Oral fenofibrate for hyperbilirubinemia in term neonates: A single-blind randomized controlled trial.

Background: Hyperbilirubinemia is common in the neonatal period; however, delayed diagnosis or inadequate treatment can cause irreparable damage to the neonates. We aimed to evaluate the efficacy of oral fenofibrate for hyperbilirubinemia in term neonates. Methods: This single-blind randomized controlled trial included 86 term neonates aged 3-7 days, with birth weight ≥2500 g, admitted to Bandar Abbas Children's Hospital, Bandar Abbas Iran, from July 23, 2019, to July 22, 2020. The fenofibrate group received 10 mg/kg oral fenofibrate and phototherapy, while controls only received phototherapy. Serum total bilirubin was measured at 24 and 48 h and at the time of discharge. Hospital length of stay was also noted. Results: The two study groups were comparable regarding age, gender, gestational age, birth weight, and baseline total serum bilirubin levels. Serum total bilirubin levels at 48 h (P < 0.001) and at discharge (P < 0.001) were significantly lower in the fenofibrate group compared to controls. Although hospital length of stay was lower in the fenofibrate group compared to controls, the difference was not statistically significant (P = 0.612). Fenofibrate was more effective on the reduction of serum bilirubin in neonates aged 3-4.5 days starting at the 24th hour. Moreover, it was more effective in female neonates compared to males starting at the 48th hour. Conclusions: A single dose of oral fenofibrate reduced total serum bilirubin in term neonates with hyperbilirubinemia without any side effects; however, this effect was more prominent after 48 h.

The Role of Entrustable Professional Activities in Competency-based Medical Education for Anesthesiology Residents: A Pilot Phase.

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

An investigation into the Effects of Intravenous Vitamin C on Pulmonary CT Findings and Clinical Outcomes of Patients with COVID 19 Pneumonia A Randomized Clinical Trial.

PURPOSE: In late December 2019, a series of unexplained cases of pneumonia were reported in Wuhan, China. On January 12, 2020, the World Health Organization temporarily named the virus responsible for the emerging cases of pneumonia as the 2019 coronavirus. Acute respiratory distress syndrome (ARDS) due to Covid-19 has rapidly spread around the world, and while no specific treatment or vaccine has been reported, mortality rates remain high. One of the suggested treatments for cellular damage in the pathogenesis of ARDS caused by the coronavirus is the administration of high doses of intravenous vitamin C. Considering the paucity of literature on the therapeutic effects of high doses of intravenous vitamin C in patients with ARDS resulting from the coronavirus, this study was conducted to assess this therapeutic supplement in these patients. MATERIALS AND METHODS: This study was performed as a single-center clinical trial in patients with a documented diagnosis of COVID-19 pneumonia. 54 eligible patients with moderate to severe COVID-19 symptoms, based on specific inclusion and exclusion criteria, were included in the investigation and randomly divided into two groups. The control group consisted of 26 patients who received standard treatment, whereas the treatment group was comprised of 18 patients administered intravenous vitamin C at a dose of 2 g every 6 hours for 5 days in addition to standard treatment. Demographic characteristics, underlying diseases, length of hospital stay, and mortality rates were reviewed and collected. Oxygen saturation, respiratory rates, serum C Reactive Protein (CRP) levels, lymphopenia and lung parenchymal involvement on CT were investigated at the time of admission and on the sixth day after hospitalization. Finally, all variables were analyzed with IBM SPSS Statistics 23 software and a significant statistical difference was defined for all variables, P <0.05. RESULTS: Of these variables, the amount of oxygen saturation in the vitamin C group increased significantly from 86±5% on the first day of hospitalization to 90±3% on the sixth day of hospitalization (P value=0.02). Also, the respiratory rate in the vitamin C group decreased significantly from 27±3 on the first day of hospitalization to 24±3 on the sixth day of hospitalization (P value=0.03). Lung CT scans of patients in the two groups reported by two radiologists were also compared. Based on the report of the radiologists, the rate of lung involvement in the vitamin C group was significantly lower than in the control group at the end of treatment (P value=0.02). CONCLUSION: Due to the effectiveness of high doses of intravenous vitamin C on reducing lung involvement and improving clinical symptoms, further studies with a larger sample size are recommended to demonstrate the effects of this drug supplement.

Comparison of Hemodynamic Stability and Pain Control in Lateral and Prone Positions in Patients Undergoing Percutaneous Nephrolithotomy: A Randomized Controlled Trial.

PURPOSE: Percutaneous nephrolithotomy (PCNL) is the preferred surgical treatment in many cases of kidney stones which is performed in different positions such as prone, lateral, and supine. This study was designed to evaluate whether patient position (lateral versus . prone) has an effect on the need for analgesia and onset of pain after surgery. MATERIALS AND METHODS: Patient with confirmed kidney stones (size ? 2 cm) who were candidates for PCNL were enrolled in this study. The required biochemical analyses were performed preoperatively. All patients  underwent spinal anesthesia by the same anesthesiologists and then were randomly divided into two separate groups as lateral (L) and prone (P) positions. The operations' start and end time, required time for proper access into target calyces, additional need for analgesic or cardiac drugs, duration of analgesia, and onset of pain after PCNL were carefully recorded and then compared between the two groups. RESULTS: In total, 51 patients were evaluated of whom 39 were men and 12 were women. Mean duration of analgesia after PCNL surgery in P group (173 ± 8 min) was significantly longer than in L group (147±12 min) (P = .001). Furthermore, the amount of ephedrine usage in L group (3.6 ± 1.5mg) was significantly lower than in the P group (16.4 ± 12mg), suggesting more hemodynamic variations in the P group during the operation. CONCLUSION: Our randomized control trial study shows that choosing the optimal position in the PCNL technique depends on  patient's condition. If hemodynamic control is of matter to the anesthesiologist, then lateral position is more appropriate. However, if control of pain and longer time of analgesia are important,  prone position may be preferred.

Is Corticosteroid of No Use for Pediatric Patients with Common Cold Undergoing Anesthesia? A Randomized, Double-Blind, Clinical Trial.

BACKGROUND: Use of laryngeal mask airways (LMAs) has been advocated for children with upper respiratory tract infection (URI). However, no randomized trial has yet compared intravenous corticosteroids versus placebo in these patients. OBJECTIVES: We hypothesized the lower incidence of postoperative cough (as the primary outcome) with intravenous corticosteroid versus placebo in pediatric patients with mild URI, who were anesthetized with LMA. METHODS: A total of 210 patients with mild URI, aged 1 - 6 years, were included. The patients underwent full ophthalmic examination immediately (within few days). They were randomized to receive either intravenous corticosteroids (1 mg/kg of hydrocortisone and 0.1 mg/kg of dexamethasone 10 minutes prior to anesthesia induction) or placebo. Anesthesia was induced with sevoflurane. Following LMA insertion, the patients were maintained on anesthesia with spontaneous ventilation on N2O, O2, and 3% sevoflurane; LMA was removed under deep anesthesia. The outcomes were evaluated during anesthesia, recovery, and the first postoperative week. RESULTS: A total of 204 patients completed the trial. Cough, which was designated as the primary outcome, was not significantly different among patients receiving corticosteroids and placebo (31% vs. 34%; P = 0.7). Also, the incidence of laryngospasm (16% vs. 14%), apnea (9% VS 5%), desaturation (4% vs. 5%), bronchospasm (14% vs. 7%), vomiting (4% vs. 6%), and postoperative symptoms (8% vs. 7%) was not significantly different between the groups. CONCLUSIONS: Based on the present research, intravenous injection of corticosteroids has no beneficial effects for pediatric patients with minor uncomplicated URI (without a history of allergy), undergoing LMA anesthesia.

Topical Versus Intravenous Lidocaine in Children With Upper Respiratory Infection Undergoing Anesthesia: A Randomized, Double Blind, Clinical Trial.

BACKGROUND: The current randomized double-blind clinical trial aimed to compare the incidence of post-operative cough with intravenous vs. topical lidocaine in children with mild upper respiratory infection (URI) anesthetized with laryngeal mask airway (LMA) in the university-affiliated medical center. OBJECTIVES: To assess the incidence of adverse respiratory event including cough, apnea, laryngospasm, bronchospasm following two different methods of lidocaine administration in anesthetized children with mild URI. PATIENTS AND METHODS: One hundred and thirty pediatric patients with mild URI (within the previous two weeks) aged between one and six years were enrolled. They were candidates to undergo immediate full ophthalmic examination, and randomly divided into two groups of 65to receive intravenous (1.5 mg/kg) or topical lidocaine on LMA. Anesthesia was induced with sevoflurane, subsequently LMA was inserted when the patient was in deep anesthesia status and maintained on (50% N2O, 50% O2) and 3% sevoflurane. Spontaneous ventilation was maintained throughout the procedure and LMA was removed in deep anesthesia. Outcomes (cough, laryngospasm, bronchospasm and vomiting) were evaluated peri-operatively and one day post-operation. RESULTS: One hundred and twenty four patients fulfilled the trial. Cough (primary outcome) was significantly more frequent among those with topical compared with intravenous lidocaine (46% vs. 26%; P = 0.004). The incidence of laryngospasm (32% vs. 27%), bronchospasm (18% vs. 12%), desaturation (18% vs. 12%) and vomiting (5% vs. 2%) was not statistically different between the groups. CONCLUSIONS: The pediatric patients undergoing general anesthesia with LMA with intravenous lidocaine experienced fewer incidence of postoperative cough compared to the ones in the topical lidocaine group.

Do the Concentration and Volume of Local Anesthetics Affect the Onset and Success of Infraclavicular Anesthesia?

BACKGROUND: Although local anesthesia is a suitable method for upper limb surgeries, there is debate regarding the effects of appropriate dosing. OBJECTIVES: In the current study, we investigated the effects of the concentration and volume of a local anesthetic on the beginning and quality of anesthesia during upper limb orthopedic surgeries. PATIENTS AND METHODS: This double-blinded, randomized, clinical trial was conducted on 60 patients aged between 18 and 85 years candidated for upper limb orthopedic operations. The patients were equally and randomly distributed into two groups (n = 30). Under ultrasound imaging guidance, the first group received 7 mL of 2% lidocaine and the second group 10 mL of 1.3% lidocaine into the brachial plexus cords. The onset of block and the level of sensory and motor block were documented for each nerve territory. RESULTS: The onset of sensory and motor block was significantly shorter in the 1.3% lidocaine group than in the 2% lidocaine group (P ≤ 0.05). The success rate of sensory and motor block was not different. The quality (completeness) of sensory block for the musculocutaneous nerve and that of motor block for the radial nerve were significantly better in the 1.3% lidocaine group than in the 2% lidocaine group. CONCLUSIONS: The volume of the injected anesthetic accelerated the onset of sensory and motor block without affecting the rate of success in our patients.

Propofol and alfentanil in treatment of a patient with episodic cluster headache.

INTRODUCTION: Cluster headache is a severe hemifacial pain with concomitant symptoms such as lacrimation, conjunctival congestion, and nasal discharge. Peripheral (to be a spectrum of trigeminal autonomic cephalgia) and central (hypothalamus) disorders have been suggested to be involved. Several modalities have been recommended to prevent or alleviate this devastating headache. CASE PRESENTATION: In this case report, we presented a young man with an acute cluster headache who responded dramatically to the treatment with propofol and alfentanil. CONCLUSIONS: Propofol and alfentanil combination can be considered as a treatment approach in the attack phase of cluster headache.

Comparison of percutaneous nephrolithotomy under spinal versus general anesthesia: a randomized clinical trial.

PURPOSE: To evaluate the safety and efficacy of spinal anesthesia compared with general anesthesia in patients who underwent percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: One hundred patients with American Society of Anesthesiologists (ASA) score <3 were randomly divided into two groups according to the type of anesthesia. Spinal anesthesia was performed using an injection of 0.25 mg/kg bupivacaine 0.5% in the intrathecal space; no opium (fentanyl) agent was used. All procedures were performed with the patient in the prone position. Stone access was made by using fluoroscopic guidance, and the tract was dilated using a single-stage technique. All patients received a solution including 1 mg/kg morphine in every 100 mL physiologic saline through the volumetric pump during the 3-hour post-PCNL period in the recovery room. Afterward, morphine (0.05 mg/kg) was injected only according to the verbal rating scale greater than 3 after discharge from the recovery room until 24 hours after surgery. RESULTS: The two groups were matched by mean age, distribution of stone location, and stone burden. Mean operative time, hospital stay, stone-free rate and mean hemoglobin drop were comparable between the two groups. The rate of complications according to the Clavien grading system was nearly similar in both groups. Mean analgesic requirement during 24 hours after PCNL was 6.8 mg in the spinal group and 13.2 mg in the general group (P<0.001). CONCLUSION: It seems that using spinal anesthesia by intrathecal injection of local anesthetic solutions vs general anesthesia has comparable surgical outcomes and reduces the requirement for analgesia after PCNL in the early postoperative period.

Neurologic complications in percutaneous nephrolithotomy.

PURPOSE: Percutaneous nephrolithotomy (PCNL) has been the preferred procedure for the removal of large renal stones in Iran since 1990. Recently, we encountered a series of devastating neurologic complications during PCNL, including paraplegia and hemiplegia. There are several reports of neurologic complications following PCNL owing to paradoxical air emboli, but there are no reports of paraplegia following PCNL. MATERIALS AND METHODS: We retrospectively reviewed the medical records of patients who had undergone PCNL in 13 different endourologic centers and retrieved data related to neurologic complications after PCNL, including coma, paraplegia, hemiplegia, and quadriplegia. RESULTS: The total number of PCNL procedures in these 13 centers was 30,666. Among these procedures, 11 cases were complicated by neurologic events, and four of these cases experienced paraplegia. All events happened with the patient in the prone position with the use of general anesthesia and in the presence of air injection. There were no reports of neurologic complications in PCNL procedures performed with the patient under general anesthesia and in the prone position and with contrast injection. CONCLUSIONS: It can be assumed that using room air to opacify the collecting system played a major role in the occurrence of these complications. Likewise, the prone position and general anesthesia may predispose to these events in the presence of air injection.

Opioid-sparing effect of preemptive bolus low-dose ketamine for moderate sedation in opioid abusers undergoing extracorporeal shock wave lithotripsy: a randomized clinical trial.

BACKGROUND: Ketamine has been used as part of a multimodal analgesia regime in opioid abusers undergoing general anesthesia. We studied the opioid-sparing effect of a very low-dose bolus of ketamine as part of moderate sedation for opioid abuse patients undergoing extracorporeal shock wave lithotripsy. METHODS: In this randomized, placebo-controlled clinical trial, 190 opioid abusers were enrolled. They were stratified into 2 blocks based on their daily opioid consumption. Both blocks were then randomized to receive 0.1 mg/kg IV ketamine (group K) or placebo (group P). Lithotripsy was performed under moderate sedation with intermittent bolus doses of remifentanil (0.2 µg/kg) to alleviate pain. The total remifentanil dose (primary outcome) and respiratory adverse events (secondary outcome) were compared in the 2 groups. RESULTS: Remifentanil administration in the group with low-opioid consumers was 1.6 ± 0.4 µg/kg (group P) compared with 1.0 ± 0.2 µg/kg in group K (confidence interval [CI](of difference) 95%, 0.4-0.7; P < 0.001). Patients who had high-opioid consumption received 2.0 ± 0.5 µg/kg (group P) vs 1.5 ± 0.3 µg/kg (group K) remifentanil (CI(of difference) 95%, 0.40-0.75; P < 0.001). Ready to discharge time was statistically longer in high-consumption opioid abusers who received placebo compared with group K (55 ± 13 minutes vs 44 ± 8 minutes, CI(of difference) 95%, 6-15; P < 0.001). The incidences of bradypnea, apnea, nausea, vomiting, and hemodynamic changes were not statistically different between the ketamine and placebo groups. CONCLUSION: Preemptive low-dose ketamine (0.1 mg/kg) as a bolus has opioid-sparing effects in opioid abusers undergoing moderate sedation.

Comparison of acromioaxillosuprasternal notch index (a new test) with modified Mallampati test in predicting difficult visualization of larynx.

BACKGROUND: We aimed to compare the efficacy of a new bedside screening test named acromioaxillosuprasternal notch index (AASI) with modified Mallampati (MMP). METHODS: A total of 603 adult patients, who were candidates for tracheal intubation in elective surgery, were enrolled in this prospective study. Preoperative airway assessment was carried out with AASI and MMP. The new AASI score is calculated based on the following measurements: (1) using a ruler, a vertical line is drawn from the top of the acromion process to the superior border of the axilla at the pectoralis major muscle (line A); (2) a second line is drawn perpendicular to line A from the suprasternal notch (line B); and (3) the portion of line A that lies above the point where line B intersects it is line C. AASI is calculated by dividing the length of line C by that of line A (AASI = C/A). After induction of anesthesia, the laryngeal view was recorded according to the Cormack-Lehane grading system. Receiver operating characteristic curve analysis was employed to compare between AASI and MMP. RESULTS: Difficult visualization of larynx (DVL, Cormack-Lehane III and IV) was observed in 38 (6.3%) patients. The best cutoff point for DVL was defined at AASI > 0.49. AASI had a lower false negative rate and higher predictive values (sensitivity, positive predictive value, and accuracy) in comparison with MMP. CONCLUSION: AASI was associated with higher predictive values than MMP and could be used for estimation of DVL.

Comparing vertical and coracoid approaches for infraclavicular block in orthopedic surgery of the forearm and hand.

STUDY OBJECTIVE: To determine if there is a difference between the vertical and coracoid approaches to the infraclavicular block. DESIGN: Randomized, double-blinded clinical trial. SETTING: University-affiliated medical center. PATIENTS: 60 ASA physical status 1 and 2 patients undergoing surgery of the forearm and hand. INTERVENTIONS: Patients were randomized to two groups: Group VIP (vertical infraclavicular approach; n=30) and Group Coracoid (coracoid infraclavicular approach; n=30). In the infraclavicular coracoid approach, the coracoid process was used as the landmark. Needle positioning was guided by nerve stimulation. MEASUREMENT: For each approach, the quality of sensory and motor block was assessed and recorded separately for each of the 4 major nerves of the upper limb. MAIN RESULTS: The infraclavicular coracoid approach (11±1 min) was faster to perform than the vertical infraclavicular block (14±1 min; P < 0.05). The infraclavicular coracoid approach yielded a shorter sensory block onset time (2.3±1.3 vs 3±1.3 min; P < 0.05). In the coracoid group, a pronounced sensory and motor block was noted in the area innervated by the musculocutaneous nerve (P < 0.05). CONCLUSION: The coracoid approach is convenient to perform with extensive block, and is thus an appropriate alternative to the vertical approach in infraclavicular block.

Use of laryngeal mask airway in children with upper respiratory tract infection, compared with face mask: randomized, single blind, clinical trial.

OBJECTIVE: The incidence of postoperative cough (primary outcome) and adverse respiratory events (secondary outcome) in children who received anesthesia by laryngeal mask airway (LMA) with children who received anesthesia by face mask (FM) was compared in a blind randomized trial with uncomplicated upper respiratory track infection (URI) undergoing general anesthesia. Previous studies of pediatric patients with URI receiving anesthesia by endotracheal tube have reported a greater number of anesthetic complications; however reports concerning adverse effects in pediatric patients with URI receiving anesthesia by LMA or FM are scanty. METHOD: For the present trial, 150 children with uncomplicated URI and requiring general anesthesia for ophthalmic procedures were enrolled. Once the severity of preoperative URI symptoms was stratified, the children were randomized to receive general anesthesia by FM or LMA. Anesthesia was induced with sevoflurane and nitrous oxide in oxygen (N(2)O in O(2)). Respiratory adverse events were evaluated peri- and post-operatively. RESULTS: The two groups did not differ in age, weight, American Society of Anesthesiologists (ASA) physical status, sex, duration of surgery or severity of URI symptoms. The incidences of cough (19% in LMA vs. 42% in FM), vomiting (4% in LMA vs. 12% in FM) and intervention to maintain the patency of the airway were statistically higher in the FM group (p<0.05). There were no differences between the two groups with respect to the incidences of apnea, laryngospasm, desaturation, bronchospasm, readmission and sore throat. CONCLUSION: In children with uncomplicated URI, the administration of inhalation anesthetics in general anesthesia by LMA is likely to cause fewer adverse events than the use of FM.

A rapidly enlarging neck mass: the role of the sitting position in fiberoptic bronchoscopy for difficult intubation.

Difficult airway management is a dilemma for any anesthesiologist. Although practice guidelines and algorithms may help in such situations, the anesthesiologist's judgment and vigilance remain the primary means to save lives. In the following case, we encountered an acutely enlarging thyroid mass that was compromising the airway. This huge neck mass precluded tracheostomy under local anesthesia, and the patient could breathe only in the sitting position. Therefore, there were few safe strategies for airway management for general anesthesia. We reiterate the role of awake fiberoptic intubation in such circumstances.

The contribution of diabetes mellitus per se to the severity of coronary artery disease.

BACKGROUND: Coronary artery disease (CAD) is the most common chronic, life-threatening illness in many Western countries. The risk factors associated with diabetes mellitus and the metabolic syndrome in diabetics are generally considered more important in the evolution of CAD than the diabetic state itself. AIM: This study was undertaken to determine the contribution of diabetes mellitus to the characteristics and severity of coronary artery disease among young patients. METHODS: Thirty diabetics (group 1) were selected from a group of young patients (