ISSN: 2538-2462

July 2021
Vol. 6 No. 3 (2021)

Editorial


Original Articles


Potential Neuroprotective Effect of Apis dorsata Honey Against Morphine Tolerance: An in-vivo Study

Nur Husna Zakaria, Nasir Mohamad , Nor Hidayah Abu Bakar, Siti Norhajah Hashim, Halim Shariff, Liyana Hazwani Mohd Adnan

Journal of Cellular & Molecular Anesthesia, Vol. 6 No. 3 (2021), 7 September 2021 , Page 207-215
https://doi.org/10.22037/jcma.v6i3.35252

Background: To determine the effects of Apis dorsata honey on the development of morphine tolerance and oxidative stress in rats.
Materials and Methods: A total of 40 male Sprague Dawley rats were injected (subcutaneous) with 10 mg/kg of morphine following oral administration of A. dorsata honey (0.5, 1.5, and 2.5g/kg). On day 15, the rats were euthanized, and the thalamus, spinal cord, and hippocampus were homogenized to assess iNOS and MDA using ELISA kits.
Results:
The honey of A. dorsata significantly prevented morphine tolerance to analgesia in the hotplate test on Day 14 (p<0.05). The biochemical assessment showed that A. dorsata honey significantly reduced MDA formation in the brain regions compared to the morphine control group at dose 2.5g/kg. Elevation of iNOS caused by chronic morphine intake was reduced in A. dorsata honey co-treatment.
Conclusion: This study suggests the therapeutic role of A. dorsata honey in preventing morphine tolerance via inhibition of oxidative stress.

Molecular Epidemiology of AmpC-Producing Klebsiella Pneumoniae Isolated from Perioperative Patients in a Tertiary Hospital

Roghayeh Gholizadeh Doran Mahalleh, Nadia Kazemi Pour, Farokh Rokhbakhsh-Zamin

Journal of Cellular & Molecular Anesthesia, Vol. 6 No. 3 (2021), 7 September 2021 , Page 216-221
https://doi.org/10.22037/jcma.v6i3.35261

Background: Extended-spectrum cephalosporin-resistant organisms are the sources of AmpC- type β-lactamase isolates. AmpC-producing Klebsiella pneumoniae isolates are a major challenge in clinics due to their high rate of antibiotic resistance. This study aimed to detect AmpC β-lactamases in K. pneumoniae isolated from hospitalized patients with a surgical history.
Materials and Methods: This cross-sectional study was performed on 120 urine catheter samples. After antibiotic susceptibility testing, plasmid-mediated AmpC was detected by double-disc plus combined disc test (DCDT) and three-dimensional extract test (TDET). The genotypic detection of plasmid-mediated AmpC was carried out using multiplex-polymerase chain reaction (PCR).
Results: Of 120 samples, 60 (50%) instances of K. pneumoniae were isolated. The highest and lowest resistance rates were related to cefotaxime (CTX) (50%) and ciprofloxacin (CIP) (23.3%), respectively. 18.3% (n: 11) K. pneumoniae showed an AmpC phenotype in DCDT and TDET tests. AmpC genotyping showed that the prevalence of CIT, DHA, EBC, and ACC genotypes were 47.1%, 35.3%, 29.5%, and 23.6%, respectively. MOX and FOX genotypes were not identified in the isolates of interest.
Conclusion: AmpC β-lactamase identification tests should be considered a routine microbiology workup for gram-negative microorganisms. Multiplex-PCR can identify the plasmid AmpC genotypes.


 

Bioinformatics Prediction of Potential Inhibitors For the SARS-CoV-2 NTPase/Helicase Using Molecular Docking and Dynamics Simulation From Organic Phenolic Compounds

Massoud Saidijam, Negin Khaksarimehr, Mostafa Rezaei-Tavirani, Amir Taherkhani

Journal of Cellular & Molecular Anesthesia, Vol. 6 No. 3 (2021), 7 September 2021 , Page 222-239
https://doi.org/10.22037/jcma.v6i3.34490

Background: Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a disorder with human-to-human rapid transmission. Besides several vaccines that have been represented, it is crucial to discover effective drugs to combat this infection in a short-period therapeutic procedure. The NTPase/helicase contributes to playing an important role in the replication of the viral RNA.


Materials and methods: We estimated the binding affinity of several natural polyphenolics, commonly found in fruits and vegetables, with the catalytic site of SARS-CoV-2 helicase by molecular docking analysis using the AutoDock tool. The stability of connections between top-ranked components inside the catalytic site of the helicase was evaluated by molecular dynamics (MD) simulations. The most active residues within the catalytic site of the helicase were ranked based on their degree in a phenolics-residue interaction (PRI) network.


Results: Amentoflavone, theaflavin 3'-gallate, and procyanidin were estimated to be the most potential effective SARS-CoV-2 helicase inhibitors with the salient inhibition constant value (Ki) at the picomolar scale. The energy of binding of these compounds with the helicase catalytic site was estimated between -13.90 and -12.77 kcal/mol. Asp534 and Leu412 demonstrated more degrees than the other residues.


Conclusion: The present study predicts that amentoflavone, theaflavin 3'-gallate, and procyanidin might be helpful for the treatment of COVID-19.

Background: Hypotension remains the most common complication following spinal anesthesia in cesarean sections. Despite using various preventive measures, hypotension occurs in most cases; vasopressors are often required. The current study evaluated the safety and efficacy of prophylactic phenylephrine infusion in preventing spinal anesthesia-induced hypotension in the Cesarean Section.


Materials and Methods: A total of 50 parturients aged 20-35 years with American Society of Anesthesiologists (ASA) grade II, scheduled for elective cesarean sections were randomly allocated into one of the two groups. Group A (n=25) received intravenous prophylactic phenylephrine infusion at 100μg/min for 3min after spinal anesthesia using a syringe pump. Each minute, systolic arterial pressure (SAP) was measured, and infusion stopped if SAP > baseline and continued if less than or equal to baseline systolic arterial pressure. Intravenous phenylephrine bolus 100μg was given when SAP decreased to <80% of baseline. Group B (n=25) received only intravenous phenylephrine bolus 100μg when SAP decreased to <80% of baseline. After 1 minute of spinal anesthesia, Heart Rate (HR), SAP, and diastolic blood pressure (DBP) were recorded every minute until the baby's extraction. After the delivery of the baby, APGAR scores at 1 minute and 5 minutes were noted. Umbilical artery blood was sent for analysis of the pH. The total volumes of study solutions given up to the time of delivery of the baby were recorded.


Results: Phenylephrine infusion decreased the incidence and frequency of hypotension compared with control and the phenylephrine dose was much higher in the infusion group than in the control group (p=0.0001). None of the patients had any incidence of nausea or vomiting. There was no significant difference in umbilical artery blood pH and no reduction in the APGAR scores. HR was significantly slower in the infusion group compared with the control group.


Conclusion: A prophylactic infusion of phenylephrine100 μg/min in patients receiving spinal anesthesia for elective cesarean delivery decreased the incidence of hypotension and without any deleterious neonatal outcome.

A Comparative Study of Clonidine and Dexmedetomidine with 0.5% Levobupivacaine in ultrasound-guided Axillary Brachial Plexus Block for Upper Limb Surgeries

Valluri Anil Kumar, Busetty Prithvi Raj, K Krishna Chaitanya, S Md Shamiq Muthaib

Journal of Cellular & Molecular Anesthesia, Vol. 6 No. 3 (2021), 7 September 2021 , Page 249-258
https://doi.org/10.22037/jcma.v6i3.34421

Background: Clonidine and Dexmedetomidine as an additive to Levobupivacaine in ultrasound-guided axillary brachial plexus block are not studied well. Hence, this study was designed to compare the efficacy of the Clonidine and Dexmedetomidine, used as an adjunct to Levobupivacaine in ultrasound-guided axillary brachial plexus block in upper limb elective surgery.
Materials and Methods: Eighty patients of the American Society of Anesthesiologists Grade I/II undergoing upper limb elective surgery were divided into two equal age/gender-matched groups. Group-LD received ultrasound-guided axillary brachial plexus block using injection 0.5% Levobupivacaine 20 ml+dexmedetomidine (1 μg/Kg), and group LC received ultrasound-guided axillary brachial plexus block using injection 0.5% Levobupivacaine 20 ml + Clonidine (1.5 μg/Kg). The onset and duration of sensory and motor block, hemodynamics, and side effects were recorded.
Results: The time for onset of sensory block and motor block in group LD was significantly faster than group LC (4.53±1.07 and 7.88±1.29 min vs. 5.90±0.81 and 8.85±1.81min, p<0.0001). The duration of motor block in group LD was significantly longer than group LC (Sensory and motor block: 662.50 ± 50.95 and 625.50 ± 51.95min, vs 567.75 ± 62.33 and 560.62 ± 67.19 min. p< 0.0001). The sedation score was highly significant at 30 min (p<0.0001) and was significant at 60 min (p<0.05), postoperatively.


Conclusion: The addition of Dexmedetomidine (1μg/Kg) as an adjuvant to Levobupivacaine (0.5%) for upper limb surgeries by axillary brachial plexus block had provided the rapid onset of sensory block and motor block and enhanced duration of sensory and motor block with arousable sedation without any adverse effects compared to clonidine (1.5μg/Kg).

Long-term Dexmedetomidine versus Midazolam in Patients Under Mechanical Ventilation: A Double-blinded Randomized Clinical Trial

Nader D. Nader, Kamran Shadvar, Nina Pilehvar, Sarvin Sanaie, Afshin Iranpour, Hadi Hamishehkar, Saeid Safiri, Ata Mahmoodpoor

Journal of Cellular & Molecular Anesthesia, Vol. 6 No. 3 (2021), 7 September 2021 , Page 259-268
https://doi.org/10.22037/jcma.v6i3.33104

Background: Dexmedetomidine has been approved for short-term analgesia and sedation of patients in the intensive care unit (ICU). Longer duration of sedation with Dexmedetomidine is off-label and its safety has not yet been tested. This study aims to examine the safety profile for long-term use of Dexmedetomidine and compare it to midazolam (MID) based sedation in the ICU.


Methods: One hundred and one patients on mechanical ventilation were randomized to receive either Dexmedetomidine 0.2-1.0 µg/kg/h or MID 20- 40 µg/kg/h in a double-blinded fashion to reach the target of -2 to 1 on the Richmond Agitation-Sedation Scale (RASS). Duration of mechanical ventilation was the primary endpoint; secondary endpoints included the occurrences of composite cardiac adverse event (CCAE), bradycardia, hypotension, significant dysrhythmias, heart failure myocardial infarction or death within 28 days, ICU length of stay, need for additive analgesic, time spent at target sedation, and delirium.


Results: The duration of mechanical ventilation and ICU stay were almost 2 days shorter in the DEXMEDETOMIDINE group (P= 0.002 and 0.001, respectively), but regarding CCAE, sinus bradycardia occurred more frequently (P= 0.399 ) and mortality was similar in both groups (P=0.378).


Conclusion: Our results confirmed the results of previous trials showing that long-term Dexmedetomidine was comparable to benzodiazepines for the frequency of major complications in critically ill patients. Although Dexmedetomidine is capable to reduce the duration of mechanical ventilation and ICU stay, physicians should weigh these benefits against the occurrence of significant bradycardia and hypotension.

Review


Homocysteine Levels and Ischemic Stroke: A Systematic Review

Pourya Pezeshgi, Alireza Zali, Saeid Safari, Meisam Akhlaghdoust, Amirreza Sharghi Marandi

Journal of Cellular & Molecular Anesthesia, Vol. 6 No. 3 (2021), 7 September 2021 , Page 269-275
https://doi.org/10.22037/jcma.v6i3.33877

The most common type of stroke is ischemic stroke. Given that death due to stroke is one of the three leading causes of death globally, it is essential to identify its risk factors, especially modifiable risk factors. Nowadays, High homocysteine is recognized as one of the risk factors for stroke. Our aim in this study was to investigate the association between homocysteine levels and ischemic stroke. We searched the keywords in Scopus, Web of Science, Google Scholar, PubMed, and Science Direct with a 15-year time limit. At first, 3884 studies were found, and after further investigation and based on inclusion and exclusion criteria, only nine studies were selected. Of the nine selected studies was a clinical trial and eight observational studies, and in total, there were 16227 participants in these studies. The prevalence of ischemic stroke was higher in people with high homocysteine levels than in people with normal homocysteine levels (14.1% vs. 9.8%). The prevalence was generally higher in men, but among people with high homocysteine levels, the prevalence of ischemic stroke was slightly higher in women than in men (12% vs. 11%), and also, in women and men, the prevalence of ischemic stroke was higher in people with high homocysteine levels than in people with normal levels. Based on selected studies, increased homocysteine levels in men and women increases the risk of ischemic stroke. Because homocysteine levels are a modifiable risk factor, diet and prevention of vitamin B12 decrease can help prevent an increased risk of ischemic stroke.

Letter to the Editor


Acute lower Limb Ischemia Caused by Fungal Infective Atrial Thrombus: A Case Report

Nasser Malekpour, Maryam Abbasi, Faezeh Shams, Atoosa Gharib, Sara Besharat

Journal of Cellular & Molecular Anesthesia, Vol. 6 No. 3 (2021), 7 September 2021 , Page 276-278
https://doi.org/10.22037/jcma.v6i3.33279

Introduction:


Septic thromboemboli have two consequences, ischemic and infection. In this paper we discuss a case with acute lower limb ischemia caused by fungal infective atrial thrombus. The patient underwent an anticoagulant therapy.


Case presentation:                


A 43-year-old female patient who suffered from valvular heart disease (history of mitral and tricuspid valve replacement) was referred to the vascular surgery department of Modarres hospital with acute left limb ischemia. She underwent a successful emergency surgical thrombectomy. The pathological report of thrombus demonstrated fungal infection.


 Conclusion:


After surgical thrombectomy to control the acute lower limb ischemia, antimicrobial treatment of septic emboli is necessary.

 


How to use non-Invasive ventilation in acute respiratory failure due to  Covid 19? Early, short-time, low drive pressure.


Parviz Amri 1


Clinical Research Development Unit of Ayatollah  Rouhani  Hospital,  Babol University of Medical Sciences, Babol, Iran


 


Special recommendations for patients with Covid 19 who use non-invasive ventilation:
It is recommended that patients who are candidates for non-invasive ventilation be admitted to the ICU or to a ward reserved only for non-invasive ventilated patients with Covid 19 disease.
Due to the risk of transmission of the disease to the patient's staff and nurse, all instructions related to hospital infection control should be followed especially wearing masks and hats and glasses and clothing. Use ventilators that have both inhaled and exhaled arms and nonvented masks to reduce the risk of infection with low leakage. (1, 2).  
Non-invasive ventilation should be started in the early stages of Covid 19 disease. This means that non-invasive ventilation is helpful when the lungs have not yet reached a low compliance level, and the oxygen saturation is not too low, especially in obese patients when atelectasis occurs, the lungs will not open with non-invasive ventilation. And if recruiting maneuvers are performed, it has many complications such as cardiac arrest, subcutaneous emphysema, pneumomediastinum and pneumothorax.
In mild cases, even if the patient has normal oxygen with mask or reservoir bag, to prevent the disease from progressing to lung atelectasis, the patient should attach the oronasal mask for 5 minutes every hour. During non-invasive ventilation, if the oxygen saturation is acceptable, it should be oxygen-free. In the patient's recovery, sometimes non-invasive ventilation is left every one to two hours for 1 to 2 minutes to keep the lungs open and prevent atelectasis.
If the disease is good without oxygen, be sure to check the oxygen saturation after walking or after activity (walking for 6 minutes). It comes down most of the time. So give oxygen after activity. The main reason for the decrease in oxygen saturation in this situation is the involvement of Interstitial tissues of the lungs.
NIV setting: To adjust the ventilator (aggressive and non-invasive), the drive pressure should be between 12 and 14 cm of water. The mod of PSV + PEEP is more easily tolerated in different experiments. In this method, PSV = 12-14 cm/H2O of water and PEEP = 6-8 cm/H2O are usually required. Higher pressure is not necessary and can cause discomfort to the patient and even damage to the lungs (3).


When the lungs open slowly for the first time and the patient has a frequent cough, in these cases, first set the IPAP and EPAP to the minimum pressure and then gradually increase it. If the cough continues, you can use morphine or dexmedetomidine in the ICU. Increase EPAP in cases of hypoxia and Bipap with Back up rate in hypercarbia(3).
If you have a decrease in oxygen saturation during non-invasive ventilation, one of the reasons could be the simultaneous heart injury that we have in Covid 19(4). I recommend giving furosemide 10 mg per 6 hour. Patients often have diastolic dysfunction and therefore patients are sensitive to both hypovolemia and hyperolomia. If the patient develops severe respiratory distress, hypoxia, and hypercarbia during non-invasive ventilation, the patient should be intubated. Excessive delay in intubation increases mortality.
If intubated, use pressure control modes (with a pressure of less than 20 if the volumes are slightly more than 300 ml).


 Conflicts of Interest


I declare that there are no conflicts of interest