Tehran University Medical Journal

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Background: Acute lung injury (ALI) is a pulmonary pathology occuring in context of infection, trauma, burn, and sepsis. Tissue injury and release of chemical mediators result in tissue damage and organ failure especially respiratory failure. Many therapeutic modalities including vitamin E, allopurinol, and N-acetylcystein (NAC) have been used to decrease levels of inflammatory factors and to control and improve signs and symptoms. The antioxidant feature of NAC induces synthesis of glutathione- the scavenger of free radicals- and increase respiratory drive and PaO₂. In time diagnosis of ALI, prompt institution of treatment will reduce mortality and morbidity in critical illness.
Methods: This open label analytical clinical trial included a total of 50 patients admitted in the ICU ward of Sina University Hospital. They were randomly divided into two groups of 25, the case group received NAC 150mg/kg in 100ml Normal saline within 20 minutes then 50mg/kg in 100ml Normal saline within 4 hr after that 50mg/kg daily for three days. The controls received only normal saline. Oxygenation and ventilation parameters were studied In both groups.
Results: There were no significant difference between the groups in terms of demographic indices, mean SpO₂, ABG values, mortality rates, and clearing of chest x-rays. The best outcome was seen in young traumatic patients.

Conclusion: In this relatively small group of patients presenting with an established ALI/ ARDS subsequent to a variety of underlying disease, intravenous NAC treatment during first four days neither significantly improved systemic oxygenation nor reduced the need for ventilatory support.

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Background: Axillary block is used for inducing anesthesia in outpatient hand and forearm surgeries. Few researches have studied hemodynamic and blockade effects of low doses of Epinephrine. The aim of the present study was to compare the duration of analgesia and hemodynamic changes following the injection of high/low epinephrine doses in such surgeries.

Methods: The present randomized clinical trial study was conducted on healthy individuals (ASA I-II) who were candidates for hand and forearm surgeries. The patients were randomly divided into three groups. The first two groups were allocated to receive lidocaine with low (0.6µg/cc) and high (5µg/cc) doses of epinephrine whereas lidocaine plus normal saline was injected in the third group. The hemodynamic changes (Mean arterial blood pressure and heart rate) and the occurance of any side-effects along with the duration of analgesia and motor block were recorded.

Results: From among the total of 75 patients, 15 cases were excluded due to incomplete blockade or failure needing general anesthesia. The duration of analgesia and the motor block were longer in the high dose epinephrine group, the difference, however, was not statistically significant. Heart rate changes within the groups was significant in the 4^th-7^th and 10^th minutes. Mean arterial blood pressure changes was only significant in the 4^th minute, within the groups.

Conclusions: Administering low doses of epinephrine plus lidocaine as a local anesthetic not only provides acceptable analgesia compared to higher doses of the medication, but also is associated with fewer side effects.

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Background: Today Anesthesiologists occasionally face with bradycardia during gastric surgery and recognized this phenomenon as a vagal reflex. The objective of this study is finding of anesthesia risk factors for bradycardia and prevention of its hazardous complications during gastric surgeries. Methods: In this retrospective study, fifty patients undergoing laparatomy and gastric surgery in Sina hospital between September 2009 to September 2013. They had been anesthetized with propofol or thiopental and their maintenance was kept by isoflurane or propofol were enrolled. The age, gender, underlying diseases, drug history, chemotherapy, kind of surgery, heart rate variability, onset time of bradycardia and its complication during a period of four years was noted. Results: Of Fifty patients, 31 males and 19 females was enrolled in this study. The mean age of patients was 48±8.3 yr all patients had laparatomy under general anesthesia. The kind of surgery were mainly gasterectomy and gastrojejunostomy. The mean onset of episode bradycardia was 24.5±3.5 min after initiation of surgery incision, and most of the bradycardia was mild to moderate (47 patients) that with injection of atropine it resolved. There was no relationships between anesthetic drugs and anesthetic maintenance, age, gender, and incidence of bradycardia event during the surgery. The risk factors of bradycardia were, diabetes mellitus in seven patients, use of beta blockers in 17 patients in perioperative period and gastric cancer and chemotherapy (neoadjuant therapy) in three patients that lead to asystole, they were not response to standard treatment during surgery and lead to death. Conclusion: The history of gastric cancer and previous chemotherapy might be the only common factors that cause to bradycardia and irresponsible asystole during gastric surgery in these patients. It seems that only close monitoring and vigilant anesthesiologist require for treatment and prevention from adverse effect of such a sever bradycardia event.

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Background: Pain control after orthognathic surgeries due to severity of pain and limitations of opioids use in these patients are particular importance. The aim of this study was to evaluate the effect of oral gabapentin and intramuscular ketorolac in combination with intravenous acetaminophen for pain control after this surgery.

Methods: This study was a randomized clinical trial (RCT) on 75 patients (18-60 years old American Society of Anesthesiologists (ASA) physical status classification system, I, II) that undergo orthognathic surgery in Sina University Hospital, Tehran University of Medical Sciences, Tehran, Iran from June 2013 to August 2014. The patients were randomly divided in 3 groups. All of groups received 1 gr (intravenous acetaminophen) 30 minutes before the end of surgery. The control group (n= 25) received placebo. The second group (n= 25) received 30 mg ketorolac intramuscular after induction of anesthesia and the third group (n= 25) received 600 mg Gabapentin orally 30 minute before the induction of anesthesia. The pain severity score assessed by visual analogue scale (VAS), the level of sedation assessed by Ramsey scale, opioid requirement, nausea and vomiting was recorded in the post-anesthesia care unit (PACU) at 1, 3, 6, 12 and 24 hours after surgery. For rescue pain management intravenous morphine was administered.

Results: Seventy-five patients were enrolled in this study. Use of Ketorolac and gabapentin declines the pain intensity, level of agitation and morphine requirement in the recovery room and early hours in the ward (P= 0.011). The 24-hour opioid consumption, nausea and vomiting was significantly higher in control group compared with the both intervention groups (15±1.4 vs. 5±0.5 mg) (P< 0.05) retrospectively. Mean arterial pressure and heart rate changes was significantly lower in ketorolac and gabapentin groups compare to control group in recovery room (P< 0.05).

Conclusion: The result of this study suggest that ketorolac as well as gabapentin can decline the pain intensity and opioid requirement with less nausea and vomiting and good hemodynamic control after orthognathic surgery.