Evaluation of the Response Rates of Hospitals in the Prevention and Control of COVID-19 in Hamadan Province of Iran.

The COVID-19 pandemic has challenged the capacity of health systems in various countries. This study was designed to evaluate the response rates of hospitals in the prevention and control of COVID-19 in Hamadan province, Iran. In this cross-sectional study, all 20 hospitals in Hamadan province were monitored in February 2020. The instrument used in this study was the WHO checklist, entitled "Infection prevention and control health-care facility response for COVID-19." In each hospital, the hospital infection control officials completed the checklists under the supervision of the hospital managers and were then provided to the project manager. Data analyzed by SPSS 22 software. There were 3482 hospital beds (the average beds of each hospital was 174) in the studied hospitals. Of 15 055 patients admitted to all hospitals, 2196 (14.6%) individuals were COVID-19 patients. The total average score obtained from the checklist was 62.25. Among 7 domains studied, the lowest scores belonged to 2 domains of "infrastructure and equipment" and "patient screening and triage." The scores of domains "IPC programs" and "visitors" were significantly higher in hospitals with ICU beds than other hospitals (P-value = .03 in both domains). A comparison between university-teaching hospitals with other hospitals and those in Hamadan city with other cities revealed no significant differences in any of the domains. The mean response rate (62.25) of hospitals in terms of COVID-19 in Hamadan province indicates their relative readiness to prevent and control the COVID19 pandemic. The shortage of infrastructure and equipment and screening and triage problems of patients were the main challenges of hospitals in managing the COVID-19 pandemic in Hamadan province, Iran.

Evaluation of the Effects of Oral Magnesium Sachet on the Prevention of Spinal Anesthesia-Induced Headache After Cesarean Section: A Randomized Clinical Trial.

Background: Post-dural puncture headache (PDPH) is a common complication of spinal anesthesia. It often goes away after a few days but may be more severe in some patients and persists for weeks. Objectives: This study aimed to evaluate the effect of oral magnesium on the prevention of PDPH after cesarean section for the first time. Methods: In this double-blind, randomized clinical trial, 100 candidates for elective cesarean section under spinal anesthesia were randomly divided into 2 groups: (i) the intervention group that received 300 mg of oral magnesium powder and (ii) the control group that received starch powder. The frequency and severity of headache and amount of analgesic consumption in both groups were measured 1, 2, and 3 days after cesarean section. Data were analyzed using SPSS version 22 at 95% CI. Results: The frequency of PDPH 1, 2, and 3 days after surgery was 8% vs 24% (P = 0.029), 10% vs 26% (P = 0.039), and 12% vs 18% (P = 0.401) in the intervention and control groups, respectively. The mean and SD of pain severity was 0.52 ± 1.83 vs 1.5 ± 2.84 (P = 0.03) on the first day, 0.70 ± 2.19 vs 1.58 ± 2.86 (P = 0.05) on the second day, and 0.82 ± 2.32 vs 1.18 ± 2.62 on the third day (P = 0.43) in the intervention and control groups, respectively. Although more patients in the control group received rescue analgesia, no significant difference was seen between the 2 study groups. Conclusions: In women candidates for cesarean section, oral administration of 300 mg magnesium 2 hours before surgery significantly reduces the frequency and severity of PDPH, but its impact on reducing analgesic consumption is not significant.

The Effects of Intravenous Nitroglycerin Bolus Doses in Reducing Hemodynamic Responses to Laryngoscopy and Endotracheal Intubation.

BACKGROUND: Hemodynamic responses to laryngoscopy and endotracheal intubation are transient in most patients. However, in some patients with a history of heart disease, systemic hypertension, or cerebrovascular disease, these may lead to dangerous complications. This study is aimed at determining the effectiveness of intravenous nitroglycerin bolus doses in reducing hemodynamic responses to laryngoscopy and endotracheal intubation. Material and Method. In this double-blind randomized controlled trial, 78 patients aged 18 to 65 years were randomly divided into three groups: 1 µg/kg dose of nitroglycerin (first group), 2 µg/kg dose of nitroglycerin (second group), and normal saline or placebo (third group). 26 samples were allocated for each group. Patients' hemodynamic responses to laryngoscopy and endotracheal intubation were measured at different times. Data were analyzed using SPSS V 16. RESULTS: Patients in the three study groups were similar in terms of age, sex, and weight. There was no significant difference between the mean saturation of peripheral oxygen (SPO2) and the mean heart rate between the three groups before endotracheal intubation and 1 to 10 minutes after intubation (P > 0.05). The difference of mean arterial blood pressure between study groups was only significant in the first and fifth minutes after intubation. Mean systolic and diastolic blood pressure in the first, third, and fifth minutes after intubation was significantly lower in the intervention groups than the control group (P < 0.05). However, no significant difference was observed between the intervention groups. The frequency of systolic blood pressure decrease was significantly different in the first and fifth minutes after intubation in the three study groups (P < 0.05). CONCLUSION: Bolus doses of 1 and 2 µg/kg nitroglycerin in noncardiac elective surgery prevents the increase of mean systolic, diastolic, and arterial blood pressure but has no significant effect on heart rate after intubation.

The Effects of Ondansetron on the Analgesic Action of Intravenous Acetaminophen after Tonsillectomy in Children: A Triple-Blind Randomized Controlled Trial.

INTRODUCTION: Severe pain, nausea, and vomiting after tonsillectomy surgery are among the issues that not only affect patient satisfaction but also may result in complications and delay patient discharge. This study was conducted to assess the effect of intravenous administration of ondansetron on the analgesic action of intravenous acetaminophen after tonsillectomy in children. Materials and methods. This randomized controlled trial was conducted on 53 children between the age of 3 and 12 years old who were referred to Besat Hospital Hamadan, Iran, for tonsillectomy. Patients were randomly assigned to two groups. The intervention group (I) received intravenous acetaminophen plus 0.1 mg/kg ondansetron intravenously while the control group (C) received intravenous acetaminophen plus 2 ml of normal saline intravenously. Postoperative pain severity was assessed using the Children's Hospital Eastern Ontario Pain Scale (CHEOPS). Frequency of nausea, vomiting, and need for analgesic was assessed and recorded four times, at recovery unit, after 6, 12, and 24 hours postsurgery. Data analysis was performed at 95% confidence level using the statistical package for social sciences (SPSS) software version 21. RESULTS: The number of patients in groups I and C was 27 and 26 patients, respectively. Mean pain score in I and C groups was 4.48 and 2.88 at recovery unit, 2.74 and 2.04 after 6 hours, 1.67 and 0.81 after 12 hours, and 0.67 and 0.20 after 24 hours postsurgery, respectively. Frequency of nausea at recovery unit was 23.1% in I group and 0.0% in group C (p = 0.010) while the mean number of analgesic requirements in I and C groups was 1.07 and 0.56 times, respectively (p = 0.027). CONCLUSIONS: Intravenous administration of 0.1 mg/kg ondansetron reduces the analgesic action of intravenous acetaminophen after tonsillectomy in 3 to 12-year-old children.

A Clinical Trial on the Effects of Different Regimens of Phenylephrine on Maternal Hemodynamic After Spinal Anesthesia for Cesarean Section.

BACKGROUND: Phenylephrine is used to prevent and treat hypotension during spinal anesthesia for cesarean delivery. OBJECTIVES: The present study aims to investigate the effects of different regimens of phenylephrine on blood pressure of candidates for the cesarean section. METHODS: In this double-blind, randomized clinical trial, a total of 120 candidates of elective cesarean delivery under spinal anesthesia was randomly categorized into three groups. Groups 1, 2, and 3 received bolus and prophylactic saline (control group), prophylactic bolus phenylephrine (100 µg), and prophylactic phenylephrine infusion (50 µg/min), respectively. The incidence of hypotension, maternal hemodynamics, hypertension, rescue phenylephrine dose, nausea, and vomit were compared between the groups. RESULTS: In all the three groups, the incidence of nausea and vomit, bradycardia, hypertension, and neonatal Apgar score were not statistically different (P > 0.05). However, the adjuvant phenylephrine dose requirement was remarkably different. Moreover, the mean systolic blood pressure differed significantly in the second and 7th minutes after the spinal block (P < 0.05). 35% in the first group, 15% in the second group, and 2.5% in the third group had hypotension (P = 0.001). Apart from the first measurement after spinal anesthesia, the mean heart rate showed no significant difference between the groups. CONCLUSIONS: The use of prophylactic phenylephrine infusion is recommended to control the optimal blood pressure in parturients undergoing cesarean section after spinal anesthesia.

The Impact of Preoperative Fasting Duration on Blood Glucose and Hemodynamics in Children.

BACKGROUND: Prolonged preoperative fasting is one of the concerns of pediatricians and anesthesiologists in pediatric surgery. The aim of this study was to assess the impact of preoperative fasting duration on blood glucose and hemodynamics in children. METHODS: This cross-sectional study was conducted on 50 children who were between the ages of 3 and 12 years in Besat Hospital, Hamedan, Iran. The time of the last solid and liquid meal taken by child were recorded based on interview with the parents. The first blood glucose test was obtained in the operation room, and the second test was performed 20 minutes after induction of anesthesia by glucometer. Systolic blood pressure (SBP), mean arterial pressure (MAP), and heart rate (HR) were recorded before anesthesia induction and in five-minute intervals in the first 20 minutes of surgery. RESULTS: The mean age of the children was 6.63 (SD 1.85) years. Mean blood glucose 20 minutes after surgery was 101.17 (SD 92) mg/dl, which was significantly higher than the baseline values (87.66 (SD 11.84) mg/dl) (P < 0.001). The comparison of mean blood glucose level between groups of fasting with different duration for solids (<12 hours and >12 hours) and for liquids (<6 hours and >6 hours) revealed no significant difference in either groups (P > 0.05). No significant correlation was observed between blood glucose level at the induction of anesthesia with weight and age (P > 0.05). There was a significantly negative correlation between duration of fasting for liquids and SBP (P > 0.05). CONCLUSION: Prolonged preoperative fasting cannot affect blood glucose in children; however, maybe it has impact on systolic blood pressure.

Comparison of Two Pain Scales: Behavioral Pain Scale and Critical-care Pain Observation Tool During Invasive and Noninvasive Procedures in Intensive Care Unit-admitted Patients.

BACKGROUND: Critically ill patients admitted to intensive care units (ICUs) frequently experience pain, but the severity of pain in this group of patients is underestimated by the treatment team due to barriers to verbal communication. The aim of the present study was comparing the severity of pain measured by two scales: behavioral pain scale (BPS) and critical-care pain observation tool (CPOT) in ICU-admitted patients during routine daily procedures. MATERIALS AND METHODS: Ninety patients were enrolled in the study. The severity of pain was measured during resting, invasive (suctioning) and noninvasive (mouthwash and body position change) procedures, and respiratory physiotherapy with two scales: BPS and CPOT. Wilcoxon and Friedman statistical tests were used to compare the score of pain in different situations, and Spearman correlation coefficient was also used to measure the correlation of pain score measured by two scales. RESULTS: Patients experienced no pain during resting, mild pain during changing position, and respiratory physiotherapy, mild-to-moderate pain during mouthwash and moderate pain during secretion suctioning. Wilcoxon test used for pairwise comparisons between pain score in different situations showed a significant difference in both scales (p < 0.05). There were positive and strong correlations (r > 0.80, p < 0.05) between the pain score measured by BPS and CPOT from ICU-admitted patients in all procedures. CONCLUSIONS: Critically ill patients in ICU experience a different range of pain in routine daily care. BPS and CPOT scales could be used successfully for monitoring of pain in this group of patients.

Comparison of 1- and 2-Minute Sitting Positions Versus Immediately Lying Down on Hemodynamic Variables After Spinal Anesthesia with Hyperbaric Bupivacaine in Elective Cesarean Section.

BACKGROUND: Hypotension is one of the most common complications of spinal anesthesia in parturients undergoing cesarean section. In this regard, the patient's position may affect the incidence of hypotension. OBJECTIVES: In this clinical trial, we evaluated the effects of 1- and 2-minute sitting positions versus immediately lying down after spinal anesthesia on hypotension and vasopressor requirements. METHODS: A total of 72 parturients, scheduled for cesarean section under spinal anesthesia, were randomly divided into 3 groups (24 subjects per group). Groups S1 and S2 remained in a sitting position for 1 and 2 minutes after the induction of spinal anesthesia, respectively, while group T was immediately placed in a lying position. Systolic, diastolic, and mean arterial blood pressure, as well as heart rate, was recorded at 1, 2, 3, and 5 minutes after anesthesia induction, every 5 minutes during the first 30 minutes of surgery, and then every 10 minutes until the end of surgery. P-value less than 0.05 was considered statistically significant. RESULTS: The overall frequency of hypotension was 50 (69%) cases during surgery; the reported frequency was higher in group T in comparison with group S2 (P = 0.003). The frequency of hypotension before delivery (the first 5 minutes after spinal anesthesia) was 40 (55%) cases, with a higher frequency reported in group T (20, 83%), compared to groups S1 (12, 50%) and S2 (8, 33%) (P = 0.03 and P = 0.001, respectively). The ephedrine requirement in group T (11.73 ± 7.16 mg) was higher than the other two groups (8.69 ± 7.57 and 7.82±7.95 mg in groups S1 and S2, respectively); nevertheless, the difference was not statistically significant (P = 0.19). Moreover, the difference in time to achieve T6 sensory level was only significant between group T (3.25 ± 1.1 minutes) and group S2 (4.73 ± 1.73 minutes) (P = 0.03). CONCLUSIONS: The present study showed that 1- or 2-minute sitting position after spinal anesthesia with 2.5 cc of hyperbaric bupivacaine in elective cesarean section results in more hemodynamic stability, compared with immediately lying down.

Comparing the Hemodynamic Effects of Spinal Anesthesia in Preeclamptic and Healthy Parturients During Cesarean Section.

BACKGROUND: Despite controversies about the safest anesthetic technique for cesarean delivery in severely preeclamptic women, there is evidence that supports the use of spinal anesthesia in this group of patients. OBJECTIVES: This prospective randomized clinical trial was designed to determine the hemodynamic effects of low-dose spinal bupivacaine and the incidence of spinal anesthesia-associated hypotension in severely preeclamptic and healthy parturients undergoing cesarean sections. PATIENTS AND METHODS: Spinal anesthesia was performed with 10 mg (= 2 mL) hyperbaric 0.5% bupivacaine plus 2.5 µg sufentanil in two groups of patients after they received 500 mL of IV lactated Ringer's solution. Heart rate and blood pressure were recorded before spinal anesthesia and at two minutes intervals for 15 minutes after the block, and then every five minutes until the end of the surgery. Hypotension was defined as more than 25% of decline in the mean arterial blood pressure compared to the baseline in both groups (or systolic blood pressure < 100 mmHg in healthy parturients) and was treated with 5 mg IV ephedrine. The total amounts of intravenous administered fluid and the total doses of ephedrine were recorded for each patient as well. RESULTS: The incidence rate of hypotension among the preeclamptic patients was lower than that of the healthy parturients, despite the former group receiving smaller volumes of intravenous fluids (P < 0.05). The total doses of IV ephedrine for treating hypotension were significantly lower among the preeclamptic patients (3.2 mg in preeclamptic patients versus 7.6 mg in normotensive patients) (P = 0.02). The one-minute Apgar score was significantly lower for the preeclamptic parturients (8.4 ± 0.7 versus 7.2 ± 1.5) (P = 0.001), but there was no significant difference in the five-minute Apgar scores between the two groups. CONCLUSIONS: Our results confirm that low-dose bupivacaine spinal anesthesia is associated with a lower risk of hypotension than previously believed, and it can therefore be safely used in severe preeclamptic women undergoing cesarean delivery.

Diclofenac Suppository vs. IV Acetaminophen Combined With IV PCA for Postoperative Pain Management in Patients Undergoing Laminectomy: A Randomized, Double-Blinded Clinical Trial.

BACKGROUND: Tissue damage caused by surgical procedures nearly always results in pain. The effective management of postoperative pain remains a challenge because of its influence on the surgical outcome and its critical role in early mobilization and functionality. Recent research on postoperative pain management supports a treatment approach known as "multimodal analgesia," which comprises the use of more than one method or modality of pain control and management. OBJECTIVES: In the present study, we compared the effects of diclofenac suppository and intravenous (IV) acetaminophen combined with IV patient-controlled analgesia (PCA) for pain management after laminectomy surgery. PATIENTS AND METHODS: Our randomized, double-blinded controlled trial during 2013 at Besat hospital in Hamadan, Iran, included 102 ASA I-II patients aged 18 to 65 years who were candidates for laminectomy surgery. The patients were randomly assigned to receive the diclofenac suppository (100 mg) (n = 51) or IV acetaminophen (1 g in 100 mL normal saline) (n = 51) 10 minutes before completing surgery and 12 hours after the operation. RESULTS: The patients' characteristics were the same in both study groups. The patients' satisfaction levels were higher among those who received diclofenac when compared with the acetaminophen group, especially at the time points of 6 and 12 h after surgery. The consumed narcotic using the PCA pump within 24 h of surgery in the diclofenac group was significantly lower than that of the acetaminophen group (735.70 ± 59.61 µg vs. 819.70 ± 80.02 µg; P < 0.001). CONCLUSIONS: The use of diclofenac suppository combined with IV PCA results in reduced narcotic usage and a higher level of patient satisfaction compared to the use of IV acetaminophen combined with IV PCA.

The Effect of Administration of Ketamine and Paracetamol Versus Paracetamol Singly on Postoperative Pain, Nausea and Vomiting After Pediatric Adenotonsillectomy.

BACKGROUND: Tonsillectomy is one of the most common surgeries in children and posttonsillectomy pain and agitation management is a great challenge for anesthesiologists. OBJECTIVES: The aim of this study was to compare the efficacy of a single dose of ketamine combined with paracetamol with paracetamol alone in the management of postoperative pain in tonsillectomy. MATERIALS AND METHODS: In this study, the subjects were randomly allocated into the two groups: the ketamine and control. Intravenous paracetamol infusion (15 mg/kg) was started 15 minutes before the end of surgery in both groups, continued with the IV injection of ketamine (0.25 mg/kg) in the ketamine group and an equal volume of saline in the control group. Using the children's hospital of eastern Ontario (CHEOPS) pain scale, pain and agitation score and also the incidence of nausea and vomiting after the surgery were recorded in 0.5, 6 and 12 hours after the operation. Data were analyzed using SPSS software version 16 and P value less than 0.05 was considered as statistically significant in all cases. RESULTS: There was no significant difference between the two groups considering demographic data (age, sex distribution, weight and height). The CHEOPS pain scales were significantly lower in the ketamine group compared to the control group at 0.5 and 6 hours after the surgery (P = 0.003 and P = 0.023, respectively). There was no significant difference in the CHEOPS scale at 12 hours after the surgery, dose of adjuvant analgesic and the incidence of nausea and vomiting after the surgery between the two groups. CONCLUSIONS: According to the results of the current study, postoperative analgesia in children was improved in the ketamine group. Therefore, for better management of posttonsillectomy pain, low-dose ketamine administration with paracetamol is recommended.

Ultrasound as a screening tool for performing caudal epidural injections.

BACKGROUND: The caudal approach to the epidural space has been used for decades to treat low back pain caused by lumbosacral root compression. The use of fluoroscopy during epidural steroid injection is the preferred method for placing the needle more accurately in the sacral hiatus, but it carries the risk of radiation hazard. OBJECTIVES: The aim of the study was to assess the anatomical structure of the sacral hiatus and the feasibility of caudal epidural injections under ultrasound guidance. PATIENTS AND METHODS: Two hundred and forty patients (male = 100, female = 140) with low back pain and sciatica who were candidates for caudal epidural injection were enrolled into this study. Ultrasound images of the sacral hiatus and bilateral cornua were obtained by a real-time linear array ultrasound transducer. The distance between bilateral cornua and the anterior and posterior wall of the sacrum were measured at the base (sacral hiatus). Under the guide of ultrasonography, we defined the injection successful if turbulence of medication fluid was observed in the sacral canal, but correct placement of the needle and injectant was confirmed on fluoroscopic view as the gold standard technique. RESULTS: The epidurogram showed that the injection was successful in 230 of the 240 patients (95.8%). In eight patients, the injection was not in the correct place in the sacral canal. The sacral hiatus could not be identified by ultrasound images in only two patients who had a closed sacral hiatus identified by fluoroscopy. The mean distance of the sacral hiatus was 4.7 ± 1.7 mm and the mean distance between bilateral cornua was 18.0 ± 2.8 mm. The mean duration of the procedure was 10.8 ± 6.8 minutes. No major complication was observed in the next month. CONCLUSIONS: In conclusion, ultrasound could be used as a safe, fast and reliable modality to observe the anatomic variation of the sacral hiatus and to perform caudal epidural injections.

Prevention of propofol injection pain with small-dose ketamine.

PURPOSE: Propofol is a popular i.v. anesthetic induction drug that causes pain when given i.v., the incidence of which is between 28%-90%. We plan to determine the optimal dose of ketamine in the prevention of propofol injection pain and compare it with lidocaine, the commonly proposed pre-treatment. METHODS: In a double-blind randomized study 500 Patients (ASA I, II) scheduled for elective strabismus surgery under general anesthesia were randomly allocated into five groups. After obtaining the informed consent., patients received normal saline (Group NS), lidocaine 1 mg x kg(-1) (Group L), and different doses of ketamine 50-75-100 microg x kg(-1) (Group K50-K75-K100 respectively), immediately before the injection of 2.5 mg.kg(-1) propofol. Each patient's pain scores were measured at five seconds intervals by a blinded anesthesiologist. Statistical analysis were made by SPSS vs 11.5. RESULTS: The incidence and intensity of pain in all study groups were significantly lower than placebo group (Group NS) (P < 0.005). Patients in the K100 Group had significantly lower incidence of pain and lower pain scores compared with the K50 and L Groups (P < 0.0001). There were no significant differences in hemodynamic parameters between groups. CONCLUSION: Administration of ketamine 100 microg x kg(-1) immediately before propofol injection is a safe and effective method in preventing propofol injection pain.