Effect of Vitamin D Supplementation on Procalcitonin as Prognostic Biomarker in Patients with Ventilator Associated Pneumonia Complicated with Vitamin D Deficiency.

Ventilator-associated pneumonia (VAP) is a common and serious problem that develops after more than 48 h of mechanical ventilation. Improving the activity of immune system with vitamin D, and its consequent impact on prognostic biomarkers of VAP was studied in the current study. A randomized double blind placebo controlled clinical trial was designed. A total of 46 patients with VAP, who were suffering from vitamin D deficiency, were randomly allocated into the study groups of placebo (n=22) and treatment (n=24) The treatment group received 300,000 units of intramuscular vitamin D. Serum levels of procalcitonin and vitamin D along with SOFA and CPIS scores were determined at baseline and on day 7 after intervention. The mortality rate of patients was also monitored for the succeeding 28 days after the injection. The administration of vitamin D significantly enhanced its levels (P<0.0001) in the treated patients (12.28 ± 8.26) in comparison to placebo group (1.15 ± 1.50). The levels of PCT were significantly decreased (p=0.001) in the treatment group (- 0.02 ± 0.59 ng/mL) compared to that of placebo group (0.68 ± 1.03 ng/mL). However, changes in (SOFA) and CPIS scores were not significantly different between study groups (p=0.63 and p=0.32, respectively). Interestingly, the mortality rate of patients in the treatment group (5/24) was significantly lower (p=0.04) than that of the placebo group (11/22). In conclusion, our results indicate that vitamin D supplementation can significantly reduce the procalcitonin in (VAP) patients, and must be considered as a preventive and/or therapeutic strategy.

Analgesic Effects of Intravenous Ketamine during Spinal Anesthesia in Pregnant Women Undergone Caesarean Section; A Randomized Clinical Trial.

BACKGROUND: Suitable analgesia after cesarean section helps mothers to be more comfortable and increases their mobility and ability to take better care of their infants. OBJECTIVES: Pain relief properties of ketamine prescription were assessed in women with elective cesarean section who underwent spinal anesthesia with low dose intravenous ketamine and midazolam and intravenous midazolam alone. PATIENTS AND METHODS: Sixty pregnant women scheduled for spinal anesthesia for cesarean section were randomized into two study groups. Ketamine (30 mg) + midazolam (1 mg = 2CC) or 1mg midazolam (2CC) alone, was given immediately after spinal anesthesia. Pain scores at first, second and third hours after CS operation, analgesic requirement and drug adverse effects were recorded in all patients. RESULTS: Ketamine group had significant pain relief properties in compare with control group in first hours after cesarean section (0.78 ± 1.09 vs. 1.72 ± 1.22, VAS score, P = 0.00). Total dose of meperidine consumption in women of ketamine group was significantly lower than women of control group (54.17 ± 12.86 vs. 74.44 ± 33.82 mg, P = 0.02). There were no significant drug side effects in participated patients. CONCLUSIONS: Intravenous low-dose ketamine combined with midazolam for sedation during spinal anesthesia for elective Caesarean section provides more effective and long lasting pain relief than control group.

Unwanted intra-operative penile erection during pediatric hypospadiasis repair. Comparison of propofol and halothane.

PURPOSE: To compare the erectile effect of propofol and halothane on unwanted intraoperative penile erection (UIOPE) during pediatric hypospadiasis repair. MATERIALS AND METHODS: One hundred and seventeen boys who were in the age range of 6 months to 6 years and referred for hypospadiasis repair to our referral teaching hospital were included in this randomized clinical trial. Patients were randomly assigned to one of the two study groups before anesthesia induction. Anesthesia was maintained with a continuous intravenous infusion of propofol and inhalational halothane in the propofol (P) and halothane (H) groups, respectively. Data regarding the patients' age, weight, pre- and intra-operative chordee, UIOPE, anesthesia time, surgery time, hematoma formation, and wound infection were collected. The Chi-Square and Fisher's exact tests were used for comparison. RESULTS: No statistically significant differences were noted regarding age, weight, and pre and intra-operative chordee between the two groups. The incidence of UIOPE (10.34% versus 57.63%; P = .000), anesthesia time (174.15 +/- 15.02 versus 181.26 +/- 15.19; P =.012), and surgery time (162.34 +/- 12.99 versus 167.69 +/- 13.90 +/- 13.90; P = .034) were significantly lower in group P compared with group H. CONCLUSION: The use of propofol during hypospadiasis surgical repair is more safe and effective than halothane in preventing UIOPE and reducing surgery and anesthesia time.

Efficacy of core decompression of femoral head to treat avascular necrosis in intravenous drug users.

Core decompression (CD) of the femoral head is one of the effective treatments of avascular necrosis (AVN), especially in the early stages of the disease. To investigate further the value of CD in treating the AVN, this study was performed on patients with symptomatic AVN with different etiologies who were treated with CD. This study was carried out on 25 patients (with the total number of 37 femoral head) who were diagnosed AVN using X-Ray and MRI. The CD treatments for these patients were started soon after the diagnosis. The results were considered as a success if there was no progression of disease confirmed by X Ray or no subsequent operation was required. Modified Ficat staging was used to record changes before and 2 years after CD treatment. Twenty five patients were participated in this study in which 68% (n=17) were female, 32% (n=8) were male, and the average of the age of the patients were 29.58±4.58. Eight of these patients had systemic lupus erythematous (SLE) (32%), 4 rheumatoid arthritis (RA) (16%), 3 with kidney transplant (12%), 1 Takayasu's vasculitis (4%) and 1 Wegner vasculitis (4%). Eight of patients had a history of intravenous injection of Temgesic (32%). In patients using Temgesic the changes in Modified Ficat staging were significantly different before and after CD treatment (P=0.03) in comparison with other groups. And in all 8 Temgesic users AVN progressed to the stage 3 and 4 after CD treatment. This study demonstrated that CD treatment to prevent the changes in the femoral head has been more effective in patients with collagen vascular diseases and kidney transplant than patients using intravenous Temgesic. These patients, in spite of early operation, showed no benefit of CD to prevent the changes in the femoral head.

Effects of ranitidine and pantoprazole on ventilator-associated pneumonia: a randomized double-blind clinical trial.

BACKGROUND: Acid suppressive medications are used to prevent stress ulcers in critically ill patients. Few studies have been done to evaluate the effect of ranitidine and pantoprazole on stress ulcers. We aimed to compare the effects of ranitidine and pantoprazole on Ventilator Associated Pneumonia (VAP). MATERIALS AND METHODS: In this double-blind randomized controlled trial, we enrolled 120 traumatic patients with trauma admitted to the intensive care unit (ICU) of Besat Hospital in Hamadan Province located in northwest Iran. The patients were divided into two equal groups receiving either intermittent intravenous ranitidine or pantoprazole to prevent stress ulcers. The incidence of VAP, duration of tracheal intubation, length of ICU stay, duration of hospital stay, and the outcome of treatment including mortality or hospital discharge were compared in both groups. RESULTS: The incidence of VAP was 10% and 30% in patients receiving ranitidine and pantoprazole, respectively (P=0.006). There was no significant difference between the two groups with respect to the duration of tracheal intubation. However, the patients treated with pantoprazole stayed at the hospital two days longer than the other patients (P=0.027). Although patients with VAP stayed at the hospital for 12 more days, the two groups had almost equal mortality rates (P=0.572). CONCLUSION: ICU patients using pump inhibitors have a three-fold increased risk of developing VAP in comparison to H2-blocker receivers. Thus, prevention of stress ulcers should be limited to its own specific indications.

Effect of etomidate versus thiopental on major depressive disorder in electroconvulsive therapy, a randomized double-blind controlled clinical trial.

BACKGROUND: Although the therapeutic effect of electroconvulsive therapy (ECT) on major depressive disorder is widely investigated, there is a gap in literature regarding the possible effects of the medications used for induction of anesthesia in ECT. To the best of the authors' knowledge, this study is the first randomized double-blind clinical trial comparing the effect of etomidate and sodium thiopental on the depression symptoms in patients who have received ECT. METHODS: The participants of this study are 60 adult patients with major depressive disorder who were referred for ECT. They were randomly allocated into 1 of the 2 groups. One group received etomidate, and the other group received sodium thiopental, as medication for induction of anesthesia. All the patients received bilateral ECT. The outcomes measures included the Beck Depression Inventory score, seizure duration, and recovery duration after induction of anesthesia. RESULTS: The sex ratio and mean age were not different between the 2 groups. Linear regression analysis showed that etomidate decreased the depression score more than did sodium thiopental. Seizure duration in all of the sessions in the etomidate group was significantly higher than that of sodium thiopental group. CONCLUSIONS: In conclusion, etomidate may improve major depressive disorder more than sodium thiopental in patients who are receiving ECT.

Remifentanil versus Fentanyl for Assisted Reproductive Technologies: Effect on Hemodynamic Recovery from Anesthesia and Outcome of ART Cycles.

BACKGROUND: We conducted this study to compare the outcome of assisted reproductive technology (ART) procedures and recovery from anesthesia in women who received opioid analgesia with remifentanil versus fentanyl. MATERIALS AND METHODS: This double-blind, randomized clinical trial was carried out in the Yazd Research and Clinical Center for Infertility, Yazd, Iran. We studied 145 women who were participants in an ART program. During the first phase of the study, all patients underwent induction of anesthesia with thiopental and received analgesia with remifentanil or fentanyl. The primary endpoint was pregnancy rate per transfer. The numbers of oocytes collected, fertilized and cleaved were recorded, as was the number of oocytes transferred and recovery profile. In the second phase of the study, all patients were followed for outcome of ART cycle. RESULTS: This study suggested that in women undergoing transvaginal ultrasound-guided oocyte retrieval procedures, the likelihood of a successful pregnancy was higher with a remifentanil-based monitored anesthesia care (MAC) technique than with a fentanyl-based MAC technique. The recovery from anesthesia was significantly better in the remifentanil group versus fentanyl group. CONCLUSION: The results of this study suggest that remifentanil in clinical practice is superior to fentanyl ( REGISTRATION NUMBER: IRCT201009283468N3).

Comparison of prophylactic use of meperidine and two low doses of ketamine for prevention of post-anesthetic shivering: A randomized double-blind placebo controlled trial.

BACKGROUND: Postanesthetic shivering is one of the most common complications of anesthesia. We compared the efficacy of meperidine and two low doses of ketamine with placebo to prevent postanesthetic shivering after general anesthesia. METHODS: This was a prospective, randomized double-blind placebo controlled clinical trial involving 120 ASA I-II patients aging 20-50 years, undergoing endoscopic sinus surgery with general anesthesia. Patients were randomly allocated to receive meperidine 0.4 mg/kg (Group M, n = 30), ketamine 0.3 mg/kg (Group K(1), n = 30), ketamine 0.5 mg/kg (Group K(2), n = 30), or normal saline (Group N, n = 30) 20 minutes before completion of the surgery. Tympanic temperature, blood pressure, and heart rate were measured before and immediately after induction of anesthesia, 30 minutes after induction, and before administration of the study drugs. The drugs were prepared and diluted to a volume of 2 ml and presented as coded syringes. An investigator, blinded to the groups, graded postanesthetic shivering using a four-point scale. Statistical analyses were performed using Statistical Package for Social Sciences (SPSS) Windows version 16. A p-value < 0.05 was considered statistically significant. RESULTS: Patient characteristics of the four groups were similar. The number of patients with observed shivering in groups was 0, 3, 1, and 9 in Groups M, K(1), K(2) and N, respectively. The difference between groups M, K(1), and K(2) with Group N was statistically significant. However, differences between groups M and K(1), M and K(2), and K(1) and K(2) were not significant. The number of patients with a shivering score of 2 or 3 was higher in Group N compared with other groups. CONCLUSIONS: Prophylactic use of low doses of intravenous ketamine (0.3 or 0.5 mg/kg) was found to be effective to prevent postanesthetic shivering. However, administration of 0.3 mg/kg ketamine lowered the rate of hallucination as compared with 0.5 mg/kg.