Original/Research Article


Magnesium Sulfate and Fentanyl for Facilitating Awake Fiberoptic Nasotracheal Intubation: A Randomized Study

Shweta Dhiman, Anju Romina Bhalotra, Ruchi Kumari, Kavita Rani Sharma, Uttam Chand Verma

Annals of Anesthesiology and Critical Care, Vol. 4 No. 1 (2019), 1 April 2019 , Page 1-6 (e90482)

Background: Various drugs have been used to facilitate awake fiberoptic intubation (AFOI). Although fentanyl is probably used most frequently, magnesium sulfate can provide muscle relaxation without respiratory depression and attenuate hemodynamic responses.


Methods: We randomly allocated 20 patients of both sexes, aged 18 - 60 years, and ASA status I-II to receive fentanyl 2 g/kg (group F) ormagnesiumsulfate 45mg/kg (groupM) before AFOI. The intubating conditionswere evaluated by Ramsay sedation score (RSS), cough score, post-intubation score, additional topicalization requirement, and hemodynamic response. Oxygen desaturation, airway morbidity, recall of procedure, and the patient’s willingness to return for the same kind of anesthesia, if required, were also studied. Statistical analyses were done using SPSS V. 17.0 software. Numerical data were analyzed using independent and paired t-tests and categorical data using the chi-square test. P values of < 0.05 were considered significant.


Results: RSS, cough score, post-intubation score, lignocaine dose, airway-related morbidity, and willingness to undergo the same kindof anesthesia for a secondtimewere comparablebetweenthe twogroups. Bothdrugshadcomparable effectsonhemodynamic response to intubation. However, the incidence of recall of the procedure was significantly lower in group F (P = 0.003).


Conclusions: The degree of coughing during fiberoptic bronchoscopy, tolerance of the endotracheal tube after intubation, and the hemodynamic response to intubationwere similar after the administration of either fentanyl 2 g/kg ormagnesiumsulfate 45 mg/kg.

Magnesium Sulfate and Fentanyl for Facilitating Awake Fiberoptic Nasotracheal Intubation: A Randomized Study

Shweta Dhiman, Anju Romina Bhalotra, Ruchi Kumari, Kavita Rani Sharma, Uttam Chand Verma

Annals of Anesthesiology and Critical Care, Vol. 4 No. 1 (2019), 1 April 2019 , Page 1-6

Background: Various drugs have been used to facilitate awake fiberoptic intubation (AFOI). Although fentanyl is probably used most frequently, magnesium sulfate can provide muscle relaxation without respiratory depression and attenuate hemodynamic responses.


Methods: We randomly allocated 20 patients of both sexes, aged 18 - 60 years, and ASA status I-II to receive fentanyl 2 _g/kg (group F) or magnesium sulfate 45 mg/kg (group M) before AFOI. The intubating conditions were evaluated by Ramsay sedation score (RSS), cough score, post-intubation score, additional topicalization requirement, and hemodynamic response. Oxygen desaturation, airway morbidity, recall of procedure, and the patient’s willingness to return for the same kind of anesthesia, if required, were also studied. Statistical analyses were done using SPSS V. 17.0 software. Numerical data were analyzed using independent and paired t-tests and categorical data using the chi-square test. P values of < 0.05 were considered significant.


Results: RSS, cough score, post-intubation score, lignocaine dose, airway-related morbidity, and willingness to undergo the same kind of anesthesia for a second time were comparable between thetwogroups. Both drugshadcomparable effectsonhemodynamic response to intubation. However, the incidence of recall of the procedure was significantly lower in group F (P = 0.003). Conclusions: The degree of coughing during fiberoptic bronchoscopy, tolerance of the endotracheal tube after intubation, and the hemodynamic response to intubation were similar after the administration of either fentanyl 2 _g/kg or magnesium sulfate 45 mg/kg.

Evaluation of Maternal and Fetal Hemodynamic Alterations in Delivery in Epidural and Combined Spinal-Epidural Analgesia: A Randomized Clinical Trial

Hojjat Pourfathi, Haleh Farzin, Hanie Sakha, Mohamad Mahdi al Miski, Nabiha Aldarir

Annals of Anesthesiology and Critical Care, Vol. 4 No. 1 (2019), 1 April 2019 , Page 1-6

Background: The pain of vaginal delivery is considered as the worst experience in women life that negatively affects mother and fetus. The most important methods advised by anesthesiologists for pain reduction include epidural and combined spinal-epidural analgesia. The ideal method provides convenient pain relief and guarantees maternal and fetal safety, simultaneously. Fetal heart rate (FHR), fetal movement (FM), and maternal hemodynamics (i.e. blood pressure (BP), heart rate (HR), and SpO2) monitoring are the most available ways for controlling the fetus and mother’s conditions during the delivery process.


Methods: This randomized-blinded clinical trial was performed on 100 pregnant women (50 cases in each group) during labor under epidural or combined spinal-epidural analgesia using lidocaine, fentanyl, and bupivacaine. FHR, FM, BP, HR, and SpO2 were monitored and recorded by blinded nurses. Data were analyzed by SPSS 22.


Results: There were no significant differences in FHR, FM, and Apgar scores between the two groups. No significant difference was found between the two groups in maternal hemodynamics. Generally, FHR, maternal BP, and HR were in the normal ranges. The C/S rate was lower in the epidural group but not statistically significantly.


Conclusions: In our survey, epidural and combined spinal-epidural analgesia were comparable in terms of FHR, FM, and maternal hemodynamics. Therefore, there is no priority in using each of the methods. The monitoring of FHR and maternal hemodynamics is essential during analgesia. It is suggested that further surveys evaluate the incidence and causes of C/S after analgesia.

Comparison of Preventive Acetaminophen and Placebo in Pain Reduction After Cesarean Section; A Randomized Clinical Trial

Ehsan Bastanhagh, Fardin Yousefshahi, Somayeh Alsadat Moosavian, Saghar Samimi Sadeh, Fatemeh Davari-Tanha

Annals of Anesthesiology and Critical Care, Vol. 4 No. 1 (2019), 1 April 2019 , Page 1-5

Background: In subjects having a cesarean section, pain can increase hospital length of stay and postoperative complications. The preventive analgesia in the postoperative phase is known to be more effective than analgesic treatment in response to pain.


Objectives: In this study, the analgesic efficacy of preventive intravenous acetaminophen was compared with placebo in relieving postoperative pain after cesarean sections under spinal anesthesia.


Methods: In this double-blind randomized controlled study, 49 women undergoing elective cesarean section under spinal anesthesia were randomly allocated into two groups by block randomization in a referral hospital in Tehran in 2016. The intervention group received intravenous acetaminophen (Apotel®) (1 gram) and the placebo group received normal saline on arrival to the recovery room within 20 minutes. Then the total consumed doses of meperidine, visual analogue scale (VAS) score of pain, and the incidence of vomiting were determined and recorded for 24 hours postoperatively.


Results: Pain scores (VAS) were lower in the acetaminophen group throughout the study, but the difference was only significant at forth to eighth hours after the surgery (P = 0.0001). The total consumed doses of meperidine to treat the pain was significantly lower in the acetaminophen group at the fourth to the eighth hours after the surgery (P = 0.0001). The incidence of vomiting was the same between the groups (P > 0.05).


Conclusions: A single dose preventive intravenous acetaminophen has good efficacy in reduction of postoperative pain and reduces opioid use after cesarean sections under spinal anesthesia up to 8 hours after the administration.

Effect of Equal Ringer’s Lactate and Normal Saline Solution Infusion Versus Normal Saline on Acid-Base Balance and Serum Electrolytes After Living-Related Renal Transplantation: A Randomized Controlled Trial

Mehrdad Mesbah Kiaee, Sarah Faghfuri, Gholamreza Movaseghi, Mahmoud Reza Mohaghegh Dolatabadi, Masoud Ghorbanlo

Annals of Anesthesiology and Critical Care, Vol. 4 No. 1 (2019), 1 April 2019 , Page 1-6

Background: Hyperkalemia is a common complication of renal transplantation (RT). Normal saline (NS) remains the most commonly used infusion solution during RT to avoid hyperkalemia, but it is associated with hyperchloremic metabolic acidosis.


Objectives: We aimed to study the metabolic profile and renal function in RT patients managed with equal NS and ringer’s lactate (RL) solution versus NS alone.


Methods: In this randomized controlled trial, 46 adult patients (17 females and 29 males) undergoing living-related RT were recruited and divided into the two groups according to the IV fluid infusion: NS and RL-NS. Subsequently, patients were evaluated based on arterial blood gas (ABG) test, sodium (Na), potassium (K), blood urea nitrogen (BUN), and creatinine (Cr) before and after RT and 3 and 7-day BUN and Cr.


Results: The mean age of the patients was 44.52_12.58 years in NS and 45.43_14.29 years in NS-RL group. There were no significant differences in the demographic and baseline patients’ characteristics between the two groups. BUN and Cr were lower in the NS group up to 7 days after RT (all P < 0.05). Serum Na was lower in the NS-RL group and serum K was higher in this group significantly (P = 0.004 and 0.028, respectively). No significant difference was observed regarding acid-base balance and other ABG measures. No case of hyperkalemia or acidosis was observed after RT.


Conclusions: Our study showed that neither NS nor NS-RL solutions were associated with the risk of hyperkalemia or acidosis after RT; however, renal function was superior in patients receiving the NS infusion.

Letter to Editor


Estimating the Cost of Anesthetic Agents as the First Step in Cost Minimization Strategy: The Second Half of the Story

Nasrin Nouri, Masood Mohseni

Annals of Anesthesiology and Critical Care, Vol. 4 No. 1 (2019), 1 April 2019 , Page 1-2

Dear Editor,


There is a traditional belief that higher costs are associated with better performance and clinical outcome.


Sure, this assumption is not true as far as we go. There is a need to consider ‘value for money’ in providing health services (1). In countries with limited financial resources the importance of clinical decision making based on value rather than price is doubled. Preliminary investigations show that there is a room for cost saving measures in all disciplines of clinical practice without negative impact on health outcomes. To be accurate, allocating economic resources on a ‘value-based’ approach is more affordable than ‘free-for-all’ approach (1). However, there are some public and governmental concerns with this reforming. Is it ethical to deprive patients from effective but expensive treatment modalities? Is it reasonable to deprive medical students from practice with costly treatments and medications? May this approach fade educational purposes or research activities? These questions should be asked but may not stop the process of reforming the allocation of resources on a value-based approach in a reasonable health care system.


There is no “one-size-fits-all” approach to value-based practice among medical disciplines. Cost-minimization analysis is a type of cost-effective analysis where the alternatives are considered equivalent. Although the effects of anesthetics are not equal, their difference is not big enough to be clinically significant in most of scenarios.


Thus, cost minimization surveys targeting the elimination of certain medications could be considered reasonable (2). Regarding the fact that cost of services, devices and medications are unknown to the majority of clinicians, clarifying the costs is the first step in cost minimization plans. As a miniature of cost minimization in the discipline of anesthesia practice, we estimated the cost of induction and maintenance of anesthesia with commonly used medications.


Our survey shows that among intravenous anesthetics etomidate is 12 times more expensive than ketamine and should be reserved for certain conditions. Sodium thiopental, propofol and benzodiazepines remain reasonable choices regarding their average cost (Table 1). For maintenance of anesthesia, sevoflurane is several times more costly than other anesthetics. As an example, it is nine times more costly than other commonly used volatile agent isoflurane. In our center it is a usual practice to apply inhalation induction of anesthesia with sevoflurane in small kids without intravenous access. It is wise to switch from sevoflurane to isoflurane for maintenance of anesthesia in pediatrics with comparable safety and efficacy of volatile agents. Among intravenous drugs, propofol is the commonly used but expensive choice. In most patients it could be safely replaced with other medications namely midazolam especially for maintenance of anesthesia. It is widely accepted that only in a minority of patients’ particular medications may be safer or have superiority over the cheaper substitutes. Earlier studies have evaluated the effects of limited access to the relatively expensive drugs of remifentanil, dexmedetomidina and desflurane.


The results demonstrated some drug cost savings without significant effect on clinical outcomes or duration of hospital stay (3-5). The reasonable approach is to identify cost contaminant interventions and actively replace the appropriate interventions and medications. A study of surgical costs in the U.S. private setting showed that operating rooms included 40% of hospital expenses, while 70% of the hospital’s income is from the operating room(6). Drug costs (anesthetic and non-anesthetic) account for 6% of the total costs of the hospital, 22% of which is owned by anesthetic agents. The cost of intraoperative anesthetic drugs included only 5.6% of the perioperative costs. Despite a small percentage of the total perioperative costs of anesthetic drugs, we need to find interventions that have a reasonable cost to be implemented.


In summary, habitual use of anesthetics without considering their prices precludes the cost-effective administration of them. It should be noted that the existence of a costly medication in the market does not necessarily translate to higher benefit compared with alternatives. The clinicians should restrict the use of these medications when their added benefit is not proven or is not large enough to warrant their administration. This strategy will help to reduce the drug shortages especially in health systems with limited financial resources. In educational centers, it is worthwhile to maintain access to multiple anesthetic drugs for educational and research purposes. Finally, as Sir Muir Gray, chief knowledge officer, UK National Health Service says “Doing things right is only half the story- it is also essential to use our limited resources most effectively by identifying and discontinuing lower value activities”.