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Adjustment of immunosuppressive and COVID-19 treatment in terms of drug interactions is still challenging. Herein, we report a 45-year-old woman with end-stage renal disease due to autosomal dominant polycystic diseases (ADPKD) with COVID-19 and pulmonary involvement following kidney transplantation. The patient was properly treated by discontinuation of immunosuppressive drugs, bronchoscopy, and high volume of blood transfusions. The fact that we quickly used early intubation and a new treatment regimen that suppressed immune systems may help physicians develop optimal treatment strategies for similar severe cases. However, this treatment method requires more detailed evaluations due to the contradictory results in reviewing other studies.

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Acinetobacter baumannii is a rare but dangerous gram-negative bacteria causing nosocomial infections, especially in intensive care units. The increased use of antibiotics in the treatment of bacterial infections leads to drug resistance, delays, or failures in treatment. The patient is a 48-year-old man with coronavirus disease (COVID-19) being treated in the intensive care unit. After contracting Acinetobacter baumannii, the patient's condition deteriorated, and he developed severe pulmonary problems. Due to the unknown presence of Acinetobacter baumannii in the patient, this bacterium transmitted to six other patients in the ward, which resulted in their deaths. In this report, we describe the causes and risk factors of the disease, and the results of laboratory tests and therapeutic processes.

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PURPOSE: Percutaneous nephrolithotomy (PCNL) is the preferred surgical treatment in many cases of kidney stones which is performed in different positions such as prone, lateral, and supine. This study was designed to evaluate whether patient position (lateral versus . prone) has an effect on the need for analgesia and onset of pain after surgery. MATERIALS AND METHODS: Patient with confirmed kidney stones (size ? 2 cm) who were candidates for PCNL were enrolled in this study. The required biochemical analyses were performed preoperatively. All patients  underwent spinal anesthesia by the same anesthesiologists and then were randomly divided into two separate groups as lateral (L) and prone (P) positions. The operations' start and end time, required time for proper access into target calyces, additional need for analgesic or cardiac drugs, duration of analgesia, and onset of pain after PCNL were carefully recorded and then compared between the two groups. RESULTS: In total, 51 patients were evaluated of whom 39 were men and 12 were women. Mean duration of analgesia after PCNL surgery in P group (173 ± 8 min) was significantly longer than in L group (147±12 min) (P = .001). Furthermore, the amount of ephedrine usage in L group (3.6 ± 1.5mg) was significantly lower than in the P group (16.4 ± 12mg), suggesting more hemodynamic variations in the P group during the operation. CONCLUSION: Our randomized control trial study shows that choosing the optimal position in the PCNL technique depends on  patient's condition. If hemodynamic control is of matter to the anesthesiologist, then lateral position is more appropriate. However, if control of pain and longer time of analgesia are important,  prone position may be preferred.

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Sturge-Weber syndrome (SWS) is a neurocutaneous disorder, characterized by leptomeningeal angiomas involving the oral cavity, trachea, larynx, and face. Herein, we present a case of vitrectomy in a seven-year-old boy with SWS. The patient showed hemangioma on the left side of his face, as well as mental retardation and epilepsy. Preoperative examination revealed no apparent hemangioma in the oral cavity, pharynx, larynx, or trachea. However, he was predicted to have difficult airway intubation, as the oral cavity was smaller than the normal size. The minimum Mallampati score was 3-4 due to macroglossia. First, we applied awake intubation, but he failed to follow the commands. We proceeded to general anesthesia with propofol and did not use any muscle relaxants to maintain spontaneous breathing. A laryngeal mask airway was inserted to minimize any harm to possible oral angiomas. The patient was hemodynamically stable and extubated without any complications, such as bleeding or respiratory problems.

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BACKGROUND: A detrimental effect of commonly used anesthetics on the neurodevelopmental and behavioral parameters has long been shown in young animals subjected to early childhood anesthesia. Epidemiologic studies suggest the possibility of a modestly elevated risk of adverse neurodevelopmental outcomes in children exposed to anesthesia during early childhood. However, these results are still preliminary and inconclusive. AIM: To further elucidate the probability of occurrence of such adverse outcomes, we evaluated cognitive performance of children who underwent general anesthesia early in their childhood. METHOD: One hundred and fifteen children aged 5-16 years with established glaucoma were included in the study. Of these, 68 children had a history of at least one general anesthesia with sevoflurane before age 3. Phonemic and semantic verbal fluency, and forward and backward digit span tests were performed to evaluate cognitive function in the study subjects. RESULTS: The two-way anova revealed that all these variables showed significant changes in various age groups, but they were comparable among subjects with no, single, or multiple childhood anesthesia. CONCLUSION: It can be concluded that brief periods of anesthesia with single anesthetic sevoflurane may be safe for children under age 3.

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PURPOSE: To evaluate the incidence of the oculocardiac reflex (OCR) and its associated risk factors during strabismus surgery at a tertiary referral center. METHODS: Over a 2-year period, all strabismus surgery candidates were enrolled in the study. OCR was defined as heart rate reduction ≥15% after traction on extraocular muscle(s). The rate of OCR was determined and possible associations were explored. Variables included age, gender, type of strabismus, nature of surgery (weakening versus strengthening), specified extraocular muscle, times of surgery, and the sequence of operated muscles (eg, first, second, or third operated muscle). We avoided the use of atropine pre- and postoperatively. RESULTS: Seventy-six patients with mean age of 15±12 years were enrolled; 51.3% of subjects were male. OCR occurred in 65 out of 76 (85.5%) patients and with 84 out of 173 (48.6%) operated muscles. OCR was more common in subjects less than 20 years of age; however, it showed a decreasing trend afterwards. OCR was more frequent during operation on cyclovertical muscles than horizontal recti (P=0.02). Moreover, during procedures on horizontal rectus muscles, OCR was more common if baseline heart rate was more than 61 (P=0.008). OCR was not correlated with gender, type of strabismus, nature of surgery, times of the surgery, or the sequence of operated extraocular muscles. CONCLUSIONS: The great majority of patients undergoing strabismus surgery, especially younger subjects, those undergoing operation on cyclovertical muscles, and subjects with higher baseline heart rate, experience OCR during strabismus surgery. During surgery on cyclovertical muscles, the amount of pull is usually more due to more difficult exposure.

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BACKGROUND: The current randomized double-blind clinical trial aimed to compare the incidence of post-operative cough with intravenous vs. topical lidocaine in children with mild upper respiratory infection (URI) anesthetized with laryngeal mask airway (LMA) in the university-affiliated medical center. OBJECTIVES: To assess the incidence of adverse respiratory event including cough, apnea, laryngospasm, bronchospasm following two different methods of lidocaine administration in anesthetized children with mild URI. PATIENTS AND METHODS: One hundred and thirty pediatric patients with mild URI (within the previous two weeks) aged between one and six years were enrolled. They were candidates to undergo immediate full ophthalmic examination, and randomly divided into two groups of 65to receive intravenous (1.5 mg/kg) or topical lidocaine on LMA. Anesthesia was induced with sevoflurane, subsequently LMA was inserted when the patient was in deep anesthesia status and maintained on (50% N2O, 50% O2) and 3% sevoflurane. Spontaneous ventilation was maintained throughout the procedure and LMA was removed in deep anesthesia. Outcomes (cough, laryngospasm, bronchospasm and vomiting) were evaluated peri-operatively and one day post-operation. RESULTS: One hundred and twenty four patients fulfilled the trial. Cough (primary outcome) was significantly more frequent among those with topical compared with intravenous lidocaine (46% vs. 26%; P = 0.004). The incidence of laryngospasm (32% vs. 27%), bronchospasm (18% vs. 12%), desaturation (18% vs. 12%) and vomiting (5% vs. 2%) was not statistically different between the groups. CONCLUSIONS: The pediatric patients undergoing general anesthesia with LMA with intravenous lidocaine experienced fewer incidence of postoperative cough compared to the ones in the topical lidocaine group.

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BACKGROUND: Retinopathy of prematurity (ROP) is the most common reason behind surgical procedures in premature newborns. Anesthesia in these patients is life-threatening due to post-operative apnea of prematurity (POA). This study aimed to determine the predisposing factors to POA in premature infants and to explore the role of prophylactic aminophylline in decreasing the incidence of POA. MATERIALS AND METHODS: Fifty patients with prematurity who were candidates for elective eye surgery (less than one hour) were selected and received aminophylline (3 mg/kg) 5 minutes after the induction of anesthesia with sevoflurane. Patients were kept in the recovery room for 2 hours post-operation in an incubator and were monitored for SPO2, apnea, bradycardia and other signs of desaturation and apnea. RESULTS: There were no statistically significant differences in the gestational age and weight, sex, postconceptual age and weight and other demographic characteristics between the experimental and control groups. Gestational age<28 weeks, postconceptual age<60 weeks, birth weight, operation weight and anemia (OR=1.91; 95% CI: 1.24-3.73; P=0.012) were the predisposing factors associated with postoperative apnea. Treatment with aminophylline as compared with the placebo was associated with a significantly decreased risk of post-operative apnea (OR=0.53; 95% CI 0.28-0.98; P=0.034). CONCLUSION: Aminophylline can be used prophylactically to decrease the risk of postoperative apnea with no major adverse effects.

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PURPOSE: To evaluate the safety and efficacy of spinal anesthesia compared with general anesthesia in patients who underwent percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: One hundred patients with American Society of Anesthesiologists (ASA) score <3 were randomly divided into two groups according to the type of anesthesia. Spinal anesthesia was performed using an injection of 0.25 mg/kg bupivacaine 0.5% in the intrathecal space; no opium (fentanyl) agent was used. All procedures were performed with the patient in the prone position. Stone access was made by using fluoroscopic guidance, and the tract was dilated using a single-stage technique. All patients received a solution including 1 mg/kg morphine in every 100 mL physiologic saline through the volumetric pump during the 3-hour post-PCNL period in the recovery room. Afterward, morphine (0.05 mg/kg) was injected only according to the verbal rating scale greater than 3 after discharge from the recovery room until 24 hours after surgery. RESULTS: The two groups were matched by mean age, distribution of stone location, and stone burden. Mean operative time, hospital stay, stone-free rate and mean hemoglobin drop were comparable between the two groups. The rate of complications according to the Clavien grading system was nearly similar in both groups. Mean analgesic requirement during 24 hours after PCNL was 6.8 mg in the spinal group and 13.2 mg in the general group (P<0.001). CONCLUSION: It seems that using spinal anesthesia by intrathecal injection of local anesthetic solutions vs general anesthesia has comparable surgical outcomes and reduces the requirement for analgesia after PCNL in the early postoperative period.

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Mucopolysaccharidoses (MPSs) are a group of hereditary diseases characterized by accumulation of Glycosaminoglycans (GAGs) due to deficiency or malfunctioning of lysosomal enzymes. Difficult intubation is anticipated in these patients because of a variety of anatomical and functional abnormalities. We report the successful use of sevoflurane and laryngeal mask for airway management of a 15 year-old boy requiring corneal transplantation surgery.

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PURPOSE: To study the simultaneous effects of prone position and anesthesia on intraocular pressure (IOP) and the time impact on post anesthesia visual loss development in percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS: Twenty patients who were candidates for PCNL were recruited in this study. Intraocular pressure was measured in five occasions: 1. Base line; 2. Ten minutes after anesthesia (Supine-I); 3. Ten minutes after position change to prone (Prone-I); 4. At the end of the operation (Prone-II); and 5. Ten minutes after position change to supine (Supine-II). The data were analyzed by SPSS software using repeated measures ANOVA and paired t test. RESULTS: The participants consisted of 17 (85%) men and 3 (15%) women, with the mean age of 44 years. The duration of the prone position was 79.75 ± 22.73 minutes. Intraocular pressure changed significantly in five positions (P = .000). It was lower in supine-I than baseline, higher in prone-I than base line and supine-I, lower in supine-II than prone-II, and highest in prone-II (P = .000). There was a linear relationship between IOP and prone position duration (r = 0.67; P = .001). CONCLUSION: Intraocular pressure dropped significantly after anesthesia and increased in prone position. There was a linear relationship between IOP rise and the prone position duration, doubled within two hours. Therefore, in PCNL carried out in prone position, it is recommended to observe safety measures and necessary precautions for IOP rise and possible post anesthesia visual loss, particularly in glaucoma.

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BACKGROUND: The main responsibility of an anesthesiologist is to safely maintain an open airway and preserve sufficient gas exchange in the lungs. This role becomes more significant when managing children especially those with difficult airways (DA). In such cases, a quick appropriate action can decrease the related mortality and morbidity. Laryngeal mask airway (LMA) is a device used in cases with difficult airways. Its placement is much more difficult in children especially those with DA. There is a greater risk of malpositioning and its insertion with routine techniques is sometimes impossible. In this article, we introduce a new method for replacement of LMA in difficult pediatric airways (DPA). MATERIALS AND METHODS: In this before and after, pre and post design clinical trial, we evaluated 30 children with congenital anomalies and difficult airways who were candidates for elective eye surgery (short term). A written consent was obtained from the parents or the legal guardians of those who met the inclusion criteria. Inhalation anesthesia was induced by sevoflurane. The patients had assisted spontaneous respiration. No muscle relaxant was administered. LMA was inserted using the classic method in the anesthesia depth of BIS = 35-40. After 2 unsuccessful attempts according to the criteria for adequate function of LMA, we tried placing the LMA using our innovated method after meeting the primary requirements and reaching the anesthesia depth of 35-40. In this method, the index finger of the left hand was placed on the tongue pushing it downwards (towards the floor of the mouth) when inserting the LMA. This way, we assisted LMA passing down the pharynx resulting in its adequate positioning. Criteria for adequate function of LMA in both classic and innovated insertion methods included monitoring of easy ventilation, no resistance during exhalation, adequate chest movement, no air leakage, optimal airway pressure, optimal lung compliance, level of oxygenation of arterial blood and level of CO2 at the end of exhalation. In case of presence of air leakage with bag pressure below 15 cm of water, lack of chest movement during inhalation, upper airway pressure over 20 cm of water, SPO2 lower than 90% and low compliance of the lung, LMA placement would be considered a failure. In such cases, LMA would be immediately extracted and the required depth of anesthesia would be reached using an oxygen mask and required inhalations. Complications occurring during the procedure and after LMA extraction would be recorded. RESULTS: Our understudy population included 30 children in the age range of 1.5 months to 10 yrs (11 girls and 19 boys) who had clear DA criteria due to syndromes and severe congenital anomalies and were candidates for elective eye surgery. Duration of the operation was 30 to 60 minutes. In all 30 cases, LMA placement with the classic method was not successful after 2 attempts by an expert. LMA was successfully inserted for all cases by the same person using the innovated method after meeting the required criteria (BIS = 35-40). All ventilation indices were met and the operation was performed successfully with no complication. CONCLUSION: There is always a risk of unsuccessful LMA placement in difficult pediatric airways using the classic method of insertion. The innovated method recommends pushing down the tongue by the index finger of the left hand. Considering the hypersensitivity of children to hypoxia and risk of unsuccessful LMA placement by the classic method, the innovated placement method is advised in children suffering from anomalies associated with macroglossia.