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Anesthesiology and Pain Medicine - Volume:7 Issue: 6, Dec 2017

Anesthesiology and Pain Medicine
Volume:7 Issue: 6, Dec 2017

  • تاریخ انتشار: 1396/10/30
  • تعداد عناوین: 12
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  • Chrysanthi Batistaki *, Athina Angelopoulou, Maria-Eleni Smyrnioti, Maria-Chrysanthi Kitsou, Georgia Kostopanagiotou Page 1
    Epidural steroid injections (ESIs) are commonly used in the management of chronic lower back and leg pain. The aim of this study was to investigate the short- and long-term electromyographic and clinical outcome of patients with chronic radicular pain after ESIs. This prospective, open-label study, included patients with chronic radicular pain due to disc herniation or spinal stenosis, who underwent interlaminar, fluoroscopy-guided ESIs. Patients were assessed before ESIs, as well as after 6 and 12 months, clinically (VAS 0-10, BPI, DN4, Rolland Morris, DASS, STAI) and electromyographically for the improvement of spontaneous activity (SA) and of motor unit recruitment/interference pattern (IP/MUR). A total of 39 patients were studied, 20 (51.3%) who had a significant improvement in VAS, RM, DN4 and BPI were revealed, mainly during the first 6 months (P
    Keywords: Low Back Pain, Chronic, Electromyography, Epidural, Steroids
  • Mohammad Ali Sahmeddini *, Mohammad Bagher Khosravi, Masoome Seyedi, Zahra Hematfar, Sedighe Abbasi, Arash Farbood Page 2
    Background
    Intravenous Regional Anesthesia (IVRA) is a simple efficient method for providing regional anesthesia of the limbs. However, it has some limitations such as lack of postoperative analgesia.
    Objectives
    This study aimed to compare the analgesic effects of magnesium sulfate and tramadol when added to lidocaine used for IVRA in upper limb surgery.
    Methods
    In this double - blind randomized clinical trial, 69 patients who underwent elective upper limb surgery with IVRA were randomly allocated into 3 groups. Patients in group A, received IVRA with 0.5% lidocaine and tramadol 100 mg, in group B received IVRA with 0.5% lidocaine and magnesium sulfate 1.5 g, while in group C patients received IVRA with 0.5% lidocaine and normal saline. The onset of sensory block and the duration of postoperative analgesia pain intensity were noted in each patient. Furthermore, the incidence of postoperative nausea and vomiting, respiratory depression, and skin rash were recorded.
    Results
    Duration of postoperative analgesia was more prolong in the tramadol group than other groups (P = 0.01). Also, the total amount of morphine consumption in the group A, group B, and C was 8.91 ± 5.81, 11.95 ± 4.81, 16.72 ± 4.07 mg, respectively, which was significantly lower in the tramadol group in comparison to the other groups (P = 0.01).
    Conclusions
    It seems that adding tramadol as an adjuvant to lidocaine during IVRA in comparison to magnesium sulfate increases duration of postoperative analgesia and decreases analgesic consumption without increasing opioid-related side effects.
    Keywords: Tramadol, Magnesium Sulfate, Intravenous Regional Anesthesia
  • Seyed Reza Akbarzadeh, Maryar Taghavi Gillani *, Masoumeh Tabari, Negar Morovatdar Page 3
    Background
    Difficult intubation is dangerous and sometimes fatal, especially in patients with obesity. In difficult intubation cases the best device should be applied to decrease the risk of complications. The current study aimed at comparing laryngoscopes, Macintosh, McCoy, GlideScope® and devices for intubation purposes.
    Methods
    A total of 102 patients with obesity and ASA (American society of anesthesiologists) class I or II, and body mass index (BMI) of > 30 kg/m2 were selected. After obtaining the informed consent, the patients were divided into 3 groups based on the 3 laryngoscope types. Preoperative airway assessment including the Mallampati score, thyromental distance (TMD), and neck circumference was performed and all the patients were anesthetized based on the same protocol. Subsequently, all of the patients were intubated using a Macintosh, McCoy, or GlideScope® laryngoscope. Laryngoscopy time, Cormack-Lehane score (1 - 4), and the percentage of glottic opening (POGO; 1 - 100) were evaluated. Data were analyzed using SPSS version 16, and results were considered statistically significant at P ≤ 0.05.
    Results
    There was no significant difference between demographic characteristics and preoperative airway evaluations. The shortest and longest laryngoscopy time were obtained in the GlideScope® and McCoy laryngoscope groups, respectively (P = 0.001). The highest Cormack-Lehane score was obtained using the GlideScope® method (P = 0.04). The POGO was higher and, therefore, more appropriate in the McCoy laryngoscope group (P = 0.009). A direct relationship was observed between neck circumference (P = 0.008), BMI (P = 0.023), Mallampati score (P = 0.000), and laryngoscopy.
    Conclusions
    In the current study, the shortest and longest intubation time in patients with obesity was observed in the GlideScope® and the McCoy laryngoscope groups, respectively. Moreover, the direct relationships of BMI and neck circumference with laryngoscopy time were observed in all 3 groups. These results suggested using GlideScope® in patients with high BMI to reduce laryngoscopy time.
    Keywords: GlideScope®, Macintosh Laryngoscope, McCoy Laryngoscope, Intubation, Patients with Obesity
  • Farzad Rahmani, Zahra Parsian, Kavous Shahsavarinia, Mahboob Pouraghaei, Sohrab Negargar, Robab Mehdizadeh Esfanjani, Hassan Soleimanpour * Page 4
    Background
    Intubation and maintaining airway are crucial in the management of critically ill patients in the emergency department. Correct tracheal intubation should be confirmed by the physician, otherwise oesophageal intubation could lead to hypoxia with detrimental consequences and even death. Sonography can be used to determine proper placement of the tracheal tube.
    Methods
    In this study, 75 patients, with an indication of intubation and age older than 18 years entered the study. An emergency medicine performed real-time sonography of the trachea to evaluate the correct placement of endotracheal tube. Tube passage (snowstorm) and vocal cord angel widening (bullet sign) were evaluated, and then both lungs sliding and diaphragm movement were evaluated to confirm correct tube placement and ventilation.
    Results
    In this study, 75 patients entered the study. The mean age of the patients was 61.12; 47 patients (62.7%) were male and 28 (37.3%) were female. The reason of intubation was the decreased level of consciousness in 22 cases (29.3%), cardiopulmonary arrest in 22 patients (29.3%), respiratory distress in 9 patients (12%), shock in 10 patients (13.3%), and seizure in 1 case. Snowstorm sign was seen in 72 patients (96%). Bullet sign was objected in 24 cases (32%). Lung sliding was seen bilaterally in 63 patients (84%) and unilaterally in 7 patients (9.3 %), but it was not noticed in 6.7% of the patients (5 patients).
    Conclusions
    Transverse tracheal and lung sonography in the emergency department can be a fast measure to confirm correct endotracheal intubation.
    Keywords: Intubation, Sonography, Capnography, Emergency Department
  • Farsad Imani, Fatemeh Shirani Amniyeh, Ehsan Bastan Hagh, Mohammad Reza Khajavi, Saghar Samimi, Fardin Yousefshahi * Page 5
    Background
    Regarding the role of gas entry in abdomen and cardiorespiratory effects, the ability of anesthesiologists would be challenged in laparoscopic surgeries. Considering few studies in this area and the relevance of the subject, this study was performed to compare the arterial oxygen alterations before operation in comparison with after surgery between laparoscopic cholecystectomy and ovarian cystectomy.
    Methods
    In this prospective cohort, 70 consecutive women aged from 20 to 60 years who were candidate for laparoscopic cholecystectomy (n = 35) and ovarian cystectomy (n = 35) with reverse (20 degrees) and direct (30 degrees) Trendelenburg positions, respectively, with ASA class I or II were enrolled. After intubation and before operation, for the first time, the arterial blood gas from radial artery in supine position was obtained for laboratory assessment. Then, the second blood sample was collected from radial artery in supine position and sent to the lab to be assessed with the same device after 30 minutes from surgery termination. The measured variables from arterial blood gas were arterial partial pressure of oxygen (PaO2) and Oxygen saturation (SpO2) alterations.
    Results
    Total PaO2 was higher in the first measurement. The higher values of PaO2 in cholecystectomy (upward) than in ovarian cystectomy (downward) were not significant in univariate (P = 0.060) and multivariate analysis (P = 0.654). Furthermore, higher values of SpO2 in cholecystectomy (upward) than in ovarian cystectomy (downward) were not significant in univariate (P = 0.412) and multivariate analysis (P = 0.984).
    Conclusions
    In general, based on the results of this study, the values of PaO2 in cholecystectomy (upward) were not significantly higher than the values in cystectomy (downward) in laparoscopic surgeries when measured 30 minutes after surgery.
    Keywords: Respiratory Function, Laparoscopic Surgery, Position
  • Babak Mahshidfar *, Mani Mofidi, Maryam Fattahi, Davood Farsi, Peyman Hafezi Moghadam, Saeed Abbasi, Mahdi Rezai Page 6
    Background
    Ketamine, as an opium alternative, has been proposed for pain relief in the emergency department (ED).
    Objectives
    This study was carried out to compare low dose ketamine (LDK) with morphine for pain relief in trauma patients.
    Methods
    In this randomized double-blinded clinical trial, 300 trauma patients from the ED of 2 teaching hospitals in Tehran, Iran were enrolled and randomly divided into 2 equal groups. The 1st group received 0.2 mg/kg of ketamine while the 2nd group received 0.1 mg/kg of intravenous morphine. The pain intensity and complications were measured and compared every 15 minutes to 1 hour.
    Results
    Fifteen minutes after drug injection in both groups, a significant reduction was found in average pain intensity compared to the initial pain (P = 0.01). At 15 minutes, no significant difference was found in both groups in regards to average pain intensity (P = 0.23). The average pain intensity at 30, 45, and 60 minutes in the group receiving morphine was lower than the ketamine group (P = 0.01, P
    Conclusions
    The results of this study suggest that LDK, at a dose of 0.2 mg/kg, in the earlier minutes leads to significant reduction of pain when compared to that of intravenous morphine. It also created fewer complications than morphine.
    Keywords: Morphine, Ketamine, Pain, Emergency Department
  • Hamid Mirhosseini, Mohammad Hossein Avazbakhsh, Meysam Hosseini Amiri *, Ahmad Entezari, Reza Bidaki Page 7
    Background
    Shoulder tip pain is a common problem after laparoscopic cholecystectomy. There are a few clinical trial studies on the effect of clonidine on post laparoscopic shoulder pain (PLSP). This study aimed at evaluating the effect of oral clonidine on PLSP in semi-sitting position and post-operative hemodynamic response of patients undergoing LC surgery.
    Methods
    This randomized controlled clinical trial was conducted on 60 patients, who were candidates for elective laparoscopic cholecystectomy surgery under general anesthesia, and were randomly allocated to clonidine and placebo groups. Patients in the clonidine group received 0.2 mg oral, 90 minutes prior to induction. Patients in the placebo group received vitamin C tablets during the same time. Postoperative pain intensity was assessed, using a visual analog scale at the emergence from anesthesia, 4 and 8 hours after the operation by an anesthetist, who was blinded to the patient group. Mean arterial blood pressure and heart rate were recorded before clonidine administration and in post-operative period.
    Results
    The mean age was 36.85 ± 10.93 years and the mean Body Mass was 26.34 ± 3.46 kg/m2. Two groups were not comparable with respect to occurrence of PLSP (P = 0.739). There was a significant difference in intensity of PLSP between the 2 groups at emergence from anesthesia (P = 0.012), 4 and 8 hours after the operation (P = 0.001) between 2 groups. The clonidine group showed a larger reduction of pain intensity at these phases. The result of independent t test indicated significant differences in the MABP value between the 2 groups at the time of emergence from anesthesia (P = 0.031). The clonidine group demonstrated a lower MABP level at this time.
    Conclusions
    Oral clonidine is not effective in preventing the PLSP. However, it alleviates PLSP intensity in the patient under LC procedure on the first post-operative hours.
    Keywords: Clonidine, Post-Operative Period, Acute Pain, Hemodynamics, Laparoscopy
  • Mahzad Alimian, Masood Mohseni *, Seyed Hamid Reza Faiz, Alireza Rajabi Page 8
    Background
    Decreasing side effects and improving the quality of block in caesarean sections by appropriate dosage of local anesthetics and adjuvants could play an important role in the safe management of cesarean section. The present study aimed at comparing the effects of 3 different doses of intrathecal hyperbaric bupivacaine injected with a fixed dose of sufentanil in cesarean sections.
    Methods
    In a double- blind randomized clinical trial, 105 candidates of elective cesarean section were randomly assigned into 3 groups of 8, 9, and 10 mg of intrathecal bupivacaine plus sufentanil 2.5 µg. The maximum level of sensory block, the intensity of motor block, and vital signs were measured at regular intervals. The incidence of hypotension and bradycardia were also recorded.
    Results
    No significant difference was found between the maximum level of sensory block and the intensity of motor block in 3 groups. The incidences of hypotension and bradycardia as well as administration of atropine and ephedrine were comparable among the 3 groups (P > 0.05).
    Conclusions
    According to similar effects of different doses of bupivacaine, administration of lower doses of bupivacaine (8mg) is more reasonable for spinal anesthesia for cesarean section.
    Keywords: Cesarean Section, Bupivacaine, Sensory Block, Motor Block, Anesthesia
  • Faranak Rokhtabnak, Soudabeh Djalali Motlagh*, Mohamadreza Ghodraty, Alireza Pournajafian, Mojtaba Maleki Delarestaghi, Arash Tehrani Banihashemi, Zeinab Araghi Page 9
    Objective
    The current study aimed at comparing the efficacy of dexmedetomidine and magnesium sulfate to control blood pressure (BP) during rhinoplasty and the resultant effects on the quality of surgical field in terms of bleeding and visibility.
    Methods
    The current randomized, prospective, double-blind study was conducted on 60 patients aged 18 to 50 years classified as ASA (American Society of Anesthesiologists) physical status I who were candidates for rhinoplasty. Patients were randomly divided into 2 groups: (1) group Dex, received 1 µg/kg dexmedetomidine in 10 minutes before induction of anesthesia, followed by 0.4 - 0.6 µg/kg/hour during the maintenance of anesthesia, and (2) group Mg, received 40 mg/kg in 10 minutes before anesthesia induction followed by 10 - 15 mg/kg/hour during anesthesia maintenance. In both groups, the goal was to achieve a mean arterial pressure (MAP) of 60 - 70 mmHg. Hemodynamic variables, anesthetic, opioid, muscle relaxant requirements, and surgical field condition were recorded. Sedation score, time to reach modified Aldrete score ≥ 9, and adverse effects including nausea and vomiting (N&V) and shivering were recorded.
    Results
    Controlled hypotension was achieved in both groups. There was no significant difference in MAP between the groups, but heart rate (HR) was significantly lower in the Dex group (P
    Conclusion
    Dexmedetomidine was more effective than magnesium to achieve controlled hypotension, and provide a favorable surgical field condition. However, dexmedetomidine also heightened the risk of induced bradycardia and prolonged sedation. These are 2 important points to consider when applying this drug as a hypotensive agent during operation.
    Keywords: Controlled Hypotension, Dexmedetomidine, Magnesium Sulfate, Anesthesia, Bradycardia, Rhinoplasty
  • Wei Zhao, Long-Fei Shu, Sang Cai *, Feng Zhang Page 10
    Introduction
    Spontaneous spinal epidural hematoma (SSEH) is a rare condition that can potentially cause paraplegia. SSEH has an increasing incidence rate and its cause remains unclear. Magnetic resonance imaging (MRI) results shows that SSEH presents a spinal epidural space-occupying lesion; therefore, emergency surgical treatment is required in some cases. MRI results of most SSEH cases showed that hematoma occurs in the dorsal or lateral side. By contrast, hematoma in the ventral side is very rarely shown.
    Case Presentation
    A 42-year-old healthy woman developed a sudden onset of severe neck pain with mild limb weakness, gradual breathing difficulty, and high paraplegia. MRI results revealed that an SSEH was compressing her spinal cord in the ventral epidural space from C2 to T3. Upon admission, she received emergency decompressive laminectomy in a posterior approach from C3 to T1, and the epidural hematoma was evacuated through full incision of the dorsal side dural, release of cerebrospinal fluid, and intermittent incision of the ventral side dural. The symptoms of limb paralysis and breathing distress gradually improved after recover rehabilitation, and the patient was discharged with life self-care after 2 months.
    Conclusions
    Performing early decompressive laminectomy and evacuation of hematoma on severe SSEH patients improves neurological outcomes. For patients with ventral side SSEH, the cerebrospinal fluid should be released after the incision on the dorsal side dural, and the ventral side dural should be gradually as well as intermittently clipped to evacuate the hematoma. The patient would also receive a good prognosis after the total release of the spinal cord compression.
    Keywords: Cervical, Thoracic, Spinal Epidural Hematoma, Magnetic Resonance Imaging, Decompressive laminectomy
  • Hamed Shafiee, Saeid Safari, Reza Aminnejad * Page 11
    Central venous catheterization is a common procedure in critical care and trauma patients. Complications are not rare and in some studies more than 15% incidence has been reported (1). Femoral vein is one of the commonest site for this purpose yet it carries complications, such as infection and misplacement. The current study reports an unexpected secondary malposition of right femoral CVC in the peritoneal cavity. It was concluded that in any case of acute abdominal issues, following insertion of femoral venous catheter, evaluation of catheter misplacement by the means of contrast injection through it can be helpful for better diagnosis, and may help avoid unnecessary surgical interventions.
  • Letter to: The Effect of Different Doses of Intrathecal Hyperbaric Bupivacaine Plus Sufentanil in Spinal Anesthesia for Cesarean Sections
    Mahnaz Narimani Zamanabadi * Page 12