Annals of Anesthesiology and Critical Care

Background: Aortic dissection is a nonprevalent disease and its late diagnosis can be life-threatening with a high mortality rate.
The timely treatment of this disease can increase the survival rate considerably.
Objectives: The aim of this study was to provide a surgery report of patients with aortic dissection operated in a community hospital.
Methods: In this descriptive study, the mortality rate and operation events of five patients with an acute aortic dissection referred
to a community hospital were reported during the period of 2011 to 2015.
Results: In this study, 5 patients with aortic dissection referred to the cardiology emergency ward of the hospital were operated.
Twoof five patients were males; one of them had the Marfan’s disease and another one had the bicuspid aortic valve. The remainders
were females; the first case was an old woman with a traumatic chest injury who died during the operation due to arrhythmia. The
second case was a 42-year-old pregnant woman suspicious to Marfan’s disease with a history of sudden death in her brother. The
third woman was a case of aneurysm of ascending aorta with a bicuspid aortic valve.
Conclusions: The findings of this study show that early diagnosis and timely operation can increase the survival rate of patients
with an aortic dissection.

Background: The anticipation of the length of ICU stay would enable physicians to provide reliable information for better treatment
methods. There are several risk factors for prolonged ICU stays after cardiac surgery in the related studies.
Objectives: The aim of this study was to assess the possible factors contributing to the prolonged ICU stay in a referral heart center.
Methods: In this retrospective case-control study, 515 adult patients admitted to ICU after cardiac surgery in Madani heart center in
Tabriz (since March to September 2014) were divided into 2 short and prolonged ICU stay groups. ICU stays more than 3 days were
considered prolonged. Various risk factors were compared between the two groups.
Results: A total number of 64.9% of the patients were in the prolonged ICU stay group and 35.1% had a short stay. Among35 potential
risk factors, some were significant factors affecting the length of ICU stay (age, type of surgery, previous cardiac surgery, a high dose
of inotropes support, duration of surgery, length of CPB and aortic clamp time, arrhythmia in ICU, and re-operation).
Conclusions: We can reduce ICU stay using the correction of high levels of serum creatinine before surgery, improvement of functional
class with drug treatment, shortening of CPB and aortic cross clamp times, adequate hemostasis with surgeon and more
correction of the coagulation status of the patient by the anesthesiologist at the end of the surgery.

“Awake craniotomy” is a technique used in neurosurgical procedures, commonly performed to remove a tumor or an epileptogenic
focus while the patient is awake. There has been an increasing trend towards performing this type of procedure because of its advantages;
above all, the ability to map the eloquent cortex to reduce post-surgical neurological sequel. The aim of this article is to
introduce 8 cases of awake craniotomies, performed in Loghman-e-Hakim hospital in Tehran, Iran. Patients were selected according
to our specific criteria. Oral clonidine (4 g/kg), dexamethason (8 mg/IV), midazolam (0.03 mg/kg/IV), and sufentanil (3 g/kg/IV)
were used as premedication. Patients underwent cerebral state monitoring and other monitoring modalities during the procedure.
A laryngeal mask was used during the asleep phase of the anesthesia. General anesthesia was induced using propofol and lidocaine.
Local anesthesia was provided with bupivacaine in the incision and pin insertion sites. Anesthesia was maintained using propofol
and remifentanil infusion. A total of 8 patients underwent the procedure. No significant complications, including hemodynamic
instability, depressed respiration, the need to put the patient to sleep before mapping or tumor resection, intraoperative seizures,
aspiration, and brain edema were observed in any of our patients. In conclusion, we believe that a modified asleep-awake-awake
technique instead of the asleep-awake-asleep technique may provide less complications and less need to manage the patients’ airway.“Awake craniotomy” is a technique used in neurosurgical procedures, commonly performed to remove a tumor or an epileptogenic
focus while the patient is awake. There has been an increasing trend towards performing this type of procedure because of its advantages;
above all, the ability to map the eloquent cortex to reduce post-surgical neurological sequel. The aim of this article is to
introduce 8 cases of awake craniotomies, performed in Loghman-e-Hakim hospital in Tehran, Iran. Patients were selected according
to our specific criteria. Oral clonidine (4 g/kg), dexamethason (8 mg/IV), midazolam (0.03 mg/kg/IV), and sufentanil (3 g/kg/IV)
were used as premedication. Patients underwent cerebral state monitoring and other monitoring modalities during the procedure.
A laryngeal mask was used during the asleep phase of the anesthesia. General anesthesia was induced using propofol and lidocaine.
Local anesthesia was provided with bupivacaine in the incision and pin insertion sites. Anesthesia was maintained using propofol
and remifentanil infusion. A total of 8 patients underwent the procedure. No significant complications, including hemodynamic
instability, depressed respiration, the need to put the patient to sleep before mapping or tumor resection, intraoperative seizures,
aspiration, and brain edema were observed in any of our patients. In conclusion, we believe that a modified asleep-awake-awake
technique instead of the asleep-awake-asleep technique may provide less complications and less need to manage the patients’ airway.

Background and Aims: Maintaining the sufficient depth of anesthesia with an adequate anesthetic drug dosage in patients undergoing
surgery is one of the most significant issues. Inadequate depth of anesthesia can cause significant disturbances in hemodynamic
parameters. In this study, clinical assessment and bispectral (BIS) index monitoring compare the depth of general anesthesia
and recovery time in patients undergoing open renal surgery.
Method: In this double-blind, randomized, controlled trial, all patients undergoingopenrenal surgery were enrolledandrandomly
divided into a BIS group and clinical assessment group (control). In the BIS group, the electrodes of BIS monitoring system were
placed on frontal and temporal lobes of the patient. The time of eye opening, verbal response to verbal stimulation, extubation time,
the duration of stay in the recovery unit, the first-time of narcotic usage, and total dosage of intravenous narcotics were assessed in
2 groups.
Results: A total of 96 patients were enrolled. Sex, age, BMI, duration of surgery, length of stay in the recovery room and first-time
narcotic drug usage were not significantly different in the two groups. However, the length of time from the anesthetic drug discontinuation
to eye opening, verbal responses to verbal stimulation and extubation was significantly lower in the BIS group than
the control group, respectively (P = 0.002, P = 0.007, P = 0.019).
Conclusions: The evaluation of the aneasthesia status of patients based on the BIS index would be more efficient in decreasing the
emergence anaesthesia including eye opening, verbal response, extubation after anesthesia

Background: The economic burden of the treatment of hip fracture would be enormous, especially in countries like Iran with an
aging population and limited financial resources. The choice of anesthetic technique for hip fracture surgery is controversial. We
conducted this retrospective 4 year study to evaluate the effect of regional versus general anesthesia on the length of hospital stay
and the cost of hospitalization in an academic governmental setting.
Methods: We reviewed the medical records of 751 adult patients who underwent a surgery for intertrochanteric or femoral neck
fracture since 2008 to 2012 in a University hospital located in Tehran, Iran. Data regarding days of hospital stay and total direct
hospitalization costs as well as patients’ demographics were analyzed based on the type of planned anesthesia. The source of data
collection was local electronic database.
Results: Neuraxial anesthesia was associated with less hospital stay and costs in patients with intertrochanteric fracture surgery.
The advantage of neuraxial over general anesthesia was not statistically significant in patients with femoral neck fracture.
Conclusions: Neuraxial anesthesia followed by meticulous postoperative pain control may reduce the hospitalization period and
costs of hip fracture treatment. This is especially true for the patients with intertrochanteric fracture.

Introduction: Manypatients withemphysemawill develop cystic air spaces in the lung parenchymaknownas bullae. Positive pressure
ventilation increases the pressure in a bulla and increases the risk of rupture and tension pneumothorax. Therefore, anesthesia
management, for surgeries other than lung volume reduction surgery (LVRS), is challenging in these patients.
Case Presentation: A 62-year-old male patient was brought to the emergency department due to a fall resulting in head trauma and
a leak of CSF from a previous surgical site of a CP (cerebellopontine) angle tumor. The chest CT scan depicted bilateral bullae in the
lungs. Anesthesia was induced and maintained with an inhalational method using Sevoflurane and spontaneous mask ventilation.
Conclusions: Patients with bilateral bullae could be managed with spontaneous ventilation; one of the safe choices is inhalational
induction and maintenance with Sevoflurane.

The laryngoscope blade has a potential role for cross
infection due to its contamination with bacteria, blood,
and microorganisms. Cleaning the laryngoscope blade
has various methods in different countries. Most operating
rooms have no guidelines for laryngoscope disinfection
after each usage (1). Some use tap water for cleaning
which is an inadequate method while others add disinfectant
to tap water which is more effective for the control
of infection, but this may result in the emergence of
resistant bacteria. There are so many disinfectants like
aldehyde-free biguanide and Chlorine dioxide or chlorhexidine
without any international guideline for common
practice. Cleaning with most of these disinfectants is
time consuming and needs at least 10 minutes for disinfection
(2). In some centers, anesthesiologists use disposable
blade laryngoscopes which brings, sometimes, difficulty
in airway management especially in the emergency
situations compared to standard laryngoscopes, because
of the shape of the blade or light carrying capacity. Most of
the single-use laryngoscopes tested were significantly inferior
to the standard Macintosh blade. This raises concern
over their use in clinical practice, particularly if intubation
is difficult (3). The cost of disposable blades for laryngoscopes
is almost 5 to 10 dollars.

Do you belong to the camp of the physicians who wear
glasses at work to have a more accurate eyesight? Do you
hold the opinion that anyone who does not wear glasses
is somewhat categorized as one who does not subscribe to
the idea that wearing glasses gives him a sharper view of
the world and puts him in a better position to pass judgments?
The fact of the matter is that a physician, besides wearing
physical eyeglasses, may an advantage of other mechanisms
that function as glasses forhimto diagnose the overt
andcovertsymptomsfor a variety of diseasesandailments,
deeply analyze them, and decide on a prognosis course for
each patient accordingly. Students of medicine and their
patients habitually carry such metaphorical glasses, and
every single one of them gets used to that particular set of
lenses over time, resulting in viewing the treatment with
their own set of beliefs and biases.

Context: Family presence during resuscitation (FPDR) is a controversial debate throughout the world. Experts believe that FPDR
is a cultural and ethnical issue and that countries have different views regarding this matter. The aim of this study is a systematic
review and meta-analysis of all available studies assessing patient families’ views regarding their presence during resuscitation.
Evidence Acquisition: Studies reported attitudes of the patients’ relatives toward FPDR were eligible for inclusion. Case reports,
letters, opinion pieces, and reviews were excluded from the study. A systematic search was conducted in Medline, Embase, CINAHL,
Cochrane library,Web of Science, SCOPUS, PsycInfo, and other related databases based on selected keywords. The qualities of studies
were assessed using Critical Appraisal Skills Programme (CASP) and STROBE statement. Comprehensive meta-analysis (version-2)
was used for data analysis. Heterogeneity was assessed using the Cochrane Q-statistic and the I2 statistic. Publication bias was detected
through funnel plot.
Results: A total of 18 studies were selected, including 10 cross-sectionals and 8 control trials. The results were categorized in three
items: tendency for being present, satisfaction, and coping. A meta-analysis was done for 9 descriptive cross-sectional studies. The
event rate of being present was 0.73 (95% CI: 0.60 - 0.83), which was statistically significant (P = 0.001), whereas the event rate of
coping was 0.62 (95% CI: 0.48 - 0.73) and was not statistically significant.
Conclusions: The results of this study showed that the patients’ families tend to be present during resuscitation and believe that
some rules should support FPDR. In terms of anxiety disorders and PTSD, when there were more intervals, family’s presence and
their emotional supports had a positive effect on them. However, the role of the medical staff cannot be ignored in this regard.