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Mahmoodpoor A, Sanaie S, Saghaleini SH, Ostadi Z, Hosseini MS, Sheshgelani N, Vahedian-Azimi A, Samim A, Rahimi-Bashar F. Prognostic value of National Early Warning Score and Modified Early Warning Score on intensive care unit readmission and mortality: A prospective observational study. Front Med (Lausanne) 2022; 9:938005. [PMID: 35991649 PMCID: PMC9386480 DOI: 10.3389/fmed.2022.938005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 07/19/2022] [Indexed: 12/03/2022] Open
Abstract
Background Modified Early Warning Score (MEWS) and National Early Warning Score (NEWS) are widely used in predicting the mortality and intensive care unit (ICU) admission of critically ill patients. This study was conducted to evaluate and compare the prognostic value of NEWS and MEWS for predicting ICU readmission, mortality, and related outcomes in critically ill patients at the time of ICU discharge. Methods This multicenter, prospective, observational study was conducted over a year, from April 2019 to March 2020, in the general ICUs of two university-affiliated hospitals in Northwest Iran. MEWS and NEWS were compared based on the patients’ outcomes (including mortality, ICU readmission, time to readmission, discharge type, mechanical ventilation (MV), MV duration, and multiple organ failure after readmission) using the univariable and multivariable binary logistic regression. The receiver operating characteristic (ROC) curve was used to determine the outcome predictability of MEWS and NEWS. Results A total of 410 ICU patients were enrolled in this study. According to multivariable logistic regression analysis, both MEWS and NEWS were predictors of ICU readmission, time to readmission, MV status after readmission, MV duration, and multiple organ failure after readmission. The area under the ROC curve (AUC) for predicting mortality was 0.91 (95% CI = 0.88–0.94, P < 0.0001) for the NEWS and 0.88 (95% CI = 0.84–0.91, P < 0.0001) for the MEWS. There was no significant difference between the AUC of the NEWS and the MEWS for predicting mortality (P = 0.082). However, for ICU readmission (0.84 vs. 0.71), time to readmission (0.82 vs. 0.67), MV after readmission (0.83 vs. 0.72), MV duration (0.81 vs. 0.67), and multiple organ failure (0.833 vs. 0.710), the AUCs of MEWS were significantly greater (P < 0.001). Conclusion National Early Warning Score and MEWS values of >4 demonstrated high sensitivity and specificity in identifying the risk of mortality for the patients’ discharge from ICU. However, we found that the MEWS showed superiority over the NEWS score in predicting other outcomes. Eventually, MEWS could be considered an efficient prediction score for morbidity and mortality of critically ill patients.
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Affiliation(s)
- Ata Mahmoodpoor
- Research Center for Integrative Medicine in Aging, Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
- *Correspondence: Ata Mahmoodpoor,
| | - Sarvin Sanaie
- Research Center for Integrative Medicine in Aging, Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Seied Hadi Saghaleini
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Zohreh Ostadi
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Naeeme Sheshgelani
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Amir Vahedian-Azimi
- Trauma Research Center, Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Abbas Samim
- Chemical Injuries Research Center, Systems Biology and Poisonings Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Farshid Rahimi-Bashar
- Anesthesia and Critical Care Department, Hamadan University of Medical Sciences, Hamadan, Iran
- Farshid Rahimi-Bashar,
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Mahmoodpoor A, Fouladi S, Ramouz A, Shadvar K, Ostadi Z, Soleimanpour H. Diaphragm ultrasound to predict weaning outcome: systematic review and meta-analysis. Anaesthesiol Intensive Ther 2022; 54:164-174. [PMID: 35792111 PMCID: PMC10156496 DOI: 10.5114/ait.2022.117273] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 04/10/2022] [Indexed: 07/24/2023] Open
Abstract
Proper timing for discontinuation of mechanical ventilation is of great importance, especially in patients with previous weaning failures. Different indices obtained by ultra-sonographic evaluation of the diaphragm muscle have improved determination of weaning success. The aim of the present systematic review was to evaluate and compare the accuracy of the diagnostic indices obtained by ultrasonographic examination, including diaphragm thickening fraction (DTF), diaphragmatic excursion (DE) and the rapid shallow breathing index (RSBI). A systematic literature search (Web of Science, MEDLINE, Embase and Google Scholar) was performed to identify original articles assessing diaphragm muscle features including excursion and thickening fraction. A total of 2738 citations were retrieved initially; available data of 19 cohort studies (1114 patients overall) were included in the meta-analysis, subdivided into groups based on the ultrasonographic examination type. Our results showed the superiority of the diagnostic accuracy of the DTF in comparison to the DE and the RSBI. Data on the combination of the different indices are limited. Diaphragmatic ultrasound is a cheap and feasible tool for diaphragm function evaluation. Moreover, DTF in the assessment of weaning outcome provides more promising outcomes, which should be evaluated more meti-culously in future randomised trials.
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Affiliation(s)
- Ata Mahmoodpoor
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Shahnaz Fouladi
- Department of Anesthesiology and Intensive Care Medicine, Ardabil University of Medical Sciences, Tabriz, Iran
| | - Ali Ramouz
- Department of General, Visceral and Transplant Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Kamran Shadvar
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Zohreh Ostadi
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hassan Soleimanpour
- Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Mahmoodpoor A, Hosseini M, Soltani-Zangbar S, Sanaie S, Aghebati-Maleki L, Saghaleini SH, Ostadi Z, Hajivalili M, Bayatmakoo Z, Haji-Fatahaliha M, Babaloo Z, Farid SS, Heris JA, Roshangar L, Rikhtegar R, Kafil HS, Yousefi M. Reduction and exhausted features of T lymphocytes under serological changes, and prognostic factors in COVID-19 progression. Mol Immunol 2021; 138:121-127. [PMID: 34392110 PMCID: PMC8343383 DOI: 10.1016/j.molimm.2021.06.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 05/24/2021] [Accepted: 06/06/2021] [Indexed: 12/27/2022]
Abstract
Aims Coronavirus disease 2019 (COVID-19) is a novel viral infection threatening worldwide health as currently there exists no effective treatment strategy and vaccination programs are not publicly available yet. T lymphocytes play an important role in antiviral defenses. However, T cell frequency and functionality may be affected during the disease. Material and methods Total blood samples were collected from patients with mild and severe COVID-19, and the total lymphocyte number, as well as CD4+ and CD8 + T cells were assessed using flowcytometry. Besides, the expression of exhausted T cell markers was evaluated. The levels of proinflammatory cytokines were also investigated in the serum of all patients using enzyme-linked immunesorbent assay (ELISA). Finally, the obtained results were analyzed along with laboratory serological reports. Results COVID-19 patients showed lymphopenia and reduced CD4+ and CD8 + T cells, as well as high percentage of PD-1 expression by T cells, especially in severe cases. Serum secretion of TNF-α, IL-1β, and IL-2 receptor (IL-2R) were remarkably increased in patients with severe symptoms, as compared with healthy controls. Moreover, high levels of triglyceride (TG) and low density lipoprotein cholesterol (LDL-C), were correlated with the severity of the disease. Conclusion Reduced number and function of T cells were observed in COVID-19 patients, especially in severe patients. Meanwhile, the secretion of proinflammatory cytokines was increased as the disease developed. High level of serum IL-2R was also considered as a sign of lymphopenia. Additionally, hypercholesterolemia and hyperlipidemia could be important prognostic factors in determining the severity of the infection.
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Affiliation(s)
- Ata Mahmoodpoor
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran; Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Maryam Hosseini
- Department of Immunology, Faculty of Medicine, Tarbiat Modares University, Tehran, Iran
| | | | - Sarvin Sanaie
- Neurosciences Research Center, Aging Research Institute, Tabriz University of Medical Sciences, Iran
| | | | - Seyed Hadi Saghaleini
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Zohreh Ostadi
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mahsa Hajivalili
- Department of Immunology, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zhinous Bayatmakoo
- Department of Infectious Diseases and Tropical Medicine, Infectious and Tropical Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mostafa Haji-Fatahaliha
- Department of Immunology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Zohreh Babaloo
- Department of Immunology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sima Shahmohammadi Farid
- Department of Immunology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Javad Ahmadian Heris
- Department of Allergy and Clinical Immunology, Pediatric Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Leila Roshangar
- Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Reza Rikhtegar
- Department of Neurology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hossein Samadi Kafil
- Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mehdi Yousefi
- Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, Iran; Department of Immunology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran.
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Abstract
Thrombocytopenia is a frequent finding in intensive care unit especially among adults and medical ICU patients. Thrombocytopenia is defined as a platelet count less than 100×109/l in ICU setting. Platelets are made in the bone marrow from megakaryocytes. Although not fully understood, proplatelets transform into platelets in the lung. The body tries to maintain platelet count relatively constant throughout life. Pathophysiology of thrombocytopenia can be defined by hemodilution, elevated levels of platelet consumption, compromise of platelet production, increased platelet sequestration and increased platelet destruction. Unlike in other situations, absolute platelet count alone does not provide sufficient data in characterizing thrombocytopenia in ICU patients. In such cases, the time course of changes in platelet count is also pivotal. The dynamics of platelet count decrease vary considerably between different ICU patient populations including trauma, major surgery and minor surgery/medical conditions. There are strong evidences available that delay in platelet count restoration in ICU patients is an indicator of a bad outcome.
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Affiliation(s)
- Zohreh Ostadi
- Zohreh Ostadi, Anesthesiologist, Fellowship of Critical Care Medicine, Department of Anesthesiology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Kamran Shadvar
- Kamran Shadvar, Associate Professor of Anesthesiology, Fellowship of Critical Care Medicine, Department of Anesthesiology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sarvin Sanaie
- Sarvin Sanaie, Assistant Professor of Nutrition, MD, PhD, Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ata Mahmoodpoor
- Ata Mahmoodpoor, Professor of Anesthesiology, Fellowship of Critical Care Medicine, Department of Anesthesiology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Seied Hadi Saghaleini
- Seied Hadi Saghaleini, Assistant Professor of Anesthesiology, Fellowship of Critical Care Medicine, Department of Anesthesiology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
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Mahmoodpoor A, Hamishehkar H, Shadvar K, Ostadi Z, Sanaie S, Saghaleini SH, Nader ND. The Effect of Intravenous Selenium on Oxidative Stress in Critically Ill Patients with Acute Respiratory Distress Syndrome. Immunol Invest 2018; 48:147-159. [PMID: 30001171 DOI: 10.1080/08820139.2018.1496098] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To modulate the inflammatory response in respiratory distress syndrome (ARDS) with selenium. BACKGROUND Selenium replenishes the glutathione peroxidase proteins that are the first line of defense for an oxidative injury to the lungs. METHODS Forty patients with ARDS were randomized into two groups: the SEL+ group being administered sodium selenite and the SEL- group receiving normal saline for 10 days. Blood samples were taken on Day-0, DAY-7, and Day-14 for assessment of IL-1 beta, IL-6, C-reactive protein, GPx-3, and selenium. Ferric reducing antioxidant power (FRAP) was measured in the bronchial wash fluids. Pearson correlation and repeated measure analysis were performed to examine the effects of selenium on the inflammatory markers. RESULTS Sodium selenite replenished selenium levels in the SEL+ group. Selenium concentrations were linearly correlated to serum concentrations of GPx3 (R value: 0.631; P < 0.001), and FRAP (R value: -0.785; P < 0.001). Serum concentrations of both IL 1-beta (R value: -0.624; P < 0.001) and IL-6 (R value: -0.642; P < 0.001) were inversely correlated to the serum concentrations of selenium. There was a meaningful difference between two groups in airway resistance and pulmonary compliance changes (P values 0.008 and 0.028, respectively). CONCLUSION Selenium restored the antioxidant capacity of the lungs, moderated the inflammatory responses, and meaningfully improved the respiratory mechanics. Despite these changes, it had no effect on the overall survival, the duration of mechanical ventilation, and ICU stay. Selenium can be used safely; however, more trials are essential to examine its clinical effectiveness.
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Affiliation(s)
- Ata Mahmoodpoor
- a Department of Anesthesiology & Critical Care Medicine , Tabriz University of Medical Sciences , Tabriz , IRAN
| | - Hadi Hamishehkar
- b Department of Clinical Pharmacy , Tabriz University of Medical Sciences , Tabriz , IRAN
| | - Kamran Shadvar
- a Department of Anesthesiology & Critical Care Medicine , Tabriz University of Medical Sciences , Tabriz , IRAN
| | - Zohreh Ostadi
- a Department of Anesthesiology & Critical Care Medicine , Tabriz University of Medical Sciences , Tabriz , IRAN
| | - Sarvin Sanaie
- c Tuberculosis and lung disease Research center , Tabriz University of Medical Sciences , Tabriz , IRAN
| | - Seied Hadi Saghaleini
- a Department of Anesthesiology & Critical Care Medicine , Tabriz University of Medical Sciences , Tabriz , IRAN
| | - Nader D Nader
- d Department of Anesthesiology , University at Buffalo , Buffalo , NY , USA
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Abstract
Pressure ulcers can diminish global life quality, contribute to rapid mortality in some patients and pose a significant cost to health-care organizations. Accordingly, their prevention and management are highly important. Nutritional deprivation and insufficient dietary intake are the key risk factors for the development of pressure ulcers and impaired wound healing. Unplanned weight loss is a major risk factor for malnutrition and pressure ulcer development. Suboptimal nutrition interferes with the function of the immune system, collagen synthesis, and tensile strength. No laboratory test can exactly define an individual's nutritional status. Although serum albumin, prealbumin, transferrin, and retinol-binding protein as well as anthropometric measures such as height, weight, and body mass index and the other laboratory values may be suitable to establish the overall prognosis, still they might not well represent the nutritional status. Although the ideal nutrient intake to encourage wound healing is unknown, increased needs for energy, protein, zinc, and Vitamins A, C, and E and also amino acids such as arginine and glutamine have been documented. Hydration plays a vital role in the preservation and repair of skin integrity. Dehydration disturbs cell metabolism and wound healing. Adequate fluid intake is necessary to support the blood flow to wounded tissues and to prevent additional breakdown of the skin. The main aim of the present article is to review the current evidence related to hydration and nutrition for bedsore prevention and management in adults.
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Affiliation(s)
- Seied Hadi Saghaleini
- Department of Anesthesiology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Kasra Dehghan
- Department of Anesthesiology, Faculty of Medicine, Urmia University of Medical Sciences, Urmia, Iran
| | - Kamran Shadvar
- Department of Anesthesiology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sarvin Sanaie
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ata Mahmoodpoor
- Department of Anesthesiology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Zohreh Ostadi
- Department of Anesthesiology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
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Shakeri A, Shakeri M, Ojaghzadeh Behrooz M, Behzadmehr R, Ostadi Z, Fouladi DF. Infrarenal aortic diameter, aortoiliac bifurcation level and lumbar disc degenerative changes: a cross-sectional MR study. Eur Spine J 2017; 27:1096-1104. [PMID: 29143100 DOI: 10.1007/s00586-017-5388-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 10/15/2017] [Accepted: 11/07/2017] [Indexed: 12/29/2022]
Abstract
PURPOSE To examine a possible correlation of infrarenal aortic diameter and aortoiliac bifurcation level with lumbar disc degenerative changes. METHODS This was a cross-sectional, single-center retrospective study on lumbar magnetic resonance images of patients with low back pain (n = 496). Lumbar disc degenerative changes were reported on the basis of the Pfirrmann grading system and accordingly, patients were grouped as with grade I-II findings (n = 192), with grade III findings (n = 64) and with grade IV-V findings (n = 240). The groups were matched for sex, body mass index and the history of diabetes mellitus, hypertension, hyperlipidemia and smoking. Infrarenal aortic diameter and aortoiliac bifurcation level were compared between the three groups. RESULTS Pairwise comparisons between the three groups of patients with Pfirrmann grades of I-II, III and IV-V revealed significant differences (p < 0.05) in terms of the median infrarenal aortic diameter (17 mm [interquartile range 4], 18 mm [4] and 19 mm [4], respectively) and the median aortoiliac bifurcation level (3 [2], 4 [2] and 5 [3], respectively; the higher the value, the more the caudal displacement). These associations were independent of conventional risk factors of atherosclerosis (including age) and from each other. CONCLUSIONS This study showed a significant, direct correlation of the infrarenal aortic diameter and the level of aortoiliac bifurcation with lumbar intervertebral degenerative changes according to the Pfirrmann grading system. The associations were independent of well-known risk factors of atherosclerosis and from each other.
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Affiliation(s)
- Abolhassan Shakeri
- Department of Radiology, Imam Reza Teaching Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Moslem Shakeri
- Department of Neurosurgery, Imam Reza Teaching Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Razieh Behzadmehr
- Department of Radiology, Zabol University of Medical Sciences, Zabol, Iran
| | - Zohreh Ostadi
- Department of Anesthesiology, Imam Reza Teaching Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Daniel Fadaei Fouladi
- Neurosciences Research Center, Tabriz University of Medical Sciences, Golgasht Street, Tabriz, Iran.
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Eydi M, Golzari SEJ, Aghamohammadi D, Kolahdouzan K, Safari S, Ostadi Z. Postoperative Management of Shivering: A Comparison of Pethidine vs. Ketamine. Anesth Pain Med 2014; 4:e15499. [PMID: 24829883 PMCID: PMC4013503 DOI: 10.5812/aapm.15499] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2013] [Revised: 11/17/2013] [Accepted: 11/28/2013] [Indexed: 12/16/2022] Open
Abstract
Background: One of the unpleasant side effects of general anesthesia is shivering in the process of recovery. It is an involuntary oscillatory mechanical movement that can be classified as clonic movements. These movements can affect one or several groups of skeletal muscles beginning from 5 to 30 minutes after the discontinuation of anesthesia. Objectives: We aimed to study ketamine’s effect on shivering after operation compared to pethidine as a way for treatment of postoperative shivering. Patients and Methods: In this study, 60 patients who underwent ENT surgery with general anesthesia and had shivering during recovery were randomly divided into two groups of 30 patients each receiving ketamine (0.2 mg/kg IV) and pethidine (0.5 mg/kg). Results: There was no statistically significant difference between the shivering intensity in both groups. Only regarding the shivering in the first minute after entering the recovery room, there was an obvious difference between ketamine and pethidine groups which was again not statistically significant (P = 0.07). Conclusions: The results of this study showed that ketamine and pethidine are both equally effective in the reduction of postoperative shivering.
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Affiliation(s)
- Mahmood Eydi
- Department of Anesthesiology, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Samad EJ Golzari
- Liver and Gastrointestinal Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
- Corresponding author: Samad EJ Golzari, Liver and Gastrointestinal Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran. Tel: +98-9141151894, Fax: +98-4113367373, E-mail:
| | - Davood Aghamohammadi
- Department of Anesthesiology, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Khosro Kolahdouzan
- Faculty of Paramedical, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Saeid Safari
- Department of Anesthesiology, Rasoul Akram Medical Center, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Zohreh Ostadi
- Department of Anesthesiology, Tabriz University of Medical Sciences, Tabriz, Iran
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