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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.

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.

Background: Current knowledge on antioxidant properties of anesthetics is inconclusive. Nevertheless, experiments on different anesthesia-related drugs and techniques are growing. Objectives: The aim of this prospective blinded randomized study was to assess the effect of dexmedetomidine (Dex) infusion during anesthesia on oxidative stress resulting from lumbar laminectomy. Methods: The antioxidant activity of Dex compared to placebo (normal saline) was evaluated by measuring the antioxidant enzyme activity of catalase (CAT), superoxide dismutase (SOD), and glutathione peroxidase (GPX). A total of 56 patients who underwent laminectomy surgery were allocated into two groups of intervention and control. Dex group received 0.6 µg.kg-1 dexmedetomidine infusion before induction of anesthesia over 15 minutes, followed by 0.4 µg.kg-1.hr-1 maintenance. Control group received the same volume and sequence of normal saline. Anesthesia protocol was similar in both groups. The antioxidant activity of the previously mentioned enzymes was measured at the beginning of the anesthesia (T1) and after surgery (T2). Propofol consumption, hemodynamic indices, shivering, bleeding volume, and pain Numeric Rating Scale (NRS) were recorded. Results: Although the serum levels of CAT and GPX increased during the procedure, these changes were not significant (P-values 0.579 and 0.762, respectively). Also, the mean SOD level did not change over time in any of the groups, and it was not meaningfully different between the groups at any of the predetermined times (P-value 0.665). Conclusions: As expected, Dex decreased propofol consumption, mean heart rate, mean arterial pressure, and pain intensity allover the perioperative period. It seems that adding Dex to anesthesia regimen during laminectomy had no dominant antioxidant effects.

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.

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.

One of the main objectives in neurosurgical procedures is the prevention of cerebral ischemia and hypoxia leading to secondary brain injury. Different methods for early detection of intraoperative cerebral ischemia and hypoxia have been used. Near-infrared spectroscopy (NIRS) is a simple, non-invasive method for monitoring cerebral oxygenation increasingly used today. The aim of this study was to systematically review the brain monitoring with NIRS in neurosurgery. The search process resulted in the detection of 324 articles using valid keywords on the electronic databases, including Embase, PubMed, Scopus, Web of Science, and Cochrane Library. Subsequently, the full texts of 34 studies were reviewed, and finally 11 articles (seven prospective studies, three retrospective studies, and one randomized controlled trial) published from 2005 to 2020 were identified as eligible for systematic review. Meta-analysis was not possible due to high heterogeneity in neurological and neurosurgical conditions of patients, expression of different clinical outcomes, and different standard reference tests in the studies reviewed. The results showed that NIRS is a non-invasive cerebral oximetry that provides continuous and measurable cerebral oxygenation information and can be used in a variety of clinical settings.

Background: Reform in medical education is a basic process in every academic department, especially in residency programs. Objectives: This study was designed to assess the indices of education and research as part of the Medical Education Reform program (MERP) in the Department of Anesthesiology and Critical Care (DACC), Shahid Beheshti University of Medical Sciences (SBMU) for four years. Methods: MERP in DACC, SBMU was designed and implemented as a modern academic reform model; different outcome measures in education and research were assessed to demonstrate the effects of the reform plan in academic improvements. Results: there were significant improvements regarding education indices (i.e., teaching methods, passing comprehensive exams, mentorship, assessment methods, faculty development, professionalism in medical education, integration in education, and crisis management) and research indices (targeted research activities, innovation in research approaches, increasing the impact of research). Conclusions: Based on the experiences of DACC, SBMU regarding clinical anesthesiology residency, reform could be achieved using painstaking plans and continuous efforts with tangible documented outcomes. Often, the management period is not durable, and these reforms require meticulous care to sustain.

Background: Dexmedetomidine protective effects on apoptosis in the brain and peripheral organs have been reported in vivo and in vitro. Apoptotic factors of cerebrospinal fluid (CSF) may influence the prognosis of patients undergoing open discectomy surgery. Objectives: This study evaluated the effect of intrathecal dexmedetomidine administration on the CSF levels of apoptotic factors and clinical outcomes in patients undergoing lumbar discectomy. Methods: This clinical trial was conducted on patients undergoing open lumbar discectomy. Forty patients were randomly divided into control and dexmedetomidine groups. In the dexmedetomidine group, 0.1 μg/kg of dexmedetomidine was intrathecally injected after anesthesia induction. Patients’ hemodynamic status during surgery was recorded; additionally, their pain scores were recorded by the Numeric Rating Scale (NRS) in the recovery room. The levels of apoptotic factors including Bax/Bcl-2 and caspase-3 in the CSF were measured at the beginning and end of discectomy, and the results were compared between the two groups. Results: Of the 40 evaluated patients, the mean levels of caspase-3 in the intervention and control groups were 2.28 ± 0.35 and 2.34 ± 0.32 ng/mL before surgery and 2.56 ± 0.42 and 2.72 ± 0.39 ng/mL after surgery, respectively. The levels of Bax/Bcl-2 in the intervention and control groups were 1.01 ± 0.11 and 0.89 ± 0.07 before surgery and 1.28 ± 0.14 and 1.16 ± 0.19 after surgery, respectively. The levels of these two factors were not significantly different. However, the NRS scores were significantly lower in the dexmedetomidine group than in the control group. Conclusions: Intrathecal dexmedetomidine could significantly and safely reduce the NRS score in the intervention group but did not have any significant effect on the CSF levels of apoptotic factors before and after lumbar discectomy surgery.

The correct placement of the endotracheal tube is a cornerstone of safe anesthesia. Different methods, such as auscultation, capnography, and ultrasound, have their own limitations regarding the confirmation of endotracheal intubation, reinforcing the idea that a single technique is not foolproof. This study proposes a new technique in this regard.A total of 600 patients were enrolled in this study, and tracheal intubation was checked with palm pressure and disposable plastic glove inflation and pulsation.The data were analyzed using the t-test and Mann-Whitney U test that indicate 94% and 94.8% sensitivity for palm pressure and bag pulsation, respectively, and a 100% positive predictive value for both tests.Palm pressure and bag pulsation are accurate, inexpensive, and reliable techniques to confirm proper tracheal intubation.

In the current study, we reported a successfully managed case of giant cerebral hydatid cyst in a 59-year-old male. Cerebral hydatid disease is a rare manifestation of echinococcosis representing 1% - 2% of all cases with hydatid disease. The mainstay of its treatment is surgical excision of entire intracranial cystic lesion, avoiding intra-operative rupture, which can result in subsequent recurrence or anaphylactic reaction. The surgery can be associated with intraoperative complications (including anaphylaxis, bleeding, neurological deficits, development of subdural effusion, epidural hematoma, and pneumocephalus), especially in the cases where the cyst is infected. All of these complications are of significant concern for the anesthesiologists. Thus, it is of paramount importance for anesthesiologists to consider the intra-operative challenges and possible required actions preoperatively.

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.

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

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)

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.

A case of Churg-Strauss syndrome with schwannoma of T12 in a middle-aged female with large hepatic hemangioma was presented with special emphasis on its anesthetic management and therapeutic protocol. To the authors' best knowledge, it was the first report of a case with a myriad of symptomatology.

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: Pain control is essential for ideal care of surgery patients. Noninvasive or minimally invasive procedures outside the operation room have had an increasing trend in the recent years. Sedation, analgesia or both may be necessary for the majority of these diagnostic or interventional procedures. Objectives: We sought to compare sedative and analgesic effects of Ketamine-Propofol (Ketofol) and Fentanyl-Midazolam (Fentazolam) Combinations in emergent outpatient orthopedic operations. Methods: Sixty male candidates for closed reduction of Colle’s fracture were divided into two groups of ketamine-propofol (Ketofol, KF) and fentanyl-midazolam (Fentazolam, FZ). Pain, sedation score, hemodynamic variables, recovery times, patients’ and the operator’s satisfaction and complications were evaluated. Results: Pain score decreased 4.57 units in the KF group and 3 units in the FZ group (P < 0.001); this decrease was more significant in the KF group in comparison with the FZ group (P < 0.001). The patients’ sedation score during the procedure was 3.43±0.73 and 2.4 ± 0.49 in KF and FZ groups, respectively (P < 0.001). The 5th minute systolic blood pressure was significantly higher in the KF group in comparison with the FZ group (P < 0.001). The 5th minute diastolic blood pressure was significantly more in the KF group in comparison with the FZ group (P < 0.001). The 5th minute pulse rate was significantly greater in the KF group in comparison with the FZ group (P < 0.001). The mean recovery time was significantly more in the FZ group (25.6 versus 18.67 minutes, P < 0.001). The mean patient’s satisfaction was 4.37 ± 0.85 in the KF group and 3.73 ± 0.87 in the FZ group (P = 0.006), and the mean doctor’s satisfaction was 4.35 ± 0.89 in the KF group and 3.27 ± 1.08 in the FZ group (P < 0.001). Conclusions: Ketamine-Propofol, with lower dose of each drug, had a better sedation and analgesic effect as well as lower complications and shorter recovery time when compared to fentanyl-midazolam.

Scientists are customarily categorised based on their seminal and extraordinary contributions as being top, medium and low, and in this regard the ‘h-index’ is usually cited as a pivotal index to demarcate the scientific credibility of scientists. The h-index was initially proposed by Hirsch1 to provide a global impact of a scientist’s contributions. The h-index, however, provides a rough approximation to a scientist’s multifaceted profile and thus fails to reflect a scientist’s cumulative scientific and research accomplishments. Having said that, some genuine criticisms have cropped …