (P = 0.694) had no significant difference. The mean pain scores, 10, 30, and 60 minutes after drug administration in the ketorolac group was significantly lower than the desmopressin group, and decreased more rapidly (P < 0.001). Conclusions: It is likely for desmopressin to be less efficacious than ketorolac, and desmopressin leads to a significant alleviation of pain in patients with renal colic.

Introduction: The choice of anesthetic technique in patients with osteogenesis imperfecta (OI) can be a challenge for anesthesiologists and must be adjusted based on specific circumstances and abnormalities. We report our anesthetic technique in an OI patient to emphasize this point, and to frame a discussion of this subject. According to the accessible data, we report one of the rare OI patients who have undergone spinal anesthesia for emergency surgery. Case Presentation: The patient was a 21-year-old female with OI type IV, who was admitted due to severe anal pain. The surgeon decided to perform an emergency reduction of a prolapsed rectum, with late permanent fixation. Considering the circumstances, we decided to perform spinal anesthesia for the operation, which lasted for 30 minutes. The patient underwent rectal prolapse reduction via rectosigmoidoscopy, of up to 25 cm of rectum. She was transferred to the post-anesthesia care unit after her vital signs were stabilized. After gaining lower extremity strength, she was transferred to the surgery ward. The next day, she was discharged from the hospital. Conclusions: Although most authors believe that general anesthesia following fiberoptic intubation is the preferred method for OI patients, it is likely that spinal anesthesia is acceptable in such patients. Although it is technically difficult, the procedure can be performed by expert anesthesiologists.

Background: Spinal anesthesia is an important and commonly used method for surgical anesthetic in operating rooms. However, even with identical drug dosage and administration mode, the extent of drug distribution in vivo is highly variable and difficult to control. Preanesthetic administration of fluids immediately before spinal anesthesia (preload) is normal practice. The choice of fluid type may affect drug distribution as well as the duration and level of the block. Objectives: We examined whether preloads of normal saline, Ringer, or hydroxyethyl starch has different effects on the time it takes to reach maximum block, and the distribution and duration of spinal block level. Patients and Methods: This was a randomized trial and the 150 patients selected were evenly divided into three groups and given; normal saline, Ringer, or hydroxyethyl starch 130/0.4f luids. Preload was given at 10 mL/kg for the normal saline and Ringer groups, and 5 mL/kg for the hydroxyethyl starch group, 10 min before the spinal anesthesia. Sensory block levels were recorded every 5 min until 30 min after spinal anesthesia and then at 60 and 90 min. Time taken to reach maximum and median sensory block, maximum and median level of block, duration of block, and hemodynamic status were recorded. Results: There were no statistically significant differences in the demographic characteristics between the three groups. Maximum block was higher in normal saline compared to Ringer (P = 0.029). Time taken to reach maximum block was greater in Ringer compared to both normal saline (P = 0.001) and hydroxyethyl starch (P = 0.003). Normal saline had a longer duration of sensory block T10 compared to Ringer and hydroxyethyl starch (P = 0.03). Conclusions: Preload fluids have an impact on the level, distribution and duration of sensory block in spinal block. Of the three fluids, normal saline produced the greatest maximum and longest duration of block, whereas time taken to reach maximum block was longer in the Ringer group.

In this report, we present a case of death caused by a broken ETT. Our patient (male) was a 32-year-old, with a known case of Hodgkin's lymphoma of eight years duration, prior to admission to our infectious disease department (Imam Hosein Medical Center, Tehran, Iran) with fever, cachexia, and dyspnea. Antibiotic treatment (imipenem, vancomycin) was started with a diagnosis of pneumonia. After 48 hours from the admission, the patient was transferred to the ICU because of his decreased level of consciousness, and intubation was ordered. When visited by an anesthesiologist, the patient was confused, cachectic, sweating, and suffering from respiratory distress. Vital signs were recorded as follows: PR = 110 /min, RR = 40/min, axillary temperature = 38°C, and blood pressure = 90/50 mmHg. In lung auscultation, the breathing sounds were muffled in the left superior and middle lobes, and coarse crackles were heard in the lung bases. Arterial blood gas analysis results were: pH = 7.18, HCO3 = 15 mmol/L, PCO2 = 23 mmHg, PO2 = 48 mmHg, BE = -8 mmol/L O 2 , and saturation = 85%. Considering the patient’s condition, cardiorespiratory monitoring and pulse oximetry were established. After suctioning the oral secretions, an intravenous injection of 150 µg fentanyl and 80 mg lidocaine 2%, plus four puffs of lidocaine 10%, were administered to anesthe tize the glossopharyngeal nerve and a direct laryngoscopy was carried out. Then, the patient was intubated with a high volume low-pressure tracheal tube No 8, with an inflated cuff. After the correct position of tube was con firmed, the cuff was filled with 5cc air. Mechanical ventilation was established in the synchronized intermittent mandatory ventilation (SIMV) mode with pressure support parameters as follows: RR = 12/ min, TV = 450 cc, PEEP = 3 cm H 2 O, pressure support = 15 cm H 2 O, flow trigger = 2 L/min, inspiratory time = 1.5 sec, inspiratory flow rate = 50 L/min, and FIO 2 = 100%.

Background and Aims: The present study was designed and carried out aiming to evaluate the effects of local dexmedetomidine (Dex) on sedation rate and hemodynamic changes in candidate patients for fiberoptic nasotracheal intubation. Material and Methods: Candidate patients for fiberoptic nasotracheal intubation were randomly divided into three groups including intravenous (IV) Dex group, local Dex group, and control group. Local anesthesia using lidocaine was performed in all patients. After performing the intubation, propofol infusion was used to keep the patients on predetermined cerebral state index (CSI). Hemodynamic parameters, arterial blood O2 saturation (SpO2), and CSI were monitored in all patients before, during, and after the procedure. Coughing score, intubation score, and patient tolerance score during and after nasotracheal intubation were assessed. Propofol consumption was also measured. Results: A total of 95 patients with the mean age of 45.4 ± 6.7 years were evaluated (54.2% of females). Hemodynamic parameters and SpO2 were significantly different between the three groups (P < 0.001). The dose of propofol used for reaching proper CSI was significantly higher in the control group compared to IV and local Dex groups (P < 0.001). There is no significant statistical difference in propofol consumption between local and IV Dex groups. The number of patients who were cooperative during intubation was higher in local Dex group compared to IV Dex and control groups; however, the difference was not statistically significant. Conclusion: It is likely that using local Dex during fiberoptic bronchoscopy decreases sudden changes in hemodynamic values and decreases coughing and improves patient tolerance and intubation scores. Local Dex can be useful as IV form with the aim of propofol dose saving.

This study was performed to assess the effect of dexmedetomidine on the level of N-terminal pro–B-type natriuretic peptide (NT-pro-BNP) in patients undergoing major orthopedic surgery. Patients undergoing general anesthesia for femoral shaft fracture surgery were randomly assigned to either 0.5 µg/kg/hour dexmedetomidine or normal saline. Changes in levels of NT-pro-BNP and hemodynamic parameters were compared. Data of 46 patients were analyzed and it was found that the change in NT-pro-BNP levels in the dexmedetomidine group was significantly less than the control group (p = 0.001). In addition, bleeding, changes in systolic and diastolic blood pressure in dexmedetomidine group was significantly less than the control group (p˂0.001). It is likely that dexmedetomidine infusion can reduce the rise of NT–pro-BNP level and therefore is associated with better cardiac outcome. In addition, dexmedetomidine infusion can achieve hemodynamic stability in femoral shaft fracture under general anesthesia.

Background: Opium is a highly addictive agent and the most common narcotic often misused in Iran. The pharmacokinetic of anesthetic drugs in patients with opium addiction is one of the great challenges for anesthesiologists. Hemodynamic instability and postoperative side effects are of these challenges which should be managed correctly. Objectives: In this study we aimed to assess the effects of clonidine upon post anesthesia shivering and recovery time in patients with and without opium addiction after general anesthesia to decrease the subsequent complications related to the shivering and elongation of recovery time.\r\n Patients and Methods: In a randomized clinical trial, 160 patients candidates for elective leg fracture operations under general anesthesia were studied in four groups of 40 patients: Group 1 (placebo 1) were patients without addiction who got placebo 90 minutes before the operation. Group 2 (placebo 2) were patients with opium addiction which received placebo as group 1. Group 3 (Clonidine 1) patients without addiction who got clonidine 90 minutes before the operation and group 4 (Clonidine 2) who were opium addicted ones which received clonidine as premedication. Results: None of the patients with and without addiction in clonidine groups had shivering after the operation but in placebo groups shivering was observed and the difference between clonidine and placebo groups was statistically significant (P < 0.01). Recovery time in clonidine groups of patients with and without addiction was less than placebo ones (both P < 0.01) which the magnitude of difference was higher in opium addicted than non-addicted patients (P = 0.04). Conclusions: Premedication with clonidine in patients with and without opium addiction can be effective to decrease the incidence of shivering and recovery time after operation.

Background: Rapid and proper diagnosis of sepsis is one of the daily challenges of emergency department (ED) and intensive care units. The general aim of the present study was to determine the efficacy of measuring procalcitonin levels in the early diagnosis of bacterial resistance to antibiotics administered empirically in patients with sepsis. Materials and Methods: The present cross-sectional study consisted of patients with clinical evidence of sepsis or systemic inflammatory response syndrome (SIRS), referring to the ED of a third-level hospital in Tehran, Iran in 2012. After collection of basic and clinical data of patients, venous blood samples were taken for routine laboratory tests and determination of procalcitonin serum levels at baseline and 6 and 24 hours after administration of the first dose of an empirical antibiotic. The subjects were divided into two groups of discharged and expired and then comparisons were made using t-test, Chi-squared test and Fisher's test. Specificity and sensitivity of procalcitonin were evaluated along with ROC curve. Results: In the present study, 170 patients with sepsis were included. Evaluation of serum levels of procalcitonin 24 hours after administration of antibiotics exhibited the best sensitivity and specificity for each patient's response to antibiotics. Use of the cutoff point of 6.5 mg/mL for procalcitonin can predict the disease outcome with sensitivity and specificity of 67% and 80%, respectively. Conclusion: It is suggested that procalcitonin be used for the diagnosis of sepsis or SIRS resulting from an infectious disease, for follow-up of treatment and for evaluation of response to treatment.