Electroconvulsive therapy-related cognitive impairment and choice of anesthesia: the tipping point.

INTRODUCTION: Electroconvulsive therapy (ECT) is among the most effective treatments of several life-threatening psychiatric disorder. Despite effective therapy, ECT-induced seizure could cause several adverse effects including cognitive disorders and memory impairment. Drugs such as thiopental, which have been prescribed for anesthesia required for ECT, are known as drugs with cognitive effects. This pilot randomized clinical trial tried to assess the feasibility of using a lower dose of thiopental in combination with remifentanil instead of a higher challenging dose of a single drug with cognitive side effects such as thiopental. We evaluated post-ECT cognitive impairment in patients who received remifentanil-thiopental compared with thiopental-placebo group. PATIENTS AND METHODS: One hundred twenty patients with psychiatric disorders between the ages of 18 and 60 years were enrolled. The patients were randomized into 2 groups who received either thiopental sodium (4 mg/kg) and remifentanil (1 µg/kg) or thiopental sodium (3 mg/kg, placebo). The psychiatric patients were examined using mini-mental state examination in terms of the cognitive deficits before ECT as well as 5 and 24 hours after ECT. Statistical analyses were done using Statistical Package for the Social Sciences version 16. Unpaired t test, χ2 test, and analysis of variance were used to determine the association of variables. RESULTS: All the patients completed the trial. There were no reports of adverse effects. In terms of depth of anesthesia measured by bispectral index, no significant difference was observed. Regarding mini-mental state examination scores, the difference was not statistically significant. CONCLUSIONS: Depth of anesthesia was similar between the groups.

Placenta accreta outcomes and risk factors in a referral hospital in north of Iran: A case control study.

Background: Placenta accreta syndrome (PAS) may led to heavy blood loss and maternal death. Here we analyzed the main risk factors of PAS+ pregnancies and its complications in a referral hospital in the north of Iran. Methods: In a case control study, all pregnant women with PAS referred to our department during 2016 till 2021 were enrolled and divided in two groups case (PAS+) and control (PAS-) based on preoperative imaging, intraoperative findings, and pathological reports. The sociodemographic features and neonatal-maternal outcomes also were recorded. Results: The most frequent reason for cesarean (C/S) was repeated C/S (62.9%, 56/89). A significant difference showed up in the time lag between previous C/S and the present delivery (p < 0.001) which shows that when the time distance is longer, the risk of PAS rises (OR: 1.01 [95% CI: 1.003-1.017]). Also, a positive history of prior abortion and elective type of previous C/S were related to PAS+ pregnancies. Our other finding showed that PAS+ pregnancies will end in lower gestational age and have a longer duration of operation and hospitalization, heavy blood transfusion, and hysterectomy. Also, PAS+ pregnancies were not related to poor neonatal outcomes. Conclusions: It seems that, in addition to repeated C/S as a strong risk factor, previous abortion is a forgotten key which leads to incomplete evacuation or damage the endometrial-myometrial layers.

Intraoperative Awareness in Patients Undergoing Cardiac Surgery in an Academic Center in the North of Iran.

Background: Coronary artery bypass grafting (CABG) has distinctive characteristics that may increase the risk of awareness during general anesthesia (AGA). Objectives: This study was conducted to assess the incidence of AGA in cardiac surgery in an academic hospital in Guilan, Iran. Methods: This descriptive cross-sectional study was performed in Dr. Heshmat Hospital in Rasht, Iran. Eligible patients candidates for CABG were enrolled in the survey in 2022. After surgery, when the patient was cooperative enough, a questionnaire including demographic data and specialized questions related to different stages of anesthesia was completed via face-to-face interviews. The data were analyzed using IBM SPSS Statistics 21 with chi-square, Fisher's exact, and t-test. Results: The data from 322 patients were analyzed, of whom 14 (4.3%) experienced AGA. Among them, the "feeling of fear and anxiety" reported by 9 (39.1%) cases was the most common awareness state. "Dreaming during surgery and anesthesia" and "feeling unable to move during anesthesia,", each reported by 6 (26.1%) cases, were the other common types of awareness state. None of the demographic data had a significant association with the occurrence of AGA. Conclusions: The incidence of AGA during CABG was almost acceptable according to the credible evidence.

Glycemic Control in Coronary Artery Bypass Graft Surgery: A Different Perspective.

Background: Hyperglycemia during coronary artery bypass graft surgery (CABG) strongly predicts intra- and post-operative adverse consequences. Objectives: This study aimed to evaluate the quality of glycemic management during CABG in an academic center regarding peripheral blood and coronary sinus values. Methods: This prospective descriptive study encompassed 55 eligible patients undergoing on-pump CABG surgery in 2020. Peripheral blood glucose (BG) was measured four times, before anesthesia induction (T0), before cardiopulmonary bypass pump (CPB) (T1), during CPB (T2), at the end of CPB (T3), and at the end of surgery (T4). The surgeon also took a sample of the coronary sinus BG. Results: The BG variations from T0 to T4 were statistically significant (P < 0.0001). The higher values detected in the ASA class III compared to ASA classes II were statistically significant at T1 (P = 0.01) and T2 (P = 0.025): patients with the higher BMI showed the higher levels of BG. In this regard, the differences were significant at T0 (P = 0.0001), T2 (P = 0.004), and T3 (P = 0.015). Regarding coronary sinus, the mean BG was 222.18 ± 75.74 mg/dL. It was also observed that the ASA class III (P = 0.001), longer duration of CPB (P = 0.021), higher IV fluid volume administrated during surgery (P = 0.023), higher BMI (P = 0.0001), and less urine volume at the end of surgery (P = 0.049) were significantly associated with the higher BG of the coronary sinus. Conclusions: The existing glycemic management protocols on the CABG patients were acceptable in our hospital. However, the BG level of the coronary sinus was higher than the peripheral one.

Comparing the Effects of Low Dose of Ketamine, Tramadol, and Ondansetron in Prevention of Post Spinal Anesthesia Shivering in Cesarean Section.

BACKGROUND: Shivering frequently occurs in cesarean section (CS) under spinal anesthesia (SA), resulting in several complications. To date, pethidine has been considered as the gold standard for post-SA shivering control, but it is contraindicated in breastfeeding women. METHODS: This randomized, double-blind study was conducted at Alzahra hospital in Guilan, Iran, From January 2019 to November 2020. A total of 508 eligible term parturient women were enrolled and randomly divided into four groups of low dose ketamine (K), tramadol (T), ondansetron (O), and placebo (P). The incidence and severity of shivering and patients' complications were recorded and compared among the groups. RESULTS: The patients were homogenous in terms of demographic variables. Shivering was witnessed in 68 (53.5%), 26 (20.5%), 75 (59.1%), and 82 (64.6%) patients in K, T, O, and P groups, respectively (P = 0.0001). Regarding shivering severity, there was a significant difference among the four groups (P = 0.0001). In addition, a significant difference was seen regarding Apgar scores at the first minute, but not at the fifth minute (P = 0.168). CONCLUSIONS: Considering the high incidence of shivering in placebo group, prophylactic intervention in CS under SA seems to be necessary. Among the studied drugs, tramadol was the most effective one, followed by a low dose of ketamine and ondansetron.

Breaking Bad News: A Valid Concern among Clinicians.

Objective: Delivering bad news is the duty of specialist physicians. However, they find it very difficult due to insufficient experience. In this study, the way faculty and residents of Guilan University of Medical Sciences (GUMS) delivered bad news to the patients was investigated. Method : This study was conducted at hospitals affiliated to GUMS during 2017. A questionnaire containing 18 items on environmental and psychical support was filled through a face to face interview. The first 10 questions evaluated psychical support and the next eight environmental supports. The scoring of each question ranged from 10 to 50, with 10 indicating "never" and 50 "always". Results: According to the analysis of 235 questionnaires, only 32 (13.6%) of the participants had been taught to deliver bad news and 195(83%) felt they need educational courses. Also, 40 (17%) believed that they had enough ability to deliver these massages. No significant differences were observed among physicians who had taken teaching courses in breaking bad news to patients. Conclusion: This study revealed that educational courses to improve physicians' communication skill to break bad news to patients are strongly warranted.

General Anesthesia-Related Neurotoxicity in the Developing Brain and Current Knowledge and Practice of Physicians at Guilan Academic Hospitals.

BACKGROUND: Recent articles about the topic of the anesthetic agents-related neurotoxicity have currently attracted the attention to the issue in the anesthesiology community. However, specialists in other fields should also be aware of this potential risk. OBJECTIVES: This study aimed to evaluate the knowledge and practice of physicians at Guilan academic hospitals regarding general anesthesia-related neurotoxicity. METHODS: Firstly, the responsible anesthesia resident explained the purpose of this work to Guilan faculty and residents and if they agreed to participate a questionnaire containing 12 items was filled via a face to face interview. RESULTS: A response rate of 100% was achieved (271 responders from 271 eligible study responders). Also, 89 (33.1%) responders were attending, 180 (66.9%) were residents, 112 (41.6%) were female, and 157 (58.4%) were male. The mean years of experience was 8.8 ± 4.82 (2 - 28 years). According to the achieved data, the majority of the precipitants did not believe in GA toxicity. CONCLUSIONS: This paper revealed that the current curriculum does not sufficiently address the anesthesia-related neurotoxicity problem. Indeed, the need for training and communication with non-anesthesia medical colleagues was highlighted.

Right ventricular dysfunction and associated factors in patients after coronary artery bypass grafting.

BACKGROUND: Coronary artery bypass grafting (CABG) surgery is widely accepted as a revascularization method for coronary artery disease (CAD). Despite survival benefit and improvement in quality of life, CABG may impose major morbidities and significant complications. Right ventricle (RV) dysfunction is an important complication that may affect patient's longevity and functional capacity. The aim of this study was to evaluate the relationship between RV dysfunction and some invisible parameters like inferior vena cava (IVC) size with physical capacity. METHODS: In this prospective study, 61 eligible CABG candidates were enrolled and RV function was assessed by echocardiographic parameters before CABG and one week and six months after the procedure, using tricuspid annular plane systolic excursion (TAPSE), Tei Index (TI), peak systolic movement (Sm) (cm/s), and IVC size. Functional capacity was assessed by six-minute walk test (6-MWT) 6 months after CABG. RESULTS: 58 patients who did not have any perioperative RV dysfunction were remained until the end of study; mean age was 58.2 ± 7.9 years with 68.9% being men, and 3 patients died after CABG. Preoperatively, septal motion, RV indices, and IVC size were normal in all patients. The frequency of RV dysfunction according to abnormal TAPSE index, TI, and peak Sm one week after surgery was 81.0%, 79.0%, and 62.0%, respectively, and 6 months after surgery was 49.0%, 49.0%, and 37.0%, respectively. Mean walked distance in 6-MWT was significantly less in patients with RV dysfunction, older age, and higher number of involved vessels (P < 0.001). CONCLUSION: The significant reduction in RV function and impairment of exercise capacity after CABG in this study suggests cardiologists to pay more attention to RV assessment in follow-up visits of patients undergoing GABG.

Does Adding Lidocaine to Intrathecal Bupivacaine Affect Hemodynamic Parameters during Hip Fracture Surgery?

BACKGROUND: Hip fracture is one of the most common problems in elderly that needs surgical repair. As, the majority of these patients have chronic diseases, they are at increased risk of peri-operative mortality and morbidity. The purpose of this study was to evaluate spinal anesthesia with bupivacaine vs bupivacaine in combination with lidocaine in terms of hemodynamic changes in patients undergoing hip fracture surgery. METHODS: This double-blind clinical trial was conducted on 292 patients undergoing surgery for hip fracture under spinal anesthesia. Patients were allocated into two groups of B (10 mg of hyperbaric 0.5% Bupivacaine) and BL (5 mg hyperbaric Bupivacaine 0.5% plus 50 mg Lidocaine 5%). Sensory and motor block and hemodynamic changes were consecutively measured before spinal anesthesia (T0), immediately after spinal injection (T1), every 5 minutes for half an hour (T2- T7), and at 45 minutes (T8) and 60 minutes (T9) after injection. RESULTS: Patients in the two groups were homogeneous in demographic characteristics including age, sex, BMI, ASA Class, baseline blood pressure and heart rate. The onsets of sensory and motor blocks in group BL were faster than group B (P=0.0001). Also, the durations of sensory and motor blocks in group B were significantly longer than group BL (P=0.0001). The BL group had a significantly lower systolic blood pressure in all periods (P<0.05). Although the heart rate in the BL group was lower than group B at all time points, this difference was only significant during T2-T3 (P=0.033 and P=0.0001, respectively). Group BL had significantly more episodes of hypotension, bradycardia, nausea and vomiting (P=0.0001, P=0.023, P=0.003, and P=0.033, respectively). CONCLUSION: According to our findings, using Lidocaine 50 mg in combination with Bupivacaine 5 mg, compared with Bupivacaine 10 mg alone for spinal anesthesia in hip fracture fixation surgeries was associated with more hypotension and bradycardia. As a result, combination of Bupivacaine with Lidocaine at this dose is not recommended for induction of anesthesia in these patients.

Does Tranexamic Acid Reduce Bleeding during Femoral Fracture Operation?

BACKGROUND: Proximal Femoral shaft fractures are commonly associated with marked blood loss which can lead to postoperative acute anemia and some other complications. Tranexamic acid (TA) is an antifibrinolytic medication that reduces intra-and postoperative blood loss and transfusion requirements during some elective surgeries. The aim of this study is to evaluate the effect of intravenous Tranexamic acid (TA) on intraoperative blood loss and a subsequent need for transfusion in patients who were undergoing surgery for femoral shaft fractures in trauma setting. METHODS: Thirty-eight ASA grade I-II patients undergoing proximal femoral shaft fracture surgery with intra medullary nailing were included in this double blind randomized controlled clinical trial. They were allocated into two groups. Group I, the intervention group with eighteen patients received 15 mg/kg (TA) via intravenous infusion before surgical incision. Patients in the placebo group received an identical volume of normal saline. Hemoglobin level was measured four hours before and after the surgeries. Postoperative blood loss and hemoglobin change as well as transfusion rates and volumes were compared between the two groups. RESULTS: Mean Percentage fall in hemoglobin after surgery were 1.75±0.84 and 2.04±1.9 in the study and placebo groups, respectively (P=0.570). Hemoglobin loss was higher in the placebo group. Transfusion rates was lower in TA group (5.6%) compared to the placebo group (30%) (P=0.06). No significant difference in The Allowable Blood Loss during the surgery was found between the two groups (P=0.894). CONCLUSION: Preoperative treatment with TA reduces postoperative blood loss and the need for blood transfusion during traumatic femoral fracture operation.

Acupuncture and botulinum toxin A injection in the treatment of chronic migraine: A randomized controlled study.

BACKGROUND: Migraine is a common type of headache. Sometimes adequate pain relief is not achieved by conventional treatments. Acupuncture and botulinum toxin-A injection are known as non-pharmacological interventions for this purpose. The aim of this research was to compare the effect of acupuncture with botulinum toxin-A injection and pharmacological treatment in controlling chronic migraine. METHODS: This clinical trial was conducted on patients with chronic migraine in the North of Iran during 2014-2015. Eligible patients were randomly allocated to groups receiving acupuncture (A) or botulinum toxin A (B) and controls (C) by designed quadripartite blocks. All patients were evaluated at baseline, one, two and three months after treatment using visual analogue scale (VAS) score and other parameters. The analysis of data was performed in SPSS software Version 19. RESULTS: One hundred fifty patients (48 males and 102 females) completed this study. During the 3- month study, the pain severity significantly diminished in three groups (P=0.0001), with greater reduction in group A (P=0.0001). The number of days per month with migraine, absence from work and the need for medication significantly decreased in three groups at 3 times of evaluation (p<0.05) with fewer side effects in group A (P=0.021). CONCLUSION: Acupuncture, botulinum toxin-A injection and pharmacological treatment have beneficial effects on chronic migraine; however, acupuncture showed more effectiveness and fewer complications.

Is Spinal Anesthesia with Low Dose Lidocaine Better than Sevoflorane Anesthesia in Patients Undergoing Hip Fracture Surgery.

BACKGROUND: To evaluate general anesthesia with sevoflurane vs spinal anesthesia with low dose lidocaine 5% on hemodynamics changes in patients undergoing hip fracture surgery. METHODS: In this randomized double blind trial 100 patients (50 patients in each group) older than 60 years under hip surgery were randomized in general anesthesia with sevoflurane and spinal anesthesia with lidocaine 5%. Hemodynamic changes including mean arterial pressure (MAP) and heart rate, blood loss, pain severity, nausea and vomiting and opioids consumption were compared in two groups. RESULTS: During surgery, difference between two groups regarding changes in mean arterial pressure was not significant, but the changes in heart rate were significantly different. Mean arterial pressure changes during recovery between two groups were significantly different. But there was no significant difference in heart rate changes. Bleeding in the sevoflurane group was significantly more than spinal group (513.ml vs. 365 ml). Moreover, AS Score, opioid consumption, and the nausea and vomiting in spinal anesthesia group was significantly lower than the sevoflurane group. CONCLUSION: We showed that general anesthesia with sevoflurane and spinal anesthesia with low dose lidocaine 5% have comparable effects on hemodynamics changes in patients undergoing hip fracture surgery. However postoperative pain score, vomiting and morphine consumption in patients with spinal anesthesia were lower than general anesthesia.

Comparison of the Effects of Low-Dose Midazolam, Magnesium Sulfate, Remifentanil and Low-Dose Etomidate on Prevention of Etomidate-Induced Myoclonus in Orthopedic Surgeries.

BACKGROUND: Etomidate is a potent hypnotic agent with several desirable advantages such as providing a stable cardiovascular profile with minimal respiratory adverse effects and better hemodynamic stability compared with other induction agents. This drug is associated, however, with myoclonic movements which is characterized by a sudden, brief muscle contractions as a disturbing side-effect. OBJECTIVES: The present study was designed to compare the effectiveness of low- dose midazolam, magnesium sulfate, remifentanil and low-dose etomidate to suppress etomidate-induced myoclonus in orthopedic surgery. PATIENTS AND METHODS: A double-blind clinical trial study was conducted in an academic hospital from September 2014 to August 2015. Two hundred and eighty-four eligible patients, American society of anesthesiologists class I - II, scheduled for elective orthopedic surgery were randomly allocated into four equal groups (n = 71). They received premedication with intravenous low-dose midazolam 0.015 mg/kg, magnesium sulfate 30 mg/kg, remifentanil 1 µg/kg and low-dose etomidate 0.03 mg/kg two minutes before induction of anesthesia with 0.3 mg/kg intravenous etomidate. Then the incidence and intensity of myoclonus were evaluated on a scale of 0 - 3; 0 = no myoclonus; 1 = mild (movement at wrist); 2 = moderate (movement at arm only, elbow or shoulder); and 3 = severe, generalized response or movement in more than one extremity, within ninety seconds. Any adverse effect due to these premedication agents was recorded. RESULTS: The incidence and intensity of myoclonus were significantly lower in the low-dose etomidate group. The incidence rates of myoclonus were 51 (71.85%), 61 (85.9%), 30 (42.3%) and 41 (57.7%), and the percentages of patients who experienced grade III of myoclonus were 30 (58.8%), 32 (52.5%), 9 (30%) and 14 (34.1%) in the midazolam, magnesium sulfate, etomidate and remifentanil groups, respectively. The incidence and intensity of myoclonus were significantly lower in the low-dose etomidate group (P = 0.0001). No notable adverse effect was detected in our patients during the study period. CONCLUSIONS: Intravenous etomidate 0.03 mg/kg prior to induction can effectively reduce the incidence and severity of myoclonus linked to etomidate.

The Incidence and Predictors of Headache and Myalgia in Patients After Electroconvulsive Therapy (ECT).

BACKGROUND: Electroconvulsive therapy (ECT) is a safe and effective mode of therapy for a wide variety of psychiatric disorders. However, it is associated with some disturbing side effects, such as nausea and vomiting, dental and tongue injury, confusion, dizziness, headache, and myalgia. OBJECTIVES: The present study focused on the evaluation of myalgia and headache and their predictors after ECT. PATIENTS AND METHODS: A prospective analytical descriptive study was conducted from October 2014 to January 2015, in an academic hospital in northern Iran. Before sampling, the study was approved by the ethics committee of Guilan University of Medical Sciences. 621 patients with psychiatric disorders who were referred to Shafa hospital enrolled in the study. They were evaluated based on a verbal rating scale (4 point scales) 6 hours after ECT, regarding headache and myalgia side effects. RESULTS: 6 hours after ECT, 126 patients (21.9%) reported headaches, and 56 patients (9%) reported myalgia. The presence of headache or myalgia 6 hours after ECT was not correlated to the duration of convulsion, treatment sessions, sex, or age. But myalgia at 2 hours after treatment was correlated with sex (0.04). Sex, age, duration of seizure, and treatment sessions were not predictors of headache and myalgia 6 hours after ECT (log regression, enter mode). The intensity and frequency of headaches decreased during 6 hours after ECT (P = 0.0001 and P = 0.0001, respectively), and myalgia frequency decreased (P = 0.062) but the intensity increased (P = 0.87). CONCLUSIONS: The results of the present study demonstrate that headache after ECT procedures was more common than myalgia, but it was mild, tolerable, and decreased within 6 hours of the treatment. It is also notable that we did not found any predictors for post-ECT headache and myalgia.

Effects of Low-dose Selenium on the Inflammatory Response in Coronary Artery Bypass Graft Surgery: A Clinical Trial.

BACKGROUND: Coronary artery bypass graft (CABG) surgery with cardiopulmonary bypass (CPB) triggers an inflammatory reaction, leading to the development of myocardial damage and dysfunction. It is suggested that selenium (Se), an essential trace element, has a protective role against oxidative stress. Decreased intraoperative Se levels might be an independent predictive factor for postoperative multiorgan failure. In spite of its proposed advantages, however, the optimal timing and dosage are not well known. OBJECTIVES: To determine whether 600 µg of intravenous Se administration before induction of anesthesia for CABG surgery could attenuate inflammatory reactions in an Iranian population. METHODS: This randomized triple-blind clinical trial took place in the department of cardiac surgery of an academic hospital affiliated with Guilan University of Medical Sciences (GUMS) from May 2015 to September 2015. Eighty-eight eligible patients scheduled for elective on-pump CABG surgery were divided into two groups using randomized fixed quadripartite blocks. They received either an intravenous bolus of 600 µg Se before induction of anesthesia, or normal saline as a placebo. We had four measurement time-points: just before induction of anesthesia (T0), immediately after the end of CPB (T1), 24 hours after surgery (T2), and 48 hours after surgery (T3). Interleukin 6 (IL-6), tumor necrosis factor-alpha (TNF-α), and C-reactive protein (CRP) serum levels were measured using the enzyme-linked immunosorbent assay (ELISA). RESULTS: Data from a total of 81 patients were analyzed: group S (n = 41) and group C (n = 40). There was no significant difference between the two groups with regard to baseline characteristics. In both groups, CPB caused markedly increased IL-6, TNF-α, and CRP plasma concentrations compared with baseline (P = 0.0001). However, the pattern of changes was not significantly different between group S (P = 0.068) and group C (P = 0.26). The IL-6 and TNF-α change trends were significant in each group (P=0.0001). However, comparing the two groups showed no significant difference. With regard to IL-6, there was no significant difference between the two groups at the time-points of T1 (P = 0.34), T2 (P = 0.17), and T3 (P = 0.056), and the same was found for TNF-α at T1 (P = 0.34), T2 (P = 0.17), and T3 (P = 0.056). With regard to CRP, the trend of the changes was significant in each group (P = 0.0001). However, comparing two groups showed a borderline significant difference between them at T1 (P = 0.039), but not at T2 (P = 0.075) or T3 (P = 0.11). CONCLUSIONS: This study revealed that the administration of 600 µg of intravenous Se immediately before induction of anesthesia was safe, but when compared to a placebo, no predominant clinical effects or modifications in the systemic inflammatory response induced by on-pump CABG were observed.

The Effect of Desmopressin on the Amount of Bleeding in Patients Undergoing Coronary Artery Bypass Graft Surgery with a Cardiopulmonary Bypass Pump After Taking Anti-Platelet Medicine.

BACKGROUND: Coronary artery bypass grafting (CABG) is a common surgical intervention at the end-stages of coronary artery occlusion disease. Despite the effectiveness of CABG, it may have particular complications, such as bleeding during and after surgery. So far, there have been many drugs used to reduce bleeding. OBJECTIVES: This study aimed at investigating the effects of desmopressin on the amount of bleeding in patients undergoing CABG with a cardiopulmonary bypass pump (CPBP) who were taking anti-platelet medicine. METHODS: One hundred patients scheduled for elective CABG with a CPBP were included in a prospective, placebo-controlled, double-blinded clinical trial study. They were randomly divided into two groups. One group received desmopressin (40 µg) and the other group received a placebo (isotonic saline). Seven patients were excluded from the study, and 47 and 46 patients participated in the desmopressin and control groups, respectively. The methods of monitoring and the anesthetic techniques were similar in both groups, and all surgeries were performed by one surgeon. Variables including age, gender, pump time, aortic clamp time, duration of surgery, complications (e.g., nausea and vomiting, blood pressure changes), the necessity to receive blood products, and coagulation tests (prothrombin time, partial thromboplastin time, international normalized ratio, and bleeding time) were assessed. Data were statistically analyzed with SPSS software version 17. RESULTS: There was no significant difference between the groups regarding age, gender, pump time, clamp time, duration of surgery, complications, and the changes in hemoglobin and coagulation test measurements (P > 0.05). No significant difference was noted between the groups regarding the rate of bleeding after surgery (359.3 ± 266.2 in group D vs. 406.3 ± 341.6 in group P (control group); P = 0.208). However, the platelet changes after surgery in both groups were significantly different. The analysis revealed that the rate of thrombocytopenia after surgery was higher in the control group (P = 0.012). CONCLUSIONS: Our study showed that desmopressin could not reduce the amount of blood loss after CABG. Also, desmopressin did not have a significant effect on coagulation status. Therefore, based on the results of our study, it seems that the use of this medication cannot be a helpful for patients with any indication for CABG.

A Survey on Transfusion Status in Orthopedic Surgery at a Trauma Center.

BACKGROUND: Increased costs and mortality associated with inappropriate blood transfusions have led to investigations about blood request and blood transfusion techniques. We investigated the transfusion status in patients who underwent orthopedic surgery in Poursina Hospital (Rasht, Iran) to optimizing blood usage and determine if a scheduled transfusion program for every orthopedic surgery could improve blood transfusion management. METHOD: In this descriptive-prospective study, all orthopedic surgeries in Poursina Hospital, Rasht, between April to June 2013 were reviewed. All patient information was recorded, including: demographics, type of surgery, hemoglobin level, cross-match test, duration of surgery, and blood loss, and transfusion. Based on the one-way ANOVA and independent samples test analysis, cross-match to transfusion ratio and transfusion possibility, the transfusion index, and maximal surgical blood order schedule were calculated to determine blood transfusion status. RESULTS: Among 872 selected orthopedic surgery candidates, 318 of them were cross-matched and among those, 114 patients received a blood transfusion. In this study, the cross-match to transfusion ratio was 6.4, transfusion possibility 36.47%, transfusion index 0.6, and maximal surgical blood order schedule 0.9. CONCLUSION: We found that blood ordering was moderately higher than the standard; so it is highly recommended to focus on the knowledge of evidence based on transfusion and standard guidelines for blood transfusion to avoid over-ordering.

Comparing the Effects of Isoflurane-Sufentanil Anesthesia and Propofol-Sufentanil Anesthesia on Serum Cortisol Levels in Open Heart Surgery with Cardiopulmonary Bypass.

BACKGROUND: Major surgeries such as open-heart surgery with cardiopulmonary bypass are associated with a complexity of stress response leading to post-operative complications. Studies have confirmed that anesthesia can mitigate the surgically induced stress response. OBJECTIVES: The aim of this study was to compare the effects of propofol and isoflurane, both supplemented with Sufentanil, on the stress response in coronary artery bypass graft surgery with cardiopulmonary bypass, using cortisol as a biochemical marker. METHODS: This double-blind randomized clinical trial was conducted on 72 patients who underwent coronary artery bypass grafting (CABG) with cardiopulmonary bypass meeting the inclusion criteria. The subjects were randomly divided into two groups of isoflurane (n = 36) and propofol (n = 36) both supplemented with sufentanil. Serum cortisol levels were measured and compared between the groups; 30 minutes before the surgery (T0), at the end of the cardiopulmonary bypass (T1), and 24 hours after the surgery (T2). RESULTS: Compared to the baseline (T0), at the end of cardiopulmonary bypass (T1), both groups demonstrated a decrease in plasma cortisol levels with no statistical significant difference (P = 0.4). At T2 measuring time point, the level of plasma cortisol significantly increased in both groups (P = 0.02), however this increase was less in the Isoflurane group. CONCLUSIONS: In CABG with cardiopulmonary bypass, using plasma cortisol level as a measure, Isoflurane-Sufentanil significantly reduces the stress response to the surgery, when compared to propofol-Sufentanil.

The effect of magnesium sulfate on motor and sensory axillary plexus blockade.

BACKGROUND: Magnesium is a physiologic cation that blocks neuromuscular transmission and does not allow the nerve to be stimulated. OBJECTIVES: This study investigates the effect of adding magnesium sulfate to lidocaine to extend the duration of sensory and motor blocks of the axillary plexus in orthopedic surgeries of the upper extremities. PATIENTS AND METHODS: This controlled randomized double-blind study was performed on patients who were candidates for orthopedic surgery of the upper extremities. A total of 60 patients between 18-60 years with ASA Class 1 or 2 participated in the study. One group received lidocaine (5 mg/kg) with magnesium sulfate 20% (3 mL) as the case group, while the second group received lidocaine (5 mg/kg) with normal saline (3 mL) as a placebo to block the axillary plexus using the trans-arterial technique. The duration of the sensory and motor block of the axillary plexus was monitored and evaluated using the pinprick and modified Bromage scale. RESULTS: A total of 60 patients were included in the study with 30 patients having received lidocaine plus magnesium and the other 30 patients having received lidocaine plus normal saline. The mean sensory block duration in the case group was 248.83 ± 18.36 and in control group was 204.67 ± 22.62. The mean motor block duration in the case group was 207.0 ± 16.64 and in control group was 147.33 ± 21.52 (both P < 0.0001). The mean onset of sensory block in case group was 15.5 ± 3.79 and the onset block in control group was 10.33 ± 4.13 (P < 0.0001). The mean onset of motor block in case group was 20.66 ± 4.09 and the onset block in control group was 19.73 ± 26.18 (P < 0.848). CONCLUSIONS: The addition of magnesium sulfate to lidocaine increased the duration of motor and sensory axillary block in the upper extremities during surgeries when compared to the use of lidocaine alone.

Comparison of Transcutaneous Electrical Nerve Stimulation and Pulsed Radiofrequency Sympathectomy for Treating Painful Diabetic Neuropathy.

BACKGROUND: Painful diabetic peripheral neuropathy (DPN) is a long-term complication of type 1 and type 2 diabetes that majorly impacts quality of life. Its prevalence increases with age and duration of diabetes. It is more common in patients who have suboptimal glycemic control over several years. Because DPN may be resistant to conventional treatments, it is common for patients to only have partial pain relief. Therefore, new therapeutic options are needed for the condition. OBJECTIVES: The aim of the present study was to compare the efficacy of transcutaneous electrical nerve stimulation (TENS) and pulsed radiofrequency (PRF) lumbar sympathectomy in treating painful DPN. PATIENTS AND METHODS: Sixty-five patients with painful DPN refractory to conventional treatment were randomly and evenly assigned to either the TENS or PRF lumbar sympathectomy groups. Pain evaluations were based on the 10-point numerical rating scale (NRS). Subjects were followed for three months and had a total of four study visits (baseline and 1 week, 1 month, and 3 months after treatment). RESULTS: Sixty patients completed all study visits. In both groups, the NRS rating significantly decreased after treatment, with a marked pain reduction observed at the first follow-up evaluation. In the PRF group, the NRS decreased from 6.46 at baseline to 2.76 at the 1 week visit. One and 3 months after treatment, the NRS was 4.30 and 5.13, respectively (P < 0.0001). In the TENS group, the NRS decreased from 6.10 at baseline to 3.96 at the 1 week visit. One and 3 months after treatment, the NRS was 5.23 and 5.90, respectively (P < 0.0001). Unfortunately, the NRS steady increased almost back to baseline levels in the TENS group. The NRS only slightly increased during the follow-up period in the PRF group, but did not reach baseline levels. CONCLUSIONS: Both TENS and PRF lumbar sympathectomy are promising pain relief treatments for painful DNP. However, PRF lumbar sympathectomy seems to have a superior efficacy. Further studies with a larger sample size and a longer follow-up period are needed.