Obstructive sleep apnea(OSA) is a syndrome characterized by obstruction in the upper airway during sleep. OSA patients undergoing procedures under GA are at increased risk for hypoxemia, pneumonia, difficult intubation, atelactasis, myocardial infarction making it a challenge for anesthesiologist. Retrograde intrarenal surgery(RIRS) is normally performed under GA to prevent respiratory embaracement. There are very few studies focusing on Regional anesthesia in RIRS procedure. A Sixty-three-year-old male known case of morbid obesity (BMI- 35 kg/meter square), OSA (on CPAP support at night) presented with left renal pelvis calculus, STOP BANG score (=5) therefore making it a case of difficult airway. Respiratory discomfort improved at 30-35-degree head up due to existing OSA considering the severe OSA and anticipated difficult airway, the surgery was planned under Lumbar subarachnoid block with preparation for management of difficult airway if conversion to GA required. 3 ml of 0.5 percent Bupivacaine heavy and 25 mcg fentanyl injected into subarachnoid space. T6 level block acheived after 3 minutes. The patient was put on his home CPAP machine with 5cm H2O PEEP. The patient was maintained on sponatneous ventilation and monitored using Etco2 at aliquot of 1mg midazolam given to mimic natural sleep pattern. The surgery was uneventful and the risk of induction of GA and difficult intubation was succesfully avoided. Patient with regional anaesthesia who are prone to converted to GA due to multiple risk factors, i.e., OSA with anticipated difficult airway can create a chaotic situation. So as a preliminary step NIV can be used, and along with it, mild sedation can be supplemented to improve acceptance and to avoid asynchrony. In this case NIV was used as a preemptive ventilation strategy even before actual requirement of BiPAP by mimicing the natural sleep pattern and make patient comfortable while a smooth conductance of the procedure.

Pulmonary bullae typically occur either idiopathically or in the context of chronic obstructive pulmonary disease and pulmonary infections. Clinical manifestations of pulmonary bullae include cough, shortness of breath, and chest pain. In some cases, they may be asymptomatic. Differentiating between pneumothorax and pulmonary bullae can be challenging when they coexist. Therefore, obtaining a detailed patient history, conducting a physical examination, performing laboratory tests, and utilizing radiology studies are essential diagnostic tools that should be employed simultaneously. In this case report, we present a patient who developed a wide pneumothorax due to a penetrating chest wound caused by a knife. Initially, the large lung cavity, which had already formed due to tuberculosis, was misdiagnosed as a loculated pneumothorax.

Background: One of the most important treatments used in women with infertility is IVF, and improving its results can affect the success of assisted reproductive techniques. It was previously shown that anesthetics can enter the follicular fluid (FF), so there is concern about the accumulation of anesthetics in the FF and their negative effects on fertilization and fetal growth under general anesthesia. The use of drugs that have both analgesic and sedative effects but do not have hemodynamic side effects is of particular importance and dexmedetomidine is one of the drugs introduced in this field. On the other hand, the use of sedatives such as midazolam and propofol may cause hemodynamic disturbances and severe hypotension in these patients, which limits the use of such drugs. Accordingly, and considering the importance of the issue, in this study, we decided to evaluate and compare the effect of propofol and dexmedetomidine on fertility in IVF candidates. Methods: In this clinical trial study, 78 infertile patients who underwent IVF were randomly examined. After dividing the patients into two groups receiving dexmedetomidine and propofol or standard recording doses, the fertility rate of the patients in the two groups was evaluated using chi-square and Fisher tests at a significance level of 0.05. Results: The use of dexmedetomidine for (P = 0.0348) Pressure_After_Dia, HR_Before (P = 0.0204), Injection_Time (P =0.000) and Recovery Time (P =0.000) indices caused a significant increase compared to the propofol group. Conclusion: The results of the present study did not show a significant difference in the use of these two drugs on fertility.

Background: The combined spinal-epidural (CSE) anesthesia technique gives a reliable subarachnoid block as well as the flexible epidural block. One of the modified technique of CSE is epidural volume expansion (EVE) in which normal saline or local anesthetic (LA) is instilled though epidural catheter leading to increase in level of sensory blockade. Aim of the study was to compare two different volumes of normal saline for enhancing the effects of spinal anaesthesia in adult patients undergoing elective lower limb surgeries.
 Methods: 90 patients were randomly divided into two group. Group A - 45 patients who were received intrathecal 2.0ml of 0.5% hyperbaric bupivacaine and epidural 10ml of 0.9% normal saline for EVE using CSE technique. Group B - 45 patients who were received intrathecal 2.0ml of 0.5% hyperbaric bupivacaine and epidural 15ml of 0.9% normal saline for EVE using CSE technique.
 Results: The demographic data were comparable in both groups. Significant difference was seen in total duration of sensory blockade between group A (192.11±9.80) and group B (Mean ± SD 215.33±17.57minutes) (p<0.0001). Total duration of motor blockade was longer in group B (Mean± SD: 181.91± 16.42) as compared to group A (Mean ± SD: 162.48 ± 9.35 minutes) (p<0.0001).
 Conclusion: We conclude that epidural volume expansion (EVE) with 15 ml epidural normal saline was associated with faster onset, higher level and early achieve maximum level of sensory blockade, longer two segment regression time, early onset and longer duration of motor blockade as compared to EVE with 10 ml epidural normal saline.

Background: Diabetic patients are known to have gastroparesis and consequent delayed gastric emptying which predisposes them to an increased risk of aspiration as compared to the general population. This study compares the gastric volumes in diabetic and non-diabetic patients using point-of-care ultrasound and correlates it with the HbA1c levels in diabetic patients.
 Methods: This cross-sectional study included 180 patients, 90 diabetic (>5 years) and 90 nondiabetic, aged >40 years, American Society of Anaesthesiologists' physical status I–II kept fasting for 8 hours. Before induction, gastric ultrasound was performed to measure craniocaudal (CC) and anteroposterior (AP) diameters followed by calculation of antral cross-sectional area (CSA) and gastric volume (GV) in right lateral decubitus (RLD) position using curved array probe. In diabetic patients, the gastric volumes were correlated with HbA1c values.
 Results: In the RLD, the mean CC and AP diameters were higher in diabetic Group. The calculated CSA in RLD in diabetics (8.014 ± 2.412 cm2) were significantly higher than non-diabetic (6.314± 2.894 cm2) (p < 0.0001). The calculated GV of 71.501 ± 35.937 ml in the diabetic group was significantly higher than 48.0022± 41.587 ml in the non-diabetic group (p < 0.0001). In diabetics, the gastric volumes showed significant correlation with HbA1c.
 Conclusion: Diabetic patients show higher residual gastric volume as compared to non-diabetic patients indicating gastroparesis. The gastric volumes are further increased in those with poorly controlled disease with high HbA1C levels. Ultrasound is an effective tool in assessing the risk of aspiration and altering anaesthetic management accordingly.

Background: In the majority of cases, the treatment method for Cleft lip is surgery. Providing adequate pain control during and after surgery for children, is too important. Also, different methods are used for pain relief like analgesic prescription and nerve block and different adjuvants can be added to anesthetics to reduce pain.
 Aims: This trial was aimed to compare the analgesic effect of Bupivacaine with or without dexmedetomidine or dexamethasone for cleft lip surgery.
 Methods: This study is a prospective, double-blinded, randomized trial which conducted on 75 pediatrics, aged between 3 to 10 months, who needed unilateral cleft lip surgery. Patients were divided into 3 groups (n=25 in each group). Children in group A, were given a combination of bupivacaine and 0.5 µg/kg of dexmedetomidine, those in group B, 0.1 mg/kg of dexamethasone as an adjuvant to bupivacaine, and in group C, plain 1 cc of bupivacaine 0.5% was injected in the operation site. Outcomes were assessed via FLACC and WATCHA scores.
 Results: The mean age among children was 4.3 ±1.29 months and mean weight was 6.3± 1.09 kg. Pain score and frequency of analgesic request intra and post-operation in group A was lower than others (p<0.0001). Also, FLACC and WATCHA scores were significantly lower in group A (p<0.0001) and parental and surgeon satisfaction was higher in group A (p<0.05).
 Conclusion: Our study showed that, dexmedetomidine as an adjuvant to bupivacaine 0.5% is more effective to improve the analgesia, in children who underwent unilateral cleft lip surgery.

Complete remaining guide wire in the vascular system after CVC is very rare. For which the maximum symptom-free reporting time in studies was five months, and in our case, the patient was symptom-free for one year. The only finding was one session complaining of ear pain and mastoid tenderness two weeks after catheter placement.
 A 42-year-old male patient with the diagnosis of necrotizing pancreatitis and a retroperitoneal abscess was a candidate for laparotomy after ERCP. The patient was a candidate for central venous catheter insertion through the internal jugular vein before the surgery in the operating room by a third-year anesthesia resident. After one year, discovered that incidentally remaining guide wire during a follow-up MRI before pancreatitis. Which has been asymptomatic during this period. And despite the risk of rupture of the right heart and blood vessels due to possible fibrosis due to a long stay in the cardiovascular system, it is successfully removed by an endovascular surgeon.
 The main reasons for the incident were the non-observance of scientific and safety principles at the time of catheter insertion and the failure to perform CXR after that

The Article Abstract is not available.

Background: Both ketamine and dexmedetomidine have proven effective in relieving the pain resulting from propofol injection. However, studies comparing them directly are limited. The primary outcome was to compare the incidence of propofol injection pain after dexmedetomidine pretreatment with ketamine pretreatment. Secondary outcome was to study the changes of haemodynamic parameters that arise after the administration of the pretreatment drug till anaesthesia was induced with propofol.
 Methods: In this randomized, triple blinded, parallel arm single centre study, we compared pre-treatment with dexmedetomidine 0.5mcg/kg (Group A) and ketamine 0.5mg/kg (Group B). Our primary objective was to compare the incidence of propofol injection pain. The McCririck and Hunter scale was used to evaluate the pain. Secondarily, we compared the changes of haemodynamic parameters that arose after the administration of the pre-treatment drug till induction of anaesthesia with propofol.
 Results: Among 168 patients evaluated for eligibility, 140 were included for final analysis with 70 patients in each group. The incidence of propofol injection pain in Group A was 74.3% (52/70) and that in Group B was 42.9% (30/70) (p value <0.001). No pain was reported by 25.7% (18/70) and 57.1% (40/70) patients in Group A and B respectively. Mild and moderate to severe pain was experienced by 58.6% and 15.7% patients in Group A, where as it was 40% and 2.9% patients in Group B respectively.
 Conclusion: Ketamine leads to a greater reduction in both the frequency and intensity of pain resulting from propofol injection when compared to dexmedetomidine.

Background: Ventilator-associated pneumonia (VAP) is a consequence of mechanical ventilation, which can be fatal. Several markers are available to predict outcomes related to VAP. Choosing a predictor that is inexpensive, affordable, and accurate is advantageous. This study aimed to examine red cell distribution width (RDW) as a predictor of mortality in patients with VAP.
 Methods: This prospective cohort study was conducted among 49 patients in the intensive care unit (ICU) of Valiasr Hospital in Tehran. A researcher-made checklist was used to collect RDW and other marker data, as well as mortality outcomes and length of stay (LOS) in the ICU. The Pearson correlation coefficient in the SPSS software and the regression model in the Eviews software were used to examine the relationship between markers and different outcomes.
 Results: Of a total of 49 patients (57.1% male; mean age = 54 ± 16), the length of ICU stays ranged from 7 to 14 days. According to the Pearson correlation coefficient, a significant association between RDW and mortality (P =.009) was noted. But no significant relationship between RDW and length of stay in the ICU (P =.81) was noted. Additionally, the regression model showed a positive relationship between RDW and white blood cells (WBC), lactate, and sequential organ failure assessment (SOFA).
 Conclusion: Our study showed a positive but weak correlation between RDW and ICU mortality in patients with VAP. Due to its availability and low cost of measurement, RDW is an appropriate option for predicting mortality risk in patients who are admitted to the ICU and develop VAP.