Comparing the Sedative Effects of Intranasal Dexmedetomidine, Midazolam, and Ketamine in Outpatient Pediatric Surgeries: A Randomized Clinical Trial.

Background: The management of preoperative anxiety in pediatric patients, as well as its implications, has remained challenging for anesthesiologists. In this study, we compared the safety and efficacy of intranasal dexmedetomidine, midazolam, and ketamine as surgical premedication in children. Methods: This double-blinded randomized clinical trial was conducted at two tertiary hospitals in January 2014, on 90 children aged between 2-7 years old. The participants' American Society of Anesthesiologists (ASA) physical status was I or II, and they were scheduled for elective unilateral inguinal herniorrhaphy. Using the block randomization method, the patients were randomly assigned to three groups, each receiving intranasal dexmedetomidine (2 µg/Kg), midazolam (0.2 mg/Kg), and ketamine (8 mg/Kg) 60 min before induction of anesthesia. Anxiety and sedation state were evaluated before drug administration, and then every 10 min for the next 50 min. Parental separation anxiety, mask acceptance, postoperative agitation, pain, nausea, and vomiting were also recorded and compared between these groups. All the statistical analyses were performed using SPSS software (version 21.0). P<0.05 was considered statistically significant. Results: Ketamine indicated the strongest sedative effect 10, 20, and 30 min after administration of premedication (P<0.001, P=0.03, P=0.01, respectively). However, dexmedetomidine was more effective than other drugs after 40 and 50 min (P<0.001). Other variables indicated no statistically significant difference. Conclusion: In case of emergencies, intranasal ketamine, with the shortest time of action, could be administered. Intranasal dexmedetomidine, which was revealed to be the most potent drug in this study, could be administrated 40-50 min before elective pediatric surgeries.Trial registration number: IRCT2013081614372N1.

Association Between Preoperative Hyponatremia and Survival After Liver Transplant: A Systematic Review and Meta-Analysis.

OBJECTIVES: Numerous studies have been conducted to investigate the effects of preoperative hyponatremia on survival after liver transplantation. The variable findings underscore the necessity for performing a systematic review to elucidate the potential effects of preoperative hyponatremia. MATERIALS AND METHODS: We searched PubMed, Scopus, Web of Science, Science Direct, Cochrane Library, and reference lists of articles for observational cohort studies that reported association between preopera-tive hyponatremia and survival after liver transplant in adults regardless of publication year. We used the random-effect model to pool the extracted data for meta-analysis. RESULTS: Meta-analyses of mean difference in serum sodium levels showed that nonsurviving recipients had 2.58 mEq/L lower preoperative serum sodium levels than surviving recipients (0.02; 95% CI, .33-4.83). Two observational methods were used to assess survival after liver transplant of patients with preoperative hyponatremia. According to meta-analyses, no dif-ference in survival was shown between recipients with and without preoperative hyponatremia (sodium> 130 mEq/L) (≤1 month : 0.69 [95% CI, 0.9-1.07], 3-month survival: 0.54 [95% CI, 0.95-1.02]). Second, when we compared posttransplant survival of recipients with preoperative hypo-natremia versus those with normal serum sodium levels (sodium = 130-145 mEq/L), we found that recipients with preoperative hyponatremia had lower survival after liver transplant than those with normal preoperative serum sodium levels. CONCLUSIONS: Liver transplant recipients with preop-erative hyponatremia probably have shorter survival posttransplant than those with normal preoperative serum sodium level.

Successful bilateral lung transplantation in pulmonary alveolar microlithiasis: A case report and review of literature.

BACKGROUND: Pulmonary alveolar microlithiasis (PAM) is a rare autosomal recessive genetic disorder with approximately 1000 known cases worldwide, in which calcium phosphate microliths deposit in the alveolar air spaces. As of writing this report, no definitive conventional therapy exists, and many PAM cases may progress to severe respiratory failure and potential death. Bilateral lung transplantation (BLx) seems to be the most optimal solution; however, this procedure is challenging along with limited reports regarding the outcome in PAM. We report a case of PAM successfully treated with BLx for the first time in Iran. METHOD: We present the case of a 42-year-old female with a longstanding history of cough, not responding to conventional antitussive medication, who was diagnosed as a case of PAM following a hospitalization due to coughing, dyspnea on exertion, and hemoptysis. Despite treatment with corticosteroid and medical treatment, no improvement was achieved and she subsequently developed respiratory and right ventricular failure, with oxygen ventilation dependence. Eventually, she was scheduled for BLx. The operation was successful and during her 2-year follow-up, no recurrence or significant postoperative complications has been reported. CONCLUSION: This case presentation and literature review confirm the effectiveness of BLx as a promising treatment for PAM-diagnosed patients, improving both life expectancy and quality of life.

Adequate Anesthesia and More Effective Analgesia by Adjusted Doses of Bupivacaine during Cesarean Section: A Randomized Double-blind Clinical Trial.

Background: Several adjuvants, added to local anesthetics, were suggested to induce an ideal regional block with high-quality analgesia. The purpose of this study was to evaluate the particular blocking properties of low-dose bupivacaine in combination with meperidine and fentanyl in spinal anesthesia during Cesarean sections. Methods: A randomized, double-blind clinical trial was conducted at Hafez Hospital affiliated with Shiraz University of Medical Sciences (Shiraz, Iran) from February 2015 to February 2016. A total of 120 pregnant women, who underwent spinal anesthesia during elective Cesarean section were enrolled in the study. Based on block-wise randomization, the patients were randomly assigned to three groups, namely "B" group received 2 mL bupivacaine 0.5% (10 mg), "BM" group received 8 mg bupivacaine and 10 mg meperidine, and "BF" group received 8 mg bupivacaine and 15 µg fentanyl intrathecally. The block onset, the duration of analgesia, and the time of discharge from the post-anesthesia care unit (PACU) were all assessed. Data were analyzed using SPSS software version 21, and P<0.05 were considered statistically significant. Results: The mean duration of motor blocks in the B group (150 min) were significantly higher than the BM (102 min) and BF (105 min) groups (P<0.0001). In both the BM and BF groups, the duration of sensory and motor blocks was the same. The length of stay in the PACU was significantly longer in the B group (P<0.001) than the BM and BF groups. When meperidine or fentanyl was added to bupivacaine, the duration of the analgesia lengthened (P<0.001). Conclusion: Intrathecal low-dose spinal anesthesia induced by bupivacaine (8 mg) in combination with meperidine and/or fentanyl for Cesarean section increased maternal hemodynamic stability, while ensuring effective anesthetic conditions, extending effective analgesia, and reducing the length of stay in PACU.Trial Registration Number: IRCT2015013119470N14.

Comparing the effect of administering gelatin-low dose albumin versus albumin on renal function in liver transplantation: A randomized clinical trial.

BACKGROUND: Acute kidney injury (AKI) is a common complication after liver transplantation (LT) that is independently associated with an increased risk of morbidity and mortality. This study aimed to evaluate the effects of administering gelatin-low dose albumin versus albumin on renal function and other early outcomes in LT. METHODS: This randomized controlled clinical trial was conducted on 140 patients undergoing LT from brain death donors. Patients were randomly assigned to two groups: albumin or modified gelatin with albumin. Blood samples were collected before (T0) and on the first (T1), second (T2), third (T3), fifth (T4), and last day of hospitalization (T5) after LT for the detection of laboratory parameters, including renal and liver function tests. RESULTS: The incidence of AKT on the basis of RIFLE criteria was 31.42% in the gelatin group (R: 59.10%, I: 36.40%, and F: 4.50%) and 25.71% in the albumin group (R: 66.70%, I: 27.80%, and F: 5.50%) (p = .845). Two patients in the gelatin and one in the albumin groups required renal replacement therapy (RRT). There was no significant difference between groups when the trends of changes in renal and liver function parameters were assessed during the study period (T0-T5). Furthermore, the incidence of complications was similar across groups. CONCLUSION: This study showed that modified gelatin could be used without inappropriate outcomes on renal function in patients with normal preoperative kidney function tests undergoing LT.

Intestinal Transplantation in a Country Without Home Parenteral Nutrition: The Largest Report from the Middle East.

BACKGROUND: Many regions of the world, especially middle- and low-income countries, lack facilities for home parenteral nutrition and thus cannot follow existing guidelines for intestinal transplantation. Herein, we report our experiences with treatment protocols, intraoperative management, and early postoperative outcomes among patients undergoing either isolated intestinal transplantation or multivisceral transplantation in our center. METHODS: During a 1-year period from March 2019 to March 2020, a total of 9 intestinal transplantations including 6 isolated intestinal transplantations and 3 multivisceral transplantations were performed in our center. We reported on donor selection strategies, surgical treatment, anesthesiology care and protocols for total parenteral nutrition, immunosuppression regimen, and pathology evaluation. RESULTS: Mean (standard deviation) age of patients was 37.5 ± 12.5 years. The majority of patients were females (7/9). The median (interquartile range) waiting time for patients from diagnosis to transplantation was 79 (34, 164) days. Our 7-day survey of the amount of fluid therapy after transplantation revealed that the greatest need for fluid therapy was seen on the second postoperative day. After transplantation, 2 patients showed a total of 3 episodes of severe rejection, 1 of which was antibody-mediated. The 1-year survival was 66.6% and the 2-year survival was 44.5% in our study population. The median (interquartile range) time to death was 157 (26.5, 382) days. The most common cause of death was sepsis in our series (3/5). CONCLUSION: Acceptable outcomes can be obtained with intestinal transplantation in countries without home parenteral nutrition by application of specific treatment protocols.

Tracheal myoepithelioma resected by using rigid bronchoscopy: a case report and review of the literature.

BACKGROUND: Endotracheal tumors are rare in the respiratory system. Myoepitheliomas are benign tumors, which are rarely reported in the respiratory system. Herein, we report a rare case of endotracheal myoepithelioma, which was resected by rigid bronchoscopy. CASE PRESENTATION: A 36-year-old man, presenting with chest pain, dyspnea, stridor, and hemoptysis, was referred to our center with radiological features of near-total tracheal obstruction due to mass. Fiberoptic bronchoscopy with argon plasma coagulation and rigid bronchoscopy with grasper forceps was utilized to resect the mass. Pathological evaluation of the mass demonstrated myoepithelioma. The patient was discharged in good condition. Now, after 6 months, the patient is symptom-free with no evidence of tumor recurrence or re-growth. CONCLUSIONS: Despite being extremely rare, myoepithelioma should be considered a possible differential diagnosis for endotracheal tumors. Fiberoptic and rigid bronchoscopy management is an effective method for the resection of endotracheal tumors.

Risk factors of the post-reperfusion syndrome during orthotopic liver transplantation: a clinical observational study.

BACKGROUND: Post reperfusion syndrome (PRS) is a relatively common and life-threatening complication during orthotopic liver transplantation (OLT). It is associated with poor patient and transplanted liver outcomes. OBJECTIVE: This study aimed to compare the risk factors of PRS during OLT. DESIGN: Clinical-epidemiological observational retrospective study. SETTING: We gathered the records of patients who underwent OLT in 3 years, from May 22, 2016, to May 22, 2019, in Namazi and Bu-Ali Sina organ transplantation hospitals. PATIENTS: In this study, we assessed 1182 patients who underwent OLT. Patients were divided into two groups based on the presence or absence of PRS. MAIN OUTCOME MEASURES: Diagnosing the predictors of PRS was the primary outcome of this study. RESULTS: Results showed that age > 60 years, Child-Pugh scores C, higher Model End Stage liver disease score, and preoperative sodium < 130 mmol/l (parameters of the liver recipient), increase in cold ischemic time (the donors' parameters), and the classical technique (the surgical parameters) were the strong predictors of PRS. CONCLUSIONS: The results indicated that underlying liver disease was not the predictor of PRS in the presence of other risk factors; therefore, clinicians have to consider these risk factors in patients undergoing OLT.

Evaluation of high-dose atorvastatin pretreatment influence in patients preconditioning of post coronary artery bypass graft surgery: A prospective triple blind randomized clinical trial.

Context: Atorvastatin is considered as lipid reductive drugs with anti-inflammatory and pleotherapic effects in coronary artery bypass graph (CABG). Aim: This study is conducted to evaluate the effects of atorvastatin in CABG. Setting and Design: Patients with a coronary bypass graph procedure in Nemazee hospital in Shiraz were divided into two 50-groups receiving high-dose (80 mg) and low-dose (20 mg) atorvastatin. Materials and Methods: Troponin I, creatinine kinase-MB (CK-MB), atrial fibrillation (AF) after CABG, duration of mechanical ventilation, inotrope duration of consumption, blood sugar profile, liver and renal function, death during 30 days of CABG, MACE (major advance cardiac events) during admission in ICU, and 1 month follow up were surveyed. Statistical Analysis: Collected data were analyzed by independent and paired t-test and Chi square. Results: AST was increased, ALT, ALK-P after CABG were decreased, and urine volume in the second day of admission in ICU was increased in the high-dose group. There was an increase and following decrease in blood sugar of patients in the high-dose after CABG. An inflammatory marker after CABG was raised in both groups, ck-mb had an increase, and then followed by a reduction. Troporin had no significant differences between groups. Patients with high-dose atorvastatin had better glomerular filtration rate and renal performance. Along with decreasing AF in the case group, hemodynamics' disorder reduced and there was less bleeding. Conclusion: According to the above, it seems that a short-time prescription of high dose of atorvastatin in CABG can lead to better renal function, decreasing of arrhythmia and AF.

Cystic Echinococcosis/Hydatid Cyst Coinfection with HIV: A Report from Shiraz, Iran.

HIV coinfected with other parasitic diseases may cause a serious problem for the patients. A few case reports describing echinococcosis with human immunodeficiency virus (HIV) infection have been reported in the world; however, it has not been reported in Iran, so far. Here, the first case of liver hydatid cyst coinfected with HIV in Iran is reported. The patient is a 46-year-old female HIV-positive based on the laboratory report. Her clinical symptoms included abdominal pain, abdominal enlargement, and anorexia. Ultrasound showed three large hepatic hydatid cysts with hundreds of daughter cysts. Ultrasonography of the cyst revealed it as a CE2 stage according to the WHO classification. The patient went under complete anesthesia followed by complete cyst removal by surgery. Observation of the hydatid cyst fluid using eosin 0.1% revealed more than 70% viable protoscoleces. Histopathology examination, polymerase chain reaction (PCR), and viable protoscoleces confirmed the diagnosis of echinococcosis. The IgG ELISA test with native AgB for E. granulosus infection was also positive. mtDNA amplification using PCR and sequencing showed the cyst as E. granulosus sensu stricto genotype. Our observations show that huge, large, and high-pressure cysts with hundreds of daughter cysts are difficult to be completely removed, and drug treatment has not been able to reduce their size. Therefore, in HIV coinfection with hydatid cyst, surgery is preferable to other treatments.

Preconditioning Effect of Remifentanil Versus Fentanyl in Prevalence of Early Graft Dysfunction in Patients After Liver Transplant: A Randomized Clinical Trial.

OBJECTIVES: One of the most prevalent complications of orthotopic liver transplant is primary graft dysfunction. Recent studies have shown the preconditioning effect of remifentanil on animal livers but not human livers. Here, we compared the preconditioning effects of remifentanil and fentanyl in orthotopic liver transplant in human patients. MATERIALS AND METHODS: In this double-blind clinical trial, 100 patients who underwent liver transplant from deceased donors were randomly allocated into 2 groups. Patients in the remifentanil group received remifentanil infusion, and those in the fentanyl group received fentanyl infusion during maintenance of anesthesia. Serum aminotransferase levels, prothrombin time (international normalized ratio), partial thrombin time, arterial blood gas levels, and renal function tests were evaluated over 7 days posttransplant. Intensive care unit stay and hospitalization were also recorded. RESULTS: The median peak alanine aminotransferase level during 7 days after transplant was 2100 U/L (interquartile range, 1230-3220) in the remifentanil group and 3815 U/L (interquartile range, 2385-5675) in the fentanyl group (P = .048). Metabolic acidosis, renal state, prothrombin time (international normalized ratio), and partial thrombin time were similar in both groups (P > .05). Durations of stay in the intensive care unit and hospital were not significantly different between the 2 groups (P = .75 and P = .23, respectively). Overall, the clinical outcomes were similar in the remifentanil and fentanyl groups (P > .05). CONCLUSIONS: We found that remifentanil and fentanyl were not different with regard to their preconditioning effects and graft protection in orthotopic liver transplant recipients.

Magnesium Therapy Improves Rotational Thromboelastometry Findings Prior to Liver Transplantation: A Randomized Clinical Trial.

An important challenge during orthotopic liver transplantation (OLT) is optimal coagulation management. There are diverse studies regarding effect of Mg sulfate on coagulation system. This study evaluates the impact of Mg sulfate on the coagulation parameters of the rotational thromboelastometry (ROTEM) in patients about to undergo OLT. In this randomized clinical trial, 60 patients who were going to undergo OLT were randomly allocated into two groups. In the Mg group, the patients received a 1.5 g infusion of Mg 5 min before the surgical incision. In the control group, patients received a physiological saline instead of Mg. Plasma Mg levels before and after the infusions were measured in both groups. Also, three ROTEM tests: EXTEM, INTEM and FIBTEM were performed before and after the infusions. Baseline mean plasma magnesium levels were within normal range in the control and Mg groups: 2.06 and 2.18 mg/dl, respectively. After magnesium therapy, the mean plasma Mg level in the Mg group increased to 2.78 mg/dl in compared to the control group that was 2.01 mg/dl (P < 0.000). Mean value of the clotting time (CT) in the magnesium group were significantly decreased from 129.50 ± 7.76, 381.86 ± 8.51 and 114.26 ± 6.80 to 86.13 ± 3.4, 209.33 ± 6.68 and 81.56 ± 5.01 in the EXTEM, INTEM, and FIBTEM respectively after intervention in the Mg group (P = 0.001). Among patients with end-stage liver diseases who have ROTEM evidence of hypocoagulability, magnesium could correct CT parameter of the ROTEM tests.

Educating Health Science Students About Peace through Health Topic; A Panel Discussion.

This report describes an experience of the first international health for peace conference held in November 2018 in Shiraz University of Medical Sciences. This paper discusses the panel on peace education in medical and paramedical schools and the way for the future.

Comparison of Perioperative Systemic Lidocaine or Systemic Ketamine in Acute Pain Management of Patients With Opioid Use Disorder After Orthopedic Surgery.

INTRODUCTION AND AIMS: Patients with opioid use disorder experience great challenges during acute pain management due to opioid tolerance or withdrawal symptoms. Previous studies have recommended the use of adjuvant drugs in these patients. In this study, we compared the effect of intraoperative lidocaine with ketamine in postoperative pain management of these patients. DESIGN AND METHODS: In this randomized clinical trial, 180 patients with opioid use disorder who underwent orthopedic surgery under general anesthesia were randomly allocated into 3 groups. Patients in groups A, B, and C received intravenous lidocaine, ketamine, or normal saline, respectively, during the operation. Then, postoperative pain scores, analgesic requirements, patient satisfaction, and patient sleepiness were recorded and compared among the 3 groups. RESULTS: Numerical rating scales during the first hour postoperation were significantly lower in the lidocaine group than in the ketamine or control group (P < 0.001). The mean total amount of morphine consumption during the first 24-hour postoperation was 14.49 ±â€Š26.89, 16.59 ±â€Š30.65, and 21.72 ±â€Š43.29 mg in the lidocaine, ketamine, and control group, respectively, being significantly lower in the lidocaine group in comparison with the other groups (P < 0.001). Patients in the lidocaine group were less restless, calmer, and less drowsy than patients in the ketamine and control group (P < 0.001). DISCUSSION AND CONCLUSION: According to these findings, systemic lidocaine is more effective than systemic ketamine to improve the quality of acute pain management without causing any significant complications in patients with opioid use disorder.

The Impact of Preoperative Variables on Intraoperative Blood Loss and Transfusion Requirements During Orthotopic Liver Transplant.

OBJECTIVES: Liver transplant traditionally and potentially is associated with the risk of massive blood loss and transfusion, which can adversely affect transplant outcomes. Many variables influence the amount of bleeding, and these can be categorized as patient related, surgery related, and graft related. We aimed to assess the effects of these variables on the amount of bleeding and transfusion during liver transplant; predicting the risk of massive blood loss can help transplant teams to select and manage patients more effectively. MATERIALS AND METHODS: We retrospectively studied 754 patients who underwent liver transplant from 2013 to 2016 and analyzed more than 20 variables that could influence the volume of blood loss and packed cell transfusion. RESULTS: We found that at least 4 variables are strongly and independently correlated with blood loss volume: age, Model for End-Stage Liver Disease score, warm ischemia time, and total bilirubin. Furthermore, intraoperative blood loss had a weak but clinically important correlation with the underlying disease (ie, the cause of liver cirrhosis). Some variables, including international normalized ratio, platelet count, albumin, serum urea nitrogen, creatinine level, sodium level, and the amount of ascites, could be considered as 'dependent' and weak predictors of massive blood loss. Sex of patient, cold ischemia time, surgery technique, and history of previous abdominal surgery were not correlated with the amount of bleeding. CONCLUSIONS: With the use of the variables identified, we can properly select patients and surgical teams and promptly use modalities for decreasing and managing blood loss.

Effect of the Aortic Root Infusion of Sufentanil on Ischemia-Reperfusion Injury in Patients Undergoing Coronary Artery Bypass Grafting: A Randomized Clinical Trial.

Background: Ischemic postconditioning is a novel strategy for attaining cardioprotection. Remarkable evidence from various in vitro and in vivo animal and human studies have shown significant opioid-induced cardioprotection against myocardial ischemia/reperfusion (I/R) injury. The purpose of this study was to assess the cardioprotective effect of sufentanil against I/R injury after on-pump coronary artery bypass grafting (CABG). Methods: Between June 2016 and July 2017, 80 consecutive patients with triple-vessel disease undergoing on-pump CABG were enrolled in this prospective randomized study. The patients assigned to the sufentanil group received a single dose of sufentanil (0.2 µg/kg diluted with 50 cc of saline) 5 minutes before the removal of the aorta cross-clamp, with the sufentanil injected via a cardioplegia needle into the aortic root. In the control group, the same volume of normal saline was injected as a placebo. Cardiac enzymes, the inotrope score, and the outcome data were compared between the 2 groups. Results: The mean age of the patients was 60.48±7.50 years (range=41-69 y), and men comprised 65.0% of the study population. The levels of CK-MB and cardiac troponin I were significantly lower in the sufentanil group (P<0.001). The amount of inotrope use (P<0.001), the incidence of atrial fibrillation (P=0.014), electrical shock (P=0.007), and the mechanical ventilation time (P<0.001) decreased in the sufentanil group compared with the control group. However, the use of intra-aortic balloon pumps (P=0.247) and the ICU length of stay (P=0.867) were not significantly different between the 2 groups. Conclusion: The injection of a single dose of sufentanil into the aortic root prior to aorta cross-clamp removal diminished cardiac injury during on-pump CABG in our patients.

Oleuropein improves glucose tolerance and lipid profile in rats with simultaneous renovascular hypertension and type 2 diabetes.

Oleuropein mediates most of the beneficial effects of olive products. This study examined the role of oxidative stress in the effects of oleuropein on lipid profile and blood glucose in rats with simultaneous renovascular hypertension and type 2 diabetes. Eight groups (n = 7-9 each) of male Sprague-Dawley rats including a control, a type 2 diabetic, a renovascular hypertensive, a sham, a simultaneously hypertensive diabetic receiving vehicle, and 3 simultaneously hypertensive-diabetic receiving 20, 40, or 60 mg/kg/day oleuropein were used. Four weeks after treatment, blood glucose, lipid profile, and biomarkers of oxidative stress were measured, and glucose tolerance test (GTT) was performed. Simultaneously hypertensive diabetic rats had significantly higher blood pressure, blood glucose, and serum total cholesterol, low-density lipoprotein cholesterol (LDL-C), triglyceride and malondialdehyde. They also had lower serum high-density lipoprotein cholesterol, erythrocyte superoxide dismutase, and impaired glucose tolerance. Oleuropein significantly reduced blood pressure, blood glucose, and serum total cholesterol, LDL-C, triglyceride and malondoaldehyde. It also increased serum high-density lipoprotein cholesterol, erythrocyte superoxide dismutase, and improved glucose tolerance. The findings show that the model is associated with impaired glucose tolerance, and adverse lipid profile. They also show that oleuropein, partly by an antioxidant mechanism, improves glucose tolerance and changed lipid profile favorably.

Comparison of Magnesium Sulfate and Tramadol as an Adjuvant to Intravenous Regional Anesthesia for Upper Extremity Surgeries.

BACKGROUND: Intravenous Regional Anesthesia (IVRA) is a simple efficient method for providing regional anesthesia of the limbs. However, it has some limitations such as lack of postoperative analgesia. OBJECTIVES: This study aimed to compare the analgesic effects of magnesium sulfate and tramadol when added to lidocaine used for IVRA in upper limb surgery. METHODS: In this double - blind randomized clinical trial, 69 patients who underwent elective upper limb surgery with IVRA were randomly allocated into 3 groups. Patients in group A, received IVRA with 0.5% lidocaine and tramadol 100 mg, in group B received IVRA with 0.5% lidocaine and magnesium sulfate 1.5 g, while in group C patients received IVRA with 0.5% lidocaine and normal saline. The onset of sensory block and the duration of postoperative analgesia pain intensity were noted in each patient. Furthermore, the incidence of postoperative nausea and vomiting, respiratory depression, and skin rash were recorded. RESULTS: Duration of postoperative analgesia was more prolong in the tramadol group than other groups (P = 0.01). Also, the total amount of morphine consumption in the group A, group B, and C was 8.91 ± 5.81, 11.95 ± 4.81, 16.72 ± 4.07 mg, respectively, which was significantly lower in the tramadol group in comparison to the other groups (P = 0.01). CONCLUSIONS: It seems that adding tramadol as an adjuvant to lidocaine during IVRA in comparison to magnesium sulfate increases duration of postoperative analgesia and decreases analgesic consumption without increasing opioid-related side effects.

Evaluation of the Effect of Ascorbic Acid Administration on Gene Expression Level of IL-6 and TNF-α Cytokines in Deceased Donors.

Brain death is associated with increased inflammatory cytokines levels and poor graft quality to transplant. We aimed to evaluate the impact of Ascorbic Acid (AA) on the inflammatory status of Brain-Dead Donors (BDDs). Forty BDDs were randomly divided into two groups. Donor treatment (n=20) consisted of 100 mg/kg AA infusion 6 hours before donor operation and subsequent infusion of 100 mg/kg/p6h until organ removal. Blood samples were taken at three times, 6 hours before donor surgery (TP(1)), immediately after laparotomy (TP(2)), and before organ removal (TP(3)). Gene expression level and serum concentration of IL-6 and TNF-α cytokines were assessed by real-time PCR and ELISA methods. To investigate transplanted liver function, serum values of Aspartate Aminotransferase (AST), Alanine Aminotransferase (ALT), and Billirubin-Total were evaluated on the 1(st), 3(rd), and 10(th) postoperative days. We found a significant reduction in IL-6 mRNA expression ratio of TP(3) to TP(1) following AA application among BDDs. Despite the considerable decrease in treated donors regarding IL-6 mRNA expression ratio of TP(2) to TP(1), TP(3) to TP(2), and also TNF-α variations in these periods, the results were not significant. Regarding serum concentration of these cytokines, particularly IL-6, there was a decrease between TP(2) and TP(3) following AA application in the treated donors. Furthermore, a significant reduction was found in serum AST and ALT levels in the recipients of treated group on the 3(rd) day compared to the 1(st) day after transplantation. It seems that AA beneficially affects the inflammatory status of BDDs, resulting in improved primary allograft function.