Effect of fentanyl and epinephrine, alone or together with and without lidocaine on the sensory and motor block duration and hemodynamic variations in spinal anesthesia

چکیده: زمینه و هدف: بی هوشی نخاعی به دلیل راحتی تکنیک و نیاز به میزان کم داروی بیحسی موضعی و عوارض نسبتاًً کمتر در مقایسه با بیهوشی عمومی در بین متخصصین بیهوشی از مقبولیت زیادی برخوردار است. لیدوکائین بطور وسیعی در این روش بکار می رود و مسلماً افزایش طول مدت بی دردی آن در طی عمل جراحی می تواند بر مقبولیت این روش بیفزاید. امروزه اپی نفرین و فنتانیل به طور وسیعی جهت بهبود کیفیت بلوک و افزایش زمان بلوک بی هوشی نخاعی استفاده می شوند و از آنجا که مقایسه ای بین این دو دارو صورت نگرفته است، مطالعه حاضر با هدف بررسی مدت زمان بلوک حسی و حرکتی ناشی از تزریق این دو دارو با هم و به تنهایی به همراه لیدوکائین انجام گرفت. روش بررسی: این مطالعه به صورت کارآزمائی بالینی دو سویه کور انجام شده است. سه گروه 20 نفری از بیماران کاندید عمل جراحی قسمت تحتانی شکم به طور تصادفی انتخاب و تحت بی هوشی نخاعی به ترتیب با مخلوط 50 میلی گرم لیدوکائین+2/0 میلی گرم اپی نفرین (گروه اول)، 50 میلی گرم لیدوکائین+20 میکروگرم فنتانیل+2/0 میلی گرم اپی نفرین (گروه دوم) و 50 میلی گرم لیدوکائین+20 میکروگرم فنتانیل (گروه سوم) قرار گرفتند. سپس بیماران از نظرطول مدت بلوک حسی و حرکتی و تغییرات همودینامیک مورد بررسی قرار گرفته و با استفاده از آزمون های آماری کای دو و ANOVA مقایسه گردیدند. یافته ها: توزیع فراوانی از نظرجنس و میانگین سنی در هر سه گروه یکسان بود (05/0p>). میانگین طول مدت بلوک حسی در گروه اول 02/19±25/130 دقیقه، در گروه دوم 7/32±133 دقیقه و در گروه سوم 58/14±116 دقیقه بود که تفاوت معنی دار آماری بین سه گروه وجود نداشت. میانگین طول مدت بلوک حرکتی در گروه اول 63/14±95/120 دقیقه و در گروه دوم 74/25±75/118 دقیقه و در گروه سوم 23/18±107 دقیقه بود که تفاوت معنی دار آماری بین سه گروه وجود نداشت و همچنین تغییرات همودینامیک در هر سه گروه اختلاف معنی داری با هم نداشتند. نتیجه گیری: نتایج این مطالعه نشان داد که افزودن ترکیب داروئی 20 میکروگرم فنتانیل و 2/0 میلی گرم اپی نفرین به داروی بی حسی موضعی لیدوکائین طول مدت بلوک حسی و حرکتی و تغییرات همودینامیک را نسبت به هر یک از دو داروی فوق به تنهائی تغییر نمی دهد و در نتیجه نیازی به استفاده هم زمان از دو دارو نیست. لذا مطالعات تکمیلی با دوزهای متفاوتی از داروهای فوق پیشنهاد می گردد

Adjunctive Local Application of Lidocaine during Scleral Buckling under General Anesthesia

Purpose: To evaluate the effect of local lidocaine application on the incidence of the oculocardiac reflex (OCR) during scleral buckling (SB) for rhegmatogenous retinal detachment (RRD) under general anesthesia. Methods: In a randomized clinical trial, eyes with RRD scheduled for SB under general anesthesia were randomized to adjunctive local application of 1 ml lidocaine 2% versus normal saline to the muscles after conjunctival opening. Surgical stimulation was initiated 5 minutes afterwards. Additionally, 100 mg of lidocaine 2% was added to 50 ml of normal saline in the treatment group which was used for irrigation during surgery; control eyes were irrigated with normal saline. The incidence of the OCR, rate of postoperative nausea/vomiting (PONV), total intravenous (IV) analgesic dose, duration of surgery, and period of hospitalization were compared between the study groups. Results: Thirty eyes of 30 patients including 22 (73.3%) male and 8 (26.7%) subjects with mean age of 49.4΁16.3 years were operated. OCR and PONV occurred less frequently, and total intravenous analgesic dose was significantly lower in the lidocaine group (P < 0.05 for all comparisons). However, no significant difference was noted between the study groups in terms of duration of surgery and period of hospitalization. Conclusion: Adjunctive local application of lidocaine during SB under GA for RRD decreases the rate of OCR and PONV, reduces the intravenous analgesic dose, but does not affect the duration of surgery or hospitalization

Psychometric analysis of the ambulatory care learning education environment measure (ACLEEM) in Iran

Background: Examining educational environment (academic and clinical) by means of a valid, reliable and comprehensive questionnaire is a major key in achieving a highly qualified student - oriented curricula. The Persian translation of Ambulatory Care Learning Education Environment Measure-ACLEEM questionnaire has been developed to support this goal, and its psychometrics has been explored in this administration in teaching hospitals affiliated to Tehran University of Medical Sciences. Methods: This descriptive - analytical study involved medical residents in four major clinics. In this study, the ACLEEM Questionnaire was conducted after translating and retranslating the questionnaire and examine the face and content validity, construct validity, test retest reliability and internal consistency coefficient. Results: In this study, 157 out of 192 residents completed the questionnaire (response rate 82). The mean age of the residents was 31.81 years. The final mean of the questionnaire was calculated as 110.91 out of 200 (with 95 confidence interval). Test - retest stability of the questionnaire was between 0.322 and 0.968. The face validity of the questionnaire was confirmed. The content validity ratio was 0.64; and content validity Index was 0.78. In Exploratory factor analysis, eight factors were confirmatory that changed the orientation of some questions. The Cronbach's alpha coefficient of the whole questionnaire was 0.936. Conclusion: According to the data, the Persian version of the ACLEEM questionnaire has sufficient psychometric reliability and validity to be used for conducting research, teaching and practicing the educational learning environment in ambulatory care in Iran

Burden of disease scenarios for 204 countries and territories, 2022–2050: a forecasting analysis for the Global Burden of Disease Study 2021

Background: Future trends in disease burden and drivers of health are of great interest to policy makers and the public at large. This information can be used for policy and long-term health investment, planning, and prioritisation. We have expanded and improved upon previous forecasts produced as part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) and provide a reference forecast (the most likely future), and alternative scenarios assessing disease burden trajectories if selected sets of risk factors were eliminated from current levels by 2050. Methods: Using forecasts of major drivers of health such as the Socio-demographic Index (SDI; a composite measure of lag-distributed income per capita, mean years of education, and total fertility under 25 years of age) and the full set of risk factor exposures captured by GBD, we provide cause-specific forecasts of mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) by age and sex from 2022 to 2050 for 204 countries and territories, 21 GBD regions, seven super-regions, and the world. All analyses were done at the cause-specific level so that only risk factors deemed causal by the GBD comparative risk assessment influenced future trajectories of mortality for each disease. Cause-specific mortality was modelled using mixed-effects models with SDI and time as the main covariates, and the combined impact of causal risk factors as an offset in the model. At the all-cause mortality level, we captured unexplained variation by modelling residuals with an autoregressive integrated moving average model with drift attenuation. These all-cause forecasts constrained the cause-specific forecasts at successively deeper levels of the GBD cause hierarchy using cascading mortality models, thus ensuring a robust estimate of cause-specific mortality. For non-fatal measures (eg, low back pain), incidence and prevalence were forecasted from mixed-effects models with SDI as the main covariate, and YLDs were computed from the resulting prevalence forecasts and average disability weights from GBD. Alternative future scenarios were constructed by replacing appropriate reference trajectories for risk factors with hypothetical trajectories of gradual elimination of risk factor exposure from current levels to 2050. The scenarios were constructed from various sets of risk factors: environmental risks (Safer Environment scenario), risks associated with communicable, maternal, neonatal, and nutritional diseases (CMNNs; Improved Childhood Nutrition and Vaccination scenario), risks associated with major non-communicable diseases (NCDs; Improved Behavioural and Metabolic Risks scenario), and the combined effects of these three scenarios. Using the Shared Socioeconomic Pathways climate scenarios SSP2-4.5 as reference and SSP1-1.9 as an optimistic alternative in the Safer Environment scenario, we accounted for climate change impact on health by using the most recent Intergovernmental Panel on Climate Change temperature forecasts and published trajectories of ambient air pollution for the same two scenarios. Life expectancy and healthy life expectancy were computed using standard methods. The forecasting framework includes computing the age-sex-specific future population for each location and separately for each scenario. 95% uncertainty intervals (UIs) for each individual future estimate were derived from the 2·5th and 97·5th percentiles of distributions generated from propagating 500 draws through the multistage computational pipeline. Findings: In the reference scenario forecast, global and super-regional life expectancy increased from 2022 to 2050, but improvement was at a slower pace than in the three decades preceding the COVID-19 pandemic (beginning in 2020). Gains in future life expectancy were forecasted to be greatest in super-regions with comparatively low life expectancies (such as sub-Saharan Africa) compared with super-regions with higher life expectancies (such as the high-income super-region), leading to a trend towards convergence in life expectancy across locations between now and 2050. At the super-region level, forecasted healthy life expectancy patterns were similar to those of life expectancies. Forecasts for the reference scenario found that health will improve in the coming decades, with all-cause age-standardised DALY rates decreasing in every GBD super-region. The total DALY burden measured in counts, however, will increase in every super-region, largely a function of population ageing and growth. We also forecasted that both DALY counts and age-standardised DALY rates will continue to shift from CMNNs to NCDs, with the most pronounced shifts occurring in sub-Saharan Africa (60·1% [95% UI 56·8–63·1] of DALYs were from CMNNs in 2022 compared with 35·8% [31·0–45·0] in 2050) and south Asia (31·7% [29·2–34·1] to 15·5% [13·7–17·5]). This shift is reflected in the leading global causes of DALYs, with the top four causes in 2050 being ischaemic heart disease, stroke, diabetes, and chronic obstructive pulmonary disease, compared with 2022, with ischaemic heart disease, neonatal disorders, stroke, and lower respiratory infections at the top. The global proportion of DALYs due to YLDs likewise increased from 33·8% (27·4–40·3) to 41·1% (33·9–48·1) from 2022 to 2050, demonstrating an important shift in overall disease burden towards morbidity and away from premature death. The largest shift of this kind was forecasted for sub-Saharan Africa, from 20·1% (15·6–25·3) of DALYs due to YLDs in 2022 to 35·6% (26·5–43·0) in 2050. In the assessment of alternative future scenarios, the combined effects of the scenarios (Safer Environment, Improved Childhood Nutrition and Vaccination, and Improved Behavioural and Metabolic Risks scenarios) demonstrated an important decrease in the global burden of DALYs in 2050 of 15·4% (13·5–17·5) compared with the reference scenario, with decreases across super-regions ranging from 10·4% (9·7–11·3) in the high-income super-region to 23·9% (20·7–27·3) in north Africa and the Middle East. The Safer Environment scenario had its largest decrease in sub-Saharan Africa (5·2% [3·5–6·8]), the Improved Behavioural and Metabolic Risks scenario in north Africa and the Middle East (23·2% [20·2–26·5]), and the Improved Nutrition and Vaccination scenario in sub-Saharan Africa (2·0% [–0·6 to 3·6]). Interpretation: Globally, life expectancy and age-standardised disease burden were forecasted to improve between 2022 and 2050, with the majority of the burden continuing to shift from CMNNs to NCDs. That said, continued progress on reducing the CMNN disease burden will be dependent on maintaining investment in and policy emphasis on CMNN disease prevention and treatment. Mostly due to growth and ageing of populations, the number of deaths and DALYs due to all causes combined will generally increase. By constructing alternative future scenarios wherein certain risk exposures are eliminated by 2050, we have shown that opportunities exist to substantially improve health outcomes in the future through concerted efforts to prevent exposure to well established risk factors and to expand access to key health interventions

Global age-sex-specific mortality, life expectancy, and population estimates in 204 countries and territories and 811 subnational locations, 1950–2021, and the impact of the COVID-19 pandemic: a comprehensive demographic analysis for the Global Burden of Disease Study 2021

Background: Estimates of demographic metrics are crucial to assess levels and trends of population health outcomes. The profound impact of the COVID-19 pandemic on populations worldwide has underscored the need for timely estimates to understand this unprecedented event within the context of long-term population health trends. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 provides new demographic estimates for 204 countries and territories and 811 additional subnational locations from 1950 to 2021, with a particular emphasis on changes in mortality and life expectancy that occurred during the 2020–21 COVID-19 pandemic period. Methods: 22 223 data sources from vital registration, sample registration, surveys, censuses, and other sources were used to estimate mortality, with a subset of these sources used exclusively to estimate excess mortality due to the COVID-19 pandemic. 2026 data sources were used for population estimation. Additional sources were used to estimate migration; the effects of the HIV epidemic; and demographic discontinuities due to conflicts, famines, natural disasters, and pandemics, which are used as inputs for estimating mortality and population. Spatiotemporal Gaussian process regression (ST-GPR) was used to generate under-5 mortality rates, which synthesised 30 763 location-years of vital registration and sample registration data, 1365 surveys and censuses, and 80 other sources. ST-GPR was also used to estimate adult mortality (between ages 15 and 59 years) based on information from 31 642 location-years of vital registration and sample registration data, 355 surveys and censuses, and 24 other sources. Estimates of child and adult mortality rates were then used to generate life tables with a relational model life table system. For countries with large HIV epidemics, life tables were adjusted using independent estimates of HIV-specific mortality generated via an epidemiological analysis of HIV prevalence surveys, antenatal clinic serosurveillance, and other data sources. Excess mortality due to the COVID-19 pandemic in 2020 and 2021 was determined by subtracting observed all-cause mortality (adjusted for late registration and mortality anomalies) from the mortality expected in the absence of the pandemic. Expected mortality was calculated based on historical trends using an ensemble of models. In location-years where all-cause mortality data were unavailable, we estimated excess mortality rates using a regression model with covariates pertaining to the pandemic. Population size was computed using a Bayesian hierarchical cohort component model. Life expectancy was calculated using age-specific mortality rates and standard demographic methods. Uncertainty intervals (UIs) were calculated for every metric using the 25th and 975th ordered values from a 1000-draw posterior distribution. Findings: Global all-cause mortality followed two distinct patterns over the study period: age-standardised mortality rates declined between 1950 and 2019 (a 62·8% [95% UI 60·5–65·1] decline), and increased during the COVID-19 pandemic period (2020–21; 5·1% [0·9–9·6] increase). In contrast with the overall reverse in mortality trends during the pandemic period, child mortality continued to decline, with 4·66 million (3·98–5·50) global deaths in children younger than 5 years in 2021 compared with 5·21 million (4·50–6·01) in 2019. An estimated 131 million (126–137) people died globally from all causes in 2020 and 2021 combined, of which 15·9 million (14·7–17·2) were due to the COVID-19 pandemic (measured by excess mortality, which includes deaths directly due to SARS-CoV-2 infection and those indirectly due to other social, economic, or behavioural changes associated with the pandemic). Excess mortality rates exceeded 150 deaths per 100 000 population during at least one year of the pandemic in 80 countries and territories, whereas 20 nations had a negative excess mortality rate in 2020 or 2021, indicating that all-cause mortality in these countries was lower during the pandemic than expected based on historical trends. Between 1950 and 2021, global life expectancy at birth increased by 22·7 years (20·8–24·8), from 49·0 years (46·7–51·3) to 71·7 years (70·9–72·5). Global life expectancy at birth declined by 1·6 years (1·0–2·2) between 2019 and 2021, reversing historical trends. An increase in life expectancy was only observed in 32 (15·7%) of 204 countries and territories between 2019 and 2021. The global population reached 7·89 billion (7·67–8·13) people in 2021, by which time 56 of 204 countries and territories had peaked and subsequently populations have declined. The largest proportion of population growth between 2020 and 2021 was in sub-Saharan Africa (39·5% [28·4–52·7]) and south Asia (26·3% [9·0–44·7]). From 2000 to 2021, the ratio of the population aged 65 years and older to the population aged younger than 15 years increased in 188 (92·2%) of 204 nations. Interpretation: Global adult mortality rates markedly increased during the COVID-19 pandemic in 2020 and 2021, reversing past decreasing trends, while child mortality rates continued to decline, albeit more slowly than in earlier years. Although COVID-19 had a substantial impact on many demographic indicators during the first 2 years of the pandemic, overall global health progress over the 72 years evaluated has been profound, with considerable improvements in mortality and life expectancy. Additionally, we observed a deceleration of global population growth since 2017, despite steady or increasing growth in lower-income countries, combined with a continued global shift of population age structures towards older ages. These demographic changes will likely present future challenges to health systems, economies, and societies. The comprehensive demographic estimates reported here will enable researchers, policy makers, health practitioners, and other key stakeholders to better understand and address the profound changes that have occurred in the global health landscape following the first 2 years of the COVID-19 pandemic, and longer-term trends beyond the pandemic

Increase in intraocular pressure is less with propofol and remifentanil than isoflurane with remifentanil during cataract surgery: A randomized controlled trial

Background: This double-blinded, randomized clinical trial was designed to evaluate intraocular pressure (IOP) change in cataract surgery using the combination of propofol and remifentanil or the combination of isoflurane and remifentanil. Materials and Methods: One hundred sixty patients were randomly allocated to a maintenance anesthetic consisting of remifentanil + isoflurane (group I), normal saline + isoflurane (group II), propofol + remifentanil (group III) or normal saline + propofol (group IV). IOP was measured at seven predefined time points, baseline (T0), 3 min after the start of continuous remifentanil infusion (T2), after induction of anesthesia (T3), immediately after laryngoscopy and intubation (T4), 5 min after laryngoscopy (T5), immediately after the block of continuous remifentanil infusion (T6) and 3 min after T6 (T7). Outcomes included IOP, systole blood pressure (SBP) and diastole blood pressure (DBP), mean arterial pressure (MAP) and heart rate (HR). Results: The mean of IOP in Group III was lower than other groups and in group IV was higher than other groups. At time point T4 and T5 differences in the mean of IOP between groups III and IV was significantly different (P > 0.05). The trend in changes in the mean of IOP was statistically significant among groups (P value = 0.01). The trends in changes in the mean of SBP, DBP and MAP were not significantly different among groups (P value = 0.41). HR in group III was significantly lower than other groups. The trend in changes in the mean of HR was significantly different among groups (P value = 0.002). Conclusion: Propofol with remifentanil was more effective than placebo or adding remifentanil to isoflurane in management of IOP in cataract surgery

Effect of hypertonic saline on hypotension following induction of general anesthesia: A randomized controlled trial

Background: The aim of this study was to examine the effects of preoperatively administered i.v. hypertonic saline on hypotension following induction of general anesthesia. Materials and Methods: Fifty-four patients who scheduled for elective surgery were randomly allocated to two groups of 27 patients who received hypertonic saline 5% (2.3 ml/kg) or received normal saline (13 ml/kg). Infusion of hypertonic saline was done half an hour before induction of anesthesia during 30 minutes. Anesthesia was conducted in a standard protocol for all patients. Age, sex, body mass index (BMI), systolic and diastolic blood pressure (SBP, DBP), heart rate (HR) and mean arterial pressure (MAP) were assessed in all patients. Results: The mean age of patients was 36.68 ± 10.8 years. Forty percent of patients were male. The mean SBP at min 2 and min 5, mean of DBP at min 2, 5, and 15, mean of HR at all time points and mean of MAP at min 2 and 15 between groups were no significantly different (P > 0.05), but mean of SBP at min 10 and 15, mean of DBP at min 10, and mean of MAP at min 5 and 10 in hypertonic saline group was significantly more than the normal group (P 0.05). Conclusions: Infusion of hypertonic saline 5% (2.3 mg/kg) before the general anesthesia led to a useful reduction in MAP and reduced heart rate, with no episodes of severe hypotension

Preemptive low-dose of ketamine does not effective on anesthetic consumption, perioperative analgesic requirement and postoperative pain, nausea and vomiting in painful ophthalmic surgery

Background: Ketamine, a non-competitive NMDA (N-Methyl-D-Aspartate) receptor antagonist, is recognized as an intraoperative anesthetic agent. Increasing interest in the use of low-dose ketamine for postoperative analgesia has developed in part because of its NMDA-antagonistic properties, which may be important in attenuating central sensitization and opioid tolerance. Despite of many trial evaluations which have been done on the effect of low-dose ketamine in postoperative pain, the role of ketamine, as a component of perioperative analgesia, remains unclear. We evaluated the analgesic effect of low-dose ketamine during anesthesia induction in painful ophthalmic surgery. Materials and Methods: After institutional approval and written informed consent, 88 patients undergoing retinal detachment, strabismus, and keratoplasty surgery aged 18-80 years old were randomly divided intoequal case and control groups. Anesthesia was induced with sodium thiopental, fentanyl, atracurium, and liducaine, and maintained with N 2 O, O 2 , and propofol. Ketamine 0.5 mg/kg was administered intravenously to patients in the case group during anesthetic induction. Mean blood pressure and pulse rate were listed in questionnaire every 5 minutes. The consumption of anesthetic, perioperative additional analgesic, extubation time, postoperative pain and nausea scores (based on Visual Analog Scale), vomiting frequency, and the recovery time were recorded. Results: There were no differences in the recovery time (17.3 ± 3.4 in the case group vs. 16.3 ± 3 in the control group, P < 0.05), postoperative pain scores (5 ± 1 in the case group vs. 5.6 ± 2 in the control group, P < 0.05), the consumption of anesthetic (9376.9 ± 1245.8 in the case group vs. 9012.9 ± 1620 in the control group, P < 0.05), the analgesic requirements (1000 in the case group vs. 940.9 ± 135.6 in the control group, P < 0.05), and perioperative additional analgesic (63.4 ± 26.5 in the case group vs. 69.4 ± 25.6 in the control group, P < 0.05) between two groups. The extubation time in the case group (13.59 ± 4.83) was significantly shorter than in the control group (15.9 ± 3.6) (P = 0.01). Conclusion: This study demonstrates that a low dose administration of ketamine during anesthesia induction in retinal detachment, strabismus, and keratoplasty surgery improves the extubation time but have no effect on postoperative pain, nausea and vomiting, and perioperative additional analgesic requirements