BackgroundEtomidate is a potent hypnotic agent with several desirable advantages such as providing a stable cardiovascular profile with minimal respiratory adverse effects and better hemodynamic stability compared with other induction agents. This drug is associated, however, with myoclonic movements which is characterized by a sudden, brief muscle contractions as a disturbing side-effect.ObjectivesThe present study was designed to compare the effectiveness of low- dose midazolam, magnesium sulfate, remifentanil and low-dose etomidate to suppress etomidate-induced myoclonus in orthopedic surgery.Patients and MethodsA double-blind clinical trial study was conducted in an academic hospital from September 2014 to August 2015. Two hundred and eighty-four eligible patients, American society of anesthesiologists class I - II, scheduled for elective orthopedic surgery were randomly allocated into four equal groups (n = 71). They received premedication with intravenous low-dose midazolam 0.015 mg/kg, magnesium sulfate 30 mg/kg, remifentanil 1 μg/kg and low-dose etomidate 0.03 mg/kg two minutes before induction of anesthesia with 0.3 mg/kg intravenous etomidate. Then the incidence and intensity of myoclonus were evaluated on a scale of 0 - 3; 0 = no myoclonus; 1 = mild (movement at wrist); 2 = moderate (movement at arm only, elbow or shoulder); and 3 = severe, generalized response or movement in more than one extremity, within ninety seconds. Any adverse effect due to these premedication agents was recorded.ResultsThe incidence and intensity of myoclonus were significantly lower in the low-dose etomidate group. The incidence rates of myoclonus were 51 (71.85%), 61 (85.9%), 30 (42.3%) and 41 (57.7%), and the percentages of patients who experienced grade III of myoclonus were 30 (58.8%), 32 (52.5%), 9 (30%) and 14 (34.1%) in the midazolam, magnesium sulfate, etomidate and remifentanil groups, respectively. The incidence and intensity of myoclonus were significantly lower in the low-dose etomidate group (P = 0.0001). No notable adverse effect was detected in our patients during the study period.ConclusionsIntravenous etomidate 0.03 mg/kg prior to induction can effectively reduce the incidence and severity of myoclonus linked to etomidate.

BackgroundCoronary artery bypass graft (CABG) surgery with cardiopulmonary bypass (CPB) triggers an inflammatory reaction, leading to the development of myocardial damage and dysfunction. It is suggested that selenium (Se), an essential trace element, has a protective role against oxidative stress. Decreased intraoperative Se levels might be an independent predictive factor for postoperative multiorgan failure. In spite of its proposed advantages, however, the optimal timing and dosage are not well known.ObjectivesTo determine whether 600 µg of intravenous Se administration before induction of anesthesia for CABG surgery could attenuate inflammatory reactions in an Iranian population.MethodsThis randomized triple-blind clinical trial took place in the department of cardiac surgery of an academic hospital affiliated with Guilan University of Medical Sciences (GUMS) from May 2015 to September 2015. Eighty-eight eligible patients scheduled for elective on-pump CABG surgery were divided into two groups using randomized fixed quadripartite blocks. They received either an intravenous bolus of 600 µg Se before induction of anesthesia, or normal saline as a placebo. We had four measurement time-points: just before induction of anesthesia (T0), immediately after the end of CPB (T1), 24 hours after surgery (T2), and 48 hours after surgery (T3). Interleukin 6 (IL-6), tumor necrosis factor-alpha (TNF-α), and C-reactive protein (CRP) serum levels were measured using the enzyme-linked immunosorbent assay (ELISA).ResultsData from a total of 81 patients were analyzed: group S (n = 41) and group C (n = 40). There was no significant difference between the two groups with regard to baseline characteristics. In both groups, CPB caused markedly increased IL-6, TNF-α, and CRP plasma concentrations compared with baseline (P = 0.0001). However, the pattern of changes was not significantly different between group S (P = 0.068) and group C (P = 0.26). The IL-6 and TNF-α change trends were significant in each group (P=0.0001). However, comparing the two groups showed no significant difference. With regard to IL-6, there was no significant difference between the two groups at the time-points of T1 (P = 0.34), T2 (P = 0.17), and T3 (P = 0.056), and the same was found for TNF-α at T1 (P = 0.34), T2 (P = 0.17), and T3 (P = 0.056). With regard to CRP, the trend of the changes was significant in each group (P = 0.0001). However, comparing two groups showed a borderline significant difference between them at T1 (P = 0.039), but not at T2 (P = 0.075) or T3 (P = 0.11).ConclusionsThis study revealed that the administration of 600 μg of intravenous Se immediately before induction of anesthesia was safe, but when compared to a placebo, no predominant clinical effects or modifications in the systemic inflammatory response induced by on-pump CABG were observed.

Background:Uncontrolled postoperative pain, characteristic to abdominal hysterectomy, results in multiple complications. One of the methods for controlling postoperative pain is preemptive analgesia. Gabapentin and tramadol are both used for this purpose.Objectives:This study aims to compare the effects of tramadol and gabapentin, as premedication, in decreasing the pain after hysterectomy.Patients and Methods:This clinical trial was performed on 120 eligible elective abdominal hysterectomy patients, divided in three groups of 40, receiving tramadol, gabapentin and placebo, respectively. Two hours before the surgery, the first group was given 300 mg gabapentin, the second one was given 100 mg tramadol, while the other group was given placebo, with 50 ml water. After the surgery, in case of visual analog pain scale (VAS) > 3, up to 3 mg of diclofenac suppository would be used. Pain score, nausea, vomiting, sedation, patient’s satisfaction and the number of meperidine administered during 24 hours (1 - 4 - 8 - 12 - 16 - 20 - 24 hours) were recorded. If patients had VAS > 3, despite using diclofenac, intravenous meperidine (0.25 mg/kg) would be prescribed. Data were analyzed using SPSS 21 software, chi-square test, general linear model and repeated measurement.Results:The three groups were similar regarding age and length of surgery (up to 2 hours). The average VAS, in the placebo group, was higher than in the other two groups (P = 0.0001) and the average received doses of meperidine during 24-hour time were considerably higher in placebo group, compared to the other two groups (55.62 mg in placebo, 18.75 mg in gabapentin and 17.5 mg in tramadol groups, P = 0.0001). Nausea, vomiting and sedation, in the tramadol group, were higher than in the other two groups, although they were not significant. Patients’ dissatisfaction, in the placebo group, during initial hours, especially in the fourth hour, was higher (P = 0.0001). In the gabapentin and tramadol groups, the trend of changes in satisfaction score was similar. However, satisfaction in the gabapentin group, during the initial 4 hours was higher, in comparison to the tramadol group (P = 0.0001).Conclusions:This study revealed that prescribing gabapentin or tramadol, as premedication, was effective in reducing postoperative pain, without any concerning side-effects.

Background Myocardial dysfunction is frequently described as an underlying cause of mortality in traumatic brain injury (TBI) known as brain-cardiac link. However the impact on prognosis of a disease remains uncertain. Objectives The current study aimed at investigating the correlation between TBI and cardiac troponin I (cTnI) rise and in-hospital mortality rate among patients with TBI. Methods In the current prospective study TBI patients with abbreviated injury scale score (AIS) > 3 and Glasgow coma scale (GCS) score ≤ 8 with cTnI measurement within the first 24 hours of admission were evaluated. Chi-square, Kruskal-Wallis, Mann-Whitney U and Logistic Regression tests were used for data analysis. Results A total of 166 eligible patients were studied .The mean age of the cases was 37.64 ± 17.21 years, largely under 65 (93.4%) and male (86.7%).The most common injuries were cerebral contusion (35.1%), while motor vehicle crash (MVC) was the most common cause of injuries (83.73%); 59 % of the patients showed detectable cTnI concentrations within 24 hours of admission; 65.7% of the patients expired; they showed higher levels of cTnI compared to survivors that showed lower levels, 0.148 ± 0.074 vs 0.057 ± 0.055, respectively (P < 0.001). Moreover, a significant association was observed between mortality rate and lower admission GCS 3.49 ± 1.08 vs 6.79 ± 1.66, respectively (P < 0.001). Conclusions Increased cTnI levels could be a predictor of mortality among patients with TBI. Its measurement and investigation for therapeutic strategies could lead to better management of these cases.

Background:Postoperative analgesia is one of the concerns of anesthesiologists and patients. Systemic opioid administration is the gold standard in reducing the severe pain after the surgery but some side effects prevent the use of adequate dosage of opioids.Objectives:The aim of this study was to evaluate the result of adding magnesium sulphate to sufentanil in patient-controlled intravenous analgesia (PCIA) system.Patients and Methods:In this randomized clinical trial, 60 patients candidate for lower limb orthopedic surgery were recruited in Poursina Medical Center for six months. They were randomly classified in two group of patient-controlled intravenous analgesia for postoperative pain control, one was group S [(sufentanil) (n = 30)] and the other was group S + M [(magnesium sulphate/sufentanil) (n = 30)]. The drug infusion rate was 5 mL/h. Each mL of solution in group S contained 1 mcg of sufentanil and in group M + S, 1 mcg of sufentanil and 200 mcg magnesium sulphate, respectively. Pain score, sedation score, satisfaction score, nausea and vomiting score were evaluated 6, 12, 24, 36 and 48 hours after surgery.Results:The demographic data between two groups were not significantly different. The pain scores after 6, 12 and 24 hours in S and S + M groups were significantly different. But the comparison of Visual Analogue Scale (VAS) scores after 36 and 48 hours didn’t show significant differences (P < 0.001). Comparison of the sedation, nausea and vomiting scores between two groups did not show any difference. But the number of patient’s satisfaction in S + M group was more than S group which suggests significant differences (P < 0.05).Conclusions:This study showed that magnesium sulphate added to sufentanil through PCIA is an effective method to alleviate pain in patients undergoing lower limb orthopedic surgery. Moreover, we found fewer side effects on magnesium-sufentanil regimen in terms of in nausea, vomiting, and sedation; and patients’ satisfaction in this regimen was more rather than that in the regiment of sufentanil alone.