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In the present manuscript, an 87-year-old man, who was a candidate for knee joint replacement surgery due to severe osteoarthritis of the right knee, was case reported. He underwent neuroaxial anesthesia. Following spinal anesthesia with bupivacaine 0.5% in the fourth and fifth lumbar vertebra, the patient developed myoclonic seizures in the lower limbs and abdomen that lasted during the surgery, as well. Due to the continuation of the seizures, the necessary examinations were performed and an extra-axial tumor in the left parasagittal was detected in the patient’s brain imaging.

Background: The present study aimed at comparing the hemodynamic responses to laryngoscopy and initiation of intubation with either direct or video-assisted laryngoscopy. Materials and Methods: This double-blind clinical trial was performed on 90 pregnant women candidates for cesarean section under general anesthesia. The participants were divided into two groups. In the first group, intubation was performed using direct Macintosh laryngoscope (MCL group). The second group underwent intubation using the GlideScope video laryngoscope (GSL group). Then, systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate (HR), the percentage of the saturation of peripheral oxygen (SpO2), the time-to-intubation (TTI), and the number of intubation attempts were recorded. Results: SBP, DBP, and MAP in the MCL group were significantly higher than GSL group 1, 3, and 5 min after laryngoscopy (P < 0.05). HR in the MCL group with the mean of 118.44 ± 15.53 bpm was significantly higher than that the GSL group with the mean of 110.11 ± 16.68 bpm only 3 min after laryngoscopy (P = 0.016). The TTI in the MCL group was significantly longer than that of the GSL group (12.80 ± 1.86 vs. 10.15 ± 2.61; P = 0.001). The frequency of the first intubation attempt in the GSL group with 91.1% was significantly higher than that the MCL group with 84.4% (P = 0.003). Conclusion: It seems that the GSL technique is a better choice to conduct laryngoscopy with more success in intubation and a higher stability of the patients’ hemodynamic status.

مقدمه: لرز بعد از بی‌حسی نخاعی، عارضه‌ی ناخوشایندی است که باعث ناراحتی بیمار و تداخل در دستگاه‌های پایش و مراقبت می‌شود. هدف از انجام این مطالعه، بررسی تأثیر تزریق سولفات منیزیم و ترکیب میدازولام کتامین بر پیش‌گیری از لرز در بی‌حسی نخاعی بود. روش‌ها: در این مطالعه‌ی دو سو کور تصادفی، 90 بیمار با American Society of Anesthesiologists (ASA) درجه‌ی I و II، تحت عمل جراحی ارتوپدی اندام تحتانی با بی‌حسی نخاعی با استفاده از بوپیواکائین انتخاب شدند و به طور تصادفی در یکی از سه گروه مورد مطالعه قرار گرفتند. گروه میدازولام- کتامین، كتامين به ميزان 25/0 میلی‌گرم بر کیلوگرم و ميدازولام به ميزان 5/37 میکروگرم بر کیلوگرم دریافت کردند. گروه منیزیم سولفات، به میزان 80 میلی‌گرم بر کیلوگرم منيزيم سولفات در عرض 30 دقيقه و سپس تزریق با سرعت 2 گرم در ساعت دریافت کردند. گروه شاهد، هیچ داروی پروفیلاکتیک دریافت نکردند. فراوانی و شدت لرز هر 10 دقیقه تا زمان خروج از ریکاوری ارزیابی و ثبت شد. یافته‌ها: میزان فراوانی و شدت لرز در گروه شاهد به طور معنی‌داری بیشتر از گروه میدازولام- کتامین (001/0 = P) و گروه منیزیم سولفات (001/0 = P) بود، اما اختلاف بین دو گروه میدازولام- کتامین و منیزیم سولفات معنی‌دار نبود (232/0 = P، 248/0 = P). دز مصرفی پتدین در گروه شاهد نسبت به گروه‌های میدازولام- کتامین و منیزیم سولفات بیشتر و اختلاف آن معنی‌دار بود (001/0 > P)؛ در حالی که بین دو گروه میدازولام- کتامین و منیزیم سولفات، تفاوت معنی‌داری وجود نداشت (999/0 < P). نتیجه‌گیری: تأثیر تجویز منیزیم سولفات و ترکیب میدازولام- کتامین بر جلوگیری از لرز قبل و حین عمل تحت بی‌حسی نخاعی، تفاوت معنی‌داری نداشت.

Context: Postoperative sore throat (POST) is a common annoying problem following endotracheal (ET) intubation. Aims: Comparing the impact of low and high doses of ketamine gargle on lowering POST incidence and severity. Settings and Design: 96 patients selected for septoplasty surgery under general anesthesia were investigated through a single-blind randomized controlled trial. Methods: This study was performed on three equal groups. Group K and G gargled 50 and 100 mg ketamine, respectively, solved in normal saline and group C gargled pure normal saline for 30 s at 5 min before tracheal intubation. POST severity measured immediately after the entrance to the postanesthetic care unit (PACU) and then 2 h, 4 h, 8 h, and 24 h after operation. Statistical Analysis Used: Collected data were analyzed by the Chi-square test, Mann-Whitney test, Kruskal-Wallis test, one-way analysis of variance (ANOVA) and Friedman test using SPSS version 20. Results: POST incidence and severity in group C were significantly higher than both K and G groups at all times. Although significant differences between low and high doses of ketamine were acknowledged at 8 h post-operation, 100 mg ketamine could attenuate POST severity further than 50 mg at all times. Conclusions: It seems that 100 mg outperformed 50 mg ketamine without rising complications and dissatisfaction for subjects. So, it gives us a powerful reason to suggest gargling 100 mg ketamine for lessening POST incidence and severity.

مقدمه: لارنگوسکوپی (Laryngoscopy) روشی تهاجمی است که با عوارض شدید قلبی- عروقی همراه است. هدف از انجام مطالعه‌ی حاضر، بررسی اثر تزریق دو دوز پیش‌گیرانه از ترامادول بر تغییرات ضربان قلب و فشار خون بعد از لارنگوسکوپی و لوله‌گذاری داخل تراشه در بیماران جراحی انتخابی بود. روش‌ها: در این مطالعه‌ی کارآزمایی بالینی که در سال 1394 انجام شد، 180 بیمار داوطلب عمل جراحی انتخابی در بیمارستان آیت‌اله کاشانی اصفهان به صورت تصادفی به سه گروه شاهد و ترامادول (1 میلی‌گرم بر کیلوگرم) و ترامادول (2 میلی‌گرم بر کیلوگرم) تقسیم شدند. تعداد نبض و فشار خون (سیستول، دیاستول و متوسط فشار شریانی و تنفس) قبل، بلافاصله، 1، 3، 5 و 10 دقیقه بعد از لارنگوسکوپی اندازه‌گیری شد. تحلیل داده‌ها با استفاده از نرم‌افزار SPSS و آزمون‌ Repeated measures ANOVA انجام گرفت. یافته‌ها: بین گروه شاهد و ترامادول به میزان 2 میلی‌گرم بر کیلوگرم، تفاوت معنی‌داری در فشار خون سیستول و دیاستول و فشار متوسط شریانی مشاهده شد. بین دو گروه از نظر تعداد ضربان قلب نیز تفاوت معنی‌داری وجود داشت (050/0 > P). فراوانی پرفشاری خون، تاکی‌کاردی، کم‌فشاری خون و برادی‌کاردی نیز درگروه ترامادول به میزان 2میلی‌گرم بر کیلوگرم کمتر بود. نتیجه‌گیری: تجویز 2 میلی‌گرم بر کیلوگرم ترامادول در مقایسه با گروه شاهد باعث ثبات بهتر فشار خون و ضربان قلب بعد از لارنگوسکوپی می‌شود.

Background: Lower extremity pain after orthopedic surgery is so frequent that has led to many treatment modalities. This study aims to compare the prophylactic effects of oral gabapentin, pregabalin, and celecoxib on reducing postsurgical pain of the lower extremity orthopedic surgery. Materials and Methods: In a double-blind randomized controlled trial, 120 patients were randomly divided into four groups using block design randomization. 1 h before spinal anesthesia, the studied groups received 300 mg oral gabapentin; 75 mg oral pregabalin; 200 mg oral celecoxib; and starch as placebo. The severity of postoperative pain (using visual analog scale), mean arterial pressure, heart rate, opioid consumption dose, and drug side effects were recorded for six times (each 60 min up to two times and then every 6 h for the next four times). Chi-square, one-way analysis of variance (ANOVA), and ANOVA repeated measure tests were used for statistical analysis. Results: Significant reduction of pain severity was observed only at the first time measurement between pregabalin and placebo groups (P: 0.014). Patients in the pregabalin group required lower dose of opioid compared to placebo group during admission in surgical ward. There were no significant differences concerning pain reduction, opioid administration, and side effects between pregabalin, gabapentin, and celecoxib groups. Conclusion: Taking 75 mg oral pregabalin before lower extremity orthopedic surgery can attenuate postoperative pain, especially during the 1st h postoperation as well as less opioid consumption and much more patients' satisfaction.

Background: Hemodynamic changes during and after coronary artery bypass graft surgery and the effects of these changes on postoperative complications are important. As there was not any study to compare the effects of propofol and isoflurane on hemodynamic changes during and after coronary artery bypass grafting, we decided to do this. Methods: This clinical trial study was done on 80 patients undergoing coronary artery bypass surgery at the ages of 40 to 70 years in 2014 in Chamran Hospital, Isfahan, Iran. The subjects received isoflurane or propofol in two groups. Hemodynamic changes during coronary artery bypass graft surgery and then every 30 minutes until the end of the surgery and in intensive care unit every two hours to eight hours were compared. Findings: Based on the repeated measure ANOVA test, the differences between the two groups in systolic blood pressure (P = 0.475), diastolic blood pressure (P = 0.885), heart rate (P = 0.130), pulse pressure (P = 0.572) and arterial oxygen saturation (P = 0.425) in 10 times of measuring (before the pumping starts, at pumping, 30, 60, 90 and 120 minutes later, immediately after the pumping and 2, 6 and 8 hours after admission to the intensive care unit) were not significant. Conclusion: In our study, isoflurane and propofol did not cause significant differences in the hemodynamic variables before, during and after coronary artery bypass graft surgery.

Background: This double-blinded, randomized clinical trial was designed to evaluate the comparison of intravenous versus intraarticular (IA) administration of midazolam on postoperative pain after knee arthroscopy. Materials and Methods: In this study, 75 patients randomized in three groups to receive 75 mc/kg IA injection of midazolam and 10 ml intravenous injection of isotonic saline (Group I), 75 mc/kg intravenous injection of midazolam and 10 cc IA injection of isotonic saline (Group II) or IA and intravenous injection of isotonic saline (Group III) at the end of knee arthroscopy. Pain scores, time until the first request for analgesics, cumulative analgesic consumption, satisfaction, sedation, and complications as studied outcomes were assessed. Patients were observed for 24-h. Results: IA administration of midazolam significantly reduced pain scores in the early postoperative period compared with intravenous injection. Mean of time to first analgesic requirement in Group III (33.6 min) was significantly lower than Group II (288.8 min) and Group I (427.5 min). Cumulative analgesic consumption was increased in Groups II (35.5 mg), and III (70 mg) compared with Group I (16 mg), (P < 0.0001). Complications significantly occurred in 3 of 25 patients in Group I in contrast to 20 of 25 patients in Group III (P < 0.0001). At 2-, 4- and 8-h after arthroscopy pain score significantly decreased in Group I than other groups (P < 0.0001). Patients in Group I were significantly satisfy than other groups (P < 0.0001). Conclusion: Results show the greater analgesic effect after IA administration of midazolam than after intravenous injection and hence, IA administration may be is the method of choice for pain relief after knee arthroscopy.

Background: Laryngoscopy is an invasive technique that is associated with severe cardiovascular complications. This study was designed to compare the preventing effect of two doses tramadol injection on the heart rate and blood pressure changes after laryngoscopy and tracheal intubation in elective surgical patients. Methods: In this clinical trial study, 189 elective surgical patients randomly divided to three groups: Group A and Group B, received tramadol 1mg/kg, 2mg/kg iv 5 minutes before induction of anesthesia respectively; Group C, received normal saline. The heart rate(HR), systolic blood pressure(SBP), diastolic blood pressure(DBP) and mean arterial pressure(MAP) were measured just before induction of anesthesia, just before laryngoscopy, at 1, 3, 5, 10 minutes after laryngoscopy and tracheal intubation. Results: Mean HR, SBP, DBP and MAP changes at 1, 3, 5, 10 minutes after laryngoscopy was significantly less in Group B, compared with Group A and Group C(P

Background and Aim : Adjustment of an accurate curve to the dental arch is an important part of orthodontic treatment. Our goal was comparing the fitting accuracy of two curves constructed by different numbers of clinical bracket points (CBP) to the dental arch form using 4th degree polynomial function. Materials and Methods : A mathematical formula associated with a polynomial function was used to reconstruct the dental arch forms of 18 adolescents (18 casts) with normal occlusion. CBPs were marked on every tooth present in each maxillary and mandibular model (second molar to second molar) using an orthodontic bracket positioning gauge. A coordinate measuring machine (CMM) was used to record the coordinates of each CBP (x, y). Then a curve fitting software was used to obtain the best 4th degree polynomial function and the associated curve fitted to all 14 CBPs. Another polynomial 4th degree function curve was obtained for the same models using CBPs only on central incisors, canines and second molars. Curves for each model were compared using statistical values including correlation coefficient, standard error, sum of residuals and R^2. Results: The mean root squares for curves fitted to 14 points in all samples were 0.8855 and it was 0.9629 when 6 points were compared with 14 points . The intraclass correlation coefficient (ICC) between curves fitted to 6 and 14 points was 0.946 in mandible, 0.983 in maxilla and 0.969 for both . Conclusion : Six CBPs were enough for proper fitting of 4th degree polynomial function to dental arch forms of both jaws .

Background: Either general or regional anesthesia can be used for lumbar disk surgery. The common anesthetic technique is general anesthesia (GA). The aim of this study was to compare the intra and postoperative outcomes of spinal anesthesia (SA) with GA in these patients. Methods: Seventy-two patients were enrolled in the study. They were randomized into two groups with 37 patients in GA Group and 35 ones in SA Group. The heart rate (HR), mean arterial pressure (MAP), blood loss, surgeons satisfaction with the operating conditions, the severity of postoperative pain based on visual analogue scale (VAS) and analgesic use were recorded. Results: The mean blood loss was significantly less in the SA Group compared to GA Group (p < 0.05). Intraoperative maximum blood pressure and heart rate changes were significantly less in SA Group (p < 0.05). The surgeons satisfaction was significantly more in the SA Group (p < 0.05). The number of patients who used postoperative analgesic as well as postoperative mean VAS was significantly less in SA Group in comparison with GA group (p < 0.05 for both). Conclusions: Our study showed that SA was superior to GA in providing postoperative analgesia and decreasing blood loss while maintained better perioperative hemodynamic stability without increasing adverse side effects.

BACKGROUND: The oculocardiac reflex (OCR), which is most often encountered during strabismus surgery in children, may cause bradycardia, arrhythmias and cardiac arrest following a variety of stimuli arising in or near the eyeball. The main purpose of this study was to evaluate the effects of various anesthetic regimens on modulation of the cardiovascular effects of the OCR during strabismus surgery. METHODS: Three hundred ASA physical status I-II patients, scheduled for elective strabismus surgery under general anesthesia, randomly allocated in a double blind fashion to one of the three anesthetic regimens: group P: propofol (2 mg/kg), alfentanil 0.02 mg/kg and atracurium 0.5 mg/kg at induction; group K: ketamine racemate (2 mg/kg), alfentanil 0.02 mg/kg and atracurium 0.5 mg/kg at induction; group T: thiopental (5 mg/kg), alfentanil 0.02 mg/kg, and atracurium 0.5 mg/kg at induction. Mean arterial pressure (MAP) and heart rate (HR) were recorded just before induction, at 1, 15, 30, 45 and 60 minutes after induction. OCR was defined as a 20 beats/minute change in HR induced by traction compared with basal value. RESULTS: Mean HR (± SD) during total period of surgery in group P was significantly slower than that in group K (111.90 ± 1.10 vs. 116.7 ± 0.70, respectively; P than that in group P (11.2 ± 1.44 vs. 8.7 ± 1.50 respectively, P patients in group P compared with patients in group K or T (12.5 ± 1.13 vs. 19.3 ± 0.80 or 18.9 ± 0.91, respectively; P vs. 16% and 13%. Respectively; P CONCLUSIONS: Induction of anesthesia with ketamine is associated with the least cardiovascular changes induced by OCR during strabismus surgery. KEY WORDS: Oculocardiac reflex, strabismus surgery, ketamine, propofol, thiopental.

Background: Pain relief after nasal bone fracture surgery is unsatisfactory. The present study aimed to evaluate the effects of adding low-dose ketamine to remifentanil-midazolam infusion under topical anesthesia on pain relief after nasal bone fracture. Methods: In a controlled study, 68 nasal bone fracture surgery candidates were allocated to two groups receive infusion of 2 µg/kg remifentanil and 0.05 mg/kg midazolam plus 0.5 mg/kg of either ketamine (ketamine group) or placebo (control group). Pain intensity was assessed using a visual analogue scale. Patient satisfaction and the amount of rescue analgesic used were recorded until 60 minutes after surgery. Repeated measures analysis of variance (ANOVA) was used to analyze the data. Findings: In the ketamine group, pain intensity 0, 15, 30, 45, and 60 minutes after operation was 3.5 ± 2.1, 1.2 ± 2.0, 1.8 ± 2.4, 1.3 ± 2.1, and 1.9 ± 2.2, respectively. The corresponding values in the control groups were 3.7 ± 2.2, 8.6 ± 2.0, 4.7 ± 1.2, 3.1 ± 1.2, and 3.7 ± 0.9. The difference between the two groups was statistically significant (P = 0.001). Moreover, patient satisfaction in the ketamine group was higher than the control group (P = 0.005). The dosage of rescue pethidine was significantly lower in the ketamine group compared to the control group (P = 0.045). Conclusion: This study showed that adding 0.5 mg/kg ketamine to 2 µg/kg remifentanil and 0.05 mg/kg midazolam improved postoperative pain relief. Keywords: Ketamine, Postoperative pain, Nasal bone fracture, Infusion, Topical anesthesia

Background: Prediction of difficult laryngoscopy is an essential part of airway management in general anesthesia .The purpose of the present study was comparison of commonly used tests of prediction of difficult laryngoscopy and endotracheal intubation ratio of height to thyromental distance (RHTMD), Modified Mallampati test (MMT), upper lip bite test (ULBT), ratio of neck circumference to thyromental distance (NC/TMD) with acromio-axillo-suprasternal notch index (AASI) in general anesthesia. Methods: A total of 728 patients scheduled for surgery under general anesthesia with endotracheal intubation were enrolled in this study. The dimensional predictive test measurements (AASI, ULBT, RHTMD, NC/TMD, MMT) were accomplished on all patients. The laryngoscopic view was graded with Cormack-Lehane (CL) grading system. Receiver operating characteristic (ROC) curve, Sensitivity, specificity, and Positive predictive value (PPV) were used to compare the tests. Findings: Our study showed that the incidence of difficult view laryngoscopy (DVL) is about 2.9%. AASI had the highest specificity, positive likelihood ratio, PPV and NPV in comparison with the other predictive tests. AASI with cutoff point ≤ 0.6 had the higher cut off point. AASI has the highest ROC with significant difference to other prediction tests. RHTMD had the least sensitivity. Conclusion: Our study showed that AASI can be a good screening test to predict difficult laryngoscopy in general anesthesia.

Background: The purpose of the present study was to evaluate the efficacy of midazolam-ondansetron combination in prevention of postoperative nausea and vomiting (PONV) after middle ear surgery and its comparison with using midazolam or ondansetron alone. Methods: 140 patients were divided to four groups to received midazolam 0.75 mg/kg, ondansetron 4 mg, midazolam 0.75 mg/kg and ondansetron 4 mg or normal saline 0.9% (as control) intravenously just before the anesthesia. Assessment of nausea, vomiting, rescue antiemetic and side effects of study drugs such as headache and dizziness were carried out postoperatively for 24 hours. Findings: The incidence of postoperative nausea and vomiting was significantly lower in midazolam-ondansetron group compared to midazolam and ondansetron groups (P < 0.001) and there was no significant difference between the two last groups during the first 24 hours postoperatively. Need to the additional antiemetic was significantly more in the control group (71.4%) compared to other three groups; and in midazolam-ondansetron group (11.4%), it was lower than the midazolam (31.4%) and ondansetron (34.3%) groups (P < 0.001). Conclusion: Our study showed that prophylactic administration of midazolam 0.75 mg/kgcombined with ondansetron 4 mg was more effective than using midazolam or ondansetron alone in prevention of PONV after middle ear surgery.

Background: Clopidogrel is an adenosine-5' diphosphate (ADP) receptor antagonist that eventually inhibits platelet aggregation. It is used concomitantly with percutaneous coronary interventions and in patients with acute coronary diseases. This study was conducted to determine the effects of preoperative clopidogrel administration on perioperative blood loss and transfusion requirements in patients undergoing coronary artery bypass graft (CABG) surgery. Methods: For 100 patients who underwent nonurgent first-time coronary artery bypass grafting surgery participated in this study. clopidogrel was discontinued in 2, 3, 5-6 or 7-8 days before surgery. A cell salvage device was used during surgery and salvaged blood was recorded. After surgery, chest tube output and need for blood transfusion were measured and recorded. Findings: Patients' mean age was 61.7 ± 8.0 years (range: 50 to 77). There was a reverse relation between the time clopidogrel had been discontinued and blood loss and need for transfusion of packed cell and blood products during and after surgery (P < 0.05 for all). Conclusion: Preoperative clopidogrel administration increases perioperative blood loss and need for blood transfusion in patients undergoing coronary artery bypass grafting surgery.