Mohammad Reza Habibi

Comparison of Proposed Modified and Original Sequential Organ Failure Assessment Scores in Predicting ICU Mortality: A Prospective, Observational, Follow-Up Study

Background. The sequential organ failure assessment (SOFA) score has been recommended to triage critically ill patients in the intensive care unit (ICU). This study aimed to compare the performance of our proposed MSOFA and original SOFA scores in predicting ICU mortality. Methods. This prospective observational study was conducted on 250 patients admitted to the ICU. Both tools scores were calculated at the beginning, 24 hours of ICU admission, and 48 hours of ICU admission. Diagnostic odds ratio and receiver operating characteristic (ROC) curve were used to compare the two scores. Results. MSOFA and SOFA predicted mortality similarly with an area under the ROC curve of 0.837, 0.992, and 0.977 for MSOFA 1, MSOFA 2, and MSOFA 3, respectively, and 0.857, 0.988, and 0.988 for SOFA 1, SOFA 2, and SOFA 3, respectively. The sensitivity and specificity of MSOFA 1 in cut-off point 8 were 82.9% and 68.4%, respectively, MSOFA 2 in cut-off point 9.5 were 94.7% and 97.1%, respectively, and MSOFA 3 in cut-off point of 9.3 were 97.4% and 93.1%, respectively. There was a significant positive correlation between the MSOFA 1 and the SOFA 1 (r: 0.942), 24 hours (r: 0.972), and 48 hours (r: 0.960). Conclusion. The proposed MSOFA and the SOFA scores had high diagnostic accuracy, sensitivity, and specificity for predicting mortality.

Can Vitamin C Be Used as an Adjuvant for Managing Postoperative Pain? A Short Literature Review

Received January 14, 2013. Accepted January 29, 2013. Correspondence to: Mohammad Reza Habibi, MD Mazandaran Heart Center, Hazrat Fatima Hospital, Artesh Boulevard, Mazandaran Province, Sari, Iran Tel: +98-1512226262, Fax: +98-1512268915, E-mail: contactroute@yahoo.com This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright c The Korean Pain Society, 2013 LETTER TO EDITORS

Mirror Therapy as an Alternative Treatment for Phantom Limb Pain: A Short Literature Review

Received May 10, 2013. Accepted May 21, 2013. Correspondence to: Aria Soleimani, MD Department of Anesthesiology, Mazandaran Heart Center, Hazrat Fatima Hospital, Artesh Boulevard, Mazandaran Province, Sari, Iran Tel: +98-1512226262, Fax: +98-1512268915, E-mail: contactroute@yahoo.com This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright c The Korean Pain Society, 2013 LETTER TO EDITORS

INVASIVE ASPERGILLOSIS IN INTENSIVE CARE UNIT PATIENTS IN IRAN

We assessed the intensive care unit (ICU) patients for Invasive aspergillosis (IA) with culture and non-culture based diagnostic methods from Iran. Thirty-six ICU patients with underlying predisposing conditions for IA were enrolled in the study. Sixty eight Bronchoalveolar lavage (BAL) samples were collected by bronchoscope twice a weekly. BAL samples were analyzed by microscopic examination, fungal culture and galactomannan (GM) detection. The Platelia Aspergillus GM EIA was used to quantify GM indices. Samples with a BAL GM index > or = 1 were considered as positive for GM. Patients were classified as having probable or possible IA. Out of 36 suspected patients to IA, 36.1% of cases showed IA which were categorized as: 4 cases of possible IA and 9 of probable IA. 76.2% of BAL samples were positive for GM. From 13 patients with IA, 11 (84.6%) had at least one positive BAL GM index. Of these patients, 9 (81.8%) showed probable IA. The main underlying predisposing conditions were neutropenia (53.8%) and COPD (30.8%). Our study has indicated that COPD must be considered as one of the main predisposing condition for occurrence of aspergillosis in ICU patients. Our data have also revealed that GM detection in BAL samples play a significant role to IA diagnosis.

Does high-dose metformin cause lactic acidosis in type 2 diabetic patients after CABG surgery? A double blind randomized clinical trial.

Metformin is a dimethyl biguanide oral anti-hyperglycemic agent. Lactic acidosis due to metformin is a fatal metabolic condition that limits its use in patients in poor clinical condition, consequently reducing the number of patients who benefit from this medication. In a double blind randomized clinical trial, we investigated 200 type 2 diabetic patients after coronary artery bypass surgery in the open heart ICU of the Mazandaran Heart Center, and randomly assigned them to equal intervention and control groups. The intervention group received regular insulin infusion along with 2 metformin 500 mg tablets every twelve hours, while the control group received only intravenous insulin with 2 placebo tablets every twelve hours. Lactate level, pH, base excess, blood glucose and serum creatinine were measured over five 12 h periods, with data averaged for each period. The primary outcome in this study was high lactate levels. Comparison between the 2 groups was made by independent Student’s t-test. To compare changes in multiple measures in each group and analysis of group interaction, a repeated measurement ANOVA test was used. There was no significant difference between the 2 groups regarding pH, base excess, or bicarbonate intake (P>0.05). No patient showed lactic acidosis in either group. Lactate levels were 23.0 vs 23.4 in the insulin-metformin and insulin only groups when the study was started, respectively. At the end of the study, those levels were 18.7 vs 18.9, respectively. In addition, the ANOVA repeated measurement test did not show a significant difference in terms of changes in the amount of lactate level between the 2 groups during the five measurement tests of the study period (P>0.05). High-dose metformin (1,000 mg twice daily with insulin) does not cause lactic acidosis in type 2 diabetic patients after coronary artery bypass surgery.

Detection of galactomannan in bronchoalveolar lavage of the intensive care unit patients at risk for invasive aspergillosis

Background and Purpose: Invasive aspergillosis (IA) is one of the most common life-threatening fungal infections among the critically ill patients including intensive care unit (ICU) patients. Delayed diagnosis and therapy may lead to poor outcomes. Diagnosis may be facilitated by a test for molecular biomarkers, i.e. detection of galactomannan (GM) antigen based on enzyme immunoassay, which is of increasing interest in the clinical settings for the diagnosis of IA. In the present study, we assessed GM testing of bronchoalveolar lavage (BAL) fluid as a tool for early diagnosis of IA among ICU patients who were at risk for developing IA. Material and Methods: A prospective study was performed in ICU patients with underlying predisposing conditions for IA between August 2010 and September 2011. BAL samples for direct microscopic examination, culture, and GM detection were obtained once or twice weekly. GM in BAL levels was measured using the Platellia Aspergillus EIA test kit. According to modified European Organization for the Research and Treatment of Cancer/ Mycoses Study Group (EORTC/MSG) criteria, patients were classified as having probable or possible IA. Results: Out of 43 suspected patients to IA, 13 (30.2%) cases showed IA. According to the criteria presented by EORTC/MSG, they were categorized as: 4 cases (30.8%) of possible IA and 9 (69.2%) of probable IA. Out of 21 BAL samples from patients with IA, 11 (52.4%) had at least one positive BAL GM index. Using a cutoff index of 0.5, the sensitivity and specificity, positive and negative predictive values of GM detection in BAL fluid were 100%, 85.7%, 65.7% and 96%, respectively. The sensitivity and specificity was 73% and 92.7% at cutoff ≥1.0, respectively. In 6 of 13 IA cases, BAL culture or direct microscopic examination remained negative, whereas GM in BAL was positive. Conclusion: Our data have revealed that the sensitivity of GM detection in BAL was better than that of conventional tests. It seems that GM detection in BAL is beneficial to establish or exclude the early diagnosis of IA in ICU patients.

Sedation and analgesia during bone marrow aspiration in children: Is ketamine and propofol combination (Ketofol) an appropriate agent?

DOI: 10.4103/0971-5851.125267 patients to develop thrombocytopenia, like subclinical disseminated intravascular coagulation to paraneoplastic thrombocytopenia. There are multiple drugs, which can induce immune and non-immune thrombocytopenia including anticancer drugs. In reference patient, bone marrow, anti-nuclear antibody, urine for proteins, ultrasonography abdomen as a protocol for evaluation of thrombocytopenia was not done. The patient presented was on capecitabine, drug used in colonic cancer, which can have profound effect on platelets to cause significant thrombocytopenia.[6]

Comparing Hemodynamic Responses to Diazepam, Propofol and Etomidate During Anesthesia Induction in Patients with Left Ventricular Dysfunction Undergoing Coronary Artery Bypass Graft Surgery: a Double-blind, Randomized Clinical Trial

Background: Anesthesia induction is often accompanied by a period of hemodynamic instability, which could be deleterious in patients with coronary artery disease (CAD) and left ventricular dysfunction undergoing coronary artery bypass graft (CABG) surgery. The aim of this study was to compare the hemodynamic responses to propofol, etomidate, and diazepam following anesthesia induction, laryngoscopy and intubation in CABG surgery patients with low ejection fraction (EF). Methods: A double-blind randomized, clinical study was performed on 150 patients with CAD and left ventricular dysfunction (EF≤35%) scheduled for elective CABG surgery with Cardiopulmonary bypass (CPB). Patients were randomly allocated to three groups A, B, and C. These patients received propofol, etomidate or diazepam at induction of anesthesia, respectively. Hemodynamic variables (systolic and diastolic blood pressure [SBP, DBP], mean arterial pressure [MAP] and heart rate [HR]) were measured and recorded at baseline, immediately before laryngoscopy and tracheal intubation and one and three minutes after intubation. Result: One minute after induction and before laryngoscopy, there was a statistically significant decrease from the baseline in SBP, DBP and MAP in all three groups, but these variables in each hemodynamic parameters in diazepam group were less than other two groups (p<0.001). Moreover, the mean HR decreased in patients receiving propofol and etomidate one minute after induction and before laryngoscopy, but did not decreased in the diazepam group (p=0.005). Conclusion: The present study showed that in patients undergoing CABG surgery with low EF, diazepam is more favorable in terms of hemodynamic stability compared to propofol and etomidate and this drug can be used safely for induction of anesthesia in patients with impaired ventricular function.

Administration of lidocaine to prevent cognitive deficit in patients undergoing coronary artery bypass grafting and valve plasty: a systematic review and meta-analysis.

ABSTRACT Introduction: The administration of lidocaine to maintain cognitive function following coronary artery bypass grafting (CABG) and valve plasty is a controversial concept in terms of its effectiveness. We performed a systematic review to determine the effectiveness of treatment with lidocaine in preventing the occurrence of cognitive deficit after cardiac surgery. Area covered: To review the current literature on the subject, we searched the PubMed database and the Cochrane Library database (up to May 2015) and compiled a list of retrieved articles. Our final review includes only randomized controlled trials (RCTs) that compared lidocaine to a control (placebo) following CABG and valve plasty. Statistical analysis of the odds ratio (OR) and corresponding 95% confidence interval (CI) were used to determine the overall effectiveness of lidocaine for the prevention of cognitive deficit with both procedures. The Mantel–Haenszel method was used to pool data of the outcomes of cognitive deficit occurrence into fixed-effect model meta-analyses. Five RCTs were included in this study, with a total of 688 patients. Perioperative administration of lidocaine in patients undergoing cardiac surgery reduced occurrence of cognitive deficit (OR 0.583 [95% CI 0.438–0.777]; Z = -3.680; P = 0.00; I2 = 52%). No significant difference in the early occurrence of cognitive deficit was revealed in patients after cardiac surgery (OR 0.909 [95% CI 0.600–1.376]; Z = -0.451; P = 0.652; I2 = 11%). Expert commentary: Cognitive deficit associated with cardiac surgery is a common postoperative event. Lidocaine is contributed to a significantly reduced occurrence of cognitive deficit. Cognitive deficit management is recommended.

A randomized clinical trial comparing hemodynamic responses to ketamine-propofol combination (ketofol) versus etomidate during anesthesia induction in patients with left ventricular dysfunction undergoing coronary artery bypass graft surgery

Introduction Anesthesia induction is often accompanied by a period of hemodynamic instability, which could be a significant problem in patients with compromised ventricular function. The aim of this study is to compare the hemodynamic responses to etomidate versus a combination of ketamine and propofol (ketofol) for anesthetic induction in patients with left ventricular dysfunction undergoing coronary artery bypass graft (CABG) surgery. Material and methods In a double-blind randomized clinical study, a total of 84 patients with ischemic left ventricular dysfunction (EF < 40%) were randomly assigned to two groups (A and B). Patients in group A received etomidate 0.2 mg/kg and a placebo (normal saline); group B received a combination of ketamine (1 mg/kg) and propofol (1.5 mg/kg) at the induction of anesthesia. Two minutes after induction, hemodynamic variables, including systolic, diastolic, mean arterial pressure (SAP, DAP, MAP) and heart rate (HR), were measured immediately before and after the laryngoscopy, and before intubation and post-intubation at 1, 2, and 3 min. Results The decrease in all hemodynamic parameters (SBP, DBP, MAP and HR) from induction time to laryngoscopy was greater in the ketofol group (group B) than in the etomidate group (group A) (p < 0.05). The ephedrine prescription rate due to hemodynamic changes was 24.4% (10 patients) and 5% (2 patients) in group B and group A, respectively (p = 0.03). Conclusions We found that etomidate provides superior hemodynamic stability as compared to ketofol in patients with left ventricular dysfunction undergoing CABG surgery under general anesthesia.