Anesthesiology ,Critical Care, Pain management

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Inflammation Mastery / Functional Inflammology, Volume 1 (2014, updated and expanded in 2016). This work is the culmination of several thousand research publications combined with Dr Vasquez's many years of clinical experience and teaching graduate-level students and doctorate-level clinicians worldwide. With radiographs, photos, acronyms, illustrations, flowcharts, and detailed-yet-simplifying explanations, Dr Vasquez makes it easier than ever for clinicians to grasp important concepts in integrative care and functional medicine and then to translate the basic science research and molecular biology into treatment plans that can be explained and used in " the real world " of clinical practice with patients. The associated video tutorials and recorded live conference presentations further help students and clinicians " get it " via Dr Vasquez's effective teaching style which embraces complexity while always emphasizing clinical applicability and psychosocial context. The Inflammation Mastery & Functional Inflammation Mastery & Functional Inflammation Mastery & Functional Inflammation Mastery & Functional Inflammology series of books and videos Inflammology series of books and videos Inflammology series of books and videos Inflammology series of books and videos translates important concepts and nutritional/biomedical science into easy and practical clinical applications for the prevention and treatment of disorders of sustained inflammation, which Dr Vasquez describes as " patterns of metabolic disturbance and inflammatory dysfunction " existing in three sequential and overlapping categories: 1) metabolic inflammation, 2) allergic inflammation, 3) autoimmune inflammation. This book includes access to video presentations which introduce the origin and components of the Functional Inflammology Protocol and FINDSEX ® acronym. Post-publication updates to this information and important social and clinical contextualization are made available in videos and online repositories (access provided in the book), and the e-newsletter available from ICHNFM.ORG. This textbook also provides access, via reprints or hyperlinks, to Dr Vasquez's published articles—an example of which is his recent paradigm-shifting editorial published in the journal Alternative Therapies in Health and Medicine (2014 January). The updated section on pain management allows students and clinicians to understand and apply manual, pharmacologic, nutritional and botanical medicine treatments for musculoskeletal pain, thereby providing better relief for patients and avoiding the hazards of NSAIDs, coxibs, steroids, opioids, immunosuppressants and biologics.

Nyeri adalah kekhawatiran terbesar pasien di unit perawatan intensif (ICU). Sebagian besar pasien sakit kritis mengalami nyeri sedang sampai hebat. Penatalaksanaan nyeri telah menjadi prioritas nasional dalam beberapa tahun terakhir, namun nyeri terus disalah artikan, dikaji dengan buruk, dan tidak ditangani dengan adekuat di ICU dan banyak tatanan perawatan kesehatan lainnya. Nyeri yang tidak terkontrol memicu respon stres fisik dan emosional, menghambat penyembuhan, meningkatkan resiko komplikasi lainnya dan meningkatkan masa rawat inap di ICU (Gonce P, Fontaine D, Hudak C, Gallo B, 2012). Banyak pasien sakit kritis di unit perawatan intensif (ICU) menderita nyeri, terutama yang menggunakan ventilasi mekanik. Dari 35% menjadi 55% perawat telah dilaporkan meremehkan nyeri pasien, dan sebuah studi praktek saat mengungkapkan pada saat diamati penilaian nyeri selama prosedural pada pasien ventilasi mekanik masih di bawah 40%. Para peneliti telah mengakui bahwa rasa sakit dan nyeri yang tidak memadai adalah penyebab utama kesulitan fisiologis dan stres emosional. Oleh karena itu, tampaknya penting untuk mencapai manajemen yang efektif dari analgesik, namun sebelumnya harus mengukur rasa nyeri dengan cara yang valid dan reliabel (Ahlers S dkk, 2010). Penilaian skala nyeri dapat dibagi atas pasien yang memiliki kemampuan verbal dan dapat melaporkan sendiri rasa sakitnya (self reported) dan pasien dengan ketidakmampuan verbal baik karena terganggu kognitifnya, dalam keadaan tersedasi, ataupun berada dalam mesin ventilator. Salah satu alat yang paling umum digunakan di ICU adalah Critical-Care Pain Observation Tool (CPOT), yang telah terbukti dapat diandalkan dan valid dalam berbagai populasi pasien sakit kritis (Gelinas C dkk, 2006). Penilaian nyeri yang tepat merupakan bagian penting dari perawatan berkualitas bagi pasien sakit kritis, dan penggunaan ukuran nyeri yang valid dapat membantu dalam evaluasi teknik manajemen nyeri multidisiplin untuk pasien sakit kritis nonverbal.

In December of 2014, an anonymous working group under the United States’ Centers for Disease Control and Prevention (CDC) issued a draft of the first-ever federal recommendations regarding male circumcision. In accordance with the American Academy of Pediatrics’ circumcision policy from 2012 – but in contrast to the more recent 2015 policy from the Canadian Paediatric Society as well as prior policies (still in force) from medical associations in Europe and Australasia – the CDC suggested that the benefits of the surgery outweigh the risks. In this article, we provide a brief scientific and conceptual analysis of the CDC’s assessment of benefit versus risk, and argue that it deserves a closer look. Although we set aside the burgeoning bioethical debate surrounding the moral permissibility of performing non-therapeutic circumcisions on healthy minors, we argue that, from a scientific and medical perspective, current evidence suggests that such circumcision is not an appropriate public health measure for developed countries such as the United States.

Dilaporkan penatalaksanaan anestesi pada operasi sirkumsisi pada seorang anak laki-laki usia 14 tahun, berat badan 46 kg, status fisik ASA III, karena memiliki riwayat TOF dengan diagnosis Phimosis Grade III dengan general anestesia menggunakan teknik sungkup muka (face mask).
Penderita di premedikasi dengan midazolam 2 mg dan ketamin 50 mg, preemtive analgetic Fentanyl 50 mcgr, induksi dengan sevoflurane-O2. Pemeliharaan anestesi dengan O2, N2O, dan sevoflurane. Selama operasi pernafasan di kontrol secara spontan assist. Operasi berlangsung sekitar 1  jam, dengan perdarahan 75 cc.
Selama operasi tidak didapatkan penyulit anestesi maupun pembedahan. Pasca operasi pasien di observasi di ruang pulih (recovery room), status hemodinamik selama observasi di ruang pulih stabil. Pemberian analgetik dilanjutkan menggunakan Metamizole 500 mg per 8 jam. Pasien diobservasi selama 1 jam kemudian dipindahkan ke bangsal.

Ketamine has been rarely described for use in critically ill patients. We describe our institutional experience using continuous infusion ketamine for sedation. This was a retrospective chart review of patients admitted to the medical intensive care units (MICUs). An informatics query of patients who received continuous infusion ketamine between 1/1/2010 and 7/1/2012 was conducted. Mechanically ventilated patients in the MICU who received continuous infusion ketamine were included. Twelve patients met criteria. Mean age was 41; 60% were Caucasian and 60% were female. Six patients were admitted for pneumonia, three for asthma exacerbation. Median duration of ketamine therapy was 1.57 days. Median minimum and maximum rates were 0.24mg/kg/hr and 0.83mg/kg/hr. The maximum documented dose used was 2.8mg/kg/hr. The ketamine infusion was discontinued secondary to tachycardia or hypertension in two patients. No patient who received concomitant benzodiazepines experienced hemodynamic changes prompting ketamine cessation. Median maximum SBP, DBP, and HR while on ketamine were 154, 96 and 121, respectively. No further adverse events were identified. Five of the patients had decreases in concomitant sedative and analgesic doses while five had increases. Continuous infusion ketamine can safely be used for adjunctive sedation/analgesia in mechanically ventilated MICU patients. Larger trials are needed to further define optimal dosing and confirm safety.

Background
Diurnal variations in pain have been observed in experimental protocols, post-surgery states and pathological conditions. Chronotype is considered to have the most profound effect on diurnal variations, and in addition, previous studies suggest that evening types may be more vulnerable to pain than morning types. This study aimed to examine whether or not morning and evening chronotypes differ in terms of their daily levels and diurnal fluctuations of pain sensitivity.

Methods
A total of 16 morning-healthy and 15 evening-healthy men were selected using the Morningness-Eveningness Questionnaire and underwent nine measurements during 1 day (between 08:15 and 20:15 h), each consisting of five heat stimuli situated at the ventral side of the wrist.

Results
A marked difference between chronotypes was found, with morning types showing less sensitivity to pain than evening types all day long [M = 50.1; standard error (SE) = 1 and M = 47.2; SE = 1, respectively; pain thresholds in centigrade]. Diurnal variations in pain were not statistically significant.

Conclusions
The results showed that chronotype could be an important factor determining sensitivity to pain, regardless of time of day.

Abstract Background: It is well known by now that during open heart surgery many detrimental factors are involved in lung injury. The influence mainly of cardiopulmonary bypass (CPB), anesthesia, hypothermia, operation itself, as well as medication and transfusion, can cause a diffuse injury in the lungs, which most often leads to a postoperative pulmonary edema and abnormal gas exchange. Methods: We performed an unrestricted search of Pubmed Medline and EMBASE from 1966 through 2008. Clinical, experimental, basic science, and review papers were included. Results: The hypothesis that a systemic inflammatory reaction takes place after the use of CPB, could explain most of these effects influences in the lung. On the other hand, the release of various pro-inflammatory cytokines like TNF-á, IL-1, IL-2, IL-6, IL-8, and endotoxin during CPB can lead to the entrapment of neutrophils in the pulmonary capillaries. Consequently, the following chain of reactions is likely to occur: an endothelial cell swelling, plasma and protein extravasation into the interstitial tissue, release of proteolytic enzymes, congestion of the alveoli with plasma, erythrocytes and inflammatory debris. Conclusion: In this review we highlight the possible pathophysiological mechanisms implicated in the observed postoperative lung dysfunction.(J Card Surg 2010;25:47-55)

Les blocs des nerfs ulnaire, médian et radial sont des techniques de choix dans l’abord de la main traumatisée en urgence: fracture, luxation, plaie, douleur par exemple. L’anatomie fonctionnelle doit être connue et comprise. La réalisation de ces blocs permet dans la majorité des cas le traitement en urgence d’une main traumatisée, sans avoir recours nécessairement à la neurostimulation ou encore à l’échographie. Le principe est de déposer à proximité du nerf une quantité de xylocaïne suffisante permettant l’anesthésie de celui-ci par diffusion et en sécurité. En France et depuis 2002, la Société Française d’Anesthésie et de Réanimation (SFAR), le Service d’Aide Médicale Urgente (SAMU) ainsi que la Société Francophone de Médecine d’Urgence (SFMU) autorisent le médecin urgentiste à pratiquer les anesthésies locorégionales de la main : Pratique des anesthésies locales et locorégionales par des médecins non spécialisées en anesthésie-réanimation. Les recommandations actualisées de 2010 par ces mêmes sociétés savantes propose de diffuser plus largement les techniques d’ALR en médecine d’urgence. Le but de ce travail est de faire le point sur les blocs au poignet.

pages 37-40
EVIDENCE-BASED SCIENCE EXPLAINING
HOW AND WHY IN-FLIGHT PHYSIOLOGICAL
STRESSORS AFFECT THE HUMAN SYSTEM HAS
REMAINED A MYSTERY

Preface:
The US Air Force (USAF) Aeromedical Evacuation (AE) System is a
significant part of the nation’s primary mode of patient movement
within the theatre of operations (intra-theatre) or between two theatres
(inter-theatre) to medical treatment facilities (MTF) where essential and/
or definitive care can be administered. Through AE crews and Critical
Care Air Transport Teams (CCATT), the AE force provides mission critical en route patient care, scalable En Route Patient Staging Systems
(ERPSS), and transport of contaminated and contagious patients using
the Transport Isolation System. Air Force AE clinical protocols are guided by Air Mobility Command, the lead command responsible for clinical and operational policy, organising, training and equipping AE forces and CCATT. The Air Force AE department charged with improving En Route Care (EC) for the Joint Force is the 711th Human Performance
Wing, Division of EC, USAF School of Aerospace Medicine (USAFSAM)
Aeromedical Research Department at Wright-Patterson Air Force Base
(AFB) in Dayton, Ohio.

Sources:
Fouts, Brittany; Butler, William; Connor, Susan; Smith, Danny;
Maupin, Genny; Greenwell, Brandon; Serres, Jennifer; Dukes, Susan.
Final Report Aug 2017, March 2014 to August 2017; Assessment of
Aeromedical Evacuation Transport Patient Outcomes with and without
Cabin Altitude Restriction, [Online] REPORT DOCUMENTATION
PAGE.1-4; 8; 22-23. Interview 15 Feb 2018; Armitage, Nicole H.;
Averett-Brauer, Tamara; Burch, David. Air Force Research Laboratory,
711th Human Performance Wing, U.S. Air Force School of Aerospace
Medicine, Aeromedical Research Department, Wright-Patterson AFB,
OH. Available from: http://www.dtic.mil/dtic/tr/fulltext/u2/1039508.pdf
Access: 28 Jan 2018.

Background: Humans maintain constant body temperature within a wide range of changes in external environment. Core body temperature is maintained within narrow range; Enzyme systems in the body have narrow temperature ranges in which they function optimally for caring out different activities in the body as metabolism, conduction of nervous function and skeletal muscle contraction. Perioperative hypothermia is one of the major problems during surgery that can affect operated patients. It has been shown by different researchers that Perioperative hypothermia will result in to various adverse events such as myocardial ischemia, coagulopathy, delayed awakening and wound infections.

Objective: The objective of this study was to determine incidence of perioperative hypothermia and determinant factors among patients operated in Gondar university hospital from March to April, 2015.

Methods: A prospective observational study was conducted to determine incidence of perioperative hypothermia and associated risk factors among patients that underwent surgery in Gondar university hospital. All consecutive patients from both elective and emergency surgery were included in this study.

Result: A total of 312 patients were participated in this study. The incidence of Pre, Intra and post-operative hypothermia were 23.4%, 49.7% and 50.6% respectively. Use of general anesthesia (AOR=2.3), co-morbidity (AOR=2.1), low body temperature before the start of anesthesia (AOR=4.7) and elective procedures (AOR=2.1) were found to be independent predictors of intra-operative hypothermia.

Conclusion and Recommendation: The incidence of perioperative hypothermia is high in Gondar University Hospital. Passive and active warming techniques should be implemented in the hospital.

Autonomic nervous system’s role as a “life-sustaining” system is
well known. However, the anatomical and functional complexity of
ANS, makes difficult its monitoring in perioperative setting. Various
methods have been proposed for measuring its activity. The current
review focuses on selected tools- electrodermal activity, pupilometry,
heart rate variability, surgical skin index and salivary-a amylase- and
their application in the field of anesthesia, intensive care and emergency
medicine.

Des étudiatns en médecine analysent une situation vécue, éthiquement problématique.
"Nous avons pu, à travers l’analyse, prendre conscience de la complexité de la relation patient-soignant, dans ses nombreuses dimensions : éthique, psychologique, médicale, etc. Sans qu’il soit possible d’être exhaustif, nous voulons retenir pour  notre  pratique  future  de  tenter  de  toujours  donner  des informations complètes et claires, et s’assurer que celles-ci soient bien comprises, en prenant pour cela le temps nécessaire. Chaque patient peut ainsi être respecté dans sa singularité et dans ses besoins. Il importe également de tenter de reconnaître et maîtriser
les stéréotypes ainsi que les émotions négatives envers le patient afin que ceux-ci n’altèrent pas les soins à prodiguer. Pour ce faire, il convient d’être attentif aux raisons personnelles à l’origine de ces émotions, et de ne pas hésiter à se tourner vers le reste de l’équipe soignante en cas de besoin. De plus, la relation avec le patient nécessite sans cesse de s’adapter, et de reconnaître ses limites.

. Trend towards noninvasive, easy to use monitor was always a challenge. Numerous indices have been used to monitor the progress of patients on positive pressure ventilation. The present study compares different indices in a mixed larger intensive care unit (ICU) population. In a prospective observational study Arterial blood gases (ABG) analyses were obtained from 225 patients under mechanical ventilation in a polyvalent adult ICU. Values of ideal body weight (IBW), Body mass index (BMI), PAO 2, PaO 2 /FiO 2 ratio (PFr), SpO 2 /FiO 2 ratio (SFr), SpO 2 /PEEP ratio (SPr), SpO 2 /PaCO 2 ratio (SPCr), Oxy-genation index(OI) and Ventillatory ratio (VR) were calculated; and further correlation analysis was conducted. In Pressure control ventilation mode a relative strong relation between PFr and SFr and OI was found; yet further regression analysis implies that no direct replacement of PFr with SFr can be made without limitations, in clinical setting. In Volume control ventilation mode moderate relation was found between SFr and PFr. In the present study a moderate relation was found between SFr and

Le bloc ilio-fascial est une technique d’analgésie de référence ayant montrée son intérêt et son innocuité en urgence préhospitalière. Les indications du bloc ilio-fascial sont les fractures de la diaphyse fémorale mais aussi les lésions touchant les structures osseuses de la hanche. Les contre-indications sont nombreuses en traumatologie préhospitalière et doivent être scrupuleusement respectées. Le geste technique est réalisé après information du patient. Cette anesthésie locorégionale nécessite peu de matériel et consiste en l'injection d’un anesthésique local dans l'espace ilio-fascial où transitent les nerfs fémoral, cutané latéral de la cuisse et obturateur. Le mécanisme de cette analgésie est double : direct par bloc sensitif et indirect par relâchement musculaire. Comme pour toute anesthésie locorégionale les conditions de sécurité élémentaires sont requises avec à disposition immédiate les moyens nécessaires pour palier effets indésirables et complications immédiates (malaise, toxicité systémique, allergie). Nous présentons la technique du bloc ilio-fascial en urgence préhospitalière.

Objective. - The regional anesthesia (LRA) has great benefits in the management of emergency patients. A regional investigation was conducted to estimate the practice of LRA by emergency physicians.
Patients and method. - This multicenter and descriptive survey was conducted from January 1 to April 30, 2012 in the 46 emergency departments of a French county. One hundred forty-four emergency physicians completed a questionnaire about their training and daily LRA's practice.
Results. - The rate of participation reached 45 % and 71 % of doctors practiced LRA. Indications were: pain relief (71 %), exploration (60 %) or reduction of fracture (52 %). There was a statistical association between the experiment of the doctor and the practice of the LRA (p = 0.01). 72 % of physicians judged the usefulness of LRA. However, the practitioners underlined a lack of training (46 %), rare indications (30 %), a fear (6 %) and a lack of interest (3 %). The nerve block realized were: the femoral block (60 %), the hand block (21%), the face block (13 %) and the footblock (2 %). Physicians were 65 % didn’t' know the recommendations and 69 % were unaware of lipid emulsions used for treatment of local anesthetic systemic toxicity. 97 % of practitioners are interested in a regional training.
Conclusion. - Ten years after the recommendations, it turns out that there is a lack of knowledge and a real need for training of emergency physicians in the studied county.
Introduction. - Les techniques d’anesthésie loco-régionales (ALR) sont des grands bénéfices dans la prise en charge des patients en urgence. But du travail : évaluer la pratique régionale de ALR par les médecins exerçant dans les services d’urgences-Samu-Smur.
Patients et méthode. - Enquête multicentrique, observationnelle, descriptive menée du 1er janvier au 30 avril 2012 auprès des 46 structures d’une région de France. Cent quarante-quatre médecins urgentistes ont complété un questionnaire concernant leur formation et leur pratique quotidienne en ALR.
Résultats. - Le taux de participation s’élevait à 45 % et 71 % des répondeurs (n = 102) pratiquaient l’ALR. Les indications retenues étaient : l’analgésie (71 %), l’exploration de plaies (60 %), la réduction de fracture ou luxation (52 %). La pratique de l’ALR était liée à l’expérience du médecin (p = 0,01).. Les médecins étaient 72% à juger l’ALR utile et soulignaient un manque de formation (46%), des indications rares (30%), une crainte (6 %) et un manque d’intérêt (3 %). Les ALR réalisées étaient : le bloc fémoral (60 %), de la main au poignet (21 %), de la face (13 %) et du pied (2 %). Si 65 % ne connaissaient pas les recommandations, 69 % ignoraient l’existence des émulsions lipidiques pour traiter les intoxications aux anesthésiques locaux. 97 % seraient intéressés par une formation régionale.
Conclusion. - Dix ans après les recommandations, au sein de la région française étudiée, il existait une méconnaissance de ces techniques, alors que les urgentistes exprimaient un souhait réel de formation.

Pectoralis minor blocks are still relatively new and require further evaluation, but may have a place in peri-operative pain management for the appropriate cases. Still considered as less invasive procedure in comparison to thoracic epidurals and para-vertebral blocks. Complications of thoracic epidural and para-vertebral blocks like spinal cord injury and pneumothorax makes many anaesthetists interested in practising pectoralis minor block guided by ultrasound. Blanco first introduced the pectoralis minor block in 2011, he did study on 50 patients within 2 years. Results were very promising, all patients did not need any opiates but only paracetamol and non-steroidal anti-inflammatory (NSAID) drugs got used.

Introduction: Postponed recuperation from anesthesia can lead to different complications such as apnoea, aspiration of gastric content whit consequent development of aspiration pneumonia, laryngospasm, bradycardia, and hypoxia. Aim of this research was to determine infl uence of propofol, sevoflurane and isoflurane anesthesia on post anesthesia recovery rate.
Methods: This was a prospective study; it included 90 patients hospitalized in period form October 2011 to may 2012 year, all patients included in the study underwent lumbar microdiscectomy surgery. Patients were randomly allocated to one of three groups: group 1: propofol maintained anesthesia, group 2: sevoflurane and group 3: isofl urane maintained anesthesia. Assessments of recovery rate were done 1, 5 and 10 minutes post extubation using White fast tracking scoring system.
Results: Significant difference was observed only 1 minute after extubation (p=0,025) finding recovery rate to be superior in propofol group. Propofol group compared to inhaled anesthesia with sevoflurane group, shows significantly faster recovery from anesthesia only one minute after extubation (p=0,046). In comparison of propofol group and isofl urane anesthesia group, statistical significance was noticed one minute following extubation (p=0,008). Comparison of propofol group and inhaled anesthesia groups recovery rates were not significantly different at all times measured. When we were comparing sevoflurane and isoflurane anesthesia, recovery rates shoved no signifi cant statistical difference.
Conclusions: Recovery rate evaluated by using White fast tracking scoring system was superior and with fewer complications in propofol maintained in comparison to sevoflurane and isoflurane maintained anesthesia only one minute post extubation, while after fifth and tenth minute difference was lost.

OBJECTIVE:
To determine whether anaesthetised patients undergoing surgery could benefit from intraoperative protective ventilation strategies.
METHODS:
MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) were searched up to February 2014. Eligible studies evaluated protective ventilation versus conventional ventilation in anaesthetised patients without lung injury at the onset of mechanical ventilation. The primary outcome was the incidence of postoperative pulmonary complications. Included studies must report at least one of the following end points: the incidence of atelectasis or acute lung injury or pulmonary infections.
RESULTS:
Four studies (594 patients) were included. Meta-analysis using a random effects model showed a significant decrease in the incidence of atelectasis (OR=0.36; 95% CI 0.22 to 0.60; p<0.0001; I(2)=0%) and pulmonary infections (OR=0.30; 95% CI 0.14 to 0.68; p=0.004; I(2)=20%) in patients receiving protective ventilation. Ventilation with protective strategies did not reduce the incidence of acute lung injury (OR=0.40; 95% CI 0.07 to 2.15; p=0.28; I(2)=12%), all-cause mortality (OR=0.77; 95% CI 0.33 to 1.79; p=0.54; I(2)=0%), length of hospital stay (weighted mean difference (WMD)=-0.52 day, 95% CI -4.53 to 3.48 day; p=0.80; I(2)=63%) or length of intensive care unit stay (WMD=-0.55 day, 95% CI -2.19 to 1.09 day; p=0.51; I(2)=39%).
CONCLUSIONS:
Intraoperative use of protective ventilation strategies has the potential to reduce the incidence of postoperative pulmonary complications in patients undergoing general anaesthesia. Prospective, well-designed clinical trials are warranted to confirm the beneficial effects of protective ventilation strategies in surgical patients.

AIM: To compare and evaluate the clinical efficacy of the
combination of propofol and ketamine (ketofol) versus propofol
alone when each regimen is used as sedative agents for
colonoscopy.
METHODS: 100 patients who underwent colonoscopy in two
years, were randomly assigned to PN and PK groups. 50 patients in group PN received propofol and normal saline and 50 patients in group PK received propofol and ketamine for deep sedation. All patients were premedicated with 0.02-0.03 mg/kg of midazolam. Immediately after the procedure, the endoscopist was asked to rate tolerability for the patient, discomfort during insertion and satisfaction. As well, a blinded member of the research team evaluated the patient satisfaction, procedural pain, recovery time and recovery score. The primary outcome was the successfully completed colonoscopic procedure. The secondary outcome variables were patient tolerance, discomfort during insertion, patient and endoscopist satisfaction, recovery time and recovery
score, hemodynamic parameters, as well as adverse events during and immediately after procedure.
RESULTS: All endoscopies were completely successfully. Mean
total dose of midazolam in group PK and PN was 0.027±0.005
mg/kg and 0.026±0.005 mg/kg, respectively (p=0.469). Mean
total dose of propofol in group PK and PN was 7.28±3.03 mg/kg/h and 8.02±2.99 mg/kg/h, respectively (p=0.451). Mean total dose of ketamine in group PK was 1.49±0.61 mg/kg/h. There were no significant differences in the patient and endoscopist satisfaction, procedural pain and recovery time, but the recovery score at 30 min post-procedure in group PK was significantly lower than group PN (p=0.025). Tolerability of the patient and comfort during insertion in group PN were statistically significantly lower than the patients in group PK. Overall and sedation-related adverse event rate in group PN were also significantly higher than in group PK. However, these adverse events were transient and easily treated with no sequelae.
CONCLUSION: Deep sedation in both regimens provided
effective and safe for colonoscopy. No serious adverse events were observed. However, the combination of propofol and ketamine (ketofol) used as sedative agents for deep sedation had significantly higher efficacy than the propofol alone.

Experiential evidence shows that pain is associated with common meanings. These include a meaning of threat or danger, which is experienced as immediately distressing or unpleasant; cognitive meanings, which are focused on the long-term consequences of having chronic pain; and existential meanings such as hopelessness, which are more about the person with chronic pain than the pain itself.

This interdisciplinary book - the second in the three-volume Meanings of Pain series edited by Dr Simon van Rysewyk - aims to better understand pain by describing experiences of pain and the meanings these experiences hold for the people living through them. The lived experiences of pain described here involve various types of chronic pain, including spinal pain, labour pain, rheumatic pain, diabetic peripheral neuropathic pain, fibromyalgia, complex regional pain syndrome, endometriosis-associated pain, and cancer-related pain. Two chapters provide narrative descriptions of pain, recounted and interpreted by people with pain.

Language is important to understanding the meaning of pain since it is the primary tool human beings use to manipulate meaning. As discussed in the book, linguistic meaning may hold clues to understanding some pain-related experiences, including the stigmatisation of people with pain, the dynamics of patient-clinician communication, and other issues, such as relationships between pain, public policy and the law, and attempts to develop a taxonomy of pain that is meaningful for patients. Clinical implications are described in each chapter.

This book is intended for people with pain, their family members or caregivers, clinicians, researchers, advocates, and policy makers.

“It is my opinion that this ... work will stand as the definitive reference work in this field. I believe it will enrich the professional and personal lives of health care providers, researchers and people who have persistent pain and their family members. The combination of framework chapters with chapters devoted to analysing the lived experience of pain conditions gives the requisite breadth and depth to the subject.” - Dr Marc A. Russo, MBBS DA(UK) FANZCA FFPMANZCA, Newcastle, Australia, from the Foreword

Background
This study was designed to evaluate the role of intraperitoneal S (+) ketamine in peripheral NMDA receptors blockade, and whether it reduces the
postoperative analgesic requirements after bariatric surgery in morbidly obese patients in comparison with intraperitoneal lidocaine.
Patients and Methods
The study included 45 patients, and a standardized general anesthetic technique including fentanyl, propofol, isoflurane, and vecuronium for muscle
relaxation were used. At the end of surgery, patients were divided into three groups ,15 patients each, S (+) Ketamine 0.5 mg /kg diluted in 50 ml saline
was injected intra peritoneally in (ketamine group), 50 ml of 1% lidocaine in saline was injected intra peritoneally in (lidocaine group), 50 ml of normal
saline was injected intra peritoneally in (saline group). Parameters were evaluated time of first request of analgesia in minutes ,postoperative shoulder
pain and arm pain for 24 hours(VAS score), and the amount of post operative mepridine (mg) consumed in 0-6.6-12,12-18,18-24, hours after extubation.
Results
Times of the first request of postoperative analgesia were 60(10), 50(5), 20(5) minutes, in Intra peritoneal S Ketamine group, Intra peritoneal lidocaine
group, and Intra peritoneal Saline group respectively. It was statistically longer in Ketamine group and Lidocaine group than Saline group, with statistically
longer duration in Ketamine group than Lidocaine group.
However the amount of mepridine was statistically higher in Lidocaine group and Saline group than in Ketamine group, at 6, 8,12,18,24 hours
postoperatively, it was statistically higher in Saline group than in Lidocaine group.
Both the incidence postoperative shoulder pain, and the visual analogue score were significantly higher in Lidocaine group and Saline group than in
Ketamine group, but it was statistically higher in Saline group than in Lidocaine group.
Conclusion
Peripheral (peritoneal) NMDA receptors blockade by S (+) Ketamine was involved in reduction of postoperative pain, and analgesic requirement
following bariatric surgery.

Wolff-Parkinson-White (WPW) syndrome is a cardiac disorder having abnormal electrical communication between atria and ventricles. It is an uncommon disorder may be asymptomatic or present with symptoms like palpitation. Intraoperatively these patients may present with serious cardiac emergencies like paroxysmal supraventricular tachyarrythmias (PSVT) and atrial fibrillation (AF). We report a case of 35 years old female posted for elective laparoscopic cholecystectomy under general anesthesia with the use of dexmedetomidine in the perioperative period. Perioperative management of these patients under general anesthesia is a real challenge for the anesthesiologists particularly under general anesthesia.

Assessment and optimization of hemodynamic parameters and oxygen delivery may improve outcome in critically ill patients. Optimum fluid management often needs to take hemodynamic parameter in to account. Comorbidity and critical illness during pregnancy contribute significantly to maternal and fetal morbidity and mortality. This article will focus on the role of hemodynamic monitoring in the field of practice of obstetrics, perioperative and critical care management of obstetric patients with current evidence and type of hemodynamic monitoring technique for such patients. PubMed advanced and Google Scholar search with index word "hemodynamic monitoring", "haemodynamic monitoring", "shock", "obstetric", "preeclampsia", "heart disease", "cardiac disease", "hemodynamic monitoring in obstetric", "hemodynamic monitoring in obstetrics", and "haemodynamic monitoring in obstetric" in different combinations to retrieve clinical trials, case series, and review articles for the current literature review.

OBJECTIVE:
The aim of this meta-analysis is to compare the potential effects of inhalation anesthetics with total intravenous anesthetics on alveolar cytokine expression and lung-related clinical outcomes in patients undergoing one-lung ventilation (OLV) for thoracic surgery.
METHODS:
We retrieved the PubMed, EMBASE, and the Cochrane Library respectively to identify randomized controlled trials comparing different anesthetics (volatile anesthetics vs. intravenous anesthetics) on the pulmonary inflammatory response to OLV. The primary outcomes were the levels of alveolar concentrations of inflammatory cytokines.
RESULTS:
Eight randomized controlled trials that included 365 patients were screened. Overall, there were significant differences in the concentration of alveolar inflammatory mediators between volatile group and intravenous group, in which volatile group had lower levels of TNF-α (SMD -1.51; 95 % CI -2.15 to -0.87; p < 0.001), IL-6 (SMD -0.70; 95 % CI -0.99 to -0.41; p < 0.001) and IL-8 (SMD -1.32; 95 % CI -2.20 to -0.45; p = 0.003). The overall number of pulmonary complications in the volatile group was smaller (RR 0.42; 95 % CI 0.23-0.77; p = 0.005) and patients in that group had significantly abridged hospitalization stay (WMD -3.59 days; 95 % CI -5.70 to -1.48 days; p = 0.001).
CONCLUSIONS:
Inhalation anesthetics might be preferable in patients undergoing OLV for thoracic surgery and their protective effects might work via attenuating inflammatory responses.

Monitoring of patients in the recovery room is considered the most serious part for safe
anesthesia. Anesthesiologists are some times so busy in completing the list of the
operations so they can not follow up thoroughly their discharged patient from the
theatre. This study determines the most common recovery room incidents in the last
three years at AlSadir Teaching Hospital in Basrah. Of the about 7000 patients operated
upon in this period, 669 patients (9.5%) had some event in the recovery room. The most
common incident was respiratory problems (26%), irritability (22%), thermal (19%),
cardiovascular (18%), nausea and vomiting (9%), low urine output (5%) and fall from
couch (1%). Most of these incidents were treated immediately at the recovery room. The
outcome was 5 deaths and 61 ICU admissions. Skilled anesthesia assistant present in
the recovery room is the keystone for taking care and reducing recovery room incidents.

The stress response to surgery includes a number of hormonal changes initiated by neuronal activation of the Hypothalamo-Pituitary-Adrenal (HPA) axis. Surgery is one of the most potent activators of ACTH and cortisol secretion, and increased plasma concentrations of both hormones can be measured few minutes after the start of surgery. A variable inhibition of ACTH-stimulated production of cortisol by anesthetic drugs has been demonstrated in clinical studies. Endocrine response to stress also includes a release of pituitary hormone prolactin which is poorly affected by anesthesia. These two hormones seem to mostly contribute to memory consolidation processes during anesthesia. This review summarizes the main aspects of interaction between stress response to surgery and cognition during general anesthesia.

Introduction: The aim of the study was to assess whether adults admitted to hospitals with both Intensive Care
Units (ICU) and Intermediate Care Units (IMCU) have lower in-hospital mortality than those admitted to ICUs
without an IMCU.
Methods: An observational multinational cohort study performed on patients admitted to participating ICUs during
a four-week period. IMCU was defined as any physically and administratively independent unit open 24 hours a
day, seven days a week providing a level of care lower than an ICU but higher than a ward. Characteristics of
hospitals, ICUs and patients admitted to study ICUs were recorded. The main outcome was all-cause in-hospital
mortality until hospital discharge (censored at 90 days).
Results: One hundred and sixty-seven ICUs from 17 European countries enrolled 5,834 patients. Overall, 1,113
(19.1%) patients died in the ICU and 1,397 died in hospital, with a total of 1,397 (23.9%) deaths. The illness severity
was higher for patients in ICUs with an IMCU (median Simplified Acute Physiology Score (SAPS) II: 37) than for
patients in ICUs without an IMCU (median SAPS II: 29, P <0.001). After adjustment for patient characteristics at
admission such as illness severity, and ICU and hospital characteristics, the odds ratio of mortality was 0.63 (95% CI
0.45 to 0.88, P = 0.007) in favour of the presence of IMCU. The protective effect of the IMCU was absent in patients
who were admitted for basic observation, for example, after surgery (odds ratio 1.15, 95% CI 0.65 to 2.03, P = 0.630)
but was strong in patients admitted to an ICU for other reasons (odds ratio 0.54, 95% CI 0.37 to 0.80, P = 0.002).
Conclusions: The presence of an IMCU in the hospital is associated with significantly reduced adjusted hospital
mortality for adults admitted to the ICU. This effect is relevant for the patients requiring full intensive treatment.

Abstract:
Background: This study was done to evaluate the efficacy of dexmedetomidine (DEX) in prevention of supraventricular tachyarrhythmias (SVTs) after non cardiac Thoracic Surgery. Methods: Sixty five patients were enrolled in our study scheduled for elective non cardiac thoracic surgery. The patients were randomly assigned into two groups: Control Group 33 patients who did not receive dexmedetomidine prophylaxis and dexmedetomidine Group enrolling 32 patients who will receive continuous infusion of dexmedetomidine 0.2 µg/Kg/h which was initiated with induction of anesthesia and continued for 24h. Patients were observed throughout the first three days in ICU for the incidence of supraventricular dysrhythmias. Results: There were no significant differences between dexmedetomidine and control groups in patient characteristics & surgical Data.  Eleven patients (36.7%) in group C developed (SVTs) of which eight had atrial fibrillation and three developed supraventricular tachycardia. In group D the incidence of SVTs was 10% (three patients) which was significantly less (p =0.031) when compared to matched control group as two patients in group D developed supraventricular tachycardia and one patient had AF. Patients in group C received significantly more PCA morphine and ketorelac than group D to achieve the same quality of analgesia. The mean time of ICU stay was significantly longer in group C (86 ±11hrs) versus (74±15 hrs) in group D (p =0.001), but there was no significant difference between the two groups in the incidence of adverse effects. Conclusions: We conclude that dexmedetomidine infusion can safely reduce the incidence of (SVTs) after non-cardiac thoracic surgery. 
Key words: dexmedetomidine, supraventricular tachydythrysmias, morphine, non- cardiac thoracic surgery.

Colonoscopy has become an essential modality for evaluation and treatment of lower gastrointestinal tract. This endoscopic procedure is complex and may be unsafe if special concerns are not considered. It is well accepted that children undergoing colonoscopy should receive sedation for the procedure. Nevertheless, considerable practice variation prevails. The goal of procedural sedation is the
safe and effective control of pain, anxiety and motion as well as to provide an appropriate degree of memory loss or decreased awareness. Regardless of regimen used, the safe administration of sedation to children requires an awareness of the particular needs of this population. Although colonoscopy is considered safe, the procedure has a potential for complications. Procedure and sedation-related complications can more easily occur in pediatric patients. Increased awareness of the complications associated with sedation during colonoscopy in children and involving the anesthesiologists in caring for these children may be optimal for safety. Proper patient preparation, endoscopic personnel and endoscopic unit are imperative
to successful sedation and procedure. Additionally, postprocedural monitoring is important to insure that children have fully recovered from sedation.

A 35 years old male patient presented with a chop wound in posterior neck between C2 and C3 interspace. After initial resuscitation this patient was put for surgery and general anesthesia was induced in left lateral position. Our experience suggested that a proper size ILMA (intubating laryngeal mask airway) is useful in managing difficult airway in left lateral position. Blind intubation attempt via ILMA is generally successful. We recommend routine use of ILMA as a backup plan in managing anticipated difficult intubation in nonconventional position.

Selective alpha2 adrenergic agonist dexmedetomidine is well known to inhibit catecholamine release. The present
study has been conducted to determine the effects of intravenously administered dexmedetomidine in attenuating
hemodynamic pressor responses to endotracheal intubation during elective cardiac surgery. 90 patients of American
Society of Anesthesiologists (ASA) physical status II and III, aged between 18 to 45 years of both the sex, were
randomized into 2 groups receiving dexmedetomidine 0.5 µg/kg and normal saline respectively, administered over
a period of 10 minutes before induction. Following intubation, significant (p<0.05) rise in heart rate and arterial
pressure was observed in control group while dexmedetomidine group showed better control of hemodynamic
pressor responses. In our double-blinded randomized controlled trial, administration of dexmedetomidine before
commencement of anesthetic induction effectively attenuated hemodynamic pressor response to laryngoscopy and
intubation. Further, larger trials are needed to confirm our findings.

The number of patients with elderly age and heart failure presenting for surgery continues to rise, due to increase in life span, and anaesthesiologists are called upon to provide quality, safe care in the operating room for the patients with low ejection fraction (EF). EF is an important measurement in determining how well the heart is pumping out blood and in diagnosing as well as tracking the heart failure (HF). Normal EF varies at 55% to 70%, while EF 40% to 55% may indicate damage perhaps from previous heart attack, but may not indicate HF. However, measurement under 40% may show evidence of HF or cardiomyopathy; and patient with EF< 35% may be at the risk of life threatening irregular heartbeats. Such patients are considered to be at high risk for anaesthesia as life threatening irregular heartbeats lead to sudden cardiac arrest and sudden death. Objectives in the anaesthetic management of these patients include maintaining forward flow, promoting adequate heart rate, avoidance of arrhythmias and maintaining stable condition in the postoperative period. Sometimes anaesthesia requires invasive cardiovascular monitoring, ultimately the skill with which anaesthesia technique is selected and delivered determines the outcome of the patient. Here we present a case of 80 year old man with chronic obstructive pulmonary disease (COPD), and EF 47% who successfully underwent right side inguinal hernia repair under regional anaesthesia technique with modified hernia block.

Anesthetic management in a pediatric patient posted for an impacted foreign body in bronchus is quite challenging, Hemorrhage, Tension pneumothorax
during rigid bronchoscopy for foreign body removal is a rare but life threatening complication. We hereby present a case of 3yrs old child who underwent
bronchoscopy for foreign body removal from bronchus under general anesthesia where hemorrhage and tension pneumothorax was successfully managed.

A 27-year-old man underwent general anesthesia for arthroscopic Bankart repair surgery. Glycopyrrolate was administered for premedication and anesthesia was induced with propofol and rocuronium. After tracheal intubation, the patient’s position was changed to right lateral position for operation. Gradual elevation of airway pressure and decrease of oxygen saturation occurred, and was suspected to be due to endobrochial intubation. Nonetheless, the endotracheal tube was drawn to 22 cm at the upper incisor and breathing sound was not auscultated over the right lung field. Bronchoscopy was performed for diagnosis, right main bronchus was filled withclear mucus secretion. After suction of the secretion, ventilation was improved. After finishing the operation, a chest X-ray showed aspiration pneumonia overthe right lung. The patient was treated with antibiotics and discharged uneventfully 5 days postoperatively.

Acute electrodermal activity changes to short-time noise stimulation in adult Intensive Care Unit patients. Aslanidis Th, Grosomanidis V, + Karakoulas K, Chatzisotiriou A The electrical properties of the skin, also known as electrodermal activity (EDA), are considered as an indirect measure of autonomous nervous system. Along with that, the effects of noise-induced stress in intensive care units, is well explored. This study explores the noise-induced acute electrodermal activity changes in adult critical care patients and to compare these changes with cardiovascular effects of the same stress (noise) stimulus. Skin conductance variability, noise level, selected hemodynamic and respiratory parameters were monitored during 4 hour routine daytime intensive care nursing and treatment in an adult Intensive Care Unit. Average ambient noise levels during the time window (4 min) before the stimulation were 54.33(2.65) dB for Group A and 55.65(3.31) dB, while the noise stimulation was on average for Group A 70.8 (1.98) dB, and for Group B: 71.31(3.31) dB. EDA changes to noise stimulus were more distinct than hemodynamic and respiratory parameters. Yet, a weak relation was found between all EDA parameters and the particular noise level changes. Noise-induce stress causes more distinct EDA changes when measured immediately post stimulus. In addition, sedation level seems to affect the intensity of these changes. However, further studies are needed in to order to reach a definite conclusion.

Background
Identification of the epidural space has a critical role in epidural anesthesia. Epidrum® has been a recently developed air operated device used for
identifying the epidural space. This study compares the usage of Epidrum® with saline or air to identify epidural space in performing epidural or combined
spinal-epidural(CSE) anesthesia; by paying attention to the ease and duration of the application process, certainty of epidural space distinction, and
possible complications.
Methods
Sixty ASA I or II patients between the ages of 18 and 60 years old scheduled for elective gynecologic, orthopedic or hip surgery under CSE anesthesia
were enrolled in this study. The patients were randomly assigned to two groups: either, Epidrum® was used with air (Group A) (n=30) or with saline
(Group S) (n=30).
Results
No significant differences were noted between the two groups in terms of the time taken to determine the epidural space or the number of attempts
required to find it. Deflation time in Group A was statistically shorter than Group S (p=0.024). It was reported that Epidrum® usage with air was easier
to apply (73% vs. 30%), and discrimination of the epidural space was more significant (63% vs. 13%) compared to saline (p=0.001 in both groups). No
complications were recorded in both groups.
Conclusion
Despite more significant discrimination of the epidural space, shorter deflation time and ease of application of Epidrum® use with air versus saline, saline could be also used successfully in consideration of possible complications with air.

Pregnancy is a recognized risk factor for aneurysmal subarachnoid hemorrhage (SAH). Headache is very frequent in normal pregnancy and it is a common sign shared between several intracranial diseases. We present a case series of 10 women in the third trimester of pregnancy admitted to our intensive care unit (ICU) with neurological signs and symptoms. 4 of these patients were diagnosed with SAH. Data in this study suggest that a timely diagnosis and an appropriate treatment is crucial for mother and baby.

Explanation of the problem: Study of ketamine postoperative for paediatrics as analgesics in kids gathering to accomplish great absence of pain, diminish opioid utilization postoperative. Target patients in the event that review are paediatrics over 1-year age (a half year to 6 years old). Strategy and Theoretical Orientation: 1-2 mg/kg of ketamine was given IM postoperative in 42 paediatric cases and after that evaluate understanding solace and agony seriousness in recuperation space for 30 minutes postoperative up to 12 hours in ward. Discoveries: Achieve great smooth easy recuperation and diminishing opioid utilization, arousable reacting to charges kid with kept up unconstrained breathing causing absence of pain up to 12 hours postoperative in 30 of 42 cases. The rest of the 12 required postoperative analgesics following 6 hours. Conclusion and significance: Ketamine can be given 1 mg/kg IM in the wake of completing surgery before exudation; particularly if different analgesics neglected to calm torment with full close perception and fundamental signs checking of tyke in recuperation space for 30 minutes postoperative at that point survey tyke agony, vitals and cognizant level before moving to ward.

Objective
To evaluate early echocardiographic variables of neonates with alveolar capillary dysplasia (ACD).
Study Design
A case-control study of five neonates with ACD and their matched controls on extracorporeal membrane oxygenation from 2000-2011. Two cardiologists
prospectively reviewed first admission echocardiograms. Statistical tests included Kappa, T-test, Mann-Whitney, Fisher’s exact, and Chi-square analysis.
Results
Excellent inter-rater reliability readings were achieved (Kappa 0.75-1). Tricuspid regurgitation (TR) velocities between the groups were not statistically
significant; all ACD cases and 75% of the controls had TR velocities ≥ 3.2 m/sec. More ACD cases had moderate-severe TR jet (80% vs. none, p<0.01);
moderate-severe right atrial enlargement (RAE) (100% vs. none, p<0.01); moderate-severe right ventricular (RV) dilatation (100% vs. none, p<0.01); and
moderate-severely depressed RV function (60% vs. none, p<0.01). ACD patients were 12 times more likely to have a combination of moderate-severe
RAE and moderate-severe TR jet compared to controls (OR = 11.6 [2-68]).
Conclusion
The combination of moderate-severe RAE and TR jet unresponsive to maximal interventions should alert clinicians of the possibility for ACD. We
speculate that early echocardiographic predictors may identify at-risk neonates with fatal ACD and lead to early consideration of lung transplant.

Endotracheal intubation using flexometallic tubes are often required in anaesthesia practice for a variety of reasons. It is preferred in the head and neck region surgeries due to its
relative resistance to kinking forces. At times, these patients postoperatively may need to be shifted to ICU or HDU without extubation for further stabilization/management and extubation after adequate recovery. We present an unusual accident where a new flexometallic endotracheal tube was permanently tapered, transected and migrated proximally due to patient’s bite on tube leading to airway emergency in post-operative recovery period.

AIMS: To compare the pain score within twenty-four hours postendoscopic ultrasonography (EUS) with or without fine needle aspiration (FNA) procedure in adult patients.
METHODS: We prospectively analyzed the patients who
underwent EUS procedures from January, 2009 to December,
2009. Pain score was compared by using verbal rating scale (VRS, 0-100) and pain rescued medications at 2, 6, 12, 18, 24 hours postprocedure.
RESULTS: One hundred and twenty-four patients, 84 patients only with EUS procedure (group D) and 40 patients with EUS and FNA procedures (group F), were enrolled. All procedures were completed successfully. Sedative and analgesic agents in both groups were propofol, midazolam and fentanyl and were comparable the dose among the two groups. The mean procedural time in D and F was 39.8±19.1 and 60.6±26.0 minutes, respectively. Mean pain score at baseline and at 2, 6, 12, 18 and 24 hours post-EUS was not significantly different between the two groups. Additionally, total dose of pethidine used for pain control after EUS procedure in both groups was not significantly different.
CONCLUSION: EUS-induced abdominal pain is mild and mainly
occurs within six hours after the procedure. Pain score within
twenty-four hours after EUS with or without fine needle aspiration procedure is comparable.