Drug Utilization Evaluation of Colistin: A Retrospective Study

Background: Colistin, is used as the last treatment line for infections concluded from multiple drug-resistant gram-negative microorganisms. Increased consumption of colistin leads to resistance to this antibiotic in many countries. This study investigated the usage pattern of colistin administration in a selected hospital in Iran. Methods: This study was conducted in a selected hospital in Ahvaz. Inclusion criteria were all patients who received colistin during this time according to the health information system. Patients who were received less than three doses of colistin were excluded from the study. Prescription of colistin in all patients was evaluated according to the protocol extracted from the last version of Lexicomp written by Wolters Kluwer. The descriptive and analytical statistics were carried out by the R software. Results: Among 27 patients who received colistin, pneumonia (30%) was the main diagnoses. Colistin administration was based on the microbiological culture data in 70% of cases. Considering the involved microorganism, most cases were Acinetobacter spp., followed by Klebsiella spp. Loading dose was prescribed for seven (26%) patients. In only five (19%) cases, colistin dosing, including loading dose, maintenance dose, and the interval of colistin administration, was appropriate during the study time. Increasing in serum creatinine was seen in two (7.4%) patients. In 29.4% of patients, the combination of colistin and carbapenems was observed. Conclusion: Given the lack of appropriate dose adjustment of colistin that may lead to incidence of resistance and adverse effect, applying of the specialist clinical pharmacist will be suggested.

Experiences of Conscious Patients Undergoing Tracheal Intubation; A Qualitative Study

Background: Tracheal intubation is a life-saving action in situations such as respiratory failure. However, this therapeutic approach may produce a series of side effects and physiological stress, such as pain, insomnia, anxiety, fear, etc. Methods: The present study is a qualitative research with a content analysis method conducted for a period of two years. This study's required information has been collected using non-structured face-to-face interviews with 22 patients hospitalized in emergency and intensive care units. The data were analyzed using open coding and MAXQDA 12. Results: Findings from the interviews' were divided into two main categories of mental and physical experiences. Mental experiences are divided into 12 sub-categories and physical experiences into 7 sub-categories, each of them is also divided into further categories. Inability to speak is the most frequent complaint of patients in this study. The pain was the most common physical complaint of patients, mostly due to pain in the organs and pain due to blood sampling. Conclusion: Despite special training of medical staff in emergency and intensive care units to take care of patients and to obviate their special needs, it is observing that some patients under certain conditions such as intubation still face many unmet needs.

Comparative Study of the Effect of Midazolam Administration Before and after Seizures on the Prevention of Complications in Children Undergoing Electroconvulsive Therapy Compared with a Control Group

Background: One of the complications of ECT treatment is headache. There is a need to use sedation during ECT. As a result, midazolam has been used to address a safe and effective strategy in this regard. Methods: This study is a double-blind clinical trial that has been performed in three groups: group A, which receives midazolam based on the usual regimen, group B, which receives midazolam after shock, and group C, which is the control group. Patients were asked about headache, nausea, and muscle aches during the recovery time, seizure duration and after becoming fully conscious. Data were analyzed in the PASW version18 software using analysis of variance and repeated measurement tests, ANOVA, independed t and χ2 tests. Results: Analysis showed that the frequency of muscle pain after full consciousness in group C was significantly higher than group B, with group B being higher than group A. χ2 test showed that the frequency of headache, cough and nausea in group C was significantly higher than the two groups A and B. Conclusion: The result of this research showed that midazolam prodrug plays an effective role in preventing post-ECT complications in children. The effect of midazolam before and after ECT on headache, muscle pain and nausea was investigated and compared with the control group. Also, due to its anterograde amnesia, midazolam can reduce the patient's stress in the next visits, and this issue is even more important when the patient is a child.

Barotrauma in COVID-19 Patients

Clinical manifestations of COVID 19 is still unknown. We performed this study to determine the occurrence of pulmonary barotrauma as a complication of this disease. In this retrospective study, a total of 955 COVID 19 patients with respiratory insufficiency requiring oxygen support or invasive ventilation admitted to ICU of Sina Hospital from 20 March 2020 to 9 June 2021, were included and their chest imaging reviewed. Here, we report results of chest imaging of first 92 patients of this group. Barotrauma (pneumothorax, pneumomediastinum, pneumopericardium) occurred in 11 (11.9%) of 92 patients with coronavirus disease 2019 (COVID-19) infection requiring ICU admission for respiratory support and monitoring. It seems barotrauma is a common complication of COVID 19 disease. The role of increased respiratory efforts, patient or ventilation induced lung injury, viral and host response should be assessed. It needs to consider the occurrence of barotrauma in Patients with COVID-19, before expansion of dead space for treatment and limiting the ventilation effects.

Hemodynamic Stress Response in Controlled Hypertensive Patients- A Randomized Comparison of I-Scope Video Laryngoscope and Macintosh Laryngoscope

Background: Laryngoscopy and intubation cause activation of the sympathetic nervous system and can results in tachycardia, arrhythmias and hypertension. Hypertensive patients demonstrate a relatively greater rise in catecholamine secretion and an increased sensitivity to them. Aim of the study is to compare the haemodynamic stress response associated with orotracheal intubation using videolaryngoscope or Macintosh laryngoscope in controlled hypertensive patients. Methods: Sixty hypertensive, American Society of Anesthesiologist’s class II, patients were randomly divided in to two groups. In group V (videolaryngoscope), intubation was done with i-scope videolaryngoscope. In group M (Macintosh), intubation was done using Macintosh laryngoscope. Primary objectives of the study pulse rate (PR), systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean blood pressure (MBP) were noted immediately after and at 1, 2, 3, 5 and 10 minutes after intubation. Results: The demographic data were comparable in both groups. There was no significant difference at baseline for mean (SD) PR, SBP, DBP and MBP at baseline and after induction/before intubation (p>0.05). The mean (SD) PR, SBP, DBP and MBP were significantly higher in Macintosh laryngoscope group as compared to i-scope videolaryngoscope immediately after intubation, 1, 2, 3, 5 and 10 minutes after intubation (p<0.001). Conclusion: We found that intubation with the use of i-scope videolaryngoscope results in less haemodynamic stress response than Macintosh laryngoscope in controlled hypertensive patients.

Perioperative Management of a Rare Pancreatic Insulinoma Resection: Anaesthetic Challenge!

Insulinoma is a rare, mostly benign and solitary neuroendocrine tumour of the β-cells of islets of langerhans of pancreas. Clinically it presents with a classical ‘Whipple Triad’ encompassing symptomatic hypoglycemia, fasting hypoglycemia (<50 mg/dl) and immediate relief of symptoms after glucose administration. Definitive treatment is laparoscopic or open surgical excision of the tumour. We report and discuss the distinctive anaesthetic considerations and implications during perioperative period. A comprehensive approach including preoperative optimization of blood glucose levels with various drugs and dietary modifications, scrupulous hemodynamic and blood sugar monitoring with prompt initiation of dextrose infusion during surgical handling of tumour and meticulous management of rebound hyperglycemia with insulin infusion in postoperative period remains the essence for better outcome in these subset of patients.

Early versus Delayed Intubation and Technique in COVID-19: A Review Article

Background: The novel coronavirus 2019 is the cause of the 2020 pandemic that was announced by the world health organization in March 2020. The coronavirus attacks the respiratory system and causes mild to severe hypoxemia. Therefore, a fraction of COVID-19 patients may need intubation and mechanical ventilation. Methods: We conducted a narrative review by searching for articles that mentioned the time of intubation for COVID-19 patients and intubation techniques in PubMed, Google Scholar, Scopus, the Web of scenic, the Cochrane library, and Embase, as well as manual searching. All the selected reviews and studies were limited to humans and the English language. Results: The first data from China shows that 5% of patients require intubation and mechanical ventilation (MV), and there has been considerable debate about the timing of intubation for patients with acute respiratory failure and the technique of intubation. At first, the specialists recommended early intubation. Although we are more familiar with the pathophysiology of coronavirus, the drawbacks and the benefits of early intubation are still controversial. In addition, the intubation process itself is an aerosol-generating procedure and carries a high risk for patients and health care providers. In this review, we aim to review the previous studies and guidelines recommendations related to the time of intubation and intubation technique for COVID-19 patients. Conclusion: Previous research has suggested that early tracheal intubation should be prioritized in severe COVID-19 patients, whereas other studies advocate late intubation due to poor intubation outcomes and weaning difficulties. However, intubation timing should be based on personalized medicine and case-by-case decision making to ensure the best care and benefit of patients. And relying only on theoretical justification may not have good consequences.

Comprehensive Analysis of Perioperative Anaesthesia Concerns in Covid Associated Mucormycosis: A Retrospective Study of Surgical Patients

Background: Data regarding sudden surge of mucormycosis cases with COVID-19 outbreak and its impact on anaesthesia management are lacking. This retrospective study was designed to analyze the number and characteristics of patients posted for mucormycosis surgery in COVID19 pandemic while emphasizing upon the anaesthesia concerns. Methods: Data was collected from all patients who were admitted with mucormycosis in our institute from the year 2020 onwards. Further analysis of patients who were surgically treated was carried out in terms of demographic characteristics, association with COVID19 and perioperative course of mucormycosis and anaesthetic management. All statistical analyses were performed with the Statistical package for social sciences (SPSS) version 25·0 software. Results: We report an incidence of 30 operated patients of the average age 52.60 years with mucormycosis from August 2020 to May 2021. Diabetes as a comorbidity was common (86.90%). Previous infection with COVID-19 was observed in 29 (96.60%) out of which 80% patients had residual pulmonary involvement. Concomitant medical therapy with Amphotericin B was received by 90% patients and subsequently 70% had deranged renal profile. While 20 % patients had compromised airway, 60 % required blood transfusion and 76.6% patients were electively ventilated while 1 patient (3.3%) succumbed amounting to a survival rate of 96.6%. Conclusion: To conclude elderly male diabetic patients with history of COVID19 infection is the most vulnerable population for developing mucormycosis. Airway management, glycemic control, concomitant Amphotericin B therapy and intraoperative bleeding are the major challenges for anaesthesiologist along with an element of post Covid respiratory compromise.

Cardiac Function in Brain Death, Usage of Advanced Hemodynamic Monitoring

Background: This study used advanced hemodynamic monitoring along with simultaneous echocardiography to assess donated heart function of brain death patients using advanced hemodynamic monitoring and its efficacy in organ donation. Methods: Forty-eight brain death patients who were candidates of heart donation on the basis of primary standard investigations were selected with purposive and convenient sampling methods. They were investigated with advanced hemodynamic monitoring after echocardiography and primary assessments and the gleaned data were recorded. Results: Echocardiography showed that LVS (left ventricle size) and LVF (left ventricle function) were normal in %100 and %87.5 of patients, respectively. LVEF (left ventricle ejection fraction) was <%50 in %12.5 and >%50 in %87.5 of patients. SVR was smaller than 1200 at the beginning of the study that reached %54.4 at the end of the study. CI (cardiac index) was < 2.4 in %16.7 of the patients at the onset of the study that reached %25 at the end. Reduction of CI and SVR in patients with EF <%50 was significantly higher than that in patients with EF>%50. Conclusion: Given the extensive pathological changes in the cardiovascular system exerted by brain death, advanced hemodynamic monitoring, if performed continually, can greatly aid in managing inotropic drugs in these patients, decision-making for managing intravascular volume, creating hemodynamic stability, and finally, preventing deterioration of function of the donated heart and loss of a donated organ.

Sedation-Paralysis as Cornerstone on Rabies Management (Milwaukee Protocol)

Rabies is a viral infection involving the central nervous system that is almost always fatal without proper post exposure prophylaxis. Here, we present a 38 years-old male with dog-bite and late attention whom, managed in intensive care unit. After 21 days, the disease progressed to serious neurologic and hemodynamic damage including motor disorders and imbalance in blood pressure and cardiac rhythm. Clinical management of the patient consisted of antiviral agents (Amantadine and Ribavirin), neuroprotection, sedation-paralysis and supportive care. Patient was survived 43 days from the clinical disease onset. Although our patient died in spite of intensive care, advances in the use of sedation-paralysis and early prescription of antiviral agents raised hopes that it may eventually be possible to save rabies patients.